The Federal Agency in Health Protection and Social Development
The Stavropol State Medical Academy
The Department of General Surgery
MEDICAL SURGICAL CARE.
SURGICAL MANIPULATIONS.
For Students of General Medicine of the English-speaking Medium
Stavropol 2009
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УДК 647.258:616-089(07)
ББК 54.5я73
С 33
УХОД ЗА ХИРУРГИЧЕСКИМИ БОЛЬНЫМИ (Для студентов
лечебного факультета англо-язычного отделения). Ставрополь: Изд-во
СтГМА. – 2009.
MEDICAL SURGICAL CARE. SURGICAL MANIPULATIONS. (For
Students of General Medicine of the English-speaking Medium). Stavropol:
St.SMA. – 2009.
Cоставители:
Владимирова О.В., ассистент кафедры общей
Ставропольской государственной медицинской академии.
Линченко В.И., к.м.н., ассистент кафедры общей
Ставропольской государственной медицинской академии.
Кораблина
С.С.,
ассистент
кафедры
общей
Ставропольской государственной медицинской академии.
хирургии
хирургии
хирургии
Данное учебное пособие представляет собой комплекс наиболее
необходимой информации для студентов 2 курса лечебного факультета при
изучении ухода за хирургическими больными и основных хирургических
манипуляций в рамках программы общей хирургии. Предназначено для
студентов англоязычного отделения медвузов.
Рецензенты:
Лаврешин П.М., д.м.н., профессор, зав.кафедрой общей хирургии
Ставропольской медицинской академии.
Знаменская С.В., к.пед.н., доцент, зав.кафедрой иностранных языков
с курсом латинского языка, декан факультета иностранных студентов
Ставропольской государственной медицинской академии.
УДК 647.258:616-089(07)
Рекомендовано к изданию Цикловой методической комиссией по
англоязычному обучению иностранных студентов Ставропольской
государственной медицинской академии
© Ставропольская государственная медицинская академия, 2009
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Contents:
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Introduction in to the surgical medical care.
The basic actions of the general care for patients.
Deontology of the medical care.
The international codex.
Problem of infection in surgery. The aim of care – to prevent infection.
Nosocomial infection.
Hygiene of natural and artificial feeding of the surgical patients.
Pain.
Venous and arterial catheterization.
Urinary catheterization.
Naso-gastral intubation.
Splinting
Care for ostomy patients.
Tracheotomy.
Thoracentesis.
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Achievements of modern surgery are not possible without the qualified care of
patients. In its realization in a surgical hospital the basic role is allocated to the
average and younger medical personnel who work under a direct management of
the doctors.
Distinguish:
- The general care which is carried out concerning all patients, irrespective of a
kind and character of disease (distribution of medical products, injections,
infusions, feeding, cleaning of premises and others);
- Special, carried out only to patients with the certain diseases: surgical (bandages,
immobilization, preventive maintenance sore spot and others), gynecologic,
urological.
In the separate (insignificant) group there are patients of the surgical branch, not
requiring in operative intervention (make some kinds of trophy wounds,
inflammatory diseases of veins, initial stages of disease of the artery, not
complicated crises of edges and others) for which corresponding care also is
necessary depending on weight of a condition, age and accompanying diseases.
To the basic actions of the general care of patients concern:
1. Creation and maintenance of a medical - guarding mode of medical institution.
2. Performance of medical purposes.
3. Rendering assistance is hard for patients at carrying out of actions of personal
hygiene, and also during reception of food and physiological departures.
4. Carrying out of sanitary-and-hygienic processing (preventive maintenance and
antisore spot treatment, a bath, souls, rubdown and others).
5. First-aid treatment at some conditions (a fever, a faint, pain in the heart,
vomiting, a short wind and others).
Also, in surgical branch, alongside with the general care of patients include the
complex of actions of preparation the patient for various researches, for operation
and the prevention of complications which can arise during operation is carried out
also, during a narcosis and in the postoperative period.
The basic purpose of care - simplification of sufferings the patient and creation the
optimum conditions for treatment and recovery of the patient. Achievement of it is
impossible without precise interaction of the surgeon, the average and younger
medical personnel as many actions of care for the patient have medical character,
and medical procedures serve as the integral component of care to patients.
Harmonious and close interaction of the medical personnel in a surgical hospital
has great importance in recovery of the patient that some times it is difficult to
define, what actions are only medical and what concern to care for patients. For
example, carrying out the care in the postoperative period behind a wound or
drainage system, the medical personnel not only promotes the fastest healing of a
wound, but also warns development of terrible complications. Depending on what
bodies and systems operation is carried out, care of such patients has the feature.
Some patients cannot wash themselves; accept without assistance peep. The toilet
of a skin, an oral cavity, perineum, the help to the hardly patients at the defecation
act and urinary excretion, correct feeding the patients, maintenance of a dietary
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and drinking mode, duly change of the linen and other hygienic actions - all this
enters into concept « care for the patients ».
Also, care includes supervision over changes in a condition of the patient and
rendering to him the first aid in case of occurrence of a fever, pains in the field of
heart, a short wind, an asthma and other changes.
It is necessary to remember, that care includes also a line of the sanitary –
epidemiological actions carried out by the medical personnel and directed on
maintenance of cleanliness in medical institution and the prevention of occurrence
and distribution of infectious diseases. Regular cleaning and airing of the rooms,
sanitary processing of the patients concern to such actions, their clothes, linen,
subjects of care, some disinfection and others.
The important component of care for the patients is creation of the maximal
physical and mental rest. Quiet in the rooms where the patients are, benevolent
relation to them of the medical personnel, elimination of all adverse factors which
can injure mentality of the patient, - some main principles of a medical - guarding
mode of medical institutions on which in many respects efficiency of treatment of
the patients depends.
Care of patients is a direct duty of the medical sister. Only separate manipulations
of the general care with patients can be carried out by the younger medical
personnel. But also this case the medical sister bears the full responsibility for
correctness of performance of these manipulations.
For preparation of the qualified doctors care of surgical patients which basic
purposes are is entered into the program of training in medical high schools:
training of students to main principles of care of surgical patients, studying of
sanitary-and-hygienic conditions of treatment of patients in a surgical hospital and
works of the younger and average medical personnel.
Undoubtedly, the future doctor himself should be able to execute classically all
necessary receptions of the care as in the subsequent its duties will include training
to these receptions of the average both younger medical personnel and the
requirement of their precise performance.
Deontology of the medical care.
Specificity of medicine consists first of all in the necessity of constant, everyday
dialogue of the medical personnel with the patient and his relatives. Thus it is
necessary to remember about observance medical deontology and ethics in each
independent situation.
First of all it is necessary to remember, that the concept of medical secret is
distributed to all medical workers, it is their professional duty.
In conversations with the patients and their relatives it is necessary to be extremely
polite, attentive and not to suppose the development of iatrogenic - the unhealthy
condition caused by activity of the medical worker.
Basis principle of medicine - not to cause harm, it should be observed by all
without exception medical workers.
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Important point is dialogue of students with patients during care of them,
detour of patients by the attending physician, the teacher. As a rule, we represent
students as the future doctors, therefore and students should feel themselves
doctors, to be attentive, sensitive, quiet, empathizing a condition of the patient
and his stay in the surgical clinic. Sometimes the top takes from students not
reason, and a youth. Therefore it is possible to see, how in chamber or the
other place of surgical clinic, students rustle, are dared, push each other, etc.,
forgetting, that beside the patients having in connection with disease of a
deviation in mentality, perceive laughing and separate words of students on
the account. It aggravates current of process and complicates recovery. Many
other aspects of the surgical deontology, especially concerning care of heavy
patients, for patients after operations it is not authorized to them to rise. Here
not only there should be a compassion, mercy, understanding of a situation,
but also to execute procedure without serious consequences appointed to the
patient, it is more convenient to lay professional skill in bed, to correct bedclothes, to help the patient to carry out physical departures. The request to
remember, that you have no right to inform the patient or his relatives the any
information about the state of health of the patient, to allow recommendations.
Sacred place in surgical clinic is operational. For all students and
employees the cult of deep respect to operational, as to a solemn place where
the destiny of health and a life of people daily is solved should be developed.
In operational rules of behavior everything which is taking place in it of
employees and students should be observed strictly. For the order and
execution of rules of behavior in operational answers the operational sister.
Therefore its orders should be carried out by all strictly, without any
comments and conversations. Only the operating surgeon to whom the
operating brigade submits speaks in operational. It is authorized to explain a
course of operation to the teacher. In the operational-room there should be no
unjustified movements, circulations. Students are obliged to stand silently,
there, where they were put by the teacher, to observe of a course of operation,
to listen to the teacher and the operational sister. All questions, opinions, etc.
are solved outside of operational.
The international codex
It is accepted on the 3 General Assembly of the World Medical Association,
Geneva, Switzerland, in October, 1949, Sydney, Australia, in August, 1968 and 35
the World Medical Assembly, Venice, Italy, in October, 1983 is added 22 the
World Medical Assembly.
The general duties of doctors:
The doctor is obliged to always support the best professional standards.
Making of professional decisions, the doctor should start with reasons of the
blessing for the patient, instead of from own material interests.
Without dependence from professional specialization, the doctor should regard as
of paramount importance compassion and respect for human advantage of the
patient and completely to be responsible for all aspects of medical aid.
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The doctor should be fair with the patient and colleagues. He has no right to cover
the colleagues deceiving the patients.
With norms of medical ethics are not compatible:
а) Self-advertisement if she it specially is not stipulated by laws of the country and
the ethical code of National Medical Association.
б) Payment by the doctor of the commission for a direction to it of the patient, or
reception of a payment or other compensation from any source for a direction of
the patient in the certain medical establishment, to the certain expert or purpose of
the certain kind of treatment without the sufficient medical bases.
The doctor should respect rights of the patient, colleagues, other medical workers,
and also to keep medical secret.
The doctor can carry out the intervention, capable to worsen a physical or mental
condition of the patient only in interests of the last.
The doctor should be extremely cautious, giving the information on the opening,
new technologies and methods of treatment through nonprofessional channels.
The doctor should assert only that is checked up by him personally.
Duties of the doctor in relation to the patient:
With the purpose of preservation of health and a life of the patient the doctor
should use all professional potential. If necessary inspection or treatment leaves
for a level of opportunities of the doctor, it should address to more competent
colleagues.
The death of the patient does not release the doctor from a duty to keep medical
secret.
Rendering the urgent help - a human duty of the doctor.
Duties of the doctor under the attitude to each other:
In relation to the colleagues the doctor should behave how he would like, that they
behaved in relation to him.
The doctor should not entice patients at the colleagues.
The doctor is obliged to observe principles of the Geneva Declaration approved by
the World Medical Association.
Because medicine is a profession and doctors are professionals, it is important to
have a clear understanding of what "professionalism" means. As a physician-intraining, you will be developing a personal sense of what it means to be a
professional. This topic page outlines some common features. Please see the topic
page on the Doctor-Patient Relationship for further discussion of the professional
responsibilities of physicians.
What does it mean to be a member of a profession?
The words "profession" and "professional" come from the Latin word "professio,"
which means a public declaration with the force of a promise. Professions are
groups which declare in a public way that their members will act in certain ways
and that the group and the society may discipline those who fail to do so. The
profession presents itself to society as a social benefit and society accepts the
profession, expecting it to serve some important social goal. The traditional
professions are medicine, law, education and clergy.
The marks of a profession are:
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

competence in a specialized body of knowledge and skill;
an acknowledgment of specific duties and responsibilities toward the
individuals it serves and toward society;
 the right to train, admit, discipline and dismiss its members for failure to
sustain competence or observe the duties and responsibilities.
What is the difference between a profession and a business?
The line between a business and a profession is not entirely clear, since
professionals may engage in business and make a living by it. However, one
crucial difference distinguishes them: professionals have a fiduciary duty toward
those they serve. This means that professionals have a particularly stringent duty to
assure that their decisions and actions serve the welfare of their patients or clients,
even at some cost to themselves. Professions have codes of ethics which specify
the obligations arising from this fiduciary duty. Ethical problems often occur when
there appears to be a conflict between these obligations or between fiduciary duties
and personal goals.
What are the recognized obligations and values of a professional doctor?
The American Board of Internal Medicine has been working on a project to
develop and promote professionalism since 1990. According to the report, Project
Professionalism (1995), professionalism requires that one strive for excellence in
the following areas which should be modeled by mentors and teachers and become
part of the attitudes, behaviors, and skills integral to patient care:






Altruism: A physician is obligated to attend to the best interest of
patients, rather than self-interest.
Accountability: Physicians are accountable to their patients, to society on
issues of public health, and to their profession.
Excellence: Physicians are obligated to make a commitment to life-long
learning.
Duty: A physician should be available and responsive when "on call,"
accepting a commitment to service within the profession and the
community.
Honor and integrity: Physicians should be committed to being fair,
truthful and straightforward in their interactions with patients and the
profession.
Respect for others: A physician should demonstrate respect for patients
and their families, other physicians and team members, medical students,
residents and fellows.
While circumstances may arise that hinder adherence to these values, they should
provide guidance for promoting professional behavior and for making difficult
ethical decisions.
Is professionalism compatible with the restrictions sometimes placed on
physician's judgments in managed care?
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One of the principal attributes of professionalism is independent judgment about
technical matters relevant to the expertise of the profession. The purpose of this
independent judgment is to assure that general technical knowledge is
appropriately applied to particular cases. Managed care may impose conditions on
the clinical judgment of professionals who work in such settings but those
conditions must be designed to enhance and improve professional judgment, not
restrict it. Thus, requiring consultation may often be an obligation; restricting
consultation may be ethically inappropriate. Also, requiring physicians to adhere
to practice guidelines and to consult outcome studies may improve professional
judgment; requiring blind adherence to those guidelines may be a barrier to the
exercise of professional judgment.
Infection in surgery
One of the most dangerous problem in surgery still stays the infection.
Measures of preventive maintenance and struggle against an infection are included
in concept of the care in a surgical hospital.
The surgical infection is a difficult process of interaction between macroand microorganisms, realized by the local and general phenomena, attributes,
symptoms of disease.
Infectious processes concern to a surgical infection in an organism of the
person, in treatment and which preventive maintenance are necessary or there can
be necessary those or other surgical manuals, and also any infectious processes
complicating surgical diseases, surgical interventions and traumas.
Classification of a surgical infection.
1. Sharp
1.1.
Purulent
1.2.
Anaerobic
1.2.1.
Putrefactive
1.2.2.
Anaerobic (gas) gangrene
1.2.3.
A tetanus
2. Chronic
2.1. Nonspecific (purulent, serous-purulent): primary, secondary;
2.2. Specific (a tuberculosis, a syphilis, actinomicose).
On prevalence of process a surgical infection subdivide on local and the
general.
The factors, determining the development and the current of a surgical
infection.
1. Etiology factors.
2. Local conditions.
3. Resistibility (resistency) of an organism.
Etiological factors.
1.1.
A kind of microbe, its pathogenic, virulence.
1.2.
Mono-or a polymicrobe landscape.
1.3.
Amount of the acted microorganisms (critical size 1х105 in 1
sm3 fabric, a secret).
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So, the problem of the medical personnel to carry out qualitative medical
care for the patient and not to admit the development of the intrahospital infection.
INFLAMMATORY RESPONSE
When cells are damaged by any kind of agent, there is an active local
reaction of tissue to injury. This is called inflammation. The suffix it is added to a
combining word to indicate inflammation; for example, phlebitis means inflammation of a vein (phlebo). The inflammatory response is an attempt by the
body to localize the effects of the injury and to overcome invading bacteria. It is
the first line of internal defense against invasion. The agent can be physical (heat
or cold, radiant or radioactive rays, trauma), chemical (acids, bases, digestive
juices), or biologic (microorganisms). The inflammatory response to a pathogenic
organism is termed infection.
Knowledge of the physiologic changes that occur during the
inflammatory process helps the nurse to understand the changes that occur in a
wide variety of diseases. For example, whenever cells die as a result of injury or
disease (necrosis) such as during a myocardial infarction. the inflammatory
process occurs. Fat deposits (atheromas) on blood vessel walls cause injury to the
lining of the vessel wall and initiate an inflammatory response. Irritation of the
peritoneum by trauma or bacterial invasion can cause inflammation of the
peritoneum (peritonitis). Bacteria that can cause disease (-pathogenic) may resist
the body's defense mechanisms, multiply, and spread from the portal of entry to
produce a continued stimulus for an inflammatory response in susceptible tissue.
Infectious diseases are those caused by pathogenic bacteria.
Pathophysiology
There are three major physiologic responses that occur during the
inflammatory process: vascular response, fluid exudation, and cellular exudation.
The vascular response consists of a transitory vasoconstriction (stress response)
followed immediately by vasodilation. This occurs as a result of chemical
substances such as histamine or kinins released at the site of injury or invasion.
The amount of blood flow to the area is thus increased (hyperemia), causing
redness and heat. As the capillaries dilate, there is increased permeability of the
capillary walls, facilitating fluid and cellular exudation.
Fluid exudation from the capillaries into the interstitial spaces begins
immediately and is most active during the first 24 hours after injury or invasion.
Initially the fluid exudate is primarily serous fluid, but as the capillary wall becomes more permeable, protein (albumin) is lost into the interstitial spaces. This
increases the colloid osmotic pressure in the interstitial spaces, which encourages
more fluid exudation. The swelling of the tissue from the fluid in the interstitial
spaces is called edema. Cellular exudation refers to the migration of white blood
cells (leukocytes) through the capillary walls into the affected tissue. An increased
number of white blood cells are attracted to the vessels in the affected area, adhere
to the capillary wall, and then pass ameboid fashion through the widened endothelial junctions of the capillary wall. Neutrophils (polymorphonuclear
leukocytes), which comprise about 60% of the circulating white blood cells, are
the first leukocytes to respond, usually within the first few hours. The neutrophils
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ingest the bacteria and dead tissue cells (phagocytosis); then they die, releasing
proteolytic enzymes that liquefy the dead neutrophils, dead bacteria, and other
dead cells (pus). Monocytes and lymphocytes appear later. The monocytes
continue the phagocytosis, and the lymphocytes play a role in the immune
response.
The nature and amount of exudate produced is determined by the cause
and intensity of the injury. Serous exudate resulting from the inflammatory fluid
exudate is clear in appearance and is easily reabsorbed with no damage.
Serosanguineous exudate is serous exudate mixed with small amounts of blood
from injured capillaries. Sanguineous exudate contains a larger amount of blood
from more extensive vascular damage. Purulent exudate (pus) results from
bacterial invasion and may lead to tissue scarring if cellular necrosis is extensive.
Catarrhal exudate contains mucous secretions and usually results from viral
infections of the respiratory tract.
Bacterial invasion. The inflammatory response serves to prepare the
tissue for healing or to contain the spread of bacterial invasion. To prevent the
spread of bacteria, fibroblasts are attracted to the area and secrete fibrin, a threadlike substance that encircles the affected area to wall it off from healthy tissue. The
purulent exudate thus becomes contained in one area (abscess) and is either
reabsorbed after phagocytosis is completed or "comes to a head" by itself and
breaks open to the surface through a sinus tract or into another cavity. If attempts
are made to drain an abscess (such as by squeezing a pimple) before the walling
off process is completed, the infection will spread into the surrounding tissue.
Small abscesses usually drain by themselves; large abscesses require medical
intervention. Abnormal tubelike passageways (fistulas) from an abscess to the
surface or from one cavity to another may result from large abscess formation and
may require surgical repair. A localized suppurative (pus-forming) infection may
also coat the surface of a tract such as the urinary tract, or it may develop a membrane such as in diphtheria. One of the most common organisms causing large
abscess formation is Staphylococcus.
Spread of bacteria. Bacteria may spread through adjacent tissues or be
carried to other parts of the body. Spreading suppurative infections are usually
caused by group A Streptococcus. The exudate is usually watery in character and
bacteria move interstitially; the resulting inflammation is termed cellulitis. The
tissue appears swollen (edematous) and red, and the exudate may form blisters or
drain from the surface.
Bacteria may fail to be contained locally and spread to other parts of the body by
means of the lymph system or bloodstream. If picked up by the lymph stream, the
bacteria will be carried to the nearest lymph node. These nodes are located along
the course of all lymph channels, and here, too, bacteria can be ingested and
destroyed. If the bacteria are virulent enough to resist the action in the lymph
nodes, leukocytes are brought in by the bloodstream to attack and engulf the
bacteria in the node. The node then becomes swollen and tender because of the
accumulation of phagocytes, bacteria, and destroyed lymphoid tissue. This is
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known as lymphadenitis. Swollen lymph nodes can be palpated primarily in the
neck, axilla, and groin.
If bacteria spread from the local site into the bloodstream (bacteremia), they can be
ingested by tissue macrophages (large phagocytic cells) that are located along the
course of the blood vessels in the spleen, liver, lungs, bone marrow, and adrenal
glands. These cells function similarly to lymph nodes and engulf and digest
bacteria, dead cells, and foreign particles in the bloodstream. When bacteria are
present, growing and producing toxins in the bloodstream, the infection is called
septicemia. Bacteria circulating in the bloodstream may lodge at points distant to
the original site of infection and cause a secondary infection. This is the process by
which infections such as bacterial endocarditis and pyelonephritis occur.
Certain pathogenic bacteria can produce chemical substances called toxins that can
be disseminated by the bloodstream to other parts of the body, producing a toxic
effect on distant cells. Toxins destroy cells by interfering with enzyme activity.
The toxins of hemolytic streptococci, producing symptoms of a "strep throat," may
cause complications such as rheumatic fever or glomerulonephritis. The heart can
be damaged by the toxin produced by the bacteria that cause diphtheria. The
systemic reaction caused by the absorption of toxins in the bloodstream is called
toxemia.
Factors influencing inflammation
There are several factors relating to the agent per se, the invasiveness of
the agent, or the host that determine the severity or extent of an inflammatory
response. If the agent is a pathogenic microorganism, the degree of each factor
determines the infectivity potential. Factors relating to the agent per se are strength
(virulence), number, and nature of the agent. Different pathogenic microorganisms
produce different effects on the host. Pyogenic bacteria usually produce fever and
leukocytosis. Virus infections are characterized by increased fluid exudation.
Certain diseases such as German measles (rubella) are usually mild, whereas
measles (rubeola) can produce severe reactions.
Factors relating to the invasiveness of the agent are the duration of the
exposure or the ability of the agent to reach the host and the portal of entry or
ability of the agent to enter the host. Some bacteria such as streptococci can produce inflammation through any portal of entry to the body; other bacteria such as
gonococci produce inflammation only when entry is at a specific site such as the
genitourinary tract or eyes of the newborn.
Several factors determine the ability of the host to respond to injury or invasion:
1. Age. Both extremes of age (the infant and the aged) are the groups most
susceptible to infection. Infants have not yet built up immunity factors. The elderly
have decreased lymphoid tissue and decreased antibody formation. The young
adult or middle-aged person has increased resistance to infection but may have an
increased reaction when infection does occur.
2. Nutrition. Individuals who are malnourished have decreased resistance to
infection. Energy and nitrogen are two primary requirements for the person with a
severe inflammation. Energy is expended during stress and fever, and energy
requirements are also increased during cellular growth (anabolism). Persons who
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are undernourished do not have reserves for energy production. White blood cells
and fibroblasts necessary during the inflammatory process are composed primarily
of protein, the basis of which is nitrogen. Nitrogen is lost when cells break down
(catabolism). During stress and inflammation, more nitrogen is lost from the body
than is taken in, producing a negative nitrogen balance. The malnourished person
has less of a supply of available nitrogen to produce the cells necessary to counteract the injury or invasion by microorganisms.
3. Adequacy of blood supply. Tissue affected during inflammation needs
sufficient blood to supply the fluid exudate to dilute the toxins; white blood cells
and fibroblasts to fight infection; and oxygen and nutrients to promote healing. If
the blood supply is decreased through vascular disease or shock, the inflammatory
process is impeded.
