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CONTENTS
A SIGNIFICANT STATUS CHANGE
The 3rd year as a student at the Faculty of General Medicine represents the
beginning of the clinical training activity, therefore the direct contact with the
patient.
It is very important to remember that the study materials, rather impersonal, that
characterize the first two academic years (mainly focused on 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 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.
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 your
presence must not be considered a barrier in the deployment of this activity.
Surgery represents the last redoubt of the therapeutic possibilities of a 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 surgical
resources are exceeded, in the majority of cases, death occurs in the 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 emergency
conditions with immediate vital risk. As a result, the patient is a fine observer
and even judge of your behavior.
BACK
PREPARATION
Aspect
Clean aspect the negligent beard or haircut creates
a very bad impression since the beginning;
decent clothing (a too short skirt or a dirty pair of
jeans will significantly distance you from the image of
future doctor);
The shoes must not be dirty with mud, dust etc.
White, clean gown, without spots (or you risk to be
mistaken with the cleaning personnel);
Devices (compulsory) : tensiometer and stethoscope.
Internship copybook, writing tools (compulsory)
BACK
BEHAVIOUR RULES IN THE SURGERY
THEATRE
These rules complete the duties and obligations that the students have in an educational institution.
General rules
-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.
-The noisy discussions in the presence of patients, no matter the subject, are prohibited;
-It is prohibited to wait on the patients 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;
-At the end of the internship, washing the hands is compulsory;
BACK
ORGANIZING THE SURGICAL
SERVICE
General organization
Clinic I - II Surgery Sf.
Spiridon Hospital Iai
CONTENTS
GENERAL ORGANIZATION
The ambulatory
The in-patient unit
The operating theatre
The sterilizing unit
BACK
THE AMBULATORY
It is an integrating part of each service, ensuring the medical care without the patient's
hospitalization.
At this level the medical specialty examination is performed, the diagnosis is established
(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
even the surgical intervention, afterwards this service taking over the post-operatory
directly observed therapy of patients.
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
registration-archive.
The examination room 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.
The operating room from the ambulatory must have the same equipment with that of the
operating theatre (operating table, scialitic lamp, instrument table, anesthesia apparatus,
medical Aspirator, electrical bistoury) and to accomplish the same architectural conditions,
of heating, illumination and ventilation as the latter.
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
even if the medical file of each patient is archived by the family physician
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, they
can examine their patients, establish the diagnosis, schedule for hospitalization and
surgery and send to directly-observed therapy after surgery.
BACK
THE IN-PATIENT UNIT
BACK
In all the classical manuals, the patient rooms are described from the
point of view of architectonic and equipment characteristics.
We must mention that, although this data remains valid, we must
respect 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 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 facilities (bathroom,
telephone, radio, television).
In these conditions, the existence of dining halls, or bandage rooms is
no longer necessary. These, especially the bandage rooms are
necessary for carrying out some intervention maneuvers or particular
explorations.
Reducing the number of stationary beds can be compensated by their
rational use and the fast flow of patients.
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 personnel.
The in-patient unit must be seen as an accommodation space (hotel)
of high quality, where the patients must benefit from the best
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
THEATRE
The filter room
The surgery preparation room
The operating room
The induction and wakeup room
The room for preparing the surgical
instruments
Depositing rooms BACK TO
GENERAL
Click with the mouse over the underlined titles ORGANIZATION
The filter room
It is the first room in the medical
personnel circuit where they dress up in
special clothes, for the operating theatre.
It may have the role of rest room
between the surgeries.
The doctors preparation
room
It is provided with multiple sinks with special
taps that allow the use without manual
touch. For touching the hands antiseptics
are used (soap, betadine, chlorhexidin).
Then, in the same room or in another one,
the next step is putting on the gown and the
sterile gloves. In particular situations
(transplant surgery, osteo-articular surgery
etc.) special equipment is used.
The operating room
Architectural conditions: insulation, dimensions, construction materials, illumination installations, ventilation, heating and 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 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 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 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 easy and correct as
possible;
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 20-22 C and a 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, 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 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 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 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 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.
The operating table is special, multi-articulate, allowing different positions of the patient according to the necessities of the operating act.
Due to some accessories, it facilitates the operating gestures. It must allow the carryout of some intraoperative radiological explorations.
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 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 patient during the
anesthesia and for resuscitation gestures,
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 induction and wakeup
room
It is the first room in the patients circuit, where
they are administered the anesthetic induction
(and then they are transported into the operating
room), and when there is no separate room, they
are woken up through anesthesia. For these, the
room is equipped with a special bed for intensive
care, anesthesia apparatus and medical flows.
In the modern hospitals, the patient is taken from
the room to his bed (provided with wheels) and
transported with this bed to the induction room.
The room for the preparation
of surgical equipment
It is equipped with sinks or lavatories for
the mechanical and chemical cleaning of
the equipment, with boilers for them, with
tables and shelves for the boxes of
medical equipment.
The depositing rooms
BACK
DEFINITION
A general principle that consists in the systematic avoiding of the
contamination of surgical wounds and secondary infection of
burns and wounds
It includes methods and rules that prevent the wound
contamination and infection
These rules and methods address all the possible vectors of the
microbial germs to the surgery wounds, equipment, textile
materials, hands, clothes, syringes, probes, medicines, air from
the operating room etc.)
Methods : sterilization, disinfection of live tissues
The rules generally refer to the behavior of the personnel that
handles the sterile materials: surgeons, registered nurses from the
operating theatre or bandage rooms, the students involved in the
therapeutic act or just the watchers.
