basic surgical practice pekeño.doc

8/11/2019 BASIC SURGICAL PRACTICE pekeo.doc

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BASIC SURGICAL PRACTICE

FOR THE THIRD YEAR MEDICAL STUDENTS

LIDIA IONESCU

ASSOCIATE PROFESSOR

DEPARTMENT OF SURGERY

UNIVERSITY OF MEDICINE AND PHARMACY

GR. T. POPA IASI


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INT ROD UCT ION

This practical guide in surgery is aimed to help you during your medical

training in the different surgical setting such as wards, dressing

rooms, consultation rooms and operative rooms.

asy to read, here you will find when, why and how, different surgical

procedures are applied.

!ife in surgery is not comforta"le if you are a hesitating andconfused

medical student. To get rid of such annoying feelings read the "oo#,

watch carefully what and how the senior surgeons are doing and then

start to practice under supervision.

$ou will soon reali%e that what was cloudy has gone.

$ou will find out in here how to cope with a patient in acute retention of urine

who desperately needs urinary catheteri%ation, how to deal with a

septic wound, what are principles of asepsis and antisepsis upon which

is "ased the surgical procedures and so on.

Read, watch and practice& this is my advice in your 'uest to "ecome a

successful doctor.

1. ASEPSIS AND ANTISEPSIS

Asepsis

A simple definition of asepsis is the absence of any infectious agents.

Surgical asepsis refers to any procedure used to eliminate any

microorganisms.

By the process of sterilization it is achieved sterile medical items which are

used during surgical work.

Aseptic technique means any medical procedure used to prevent

contamination of a person, area or object by microorganisms.

So any surgical work must respect aseptic principles in order to ensure the

safety of the patient and of the surgeon himself.

Sterilization

Sterilization is the process that kills all forms of living matter including

bacteria, viruses and molds with the use of special equipment

employing different physical or chemical agents moist heat, dry heat,

ethylene o!ide gas, gamma irradiation, etc".

#he practical criterion of sterility is the failure of microbiological growth to

appear on tests in suitable bacteriologic media.

Sterile is an object or part of the human body without living organisms on

its surface.

Sterilization $rocedures


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1. Moist het o! ste" #$%e! p!ess#!e

This p!o&e%#!e %est!o's (( "i&!o)i( (i*e th!o#+h the %e$t#!tio$ $%

&o+#(tio$ o* i$t!&e((#(! p!otei$.

The p!"ete!s o* e**i&ie$&' !e,

- te"pe!t#!e o* 1/ %e+!ee Ce(si#s0

- t"osphe!i& p!ess#!e o* .2

- 3/ "i$#tes ti"e o* ste!i(i4tio$.

The t'pe o* "oist het ste!i(i4e! &o""o$(' #se% is &((e% #to&(5e0 6hi&h is

%esi+$e% to *#$&tio$ !pi%(' t hi+h te"pe!t#!e $% i$&!ese% p!ess#!e.

Moist het is the "ost !e(i)(e "etho% o* ste!i(i4i$+ so*t s#!+i&( s#pp(ies s#&h

s %!pes0 sheets0 +o6$s0 %!essi$+s0 &otto$ )ese o* its po6e! o* pe$et!tio$0

"i&!o)io(o+i& e**i&ie$&'0 ese o* &o$t!o( $% e&o$o"' o* ti"e.

. D!' het ste!i(i4tio$

This p!o&e%#!e o* ste!i(i4tio$ is #se% *o! ite"s tht !e spoi(e% )' "oist#!e $%

*o! "te!i(s tht !esist pe$et!tio$ )' ste"0 #s#((' "et((i& i$st!#"e$ts $%

+(ss "e%i&( !ti&(es.

The p!o&ess &o$sists o* )7i$+ the "te!i( to )e ste!i(i4e% i$ hot-i! o5e$

&((e% Po#pi$e(.

I$ the )se$&e o* "oist#!e0 the p!"ete!s o* e**i&ie$&' !e,

- hi+he! te"pe!t#!e 819/ %e+!ee Ce(si#s:

- (o$+e! e;pos#!e ti"e 81ho#!: !e !e


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Disi$*e&tio$ o* the hospit( e$5i!o$"e$t is &hie5e% th!o#+h the #se o*

&he"i&( s#)st$&es to %est!o' ptho+e$i& i$*e&tio#s +e$ts.

Disi$*e&t$t is &he"i&( s#)st$&e #se% to 7i(( o!+$is"s o$ the s#!*&e o*

i$$i"te o)?e&ts s#&h s s#!+i&( i$st!#"e$ts )e*o!e ste!i(i4tio$0 *(oo!s0 *(#sh

toi(ets0 et&.

A %isi$*e&t$t t (o6 &o$&e$t!tio$ &$ )e #se% s $ $tisepti&.

The ope!ti$+ !oo"s $% (( the *#!$it#!e s#&h s ope!ti$+ t)(es0 i$st!#"e$t

t)(es0 (i+hts !e &(e$e% 6ith %isi$*e&t$ts *te! e&h ope!tio$.

C(e$si$+ 6ith %isi$*e&t$t $% 6te! o* the #se% s#!+i&( i$st!#"e$ts is $

esse$ti( p!e(i"i$!' to ste!i(i4tio$.

Antisepsis

This !e*e!s to the #se o* &he"i&( s#)st$&es o$ s7i$0 "#&os $% 6o#$%s to%est!o' i$*e&tio#s +e$ts.

S#!+eo$s pe!*o!" the s#!+i&( s&!#) o$ h$%s )e*o!e the ope!ti5e p!o&e%#!e

6ith $tisepti& so(#tio$s.

A(so0 $tisepti& so(#tio$s !e #se% &!e*#((' *o! p!eope!ti5e p!ep!tio$ o* the

ptie$t@s s7i$ i$ o!%e! to &!ete $ !e o* "i$i"( )&te!i( &o$t"i$tio$. This

!e is &((e% ope!ti5e *ie(% $% i$ the &e$te! o* this !e 6i(( )e the s#!+i&(

i$&isio$ o* the s7i$. The "!+i$s o* the ope!ti5e *ie(% !e %e(i$ete% )' ste!i(e

sheets "i$ti$e% i$ positio$ )' spe&i( &(ips.

A +oo% $tisepti& "#st &&o"p(ish the *o((o6i$+


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3= h'%!o+e$ pe!o;i%e is o$e o* the )est $tisepti&s #se% *o! the t!et"e$t o* the

i$*e&te% 6o#$%s. It hs )oth +oo% )&te!i&i%e &tio$ $% &ts s "e&h$i&(

&(e$se! )' !e"o5i$+ %e)!is o! $e&!oti& tiss#e %#e to its *o"i$+ e**e&t i$

&o$t&t 6ith ope$ 6o#$% tiss#es.

It &o#$te!&ts the *o#( s"e(( o* i$*e&te% 6o#$%s $% hs he"ostti& &tio$ s

6e((.

hloramine

This $tisepti& is 5e!' e**i&ie$t s it !e(eses &h(o!i$e i$ &o$t&t 6ith tiss#es o*

$ ope$ 6o#$% !e"o5i$+ (( %e)!is $% s(o#+h st#**. The!e*o!e it is &((e% the

&he"i&( s&(pe(.

Silver nitrate

I$ &o$&e$t!tio$ o* 1- =o it is #se% s $ $tisepti& *o! i$*e&te% 6o#$%s0

espe&i((' 6ith Pse#%o"o$s e!#+i$os.