4. Availability of white blood cells. If the number of leukocytes is below normal
(leukopenia) or if there is an increased number of immature cells such as occurs in
leukemia, the ability of phagocytes to ingest offending organisms is lessened.
5. Immune response. The ability of the host to resist foreign protein depends on the
autoimmune mechanism of the host. The presence of specific antibodies or antitoxins decreases the inflammatory response.
6. Hormonal influences. The hormones of the adrenal cortex have an antiinflammatory effect. Individuals who have increased production of the
corticosteroids or who are receiving corticosteroid therapy are more susceptible to
infection. Diabetics are highly susceptible to infection due in part to decreased
peripheral circulation and high levels of glucose on the skin (and urine if control of
the diabetes is poor) providing a media for growth of bacteria and decreased
phagocytic ability.
Signs and symptoms of inflammations
Inflammations can be classified as acute, subacute, or chronic. Acute
inflammations are short-term and are characterized by a sudden onset and an
increase in the exudative (fluid and leukocytes) responses. Chronic inflammations
have a slower, more insidious onset, develop from a persisting injurious agent, and
usually last longer than 4 to 6 weeks. They are characterized by an increase in
fibrocytes, macrophages, and lymphocytes and usually result in some permanent
damage. Subacute inflammations have some characteristics of both the acute and
chronic inflammations.
Local signs and symptoms of inflammations include the five cardinal
symptoms of inflammation identified many centuries ago. These are redness
(rubor) and heat (calor) due to the hyperemia, swelling (tumor) due to the fluid
exudate, pain (dolor) due to the pressure of the fluid exudate and to chemical
(bradykinin) irritation of the nerve endings, and loss of function of the affected
part due to the swelling and pain.
Moderate-to-severe inflammatory responses can produce generalized
systemic effects. Loss of appetite (anorexia) and fatigue occur not only from
energy expenditure during fevers but also when fever is not present; the cause of
this is unknown. Fever is a prominent symptom, especially in inflammatory states
associated with bacterial invasion. The body increases the production of white
13
blood cells to help fight an infection, and leukocytosis (serum white blood cell
levels greater than 10,000/mm3) may occur.
Management of persons with inflammations
General management. Moderate-to-severe inflammations have different
effects on the ability of the person to meet basic needs depending on the site and
severity of the inflammation. In caring for the person with an inflammation, the
question must be asked, "To what extent is the inflammation affecting this patient's
basic needs?" Specific problems are identified and appropriate interventions
instituted.
Conserving energy. Since the person is already fatigued and weak and
since energy must be available to resist infection, measures are instituted to
promote rest. A daily schedule of activities is planned with the patient to allow for
periods of planned rest. Any affected limb is kept supported and at rest. Since
"rest" is an elusive term, it must be analyzed in terms of what the patients find
brings them most ease with the least fatigue. Enforced bedrest is sometimes more
fatiguing than being up for limited periods.
Enhancing the inflammatory process. The purpose of the inflammatory
process is to prepare tissue for healing and to prevent bacterial spread. The
application of warmth facilitates the process by dilating the blood vessels and thus
increasing circulation to the part to bring the leukocytes and fibroblasts to the area.
Heat also relaxes muscles under strain from pain. Warmth may be applied through
dry heat by means of hot water bottle, heating pad, lamp, or flannel covering, or by
moist heat in the form of wet dressings or soaks. Moist heat penetrates faster than
dry. High temperatures are not used for dressings or soaks, since excessive heat
causes vasoconstriction instead of the desired vasodilation and, in addition,
sensitive skin may sustain burns. An effective temperature is 38° С (100° F).
Increased fluid intake augments the supply of fluid available and replaces
fluid lost through the fluid exudate. An increased intake produces an increased
output to facilitate elimination of toxins. A high fluid intake is especially necessary
for urinary tract infections to help wash away bacteria and the products of the
inflammation. A daily fluid intake greater than 2400 ml/day is recommended for a
person with a moderate or severe inflammation unless otherwise indicated. A diet
high in protein and carbohydrates supplies the necessary nitrogen and calories. If
anorexia is present, high-protein, high-carbohydrate fluids such as eggnogs or
milkshakes are often well tolerated.
Diminishing the effects of inflammation. In those instances when the
inflammatory response is not desired, that is, when further tissue damage or
increased pain can occur because of the effect of the fluid exudate, application of
cold rather than heat may be more effective. Cold causes vasoconstriction, thereby
decreasing blood supply to the af-fected area and decreasing vascular permeability.
Examples of these situations are following trauma such as a sprained ankle or in
acute bursitis in the initial phase when the increased fluid exudate creates pressure
in the joint capsule. In some instances it is desirable to slow down the inflammatory process to prevent complications. Thus, if appendicitis is suspected, cold is
14
applied to the lower abdomen to try to prevent rupture of the appendix with
subsequent peritonitis and to aid in decreasing pain.
Corticosteroids. Hormones of the adrenal cortex (corticosteroids) have an
anti-inflammatory effect; they stabilize lysosomal membranes, thus preventing
release of proteolytic enzymes during inflammation, and they potentiate vasoconstrictor effects. The corticosteroids are not curative, but they do suppress the
adaptive phenomena of the body to inflammation; therefore they are used to treat
severe inflammatory conditions that are not self-limiting.
Corticosteroids may be administered systemically or topically and sometimes are
injected into involved joints or into body cavities. The adrenocorticotropic
hormone (corticotropin, or ACTH) or one of the corticosteroids may be used.
ACTH is used less commonly, since it must be given parenteral and is only
effective for those patients whose adrenal glands are capable of producing the
adrenocortical steroids. The synthetic glucocorticoids are the ones used primarily
for their anti-inflammatory effect.
Because corticosteroids affect a wide variety of body functions, their therapeutic
uses are numerous, but their effects also make them potentially dangerous. They
should be used only with the utmost care and discretion. (Consult a pharmacology
text for additional information on corticosteroids).
Because corticosteroids depress the inflammatory process and the production of
lymphocytes, the patient on corticosteroid therapy must be carefully protected
against infection. The person is advised to minimize exposure to crowds and to
avoid fatigue, chilling, and contact with persons who have colds and other
infectious disorders.
Isolating the patient. Isolating a patient has one of two purposes: either to
prevent spread of a pathogen from the infected patient to others or to protect the
susceptible patient from pathogens carried by others or present in the environment.
Reverse isolation precautions (also referred to as protective isolation) are
used to protect the highly susceptible patient from pathogens. The patient is placed
in a single room that has been thoroughly cleaned and aired. Anyone entering the
room wears a face mask, and sometimes the hair is covered. The door to the room
is kept closed, and traffic in and out of the room is kept at a minimum. No one
with a known infection of any kind (local or generalized) should be allowed in the
room. Anyone giving direct care to the patient washes the hands thoroughly first
and wears a freshly laundered (sometimes sterile) gown. In some instances, only
sterile bed linen is used. If possible, the patient is not transported to other areas of
the hospital, but should this be necessary, the patient usually is asked to wear a
face mask, and open wounds are covered with a sealed dressing. The room should
be kept free from dust; however, only damp dusting and mopping or vacuuming
should be permitted.
Sometimes even stricter precautions are desired and the patient may be placed in a
laminar airflow room. This room is specially designed with air filters to remove
airborne bacteria so that purified air flows across the width and breadth of the
room. Persons not in direct contact with the patient remain downstream from the
patient. Anyone giving direct care wears a cap, mask, and gown.
15
Another more constricting method of isolation is the life island. This consists of a
plastic tent that completely shields the patient from the environment. The air inside
the tent is filtered, and sterilized articles are passed to the patient through portholes
irradiated by ultraviolet light. Patient contact is through arm-length gloves built in
the side of the tent.
Social isolation is a form of sensory deprivation, and anyone who is medically
isolated is also socially isolated. Therefore the nurse must make plans to minimize
social isolation. The patient, family, and friends need to understand why isolation
is necessary. Unless special care is taken, the patient of any age may undergo
personality changes. The young child fails to develop at a normal rate, whereas the
older child may revert to earlier patterns of social behavior that often persist on
return home. Adolescent and adult patients sometimes become paranoid and may
even have hallucinations or become delirious.
Patients isolated from the physical environment for any length of time must be
reintroduced to it carefully. They should be warned to avoid contact with persons
who have a known infectious disease and to notify the physician if they develop an
infection,
Management of the patient with a fever
Pathophysiology. Fever is an elevation of body temperature above
normal. The chemical agents that give rise to a fever are classified as pyrogens.
The fever is apparently due to the action of pyrogens on the thermoregulatory
mechanism in the hypothalamus, which behaves as if it were a thermostat set at a
higher than normal level. The body reacts to the sudden increase in the thermostat
setting by chills, which is a compensatory mechanism of the body to raise the
internal heat to the new thermostatic setting. The patient feels cold during the
initial stage because of vasoconstriction as the body attempts to conserve heat.
When the body temperature reaches the new setting, the patient feels neither hot
nor cold, although malaise and anorexia are present. If the factor causing the fever
is suddenly removed (crisis), the hypothalamic thermostat is reset at normal body
temperature. The body then attempts to eliminate heat by vasodilation and
diaphoresis, and the patient feels hot and sweaty.
Body dehydration also leads to an elevated temperature characterized as
fever. The reverse is also true; fever causes dehydration because of the activity of
the body defenses. Sudden rises (spikes) in temperature are not unusual in infants
and young children who have acute infections because their temperature control
mechanism is labile.
Comfort. Although fever is an essential part of the defense mechanism,
most physicians advise that patients with a temperature over 38° С (100.4° F) stay
in bed, since respiratory and pulse rates are increased. Usually they are permitted
to get up to go to the bathroom. Because headache and irritability often accompany
severe systemic infection with a high fever, the room should be kept quiet and
lights dimmed. The patient should be encouraged to sleep. A warm sponge bath, a
back rub, and a smooth bed may help to induce sleep. Frequent baths may be
needed, since more body wastes may be excreted through increased perspiration.
Bathing also helps to dissipate body heat by increasing evaporation from the skin
16
surface. To prevent drying of the mucous membranes of the mouth and nose,
patients are provided with a lubricant such as cold cream with which to lubricate
the anterior nasal passages and lips.
Fluids and nutrients. In an infection with an accompanying fever, toxins
are often excreted through the kidneys, more fluid than usual is lost by evaporation
from the skin and by the rapid respiration, and more fluids are needed for
accelerated metabolic processes. The adult patient therefore usually is urged to
take 2500 to 3000 ml of fluid a day. Infants and children are given smaller
amounts. In addition to water, fluids high in calories and containing vitamin C,
protein, salt, and potassium, if not contra-indicated by the disease, should be taken
by the patient because they help to supply the body's metabolic and electrolyte
needs. Solid foods usually are not palatable to the patient with a fever but may be
eaten if desired.
Since kidney damage can occur, the nurse should determine whether the urine
excreted is normal in appearance and adequate in amount. If, despite forcing
fluids, the urine becomes concentrated or less than 1000 ml is voided daily by an
adult, less than 500 ml by a child, or less than 300 ml by an infant, the physician is
notified.
Control of excessive body temperature. Temperatures that are considered
too high to be permitted to continue without heart or other tissue damage (usually
over 40° С [ 104° F] in an older child or adult and over 39° С [ 102° F] in an infant
or young child) and prolonged elevations that tend to debilitate the patient by
increasing metabolic needs may be lowered to safer levels by the administration of
acetyl-salicylic acid orally or rectally. The salicylates produce vasodilation and
diaphoresis, and heat is dissipated by this mechanism. Even in the absence of
diaphoresis, the salicylates are usually effective in lowering temperature. It is
believed that these antipyretic effects are due either to protection of the heatregulating center against pyrogens or interference with the peripheral release or
production of endogenous pyrogenic factors.
Sponge baths with tepid water or alcohol (half alcohol and half water) may be
given. Ice bags are sometimes applied to the head, groin, and axillae. Care is taken
not to initiate shivering by the excessive use of cold applications.
If chills accompany a fever, the patient should be lightly covered to prevent further
dissipation of surface heat until the fever can be lowered. Shivering is the body's
physiologic response to excessive loss of heat from its surface and acts to raise the
body temperature. The mechanism comes into play regardless of fever. The use of
warm covering only serves to raise the temperature higher and to produce excessive sweating, which can cause a serious loss of sodium and water in the infant
and small child.
A high fever increases metabolism, which in turn increases heart action and
subsequently the rate of the pulse. It also causes nitrogen wastage and weight loss
and increases loss of fluid and sodium through perspiration. For these reasons,
hypothermia may be used to treat serious generalized infections, especially in
patients who tolerate high fever poorly, such as infants, debilitated patienfs, and
patients who have cardiac or renal disease. Hypothermia decreases the body's
17
metabolic needs. The lowered body temperature also inhibits multiplication of the
infecting organism, making it easier for the body's defenses and the prescribed
treatment to control the infection producing the fever.
Needs during recovery.
After a high fever the patient usually stays in bed until the body
temperature has been normal for 24 hours. After a high or prolonged fever most
adults feel weak, perspire on physical exertion, and become tired easily. For
several days (or even weeks after a prolonged fever) the patient of any age should
have extra rest and should eat foods high in protein and calories. Children and
young adults usually recover much more rapidly than elderly persons, even when
the infection has been severe. During recovery the patient of any age needs visitors
and quiet activities such as reading to help pass the time.
Management of local infections
Causative organisms. Wounds are most often infected by Staphylococcus
aureus. Open wounds that are exposed frequently to the air may become infected
with the bacteria Pseudomonas aeruginosa. Deep wounds may become infected by
an anaerobic Clostridium bacteria. Although staphylococci are responsible for
most suppurative infections of the skin, streptococci and enteric organisms also
may infect wounds.
Staphylococcal infections. Staphylococci are found normally in the nose,
throat, hair follicles, and sweat glands. Most people have a high tolerance for these
microorganisms, but the very old, the very young, and those with metabolic
disease, acute infections, and wounds are very susceptible to them. The incidence
of Staphylococcus infections in hospitals is a continuing problem, and staphylococcal organisms have become increasingly resistant to one or more antibiotics. In
hospitals the most important mode of transmission is the hands of personnel.
Careful attention to hand washing before and after contact with patients (particularly those with known staphylococcal infections) and institution of woundisolation techniques are the two most effective measures to prevent cross-infection.
Personnel who are identified as carriers of staphylococci or who have a
staphylococcal infection are treated with antibiotics and are not permitted to be in
contact with susceptible patients until subsequent cultures are negative.
If, when the staphylococci are implanted in susceptible tissues, body defenses do
not overcome them quickly, they produce coagulase and toxins that destroy cells
and phagocytes and cause a dense, hard, fibrinous wall to surround the infected
area. This wall protects staphylococci from the body defenses, allowing the
bacteria to multiply and extend the infection. Necrosis of tissue develops, and the
subsequent degeneration and liquefaction of cells results in abscess formation.
Local infections caused by pathogenic staphylococci usually are treated by hot
soaks, incision and drainage of the abscess, and penicillinase-resistant penicillin or
other effective antibiotics. Surgical incision of the abscess is necessary because the
drugs are less effective in the presence of pus.
Pseudomonal infections. Pseudomonas aeruginosa is a gram-negative
organism commonly found throughout the hospital environment, especially where
there is a persistent presence of water (in sinks, irrigating solutions, nebulizers). It
18
is a significant cause of infection in persons receiving prolonged antibiotic
therapy, immunosuppressive drugs, and inhalation therapy. Persons at high risk are
the newborns (particularly prematures), the elderly, the debilitated, recipients of
renal transplants, and those persons undergoing instrumentation (tracheostomy,
urinary catheterization). It is a significant problem in patients with burns.
Wounds infected with P. aeruginosa are irrigated with Dakin's solution or acetic
acid (0.25% to 1%) to aid debridement. The pseudomonal bacteria are generally
resistant to most antibiotics. Gentamicin sulfate (Garamycin) is effective against a
wide variety of pathogenic gram-negative and gram-positive bacteria. It can be
injected intravenously or used as an ointment on the infected wound.
Tetanus. Tetanus, or lockjaw, is an infectious disease caused by the grampositive, anaerobic, spore-forming bacteria Clostridium tetani, which are normal
inhabitants of the intestinal tracts of men and other animals and can survive for
years in soil and dirt. They enter the bloodstream of human beings through wounds
and travel to the central nervous system. They produce a powerful toxin that acts at
the myoneural junction, causing prolonged muscular contractions. The symptoms
of tetanus appear from 3 days to 7 weeks (usually 5 to 10 days) after the
introduction of the bacteria into a wound. The patient first notices stiffness of the
jaws and then develops difficulty in opening the mouth. Rigidity of die facial and
sternocleidomastoid muscles causes stiffness of the neck and spasm of the facial
muscles, which produces the characteristic sardonic smile (risus sardonicus). The
abdominal and lumbar muscles also become rigid, and opisthotonos (arching of the
back) occurs. Painful muscle spasms may occur on the slightest stimulation (a
draft, jarring the bed, touching the bedclothes).
Treatment consists of measures to maintain adequate pulmonary ventilation, to
control or prevent muscle spasms, to neutralize toxins that have not become
fixated to CNS cells, to eliminate the source of the microorganism and prevent
secondary infection, and to maintain fluid balance. The patient needs constant
attention and is usually placed in a single room associated with an intensive care
unit. Ex-ternal stimuli are kept at a minimum, and gentleness is a prerequisite for
all patient contacts to prevent muscle spasms. Sedatives and muscle relaxants are
also given for this purpose. Tetanus immune globulin, human (T1GH) is
administered intramuscularly in high doses; part of the dose may be infiltrated
around the wound. The wound is also excised and debrided. An antibiotic such as
penicillin G or tetracycline may be given to prevent further multiplication of the C.
tetani and prevent secondary infections.
Tetanus prophylaxis. All persons sustaining a contaminated or deep
puncture wound should receive tetanus prophylaxis. Primary immunization is
superior to antitoxin given at the time of injury; therefore all children should receive tetanus prophylaxis during their planned immunization program. This is
usually done in conjunction with immunization for diphtheria and pertussis (DPT).
Persons who have had previous tetanus immunizations within 10 years are given a
booster dose after injury. Nonimmunized persons are started on a tetanus
immunization series and are also given TIGH.
19
Gas gangrene. Gas gangrene (clostridial myositis) is a much-feared
infection that usually occurs following traumatic wounds in which there is damage
to muscles. It is caused primarily by Clostridium perfringens, which is found in the
intestinal tract of human beings and domestic animals. These bacteria are able to
survive for indefinite periods of time in dust, dirt, and woolen clothing.
Gas gangrene is characterized by the onset of pain and swelling in the infected
area within 1 to 5 days after the introduction of the bacilli. The patient becomes
prostrated with extreme weakness and exhaustion and is very pale. The pulse and
respirations become rapid, and the blood pressure falls. The temperature may be
only slighdy elevated. The infected area is extremely tender, and there may be gas
bubbles within the wound and under the skin. A thin, brownish, odorous, watery
discharge comes from the wound. This drainage contains large numbers of the bacteria. The involved area is swollen, brick red, and necrotic. The surrounding area
may be blanched at first and later a mottled purple. Because not all wounds
containing gas bubbles are infected with gas gangrene, the diagnosis can be made
only by culture of wound discharge.
Gas gangrene can be spread to others and therefore precautions must be taken. The
patient should be isolated, the soiled dressings burned, and any instruments used
for wound care washed and sterilized immediately after use. Gas gangrene,
fortunately, is less prevalent and less serious since the advent of antibiotic therapy.
However, an occasional patient may still develop the disease. Specific treatment
includes early surgery with meticulous cleansing and debridement. Large doses of
penicillin and tetracycline or chloramphenicol are given. Tetanus toxoid and TIGH
are also given. Usually the patient is alert and requires constant supportive nursing
care to provide comfort and freedom from pain and apprehension. Frequent blood
transfusions are required to correct the profound anemia that results.
The use of hyperbaric oxygen is controversial. It increases the oxygen level in the
blood and aids in the de-struction of the anaerobic C. perfringens. Polyvalent gas
gangrene antitoxin prepared from the blood of hyperimmunized horses is now
available for passive immunization, but its use is limited.
Wound irrigation and packing. Wounds must be cleared of infection before healing
can take place. It is important that these wounds heal from the bottom since, if the
skin and superficial layers of tissue heal first, a collection of pus may form in the
unhealed space. When deep wounds or sinus tracts are irrigated, a catheter usually
is placed as deep into the wound as possible. Then, with an Asepto syringe, the
irrigating fluid is instilled until the returns are clear. The physician should be
consulted as to the direction in which the catheter should be inserted and the depth
to which it should go. This information should be recorded on the nursing care
plan. In irrigating fistulas the fluid instilled in one opening should return from the
other. The patient should turn so that all the irrigating solution drains back, or the
solution should be aspirated from the wound with an Asepto syringe, since fluid
that is left in a deep wound becomes a culture medium for bacterial growth.
If the wound is to be packed, the packing also should be placed into the bottom of
the wound cavity. Diluted sodium hypochlorite solution, 0.5% (modified Dakin's
solution), often is used to irrigate or pack infected wounds. It is a powerful
20
germicide and deodorant and dissolves necrotic tissue, preparing the area for
granulation. It also interferes with formation of thrombin and delays clotting of
blood and usu-ally is not used if there are catgut sutures, since it may dissolve
them. Dakin's solution is irritating to normal skin, and a protective ointment such
as petroleum jelly gauze must be applied around the wound before it is used. Since
Dakin's solution is unstable, it should be made fresh every 48 hours. Hydrogen
peroxide solution also is ordered for the irrigation of infected wounds and is the
solution most often used for home care. It acts as a cleansing agent, by removing
organic debris, but its bactericidal action is limited in the presence of blood or pus.
The antiseptic povidone-iodine (Betadine), in 0.5% dilutions, may also be used.
Antibiotic solutions and solutions containing proteolytic enzymes such as
streptokinase and trypsin, which digest the necrotic tissue, may be instilled into the
wound. No special care of the skin is needed when one is using hydrogen
peroxide, povidone-iodine, acetic acid, or antibiotic solutions. If solutions
containing enzymes are used, however, care should be taken to keep them off the
normal skin, where they will cause irritation. If, in caring for the wound, the nurse
notices any increased inflammation or any increased suppuration or necrosis, this
change should be recorded and the physician notified.
Debridement is the removal of all foreign matter or dead or damaged tissue that
delays healing. The physician may debride a wound by scraping it or by trimming
it with scissors. If large areas are to be debrided in this manner, it may be done
under anesthesia. Proteolytic enzymes also debride devitalized tissue. A third
method of debridement is by the use of wet-to-dry dressings. The wound is packed
with a moist (not wet) packing or dressing. After 4 to 6 hours the packing or
dressing is removed dry. The debris will be removed with the dressing; the tissue
will ooze readily and it should be handled gently.
Common local infections. Patients often ask the nurse for advice on
minor infections involving the superficial tissues. Therefore the nurse must be able
to recognize the most common infections, know when medical attention is
indicated, and teach measures for preventing these infections.
Infections of the hand. Infections of the hand occur frequently because the
hands are functionally involved in most activities and thus are likely to be injured
or exposed to infection. These injuries and infections usually are painful, and rest
is essential to healing.
An infection involving the soft tissues around and underneath the nail is called a
paronychia. It usually results from the infection of a hangnail. The involved finger
is painful, and the patient complains of a continuous throbbing sensation. The pain
is relieved immediately by lifting the soft tissues away from the nail with a scalpel
and draining the pus. The patient then may be given an antibiotic and instructed to
soak the finger in warm, sterile saline solution for 15 to 20 minutes several times a
day and to refrain from using the hand.
An infection that involves the soft tissue of the fingertip is called a felon.
