Ward procedure

 Preoperative and postoperative care
 Emergency drugs
 Drains
 Dressings
 catheter

Preoperative &
post operative care
•History
•Examination
•Investigations
•Preoperative preparation
•Preoperative orders
•Postoperative orders

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

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

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

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

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

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

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

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

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

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

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

 Adrenaline
 Noradrenaline
 Dopamine
 Propranolol
 Atropine sulphate
 Hydrocortisone
 Aminophyline
 Morphine
 Diazepam
 Avil
 Insulin
 Lasix
 bupivacaine

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

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

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

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

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

Indications
 0.65-mg/ml :
preanesthetic medication
Bradyarrhythmias.
Parkinsonism
 6 -mg/ml
In the treatment of organophosphorus poisoning

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 Mansukh b patel & yogesh p upadhyay

Ward procedure

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