Basic General Clin-CSP Proof-05!26!13

See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/240054991
Basic & General Clinical Skills
Book · May 2013
CITATIONS READS
0 11,848
1 author:
Vladimir J Simunovic
University of Split
79 PUBLICATIONS 239 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
Preparation for new book, "Special Clinical Skills" View project
Cooperative Development of Health Information Technology in Split (CODE-HITS) View project
All content following this page was uploaded by Vladimir J Simunovic on 29 May 2014.
The user has requested enhancement of the downloaded file.

Basic & General Clinical Skills
Table of Content
INTRODUCTORY REMARKS 5
I BASIC LIFE SUPPORT, BLS 11
1 Goal 12
2 Expected outcome 12
Digital Proofer 3 Content 12
4 Cardiopulmonary resuscitation: basic life support, BLS 13
II ADVANCE LIFE SUPPORT, ALS 19
1 Goal 20
Basic & General Clin... 3 Content 20
Authored by Prof Vladimir J. S... 4 Advanced life support, ALS 21
5 Procedure 23
6.0" x 9.0" (15.24 x 22.86 cm) 6 Post cardiac arrest care 23
Color on White paper 7 Changes and new recommendations– CAB algorithm 24
216 pages 8 Procedure recording 24
III BASIC & ADVANCED LIFE SUPPORT: VIRTUAL REALITY TRAINING 25
ISBN-13: 9781489556646 How to use simulator 26
ISBN-10: 1489556648 1 The Main Screen 26
2 The Bottom Panel 26
3 The Pop-up Windows 26
Please carefully review your Digital Proof download for formatting,
4 The Other Buttons 27
grammar, and design issues that may need to be corrected.
5 Configuration 27
6 Features 27
We recommend that you review your book three times, with each time
focusing on a different aspect. 7 Locations 28
8 Storing configurations 28
9 Time 28
10 Transfer 29
Check the format, including headers, footers, page
1
11 Discharges 30
numbers, spacing, table of contents, and index. 12 Medical record 30
IV HOSPITAL ENVIRONMENT AND EQUIPMENT 31
2 Review any images or graphics and captions if applicable. 1 Goals
2 Skills to be acquired
32
32
3
3 Expected outcomes and competencies 32
Read the book for grammatical errors and typos. 4 Module content 33
5 Environment 34
6 Hospital bed 35
7 Patient positions in the bed and during transport 37
Once you are satisfied with your review, you can approve your proof
and move forward to the next step in the publishing process. 8 Monitoring of vital signs 42
9 Mobility aids and devices to assist walking 44
To print this proof we recommend that you scale the PDF to fit the size 10 Transportation devices 45
of your printer paper. 10.1 Hospital bed with rails 45
10.2 Transporters 45
10.3 Stretchers 45
11 Transport preparation 46
12 Prevention of fall and self-injury 47
1
Basic & General Clinical Skills Basic & General Clinical Skills
V HYGIENIC AND PREVENTIVE MEASURES 49 9 Infusion and drug administration systems 150
1 Introduction 50 10 Monitoring 156
2 Asepsis 50 X DIGESTIVE AND EXCRETORY SYSTEMS 179
3 Personal protection measures 50 1 Goal 180
4 Hand hygiene 50 2 Expected outcome 180
5 Medical protective clothing 53 3 Assessment of nutritional status 181
6 Medical wastes 59 4 Assessment of hydration 185
VI PRINCIPLES OF PATIENT CARE 61 5 Clinical nutrition and nutritional needs 187
1 GOAL 62 6 Digital rectal examination, DRE 196
2 CONTENT AND PROGRAM 62 7 Constipation 199
3 EXPECTED RESULTS 62 8. Enema 201
4 PATIENT’S BED 63 9 Urinary catheterization 204
5 Patient diet and feeding 64 10 Suprapubic catheterization 209
6 Feeding the patient 64 APPENDIX 1 214
6.4 Methods of tube feeding 67 REFERENCES 215
7 Washing the patient 69
8 Mouth hygiene 71
9 Hair hygiene and hair washing 73
10 Eye care 75
11 Cleaning and rinsing of ears 76
12 External orifices hygiene (urethral orifice, perineum, anus and perianal region) 76
13 Preventive measures for normal and sensitive skin 77
VII MEDICAMENTS AND SOLUTIONS HANDLING 83
1 Objectives 84
3 Content 84
5 Training methodology 85
5 Storage of medicines 85
6 Medicaments administration route 85
7 Drug administration principles 86
8. Handling and disposal of sharps and infectious waste 99
9. Anaphylaxis and anaphylactic shock 100
VIII AIRWAY AND BREATHING 103
1 Goal 104
3 Content 104
4 Airway 105
5 Artificial breathing during cardio-pulmonary resuscitation 124
6 Oxygen treatment 128
IX CIRCULATION 133
1 Goals 134
3 Pulse 134
4 Assessment of the bleeding severity 136
5 Temporal control of bleeding 137
6 Defibrillation and use of defibrillator 139
7 Essential drugs for arrhythmia treatment 142
8 Infusion and transfusion systems 145
2 3
Introductory remarks
Background
The majority of authors dealing with medical curricular reform agree that substantial progress in the training of
clinical skills is still to be achieved. Clinical skills’ training that is well organized and executed is one of the most
essential components of a modern medical curriculum. Despite marked improvements in medical education, in-
hospital hands-on training remains the weakest point in many curriculums (1-9). The “art of teaching” is still to
be recognized as a respected professional skill that needs to be properly mastered and permanently improved,
alongside with clinical competencies and research activities. Unfortunately, teaching is quite often regarded as
a less prestigious academic activity, particularly when both time and effort invested into teaching is compared
with efforts put into clinical work and research activities (1, 2).
Today, mastery of a significant number of rather complex clinical skills cannot be achieved during
undergraduate training; this task appears to be shifted to residency programs, which certainly is not a
preferable option (3, 4). In previous publications, we have compared a traditional and a contemporary clinical
skills training programs, in order to identify the most relevant advances and principal obstacles, resistant to
changes (5, 6). Diligent efforts of many scholars, combined with the introduction of advanced technology, have
resulted in substantial changes in the methodology of clinical skills training. Still, when dealing with clinical
skills, as well as medicine in general, it is advantageous to bear in mind that technology is only a tool (7, 8).
Major obstacles affecting the progress of clinical teaching are (i) the institutional value system, impeding the
motivation of the teaching staff; (ii) lack of a strong mentoring system; (iii) organization, timing, and placement
of training in the curriculum; (iv) lack of publications pertinent to training; and (v) unwillingness of patients to
participate in student training.
Institutional value system
In most university hospitals, teaching is strongly influenced by the institutional value system: while research
accomplishments and generation of clinical revenues are rewarded, excellence in teaching is often neglected.
Clinical faculty members, who are willing to serve as teachers and mentors, are under permanent pressure to
be “clinically productive,” which is just another euphemism referring to the amount of revenues generated.
Substantive reform of institutional values will be possible only if there is strong willingness of hospital
management to support the educational mission. All teaching hospitals should develop an internal set of acts
and regulations that will support teaching with adequate financial input and career promotion mechanisms. At
the same time, the mechanisms for the control of the teaching process, regular assessment and evaluation of
teaching staff, including students’ anonymous surveys, should be defined (16-20). In the long run, this novel
approach could be looked at as a sound investment: without outstanding teaching, one can hardly expect
highly competent physicians, upon which the flow of hospital revenues depends.
It may be possible to introduce “credits” for outstanding teaching practice. Over the past decades, the
requirements of life-long learning and continuous medical education have become an inseparable part of every
physician’s professional life. A similar principle may be applied to education, such that every member of the
teaching staff would need to collect credits for successful teaching and research and publications related to
medical education.
4 5
Finally, during the final assessment, the senior assessors would have an opportunity to re-evaluate the students
Mentorship “portfolio of acquired skills,” estimate the students’ level of competency, and affirm that a skill in question has
been completely mastered.
The essential prerequisite in clinical training is “a meaningful, ongoing relationship between faculty and
students" (9). Unfortunately, mentorship in the majority of today's teaching hospitals and medical schools is In order for the proposed model to succeed, students should have regular meetings with their mentors to
“either fragile or does not exist, and the progressive advancement of student competencies is not well guided reflect on their achievements, “diagnose” the state of their competencies, and set further learning goals.
across the curriculum…” (10). We believe, as argued in recent literature, that mentorship has to be Evidence shows that portfolios improve planning and monitoring of education by combining external
reestablished to ensure adequate observation, supervision, and mentoring of students’ professional assessment, self-assessment, and mentoring. They enable students to develop more challenging learning goals
development (8,17-21, 24-28). than is customary in traditional medical education (12).
Students should be introduced, at the beginning of their course, to a competent mentor who will instruct, Scheduling bed-side teaching
coach, monitor, and assess their level of proficiency in clinical skills, to rate the performance of students to
determine whether they are trained well enough to apply for the official examination. In order to provide a Rigid scheduling of training is another factor to blame for poor training results. A programmed schedule of
sufficient number of competent mentors in a medical school, it is necessary to create a well-organized and clinical practice very often does not match with the availability of appropriate clinical cases for demonstration,
carefully structured network of teachers who will cooperate across clinical specialties through “interdisciplinary and even the simplest demonstrations are sometimes not possible for myriad reasons. Standardized patients
ownership of the clinical curriculum” (11). cannot solve these problems even if they are very talented actors, since they cannot be subjected to painful
procedures such as venous punctures, lumbar taps, or rectal examinations. This problem can partly be solved
In the proposed scheme, the mentor would be an experienced clinician, competent and able to organize and by using a flexible schedule that can be adapted to changing circumstances. We suggest that students and their
manage a large network of clinical instructors, composed of preceptors, residents, tutors, technicians, and instructor plan the schedule of in-hospital activities together. The priority should be to master a specific skill,
nurses. The mentor must be a senior person with sufficient clinical experience. The other members of the not master it at a specific time.
network will be responsible for instructing the student in particular segments of clinical curriculum. At the end
of a predefined period, such as at the end of each academic year, an independent assessor should perform an Catalogue of Knowledge and Clinical Skills
overall assessment of students’ competency. The results achieved by students would reflect the quality of the
mentor’s work and serve, in addition to the teaching credits and other criteria, as a reliable basis for his or her The principal goal of this catalogue is to clarify some of the dilemmas confronting medical students at the
academic promotion and advancement. beginning of their study, such as "What is expected of me? Where is the line between necessary knowledge and
desirable supplementary knowledge? How can I be confident that I am a competent doctor?”
Organization of clinical training
The Catalogue of Knowledge and the Clinical Skills not only lists the knowledge and skills that a competent
In most medical schools, curriculum is traditionally divided in two parts, preclinical and clinical. Consequently, graduate should possess, but it also classifies these skills in relation to their significance. Such catalogues allow
clinical skills are taught in senior years of the course and students should master a large number of skills over a students to know exactly what is expected of them and teachers can also use them when planning their
short period of time. teaching.
This problem can be at least partially solved if training of simple skills starts early in the curriculum, at the very Within the framework of a curriculum reform project sponsored by the Trans-European Program for Co-
beginning of the course. The instructions should start with the simplest tasks of patient care, such as operation in Higher Education in Central and Eastern Europe (Tempus), we created the “The Catalogue of
positioning them in the bed, proper cleaning and skin care, and control of antiseptic measures. Gradually, the Knowledge and Clinical Skills” for use at the Faculties of Medicine in Bosnia and Herzegovina (13) in
complexity of the training would increase leading to the acquisition of more demanding skills. If such a collaboration with 13 medical schools from 8 European countries (14).
curriculum were adopted, students, their mentors, and clinical instructors would have more time for clinical
training, which would be organized in several phases. Practicum of Clinical Skills
In the first phase, the clinical skills instructor would explain the rationale for the procedure, introduce the Composition of an all-inclusive practicum of clinical skills is another crucial step in clinical skills training. To
equipment, instruments and materials, and present the procedure in detail. It is not necessary for all the execute a skill, a student should understand its importance, be aware of both indications and contraindications
instructors to be physicians: many skills can be mastered with the assistance of preceptors, nurses, and for the procedure, and know which instruments, materials, and equipment are necessary for its successful
technicians. completion. Many essential details that are not explained in textbooks should be covered: for example, how to
explain the procedure to the patient, how to position the patient, what kind of anesthesia needs to be applied,
In the second phase, the instructor would practice a skill with students in the Clinical Skills Laboratory on how to handle the specimens for analysis. The procedure should be described in a step-by-step manner, with
mannequins, models, or in virtual reality. At the end of this phase, the instructor would inform each student’s appropriate comments on anatomy and physiology, as well as warnings on possible complications and their
mentor and confirm with his signature that the student had mastered the skill well enough to be allowed to management. In 2007, we published the first edition of the Practicum of Clinical Skills (15), where we tried to
practice it in the real environment. apply all of the abovementioned concepts and principles.
In the third phase, the clinical instructor would introduce the same skill in a clinical setting, first showing to
students the complete procedure, and finally allowing them to execute the tasks and procedures under his
supervision.
6 7
Portfolio (logbook) of Acquired Clinical Skills

Research and experimental animals as training tools
It has long been observed that assessment drives learning. If we care whether medical students become skillful
practitioners and sensitive and compassionate healers, we must employ all instruments we have today at Another possibility rarely explored in the context of clinical skills training is basic research on experimental
disposal: self-assessment, peer evaluations, written assessments of clinical reasoning, standardized patient animals. Tedious work with small laboratory animals can provide significant experience to students. Once the
examinations, oral examinations, and sophisticated simulations. Most importantly, all results of the learner's student punctures a rat’s tail vein, the fragile veins of elderly people become less of a mystery. Once the
work should be duly noted in portfolios. Rigorous assessment has the potential to inspire learning, influence student becomes acquainted with grave repercussions of blood loss or dehydration in rats, this lesson will stay
values, reinforce competence, and reassure the public (12). embedded throughout their clinical career. We believe that, while working in the laboratory and generating
original scientific data, students also acquire relevant manual proficiency and technical ability, in addition to
Permanent follow-up of a student’s progress during clinical skills acquisition is a prerequisite to building a gaining exposure to research (26).
competent physician. Therefore, we propose that students receive a logbook at the beginning of their training
(called a “Portfolio of Acquired Clinical Skills”). In this logbook, all skills that are essential to the practice of The challenge of institutional change at the University of Split School of Medicine
contemporary medicine should be listed and classified. Having the Portfolio in possession, students will know
from beginning what to expect and what are the "must-have" skills if one aspires to becoming a competent This article examines the processes by which the clinical skills training agenda has been translated into practice
medical graduate. Clear guidelines on the purpose, contents, and organization of the training are essential. No at the Split University School of Medicine, and we believe that similar approaches can be used at other medical
less importantly, students would be able to plan in advance and set their own pace individually. As previously schools. Such attempts at curriculum reform face a plethora of problems, many of which have remained
discussed, every acquired skill should be assessed by clinical instructors, first in a virtual and subsequently a constant over decades.
real-world setting. When a particular skill is mastered, this would be acknowledged with the instructor’s
signature. The concept of combining formative professional development alongside overall assessment is Tackling those problems requires a multifaceted approach and integrated support of both the medical faculty
relatively new, and we believe that if such approach is applied, nothing of importance would be neglected, and and the clinical service provider or the affiliated teaching hospital. They must cooperate in the clinical part of
the number of medical graduates who start their careers with considerable gaps in their armamentarium would the curriculum, yet both systems currently seem reluctant to devote the required resources, and they expect
be significantly reduced (11, 12). the other side to take responsibility for the clinical part of the curriculum. Such weak and even conflicting
relationships result in poor quality of clinical teaching. As a starting point, both institutions, if willingness for
Patients reform exists, have to re-evaluate their system of values and introduce the adequate changes in their structure
and ethos.
Cooperation with patients is instrumental for teaching of clinical skills. Young physicians-to-be has to touch,
feel, hear, and smell the textbook stories and cases in a real world. This presents a serious problem, because, At the Split University School of Medicine, discussion on clinical training intensified in summer 2009 and the
during the last half-century, patients’ way of thinking and their attitudes towards physicians have radically Curriculum Reform Committee entered into permanent session. Many elements necessary for successful
changed (16-20). Today, “the common patient” is not a humble, grateful, and obedient one. Patients are more implementation of a new paradigm are still missing, but there is already some progress. In March 2010, the
informed, more knowledgeable about their conditions, and less willing to be used as teaching subjects. new paradigm of teaching clinical skills was presented during a two-day international symposium in honor of
Consequently, the student’s chances to palpate a lump in a woman’s breast are considerably reduced. Over the Alexander Flexner. Subsequently, a partial curricular reform began, and training of clinical skills was
last years, there have been quite a few attempts to resolve this problem. Mannequins and different models of programmed to start early, as three, one-week modules in the first two ("preclinical") years. Teaching of clinical
the human body are useful, even indispensable in introductory lessons. In addition, there is an increasing examination will not undergo many changes, and clinical skills training will continue in the fourth and fifth
number of outstanding interactive software that create virtual reality, and their quality is improving constantly (clinical) years, where it will take place in appropriate blocks of clinical courses. Radical changes are anticipated
(21, 22). A third track is the use of patient-actors, as we described previously (23, 24). for the sixth year of study, which will become “the clinical practical year” when the students will have the
opportunity to immerse themselves in the real world of clinical practice. The new curriculum is scheduled to
Moving the frontiers in clinical skills education: added value of basic clinical skills training integrated into an become operational in the academic year 2010/2011.
anatomy course
The next planned step is to revitalize the laboratory of clinical skills, upgrade it, and increase its use and the use
Numerous diagnostic and treatment procedures are invasive and involve manipulation of body parts; hence, of interactive software for practicing clinical skills in virtual reality. In addition, working groups revised the
they involve sound anatomical knowledge and understanding. For this reason, these procedures should be existing “Catalog and Practicum of Clinical Skills” and published new “Catalogue of Acquired Clinical Skills.
practiced for the first time on cadavers rather than on patients. At this stage, the student’s focus should be on
the comprehension of a routine procedure's anatomical basis, rather than on its clinical benefits and outcomes. This textbook, “Basic and General Clinical Skills,” is a supplement to these efforts. First seven chapters are
This involves knowledge of anatomical features facilitating the selection of an appropriate procedure site; related to basic clinical skills and aimed to first and second year students, and chapters related to general
anatomical structures that are visualized, palpated, or pierced during the procedure; and anatomical hazards clinical skills are aimed to all undergraduate students. For example, in section that describe the procedure of
that might be encountered during the procedure. blood pressure measurement, the first and second year students will get acquainted with the phenomenon in
broadest way, sufficient to understand its significance in basic resuscitation measures. In third year, during
A short and well-illustrated guide through the anatomical basis of clinical procedures that might be required of Clinical examination course (propedeutics) students will master the standard measurement procedure, which
a general practitioner can be found in An@tomediaTM (25), a series of self-paced learning programs that will be repeated during Internal medicine course, as well. In fifth year, during Anesthesia and intensive therapy
explore anatomy from numerous perspectives, including the perspective of clinical procedures. course, the invasive blood pressure measurement procedure will be demonstrated, and, finally, in sixth year,
during Family medicine course and during Clinical rotations, all acquired knowledge and skills pertinent to
blood pressure will be re-evaluated and finally re-assessed. The same principle should be applied to all general
clinical skills. In our opinion, this is the only possible approach to guarantee the mastering of all important skills
in systematic manner and in full extent.
8 9
To summary, this is a textbook devoted to basic and general clinical skills. In order to clarify this goal, some
points are underlined: I Basic Life Support, BLS
1. General clinical skills are, in our concept, those that belong to all clinical disciplines (e.g. skills pertinent
to respiration, circulation, digestion and excretion).
2. Those skills are complex; therefore, their basic will be explained at the beginning of the study, to be
gradually mastered over the course of undergraduate study, with participation of many chairs.
Certainly, their mastering will continue during the graduate study and latter, during the chosen career,
in accordance to principle of life-long learning.
3. For this reason, when we discuss those general skills, we describe it in its wholeness, because it is
impossible to write, e-g-, airway for first year, than for third and for sixth. Skill is described as a whole,
and teachers and instructors will teach a pert which is appropriate to students’ level.
4. Accordingly, this is a textbook which could be use in all years of medical undergraduate education, as
well as in nursing schools. It is not textbook devoted solely to cardio-pulmonary resuscitation.
It is understandable it is impossible to write separate chapters of “blood pressure measurement procedure” for
first, second or fifth study year, and in our textbook they are presented as a whole. It depends of teachers and
clinical instructors to present the separate sections in an appropriate manned, which suits the students level.
Obviously, it would be highly inappropriate to present intra-arterial catheterization and invasive blood pressure
measurement procedure to first year students.
Finally, different methods to introduce and empower a well-defined mentorship structure are under discussion
and hopefully all dilemmas will be resolved reasonably quickly. Difficulties have arisen around the position of
the clinical instructor, as the status of this role within the higher education system has not yet been defined.
New paradigm (30), addressing many longstanding and unsolved problems, should be observed as a call for
discussion and not as a ready-made recipe. We hope that some of our suggestions can be implemented with
success and that future generations will not be confronted with the same obstacles as ours were).
Authors: Mihajlo Lojpur, MD, PhD

Coworkers
Ivana Buklijaš, MD
Ana Hrga, bacc. med. techn.
Ivan Maleš, med. tech.
Nikša Matas, dipl. med. tech.
Petar Jur, bacc. med. radiol.
10 11
1 Goal
4 Cardiopulmonary resuscitation: basic life support, BLS
Goals of teaching of this course are:
4.1 Definition
1. To enable students to recognize critically ill patients;
2. To assess the status of the vital body functions and level of risk; Cardiopulmonary resuscitation (CPR) is emergency procedure performed in an effort to manually
3. To train the basic life support measures; preserve intact brain function until further measures are taken to restore spontaneous blood
4. To prepare the patient for safe transport. circulation and breathing in a person in cardiac and breathing arrest. Patients are unconscious (loss of
consciousness develop 6-12 seconds after blood flow cessation), with dilated pupils (they dilate 30 –
90 seconds after flow cessation). Breathing stops 15 - 40 seconds after cardiac arrest.
2 Expected outcome
In resuscitation, the objective is to delay tissue death and to extend the brief window of opportunity
At the end of this module, the students who successfully adopt its content will have the knowledge for a successful resuscitation without permanent brain damage. Therefore, the most decisive factor
and skills and will be competent: is the time, because approximately 4 minutes after cardiac arrest start the irreparable brain damage,
and death come out somewhere between seventh and tenth minute. Besides, hearth quickly lost its
1. To identify the conditions that threaten the health and life of patients; contractibility, and restoration of a normal heart rhythm is impossible. Apparently, only resuscitation
2. To understand the critical situation and to assess the level of hazard; in due time makes common sense: with properly executed procedure, the brain death is postponed,
3. To plan and to carry on a life saving procedure; and heart contractibility properties are persevered.
4. To eliminate all life-endangering factors (bleeding, heart arrest, suffocation)
5. To prevent the development of complications (shock, infections, hypoxia) Procedure is usually unsuccessful if starts 15 minutes after cardiac arrest. There is an exception; if
6. To execute the proper procedure; and patient was exposed to extremely low temperature, the metabolic processes are slowed down.
7. To prepare the patient for safe transport.
4.2 Indications
3 Content Cardio-pulmonary arrest caused by:
1. Heart infarction;
2. Heart rhythm disturbances;
1 Pulse, arterial (carotid, radial, apical);
3. Drowning
2 Breathing, assessment of quality;
4. Medicaments intoxication;
3 Airway, cleaning of the oral cavity and pharynx;
5. Poisoning; and
4 Airway, assessment of patency;
6. Electricity stroke.
5 Airway opening, positioning the head and jaw trust;
6 Airway maintenance during the transportation;
7 Blood pressure, measurement 4.3 Contraindications
8 Basic breathing support;
9 Basic circulation support; Contraindications do not exist. Precaution is necessary in:
10 Consciousness, assessment and rating; and
11 Measurement of temperature (oral, axillary, rectal). 1. Anterior neck trauma with tracheal damage;
2. Fixed anterior cervical spine flexion;
3. Cervical spine trauma;
4. Mandible fracture;
5. Trismus;
6. Diffuse oropharyngeal bleeding;
7. Anomalies of the oral cavity and tongue.
12 13
12. Presuming that the head is properly positioned and airway open, rescuer close the nose with
4.4 Materials one hand, cover the patient’s mouth with own one and inhale his lung volume into the patient,
over a period of one second, observing the chest movement in the same time. If there is no
There is no need for any special materials. chest movement, head has to be repositioned, neck additionally extended, and inhalation
repeated. If rescuer delivers the air to nose, the mouth should be closed by the other hand.
4.5 Procedure
13. C stands for compression/circulation. Rescuer kneel besides the patient, with arms fully
First step is to check the consciousness level. If there is no response, and rescuer is alone, the extended in elbows, and compress the chest with both palms (one arm is positioned over
resuscitation has to be started immediately, and after two minutes call for help. If there is an another), using the body weight, not muscle strength. The site of compression is the central part
assistant, he can call emergency service. Over the years, the reanimation sequence was well-known of sternal bone, depth of compression is 4-5 cm. One hundred compressions should be delivered
and memorized as ABC sequence (Airway, Breathing, Chest Compression), i.e. airway opening, mouth in one minute, approximately two per second. After each compression, a full expansion of the
to mouth breathing and external chest compression. chest should be allowed. With proper chest compression, a 20 -25% heart output can be
achieved, what is sufficient for perfusion of the most vital organs.
Last international conference on resuscitation was held in 2010 in Dallas, Texas, and an agreement on
new resuscitation guidelines was reached. After analysis of 411 review articles (research and results 14. CPR has to be applied in children, too. The deference is that in children younger of eight years
were evidence-based), 356 experts from 29 countries recommended a new approach (27-29). rescuer use only one hand, and in newborn use two fingers, index and the middle one,
Detailed account is added as an appendix to this manuscript. An executive summary is added to this compressing the sternum 1 – 2 cm.
text, after presentation of the standard long-standing procedure.
15. Compression/breathing ratio is 30:2, after 30 compressions the rescuer inhales two times,
4.6 Procedure sequence delivering 500 – 600 ml of air with each inhalation, over one second.
1. Check the consciousness level, shaking the patient and calling him/her. 16. The cannula or catheter in the peripheral vein should be inserted as soon as possible.
2. If there is no response, and rescuer is alone, resuscitation should start immediately, and after 17. If the rescuer has a defibrillator at disposal, and presume that the patient has ventricular
two minutes call for help. fibrillation, an electric shock should be delivered (with monophasic apparatus one starts with
200 J, with biphasic with 120 J).
3. If there is an assistant, ask him to call an emergency number.
4. There is no need to palpate the pulse, auscultate the heart tones, measure the blood pressure –
all of this are, in cardiac arrest, useless actions.
5. The patient is positioned in the supine position, on the firm ground.
6. The rescuer kneels beside the patient.
7. Deliver a single precordial thump at the center of sternal bone, using the ulnar side of a closed
fist, from 20 - 30 cm distance. With such maneuver, it is possible to arrest the initial ventricular
fibrillation.
8. Next follow the resuscitation in ABC sequence.
9. A stands for airway and relate to assessment the patency and opening of airway. By extension of
the neck and head-tilt backward, the tongue is extended and elevates the epiglottis. The
alterative is jaw thrust, applied when the neck extension is not recommended. More details one
can find in the chapter on breathing and airway in this manuscript.
10. With one finger the rescuer explores the oral cavity, and removes the foreign bodies and
materials which obstruct the airway.
11. B stands for breathing. Rescuer has to establish does breathing exist (listening, observing the
chest movements, feeling the air flow) – this last no more than 10 seconds. If there is any
dilemma, the artificial breathing must be started, mouth to mouth or mouth to nose.
14 15
4.7 Changes and new recommendations– CAB algorithm 4.8 Complications
The most significant new recommendations are: 1. Rib fractures.
1 A compression rate of at least 100/min (a change from “approximately” 100/min) 2. Pneumothorax.
2 A compression depth of at least 2 inches (5 cm) in adults and a compression depth of at least 3. Rupture of the liver.
one third of the anterior posterior diameter of the chest in infants and children (approximately
1.5 inches [4 cm] in infants and 2 inches [5 cm] in children). Note that the range of 1 to 2 inches 4. Rupture of the spleen.
is no longer used for adults, and the absolute depth specified for children and infants is deeper
than in previous versions of the AHA Guidelines for CPR and ECC. 5. Airway obstruction (by tongue, secretions, vomitus).
3 Allowing for complete chest recoil after each compression
4 Minimizing interruptions in chest compressions 4.9 Side effects
5 Avoiding excessive ventilation 1 Hyper- and hypotension.

6 A Change From ABC to CAB sequence: the 2010 AHA Guidelines for CPR and ECC recommend a 2 Bradycardia or tachycardia, arrhythmia
change in the BLS sequence of steps from A-B-C (Airway, Breathing, Chest compressions) to C-A-
B (Chest compressions, Airway, Breathing) for adults, children, and infants (excluding the newly 3 Dysphagia.
born; see Neonatal Resuscitation section). This fundamental change in CPR sequence will require
reeducation of everyone who has ever learned CPR.
Students who wish to learn more on this topic will find many more details in Appendix 1: “American
Heart Association: Guidelines for CPR and ECC”
16 17
II Advance life support, ALS
Authors: Mihajlo Lojpur, MD, PhD & Prof. Vladimir J. Š
Collaborators
Ivana Buklijaš , MD
Ana Hrga, bacc. med. techn.
Nikša Matas, dipl. med.techn.

18 19
1 Goal 4 Advanced life support, ALS
Goal of teaching of this content is: Advanced Life Support Measures, ALSM is term which implicates a sequence of measures used to
supplement basic measures, executed by health professionals.
1 To enable the students to identify the critically ill patients;
2 To assess the status of the vital body functions and level of risk; 4.1 Indications
3 To train the advanced life support measures; and
4 To prepare the endangered patient for safe transportation. When basic life support measures are not sufficient, Advanced Life Support Measures – ALSM should
be applied
4.2 Contraindications
2 Expected outcome
Contraindications do not exist.
At the end of this module, the students who successfully adopt its content will have the knowledge
and skills and will be competent: 4.3 Materials, equipment and medicaments
1. To identify the conditions that threaten the health and life of patients; 4.3.1 Devices and accessories for airway maintenance
2. To understand the critical situation and to assess the level of hazard;
3. To plan and to carry on a life saving procedure; 1. Nasopharyngeal and oropharyngeal airways.
4. To eliminate all life-endangering factors (bleeding, heart arrest, suffocation) 2. Nasogastric tube is used for gastric lavage and prevention of gastric content aspiration.
5. To prevent the development of complications (shock, infections, hypoxia) 3. Aspirators (suctions) are used to eliminate the foreign content, blood and secretion from oral
6. To execute the proper procedure; and cavity and airway.
7. To prepare the patient for safe transport. 4. Laryngeal mask is used to ensure a safe airway, facilitate the ventilation and prevent the
aspiration of gastric content.
5. Laryngeal tube has similar function as laryngeal mask, aspiration protection is better.
3 Content
6. Esophageo-tracheal tube is two-lumen tube, and it is used when endotracheal intubation is not
feasible.
1 Aspirators (suctions), standard and portable
2 Breathing, equipment for support
4.3.2 Automated external defibrillator, AED
3 Breathing, humidifiers
4 Breathing, oxygen delivery equipment
Device is smaller than standard one, and an analyzer of heart rhythm is integrated. There are 2 types
5 Breathing, pulse oximeter and capnometer
of AEDs: Fully Automated and Semi Automated. Most AEDs are semi automated. A semi automated
6 Clinical death, signs
AED automatically diagnoses heart rhythms and determines if a shock is necessary. If a shock is
7 Consciousness, assessment and rating
advised, the user must then push a button to administer the shock. A fully automated AED
8 Defibrillation, electrodes placement
automatically diagnoses the heart rhythm and advises the user to stand back while the shock is
9 Defibrillation, device and procedure
automatically delivered.
10 Heimlich maneuver
20 21
4.3.3 Medicaments used in resuscitation

5 Procedure
There is a large number of drugs used during resuscitation, here will be shortly described the most
important ones. 5.1 Informed consent
1. Epinephrine (synthetic adrenaline) is a hormone and a neurotransmitter. It increases heart rate,
Impossible to obtain from patient and the patient family may be absent and cannot be informed.
constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the
sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines 5.2 Patient positioning
called the catecholamines.
According to circumastances; if possible optimal is a supine position on the firm ground.
2. Vazopressine (also known as Arginine vasopressin, AVP, argipressin or antidiuretic hormone,
ADH), is a neurohypophysial hormone responsible for increasing water absorption in the 5.3 Procedure sequence
collecting ducts of the kidney nephron. Vasopressin is a peptide hormone that controls the
reabsorption of molecules in the tubules of the kidneys and increases peripheral vascular Same as in basic life support, with use of defibrilators and medicaments.
resistance, which in turn increases arterial blood pressure. It plays a key role in homeostasis, and
the regulation of water, glucose, and salts in the blood. In resuscitation has similar effect as 5.4 Defibrillation
adrenaline, and it is mainly used in resistant ventricular fibrillation.
Defibrillation is a common treatment for life-threatening cardiac arrhythmias, ventricular fibrillation,
3. Atropine is alkaloid, a competitive antagonist for the muscarinic acetylcholine receptor. It is and pulseless ventricular tachycardia. Defibrillation consists of delivering a therapeutic dose of
classified as an anticholinergic drug (parasympatholytic). Injections of atropine are used in the electrical energy to the affected heart with a device called a defibrillator. This depolarizes a critical
treatment of bradycardia. Atropine blocks the action of the vagus nerve and its primary function mass of the heart muscle, terminates the arrhythmia, and allows normal sinus rhythm to be
in this circumstance is to increase the heart rate. Atropine was previously included in international reestablished by the sinoatrial node of the heart.
resuscitation guidelines for use in cardiac arrest associated with asystole and pulsless electrical
activity, PEA, but was removed from these guidelines in 2010 due to a lack of evidence. For Defibrillators can be external, transvenous, or implanted, depending on the type of device used or
symptomatic bradycardia, the usual dosage is 0.5 to 1 mg IV push, may repeat every 3 to 5 needed. Some external units, known as automated external defibrillators (AEDs), automate the
minutes up to a total dose of 3 mg (maximum 0.04 mg/kg) diagnosis of treatable rhythms, meaning that lay responders or bystanders are able to use them
successfully with little, or in some cases no training at all.
4. Lidocaine is the most important antiarrhythmic drug: it is used intravenously for the treatment of
ventricular arrhythmias (for acute myocardial infarction, digitalis poisoning, cardioversion or If after first defibrillation ventricular fibrillation persists, procedure is repeated with a charge of 200 -
cardiac catheterization). 300 Jouls. If after second defibrilation status persisits, third defibrilation should deliver 360 Jouls. All
three defibrilation should be performed in 90 seconds time span.
5. Amiodarone is an antiarrhythmic drug that has potentially fatal side effects and is used to control
serious heart rhythm problems only when safer agents have been ineffective In addition to defibrilation, medicaments are used to correct the acidosis, adrenaline is given, as well
as antiarrhitmic drugs.
6. Procainamid is less effective substitute for lidocaine and amiodarone.
7. Sodium bicarbonate as intravenous solution is administred if cause of cardic arrest is existing 6 Post cardiac arrest care
acidosis or hyperkalemia.
The patient should be monitored at least 48 hours after attack in special intensive care units. Care
should include:
1 Optimizing vital organ perfusion

2 Titration of FiO2 to maintain O2 sat !#$ *+<<$
3 Transport to comprehensive post-arrest system of care
4 Emergent coronary reperfusion for STEMI or high suspicion of AMI
5 Temperature control
6 Anticipation, treatment, and prevention of multiple organ dysfunction
22 23
III Basic & advanced life support: virtual reality training