It often is caused when staphylococci are introduced into the finger by a pinprick
and sometimes can be prevented by making pinpricks bleed. In the early stages the
infection responds to warm soaks, and sometimes an antibiotic is given. If it is
21
allowed to progress untreated, the swelling may cause obstruction of the arterial
blood supply to the soft tissues of the finger, and necrosis of the tissue and
underlying bone may occur. The infected area then has to be surgically incised and
drained and the necrotic tissue excised. A pricked finger should be watched
carefully, and if swelling or pain develops, medical treatment should be obtained.
Infection of the tendon sheath, particularly on the palmar surface, often
follows puncture wounds of the fingers or hand. Streptococci are most often the infecting organisms. The hand becomes red and swollen along the tendon, and
movement is painful. This kind of infection usually responds to early treatment
with antibiotics and hot soaks, but surgical incision and drainage may be
necessary. Untreated infections of the tendon sheath lead to destruction of the
tendon with resulting finger and hand deformities. If the tendon has been damaged,
a tendon graft to correct deformities may be necessary after healing has occurred.
Lymphangitis and lymphadenitis. Lymphangitis is an inflammation of the
lymphatic vessels. It is usually of streptococcal origin and is a sequela of
infections of the feet, legs, hands, or arms. The first symptom to appear is a red,
tender streak under the skin of the leg or forearm, indicating the spread of the
infection to the lymphatic vessels. The lymph nodes above the infection (in the
knee, groin, elbow, or axilla) become swollen and tender as the infectious organisms invade them. This condition is known as lymphadenitis. If the infection
continues uncontrolled and bacteria reach the bloodstream, septicemia with fever,
chills, malaise, and increase in the pulse rate may develop. Infections of the lymph
channels are treated by drainage of the original infection, antibiotics, hot wet
dressings, and elevation of the affected extremity.
Furuncles and carbuncles. Furuncles (boils) and car-buncles (multiple
boils) are common local infections.
Ulcerations. An ulcer is an erosion of the skin. It may be caused by
infection, second-degree burns, or inadequate blood supply and nutrients to the
part. Debilitated persons are prone to develop pressure sores or decubitus ulcers
from prolonged pressure over bony prominences. Ulcers of the lower legs and feet
are rather common in persons with poor arterial or venous circulation in the lower
extremities. If the ulcer does not become secondarily infected, it will heal by
second intention. Because of their location, however, ulcers of the skin usually
become infected with staphylococci, streptococci, or enteric bacteria and require
extensive treatment with antibiotics both systemically and locally.
Warm saline solution soaks usually are prescribed to cleanse the ulcer and
stimulate granulation. If the ulcer is infected, irrigations and packings may be
ordered. Pressure on the part should be relieved and circulation to it stimulated.
Patients with large ulcers on the trunk may be placed in CircOlectric beds or on
Stryker frames and turned from the abdomen to the back at 1- to 2-hour intervals.
Patients with ulcers on the legs or feet may be placed on CircOlectric beds and the
bed tilted up or down at regular intervals. An oscillating bed may also be used.
There may be an order to keep the part elevated, with intermittent exercise
prescribed. Alternating air-pressure mattresses, flotation pads, or water beds may
be used. Padding bony prominences with lamb's wool also reduces pressure. There
22
is some evidence that topical hyperbaric oxygen treatment may be a promising
approach in the therapy of certain superficial skin ulcers. If the ulcer does not heal,
as often occurs in arteriosclerotic diseases, a skin graft may be necessary to close
the wound.
An ulcer of the skin usually is easier to prevent than to cure. The measures just
discussed for relief of pressure over bony prominences and for improvement of
circulation should be used prophylactically for debilitated patients, patients who
must be confined to bed for long periods, and patients with any disease that tends
to impair circulation.
Hospital infection
Hospital infection or nosocomial infection or cross-infection means that
the patient was infected by the flora existing in the medical establishment, this
flora being virulent and resistant to most antibiotics.
The most common types of hospital infection are: infection of the urinary
tract (40 %), wound infection (25 %) and respiratory infection (16 %),
septicemia (3.5 %).
Microorganisms can be transferred into hospital in various ways. The
patients, visitors and medical staff are a major source of microbes. Man
releases microbes into the environment at the following rate: from 10 000 to
100 000 from airways and skin at rest, while moving hands – up to 1 million,
while sneezing, coughing or talking – up to 7 million microorganisms a
minute.
Channels of infection: from patient to patient, from staff and visitors to
the patient and the other way round. The longer the patient stays in hospital,
the more infected he becomes.
Unfortunately, hospital infection is a common phenomenon; there are,
however, measures aimed at fighting hospital infection which should kill off
microbes in the setting where the patients are.
Preventive administration of antibiotics has proved totally senseless and
harmful as it results in the emergence of highly resistant causative agents.
That is why measures fighting hospital infection should be aimed at observing
stringent hygienic standards in all divisions of hospital. To arrest cross
infection as much as possible, disposable clothes, towels, caps and gloves
should be widely used. Frequently repeated hygienic disinfection of hands is
of great importance, too.
Prevention of hospital infection is of primary importance in intensive care
and operating units where hygiene can be observed only as a result of strict
professional discipline. Resistance of young staff members who often regard
hygienic requirements as excessive should be overcome with the help of
persuasion or administrative punishment. People fond of long hair and beards
can be a source of trouble as they harbour large amounts of staphylococci.
Regular control should be exercised in hospitals and operating units as
this is the only way to get the staff observe rules of asepsis, antisepsis and
hospital hygiene automatically.
23
Hygiene of natural and artificial feeding of the surgical patients
The major part of general care for patients is the correct organization of
dietary feeding. The diet is keeping healthy or sick person of the certain regimen
and food allowance, qualitative and quantitative structure of nutrition, time of its
reception, etc.
Purpose of a diet is important for all hospitalized patients. It is necessary to realize
clearly, that the correcting hospital diets containing nearby 8400-9200 kDj (20002200 kcal), and it is quite enough three meals a day for satisfaction of needs for a
feeding.
For the majority of hospitalized patients the diet containing 105 kDj (25 kcal) on 1
kg mass of a body is sufficient. For maintenance positive power balance in
situations when the power consumption (burns, infections, a trauma, a surgical
intervention, a thyrotoxicosis grows), and for a restore of deficiency for patients
with a failure of feeding consumption of peep should increase in 1,5-2 times.
Consumption of fiber in amount the mass of a body about 0,8 g/kg day is
recommended to healthy adults, at stress it can increase up to 2-4 g/kg in a day.
The optimum attitude kDj on 1 g fiber at healthy people makes (kcal) 625:1
(150:1), this ratio is suitable and in cases of disturbance of processes in the body
height and restoration.
The percentage of usual body weight calculated by these equations:
Necessity for special restrictions and additions to a diet depends on the
diagnosis. Apply in the form of per oral reception, probe or a parenteral feeding.
At a per oral feeding the consistence of peep varies from liquid up to mashed or
from soft up to firm; a probe feeding and introduction of parenteral compounding
their concentration and an osmolality should be certain.
At the present time there are over 35 nutrients known to be required by
the human body for normal function. They are grouped as carbohydrates (starches,
sugars, and fibers), proteins (amino acids), fats, minerals, vitamins, water.
In surgical unit walking patients should eat in a dining room.
Expediently, for patients who receives one diet to place on one table. At a
disadvantage of landing places in the dining room there feeding should organize
24
in two changes. In surgical hospitals, it is desirable to feed first of all patients
from pure unit, and in the second - purulent unit.
Dishes should be beautifully mounting and have the certain temperature at
distribution: the first dishes (except for the diets demanding thermal care) nearby 60°С, the second - 55-57°С. Distribution of nutrition is necessary for
making quickly, as much as possible reducing term of its storage (not more
than 2 hours from the moment of preparing).
Quite often gravity of general condition does not allow the patient to
accept nutrition independently by themselves. It is necessary to help the
patients in such cases. Laying and seriously ill patients feeding with the help
of medical bedside sister. Before this it is necessary to re-make bed, to help the
patient make a toilet (to wash up hands, to rinse a mouth, etc.) to air chamber,
to encourage the patient and to explain benefit of feeding.
Near a bed of the patient, is located the bedside little table or a bedsidetable which height is corresponds with the height of the bed. To seriously ill
patients can be applying the special little tables which are settling down above
a bed, and owing to it the conditions favorable for nutrition are framed.
Presence in chambers for the postoperative sick functional beds, is allowing
to framing the semisitting position to the patient, also facilitates process of
feeding. A neck and a breast of the patient cover with an oilcloth or an apron.
Feeding can be execute either from the spoon, or by means of a special
invalid's cup. Delivery of peep is making in dressing gowns with marks « For
distribution of nutrition ». To distribution of peep the technicians occupied by
cleaning of chambers and other premises, is not supposed. Students of
educational medical institutions are broken into three groups: the first participates in the feeding, the second-carries out medical manipulations, the
third - carries out actions for maintenance of cleanliness in the unit.
The senior medical sister of the unit supervises over work of the
deliver and delivery nurses, control after distribution of nutrition according to
diets, keeping of sanitary norms. Diet sister keeps up after the correct
distribution of calories, goes with nutrition within a day (a breakfast - 30 %, a
dinner - 40 %, a supper - 25-30 %, before a dream - 5-10 %). In the medical
institutions in Russia is established the four-single diet.
In the case of some diseases patients require more frequent (fractional)
feeding.
In occasion the diet for patients can be broken in connection with
forthcoming various tool (an endoscopy, a cholecystography, etc.) and
laboratory researches (a capture of a gastric juice, etc.), and also in
connection with forthcoming operation.
The patients who are being on artificial feeding make the special group.
The last is applied at impossibility or a failure of delivery by oral. Artificial
feeding happens parenteral and by probe. The probe delivery is carried out in
three kinds: through nosogastric probe, through gastrostome and eunostome or
25
intestinal fistulas. The artificial enteroalimentation through a probe (rubber or
silicone) is applied: after traumas of a mouth, traumas (more often combustions)
of esophagus and after operations on esophagus and stomach with restoration
of a continuity of a gastrointestinal tract; enteric fistulas, tumors of
esophagus and cardial department of stomach, comas, etc.
The probe delivery is carried out by specially picked up admixtures containing
enough of fibers, adepses, carbohydrates and vitamins. For this purpose use
various foodstuff in a liquid or semifluid condition (milk, a butter, crude
eggs, broths, juices, etc.).
Calculation of necessary amount the basic alimentary ingredients is facilitated
by application of special preparations for an enteroalimentation, released by
the industry. The bedside sister, in coordination with the attending physician,
prepares for a necessary nutritious admixture and during established time by
means of funnel (sometimes a Janet's syringe) enters it through a probe.
Many patients, after normalization of the general condition and at presence of
gastrostome, easily seize techniques of feeding and enter to itself nutritious
admixtures into a gastrointestinal tract through the tube which is constantly
being a lumen of a stomach. Hygienic requirements in these cases are reduced
to obligatory processing a probe by antiseptics, a lavage of a probe after
feeding by water in order to prevent rotting nutrition in a probe.
The indications for zond feed are: infringement of the swallowing act after
insult, sharp polinevritis, miastenius, tumours of a brain trunk, encephalitis various
etiology, heavy craniocereberal traumas, neurotoxis (a botulism, a tetanus);
damages and operations in the neck zone; crises; the certain pathological
conditions of a digestive path, for example burns and cicatricial changes of a
gullet, impassability of a target department of a stomach various etiology; an
anorexia connected to chemotherapy, sepsis, extensive burns.
Contra-indications: impassability, pares or a heart attack of intestines,
infringement absorption abilities of a thin gut.
For zond feed apply food mixes which can be divided into three groups. The
mixes prepared from natural products concern to the first group; they are exposed
highdispertion to homogenization. Frequently applied homogenization meat and
vegetable dietary canned food. Mixes prepare in easting establishment of hospital.
Lacks of these mixes: imbalance on the basic food substances, inferiority with
vitamin and mineral structure and the high viscosity complicating application
through probes of small sections.
The high-grade mixes which are specially let out for zond feed the domestic
industry ("Inpitan", "Ovolact", “Nutrizone” etc.), possess essential advantages in
comparison with mixes of hospital preparation. Their structure is precisely known,
they have small viscosity that promotes introduction through probes of small
diameter, can be prepared within several minutes, the account of their consumption
is rather simple. These mixes completely provide needs of an organism for the
26
basic food substances. They develop from fibers of milk, egg fiber, vegetable oil,
corn treacle with addition water-and fat-soluble vitamins, macro-and micro cells.
Power value of mixes: fiber - 12-15-; fats - 30-37-; carbohydrates 50-55-. Fiber in
these mixes is in the high-molecular form and consequently they frequently name
polymeric. Some mixes (for example, "Inpitan") do not contain lactose in
connection with that the part of patients of it does not transfer to infringement of
splitting by last in a thin gut. Mixes let out in a liquid kind and as a powder which
before use plant warm boiled water. Power value of ready mixes for the use makes
4,18 kDj (1 kcal) on 1 ml of a solution at introduction in a thin gut and 4,18-8,36
kDj - at introduction in a stomach. Polymeric mixes are shown patients without
sharply expressed infringements of digestion (infringement of the act of chewing
and swallowing, at an anorexia, after operative interventions on a gullet and a
stomach, etc.). They can be used as the unique power supply long time (many
months).
The second group - the hydrolyzed food mixes making mono-and poly diets. In
them fiber and carbohydrates are in the hydrolyzed form. These diets contain all
amino acids, simple sugar, oligosugars, essential fat acids, vegetable oils and a
wide set of vitamins, macro-and micro cells. This group of mixes is characterized
by the small contents of ballast substances, high osmotic and absence of lactose.
They do not demand active digestion and are easily soaked up. Hydrolyzed food
mixes appoint the patient with the broken digestion (sharply expressed
insufficiency exocrine functions of a pancreas, extensive resections of a thin gut,
intestinal fistulas, etc.). Because of high osmosis diets by-effects as a nausea, a
dumping - syndrome, diary are quite often observed.
The third group - nutritious modules. They will consist of any one component fiber, fat, carbohydrates. These preparations serve for addition to the basic diet
with the purpose of maintenance of needs of the patients requiring for raised
amount of this or that food substance. In the certain measure to modules concern
enpits - the dry dairy mixes possessing high biological value and good
comprehensibility. On their basis if necessary prepare also for a polymeric mix.
Enpits are issued by the industry as a powder which plant water up to the certain
concentration (enpit fatty, antianemic enpit, etc.).
There are various nutritious mixes for probe feed, used in clinics, but essentially
they can be divided into two categories.
The facilitated nutritious mixes. Will consist from two - and three peptides
and (or) amino acids, oligosugars glucose and vegetative fats or three glaciered
with average circuits. The rest is minimal and mastering needs insignificant
loading on processes of digestion. Such mixes apply at patients with a syndrome of
the short intestines, partial intestinal impassability, pancreatic insufficiency,
radiating enteritis and intestinal fistulas.
Completely liquid nutritious mixes. Contain a complex set of nutrients and
are applied at the majority of patients with functioning of the digestive tract.
27
Bolus feed each 3 hour begin with introduction in to a probe 50-100 ml of
isotonic or slightly hypotonic solution of a nutritious mix. This volume can be
increased gradual addition on 50 ml by each feeding at normal bearableness
patients up to achievement of the established daily volume of feeding. The rest in a
stomach should not exceed 100 ml through 2 hours after feeding. At increase in
volume it is necessary to detain the following feeding and to measure the rest in a
stomach through 1 hour.
Constant gastric infusion is begun with introduction of the nutritious mix
diluted twice with a speed of 2550 ml. In process of bearableness the patient speed
of infusion and concentration of a nutritious mix increase up to satisfaction of
necessary energy needs. The bed’s headboard of patients during feeding should be
lifted.
Complications of enteral way of a feed:
1. Diarrhea.
2. A stretching of a stomach or a delay in a stomach.
3. Aspiration.
4. Infringement electrolyte balance.
5. An overload.
6. Varpharini resistency.
7. A sinusitis.
8. Esophagitis.
Monocomponent nutrition solutions of fibers, carbohydrates and fats
Can be combined for creation of the mixes intended for the decision of
certain problems, for example, high-energy with the low maintenance of fiber and
sodium for exhausted patients with a cirrhosis of a liver, ascites and an
encephalopathy.
Parenteral feed
In cases when the patient cannot eat normally or thus its condition
worsens, it is necessary to use partial or full parenteral feed.
Indications for full parenteral feed:
1) patients with insufficiency of the feed, not capable normally to accept or
acquire I peep;
2) patients with enteritis when it is necessary to unload intestines;
3) patients with a satisfactory condition of a feed for which it is necessary
10-14 days abstention from per oral food reception;
4) patients with delayed coma with impossibility of feeding through a
probe;
5) for realization nutrition supports of patients with amplified catabolism,
the caused sepsis;
6) the patients receiving chemotherapy, interfering a natural way of a feed;
7) with the preventive purpose for patients with the expressed insufficiency
of a feed before forthcoming surgical operation.
28
Essentially full parenteral feed should provide reception 140170 kDj (3040 kcal) on 1 kg of weight of a body, amount of entered liquid should make 0,3 ml
(1,2 ml / kcal) day. To this quantity it is necessary to add the volumes equivalent
to losses with diarrhea, through the stoma, during suction through the nasogastric
probe and drainaging of fistula.
The patients with oliguria the basal quantity of poured in liquid should
make 750-1000 ml, to it add the volume equivalent to allocated urine and other
losses. At presence of hypostases the introduction of sodium should be limit till
20-40 mmol-a-day. The positive nitric balance is usually reached by introduction
0, 51 g amino acids on 1 kg of weight of a body day together with infusion of
power components of not albuminous nature. Maximal protein care effect of
carbohydrates and fats falls at a diet with 230250 kDj (5560 kcal) on 1 kg in a day
of ideal weight of a body. To provide a sufficient not albuminous high-calorie
feed, carbohydrates and fats enter together with amino acids, applying for this
purpose at a figurative tee.
Essential fuels used by glycolytic tissues; normally the
Carbohy
Dextrose
major or sole energy source for the central nervous
drate (3.4
system, peripheral nerves, red blood cells, and some
kcal/g)
phagocytes. During prolonged starvation, the glucose
requirement of the brain decreases as adaptation to ketone
oxidation occurs. Are used by tissues that oxidize fat
(e.g., muscle) when carbohydrates are administered as the
major fuel source. Maintain hepatic glycogen stores,
which may protect hepatocytes during hypoxia or
exposure to toxins.
The most concentrated forms of energy. Stabilize,
Lipids
Polyunsaturaed
support, and protect vital structures.
(10
long-chain
Complex with fat-soluble molecules like some
kcal/g)
Triglycerides
from soybean vitamins; are used as structural components in biological
membranes.
oil or a
safflower
soybean oil
mixture
Major structural component of the body. Some are
Protein Crystalline
essential (histidine, isoleucine, leucine, valine,
(4
amino acids
methionine, cysteine, phenylalanine, tyrosine, threonine,
kcal/gm)
tryptophan, and lysine) because they cannot be
synthesized by the body. Others are nonessential because
they can be made from carbon and nitrogen precursors.
Act as peptide hormones, enzymes, and antibodies. May
join with carbohydrates to form glycoproteins, to serve as
plasma proteins and immune globulins, and components
of connective tissue cell membranes and mucous
secretions.
29
Preparations for parenteral feeding.
• For parenteral albuminous feeding:
• - Albuminous hydrolyzates: hydrolysine, aminopeptid, "aminokrovin",
amikin, aminozol, amigen;
• - Mixes of amino acids: polyamin, moriamin, aminofusin, vasin,
friamin, aminon, levamin, alvesin.
• Indications - treatment of the albuminous insufficiency developing at
various heavy diseases and in the postoperative period.
• For parenteral carbohydrate feed: solutions of glucose of 5%, 10%,
20%.
• For parenteral fatty feed - fatty emulsion: lipofundin, intralipid,
lipomaiz.
• Example: Gelofusine is a colloidal plasma volume substitute. When
used in the treatment of hypovolumia it produces significant increase
in blood volume, cardiac output, stroke volume, blood pressure,
urinary output and oxygen delivery. As a plasma volume substitute in
the initial management of hypovolaemic shock due to, for example,
haemorrhage, acute trauma or surgery, burns, sepsis, peritonitis,
pancreatitis or crush injury.
The student should know that the dietetic is an integral part of the general plan of
treatment and consequently this or that diet is appointed in view of character of
disease, indications and contraindications. Alongside with 15 basic diets which
sometimes name tables of dietetic therapy, under individual indications daily
regimens - « contrast days » - days of limited intake of food which name is defined
by structure of products (milk, cottage cheese, apple, etc.), and also special diets
(zero, potassium, magnesian diets, Karrel’s diet, etc.) are applied.
30
Pain has never been satisfactorily defined or understood. It is an unpleasant feeling,
entirely subjective, which only the person experiencing it can describe. It can be
evoked by a multiplicity of stimuli (chemical, thermal, electrical, mechanical), but the
reaction to it cannot be measured objectively. Pain is a learned experience that is
influenced by the entire life situation of each person. What is perceived as pain and the
reaction to that pain differ among people and sometimes differ in the same person from
one time to another.
Continuous, severe pain eventually causes physical and mental exhaustion and
prevents the individual from functioning productively. Pain accompanies almost all
illnesses, and perhaps no sensation is more dreaded by patients undergoing medical
treatment or surgery.
It is not necessary to have an elaborate definition of pain to provide nursing
care. McCaffery, a nurse who has done considerable work in the area of pain, points
out that "pain is whatever the experiencing person says it is and it exists whenever he
says it does". Thus, pain is a subjective symptom, and nurses need to learn how to
assist each individual to deal with it as effectively as possible.
Care of patients suffering pain demands skill in both the science and the art of
nursing. The nurse's responsibility is to make the patient as comfortable as possible
physically and emotionally and to observe and report findings so that they may help the
physician make a correct diagnosis and prescribe appropriate treatment.
IMPORTANCE AND FREQUENCY OF PAIN
Pain serves a major function by alerting us to possible harm or damage. It may
or may not influence us to seek medical attention. Pain may have other meanings for an
individual: the possible loss of mobility or activity, the recurrence of a particular
disease, the reminder that the individual may be aging. Pain may precipitate feelings of
fear, anger, uneasiness, challenge, or punishment. Other individuals may see pain as an
opportunity for creative expression, self-searching, self-testing, or for fostering an
appreciation of what less fortunate patients have gone through.
Factors that influence the meaning of pain to an individual are many and varied.
Some of these include age, sex, cultural background, psychosocial factors,
environmental factors, expected response, and other assorted problems and diagnoses.
The setting in which pain occurs may be important. For example, the pain incurred by a
professional athlete injured during a sports event may be severe if it also means he
must leave the game and perhaps forfeit play during the remainder of the season. A
soldier injured in battle may associate injury and pain as relatively minor if the injury
also means relief from the pressure of battle and possible return home.
Pain is experienced by most individuals at various times throughout life. It may
be the result of, or associated with, trauma, exposure to excessive heat or cold,
excessive strain or use of body parts (as in the person who exercises vigorously),
normal bodily functions such as labor and delivery, surgical intervention, and so on.
Most individuals try to avoid pain, but at the same, they expect that it will occur with
various activities associated with living.
THEORIES OF PAIN TRANSMISSION
Pain has been studied extensively for centuries, and currency there are three
recognized theories of pain transmission:
- the specificity theory,
- pattern theory,
- gate-control theory.
None of these provides all the answers to explain pain transmission, but many
recent experiments in pain therapy have been based on the gate-control theory.
The specificity theory holds that there are certain specific nerve receptors that
respond to noxious stimuli and that these noxious stimuli are always interpreted as
pain. In addition, this theory states that pain impulses are carried by pain fibers fast,
myelinated A-delta fibers, and more slowly conducting unmyelinated С fibers to the
lateral spinothalamic tract in the spinal cord to a pain center in the thalamus. Impulses
are then sent to the cerebral cortex via the corticothalamic tract, where the actual
perception of pain takes place. Opponents of this theory point out that specific pain
receptors have not been identified, and the body does not always interpret certain
stimuli as noxious.
