Ward procedure

basic ward procedure for under and post graduates

1. WARD PROCEDURE BY : dr nikil jain

2. Preoperative and postoperative care Emergency drugs Drains Dressings catheter

3. PREOPERATIVE & POST OPERATIVE CARE

4. Preoperative & post operative care History Examination Investigations Preoperative preparation Preoperative orders Postoperative orders

5. History The patient is enquired about; Illness diabetes asthma and tuberculosis hypertension and myocardial infraction intake of insulin, steriods , antiepileptics

6. Examination General examination includes Nutritional status and built Hydration Anemia Jaundice Oral hygiene Cvs Pulmonary function

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

8. Preoperative preparation Diet Appropriative diet should be considered; Soft diet : edentulous patient Fat free diet: biliary tract disease Liquid diet : oral tumor and obstructing esophageal lesion Salt free diet: hypertensive patient Vit B ,C : indicated for debilitated patient Vit K : jaundiced patient and newborn

9. Medications IV fluids indicated The use of Antibiotics , cardiac drugs, diuretics and patient’s current medication must be carefully considered No medication should be given for the relief of pain until a diagnosis has been established

10. Preoperative orders Emergency admission for the urgent operation Diet: NBM[ nothing by mouth] Medications: no medication should be given for the relief of the pain until a diagnosis has been established and decision made whether or not to operate , because pain may be the only clue for the diagnosis which must not be masked by narcotics . Fluid therapy : IV fluids should be started

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

12. Post operative care the patient should be observed diligently and given intensive care until the overall condition stabilizes. Postoperative orders Name of the operation performed and type of anesthesia Vital signs: temperature , blood pressure, pulse and respiration should be taken six hourly Intake, output of fluids and bodyweight to decide the volume of fluid replacement Care of tube and drains Diet:NBM for at least 4 hours after GA Medication: IV fluid,analgesics , antibiotics, other medications Vomitting : It is due to anesthetic agents

13. Certain common post operative problems Recovery from anesthesia: Care should be taken for suction of vomited material. The patient should lie in lateral or supine position with head low and face turned on one side to prevent aspiration of vomitus in respiratory tract and falling back of the tongue.

14. Shock Foot end elevation with blocks IV fluids\ blood transfusion Oxygen inhalation Keeping the patient warm by blankets Vasopressor drugs Pain:As the patient recovers from the effect of GA , the pain which is relieved by Inj : Diclofenac sodium Inj:Diazepam

15. Retention of urine : in early postoperative period should be treated with Change of posture Hot water bag Sending the patient to toilet if not contraindicated Inj carbachol `1ml IM Care of wound : this is done by cleaning Applying an antiseptic Applying dressing

16. Emergency drugs

17. injection Adrenaline Noradrenaline Dopamine Propranolol Atropine sulphate Hydrocortisone Aminophyline Morphine Diazepam Avil Insulin Lasix bupivacaine

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

19. Adverse Reactions Palpitation, tremors, pallor, headache. lf injected rapidly and intravenously, adrenaline may cause sudden marked increase in blood pressure, precipitating subarachnoid hemorrhage and hemiplegia . Ventricular arrhythmias. Acute pulmonary edema in patients with cardiac decompensation . Anginal pain. ·

20. Inj. Noradrenaline Dose Two ml of noradrenaline is added to 1000 ml of 5% dextrose solution (acidic) resulting in a concentration of 4 ug /ml. After judging the response with a test dose of 2-3 ml, solution is administered at the rate of 0.5 ml/minute, according to the blood pressure response. lf noradrenaline is to be used and infused in normal saline, vitamin C (500-1000 mg)should be added to ma.ke the solution acidic

21. Indications Treatment of hypotension of circulatory failure. Hypotension following removal of chromaffin cell tumors. Side Effects Same as for adrenaline. necrosis

22. Inj. Dopamine Dose A 5-ml ampoule, containing a total of 200mg solution, is added to 500 ml of normal saline or 5% dextrose Indications Hypotension with inadequate cardiac output, to increase peripheral circulation. Open heart surgery. Renal failure (renal vasodilator dose is l-2.5 ug /kg/minute) in acute renal failure due to hypotension. Cardiac failure

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

24. Inj. Atropine Sulphate Indications 0.65-mg/ml : preanesthetic medication Bradyarrhythmias . Parkinsonism 6 -mg/ml In the treatment of organophosphorus poisoning

25. Inj. Neostigmine indications Myasthenia gravis. Acute congestive glaucoma. Treatment of curare poisoning. To reverse the neuromuscular blockade by D- tubocurarine and Pavulon (muscle relaxant used for relaxation in anesthesia). Treatment of neuromuscular paralysis due to snake-bite Side Effects Salivation, sweating, and lacrimation Nausea, vomiting; abdominal pain, and diarrhea Tremors and fasciculations Hypertension