7 Changes and new recommendations– CAB algorithm
Last international conference on resuscitation was held in 2010 in Dallas, Texas, and an agreement on
new resuscitation guidelines was reached. After analysis of 411 review articles (research and results
were evidence-based), 356 experts from 29 countries recommended a new approach (1-3). Detailed
account is added as appendix to this manuscript, an executive summary is added to this text, after
presentation of the standard long-standing procedure.
The most important new recommendations are:
1. Quantitative waveform capnography is most reliable method to confirm and monitor correct ET
tube placement (Class I, LOE A 1).
2. Focus on high-quality CPR and defibrillation
3. Atropine no longer recommended for routine use in management of PEA/asystole.
4. Chronotropic drug infusions now recommended as alternative to pacing in symptomatic and
unstable bradycardia.
5. Adenosine recommended as safe and potentially effective for treatment and diagnosis in initial
management of undifferentiated regular monomorphic wide-complex tachycardia.
Medications for Pulseless Arrest
1 Atropine: deleted from pulseless arrest algorithm

2 Epinephrine: dose, interval unchanged
3 Vasopressin: dose, use unchanged
4 Amiodarone: dose, indications unchanged
5 Lidocaine: dose, indications unchanged
6 Sodium Bicarbonate: Routine use not recommended (Class III, LOE B). Author: Professor Vladimir J. Šimun, MD, PhD
7 Calcium: Routine administration for treatment of cardiac arrest not recommended (Class III, LOE
B).
Colaborators
8 Procedure recording
Professor Mladen Ra=, MD, PhD
All measures, including all administred medicaments, should be chronologicaly noted in resuscitation
=, MD
protocol.
>XZ, MD
\, MD
1
LOE – Level of Evidence
24 25
How to use simulator 4 The Other Buttons
The Time Buttons are used to control the simulation time - including pause, fast-forward and stop. If
1 The Main Screen you press stop, you will proceed directly to the debriefing. From here you can choose to resume the
scenario by clicking Resume Scenario. The time button panel is placed in the top right corner of the
The main way of controlling the simulation is to interact with the picture. Click directly on the objects main screen.
on the screen to open a menu from which you can choose the action you wish to perform. To
perform an action, for example examine the patient's head, click on the head, and only the The Medical Record icon - placed in the bottom left corner of the main screen - enables you to view
appropriate actions will be displayed. In the same way you can click on the rescuers, the defibrillator, data concerning the patient.
etc. to see the actions concerning these items.
In the bottom right corner of the main screen you will find the Transfer / Ambulance / MEDEVAC
icon.
2 The Bottom Panel
Choosing an action by clicking on one of the rescuers in the picture will cause that rescuer to perform
Another way to use the simulator is by using the panel at the bottom of the screen. This panel is
the action immediately. If he or she is occupied with something else, they will abort that action if
grouped into eight sections:
both the selected actions can't be performed at the same time. Alternatively, choosing the same
action from the panel lets the program decide which available person should do the action.
1 The first contains the response actions, where you can check consciousness of the patient and
ask the patient questions.
The two rescuers can perform the same actions. Any action not available by clicking on the rescuers
2 The box below contains the drugs actions. Here you can choose and administer drugs and fluids.
can be found by clicking directly on the patient or by using the bottom panel.
3 The third group contains actions concerning the airway of the patient.
4 The fourth group contains actions to ventilate and administer oxygen to control the breathing of
the patient. 5 Configuration
5 Actions concerning the circulation of the patient are placed in the fifth group.
6 The sixth group contains general actions for the examination of the patient. The configuration screen is designed to enable instructors to control most aspects of the program,
7 The seventh group contains the actions concerning exposure of the patient - eg temperature and the conditions under which simulations can be run. The configuration screen lets you choose the
control. availability of each drug, patient, piece of equipment, etc., collectively called features.
8 Finally the last group, miscellaneous, provides access to different investigations and procedures.
To ease your navigation in the configuration screen, features are grouped by function. Each function
group is represented as a folder tab in the top of the configuration screen. When you select a tab, the
3 The Pop-up Windows window to the left will display a picture that matches that tab, and the main window in the middle
will present a number of features arranged into a tree.
When you click an item such as the defibrillator in the main screen or in the button panel, a small
window pops up, in order to show you features of the item you've clicked. For example, a window,
showing the current heart rate will pop up when you attach the 3-lead ECG electrodes. By clicking the 6 Features
ECG window you can access other functions such as Use Pacemaker if, for example, you want to
perform transcutaneous pacing. If you click on a feature, you will get a description of that feature in the right-hand side window.
Here you can enable or disable some features - and change the value of others - to customise the
simulator exactly to your needs.
26 27
Stop: To stop the session and return to the debriefing screen, click Stop (the square). If you click Stop
7 Locations by accident, you can still resume by clicking Resume scenario . However, to get the full benefit of the
simulation, it is recommended that you continue until you decide either to abort the treatment, or to
Most features can be configured on a per-location basis, which means that you can instruct the
transfer the casualty.
simulator to enable a feature at one location, and disable it at another location. In the configuration
screen, you control which location you are configuring by changing the location in the drop-down
menu labeled Choose which setting to configure above the tree of features. When you are 10 Transfer
configuring a specific location, a location-specific picture will be shown in the left-hand side window,
and some features will fade out to show you that they cannot be configured per location. If you The Transfer icon is placed in the bottom right corner of the main screen. By clicking the icon, you can
change the location to All settings , the configuration screen will give you a summary of the settings choose between several options for how you wish to transfer the patient to further care:
for all locations. In summary mode, a check box with a check mark on a grey background means that
the feature is enabled at some locations and disabled at others. The configuration state of the Stop further treatment
various locations is summarized in parentheses after the feature. Similarly, a grey entry means that
If you decide that there is nothing more that can be done for the patient, you can end the simulation
the feature is enabled at some locations and disabled at others. When in summary mode, any
by clicking on this button.
configuration you perform will be applied to all locations (if possible).
Transfer the patient to ICU

8 Storing configurations
If you feel that your patient is stabilised, you can choose to transfer to ICU/monitored bed for further
You have access to profiles, which allow you to save the settings of the configuration. care.
Transfer to medical ward

9 Time
This option will end the scenario. Select this option if you find the patient has received sufficient
By using the time panel at the top right corner, you can control the time in the scenario. The controls treatment for now, but should be kept at the medical ward for observation or further treatment in
work in much the same way as those on an ordinary CD player or VCR with four buttons: the near future.
Start/Restart the time, Fast forward, Pause and Stop . The clock shows you, in real-time, how much
time has elapsed since you arrived at the scene. Transfer patient to transvenous pacing
Start/Restart the time is the standard setting. You use this button to resume play after pausing or to Transvenous pacing is an invasive procedure stimulating the heart to contract, thereby supporting
cancel fast forward. cardiac output. In contrast to transcutaneous pacing, which can be started quickly and conveniently
at the bedside, transvenous pacing requires involvement of the invasive cardiology team.
Fast-forward (two triangles pointing to the right) allow you to jump one minute forward in time.
During the jump in simulation-time, the casualty behaves as if in normal time. If the condition of the Transfer patient to CT
casualty changes during the jump, the time will automatically revert to normal time. You can also
interrupt fast forward manually, by pressing the Start/Restart the time button. A CT scan of the cerebrum is primarily used to identify intracerebral or subarachnoid haemorrhage in
suspected stroke patients. A noncontrast CT scan is the single most important test when ruling out
Pause: If you have to leave the computer temporarily, you can pause the time by clicking the Pause haemorrhagic stroke.
button (the two vertical lines). When you do this, the game is brought to a complete halt, and you
cannot perform any actions (also indicated by the greyed-out menus). To start the time again, click Transfer patient to PCA
Start/Restart the time , and the scenario will resume exactly as when you left it.
Patients with acute chest pain should be evaluated as potential candidates for percutaneous
coronary angioplasty (PCA) - either angioplasty or intracoronary stenting. PCA is superior to
fibrinolytic therapy when treating ACS or cardiogenic shock in patients who are less than 75 years of
age.
28 29
11 Discharges IV Hospital environment and equipment

This option will end the scenario and send the patient home. Select this option if you find the patient
has received sufficient treatment and is ready to be discharged.
12 Medical record
The Medical Record icon gives access to patient data, investigation results such as venous blood
samples, ABG-sample, X-ray results, Glasgow Coma Scale etc. It also gives you a brief outline of what
has occurred up to the point at which the scenario starts.
Author: ==
Collaborators:
Vjera Marinov, MD
Ivana Buklijaš, MD
_, bacc. med. techn.
Nikolina Udiljak, bacc. med. techn.
30 31
1 Goals 4 Module content

In this chapter students will understand the hospital structure, organization and different types of 4.1 Environment and equipment
environment allocated to different type of the diagnostic and treatment, as well as out-hospital
health facilities. In addition, the students will get acquainted with basic hospital equipment and 1. Hospital bed, standard setup and adjustments
furniture, and will be introduced to different devices and ways of in- and out-hospital transportation. 2. Observation and monitoring (monitors, oxygen delivery devices, ventilators)
3. Medical orders recording, saving the tests and relevant diagnostic findings
4. Course and treatment recording
2 Skills to be acquired 5. Patient record, classic and electronic
1. Hospital bed: standard bed setup; patient’s positioning in the bed (standard and special); 4.2 Patient's position in the bed
2. Organization and standards of hospital’s rooms.
3. Organization of the hospital space. 1. Accommodation
4. Patient’s positioning and accommodating in the bed. 2. Turning, principles and aids
5. Patient’s positioning and accommodating during transportation. 3. Decubitus prevention
6. Observation and monitoring of patients’ vital signs: arterial pulse and pulse oximeter), arterial 4. Fall prevention, self-injury prevention
blood pressure measuring, attachment of ECG electrodes, parameters of artificial ventilation. 5. Patient transfer assist devices (slide sheets, roller sheets, transfer belts, slide/transfer boards,
7. Transferring and turning the patient turning discs).
8. Patient safety and prevention of fall.
9. Bed restraints.
10. Devices for patient transfer: slide sheets, roller sheets, transfer belts, slide/transfer boards, 4.3 Transportation
turning discs).
11. Special measures for transfer unconscious patient and patient with unstable spine fracture. 1. Mobility aids and devices to assist walking (canes, crutches, walkers, gait trainers).
12. Mobility aids and devices to assist walking (canes, crutches, walkers, gait trainers). 2. Wheelchairs.
13. Patient transport devices 3. Stairs lift.
14. Wheelchairs. Stairs lift. 4. Patient transport devices (transportation beds, gurney, stretchers, wheelchairs)
5. Preparation for transport
6. Patient transfer from bed to transport device
3 Expected outcomes and competencies 7. Position of patient during transport
8. Safety measures during transport
At the end of this module, the students who successfully adopt its content will have the knowledge 9. Restraint of patient during transport
and skills and will be competent: 10. Special transport positions
1. To organize an adequate environment for patient treatment;

2. To equip it with all necessary furniture, equipment and device;
3. To use and apply the equipment and devices in standard fashion;
4. To give the directions and orders in a standard manner;
5. To understand and use the health facility documentation and records;
6. Understand the specific rules of conduct in special area (operating rooms, intensive care units,
isolation wards, etc.)
7. Be acquainted with transportation equipment and walking aid devices and use them in a proper
manner.
32 33
5 Environment 6 Hospital bed

5.1 Hospital units and rooms 6.1 Standard hospital bed
Patient room can accommodate maximum of four beds, and two beds if there is a contagious A hospital bed is a bed specially designed for hospitalized patients or others in need of some form of
disease, with an isolated bathroom. health care. These beds have special features both to ensure the comfort and well-being of the
patient and to facilitate all activities of health care workers. Common features include adjustable
In intensive care unit (ICU) the space of 20 m2 is needed for each of the beds, and permanent direct height of entire bed, the head, and the feet, adjustable side rails, and electronic buttons to operate
visual contact and supervision of each of beds should be assured. The total number of ICU beds in both the bed and other nearby electronic devices. Standard dimension of bed is 200 X 90 cm, and has
hospital is at least 3% of all acute care beds. four wheels. Wheels enable easy movement of the bed, either within the facility or within the room
Every hospital unit of 25 beds should have one one-bed and two two-bed rooms, and contagious and for patient’s safety must be locked whenever the patient is transferred in or out of the bed. Beds
disease department should have at least two one-bed rooms. have side rails that can be raised or lowered. These rails serve as protection for the patient, too
(Figure 1).
One-bed room should have at least 12 m2 (16 m2 for contagious diseases), and each patient room
should have its own bathroom. Parts of the bed can be raised and lowered at the head, feet, as well as whole bed. While on older
beds’ model this is done with cranks at the foot of the bed, on modern beds this feature is electronic.
For each of bed an appropriate space should be provided, as follow: Today, while a full electric bed has many features that are electronic, a semi-electric bed has two
motors, one to raise the head, and the other to raise the foot
Newborns and children up to 2 years 4.5 m2
Children from 2 to 6 years 5.5 m2
Children older than 6 years and adults 6.0 m2
Adults with limited mobility 6.5 m2
Adults with contagious diseases 7.0 m2
Distance from bed to bed and bed to wall should be at least 75 cm, and 250 cm in ICU and isolation
wards. The doors in patient rooms should be at least 110 cm wide. Rooms should have supporting
rails.
Each hospital unit should have a bathroom with showers and bathtub, and a separate area with Figure 1. Standard bed with rails
bedpan cleaning system
5.2 Outpatient clinic (ambulatory care clinic)
Outpatient clinic consists of:
x Examination room, minimum 12 m²;

x Nurse room, minimum 12 m²;
x Waiting area 9 m²;
x Staff toilet/bathroom/lavatory;
x Patient’s toilet/bathroom/lavatory.
x
Pediatrician clinic and infectious disease clinic should have an isolation space of at least 9 m2.
34 35
6.2 Intensive care beds
External dimension: 220 x 95 cm; 7 Patient positions in the bed and during transport
x Bed should have four wheels, 200 mm in diameter, which are lockable. For safety wheels must be
locked whenever the patient is transferred in or out of the bed. Active position is position in the bed chosen by patient, and it is allowed for all patients who do not
require special position. Therefore, patient is allowed to take position which is the most convenient
x Bed construction consists of 2 telescopic columns, and foundation of 4-part board of laminate, freely.
permeable for x-rays.
Passive position is position for severely ill patients, who cannot move and turn at free will, but stay in
x Head and foot part are from acrylonitrile butadiene styrene (ASB) plastic or laminate, easy-to- the position chosen by their attendant. Passive position should alternate every two hours, to prevent
remove; bed sores (decubital ulcers).
x Bed has side rails of ABS plastic that can be raised or lowered.
Compulsory position is position in which attendant restrain the patient, in order to prevent self-
x Bed is powered by two eclectic motors, and in addition has battery pack, which secure the power injury or any other adverse event.
when bed is disconnected from electric power network. Motors’ functions are controlled by
central console, inaccessible to the patient. 7.1 Transport position
x Metal parts of bed are protected by electrostatic coating.
x Bed has holders for oxygen cylinder, trapeze, urine bag, infusion bottle holder, infusion pump
holder, restraints, and fractured limbs tractions. Small bed linen storage is incorporated in the
bed basement.
x Bed can be extended and positioned in all required positions (Figure 2).
Position of patients during transport depends on their illness or injury, and can be active or passive
one. Before the transport patient has to be stabilized and all vital functions under control. Active
position is chosen by the patient, and this is a most convenient and the most comfortable one.
Passive and compulsory position should be the most useful one (in regard to main problems patient
has), and should prevent possible deterioration of health status, adverse events or injuries.
Figure 2. Intensive care bed
36 37
7.4 Fowler position

7.2 Semi-sitting position
Fowler position is recommended for patient with abdominal pain and abdominal injury, and
Semi-sitting position is achieved if the head of the bed (stretcher) is elevated for 450; it is mainly used facilitates the relaxation of abdominal wall muscles. Patient is in semi-sitting position, head is
to facilitate the patient breathing, and when there is an injury of chest. elevated for 450, and legs are bended at the knees.
7.3 Supine position (Magnus) 7.5 Orthopneic position
Patient is lying on the back; having the face upward; it is mainly used in spine injured patient, or
whenever a spin injury is suspected. During transportation such patients are usually stabilized on a
long firm board. Orthopneic position is aimed to facilitate the breathing in orthopneic status, when the patient
breaths without the strain only when in an upright position. The patient is positioned in an upright or
semi vertical position by pillows to support the head and chest. Head of the bed is elevated 90°.
38 39
7.6 Trendelenburg position 7.8 Coma position
In Trendelenburg's position the patient is supine on a table or bed whose upper section is lowered 45
degrees and the head is lower than the rest of the body. It is used in patient with hypotension,
syncope and in hypovolemic shock.
The recovery (coma) position refers to one of a series of variations on a lateral recumbent or three-
7.7 Auto transfusion position quarters prone position of the body, in to which an unconscious but breathing casualty can be placed
as part of first aid treatment.
An unconscious person (GCS *`{supine position may not be able to maintain a patent airway as a
conscious person would. This can lead to an obstruction of the airway, restricting the flow of air and
preventing gaseous exchange, which then causes hypoxia, which is life threatening. Thousands of
fatalities occur every year in casualties where the cause of unconsciousness was not fatal, but where
airway obstruction caused the patient to suffocate. The cause of unconsciousness can be any reason
from trauma to intoxication from alcohol. Position should be stable, to prevent airway obstruction
and aspiration of gastric content.
Posturing procedure: patient is supine on the firm board. Left arm is flexed, head turned to left, with
cheek on the left palm. Next attendant hold right leg and flex it, bringing the foot in level with left
knee. Pulling the knee attendant starts rotation of the patient. Right leg is fully flexed in hip and
knee, patient is in semi-lateral prone position, head (right cheek) is resting on the left hand palm. A
permanent supervision of the breathing is necessary. During transportation patients should be
turned on the other side every 30 minutes.
This is a modification of Trendelenburg’s position. The head and upper part of body are supine in
horizontal position, and the adjustable lower section of the table or bed is bent so that the patient's
legs and knees are flexed and elevated for 40 - 50°. Indications are the same as for Trenedelenburg’s
position.
40 41
8 Monitoring of vital signs 8.2.2 Procedure
8.1 Pulse 1. Calm down the patient and explain the procedure. Blood pressure is measured at least 30
minutes after physical activity, smoking or coffee consummation.
8.1.1 Definition
2. Wash the hands
3. Prepare and check the instruments, disinfect the stethoscope’s olives (ear pieces) and
Pulse represents the tactile arterial palpation of the heartbeat. The pulse may be palpated in any membrane.
place that allows an artery to be compressed against a bone, such as at the neck (carotid artery), at 4. Choose the appropriate cuff.
the wrist (radial artery), behind the knee (popliteal artery), on the inside of the elbow (brachial 5. Position the patient in a comfortable position, select the measurement area.
artery), and near the ankle joint (posterior tibial artery). Dorsal foot artery cannot be palpated in 6. Patient’s arm have to rest on background, with measurement are at level of his heart. Hand is
approximately 10% of population. Trained fingertips felt pulsation of an artery, caused by changes in relaxed, palm turned up.
blood pressure, produced in turn by contractions of left heart ventricle. 7. Feel the pulse of brachial artery at elbow.
8. Apply the cuff, not to tight – fingertip can be inserted between cuff and patient’s arm.
8.1.2 Pulse palpation procedure 9. Simultaneously palpate the arterial pulse and inflate the cuff; when the pulse cannot be felt,
record the value and deflate the cuff.
Radial artery palpation is the most frequent one 10. Position stethoscope membrane over brachial artery at elbow and inflate the cuff 30 mm over
previously recorded value.
1. Explain the procedure to patient 11. Start slow deflation, 2 – 3 mm/sec, and note the first tone of heartbeat, as well as the last one.
2. Wash the hands First beat correspond to systolic blood pressure, last one to diastolic.
3. Extend the patient’s arm, palm turned upside. 12. If there is any doubt, procedure should be repeated.
4. Position the fingertips of 2nd, third and fourth at lateral side of patient wrist. 13. Remove the cuff, disinfect the stethoscope membrane and ear pieces, and wash the hands.
5. Apply the firm but not too strong pressure 30 up to 120 seconds. 14. Record the blood pressure values in patient’s record.
6. Note (i) frequency; (ii) rhythm; and (iii) pulse amplitude.
7. Wash the hands 8.3 Prevention of bed sores (decubital ulcer)
8. Record the findings
Procedure is described in chapter on patients’ health care
8.2 Blood pressure
8.4 Positioning of the patient
8.2.1 Definition
Procedure is described in chapter on patients’ health care
Blood pressure (BP) is the pressure exerted by circulating blood upon the walls of blood vessels. This
is one of the principal vital signs. When used without further specification, "blood pressure" usually 8.5 Prevention of fall and self-injury
refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies between a
maximum (systolic) and a minimum (diastolic) pressure, and can be expressed in mm of mercury or in Procedure is described in chapter on patients’ health care
kilopascals.
Systemic arterial pressure is most often measured at a person's upper arm, on the inside of an elbow 8.6 Patient transfer from bed to gurney
at the brachial artery, with a blood pressure meter (sphygmomanometer) a device comprising an
inflatable cuff to restrict blood flow, and a mercury or mechanical manometer to measure the To facilitate the transfer, the transporting board is used, or bed sheet. In optimal circumstances, for
pressure. safe transfer five persons are needed. One of them control head and neck (and direct the process),
two control shoulders and arms, two hips and legs. If there is any fractured bone, it should be
immobilized before the transfer.
42 43
10 Transportation devices
9 Mobility aids and devices to assist walking
Transportation devices are gurneys, stretchers, wheelchairs, transport board. During transport
9.1 Wheelchair
additional equipment should be available: oxygen cylinder, masks, suctions, monitors, defibrillator,
ventilator, essential drugs and infusions.
10.1 Hospital bed with rails
Beds with rails are described in this chapter in one of previous sections.
10.2 Transporters
Wheelchair is used for transport of patients who cannot walk, with walking difficulties or those
whom walking is forbidden because of their medical condition. Wheelchair is used only when patient
can sit upright independently.
Contemporary transporters should have rails, restraining strips, foundation for oxygen cylinder and
9.2 Crutches monitors mount.
10.3 Stretchers
Crutches are used as walking aids, and can be forearm crutches and armpit ones. The other walking
aids are canes, walkers and gait trainers.
Stretchers are mainly used in emergencies and during transport by ambulance, helicopter and
airplane. Transportation board is usually used to facilitate transfer of patient to bed.
44 45
10.4 Splints and air pillows

11.2 Standard transport
Transport conducted inside one health facility (from department to department), as well from one
health facility to another, is termed regular transport. With patient all essential documents have to
Splints are used mainly for immobilization of a fractured limbs, and air pillows to stabilize and be attached, including:
accommodate patient during transportation.
x Referral letter
11 Transport preparation
x Case summary
x X-rays
Patient should be prepared for transportation carefully. Breathing has to be assessed, as well as
x Transport permission (with names of attendants)
airway patency. Airway should be clean and open, breathing aids and oxygen supply attached,
respiration support available. Intravenous line has to be inserted and patent, proper body
temperature maintained. Basic vital signs has to be monitored, including ECG, pulse rate, breathing
12 Prevention of fall and self-injury
rate, oxygen saturation level, temperature, etc.
All details of transport preparation should be noted in patient record, including the administration of
medicaments and solutions.
11.1 Emergency transport
Hospitals have used leather wrist and ankle restraints for over 135 years. Today’s trend is to see
hospitals moving to polyurethane restraint systems or web restraints (polypropylene or nylon
restraints).
Emergency transport is transport towards the health institution, which cannot be postponed, and
conducted by ambulance, ship, helicopter or airplane.
46 47
V Hygienic and preventive measures
Author: |}X~
Collaborator: Jadranka Maras, bacc. med. techn.
Translation: \

48 49
1 Introduction There are three modes/levels of hand hygiene:
Every health facility is obliged to prevent nosocomial infections and their spreading. It is well documented that x Standard hand washing
health care personnel have an instrumental role in the spreading of nosocomial infections. However, health x Hygienic disinfection and
care personnel are under a risk, too. They can get infected from patients in four principal ways: direct contact x Surgical disinfection or antisepsis of the hands.
with patients, by fecal-oral route (eating and drinking), through air (inhalation) and blood handling. The causes
of infections are bacteria, viruses, fungi, present in water, air and in the patients` environment. Patients 1.1 Standard hand washing
themselves can be potential source of infection, too.
2 Asepsis
Applying asepsis principles in hospital one prevent transmission of microorganisms from one place to the other,
from one patient to the other or to the personnel. Asepsis is achieved by disinfection and sterilization
techniques. Disinfection is a technique of minimizing the total number of microorganisms on live and non-live
subjects and surfaces, which eradicate most or all pathogenic microorganisms, except bacterial spore.
Disinfectants of high potential can, if they are applied 6 to 10 hours, eradicate the bacterial spores, too.
Disinfection has better effect if the objects and surfaces have been previously cleaned. It is common procedure
in healthcare facilities, but it should be used in all facilities where is a significant circulation of people (public
Figure 1. Smear of unwashed hands Figure 2. Smear of washed dshan.
facilities, schools, daycare center, etc.) Disinfection in healthcare facilities is used on:
Only on washed, clean hands one can apply antiseptic disinfectants based on alcohol. These antiseptic agents
1 Hands of healthcare personnel
are used for further reduction of pathogenic microbes, having non-significant influence on bacterial flora that
2 Skin and mucous membranes of patients
an individual regularly has on skin. Alcohol-based antiseptic are more effective and act faster than soap proper.
3 Instruments and equipment
4 Working areas, floors, walls 4.2 Hygenic disinfection (hand antisepsis)
5 The air in facility
6 Equipment and furniture used by patients Hygienic disinfection or hand antisepsis is a hand washing with alcohol-based antiseptic agents. Hands should
7 Laundry of patients and protective work clothing and footwear of patients and personnel be disinfected:
3 Personal protection measures 1. Before and after direct contacts with patients
2. Before invasive procedures
Health care personnel have to observe preventive measures in order to protect themselves, their colleagues 3. Before gloving and after taking gloves off
and patients. The most important measure is hand washing, because it is the most common way of 4. After contact with blood, secretions and excretions
microorganisms’ transmission. 5. Before and after handling the patients’ dressings, urinary catheters, tubes, drain, etc.
Personal protection measures include: 6. After contact with patient who is infected with in-hospital germs
x Washing hands, properly and regularly Hand disinfection has two steps:
x Proper use of protective clothes and footwear
x Proper use of masks and gloves x hand washing with antiseptic detergent for one minute
x Proper handling of sterile material x hand scrubbing with waterless alcohol-based antiseptic rub for one minute
4 Hand hygiene Sanitizers (rubs, gels or rinses) are excellent hand disinfectants if they contain 60% alcohol or more.
The term hand hygiene refers to hand washing and disinfection. Washing hands is the most important and the
most efficient method of preventing transfer of microorganisms between medical personnel and patients. The
main prerequisite for hand hygiene is the length of nails. Nails must be clean and short, not longer than
fingertips, and nail polish should not be worn. Artificial fingernails/extensions and wrist/ hand jewelry should
not be worn when providing care.
50 51
Figure 3 illustrate recommended washing procedure 4.3 Surgical hand disinfection
The goal of surgical disinfection or antisepsis is to eradicate pathogens. Sanitizers (rubs, gels or rinses) used for
surgical hand washing are the same as those used for hands disinfection. The difference is in:
x length of the hand washing

x larger skin area to be washed, including washing of wrists and forearms.
Surgical disinfection can be done in two ways; by hand washing and by rubbing of an antiseptic agent. When
performing surgical hand washing, hands are being scrubbed with antiseptic detergent for one to two minutes.
After scrubbing an antiseptic, alcohol-based agent is rubbed in 30 – 60 seconds. For surgical rubbing, the first
Use alcohol-based waterless antiseptic Lather and scrub 1 minute
step is hands washing with liquid soap or lotion for 30 – 60 seconds, hands are rinsed, and finally an alcohol-
based antiseptic agent is rubbed for three minutes. In smears after surgical disinfection should be no
microorganisms to be found. (Figure 5).
Rub palm against palm with crossed fingers Rub right hand palm against backhand of the left
Figure 5. Smear after surgical hand disinfection
Antiseptics are disinfecting agents. Their toxicity is low and they can be applied directly on the skin, mucous
membranes and on the wounds. The most significant antiseptics are the ones belonging to groups of
chlorhexidine, iodine preparations and alcohol.
5 Medical protective clothing

Hook fingers of right hand with fingers of left Drying last 20 - 30 seconds
Medical protective clothing is essential equipment not only to protect medical professionals from
pathogens, but also to protect patients from possible contamination by non-sterile garments. There
are different types of protective attire to cover every part of the body. Different medical
professionals choose which type of clothing they wear based on the requirements of their job, the
hazardous or delicate situations they may encounter.
52 53
5.1Safety glasses or face shields 5.3 Gloves
Gloves are necessary when working with body fluids or sterile equipment. Latex gloves are thin and flexible
enough not to impair the wearer's dexterity. Individuals with latex allergies may opt for other materials with
similar performance properties. Protective gloves prevent transfer of microorganisms from patients to
personnel and the other patients. Non-sterile gloves are used for longer contacts with patients, linen and
equipment. Sterile gloves are used for medical procedures and some diagnostic procedures.
It is necessary to wash hands before and after using gloves. Gloves cannot be substitute for hand hygiene.
Personnel should not touch phones, keyboards, hospital records, doorknobs when wearing the gloves. Gloves
should not be worn outside work area, e.g. in hospital corridors. One pair of gloves can be used for one
procedure only, at the end they are discarded, and hands washed. Every new procedure requires use of a new
pair of protective gloves.
Plastic goggles protect against sudden splashes of fluids such as blood, vomit or excrement. They should
completely cover the eyes and may wrap around to the temples for extra protection on the sides.
5.2 Masks
Masks are generally worn over the nose and mouth either to prevent exhaling microorganisms in a
sterile environment or to protect them from particulate matter or contagious diseases in the
surrounding air. The mask must cover both nose and mouth. It should be changed after sneezing and
coughing and should not be reused.
54 55
5.3.1 Gloving procedure 5.4 Lab coats
1. Prepare the package with gloves of the appropriate size (most often used sizes vary from 6 to 8,5); These garments are generally more formal than other protective clothing and are not necessarily suitable for a
2. After hands disinfection, dry them completely; sterile environment. At the same time, they usually come equipped with convenient pockets and can still
3. After opening the package (by an attendant), be careful not to contaminate the gloves; provide a minimal level of protection in case of emergency use.
5.5 Scrubs
4. Distinguish the right from the left glove;

5. Check if the cuffs on the gloves have been folded properly;
6. Glove the dominant hand first.
These are some of the most familiar medical garments and are widely available in different solid colors, prints
and matching sets. Scrubs may be worn over other clothing and are easy to change and replace if soiled or
contaminated.
5.6 Shoe and boot covers

7. The glove is held with the thumb and two fingers of the non-dominant hand. Only the folded edge of the
cuff is in contact with “non-sterile” hand.
8. When the dominant hand is inside the glove, the glove should then be pulled on and stretched.
9. The cuff on the glove is unfolded;
10. In due process, the outer surface of the glove shouldn`t touch skin or any non-sterile surface.
11. When gloving the other, non-dominant hand, the gloved hand should slip into the folded cuff from outside.
12. The second glove is lifted and pulled over, and adjusted to get a snug fit.
13. Gloved hands should be held above the waist level.
5.3.2 Taking off the gloves
When taking the gloves off, attention should be paid to not contaminate the hands. First the glove of one hand
should be pulled inside out, then another one. Gloves are disposable and should be discarded. Finally, person Thin, elastic booties cover footwear completely and are available in a range of sizes to accommodate different
should wash hands thoroughly after removing gloves. shoe sizes and styles. They are used when aseptic work conditions are needed, when working with toxic agents
(cytostatic drugs) and with infectious materials.
56 57
5.7 Scrub and surgical caps

6 Medical wastes
Many medical wastes are classified as infectious or biohazard us and could potentially lead to the spread of
infectious disease. Examples of infectious waste include blood, potentially contaminated "sharps" such as
needles and scalpels, and identifiable body parts. Sharps include used needles, lancets, and other devices
capable of penetrating skin. Infectious waste is often incinerated. The most common method of sterilization is
an autoclave. The autoclave uses steam and pressure to sterilize the waste. Additionally, medical facilities
produce a variety of waste hazardous chemicals, including radioactive materials. While such wastes are
normally not infectious, they may be classified as hazardous wastes, and require proper disposal. Disposal of
this waste is an environmental concern.
Syringes, infusion systems, gloves, bandages, PVC bags containing biological material, catheters, tubes,
drainage tubes, infectious patient`s waste and containers are defined as infectious waste and are disposed into
This headgear covers the hair and scalp not only to keep microorganisms contained but also to keep control of red bags.
the wearer's hair. Scrub caps are generally looser while surgical caps are tighter and more restrictive for the
more sterile environment. Used needles, sharp objects, test tubes, ampoules etc. should be disposed into plastic containers that are
closed and sealed after being filled up to two thirds.
5.8 Coveralls or jumpsuits
Special attention must be paid to prevention of stabbing incidents while working, cleaning and disposing used
These one-piece garments cover an individual from head-to-toe and include attached booties. They generally needles, scalpels and other sharp instruments.
fasten in the front and may include a hood or attached mask.
5.9 Surgical gowns
These rear-closure gowns are used by surgeons and are generally discarded after use to prevent any contagion.
They may include long sleeves with elastic cuffs, and the gown lengths vary but generally reach at least as low
as the calves.
5.10 Sleeves
Independent sleeves have elastic at both the top and the bottom for a secure fit and are worn when gloves do
not provide enough coverage but when a full gown is not required.
5.11 Aprons
Aprons are being used by nurses when taking care of patients and physicians when they expect spraying of
blood and excretions. They are disposable and used for one patient only.
58 59
VI Principles of patient care
Author }
Collaborators:
=

