FEU – NICANOR REYES MEDICAL FOUNDATION
SURGERY B
DEPARTMENT OF SURGERY
SKILLS - PRELIMS
SGD 1: CONSULTATION SKILLS AND PHYSICAL EXAMINATIONS IN
SURGERY
Describe how to build rapport between a patient and a surgeon.
Initial moments of your encounter lay the foundation for your ongoing
relationship. Some points we consider in building rapport are:
• Greet the patient and other visitor
• Patient’s comfort
• Physical setting
1. As you begin, greet the patient by name and introduce yourself. If
possible, shake hands with the patient. If this is the first meeting,
explain your role or how you will be involved in the patient’s care. Also,
ask the patient how they prefer to be addressed. Always introduce
yourself during future meetings to make sure the patient knows who
you are
2. When visitors are in the room, acknowledge and greet each one in
turn. As much as possible, know each person’s name and relation to
the patient. Let the patient decide if visitors or family members should
stay in the room. Ask for the patient’s permission before conducting
the interview.
3. During the interview, always be attuned to the patient’s comfort. Help
the patient find a place for belongings. After greeting the patient, ask
how the patient is feeling. Look for signs of discomfort and attend to
these signs first.
4. Give the patient your undivided attention. Spend enough time on
small talk to put the patient at ease. Avoid looking down to take notes
or scan a computer screen.
Consider the best way to arrange the room and how close you should
be to the patient. In an outpatient setting, sitting on a rolling stool, for
example, allows you to change distances in response to patient cues.
Describe how to completely perform AND enumerate and report
normal findings in the following:
A. BIMANUAL ORAL CAVITY EXAMINATION
Lips
• Vermillion – look for even coloring, symmetry, and sharp demarcation
between the skin and the lip vermillion.
• Labial mucosa – gently grasp the lower lip between the thumb and the
first finger of each hand and evert the lip. This can be done to the
lower lip and then the upper lip. Record any abnormalities of the
labial mucosa, such as polyps, scars, or ulcers. Scars inside the lower
lip are seen frequently as a result of trauma as a child.
Buccal mucosa and vestibular mucosa
• Use tongue depressor to retract the buccal mucosa on one side.
Examine the buccal mucosa and the maxillary and mandibular
vestibules. Move slowly from the posterior buccal mucosa to the
anterior, and examine the mandibular anterior vestibule, Continue
your examination on the opposite buccal mucosa and vestibules, then
move to the maxillary anterior vestibule. The mucosa should be
smooth, pinkish, moist and shiny.
Tongue
• Only the anterior 2/3 of the tongue is in the oral cavity (oral tongue).
The posterior 1/3 cannot normally be seen on dental examination.
Check for symmetry and mobility. Examine the dorsum of the tongue
first. This should be pink with numerous papilla that may be stained by
food or nicotine. Then inform the patient that the sides of the tongue
will be examined and this may stretch the tongue slightly. The foliate
papillae are multiple small vertical folds in the posterior of the lateral
oral tongue. There may be accessory lymphoid tissue in this area that
appears slightly yellow in colour. The tissue in this area should be soft.
The opposite side of the tongue should be examined in the same way.
Hard and soft palate
• The hard and soft palate usually have ridges. The soft palate should
move as the patient breathe through the mouth or when he says
“aaahh”. You should also check if the uvula is in the midline, whether it
is bifid, or inflamed. Check for the tonsils since they are common area
for inflammation, exudates, ulcers, masses.
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Floor of mouth
• Ask the patient to flip his tongue. A thin band of mucosa is prominent
on this part of the mouth, which is called the Lingual Frenum. Also, the
openings of the right and left submandibular ducts (Wharton’s ducts)
are found on either side of the lingual frenum into the anterior floor of
mouth.
• Bimanual palpation is used to feel the soft tissue structures in the floor
of the mouth. Place one index finger of one hand in the floor of the
mouth lingual to the molars, and place the index finger of your other
hand on the skin medial to the patient’s mandible, inferior to your
intraoral index finger. Using a gentle up and down motion, palpate
the submandibular gland and move your fingers forward to palpate
the sublingual gland and floor of mouth. The sublingual gland usually
feels ropey or lobulated.
Normal findings:
• Lips: pinkish, moist, symmetrical, no lesions
• Buccal mucosa and gums: pink, smooth, no lesions
• Teeth: complete set, no dental caries, good oral hygiene
• Roof, floor and palate: pinkish, no lesions
• Uvula in midline,
• Tonsils not enlarged
• Pharynx is pink, no lesions, no exudates
If there is an abnormality, further details are noted, such as:
• type of abnormality – eg. polyp, macule, ulcer
• size – measure exact size with a perio probe or ruler,
• color,
B. PHYSICAL EXAMINATION OF THE NECK
• location,
• surface texture - eg. smooth, papillary, lobulated
• and consistency eg. soft, firm, fluctuant
Before we perform the physical examination of the neck, we all know
that we know the different structures or organs within the area
In neck, we can see here or under the neck there most important that we
should know the location of the sternocleidomastoid, thyroid gland,
trachea, and lymph nodes
So first thing we do in the PE of the neck is the Inspection of the
area or looking for the range of motion of the neck
Physician should
1. Stand or sit in front of the patient and examine the neck anteriorly,
laterally and posteriorly.
2. Inspect the neck for: a. symmetry b. size (if unusually long or short) c.
deformity, mass and swelling
3. Observe how the patient carries his head
Check the range of motion of the neck.
1. Ask the patient to bend neck forward (chin to chest) to assess flexion.
2. Ask the patient to tilt his head backwards to assess extension.
3. Ask the patient to turn his chin towards his right and left shoulders to
assess lateral rotation.
4. Ask the patient bend his neck laterally towards his right and left
shoulders (ear to shoulder) to assess lateral flexion/bending
For the palpation
1. Palpation is performed with the examiner in front of and behind the
patient.
2. In front, palpate the posterior cervical spine, mastoid process,
trapezius and sternocleidomastoid.
3. From behind, palpate the thyroid gland and lymph nodes.
4. If a mass is palpable, describe its location, consistency, size, and
mobility.
For the trachea
1. Palpate the trachea for any deviation from its usual midline position
by placing your finger (index finger or thumb) along one side of the
trachea and note the space between it and the sternocleidomastoid.
2. Compare it with the other side. The spaces should be symmetrical. If
asymmetrical, there is deviation on the narrower side.
 6. Consistency (soft, firm or hard)
SURGERY B
For the Thyroid Gland 7. Tenderness
Inspection DESCRIPTION OF NORMAL FINDINGS: The neck is normal in size,
1. With the patient seated, inspect the anterior lower half of the neck. symmetrical, no visible mass, normal muscle tone, no tenderness, full range
Have him swallow to note any ascending mass in the midline or behind of motion; trachea in the midline, no palpable lymph nodes, the thyroid
the sternocleidomastoid. gland is not visible or palpable
2. The thyroid gland, the thyroid cartilage, and the cricoid cartilage all
normally rise as the person swallows. C. PHYSICAL EXAMINATION OF THE BREAST
3. If the patient is obese, or has a short neck, tilt the patient's neck FEMALE BREAST
backward, and ask him to place his clasped hands on the occiput for Inspection
support; instruct him to swallow while in this position. 1) An adequate inspection initially requires full exposure of the chest.
2) Inspect the breasts and nipples; sitting position and disrobed to the
Palpation waist.
This is probably best done from behind the patient. Because you cannot 3) Examination should include:
see what you are doing, you may initially find this position awkward. Feeling a. careful inspection for skin changes,
for any thyroid tissue beforehand from in front of the patient may guide b. symmetry,
you. c. Contours,
1. Place the fingers of both hands on the patient’s neck so that the index d. retraction in four views
fingers are just below the cricoid cartilage – the basic landmark for ii) arms at sides,
examination. iii) arms over head,
2. Extend the patient’s neck but not far enough to tighten the muscles. iv) arms pressed against hips,
Adjust the degree of extension as you find necessary. v) leaning forward.
3. Feel the thyroid isthmus rise under your fingers as the patient 4) When examining an adolescent girl, assess her breast development
swallows. according to Tanner’s sex maturity ratings.
4. Rotate your finger slightly downward and laterally. Feel as much of • Arms at Sides.
the lateral lobes as possible, including their lower borders. o The appearance of the skin, including:
5. During both maneuvers, the patient should sip water as necessary to § Color
swallow as you repeat your palpation. § Thickening of the skin and unusually prominent pores,
which may accompany lymphatic obstruction
Auscultation o The size and symmetry of the breasts.
This should be done if the thyroid gland is palpably enlarged. With the bell o The contour of the breasts. Look for changes such as masses,
of the stethoscope, listen for bruits while the patient holds his breath. dimpling, or flattening. Compare one side with the other
The thyroid gland should be described as to: o The characteristics of the nipples, including size and shape,
• Size direction in which they point, any rashes or ulceration, or any
• Shape discharge.
• Symmetry • Arms Over Head; Hands Pressed Against Hips; Leaning Forward. To
• Consistency bring out dimpling or retraction that may otherwise be invisible, ask
• Presence of nodule the patient to raise her arms over her head, then press her hands
• Tenderness against her hips to contract the pectoral muscles. Inspect the breast
• Bruit contours carefully in each position. If the breasts are large or
pendulous, it may be useful to have the patient stand and lean
Palpation for the lymph node forward, supported by the back of the chair or the examiner’s hands.
1. With the examiner standing behind the seated patient, palpate the
lymph nodes. Palpation
2. Using the 2nd and 3rd finger pads of both index and middle fingers, 1. Palpation is best performed when the breast tissue is flattened. The
move the skin over the underlying tissues in each area (rather than patient should be supine.
moving your fingers over the skin) in a rotatory fashion. You can 2. Plan to palpate a rectangular area extending from the clavicle to the
examine both sides simultaneously. inframammary fold or bra line, and from the mid- sternal line to the
3. For the submental nodes, feel the nodes with one finger while while posterior axillary line and well into the axilla for the tail of the breast.
bracing the top of the head with your other hand. 3. A thorough examination will take 3 minutes for each breast.
4. Palpate the following nodes 4. Use the fingerpads of the 2nd, 3rd, and 4th fingers, keeping the
a) Preauricular – in front of the ear fingers slightly flexed. It is important to be systematic.
b) Posterior auricular – superficial to the mastoid process 5. Although a circular or wedge pattern can be used, the vertical strip
c) Occipital – at the base of the skull posteriorly pattern is currently the best validated technique for detecting breast
d) Tonsillar – at the angle of the mandible masses.
e) Submandibular – midway between the angle and the tip of the 6. Palpate in small, concentric circles at each examining point, if
mandible possible applying light, medium, and deep pressure. You will need to
f) Submental – in the midline a few centimeters behind the tip of press more firmly to reach the deeper tissues of a large breast.
the mandible 7. Your examination should cover the entire breast, including the
g) Superficial cervical – superficial to the sternocleidomastoid periphery, tail, and axilla.
h) Posterior cervical chain – along the anterior edge of the • lateral portion of the breast,
trapezius o ask the patient to roll onto the opposite hip, placing her hand
i) Deep cervical chain - deep in to the sternocleidomastoid but on her forehead but keeping the shoulders pressed against the
often inaccessible to examination. Hook your thumb and fingers bed or examining table. This flattens the lateral breast tissue.
around either side of the sternocleidomastoid muscle to find o Begin palpation in the axilla, moving in a straight line down to
them. the bra line, then move the fingers medially and palpate in a
j) Supraclavicular – deep in the angle formed by the clavicle and vertical strip up the chest to the clavicle.
the sternocleidomastoid o Continue in vertical overlapping strips until you reach the nipple,
5. Palpable lymph nodes can be described as to: then reposition the patient to flatten the medial portion of the
1. Size breast.
2. Shape • medial portion of the breast
3. Surface/Texture (smooth or irregular) o ask the patient to lie with her shoulders flat against the bed or
4. Delimitation (discrete or matted) examining table, placing her hand at her neck and lifting up her
5. Mobility (fixed or movable) elbow until it is even with her shoulder.