The pattern theory suggests that pain is produced by intense stimulation of
nonspecific fiber receptors. In other words, any stimulus could be perceived as painful
if the stimulation were intense enough. This model does not explain, for example, the
functioning of the spinal cord in pain transmission and thus does not explain the pain
relief provided by many neurosurgical therapies.
In 1965, Melzack and Wall proposed the gate-controltheory. The theory
proposes that pain and its perception depend on the interaction of three systems: the
substantia gelatinosa in the dorsal horn of the spinal cord, which modulates impulses
entering the spinal cord; a central control system in the cortex and thalamus, which
influences the impulses reaching the brain; and the neural system associated with
perception of pain. The theory proposes that pain impulses are conducted over smalldiameter fibers to the spinal cord, travel across an "opened gate" in the substantia
gelatinosa to the anterolateral spinothalamic tract, and then ascend the tract to the
thalamus and cortex, where pain perception and interpretation occur. The "gate" in the
substantia gelatinosa can be "closed" so that the contact is not made, thus interrupting
the pain impulse. This gate can be closed by conflicting impulses from the skin
conducted over large-diameter fibers, by impulses from the reticular formation in the
brainstem, or by impulses from the entire cortex or thalamus (central control system).
Thus, impulses from the skin, brain stem, thalamus, or cortex can effectively block the
transmission of pain impulses or can intensify the impulse. In these manner thoughts
(cognition), attitudes, past experiences, and other factors can modify or intensify the
pain experience.
Not all scientists accept the gate-control theory, and in fact new theories are
being proposed. It would seem, though, that most new theories take as their starting
point the gate-control theory, and it is still the most widely accepted theory.
PHYSIOLOGIC RESPONSES TO PAIN
32
The simplest response to painful stimuli is the withdrawal reflex, in which
impulses are conducted over the shortest nerve pathways from the place of injury to the
spinal cord, where they synapse and travel back to local muscles as motor impulses.
This reflex occurs when one accidentally touches a finger to a hot object and
immediately withdraws the hand. Visceral responses, involving the vital organs and the
glands of internal secretion, prepare one for "fight or flight." These responses account
for the increased pulse and respiratory rates, dilated pupils, and muscle tension that
often occur in sudden severe pain. The body is prepared for the possible need to flee
from the cause of pain. Because the blood supply is suddenly withdrawn from the
viscera, nausea may also occur.
Sensation of pain
Cutaneous or surface injuries usually are more painful than injuries of deeper
tissues, since the skin is richly supplied with sensory nerve endings. In surface injuries
the intensity of the pain is usually proportional to the extent of injured tissue, but this is
not always so, as is exemplified by the severe pain caused by herpes zoster (shingles).
Pain receptors in the visceral organs are fewer in number than those on surface areas,
and they respond only to marked changes in pressure and chemical irritants. It is also
believed that in diseased visceral organs, pain results from traction, pressure, and
tension on the parietal peritoneum or on mesenteric attachments. The impulses from
pain receptors in the visceral organs are conducted to the spinal cord primarily by
sympathetic fibers. The cerebrum frequently misinterprets the source of pain as coming
from skin surface areas innervated by sensory fibers, which enter the same segment of
the cord as the fibers from the deep structure actually involved. This is the
phenomenon of "referred pain." Pain transmitted in this way is usually not well
localized, and in diseases affecting the viscera, other symptoms often precede pain. The
appearance of pain in visceral disease may indicate far-advanced disease and extensive
tissue damage.
Referred pain
Referred pain is felt in areas other than those stimulated. It may occur when
stimulation is not perceived in the primary area. For example, the person experiencing
a heart attack may complain only of pain radiating down the left arm, when in fact the
tissue damage is occurring in the heart.
Referred pain seems to occur most often with damage or injury to visceral
organs, and the pain is referred to cutaneous surfaces. The exact physiologic
mechanism that occurs during referred pain is not clearly understood, but it may relate
in part to the lack of sensory nerve endings near visceral organs. The cutaneous pattern
of various referred pain is fairly constant and frequently seen in practice. The nurse
should be able to recognize the possibility of visceral organ disease in patients with
complaints of cutaneous pain.
The pain caused by a tension or pressure on the viscera may be described as
aching, dragging, or boring. Muscle contractions may cause sensations described as
cramping or spasm. Muscles that have peristaltic action frequentiy cause the pain to be
33
stabbing. A sudden, sharp, popping sensation is characteristic of rupture of a visceral
organ.
Deep pain does not produce a body defense reaction (visceral response) similar
to that, which occurs when surface pain is experienced. Severe visceral pain, therefore,
can cause shock. The patient becomes weak and prostrate. Blood pressure may drop,
and skin may become cold and clammy, and nausea and vomiting may occur. Cardiac
and kidney damage can follow, and if the vital organs are already impaired by disease,
even death may result.
Perception of pain
The perception of pain or the actual feeling of pain takes place in the cerebral
cortex. It is known that a functioning frontal lobe of the brain is required to experience
the full suffering and worry that result from pain. The reaction to the same stimuli
differs widely among people and in the same person from one time to another because
the final perception of pain depends more on the interpretation in the cerebral cortex
than on the characteristics of the original stimuli. What the cerebral cortex interprets as
pain depends on childhood training, previous experience, cultural values, religious
beliefs, physical and mental health, knowledge and understanding, attention and
distraction, fatigue, anxiety, tension, fear, state of consciousness, and the frequency and
the intensity of pain impulses.
Atrophy of nerve endings, degenerative changes in the pain-bearing pathways,
and decreased alertness may reduce the perception of pain in the elderly, and more
stimulation may be required to evoke a response. Elderly persons therefore may fail to
perceive tissue damage that normaUy would cause pain and thus alert a younger
person.
The perception of a pain stimulus may be altered at many points by both normal
and abnormal conditions. A pleasant environment, an enjoyable book, stimulating
conversation, or other distracting activity of a pleasing nature may serve to lessen the
sensation of pain. Tissue damage or inflammatory conditions at the site where the
stimuli originate may increase or decrease the impulse. For example, slapping a person
who has a sunburn may set off a far greater impulse than if the person were not
sunburned. On the other hand, if a severe burn has damaged the local nerve endings,
the patient may not respond at all, to what would ordinarily be painful stimuli.
Abnormal conditions within the spinal cord such as inflammatory diseases, tumors, or
injuries may prevent transmission of nerve impulses. This may occur at either the
spinal or the thalamic relay stations. The impulse may also be altered at either of these
two relay stations by other activity going on simultaneously within the spinal cord.
This probably accounts for the fact that sometimes bruises and cuts sustained during
absorbing activities go unnoticed until the activity is over. This is a common
phenomenon demonstrated by athletes. Perception in the cortex may be influenced by
abnormal conditions such as inflammatory processes, degenerative changes, and
depression of brain function, which may alter the original signal pattern. Anesthesia
and analgesia also cause depression of sensory perceptions.
34
Pain threshold. The point at which a person first feels pain is called the pain
threshold. It varies from person to person and may not be constant in the same
individual from one time to the next because experience and physical and mental health
also enter into its determination. Some authorities believe that the pain threshold and
the threshold for tissue damage are the same. The sensation of pain often appears only
a short time before actual damage to the tissue occurs.
The pain threshold or tolerance for pain may be raised by alcohol, drugs,
hypnosis, warmth, rubbing, or distracting activities. Strong beliefs and faith seem to
increase tolerance for pain, and it is sometimes difficult to judge how much pain a
patient with deep faith is actually experiencing. Fatigue, anger, boredom, and
apprehension may decrease one's ability to tolerate pain. The pain threshold also is
lowered by persistent pain such as that which is sometimes experienced by patients
with far-advanced carcinoma. A weak, debilitated patient usually tolerates pain less
well than a stronger one, although increasing debility eventually causes mental dulling,
with a resultant decrease in pain perception.
Reaction to pain
Perception of pain is accompanied by reaction to pain. Reaction to pain is
influenced also by such factors as past experience, conditioning, cultural values, and
physical and mental health. Consequently, people respond differently to the same
stimuli. Some may accept the pain and be patient and resigned; others may become
depressed and withdrawn. Some may be fearful, apprehensive, and anxious, whereas
others are tolerant and optimistic. Some weep, moan, scream, beg for relief or help,
threaten to destroy themselves, thrash about in bed, or move about aimlessly when they
are in severe pain. Others lie quietly in bed and may only close their eyes, grit their
teeth, bite their lips, clench their hands, or perspire profusely when experiencing pain.
Some people, by training and example, are taught to endure severe pain without
reacting outwardly. American Indian men have rites in which they show their strength
by the amount of pain they cart endure. Such individuals probably would tolerate pain
from disease or injury better than those from a culture in which free expression of
feelings is encouraged. Persons frorh cultures in which health teaching and disease
prevention are emphasized tend to accept pain as a warning to seek help and expect the
cause of pain will be found and cured.
Parents' attitudes toward pain may determine their children's lifelong reaction to
pain. In the American culture, parents usually begin to teach their children what is
expected of them in regard to courage and self-control at about the age of 2 or 3 years.
They try not to appear tod concerned about minor injuries and usually encourage their
children not to cry when they are hurt. Children try hard to be brave, especially in the
presence of' other children.
The setting in which injury occurs may influence the external response to pain.
A boy may feel, for example, that pain suffered from injury during a football game
should be borne quietly, whereas pain resulting from an automobile accident may be
expressed freely.
35
Influence of fear. Morbid fear of a disease may intensify pain caused by it, or it
may lead people to deny pain in their eagerness to believe that nothing is wrong.
Anticipation of pain based on past experience often intensifies pain. For example,
children who enter the hospital for the last of several operations may react more
vigorously to postoperative pain than they did on their first encounter with the
sensation.
One's personality also influences reaction to pain. A person who reacts
hysterically to trying situations may find even a small amount of pain intolerable.
People may sometimes use moderate pain as an escape from unacceptable life
situation, or they may try to use it to control situations around them. This latter reaction
is often demonstrated both in the hospital and in the home.
There is more reaction to pain during the night and early morning hours, when
the person's physiologic processes are at low ebb and there is little distracting activity.
The patient's thoughts may easily turn to self-concern, and worry may increase the
reaction to pain.
Age affects the reaction to pain. The young fear it because it usually is an
unfamiliar experience, and they frequently respond to it by crying. The older person
may know what to expect and accept it, or may be withdrawn and quiet while
experiencing it because of emotional exhaus-tion.
ASSESSMENT OF THE PATIENT IN PAIN
As is true in any situation in which a patient seeks assistance with a problem, a
careful history is taken. This would include location and type of pain, when it occurs
and the 1 duration of it, circumstances preceding the pain, whether this is a first
occurrence, whether the pain is constant or intermittent, and whether it is relieved or
increased by medication, food, rest, change in position, or other activity such as
application of heat or cold. The responses are recorded in the patient's own words.
Sociocultural data that might be helpful in understanding the patient's response to pain
are also elicited and recorded.
Patience, tolerance, gentleness, technical skill, and keen powers of observation
are needed in giving care to the patient in pain. The nurse and the physician are the two
professional team members to whom the patient turns when pain is a major problem.
Every report of pain should be responded to, and the patient should be observed
carefully.
Objective data
Close observation of the patient often gives clues to the intensity of pain.
Pinched faces, drawn and wrinkled brows, clenched teeth, and tightened fists may
indicate severe pain. Diaphoresis and a rapid pulse also are valuable clues. The patient
who lies very still, who is curled up in bed, or whom I tosses about is often in pain or at
least uncomfortable.
Observing the behavior of the young child who cannot yet talk is the only way
to determine whether there is pain and where it is located. Children who tug at their
ears, double their body over and clasp their abdomen, or refuse to move a certain area
36
of their body or permit it to be touched may be having pain in that area. Irritability and
continuous crying that is unrelieved by the usual comfort measures may mean that the
child is in pain. Parents may be asked about activities they have observed that appear to
cause discomfort. When signs of pain are apparent, a close examination of the child's
body should be made to rule out an injury or offer obvious causes of distress.
The nurse must be able to assess the patient's pain and emotional response to it
without being judgmental. How the patient perceives and reacts to pain has been
influenced by his or her whole life and cannot voluntarily be modified much.
Regardless of the cause of pain or the patient's behavior, the immediate need is for
relief from pain. Knowing how the person feels about pain helps the nurse take
appropriate measures td increase comfort.
INTERVENTIONS TO RELIEVE PAIN
After the nurse has assessed the patient's pain, nursing I intervention is planned.
If the pain is the usual type experienced by the patient, the previous methods of relief
are indicated. If the pain is different or does not respond to nursing intervention, the
physician is notified.
Even though the nurse can determine no physical cause for the pain, it is
important to remember that the patient feels the pain regardless of its cause.
Recognition of this fact should guide the nurse in care of the patient and thus prevent
labeling patients and their families as "complainers". The patient whose pain is largely
based on emotional reactions needs as much interest and support from the nurse as the
one whose pain is mainly caused by a physical ailment. At no time should patients in
pain think that the nursing staff is lacking in sympathy and understanding, or that the
time and effort spent in attempting to alleviate their pain is not worthwhile. Every
member of the nursing team who gives any kind of care to the patient in severe pain
should be familiar with the patient's nursing care plan.
The first step in developing and implementing the plan of care is to obtain the
patient's trust. To convey trust and interest, the nurse needs to remember that the pain is
whatever the experiencing person says it is and that it exists whenever the person says
it does. Thus, the nurse may not always know when to anticipate that the patient will
have pain. Patience, conveying an interest, being willing to help, and avoiding
prejudging the patient are helpful. Interventions can be directed at modifying the pain
stimulus, altering the mode of transmission, or modifying the response to pain.
Modification of stimulus:
Explaining the problem. As the nurse assesses the individual, it may become
clear that the response to the pain is really a manifestation of lack of knowledge about
what is happening. The nurse explains, in simple terms if necessary, what is causing
the pain, if and when it is to be expected, and how long it may last. This explanation
should continue with each new experience, for example, before each new diagnostic
test. Understanding that pain is to be expected may relieve patients' anxiety or help
them alter their expectations and approach. A simple example might be the pain
associated with a lumbar puncture.
37
Decision making. Allowing patients to regain some control over their daily
activities may allow them to exert better control over pain. If possible and within
limits, the patient should be allowed to make decisions about the frequency of certain
tasks such as exercises and turning and the order of such daily events as the bath, and
getting out of bed. If the patient has indicated the least painful way of doing a certain
activity, such as turning, this method is recorded on the plan of care, and everyone
working with the patient is expected to follow this method.
Consistency and careful planning. Assigning the same nursing staff members to
care for the patient regularly usually results in a more consistent approach and plan of
care. Between the small group of health care team members and the patient, a plan of
care can be developed in which the patient's decisions are honored, the day-to-day
activities are put in order, and a daily routine can be devised that reduces anxiety and
frustration about constant changes. This plan should include, if appropriate, such items
as specified hours for drug administration before uncomfortable procedures, specified
blocks of time for rest or sleep, and coordination between various departments such as
physical therapy and occupational therapy. For some patients, fatigue is a great
problem, so regular visits to other departments should be interspersed with rest periods
throughout the day; for other patients the most beneficial plan includes ensuring that
they go directly from one department to the next each day, so that time is not wasted
getting in and out of bed or performing other painful maneuvers.
Distraction. Many individuals can be distracted from constant preoccupation
with discomfort. Distraction interferes with the pain stimulus, thereby modifying the
awareness of the pain. Mild or moderate pain can be modified by focusing on activity
in the environment. A quiet environment providing little or no sensory input can
actually intensify the pain experience because the individual has nothing to focus on
but the painful stimulus.
Severe pain requires more active participation by the individual in an effort to
block out the painful stimulus. This can be enhanced by involving two or more of the
senses (vision, hearing, touch, or movement). The distractors must be powerful enough
to involve the individual's total interest without resulting in fatigue. Pain of long
duration requires a variety of meaningful distractors.
Careful assessment may indicate ways in which the patient can be distracted, for
example, playing games such as chess or checkers, watching television, or getting
away from a particular setting. Simply talking with someone may be a sufficient
distraction for some persons, and allowing time for this in a patient's daily routine may
be helpful. This same intervention can easily be used during some diagnostic
procedures. With careful goal-directed questions and comments, the nurse may be able
to take the patient's mind off the test. Discomfort will probably still occur, but
preoccupation with the pain may be lessened.
Another form of distraction that may help involves the use of rhythmic
breathing; the nurse assists the patient to concentrate on respirations, breathing more
slowly and more deeply with each respiration. The patient practices inhaling through
the nose and exhaling through the mouth. Pain reduction is enhanced by keeping the
38
eyes open and focusing on one object. This in combination with efforts to relax and
breathe may help the person focus on something other than pain.
Exercise. In selected situations, exercises may be prescribed to assist in the
alleviation of discomfort. The individual may need frequent encouragement to do what
may actually be painful or what may not seem to be working as well or as quickly as
anticipated. Patients should be observed while doing the exercises to make sure they
are not having difficulty or perhaps doing them incorrectly.
Working, dressing, and eating may be strenuous exercises for someone who has
been unable to do these activities of daily living because of pain. Reasonable
expectations should be set for the rate and frequency of exercising. Actually doing the
exercises may serve as a form of distraction.
Rest, relaxation, and sleep. If the patient has not been able to sleep because of
pain or if daily activities are so strenuous or hectic as not to allow rest periods, the
response to pain may reflect exhaustion or fatigue. The nurse may be able to assist in
several ways. The nurse can determine the patient's usual rest and sleep patterns, decide
if they are adequate, determine why the patient is not getting sufficient rest, and
develop a plan to improve the situation. The plan might include decreasing the number
of interruptions during the night to check vital signs and for other activities, ensuring
that the environment is quiet after a certain hour, providing a warm, noncaffeinated
drink before sleep, providing rest periods during the day, and administering a sleeping
medication or analgesic at a regular time each night.
The nurse may need to assist the patient to relax. The approach is different with
each individual, but it may include the following. Have the patient assume a
comfortable position. Make certain that this position is one the patient can remain in
for 2 to 3 hours. Also make certain the sheets are not constricting, the patient is warm
enough, and so on. Instruct the person to concentrate on each extremity, one at a time,
to focus on how light and relaxed each extremity is, and to begin to breathe slowly but
fully, allowing no other thoughts to enter the mind. With practice patients may be able
to use this method to fall asleep.
The Lamaze method of childbirth and other forms of relaxation combined with
exercise are examples of ways the patient may be assisted to relax. Just as success with
Lamaze depends pardy on how well the woman has practiced the exercises and
relaxation, the same is true of the person in pain. The patient should not be led to
expect success on the first couple of tries; the nurse and the patient may have to work
together for a period of time before the best method for relaxation is achieved.
Waking-imagined analgesia. Waking-imagined analgesia is identified as
"imagining a pleasant situation when a noxious stimulus is applied." In this approach
the person concentrates on trying to relive the sensations that occurred during a
previous pleasant experience. Usually only a small number of persons in pain can
actually use this method of analgesia, but nurses should be aware of it as a possible
approach.
Reducing social isolation. Social isolation may occur for the patient in pain for
a variety of reasons: the serious nature of a patient's disease may necessitate placement
in a private room for an extended period; isolation to prevent spread of infection may
39
be necessary; hospitalization far away from home may mean few family members and
friends can visit; extended periods of hospitalization may result in friends' losing
interest in visiting; or the patient may complain so much that visitors stop coming.
In the hospital, careful selection of roommates may provide mutual support for
patients. The need for actual isolation cannot be ignored, but perhaps more frequent
visits by-the health care team members would help. The nurse might assist a patient to
write or telephone often to family and friends so they keep in close touch. In many
cases the hospital staff almost becomes the family for the patient; each day a staff
member fails to stop in to talk may contribute to feelings of loneliness for the patient.
If the patient is at home or hospitalized, it may be possible to contact friends
and arrange a time for them to visit. It may be that certain friends are reluctant to come
because they feel unsure of their role; the nurse may be able to reassure them or clarify
expectations with them before their visits.
A careful but frank discussion with the patient about behavior that is upsetting
guests and family may be necessary. The nurse may be able to help the patient develop
new methods for coping with constant pain, and this coupled with genuine interest and
support of the nurse may help reduce the patient's social isolation.
Counterirritants and cutaneous stimulation. For some individuals a change in
the type of stimulation at the site of pain may result in pain relief. For example, lighdy
rubbing the affected area may cause significant reduction in pain. The gate-control
theory would support changing the amount and type of sensory receptor stimulation,
and the nurse with the help of the patient may be able to find a satisfactory and
relatively simple stimulus modification to ease the patient's discomfort.
Associated with sensory input modification at the site of discomfort are other
forms of cutaneous stimulation. Depending on the individual, various forms of touch,
such as a back rub, application of heat or cold, or simply holding the patient's hand
may be helpful in diminishing pain.
Reducing painful stimuli. With skill and adequate help, the nurse usually can
move the patient without causing excessive pain. Proper technique when handling the
patient with generalized pain or a painful limb or other body part is important. Support
to painful parts of the body is essential. Supporting the trunk and limbs in good body
alignment prevents increasing the pain by unnatural pulling on muscles, joints, and
ligaments. A "turning sheet" is often useful in preventing uneven lifting or pull on
patients with severe neck, back, or general trunk pain. Painful joints may be moved
with less discomfort if they are placed on a pillow or otherwise supported, rather than
being lifted direcdy. If there is tenderness or pain in the shaft of the bone, in muscles,
or in large skin areas, the limb should be supported at the joints when the patient moves
to prevent additional pain.
Binders, surgical belts, and girdles give support to the abdomen. Body casts,
corsets, and braces are used to immobilize the vertebral column and thus decrease pain.
A firm bed gives support and thereby lessens pain both when the patient is at rest and
when he is moving. Traction, splints, casts, and braces are used to immobilize a painful
part of the body such as an ankle. Special beds (e.g., Stryker frame, Foster bed,
CircOlectric bed, Bradford frame) allow movement with minimal handling of the body
40
and thereby help lessen pain. If the nurse in caring for a patient in pain thinks that any
of these mechanical devices would be of benefit, the problem can be discussed with the
physician.
Reducing noise and visual stimulation. The patient may be suffering from
sensory overload. If nurses could stand still for 5 minutes in the persons' environment
and watch and listen, they might understand that some persons are simply bombarded
with noise and visual stimulation. If these are problems, it may be possible to change
the environment. Changes include moving the individual away from a busy nurses'
station or, in the home, away from a busy family room. Try to ensure that the lights are
turned out or at least significantly dimmed at night. In the home or in the hospital,
those around the patient may need to be reminded to talk and move more quietly at
night.
Television and radio can serve as wonderful distractors, but most individuals
tire of them after several consecutive hours. It may be possible to determine a schedule
based on the likes and dislikes of family members or roommates that would include
periods of silence during the day. Radio and television volume should be at a level
comfortable for listening.
Overtalkativeness and overoptimism are often annoying to the person in pain.
This is particularly true when the patient has a poor prognosis. Florence Nightingale
gave the following advice on this subject.
But the long chronic case, who known too well himself, and who has been told
by his physician that he will never enter active life again, who feels that every month
he has to give up something he could do the month before spare such sufferers your
chattering hopes. You do not know how you worry and weary them. Such real sufferers
cannot bear to talk of themselves, still less to hope for what they cannot at all expect.
Plans should be made so that a minimum number of persons enter the room of
the patient. The patient cannot possibly learn to know and trust all the individuals who
enter a hospital room each day. Unless some effort is made to control traffic in and out
of the room, the patient may be unable to relax and rest. The same principle applies to
care of the patient at home, where the problem of too many visitors is frequently a real
one. The nurse, of all members of the health care team, is in the best position to give
attention to this need of the patient. Some patients in pain welcome interruptions and
distractions, whereas others prefer privacy and seclusion. The nurse should see that the
patient's wishes are respected.
