Emulsifcation of fats by bile salts - Bile salts lower the surface tension of the fat droplets in the duodenum discount 5mg proscar amex, which aids in digestion and absorption of lipids purchase discount proscar. Surface tension of plasma: The surface tension of plasma is 70 dynes/cm buy proscar 5 mg otc, which is slightly lower than that of water order proscar master card. Hay’s test for bile salts - The principle of surface tension is used to check the presence of bile salts in urine. When fne sulphur powder is sprinkled on urine containing bile salts ( as in jaundice), it sinks due to the surface tension lowering effect of bile salts. Dipalmitoyl lecithin is a surfactant that is secreted by the lung alveoli, which reduces the surface tension and prevents the collapse of lung alveoli during expiration. Osmosis is a colligative property of solution that depends on the number of molecules or ions of the solute in the solutions. A solution having lower or higher osmotic pressure with respect to the other is called as hypo-osmotic or hyperosmotic solutions respectively. The osmotic pressure exhibited by these impermeable solutes is called as the tonicity of the solution. A solution having lower or higher tonicities with respect to the other is called as hypotonic or hypertonic solutions respectively. The ability of the membrane to withstand hypotonic solution depends upon the integrity of the membrane. Certain genetic disorders like sickle cell anemia and defciency of vitamin E makes the erythrocyte membrane more fragile. Osmotic pressure of blood is largely due to its mineral ions such as sodium, potassium, chloride, calcium and protein. The osmotic pressure exerted by proteins is of considerable biological signifcance owing to the impermeability of the plasma membrane to the colloidal particles. The net difference in the hydrostatic pressure and osmotic pressure is responsible for the fltration of water at the arterial end of the capillary and the reabsorption of the same at the venous end. The renal excretion of water is regulated partly by the osmotic pressure exerted by the colloids in the blood plasma. Increased urination (polyuria) occurring in diabetes patients is due to the increased water retention by the urinary glucose. Donnan Membrane Equilibrium Let us consider two compartments separated by a semi permeable membrane, which is permeable to water and crystalloids, but not to colloidal particles. One of the compartment (A) is flled with a moles of NaCl, and the other compartment (B) is flled with b moles of NaR, in which R happens to be a non diffusible ion. So, the ionic concentration at equilibrium in both the compartments will be as follows, (A) (B) a-x Na+ Na+ b + x a-x Cl- R- b. Due to imbalance in the electrolytes, swelling of proteins occur, which is called as Donnan osmotic effect. Due to metabolism and dietary intake, large quantities of acids and bases are produced in the body and they have to be transported through blood for elimination. This is effectively done in the body by means of the buffers present in the blood and by two mechanisms, namely the respiratory mechanism and the renal mechanism. Since the concentrations of phosphate and organic acids are low in plasma, they do not play a major role in regulation of pH. Hemoglobin buffer system The buffering capacity of hemoglobin is due to the presence of imidazole groups in its histidine residues. When the blood returns to the lungs, O2 tension in the lungs is high resulting in the oxygenation of Hb. These acids are effectively buffered by the bicarbonate system, but at the expense of the bicarbonate, which is called as the alkali reserve of the body. In acidemia, inorder to bring the low pH to normal, the excessive H+ ions should be excreted and bicarbonate excretion should be reduced. On the other hand, during alkalemia, the kidneys excrete the excess bicarbonate producing an alkaline urine (pH 8. The three important mechanisms attributed by the kidneys to regulate the blood pH are (i) Reabsorption of bicarbonate (ii) Buffering by phosphate buffers (iii) Formation of ammonium ions. It starts in the mouth, continues in the stomach and small intestine and is completed in the large intestine. Saliva contains ptyalin, an a amylase, which attacks the a 1-4 linkages resulting in the formation of monosaccharide glucose, disaccharide maltose and trisaccharide maltotriose. However, because of steric hindrance caused by the branches, some of the interior a 1-4 linkages are inaccessible for the enzyme. Glycogen, Starch Glucose, Maltose, Maltotriose, Limit Dextrin Glycogen Limit Dextrin When food along with ptyalin reaches the stomach, ptyalin is inactivated due to low pH. Its action is similar to that of the ptyalin, but it is more powerful because (i) It can act upon raw starch. Intestinal amylase : It hydrolyses the terminal a 1-4 linkages in polysaccharides and oligosaccharides releasing free glucose molecules. Lactase : It is b-galactosidase that hydrolyses lactose molecule to equimolar amounts of glucose and galactose. Sucrase : It hydrolyzes sucrose to equimolar amounts of glucose and fructose by hydrolyzing b 1-2 linkages. Isomaltase : It hydrolyses the a 1-6 branch points of limit dextrin and liberates maltose and glucose. There are no enzymes present in our digestive system to hydrolyze b1,4 linkages in cellulose, so it cannot be digested. The absorption rate of the monosaccharides is in the following order: Galactose > Glucose > Fructose > Mannose > Xylose > Arabinose 20 Mechanism of absorption 1. Simple Diffusion: Initially, when the concentration of glucose in the intestinal lumen is high, by simple diffusion it crosses the membrane. The steps involved in the transport of glucose are : (i) One molecule of Na+ and glucose binds to the transporter. Hormones like thyroid hormone, adrenal cortex hormones and pituitary hormones enhance the absorption of carbohydrates. It is secreted in the inactive zymogen form called as pepsinogen, which has a molecular weight of 42,500 daltons. Pepsin acts on protein to convert it to proteoses and peptones, which are low molecular weight peptides. Proteins Proteoses + Peptones It has a broader specifcity and acts on peptide linkages constituted by the carboxyl group of an aromatic / hydrophobic amino acid or amino group of a dicarboxylic acid. It is an endopeptidase that is specifc for peptide linkages formed by carboxyl groups of basic amino acids, namely arginine, lysine. It hydrolyses peptide linkages with carboxyl group of aromatic amino acids like tryptophan, tyrosine and phenyl alanine. The optimum pH for chymotrypsin is 7 - 8 Carboxy peptidase Two types of carboxy peptidases, carboxy peptidase A and B are known. Carboxy peptidase A is specifc for aromatic amino acids at the C terminal end, while carboxy peptidase B is specifc for basic amino acids at the C terminal end. Thus by the concerted action of all the above enzymes, proteins are broken down to di and tri-peptides. Di and tri peptidases present in the intestinal mucosal cells or inside the absorptive cells cleave them to amino acids. Absorption of amino acids are similar to those of carbohydrates and they need a carrier and sodium ions. Vegetables sources are superior to animal sources because of the presence of the various polyunsaturated fatty acids. There are four different phosopholipases that can cleave phospholipids to glycerol, free fatty acids, phosphoric acid and the base. A part of glycerol and short chain fatty acids are directly absorbed by the portal circulation and taken to the liver. Glycerol and fatty acids that enter to the intestinal epithelial cells are converted to triglycerides and in the lacteals, they are covered with a layer of hydrophilic phospholipids, cholesterol, cholesterol esters and an apoprotein apo B. After being packaged to a more hydrophilic soluble form, they enter into the lymphatic circulation and fnally enters the systemic circulation via the thoracic duct. The highly acidic medium in the stomach destabilizes the nucleoprotein structure and the proteolytic enzymes split them to nucleic acids and proteins. Depending upon the site of action, nucleases canbe either endonuclease that attacks the interior linkages and exonuclease that attacks the terminal linkages. All of them are polypeptides synthesized by the mucosal endocrine cells of the stomach and small intestine. Gastrin is produced by the mucosal cells of the pyloric region of the stomach and is the most effective activator of gastric acid secretion.