I$ &o$&e$t!tio$ o* 1- = it is #se% *o! #!i$!' )(%%e! 6sh o#ts.

I$ &o$&e$t!tio$ o* 1/-/ = it &$ te!i4e the o5e!+!o6th o* the +!$#(tio$

tiss#e o* 6o#$%.

It "' (so )e #se% i$ the p!oph'(;is o* $eo-$tes &o$?#$&ti5itis.

Boric acid

This s#)st$&e p!ese$ts s 6hite po6%e! 6hi&h &$ )e po#!e% i$ i$*e&te%

6o#$%s $% it is spe&i((' e**e&ti5e +i$st Pse#%o"o$s e!#+i$os.

)odoform

This s#)st$&e p!ese$ts s 'e((o60 s"e((' po6%e!0 "i$(' *o! the%e$t!ist'

#se0 i$ $e!o)es i$*e&te% &5ities.

Surgical scrub

S7i$ ste!i(i4tio$ is $ot possi)(e ho6e5e! e5e!' e**o!t is "%e to !e%#&e the

)&te!i( &o#$t o* the s7i$ i$ o!%e! to "i$i"i4e the possi)i(it' o* "i&!o)i(

&o$t"i$tio$ o* the s#!+i&( 6o#$%s.

The s#!+i&( s&!#) is p!o&ess o* "e&h$i&( s&!#))i$+ 6ith &he"i&(

$tisepti& so(#tio$.

Ge$e!( p!ep!tio$ *o! s#!+i&( s&!#) i$&(#%es the *o((o6i$+, "7i$+ s#!e

*i$+e!$i(s !e sho!t $% #$po(ishe% $% !e"o5( o* (( h$% ?e6e(!'.

The !it#( o* s#!+i&( s&!#) 6s i"+i$e% )' I+$4 Se""e(6eiss 8ie$0 19:

)#t it 6s $ot &&epte% i$to s#!+i&( p!&ti&e #$ti( )o#t 199/.

The %#!tio$ o* h$%s s&!#))i$+ 5!ies *te! the %i**e!e$t $tisepti& so(#tio$s. A

"i$i"#" o* -2 "i$#tes is &o$si%e!e% $e&ess!' )e*o!e the *i!st ope!tio$ $%

*#!the! o$ "i$#tes s&!#) is %e


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I$ hospit(s0 %o&to!@s h$%s "' )e&o"e &o$t"i$te% 6ith "i&!oo!+$is"s

*te! to#&hi$+ ptie$ts o! se&!etio$s i$*e&te% o! &o(o$i4e% 6ith these +e!"s.

T!$sie$t h$% &!!i+e o* this t'pe o* *(o! is o$e o* the "?o! !o#tes o* &!oss-

i$*e&tio$ )et6ee$ ptie$ts.

I$ the hospit(0 this t!$sie$t *(o! o*te$ &o$sists o* ptho+e$s !esist$t to

$ti)ioti&s. The!e*o!e ptho+e$i& )&te!i o$ the h$%s o* ope!!ti$+ pe!so$$e(

t the ti"e o* ope!tio$ "#st )e !e"o5e% )' s&!#))i$+ $% %est!o'e% )' $

$tisepti& +e$t.

-nvironmental control of the surgical suite

E$5i!o$"e$t( &o$t!o( o* the s#!+i&( s#ite is esse$ti( to 7eep &o$t"i$tio$ to

"i$i"#" $% p!o5i%e ";i"#" p!ote&tio$ *o! the ptie$t.

These *&to!s i$&(#%e,

- +!ete! !oo" i! p!ess#!eth$ i$ h((6' *o!&i$+ i!*(o6 o#t o* the s#!+i&(

!e0

- !est!i&te% t!**i&0

- &o$t!o((e% !oo" te"pe!t#!e o* 19- %e+!ees Ce(si#s0

&o$t!o((e% h#"i%it' o* 2/=

- i! &h$+e !te o* 19-2 ti"es pe! ho#!0

- #(t!5io(et i!!%itio$ *o((o6i$+ %isi$*e&tio$ o* the ope!ti$+ !oo".

The ope!ti$+ !oo" sho#(% )e &o$si%e!e% $ iso(tio$ 4o$e tht "' )e e$te!e%

o$(' )' pe!so$s 6e!i$+ &(e$ ope!ti$+ tti!e 6hi&h "' $ot )e 6o!$

e(se6he!e.

$reparation of the patient/s skin

A 6i%e !e o* s7i$ !o#$% the ope!ti5e i$&isio$ is p!ep!e% )' sh5i$+ $%

s&!#))i$+.

Sh5i$+0 i* !e


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- pi&7 #p the ste!i(e +o6$ *te! s&!#))i$+ the h$%s0 )ei$+ &!e*#( to to#&h o$('

the i$$e! p!t.

- ho(% the i$si%e o* the $e&7)$% $% (et the +o6$ #$*o(% 7eepi$+ the i$si%e p!t

o* the +o6$ to6!%s 'o#.

- 6ith 'o#! h$%s t 'o#! sho#(%e! (e5e(0 i$se!t 'o#! !"s i$to the s(ee5es07eepi$+ 'o#! !"s e;te$%e%.

- the $#!se 6i(( ssist 'o# )' p#((i$+ the +o6$ o5e! the sho#(%e!s $% t'i$+ it i$

the )&7.

- 7eep 'o#! h$%s i$ the i! )ei$+ &!e*#( $ot to to#&h $' #$ste!i(e ite"s.

0loving

- t7e the (e*t +(o5e *!o" the p&7+e )' p(&i$+ the *i$+e!s the !i+ht h$% o$

the *o(%e%-)&7 **0 to#&hi$+ o$(' the i$$e! s#!*&e o* the +(o5e

- i$se!t the (e*t h$% i$to the +(o5e0 )#t %o $ot t#!$ #p the **

- $o6 t7e the !i+ht +(o5e *!o" the p&7+e )' s(ippi$+ +(o5e% (e*t *i$+e!s

#$%e! the i$5e!te% ** $% p#(( the +(o5eo$to the !i+ht h$%

- the **s !e $o6 p#((e% o5e! the s(ee5es o* the +o6$

- i* +(o5e )e&o"es &o$t"i$te% it "#st )e &h$+e% i""e%ite('.

The *o((o6i$+ )si& p!i$&ip(es !e+!%i$+ ste!i(e te&h$i


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e. the )se$&e o* $' (i5i$+ "tte!.

1. A ste!i(e s#!+i&( i$st!#"e$t "e$s,

. &(e$se% i$st!#"e$t 6ith $o!"( s(i$e0

). &(e$se% i$st!#"e$t )' )oi(i$+0

&. $ i$st!#"e$t 6ith (o6 &o$te$t o* )&te!i0

%. $ i$st!#"e$t 6itho#t $' (i5i$+ "tte!0

e. $ i$st!#"e$t &(e$se% 6ith )et%i$e.

1.3 ht %o 'o# %o i* 'o# $oti&e tht the #!i$!' &thete! 'o# !e +oi$+ to #se it

*o! ptie$t 6ith te !ete$tio$ o* #!i$e0 is o#t%te%,

. 'o# #se it )ese the!e is $o ti"e to 6ste s the ptie$t is i$ +o$'0

). 'o# #se it *te! &(e$si$+ it 6ith )et%i$e0

&. 'o# s7 *o! $othe! o$e 6hi&h is 6ithi$ s*et' ti"e o* e;pi!'0

%. 'o# +i5e the ptie$t so"e pi$ 7i((e!s $% postpo$e the p!o&e%#!e0

e. 'o# #se it s it is.

