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Ministry of public health of ukraine Bukovinian state medical university

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Ministry of public health of ukraine

Bukovinian state medical university


on the cathedral meeting of the

Department of patient care and higher nurse education


minute № ____

Head of department

Associate professor Plesh I.A.

Methodical guidelines

for 3rd – year students of the medical faculty

Module 2

The main duties and professional skills of nurse

at the surgical department

Semantic module 1

Haemostasis. Blood transfusion.

Resuscitation in surgical patients.


Reanimation in surgical patients

Subject: Nursing practice

3rd-year students of Medical faculty

Speciality: "General medicine" – 7.110101

7.110104 – "Pediatrics"

Duration - 2 hours

Methodical guidelines composed by:

Professor R.I. Sydorchuk

Assoc. professor O.Y. Khomko

Assistant R.P. Knut

Chernivtsi – 2008

AIM: To carry out reanimation actions in surgical patients.

^ PROFESSIONAL MOTIVATION: Achievements of modern anesthesiology especially in general anesthesia with use of miorelaxation let surgeons to perform very complicated and traumatic operations.

Sometimes during or after the anesthesia unexpected dysfunctions, damage of organs and tissues can occur. These dysfunctions can serve as a reason of hard complications development or can lead to patient's death. Complications can occur in any kind of anesthesia as a dysfunction of vital organs and systems what can lead to the death of the patient. Knowing of these complications, ability to diagnose, prevent them and provide the first aid to the patient in time can save the patient's life.

Decrease of the pain sensitivity and or its full cutoff during performing of operative interventions and treatment without decrease of the consciousness lets surgeon to perform the operation qualitatively and to avoid the harmful influence of general anesthetics.

All doctors in their practical work face a necessity to provide a patient the first aid due to one or another terminal state. This is especially characteristic for doctors working in surgical specialties.


Technique for local anaesthesia

The equipment necessary for local anaesthesia need not be elaborate, but it must be kept in good condition at all times. Lock type glass syringes of 5ml and 10ml capacity, with metal tips, are the most satisfactory. Metal rings for the fingers, permitting a firmer grip and better control of the syringe, are preferred (Fig.1 a,b ). Needles must be selected carefully.

Beveled point of needle is used for the initial skin wheal or endodermic infiltration. Longer needles should be available for deep infiltration and nerve blocks.

Syringes and needles must be cleansed thoroughly after use and sterilized for subsequent use.

Fig 1. (a) The initial skin-wheal (like skin of lemon) is made by the short 25-gauge needle. The needle is inserted with the level parallel to the skin surface and the anaesthetic solution is injected as the needle is carried through the skin tissues. In this way there is little discomfort associated with the injection, (b) Infiltration of the deeper tissues is carried out with the long needle, which is always inserted through skin areas that have previously been anaesthetised. Injection of the anaesthetic solution is made as the needle advances

Local anaesthesia is produced most commonly by the direct infiltration of the tissues with the anaesthetic solution. Thus, suitable anaesthesia may be obtained for superficial tumors, cysts, thrombosed external haemorrhoids and a number of other superficial lesions.

Acute fractures may be reduced easily after the direct infiltration of the haematoma about the fracture site with the anaesthetic solution. Superficial infections, contrary to general opinion, may be opened under local anaesthesia by infiltration of the skin along the line of the proposed incision without fear of spreading the infection.

Procaine hydrochloride 0.5% is used for local infiltration for removing superficial lesions, suturing small wounds, skin grafting and incising superficial abscesses. An initial skin wheal is first made, using the small 25-gauge hypodermic needle. The point of the needle is inserted with the bevel down directly into the skin. In places where the skin is loose, it should be held under tension during this.

Injection. The anaesthetic solution is injected as the needle is inserted into the skin. Thus a cutaneous wheal, which shouldbe about 1 cm in diameter, is produced with little or no pain to the patient. Then a longer needle is attached to the syringe, inserted through the anaesthetized skin at the site of the wheal, and a subcutaneous linear or elliptical line of infiltration is produced; or the intradermal infiltration may be continued from the original wheal. When the infiltration is to be continued subcutaneously, it may be necessary to make more than one cutaneous wheal; or, better still, the longer needle may be inserted into the cutaneous layer from beneath, at the end of the subcutaneous infiltration, a wheal produced, and the subcutaneous infiltration continued further by reinserting the needle through this wheal.

