Practical Guide of Surgical Semiology

Ştefan Octavian GEORGESCUŞtefan Octavian GEORGESCUDan VINTILĂDan VINTILĂ

Cornel Nicu NEACŞUCornel Nicu NEACŞUPaula POPA Paula POPA

PRACTICAL GUIDE PRACTICAL GUIDE OF SURGICALOF SURGICALSEMIOLOGYSEMIOLOGY

NEXT

Editura SEDCOM LIBRIS

CONTENTSCONTENTS

First day in the surgery service Organizing the surgery service Asepsis Antisepsis Evaluating the surgical patient Preoperative preparation Postoperative care Cardio-pulmonary resuscitatio

n Hemostasis Blood transfusions Injections Vascular probe Punctures

Incisions Surgical suture Surgical drainage Bandage Bandaging Digestive probes Preparing the colon Enema Vesical probing Attending the stomies The surgical instrument Bibliography Instructions of use

EXIT

CLICK CU MOUSE-UL PESTE FIECARE TITLU

A significant status changeA significant status change Preparation Preparation The contact with the teachers The contact with the teachers Behavior rules in the surgery theatreBehavior rules in the surgery theatre

CONTENTS

THE FIRST DAY IN THE SURGICAL SERVICE

A SIGNIFICANT STATUS CHANGE A SIGNIFICANT STATUS CHANGE

The 3The 3rdrd year as a student at the Faculty of General Medicine represents the year as a student at the Faculty of General Medicine represents the beginning of the clinical training activity, therefore the direct contact with the beginning of the clinical training activity, therefore the direct contact with the patient. patient. It is very important to remember that the study materials, rather impersonal, It is very important to remember that the study materials, rather impersonal, that characterize the first two academic years (mainly focused on the that characterize the first two academic years (mainly focused on the preclinical subjects), will be replaced by pathology, and not by people. The preclinical subjects), will be replaced by pathology, and not by people. The patient must not be considered as an object of study, but as a human being in patient must not be considered as an object of study, but as a human being in suffering who will share the signs and symptoms of his disease, so that you suffering who will share the signs and symptoms of his disease, so that you learn to recognize it anytime you see it in your future practice.learn to recognize it anytime you see it in your future practice.

During the internships, you will come into contact not only with the patients, During the internships, you will come into contact not only with the patients, but with different categories of personnel involved in the medical activity, and but with different categories of personnel involved in the medical activity, and your presence must not be considered a barrier in the deployment of this your presence must not be considered a barrier in the deployment of this activity.activity.Surgery represents the last redoubt of the therapeutic possibilities of a Surgery represents the last redoubt of the therapeutic possibilities of a disease. When the conservatory treatment failed or it is not indicated, the only disease. When the conservatory treatment failed or it is not indicated, the only chance given to the patient refers to the surgical intervention. When the chance given to the patient refers to the surgical intervention. When the surgical resources are exceeded, in the majority of cases, death occurs in the surgical resources are exceeded, in the majority of cases, death occurs in the nearest future. Therefore, remember that the surgical patient is rather special, nearest future. Therefore, remember that the surgical patient is rather special, he came to you after a longer or shorter journey in other services or in he came to you after a longer or shorter journey in other services or in emergency conditions with immediate vital risk. As a result, the patient is a emergency conditions with immediate vital risk. As a result, the patient is a fine observer and even judge of your behavior. fine observer and even judge of your behavior.

BACK

PREPARATIONPREPARATION Aspect Aspect

•Clean aspect – the negligent beard or haircut Clean aspect – the negligent beard or haircut creates a very bad impression since the beginning;creates a very bad impression since the beginning;•decent clothing (a too short skirt or a dirty pair of decent clothing (a too short skirt or a dirty pair of jeans will significantly distance you from the image jeans will significantly distance you from the image of future doctor);of future doctor);•The shoes must not be dirty with mud, dust etc.The shoes must not be dirty with mud, dust etc.•White, clean gown, without spots (or you risk to be White, clean gown, without spots (or you risk to be mistaken with the cleaning personnel);mistaken with the cleaning personnel);•Devices Devices (compulsory) : tensiometer and (compulsory) : tensiometer and stethoscope. stethoscope. •Internship copybook, writing tools (compulsory) Internship copybook, writing tools (compulsory)

BACK

BEHAVIOUR RULES IN THE SURGERY THEATRE BEHAVIOUR RULES IN THE SURGERY THEATRE

These rules complete the duties and obligations that the students have in an educational institution. These rules complete the duties and obligations that the students have in an educational institution.

General rules General rules -At the beginning of the internship course the students will be present in the theatre where they were distributed, NOT on the At the beginning of the internship course the students will be present in the theatre where they were distributed, NOT on the hallways, dressing rooms, etc. hallways, dressing rooms, etc. -The noisy discussions in the presence of patients, no matter the subject, are prohibited;The noisy discussions in the presence of patients, no matter the subject, are prohibited;-It is prohibited to wait on the patient’s bed; the bed is the only privacy oasis that the patient has, therefore respect it as such!It is prohibited to wait on the patient’s bed; the bed is the only privacy oasis that the patient has, therefore respect it as such!-It is prohibited to consume coffee, sodas, tobacco, snacks etc. in the theatre; It is prohibited to consume coffee, sodas, tobacco, snacks etc. in the theatre; -At the end of the internship, washing the hands is compulsory; At the end of the internship, washing the hands is compulsory;

Special rules regarding patiens Special rules regarding patiens -The patients may ask you questions related to their disease (explorations, evolution, prognosis), but it is better to avoid the The patients may ask you questions related to their disease (explorations, evolution, prognosis), but it is better to avoid the answer in an elegant manner (Ex. “answer in an elegant manner (Ex. “You should ask the doctor attending you); You should ask the doctor attending you); -Do not discuss the disease of a patient in his presence, especially when it is very serious (cancer), unless the group assistant Do not discuss the disease of a patient in his presence, especially when it is very serious (cancer), unless the group assistant is present as moderator;is present as moderator;-Do not refuse the patients who require a qualified maneuver (pulse, taking the blood pressure);Do not refuse the patients who require a qualified maneuver (pulse, taking the blood pressure);-It is prohibited the immixture in the therapeutic scheme or comments related to the presence of the respective patient, if the It is prohibited the immixture in the therapeutic scheme or comments related to the presence of the respective patient, if the group assistant is not present;group assistant is not present;-Address the patients using the name “DumneavoastrAddress the patients using the name “Dumneavoastrăă” (You) (it is prohibited to use names such as “” (You) (it is prohibited to use names such as “mamaie”mamaie” (granny) (granny), , „tataie”„tataie”(grandpa)(grandpa), „moşule”, „moşule”(old man)(old man) etc etc..

Recommendations related to the medical personnel Recommendations related to the medical personnel -Besides the group assistant and the other doctors you will come into contact with, in the respective theatre you will also Besides the group assistant and the other doctors you will come into contact with, in the respective theatre you will also interact with the medical personnel (registered nurses) and the auxiliary personnel (nurses).interact with the medical personnel (registered nurses) and the auxiliary personnel (nurses).-The registered nurses from the surgery service are overqualified and are very experienced in attending the patients, The registered nurses from the surgery service are overqualified and are very experienced in attending the patients, experience that a part of you will not acquire very soon. Respect them to be respected. Moreover, they can answer very many experience that a part of you will not acquire very soon. Respect them to be respected. Moreover, they can answer very many questions regarding the caring of the surgical patient, especially during the shifts when the teacher is more preoccupied with questions regarding the caring of the surgical patient, especially during the shifts when the teacher is more preoccupied with the medical problems specific to the emergency service. You have the chance that, by modestly approaching a nurse, to make the medical problems specific to the emergency service. You have the chance that, by modestly approaching a nurse, to make more maneuvers from the III year schedule (injections, enemas, perfusion mounting, transfusions etc.) than other colleagues. A more maneuvers from the III year schedule (injections, enemas, perfusion mounting, transfusions etc.) than other colleagues. A maneuver that you carried out by yourself is never forgotten. maneuver that you carried out by yourself is never forgotten. -And in the end, remember that a fully-trained physician must know anytime to do the work of the registered nurse. Maybe in And in the end, remember that a fully-trained physician must know anytime to do the work of the registered nurse. Maybe in the future you will have to guide the first steps of a recently graduated nurse. the future you will have to guide the first steps of a recently graduated nurse.

BACK

ORGANIZING ORGANIZING THE SURGICAL SERVICETHE SURGICAL SERVICE

General organizationGeneral organization Clinic I - II SurgeryClinic I - II Surgery–– “ “Sf. Sf. Spiridon”Spiridon” Hospital Hospital Iaşi Iaşi

CONTENTS

GENERAL ORGANIZATIONGENERAL ORGANIZATION

The ambulatoryThe ambulatory The in-patient unitThe in-patient unit The operating theatre The operating theatre The sterilizing unit The sterilizing unit

BACK

THE AMBULATORYTHE AMBULATORYIt is an integrating part of each service, ensuring the medical care without the patient's It is an integrating part of each service, ensuring the medical care without the patient's hospitalization.hospitalization.At this level the medical specialty examination is performed, the diagnosis is established At this level the medical specialty examination is performed, the diagnosis is established (including by paraclinical explorations), the appropriate therapy is indicated and applied (including by paraclinical explorations), the appropriate therapy is indicated and applied *in simple cases), and in the most difficult cases the hospitalization is programmed and *in simple cases), and in the most difficult cases the hospitalization is programmed and even the surgical intervention, afterwards this service taking over the post-operatory even the surgical intervention, afterwards this service taking over the post-operatory directly observed therapy of patients.directly observed therapy of patients.The ambulatory must be organized in such a manner as to cover all these activities, The ambulatory must be organized in such a manner as to cover all these activities, therefore it must comprise: the examination room, the room of small interventions and a therefore it must comprise: the examination room, the room of small interventions and a registration-archive. registration-archive.

The examination room The examination room must be equipped with a couch, a gynecological table, a source must be equipped with a couch, a gynecological table, a source of light, a carriage for the medical equipment , sanitary materials and cupboards for them.of light, a carriage for the medical equipment , sanitary materials and cupboards for them.The operating room The operating room from the ambulatory must have the same equipment with that of from the ambulatory must have the same equipment with that of the operating theatre (operating table, scialitic lamp, instrument table, anesthesia the operating theatre (operating table, scialitic lamp, instrument table, anesthesia apparatus, medical Aspirator, electrical bistoury) and to accomplish the same architectural apparatus, medical Aspirator, electrical bistoury) and to accomplish the same architectural conditions, of heating, illumination and ventilation as the latter.conditions, of heating, illumination and ventilation as the latter.The Archive must comprise the medical documents of each patient who was examined, The Archive must comprise the medical documents of each patient who was examined, investigated and tested at the ambulatory level, for a correct directly observed therapy investigated and tested at the ambulatory level, for a correct directly observed therapy even if the medical file of each patient is archived by the family physicianeven if the medical file of each patient is archived by the family physicianThe doctors who work in the ambulatory should also work in the in-patient unit. They The doctors who work in the ambulatory should also work in the in-patient unit. They would have a program in the in-patient unit and a periodical one in the ambulatory. Thus, would have a program in the in-patient unit and a periodical one in the ambulatory. Thus, they can examine their patients, establish the diagnosis, schedule for hospitalization and they can examine their patients, establish the diagnosis, schedule for hospitalization and surgery and send to directly-observed therapy after surgery.surgery and send to directly-observed therapy after surgery.

BACK

THE IN-PATIENT UNITTHE IN-PATIENT UNITIn all the classical manuals, the patient rooms are described from the point of In all the classical manuals, the patient rooms are described from the point of view of architectonic and equipment characteristics.view of architectonic and equipment characteristics.We must mention that, although this data remains valid, we must respect We must mention that, although this data remains valid, we must respect other principles as well, and namely those regarding the comfort and privacy other principles as well, and namely those regarding the comfort and privacy of the patient. Thus, the rooms of 1-2 beds are preferable, and in the case of of the patient. Thus, the rooms of 1-2 beds are preferable, and in the case of large rooms, their boxing. The rooms will be equipped, besides the bed, with large rooms, their boxing. The rooms will be equipped, besides the bed, with bed table, table and chair, installations for the “medical fluids: and other bed table, table and chair, installations for the “medical fluids: and other facilities (bathroom, telephone, radio, television). facilities (bathroom, telephone, radio, television). In these conditions, the existence of dining halls, or bandage rooms is no In these conditions, the existence of dining halls, or bandage rooms is no longer necessary. These, especially the bandage rooms are necessary for longer necessary. These, especially the bandage rooms are necessary for carrying out some intervention maneuvers or particular explorations. carrying out some intervention maneuvers or particular explorations. Reducing the number of stationary beds can be compensated by their rational Reducing the number of stationary beds can be compensated by their rational use and the fast flow of patients.use and the fast flow of patients.For the good collaboration of the two sectors of the surgical service – the For the good collaboration of the two sectors of the surgical service – the ambulatory and the in-patient unit- they must have the same superior medical ambulatory and the in-patient unit- they must have the same superior medical personnel. personnel. The in-patient unit must be seen as an accommodation space (hotel) of high The in-patient unit must be seen as an accommodation space (hotel) of high quality, where the patients must benefit from the best conditions. quality, where the patients must benefit from the best conditions.

BACK

THE OPERATING THEATRE THE OPERATING THEATRE Particular element in the surgical service, the operating theatre must be organized and equipped to correspond to the principles of asepsis and antisepsis, complexity and efficiency of the activities that are carried out at this level. The operating theatre supposes a complex organization and functionality which allow the carryout of the most diverse and complex surgical interventions, with the maximum safety and efficacy. According to the number of operating theatres, multiple plans of construction of the operating theatres are described. It must comprise rooms with special destination: operating rooms, rooms for waking up the doctors, filter room, room for inducing the anesthesia and waking up the patients, room for depositing the instruments and sterile and used materials; they must have special illumination, ventilation installations, and “medical flows”; circuits for the evacuation of the used sanitary materials (waste) and means of communication. At the level of the operating theatre, the access is limited and restrictive in order to reduce to the minimum the contamination risks.

THE OPERATING THEATRETHE OPERATING THEATRE

The filter room The surgery preparation room The operating room The induction and wakeup room The room for preparing the surgical i

nstruments Depositing rooms

BACK TO GENERAL

ORGANIZATION Click with the mouse over the underlined titles

The filter roomThe filter room

It is the first room in the medical It is the first room in the medical personnel circuit where they dress up personnel circuit where they dress up in special clothes, for the operating in special clothes, for the operating theatre. It may have the role of rest theatre. It may have the role of rest room between the surgeries. room between the surgeries.

The doctors preparation roomThe doctors preparation room

It is provided with multiple sinks with It is provided with multiple sinks with special taps that allow the use without special taps that allow the use without manual touch. For touching the hands manual touch. For touching the hands antiseptics are used (soap, betadine, antiseptics are used (soap, betadine, chlorhexidin). Then, in the same room chlorhexidin). Then, in the same room or in another one, the next step is or in another one, the next step is putting on the gown and the sterile putting on the gown and the sterile gloves. In particular situations gloves. In particular situations (transplant surgery, osteo-articular (transplant surgery, osteo-articular surgery etc.) special equipment is used. surgery etc.) special equipment is used.

The operating roomThe operating room Architectural conditions: insulation, dimensions, construction materials, illumination installations, ventilation, heating and Architectural conditions: insulation, dimensions, construction materials, illumination installations, ventilation, heating and

communication equipment, circuits of the personnel and patients, possibilities of cleaning and maintenance;communication equipment, circuits of the personnel and patients, possibilities of cleaning and maintenance; Equipped with furniture and devices: operating table, surgical lamps, anesthetics and monitoring apparatuses, tables for Equipped with furniture and devices: operating table, surgical lamps, anesthetics and monitoring apparatuses, tables for

instruments; Aspirator, electrical bistoury, cupboards/shelves for instruments sanitary materials and anesthetics; instruments; Aspirator, electrical bistoury, cupboards/shelves for instruments sanitary materials and anesthetics; The operating room must not communicate directly with the exterior, it must have dimensions so that to allow the placement of the The operating room must not communicate directly with the exterior, it must have dimensions so that to allow the placement of the

furniture, apparatus, and of the presence of the operating team, anesthetic doctors and afferent medical personnel;furniture, apparatus, and of the presence of the operating team, anesthetic doctors and afferent medical personnel; The presence of other persons in the operating room is prohibited. The interested persons (residents, students) can watch the The presence of other persons in the operating room is prohibited. The interested persons (residents, students) can watch the

operatory act from a special balcony or through a television system with closed circuit;operatory act from a special balcony or through a television system with closed circuit; The construction materials used for the operating room (as of the entire operating theatre) must allow a cleaning and disinfection as The construction materials used for the operating room (as of the entire operating theatre) must allow a cleaning and disinfection as

easy and correct as possible;easy and correct as possible; The artificial illuminating installation will support the lack of natural light.The artificial illuminating installation will support the lack of natural light. The artificial heating and ventilation will be achieved through air conditioning system that ensure temperatures of 20-22The artificial heating and ventilation will be achieved through air conditioning system that ensure temperatures of 20-22°°C and a C and a

humidity of 40-60 % , thus preventing the contamination of the air from the operating room.humidity of 40-60 % , thus preventing the contamination of the air from the operating room. The communications between the different departments of the operating theatre and with the exterior are ensured by phone, The communications between the different departments of the operating theatre and with the exterior are ensured by phone,

interphone and different signaling systems.interphone and different signaling systems. The cleaning and disinfection of the operating room must be achieved daily and in accordance with the asepsis and antisepsis rules The cleaning and disinfection of the operating room must be achieved daily and in accordance with the asepsis and antisepsis rules

provided in the operating theatre documents,provided in the operating theatre documents, The access and evacuation circuits in the operating theatre and in the operating room are different for the patients and the medical The access and evacuation circuits in the operating theatre and in the operating room are different for the patients and the medical

personnel. They must be strictly respected. Thus, in the operating room, only the operative team already trained, the personnel of personnel. They must be strictly respected. Thus, in the operating room, only the operative team already trained, the personnel of the room (one-two registered nurses and a nurse), the anesthetic team must be present.the room (one-two registered nurses and a nurse), the anesthetic team must be present.

The patient is brought into the operating room after having been put to sleep in the induction room.The patient is brought into the operating room after having been put to sleep in the induction room. The surgical instruments, the medical and anesthetic materials are prepared in the operating room or in its proximity, easily The surgical instruments, the medical and anesthetic materials are prepared in the operating room or in its proximity, easily

accessible. After use, they will follow a separated circuit towards the sterilization unit or towards the crematory. accessible. After use, they will follow a separated circuit towards the sterilization unit or towards the crematory. Out of prudence, the medical materials offered to the operating team and the used ones will be registered.Out of prudence, the medical materials offered to the operating team and the used ones will be registered. The operating table is special, multi-articulate, allowing different positions of the patient according to the necessities of the operating The operating table is special, multi-articulate, allowing different positions of the patient according to the necessities of the operating

act. act. Due to some accessories, it facilitates the operating gestures. It must allow the carryout of some intraoperative radiological Due to some accessories, it facilitates the operating gestures. It must allow the carryout of some intraoperative radiological

explorations.explorations. The table of instruments allows the preparation and display of the instruments necessary for the operating act.The table of instruments allows the preparation and display of the instruments necessary for the operating act. The source of light (scialitic lamps, lights) of different models must ensure a good light in the operating field and be easy to operate The source of light (scialitic lamps, lights) of different models must ensure a good light in the operating field and be easy to operate

according to the necessities of the surgical act.according to the necessities of the surgical act. The anesthesia apparatus and the monitors will ensure the anesthesia and the monitoring of the vital functional parameters of the The anesthesia apparatus and the monitors will ensure the anesthesia and the monitoring of the vital functional parameters of the

patient during the anesthesia and for resuscitation gestures,patient during the anesthesia and for resuscitation gestures, For the operatory gestures, the aspiration apparatuses and electrical bistoury are necessary.For the operatory gestures, the aspiration apparatuses and electrical bistoury are necessary. The modern operating rooms ensure, through centralized installations, both the oxygen admission and aspiration. The modern operating rooms ensure, through centralized installations, both the oxygen admission and aspiration.

The induction and wakeup roomThe induction and wakeup room

It is the first room in the patient’s circuit, where It is the first room in the patient’s circuit, where they are administered the anesthetic induction they are administered the anesthetic induction (and then they are transported into the (and then they are transported into the operating room), and when there is no separate operating room), and when there is no separate room, they are woken up through anesthesia. room, they are woken up through anesthesia. For these, the room is equipped with a special For these, the room is equipped with a special bed for intensive care, anesthesia apparatus bed for intensive care, anesthesia apparatus and “medical flows”. In the modern hospitals, and “medical flows”. In the modern hospitals, the patient is taken from the room to his bed the patient is taken from the room to his bed (provided with wheels) and transported with (provided with wheels) and transported with this bed to the induction room. this bed to the induction room.

The room for the preparation of surgical equipment It is equipped with sinks or lavatories It is equipped with sinks or lavatories

for the mechanical and chemical for the mechanical and chemical cleaning of the equipment, with cleaning of the equipment, with boilers for them, with tables and boilers for them, with tables and shelves for the boxes of medical shelves for the boxes of medical equipment. equipment.

The depositing rooms The depositing rooms

They are destined for the surgical They are destined for the surgical equipment and the reserve medical equipment and the reserve medical materials necessary for the surgical materials necessary for the surgical interventions. interventions.

THE STERILIZING UNITTHE STERILIZING UNIT

Absolutely compulsory, even in the current conditions when more and Absolutely compulsory, even in the current conditions when more and more disposable equipment and medical materials are used, this more disposable equipment and medical materials are used, this component of the medical service can exist whether as an independent component of the medical service can exist whether as an independent unit within the hospital, or as a component of the operating theatre.unit within the hospital, or as a component of the operating theatre.It must comprise rooms for the preparation of medical materials and It must comprise rooms for the preparation of medical materials and equipment for sterilization (if they do not exist in the operating theatre); equipment for sterilization (if they do not exist in the operating theatre); rooms with sterilizing apparatus (autoclaves, drying chambers, rooms with sterilizing apparatus (autoclaves, drying chambers, installation of vapor production) and rooms (with cupboards and shelves) installation of vapor production) and rooms (with cupboards and shelves) for depositing the sterile equipment and materials.for depositing the sterile equipment and materials.Such a sterilizing unit must have a reception for the receipt and issuance Such a sterilizing unit must have a reception for the receipt and issuance of sterile materials, so that the access into the unit space is allowed only of sterile materials, so that the access into the unit space is allowed only for the persons who work at this level.for the persons who work at this level.The constructive characteristics (construction materials and especially The constructive characteristics (construction materials and especially finishing materials) and the equipment must be identical with those from finishing materials) and the equipment must be identical with those from the operating theatre. the operating theatre.

BACK

DEFINITIONDEFINITION A general principle that consists in the systematic avoiding A general principle that consists in the systematic avoiding

of the contamination of surgical wounds and secondary of the contamination of surgical wounds and secondary infection of burns and woundsinfection of burns and wounds

It includes methods and rules that prevent the wound It includes methods and rules that prevent the wound contamination and infectioncontamination and infection

These rules and methods address all the possible vectors of These rules and methods address all the possible vectors of the microbial germs to the surgery wounds, equipment, the microbial germs to the surgery wounds, equipment, textile materials, hands, clothes, syringes, probes, textile materials, hands, clothes, syringes, probes, medicines, air from the operating room etc.)medicines, air from the operating room etc.)

Methods : Methods : sterilization, disinfection of live tissues The rules generally refer to the behavior of the personnel generally refer to the behavior of the personnel

that handles the sterile materials: surgeons, registered that handles the sterile materials: surgeons, registered nurses from the operating theatre or bandage rooms, the nurses from the operating theatre or bandage rooms, the students involved in the therapeutic act or just the students involved in the therapeutic act or just the watchers.watchers.

CONTENTS CLICK WITH THE MOUSE ON THE UNDERLINED WORDS

STERILIZATIONSTERILIZATIONDEFINIDEFINITIONTION

The totality of methods through The totality of methods through which the complete and total which the complete and total destruction of microbial particles, destruction of microbial particles, both of the stagnant forms and of the both of the stagnant forms and of the sporulated ones is achieved sporulated ones is achieved

It can be achieved through It can be achieved through physical physical and chemical means and chemical means

CLICK WITH THE MOUSE ON THE UNDERLINED WORDS

STERILIZASTERILIZATIONTIONPHYSICAL MEANS PHYSICAL MEANS

HEATHEAT ULTRAVIOLET RADIATIONSULTRAVIOLET RADIATIONS IONIZING RADIATIONSIONIZING RADIATIONS UULTRASOUNDS LTRASOUNDS FILTRATION FILTRATION

BACK

STERILIZATION THROUGH HEAT STERILIZATION THROUGH HEAT

STERILIZATION THROUGH STERILIZATION THROUGH DRY HEATDRY HEAT

STERILIZATION THROUGH STERILIZATION THROUGH HUMID HEAT HUMID HEAT

BACK

STERILIZATION THROUGH STERILIZATION THROUGH DRY HEAT DRY HEAT

BUCKLING INCINERATION HOT AIR OVEN

CLICK WITH THE MOUSE ON EACH TITLE

BUCKLINGBUCKLING

The passage through flame of the metallic The passage through flame of the metallic or glass objects in view of sterilizing themor glass objects in view of sterilizing them

Sterilizing the phials before aspirating Sterilizing the phials before aspirating their contents into the syringe, test tubes, their contents into the syringe, test tubes, metallic handles (microbiology) metallic handles (microbiology)

Disadvantage – the fast degradation of Disadvantage – the fast degradation of metallic instruments, especially the metallic instruments, especially the cutting onescutting ones

INCINERAINCINERATIONTION

The complete destruction by burning The complete destruction by burning of the waste with biological riskof the waste with biological risk

It is applied in the crematories found It is applied in the crematories found in all the hospitals in all the hospitals

THE HOT AIR STOVETHE HOT AIR STOVE

Device Sterilization parameters Check Indications Advantages Disadvantages


THE HOT AIR STOVETHE HOT AIR STOVEDEVICEDEVICE

SSynonymynonym: Poupinel (improp: Poupinel (improperer)) Conceived as a metallic cupboard with double Conceived as a metallic cupboard with double

walls and thermally insulated from the exterior walls and thermally insulated from the exterior The door is provided with safety systems that The door is provided with safety systems that

do not allow the building-up of the electrical do not allow the building-up of the electrical circuits when it is open circuits when it is open

Components: source of heat (electrical), safety Components: source of heat (electrical), safety systems, thermometer, recorders (show how systems, thermometer, recorders (show how much time the sterilizing temperature was much time the sterilizing temperature was maintained), system of temperature maintained), system of temperature uniformization in the precincts uniformization in the precincts

PHOTO

THE HOT AIR STOVETHE HOT AIR STOVESTERILIZATION PARAMETERS STERILIZATION PARAMETERS

160160°° C C for for 1h1h 170 170 °° C C for for 40’40’ 180 180 °° C C for for 20’20’ In our countryIn our country: 180 : 180 °°C C for for 30’-40’30’-40’

THE HOT AIR STOVETHE HOT AIR STOVECHECKING THE STERILIZATION CHECKING THE STERILIZATION

Classical thermal tests: caramelizing Classical thermal tests: caramelizing of paper or cotton cellulose of paper or cotton cellulose

Modern: Modern: thermocouples with thermocouples with temperature recording temperature recording

THE HOT AIR STOVETHE HOT AIR STOVEINDICATIONS INDICATIONS

Objects of thermo-resistant glassObjects of thermo-resistant glass Metallic instruments (the cutting Metallic instruments (the cutting

instruments must have a protected instruments must have a protected cut)cut)

PowdersPowders

THE HOT AIR STOVETHE HOT AIR STOVEADVANTAGES ADVANTAGES

Dried instruments at the end of the Dried instruments at the end of the sterilizationsterilization

The instruments are in boxes or The instruments are in boxes or other closed packagesother closed packages

They do not require other handling They do not require other handling before usebefore use

THE HOT AIR STOVETHE HOT AIR STOVEDISADVANTAGES DISADVANTAGES

The long sterilization duration The long sterilization duration Long cooling time before use Long cooling time before use

((aboutabout 1 1 hour)hour) Cannot be used for textile, plastic, Cannot be used for textile, plastic,

rubber materialsrubber materials It modifies the properties of the metallic It modifies the properties of the metallic

instruments (annealing) and favors its fast instruments (annealing) and favors its fast degradation (corrosion, breakage) degradation (corrosion, breakage)

THE AMBULATORY OF THE AMBULATORY OF “SF. SPIRIDON”“SF. SPIRIDON” hospital hospital

The emergency unit of The emergency unit of “SF. SPIRIDON”“SF. SPIRIDON” Hospital Hospital

The in-patient unit of The in-patient unit of CLINIC I – II SURGERY CLINIC I – II SURGERY

Anesthesia and Intensive Care Anesthesia and Intensive Care SECSECTIONTION

OPERATING THEATRE OPERATING THEATRE

FILTER ROOM

OPERATING ROOMOPERATING ROOMScialitic lamp

Cautery

Medical flows inlets (Aspirator, oxygen, electricity)

Ultraviolet lamp

Anesthesia apparatus

Aspirator Operating tableAspirator

Operating room Operating room OTHER EQUIPMENTS OTHER EQUIPMENTS

Apparatus for intraoperatory radiological examination For the minimally invasive surgery

“Turn” Table for instruments

THE STERILIZATION THE STERILIZATION THROUGH HUMID HEAT THROUGH HUMID HEAT

It is the most efficient sterilization It is the most efficient sterilization methodmethod

The first form of sterilization through The first form of sterilization through humid heat was boiling, but it does not humid heat was boiling, but it does not create sufficiently high temperatures in create sufficiently high temperatures in order to destroy the bacteria spores order to destroy the bacteria spores

The AUTOCLAVE= the device through The AUTOCLAVE= the device through which the sterilization through humid which the sterilization through humid heat is made, by obtaining sufficiently heat is made, by obtaining sufficiently high temperatures and pressures that high temperatures and pressures that destroy all the pathogen agents destroy all the pathogen agents

THE THE AUTOCLAVAUTOCLAVEE

Device Sterilization parameters Check Indications Advantages Disadvantages

CLICK WITH THE MOUSE ON EACH TITLEBACK

THE AUTOCLAVE THE AUTOCLAVE DEVICE DEVICE

With the help of a vacuum air pump, the air from the autoclave is With the help of a vacuum air pump, the air from the autoclave is evacuated, which is resistant to pressure and is closed air-proof evacuated, which is resistant to pressure and is closed air-proof achieving an thermal insulation from the environmentachieving an thermal insulation from the environment

Through an admission pump, water vapors are introduced under Through an admission pump, water vapors are introduced under pressure, which will lift to the surface allowing the evacuation in pressure, which will lift to the surface allowing the evacuation in successive stages of the air that descends in the inferior part of successive stages of the air that descends in the inferior part of the autoclavethe autoclave

After obtaining the vacuum, the vapor admission is continued After obtaining the vacuum, the vapor admission is continued until the obtaining od the set sterilizing parametersuntil the obtaining od the set sterilizing parameters

The time, pressure and temperature of sterilization are variable The time, pressure and temperature of sterilization are variable according to the type of the autoclave and the sterilized materials according to the type of the autoclave and the sterilized materials (quantity, quality and their dimensions) (quantity, quality and their dimensions)

At the end of the sterilization, the vacuum air pump will evacuate At the end of the sterilization, the vacuum air pump will evacuate the water vapors from the autoclave, introducing a jet of filtered the water vapors from the autoclave, introducing a jet of filtered cold air, with role of drying the sterilized material cold air, with role of drying the sterilized material

Entry into the sterilization On the right door the non-sterile materials are introducedThrough the left door, the sterile materials are issued

The carriage for introducing and removing the materials

from the autoclave

Shelf for depositing the boxes with medical materials

The Autoclave

Regulation buttons of temperature and pressure

Recording on the paper the date, hour and sterilization parameters

AUTOCLAVE

Removing the material from the autoclave after sterilization

Depositing the sterile material Depositing the sterile material

TH TH AUTOCLAVAUTOCLAVEESTERILIZATION PARAMETERSSTERILIZATION PARAMETERS

24 hours validity 24 hours validity

PressurePressure temperaturetemperature

1 atm1 atm 120120°°CC

2 atm2 atm 136136°°CC

3 atm3 atm 144144°°CC

THE AUTOCLAVETHE AUTOCLAVECHECKCHECK

Physical methods: test band Physical methods: test band Biological tests Biological tests Electrotechnical methods: recording Electrotechnical methods: recording

on thermocouples the temperature on thermocouples the temperature variation for the sterilization duration variation for the sterilization duration

Tests for checking Tests for checking the sterilization the sterilization

THE AUTOCLAVETHE AUTOCLAVEINDICATIONS INDICATIONS

Textile material Textile material ((fields, masks, fields, masks, gowns, compresses, tampons, suture gowns, compresses, tampons, suture yarns, etc.)yarns, etc.)

Thermoresistant glass objectsThermoresistant glass objects Metallic instruments (the cutting Metallic instruments (the cutting

instruments must have the cut instruments must have the cut protected with smooth material)protected with smooth material)

Sterile medicinesSterile medicines Sterile water Sterile water

THE AUTOCLAVETHE AUTOCLAVEADVANTAGES ADVANTAGES

It allows the sterilization of the entire It allows the sterilization of the entire surgical materialsurgical material

The reduced degradation of the smooth The reduced degradation of the smooth sterilized materialssterilized materials

Reduced sterilization timeReduced sterilization time The material resulted from sterilization is The material resulted from sterilization is

dry and pre-packed therefore easy to dry and pre-packed therefore easy to handlehandle

Reduced costsReduced costs Contains the source of vapors as wellContains the source of vapors as well Does not require special installation Does not require special installation

conditionsconditions

THE AUTOCLAVETHE AUTOCLAVEDISADVANTAGESDISADVANTAGES

Technical breakdownsTechnical breakdowns Rapid degradation of the corrosive Rapid degradation of the corrosive

metallic instrumentsmetallic instruments

THE STERILIZATION WITH THE STERILIZATION WITH ULTRAVIOLET RADIATIONSULTRAVIOLET RADIATIONS

These radiations act at the level of nucleic These radiations act at the level of nucleic acids = bactericide and bacteriostatic acids = bactericide and bacteriostatic effect effect

It is necessary to previously wash the It is necessary to previously wash the surfaces to sterilize (the UV radiations surfaces to sterilize (the UV radiations have small penetration power)have small penetration power)

Indications: the sterilization of the air from Indications: the sterilization of the air from the operating and bandage rooms, the the operating and bandage rooms, the sterilization of work surfacessterilization of work surfaces

ATTENTION: They are harmful for the ATTENTION: They are harmful for the people people

Protection of teguments and eyes Protection of teguments and eyes

SSTERILIZATION THROUGH TERILIZATION THROUGH IONIZING RADIATIONS (GAMMA)IONIZING RADIATIONS (GAMMA)

DEVICEDEVICE: container: container with pre-packed material on with pre-packed material on which a radiation of 2.5 up to 5 Mrad which a radiation of 2.5 up to 5 Mrad (Ce(Cellsius sius 137 137 oror Cobalt 60) Cobalt 60) is projected is projected

CHECK CHECK : : measuring the radiation level measuring the radiation level INDICAINDICATIONSTIONS: : any medical material any medical material AADVANTAGESDVANTAGES: : large quantities of pre-packed large quantities of pre-packed

material is sterilized, reduced costs under material is sterilized, reduced costs under continuous functioning conditionscontinuous functioning conditions

DDisadvantagesisadvantages: : the irradiation, formation the irradiation, formation of toxic compounds with ethylenoxide of toxic compounds with ethylenoxide

Used only in the industrial environment Used only in the industrial environment

THE ULTRASOUND STERILIZATIONTHE ULTRASOUND STERILIZATION

The high-frequency ultrasounds The high-frequency ultrasounds in liquid medium in liquid medium cavitation cavitation phenomenon phenomenon mechanical rupture mechanical rupture of the cellular membrane of the cellular membrane of microorganisms of microorganisms

IndicaIndications: especially for the tions: especially for the sterilization of the dental equipment sterilization of the dental equipment

STERILIZATION THROUGH FILTRATION STERILIZATION THROUGH FILTRATION

IIn n bacteriology, for the sterilization of bacteriology, for the sterilization of culture mediumsculture mediums

The sterilization of some medicinesThe sterilization of some medicines The sterilization of the air from the The sterilization of the air from the

operating rooms operating rooms

THE STERILIZATIONTHE STERILIZATIONCHEMICAL MEANS CHEMICAL MEANS

THE STERILIZATION WITH FORMALDEHYDE VAPORS

THE STERILIZATION WITH ETHYLENOXIDE VAPORS THE STERILIZATION BY IMMERSION

THE STERILIZATION WITH THE STERILIZATION WITH FORMALDELHYDE VAPORS FORMALDELHYDE VAPORS

DDEVICEEVICE: : special container where a depression of special container where a depression of 50 50 mmHg mmHg is achieved for 10 minutes which evacuates the is achieved for 10 minutes which evacuates the air, followed by the introduction of water vapors at air, followed by the introduction of water vapors at 9090°°C C vegetative bacteria. Cyclically, at 90 seconds, formaline vegetative bacteria. Cyclically, at 90 seconds, formaline vapors are introduced, that destroy the sporulated forms.vapors are introduced, that destroy the sporulated forms.