1. Che"i&( ste!i(i4tio$ is i$%i&te% *o!,

. sheets $% %!essi$+s0

). "et((i& i$st!#"e$ts0

&. +(o5es0 %. s'!i$+es0

%. het-se$siti5e s#!+i&( e


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- s'!i$+e o* pp!op!ite &p&it' 8%o$t )e +ht sho!t #si$+ 1/ "( s'!i$+e

6he$ 'o# $ee% / "( )(oo%:

- $ (&oho( s6) 85oi% tht 6he$ t7i$+ )(oo% *o! (&oho(e"i:

- to#!$i


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O$&e s#&&ess*#(0 tpe the &$$#( $% +i5i$+ set se!e(' $% &o"*o!t)(' to

the ptie$t@s !".

P!o)(e"s 'o# "i+ht *&e $% so(#tio$s

1. Poo! 5ei$s - p(&e the *o!e!" i$ (o6e! positio$ th$ the )o%'s (e5e(

to se 5e$o#s %i(ttio$.

2. F!+i(e 5ei$s0 p!ti(!(' i$ the e(%e!(' $% ptie$ts o$ &h!o$i& ste!oi%

t!et"e$t - &o$si%e! s"((e! &$$#( o! #se )#tte!*('.

3. Post-p!o&e%#!e )(ee%i$+-e(e5te the ptie$ts !" )o5e the he%0 this

6i(( se the 5ei$s to &o((pse $% the )(ee%i$+ stop0 i$ the "e$6hi(e

7eep p!ess#!e 6ith s6) o5e! the )(ee%i$+ p#$&t#!e-site.

4. Th!o")oph(e)itis !e(te% 6ith $ i$%6e((i$+ &$$#( - &hoose $othe!

5ei$ i* the ptie$t $ee%s *#!the! i.5. *(#i%s $% +i5e $o$ste!oi%(

$tii$*(""to!' "e%i&tio$. The pi$ is t!o#)(eso"e )#t this&o$%itio$ $e5e! &o"p(i&tes 6ith p#("o$!' e")o(is" s %eep

5ei$ th!o")osis %oes.

MC tests

.1 Fo! pe!iphe!( 5e$o#s &&ess0 6ht is the )est 5ei$ to #se i$ $ 'o#$+ p&te,,

. e;te!$( ?#+#(! 5ei$0

). i$te!$( sphe$o#s 5ei$0

&. e;te!$( sphe$o#s 5ei$0

%. 5ei$ i$ the $te)it( *oss0

e. 5ei$ i$ the *o!e!" o! %o!s#" o* the h$%.

. Fo! si"p(e 5e$#p#$&t#!e 'o# sho#(% #se,

. the "ost 5isi)(e 5ei$ o* the *o!e!"0

). e;te!$( ?#+#(! 5ei$0

&. i$te!$( sphe$o#s 5ei$0

%. i$te!$( ?#+#(! 5ei$0

e. *e"o!( 5ei$.

.3 ht %o 'o# %o i* ptie$t p!ese$ts *!e


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e. s#pe!*i&i( th!o")oph(e)itis &$ $e5e! &o"p(i&tes 6ith p#("o$!'

e")o(is".

6. A5#-5)A7 $43#45-

A!te!i( p#$&t#!e is i$%i&te% i$ &!iti&((' i(( ptie$ts *o! !te!i( )(oo% +s

"es#!e"e$ts 8A>G@s:.

This is $ i"po!t$t i$5esti+tio$ 6hi&h +i5es #s &(#e )o#t &i%-)se

i")($&e.

ht 'o# $ee% *o! !te!i( p#$&t#!e,

- +!ee$ $ee%(e

- spe&i( s'!i$+e o* "( &o$ti$i$+ 1// #$its o* hep!i$e

- (&oho( s6) $% )(i$% s'!i$+e h#)

he$ the *e"o!( !te!' is #se% *o! p#$&t#!e0 (' the ptie$t s#pi$e o$ the )e%.

I$ *t ptie$ts0 s7 'o#! ssist$t to !et!&t the )%o"i$( p!o$ to %isp(' the

+!oi$.

Fe"o!( !te!' e$te!s the thi+h )' pssi$+ )ehi$% the i$+#i$( (i+"e$t0 s

&o$ti$#tio$ o* the e;te!$( i(i& !te!'. He!e it (ies "i%6' )et6ee$ the

$te!io! s#pe!io! i(i& spi$e $% the s'"phisis p#)is. Its p#(stio$s !e esi('

*e(t.

The *e"o!( 5ei$ (e5es the thi+h )' pssi$+ )ehi$% the i$+#i$( (i+"e$t

"e%i( to the p#(sti$+ *e"o!( !te!'.

he$ the !%i( !te!' is #se% *o! p#$&t#!e pe!*o!" *i!st(' the A((e$ test to

est)(ish the &o"pete$&e o* the !%i( $% #($! !te!ies i$ the s#pp('i$+ the

h$%.

The p#(stio$s o* the !%i( !te!' &$ esi(' )e *e(t $te!io! to the %ist( thi!% o*

the !%i#s. He!e0 it (ies ?#st )e$eth the s7i$ $% *s&i (te!( to the te$%o$ o*

*(e;o! &!pi #($!i.

A((e$ test

Ho(% the ptie$ts h$% #p $% p(pte the !%i( $% #($!is !te!ies t the 6!ist.

O&&(#%e )oth 6ith p!ess#!e $% s7 the ptie$t to &(e$&h $% ope$ the h$%se5e!( ti"es.

The h$% )e&o"es )($&he%. Re(ese p!ess#!e o$ the #($! !te!' $% 6t&h

)(#sh ppe!i$+ !pi%(' o5e! the h$%0 %e"o$st!ti$+ the pte$&' o* the #($!

!te!'.

Repet 6ith the !%i( !te!'. Pte$&' o* )oth !te!ies is !eP "o$ito!i$+ i$ i$te$si5e &!e #$it.


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A!te!i( )(oo% +sses- $o!"( 5(#es

Ph B.32- B.2

PCO 32-2"" H+

POJ/-11/"" H+

HCO3 -B ""o(K(

>se e;&ess -3 to 3

A&i%-)se ho"eostsis !ep!ese$ts $ e


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5espiratory alkalosis

This is the !es#(t o* te o! &h!o$i& h'pe!5e$ti(tio$.

C#ses,

- te h'po;i0 %#e to p$e#"o$i0 p$e#"otho!;0 p#("o$!' e%e"

- &h!o$i& h'po;i0 %#e to &'$oti& he!t %iseses0 $e"i

- !espi!to!' &e$te! sti"#(tio$ se% )' $;iet'0 *e5e!0 G!" $e+ti5e

sepsis

- e;&essi5e 5e$ti(tio$ i$ the "e&h$i&((' 5e$ti(te% ptie$t.

Definitions of the medical terms used in text

Pneumonia is inflammation of the lungs with exudation and consolidation.

Pneumothorax is presence of air in the pleural space# usually as a result of

chest trauma.

Pulmonary edema is diffuse extra!ascular accumulation of fluid in the

pulmonary tissues and air spaces due to change in hydrostatic forces in the

capillaries or to increased capillary permeability$ the clinical sign is dyspnea.

%dema in general is an abnormal accumulation of fluid in intercellular spaces

of the body.