Dubravka Kocen, MD
Rahela Orlandini, dipl. med. techn
60 61
4 PATIENT’S BED
1 GOAL Based on their construction, patients’ beds can be:
The aim of this chapter is to familiarize the student with essentials of patient care, necessary Standard – with metal frame, netted mattress support and bed legs with wheels to enable moving
equipment, devices and furniture, and with prevention measures for decubitus ulcers and deep vein and repositioning of the bed. Most hospital beds allow head adjustment. Standard dimensions are 2
thrombosis. x1 m, and 80 cm height (working level). They are most commonly used on standard hospital wards.
Special – made of multiple connected adjustable parts, with bed legs most commonly on wheels.
2 CONTENT AND PROGRAM Often electric or semi-electric, they allow easy manipulation of height and body position. Standard
dimensions are 2 x 1 m with hydraulic height adjustment of height, in the range of 50 – 80 cm. They
1. Feeding the patient; are most commonly used in intensive care units (ICU) and intensive treatment units (ITU), (Fig.1).
2. Washing the patient in a bath tub;
3. Washing the patient in a bed;
4. Oral hygiene;
5. Hair washing and hair hygiene;
6. Handling hair parasites;
7. Cleaning and protecting of eyes;
8. Cleaning and rinsing of ears;
9. Perineal and perianal hygiene;
10. Preventive measures for normal and sensitive skin;
11. Thrombophlebitis prevention
3 EXPECTED RESULTS
Figure 1. Special hospital bed
Rooms in hospitals should not have more than 4 beds. Each of the beds requires a minimum of 6 m2
and skills and will be competent:
of space, with 20 m2 of space per bed in ICU-s. Patient isolation rooms require 25 m2 per bed.
1. Prepare the bed for the patient’s comfortable accommodation;
2. Properly position patients according to their needs; Patients’ beds are described in detail in chapter “Environment, equipment, transport”.
3. Prevent bed sores (decubitus ulcer) formation;
4.1 Preparing the bed and positing the patient
4. Prevent accidents, self-injury and falls of patients;
5. Execute proper skin, mucous membrane and external orifices care; Positioning of the patient should always be done in teams, with specific responsibility for each
6. Control and measure fluid intake and output; member.
7. Feed patients naturally, through a feeding tube, stoma or parenteraly.
Patients should be covered in order to maintain their body temperature and to keep them warm,
using an extra blanket if needed (operating rooms are often air conditioned). The loss of blood or low
temperature in the room can significantly decrease patients’ body temperature.
Patients are positioned in the in accordance to their treatment needs. Specific positions are
described in the chapter “Environment, equipment, transport”.
62 63
through urine output, stool, vomiting, perspiration and breathing (400 ml daily for an average adult).
5 Patient diet and feeding The fluid loss is deducted from the intake, resulting in the positive or negative fluid balance. Clinical
signs of dehydration must always be checked for (dry skin, decreased skin turgor, decreased urine
Proper diet with an adequate intake and absorption of both nutrients and fluids is a prerequisite for
volume, darker urine, dry tongue, increased heart rate, orthostatic hypotension, and headache.
the body’s normal functioning and balance. Patient’s diet includes standard per oral diet, specific
Patients should be reminded to take more fluids, until the fluid balance is met.
food diet, food supplements, enteral and parenteral diet. Proper diet shortens hospitalization time,
lowers morbidity and has a positive influence on the treatment outcome. 6.2 Enteral feeding
5.1 Peroral diet Enteral feeding should be administered to those patients that require specific diets, to unconscious
patients, and to patients with the inability to swallow food. Enteral feeding should be started as soon
Per oral diet is the best nutritive support for the patient and should be provided whenever possible. as possible (within 24 to 48 hours) unless specific contraindications exist. Enteral feeding is
It includes the standard diet; specific diets are tailored for particular clinical conditions, e.g. cardiac, administered through nasogastric or nasojejunal tubes, or gastric and jejunal stomas. Transnasal
diabetic, kidney diet. access is used when the feeding is expected to last up to 4 weeks. The tubes are inserted blindly, or
5.2 Enteral diet using endoscopic or x-ray guidance. Silicone tubes are used when the feeding is expected to last for
only a few days, because they, when exposed to gastric acids, becomes rigid and can cause stomach
Enteral diet is a nutrition process achieved through digestive system. Food and pharmaceutical ulceration.
products can be given per oral or through a gastric or an intestinal tube.
Endoscopically or surgically made gastric and jejunal stomas are installed when enteral feeding is
5.3 Parenteral diet expected to last longer than 4 weeks.
Parenteral diet is a method of providing nutrients (carbohydrates, amino acids, fats, minerals and 6.2.1 Nasogastric tube
vitamins) and fluids through blood vessels. Normal intake of nutrients and fluids with their
Food can be given through the nasogastric tube (Figure 2) intermittently in boluses, 6-10 times a day,
absorption within the intestines is not only the optimal pathway for energy uptake, but it also serves
or continually 20-150 ml/hour. During food intake the patient’s upper body must be slightly elevated
to balance the defensive mechanisms and barriers of both the intestine and the whole body (the
200 – 450 in order to lower the possibility of food aspiration. Position of the nasogastric tube (NG) is
intestines are the largest immune organ). Without the food’s stimulation of enterocytes, even within
always checked by two medical professionals.
such short period as 24 - 48 hours, intestinal barrier becomes weakened, the mucosa atrophies and
the loss of fat begins. Immune system is compromised, bacterial flora is altered and more pathogenic
microorganisms enter through the intestine, which can have serious septic consequences.
6 Feeding the patient
6.1 Peroral feeding
In conscious patients with intact swallowing reflex, if there are no contraindications for per oral
feeding (mechanical obstructions, intestine ischemia) per oral feeding is preferable. Depending on
the patient’s capacity to chew and swallow, food of different consistency will be given, from liquid to
fibers. Age and the patient’s condition should always be considered.
Elderly patients can have difficulties with swallowing food, feeding sequence coordination and poor
understanding of medical personnel instructions. Therefore, the first is to explain them that they
should eat, and that the food was especially prepared for them. Before feeding patient is positioned
in upright position suitable for eating and swallowing, and their attention is directed toward the food Figure 2. Nasogastric tube
and cutlery. If patient needs additional assistance, it has to be provided for each of the meals.
Sufficient intake of fluids must always accompany per oral intake of food. If there is a decrease in
food intake, body requirements for fluids increase. Fluid intake must be monitored, and calculated,
including its content in food, per oral drinks, and intravenous intake. The fluid loss usually happens
64 65
6.2.5 Nasogastric-duodenal tube
A nasogastric-duodenal tube must be visible when exposed to radiation. If air is injected then it can
be detected by radiation imaging techniques, ultrasound or by auscultation. Long tubes that must
reach areas after the Treitz ligament usually have guiding wires within the tubes themselves. They
can damage the mucosa, and therefore must be inserted by experienced professionals.
6.3 Nutritive solution for enteral feeding
Nutritive solution preparation in the hospital for nasogastric or other tubes feeding is rare today, due
to the high cost of their preparation in comparison to commercial nutrients. These commercial
products have strictly controlled nutrient values, and offer calories and content in wide range of
Figure 3. Position of inserted nasogastric tube varieties.
in relation to anatomical landmarks.
Basic diets are made of oligopeptides and amino acids, sucrose, disaccharides and basic sugars, along
6.2.2 Nasogastric tube insertion with small amount fat.
1. Determine the insertion depth, measuring the distance from the patient’s nose tip to the ear lobe Chemically defined diets are made mostly of amino acids and oligosaccharides. They are specifically
(distance 1) and from the tip of the nose to the xyphoid process (distance 2). made for patients with specific problems (polytrauma, kidney failure, liver diseases, hemodialysis,
2. Check for nasal passage obstruction. etc.).
3. Lubricate the tube, first 15 - 20 cm, which is the part of tube going to the pharynx.
4. Tilt the patient’s head backwards, put the tip of the tube in the patient’s nostril, direct the tube
toward the inferior nasal corridor and gently insert the tube to the length of first measured 6.4 Methods of tube feeding
distance (tip of the nose to the ear).
5. Continue slowly and gently to insert the tube, until you reach the distance of the second Patients can be fed continually or intermittently.
measured one.
6. Do not exert any force during tube insertion. If resistance is encountered, tube should be Continual feeding is maintained throughout all 24 hours. If fed this way, patient’s stomach is not
advance by gentle rotational movements.
burdened and the side effects occur less frequently. Continual feeding is especially indicated for
7. In case of choking, coughing, cyanosis, (respiratory distress signs, which indicate that the tube is
in the airway) insertion must be stopped, and the tube pulled out up to its first measured patients with tubes in the small intestine and those suffering from severe malnourishment and
distance (tip of the nose to the ear). fatigue with partially damaged alimentary tract.
8. After short rest the procedure is repeated.
9. Determine whether the tube is in the stomach (aspirate the gastric fluids or listen through a Intermittent feeding is most commonly used, and imitates regular food intake. Daily amount of
stethoscope for a sound generated when 10 cc of air is injected through the tube) nutrients are divided into 3 or more meals, with the biggest meal size being 350 ml, as larger meals
10. Secure the NG tube to the nostril using hypoallergenic tape. decrease digestion time. A single meal is given 30 ml/min, which means that a 350 ml meal
administration lasts at least 12 minutes. However, in practice food is usually given 7 ml/min, 50
6.2.3 Percutaneous gastrostomy
minutes per meal. It is recommended to give smaller amounts more often. As with continual feeding,
Percutaneous gastrostomy is indicated in patients in whom due to mechanical or other reasons infusion pump or simple feeding system dependant on gravity delivers the food, however the later is
(deformations, obstructions or operations in the oral cavity or esophagus) a tube cannot be inserted more difficult to monitor and ensure the delivering of the proper amount of food per time unit.
nasally. The procedure is most commonly endoscopic, but it can be done with classic surgery. Nutrients given in one meal (bolus) are often accompanied by aspiration and regurgitation because
the large amount delivered, and should therefore be avoided.
6.2.4 Jejunostomy
Jejunostomy is indicated in patients in whom due to anatomical changes of the gastroduodenal tract
(including surgeries and obstructions) a tube cannot be inserted nasally. The procedure is most
commonly surgical (laparotomy).
66 67
6.5 Complications of enteral feeding

7 Washing the patient
6.5.1 Mechanical complications
7.1 Washing the patient in the bed
Mechanical complications are largely dependent on the tube type, its width, length and method of
insertion. Thicker tubes can damage the gastric or enteral mucosa, while the thinner ones (3 mm and 7.1.1 Preparing the patient
less) easily become clogged, and therefore need to be flushed by 20-50 ml of water after feeding.
The patient should be informed that he is going to be washed, and the washing method should be
The area around the gastrostomy or jejunostomy can become infected or damaged if adequate care
explained.
and hygiene is not conducted.
7.1.2 Accessories
6.5.2 Gastrointestinal complications
Most common gastrointestinal complications are regurgitation, diarrhea or constipation. x oral cavity washing kit
x pot with water
Regurgitation is most commonly caused by inadequate tube position, tube width, high food
x liquid soap or bath
osmolarity, fast feeding or medication given together with the food.
x bath or hand sponges (puffs)
x towels
Diarrhea is most commonly caused by fast feeding, high food osmolarity, sensitivity of the patient to
x nail scissors or clippers
some food supplements or compounds (e.g. lactose), antibiotics, severe protein malnutrition, x nail file
malabsorption or bacteria proliferation. x hairbrushes
x massage lubricants (alcohol, lotions, oils, creams)
Constipation is most commonly caused by fiber free diet, patient inactivity and inadequate fluid
x rubber gloves, disposable gloves
intake. x clean and folded bed sheets
x pajamas or nightgowns
6.5.3 Metabolic complications
x emesis basin (kidney shaped basin)
Metabolic complications should not occur when patient is being properly fed. Laboratory parameters x bins
need to be checked regularly, especially electrolytes, sugars, fats and vitamins making any metabolic 7.1.3 Preparing the patient’s room
complications easier to remedy.
x close the windows
6.6 Parenteral feeding x fix the trolley beneath the bed
Parenteral feeding can be the only method of providing nutrients (total parenteral nutrition, TPN) x adjust the bed screen
when all nutrient needs and energy of the patient are met, or it can be partial (partial parenteral 7.1.4 Washing procedure
nutrition, PPN). The nutrients are administered through a peripheral or central vein, depending on
the osmolarity of the food. It is used when any contraindications for enteral feeding exist 1. Bring the trolley with prepared washing equipment and accessories in the patient’s room.
(hemodynamic instability, intestine ischemia, and ileus). The common side effects include liver 2. Before undressing the patient perform oral hygiene
steatosis, cholelithiasis, and pancreatitis. Parenteral feeding should begin after 3 days, if the patient 3. Remove the bed’s sheets, pillows and covers. Take off the patient’s pajamas or nightgown.
is unlikely to be fed enteral. In patients with severe burns or severe malnutrition, it can be started 4. The patient should be washed in the following order: using the hand sponge wash first one, and
earlier. then the other eye lid of the patient, using separate glove corners for each side. Eyes are washed
from the outside corners in. The face is then washed with water, starting from the middle of the
forehead, going below the eyes to the nose, and then back below the lips to the middle of the
chin, making a number 3 sign. Then the same is repeated for the other side of the face.
Afterwards the area beneath the patient’s nose and around the mouth is washed. Ears are
washed with water and soap, or shampoo.
68 69
5. The neck is washed with semicircular movements from the inside out. Shoulders and the neckline
follow the same patter. Patient’s chest are washed making an 8 sign, following the washing of 7.2.4 Bathing
both armpits. The abdomen is washed using long movements, with special attention given to the
1. Bring the movable trolley with washing equipment in the bathroom and a basket for used cloth.
umbilicus.
2. Before every wash, the bathtub should be disinfected and washed with water, and then
6. Arms are washed from the hands up, with needed attention given to areas between the fingers.
mechanically cleaned.
The lower and upper arm is washed separately, using long transversal or semicircular
3. Fill the bathtub with water, first cold then warm – avoiding making vapor this way.
movements. The legs are washed the same way as arms. Patient genital are washed using hand
4. Check the water temperature (35 - 36°C).
sponges and rinsed with water. Special care should be given to the area around the urinary
5. Cover the patient, and bring him with the movable bed to the bathroom. Position the bed next to
catheter (if present).
the bathtub. Take the pajamas off the patient. Patient’s leg should be moved over into the
7. The patient is dried using a towel.
bathtub, and then the nurses or caretakers would take the patient beneath his armpits and
8. Afterwards, the patient is turned on the side (by holding the patient to his shoulder and hip of
slowly immerse him/her into water.
the opposite side). The back are washed using long movements from the gluteus to the neck and
6. The patient is washed in the same order as the patient in bed, except that the face is washed
back. Each half of the back is washed separately. In the end the area between the gluteus is
using hot water.
washed.
7. After being washed the patient is put back on the bed using the same method as before, where
9. The back is then dried using a hand towel, and alcohol, lotion or oil is used to massage the back.
he/she is then dried, massaged and clothed. Patient’s hair should then be bruised, and finally the
The area between the gluteus and the genital area should not be cleaned with alcohol.
patient should be brought back to his room.
10. Bed sheets are then changed with clean sheets.
8. Movable trolley and the accessories are taken out, and the bathroom left cleaned.
11. Patient is then positioned on their back, and their front massaged with lotions or alcohol. The
patient’s nightgown or pajamas are put on. 8 Mouth hygiene
12. Patient’s hair is then brushed one wisp of hair a time, following which the comb or brush are
cleaned. Mouth cavity is moist from the oral fluid composed of mucous and saliva, secreted by the salivary
13. Immobile and passive patients should be washed by two persons. glands. In patients with high temperature or those on parenteral feeding, mucous membrane is dry,
and the gums and tongue becomes covered with detriments of different color, depending on food
7.2 Washing the patient in a bathroom ruminants, bacteria and fungus. Dry mucous is easily damaged and susceptible to infection.
A patient can use a bath only with the permission of a doctor. Baths should not be used by bleeding 8.1 Oral cavity care
patients, patients in shock or with high temperature. Before a bath patient’s pulls and temperature
should be measured. 8.1.1 Equipment
7.2.1 Preparing the patient 1. Gloves, tongue depressor and torch for examining mouth;
2. A small, soft bristle toothbrush;
The patient should be informed that he is going to be washed, and the washing method should be 3. Fluoride toothpaste;
4. Foam sponge sticks;
explained.
5. Plastic disposable beaker;
6. Jug of water;
7.2.2 Washing accessories 7. Receiver;
8. Box of tissues and towel
The same accessories are needed as with washing the patient in bed, with exception of the pot with
water. It is useful to have a water thermometer.
7.2.3 Preparing the bathtub
x close the windows

x check the temperature of the room (17 - 20° C)
x check the shower
70 71
8.1.2 Procedure
9 Hair hygiene and hair washing
1. Aspirate the secretions present in the mouth.
2. Check the oral cavity using the tongue depressor and torch. 9.1 Washing the hair of a bed ridden patient
3. The most effective aid for maintaining dental and gingival health is a toothbrush. The brush
9.1.1 Preparing the patient
should have a small head with evenly spaced, soft bristles. Always use fluoride toothpaste.
4. It is easier to stand behind the patient when you clean their teeth, if they are able to sit in a chair. The patient should be informed that the hair is going to be washed, and the washing method should
For patients confined to bed you have to stand to one side of the bed. be explained.
5. Top teeth: hold the brush at an angle of 45
6. Bottom teeth: the same angle of 45 9.1.2 Preparing the accessories
7. Move the brush in a circular motion. Clean the gums next to the teeth as well.
Trolley with a pot of warm water, an empty pot, shampoo, rolled sheets, leak tight sheets, two
8. When tenacious mucous is present or mouth is crusted moisten the damaged areas with sodium-
towels, hair dryer, hair brush, kidney shaped basin.
bicarbonate solution (dilute one teaspoon in 500mls of warm water) or hydrogen peroxide
solution, using cotton sticks, foam sponge sticks or soft gauze. 9.1.3 Preparing the patient’s room
9. Wait for a few minutes until the debris is softened and can be easily separated from the mucous.
10. Remove the debris using a spatula, spatula with a gauze, or surgical forceps. Close the room’s windows and open the bed’s sheet storage.
11. To rinse the oral cavity use 5 cc of oral hygiene solutions and aspirate (Fig. 4)
9.1.4 Washing the patient’s hair
12. Repeat several times if necessary.
13. Using soft gauze and a spatula, or cotton swabs to clean the oral cavity. 1. Remove the bed covers and pillows.
14. For refreshing mouth use glycerin/thymol tablets (1 tablet to a beaker of water). 2. Position the patient in semi-sitting position, put a rolled sheet beneath the patient’s neck, and
15. Dry the lips and rub them using paraffin oil or lip balm, which prevents lips cracking- put an empty pot nearby and a towel beneath the patient.
3. Water the patient’s hair, shampoo it, rinse and repeat the procedure.
4. Remove the leak tight sheets, and protect the front of the neck from getting wet.
5. Remove the rolled sheets, put the patient’s hair in the towel, position the patient in the lying
position, and put the pillows beneath this head.
6. Dry the patient’s hair and brush it.
7. Remove the accessories from the room, including the movable trolley and open the room’s
windows.
8. Washing is done by two persons, one at the each side of the patient’s bed. One person washes
the hair, while the other pours the water.
9.2 Washing the patient’s hair in a bath
Figure 4. Accessories for oral cavity care Prepare the patient and the necessary equipment, including the bathroom. Bring the patient to the
bathroom using transport beds or gurney. Position the patient next to the sink or a bathtub, and
position his head above the sink/bath. One person holds the patient’s head, while the other washes
it, similar to washing the hair in the patient’s bed.
9.3 Head lice
Head lice (Pediculus humanus capitis, Figure 5) are small insects, gray-white in color, and 2 - 4 mm
long. They live exclusively on the human scalp, and cannot survive more than 48 hours if not on the
scalp, sucking human blood. Their life span is around 2 months. Careful examination of the scalp and
hair follicles can reveal either living lice, or only eggs attached to the base of the host’s hair shaft.
72 73
A grown female is 3 - 4 mm in size, and bigger than the male. Lice have 3 pairs of legs that end in
10 Eye care
small claws and an opposable thumb, with which they hold to the hair. Their mouths are adapted for
piercing skin and sucking blood. Lice can also be detected with an electric comb, which announce the 10.1 Cleaning and protection
presence of lice in the hair with sound, and kills the lice using sounds waves.
In patients with altered level of consciousness eyes are often constantly open. In order to prevent
keratitis, cornea damage and ulceration eyes need to be moistened using saline solution.
Eyes are wiped from the outer rim in, eye drops should then be dribbled, and eye ointments (Tobrex
or similar) applied when needed.
10.2 Dribbling of eye drops
Before applying eye drops, eye lids should be firmly held. Using ones thumb outer third of the lower
lid is pushed down and the index finger of the same hand is used to lift the outer upper lid without
touching the bulb of the eye. Dropper should be at least 1-2 cm away from the eye, and if the eye lids
close, they will not contaminate the dropper. One to two eye drops are dribbled in each eye (Figure
6).
Figure 5. Pediciulus capitis
9.3.1 Lice removal
It is important to interrupt their reproduction cycle. Among the available substances, some are toxic,
and special care needs to be taken to avoid the contact of products eyes, nose or the mouth. Lice can
also be removed mechanically and combing the hair with electric combs. This is an efficient
procedure, especially for dry hair. With prolonged lice infestation, it is recommended to cut ones
hair, and then remove the lice. Long blond hair is a problem, for the lice cannot easily be detected Figure 6. Dribbling the eye drops.
due to their color.
10.3 Application of eye cream
9.3.2 Nit removal
To apply eye cream or ointment, open the eye as described in previous paragraph. Ask the patient, if
Following the procedure to remove lice from the hair, their eggs (nit) need to be removed communicative, to look up, and approximate the tube toward the eye. Squeeze the tube gently, and
thoroughly. If only a single pair remain, this is sufficient to produce a new generation of lice. The apply ointment from inside rim out. When ointment is applied ask the patient to keeps the eyes
process is facilitated if both lice and eggs are removed together, using a very dense metallic combs. closed for several minutes, for better distribution of the ointment within the conjunctiva and cornea.
74 75
11 Cleaning and rinsing of ears 13 Preventive measures for normal and sensitive skin
Cerumen or earwax is a natural secretion of sebaceous glands within the ear canal. It contains 50% 13.1 Skin function
water and 50% of salts and solids, making it semi-fluid and light yellow in color when fresh, and
Human skin has (i) protective (mechanical, chemical, thermoregulatory), (ii) secretory, (iii) excretory,
darker and more solid with time passage. It is produced gradually over time and physiologically
(iv) respiratory, (v) sensual, (vi) immune, and (vii) nutritive (vitamin production) function.
removed during sleeping and chewing. However, in certain instances it accumulates and can cause
blockage of the ear canal. Possible reasons include: Only clean and health skin can accomplish all those function. Maintaining proper skin care is of great
importance for the patient, and regular removal of layers of dirt enables skin functioning. Washing
x increased earwax production (hypersecretion); and massage increases peripheral circulation, enhances respiratory function and skin nutrition. In
x mechanical obstacles (narrow or irregularly curved ear canal), what cause irregular removal of
patients with heart and respiratory conditions, increased peripheral circulation unburdens the
earwax
x decreased earwax secretion (hyposecretion). Dried earwax prevents removal of the newly principal blood flow. Decubitus ulcers are a common complication of inadequate skin care of bed
formed earwax, causing over time the formation of ear wax buildup in layers, in the shape of an ridden patients; however, even with proper care some skin damage is still possible.
onion.
Ear wax is rinsed using a large syringe filled with warm (not hot) water. The tip of the syringe is
13.2 Decubitus ulcer prevention
inserted into the outer third of ear canal, and water is applied under moderate pressure. When water
reaches the deepest part of the canal, a vortex is built, which dissolves earwax buildup and push it
outside of the canal. Temperature of the water should be 37 °C. During ear infections and following
ear surgery 3%- boric acid should be used instead of water.
12 External orifices hygiene (urethral orifice, perineum, anus and perianal region)
Regular and proper external orifice hygiene is of great importance for the patient. Washing the
gluteus region requires the patient to be positioned on the side. Those patients who are capable
should wash their genitals themselves or with the assistance of medical professionals, following
which they need to wash their hands. Genitals and perineal area of patients who are unable to
perform the procedure independently, assistance of health workers is provided.
Washing the vulva and the perianal region in females, or preputium and perianal region in males is Figure 7. Decubitus of the sacral region
executed with warm water, soap and gel of appropriate pH value, to avoid irritation the mucous
Decubitus ulcers (bedsores, pressure sores) are local skin lesions caused by prolonged pressure on
membrane and sensitive skin. Afterwards the area should be dried with a paper napkin. Special care
the skin (Fig. 7). Compression leads to decreased circulation and subsequently lowers oxygen and
needs to be given to the hygiene of the urinary catheter.
nutrient supply to the skin. The process occurs most commonly on areas most exposed to the skin
compression (back of the head, shoulder blades, elbows, tailbone, heels, outer parts of ankles and
knees), (Fig. 8).
76 77
Figure 9. Decubitus stage I: Figure 10. Decubitus stage II:

Local redness with intact skin. Partial skin damage or skin blisters.
Figure 8. Common decubitus locations
The aggravating factors for decubitus ulcer formation can be internal (problems with circulation,
malnutrition, neurological disorders, malignant diseases) and external (bed sheet folds, moisture and
dirt, uncomfortable beds, immobilization), (Fig. 9-12).
With proper care, external aggravation factors should be reduced to minimum.
13.2.1 Prevention of decubital ulcers
It is necessary to understand the path physiological mechanisms leading to decubitus ulcer

Figure 11. Decubitus stage III: Figure 12. Decubitus stage IV:
formation, in order to: Skin and subdermal lesion Lesions of muscles and bone-
x evaluate the susceptibility for decubitus ulcers;
x plan the preventive measures; 13.2.3 Antidecubital aids and materials
x recognize early signs of ulcer in formation timely; and
Antidecubital accessories aimed to decrease local pressure, accompanied with proper nursing
x apply appropriate measures of prevention.
procedures, prevent decubitus ulcer formation. Most commonly antidecubital mattresses cover the
13.2.2 Measures full length of the bed and lower overall pressure to the skin. Mattresses are made of 3-5 cm wide
pads, which are intermittently inflated and deflated by an external air pump, producing continually
Firstly, personal hygiene and appropriate circulation of susceptible spots needs to be maintained by: oscillation of the pressure on skin areas. Special pillows are also used and exists for specific body
parts (buttocks), alleviating the pressures on the skin of bedridden patients, (Fig. 13).
x washing, cleaning, massaging with hydrating lotions several times a day;
x washing the skin following every defecation;
x using protective skin cream;
x regularly changing personal and bed cloths;
x changing the patient’s position in the bed (reliving pressure areas);
x applying antidecubital aids and mattresses, which decreases local or global pressure ;
x appropriate nutrient intake, which maintains normal skin function and protection.
Figure 13. Antidecubital mattress and pillow
78 79
14 Thrombophlebitis prevention 14.1.2.2 Intermittent pneumatic compression, IPC
Formation of a blood clot (thrombus) in the superficial or deep veins and the following inflammation Devices for IPK periodically compress muscles of the thigh and leg inducing fibrinolysis. They are
response is called a vein thrombosis or thrombophlebitis. usually applied immediately before or during surgical procedures, and then substituted with
compression stockings.
Thrombosis includes:
14.1.3 Medication, prevention and treatment
x deep vein thrombosis (DVT)
x massive or submassive pulmonary embolism (PE) 14.1.3.1 Antiplatelet drugs
x post thrombotic syndrome (PTS)
Aspirin (acetylsalicylic acid) is most commonly used.
Virchow's triad contains three categories of factors contributing to thrombosis: 14.1.3.2 Anticoagulants
x Vein stasis Unfractionated heparin

x Endothel damage/dysfunction Low molecular weight heparin
x Hypercoagulibility and/or increased blood viscosity
14.1.3.3 Oral anticoagulation drugs
14.1 Thromboprophilactic measures 14.1.3.4 Dextrans
14.1.1 General measures 14.1.3.5 Heparinoids
14.1.1.1 Mobilization and exercises 14.1.3.6 Hirudins
14.1.3.7 Pentasacharids
Lower limb exercises in bed ridden and immobile patients prevent vein stasis and should therefore
be conducted regularly.
14.1.1.2 Hydration and hemodilution
Hemoconcentration increases blood viscosity and decreases blood flow, especially in deep veins of
lower limbs, and should therefore be prevented.
14.1.2 Mechanical measures
Mechanical measures increase the average blood flow and lower vein stasis.
They do not increase hemorrhage risk, and should therefore be used even in patients with increased
hemorrhage risk.
They are contraindicated in patients with risk of skin necrosis and ischemia.
14.1.2.1 Compression stockings
Stockings are efficient for prevention of asymptomatic DVT and symptomatic PE in patient’s following
surgical procedures. Long stockings are more efficient then knee-high stockings. Proper size should
be selected, following which they should be properly administered, regularly check for their elasticity
and strength. They should be taken off for periods not longer than 30 minutes a day.
Contraindications are: severe leg burns, pulmonary edema, heart failure, peripheral artery diseases,
peripheral neuropathy, significant leg deformities, local dermatitis.
80 81
VII Medicaments and solutions handling
Author: Professor Mladen Carev, MD, PhD.
Collaborators:
~ ~-~X
~

82 83
1 Objectives 5 Training methodology
To inform the students about: 1 participating with clinical instructors in the preparation of patient and drugs, as well as in
administration of drugs
x all forms of medicaments; 2 training subcutaneous and intramuscular injections on models
x routes of their administration; 3 using «artificial hand with blood vessels for practicing intravenous injections and inserting
x procedures for administration: and intravenous line
x medicaments handling and storage 4 preparing infusions (opening of infusion bottles, set up of infusion systems)
5 preparation of vasoactive drugs, use of infusers
After a short lecture and demonstration, the students will practice the drug administration and 6 independent implementation of other routes of drug administration (topical application, eye
accompanying procedures at the Clinical Skills Center and at departments of the Clinical Hospital drops, inhalation, etc.)
Center Split. 7 accurate knowledge of all drugs needed for treatment of severe allergic reactions, with special
emphasis on epinephrine
8 proper handling of used syringes, needles, drugs and other equipment.
2 Expected outcome
After successfully mastering the contents of this module the students will have the basic knowledge
5 Storage of medicines
and skills, and will be able (competent) to: 1. Drugs are stored in a separate, only for that purpose intended locker. Moreover, opiates are
x distinguish all drug forms; kept separately, under lock and key locker.
2. Drugs for oral and external use are stored separately from drugs for parenteral use.
x assess the validity of drugs, check expiration date and the adequacy of conditions for drugs
3. Drugs should be stored at room temperature, protected from sunlight and heat sources.
storage;
4. Drugs which demand low temperatures are kept in a refrigerator.
x prepare infusions;
5. Drugs must be stored in the original package (vials, boxes), which contains the information
x know the standard disposal procedure of used needles and syringes;
about the drug.
x understand procedures related to drugs and infusions administration;
6. Medicines should not be transferred (from the vial into the vial, from the box to another box,
x recognize allergic reaction to medication and to handle the condition in proper manner. etc.).
7. There must be a clearly marked expiry date on the vials and pillboxes.
3 Content 6 Medicaments administration route
During this module the students are supposed to adopt the following skills:
STANDARD ROUTES OF DRUG ADMINISTRATION DRUG FORM
x safe-keeping of drugs, surveillance and care for stock
x principles of drug administration Oral tablets, dragees, capsules, solutions
x double control technique during drug administration Sublingual Sublingual tablets
ENTERAL Rectal suppositories, enemas
x routes of drug administration;
x methods for proper disposal of sharps, biological and infectious waste; Intracutaneous injections
x treatment algorithms of some adverse reactions to drug therapy; Subcutaneous injections
x recognizing and treatment of allergic reactions; Intramuscular injections
Intraarticular injections
x recognizing and treatment of the anaphylactic shock. PARENTERAL Intravenous Injections, infusions
Intrathecal Intradural subarachnoid injections
Pulmonary Inhalation (anesthetics), aerosols
Percutaneous (through the skin) ointments, pastes, creams, solutions
Rectal (through the anus) suppositories, ointments
Vaginal (through vagina) vaginalettes
Oral (into the oral cavity) Solutions, sublingual tablets
TOPICAL Mucosa of eye, ear, nose Drops, ointments
84 85
7.2. Preparation of a medicament

7 Drug administration principles
There are five important points to observe during drugs administration: 1. The physician prescribes the drug and notes the order in patient’s record. This note should
contain drug name, dosage, route and time of administration. The exception from this rule is the
1. Patient identity emergency, when staff is allowed to administer a drug upon physician's verbal orders, but the
2. Proper drug physician must record all medicaments given, as soon as the emergency situation ends.
3. Proper dosage 2. Any ambiguous or unclear order of drug administration must be checked and clarified. Examples
4. Proper route of administration are illegible physician’s handwriting on the list, an unclear dose which may be higher or lower
5. Proper time of administration than usual ones, etc.
3. Physician's instructions and orders (recorded on temperature charts or in patient’s record)
Errors may occur if one or several of these points are not strictly observed. In addition to these rules, health should be re-checked immediately before drug's application.
worker has to posses all vital information about the drug (purpose, effect, contraindications, and side effects). 4. Preparation of drug for administration should be conducted in a quiet and well lit room. To
ensure that the right drug is taken, one has to check its name from the label, by reading it three
7.1 Preparation of patients for intake of medication
times:
a) First time, when taking the drug from the pharmacy;
A. Mentally – to explain, teach, reassure; and
b) Second time, after taking the drug from the original boxes or bottles;
c) Third time, returning the excess of the drug back or during disposal of empty boxes.
B. Physically – to accommodate the patient in a position that will allow him an appropriate and
Note: The drug should never be taken and used out of an unmarked box or box with illegible or
comfortable intake of a medicament. Patient position should provide a comfortable working
incomplete label (name, dosage, expiry date).
condition for medical staff, enabling them to administer the drug properly.
5. Hands should be washed before drug preparation and distribution.
6. Tablets, capsules and dragées should not be touched with hands. We use a spoon or bottle cap
1 Prior to administration of a drug, the patient should be asked about allergic reactions in the
for taking oral medicines, and then the required quantity is laid into a patient's drugs container.
past; it is particularly important whether the patient has already received particular drug.
7. During parenteral administration of drugs (syringes, needles) all principles of asepsis should be
2 All patients’ questions about a drug should be answered, especially prior to the first intake of
strictly observed.
the drug; a distrustful patient should be reassured and the necessity for medication explained.
8. Antibiotics and cytostatic dilution with solvent should be carried out on the metal or marble
3 The patient should be put in a position suitable for taking the drug orally, by an injection,
board with protection of the skin of the arm.
enema, suppository or through nasogastric tube.
9. Having once a drug taken out of the box or bottle and prepared for distribution, it should not be
4 When patient is taking oral medications, a glass of water should be prepared.
returned to the original package.
5 The patient should be offered the juice, honey or sugar while taking drugs with an unpleasant
10. Box with medicines should be returned to their original place as soon as the drug was taken out.
taste, whenever his condition permits (e.g. diabetes).
11. Drugs that require special way of storage should be immediately returned to their original place
6 The patient should be encouraged to defecate and urinate before taking drugs that have
(e.g., insulin in a refrigerator, medications that must be protected from light in a dark room, etc.).
sedative action or when the long-term drug administration is anticipated (e.g. intravenous
12. The pills should not be broken or capsules opened, except when the patient cannot swallow the
infusion).
drug; in that case the contents of crushed tablets or capsule contents is poured in water and
7 Health staff should monitor patient’s reaction for several minutes, whenever patient receives
administered through the nasogastric or gastrostomy tube.
medication in any parenteral route; an anaphylactic reaction should always be anticipated.
13. Note: Never administer the medication prepared by someone else. Always prepare the drug by
yourself and deliver it personally to the patient!
14. Each drug administration, as well as time of administration should be documented in the therapy
list, an integral part of patient records.
15. The original covers, labels and vials of used drugs, solutions and transfusion should be
temporarily stored until the tolerability of applied remedies is not clear; some are permanently
stored in the medical records of patients (e.g. labels with numbers of transfusion products).
16. A drug that has changed color, odor, or consistency should not be administered.
17. A drug in liquid form that has changed color, become foggy or precipitated after mixing or
shaking should not be administered
86 87
5. Preparing equipment and materials:

7.3 Drug administration
a) sterile syringes of appropriate volumes,
7.3.1 Oral drug administration (through the mouth)
b) appropriate sterile needles,
c) solutions for disinfection of vials and patient’s skin,
Oral route is the most common route of drug administration. The application of the drug through the d) rolls of cotton or gauze,
patient's mouth is an easy procedure and seldom uncomfortable. It is necessary to: e) Sharps disposal container.
1. prepare the patient and medication as previously described; 6. Preparing the drug
2. bring the drug on the tray in the patient’s room ;
3. prepare a glass of fresh water or other beverage; a) Take a drug and check the name, dosage, route of administration, expiry date.
4. erect the patient in a sitting position or elevate her/his head; b) Prepare the syringe and needle of appropriate size, check whether the packaging is damaged,
5. assess whether the patient needs support (when taking the drug from the container, holding check the expiry date of syringe, open the pack from the side of the syringe plunger and draw the
glass, drinking through a straw); syringe from the cover, attach the needle for aspiration of substance.
6. explain the patient how to take a few sips of fluid before he puts a pill or a capsule in his mouth; c) Open the vial, aspirate the substance.
7. explain the patient how to place a pill or a capsule in the middle of the tongue, and then tilts his d) If the drug is in solid form, aspirate either a solvent which is packed together with the drug or a
head slightly backward or forward while swallowing the drug, following with a few sips of water; sterile solution that can serve as diluents (sterile saline, water for injections), inject the required
8. repose the patient in a comfortable position. amount of solvent in the bottle with the stopper previously disinfected, dissolve the drug
completely and aspirate the content into the syringe.
Note: The drug(s) should never be left with the patient and intended for later use (the patient must take a drug
in the presence of an attending health worker), unless it is explicitly prescribed otherwise (nitroglycerin, 7. Drug administration
antacids).
7.3.2 Parenteral drug administration a) After drug aspiration put on the protective guard on the needle.
b) Remove the protected needle and store it in an impenetrable sharps disposal container.
Parenteral drug administration includes: c) Take the needle of appropriate length and thickness for administering injection, depending on
the way of the drug administration (sc, im, iv).
1. subcutaneous administration (sc – under the skin), d) Accommodate the patient in a comfortable position.
2. intramuscular administration (im – into a muscle), e) Disinfect the puncture site.
3. intravenous administration (iv – into a vein), f) Hold up the syringe and gently push the plunger to eject the air out, until the droplets of the drug
4. intradermal administration (into the skin), appear. During air ejection the protective cap should be kept on, in order to avoid spraying
5. intra-arterial administration (into an artery) potentially toxic drug into the environment (cytostatic, antibiotics).
6. intracardiac administration (into the heart), g) Remove protective guard from needle.
7. intrathecal administration (into the spinal canal), h) Give a needle prick depending on the route of drug administration (sc, im, iv).
8. intraarticular (into the joint) i) Slowly aspirate by pulling the plunger out of the syringe, to check inadvertent blood vessel
9. intraosseous (into the bone marrow) puncture.
10. intraperitoneal (into the peritoneum) j) Inject the drug.
k) Pull out the needle.
7.3.2.1 General principles
l) Disinfect the puncture site and protect it with a roll of gauze or cotton roll soaked in the
disinfectant.
1. Preparing the patient (see chapter 7.1) m) Hold it firmly or instruct a patient to do so (if cooperative) until the cessation of oozing or
2. Preparing the room: to provide favorable conditions in the room, which must be kept clean and bleeding from puncture site.
aerated; cleaning should not be performed during drug administration n) Put the needle tip into the needle protective guard, using one-hand technique or special stand
3. Preparation of the work surface, which should be cleaned and disinfected for removing needles.
4. Washing hands, o) Dispose a needle into an impenetrable sharps disposal container.
p) Accommodate the patient into a comfortable position.
8. Clear away the equipment
9. Wash hands.
10. Record drug(s) administration.
88 89
„Z“ technique of intramuscular injections is used if we assume that the drug could cause and adverse reaction
7.3.3 Subcutaneous injections in subcutaneous tissue, or if the tissue has been already irritated by previous injections.
1. Drug is administered just under the patient’s skin. 1. Aspirate the drug into the syringe.
2. This route is convenient for drugs with preferred slower absorption and smaller quantity (up to 2 2. Change the needle (prevents drug contact with tissue before needle entry into a muscle).
ml). If a larger amount of a drug is prescribed for sc administration, it should be injected at two 3. Pulling the plunger intake 0.1 - 0.2 ml of air into the syringe. The air bubble will follow the drug
separate places, with special needles and syringes. injected into tissue and prevent its return out through injection channel.
3. Common sites for sc administration are upper arm, upper abdominal wall, and thigh. 4. Patient should be placed in an appropriate position. During injection in gluteus region, patient
4. Gather gently about 1 1/2 to 2 inches of skin between your thumb and first finger creating a lies prone or stands upright, while during injection in deltoid or quadriceps muscle he sits or lies
slight mound of skin taking care not to bruise or damage the tissue. on his back.
5. Insert the syringe at a 90 degree angle (straight up and down) into the skin with a slight snapping 5. Disinfect the skin,
motion of your wrist. 6. Pull the skin and subcutaneous tissue aside from the site of presumed needle entry into a muscle.
7. Hold the tissue in the lateral position, trust the needle into the muscle medially from the site of
7.3.4 Intramuscular injection
pulled tissue and inject the drug.
8. Release the skin and subcutaneous tissues pulled aside and pull out the needle.
1 When administered into a muscle the absorption of drug is significantly faster than with sc 9. Firmly press the puncture site with a roll of cotton wool soaked in a disinfectant.
administration.
2 Larger amount could be administered, up to 5 ml. 7.3.5 Intravenous injection
3 Sites for im drug administration are:
x in adults – deltoid muscle, upper external quadrant of gluteus muscle (Fig. 1), antero-lateral 1. The drug is injected directly into the bloodstream and acts immediately.
region of the thigh (quadriceps muscle), 2. It could be administered directly with iv needle, but today the most common technique is the use
x in children – antero-lateral thigh, because the quadriceps muscle is better developed than of iv cannula. The technique for insertion of iv cannula will be explained in Circulation chapter.
gluteus or deltoid muscle.
4 Technique: the needle is advanced perpendicular to the skin, at an angle of 90°. 7.3.6 Intracutaneous injection
1. By this route usually are administered small amounts of a drug, principally in order to test
hypersensitivity reactions (tuberculin skin test, allergy tests).
2. The preferred puncture site for intradermal injections is inner side of forearm.
3. Injections in the proximity of moles, as well as in pigmented parts of skin should be avoided
7.3.7 Complications related to parenteral drug administration
Complications may be local and systemic. Possible local complications are:
1 broken needle;
2 blood vessel damage and hematoma formation;
3 nerve injuries;
4 abscess at the needle puncture site;
5 aseptic necrosis;
Figure 1. The site of intramuscular injection is
upper external quadrant of gluteus muscle 6 atrophy of fat tissue (skin indentation);
7 Some patients may develop allergic reactions, either local reactions (swelling of skin/mucosa,
urticaria) or the anaphylactic shock being the most severe form (the patient is pale, with clammy
and cold skin, hypotension, and with impaired level of consciousness)
90 91
Important Colloids
1. Injections should not be administered into the adipose tissue, or into any tissue that is reddish, Colloids are fluids that contain solutes in the form of large proteins or other similarly sized molecules.
swollen, scared or changed in any way. The proteins and molecules are so large that they cannot pass through the walls of the capillaries and
2. Observe completely the rules for drug administration, including the rules of drug preparation and onto the cells. Accordingly, colloids remain in the blood vessels for long periods of time and can
administration. significantly increase the intravascular volume. Colloids are effective in maintaining blood volume,
3. Apply completely all rules for asepsis. but they are more expensive, and could have some adverse reactions (allergies, adverse influence on
coagulation and renal function).
7.4 Intravenous infusions administration
Important
Intravenous infusion is a method of administering larger amount of fluids into body through a vein.
This is the most common way of drug administration in critical care. Normal saline was the first IV fluids are packaged in soft plastic or vinyl bags, as well as in glass bottles of various sizes and
infusion applied in humans in 1891. Infusions were first administered subcutaneously, than volumes. The most common volume sizes are 100, 200, 500 and 1000 milliliters. Every iv fluid
intravenously with syringes, and today we use single-use systems for administering fluid directly into container must be labeled. On the label one can find all significant information, which should be
bloodstream. considered before fluid administration a patient. That information includes.
7.4.1 Indications for infusion therapy x Type of iv fluid (by name and by type of solutes contained within).
x Amount of fluid (expressed in milliliters or ml).
1 dehydration, fluid losses which could not be supplemented with oral intake (vomiting, diarrhea, x Expiry date.
high fever, blood loss);
2 excessive loss of proteins (extensive wounds and burns); 7.4.3 Intravenous cannula
3 parenteral nutrition (before and after surgery, long lasting diarrhea and vomiting, impossible or
contraindicated enteral nutrition); Intravenous cannula is plastic tubule with wire guide, which facilitate its insertion into a peripheral
4 various poisonings with drugs and other agents; and vein, and it is used for:
5 administration of diluted drugs and long-term maintenance of their concentration in a body
(vasoactive drugs, etc.) x administration of intravenous fluids;
x administration of medicaments; and
x for blood sampling.
7.4.2 Types of infusions:
Flexible plastic cannula is mounted on a metal trocar. When the tip of the needle and cannula
Intravenous fluids or infusions are chemically prepared solutions that are administered to a patient perforate the vein, the trocar is withdrawn and discarded, and the cannula is advanced inside the
through the iv site. There are two main types of infusions; crystalloids and colloids. Crystalloids are vein to the appropriate depth and secured. Blood may be drawn at the time of insertion.
aqueous solutions of varying concentrations of mineral salts or other water-soluble molecules.
Colloids contain larger insoluble molecules that tend to stay within the vascular space (blood vessels).
Crystalloids
In regard to their tonicity in comparison to plasma crystalloids could be further divided into:
1 Isotonic, a solution which has the same concentration of electrolytes as the body plasma,
includes:
a) Regular saline – contains sodium chloride (salt) as the solute, dissolved in sterile water
(solvent). The specific concentration for normal saline solution is 0.9%;
b) Lactated Ringer’s solution (LR) - contains the solutes sodium chloride, potassium chloride,
calcium chloride, and sodium lactate, dissolved in sterile water (solvent); and
c) 5% dextrose in water.
2 Hypotonic are the crystalloid solution with a lower concentration of electrolytes than the body Figure 2. Cannulas of different sizes
plasma (e.g. 0.45% NaCl).
3 Hypertonic are the crystalloid solution with a higher concentration of electrolytes than the body The caliber of cannula is indicated in gauge (G) numbers; lower number indicates larger diameter.
plasma (e.g. 7.5% NaCl, 10% dextrose). The selection of caliber depends on the flow speed one intent to establish: the most rapid flow is
obtained with short cannula of large diameter, using non-viscous fluids.
92 93
7.4.4 Administration of intravenous infusion 7.4.4.4 Procedure
4.4.4.1 Preparation of patient 1. Introduce yourself to the patient, explain what you are going to do and ask for consent.
2. To make the procedure more tolerable for children medical staff may apply a topical local
1. Check the identity of the patient prior to infusion therapy. anesthetic (such as EMLA2).
2. Explain the patient about infusion therapy. 3. Place the patient in a comfortable position.
3. Describe the method of administration. 4. Extend and when appropriate fix the patient’s arm on arm support.
4. Recommend use of the toilet prior the start of therapy 5. Protect a patient’s bed linen with waterproof cloth beneath the venous puncture site.
6. Secure the infusion bottle in a bottle holder, and hang it on an infusion stand
7.4.4.2 Preparation of necessary equipment 7. Position the arm in a position comfortable for the patient.
8. Identify and choose the appropriate vein for cannula insertion. Whenever possible a vein on the
1. Infusion fluid according to prescription. dorsal area of the hand should be selected, the cubital vein being the last choice, when other
2. Infusion systems of various types. puncture sites are not available. Cubital vein is the most often used for blood sampling.
3. Sterile syringes, needles, intravenous cannulas of various length and diameters. 9. Apply a tourniquet circumferentially above the puncture site of a vein, and tighten it.
4. Infusion bottles holders. 10. Disinfect the skin over puncture site.
5. Skin disinfectant based on 70 per cent alcohol. 11. Put on the gloves.
6. Tourniquet. 12. Remove the cannula from its packaging and remove the needle cover, not touching the needle.
7. Sterile rolls of gauze and cotton wools. 13. Stretch the skin distally and warn the patient about the stick.
8. Infusion stands. 14. Insert the cannula into a vein, at an angle of 30-45° (the needle bevel is turned upwards); wait
9. Adhesive tapes. until blood appears in the cannula flashback chamber.
10. Compresses, waterproof sheets. 15. Advance the entire cannula 2 mm; both the needle and cannula are now located in the vein and
11. Kidney shaped bowls for medical waste. the trocar is withdrawn
12. Scissors. 16. Fix the needle while advancing the rest of the cannula deeper into the vein; angle of insertion is
13. Patient’s arm support. changed to almost parallel to the patient’s skin.
14. Latex gloves. 17. Release the tourniquet above the puncture site, apply pressure to the vein at the tip of the
cannula and remove the needle. Remove the cap from the needle and attach it on the end of the
cannula, or connect the previously prepared infusion system.
7.4.4.3 Preparation of infusion fluids
18. Fix cannula with adhesive tape or transparent dressing.
19. Dispose of the needle into the sharps container.
1. Checkout the identity of patient and match the prescribed drug/infusion with the patient’s
20. Fill the syringe with saline and flush it through the cannula injection port cap to check its patency.
record.
If there is any resistance, if this maneuver causes any pain or localized tissue swelling appear,
2. Wash the hands.
stop flushing immediately, remove the cannula and start procedure from beginning.
3. Check out the infusion bottle/bag (fluid name, expiry date, an undamaged stopper, color and
21. If flushing is smooth, ensure that the patient is comfortable and thank him.
clarity of infusion).
22. If iv drip is required a flow meter should be opened, and the speed of infusion adjusted.
4. Secure the bottle in an infusion bottle holder.
23. Upon completion of iv drip, the flow regulator is shut down, the infusion system is disconnected
5. Check out the infusion system (expiry date, perseveration of package).
from cannula, and the end of the cannula is closed with the needle cap.
6. Remove the system from the sterile package.
24. Clear away the used equipment, take off the gloves, and wash the hands.
7. Disinfect the bottle stopper with 70 per cent alcohol.
25. Drug/infusion administration should be recorded.
8. Set the infusion system, sticking it in a bottle or plastic bag through stopper.
9. Hang the bottle/bag on an infusion stand.
10. Adjust the flow meter of the infusion system; eject all air bubbles from system. The entire tubing
of the infusion system should be filled with infusion fluid.
11. Close the flow meter of the infusion system
2
EMLA is an abbreviation for Eutectic Mixture of Local Anesthetics, a 5% emulsion preparation,
containing 2.5% each of lidocaine and prilocaine,
94 95
7.5 Other routes of drug administration

7.5.1 Percutaneous drug administration
1. The effect is predominantly topical, with slow or minimal systemic absorption (although there are
exceptions, e.g. trans-dermal delivery systems, patch).
2. Drugs can be in form of creams, ointments, lotions, liquids, gel, powders, etc.
3. Transdermal delivery systems consist of adhesive surface that contains a drug reservoir that
slowly releases the active substance (e.g. fentanyl, nicotine patch, nitroglycerin patches,
transdermal scopolamine for motion sickness, etc).
4. Advantages are that the drug is released in a controlled manner, and have a stable
pharmacologic effect.
5. Disadvantage is that the skin could be an effective barrier, and only small molecules may
Figure 3. IV cannula penetrate.
7.5.2 Sublingual drug administration

7.4.4.5 Complications of infusion therapy
1. The drug is laid beneath the tongue, where it is dissolved and absorbed (e.g. nitroglycerine).
Complications may occur in and around the vein as a consequence of the cannulation procedure: 2. When the drug is administered by this route there is no liver metabolism and breakdown and no
influence of gastro-intestinal fluids.
1. Paravenous infiltration appears when the vein is perforated and solution enters into the 3. The patient should be warned not to swallow the drug, but to keep it under the tongue and
subcutaneous tissue instead into the vein. If this happen, administration of infusion must be restrain of drinking and eating until the drug is dissolved.
stopped, and a new cannula inserted at another location. The site of infiltration should be
compressed. This complication happen when properly placed cannula was not adequately
secured in vein. 7.5.3. Drug administration per inhalation
2. Hematoma is a collection of blood, and appears as a consequence of blood leak from damaged 1. Gaseous and volatile drugs may be inhaled and absorbed through the pulmonary epithelium and
vein. It may result from failure to enter into the vein lumen when the cannula is inserted or mucous membranes of the respiratory tract.
during cannula removal. Too large cannula also may lead to hematoma formation. Selection of an 2. Access to the circulation is very rapid.
appropriate vein and gently applying pressure slightly above the insertion point after removal of 3. Some solutions of drugs can be converted to fine droplets in air (aerosols) and inhaled (e.g. beta-
the cannula will prevent this complication. It is necessary to compress the site of hematoma and adrenergic agonists in the treatment of asthma.
apply heparin-based creams.
7.5.4. Eye drugs administration
3. Phlebitis is an inflammation of the vein, resulting from its mechanical or chemical irritation or
from an infection. It is manifested by redness and pain, corresponding to the anatomy of 1. Drops, creams and ointments.
cannulated vein. Phlebitis can be avoided by carefully choosing the site for cannulation and by 2. Depending on the condition being treated, they may contain steroids, antihistamines,
checking the type of infusion used. sympathomimetics, beta blockers, parasympathomimetics, parasympatholytics, non-steroidal
anti-inflammatory drugs (NSAIDs) or topical anesthetics.
4. Circulatory overload can happen when too large amount of fluid is given over short period of 3. Eye drops have less risk of side effects than do oral medicines, and such risk can be further
time, especially to patients with heart conditions. It is manifested by tachycardia and/or minimized by occluding the lacrimal punctum, (i.e. pressing on the inner corner of the eye) for a
arrhythmia, orthopnea, hypotension, cyanosis and prominent neck veins. short while after instilling drops.
4. The drug is applied into the pouch between lower eyelid and the eyeball with head tilted
5. Embolism. The most common embolism is air embolism, although can be caused by thrombus, or backward.
fragment of a broken catheter entering in venous system. Emboli pass via bloodstream to 5. One should be careful not to touch any part of the eye with the dropper tip.
pulmonary artery, and could produce signs of pulmonary embolism; cough, chest pain, dyspnea, 6. Hands should be washed thoroughly before and after the procedure.
tachycardia, hypotension.
6. Allergy could be manifested in the most severe, life-threatening form, as anaphylactic shock, or
as a moderate local reaction (urticaria, swelling of mucosa). It is necessary to stop the infusion
immediately and to administer anti-allergy medications.
96 97
7.5.6 Ear drug administration

8. Handling and disposal of sharps and infectious waste
1. Drops, solutions, ointments.
2. Head should be turned with affected ear facing upward. Sharps and infectious waste is a form of medical waste composed of used sharps, that came in
3. The earlobe should be pulled gently up and toward the back in order to straighten the ear canal. contact with a patient or a potentially infectious material – syringes and needles, blades, razors,
4. With the other hand, drop the drug in the ear canal; the tip of ear dropper should not touch the scalpels, scissors, contaminated glass tubes, etc. It could cause needle stick injuries and the waste
ear or any other surface. should be disposed into rigid and impenetrable plastic containers, with minimal manipulation.
5. A position with affected ear facing upward should be maintained for 5 minutes.
8.1 Sharps disposal container
7.5.7 Transnasal drug administration x Container must always be located at the workplace (blood tests, drug administration).
x Container must be of material that the needle cannot penetrate (plastic), and which cannot be
1. Drops, sprays. broken; it is never made of glass.
2. The patient head should be tilted as far back as possible; if the patient is on a flat surface (bed) x Container should not be overfilled. When filled up to 3/4 of its content, container should be
his head should be hanged over the edge. deposited into the infectious waste containers.
3. With one hand pull up the tip of the nose, and with other hand instill prescribed number of
drops. 8.2 Disposal of needles and syringes:
4. The nasal mucosa should not be touched with the dropper tip.
7.5.8 Vaginal drug administration
1 Vaginal drugs are topical agents prepared specifically for insertion into a woman's vagina.
2 In the form of a cream, foam, gel, tablet, or suppository, and are absorbed through the vaginal
mucosa.
3 The medicament is the most frequently applied in gynecological position.
4 The most often administered using a specific applicator that is provided by the manufacturer.
5 Vaginal medicines are most often administered at bedtime, as the reclined position enhances
medication absorption.
7.5.9 Rectal drug administration
The potential for hepatic metabolism damage is lower than for an equal oral dose; however the
drug’s absorption could be incomplete, because some drugs cause the irritations of the rectal
mucosa. Indication for this route type of drug administration is:
1 After the surgery in oral cavity;

2 In patients with severe nausea and vomiting;
Figure 4. Sharps container
3 Drugs with unpleasant smell administration;
4 Drugs which can be destroyed by digestive enzymes;
Immediately after each use the needle with a syringe (with no separation!) should be disposed in a
5 Children and patients with poor contact; and
sharps container
6 Use for local effects (e.g. hemorrhoids)
Drugs are manufactured in various forms of enemas and suppositories. Administration of rectal
medication should be done after the patient is positioned correctly. Lifting the upper buttocks will
enable visualization of his or her rectal opening. The patients could lie supine, or on his left side with
the right leg bent over the left. Rectal drug could be administered with finger or applicator
98 99
9.1 Algorithm of UK resuscitation council

9. Anaphylaxis and anaphylactic shock
1. Anaphylaxis is a severe, life-threatening systemic hypersensitivity reaction.

2. It is characterized by rapid development of life-threatening breathing and/or circulation
disturbances, usually associated with skin and mucosal changes, after a contact with triggering
allergen.
3. Airway and breathing involvement in anaphylaxis is manifested by tongue swelling, stridor,
hoarseness, laryngeal edema, bronchial spasm, hypoxia, respiratory arrest.
4. Circulation disturbances are manifested by hypotension, tachycardia and pale and clammy skin.
This cardiovascular collapse occurring in an anaphylactic reaction is called anaphylactic shock.
This is a form of distributive shock resulting from both severe systemic vasodilatation and an
increase of permeability of capillary bed and fluids leak.
5. The most frequent causes of life-threatening reactions are drugs, contrast dyes, blood products,
stinging insects and food. In as many as 5% of the cases the antigen triggering the anaphylaxis
cannot be identified.
6. Due to the high importance of this condition, here will be described in detail the most advanced
algorithms for recognizing and treating the anaphylactic shock and the latest guidelines.
7. Less dramatic allergic and idiosyncratic reactions to drugs are described, too.
Figure 5. Anaphylactic reaction

3
3 th
http://www.resus.org.uk/pages/anapost1.pdf (accessed on March 4 , 2012)
100 101
VIII Airway and breathing
Author: Professor =, MD, PhD
Coworkers
\, MD
Ana Hrga, bacc.med.techn.

bacc. med. techn.
bacc. med. radiol.
Nikša Matas, reg. med. techn.
102 103
1 Goal 4 Airway
The goal is to explain and to demonstrate to the students, on mannequins and in hospital 4.1 Assessment of breathing and airway patency
environment, how to notice the airway patency problems and respiration problems, how to clean
4.1.1 Breathing assessment
and secure the airway and how to provide the breathing support.
2 Expected outcome
1. To assess the patency of airway;

2. To determine the cause of obstruction;
3. To remove the cause of obstruction;
4. To clean the airway and maintain its patency;
5. To be familiar with all techniques used in airway maintenance:
6. To assess the breathing quality;
7. To determine the cause of breathing difficulties;
8. To remedy the difficulties;
9. To institute the support to breathing; 1 Apply head tilt - chin lift technique to ensure an open airway.
10. Will be familiar with suction machines: 2 Situate yourself so that you have your ear near the victim's nose and mouth and your eyes
11. Will be familiar with oxygen deliver systems; and looking towards the chest.
12. Will be familiar with machines for artificial ventilation. 3 Listen for shallow breathing.
4 Feel expired air on your cheek.
3 Content Assessment procedure should not last more than 10 seconds.
In this module student will master:

4.1.2 Airway obstruction
1. How to assess the airway status and patency;
2. How to determine the cause of the airway obstruction;
3. Which procedure to apply to remedy the airway patency;
4. The standard methods of airway cleaning;
5. All accessories for airway support (catheters, masks, tubes, etc);
6. Assessment of breathing quality;
7. How to detect the causes of breathing problems;
8. How to eliminate the causes of breathing problems;
9. How to support the breathing;
10. Oxygen therapy and oxygen delivery systems.
Airway obstruction can be:

1. Complete
2. incomplete
104 105
4.1.2.1 Complete airway obstruction 4.2 Procedures and devices for airway maintenance in Basic Life Support (BLS)
There is no airflow through mouth or nose, no breathing sounds, and airflow cannot be felt. Artificial 4.2.1 Positioning of the patient
ventilation is not effective, and cardiac arrest is imminent.
4.2.1.1 Stable lateral position, coma position
4.1.2.2 Incomplete airway obstruction
Breathing is weakened, and different breathing sounds can be present. In accordance to

characteristics of those sounds, observer is usually able to identify the location and cause of
obstruction. In unconscious patient, pharynx is the most frequent location of obstruction, caused by
patient's tongue or solid foreign body.
4.1.2.3 Sounds in airway obstruction
A: If sounds are present during inspiration, they point to incomplete obstruction of upper airway. If
obstruction is located in pharynx, sound resemble to snoring. If obstruction is in trachea, there is a
sound called stridor, high-pitched wheezing sound resulting from turbulent air flow in the upper
airway. Sounds resembling to boiling point out to presence of liquid foreign substance in the airway.
B: If sounds are present during expiration, obstruction is located in lower airway (bronchospasm).
This position is recommended for unconscious patens, who are breathing spontaneously. It is not
recommended if a cervical spine injury is suspected. The advantages of this position are that:
Incomplete airway obstruction can cause the brain hypoxia and brain and lung edema, leading to
apnea and cardiac arrest. x tongue cannot obstruct the airway
4.1.2.4 The most frequent causes of airway obstruction x all secretion, blood and gastric content will be drained freely from the oral cavity
A. Upper airway Procedure/Positioning

x tongue
x soft tissue edema Patient is supine on the firm board. Left arm is flexed, head turned to left, with cheek on the left
x foreign body in oral cavity, blood, vomit palm. Next attendant hold right leg and flex it, bringing the foot in level with left knee. Pulling the
knee attendant starts rotation of the patient. Right leg is fully flexed in hip and knee, patient is in
B. Larynx semi-lateral prone position, head (right cheek) is resting on the left hand palm. A permanent
x laryngospasm supervision of the breathing is necessary. During transportation patients should be turned on the
x foreign body other side every 30 minutes.
x larynx injury
C. Lower airway
x secretions, blood
x bronchospasm
x foreign body
x aspiration of gastric content
106 107
4.2.1.2 Head tilt backward and jaw trust

4.2.2 Airway maintenance devices
4.2.2.1 Oropharyngeal and nasopharyngeal airways
Head tilt backward, with or without chin lift, is the first and in most occasion sufficient maneuver to
ensure the airway in unconscious patient. Airways are tubes in different sizes, made of soft rubber, silicone or plastic materials. They are
designed to lift and support the basis of the tongue in unconscious patient, securing an open airway.
Attention: be aware of possible cervical spine injury! In addition, be aware also that hypoxia is The maneuver can provoke vomiting and development of laryngospasm, if airway tube is inserted in
much more often a cause of death than cervical spine injury. patient with an intact pharyngeal reflex. Airways do not prevent aspiration.
Procedure: rescuer kneels beside the patient; one hand is positioned on the patient’s forehead, and
with other hand lifts the chin. In 20% of cases this maneuver is not sufficient, and jaw trust should be
applied.
For jaw trust the rescuer is positioned behind the patient’s head, with elbows leaning on the ground.
The fingers of both hands grip the mandible, lifting it up; the thumbs are positioned on the chin and
push it downward, to open the mouth.
Nasopharyngeal airway
Size is selected after measurement of distance between the nose apex and ear lobe. The tube should
be lubricated by lubricant containing the anesthetic and inserted gently, sliding along the curve of
selected nasal passage. The moderate bleeding is an expected complication.
108 109
Laryngeal mask insertion
Before the insertion, the rescuer inflates the mask with 5 cc of air, forming it in the proper shape with
adequate firmness, and lubricates it with a lubricant over back side. The tube is held as a pencil, with
the opening facing the front side, and it is gently pushed along the hard palate, down into the
pharynx, until the upper part of esophagus is reached. Well-positioned mask is additionally inflated,
and ventilation checked with airbag.
Oropharyngeal airway
The size is selected after measurement of distance between mid-section of the lips and mandibular
angle, or the distance between lips angle and ear lobe.
This airway is inserted in the mouth with lower end turned up and pushed gently along the hard
palate. During insertion the airway should be slowly rotated for 180 o along its longitudinal axis, so at
Laryngeal mask size is selected in accordance to patient weight, using this table.
the end of the procedure the opening is pointed downward towards larynx. In 1992 a cuff at the
airway was added, similar those on the endotracheal tube. This airway is called Cuffed OroPharyngeal Body weight 6,5 kg > 6,5 kg 6,5-20 kg 20-30 kg 30-50 kg 50-80 kg > 80 kg
Airway, COPA. Laryngeal mask 1 2 2,5 3 4 5 6
3,5 4,5 5,0 6,0 6,0 7,0
4.2.2.2 Laryngeal Mask, LM Endotracheal tube
cuffless cuffless cuffless cuffed cuffed cuffed
Accessories: gloves, lubricant, syringe, tape.
Proseal laryngeal mask has, besides standard duct for ventilation, an additional narrow duct, where
a gastric tube can be inserted.
Intubation laryngeal mask
Through this mask an endotracheal tube can be inserted, its size depending on the mask’s size.
Advantages
x better ventilation than in ventilation with standard mask; and

x easy to insert, laryngoscope is not needed.
Disadvantages
Laryngeal mask is a plastic tube, which on the upper end has a standard plastic extension of 15 mm
There is no protection of regurgitation, especially if ventilation pressure is higher than 20 cm H2O. Its
diameter, suitable for connection with airbag or ventilator’s tubing. On the lower end there is a mask,
application is contraindicated if there is high risk of regurgitation and aspiration of gastric content,
which, when inflated, spread the walls of larynx. and if ventilation with high pressure is anticipated.
110 111
4.2.2.3 Esophageal-Tracheal Combitube, ETC) Indication for ETC
Difficult or failed endotracheal intubation; it can be inserted by less experienced person.
Contraindication for ETC
x persevered pharyngeal reflex

x glottis edema
x esophagus stricture.
Advantages of ETC
In relation to laryngeal mask, airway is protected of regurgitation and aspiration, and lung ventilation
is more reliable.
Disadvantages of ETC
Endotracheal aspiration is not possible, when ETC is positioned in esophagus. There is possibility of
Esophageal-tracheal combitube is a device combined of two tubes, with two cuffs. It has only one damage of oropharyngeal and tracheal mucosa, and esophagus.
size and can be used in patients older than 15 years. Blue, longer tube, is closed at the end, but has,
between two cuffs, several side openings. The other tube is transparent and has an opening at the 4.2.3 Airway cleaning
lower end and a cuff, resembling to endotracheal tube.
4.2.3.1 Manual cleaning
Insertion
Head is in neutral position, laryngoscope is not needed. Tube is inserted gently, advancing it until the
first mark on the tube reach the teeth level. Lower cuff on the longer, blue tube, is inflated, with
approximately 100 cc of air. Inflation of the second cuff follows, with 10-15 cc of air. If ventilation is
appropriate, the tube is in esophagus, and it is possible to inset a gastric tube, to aspirate the gastric
content.
Lower inflated cuff prevent regurgitation of gastric content, upper one prevent the oral cavity secrets
to overflow the airway. Endotracheal aspiration is not possible.
If there is no adequate ventilation when the airbag is connected with blue tube, the other tube
should be used, a transparent one. If there is proper ventilation, this tube is in trachea, and
Rescuer uses the index finger, bent in form of hook, or index and middle fingers, using them as
endotracheal aspiration is possible. Proper position should be checked with auscultation.
forceps. Semi-conscious patient can bite the finger, and the use of a mouth opening device is
recommended. Special attention should be paid to prevent dislocation of the foreign body deeper
In 90% of insertion attempts tube is positioned in esophagus. If it is positioned in trachea, lower cuff into the airway.
has same role as in endotracheal tube, and upper, which is positioned between soft palate and
tongue basis, held the tube in the place. If there is a tonic contraction of the muscles of mastication and jaw is locked, special tools are used
(mouth openers, retractors). If such tools are not available in an out-hospital setting, a firm piece of
wood can be inserted behind the molar teeth and used as a lever.
112 113
4.2.3.2 Magill forceps 4.2.3.4 Suction
Magill forceps is an instrument used for removing the solid foreign bodies.
Using an apparatus which generate a negative pressure up to 300 mmHg the rescuer is able to clean
4.2.3.3 Rotation of the head aside secretion from oropharyngeal, tracheal and bronchial parts of airway, using a suction catheter. This
procedure may be essential in an emergency situation.
In this manner it is possible to eliminate the vomited gastric content, blood, saliva and secrets. There
is a choice of different suction pumps, in-hospital and portable. The portable ones can operate on
electric power and on batteries; some operate by hand (for children) and the others by foot; some
generate the negative pressure on Ventury effect.
For suction rescuer needs sterile suction catheters, water for catheters’ cleaning and anesthetic spray
or gel used during for the suction through nasal passages. During insertion of catheter the pressure is
off, and when the position is reached, the machine is switched on, negative pressure is generated,
and rescuer starts to withdraw the catheter with gentle rotation movements. The airway should not
be cleaned using brusque up and down movement, as in chimney cleaning.
4.2.3.5 Heimlich maneuver
Heimlich maneuver is applied to suffocating patient, who is conscious, and the foreign body is
Turning the head aside the outflow of liquids from mouth is facilitated. One should be always aware positioned too deep to be removed manually or with instruments. Clinical picture is dramatic: the
of possible cervical spine injury. patient hold his neck, (s)he cannot speak, cough or breathe. Maneuver can be applied in standing or
sitting patient who is conscious or on supine patient, if patient is unconscious.
114 115
4.2.3.5.1 Heimlich maneuver in standing or sitting patient 4.3 Procedures and devices for airway maintenance in Advanced Life Support (ALS)
4.3.1 Endotracheal intubation, ETI
This is a procedure of insertion of a plastic tube into trachea, to secure the airway for both
spontaneous and artificial ventilation. The endotracheal tube can be inserted through nose and
through mouth.
4.3.1.1 Equipment and accessories
Rescuer stands behind the patient and embrace him/her, connecting the arms on upper part of
patient’s abdomen, between the sternum and umbilicus. When the hands are in the proper position,
the rescuer pushes the abdominal wall towards the spine and upwards. In addition, a forceful blow
between the patient’s shoulder blades should be delivered.
1 Personal protective equipment
4.2.3.5.2 Heimlich maneuver in supine patient 2 Endotracheal tube with intact cuff and 15 mm connector
3 Laryngoscope handle with fresh batteries
Rescuer is positioned over the patient lower abdominal region, and hands with interlocked fingers 4 Laryngoscope blades (straight or curved)
are positioned in the epigastric region. Strong push towards the spine and upwards is delivered; the 5 Spare bulb for laryngoscope blades
rescuer is using his/her body weight. 6 Flexible stylet
7 Self-inflating resuscitation bag with mask connected to 100% oxygen
8 Oxygen source and connecting tubes
9 Non-sterile gloves
10 Luer-tip 10 ml syringe for cuff inflation
11 Water-soluble lubricant
12 Rigid pharyngeal suction-tip catheter
13 Suction apparatus
14 Suction catheter
15 ET tube adhesive tape Stethoscope
4.3.2.2 Indications
This maneuver generates an increase in intra-abdominal pressure, which is transmitted into the
thoracic cavity and into the airway, and foreign body can be ejected, as a cork from Champagne 1. inadequate ventilation
bottle. Maneuver can be repeated up to ten times. Because of possible severe complications 2. absence of spontaneous breathing
(including expulsion of gastric content and aspiration, spleen and liver rupture, etc.), the maneuver is 3. absence of protective airway reflexes
not indicated in children, pregnant women and obese people. In newborn, only a gentle blow
between the shoulder blades is allowed.
116 117
4.3.2.3 Procedure
4.3.2.4 Endotracheal tube size selection
Age and body weight Tube internal diameter (mm) Suction catheter size
Newborn, 3 - 10 kg 3,5 - 4,0 mm 8

1 years, 10 – 13 kg 4,0 8
3 years, 14 –16 kg 4,5 8 to 10
5 years, 16 – 20 kg. 5,0 10
6 years, 18 – 25 kg 5,5 10
8 years, 24 – 32 kg 6,0 cuffed 10 to 12
12 years, 32 – 54 kg 6,5 cuffed 12
16 years, over 50 kg 7,0 cuffed 12
Adult, woman 7,0 to 8,0 cuffed 12 to 14
Adult, man 8,0 to 8,5 cuffed 14
Before the intubation procedure starts the pure oxygen should be applied 2-3 minutes, pre-
oxygenation. Patient is supine; the rescuer is positioned behind the patient’s head, holding the
4.3.2.5 Rescuer’s assistant
laryngoscope in the left hand. Right hand is situated at the nape, facilitating the retroflexion of the
head. Assistant role is:
Mouth is open with the thumb, and the laryngoscope blade is inserted and slowly advanced towards 1 To pull the right mouth angle outside;
the epiglottis, pushing the tongue to left. If the straight blade is used, epiglottis is elevated directly, if 2 To press gently cricoids cartilage generating an indirect pressure on esophagus, preventing the
curved blade is used, the tip of the blade is positioned in valecula, and glosso-epiglotic frenulum is regurgitation of gastric content in some extent;
pulled. In such manner, the entrance of trachea is visualized and vocal cords can be seen. Tube is 3 To held the head in midline and pull it upwards If cervical spine injury is suspected, to prevent the
then inserted between the vocal cords, the cuff should be positioned bellow them in trachea. Cuff is possible additional damage to the spine and spinal cord; and
inflated with 5 ml of air, and endotracheal tube is fixed up to oropharyngeal airway and to facial skin. 4 To insufflates the air into the lungs using airbag, when endotracheal tube is positioned and cuff
inflated. The rescuer check the tube position by auscultation of both lung bases and measuring
Note: never use the teeth in upper jaw as the support of laryngoscope blade. the end-tidal CO2
4.3.2.6 Advantages of endotracheal intubation
1. Prevent aspiration
2. Prevent insufflation of air into stomach
3. Facilitate airway cleaning
4. Increase effectiveness of resuscitation
5. Facilitate application of high concentration of oxygen and exact volume of ventilation
6. Ensure the support to spontaneous breathing
4.3.2.7 Complications of intubation
1 Esophagus intubation.
2 Injury of lisp, teeth, tongue, pharynx and trachea.
3 Bleeding.
4 Elective intubation of one bronchi and one lung ventilation.
118 119
4.4 Nasotracheal intubation, NTI 4.4.4 Possible complications
Patient breaths spontaneously, and he can be conscious, sedated or unconscious. 1 Intensive bleeding (Note: coagulopathy is the absolute contraindications for nasal intubation).
2 Impossible passage through nose corridors.
3 Cartilage necrosis upon the tube pressure.
4.4.1 Advantages
4.5 Intubation with flexible bronchoscope
1 Better tube toleration.
2 Easier to fix. 4.5.1 Indications
3 Rarely advance to one of bronchi.
4 Suitable for transport.
5 Route of choice in mouth and oral cavity injury.
6 Route of choice in patient with trismus.
7 Suitable for circulatory unstable patient.
4.4.2 Disadvantages
1 More difficult to insert the tube.