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 o Palpate in a straight line down from the nipple to the bra line,
then back to the clavicle, continuing in vertical overlapping
strips to the midsternum.
Examine the breast tissue carefully for:
• Consistency of the tissues. Normal consistency varies widely,
depending in part on the relative proportions of firmer glandular tissue
and soft fat. Physiologic nodularity may be present, increasing before
menses. There may be a firm transverse ridge of compressed tissue
along the lower mar- gin of the breast, especially in large breasts. This
is the normal inframammary ridge, not a tumor.
• Tenderness, as in premenstrual fullness
• Nodules. Palpate carefully for any lump or mass that is qualitatively
different from or larger than the rest of the breast tissue. This is
sometimes called a dominant mass and may reflect a pathologic
change that requires evaluation by mammogram, aspiration, or
biopsy. Assess and describe the characteristics of any nodule:
o Location—by quadrant or clock, with centimeters from the nipple
o Size—in centimeters
o Shape—round or cystic, disclike, or irregular in contour
o Consistency—soft, firm, or hard
o Delimitation—well circumscribed or not
o Tenderness
o Mobility—in relation to the skin, pectoral fascia, and chest wall.
Gently move the breast near the mass and watch for dimpling.
o Next, try to move the mass itself while the patient relaxes her arm
and then while she presses her hand against her hip.
The Nipple. Palpate each nipple, noting its elasticity. Press more firmly if
there is a history of nipple discharge
MALE BREAST
Examination of the male breast may be brief but is important.
1. Inspect the nipple and areola for nodules, swelling, or ulceration.
2. Palpate the areola and breast tissue for nodules.
3. If the breast appears enlarged, distinguish between the soft fatty
enlargement of obesity and the firm disc of glandular enlargement,
called gynecomastia.
THE AXILLAE
Although the axillae may be examined with the patient lying down, a sitting
position is preferable.
Inspection
1) Inspect the skin of each axilla, noting evidence of:
a) Rash
b) Infection
c) Unusual pigmentation
2) To examine the left axilla, ask the patient to relax with the left arm
down. Help by supporting the left wrist or hand with your left hand.
3) Cup together the fingers of your right hand and reach as high as you
can toward the apex of the axilla. Warn the patient that this may feel
uncomfortable.
4) Your fingers should lie directly behind the pectoral muscles, pointing
toward the mid-clavicle.
5) Now press your fingers in toward the chest wall and slide them
downward, trying to feel the central nodes against the chest wall. Of
the axillary nodes, these are the most often palpable. One or more
soft, small (<1 cm), nontender nodes are frequently felt.
6) Use your left hand to examine the right axilla.
7) If the central nodes feel large, hard, or tender, or if there is a
suspicious lesion in the drainage areas for the axillary nodes, feel for
the other groups of axillary lymph nodes:
a) Pectoral nodes—grasp the anterior axillary fold between your
thumb and fingers, and with your fingers, palpate inside the
border of the pectoral muscle.
b) Lateral nodes—from high in the axilla, feel along the upper
humerus.
c) Subscapular nodes—step behind the patient and, with your
fingers, feel inside the muscle of the posterior axillary fold.
8) Also, feel for infraclavicular nodes and re-examine the supraclavicular
nodes.
REPORTING OF NORMAL FINDINGS:
“Breasts are symmetric and smooth without masses. Nipples without
discharge.”
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D. PHYSICAL EXAMINATION OF THE ABDOMEN
SURGERY B
For a skilled abdominal examination, you need good light and a
relaxed and well-draped patient, with exposure of the abdomen from just
above the xiphoid process to the symphysis pubis. The groin should be
visible. The genitalia should remain draped. The abdominal muscles should
be relaxed to enhance all aspects of the examination, but especially
palpation. Visualize each organ in the region you are examining. Stand at
the patient’s right side and proceed in an orderly fashion with inspection,
auscultation, percussion, and palpation.
• Check if the bladder is empty
• Make the patient comfortable in a supine position, pillow under the
head and the knees.
• Ask the patient to keep arms at the sides
• Before you begin with palpation, ask the patient to point any areas of
pain so you can examine these areas last.
Inspection
• Stand at the right side of the bed
• Inspect the surface, contours, and movements of the abdomen
including the following: Skin: Scars, striae, dilated veins, rashes or
ecchymoses
• Umbilicus: Observe contour and location and any inflammation or
bulges (ventral hernia) Contour of the abdomen: flat, rounded,
protuberant, scaphoid, bulges, symmetric, visible organ or masses
• Peristalsis: Observe for several minutes. Normally, peristalsis may be
visible in very thin people.
• Pulsations: Normal aortic pulsation is frequently visible in the
epigastrium
Auscultation
• Auscultation provides important information about bowel motility.
Listen to the abdomen before performing percussion or palpation
because these maneuvers may alter the frequency of bowel sounds.
• Place the diaphragm of your stethoscope gently on the abdomen.
• Listen for bowel sounds and note their frequency and character.
Normal sounds consist of clicks and gurgles, occurring at an estimated
frequency of 5 to 34 per minute.
• Listen for bruits over the aorta, the iliac arteries, and the femoral
arteries, as illustrated. Listen over the liver and spleen for friction rubs.
Percussion
• Percussion helps you to assess the amount and distribution of gas in
the abdomen, possible masses that are solid or fluid-filled, and the
size of the liver and spleen.
• Percuss the abdomen lightly in all four quadrants to assess the
distribution of tympany and dullness. Tympany usually predominates
because of gas in the gastrointestinal tract, but scattered areas of
dullness from fluid and feces are also typical.
Palpation
Light Palpation
• Gentle palpation is especially helpful for eliciting abdominal
tenderness, muscular resistance, and some superficial organs and
masses.
• It also serves to reassure and relax the patient.
• Keeping your hand and forearm on a horizontal plane, with fingers
together and flat on the abdominal wall, palpate the abdomen with a
light, gentle, dipping motion. As you move your hand to different
quadrants, raise it just off the skin. Gliding smoothly, palpate in all
four quadrants.
Deep Palpation
• This is usually required to delineate abdominal masses.
• Again using the palmar surfaces of your fingers, press down in all four
quadrants.
• Identify any masses; note their location, size, shape, consistency,
tenderness, pulsations, and any mobility with respiration or pressure
from the examining hand.
• Correlate your palpable findings with their percussion notes
Liver.
• The size and shape of the liver is assessed through percussion and
palpation. The lower and upper border of dullness of the liver is first
identified using percussion. The lower border of dullness is identified
by first percussing from below the umbilicus in the RLQ in an area of
 tympany then moving upwards towards the lower border of dullness.
SURGERY B
The upper border is identified by percussing from the nipple line
downwards in the midclavicular line until the percussion shifts from
resonant to dull. The vertical span between the upper and lower
border is then measured in centimeters in which the normal span is 4-
8 cm midsternal line and 6-12cm midclavicular line.
• The liver edge is palpated by pressing the right hand downwards just
well below the lower border of dullness. The left hand is placed
behind the patient parallel to and supporting the right 11th and 12th
ribs. The liver edge is felt during a deep inspiration where it will slide
down to meet the fingertips. The normal liver edge is soft, sharp, and
regular with a smooth surface. The hooking technique is also done
when the patient is obese. Standing on the right of the patient’s
chest, both hands are placed side by side on the right abdomen
below the border of liver dullness and pressed with the fingers going
NORMAL FINDINGS:
up and towards the costal margin during inspiration.
Abdomen is protuberant with active bowel sounds. It is soft and nontender;
Spleen.
no palpable masses or hepatosplenomegaly. Liver span is 7 cm in the right
• The spleen is percussed using two techniques to detect splenomegaly.
mid- clavicular line; edge is smooth and palpable 1 cm below the right
The first involves percussing the left lower anterior chest wall from the
costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA)
border of cardiac dullness (6th rib) to the anterior axillary line and
tenderness.
then to the costal margin, an area called Traube space. The second
Additional…
involves percussing the lower interspace in the left anterior axillary
Topographical Division of the Abdomen
line. In both cases, tympany should be prominent so that splenomegaly
will be unlikely. To palpate the spleen, the left hand will reach over
and around the patient while the right hand, below the left costal
margin, will press on toward the spleen during inspiration. Describe
the contour, tenderness, and the distance between the spleen’s
lowest point and the left costal margin.
Kidneys.
• Starting with the right (or left kidney), place the left hand behind the
patient just below and parallel to the 12th rib. The right hand is placed
on the RUQ, lateral and parallel to the rectus muscle. During Right Upper (RUQ) Left Upper (RUQ)
inspiration, the right hand will press firmly into the RUQ just below the Small bowel Small bowel
costal margin as if trying to capture the kidney between the right and Liver and Gallbladder Left lobe of liver
left hands. The patient is then asked to stop breathing for a bit in Pylorus Spleen
Duodenum Stomach
which the left hand will then slowly release pressure to feel for the Head of Pancreas Body of pancreas
kidney as it slides back during expiration. Describe its size, contour, Hepatic flexure of colon Splenic flexure of colon
and any tenderness. Repeat on the right side to palpate for the right Portions of ascending and transverse Portions of transverse and descending
kidney. colon colon
Right adrenal gland Left adrenal gland
Aorta. Portion of right kidney Portion of left kidney
• Both hands are placed on the epigastrium slightly to the left of the Right Lower (RLQ) Left Lower (LLQ)
midline and are pressed firmly and deeply to identify aortic pulsations. Small bowel Small bowel
For assessing aortic width, both hands are placed on each side of the Cecum and appendix Sigmoid colon
aorta and then pressed deeply in the upper abdomen. Portion of ascending colon Portion of descending colon
Lower pole of right kidney Lower pole of left kidney
CVA tenderness. Right ureter Left ureter
• The examiner applies gentle pressure to the region inside of the CVA
with their finger to elicit tenderness. The examiner can also place one Right hypochondriac Epigastric Left hypochondriac
hand over the region inside the CVA and taps the hand gently with Right lobe of liver Pyloric end of stomach Stomach
the closed fist of the other hand. Nephrolithiasis, ureteropelvic Gallbladder Duodenum Spleen
junction obstruction, or pyelonephritis Part of duodenum Pancreas Tail of pancreas
Hepatic flexure of colon Aorta Splenic flexure of colon
Ascites. Part of right kidney Portion of liver Upper pole of left kidney
• In ascites, there will be shifting dullness and fluid wave. Shifting Suprarenal gland Suprarenal gland
dullness is where the dullness shifts to the more dependent side, and Right lumbar Umbilical Left lumbar
tympany shifts to the top. In testing for fluid wave, ask the patient or Ascending colon Omentum Descending colon
Lower half of right kidney Mesentery Lower half of left kidney
an assistant to press the edges of both hands firmly down the midline
Part of duodenum and Transverse colon Parts of jejunum and ileum
of the abdomen to prevent transmission through fat. While you tap jejunum Lower part of duodenum
one flank sharply with your fingertips, feel on the opposite flank for an Jejunum and ileum
impulse transmitted through the fluid. An easily palpable impulse Right iliac Hypogastric or Pubic Left iliac
suggests ascites. Cecum Ileum Sigmoid colon
Appendix Bladder Left ureter
Appendicitis. Lower end of ileum Left ovary in females
• Appendicitis involves tenderness at the McBurney point. Palpate Right ureter
carefully for an area of local tenderness. Classically, “McBurney point” Right ovary in females
lies 2 inches from the anterior superior spinous process of ilium on a
line drawn from that process to the umbilicus. E. DIGITAL RECTAL EXAM
A DRE is a test that examines a person’s lower rectum, pelvis, and lower
It is also important to take note of examination signs or physical findings abdomen. The purpose of this test is to:
that have come to be associated with specific diseases, as seen in the • Diagnose rectal tumors
table below: • Assess the size of the prostate and check for tumors or infection of
the prostate
• Obtain feces for a fecal occult blood test (used to screen for GIT
bleeding or colon cancer
• Asess mass in the anus or rectum
• Assess the function of the anal sphincter in cases of fecal
incontinence