&ypoxia is reduction of oxygen supply to a tissue below physiological leels

despite ade'uate perfusion of the tissue by blood.

&ypoxemia means deficient oxygenation of the blood.

yanosis means a bluish discoloration of skin and mucous membranes due to

excessie concentration of reduced hemoglobin in the blood.

nemia is reduction of the number of red cells and 'uantity of hemoglobin in

the blood.

8etabolic acidosis

This !es#(ts *!o" the &"#(tio$ o* &i%s0 !e%#&tio$ o* !e$( &i% e;&!etio$ o!

(oss o* (7(i.

C#ses

- i$&!ese% &i% p!o%#&tio$

- 7eto&i%osis 8%i)etes0 (&oho(is"0 st!5tio$:

- (&ti& &i%osis 8&!iti&((' i(( ptie$t:

- to;i& i$+estio$ 8s(i&'(tes0 "eth$o(:

- !e$( *i(#!e

- (oss o* (7(i 8%i!!he:

T!et"e$t "#st )e %i!e&te% p!i"!i(' to the #$%e!('i$+ se.

>i&!)o$te the!p' sho#(% )e &o$si%e!e% i$ ptie$ts 6ith "o%e!te to se5e!e

"et)o(i& &i%osis0 %epe$%i$+ o$ the etio(o+'.

8etabolic alkalosis

The "ost &o""o$ ses o* "et)o(i& (7(osis i$ the s#!+i&( ptie$t i$&(#%e,

- %i#!eti& the!p'

- &i% (oss th!o#+h +st!o-i$testi$( se&!etio$s 8*!e


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14

Pyloric ulcer (peptic ulcer) * lack of substance in the parietal layers of pyloric

region# due to the action of the acid gastric "uice.

U$%e! $o!"( &i!"st$&es0 the e;&ess i$ )i&!)o$tes is e;&!ete% !pi%(' i$

the #!i$e.

Co$se


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15

9. $ASS)30 A 3AS10AS#5) #4B-

Nso+st!i& t#)es !e #se% i$ 5!iet' o* &(i$i&( &o$%itio$s,

- to ((o6 *(#i% i$ e;&ess to es&pe *!o" %iste$%e% sto"&h 8p'(o!i& ste$osis0

hi+h s"(( )o6e( o)st!#&tio$:

- to i$sti(( *(#i% *o! +st!i& (5+e 8 p!ep!tio$ o* the sto"&h *o! #ppe!

e$%os&op':

- to i$sti(( *ee%i$+ so(#tio$s i$to the sto"&h0 i$%i&te% i$ ptie$t i$ &o" o!

i$ p!o(o$+e% "e&h$i&((' 5e$ti(te% ptie$t:.

Nso+st!i& t#)es !e eithe! si$+(e (#"e$ 8Le5i$: o! %o#)(e (#"e$ 8s#"p t#)e:.

Most NG t#)es h5e !%ioop


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- CR o! )%o"i$( !' &$ )e o)ti$e% to &o$*i!" &o!!e&t p(&e"e$t0 )#t

#s#((' this is #$$e&ess!'.

The t#)e sho#(% )e *(#she% 6ith 3/ "( o* s(i$e o! 6te! e5e!' ho#!s to

"i$ti$ pte$&'.

S#"p t#)e 8%o#)(e (#"e$ t#)e: &$ )e &o$$e&te% to (o6 i$te!"itte$t s#&tio$ 8 pte$t i! po!t p!e5e$ts t#)e %he!e$&e to the sto"&h 6((: o! &$ )e (e*t to

+!5it' %!i$+e o! &ppe% o**.

To p!e5e$t i$?#!' to the +st!i& "#&os0 si$+(e-(#"e$ t#)e sho#(% $ot )e

&o$$e&te% to &o$ti$#o#s s#&tio$.

The NG t#)e is !e"o5e% 6ith +e$t(e t!&tio$.

P!o)(e"s 'o# "i+ht *&e $% so(#tio$s

1. Ptie$t 6o$@t s6((o6- t!' +i$ 6hi(e t the s"e ti"e the ptie$t is

s6((o6i$+ sips o* 6te!.

. Meet !esist$&e i$ the esoph+#s- +i5e #p0 this t#)e $ee%s to )e psse% #$%e!

!%io(o+i&( &o$t!o(.

3. A$;io#s ptie$t - e;p(i$ the p!o&e%#!e $% !ess#!e tht p!o&e%#!e is *o! his

)e$e*it $% 'o# $ee% his &oope!tio$.

Co"p(i&tio$s

Pe!*o!tio$ o* the esoph+#s0 sto"&h o! %#o%e$#" is !!e "' !es#(t i$

"e%isti$itis o! pe!ito$itis.

The t#)e p!e5e$ts &(os#!e o* the (o6e! +st!oesoph+e( sphi$&te! $% "i+ht

(e% to +st!oesoph+e( !e*(#;0 esoph+itis0 esoph+e( st!i&t#!e o! )!o$&hi(

spi!tio$ o* +st!i& &o$te$ts i$%#&i$+ spi!tio$ p$e#"o$itis.

Medical terms definitions

Mediastinitis ! inflammation of the mediastinum (life!threatening medical

condition)

Peritonitis ! inflammation of the peritoneum which may be due to chemical

irritation (gastric acid from a perforated peptic ulcer) or bacterial inasion.

+astro!esophageal reflux means the ascending of the gastric content into the

esophagus due to lower esophageal sphincter incompetence.

%sophagitis ! inflammation of the esophageal mucosa due to chemical irritation(gastric acid or bile reflux).

spiration pneumonitis ! inflammation of the lungs due to aspiration of gastric

content into the respiratory tree.

MC TESTS

.1 The *o((o6i$+ i$%i&tio$s o* the $so+st!i& t#)e !e &o!!e&t ECEPT ONE,

. %e&o"p!essio$ o* the sto"&h0

). spi!ti$+ p$e#"o$itis0

&. +st!i& (5+e0

%. i$sti((i$+ the *ee%i$+ so(#tio$s0

e. s"(( )o6e( o)st!#&tio$.

. The (e$+th o* $so+st!i& t#)e "#st )e,

. / &"0

). 2 &"0

&. 3/ &"0

%. "o!e th$ / &"0

e. 32 &".

.3 The *o((o6i$+ stte"e$ts !e+!%i$+ pssi$+ $so+st!i& t#)e !e &o!!e&t

ECEPT ONE,

. the t#)e is psse% th!o#+h $ost!i(0


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). the ptie$t "#st &oope!te )' s6((o6i$+ i$ o!%e! to e$++e the t#)e i$to

the esoph+#s0

&. the t#)e hs !e&he% the sto"&h 6he$ +st!i& &o$te$t &$ )e spi!te% i$to

s'!i$+e0

%. the $so+st!i& t#)es !e (6's psse% th!o#+h the "o#th0

e. the $so-+st!i& t#)e &$ )e #se% *o! *ee%i$+.

. The *ee%i$+ $so+st!i& t#)e &$ )e #se% ,

. i$ ptie$t 6ith p!o(o$+e% "e&h$i&( 5e$ti(tio$0

). i$ ptie$t 6ith esoph+e( pe!*o!tio$0

&. i$ ptie$t 6ith !e*(#; esoph+itis0

%. i$ ptie$t 6ith spi!ti$+ p$e#"o$itis0

e. i$ ptie$t 6ith &o"p(ete esoph+e( o)st!#&tio$.