2 Nose bleeding.
3 Not advisable during resuscitation.
4 Airway cleaning is more difficult.
5 Tube is longer and narrower, and nasopharyngeal curve is bigger.
6 Laryngeal mask invention diminishes the usefulness of nasal intubation.
1 Patient is awake, difficult intubation is expected.

2 Unstable fracture of cervical spine.
3 Burns of upper airway.
4 Large cervical hematoma in progression.
4.5.1 Contraindications
1 Not recommended for penetrating neck injury.

2 Excessive bleeding and hyper secretion can diminish visuality.
4.4.3 Selection of tube for nasotracheal intubation
1 The tube is as large as the narrowest part of the airway. In nasotracheal intubation this is the
nasal passage; in oral intubation the narrowest section is the space between the vocal cords in
adults, and subglottic area in children.
2 Nose septum is frequently bended.
3 The initial part of nose passage can be expanded by operator’s gloved finger.
4 As an orientation, trachea entrance has diameter of patient’s smallest finger.
120 121
4.6 Coniotomy (cricothyrotomy) and tracheotomy 4.6.3.2 Standard procedure
Coniotomy (cricothyrotomy) and tracheotomy are procedures which are executed rarely during The goal is to insert, after the puncture of crycothyroid membrane with iv cannula or scalpel, a tube
advanced life support. that will maintain the opening and provide a new artificial airway.
4.6.1 Indications
The procedure is executed in complete obstruction of airway, when it is not possible to establish one
with all other already described means. Therefore, Coniotomy is indicated when:
1 Cannot intubate
2 Cannot ventilate
3 Severe facial or nasal injuries that do not allow oral or nasal tracheal intubation
4 Massive midfacial trauma
5 Possible cervical spine trauma preventing adequate ventilation
6 Anaphylaxis
7 Chemical inhalation injuries
4.6.2 Complication
1. Patient is supine, head in retroflexion.
Bleeding and insertion of tracheotomy tube at an incorrect location. 2. Index finger of non-dominant hand feels the laryngeal prominence (Adam apple). Finger is
moved downward, until a recess can be palpated. This is crycothyroid membrane, the puncture
4.6.3 Procedure or incision point.
3. If there is a time and patient is conscious, anesthetic is infiltrated locally. In solution adrenaline
4.6.3.1 Equipment
is added, diluted 1:200,000 to diminish the local skin bleeding.
4. Skin cut is longitudinal one, maximum one centimeter on both side of the midline.
1 Personal protective equipment
5. With the tip of scalpel the membrane is punctured in the midline, half centimeter in depth, and
2 Large intravenous cannula.
opening is enlarged with longitudinal cuts on both sides, no more than one centimeter.
3 Scalpel.
6. A tracheotomy or endotracheal tube are inserted into the opening, cuff is inflated with 5 cc of
4 Endotracheal or tracheostomy tube with intact cuff and 15 mm connector
air.
5 Self-inflating resuscitation bag with mask connected to 100% oxygen
7. Tube is fixed around the neck by stripes.
6 Oxygen source and connecting tubes
7 Non-sterile gloves 4.6.3.3 Emergency procedure
8 Luer-tip 10 ml syringe for cuff inflation
9 Water-soluble lubricant In emergency patient can be temporarily ventilated through large bore cannula (14 G) or catheter
10 Rigid pharyngeal suction-tip catheter size 8 F. Cannula or catheter are connected to syringe, on the other side of syringe an adapter of 7
11 Suction apparatus mm is inserted, to connect this ad lib system with airbag or ventilator tube. There are on the market
12 Suction catheter the different Coniotomy emergency sets (QuickTrach, etc).
13 ET tube adhesive tape
14 Stethoscope
122 123
5 Artificial breathing during cardio-pulmonary resuscitation

5.1.4 Mouth-to-tracheotomy tube breathing
Artificial breathing in cardio-pulmonary resuscitation is provided by insufflations of air from rescuer
lungs to the patient. This procedure is based on fact that exsufflated air still has 16% of oxygen. This method is applied in patients with tracheotomy. Positioning of the head is not necessary.
Tracheotomy tube and environment are cleaned, mouth and nose closed, an insufflations instituted,
In accordance to new guidelines for adults, frequency is 8/min, and insufflated volume is 400 - 600 ml on same principles as in previous techniques.
or 6-8 ml/kg body mass. Duration of insufflations is shortened, too, to 1 sec. Artificial breathing stops
5.2 Artificial breathing with breathing accessories
when spontaneous chest movement starts, because the hyperventilation has a harmful effect.
5.2.1 Airbag with mask
Smaller insufflations volume diminishes the regurgitation and aspiration risk. Use of mask and mouth
to mask breathing ensure an additional volume of oxygen and better oxygenation.
5.1 Direct insufflations of air into the patient lungs
5.1.1 Mouth-to-mouth breathing
The rescuer kneels by side, trust the patient head backward. Hand on the forehead maintains the
head position, and close the nose with fingers. The other hand lifts the chin and opens the mouth.
After deep insufflations, the rescuer delivers the air to the patient, encircling his mouth with his.
5.1.2 Mouth-to-nose breathing
This breathing is performed when it is not possible to open the patient’s mouth, or when there is a
severe injury of lower part of face. Positioning of the patient and his head is the same as in the Airbag is used to support artificial ventilation. It is:
previous procedure. Lower hand push the chin upwards, to close the mouth, an air is insufflated x Simple and easy-to-use;
through nose. x Able to deliver 80-100% of oxygen;
x Has connection for oxygen delivery;
5.1.3 Mouth-to-mask breathing x Has oxygen reservoir;
x Equipped with one-way valve, permitting oxygen intake, but not the rebreathing;
x Air inlet valve is during airbag compression closed, and create the positive pressure;
x Airbag reservoir has two one-way valves; one permit the intake of fresh air, if flow values are too low, the
other one permit output of air in environment, if flow values are too high.
5.2.1.1 Disadvantages
Airbag demand high flow of gas, because the fraction of inspired oxygen (FiO2) depends of air flow and its O2
concentration. Laerdal resuscitator with reservoir needs the flow 10 L/min to achieve FiO2 of 100%, with
ventilation frequency of 12/min and breathing volume of 750 ml.
Mask has one-side valve, and during insufflations, flow towards the patient is ensured, but backflow
from patient to rescuer is blocked. Patient’s exsufflated air exits through side openings.
124 125
5.2.1.2 Procedure 5.2.2.1 Application
Controlled artificial ventilation with airbag is executed with insufflations of air into the lungs, with pause to Rescuer is positioned behind the patient’s head. With one hand he tilt the head backward, with the other hand
allow a passive expiration. Assisted artificial ventilation is a support to patient, who is breathing on his own; the mask is applied and held over the nose and mouth. Narrower part of mask covers the nose, the wider the
patient starts to inspire, and rescuer assist supplementing an additional volume of air. mouth. The thumb and index finger of left hand held the mask, at its connection with airbag, and other fingers
lift the mandible.
If satisfactory ventilation cannot be achieved, or if air accumulates in the stomach, the mask should be
repositioned, and airway opened by jaw trust or by insertion of oropharyngeal airway. If those maneuvers do
not solve the problem, mandible should be lifted by both hands upward and mask firmly fixed over mouth and
nose. The expulsion of air from the stomach by external pressure is forbidden.
The airbag should be squeezed 1 second, 6 to 8 times in minute, what is sufficient to cover the patient’s
requirements of air and oxygen. If vomit is noticed under the mask, patient should be turned at side, mouth
cleaned and then ventilation continued.
If ventilation is a part of resuscitation effort, synchronization with chest compression should be observed: after
every 30 compression, a short pause will allow two insufflations. Is the ventilation is done over endotracheal
Airbags have different size, for adults of 1.1 to 2.2 L, and 0.2 to 0.9 L for children. Air in the bag can be mixed tube or tracheal cannula, such synchronization is not necessary.
with oxygen. If rescuer uses the oxygen reservoir large as breathing volume, concentration of oxygen in inhaled
air can reach 80 to 100%. If airbag without the reservoir is used, the concentration of oxygen can reach 30 to If patient breathe spontaneously, but the level of oxygenation is not sufficient, his/her breathing should be
50%. assisted with an additional volume of air from airbag. Patient’s breathing and ventilation should be
synchronized.
Airbag can be connected with mask, laryngeal mask, two-volume tube, endotracheal tube and tracheotomy
tube. 5.3 Ventilator-assisted breathing
5.2.2 Ventilation with mask Machine-assisted breathing, when the air or oxygen/air mixture is insufflated into the lungs can be done by
standard or transport ventilators.
It is important to select an appropriate size: # 2 or 3 for women, # 4 or 5 for men and # 0 to 3 for children. Mask Transport respirator operates on pressured air in oxygen cylinder, powered by dry batteries. This is a small
is connected with airbag. Translucent masks secure good visuality of vomit, blood or other foreign bodies. apparatus, weight up to 2 kg, and simple to use. The ventilator is connected with oxygen cylinder by high-
pressure tube; on the other side is a tube which can be connected to mask, endotracheal tube, laryngeal mask,
etc. This tube is equipped by a one-way valve, which allows the air passage to patient, but the air rebreathing is
not possible.
126 127
Those ventilators are capable to deliver a minute volume (MV) of 2 to 20 L/min, at positive pressure of 50 cm 6.2.1.1 Nasal cannula
H2O. Breathing frequency can be adjusted between 10 and 35 cycles per minute, with inspiration v. expiration
ratio of 1: 1.5, and oxygen concentration in delivered air can be up to 100%.
6 Oxygen treatment
Nasal cannula consists of a plastic tube which fits behind the ears, and a set of two prongs which are
placed in the nostrils. Oxygen flows from these prongs. The nasal cannula is connected to an oxygen
tank, a portable oxygen generator, or a wall connection in a hospital via a flow meter. The nasal
cannula carries 1–6 liters of oxygen per minute. There are also infant or neonatal nasal cannulas
x Oxygen is a prerequisite for aerobic metabolism. which carry less than one liter per minute; these also have smaller prongs. The oxygen fraction
x Oxygen therapy must be monitored. provided to the patient ranges roughly from 24% to 44%. When the flow is up to 4 liters,
x Control of oxygen delivery is done by flow meter, an instrument for monitoring, measuring, or humidification is not necessary.
recording the rate of flow, pressure, or discharge of oxygen. Flow meter is attached on oxygen
cylinder or in-build in central oxygen supply system. Nasal cannula is convenient for treatment; it is comfortable and patients can eat, drink and talk.
x Rate of achieved oxygenation is monitored by oximeter.
6.2.1.2 Oxygen mask
x Treatment goal is to achieve the peripheral oxygen saturation of 92 to 94%.
x During reanimation, pure oxygen should be applied.
6.1 Indications for oxygen therapy
1 All critically ill patients should be treated by oxygen.

2 Pectoral angina patients.
3 Arterial hypoxia.
4 Cardiac arrest.
5 Cyanide poisoning.
6 Carbon monoxide poisoning.
7 Chronic hypoxia.
6.2 Systems and devices for oxygen therapy An oxygen mask provides a method to transfer breathing oxygen gas from a storage tank to the
lungs. Oxygen masks may cover the nose and mouth (oral nasal mask) or the entire face (full-face
6.2.1 Low-flow oxygen delivery systems
mask). They may be made of plastic, silicone, or rubber. Mask is used for delivery of high
Amount of delivered oxygen cannot satisfy all patients’ needs, and additional oxygen is inhaled from concentration of oxygen, and flow has to be over 5 liters per minute, to prevent rebreathing. At flow
atmosphere. rate of 5 do 8 liters per minute the oxygen fraction provided to the patient ranges roughly from 35% -
50%.
128 129
6.2.1.3 Non-rebreather mask, NRB 6.2.2.2 Venturi valves
x Valves are used to increase the air flow towards the patient, using environmental air, too.
x NRB is used for delivery of high concentrations of oxygen. x The continuous flow with exact oxygen concentration is secured.
x One-way valve in the mask the inhalation of room air and the re-inhalation of exhaled air. x Increase of oxygen flow does not increase the oxygen concentration in inhaled air.
x At flow rate of 10 do 15 liters per minute, the oxygen fraction provided to the patient ranges x The Ventury valves are most often uses in patients with chronic pulmonary diseases with CO2
roughly from 60% - 80%. Lowest acceptable flow is 10 liters.
retention.
x Approximately ¹Ύ of the air from the reservoir is depleted as the patient inhales, and it is then
replaced by the flow from the O2 supply 6.3 Adverse effects of oxygen therapy
6.2.2 High-flow oxygen delivery systems
x Oxygen can have toxic impact, if used in high concentration over prolonged period of time.
6.2.2.1 Venturi masks x Oxygen can induce the hypoventilation in patients whose breathing is dependent of hypoxia.
Venturi masks are considered high-flow oxygen therapy devices, used to deliver a known oxygen
concentration to patients on controlled oxygen therapy. They are based on Venturi valves principle. 6.4 Hypoxia and hypoxemia
The kits usually include multiple jets in order to set the desired FiO2, which are usually color coded.
Hypoxia is a pathological condition in which the body as a whole (generalized hypoxia) or a region of
The color of the device reflects the delivered oxygen concentration, and at flow rate of 2 do 15 liters
the body (tissue hypoxia) is deprived of adequate oxygen supply. Partial pressure of oxygen in arterial
per minute, the oxygen fraction provided to the patient ranges roughly from 24% - 60%.
blood (PaO2) is under 60 mmHg. Normal values of PaO2 are 75 to95 mmHg. Hypoxemia is the
condition in which the oxygen concentration within the arterial blood is abnormally low. Normal
values are about 200 ml per one liter of arterial blood. Hypoxemia can be induced:
x when lung ventilation is inadequate, with low minute volume, because of low respiratory volume
of low breathing rate, and
x when the oxygen concentration in the inhaled air is low, saturation of the blood gradually
decrease and anaerobic metabolism develop.
Therapy with high percentage of oxygen in inhaled air or treatment with 100% oxygen are indicated
in all critically ill patients, whatever the cause are, cardiac failure, respiratory conditions (including
airway obstruction, acute pulmonary disease, pulmonary embolism), metabolic disorders,
intoxication or severe trauma.
130 131
IX Circulation
Author: Professor }, MD, PhD
Co-workers
Dubravka Kocen, MD
=, MD
}=X, MD
Katjana bacc. med. techn.
Rahela Orlandini, dipl. med. techn.
132 133
1 Goals In clinical practice, the most frequent artery for pulse palpation and assessment is radial artery,
because of its accessibility. In critically ill patients palpation of central arteries is more reliable means
The goal of this course is to explain and demonstrate, on mannequins and in clinical setting, how to
of pulse quality assessment, because of collapse of peripheral arteries.
notice and diagnose the malfunction of heart and circulation, how to temporarily control the
bleeding and how to support the circulatory function. Method is simple: after careful choice of pulse location, examiner lay down the tips of fingers along
the course of artery, applying moderate pressure, until the pulsation is felt. The thumb is not used,
because its own pulsation can confuse the examiner. Assessment usually last 60 seconds, and (i) the
2 Expected outcome
frequency, (ii) rhythm, and (iii) amplitude should be assessed and recorded.
3.1 Pulse frequency
Pulse frequency id expressed as number of heart bite per minute. Normal pulse frequency depends
1. To assess the quality of carotid, peripheral and apical pulse;
on many factors, as patient’s age, sex, health status, etc. Average frequencies are listed in the
2. To assess the intensity of the bleeding;
attached table. An elevated resting heart rate is called tachycardia, and frequency below the limits of
3. To apply the temporary methods of bleeding control;
normal range is called bradycardia.
4. To apply the defibrillator’s pads and electrodes
5. To use defibrillator properly; 3.2 Pulse patterns
6. To use the basic pharmaceuticals for circulation support;
7. To assemble the infusion system; Several pulse patterns have clinical significance.
8. To assemble the transfusion system;
9. To use infusion pump; and
1. Pulsus alternans: an ominous medical sign that indicates progressive systolic heart failure: a
10. To understand the circulation monitoring systems. strong pulse followed by a weak pulse over and over again.
2. Pulsus bigeminus: indicates a pair of hoof beats within each heartbeat.
3 Pulse 3. Pulsus tardus et parvus: a slower than normal rise in the tactile pulse caused by an increasingly
stiff aortic valve.
Pressure waves, generated by the heart in systole, extend the arterial walls, what may be palpated in 4. Pulsus paradoxus: a condition in which some heartbeats cannot be detected at the radial artery
any place that allows an artery to be compressed against a bone, such as at the neck (carotid artery), during the inspiration phase of respiration.
at the wrist (radial artery), behind the knee (popliteal artery), on the inside of the elbow (brachial
artery), and near the ankle joint (posterior tibial artery). This phenomenon is called the pulse, and 3.3 Pulse rhythms
can be detected by fingertips palpation, by auscultation and by ultrasound.
Analysis of arterial pulsation can provide the data on local circulation, and on hemodynamic as a Pulse rhythm reflects the time intervals between pulses. Each deviation of regular, equal intervals
whole. Information is usually collected by palpation of central arteries (carotid artery) and the between heart beats is called arrhythmia. The most important are:
peripheral ones (Fig.1).
1. Respiratory arrhythmia in young persons, pulse is speeding up during inspiration, and slowing
down during expiration.
2. Extrasystolia is a premature heart contraction
3. Arrhythmia absoluta manifest itself with absolute irregularity of beats, and pulse strength vary,
too.
3.4 Pulse strength
Pulse strength reflects the strength of hearth contractions and elasticity of arterial walls.
If the pulse is very strong, and artery cannot be pressured, it is described as firm, overfilled and
tense, and the most common cause is high blood pressure.
Poorly filled and barely palpable pulse is described as weak, soft or thready pulse (filiform), caused by
hypotension, hypovolemia and heart failure. Pulse which cannot be palpated is the most often
caused by artery occlusion and cardiac arrest.
Figure 1. Body site to palpate pulse
134 135
Table 1. Normal pulse frequency in relation to ages Another indicative laboratory test is determination of oxygen saturation difference in arterial and
venous blood, which is normally 95% and 65%, respectively, or a difference between 20 to 30%. If
Normal pulse frequency
this difference increase between 30 and 50%, volume loss is significant; if values are over 50%, this
Ages Pulse point out to cardiogenic or hypovolemic shock.
Newborn 120 – 160
Decrease of hematocrit values are, especially in acute phase, insufficiently correlated and cannot be
1 – 12 months 100 – 150 used to assess precisely the amount of blood loss. During the bleeding, there is an equal loss of
1 – 2 years 80 – 140 plasma and blood cells, and diminishment of hematocrit is apparent after 8 to 12 hours, as
consequence of absorption of sodium and water into intravascular domain. Also, one should bear in
2 – 6 years 75 – 120
mind, that solutions infusion, administered during resuscitation, can dilute the intravascular content.
6 – 12 years 75 – 110
If patient is bleeding in operating theatre, blood loss can be assessed by measuring the content of
Adolescent 60 – 100 suction machine, and by counting the gauzes soaked in blood. Depending of its size, each gauze can
Adults 60 – 100 contains between 100 to 200 ml of blood. In accordance to clinical symptoms and signs, blood loss
can be classified in four groups.
4 Assessment of the bleeding severity Parameter Level I Level II Level III Level IV
% of blood loss *+ 15 - 30 30 - 40 > 40
Intensity of bleeding can be assessed by clinical examination and by laboratory data. Pulse per minute *+<< > 100 > 120 > 140
Arterial pressure normal normal, orthostatic decrease > 10 mm Hg low low

Systolic blood pressure (SAP), central venous pressure (CVP) and pulmonary artery wedge pressure Diuresis normal decrease significant decrease significant decrease
(PAWP) are not too sensitive and poorly reflect the amount of blood loss. Such poor correlation Consciousness frighten agitated disoriented lethargic
happens by virtue of many compensatory mechanisms, aimed to maintain arterial pressure in normal
range, up to blood loss of 15-30%. Among others, the most important mechanisms are (i) shift of
intracellular water into the vascular space, (ii) vasoconstriction, (iii) activation of renin-angiotensin 5 Temporal control of bleeding
system (RAS).
5.1 Direct pressure on the wound
Orthostatic differences in pulse frequency (over 15 per minute) and decrease of systolic arterial
pressure over 10 mmHg are important omens, which always antecede the tachycardia and decrease Placing pressure on the wound will constrict the blood vessels manually, helping to stem any blood
of the pressure in recumbent position, at blood loss up to 15% of circulating volume. flow. In the same time, the limb is elevated above the heart level. This method is used the most
frequently, and this is the simplest method of temporal control of bleeding. Ideally a barrier, such as
Decrease of urine output starts because of lower heart minute volume, when the blood loss is up to sterile, low-adherent gauze should be used between the pressure supplier and the wound, to help
30% of circulating volume. Tachycardia, as a compensatory mechanism, can recompense the loss up reduce chances of infection, and held in situ at least five minutes continuously. When bleeding stops,
to 30%. an elastic bandage is applied. If gauze is saturated with blood, it should not be removed, but a fresh
layer or gauze should be applied. This method is usually sufficient to stop capillary, venous and
Laboratory test results are helpful to differentiate pre-renal and renal oliguria: urea vs. creatinine
arteriolar bleeding (Figure 2).
ratio is 1:20 in pre-renal, and 1:10 (or less) in renal failure. Composite density of urine is 1.020 in
prerenal and less than 1.010 in renal failure.
Diminution of expiratory-end CO2 is an indicator of lower heart minute volume, too, and can be
registered at low minute volume caused by bleeding. Continuous monitoring of expiratory-end CO2 is
valuable for assessment of efficacy of cardio-pulmonary resuscitation and compensation of
circulating volume.
136 137
5.3 Tourniquet
A tourniquet is an inflatable compressing cuff, used to control venous and arterial circulation to an
extremity for a period of time. Pressure is applied circumferentially upon the skin and underlying
tissues of a limb; this pressure is transferred to the walls of vessels, causing them to become
temporarily occluded. It is generally used as a tool for a medical professional in applications such as
cannulation or to stem the flow of traumatic bleeding, especially by military medics.
Application of the tourniquet should not last over 20 minutes; ischemia which last longer can cause
the permanent ischemic damage of the limb.
5.4 Surgical methods of permanent bleeding control
Surgical methods are:

1. Ligation of blood vessels
Figure 2. Bleeding control by direct pressure
2. Reconstruction of blood vessels
In such manner, majority arterial bleeding can be controlled, too, except the bleeding from major 3. Electrocautery, a surgical technique that uses a high frequency current
arteries, which should be surgically reconstructed or ligated.
Surgical methods will be described and trained during the course of surgery.
5.2 Compression on pressure points
6 Defibrillation and use of defibrillator
In situations where direct pressure and elevation are either not possible or proving ineffective, and
there is a risk of exsanguination, the pressure should be applied at pressure points, to constrict the
Defibrillation is introduced in 1899, by Jean Louis Prevost and Frederic Batelli, Swiss physiologists
major artery which feeds the area of the bleeding (figure 3). This is usually performed at a place
from Geneva.
where a pulse can be found, such as in the femoral artery, brachial artery, etc. There are significant
risks involved in performing pressure point constriction, including necrosis of the area below the Defibrillation is a process in which an electronic device sends an electric shock to the heart, lasting
constriction, and most protocols give a maximum time for constriction around 10 minutes. approximately 10 milliseconds, to stop an extremely rapid, irregular heartbeat, and restore the
normal heart rhythm. Electric shock can be applied directly at heart muscle, during open surgery,
internal defibrillation), and indirectly, through the chest wall, external defibrillation. It is the most
often used in ventricular fibrillation (VF), (Fig. 4) and pulseless ventricular tachycardia (VT).
Physiological basis of defibrillation is delivering the electric current blocked from an external source,
strong enough to depolarize most of the miocard, 75% or more. In such manner unsynchronized
heart activity is blocked, enabling the heart’s sinus node to starts control over electrically voided
heart muscle. Favorable outcome is directly related to duration of VF/VT.
During reanimation, external defibrillation is mostly used. There are two main types: manual external
defibrillation and automatic external defibrillation.
Figure 3. Compression at pressure point
Figure 4. Electrocardiogram of ventricular fibrillation
138 139
6.1 Manual external defibrillation
Manual external defibrillation (MED) is executed with standard defibrillator, which generate
monophasic (older models) or biphasic shock. Manual defibrillation is applied only by medical expert,
who is trained to recognize the type of arrhythmia and heart failure. Automatic external defibrillators
(AED) are developed for use by laymen and not specifically trained medical personnel. AED apparatus
automatically recognize the hearth rhythm disturbances and lead the rescuer through procedure.
Strength of electrical power delivered depends of age and body mass. In general, the European
Resuscitation Council, ERC guidelines from 2010 recommend first shock with 150 - 200 Joules, when
biphasic defibrillator is used. American Heart Association Guidelines 2005 are shown on this table.
First shock is effective in 90% patients.
Monophasic Biphasic
Defibrillation 200J 300J 360J 360J 120J 150J 200J 200J

Pediatric defibrillation 2J/kg
Internal defibrillation Max. 50J 5J 10J 20J 30J
The defibrillation procedure should be strictly followed:
1. Defibrillation should be executed immediately, as soon as reversible heart rhythm failure is

diagnosed. Every minute of delay diminish the success rate for 10%.
2. Position of pads or electrodes is important: the hearth must be located between them.
3. Recommended position for right electrode is below the clavicle, at right sternal margin. Left
electrode is positioned in left mid-maxillary line, below the nipple (figure 5).
4. Alternative positions of electrodes are at the front and at the back of the chest, hearth positioned
between them (figure 6).
5. Standard size pads and electrodes should be used. Use of pediatric pads in adults is mostly
unsuccessful.
6. Contact between the pads and skin should be firm, in order to diminish the resistance to current
flow.
7. Shock should be delivered during expiration, because the air is poor current conductor.
8. Hypoxia and hypercarbia diminish the reanimation success rate.
¸
Figure 7. Advance Life Support algorithm
Figure 5: Standard position of electrodes Figure 6: Alternate position of electrodes
140 141
7.3 Ventricular tachycardia
7 Essential drugs for arrhythmia treatment 7.3.1 Ventricular extrasystoles
7.1 Bradycardia Recommended:

x Control of electrolyte and acid-basic status
Recommended:
x Potassium chloride to maintain serum level of 4,5 - 5 mmol per liter
a) Atropine 0.01 mg/kg iv. (usually 0.5 - 1 mg iv), can be repeated up to 3 mg iv
b) Adrenaline 1 - 2 μg/min iv, Ephedrine 5 - 10 mg iv x Amiodarone 300 mg iv in bolus, continue 900 mg/24 hours
c) Aminophiline, dopamine, glucagon ( or Ca-channels block) x Lidocaine 1 mg/kg iv as loading dose, and 1 to 2 additional dose of 0,5 mg/kg after 10 minutes
Figure 8: Bradycardia
7.2 Sinus tachycardia

Figure 10: Ventricular extrasystole
Vagotonic maneuvers: Valsalva maneuver, carotid sinus massage
7.3.2 Ventricular tachycardia
Beta-blockers:
Recommended:
Esmolol 0.125 mg/kg iv (short acting), Metoprolol 5 mg iv every 5 min up to 15 mg max, Propanolol
0.5 - 1 mg iv every 5 min up to 0.2 mg/kg max. x Control of electrolyte and acid-basic status
Ca channels blocker: x Amiodarone 300 mg iv in bolus, continue 900 mg/24 hours
x Lidocaine 1 mg/kg iv as loading dose, and 1 to 2 additional dose of 0,5 mg/kg after 10 minutes
Verapamil 2.5 – 10 mg iv over 10 min. x Magnesium 2g over 10 minutes, if tachycardia is polymorphic
Note: do not mix beta blockers and Ca channels blockers!
Figure 9: Sinus tachycardia Figure 11. Ventricular tachycardia
142 143
7.3.3 Ventricular fibrilation
Recommended (before defibrillation): 8 Infusion and transfusion systems
An infusion system infuses fluids, medication or nutrients into a patient's circulatory system, using:
x Control of electrolyte and acid-basic status
x Amiodarone 300 mg iv in bolus, continue 900 mg/24 hours a) Central veins – v. jugularis, v. subclavia and v. femoralis,
x Lidocaine 1 mg/kg iv as loading dose, and 1 to 2 additional dose of 0,5 mg/kg after 10 minutes b) Peripheral veins – usually of arm and hand, rarely veins of legs
System is connected to intravenous cannulas, which are in different size, from 14 to 24 Gauge.
Cannula with lower size number has larger diameter
8.1 Infusion systems
The simplest IV system consists of an elevated bag or bottle, a length of flexible tubing and a catheter
placed into the patient’s vein. An adjustable roller clamp compresses the tubing, to slow fluid flow
and allowing the manual control by a clinician. The rate at which drop form is assessed visually, and
roller clamp is adjusted manually as needed. Tubing is disposable, for single use only, made from
polyvinyl chloride, its length is 150 to 200 cm (extensions are available), its interior is protected with
caps.
Figure 12 a) ventricular tachycardia;

Those simple systems use gravity, Gravity Drip Flow Manual IV System. The pressure available from
b) polymorphic ventricular tachycardia and
an infusion bag (e.g. of saline) depends of the height the bag is above the patient's heart. If a saline
c) ventricular fibrillation
bag is 68 cm above the patient’s heart, the infusion pressure available is 50 mm Hg, if the bag is twice
that height above the patient 136 cm available pressure is 100 mm Hg.
Figure 13. Gravity infusion system
144 145
8.2 Transfusion systems 8.4.2 Hematoma
Systems are used to infuse the blood and blood products into a patient's circulatory system. Those A hematoma occurs when there is leakage of blood from the vessel into the surrounding soft tissue.
system are similar to infusion ones, and main difference is an additional filtration chamber, to This can occur when a vascular catheter passes through more than one wall of a vessel or if pressure
prevent the entry of blood particles and clots into the patient’s vascular system. is not applied to the site of the puncture when the catheter is removed. A hematoma can be
controlled with direct pressure and will resolve over the course of 2 weeks.
8.3 Procedure
8.4.3 Air embolism
8.3.1 Preparation the patient
x Check the patient's identity Air embolism occurs as a result of a large volume of air entering the patient's vein via the IV
administration set. The IV tubing holds about 13 CCs of air, and a patient can generally tolerate up to
x Check the patency of patient's cannula
1 cc per kilogram of weight of air; small children are at greater risk. Air embolisms are easily
x Explain the procedure to patient and ensure the patient's comfort
prevented by making sure that all the air bubbles are out of the IV tubing; fortunately, it is an
8.3.2 Preparation of material extremely rare complication.
x Check the prescribed solution 8.4.4 Phlebitis and thrombophlebitis

x Prepare the infusion system
x Prepare the infusion stalk Phlebitis and thrombophlebitis occur more frequently. Phlebitis is inflammation of the vein, which
x Prepare the materials (cotton swab, gauze, alcohol, adhesive tape, etc.) occurs due to the pH of the agent being administered during the administration of the IV, while
thrombophlebitis refers to inflammation associated with a thrombus. Both are more common on the
8.3.3 Preparation of system dorsum of the hand than on the antecubital fossa, and may occur especially in hospitalized patients
where an IV may be in for several days. Use of an intravascular catheter, as opposed to a needle, can
x Wash the hands properly;
increase the risk of phlebitis, as the metal needle is less irritating to the endothelium. Needles are
x Recheck the infusion solution: expiration date, solution color and clarity, the seal;
generally used for short term IV access of less than three hours, while catheters are used for longer
x Penetrate the infusion bag (bottle) seal in aseptic manner;
x Release air bubbles completely from tubing, using the roller clamp. periods of time. Older patients are also more susceptible to phlebitis.
8.3.4 Procedure Treatment: elevating the site and application of warm compresses and administering non-steroidal
analgesics to the patient. Anticoagulants and antibiotics are usually not required.
x Hang the bag (bottle) on infusion stalk
x Connect the tubing to patient's cannula 8.4.5 Extravascular injection
x Open the roller clamp
x Adjust the drip rate. Standard rate of drip is 60 drops per minute. Extra vascular injection of a drug may result in pain, delayed absorption and/or tissue damage, if the
pH of the agent being administering is too high or too low. If large volumes have been injected and
8.4 Complications the skin is raised and looks ischemic, then 1% procaine should be infiltrated. Procaine is a vasodilator,
8.4.1 Infiltration which will improve the blood supply both to the area and improve venous drainage away.
Infiltration is the infusion of fluid and/or medication outside the intravascular space, into the 8.4.6 Intra-arterial injection
surrounding soft tissue. It is usually caused by poor placement of a needle or catheter outside of the
An intra-arterial injection occurs rarely, but is much more critical. The most important measure is
vessel lumen. Clinically, swelling of the soft tissue surrounding the IV can be noticed, and the skin will
prevention, by making sure that the needle is inserted in a vein. Remember that veins are more
feel cool, firm, and pale. Small amounts of IV fluid will have little consequence, but certain
superficial than arteries. If an artery is cannulated, there should be a pumping of bright red blood
medications even in small amounts can be very toxic if infiltrate the surrounding soft tissue.
back into catheter, which would not be seen when a vein is cannulated.
146 147
8.4.7 Circulation overload