Alteration of pain transmission
Medication to alter pain. The nurse needs to know the precise effect on the
body of medications used to treat pain. The time curve of beginning effect, the height
of effectiveness, and the time of declining effect must be understood. In addition, the
effects of the medication may vary according to the time of day it is administered and
the physiologic status of the individual. A brief summary of several categories of drugs
is presented here; for a more definitive discussion, refer to a pharmacology text.
Medication to relieve the cause of pain. Pain may be treated by drugs that help
to relieve its cause. For example, the belladonna group of drugs (atropine) or synthetic
41
substitutes such as propantheline bromide (Pro-Banthine), which cause relaxation of
smooth muscle, may diminish the pain caused by spasm of the smooth muscles. If pain
is caused by impairment of circulation, drugs that dilate the blood vessels such as
papaverine hydrochloride, nitroglycerin, and tolazoline hydrochloride (Priscoline) may
do more good than analgesic drugs. A final example includes antibiotics used to reduce
inflammation that may be causing pain. Specific drugs are chosen on the basis of the
nature of the infection, the sensitivity of the organism to the antibiotic, and the general
condition of the patient.
Salicylates. One of the most widely used analgesic drugs is acetylsalicylic acid
(aspirin). This is the safest of the coal-tar products; it usually relieves headache, muscle
ache, and arthritic pain. The specific action of aspirin on pain is not known, but it does
not cause clouding of the sensorium. Aspirin is highly effective when given with
codeine, the combined effect being much superior to the use of either drug alone. The
nurse needs to be constantly aware that some persons are allergic to aspirin. Death can
occur when aspirin is given to such individuals. Common side effects of acetylsalicylic
acid are irritation of the gastric mucosa and reactivation of peptic ulcers. Salicylism can
occur in persons who take large doses of aspirin over long periods of time. Nausea,
vomiting, ringing in the ears, deafness, and severe headache are common
manifestations. A decreased prothrombin level with hemorrhagic manifestations can
also occur. Hemorrhage is uncommon when the dose is less than 1 g/day.
Aspirin products are available in a variety of combinations and forms such as
timed-release aspirin, enteric-coated aspirin, and aspirin with phenacetin or caffeine.
Individuals vary widely in their response to these, but there have been few conclusive
data to indicate that any one form or combination is best. Aspirin is also widely used as
an antipyretic.
Acetaminophen (Tylenol, Datril), a salicylate-like analgesic, achieved wide
popularity because it causes less alteration of the prothrombin level and fewer side
effects. It can, however, cause severe liver damage and should not be used
indiscriminately. This drug also has antipyretic action but does not have as much antiinflammatory action as aspirin. It is frequently prescribed for persons for whom aspirin
is contraindicated.
Salicylate-like anti-inflammatory agents. Phenylbutazone (Butazolidin) is
prescribed to relieve symptoms of an acute episode of gout. It has some antiinflammatory properties, but it is poorly tolerated by many individuals and has
numerous side effects including hematologic changes, gastric irritation, and fluid and
electrolyte disturbances.
Indomethacin (Indocin) also is an effective anti-inflammatory drug with
antipyretic action. It has many side effects but may be helpful in decreasing pain in
individuals with rheumatoid arthritis, osteoarthrosis, and ankylosing spondylitis.
Propoxyphene hydrochloride (Darvon) is the third most frequently prescribed
drug in the United States. It is a mild analgesic structurally related to methadone. Drug
dependence can occur, and patients need to be warned not to exceed the prescribed
dose. Overdosage and additive effects are a danger when propoxyphene is taken in
combination with alcohol, tranquilizers, sedative-hypnotics, and other central nervous
42
system (CNS) depressants. Toxic effects and deaths have resulted from overdoses of
the drug and from combination with CNS depressants. Early in 1979 the Department of
Health, Education and Welfare issued an alert to physicians and dentists urging them to
talk with patients about the risks of the drug. Adverse reactions include dizziness,
sedation, and nausea and vomiting, all of which may be more pronounced in
ambulatory patients. Some of these effects may be relieved by lying down. Other side
effects are constipation, abdominal pain, skin rashes, light-headness, headache,
weakness, euphoria, and mild visual disturbances.
Propoxyphene hydrochloride is sometimes prescribed in combination with
aspirin (Darvon Compound) and with aspirin, phenacetin, and caffeine (Darvon
Compound).
Counter irritants. Ointments, emollients, and liniments such as ethyl
aminobenzoate and methyl salicylate (oil of wintergreen) are counterirritants that may
be applied locally to alleviate pain. Oil of clove, used for toothache, is another
example.
Medications to control pain. Other types of pain medications work by
modifying the response of the person experiencing the pain rather than by altering the
transmission of the pain stimuli. Following is a discussion of these medications.
Narcotics. The opiates are the drugs most widely recognized and used for the
control of pain. Morphine and codeine are usually ordered. Synthetic narcotic drugs
such as meperidine hydrochloride (Demerol) and methadone hydrochloride are also
widely used. When given in therapeutic doses, narcotics act by depressing brain cells
involved in pain perception without seriously impairing other sensory perceptions.
They also affect to some extent the patient's feeling about pain and thus affect both
physical pain and the reaction to it. In addition, the synthetic narcotic drugs have some
antispasmodic action and thereby encourage relaxation.
The effects of narcotics vary with the physiologic state of the patient. The very
young and the very old are sensitive to the effects of narcotics and require smaller
doses to obtain relief from pain. A person of any age may be more depressed
physically and emotionally by narcotics during the early morning hours (1 to 6 am)
than at any other time of the day and therefore should be watched carefully for
untoward effects.
Narcotics cause lowering of the blood pressure and general depression of vital
functions. This reaction can be an advantage in treating a condition such as
hemorrhage, in which some lowering of blood pressure may be desirable. It may be a
disadvantage in treating the debilitated patient, who may go into shock from an
excessive dosage of a drug. The narcotic drugs are less likely to cause shock if the
patient is up and moving about and taking food and fluids, since these activities tend to
maintain the blood pressure at a safe level.
So much emphasis has been placed on the danger of drug addiction (and to be
sure, the danger is potentially real) that nurses sometimes withhold narcotic drugs and
allow patients to suffer more than is advisable. The patient in severe pain will not
become addicted to narcotic drugs, even if they are given at frequent intervals for
several days. Provided there are no physical contraindications, narcotics prescribed by
43
the physician should be given to the patient with intractable pain as often as every 3 to
4 hours regardless of the possibility of addiction. However, before giving any patient
an analgesic drug the nurse should always determine whether the patient's pain is that
for which the drug was ordered. If it is a "new" pain, analgesics may mask symptoms
of undiagnosed disease.
A commonly used synthetic, nonnarcotic analgesic is pentazocine (Talwin). It is
often prescribed in place of morphine or meperidine for the relief of moderate-tosevere pain. It is given orally or parenterally. The most commonly occurring reactions
are vertigo, nausea, and euphoria. Since sedation and dizziness have been noted in
some instances, persons receiving pentazocine should be warned not to operate
machinery, drive cars, or unnecessarily expose themselves to hazards. Pentazocine is
contraindicated in persons with increased intracranial pressure, head injury, or
pathologic brain conditions in which clouding of the sensoriumis particularly
undesirable.
Sedatives. Sometimes the patient needs a sedative drug instead of additional
analgesics. Phenobarbital, for example, often enables the patient to be comfortable with
a lower narcotic dose than might otherwise be necessary. The patient with a severe
emotional reaction to illness often gets relief when analgesic drugs are interspersed
with sedative drugs. This arrangement has been found useful when the narcotic or other
analgesic drug does not seem to quite "hold" the patient for the desired interval. Small
doses of phenobarbital appear to relieve most of the discomfort expressed by infants
and small children when they have pain. The effect of sedative drugs, similar to
narcotics, may be increased when physiologic responses are slowed down. In the presence of fever they sometimes produce excitement rather than relaxation. This effect is
also seen in older patients. Because barbiturates may make patients less aware of their
surroundings, side rails and constant nursing supervision may be necessary to protect
them from injuries such as falls. Ataractic drugs. Ataractic drugs, or so-called
tranquilizers, which affect the mood of the patient, have been found helpful in the
treatment of pain, particularly when given in combination with narcotics. This
combination of drugs tends to separate the perception of pain from reaction to pain.
The sensation of pain appears less acute, and therefore the reaction to it becomes less
severe. When fear and apprehension appear to be the most striking features of the
patient's reaction, tranquilizers alone may be sufficient to aid relaxation. Diazepam
(Valium), prochlorperazine (Compazine), and chlordiazepoxide hydrochloride
(Librium) are examples of commonly used tranquilizers. If these drugs cause lethargy
and failure of normal response, this should be reported to the physician at once. The
physiologic state of the person may cause a variance in response to these drugs similar
to that seen with narcotics.
Placebos. Placebos are sometimes used for their psychogenic effect in relieving
pain, but they should never be given without a physician's order. Although the most
usual response to a placebo is positive, some persons have negative reactions and may
report intensified pain or other symptoms. Therefore, when a placebo is being used, the
nurse should observe the patient carefully and share with the physician any information
that helps determine the best treatment for the patient. Favorable response to a placebo
44
should not lead the nurse to ignore complaints of pain, for the individual who responds
to placebos is in great need of the nurse's interest and support. Furthermore, the patient
may have a new physical pain that needs to be evaluated.
Transcutaneous electrical stimulators. A transcutaneous electrical stimulator is
a battery-powered stimulator that is worn externally. Two or more electrodes attached
to the battery box are applied on, around, or near the site of pain, and the patient then
manually regulates the power source to vary the amplitude and frequency of electrical
stimulation passing between the electrodes. The goal of the device is to modify the
sensory input by blocking or replacing the painful stimulation with stimulation
perceived as less painful or nonpainful. Success with this device may come only after
repeated trials with various electrode placements or battery-box manipulations. The
nurse may be valuable in encouraging and assisting the patient to make these small
manipulations.
Because the transcutaneous electrical stimulator is noninvasive in its
application, it may be particularly useful for the person who cannot tolerate more
extensive procedures. The only absolute contraindication to its use is the presence of a
demand-type cardiac pacemaker.
Dorsal column stimulators. The dorsal column stimulator is similar to the
transcutaneous electrical stimulator, except that an electrode is surgically implanted
over the dorsal column of the spinal column through laminectomy and the transmitter
is worn externally. The low-voltage pulses produced by the stimulator are thought to
block transmission of pain by stimulating large sensory fibers. The success of both
dorsal column and transcutaneous stimulators is thought to be explained by the gatecontrol theory of pain transmission.
In many institutions where dorsal column stimulators are implanted, candidates
for this surgery are chosen only after they demonstrate success with the use of the
transcutaneous stimulator. The nurse needs to be alert to postoperative complications
associated with spinal cord surgery, especially infection and cerebrospinal fluid leak.
Newer, less intrusive approaches to spinal cord stimulation are available. In
these systems the leads are inserted percutaneously into the epidural space with the
patient under local anesthesia.
Neurosurgical procedures. Constant, relentless pain (intractable pain) that
cannot be controlled by analgesics may be reduced or abolished by one of various
neurosurgical procedures.
Rhizotomy. Rhizotomy involves the surgical interruption of posterior nerve
roots (i.e., the sensory roots) just before they enter the spinal canal. There are a number
of disadvantages to rhizotomy:
(1) it involves major surgery (laminectomy), and not all patients are appropriate
candidates,
(2) it is less effective for areas below the head and neck, and
(3) the person loses all sensory input from the affected area after surgery.
Nursing management involves the usual postlaminectomy care. Teaching the patient
what to expect is important so that expectations can be adjusted accordingly. The
patient must understand that the loss of sensory transmission from the area of the
45
rhizotomy interferes with the ability to perceive heat and cold. Care must be taken
when the affected area is exposed to extremes in temperature (e.g., heat used for
cooking and baking).
Cordotomy. Cordotomy involves the surgical interruption of pain-conducting
pathways in the spinal cord. This interruption involves cutting the spinothalamic
portion of the anterolateral tract. Laminectomy is usually required unless the surgeon is
skilled in performing the procedure percutaneously. In the latter method no incision is
required. Needle electrodes are inserted into the appropriate quadrant of the spinal
cord, and the pathway is interrupted by electrical coagulation.
Cordotomy results in the loss of pain and temperature sensation below the level
that is severed, but other sensations and motor function remain intact. It is especially
effective for intractable pain of the trunk and legs. The procedure may be unilateral or
bilateral. Postoperatively, even with the percutaneous approach and when done on only
one side, the patient may have trouble with paralysis below the level of the lesion and
with urinary retention; men may become impotent. For some, these problems are only
temporary. Nursing management involves teaching and emotional support, especially if
complications occur.
Interruption of nerve pathways in the brain. Numerous attempts have been
made to alter the transmission of pain and the response to pain by surgical or
stereotactic interruption of pathways in the brain. Lesions have been placed in the
thalamus, the cingulum, the mesencephalon, the medulla, and the frontal lobe. The
success rate has varied considerably, depending on the skill of the surgeon, the type of
pain, and the patient's general physical and emotional condition.
These surgeries may have complications, particularly changes in the personality
of the patient. Although the assistance of a psychiatrist is helpful in managing all
patients with chronic pain, it is highly recommended for any surgery that may change
the patient's personality.
Intrathecal phenol. Another medical intervention used at some institutions is the
injection of phenol in combination with glycerin into the subarachnoid space by means
of lumbar puncture. The phenol combination is heavier than the cerebrospinal fluid and
descends to lower nerve roots to block pain intramission. The effect is analogous to a
chemical posterior rhizotomy, and effects may last several weeks to months. Side
effects are common and include bladder and bowel dysfunction and varying degrees of
lower extremity weakness. The value of this intervention is that no major surgery is
required, but its use is limited to pain in the trunk, abdomen, and lower extremities.
Nursing management is the same as for a patient undergoing lumbar puncture.
Acupuncture. Acupuncture is an ancient form of disease treatment that can be
used for pain relief. Only recently, however, has the method been used in Western
countries. Small needles skillfully inserted and manipulated at specific body points
depending on the type and location of pain produce often immediate and continued
relief of pain. The gate-control theory provides the best explanation for the success of
acupuncture: the local stimulation of large-diameter fibers by the needles "closes the
gate" to pain. It is not known to what extent the psyche and the power of suggestion
46
contribute to effectiveness of this therapy. Nursing management includes careful
assessment and teaching.
Interventions to modify response to pain
Decreasing anxiety. Patients in pain are often afraid. Fear may be allayed in part
by the nurse's calm, quiet manner and particularly by a demonstration of competence.
Confidence in the persons who care for them is a tremendous help to these patients. It
is a great comfort to patients to know, for example, that the nurses do not hurry while
giving nursing care, thus increasing their pain, or are not so "busy" that pain
medication is not given at the prescribed intervals.
Sometimes preparation for pain helps to increase acceptance of it and in turn
produces relaxation, which decreases pain. An example is the benefit derived from
special preparation for childbirth. Fear and irritability can sometimes be allayed by
explaining the reason for pain. This knowledge may relax patients somewhat and
thereby lessen their discomfort. Postoperative pain is often aggravated by movement.
Therefore, when certain activities such as turning and coughing are necessary to
prevent complications, the nurse explains this to the patient. The nurse may be able to
comfort a child by holding, rocking, or talking. Older patients also may be comforted
by having someone sit quietly with them, and some patients benefit from the personal
contact of holding another's hand.
It is understandable that the family is upset when the patient is in pain. The
patient not only appears uncomfortable, but may also not be able to respond in the
usual manner or relate appropriately emotionally and socially with people because of
the psychic energy absorbed by the pain. Prompt attention to the patient's needs helps
reduce the family's concern, and the patient's behavior should be interpreted as
necessary to family and friends with simple, clear explanations. Regardless of
explanations, persons who are emotionally close to the patient may need extra time to
accept the patient's behavior, and they may need repeated explanations. Reassurance of
family members is an essential part of nursing care because it may prevent them from
communicating their concern to the patient. Expressions of concern by others may
make the patient increasingly tense, which in turn lowers tolerance to pain. Helping the
family understand the patient's behavior often reduces their demands for the patient to
relate to them as usual.
Patient teaching. Teaching has been mentioned frequently in relation to helping
the person who has pain. Just as each patient's plan of care should be individualized, so
should the teaching within that plan of care. Careful assessment of the patient's
willingness and interest to learn and ability to tolerate teaching is made before teaching
is initiated. Teaching varies with each patient, but it may include the cause of the pain,
even at the physiologic level if the patient wishes to know, why or how various
attempts at pain relief could or should work, and alternate ways to do daily activities
that might be less painful or consume less energy. All nursing measures, even if not
primarily for pain relief, are explained.
In preparation for surgery or diagnostic procedures, the patient is told honestly
what to expect in terms of duration and intensity of pain usually experienced and what
47
measures will be available to assist with this discomfort. If the patient must actually
perform certain maneuvers or treatments such as coughing and deep breathing, it is
helpful to practice these preoperatively. If possible, the family should be included in
these teaching sessions, not only so they can support and assist the patient, but also so
they will understand what is expected of the patient.
Providing spiritual assistance. Even if no estimate can be made as to the
duration of pain, the patient should be given encouragement that the problem will not
become too great to accept with the assistance that is available. Many patients who
have prolonged pain with no hope of relief can and do derive benefit from their
religious faith. This may help them to consider pain in a more positive way and thus
make it more bearable for them. The nurse can arrange for the appropriate religious
advisor to be available to the patient who so desires.
Psychiatric assistance. In some situations a psychiatrist will be asked to
evaluate the patient and perhaps begin ongoing psychiatric care. The individual
suffering from chronic or intractable pain may appear sad, hostile, anxious, or
otherwise upset. These persons often have spent years undergoing various diagnostic
and surgical procedures and have seen many different physicians without significant
pain relief.
For many individuals psychiatric care is still not as acceptable as other kinds of
medical care. The nurse should be supportive and help the patient understand why this
type of therapy may be helpful. The nurse's role also includes the careful recording and
reporting of objective data about the patient's behavior and interactions with family and
others.
Behavior modification. Behavior modification can be used frequently with the
person in pain. For example, the nurse may praise and congratulate the patient each
time postoperative exercises are performed. If the patient is being encouraged to try a
new pain relief measure such as relaxation, it is hoped the ultimate reward will come in
the form of pain relief. During the practice and learning phase, however, positive
reinforcement and verbal praise and encouragement by the nurse when the patient does
try relaxation should stimulate the patient to practice. The basis for this therapy is the
idea that "a behavior will tend to occur more frequently if it is consistently followed by
a reward such as praise." Forms of this behavior therapy are used unconsciously all the
time: a child "throwing a tantrum" may be ignored, but as the child's behavior becomes
more appropriate, the mother may point this out and reward the child with her time and
attention.
Recent work with patients in pain has also been focused on the perception of
pain. In certain settings, hypnosis has met with some success for some patients in
reducing pain perception. Other experimenters have tried forms of distraction,
suggestion, or operant conditioning with varied success. In some of the operant
conditioning trials the patient is connected to an electroencephalogram. When the
patient increases his alpha brain wave activity, usually associated with a pain-free state
of relaxation, a light is turned on. The patient "trains" himself to turn on the light more
frequently and regularly and thus reduces his pain. This mechanism is known as
biofeedback.
48
Nutrition. Appetite is affected by pain. When a person is in continuous pain,
nothing, including meals, seems right. Care should be taken that foods the patient likes
are prepared appropriately. The patient's appetite may be improved by small, attractive
servings and by a sincere interest in the patient's reactions to food. Foods that the
patient does not bke should not be offered. Gratifying improvement in appetite has
followed the control of intractable pain by surgical procedures that interrupt sensory
pathways that transmit the painful sensation.
Suicide prevention. When caring for the patient who is experiencing severe,
continuous, or intractable pain, the nurse must keep in mind the possibility of suicide.
Pain is wearing and demoralizing, especially when it is difficult to control with
medications and when the individual knows or suspects that no permanent relief will be
forthcoming. These patients may dread the danger of a growing dependence on drugs,
they may fear that drugs will no longer help, and they may be depressed by thoughts of
being a burden and an expense to their families. They may appear to tolerate pain well,
but at the same time they may be planning their own destruction. Plans for protection
need to be individualized for each patient and depend on such factors as whether the
person is confined to bed.
Venous and arterial catheterizations.
Aubaniac first reported use of central venous catheter in 1952.
Current indications:
 inadequate peripheral venous access,
 central venous pressure monitoring for optimal fluid management,
 rapid fluid replacement,
 administration of vasoactive and phlebitic
drugs,
 long-term venous access,
 hemodialysis,
 plasmapharesis and total parenteral
nutrition.
There are a number of central veins and for each of
these there are a variety of techniques. It should be
remembered that, with the exception of the external
jugular, central veins are often deep and have to be
located blindly. This is associated with risk to nearby
structures, especially in the hands of the
inexperienced operator. Veins commonly lie close to
arteries and nerves, both of which can potentially be
damaged by a misplaced needle. The subclavian vein
also lies close to the dome of the pleura, damage to
which can cause a pneumothorax.
Insertion sites used for percutaneous central venous catheterization (CVC) are:
49




internal jugular vein,
subclavian vein,
femoral vein,
Peripherally inserted central catheters through cephalic, basilic or saphenous
veins.
Catheters are available which differ in length, internal diameter, number of channels
(access ports), method of insertion (see below), material and means of fixation. Two
useful lengths are 20cm catheters for subclavian and internal jugular lines, and 60cm
catheters for femoral and basilic lines.
There are several basic methods of inserting the catheter after the vein has been found:

Catheter over the needle. This is a longer version of a conventional
intravenous cannula and may be quickly inserted with a minimum of
additional equipment. The catheter is larger than the needle, which reduces the
leakage of blood from the insertion site, but using a larger needle to find the
vein makes the consequences of accidental arterial puncture more serious. In
addition it is easy to over-insert the needle.
 Catheter over guidewire (Seldinger technique). This is the preferred method of
insertion. A small diameter needle (18 or 20 gauge) is used to find the vein. A
guidewire is passed down the needle into the vein and the needle removed.
The guidewire commonly has a flexible J-shaped tip to reduce the risk of
vessel perforation and to help negotiate valves in the vein e.g the external
jugular vein (EJV). Once the wire is placed in the vein, the catheter is passed
over it until positioned in the vein. The wire should not be over-inserted as it
may kink, perforate the vessel wall or cause cardiac arrhythmias. This
technique allows larger catheters to be placed in the vein after the passage of
appropriate dilators along the wire and a small incision in the skin at the point
of entry.
 Catheter through the needle or catheter through cannula. The catheter is
passed through a cannula or needle placed in the vein. The technique is
becoming less popular as the hole made in the vein by the needle is larger than
the catheter thatis passed leading to some degree of blood leakage around the
site. If a problem is encountered during threading the catheter, withdrawal of
it through the needle risks shearing part of the catheter off with catheter
embolisation into the circulation. This technique is mainly reserved for the
antecubital route.
The basic preparation and equipment that is required for central venous cannulation is
the same regardless of the route or technique chosen. Clinicians who insert central
venous lines should be taught the technique by an experienced colleague. If this is not
possible then the access routes associated with the fewest complications are the basilic
vein or femoral vein.
Equipment required for central venous access:
 Patient on a tilting bed, trolley or operating table
50
 Sterile pack and antiseptic solution
 Local anaesthetic - e.g. 5ml lignocaine 1% solution
 Appropriate CV catheter for age/route/purpose
 Syringes and needles
 Saline or heparinised saline to prime and flush the line after insertion
 Suture material - e.g. 2/0 silk on a straight needle
 Sterile dressing
 Shaving equipment for the area if very hairy (especially the femoral)
 Facility for chest X-ray if available
Additional equipment required for CVP measurement includes: manometer tubing, a 3way stopcock, sterile saline, a fluid administration set, a spirit level and a scale
graduated in centimeters.
