INSTRUMENT INDENTIFICATION IN THE WARD

1. NASAL PRONG/ NASAL CANNULA

 A nasal cannula/nasal prong allows the delivery of

oxygen concentrations of between 24 to 40% at flow rates
between 1 to 6LPM making them suitable for use with most
portable oxygen concentrator units.
 One end of the plastic tubing is equipped with
curved nasal prongs which fit into the front of the nostrils,
with the loop hooked over the ears and the end attached to
an oxygen source.

2. VENTI MASK/ FACE MASK

 open side ports to allow air to enter

and dilute the oxygen as well as allow
the escape of carbon dioxide.
 The mask is attached via an elastic
strap which fits behind the head and
over the ears with the end of the tubing
attached to an oxygen source.
 A face mask allows oxygen delivery
via either the nose or mouth so is
suitable for nose and or mouth
breathers.
 allow higher concentrations and
rates of flow of oxygen.

3. HUMIDIFIER OXYGEN

Rationale:

 Cold, dry air increases heat and fluid

loss
 Medical gases including air and
oxygen have a drying effect and
mucous membranes become dry
resulting in airway damage.
 Secretions become thick & difficult
to clear or cause airway obstruction
 Indications:

I.
Patients with thick copious secretions
II.
Non-invasive and invasive ventilation
III.
Nasal prong flow rates of greater than 2 LPM (under 2 years of age) or 4 LPM (over 2
years of age)
IV. Facial mask flow rates of greater than 5 LPM
V. Patients with tracheostomy
4. high flow mask

5. nebulizer

 there will
be gas coming
out from the
mask

6. IV CANNULA

Indications : Contraindications :

I. Administration of fluids I. Sites close to infection

II. Administration of medication II. Veins of fractured limbs
III. Administration of blood and blood III. Where there is AV fistula present
product IV. Oedema
IV. Radiological imaging using IV contrast V. Affected side of CVA
VI. Side of mastectomy

Location of IV cannula :
Arm and forearm

Complications :

•hematoma:

•infiltration:
-when infusate enters the
subcutaneous tissue instead of the
vein.

•embolism:
-this can be caused by air, a
thrombus, or fragment of a
catheter breaking off and entering
the venous system. Possibly even
causing a Pulmonary Embolism.
Air emboli can be avoided by making sure that
there is no air in the system. A
thromboembolism can be avoided by using a
smaller cannula.

•phlebitis:
-inflammation of the vein
7. IV solution
8. TPN (TOTAL PARENTERAL NUTRITION)
 INDICATIONS : COMPLICATIONS :

I. Some stages of UC I. Infection

II. Chron’s disease II. Blood clots
III. Bowel obstruction III. Fatty liver, liver failure
IV. Gastroschisis IV. Hunger
V. Prolonged diarrhea V. Cholecystitis
-statis of bile salts because no food
CONTENTS :
ingestion
I. Water VI. Gut atrophy
II. Glucose -GIT lama xpakai
III. Amino acids
IV. Essential vitamins, minerals

Biasa case bladder ca.

9. Incentive spirometry

INDICATIONS :

I. Improve lung functions after surgery (post-anesthesia)

II. Prevent pneumonia
III. Prevent atelectasis

Xnak bagi
alveolar
collapse
10. DRAIN Classifications :
Indications:
• Open Vs Closed Systems
1. To eliminate dead space
Open: ada gauze pad atau stoma bag. ↑ the
2. To evacuate existing accumulation
risk of infection
of fluid or gas, To remove pus, blood,
Closed: tubes draining into a bag or bottle.
serous exudates, chyle or bile
Include chest and abdominal drains
3. To prevent the potential
accumulation of fluid or gas • Active (suction) Vs. Passive (gravity)
4. To form a controlled fistula e.g.
after common bile duct exploration
Indication

Types:

Penrose drain

T-tube

Redivac
Active drainage. with
Pigtail catheter
vacuum. (high negative
Drain from pleura space.
pressure)
bengkok sbb nak
slowkan flow kalau x Cth: drain blood bawah kulit,
burst out leads to injury (mastectomy, thyroidectomy)
abscess drainage. Cth: or deep space
bile, urine, pancreatic
fluid