8.5.4 Equipment
Circulation overload occurs rarely, when a large volume of solution is given over a short period of
time. 1. Unit of whole blood of blood component
2. Blood administration set either a straight line or a Y set
8.4.8 Allergic reaction 3. Normal saline solution
4. IV dressing
An allergic reaction can be manifested as local reaction or as anaphylactic shock. Detailed description
5. Vein puncture set containing a # 18 needles or catheter. If blood is to be administered quickly #
can be found in “Drugs and solution” chapter.
16 needle or a larger.
8.5 Blood transfusion procedure 6. Alcohol swab
7. Tape
8.5.1 Definition
8. Disposable gloves, sterile.
Transfusion is the introduction of whole blood or component of the blood, e.g. plasma or
8.5.5 Procedure
erythrocytes into venous circulation.
1. Wash and dry hands
8.5.2 Purpose
2. Prepare the patient:
1. To restore blood volume after hemorrhage. a) Identify the patient
2. To maintain hemoglobin levels in severe anemia. b) Explain the procedure and its purpose (blood product to be transfused, approximate length
3. To replace specific blood component. of time, and desired outcome of transfusion.
c) Positioning the patient comfortably.
8.5.3 Pre-procedure 3. Assemble the equipment and bring to the patient
4. Wear gloves.
1. Check the requisition form and the blood bag label with a specially check the patient name,
5. Prime the tubing with saline solution.
identification number, blood type and Rh group the blood donor number, and the expiration date
6. Establish the saline infusion If the patient has an intravenous solution infusing check whether the
of blood.
needle and solution are appropriate to administer blood. The needle should be # 18 gauge or
2. Establish patient’s base line data: temperature, pulse, respiration rate and blood Pressure.
larger and the solution must be saline.
3. Determine any known allergies or previous adverse reaction to blood.
7. If patient does not have an intravenous solution infusing, vein should be cannulated. Select a
4. Obtain the correct blood component for the patient.
large vein that allows patient some degree of mobility and place bed protector under the site.
5. With another health worker compare the laboratory blood type round with the patient’s name
8. Start the prescribed intravenous infusion
and identification number. Ask the patient to state the full name
9. Establish the blood transfusion. Invert the blood bag gently several times to mix the cell within
as a double check.
the plasma.
6. Check the number on the blood bag label, the patient’s blood group and label, amount of blood.
10. Start infusion slowly at 2 ml/min. Remain at bed side for 5-30 minutes. If there
7. Check blood for any abnormalities, gas bubbles, dark color or cloudiness, clots and excess air.
are not sign of circulatory overloading, the infusion rate may be increased
8. Make sure that the blood is left at room temperature for no more than 30 minutes before
11. Observe the patient closely for chilling, nausea, vomiting, skin rashes and tachycardia as early
starting the transfusion. RBCs deteriorate and lose their effectiveness after 2 hours at room
sign of transfusion reaction. Check vital sign at least hourly until 1 hour post transfusion. Report
temperature.
signs and symptoms of reaction immediately to minimize consequences.
12. Blood transfusion in volume of 500 cc should be given over 1 to 2 hours; dripping rate is 80 to
100 drops per minute.
148 149
9.1.1 Procedure
8.6 Complications
First step is the proper choice of infusion system for pump, because every manufacturer has the
The majority of acute fatal transfusion reactions are caused by clerical errors. Patient and product different one. Note: it is recommended to change the infusion system every 24 hours.
verification is the single most important function of health personnel, and it is strongly
recommended that two qualified individuals perform this task. Do not proceed with the transfusion if Next step is preparation of infusion bag and system (figure 13), described previously in this manual.
there is any discrepancy. Contact the blood bank immediately. In short:
Transfusion reaction can occur during the course of transfusion, and in post-transfusion period. a) Penetrate the infusion bag or bottle at straight angle.
Reactions can be mild, and occurs in 2% of patients. The most frequent are: b) Fill the tubing with solution, eliminating the air bubbles.
c) Close the roller clamp
1 Chilling
d) Hang the bag on infusion stand
2 Nausea
3 Vomiting Third step is preparation of infusion pump.
4 Skin rashes
5 Temperature elevation, and a) Switch the pump on, pressing the power button (figure 15)
6 Tachycardia b) Pump starts its internal check automatically, the message on display is Self test active
c) Sound and light alarm announce that the self test is finished, and that the system is ready to be
Severe transfusion reactions are rare, but can have severe consequences, even fatal ones. Acute used.
d) Press the port door control button to open the port (figure 16)
reaction may occur at anytime during the transfusion: close clamp on transfusion set immediately
and run normal saline, report to doctor in charge, save urine and observe. Every hospital should have
an established protocol of conduct in such occasions, and standard form to report all adverse events.
9 Infusion and drug administration systems
9.1 Infusion pump
Infusion pump (figure 14) is used to infuse solution, medicaments and nutrients into the vascular
system. They ensure the full control of drug’s and solution’s dosage and speed of its administration, ¸
and lower the possibility of errors.
Figure 15. Power on/off button Figure 16. Port door opening button
Figure 17. Door is open. Figure 18: Infusion system installed

Figure 14. Infusion pump
Pumps can be used for intravenous, intra-arterial, epidural and subcutaneous drugs’ administration.
150 151
Infusion system is installed in proper slot, with roller clam closed. System can be installed only if the
pump is active (figure 18). When system is properly positioned, the roller clamp should open (figure 9.2 Infusion pump with syringe
19).
A syringe driver or syringe pump (figure 24) is a small infusion pump, used to gradually administer
small amounts of fluid (with or without medication) to a patient. The most popular use of syringe
drivers is in palliative care, to continuously administer analgesics, antiemetics and other drugs. This
prevents periods during which medication levels in the blood are too high or too low, and avoids the
use of multiple tablets. Syringe drivers are also useful for delivering IV medications over several
minutes. In the case of a medication which should be slowly pushed in over the course of several
minutes, this device saves staff time and reduces errors.
Figure 19. Opening of roller clamp
In next phase the volume of solution is entered and confirmed by pressing an OK button.
(Figure 20). Next set of entered data determine the time span, in which the solution volume will be
delivered to patient (Figure 21)
Figure 24: Syringe pump Figure 25: Infusion system for syringe pump
Selection of adequate syringe and infusion system (Figure 25) is imperative, because each of
manufacturers has a different one. Note: it is recommended to change the infusion system every 24
hours.
9.2.1 Procedure
First phase:
a) Prepare the syringe with the solution (figure 26);
b) Attach the infusion system;
Figure 20: Entering the volume and Figure 21. Time-span c) Fill the system with solution, to eliminate air bubble (figure 27); and
d) Mount the unit 1 m over patient’s heart level.
Last phase is connection of the pump with the patient (figure 22). On pump’s display is possible to
verify the predicted infusion speed, expressed as ml per hour. To start the infusion, one pushes the
start/stop button (Figure 23).
Figure 22. Connecting the pump Figure 23. Start of pump Figures 26 and 27 Preparation of syringe and infusion system
152 153
Next step is preparation of the syringe pump: Next set of entered data determine the time span, in which the solution volume will be delivered to
patient (figure 33). Again, the data are verified by pressing an OK button.
a) Switch the pump on, pressing the power button (figure 28)
b) Pump starts its internal check automatically, the message on display is Self test active
c) Sound and light alarm announce that the self test is finished, and that the system is ready to
be used.
d) Piston with syringe holder moves out
Figure 32: Closing the pump’s door Figure 33. Entering the volume and time data
Last phase is connection of the pump with the patient (figure 34). On pump’s display is possible to
verify the predicted infusion speed, expressed as ml per hour. To start the infusion, one pushes the
Figure 28. Turning the pump on Figure 29. Piston moved out of pump start/stop button.
In next phase the syringe is installed in pump’s slot.
a) Press the port door control button to open the port (Figure 30)
b) Insert the syringe into the slot; barrel’s wings should be in vertical direction, up and down (Figure
31).
c) Close the syringe holder and door of the pump (Figure 32).
d) Piston automatically moves back, to clasp the syringe plunger
Figure 34. Connecting the syringe pump to patient
Note
a) Administration of medicaments can be suspended at any moment, by pressing the start/stop

button.
Figure 30: Opening the door of pump Figure 31. Positioning of syringe b) Pump can be switched off by pressing the power button at least 3 seconds.
c) During the infusion system change tubing to patient should be disconnected.
In following phase the volume of solution is entered and confirmed by pressing an OK button d) Working alarm announce the interruption of procedure. There is a sound alarm and blinking
(Figure 33). of red lamp. On screen is the message, describing the cause of procedure failure.
e) Reminder alarm announces the error in execution of the procedure.
f) Warning alarm announce that the inappropriate data are entered.
g) Infusion pump should be serviced at least every two years.
h) The recommendations in User Manual should be strictly followed.
154 155
10.2 Technical monitoring

10 Monitoring
Technical monitoring is performed with contemporary monitoring devices, assisted with information
The origin of word monitor is in Latin ( = to warn) and describe one that warns, overseer. In technology, which ensure a dynamic and continuous observation of vital parameters. Registered
medicine, monitoring a patient means a dynamic and permanent supervision of patient’s vital values are displayed on monitors’ screen as numeric values or as graphic curves. The most frequent
functions with specially designed apparatus, monitors, which are usually equipped by warning and monitored parameters are electrocardiogram, arterial pulse, respiration rate, blood pressure, central
alarm systems. venous pressure, hemoglobin saturation with oxygen, CO2 concentration in expired air, body
temperature, etc. Registered values are stored in monitors’ memory, and can be displayed as trends
The goal of monitoring is not only a follow-up of patient’s function; the principal task is to notice any
over the selected period of time, and can be printed as hard copy for patient’s record.
malfunction on time, what allow a proper and timely intervention.
10.3 Laboratory monitoring
Basically, the most often are monitored pulse rate, blood pressure, electrocardiogram (ECG),
temperature and oxygen saturation. Specialized monitoring is used in different sub-specialties Laboratory monitoring is collection of selected parameters (hematological, biochemical,
(cardiology, neurosurgery, etc.) in special intensive care units, where is possible to monitor microbiological, coagulation factors, etc.) in intervals, and data are stored to enable the trends
electroencephalogram, evoked potentials, intracranial pressure, wedge pressure of pulmonary analysis. It is important to collect and process all specimens in an identical standard manner, to avoid
artery, minute heart output, and many others functions. possible aberrations and errors.
Monitoring is classified as clinical, technical and laboratory. Further, it can be non-invasive, when the 10.4 Monitoring in Intensive Care Unit, ICU
skin integrity is not interrupted, and invasive one, when the skin and underlying tissues and organs
are penetrated with instruments, probes, tubes or electrodes. Understandably, intensive monitoring In contemporary ICU, the most frequent monitoring are:
is a potential greater risk for the patients.
1 oxygenation, by pulse oxymetry;
Monitoring device is usually equipped with an alarm system, whose highest and lowest borderline 2 ventilation, by capnography;
can be selected, in accordance to monitoring requirements. Alarm should be always functional, and 3 blood pressure, non-invasive and invasive;
4 heart dynamics, by electrocardiogram
sound warning signals should never be muted. Contemporary monitoring systems are sophisticated,
5 central venous pressure;
accurate and reliable; still, as all machines, they are damageable and permanent health personnel 6 pulmonary wedge pressure;
supervision is 7 minute heart volume;
8 cardiac index;
10.1 Clinical monitoring 9 intracranial pressure, intra-ventricular, epidural and subarachnoidal;
10 temperature; and
In clinical monitoring the following features are observed, noted and reported: 11 kidney functions.
1 general appearance, skin color, posture in bed, etc; 10.4.1 Monitoring of respiration
2 reported subjective symptoms, as pain, fear, etc;
3 conscious level; Monitoring of respiration is essential one, focused on continuous assessment the respiratory system
4 pupils reaction to light
function. Clinically, observer should notes the color of skin and mucosa, and assess the breathing
5 pulse quality, strength, frequency, rhythm;
rate, rhythm, strength, use of auxiliary respiratory muscles and duration of expiratory vs. inspiratory
6 blood pressure;
7 respiration rate, breathing sounds, breathing difficulties; phases. Paradoxal breathing should be noted, if present.
8 body temperature;
9 diuresis; 10.4.1.1 Monitoring of oxygenation - pulse oxymetry
10 drains content and quantity of output;
11 water balance, input and output: and Pulse oxymetry is non-invasive method, used to measure the saturation of hemoglobin by oxygen in
12 bandages status. arterial blood. This device measure continuously the pulse rate, too. Contemporary oximeter is
functioning simultaneously on principles of plethismography and spectrophotometry. Sensors absorb
red (wave length 660 nm) and infrared (920-940) waves in pulsating arterial blood, calculate the
values and display them on the screen as numeric value or as graphic representation. The oximeter is
equipped by alarm, whose lower borderline should be adjusted on 94%, what represent partial
156 157
oxygen pressure of 10 kPa (75 mm Hg). The displayed values are not the actual ones; there is a delay 10.4.2.1 Capnography and capnometry
of 60 seconds, if sensor is hooked to finger, and 5-10 seconds, if it is hooked to ear lobe.
Capnography and capnometry relate to continuous monitoring of CO2 concentration in every
Pulse oxymetry is effective, reliable, inexpensive and easy to use methodology. Reliability is high at respiratory cycle. During capnometry the numeric values are displayed on monitor’s scree, and in
oxygen saturation between 75-100%; methodology is less relable at lower saturation values. capnography tha values are displayed graphically, as a courve. The highest concentration CO2 reach
at the end of expiratory phase, end-tidal CO2, EtCO2, and this is a value which correspond with
Procedure
alveolar CO2 concentration. Results are expressed in mmHg or in kPa.
1 Sensor can be hooked on finger (figure 35), tip of the nose and on the ear lobe.
The best method of EtCO2 measurement is infrared spectography. Infrared sensor is located at
2 Sensor should be in contact with skin, and artificial nails, nail polish, make up or ear rings should
be removed. connection of endotracheal tube and Y-shaped extension – mainstream method (fig. 36). An
3 Status of the skin under the sensor should be examined at regular intervals, and position of the alternative sensor position in the capnometer, and air sample is collected by small tube attached at
sensor should be changed every four hours. the side of tube extension (fig. 37). This method can be used in non intubated patient, using the set
4 If peripheral circulation is not satisfactory, the sensor position should be changed every half hour. of two prongs which are placed in the nostrils.
5 Positioning of sensor on extremity already used for blood pressure monitoring or administration
of an infusion should be avoided, because the results of oxymetry can be compromised.
Figure 36 Mainstream method Figure 37. Side-stream method
Capnography is a continuous non-invasive monitoring of gas exchange, enabling the early warning if
Figure 35. Pulse oximeter sensor hooked on finger tip. any disfunction arises. EtCO2 values correspond to values of partial pressure of CO2 in arterial blood,
PaCO2, and there is no need for laboratory analysis of blood gases.
10.4.2.2 Analisis of gases in arterial blood

10.4.1.2 Transcutaneous measurement of partial pressure of oxygen
This is an invasive method, because one needs to sample the arterial blood for laboratory analysis.
Transcutaneous oximeter is a polarographic oxygen electrode, positioned on the skin and warmed at
The values of partial pressure of oxygen, pO2, partial pressure of carbon dioxide, pCO2 and pH values
43 - 45qC, because the warming accelerate the diffusion of oxygen through skin. The results are
are accurate and reflect the functional status of the respiratory system. Disadvantage is that the
reliable in newborn and small children, and less reliable in adults.
method is invasive, with a possibility of infection at the puncture site, and laboratory analysis takes at
10.4.2 Ventilation Monitoring least 10 minutes. Besides, the blood sample can be saturated by oxygen or heparinized, what
influence the results. The normal values are presented at table 3.
One of principal task of ventilation is elimination of CO2, a process which can be monitored by
capnometry.
158 159
Table 3. Normal values of gases in blood

10.4.3.2.1 Non-invasive measurement of blood pressure
Indirect measurement of blood pressure was described in 1896 by Scipione Riva-Rocci, an Italian
Normal values internist and pediatrician, who developed an easy to use version of the sphygmomanometer. In the
year 1905 Korotkoff, a pioneer of vascular surgery, invented an auscultatory technique for blood
pH 7.35 - 7.45 pressure measurement, which is still in use worldwide. Therefore, first technique is called palpatory,
and the second one auscultatory.
pCO2 4.6 - 5.9 kPa
Palpatory technique of blood pressure measurement
pO2 10.6 - 13.3 kPa
A cuff, connected with manometer, is applied around the upper arm circumference and inflated until
the pulse on distal artery cannot be felt. Than the cuff is slowly deflated, and we it is possible to feel
the pulse again, this is approximate value of systolic pressure. Diastolic pressure cannot be
10.4.3 Cardiocirculatory monitoring determined with this technique. As said, the value of systolic pressure is approximate one, about 10
mmHg lower than the real one.
10.4.3.1 Electrocardiography
Auscultatory technique of blood pressure measurement
Electrocardiography, ECG is a simple non-invasive monitoring of electrical activity of the heart and
heart rhythm, as detected by electrodes attached to the outer surface of the skin and recorded by a
To execute the procedure, one need manometer connected with cuff and a stethoscope. The cuff of
device external ECG is used to measure the rate and regularity of heartbeats, as well as the size and
position of the chambers, the presence of any damage to the heart (eg heart ischemia), and the manometer is placed on the middle third of the upper arm; the pressure within the cuff is quickly
effects of drugs used to regulate the heart. The most useful leads are the second and fifth. The raised up to complete cessation of circulation below the cuff. Then, letting the mercury of the
second lead is useful in detection of arrhythmia and heart ischemia of heart’s inferior wall; the fifth manometer fall one listens to the artery just below the cuff with a stethoscope. At first no sounds are
lead is the best for registration of ischemia of anterior and lateral heart wall. heard. With the falling of the mercury in the manometer down to a certain height, the first short
tones appear; their appearance indicates the passage of part of the pulse wave under the cuff. It
On monitor screen the pulse frequency and ECG curve are displayed, and heartbeats can be heard as follows that the manometric figure at which the first tone appears corresponds to the systolic
sound tone. Tone loudness can be adjusted, and an alarm can be set, to alert of any irregularity in
pressure. Finally, all sounds disappear. The time of the cessation of sounds indicates the free passage
pulse frequency.
of the pulse wave; in other words at the moment of the disappearance of the sounds the minimal
10.4.3.2 Monitoring of blood pressure blood pressure within the artery predominates over the pressure in the cuff. It follows that the
manometric figures at this time correspond to the diastolic blood pressure.
Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps
blood. If this pressure rises and stays high over time, it can damage the body in many ways. Blood Oscillometric measurement of blood pressure
pressure is measured as systolic and diastolic pressures. "Systolic" refers to blood pressure when the
heart beats while pumping blood, and “diastolic" refers to blood pressure when the heart is at rest
Oscillometric measurement devices use an electronic pressure sensor with a numerical readout of
between beats. Normal and elevated values are presented in table 4.
blood pressure. In most cases the cuff is inflated and released by an electrically operated pump and
Table 4. Categories for Blood Pressure Levels in Adults valve, which may be fitted on the wrist (elevated to heart height), although the upper arm is
preferred. Initially the cuff is inflated to a pressure in excess of the systolic arterial pressure, and then
Category Systolic Diastolic the pressure reduces to below diastolic pressure. The values of systolic and diastolic pressure are
Normal Less than 120 Less than 80 computed from the raw data, using an algorithm, displayed on monitor’s screen, and can be stored.
Mean arterial pressure is computed as well, being the best indicator of body systems perfusion.
Prehypertension 120–139 80–89 Factors influencing the accuracy of non-invasive measurements are:
High blood pressure
1 Inadequate cuff length, which should be 25-50% longer then arm circumference
Stage 1 140–159 90–99 2 Inadequate cuff breadth; cuff should cover 2/3 of upper arm. If cuff is too narrow, the systolic
pressure values will be higher, if cuff is too broad, the values will be lower.
Stage 2 160 or higher 100 or higher
3 Speed of cuff deflation. Too quick deflation influences the measurement accuracy.
Recommended speed is 2 - 3 mm Hg per second.
The pressure can be measured with an invasive and non-invasive technique. 4 Point of measurement should be at heart level. If arm is above the heart, the measured values
are lower, and vice versa.
160 161
Table 5. Cuff size in relation to age Components and principles of IBP monitoring
Recommended cuff size The components of an intra-arterial monitoring system are:

Newborn 5 cm
1. the measuring system
Child 5-7 cm
Adult 14-15 cm 2. the transducer
Big adult 20 cm 3. the monitor
Measurement at thigh 20-25 cm
1. The measuring system
Whatever of those techniques is used, the health personnel should be aware of complications which The measuring system consists of an arterial cannula (20G in adults and 22G in children) connected
can arise from cuff use. Too frequent and too aggressive inflation of cuff can result in peripheral to tubing containing a continuous column of saline, which conducts the pressure wave to the
nerve damage and in extravasation of fluid from veins.
transducer. The arterial line is also connected to a flushing system consisting of a 500 ml bag of saline
10.4.3.2.2 Invasive measurement of blood pressure pressurized to 300 mmHg via a flushing device. Formerly 500 IU heparin was added to this fluid, but
many centers now consider this to be unnecessary. The flush system provides a slow but continual
Invasive measurement of blood pressure facilitates continuous and accurate measurement of blood flushing of the system at a rate of approximately 4-5ml per hour. A rapid flush can be delivered by
pressure; all errors pertinent to non-invasive measurement are avoided. Indications for invasive manually opening the flush valve. There is also usually a 3-way tap to allow for arterial blood
measurement of blood pressure are: sampling and the ejection of air from the system if necessary.
a) Necessity of continuous measurement in real-time (eg severe bleeding, polytrauma, sepsis). 2. The transducer
b) Long-lasting and complex surgery.
c) Administration of short-action vasoactive drugs (vasodilators, inotropes). A transducer is any device that converts one form of energy to another. The output of transducers is
d) Monitoring after cardiac arrest and resuscitation. usually in the form of electrical energy. In the case of intra-arterial monitoring the transducer
e) Necessity of frequent arterial blood sampling. consists of a flexible diaphragm with an electric current applied across it. As pressure is applied to the
diaphragm it stretches and its resistance changes, altering the electrical output from the system. The
For invasive measurement of blood pressure an artery must be cannulated, and measured pressure transducers used are differential pressure transducers and so must be calibrated relative to
energy should be transduced in an electronic impulse. atmospheric pressure before use.
Site of artery cannulation can be on arm (a. radialis, a. brachialis, a. axillaris) or on leg (a. dorsalis
pedis, a. tibialis posteror and a. femoralis). It is essential that the selected artery has a sufficient
3. The monitor
collateral network. The most frequent selected artery is radial: collateral network is excellent, Modern monitors amplify the input signal; amplification makes the signal stronger. They also filter
technique of cannulation is not too demanding, and maintenance is convenient. (Figure 38). the ‘noise’ from the signal and display the arterial waveform in ‘real time’ on a screen. They also give
a digital display of systolic, diastolic and mean blood pressure. Most monitors incorporate various
safety features such as high and low mean blood pressure alarms and tachycardia and bradycardia
alerts.
Procedure
Equipment (Fig. 39)
1. Materials for hand hygiene, skin preparation, and sterile field

2. Arterial cannula and accessories to secure catheter
3. Pressure transducing device
4. Flush system
Figure 38. Cannulated radial artery 5. Monitor
6. Tubing, stopcocks, and cables
162 163
Preparation and patient’s positioning Interpretation of results
1. Procedure explained to patient, informed consent signed. a) Monitoring system should be calibrated
2. Patient personal hygiene as in preparation for surgery. b) Transducer positioned in mid-axillar line
3. Patient is supine. c) Connections secured.
4. The arm should be abducted in the anatomical position and the wrist should be hyper-extended d) Flushing system functional
to aid cannulation. e) Results saved and documented in patient’s record.
Procedure execution
1. Operator hand hygiene, sterile gloves;

2. Patient’s skin preparation with 2% chlorhexidine, sterile field set up;
3. Local anesthesia with 1% lindocaine
4. Insertion of catheter into artery
a) Catheter over needle, as in standard intravenous access; or
b) Seldinger technique, catheter over wire
5. Catheter fixation with tape or stitch
6. Use of ultrasound to identify artery
7. Connection to catheter flush system and to monitor
8. Zeroing: for electronic equilibration of the monitor and pressure transduction system
Complications
Figure 40. Invasive blood pressure monitoring
1. Artery occlusion and consecutive ischemia of the distal part of limb
2. Infection at the puncture site
3. Bleeding and hematoma
4. Disconnection and bleeding from cannulated artery 10.4.3.3 Monitoring of central venous pressure
5. Erroneous substitution of arterial catheter for venous one
6. Median nerve injury during brachial artery punction. Central venous pressure (CVP) describes the pressure of blood in the thoracic vena cava, near the
right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of
It is recommended to monitor the circulation in the arm where the artery is cannulated with a pulse the heart to pump the blood into the arterial system, and it is a reliable indicator of circulating blood
oximeter; with this precaution any decrease in oxygen saturation level can be detected promptly. volume.
Indications
1 Assessment of intravascular blood volume.

2 Volume resuscitation, central venous line as an appropriate route for quick delivering of large
amount of fluids and blood.
3 Appropriate route for hypertonic or irritant substance infusion (eg vasoactive drugs,
chemotherapy, long-term antibiotics therapy, parenteral nutrition, etc.
4 Hemodialysis
5 Inaccessible peripheral veins.
6 Possibility of aspiration of air bubbles, if possibility of air embolism is anticipated.
Central lines are typically introduced into the internal jugular, subclavian, or femoral veins. Femoral
vein cannulation should be avoided, because of increased risk of vein thrombosis.
Figure 39. Equipment for artery cannulation
164 165
Measurement
The CVP is measured using a manometer filled with intravenous fluid attached to the central venous
catheter. It needs to be 'zeroed' at the level of the right atrium, approximately the mid-axillary line in
the 4th interspace supine.
1 Measurements should be taken in the same position each time.

2 Check that the catheter is not blocked or kinked and that intravenous fluid runs freely in, and
blood freely out.
3 Open the 3-way tap so that the fluid bag fills the manometer tubing.
4 Turn the tap to connect the patient to the manometer. The fluid level will drop to the level of
the CVP which is usually recorded in centimeters of water.
5 If the water column is calibrated properly the height of the column indicates the CVP (fig. 41).
6 It will be slightly pulsatile and will continue to rise and fall slightly with breathing
An alternate mean is measurement by pressure transducer, which must be zeroed, calibrated, and
placed in the appropriate position relative to the patient. Transducer calibration is not required with
the current generation of disposable transducers that are designed to meet acceptable standards for
accuracy. The CVP reading from an electronic monitor is sometimes given in mmHg. The values can Figure 42. Central line catheter connected to
easily be converted knowing that 10cmH20 is equivalent to 7.5mmHg (which is also 1kPa). a small diameter water column
Normal CVP value is 0 - 12 cm H20, or 0 - 9 mm Hg, when measured with pressure transducer. Complications of Central Venous Pressure Monitoring
Factors affecting CVP 1. Mechanical complications

a) Arterial puncture and cannulation
Factors that increase CVP include: b) Hematoma
c) Hemothorax
1. Hypervolemia
d) Surrounding nerve injuries
2. Forced exhalation
e) Pneumothorax
3. Tension pneumothorax
f) Embolization of broken catheter or guide wire
4. Heart failure
g) Air embolism
5. Pleural effusion
h) Arrhythmias
6. Decreased cardiac output
i) Lymphatic system injury
7. Cardiac tamponade
8. Mechanical ventilation and the application of positive end-expiratory pressure (PEEP)
2. Infectious complications
a) Sepsis
Factors that decrease CVP include:
b) Endocarditis
1. Hypovolemia
3. Thrombotic complications
2. Deep inhalation
a) Venous thrombosis
3. Distributive shock
b) Pulmonary embolism
To minimize a possibility to overlook the complication (especially pneumothorax), a chest x-rays must
be always obtained after central line insertion.
166 167
10.4.3.4 Monitoring of pulmonary artery wedge pressure Pulmonary artery catheter, PAC (Swan-Ganz)
Pulmonary artery catheter (PAC), Swan-Ganz or right heart catheter was initially developed for the PAC is a multilumen catheter, 110 cm long and 7 - 8 French in diameter size, with extra connecting
management of acute myocardial infarction, and gradually it gained widespread use in the tubes for attachment to the pressure transducer (fig. 42).
management of a variety of critical illnesses and surgical procedures.
Indications
1. Diagnostic
a) Diagnosis of shock states
b) Differentiation of high- versus low-pressure pulmonary edema
c) Diagnosis of idiopathic pulmonary hypertension
d) Diagnosis of valvular disease, intracardiac shunts, cardiac tamponade, and pulmonary embolus
(PE)
e) Monitoring and management of complicated AMI
f) Assessing hemodynamic response to therapies
g) Management of multiorgan system failure and/or severe burns
Figure 42. Pulmonary artery catheter (Swan-Ganz)
h) Management of hemodynamic instability after cardiac surgery
i) Assessment of response to treatment in patients with idiopathic pulmonary hypertension At the tip is PA lumen, or distal lumen, and a 1.5-cc balloon is located just proximal to the tip.
Approximately 4 cm proximal to the balloon is the thermistor used to measure temperature changes
2. Therapeutic
for calculation of CO. Two additional lumens usually are present at 19 cm and 30 cm from the tip.
These lumina reside within the right ventricle (RV), right atrium (RA), or the superior vena cava (SVC).
a) Aspiration of air emboli
Insertion of pulmonary artery catheter (PAC)
3. Monitoring and measurement
a) Systolic, diastolic and mean pulmonary pressure The PAC is inserted percutaneously into a major vein (jugular, subclavian, femoral) via an introducer
b) Pulmonary artery occlusive pressure (PAOP) and pulmonary artery wedge pressure (PAWP) sheath. The actual venous access techniques are not described here. Proper attachment of the PAC
c) Central venous pressure
to the monitoring equipment is essential for accurate measurements. Transmission of pressures from
d) Heart minute volume
e) Temperature of circulating blood the body to the display system is accomplished via semirigid, noncompliant tubing filled with fluid,
f) Mixed venous oxygen saturation (SvO2) usually isotonic saline with a small amount of heparin. This, in turn, is connected to a fluid-filled
pressure transducer and pressure values and waves are displayed on monitor’s screen. Adequate
Contraindications position of the PAC in pulmonary artery can be confirmed when, after the inflation of catheter’s
balloon, the pressure wave disappears. X-ray of thorax after procedure is obligatory.
1. Tricuspid or pulmonary valve mechanical prosthesis
2. Right heart mass (thrombus and/or tumor) Complications
3. Tricuspid or pulmonary valve endocarditis
Complications are numerous, and besides those listed with central venous line insertion, the specific
ones are:
1 Arrhythmias;
2 Pulmonary artery thrombosis;
3 Pulmonary artery embolism and lung infarction;
4 Pulmonary artery rupture;
5 Sepsis;
6 Lesion of tricuspidal valve;
7 Catheter balloon rupture.
During procedure, complete reanimation set, including defibrillator, must be at hand.
168 169
Via intermittent transpulmonary thermodilution the available information are:

10.4.3.5 Assessment of cardiac output
a) Transpulmonary cardiac output (C.O.);
Cardiac output (Q) is the volume of blood being pumped by the heart, in particular by a ventricle in a
b) Intrathoracic blood volume (ITBV);
minute. Cardiac output is equal to the stroke volume (SV ) multiplied by the heart rate (HR). SV is the
c) Extravascular lung water (EVLW); and
volume of blood pumped per beat and the HR is the number of beats per minute. Therefore, if there
d) Cardiac function index (CFI)
are 70 beats per minute, and 70 ml blood is ejected with each beat, the cardiac output (Q) is 4900
ml/minute. This value is typical for an average adult at rest; sometimes is called heart minute
volume. Assessment and monitoring of cardiac output is essential in critically ill patients (eg severe
myocardial infarction, sepsis) and for estimation of effectiveness of therapy on heart.
10.4.3.5.1 Thermodilution technique
Several direct and indirect techniques for measurement of cardiac output are available, but
thermodilution is the prevailing one today. It uses a special thermistor-tipped catheter (Swan-Ganz
catheter) that is inserted from a peripheral vein into the pulmonary artery. A cold saline solution of
known temperature and volume is injected into the right atrium from a proximal catheter port. The
saline mixes with the blood as it passes through the ventricle and into the pulmonary artery, thus
cooling the blood. The blood temperature is measured by a thermistor at the catheter tip, which lies
within the pulmonary artery, and a computer is used to acquire the thermodilution profile. Figure 43. PCCO monitor
The cardiac output computer then calculates flow (cardiac output from the right ventricle) using the PCCO normal values are as follows:
blood temperature information, and the temperature and volume of the saline. The injection is
a) Cardiac output 4 – 8 L/min
normally repeated a few times and the cardiac output averaged.
b) Cardiac Index 3.0 – 5.0 L/min/m2
10.4.3.5.2 Pulse Contour Continuous Cardiac Output, PCCO c) Cardiac Function Index 4.5 – 6.5 L/min
d) Global end diastolic volume 680 – 800 ml/m2
PCCO is a method of monitoring continuous cardiac output, lung water and other indices of cardiac e) Intrathoracic blood volume index 850 – 1000 ml/m2
function. It is less invasive than using pulmonary artery catheters since it employs a central line and f) Extravascular lung water index 3 – 7 ml/kg.
an arterial line. It does not involve pulmonary artery monitoring. This technology provides clinicians g) Stroke Volume 55 – 85 ml per beat
with the number of clinical measurements, displayed as absolute or indexed values (fig. 43). h) ~=