CLICK WITH THE MOUSE ON THE UNDERLINED WORDS
CONTENTS
STERILIZATION
DEFINITION
HEAT
ULTRAVIOLET RADIATIONS
IONIZING RADIATIONS
ULTRASOUNDS
FILTRATION
BACK
STERILIZATION THROUGH HEAT
BACK
STERILIZATION
THROUGH DRY HEAT
BUCKLING
INCINERATION
HOT AIR OVEN
Device
Sterilization parameters
Check
Indications
Advantages
Disadvantages
160 C for 1h
170 C for 40
180 C for 20
In our country: 180 C for 30-40
THE HOT AIR STOVE
CHECKING THE STERILIZATION
FILTER ROOM
OPERATING ROOM Anesthesia apparatus
Scialitic lamp
Medical flows inlets (Aspirator,
oxygen, electricity)
Cautery
Ultraviolet lamp
Aspirator Aspirator
Operating table
Operating room
OTHER EQUIPMENTS
Apparatus for intraoperatory Turn
For the minimally invasive surgery Table for instruments
radiological examination
THE STERILIZATION
THROUGH HUMID
HEAT
It is the most efficient sterilization method
The first form of sterilization through humid
heat was boiling, but it does not create
sufficiently high temperatures in order to
destroy the bacteria spores
The AUTOCLAVE= the device through which
the sterilization through humid heat is made, by
obtaining sufficiently high temperatures and
pressures that destroy all the pathogen agents
THE AUTOCLAVE
Device
Sterilization parameters
Check
Indications
Advantages
Disadvantages
BACK
CLICK WITH THE MOUSE ON EACH TITLE
THE AUTOCLAVE
DEVICE
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
achieving an thermal insulation from the environment
Through an admission pump, water vapors are introduced under
pressure, which will lift to the surface allowing the evacuation in
successive stages of the air that descends in the inferior part of
the autoclave
After obtaining the vacuum, the vapor admission is continued
until the obtaining od the set sterilizing parameters
The time, pressure and temperature of sterilization are variable
according to the type of the autoclave and the sterilized materials
(quantity, quality and their dimensions)
At the end of the sterilization, the vacuum air pump will evacuate
the water vapors from the autoclave, introducing a jet of filtered
cold air, with role of drying the sterilized material
The carriage for introducing and removing the materials from the autoclave
The Autoclave
Removing the material from the autoclave
after sterilization
Depositing the sterile material
TH AUTOCLAVE
STERILIZATION PARAMETERS
24 hours validity
Pressure temperature
1 atm 120C
2 atm 136C
3 atm 144C
THE AUTOCLAVE
CHECK
Technical breakdowns
Rapid degradation of the corrosive
metallic instruments
THE STERILIZATION WITH
ULTRAVIOLET RADIATIONS
These radiations act at the level of nucleic acids
= bactericide and bacteriostatic effect
It is necessary to previously wash the surfaces to
sterilize (the UV radiations have small
penetration power)
Indications: the sterilization of the air from the
operating and bandage rooms, the sterilization of
work surfaces
ATTENTION: They are harmful for the people
Protection of teguments and eyes
STERILIZATION THROUGH
IONIZING RADIATIONS
(GAMMA)
DEVICE: container with pre-packed material on
which a radiation of 2.5 up to 5 Mrad (Celsius
137 or Cobalt 60) is projected
CHECK : measuring the radiation level
INDICATIONS: any medical material
ADVANTAGES: large quantities of pre-packed
material is sterilized, reduced costs under
continuous functioning conditions
Disadvantages: the irradiation, formation of
toxic compounds with ethylenoxide
Used only in the industrial environment
THE ULTRASOUND
STERILIZATION
Antiseptic solution
Sandglass
Taps with
sterile water
for
disinfecting
the surgeons
hands
THE DISINFECTION OF
LIVING TISSUES
THE PATIENTS SKIN
R
ULES FOR THE STERILIZATION OF THE O
PERATING ROOM
RULES FOR THE PREPARATION OF THE STE
RILIZATION MATERIALS
The air must enter the room from the superior side
and be evacuated through the inferior side. The
admission inlet is in the center of the room, above
the table, without blowing the air directly onto the
patient. The evacuation will be made through the
lateral sides
The air circulated through the operating rooms
requires a special filtering process both at the
entry and at the exit of the operating room. There
are high-performance apparatuses that can even
obtain sterile air
STERILIZING THE
OPERATING ROOM
PREPARING THE AIR
Washing
Ironing
Folding according to
the standard
technique
Positioning into
metallic containers or
packed individually in
paper
Autoclaving
PREPARING THE MATERIAL
FOR STERILIZATION
METALLIC EQUIPMENT
Cardiorespiratory resuscitation
AIC
Successful resuscitation
Continuing the resuscitation
In-patient unit
Stabilization
Investigations Investigations
Preparation for surgery Preparation for surgery
Operating room
EVALUATING THE SURGICAL
PATIENT
ELECTIVE SURGERY
Surgical disorder
Usual investigations
Staff Staff
Operating room
EVALUATING THE SURGICAL
PATIENT
THE ONE-DAY SURGERY
Motivation:
Financial: the high cost of hospitalization,
consume of expensive medical materials
Personal: the patients desire to be in the
family environment and not in the hospital,
the socio-professional reintegration as soon
as possible
Medical: patients with a good medical
education
EVALUATING THE SURGICAL
PATIENT
THE ONE-DAY SURGERY
Completely investigated patient
Local preparation
Premedication
Operating room
Hospital
Post-operatory monitoring for a release In-house monitoring
few hours
PRE-OPERATORY
EVALUATION
Any hospitalized patient will have an observation sheet that
needs to be completed after a complete clinical examination
Appropriate paraclinical explorations are necessary,
corresponding to each case, the assessment of all the
associated disorders, establishing the anesthetic risk and
Choosing the therapeutic behavior (the operatory moment,
the type of anesthesia and the type of surgical intervention
that the patient will be submitted to)
It would be very useful that the family doctor has a medical
file for each patient, file that the attending physician must
have access to, at hospitalization
CLICK WITH THE MOUSE ON THE UNDERLINED WORDS
THE PREOPERATORY
EVALUATION
OBSERVATION SHEET
Comprise:
Identification data: surname, first name, sex,
date of birth, age, address, telephone number,
job
Hospitalization place: hospital, clinic
Hospitalization period: date of hospitalization,
date of hospital release
Allergic to.
Blood group and Rh
THE PRE-OPERATORY
EVALUATION
DIAGNOSIS
Diagnosis at hospitalization
Diagnosis at 72 hours
Diagnosis at hospital discharge: it must comprise the
diagnosis of the basic disease, the evolution stage, the
clinical form, complications
Secondary diagnosis: the diagnosis of all the associated
diseases
Diagnosis in case of death:
a. The direct cause of death
b. Initial pathology
c. Associated disorders
d. Associated morbid states
THE PRE-OPERATORY
EVALUATION
ANAMNESIS
It must be performed in such a manner as to obtain the patients trust to
tell us the most detailed information
Reasons for hospitalization: all the objective and subjective problems that
the patient speaks of will be enumerated
Physiological personal antecedents: they are important especially in the
case of women, providing information regarding the first menstruation, the
date of the last menstruation, the number of pregnancies, the number of
births, and abortions (spontaneous, therapeutic or at request), the state of
fetuses at birth, the lactation
Pathological personal antecedents: you will have to obtain data from the
patient regarding any disorder he suffered from previously (allergies,
infections, surgical interventions, degenerative diseases, neoplasias)
Family history antecedents: they present a special importance especially
in the case of transmittable diseases or with generic predisposition (atopy,
neoplasia, metabolic diseases, infections)
Life conditions, customs and work: the dwelling place (important in the
case of a family in which a member has a transmittable disease
tuberculosis), alimentary habits the predisposition towards certain
pathologies- obesity), smoking (the number of cigarettes a day and the
period since when they have been smoking), the alcohol consume (grams
of alcohol 100% expressed per day or weeks), drugs, birth control pills, or
the working place (toxic environment, allergic, carcinogenic substances,
intense physical effort)
PREOPERATORY
EVALUATION
HISTORY
OSTEO-ARTICULAR SYSTEM
ON BODY SEGMENTS
A more cursive and elegant method to examine
the patient than the classic examination ON
APPARATUSES AN SYSTEMS
Modalities of perfomance
Sitting down
Clinostatism
Orthostatism
CLICK WITH THE MOUSE ON THE UNDERLINED TITLES
PREOPERATIVE
EVALUATION
GENERAL PHYSICAL EXAMINATION ON BODY SEGMENTS
SITTING DOWN
Chephalic extremity : teguments, conjunctiva
mucous, implantation of exoskeletons,