26. Inj. Hydrocortisone Indications Life-threatening emergencies, e.g. anaphylactic shock, status asthmaticus , hypoglycemia, thyrotoxic crisis, Addison’s crisis, hypercalcemia , etc. Intra- articularly in osteoarthritis, painful fascial nodules, etc. Topically injected in the treatment of keloids . As retention enema

27. Side Effects Gastritis, gastric hemorrhage, peptic ulcer, perforation, and pancreatitis. Hypertension. Osteoporosis. lt suppresses immunity and inflammation and may mask serious infections. Tuber- culosis often spreads and there may be super—infection with fungi. Delays wound healing.

28. Inj. Aminophylline Indications Bronchial asthma. Cardiac asthma Side Effects Nausea, vomiting. Epileptiform fits, preceded by twitching of mouth or severe hyperventilation. Collapse and death

29. Inj. Morphine Dose 5-20 mg subcutaneously or intramuscularly Indications As an analgesic, e.g. in colic (given along with atropine) and myocardial infarction. . As a preanesthetic medication, In acute left ventricular failure

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

31. Inj. Diazepam Dose 10 mg intravenously or intramuscularly. Indications ` As muscle relaxant in tetanus. As preanesthetic rnedication . In the treatment of convulsions: Psychomotor epilepsy and status epilepticus . As tranquillizers.

32. Inj. Avil ( pheniramine maleate ) Action It inhibits the action of histamine release on gastrointestinal tract, uterus and blood vessels, but no effect on bronchospasm , hypotension, and gastric secretion Indications Allergic reaction Pruritus Hypnotic Side Effects l. Sedation, lassitude, and fatigue 2. Dryness of mouth, blurring of vision 3. Nausea, vomiting, and epigastric distress 4. Blood dyscrasias

33. Inj. Insulin Plain insulin is available in a concentration of 40 units/ml and 100 units/ml in l0—ml bulb Indications Diabetic ketoacidotic coma. Glucose insulin drip in hyperkalemia IDDM,NIDDM Side Effect Hypoglycemia.

34. Inj. Lasix ( Frusemide ) 20 mg intravenously or intramuscularly. indications In the treatment of pulmonary edema (given intravenously). . To induce forced diuresis in the treatment of barbiturate poisoning. In the treatment of mannitol -resistant acute oliguria . Advanced renal failure. In prostatectomy, while closing the urinary bladder, and postoperatively, after 4 hours to induce diuresis and thus to prevent clot retention.

35. Side- Effects When used unintelligently Lasix can precipitate serious water and electrolyte disturbances due to excessive loss of sodium (Na), potassium (K), chloride ( Cl ) and water, leading to weakness, fatigue, dizziness, and cramps Rapid diuresis in elderly patients may precipitate into retention of urine. It can cause hepatic coma in the presence of liver disease. Cardiac arrest Hearing loss

36. Bupivacaine Hydrochloride ( Sensorcaine ) Sensorcaine is used for regional or local anesthesia or analgesia for surgery, for oral surgery procedures, for diagnostic and therapeutic procedures, and for obstetrical procedures. It is four times more potent than lignocaine . It has longer duration of action. Availability Hyperbaric solution Isobaric solution if Hypobaric solution

37. Adverse Reactions Systemic: · Underventilation Hypotension Secondary cardiac arrest central nervous system reactions: Excitation and/or depression Restlessness, anxiety, dizziness, tinnitus, blurred vision or tremors may occur, possibly, proceeding to convulsions

38. Drains Drain is an appliance or piece of material that acts as a channel for the escape of fluid Prophylactic To prevent accumulation of fluid (bile, lymph, exudate , etc.) or blood. to encourage the obliteration of dead space, otherwise the accumulated fluid acts as a separating agent and will not allow the raw surfaces to collapse. Therapeutic : To promote escape of fluids already accumulated

39. Principle The simplest and most effective method of drainage is to bring the cavity to be drained to the surface, But as this is not always possible. alternatively an artificial drain is passed down to the cavity to be drained.

40. Advantages Drainage of the collected fluids removes the nidus for the infection. It helps in monitoring the future development of the complications like hemorrhage or leakage from the suture line. It removes the separating fluid from the cavity, so that raw surfaces can collapse and come into contact with each other which will enhance the rapid healing. Disadvantages It forms a portal of entry for the bacteria. It delays the healing. lt can break down suture lines. It initiates the tissue reaction It gets blocked within 6 hrs

41. Drain Placement The drain used should be: soft, so as not to erode the surrounding tissues preferably radio-opaque or having radioopaque line along the tube of a material that will not disintegrate and leave foreign bodies in the wound it should be non-irritant. Proper daily dressing of the drainage site should be done to prevent infection It should not damage the nerve or blood vessel. The inner end should not be placed near the suture lines. The drain should be secured properly

42. Types of Drains Cotton Gauze Gauze acts as a drain by capillary action in the fabric which absorbs the fluid Uses To prevent its closure and allow healing from floor Adv Its acts as a temporary drainage Disadv Gets soaked rapidly. Gets sealed within 6 hours by fibrin network. When soaked it acts as a moist channel for the penetration of bacteria. ` When a soaked gauze is removed, it is often followed by a gush of accumulate fluid from the cavity.