General technique for all routes:
 Confirm that central venous access is needed and select the most appropriate
route. Explain the procedure to the patient
 Shave the needle insertion area if very hairy
 Using a strict aseptic technique, prepare and check all the equipment for use.
Read instructions with the catheter.
 Sterilise the skin and drape the area
 Infiltrate the skin and deeper tissues with local anaesthetic. In cases where
difficulty is anticipated use the small local anaesthetic needle to locate the
vein before using the larger needle. This reduces the risk of trauma to other
structures.
 Position the patient as for the specific route described - avoid long periods of
head down, particularly in breathless patients
 Identify the anatomical landmarks for the chosen route and insert the needle at
the recommended point. After the needle has penetrated the skin, aspirate
gently whilst advancing the needle as directed until the vein is entered. If the
vein is not found, slowly withdraw the needle whilst gently aspirating; often
the vein has been collapsed and transfixed by the entry of the needle.
 If using a catheter over or through needle technique, thread the catheter into
the vein, remove the needle, flush with saline and secure it in place (see
checks below)
 If using a guidewire (Seldinger technique), pass this into the vein, flexible Jshape end first, then remove the needle. Small single lumen catheters may
pass directly over the wire into the vein. In this case, thread the catheter over
it until the end of the wire protrudes from the end of the catheter and whilst
holding the wire still advance the catheter into the vein. TAKE CARE not to
allow the wire to be pushed further into the vein whilst advancing the catheter
 It may be necessary to dilate up the hole in the vein when larger catheters are
used. Make a small incision in the skin and fascia where the wire enters the
patient. Thread the dilator over the wire into the vein with a twisting motion.
51







Excessive force should not be needed. Remove the dilator taking care not to
dislodge the guidewire. Thread the catheter over the wire as described above.
Check that blood can be aspirated freely from all lumens of the catheter and
flush with saline
Secure the catheter in place with the suture and cover with a sterile dressing.
Tape any redundant tubing carefully avoiding any kinking or loops which may
snag and pull out the catheter.
Connect catheter to a bag of intravenous fluid
Checks before using the line
Ensure fluid runs in freely and that blood flows freely back. To observe the
latter place the infusion bag below the level of the bed
If available, take a chest X-ray (ideally erect) to check the position of the
catheter tip and to exclude a pneumo, hydro or haemothorax. An early
radiograph may not show up abnormalities and it may be best to wait 3-4
hours unless symptoms develop. The tip of the CVP line should lie in the
superior vena cava just above its junction with the right atrium.
Ensure that the patient will be nursed where their CV line can be supervised.
Give appropriate written instructions regarding how, and what it is to be used
for, and who to contact if there is a problem
Practical problems common to most techniques of insertion
Arterial puncture
Usually obvious but may be missed in a patient who is hypoxic or
hypotensive. If unsure, connect a length of manometer tubing to the
needle / catheter and look for blood flow which goes higher than
30cm vertically or is strongly pulsatile. Withdraw the needle and
apply firm direct pressure to the site for at least 10 minutes or
longer if there is continuing bleeding. If there is minimal swelling
then retry or change to a different route.
Suspected
pneumothorax
If air is easily aspirated into the syringe (note that this may also
occur if the needle is not firmly attached to the syringe) or the
patient starts to become breathless. Abandon the procedure at that
site. Obtain a chest radiograph and insert an intercostal drain if
confirmed. If central access is absolutely necessary then try another
route ON THE SAME SIDE or either femoral vein. DO NOT
attempt either the subclavian or jugular on the other side in case
bilateral pneumothoraces are produced.
Arrhythmias
during the
procedure
Usually from the catheter or wire being inserted too far (into the
right ventricle). The average length of catheter needed for an adult
internal jugular or subclavian approach is 15cm. Withdraw the wire
or catheter if further than this.
Air embolus
This can occur, especially in the hypovolaemic patient, if the
52
needle or cannula is left in the vein whilst open to the air. It is
easily prevented by ensuring that the patient is positioned head
down (for jugular and subclavian routes) and that the guidewire or
catheter is passed down the needle promptly.
The wire will not
thread down the
needle
Check that the needle is still in the vein. Flush it with saline. Try
angling the needle so the end of it lies more along the plane of the
vessel. Carefully rotate the needle in case the end lies against the
vessel wall. Reattach the syringe and aspirate to check that you are
still in the vein. If the wire has gone through the needle but will not
pass down the vein it should be very gently pulled back. If any
resistance is felt then the needle should be pulled out with the wire
still inside, and the procedure repeated. This reduces the risk of the
end of the wire being cut off by the needle tip.
Apply firm direct pressure with a sterile dressing. Bleeding should
Persistent
usually stop unless there is a coagulation abnormality. Persistent
bleeding at the of
severe bleeding may require surgical exploration if there is an
entry
arterial or venous tear
Potential complications.
Early
Late
Arterial puncture
Bleeding
Cardiac arrhythmias
Injury to the thoracic duct
Injury to surrounding nerves
Air embolism
Catheter embolus
Pneumothorax
Venous thrombosis
Cardiac perforation and tamponade
Infection
Hydrothorax
The Subclavian Vein
The subclavian vein (SCV) has a wide calibre (1-2cm diameter in adults) and
is thought to be held open by surrounding tissue. In severely shocked patients,
however, it may be safer to perform a venous cutdown (eg. onto the long saphenous
vein) or use the EJV which may be accessible. In conscious patients the subclavian
route is often preferred (since head movement does not affect it) and also in trauma
patients with suspected cervical spine injury. Subclavian cannulae are easier to secure
which reduces subsequent movement and dislodgment. Whilst a high success rate for
placement can be achieved, serious complications occur more commonly than with the
other routes. Subclavian puncture should be avoided in patients with abnormal clotting
53
since it is difficult to apply pressure to the subclavian artery following accidental
puncture.
Anteriorly, the vein is covered throughout its entire course by the clavicle. It lies
anterior to, and below the subclavian artery as it crosses the first rib. Behind the artery
lies the cervical pleura which rises above the sternal end of the clavicle.
Preparation and positioning. The patient should be supine, both arms by the sides,
with the table tilted head down to distend the central veins and prevent air embolism.
Turn the head away from the side to be cannulated unless there is cervical spine injury.
Normally the right SCV is cannulated since the thoracic duct is on the left and may
occasionally be damaged during SCV cannulation.
Technique. Stand beside the patient on the side to be cannulated. Identify the
midclavicular point and the sternal notch. The needle should be inserted into the skin
1cm below and lateral to the midclavicular point. Keeping the needle horizontal,
advance posterior to the clavicle aiming for the sternal notch. If the needle hits the
clavicle withdraw and redirect slightly deeper to pass beneath it. Do not pass the needle
further than the sternal head of the clavicle.
Complications. Any of the complications described above can occur but pneumothorax
(2-5%) or rarely haemothorax or chylothorax (fatty white fluid in the pleural cavity due
to leakage of lymph from thoracic duct) are more common with this route than the
others. Occasionally the catheter may pass up into either jugular or the opposite SCV
rather than into the chest. This will not give reliable CVP readings and infusion of
some drugs (hypertonic solutions/vasoconstrictors) may be contra-indicated.
The Internal Jugular Vein
The internal jugular vein (IJV) is a potentially large vein commonly used for
central venous access which drains blood from the brain and deep facial structures.
Cannulation is associated with a lower incidence of complications than the subclavian
approach. Unlike the subclavian route, failure on one side does not prevent the operator
from trying the other side although this should be discouraged if arterial puncture had
occurred. Many approaches have been described depending upon the level in the neck
where the vein is entered. High approaches reduce the risk of pneumothorax but
increase the risk of arterial puncture the opposite being true of a low approach. A
middle level approach is described below.
Preparation and positioning. The patient should be supine, both arms by the sides,
with the table tilted head down to distend the central veins and prevent air embolism.
Slightly turn the head away from the side to be cannulated for better access (turning it
too far increases the risk of arterial puncture).
Technique. Stand at the head of the patient. Locate the cricoid cartilage and palpate the
carotid artery lateral to it at this level. Keeping a finger gently over the artery, insert the
needle at an angle of 30-40o to the skin and advance it downward towards the nipple on
the same side (in a woman guess where the nipple would be if she were a man).
Always direct the needle away from the artery under your finger. The vein is usually
within 2-3cm of the skin. If the vein is not found, redirect the needle more laterally.
54
Complications. With experience this route has a low incidence of complications.
Arterial puncture is easily managed by direct pressure. Pneumothorax is rare providing
the needle is not inserted too deeply.
The External Jugular Vein
Since the external jugular vein (EJV) lies superficially in the neck and is often
visible or palpable, complications associated with 'blind' venepuncture of deep veins
are avoided. The EJV is preferred when expertise is lacking,for emergency intravenous
fluid administration and in cardiac arrests, when the carotid pulsation cannot be felt.
However, because of the way the EJV joins the SCV there is a 10-20% chance that a
cannula will not pass into the SVC. In this situation it will not be suitable for CVP
measurements but can still provide central access for other purposes.
The vein is variable in size and has valves above the clavicle and just before its
junction with the SCV which may obstruct the passage of CV catheters. If a guidewire
with a J shaped tip is used the wire can often pass through these valves by rotating it at
the lower end of the EJV. Natural variations and disease states are responsible for the
wide range in the degree on prominence of the EJV.
Preparation and positioning. The patient should be supine, both arms by the sides,
with the table tilted head down to distend the central veins and prevent air embolism.
Turn the head away from the side to be cannulated for better access.
Technique. Stand at the head of the patient and identify the EJV as it crosses the
sternocleidomastoid muscle. If it is not palpable or visible (see problems) then choose
an alternative vein for catheterisation. Insert the needle in line with the vein where it is
most easily seen or palpated. Thread the guidewire and then the catheter.
Complications. If the vein is easily seen or palpated this route carries a very low risk.
The Femoral Vein
This may be the safest and most accessible central vein in children requiring
resuscitation where peripheral access has failed. It is also a preferred route for
inexperienced operators, due to the minimal risk of serious complications. The femoral
vein (FV) should not be used for more than a few days due to the risk of contamination
and infection from the groin area. With pelvic or intra-abdominal injury an alternative
central vein is preferred. Remember that the femoral route is not a good choice for
CVP monitoring since the value will be altered by the intra-abdominal pressure unless
a long catheter is used to pass above the level of the diaphragm.
Preparation and positioning. Abduct and externally rotate the thigh slightly.
Performance of the technique. Identify the pulsation of the femoral artery 1-2 cm
below the inguinal ligament. Insert the needle about 1cm medial to the pulsation and
aim it towards the head and medially at an angle of 20-30° to the skin. In adults, the
vein is normally found 2-4cm from the skin. In small children reduce the elevation on
the needle to 10-15° since the vein is more superficial.
Complications. Arterial puncture is possible if the needle is directed too lateral.
Femoral nerve damage may follow incorrect lateral insertion of the needle. Infection is
the commonest problem with femoral catheters and they are not recommended for
long-term use.
The Antecubital Veins
55
A palpable vein in the antecubital fossa provides the safest route for central
venous access. A long 60cm catheter is required. There are a number of veins in the
antecubital fossa - use one on the medial side.
Basilic vein. Ascends from the hand along the medial surface of the forearm draining
blood from that area and medial side of the hand. Near the elbow the vein changes to a
position in front of the medial epicondyle where it is joined by the median cubital vein.
It then runs along the medial margin of the biceps muscle to the middle of the upper
arm where it pierces the deep fascia to run alongside the brachial artery becoming the
axillary vein.
Cephalic vein. Ascends on the front of the lateral side of the forearm to the front of the
elbow, where it communicates with the basilic vein through the median cubital vein. It
then ascends along the lateral surface of the biceps muscle to the lower border of
pectoralis major muscle, where it turns sharply to pierce the clavipectoral fascia and
pass beneath the clavicle. It then usually terminates in the axillary vein although it can
join the EJV. There are valves at the termination of the cephalic vein. The sharp angle
and the valves frequently obstruct the passage of a catheter along the cephalic system.
Median cubital vein. The median cubital vein is a large vein that arises from the
cephalic vein just below the bend in the elbow and runs obliquely upwards to join the
basilic vein just above the bend in the elbow. It receives veins from the front of the
forearm which themselves may be suitable for catheterisation. It is separated from the
brachial artery by a thickened portion of the deep fascia (bicipital aponeurosis).
Care of the Central venous Catheter
 Use an aseptic technique when inserting the catheter and any subsequent
injections or changing fluid lines
 Keep the entry site covered with a dry sterile dressing
 Ensure the line is well secured to prevent movement (this can increase risks of
infection and clot formation)
 Change the catheter if there are signs of infection at the site.
 Remember to remove the catheter as soon as it is no longer needed. The
longer the catheter is left in, the greater the risks of sepsis and thrombosis
 Some people suggest changing a catheter every 7 days to reduce the risks of
catheter related sepsis and thrombosis. However, providing that the catheter is
kept clean (sterile injections and connections) and there are no signs of
systemic sepsis, routine replacement may not be necessary. Repeated
cannulation to change lines on a routine basis, rather than based on clinical
need, can increase the risks to the patient.
What is Central Venous Pressure?
Blood from systemic veins flows into the right atrium; the pressure in the right atrium
is the central venous pressure (CVP). CVP is determined by the function of the right
heart and the pressure of venous blood in the vena cava. Under normal circumstances
an increased venous return results in an augmented cardiac output, without significant
changes in venous pressure. However with poor right ventricular function, or an
obstructed pulmonary circulation, the right atrial pressure rises. Loss of blood volume
56
or widespread vasodilation will result in reduced venous return and a fall in right atrial
pressure and CVP.
The CVP is often used to make estimates of circulatory function, in particular cardiac
function and blood volume. Unfortunately the CVP does not measure either of these
directly, but taken in the context of the other physical signs useful information can be
gained. The supply of blood to the systemic circulation is controlled by the left
ventricle. In a normal patient the CVP closely resembles the left atrial pressure and is
usually used to predict it. However in patients with cardiac disease the right and left
ventricles may function differently - this can only be detected clinically by measuring
the pulmonary capillary wedge pressure.
When should CVP be measured?
 Patients with hypotension who are not responding to basic clinical
management.
 Continuing hypovolaemia secondary to major fluid shifts or loss.
 Patients requiring infusions of inotropes.
How to measure the CVP:
The CVP is measured using a manometer filled with intravenous fluid attached to the
central venous catheter. It needs to be 'zeroed' at the level of the right atrium,
approximately the mid-axillary line in the 4th interspace supine. Measurements should
be taken in the same position each time using a spirit level and the zero point on the
skin surface marked with a cross. Check that the catheter is not blocked or kinked and
that intravenous fluid runs freely in, and blood freely out. Open the 3-way tap so that
the fluid bag fills the manometer tubing (check there is no obstruction to fluid flow and
that the cotton wool in the top of the manometer is not blocked or wet). Turn the tap to
connect the patient to the manometer. The fluid level will drop to the level of the CVP
which is usually recorded in centimeters of water (cmH2O). It will be slightly pulsatile
and will continue to rise and fall slightly with breathing - record the average reading.
An alternative to the manometer and 3-way tap is a butterfly needle inserted into the
rubber injection port of ordinary intravenous tubing. In Intensive Care Units or
theatres, electronic transducers may be connected which give a continuous readout of
CVP along with a display of the waveform. Useful information can be gained by
studying the electronic waveform. The CVP reading from an electronic monitor is
sometimes given in mmHg (same as blood pressure). The values can easily be
converted knowing that 10cmH20 is equivalent to 7.5mmHg (which is also 1kPa).
CVP does not measure blood volume directly and is influenced by right heart
function, venous return, right heart compliance, intrathoracic pressure and patient
positioning. It should always be interpreted alongside other measures of cardiac
function and fluid state (pulse, BP, urine output etc.). The absolute value is not as
important as serial measurements and the change in response to therapy. A normal
value in a spontaneous breathing patient is 5-10cm water cmH2O, rising 3-5cmH2O
during mechanical ventilation. The CVP measurement may still be in the normal range
even with hypovolaemia due to venoconstriction.
Guide to interpretation of the CVP in the hypotensive patient
57
CVP
reading
Other features that may be Diagnosis to
present
consider
Treatment
Low
Rapid pulse
Blood pressure normal or
low
Low urine output
Poor capillary refill
Hypovolaemia
Give fluid challenges* until
CVP rises and does not fall
back again. If CVP rises and
stays up but urine output or
blood pressure does not
improve consider inotropes
Low or
normal
or high
Rapid pulse
Signs of infection
Pyrexia
Vasodilation/constriction
Sepsis
Ensure adequate circulating
volume (as above) and
consider inotropes or
vasoconstrictors
Normal
Rapid pulse
Low urine output
Poor capillary refill
Hypovolaemia
Treat as above.
Venoconstriction may cause
CVP to be normal. Give fluid
challenges* and observe
effect as above.
High
Unilateral breath sounds
Assymetrical chest
movement
Resonant chest with
tracheal deviation
Rapid pulse
Tension
pneumothorax
Thoracocentesis then
intercostal drain
High
Breathlessness
Third heart sound
Pink frothy sputum
Oedema
Tender liver
Heart failure
Oxygen, diuretics, sit up,
consider inotropes
Very
High
Rapid pulse
Muffled heart sounds
Pericardial
tamponade
Pericardiocentesis and
drainage
*Fluid challenge. In hypotension associated with a CVP in the normal range give
repeated boluses of intravenous fluid (250 - 500mls). Observe the effect on CVP, blood
pressure, pulse, urine output and capillary refill. Repeat the challenges until the CVP
shows a sustained rise and/or the other cardiovascular parameters return towards
normal. With severe blood loss, blood transfusion will be required after colloid or
crystalloid have been used in initial resuscitation. Saline or Ringers lactate should be
used for diarrhoea/bowel obstruction/vomiting/burns etc.
Catheter removal
58
Remove any dressing and suture material. Ask the patient to take a breath and
fully exhale. Remove the catheter with a steady pull while the patient is breath holding
and apply firm pressure to the puncture site for at least 5 minutes to stop the bleeding.
Excessive force should not be needed to remove the catheter. If it does not come out,
try rotating it whilst pulling gently. If this still fails, cover it with a sterile dressing and
ask an experienced person for advice.
Pulmonary artery flotation catheters (PAFC) catheters
A PAFC or Swan-Ganz catheter is a central venous catheter with a small
inflatable balloon at the end. An introducing catheter is sited in a central vein and the
catheter is then 'floated' along the central vein with the balloon inflated, through the
right atrium and ventricle until it lies in a branch of the pulmonary artery. The position
of the PAFC can be predicted as it moves through the circulation by the pressure
waveform obtained by measuring the pressure at the tip of the PAFC. Once correctly
positioned, when the balloon is inflated it occludes the branch of the pulmonary artery
and measures the pressure distal to it (pulmonary artery occlusion pressure or 'wedge'
pressure since it is 'wedged' in the artery). With the balloon inflated there is a
continuous column of fluid between the tip of the PAFC and the left atrium, without
interference from heart valves and lung pathology. It is therefore a better guide to the
venous return to the left side of the heart than CVP. However, it is a more invasive
monitor, requires more expertise to insert, has a greater complication rate and is more
expensive.
Arterial Catheterization
An arterial catheter is a thin, hollow, tube which is placed into the artery (most
commonly of the wrist or groin) to measure blood pressure more accurately than is
possible with a blood pressure cuff. The catheter can also be used to get repeated blood
samples when it is necessary to frequently measure the levels of oxygen and/or carbon
dioxide in the bloodstream.
Common reasons for its use and benefits:
 Low blood pressure (hypotension or shock) - When a low blood pressure
cannot be corrected rapidly with fluid given through a patient's veins. The
need to measure pressures in the large blood vessels is greatest when the
patient is receiving powerful medications that stimulate the heart as a way of
keeping the blood pressure up. The arterial catheter allows accurate, secondto-second measurement of the blood pressure; repeated measurement is called
monitoring.
 High blood pressure (hypertension) - In some situations, the blood pressure
can go so high that it is life-threatening. Such high blood pressure must be
lowered gradually in steps, and measurements with an arterial catheter help
guide the treatment.
 Severe lung problems - When a patient has a lung problem that is so severe
that it requires checking the levels of oxygen or carbon dioxide of the blood
more frequently than 3 to 4 times a day, the arterial catheter can be used to
draw blood without having to repeatedly stick a needle into the patient.
Risks:
59
Some of the risks of arterial catheterization include:
 Pain during placement - Discomfort can result from the needle stick and
placement of the catheter at the time it is inserted. Doctors try to lessen the pain with a
local numbing medicine (anesthetic like novocaine). The discomfort is usually mild
and goes away once the catheter is in place.
 Infections - As in the case with all catheters inserted into the body, bacteria
can travel up the catheter from the skin and into bloodstream. The longer the catheter
remains in the artery, the more likely it is to get infected. Special care in bandaging the
skin at the catheter site and changing tubing can help to decrease the risk of infection.
 Blood clots - If blood clots form on the tips of arterial catheters, the clots can
block blood flow. If another blood vessel does not carry blood to the area beyond the
clot, this can cause the loss of a hand or leg. Such a loss is very rare. To decrease the
likelihood of these problems, the ICU staff check regularly for blood flow in the hand
or leg when a catheter is in the artery.
 Bleeding - Bleeding can occur at the time of inserting the catheter. The
bleeding may stop without doing anything. Sometimes, the ICU staff need to remove
the catheter and apply pressure to the site.
Catheterization of the Urinary Bladder
Intermittent Catheterization of the Urinary Bladder
Intermittent catheterization is a temporary or permanent alternative to the use of
an indwelling catheter, or to divert urine from the bladder.
If this is for the management of a dysfunctional bladder, the patient should be taught
self-catheterization. When self-catheterization is initiated, the steps of the procedure
must be modified to fit the patient activities at home, e.g., catheterize every 4 hours
until bedtime, beginning when the
patient arises in the morning. If
patient will be taught selfcatheterization, allow him to utilize
clean technique. Residual urine can
serve as an excellent culture
medium for bacterial growth and
intermittent catheterization can
serve to minimize urinary tract
infection (UTI) risk for some
patients. However, for severely
debilitated patients risk of UTI due
to catheterization is increased.
Over-distension of the bladder can
also lead to renal deterioration due to ischemia of the bladder wall.
Potential candidates include any patient who is unable to empty his bladder effectively
by voiding (determined by catheterizing the patient 2-3 times for post-void residual
60
(PVR). PVR’s greater than 75-100mL (adult) or 30-60mL (child) indicate incomplete
emptying.
The goals for intermittent catheterization are:
1. Complete drainage of the bladder at regular intervals
2. Prevention of overdistension: volume greater than 350mL (adults) or 90-350mL
(child, dependent on age and size of child)
3. Prevention of wetness between catheterizations (unless patient is
infant/toddler)
4. Minimize UTIs and other complications associated with bladder
dysfunction.
EQUIPMENT
• Appropriate size urinary catheter
• Washcloth
• Soap and water
• Small packet of water soluble lubricant
• Drainage container
• Underpad
Males:
Infant: 8-10 French Catheter
1-3 years: 10-12 Fr Cath
3 + years: 12-14 Fr Cath
Adult: 14-16 Fr Cath
Females:
Infant: 5 – 8 French Catheter
1-3 years: 8-10 Fr Cath
3-7 years: 10-12 Fr Cath
7 + years: 12-14 Fr Cath
Adult: 14-16 Fr Cath
STEPS:
1. Explain catheterization procedure and schedule to patient.
STEPS:
1. Catheterize adults and children over 12 years old at the ordered interval not later.
If patient will be off unit at cath time, cath early, and adjust the schedule accordingly.
If patient will be taught selfcatheterization, allow him to utilize clean technique
(procedure follows).