ganglions, photomotor reflex, sinus points
(frontal and maxillary), mouth cavity (mucous,
dentition, dentures, tonsils), thyroid gland
Thorax: respiratory apparatus, heart
ascultation, exploration of mammary gland,
adenopathies (axillary, supraclavicular), spine
Lumbuses: urogenital apparatus, examination
of lumbar spine
PREOPERATIVE
EVALUATION
GENERAL PHYSICAL EXAMINATION ON BODY SEGMENTS
CLINOSTATISM
Thorax: cardiovascular apparatus
Abdomen: digestive apparatus, week
abdominal points, inguinal region
Lumbar region: palpation of renal lodges,
urethral points
Limbs: inspection, passive and active mobility,
osteotendinous reflexes, pulse and peripheral
sensitivity
Rectal and vaginal palpation
PREOPERATIVE
EVALUATION
GENERAL PHYSICAL EXAMINATION ON BODY SEGMENTS
ORTHOSTATISM
Balance
Gait
Varices
Hernial regions
PREOPERATIVE
EVALUATION
LOCAL EXAM
ROUTINE EXPLORATIONS
Biological
Hemoleucogram (hemoglobin, hematocrit, trombocyes,
leukocytes, leukocyte formula)
Glycaemia, urea, creatinine
Coagulation tests (bleeding time, coagulation time, prothrombin
time, fibirin degradation products)
Hepatic tests, total proteins
RBW (syphillis), viral serology for AIDS and hepatitis
Urine test, urine elimination in 24h
Imagistic and functional
Chest X-Ray (radiography)
Simple abdominal radiography
Abdominal echography
EKG
PREOPERATIVE
EVALUATION
PARACLINIC EXPLORATIONS
SPECIAL EXPLORATIONS
They have to be as targeted as possible and to offer a complete and clear
image of each patient
Biological:
Ionogram: Na+, K+, Cl -, alkaline reserve
Hepatic tests: hepatocytolisis syndrome (TGP, TGO, GGT, alkaline
phosphatasis, iron content in blood), hepatoprive syndrome
(fibrinogen, total lipids, cholesterol), serum proteins electrophoresis,
biliary function, (total direct and indirect bilirubin)
Amylasaemia, amylasuria
Hemocultures, urocultures
Imagistic and functional:
Echocardiography, respiratory tests, eso-gastro-duodenal
radiography with contrast substance, irigography, fistulography,
cavitatography, CT, IRM, scintigram, endoscopy, biopsy puncture,
diagnostic laparoscopy
SURGICAL INTERVENTION
To write down:
Number of the operatory protocol
Operatory diagnosis
Operation description
Type of anesthesia
Operatory team
TREATMENT AND EVOLUTION
CLASSIC
MODERN
PHOTO
ANTISEPTICS WITH
ALCOHOL CONTENTS
VIDEO PHOTO
IODIDES AND IODOFORMS
DEFINITION
PSYCHOLOGICAL PREPARATION
PHYSICAL PREPARATION
OPERATION TIME
NUTRITIONAL PREPARATION
It represents an important aspect of the preoperative
preparation because a denutrited patient cannot
epithelize and its immune system will be deficient, not
being able to defend itself against infections
It is recommended that whenever possible the patients
postoperative nutritional state should be the best
possible. In emergency situations when the patients
life depends upon the surgical intervention, the
nutritional recovery will be done after the operation
The nutritional recovery can be carried out in two ways:
parenteral route and enteral route
HISTORY
>70 years 5p
CARDIOVASCULAR APPARATUS IMA the last 6 months 10p
EKG
3p
7p
4p
RESPIRATORY APPARATUS
It is useful for the patients with preexisting pulmonary
diseases, for old, obese, sick patients who will need
extended immobilization
There will be used bronchodilators, targeted antibiotherapy
Respiratory gymnastics is recommended especially to the
patients who are going to undergo a surgical intervention to
the upper abdominal level or thorax. It involves ample
respirations, deep inspiration followed by expulsion of the
inspired air into a water bottle by means of a perfusor tube,
tapotement with efficient coughing to eliminate secretions
Smoking is forbidden at least a week before surgery
(smokers have a state of chronic hypoxia )
PHYSICAL PREPARATION
SYSTEMIC PREPARATION
RENAL FUNCTION
The renal function which was affected after the surgery
results in a more difficult elimination of drugs
(anesthetics, nephrotoxic antibiotics), needing and
adjustment of the doses used
For patients who have diseases of the lower urinary tract,
in case of complicate surgeries, at the genital or rectal
level, it is recommended to put a catheter in the bladder
on the operating table after the patient was asleep. The
catheter will be kept till the spontaneous resumption of
mictions
PHYSICAL
PREPARATION
SYSTEMIC PREPARATION
HEPATIC FUNCTION
The disorders of the hepatic function manifest
themselves by blood coagulation disorders,
nutrition disorders which will determine
deficient cicatrization as well as metabolization
disorders of various substances with hepatic
elimination
It is necessary to assess hepatic excretion,
hepatic cytolysis, protein synthesis,
coagulation samples, etc.
Risk factors: denutrition, ascites, bilirubin >3mg
%ml, albumin < 3mg%ml
PHYSICAL PREPARATION
SYSTEMIC PREPARATION
NEUROLOGICAL
It is important to identify the neurological
pathology that may be aggravated by the
anesthesia
The patients with motor deficiency have
a higher risk of postoperative
complications
PHYSICAL PREPARATION
LOCAL PREPARATION
INFECTIONS
They determine a difficult postoperative recovery delaying the cicatrization, extending the
convalescence or even with the appearance of septicemia.
They may be prevented with a correct preoperative preparation depending on the surgery
that is going to be performed (skin, colon preparation, etc.)
Risk factors: old age, obesity, malnutrition, neoplastic problems, diabetes mellitus and its
complications, corticosteroid or immunosuppressor treatment, other infections,
radiotherapy, adrenocortical insufficiency
Necessary preparations: restoring nutritional status, balancing diabetes (glycaemia below
1,2g%ml), treatment of concomitant infections, solving the adrenocortical insufficiency,
prophylaxis with antibiotics, shaving the operating region on the morning of the surgery , etc
Indications for antibioprophylaxis:
Neck and head surgery with opening the upper air ways
Esophagus surgery (except for the hiatal hernia
Gastro-duodenal surgery except for uncontrolled hyperacidity
Surgery of biliary tract for patients with acute cholecystis, over 70 years old who need
choledocotomy
Bowel resections
Gangrenous acute appendicitis or peritonitis
Gynecological surgery
Prosthetic surgery for different organs: heart, hip, knee, valves, vessels
PHYSICAL PREPARATION
PREVENTION OF POSTOPERATTIVE COMPLICATIONS
THROMBEMBOLISM
The risk of appearance of thromboembolisms
increases: if the duration of the intervention
exceeds one hour, obesity, blood
hypercoagulability, antecedent of vascular
thrombosis, pelvic surgery, treatment with oral
contraceptive pills
Prevention: elastic bandages on the lower limbs
to ensure higher return pressure, precocious
postoperative mobilization, prophylaxis with
anticoagulant medicines (normocoagulant dose)
PHYSICAL PREPARATION
PREVENTION OF POSTOPERATIVE COMPLICATIONS
ORGANIC INSUFFICIENCY
Respiratory apparatus: pneumonias, broncho-pneumonias,
respiratory insufficiency, respiratory distress syndrome
Heart system: rhythm disorders, cardiac insufficiency,
myocardial infarction
Hepatic function: coagulation disorders, hepatic
insufficiency
Urinary system: acute renal insufficiency
Neurological system: coma
The correct PREOPERATIVE EVALUATION allows
identifying the risk factors for these possible complications
and at the same time preventing their appearance by
measures specific to each system
SURGERY TIME
PARACLINICAL
MONITORING
BLOOD PRESSURE
Normal values: systolic 90-160mmHg, diastolic 60-
90mmHg
Technique: manually with tensiometer and stethoscope or by
means of an electric apparatus
PULSE
Normal values: 60-80 beats / minute
Technique: manually by direct palpation or with the
sfigmometer sensor; to be measured for 30 seconds
minimum, simultaneously with heart auscultation
Tachycardia = pulse > 100 beats / minute
Bradycardia = pulse < 60 beats / minute
STANDARD
PARACLINICAL
MONITORING
BODY TEMPERATURE
Normal values: 36-37C
The most accurate is intrarectal measurement of body
temperature
The most used method is to measure temperature in
the axillary region
BREATHING FREQUENCY
Normal values: 10-16/minute
Technique: direct count or nasal sensor
Tachypnea = over 20 respirations/minute
Bradypnea = below 8 respirations/minute
STANDARD
PARACLINICAL
MONITORING
DIURESIS
Normal flow rate 1ml/kg/h
Technique: to be measured the amount of urine
gathered in a gradated recipient which is connected to
the urinary probe
Oliguria = below 400 ml/24h
Anuria = below 200ml/24h
STATE OF CONSCIOUSNESS
PARACLINICAL
MONITORING
SPECIAL MONITORING
GUEDEL PIPE
LARHYNGOSCOPE OROTRACHEAL
INTUBATION CANNULA
TECHNIQUE
The patient will be removed from the action of the
nocuous factors (place of accident, etc.)