STERILIZATION PARAMETERS:STERILIZATION PARAMETERS:• Sterilization, 90 minutesSterilization, 90 minutes• Washing stage of the formaldehyde with cold water Washing stage of the formaldehyde with cold water

vapors, 12 minutesvapors, 12 minutes• Drying stage, 8 minutes Drying stage, 8 minutes

CHECKCHECK: : biological, physical testsbiological, physical tests INDICAINDICATIONSTIONS: : thermosensitive materials (more and more thermosensitive materials (more and more

rarely used)rarely used)

THE STERILIZATION WITH THE STERILIZATION WITH ETHYLENOXIDE VAPORSETHYLENOXIDE VAPORS

Device Check Indications Advantages Disadvantages


DEVICEDEVICE The ethylenoxide requires depositing in metallic containers The ethylenoxide requires depositing in metallic containers

at small pressure because it boils at the temperature of at small pressure because it boils at the temperature of 10.710.7°°CC

It is used in the following combinations It is used in the following combinations : 10% et: 10% ethyhylenoxidlenoxidee + 90% + 90% carbon dioxide or carbon dioxide or 12% et12% ethyhylenoxidlenoxidee + 88% + 88% fluorocarbonfluorocarbon

The container is hermetically closed, the ethylenoxide The container is hermetically closed, the ethylenoxide vapors or the gas mixture are introduced, the substances vapors or the gas mixture are introduced, the substances having a variable action time according to the producer having a variable action time according to the producer (10 minutes up to a few hours). The ventilation of the room (10 minutes up to a few hours). The ventilation of the room where the sterilizer is found follows, for 15 minutes and where the sterilizer is found follows, for 15 minutes and afterwards the depositing of sterilized materials in a afterwards the depositing of sterilized materials in a container that allows their ventilation for 3-6 hours.container that allows their ventilation for 3-6 hours.

The ethylenoxide is combined with the nucleoid acids The ethylenoxide is combined with the nucleoid acids of bacteria, determining a denaturation of the proteins of bacteria, determining a denaturation of the proteins through an alkylation process that has as a result the through an alkylation process that has as a result the destruction of microbes destruction of microbes


CHECKCHECK

Chemical methods: Chemical methods: of torsion, of colorof torsion, of color

Biological methodsBiological methods


INDICATIONSINDICATIONS Plastic materialsPlastic materials Thermally fragile materials: Thermally fragile materials:

catheters, endoscopes, cystoscopes, catheters, endoscopes, cystoscopes, plastic tubes, aspiration probes, plastic tubes, aspiration probes, Blakemore probes, ophthalmological Blakemore probes, ophthalmological instruments, arterial graftsinstruments, arterial grafts

Wood, paperWood, paper The industrial or hospital use The industrial or hospital use


ADVANTAGESADVANTAGES It allows the sterilization and use It allows the sterilization and use

of some thermolabile medical of some thermolabile medical instruments and materials instruments and materials

The sterilized objects are pre-packed The sterilized objects are pre-packed


DISADVANTAGES DISADVANTAGES The gas is irritating for the eyes and the The gas is irritating for the eyes and the

respiratory ways producing cephalalgea, respiratory ways producing cephalalgea, nausea, vomiting, dizziness to those who nausea, vomiting, dizziness to those who come into direct contact (medical come into direct contact (medical personnel, patient)personnel, patient)

It requires a good ventilationIt requires a good ventilation The sterilized materials through gamma The sterilized materials through gamma

radiations cannot be resterilized through radiations cannot be resterilized through ethylenoxide vapors because of the ethylenoxide vapors because of the appearance of some toxic productsappearance of some toxic products

THE STERILIZATION THE STERILIZATION THROUGH IMMERSIONTHROUGH IMMERSION

Used in hospitals or dispensariesUsed in hospitals or dispensaries DDEVICEEVICE: : the instruments are immersed for a minimum period of the instruments are immersed for a minimum period of

time into the substances that have the property to destroy the time into the substances that have the property to destroy the microbes chemicallymicrobes chemically

The Glutaraldehyde 2%: in 10-15 minutes it destroys the The Glutaraldehyde 2%: in 10-15 minutes it destroys the vegetative forms of the bacteria and their spores after 10 hours vegetative forms of the bacteria and their spores after 10 hours (the tuberculosis bacilli in 20 minutes)(the tuberculosis bacilli in 20 minutes)

The peracetic acid: action time of minimum 10 minutes, it is The peracetic acid: action time of minimum 10 minutes, it is corrosive for the coppercorrosive for the copper

INDICINDICATIONSATIONSII: : optical, laparoscopic, endoscopic instrumentsoptical, laparoscopic, endoscopic instruments ADVANTAGES ADVANTAGES

• Does not require special installationsDoes not require special installations• It is fast It is fast

DDISADVANTAGESISADVANTAGES::• THE RESULTED MATERIAL IS WET THE RESULTED MATERIAL IS WET • IT requires cleaning with sterile water, the glutaraldehyde IT requires cleaning with sterile water, the glutaraldehyde

being toxic and irritating being toxic and irritating

PHOTO

Container Container for the sterilization for the sterilization through immersionthrough immersion

THE DISINFECTION THE DISINFECTION OF LIVE TISSUES OF LIVE TISSUES

THE SURGEON’S HANDS THE PATIENT’S SKIN


THE DISINFECTION OF THE DISINFECTION OF LIVING TISSUES LIVING TISSUES

THE SURGEON’S HANDS THE SURGEON’S HANDS

The liquid soap, solution of chlorhexidine soap The liquid soap, solution of chlorhexidine soap or povidone iodine are usedor povidone iodine are used

Liquid soap: washing for 5 minutes up to the Liquid soap: washing for 5 minutes up to the superior third part of the forearm, the following superior third part of the forearm, the following 5 minutes up to the half of the forearm and 5 minutes up to the half of the forearm and other 5 minutes only the surgeon’s handsother 5 minutes only the surgeon’s hands

Soap with chlorhexidine or povidone iodine: Soap with chlorhexidine or povidone iodine: the same stages each lasting only 2-3 minutesthe same stages each lasting only 2-3 minutes

The immersion of the surgeon’s hands into the The immersion of the surgeon’s hands into the germicide solution for a few minutes (some germicide solution for a few minutes (some countries)countries)

In the end the embrocation of hands with In the end the embrocation of hands with concentrated alcohol or iodine tincture concentrated alcohol or iodine tincture

THE DISINFECTION THE DISINFECTION OF LIVING TISSUES OF LIVING TISSUES

SURGEON’S HANDSSURGEON’S HANDS

Antiseptic solution

The sponge with antiseptic substance

Taps with sterile Taps with sterile water for water for

disinfecting the disinfecting the surgeon’s hands surgeon’s hands

Sandglass

THE DISINFECTION OF THE DISINFECTION OF LIVING TISSUESLIVING TISSUES

THE PATIENT’S SKIN THE PATIENT’S SKIN

The area subject to the incision and broadly, the The area subject to the incision and broadly, the teguments around it, will be preparedteguments around it, will be prepared

Solution: iodine tincture, povidone iodine, Solution: iodine tincture, povidone iodine, chlorhexidine chlorhexidine

The three times embrocation of the surgical The three times embrocation of the surgical drapes, the first 2 stages being followed by drapes, the first 2 stages being followed by drying with sterile compresses and in the end drying with sterile compresses and in the end the drying of the tegument is expected, that the drying of the tegument is expected, that ensures a sufficient action timeensures a sufficient action time

The transparent self-adhesive drapes applied on The transparent self-adhesive drapes applied on the skin prepared as mentioned previously, the skin prepared as mentioned previously, the incision being made through the drape, the incision being made through the drape, increasing the asepsis safetyincreasing the asepsis safety

VIDEO

STERILIZATION STERILIZATION RULESRULES

RULES FOR THE STERILIZATION OF THE OPERATING ROOM

RULES FOR THE PREPARATION OF THE STERILIZATION MATERIALS


RULES FOR THE RULES FOR THE STERILIZATION OF THE STERILIZATION OF THE

OPERATING ROOMOPERATING ROOM

PPreventing the post-operatory infectionsreventing the post-operatory infections requires the carryout of the surgical intervention requires the carryout of the surgical intervention

in an environment as appropriate as possible in an environment as appropriate as possible from the point of view of the asepsis from the point of view of the asepsis

In the operating theatre there must be septic and In the operating theatre there must be septic and aseptic operating rooms. Generally nowadays aseptic operating rooms. Generally nowadays there is a room for emergencies where the septic there is a room for emergencies where the septic surgical interventions are usually performed surgical interventions are usually performed

The sterilization of the operating room supposes: The sterilization of the operating room supposes: preparing the surfaces ((operating table, floor, operating table, floor, walls or ceiling) and walls or ceiling) and preparing the air


STERILIZING THE STERILIZING THE OPERATING ROOM OPERATING ROOM

PREPARING THE SURFACES PREPARING THE SURFACES

Washing the surfaces three times with water and Washing the surfaces three times with water and detergentsdetergents

Removing the dust from the equipment (cloths with Removing the dust from the equipment (cloths with antistatic properties will be used)antistatic properties will be used)

The hermetic closing of the roomThe hermetic closing of the room Formolization (formaldehyde vapors 4 g formalin/Formolization (formaldehyde vapors 4 g formalin/mm²²

susurfacerface) ) at least 7 hours at least 7 hours Ventilation 2 hours before the beginning of the surgical Ventilation 2 hours before the beginning of the surgical

program program Removing the dust Removing the dust Neutralizing the formalin with ammoniac solution Neutralizing the formalin with ammoniac solution The materials necessary for the surgeries will be brought The materials necessary for the surgeries will be brought

in the morning in the morning It is compulsory to respect the circuits in the operating It is compulsory to respect the circuits in the operating

theatre theatre

STERILIZING THE STERILIZING THE OPERATING ROOMOPERATING ROOM

PREPARING THE AIRPREPARING THE AIR The air must enter the room from the superior The air must enter the room from the superior

side and be evacuated through the inferior side and be evacuated through the inferior side. The admission inlet is in the center of side. The admission inlet is in the center of the room, above the table, without blowing the room, above the table, without blowing the air directly onto the patient. The the air directly onto the patient. The evacuation will be made through the lateral evacuation will be made through the lateral sidessides

The air circulated through the operating The air circulated through the operating rooms requires a special filtering process both rooms requires a special filtering process both at the entry and at the exit of the operating at the entry and at the exit of the operating room. There are high-performance room. There are high-performance apparatuses that can even obtain sterile airapparatuses that can even obtain sterile air

STERILIZING THE STERILIZING THE OPERATING ROOMOPERATING ROOM

PREPARING THE AIRPREPARING THE AIR

The ultraviolet lamp that will lead to a The ultraviolet lamp that will lead to a sterilization of the surfaces and air is also usedsterilization of the surfaces and air is also used

It is used outside the operating programIt is used outside the operating program It is placed at 150 cm from the walls and at 300 It is placed at 150 cm from the walls and at 300

cm in front of the other, facing the wallcm in front of the other, facing the wall The control of sterilization in the operating room The control of sterilization in the operating room

is made with bacteriological tests (Petri boxes is made with bacteriological tests (Petri boxes placed open for 30 minutes in the corners of the placed open for 30 minutes in the corners of the operating room after which we will monitor the operating room after which we will monitor the colonies that will grow, their type and number colonies that will grow, their type and number being related to a national standard being related to a national standard

PREPARING THE MATERIAL PREPARING THE MATERIAL FOR STERILIZATIONFOR STERILIZATION

THE TEXTILE MATERIAL THE METALLIC EQUIPMENT RUBBER GLOVES PLASTIC EQUIPMENT BRUSHES AND LOOFAHS



TEXTILE MATERIAL TEXTILE MATERIAL

WashingWashing IroningIroning Folding according to Folding according to

the standard the standard technique technique

Positioning into Positioning into metallic containers metallic containers or packed or packed individually in paperindividually in paper

Autoclaving Autoclaving


METALLIC EQUIPMENT METALLIC EQUIPMENT

Washing with hot waterWashing with hot water BoilingBoiling Diluted Perhydrol solution that Diluted Perhydrol solution that

precipitates the organic precipitates the organic materials from the equipment materials from the equipment surfacesurface

WashingWashing WipingWiping DryingDrying Dressing the sharp and cutting Dressing the sharp and cutting

materials into textile materialmaterials into textile material Positioning the equipment into Positioning the equipment into

metallic containersmetallic containers Autoclaving Autoclaving


RUBBER GLOVES RUBBER GLOVES Meticulous washingMeticulous washing DryingDrying Applying French chalk Applying French chalk Introducing gloves of textile materialIntroducing gloves of textile material into the interior into the interior Autoclaving or ethylenoxide vaporsAutoclaving or ethylenoxide vapors


PLASTIC OR RUBBER INSTRUMENTS PLASTIC OR RUBBER INSTRUMENTS

Washing with detergentsWashing with detergents Disinfectant Disinfectant It is packed in casseroles, It is packed in casseroles,

wire baskets or individually wire baskets or individually


BRUSHES AND LOOFHAS BRUSHES AND LOOFHAS

Used by the surgeon for disinfecting Used by the surgeon for disinfecting the hands the hands

They are cleaned, individually They are cleaned, individually packed and sterilized in metallic packed and sterilized in metallic boxes boxes

EVALUATING THE EVALUATING THE SURGICAL PATIENT SURGICAL PATIENT

Although the surgery, in itself, Although the surgery, in itself, can be “MINOR” for the surgical can be “MINOR” for the surgical

team, for the patient it is team, for the patient it is always “MAJOR”always “MAJOR”

EVALUATING EVALUATING THE SURGICAL PATIENT THE SURGICAL PATIENT

THE EMERGENCY SURGERY THE ELECTIVE - “COLD REASON ”

SURGERY THE ONE-DAY SURGERY THE PRE-OPERATORY EVALUATION

CLICK WITH THE MOUSE ON EACH TITLE CONTENTS

Surgical emergency

On-duty room

AIC

Continuing the resuscitation

StabilizationInvestigations

Preparation for surgery

Successful resuscitation

In-patient unit

InvestigationsPreparation for surgery

Operating room

Death Morgue

Cardiorespiratory resuscitation

EVALUATING THE SURGICAL EVALUATING THE SURGICAL PATIENTPATIENT

THE EMERGENCY SURGERY THE EMERGENCY SURGERY

EVALUATING EVALUATING THE SURGICAL PATIENTTHE SURGICAL PATIENT

ELECTIVE SURGERYELECTIVE SURGERYSurgical disorder

Usual investigations

Surgical and anestheological consultation

Hospitalization

Staff

Additional investigationsSpecific preparation

Staff

Operating room

EVALUATING EVALUATING THE SURGICAL PATIENTTHE SURGICAL PATIENT

THE ONE-DAY SURGERYTHE ONE-DAY SURGERY

MotivaMotivationtion::• Financial: the high cost of Financial: the high cost of

hospitalization, consume of expensive hospitalization, consume of expensive medical materialsmedical materials

• Personal: the patient’s desire to be in Personal: the patient’s desire to be in the family environment and not in the the family environment and not in the hospital, the socio-professional hospital, the socio-professional reintegration as soon as possiblereintegration as soon as possible

• Medical: patients with a good medical Medical: patients with a good medical education education

EVALUATING THE SURGICAL EVALUATING THE SURGICAL PATIENTPATIENT

THE ONE-DAY SURGERYTHE ONE-DAY SURGERY

Completely investigated patient

Hospitalization in the morning of the surgery

Local preparation

Premedication

Operating room

Post-operatory monitoring for a few hours

Hospital release In-house monitoring

PRE-OPERATORY PRE-OPERATORY EVALUATIONEVALUATION

Any hospitalized patient will have an Any hospitalized patient will have an observation sheet that needs to be completed after a complete clinical that needs to be completed after a complete clinical examinationexamination

Appropriate paraclinical explorations are necessary, Appropriate paraclinical explorations are necessary, corresponding to each case, the assessment of all the corresponding to each case, the assessment of all the associated disorders, establishing the anesthetic risk associated disorders, establishing the anesthetic risk and Choosing the therapeutic behavior (the operatory and Choosing the therapeutic behavior (the operatory moment, the type of anesthesia and the type of surgical moment, the type of anesthesia and the type of surgical intervention that the patient will be submitted to)intervention that the patient will be submitted to)

It would be very useful that the family doctor has a It would be very useful that the family doctor has a medical file for each patient, file that the attending medical file for each patient, file that the attending physician must have access to, at hospitalizationphysician must have access to, at hospitalization


THE PREOPERATORY THE PREOPERATORY EVALUATIONEVALUATION

OBSERVATION SHEETOBSERVATION SHEET

The Observation Sheet (OS) is a medical-legal document that The Observation Sheet (OS) is a medical-legal document that must reflect an image as exact and complete as possible of the must reflect an image as exact and complete as possible of the patient’s state at hospitalization, of his evolution during patient’s state at hospitalization, of his evolution during hospitalization, data as complete as possible that lead to the hospitalization, data as complete as possible that lead to the correct disease diagnosis. correct disease diagnosis.

According to the evolution mentioned in the observation sheet, According to the evolution mentioned in the observation sheet, the therapeutic indications will also be made, and the hospital the therapeutic indications will also be made, and the hospital release recommendations as wellrelease recommendations as well

The OS must offer exact data related to the patient’s The OS must offer exact data related to the patient’s identificationidentification

The OS represents a medical-legal document that can defend or The OS represents a medical-legal document that can defend or accuse the doctor in the case of a judicial confrontation with accuse the doctor in the case of a judicial confrontation with one of the patientsone of the patients

It is an useful document in the scientific research (retrospective It is an useful document in the scientific research (retrospective studies etc.)studies etc.)

Probably, in our country as well, there will be detailed file for Probably, in our country as well, there will be detailed file for each patient, with all the services that he goes through during each patient, with all the services that he goes through during his lifetime, these files having a much bigger scientific value, his lifetime, these files having a much bigger scientific value, allowing a better evaluation of the patient and establishing a allowing a better evaluation of the patient and establishing a correct therapy correct therapy

THE PRE-OPERATORY THE PRE-OPERATORY EVALUATIONEVALUATION

OBSERVATION SHEET OBSERVATION SHEET

The components of the observation sheetsThe components of the observation sheets:: GENERAL DATA DIAGNOSIS ANAMNESIS THE GENERAL PHYSICAL EXAMINATION PARACLINICAL EXPLORATIONS THE SURGICAL INTERVENTION TREATMENT AND EVOLUTION EPICRISIS TEMPERATURE SHEET


THE PRE-OPERATORY THE PRE-OPERATORY EVALUATION EVALUATION

GENERAL DATA GENERAL DATA

Comprise: Comprise: Identification data: Identification data: surname, first name, surname, first name,

sex, date of birth, age, address, telephone sex, date of birth, age, address, telephone number, jobnumber, job

Hospitalization place: Hospitalization place: hospital, clinic hospital, clinic Hospitalization period: Hospitalization period: datdate of e of

hospitalization, date of hospital releasehospitalization, date of hospital release Allergic to…. Allergic to…. Blood group and Rh… Blood group and Rh…

THE PRE-OPERATORY THE PRE-OPERATORY EVALUATIONEVALUATION

DIAGNOSDIAGNOSISIS

The diagnosis has three stagesThe diagnosis has three stages::

DiagnosiDiagnosiss at hospitalizationat hospitalization Diagnosis at 72 hoursDiagnosis at 72 hours Diagnosis at hospital discharge: it must comprise Diagnosis at hospital discharge: it must comprise

the diagnosis of the basic disease, the evolution the diagnosis of the basic disease, the evolution stage, the clinical form, complicationsstage, the clinical form, complications• Secondary diagnosisSecondary diagnosis: : the diagnosis of all the the diagnosis of all the

associated diseases associated diseases DiagnosDiagnosisis in case of deathin case of death::

a.a. The direct cause of death The direct cause of death b.b. Initial pathology Initial pathology c.c. AAssociated disordersssociated disordersd.d. Associated morbid states Associated morbid states

THE PRE-OPERATORY THE PRE-OPERATORY EVALUATION EVALUATION

ANAMNESIS ANAMNESIS It must be performed in such a manner as to obtain the patient’s trust to It must be performed in such a manner as to obtain the patient’s trust to

tell us the most detailed informationtell us the most detailed information Reasons for hospitalizationReasons for hospitalization:: all the objective and subjective problems all the objective and subjective problems

that the patient speaks of will be enumeratedthat the patient speaks of will be enumerated Physiological personal antecedentsPhysiological personal antecedents: they are important especially in the : they are important especially in the

case of women, providing information regarding the first menstruation, case of women, providing information regarding the first menstruation, the date of the last menstruation, the number of pregnancies, the the date of the last menstruation, the number of pregnancies, the number of births, and abortions (spontaneous, therapeutic or at request), number of births, and abortions (spontaneous, therapeutic or at request), the state of fetuses at birth, the lactation the state of fetuses at birth, the lactation

Pathological personal antecedentsPathological personal antecedents:: you will have to obtain data from the you will have to obtain data from the patient regarding any disorder he suffered from previously (allergies, patient regarding any disorder he suffered from previously (allergies, infections, surgical interventions, degenerative diseases, neoplasias)infections, surgical interventions, degenerative diseases, neoplasias)

Family history antecedentsFamily history antecedents: : they present a special importance especially they present a special importance especially in the case of transmittable diseases or with generic predisposition in the case of transmittable diseases or with generic predisposition (atopy, neoplasia, metabolic diseases, infections)(atopy, neoplasia, metabolic diseases, infections)

Life conditions, customs and work: Life conditions, customs and work: the dwelling place (important in the the dwelling place (important in the case of a family in which a member has a transmittable disease – case of a family in which a member has a transmittable disease – tuberculosis), alimentary habits the predisposition towards certain tuberculosis), alimentary habits the predisposition towards certain pathologies- obesity), smoking pathologies- obesity), smoking ( (the number of cigarettes a day and the the number of cigarettes a day and the period since when they have been smoking), the alcohol consume period since when they have been smoking), the alcohol consume (grams of alcohol 100% expressed per day or weeks), drugs, birth (grams of alcohol 100% expressed per day or weeks), drugs, birth control pills, or the working place (toxic environment, allergic, control pills, or the working place (toxic environment, allergic, carcinogenic substances, intense physical effort)carcinogenic substances, intense physical effort)

PREOPERATORY PREOPERATORY EVALUATIONEVALUATION

HISTORYHISTORY

It must be as detailed as possible, indicate the date of the It must be as detailed as possible, indicate the date of the disorder beginning, the manner in which it started (acute, disorder beginning, the manner in which it started (acute, insidious), the symptomatology present at the beginning insidious), the symptomatology present at the beginning and the symptomatology evolution until the present. In and the symptomatology evolution until the present. In addition, it must be mentioned if during this time interval addition, it must be mentioned if during this time interval the patient was examined by a physician or if he performed the patient was examined by a physician or if he performed certain investigations, what are their results, what certain investigations, what are their results, what treatment he followed and which are the modifications treatment he followed and which are the modifications from the last period of time that determined hospitalization.from the last period of time that determined hospitalization.

A correct anamnesis leads to a presumptive diagnosis A correct anamnesis leads to a presumptive diagnosis that will orient the patient’s physical examination and that will orient the patient’s physical examination and the subsequent paraclinical explorations. the subsequent paraclinical explorations.

PREOPERATORY EVALUATIONPREOPERATORY EVALUATIONTHE GENERAL PHYSICAL EXAMINATION THE GENERAL PHYSICAL EXAMINATION

It requires an examination room that offers privacy to the It requires an examination room that offers privacy to the patientpatient

It is performed with the patient in clino-orthostatism and It is performed with the patient in clino-orthostatism and during walkingduring walking

It must be performed comparatively with the contralateral It must be performed comparatively with the contralateral organ or segmentorgan or segment

It comprises:It comprises:1.1. PalpationPalpation2.2. InspectionInspection3.3. PercussionPercussion4.4. Listening Listening

Means of performing: Means of performing: • ON APPARATUSES AND SYSTEMS• ON BODY SEGMENTS

LOCAL EXAMINATIONLOCAL EXAMINATIONCLICK WITH THE MOUSE ON THE UNDERLINED TITLES

PREOPERATORY EVALUATIONPREOPERATORY EVALUATIONTHE GENERAL PHYSICAL THE GENERAL PHYSICAL

EXAMINATIONEXAMINATION ON APPARATUSES AND SYSTEMS ON APPARATUSES AND SYSTEMS The general state Tegument and mucuses Subcutaneous cellular test Lymphatic-ganglionic system Muscular system Osteoarticular systemOsteoarticular system Respiratory apparatus Cardiovascular apparatus Digestive apparatus and annexed glands Genital-urinary apparatus Nervous system, sense organs and endocrine glands


PREOPERATORY EVALUATIONPREOPERATORY EVALUATIONGENERAL PHYSICAL EXAMINATIONGENERAL PHYSICAL EXAMINATION– –

ON APPARATUSES AND SYSTEMSON APPARATUSES AND SYSTEMS

GENERAL STATE GENERAL STATE Can be : serious, influenced, good Can be : serious, influenced, good The patient’s aspect The patient’s aspect :: scarred patient, tormented with scarred patient, tormented with

pain – peritonitispain – peritonitis AtAttitudetitude:: Paralysis, opisthotonus – tetanus, supporting Paralysis, opisthotonus – tetanus, supporting

the traumatized limb with the healthy onethe traumatized limb with the healthy one Facies:Facies: h hypocratic (pale, with dark circles, pointed nose, ypocratic (pale, with dark circles, pointed nose,

prominent cheek) – peritonitisprominent cheek) – peritonitis WalkingWalking:: ataxic ataxic –– tabetic lesions tabetic lesions Nutrition stateNutrition state:: disassimilation, normal weight , obesity disassimilation, normal weight , obesity

(IMC=Gx100/T(IMC=Gx100/T²²)) Conscious stateConscious state:: cooperant, cooperant, temporo-spatially oriented, temporo-spatially oriented,

somnolent, obnubilated, comasomnolent, obnubilated, coma

PREOPERATORY PREOPERATORY EVALUATIONEVALUATION

GENERAL PHYSICAL EXAMINATION – GENERAL PHYSICAL EXAMINATION – ON APPARATUSES AN SYSTEMSON APPARATUSES AN SYSTEMS

Teguments and mucuses Teguments and mucuses CColorolor:: ciano cianosissis – – chronic cardiac chronic cardiac

insufficiency, bronchopenumopathies, pale - insufficiency, bronchopenumopathies, pale - hemorrhages, anemia, yellow – icterushemorrhages, anemia, yellow – icterus

Postoperatory scarsPostoperatory scars:: normally scarred normally scarred wound, keloid scarwound, keloid scar

ElasElasticityticity:: idle abdominal cutaneous ply – idle abdominal cutaneous ply – dehydrationdehydration

MucMucusesuses:: jugal mucus with roasted aspect – jugal mucus with roasted aspect – dehydrationdehydration

LeLesionssions:: petechia, ecchymoses, coagulation petechia, ecchymoses, coagulation disorders, excoriations – aggression, disorders, excoriations – aggression, traumatism traumatism , ,

PREOPERATORY EVALUATIONPREOPERATORY EVALUATIONGENERAL PHYSICAL EXAMINATION – GENERAL PHYSICAL EXAMINATION –

ON APPARATUSES AN SYSTEMSON APPARATUSES AN SYSTEMS

SUBCUTANEOUS SUBCUTANEOUS CELLULAR TISSUECELLULAR TISSUE It mentions the nutrition degreeIt mentions the nutrition degree The coetaneous fold will be measured on The coetaneous fold will be measured on

the antero-lateral side of the abdomen the antero-lateral side of the abdomen and thorax – normal about 2 cm.and thorax – normal about 2 cm.



THE LYMPHATIC- GANGLIONIC SYSTEM THE LYMPHATIC- GANGLIONIC SYSTEM The superficial ganglionic systemThe superficial ganglionic system The presence of adenopathies must be mentioned: The presence of adenopathies must be mentioned:

localization, consistency, mobility, presence of pain, localization, consistency, mobility, presence of pain, spontaneously or at palpation, the moment of the spontaneously or at palpation, the moment of the appearance and their evolutionappearance and their evolution

Examined regions : occipitals, retro-auricular, Examined regions : occipitals, retro-auricular, submandibular, cheek, laterocervical, submandibular, cheek, laterocervical, supraclavicular, axillary, epitrochlear, inguinal supraclavicular, axillary, epitrochlear, inguinal

The lymphatic system : The lymphatic system : localized or generalized localized or generalized edema – cardiac insufficiency, renal insufficiency, edema – cardiac insufficiency, renal insufficiency, hypoproteinemiahypoproteinemia

Superficial venous systemSuperficial venous system: : circulation - periumbilical circulation - periumbilical venous superficial –gorgon – vascularly venous superficial –gorgon – vascularly decompensated hepatic cirrhosis decompensated hepatic cirrhosis



THE MUSCULAR SYSTEMTHE MUSCULAR SYSTEM

Tonus: Tonus: hhyypotonpotonicic, normoton, normotonicic, , hhyypertonpertonicic

The musculature development The musculature development Carrying out the movementsCarrying out the movements: :

normokinetically normokinetically

PREOPERATIVE EVALUATIONPREOPERATIVE EVALUATIONGENERAL PHYSICAL EXAMINATION – GENERAL PHYSICAL EXAMINATION –

ON APPARATUSES ANON APPARATUSES ANDD SYSTEMS SYSTEMS

OSTEO-ARTICULAR SYSTEMOSTEO-ARTICULAR SYSTEM

Bone deformities: Bone deformities: “rachitic rosary“rachitic rosary”” – – ricketsrickets

Continuity of bone reliefs:Continuity of bone reliefs: discontinuity discontinuity accompanied by crepitations – fracturesaccompanied by crepitations – fractures

Active and passive articular mobility:Active and passive articular mobility: immobile, partial mobility, normal immobile, partial mobility, normal mobility, hyperlax articulationmobility, hyperlax articulation

PREOPERATIVE EVALUATIONPREOPERATIVE EVALUATIONGENERAL PHYSICAL EXAMINATION –GENERAL PHYSICAL EXAMINATION –

ON APPARATUSES AND SYSTEMS ON APPARATUSES AND SYSTEMS

THE RESPIRATORY APPARATUSTHE RESPIRATORY APPARATUS Thorax conformation :Thorax conformation : normal, rickets sequels, normal, rickets sequels,

emphysematous thoraxemphysematous thorax Amplitude of breathing movements:Amplitude of breathing movements: draw, draw,

pathological whistlingpathological whistling Dyspnea:Dyspnea: inspiratory , expiratory, mixedinspiratory , expiratory, mixed Transmission of vocal vibrations :Transmission of vocal vibrations : it can be perceived by it can be perceived by

palpating the thorax when the patient says “33”palpating the thorax when the patient says “33” PercuPercussssion: ion: normal sonority, sub-dullness or dullness – normal sonority, sub-dullness or dullness –

pleurisy, pneumonia, hypersonority – pneumothoraxpleurisy, pneumonia, hypersonority – pneumothorax Ascultation: Ascultation: crepitating rales – pneumonia, crepitating rales – pneumonia,

subcrepitanting– bronsubcrepitanting– broncchopneumonia, sibilant – bronchial hopneumonia, sibilant – bronchial asthma, sonorous rhonous – chronic asthma, sonorous rhonous – chronic nicotine addictionnicotine addiction



CARDIOVASCULAR APPARATUSCARDIOVASCULAR APPARATUS The anamnesis The anamnesis may show effort dyspnea, nocturnal dyspnea, may show effort dyspnea, nocturnal dyspnea,

presternpresternum um pain due to effortpain due to effort Color of teguments, mucuses, extremities: Color of teguments, mucuses, extremities: ccyyanoses in chronic anoses in chronic

cardiac insufficiency cardiac insufficiency PalpationPalpation

• Apexian shock:Apexian shock: normal – left normal – left 5th5th intercostal space intercostal space medioclavicular linemedioclavicular line

• Peripheral pulse: Peripheral pulse: temporal artery, carotid artery, radial artery, temporal artery, carotid artery, radial artery, femoral artery, popliteal artery , dorsal artery of footfemoral artery, popliteal artery , dorsal artery of foot

Ascultation: Ascultation: cardiac noises, rhythm, central frequencycardiac noises, rhythm, central frequency• Ascultation of the carotid, femoral arteries, abdominal aorta, Ascultation of the carotid, femoral arteries, abdominal aorta,

renal arteryrenal artery Percussion: Percussion: cardiac dullness (rarely used nowadays)cardiac dullness (rarely used nowadays) Measurement of arterial pressure :Measurement of arterial pressure : clino- and orthostatismclino- and orthostatism



THE DIGESTIVE APPARATUS AND THE ANNEX GLANDS THE DIGESTIVE APPARATUS AND THE ANNEX GLANDS Anamnesis:Anamnesis: appetite, weight loss, nausea, vomiting, pain, bowel transit appetite, weight loss, nausea, vomiting, pain, bowel transit Examination:Examination: mouth cavity, coordination of abdomen movements with mouth cavity, coordination of abdomen movements with

breathing, existence of scars or other tegument lesions, (bruises, breathing, existence of scars or other tegument lesions, (bruises, hematomas, scratching lesions, abrasions)hematomas, scratching lesions, abrasions)

PalpationPalpation Superficial:Superficial: cutaneous hyperesthesia: peritonitiscutaneous hyperesthesia: peritonitis

