Practical Guide of Surgical Semiology

tefan Octavian GEORGESCU
Dan VINTIL
Cornel Nicu NEACU
Paula POPA
PRACTICAL GUIDE
OF SURGICAL
SEMIOLOGY

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Editura SEDCOM LIBRIS
CONTENTS
First day in the surgery service
Organizing the surgery service
Asepsis
Antisepsis
Evaluating the surgical patient
Preoperative preparation
Postoperative care
Cardio-pulmonary
resuscitation
Hemostasis
Blood transfusions
Injections
Vascular probe
Punctures

Incisions
Surgical suture
Surgical drainage
Bandage
Bandaging
Digestive probes
Preparing the colon
Enema
Vesical probing
Attending the stomies
The surgical instrument
Bibliography
Instructions of use

EXIT
CLICK CU MOUSE-UL PESTE FIECARE TITLU

A significant status change
Preparation
The contact with the teachers
Behavior rules in the surgery theatre
CONTENTS
THE FIRST DAY IN THE SURGICAL SERVICE
A SIGNIFICANT STATUS CHANGE

The 3
rd
year as a student at the Faculty of General Medicine represents the
beginning of the clinical training activity, therefore the direct contact with the
patient.
It is very important to remember that the study materials, rather impersonal,
that characterize the first two academic years (mainly focused on the
preclinical subjects), will be replaced by pathology, and not by people. The
patient must not be considered as an object of study, but as a human being in
suffering who will share the signs and symptoms of his disease, so that you
learn to recognize it anytime you see it in your future practice.

During the internships, you will come into contact not only with the patients,
but with different categories of personnel involved in the medical activity, and
your presence must not be considered a barrier in the deployment of this
activity.
Surgery represents the last redoubt of the therapeutic possibilities of a
disease. When the conservatory treatment failed or it is not indicated, the only
chance given to the patient refers to the surgical intervention. When the
surgical resources are exceeded, in the majority of cases, death occurs in the
nearest future. Therefore, remember that the surgical patient is rather special,
he came to you after a longer or shorter journey in other services or in
emergency conditions with immediate vital risk. As a result, the patient is a
fine observer and even judge of your behavior.
BACK
PREPARATION

Aspect
Clean aspect the negligent beard or haircut
creates a very bad impression since the beginning;
decent clothing (a too short skirt or a dirty pair of
jeans will significantly distance you from the image
of future doctor);
The shoes must not be dirty with mud, dust etc.
White, clean gown, without spots (or you risk to be
mistaken with the cleaning personnel);
Devices (compulsory) : tensiometer and
stethoscope.
Internship copybook, writing tools (compulsory)

BACK
BEHAVIOUR RULES IN THE SURGERY THEATRE

These rules complete the duties and obligations that the students have in an educational institution.

General rules
-At the beginning of the internship course the students will be present in the theatre where they were distributed, NOT on the
hallways, dressing rooms, etc.
-The noisy discussions in the presence of patients, no matter the subject, are prohibited;
-It is prohibited to wait on the patients bed; the bed is the only privacy oasis that the patient has, therefore respect it as
such!
-It is prohibited to consume coffee, sodas, tobacco, snacks etc. in the theatre;
-At the end of the internship, washing the hands is compulsory;

Special rules regarding patiens
-The patients may ask you questions related to their disease (explorations, evolution, prognosis), but it is better to avoid the
answer in an elegant manner (Ex. You should ask the doctor attending you);
-Do not discuss the disease of a patient in his presence, especially when it is very serious (cancer), unless the group
assistant is present as moderator;
-Do not refuse the patients who require a qualified maneuver (pulse, taking the blood pressure);
-It is prohibited the immixture in the therapeutic scheme or comments related to the presence of the respective patient, if the
group assistant is not present;
-Address the patients using the name Dumneavoastr (You) (it is prohibited to use names such as mamaie (granny),
tataie(grandpa), moule(old man) etc.

Recommendations related to the medical personnel
-Besides the group assistant and the other doctors you will come into contact with, in the respective theatre you will also
interact with the medical personnel (registered nurses) and the auxiliary personnel (nurses).
-The registered nurses from the surgery service are overqualified and are very experienced in attending the patients,
experience that a part of you will not acquire very soon. Respect them to be respected. Moreover, they can answer very many
questions regarding the caring of the surgical patient, especially during the shifts when the teacher is more preoccupied with
the medical problems specific to the emergency service. You have the chance that, by modestly approaching a nurse, to make
more maneuvers from the III year schedule (injections, enemas, perfusion mounting, transfusions etc.) than other colleagues.
A maneuver that you carried out by yourself is never forgotten.
-And in the end, remember that a fully-trained physician must know anytime to do the work of the registered nurse. Maybe in
the future you will have to guide the first steps of a recently graduated nurse.

BACK
ORGANIZING
THE SURGICAL SERVICE

General organization
Clinic I - II Surgery
Sf. Spiridon Hospital
Iai
CONTENTS
GENERAL ORGANIZATION
The ambulatory
The in-patient unit
The operating theatre
The sterilizing unit
BACK
THE AMBULATORY

It is an integrating part of each service, ensuring the medical care without the patient's
hospitalization.
At this level the medical specialty examination is performed, the diagnosis is established
(including by paraclinical explorations), the appropriate therapy is indicated and applied
*in simple cases), and in the most difficult cases the hospitalization is programmed and
even the surgical intervention, afterwards this service taking over the post-operatory
directly observed therapy of patients.
The ambulatory must be organized in such a manner as to cover all these activities,
therefore it must comprise: the examination room, the room of small interventions and a
registration-archive.

The examination room must be equipped with a couch, a gynecological table, a source
of light, a carriage for the medical equipment , sanitary materials and cupboards for them.
The operating room from the ambulatory must have the same equipment with that of
the operating theatre (operating table, scialitic lamp, instrument table, anesthesia
apparatus, medical Aspirator, electrical bistoury) and to accomplish the same architectural
conditions, of heating, illumination and ventilation as the latter.
The Archive must comprise the medical documents of each patient who was examined,
investigated and tested at the ambulatory level, for a correct directly observed therapy
even if the medical file of each patient is archived by the family physician
The doctors who work in the ambulatory should also work in the in-patient unit. They
would have a program in the in-patient unit and a periodical one in the ambulatory. Thus,
they can examine their patients, establish the diagnosis, schedule for hospitalization and
surgery and send to directly-observed therapy after surgery.

BACK
THE IN-PATIENT UNIT

In all the classical manuals, the patient rooms are described from the point of
view of architectonic and equipment characteristics.
We must mention that, although this data remains valid, we must respect
other principles as well, and namely those regarding the comfort and privacy
of the patient. Thus, the rooms of 1-2 beds are preferable, and in the case of
large rooms, their boxing. The rooms will be equipped, besides the bed, with
bed table, table and chair, installations for the medical fluids: and other
facilities (bathroom, telephone, radio, television).
In these conditions, the existence of dining halls, or bandage rooms is no
longer necessary. These, especially the bandage rooms are necessary for
carrying out some intervention maneuvers or particular explorations.
Reducing the number of stationary beds can be compensated by their rational
use and the fast flow of patients.
For the good collaboration of the two sectors of the surgical service the
ambulatory and the in-patient unit- they must have the same superior
medical personnel.
The in-patient unit must be seen as an accommodation space (hotel) of high
quality, where the patients must benefit from the best conditions.

BACK
THE OPERATING THEATRE

Particular element in the surgical service, the operating theatre must be
organized and equipped to correspond to the principles of asepsis and
antisepsis, complexity and efficiency of the activities that are carried out
at this level. The operating theatre supposes a complex organization and
functionality which allow the carryout of the most diverse and complex
surgical interventions, with the maximum safety and efficacy. According to
the number of operating theatres, multiple plans of construction of the
operating theatres are described.
It must comprise rooms with special destination: operating rooms, rooms
for waking up the doctors, filter room, room for inducing the anesthesia
and waking up the patients, room for depositing the instruments and
sterile and used materials; they must have special illumination, ventilation
installations, and medical flows; circuits for the evacuation of the used
sanitary materials (waste) and means of communication. At the level of
the operating theatre, the access is limited and restrictive in order to
reduce to the minimum the contamination risks.

THE OPERATING THEATRE
The filter room
The surgery preparation room
The operating room
The induction and wakeup room
The room for preparing the
surgical instruments
Depositing rooms

BACK TO
GENERAL
ORGANIZATION Click with the mouse over the underlined titles
The filter room

It is the first room in the medical
personnel circuit where they dress up
in special clothes, for the operating
theatre. It may have the role of rest
room between the surgeries.

The doctors preparation room
It is provided with multiple sinks with
special taps that allow the use without
manual touch. For touching the hands
antiseptics are used (soap, betadine,
chlorhexidin). Then, in the same room
or in another one, the next step is
putting on the gown and the sterile
gloves. In particular situations
(transplant surgery, osteo-articular
surgery etc.) special equipment is used.

The operating room
Architectural conditions: insulation, dimensions, construction materials, illumination installations, ventilation, heating and
communication equipment, circuits of the personnel and patients, possibilities of cleaning and maintenance;
Equipped with furniture and devices: operating table, surgical lamps, anesthetics and monitoring apparatuses, tables for
instruments; Aspirator, electrical bistoury, cupboards/shelves for instruments sanitary materials and anesthetics;
The operating room must not communicate directly with the exterior, it must have dimensions so that to allow the placement of the
furniture, apparatus, and of the presence of the operating team, anesthetic doctors and afferent medical personnel;
The presence of other persons in the operating room is prohibited. The interested persons (residents, students) can watch the
operatory act from a special balcony or through a television system with closed circuit;
The construction materials used for the operating room (as of the entire operating theatre) must allow a cleaning and disinfection as
easy and correct as possible;
The artificial illuminating installation will support the lack of natural light.
The artificial heating and ventilation will be achieved through air conditioning system that ensure temperatures of 20-22C and a
humidity of 40-60 % , thus preventing the contamination of the air from the operating room.
The communications between the different departments of the operating theatre and with the exterior are ensured by phone,
interphone and different signaling systems.
The cleaning and disinfection of the operating room must be achieved daily and in accordance with the asepsis and antisepsis rules
provided in the operating theatre documents,
The access and evacuation circuits in the operating theatre and in the operating room are different for the patients and the medical
personnel. They must be strictly respected. Thus, in the operating room, only the operative team already trained, the personnel of
the room (one-two registered nurses and a nurse), the anesthetic team must be present.
The patient is brought into the operating room after having been put to sleep in the induction room.
The surgical instruments, the medical and anesthetic materials are prepared in the operating room or in its proximity, easily
accessible. After use, they will follow a separated circuit towards the sterilization unit or towards the crematory.
Out of prudence, the medical materials offered to the operating team and the used ones will be registered.
The operating table is special, multi-articulate, allowing different positions of the patient according to the necessities of the operating
act.
Due to some accessories, it facilitates the operating gestures. It must allow the carryout of some intraoperative radiological
explorations.
The table of instruments allows the preparation and display of the instruments necessary for the operating act.
The source of light (scialitic lamps, lights) of different models must ensure a good light in the operating field and be easy to operate
according to the necessities of the surgical act.
The anesthesia apparatus and the monitors will ensure the anesthesia and the monitoring of the vital functional parameters of the
patient during the anesthesia and for resuscitation gestures,
For the operatory gestures, the aspiration apparatuses and electrical bistoury are necessary.
The modern operating rooms ensure, through centralized installations, both the oxygen admission and aspiration.

The induction and wakeup room
It is the first room in the patients circuit,
where they are administered the anesthetic
induction (and then they are transported into
the operating room), and when there is no
separate room, they are woken up through
anesthesia. For these, the room is equipped
with a special bed for intensive care, anesthesia
apparatus and medical flows. In the modern
hospitals, the patient is taken from the room to
his bed (provided with wheels) and transported
with this bed to the induction room.
The room for the preparation
of surgical equipment
It is equipped with sinks or lavatories
for the mechanical and chemical
cleaning of the equipment, with
boilers for them, with tables and
shelves for the boxes of medical
equipment.
The depositing rooms
They are destined for the surgical
equipment and the reserve medical
materials necessary for the surgical
interventions.

THE STERILIZING UNIT

Absolutely compulsory, even in the current conditions when more and
more disposable equipment and medical materials are used, this
component of the medical service can exist whether as an independent
unit within the hospital, or as a component of the operating theatre.
It must comprise rooms for the preparation of medical materials and
equipment for sterilization (if they do not exist in the operating theatre);
rooms with sterilizing apparatus (autoclaves, drying chambers,
installation of vapor production) and rooms (with cupboards and shelves)
for depositing the sterile equipment and materials.
Such a sterilizing unit must have a reception for the receipt and issuance
of sterile materials, so that the access into the unit space is allowed only
for the persons who work at this level.
The constructive characteristics (construction materials and especially
finishing materials) and the equipment must be identical with those from
the operating theatre.

BACK
DEFINITION
A general principle that consists in the systematic avoiding
of the contamination of surgical wounds and secondary
infection of burns and wounds
It includes methods and rules that prevent the wound
contamination and infection
These rules and methods address all the possible vectors of
the microbial germs to the surgery wounds, equipment,
textile materials, hands, clothes, syringes, probes,
medicines, air from the operating room etc.)
Methods : sterilization, disinfection of live tissues
The rules generally refer to the behavior of the personnel
that handles the sterile materials: surgeons, registered
nurses from the operating theatre or bandage rooms, the
students involved in the therapeutic act or just the
watchers.

CONTENTS
CLICK WITH THE MOUSE ON THE UNDERLINED WORDS
STERILIZATION
DEFINITION
The totality of methods through
which the complete and total
destruction of microbial particles,
both of the stagnant forms and of
the sporulated ones is achieved
It can be achieved through physical
and chemical means
STERILIZATION
PHYSICAL MEANS
HEAT
ULTRAVIOLET RADIATIONS
IONIZING RADIATIONS
ULTRASOUNDS
FILTRATION
BACK
STERILIZATION THROUGH HEAT

STERILIZATION THROUGH
DRY HEAT
HUMID HEAT
BACK
DRY HEAT
BUCKLING
INCINERATION
HOT AIR OVEN
CLICK WITH THE MOUSE ON EACH TITLE
BUCKLING
The passage through flame of the metallic
or glass objects in view of sterilizing them
Sterilizing the phials before aspirating
their contents into the syringe, test tubes,
metallic handles (microbiology)
Disadvantage the fast degradation of
metallic instruments, especially the cutting
ones
INCINERATION

The complete destruction by burning
of the waste with biological risk
It is applied in the crematories found
in all the hospitals
THE HOT AIR STOVE
Device
Sterilization parameters
Check
Indications
Advantages
Disadvantages
THE HOT AIR STOVE
DEVICE
Synonym: Poupinel (improper)
Conceived as a metallic cupboard with double
walls and thermally insulated from the exterior
The door is provided with safety systems that
do not allow the building-up of the electrical
circuits when it is open
Components: source of heat (electrical), safety
systems, thermometer, recorders (show how
much time the sterilizing temperature was
maintained), system of temperature
uniformization in the precincts
PHOTO
THE HOT AIR STOVE
STERILIZATION PARAMETERS
160 C for 1h
170 C for 40
180 C for 20
In our country: 180 C for 30-40
THE HOT AIR STOVE
CHECKING THE STERILIZATION
Classical thermal tests: caramelizing
of paper or cotton cellulose
Modern: thermocouples with
temperature recording
THE HOT AIR STOVE
INDICATIONS
Objects of thermo-resistant glass
Metallic instruments (the cutting
instruments must have a protected
cut)
Powders

THE HOT AIR STOVE
ADVANTAGES
Dried instruments at the end of the
sterilization
The instruments are in boxes or
other closed packages
They do not require other handling
before use

THE HOT AIR STOVE
DISADVANTAGES
The long sterilization duration
Long cooling time before use
(about 1 hour)
Cannot be used for textile, plastic,
rubber materials
It modifies the properties of the metallic
instruments (annealing) and favors its fast
degradation (corrosion, breakage)
THE AMBULATORY OF
SF. SPIRIDON hospital
The emergency unit of
SF. SPIRIDON Hospital
The in-patient unit of
CLINIC I II SURGERY

Anesthesia and Intensive Care SECTION
OPERATING THEATRE
FILTER ROOM
OPERATING ROOM
Scialitic lamp
Cautery
Medical flows inlets
(Aspirator, oxygen, electricity)
Ultraviolet lamp
Anesthesia apparatus
Aspirator
Operating table
Aspirator
Operating room
OTHER EQUIPMENTS
Apparatus for intraoperatory
radiological examination
For the minimally invasive surgery
Turn
Table for instruments
THE STERILIZATION
THROUGH HUMID HEAT
It is the most efficient sterilization
method
The first form of sterilization through
humid heat was boiling, but it does not
create sufficiently high temperatures in
order to destroy the bacteria spores
The AUTOCLAVE= the device through
which the sterilization through humid
heat is made, by obtaining sufficiently
high temperatures and pressures that
destroy all the pathogen agents
THE AUTOCLAVE
Device
Sterilization parameters
Check
Indications
Advantages
Disadvantages
BACK
THE AUTOCLAVE
DEVICE
With the help of a vacuum air pump, the air from the autoclave is
evacuated, which is resistant to pressure and is closed air-proof
achieving an thermal insulation from the environment
Through an admission pump, water vapors are introduced under
pressure, which will lift to the surface allowing the evacuation in
successive stages of the air that descends in the inferior part of
the autoclave
After obtaining the vacuum, the vapor admission is continued
until the obtaining od the set sterilizing parameters
The time, pressure and temperature of sterilization are variable
according to the type of the autoclave and the sterilized materials
(quantity, quality and their dimensions)
At the end of the sterilization, the vacuum air pump will evacuate
the water vapors from the autoclave, introducing a jet of filtered
cold air, with role of drying the sterilized material
Entry into the sterilization
On the right door the non-sterile materials are introduced
Through the left door, the sterile materials are issued
The carriage for introducing
and removing the materials
from the autoclave
Shelf for depositing the boxes
with medical materials
The Autoclave
Regulation buttons of temperature and pressure
Recording on the paper the date,
hour and sterilization parameters
AUTOCLAVE
Removing the material from the autoclave
after sterilization
Depositing the sterile material
TH AUTOCLAVE
STERILIZATION PARAMETERS
24 hours validity
Pressure temperature
1 atm 120C
2 atm 136C
3 atm 144C
THE AUTOCLAVE
CHECK
Physical methods: test band
Biological tests
Electrotechnical methods: recording
on thermocouples the temperature
variation for the sterilization duration
Tests for checking
the sterilization
THE AUTOCLAVE
INDICATIONS
Textile material (fields, masks,
gowns, compresses, tampons, suture
yarns, etc.)
Thermoresistant glass objects
Metallic instruments (the cutting
instruments must have the cut
protected with smooth material)
Sterile medicines
Sterile water
THE AUTOCLAVE
ADVANTAGES
It allows the sterilization of the entire
surgical material
The reduced degradation of the smooth
sterilized materials
Reduced sterilization time
The material resulted from sterilization is
dry and pre-packed therefore easy to
handle
Reduced costs
Contains the source of vapors as well
Does not require special installation
conditions