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Dehydration also can be caused by a lot of vomiting proscar 5 mg with mastercard, which often accompanies diarrhea discount 5mg proscar with amex. Treating Diarrhea: The most important measures in treating diarrhea are to: - Prevent dehydration from occurring if possible - Treat dehydration quickly and well if it does occur - Feed the child 121 Pediatric Nursing and child health care 9 discount proscar 5mg otc. Mix well with a clean spoon until the powder is dissolved - Taste the solution so that you would know its taste like salt - Then give the child frequent small sips out of a cup or spoon generic proscar 5mg overnight delivery. If the answer to either question is ‘yes’, use the following management chart to assess, classify and treat the child Calcifying Dehydration: - There are three possible calcifications of dehydrations for a child with diarrhea. If there is Falciparum malaria in the area and the child has any fever (38 or above) or history of fever in the past 5 days give anti-malarial treatment according to malaria program recommendation in your area 128 Pediatric Nursing and child health care 9. Treatment of Diarrhea Decide on appropriate treatment: After the examination, decide how to treat the child - if the child has any of the signs in the column labeled “for other problems” specific treatment is needed in addition to treatment given for dehydration - if there is blood in the stool and diarrhea for less than 14 days, the child has dysentry and appropriate antibiotics should be given - if there is diarrhea for longer than 14 days with or without blood in the stool and/or if there is severe under nutrition, continue feeding the child and refer for treatment. Determine the degree of dehydration Look at the upper row, the assessing and classifying chart. What important measures should be taken to prevent dehydration in children with diarrhea? What important pieces of advice would you give to the mother for home treatment of diarrhea? Older children are more likely to have acquired heart diseases such as rheumatic fever, endomyocardial fibrosis. Cyanosis can best be detected under the fingernails or on the mucus membranes of the mouth (lips, under side of the tongue). One of the main causes of this is chronic under saturation of the blood with oxygen. Signs of Cardiac Failure: ƒ Tachycardia-rapid pulse ƒ Tachyponea-rapid respiration ƒ Dyspnea-shortness of breath ƒ Edema and other signs of raised venous pressure ƒ Fatigue and failure to thrive ƒ Arrhythmia-irregular heart beat ƒ Systolic and more frequently diastolic murmurs ƒ Cough ƒ Orthophea Management: Any child with congestive heart failure should be referred to hospital whenever possible. In all cases where you have to start treatment: - check weight of the child ,record the pulse and respiration carefully at 2 hours intervals and indicate the exact time of any drugs given. Digitalization is most important In order to achieve effective blood levels quickly a digitizing dose is calculated and given over 24 hours. The only known cause is damage to the fetus by rubella Virus, when the mother is one to three months pregnant, or by chromosomal abnormality in children with Down’s syndrome. Abnormal communication in the heart or between big vessels ƒ Atrial septal defect ƒ Ventricular septal defect ƒ Patent ductus arteriosus In these due to the highest pressure in the left heart, there is a shunt from left to right heart with an increased blood load in lesser circulation. Congenital obstruction of the blood flow ƒ pulmonary stenosis ƒ aortic stenosis coarctation of the aorta) c. Combination of abnormal communication and stenosis (pallot’s disease is one example) Clinical Features: Besides the above-mentioned symptoms, failure of normal growth and development, repeated attacks of respiratory tract infections, and a loud murmur is usually present. Any child with congestive heart failure should be referred to hospital whenever possible. In all cases where you have to start treatment: ƒ check weight of the child ,record the pulse and respiration carefully at 2 hours intervals and indicate the exact time of any drugs given. Give prophylaxis against subacute bacterial endocarditis Prognosis: Many children with congenital heart disease die in early childhood. Rheumatic Heart Disease: Rheumatic fever is an inflammatory disease related to streptococcal infection affecting mostly the heart and joints, but also other tissues including the brain and skin. This is due to a specific reaction of tissues, mainly the heart and the joints, to the streptococcal toxins. Clinical Features: Painful swelling of one or more big joints ( knee, ankle, elbow, shoulder) may last for one day or longer, subside and another joint may then be affected ( rheumatic polyarthritis) ƒ Fever ƒ malaise ƒ rheumatic carditis (heart become enlarged murmur develops and sign ƒ Of congestive heart failure may occur. Etiology: a) Congenital heart disease ( in the first 3 years of life) b) Acquired heart disease (rheumatic heart disease) c) Non cardiovascular causes (anemia, pulmonary disease. Palpation (may have weak peripheral pulse) Auscultation (gallop rhythm, cardiac murmur may or may not be present) Chest x-ray (cardiomegally may be present) Nursing Care: 1. Administer diuretics as prescribed to remove accumulated sodium and fluid and restrict sodium intake. Practice careful hand washing technique to decrease the dangers of infection 143 Pediatric Nursing and child health care 7. Monitor vital signs frequently and report any significant changes to observe signs off disease progress or response to treatment 10. Central nervous system Diseases Meningitis: Meningitis is an inflammation of the meninges (membranes surrounding the brain and spinal cord) and is caused by a viral, bacterial or fungal organisms. Aseptic meningitis refers either viral or other causes of meningeal irritation such as brain abscess or blood in the subarachnoid spaces. Septic meningitis refers to meningitis caused by bacterial organisms such as meningococcus, Staphylococcus, or influenza bacillus. Meningeal infections generally originate in one of two ways either through the blood stream as a consequence of other infections such as cellulites or by direct extension after traumatic injury to the facial bones. In a small number of cases the cause is iatrogenic or secondary to invasive procedures (e. Headache and fever: 144 Pediatric Nursing and child health care Are frequently the initial symptoms. Positive kerning sign: When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. Positive Brudzink’s sign: When the patient’s neck is flexed, flexion of the knees and hips is produced. Assure the patient that inserting the needle into the spine will not cause paralysis 145 Pediatric Nursing and child health care 2. The thighs and legs are flexed as much as possible to increase the space between the spines of the vertebrae for easier entry into the subarachnoid space 5. Small pillow is placed under the patient’s head to maintain the spine in horizontal position 6. Assist the patient to maintain the position to avoid sudden movement, which can produce trauma 7. Instruct the patient to