43. Wicks The wick is formed from gauge or threads of ligatures or suture material twisted together or bound loosely Disadvantages : , It becomes soaked by the fluid. It can adhere to the surface It requires frequent change

44. Glove Rubber Drain A strip of glove rubber, which is made up of latex, is used to drain the superficial dead space uses To drain dead space after removal of large subcutaneous lipoma sebaceous cyst, and after thyroidectomy . Drainage of abdominal wall wound if hematoma or infection is anticipated. Disadv It drains only deeper tissue since its surface sticks to the raw area.

45. Red Rubber Corrugated Drain (Sheet Drain) It is made up of red rubber which is available in the form of unsterile sheets, from which the strips of required length and breadth are cut and sterilized by autoclaving Adv; Drainage of the fluid occurs along the grooves of the drain, so chances of blockage are less. Red rubber is an irritant This drain is used only when there is minimal amount of discharge Disadv ; it is used for a prolonged period and removed at a time, the track of the drain will start healing from superficial and deep aspects while the middle part remains infected

46. Uses As per glove rubber drain To drain subcutaneous tissue after removal of multiple enlarged nodes in neck Drainage of large abscess cavity

47. Tube Drain When the fluid enters the tube, it can be guided into a collecting apparatus Advantage: tube drain forms the closed drainage system so that raw surface cannot be contaminated due to entry of bacteria. Disadvantages: It drains only in the direction of the gravity. If the tube is too thin, the force of capillarity tends to retard the free flow through it. lt cannot drain viscous fluid. It drains the fluid only when the tube is larger; so the fluid can be replaced by the air

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

49. Dressings Dressing Basic Dressing Materials Gauze, Gamgee Bandages Elastic bandages Elastic adhesives Specialized Dressing Materials Vaseline gauze Framycetin -medicated gauze Sialistic Gauze Advantages: Porous Autoclavable Does not get wet Transparent

50. Treatment of Wounds While treating any wound, one must broadly consider whether it is an open wound or closed wound. The decision to repair any injured structure in an open wound depends entirely on whether it is tidy or untidy. Types of Wounds Open wounds 1 . lncised wound : Clean cut by sharp instruments (knife, glass, razor blade). No bruising or crushing. It tends to gap, and bleeds freely. Damage to all structures is linear with minimum loss of tissue.

51. Puncture wound (stab) Wound is deeper than its breadth, and is caused by sharp, pointed narrow objects such as pins. knives, and splinters of wood. Entrance of wound is surprisingly small and may be missed. Perforating or penetrating wounds: These are punctured wounds, caused by missiles which may pass through the tissue.

52. Lacerated wound: Caused by tearing, crushing, and forcible disruption of tissues. Loss of skin continuity. It has jagged, rough edges. Extensive tissue devitalization by loss of blood supply. Bleeding is often at first slight. Abrasion and degloving : Caused by scrapping away of the superficial layers of skin. When more pressure is applied in rubbing, a flap of skin and subcutaneous tissue may roll off, exposing the deeper tissue.

53. Closed wounds Contusion Caused by pressure of blunt object. Extravasation of the blood in the tissue augmented by edema. Skin maybe intact. If skin is involved in contusion, the visible bruise is an ecchymosis . Hematoma Caused by blunt object. Larger blood vessels are ruptured.

54. Instructions for the Wound Dressing Take utmost care to prevent cross-infection. The instruments to be used for the dressing should be sterilized. Wash hands thoroughly before and after the procedure. Use instruments for one dressing only. After dusting or sweeping the room, do not dress for l5 minutes. lt is advisable to have a bag for each dressing. Avoid coughing, sneezing, and talking when the wound is opened. Clean the wound from the centre to its periphery. lf dressing is sticking to the wound, pour Savlon or normal saline to make it wet for its easy removal. The wound and the drain area should be dressed separately. The amount of discharge should be examined for its color, odor, and consistency. Give an analgesic prior to the painful dressing Isolate the wound by spreading sterile towels.

55. Treatment l. The aseptic treatment of a wound: The aim of surgery is to make all wounds as tidy as possible by removing dead or damaged tissue and by re-aligning living tissues nearly together.If slough present , removed by hydrogen peroxide or Eusol. 2. Cleansing the surrounding skin Pad of sterile dry gauze is held on the wound. Surrounding skin, if hairy, is shaved.