Geriatric patients, insulin-dependent diabetics, or those taking diuretics or steroids or
IV fluids may need to be catheterized round-the-clock.
Infants and children under 12: Catheterize every 3 hours, 6 am – 10pm, or as ordered.
If infant awakens during the night to feed, catheterize during this time.
2. Position patient in semi-Fowler’s position with head-of-bed slightly raised.
3. Slightly elevating the head of the bed will assist with bladder drainage. Assure
patient privacy.
3. Place underpad under patient.
4. Perform hand hygiene.
61
5. Open catheter kit. Put on sterile gloves.
5. Use kit sterile wrapping as a sterile field drape for supplies.
6. Saturate cotton-balls with povidone-iodine solution.
7. Open water-soluble lubricant and squeeze onto sterile field drape. Lubricate catheter
tip with lubricant.
7. Take care to maintain catheter sterility.
8. Remove specimen container and label from basin (supplied in kit).
9. Cleanse patient as follows:
Female patient:
Expose urinary meatus and cleanse area with povidone-iodine saturated cotton ball
wiping from front-to-back, inside the labia.
Use 1-2 cotton balls.
Male patient:
Grasp shaft of penis with non-dominant hand and elevate it. Cleanse glans penis with
saturated cotton ball (if uncircumcised, retract foreskin for cleansing).
9. Explain procedure to patient.
10. Catheterizing:
Female patient:
Position urinary drainage container. Gently insert lubricated catheter into urethra until
urine begins to flow.
Male patient:
Position urinary drainage container. Apply gentle traction to penis and gently insert
lubricated catheter into urethra until urine begins to flow.
10. Do not advance catheter further once urine begins to flow.
11. Use Credé maneuver prior to removal of the catheter.
11. Gentle pressure/massaging of the suprapubic area can help ensure that all urine is
removed.
12. When urine flow stops, gently remove catheter and discard.
12. If uncircumcised return foreskin to original position.
13. Collect urine specimen if ordered.
14. Record output and urine specimen collection (if applicable) on PCR.
14. If patient reports voids (or leaks) urine in addition to cath, record that volume
separately. This helps to determine the need for adding anti-cholinergic medications.
15. Record patient and/or caregiver teaching in reference to self-catheterization
instruction (if applicable).
15. If patient is to learn self-cath, teach the relationship between I&O.
If teaching intermittent self-catheterization
STEPS:
1. Instruct patient on importance of hand hygiene.
1. Improper hand hygiene can cause UTIs.
2. Demonstrate and explain how patient should cleanse prior to self-catheterization:
Female
Instruct patient to cleanse perineal area with a soapy washcloth, using downward
strokes.
62
Rinse the area with the washcloth using downward strokes.
Male:
Instruct patient to cleanse the end of his penis with soap and water. Pulling back
foreskin if appropriate. Rinse with washcloth.
2. Clean technique is normally used for selfcatheterization.
Explain that downward cleansing strokes reduce the risk of infection.
3. Instruct patient to use water-soluble lubricant on first 3-inches of catheter tip.
3. Explain to patient that lubricant will make procedure more comfortable.
4. Teach patient to hold catheter about 1-inch from tip, in non-dominant hand, to
perform
catheterization.
4. Instruct patient to slowly insert catheter into urethra allowing all urine to drain into
drainage container/toilet:
Female:
Insert about 3-inches until urine begins to flow.
Male:
Insert 7-10-inches until urine begins to flow.
5. Instruct patient that pressing down on the abdominal muscles can be helpful in
completely draining the bladder.
6. Advise patient to wash catheter after each use in warm, soapy water, rinse inside and
out, and dry with a clean towel. Store dry catheter in a clean, dry plastic bag.
6. Catheters become brittle with repeated use, so tell patient to check them often and
order a new supply well in advance. Store catheters only after they are completely dry
to prevent the growth of gram-negative organisms.
7. Instruct patient on importance of timing of catheterization (every 4-6 hours).
7. Over-distention of the bladder can lead to UTI and urine leakage.
8. Instruct patient on importance of regulating fluid intake, as ordered, to balance I &
O.
8. Regulating fluid balance helps maintain adequate hydration while preventing
incontinence.
I.
II.
III.
Indications for long-term indwelling catheterization
A.
Refractory bladder outlet obstruction
B.
Neurogenic bladder with urinary retention
C.
Complications of Incontinence
1.
Refractory skin breakdown
2.
Palliative care for terminally ill
3.
Patient preference
Indications for short-term catheterization
A.
Urologic or pelvic surgery
B.
Acute urinary retention (trial voiding at 14 days)
C.
Urinary output monitoring in critically ill
Contraindication: Signs of Urethral trauma
A.
If trauma, perform genital and rectal exam first
63
IV.
V.
VI.
64
B.
Blood at meatus
C.
Scrotal hematoma
D.
High riding prostate
Complications of longterm catheterization
A.
See Urinary Catheter associated Urinary Tract Infection
1.
Urosepsis
2.
Bacteriuria
a.
Single intermittent catheterization: 20% of elderly
b.
Bacteriuria occurs in most patients in 2-3 weeks
B.
Chronic renal inflammation
C.
Pyelonephritis
D.
Nephrolithiasis
E.
Cystolithiasis
Alternatives to Indwelling Urinary Catheters
A.
Intermittent catheterization (dysfunctional voiding)
1.
Spinal cord injury
2.
Nursing home residents
3.
Surgery
a.
Hip Fracture repair
b.
Total abdominal Hysterectomy
B.
External Catheter (Condom catheter)
1.
Incontinent men without obstructive uropathy
2.
More comfortable than indwelling catheters
3.
Lower Incidence of bacteruria
4.
Skin breakdown may occur
C.
Suprapubic Catheterization (short-term post-operative)
1.
Lower infection risk
2.
Improved comfort and convenience
3.
Risks
a.
Cellulitis
b.
Hematoma or leakage at puncture site
c.
Urethral prolapse
Catheter Characteristics
A.
Catheter Material
1.
Latex: Long-term catheterization
2.
Silastic: Short-term catheterization or Latex Allergy
B.
Minocycline and Rifampin impregnated catheters
1.
May reduce bacteriuria for up to 2 weeks
2.
Reference
C.
Catheter size
1.
Narrowest, softest efective tube
a.
Range: 12F (smallest) to 18F (largest)
b.
Most common: 14F to 16F
2.
Balloon size: 5 ml balloon with 5-10 ml fluid
VII.
VIII.
Management: Urinary Tract Infection
A.
Urinary Catheter associated Urinary Tract Infection
B.
Prevention of Urinary Catheter associated UTI
Management: General
A.
Urinary Catheter Blockage
1.
Maximize patient hydration
2.
Consider Methanamine preparations to prevent blockage
3.
Consider bladder irrigation
4.
Change catheter before expected time to obstruction
5.
Change catheter if no urine flow in 4 to 8 hours
6.
Evaluate for UTI for more frequent catheter blockage
B.
Urinary Catheter leakage
1.
Do not increase catheter diameter
2.
Evaluate for catheter blockage (above)
3.
Evaluate for Urinary Catheter associated UTI
4.
Consider Bladder Antispasmodic
The urinary tract is the most common site of nosocomial infection, accounting for more
than 40% of the total number reported by acute-care hospitals and affecting an
estimated 600,000 patients per year. Most of these infections - 66% to 86% - follow
instrumentation of the urinary tract, mainly urinary catheterization. Although not all
catheter-associated urinary tract infections can be prevented, it is believed that a large
number could be avoided by the proper management of the indwelling catheter.
Catheter-associated urinary tract infections are generally assumed to be benign. Such
infection in otherwise healthy patients is often asymptomatic and is likely to resolve
spontaneously with the removal of the catheter. Occasionally, infection persists and
leads to such complications as prostatitis, epididymitis, cystitis, pyelonephritis, and
gram-negative bacteremia, particularly in high-risk patients.
Recommendations
1. Personnel
a. Only persons (e.g., hospital personnel, family members, or patients
themselves) who know the correct technique of aseptic insertion and maintenance of
the catheter should handle catheters. Category I
b. Hospital personnel and others who take care of catheters should be given
periodic in-service training stressing the correct techniques and potential complications
of urinary catheterization. Category II
2. Catheter Use
a. Urinary catheters should be inserted only when necessary and left in place
only for as long as necessary. They should not be used solely for the convenience of
patient-care personnel. Category I
b. For selected patients, other methods of urinary drainage such as condom
catheter drainage, suprapubic catheterization, and intermittent urethral catheterization
can be useful alternatives to indwelling urethral catheterization. Category III
3. Handwashing
65
Handwashing should be done immediately before and after any manipulation of the
catheter site or apparatus. Category I
4. Catheter Insertion
a. Catheters should be inserted using aseptic technique and sterile equipment.
Category I
b. Gloves, drape, sponges, an appropriate antiseptic solution for periurethral
cleaning, and a single-use packet of lubricant jelly should be used for insertion.
Category II
c. As small a catheter as possible, consistent with good drainage, should be
used to minimize urethral trauma. Category II
d. Indwelling catheters should be properly secured after insertion to prevent
movement and urethral traction. Category I
5. Closed Sterile Drainage
a. A sterile, continuously closed drainage system should be maintained.
Category I
b. The catheter and drainage tube should not be disconnected unless the
catheter must be irrigated. Category I
c. If breaks in aseptic technique, disconnection, or leakage occur, the
collecting system should be replaced using aseptic technique after disinfecting the
catheter-tubing junction. Category III
6. Irrigation
a. Irrigation should be avoided unless obstruction is anticipated (e.g., as might
occur with bleeding after prostatic or bladder surgery); closed continuous irrigation
may be used to prevent obstruction. To relieve obstruction due to clots, mucus, or other
causes, an intermittent method of irrigation may be used. Continuous irrigation of the
bladder with antimicrobials has not proven to be useful and should not be performed as
a routine infection prevention measure. Category II
b. The catheter-tubing junction should be disinfected before disconnection.
Category II
c. A large-volume sterile syringe and sterile irrigant should be used and then
discarded. The person performing irrigation should use aseptic technique. Category I
d. If the catheter becomes obstructed and can be kept open only by frequent
irrigation, the catheter should be changed if it is likely that the catheter itself is
contributing to the obstruction (e.g., formation of concretions). Category II
7. Specimen Collection
a. If small volumes of fresh urine are needed for examination, the distal end of
the catheter, or preferably the sampling port if present, should be cleansed with a
disinfectant, and urine then aspirated with a sterile needle and syringe. Category I
b. Larger volumes of urine for special analyses should be obtained aseptically
from the drainage bag. Category I
8. Urinary Flow
a. Unobstructed flow should be maintained. Category I (Occasionally, it is
necessary to temporarily obstruct the catheter for specimen collection or other medical
purposes.)
66
b. To achieve free flow of urine 1) the catheter and collecting tube should be
kept from kinking; 2) the collecting bag should be emptied regularly using a separate
collecting container for each patient (the draining spigot and nonsterile collecting
container should never come in contact ); 3) poorly functioning or obstructed catheters
should be irrigated (see Irrigation Recommendation 6) or if necessary, replaced; and 4)
collecting bags should always be kept below the level of the bladder. Category I
9. Meatal Care
Twice daily cleansing with povidone-iodine solution and daily cleansing with soap and
water have been shown in 2 recent studies not to reduce catheter-associated urinary
tract infection. Thus, at this time, daily meatal care with either of these 2 regimens
cannot be endorsed. Category II
10. Catheter Change
Interval
Indwelling catheters should not
be changed at arbitrary fixed
intervals. Category II
11. Spatial Separation
of Catheterized Patients
To minimize the chances of
cross-infection, infected and
uninfected
patients
with
indwelling catheters should not
share the same room or adjacent beds. Category III
12. Bacteriologic Monitoring
The value of regular bacteriologic monitoring of catheterized patients as an infection
control measure has not been established and is not recommended. Category III
Summary of Major Recommendations
Category I. Strongly Recommended for Adoption
- Educate personnel in correct techniques of catheter insertion and care.
- Catheterize only when necessary.
- Emphasize handwashing.
- Insert catheter using aseptic technique and sterile equipment.
- Secure catheter properly.
- Maintain closed sterile drainage.
- Obtain urine samples aseptically.
- Maintain unobstructed urine flow.
Category II. Moderately Recommended for Adoption
- Periodically re-educate personnel in catheter care.
- Use smallest suitable bore catheter.
- Avoid irrigation unless needed to prevent or relieve obstruction.
- Refrain from daily meatal care with either of the regimens discussed in text.
- Do not change catheters at arbitrary fixed intervals.
Category III. Weakly Recommended for Adoption
67
- Consider alternative techniques of urinary drainage before using an indwelling
urethral catheter.
- Replace the collecting system when sterile closed drainage has been violated.
- Spatially separate infected and uninfected patients with indwelling catheters.
- Avoid routine bacteriologic monitoring.
Nasogastric intubation
Nasogastric intubation refers to the process of placing a soft plastic nasogastric (NG)
tube through a patient's nostril, past the pharynx, and down the esophagus into a
patient's stomach.
Indications:
1.
Removing stomach contents
A. Diagnostic
GI bleeding
Penetrating or blunt trauma
B. Therapeutic
Paralytic ileus
Gastric dilatation
Intestinal obstruction Persistent vomiting
Removal of toxins and pill fragments
Heating or cooling for temperature abnormalities
C. Prophylactic
Decompression prior to abdominal surgery or peritoneal
lavage
Prevention of aspiration in multiple trauma
2. Instillation of materials
Medications, feedings, contrast, charcoal
Contraindications:
 Loss of integrity of cribriform plate (midface fracture)



Esophageal stricture
Comatose patients without airway protection
Penetrating neck trauma
(Note: varices are not a contraindication)
Equipment:
1. Salem sump tube of appropriate size, Catheter tip irrigation 60ml syringe
2.
68
Suction apparatus, Stethoscope
3.
4.
5.
6.
7.
Cup of water with straw (for cooperative patients)
2% Lidocaine gel, small syringe
Lubricant
Tape, benzoin
Nasal decongestant (optional), Emesis basin, pH indicator strips.
Procedure:
1. Position patient: fully sitting if awake; supine wlneck flexion if comatose.
2. Inspect nares for obstruction; apply nasal decongestant and anesthetic to
nasal mucosa, pharynx.
3. Estimate tube insertion length: ear-nose-xiphoid, mark wltape.
4. Pass lubricated tube along floor of nose.
5. Ask patient to sip water, advance tube quickly with swallowing
6. Confirm placement by auscultation over stomach, aspiration of gastric
contents.
Before an NG tube is inserted, the Health Care Provider - most often the nurse, must
measure with the tube from the tip of the patient's nose, to their ear and down to the
xyphoid process. Then the tube is marked at this level to ensure that the tube has been
inserted far enough into the patient's stomach. The end of a plastic tube is lubricated
and inserted into one of the patient's anterior nares. It is then moved through the nasal
cavity and down into the throat. Once the tube is past the pharynx, it is rapidly inserted
down into the stomach.
During the tube's insertion, the patient may gag; in this situation the patient is given
water to drink, and the tube continues to be inserted as the patient swallows. Great care
must be taken to ensure that it has not passed through the windpipe and down into the
lungs. To ensure proper placement it is recommended (though not unequivocally
confirmed) that injection of air into the tube be performed, if the air is heard in the
stomach with a stethoscope, then the tube is in the correct position. Another method is
to aspirate fluid from the tube with a syringe. This fluid is then tested with pH paper
(note not litmus paper) to determine the acidity of the fluid. If the pH is 5.5 or below
then the tube is in the correct position. If this is not possible then correct verification of
tube position is obtained with an X-ray of the chest/abdomen.This is the most reliable
means of insuring proper placement of a NG tube. If the tube is to remain in place then
a tube position check is recommended before each feed and at least once per day.
A commonly used NG tube is the Levin tube.
The main use of a nasogastric tube is for feeding and for administering drugs and other
oral agents (such as activated charcoal and radiographic contrast material). For drugs
and for minimal quantities of liquid, a syringe is used for injection into the tube. For
continuous feeding, a gravity based system is employed, with the solution placed
higher than the patient's stomach. If accrued supervision is required for the feeding, the
tube is often connected to an electronic pump which can control and measure the
patient's intake and signal any interruption in the feeding.
69
Treatment for Superior Mesenteric Artery Syndrome or severe anorexia can include
nasogastric feeding to stabilize body weight.
Nasogastric aspiration (suction) is the process of draining the stomach's contents via
the tube. Nasogastric aspiration is mainly used to remove gastric secretions and
swallowed air in patients with gastrointestinal obstructions. Nasogastric aspiration can
also be used in poisoning situations when a potentially toxic liquid has been ingested,
for preparation before surgery under anesthesia, and to extract samples of gastric liquid
for analysis.
If the tube is to be used for continuous drainage, it is usually appended to a collector
bag placed below the level of the patient's stomach; gravity empties the stomach's
contents. It can also be appended to a suction system, however this method is often
restricted to emergency situations, as the constant suction can easily damage the
stomach's lining.
Suction drainage is used for patients who have undergone a pneumonectomy in order
to prevent anesthesia-related vomiting and possible aspiration of any stomach contents.
Such aspiration would represent a serious risk of complications to patients recovering
from this surgery.
Contraindications
Nasogastric intubation is contraindicated (inadvisable) in patients with base of skull
fractures, severe facial fractures especially to the nose and obstructed esophagus and/or
obstructed airway.
NG tube is also contraindicated in patients who have had gastric bypass surgery.
Complications
Minor complications include nose bleeds, sinusitis, and a sore throat. Sometimes more
significant complications occur including erosion of the nose where the tube is
anchored, esophageal perforation, pulmonary aspiration, a collapsed lung, or
intracranial placement of the tube.
70
Complication:
Prevention:
Management:
Inability to insert tube
into the naris due to
resistance:
Nasal bleeding:
Topical vasoconstriction
Try other naris; a smaller
caliber tube; or consider
oral gastric intubation.
Local pressure.
Consider oral gastric
intubation.
Topical vasoconstrictor.
Rule out coagulopathy.
Excessive gagging:
Topical anesthetic.
Coiling of the tube in the
oral cavity:
Mild neck flexion;
stiffening of the tube tip
by cooling in ice.
Partially withdraw, and
again encourage patient
to swallow.
Tracheal intubation:
Reflux of gastric contents
into the vent lumen:
Do not clamp vent lumen.
Bronchial placement:
Radiologic exam is
mandatory in comatose
patients.
Only liquids should be
administered, followed by
30 -50cc water flush.
Obstruction of tubes used
for instillation:
Withdraw and readvance with slight neck
flexion.
Flush vent lumen with a
syringe filled with air.
Remove and replace.
Attempt to flush with
50cc water.
After correct positioning of the NG tube has been established, the NG tube should be
secured to the nose with a second piece of plastic tape or a transparent dressing used to
hold the tubing to the nose. The intent is to secure the tube so that it will not slip in or
out. The method of securing the tube may vary according to the size of the patient, their
type of skin, and the amount of perspiration on the nose. Securing the other end of the
NG tube to the patient's gown with a looped rubber band and safety pin can prevent
accidental pulling on the NG tube as the patient moves around. The end of the NG tube
should be plugged or clamped when not connected to suction or in use for feedings.
Ongoing care of the patient with a NG tube includes encouraging good mouth care and
cleansing the nostrils routinely. The tape position should be changed daily and the
tissue around the nose and under the tape examined for signs of irritation or
breakdown. The head of the bed should be elevated 30 degrees at all times to decrease
gastric reflux. The head of the bed should be at 30-45 degrees during tube feedings and
for 30-60 minutes after intermittent tube feedings if the patient can tolerate this
position.
SPLINTING
INDICATIONS:
Temporary immobilization to improve pain and discomfort, decrease blood loss,
reduce the risk for fat emboli and minimize the potential for further neurovascular
injury associated with:
·
Fractures
·
Sprains
·
reduced dislocations
·
tendon lacerations
·
deep lacerations across joints
·
painful joints associated with imflammatory disorders
MATERIALS:
Plaster Rolls or sheets
71
Strips or rolls of various width made from crinoline-type material impregnated with
plaster which crystallizes or “sets” when water is added
Prefabricated Splint Rolls (Ortho-Glass)
Layers of fiberglass between polypropylene padding
Stockinette
Cast padding
Elastic bandages
Adhesive tape
Heavy scissors
Bucket
Protective sheets or pads to protect patient clothing
gloves
PATIENT EDUCATION:
Instructions should be both verbal and written.
Explain and demonstrate the importance of elevation to minimize swelling and
decrease pain.
Apply ice bags or cold packs (bags of frozen vegetables also work well) for at least 30
minutes at a time during the first 24-48 hours after injury to decrease swelling and pain
Avoid getting the splint wet – some splints may be removable for bathing purposes,
otherwise plastic bags may be placed over the splint to keep it dry while bathing
Explain signs of infection and vascular compromise, instruct patient to seek help for
any concerns
Instruct patient to return for evaluation of damaged/broken or wet splint
Discuss follow-up guidelines
PROCEDURE/TECHNIQUE:
Prepare the patient
Cover patient with sheet or gown to protect clothing
Inspect skin for wounds and soft tissue injuries
Clean, repair and dress wounds as usual prior to splint application
Padding
Apply stockinette to extremity to extend several cm beyond edges of plaster, so that it
may be folded back over the edges of the splint after plaster is applied to create a
smooth edge
Roll on two to three layers of cast padding evenly and smoothly (but not too tight) over
the area to be splinted.
Extend the padding out beyond the planned area to be splinted so that it can be folded
back with the stockinette over the edges of plaster to create smooth edges.
Each turn of the webril/cast padding should overlap the previous by 25-50 % of its
width.
Place extra padding over bony prominences to decrease chance of creating pressure
sores
An alternative to circumferential stockinette and cast padding is to place 2-3 layers of
padding directly over wet plaster, and then apply this webril-lined splint over the area
to be immobilized and secure it with an elastic bandage
72
Prepare the plaster splint material
Ideal length and width of plaster depends on body part to be immobilized in the splint
Estimate the length by laying the dry splint next to the area to be splinted
Be generous in estimating length, the ends can always be trimmed or folded back
Width should be slightly greater than the diameter of the limb to be immobilized
Cut or tear the splint material to the desired length
Choose thickness based on body part to be immobilized, patient body habitus, and
desired strength of splint.
Average of 8-12 layers
Less layers (8-10) for upper extremities
More layers (12-15) for lower extremities
More layers may be needed for large patients
Fill a bucket with cool water, deep enough to immerse the splint material into
Using cool water decreases the chances of thermal burns, but takes longer for the splint
to dry
Application of the splint
Submerge the dry splint material in the bucket of water until bubbling stops
Remove splint material and gently squeeze out the excess water until plaster is wet and
sloppy
Smooth out the splint to remove any wrinkles and laminate all layers
Place the splint over the webril cast padding and smooth it onto the extremity
An assistant (or a cooperative and willing patient) may be required to hold the splint in
place while you adjust the splint
Fold back the edges of the stockinette and cast padding over the ends of the splint
Secure the splint with an elastic bandage
Place the extremity in the desired position and mold the splint to the contour of the
extremity using the palms of your hand. (Avoid using your fingers to mold in order to
decrease indentations in the plaster which can lead to pressure sores)
Hold the splint in the desired position until it hardens
Check and finish the splint
Check for vascular compromise
Check for discomfort or pressure points
Apply tape along the sides of the splint to prevent elastic bandages from rolling or
slipping, (avoid circumferential tape to allow for swelling)
Provide sling or crutches as needed
COMPLICATIONS:
Compartment Syndrome
Usually less common in splints than with circumferential casts
may occur associated with splints from constricting webril (cast padding) or elastic
bandages that cause increased pressure within a closed space on an extremity
increased pressure leads to inadequate tissue perfusion and loss of tissue (muscle,
vascular and nerve) function within the compartment.