breathe normally, because hyperventilation may lower an elevated pressure Post procedure Care: 1. The specimen should be sent to the laboratory immediately because changes will take place and alter the result if the specimens are allowed to stand. These jerky movements are called Convulsions and are diagnostic of major or Grand mal epilepsy. When convulsions are prolonged or repeated the condition is known as “Status epilepticus”. Such convulsions are very exhausting and unless controlled may lead to patient death. During the third part of the fit or convulsion ƒ Patient lies quietly ƒ Muscles are relaxed ƒ He is still unconscious 148 Pediatric Nursing and child health care This part lasts from a few minutes to an hour or more. Then ƒ Patient return to consciousness ƒ He may have bad headache ƒ Remembers nothing of the fit ƒ Often feels very sleepy B, Some patients do not show the first or second part of the fit, and suddenly become unconscious for only a few seconds. The eye may stare but see nothing and these are the ‘lesser fit of epilepsy (petit Mal)”. Phenytoin sodium from 45 mg daily to 180 mg three times a day may be given Nursing Management during seizure: ƒ Provide privacy ƒ Protect head injury by placing pillow under head and neck ƒ Loosen constrictive clothing’s ƒ Remove any furniture from patient side ƒ Remove denture if any ƒ Place padded tongue blade teethes to prevent tongue bit ƒ Do not attempt to restrain the patient during attack ƒ If possible place patient on side 149 Pediatric Nursing and child health care Nursing Management after seizure: ƒ Prevent aspiration by placing on side ƒ Admister medication as ordered to control the seizure ƒ Remove hard toes from the bed to protect the child from injury during convulsion ƒ Donot give any thing by mouth during convulsion ƒ Place the child where he can be watched closely to observe for recurrent seiures ƒ On awaking re-orient the patient to the environment. Acute glomerlonephritis is predominately a disease of childhood and is the most common type of nephritis in children. Initial infection of (upper respiratory system or skin) most frequently a beta hemolytic streptococcus and other bacteria’s and viruses. Antibodies produced to fight the invading organism also react against the glomerular tissue 2. General vascular disturbances, including loss of capillary integrity and spasm of arterioles, are secondary to kidney changes and are responsible for much of the symptomatolgy of the disease. Urinalysis (decreased out put, hematuria, high specific gravity, protein urea, white cells, casts) may be reported 151 Pediatric Nursing and child health care 2. Chest x-ray may show pulmonary congestion and cardiac enlargement Complications: 1. Hypertensive-encephalopathy (restlessness, stupor, convulsions, vomiting severe headache, visual disturbances) occur frequently.

Anticholinesterases Inability to perform these activities and/or the The action of all the neuromuscular blocking presence of ‘see-sawing’ or paradoxical respiration drugs wears off spontaneously with time safe 5mg proscar, but this is suggests a degree of residual neuromuscular block buy proscar 5mg with amex. In patients who A further dose of neostigmine and an anticholiner- require reversal of neuromuscular blocking drugs purchase 5mg proscar otc, gic may be required buy proscar canada. This inhibits the ac- tion of the enzyme acetylcholinesterase, resulting Peripheral nerve stimulation in an increase in the concentration of acetyl- choline at the neuromuscular junction (nicotinic This is used in anaesthetized patients, the details effect). Anticholinesterases cannot be used to reverse very A peripheral nerve supplying a discrete muscle intense block, for example if given soon after the group is stimulated transcutaneously with a cur- administration of a relaxant (no response to a rent of 50mA. One arrangement is to stim- Anticholinesterases also function at parasympa- ulate the ulnar nerve at the wrist whilst monitor- thetic nerve endings (muscarinic effect), causing ing the contractions (twitch) of the adductor bradycardia, spasm of the bowel, bladder and pollicis. There- feeling the response, measuring either the force of fore they are always administered with a suitable contraction or the compound action potential is dose of atropine or glycopyrrolate to block the un- more objective. Sequences of stimulation used include: The most commonly used anticholinesterase is • four stimuli each of 0. There are several opioid receptors, each ade, there is a progressive decremental response to identified by a letter of the Greek alphabet, at all the sequences, termed ‘fade’. Two of the most important re- the first twitch (T1) is used as an index of the de- ceptors are m (mu) and k (kappa), and stimulation gree of neuromuscular blockade. During depolariz- (agonist actions) of these by a pure agonist pro- ing blockade, the response to all sequences of duces the classical effects of opioids: analgesia (m, stimulation is reduced but consistent, that is, there k), euphoria (m), sedation (k), depression of ventila- is no fade. The sys- temic effects of opioids due to both central and peripheral actions are summarized in Table 2. When is it useful to assess the degree of A synopsis of the pure agonists used in anaesthe- neuromuscular block? Because of the potential for • During long surgical procedures to control the physical dependence, there are strict rules govern- timing of increments or adjust the rate of an infu- ing the issue and use of most opioid drugs under sion of relaxants to prevent coughing or sudden the Misuse of Drugs Act 1971 (see below). This is particularly important during Opioid analgesics can also be partial agonists or surgery in which a microscope is used, for example partial agonists/antagonists. These drugs were introduced in the hope that, with • In recovery, to help distinguish between residual only partial agonist activity at m receptors or mixed neuromuscular block and opioids overdose as a agonist/antagonist actions at m and k receptors, cause of inadequate ventilation postoperatively. Analgesic drugs Nalbuphine (Nubaine) Analgesic drugs are used as part of the anaesthetic This is a synthetic analgesic with antagonist ac- technique to eliminate pain, reduce the auto- tions at m receptors and partial agonist actions at k nomic response and allow lower concentrations of receptors. It is similar in potency and duration of inhalational or intravenous drugs to be given to action to morphine, and exhibits a ceiling effect of maintain anaesthesia. Opioid analgesics This term is used to describe all drugs that have an Tramadol (Zydol) analgesic effect mediated through opioid receptors and includes both naturally occurring and syn- A relatively complex analgesic, a weak opioid 37 Chapter 2 Anaesthesia Table 2. It is claimed to cause less respiratory depression Schedule 2 This includes opioids, major stimulants than equivalent doses of morphine, but if this does (amphetamines and cocaine) and quinal- occur it is readily reversed by naloxone. The pure antagonist Schedule 4 This is split into two parts: The only one in common clinical use is naloxone. This has antagonist actions at all the opioid