Suturing

WIPERNA

Hello, I'm________
I'm a_________
How are you?

Explain
Okay, I understand you had an accident. It seems that you'll need a few stitches for your wound, just to help it heal properly, and reduce scar formation, hopefully. This involves using a small needle and special thread, and we'll use LA to help ensure that you're not in pain. Does that sound okay? You're happy for us to go ahead? Are you alright with needles?


I'll just get my equipment.

... Wash hands...
Equipment
Sterile gloves

Lignocaine 1% LA (max 3mg/kg)
Syringe
Green needle

Orange needle

Sterile water/Saline
Gauze
Syringe
Suture pack
-tray
-needle holder
-scissors
-curved scissors
-toothed forceps (skin only)
-non-toothed forceps (needle only)
Suture Needle

Sharps box

Prepare Equipment
Wash hands

Open suture pack with sterile technique

Drop pair of gloves, syringes, sutures and needles into field

Put antiseptic solution into bowl

Sterile gloves on

WH/SF/SW/Gl

Prepare Patient
Questions - tetanus, allergy, LA ?
Inspect wound for debris/dirt - clean and debride if present
X-ray - potential of foreign body
Cleanse/irrigate wound and surrounding skin

0.9% saline soaked gauze/in syringe or with chlorhexidine/betadine (high risk contamination)

Swab held with forceps/hand

Centre outwards

Postion pt so they're comfortable

Cover wound with drape with hole in it - sterile field

Q/Insp/Clean/SF

Anaesthetic
Select syringe and attach the 21G green needle
Draw up 10ml of 1% lignocaine
Dispose of green needle
Attach orange needle

Inject LA into skin encompassing wound approx 0.5-1cm from its edge
Aspirate needle on inserting to ensure a vessel has not been entered
Fan shape around wound

Wait 5-10mins for anaesthetic to work - test area
Ask pts after signs of LA toxicity eg tingling in mouth, metallic taste, dizziness or light headaches, ringing in ears or difficulty in focusing eyes

Max lignocaine = 3mg/kg
Lasts approx 30 mins

Lg/Fan/Wt

Suturing
Mount needle
Grasp curved needle with needle holder (short. blunt forceps with straight jaw)
Hold needle 2/3 along shaft from tip
Perpendicular to needle holder
Hold needle holder with thumb and ring finger, with index to stabilise

Pass through skin about 0.5cm wound edge at middle of wound
Use forceps to pick up skin (toothed) - above hand
Pass N perpendicularly
Full thickness through skin to the base of the wound - xbacteria
Pull suture threat through hole, leaving 2-3cm tail behind
Pass N through opposite skin edge using forceps to hold the skin
Not too tight or loose
Make sure exit hole opposute insertion hole, and 0.5cm from edge
Put needle in sterile tray

Tie knot
- double throw
- needle holder parallel to wound
- wind two loops of long end of suture in a clockwise motion around the needle holder
- needle holder to 12 o'clock
- pull short end of stitch through the loops using the mouth of the needle holder
down to 6 o'clock
- pull knot gently down to the skin, opposing the two sides of wound at the same time

- tighten so skin edges are apposed but without tension

2nd throw - single

3rd throw - single
- single throws in opposite direction
Suture material can then be cut to complete the stitch
- 1cm
- ensure the knots created are everted and spaced 5-10mm apart
- knots on same size
- good opposition - no pie crust or puckering

Halves
- offer to place the next suture (rule of halves) half-way between the present suture and the distal, medial end of the wound. Repeat until the wound closed

Mount/SgKn/Hvs

Tidy Up
Dressing
- dry dressing
- Tetanus immunity if wound contaminated / pt has not had booster in last 10years

Document
- detail of sutures
- polypropelene

Dispose of waste
inform pt that sutures can be removed in 10days

Tell the patient to attend GP
- if any worries (red, oozing wound, stitches come out etc)
- and to in about 7-10 days time for stitches removal./or come back to A&E

Dr/Tt/Doc/Disp/GP

Thank you
Any questions?