Infiltration of the skin along the line of proposed incision of a superficial abscess will not spread the infection if adequate drainage is obtained, and the abscess may be opened with no discomfort to the patient if pain produced by pressure is prevented. Incision and drainage of superficial abscesses may be easily performed. After the skin has been anaesthetized it is grasped with a towel clip or between 2 towel clips and lifted up while the incision is made . Thus deep pressure over the inflamed area is avoided, and painless incision can be performed, since the skin has been anaesthetized. No epinephrine is used in the anaesthetic solution.

Anaesthesia for the reduction of acute fractures of any of the bones of the extremities may be obtained readily by the direct infiltration of a local anaesthetic solution at the fracture site . The longer 2-in. or 3-in. needle is introduced through one or more skin wheals toward the fracture line, avoiding the larger vessels and nerves.

After contacting the bone, the needle may be partially withdrawn and reinserted until aspiration of bloody fluid indicates that the haematoma about the fracture has been reached. Occasionally, one may be able to feel the needle slip between the bone fragments at the line of fracture. The fact that bloody fluid may be aspirated at several levels indicates that the haematoma has been pierced, rather than that an accidental venipuncture has been performed. The blood aspirated from a haematoma of several hours duration may aiso be identified by its dark appearance.

Fig.2. Local anaesthesia in the reduction of fractures. The long needle is inserted through an initial skin wheal until bloody fluid can be aspirated or the tip of the needle itself slips between the bony fragments. The anaesthetic solution is then injected into the hematoma at the fracture site

Procaine hydrochloride in I or 2% solution, preferably with epinephrine, is used for the infiltration about a fracture. Not more than 30 ml of the 2% solution or more than 60 mi of the 1% solution should be used routinely, and the injection always should be performed slowly and cautiously in order to avoid systemic reactions. Full anaesthesia is not obtained until at least 15 minutes after the injection.

The best results with infiltration anaesthesia for the reduction of fractures are obtained with early, acute fractures. After from 48 to 72 hours, the haematoma about the fracture site becomes organised, making it more difficult to obtain satisfactory infiltration. However, this anaesthesia may be used with almost any fracture of less than 48 hours duration and is the most efficient anaesthesia in such cases. Reduction may be performed safely under roentgenoscopic guidance and the full cooperation of the patient maintained throughout the procedure; this greatly facilitates the reduction and the subsequent application of splints or plaster casts for immobilization. It is a distinct advantage in the reduction of fractures in a dark fluoroscopic room and at times when an anaesthetist is not available. It is the anaesthesia of choice for the reduction of fractures in ambulatory patients.

Field block Diffuse infiltration of an anaesthetic solution through all tissues containing sensory nerves leading from the field of proposed operative intervention effectively blocks sensory impulses in these nerves and their branches. Anaesthesia of the operative field is thus produced without direct infiltration at the operative site. This is known as field-block anaesthesia and is an intermediate procedure between purely local infiltration and nerve block. A wider zone of anaesthesia, which usually lasts longer, may be obtained with smaller quantities of anaesthetic solution than would be required for local infiltration of the entire operative field. In addition, it requires less technical skill than nerve block and therefore may be used to advantage when the operative site is supplied by a number of small sensory nerves.

A field-block type of anaesthesia may be preferred to direct local infiltration for the removal of sebaceous cysts, lipomas, benign tumors and other superficial lesions of the body surface, as the tissue at the site of operation are not distorted by infiltration with the anaesthetic solution. The anaesthetic solution is injected into the skin and subcutaneous tissues through an initial skin-wheal to form an elliptical or diamond-shaped zone of infiltration round the operative field. Procaine hydrochloride 0.75 or 1% should be used for this type of anaesthesia .

The Scalp. Anaesthesia of the scalp may be obtained by a zone of infiltration encircling the lesion, since all the sensory nerves pass upward in the subcutaneous tissues. Thus any portion of the scalp may be anaesthetized conveniently by a field block with 0.5 - 1% procaine hydrochloride .

The Neck. The majority of operations about the neck on ambulatory patients may be accomplished by the use of local infiltration anaesthesia. Deep cervical block, which may be used for more extensive operations, is not indicated, although superficial cervical block, a form of field-block anaesthesia, may be useful occasionally in conjunction with local infiltration. The superficial branches of the cervical plexus may beblocked as they cross over the posterior border of the sternocleidomastoid muscle. 20-30 ml of 0.5% procaine are injected on the posterior border of this muscle where the superficial jugular vein crosses it.