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• Assess the extent of hemorrhoids (swollen veins in the anus)
• Check for causes of rectal bleeding
• Check the space between the vagina and the rectum in women
• Assess for uterine cancer or ovarian cancer in women (done during
vaginal examination)
Preparation:
1) Wash hands and put on gloves
2) Ask the patient to remove clothes (pants and underwear) and put on a
hospital gown. Cover the patient with a blanket when appropriate.
3) Position the patient on their left side and bring their knees to their
chest (left lateral position). Ensure there is adequate lighting available
for good visibility during examination.
a) Other positions:
i) Modified lithotomy position - patient lies on the back with
this knees flexed and hips flexed and abducted. Lying on
the table with your feet raised (common for female during
examination of the genitalia in the lithotomy position)
ii) Bending over the table
iii) Squatting on the exam table
Inspection:
1) Ask them to relax and gently part the buttocks and expose the natal
cleft (Deep groove which runs between the two buttocks)
2) Inspect the perianal area for:
a) Skin disease (dermatitis) or skin tags
b) Pilonidal sinus, anal fissures or anal fistula
c) External hemorrhoids
d) Rectal prolapse
Palpation:
1. Lubricate your examination finger.
2. Press your finger by the posterior anal edge. Note for any anal fissures
that can be felt
3. Gently insert your finger into the anal canal, following the natural
curve of the sacrum (facing down - 6 o’clock position). Assess the anal
tone and confirm by asking the patient to squeeze your finger.
4. Carefully rotate your finger to feel all walls of the rectum. This is best
done by pronating at the wrist.
5. In males, palpate the prostate on the anterior wall.
6. Withdraw the finger and inspect contents for stool, blood or mucus.
6.
SURGERY B
Repeat the test with a placebo maneuver by putting your hand in the
same position but do not push in with your thumb. Note if the patient
can complete a full inspiration
Results
• The result is said to be positive when the patient experiences
pain/tenderness sufficient to cause an abrupt halt in inspiration
(normally occurs toward the end of inspiration) and acute cholecystitis
is suspected.
• The result is negative when the patient is able to complete a full
inspiration without significant pain/tenderness.
Notes
• The signs and symptoms of an acute abdomen in older patients are
not as classic or specific (which may explain the differences in
sensitivity and specificity).
• In elderly patients, a positive Murphy's sign is useful, but a negative
sign is not exclusive and other diagnostic tests should be performed
promptly.
B. ROVSING'S SIGN
• The Rovsing test is usually indicated for appendicitis. However it is not
commonly done as doctors usually prefer the Blumberg’s sign test for
rebound tenderness. It is not an absolute diagnostic test for
appendicitis as it is just a helping tool and needs correlation with
other signs and symptoms
Technique
• Rovsing’s sign is elicited by deep palpation of the left lower quadrant
of the patient’s abdomen. This pressure in the left iliac fossa results in
the pain on the right iliac fossa. This is called positive rovsing’s sign. If
the pressure in left iliac fossa doesn’t cause pain in right iliac fossa,
then rovsing’s sign is negative.
• Make sure that you follow the proper guidelines of clinical
examination for this test too, including:
1. Approach the patient from right side, not left.
2. Ask the patient if touching or pressing in the left iliac fossa is
painful or not.
3. First acclimatise the abdomen in the typical S pattern.
4. Press the left iliac fossa gently but gradually, keeping your eyes
on his face to see the response and any sign of pain.