recep- Schedule 5 Preparations which contain very low tors, reversing all the centrally mediated effects of concentrations of codeine or morphine, pure opioid agonists. Supply and custody of schedule 2 • It has a limited effect against opioids, with par- drugs tial or mixed actions, and complete reversal may require very high (10mg) doses. In the theatre complex, these drugs are supplied by • Following a severe overdose, either accidental or the pharmacy, usually at the written request of a deliberate, several doses or an infusion of naloxone senior member of the nursing staff, specifying the may be required, as its duration of action is less drug and total quantity required, and signed. These drugs must be stored in a locked safe, cabinet • Naloxone will also reverse the analgesia pro- or room, constructed and maintained to prevent duced by acupuncture, suggesting that this is prob- unauthorized access. A record must be kept of their ably mediated in part by the release of endogenous use in the ‘Controlled Drugs Register’ and must opioids. The regulation of opioid drugs •The class of drug must be recorded at the head of Some drugs have the potential for abuse and con- each page. The Misuse of • Entries must be made on the day of the transac- Drugs Act 1971 controls ‘dangerous or otherwise tion or the next day. The Act imposes a • No cancellation, alteration or obliteration may total prohibition on the manufacture, possession be made. The specific details required with respect to supply • The initial parenteral dose is 10mg, subsequently of Controlled Drugs (i. Only available • protect the integrity of the gastric mucosa; for parenteral use; the initial dose is 40mg, with • maintain renal blood flow, particularly during subsequent doses of 20–40mg, 6–12 hourly, maxi- shock; mum 80mg/day. The delivery of gases to the These target only the inducible form of the enzyme operating theatre at the site of inflammation. The pipelines’ outlets act patients (especially those with recurrent nasal as self-closing sockets, each specifically configured, polyps) are prone to bronchospasm precipitated by coloured and labelled for one gas. The gases (and vacu- um) reach the anaesthetic machine via flexible rein- forced hoses, colour coded throughout their length 40 Anaesthesia Chapter 2 Figure 2. Gas Body Shoulder Nitrous oxide Oxygen Black White Nitrous Oxide Blue Blue Piped nitrous oxide is supplied from large cylin- Entonox Blue Blue/white ders, several of which are joined together to form a Air Grey White/black bank, attached to a common manifold. There are Carbon dioxide Grey Grey usually two banks, one running with all cylinders turned on (duty bank), and a reserve. Cylinders, the tradi- remains the pressure within the cylinder remains tional method of supplying gases to the anaesthetic constant (440kPa, 640psi). When all the liquid has machine, are now mainly used as reserves in case of evaporated, the cylinder contains only gas and as it pipeline failure. Medical air Oxygen This is supplied either by a compressor or in cylin- Piped oxygen is supplied from a liquid oxygen re- ders. A compressor delivers air to a central reser- serve, where it is stored under pressure (10–12bar, voir, where it is dried and filtered to achieve the 1200kPa) at approximately -180°C in a vacuum- desired quality before distribution. Two pumps are connected to a system oxygen is kept adjacent in case of failure of that must be capable of generating a vacuum of at the main system. This directly to the anaesthetic machine as an emer- is delivered to the anaesthetic rooms, operating gency reserve. Safety features • The oxygen and nitrous oxide controls are linked such that less than 25% oxygen cannot be delivered. This discontinues the nitrous oxide supply and if the patient is breathing spontaneously air can be entrained. The addition of anaesthetic vapours The anaesthetic machine Vapour-specific devices are used to produce an Its main functions are to allow: accurate concentration of each inhalational • the accurate delivery of varying flows of gases to anaesthetic: an anaesthetic system; •Vaporizers produce a saturated vapour from a • an accurate concentration of an anaesthetic reservoir of liquid anaesthetic. Sevotec) to account for the loss of latent heat that causes cooling and reduces Measurement of flow vaporization of the anaesthetic. This is achieved on most anaesthetic machines by The resultant mixture of gases and vapour is the use of flowmeters (‘rotameters’; Fig. From this point, specialized the patient’s peak inspiratory demands (30– breathing systems are used to transfer the gases 40L/min) to be met with a lower constant flow and vapours to the patient. It also acts as a further Checking the anaesthetic machine safety device, being easily distended at low pres- It is the responsibility of each anaesthetist to check sure if obstruction occurs. The main danger is that the anaesthetic spontaneous ventilation, resistance to opening is machine appears to perform normally, but in fact is minimal so as not to impede expiration. In the valve allows manual ventilation by squeezing order to minimize the risk of this, the Association the reservoir bag. Its main aim is to ensure that oxygen flows through the oxygen delivery system and is The circle system unaffected by the use of any additional gas or vapour. Most modern anaesthetic machines now The traditional breathing systems relied on the po- have built-in oxygen analysers that monitor the in- sitioning of the components and the gas flow from spired oxygen concentration to minimize this risk. Even the most efficient system is Anaesthetic breathing systems still wasteful; a gas flow of 4–6L/min is required The mixture of anaesthetic gas and vapour travels and the expired gas contains oxygen and anaes- from the anaesthetic machine to the patient via an thetic vapour in addition to carbon dioxide. Delivery to the patient is via a inefficiencies: facemask, laryngeal mask or tracheal tube (see pages • The expired gases, instead of being vented to the 18–25). There are a number of different breathing atmosphere, are passed through a container of systems (referred to as ‘Mapleson A’, B, C, D or E) soda lime (the absorber), a mixture of calcium, plus a circle system. The details of these systems are sodium and potassium hydroxide, to chemically beyond the scope of this book, but they all have a remove carbon dioxide. As • Supplementary oxygen and anaesthetic vapour several patients in succession may breathe through are added to maintain the desired concentrations, the same system, a low-resistance, disposable bacte- and the mixture rebreathed by the patient. Gas rial filter is placed at the patient end of the system, flows from the anaesthetic machine to achieve this and changed between each patient to reduce the can be as low as 0. Components of a breathing system There are several points to note when using a circle All systems consist of the following: system. The inspired oxygen 43 Chapter 2 Anaesthesia Connection to scavenging system Adjustable expiratory valve Fresh gas input Reservoir bag Figure 2. Note the port on the expiratory valve (white) to allow connection to the anaesthetic gas scavenging system.