73
Presenting signs and symptoms: (The “5 P’s” are pathognomonic for ischemia: pain,
pallor, paresthesias, paralysis, and pulselessness, but seldom all occur simultaneously,
and when they do – indicate a late finding associated with poor prognosis).
 pain in the extremity
 tenderness over the involved compartment
 significant pain with passive stretching of ischemic muscle tissue
 diminished distal pulses and sensation
 delayed capillary refill, and pale cool skin.
Prevention
·
avoid wrapping bandages too tightly or making circumferential splints
·
elevate the extremity to decrease swelling
·
apply topical cold packs
·
no weight bearing
·
early (24-48 hour) follow-up for high-risk injuries
Management
·
remove all constricting bandages and splint materials
·
consider compartment pressure monitoring
·
early consultation with orthopedist and/or vascular surgeon for possible
fasciotomy.
Pressure Sores
Uncommon with short term splinting
Can result from stockinette wrinkles, irregular wadding of padding, insufficient
padding over bony prominences or indentions in plaster form using fingers to mold
splint
If suspected, remove the splint materials and check the skin carefully, care for wounds
and revise the splint if necessary.
Heat Injury
can result from drying plaster which produces heat and may cause burns to underlying
skin
To reduce risk for thermal injury, use cool water to wet the splint material and keep
splint thickness less than 12 sheets of plaster.
Infection
More common with open wounds, but may occur with intact skin
Clean and debride wounds well prior to splint application
Consider using a removable splint for periodic wound checks
Joint Stiffness
Expected to some extent after any immobilization of a joint
Avoid prolonged immobilization if possible
DOCUMENTATION FOR THE MEDICAL RECORD:
Note the indication for the splint
Describe any wounds and their location under the splint
Document the neurovascular exam findings
Describe the type of splint applied, area immobilized, and materials used to make the
splint
74
Indicate what follow-up is planned for re-assesment of injury
Care for ostomy patients.
An ostomy is a surgically-created opening from an internal organ to the body's
surface. Colostomy, from "colon" and "ostomy," is the surgery where an opening is
made from the colon (or large intestine) to the outside of the abdomen.
The terms ostomy and stoma are general descriptive terms that are often used
interchangeably though they have different meanings. An ostomy refers to the
surgically created opening in the body for the discharge of
body wastes. A stoma is the actual end of the ureter or small
or large bowel that can be seen protruding through the
abdominal wall. The most common specific types of
ostomies are described below.
Colostomy
The surgically created opening of the colon (large
intestine) which results in a stoma. A colostomy is
created when a portion of the colon or the rectum is
removed and the remaining colon is brought to the
abdominal wall. It may further be defined by the
portion of the colon involved and/or its permanence.
Temporary
Colostomy
Allows the lower portion of the colon to rest or heal. It
may have one or two openings (if two, one will
discharge only mucus).
Permanent
Colostomy
Usually involves the loss of part of the colon, most
commonly the rectum. The end of the remaining
portion of the colon is brought out to the abdominal
wall to form the stoma.
Sigmoid
Descending
Colostomy
Transverse
Colostomy
or
The most common type of ostomy surgery, in which
the end of the descending or sigmoid colon is brought
to the surface of the abdomen. It is usually located on
the lower left side of the abdomen.
The surgical opening created in the transverse colon
resulting in one or two openings. It is located in the
upper abdomen, middle or right side.
75
76
Loop Colostomy
Usually created in the transverse colon. This is one
stoma with two openings; one discharges stool, the
second mucus.
Ascending Colostomy
A relatively rare opening in the ascending portion of
the colon. It is located on the right side of the
abdomen.
Ileostomy
A surgically created opening in the small intestine, usually at the
end of the ileum. The intestine is brought through the abdominal
wall to form a stoma. Ileostomies may be temporary or
permanent, and may involve removal of all or part of the entire
colon.
Ileoanal
Reservoir
(J-Pouch)
This is now the most common alternative to the conventional
ileostomy. Technically, it is not an ostomy since there is no
stoma. In this procedure, the colon and most of the rectum are
surgically removed and an internal pouch is formed out of the
terminal portion of the ileum. An opening at the bottom of this
pouch is attached to the anus such that the existing anal sphincter
muscles can be used for continence. This procedure should only
be performed on patients with ulcerative colitis or familial
polyposis who have not previously lost their anal sphincters. In
addition to the "J" pouch, there are "S" and "W" pouch geometric
variants. It is also called ileoanal anastomosis, pull-thru,
endorectal pullthrough, pelvic pouch and, perhaps the most
impresssive name, ileal pouch anal anastomosis (IPAA).
Continent
Ileostomy
(Kock
Pouch)
In this surgical variation of the ileostomy, a reservoir pouch is
created inside the abdomen with a portion of the terminal ileum.
A valve is constructed in the pouch and a stoma is brought
through the abdominal wall. A catheter or tube is inserted into
the pouch several times a day to drain feces from the reservoir.
This procedure has generally been replaced in popularity by the
ileoanal reservoir (above). A modified version of this procedure
called the Barnett Continent Intestinal Reservoir (BCIR) is
performed at a limited number of facilities.
Urostomy
This is a general term for a surgical procedure which diverts
urine away from a diseased or defective bladder. The ileal or
cecal conduit procedures are the most common urostomies.
Either a section at the end of the small bowel (ileum) or at the
beginning of the large intestine (cecum) is surgically removed
and relocated as a passageway (conduit) for urine to pass from
the kidneys to the outside of the body through a stoma. It may
include removal of the diseased bladder.
Continent
Urostomy
There are two main continent procedure alternatives to the ileal
or cecal conduit (others exist). In both the Indiana and Kock
pouch versions, a reservoir or pouch is created inside the
abdomen using a portion of either the small or large bowel. A
valve is constructed in the pouch and a stoma is brought through
the abdominal wall. A catheter or tube is inserted several times
daily to drain urine from the reservoir.
Indiana
Pouch
The ileocecal valve that is normally between the large and small
intestines is relocated and used to provide continence for the
pouch which is made from the large bowel. With a Kock pouch
version, which is similar to that used as an ileostomy alternative,
the pouch and a special "nipple" valve are both made from the
small bowel. In both procedures, the valve is located at the pouch
outlet to hold the urine until the catheter is inserted.
Orthotopic
Neobladder
A replacement bladder, made from a section of intestine, that
substitutes for the bladder in its normal position and is connected
to the urethra to allow voiding through the normal channel. Like
the ileoanal reservoir, this is technically not an ostomy because
there is no stoma. Candidates for neobladder surgery are
individuals who need to have the bladder removed but do not
need to have the urinary sphincter muscle removed.
Types of Pouching Systems
Pouching systems may include a one-piece or two-piece system. Both kinds
include a skin barrier/wafer ("faceplate" in older terminology) and a collection
pouch. The pouch (one-piece or two-piece) attaches to the abdomen by the skin
barrier and is fitted over and around the stoma to collect the diverted output,
either stool or urine. The barrier/wafer is designed to protect the skin from the
stoma output and to be as neutral to the skin as possible.
Colostomy
and
Can be either open-ended, requiring a closing device
(traditionally a clamp or tail clip); or closed and sealed at the
77
Ileostomy
Pouches
bottom. Open-ended pouches are called drainable and are left
attached to the body while emptying. Closed end pouches are
most commonly used by colostomates who can irrigate (see
below) or by patients who have regular elimination patterns.
Closed end pouches are usually discarded after one use.
Two-Piece
Systems
Allow changing pouches while leaving the barrier/wafer
attached to the skin. The wafer/barrier is part of a "flange" unit.
The pouches include a closing ring that attaches mechanically
to a mating piece on the flange. A common connection
mechanism consists of a pressure fit snap ring, similar to that
used in Tupperware™.
One-Piece
Systems
Consist of a skin barrier/wafer and pouch joined together as a
single unit. Provide greater simplicity than two-piece systems
but require changing the entire unit, including skin barrier,
when the pouch is changed.
Both two-piece and one-piece pouches can be either drainable or closed.
Irrigation
Systems
Some colostomates can "irrigate," using a procedure analogous
to an enema. This is done to clean stool directly out of the
colon through the stoma. This requires a special irrigation
system, consisting of an irrigation bag with a connecting tube
(or catheter), a stoma cone and an irrigation sleeve. A special
lubricant is sometimes used on the stoma in preparation for
irrigation. Following irrigation, some colostomates can use a
stoma cap, a one- or two-piece system which simply covers
and protects the stoma. This procedure is usually done to avoid
the need to wear a pouch.
Urinary
Pouching
Systems
Urostomates can use either one or two piece systems.
However, these systems also contain a special valve or spout
which adapts to either a leg bag or to a night drain tube
connecting to a special drainable bag or bottle.
These are the major types of pouching systems. There are also a number of
styles. For instance there are flat wafers and convex shaped ones. There are fairly
rigid and very flexible ones. There are barriers with and without adhesive
backing and with and without a perimeter of tape. Some manufacturers have
introduced drainable pouches with a built-in tail closure that doesn't require a
separate clip. The decision as to what particular type of system to choose is a
78
personal one geared to each individual's needs. There is no right or wrong choice,
but each person must find the system that performs best for him or her.
The larger mail-order catalogues will illustrate the types and styles from all or
most of the suppliers. If you have any trouble with your current pouching system,
discuss the problem with an ostomy nurse or other caregiver and find a system
that works better for you. It is not uncommon to try several types until the best
solution is found. Free samples are readily available for you to try. There is no
reason to stay with a poorly performing or uncomfortable pouching system.
Types of Accessories
You may need or want to purchase certain pouching accessories. The most
common items are listed below.
Convex
Inserts
Convex shaped plastic discs that are inserted inside the flange
of specific two-piece products.
Ostomy Belts
Belts that wrap around the abdomen and attach to the loops
found on certain pouches. Belts can also be used to help
support the pouch or as an alternative to adhesives if skin
problems develop. A belt may be helpful in maintaining an
adequate seal when using a convex skin barrier.
Pouch Covers
Made with a cotton or cotton blend backing, easily fit over the
pouch and protect and comfort the skin. They are often used to
cover the pouch during intimate occasions. Many pouches now
include built-in cloth covers on one or both sides, reducing the
need for separate pouch covers.
Skin Barrier
Liquid/Wipes
/Powder
Wipes and powder help protect the skin under the wafer and
around the stoma from irritation caused by digestive products
or adhesives. They also aid in adhesion of the wafer.
Skin Barrier
Paste
Paste that can be used to fill in folds, crevices or other shape or
surface irregularities of the abdominal wall behind the wafer,
thereby creating a better seal. Paste is used as a "caulking"
material; it is not an adhesive.
79
Tapes
Tapes are sometimes used to help support the wafer or flange
(faceplate) and for waterproofing. They are available in a wide
range of materials to meet the needs of different skin
sensitivities.
Adhesive
Remover
Adhesive remover may be helpful in cleaning the adhesive that
might stick to the skin after removing the wafer or tape, or
from other adhesives.
Psychosocial Issues
A. Patient’s Concerns about Surgery.
The reaction to intestinal or urinary diversion surgery varies from one individual to the
other. To some, it will be a problem, to other, a challenge; where one person considers
its life-saving, another finds it a devastating experience. Each person will adapt or
adjust in their own way and in their own time.
Body Image/Self-Esteem Concerns.
Permanent and significant changes in the body’s appearance and functional ability may
change the way the person internalizes their body image and self-concept.
Fear of loss is normal and facing any loss is difficult. What are patients giving up by
having this operation? Is there any gain? How changed will they be? Such thoughts
may lead to weeping or depression, or they may be denied.
It is important to understand the impact of the ostomy surgery on the patient’s change
in self-image and how they perceive themselves. It may be accepted as the lesser of
two evils, or they may refuse to acknowledge its existence, or may hold onto the belief
that it is a temporary situation.
Within the rehabilitation process there are times that patients should have the
opportunity to express or deny their feelings, about their surgery, the changes in their
body or their self-image.
Self-Care Concerns.
Patients have to be reassured that they will be taught self-care and that they will be able
to master the management process. Basic anatomy and physiology should be explained
to new patients, so they can better understand the extent of their surgery. Management
options should be offered.
Patients should begin to assist the ostomy nurse with caring for the ostomy as soon as
possible. Becoming involved in this process will begin to build confidence and help the
patient to regain control of his situation.
Relationship Concerns
Patients may fear that their social role may be changed and that others may not accept
them as in the past. One of the first concerns seems to be how to tell others about your
surgery, who to tell and when.
• Patients should be prepared to explain their surgery with a few brief statements such
as, “An ostomy is a surgical procedure for the diversion of bowel (or bladder).”
• They should understand that they do not have to tell everyone about the surgery. Be
80
selective about who and how much to tell. It may be only to friends who will be
supportive throughout the rehabilitation process.
Returning to the work place may present a concern about restroom facilities,
interaction
with
co-workers,
and
feelings
of
being
“watched.”
• Maybe a few of their co-workers may need to know in the event of an emergency.
• Employability and insurability are issues for some individuals. If these issues
develop, seek help from healthcare professionals and/or talk with others who have
found solutions to any of these issues.
Sexuality issues are common concerns for the new ostomate. Linked closely to our
feelings of sexuality is how we think about ourselves and our body image.
• Any sexuality concerns should be discussed between the patient and his partner. It is
likely that the partner will have anxieties due to a lack of information. An intimate
relationship is one in which it matters how well two people can communicate about the
most personal of human functions, that is, bodily elimination and sex.
• Ostomy surgery may present more concerns for single individuals. When to tell
depends upon the relationships. Brief casual dates may not need to know. If the
relationship grows and leads to intimacy, the partner needs to be told about the ostomy
prior to a sexual experience.
B. Phases of Psychological Adaptation.
Almost every patient goes through four phases of recovery following an accident or
illness that results in loss of function of an important part of the body. The patient,
along with the family, goes through these phases, varying only in the time required for
each phase. People may experience the various phases of adaptation in a different order
and at varying rates. Some people may skip certain phases entirely and some may
move up and down at different times.
These phases are shock, denial, acknowledgment and resolution.
Shock or Panic.
Usually occurs immediately after surgery. The patient is unable to process information
and may be tearful, anxious and forgetful. This phase may last from days to weeks.
Defense/Retreat/Denial.
This phase may last for weeks or months and delays the adaptation process. During this
phase, the individual denies or minimizes the significance of the event and defends
himself against the implications of the crisis. You may note the avoiding of reality and
“wishful” thinking.
Acknowledgment.
As the patient moves to the next step of acknowledgment, he begins to face the reality
of the situation. As you give up the existing old structure, you may enter into a period,
at least temporarily, of depression, of apathy, of agitation, of bitterness, and of high
anxiety.
Adaptation/Resolution.
During this phase, the acute grief begins to subside. The patient copes with their
situation in a constructive manner and begins to establish new structures. They develop
a new sense of worth. This phase may take one to two years.
81
Tracheotomy
Tracheotomy is a surgical procedure that is
usually done in the operating room under
general anesthesia. A tracheotomy is an
incision into the trachea (windpipe) that
forms a temporary or permanent opening
which is called a tracheostomy. Sometimes
the
terms
"tracheotomy"
and
"tracheostomy" are used interchangeably. The opening, or hole, is called a stoma. The
incision is usually vertical and runs from the second to the fourth tracheal ring.
Technique: Seldinger method:
The patient is positioned with the neck extended, with an intravenous fluid bag
between the shoulder blades and the head in a head ring. This brings as much of the
trachea as possible into the neck.
The larynx and cricoid cartilage with the intervening cricothyroid membrane are
identified. From the cricoid, moving caudally, the tracheal rings are identified. The
tracheostomy should ideally pass between the second and third tracheal rings, lthough a
space one higher or lower may be employed. Placing the airway higher, next to the
cricoid, can cause tracheal erosion and long-term problems.
Local anaesthetic with adrenaline is infiltrated subcutaneously, and a 1 cm incision
made horizontally with a scalpel. Keeping in the midline at all times, the introducer
needle and syringe are advanced, at 45 degrees to the skin, until air is aspirated from
the trachea.
The guidewire is passed through the needle, then the small dilator (green) is passed.
This is then removed and the white introducer passed into the trachea. The guidewire is
removed. Now only the white introducer is left in the trachea. Over this the tracheal
dilator(s) (blue) are passed in order, gradually dilating the incision to accommodate the
appropriately sized tracheostomy tube. Plenty of lubricating jelly is applied to each
dilator, and they are passed down the tract with a twisting motion. Only moderate
downward force is applied. If the dilator does not pass easily, return to the previous
smaller dilator and ensure that it passes freely and easily. Often, it is the skin that
impedes progress, and the incision has to be slightly widened with the scalpel. The
portex kit consists of a one-step dilatation.
Each size of tracheostomy tube has a corresponding dilator size (see the manufacturers'
instructions), and this should pass freely and easily into the trachea before attempting
to insert the tracheostomy tube. Once the tracheostomy will easily accept the final
dilator, the tracheostomy tube (cuff already checked) is loaded onto the dilator one size
lower. The tracheal tube is wathdrawn, under direct vision, into the larynx, and the
tracheostomy tube is passed over the introducer into the trachea. Once again, undue
force should not be necessary. Use plenty of jelly and, if required, return to the
previous dilator.
The use of the tracheal dilator instruments is rarely necessary, and may be hazardous.
However, if the introducer is inadvertently pulled out of the trachea, or some other
mishap occurs, they may be useful in relocating the tract for replacement.
82
With the tracheostomy tube in place, the tracheal tube is removed and the ventilator is
connected to the tracheostomy. The chest is auscultated for adequate ventilation and
the ventilator checked for appropriate tidal volumes and airway pressures. The tube is
secured with tapes or ties.
Introduction of tracheal needle
Insertion of guiding catheter
Placement of guide wire
Placement of tracheostomy tube
Percutaneous tracheostomy in not indicated for gaining access to the airway in
emergency situations and should not be confused with cricothyroid puncture. The
procedure is most commonly performed at the beside in the intensive care unit with the
patient sedated and fully monitored.
Laryngoscopy
Laryngoscopy is an examination a doctor uses to look at the back of the throat,
including the voice box (larynx) and vocal cords. A laryngoscopy examination is either
indirect or direct.
Indirect laryngoscopy
Indirect laryngoscopy is done in a doctor's office using a small hand mirror held in the
mouth at the back of the throat, a head mirror worn by the doctor, and a light source.
The mirror worn by the doctor reflects light into the mouth. Some doctors now use
headgear equipped with a bright light.
83
Indirect laryngoscopy has been largely replaced by newer direct fiber-optic
laryngoscopic techniques that provide better views and greater comfort during the
examination.
Direct fiber-optic (flexible or rigid) laryngoscopy
Direct laryngoscopy uses a fiber-optic scope that allows the doctor to see deeper into
the throat than during indirect laryngoscopy. The laryngoscope is either flexible or
rigid. Fiber-optic scopes provide better views and are better tolerated than older, rigid
scopes. Rigid scopes are still used in surgery.
THORACENTESIS
Bedside thoracic procedures may be diagnostic, therapeutic, or in certain situations,
life-saving.
Indications:
a. Diagnostic thoracentesis is performed to determine the specific cause of a
pleural effusion.
b. Therapeutic thoracentesis is performed to relieve dyspnea.
Contraindications:
There are no absolute contraindications to thoracentesis; relative contraindications
include the following:
a. Coagulopathy (PT or PTT < 1.3 ratio, platelets < 50,000)
b. Small-volume pleural fluid
c. Mechanical ventilation
d. Uncooperative patient
Anesthesia: 1% lidocaine
Positioning:
Sitting erect on the edge of the bed resting their head
and extended arms on a bedside table. Alternatively,
in mechanically ventilated patients, thoracentesis
may be performed in the lateral recumbent position.
Equipment:
Several commercially available kits are available with a variety of silastic catheters and
one-way valves. Manufacturers' instructions should be consulted for information
unique to each system. If commercially available thoracentesis set is not available, a
single-lumen central line kit may be used as described.
a. Sterile prep solution
b. Sterile gloves and towels
c. 22- and 25-gauge needles
d. 18-gauge insertion needle
e. 16-gauge single-lumen central line and dilator
f. 0.035-inch-diameter J wire
g. Fine scissors
h. Nonvented IV tubing
i. Extension tubing
j. Three-way stopcock
k. 10 and 30 ml or larger syringe
l. Vacuum bottles.
Technique:
a. Percuss the chest and identify the inferior margin and superior margin of the pleural
effusion. Mark these landmarks on the patient's skin. If the lateral recumbent position is
84
used or if the pleural effusion is small and/or loculated, ultrasound guidance should be
used to accurately identify the safest site for thoracentesis.
b. Prep and drape the area in the usual sterile fashion.
c. Cut side holes in the 16-gauge catheter by folding it in half and cutting the edge of
the fold with fine scissors. No more than one third of the catheter's diameter should be
cut to avoid weakening the catheter and shearing on removal from the chest.
d. Locate the rib two interspaces below the top of the effusion, but not below the eighth
intercostal space. Raise a skin wheal with a 25-gauge needle and 1% lidocaine at that
interspace, in the midscapular line. Alternatively, anesthetize a point two finger-breaths
below the tip of the scapula.
e. Using a 22-gauge needle, infiltrate the skin, subcutaneous tissue, and periosteum of
the rib. Carefully walk the needle superiorly over the edge of the rib while infiltrating
with lidocaine. Once over the top of the rib, slowly advance the needle while
aspirating; until pleural fluid is encountered, administer an additional 1–2 ml of
lidocaine and then withdraw the needle.
f. Place the 18-gauge needle on a 10-ml syringe, and insert it into the pleural space as
described above. It is often helpful to use a two-handed technique with one hand
stabilizing the shaft of the needle at the skin surface and the other aspirating the
syringe. This decreases the chances of the needle entering the lung if the patient
inadvertently moves. Make sure that the bevel of the needle is directed inferiorly; this
will ensure that the wire will pass inferiorly into the effusion (see Figure 4.3). Once
pleural fluid is encountered, remove the syringe and place a finger over the needle to
prevent air from entering the pleural cavity
g. Using the Seldinger technique, insert the wire through the needle into the chest, and
then carefully remove the needle, leaving the wire
h. With the scalpel, carefully make a small nick in the skin at the site of the wire
insertion to allow easy introduction of the dilator.
i. Introduce the dilator over the wire to dilate the skin and subcutaneous tissues. The
dilator should not be introduced any farther than is necessary to dilate the subcutaneous
tissue and allow smoother insertion of the catheter.
j. Insert the catheter into the chest over the wire and then remove the wire. Keep a
finger over the end of the catheter to prevent air from entering the chest.
k. Connect the extension tubing and vacuum apparatus.
l. Open the stopcock and withdraw fluid. Once the return of fluid has slowed,
reposition the patient on the side and then the back to improve flow.
m. Slowly withdraw catheter to remove any pockets of fluid located proximal to the
tip.
n. Place Betadine ointment and a dry sterile dressing on the puncture site. An occlusive
dressing is generally not necessary because the needle tract will seal.
o. Obtain a CXR to rule out pneumothorax and evaluate remaining fluid.
Complications and Management:
a. Intercostal vessel damage:
1.Risk of lacerating the intercostal vessels is minimized by positioning needle closely
to the superior edge of the rib.
85
2.If a laceration occurs, monitor hemodynamics closely and obtain serial CXRs. If the
hemothorax is significant, tube thoracostomy may be necessary.
b. Poor flow:
1.Rotate the patient in all directions to mobilize the thoracic fluid.
2.Occasionally manual aspiration of the fluid with a 30- to 60-ml syringe placed on a
three-way stopcock may be useful.
3.Consider tube thoracostomy if effusion is viscous and unable to be drained
adequately.
c. Pneumothorax—occurs through either lung puncture or leakage of exogenous
air:
1.Keep air out of the system at all times.
2.Stabilize the needle on insertion and do not advance needle after fluid is aspirated.
3.Monitor with serial CXRs. If the pneumothorax is significant or increasing (> 20%),
tube thoracostomy.
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