Completing the exam: Results

1. Clean the patient with a paper towel. • If a patient has positive rovsing’s sign, he’s suspected to have
2. Ask the patient to re-dress appendicitis, if other symptoms of the disease are also present.
3. Wash your hands
4. Perform a git examination if indicated. Notes
Normal Findings: • Appendicitis does not always result in positive rovsing’s sign.
Rectal exam is unpleasant. • To elicit rovsing’s sign, the doctor pushes the abdomen in left iliac
• The sphincter has sufficient tone to grasp the finger fossa. This is done far from appendix (assuming that most people have
• Soft stools may be felt appendix in the right iliac fossa). This stretches the peritoneal lining all
• The walls of the mucosa are smooth over the abdomen. However, it doesn’t cause pain elsewhere, except
• The prostate gland is about 2.5cm in length, with a medial sulcus, is the part where the inflammation causes irritation, which in this case
firm and non-tender would be appendicitis, thus in right iliac fossa.So if the patient is
• Stools may be seen on the gloved finger (retained for Guaiac Testing) suffering from appendicitis, he will feel pain in right lower quadrant of
his abdomen when the pressure is applied on the left lower quadrant.
DEMONSTRATE HOW TO PERFORM SPECIFIC MANEUVERS IN ELICITING
POSSIBLE CAUSES OF ABDOMINAL PAIN SUCH AS: C. PSOAS' SIGN
A. MURPHY'S SIGN • The psoas test can be performed in order to identify the inflammation
• The maneuver for eliciting the Murphy’s sign is usually indicated for of the appendix or in case of pelvic pain.
o A patient presenting with upper right quadrant pain/tenderness • However, this sign is encountered in other medical problems as well,
o Concern for cholecystitis such as the abscess at the level of the psoas. If there are other
factors leading to the irritation of the retroperitoneum, such as the
Technique hemorrhage of a major blood vessel (iliac vessel), the psoas sign might
1. Have the patient lie supine on the exam table be positive as well.
2. Place your left hand, fingers pointing toward the midline, on the
patient's lowermost right anterior rib cage so that your index finger is Technique
resting on the most inferior rib • In order for the psoas test to be performed, the patient has to lie on
3. Extend your left thumb and push it into the patient's belly and hold. his/her side, with the knees extended. From this position, the doctor
Note: Do not lean on the patient's rib cage will try to passively extend the thigh. The doctor can also make the
4. Ask the patient to take a deep breath. patient to perform the active flexion of the thigh on the hip.
Note: You should feel the rib cage move toward you during
inspiration
5. Note the patient's breathing and the degree of tenderness

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Results
SURGERY B
SGD 2: PREOPERATIVE PREPARATION AND POSTOPERATIVE CARE
• In particular, the right iliopsoas muscle lies under the appendix when 1. Differentiate between elective and emergency surgery, and cite
the patient is supine, so a positive psoas sign on the right may suggest examples
appendicitis. A positive psoas sign may also be present in a patient According to Johns Hopkins School of Medicine, elective surgery
with a psoas abscess. It may also be positive with other sources of is defined as a surgery that can be scheduled in advance. It may not
retroperitoneal irritation, e.g. as caused by hemorrhage of an iliac always be optional, and it can be done for a better quality of life, but not
vessel. for a life-threatening condition. However, in some cases it may be for a
serious condition such as cancer. Emergency surgery on the other hand, is a
Notes type of surgery that is done because of an urgent medical condition. The
• Psoas sign is also known as Cope’s psoas test or Obraztsova’s sign condition may even be life threatening.
• The iliopsoas muscle is responsible, along with other muscles, for the Elective Surgery Emergency Surgery
flexion of the hips, being located at the level of the abdomen 1. Plastic surgeries like rhinoplasty, 1. Appendectomy (removal if
• The doctor might also decide to perform the psoas test in patients blepharoplasty, liposuction and ruptured appendix)
who complain of low back pain. breast augmentation 2. Coronary artery bypass
2. Eye surgeries like cataract for someone with heart
References: surgery attack
• Busti, A.J., 2015. Murphy's Sign: Physical Exam. Evidence-based 3. Mastectomy — removal of mass 3. Removal of bullet from a
Consult Medicine. Retrieved from from the breast gunshot wound
https://www.ebmconsult.com/articles/physical-exam-murphys-sign 4. Orthopedic procedure ACL 4. Fixing of a complicated
• Bickley, Lynn S. (2013). Bates' guide to physical examination and repair and Scoliosis repair open fracture
history taking (11th ed.). Philadelphia: Lippincott Williams & Wilkins (pp. 5. Heart valve replacement 5. Evacuation of hematoma
420-424). 6. Removal of gallstones or fr the brain after a
• Bickley, Lynn S. (2017). Bates' guide to physical examination and inflammed gallbladder - hemorrhagic stroke
history taking (12th ed.). Philadelphia: Lippincott Williams & Wilkins. cholecystectomy
• Schwartz’ Principles of Surgery 11th edition, Chapters 26, 28, 29, 30 2. Discuss the different risk assessment tools for a patient
• Travaline JM, Ruchinskas R, D'Alonzo GE. Patient-Physician undergoing elective surgery.
Communication: Why and How. J Am Osteopath Assoc 2005;105(1):13– • Risk assessment is the overall process of identifying the hazards and
18. risk factors that have the potential to cause harm, analyzing and
evaluating the risk associated with that hazard and determining the
appropriate ways to control the hazard.
• The contribution of patient risk factors to perioperative morbidity and
mortality is best estimated by validated quantitative risk calculators.
For example, the American College of Surgeons National Surgical
Quality Improvement Program (ACS NSQIP) has developed a risk
calculator to predict perioperative adverse events. Use of these tools
not only allows uniformity in interpreting surgeons' outcomes data but
also contributes to better shared decision-making and informed
consent for patients and family members.
• The ACS NSQIP Developed a tool to allow surgeons to easily enter 21
preoperative factors (demographics, comorbidities, procedure).
Regression models were developed to predict 8 outcomes based on
the preoperative risk factors(see figure below for sample results).

• Another tool developed is SURPAS or Surgical Risk Preoperative

Assessment System predicting risk of 11, 30-day postoperative
complications (mortality, overall morbidity, unplanned readmission,
infection, UTI, pulmonary, renal, cardiac, transfusion, VTE, stroke) from
input of 7 variables (primary operation, patient age, functional status,
ASA class, inpatient/outpatient operation, emergency operation,
surgeon specialty). The input comes from surgeons and the patients
themselves.