Sutures
- scalp
3/0, non absorbable
7 days

- trunk
3/0, non absorbable
10 days

- limbs
4/0, non absorbable
10 days

- hands
5/0, non absorbable
10days

- face
6/0 non absobable
3-5days

Deep wounds
Absorbable eg monocryl, vicryl, dexon
Superficial wounds
Monofilament non-absprbable
eg Nylon (Ethilon) or Prolene

Male Catheterisation

WIPERNA

Hello________
My name is_______________
I'm a doctor
How are you feeling?

I was wondering whether I could catheterise you? Do you know what a catheter is?
We insert a small plastic tube to reach your bladder through your penis, so we can collect the urine into a bag. It helps us monitor how you are doing, and means you won't have to get up to go to the loo. We'll use local anaesthetic so it won't be painful, but it might be uncomfortable at first. Any concerns? Okay - so you're happy with us to go ahead?


I'll just go get my equipment ready

Equipment
Catheter pack
Foley catheter 16/18 - smallest cath poss

Catheter bag

Trolley
Sterile gloves x2
Lignocaine gel 2%
Sterile water/saline
Syringe x2
Bin

Prepare Trolley
Wash hands - 7 stage
Put on apron
Clean trolley - top & bottom
Open cath pack and slide onto trolley, preparing sterile field

Place equipment into sterile field

Attach yellow disposable bag onto side of trolley/move bin nearby

Pour sterile water into small bowl with swabs

Fill syringe with 10mls and place outside sterile field if not already within pack

Put on sterile gloves

Put on disposable gloves

WH/Ap/CT/CP/SF/SW/GL/GL

Prepare Patient
Expose + reposition
Make hole in drape and place onto pt - 2nd sterile field
Wrap gauze around shaft and keep in sling, with left hand raised
Retract foreskin
Clean penis - holding swabs in right hand/with forceps and wipe out from meatus x2
Dispose
Warn anaesthetic
Insert LA (lignocaine 2%) - squeeze 5ml into urethra
Hold for 3-5mins to give time for the anesthetic to work
Discard top gloves

E+R/SF/SL/FSK/x2Cl/LA/Wait/xGl

Catheter
Place receiver dish inbetween legs/attach catheter to bag
Open catheter
Insert catheter into urethra - ANTT
 - touch plastic only
 - massage out and into urethra
 - if necess when negotiating prostate, lower penis
 - if resistance ask pt to breathe deeply
 - move till bifurcation
 - by now urine should start emptying into plastic/kidney dish
Inflate balloon - 1ml of sterile water
Any pain?
Continue to fill with remaining 9ml
Withdraw catheter to make sure balloon becomes lodged into neck of bladder
Attach catheter bag if not yet attached

Dish/Cath/Ball/WD/Bag

Finishing Off
Restore foreskin/ask pt to (avoid paraphimosis)
Thank pt

Cover them up

Throw away remaining waste

Document:
A) date & time
B) size and type of catheter
C) amount of water in balloon
D) ?problems

E) residual volume of urine intially collected

Tests - dipstick & MSU
10ml from sampling port

Fsk!!/TY/Cov/Cl/DocRV/Ix

Making Errors

Digoxin Side Effect 
Excessive/ppt by hypokalaemia: anorexia, nausea, vomiting, diarrhoea, abdominal pain, visual disturbances, headache, fatigue, drowsiness, confusion, dizziness, delirium, hallucinations, depression, arrhythmias, heart block
Tx: Potassium-sparing diuretics, potassium supplements, digoxin-specific antibody fragments

Mx: blood levels, cardiac monitoring

Methotrexate 

Toxicity: anorexia, diarrhoea, toxic megacolon, hepatotoxicity, pulmonary oedema, dizziness, blood disorders (sore throat, bruising, mouth ulcers), liver toxicity (nausea, vomiting, abdominal discomfort, dark urine), respiratory effects (shortness of breath)