THE AUTOCLAVE
DISADVANTAGES
Technical breakdowns
Rapid degradation of the corrosive
metallic instruments
THE STERILIZATION WITH
ULTRAVIOLET RADIATIONS
These radiations act at the level of nucleic
acids = bactericide and bacteriostatic
effect
It is necessary to previously wash the
surfaces to sterilize (the UV radiations
have small penetration power)
Indications: the sterilization of the air
from the operating and bandage rooms,
the sterilization of work surfaces
ATTENTION: They are harmful for the
people
Protection of teguments and eyes
IONIZING RADIATIONS (GAMMA)
DEVICE: container with pre-packed material on
which a radiation of 2.5 up to 5 Mrad (Celsius
137 or Cobalt 60) is projected
CHECK : measuring the radiation level
INDICATIONS: any medical material
ADVANTAGES: large quantities of pre-packed
material is sterilized, reduced costs under
continuous functioning conditions
Disadvantages: the irradiation, formation
of toxic compounds with ethylenoxide
Used only in the industrial environment
THE ULTRASOUND STERILIZATION
The high-frequency ultrasounds
in liquid medium cavitation
phenomenon mechanical rupture
of the cellular membrane
of microorganisms
Indications: especially for the
sterilization of the dental equipment
STERILIZATION THROUGH FILTRATION

In bacteriology, for the sterilization
of culture mediums
The sterilization of some medicines
The sterilization of the air from the
operating rooms
THE STERILIZATION
CHEMICAL MEANS
THE STERILIZATION WITH FORMALDEHYDE
VAPORS
THE STERILIZATION WITH ETHYLENOXIDE
VAPORS
THE STERILIZATION BY IMMERSION

FORMALDELHYDE VAPORS
DEVICE: special container where a depression of 50
mmHg is achieved for 10 minutes which evacuates the
air, followed by the introduction of water vapors at 90C
vegetative bacteria. Cyclically, at 90 seconds, formaline
vapors are introduced, that destroy the sporulated forms.
STERILIZATION PARAMETERS:
Sterilization, 90 minutes
Washing stage of the formaldehyde with cold water
vapors, 12 minutes
Drying stage, 8 minutes
CHECK: biological, physical tests
INDICATIONS: thermosensitive materials (more and
more rarely used)
ETHYLENOXIDE VAPORS
Device
Check
Indications
Advantages
Disadvantages
ETHYLENOXIDE VAPORS
DEVICE
The ethylenoxide requires depositing in metallic containers
at small pressure because it boils at the temperature of
10.7C
It is used in the following combinations : 10% ethylenoxide
+ 90% carbon dioxide or 12% ethylenoxide + 88%
fluorocarbon
The container is hermetically closed, the ethylenoxide
vapors or the gas mixture are introduced, the substances
having a variable action time according to the producer
(10 minutes up to a few hours). The ventilation of the room
where the sterilizer is found follows, for 15 minutes and
afterwards the depositing of sterilized materials in a
container that allows their ventilation for 3-6 hours.
The ethylenoxide is combined with the nucleoid acids
of bacteria, determining a denaturation of the proteins
through an alkylation process that has as a result the
destruction of microbes

ETHYLENOXIDE VAPORS
CHECK
Chemical methods:
of torsion, of color
Biological methods
ETHYLENOXIDE VAPORS
INDICATIONS
Plastic materials
Thermally fragile materials:
catheters, endoscopes, cystoscopes,
plastic tubes, aspiration probes,
Blakemore probes, ophthalmological
instruments, arterial grafts
Wood, paper
The industrial or hospital use
ETHYLENOXIDE VAPORS
ADVANTAGES
It allows the sterilization and use
of some thermolabile medical
instruments and materials
The sterilized objects are pre-packed
ETHYLENOXIDE VAPORS
DISADVANTAGES
The gas is irritating for the eyes and the
respiratory ways producing cephalalgea,
nausea, vomiting, dizziness to those who
come into direct contact (medical
personnel, patient)
It requires a good ventilation
The sterilized materials through gamma
radiations cannot be resterilized through
ethylenoxide vapors because of the
appearance of some toxic products

THE STERILIZATION
THROUGH IMMERSION
Used in hospitals or dispensaries
DEVICE: the instruments are immersed for a minimum period of
time into the substances that have the property to destroy the
microbes chemically
The Glutaraldehyde 2%: in 10-15 minutes it destroys the
vegetative forms of the bacteria and their spores after 10 hours
(the tuberculosis bacilli in 20 minutes)
The peracetic acid: action time of minimum 10 minutes, it is
corrosive for the copper
INDICATIONSI: optical, laparoscopic, endoscopic instruments
ADVANTAGES
Does not require special installations
It is fast
DISADVANTAGES:
THE RESULTED MATERIAL IS WET
IT requires cleaning with sterile water, the glutaraldehyde
being toxic and irritating
PHOTO
Container for the sterilization
through immersion
THE DISINFECTION
OF LIVE TISSUES
THE SURGEONS HANDS
THE PATIENTS SKIN
THE DISINFECTION OF
LIVING TISSUES
THE SURGEONS HANDS
The liquid soap, solution of chlorhexidine soap
or povidone iodine are used
Liquid soap: washing for 5 minutes up to the
superior third part of the forearm, the following
5 minutes up to the half of the forearm and
other 5 minutes only the surgeons hands
Soap with chlorhexidine or povidone iodine:
the same stages each lasting only 2-3 minutes
The immersion of the surgeons hands into the
germicide solution for a few minutes (some
countries)
In the end the embrocation of hands with
concentrated alcohol or iodine tincture

THE DISINFECTION
OF LIVING TISSUES
SURGEONS HANDS
Antiseptic solution
The sponge with antiseptic substance
Taps with sterile
water for
disinfecting the
surgeons hands
Sandglass
THE DISINFECTION OF
LIVING TISSUES
THE PATIENTS SKIN
The area subject to the incision and broadly, the
teguments around it, will be prepared
Solution: iodine tincture, povidone iodine,
chlorhexidine
The three times embrocation of the surgical
drapes, the first 2 stages being followed by
drying with sterile compresses and in the end
the drying of the tegument is expected, that
ensures a sufficient action time
The transparent self-adhesive drapes applied on
the skin prepared as mentioned previously,
the incision being made through the drape,
increasing the asepsis safety
VIDEO
STERILIZATION
RULES
RULES FOR THE STERILIZATION
OF THE OPERATING ROOM
RULES FOR THE PREPARATION
OF THE STERILIZATION MATERIALS
RULES FOR THE
STERILIZATION OF THE
OPERATING ROOM

Preventing the post-operatory infections
requires the carryout of the surgical intervention
in an environment as appropriate as possible
from the point of view of the asepsis
In the operating theatre there must be septic
and aseptic operating rooms. Generally nowadays
there is a room for emergencies where the septic
surgical interventions are usually performed
The sterilization of the operating room supposes:
preparing the surfaces (operating table, floor,
walls or ceiling) and preparing the air

STERILIZING THE
OPERATING ROOM
PREPARING THE SURFACES
Washing the surfaces three times with water and
detergents
Removing the dust from the equipment (cloths with
antistatic properties will be used)
The hermetic closing of the room
Formolization (formaldehyde vapors 4 g formalin/m
surface) at least 7 hours
Ventilation 2 hours before the beginning of the surgical
program
Removing the dust
Neutralizing the formalin with ammoniac solution
The materials necessary for the surgeries will be brought
in the morning
It is compulsory to respect the circuits in the operating
theatre
STERILIZING THE
OPERATING ROOM
PREPARING THE AIR
The air must enter the room from the
superior side and be evacuated through the
inferior side. The admission inlet is in the
center of the room, above the table, without
blowing the air directly onto the patient. The
evacuation will be made through the lateral
sides
The air circulated through the operating
rooms requires a special filtering process both
at the entry and at the exit of the operating
room. There are high-performance
apparatuses that can even obtain sterile air

STERILIZING THE
OPERATING ROOM
PREPARING THE AIR
The ultraviolet lamp that will lead to a
sterilization of the surfaces and air is also used
It is used outside the operating program
It is placed at 150 cm from the walls and at 300
cm in front of the other, facing the wall
The control of sterilization in the operating room
is made with bacteriological tests (Petri boxes
placed open for 30 minutes in the corners of the
operating room after which we will monitor the
colonies that will grow, their type and number
being related to a national standard

PREPARING THE MATERIAL
FOR STERILIZATION
THE TEXTILE MATERIAL
THE METALLIC EQUIPMENT
RUBBER GLOVES
PLASTIC EQUIPMENT
BRUSHES AND LOOFAHS
FOR STERILIZATION
TEXTILE MATERIAL
Washing
Ironing
Folding according to
the standard
technique
Positioning into
metallic containers
or packed
individually in paper
Autoclaving
FOR STERILIZATION
METALLIC EQUIPMENT
Washing with hot water
Boiling
Diluted Perhydrol solution
that precipitates the organic
materials from the
equipment surface
Washing
Wiping
Drying
Dressing the sharp and
cutting materials into textile
material
Positioning the equipment
into metallic containers
Autoclaving

FOR STERILIZATION
RUBBER GLOVES
Meticulous washing
Drying
Applying French chalk
Introducing gloves of textile material
into the interior
Autoclaving or ethylenoxide vapors

FOR STERILIZATION
PLASTIC OR RUBBER INSTRUMENTS
Washing with detergents
Disinfectant
It is packed in casseroles,
wire baskets or individually

FOR STERILIZATION
BRUSHES AND LOOFHAS
Used by the surgeon for disinfecting
the hands
They are cleaned, individually packed
and sterilized in metallic boxes
EVALUATING THE
SURGICAL PATIENT
Although the surgery, in itself,
can be MINOR for the surgical
team, for the patient it is
always MAJOR
EVALUATING
THE SURGICAL PATIENT
THE EMERGENCY SURGERY
THE ELECTIVE - COLD REASON
SURGERY
THE ONE-DAY SURGERY
THE PRE-OPERATORY EVALUATION

CONTENTS
Surgical emergency
On-duty room
AIC
Continuing the resuscitation
Stabilization
Investigations
Preparation for surgery
Successful resuscitation
In-patient unit
Investigations
Preparation for surgery
Operating room
Death Morgue
Cardiorespiratory resuscitation
EVALUATING THE SURGICAL
PATIENT
THE EMERGENCY SURGERY
EVALUATING
ELECTIVE SURGERY
Surgical disorder
Usual investigations
Surgical and anestheological consultation
Hospitalization
Staff
Additional investigations
Specific preparation
Staff
Operating room
EVALUATING
THE ONE-DAY SURGERY
Motivation:
Financial: the high cost of
hospitalization, consume of expensive
medical materials
Personal: the patients desire to be in
the family environment and not in the
hospital, the socio-professional
reintegration as soon as possible
Medical: patients with a good medical
education

EVALUATING THE SURGICAL
PATIENT
THE ONE-DAY SURGERY
Completely investigated patient
Hospitalization in the morning of the surgery
Local preparation
Premedication
Operating room
Post-operatory monitoring
for a few hours
Hospital
release
In-house monitoring
PRE-OPERATORY
EVALUATION

Any hospitalized patient will have an observation sheet
that needs to be completed after a complete clinical
examination
Appropriate paraclinical explorations are necessary,
corresponding to each case, the assessment of all the
associated disorders, establishing the anesthetic risk
and Choosing the therapeutic behavior (the operatory
moment, the type of anesthesia and the type of surgical
intervention that the patient will be submitted to)
It would be very useful that the family doctor has a
medical file for each patient, file that the attending
physician must have access to, at hospitalization

THE PREOPERATORY
EVALUATION
OBSERVATION SHEET
The Observation Sheet (OS) is a medical-legal document that
must reflect an image as exact and complete as possible of the
patients state at hospitalization, of his evolution during
hospitalization, data as complete as possible that lead to the
correct disease diagnosis.
According to the evolution mentioned in the observation sheet,
the therapeutic indications will also be made, and the hospital
release recommendations as well
The OS must offer exact data related to the patients
identification
The OS represents a medical-legal document that can defend or
accuse the doctor in the case of a judicial confrontation with
one of the patients
It is an useful document in the scientific research (retrospective
studies etc.)
Probably, in our country as well, there will be detailed file for
each patient, with all the services that he goes through during
his lifetime, these files having a much bigger scientific value,
allowing a better evaluation of the patient and establishing a
correct therapy
THE PRE-OPERATORY
EVALUATION
OBSERVATION SHEET
The components of the observation sheets:
GENERAL DATA
DIAGNOSIS
ANAMNESIS
THE GENERAL PHYSICAL EXAMINATION
PARACLINICAL EXPLORATIONS
THE SURGICAL INTERVENTION
TREATMENT AND EVOLUTION
EPICRISIS
TEMPERATURE SHEET
THE PRE-OPERATORY
EVALUATION
GENERAL DATA
Comprise:
Identification data: surname, first name,
sex, date of birth, age, address, telephone
number, job
Hospitalization place: hospital, clinic
Hospitalization period: date of
hospitalization, date of hospital release
Allergic to.
Blood group and Rh
THE PRE-OPERATORY
EVALUATION
DIAGNOSIS
The diagnosis has three stages:

Diagnosis at hospitalization
Diagnosis at 72 hours
Diagnosis at hospital discharge: it must
comprise the diagnosis of the basic disease, the
evolution stage, the clinical form, complications
Secondary diagnosis: the diagnosis of all the
associated diseases
Diagnosis in case of death:
a. The direct cause of death
b. Initial pathology
c. Associated disorders
d. Associated morbid states
THE PRE-OPERATORY
EVALUATION
ANAMNESIS
It must be performed in such a manner as to obtain the patients trust
to tell us the most detailed information
Reasons for hospitalization: all the objective and subjective problems
that the patient speaks of will be enumerated
Physiological personal antecedents: they are important especially in the
case of women, providing information regarding the first menstruation,
the date of the last menstruation, the number of pregnancies, the
number of births, and abortions (spontaneous, therapeutic or at
request), the state of fetuses at birth, the lactation
Pathological personal antecedents: you will have to obtain data from the
patient regarding any disorder he suffered from previously (allergies,
infections, surgical interventions, degenerative diseases, neoplasias)
Family history antecedents: they present a special importance especially
in the case of transmittable diseases or with generic predisposition
(atopy, neoplasia, metabolic diseases, infections)
Life conditions, customs and work: the dwelling place (important in the
case of a family in which a member has a transmittable disease
tuberculosis), alimentary habits the predisposition towards certain
pathologies- obesity), smoking (the number of cigarettes a day and the
period since when they have been smoking), the alcohol consume
(grams of alcohol 100% expressed per day or weeks), drugs, birth
control pills, or the working place (toxic environment, allergic,
carcinogenic substances, intense physical effort)
PREOPERATORY
EVALUATION
HISTORY
It must be as detailed as possible, indicate the date of the
disorder beginning, the manner in which it started (acute,
insidious), the symptomatology present at the beginning
and the symptomatology evolution until the present. In
addition, it must be mentioned if during this time interval
the patient was examined by a physician or if he performed
certain investigations, what are their results, what
treatment he followed and which are the modifications
from the last period of time that determined hospitalization.
A correct anamnesis leads to a presumptive diagnosis
that will orient the patients physical examination and
the subsequent paraclinical explorations.

PREOPERATORY EVALUATION
THE GENERAL PHYSICAL EXAMINATION
It requires an examination room that offers privacy to the
patient
It is performed with the patient in clino-orthostatism and
during walking
It must be performed comparatively with the contralateral
organ or segment
It comprises:
1. Palpation
2. Inspection
3. Percussion
4. Listening
Means of performing:
ON APPARATUSES AND SYSTEMS
ON BODY SEGMENTS

LOCAL EXAMINATION
CLICK WITH THE MOUSE ON THE UNDERLINED TITLES
THE GENERAL PHYSICAL
EXAMINATION
The general state
Tegument and mucuses
Subcutaneous cellular test
Lymphatic-ganglionic system
Muscular system
Osteoarticular system
Respiratory apparatus
Cardiovascular apparatus
Digestive apparatus and annexed glands
Genital-urinary apparatus
Nervous system, sense organs and endocrine glands

GENERAL PHYSICAL EXAMINATION
GENERAL STATE
Can be : serious, influenced, good
The patients aspect : scarred patient, tormented with
pain peritonitis
Attitude: Paralysis, opisthotonus tetanus, supporting
the traumatized limb with the healthy one
Facies: hypocratic (pale, with dark circles, pointed nose,
prominent cheek) peritonitis
Walking: ataxic tabetic lesions
Nutrition state: disassimilation, normal weight , obesity
(IMC=Gx100/T)
Conscious state: cooperant, temporo-spatially oriented,
somnolent, obnubilated, coma
PREOPERATORY
EVALUATION
ON APPARATUSES AN SYSTEMS
Teguments and mucuses
Color: cianosis chronic cardiac
insufficiency, bronchopenumopathies, pale -
hemorrhages, anemia, yellow icterus
Postoperatory scars: normally scarred
wound, keloid scar
Elasticity: idle abdominal cutaneous ply
dehydration
Mucuses: jugal mucus with roasted aspect
dehydration
Lesions: petechia, ecchymoses, coagulation
disorders, excoriations aggression,
traumatism ,
SUBCUTANEOUS CELLULAR TISSUE
It mentions the nutrition degree
The coetaneous fold will be measured on
the antero-lateral side of the abdomen
and thorax normal about 2 cm.