The patient will be lain on the back
The reanimator or reanimators should be at the
same level with the patient, if there is only one
savior this one will place himself/herself on the left,
if there are two, the one who will perform cardiac
resuscitation will stay on the left and the one who
will perform artificial respiration will stay on the right
1 2 30
2 1 5
INTERNAL
CARDIAC
MASSAGE
Incision in the left 4th intercostal space
Take the heart in the right hand with the
left ventricle in the palm and squeeze it
with a frequency of 80-90 per minute
At the same time perform artificial
respiration
DEFIBRILLATION
Start external cardiac massage simultaneously
with the artificial respiration
If the patient does not respond to the resuscitation,
continue with the stimulation of cardiac activity
using electric shocks produced by the defibrillator
(150-400 W/sec)
Electric stimulation may be repeated, and at the
same time efficient medication has to be
administered compliant to the resuscitation
protocols (adrenalin, atropine, dopamine,
lidocaine, sodium bicarbonate, calcium blockers,
antiarrhythmic agents, etc.)
ABCDEFGHI
A (airways): permeable respiratory air tract
B (breath): artificial respiration
C (circulation): restoring circulatory function
D (drugs): drug administration
E (EKG): monitoring the cardiac function by EKG
F (fibrillation): electric defibrillator
G: establishing the diagnosis that determined the
cardiac arrest
H: neuropsychic therapy
I (intensive care): intensive care service
HELP ME
(BEJAN)
H: head hyperextension
E: clearing upper airway (foreign bodies,
secretions)
L: anterior luxation of the jaw
P: nose pinching, mouth-to-mouth resuscitation
M
External cardiac massage
E
POST
RESUSCITATION
CARE
The patient will still be kept under medical
supervision because there is the risk that the
cardiac arrest may start again or of appearance
of complications
Administer oxygen
Correct hydro-electrolytic and acido-basic
unbalances
Do not administer glucose (risk of
hyperglycemia and damage of nervous function)
INCIDENTS, ACCIDENTS,
COMPLICATIONS
Respiratory function: tongue swallowing, loss of
insufflated air near the mask or th rough the nostrils,
rupture of pulmonary parenchyma leading to the
appearance of pneumothorax due to the insufflation of a
too large amount of air
Cardiac function:
External cardiac massage: rib and sternum fractures
which may induce secondary lesions (lung,
pericardium, liver lesions)
Internal cardiac massage: myocardial ischemia, heart
rupture, disinsertion of large vessels
Defibrillation: tegument burns, ventricular fibrillation
BLOOD TRANSFUSION
Serum Rh+ Rh
-
anti-D lyse -
DIRECT
COMPATIBILITY TEST
Put on a glass strip a drop of the
patients blood (receiver) in direct contact
with a drop of the donated blood
If there is no agglutination, then the two
types of blood are compatible and the
transfusion may be made
TECHNIQUE
The patient will be informed on the transfusion technique,
benefits and disadvantages and its agreement has to be
obtained
The patient will be placed in a comfortable position,
preferably in dorsal decubitus
The product to be transfused will be brought to the
transfusion service and the direct compatibility test will me
made
Find a new vein into which the preparation will be
administered
The administration rhythm is of 50 drops/min 15 minutes (to
observe possible adverse reactions), then 60-80
drops/minute. For emergencies a unit (500 ml) may be
administered in 10 minutes.
INCIDENTS, ACCIDENTS,
COMPLICATIONS
Precocious hemolytic reaction: cephalea, fever, shiver, lumbar
pain, tachycardia, hypotension, respiratory problems,
hematuria
Late hemolytic reaction: unexplainable icterus, decrease of
hemoglobin
Fever shiver. If the temperature increases by more than one
degree Celsius the transfusion will be stopped
Allergic reaction: urticaria, pruritus, rash, wheezing, fever,
shiver
Bacterial contamination of transfused blood
Immune reactions (pulmonary edema, excessive bleeding),
hypothermia, hyperpotassemia, hypocalcemia, acidose,
thrombophlebitis, embolisms, transmission of certain
diseases (hepatitis B, C, AIDS, cytomegalovirus, syphilis, etc.)