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3. Discuss antibiotic prophylaxis in patients undergoing surgery
based on wound classification.
Prophylaxis consists of the administration of an antimicrobial agent or
agents prior to initiation of certain specific types of surgical procedures in
order to reduce the number of microbes that enter the tissue or body
cavity. Agents are selected according to their activity against microbes
likely to be present at the surgical site, based on knowledge of host
microflora. By definition, prophylaxis is limited to the time prior to and
during the operative procedure; in the vast majority of cases only a single
dose of antibiotic is required, and only for certain types of procedures.
Surgical wounds are classified based on the presumed magnitude of the
bacterial load at the time of surgery:
• Clean wounds (class I) include those in which no infection is present;
only skin microflora potentially contaminate the wound, and no hollow
viscus that contains microbes is entered.
• Clean/contaminated wounds (class II) include those in which a
hollow viscus such as the respiratory, alimentary, or genitourinary
tracts with indigenous bacterial flora is opened under controlled
circumstances without significant spillage of contents.
• Contaminated wounds (class III) include open accidental wounds
encountered early after injury, those with extensive introduction of
bacteria into a normally sterile area of the body due to major breaks
in sterile technique (e.g., open cardiac massage), gross spillage of
viscus contents such as from the intestine, or incision through
inflamed, nonpurulent tissue.
• Dirty wounds (class IV) include traumatic wounds in which a
significant delay in treatment has occurred and in which necrotic
tissue is present, those created in the presence of overt infection as
evidenced by the presence of purulent material, and those created to
access a perforated viscus accompanied by a high degree of
contamination.
Appropriately administered antibiotic prophylaxis reduces the
incidence of surgical wound infection. Prophylaxis is uniformly
recommended for all clean-contaminated, contaminated and dirty
procedures. It is considered optional for most clean procedures, although it
may be indicated for certain patients and clean procedures that fulfill
specific risk criteria. Timing of antibiotic administration is critical to
efficacy. The first dose should always be given before the procedure,
preferably within 30 minutes before incision. Re-administration at one to
two half-lives of the antibiotic is recommended for the duration of the
procedure. In general, postoperative administration is not recommended.
Antibiotic selection is influenced by the organism most commonly causing
wound infection in the specific procedure and by the relative costs of
available agents.
4. Enumerate all preoperative parameters assessed in patients
prior to elective surgery.
Preoperative assessment (POA) of a patient presenting for surgery is a
crucial component of management and embraces medical, surgica, and
anaesthetic care. The goals of POA are to:
1. Documentation of the condition(s) for which surgery is needed.
2. Assessment of the patient’s overall health status.
3. Uncovering of hidden conditions that could cause problems both
during and after surgery.
4. Perioperative risk determination.
5. Optimization of the patient’s medical condition in order to
reduce the patient’s surgical and anesthetic perioperative
morbidity or mortality.
6. Development of an appropriate perioperative care plan.
History
The history is the most important component of the preoperative
evaluation. Parts of the patient’s pertinent history included:
1. History of Present Surgical Illness
2. Co-existing Medical Illness
3. Medication History
4. Allergies and Drug Reactions
5. Anesthesia Exposure
6. Family History
7. Social History
8. Alcohol Abuse
9. NPO “Non Per Orem” Status / Last Oral Intake
10. Review of Systems
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Physical Examination
SURGERY B
The physical examination should build on the information
gathered during history. At a minimum, a focused preanesthesia physical
examination includes an assessment of the airway, lungs and heart, with
documentation of vital signs. Unexpected abnormal findings on the
physical examination should be investigated before elective surgery.
The following are the parts of the PE and its focus in anesthesia:
I. General Survey - Indicates if a patient is in or not in
cardiorespiratory distress and must state the degree of severity of
cardiorespiratory distress.
II. Vital Signs
A. Height: cm | Weight: kg | BMI: kg/m2
B. Blood pressure in mmHg
C. Heart rate in beats per minute
D. Respiratory in cycle per minute
E. Pain score (level of pain) using 1-10 scale; 0 – no pain; 10–severe
pain
III. Head and Neck
• The examination should focus on airway evaluation and the predictors
of difficult ventilation or difficult intubation. The most common
classification used for airway evaluation is the Mallampati Scoring
IV. Chest and Lungs
• The examination gives focus on the baseline findings of lung
expansion, chest rise, breath and heart sounds in search for any
abnormal findings that may warrant further preoperative testing.
V. Abdomen
• In the examination of the abdomen, the anesthesiologist gives
importance to any findings that may point to an increase in
intraabdominal pressure.
• Patients with an increase in IAP presents with numerous anesthetic
implications, depending on the level of pressure.
• These implications may translate to morbidity or even mortality if not
addressed properly.
o An example is the decrease in lung volumes and capacities in
patients with massive ascites.These patients are more prone to
desaturation and hypoxia upon induction of anesthesia.
VI. Extremities
• The anesthesiologist determines the quality of the pulses as a baseline
for comparison intra-operatively, as well as the visibility and
palpability of the veins, at times an additional vascular access is
needed in the operating room.
VII. Back / Spine
• Examination includes inspection for gross deformities and active skin
dermatoses that may be a contraindication for regional anesthesia
and palpation of the lumbar spine to assess ease or difficulty of
lumbar puncture.
VIII. Neurological Examination
• A focused neurologic exam is performed to find any deficits that may
affect general and regional anesthesia techniques.
• More importantly, the neurologic exam is performed to obtain a
baseline, to determine any improvement or deterioration of function in
patients who will undergo neurosurgical procedures.
 IX. Preoperative Tests
Preoperative Tests are included for the purpose of identification
and verification of a disease or disorder that may affect during
perioperative anesthetic care and formulation of anesthetic plans and
alternatives for the proposed procedure.
This part of the preanesthetic evaluation is often used to
determine fitness for surgery and anesthesia and to identify patients at
high risk of postoperative complications.
X. Cardio-Pulmonary Evaluation
This is a referral by the surgeon, anesthesiologist or at times even
the patient himself to an internist, for the evaluation of the cardiac and
pulmonary status and the risk assessment of the patient for the planned
procedure.
The American Society of Anesthesiologists (ASA) has its own
physical status evaluation tool and this is what the Philippine Society of
Anesthesiologists (PSA) follow.
Class 1 A normal healthy patient
Class 2 A patient with mild systemic disease and no functional
limitations
Class 3 A patient with moderate to severe systemic disease that
results in some function limitation
Class 4 A patient with severe systemic disease that is a constant
threat to life and functionally incapacitating
Class 5 A moribund patient who is not expected to survive 24 hours
with or without surgery
Class 6 A brain-dead patient whose organs are being harvested
“E” If the procedure is an emergency, the physical status is
followed by an “E
5. Describe possible complications during the immediate post-
operative period presenting with fever
• Malignant hyperthermia: high-grade fever (greater than 40 C),
occurs shortly after inhalational anesthetics or muscle relaxant (e.g.,
halothane or succinylcholine), may have a family history of death after
anesthesia. Laboratory studies will reveal metabolic acidosis and
hypercalcemia. If not readily recognized, it can cause cardiac arrest.
The treatment is intravenous dantrolene, 100% oxygen, correction of
acidosis, cooling blankets, and watching for myoglobinuria.
• Bacteremia: High-grade fever (greater than 40 C) occurring 30 to 40
minutes after the beginning of the procedure (e.g., Urinary tract
instrumentation in the presence of infected urine). Management
includes blood cultures three times and starting empiric antibiotics.
• Gas gangrene of the wound: High-grade fever (greater than 40 C)
occurring after gastrointestinal (GI) surgery due to contamination with
Clostridium perfringens; severe wound pain; treat with surgical
debridement and antibiotics.
• Febrile non-hemolytic transfusion reaction: Fevers, chills, and
malaise 1 to 6 hours after surgery (without hemolysis). Management:
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SURGERY B
Stop transfusion (rule out hemolytic transfusion reaction) and give
antipyretics (avoid aspirin in the thrombocytopenic patient).
• Adrenal insufficiency: Acute adrenocortical insufficiency is a life-
threatening condition that should always be in the early differential
diagnosis of postprocedural fever. Undiagnosed or untreated, it can
lead to severe rates of morbidity and mortality. The diagnosis can be
challenging, because many of the presenting signs and symptoms are
nonspecific. For instance, a postoperative fever might be treated
presumptively as infection or systemic inflammatory response
syndrome when it actually is a subtle indicator of adrenal
insufficiency. Aggressive supportive management should be initiated
promptly, beginning with the ABCs of resuscitation (airway, breathing,
circulation). Electrolyte abnormalities and hypoglycemia should be
corrected. Hydrocortisone, 100 mg intravenously every 6 hours, and
fludrocortisone acetate (mineralocorticoid), 0.1 mg daily, should be
administered. The key management principle is treatment of the
underlying problem that precipitates the crisis.
• Pulmonary embolism: In general, fever associated with pulmonary
embolism is of low grade (temperature rarely exceeding 38.3C [101F])
and short-lived, peaking the same day on which the pulmonary
embolism occurs and gradually disappearing within 1 week. Septic
thrombophlebitis can lead to septic pulmonary emboli, causing a high
postprocedural temperature.
• Pneumonia: Almost all surgical patients are at increased risk for
postoperative pneumonia. Pain limits their mobility, inspiratory effort,
and ability to cough. Exposure to mechanical ventilation, even for a
short duration, increases the risk of pneumonia. The depressed mental
status induced by general anesthesia makes patients susceptible to
aspiration if they vomit. Management of postprocedural pneumonia
includes evaluation for leukocytosis, radiographic imaging, sputum
culture, and, if appropriate, broad-spectrum antibiotics. The clinician
should be mindful that, following laparotomy, radiography might
reveal basilar atelectasis or pleural effusion below the diaphragm; in
such cases, antibiotics are not required. The decision to administer
antibiotics should be based on culture and sensitivity information.
6. Describe the possible complications during the post-operative
period presenting with hypotension and Tachycardia.
HYPOTENSION
• Post operative Bleeding - Can be mainly due to incomplete or
impaired hemostasis or presence of coagulopathy which makes blood
unable to stop leaking out of the channels and cause bleeding and
hemorrhage. This is the primary consideration in post-operative
measures because if unmonitored, may cause the patient a trip back
to the operation room.
• Sepsis - This is the cause of bacterial infection being distributed in
the blood and eventually althrough out the body. This phenomenon
causes shock in all the parts of the body initiating the inflammatory
cascade. This cascade may cause the vessels to dilate because of the
demand of the different parts of the body for oxygen. Because of
vasodilation, there will be more blood that can travel to the channels
than being pumped by the heart and the shunts in the arteries causing
hypotension.
• Adrenal insufficiency - Causes systemic hypotension due to low
levels of glucocorticoids, which are necessary for adequate systemic
vascular resistance (SVR). Adrenal insufficiency can be primary
(Addison’s disease), or secondary as a result of suppression of the
hypothalamic-pituitary-adrenal (HPA) axis. In either case, any stress
on the body, such as with surgery, trauma, or major illness, will require
additional glucocorticoid to maintain SVR and blood pressure.
However, patients with adrenal insufficiency will be unable to
endogenously produce this additional steroid, and can present with
refractory hypotension postoperatively.
• Cardiac problems - Causes of postoperative hypotension include
acute myocardial infarction (MI) from coronary artery plaque rupture
resulting in left ventricular (LV) dysfunction, exacerbation of
congestive heart failure (CHF), or arrhythmias. Atrial fibrillation with
rapid ventricular response (RVR) occurs frequently after surgery due to
fluid shifts and electrolyte imbalances, and can result in hypotension
due to decreased filling time of the LV and decreased preload.
Preoperative cardiac assessment, which may involve stress testing,
should be done for all patients to evaluate their risk of perioperative
cardiac complications, and coronary revascularization may be needed
to decrease risk prior to non-cardiac surgery.
TACHYCARDIA
• Pain is the most common cause of Post-operative surgery
Tachycardia.
• Myocardial Infarction- appears to be aypical due to the presence of
Post surgical pain. This can be prevented by good assessment before
operation
• Pulmonary embolism- commonly due to prolonged bed rest. It is also
attributed to a painful incision site which makes the Extremities
become less movable.
• Anxiety
• Bleeding- as part of the compensatory mechanism of the body, The
heart compensates by increasing its force of contraction to supply
blood to the vital organs.
• Fever
• Hypoxia
• Sepsis
References:
• https://www.facs.org/-/media/files/education/core-
curriculum/postoperative_care.ashx#:~
:text=Hypotension%20in%20the%20postoperative%20patient,multi%2
Dorgan%20failure %20and%20death.
• Klingensmith, M. E., Vemuri, C., Fayanju, O. M., Robertson, J. O., &
Samson, P. P. (2015). The Washington Manual of Surgery (Lippincott
Manual) (7th ed.). Wolters Kluwer Health.
• Kingsnorth, A. (2011). Fundamentals of Surgical Practice (A Preparation
Guide for the Intercollegiate MRCS Examination) (3rd ed.).
Cambridge University Press.
• O’Donnell, F. T. (2016, May). Preoperative Evaluation of the Surgical
Patient. PubMed Central (PMC).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140067/
SURGERY B
SGD 3: TUBES AND DRAINS: NGT/FEEDING TUBES/CTT/IFC/DRAINS
NASOGASTRIC TUBE
1. Describe the function and applications of a nasogastric tube
• A nasogastric (NG) tube is a flexible tube of rubber or plastic that is
passed through the nose, down through the esophagus, and into the
stomach. Function of NG tube involves the following: administering
nutrients or medication, removing liquids or air from the stomach,
protecting the bowel after surgery or during bowel rest.
Indications for NG tube:
• Treatment of ileus or bowel obstruction - Small bowel obstructions
block the passage of body fluids leading to the accumulation of
fluids, so there is abdominal distention, pain nausea, bloated feeling.
This can lead to emesis and eventually aspiration. Ileus occurs from
hypomotility of the gastrointestinal tract in the absence of mechanical
bowel obstruction. There is obstipation, cannot pass stool or gas so
there is abdominal distention, bloating, gassiness, abdominal pain,
inability to tolerate an oral diet. This is treated with a nasogastric tube
through gastrointestinal decompression. Fluids and gas is removed
from the stomach, to improve patient comfort, minimizes or prevents
vomitting, and possible aspiration.
• Administration of medications - A nasogastric tube may be needed
to administer medications, or oral contrast for computed tomography,
to patients who have functional intestinal tract but are unable to
tolerate oral intake, or patients who cannot swallow or who are
neurologically impaired like stroke patients.
• Enteral feeding - For those that are unable to tolerate oral intake, for
those unable to swallow, prioritized nutrition, and to assist the bowels
after a long bowel rest.
• Stomach lavage - Lavage may be needed to remove blood or clots
to facilitate endoscopy.

