Download S.O.P Ortho-1

1. ADMISSION
1.
Doctor admitting the patient should check for availability of bed in the
ward before admitting any patient.
2.
Greet the patient and patient attendants.
3.
Explain to the patient the reason for his/her admission.
4.
Fill in the admission form and the indoor register. Always ask for old
registration number. And if not, send for new one. By Nursing staff.
Include the patient’s surname wherever necessary.
5.
Maintain the correct permanent and current address of the patient Nursing
staff.
6.
Obtain the address of Panchayat Pradhan/village leader for patients who
do not have anybody to look after.
7.
Assess patient’s condition for immediate care plan.
8.
Check patient’s file to ensure that the orders are carried out completely.
9.
Follow up investigation(s) sent from transferring unit (if it is a transferred
patient).
10.
Read out or explain the hospital rules and regulation to the patient and
attendants and get informed consent by Nursing staff.
11.
In times of emergencies, no time should be wasted in such procedures
rather the patient should be attended to and managed immediately.
12.
Orientation to patients and their attendants about ward, toilet and visiting
time and meal time by Nursing staff.
13.
Handover the visitor’s card (two cards) and attendants’ card (one card)
Nursing staff.
14.
Introduce the patient to other patients Nursing staff.
15.
Hand over the bed linens to the patients (as far as possible try to avoid
patient’s home linens) Nursing staff.
16.
Check and record vital signs.
17.
Read the Patient’s case sheet thoroughly.
18.
Ensure YELLOW alert sticker is placed on all documentation for patients
with similar names.
19.
Carry out all doctor’s order Nursing staff.
20.
Inform the patient and patient attendants not to keep any valuables in the
hospital. The hospital and staff will not be responsible for loss Nursing
staff.
21.
Place relevant forms in the respective places Nursing staff
22.
TPR sheet, I/O charts Nurses note and relevant chart at the Nursing
Station
23.
Explain in case patient needs to remain fasting overnight or any other
issues.
1.1
EMERGENCY DEPARTMENT
1.
All patients presenting at the Emergency department should be registered
at the reception except those who are critically ill. Those cases will be
registered inside the resuscitation room.
2.
The OPD patients requiring admission to the ward should not be routed
through Emergency department
1.2
MEDICATION
1.
Medication should be done by the registered nurses (If the nursing student
does it, it should be done under supervision).
2.
Pre-operative care and post-operative care should be followed as per the
Nursing procedure manual.
3.
I.V Canula Insertion, I.V Injection, and I.V fluid should be done by
registered
nurses, following aseptic technique.
The following equipment’s and drugs should be kept ready and fully
functional
in all the wards:
Oxygen
Suction machine
Resuscitation tray and emergency drugs
Pulse Oxymeter etc
1.3
CROWD CONTROL IN THE WARD
1.
Call security personal and help them to control the visitors.
2.
Security personal should be responsible for the security of the ward. In
case of any disturbance in the ward by any unauthorized person, security
supervisor should be informed.
3.
Check for visitor’s card.
4.
Ensure there are only two people beside patient during visiting hours and
one attendant during other times.
5.
1.4
Seize the cards if there is misuse.
CONTROL OF DRUNK ATTENDANT
1.
Call Security personal / security supervisor any time.
2.
Reassure the patient.
3.
Observe and report if he/she is damaging any of the hospital equipments
2.
CONSENT PROCEDURE
1.
Informed consent regarding various treatment procedures should be
obtained from the patient/ patient attendants by the treating physician.
2.
The doctor should explain the details of the procedures to the patient and.
patient attendants
3.
For children below the age of 18 years, informed consent should be
obtained from their parents or guardians.
4.
If the patient condition is serious, like in profound shock, poly trauma etc.,
high risk consent must be taken.
5.
If there is no one to give consent or the patient is unconscious/ unable to
give consent, the doctor and the unit incharge should take a collective
decision in the best interest of the patient after informing the hospital
administration.
6.
OT staff must check the consent form on receiving the patient and also
before starting surgery
3.
ON CALL PROCESS
1.
Prepare duty roster monthly and appoint 2 staff for on call.
2.
Duty roster should be distributed in the ward, Emergency department etc.
3.