.2 Pssi$+ $so+st!i& t#)e is $ot i$%i&te% i$,

. p'(o!i& ste$osis0

). %#o%e$( o)st!#&tio$0

&. s"(( )o6e( o)st!#&tio$0

%. +st!o-esoph+e( !e*(#;0

e. +st!i& (5+e.

5. 45-#+5A7 A#+-#-5):A#)13

Anatomy

M(e #!eth!

The "(e #!eth! is )o#t / &" i$ (e$+th *!o" the )(%%e! to the e;te!$(

"et#s o$ the +($s pe$is.

It is %i5i%e% i$to th!ee p!ts, p!ostti&0 "e")!$o#s $% pe$i(e.

The p!ostti& #!eth! (ies 6ithi$ the p!ostte $% is the 6i%est $% the "ost

%i(t)(e po!tio$ o* the #!eth!.

The "e")!$o#s #!eth! (ies 6ithi$ the #!o+e$it( %iph!+" s#!!o#$%e% )'

the sphi$&te! #!eth!e "#s&(e. It is the (est %i(t)(e po!tio$ o* the #!eth!.

The pe$i(e #!eth! is e$&(ose% i$ the )#() $% the &o!p#s spo$+ios#" o* the

pe$is.

The e;te!$( "et#s is the $!!o6est p!t o* the e$ti!e #!eth!.

The p!t o* the #!eth! tht (ies 6ithi$ the +($s pe$is is %i(te% to *o!" the

*oss te!"i$(is 8$5i(! *oss:.

Fe"(e #!eth!

The *e"(e #!eth! is )o#t &" (o$+. It e;te$%s *!o" the $e&7 o* the )(%%e!

to the 5esti)#(e0 6he!e it ope$s )o#t .2 &" )e(o6 the &(ito!is. It t!$s5e!ses

the sphi$&te! #!eth!e $% (ies i""e%ite(' i$ *!o$t o* the 5+i$.

The $to"' 'o# sho#(% !e"e")e! )e*o!e pssi$+ $ #!i$!' &thete! i$ "e$.

1. the e;te!$( o!i*i&e t the +($s pe$is is the $!!o6est p!t o* the e$ti!e

#!eth!

. 6ithi$ the +($s the #!eth! %i(tes to *o!" the *oss te!"i$(is

3. $e! the poste!io! e$% o* the *oss0 *o(% o* "#&o#s "e")!$e p!o?e&ts i$to

the (#"e$ *!o" the !oo*.

. the "e")!$o#s p!t o* the #!eth! is $!!o6 $% *i;e%

2. the p!ostti& p!t o* the #!eth! is the 6i%est $% "ost %i(t)(e p!t o* the

#!eth!


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. )' ho(%i$+ the pe$is #p6!%0 the S-shpe% !5e o* the #!eth! is &o$5e!te%

i$to -shpe% !5e.

)ndications;

-"o$ito!i$+ #!i$!' o#tp#t 8&!iti&((' i(( ptie$t $% pe!iope!ti5e(':

- te !ete$tio$ o* #!i$e

- #!i$!' i$&o$ti$e$&e

- *&i(ittio$ o* )%o"i$( s#!+i&( p!o&e%#!e 8p!ti(!(' pe(5i& ope!tio$s:.

ht 'o# $ee% *o! #!eth!( &thete!i4tio$,

- Fo(e' &thete! 8si4e 1-1 F:

- s'!i$+e 6ith s(i$e (!e%' %!6$ #p

- ste!i(e &thete! p&7 &o$ti$i$+ %!pes0 7i%$e' %ish0 &otto$ )((s0

s6)s0 pots0 p(sti& *o!&eps0 $tisepti& &(e$si$+0 (i+$o&i$e ?e((' $%

$ #!i$!' &o((e&ti$+ s'ste"

- !e(;e% $% !ess#!e% ptie$t.

$rocedure

1. ith the ptie$t s#pi$e o$ the )e%0 &(e$ the +e$it( !e 8+($s 6ith e;te!$(

#!eth!( "et#s:. I$ "$ !et!&t *o!es7i$ 8p!ep#&e: #$(ess he is &i!"&ise%0 to

%isp(' e;te!$( #!eth!( "et#s. I$ 6o"$0 s7 he! to ope$ he! (e+s0

s#ppo!ti$+ he! 7$ees p(&i$+ the so(es o* he! *eet to+ethe!. ith the *i$+e!s o*

'o#! (e*t h$% +e$t(' (i*t $% !et!&t the ()i to e;pose the #!eth!( "et#s.

C(e$ the !e 6ith $ pp!op!ite $tisepti&.

. Ge$t(' i$?e&t the #!eth! 6ith ste!i(e (i+$o&i$e ?e(('.

3. I$ "$ (i*t #p the pe$is $% ho(% it i$ 5e!ti&( positio$.

. >e+i$ to pss the &thete!. Do $ot *o!&e it i* 'o# e$&o#$te! $' !esist$&e0 this

"' )e st!i&t#!e $% 6i(( o$(' %"+e the #!eth! *#!the! $% "' &!ete

*(se pss+e.

2. he$ the &thete! hs %5$&e% to the ?#$&tio$ o* the pe$i(e $%

"e")!$o#s #!eth! t the (e5e( o* the e;te!$( sphi$&te!0 )!i$+ the pe$is %o6$

to (ie ho!i4o$t((' 6hi(e 'o# %5$&e the &thete! th!o#+h the p!ostti& #!eth!.

. he$ #!i$e )e+i$s to *(o60 i$*(te the )((oo$ o* the &thete!.

B. Co$$e&t #p the &thete! to &o((e&ti$+ )+.

Problems you might face and solutions

1. U$)(e to pss the &thete!- %o $ot 7eep o$ t!'i$+ to pss it 'o#!se(*0 &(( *o!

he(p the!e "' )e st!i&t#!e o! *(se pss+e $% these !e


19/70


20/70

20

#(t!so#$% e;"i$tio$ o* the pe(5is to &o$*i!" the &(i$i&( %i+$osis o* te

!ete$tio$ o* #!i$e.

$rocedure

1. C(e$ the s#p!p#)i& s7i$ $% se(e&t poi$t 2 &" )o5e the p#)i& s'"ph'sis

$% i$ the "i%-(i$e.

. Use (i+$o&i$e 1= i$ 1/ "( s'!i$+e 6ith +!ee$ $ee%(e $% s(o6(' i$?e&t

the s#)st$&e i$ the s7i$0 s#)t$eo#s tiss#e0 *s&i $% p!ope!ito$e( *t.

3. he$ the $ee%(e is &o"p(ete(' )#!ie% $% (( the (o&( $estheti& hs )ee$

e;pe((e%0 6ith%!6 the p(#$+e!0 'o# sho#(% o)ti$ #!i$e.

I* 'o# %o0 "7e s"(( i$&isio$ i$ the s7i$ $% !e&t#s sheth 6ith 7$i*e )(%e

$% p!o&ee% 6ith the te&h$i


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2. The i$%i&tio$s o* #!i$!' &thete!i4tio$ !e the *o((o6i$+ ECEPT ONE,

. te !ete$tio$ o* #!i$e0

). #!i$!' t!&t i$*e&tio$0

&. #!i$!' i$&o$ti$e$&e0

%. "o$ito!i$+ the #!i$e o#tp#t i$ &!iti&((' i(( ptie$t0

e. pe!iope!ti5e i$ pe(5i& s#!+e!'.