Types of exudate:
Serous (clear)
Sero-sanguineous (pink)
Sanguineous (red)
Wound Assessment
Location
Size
Condition (Odor, Colour &Temp)
Types of tissue found
Wound drainage
 11. TED stockings (thrombo-embolism deterrent stockings)

INDICATIONS : CONTRAINDICATIONS :

I. Prevent DVT I. Peripheral obstructive arterial disease

II. Use in chronic venous disease II. Heart failure
III. Support venous and lymphatic III. Septic phlebitis
drainage in bed ridden patient IV. Oozing dermatitis
-post surgery patient V. Advance neuropathy

12. URINE CATHETER/FOLEY CATHETER (CBD)

-Size state 14-18 french(male)

Or

-size 10-12 french(female)

INTRODUCTION INDICATION

1. Made from latex-cannot keep more 1. Bladder outlet obstruction

than 1 week -mass on hypogastrium

2. There are other foley catheter that 2. Renal failure

made from silicon that can last for 3
3. Intravesical chemotheraphy
months.
4. Hemostasis drainage
3. Inflate by 30ml of distilled water
 5. Take foreign body in esophagus 2. Catheter

6. Monitor urine output 3. Lubricant

-postoperative
4. Sterile glove
7. Empty bladder before surgery to
5. Drainage bag
avoid infection during surgery
PROCDURE
8. Take sample of urine for culture
Putting inside the bladder
CONTRAINDICATION
1. Wear glove
1. Urethral trauma
2. Hold pens straight
COMPLICATION
3. Clean penis straight with swab
1. Infection
4. Put lubricant on the catheter
2. Trauma
5. Insert catheter whole inside penis
3. Aggrevate trauma
until reach the bladder
4. Retention of the catheter
6. Attach bag
5. Stricture
7. Insert 30ml distilled water and inflate
IMPORTANT STEP ballon

1. Consent 8. Tape the catheter to the hip

2. Indication 9. Clean the part

3. Ask patient for urogenic bladder Taking out the bladder

-do not feel to pass urine
1. Drain water to deflate the ballon
4. Sterile table of procedure
2. Take out and dispose in to yellow bin
PREPARATION
3. Clean the penis and surrounding
1. Cleaning solution
-chloro hexidine

15. 24 hours urine collection/ hourly urine collection aka Urine meter

 to calculate urine output hourly

 risk of AKI in a patient
 16. STOMA

INTRODUCTION :

I. Surgically opening from the inside of an organ to the outside.

II. Stoma from the word “mouth”/ opening

TYPES :

I. Colostomy
- opening from the large intestine to the abdominal wall so faeces bypass the anal canal.

II. Ileostomy
- opening from the small intestine to the abdominal wall so faeces bypass the large intestine
and the anal canal.

III. Urostomy
- connection between the urinary tract and abdominal wall leading to a 'urinary conduit' so
urine passes straight into a stoma bag and thus bypasses the urethra.
IV. Gastrostomy and jejunostomy
- openings between the stomach and jejunum respectively and the abdominal wall, used
predominantly for enteral feeding tubes
ILEOSTOMY COLOSTOMY
type: temporary (as a loop ileostomy) or type: temporary (as a loop, but largely
permanent replaced by loop ileostomy) or permanent (an
indications: IBD, inherited polyposis coli as end)
syndrome indications: colorectal cancer, diverticular
appearance: spout of mucosa disease

location: RIF appearance: flush with the skin, mucosa

sutured to skin
effluent: continuous, liquid
location: permanent: LIF, temporary, LIF or
right hypochondrium
effluent: intermittent and solid

Introduction

 name and role

 explain dkt pt
 explain kenapa nak check
 dpt consent
 confirm the patients name and age

Preparation

 wash hands
 put on gloves
 appropriate exposure 'nipples to knees'

Examination

 ask PAIN

EXTRA: asking the patient about pain shows good clinical care to the patient and avoids you looking
incompetent infront of the examiner (and the patient!) if later on pain is ellicited to your surprise.

 INSPECT from the end of the bed to see if the patient looks well, abdominal contour, scars,
swellings and the site of the stoma

EXTRA: a general inspection allows one to ascertain the sick from the well patient and to pick up
clues as to the possible underlying disease/s that the patient may be suffering from, while assessing
its site allows one to begin to build up clinical information to differentiate between ileostomies,
colostomies and urostomies.