*+$
i) Systemic vascular resistance 770 – 1500 dynes/sec/cm5
Via continuous pulse contour analysis the available information are:
a) Continuous pulse contour cardiac analysis (PCCO); Indications
b) Arterial blood pressure (AP);
c) Heart rate (HR); 1 Shock;
d) Stroke volume (SV); 2 Acute respiratory distress syndrome, ARDS;
e) Stroke volume variation (SVV); 3 Acute heart failure;
f) Systemic vascular resistance (SVR); and 4 Pulmonary hypertension;
5 Polytrauma;
g) Index of left ventricular contractility.
6 Major surgical procedures, transplantations; and
7 Severe burns.
Contraindication
Restricted arterial access (eg following severe burns).
170 171
Equipment
Table 5. Glasgow Coma Scale, GCS
1 A central line, (internal jugular or subclavian site are preferable)
2 An arterial line, inserted in large central artery such as femoral or brachial; Function Reaction Points
3 PCCO Monitor; Spontaneously 4
4 PCCO monitoring kit; To speech 3
Eyes opening
5 Bowl filled with ice, and To pain stimuli 2
6 Ice cold normal saline for injection. No eyes opening 1
Oriented 5
10.4.4 Monitoring of nervous system Confused. (The patient responds to questions 4
coherently but there is some disorientation
10.4.4.1 Consciousness and confusion.)
Inappropriate words. (Random or exclamatory 3
Best verbal response
articulated speech, but no conversational
Consciousness is the quality or state of being aware of an external object or something within exchange
oneself. It has been defined as: subjectivity, awareness, the ability to experience or to feel, Incomprehensible sounds. (Moaning but no 2
words.)
wakefulness, having a sense of selfhood, etc.
No verbal response 1
Obeys commands. (The patient does simple 6
Fully conscious patient is well-oriented in time and space, can state his name, respond in a things as asked.)
meaningful way to questions and commands, and react appropriately to environment. Medical Localizes to pain. (Purposeful movements 5
towards painful stimuli.
conditions that inhibit consciousness are considered disorders of consciousness, and can be Flexion/Withdrawal to pain (flexion of elbow, 4
qualitative and quantitative ones. supination of forearm, flexion of wrist)
Abnormal flexion to pain (flexor posturing: 3
Best motor response adduction of arm, internal rotation of
Assessment shoulder, pronation of forearm, flexion of
wrist, decorticate response)
Extension to pain (extensor posturing: 2
Assessment of the qualitative disorders is the domain of specialist, psychiatrists and psychologists. A
abduction of arm, external rotation of
formal neurological examination runs through a precisely delineated series of tests, beginning with shoulder, supination of forearm, extension of
tests for basic sensorimotor reflexes, and culminating with tests for sophisticated use of language. wrist, decerebrate response)
No motor response 1
The result of assessment may be summarized using the Glasgow Coma Scale (GCS), which yields a
number in the range 3 - 15, with a score of 3 indicating brain death (the lowest defined level of
consciousness), and 15 indicating full consciousness. The Glasgow Coma Scale has three subscales,
measuring the best motor response (ranging from "no motor response" to "obeys commands"), the
best eye response (ranging from "no eye opening" to "eyes opening spontaneously") and the best
verbal response (ranging from "no verbal response" to "fully oriented"), (table 4).
172 173
4. Catheter-tip transducer
10.4.4.2 Observation of eyes and pupillary light reflex
Catheter-tip transducers have miniature implantable transducers. Pressure is measured at the tip of a
The most important sign is pupilar reaction to light. Normally, pupils are equal, round, in mid- narrow fiberoptic catheter where there is a flexible diaphragm. Light is reflected off the diaphragm
position, with prompt reaction to light. Normal diameter is 2 - 6 mm, average size is 3.5 mm. and these changes in light intensity are interpreted in terms of pressure. The outside diameter of the
device is only 4 FG (1.3 mm). The system is not dependent on a fluid column, or on an external
Observation: transducer where the height needs constant readjustment depending on the level of the patient’s
head.
During an intensive observation, until the patient is not in a stable condition, reflex should assess
every 15 do 30 minutes, once the patient is stable every 2 to 4 hours. 5. Implanted microchip transducer
10.4.4.3 Monitoring of intrakracranial pressure Implanted microchip sensors have now been developed. It consists of a miniature solid state pressure
sensor mounted in a very small titanium case (diameter 1.2 mm) at the tip of a 100 cm long flexible
Intracranial pressure monitoring uses a device, placed inside the head, which senses the pressure nylon tube (diameter 0.7 mm). The transducer tip contains a silicon microchip with diffused
inside the skull and sends its measurements to a recording device. piezoresistive strain gauges which are connected by wires in the nylon tube. When the transducer is
There are three ways to monitor pressure in the skull (intracranial pressure). energized and pressure is applied, the silicon diaphragm deflects a small amount of applied pressure,
inducing strain in the embedded piezoresistors. This resistance change is reflected in the form of a
1. Intraventricular catheter
differential voltage which is then converted into units of pressure. The micro sensor transducer can
The intraventricular catheter is thought to be the most accurate method. To insert an intraventricular be inserted directly into the brain parenchyma but is also fine enough to be passed through a
catheter, a burr hole is drilled through the skull. The catheter is inserted through the brain into the catheter into the lateral ventricle.
lateral ventricle. This area usually contains cerebrospinal fluid. The intracranial pressure (ICP) can be
monitored this way. The ICP also can be lowered by draining cerebral spinal fluid (CSF) out through Indications
the catheter, This method has the advantage of minimal expense and maximal accuracy
1. Severe head injury
2. Subdural screw a) | ~{*`, CT scan abnormal;
b) ~*`, CT scan normal, when:
This method is used if the patient needs to be monitored right away. A subdural screw or bolt is a i. Patient >40 years;
hollow screw that is inserted through a hole drilled in the skull. It is placed through dura mater, and ii. Hypotension; or
this allows the sensor to record from inside the subdural space. These devices are simple to insert iii. Decerebrate posturing
but they have a tendency to block and so produce a damped, inaccurate trace. At high pressures, the
2. Moderate head injury, GSC > 8, if:
subdural bolt tends to read lower than a ventricular catheter. i. Sedation of patient is necessary;
ii. CT scan is abnormal;
3. Epidural sensor iii. Possibility of external influence to ICP (eg positive-end expiratory pressure ventilation).
If an epidural sensor is used, it is inserted between the skull and dura mater. The epidural sensor is 3. Intracranial mass lesions (tumors, intracranial spontaneous hematoma, brain abscess, etc)).
placed through a burr hole drilled in the skull; this procedure has the advantage avoiding penetration
of the dura, being less invasive than other methods, but it cannot remove excess CSF. Besides, there
are technical problems associated with the inelasticity of the dura and the need for the transducer to
lie flat (co-planar) on the dura.
174 175
10.4.4.4 Electroencephalography 10.4.5 Monitoring of temperature
Electroencephalography records the electrical activity in brain cortex. The data can be displayed on Normal temperature, normothermia or euthermia, depends upon the place in the body at which the
monitor’s screen, stored and analyzed. One can notice the recorded curve shape and pattern, its measurement is made, and the time of day and level of activity of the person. Different parts of the
amplitude, electrical wave’s frequency, and outburst of pathological electrical activities. This body have different temperatures. Taking a patient's temperature is an initial part of a full clinical
methodology is instrumental for detection of epileptic activity and fits, in diagnosis of cortical examination. Sites used for measurement include:
ischemia and brain death and can give the valuable date about the effects of anesthesia and sedation
on brain. 1 in the anus (rectal temperature)
2 in the mouth (oral temperature)
10.4.4.5 Evoked potentials
3 under the arm (axillary temperature)
Evoked potentials (EPs), or evoked responses, measure the electrophysiological responses of the 4 in the ear (tympanic temperature)
nervous system to a variety of stimuli. Almost any sensory modality can be tested; however, in 5 in the vagina (vaginal temperature)
clinical practice, only a few are used on a routine basis. An evoked potential or evoked response is an 6 on the skin of the forehead
electrical potential recorded from the nervous system of a human following presentation of a 7 over the temporal artery
stimulus, as distinct from spontaneous potentials as detected by electroencephalography (EEG), 8 in the gut (by swallowing a small thermometer)
electromyography (EMG), or other electrophysiological recording method. The EPs most frequently
encountered are: Note:
x Temperature in the anus (rectum/rectal), vagina, or in the ear (otic) is about 37.5o C (99.5 o).
1. Somatosensory Evoked Potentials (SSEPs) are the most frequently used in neuromonitoring to x Temperature in the mouth (oral) is about 37.0 o C (98.6 o F).
assess the function of a patient's spinal cord during surgery. They are recorded by stimulating x Temperature under the arm (axillary) is about 36.5VC (97.7VF).
peripheral nerves, most commonly the tibial nerve, median nerve or ulnar nerve, typically with
an electrical stimulus. The response is then recorded from the patient's scalp. The two most Monitoring of trends of temperature in patients is an instrumental procedure in hospitals, along the
looked at aspects of an SSEP are the amplitude and latency of the peaks. Dramatic increases in pulse frequency and blood pressure. Hypothermia can provoke arrhythmia, hypoventilation,
latency or decreases in amplitude are indicators of neurological dysfunction. hypoxemia, vasoconstriction and consequent shivering. The elderly, newborn and small children are
susceptible to temperature oscillation, as well as severely burned patients and those with spinal cord
2. Brainstem auditory evoked potentials (BAEPs) are used to trace the signal generated by a sound
injuries.
through the ascending auditory pathway. The evoked potential is generated in the cochlea, goes
through the cochlear nerve, through the cochlear nucleus, through brainstem and finally reach Hyperthermia (fever) is sign of a non-specific reaction of body to adverse physical and chemical
cortex. In clinical practice BAEPs are the most frequently used in neuromonitoring to assess the agents, and the most frequent sign of inflammation.
function of a patient's brainstem during surgery, and in assessment of brain death.
Tools for temperature measuring
3. Visual evoked potentials (VEPs) test the function of the visual pathway from the retina to the
occipital cortex. It measures the conduction of the visual pathways from the optic nerve, optic Most thermometers fall into one of two categories - those that use a heat-sensitive liquid to measure
chiasm, and optic radiations to the occipital cortex. VEPs are most useful for testing optic nerve temperature, and those that use electronic technology.
function and less useful for assessing postchiasmatic disorders. VEPs are most useful for testing
1. Traditional thermometer is a glass or plastic tube that contains a heat-sensitive liquid. Heat causes
optic nerve function and less useful for assessing postchiasmatic disorders. VEPs are most useful the liquid, traditionally mercury but now more often a form of alcohol, to expand. This expansion
for testing optic nerve function and less useful for assessing postchiasmatic disorders. causes the liquid to climb as it is pressed higher into the tube. The tube is gauged, so as the liquid
climbs a temperature measurement can be read. However, these methods do not correlate well with
4. Motor evoked potentials (MEPs) are recorded from muscles following direct stimulation of core temperature and do not allow continuous monitoring in intensive care units
exposed motor cortex, or transcranial stimulation of motor cortex, either magnetic or electrical. 2. Electronic thermometers have been developed to continuously monitor temperature in esophageal,
They have been in widespread use recently for several years for intraoperative monitoring of rectal, urinary bladder, and oral sites and allow a quick and easy measurement of core temperature,
pyramidal tract functional integrity. which can also be assessed using tympanic thermometers.
176 177
3. Double sensor thermometer is a new type of continuous, non-invasive thermometer, consisting of

two thermometers separated by a known thermal resistance. The sensor consists of two temperature
X Digestive and excretory systems
probes on each side of a standardized insulator (one side adjacent to the patient’s skin and the other
facing the environment) in a plastic shell which can be affixed to a patient’s forehead. In comparison
to measured core temperature this methodology prove to be sufficiently accurate to be considered
an alternative to distal esophageal measurements, and thus allows accurate, continuous core
temperature measurements.
4. Thermistor probe are used as temperature sensors. Previously, thermistor wire was placed against
the tympanic membrane, and thermistor probe into the esophagus and in the rectum. Those
methods were invasive and uncomfortable, and today the most frequently used are thermistors
integrated in pulmonary artery catheter, urinary catheter and in auditory canal infrared probe.
10.4.6 Monitoring of kidney function
Normal daily diuresis is 0.5 - 1 ml/kg/hour. Close observation and recording is essential, because a
decrease of urine excretion may indicate a decrease of blood volume, a kidney hypoperfussion or an
acute renal failure. Decrease of diuresis bellow 0.5 ml/kg/hour should alarm the attending staff to
severe malfunction of organism. The best possible way to follow the diuresis is by an indwelled
urinary catheter, connected to urine bag.
Kidney function is observed by urine analysis, too; the most important parameters are urea,
creatinine and electrolytes measurement.
Author: =MD, M.Sc.
Coworkers
XMD, M.Sc.

Ana Hrga, bacc. med. tech.
Dijana Radmilo, bacc. med. tech.
=
178 179
1 Goal 3 Assessment of nutritional status
3.1 Malnutrition
Goal of this module is to explain and demonstrate in clinical skills laboratory and in clinical
environment how to assess the patient’s nutritional status and hydration, the modes of enteral and The malnutrition is the condition that results from taking an unbalanced diet in which certain
parenteral nutrition, and techniques of support of food digestion and urine excretion. nutrients are lacking in excess or in the wrong proportions. Whenever the nutritients intake is lower
than their consumption a catabolic metabolism is evoked, with breakdown of muscular mass and
2 Expected outcome release of amino acids and proteins. All body organs lost their volume except the brain.
At the end of this module, the students who successfully adopt its content will have the knowledge The World Health Organization cites malnutrition as the greatest single threat to the world's public
and skills and will be competent: health, and improving nutrition is widely regarded as the most effective form of aid.
1. To assess the patient’s nutritional status. 3.1.2 Malnutrition consequences

2. To assess the level of hydration and recognize the dehydration.
3. To select the appropriate enteral nutrition. a) Decrease of immunity.
4. Select the appropriate parenteral nutrition. b) Increased sensibility to infections.
5. To insert the nasogastric tube. c) Poor wounds healing.
6. To intervene appropriately in constipation. d) Increased incidence of bed sores.
7. To take care of gastro- and enterostoma. e) Increase of harmful bacterial flora in colon.
8. To insert urinary catheter. f) Increased lost of nutritients in stool.
9. To maintain and care for urinary catheter. g) Increased hospital stay.
10. To care for suprapubic catheter. h) Increased hospital costs.
i) Increased mortality.
3.1.3 Factors influencing malnutrition
a) Poor assessment of nutritional status.

b) Malnutrition neglect.
c) Inaccurate registration of body weight and height.
d) Poor control of patient’s food intake.
e) Omission of meals because of diagnostic protocol.
f) Inadequate prescription of enteral of parenteral diet.
g) Neglect of patient’s specific needs.
h) Delay in nutritional intervention.
i) Insufficient cooperation between doctors and nutritionists.
3.2 Assessment of nutritional status
3.2.1 Anamnesis
Data should be collected about the appetite, food intake, basic digestive functions, medicaments and
body mass loss. Patient previous health history should be taken, as well as data on previous surgery,
which could influence the digestion and digestive system.
3.2.2 Essential anthropometric parameters.
Age, sex and height of patient have influence on measurement results. Body mass index, BMI should
be calculated, fat tissue distribution in the body recorded. Circumference of extremities at standard
location is measured, too.
180 181
3.2.2.1 Body mass
Standard body mass is calculated when from patient's height subtract 100 centimeters, and subtract
10% of this value. E.g., if patient's height is 170 cm, 100 cm is subtracted, and result is 70. 10% of 70
are 7, and when this is subtracted, the result represents advisable body mass of 63 kg.
3.2.2.2 Relative body mass
Advisable body mass should be observed in relation to ages and sex of patient. There are many
guidelines, and the most frequently used is Metropolitan Life Insurance Company guidelines from
1983.
3.2.2.3 Body mass index, BMI

Figure 1. Caliper
Body Mass Index, BMI is a measure of body composition. BMI is calculated by taking a person's
weight and dividing by their height squared. For instance, if patient’s height is 1.82 meters, the Measurement sites are: (i) triceps skinfold; (ii) pectoral skinfold; (iii) abdominal skinfold; and (iv) thigh
divisor of the calculation will be (1.82 x 1.82) = 3.3124. If weight is 70.5 kilograms, then BMI is 21.3 skinfold (Figure 2). Results are added and compared with standard values in tables.
(70.5 / 3.3124). BMIs are good indicators of healthy or unhealthy weights for adult men and women,
regardless of body frame size. A BMI of less than 25 indicates a healthy weight; a BMI of less than
18.5 is considered underweight. A BMI between 25 and 29.9 is considered overweight and a BMI of
30 or higher indicates obesity.
3.2.2.4 Anthropometric studies
Bioimpedance analysis (BIA) is a valuable tool for measuring body composition, including the
measurement of body fat in relation to lean body mass. It is an important part of any comprehensive
health and nutrition assessment. Measurements are taken with the bioimpedance analyzer, which
uses electrodes similar to EKG electrodes placed on one hand and foot. The analyzer calculates tissue
and fluid compartments using an imperceptible electrical current passed through pads. Lean tissue,
which is over 70% water, is a good conductor of electrical current, and fatty tissue, which is low in
water, is not. Thus, the resistance to the flow of electrical current measured by the analyzer can be
used to calculate the body composition. Optimal body fat ranges from 15% to 25% for women and
10% to 20% for men.
Hydrostatic weighting, also known as hydrodensitometry or underwater weighting is a classic

measure of body composition. The dry weight of the subject is first determined, and then the patient
sits on a specialized seat, expels all the air from their lungs, and is lowered into the water tank until
all body parts are emerged. The person must remain motionless underwater while the underwater
weight is recorded.
Skinfold measurement is simple and less expensive methods of estimating body composition. There
are precise sites on which the measurements are to be taken. To take a skin-fold measurement, first
Figure 2. Sites of skinfold measurement
determine the correct measurement site. Grab the skin with the thumb and forefinger about 1 cm
from the measurement site following the natural fold of the skin. Lift the skin up from the muscle,
apply the calipers (Figure 1) and wait for 4 seconds before reading the calipers. Fat is compressible,
so reading the scale before or after the 4-sec delay may affect the results.
182 183
Circumference measurement is an alternative method. There are numerous circumference formulas

4 Assessment of hydration
available for estimating body fat and they are all based on the fact that while a tape measure cannot
directly measure body fat, there is a correlation between body circumferences and your body fat Body water is the water content of the human body. A significant fraction of the human body is
percentage. water; the total amount of water in a man of average weight (70 kilograms) is approximately 40
liters, averaging 57 percent of his total body weight. In a newborn infant, this may be as high as 75
Measurements are done at waist, hips, thigh, lower leg, upper and lower arm, using ruler band percent of the body weight, but it progressively decreases from birth to old age. Body water is
(Figures 3 and 4). Useful overweight index is waist to hip ratio, WHR. If WHR is > 0.75, this is broken down into the following compartments:
considered as mild overweight. Ratio should not exceed 1.0 in men and 0.8 in women.
1 Intracellular fluid (2/3 of body water). In a body containing 40 liters of fluid, about 25 liters is
intracellular.
2 Extracellular fluid (1/3 of body water). For a 40 liter body, about 15 liters is extracellular, which
amounts to 37.5%
3 Plasma (1/5 of extracellular fluid). Of the 15 liters of extracellular fluid, plasma volume averages 3
liters.
4 Interstitial fluid (4/5 of extracellular fluid)
5 Transcellular fluid (a.k.a. "third space,") is often ignored in calculations.
Sodium, as the principal extracellular ion, determines the osmolarity in different body compartments.
Hypernatriemia results in water retention, hyponatriemia in water loss. Volume receptors, situated
through body, notice the water volume changes, a signal to kidney to activate the regulatory
mechanisms. In clinical practice, volume decrease is termed hypohydration and dehydratation.
Figure 3. Ruler band Figure 4. Measurement the circumference
4.1 Cause of dehydratation
4.1.1 Kidneys
3.2.2.5 Laboratory Natriuresis is the process of excretion of sodium in the urine via action of the kidneys. It exceeds 20
mmol/L in:
In nutrition status assessment laboratory data are used, too. Useful information can be collected
measuring the levels of albumin, prealbumin, transferrin, iron, hemoglobin, folic acid, vitamin B12, a) Kidneys disease (chronic kidney failure, nephritis, polyuria in acute kidney failure);
white blood cells, lymphocytes, potassium, sodium, phosphates, C-reactive protein (CRP), and urea. b) Osmotic diuresis (glicosuria, urea, manitol)
c) High doses of diuretics;
3.2.2.6 Mini nutritional assessment, MNA d) Deficiency of mineralocorticoidsis
4.1.2 Skin
Test for quick assessment of nutrition status are available at Internet at:
http://www.sciencedirect.com/science/article/pii/S0899900798001713 Natriuresis is bellow of 20 mmol/L
a) Burns;
b) Excessive sweating.
184 185
4.1.3 Digestive system

5 Clinical nutrition and nutritional needs
Natriuresis is bellow of 20 mmol/L
Clinical nutrition is nutrition of patients in health care, mainly inpatients in hospitals. It aims to keep a
a) Diarrhea; healthy energy balance in patients, as well as providing sufficient amounts other nutrients such as
b) Vomiting; protein, vitamins, minerals, in order to prevent malnutrition, decrease the morbidity and shorten the
c) Fistulae and stomas;
hospital stay.
d) Nasogastric tube;
e) Peritonitis; Methods of nutrition
f) Pancreatitis.
Among the routes of administration, the preferred means of nutrition is, if possible, oral
4.2 Clinical signs of dehydratation
administration. Alternatives include enteral administration (in nasogastric tube feeding) and
a) Dryness of oral cavity mucosa; intravenous (in parenteral nutrition).
b) Decreased skin turgor;
c) Insufficient filling of neck’s veins; 5.1 Parenteral nutrition
d) Slow filling of neck’s vein;
e) Softness of eyeballs; Parenteral nutrition (PN) is feeding a person intravenously, bypassing the usual process of eating and
f) Orthostatic hypotension and tachycardia; digestion. The patient receives nutritional formulae that contain nutrients such as glucose, amino
g) Oliguria (natriuresis bellow 20 mmol/L indicate extra renal causes) acids, lipids and added vitamins, electrolytes and dietary minerals.
h) Weakness, confusion, consciousness disturbances; and
i) Signs of hypovolemic shock. 5.1.1 Indications
Parenteral nutrition is indicated when enteral intake of food is impossible (or insufficient) in:
Table 1. Signs of dehydratation of different severity
a) Digestive system dysfunction;
b) Preparation of severely underweight patient for major surgery;
Signs Dehydratation
Mild Moderate Severe c) Protection of digestive system (pancreatic and enteral fistulae); and in
Skin normal dry clammy d) Short bowel syndrome (length under 60 cm).
Lips/tongue moist dry parched
Eyes normal deep set Sunken 5.1.2 Routes for application
Tears present reduced none
Fontanel flat soft sunken
Nutritients are delivered intravenously, via the bloodstream, in two ways:
Mood consolable irritable lethargic
Pulse normal increased rate, weak increased rate, feeble
Urine output normal, yellow decreased, dark yellow no urine a) into a central vein, Central Parenteral Nutrition (known as Total Parenteral Nutrition, TPN;
b) into a peripheral vein, Peripheral Parenteral Nutrition (PPN).
4.3 Laboratory findings For shorter periods the parenteral feeding can be administered by peripheral veins route (Figure 5).
Osmolarity of nutritional formula should not exceed 900 mOsm/L. Therefore, in PPN 3% amino acids,
a) Increase of hematocrit and red blood cells number; 10% glucoses and 20% fat solutions could be administered.
b) Hyperproteinemia;
c) Hyperazotemia with inconsistency between increase of urea and creatinine; increase of urea is All other nutritional formulae with higher concentration should be administered into central veins
dominant;
(Figure 6), usually through central venous line inserted in jugular or subclavian vein. The most
d) Decrease of sodium excretion in extra renal, and increase in renal causes
frequent feeding method is one bag system (Figures 11 and 12), in which there are the total
estimated daily needs of patient of energy, proteins, fats, electrolytes vitamins and water (Kabiven,
Aminomix).
186 187
Carbohydrates are the basis for nucleic acid building, and essential part of mucopolysaccharide,
glycoprotein and glycolipid.
Figure 5. Peripheral vein catheter Figure 6. Biluminal central line

Figure 7. Glucose solutions
Fats
5.1.3 Estimation of energy needs
Fats have high caloric values (8.1 – 9.3 kcal/g) and therefore they are a valuable nutritional
To calculate the basal energy expenditure (BEE), Harris-Benedickt equation for calculation of basal component and energy source, being 70% of stored energy component in organism. They have low
metabolism (BM) is used.
osmolarity and 20% fat solution, which releases 2.000 kcal/L, has osmolarity of 300 mOsmol. Same
amount of glucose has osmolarity of 2.800 mOsml. In nutrition dominate the use of triglycerides and
BM (male) = 66.47 + 13.75 (weight in kg) +5 (height in cm) – 6.76 (ages).
BM (female) = 65.5 + 9.6 (height in kg) + 1.7 (height in cm) – 4.7 (ages). lipoids. Triglycerides are esters of glycerol and fat acids, which can be saturated and non-saturated.
Lipoids are phospholipids and cholesterol, important as building material of cell membranes.
Energy expenditure is higher than basal metabolism, depending on daily activities, body temperature
and stress. It can be estimated using the following equation: Principal component of fats in parenteral nutrition are essential fat acids, linolenic fat acid, linoleinic
acid and arachidonic acid. In daily intake formula fats should be given in amount to provide 20-35%
Total Energy Expenditure = BM x activity factor x temperature x stress factor. of total energy requirements. Fat emulsion is administered as 10 and 20% solution.
Activity factor for inactive patient is 1.2, for ambulatory patient 1.3. Stress factor for intermediary Amino acids
metabolism is 1.2, for increased 1.5 and 1.8-2.5 for significantly increased one. Thermal factor is
calculated if for 1°C a number of 0.13 is added. Usual daily doses are 0.5 do 2 g/kg/tm (Figure 8 and 9). Burnout of 1 gram of proteins results in 4
kcal. Needs estimation is usually empiric one; exact calculation can be done by monitoring of
5.1.4 Energy sources
nitrogen loss in urine. Typical amino acid solutions contain 50% of essential and 50% non-essential
amino acids.
Carbohydrates
The most frequent source of energy is glucose (Figure 7), which is able to generate 4.1 kcal/g in vitro
and 3.75 kcal/g in vivo. It is a principal source of energy in healthy individuals, and a single source of
energy for red and white blood cells, reticuloendothelial system, and nervous tissue, especially for
brain. The other energy sources are fructose, xilitol and sorbitol.
Figure 8. Amino acid solutions
188 189
Electrolytes (Figure 10) (K, Na, Ca, Mg, P) should be restored daily in accordance to loss. Daily loss of water is about 2400 ml and this should be recovered. If there are, besides these regular
losses, some extra loss (e.g. vomiting, diarrhea, etc.), they have to be estimated and recovered, too.
Oligoelements (essential trace elements, chrome, iodine, manganese, iron, selenium and zinc) two
times per week. 5.1.6 Parenteral nutrition in illness
In many diseases (e.g. hepatic, kidney and respiratory failure, diabetes, polytrauma and brain injury,
etc.) nutrition should be adjusted to special metabolic needs of such patients. Today there are special
formulas prepared for such patients.
Figure 9. Glutamine solution Figure 10. Electrolytes solutions
Water-soluble vitamins (B-complex and C) should be given daily, because there are no storage
possibility for them in organism, opposite to fat-soluble vitamins (A, D, E, K), which can be stored.
Therefore, their daily administration is not necessary.
Figure 11. „One-bag system“or parenteral nutrition
5.1.5 Fluid balance
5.2 Enteral nutrition
Fluid balance is the concept of human homeostasis that the amount of fluid lost from the body is
equal to the amount of fluid taken in. Old formula states that daily requirements for adults are Nutrition via gastrointestinal system is a natural one and should be use whenever possible. Principal
approximately 30 ml/kg. New the recommended daily intake (RDI) for water is 3.7 liters per day reason is the preservation the function of intestinal mucosa. In every occasion when mucosa is not
(L/day) for human males older than 18, and 2.7 L/day for human females older than 18 including functional, atrophic changes start quickly, barrier is broken and bacteria and toxins penetrate into
water contained in food, beverages, and drinking water. The amount of water varies with the the blood. 100 - 200 ml of nutritients daily is sufficient to prevent the mucosa atrophy. Besides,
individual, as it depends on the condition of the subject, the amount of physical exercise, and on the
enteral secretion of immunoglobulin happens only when the food is present.
environmental temperature and humidity.
Enteral nutrition sustains normal intestinal flora, prevent the increase of pathogens and simulate the
The children needs are estimated using a simple equation. For the first 10 kg of weight, a child needs
intestinal peristalsis. The bile secretion is provoked, too, and this decreases the threat of cholecystitis
100 ml per kg of weight. For the next 10 kg of weight (11-20 kg), a child only needs 50 ml per kg of
weight. And for anything over 20 kg (21 kg of weight and higher), the child only needs 20 ml per kg of and liver fat infiltration, as well as intestinal bleeding.
weight. Take a 35 kg child, for example. He needs 1000 ml for his first 10 kg of weight (10 kg x 100
ml), 500 ml for his second 10 kg of weight (10 kg x 50 ml), and 200 ml for any weight above 20 kg (15 Enteral nutrition can be accomplished by:
kg x 20 ml). A 35 kg child, therefore, needs approximately 1800 ml of water or free liquids.
a) oral intake and
Routes of water loss b) nasogastric tube.
"Sensible" water loss is loss that can be perceived by the senses and can be measured. "Insensible"
losses (perspiratio insensibilis) can neither be perceived nor measured directly. Person lost it, but Tubes can be inserted
don't know that it was lost. The standard routes are:
1. Transnasal route, and in accordance to location can be:
a) Skin, about 400 ml in standard weather condition (perspiratio insensibilis);
b) Respiratory system, about 400 ml (perspiratio insensibilis), a) nasogastric (Figure 13);
c) Diuresis, about 1.500 ml: and b) nasoduodenal; and
d) Gastrointestinal tract, about 100 ml per each stool. c) nasojejunal (Figure 14).
190 191
Nutritients can be given intermittently, in 6 – 10 doses daily, each of 50 - 200 ml and given over 5 - 30
minutes. This is more natural way of feeding, but the risk of stomach content regurgitation and
aspiration is increased. Nutritients also can be given continuously, 20 - 150 ml of content per hour
(no more than 12 hours), using gravity drip method or enteral feeding pump (Figure 17). In such
manner digestive system distension is prevented, as well as risk of vomiting and food aspiration.
Figure 13. Nasogastric tube (5,3 mm) Figure 14. Nasojejunal tube
2. Endoscopy technique
a) Percutaneous endoscopic gastrostomy, PEG; and
b) Percutaneous endoscopic jejunostomy, PEJ.
3. Open surgery technique

a) Gastrostomy
b) Jejunostomy. Figure 17: Enteral feeding pump
Word of prudence is due here. Enteral nutrition is often stopped because the abdominal sounds are Contraindications
absent (“silent abdomen”) and this is understood as intestinal paralysis. This is not always a proper 1 Bowel obstruction;
decision. Abdominal sounds are generated by passage of swallowed air and fluids through stomach 2 Bowel ischemia;
and bowels. If a patient is sedated and breathing through endotracheal tube, there is no air in the 3 Bowel perforation;
bowels, and sounds are absent in spite of normal intestinal function. This “abdominal silence” can be 4 Shock
explained, by less experienced physicians, as intestinal malfunction, and wrongly deprive the patient 5 Enterocutaneous fistula;
of all benefits of enteral nutrition. Recent studies proved that small intestine has a food absorption 6 Short bowel syndrome;
potential in early postoperative period, and that enteral nutrition can be used even in patients with 7 Severe vomiting and diarrhea; and
acute pancreatitis. 8 Acute gastrointestinal bleeding.
Nutritive solution for enteral feeding are composed of easy-to-digest and easy-to-absorb nutritients 5.2.1 Nasogastric tube
(Figure 15 and 16).
5.2.1.1 Definition
Nasogastric tube (NG tube) is a flexible tube, made of rubber or plastic, that is passed through the
nose and down through the nasopharynx and esophagus into the stomach. It has bidirectional
potential; can be used to remove the contents of the stomach, including air, to decompress the
stomach, or to remove small solid objects and fluid, such as poison, from the stomach, and can also
be used to put solutions and nutritients directly into the stomach, when a patient cannot take food
or drink by mouth. NG tube is 80 cm long, with 3 - 10 mm diameter, with several openings at the tip.
Figures 15 and 16: Nutritive solutions for enteral feeding
192 193
5.2.2.2 Nasogastric tubes types

5.2.1.5 Procedure
NG aspiration tube is used for draining the stomach's contents, mainly to remove gastric secretions
and swallowed air in patients with gastrointestinal obstructions, and in postoperative period, when 1. Patient is sitting, head flexed.
2. Procedure executer is standing on the right side of patient.
digestive tract anastomoses are performed. Tube is used in treatment of paralytic ileus and acute
3. NG tube is moisten with water, tip of the tube soaked in 2% lindocaine gel.
pancreatitis, and for monitoring of intensity of gastrointestinal bleeding. 4. Nasal cavity is sprayed with 2% lindocaine spray.
5. Left hand support the patient’s head, right hand insert the tube in larger nostril, applying the
NG feeding tube is inserted when an oral feeding is not possible or feasible. The tube can be inserted constant firm pressure, with rotator movement, if necessary.
orally, but nasal route is recommended and better tolerated by patients. Position of tube in the 6. When tube teach pharynx, the patient should starts swallowing.
nostril should be exchanged every week to prevent decubital sores. The medicaments can be given 7. Coughing, aphonia and airflow from tube indicate that the tube is in the airway.
through this tube, too. 8. When the tube is inserted up to 50 cm mark, it is likely in the stomach.
9. Tube position check is performed by injection of 50 ml of air into the tube, what can be
Nasogastric rinsing and aspiration tube is used in poisoning situations when a potentially toxic liquid auscultating with stethoscope positioned over epigastria (Figure 18).
has been ingested. In procedure, 100 - 300 ml of warm water or saline (37 °C) is feed and, lowering 10. The efflux (when the stomach is not empty) of gastric content is another proof that the tube is
the level of canister, the stomach is emptied. Procedure is repeated until the aspirate is not clear. properly positioned.
After aspiration animal medicinal charcoal (Carbo medicinalis), a substance with strong absorptive 11. Proximal end of the tube is connected to collecting bag, and secured with adhesive tape.
and protective properties, is given, 4 - 5 teaspoons u 100 - 200 ml of water.
Nasogastric diagnostic tube is used for application of contrast media and for sampling of stomach
content for laboratory analysis.
5.2.1.3 Contraindications for NG tube insertion
1. Comatose patients, if the airway is not fully protected;

2. Ingestion of acids and bases before more than 30 minutes;
3. Nose and sinuses injury;
4. Missile neck injuries;
5. Esophageal structures; and
Figure 18. Check-out of position of NG tube
6. Zenker’s diverticle.
5.2.1.6 Complications
5.2.1.4 Equipment and material
1 Vomiting;
1. Gloves and mask;
2 Aspiration pneumonia.
2. Stethoscope; 3 Perforation of esophagus and stomach.
3. Endotracheal intubation set; 4 Severe nose bleeding.
4. Aspirator; 5 Pneumothorax.
5. Kidney tray;
6. Spatula;
7. Nasogastric tube;
8. Urine collecting bag;
9. 50 ml syringe; and
10. Lindocaine gel 2% and lindocaine spray 2%.
194 195
6.1 Digital rectal examination technique

6 Digital rectal examination, DRE
6.1.1 Definition
Rectum or straight intestine (lat. intestinum rectum, Figure 19) is the final straight portion of the
large intestine. It is about 12 centimeters (4.7 in) long and dilated near its termination, forming the Rectal examination consists of visual inspection of the perianal skin, digital palpation of the rectum,
rectal ampoule followed by the anal canal, before the gastrointestinal tract terminates at the anal and assessment of neuromuscular function of the perineum.
verge. 6.1.2 Positioning of patient
The rectum intestine acts as a temporary storage site for feces. As the rectal walls expand due to the Position of the patient is where the anus is accessible: (i) lying on the side; (ii) squatting on the
materials filling it from within, stretch receptors from the nervous system located in the rectal walls examination table; or (iii) lying down supine with feet in stirrups.
stimulate the desire to defecate. If the urge is not acted upon, the material in the rectum is often
returned to the colon where more water is absorbed from the feces. When defecation is delayed for 6.1.2.1 Proctologic position
a prolonged period of time constipation and hardened feces results.
The proctologic position (knee–chest, prone jackknife or a la vache) is the preferred position in which
to examine the perineum and rectum properly. The patient bends over the examination table, with
their elbows placed on the table and squat down slightly. Beside the rectum examination, this
position is convenient for seminal vesicles and prostate examination.
6.1.2.2 Lateral decubitus
The lateral decubitus, or Sim's position, provides optimal examination when the patient is too ill or
otherwise unable to assume other positions. The patient lies on the left side with the buttocks near
the edge of the examining table or bedside with the right knee and hip in slight flexion. This position
is convenient in female examination, because allows the palpation of structures highly positioned in
Figure 19. Terminal part of large intestine rectum.
6.1.2.1 Lithotomy position