2.3 A$#!i is,

. &o"p(ete s#pp!essio$ o* #!i$e *o!"tio$ )' the 7i%$e's0

). %i"i$ishe% #!i$e se&!etio$ )' the 7i%$e's0

&. i$)i(it' to &o$t!o( the 5oi%i$+ o* #!i$e0

%. the p!ese$&e o* )(oo% i$ the #!i$e0

e. the p!ese$&e o* p#s i$ the #!i$e.

2. ht is the "ost se!io#s &o"p(i&tio$ o* the #!i$!' &thete!i4tio$,

. #!i$!' t!&t i$*e&tio$0

). (o&( pi$0

&. #$)e!)(e se$stio$ to "i&t#!te0

%. !e$( &o(i&0

e. &!ete *(se pss+e !es#(ti$+ i$ $ #!eth!( st!i&t#!e.

2.2 The "e&h$i&( ses o* the te !ete$tio$ o* #!i$e !e ECEPT ONE,

. #!eth!( t#"o#!0

). #!eth!( sto$es0

&. spi$( &o!% i$?#!'0

%. !#pt#!e o* the #!eth!0

e. p!ostti& e$(!+e"e$t.

=. AS$)5A#)13 1< A $7-45A7 -


22/70

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spo$t$eo#s )!ethi$+ $% the &o")i$tio$ o* s"(( ho(e $% positi5e

p!ess#!e "' !es#(t i$ (!+e (e7-$(o+o#s to p#$&t#!e i$ the i$$e! t#)e o*

t'!e.

The si4e o* the e**#sio$0 s %ete!"i$e% )' -!' $% &(i$i&( ?#%+e"e$t0 sho#(%

i$%i&te the site o* p#$&t#!e.

ht 'o# $ee% *o! &hest spi!tio$,

- ste!i(e +(o5es

- &hest spi!tio$ p&7 &o$ti$i$+ ste!i(e %!essi$+ p&70 (!+e s'!i$+e0 (o$+

6i%e )o!e $ee%(e0 3-6'-tp $% (!+e ?#+.

- (o&( $estheti& 81/ "( o* 1= (i+$o&i$e:

- spe&i"e$ )ott(es *o! )io&he"ist!'0 "i&!o)io(o+' $% &'to(o+'

- o$e ssist$t.

Positio$ o* the ptie$t

Sete% $% (e$e% o5e! )e%si%e t)(e 6ith the h$%s o$ the t)(e.

$rocedure

1. A*te! the i"+e o* &hest !' o! *te! the +#i%$&e o* $ #(t!so#$% o* the

&hest *(#i%0 the site o* p#$&t#!e is est)(ishe%.

. I$*i(t!te the site o* &hest %!i$+e 6ith (o&( $estheti& 1= (i+$o&i$e to

o)ti$ $#")e% !e. Us#((' the site o* p#$&t#!e is i$ $ i$te!&ost( sp&e

*!o" to 9 i$ the "i%;i((!' o! poste!io! ;i((!' (i$e.

3. Mo#$t the 3-6'-tp o$to the s'!i$+e $% tt&h the $ee%(e to the 3-6'-tp.

. Ge$t(' i$se!t the $ee%(e th!o#+h the $estheti4e% s7i$ $% s(i%e the $ee%(e

o5e! the s#pe!io! "!+i$ o* the !i) i$to the p(e#!( sp&e so 5oi%i$+ the

$e#!o5s(! )#$%(e.

2. Aspi!te the e**#sio$0 t7i$+ s"p(es o* the *i!st spi!te *o! ()o!to!'

i$5esti+tio$. As the s'!i$+e *i((s0 e"pt' the &o$te$ts 5i the 3-6'-tp i$to the

?#+. T7e )o#t 1 ( o* the e**#sio$ t e&h sitti$+0 $o "o!e J ( 8!e-e;p$sio$ o*

the (#$+ tht o&!s 6he$ the *(#i% is !e"o5e% &$ !es#(t i$ p#("o$!' e%e".

. he$ *i$ishe%0 p(&e 6te!p!oo* %!essi$+ o5e! the site $% &he&7 the !es#(t

)' &hest !'.

P!o)(e"s

1. D!' tp- "' )e $ o!+$i4e% e"p'e"0 +et he(p

2. P$e#"otho!;-the %!i$+e t#)e is the )est optio$

3. U$e;pe&te%(' 5e!' )(oo%' spi!te-'o# h5e p#$&t#!e% $ i$te!&ost(s

5esse(. eep the ptie$t o$


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e. &h'(otho!;.

.3 ht is the positio$ o* the ptie$t 6he$ 'o# 6$t to %o (e*t &hest

spi!tio$, . %e)it#s positio$0

). p!o)it#s positio$0

&. o$ the (e*t (te!( si%e0

%. T!e$%e(e$)#!+ positio$0

e. sete% $% (e$e% o5e! )e%si%e t)(e.

. he!e is the )est site *o! &hest spi!tio$,

. se&o$% i$te!&ost( sp&e0

). thi!% i$te!&ost( sp&e0

&. Bthi$te!&ost( sp&e0 i$*e!io! "!+i$ o* the !i)0 i$ the poste!io! ;i((!' (i$e0

%. Bthi$te!&ost(s sp&e0 o5e! the s#pe!io! "!+i$ o* the !i) i$ the poste!io!

;i((!' (i$e0

e. 1/thi$te!&ost( sp&e i$ the $te!io! ;i((!' (i$e.

.2 Ho6 &$ 'o# ssess the )est site *o! &hest spi!tio$,

. s(ttio$ o* the &hest0

). pe!ssio$ o* the &hest0

&. o)se!5tio$ o* the !espi!to!' "o5e"e$ts0

%. p(ptio$ o* the &hest0

e. &hest !' o! #(t!so#$% o* the (o6e! tho!; i$ sete% positio$

&. +-S# %5A)3A0- 15 #4B- #+15A1S#18>

This is the te&h$i


24/70

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A5oi%i$+ the (o6e! "!+i$ o* the th0 6he!e the $e#!o5s(! )#$%(e !#$s0 #se

pi! o* *o!&eps o! s&isso!s *o! )(#$t %isse&tio$ th!o#+h the i$te!&ost(s "#s&(es

to the p(e#!( $% p#sh the *o!&eps th!o#+h i$to the p(e#!( sp&e.

A(te!$ti5e('0 i$t!o%#&e sho!t t!o&! th!o#+h the &hest 6((0 th!o#+h 6hi&h the

%!i$ &$ )e p(&e%.

A%5$&e the i$te!&ost(s t#)e i$to the p(e#! $% #se 'o#! *i$+e! to %i!e&t it i$

the !e


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25

A se&o$% )ott(e &$ )e %%e% so tht the ptie$t %!i$s i$to $ e"pt' )ott(e

6hi&h &ts s *(#i% t!p this is the$ &o$$e&te% to $ #$%e!6te! se( %!i$. Ai!

&$$ot )e e$t!i$e% pst the se( )#t *(#i% &$ %!i$ esi('.

Re"o5( o* &hest %!i$

A &hest %!i$ sho#(% o$(' )e (e*t i$ sit# *o! s (o$+ s it se!5es p#!pose.

Ho6e5e!0 i$ i$te$si5e &!e #$it0 spe&i( tte$tio$ sho#(% )e +i5e$ s positi5e

p!ess#!e 5e$ti(tio$ 6i(( te$% to pote$tite (e7s.

I* %!i$+e o* i!0 )(oo% o! *(#i% hs stoppe% the$ the $ee% *o! the %!i$ is $o

(o$+e! pp!e$t $% the t#)e &$ )e !e"o5e%.