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If fluid analysis shows non loculated fluid without organism and serial x-ray demonstrates lung expansion order 5mg proscar, this procedure is adequate with appropriate antibiotics for 10% of patients purchase 5mg proscar with visa. Closed tube thoracostomy: A procedure of inserting tube into the pleural cavity and connecting it to underwater seal bottle with or without suction order proscar 5mg overnight delivery. Open tube drainage: Drainage procedure by cutting the tube from under water seal to convert it to open one and follow the progressive obliteration of cavity buy generic proscar 5 mg on-line. Rib resection and open drainage: Is a drainage procedure by resecting the rib and break all loculation. Thoracotomy and decortication: A procedure of removing fibrous peel, which entraps the lung. B: Tuberculous empyema needs drainage only if super infected, a bronchopleural fistula occurs or the patient is distressed. On examination, patients appear chronically sick, febrile with coexisting effusive finding. Conservative: Includes use of antibiotics, penicillin and metronidazole for up to six weeks in most case, periodic sputum bacteriology, and internal drainage (postural, percussion, coughing). Operative: Surgical treatment is indicated in case of failure of conservative approach, massive hemoptysis, thick or large cavity which is unlikely to collapse and in case of suspected malignancy. However, when complicated with some other systemic illness, the mortality rate reaches 75-90%. A 45-year old male patient involved in a motor vehicle accident presents with severe respiratory distress. On examination, he is found to have tachypnea, hypotension and distended neck veins. A 30-year old lady who was on antibiotic therapy for severe pneumonia started to shoot fever on the third day. She was found to be in respiratory distress and examination revealed evidence of fluid in left hemi thorax. Mane Ravitea, Kenneth Welen, Clifford Penson,, paediatrics surgery, 3 edition, 1979: 390 – 400 nd 6. Principles and practice of surgery, including pathology in tropics, 2 edition, 1994. Bleeding is an alarming symptom and represents the initial presenting complaint in a significant proportion of patients. Although majority the of gastrointestinal bleeding will stop spontaneously or with conservative management, persistent bleeding and/or recurrence carries worse outcomes without immediate intervention. Hematemesis is the vomiting of blood, which may be a coffee ground material, fresh blood or blood clots. Melena without Hematemesis usually indicates a lesion distal to the ligament of Treitz. Hematochezia is the passage of liquid blood or blood clots of varied brightness in color per rectum. Bleeding may be profuse, but in over 90 % of cases, it stops spontaneously without specific therapy and responds to conservative measures such as sedation and volume replacement. Urgent examination aims to pick up signs suggestive of seriously depleted blood volume and probably continuing blood loss which include: - Rising pulse rate and respiratory rate - Decreasing blood pressure and pulse pressure - Restlessness - Increasing pallor - Cold nose and extremities - Sweating (beads of sweat on the forehead) - Decreased urine output Also look for: • palpable glands, e. The causes include: • Neoplasms and polyps • Diverticulosis/ diverticulitis • Vascular malformations • Inflammatory causes e. Assess for the homodynamic status of the patient and clinical diagnosis of the possible underlying cause and site of bleeding. Do complete abdominal examination including digital rectal examination, and pelvic examination in female patients Treatment: Patients who are low risk (e. Resuscitation: Resuscitation is the first priority initiated while the patient is being assessed and its progress should be monitored closely (refer to the management of hypovolemic shock). Diagnostic evaluation: With further clinical assessment and investigations performed after the patient is hemodynamically stable. Introduction Colorectal malignant tumors (Particularly colorectal carcinoma) are among the common causes of death due to malignant diseases. However, early diagnosis is less likely as the symptoms are largely nonspecific early in the course of the diseases and likely to confuse with a number of other diseases. The effects of these diseases are made worse in places where health service availability is minimal, and the available ones commonly lack adequate diagnostic and therapeutic facilities. As a practitioner under these situations you will have to rely on your clinical assessment, aided by high index of suspicion, to reach at the diagnosis of these diseases and refer timely, patients for further workup and treatment to where the appropriate facilities are available. Females are affected more often than males and the sigmoid, along with the rectum, is the most frequent site of cancers (and polyps) in the gastrointestinal tract. Pathology: Macroscopic varieties (forms) include ƒ Polypoid ƒ Malignant ulcer ƒ Annular ƒ Tubular Microscopically, it is a columnar cell carcinoma originating in the colon (adenocarcinoma) 164 Predisposing factors • pre-existing polyps • Familial adenomatous polyposis • Ulcerative colitis Spread • Generally the growth is comparatively slow • Local spread- • Lymphatic spread- to the regional lymph nodes • Blood stream spread- to the liver and then to the lungs, skin, bone. Clinical features: The local effects of the tumor depend on the site and macroscopic variety of the primary tumor. Tumors in the right colon commonly present with: - Anemia - Loss of appetite, weight and generalized body weakness - Palpable lump on abdominal, rectal or bimanual palpation e. Management: The management depends on mode of presentation, stage of the disease, the site of the primary lesion and presence or absence of multiple lesions. Modalities include: ¾ Surgery (curative or palliative) - Emergency laparotomy- for acute significant bleeding and/or acute abdomen with the primary aim of treating the acute complication followed by elective surgery. Introduction Anorectal diseases can occur at any age and in many of them, symptoms are non-specific. Generally the inflammatory ones are common in younger patients and tumors in the middle- aged and the elderly. It is worth remembering that common distal lesions can present with proximal ones and they may be manifestations of proximal diseases for which the patients need full evaluation. The surgically important rectal, anorectal and perianal diseases, which will be dealt with in this unit, are, anorectal abscesses, perianal fistulas, anal fissures and Hemorrhoids. Because, an abscess: ƒ May be the presenting manifestation of an underlying systemic or local diseases (e. Infection of anal gland is the initiating factor in the majority of cases, which spreads along tissue planes. An abscess can also develop following infection of a Perianal hematoma, infection following Perianal injuries, extension from cutaneous boils etc. Classification Based on their anatomical location, anorectal abscesses are classified into four main varieties: Perianal(subcutaneous) abscess:- This is the commonest type and can affect people of all age groups. Ischiorectal abscess:- Is also common and is located in the ischiorectal fossa Sub mucous abscess:- This an abscess located under the mucous membrane 167 Pelvirectal abscess:- This is an abscess located above levator ani and follows spread from pelvic abscess Clinical features: Patient complaints include pain (usually severe), fever, constitutional symptoms such as sweating and anorexia, features of proctitis and constipation Physical findings (rectal examination) include - A lump visible and palpable at the anal margin/anal canal or ischiorectal fossa which is tender brownish induration palpable on the affected side - Rectal tenderness, rectal tender mass Management of anorectal abscess: The abscess needs drainage as soon as it is diagnosed followed by irrigation, packing with saline soaked gauze and Sitz bath twice daily till wound healing. They are needed when there are systemic manifestations and in immunocompromised patients. Causes (risk factors) - It results from: • Usually an untreated or inadequately treated anorectal abscess (see also causes and risk factors for anorectal abscesses) • Granulomatous infections and inflammatory bowel diseases • May give rise to multiple external openings and include e. Tuberculous proctitis Crohn’s disease Classification: It can be grouped into two according to the level of the internal opening: - Low level: with an internal opening below the anorectal ring - High level: with an internal opening at or above the anorectal ring. Clinical features - Seropurulent discharge with perianal irritation - An external opening (frequently single) seen as a small elevated opening on the skin around the anus with a granulation - An internal opening may be felt as a nodule on digital rectal examination (almost always single) irrespective of the number of external openings) - Sings of underlying/associated diseases Management - Emergency treatment for abscesses - Treatment of underlying cause - Surgery for fistula in ano - Preceded by • Preoperative bowel cleansing (enema) • Examination under anesthesia Low level fistula • Laying open the entire fistulous tract, fistulotomy. It is located commonly in the posterior midline, occasionally along the anterior midline and rarely at multiple sites. Classification: Anal fissure can be classified as acute or chronic based on its pathologic features. Clinical features: A patient with anal fissure presents with: - Pain is the commonest feature - Characteristic sharp, severe pain starting during defecation and lasting an hour or more and ceases suddenly to reappear during the next bowel motion. It includes: - A high fiber diet and high fluid intake with a mild laxative, such as liquid paraffin, to encourage passing of soft, bulky stools - Administration of a local anesthetic ointment or suppository Surgical Measures: Surgical measures are needed when the above measures fail, in chronic fissures with fibrosis, a skin tag or a mucous polyp or recurrent anal fissures. Procedures include: • Lateral anal sphincterotomy • fissurectomy and • sphincterotomy This procedure can be used for cases with a chronic fissure. It needs an experienced operator to reduce complications, which include hematoma formation, incontinence and mucosal prolapse. After care: This consists of bowel care, daily bath and softening the stool till wound healing. They develop within areas of enlarged anal lining (anal cushions’) as they slide downwards during straining. Since the internal and external (subcutaneous perianal) venous plexus communicate (Porto-systemic anastomosis) engorgement of the internal plexus is likely to lead to involvement of the latter. With the patient in the lithotomy position, internal hemorrhoids are frequently arranged in three groups at 3, 7 and 11 o’clock positions.