The digital rectal examination, DRE (Figure 20) is an essential technique in diagnostic protocol of
rectal diseases. It is used: In lithotomy position, the patient is supine with the legs drawn in toward the trunk and the knees
allowed to fall out to the side. This position is customarily used when examining the pelvic organs in
x for the diagnosis of rectal tumors and other forms of cancer; women and may offer a better examination of the anterior rectum. It is used for bimanual
x for the diagnosis of prostatic disorders, notably tumors and benign prostatic hyperplasia; examination; finger of one hand examines the rectum, the other hand palpate abdomen.
x for the diagnosis of appendicitis or other examples of an acute abdomen;
x for the estimation of the tonicity of the anal sphincter; 6.1.3 Procedure
x in females, for gynecological palpations of internal organs;
x for examination of the hardness and color of the feces (i.e. in cases of constipation, and fecal 1. The rectal examination involves both inspection and palpation.
impaction); 2. Patient takes off the underwear and places in one of described.
x prior to a colonoscopy or proctoscopy; 3. The examiner gloves the sterile surgical gloves.
x to evaluate hemorrhoids; and 4. The examiner inspects the buttocks for fistulous tracts, the skin tags of hemorrhoids,
x in newborns to exclude imperforate anus. excoriations, blood, and rectal prolaps.
5. The patient then is asked to bear down to check again for rectal prolaps and for proper descent
of the perineum.
6. The next step of the rectal examination involves the assessment of neuromuscular integrity. First,
each side of the buttocks is scratched with the gloved finger to elicit the superficial anal reflex
7. Next, using a generous amount of water-soluble gel for lubrication, the gloved index finger is
inserted gently into the rectum.
196 197
8. The patient is asked to consciously act as to resist defecation and the examiner can evaluate the
anterior contraction of the puborectalis muscle and the contraction of the external anal 7 Constipation
sphincter.
9. Finally, the patient bears down again, expelling the examining finger, causing the puborectalis Constipation has been described in terms of both the character and frequency of stool. Normal
muscle to move posteriorly and the internal anal sphincter to relax.
bowel frequency ranges between three bowel movements per day to one movement every three
10. The final step of the rectal examination assesses anatomic integrity by digital palpation. Once
days. However, a well-formed and otherwise normal stool that occurs once a week does not require
again, the gloved finger is slipped gently into the rectum, and the entire circumference of the
therapy. A constipated stool is over desiccated, hard, dry, and difficult to pass. Causes for
rectum is systematically palpated in two stages.
constipation can be organic and functional.
11. The first stage involves the area 1 to 2 cm beyond the external sphincter (the length of the finger
pad). 7.1 Causes of constipation
12. The second stage deals with the remainder of the rectum within reach of the examining finger,
about 7 or 8 cm. Attention should be given to the presence of masses, tenderness, hemorrhoids, The commonest causes of constipation are:
fissures, ulcers, and the color and consistency of the stool.
13. In men, the prostate, its size, consistency, and presence of nodules should be noted. 1. Alimentary constipation is manifested by decreased stool weight or bulk, usually from a lack of
14. In women, the rectouterine pouch of Douglas should be palpated for masses or tenderness. dietary fiber or liquids.
15. Bimanual examination (rectoabdominal or rectovaginal) often facilitates examination of the 2. Medicaments caused constipation manifests as decreased propulsive activity, usually from
lower abdomen and genitourinary structures. medication with anticholinergic properties, such as the antidepressants and some antiarrhythmic
16. At the end of examination the examination glove should be carefully examined to assess the drugs, the opiates, certain antacids, calcium channel blockers, and laxatives.
color and consistency of bowel content, looking for melena, pus, mucus, blood, etc. 3. Laxative "addiction" constipation refers to a situation when defecation occurs only with the use
of a laxative.
4. Proctogenic constipation (dychesia) is a suppression of the normal defecatory rectal stimulus by
voluntarily contracting the external anal sphincter because of inconvenience or painful anal
disease, such as a thrombosed hemorrhoid or anal fissure.
5. Atonic constipation is caused by impaired innervations of Auerbach plexus.
6. Symptomatic constipation appears as an additional symptom in many diseases which are not
directly related to digestive system, e.g.
a. Hypothyroidism;
b. Depression;
c. Multiple sclerosis;
d. Biliary and renal colics;
e. Spinal cord diseases.
7. Organic causes of constipation are:
Figure 20. Digital rectal examination a. Strictures and adhesions after abdominal surgery or inflammation
b. Colonic tumors inside the lumen or tumors which obliterate the lumen by an external
compression.
c. Anomalous anatomic bowel position, colonoptosis.
d. Megacolon, congenital and acquired.
8. Inactivity constipation. Decrease in physical activity, as an illness forcing bed rest, frequently
leads to constipation.
198 199
7.2.2 Procedure
7.2 Fecal impaction in rectum
1 Wash and dry hands thoroughly.
Fecal impaction refers to a huge accumulation of hard stool, usually in the rectum, that cannot be 2 Put on gloves.
passed because of its size and consistency. 3 Screen patient for privacy.
Causes are: 4 Explain the procedure to the patient.
1. Chronic constipation; 5 Drape bath blanket over patient so that he is minimally exposed.
2. Megacolon and dolichocolon; 6 Place waterproof pad under buttocks.
7 Place bedpan behind patient near their thighs on the bed within easy reach.
3. Psychiatric conditions;
8 Lubricate gloved index finger and middle fingers of your dominant hand with water soluble
4. Neurologic maladies; lubricant.
5. Medications (cholinergic, codeine, methadone); 9 Gradually insert the index finger and feel the anus relax around the finger. Then insert the
6. Painful lesions of anal region (hemorrhoids, anal fissure, prolaps). middle finger.
10 Gradually advance fingers slowly along the rectal wall upward.
Fecal impact is the most frequently situated in rectal ampoule. Common symptoms include: 11 Gently loosen fecal mass by moving fingers in a scissor s motion to fragment the fecal mass.
Work fingers into hardened mass.
a) Abdominal cramping and bloating. 12 Work stool downward toward end of rectum. Remove small sections of feces and place in the
b) Leakage of liquid or sudden episodes of watery diarrhea in someone who has chronic bedpan.
constipation. 13 After removal of impactions, use washcloth and towel with warm water to bathe patient's
c) Rectal bleeding. buttocks and anal area.
d) Small, semi-formed stools. 14 Remove bedpan and inspect feces for color and consistency. Dispose of feces in toilet and flush.
e) Straining when trying to pass stools. 15 Remove gloves by turning inside out and discard into designated receptacle.
f) Bladder pressure or loss of bladder control 16 Assist patient to toilet or clean bedpan if needed.
g) Lower back pain 17 Wash and dry your hands thoroughly.
h) Rapid heartbeat or light-headedness from straining to pass stool
i) The rectal exam will reveal a hard mass of stool in the rectum. Surgical intervention is rarely indicated, mostly in case of complete mechanical obstruction
(mechanical ileus) or bowel perforation and peritonitis development.
Treating a fecal impaction involves removing the impacted stool. After that, measures are taken to
prevent future fecal impactions. Often a warm mineral oil enema is used to soften and lubricate the
stool. However, enemas alone are usually not enough to remove a large, hardened impaction. The 8. Enema
mass may have to be broken up by hand. This is called manual removal of fecal impact. 8.1 Definition
7.2.1 Equipment The enema is the procedure of introducing liquids into the rectum and colon via the anus.
1 Disposable gloves 8.2 Indications
2 Water soluble lubricant
3 Waterproof absorbent pads 1. Treatment for medical conditions (constipation, encopresis).
4 Bed pan
2. Administration of medicaments.
5 Bedpan cover or paper towel
6 Bath blanket 3. Rehydration therapy (proctoclysis) in patients for whom intravenous therapy is not applicable.
7 Wash basin 4. Bowel cleansing prior to surgery, because the bowel surgeries and procedures require empty
8 Wash cloths intestines.
9 Towels
10 Soap 8.3 Contraindications
11 Wash basin and warm water
1. Bowel surgery (recent).
2. Colon ailments (cancer, ulcers, diverticulitis)
3. Heart infarct (recent)
4. Arrhythmia, severe.
200 201
8.4 Mechanism of action 8.5.2 Procedure
The increasing volume of the liquid causes rapid expansion of the lower intestinal tract, often 1 Wash and dry hands thoroughly.
resulting in very uncomfortable bloating, cramping, powerful peristalsis, a feeling of extreme urgency 2 Put on gloves.
and complete evacuation of the lower intestinal tract. 3 Screen patient for privacy.
4 Explain the procedure to the patient.
8.5 Types of Enemas: 5 Drape bath blanket over patient so that he is minimally exposed.
6 Place waterproof pad under buttocks.
1 Tap water (hypotonic). 7 Position the patient in the left-side lying position with knees bent. In this position sigmoid colon is
2 Physiologic normal saline (best tolerated and safest). lower than rectum. If the patient has poor sphincter control, place in dorsal recumbent position
on bedpan, legs flexed at knees.
3 Hypertonic solution (used for clients who cannot tolerate large volumes of fluid).
8 Place waterproof, absorbent pad under hips and buttocks.
4 Soap solution added to water or saline. 9 Administration of prepackaged enema:
5 Oil retention. a) Remove cap from lubricated rectal tip. Add more lubricant as needed.
6 Carminative provides relief from gaseous distention; mixture contains magnesium, glycerin and b) Insert entire rectal tip slowly into rectum (adults 8-10 cm; children 5-8 cm).
water. c) Squeeze bottle until all the solution has been administered.
8.6 Procedure 10 Administration of Enema with Bag:
a) Prepare enema solution, 500 to 1000 ml for high enema. Use warm tap water. Check
8.6.1 Equipment/Supplies temperature using a bath thermometer.
b) Raise bag, open clamp, and allow solution to fill tubing. Close clamp.
1 Enema container with tubing and clamp (Figure 21). c) Lubricate insertion tip with water-soluble lubricant.
2 Rectal tube, 1.5 meter, diameter 22 to 30 Fr. for adults, 12 to 18 Fr. for children. d) Insert rectal tip slowly into rectum.
3 Volume of warmed solution, 1 to 2 L. e) Holding tubing securely, open clamp and raise bag to the appropriate level (adults 30 cm to 50
4 Bath thermometer. cm for high enema; children 30 cm; newborns 8 cm).
5 Disposable gloves. f) If the patient complains of cramping, lower the container and slow or stop flow. Continue to use
6 Water-soluble lubricant. stop-and-start procedure until all fluid is administered.
7 Waterproof, absorbent pads. g) When all the fluid has been administered, clamp tubing.
8 Toilet paper. h) Place toilet paper around tube at anus and slowly withdraw tube.
9 Wash basin.
10 Washcloths, towels, and soap. 11. Instruct the patient to try to retain solution as long as possible (average 5 to 10 minutes),
11 Bedpan, commode, or access to toilet. squeezing buttocks together.
12. Assist the patient onto bedpan, commode, or to toilet.
13. After the patient has expelled all of feces and solution, assist in washing buttocks.
14. Reposition the patient.
15. Remove gloves and dispose of equipment.
16. Wash hands.
17. Document in the clinical record:
a) Color consistency and amount of stool and fluid passed.

b) Characteristics of stool.
c) Procedure performed with type of solution administered.
d) The patient's tolerance of the procedure.
8.5.3 Complication
1 Tearing of rectal mucosa.

Figure 21. Enema equipment 2 Perforation of rectum and peritonitis.
3 Mucosa damage with inappropriate enema solution
4 Circulation overload and electrolyte imbalance after too frequent use of enema.
202 203
The Tiemann catheter has rather rigid and slightly bent tip to facilitate passage through the prostate.
The Malécot catheter has small folds at a tip and will stay put in the bladder because the tip will fold
9 Urinary catheterization out once the mandrin, which is used to push the tip out so the folds fall flat, is retracted. The Pezzer
catheter is made actually on the same principle.
Urinary catheterization is a medical procedure used to drain and collect urine from the bladder.
Catheter size
9.1 Types of catheters
Catheter diameters are measured in Charriëres (French scientist), or French. The actual diameter of
Indwelling catheters are left in the bladder days and weeks. The most common used are Foley the catheter can be estimated at 3 French per millimeter, so an 18 French catheter would have a
catheters with balloon. diameter of about 6 millimeter.
Intermittent catheter is used for one-time emptying of the bladder and for diagnostic and
therapeutic purpose. The most common used are Nelaton catheters.
The condom catheter is a male urinary incontinence device consisting of a flexible sheath that fits
over the penis just like a condom. The condom part is then attached to a tube that drains the urine
into a urinary storage bag.
9.2 Models of catheters
Several models are available, along with different material they are made of. The most common
models today are: Figure 22. Foley catheter, with deflated and inflated balloon
a) Nelaton catheter, a simple straight tube with a hole at the end;

9.3 Indications
b) Foley catheter, a tube with a balloon at the end to keep it in the bladder;
c) Three-way catheters, (haemostatic catheters), which are generally thicker with an extra channel Therapeutics
used to flush the bladder.
d) Tiemann catheter; 1 Acute or chronic urine retention (benign prostatic hyperplasia, urethra stricture);
e) Malécot catheter. 2 Incontinence;
3 Procedures that may limit a patient's movement;
4 Nursing care problems (like decubitus;
The Nelaton catheter is a simple straight tube with one hole at the side of the tip and a connecting
5 The need for accurate monitoring of urine input and output;
piece at the other end to connect a collecting bag, made of PVC. It can be used for one-time
6 Gross hematuria leading to blood clots and obstruction;
emptying of the bladder in males and females or to determine the amount of urine in the bladder
7 Various surgical interventions involving the bladder and prostate;
when incomplete emptying is suspected.
8 Neurogenic bladder.
The original Foley catheter (Figure 22) was a Nelaton catheter, made of latex-rubber with a balloon
Diagnostics
at the end, which could be filled with a couple of cc's of water through a nozzle at the other end that
was connected to the balloon through a tiny tube within the wall of the catheter. The amount of
1 Determination of residual urine.
water to be inserted into the balloon is usually printed on the side of the nozzle end. Because the
2 Cystography.
nozzle is equipped with a valve mechanism, the water will remain trapped inside the balloon,
3 Sampling of urine for microbiological analysis.
effectively preventing the catheter from falling out of the bladder. Today Foley catheters are made of
silicone and of silikonized latex; prices of silicone one has dropped, although they still cost 5-10 times 9.4 Contraindications
as much as a siliconized latex catheter. The use of siliconized latex catheters is restricted to 1-2
weeks, than they should either be removed or replaced after that period. 1 Urethral bleeding;
2 Posterior (pelvic) urethral injury;
Three-way haemostatic catheters are specialized Foley catheters, usually with an extra nozzle at the
3 Acute prostatitis;
end that is connected to an extra tube in the wall of the catheter that opens distally to the balloon.
4 Urethra surgery.
Through this tube, it is possible to inject water or NaCl 0.9% into the bladder to be able to flush it
continuously in order to clean the bladder of blood cloths or other debris. The main difference from
an ordinary Foley type catheter is the extra tube and an often reinforced casing of the main tube.
204 205
Those patients could be catheterized by suprapubic route. 20 If the urethral opening is not visible, try to feel for it just around the corner at the anterior side of
the vagina, where opening is felt as a small horse-shoe like rim. Then put the tip of the catheter
9.5 Equipment and supply on your index finger and let the tip slip into the opening.
21 In case of a Foley catheter, the balloon should be filled with the appropriate amount of water.
1 Sterile gloves 22 The catheter should be gently retracted from the urethra until you feel a slight tug to indicate
2 Sterile drapes that the balloon rests against the bladder neck/prostate (Figure 23) and about 10-15 cm of the
3 Cleansing solution, cotton swabs catheter tube will now stick out of the urethra.
4 Forceps 23 Urine flows through the tube. If it does not a push on the lower abdomen will start the flow.
5 Sterile water (usually 10 cc) 24 Collecting bag usually has capacity of 2.000 ml (Figure 24), and should be positioned under
6 Catheter (usually 16-18 French) bladder level, usually under the bed and changed when full or every 8 hours.
7 Syringe (usually 10 cc)
8 Lubricant (water based jelly or lindocaine jelly) 9.7 Problems with catheter insertion in a male patient
9 Collection bag and tubing
10 Kidney shaped basin. 1. Phimosis:
a) The opening is wide enough: try to pass the catheter blindly.
9.6 Procedure b) The opening is too narrow: try dilating with sounds.
1 Wash and dry hands thoroughly. 2. The catheter stops just behind the entrance:
2 Put on gloves. a) Try a slightly smaller catheter.
3 Screen patient for privacy.
4 Explain the procedure to the patient. 3. The catheter does not pass the prostate:
5 Drape bath blanket over patient so that he is minimally exposed. a) Try a catheter with a larger diameter. This may sound illogical, but it is not. The urethra at the
6 Place waterproof pad under buttocks. site of the prostate is not narrow, but it is pushed flat by the surrounding prostate, so the
7 Position the patient in the supine position with knees bent. prostate lobes have to be pushed back to the side to allow passage of the catheter.
8 Place waterproof, absorbent pad under hips and buttocks. b) Try a silicone catheter, which is more rigid than a siliconized latex catheter.
9 Grease the tip of the catheter generously with 2% lindocaine gel. c) Try a Foley catheter with a Tiemann tip. Attention: the Tiemann tip is rather 'pointy ‘and rigid, so
10 Retract the foreskin, if not circumcised, if no phimosis. it is easy to push it right through the wall of the urethra or into the prostate tissue, in which
11 Firmly take the penis between your index finger and thumb just behind the rim of the glans, then cases one will have a problem, and so does the patient.
stretch it straight up, thus stretching the first curve in the urethra. d) Try a catheter with stylet, which is inserted into the catheter to render it more rigid and make it
12 In the female patients spread the labia. steerable. This is potentially even more hazardous than a using a Tiemann tip and one have to
13 Insert about 10 ml of 2% lindocaine gel into the urethra (5 ml in female), using an insertion be experience with this technique
device specially made for that purpose, and spill a little on the surrounding glans.
14 To make sure that you do not wet the bed when the urine flow through the catheter starts, you 4. The catheter does not pass the bladder neck:
may connect a collecting bag to the catheter. a) Try a slightly smaller catheter.
15 Catheter is held with forceps at 5 cm from tip, and its posterior end is held between 4th and 5th b) Try a catheter stylet.
finger.
16 In male, let the catheter slide gently but firmly into the urethra until you feel a soft obstacle - this 9.8 Complications
is the second curve in the urethra.
17 Turn the stretched penis downwards, while pushing against the catheter. When needed, the 1 False passage (Fr. a fausse route) can incur when the procedure is executed in clumsy manner,
penis may need to be turned further downwards, against the bed, to be able to pass the catheter and the catheter is pushed through the urethral wall. This may cause bleeding and an inability to
along the prostate in a slightly upward direction. pass a catheter. It may lead to urethral strictures later.
18 Push the catheter in as far as possible, until the connector or the 'fork' of a Foley catheter. This is 2 Urinary infection.
an essential part of catheterization: often, a Foley catheter is not pushed in completely into the 3 Bleeding and bladder tamponade with clots.
bladder and the balloon of the Foley catheter is then inflated inside the prostate. It is therefore 4 The balloon of a Foley catheter is filled while inside the urethra or prostate because the catheter
essential to push in the catheter completely and not to stop when urine starts to flow through it - has not been pushed far enough into the bladder, which is, unfortunately, a common mistake.
it may very well be that only the tip of the catheter is inside the bladder while the balloon is not. This may cause urinary retention (the bladder outlet is effectively blocked by the filled balloon),
19 In female, Spread the labia and let the catheter gently slide inside. bleeding and an inability to remove the catheter because the outlet of the balloon is squeezed
shut.
5 Forcible removal of catheter with inflated balloon, common in patients in delirium state, which
can damage urethra and may lead to urethral strictures later.
206 207
10 Suprapubic catheterization
10.1 Definition
Suprapubic catheterization is a technique of draining the bladder using a catheter, which is passed
percutaneously through the anterior abdominal wall.
10.2 Indications
1 Patients with surgical or acquired urethral closure.

2 Anatomically difficult to catheterize urethrally.
3 Elective procedures following abdominal or urological surgery.
4 Prostatitis.
5 Advanced neurological disease requiring long-term catheterization for incontinence
6 Incurable incontinence.
Figure 23. Insertion and position of Foley catheter in bladder; male & female 10.3 Contraindications
Note: Within a few days the catheter becomes colonized and impregnated with bacteria, and 1 \ *¡<<{ ¢|¢ £
bacteria will be found in the urine. Any catheter will cause irritation of the bladder wall, leading to 2 A known or suspected carcinoma of the bladder.
mucous discharge, leucocytes, erythrocytes and protein in the urine. Together, this may give the
3 Undiagnosed hematuria.
impression of a urinary infection, which is often characterized as a combination of bacteria, protein
and leucocytes. In this case, the combination is a coincidence. Simple urinalysis will, however, show 4 Ascites.
'infection'. Prescription of antibiotics will lead to development of bacterial resistance. 5 Blood clotting disorders, which may lead to gross bleeding due to the puncture.
6 Previous lower abdominal surgery.
7 Overactive bladder leading to incontinence after suprapubic catheterization and removal of the
transurethral catheter.
10.4 Suprapubic catheter insertion procedure
10.4.1 Equipment
1 Sterile gloves
2 Antiseptic solution
3 Gauze squares, 4 X 4
. 4 Sterile drapes
5 Anesthetic solution without epinephrine
Figure 24. Urine collecting bag 6 Syringe, 10 ml
7 Syringe, 60 ml
8 Needles, 18 and 25 gauge
9 Scalpel blade, No. 11
208 209
10 Percutaneous suprapubic catheter set (pediatric: 8F, 10F; adult: 12F, 14F, 16F) Note: if Foley catheter is used, bladder should be punctured by troacar, a sharply pointed shaft used
within a cannula designed to be inserted into a body cavity. Once the cannula is into the bladder, the
a) Needle obturator troacar is removed and catheter inserted and balloon inflated.
b) Malécot catheter
c) Connecting tube
d) One-way stopcock
11 Sterile urinometer or urine leg bag

12 Drain sponges
13 Skin tape or nylon suture (3-0) with a needle holder
10.4.2 Procedure
1 Obtain informed consent from the patient or guardian.

2 Provide adequate parenteral analgesia with or without sedation.
3 Clean the lower abdominal wall.
4 Shave the suprapubic area if necessary.
5 Palpate the distended bladder and mark the insertion site at the midline and 2 fingers (4-5 cm)
above the pubic symphysis.
6 The routine use of ultrasonography to verify the bladder location is recommended to ensure that Figure 25. Suprapubic puncture4
no loops of bowel are present between the abdominal wall and the bladder.
7 Apply sterile drapes and verify the insertion site by palpating the anatomic landmark. 10.5. Suprapubic catheter exchange procedure
8 Fill the 10-ml syringe with a local anesthetic agent and use the 25-gauge needle to raise a skin
wheal at the insertion site. Inserted tubes should be changed at least once a month to decrease infections.
9 Advance the needle through the skin, subcutaneous tissue, rectus sheath, and retropubic space,
while alternating injection and aspiration, until urine enters the syringe. 10.5.1 Equipment
10 Using the No. 11 blade, make a 4-mm stab incision at the insertion site with the blade facing
inferiorly. 1 Sterile catheterization pack
11 Insert the needle obturator into the Malécot catheter and lock it into the port by twisting it so 2 Sterile gloves x 2
that the needle tip projects 2.5 mm from the distal end of the catheter. 3 Sterile anesthetic lubricating jelly
12 Connect the 60-ml syringe to the port of the needle obturator. 4 Appropriate catheters x 2
13 Place the tip of the catheter - obturator unit into the skin incision and direct it caudally and at a 5 Cleansing solution
20 to 30-degree angle from true vertical toward the patient’s legs (Figure 25). 6 Sterile water 10ml
14 The practitioner’s nondominant hand should be placed on the lower abdominal wall, and the unit 7 Syringe 10 ml and needle
should be stabilized between the thumb and index fingers. 8 Disposable plastic apron
15 The dominant hand should be used to advance the unit, while aspirating, until urine enters the 9 Sterile leg bag and straps
syringe. 10 Retaining strap to fix catheter to the thigh
16 Once urine enters the syringe, advance the unit 3-4 additional centimeters into the bladder. 11 Sterile 2-litre bag for overnight use
17 While securing the unit with the nondominant hand, unscrew the obturator from the catheter. 12 Catheter bag stand
18 Advance the catheter approximately 5 additional centimeters over the obturator and then
completely withdraw the obturator needle.
19 Connect the extension tubing to the catheter and connect the tubing to a leg bag.
20 Gently withdraw the catheter to lodge the wings against the bladder wall.
21 Undrape the patient and apply skin preparatory solution to the skin.
22 Apply drain dressings around the catheter at the insertion site.
23 Tape the catheter to the skin or stitch the catheter to the skin.
24 Do not change a newly inserted catheter for 4 weeks; this allows the catheter tract to become
established.
4
Anatomical illustration are used, with permission, from Eizenberg N, Briggs C, Barker P, GrkoviI.
Anatomedia CD:ROM. Maidenhead McGraw Hill Education EMEA, 2007.
210 211
10.5.2 Procedure 10.7 Clinical symptoms and signs of acute urine retention due catheter obstruction
1 Explain and discuss the procedure with the patient. a) Urine does not flow, bladder expands.
2 Obtain informed consent b) Lower part of abdomen is rigid and strained.
3 Consideration should be given to the patient’s privacy and dignity. c) There is a sharp pain in suprapubic area.
4 Assist the patient to adopt a supine position with legs extended. d) Pain is accompanied by sweating, increase of blood pressure and temperature and tachycardia.
5 Do not expose the patient at this stage of the procedure. e) Abdominal muscles are spastic.
6 Prepare a suitable clean working area near the bedside. f) All symptoms and signs immediately when urine flow is re-established by flushing or by catheter
7 Wash hands and put on apron. exchange.
8 Open outer cover of the catheterization set and slides it onto the prepared working area. Check
the expiry date before using the catheter. Using an aseptic technique open all other packs
(catheterization pack, sterile anesthetic gel, catheter, syringe and gloves).
9 Using 10 ml syringe, draw up 10 ml of sterile water. Pour cleansing lotion into an appropriate jar.
10 Remove cover that is maintaining patient’s privacy.
11 Clean hands and put on sterile gloves.
12 Clean around suprapubic insertion site.
13 Deflate the balloon on catheter.
14 Change gloves to another sterile pair.
15 Place sterile towel across patient’s thigh.
16 Place fingers of one hand around the catheter as close to the skin as possible. Remove the
catheter ensuring that the fingers are kept in the same position on the catheter.
17 Hold new catheter in the other hand alongside but not touching the old one to compare lengths.
The fingers on the new catheter should be positioned so that they mirror the position of those on
the catheter being removed.
18 Discard old catheter.
19 Lubricate new catheter tip and insert so that the same length is inserted into the bladder.
20 Ensure urine is draining through the new catheter.
21 Inflate the balloon with 10 ml sterile water through the side arm.
22 Attach the catheter to a previously selected drainage system.
23 Secure the catheter to the leg or abdomen.
24 If a urine specimen is required, this should be collected from the catheter into a specimen bottle.
25 Dispose of equipment safely.
Note: Should the catheter become contaminated in the process, it must be discarded and another
used. Never reinsert a catheter; a new one must always be used.
10.6 Suprapubic catheter maintenance
a) Catheter should be flushed at least twice daily with 5 - 10 ml 0.9% NaCl or 3% boric acid.
b) Standard catheter exchange is every 5 to 7 days
c) Suprapubic catheter exchange is at least once in the month.
212 213
References
Appendix 1 1. Arky RA. Shattuck Lecture. The family business--to educate. N Engl J Med. 2006 May 4;354(18):1922-6.
2. Wellbery C. Medical education must be more patient centered to be relevant. BMJ. 2006;333:813.
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular 3. Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students'
Care. http://www.heart.org/idc/groups/heart- perceptions of teaching. BMJ. 2004 Oct 2;329(7469):770-3.
4. Stockdale A. Medical education must be more patient centred: Good in theory but not in practice. BMJ. 2006;333.
public/@wcm/@ecc/documents/downloadable/ucm_318152.pdf
5. Simunovic F, Simunovic VJ. Clinical Skills Training in 20th and 21st century: Two Generations and Two Worlds Apart.
Part One. Acta Medica Academica. 2010;38 70-6.
6. Simunovic F, Simunovic V. Clinical Skills Training : A New Paradigm. Part Two. Acta Medica Academica. 2010;29 :(in
press).
7. Simunovic V. The influence of medical informatics and communication and information technologies on medical
education. Periodicum Biologorum. 2004;106(4):84-93.
8. Ziv A, Ben-David S, Ziv M. Simulation Based Medical Education: an opportunity to learn from errors. Medical Teacher.
2005;27(3):193-9.
9. Ludmerer KM. Learner-centered medical education. N Engl J Med. 2004 Sep 16;351(12):1163-4.
10. Irby DM. Educational continuity in clinical clerkships. N Engl J Med. 2007 Feb 22;356(8):856-7.
11. Hirsh DA, Ogur B, Thibault GE, Cox M. "Continuity" as an organizing principle for clinical education reform. N Engl J
Med. 2007 Feb 22;356(8):858-66.
12. Driessen E. Are learning portfolios worth the effort? Yes. BMJ. 2008;337:a513.
13. Simunovic VJ. Catalogue of knowledge and clinical skills. Zagreb: Medicinska naklada; 2007.
14. Simunovic V. The Catalogue of Knowledge and Clinical Skills. Zagreb: Medicinska naklada; 2007.
15. Simunovic VJ, Mimica M. Practicum of clinical skills. Mostar, BH: Mostar University Press; 2007
16. Hartzband P, Groopman J. Keeping the Patient in the Equation - Humanism and Health Care Reform. N Engl J Med.
2009;361(6):554-5.
17. Hojat M, Gonnelle J, TJ N, al e. Physician empathy: definition, components, measurement, and relationship to gender
and specialty. Am J Psych. 2002;159:1563-9.
18. Kirklin D. Ancient answers to modern maladies: the art of actively seeking out the patient''s voice. Med Humanities.
2009;35:1-2.
19. McGovern M, Johnston M, Brown K, Zinberg R, Cohen D. Use of standardized patients in, undergraduate medical
genetics education. Teach Learn Med. 2006 18(3):203-7.
20. Mueller P. Incorporating professionalism into medical education: the Mayo Clinic experience. Keio J Med. 2009
58(3):133-43.
21. MicroSim Inhospital. Stavanger Laerdal Medical; 2005. p. CD-ROM.
22. Tuthill J. See one, do one, teach one. The Lancet 2008;371(9628):1906.
23. ~=\|¥¢ ¦\\¡<<!§¨<¡¡¨{¡!+-2.
24. ~=~ ~\|\ \~£ \\¡<<©§¡!©!{++<¨-
15.
25. Eizenberg N, Briggs C, Barker P, Grkovic I. Anatomedia: General anatomy. Maidenhead: McGraw Hill Education EMEA;
2007.
26. Simunovic F. Is there a place for medical students in research laboratories? A student's perspective. Med Teach. 2008
Sep 29:1-2.
27. Field JM, Hazinski MF, Sayre M, et al. Part 1: Executive Summary of 2010 AHA Guidelines for CPR and ECC. Circulation.
2010; 122 (18 Suppl 3): S640–562.
28. Hazinski MF, Nolan JP, Billi JE, et al. Part 1: Executive Summary: 2010 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122 (16
Suppl 2):S250-75.
29. Nolan JP, Hazinski MF, Billi JE, et al. Part 1: Executive Summary: 2010 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2010; 81
(Suppl 1):e1-25
30.
||ª | ~= ZªZ-CS project at the
Split University School of Medicine. Croat Med J. 2010; 51: 373-80. Cover page.
214 215
Proof Digital Proofer
Printed By Createspace
View publication stats

Basic General Clin-CSP Proof-05!26!13

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Basic General Clin-CSP Proof-05!26!13

Uploaded by

Copyright:

Available Formats

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

Basic & General Clinical Skills

Book · May 2013

Preparation for new book, "Special Clinical Skills" View project

Cooperative Development of Health Information Technology in Split (CODE-HITS) View project

The user has requested enhancement of the downloaded file.

Institutional value system

Portfolio (logbook) of Acquired Clinical Skills

Authors: Mihajlo Lojpur, MD, PhD  

3 Content Cardio-pulmonary arrest caused by:

5. The patient is positioned in the supine position, on the firm ground.

6. The rescuer kneels beside the patient.

8. Next follow the resuscitation in ABC sequence.

4.7 Changes and new recommendations– CAB algorithm 4.8 Complications

The most significant new recommendations are: 1. Rib fractures.

1 A compression rate of at least 100/min (a change from “approximately” 100/min) 2. Pneumothorax.

3 Allowing for complete chest recoil after each compression

4 Minimizing interruptions in chest compressions 4.9 Side effects

5 Avoiding excessive ventilation 1 Hyper- and hypotension.

II Advance life support, ALS

Authors: Mihajlo Lojpur, MD, PhD & Prof. Vladimir J. Š

1 Goal 4 Advanced life support, ALS

4.3.3 Medicaments used in resuscitation

1 Optimizing vital organ perfusion

III Basic & advanced life support: virtual reality training

The most important new recommendations are:

Medications for Pulseless Arrest

1 Atropine: deleted from pulseless arrest algorithm

How to use simulator 4 The Other Buttons

Transfer the patient to ICU

Transfer to medical ward

11 Discharges IV Hospital environment and equipment

Author:   ==

1 Goals 4 Module content

1. To organize an adequate environment for patient treatment;

5 Environment 6 Hospital bed

Children from 2 to 6 years 5.5 m2

Children older than 6 years and adults 6.0 m2

Adults with limited mobility 6.5 m2

Adults with contagious diseases 7.0 m2

5.2 Outpatient clinic (ambulatory care clinic)

Outpatient clinic consists of:

x Examination room, minimum 12 m²;

6.2 Intensive care beds

7.4 Fowler position

7.3 Supine position (Magnus) 7.5 Orthopneic position

7.6 Trendelenburg position 7.8 Coma position

8 Monitoring of vital signs 8.2.2 Procedure

10.1 Hospital bed with rails

10.4 Splints and air pillows

11.1 Emergency transport

V Hygienic and preventive measures

Author:  | }X~

Collaborator: Jadranka Maras, bacc. med. techn.

Translation: \   

1 Introduction There are three modes/levels of hand hygiene:

Figure 3 illustrate recommended washing procedure 4.3 Surgical hand disinfection

x length of the hand washing

Figure 5. Smear after surgical hand disinfection

5 Medical protective clothing

5.1Safety glasses or face shields 5.3 Gloves

5.3.1 Gloving procedure 5.4 Lab coats

4. Distinguish the right from the left glove;

5.6 Shoe and boot covers

Authors: Mihajlo Lojpur, MD, PhD

Authors: Mihajlo Lojpur, MD, PhD & Prof. Vladimir J. Š

Author: ==

Author: |}X~

Translation: \

Author }

=

Author: Professor =, MD, PhD