CARE
The flask label will be stuck in the patients observation
sheet
15 minutes after starting the perfusion the vital signs will be
monitored (pulse, tension, breathing frequency) as well as
the existence of possible adverse reactions
At that moment if there are no incidents the transfusion
rhythm will be increased
The patient will be checked every 30 minutes
At the end of the transfusion the vital signs will be checked
again and the diuresis, and they will be written down in the
observation sheet
The catheter will be cleaned with physiological serum
The packages will be returned to the transfusion service
INJECTIONS
DEFINITION, PURPOSE, PRINCIPLES
INJECTION ADVANTAGES
INDICATIONS
CONTRAINDICATIONS
NECESSARY MATERIALS
STANDARD TECHNIQUE
INJECTION TYPES
INCIDENTS, ACCIDENTS, COMPLICATIONS
CARE
Hemophilia
Anticoagulant treatment
Tetanus
Induction from general anesthesia
NECESSARY MATERIALS
Active substance PHOTO
Needle
Luer tapers
Cotton tampons with
solution for making
the tegument aseptic
Garrot
Sterile gloves
PERFUSION SOLUTIONS
PERFUSION SOLUTIONS
INJECTION TYPES
INTRADERMIC INJECTIONS
SUBCUTANEOUS INJECTIONS
INTRAMUSCULAR INJECTIONS
INTRAVENOUS INJECTIONS
INTRA-ARTERIAL INJECTIONS
TE C HNI QUE
The patient will be informed on the manoeuvre to be performed, obtaining
his agreement
The patient will be placed in a comfortable position depending on the
injection type to be administered
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
will be aspired in the taper
The needle used to aspire the substance will be changed with another
sterile needle in order to perform the injection
If necessary, apply the garrot
Make aseptic the region where the injection has to be made by rubbing it
with an alcohol tampon
Take off the protecting cap from the needle, puncture the skin and the
other anatomic structures till the plane where you want to get to
Slightly aspire into the taper to see if the position is correct (vein dark
red, artery crimson, muscle no blood)
Inject the active substance compliant to the indications
Take out the needle and the taper with a firm movement
Massage the injection place to perform the hemostasis
The waste will be deposited in recipients specific to each of them
INTRADERMIC
INJECTION
Make the tegument aseptic
The needle with the tip upwards will be
introduced in the superficial tegument until the
needle orifice disappears under the tegument
Inject the substance from the tape
At the injection place there appears a tegument
deformation as an orange skin
Indications: intradermic reactions
Injection region: anterior side of the forearm
VIDEO
INTRADERMIC
INJECTION
VIDEO
INTRAMUSCULAR
INJECTION
Picture 036.avi
VIDEO
RADIAL ARTERY
PUNCTURE
CONTENT
DEFINITION,
PURPOSE,
PRINCIPLES
Definition: they mean cutting tissues with a cutting object
Purpose: they make access to a certain anatomic structure, pathologic collection or for
exploration
Principles:
The asepsis and antisepsis requirements have to be complied with
Knowing the region anatomy
Anaesthesia has to be performed
The incision dimensions have to be adapted to the purpose
The incision orientation has to take into account local innervation so that cicatrization may
take place without any complications
The incision direction has to follow the force lines on the skin, this way avoiding faulty
cicatrizations
The incision will be performed with a single movement, it has to be regulated and rectilinear
The incision will be made plane after plane, for deeper planes the incision being shorter
thus allowing better closing the wound at the end of the intervention
Point out the important structures and avoid cutting them
For collections the incisions have to be performed in the maximum fluctuation point and
their length adapted to the collection length
INDICATIONS
Opening purulent infections
Excisions of tegument formation or lesion
Creating an approach for a certain abdominal
or thoracic organ
Retouch of bad incisions
Clearing incisions to bring near the margins of
the wound
Opening the capsule to get deep into the
viscera
CONTRAINDICATIONS
Hemophilia
Anticoagulant treatment
Tetanus
Induction in general anesthesia
NECESSARY
MATERIALS
Sterile soft material
Materials for
anesthesia
Scalpel
Scisors SCALPEL BLADE
Saw
Knife
ELECTROCAUTERY
TECHNIQUE
The patient will be explained the technique obtaining its written agreement
for the surgery
The patient will be placed in a comfortable position to point out the best way
possible the region where the incision is going to be made
The preparation of the operative field will be done compliant to the
description in the chapter preoperative preparation
The surgeon will stay on the patients right side (except for the interventions
in the gynaecological field , pelvic region or left limbs) and its help will stay in
front of the operator, on the patients left side
(Local, general, rahianesthesia, etc) anesthesia will be performed
The skin will be kept under tension with the forefinger and medius of the left
hand, 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 an
almost vertical position, then it will be oriented to about 30
The incision will be made in a single movement
To the lower angle of the incision the scalpel will be brought again to an
almost vertical position as to the skin
Each anatomic plane will be cut in a single movement
The incision will cut plane after plane till the desired depth
CONTENT
DEFINITION,
PURPOSE,
PRINCIPLES
Definition: mechanical and biological
preparation of the colon in order to be explored
or for surgery
Purpose: discharging of feaces from the colon,
decreasing the degree of contamination of the
peritoneal cavity during the surgical
intervention
Principles: it is necessary to eliminate the
feaces as completely as possible
INDICATIONS
CONTENT
CLIC WITH THE MOUSE OF EACH TITLE
DEFINITION
Lubricant PHOTO
Irrigator PHOTO
The substance to be introduced
Basin
Protection oilcloth
NECESSARY MATERIALS
Irrigator
Rectal cannula
NECESSARY MATERIALS
Lubricant
INDICATIONS
Colon discharge for persons with constipation, old
people, cachectic people, etc.
Preoperative preparation of the colon and rectum
Enema before a surgery with general anesthesia (it
prevents defecation due to the relaxation of the anal
sphyncter)
Barium enema for diagnosis
Medicated enemas (in digestive intolerance)
Hydrating enema (to be administered in a low rate drop
by drop)
Anesthetic enemas
CONTRAINDICATIONS
Suspicion of colon perforation
The pathology that makes the bowel wall thinner and
it induces perforation risk (bowel infarction, colitis,
ulcero-hemorrhagic rectocolitis)
Low tumor that may be damaged by this maneuver
(rectorragia may appear)
In case of barium enemas for low tumors the valve
phenomenon may appear due to the passage of the
tumor substance and its retention due to water
absorption which forms barium sulphate stones which
are difficult to eliminate
In diagnosis uncertainty, the barium enema may
determine a change of the clinical image which may
delay the therapeutic indication and aggravate the
general state
TECHNIQUE
The technique will be explained to the patient, especially the fact
that the substance introduced has to be kept in the colon for at
least 15 minutes. The patient will lie on the back or on one side
The oilcloth is put under the patients pelvis
Put on the gloves, take the lubricated cannula and attach it to the
irigator
Let some fluid drip to eliminate the air inside the tube
Introduce the cannula in the patients anus, about 8 cm being
cranially and posteriorly oriented
Slowly introduce the fluid from the irigator (it prevents the sudden
distention of the rectal ampulla and the activation of the defecation
reflex)
Slowly take out the cannula from the anus, following the opposite
direction as when it was introduced
Perform local perianal cleaning
Clean the place where the enema has been performed
VIDEO
BACK TO THE TECHNIQUE
FOR COLON PREPRATION
TO CONTINUE THE VIDEO CLICK WITH THE MOUSE ON THE IMAGE
TECHNICAL
VARIANTS
High enema: a long flexible cannula is used,
the initial position being in lateral decubitus,
and then in dorsal decubitus and right lateral
decubitus
Medicated enema: will be performed slowly 20-
40 drops/minute. A Nelaton probe can be used,
which is thinner and shorter
Enema for patients with colostom or fecal
incontinence: insert a Foley probe, and inflate
the little balloon in the anal sphincter, this way
ensuring good continence
INCIDENTS, ACCIDENTS,
COMPLICATIONS
CONTENT
DEFINITION,
PURPOSE,
PRINCIPLES
Definition: it represents the evacuation of pus collections from an
abscess cavity
Purpose: therapeutic (the evacuation of the pus collection),
postoperative observation on postoperative clinical evolution
(facilitates the recognition of bleedings, digestive fistulas, etc.)