• DeepDeep:: palpation of liver and spleen, tumopalpation of liver and spleen, tumorrs, uteruss, uterus Percussion:Percussion: hepatic dullness, hypersonority – occlusionhepatic dullness, hypersonority – occlusion Ascultation:Ascultation: absence of hydro-air noises – occlusion, suabsence of hydro-air noises – occlusion, sullphides– tumorsphides– tumors Rectal palpation –Rectal palpation – compulsory at any examination compulsory at any examination : : perianal teguments perianal teguments

(perianal fistula, moles, external hemorrhoids), tonus of anal sphincter (perianal fistula, moles, external hemorrhoids), tonus of anal sphincter (hypo-, normo- hypertonic), shape, limits and consistency of the (hypo-, normo- hypertonic), shape, limits and consistency of the prostate, suppleness of the rectal wall, existence or absence of feaces, of prostate, suppleness of the rectal wall, existence or absence of feaces, of fresh blood or melena or other tumoral lesionsfresh blood or melena or other tumoral lesions



THE GENITO-URINARY SYSTEMTHE GENITO-URINARY SYSTEM Anamnesis:Anamnesis: urination frequency, symptomatology urination frequency, symptomatology

associated to the urination (pain, smarting pain, interrupted associated to the urination (pain, smarting pain, interrupted jet), urine color, diuresis (jet), urine color, diuresis (amount of amount of urine in 24 hours), urine in 24 hours), existence of nycturia – prostate adenoma, enuresisexistence of nycturia – prostate adenoma, enuresis

Examination:Examination: lumbar regions (postoperative scars, lumbar regions (postoperative scars, deformations – renal tumor), conformation of external deformations – renal tumor), conformation of external genital organs genital organs

Palpation:Palpation: urethral points, lumbar area urethral points, lumbar area Percussion:Percussion: positive Giordano maneuver – vivid pain at the positive Giordano maneuver – vivid pain at the

percupercussssion of lumbuses – acute sufferingion of lumbuses – acute suffering Digital vaginal examination and vaginal examination with Digital vaginal examination and vaginal examination with

valves:valves: inspection, palpationinspection, palpation



NERVOUS SYSTEM, SENSE ORGANS AND NERVOUS SYSTEM, SENSE ORGANS AND ENDOCRINE GLANDSENDOCRINE GLANDS

State of consciousness:State of consciousness: cooperative, time-space cooperative, time-space oriented, drowsy, obnubilated, comaoriented, drowsy, obnubilated, coma

Reflexes:Reflexes: osteotendinous, cutaneous, pupillary, osteotendinous, cutaneous, pupillary, reaction to pain reaction to pain

The examination of the spine The examination of the spine is important for a is important for a rachianesthesiarachianesthesia

The exam of the anterior cervical region for the The exam of the anterior cervical region for the thyroid gland thyroid gland

ComparativeComparative examination of breasts examination of breasts – is – is compulsorycompulsory

Sense organs:Sense organs: hearing, sight (myopia, hearing, sight (myopia, hypermetropia), balancehypermetropia), balance

PREOPERATIVE EVALUATIONPREOPERATIVE EVALUATIONGENERAL PHYSICAL EXAMINATIONGENERAL PHYSICAL EXAMINATION

ON BODY SEGMENTS ON BODY SEGMENTS A more cursive and elegant method to A more cursive and elegant method to

examine the patient than the classic examine the patient than the classic examination ON APPARATUSES AN examination ON APPARATUSES AN SYSTEMSSYSTEMS

Modalities of Modalities of perfomanceperfomance•Sitting down•Clionostatism•Orthostatism

CLICK WITH THE MOUSE ON THE UNDERLINED TITLES

PREOPERATIVE EVALUATIONPREOPERATIVE EVALUATIONGENERAL PHYSICAL EXAMINATION – ON BODY SEGMENTS GENERAL PHYSICAL EXAMINATION – ON BODY SEGMENTS

SITTING DOWNSITTING DOWN Chephalic extremity :Chephalic extremity : teguments, conjunctiva teguments, conjunctiva

mucous, implantation of exoskeletons, mucous, implantation of exoskeletons, ganglions, photomotor reflex, sinus points ganglions, photomotor reflex, sinus points (frontal and maxillary), mouth cavity (mucous, (frontal and maxillary), mouth cavity (mucous, dentition, dentures, tonsils), thyroid gland dentition, dentures, tonsils), thyroid gland

Thorax:Thorax: respiratory apparatus, heart ascultation, respiratory apparatus, heart ascultation, exploration of mammary gland, adenopathies exploration of mammary gland, adenopathies (axillary, supraclavicular), spine(axillary, supraclavicular), spine

Lumbuses:Lumbuses: urogenital apparatus, examination of urogenital apparatus, examination of lumbar spinelumbar spine

PREOPERATIVE EVALUATIONPREOPERATIVE EVALUATIONGENERAL PHYSICAL EXAMINATION ON BODY SEGMENTS GENERAL PHYSICAL EXAMINATION ON BODY SEGMENTS

CLINOSTATISMCLINOSTATISM Thorax:Thorax: cardiovascular apparatuscardiovascular apparatus Abdomen:Abdomen: digestive apparatus, weekdigestive apparatus, week

abdominal points, inguinal regionabdominal points, inguinal region Lumbar region:Lumbar region: palpation of renal lodges, palpation of renal lodges,

urethral pointsurethral points Limbs:Limbs: inspection, passive and active inspection, passive and active

mobility, osteotendinous reflexes, pulse mobility, osteotendinous reflexes, pulse and peripheral sensitivityand peripheral sensitivity

Rectal and vaginal palpationRectal and vaginal palpation

PREOPERATIVE EVALUATION PREOPERATIVE EVALUATION GENERAL PHYSICAL EXAMINATION – ON BODY SEGMENTS GENERAL PHYSICAL EXAMINATION – ON BODY SEGMENTS

ORTHOSTATISMORTHOSTATISM BalanceBalance GaitGait VaricesVarices Hernial regionsHernial regions

PREOPERATIVE EVALUPREOPERATIVE EVALUATIONATIONLOCAL EXAMLOCAL EXAM

It is very important, providing data It is very important, providing data about the affected region, apparatus about the affected region, apparatus

It includes anamnesis, examination, It includes anamnesis, examination, palpation, percupalpation, percussssion, ascultationion, ascultation

The characteristics of the lesions The characteristics of the lesions must be described: number, shape, must be described: number, shape, dimensions, limits, surface, dimensions, limits, surface, consistency, sensitivity, mobilityconsistency, sensitivity, mobility

PREOPERATIVE EVALUATIONPREOPERATIVE EVALUATIONPARACLINIC EXPLORATIONSPARACLINIC EXPLORATIONS

For the patient who needs surgery For the patient who needs surgery it is better for the paraclinical it is better for the paraclinical investigations to be performed in investigations to be performed in ambulatory. ambulatory. If it is not possible then If it is not possible then they will be performed as soon as they will be performed as soon as possible after being hospitalized possible after being hospitalized

Routine explorations Special explorations



ROUTINE EXPLORATIONSROUTINE EXPLORATIONS BiologicalBiological

• Hemoleucogram (hemoglobin, hematocrit, Hemoleucogram (hemoglobin, hematocrit, trombocyes, leukocytes, leukocyte formula)trombocyes, leukocytes, leukocyte formula)

• Glycaemia, urea, creatinineGlycaemia, urea, creatinine• Coagulation tests (bleeding time, coagulation time, Coagulation tests (bleeding time, coagulation time,

prothrombin time, fibirin degradation products)prothrombin time, fibirin degradation products)• Hepatic tests, total proteinsHepatic tests, total proteins• RBW (syphillis), viral serology for AIDS and hepatitisRBW (syphillis), viral serology for AIDS and hepatitis• Urine test, urine elimination in 24hUrine test, urine elimination in 24h

Imagistic and functional Imagistic and functional • Chest X-Ray (radiography) Chest X-Ray (radiography) • Simple abdominal radiography Simple abdominal radiography • Abdominal echography Abdominal echography • EKGEKG


SPECIAL EXPLORATIONS SPECIAL EXPLORATIONS They have to be as „targeted” as possible and to offer a complete They have to be as „targeted” as possible and to offer a complete

and clear image of each patient and clear image of each patient Biological: Biological:

• Ionogram: NaIonogram: Na++, K, K++, Cl , Cl --, alkaline reserve, alkaline reserve• Hepatic tests: hepatocytolisis syndrome (TGP, TGO, GGT, Hepatic tests: hepatocytolisis syndrome (TGP, TGO, GGT,

alkaline phosphatasis, iron content in blood), hepatoprive alkaline phosphatasis, iron content in blood), hepatoprive syndrome (fibrinogen, total lipids, cholesterol), serum proteins syndrome (fibrinogen, total lipids, cholesterol), serum proteins electrophoresis, biliary function, (total direct and indirect electrophoresis, biliary function, (total direct and indirect bilirubin)bilirubin)

• Amylasaemia, amylasuriaAmylasaemia, amylasuria• Hemocultures, uroculturesHemocultures, urocultures

Imagistic and functional:Imagistic and functional:• Echocardiography, respiratory tests, eso-gastro-duodenal Echocardiography, respiratory tests, eso-gastro-duodenal

radiography with contrast substance, irigography, radiography with contrast substance, irigography, fistulography, cavitatography, CT, IRM, scintigram, endoscopy, fistulography, cavitatography, CT, IRM, scintigram, endoscopy, biopsy puncture, diagnostic laparoscopybiopsy puncture, diagnostic laparoscopy

SURGICAL INTERVENTIONSURGICAL INTERVENTION

To write down:To write down: Number of the operatory protocolNumber of the operatory protocol Operatory diagnosis Operatory diagnosis Operation descriptionOperation description Type of aneType of anessthesiathesia Operatory teamOperatory team

TREATMENT AND EVOLUTIONTREATMENT AND EVOLUTION

To write down every day the medicines To write down every day the medicines administered, the dose (g/day), dose fractioning, administered, the dose (g/day), dose fractioning, the way of administration (oral pills, the way of administration (oral pills, intramuscular, intravenous perfusion, etc.)intramuscular, intravenous perfusion, etc.)

The evolution has to include: temperature, The evolution has to include: temperature, pulse, blood pressure, general condition, pulse, blood pressure, general condition, postoperative evolution (bandage and woupostoperative evolution (bandage and wounnd d aspect, drainage, resumption of bowel transit, aspect, drainage, resumption of bowel transit, resumption of feeding), diuresisresumption of feeding), diuresis

For the surgical treatment one should establish: For the surgical treatment one should establish: the operatory indication, preoperative the operatory indication, preoperative preparation, operatory risk and anesthesia, preparation, operatory risk and anesthesia, operatory time, postoperative treatment, operatory time, postoperative treatment, dischargedischarge

EPICRISISEPICRISIS

It is a summary of the entire observation It is a summary of the entire observation sheet and isheet and itt must include: must include:

DisDisccharge reasonsharge reasons ExplorationExplorationss performed and their results performed and their results (medicated and surgical) Treatments (medicated and surgical) Treatments

takentaken EvolutionEvolution Recommendations and dischargeRecommendations and discharge

TEMPERATURE SHEETTEMPERATURE SHEET

It represents a complete description of It represents a complete description of the patient’s condition and evolution the patient’s condition and evolution

To be written down daily: To be written down daily: • Body temperature Body temperature • PulsePulse• Blood pressureBlood pressure• DiuresisDiuresis• AmountAmount of drained fluids of drained fluids • Digestive aspiration Digestive aspiration • Administered medicationAdministered medication

DEFINIDEFINITIONTION

It is the method that uses a series of It is the method that uses a series of physical or chemical means in order to physical or chemical means in order to destroy the saprophyte or pathogen destroy the saprophyte or pathogen agents, to combat the infection after it has agents, to combat the infection after it has been identified been identified

PURPOSE AND PRINCIPLES INDICATIONS CONTRAINDICATIONS ANTISEPTICS

CONTENTCLICK WITH THE MOUSE ON EACH UNDERLINED TITLE

PURPOSE AND PURPOSE AND PRINCIPLESPRINCIPLES

The purposeThe purpose of the antiseptics is to of the antiseptics is to destroy the infectious agents from the destroy the infectious agents from the wounds or tegumentswounds or teguments

Operation mode:Operation mode: they dissolve the they dissolve the bacterial membrane or modify the bacterial membrane or modify the macromolecules at this level determining macromolecules at this level determining the destruction of the microorganismthe destruction of the microorganism

Types of antiseptics:Types of antiseptics:• Cytophilactic: they respect the integrity Cytophilactic: they respect the integrity

of the organism cellsof the organism cells• Cytotoxic: they destroy the organism Cytotoxic: they destroy the organism

cellscells


THE IDEAL ANTISEPTICTHE IDEAL ANTISEPTIC::1.1. HydrosolubleHydrosoluble2.2. Non toxic and non irritant for live tissueNon toxic and non irritant for live tissue3.3. Broad bacterial spectrumBroad bacterial spectrum4.4. Bacteriostatic and bactericidal actionBacteriostatic and bactericidal action5.5. To be biochemical stableTo be biochemical stable6.6. Not to produce toxic compounds after Not to produce toxic compounds after

metabolizationmetabolization7.7. The bactericidal effect should not depend on The bactericidal effect should not depend on

the presentation shapethe presentation shape 8.8. BactericidalBactericidal effect in presence of organism effect in presence of organism

fluidsfluids9.9. Cheap Cheap

INDICATIONSINDICATIONS To make aseptic the skin around the wounds To make aseptic the skin around the wounds To make aseptic the wound destroying the To make aseptic the wound destroying the

bacteria bacteria To make aseptic the patient’s skin (operatTo make aseptic the patient’s skin (operativeive

field) beforfield) beforee the surgical intervention the surgical intervention To wash and make asepticTo wash and make aseptic the surgeon’s handsthe surgeon’s hands To sanitize the instrumentsTo sanitize the instruments To sanitize the surfaces in the operation roomTo sanitize the surfaces in the operation room To sanitize the sanitary installationsTo sanitize the sanitary installations

CONTRAINDICATIONSCONTRAINDICATIONS

The use of alcoholized, irritant or toxic substances in the wound (alcohol The use of alcoholized, irritant or toxic substances in the wound (alcohol denatures the proteins adenatures the proteins annd determines the appearance of a proteid determines the appearance of a proteicc film film which favors the development of infection by preventing the antiseptic which favors the development of infection by preventing the antiseptic substances from getting into the wound)substances from getting into the wound)

Only use substances indicated at the level of the mucuses Only use substances indicated at the level of the mucuses (nasopharyngeal mucous, oral mucosa, ocular mucous membrane) (nasopharyngeal mucous, oral mucosa, ocular mucous membrane) because they can be absorbed in the systemic circulation resulting in because they can be absorbed in the systemic circulation resulting in intoxications or anaphylactic shockintoxications or anaphylactic shock

Vaginal lavages, enemas will only be perfoVaginal lavages, enemas will only be perforrmed with recommended med with recommended substances having the risk of irritations or ulcerations at this level substances having the risk of irritations or ulcerations at this level

There will not be used to sterilize the instruments substances that only There will not be used to sterilize the instruments substances that only destroy the vegetative forms of bacteria without destroying the bacterial destroy the vegetative forms of bacteria without destroying the bacterial spores, too spores, too

The patients with atopy need special attention when choosing the The patients with atopy need special attention when choosing the antiseptic antiseptic agent agent to be used (e.g.: allergic to iodine)to be used (e.g.: allergic to iodine)

The iodine antiseptics shall not be used for the new-born child and the The iodine antiseptics shall not be used for the new-born child and the little child (great capacity of iodine absorptionlittle child (great capacity of iodine absorption))

ANTISEPTICSANTISEPTICS

CLASSIC MODERN


CLASSICCLASSICANTISEPTICSANTISEPTICS

Antiseptics with alcohol contents Antiseptics which liberate chlorine Antiseptics which liberate oxygen Compounds of heavy metals Potassium permanganate


ANTISEPTICS WITH ALCOHOL ANTISEPTICS WITH ALCOHOL CONTENTSCONTENTS

EHTYL ALCOHOL 70EHTYL ALCOHOL 70°: °: • Indications: to make aseptic the tegument Indications: to make aseptic the tegument • Advantages: osmotic power, penetrating the deep layers of the Advantages: osmotic power, penetrating the deep layers of the

epidermis and in the sebaceous glands epidermis and in the sebaceous glands • Disadvantages: diminished action when applied on wet Disadvantages: diminished action when applied on wet

teguments teguments TINCTURE OF IODINE TINCTURE OF IODINE

• Indications: to make aseptic the tegument Indications: to make aseptic the tegument • Better penetration than simple alcohol Better penetration than simple alcohol • Composition: iodine 10g, potassium iodide 4g, alcohol 90Composition: iodine 10g, potassium iodide 4g, alcohol 90° 136g° 136g• Advantages Advantages : it indicates the region made aseptic by the yellow : it indicates the region made aseptic by the yellow

colorcolor• Disadvantages : toxic if older than 6 days because it produces Disadvantages : toxic if older than 6 days because it produces

iodine derivates, irritant for the areas covered with hair (axilla, iodine derivates, irritant for the areas covered with hair (axilla, scrotum), it does not apply on wounds scrotum), it does not apply on wounds

• Other products: ANCOHOL IODATE, GAS IODATE, EHTER IODATE Other products: ANCOHOL IODATE, GAS IODATE, EHTER IODATE SULPHURIC ETHER: to make aseptic the (peritoneal, articular)SULPHURIC ETHER: to make aseptic the (peritoneal, articular)serous membranesserous membranes GOMENOL: rhynopharyngeal and urological infectionsGOMENOL: rhynopharyngeal and urological infections

PHOTO

ANTISEPTICS WITH ANTISEPTICS WITH ALCOHOL CONTENTSALCOHOL CONTENTS

Ethyl alchool 70° Products based on iodine

ANTISEPTICS WHICH ANTISEPTICS WHICH LIBERATE CHLORINELIBERATE CHLORINE

They have bactericidal action by liberating They have bactericidal action by liberating chlorine as it is produced chlorine as it is produced

DAKIN’S SOLUTION (SODIUM HYPOCHLORITE): DAKIN’S SOLUTION (SODIUM HYPOCHLORITE): • ““chemical schemical sccalpel” of alalpel” of alll sphaceluses and pus sphaceluses and pus• To be administered in intermittent or To be administered in intermittent or

continuous irrigationscontinuous irrigations• It dissolves and eliminates sphacelusIt dissolves and eliminates sphacelusees, clots s, clots

and pusand pus CHLORAMINE B SOLUTION 0.2-2%CHLORAMINE B SOLUTION 0.2-2%

• More powerful action than Darkin’s solutionMore powerful action than Darkin’s solution• Local applications, continuous or intermittent Local applications, continuous or intermittent

irrigation, local bathsirrigation, local baths PHOTO

ANTISEPTICS WHICH ANTISEPTICS WHICH LIBERATE CHLORINELIBERATE CHLORINE

Chloramine tablets Chloramine solution

ANTISEPTICS WHICH ANTISEPTICS WHICH LIBERATE OXYGENLIBERATE OXYGEN

There are substances which rapidly liberate a large quantity of There are substances which rapidly liberate a large quantity of oxygen or after a while, a constant quantity but with a smaller oxygen or after a while, a constant quantity but with a smaller volumevolume

They determine the formation of hydrogen peroxide resulting in They determine the formation of hydrogen peroxide resulting in the destruction of microorganismsthe destruction of microorganisms

OXYGENOXYGEN• Cytophilactic, hemostatic antisepticCytophilactic, hemostatic antisepticss• It melts and eliminates sphaceluses It melts and eliminates sphaceluses

OXYGENATED WATEROXYGENATED WATER• Cytophilactic, hemostatic solutionCytophilactic, hemostatic solution• By effervescence it can eliminate foreign bodies from the By effervescence it can eliminate foreign bodies from the

woundwound• Disadvantages: it lyses the catgut, it delays the wound Disadvantages: it lyses the catgut, it delays the wound

cicatrizationcicatrization BORIC ACIDBORIC ACID

• It gradually liberates oxygenIt gradually liberates oxygen• Form of existence :Form of existence :

Crystals: wounds infected with pyocyanic bacillusCrystals: wounds infected with pyocyanic bacillus Solution 1-4% as antiphlogistic in ophthalmology and Solution 1-4% as antiphlogistic in ophthalmology and

dermatologydermatology

COMPOUNDS OF HEAVY METALSCOMPOUNDS OF HEAVY METALS

Mercury salts: MERCURY Mercury salts: MERCURY OXYCIANIDE for mucous lavage, OXYCIANIDE for mucous lavage, MERCURY BICHLORIDE MERCURY BICHLORIDE (SUBLIMATE) for making (SUBLIMATE) for making teguments asepticteguments aseptic

SILVER NITRATE: for making the SILVER NITRATE: for making the wounds aseptic, cauterizing wounds aseptic, cauterizing action on granulated wounds action on granulated wounds and epithelizing action on atone and epithelizing action on atone wounds. The solutions are wounds. The solutions are widely used in dermatologywidely used in dermatology

COLARGOL 1%, COLARGOL 1%, PROTARGOL 2%PROTARGOL 2% Less and less used Less and less used

POTASSIUM POTASSIUM PERMANGANATEPERMANGANATE

POTASSIUM PERMANGANATE POTASSIUM PERMANGANATE SOLUTION 2-4%SOLUTION 2-4%

Cytophilactic antiseptic Cytophilactic antiseptic The only one in the group of The only one in the group of

colorant substances that is still usedcolorant substances that is still used Indications: washing anfractuous Indications: washing anfractuous

wounds with sphaceluses, cavities wounds with sphaceluses, cavities and ducts (urethra, bladder), and ducts (urethra, bladder), disinfecting disinfecting bathsbaths

MODERN MODERN ANTISEPTICSANTISEPTICS

Antiseptics based on phenols and derivates

Quaternary ammonium compounds Biguanide antisepticsntiseptics Hypochlorites and dichloroisocyanura

tes Iodides and iodoforms


ANTISEPTICS BASED ON ANTISEPTICS BASED ON PHENOLS AND DERIVATESPHENOLS AND DERIVATES

PHENOL: it is not used anymore because it PHENOL: it is not used anymore because it is corrosive and irritant for the respiratory is corrosive and irritant for the respiratory ductsducts

PRINTOL: disinfectant for surfacesPRINTOL: disinfectant for surfaces CLEARSOL: detergent for cleaning surfaces CLEARSOL: detergent for cleaning surfaces HEXACLOROFENHEXACLOROFEN

• Combined with soap it is used to make Combined with soap it is used to make aseptic the surgeon’s hands aseptic the surgeon’s hands

• Disadvantages: toxic, cutaneous lesions Disadvantages: toxic, cutaneous lesions

QUATERNARY AMMONIUM QUATERNARY AMMONIUM COMPOUNDSCOMPOUNDS

Cytophilactic antiseptics but also Cytophilactic antiseptics but also hhaving aving detergent action contributing by the foam detergent action contributing by the foam they produce to eliminate the cellular they produce to eliminate the cellular remainders and foreign bodiesremainders and foreign bodies

CETAVLON, BROMOCET, CETAZOLINA, CETAVLON, BROMOCET, CETAZOLINA, CETRIMIDE BP, SAVLONCETRIMIDE BP, SAVLON

Indication: tIndication: too clean wounds, burns, surface clean wounds, burns, surface disinfection (depending on the disinfection (depending on the concentration of the solutions)concentration of the solutions)

BIGUANIDE BIGUANIDE ANTISEPTICSANTISEPTICS

CHLORHEXIDINECHLORHEXIDINE• Indications: used to make aseptic the surgeon’s hands, Indications: used to make aseptic the surgeon’s hands,

wounds, emergency disinfection of medical termolable wounds, emergency disinfection of medical termolable instruments (chlorhexidine 10% + alcohol 70instruments (chlorhexidine 10% + alcohol 70° - 10 ° - 10 minutes)minutes)

• Advantages: it can be diluted at the desired Advantages: it can be diluted at the desired concentration, it is not allergenicconcentration, it is not allergenic

• Disavantages: it is not active on tuberculous bacilli, Disavantages: it is not active on tuberculous bacilli, spores and some viruses, it cannot be combined with spores and some viruses, it cannot be combined with soapsoap

• One of the most used antiseptics in surgeryOne of the most used antiseptics in surgery BENZALKONIUM CHLORIDE BENZALKONIUM CHLORIDE

• Bactericidal effect Bactericidal effect • Indications: to clean wounds, bladder, to make aseptic Indications: to clean wounds, bladder, to make aseptic

the surgeon’s handsthe surgeon’s hands• Advantages: slightly irritant for skinAdvantages: slightly irritant for skin

HYPOCLORITES AND HYPOCLORITES AND DICHLOROISOCYANURATESDICHLOROISOCYANURATES

Antiseptics active on bacteria and spores, Antiseptics active on bacteria and spores, funguses, viruses funguses, viruses

Rapid action Rapid action Form of presentation: concentrated Form of presentation: concentrated

solutions (when used they need to be solutions (when used they need to be diluted)diluted)

Indications: to sterilize the instruments, Indications: to sterilize the instruments, to disinfect surfacesto disinfect surfaces

Disadvantages: unpleasant smell, irritant, Disadvantages: unpleasant smell, irritant, corrosive for metallic instrumentscorrosive for metallic instruments

IODIDES AND IODOFORMSIODIDES AND IODOFORMS

IODOFORM (POVIDONE IODIDE)IODOFORM (POVIDONE IODIDE)• It liberates active iodine, it destroys funguses, bacteria It liberates active iodine, it destroys funguses, bacteria

and their spores and their spores • Form of presentation: yellow crystals with strong smell, Form of presentation: yellow crystals with strong smell,

solutions of various concentrations or associated with solutions of various concentrations or associated with detergents to increase the cleaning effect, spraydetergents to increase the cleaning effect, spray

• Indications: to clean wounds, for the preoperatIndications: to clean wounds, for the preoperativeive preparation of the patient’s tegument, lavage of natural preparation of the patient’s tegument, lavage of natural cavities and ducts, iodoform gauze, stomatologycavities and ducts, iodoform gauze, stomatology

• Advantages: it doesn’t need alcohol to be dissolved, it Advantages: it doesn’t need alcohol to be dissolved, it is not irritant for skin and mucuses, it doesn’t stain the is not irritant for skin and mucuses, it doesn’t stain the cloths it touches, it can be easily removed by washing itcloths it touches, it can be easily removed by washing it

• The most often used antisepticThe most often used antiseptic

PHOTOVIDEO

IODIDES AND IODOFORMSIODIDES AND IODOFORMS

DEFINIDEFINITIONTION

All gestures and maneuvers used All gestures and maneuvers used in order to prepare the patient in order to prepare the patient for a surgical interventionfor a surgical intervention

PURPOSE AND PRINCIPLES INDICATIONS CONTRAINDICATIONS STAGES

CONTENTCLICK WITH THE MOUSE ON EACH UNDERLINED TITLE

PURPOSE AND PRINCIPLESPURPOSE AND PRINCIPLES

The purpose of the preoperative preparation is to prepare the patient for The purpose of the preoperative preparation is to prepare the patient for the surgical interventionthe surgical intervention

The patient has to be informed on the pathology he suffers from, on the The patient has to be informed on the pathology he suffers from, on the possible therapy (a few data concerning the intervention), the risks and possible therapy (a few data concerning the intervention), the risks and the benefits of the treatment, possible mutilations or infirmities, on the the benefits of the treatment, possible mutilations or infirmities, on the possible changes of the postoperative life stylepossible changes of the postoperative life style

One also has to provide information on the immediate and later One also has to provide information on the immediate and later prognosis of the disease (Romanian legislation does not stipulate what prognosis of the disease (Romanian legislation does not stipulate what the patient should know, so generally in practice the patient’s questions the patient should know, so generally in practice the patient’s questions are answered and the non expressed desire not to be given too many are answered and the non expressed desire not to be given too many details)details)

The physical preparation of the patient is another stage of the The physical preparation of the patient is another stage of the preoperative preparation, and it intends to bring the patient to a physical preoperative preparation, and it intends to bring the patient to a physical condition which is good enough to support the surgical intervention as condition which is good enough to support the surgical intervention as easeasilyily as possible as possible

The preparation has to be done step by step, the patient has to be in a The preparation has to be done step by step, the patient has to be in a condition as good as possible at the moment of the interventioncondition as good as possible at the moment of the intervention

Any patient will have to give his/her written agreement for the Any patient will have to give his/her written agreement for the investigations and therapy he/she is going to benefit frominvestigations and therapy he/she is going to benefit from

INDICAINDICATIONSTIONS

Any surgical intervention carries Any surgical intervention carries some risks, that is why it is some risks, that is why it is necessary for any patient that is necessary for any patient that is going to undergo a surgical going to undergo a surgical intervention to receive psychological intervention to receive psychological and physical preparation specific to and physical preparation specific to the pathology and surgery he/she will the pathology and surgery he/she will undergoundergo

CONTRAINDICACONTRAINDICATIONSTIONS They are not absolute, concerning especially the They are not absolute, concerning especially the

patients who need emergency surgery, when patients who need emergency surgery, when there is no time for ideal psychological or physical there is no time for ideal psychological or physical preparation, this being done as it goes depending preparation, this being done as it goes depending on the general condition of the patienton the general condition of the patient

In case the patient is unconscious, they have to In case the patient is unconscious, they have to talk to the patient’s family about his/her conditiontalk to the patient’s family about his/her condition

The written agreement for the surgery has to be The written agreement for the surgery has to be urgently obtained from the patient or his/her urgently obtained from the patient or his/her relatives in case he/she is unconsciousrelatives in case he/she is unconscious

PREOPERATIVEPREOPERATIVEPREPARATIONPREPARATION

PSYCHOLOGICAL PREPARATION PHYSICAL PREPARATION

OPERATION TIME

CLICK WITH THE MOUSE ON THE TITLE

PSYCHOLOGICAL PSYCHOLOGICAL PREPREPARATIONPARATION

It will be done by the attending physician (the physician who will perform It will be done by the attending physician (the physician who will perform the surgical intervention)the surgical intervention)

The patient’s information has to be very objective, informing him/her The patient’s information has to be very objective, informing him/her both on the risks and benefits without trying to convince the patient to both on the risks and benefits without trying to convince the patient to get operatedget operated

The decision to benefit from the surgical treatment is entirely up to the The decision to benefit from the surgical treatment is entirely up to the patient, who will decide himself/herself for his/her lifepatient, who will decide himself/herself for his/her life

In order to help the patient take a decision on the surgical act the patient In order to help the patient take a decision on the surgical act the patient is recommended to consult another doctor, to have access to a second is recommended to consult another doctor, to have access to a second opinionopinion

The psychological preparation also has to inform the patient on the The psychological preparation also has to inform the patient on the changes that may appear after the surgery. So there may appear some changes that may appear after the surgery. So there may appear some mutilations (iliac anus), infirmities (thigh amputation) which latter may mutilations (iliac anus), infirmities (thigh amputation) which latter may need prosthesis, transitory or definitive loss of sexual potency or need prosthesis, transitory or definitive loss of sexual potency or metabolic or psychic disorders (interventions ometabolic or psychic disorders (interventions onn the endocrine glands) the endocrine glands)

A topic difficult to approach is the severe prognosis, the situation varying A topic difficult to approach is the severe prognosis, the situation varying from patient to patient. Some people insist on being informed on the from patient to patient. Some people insist on being informed on the evolution and prognosis, whereas some other patients are not interested evolution and prognosis, whereas some other patients are not interested in this aspect. It is recommended to answer according to the patient’s in this aspect. It is recommended to answer according to the patient’s desire to know more or less about the pathology he/she suffers fromdesire to know more or less about the pathology he/she suffers from

PHYSICAL PREPARATIONPHYSICAL PREPARATIONIt includes: It includes: GENERAL PREPARATION SYSTEMIC PREPARATION LOCAL PREPARATION PREVENTION OF POSTOPERATIVE CO

MPLICATIONS


PHYSICAL PREPARATIONPHYSICAL PREPARATION GENERALGENERAL PREPARATION PREPARATION

Hydroelectronic and acido-basic balance

Nutritional preparation


PHYSICAL PHYSICAL PREPREPARATION PARATION GENERALGENERAL PREPARATION PREPARATION

HYDROELECTROLYTIC AND ACIDO-BASIC BALANCEHYDROELECTROLYTIC AND ACIDO-BASIC BALANCE The hydroelectrolytic balance has two aspects: filling the vascular bed and the The hydroelectrolytic balance has two aspects: filling the vascular bed and the

electrolytic balanceelectrolytic balance The filling of the vascular bed is monitored with the blood pressure in clino and The filling of the vascular bed is monitored with the blood pressure in clino and

orthostantism, diuresis measurement, as well as of central venous pressureorthostantism, diuresis measurement, as well as of central venous pressure Depending on these constant values the hydric balance of the organism will be Depending on these constant values the hydric balance of the organism will be

calculated (input and losses) and one should try to correct the unbalance using different calculated (input and losses) and one should try to correct the unbalance using different solutions (physiological serum, Ringer solution, glucose 5% or 10% to which one may solutions (physiological serum, Ringer solution, glucose 5% or 10% to which one may add various chlorides in case of dehydration or macromolecules in case of hemorrhage). add various chlorides in case of dehydration or macromolecules in case of hemorrhage). The solutions used should be normotonic, the hypertonic ones having limited indications The solutions used should be normotonic, the hypertonic ones having limited indications (patients with severe brain disorders). Refilling the vascular bed is (patients with severe brain disorders). Refilling the vascular bed is performedperformed gradually gradually during the preoperative period having the role to prevent the drops of blood pressure or during the preoperative period having the role to prevent the drops of blood pressure or even vascular collapse and exitus during the surgical interventioneven vascular collapse and exitus during the surgical intervention

The electrolytic and acido-basic unbalance needs to be balanced according to the The electrolytic and acido-basic unbalance needs to be balanced according to the ionogram and the blood pH. In case the kidney function is affected the preoperative ionogram and the blood pH. In case the kidney function is affected the preoperative dialysis may be useful that will reestablish the electrolytic and acido-basic balancedialysis may be useful that will reestablish the electrolytic and acido-basic balance

In case of hemorrhages with great losses of blood it is necessary to restore not only the In case of hemorrhages with great losses of blood it is necessary to restore not only the circulating volume but also to restore the hemoglobin quantity which may ensure an circulating volume but also to restore the hemoglobin quantity which may ensure an appropriate transport of oxygen in the tissues (the “surgical ceiling” when one may appropriate transport of oxygen in the tissues (the “surgical ceiling” when one may proceed in safety conditions is of 10gHg/100ml blood)proceed in safety conditions is of 10gHg/100ml blood)

PHYSICAL PREPARATIONPHYSICAL PREPARATIONGENERALGENERAL PREPARATION PREPARATION

NUTRITIONAL PREPARATION NUTRITIONAL PREPARATION It represents an important aspect of the preoperative It represents an important aspect of the preoperative

preparation because a denutrited patient cannot preparation because a denutrited patient cannot epithelize and iepithelize and itts immune system will be deficient, not s immune system will be deficient, not being able to defend itself against infectionsbeing able to defend itself against infections

It is recommended that whenever possible the It is recommended that whenever possible the patient’s postoperative nutritional state should be the patient’s postoperative nutritional state should be the best possible. In emergency situations when the best possible. In emergency situations when the patient’s life depends upon the surgical intervention, patient’s life depends upon the surgical intervention, the nutritional recovery will be done after the the nutritional recovery will be done after the operationoperation

The nutritional recovery can be carried out in two The nutritional recovery can be carried out in two ways:ways: potential route and and enteral route