 INSPECT the stoma closely noting its colour, number of lumens, presence of a spout or flush with
the skin, presence of blood, mucus or leakage of faeces
EXTRA: stomas should be a healthy pink/red colour and should be moist and glistening. Darker and
matter hues may indicate ischaemia while a pallor may suggest anaemia. Sometimes the number of
lumens is difficult to determine by inspection alone and a digital examination may be required. The
number of lumens detected will allow distinction between an end, loop or double barrelled stoma. The
presence of a spout identifies an ileostomy while a stoma flush with the skin is usually a colostomy.

 INSPECT the stoma bag noting the colour, consistency and the volume of the contents

EXTRA: brown fully formed contents suggest a colostomy. Semi-solid or liquid contents dark green in
colour suggest and ileostomy. Ribbon like stools may indicate stenosis. Yellow liquid suggests a
urostomy and hence urine in the bag. The volume of the stoma bag contents is extremely important
as a common complication of stomas is high output loss and fluid and electrolyte imbalance. Large
volumes passed may therefore require adequate fluid management, while reductions in volume may
indicate stenosis and therefore an impending obstruction.

 INSPECT the surrounding skin for erythema, rash, ulceration and mucocutaneous junction
seperation
 PALPATE the surrounding area for tenderness and masses such as parastomal hernias

EXTRA: stomas cause a range of complications such as skin changes that include erythema,
fissuring and allergic reactions due to the materials used in the stoma equipment, necessitating the
use of barrier creams and seals. Other complications include bleeding, separation between the
mucocutaneous edge and skin, prolapse, parastomal hernias, narrowing and subsequently
obstruction.

 PERCUSSION of the abdomen

 AUSCULTATION to ensure bowel sounds are present and therefore an indication of a working
bowel

EXTRA: Digital examination of the stoma

This is not routinely done in a stoma examination and is more often left to a senior or more
experienced member of the team to carry out when indicated. For completion, it includes the insertion
of a gloved lubricated index finger into the stoma lumen. At times, this may be all that is needed to
relieve an obstruction due to adhesions or fibrosis. The removed gloved finger is then inspected for
faeces, blood or mucus.

FEATURES HEALTHY STOMA :

I. Stoma should be above the skin level.

II. Red and moist stoma (pallor = anaemia; dark hue=
ischaemia).
III. No separation between the mucocutaneous edge
and the skin.
IV. No erythema, rash, ulceration or inflammation

Complications of Stomas
 Poor siting – site susah nak jaga. Should be senang nampak and away from bone, old scars or
the umbilicus.

 Stoma proper – masalah stoma tu sendiri necrosis, retraction, prolapse, bleeding and luminal
stenosis, functional disorders such as diarrhoea and constipation

 Peri-intestinal area - parastomal hernia.

 Mucocutaneous junction – stoma dgn kulit tepi stoma terpisah. separation of the stoma from
the peri-stomal skin. erythema complication of poor surgery or secondary to retraction or
necrosis. Common in the immunocompromised state such as patients receiving steriods, DM and
malnourished

 Iatrogenic - Iatrogenic complications include belts that rub the stoma, razors when shaving peri-
stomal skin. Injury to stomas often goes unnoticed as stomal mucosa has no nerve endings.

MEDICATION THAT HELPS PATIENT

I. DIARRHOEA
-loperamide, opiates, codeine phosphate
II. Constipation
-magnesium hydroxide, ispaghula husk

RESECTION TYPE OF STOMARESECTION TYPE OF STOMA

Hartmann procedure
Emergency procedure

Diseased large bowel

(eg. colorectal tumours)
is removed leaving the
proximal segment of
bowel as an end
colostomy while the
remaining distal bowel is
oversewn as a rectal
stump.

months later, once the

inflammatory process
has subsided, the two
ends of bowel may be
rejoined. However, often the colostomy is well tolerated that another major rejoining operation is
avoided.
 17. TYPES OF ABDOMINAL INCISION Paramedian
Ke tepi sikit boleh
dapat Kidney,
adrenal, spleen

Midline= semua abs

procedure boley CS atau anything
lower abs atau pelvis
Lanz lagi
lawa dari
McBurney.
Can wear
bikini :p