Principles:
Drainage tube must be positioned in the lowest part of the cavity
Dimensions (length, diameter, material) must be adjusted to the
purpose of the drainage and to the characteristics of the
evacuated cavity
The path of the drainage tube must be as short as possible and
should avoid the intestinal loop
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 connected to a collecting container
RECOMMENDATIONS
Pus collections
Peritonitis
Interventions with septic stage
Difficult, incomplete haemostases
Interventions with laborious starts
Fistulas, continuity solutions at the level of
cavity organs
Purulent pleurisies
Pneumothorax, hemothorax
CONTRAINDICATIONS
Are relative
In case of interventions that need
prostheses or explants that imply a risk
of septic contamination by means of the
drainage tube
REQUIRED
MATERIALS
Plastic or silicon tubes PHOTO
Medical wigs
Collecting systems PHOTO
Drainage tubes of various dimensions
VIDEO PHOTO
INCIDENTS, ACCIDENTS,
COMPLICATIONS
CONTENT
DEFINITION,
PURPOSE,
PRINCIPLES
Stoma = a constructed opening to the
exterior of a cavity organ
The stoma allows the alimentation or the
evacuation of some cavity organs
Purpose: attending the stomies should
guarantee their correct functioning
Principles: the tolerance of the patient to
the stoma care products must be tested
DIFFERENT
STOMA TYPES
GASTROSTOMY
JEJUNOSTOMY
ILEOSTOMY
COLOSTOMY
CUTANEOUS URETEROSTOMY
REQUIRED
MATERIALS
Self-adhesive collecting bags
Plastic disk (that will cover the stoma
allowing the accumulation of the
collecting pus)
Adhesive gel
Probes, tubules
Sterile dressing/cloth
STANDARD
TECHNIQUE
The tissues around the stoma will be cleaned
using warm water, preferably without soup
We wait until the skin is dry
The self-adhesive collecting beg that has been
previously adjusted according to the
dimensions of the stoma will be attached
In case the bag will be evacuated it is better to
have it cleaned first with a syringe filled in with
50 ml of warm water
GASTROSTOMY
Indications: high gastric obstacle that impedes
the normal feeding (pharyngeal, esophageal
neoplasm, etc.)
Changing the bandage daily until the wound is
healed
The probe permeability must be tested by using
special substances
When not used, the probe lumen will be sealed
with a plastic stopper
PHOTO
GASTROSTOMY PROBES
FOLEY PROBE
(in fact a urinary probe that can be also used for
gastrostomy, if needed)
JEJUNOSTOMY
Surgical incisions
Accidental wounds
Burns
Varicose leg ulcers
CONTRAINDICATIONS
The facial injuries are usually left un-
bandaged
THE BANDAGING ROOM
PHOTO
REQUIRED MATERIALS
Antiseptic solutions
Sterile and
Cotton wool non-sterile gloves
Ointment
BANDAGING
TECHNIQUE
The patient will be informed regarding the medical maneuver after
and he/she will be placed in a comfortable position so that the person
taking care of the bandaging will have optimal work conditions
Before applying or changing the bandage the medical personnel must
have the hands clean
The wound surrounding tissues will be cleaned and disinfected with
tincture of iodine
The wound will be disinfected, examined and treated
The wound will be covered with soft sterile cloth according to the
characteristics of the injury
The bandage will be secured with dressing, band aids, etc.
The evolution of the wound, the eventual drainages performed , etc.
will be noted in the patients observation sheet
The secretory wounds need an absorbent bandage with cotton buffer
and a thick cotton wool layer
The wounds presenting local congestive manifestations need wet
bandages impregnated with chloramine or alcohol, then covered with
absorbent cotton buffer
The suppurative wounds need drainage and a proper medical care
BANDAGE TYPES
Recommended for :
cleaning non-
secretory wounds
It is the most
commonly used
bandage for wounds
It is made out if
gauze padded
compresses and GAUZE SWABS COVERED WITH AN
PHOTO VIDEO
PRE-WARPPED AND STERILIZED MATERIALS FOR DRY
BANDAGE
BANDAGE TYPES
DRY BANDAGE
Recommended for:
inflamed non-secretory
wounds
It has antiphlogistic effect
It should be used on short
periods of time due to the
fact that it can be irritant
It is made out of a
moistured compresses
impregnated with antiseptic
solution covered up in the
end by a dry dressing
Another word used for this
type of bandage is
cataplasm
BANDAGE TYPES
COMPRESSION BANDAGE
CONTENT
Haemophilia
Anticoagulant treatment
Tetanus
Induction from general anesthesia
REQUIRED MATERIALS
Syringe and needle
Xyline
Sterile gauze compress
Sterile gloves
(needle) Holder and
needle with suture
Medical tray containing:
syringe, thick needle,
guide wire, catheter,
fixing support
CENTRAL VENOUS CATHETER TRAY
THE STANDARD
TECHNIQUE
The patient will be informed about the medical procedure he/she will go through
and his/hers written agreement will be obtained
The patient will be placed in a comfortable position
The skin area where the puncture will be made is disinfected
The sterile gloves are put on
The local anesthesia is performed
The vein will be punctured according to the technique described in the chapter
About punctures
5-6 ml of blood will be aspirated into the syringe
The syringe will be detached and the guide wire will be introduced through the
lumen of the needle with the patient in voluntary apnea
The needle will be removed
The catheter will be introduced along the guide wire, then the guide wire 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 desired
position after which the guide wire will be removed
The blood will be aspirated into the syringe to check the position of the catheter
The catheter will be connected to a perfusion with Normoton or heparin serum
The catheter will be secured to the skin with sutures
In the end a sterile bandage is applied
ARTERIAL VENOUS
CATHETERIZATION CATHETERIZATION
SELDINGER TECHNIQUE FOR
INTERNAL JUGULAR VEIN
CATHETERIZATION
CONTENT
DEFINITION, PURPOSE,
PRINCIPLES
Definition: it represents the medical maneuver through
which various probes are introduced through the
digestive proximal tract for various purposes
Purpose: collection of digestive secretions (gastric,
duodenal, biliary, pancreatic), qualitative and quantitative
biochemical measurement (pH meters, cytology,
microbiology), gastrointestinal manometry, tract
evacuation, cavity washing (gastric lavage), enteral
nutrition
Principles:
The principles of asepsis and antisepsis must be
respected
A proper probe is to be used
INDICATIONS
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
TECHNIQUE
Gloves
Faucher Probe (photo)
Funnel
Lavage fluid, antidote
Medicines
Container for collecting
the evacuated digestive
content
GASTRIC LAVAGE
TECHNIQUE
The patient will be informed about the maneuver, his cooperation
is important during the gastric lavage
The patient will be placed in the sitting position or right lateral
decubitus
The Faucher probe will be inserted through the patients mouth,
up to the pharynx, asking the patient to swallow
The probe will slowly progress into the stomach, no more than 45-
60 cm
The funnel will be adjusted to the probe
The lavage fluid will be poured through the funnel placed to the
chest level, slightly raising it up to the head
Then the funnel will be descended below the abdomen, while
evacuating the gastric fluid
The operation will be repeated until the evacuated fluid is clean
The probe will be gently extracted to prevent its evacuation into
the respiratory tree
GASTRIC LAVAGE
INCIDENTS, ACCIDENTS, COMPLICATIONS
Gloves
Radiopaque probes
Graded collecting containers
GASTROINTESTINAL
SUCTION
TECHNIQUE
Gloves
Radiopaque tubes with single or multiple lumen
Containers
Connection tubing
Dosing pumps
Nutrient preparations that are to be
administered according to specific nutritional
deficiencies of each patient
PHOTO
NUTRITIENT SOLUTION TO BE
ADMINISTRATED THROUGH DIGESTIVE
PROBES
ENTERAL FEEDING
THROUGH
THE DIGESTIVE PROBE
TECHNIQUE
CONTENT
CLICK WITH THE MOUSE ON THE UNDERLINED TITLES
DEFINITION,
PURPOSE,
PRINCIPLES
Definition: the maneuver through which
the bleeding is stopped
Purpose: stopping blood from flowing
from the vascular bed
Principles: hemostasis can be done
spontaneously (physiological
mechanisms of the body) or surgically by
physical and chemical methods
INDICATIONS
TEMPORARY HEMOSTASIS
FINAL HEMOSTASIS
TECHNIQUE
TEMPORARY HEMOSTASIS
TOURNIQUET
If there is no tourniquet it can be improvised using a cord, a
belt, a scarf
Indications: limbs
By applying it the vascular walls are crushed and bleeding
stops
It is very important to attach a note where the date and exact
time of tourniquet application are recorded . If the transport
takes longer than 15-30 minutes, the tourniquet will be
opened for a few seconds to restore the blood flow to the
affected limb
In case of a jet bleeding with red blood, the bleeding has
arterial origin, and the tourniquet will be applied proximally to
the lesion, to the concerned member
In case of a continuous jet bleeding with dark red blood, the
bleeding has venous origin, and the tourniquet will be
applied distally to the lesion, to the tip of the concerned limb
TECHNIQUE
TEMPORARY HEMOSTASIS
POWERFUL COMPRESSION
Indications: head, neck, thorax, abdomen
It can be done by the strong compression of the injured
vessel against a skeletal plan, or by compression
bandage
The compressive bandage is made with sterile
compresses, the bandage is large enough to make the
injured blood vessel cooperate. Over sterile compresses
a crumpled of folded compresses or a roll of infancy
can be added, followed by a tight enswathement of the
area by circular infancy turns, with hemostatic role
TECHNIQUE
TEMPORARY HEMOSTASIS
Forcipression
The tourniquet
Loops
Balloon probes: Foley, Fogarthy
Compressive bandage
Swabbing
Ligature
Electrocoagulation
Embolization
Cushioning
Mass suture
Hemostatic substances
Definition: applying a loop suture by knotting in the blood vessel that will
determine HEMOSTASIS
Required materials: absorbable or non absorbable sutures, metal clips,
rubber rings
Technique: a hemostatic forceps will be applied to the damaged 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 tip of the forceps
being beyond the vessel by 1-2mm. Forceps should be applied only on
the blood vessel without catching other structures nearby. The suture
will be passed around the forceps 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 operator will open the forceps , and now the assistant
will tighten the node perfectly. After checking hemostasis the loop is cut
to 3-4 mm from the node.