NUTRITIONAL PREPARATION – PARENTERAL NUTRITIONAL PREPARATION – PARENTERAL ROUTEROUTE

It uses glucose solutions, special nutritive It uses glucose solutions, special nutritive solutions for parenteral administration (they solutions for parenteral administration (they are very expensive)are very expensive)

It is recommended to the cases with minor It is recommended to the cases with minor nutritional deficitnutritional deficit

It can also be used for patients with diabetes It can also be used for patients with diabetes using as energetic support the glucose using as energetic support the glucose dabbed with insulindabbed with insulin


NUTRITIONAL PREPARATION – ENTERAL NUTRITIONAL PREPARATION – ENTERAL ROUTEROUTE

TherTheree are used hypercaloric substances are used hypercaloric substances (Fresubin)(Fresubin)

It can be used when the digestive tube is It can be used when the digestive tube is functional, allowing the absofunctional, allowing the absorprption and tion and digestion of food principles, if not the digestion of food principles, if not the parenteral routeparenteral route may usemay usedd

PHYSICAL PREPARATIONPHYSICAL PREPARATIONSYSTEMIC PREPARATIONSYSTEMIC PREPARATION

It needs the evaluation and support It needs the evaluation and support ofof all apparatuses and systems: all apparatuses and systems:

Cardiovascular apparatus Respiratory apparatus Renal function Hepatic function Neurological



CARDIOVASCULAR APPARATUSCARDIOVASCULAR APPARATUS The score for establishing the risk The score for establishing the risk of postoperative cardiac morbidityof postoperative cardiac morbidity or mortality (table). or mortality (table). Maximum score is 53 points.Maximum score is 53 points.A score over 28 pointsA score over 28 pointsdetermines postponing the surgical intervention determines postponing the surgical intervention Other risk factors: smoking, diabetes, blood Other risk factors: smoking, diabetes, blood

pressure, hyperlipaemia, unstable angina pectoris, pressure, hyperlipaemia, unstable angina pectoris, rhythm disorders, valvulopathiesrhythm disorders, valvulopathies

HISTORYHISTORY

>>70 70 yearsyears 5p5p

IMA the last 6 monthsIMA the last 6 months 1010pp

CLINICAL EXAMCLINICAL EXAM

Gallop S3 or distension of jugular veinGallop S3 or distension of jugular vein 1111pp

Significant aortic stenosisSignificant aortic stenosis 3p3p

EKGEKG

Premature atrial systoles or nonsinus Premature atrial systoles or nonsinus rhythms rhythms

7p7p

>>5 premature ventricular systoles / 5 premature ventricular systoles / minuteminute

7p7p

SURGERYSURGERY

EmergencyEmergency 4p4p

Intraperitoneal or intrathoraric or aorticIntraperitoneal or intrathoraric or aortic 3p3p


RESPIRATORY APPARATUS RESPIRATORY APPARATUS It is useful for the patients with preexisting pulmonary It is useful for the patients with preexisting pulmonary

diseases, for old, obese, sick patients who will need diseases, for old, obese, sick patients who will need extended immobilizationextended immobilization

There will be used bronchodilators, targeted There will be used bronchodilators, targeted antibiotherapyantibiotherapy

RRespiratory gymnastics is recommended especially to the espiratory gymnastics is recommended especially to the patients who are going to undergopatients who are going to undergo a a surgical intervention surgical intervention toto the upper abdominal level or thorax. It involves ample the upper abdominal level or thorax. It involves ample respirations, deep inspiration followed by expulsion of the respirations, deep inspiration followed by expulsion of the ininsspired air into a water bottle by means of a perfusor pired air into a water bottle by means of a perfusor tube, tapotement with efficient coughing to eliminate tube, tapotement with efficient coughing to eliminate secretionssecretions

Smoking is forbidden at least a week before surgery Smoking is forbidden at least a week before surgery (smokers have a state of chronic hypoxia(smokers have a state of chronic hypoxia))


RENAL FUNCTIONRENAL FUNCTION The renal function which was affected after the The renal function which was affected after the

surgery results in a more difficult elimination of surgery results in a more difficult elimination of drugs (anesthetics, nephrotoxic antibiotics), drugs (anesthetics, nephrotoxic antibiotics), needing and adjustment of the doses usedneeding and adjustment of the doses used

For patients who have disFor patients who have diseases of the lower eases of the lower urinary tract, urinary tract, in case of complicate surgeries, at in case of complicate surgeries, at the genital or rectal level, it is recommended to the genital or rectal level, it is recommended to put a catheter in the bladder on the operating put a catheter in the bladder on the operating table after the patient was asleep. The catheter table after the patient was asleep. The catheter will be kept till the spontaneous resumption of will be kept till the spontaneous resumption of mictionsmictions

PHYSICAL PHYSICAL PREPARATIONPREPARATION

SYSTEMIC PREPARATIONSYSTEMIC PREPARATION

HEPATIC FUNCTIONHEPATIC FUNCTION The disorders of the hepatic function The disorders of the hepatic function

manifest themselves by blood coagulation manifest themselves by blood coagulation disorders, nutrition disorders which will disorders, nutrition disorders which will determine deficient cicatrization as well as determine deficient cicatrization as well as metabolimetabolizzation disorders of various ation disorders of various substances with hepatic eliminationsubstances with hepatic elimination

It is necessary to assess hepatic excretion, It is necessary to assess hepatic excretion, hepatic cytolysis, protein synthesis, hepatic cytolysis, protein synthesis, coagulation samplescoagulation samples, etc., etc.

Risk factors: Risk factors: denutrition, ascites, denutrition, ascites, bilirubin bilirubin >>3mg%ml, albumin 3mg%ml, albumin < < 3mg%ml3mg%ml


NEUROLOGICALNEUROLOGICAL It is important to identify the It is important to identify the

neurological pathology that may be neurological pathology that may be aggravated by the anesthesia aggravated by the anesthesia

The patients with motor deficiency The patients with motor deficiency have a higher risk of have a higher risk of postoperatpostoperative ive complicationscomplications

PHYSICAL PREPARATIONPHYSICAL PREPARATIONLOCAL PREPARATIONLOCAL PREPARATION

Local preparation:Local preparation: on the morning of the surgical intervention, on the morning of the surgical intervention, the region where the tegument will be incised will be epilated, the region where the tegument will be incised will be epilated, and then it will be made aseptic with alcohol iodateand then it will be made aseptic with alcohol iodate

Stomach preparation:Stomach preparation: in case o duodenal stenoses the lavage in case o duodenal stenoses the lavage and the aspiration throughand the aspiration through a a naso-gastric tube are naso-gastric tube are recommended to empty the stomach of food remainders and recommended to empty the stomach of food remainders and secretionssecretions

Colon preparation:Colon preparation: will be carried out for all patients who will will be carried out for all patients who will undergo surgical intervention by means of two enemas (the undergo surgical intervention by means of two enemas (the evening beforevening beforee surgery and one surgery and one oon the morning before n the morning before susurrgery). The patients who will undergo colon surgery need gery). The patients who will undergo colon surgery need more laborious preparation which may ensure the complete more laborious preparation which may ensure the complete discharge of the digestive tube of food residues. Thus the day discharge of the digestive tube of food residues. Thus the day before surgery the patient will have a hydric diet, he/she will before surgery the patient will have a hydric diet, he/she will be administered 4 sachets of Fortrans followed by 2 be administered 4 sachets of Fortrans followed by 2 eenemas nemas (one in the evening and the second one (one in the evening and the second one oon the morning n the morning before surgery)before surgery)

PHYSICAL PREPARATIONPHYSICAL PREPARATIONPREVENTION OF POSTOPERATPREVENTION OF POSTOPERATIVEIVE COMPLICATIONS COMPLICATIONS

PreoperatPreoperativeive preparation plays an preparation plays an important role in preventing important role in preventing postoperatpostoperative ive complications complications

The most frequent postoperatThe most frequent postoperative ive complications are: complications are: infections, , thrombembolisms and and organic insufficiency



INFECTIONSINFECTIONS They determine a difficult postopThey determine a difficult postopeeratrativeive recovery delaying the cicatrization, recovery delaying the cicatrization,

extending the convalescence or even with the appearance of septicemiaextending the convalescence or even with the appearance of septicemia.. They may be prevented with a correct preoperatThey may be prevented with a correct preoperativeive preparation depending on the preparation depending on the

surgery that is going to be performed (skin, colon preparation, etc.)surgery that is going to be performed (skin, colon preparation, etc.) Risk factors: old age, obesity, malnutrition, neoplastic problems, diabetes mellitus Risk factors: old age, obesity, malnutrition, neoplastic problems, diabetes mellitus

and its complications, corticosteroid or immunosuppressor treatment, other and its complications, corticosteroid or immunosuppressor treatment, other infections, radiotherapy, adrenocortical insufficiency infections, radiotherapy, adrenocortical insufficiency

Necessary preparations: restoring nutritional status, balancing diabetes (glycaemia Necessary preparations: restoring nutritional status, balancing diabetes (glycaemia below 1,2g%ml), treatment of concomitant infections, solving the adrenocortical below 1,2g%ml), treatment of concomitant infections, solving the adrenocortical insufficiency, prophylaxis with antibiotics, shaving the operating region on the insufficiency, prophylaxis with antibiotics, shaving the operating region on the morning of the surgerymorning of the surgery, etc, etc

Indications for antibioprophylaxis:Indications for antibioprophylaxis:• Neck and head surgery with opening the upper air ways Neck and head surgery with opening the upper air ways • Esophagus surgery (except for the hiatal herniaEsophagus surgery (except for the hiatal hernia• Gastro-duodenal surgery except for uncontrolled hyperacidity Gastro-duodenal surgery except for uncontrolled hyperacidity • Surgery of biliary tract for patients with acute cholecystis, over 70 years old Surgery of biliary tract for patients with acute cholecystis, over 70 years old

who need choledocotomywho need choledocotomy• Bowel resections Bowel resections • Gangrenous acute appendicitis or peritonitis Gangrenous acute appendicitis or peritonitis • Gynecological surgery Gynecological surgery • Prosthetic surgery for different organs: heart, hip, knee, valves, vesselsProsthetic surgery for different organs: heart, hip, knee, valves, vessels

PHYSICAL PREPARATIONPHYSICAL PREPARATIONPREVENTION OF POSTOPERATPREVENTION OF POSTOPERATTIVETIVE COMPLICATIONS COMPLICATIONS

THROMBEMBOLISMTHROMBEMBOLISM The risk of appearance of thromboembolisms The risk of appearance of thromboembolisms

increases: if the duration of the intervention increases: if the duration of the intervention exceeds exceeds oneone hour, obesity, blood hour, obesity, blood hypercoagulability, antecedent of vascular hypercoagulability, antecedent of vascular thrombosis, pelvic surgery, treatment with thrombosis, pelvic surgery, treatment with oral conoral contratraceptive ceptive pillspills

Prevention: elastic bandages on the lower Prevention: elastic bandages on the lower limbs to ensure higher return pressurelimbs to ensure higher return pressure, , precocious postoperatprecocious postoperativeive mobilization, mobilization, prophylaxis with anticoagulant medicines prophylaxis with anticoagulant medicines (normocoagulant dose)(normocoagulant dose)


ORGANIC INSUFFICIENCYORGANIC INSUFFICIENCY Respiratory apparatus: Respiratory apparatus: pneumonias, broncho-pneumonias, broncho-

pneumonias, respiratory insufficiency, respiratory pneumonias, respiratory insufficiency, respiratory distress syndrome distress syndrome

Heart system:Heart system: rhythm disorders, cardiac rhythm disorders, cardiac insufficiency, myocardial infarctioninsufficiency, myocardial infarction

Hepatic function: Hepatic function: coagulation disorders, hepatic coagulation disorders, hepatic insufficiencyinsufficiency

Urinary system:Urinary system: acute renal insufficiency acute renal insufficiency Neurological system: Neurological system: comacoma The correct PREOPERATIVE EVALUATION allows The correct PREOPERATIVE EVALUATION allows

identifyingidentifying the risk factors for these possible the risk factors for these possible complications and at the same time preventing their complications and at the same time preventing their appearance by measures specific to each systemappearance by measures specific to each system

SURGERY TIMESURGERY TIME

Programming the surgery time Programming the surgery time differs from differs from elective surgery to to emergency surgery


SURGERY TIMESURGERY TIMEELECTIVE SURGERYELECTIVE SURGERY

The choice of surgery time is very important in The choice of surgery time is very important in elective surgeryelective surgery

Its choice depends on the patient, surgeon and Its choice depends on the patient, surgeon and anesthetistanesthetist

The patient has to be prepared having a good The patient has to be prepared having a good general physical and mental condition, good general physical and mental condition, good enough to be able to undergo the surgery and the enough to be able to undergo the surgery and the postoperative evolution and recovery which should postoperative evolution and recovery which should be as fast as possiblebe as fast as possible

As to the surgeon, it is necessary for him/her to go As to the surgeon, it is necessary for him/her to go through all the stages of the preoperative through all the stages of the preoperative preparation and to establish the surgical techniquepreparation and to establish the surgical technique

These requirements are also necessary for the These requirements are also necessary for the anesthetistanesthetist

SURGERY TIME SURGERY TIME EMERGENCY SURGERYEMERGENCY SURGERY

Depending on the seriousness of the situation Depending on the seriousness of the situation the preoperative preparation may be skipped the preoperative preparation may be skipped (massive hemorrhages) or it may be partially (massive hemorrhages) or it may be partially replaced in the preoperative room and replaced in the preoperative room and continued postoperativecontinued postoperativelyly (bowel occlusions) (bowel occlusions)

So there may be:So there may be:• Immediate emergenciesImmediate emergencies• Emergencies postponed for the immediate Emergencies postponed for the immediate

following period – 24 hoursfollowing period – 24 hours• Emergencies postponed for later – up to 7 Emergencies postponed for later – up to 7

daysdays

POSTOPERATPOSTOPERATIVEIVECARECARE

DEFINITIONS

PURPOSE AND PRINCIPLES

CONTENTCLICK WITH THE MOUSE ON EACH TITLE

DEFINIDEFINITIONTION It varies depending on the anesthesia type: local, It varies depending on the anesthesia type: local,

rahianesthesia, generalrahianesthesia, general Postoperative periods: Postoperative periods:

• Immediate (post-anesthesia):Immediate (post-anesthesia): the patient recovers the patient recovers consciousness and consciousness and the the vital functions are stablevital functions are stable

• Intermediate: it takes from the complete recovery Intermediate: it takes from the complete recovery after anesthesia till after anesthesia till the the dischargedischarge from hospital from hospital

• Belated (convalescence): starts on discharge when the Belated (convalescence): starts on discharge when the patient has stable vital functions and a cicatrized patient has stable vital functions and a cicatrized wound and continues at homewound and continues at home

The postoperative care involves the The postoperative care involves the clinical and and paraclinical paraclinical monitoring of the patient of the patient

Monitoring represents observation, registration and Monitoring represents observation, registration and detection by clinical observation or paraclinical methods detection by clinical observation or paraclinical methods of the patient’s stateof the patient’s state



Monitoring is carried out Monitoring is carried out in order toin order to detect detect any change of the patient’s state to a any change of the patient’s state to a possible complication as well as to a possible complication as well as to a favorable evolution, and also in order to favorable evolution, and also in order to take the necessary compensatory otake the necessary compensatory orr support measures for rapid healingsupport measures for rapid healing

The most important The most important principle principle is careful and is careful and complete monitoring of the patient’s state complete monitoring of the patient’s state which will allow adopting the necessary which will allow adopting the necessary measures for a favorable evolutionmeasures for a favorable evolution

CLINICCLINICALAL MONITORI MONITORINGNG

It starts on the operating table and continues until the It starts on the operating table and continues until the patient’s dischargepatient’s discharge

It will be carried out following a certain schedule It will be carried out following a certain schedule which will allow the temporary distribution of the which will allow the temporary distribution of the clinical parameters during the dayclinical parameters during the day

Parameters watched: state of consciousness, facies, Parameters watched: state of consciousness, facies, tongue, tegument and mucous color, cutaneous tongue, tegument and mucous color, cutaneous foldfold, , breathing frequency and amplitude, frequency of breathing frequency and amplitude, frequency of central and peripheral pulse, blood pressure, diucentral and peripheral pulse, blood pressure, diurresis esis in 24 hours, operatory wound aspect, drainages (flow in 24 hours, operatory wound aspect, drainages (flow rate, aspect), functioning of venous catheters, rate, aspect), functioning of venous catheters, patient’s mobilization, resumption of bowel transit for patient’s mobilization, resumption of bowel transit for gas and feacesgas and feaces

PARACLINICPARACLINICALAL MONITORI MONITORINGNG

Definition: Definition: it represents a series of it represents a series of measures intended to watch the patient’s measures intended to watch the patient’s conditioncondition

Indications:Indications:• It is useful because a surgical patient It is useful because a surgical patient

carries a risk of complications of different carries a risk of complications of different gravity, which have to be preventedgravity, which have to be prevented

• The unconscious patients, who cannot The unconscious patients, who cannot describe the changes that come up in describe the changes that come up in their evolution, need special monitoringtheir evolution, need special monitoring


Contraindications: Contraindications: any patient has to be any patient has to be monitored, the only contraindication being monitored, the only contraindication being represented by the economic criterion represented by the economic criterion (very expensive costs)(very expensive costs)

Necessary materials:Necessary materials: various devices and various devices and apparatuses are necessary in order to apparatuses are necessary in order to measure body weight, temperature, blood measure body weight, temperature, blood pressure, breathing frequency and pressure, breathing frequency and amplitude, quantity of ingested fluids, amplitude, quantity of ingested fluids, blood tests, (ionogram, blood ph), blood tests, (ionogram, blood ph), electrocardiogram, sfigmogram, etc.electrocardiogram, sfigmogram, etc.


The patient lies on the bed in a position as The patient lies on the bed in a position as close to the anatomic oneclose to the anatomic one as possible as possible, he/she , he/she has to take off his/her clothes so that the has to take off his/her clothes so that the access to any anatomic region may be easy access to any anatomic region may be easy

All sensors and necessary catheters have to be All sensors and necessary catheters have to be monitored monitored

Standard monitoring includes: measurement of includes: measurement of blood pressure, body temperature, breathing blood pressure, body temperature, breathing frequency, diuresis and state of consciousness frequency, diuresis and state of consciousness

Special monitoring vary depending on the vary depending on the patient’s pathologypatient’s pathology


STANDARDSTANDARD PARACLINIC PARACLINICALAL MONITORI MONITORINGNG

BLOOD PRESSURE BLOOD PRESSURE Normal values: systolic – 90-160mmHg, diastolic – 60-Normal values: systolic – 90-160mmHg, diastolic – 60-

90mmHg90mmHg Technique: manually with tensiometer and stethoscope or Technique: manually with tensiometer and stethoscope or

by means of an electric apparatus by means of an electric apparatus

PULSEPULSE Normal values: 60-80 beats / minuteNormal values: 60-80 beats / minute Technique: manually by direct palpation or with the Technique: manually by direct palpation or with the

sfigmometer sensor; to be measured for 30 seconds sfigmometer sensor; to be measured for 30 seconds minimum, simultaneously with heart auscultationminimum, simultaneously with heart auscultation

Tachycardia = pulse Tachycardia = pulse > 100 > 100 beats / minutebeats / minute Bradycardia = pulse < 60 Bradycardia = pulse < 60 beats / minutebeats / minute


BODY TEMPERATURE BODY TEMPERATURE Normal valuesNormal values: 36-37°C: 36-37°C The most accurate is intrarectal measurement The most accurate is intrarectal measurement

of body temperature of body temperature The most used method is to measure The most used method is to measure

temperature in the axillary regiontemperature in the axillary region

BREATHING FREQUENCY BREATHING FREQUENCY Normal valuesNormal values: 10-16/minute: 10-16/minute Technique: direct count or nasal sensor Technique: direct count or nasal sensor Tachypnea = over 20 respirations/minuteTachypnea = over 20 respirations/minute Bradypnea = below 8 respirations/minuteBradypnea = below 8 respirations/minute


DIURESISDIURESIS Normal flow rate 1ml/kg/hNormal flow rate 1ml/kg/h Technique: to be measured the Technique: to be measured the amount of amount of urine urine

gathered in a gradated recipient which is gathered in a gradated recipient which is connected to the urinary probeconnected to the urinary probe

Oliguria = below 400 ml/24hOliguria = below 400 ml/24h Anuria = below 200ml/24hAnuria = below 200ml/24h

STATE OF CONSCIOUSNESSSTATE OF CONSCIOUSNESS


SPECIAL MONITORINGSPECIAL MONITORING CardiociCardiocirrculatory disorders:culatory disorders: central venous pressure, central venous pressure,

medium pressure in the pulmonary artery, pressure medium pressure in the pulmonary artery, pressure at the extremity of the pulmonary capillaries, at the extremity of the pulmonary capillaries, plasma osmolarity, hemoglobin and hematocrit plasma osmolarity, hemoglobin and hematocrit values, oxygen saturation of arterial bloodvalues, oxygen saturation of arterial blood

Respiratory function:Respiratory function: lip color, psychomotory lip color, psychomotory agitation, capnometry, amount of oxygen and agitation, capnometry, amount of oxygen and carbon dioxide in blood, value of alkaline reserve carbon dioxide in blood, value of alkaline reserve and serum lactates and serum lactates

Renal function:Renal function: value of urea and serum creatinin, value of urea and serum creatinin, urea and blood osmolarity, creatinin clearance, urea and blood osmolarity, creatinin clearance, ionogramionogram

To see if the tissues function correctly you need an To see if the tissues function correctly you need an evaluation of how evaluation of how oxygen is used in the tissuesoxygen is used in the tissues, and , and this process needs complex equipment this process needs complex equipment

The instruments used to monitor the patient haThe instruments used to monitor the patient haveve to be take to be takenn care of care of compliant to the following requirements:compliant to the following requirements:• All materials used shall be sterile, for single-use only All materials used shall be sterile, for single-use only • The orotracheal intubation probe shall be aspired and changed The orotracheal intubation probe shall be aspired and changed

regularly regularly • The vascular catheters shall be kept permeable by washing them The vascular catheters shall be kept permeable by washing them

with heparin with heparin • The digestive aspiration probe shall be aspired and washed The digestive aspiration probe shall be aspired and washed

regularly and iregularly and iff necessary repositioned or changed necessary repositioned or changed • The urinary probe shall beThe urinary probe shall be regularly washed with antiseptic regularly washed with antiseptic

solutions solutions The patient needs to be ensured local and general rigorous hygiene to The patient needs to be ensured local and general rigorous hygiene to

prevent complications (decubitus escharres, etc.)prevent complications (decubitus escharres, etc.) The patient’s nutrition shall be carried out depending on the patient’s The patient’s nutrition shall be carried out depending on the patient’s

condition: parenterally or orallycondition: parenterally or orally

CARDIO-CARDIO-PULMONAPULMONARRYYRESUSCITARESUSCITATIONTION

DEFINITION, PURPOSE, PRINCIPLES

INDICATIONS

CONTRAINDICATIONS

NECESSARY MATERIALS

TECHNIQUE

POSTRESUSCITATION CARE

INCIDENTS, ACCIDENTS, COMPLICATIONS

CONTENTCLICK WITH THE MOUSE ON EACH TITLE

DEFINITION, PURPOSE, DEFINITION, PURPOSE, PRINCIPLESPRINCIPLES

They represent all therapeutic measures to be applied in They represent all therapeutic measures to be applied in emergency, in cardiac arrest, in order to recover the vital emergency, in cardiac arrest, in order to recover the vital functionsfunctions

The cardiac arrest diagnosis has to be established quickly and the The cardiac arrest diagnosis has to be established quickly and the resuscitation maneuvers have to be performed resuscitation maneuvers have to be performed within within very short very short time from the beginning of the cardiac arrest and they also have time from the beginning of the cardiac arrest and they also have to performed fast in order to prevent the appearance of to performed fast in order to prevent the appearance of irreversible damage of the organs (6 minutes after the beginning irreversible damage of the organs (6 minutes after the beginning of the cardiac arrest the neurons suffer damage, any resuscitation of the cardiac arrest the neurons suffer damage, any resuscitation method becoming useless)method becoming useless)

The maneuvers have to be correctly performed in order to be The maneuvers have to be correctly performed in order to be efficient efficient

Diagnosis Diagnosis • Cardiac arrest: lack of heart beats, lack of peripheral pulse, Cardiac arrest: lack of heart beats, lack of peripheral pulse,

lack of carotid pulse, low blood pressurelack of carotid pulse, low blood pressure• Pulmonary arrest: disappearance of respiratory movements, Pulmonary arrest: disappearance of respiratory movements,

peripheral cyanosis, mydriasis, lack consciousness, drop of peripheral cyanosis, mydriasis, lack consciousness, drop of sphincter tonussphincter tonus

Mnemotechnical formulas: Mnemotechnical formulas: ABCDEFGHI, , HELP MECLICK WITH THE MOUSE ON THE UNDERLINED WORDS

INDICATIONSINDICATIONS Arrest of cardiac Arrest of cardiac andand respiratory respiratory

function:function:• Ventricular fibrillationVentricular fibrillation• Cardiac asystoleCardiac asystole• Apnea of central originApnea of central origin• Obstructions of upper airway Obstructions of upper airway • Posttraumatic Posttraumatic

CONTRAINDICATIONSCONTRAINDICATIONS Cardiopulmonary resuscitation is Cardiopulmonary resuscitation is

contraindicated only when it is useless:contraindicated only when it is useless:• More than 7 minutes from the beginning More than 7 minutes from the beginning

of the cardiac arrest (relative of the cardiac arrest (relative contraindication)contraindication)

• Unrecoverable patientUnrecoverable patient• Biological death (they are maintained in Biological death (they are maintained in

this state for organ donation)this state for organ donation)• Multiple organic failureMultiple organic failure

NECESSARY NECESSARY MATERIALS MATERIALS

Oxygen mask Oxygen mask Oxygen pumpOxygen pump Guedel pipeGuedel pipe LarhyngoscopeLarhyngoscope Intubation cannulaIntubation cannula DefibrillatorDefibrillator EKG monitor EKG monitor Flexules for venous catheters Flexules for venous catheters Equipment for venous denudation Equipment for venous denudation Syringes, needlesSyringes, needles DrugDrugs for emergenciess for emergencies

PHOTO

OXYGEN MASKS OXYGEN PUMP (AMBU)

GUEDEL PIPE

LARHYNGOSCOPE OROTRACHEAL INTUBATION CANNULA

TECHNIQUETECHNIQUE The patient will be removed from the The patient will be removed from the

action of the nocuous factors (place of action of the nocuous factors (place of accident, etc.)accident, etc.)

The patient will be lain on the back The patient will be lain on the back The reanimator or reanimators should be The reanimator or reanimators should be

at the same level with the patient, if there at the same level with the patient, if there is only one savior this one will place is only one savior this one will place himself/herself on the left, if there are two, himself/herself on the left, if there are two, the one who will perform cardiac the one who will perform cardiac resuscitation will stay on the left and the resuscitation will stay on the left and the one who will perform artificial respiration one who will perform artificial respiration will stay on the rightwill stay on the right

INTERNAL CARDIAC MASSAGE DEFIBRILLATION

TECHNIQUETECHNIQUE Deconstruction of upper airway Deconstruction of upper airway Keeping it free: Guedel pipe, anterior mandible dislocation Keeping it free: Guedel pipe, anterior mandible dislocation Pinch the patient’s nostrils with the fingers of the right hand and give two Pinch the patient’s nostrils with the fingers of the right hand and give two

full breaths. The rhythm is of 12 breaths per minute full breaths. The rhythm is of 12 breaths per minute External cardiac massage has to be performed in the lower 1/3 of the External cardiac massage has to be performed in the lower 1/3 of the

sternum with the right hand positioned on the left hand so that the fingers sternum with the right hand positioned on the left hand so that the fingers of the left hand may not touch the thorax (this position offers maximum of the left hand may not touch the thorax (this position offers maximum pressure on minimum thoracic surface). The depression of the thorax shall pressure on minimum thoracic surface). The depression of the thorax shall be done on 4 cm minimum. The rhythm is of 80-90 compressions per be done on 4 cm minimum. The rhythm is of 80-90 compressions per minuteminute

Efficiency may be followed by the appearance of Efficiency may be followed by the appearance of the the peripheral pulse after peripheral pulse after the sternum compressions, the sternum compressions, the the extremities regain color again, extremities regain color again, disappearance of mydriasisdisappearance of mydriasis

For the new born child and little child the resuscitation will be performed For the new born child and little child the resuscitation will be performed with three fingerswith three fingers

The resuscitation will continue after the appearance of spontaneous pulse The resuscitation will continue after the appearance of spontaneous pulse because there the risk that the cardiac arrest may start again due to because there the risk that the cardiac arrest may start again due to hypoxiahypoxia

In case the resuscitation maneuvers are inefficient, they will be interrupted In case the resuscitation maneuvers are inefficient, they will be interrupted when they become useless (reappearance of clinical signs of hypoxia, fixity when they become useless (reappearance of clinical signs of hypoxia, fixity of mydriasis)of mydriasis)

Reanimator Reanimator No.No.

Breath no.Breath no. Compression Compression no. no.

11 22 3030

22 11 55

INTERNINTERNAL AL CARDIACCARDIAC MASSAGEMASSAGE

Incision in the left 4Incision in the left 4thth intercostal intercostal spacespace

Take the heart in the right hand with Take the heart in the right hand with the left ventricle in the palm and the left ventricle in the palm and squeeze it with a frequency of 80-90 squeeze it with a frequency of 80-90 per minuteper minute

At the same time At the same time perform perform artificial artificial respirationrespiration

DEFIBRILDEFIBRILLATIONLATION Start external cardiac massage Start external cardiac massage

simultaneously with the artificial respiration simultaneously with the artificial respiration If the patient does not respond to the If the patient does not respond to the

resuscitationresuscitation,, continue with the stimulation of continue with the stimulation of cardiac activity using electric shocks cardiac activity using electric shocks produced by the defibrillator (150-400 W/sec)produced by the defibrillator (150-400 W/sec)

Electric stimulation may be repeated, and at Electric stimulation may be repeated, and at the same time efficient medication has to be the same time efficient medication has to be administered compliant to the resuscitation administered compliant to the resuscitation protocols (adrenalin, atropine, dopamine, protocols (adrenalin, atropine, dopamine, lidocaine, sodium bicarbonate, calcium lidocaine, sodium bicarbonate, calcium blockers, antiarrhythmic agents, etc.)blockers, antiarrhythmic agents, etc.)

ABCDEFGHIABCDEFGHI A (airways): permeable respiratory air tractA (airways): permeable respiratory air tract B (breath): artificial respirationB (breath): artificial respiration C (circulation): restoring circulatory functionC (circulation): restoring circulatory function D (drugs): drug administrationD (drugs): drug administration E (EKG): monitoring the cardiac function by EE (EKG): monitoring the cardiac function by EKKGG F (fibrillation): electric defibrillatorF (fibrillation): electric defibrillator G: establishing the diagnosis that determined the G: establishing the diagnosis that determined the

cardiac arrestcardiac arrest H: neuropsychic therapyH: neuropsychic therapy I (intensive care): intensive care serviceI (intensive care): intensive care service

HELP MEHELP ME(BEJAN)(BEJAN)

H: head hyperextensionH: head hyperextension E: clearing upper airway (foreign bodies, E: clearing upper airway (foreign bodies,

secretions)secretions) L: anterior luxation of the jawL: anterior luxation of the jaw P: nose pinching, mouth-to-mouth P: nose pinching, mouth-to-mouth

resuscitationresuscitation

MM EE

External cardiac massage

POSTPOSTRESUSCITARESUSCITATION CARETION CARE

The patient will still be kept under medical The patient will still be kept under medical supervision because there is the risk that supervision because there is the risk that the cardiac arrest may start again or of the cardiac arrest may start again or of appearance of complicationsappearance of complications

Administer oxygenAdminister oxygen Correct hydro-electrolytic and acido-basic Correct hydro-electrolytic and acido-basic

unbalancesunbalances Do not administer glucose (risk of Do not administer glucose (risk of

hyperglycemia and damage of nervous hyperglycemia and damage of nervous function)function)

INCIDENTINCIDENTSS, ACCIDENT, ACCIDENTSS, , COMPLICACOMPLICATIONSTIONS

Respiratory function: tongue swallowing, loss of Respiratory function: tongue swallowing, loss of insufflated air near the mask or thinsufflated air near the mask or thrrough the ough the nostrils, rupture of pulmonary parenchyma leading nostrils, rupture of pulmonary parenchyma leading to the appearance of pneumothorax due to the to the appearance of pneumothorax due to the insufflation of a too large amount of airinsufflation of a too large amount of air

Cardiac function:Cardiac function:• External cardiac massage: rib and sternum External cardiac massage: rib and sternum

fractures which may induce secondary lesions fractures which may induce secondary lesions (lung, pericardium, liver lesions)(lung, pericardium, liver lesions)

• Internal cardiac massage: myocardial ischemia, Internal cardiac massage: myocardial ischemia, heart rupture, dheart rupture, diisinsertion of large vesselssinsertion of large vessels

• Defibrillation: tegument burns, ventricular Defibrillation: tegument burns, ventricular fibrillationfibrillation

BLOOD TRANSFUSIONBLOOD TRANSFUSION


INDICATIONS

CONTRAINDICATIONS

NECESSARY MATERIALS

BLOOD GROUP DETERMINATION

DIRECT COMPATIBILITY TEST

TECHNIQUE


CARE

CONTENTSCLIC WITH THE MOUSE ON THE UNDERLINED TITLES


DefiniDefinitiontion:: it is a method used to it is a method used to introduce blood, introduce blood, erythrocyteserythrocytes or or plasma in the patient’s plasma in the patient’s cardiocirculatory system cardiocirculatory system

TransfuTransfusion has as a sion has as a purposepurpose to to correct the patient’s blood deficitscorrect the patient’s blood deficits (volum(volumee, erythrocytes, , erythrocytes, plasma factorsplasma factors))

PrincipPrinciplele:: perfect compatibility perfect compatibility between the doner and the receiver between the doner and the receiver is compulsoryis compulsory

INDICATIONSINDICATIONS

Great losses of blood volume Great losses of blood volume ((massive massive hemorhemorrhrhagageses))

Increase of oxygen transport Increase of oxygen transport ((serious serious anaemiasanaemias))

Deficit Deficit of coagulation factors of coagulation factors (hemo(hemophphilia)ilia)

CONTRAINDICATIONSCONTRAINDICATIONS Arterial hypertension, right Arterial hypertension, right

ventricular decompensation ventricular decompensation (heart surcharge)(heart surcharge)

Pulmonary diseases: Pulmonary diseases: pneumonias, bronchopneumonias pneumonias, bronchopneumonias (acute pulmonary edema)(acute pulmonary edema)

Thrombophlebitis, venous Thrombophlebitis, venous thromboses (embolisms)thromboses (embolisms)

NECESSARY NECESSARY MATERIALSMATERIALS

Transfusion substance: blood, plasma, Transfusion substance: blood, plasma, erythrocyte mass, cryoprecipitates erythrocyte mass, cryoprecipitates (factor (factor 88, factor , factor 1212))

Heating device for the perfusion substance Heating device for the perfusion substance Perfusor which is provided with a philter for Perfusor which is provided with a philter for

possible microclotspossible microclots Needle for venous punctureNeedle for venous puncture GarrotGarrot Cotton tampon and 70Cotton tampon and 70° alcohol° alcohol GlovesGloves Adhesive bandagesAdhesive bandages

PHOTO

BLOOD GROUP BLOOD GROUP DETERMINATIONDETERMINATION

On a glass strip put a drop of anti-A On a glass strip put a drop of anti-A serum and anti-B serumserum and anti-B serum

Each of them will be mixed with Each of them will be mixed with a drop of the patient’s blood a drop of the patient’s blood

Wait for a few minutes and the results Wait for a few minutes and the results will be interpreted on the microscope will be interpreted on the microscope compliant to the tablecompliant to the table

SerumSerum OO AA BB ABAB

anti-Aanti-A -- lyselyse lyselyse lyselyse

anti-Banti-B -- -- -- lyselyse

BLOOD GROUP BLOOD GROUP DETERMINATIONDETERMINATION

Rh DETERMINATIONRh DETERMINATION

Use a kit of Use a kit of anti-Danti-D serums serums UUse the same technique on the stripse the same technique on the strip The presence of The presence of D D antigen on the red antigen on the red

blood cells determines the blood cells determines the Rh+Rh+ group group

SerumSerum Rh+Rh+ RhRh--

anti-Danti-D lyselyse --

DIRECT COMPATIBILITY DIRECT COMPATIBILITY TESTTEST

Put on a glass strip a drop of the Put on a glass strip a drop of the patient’s blood (receiver) in direct patient’s blood (receiver) in direct contact with a drop of the donated contact with a drop of the donated blood blood

If there is no agglutinationIf there is no agglutination,, then the then the two types of blood are compatible two types of blood are compatible and the transfusion may be made and the transfusion may be made

TECHNIQUETECHNIQUE The patient will be informed on the transfusion The patient will be informed on the transfusion

technique, benefits and disadvantages and its technique, benefits and disadvantages and its agreement has to be obtainedagreement has to be obtained

The patient will be placed in a comfortable The patient will be placed in a comfortable position, preferably in dorsal decubitusposition, preferably in dorsal decubitus

The product to be transfused will be brought to The product to be transfused will be brought to the transfusion the transfusion serviceservice and the direct and the direct compatibility test will me madecompatibility test will me made

Find a new vein into which the preparation will be Find a new vein into which the preparation will be administeredadministered

The administration rhythm is of 50 drops/min 15 The administration rhythm is of 50 drops/min 15 minutes (to observe possible adverse reactions), minutes (to observe possible adverse reactions), then 60-80 drops/minute. For emergencies a unit then 60-80 drops/minute. For emergencies a unit (500 ml) may be administered in 10 minutes.(500 ml) may be administered in 10 minutes.