On call information board should be maintained strictly on daily basis. On
call physicians should start their morning round in the ED if there are
patients due for consultation.
4.
Concerned specialist on call should be consulted over phone depending
upon the triage level. If necessary the specialist should be called to attend
the case in person.
5.
If on call doctor, is too busy, next on call doctor should be informed. This
should preferably be done by doctors not by nurses.
6.
If there are multiple/mixed emergencies next doctor on call should help.
Second opinion must be taken
3.1 EMERGENCY DEPARTMENT
1.
Concerned specialist on call should be consulted over phone depending
upon the triage level. If necessary the specialist will be called to attend the
case in person.
2.
On call information board should be maintained strictly on daily basis.
3.
On call physicians should start their morning round in the Emergency
department if there are patients due for consultation.
4.
PATIENT TRANSFER PROCEDUR INTER
DEPARTMENTAL TRANSFER
1.
Transferring unit should inform the recipient ward before sending the
patient.
2.
Treating physician should mention which ward the patient should be
transferred to.
3.
Ensure the patient condition is fully stabilized while transferring to ward.
4.
Handing taking of patient should be done by nursing staff.
5.
Complete patient documents should be handed over.
4.1
OT to Ward:
1.
Post-operative patients should be sent back after they are stable.
2.
Proper handing taking over should be done between OT staff and ward
staff. A nurse should come to receive the patient.
3.
If a patient is to be transferred from OT to Emergency department, then
the OT should inform the Emergency department ward and that ward
should receive the patient accordingly.
4.
If the patient is required to be shifted to different ward after surgery,
then the sending ward should receive the patient and handover to other
Department.
5.
INTERDEPARTMENTAL CONSULTATION
1.
Indoor patient consultation should be given priority and seen on the same
day.
Request for the consultation should be written down by the treating
specialist
2.
6.
DISCHARGE OF THE PATIENT
6.1 DISCHARGE:
1.
The discharge plan should be conveyed to the patient before 24 to 48
hours of the discharge, so that the patient is prepared mentally to leave
the hospital and adequate arrangement are made..
2.
Explain to the patient that the medicines will be issued at the bedside.
3.
Explain instructions to the patient and when to come for follow up.
4.
A patient who needs Physiotherapy consultation and devices should be
referred to Physiotherapy Department before discharge.
5.
The discharge sheet should be written by the doctor during the round at
the patient’s bed side.
6.
Proper diagnosis should be written by doctors.
7.
The nursing staff should check if the doctors have completed the
discharge formalities.
8.
Check that all discharge certificates have admission registration number.
9.
Relevant laboratory report should be written on the discharge certificate by
the concerned doctor.
10.
If any venflon etc., inserted during surgery, it must be removed before
discharge.
11.
The hospital property such as the visiting cards, attendant’s card and the
linens used should be checked and received.The nurse should make sure
that all discharged patients receive medicines at their bedside which will
be dispensed by the pharmacy personnel.
12.
The nurse should ensure that the patient’s document is complete and
sent to the medical record section.
13.
If patient wishes to go home against medical advice make sure that the
patient sign an undertaking risk form.
14.
At the nurse station, write in the indoor register – diagnosis, date and time
of discharge, patient days in the appropriate columns in the register.
15.
The patient and accompanying person should be advised regarding the
followup.
16.
On the day of discharge the patient should be explained about the
discharge instructions and check their understanding of the instructions.
17.
Ensure that patients needing the walking support is issued crutches and
able to walk with the support.
18.
Nurses shall ensure that patient and family have replaced any damage to
hospital property before discharge certificate is issued.
19.
Take over the linens, blanket, pillow and visiting card before handing over
the discharge papers.
20.
Safai karamchari should collect bedpans, urinals, sputum mugs, tray from
patient.
21.
Refill the patient chart with history sheets, undertaking form, and face
sheet,for immediate next use.
22.
The bed(s), I.V stands should be cleaned by ward boy
23.
Inform the patient/family to go to orthopaedic OPD chamber for follow up
but not to come during operation days as mentioned on discharge card
except in case of emergency.
6.2 DISCHARGE AGAINST MEDICAL ADVICE:
1.
Patients absconding from ward or not returning to ward after day leave for
more than six hours will automatically be discharged and their bed will be
allotted to new patients and Medical superintendent to be informed.