Mx: FBCs, LFTs, Obs

Insulin 
OD: hypoglycaemia

Tx: 50% dextrose, IM glucagon, sugary drink

Mx: Blood glucose

Warfarin 
OD: haemorrhage

Mx: INR, withhold warfarin, Vitamin K

Penicillin Allergy 
Anaphylactic Reaction: urticaria, angiooedemam, fever, inflammation

Mx: Stop antibiotic, adrenaline, chlorphenamine, steroids, fluid

Communications:
- Apologise 

- ?Admit responsibility- Explain carefully what has happened
- Short-term effects
- Long-term effects
- "This shouldn't have happened and we will do everything we can to make sure it does not happen again
- There are many checks and balances"- Notify senior
- Will make an inquiry/Fill in incident form
- Direct to PALS (Patient Advice and Liaison Services)

- Independent Complaints Advocacy Service (ICAS)
- Complaints can be made to Trust Complaints Manager 

- Can talk to consultant

- Write to ward manager
- Give name and bleep number

Alzheimer's Counselling

Alzheimer’s

Normal

-          lose memory, brain cells, difficult to retain information

Alzheimer’s

-          more pronounced

-          changes in brain structure (plaques, tangles, loss of mass) and reduced chemicals involved in transmission of signals

How?

-          familial (early position)

-          basically unknown

Does it get better?

-          progressive

-          starts with forgetfulness/wandering

-          problems with cooking, cleaning, dressing

-          speech

-          difficulty recognising people

Tx

-          no cure

-          just slow progression of disease, reduce anxiety and memory loss

-          Donepezil, rivastigmine, galantamine (Ach-esterase inhibitors)

Side Effects (resolve within few weeks)

-          sleep disturbance

-          nausea

-          loss of appetite

-          diarrhoea

-          muscle cramps

ECG before & regular review

Support

-          community nurses

-          home carer

-          social worker

-          occupational therapist

-          respite care

-          Day Hospital – group Tx

-          Alzheimer’s society

-          Dementia Relief Trust

Steroid Counselling

Hello_____
My name is ________
I'm a __________

Find The Problem
I understand that you've been recently been put on steroids. How do you feel about that? What do you know about steroids? You understand what it is for? Do you have any understanding of the side effects?

Information

Steroids are naturally produced in the body and help reduce inflammation and swelling. Steroids are often used synthetically to help with health problems characterised by inflammation. They are very different from the kind that you hear about in the news that athletes take - those are known as anabolic steroids and act differently on the body.

However, steroids aren't used unless they have to as they have these side effects, but these usually only occur after prolonged use and with higher doses, and we monitor carefully to see if any of these occur.

These include:
Infection - immunosuppression
Higher blood pressure - monitored regularly
DM - can happen go to GP if feeling tired/going to the toilet more
Osteoporosis - thinning of bones - supplements of Ca and Vit D/bisphosphonates/HRT
WG - fullness of face
Increase in appetite
Skin thinning - bruising
Mood change - irritable/depressed
Dyspepsia - indigestion/stomach upsets

General Advice
Blue steroid card - keep with and inform doctors so they can prescribe safely for you. You can also wear a bracelet to let paramedics know.

You musn't stop suddenly as while you take this medication the body produces less of its own steroids, adn stopping suddenly can cause your body to react badly - for example causing confusion, abdomoinal pain, and can require you to go to hospital.

Avoid smoking/drinking
Avoid ibuprofen
as they can increase the likelihood of indigestion

PMHx
Do you suffer from epilepsy/osteoporosis/diabetes/hypotension/excessive bleeding/tuberculous/chicken pox/stomach ulcers?

DHx
Do you take NSAIDs/any other medication?
Allergies?

SHx
Smoke/Drink

Is that all clear? How do you feel about that? We can arrange a follow-upappontment with GP if you have any further questions you want to ask. What have you taken away from this?