If necessary several ligatures may be applied on the same blood vessel
a few millimeters away from each other or a supported ligature may be
applied.
VIDEO
TECHNIQUE
FINAL HEMOSTASIS- LIGATURE
VIDEO
TECHNIQUE
FINAL HEMOSTASIS - ELECTROCOAGULATION
CONTENT
DEFINITION, PURPOSE,
PRINCIPLES
Definition: it represents the manoeuvre
through which an organ, cavity or tissue
is entered with a needle or trocar
Purpose: disposal, treatment, diagnosis,
biopsy
Principles: the punctures tract should be
as short as possible, the manoeuvre must
be aseptic
INDICATIONS
Pneumothorax
Paracentesis
Pneumoperitoneum
Pancreatic pseudocyst
Abscess
Biopsy
Seldinger puncture
CONTRAINDICATIONS
Haemophilia
Treatment with anticoagulants
Tetanus
Induction of general anaesthesia
REQUIRED MATERIALS
IMAGE
THORACIC PUNCTURE
(THORACENTESIS)
PERICARDIAL PUNCTURE
Purpose: disposal
Patients position and punctures place:
Seated: intercostal space V at 6 cm from the left edge of the stern
Supine position: top of the xiphoid appendix
Morphine should be administered
Sanitization of the region, sterile gloves will be used during examination
Local anaesthesia
The needle attached to the syringe will be positioned perpendicularly to the skin
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)
The desired quantity of fluid will be sampled
The puncture needle is firmly removed the region will undergo massage
Sterile dressing
Bed rest for the patient
INCIDENTS, ACCIDENTS, COMPLICATIONS: bleeding, restlessness, irregular
heartbeats
ABDOMINAL PUNCTURE
(PARACENTESIS)
Purpose: disposal (for ascites, no more than 5 litres per session will be disposed),
diagnosis
Patients position: supine position
Punctures place: midway between the umbilicus and the left anterior-superior iliac
spine, 2 cm under umbilicus IMAGES
Local anaesthesia
Sanitization of the region, sterile gloves will be used during examination
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 transversalis
fascia
The peritoneal fluid will be drawn and stored in the indicated containers or the needle
will be coupled to an external drainage system
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 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 bottle
The puncture needle is firmly removed, sterile dressing
Bed rest for the patient
INCIDENTS, ACCIDENTS, COMPLICATIONS: puncture of an intestinal loop,
gastrointestinal bleeding or vascular collapse in the event of sudden decompression
of the abdomen
ABDOMINAL PUNCTURE
(PARACENTESIS)
Veress needle
SUPRAPUBIC PUNCTURE
Purpose: diagnosis
Patients position: supine position
Mialgin or Morphine is administered
Punctures place: stern
Sanitization of the region, sterile gloves will be used during examination
Local anaesthesia will be performed
With the Malarme trocar, placed perpendicularly on the stern, one goes
forward until feeling the entrance is entirely void of obstructions
The tenaculum is removed and with a sterile syringe are sampled 4 ml
of haematogenous medulla
The trocar is sampled
Sanitization of the region with alcohol
Sterile dressing
INCIDENTS, ACCIDENTS, COMPLICATIONS: infection, stern fracture
BIOPSY - PUNCTURE
Purpose: diagnosis
Patients position: one will choose the most comfortable
position for the patient, depending on where the region or
organ to be punctured is found
Punctures place: varies depending on localization
(adenopathies, liver, tumours)
Sanitization of the region, sterile gloves will be used during
examination
The puncture technique described above will be carried out
The sampled product will be placed in containers and sent as
soon as possible to the histopathology laboratory
INCIDENTS, ACCIDENTS, COMPLICATIONS: bleeding,
infection
Biopsy needle
VIDEO
BIOPSY - PUNCTURE
MAMMARY TUMOR
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
SURGICAL SUTURE
Infected wounds
Old septic high-risk wounds
Purulent incised collections
Suture of viscera in peritonitis
Poorly vascularised structures
REQUIRED MATERIALS
Sterile gloves
Soft sterile material
Antiseptic solutions SEE ANTISEPTICS
Suture needles
Suture threads FOTO
Metal staples
Needle holder
Anatomic clamp with or without teeth
Scissors
REQUIRED MATERIALS
REQUIRED MATERIALS
REQUIRED MATERIALS
NEEDLES
INTERRUPTED SUTURE
CONTINUOUS SUTURE
METAL STAPLES SUTURE
TECHNIQUE
INTERRUPTED SUTURE
VIDEO
TECHNIQUE
INTERRUPTED SUTURE
SIMPLE INTERRUPTED SUTURE
PERITONEUM-APONEUROTIC SUTURE
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE
INTERRUPTED SUTURE
SIMPLE INTERRUPTED SUTURE
CUTANEOUS SUTURE
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE
INTERRUPTED SUTURE
HORIZONTAL MATTRESS SUTURE - LEXER
VIDEO
TECHNIQUE
INTERRUPTED SUTURE
VERTICAL MATTRESS SUTURE
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE
CONTINUOUS SUTURE
Separate points
The mechanical
suture of the hollow
viscera (it is fast,
tight and provides a
very good approach)
INCIDENTS, ACCIDENTS,
COMPLICATIONS
Breaking of the suture threads
The wound gets opened by the sectioning of the
sutured structures
Seroma
Hematoma, bleedings
Infection
Eventrations
Eviscerations
Thread granuloma
Vicious scar
MEDICAL CARE
CONTENTS
DEFINITION, PURPOSE,
PRINCIPLES
Definition: it represents the method through which the body is
covered or fixed with gauze or elastic rollers
Purpose: fixing the bandage
Principles:
Not to cause pain, not to be too tight or too wide
To cover well the region, protecting and isolating the wound
To achieve a better fixing of the bandage
To allow mobilization of the dressed segment
The roller is unfolded from left to right
The fixing of the dressing is made at distance from the wound
in order not to cause pain
At the level of the limbs, the bandage will be made from distal
to proximal
REQUIRED MATERIALS
Plaster roller
REQUIRED MATERIALS
FIXING MATERIALS
Fixing staple
TECHNIQUE
GENERAL TECHNIQUES
BANDAGING ACCORDING TO TOPOGRAPHICAL REGIONS
CIRCULAR BANDAGING
SPIRAL BANDAGING
FAN BANDAGING
SPICA BANDAGING