2.
Patients seeking discharge against medical advice should be properly
counselled and discouraged to leave as far as possible.
3.
If the patient still insist to leave, the patient should be discharged after
signing on the case sheet and mention on the discharge slip.
6.3 ABSCONDING OF PATIENT
1.
Attendant(s) should be kept all the time with the patient to prevent patient
from absconding. In case, patient absconds from the hospital, his/her
next kin as well as the police, hospital administration and the respective
department heads/unit heads should be informed.
2.
If the absconded patient does not turn up within 6 hours, he/she shall be
automatically discharged and reflected as absconded.
7. CARE OF THE DEAD BODY
7.1 CARE OF THE DEAD BODY
1.
Death should be declared by the doctors only.
2.
Nursing staff should remove the I.V tubings, cannula, catheter, NG tube
etc from the body.
3.
The body should be removed within 1-2 hours time, if not the body should
be shifted to the mortuary.
4.
No hospital linens should be taken with the dead body.
5.
Stretchers can be taken for transportation provided that it must be
returned at the earliest to the respective units (keep the contact number of
the deceased party).
6.
Unclaimed bodies should be taken to the mortuary and the hospital
administration should be duly informed.
7.2 DEATH CERTIFICATE PROCEDURE
1.
The death certificate should be issued by the treating doctor /doctor
declaring death.
2.
Ensure to fill in all the details in the death form.
3.
Ensure that the office copy is legible, complete and clear.
8. EMERGENCY IN THE WARD
8.1 EMERGENCY
1.
In case of any emergency in the ward, the duty staff should initiate
emergency care and inform the doctor immediately.
8.2 EMERGENCY ORTHOPAEDIC PATIENT
1.
All
orthopaedic
emergencies
should
be
channelled
through
the
Emergency Department (ED) like any other emergencies.
2.
The ED staff should receive all emergency cases, perform triage, render
first-aid treatment and carry out all relevant investigations for all the
patients.
3.
When called, the orthopaedic emergency on-call personnel should report
to the ED to attend the emergency without any undue delay.
4.
He should perform additional emergency procedures or investigations and
if required inform the surgeon on-call for further instructions.
5.
Any patient requiring minor procedures should be done in the MOT of the
Emergency Department.
6.
All serious cases which require expert management should be attended
by the on-call surgeon upon information by the assistant.
7.
The orthopaedic emergency services team should consist of one
Consultant, Senior resident and two residents Another such team should
be kept on standby to act as back-up personnel in case of major
emergencies.
8.
The on-call team should request the back-up team to cover up in events
when any member of the first on-call team is unable to attend emergency
call duties.
9.
In the event of a major disaster, all the staff members of the Orthopaedic
Surgery Department should immediately attend to help the emergency
team.
10.
The emergency on-call staff’s first responsibility is to attend
to emergency cases/perform emergency operations.
11.
In case of multiple injuries, other relevant specialists should also be called
to attend the case.
9.
Patient Care
9.1. POST OPERATIVE CARE
1.
Upon receipt of the patient from the O.R., post-op orders must be read
carefully and all the instructions carried out scrupulously.
2.
Patient’s vital signs must be checked carefully and monitored regularly till
the patient’s stability is ensured.
3.
Any untoward incidents, i.e. excessive soakage at the operation site, fall of
B.P, etc. the surgeon or the anaesthetist should be informed accordingly.
9.2. WOUND CARE AND DRESSING CHANGES
1.
Dressing changes for the open wounds daily or as required
2.
Post-operative wound care 2nd, 4th day and as required till patient is
discharged.
9.3. PIN SITE CARE
1.
Patients with External Fixator Pins or k-wires protruding outside the skin
should receive proper pin care as per the pin-care protocol
9.4 SKIN TRACTION
1.
Skin traction is a ward procedure and all the orthopaedic ward resident
and nursing staff should be able to carry out this procedure whenever
such is advised by the doctor upon the patient’ admission.
9.5. SKELETAL TRACTION
1.
The application of skeletal traction is the job of the residents under
supervision of senior residents. Therefore, when the patients in the ward
are advised of skeletal traction, one senior residents should be asked to
be deputed to carry out the procedure. If this procedure is to be done after
the office hours, then the emergency on-call senior residents should be
called.