THE LYMPHATIC- GANGLIONIC SYSTEM
The superficial ganglionic system
The presence of adenopathies must be mentioned:
localization, consistency, mobility, presence of pain,
spontaneously or at palpation, the moment of the
appearance and their evolution
Examined regions : occipitals, retro-auricular,
submandibular, cheek, laterocervical,
supraclavicular, axillary, epitrochlear, inguinal
The lymphatic system : localized or generalized
edema cardiac insufficiency, renal insufficiency,
hypoproteinemia
Superficial venous system: circulation -
periumbilical venous superficial gorgon
vascularly decompensated hepatic cirrhosis

THE MUSCULAR SYSTEM

Tonus: hypotonic, normotonic,
hypertonic
The musculature development
Carrying out the movements:
normokinetically

PREOPERATIVE EVALUATION
OSTEO-ARTICULAR SYSTEM

Bone deformities: rachitic rosary
rickets
Continuity of bone reliefs: discontinuity
accompanied by crepitations fractures
Active and passive articular mobility:
immobile, partial mobility, normal
mobility, hyperlax articulation
THE RESPIRATORY APPARATUS
Thorax conformation : normal, rickets sequels,
emphysematous thorax
Amplitude of breathing movements: draw,
pathological whistling
Dyspnea: inspiratory , expiratory, mixed
Transmission of vocal vibrations : it can be perceived
by palpating the thorax when the patient says 33
Percussion: normal sonority, sub-dullness or dullness
pleurisy, pneumonia, hypersonority pneumothorax
Ascultation: crepitating rales pneumonia,
subcrepitanting bronchopneumonia, sibilant
bronchial asthma, sonorous rhonous chronic nicotine
addiction
CARDIOVASCULAR APPARATUS
The anamnesis may show effort dyspnea, nocturnal dyspnea,
presternum pain due to effort
Color of teguments, mucuses, extremities: cyanoses in chronic
cardiac insufficiency
Palpation
Apexian shock: normal left 5th intercostal space
medioclavicular line
Peripheral pulse: temporal artery, carotid artery, radial artery,
femoral artery, popliteal artery , dorsal artery of foot
Ascultation: cardiac noises, rhythm, central frequency
Ascultation of the carotid, femoral arteries, abdominal aorta,
renal artery
Percussion: cardiac dullness (rarely used nowadays)
Measurement of arterial pressure : clino- and orthostatism
THE DIGESTIVE APPARATUS AND THE ANNEX GLANDS
Anamnesis: appetite, weight loss, nausea, vomiting, pain, bowel transit
Examination: mouth cavity, coordination of abdomen movements with
breathing, existence of scars or other tegument lesions, (bruises,
hematomas, scratching lesions, abrasions)
Palpation
Superficial: cutaneous hyperesthesia: peritonitis
Deep: palpation of liver and spleen, tumors, uterus
Percussion: hepatic dullness, hypersonority occlusion
Ascultation: absence of hydro-air noises occlusion, sulphides tumors
Rectal palpation compulsory at any examination : perianal teguments
(perianal fistula, moles, external hemorrhoids), tonus of anal sphincter
(hypo-, normo- hypertonic), shape, limits and consistency of the
prostate, suppleness of the rectal wall, existence or absence of feaces,
of fresh blood or melena or other tumoral lesions
THE GENITO-URINARY SYSTEM
Anamnesis: urination frequency, symptomatology
associated to the urination (pain, smarting pain, interrupted
jet), urine color, diuresis (amount of urine in 24 hours),
existence of nycturia prostate adenoma, enuresis
Examination: lumbar regions (postoperative scars,
deformations renal tumor), conformation of external
genital organs
Palpation: urethral points, lumbar area
Percussion: positive Giordano maneuver vivid pain at the
percussion of lumbuses acute suffering
Digital vaginal examination and vaginal examination with
valves: inspection, palpation
NERVOUS SYSTEM, SENSE ORGANS AND
ENDOCRINE GLANDS
State of consciousness: cooperative, time-space
oriented, drowsy, obnubilated, coma
Reflexes: osteotendinous, cutaneous, pupillary,
reaction to pain
The examination of the spine is important for a
rachianesthesia
The exam of the anterior cervical region for the
thyroid gland
Comparative examination of breasts is
compulsory
Sense organs: hearing, sight (myopia,
hypermetropia), balance
ON BODY SEGMENTS
A more cursive and elegant method to
examine the patient than the classic
examination ON APPARATUSES AN
SYSTEMS
Modalities of perfomance
Sitting down
Clionostatism
Orthostatism
GENERAL PHYSICAL EXAMINATION ON BODY SEGMENTS
SITTING DOWN
Chephalic extremity : teguments, conjunctiva
mucous, implantation of exoskeletons,
ganglions, photomotor reflex, sinus points
(frontal and maxillary), mouth cavity (mucous,
dentition, dentures, tonsils), thyroid gland
Thorax: respiratory apparatus, heart
ascultation, exploration of mammary gland,
adenopathies (axillary, supraclavicular), spine
Lumbuses: urogenital apparatus, examination
of lumbar spine
CLINOSTATISM
Thorax: cardiovascular apparatus
Abdomen: digestive apparatus, week
abdominal points, inguinal region
Lumbar region: palpation of renal lodges,
urethral points
Limbs: inspection, passive and active
mobility, osteotendinous reflexes, pulse
and peripheral sensitivity
Rectal and vaginal palpation
ORTHOSTATISM
Balance
Gait
Varices
Hernial regions
LOCAL EXAM
It is very important, providing data
about the affected region, apparatus
It includes anamnesis, examination,
palpation, percussion, ascultation
The characteristics of the lesions
must be described: number, shape,
dimensions, limits, surface,
consistency, sensitivity, mobility
PARACLINIC EXPLORATIONS
For the patient who needs surgery
it is better for the paraclinical
investigations to be performed in
ambulatory. If it is not possible then
they will be performed as soon as
possible after being hospitalized
Routine explorations
Special explorations
ROUTINE EXPLORATIONS
Biological
Hemoleucogram (hemoglobin, hematocrit,
trombocyes, leukocytes, leukocyte formula)
Glycaemia, urea, creatinine
Coagulation tests (bleeding time, coagulation time,
prothrombin time, fibirin degradation products)
Hepatic tests, total proteins
RBW (syphillis), viral serology for AIDS and hepatitis
Urine test, urine elimination in 24h
Imagistic and functional
Chest X-Ray (radiography)
Simple abdominal radiography
Abdominal echography
EKG
SPECIAL EXPLORATIONS
They have to be as targeted as possible and to offer a complete
and clear image of each patient
Biological:
Ionogram: Na
+
, K
+
, Cl
-
, alkaline reserve
Hepatic tests: hepatocytolisis syndrome (TGP, TGO, GGT,
alkaline phosphatasis, iron content in blood), hepatoprive
syndrome (fibrinogen, total lipids, cholesterol), serum proteins
electrophoresis, biliary function, (total direct and indirect
bilirubin)
Amylasaemia, amylasuria
Hemocultures, urocultures
Imagistic and functional:
Echocardiography, respiratory tests, eso-gastro-duodenal
radiography with contrast substance, irigography,
fistulography, cavitatography, CT, IRM, scintigram, endoscopy,
biopsy puncture, diagnostic laparoscopy
SURGICAL INTERVENTION
To write down:
Number of the operatory protocol
Operatory diagnosis
Operation description
Type of anesthesia
Operatory team

TREATMENT AND EVOLUTION
To write down every day the medicines
administered, the dose (g/day), dose
fractioning, the way of administration (oral pills,
intramuscular, intravenous perfusion, etc.)
The evolution has to include: temperature,
pulse, blood pressure, general condition,
postoperative evolution (bandage and wound
aspect, drainage, resumption of bowel transit,
resumption of feeding), diuresis
For the surgical treatment one should establish:
the operatory indication, preoperative
preparation, operatory risk and anesthesia,
operatory time, postoperative treatment,
discharge
EPICRISIS
It is a summary of the entire observation
sheet and it must include:
Discharge reasons
Explorations performed and their results
(medicated and surgical) Treatments
taken
Evolution
Recommendations and discharge
TEMPERATURE SHEET
It represents a complete description of
the patients condition and evolution
To be written down daily:
Body temperature
Pulse
Blood pressure
Diuresis
Amount of drained fluids
Digestive aspiration
Administered medication
DEFINITION
It is the method that uses a series of
physical or chemical means in order to
destroy the saprophyte or pathogen
agents, to combat the infection after it has
been identified
PURPOSE AND PRINCIPLES
INDICATIONS
CONTRAINDICATIONS
ANTISEPTICS
CONTENT
CLICK WITH THE MOUSE ON EACH UNDERLINED TITLE
PURPOSE AND
PRINCIPLES
The purpose of the antiseptics is to
destroy the infectious agents from the
wounds or teguments
Operation mode: they dissolve the
bacterial membrane or modify the
macromolecules at this level determining
the destruction of the microorganism
Types of antiseptics:
Cytophilactic: they respect the integrity
of the organism cells
Cytotoxic: they destroy the organism
cells

PURPOSE AND
PRINCIPLES
THE IDEAL ANTISEPTIC:
1. Hydrosoluble
2. Non toxic and non irritant for live tissue
3. Broad bacterial spectrum
4. Bacteriostatic and bactericidal action
5. To be biochemical stable
6. Not to produce toxic compounds after
metabolization
7. The bactericidal effect should not depend
on the presentation shape
8. Bactericidal effect in presence of
organism fluids
9. Cheap
INDICATIONS
To make aseptic the skin around the wounds
To make aseptic the wound destroying the
bacteria
To make aseptic the patients skin (operative
field) before the surgical intervention
To wash and make aseptic the surgeons hands
To sanitize the instruments
To sanitize the surfaces in the operation room
To sanitize the sanitary installations
CONTRAINDICATIONS
The use of alcoholized, irritant or toxic substances in the wound (alcohol
denatures the proteins and determines the appearance of a proteic film
which favors the development of infection by preventing the antiseptic
substances from getting into the wound)
Only use substances indicated at the level of the mucuses
(nasopharyngeal mucous, oral mucosa, ocular mucous membrane)
because they can be absorbed in the systemic circulation resulting in
intoxications or anaphylactic shock
Vaginal lavages, enemas will only be performed with recommended
substances having the risk of irritations or ulcerations at this level
There will not be used to sterilize the instruments substances that only
destroy the vegetative forms of bacteria without destroying the bacterial
spores, too
The patients with atopy need special attention when choosing the
antiseptic agent to be used (e.g.: allergic to iodine)
The iodine antiseptics shall not be used for the new-born child and the
little child (great capacity of iodine absorption)
ANTISEPTICS
CLASSIC
MODERN
CLASSIC
ANTISEPTICS

Antiseptics with alcohol contents
Antiseptics which liberate chlorine
Antiseptics which liberate oxygen
Compounds of heavy metals
Potassium permanganate
ANTISEPTICS WITH ALCOHOL
CONTENTS
EHTYL ALCOHOL 70:
Indications: to make aseptic the tegument
Advantages: osmotic power, penetrating the deep layers of the
epidermis and in the sebaceous glands
Disadvantages: diminished action when applied on wet
teguments
TINCTURE OF IODINE
Indications: to make aseptic the tegument
Better penetration than simple alcohol
Composition: iodine 10g, potassium iodide 4g, alcohol 90
136g
Advantages : it indicates the region made aseptic by the yellow
color
Disadvantages : toxic if older than 6 days because it produces
iodine derivates, irritant for the areas covered with hair (axilla,
scrotum), it does not apply on wounds
Other products: ANCOHOL IODATE, GAS IODATE, EHTER
IODATE
SULPHURIC ETHER: to make aseptic the (peritoneal, articular)
serous membranes
GOMENOL: rhynopharyngeal and urological infections
PHOTO
ANTISEPTICS WITH
ALCOHOL CONTENTS
Ethyl alchool 70
Products based on iodine
ANTISEPTICS WHICH
LIBERATE CHLORINE
They have bactericidal action by liberating
chlorine as it is produced
DAKINS SOLUTION (SODIUM
HYPOCHLORITE):
chemical scalpel of all sphaceluses and
pus
To be administered in intermittent or
continuous irrigations
It dissolves and eliminates sphaceluses,
clots and pus
CHLORAMINE B SOLUTION 0.2-2%
More powerful action than Darkins
solution
Local applications, continuous or
intermittent irrigation, local baths
PHOTO
ANTISEPTICS WHICH
LIBERATE CHLORINE
Chloramine tablets
Chloramine solution
ANTISEPTICS WHICH
LIBERATE OXYGEN
There are substances which rapidly liberate a large quantity of
oxygen or after a while, a constant quantity but with a smaller
volume
They determine the formation of hydrogen peroxide resulting in
the destruction of microorganisms
OXYGEN
Cytophilactic, hemostatic antiseptics
It melts and eliminates sphaceluses
OXYGENATED WATER
Cytophilactic, hemostatic solution
By effervescence it can eliminate foreign bodies from the
wound
Disadvantages: it lyses the catgut, it delays the wound
cicatrization
BORIC ACID
It gradually liberates oxygen
Form of existence :
Crystals: wounds infected with pyocyanic bacillus
Solution 1-4% as antiphlogistic in ophthalmology and
dermatology
COMPOUNDS OF HEAVY METALS
Mercury salts: MERCURY
OXYCIANIDE for mucous
lavage, MERCURY BICHLORIDE
(SUBLIMATE) for making
teguments aseptic
SILVER NITRATE: for making
the wounds aseptic, cauterizing
action on granulated wounds
and epithelizing action on atone
wounds. The solutions are
widely used in dermatology
COLARGOL 1%,
PROTARGOL 2%
Less and less used
POTASSIUM
PERMANGANATE
POTASSIUM PERMANGANATE
SOLUTION 2-4%
Cytophilactic antiseptic
The only one in the group of
colorant substances that is still used
Indications: washing anfractuous
wounds with sphaceluses, cavities
and ducts (urethra, bladder),
disinfecting baths
MODERN
ANTISEPTICS

Antiseptics based on phenols and
derivates
Quaternary ammonium compounds
Biguanide antiseptics
Hypochlorites and
dichloroisocyanurates
Iodides and iodoforms

ANTISEPTICS BASED ON
PHENOLS AND DERIVATES
PHENOL: it is not used anymore because
it is corrosive and irritant for the
respiratory ducts
PRINTOL: disinfectant for surfaces
CLEARSOL: detergent for cleaning
surfaces
HEXACLOROFEN
Combined with soap it is used to make
aseptic the surgeons hands
Disadvantages: toxic, cutaneous lesions
QUATERNARY AMMONIUM
COMPOUNDS
Cytophilactic antiseptics but also having
detergent action contributing by the foam
they produce to eliminate the cellular
remainders and foreign bodies
CETAVLON, BROMOCET, CETAZOLINA,
CETRIMIDE BP, SAVLON
Indication: to clean wounds, burns,
surface disinfection (depending on the
concentration of the solutions)
BIGUANIDE
ANTISEPTICS
CHLORHEXIDINE
Indications: used to make aseptic the surgeons
hands, wounds, emergency disinfection of
medical termolable instruments (chlorhexidine
10% + alcohol 70 - 10 minutes)
Advantages: it can be diluted at the desired
concentration, it is not allergenic
Disavantages: it is not active on tuberculous
bacilli, spores and some viruses, it cannot be
combined with soap
One of the most used antiseptics in surgery
BENZALKONIUM CHLORIDE
Bactericidal effect
Indications: to clean wounds, bladder, to make
aseptic the surgeons hands
Advantages: slightly irritant for skin
HYPOCLORITES AND
DICHLOROISOCYANURATES
Antiseptics active on bacteria and spores,
funguses, viruses
Rapid action
Form of presentation: concentrated
solutions (when used they need to be
diluted)
Indications: to sterilize the instruments,
to disinfect surfaces
Disadvantages: unpleasant smell, irritant,
corrosive for metallic instruments
IODIDES AND IODOFORMS
IODOFORM (POVIDONE IODIDE)
It liberates active iodine, it destroys funguses,
bacteria and their spores
Form of presentation: yellow crystals with strong
smell, solutions of various concentrations or
associated with detergents to increase the
cleaning effect, spray
Indications: to clean wounds, for the preoperative
preparation of the patients tegument, lavage of
natural cavities and ducts, iodoform gauze,
stomatology
Advantages: it doesnt need alcohol to be
dissolved, it is not irritant for skin and mucuses,
it doesnt stain the cloths it touches, it can be
easily removed by washing it
The most often used antiseptic
PHOTO VIDEO
IODIDES AND IODOFORMS
DEFINITION
All gestures and maneuvers used
in order to prepare the patient
for a surgical intervention
INDICATIONS
CONTRAINDICATIONS
STAGES

CONTENT
CLICK WITH THE MOUSE ON EACH UNDERLINED TITLE
The purpose of the preoperative preparation is to prepare the patient for
the surgical intervention
The patient has to be informed on the pathology he suffers from, on the
possible therapy (a few data concerning the intervention), the risks and
the benefits of the treatment, possible mutilations or infirmities, on the
possible changes of the postoperative life style
One also has to provide information on the immediate and later
prognosis of the disease (Romanian legislation does not stipulate what
the patient should know, so generally in practice the patients questions
are answered and the non expressed desire not to be given too many
details)
The physical preparation of the patient is another stage of the
preoperative preparation, and it intends to bring the patient to a
physical condition which is good enough to support the surgical
intervention as easily as possible
The preparation has to be done step by step, the patient has to be in a
condition as good as possible at the moment of the intervention
Any patient will have to give his/her written agreement for the
investigations and therapy he/she is going to benefit from
INDICATIONS
Any surgical intervention carries
some risks, that is why it is
necessary for any patient that is
going to undergo a surgical
intervention to receive psychological
and physical preparation specific to
the pathology and surgery he/she
will undergo

CONTRAINDICATIONS
They are not absolute, concerning especially the
patients who need emergency surgery, when
there is no time for ideal psychological or
physical preparation, this being done as it goes
depending on the general condition of the patient
In case the patient is unconscious, they have to
talk to the patients family about his/her
condition
The written agreement for the surgery has to be
urgently obtained from the patient or his/her
relatives in case he/she is unconscious
PREOPERATIVE
PREPARATION
PSYCHOLOGICAL PREPARATION
PHYSICAL PREPARATION

OPERATION TIME
CLICK WITH THE MOUSE ON THE TITLE
PSYCHOLOGICAL
PREPARATION
It will be done by the attending physician (the physician who will
perform the surgical intervention)
The patients information has to be very objective, informing him/her
both on the risks and benefits without trying to convince the patient to
get operated
The decision to benefit from the surgical treatment is entirely up to the
patient, who will decide himself/herself for his/her life
In order to help the patient take a decision on the surgical act the
patient is recommended to consult another doctor, to have access to a
second opinion
The psychological preparation also has to inform the patient on the
changes that may appear after the surgery. So there may appear some
mutilations (iliac anus), infirmities (thigh amputation) which latter may
need prosthesis, transitory or definitive loss of sexual potency or
metabolic or psychic disorders (interventions on the endocrine glands)
A topic difficult to approach is the severe prognosis, the situation
varying from patient to patient. Some people insist on being informed
on the evolution and prognosis, whereas some other patients are not
interested in this aspect. It is recommended to answer according to the
patients desire to know more or less about the pathology he/she suffers
from

It includes:
GENERAL PREPARATION
SYSTEMIC PREPARATION
LOCAL PREPARATION
PREVENTION OF POSTOPERATIVE
COMPLICATIONS

GENERAL PREPARATION
Hydroelectronic and acido-basic
balance
Nutritional preparation
GENERAL PREPARATION
HYDROELECTROLYTIC AND ACIDO-BASIC BALANCE
The hydroelectrolytic balance has two aspects: filling the vascular bed and the
electrolytic balance
The filling of the vascular bed is monitored with the blood pressure in clino and
orthostantism, diuresis measurement, as well as of central venous pressure
Depending on these constant values the hydric balance of the organism will be
calculated (input and losses) and one should try to correct the unbalance using different
solutions (physiological serum, Ringer solution, glucose 5% or 10% to which one may
add various chlorides in case of dehydration or macromolecules in case of hemorrhage).
The solutions used should be normotonic, the hypertonic ones having limited indications
(patients with severe brain disorders). Refilling the vascular bed is performed gradually
during the preoperative period having the role to prevent the drops of blood pressure or
even vascular collapse and exitus during the surgical intervention
The electrolytic and acido-basic unbalance needs to be balanced according to the
ionogram and the blood pH. In case the kidney function is affected the preoperative
dialysis may be useful that will reestablish the electrolytic and acido-basic balance
In case of hemorrhages with great losses of blood it is necessary to restore not only the
circulating volume but also to restore the hemoglobin quantity which may ensure an
appropriate transport of oxygen in the tissues (the surgical ceiling when one may
proceed in safety conditions is of 10gHg/100ml blood)
GENERAL PREPARATION
NUTRITIONAL PREPARATION
It represents an important aspect of the preoperative
preparation because a denutrited patient cannot
epithelize and its immune system will be deficient, not
being able to defend itself against infections
It is recommended that whenever possible the
patients postoperative nutritional state should be the
best possible. In emergency situations when the
patients life depends upon the surgical intervention,
the nutritional recovery will be done after the
operation
The nutritional recovery can be carried out in two
ways: potential route and enteral route
GENERAL PREPARATION
NUTRITIONAL PREPARATION PARENTERAL
ROUTE
It uses glucose solutions, special nutritive
solutions for parenteral administration (they
are very expensive)
It is recommended to the cases with minor
nutritional deficit
It can also be used for patients with diabetes
using as energetic support the glucose
dabbed with insulin