A "o!e tio#s pp!o&h is to &("p the %!i$ *o! ho#!s $% i* $o i! is see$

o$ CR0 the$ it &$ )e !e"o5e%.

MC TESTS

B.1 The *o((o6i$+ &o"p(i&tio$s "i+ht ppe! *te! &hest %!i$+e ECEPT

ONE, . %iph!+"ti& pe!*o!tio$ i$ (o6 i$se!tio$ o* the t#)e0

). i$?#!' to the i$te!&ost(s 5esse(s0

&. e"p'e" o* the p(e#!( sp&e0

%. s#)t$eo#s e"ph'se"0

e. spi!tio$ p$e#"o$itis.

B. he!e is the )est e$t!' site *o! the &hest %!i$+e t#)e,

. $%i$te!&ost( sp&e0 $te!io! ;i((!' (i$e0

). *i!st i$te!&ost(s sp&e0 $te!io! ;i((!' (i$e0

&. 1/thi$te!&ost(s sp&e0 $te!io! ;i((!' (i$e0

%. thi$te!&ost( sp&e0 "i%;i((!' (i$e0

e. thi$te!&ost(s sp&e0 "i%;i((!' (i$e.

B.3 ht is the i$%i&tio$ *o! &hest %!i$+e t#)e,

. %!i$+e o* s"(( he"otho!;0

). %!i$+e o* s"(( p$e#"otho!;0

&. %!i$+e o* s"(( he"op$e#"otho!;0

%. pi$ !e(ie* *te! !i) *!&t#!e0

e. %!i$+e o* he"o o! p$e#"otho!; 6hi&h i$%#&es !espi!to!'

e")!!s"e$t.

B. Chest %!i$+e t#)e !e


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26

?. )3#-51S#A7 3-52- B71@

A$to"'

The #ppe! e%+e o* the !i)s is thi&70 !o#$%e% $% s"ooth 6hi(e the (o6e! thi$$e!

e%+e hs s#)&ost( +!oo5e. The o#te! (ip o* this +!oo5e is the i$se!tio$ site o*

the e;te!$( i$te!&ost( "#s&(e0 s the i$te!$( i$te!&ost( "#s&(e is i$se!te% o$the i$$e! (ip.

The i$te!&ost( $e!5e e"e!+es *!o" the i$te!5e!te)!( *o!"e$ $% +i5es o**

poste!io! )!$&h. It the$ psses i$to the sp&e $% +i5es th!ee *#!the! )!$&hes0

the &o((te!( )!$&h $% the $te!io! $% (te!( t$eo#s )!$&hes. The

&o((te!( )!$&h s#pp(ies the i$te!&ost( "#s&(es0 !i) pe!ioste#" $% p!iet(

p(e#!.

The $te!io! t$eo#s )!$&h s#pp(ies the s7i$ o5e! the *!o$t the tho!; o! i$

the &se o* the (o6e! i$te!&ost(s0 the #ppe! )%o"e$ $% sso&ite% "#s&(es.

The (te!( t$eo#s )!$&h !ises *!o" the "i$ $e!5e i$ the"i%-;i((!' (i$e

$% s#pp(ies the s7i$ o5e! the (te!( &hest 6((.

)ndications

I$%i&tio$s i$&(#%e $(+esi )oth i$ e"e!+e$&' $% i$ e(e&ti5e postope!ti5e

sit#tio$s.

I$ the e"e!+e$&' sit#tio$0 the pi$ !es#(te% *!o" *!&t#!e% !i)s &$ )e

((e5ite%.

These !e e;t!e"e(' pi$*#( $% "' i$hi)it &hest 6(( "o5e"e$ts "7i$+$o!"( )!ethi$+ %i**i(t.

I$te!&ost( )(o&7s &$ e**i&ie$t(' ((e5ite the pi$ sso&ite% )oth 6ith $o!"(

"o5e"e$t $% i$te!5e$tio$s s#&h s &hest ph'siothe!p'.

Ope!ti5e p!o&e%#!es0 s#&h s i$se!ti$+ &hest %!i$s0 !e "%e "o!e to(e!)(e )'

i$te!&ost( )(o&7.

ht 'o# $ee% *o! i$te!&ost( )(o&7,

- ste!i(e +(o5es

- / "( s'!i$+e $% +!ee$ $ee%(e

- / "( o* 1= "!&i$e

- %!essi$+ p&7 $% topi&( s7i$ $tisepti&.


Sete% 6ith the &hest (e$e% *o!6!%s

P!ep!tio$ o* the s7i$

Use io%i$e o5e! the )&7 o* the &hest i$&(#%i$+ the !i) 5o)e $% !i) )e(o6 the

)!o7e$ !i)s

$rocedure

1. P(pte the i$te!&ost( sp&es ssessi$+ the (o6e! "!+i$ 6he!e the

i$te!&ost( )#$%(e is (o&te%

. Pss the $ee%(e o* the s'!i$+e &o$ti$i$+ the (o&( $estheti& #$%e! the !i).

3. Aspi!te $% i* $o )(oo% o! i! is %!6$ )&70 the$ i$*i(t!te 3-2 "(.

. Repet the p!o&e%#!e t the sites )o5e $% )e(o6 the )!o7e$ !i).

2. As7 *o! &he&7 CR to e;&(#%e p$e#"otho!;.

P!o)(e"s

I* 'o# %!6 )(oo% o! i!0 s(o6(' 6ith%!6 the $ee%(e se5e!( "i((i"ete!s $%spi!te +i$

As7 the ptie$t )e*o!e p!o&e%#!e i* he is 6!e o* $' ((e!+' to the (o&(

$estheti&

I* the ptie$t is $ot 6!e0 %o s7i$ test *o! ((e!+'.

MC TESTS

9.1 h' it is so i"po!t$t to !e(ie5e the pi$ i$ !i) *!&t#!es,


27/70


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28

Co+#(opth'0 p!e+$$&' $% )%o"i$( s&!!i$+ "' (( "7e the p!o&e%#!e

h4!%o#s.

A5oi% this p!o&e%#!e i* the!e is +seo#s %iste$sio$ o* the )o6e( eithe! &(i$i&(('

o! o$ )%o"i$( -!'.

ht 'o# $ee% *o! pe!ito$e( spi!tio$,

- "i$o! %!essi$+ p&7

- $tisepti&

- (o&( $estheti& 81= (i+$o&i$e:

- +!ee$ $ee%(e *o! %i+$osti& tp.

- / "( s'!i$+e0 +!ee$ $ee%(e $% th!ee 6' tp i* *o! the!pe#ti& tp.

- spe&i"e$ )ott(es *o! )io&he"ist!'0 "i&!o)io(o+'0 &'to(o+'.


S#pi$e positio$ 6ith s(i+ht ti(t to the (e*t

P!ep!tio$

Pe!ss the )%o"e$ #s#((' i$ the (e*t i(i& *oss *o! %#(($ess.

C(e$ the s7i$ 6ith )eth%i$e.

I$*i(t!te the site o* the tp %o6$ to0 i$&(#%i$+ the pe!ito$e#"0 6ith (o&($estheti&.

#echnique

1. E$s#!e tht the )(%%e! is e"pt'. Che&7 )' p(ptio$ $% pe!ssio$.

2. Se(e&t site i$ the i(i& *oss0 o$e-thi!% o* the 6' )et6ee$ the $te!io!

s#pe!io! i(i& spi$e $% the #")i(is. A5oi% the i$*e!io! epi+st!i&

5esse(s.