9.6 CARE OF SPINAL CORD INJURY PATIENTS
1.
Spine injury patients with cord injuries (paraplegia/quadriplegia) calls for
special attention and care by the nursing staff as improper handling by the
staff can cause further harm to the patient. “FIRST DO NO HARM
“principle.
2.
Therefore, upon admission of such a patient to the ward, the resident and
nursing staff on duty should study the case file properly and clearly
understand the neurological status of the patient.
3.
If neurological impairment has been documented in the case sheet, then
spinal cord injury patient care protocol should be followed strictly at all
times.
9.7. CARE OF PATIENT WITH PLASTER OF PARIS
1.
Patients with POP splints and casts must be monitored for splint/cast
tightness as per the POP splint/cast care protocol.
2.
Any negligence in this protocol by the resident and nursing staff on duty
can lead to serious consequences to the patients, i.e., compartment
syndrome with all undesired squeal.
9.8. PREPARATION OF PATIENTS FOR EMERGENCY OPERATION:
1.
All patients going for emergency operation should have all the documents
signed by the patient/patient’s guardian. Complete preparations should be
carried out before sending the patient to O.T.
2.
When patients are called to the O.T, prompt actions should be taken in order
to avoid any undue delays.
3.
Call should be made to all the concerned emergency on-call personnel and
time of the operation must be intimated correctly.
9.9. PREPARATION OF PATIENTS FOR ROUTINE OPERATIONS:
1.
Preparation of routine O.R. list should be done one day prior to the
operation day.
2.
All the patients undergoing major operations should be admitted atleast
two day prior to the operation. Only minor operations which can be done
under localanesthesia may be admitted on the same day of the operation.
3.
All pre-operative preparations (document signing and patient preparation)
should be carried out and it’s completeness checked by the evening duty
nursing staff.
4.
Any additional cases listed for the next day that comes after the office
hours should be added in the operation list by the evening/night duty staff.
5.
Any other case that is admitted in the night but if operation is not
confirmed should be kept NPO till confirmed by the doctor in the morning.
6.
If a patient listed for operation is detected to have hypertension or any
other complaint the anesthetists should be notified before the patient is
taken to the O.T.
10. Intravenous Cannula Insertion and Care
1. Any procedure that breaks the protective skin surface has the potential to
introduce infection. It is important for resident doctors to be skilled in IV
line insertion.
2. Observation of the following procedure is essential.
10.1 Insertion
1.
Explain the procedure and its need to the patient. Verbal consent
should be obtained.
2.
Wash hands with soap and water. Non sterile gloves are
recommended in all the cases , essential if there is significant risk
of infection from blood contamination ( e.g. severe dermatitis , Open
wounds)
3.
Choose an upper limb vein if possible. Avoid antecubital vein if you can.
Use a tourniquet or sphygmomanometer.
4.
Site is prepared prior to insertion. Hair clipping is done in case of hirsuits.
2% chlorhexidine and 70% isopropylalcohol is recommended. Alcohol
alone is inadequate. Contact time of 30 seconds should be there. Make
sure arterial pulsations are felt even after tourniquet application. In
case of poor veins, warm the limb and use a sphygmomanometer at 70-80
mm Hg.
5.
Insert cannula into vein. Avoid touching puncture site. Obtain flashback
and advance further to ensure that the plastic cannula is in the vein.
Remove stylet and connect previously primed administration set or luer
plug. Ensure puncture site is clean and dry(using sterile gauze swab)
before covering site.
6.
To stabilise the cannula, use a sterile prepackaged transparent
dressing with sterile tapes which will stabilise the cannula and act as a
dressing.
7.
The insertion date and time must be written in the clinical notes and
on the dressing.
10.2
Failure to insert an IV line
1.
It is important to recognise that on occasions it is difficult to insert an IV
cannula . Under such circumstances make 2-3 attempts maximum and
then seek help from more experienced member of your team.
10.3
Care of IV Cannula
1.
Examine daily. Replace routinely every 48-72 hours or at the first signs of
phlebitis.
2.
Clinical examination detects only some infected catheters. Septic
thrombophlebitis may cause ongoing bacteremia after removal of
catheter and may need surgical drainage.