GENERAL PREPARATION
NUTRITIONAL PREPARATION ENTERAL
ROUTE
There are used hypercaloric substances
(Fresubin)
It can be used when the digestive tube is
functional, allowing the absorption and
digestion of food principles, if not the
parenteral route may used
It needs the evaluation and support
of all apparatuses and systems:
Cardiovascular apparatus
Respiratory apparatus
Renal function
Hepatic function
Neurological
CARDIOVASCULAR APPARATUS
The score for establishing the risk
of postoperative cardiac morbidity
or mortality (table).
Maximum score is 53 points.
A score over 28 points
determines postponing the surgical intervention
Other risk factors: smoking, diabetes, blood
pressure, hyperlipaemia, unstable angina pectoris,
rhythm disorders, valvulopathies
HISTORY
>70 years 5p
IMA the last 6 months 10
p
CLINICAL EXAM
Gallop S3 or distension of jugular vein 11
p
Significant aortic stenosis 3p
EKG
Premature atrial systoles or nonsinus
rhythms
7p
>5 premature ventricular systoles /
minute
7p
SURGERY
Emergency 4p
Intraperitoneal or intrathoraric or aortic 3p
RESPIRATORY APPARATUS
It is useful for the patients with preexisting pulmonary
diseases, for old, obese, sick patients who will need
extended immobilization
There will be used bronchodilators, targeted
antibiotherapy
Respiratory gymnastics is recommended especially to the
patients who are going to undergo a surgical intervention
to the upper abdominal level or thorax. It involves ample
respirations, deep inspiration followed by expulsion of the
inspired air into a water bottle by means of a perfusor
tube, tapotement with efficient coughing to eliminate
secretions
Smoking is forbidden at least a week before surgery
(smokers have a state of chronic hypoxia)
RENAL FUNCTION
The renal function which was affected after the
surgery results in a more difficult elimination of
drugs (anesthetics, nephrotoxic antibiotics),
needing and adjustment of the doses used
For patients who have diseases of the lower
urinary tract, in case of complicate surgeries, at
the genital or rectal level, it is recommended to
put a catheter in the bladder on the operating
table after the patient was asleep. The catheter
will be kept till the spontaneous resumption of
mictions
PHYSICAL
PREPARATION
HEPATIC FUNCTION
The disorders of the hepatic function
manifest themselves by blood coagulation
disorders, nutrition disorders which will
determine deficient cicatrization as well as
metabolization disorders of various
substances with hepatic elimination
It is necessary to assess hepatic excretion,
hepatic cytolysis, protein synthesis,
coagulation samples, etc.
Risk factors: denutrition, ascites, bilirubin
>3mg%ml, albumin < 3mg%ml
NEUROLOGICAL
It is important to identify the
neurological pathology that may be
aggravated by the anesthesia
The patients with motor deficiency
have a higher risk of postoperative
complications

LOCAL PREPARATION
Local preparation: on the morning of the surgical intervention,
the region where the tegument will be incised will be epilated,
and then it will be made aseptic with alcohol iodate
Stomach preparation: in case o duodenal stenoses the lavage
and the aspiration through a naso-gastric tube are
recommended to empty the stomach of food remainders and
secretions
Colon preparation: will be carried out for all patients who will
undergo surgical intervention by means of two enemas (the
evening before surgery and one on the morning before
surgery). The patients who will undergo colon surgery need
more laborious preparation which may ensure the complete
discharge of the digestive tube of food residues. Thus the day
before surgery the patient will have a hydric diet, he/she will
be administered 4 sachets of Fortrans followed by 2 enemas
(one in the evening and the second one on the morning
before surgery)
PREVENTION OF POSTOPERATIVE COMPLICATIONS
Preoperative preparation plays an
important role in preventing
postoperative complications
The most frequent postoperative
complications are: infections,
thrombembolisms and organic
insufficiency
INFECTIONS
They determine a difficult postoperative recovery delaying the cicatrization,
extending the convalescence or even with the appearance of septicemia.
They may be prevented with a correct preoperative preparation depending on the
surgery that is going to be performed (skin, colon preparation, etc.)
Risk factors: old age, obesity, malnutrition, neoplastic problems, diabetes mellitus
and its complications, corticosteroid or immunosuppressor treatment, other
infections, radiotherapy, adrenocortical insufficiency
Necessary preparations: restoring nutritional status, balancing diabetes (glycaemia
below 1,2g%ml), treatment of concomitant infections, solving the adrenocortical
insufficiency, prophylaxis with antibiotics, shaving the operating region on the
morning of the surgery, etc
Indications for antibioprophylaxis:
Neck and head surgery with opening the upper air ways
Esophagus surgery (except for the hiatal hernia
Gastro-duodenal surgery except for uncontrolled hyperacidity
Surgery of biliary tract for patients with acute cholecystis, over 70 years old
who need choledocotomy
Bowel resections
Gangrenous acute appendicitis or peritonitis
Gynecological surgery
Prosthetic surgery for different organs: heart, hip, knee, valves, vessels
PREVENTION OF POSTOPERATTIVE COMPLICATIONS
THROMBEMBOLISM
The risk of appearance of
thromboembolisms increases: if the duration
of the intervention exceeds one hour,
obesity, blood hypercoagulability,
antecedent of vascular thrombosis, pelvic
surgery, treatment with oral contraceptive
pills
Prevention: elastic bandages on the lower
limbs to ensure higher return pressure,
precocious postoperative mobilization,
prophylaxis with anticoagulant medicines
(normocoagulant dose)
ORGANIC INSUFFICIENCY
Respiratory apparatus: pneumonias, broncho-
pneumonias, respiratory insufficiency, respiratory
distress syndrome
Heart system: rhythm disorders, cardiac
insufficiency, myocardial infarction
Hepatic function: coagulation disorders, hepatic
insufficiency
Urinary system: acute renal insufficiency
Neurological system: coma
The correct PREOPERATIVE EVALUATION allows
identifying the risk factors for these possible
complications and at the same time preventing
their appearance by measures specific to each
system
SURGERY TIME
Programming the surgery time
differs from elective surgery to
emergency surgery
SURGERY TIME
ELECTIVE SURGERY
The choice of surgery time is very important in
elective surgery
Its choice depends on the patient, surgeon and
anesthetist
The patient has to be prepared having a good
general physical and mental condition, good enough
to be able to undergo the surgery and the
postoperative evolution and recovery which should
be as fast as possible
As to the surgeon, it is necessary for him/her to go
through all the stages of the preoperative
preparation and to establish the surgical technique
These requirements are also necessary for the
anesthetist
SURGERY TIME
EMERGENCY SURGERY
Depending on the seriousness of the situation
the preoperative preparation may be skipped
(massive hemorrhages) or it may be partially
replaced in the preoperative room and
continued postoperatively (bowel occlusions)
So there may be:
Immediate emergencies
Emergencies postponed for the immediate
following period 24 hours
Emergencies postponed for later up to 7
days
POSTOPERATIVE
CARE
DEFINITIONS
CONTENT
DEFINITION
It varies depending on the anesthesia type: local,
rahianesthesia, general
Postoperative periods:
Immediate (post-anesthesia): the patient recovers
consciousness and the vital functions are stable
Intermediate: it takes from the complete recovery
after anesthesia till the discharge from hospital
Belated (convalescence): starts on discharge when the
patient has stable vital functions and a cicatrized
wound and continues at home
The postoperative care involves the clinical and
paraclinical monitoring of the patient
Monitoring represents observation, registration and
detection by clinical observation or paraclinical methods
of the patients state
PURPOSE AND
PRINCIPLES
Monitoring is carried out in order to detect
any change of the patients state to a
possible complication as well as to a
favorable evolution, and also in order to
take the necessary compensatory or
support measures for rapid healing
The most important principle is careful
and complete monitoring of the patients
state which will allow adopting the
necessary measures for a favorable
evolution

CLINICAL
MONITORING
It starts on the operating table and continues until
the patients discharge
It will be carried out following a certain schedule
which will allow the temporary distribution of the
clinical parameters during the day
Parameters watched: state of consciousness, facies,
tongue, tegument and mucous color, cutaneous fold,
breathing frequency and amplitude, frequency of
central and peripheral pulse, blood pressure, diuresis
in 24 hours, operatory wound aspect, drainages (flow
rate, aspect), functioning of venous catheters,
patients mobilization, resumption of bowel transit for
gas and feaces
PARACLINICAL
MONITORING
Definition: it represents a series of
measures intended to watch the patients
condition
Indications:
It is useful because a surgical patient
carries a risk of complications of different
gravity, which have to be prevented
The unconscious patients, who cannot
describe the changes that come up in
their evolution, need special monitoring
PARACLINICAL
MONITORING
Contraindications: any patient has to be
monitored, the only contraindication being
represented by the economic criterion
(very expensive costs)
Necessary materials: various devices and
apparatuses are necessary in order to
measure body weight, temperature, blood
pressure, breathing frequency and
amplitude, quantity of ingested fluids,
blood tests, (ionogram, blood ph),
electrocardiogram, sfigmogram, etc.
PARACLINICAL
MONITORING
The patient lies on the bed in a position as
close to the anatomic one as possible, he/she
has to take off his/her clothes so that the
access to any anatomic region may be easy
All sensors and necessary catheters have to
be monitored
Standard monitoring includes: measurement
of blood pressure, body temperature,
breathing frequency, diuresis and state of
consciousness
Special monitoring vary depending on the
patients pathology
STANDARD PARACLINICAL
MONITORING

BLOOD PRESSURE
Normal values: systolic 90-160mmHg, diastolic 60-
90mmHg
Technique: manually with tensiometer and stethoscope or
by means of an electric apparatus

PULSE
Normal values: 60-80 beats / minute
Technique: manually by direct palpation or with the
sfigmometer sensor; to be measured for 30 seconds
minimum, simultaneously with heart auscultation
Tachycardia = pulse > 100 beats / minute
Bradycardia = pulse < 60 beats / minute

MONITORING
BODY TEMPERATURE
Normal values: 36-37C
The most accurate is intrarectal measurement
of body temperature
The most used method is to measure
temperature in the axillary region

BREATHING FREQUENCY
Normal values: 10-16/minute
Technique: direct count or nasal sensor
Tachypnea = over 20 respirations/minute
Bradypnea = below 8 respirations/minute
MONITORING
DIURESIS
Normal flow rate 1ml/kg/h
Technique: to be measured the amount of urine
gathered in a gradated recipient which is
connected to the urinary probe
Oliguria = below 400 ml/24h
Anuria = below 200ml/24h

STATE OF CONSCIOUSNESS

PARACLINICAL
MONITORING
SPECIAL MONITORING
Cardiocirculatory disorders: central venous
pressure, medium pressure in the pulmonary
artery, pressure at the extremity of the pulmonary
capillaries, plasma osmolarity, hemoglobin and
hematocrit values, oxygen saturation of arterial
blood
Respiratory function: lip color, psychomotory
agitation, capnometry, amount of oxygen and
carbon dioxide in blood, value of alkaline reserve
and serum lactates
Renal function: value of urea and serum creatinin,
urea and blood osmolarity, creatinin clearance,
ionogram
To see if the tissues function correctly you need an
evaluation of how oxygen is used in the tissues,
and this process needs complex equipment
The instruments used to monitor the patient have to be taken care of
compliant to the following requirements:
All materials used shall be sterile, for single-use only
The orotracheal intubation probe shall be aspired and changed
regularly
The vascular catheters shall be kept permeable by washing them
with heparin
The digestive aspiration probe shall be aspired and washed
regularly and if necessary repositioned or changed
The urinary probe shall be regularly washed with antiseptic
solutions
The patient needs to be ensured local and general rigorous hygiene to
prevent complications (decubitus escharres, etc.)
The patients nutrition shall be carried out depending on the patients
condition: parenterally or orally
CARDIO-PULMONARY
RESUSCITATION
DEFINITION, PURPOSE, PRINCIPLES
INDICATIONS
CONTRAINDICATIONS
NECESSARY MATERIALS
TECHNIQUE
POSTRESUSCITATION CARE
INCIDENTS, ACCIDENTS, COMPLICATIONS

CONTENT
DEFINITION, PURPOSE,
PRINCIPLES
They represent all therapeutic measures to be applied in
emergency, in cardiac arrest, in order to recover the vital
functions
The cardiac arrest diagnosis has to be established quickly and the
resuscitation maneuvers have to be performed within very short
time from the beginning of the cardiac arrest and they also have
to performed fast in order to prevent the appearance of
irreversible damage of the organs (6 minutes after the beginning
of the cardiac arrest the neurons suffer damage, any resuscitation
method becoming useless)
The maneuvers have to be correctly performed in order to be
efficient
Diagnosis
Cardiac arrest: lack of heart beats, lack of peripheral pulse,
lack of carotid pulse, low blood pressure
Pulmonary arrest: disappearance of respiratory movements,
peripheral cyanosis, mydriasis, lack consciousness, drop of
sphincter tonus
Mnemotechnical formulas: ABCDEFGHI, HELP ME
INDICATIONS
Arrest of cardiac and respiratory
function:
Ventricular fibrillation
Cardiac asystole
Apnea of central origin
Obstructions of upper airway
Posttraumatic
CONTRAINDICATIONS
Cardiopulmonary resuscitation is
contraindicated only when it is useless:
More than 7 minutes from the beginning
of the cardiac arrest (relative
contraindication)
Unrecoverable patient
Biological death (they are maintained in
this state for organ donation)
Multiple organic failure
NECESSARY
MATERIALS
Oxygen mask
Oxygen pump
Guedel pipe
Larhyngoscope
Intubation cannula
Defibrillator
EKG monitor
Flexules for venous catheters
Equipment for venous denudation
Syringes, needles
Drugs for emergencies

PHOTO
OXYGEN MASKS
OXYGEN PUMP (AMBU)
GUEDEL PIPE
LARHYNGOSCOPE
OROTRACHEAL
INTUBATION CANNULA
TECHNIQUE
The patient will be removed from the
action of the nocuous factors (place of
accident, etc.)
The patient will be lain on the back
The reanimator or reanimators should be
at the same level with the patient, if there
is only one savior this one will place
himself/herself on the left, if there are
two, the one who will perform cardiac
resuscitation will stay on the left and the
one who will perform artificial respiration
will stay on the right
INTERNAL CARDIAC MASSAGE DEFIBRILLATION
TECHNIQUE
Deconstruction of upper airway
Keeping it free: Guedel pipe, anterior mandible dislocation
Pinch the patients nostrils with the fingers of the right hand and give two
full breaths. The rhythm is of 12 breaths per minute
External cardiac massage has to be performed in the lower 1/3 of the
sternum with the right hand positioned on the left hand so that the fingers
of the left hand may not touch the thorax (this position offers maximum
pressure on minimum thoracic surface). The depression of the thorax shall
be done on 4 cm minimum. The rhythm is of 80-90 compressions per
minute
Efficiency may be followed by the appearance of the peripheral pulse after
the sternum compressions, the extremities regain color again,
disappearance of mydriasis
For the new born child and little child the resuscitation will be performed
with three fingers
The resuscitation will continue after the appearance of spontaneous pulse
because there the risk that the cardiac arrest may start again due to
hypoxia
In case the resuscitation maneuvers are inefficient, they will be interrupted
when they become useless (reappearance of clinical signs of hypoxia, fixity
of mydriasis)

Reanimator
No.
Breath no. Compression
no.
1 2 30
2 1 5
INTERNAL CARDIAC
MASSAGE
Incision in the left 4
th
intercostal
space
Take the heart in the right hand with
the left ventricle in the palm and
squeeze it with a frequency of 80-90
per minute
At the same time perform artificial
respiration
DEFIBRILLATION
Start external cardiac massage
simultaneously with the artificial respiration
If the patient does not respond to the
resuscitation, continue with the stimulation of
cardiac activity using electric shocks produced
by the defibrillator (150-400 W/sec)
Electric stimulation may be repeated, and at
the same time efficient medication has to be
administered compliant to the resuscitation
protocols (adrenalin, atropine, dopamine,
lidocaine, sodium bicarbonate, calcium
blockers, antiarrhythmic agents, etc.)

ABCDEFGHI
A (airways): permeable respiratory air tract
B (breath): artificial respiration
C (circulation): restoring circulatory function
D (drugs): drug administration
E (EKG): monitoring the cardiac function by EKG
F (fibrillation): electric defibrillator
G: establishing the diagnosis that determined the
cardiac arrest
H: neuropsychic therapy
I (intensive care): intensive care service
HELP ME
(BEJAN)
H: head hyperextension
E: clearing upper airway (foreign bodies,
secretions)
L: anterior luxation of the jaw
P: nose pinching, mouth-to-mouth
resuscitation

M
E
External cardiac massage
POST
RESUSCITATION CARE
The patient will still be kept under medical
supervision because there is the risk that
the cardiac arrest may start again or of
appearance of complications
Administer oxygen
Correct hydro-electrolytic and acido-basic
unbalances
Do not administer glucose (risk of
hyperglycemia and damage of nervous
function)
INCIDENTS, ACCIDENTS,
COMPLICATIONS
Respiratory function: tongue swallowing, loss of
insufflated air near the mask or through the
nostrils, rupture of pulmonary parenchyma
leading to the appearance of pneumothorax due
to the insufflation of a too large amount of air
Cardiac function:
External cardiac massage: rib and sternum
fractures which may induce secondary lesions
(lung, pericardium, liver lesions)
Internal cardiac massage: myocardial
ischemia, heart rupture, disinsertion of large
vessels
Defibrillation: tegument burns, ventricular
fibrillation
BLOOD TRANSFUSION
INDICATIONS
CONTRAINDICATIONS
NECESSARY MATERIALS
BLOOD GROUP DETERMINATION
DIRECT COMPATIBILITY TEST
TECHNIQUE
CARE
CONTENTS
CLIC WITH THE MOUSE ON THE UNDERLINED TITLES
PRINCIPLES
Definition: it is a method used to
introduce blood, erythrocytes or
plasma in the patients
cardiocirculatory system
Transfusion has as a purpose to
correct the patients blood deficits
(volume, erythrocytes, plasma
factors)
Principle: perfect compatibility
between the doner and the receiver
is compulsory
INDICATIONS
Great losses of blood volume
(massive hemorrhages)
Increase of oxygen transport
(serious anaemias)
Deficit of coagulation factors
(hemophilia)

CONTRAINDICATIONS
Arterial hypertension, right
ventricular decompensation
(heart surcharge)
Pulmonary diseases:
pneumonias, bronchopneumonias
(acute pulmonary edema)
Thrombophlebitis, venous
thromboses (embolisms)
NECESSARY
MATERIALS
Transfusion substance: blood, plasma,
erythrocyte mass, cryoprecipitates
(factor 8, factor 12)
Heating device for the perfusion substance
Perfusor which is provided with a philter for
possible microclots
Needle for venous puncture
Garrot
Cotton tampon and 70 alcohol
Gloves
Adhesive bandages
PHOTO
BLOOD GROUP
DETERMINATION
On a glass strip put a drop of anti-A
serum and anti-B serum
Each of them will be mixed with
a drop of the patients blood
Wait for a few minutes and the results
will be interpreted on the microscope
compliant to the table
Serum O A B AB
anti-A - lyse lyse lyse
anti-B - - - lyse
BLOOD GROUP
DETERMINATION
Rh DETERMINATION

Use a kit of anti-D serums
Use the same technique on the strip
The presence of D antigen on the red
blood cells determines the Rh+ group
Serum Rh+ Rh
-
anti-D lyse -
DIRECT COMPATIBILITY
TEST
Put on a glass strip a drop of the
patients blood (receiver) in direct
contact with a drop of the donated
blood
If there is no agglutination, then the
two types of blood are compatible
and the transfusion may be made
TECHNIQUE
The patient will be informed on the transfusion
technique, benefits and disadvantages and its
agreement has to be obtained
The patient will be placed in a comfortable
position, preferably in dorsal decubitus
The product to be transfused will be brought to
the transfusion service and the direct
compatibility test will me made
Find a new vein into which the preparation will be
administered
The administration rhythm is of 50 drops/min 15
minutes (to observe possible adverse reactions),
then 60-80 drops/minute. For emergencies a unit
(500 ml) may be administered in 10 minutes.