56. Remove skin fats, grease, and oil debris with 1% cetrimide ( Cetavlon ). Alternative is bactericidal solution (0.05% Savlon ). lf the wound is soiled, the wash can be augmented by ether. Then follow wash with saline or sterile water or spirit. 3. Anesthesia (general or local): Full anesthesia of wound is necessary. One per cent lignocaine is satisfactory for local anesthesia. Needle should not be inserted too far. 4. Cleansing of the wound properly: Sterile towels are applied. ' Operating surgeon should be gloved and gowned. Same order of bland fluid cleansing is used as for surrounding skin. Loose foreign bodies —are removed by sterile forceps. Wash the wound with saline. Exploration, identification. ’ Repair and closure of the wound.

57. 5. Leaving the wound open: Most wounds can be closed primarily and drain should be avoided. Exceptions, however, are _ With extensive muscle loss. Viability of tissues is in doubt. Grossly infected wound. Those caused by velocity projectiles.

58. After Care Dressings: Most dressings are left undisturbed. Dressing is removed earlier, if there is; ( i ) hematoma formation, (ii) soaking with exudate , (iii) local pain, tenderness, and (iv) unexplained pyrexia. Plaster slab or plaster: The wounds of the limbs, especially the joints, require immobilization to give rest to the wound. This can be achieved by plaster slab or plaster; it provides scope for dressing. Removal of sutures Wound can be cleaned with ether. Usually, sutures are removed between the 7th and 10th day.

59. Care of infected Wounds Infection can be controlled by local mechanical washing and appropriate antibiotics. Dead tissues (slough) that are easily visible can be excised without much pain. Time-honored and cheap lavage is hydrogen peroxide and Eusol. Eusol is prepared by mixing boric acid and bleaching powder in l liter of water. Eusol has to be fresh and should be prepared every day.

60. URINARY CATHETER

61. INTRODUCTION A Foley catheter is a thin, sterile tube inserted into your bladder to drain urine Because it can be left in place in the bladder for a period of time. It is held in place with a balloon at the end, which is filled with sterile water to hold it in place. The urine drains into a bag and can then be taken from an outlet device to be drained

62. PARTS OF THE FOLEYS CATHETER

63. INDICATIONS By inserting a Foley catheter, you are gaining access to the bladder and its contents. Thus enabling you to drain bladder contents, decompress the bladder, obtain a specimen, and introduce a passage into the tract. This will allow you to treat urinary retention, and bladder outlet obstruction. .

64. Urinary output is also a sensitive indicator of volume status and renal perfusion (and thus tissue perfusion also). In the emergency department, catheters can be used to aid in the diagnosis of bleeding. In some cases, as in urethral stricture or prostatic hypertrophy, insertion will be difficult and early consultation with urology is essential

65. CONTRAINDICATIONS Foley catheters are contraindicated in the presence of urethral trauma. Urethral injuries may occur in patients with multisystem injuries and pelvic fractures, as well as straddle impacts. If this is suspected, one must perform a genital and rectal exam first.

66. If one finds blood at the meatus of the urethra, a scrotal hematoma, a pelvic fracture, or a high riding prostate then a high suspicious of urethral tear is present. One must then perform retrograde urethrography (injecting 20 cc of contrast into the urethra).

67. Equipment Sterile gloves - consider Universal Precautions Sterile drapes Cleansing solution e.g. Savlon Cotton swabs Forceps Sterile water (usually 10 cc) Foley catheter (usually 16-18 French) Syringe (usually 10 cc) Lubricant (water based jelly or xylocaine jelly) Collection bag and tubing

68. PROCEDURE The urethra and the surrounding areas are cleaned with a cotton-ball dipped in antiseptic solution. Beginning at the urethra, the cleansing is performed in a circular motion, moving outward to the surrounding areas. A Foley catheter, lubricated with water-soluble jelly, is inserted into the bladder through the urethra. .

69. Once the catheter is passed, the balloon is in the bladder. It is then slowly inflated with about 10cc of water using a syringe. Inflating the balloon should not be painful At this time, urine, if present in the bladder, should flow back through the catheter and into the sterile drainage bag.

70. Removal of the catheter and bag The catheter balloon is deflated by inserting a syringe into the catheter valve and pulling back on the syringe. The pressure in the balloon will cause the water to flow into the syringe. Once the balloon is empty, the Foley catheter can be pulled out.

71. After the Procedure A slight irritation in the urethral area may be felt. Switch to looser fitting cotton clothing. Do not use chemical irritants in the genital area and keep the area clean.

72. reference Mansukh b patel & yogesh p upadhyay