I can give you some leaflets. Steroid cards also carry a lot of info, so don't worry if you forget.

Peak Flow

WIPER

Hi, my name is _______, I'm a doctor here. It's very nice to meet you.

Find the Problem
I understand you have symptoms that might suggest asthma. In order to rule help us to rule in or rule out the diagnosis we do a test called the Peak Flow test. Have you had this test before? Are you happy with your understanding of asthma? Are you happy with doing this test?

This is a peak flow meter. It's just a simple tube that measures how well the air flows out of your lungs, and whether you have any difficulty pushing it out. If you have asthma this shows as being less than normal for a person of your height, sex and age.

Demonstrate
I'll show you how to use it, to help you understand how to do it.
First we reset the pointer to make sure that it's one zero.
We stand up for the test. We put a fresh mouthpiece into the meter.
Breathe in fully deeply, as much as you can. Hold the meter level in front of you making sure your fingers don't cover over the pointer. Make a tight seal with your mouth on the mouthpiece. Blow as hard as you can and as fast as you can, like blowing out the candles on a cake. We're not concerned about how long or how much you blow out. Okay? Like so.

We'll do the test 3 times, and take the highest reading as your score.

General Advice

We record like thus and if we record it in a diary we can keep of track of how your breathing is throughout the day. Asthma tends to vary quite characteristically through the day, and can help us make a diagnosis and see how you are doing on medication.

The best time to take a peak flow are first thing in the morning, and before you go to bed. Also take it when you are experiencing symptoms such as coughing or wheezing.

Repeat Relevant Parts

Would you like to have a go?

ICE
Do you have any questions, concerns or expectations?

We'll need to follow-up to see how you've coped with the medication and if your symptoms have improved.


What factors affect PEFR?
- height
- age
- sex
- acute and chronic resp disease
- smoking

Using Inhalers

Hi, my name is______
I'm a final year student.
How are you today?

Find the Problem
Okay, from your symptoms and peak flow recording we believe you might have asthma. What do you know about asthma? How do you feel about it?

Asthma is a condition of the lung where you can get difficulty breathing. We find sensitive airways, that react by narrowing when they become irritated, making it difficult for air to move in or out. It's this narrowing that causes the chest tightness and wheezing that you've been experienced.

We can do something to help with these symptoms. To help with this condition we can prescribe you salbutamol, which is given in a blue inhaler. It works by opening up the airways so air can move more freely. By being given in an inhaler we can deliver the medicine exactly where it needs to be. Is that okay?

What do you know about inhalers? Have you ever used one before?

Demonstrate
Okay, I'm going to show you how to use the inhaler, because technique is very important in ensuring you get the most out of it and to help your lungs as much as possible. Use it when you art feeling wheezy or tightness of the chest.
First we shake the inhaler with the cap on to mix the medicine properly. We remove the cap from the mouthpiece and hold the inhaler like so, between your thumb and index finger, with your index finger on the canister.
Take a big breath in and fully breathe out. Put the mouthpiece in your mouth. At the same time as you breath in push down on the top of the inhaler. Hold your breath for ten seconds afterwards.

Repeat if necessary after 1 minutes.
Gargle/rinse out your mouth if you are using a steroid inhaler.

Mild side-effects of salbutamol include fast heart rate, shakiness and headaches. If they are worrying you should again come back to us.
Salbutamol can be taken 2 puffs as needed, up to 4 times a day, as the maximum. If you need more than that you should return to us, as we might need to try something else, perhaps combining it with another inhaler.

Does that sound okay to you?

Repeat Relevant Parts
Can you show me know how you would use it?
Can you tell me when should you use it?

General Advice
There may be some leaflets I can give you to help your understanding, and to take home with you.

ICE
Do you have any questions, ideas, concerns, expectations?

We'll review you in a while to see how you are doing with it, and if your symptoms have improved.
Does that sound okay?

Thank you!