COMPLICATIONS
Precocious hemolytic reaction: cephalea, fever,
shiver, lumbar pain, tachycardia, hypotension,
respiratory problems, hematuria
Late hemolytic reaction: unexplainable icterus,
decrease of hemoglobin
Fever shiver. If the temperature increases by more
than one degree Celsius the transfusion will be
stopped
Allergic reaction: urticaria, pruritus, rash, wheezing,
fever, shiver
Bacterial contamination of transfused blood
Immune reactions (pulmonary edema, excessive
bleeding), hypothermia, hyperpotassemia,
hypocalcemia, acidose, thrombophlebitis, embolisms,
transmission of certain diseases (hepatitis B, C, AIDS,
cytomegalovirus, syphilis, etc.)
CARE
The flask label will be stuck in the patients
observation sheet
15 minutes after starting the perfusion the vital signs
will be monitored (pulse, tension, breathing
frequency) as well as the existence of possible
adverse reactions
At that moment if there are no incidents the
transfusion rhythm will be increased
The patient will be checked every 30 minutes
At the end of the transfusion the vital signs will be
checked again and the diuresis, and they will be
written down in the observation sheet
The catheter will be cleaned with physiological serum
The packages will be returned to the transfusion
service
INJECTIONS
INJECTION ADVANTAGES
INDICATIONS
CONTRAINDICATIONS
NECESSARY MATERIALS
STANDARD TECHNIQUE
INJECTION TYPES
CARE

CONTENT CLIC WITH THE MOUSE ON EACH TITLE
PRINCIPLES
Definition: it is a method used
to introduce in the body different
medicated substances
Purpose: therapeutic, diagnosis
Principle: active principles are
introduced in the organism, by
means of needles with lumen,
and are resorbed in the blood
that circulates through that region
INJECTION
ADVANTAGES
The absorption speed of active principles
is well controlled
They avoid hepatic metabolization
The administered dose is not influenced by
digestive absorption (accelerate transit,
etc.)
It allows administrating medicines to
uncooperative or unconscious patients
They avoid the digestive tube: there can
be administered medicines that irritate or
are not absorbed in the digestive tube
INDICATIONS
Seriously ill patients, for exact dose control
Patients who need a shock dose by rapid
absorption (intravenously)
Controlled-release preparations which cannot
be given as tablets
Patients with digestive intolerance
Unconscious patients
Diagnosis purpose (intravenous urography)
Local anaesthesia
CONTRAINDICATIONS
Hemophilia
Anticoagulant treatment
Tetanus
Induction from general anesthesia
NECESSARY MATERIALS
Active substance
Needle
Luer tapers
Cotton tampons with
solution for making
the tegument
aseptic
Garrot
Sterile gloves
PHOTO
PERFUSION SOLUTIONS
PERFUSION SOLUTIONS
INJECTION TYPES
INTRADERMIC INJECTIONS
SUBCUTANEOUS INJECTIONS
INTRAMUSCULAR INJECTIONS
INTRAVENOUS INJECTIONS
INTRA-ARTERIAL INJECTIONS
STANDARD TECHNIQUE
The patient will be informed on the manoeuvre to be performed,
obtaining his agreement
The patient will be placed in a comfortable position depending on the
injection type to be administered
The vial or ampoule containing the active substance will be opened, the
vial neck will be sterilize by singing it with a flame and then the content
will be aspired in the taper
The needle used to aspire the substance will be changed with another
sterile needle in order to perform the injection
If necessary, apply the garrot
Make aseptic the region where the injection has to be made by rubbing
it with an alcohol tampon
Take off the protecting cap from the needle, puncture the skin and the
other anatomic structures till the plane where you want to get to
Slightly aspire into the taper to see if the position is correct (vein dark
red, artery crimson, muscle no blood)
Inject the active substance compliant to the indications
Take out the needle and the taper with a firm movement
Massage the injection place to perform the hemostasis
The waste will be deposited in recipients specific to each of them
INTRADERMIC INJECTION
Make the tegument aseptic
The needle with the tip upwards will be
introduced in the superficial tegument
until the needle orifice disappears under
the tegument
Inject the substance from the tape
At the injection place there appears a
tegument deformation as an orange skin
Indications: intradermic reactions
Injection region: anterior side of the
forearm
VIDEO
INTRADERMIC
INJECTION
TO CONTINUE THE VIDEO CLICK WITH THE MOUSE ON THE IMAGE
SUBCUTANEOUS
INJECTION
Make the tegument aseptic
Create with the left hand between the
thumb and the forefinger a cutaneous fold
The needle will be introduced parallel to
the tegument, in the axis of the fold
without penetrating the muscle
Indications: slow absorption drugs
Injection region: external side of the
forearm or thigh
VIDEO
SUBCUTANEOUS
INJECTION
INTRAMUSCULAR
INJECTION
Make the region aseptic
With the needle perpendicular to the tegument,
puncture the skin with a firm movement and push
the needle in the muscle
Slightly aspire in the taper (there mustnt be any
blood)
Inject all the contents of the taper
With a fast movement take out the needle and
the taper
Massage the region
Indications: most medicated substances (oily
substances will only be administered intramuscularly)
Injection region: upper-external quadrant of the
buttock, deltoid muscle, quadriceps muscle
VIDEO
Picture 036.avi
INTRAMUSCULAR INJECTION

INTRAVENOUS INJECTION
Apply the garrot to determine vein dilation
and to make it visible
The needle will be positioned on the vein to be
punctured, being pushed in the direction of the
blood flow
Puncture the vein
Aspire in the taper the venous blood
Inject the contents of the tapper
Extract the needle from the vein
Perform the hemostasis by compressing the vein
for a few minutes with a cotton tampon imbibed
with alcohol
Indications: when the fast absorption of active
principles is useful, administerer perfusion
solutions
Injection region: veins of upper limb
(elbow plica, forearm, hand)
VIDEO
INTRAVENOUS INJECTION
INTRAARTERIAL
INJECTIONS
Detect with the forefinger and the medius of the left hand
the artery pulsations
Puncture the skin with the needle perpendicularly on the
artery
Aspire in the taper creating lower pressure, and push the
needle until red blood appears inside the taper
Inject the contents
Extract the needle firmly
Compress for a few minutes on the injection place with a
cotton tampon imbibed with alcohol
Indications: local anesthesia, chemotherapy
Injection region: radial artery, femoral artery
VIDEO
RADIAL ARTERY PUNCTURE
COMPLICATIONS
Local hematoma
Vessel rupture
Tegument, vascular necrosis
Allergic reactions
Subcutaneous nodules
Embolisms
CARE

Generally, they dont require special
care
A sterile bandage has to be applied
on the puncture place
In case of intravesel injections
hemostasis will be performed by
compression for a few minutes with
a cotton tampon imbibed with alcohol
INCISIONS
INDICATIONS
CONTRAINDICATIONS
NECESSARY MATERIALS
TECHNIQUE
CARE

CONTENT
CLIC WITH THE MOUSE ON EACH TITLE
PRINCIPLES
Definition: they mean cutting tissues with a cutting object
Purpose: they make access to a certain anatomic structure, pathologic
collection or for exploration
Principles:
The asepsis and antisepsis requirements have to be complied with
Knowing the region anatomy
Anaesthesia has to be performed
The incision dimensions have to be adapted to the purpose
The incision orientation has to take into account local innervation so that
cicatrization may take place without any complications
The incision direction has to follow the force lines on the skin, this way
avoiding faulty cicatrizations
The incision will be performed with a single movement, it has to be
regulated and rectilinear
The incision will be made plane after plane, for deeper planes the incision
being shorter thus allowing better closing the wound at the end of the
intervention
Point out the important structures and avoid cutting them
For collections the incisions have to be performed in the maximum
fluctuation point and their length adapted to the collection length
INDICATIONS
Opening purulent infections
Excisions of tegument formation or lesion
Creating an approach for a certain
abdominal or thoracic organ
Retouch of bad incisions
Clearing incisions to bring near
the margins of the wound
Opening the capsule to get deep
into the viscera

CONTRAINDICATIONS
Hemophilia
Tetanus
Induction in general anesthesia
NECESSARY
MATERIALS
Sterile soft
material
Materials for
anesthesia
Scalpel
Scisors
Saw
Knife
SCALPEL BLADE
ELECTROCAUTERY
TECHNIQUE
The patient will be explained the technique obtaining its written
agreement for the surgery
The patient will be placed in a comfortable position to point out the best
way possible the region where the incision is going to be made
The preparation of the operative field will be done compliant to the
description in the chapter preoperative preparation
The surgeon will stay on the patients right side (except for the
interventions in the gynaecological field, pelvic region or left limbs) and
its help will stay in front of the operator, on the patients left side
(Local, general, rahianesthesia, etc) anesthesia will be performed
The skin will be kept under tension with the forefinger and medius of the
left hand, on the same direction but from the other end of the incision
The incision will be started with the scalpel perpendicularly to the skin,
in an almost vertical position, then it will be oriented to about 30
The incision will be made in a single movement
To the lower angle of the incision the scalpel will be brought again to an
almost vertical position as to the skin
Each anatomic plane will be cut in a single movement
The incision will cut plane after plane till the desired depth
VIDEO 1 VIDEO 2 VIDEO 3
CROSS INCISION FOR AN ANTHRACOID ABCESS
IN THE NAPE REGION
SCALP INCISION FOR THE EXCISION
OF A SEBACEOUS CYST
COMPLICATIONS
Hemorrhage due to vessel cutting
Hematomas
Nerve damage by intercepting its
path
Damage of internal organs
Wound infection
Eventration
Evisceration
CARE
Daily sterile bandage
Lavage with antiseptic solutions
COLON
PREPARATION
INDICATIONS
CONTRAINDICATIONS
NECESSARY MATERIALS
TECHNIQUE
CONTENT
PRINCIPLES
Definition: mechanical and biological
preparation of the colon in order to be
explored or for surgery
Purpose: discharging of feaces from the
colon, decreasing the degree of
contamination of the peritoneal cavity
during the surgical intervention
Principles: it is necessary to eliminate the
feaces as completely as possible
INDICATIONS
Explorations: rectoscopy,
colonoscopy, barium anema,
edoluminal ultrasound of the colon
Determining colon motility
Surgical interventions on various
segments of the large intestine

CONTRAINDICATIONS
Relative: patients influenced state
does not allow rigorous preparation
Absolute: surgical emergencies,
diseases with risk of colon
perforation
NECESSARY
MATERIALES
Purgative drugs
Necessary
materials for
perfoming anema
TECHNIQUE
Diet without residues (milk, yoghourt, cheese, soup) 2 days before
the surgery until 0 time of surgery day, from that moment on
suppressing the administration of any food or fluid
Medication
Manitol
The first day the patient will ingest 250 ml of Manitol and 3
liters of fluids minimum
The second day the patient will be administered 250 ml of
Manitol oral pills and 3 liters of fluids minimum. The
evening before and on the morning of the surgery an
enema will be performed
Third day surgery
Fortrans: at 2 p.m. The day before surgery, there will be
administered a sachet of Fortrans dissolved in a litre of water
which will be drunk in about one hour. Four sachets of Fortrans
will be administered. The evening before and on the morning of
the surgery an enema will be performed
Enema: the evening before and on the morning of the
surgery an enema will be performed
At present we dont administer any antibiotics after the surgery
(they cause dismicrobisms)

ENEMA VIDEO

ENEMA
CONTENT
DEFINITION
PURPOSE, PRINCIPLES
NECESSARY MATERIALS
INDICATIONS
CONTRAINDICATIONS
TECHNIQUE
TECHNICAL VARIANTS

CLIC WITH THE MOUSE OF EACH TITLE
DEFINITION
It is a maneuver used to introduce in
the anal canal at the level of the
lower digestive tube various
substances intended for discharge,
diagnosis or therapy
PURPOSE,
PRINCIPLES
Discharge: by introducing the fluids in
the rectum and colon in the lower part
this produces the distention of the
digestive tract that will determine the
simulation of the peristalsis, also soaking
the feaces to determine defecation
Diagnosis: by means of enema one may
introduce radiopaque substances which
allow showing the lesions in the colon, its
motility and caliber
Therapeutical: it consists in introducing
various active substances especially
when other ways of administration are
inaccessible
NECESSARY
MATERIALS
Gloves
Single-use sterile cannula
Lubricant
Irrigator
The substance to be introduced
Basin
Protection oilcloth
PHOTO
PHOTO
PHOTO
PHOTO
NECESSARY MATERIALS
Rectal cannula
Irrigator
Irrigator with
the substance
to be administered
NECESSARY MATERIALS

Non sterile gloves
Lubricant
INDICATIONS
Colon discharge for persons with constipation, old
people, cachectic people, etc.
Preoperative preparation of the colon and rectum
Enema before a surgery with general anesthesia
(it prevents defecation due to the relaxation of the
anal sphyncter)
Barium enema for diagnosis
Medicated enemas (in digestive intolerance)
Hydrating enema (to be administered in a low rate
drop by drop)
Anesthetic enemas
CONTRAINDICATIONS
Suspicion of colon perforation
The pathology that makes the bowel wall thinner
and it induces perforation risk (bowel infarction,
colitis, ulcero-hemorrhagic rectocolitis)
Low tumor that may be damaged by this maneuver
(rectorragia may appear)
In case of barium enemas for low tumors the valve
phenomenon may appear due to the passage of the
tumor substance and its retention due to water
absorption which forms barium sulphate stones
which are difficult to eliminate
In diagnosis uncertainty, the barium enema may
determine a change of the clinical image which
may delay the therapeutic indication and aggravate
the general state
TECHNIQUE
The technique will be explained to the patient, especially the
fact that the substance introduced has to be kept in the colon
for at least 15 minutes. The patient will lie on the back or on
one side
The oilcloth is put under the patients pelvis
Put on the gloves, take the lubricated cannula and attach it to
the irigator
Let some fluid drip to eliminate the air inside the tube
Introduce the cannula in the patients anus, about 8 cm being
cranially and posteriorly oriented
Slowly introduce the fluid from the irigator (it prevents the
sudden distention of the rectal ampulla and the activation of the
defecation reflex)
Slowly take out the cannula from the anus, following the
opposite direction as when it was introduced
Perform local perianal cleaning
Clean the place where the enema has been performed
VIDEO
BACK TO THE TECHNIQUE
FOR COLON PREPRATION
TECHNICAL
VARIANTS
High enema: a long flexible cannula is used,
the initial position being in lateral decubitus,
and then in dorsal decubitus and right
lateral decubitus
Medicated enema: will be performed slowly
20-40 drops/minute. A Nelaton probe can be
used, which is thinner and shorter
Enema for patients with colostom or fecal
incontinence: insert a Foley probe, and
inflate the little balloon in the anal
sphincter, this way ensuring good
continence
COMPLICATIONS

Disconfort to the patient
Rectal perforation: it needs
immediate diagnose, followed by
the emergency reparatory surgical
treatment
SURGICAL
DRAINAGE
CONTENT
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
TECHNIQUE
NURSING CARE
PRINCIPLES

Definition: it represents the evacuation of pus collections from
an abscess cavity
Purpose: therapeutic (the evacuation of the pus collection),
postoperative observation on postoperative clinical evolution
(facilitates the recognition of bleedings, digestive fistulas, etc.)
Principles:
Drainage tube must be positioned in the lowest part of
the cavity
Dimensions (length, diameter, material) must be adjusted
to the purpose of the drainage and to the characteristics of
the evacuated cavity
The path of the drainage tube must be as short as possible
and should avoid the intestinal loop
The drainage tube will be exteriorized by counter incision
The drainage tube will be attached to the skin by suture
The drainage tube will be connected to a collecting
container
RECOMMENDATIONS
Pus collections
Peritonitis
Interventions with septic stage
Difficult, incomplete haemostases
Interventions with laborious starts
Fistulas, continuity solutions at the level
of cavity organs
Purulent pleurisies
Pneumothorax, hemothorax
CONTRAINDICATIONS
Are relative
In case of interventions that need
prostheses or explants that imply
a risk of septic contamination by
means of the drainage tube
REQUIRED MATERIALS
Plastic or silicon tubes
Drainage external catheters
and liners
Multiple hole tubes
Medical wigs
Collecting systems
PHOTO

PHOTO

PHOTO
Drainage tubes of various dimensions
The Kehr tube (T-tube)
Multiple hole tube
The Redon bottle for aspirative draining
THE TECHNIQUE
The patient will be informed regarding the
procedure and his /hers written agreement
will be obtained
The drainage tube will be positioned in the
lowest part of the cavity
The tube will be exteriorized through the
cavity wall by counter incision if the wound
can be sutured per primam
The drainage tube will be attached by suture
A sterile bandage will be applied
The drainage tube will be connected to a
collecting container
PHOTO VIDEO
COMPLICATIONS

Incorrect positioning of the drainage
tube
Obstruction of the drainage tube
Infection
Bleeding
Incorrect adjustment of the
collecting container
Exteriorization of the drainage tube
NURSING CARE
Daily sterile bandaging
Observing the quantity and the aspect of the
drainage content
Cleaning the cavities with the help of aseptic
solutions
Reinstating vacuum pressure in case of
aspirative drainages
Evacuation of the collecting containers
Removing the obstructing factors from the
drainage tube by using antiseptic solutions
APPLYING IODOFORM
ON A SUPPURATIVE WOUND
TO REVIEW PRESS CLICK WITH THE MOUSE ON THE IMAGE
ATTENDING
THE STOMIES
CONTENT
REQUIRED MATERIALS
STANDARD TECHNIQUE
DIFFERENT STOMA TYPES