Contraindications
• Esophageal stricture:an abnormal tightening or narrowing of the
esophagus. Causes may be from long standing GERD, using NGT
increases the risk for esophageal perforation.
• Basilar skull fracture or facial fracture: due to the potential for
intracranial misplacement, may exacerbate the existing trauma.
• Esophageal trauma - ingestion of caustic substances may worsen the
perforation with the administration of NGT
• Esophageal varices - may trigger variceal bleeding
• Esophageal obstruction - neoplasm or foreign object
• Bleeding diathesis : tendency to bleed or to bruise easily , minimal
trauma to the pharynx, esophagus, or stomach from nasogastric tubes
can also lead to severe bleeding

Complications
• Most common complications related to the placement of nasogastric
tubes are discomfort, sorethroat, sinusitis, or epistaxis. There can be
misplacement, knotting or coiling of tubes, and perforation for
patients that had esoophageal or gastric injury.

2. Demonstrate proper technique in the placement of a nasogastric

tube
Insertion Equipment
• All necessary equipment should be prepared, assembled and
available at the bedside prior to starting the NG tube.
o Lubricant (water based) o 50mL catheter or Luer lock
preferably 2% Xylocaine jelly syringe (if introducer to
o Baker-PHIX pH Indicator remain in for X-ray
Strips 2.0 – 9.0 (0.5 pH purposes)Nonsterile gloves
graduation) o Apron
o Skin prep, Flexi-Trak or Naso- o Continuous drainage bag
Fix securing dressing and holder
o Tissues and towel o Naso-gastric Pack
o Disposable pad o Local anaesthetic spray
o White Plastic Container o Permanent marker pen
o Glass of water & a straw
1. Ascertain the need for the nasogastric tube, i.e. feeding or
aspiration/decompression.
2. Verify the order for tube placement – with medical staff/senior
nursing staff before proceeding.
3. Identify the correct patient, explain and discuss the procedure to the
patient forewarning them that they may experience some discomfort.
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 Agree on a signal that the patient can use to stop during the
procedure e.g. raising hand
4. Position the patient in an upright position in a bed or a chair. This
position assists swallowing and increases the esophageal opening.
Support the head with pillows and assemble equipment. Check the
patient’s nostrils are patent by asking the patient if possible, to sniff
with one nostril closed. Repeat with the other nostril. (Apply local
anesthetic spray if charted)
5. Measure the length of the tube to be inserted and mark by placing the
end of the tube at the tip of the patient’s nose and then extend the
tube to the earlobe and 5cm past the xiphisternum. Lubricate tip of
tube (3-4cms) with a reasonable coating of lubricating gel. If
possible, ask the patient to have a sip of water to lubricate pharynx.
6. Gently, insert the lubricated tube into the selected nostril. Using the
natural curve of the NGT facing downward, slide the tube backwards
and inwards along the floor of the nose to the nasopharynx. If any
obstruction is felt, withdraw the tube and try again in a slightly
different direction or use the other nostril. Resistance will be
encountered at the posterior wall of the nasopharynx. Once past the
nasopharynx rotate tube between fingers so that the natural curve
should be running along the posterior pharyngeal wall. Ask patient to
put their head as forward as possible – chin to chest (neck flexed)
7. As the tube passes down the oropharynx, instruct the patient to
swallow (if appropriate) sips of water, advancing the tube gently with
each swallow. Insert tube as far as marked length. Note: Do NOT
force the tube. Seek Medical or Specialist Nursing assistance if you
are unable to insert the tube.
8. Observe for respiratory distress. Remove the tube immediately if this
occurs. Ask the patient to open their mouth. Check that the tube is not
curled up at the back of the patient’s mouth.
9. Aspirate contents of the stomach or obtain immediate drainage with
a syringe and test acidity using the Ph indicator. Ensure the pH is < 5.5
10. Note: pH levels can be altered by certain medications, including
antacids, Omeprazole and histamine H2 – receptor blocking agents
such as Rantidine (Zantac), Cimetidine (Tagamet), Famotidine
(Pepcid) and Nizatidine (Axid). The pH can also be altered by the
presence of enteral feeds. If the patient has taken above medications
and pH indicator unclear, ensure correct placement with an X-ray
11. If aspirate cannot be obtained, inject 30 mL of air and try again. If still
unable to aspirate fluid, move the patient onto the left side so gastric
contents are sitting within the greater curvature and wait 30 minutes
before trying to aspirate again.
12. If there are any doubts regarding the placement of the tube or if the
patient’s condition causes concern such as In-effective cough,
swallow reflex Previous episode of misplacement. An X-ray must be
obtained to confirm placement. Measure the external length of the
tubing and document it in a clinical record. Tape tube to patient’s
nose to secure it. For patients with an increased risk of accidental
removal, tape the tube behind the patient’s ear and secure down the
neck. Attach a spigot or a continuous drainage bag if ordered (ensure
that the bag is placed below stomach level).
13. Educate patient re securement to avoid accidental removal.
Document the insertion of the tube, stating time, reason for insertion
and volume of aspirate in the patient’s clinical record.
Removal of tube:
SURGERY B
Equipment:
• Non-sterile Gloves
• Disposable Apron
• Tissues, Protective Sheet
• White Plastic Container
• Clinical Waste Bag
• ‘Remove’ Swabs
1. Verify verbal/written order for removal of NGT from the medical
team responsible for patient care. Identify the correct patient,
explain and discuss the procedure to the patient, ensuring
privacy and adequate lighting.
2. Wash hands and prepare equipment required as per local
infection control policy
3. Ensure that the patient is placed upright in a bed or a chair,
supporting the head with pillows.
4. Aspirate the gastric contents before removal then flush NGT with
10- 20mls of air (this will dispel any residual fluid that may be
located at the distal end of the tubing)
5. Remove securing adhesive strips or Naso-Fix dressing.
6. Instruct the patient to take a deep breath and hold, this will
close off the glottis and reduce the risk of potential aspiration
whilst removing the tubing.
7. While removing the tubing, pinch the tubing, this will prevent any
contents in the tubing from draining into the patient’s throat.
8. Observe nasal mucosa for signs of trauma or ulceration, ensuring
the patient is comfortable post removal of tubing.
9. Document procedure on Fluid balance chart and in clinical
records.
FEEDING TUBE
1. Classify and identify feeding tubes according to the location of
the insertion
• Enteral nutrition generally refers to any method of feeding that uses
the gastrointestinal tract to deliver part or all of a person’s caloric
requirements. It can include a normal oral diet, the use of liquid
supplements or delivery of part or all of the daily requirements by use
of a tube. Parenteral nutrition refers to the delivery of calories and
nutrients into a vein. This could be as simple as carbohydrate calories
delivered as simple sugar in an intravenous solution or all of the
required nutrients could be delivered including carbohydrate, protein,
fat, electrolytes, vitamins and trace elements.
• Gastrostomy and Jejunostomy tubes require surgery for placement
where a stoma site is formed. A stoma site is an opening from the
outside of the body through the skin where the feeding tube enters
into the stomach or the small intestine (jejunum).