Phrenic nerve block is one of the most useful and practical therapeutic blocks for the treatment of intractable hiccups and may be of value in the ambulatory patient. The phrenic nerve arises from the anterior primary division of the 4th cervical nerve and receives fibers from the 3rd and the 5th cervical nerves. The 3 components join together and descend as the main nerve trunk, crossing over the anterior scalenus muscle. The nerve may be blocked as it crosses the anterior surface of the muscle. With the patient in the supine position and head turned to the opposite side, the posterior border of the sternocleidomastoid muscle is palpated with the index finger. A skin-wheal is raised 3 cm above the clavicle on the posterior border of the sternocleidomastoid muscle. The anterior scalenus muscle is situated lateral and posterior to the sternocleidomastoid. A 22-gauge short beveled needle is inserted through the wheal and advanced posteromedially until the fascia of the anterior scalenus muscle is pierced. This is usually al a depth of 1 in. From 10 - 15 ml of \% solution of procaine with or without epinephrine is injected slowly. Anaesthesia is established in 10 - 15 minutes.

The Thoracic Wall. Any desired area of the thorax may be blocked by simple infiltration of all its layers with a 0.5% solution of procaine. Wider areas of anaesthesia may be produced by intercostal nerve block. Wheals are raised in the midaxillary line along the inferior border of the desired ribs.

A 5 cm needle is introduced through the wheals until the rib is contacted. It is then withdrawn slightly and reintroduced, passing beneath the lower border of the rib in a cephalic direction. It is advanced 0.5 cm beyond the rib border. After aspiration, 4 ml of 2% procaine is injected at this site (Fig.3). To complete the block it may be necessary to infiltrate the skin and subcutaneous tissues with 0.5% procaine.

Fig. 3. Intercostal nerve block. The clotted figure shows the position of the needle as it is introduced through a cutaneous wheal until the rib is contacted. The needle then is withdrawn slightly and reintroduced so that it passes just beneath the lower border of the rib. At this point r/te anaesthetic solution is injected

The Abdominal Wall. Rarely will it be necessary to provide extensive abdominal wall anaesthesia for the ambulatory patient. Infiltration of the layers of the abdominal wall with procaine will produce satisfactory anaesthesia. Abdominal field block for operations of greater magnitude may be produced by the injection of the thoracic nerves as they traverse the abdominal wall. With the patient lying in the supine position, skin-wheals are raised over the xiphoid process, at the point along the 10th costal cartilage where the lateral border of the rectus abdominis muscle crosses it (on the side of the abdomen to be anaesthetized) and along the lateral border of the rectus abdominis muscle a few centimeters above and below the umbilicus. An 8 cm needle is passed through these wheals to join them together in straight lines by subcutaneous injections of 0.5% procaine. The needle is again passed through each wheal towards the fascia of the rectus muscle. Procaine is injected as the needle pierces the superficial fascia and then passes through the fascia of the rectus muscle. Injection of several milliliters is made into the muscle. The position of the needle is then changed in fanlike manner and repeated injections are made into the muscle.

The Penis. Block anaesthesia for circumcision or other operations on the penis may be obtained by a subcutaneous injection encircling the base of the penis, supplemented by the injection of 1 - 2 cc. of 1% procaine beneath the fascia (Buck's) on each side. Procaine solution of I or 2% should be used .

For circumcision, a simple form of infiltration anaesthesia is practiced more commonly. With 1% procaine solution, the foreskin is reflected. and a circle of infiltration anaesthesia is deposited under the skin, close to the edge of the glans. Special care must be taken to infiltrate the frenulum, in which there is a rich plexus of sensory nerves. After this infiltration has been completed, the foreskin is replaced over the glans, and a second circle of infiltration is made in the skin at the same level at the base of the glans. This dual infiltration is not time consuming and gives excellent anaesthesia. In cases in which the foreskin cannot be retracted easily, the superficial skin anaesthesia is induced first, and then the anaesthetic is carried deeper into the foreskin near the edge of the glans. A line of infiltration is injected downward to the edge of the foreskin. With this anaesthesia it is possible to incise the edge of the foreskin sufficiently to permit retraction and the completion of the anaesthesia.