Frequent skin-to-skin contact during breastfeeding leads to better psychomotor order proscar amex, affective and social development of the infant and promotes bonding between mother and child cheap proscar 5 mg visa. It is also the equivalent of the first immunisation for the baby as it has many immunologic factors and a high concentration of vitamin A buy proscar 5mg cheap. Breastfeeding is more than 98% effective as a contraceptive method during the first 6 months provided breastfeeding is exclusive and amenorrhoea persists (menstruation has not started) discount proscar 5 mg otc. Putting the baby to the breast immediately after birth facilitates expulsion of the placenta as the baby’s suckling stimulates uterine contractions. Breastfeeding reduces the mother’s workload (no time is involved in boiling water, gathering fuel or preparing formula milk). Breastmilk is available at any time and anywhere, is always clean, nutritious and at the right temperature. There are no expenses in buying formula, firewood or other fuel to boil water, milk, or utensils. There should be no medical expenses due to the sickness that formula milk might cause. As illness episodes are reduced in number, the family encounters fewer emotional difficulties associated with the baby’s illness. Breastfeeding the baby reduces the mother’s work load because the milk is always available and ready. Breastmilk does not require importing formula and utensils, which saves hard currency (money). Breastfeeding leads to a decrease in the number of childhood illnesses, which leads to decreased national expenditure on treatment. An indirect benefit of breastfeeding if it is practised widely is that the environment is protected. It protects the baby from diseases and it also acts as a cleaning substance (laxative) for the baby’s stomach. It is the equivalent of first immunization of the baby, because of its immunologic factors and high concentration of vitamin A. It is very important that you know the common difficulties, how these can be prevented, and ways that you can help mothers to manage and overcome any problems. To ensure sufficient milk production you can advise the mother to do the following:. Withdraw any supplement, water, formulas, tea or liquids she has been giving the baby. Cues of hunger include rooting, licking movements, flexing arms, clenching fists, tensing body and kicking legs Malnourished mothers Mothers need to eat extra food (‘feed the mothers, nurse the baby’) Mothers need to take micronutrients 43 Mother who is separated daily from her infant The mother should express or pump milk and store it for use while separated from the baby; the baby should be fed this milk at times when he/she would normally feed The mother should frequently feed her baby when she is at home The mother who is able to keep her infant with her at the work site should feed her infant frequently Twins The mother can exclusively breastfeed both babies The more each baby nurses, the more milk is produced Inverted nipples Detect during pregnancy Try to pull nipple out and rotate (like turning the knob on a radio) Make a hole in the nipple area of a bra. When a pregnant woman wears this bra, the nipple protrudes through the opening If acceptable, ask someone to suckle the nipple Baby who refuses the breast Position the baby properly Treat engorgement (if present) Avoid giving the baby teats, bottles, pacifiers Wait for the baby to be wide awake and hungry (but not crying) before offering the breast Gently tease the baby’s bottom lip with the nipple until he/she opens his/her mouth wide Do not limit duration of feeds Do not insist on more than a few minutes if baby refuses to suckle Avoid pressure to potential sensitive spots (pain due to forceps, vacuum extractor, clavicle fracture) Express breastmilk, and give to the baby by cup 44 Study Session 4 Infant and Young Child Feeding Mother who will be away from her infant for an extended The mother expresses breastmilk by following these period expresses her breastmilk; caregiver feeds expressed steps: breastmilk from a cup. Milk can be stored 8–10 hours at room temperature in a cool place and 72 hours in the refrigerator The mother or caregiver gives the infant expressed breastmilk from a cup. You would explain to her that breastmilk contains water, sugar and salts in adequate quantities, which will help her baby recover quickly from diarrhoea. Infants older than six months should eat a variety of nutrient-rich foods, including animal products (e. It is usually not possible for an infant to consume sufficient quantities of plant foods to meet their needs for iron, zinc and calcium. Therefore, the addition of animal source foods enables the different nutrients to be absorbed more easily and is essential in the preparation of complementary foods. When you are advising mothers and caregivers about optimal complementary feeding, there are a number of key messages you can give. When the infant is six months old the mother must give the infant caregiver must introduce soft, complementary foods in addition to breastmilk to help the infant grow appropriate foods and continue strong and healthy. The mother should continue to give breastmilk as the main food throughout the infant’s first year. The mother or caregiver should begin complementary feeding by adding available, feasible, local foods (vegetables, fruits, eggs, milk) to staple foods (cereals and legumes) and increase the amount of food as the child grows. Breastmilk constitutes the largest portion of young child’s food during the first two years. The mother or caregiver should increase the frequency of feedings and the amount of food as the child gets older. The mother or caregiver should use a separate bowl for the child and As the child gets older, the continue frequent breastfeeding mother needs to provide more food and increase the frequency. The mother or caregiver should give young children small feeds frequently of meals. One way to know children are getting enough food is to put their portions in separate bowls and to help them eat. Age Meal frequency per day for Meal frequency per day for (months) breastfed baby non-breastfed baby 6- -3 times + 1-2snacks 4-5 times + 1-2 snacks 10-23 3-4 times + 1-2snacks Increase food thickness and variety At six months, the mother or caregiver can give the infant puréed (softened), Increase food thickness (density) mashed and semi-solid foods. She should also add protein-rich foods (animal/ and variety as the child gets older, to meet changing plant); beans, soya, chick peas, groundnuts, eggs, liver, meat, chicken and nutritional requirements, and the milk. Adding germinated (malt) flour to the gruel liquefies cereal gruels and child’s physical abilities. At eight months the mother or caregiver can give foods that infant can eat alone, such as cut- up fruit and vegetables (for example, mangoes, papaya, leafy greens, oranges, bananas, pumpkin, carrots and tomatoes). During complementary feeding, the aim is for the mother or caregiver to gradually accustom the child to family foods. Interact with the child during feeding The mother or caregiver should interact with the child during feeding. This helps the child take in the food they need and stimulates the child’s verbal and intellectual development. The 47 mother or caregiver should also feed the infant directly