PRINCIPLES
Stoma = a constructed opening to
the exterior of a cavity organ
The stoma allows the alimentation or
the evacuation of some cavity organs
Purpose: attending the stomies
should guarantee their correct
functioning
Principles: the tolerance of the
patient to the stoma care products
must be tested
DIFFERENT STOMA
TYPES
GASTROSTOMY
JEJUNOSTOMY
ILEOSTOMY
COLOSTOMY
CUTANEOUS URETEROSTOMY
REQUIRED MATERIALS
Self-adhesive collecting bags
Plastic disk (that will cover the stoma
allowing the accumulation of the
collecting pus)
Adhesive gel
Probes, tubules
Sterile dressing/cloth
STANDARD TECHNIQUE
The tissues around the stoma will be
cleaned using warm water, preferably
without soup
We wait until the skin is dry
The self-adhesive collecting beg that has
been previously adjusted according to the
dimensions of the stoma will be attached
In case the bag will be evacuated it is
better to have it cleaned first with a
syringe filled in with 50 ml of warm water
GASTROSTOMY
Indications: high gastric obstacle that
impedes the normal feeding (pharyngeal,
esophageal neoplasm, etc.)
Changing the bandage daily until the
wound is healed
The probe permeability must be tested by
using special substances
When not used, the probe lumen will be
sealed with a plastic stopper
PHOTO
GASTROSTOMY PROBES
PEZZER PROBE (prepacked and sterilized)
FOLEY PROBE
(in fact a urinary probe that can be also used for
gastrostomy, if needed)
JEJUNOSTOMY
Recommended for : non-resectable
gastric tumor, thus the stomach is
being saved for a future operation
Are more easy to be maintained
because for their carrying out a
probe is used by means of which the
food will be provided
COLOSTOMY
It will remain opened for 2 days post-
operative and the sutures will be
suppressed 7 days after the surgery
The colon transit will be reestablished
in 2 days from the surgery
The colostomy care has to be done on
a daily basis
In the beginning, the patient is not
aware when defecating, but later on, a
process of gaining awareness takes
place that will finally allow a perfect
conscious control of the external
sphincter
The colostoma patients need
psychotherapy in order to benefit of a
more rapid social and professional
reintegration
PHOTO VIDEO
Colostomy bags
DETACHING THE BAG THAT
NEEDS TO BE REPLACED

CLEANING THE PERFORMED COLOSTOMY
TO VIEW AGAIN CLICK WITH THE MOUSE ON THE IMAGE
PREPARING THE NEW COLOSTOMY BAG
THE COLOSTOMY BAG IS
CALIBRATED/ADJUSTED AND ATTACHED
ILEOSTOMY
Purpose: to evacuate
Recommendations: terminal (after
performing proctocolectomy upon various
indications, after right colon resections
with contraindication for ileotransverse
anastomosis in the first stage) or lateral
(neglected occlusions of right colic or iliac
artery)
Attending to the stoma in this case means
applying the same principles as in
colostomy; only that more attention
should be given to digestive losses and to
a good hydro-electrolitical, acid-base and
volemia levels

ASEPSIS OF THE LIVING TISSUES
RUBBING SURGEONS HANDS

THE PERITONIAL DRAINAGE AFTER
A CLASSICAL CHOLECYSTECTOMY
THE BANDAGE
CONTENT
INDICATIONS
CONTRAINDICATIONS
THE BANDAGING ROOM
REQUIRED MATERIALS
TECHNIQUE
BANDAGE TYPES
PRINCIPLES
Definition: it represents the medical procedure
by means of which a wound is asepticized or
antisepticized
Purpose: it protects and helps the healing of the
wound
Principles: it needs
to be sterile
to be absorbent
to ensure protection from the environment,
preventing the contamination of the wound
to not stick to the wound
to not produce pain
INDICATIONS
Surgical incisions
Accidental wounds
Burns
Varicose leg ulcers

CONTRAINDICATIONS
The facial injuries are usually left un-
bandaged
THE BANDAGING ROOM
Closet for
drugs and medical
instrument storage
Medical instrument
carriage
REQUIRED MATERIALS
Soft sterile cloth: compresses, swabs,
cotton wool, medical wigs, cotton buffers
Antiseptic solutions (see the chapter
regarding Asepsis and Antisepsis)
Surgical sterile instruments: Koher
forceps, Pean forceps, anatomic forceps,
medical scissors, scoop, scalpel, probe,
director, suture needles, sutures, drainage
tubes
Special materials for securing the
bandage: band aids, dressings, surgical
nets, adhesive solutions
PHOTO
REQUIRED MATERIALS
Sterile dressing cases
Sterilized surgical instrument case
Soft sterile non-fabric
gauze case
Pre-packaged sterile dressing case
REQUIRED MATERIALS
Antiseptic solutions
Cotton wool
Sterile and
non-sterile gloves
Ointment
BANDAGING
TECHNIQUE
The patient will be informed regarding the medical
maneuver after and he/she will be placed in a
comfortable position so that the person taking care of the
bandaging will have optimal work conditions
Before applying or changing the bandage the medical
personnel must have the hands clean
The wound surrounding tissues will be cleaned and
disinfected with tincture of iodine
The wound will be disinfected, examined and treated
The wound will be covered with soft sterile cloth
according to the characteristics of the injury
The bandage will be secured with dressing, band aids,
etc.
The evolution of the wound, the eventual drainages
performed , etc. will be noted in the patients observation
sheet
The secretory wounds need an absorbent bandage with
cotton buffer and a thick cotton wool layer
The wounds presenting local congestive manifestations
need wet bandages impregnated with chloramine or
alcohol, then covered with absorbent cotton buffer
The suppurative wounds need drainage and a proper
medical care
BANDAGE TYPES
THE DRY BANDAGE
THE WET BANDAGE
THE COMPRESSION BANDAGE
THE OCLUSSIVE BANDAGE
THE GREASY BANDAGE
THE BANDAGE OF SUPPURATIVE
WOUNDS
BANDAGE TYPES
DRY BANDAGE
Recommended for:
cleaning non-
secretory wounds
It is the most
commonly used
bandage for
wounds
It is made out if
gauze padded
compresses and
cotton wool
GAUZE SWABS COVERED WITH AN
IMPERMEABLE MATERIAL ON ONE SIDE (BLUE )
PHOTO VIDEO
PRE-WARPPED AND STERILIZED MATERIALS
FOR DRY BANDAGE
BANDAGE TYPES
DRY BANDAGE
BANDAGE TYPES
WET BANDAGE
Recommended for:
inflamed non-secretory
wounds
It has antiphlogistic
effect
It should be used on
short periods of time
due to the fact that it
can be irritant
It is made out of a
moistured compresses
impregnated with
antiseptic solution
covered up in the end
by a dry dressing
Another word used for
this type of bandage is
cataplasm
BANDAGE TYPES
COMPRESSION BANDAGE
Recommended for: bleeding injuries,
residual cavities
It has hemostatic role and the role
of flattening the residual cavities
It is made out of large pieces of gauze and
cotton wool
It needs to be more firmly attached so that
to keep the respective area compressed
without affecting the local blood circulation
It can be used no more than 7 days
BANDAGE TYPES
OCLUSSIVE BANDAGE
Recommended for:
bone injuries and wounds
(open fractures, etc.)
It is made out of a plaster
bandage that can be
shaped around the injured
area.
For granting access to the
wound an opening will
be cut into the plaster
bandage
Plaster bandage
Dressing made up of smooth
cloth in order to protect the tissue
under the plaster bandage
BANDAGE TYPES
GREASY BANDAGE
Recommended for: burns,
surrounding tissues of hole fistulas
This type of bandage is made out of
gauze compresses impregnated with
Vaseline or Lanolin but it can also be
directly conditioned by the
manufacturer
It has antalgic and antiphlogistic
effect
BANDAGE TYPES
SUPPURATIVE WOUND BANDAGE
The surrounded tissues will be
bandaged with alcohol
The wound needs to be cleaned with
antiseptic solutions, usually in
sequences: first using oxygenated
water Dakin (cloramine) drying
betadine or equivalent solutions
powder antiseptics (optional)
medical wicking
VIDEO
TYPES OF DRESSINGS
THE DRESSING OF THE SUPPURATIVE WOUNDS

THE XIPHO-UMBILICAL INCISION
VASCULAR
CATHETERIZATION
THE IDEAL CATHETER
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
STANDARD THECNIQUE
NURSING CARE

CONTENT
PRINCPLES
Definition: it represents the technique by
which various catheters can be introduced
into the vascular lumen (catheters are thin
plastic tubes)
Purpose: therapeutic (medical substances
are introduced into the body), diagnostic,
access for different organs (heart, limbs,
etc.)
Principles: it is a sterile maneuver that
must serve the purpose above
IDEAL CATHETER
Should be thin
Should not be irritant
Should not determine the platelet
aggregation in its exterior and interior
Should be long enough and wide enough
to serve its purpose
Should be radiopaque
Some catheters have more lumens
INDICATIONS
Hydro- electrolytic balance
In emergency for introducing rapid
action drugs
Parental nutrition
Determining the central venous
pressure, the pulmonary pressure
and intracavitary cardiac pressure
Interventional radiology
Diagnostic purpose
THE CATHETERIZATION OF
THE RADIAL ARTHERY
CONTRAINDICATIONS
Haemophilia
Tetanus
Induction from general anesthesia
REQUIRED MATERIALS
Syringe and needle
Xyline
Sterile gauze compress
Sterile gloves
(needle) Holder and
needle with suture
Medical tray containing:
syringe, thick needle,
guide wire, catheter,
fixing support
CENTRAL VENOUS CATHETER TRAY
THE STANDARD
TECHNIQUE
The patient will be informed about the medical procedure he/she will go
through and his/hers written agreement will be obtained
The patient will be placed in a comfortable position
The skin area where the puncture will be made is disinfected
The sterile gloves are put on
The local anesthesia is performed
The vein will be punctured according to the technique described in the
chapter About punctures
5-6 ml of blood will be aspirated into the syringe
The syringe will be detached and the guide wire will be introduced
through the lumen of the needle with the patient in voluntary apnea
The needle will be removed
The catheter will be introduced along the guide wire, then the guide wire
will be withdrawn until it reaches the distal end of the catheter
Both the guide wire and the catheter will be introduced until reaching
the desired position after which the guide wire will be removed
The blood will be aspirated into the syringe to check the position of the
catheter
The catheter will be connected to a perfusion with Normoton or heparin
serum
The catheter will be secured to the skin with sutures
In the end a sterile bandage is applied
ARTERIAL
CATHETERIZATION
VENOUS
CATHETERIZATION
SELDINGER TECHNIQUE FOR
INTERNAL JUGULAR VEIN
CATHETERIZATION

VENOUS CATHETER
JUGULAR INSERTION
COMPLICATIONS
When installing: insertion of the
catheter, catheterized blood vessel
perforations, artery puncture,
pneumothorax, chylothorax, gas
embolism, hemomediastinum,
arrhythmias
In use: infection, phlebitis
At the suppression: breaking the
catheter
MAINTENANCE
It requires maintaining the permeability of
the catheter which is achieved by
maintaining a continuous flow or by
washing the catheter with heparinized
saline after stopping the perfusion
Any maneuver that will be done must be
sterile
The perfusor will be changed in maximum
24 hours
DIGESTIVE
PROBING
DEFINITION, PURPOSE AND PRINCIPLES
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
TECHNIQUE
TYPES OF DIGESTIVE PROBING

CONTENT
PRINCIPLES
Definition: it represents the medical maneuver
through which various probes are introduced
through the digestive proximal tract for various
purposes
Purpose: collection of digestive secretions (gastric,
duodenal, biliary, pancreatic), qualitative and
quantitative biochemical measurement (pH meters,
cytology, microbiology), gastrointestinal
manometry, tract evacuation, cavity washing
(gastric lavage), enteral nutrition
Principles:
The principles of asepsis and antisepsis must be
respected
A proper probe is to be used
INDICATIONS
Gastric hypo- or hyperacidity
evaluation
Determination of PH digestive
secretions
Gastrointestinal manometry
Gastric stasis - evacuation, gastric
lavage
Pre-surgery preparation of the stomach
CONTRAINDICATIONS
The digestive probes are being
gradually replaced by modern
technique
Traumas, malformations, obstacles
that do not allow passage of the
probe
REQUIRED MATERIALS
Einhorn digestive
probes
Probes with
radiopaque marks
Syringes
Test tube
Stimulation drugs
Antidote solutions
Containers
Gloves
TECHNIQUE
The patient will be informed about the maneuver, his
cooperation is important during the digestive probing
The patient will be placed in the sitting position,
lateral or dorsal decubitus
The probe is introduced through the nose into the
throat, then the patient will be asked, while normally
breathing, to do swallowing movements, and in that
moment the probe is gently pushed up into the
esophagus and stomach. Eventually, a local anesthetic
to the pharyngeal mucosa can be done.
If you want to reach up into the duodenum, the
patient is placed in lateral decubitus for 30-60
minutes, while the probe will be spontaneously
progressing into the duodenum
COMPLICATIONS
Discomfort to the patient (agitation,
coughing, vomiting)
Exteriorization of the probe through the
mouth
Penetration of the probe into the upper
airway
Tracheobronchial aspiration syndrome
Bleeding
Esophagus or stomach perforation
Probe blockage with food debris
Decubitus lesions of the gastric mucosa
DIGESTIVE PROBING
Digestive probing types
GASTRIC LAVAGE
DIGESTIVE SUCTION
ENTERAL NUTRITION THROUGH
DIGESTIVE PROBE
GASTRIC LAVAGE
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
TECHNIQUE
GASTRIC LAVAGE
DEFINITION, PURPOSE, PRINIPLES
Definition: the maneuver by which
the stomach is emptied and cleaned
Purpose: discharge of toxic
substances, pre-surgery preparation
Principles: for intoxication lavages
specific antidote should be used
GASTRIC LAVAGE
INDICATIONS
Accidental or voluntary ingestion of
corrosive substances, toxic drugs
Preparation for endoscopies,
pre-surgery
radio-imaging explorations
Upper digestive bleeding: cold serum
lavage
GASTRIC LAVAGE
CONTRAINDICATIONS
Ingestion of caustic substances
Esophageal varices
GASTRIC LAVAGE
REQUIRED MATERIALS
Gloves
Faucher Probe (photo)
Funnel
Lavage fluid, antidote
Medicines
Container for
collecting the
evacuated digestive
content
GASTRIC LAVAGE
TECHNIQUE
cooperation is important during the gastric lavage
The patient will be placed in the sitting position or right
lateral decubitus
The Faucher probe will be inserted through the patients
mouth, up to the pharynx, asking the patient to swallow
The probe will slowly progress into the stomach, no more
than 45-60 cm
The funnel will be adjusted to the probe
The lavage fluid will be poured through the funnel placed
to the chest level, slightly raising it up to the head
Then the funnel will be descended below the abdomen,
while evacuating the gastric fluid
The operation will be repeated until the evacuated fluid is
clean
The probe will be gently extracted to prevent its
evacuation into the respiratory tree
GASTRIC LAVAGE
coughing, vomiting)
Penetration of the probe into the upper
airways
Tracheobronchial aspiration syndrome
Bleeding
Septic mediastinal complications

GASTROINTESTINAL SUCTION
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
TECHNIQUE

GASTROINTESTINAL
SUCTION
Definition: it is the maneuver by which
the excessive gastric fluid is evacuated
Purpose: the evacuation of gastric,
excessive duodenal or jejunal fluids in
order to avoid the digestive stasis
Principles: the principles of aseptis and
antisepsis must be respected, a proper
hydro-electrolytic balance must be
ensured
GASTROINTESTINAL
SUCTION
INDICATIONS
Acute dilatation of the stomach
High digestive stenosis
Intestinal occlusions
Acute pancreatitis
Gastrointestinal perforation
Post-surgery until the resumption of intestinal
transit for gases
Dynamic Ileus
Conservative treatment
(Taylor method for perforated ulcer)
Pre-surgery preparation
GASTROINTESTINAL
SUCTION
REQUIRED MATERIALS
Gloves
Radiopaque probes
Graded collecting containers
GASTROINTESTINAL
SUCTION
TECHNIQUE
The patient will be placed in the sitting position or
right lateral decubitus
The tube will be inserted through the patients mouth,
up to the pharynx, asking the patient to swallow
The tube will slowly progress into the stomach, no
more than 45-60 cm
In case of postoperative suction the tube will always
be placed upstream of the digestive suture during
surgery
In case of biliary pathology the tube can be placed
endoscopically in the ducts
The volume and the aspect of the sucked digestive
fluid will be daily noted in the patients observation
sheet
GASTROINTESTINAL
SUCTION
coughing, vomiting)
Exteriorization of the probe through the
mouth
Penetration of the tube into the upper
airways
Aspiration syndrome
Bleeding
Probe blockage with food debris
Decubitus lesions of the digestive mucosa
ENTERAL FEEDING THROUGH
THE DIGESTIVE PROBE

INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
TECHNIQUE

THE DIGESTIVE PROBE
Definition: introducing specially prepared
food by means of probes directly into the
proximal digestive tract
Purpose: ensuring the necessary intake of
nutrients for the patient
Principles: it is necessary to ensure the
patient a balanced nutrition which
determine that his/hers alimentation and
digestion is as closed to the natural as
possible
THE DIGESTIVE PROBE
INDICATIONS
Patients who cannot be fed
spontaneously
THE DIGESTIVE PROBE
CONTRAINDICATIONS
High gastrointestinal obstacles
Incoercible vomiting
Digestive fistulas
Inflammatory digestive disorders
THE DIGESTIVE PROBE
REQUIRED MATERIALS
Gloves
Radiopaque tubes with single or multiple
lumen
Containers
Connection tubing
Dosing pumps
Nutrient preparations that are to be
administered according to specific
nutritional deficiencies of each patient
PHOTO
NUTRITIENT SOLUTION TO BE
ADMINISTRATED THROUGH DIGESTIVE PROBES
THE DIGESTIVE PROBE
TECHNIQUE
The patient will be placed in the sitting position or dorsal
decubitus Fowler type
The tube will be inserted through the patients mouth, into the
pharynx while the patient will be asked to swallow
The tube will progress slowly into the stomach, up to 45-60
cm
The positioning of the probe will be made radiologically,
endoscopically or intraoperatively (always downstream of the
anastomosis)
The probe will be connected through the connection system to
the nutrient bag
The administration can be done in bolus" or continuously, the
pace being set by the patient's the digestive tolerance
A caloric intake of 3000 cal / day is necessary
THE DIGESTIVE PROBE
Discomfort to the patient (agitation, coughing,
vomiting)
Exteriorization of the probe through the mouth
Penetration of the probe into the upper airways
Aspiration syndrome
Bleeding
Dyspepsia
Gastroesophageal reflux, regurgitation, nausea
PERITONEAL DRAINAGE
ASEPTISATION
OF THE LIVING TISSUES
PATIENTS SKIN