The Amis and the Rectum. The sensory nerves which go to the anal canal and the anal orifice may be blocked easily, as they traverse the fatty tissues of the ischiorectal fossa. These nerves arise from the perineal nerve as it passes in Alcock's canal along the ramus of the pubis. They traverse the ischiorectal fossa from behind, forward and medially, to reach the anal canal. In addition, there are a few small so called coccygeal nerves which pass directly forward from the region of the coccyx to the anal canal. Therefore, it is possible to block completely all the nerves which reach the anal canal by introducing a wall of anaesthetic solution outside it in the ischiorectal fossa.This is accomplished best with 2 injections. The first is an infiltration anaesthesia into the skin of the perianal region, usually performed with \% procaine solution containing epinephrine. It may be injected without fear of subsequent infection if the area has been cleaned with soap and water and followed by the application of one of the commonly used antiseptic solutions. The local infiltration is begun at the midline posteriorly and is carried laterally on each side to anesthetize completely the skin surrounding the anal orifice. After skin infiltration, a deeper injection must be made to block the nerves as they traverse the ischiorectal fossa. Since these nerves pass from behind, forward and mesially, it is most important that the anaesthetic solution be introduced round the posterior half of the circumference of the anal canal. With the index finger of the left hand introduced through the anal orifice, the injection is begun just to the lateral side of the midline. The patient should be warned of some slight feeling of discomfort as the needle is introduced deeply into the ischiorectal fossa. Failure to give this warning may cause the patient undue apprehension, and, if he moves, considerable difficulty may ensue, even to puncturing the anal canal or the rectum with the needle. The needle is carried in a fanlike direction round the anal canal, forward and backward. The injection is made at a distance of about 0.5 in. to 1 in. away from the canal, the nerves being blocked as they .approach the canal itself. It should be earned throughout the entire length of the anal canal, about 20 ml of 1% procaine being used on each side. Occasionally, it is necessary to make an anterior injection.

In making these injections into the ischiorectal fossa for block of the nerves to the anal canal, it is important that only a small amount of the solution be deposited in one place. The needle must be kept moving practically all the time and the injection made continuously. If too much solution is deposited at any one place, a painful slough may result.

Local infiltration produces almost immediate anaesthesia and causes relatively slight distortion. The addition of epinephrine, 3 drops of the 1:1,000 solution to the ounce of anaesthetic solution (30 ml), not only prolongs the anaesthetic effect but also markedly reduces the amount of bleeding. This type of anaesthesia is especially valuable for anal-fissure operations, haemorrhoidectomy, the removal of anal polyps and anal crypts. It may be contraindicated in infected areas, such as abscesses and complicated fistulas. The incidence of postoperative urinary retention following anal operations is less after local infiltration and block anaesthesia than after any of the other anaesthetics used for anal operations.

^ Conduction Anaesthesia (Nerve Block)

Sensory anaesthesia may be produced by the injection of an anaesthetic solution into or immediately round the nerve or a plexus of nerves. Long lasting anaesthesia of a rather large area with a minimum amount of drug is the chief advantage of nerve block anaesthesia. Its only disadvantage is that a fair degree of technical skill and experience is required to master the various nerve block procedures. With increasing experience, however, one will find a few of the various types of nerve blocks very useful and suitable for operations on ambulatory patients.

Digital Nerve Block. The dorsal and the volar digital nerves may be blocked within the soft tissues at the base of the fingers or the toes for operations on the digits. Intradermal wheals are raised on each side, at the base of the digits, and the needle is introduced into the deeper tissues through these wheals.

The anaesthetic solution is deposited close to the bone, near the anterior and the posterior digital nerves. From 3 to 5 ml of 1 % procaine will produce adequate anaesthesia. It must be remembered that with a digital block or any other type of conduction anaesthesia, one must wait a short time for the full anaesthetic effect. Usually, from 5 to 10 minutes must elapse from the time of injection for complete anaesthesia of the digit. A tourniquet may be applied at the base of the digit (rubber band) to control bleeding. Epinephrine is usually omitted.

Wrist Block. Anaesthesia for operations on the hand may be obtained by a block of the sensory nerves at the wrist. Perineural infiltration of the nerves, particularly of the radial nerve, is usually performed, since it is almost impossible to block each sensory fiber innervating the hand. The superficial sensory branches which join the main nerve trunks higher in the forearm are blocked by a subcutaneous bracelet injection about the wrist.

The median nerve is superficial in the wrist and may be located easily. It lies just to the radial side of the flexor digitorum sublimes muscle and directly beneath and between the tendons of the palmaris

\ongus and the flexor carpi radialis. These superficial tendons, which can be seen or palpated easily, serve as the landmarks for the injection of the median nerve. A 2 in. needle, inserted through an intradermal wheal, should be directed between these tendons on a line with the tip of the ulnar styloid. Then the needle is inserted downward at right angles to the skin and slightly toward the radial side of the wrist for a distance of 0.5 cm. If paresthesias are obtained in the thumb or the index finger, the needle should be immobilized and 5 ml of 1% procaine injected. Best results are obtained if paresthesias are elicited before injection. If paresthesias are not obtained, 5-10 ml of procaine should be infiltrated after the needle has reached a depth of 0.5 cm.

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Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine Bukovinian state medical university

Ministry of public health of ukraine Bukovinian state medical university iconMinistry of public health of ukraine Bukovinian state medical university

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