3.
Both nursing and medical staff are responsible for assessing need of
cannula change.
10.4
Suspected cannula infection
1.
Disconnect giving set from the cannula
2.
Remove dressing and take swab of cannula site
3.
Remove the catheter and cut off subcutaneous portion using sterile
scissors. Place in a sterile container. Send to microbiology laboratory.
4.
Clean the cannulae exit site with antiseptic solution as above, leave for
30seconds and apply dressing.
5.
Consider whether infusion solution may be infected. If this is infected ,
send solution
and giving set to microbiology. If related to blood
transfusion sends to blood bank.
6.
In the event of a needle stick injury,if patient is known tobe HIV positive
or there is reason to suppose that there is an increased risk of HIV
positively, contact the on –call infectious disease physician (not the
registrar) immediately.
10.5
Central Venous and PICC Lines
1.
These require special expertise in their insertion and ongoing care. In
general we recommend CVADs to be placed in Radiology, ICU,
Anaesthesia.
11.
TRAUMATIC SPINAL CORD INJURIES
11.1 INVESTIGATIONS
1.
X RAY; AP and lateral films cervical spine must include C7 otherwise
swimmers views or oblique views are needed
2.
CT; for fracture and fractur dioslocation.very nimportant to determine
stability
3.
MRI: for significant cord injuries, checking discs and hematoma or patients
with objective neurological deficits but no obvious bony injuries
4.
MRA; when vertebral arteries are potentially compromised (cervical SCI
with severe traumatic brain injuries, fractures ,dislocations involving
foramen transversorium.)
11.2
Management
1.
NEED FOR CARE AND MONITORING IN ICU
2.
Bed rest with log rolls. Turns every 2-3 hrs
3.
Ensure airways breathing and circulation
4.
Treat neurogenic shock(features of hypotension and bradycardia)with goal
of maintain dsystolic BP >110 mm hg or mean arterial pressure >85 mm
hg. check perfusion and urine output
5.
Start prophylactic anticoagulation 24 hrs after acute spinal injury exenoxaprin 60 mcg sc daily. for spinal injuries without cord injury
enoxaparin 40 mg s.c once daily. withold anticoagulant 12-24 hrs prior to
surgical intervention.,
6.
Use ranitidine or pantoprazole to prevent stress ulcers
7.
Indwelling uretheral cathether for bladder drainage and urine output
monitoring
8.
Daily rectal bowel check and evacuation if needed.
9.
Close monitoring nursing care especially skin care and physiotherapy
input check regulary for sores over sacrum heel and occiput.
11.3 AUTONOMIC DYREFLEXIA IN SPINAL CORD INJURY
1.
It is a potentially life threatening condition that can occur anyone with
spinal cord injury at or above T6.
Sudden and significant increase in
blood pressure, pounding headache and bradycardia
2.
Profuse sweating and flushing of skin at or above the level of injury
especially face neck and shoulders
3.
Piloerection and goose bumps at or above the level of injury
4.
Cardiac arrhythmia ,atrial fibrillation premature ventricular beats and atrio
ventricular conduction abnormalities.
5.
If it is not recognized early then hypertension may lead to intracranial
hemmorhage seizures cardiac arrhythmias and death. this is a medical
emergency
11.4 MANAGEMENT
1.
Recognise the signs and symptom early
2.
Check the patients B.P
3.
If BP is elevated immediately shift the patient up if he is sitting
4.
Loosen any clothing or constrictive devices
5.
Monitor BP and pulse every 20-25 minutes
6.
Quickly survey the patient for cause beginning with urinary system’
7.
Catheterize the patient if not done
8.
If patient had an indwelling catheter check the whole system of kinks
constrictions or obstructions
9.
If catheter is draining and B.P remains elevated check faecal impaction
If not draining remove the catheter
10.
NOTE-note the patient BP during catheter drainage. sudden large fluid
loss can c
11.
ause hypotension if patient have been given drugs to lower the Bp.
If the symptoms of AD persist including elevated BP suspect faecal
impaction
12.
If BP >150 mm hg consider administering glyecryl trinitae spray 2
sublingually
12.