HEMOSTASIS
DEFINITION, PURPOSE AND
PRINCIPLES
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
TECHNIQUE
COMPLICATIONS

CONTENT
PRINCIPLES
Definition: the maneuver through
which the bleeding is stopped
Purpose: stopping blood from flowing
from the vascular bed
Principles: hemostasis can be done
spontaneously (physiological
mechanisms of the body) or surgically
by physical and chemical methods
INDICATIONS
Any bleeding that does not stop
by spontaneous hemostasis
CONTRAINDICATIONS
Pathological situations in which
surgery may be delayed in the hope
of a spontaneous hemostasis (e.g.
upper gastrointestinal bleeding that
under conservative treatment may
stop spontaneously)
REQUIRED MATERIALS
Temporary hemostasis: tourniquet, soft
tissue for the compression of damaged
vessels
Final hemostasis: common instruments
for surgery, hemostatic forceps,
atraumatic needles to restore vessel
continuity
In case of hemostasis mechanism
disorders blood derivatives are required
(see Chap. Transfusions), hemostatic
substances, etc.
TECHNIQUE
TEMPORARY HEMOSTASIS
FINAL HEMOSTASIS
TECHNIQUE
Definition: it represents the method by
which the bleeding is temporarily stopped
Purpose: avoids blood loss until final
HEMOSTASIS can be done
Temporary hemostasis is represented by
the vascular compression that is made
by/through:
TOURNIQUET
POWERFUL COMPRESSION
TECHNIQUE
TOURNIQUET
If there is no tourniquet it can be improvised using
a cord, a belt, a scarf
Indications: limbs
By applying it the vascular walls are crushed and
bleeding stops
It is very important to attach a note where the date
and exact time of tourniquet application are recorded.
If the transport takes longer than 15-30 minutes, the
tourniquet will be opened for a few seconds to restore
the blood flow to the affected limb
In case of a jet bleeding with red blood, the bleeding
has arterial origin, and the tourniquet will be applied
proximally to the lesion, to the concerned member
In case of a continuous jet bleeding with dark red
blood, the bleeding has venous origin, and the
tourniquet will be applied distally to the lesion, to the
tip of the concerned limb
TECHNIQUE
POWERFUL COMPRESSION
Indications: head, neck, thorax, abdomen
It can be done by the strong compression of the
injured vessel against a skeletal plan, or by
compression bandage
The compressive bandage is made with sterile
compresses, the bandage is large enough to
make the injured blood vessel cooperate. Over
sterile compresses a crumpled of folded
compresses or a roll of infancy can be added,
followed by a tight enswathement of the area by
circular infancy turns, with hemostatic role
TECHNIQUE
Definition: it represents the surgical
maneuvers through which final hemostasis
is obtained into the blood vessel
During surgery it can be performed:
TEMPORARY HEMOSTASIS: it enables a
postponement of the final hemostasis in
a propitious moment
FINAL HEMOSTASIS
TECHNIQUE
Forcipression
The tourniquet
Loops
Balloon probes: Foley, Fogarthy
Compressive bandage
Swabbing
TECHNIQUE
TEMPORARY HEMOSTASIS - FORCIPRESSION
Definition: catching the end of the injured
blood vessel between the arms of a
hemostatic forceps
Indications: small diameter vessels
It can cause final hemostasis by
spontaneous hemostasis into the blood
vessel or it may require a subsequent final
hemostasis technique
TECHNIQUE
TEMPORARY HEMOSTASIS TOURNIQUET
Definition: a loop suture will be passed
around the blood vessel, then both ends
of the loop suture are passed through a
plastic tube that by tightening will causes
the compression effect of the blood vessel
Advantages: does not harm the blood
vessel, easy to apply, when suppressed it
allows the reestablishment of the blood
circulation in the blood vessel
TECHNIQUE
TEMPORARY HEMOSTASIS THE LOOPS
Definition: a loop of cotton will go around
the blood vessel, determining a lifting
position by forceps traction or fixation,
temporarily stopping the bleeding
Indications: vascular surgery in the
reconstruction of damaged blood vessels
TECHNIQUE
TEMPORARY HEMOSTASIS BALOON PROBES
Definition: the balloon probe is inserted
through the injured end of the blood
vessel, which by inflation causes lumen
obstruction with temporary bleeding stop
Indications: vascular surgery
Advantages: it is an atraumatic technique
TECHNIQUE
TEMPORARY HEMOSTASIS PLUGGING,
COMPRESSION BANDAGE
Definition: compression of the blood
vessel with a tissue, a sufficient time to
allow spontaneous hemostasis
Indications: small diameter vessels,
diffuse bleeding
TECHNIQUE
FINAL HEMOSTASIS

Ligature
Electrocoagulation
Embolization
Cushioning
Mass suture
Hemostatic substances
TECHNIQUE
FINAL HEMOSTASIS - LIGATURE
Definition: applying a loop suture by knotting in the blood vessel
that will determine HEMOSTASIS
Required materials: absorbable or non absorbable sutures, metal
clips, rubber rings
Technique: a hemostatic forceps will be applied to the damaged
vessel and the forceps will be adapted to the size and length of
the blood vessel and to the depth that the vessel is located, the
tip of the forceps being beyond the vessel by 1-2mm. Forceps
should be applied only on the blood vessel without catching other
structures nearby. The suture will be passed around the forceps
and the vessel, with a forceps, then the loop will be tied with at
least three nodes (raise, fix, ensure). After the first node the
operator will open the forceps, and now the assistant will tighten
the node perfectly. After checking hemostasis the loop is cut to 3-
4 mm from the node.
If necessary several ligatures may be applied on the same blood
vessel a few millimeters away from each other or a supported
ligature may be applied.
VIDEO
TECHNIQUE
FINAL HEMOSTASIS- LIGATURE
TECHNIQUE
FINAL HEMOSTASIS - ELECTROCOAGULATION
Definition: is the
method by which
hemostasis is produced
using electricity
Principles: changing the
intensity-voltage ratio it
can produce currents
that burn the cells that
come into contact with
the electrical scalpel
causing bleeding stop in
the small blood vessels
VIDEO
TECHNIQUE
TECHNIQUE
TECHNIQUE
FINAL HEMOSTASIS - EMBOLIZATION
Definition: it means introducing
coagulant substances in the injured
blood vessel
Indications: interventional endoscopy
Coagulant substances: absolute
alcohol, polidocanol, adrenaline
TECHNIQUE
FINAL HEMOSTASIS THE CUSHIONING
Definition: it is a method of
achieving hemostasis by suture,
bringing side by side, in close contact
"raw surfaces. This creates a high
pressure cavity that will determine
hemostasis
Indications: hemostasis in the
gallbladder bed after
cholecystectomy
TECHNIQUE
FINAL HEMOSTASIS MASS SUTURE
Definition: passing sutures in "x"
around the damaged vessel, and by
tightening the loop creating pressure
in the blood vessel that will lead to
stopping the bleeding
Indications: diffuse bleeding where
the damaged vessel cannot be
identified or it is very small and
brittle, other hemostasis techniques
not being possible
TECHNIQUE
FINAL HEMOSTASIS ORGANIC SUBSTANCES
Definition: obtain hemostasis
by applying organic
substances on the surface
where you want to stop
bleeding
These products have in their
composition certain
substances (fibrin, organic
glues) that stimulate and
encourage hemostasis
Products: fibrin powder,
Gelaspon, Tisucol,
TachoComb
COMPLICATIONS
Incidents, accidents:
Ligature slipping of the blood vessel
Pulling out the blood vessel during tying
Crushing the blood vessel between the
forceps arms when its dimensions are
not adapted to the vessel size
Local hematoma
Complications: necrosis, massive bleeding,
hypovolemic shock
PUNCTURES
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
STANDARD TECHNIQUE
PUNCTURES TYPES
CONTENT
PRINCIPLES
Definition: it represents the manoeuvre
through which an organ, cavity or
tissue is entered with a needle or trocar
Purpose: disposal, treatment,
diagnosis, biopsy
Principles: the punctures tract should
be as short as possible, the manoeuvre
must be aseptic
INDICATIONS
Pneumothorax
Paracentesis
Pneumoperitoneum
Pancreatic pseudocyst
Abscess
Biopsy
Seldinger puncture
CONTRAINDICATIONS
Haemophilia
Treatment with anticoagulants
Tetanus
Induction of general anaesthesia
REQUIRED MATERIALS
Iodine alcohol, soft
material, sterile
gloves
Syringe with needle,
lidocaine
Puncture needle,
trocar and syringe
Fittings and
containers for
collection
Fluids for lavage

STANDARD TECHNIQUE
Patients information on the procedure and obtaining his written
consent
A comfortable position will be further on chosen, with removal of
the clothing from the examined region
Sterile gloves will be used during the examination
The region to be punctured will be sanitized
Local anaesthesia will be further on performed
The clinically or imagistically spotted region will be punctured
with the needle attached to the syringe
The collections content will be drawn and stored in special
containers according to the test that is to be performed
For therapeutic puncture, the desired substance will be injected
The needle is firmly removed
The region will undergo massage with a alcohol swab
Sterile dressing
Rest for 30 minutes
TYPES OF PUNCTURES
THORACIC PUNCTURE (THORACENTESIS)
PERICARDIAL PUNCTURE
ABDOMINAL PUNCTURE (PARACENTESIS)
SUPRAPUBIC PUNCTURE
LUMBAR PUNCTURE
STERNAL PUNCTURE
BIOPSY - PUNCTURE

CLICK USING THE MOUSE ON EACH TITLE
THORACIC PUNCTURE
(THORACENTESIS)
Purpose: disposal, treatment, biopsy
Patients position: leaned forward, seated on a chair facing the chairs back or
semi-seated when dealing with a patient difficult to mobilize
Punctures place:
Intercostal space III posterior axillary line for the disposal of pneumothorax
Intercostal space VI posterior axillary line for the disposal of fluid
In full dullness to percussion
Sanitization of the region, sterile gloves will be used during examination
One ampoule of Mialgin will be administered 15 minutes prior to the puncture
Local anaesthesia
The needle or the trocar will be positioned perpendicularly to the skin, grazing the
top edge of the lower coast
Skin is penetrated and at first and after that all layers of the chest wall until one
can feel a slight resistance to the needle when passing through the pleura
Then, one will go forward one centimetre more; after this, the collection will begin
The needle is firmly removed, sterile dressing
INCIDENTS, ACCIDENTS, COMPLICATIONS: paroxysms of cough, pneumothorax,
pleural shock, acute pulmonary oedema, tear of the puncture needle
IMAGE
THORACIC PUNCTURE
(THORACENTESIS)
PERICARDIAL PUNCTURE
Purpose: disposal
Patients position and punctures place:
Seated: intercostal space V at 6 cm from the left edge of the stern
Supine position: top of the xiphoid appendix
Morphine should be administered
Local anaesthesia
The needle attached to the syringe will be positioned perpendicularly to the skin
Under moderate aspiration, one goes forward with the needle until fluid enters
in the syringe (this is when one knows the pericardial cavity has been reached)
The desired quantity of fluid will be sampled
The puncture needle is firmly removed the region will undergo massage
Sterile dressing
Bed rest for the patient
INCIDENTS, ACCIDENTS, COMPLICATIONS: bleeding, restlessness, irregular
heartbeats
ABDOMINAL PUNCTURE
(PARACENTESIS)
Purpose: disposal (for ascites, no more than 5 litres per session will be
disposed), diagnosis
Patients position: supine position
Punctures place: midway between the umbilicus and the left anterior-superior
iliac spine, 2 cm under umbilicus
Local anaesthesia
The needle will be positioned perpendicularly to the skin, penetrating all the
layers of the abdominal wall (there will be two resistant layers aponeurosis and
transversalis fascia
The peritoneal fluid will be drawn and stored in the indicated containers or the
needle will be coupled to an external drainage system
Peritoneal lavage: to the puncture needle, with the help of a blood infusion
pump, a bottle of physiological serum will be placed to at least one meter above
the bed. Once emptied, the bottle will be placed at the level of the bed, thus
allowing the leaking of the fluid from the peritoneal cavity into the bottle
The puncture needle is firmly removed, sterile dressing
Bed rest for the patient
INCIDENTS, ACCIDENTS, COMPLICATIONS: puncture of an intestinal loop,
gastrointestinal bleeding or vascular collapse in the event of sudden
decompression of the abdomen
IMAGES
ABDOMINAL PUNCTURE
(PARACENTESIS)
Veress needle
Abdominal punctures place
SUPRAPUBIC PUNCTURE
Purpose: disposal, collection of urine for urinalysis
Sanitization of the region, sterile gloves will be used during
examination
Punctures place: suprapubic region
The needle attached to the syringe will be positioned
perpendicularly to the skin, under moderate aspiration,
until urine appears in the syringe
The desired quantity of urine will be disposed
The bladder is washed with antiseptic solutions, which will
be later on disposed
Sterile dressing
INCIDENTS, ACCIDENTS, COMPLICATIONS: bleeding from
the bladder wall, infection
LUMBAR PUNCTURE
Purpose: diagnosis, treatment
Patients position:
Lateral decubitus, squat
Seated, the column is curved in front, the hands are placed on
opposite shoulders
Punctures place: L2, below the vertebra
Sanitization of the region
It will pinpoint the spinous apophysis of the lumbar vertebra, left
thumb
The needle will be positioned perpendicularly to the skin, grazing
the spinous apophysis, until feeling an increased strength has been
overcome and the entrance is entirely void of obstructions
The needles tenaculum is removed
2-3 drops of Cerebro-Spinal Fluid are obtained
2-3 ml of Cerebro-Spinal Fluid are sampled or the desired substance
is injected with a sterile syringe
The region will undergo massage with a alcohol swab
Sterile dressing
Bed rest for the patient during the whole day
INCIDENTS, ACCIDENTS, COMPLICATIONS: headache, bleeding,
infection
IMAGE
LUMBAR PUNCTURE
STERNAL PUNCTURE
Purpose: diagnosis
Mialgin or Morphine is administered
Punctures place: stern
Sanitization of the region, sterile gloves will be used during
examination
Local anaesthesia will be performed
With the Malarme trocar, placed perpendicularly on the stern, one
goes forward until feeling the entrance is entirely void of obstructions
The tenaculum is removed and with a sterile syringe are sampled 4 ml
of haematogenous medulla
The trocar is sampled
Sanitization of the region with alcohol
Sterile dressing
INCIDENTS, ACCIDENTS, COMPLICATIONS: infection, stern fracture

BIOPSY - PUNCTURE
Purpose: diagnosis
Patients position: one will choose the most
comfortable position for the patient, depending on
where the region or organ to be punctured is
found
Punctures place: varies depending on localization
(adenopathies, liver, tumours)
Sanitization of the region, sterile gloves will be used
during examination
The puncture technique described above will be
carried out
The sampled product will be placed in containers and
sent as soon as possible to the histopathology
laboratory
INCIDENTS, ACCIDENTS, COMPLICATIONS:
bleeding, infection
Biopsy needle
VIDEO
BIOPSY - PUNCTURE
MAMMARY TUMOR
IN ORDER TO SEE AGAIN THE CLIP, CLICK USING THE MOUSE ON THE IMAGE
SURGICAL SUTURE
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
TECHNIQUE
MEDICAL CARE

CONTENTS
PRINCIPLES
Definition: it represents the closeness and solidarity of the
margins of a wound (skin, organ, digestive tube, etc.) by sewing
them with a needle and a thread
Purpose: restoration of the anatomical continuity of the
structure involved or of two different structures when surgery
requires so
Principles:
It is a sterile manoeuvre
Local hemostasis must be perfect
The edges to be sutured must have an adequate
vascularization
The suture begins with the deepest chain to the surface
For the hollow organs, the suture must be tight and not
stenosed. In order to comply with this rule, if necessary, one
can perform more sutures
The knots of the suture must not be made to close in order
to avoid ischemia; nor should they be too large, untight
A suture may be primary or secondary
INDICATIONS
Restoring the continuity of the incised
or broken structures
Fixing some mobile structures to other
mobile or fix structures
Fixing of prosthesis
(prostheses, grafts, etc.)
Fixing the drain tubes, probes
CONTRAINDICATIONS
Infected wounds
Old septic high-risk wounds
Purulent incised collections
Suture of viscera in peritonitis
Poorly vascularised structures
REQUIRED MATERIALS
Sterile gloves
Soft sterile material
Antiseptic solutions
Suture needles
Suture threads
Metal staples
Needle holder
Anatomic clamp with or without teeth
Scissors
SEE ANTISEPTICS
FOTO
REQUIRED MATERIALS
REQUIRED MATERIALS
REQUIRED MATERIALS
NEEDLES
Disposable needles (atraumatic)
or re-sterilizable (always traumatic,
are rarely ever used)
Straight or curved needles
Triangular needles (skin, fascia),
oval or round needles (intestines,
organs, etc.)
REQUIRED MATERIALS
SUTURE THREADS
Natural (flax, cotton, silk, catgut)
or synthetic (nylon, dacron) threads
Reabsorbable (resorption between
14 days and 6 months) or non-
reabsorbable threads
In terms of thicknesses, they vary
depending on the structure
that is to be sutured
They must be flexible
They must be resistant
TECHNIQUE
Patients information on the procedure
and obtaining his written consent
Preoperative preparation of the suture
place (waxing, sanitization, disposal and
cleaning of hollow viscera)
Preparation of the structures to be
sutured: identification and tracking of
anatomical elements, perfect hemostasis,
adequate vascularization, removal of the
fat from the level of the suture

TECHNIQUE
INTERRUPTED SUTURE
CONTINUOUS SUTURE
METAL STAPLES SUTURE

TECHNIQUE
INTERRUPTED SUTURE
SIMPLE INTERRUPTED SUTURE
HORIZONTAL MATTRESS SUTURE
VERTICAL MATTRESS SUTURE
TECHNIQUE
INTERRUPTED SUTURE
The needle will pass approximately
1 cm away from the wounds edge
penetrating all deep levels up to about
1.2 cm of the incision line
The same trajectory will be followed
on the opposite lip of the wound
The node will not fall on the wound but
on one of the places of entry or exit of
the needle
VIDEO
TECHNIQUE
INTERRUPTED SUTURE
PERITONEUM-APONEUROTIC SUTURE
TECHNIQUE
INTERRUPTED SUTURE
CUTANEOUS SUTURE
TECHNIQUE
INTERRUPTED SUTURE
HORIZONTAL MATTRESS SUTURE - LEXER
The same indications as for the
simple suture will be followed,
only that one will also return with
the needle pointing at 0.5 cm from
the needles place of exist
The node will be done on the wound
where the suturing was begun;
in the end, two parallel threads
will appear joined by a node
TECHNIQUE
INTERRUPTED SUTURE
A simple point will be made;
it will continue with a U-shape turn
at 3 mm from the wound, the needle
passing through the epidermis
The node will be made on the
wounds part where the suture
was started
It provides a very good approach
VIDEO
TECHNIQUE
INTERRUPTED SUTURE
TECHNIQUE
CONTINUOUS SUTURE
The suture begins with a simple point; then,
the needle will pass like for the interrupted
suture, this meaning that the node is no
longer made after each pass of the needle,
the thread being held in tension until the
end of the suture when it is finally tied
It can determine asymmetries of the wound
Types of continuous suture: interrupted,
Blair-Donatti, intra-dermal
TECHNIQUE
METAL STAPLES SUTURE
Separate points
The mechanical
suture of the
hollow viscera
(it is fast, tight
and provides
a very good
approach)
COMPLICATIONS
Breaking of the suture threads
The wound gets opened by the sectioning
of the sutured structures
Seroma
Hematoma, bleedings
Infection
Eventrations
Eviscerations
Thread granuloma
Vicious scar