IMAGE-OF-EIGHT BANDAGING
RECURRENT FOLD BANDAGING
Types of bandages
CAPELINE
MONOCLE, BINOCLE
NASAL SLING AND CHIN BANDAGE
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE
AT THE LEVEL OF THE HEAD-MONOCLE, BINOCLE
INDICATIONS:
ophthalmology
With one roller, are done
1-2 circular laps in the
fronto-occipital region;
then, are done oblique
laps in the temporo-sub-
auricular uni or bilateral MONOCLE BINOCLE
region, fixed by 1-2 circular
laps. The bandaging ends
with 1-2 circular laps
TECHNIQUE
AT THE LEVEL OF THE HEAD-NASAL SLING AND CHIN
BANDAGE (FOUR-TAILED BANDAGE)
A roller of approximately
80 cm length will be split
in both extremities,
leaving in the middle 6-8
cm not split. The
extremities are crossed SLING
FOUR-
TAILED
BANDAGE
TECHNIQUE
AT THE LEVEL OF THE NECK
ANTERIOR SPICA OF
THE NECK
POSTERIOR SPICA OF
THE NECK
These are complex
bandages
They apply the 8-shape
bandaging technique as
well as the circular
POSTERIOR SPICA OF THE NECK
bandaging
TECHNIQUE
AT THE LEVEL OF THE THORAX
Types of bandages:
VELPEAU BANDAGE
BREAST SPICA
INDICATIONS:
mastectomy
2-3 circular laps will
be done on the thorax
under the normal
breast, then oblique
laps over the
shoulder, altering with
circular chest laps
VIDEO
TECHNIQUE
BREAST SPICA
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE
AT THE LEVEL OF THE ABDOMEN
VIDEO
TECHNIQUE
AT THE LEVEL OF THE ABDOMEN-LOOSE BANDAGE
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE
AT THE LEVEL OF THE PERINEUM
DRESSING OF A T-
SHAPE WOUND
Two rollers are to be
used for this bandage,
one going circular
abdominal, and the
other antero-posterior
covering the genitals,
being fixed due to
abdominal circular
laps
TECHNIQUE
AT THE LEVEL OF THE LIMBS
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE
FAN BANDAGING OF THE ELBOW, KNEE
TECHNIQUE
IMAGE-OF-EIGHT BANDAGING
HAND
ANKLE
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE
IMAGE-OF-EIGHT BANDAGING-ANKLE
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE
CIRCULAR BANDAGING
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE
STUMP THIGH
Elastic stocking
DEFINITION, PRINCIPLES
PURPOSE
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
TECHNIQUE
INCIDENTS, ACCIDENTS, COMPLICATIONS
MEDICAL CARE
CLICK USING THE MOUSE ON EACH TITLE CONTENTS
DEFINITION,
PRINCIPLES
Disposal:
Monitoring: in hydro-electrolytic unstable
patients, during the postoperative immediate
phase (loss evaluation)
Therapy : acute retention of urine (urgency)
Exploration: a radio-opaque substance is
inserted allowing to obtain information on the
bladders form, shape, size
Therapy: antibiotics (urinary tract infections),
chemotherapy (cancer)
INDICATIONS
Oilcloth
Sterile gloves
Sterile solution for sanitization
Nelaton probe (women), Thyeman (men) Foley
(balloon), Pezzer
Lubrication gel
Collecting bag
Kidney tray, basin
TECHNIQUE
The oilcloth is placed under the patient, together with a basin or a
kidney tray
The patient is in supine position, with the hips flexed on the legs
and knees apart
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 right hand
will be used for handling the catheter, the glove being kept sterile
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
antiseptic solutions will be made
The physician will keep the peak of the catheter while the distal end
will be attached to the collecting bag by the nurse
The lubricant will be poured in the catheter's peak and in the penis
urinary meatus
TECHNIQUE FOR THE MALE
TECHNIQUE FOR THE FEMALE
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
TECHNIQUE FOR THE
FEMALE
The catheter is inserted into the urinary meatus
The catheter is slowly and progressively inserted
The catheter is inserted approximately 10-15 cm (the
female urethra is short and right)
The balloon fills with physiological serum
The catheter is withdrawn until it stops (at the
bladder opening of the urethra)
Local toilet
VIDEO
TECHNIQUE FOR THE
FEMALE
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
INCIDENTS, ACCIDENTS,
COMPLICATIONS
The false path" is the most common complication that can lead to rupture
of the urethra. It requires the urgent attention of the urology department
The balloons filling in the urethra causes the dilatation of the urethra, which
can be accompanied by bleeding or rupture. In order to avoid this accident,
first the catheter will be entirely inserted and only after that the balloon will
inflate
Bleeding ex vacuo" occurs due to sudden emptying of the bladder that
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 be
gradually made, evacuating small amounts of urine alternating for few
minutes with the catheters plucking
Urinary infection
The blocking of the catheter with clots, flakes, precipitates requires washing
with antiseptic and anti-obstruction solutions
MEDICAL CARE
CONTENTS
TYPES OF INSTRUMENTS
Electric scalpel
Scalpel blades
INSTRUMENTS TO SECTION
TISSUES
Saw
Costotome
Chisel
Bone cutter
INSTRUMENTS TO SECTION
TISSUES
Amputation knife
Gigli saw
INSTRUMENTS OF
EXPLORATION
Anatomic clamps with teeth (surgical clamps) Anatomic clamps without teeth
INSTRUMENTS TO GRASP
AND MANIPULATE TISSUES
Coprostatic clamps
L-shape clamp
INSTRUMENTS OF
HEMOSTASIS
Curved and straight Pan clamps
Curved and straight Kocher clamps
Mosquito clamps
Halsted clamps
Guyon clamps
Satinski clamps
Bulldog-type clamps - Dieffenbach
INSTRUMENTS OF
HEMOSTASIS
Kocher clamps
Satinski clamps
Pan clamps
INSTRUMENTS OF
HEMOSTASIS
Finochetto spreader
Farabeuf spreaders
Volkman spreader
Valves
INSTRUMENTS OF
REMOVAL
Gosset spreader
Dartigues spreader
INSTRUMENTS OF
REMOVAL
Vaginal speculum
Anal dilator
INSTRUMENTS OF
SUTURE
Round and triangular, straight or curved
Hagedorn needles
Atraumatic needles
Metal staples
Mathieu Needle holder
Hegar Needle holder
Rechargeable or disposable staplers
INSTRUMENTS OF
SUTURE
Metal staples
Clamps
Trocar
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CONTENTS
INSTRUCTIONS OF USE