INCIDENTS, ACCIDENTS, INCIDENTS, ACCIDENTS, COMPLICATIONSCOMPLICATIONS

Precocious hemolytic reaction: cephalea, fever, shiver, Precocious hemolytic reaction: cephalea, fever, shiver, lumbar pain, tachycardia, hypotension, respiratory lumbar pain, tachycardia, hypotension, respiratory problems, hematuriaproblems, hematuria

Late hemolytic reaction: unexplainable icterus, Late hemolytic reaction: unexplainable icterus, decrease of hemoglobindecrease of hemoglobin

Fever Fever ± shiver. If the temperature increases by more ± shiver. If the temperature increases by more than one degree Celsius the transfusion will be than one degree Celsius the transfusion will be stoppedstopped

Allergic reaction: urticaria, pruritus, rash, wheezing, Allergic reaction: urticaria, pruritus, rash, wheezing, fever, shiverfever, shiver

Bacterial contamination of transfused blood Bacterial contamination of transfused blood Immune reactions (pulmonary edema, excessive Immune reactions (pulmonary edema, excessive

bleeding), hypothermia, hyperpotassemia, bleeding), hypothermia, hyperpotassemia, hypocalcemia, acidose, thrombophlebitis, embolihypocalcemia, acidose, thrombophlebitis, embolismsms, s, transmission of certain diseases (hepatitis B, C, AIDS, transmission of certain diseases (hepatitis B, C, AIDS, cytomegalovirus, syphilis, etc.)cytomegalovirus, syphilis, etc.)

CARECARE The flask label will be stuck in the patient’s The flask label will be stuck in the patient’s

observation sheet observation sheet 15 minutes after starting the perfusion the vital signs 15 minutes after starting the perfusion the vital signs

will be monitored (pulse, tension, breathing will be monitored (pulse, tension, breathing frequency) as well as the existence of possible frequency) as well as the existence of possible adverse reactionsadverse reactions

At that moment if there are no incidents the At that moment if there are no incidents the transfusion rhythm will be increasedtransfusion rhythm will be increased

The patient will be checked every 30 minutesThe patient will be checked every 30 minutes At the end of the transfusion the vital signs will be At the end of the transfusion the vital signs will be

checked again and the diuresis, and they will be checked again and the diuresis, and they will be written down in the observation sheetwritten down in the observation sheet

The catheter will be cleaned with physiological serum The catheter will be cleaned with physiological serum The packages will be returned to the transfusion The packages will be returned to the transfusion

serviceservice

INJECTIONSINJECTIONSDEFINITION, PURPOSE, PRINCIPLES

INJECTION ADVANTAGES

INDICATIONS

CONTRAINDICATIONS

NECESSARY MATERIALS

STANDARD TECHNIQUE

INJECTION TYPES


CARE

CONTENTCLIC WITH THE MOUSE ON EACH TITLE

DEFINIDEFINITIONTION, , PURPOSEPURPOSE, , PRINCIPPRINCIPLESLES

Definition:Definition: it is a method used it is a method used to introduce in the body different to introduce in the body different medicated substancesmedicated substances

Purpose:Purpose: therapeutic, diagnosis therapeutic, diagnosis Principle:Principle: active principles are active principles are

introduced in the organism, by introduced in the organism, by means of needles with lumen, means of needles with lumen, andand are resorbed in the blood are resorbed in the blood that circulates through that regionthat circulates through that region

INJECTION INJECTION AADDVANTAVANTAGESGES

The absorption speed of active principles The absorption speed of active principles is well controlledis well controlled

They avoid hepatic metabolizationThey avoid hepatic metabolization The administered dose is not influenced by The administered dose is not influenced by

digestive absorption (accelerate transit, digestive absorption (accelerate transit, etc.) etc.)

It allows administrating medicines to It allows administrating medicines to uncooperative or unconscious patientsuncooperative or unconscious patients

They avoid the digestive tube: there can They avoid the digestive tube: there can be administered medicines that irritate or be administered medicines that irritate or are not absorbed in the digestive tubeare not absorbed in the digestive tube

INDICAINDICATIONSTIONS Seriously ill patients, for exact dose controlSeriously ill patients, for exact dose control Patients who need a shock dose by rapid Patients who need a shock dose by rapid

absorption (intravenously)absorption (intravenously) Controlled-release preparations which cannot Controlled-release preparations which cannot

be given as tabletsbe given as tablets Patients with digestive intolerancePatients with digestive intolerance Unconscious patientsUnconscious patients Diagnosis purpose (intravenous urography)Diagnosis purpose (intravenous urography) Local anaesthesiaLocal anaesthesia

CONTRAINDICACONTRAINDICATIONSTIONS

HemophiliaHemophilia Anticoagulant treatmentAnticoagulant treatment TetanusTetanus Induction from general anesthesiaInduction from general anesthesia

NECENECESSSARSARYY MATERIAL MATERIALSS

Active substanceActive substance NeedleNeedle Luer tapersLuer tapers Cotton tampons with Cotton tampons with

solution for making solution for making the tegument the tegument asepticaseptic

GarrotGarrot Sterile glovesSterile gloves

PHOTO

PERFUSION SOLUTIONSPERFUSION SOLUTIONS

PERFUSION SOLUTIONSPERFUSION SOLUTIONS

INJECTION TYPESINJECTION TYPES

INTRADERMIC INJECTIONS SUBCUTANEOUS INJECTIONS INTRAMUSCULAR INJECTIONS INTRAVENOUS INJECTIONS INTRA-ARTERIAL INJECTIONS


STANDARDSTANDARD TETECCHNIHNIQUEQUE

The patient will be informed on the manoeuvre to be performed, The patient will be informed on the manoeuvre to be performed, obtaining his agreement obtaining his agreement

The patient will be placed in The patient will be placed in a a comfortable position depending on the comfortable position depending on the injection type to be administeredinjection type to be administered

The vial or ampoule containing the active substance will be opened, the The vial or ampoule containing the active substance will be opened, the vial neck will be sterilize by singing it with a flame and then the content vial neck will be sterilize by singing it with a flame and then the content will be aspired in the taperwill be aspired in the taper

The needle used to aspire the substance will be changed with another The needle used to aspire the substance will be changed with another sterile needle in order to perform the injectionsterile needle in order to perform the injection

If necessaryIf necessary,, apply the garrot apply the garrot Make aseptic the region where the injection has to be made by rubbing it Make aseptic the region where the injection has to be made by rubbing it

with an alcohol tamponwith an alcohol tampon Take off the protecting cap from the needleTake off the protecting cap from the needle, , puncture the skin and the puncture the skin and the

other anatomic structures till the other anatomic structures till the plane plane where where youyou want to get to want to get to Slightly aspire into the taper to see if the position is correct (vein – dark Slightly aspire into the taper to see if the position is correct (vein – dark

red, artery – crimson, muscle – no blood)red, artery – crimson, muscle – no blood) Inject the active substance compliant to the indicationsInject the active substance compliant to the indications Take out the needle and the taper Take out the needle and the taper withwith a firm movement a firm movement Massage the injection place to Massage the injection place to performperform the hemostasis the hemostasis The waste will be deposited in recipients specific to each of themThe waste will be deposited in recipients specific to each of them

INTRADERMIC INJECTIONINTRADERMIC INJECTION

Make the tegument asepticMake the tegument aseptic The needle with the tip upwards will be The needle with the tip upwards will be

introduced in the superficial tegument introduced in the superficial tegument until the needle orifice disappears under until the needle orifice disappears under the tegumentthe tegument

Inject the substance from the tapeInject the substance from the tape At the injection place there appears a At the injection place there appears a

tegument deformation as an “orange skin”tegument deformation as an “orange skin” Indications: intradermIndications: intradermicic reactions reactions Injection region: anterior side of the Injection region: anterior side of the

forearmforearm

VIDEO

INTRADERMIC INTRADERMIC INJECTIONINJECTION

TO CONTINUE THE VIDEO CLICK WITH THE MOUSE ON THE IMAGE

SUBCUTANSUBCUTANEOUSEOUS INJEC INJECTIONTION

Make the tegument asepticMake the tegument aseptic Create with the left hand between the Create with the left hand between the

thumb and the forefinger a cutaneousthumb and the forefinger a cutaneous fold fold The needle will be introduced parallel to The needle will be introduced parallel to

the tegument, in the axis of the fold the tegument, in the axis of the fold without penetrating the musclewithout penetrating the muscle

Indications: slow absorption drugsIndications: slow absorption drugs Injection region: external side of the Injection region: external side of the

forearm or thighforearm or thigh

VIDEO

SUBCUTANSUBCUTANEOUSEOUS INJEC INJECTIONTION


INTRAMUSCULARINTRAMUSCULAR INJECTIONINJECTION

Make the region asepticMake the region aseptic With the needle perpendicular to the tegument, With the needle perpendicular to the tegument,

puncture the skin with a firm movement and push puncture the skin with a firm movement and push the needle in the musclethe needle in the muscle

Slightly aspire in the taper (there mustn’t be any Slightly aspire in the taper (there mustn’t be any blood)blood)

Inject all the contents of the taperInject all the contents of the taper With a fast movement take out the needle and With a fast movement take out the needle and

the taperthe taper Massage the regionMassage the region Indications: most medicated substances (oily Indications: most medicated substances (oily

substances will only be administered intramuscularly)substances will only be administered intramuscularly) Injection region: upper-external quadrant of the Injection region: upper-external quadrant of the

buttock, deltoid muscle, quadriceps musclebuttock, deltoid muscle, quadriceps muscle

VIDEO

Picture 036.avi

INTRAMUSCULARINTRAMUSCULAR INJECTION INJECTION


INTRAVENOINTRAVENOUS INJECTIONUS INJECTION

Apply the garrot to determine vein dilation Apply the garrot to determine vein dilation and to make it and to make it visiblevisible

Make the region asepticMake the region aseptic The needle will be positioned on the vein to be The needle will be positioned on the vein to be

punctured, being pushed in the direction of the blood punctured, being pushed in the direction of the blood flowflow

Puncture the veinPuncture the vein Aspire in the taper the venous bloodAspire in the taper the venous blood Inject the contents of the tapper Inject the contents of the tapper Extract the needle from the veinExtract the needle from the vein Perform the hemostasis by compressing the vein for a Perform the hemostasis by compressing the vein for a

few minutes with a cotton tampon imbibed with few minutes with a cotton tampon imbibed with alcoholalcohol

Indications: when the fast absorption of active Indications: when the fast absorption of active principles is useful, administerprinciples is useful, administererer perfusion solutions perfusion solutions

Injection region: veins of upper limb Injection region: veins of upper limb (elbow plica, forearm, hand)(elbow plica, forearm, hand)

VIDEO

INTRAVENOINTRAVENOUS INJECTIONUS INJECTION


INTRAARTERIALINTRAARTERIAL INJEC INJECTIONSTIONS

Make the region asepticMake the region aseptic Detect with the forefinger and the medius of the left hand Detect with the forefinger and the medius of the left hand

the artery pulsationsthe artery pulsations Puncture the skin with the needle perpendicularly on the Puncture the skin with the needle perpendicularly on the

arteryartery Aspire in the taper creating lower pressure, and push the Aspire in the taper creating lower pressure, and push the

needle until red blood appears inside the taperneedle until red blood appears inside the taper Inject the contents Inject the contents Extract the needle firmlyExtract the needle firmly Compress for a few minutes on the injection place with Compress for a few minutes on the injection place with a a

cotton cotton tampon imbibed with alcoholtampon imbibed with alcohol Indications: local anesthesia, chemotherapy Indications: local anesthesia, chemotherapy Injection regionInjection region: radial artery, femoral artery: radial artery, femoral artery

VIDEO

RADIAL ARTERY PUNCTURERADIAL ARTERY PUNCTURE



Local hematomaLocal hematoma Vessel ruptureVessel rupture Tegument, vascular necrosisTegument, vascular necrosis Allergic reactionsAllergic reactions Subcutaneous nodulesSubcutaneous nodules Embolisms Embolisms

CARECARE

Generally, they don’t require special Generally, they don’t require special carecare

A sterile bandage has to be applied A sterile bandage has to be applied on the puncture placeon the puncture place

In case of intravesel injections In case of intravesel injections hemostasis will be performed by hemostasis will be performed by compression for a few minutes with compression for a few minutes with a cotton tampon imbibed with alcohola cotton tampon imbibed with alcohol

INCIINCISIONSSIONSDEFINITION, PURPOSE, PRINCIPLES

INDICATIONS

CONTRAINDICATIONS

NECESSARY MATERIALS

TECHNIQUE


CARE

CONTENT

CLIC WITH THE MOUSE ON EACH TITLE

DEFINIDEFINITIONTION, , PURPOSEPURPOSE, , PRINCIPPRINCIPLESLES

Definition:Definition: they mean cutting tissues with a cutting object they mean cutting tissues with a cutting object Purpose:Purpose: they make access to a certain anatomic structure, pathologic collection or they make access to a certain anatomic structure, pathologic collection or

for explorationfor exploration Principles:Principles:

• The asepsis and antisepsis requirements have to be complied withThe asepsis and antisepsis requirements have to be complied with• Knowing the region anatomyKnowing the region anatomy• Anaesthesia has to be performedAnaesthesia has to be performed• The incision dimensions have to be adapted to the purposeThe incision dimensions have to be adapted to the purpose• The incision orientation has to take into account local The incision orientation has to take into account local innervation so that innervation so that

cicatrization may take place without any complicationscicatrization may take place without any complications• The iThe incision direction has to follow ncision direction has to follow the the force lines on the skin, this way force lines on the skin, this way

avoiding faulty cicatrizationsavoiding faulty cicatrizations• The incision will be performed with a single movement, it has to be regulated The incision will be performed with a single movement, it has to be regulated

and rectilinearand rectilinear• The incision will be madeThe incision will be made plane plane after after planeplane, for deeper , for deeper planesplanes the incision the incision

being shorter thus allowing better closing the wound at the end of the being shorter thus allowing better closing the wound at the end of the interventionintervention

• Point out the important structures and avoid cutting themPoint out the important structures and avoid cutting them• For collections the incisions have to be performed in the maximum fluctuation For collections the incisions have to be performed in the maximum fluctuation

point and their length adapted to the collection lengthpoint and their length adapted to the collection length


Opening Opening purulentpurulent infections infections ExciExcisions of tegument formation or lesionsions of tegument formation or lesion Creating an approach for a certain Creating an approach for a certain

abdominal abdominal oror t thhoracicoracic organorgan Retouch of bad incisionsRetouch of bad incisions Clearing incisions to bring near Clearing incisions to bring near

the margins of the the margins of the wound wound Opening the capsule to get deep Opening the capsule to get deep

into the viscerainto the viscera

CONTRAINDICATIONSCONTRAINDICATIONS HemoHemophphiliailia Anticoagulant tAnticoagulant trreeatment atment TetanusTetanus Induction in general anesthesia Induction in general anesthesia


Sterile soft Sterile soft mmaterial aterial

MateriaMaterials forls for anestanesthheesiasia

ScalpelScalpel Scisors Scisors Saw Saw KnifeKnife

SCALPEL BLADE

ELECTROCAUTERY

TECHNIQUETECHNIQUE The patient will be explained the technique obtaining its written The patient will be explained the technique obtaining its written

agreement for the surgery agreement for the surgery The patient will The patient will be placed in a comfortable position to point out the best be placed in a comfortable position to point out the best

way possible the region where the incision is going to be madeway possible the region where the incision is going to be made The preparation of the operative field will be done compliant to the The preparation of the operative field will be done compliant to the

description in the chapter preoperative description in the chapter preoperative preparation preparation The surgeon will stay on the patient’s right side The surgeon will stay on the patient’s right side ((except for the except for the

interventions in the gynaecological fieldinterventions in the gynaecological field, , pelvic region or left limbspelvic region or left limbs) ) and and its help will stay in front of the operator, on the patient’s left sideits help will stay in front of the operator, on the patient’s left side

(Local, general, rahianesthesia, etc) anesthesia will be performed (Local, general, rahianesthesia, etc) anesthesia will be performed The skin will be kept under tension with the forefinger and medius The skin will be kept under tension with the forefinger and medius of the of the

left handleft hand, , on the same direction but from the other end of the incision on the same direction but from the other end of the incision The incision will be started with the scalpel perpendicularly to the skin, in The incision will be started with the scalpel perpendicularly to the skin, in

an almost vertical position, then it will be oriented to about an almost vertical position, then it will be oriented to about 3030°° The incision will be made in a single movementThe incision will be made in a single movement To the lower angle of the incision the scalpel will be brought again to To the lower angle of the incision the scalpel will be brought again to an an

almost vertical position as to the almost vertical position as to the skinskin Each anatomic plane will be cut in a single movementEach anatomic plane will be cut in a single movement The incision will cut plane after plane till the desired depthThe incision will cut plane after plane till the desired depth

VIDEO 1 VIDEO 2 VIDEO 3

„„CROSS” CROSS” INCIINCISIONSION FOR AN FOR AN ANTANTHHRACOID RACOID ABCESS ABCESS IN THE NAPE REGIONIN THE NAPE REGION


SCALP SCALP INCIINCISION FOR THE EXCISION SION FOR THE EXCISION OF A SEBACEOUS CYSTOF A SEBACEOUS CYST



HemorHemorrhrhagagee due to vessel cuttingdue to vessel cutting HematomHematomasas Nerve damage by intercepting its Nerve damage by intercepting its

path path Damage of internal organs Damage of internal organs Wound infectionWound infection EventraEventrationtion EvisceraEviscerationtion

CARECARE

Daily sterile bandageDaily sterile bandage Lavage with antiseptic Lavage with antiseptic solutions solutions

COLON COLON PREPARATIONPREPARATION


INDICATIONS

CONTRAINDICATIONS

NECESSARY MATERIALS

TECHNIQUE

CONTENT



DefiniDefinitiontion:: mechanical and biological mechanical and biological preparation of the colon in order to be preparation of the colon in order to be explored or for surgeryexplored or for surgery

PurposePurpose:: discharging of feaces from the discharging of feaces from the colon, decreasing the degree of colon, decreasing the degree of contamination of the peritoneal cavity contamination of the peritoneal cavity during the surgical interventionduring the surgical intervention

PrincipPrinciplesles:: it is necessary to eliminate the it is necessary to eliminate the feaces as completely as possiblefeaces as completely as possible


ExplorExplorationsations: rectoscop: rectoscopyy, , colonoscopcolonoscopyy, , barium anema, barium anema, edoluminal ultrasound of the colon edoluminal ultrasound of the colon

DeterminDetermining colon motilitying colon motility Surgical interventions on various Surgical interventions on various

segments of the large intestine segments of the large intestine

CONTRAINDICATIONSCONTRAINDICATIONS Relative: Relative: patient’s influenced state patient’s influenced state

does not allow rigorous preparationdoes not allow rigorous preparation Absolute: Absolute: surgical emergencies, surgical emergencies,

diseases with risk of colon diseases with risk of colon perforation perforation

NECESSARY NECESSARY MATERIALESMATERIALES

PPurgativeurgative drugs drugs Necessary Necessary

materials for materials for perfoming anema perfoming anema

TECHNIQUETECHNIQUE Diet without residues Diet without residues ((milk, yoghourt, cheese, soupmilk, yoghourt, cheese, soup) 2) 2 days before days before

the surgery until 0 time of surgery daythe surgery until 0 time of surgery day, , from that moment on from that moment on suppressing the administration of any food or fluid suppressing the administration of any food or fluid

MedicaMedicationtion• ManitolManitol

The first day the patient will ingest The first day the patient will ingest 250 ml 250 ml of of Manitol Manitol and 3 and 3 liters of fluids minimum liters of fluids minimum

The second day the patient will be administered The second day the patient will be administered 250 ml 250 ml of of Manitol Manitol oral pills and 3 liters of fluids minimumoral pills and 3 liters of fluids minimum. . The evening The evening before and on the morning of the surgery an enema will be before and on the morning of the surgery an enema will be performedperformed

Third day Third day – – surgerysurgery• Fortrans: Fortrans: at 2 p.m. The day before surgery, there will be at 2 p.m. The day before surgery, there will be

administered a sachet of administered a sachet of FortransFortrans dissolved in a litre of water dissolved in a litre of water which will be drunk in about one hourwhich will be drunk in about one hour. . Four sachets of Fortrans Four sachets of Fortrans will be administeredwill be administered. . The evening before and on the morning of The evening before and on the morning of the surgery an enema will be performedthe surgery an enema will be performed

EnemaEnema: : the evening before and on the morning of the the evening before and on the morning of the surgery an enema will be performedsurgery an enema will be performed

At present we don’t administer any antibiotics after the surgery At present we don’t administer any antibiotics after the surgery (they cause (they cause dismicrobismdismicrobismss))

ENEMA VIDEO

ENEMAENEMA

CONTENT

DEFINITION

PURPOSE, PRINCIPLES

NECESSARY MATERIALS

INDICATIONS

CONTRAINDICATIONS

TECHNIQUE

TECHNICAL VARIANTS


CLIC WITH THE MOUSE OF EACH TITLE

DEFINITIONDEFINITION

It is a maneuver used to introduce in It is a maneuver used to introduce in the anal canal at the level of the the anal canal at the level of the lower digestive tube various lower digestive tube various substances intended for discharge, substances intended for discharge, diagnosis or therapydiagnosis or therapy

PURPOSE, PURPOSE, PRINCIPLESPRINCIPLES

DischargeDischarge:: by introducing the fluids in by introducing the fluids in the rectum and colon in the lower part the rectum and colon in the lower part this produces the distention of the this produces the distention of the digestive tract that will determine the digestive tract that will determine the simulation of the peristalsissimulation of the peristalsis, , also soaking also soaking the feaces to determine defecationthe feaces to determine defecation

DiagnosDiagnosisis:: by means of enema one may by means of enema one may introduce introduce radioparadiopaque substances which que substances which allow showing the lesions in the colon, its allow showing the lesions in the colon, its motility and calibermotility and caliber

TThherapeuticerapeuticalal:: it consists in introducing it consists in introducing various active substances especially various active substances especially when other ways of administration are when other ways of administration are inaccessibleinaccessible


GlovesGloves Single-use sterile cannula Single-use sterile cannula LubriLubriccant ant Irrigator Irrigator The substance to be introducedThe substance to be introduced BaBasinsin Protection oilclothProtection oilcloth

PHOTO

PHOTO

PHOTO

PHOTO

NECESSARY MATERIALSNECESSARY MATERIALS

Rectal cannulaIrrigator

Irrigator with the substance

to be administered

NECESSARY MATERIALSNECESSARY MATERIALS

Non sterile gloves

Lubricant


Colon discharge for persons with constipation, old Colon discharge for persons with constipation, old people, cachectic peoplepeople, cachectic people, etc., etc.

Preoperative preparation of the colon and rectumPreoperative preparation of the colon and rectum Enema before a surgery with general anesthesia Enema before a surgery with general anesthesia

((it prevents defecation due to the relaxation of the it prevents defecation due to the relaxation of the anal sphyncteranal sphyncter))

Barium enema for diagnosisBarium enema for diagnosis Medicated enemas Medicated enemas ((in digestivein digestive intolerance) intolerance) Hydrating enema Hydrating enema ((to be administered in a low rate to be administered in a low rate

drop by dropdrop by drop)) Anesthetic enemasAnesthetic enemas

CONTRAINDICATIONSCONTRAINDICATIONS Suspicion of colon perforationSuspicion of colon perforation The pThe patathhologology that makes the bowel wall thinner y that makes the bowel wall thinner

and it induces perforation risk and it induces perforation risk ((bowel bowel infarctinfarctionion, , colitcolitisis, ulcero, ulcero--hemorhemorrhrhagicagic rectocolitis rectocolitis))

Low tumor that may be damaged Low tumor that may be damaged bby this maneuver y this maneuver (rector(rectorrragiagia may appeara may appear) )

In case of barium enemas for low tumors the valve In case of barium enemas for low tumors the valve phenomenon may appear due to the passage of the phenomenon may appear due to the passage of the tumor substance and its retention due to water tumor substance and its retention due to water absorption which forms barium suabsorption which forms barium sullphate stones phate stones which are difficult to eliminate which are difficult to eliminate

IIn diagnosis uncertainty, the barium enema may n diagnosis uncertainty, the barium enema may determine a change of the clinical image which determine a change of the clinical image which may delay the therapeutic indication and aggravate may delay the therapeutic indication and aggravate the general statethe general state

TECHNIQUETECHNIQUE The technique will be explained to the patient, especially the The technique will be explained to the patient, especially the

fact that the substance introduced has to be kept in the colon fact that the substance introduced has to be kept in the colon for at least for at least 15 minute15 minutess. . The patient will lie on the back or on one The patient will lie on the back or on one side side

The oilcloth is put under the patient’s pelvis The oilcloth is put under the patient’s pelvis Put on the gloves, take the lubricated cannula and attach it to Put on the gloves, take the lubricated cannula and attach it to

the irigator the irigator Let some fluid drip to eliminate the air inside the tube Let some fluid drip to eliminate the air inside the tube Introduce the cannula in the patient’s anus, about Introduce the cannula in the patient’s anus, about 8 cm 8 cm being being

cranially and posteriorly orientedcranially and posteriorly oriented Slowly introduce the fluid from the irigator Slowly introduce the fluid from the irigator ((it prevents the it prevents the

sudden distention of the rectal ampulla and the activation of the sudden distention of the rectal ampulla and the activation of the defecation reflex)defecation reflex)

Slowly take out the cannula from theSlowly take out the cannula from the anus, anus, following the following the opposite direction as when it was introduced opposite direction as when it was introduced

Perform local perianal cleaningPerform local perianal cleaning Clean the place where the enema Clean the place where the enema has beenhas been performed performed

VIDEO


BACK TO THE TECHNIQUE FOR COLON PREPRATION

TECHNICAL TECHNICAL VARIANTSVARIANTS

High enema: a long flexible cannula is used, High enema: a long flexible cannula is used, the initial position being in lateral decubitus, the initial position being in lateral decubitus, and then in dorsal decubitus and right and then in dorsal decubitus and right lateral decubituslateral decubitus

Medicated enema: will be performed slowly Medicated enema: will be performed slowly 20-40 drops/minute. A Nelaton probe can be 20-40 drops/minute. A Nelaton probe can be used, which is thinner and shorter used, which is thinner and shorter

Enema for patients with colostom or fecal Enema for patients with colostom or fecal incontinence: insert a Foley probe, and incontinence: insert a Foley probe, and inflate the little balloon in the anal sphincter, inflate the little balloon in the anal sphincter, this way ensuring good continencethis way ensuring good continence

IINCIDENTSNCIDENTS, ACCIDENT, ACCIDENTSS, , COMPLICATIONSCOMPLICATIONS

DisconfortDisconfort to the patient to the patient Rectal perforationRectal perforation: : it needs it needs

immediate diagnose, followed by immediate diagnose, followed by the emergency reparatory surgical the emergency reparatory surgical treatmenttreatment

SURGICAL SURGICAL DRAINAGEDRAINAGE

CONTENT


INDICATIONS

CONTRAINDICATIONS

REQUIRED MATERIALS

TECHNIQUE


NURSING CARE

DEFINIDEFINITIONTION, , PURPOSEPURPOSE, , PRINCIPLESPRINCIPLES

DefiniDefinitiontion:: it represents the evacuation of pus collections from it represents the evacuation of pus collections from an abscess cavity an abscess cavity

PurposePurpose:: t thherapeutic (erapeutic (the evacuation of the pus collectionthe evacuation of the pus collection), ), postoperative observation on postoperative clinical evolution postoperative observation on postoperative clinical evolution (facilitates the recognition of bleedings, digestive fistulas(facilitates the recognition of bleedings, digestive fistulas, etc.), etc.)

PrincipPrinciplesles::• Drainage tube Drainage tube must be positioned in the lowest part of must be positioned in the lowest part of

the cavitythe cavity• DimensiDimensionsons ( (lengthlength, , diameterdiameter, material) , material) must be adjusted must be adjusted

to the purpose of the drainage and to the characteristics of to the purpose of the drainage and to the characteristics of the evacuated cavity the evacuated cavity

• The path of the drainage tube must be as short as possible The path of the drainage tube must be as short as possible and should avoid the intestinal loop and should avoid the intestinal loop

• The drainage tube will be exteriorized by counter incision The drainage tube will be exteriorized by counter incision • The drainage tube will be attached to the skin by suture The drainage tube will be attached to the skin by suture • The drainage tube will be connected to a collecting The drainage tube will be connected to a collecting

containercontainer

RECOMMENDATIONSRECOMMENDATIONS

Pus collectionsPus collections PeritonitPeritonitisis Interventions with septic stageInterventions with septic stage Difficult, incomplete haDifficult, incomplete haemostemostasesases Interventions with laborious starts Interventions with laborious starts FistulFistulasas, , continuity solutions at the level continuity solutions at the level

of cavity organs of cavity organs Purulent pleurisiesPurulent pleurisies PneumotPneumothhorax, hemotorax, hemothhoraxorax


Are relative Are relative In case of interventions that need In case of interventions that need

prostheses or explants that imply prostheses or explants that imply a risk of septic contamination by a risk of septic contamination by means of the drainage tubemeans of the drainage tube

REQUIRED MATERIALSREQUIRED MATERIALS

Plastic or Plastic or siliconsilicon tubes tubes Drainage external catheters Drainage external catheters

and linersand liners Multiple hole tubesMultiple hole tubes Medical wigsMedical wigs Collecting systemsCollecting systems

PHOTO

PHOTO

PHOTO

Drainage tubes of various dimensions

The Kehr tube (T-tube)

Multiple hole tube

The Redon bottle for aspirative draining

THE TECHNIQUETHE TECHNIQUE The patient will be informed regarding the The patient will be informed regarding the

procedure and his /hers written agreement procedure and his /hers written agreement will be obtainedwill be obtained

The drainage tube will be positioned in the The drainage tube will be positioned in the lowest part of the cavitylowest part of the cavity

The tube will be exteriorized through the The tube will be exteriorized through the cavity wall by counter incision if the wound cavity wall by counter incision if the wound can be sutured per primam can be sutured per primam

The drainage tube will be attached by suture The drainage tube will be attached by suture A sterile bandage will be appliedA sterile bandage will be applied The drainage tube will be connected to a The drainage tube will be connected to a

collecting containercollecting container

PHOTOVIDEO

INCIDENINCIDENTSTS, ACCIDENT, ACCIDENTSS, , COMPLICACOMPLICATIONSTIONS

Incorrect positioning of the drainage Incorrect positioning of the drainage tubetube

Obstruction of the drainage tube Obstruction of the drainage tube InfeInfectionction BleedingBleeding Incorrect adjustment of the collecting Incorrect adjustment of the collecting

containercontainer ExteriorizaExteriorization of the drainage tubetion of the drainage tube

NURSING CARENURSING CARE Daily sterile bandagingDaily sterile bandaging Observing the quantity and the aspect of the Observing the quantity and the aspect of the

drainage contentdrainage content Cleaning the cavities with the help of aseptic Cleaning the cavities with the help of aseptic

solutionssolutions Reinstating vacuum pressure in case of Reinstating vacuum pressure in case of

aspirative drainages aspirative drainages Evacuation of the collecting containers Evacuation of the collecting containers Removing the obstructing factors from the Removing the obstructing factors from the

drainage tube by using antiseptic solutionsdrainage tube by using antiseptic solutions

APPLYING IODOFORM APPLYING IODOFORM ON A SUPPURATIVE WOUNDON A SUPPURATIVE WOUND

TO REVIEW PRESS CLICK WITH THE MOUSE ON THE IMAGE

ATTENDING ATTENDING THE STOMIESTHE STOMIES

CONTENT


REQUIRED MATERIALS

STANDARD TECHNIQUE

DIFFERENT STOMA TYPES


DDEFINITIONEFINITION, , PURPOSEPURPOSE, , PRINCIPPRINCIPLESLES

Stoma = Stoma = a constructed opening to a constructed opening to the exterior of a cavity organ the exterior of a cavity organ

The stomaThe stoma allows the alimentation or allows the alimentation or the evacuation of some cavity organs the evacuation of some cavity organs

PurposePurpose:: attending the stomies attending the stomies should guarantee their correct should guarantee their correct functioning functioning

PrincipPrinciplesles:: the tolerance of the the tolerance of the patient to the stoma care products patient to the stoma care products must be testedmust be tested

DIFFERENT STOMA DIFFERENT STOMA TYPESTYPES

GASTROSTOMY JEJUNOSTOMY ILEOSTOMY COLOSTOMY CUTANEOUS CUTANEOUS URETEROSTOMURETEROSTOMYY


Self-adhesive collecting bagsSelf-adhesive collecting bags PPlastic lastic disk disk ((that will cover the stoma that will cover the stoma

allowing the accumulation of the allowing the accumulation of the collecting pus)collecting pus)

Adhesive gelAdhesive gel ProbesProbes, , tubulestubules Sterile dressing/cloth Sterile dressing/cloth

STANDARD TECHNIQUESTANDARD TECHNIQUE

The tissues around the stoma will be The tissues around the stoma will be cleaned using warm water, preferably cleaned using warm water, preferably without soup without soup

We wait until the skin is dry We wait until the skin is dry The self-adhesive collecting beg that has The self-adhesive collecting beg that has

been previously adjusted according to the been previously adjusted according to the dimensions of the stoma will be attached dimensions of the stoma will be attached

In case the bag will be evacuated it is In case the bag will be evacuated it is better to have it cleaned first with a better to have it cleaned first with a syringe filled in with syringe filled in with 50 ml 50 ml of warm waterof warm water

GASTROSTOMGASTROSTOMYY

IndicIndicationsations: : high gastric obstacle that high gastric obstacle that impedes the normal feeding impedes the normal feeding ((pharyngeal, pharyngeal, esophageal neoplasmesophageal neoplasm, etc.), etc.)