MEDICAL CARE
Daily dressing in the first two days,
then as needed
The threads will be removed in 4-14 days
from the suture, depending on local
factors (vascularization, etc..) and general
factors (cachexia, malignancy, etc.)
4 days for scalp and neck, 7-10 days for
thorax and abdomen, 12 days for limbs
Clips will be removed 4 days
postoperatively
BANDAGING
(DRESSING OF A WOUND)
REQUIRED MATERIALS
TECHNIQUE
CONTENTS
PRINCIPLES
Definition: it represents the method through which
the body is covered or fixed with gauze or elastic
rollers
Purpose: fixing the bandage
Principles:
Not to cause pain, not to be too tight or too wide
To cover well the region, protecting and isolating
the wound
To achieve a better fixing of the bandage
To allow mobilization of the dressed segment
The roller is unfolded from left to right
The fixing of the dressing is made at distance
from the wound in order not to cause pain
At the level of the limbs, the bandage will be made
from distal to proximal
REQUIRED MATERIALS
Gauze roller of varying lengths
and widths
Elastic roller
Adhesive strip of fixation
Nets
Staples
REQUIRED MATERIALS
Elastic roller and fixing staple
Plaster roller
Types of rollers
REQUIRED MATERIALS
FIXING MATERIALS
Galifix
Fixing staple
Elastic net
Adhesive strip
TECHNIQUE
Dressing will start with 1-3 circular fixing laps
The roller will be unfolded with the right hand
and fixed with the left hand
Bandaging will continue according to the region
involved
Bandaging will end with 1-2 circular laps
Bandaging is fixed with adhesive stripes or safety
pins placed away from the wound
Bandaging will be removed by cuts with scissors
made in a part outside the wound
TECHNIQUE
GENERAL TECHNIQUES
BANDAGING ACCORDING TO TOPOGRAPHICAL
REGIONS
GENERAL TECHNIQUES
CIRCULAR BANDAGING
SPIRAL BANDAGING
FAN BANDAGING
SPICA BANDAGING
IMAGE-OF-EIGHT BANDAGING
RECURRENT FOLD BANDAGING
TECHNIQUE
CIRCULAR BANDAGING
INDICATIONS: neck, arm, fist
Circular laps will be put one over
another
Advantages: easy to make
Disadvantages: it rolls up, gets
tighten becoming uncomfortable
TECHNIQUE
SPIRAL BANDAGING
INDICATIONS: limbs, thorax
The bandaging begins with 1-2 circular
fixing laps, continues with partially
overlapped oblique circular laps and ends
with 1-2 circular laps
Advantages: it covers important surfaces
Disadvantages: the distal part of each
lap is large

TECHNIQUE
FAN BANDAGING
INDICATIONS: elbow, knee
laps, continues with spiral laps in the
thickness of the joint space where 1-2
circular laps are followed by as many
spiral laps as necessary, ending with 1-2
circular laps
Advantages: it fixes the bandaging at
the level of the joint
TECHNIQUE
SPICA BANDAGING
INDICATIONS: shoulder, hip
laps at the level of the thorax or
abdomen, continues at the level of the
joint with 8-shape laps partially
overlapped and ends with 1-2 circular
laps
Advantages: it provides a good fixing of
the bandaging
TECHNIQUE
INDICATIONS: hand, ankle
The bandaging begins with 1-2
circular laps distal to the joint,
continues with 8-shape laps
partially overlapped and ends
proximally with 1-2 circular laps
TECHNIQUE
RECURRENT FOLD BANDAGING
INDICATIONS: head, amputation stump
2 rollers are to be used
With one roller, are done 1-2 circular laps in
the fronto-occipital region; with the other
roller, the bandage passes from anterior to
posterior and vice versa (folded roller);
each passing of the roller is fixed with the
first roller by a circular lap until the whole
surface is covered. The bandage ends by
getting fixed due to 1-2 circular laps

PHOTO
BANDAGING
ACCORDING TO
TOPOGRAPHICAL REGIONS
AT THE LEVEL OF THE HEAD
AT THE LEVEL OF THE NECK
AT THE LEVEL OF THE THORAX
AT THE LEVEL OF THE ABDOMEN
AT THE LEVEL OF THE PERINEUM
AT THE LEVEL OF THE LIMBS
TECHNIQUE
AT THE LEVEL OF THE HEAD
Types of bandages
CAPELINE
MONOCLE, BINOCLE
NASAL SLING AND CHIN BANDAGE
TECHNIQUE
AT THE LEVEL OF THE HEAD-CAPELINE
With one roller, are done 1-2 circular
laps in the fronto-occipital region; with
the other roller, the bandage passes
from anterior to posterior and vice
versa (folded roller); each passing of
the roller is fixed with the first roller by
a circular lap until the whole surface is
covered. The bandage ends by getting
fixed due to 1-2 circular laps
TECHNIQUE
CAPELINE
TECHNIQUE
AT THE LEVEL OF THE HEAD-MONOCLE, BINOCLE
INDICATIONS:
ophthalmology
With one roller, are
done 1-2 circular laps
in the fronto-occipital
region; then, are done
oblique laps in the
temporo-sub-auricular
uni or bilateral region,
fixed by 1-2 circular
laps. The bandaging
ends with 1-2 circular
laps

MONOCLE BINOCLE
TECHNIQUE
AT THE LEVEL OF THE HEAD-NASAL SLING AND CHIN BANDAGE
(FOUR-TAILED BANDAGE)
A roller of
approximately 80 cm
length will be split in
both extremities,
leaving in the middle
6-8 cm not split. The
extremities are
crossed over each
other and behind the
ear, being knotted at
the blackhead and
calvaria
SLING
FOUR-
TAILED
BANDAGE
TECHNIQUE
AT THE LEVEL OF THE NECK
ANTERIOR SPICA
OF THE NECK
POSTERIOR SPICA
OF THE NECK
These are complex
bandages
They apply the 8-
shape bandaging
technique as well as
the circular bandaging

POSTERIOR SPICA OF THE NECK
TECHNIQUE
AT THE LEVEL OF THE THORAX
Types of bandages:
VELPEAU BANDAGE
BREAST SPICA
TECHNIQUE
VELPEAU BANDAGE
INDICATIONS: orthopedic injuries of
the shoulder, humerus
Circular chest laps will be done,
alternating with oblique laps that fix
the upper limb to the thorax, as well
as vertical laps over the shoulder and
forearm, the hand being free
TECHNIQUE
BREAST SPICA
INDICATIONS:
mastectomy
2-3 circular laps
will be done on the
thorax under the
normal breast,
then oblique laps
over the shoulder,
altering with
circular chest laps
VIDEO
TECHNIQUE
BREAST SPICA
TECHNIQUE
AT THE LEVEL OF THE ABDOMEN
It is difficult to be made and lacks
functionality
Other types of fixing the bandage are
preferred, especially adhesive strips
One used dressing type is the loose
bandage
VIDEO
TECHNIQUE
AT THE LEVEL OF THE ABDOMEN-LOOSE BANDAGE
TECHNIQUE
AT THE LEVEL OF THE PERINEUM
DRESSING OF A
T-SHAPE WOUND
Two rollers are to
be used for this
bandage, one going
circular abdominal,
and the other
antero-posterior
covering the
genitals, being fixed
due to abdominal
circular laps
TECHNIQUE
AT THE LEVEL OF THE LIMBS
SPICA BANDAGING: shoulder, hip, fingers
FAN BANDAGING: elbow, knee
IMAGE-OF-EIGHT BANDAGING: hand,
ankle
CIRCULAR BANDAGING: arm, fist

TECHNIQUE
SPICA OF THE SHOULDER, HIP
TECHNIQUE
SPICA OF THE FOREFINGER
TECHNIQUE
FAN BANDAGING OF THE ELBOW, KNEE
TECHNIQUE
HAND
ANKLE
TECHNIQUE
IMAGE-OF-EIGHT BANDAGING-HAND
TECHNIQUE
IMAGE-OF-EIGHT BANDAGING-ANKLE
TECHNIQUE
CIRCULAR BANDAGING
TECHNIQUE
STUMP THIGH
Elastic stocking
Fixing bandage with an elastic net
URINARY CATHETERIZATION
DEFINITION, PRINCIPLES
PURPOSE
INDICATIONS
CONTRAINDICATIONS
REQUIRED MATERIALS
TECHNIQUE
MEDICAL CARE

CONTENTS
DEFINITION,
PRINCIPLES
Definition: it represents a method
through which the communication
between the external environment
and bladder is achieved
Principle: it is an aseptic method
Purpose
Disposal:
Monitoring: in hydro-electrolytic
unstable patients, during the
postoperative immediate phase
(loss evaluation)
Therapy : acute retention of urine
(urgency)
Exploration: a radio-opaque substance is
inserted allowing to obtain information
on the bladders form, shape, size
Therapy: antibiotics (urinary tract
infections), chemotherapy (cancer)
INDICATIONS
Acute retention of urine
Prostate stenosis (for disposal purpose
and simultaneously accomplishes
a dilatation of the urethra)
Urethral stenosis
Administration of radio-opaque
substances
Administration of drugs
(antibiotics, chemotherapeutic)
CONTRAINDICATIONS
The major urethral structure when are
created false paths or the urethral
rupture due to the catheters insertion
REQUIRED MATERIALS
Oilcloth
Sterile gloves
Sterile solution for sanitization
Nelaton probe (women), Thyeman (men)
Foley (balloon), Pezzer
Lubrication gel
Collecting bag
Kidney tray, basin
TECHNIQUE
The oilcloth is placed under the patient, together with a basin or
a kidney tray
The patient is in supine position, with the hips flexed on the legs
and knees apart
Gloves must be used for now on. Left hand will be used for the
local toilet (penis glans for men, vulvar region for women); the
right hand will be used for handling the catheter, the glove
being kept sterile
After doing the toilet with the left hand, the glans is opened or
the vulvar lips are kept apart; after this, a lavage with abundant
antiseptic solutions will be made
The physician will keep the peak of the catheter while the distal
end will be attached to the collecting bag by the nurse
The lubricant will be poured in the catheter's peak and in the
penis urinary meatus
TECHNIQUE FOR THE MALE
TECHNIQUE FOR THE FEMALE

CLICK USING THE MOUSE ON THE UNDERLINED TITLES
The penis glans is localized
The penis is oriented to zenith
The catheter is gently inserted
When the peak reaches the prostate, the penis will be
directed caudally, parallel to the bed
The catheters insertion continues until reaching the
bladder (the urine appears in the urinary tube)
The balloon fills with physiological serum
The catheter is withdrawn until it stops (at the bladder
opening of the urethra)
Local toilet
VIDEO
TECHNIQUE
FOR THE FEMALE
The catheter is inserted into the urinary meatus
The catheter is slowly and progressively
inserted
The catheter is inserted approximately 10-15
cm (the female urethra is short and right)
The balloon fills with physiological serum
The catheter is withdrawn until it stops (at the
bladder opening of the urethra)
Local toilet
VIDEO
TECHNIQUE
FOR THE FEMALE
COMPLICATIONS
The false path" is the most common complication that can lead to
rupture of the urethra. It requires the urgent attention of the
urology department
The balloons filling in the urethra causes the dilatation of the
urethra, which can be accompanied by bleeding or rupture. In
order to avoid this accident, first the catheter will be entirely
inserted and only after that the balloon will inflate
Bleeding ex vacuo" occurs due to sudden emptying of the bladder
that causes the rupture of the blood vessel in the bladder mucosa
If it is necessary to evacuate a large amount of urine, then this
will be gradually made, evacuating small amounts of urine
alternating for few minutes with the catheters plucking
Urinary infection
The blocking of the catheter with clots, flakes, precipitates
requires washing with antiseptic and anti-obstruction solutions
MEDICAL CARE
Purpose: the sterility of the bladder
and of the disposed urine must be
maintained
The catheter will be changed in 7
days time in aseptic conditions
The collecting bag must be changed
or emptied in aseptic conditions
Local hygiene
SURGICAL
INSTRUMENTS
CONTENTS
TYPES OF INSTRUMENTS
INSTRUMENTS TO SECTION TISSUES
INSTRUMENTS OF EXPLORATION
INSTRUMENTS TO GRASP AND MANIPULATE
TISSUES
INSTRUMENTS OF HEMOSTASIS
INSTRUMENTS OF REMOVAL
INSTRUMENTS OF SUTURE
INSTRUMENTS OF FIXATION
INSTRUMENTE FOR LAPAROSCOPY
INSTRUMENTS TO SECTION
TISSUES
Removable and disposable blade scalpel
Electric scalpel
Ultrasonic scalpel
Laser scalpel
Curved and straight scissors
Amputation knife
Osteotomes
Chisel
Blade-type, Gigli, electrical,
pneumatic saws
TISSUES
Electric scalpel
Hand grip scalpel
Scissors
Scalpel blades
TISSUES
Saw
Chisel
Costotome
Bone cutter
TISSUES
Amputation knife
Gigli saw
INSTRUMENTS OF EXPLORATION
Channelled catheter Button stiletto
Olive-tipped explorer
Histometer
INSTRUMENTS TO GRASP
AND MANIPULATE TISSUES
Anatomic clamp with or without teeth
Surgical clamps
Heart-shape clamps
Babckok clamp
Mice teeth-shape clamp Chaput
Coprostatic straight and curved clamps
Anastomotic clamps - Line-Thomas
L-shape clamps
Anatomic clamps without teeth
Anatomic clamps with teeth (surgical clamps)
Heart-shape clamp

Babckok clamp

Coprostatic clamps
L-shape clamp
INSTRUMENTS
OF HEMOSTASIS
Curved and straight Pan clamps
Curved and straight Kocher clamps
Mosquito clamps
Halsted clamps
Guyon clamps
Satinski clamps
Bulldog-type clamps - Dieffenbach
INSTRUMENTS
OF HEMOSTASIS
Kocher clamps
Pan clamps
Satinski clamps
INSTRUMENTS
OF HEMOSTASIS
Buldog-type clamps - Dieffenbach
INSTRUMENTS
OF REMOVAL
Farabeuf spreader
Valves
Auto-static spreaders: Gosset,
Dartigues, Finochetto, Collin
Anal dilators
Vaginal speculum
Farabeuf spreaders

Finochetto spreader
Valves
Volkman spreader
Gosset spreader
Dartigues spreader
Vaginal speculum
Anal dilator
INSTRUMENTS
OF SUTURE
Round and triangular, straight or
curved Hagedorn needles
Atraumatic needles
Metal staples
Mathieu Needle holder
Hegar Needle holder
Rechargeable or disposable staplers
Mathieu Needle holder Hegar Needle holder
Mechanical suture clamp
Round-head needle Triangular-head needle Reverdin needle
Fixing adhesive strips
Metal staples
INSTRUMENTS OF FIXATION (racks)
INSTRUMENTE FOR
LAPAROSCOPY
Clamps
Trocar
BIBLIOGRAPHY
1. Acalovschi I.: Manopere si tehnici de terapie intensiva. Ed. Dacia, Cluj-Napoca, 1989
2. Angelescu N.: Elemente de propedeutica chirurgicala. Ed. Medicala, Bucharest, 1981
3. Angelescu M.: Pregatirea preoperatorie a bolnavului chirurgical. In Patologie chirurgicala editorship N. Angelescu. Ed.
Medicala, Bucharest, 2001, 421-428
4. Bancu E.V.: Semiologie chirurgicala. In Tratat de patologie chirurgicala vol. I editorship E. Proca. Ed. Medicala, Bucharest,
1989
5. Bancu S.: Riscul operator. In Patologie chirurgicala editorship N. Angelescu. Ed. Medicala, Bucharest, 2001, 419-420
6. Bercea O.: Bolnavul chirurgical cu tara respiratorie. In Tratat de patologie chirurgicala vol. II editorship E. Proca. Ed.
Medicala, Bucharest, 1998
7. Bevan P.G., Donovan I.A.: Hand book of general surgery. Blackwell Scientific Publications, Oxford, 1992
8. Burcos T.: ASEPSIS si antisepsia. In Patologie chirurgicala editorship N. Angelescu. Ed. Medicala, Bucharest, 2001, 461-474
9. Caloghera C.: Chirurgia de urgenta. Ed. Antib, Timisoara, 1993
10. Cardan E.: Bolnavul chirurgical cu tara digestiva, metabolica si endocrina. In Tratat de patologie chirurgicala vol. II
editorship E. Proca. Ed. Medicala, Bucharest, 1998
11. Costea I.: Elemente de mica chirurgie. Ed. Apollonia, Iasi, 1999
12. Dragomirescu C.: Manual de chirurgie pentru studentii facultatilor de stomatologie. Ed. Didactica si Pedagogica, Bucharest,
1998
13. Detrie P.: Petite chirurgie. Soins. Conduite a tenir et investigations, 4-me edition, Masson, Paris, 1991
14. Dolinescu C.: Indreptar de activitati practice n clinica chirurgicala. Litografia IMF Iasi, 1982
15. Dunn CD, Ranglison N.: Chirurgie-diagnosis si tratament. Ghid de ngrijire a bolnavului chirurgical. Ed. Medicala, Bucharest,
1995
16. Georgescu S.O., Lazescu D.: Primii pasi n chirurgie. Ed. Kolos, Iasi, 2003
17. Mandache F.: Propedeutica si semiologie clinica chirurgicala. Ed. Didactica si Pedagogica, Bucharest, 1976
18. Mircea N., Leoveanu A.: Tehnici de anestezie si analgezie spinala. Ed. Academiei, Bucharest, 1989
19. Mircea N.: Monitorizregion n chirurgie si terapie intensiva. In Patologie chirurgicala editorship N. Angelescu. Ed. Medicala,
Bucharest, 2001, 327-348
20. Mircea N.: Anestezia. In Patologie chirurgicala editorship N. Angelescu. Ed. Medicala, Bucharest, 2001, 371-418
21. Mozes C.: TECHNIQUE MEDICAL CAREi bolnavului. Ed. Medicala, Bucharest, 1978
22. Onisei O.: Bolnavul chirurgical-elemente de diagnosis chirurgical. Ed. Helicon, Timisoara, 1997
23. Tefler ABM: General patient management. Brit Ind Bull 1988;44(2): 235-246
24. Ticmeanu F.: MEDICAL CARE postoperatorii generale si specifice. In Patologie chirurgicala editorship N. Angelescu. Ed.
Medicala, Bucharest, 2001, 429-444
25. Turai L.: Mica chirurgie fiziopatologica. Ed. Medicala, Bucharest, 1970
26. Way W.L.: Current surgical diagnosis and treatment. Printice-Hall International Inc, 1988

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Practical Guide of Surgical Semiology

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