Blood Transfusion
12.1
ORDERING OF BLOOD
1.
Majority of transfusion errors are of clerical in nature
2.
The same care and consideration must be taken with ordering blood
transfusion as for the prescription of dangerous drug
3.
Blood must be ordered on appropriate blood transfusion request form
which must be completed as printed forms are unacceptable unless they
show full name including surnames father names or husbands name or
identification number and date of birth
4.
For grouping and cross matching send 6 ml blood in EDTA TUBE
5.
A sample of patients blood must accompany the requisition form. all
sample must be labelled by ball point pen or ink as soon as they are taken
at the patients bedside with details from the patient file and must be word
and letter specific
6.
Sample must be signed
7.
Orders for non urgent blood transfusions must reach the blood during
routine hours and at least 2 hrs before the blood is needed.
8.
One unit of blood raise Hb by 10 g/l
9.
Blood which is not properly labelled by blood bank should not be collected
from blood bank
12.2
ADMINISTARION OF BLOOD
1.
Written consent must be obtained from the parent or guardian before
transfusion except in emergency
2.
Half an hour is maximum interval between collection and administration
and transfusion must be completed within 4 hrs of collecting blood from
blood bank.
3.
Do not store blood in ward refrigerators however short the periods. blood
which is darker than the normal must be infected and should not be taken
4.
Any blood product which is prepared by an open method for example
washed red cells ,reconstituted plasma products, is potentially infected
and must be used within 24hrs of preparation
5.
Nothing is to be added to blood
6.
Before blood is transfused the particulars on the package and file should
be cross checked.
7.
A record of transfusion should be kept in patient’s notes.
12.3
TRANSFUSION REACTIONS
1.
REPORT ALL THE TRANSFUSION RELATED REACTIONS TO BLOOD
BANK ON THE PRESCRIBED PERFORMA
2.
GUIDELINES FOR MANAGEMENT OF MILD ADVERSE TRANSFUSION
REACTIONS
12.4
Mild reaction
1.
Symptoms
A)
Mild febrile reaction temperature increase < 1.5 celsius from
baseline
2.
B)
Stable hemodynamics
C)
No respiratory distress and no other symptom
D)
Mild allergic reaction
E)
Occasional urticarial spots and no other symptom
ACTION
A)
Check compatibility label and identity
B)
Slow trasnfusion
C)
Call for medical assesment
D)
Paracetamol for pyrexia and antihistaminics for urticaria
E)
Continue transfusion at slower rates with regular monitoring of
temp, pulse BP at 15-30 minutes intervals
F)
Send group and cross match tube to blood bank along with a
complete adverse reaction notification form
G)
Document in patient’s notes
H)
If symptoms increase or persist treat as moderate or severe
reaction
I)
Febrile reaction- consider giving antipyretic
J)
Urticarial reation- consider giving pre medication of histamine /oral
phenargan .Slow transfusion rate
12.5
MANAGEMENT OF MODERATE AND SEVERE ADVERSE REACTION
1.
SYMPTOMS
A)
Fever >1.5 celsius from baseline with or without rigors and chills
B)
Unexpected tachycardia or change in B.P
C)
Acute breathlessness desaturation, wheeze stridor or cyanosis
D)
Extensive erythmeatous or urticarial rash
E)
Acute pain in transfusion arm ’chest or loin pain’ severe
apprehension’
F)
JVP acutely elevated onset of crepitation in lungs
G)
Hemoglobinuria
H)
2.
Facial oedema/laryngeal odema
ACTION IN MODERATE OR SEVERE REACTION
-
A)
STOP TRANSFUSION
B)
Check completely labelled recipient identity information
C)
Call for urgent medical review
D)
Maintain ABC and vitals
E)
Comfort and keep patient informed’
D)
replace infusion set and administer saline to keep vein open
E)
Treat and stabilise patient as per medical advises
F)
Obtain specimen as based on clinical signs
G)
And send a labelled cross match sample to blood bank
H)
If hemolysis suspected send full blood count, blood film, coag
screen to hematology, Na, K creatinine , haptoglobin , bilirubin ,
LDH , biochemistry and complete urine analysis
I)
If sepsis is suspected send blood sample to microbiology
J)
If respiratory distress present send blood gases to biochemistry
K)
Document in patients notes
L)
Additional TREATMENT –depending on cause, test results and
haematologist consultation
M)
Sepsis likely- antiobiotics as per severe sepsis guidelines
N)
Anaphylasis-as per guidelines
Transfusion assocuiated circulatory overload-diuretics and oxygen
postive airway pressure
Transfusion related acute lung injury-respiratory support
If HLA antibodies suspected clinical haematological will adivse
Acute hemolysis-maintain blood pressure force dieresis and
alkanizing urine.