Changing the bandage daily until the Changing the bandage daily until the wound is healed wound is healed

The probe permeability must be tested by The probe permeability must be tested by using special substances using special substances

When not used, the probe lumen will be When not used, the probe lumen will be sealed with a plastic stoppersealed with a plastic stopper

PHOTO

GASTROSTOMGASTROSTOMY PROBESY PROBES

PEZZER PROBE (prepacked and sterilized)

FOLEY PROBE

(in fact a urinary probe that can be also used for gastrostomy, if needed)

JEJUNOSTJEJUNOSTOOMMYY Recommended for Recommended for : : non-resectable non-resectable

gastric tumor, thus the stomach is gastric tumor, thus the stomach is being saved for a future operation being saved for a future operation

Are more easy to be maintained Are more easy to be maintained because for their carrying out a because for their carrying out a probe is used by means of which the probe is used by means of which the food will be providedfood will be provided

COLOSTOMCOLOSTOMYY It will remain opened for 2 days post-It will remain opened for 2 days post-

operative and the sutures will be operative and the sutures will be suppressed 7 days after the surgerysuppressed 7 days after the surgery

The colon transit will be reestablished The colon transit will be reestablished in 2 days from the surgery in 2 days from the surgery

The colostomy care has to be done on The colostomy care has to be done on a daily basis a daily basis

In the beginning, the patient is not In the beginning, the patient is not aware when defecating, but later on, a aware when defecating, but later on, a process of gaining awareness takes process of gaining awareness takes place that will finally allow a perfect place that will finally allow a perfect conscious control of the external conscious control of the external sphinctersphincter

The colostoma patients need The colostoma patients need psychotherapy in order to benefit of a psychotherapy in order to benefit of a more rapid social and professional more rapid social and professional reintegrationreintegration

PHOTO VIDEO

Colostomy bags

DETACHING THE BAG THAT DETACHING THE BAG THAT NEEDS TO BE REPLACEDNEEDS TO BE REPLACED


CLEANING THE PERFORMED COLOSTOMYCLEANING THE PERFORMED COLOSTOMY

TO VIEW AGAIN CLICK WITH THE MOUSE ON THE IMAGE

PREPARING THE NEW COLOSTOMY BAGPREPARING THE NEW COLOSTOMY BAG


THE COLOSTOMY BAG IS THE COLOSTOMY BAG IS CALIBRATED/ADJUSTED AND ATTACHEDCALIBRATED/ADJUSTED AND ATTACHED


ILEOSTOMILEOSTOMYY PurposePurpose: : to evacuateto evacuate RecommendationsRecommendations: : terminalterminal ( (after after

performing proctocolectomy upon various performing proctocolectomy upon various indications, after right colon resections indications, after right colon resections with contraindication for ileotransverse with contraindication for ileotransverse anastomosis in the first stageanastomosis in the first stage) ) oror laterallateral ((neglected occlusions of right colic or iliac neglected occlusions of right colic or iliac arteryartery))

Attending to the stoma in this case means Attending to the stoma in this case means applying the same principles as in applying the same principles as in colostomy; only that more attention colostomy; only that more attention should be given to digestive losses and to should be given to digestive losses and to a good hydro-electrolitical, acid-base and a good hydro-electrolitical, acid-base and volemia levelsvolemia levels

ASEPSIS OF THE LIVING TISSUES – ASEPSIS OF THE LIVING TISSUES – RUBBING SURGEON’S HANDSRUBBING SURGEON’S HANDS


THE PERITONIAL DRAINAGE AFTERTHE PERITONIAL DRAINAGE AFTER A CLASSICAL CHOLECYSTECTOMY A CLASSICAL CHOLECYSTECTOMY

THE BANDAGETHE BANDAGE

CONTENT


INDICATIONS

CONTRAINDICATIONS

THE BANDAGING ROOM

REQUIRED MATERIALS

TECHNIQUE

BANDAGE TYPES



DefiniDefinitiontion:: it represents the medical procedure it represents the medical procedure by means of which a wound is asepticized or by means of which a wound is asepticized or antisepticized antisepticized

PurposePurpose:: it protects and helps the healing of the it protects and helps the healing of the wound wound

PrincipPrinciplesles:: it needs it needs • to be sterileto be sterile• to be absorbent to be absorbent • to ensure protection from the environment, to ensure protection from the environment,

preventing the contamination of the wound preventing the contamination of the wound • to not stick to the wound to not stick to the wound • to not produce painto not produce pain


Surgical incisions Surgical incisions Accidental wounds Accidental wounds BurnsBurns Varicose leg ulcersVaricose leg ulcers

CONTRAINDICATIONSCONTRAINDICATIONS The facial injuries are usually left un-The facial injuries are usually left un-

bandagedbandaged

THE BANDAGING ROOMTHE BANDAGING ROOM

Closet for drugs and medical instrument storage

Medical instrument carriage


Soft sterile clothSoft sterile cloth: compres: compressesses, , swabsswabs, , cotton woolcotton wool, , medical wigsmedical wigs, , cotton buffers cotton buffers

Antiseptic solutions Antiseptic solutions ((see the chaptersee the chapter regarding Asepsis and Antisepsisregarding Asepsis and Antisepsis))

Surgical sterile instrumentsSurgical sterile instruments: Koher: Koher forcepsforceps, Pean, Pean forceps forceps, , anatomic forceps, anatomic forceps, medical scissors, scoopmedical scissors, scoop, , scalpelscalpel, , probeprobe, , directordirector, , suture needlessuture needles, , suturessutures, , drainage drainage tubestubes

Special materials for securing the Special materials for securing the bandage:bandage: band aidsband aids, , dressingsdressings, , surgical surgical netsnets, , adhesive solutionsadhesive solutions

PHOTO


Sterile dressing cases

Sterilized surgical instrument caseSoft sterile non-fabric

gauze case

Pre-packaged sterile dressing case


Antiseptic solutions

Cotton woolSterile and

non-sterile glovesOintment

BANDAGING BANDAGING TECHNIQUETECHNIQUE

The patient will be informed regarding the medical The patient will be informed regarding the medical maneuver after and he/she will be placed in a comfortable maneuver after and he/she will be placed in a comfortable position so that the person taking care of the bandaging will position so that the person taking care of the bandaging will have optimal work conditions have optimal work conditions

Before applying or changing the bandage the medical Before applying or changing the bandage the medical personnel must have the hands clean personnel must have the hands clean

The wound surrounding tissues will be cleaned and The wound surrounding tissues will be cleaned and disinfected with tincture of iodine disinfected with tincture of iodine

The wound will be disinfected, examined and treated The wound will be disinfected, examined and treated The wound will be covered with soft sterile cloth according to The wound will be covered with soft sterile cloth according to

the characteristics of the injury the characteristics of the injury The bandage will be secured with dressing, band aids, etc. The bandage will be secured with dressing, band aids, etc. The evolution of the wound, the eventual drainages The evolution of the wound, the eventual drainages

performed , etc. will be noted in the patient’s observation performed , etc. will be noted in the patient’s observation sheet sheet

The secretory wounds need an absorbent bandage with The secretory wounds need an absorbent bandage with cotton buffer and a thick cotton wool layer cotton buffer and a thick cotton wool layer

The wounds presenting local congestive manifestations need The wounds presenting local congestive manifestations need wet bandages impregnated with chloramine or alcohol, then wet bandages impregnated with chloramine or alcohol, then covered with absorbent cotton buffercovered with absorbent cotton buffer

The suppurative wounds need drainage and a proper The suppurative wounds need drainage and a proper medical caremedical care

BANDAGE TYPESBANDAGE TYPES

THE DRY BANDAGE THE WET BANDAGE THE COMPRESSION BANDAGE THE OCLUSSIVE BANDAGE THE GREASY BANDAGE THE BANDAGE OF SUPPURATIVE WO

UNDS


BANDAGE TYPESBANDAGE TYPESDRY BANDAGEDRY BANDAGE

Recommended forRecommended for: : cleaning non-cleaning non-secretory woundssecretory wounds

It is the most It is the most commonly used commonly used bandage for bandage for woundswounds

It is made out if It is made out if gauze padded gauze padded compresses and compresses and cotton woolcotton wool

GAUZE SWABS COVERED WITH AN IMPERMEABLE MATERIAL ON ONE SIDE (BLUE )

PHOTO VIDEO

PRE-WARPPED AND STERILIZED MATERIALS PRE-WARPPED AND STERILIZED MATERIALS FOR DRY BANDAGEFOR DRY BANDAGE

BANDAGE TYPESBANDAGE TYPESDRY BANDAGEDRY BANDAGE


BANDAGE TYPESBANDAGE TYPESWET BANDAGEWET BANDAGE

Recommended forRecommended for: : inflamed non-secretory inflamed non-secretory woundswounds

It has antiphlogistic It has antiphlogistic effecteffect

It should be used on It should be used on short periods of time short periods of time due to the fact that it due to the fact that it can be irritant can be irritant

It is made out of a It is made out of a moistured compresses moistured compresses impregnated with impregnated with antiseptic solution antiseptic solution covered up in the end by covered up in the end by a dry dressing a dry dressing

Another word used for Another word used for this type of bandage is this type of bandage is ““cataplasmcataplasm””

BANDAGE TYPESBANDAGE TYPESCOMPRESSION BANDAGECOMPRESSION BANDAGE

Recommended forRecommended for: : bleeding injuriesbleeding injuries, , residual cavitiesresidual cavities

It has hemostatic role and the role It has hemostatic role and the role of flattening the residual cavities of flattening the residual cavities

It is made out of large pieces of gauze and It is made out of large pieces of gauze and cotton wool cotton wool

It needs to be more firmly attached so that It needs to be more firmly attached so that to keep the respective area compressed to keep the respective area compressed without affecting the local blood circulation without affecting the local blood circulation

It can be used no more than It can be used no more than 7 7 daysdays

BANDAGE TYPESBANDAGE TYPESOCLUSSIVE BANDAGEOCLUSSIVE BANDAGE

Recommended forRecommended for: : bone injuries and wounds bone injuries and wounds (open fractures, etc.) (open fractures, etc.)

It is made out of a plaster It is made out of a plaster bandage that can be bandage that can be shaped around the injured shaped around the injured area. area.

For granting access to the For granting access to the wound an “opening ” will wound an “opening ” will be cut into the plaster be cut into the plaster bandagebandage

Plaster bandage

Dressing made up of smooth cloth in order to protect the tissue

under the plaster bandage

BANDAGE TYPESBANDAGE TYPESGREASY BANDAGEGREASY BANDAGE

Recommended forRecommended for: : burns, burns, surrounding tissues of hole fistulas surrounding tissues of hole fistulas

This type of bandage is made out of This type of bandage is made out of gauze compresses impregnated with gauze compresses impregnated with Vaseline or Lanolin but it can also be Vaseline or Lanolin but it can also be directly conditioned by the directly conditioned by the manufacturer manufacturer

It has antalgic and antiphlogistic It has antalgic and antiphlogistic effect effect

BANDAGE TYPESBANDAGE TYPESSUPPURATIVE WOUND BANDAGESUPPURATIVE WOUND BANDAGE

The surrounded tissues will be The surrounded tissues will be bandaged with alcoholbandaged with alcohol

The wound needs to be cleaned with The wound needs to be cleaned with antiseptic solutions, usually in antiseptic solutions, usually in sequences: first using oxygenated sequences: first using oxygenated water water Dakin (cloramin Dakin (cloraminee) ) dryingdrying betadin betadinee or equivalent solutions or equivalent solutions powder antiseptics powder antiseptics (op(optionaltional) ) medical wickingmedical wicking

VIDEO

TYPES OF DRESSINGS TYPES OF DRESSINGS THE DRESSING OF THE SUPPURATIVE WOUNDSTHE DRESSING OF THE SUPPURATIVE WOUNDS


THE THE XIXIPHPHO-O-UUMBILICALMBILICAL INCISION INCISION


VASCULAR VASCULAR CATHETERIZATIONCATHETERIZATION


THE IDEAL CATHETER

INDICATIONS

CONTRAINDICATIONS

REQUIRED MATERIALS

STANDARD THECNIQUE


NURSING CARE


CONTENT

DEFINIDEFINITIONTION, , PURPOSEPURPOSE, , PRINCPRINCPLESPLES

DefiniDefinitiontion:: it represents the technique by it represents the technique by which various catheters can be introduced which various catheters can be introduced into the vascular lumen into the vascular lumen (cat(cathhetereterss are thin are thin plastic tubesplastic tubes))

PurposePurpose: : tthherapeutic (erapeutic (medical substances medical substances are introduced into the bodyare introduced into the body), diagnostic, ), diagnostic, accessaccess for different organsfor different organs ( (heartheart, , limbslimbs, , etc.)etc.)

PrinciPrinciplesples:: it is a sterile maneuver that it is a sterile maneuver that must serve the purpose abovemust serve the purpose above

IDEAL CATHETERIDEAL CATHETER

Should be thinShould be thin Should not be irritant Should not be irritant Should not determine the platelet Should not determine the platelet

aggregation in its aggregation in its exterior exterior and interior and interior Should be long enough and wide enough Should be long enough and wide enough

to serve its purpose to serve its purpose Should be radiopaque Should be radiopaque Some catheters have more lumensSome catheters have more lumens

INDICATIONS INDICATIONS Hydro- electrolytic balance Hydro- electrolytic balance In emergency for introducing rapid In emergency for introducing rapid

action drugsaction drugs Parental nutritionParental nutrition DetermiDetermining the central venous ning the central venous

pressure, the pulmonary pressure pressure, the pulmonary pressure and intracavitary cardiac pressureand intracavitary cardiac pressure

Interventional radiology Interventional radiology Diagnostic purposeDiagnostic purpose

THE CATHETERIZATION OF THE CATHETERIZATION OF THE RADIAL ARTHERYTHE RADIAL ARTHERY


CONTRAINDICACONTRAINDICATTIIONSONS

HaemophiliaHaemophilia Anticoagulant treatment Anticoagulant treatment TetanTetanuuss InduInduction from general anesthesiaction from general anesthesia

REQUIRED MATERIALS REQUIRED MATERIALS

Syringe and needleSyringe and needle XXylineyline Sterile gauze compressSterile gauze compress Sterile glovesSterile gloves (needle) Holder and (needle) Holder and

needle with sutureneedle with suture Medical tray containingMedical tray containing: :

syringesyringe, , thick needlethick needle, , guide wireguide wire, cat, catheter, heter, fixing supportfixing support

CENTRAL VENOUS CATHETER TRAY

THE STANDARD THE STANDARD TECHNIQUETECHNIQUE

The patient will be informed about the medical procedure he/she will go The patient will be informed about the medical procedure he/she will go through and his/hers written agreement will be obtained through and his/hers written agreement will be obtained

The patient will be placed in a comfortable position The patient will be placed in a comfortable position The skin area where the puncture will be made is disinfectedThe skin area where the puncture will be made is disinfected The sterile gloves are put on The sterile gloves are put on The local anesthesia is performed The local anesthesia is performed The vein will be punctured according to the technique described in the The vein will be punctured according to the technique described in the

chapter About punctures chapter About punctures 5-6 ml 5-6 ml of blood will be aspirated into the syringe of blood will be aspirated into the syringe The syringe will be detached and the guide wire will be introduced The syringe will be detached and the guide wire will be introduced

through the lumen of the needle with the patient in voluntary apnea through the lumen of the needle with the patient in voluntary apnea The needle will be removed The needle will be removed The catheter will be introduced along the guide wireThe catheter will be introduced along the guide wire, , then the guide wire then the guide wire

will be withdrawn until it reaches the distal end of the catheter will be withdrawn until it reaches the distal end of the catheter Both the guide wire and the catheter will be introduced until reaching the Both the guide wire and the catheter will be introduced until reaching the

desired position after which the guide wire will be removeddesired position after which the guide wire will be removed The blood will be aspirated into the syringe to check the position of the The blood will be aspirated into the syringe to check the position of the

cathetercatheter The catheter will be connected to a perfusion with Normoton or heparin The catheter will be connected to a perfusion with Normoton or heparin

serum serum The catheter will be secured to the skin with sutures The catheter will be secured to the skin with sutures In the end a sterile bandage is appliedIn the end a sterile bandage is applied

ARTERIAL CATHETERIZATION

VENOUS CATHETERIZATION

SELDINGERSELDINGER TECHNIQUE FOR TECHNIQUE FOR INTERNAL JUGULAR VEIN INTERNAL JUGULAR VEIN

CATHETERIZATIONCATHETERIZATION


VENOUS CATHETERVENOUS CATHETERJUGULAR JUGULAR INSERTIONINSERTION


When installingWhen installing: : insertion of the insertion of the cathetercatheter, , catheterized blood vessel catheterized blood vessel perforationsperforations, , artery punctureartery puncture, , pneumotpneumothhorax, orax, chylothorax, gas chylothorax, gas embolism, hemomediastinum, embolism, hemomediastinum, arrhythmiasarrhythmias

In use: infection, phlebitisIn use: infection, phlebitis At the suppression: breaking the At the suppression: breaking the

cathetercatheter

MAINTENANCEMAINTENANCE

It requires maintaining the permeability of It requires maintaining the permeability of the catheter which is achieved by the catheter which is achieved by maintaining a continuous flow or by maintaining a continuous flow or by washing the catheter with heparinized washing the catheter with heparinized saline after stopping the perfusionsaline after stopping the perfusion

Any maneuver that will be done must be Any maneuver that will be done must be sterilesterile

The perfusor will be changed in maximum The perfusor will be changed in maximum 24 hours24 hours

DIGESTIVE DIGESTIVE PROBINGPROBING

DEFINITION, PURPOSE AND PRINCIPLES

INDICATIONS

CONTRAINDICATIONS

REQUIRED MATERIALS

TECHNIQUE


TYPES OF DIGESTIVE PROBING

CONTENTCLICK WITH THE MOUSE ON THE UNDERLINED TITLES


DefiniDefinitiontion:: it represents the medical maneuver it represents the medical maneuver through which various probes are introduced through which various probes are introduced through the digestive proximal tract for various through the digestive proximal tract for various purposespurposes

PurposePurpose:: collection of digestive secretions (gastric, collection of digestive secretions (gastric, duodenal, biliary, pancreatic), qualitative and duodenal, biliary, pancreatic), qualitative and quantitative biochemical measurement (pH meters, quantitative biochemical measurement (pH meters, cytology, microbiology), gastrointestinal cytology, microbiology), gastrointestinal manometry, tract evacuation, cavity washing manometry, tract evacuation, cavity washing (gastric lavage), enteral nutrition(gastric lavage), enteral nutrition

PrincipPrinciplesles::• The principles of asepsis and antisepsisThe principles of asepsis and antisepsis must be must be

respectedrespected• A proper probe is to be usedA proper probe is to be used


Gastric hypo- or hyperacidity evaluationGastric hypo- or hyperacidity evaluation Determination of PH digestive Determination of PH digestive

secretions secretions Gastrointestinal manometryGastrointestinal manometry Gastric stasis - evacuation, gastric Gastric stasis - evacuation, gastric

lavagelavage Pre-surgery preparation of the stomachPre-surgery preparation of the stomach


The digestive probes are being The digestive probes are being gradually replaced by modern gradually replaced by modern techniquetechnique

Traumas, malformations, obstacles Traumas, malformations, obstacles that do not allow passage of the that do not allow passage of the probeprobe


EinhornEinhorn digestive digestive probesprobes

Probes with Probes with radiopaque marksradiopaque marks

SyringesSyringes Test tubeTest tube Stimulation drugsStimulation drugs Antidote solutionsAntidote solutions ContainersContainers GlovesGloves

TECHNIQUETECHNIQUE The patient will be informed about the maneuver, his The patient will be informed about the maneuver, his

cooperation is important during the digestive probing cooperation is important during the digestive probing The patient will be placed in the sitting position, The patient will be placed in the sitting position,

lateral or dorsal decubituslateral or dorsal decubitus The probe is introduced through the nose into the The probe is introduced through the nose into the

throat, then the patient will be asked, while normally throat, then the patient will be asked, while normally breathing, to do swallowing movements, and in that breathing, to do swallowing movements, and in that moment the probe is gently pushed up into the moment the probe is gently pushed up into the esophagus and stomach. Eventually, a local anesthetic esophagus and stomach. Eventually, a local anesthetic to the pharyngeal mucosa can be done.to the pharyngeal mucosa can be done.

If you want to reach up into the duodenum, the If you want to reach up into the duodenum, the patient is placed in lateral decubitus for 30-60 patient is placed in lateral decubitus for 30-60 minutes, while the probe will be spontaneously minutes, while the probe will be spontaneously progressing into the duodenumprogressing into the duodenum


Discomfort to the patient (agitation, Discomfort to the patient (agitation, coughing, vomiting)coughing, vomiting)

Exteriorization of the probe through the Exteriorization of the probe through the mouthmouth

Penetration of the probe into the upper Penetration of the probe into the upper airwayairway

Tracheobronchial aspiration syndromeTracheobronchial aspiration syndrome BleedingBleeding Esophagus or stomach perforationEsophagus or stomach perforation Probe blockage with food debrisProbe blockage with food debris Decubitus lesions of the gastric mucosaDecubitus lesions of the gastric mucosa

DIGESTIVE PROBINGDIGESTIVE PROBING

Digestive probing typesDigestive probing types GASTRIC LAVAGE DIGESTIVE SUCTION ENTERAL NUTRITION THROUGH DIGE

STIVE PROBE


GASTRIC LAVAGEGASTRIC LAVAGE DEFINITION, PURPOSE AND PRINCIPLES

INDICATIONS

CONTRAINDICATIONS

REQUIRED MATERIALS

TECHNIQUE



GASTRIC LAVAGEGASTRIC LAVAGEDEFINITION, PURPOSE, PRINIPLESDEFINITION, PURPOSE, PRINIPLES

DefiniDefinitiontion:: the maneuver by which the maneuver by which the stomach is emptied and cleanedthe stomach is emptied and cleaned

PurposePurpose:: discharge of toxic discharge of toxic substances, pre-surgery preparationsubstances, pre-surgery preparation

PrincipPrinciplesles:: for intoxication lavages for intoxication lavages specific antidote should be usedspecific antidote should be used

GASTRIC LAVAGEGASTRIC LAVAGEINDICAINDICATIONSTIONS

Accidental or voluntary ingestion of Accidental or voluntary ingestion of corrosive substances, toxic drugscorrosive substances, toxic drugs

Preparation for endoscopies, Preparation for endoscopies, pre-surgerypre-surgery

radio-imaging explorations radio-imaging explorations Upper digestive bleeding: cold serum Upper digestive bleeding: cold serum

lavagelavage

GASTRIC LAVAGEGASTRIC LAVAGECONTRAINDICACONTRAINDICATIONSTIONS

Ingestion of caustic substancesIngestion of caustic substances Esophageal varicesEsophageal varices

GASTRIC LAVAGEGASTRIC LAVAGEREQUIRED MATERIALSREQUIRED MATERIALS

GlovesGloves Faucher Faucher Probe Probe ((phphoto)oto) FunnelFunnel Lavage fluid, antidoteLavage fluid, antidote MedicMedicinesines Container for Container for

collecting the collecting the evacuated digestive evacuated digestive contentcontent

GASTRIC LAVAGEGASTRIC LAVAGETECHNIQUETECHNIQUE

The patient will be informed about the maneuver, his The patient will be informed about the maneuver, his cooperation is important during the gastric lavagecooperation is important during the gastric lavage

The patient will be placed in the sitting position or right The patient will be placed in the sitting position or right lateral decubituslateral decubitus

The Faucher probe will be inserted through the patient’s The Faucher probe will be inserted through the patient’s mouthmouth, , up to the pharynx,up to the pharynx, asking the patient to swallowasking the patient to swallow

The probe will slowly progress into the stomach, no more The probe will slowly progress into the stomach, no more than 45-60 cmthan 45-60 cm

The funnel will be adjusted to the probeThe funnel will be adjusted to the probe The lavage fluid will be poured through the funnel placed The lavage fluid will be poured through the funnel placed

to the chest level, slightly raising it up to the headto the chest level, slightly raising it up to the head Then the funnel will be descended below the abdomen, Then the funnel will be descended below the abdomen,

while evacuating the gastric fluidwhile evacuating the gastric fluid The operation will be repeated until the evacuated fluid is The operation will be repeated until the evacuated fluid is

cleanclean The probe will be gently extractedThe probe will be gently extracted to prevent its to prevent its

evacuation into the respiratory treeevacuation into the respiratory tree

GASTRIC LAVAGEGASTRIC LAVAGEINCIDENTINCIDENTSS, ACCIDENT, ACCIDENTSS, COMPLICA, COMPLICATIONSTIONS

Discomfort to the patient (agitation, Discomfort to the patient (agitation, coughing, vomiting)coughing, vomiting)

Penetration of the probe into the upper Penetration of the probe into the upper airwaysairways

Tracheobronchial aspiration syndromeTracheobronchial aspiration syndrome BleedingBleeding Esophagus or stomach perforationEsophagus or stomach perforation Septic mediastinal complicationsSeptic mediastinal complications

GASTROINTESTINAL SUCTIONGASTROINTESTINAL SUCTION

DEFINITION, PURPOSE AND PRINCIPLES INDICATIONS CONTRAINDICATIONSCONTRAINDICATIONS REQUIRED MATERIALS TECHNIQUE INCIDENTS, ACCIDENTS, COMPLICATIONS


GASTROINTESTINAL GASTROINTESTINAL SUCTIONSUCTION

DEFINITION, PURPOSE, PRINCIPLESDEFINITION, PURPOSE, PRINCIPLES

DefiniDefinitiontion:: it is the maneuver by which it is the maneuver by which the excessive gastric fluid is evacuatedthe excessive gastric fluid is evacuated

PurposePurpose:: the evacuation of gastric, the evacuation of gastric, excessive duodenal or jejunal fluids in excessive duodenal or jejunal fluids in order to avoid the digestive stasisorder to avoid the digestive stasis

PrincipPrinciplesles:: the principles of aseptis and the principles of aseptis and antisepsis must be respectedantisepsis must be respected, , a proper a proper hydro-electrolytichydro-electrolytic balance must be balance must be ensuredensured


INDICAINDICATIONSTIONS Acute dilatation of the stomachAcute dilatation of the stomach High digestive stenosisHigh digestive stenosis Intestinal occlusionsIntestinal occlusions Acute pancreatitisAcute pancreatitis Gastrointestinal perforationGastrointestinal perforation Post-surgery until the resumption of intestinal Post-surgery until the resumption of intestinal

transit for gasestransit for gases Dynamic Ileus Dynamic Ileus Conservative treatment Conservative treatment

(Taylor method for perforated ulcer)(Taylor method for perforated ulcer) Pre-surgery preparationPre-surgery preparation



GlovesGloves Radiopaque probes Radiopaque probes Graded collecting containersGraded collecting containers


TECHNIQUE TECHNIQUE The patient will be informed about the maneuver, his The patient will be informed about the maneuver, his

cooperation is important during the digestive probing cooperation is important during the digestive probing The patient will be placed in the sitting position or The patient will be placed in the sitting position or

right lateral decubitusright lateral decubitus The tube will be inserted through the patient’s mouthThe tube will be inserted through the patient’s mouth, ,

up to the pharynx,up to the pharynx, asking the patient to swallowasking the patient to swallow The tube will slowly progress into the stomach, no The tube will slowly progress into the stomach, no

more than 45-60 cm more than 45-60 cm In case of postoperative suction the tube will always In case of postoperative suction the tube will always

be placed upstream of the digestive suture during be placed upstream of the digestive suture during surgery surgery

In case of biliary pathology the tube can be placed In case of biliary pathology the tube can be placed endoscopically in the ductsendoscopically in the ducts

The volume and the aspect of the sucked digestive The volume and the aspect of the sucked digestive fluid will be daily noted in the patient’s observation fluid will be daily noted in the patient’s observation sheetsheet


INCIDENTINCIDENTSS, ACCIDENT, ACCIDENTSS, COMPLICA, COMPLICATIONSTIONS Discomfort to the patient (agitation, Discomfort to the patient (agitation,

coughing, vomiting)coughing, vomiting) Exteriorization of the probe through the Exteriorization of the probe through the

mouthmouth Penetration of the tube into the upper Penetration of the tube into the upper

airwaysairways Aspiration syndromeAspiration syndrome BleedingBleeding Esophagus or stomach perforationEsophagus or stomach perforation Probe blockage with food debrisProbe blockage with food debris Decubitus lesions of the digestive mucosaDecubitus lesions of the digestive mucosa

ENTERAL FEEDING THROUGH ENTERAL FEEDING THROUGH THE DIGESTIVE PROBETHE DIGESTIVE PROBE

DEFINITION, PURPOSE AND PRINCIPLES INDICATIONS CONTRAINDICATIONS REQUIRED MATERIALS TECHNIQUE INCIDENTS, ACCIDENTS, COMPLICATIONS



DEFINITION, PURPOSE, PRINCIPLESDEFINITION, PURPOSE, PRINCIPLES

DefiniDefinitiontion:: introducing specially prepared introducing specially prepared food by means of probes directly into the food by means of probes directly into the proximal digestive tractproximal digestive tract

PurposePurpose:: ensuring the necessary intake of ensuring the necessary intake of nutrients for the patientnutrients for the patient

PrincipPrinciplesles:: it is necessary to ensure the it is necessary to ensure the patient a balanced nutrition which patient a balanced nutrition which determine that his/hers alimentation and determine that his/hers alimentation and digestion is as closed to the natural as digestion is as closed to the natural as possiblepossible



Patients who cannot be fed Patients who cannot be fed spontaneouslyspontaneously



High gastrointestinal obstaclesHigh gastrointestinal obstacles Incoercible vomitingIncoercible vomiting Digestive fistulasDigestive fistulas Inflammatory digestive disordersInflammatory digestive disorders



GlovesGloves Radiopaque tubes with single or multiple Radiopaque tubes with single or multiple

lumenlumen ContainersContainers Connection tubingConnection tubing Dosing pumpsDosing pumps Nutrient preparations that are to be Nutrient preparations that are to be

administered according to specific administered according to specific nutritional deficiencies of each patientnutritional deficiencies of each patient

PHOTO

NUTRITIENT SOLUTION TO BENUTRITIENT SOLUTION TO BE ADMINISTRAADMINISTRATEDTED THROUGH DIGESTIVE PROBESTHROUGH DIGESTIVE PROBES


TECHNIQUETECHNIQUE

The patient will be informed about the maneuver, his The patient will be informed about the maneuver, his cooperation is important during the digestive probingcooperation is important during the digestive probing

The patient will be placed in the sitting position or dorsal The patient will be placed in the sitting position or dorsal decubitus decubitus Fowler Fowler type type

The tube will be inserted through the patient’s mouthThe tube will be inserted through the patient’s mouth, , into the into the pharynx while the patient will be asked to swallowpharynx while the patient will be asked to swallow

The tube will progress slowly into the stomach, up to 45-60 The tube will progress slowly into the stomach, up to 45-60 cmcm

The positioning of the probe will be made radiologically, The positioning of the probe will be made radiologically, endoscopically or intraoperatively (always downstream of the endoscopically or intraoperatively (always downstream of the anastomosis)anastomosis)

The probe will be connected through the connection system The probe will be connected through the connection system to the nutrient bagto the nutrient bag

The administration can be done “in bolus" or continuously, the The administration can be done “in bolus" or continuously, the pace being set by the patient's the digestive tolerancepace being set by the patient's the digestive tolerance

A caloric intake of 3000 cal / day is necessaryA caloric intake of 3000 cal / day is necessary


INCIDENTINCIDENTSS, ACCIDENT, ACCIDENTSS, COMPLICA, COMPLICATIONSTIONS

Discomfort to the patient (agitation, coughing, Discomfort to the patient (agitation, coughing, vomiting)vomiting)

Exteriorization of the probe through the mouthExteriorization of the probe through the mouth Penetration of the probe into the upper airwaysPenetration of the probe into the upper airways Aspiration syndromeAspiration syndrome BleedingBleeding Esophagus or stomach perforationEsophagus or stomach perforation DyspepsiaDyspepsia Gastroesophageal reflux, regurgitation, nauseaGastroesophageal reflux, regurgitation, nausea

PERITONEAL DRAINAGEPERITONEAL DRAINAGE


ASEPTISATION ASEPTISATION OF THE LIVING TISSUESOF THE LIVING TISSUES

PATIENT’S SKINPATIENT’S SKIN


HEMOSTASISHEMOSTASIS

DEFINITION, PURPOSE AND PRINCIPLES

INDICATIONS CONTRAINDICATIONS REQUIRED MATERIALS TECHNIQUE INCIDENTS, ACCIDENTS, COMPLICA

TIONSCONTENT



DefiniDefinitiontion:: the maneuver through the maneuver through which the bleeding is stoppedwhich the bleeding is stopped

PurposePurpose:: stopping blood from flowing stopping blood from flowing from the vascular bedfrom the vascular bed

PrincipPrinciplesles:: hemostasis can be done hemostasis can be done spontaneously (physiological spontaneously (physiological mechanisms of the body) or surgically mechanisms of the body) or surgically by physical and chemical methodsby physical and chemical methods

INDICAINDICATIONSTIONS

Any bleeding that does not stop Any bleeding that does not stop by spontaneous hemostasisby spontaneous hemostasis


Pathological situations in which Pathological situations in which surgery may be delayed in the hope surgery may be delayed in the hope of a spontaneous hemostasis (e.g. of a spontaneous hemostasis (e.g. upper gastrointestinal bleeding that upper gastrointestinal bleeding that under conservative treatment may under conservative treatment may stop spontaneously)stop spontaneously)


Temporary hemostasis: tourniquet, soft Temporary hemostasis: tourniquet, soft tissue for the compression of damaged tissue for the compression of damaged vesselsvessels

Final hemostasis: common instruments Final hemostasis: common instruments for surgery, hemostatic forceps, for surgery, hemostatic forceps, atraumatic needles to restore vessel atraumatic needles to restore vessel continuity continuity

In case of hemostasis mechanism In case of hemostasis mechanism disorders blood derivatives are required disorders blood derivatives are required (see Chap. Transfusions), hemostatic (see Chap. Transfusions), hemostatic substances, etc.substances, etc.