3. Describe proper care and removal of a nasogastric tube

Proper care:
• Always assess correct placement of the NG tube prior to infusing any
fluids or tube feeds.
• Clean the patient’s mouth at least daily – use a moist towel to clean SHORT-TERM
the tongue and toothbrush and floss the teeth. Types of Enteral Location of Insertion
• Clean the area where the NG tube goes into the nose daily. Use a Feeding Tubes
cotton bud moistened with warm water. Orogastric Tube Through the mouth, to the oropharynx, down
• Change the nose tape every other day or when it is loose. (OGT) the esophagus, and into the stomach
• Make sure the nose tape is secure at all times. If the feeding tube falls Nasoenteric
out, do not re-insert it by yourself but seek medical help as soon as
Nasogastric (NGT) Through the nose, down the esophagus, and
possible.
into the stomach
• To prevent a clogged feeding tube, flush the tube with water each
time after giving a feeding or medication. Nasoduodenal (NDT) Through the nose, down the esophagus, into
• If changing the gown or repositioning the patient, take care not to the stomach, then extends into the first part of
pull on the NGT. the small intestine (duodenum)
Nasojejunal (NJT) Through the nose, down the esophagus, into
the stomach, then extends into the second part
of the small intestine (jejunum)

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 LONG-TERM Common indications for Chest tube insertion:
SURGERY B
Gastrostomy • pneumothorax (collapsed lung), a collection of air in the pleural space
1. Percutaneous Endoscopic Directly into the stomach that causes the lung to collapse. Spontaneous pneumothorax occurs
Gastrostomy (PEG) through a small incision in in the absence of disease or injury. Complicated pneumothorax may
2. Radiologically Inserted the abdomen occur during heart or lung surgery or as a result of a traumatic injury
Gastrostomy (RIG) (such as a gunshot or stab wound) to the chest. The condition may
Jejunostomy develop as a result of lung diseases, such as:
1. Surgical Jejunostomy (JEJ) Directly into the small o trauma/chest injury
2. Percutaneous Endoscopic intestine (Jejunum) (PEG-J) o cystic fibrosis
Jejunostomy (PEJ) or directly into the small o chronic obstructive pulmonary disease (COPD)
3. Jejunal Extension of intestine (Jejunum) through a o lung cancer
Percutaneous Endoscopic small incision in the o asthma
Gastrostomy (PEG-J) abdomen (JEJ & PEJ) o ventilator-related air leak, which occurs when a mechanical
ventilator pushes air into the lungs and part of the lung
Types of Parenteral Feeding Location of Insertion collapses.
Tubes • empyema, an infection within the pleural space
• hemothorax, excess blood in the pleural space caused by a chest
Total Parenteral Nutrition (TPN) Intravenously through the central
injury, tumor or other bleeding problems
vein
• pleural effusion, excess fluid in the pleural space, caused by:
Partial (PPN) Intravenously through the
o heart failure
peripheral vein
o infection: pneumonia, tuberculosis or viral infection such as HIV
o lung tumor
2. Demonstrate proper care of feeding tubes.
o lymphatic fluid (chylothorax)
Using the tube for feeding
• Keep it clean. That's the most important thing you need to know about 2. Demonstrate proper technique in the placement of a chest tube
caring for your tube. Flush the tube with warm water before and after
Placement of Chest tube
feedings or giving medicines. You can use a syringe to push water
The patient may be put under general anesthesia or given local anesthetic
through the tube. Clean the end (opening) of the tube every day with
to numb the area before inserting the tube
an antiseptic wipe.
(There are different incision approaches for inserting the chest tube, but
• Always wash your hands before touching the tube.
the procedure will follow the same essential steps):
• Tape the tube to your body so the end is facing up. Look for medical
• Elevating the head of a person’s bed by 30–60 degrees. Someone will
tape in your local drugstore. It may irritate your skin less than other
usually raise the arm on the affected side above the head.
types of tape. Change the position of the tape every few days.
• Identifying the tube insertion site. This will typically be between the
• Clamp the tube when you're not using it. Put the clamp closer to your
fourth and fifth ribs or between the fifth and sixth ribs, just behind the
body so that food and liquids don't run down the tube.
pectoralis (chest) muscle.
• Keep the skin around the tube clean and dry.
• Cleaning the skin with a solution, such as povidone-iodine or
chlorhexidine. Doctors will allow the skin to dry before placing a
Avoiding common problems
sterile drape over the patient.
• Blocked tube. A blocked tube can happen when the tube isn't flushed
• Using local anesthetic to numb the insertion site. Once the area is
or when formula or medicines are too thick.
completely numb, a doctor may insert a needle more deeply to see if
o Prevent blockage by flushing the tube with warm water before
they can pull back fluid or air. This will confirm that they are in the
and after feedings and medicines.
right area.
o If the tube is blocked, try to clear it by flushing the tube. Call
• Making an incision of about 2–3 centimeters (cm) through the skin.
your doctor if the tube won't clear.
Using a surgical instrument called a Kelly clamp, the doctor will widen
o Don't use a wire or anything else to try to unclog a tube. A wire
the incision and gain access to the pleural space. The clamp insertion
can poke a hole in the tube.
should be slow to avoid puncturing the lung.
• Tube falls out. Don't try to put the tube back in by yourself. Call your
• Inserting a gloved finger into the incision site. This is to confirm that
doctor right away. The tube needs to be replaced before the opening
the area is the pleural space. The doctor will also feel for unexpected
in your belly closes. This can happen within hours.
findings, such as a mass or scar tissue.
• Leaking tube. A tube that leaks may be blocked, or it may not fit
• Inserting the chest tube through the incision site. If fluid begins to
right. After checking the tube and flushing it to make sure that the
drain through the tube, it is in the right place. It is also possible to
tube isn't blocked, call your doctor.
attach the tube to a chamber containing water that moves when a
person breathes. If this does not occur, the tube may need
CHEST TUBE
repositioning.
1. Describe the function and applications of a chest tube
• Suturing the tube in place so that the seal is as airtight as possible.
Chest Tube • Covering the tube insertion site with gauze pads.
• A chest tube is a hollow, flexible tube placed into the chest and acts A chest X-ray can also help to confirm the tube’s placement.
as a drain.
• Chest tube thoracostomy, commonly referred to as “putting in a chest 3. Discuss the function of a water seal bottle.
tube”, is a procedure that is done to drain fluid, blood, or air from the
The aims for an adequate chest drainage system to be fulfilled
space around the lungs.
are: (I) remove fluid & air as promptly as possible; (II) prevent drained air &
• This procedure may be done when a patient has a disease that
fluid from returning to the pleural space, restore negative pressure in the
causes extra fluid to build up in the space around the lungs (called a
pleural space to re-expand the lung. Thus, a drainage device must: (I) allow
pleural effusion). A chest tube may also be needed when a patient
air and fluid to leave the chest; (II) contain a one-way valve to prevent air
has had a severe injury to the chest wall or surgery that causes
& fluid returning to the chest; (III) have design so that the device is below
bleeding around the lungs (called a hemothorax). Sometimes, a
the level of the chest tube for gravity drainage.
patient’s lung can be accidentally punctured, allowing air to gather
An underwater seal chest drainage system is used to restore
outside the lung, causing its collapse (called a pneumothorax).
proper air pressure to the lungs, re-inflate a collapsed lung as well as
• Chest tube thoracostomy involves placing a hollow plastic tube
remove blood and other fluids. The system is a two-chambered or three-
between the ribs and into the chest to drain fluid or air from around
chambered plastic unit with vertical columns bringing measurements
the lungs. The tube is often hooked up to a suction machine to help
marked in milliliters. The thoracic drainage devices cover a wide range and
with drainage. The tube remains in the chest until all or most of the air
have evolved considerably since their introduction. The basic design
or fluid has drained out, usually within a few days. Occasionally
principle of these systems has been the avoidance of air entrance in the
special medicines are given through a chest tube when the fluid or air
does not resolve within a few days
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pleural cavity during the various phases of the respiratory cycle and
continuous drainage of air and fluid from the pleural cavity.
4. Describe proper care of a chest tube and a water seal bottle.
• Keep the system closed and below chest level. Make sure all
connections are taped and the chest tube is secured to the chest
wall;
• Ensure that the suction control chamber is filled with sterile water to
the 20 cm-level or as prescribed. If using suction, make sure the
suction unit’s pressure level causes slow but steady bubbling in the
suction control chamber;
• Make sure the water-seal chamber is filled with sterile water to the
level specified by the manufacturer. You should see fluctuation
(tidaling) of the fluid level in the water-seal chamber; if you don’t, the
system may not be patent or working properly, or the patient’s lung
may have reexpanded;
• Look for constant or intermittent bubbling in the water-seal chamber,
which indicates leaks in the drainage system. Identify and correct
external leaks. Notify the health care provider immediately if you can’t
identify an external leak or correct it;
• Assess the amount, color, and consistency of drainage in the drainage
tubing and in the collection chamber. Mark the drainage level on the
outside of the collection chamber (with date, time, and initials) every
8 hours or more frequently if indicated. Report drainage that’s
excessive, cloudy, or unexpectedly bloody;
• Encourage the patient to perform deep breathing, coughing, and
incentive spirometry. Assist with repositioning or ambulation as
ordered. Provide adequate analgesia;
• Assess vital signs, breath sounds, SpO2, and insertion site for
subcutaneous emphysema as ordered;
• When the chest tube is removed, immediately apply sterile occlusive
petroleum gauze dressing over the site to prevent air from entering
the pleural space;
• Don’t let the drainage tubing kink, loop, or interfere with the patient’s
movement;
• Don’t clamp a chest tube, except momentarily when replacing the
chest drainage unit, assessing for an air leak, or assessing the
patient’s tolerance of chest tube removal, and during chest tube
removal;
• Don’t aggressively manipulate the chest tube; don’t strip or milk it;
• A patient who is free from pain, to the degree that an effective cough
can be produced, will generate a much higher pressure than can
safely be produced with suction;
• If a patient cannot re-inflate his own lung, high volume, low pressure
"thoracic" suction in the range of 15-25 cm of water can help;