Indications for ureteral catheterisation
Acute retention in patients
Unconscious or sedated patients\
In the operative and perioperative setting
Patients with prolonged epidural anaesthesia
Chronic retention if associated with impaired renal function or infection
Incontinence
Note-urinary catheterisation in case of incontinence should be assessed correctly in lieu
of social situation
MALE CATHETRISATION
A LGORITHM
STRADDLE INJURY (fall,kick,cycle) or fractured pelvis(car accident fall crush)
accompanied by penile tip blood, lower abdominal pain and inabiliy to pass urine or
perineal hematoma
History of urethroplasty or radical prostatectomy <6 weeks
This surgery indicates the presence of uretheral graft or anastomsis. cathetrisation should
therby performed by urology registrar
if not available then insert supra pubic catdhetrisation
urethroplasty and radical prostatectomy >6 weeks
proceed with urethral catheterisation with care using 14 fr cathether.
if unsuccesful insert a suprapubic catheter
potential risk for catheterisation
known prostate enlargement
known urethral stricture
history of long term difficulty in passing urine
history of difficult urethral catheterisation previously
INSERTION OF URINARY CATHETHER
Explain the procedure to the patient and gain informed consent
Select appropriate size catheter bigger is usually better
Infection prevention- catheter associated infections are most common hospital acquired
infections. risks can be reduced by adhering to standard precautions including 5 moments
of hand hygiene and usung aseptic non touch technique
Catheter size 16-18
-for uncomplicated urinary retention
-to facilitate accurate urine measurements’
for urinary incontinence
Use catheter size 20-24r with potential for clots post urological surgery, bladder prostate
cancer renal trauma
RECOMENDED BEST PRACTISE
If catheter does not pass along the length of urethra and bladder with ease seek help
If catheter is inserted for retention ensure volume of urine drained is measured and
documented
If catheter enters the bladder and urine begins to drain advance the catheter until the
connection reaches the meatus before inflating the balloon. this ensures no ballon is clear
of urethra and within the bladder preventing trauma on inflation
If patient has not been circumcised return the foreskin to its natural position after
catheterisation
CLEARLY DOCUMENT IN CLINICAL NOTESDate /consent given
Reason for catheterisation
Catheter type, length and size
Amount of water in balloon’
Any problem with procedur
Description of urinary drainage on insertion
If specimen sent for further investigations
Review date/catheter change or removal
INDICATIONS FOR SUPRA PUBIC CATHETRISATION
failed ureteral cathetrisation’
long term management of patients with neuropathic bladders
beware of low abdominal scars from previous surgery ,loops of bowel may be under the
scar between skin and bladder.
13
ASSESMENT OF TRAUMA PATIENT
Primary survey (ABCDE)
Airway (with C-spine control)
1. Assess the airway.
2. Create or maintain an airway by:
A)
Suction
B)
Chin lift or jaw thrust (with C-spine control).
C)
Oro/nasopharyngeal airway.
D)
Oro/nasotracheal intubation .
E)
Cricothyroidotomy.
3. Recognise the potential for cervical spine injury and maintain the spine in
a safe neutral position until clinical examination finding exclude injury.
Breathing
1, assess the chest clinically
2. administer high flow oxygen
3. consider chest decompression or drain where appropriate
Circulation
1. Assess circulation.
2. Arrest external haemorrhage by local pressure.
3. Insert 2 large bore IV cannulae . if no IV access, consider alternative –
intraosseeous, external jugular vein,central venous access , or cutdown
depending on the situation and the clinical skills of the operator. Take
blood for CBC+diff, croomatch, Na, K, creatinine, glucose, coagulation
profile and ethanol.