TETECHNIQUECHNIQUE

TEMPORARY HEMOSTASISFINAL HEMOSTASIS

TETECHNIQUECHNIQUETEMPORARY HEMOSTASISTEMPORARY HEMOSTASIS

DefiniDefinitiontion: : it represents the method by it represents the method by which the bleeding is temporarily stoppedwhich the bleeding is temporarily stopped

PurposePurpose:: avoids blood loss until final avoids blood loss until final HEMOSTASIS can be doneHEMOSTASIS can be done

Temporary hemostasis is represented by Temporary hemostasis is represented by the vascular compression that is made the vascular compression that is made by/throughby/through::• TOURNIQUET• POWERFUL COMPRESSION


TECHNIQUETECHNIQUETEMPORARY HEMOSTASISTEMPORARY HEMOSTASIS

TOURNIQUETTOURNIQUET• If there is no tourniquet it can be improvised using If there is no tourniquet it can be improvised using

a cord, a belt, a scarfa cord, a belt, a scarf• IndicaIndicationstions: : limbslimbs• By applying it the vascular walls are crushed and By applying it the vascular walls are crushed and

bleeding stops bleeding stops • It is very important to attach a note where the date and It is very important to attach a note where the date and

exact time of tourniquet application are recordedexact time of tourniquet application are recorded. . If the If the transport takes longer than 15-30 minutes, the transport takes longer than 15-30 minutes, the tourniquet will be opened for a few seconds to restore tourniquet will be opened for a few seconds to restore the blood flow to the affected limb the blood flow to the affected limb

• In case of a jet bleeding with red blood, the bleeding In case of a jet bleeding with red blood, the bleeding has arterial origin, and the tourniquet will be applied has arterial origin, and the tourniquet will be applied proximally to the lesion, to the concerned member proximally to the lesion, to the concerned member

• In case of a continuous jet bleeding with dark red In case of a continuous jet bleeding with dark red blood, the bleeding has venous origin, and the blood, the bleeding has venous origin, and the tourniquet will be applied distally to the lesion, to the tourniquet will be applied distally to the lesion, to the tip of the concerned limbtip of the concerned limb


POWERFUL COMPRESSIONPOWERFUL COMPRESSION• IndicaIndicationstions: : head, neck, thorax, abdomenhead, neck, thorax, abdomen• It can be done by It can be done by the strong compression the strong compression of the of the

injured vessel against a skeletal plan,injured vessel against a skeletal plan, or by or by compression bandagecompression bandage

• The compressive bandage is made with sterile The compressive bandage is made with sterile compresses, the bandage is large enough to compresses, the bandage is large enough to make the injured blood vessel cooperatemake the injured blood vessel cooperate. . Over Over sterile compresses a crumpled of folded sterile compresses a crumpled of folded compresses or a roll of infancy can be added, compresses or a roll of infancy can be added, followed by a tight enswathement of the area by followed by a tight enswathement of the area by circular infancy turns, with hemostatic rolecircular infancy turns, with hemostatic role


DefiniDefinitiontion: : it represents the surgical it represents the surgical maneuvers through which final hemostasis maneuvers through which final hemostasis is obtained into the blood vesselis obtained into the blood vessel

During surgery it can be performed:During surgery it can be performed:• TEMPORARY HEMOSTASIS:: it enables a it enables a

postponement of the final hemostasis in postponement of the final hemostasis in a propitious momenta propitious moment

• FINAL HEMOSTASIS


TETECHNIQUE CHNIQUE TEMPORARY HEMOSTASISTEMPORARY HEMOSTASIS

Forcipression The tourniquet Loops Balloon probes: Foley, Fogarthy Compressive bandage SwabbingSwabbing


TETECHNIQUECHNIQUETEMPORARY HEMOSTASIS TEMPORARY HEMOSTASIS - FORCIPRES- FORCIPRESSIONSION

DefiniDefinitiontion:: catching the end of the injured catching the end of the injured blood vessel between the arms of a blood vessel between the arms of a hemostatic forcepshemostatic forceps

IndicaIndicationstions:: small diameter vesselssmall diameter vessels It can cause final hemostasis by It can cause final hemostasis by

spontaneous hemostasis into the blood spontaneous hemostasis into the blood vessel or it may require a subsequent final vessel or it may require a subsequent final hemostasis techniquehemostasis technique

TETECHNIQUECHNIQUETEMPORARY HEMOSTASISTEMPORARY HEMOSTASIS– TOURNIQUET– TOURNIQUET

DefiniDefinitiontion:: a loop suture will be passed a loop suture will be passed around the blood vessel, then both ends of around the blood vessel, then both ends of the loop suture are passed through a the loop suture are passed through a plastic tube that by tightening will causes plastic tube that by tightening will causes the compression effect of the blood vesselthe compression effect of the blood vessel

AAdvantagesdvantages:: does not harm the blood does not harm the blood vessel, easy to apply, when suppressed it vessel, easy to apply, when suppressed it allows the reestablishment of the blood allows the reestablishment of the blood circulation in the blood vessel circulation in the blood vessel

TECHNIQUETECHNIQUETEMPORARY HEMOSTASIS TEMPORARY HEMOSTASIS – – THE LOOPSTHE LOOPS

DefiniDefinitiontion:: a loop of cotton will go around a loop of cotton will go around the blood vessel, determining a lifting the blood vessel, determining a lifting position by forceps traction or fixation, position by forceps traction or fixation, temporarily stopping the bleedingtemporarily stopping the bleeding

IndicaIndicationstions:: vascular surgery in the vascular surgery in the reconstruction of damaged blood vesselsreconstruction of damaged blood vessels

TECHNIQUETECHNIQUETEMPORARY HEMOSTASISTEMPORARY HEMOSTASIS– – BALOON PROBESBALOON PROBES

DefiniDefinitiontion:: the balloon probe is inserted the balloon probe is inserted through the injured end of the blood through the injured end of the blood vessel, which by inflation causes lumen vessel, which by inflation causes lumen obstruction with temporary bleeding stopobstruction with temporary bleeding stop

IndicaIndicationstions:: vascular surgeryvascular surgery AAdvantagesdvantages:: it is an atraumatic techniqueit is an atraumatic technique

TECHNIQUE TECHNIQUE TEMPORARY HEMOSTASISTEMPORARY HEMOSTASIS– – PLUGGINGPLUGGING, ,

COMPRESSION BANDAGECOMPRESSION BANDAGE

DefiniDefinitiontion:: compression of the blood vessel compression of the blood vessel with a tissue, a sufficient time to allow with a tissue, a sufficient time to allow spontaneous hemostasisspontaneous hemostasis

IndicaIndicationstions:: small diameter vessels, diffuse small diameter vessels, diffuse bleedingbleeding

TECHNIQUETECHNIQUEFINAL HEMOSTASISFINAL HEMOSTASIS

Ligature Electrocoagulation Embolization Cushioning Mass suture Hemostatic substances


TECHNIQUETECHNIQUEFINAL HEMOSTASIS - LIGATUREFINAL HEMOSTASIS - LIGATURE

DefinDefinitionition:: applying a loop suture by knotting in the blood vessel applying a loop suture by knotting in the blood vessel that will determine HEMOSTASISthat will determine HEMOSTASIS

Required materialsRequired materials:: absorbable or non absorbable sutures, metal absorbable or non absorbable sutures, metal clips, rubber ringsclips, rubber rings

TTechniqueechnique:: a hemostatic forceps will be applied to the damaged a hemostatic forceps will be applied to the damaged vessel and the forceps will be adapted to the size and length of vessel and the forceps will be adapted to the size and length of the blood vessel and to the depth that the vessel is located, the the blood vessel and to the depth that the vessel is located, the tip of the forceps being beyond the vessel by 1-2mm. Forceps tip of the forceps being beyond the vessel by 1-2mm. Forceps should be applied only on the blood vessel without catching other should be applied only on the blood vessel without catching other structures nearby. The suture will be passed around the forceps structures nearby. The suture will be passed around the forceps and the vessel, with a forceps, then the loop will be tied with at and the vessel, with a forceps, then the loop will be tied with at least three nodes (raise, fix, ensure). After the first node the least three nodes (raise, fix, ensure). After the first node the operator will open the forcepsoperator will open the forceps, , and now the assistant will tighten and now the assistant will tighten the node perfectlythe node perfectly. . After checking hemostasis the loop is cut to 3-After checking hemostasis the loop is cut to 3-4 mm from the node.4 mm from the node.

If necessary several ligatures may be applied on the same blood If necessary several ligatures may be applied on the same blood vessel a few millimeters away from each other or a supported vessel a few millimeters away from each other or a supported ligature may be applied.ligature may be applied.

VIDEO

TECHNIQUETECHNIQUEFINAL HEMOSTASISFINAL HEMOSTASIS- LIGATUR- LIGATUREE


TECHNIQUETECHNIQUEFINAL HEMOSTASIS FINAL HEMOSTASIS - ELECTROCOAGULA- ELECTROCOAGULATIONTION

DefiniDefinitiontion:: is the is the method by which method by which hemostasis is produced hemostasis is produced using electricity using electricity

PrincipPrinciplesles:: changing the changing the intensity-voltage ratio it intensity-voltage ratio it can produce currents can produce currents that burn the cells that that burn the cells that come into contact with come into contact with the electrical scalpel the electrical scalpel causing bleeding stop causing bleeding stop in the small blood in the small blood vessels vessels

VIDEO





TECHNIQUETECHNIQUEFINAL HEMOSTASIS FINAL HEMOSTASIS - EMBOLIZA- EMBOLIZATIONTION

DefiniDefinitiontion:: it means introducing it means introducing coagulant substances in the injured coagulant substances in the injured blood vesselblood vessel

IndicaIndicationstions:: interventional endoscopyinterventional endoscopy Coagulant substancesCoagulant substances:: absolute absolute

alcohol, polidocanol, adrenalinealcohol, polidocanol, adrenaline

TECHNIQUE TECHNIQUE FINAL HEMOSTASIS FINAL HEMOSTASIS – – THE CUSHIONING THE CUSHIONING

DefinDefinitionition:: it is a method of achieving it is a method of achieving hemostasis by suture, bringing side hemostasis by suture, bringing side by side, in close contact "raw“ by side, in close contact "raw“ surfaces. This creates a high surfaces. This creates a high pressure cavity that will determine pressure cavity that will determine hemostasishemostasis

IndicaIndicationstions:: hemostasis in the hemostasis in the gallbladder bed after gallbladder bed after cholecystectomycholecystectomy

TECHNIQUETECHNIQUEFINAL HEMOSTASISFINAL HEMOSTASIS– – MASS SUTUREMASS SUTURE

DefiniDefinitiontion:: passing sutures in "x" around passing sutures in "x" around the damaged vessel, and by tightening the damaged vessel, and by tightening the loop creating pressure in the blood the loop creating pressure in the blood vessel that will lead to stopping the vessel that will lead to stopping the bleeding bleeding

IndicaIndicationstions:: diffuse bleeding where the diffuse bleeding where the damaged vessel cannot be identified or damaged vessel cannot be identified or it is very small and brittle, other it is very small and brittle, other hemostasis techniques not being hemostasis techniques not being possiblepossible

TECHNIQUETECHNIQUEFINAL HEMOSTASISFINAL HEMOSTASIS– – ORGANIC SUBSTANCESORGANIC SUBSTANCES

DefiniDefinitiontion: : obtain hemostasis obtain hemostasis by applying organic by applying organic substances on the surface substances on the surface where you want to stop where you want to stop bleedingbleeding

These products have in their These products have in their composition certain composition certain substances (fibrin, organic substances (fibrin, organic glues) that stimulate and glues) that stimulate and encourage hemostasisencourage hemostasis

ProdProductsucts: : fibrin powderfibrin powder, , Gelaspon, Tisucol, Gelaspon, Tisucol, TachoCombTachoComb


IncidentIncidentss, accident, accidentss::• Ligature slipping of the blood vesselLigature slipping of the blood vessel• Pulling out the blood vessel during tying Pulling out the blood vessel during tying • Crushing the blood vessel between the Crushing the blood vessel between the

forceps arms when its dimensions are forceps arms when its dimensions are not adapted to the vessel sizenot adapted to the vessel size

• Local hematomaLocal hematoma ComplicaComplicationstions:: necrosis, massive bleeding, necrosis, massive bleeding,

hypovolemic shockhypovolemic shock

PUNCTURESPUNCTURES

DEFINITION, PURPOSE, PRINCIPLESINDICATIONSCONTRAINDICATIONSREQUIRED MATERIALSSTANDARD TECHNIQUEPUNCTURES TYPES

CONTENT


DEFINITION, PURPOSE, DEFINITION, PURPOSE, PRINCIPLES PRINCIPLES

Definition:Definition: it represents the manoeuvre it represents the manoeuvre through which an organ, cavity or tissue through which an organ, cavity or tissue is entered with a needle or trocar is entered with a needle or trocar

Purpose:Purpose: disposal, treatment, diagnosis, disposal, treatment, diagnosis, biopsybiopsy

Principles: Principles: the puncture’s tract should the puncture’s tract should be as short as possible, the manoeuvre be as short as possible, the manoeuvre must be asepticmust be aseptic


PneumothoraxPneumothorax ParacentesisParacentesis PneumoperitoneumPneumoperitoneum Pancreatic pseudocystPancreatic pseudocyst AbscessAbscess BiopsyBiopsy Seldinger punctureSeldinger puncture


HaemophiliaHaemophilia Treatment with anticoagulantsTreatment with anticoagulants TetanusTetanus Induction of general anaesthesiaInduction of general anaesthesia


Iodine alcohol, soft Iodine alcohol, soft material, sterile material, sterile glovesgloves

Syringe with needle, Syringe with needle, lidocainelidocaine

Puncture needle, Puncture needle, trocar and syringetrocar and syringe

Fittings and Fittings and containers for containers for collectioncollection

FFluids for lavage luids for lavage

STANDARD TECHNIQUESTANDARD TECHNIQUE

Patient’s information on the procedure and obtaining his written Patient’s information on the procedure and obtaining his written consent consent

A comfortable position will be further on chosen, with removal of A comfortable position will be further on chosen, with removal of the clothing from the examined regionthe clothing from the examined region

Sterile gloves will be used during the examinationSterile gloves will be used during the examination The region to be punctured will be sanitized The region to be punctured will be sanitized Local anaesthesia will be further on performedLocal anaesthesia will be further on performed TThe clinically or imagistically spotted region will be punctured he clinically or imagistically spotted region will be punctured

wwith the needle attached to the syringeith the needle attached to the syringe The collection’s content will be drawn and stored in special The collection’s content will be drawn and stored in special

containers according to the test that is to be performedcontainers according to the test that is to be performed For therapeutic puncture, the desired substance will be injectedFor therapeutic puncture, the desired substance will be injected The needle is firmly removed The needle is firmly removed The region will undergo massage with a alcohol swabThe region will undergo massage with a alcohol swab Sterile dressingSterile dressing Rest for 30 minutesRest for 30 minutes

TYPES OF PUNCTURES TYPES OF PUNCTURES

THORACIC PUNCTURE (THORACENTESIS)PERICARDIAL PUNCTURE ABDOMINAL PUNCTURE (PARACENTESIS)SUPRAPUBIC PUNCTURE LUMBAR PUNCTURE STERNAL PUNCTURE BIOPSY - PUNCTURE

CLICK USING THE MOUSE ON EACH TITLE

THORACIC PUNCTURE THORACIC PUNCTURE (THORACENTESIS)(THORACENTESIS)

Purpose: disposal, treatment, biopsyPurpose: disposal, treatment, biopsy Patient’s position: leaned forward, seated on a chair facing the chair’s back or Patient’s position: leaned forward, seated on a chair facing the chair’s back or

semi-seated when dealing with a patient difficult to mobilizesemi-seated when dealing with a patient difficult to mobilize Puncture’s place: Puncture’s place:

• Intercostal space III posterior axillary line for the disposal of pneumothoraxIntercostal space III posterior axillary line for the disposal of pneumothorax• Intercostal space VI posterior axillary line for the disposal of fluid Intercostal space VI posterior axillary line for the disposal of fluid • In full dullness to percussion In full dullness to percussion

Sanitization of the region, sterile gloves will be used during examination Sanitization of the region, sterile gloves will be used during examination One ampoule of Mialgin will be administered 15 minutes prior to the punctureOne ampoule of Mialgin will be administered 15 minutes prior to the puncture Local anaesthesiaLocal anaesthesia The needle or the trocar will be positioned perpendicularly to the skin, grazing the The needle or the trocar will be positioned perpendicularly to the skin, grazing the

top edge of the lower coasttop edge of the lower coast Skin is penetrated and at first and after that all layers of the chest wall until one Skin is penetrated and at first and after that all layers of the chest wall until one

can feel a slight resistance to the needle when passing through the pleuracan feel a slight resistance to the needle when passing through the pleura Then, one will go forward one centimetre more; after this, the collection will beginThen, one will go forward one centimetre more; after this, the collection will begin The needle is firmly removed, sterile dressingThe needle is firmly removed, sterile dressing INCIDENTS, ACCIDENTS, COMPLICATIONS: paroxysms of cough, pneumothorax, INCIDENTS, ACCIDENTS, COMPLICATIONS: paroxysms of cough, pneumothorax,

pleural shock, acute pulmonary oedema, tear of the puncture needlepleural shock, acute pulmonary oedema, tear of the puncture needle

IMAGE

THORACIC PUNCTURE THORACIC PUNCTURE (THORACENTESIS)(THORACENTESIS)

PERICARDIAL PUNCTUREPERICARDIAL PUNCTURE

Purpose: disposalPurpose: disposal Patient’s position and puncture’s place:Patient’s position and puncture’s place:

• Seated: intercostal space V at 6 cm from the left edge of the sternSeated: intercostal space V at 6 cm from the left edge of the stern• Supine position: top of the xiphoid appendixSupine position: top of the xiphoid appendix

Morphine should be administered Morphine should be administered Sanitization of the region, sterile gloves will be used during examinationSanitization of the region, sterile gloves will be used during examination Local anaesthesiaLocal anaesthesia The needle attached to the syringe will be positioned perpendicularly to the skinThe needle attached to the syringe will be positioned perpendicularly to the skin Under moderate aspiration, one goes forward with the needle until fluid enters Under moderate aspiration, one goes forward with the needle until fluid enters

in the syringe (this is when one knows the pericardial cavity has been reached)in the syringe (this is when one knows the pericardial cavity has been reached) The desired quantity of fluid will be sampledThe desired quantity of fluid will be sampled The puncture needle is firmly removed the region will undergo massageThe puncture needle is firmly removed the region will undergo massage Sterile dressingSterile dressing Bed rest for the patientBed rest for the patient INCIDENTS, ACCIDENTS, COMPLICATIONS: bleeding, restlessness, irregular INCIDENTS, ACCIDENTS, COMPLICATIONS: bleeding, restlessness, irregular

heartbeatsheartbeats

ABDOMINAL PUNCTUREABDOMINAL PUNCTURE(PARACENTESIS)(PARACENTESIS)

Purpose: disposal (for ascites, no more than 5 litres per session will be disposed), Purpose: disposal (for ascites, no more than 5 litres per session will be disposed), diagnosisdiagnosis

Patient’s position: supine positionPatient’s position: supine position Puncture’s place: midway between the umbilicus and the left anterior-superior Puncture’s place: midway between the umbilicus and the left anterior-superior

iliac spine, 2 cm under umbilicusiliac spine, 2 cm under umbilicus Local anaesthesiaLocal anaesthesia Sanitization of the region, sterile gloves will be used during examinationSanitization of the region, sterile gloves will be used during examination The needle will be positioned perpendicularly to the skin, penetrating all the The needle will be positioned perpendicularly to the skin, penetrating all the

layers of the abdominal wall (there will be two resistant layers – aponeurosis and layers of the abdominal wall (there will be two resistant layers – aponeurosis and transversalis fasciatransversalis fascia

The peritoneal fluid will be drawn and stored in the indicated containers or the The peritoneal fluid will be drawn and stored in the indicated containers or the needle will be coupled to an external drainage systemneedle will be coupled to an external drainage system

Peritoneal lavage: to the puncture needle, with the help of a blood infusion pump, Peritoneal lavage: to the puncture needle, with the help of a blood infusion pump, a bottle of physiological serum will be placed to at least one meter above the a bottle of physiological serum will be placed to at least one meter above the bed. Once emptied, the bottle will be placed at the level of the bed, thus allowing bed. Once emptied, the bottle will be placed at the level of the bed, thus allowing the leaking of the fluid from the peritoneal cavity into the bottlethe leaking of the fluid from the peritoneal cavity into the bottle

The puncture needle is firmly removed, sterile dressingThe puncture needle is firmly removed, sterile dressing Bed rest for the patientBed rest for the patient INCIDENTS, ACCIDENTS, COMPLICATIONS: puncture of an intestinal loop, INCIDENTS, ACCIDENTS, COMPLICATIONS: puncture of an intestinal loop,

gastrointestinal bleeding or vascular collapse in the event of sudden gastrointestinal bleeding or vascular collapse in the event of sudden decompression of the abdomendecompression of the abdomen

IMAGES

ABDOMINAL PUNCTUREABDOMINAL PUNCTURE(PARACENTESIS)(PARACENTESIS)

Veress needle

Abdominal puncture’s place

SUPRAPUBIC PUNCTURESUPRAPUBIC PUNCTURE

Purpose: disposal, collection of urine for urinalysisPurpose: disposal, collection of urine for urinalysis Patient’s position: supine positionPatient’s position: supine position Sanitization of the region, sterile gloves will be used during Sanitization of the region, sterile gloves will be used during

examinationexamination Puncture’s place: suprapubic regionPuncture’s place: suprapubic region The needle attached to the syringe will be positioned The needle attached to the syringe will be positioned

perpendicularly to the skin, under moderate aspiration, perpendicularly to the skin, under moderate aspiration, until urine appears in the syringeuntil urine appears in the syringe

The desired quantity of urine will be disposedThe desired quantity of urine will be disposed The bladder The bladder isis washed with antiseptic solutions, washed with antiseptic solutions, whichwhich will will

be later on disposedbe later on disposed The needle is firmly removedThe needle is firmly removed Sterile dressingSterile dressing INCIDENTS, ACCIDENTS, COMPLICATIONS: bleeding from INCIDENTS, ACCIDENTS, COMPLICATIONS: bleeding from

the bladder wall, infectionthe bladder wall, infection

LUMBAR PUNCTURELUMBAR PUNCTURE Purpose: diagnosis, treatment Purpose: diagnosis, treatment Patient’s position:Patient’s position:

• Lateral decubitus, squatLateral decubitus, squat• Seated, the column is curved in front, the hands are placed on opposite Seated, the column is curved in front, the hands are placed on opposite

shouldersshoulders Puncture’s place: L2, below the vertebraPuncture’s place: L2, below the vertebra Sanitization of the regionSanitization of the region It will pinpoint the spinous apophysis of the lumbar vertebra, left thumbIt will pinpoint the spinous apophysis of the lumbar vertebra, left thumb The needle will be positioned perpendicularly to the skin, grazing the spinous The needle will be positioned perpendicularly to the skin, grazing the spinous

apophysis, until feeling an increased strength has been overcome and the apophysis, until feeling an increased strength has been overcome and the entrance is entirely void of obstructions entrance is entirely void of obstructions

The needle’s tenaculum is removedThe needle’s tenaculum is removed 2-3 drops of Cerebro-Spinal Fluid are obtained2-3 drops of Cerebro-Spinal Fluid are obtained 2-3 ml of Cerebro-Spinal Fluid are sampled or the desired substance is injected 2-3 ml of Cerebro-Spinal Fluid are sampled or the desired substance is injected

with a sterile syringewith a sterile syringe The needle is firmly removedThe needle is firmly removed The region will undergo massage with a alcohol swabThe region will undergo massage with a alcohol swab Sterile dressingSterile dressing Bed rest for the patient during the whole dayBed rest for the patient during the whole day INCIDENTS, ACCIDENTS, COMPLICATIONS: headache, bleeding, infectionINCIDENTS, ACCIDENTS, COMPLICATIONS: headache, bleeding, infection

IMAGE

LUMBAR PUNCTURELUMBAR PUNCTURE

STERNAL PUNCTURESTERNAL PUNCTURE

Purpose: diagnosisPurpose: diagnosis Patient’s position: supine positionPatient’s position: supine position Mialgin or Morphine is administered Mialgin or Morphine is administered Puncture’s place: sternPuncture’s place: stern Sanitization of the region, sterile gloves will be used during Sanitization of the region, sterile gloves will be used during

examinationexamination Local anaesthesia will be performed Local anaesthesia will be performed With the Malarme trocar, placed perpendicularly on the stern, one With the Malarme trocar, placed perpendicularly on the stern, one

goes forward until feeling the entrance is entirely void of obstructionsgoes forward until feeling the entrance is entirely void of obstructions The tenaculum is removed and with a sterile syringe are sampled 4 ml The tenaculum is removed and with a sterile syringe are sampled 4 ml

of haematogenous medullaof haematogenous medulla The trocar is sampledThe trocar is sampled Sanitization of the region with alcoholSanitization of the region with alcohol Sterile dressingSterile dressing INCIDENTS, ACCIDENTS, COMPLICATIONS: infection, stern fractureINCIDENTS, ACCIDENTS, COMPLICATIONS: infection, stern fracture

BIOPSY - PUNCTUREBIOPSY - PUNCTURE Purpose: diagnosisPurpose: diagnosis Patient’s position: Patient’s position: one will choose the most one will choose the most

comfortable position for the patient, depending on comfortable position for the patient, depending on where the where the regionregion or organ to be punctured is or organ to be punctured is foundfound

Puncture’s place: varies depending on localization Puncture’s place: varies depending on localization ((adenopathiesadenopathies, liver, tumours) , liver, tumours)

Sanitization of the region, sterile gloves will be used Sanitization of the region, sterile gloves will be used during examinationduring examination

The puncture technique described above will be The puncture technique described above will be carried outcarried out

The sampled product will be placed in containers and The sampled product will be placed in containers and sent as soon as possible to the histopathology sent as soon as possible to the histopathology laboratorylaboratory

INCIDENTS, ACCIDENTS, COMPLICATIONS: bleeding, INCIDENTS, ACCIDENTS, COMPLICATIONS: bleeding, infectioninfection

Biopsy needleVIDEO

BIOPSY - PUNCTURE BIOPSY - PUNCTURE MAMMARY TUMOR MAMMARY TUMOR

IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE

SURGICAL SUTURESURGICAL SUTURE

DEFINITION, PURPOSE, PRINCIPLESINDICATIONSCONTRAINDICATIONSREQUIRED MATERIALSTECHNIQUEINCIDENTS, ACCIDENTS, COMPLICATIONS

MEDICAL CARE

CONTENTSCLICK USING THE MOUSE ON EACH TITLE


Definition:Definition: it represents the closeness and solidarity of the it represents the closeness and solidarity of the margins of a wound (skin, organ, digestive tube, etc.) by sewing margins of a wound (skin, organ, digestive tube, etc.) by sewing them with a needle and a threadthem with a needle and a thread

Purpose: Purpose: restoration of the anatomical continuity of the restoration of the anatomical continuity of the structure involved or of two different structures when surgery structure involved or of two different structures when surgery requires sorequires so

Principles: Principles: • It is a sterile It is a sterile manoeuvremanoeuvre • Local hemostasis must be perfectLocal hemostasis must be perfect• The The edges to be sutured must have an adequate edges to be sutured must have an adequate

vascularization vascularization • The suture begins with the deepest chain to the surfaceThe suture begins with the deepest chain to the surface• For the hollow organs, the suture must be tight and not For the hollow organs, the suture must be tight and not

stenosed. In order to comply with this rule, if necessary, one stenosed. In order to comply with this rule, if necessary, one can perform more suturescan perform more sutures

• The knots of the suture mustThe knots of the suture must not not be madebe made to close in order to close in order to to avoid avoid ischemia; nor should they be too large, untightischemia; nor should they be too large, untight

• A suture may be primary or secondaryA suture may be primary or secondary


Restoring the continuity of the incised Restoring the continuity of the incised or broken structuresor broken structures

Fixing some mobile structures to other Fixing some mobile structures to other mobile or fix structuresmobile or fix structures

Fixing of prosthesis Fixing of prosthesis (prostheses, grafts, etc.)(prostheses, grafts, etc.)

Fixing the drain tubes, probesFixing the drain tubes, probes


Infected woundsInfected wounds Old septic high-risk woundsOld septic high-risk wounds Purulent incised collectionsPurulent incised collections Suture of viscera in peritonitisSuture of viscera in peritonitis Poorly Poorly vascularisedvascularised structures structures


Sterile glovesSterile gloves Soft sterile materialSoft sterile material Antiseptic solutionsAntiseptic solutions Suture needlesSuture needles Suture threadsSuture threads Metal staplesMetal staples Needle Needle hholderolder Anatomic clamp with or without teethAnatomic clamp with or without teeth ScissorsScissors

SEE ANTISEPTICS

FOTO



REQUIRED MATERIALSREQUIRED MATERIALSNEEDLESNEEDLES

Disposable needles (atraumatic) Disposable needles (atraumatic) or reor re--sterilizable (always traumatic, sterilizable (always traumatic, are rarely ever used)are rarely ever used)

Straight or curved needlesStraight or curved needles Triangular needles (skin, fascia), Triangular needles (skin, fascia),

oval or round needles (intestines, oval or round needles (intestines, organs, etc.)organs, etc.)

REQUIRED MATERIALSREQUIRED MATERIALSSUTURE THREADSSUTURE THREADS

Natural (flax, cotton, silk, catgut) Natural (flax, cotton, silk, catgut) or synthetic (nylon, dacron) threads or synthetic (nylon, dacron) threads

ReReabsorbable (resorption between absorbable (resorption between 14 days and 6 months) or non-14 days and 6 months) or non-rereabsorbable threads absorbable threads

In terms of In terms of thicknesses, they vary thicknesses, they vary depending on the structure depending on the structure that is to be suturedthat is to be sutured

They must be flexibleThey must be flexible They must be resistantThey must be resistant

TECHNIQUETECHNIQUE

Patient’s information on the procedure Patient’s information on the procedure and obtaining his written consent and obtaining his written consent

Preoperative preparation of the suture Preoperative preparation of the suture place (waxing, sanitization, disposal and place (waxing, sanitization, disposal and cleaning of hollow viscera)cleaning of hollow viscera)

Preparation of the structures to be Preparation of the structures to be sutured: identification and tracking of sutured: identification and tracking of anatomical elements, perfect hemostasis, anatomical elements, perfect hemostasis, adequate vascularization, removal of the adequate vascularization, removal of the fat from the level of the suturefat from the level of the suture

TECHNIQUETECHNIQUE

INTERRUPTED SUTURE CONTINUOUS SUTURE METAL STAPLES SUTURE

TECHNIQUETECHNIQUEINTERRUPTED SUTUREINTERRUPTED SUTURE

SIMPLE INTERRUPTED SUTURE HORIZONTAL MATTRESS SUTURE VERTICAL MATTRESS SUTURE


SIMPLE INTERRUPTED SUTURESIMPLE INTERRUPTED SUTURE

The needle will pass approximately The needle will pass approximately 1 cm away from the wound’s edge 1 cm away from the wound’s edge penetrating all deep levels up to about penetrating all deep levels up to about 1.2 cm of the incision line1.2 cm of the incision line

The same trajectory will beThe same trajectory will be fol folllowedowed on the opposite lip of the woundon the opposite lip of the wound

The node will not fall on the wound but The node will not fall on the wound but on one of the places of entry or exit of on one of the places of entry or exit of the needlethe needle

VIDEO


SIMPLE INTERRUPTED SUTURE SIMPLE INTERRUPTED SUTUREPERITONEUM-APONEUROTIC SUTUREPERITONEUM-APONEUROTIC SUTURE



SIMPLE INTERRUPTED SUTURE SIMPLE INTERRUPTED SUTURECUTANEOUS SUTURECUTANEOUS SUTURE



HORIZONTAL MATTRESS SUTURE - LEXERHORIZONTAL MATTRESS SUTURE - LEXER

The same indications as for the The same indications as for the simple suture will be followed, simple suture will be followed, only that one will also return with only that one will also return with the needle pointing at 0.5 cm from the needle pointing at 0.5 cm from the needle’s place of existthe needle’s place of exist

The node will be done on the wound The node will be done on the wound where the suturing was begun; where the suturing was begun; in the end, two parallel threads in the end, two parallel threads will appear joined by a nodewill appear joined by a node


VERTICAL MATTRESS SUTUREVERTICAL MATTRESS SUTURE

A simple point will be made; A simple point will be made; it will continue with a U-shape turn at it will continue with a U-shape turn at 3 mm from the wound, the needle 3 mm from the wound, the needle passing through the epidermispassing through the epidermis

The node will be made on the The node will be made on the wound’s part where the suture wound’s part where the suture was started was started

It provides a very good approach It provides a very good approach

VIDEO


VERTICAL MATTRESS SUTURE VERTICAL MATTRESS SUTURE


TECHNIQUETECHNIQUECONTINUOUS SUTURECONTINUOUS SUTURE

The suture begins with a simple point; then, The suture begins with a simple point; then, the needle will pass like for the interrupted the needle will pass like for the interrupted suture, this meaning that the node is no suture, this meaning that the node is no longer made after each pass of the needle, longer made after each pass of the needle, the thread being held in tension until the the thread being held in tension until the end of the suture when it is finally tiedend of the suture when it is finally tied

It can determine asymmetries of the woundIt can determine asymmetries of the wound Types of continuous suture: interrupted, Types of continuous suture: interrupted,

Blair-Donatti, intraBlair-Donatti, intra--dermaldermal

TECHNIQUETECHNIQUEMETAL STAPLES SUTUREMETAL STAPLES SUTURE

Separate pointsSeparate points The mechanical The mechanical

suture of the suture of the hollow viscera hollow viscera (it is fast, tight (it is fast, tight and provides and provides a very good a very good approach)approach)


Breaking of the suture threads Breaking of the suture threads The wound gets opened by the sectioning The wound gets opened by the sectioning

of the sutured structuresof the sutured structures SeromaSeroma Hematoma, bleedingsHematoma, bleedings InfectionInfection EventrationsEventrations Eviscerations Eviscerations Thread granulomaThread granuloma Vicious scarVicious scar

MEDICAL CAREMEDICAL CARE

Daily dressing in the first two days, Daily dressing in the first two days, then as neededthen as needed

The threads will be removed in 4-14 days The threads will be removed in 4-14 days from the suture, depending on local from the suture, depending on local factors (vascularization, etc..) and general factors (vascularization, etc..) and general factors (cachexia, malignancy, etc.) – factors (cachexia, malignancy, etc.) – 4 days for scalp and neck, 7-10 days for 4 days for scalp and neck, 7-10 days for thorax and abdomen, 12 days for limbs thorax and abdomen, 12 days for limbs

Clips will be removed 4 days Clips will be removed 4 days postoperativelypostoperatively

BANDAGINGBANDAGING(DRESSING OF A WOUND)(DRESSING OF A WOUND)

DEFINITION, PURPOSE, PRINCIPLESREQUIRED MATERIALSTECHNIQUE

CONTENTS



Definition:Definition: it represents the method through which it represents the method through which the body is covered or fixed with gauze or elastic rollersthe body is covered or fixed with gauze or elastic rollers

Purpose:Purpose: fixing the bandage fixing the bandage Principles:Principles:

• Not to cause pain, not to be too tight or too wideNot to cause pain, not to be too tight or too wide• To cover well the region, protecting and isolating the To cover well the region, protecting and isolating the

woundwound• To achieve a better fixing of the bandage To achieve a better fixing of the bandage • To allow mobilization of the dressed segment To allow mobilization of the dressed segment • The roller is unfolded from left to rightThe roller is unfolded from left to right• The fixing of the dressing is made at distance The fixing of the dressing is made at distance

from the wound in order not to cause painfrom the wound in order not to cause pain• At the level of the limbs, the bandage will be made from At the level of the limbs, the bandage will be made from

distal to proximaldistal to proximal


Gauze roller of varying lengths Gauze roller of varying lengths and widthsand widths