• Patients on mechanical ventilators cannot produce an effective cough
and therefore suction is advised;
• Close surveillance is required by nursing staff trained to recognize
faults in the drainage and suction system. It is better to remove
suction than to use a faulty device;
• The depth of the water in the suction bottle determines the amount of
negative pressure that can be transmitted to the chest, NOT the
reading on the vacuum regulator;
• There is no research to support this number of −20 cm H2O, just
convention. Higher negative pressure can increase the flow rate out of
the chest, but it can also damage tissue;
• The water seal chamber and suction control chamber provide
intrathoracic pressure monitoring. Remember that in gravity drainage
without suction the level of water in the water seal chamber =
intrathoracic pressure;
• Slow, gradual rise in water level over time means more negative
pressure in pleural space and signals healing. Goal is to return to −8
cm H2O;
• When we apply suction: Level of water in suction control + level of
water in water seal chamber = intrathoracic pressure
5. Enumerate criteria of removal of a chest tube.
To minimize the risk of infectious complications, the tube should be
removed as soon as it is safe to do so. The following criteria should be met
prior to chest tube removal.
Criteria: Pneumothorax
• The lung is fully expanded.
• No visible air leak is present, and air does not accumulate when
suction is removed. If there is any question whether a leak has
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SURGERY B
completely sealed, some clinicians clamp the tube in addition to
water seal, but this is usually not necessary. There is varying practice
on the duration of water seal prior to tube removal. Proponents
suggest that clamping will identify intermittent air leaks that would
not otherwise be detected. If the tube is clamped, care of the patient
should be directly managed by the supervising clinician and the
patient monitored closely for clinical signs of
pneumothorax/effusion, and if the patient has any hemodynamic or
respiratory difficulty during clamping, the tube should be unclamped
immediately. Imaging (plain film, ultrasound) can be obtained to
identify any possible air re-accumulation that may or may not be
clinically apparent.
• Whether to maintain a chest tube in a patient on mechanical
ventilation who has developed a pneumothorax is controversial.
Proponents believe it should remain in place as long as the patient
requires mechanical ventilation, even when no air leak is present,
while others maintain that prolonged tube placement is not necessary
and increases the risk of infection. While there are no studies to guide
chest tube management in this setting, and opinion is divided, our
preference is to remove the tube as soon as it is safe.
Criteria: Effusion
• The lung is adequately expanded. With empyema, there may still be
pockets of fluid remaining. If the majority has been drained, and the
patient is doing well (afebrile, no leukocytosis, and returned appetite),
and pleural-pleural apposition has occurred as documented by
radiographic imaging, the remainder of the pleural abnormality is
likely to resolve on antibiotics alone.
• Daily fluid output is less than 100 to 300 mL/day in adults, and likely
less for the pediatric population; however, there are no studies upon
which to base a specific threshold. The threshold is individualized
depending upon the indication for the insertion and patient size (eg,
body mass).
Removal technique — If the removal criteria above are met, the suction is
eliminated. Prior to removing the chest tube, the likelihood of developing
respiratory distress due to recurrent pneumothorax should be considered,
and the patient should be monitored accordingly after removal.
In preparation for removal of a chest tube, it is important to have all
supplies in the room and readily available. Some advocate placing
petroleum gauze on the chest tube site under a dry sterile dressing.
However, this has never been shown to decrease the risk of post-pull
pneumothorax. There is also the theoretical risk of delayed wound healing
with petroleum gauze at the chest tube incision site.
DRAINS
1. Enumerate the indications for placing a post-operative drain
Surgical drain
Appliances that act as a deliberate channel through which
established or potential collection of pus, blood or body fluid egress.
Gravitation force or negative and positive pressures are needed to achieve
this. If fluid is retained and allowed to accumulate this may put pressure on
the surgical sites and also the other organs near it, surrounding blood
vessels and nerves and can also decrease perfusion and impair wound
healing. The accumulation of fluid will also be a good medium for bacterial
growth leading to increased risk of infection.
Ideal drain:
1. A drain should be firm, not too rigid, so as to remain in its intended
place .It should not be too soft either as it may twist or kink or become
blocked .
2. Smooth so as not to allow fibrin to adhere on to it and to allow easy
removal after use.
3. Should be a material that will be resistant to decomposition or
disintegration so as to avoid leaving foreign bodies behind
4. Drain should be wide and patent enough to prevent easy blockage by
effluents
5. It should be non electrolytic, non carcinogenic and non-thrombogenic
when used in vascular surgery
The purpose of a drain
I. Therapeutic drain - These are drains that permits the exit of gases
and liquid to treat conditions such as hydrocephalus, urinary
retention and abscess cavity.
 Indications may include: Therapeutic Tension pneumothorax, Pleural fluid,
Abscess cavity, Seroma, Acute urinary retention, Acute suppurative arthritis,
Infected cyst
II. Diagnostic An example is a T-tube cholangiogram for post-
cholecystectomy diagnosis of retained stones in the common bile
duct. It provides external drainage of bile into a controlled route
while the healing process of choledochotomy is maturing and the
original pathology is resolving.
Indications may include: Biliary fistula, T-tube cholangiogram for retained
gall stones in common bile duct
III. Prophylactic - To prevent post-operative complication from fluid
accumulation in a wound cavity
Indications may include: Cardiothoracic procedures, Esophageal
resection, Duodenal stump following polya gastrectomy, Elevation of
extensive skin flap, Post thyroidectomy, Thoracotomy, Uncomplicated
cholecystectomy, Splenectomy, Pancreatectomy Patient on PPV post chest
trauma
IV. Access route: For percutaneous therapy, for example in
percutaneous nephrolithotomy
V. Monitoring - For monitoring progress in patient with Upper
gatrointestinal bleeding by NGT or for monitoring urine output
Indications may include: Gastrointestinal bleeding, Urethral
catheterizations
2. Explain the difference between active and passive post-
operative drain
I. Passive drains
• are drains that will act by the mechanism of gravity and fluctuation of
intracavitary pressure. These drains are used when drainage fluid is
too viscous to pass on the tubular drains. Examples of these are the
Penrose drain and Corrugated rubber drain.
Penrose drain Corrugated rubber drain
II. Active drains
• These are tube drains that are aided by active suction(low continuous,
low intermittent, or high suction drainage). Using this drain will have
minimal tissue trauma, no skin excoriation and also decrease risk of
wound infection. The examples of these would be the Jackson-Pratt
drains, Surgivac drain, Redivac drain.
Jackson-Pratt Redivac drain
• Redivac Drain (a close drain)
o This is a fine tube with many holes at the end, which is attached
to an evacuated glass bottle providing suction. It is used to
drain blood beneath the skin e.g. after mastectomy or
thyroidectomy, or from deep space, e.g. around a vascular
anastomosis.
Table between the major differences between active and passive
drains
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3. Describe Proper Care Of Post-Operative Drain
SURGERY B
Intraoperative
Drains should be placed such that they take the safest, shortest
route possible. They should reach the deepest, most dependent part of the
cavity or wound. Bring out external drains through a stab wound, and not
from the main wound so as to minimize incidence of wound infection.
Tubing should remain free of kinks, debris and clots so as to enhance free
drainage. The drain should be secured well so as to avoid falling off or its
migration into the cavity or erosion of surrounding tissue. Drain should be
lower than the incision at all times.
Securing a Surgical Drain
Ensure the drain is secured and the system is intact to prevent
dislodgement and infection or irritation of the surrounding skin. Drains have
been secured using various techniques and materials. The commonly used
technique includes Roman Garter technique which uses silk to secure the
drain. This method relies on silk creating a sufficient friction around the
drain to secure it. However, when the technique is poorly performed or the
silk becomes wet, its friction may be lost and the drain may become loose.
Other techniques include the use of nylon suture, safety pin, drain clip,
adhesives, Tie-lok which is also known to be associated with some
limitations.
Post operative care of a surgical drain
1. The post-operative care of a drain depends on the type, purpose and
location of the drain. However, generally speaking, the skin around all
insertion sites must be kept clean and dry to prevent infection and skin
irritation. Meticulous skin care and aseptic technique must be
observed during application and change of dressing over drains.
Gauze dressings are used around and over drainage tubes, especially
passive drains, to protect the tube, absorb some amount of
drainage, assist with the stabilization of the tube and help to protect
from external contamination.
2. A drain dressing should be inexpensive, should be easy to apply and
removed without dislodging the drain. It should be absorbent and
ensure great comfort to the patient.
3. An accurate measurement and record keeping of drainage output
must be ensured. Monitor changes in character or volume of fluid;
identify any complication resulting in leaking fluid as fast as possible.
4. Replace fluid loss through drain by additional intravenous fluids.
5. Drain container or reservoir should be emptied at least once a day.
6. Regular activation of the reservoir of active drains must be ensured.
4. Enumerate Criteria For Removal Of A Post-Operative Drain
When to discontinue a surgical drain
• Generally, drains should be removed once the drainage has stopped,
its output has become <25-50ml/day, or the drain has stopped
serving the desired function.
• The character and viscosity of the drainage fluid are occasionally
considered before drains are removed such as an initial haemorrhagic
effluent becoming clear fluid.
• Some drains, particularly open (passive) e.g. corrugated or flat should
be “shortened” by withdrawing approximately 2cm/day thus allowing
gradual healing of the site from its deepest part outwardly. This is very
useful especially when a drain is placed in an abscess cavity, wound
bed, and skin flaps where apposition of tissue is required.
• Drains that were intended to protect postoperative sites, anastomotic
sites and require forming a tract should be delayed and removed
when intended desire is achieved.
Credits to reporters of Section E2, Section B and Section H. Kamsahamnida. Saranghaeyo!