and help older children eat and experiment with food combinations, tastes and textures. Most mothers will be able to find ways to encourage children who refuse certain foods. In order to help the baby finish its food, the mother or caregiver should minimise distractions during meals, especially if the child loses interest easily. The mother or caregiver has to remember that feeding times are periods of learning and love; talking to a child during feeding, with eye-to-eye contact and patience, encouraging but not forcing the infant to eat, is important. Practice good hygiene and safe food preparation In resource-poor settings, the mother or caregiver can feed liquids to the child from a small cup or bowl, as bottles are difficult to keep clean, and contaminated bottles can cause diarrhoea. Before feeding the child, the mother or caregiver should wash their hands and the child’s hands with soap and water and use clean utensils and bowls or dishes to avoid introducing dirt and germs that might cause diarrhoea and other infections. Food can be contaminated as a result of poor basic hygiene, poor sanitation, and poor methods of food preparation and storage, so food should be served immediately after preparation. Increase the amount of food provided each day As children grow older, they need to eat more food each day. Age Amount of kilocalories for the Amount of kilocalories for the (months) breastfed baby non-breastfed baby 6-8 200 Kcal 600 Kcal 9-11 300 Kcal 700 Kcal 12-23 550 Kcal 900 Kcal Increases complementary food if the child becomes sick The mother should continue to breastfeed when the child is ill and should encourage the child who is older than six months to eat during and after illness (sick child feeding). The mother should offer the child who is older than six months soft, mashed favourite foods. Children who are ill will often continue to breastfeed even if they refuse other foods. The mother diversifies the complementary food The mother should mix foods from plant sources such as fruits, vegetables, cereals and legumes with foods of animal origin in order to diversify the complementary food. During illness and for two weeks after illness, the mother or caregiver should increase the quantity of food and feed the child more often so that the child recovers quickly. Children are often very hungry during recovery from illness and need more food to support catch-up growth and to replace nutrient stores. She should also add protein-rich foods (animal/plant): beans, soya, chick peas, groundnuts, eggs, liver, meat, chicken, milk. Adding germinated (malt) flour to the gruel liquefies cereal gruels, and helps to increase the energy and other nutrient density. You should also advise her to continue breastfeeding until her daughter is at least two years old. The first 24 months of life provide a critical opportunity to ensure a child has a healthy start through optimal feeding. You have learned that malnutrition can be prevented through exclusive breastfeeding for the first six months of a baby’s life, followed by the introduction of complementary food.

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A rate of 2-liters/ minute is commonly used when oxygen used in case of emergency instead of free air buy 5mg proscar. Protect patient from asphyxia order proscar with visa, inspecting regularly pressure gauge and flow meter and noting pulse order cheap proscar line, respiration order proscar 5mg otc, color, mental state and necrosis from carbon dioxide. Steam Inhalation Definition: It is the intake of steam alone or with medication through the nose or mouth Purpose 1. In order to produce a local effect on the upper respiratory passage during cold, sinusitis, laryngitis, bronchitis etc. Either point in the graduate measure 90 cc of cold water and 500 cc of 0 boiled water to bring the temperate 82 c or half by half or pour half point (300cc) of boiling water into the inhaler than 5 cc of tincture of benzene or any other drug ordered. The patient should be covered up to the waist with a balance from a canopy, or the mouth of the jug may be covered with a towel to make the opening small enough for the patient to put his nose and mouth (not eyes) on it. Care of Equipment after use • Pour out the water from the inhaler (not onto a sink) • Wash the inhaler with hot water • Boil the mouth piece Emergency tray and Trolley List of Emergency Drugs. List of Emergency Equipment • O 2 -Tourniquet 2 • Morphine sulfate - O mask or nasal catheter • Aramine - plaster • Adrenalin( Epinephrin. Key Terminology abrasion laceration wound debridement pressure ulcer decubetus ulcer puncture exudates surgical incision The skin acts as a barrier to protect the body from the potentially harmful external environment. When the skin’s integrity (intactness) is broken, the body’s internal environment is open to microorganisms that cause infection. It may be accidental or intentional such as abrasion (rubbing off the skin’s surface); a puncture wound (stab wound); or laceration (a wound with torn, ragged edges). A wound that occurs accidentally is contaminated; intentional wounds are made under sterile conditions. First intention healing occurs in wounds with minimal tissue loss, such as surgical incisions or sutured wounds. Second intention healing occurs with tissue loss, such as in deep laceration, burns, and pressure ulcers. Third intention healing occurs when there is a delay in the time between the injury and closure of the wound. For example, a wound may be left open temporarily to allow for drainage or removal of infectious materials. Dressing of a Clean Wound 305 Purpose • To keep wound clean • To prevent the wound from injury and contamination • To keep in position drugs applied locally • To keep edges of the wound together by immobilization • To apply pressure Equipment • Pick up forceps in a container • Sterile bowl or kidney dish • Sterile cotton balls • Sterile galipot • Sterile gauze • Three sterile forceps • Rubber sheet with its cover • Antiseptic solution as ordered • Adhesive tape or bandages • Scissors • Ointment or other types of drugs as needed • Receiver • Spatula if needed • Benzene or ether. Technique Aseptic technique to prevent infection 306 Procedure ™ Explain procedure to the patient • Clean trolley or tray; assemble sterile equipment on one side and clean items on the other side. Method of Application • Ointment and paste must be smeared with spatula on gauze and then applied on the wound. The above-mentioned equipment can be prepared in a separate pack if central sterilization department is available. Dressing of Septic Wound The purpose is to • Absorb materials being discharge from the wound • Apply pressure to the area • Apply local medication • Prevent pain, swelling and injury Equipment • Sterile galipot • Sterile kidney dish • Sterile gauze • Sterile forceps 3 • Sterile test tube or slide • Sterile cotton- tipped application • Sterile pair of gloves, if needed, in case of gas gangrene rabies etc. Dressing with Drainage Tube Purpose • Aids to prevent haematoma or collection of fluid in the affected area. Procedure Explain procedure to the patient • Cleanse tray or trolley and organize the needed equipment and make sure it is covered. Pull it up a short distance while using gentle rotation and cut off the tip of the drain with sterile scissors (the length to be cut depends on the instruction or order). Equipment • Sterile galipot or kidney dish • Sterile cotton balls • Sterile gauze • 3 Sterile forceps • Sterile catheter • Sterile syringe 20 cc • 2 receiver • Rubber sheet and its cover • Rubber sheet and its cover • Solutions (H2O2 or normal saline are commonly used) • Adhesive tape or bandage • Bandage scissors 313 • Receiver for soiled dressings Procedure Explain the procedure to the patient and organize the needed items. Purpose • To approximate wound edges until healing occurs • To speed up healing of wound • To minimize the chance of infection • For esthetic purpose Equipment • Tray or trolley covered with a sterile towel • Sterile needle holder • Sterile round needle (2) • Sterile cutting needle (2) • Sterile silk • Sterile cat- gut • Sterile tissue forceps • Sterile suture scissors • Sterile cotton swabs in a galipots • Sterile solution for cleaning • Sterile dressing forceps • Sterile receiver • Sterile gauze 315 • Sterile plaster • Dressing scissors • Local anesthesia • Sterile needle & syringes • Sterile gloves • Sterile hole- towel (Fenestrated towel) Procedure • Explain procedure to patient • Adjust light • Wash your hands • Clean the wound thoroughly • Wash your hands again • Put on sterile gloves • Drape the Wound with the hold- sheet • Infiltrate the edges of the wound to be sutured with local anesthesia. How ever, such wounds have to be seen by a doctor since excision of all dead & devitalized tissue and eventual suturing may be required. Removal of the Stitch Technique: Use aseptic technique 317 Principles • Sutures may be removed all at a time or may be removed alternatively. Procedure The first part of procedure is the same as for suturing with stitch Except that instead of suturing the skin with thread and needle you would apply clips with the applier. Removal of Clips Technique Use aseptic technique Equipment • Sterile gauze • Sterile cotton balls • Sterile kidney dish • Sterile forceps 3 319 • Sterile clip removal forceps • Antiseptic solution (Savalon 1% and iodine) • Receiver • Benzene or ether • Adhesive tape or bandage Procedure Explain procedure to the patient and organize the needed equipment • Drape and position patient • Protect bedding with rubber sheet and its cover • Remove old dressing and discard. Key terminology anaesthesia hypothermia postoperatve atlectasis hypoxia preoperative elective intraoperative suture embolus perioperative evisceration pneumonia 322 Preoperative Care – Nursing Process Assessment Assessment Priorities - Nursing history - Client’s understanding of the proposed surgical procedure - Past experiences with surgery - Fear (fear of unknown, fear of pain or death, fear of change of body image or self concept) - Factors that increase surgical risk or the potential for post operative complications. Evaluation Determine the adequacy of the plan of care by evaluating the client’s achievement of the preceding goals. Equipment As necessary • It is important that the patient be in a good state of physical health before he has surgery. Try to relieve his fears about the operation and any fear of death: explain to him what will be done and that every measure will be taken for his safety. Procedure The day before surgery: Physical preparation • Give the patient a complete bed bath to keep the body clean before surgery. If the surgery is on the face, neck, shoulders or upper chest, the hair should be the thoroughly washed, combed and tied up to keep it from touching the operative area. Any thing abnormal such as pain, fever cough rapid pulse or elevated blood pressure must be reported immediately. Equipment ƒ Basin of warm water ƒ Washcloth ƒ Towel ƒ Soap ƒ Blade and razor holder, if available ƒ Scissors ƒ Rubber sheet and towel Procedure • Prepare the equipment and bring it to the bedside. Specific Area to be shaved: Head Operations • Explain the reason for having the head to the patient • If the hair is long, it must be cut short • Wash the head and hair well • Shave the area of the operation as directed. Anterior Neck Operations: • Wash the patient’s head and neck • If the patient is a woman, tie her hair, and keep it away from her neck, or cut it short. Breast Operations • Shave the anterior and posterior chest from neck to the waist line on the side where the surgery will be 331 • Shave the axilla on that side and the arm as far down as the elbow. Doing so will not only give the student a better idea of surgical procedures, but it will also help in understanding the client’s feelings and apprehensions. Duties include handling instruments to the surgeon, threading needles, cutting sutures, assisting with retraction and suction, and handling specimen. Duties include opening sterile packs, delivering supplies and instruments to the sterile team, delivering medications to sterile nurse, labeling specimens, and keeping records during the surgical procedure. This person acts as a client advocate by monitoring the situation and maintaining safety in the operating room. Post- operative Care Purpose • To prevent any complication from anesthesia • To detect any sign of post- operative complications 333 • To rehabilitate the patient. Equipment • Anesthetic bed • Oxygen • Sphygmomanometer • Stetoscope • Suction machine (as needed) • Extra rubber sheet (as needed) • I. V stand • Emergency drugs (to be ready in wards) • Bed blocks (as needed) for shock Procedure • Prepare anesthetic bed (see section on bed making) • Assist operating room nurse in placing patient in bed. Charting • Time of return • General condition and appearance ⇐ State of consciousness ⇐ Color of skin ⇐ Temperature of skin to touch ⇐ Skin- moist or dry ⇐ Blood pressure, plus and respiration ⇐ Any unusual condition such as bleeding drainage, Vomiting etc. Generals Instructions • If patient shows any signs of shock immediate action should be taken and then be reported to the doctor. The head of the bed should be lowered (If no gatches on bed, bed blocks may be used) • Do not leave unconscious patient alone. Breast Surgery • Encourage deep breathing often, because of danger of pneumonia • Special arm exercises should be given Abdominal Surgery • Encourage deep breathing • Turn from side to side often st • Sit patient on edge of bed 1 day postoperatively and • Start walking second day post operatively (unless contra- indicated) • Intake and output should be recorded 336 • If gastric suction is present make sure it is working properly • Frequent mouth care for patients who are not allowed to drink. Eye Surgery • Must lie very still because the incision and sutures can be damaged by pulling on the eye muscles. This will make it easier to breathe since the pressure of dressing and swelling may give choking feeling. Key terminology Autopsy Cheyne-Stkes respiration postmortum examination Brain death Kussmal’s breathing A. Spirituality and Death Death often forces people to consider profaned questions: the meaning of life, the existence of the soul, and the possibility of an after life. Individuals faced with death, their close friends, and family often relies on a spiritual foundation to help them meet these challenging concepts. For those whose spirituality does not include beliefs rooted in organized religion, support may take the form of compassionate care and the acceptance of personal beliefs.