Elastic rollerElastic roller Adhesive strip Adhesive strip of fixation of fixation NetsNets Staples Staples


Elastic roller and fixing staple

Plaster roller

Types of rollers

REQUIRED MATERIALSREQUIRED MATERIALSFIXING MATERIALSFIXING MATERIALS

Galifix

Fixing staple

Elastic netAdhesive strip

TECHNIQUETECHNIQUE

Dressing will start with 1-3 circular fixing lapsDressing will start with 1-3 circular fixing laps The roller will be unfolded with the right hand and The roller will be unfolded with the right hand and

fixed with the left handfixed with the left hand Bandaging will continue according to the region Bandaging will continue according to the region

involved involved Bandaging will end with 1-2 circular lapsBandaging will end with 1-2 circular laps Bandaging is fixed with adhesive stripes or safety Bandaging is fixed with adhesive stripes or safety

pins placed away from the woundpins placed away from the wound Bandaging will be removed by cuts with scissors Bandaging will be removed by cuts with scissors

made in a part outside the woundmade in a part outside the wound

TECHNIQUETECHNIQUE

GENERAL TECHNIQUESGENERAL TECHNIQUESBANDAGING ACCORDING TO TOPOGRAPHICAL BANDAGING ACCORDING TO TOPOGRAPHICAL

REGIONSREGIONS


GENERAL TECHNIQUESGENERAL TECHNIQUES

CIRCULAR BANDAGINGCIRCULAR BANDAGING

SPIRAL BANDAGINGSPIRAL BANDAGING

FAN BANDAGINGFAN BANDAGING

SPICA BANDAGINGSPICA BANDAGING

IMAGE-OF-EIGHT BANDAGING IMAGE-OF-EIGHT BANDAGING

RECURRENT FOLD BANDAGINGRECURRENT FOLD BANDAGING


TECHNIQUETECHNIQUECIRCULAR BANDAGINGCIRCULAR BANDAGING

INDICATIONS: neck, arm, fistINDICATIONS: neck, arm, fist Circular laps will be put one over Circular laps will be put one over

another another Advantages: easy to makeAdvantages: easy to make Disadvantages: it Disadvantages: it rolls up, gets rolls up, gets

tighten becoming uncomfortabletighten becoming uncomfortable

TECHNIQUETECHNIQUESPIRAL BANDAGINGSPIRAL BANDAGING

INDICATIONS: limbs, thoraxINDICATIONS: limbs, thorax The bandaging begins with 1-2 circular The bandaging begins with 1-2 circular

fixing laps, continues with partially fixing laps, continues with partially overlapped oblique circular laps and overlapped oblique circular laps and ends with 1-2 circular lapsends with 1-2 circular laps

Advantages: it covers important surfaces Advantages: it covers important surfaces Disadvantages: the distal part of each Disadvantages: the distal part of each

lap is largelap is large

TECHNIQUE TECHNIQUE FAN BANDAGINGFAN BANDAGING

INDICATIONS: elbow, kneeINDICATIONS: elbow, knee The bandaging begins with 1-2 circular The bandaging begins with 1-2 circular

laps, continues with spiral laps in the laps, continues with spiral laps in the thickness of the joint space where 1-2 thickness of the joint space where 1-2 circular laps are followed by as many circular laps are followed by as many spiral laps as necessaryspiral laps as necessary, ending with 1-2 , ending with 1-2 circular lapscircular laps

Advantages: it fixes the bandaging at the Advantages: it fixes the bandaging at the level of the jointlevel of the joint

TECHNIQUE TECHNIQUE SPICA BANDAGINGSPICA BANDAGING

INDICATIONS: shoulder, hipINDICATIONS: shoulder, hip The bandaging begins with 1-2 circular The bandaging begins with 1-2 circular

laps at the level of the thorax or laps at the level of the thorax or abdomen, continues at the level of the abdomen, continues at the level of the joint with “8”-shape laps partially joint with “8”-shape laps partially overlapped and ends with 1-2 circular overlapped and ends with 1-2 circular lapslaps

Advantages: it provides a good fixing of Advantages: it provides a good fixing of the bandaging the bandaging

TECHNIQUE TECHNIQUE IMAGE-OF-EIGHT BANDAGING IMAGE-OF-EIGHT BANDAGING

INDICATIONS: hand, ankleINDICATIONS: hand, ankle The bandaging begins with 1-2 The bandaging begins with 1-2

circular laps distal to the joint, circular laps distal to the joint, continues with “8”-shape laps continues with “8”-shape laps partially overlapped and ends partially overlapped and ends proximally with 1-2 circular lapsproximally with 1-2 circular laps

TECHNIQUE TECHNIQUE RECURRENT FOLD BANDAGINGRECURRENT FOLD BANDAGING

INDICATIONS: head, amputation stumpINDICATIONS: head, amputation stump 2 rollers are to be used2 rollers are to be used With one roller, are done 1-2 circular laps in With one roller, are done 1-2 circular laps in

the fronto-occipital region; with the other the fronto-occipital region; with the other roller, the bandage passes from anterior to roller, the bandage passes from anterior to posterior and vice versa (folded roller); each posterior and vice versa (folded roller); each passing of the roller is fixed with the first passing of the roller is fixed with the first roller by a circular lap until the whole roller by a circular lap until the whole surface is covered. The bandage ends surface is covered. The bandage ends by by getting fixed due togetting fixed due to 1-2 circular laps 1-2 circular laps

PHOTO

BANDAGING BANDAGING ACCORDING TO ACCORDING TO

TOPOGRAPHICAL REGIONSTOPOGRAPHICAL REGIONS

AT THE LEVEL OF THE HEADAT THE LEVEL OF THE HEAD AT THE LEVEL OF THE NECKAT THE LEVEL OF THE NECK AT THE LEVEL OF THE THORAXAT THE LEVEL OF THE THORAX AT THE LEVEL OF THE ABDOMENAT THE LEVEL OF THE ABDOMEN AT THE LEVEL OF THE PERINEUMAT THE LEVEL OF THE PERINEUM AT THE LEVEL OF THE LIMBSAT THE LEVEL OF THE LIMBS


TECHNIQUETECHNIQUEAT THE LEVEL OF THE HEADAT THE LEVEL OF THE HEAD

Types of bandagesTypes of bandages CAPELINECAPELINE MONOCLE, BINOCLEMONOCLE, BINOCLE NASAL SLING AND CHIN BANDAGENASAL SLING AND CHIN BANDAGE


TECHNIQUETECHNIQUEAT THE LEVEL OF THE HEAD-CAPELINEAT THE LEVEL OF THE HEAD-CAPELINE

With one roller, are done 1-2 circular With one roller, are done 1-2 circular laps in the fronto-occipital region; with laps in the fronto-occipital region; with the other roller, the bandage passes the other roller, the bandage passes from anterior to posterior and vice from anterior to posterior and vice versa (folded roller); each passing of versa (folded roller); each passing of the roller is fixed with the first roller by the roller is fixed with the first roller by a circular lap until the whole surface is a circular lap until the whole surface is covered. The bandage ends covered. The bandage ends by getting by getting fixed due tofixed due to 1-2 circular laps 1-2 circular laps

TECHNIQUETECHNIQUECAPELINECAPELINE


TECHNIQUETECHNIQUEAT THE LEVEL OF THE HEAD-MONOCLE, BINOCLEAT THE LEVEL OF THE HEAD-MONOCLE, BINOCLE

INDICATIONS: INDICATIONS: ophthalmologyophthalmology

With one roller, are With one roller, are done 1-2 circular laps done 1-2 circular laps in the fronto-occipital in the fronto-occipital region; then, are done region; then, are done oblique laps in the oblique laps in the temporo-sub-auricular temporo-sub-auricular uni or bilateral region, uni or bilateral region, fixed by 1-2 circular fixed by 1-2 circular laps. The bandaging laps. The bandaging ends with 1-2 circular ends with 1-2 circular lapslaps

MONOCLE BINOCLE

TECHNIQUETECHNIQUEAT THE LEVEL OF THE HEAD-NASAL SLING AND CHIN BANDAGE AT THE LEVEL OF THE HEAD-NASAL SLING AND CHIN BANDAGE

(FOUR-TAILED BANDAGE)(FOUR-TAILED BANDAGE)

A roller of A roller of approximately 80 cm approximately 80 cm length will be split in length will be split in both extremities, both extremities, leaving in the middle leaving in the middle 6-8 cm not split. The 6-8 cm not split. The extremities are extremities are crossed over each crossed over each other and other and behindbehind the the ear, being knotted at ear, being knotted at the blackhead and the blackhead and calvariacalvaria

SLING

FOUR-TAILED

BANDAGE

TECHNIQUETECHNIQUEAT THE LEVEL OF THE NECKAT THE LEVEL OF THE NECK

ANTERIOR SPICA ANTERIOR SPICA OF THE NECKOF THE NECK

POSTERIOR SPICA POSTERIOR SPICA OF THE NECKOF THE NECK

These are complex These are complex bandagesbandages

They apply the “8”-They apply the “8”-shape bandaging shape bandaging technique as well as technique as well as the circular bandaging the circular bandaging

POSTERIOR SPICA OF THE NECK

TECHNIQUETECHNIQUEAT THE LEVEL OF THE THORAXAT THE LEVEL OF THE THORAX

Types of bandages:Types of bandages: VELPEAU BANDAGEVELPEAU BANDAGE BREAST SPICABREAST SPICA


TECHNIQUETECHNIQUEVELPEAU BANDAGEVELPEAU BANDAGE

INDICATIONS: orthopedic injuries of INDICATIONS: orthopedic injuries of the shoulder, humerusthe shoulder, humerus

Circular chest laps will be done, Circular chest laps will be done, alternating with oblique laps that fix alternating with oblique laps that fix the upper limb to the thorax, as well the upper limb to the thorax, as well as vertical laps over the shoulder and as vertical laps over the shoulder and forearm, the hand being freeforearm, the hand being free

TECHNIQUETECHNIQUEBREAST SPICABREAST SPICA

INDICATIONS: INDICATIONS: mastectomymastectomy

2-3 circular laps 2-3 circular laps will be done on the will be done on the thorax under the thorax under the normal breast, normal breast, then oblique laps then oblique laps over the shoulder, over the shoulder, altering with altering with circular chest lapscircular chest laps

VIDEO

TECHNIQUETECHNIQUEBREAST SPICABREAST SPICA


TECHNIQUETECHNIQUEAT THE LEVEL OF THE ABDOMENAT THE LEVEL OF THE ABDOMEN

It is difficult to be made and lacks It is difficult to be made and lacks functionality functionality

Other types of fixing the bandage are Other types of fixing the bandage are preferred, especially adhesive strips preferred, especially adhesive strips

One used dressing type is the “loose One used dressing type is the “loose bandage”bandage”

VIDEO

TECHNIQUETECHNIQUE AT THE LEVEL OF THE ABDOMEN-LOOSE BANDAGEAT THE LEVEL OF THE ABDOMEN-LOOSE BANDAGE


TECHNIQUETECHNIQUEAT THE LEVEL OF THE PERINEUMAT THE LEVEL OF THE PERINEUM

DRESSING OF A “T”-DRESSING OF A “T”-SHAPE WOUNDSHAPE WOUND

Two rollers are to be Two rollers are to be used for this used for this bandage, one going bandage, one going circular abdominal, circular abdominal, and the other and the other antero-posterior antero-posterior covering the covering the genitals, being fixed genitals, being fixed due to abdominal due to abdominal circular lapscircular laps

TECHNIQUETECHNIQUEAT THE LEVEL OF THE LIMBSAT THE LEVEL OF THE LIMBS

SPICA BANDAGING:SPICA BANDAGING: shoulder, hip, fingers shoulder, hip, fingers FAN BANDAGING:FAN BANDAGING: elbow, knee elbow, knee IMAGE-OF-EIGHT BANDAGING:IMAGE-OF-EIGHT BANDAGING: hand, ankle hand, ankle CIRCULAR BANDAGING:CIRCULAR BANDAGING: arm, fist arm, fist


TECHNIQUETECHNIQUESPICA OF THE SHOULDER, HIPSPICA OF THE SHOULDER, HIP

TECHNIQUETECHNIQUESPICA OF THE FOREFINGERSPICA OF THE FOREFINGER


TECHNIQUETECHNIQUEFAN BANDAGING OF THE ELBOW, KNEEFAN BANDAGING OF THE ELBOW, KNEE

TECHNIQUETECHNIQUEIMAGE-OF-EIGHT BANDAGING IMAGE-OF-EIGHT BANDAGING

HANDHAND ANKLEANKLE


TECHNIQUETECHNIQUEIMAGE-OF-EIGHT BANDAGING-HANDIMAGE-OF-EIGHT BANDAGING-HAND


TECHNIQUETECHNIQUEIMAGE-OF-EIGHT BANDAGING-ANKLEIMAGE-OF-EIGHT BANDAGING-ANKLE


TECHNIQUETECHNIQUECIRCULAR BANDAGINGCIRCULAR BANDAGING


TECHNIQUETECHNIQUESTUMP THIGHSTUMP THIGH

Elastic stocking

Fixing bandage with an elastic net

URINARY CATHETERIZATIONURINARY CATHETERIZATION

DEFINITION, PRINCIPLESDEFINITION, PRINCIPLES PURPOSEPURPOSE INDICATIONSINDICATIONS CONTRAINDICATIONSCONTRAINDICATIONS REQUIRED MATERIALSREQUIRED MATERIALS TECHNIQUETECHNIQUE INCIDENTS, ACCIDENTS, COMPLICATIONSINCIDENTS, ACCIDENTS, COMPLICATIONS MEDICAL CAREMEDICAL CARE

CONTENTSCLICK USING THE MOUSE ON EACH TITLE

DEFINITION, DEFINITION, PRINCIPLESPRINCIPLES

Definition: Definition: it represents a method it represents a method through which the communication through which the communication between the external environment between the external environment and bladder is achieved and bladder is achieved

Principle:Principle: it is an aseptic method it is an aseptic method

PurposePurpose

Disposal:Disposal: • Monitoring: Monitoring: in hydro-electrolytic in hydro-electrolytic

unstable patients, duringunstable patients, during the the postoperative immediate phase postoperative immediate phase (loss evaluation)(loss evaluation)

• Therapy :Therapy : acute retention of urine acute retention of urine (urgency)(urgency)

Exploration:Exploration: a radio-opaque substance is a radio-opaque substance is inserted inserted allowing to obtain information on allowing to obtain information on the bladder’s form, shape, sizethe bladder’s form, shape, size

Therapy:Therapy: antibiotics (urinary tract antibiotics (urinary tract infections), infections), chemotherapy (cancer)chemotherapy (cancer)


Acute retention of urineAcute retention of urine Prostate stenosis (for disposal purpose Prostate stenosis (for disposal purpose

and simultaneously accomplishes and simultaneously accomplishes a dilatation of the urethra) a dilatation of the urethra)

Urethral stenosisUrethral stenosis Administration of radio-opaque Administration of radio-opaque

substancessubstances Administration of drugs Administration of drugs

(antibiotics, chemotherapeutic)(antibiotics, chemotherapeutic)


The major urethral structure when are The major urethral structure when are created “false paths” or the urethral created “false paths” or the urethral rupture due to the catheter’s insertionrupture due to the catheter’s insertion


OilclothOilcloth Sterile glovesSterile gloves Sterile solution for sanitization Sterile solution for sanitization Nelaton probe (women), Thyeman (men) Nelaton probe (women), Thyeman (men)

Foley (balloon), PezzerFoley (balloon), Pezzer Lubrication gelLubrication gel Collecting bagCollecting bag Kidney tray, basinKidney tray, basin

TECHNIQUETECHNIQUE

The oilcloth is placed under the patient, together with a basin or The oilcloth is placed under the patient, together with a basin or a kidney traya kidney tray

The patient is in supine position, with the hips flexed on the legs The patient is in supine position, with the hips flexed on the legs and knees apartand knees apart

Gloves must be used for now on. Left hand will be used for the Gloves must be used for now on. Left hand will be used for the local toilet (penis glans for men, vulvar region for women); the local toilet (penis glans for men, vulvar region for women); the right hand will be used for handling the catheter, the glove right hand will be used for handling the catheter, the glove being kept sterilebeing kept sterile

After doing the toilet with the left hand, the glans is opened or After doing the toilet with the left hand, the glans is opened or the vulvar lips are kept apart; after this, a lavage with abundant the vulvar lips are kept apart; after this, a lavage with abundant antiseptic solutions will be madeantiseptic solutions will be made

The physician will keep the peak of the catheter while the distal The physician will keep the peak of the catheter while the distal end will be attached to the collecting bag by the nurseend will be attached to the collecting bag by the nurse

The lubricant will be poured in the catheter's peak and in the The lubricant will be poured in the catheter's peak and in the penis urinary meatuspenis urinary meatus

TECHNIQUE FOR THE MALETECHNIQUE FOR THE MALE TECHNIQUE FOR THE FEMALETECHNIQUE FOR THE FEMALE

CLICK USING THE MOUSE ON THE UNDERLINED TITLES

TECHNIQUE FOR THE MALETECHNIQUE FOR THE MALE

The penis glans is localizedThe penis glans is localized The penis is oriented to zenithThe penis is oriented to zenith The catheter is gently insertedThe catheter is gently inserted When the peak reaches the prostate, the penis will be When the peak reaches the prostate, the penis will be

directed caudally, parallel to the beddirected caudally, parallel to the bed The catheter’s insertion continues until reaching the The catheter’s insertion continues until reaching the

bladder (the urine appears in the urinary tube)bladder (the urine appears in the urinary tube) The balloon fills with physiological serumThe balloon fills with physiological serum The catheter is withdrawn until it stops (at the bladder The catheter is withdrawn until it stops (at the bladder

opening of the urethra)opening of the urethra) Local toiletLocal toilet

VIDEO

TECHNIQUE FOR THE MALETECHNIQUE FOR THE MALE


TECHNIQUE TECHNIQUE FOR THE FEMALEFOR THE FEMALE

The catheter The catheter is inserted into the urinary meatusis inserted into the urinary meatus The catheter is slowly and progressively The catheter is slowly and progressively

insertedinserted The catheter is inserted approximately 10-15 The catheter is inserted approximately 10-15

cm (the female urethra is short and right)cm (the female urethra is short and right) The balloon fills with physiological serumThe balloon fills with physiological serum The catheter is withdrawn until it stops (at the The catheter is withdrawn until it stops (at the

bladder opening of the urethra)bladder opening of the urethra) Local toiletLocal toilet

VIDEO

TECHNIQUE TECHNIQUE FOR THE FEMALEFOR THE FEMALE



The “false path" is the most common complication that can lead to The “false path" is the most common complication that can lead to rupture of the urethra. It requires the urgent attention of the rupture of the urethra. It requires the urgent attention of the urology departmenturology department

The balloon’s filling in the urethra causes the dilatation of the The balloon’s filling in the urethra causes the dilatation of the urethra, which can be accompanied by bleeding or rupture. In urethra, which can be accompanied by bleeding or rupture. In order to avoid this accident, first the catheter will be entirely order to avoid this accident, first the catheter will be entirely inserted and only after that the balloon will inflateinserted and only after that the balloon will inflate

Bleeding “ex vacuo" occurs due to sudden emptying of the bladder Bleeding “ex vacuo" occurs due to sudden emptying of the bladder that causes the rupture of the blood vessel in the bladder mucosathat causes the rupture of the blood vessel in the bladder mucosa

If it is necessary to evacuate a large amount of urine, then this will If it is necessary to evacuate a large amount of urine, then this will be gradually made, evacuating small amounts of urine alternating be gradually made, evacuating small amounts of urine alternating for few minutes with the catheter’s plucking for few minutes with the catheter’s plucking

Urinary infectionUrinary infection The blocking of the catheter with clots, flakes, precipitates requires The blocking of the catheter with clots, flakes, precipitates requires

washing with antiseptic and anti-obstruction solutions washing with antiseptic and anti-obstruction solutions

MEDICAL CAREMEDICAL CARE

Purpose: the Purpose: the sterility of the bladder sterility of the bladder and of the disposed urine must be and of the disposed urine must be maintained maintained

The catheter will be changed in 7 The catheter will be changed in 7 days time in aseptic conditionsdays time in aseptic conditions

The collecting bag must be changed The collecting bag must be changed or emptied in aseptic conditionsor emptied in aseptic conditions

Local hygieneLocal hygiene

SURGICAL SURGICAL INSTRUMENTSINSTRUMENTS

CONTENTS

TYPES OF INSTRUMENTSTYPES OF INSTRUMENTS

INSTRUMENTS TO SECTION TISSUESINSTRUMENTS TO SECTION TISSUES INSTRUMENTS OF EXPLORATIONINSTRUMENTS OF EXPLORATION INSTRUMENTS TO GRASP AND MANIPULATE INSTRUMENTS TO GRASP AND MANIPULATE

TISSUESTISSUES INSTRUMENTS OF HEMOSTASISINSTRUMENTS OF HEMOSTASIS INSTRUMENTS OF REMOVALINSTRUMENTS OF REMOVAL INSTRUMENTS OF SUTUREINSTRUMENTS OF SUTURE INSTRUMENTS OF FIXATIONINSTRUMENTS OF FIXATION INSTRUMENTE FOR LAPAROSCOPYINSTRUMENTE FOR LAPAROSCOPY


INSTRUMENTS TO SECTION INSTRUMENTS TO SECTION TISSUESTISSUES

Removable and disposable blade scalpelRemovable and disposable blade scalpel Electric scalpelElectric scalpel Ultrasonic scalpelUltrasonic scalpel Laser scalpelLaser scalpel Curved and straight scissors Curved and straight scissors Amputation knifeAmputation knife Osteotomes Osteotomes ChiselChisel Blade-type, Gigli, electrical, Blade-type, Gigli, electrical,

pneumatic sawspneumatic saws


Electric scalpel

Hand grip scalpel Scissors

Scalpel blades


Saw

Chisel

Costotome

Bone cutter


Amputation knife

Gigli saw

INSTRUMENTS OF EXPLORATIONINSTRUMENTS OF EXPLORATION

Channelled catheter Button stiletto Olive-tipped explorer Histometer

INSTRUMENTS TO GRASP AND INSTRUMENTS TO GRASP AND MANIPULATE TISSUESMANIPULATE TISSUES

Anatomic clamp with or without teethAnatomic clamp with or without teeth Surgical clampsSurgical clamps ““Heart”-shape clamps Heart”-shape clamps Babckok clampBabckok clamp ““Mice teeth”-shape clamp – ChaputMice teeth”-shape clamp – Chaput Coprostatic straight and curved clampsCoprostatic straight and curved clamps Anastomotic clamps - Line-ThomasAnastomotic clamps - Line-Thomas ““L”-shape clampsL”-shape clamps

INSTRUMENTS TO GRASP INSTRUMENTS TO GRASP AND MANIPULATE TISSUESAND MANIPULATE TISSUES

Anatomic clamps without teethAnatomic clamps with teeth (surgical clamps)

INSTRUMENTS TO GRASP AND INSTRUMENTS TO GRASP AND MANIPULATE TISSUESMANIPULATE TISSUES

““HeartHeart””-shape clamp-shape clamp BabckokBabckok clamp clamp

INSTRUMENTS TO GRASP INSTRUMENTS TO GRASP AND MANIPULATE TISSUESAND MANIPULATE TISSUES

Coprostatic clamps

“L”-shape clamp

INSTRUMENTS INSTRUMENTS OF HEMOSTASISOF HEMOSTASIS

Curved and straight Curved and straight PPéan clampséan clamps Curved and straightCurved and straight Kocher clamps Kocher clamps Mosquito clamps Mosquito clamps Halsted clamps Halsted clamps Guyon clamps Guyon clamps Satinski clamps Satinski clamps ““Bulldog”-type clamps - DieffenbachBulldog”-type clamps - Dieffenbach


Kocher clamps

Péan clampsSatinski clampsSatinski clamps


““Buldog”-type clamps - DieffenbachBuldog”-type clamps - Dieffenbach

INSTRUMENTS INSTRUMENTS OF REMOVALOF REMOVAL

Farabeuf spreader Farabeuf spreader ValvesValves Auto-static spreaders: Gosset, Auto-static spreaders: Gosset,

Dartigues, Finochetto, CollinDartigues, Finochetto, Collin Anal dilatorsAnal dilators Vaginal speculumVaginal speculum

INSTRUMENTS OF REMOVALINSTRUMENTS OF REMOVAL

Farabeuf spreadersFarabeuf spreaders

Finochetto Finochetto spreaderspreader

Valves

Volkman spreader


Gosset spreader

Dartigues spreader


Vaginal speculum

Anal dilator

INSTRUMENTS INSTRUMENTS OF SUTUREOF SUTURE

Round and triangular, straight or Round and triangular, straight or curved Hagedorn needles curved Hagedorn needles

Atraumatic needlesAtraumatic needles Metal staplesMetal staples Mathieu Needle holder Mathieu Needle holder Hegar Needle holderHegar Needle holder Rechargeable or disposable staplersRechargeable or disposable staplers

INSTRUMENTS OF SUTUREINSTRUMENTS OF SUTURE

Mathieu Needle holder Hegar Needle holder

Mechanical suture clamp


Round-head needle Triangular-head needleReverdin needle


Fixing adhesive strips

Metal staples

INSTRUMENTS OF FIXATION (racks)INSTRUMENTS OF FIXATION (racks)

INSTRUMENTE FOR INSTRUMENTE FOR LAPAROSCOPYLAPAROSCOPY

Clamps

Trocar

BIBLIOGRAPHYBIBLIOGRAPHY

1.1. Acalovschi I.: Acalovschi I.: Manopere si tehnici de terapie intensivaManopere si tehnici de terapie intensiva. Ed. Dacia, Cluj-Napoca, 1989. Ed. Dacia, Cluj-Napoca, 19892.2. Angelescu N.: Angelescu N.: Elemente de propedeutica chirurgicalaElemente de propedeutica chirurgicala. Ed. Medicala, Bucharest, 1981. Ed. Medicala, Bucharest, 19813.3. Angelescu M.: Pregatirea preoperatorie a bolnavului chirurgical. In Angelescu M.: Pregatirea preoperatorie a bolnavului chirurgical. In Patologie chirurgicalaPatologie chirurgicala editorship N. Angelescu. Ed. editorship N. Angelescu. Ed.

Medicala, Bucharest, 2001, 421-428Medicala, Bucharest, 2001, 421-4284.4. Bancu E.V.: Semiologie chirurgicala. In Bancu E.V.: Semiologie chirurgicala. In Tratat de patologie chirurgicalaTratat de patologie chirurgicala vol. I editorship E. Proca. Ed. Medicala, Bucharest, vol. I editorship E. Proca. Ed. Medicala, Bucharest,

198919895.5. Bancu S.: Riscul operator. In Bancu S.: Riscul operator. In Patologie chirurgicalaPatologie chirurgicala editorship N. Angelescu. Ed. Medicala, Bucharest, 2001, 419-420 editorship N. Angelescu. Ed. Medicala, Bucharest, 2001, 419-4206.6. Bercea O.: Bolnavul chirurgical cu tara respiratorie. In Bercea O.: Bolnavul chirurgical cu tara respiratorie. In Tratat de patologie chirurgicalaTratat de patologie chirurgicala vol. II editorship E. Proca. Ed. vol. II editorship E. Proca. Ed.

Medicala, Bucharest, 1998Medicala, Bucharest, 19987.7. Bevan P.G., Donovan I.A.: Bevan P.G., Donovan I.A.: Hand book of general surgeryHand book of general surgery. Blackwell Scientific Publications, Oxford, 1992. Blackwell Scientific Publications, Oxford, 19928.8. Burcos T.: ASEPSIS si antisepsia. In Burcos T.: ASEPSIS si antisepsia. In Patologie chirurgicalaPatologie chirurgicala editorship N. Angelescu. Ed. Medicala, Bucharest, 2001, 461-474 editorship N. Angelescu. Ed. Medicala, Bucharest, 2001, 461-4749.9. Caloghera C.: Caloghera C.: Chirurgia de urgentaChirurgia de urgenta. Ed. Antib, Timisoara, 1993. Ed. Antib, Timisoara, 199310.10. Cardan E.: Bolnavul chirurgical cu tara digestiva, metabolica si endocrina. In Cardan E.: Bolnavul chirurgical cu tara digestiva, metabolica si endocrina. In Tratat de patologie chirurgicalaTratat de patologie chirurgicala vol. II editorship vol. II editorship

E. Proca. Ed. Medicala, Bucharest, 1998E. Proca. Ed. Medicala, Bucharest, 199811.11. Costea I.: Costea I.: Elemente de mica chirurgieElemente de mica chirurgie. Ed. Apollonia, Iasi, 1999. Ed. Apollonia, Iasi, 199912.12. Dragomirescu C.: Dragomirescu C.: Manual de chirurgie pentru studentii facultatilor de stomatologieManual de chirurgie pentru studentii facultatilor de stomatologie. Ed. Didactica si Pedagogica, Bucharest, . Ed. Didactica si Pedagogica, Bucharest,

1998199813.13. Detrie P.: Detrie P.: Petite chirurgie. Soins. Conduite a tenir et investigationsPetite chirurgie. Soins. Conduite a tenir et investigations, 4-, 4-ème edition, Masson, Paris, 1991ème edition, Masson, Paris, 199114.14. Dolinescu C.: Dolinescu C.: Indreptar de activitati practice în clinica chirurgicalaIndreptar de activitati practice în clinica chirurgicala. Litografia IMF Iasi, 1982. Litografia IMF Iasi, 198215.15. Dunn CD, Ranglison N.: Dunn CD, Ranglison N.: Chirurgie-diagnosis si tratament. Ghid de îngrijire a bolnavului chirurgicalChirurgie-diagnosis si tratament. Ghid de îngrijire a bolnavului chirurgical. Ed. Medicala, Bucharest, . Ed. Medicala, Bucharest,

1995199516.16. Georgescu S.O., Lazescu D.: Georgescu S.O., Lazescu D.: Primii pasi în chirurgiePrimii pasi în chirurgie. Ed. Kolos, Iasi, 2003. Ed. Kolos, Iasi, 200317.17. Mandache F.: Propedeutica si semiologie clinica chirurgicala. Ed. Didactica si Pedagogica, Bucharest, 1976Mandache F.: Propedeutica si semiologie clinica chirurgicala. Ed. Didactica si Pedagogica, Bucharest, 197618.18. Mircea N., Leoveanu A.: Mircea N., Leoveanu A.: Tehnici de anestezie si analgezie spinalaTehnici de anestezie si analgezie spinala. Ed. Academiei, Bucharest, 1989. Ed. Academiei, Bucharest, 198919.19. Mircea N.: Monitorizregion în chirurgie si terapie intensiva. Mircea N.: Monitorizregion în chirurgie si terapie intensiva. In In Patologie chirurgicalaPatologie chirurgicala editorship N. Angelescu. Ed. Medicala, editorship N. Angelescu. Ed. Medicala,

Bucharest, 2001, 327-348Bucharest, 2001, 327-34820.20. Mircea N.: Anestezia. Mircea N.: Anestezia. In In Patologie chirurgicalaPatologie chirurgicala editorship N. Angelescu. Ed. Medicala, Bucharest, 2001, 371-418 editorship N. Angelescu. Ed. Medicala, Bucharest, 2001, 371-41821.21. Mozes C.: Mozes C.: TECHNIQUE MEDICAL CAREi bolnavuluiTECHNIQUE MEDICAL CAREi bolnavului. Ed. Medicala, Bucharest, 1978. Ed. Medicala, Bucharest, 197822.22. Onisei O.: Onisei O.: Bolnavul chirurgical-elemente de diagnosis chirurgicalBolnavul chirurgical-elemente de diagnosis chirurgical. Ed. Helicon, Timisoara, 1997. Ed. Helicon, Timisoara, 199723.23. Tefler ABM: Tefler ABM: General patient management. General patient management. Brit Ind BullBrit Ind Bull 1988;44(2): 235-246 1988;44(2): 235-24624.24. Ticmeanu F.: MEDICAL CARE postoperatorii generale si specifice. In Ticmeanu F.: MEDICAL CARE postoperatorii generale si specifice. In Patologie chirurgicalaPatologie chirurgicala editorship N. Angelescu. Ed. editorship N. Angelescu. Ed.

Medicala, Bucharest, 2001, 429-444Medicala, Bucharest, 2001, 429-44425.25. Turai L.: Turai L.: Mica chirurgie fiziopatologicaMica chirurgie fiziopatologica. Ed. Medicala, Bucharest, 1970. Ed. Medicala, Bucharest, 197026.26. Way W.L.: Way W.L.: Current surgical diagnosis and treatmentCurrent surgical diagnosis and treatment. Printice-Hall International Inc, 1988. Printice-Hall International Inc, 1988

CONTENTS

INSTRUCTIONS OF USEINSTRUCTIONS OF USE

Slides appear only by clicking with the mouse Slides appear only by clicking with the mouse on certain parts of the presentation on certain parts of the presentation represented by buttons, titles or underlined represented by buttons, titles or underlined words and images.words and images.

BUTTONSBUTTONS For TITLES, UNDERLINED WORDS: below the For TITLES, UNDERLINED WORDS: below the

image, you will see a message containing image, you will see a message containing instructionsinstructions

When the cursor of the mouse is on a link, the When the cursor of the mouse is on a link, the cursor changescursor changes

VIDEO PHOTO Text with instructions

CONTENTS

I.S.B.N.: 978-973-670-4I.S.B.N.: 978-973-670-49898--77

Copyright © 2012 SEDCOM LIBRISCopyright © 2012 SEDCOM LIBRIS Toate drepturile asupra prezentei ediţii sunt rezervate Editurii Sedcom Libris, Iaşi. Toate drepturile asupra prezentei ediţii sunt rezervate Editurii Sedcom Libris, Iaşi.

Reproducerea parţială sau integrală a textelor, prin orice mijloc, precum şi a graficii copertei, Reproducerea parţială sau integrală a textelor, prin orice mijloc, precum şi a graficii copertei, fără acordul scris al Editurii Sedcom Libris, este interzisă şi reprezintă o încălcare a fără acordul scris al Editurii Sedcom Libris, este interzisă şi reprezintă o încălcare a proprietăţii intelectuale, fiind pedepsită în conformitate cu legislaţia în vigoare.proprietăţii intelectuale, fiind pedepsită în conformitate cu legislaţia în vigoare.

Adresa Editurii SEDCOM LIBRIS: Adresa Editurii SEDCOM LIBRIS: Şos. Moara de Foc nr. 4, cod 700527, Iaşi, RomâniaŞos. Moara de Foc nr. 4, cod 700527, Iaşi, România Informaţii, comenzi şi propuneri de editare sau colaborare: Informaţii, comenzi şi propuneri de editare sau colaborare: Tel.: +40 232 242 877; +40 232 234 582; +40 742 769 772Tel.: +40 232 242 877; +40 232 234 582; +40 742 769 772 Fax: +40 232 233 080 Fax: +40 232 233 080 E-mailuri: [email protected], [email protected]: [email protected], [email protected] www.editurasedcomlibris.rowww.editurasedcomlibris.ro

Documents

Practical Guide of Surgical Semiology