4. Benign infusion with crystalloid resuscitated fluid. This should be warmed
if possible. Patient with exsanguinating haemorrhage should be
resuscitation with blood as soonas it is available (see collection of blood
from blood bank.) activate the Massive Transfusion Protocol.
5. Monitor the patient with an ECG and BP monitor and a pulse oximeter.
Disability:
1. Determine the level of consciousness-AVPU or GCS.
Is the patient:
Awake
Responding to verbal stimuli?
Responding to painful stimuli?
Unresponsive?
2. Assess the papillary size and response
Exposure/Environmental Control
1. Expose the patient so that an adequate complex examination can be
performed.
2. However prevent the patient becoming hypothermic.
Resuscitation and monitoring
Ongoing resuscitation of physiological abnormalities detected in primary survey
is very important.
Monitoring the progress of resuscitation requires consideration of the following:
1. Respiratory
2. Pulse (ECG monitor)
3. Perfusion.
4. Blood pressure
5. Oxygen saturation (ABGs, pulse oximetry).
6. Urine output. A urethral catheter should be inserted if there are no
contraindications.
Radiology:
In general, only 3 X-rays are appropriate in the resususcitation room:
1. Chest X-ray: this is the only justified in an unresusucitated patient. If a
pneumothorax is obviously present it is not necessary to wait for a
chest X-ray. Have confidence in the clinical assessment. Insert a chest
drain , and X-ray later.
2. Pelvic X-ray: a pelvic fracture not clinically obvious can be the site of
unexplained blood loss. A dislocated hip can be missed in patient with
multiple injuries, especially if unconscious.
3. Lateral cervical spine:this should be done on patient with any history of
loss of consciousness, injury above the clavicle, or signs or symptoms
of spinal injury. In these patients a spinal injury should be assumed to
be present. A lateral C-spine X-ray may allow an an injury to be
confirmed early in the assessment process but exclusion requires a 3
view series.
Cases where C-spine X-rays are not routinely neede:
Nearly all multisystem trauma patient require CT imaging. Many
patients require a “trauma CT scan” from head to pelvis insclusive. If
this CT is done , lateral cervical spine X-ray can be omitted , as CT is
more sensitive for detecting injury than plain films.
C-spine X-ray may also be omitted if the patient requires a CT head
(do a CT head and neck), or if it is clear that they will require a CT
regardiess of the X-ray result( in which case proceed straight to CT).
In some patients it is possible to clinically clear thre neck using the
“NEXUS”
FAST(FOCUSSED ASSESMENT BY SONOGRAPHY IN TRAUMA)
FAST may be performed in trauma patients who show signs of abdominal
injury.this should be performed only by clinicians trained in technique. core
purpose of FAST is to rule out life Intra abdominal bleed as a site for major blood
loss in hemodynamically unstable patient to aid immediate diposition and
treatment.
A normal fast scan doesnot rule out all abdominal injuries and should not be
used to do this
Secondary surveyand
This is complete examination of patient fromntop to toe and front to back.
thorough history from the patient bystander ambulance staff so to have a clear
idea of what happened to patient
If possible record other aspects of AMPLE HISTORY
A- ALLERGIES
M-MEDICATIONS
P-PREVIOUS SURGERY PREGNANCY
L-TIME OF LAST MEAL
E EVENTS SURROUNDING THE INJURY
EXAMINATON OF THE PATIENT
Head and whole face and palpate the region with gloved fingers
Check the pupil again
If patient is cooperative obtain a rough assessment of visual acuity and look
at tympanic membranes
NECK
Maintain in line immobilisation of the cervical spine and remove the front of
the semi rigid collar. inspect the neck and palpate posteriorly
If not already performed and clinically indicated ask for a cross table lateral
cervical spine X ray. regardless of the result keep collar on
CHEST
Revaluate the chest as primary survey
Ask for a CX r if not already done .this should be supine in first instance
unless there is no likelihood of any spinal injury
ABDOMEN
Inspect palpate percuss and auscultate the abdomen as u would in any other
assessment of acute abdominal examination
A urinary catheter should only be inserted if there is no blood at the urethral
meatus ,no perineal bruising and the rectal examination is normal
If the patient has an abnormal level of consciousness he or she may need a CT
abdomen
SOP
ORTHOPAEDICS