3. A*te! (o&( $esthesi %o$e0 %5$&e the $ee%(e th!o#+h the s7i$ i$to

the pe!ito$e#"0 spi!ti$+ s the $ee%(e %5$&es.

4. O$&e i$ the pe!ito$e#"0 *(#i% sho#(% )e spi!te% esi('.

5. I* 'o# !e %!i$i$+ s&itis0 &o$$e&t the $ee%(e to &o((e&ti$+ t#)e $%

)+.

I* *o((o6i$+ se5e!e t!#"0 'o# %!6 )&7 )(oo%0 'o# h5e the %i+$osis o*

he"ope!ito$e#".

ith%!6 the $ee%(e $% %!ess the 6o#$%.

I$ the p!ese$&e o* i$*e&tio$0 the p!otei$ &o$te$t o* pe!ito$e( spi!te !ises

8e;#%tes: $% the!e is "!7e% i$&!ese i$ $e#t!ophi(s o$ &'to(o+i&(

e;"i$tio$.

I$ *!$7 pe!ito$itis t#!)i% *(#i% "' )e spi!te% $% "i&!oo!+$is"s "' )e

see$ o$ G!" Sti$ $% (t#!e.

I$ te p$&!etitis0 the "'(se &o$&e$t!tio$ o* the pe!ito$e( *(#i% &$ )e

5e!' hi+h.

omplications

1. D"+e to the i$*e!io! epi+st!i& 5esse(s is see$ s !pi%('

&"#(ti$+ he"to"- i&e )+ $% o)se!5tio$.

2. P#$&t#!e o* the )(%%e! sho#(% $ot o&! i* the )(%%e! e"pt'.

3. P#$&t#!e o* the )o6e( is #$#s#( )#t "' !es#(t i$ &o$t"i$tio$ o* the

othe!6ise ste!i(e s&ites.

4. I$*e&tio$ o* s&itis i* the septi& te&h$i


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29

. epi+st!i#"0

). !i+ht h'po&ho$%!i#"0

&. !i+ht i(i& *oss0

%. (e*t i(i& *oss0

e. h'po+st!i#".

J. ht $to"i&( st!#&t#!e sho#(% )e p!ese!5e% %#!i$+ $ )%o"i$(

spi!tio$, . !e&t#s )%o"i$is sheth0

). i$*e!io! epi+st!i& 5esse(s0

&. e;te!$( o)(ie! i$ "i$% tht spi$( i$?#!' &$ (so p!o%#&e "is(e%i$+ &(i$i&( si+$s.

Pe!ito$e( (5+e sho#(% i$%i&te i* i$t!)%o"i$( )(ee%i$+ is p!ese$t.

Fi(#!e to %i+$ose i$t!)%o"i$( )(ee%i$+ p!o"pt(' i$ the "#(tip(e t!#"

ptie$t &$ )e %isst!o#s.

Medical term definition


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30

Politrauma means multiple in"uries but at least one is life!threatening.

#echnique

The &o""o$(' #se% site *o! i$se!tio$ is i$ the "i%(i$e )o#t 2 &" )e(o6 the

#")i(is.

E$s#!e tht the ptie$t@s )(%%e! is e"pt' $% pss #!i$!' &thete! i* $e&ess!'.

C(e$ $% %!pe the (o6e! )%o"e$

I$*i(t!te the (o&( $estheti& i$to the s7i$ $% %o6$ i$to the (i$e ().

ith s&(pe( "7e s"(( i$&isio$ i$ the s7i$.

Eithe! )(#$t %isse&tio$ o! %i!e&t p(&e"e$t o* t!o&! &$ )e #se%.

A%5$&e this pe!pe$%i(! to the s7i$ $% p#sh C "o!e th$ 1//0 ///K""30 >C

"o!e th$ 2//K""3 0 G!" sti$ sho6s )&te!i.

I* the &(i$i&( si+$s i$%i&te (p!oto"' the$ it is poi$t(ess pe!*o!"i$+

(5+e.

omplications

1. Co+#(opth' "' !es#(t i$ )(ee%i$+ *!o" the p#$&t#!e.

2. S&!!i$+ o* the (o6e! )%o"e$ "' s#++est tethe!i$+ o* the)o6e( o!

%hesio$s tht hi+h(' i$&!ese the !is7 o* )o6e( pe!*o!tio$.

3. I* the ptie$t hs $ i(e#s 6ith %iste$%e% )o6e( the!e is si"i(! !is7.

4. A *#(( )(%%e! $ee%s to )e e"ptie% p!io! to i$se!tio$ o* pe!ito$e(

&thete! s )(%%e! p#$&t#!e is &o""o$ p!o)(e".

5. >o6e( pe!*o!tio$ &$ )e %i**i(t to %i+$ose )#t *i(#!e to %!i$

%e


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31

%. po(it!#" ptie$t i$ &o"0

e. o5e!%iste$%e% #!i$!' )(%%e!.

1/.3 ht is the i$%i&tio$ *o! pe!ito$e( (5+e *!o" the *o((o6i$+ &(i$i&(

sit#tio$s,

. po(it!#" ptie$t 6ith hi+h s#spi&io$ o* 5is&e!( i$?#!' $ot !e%i('

%i+$os)(e )' the #s#( &(i$i&( "e$s0

). 6he$ )%o"i$( spi!tio$ !e5e(s *!$7 )(oo%0

&. 6he$ )%o"i$( p!&e$tesis !e5e(s p#s0

%. 6he$ )%o"i$( tp !e5e(s t#!)i% *o#( s"e((i$+ *(#i%0

e. 6he$ )%o"i$( tp !e5e(s #!i$e i$ t!#" ptie$t.

1/. ht %o 'o# %o i* pe!ito$e( (5+e is $e+ti5e )#t the ptie$t p!ese$ts the

si+$s o* se5e!e i$te!$( )(ee%i$+,

. 6it $% see0

). )(oo% t!$s*#sio$0

&. #!+e$t (p!oto"'0

%. s7 *o! CT s&$ o* the )%o"e$0

e. "o$ito! )(oo% p!ess#!e.

1/.2 ht %o 'o# !e&o""$% i* pe!ito$e( (5+e !e5e(s *e&( pe!ito$itis,

. +i5e $ti)ioti&s0

). +i5e pi$7i((e!s0

&. +i5e )(oo% t!$s*#sio$0

%. e;p(o!to!' (p!oto"'0

e. *(#i% !ess#s&ittio$.

. BA77113 #A8$13A%-


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33

6. I$*(te the +st!i& )((oo$ 82/"( NS:. The!e sho#(% )e $o !esist$&e.

I* the!e is !esist$&e0 the )((oo$ is eithe! i$ the esoph+#s o! i$ the

%#o%e$#".

7. P#(( the t#)e )&7 #$ti( it (o%+es *i!"(' t the +st!o-esoph+e(

?#$&tio$. E;&essi5e *o!&e 6i(( se %"+e.

8. I$*(te the esoph+e( )((oo$ 6ith 1// "( NS. D#!i$+ i$*(tio$ 6t&h

*o! $' si+$s o* !espi!to!' e")!!ss"e$t o! &o"p(i$ts o* pi$.

C!%i& !!h'th"is o&&sio$((' o&! s the esoph+e( )((oo$ is

i$*(te%.

9. App(' t!&tio$ to the t#)e. A 6ei+ht o* 3// + &$ )e #se%. The esiest

"etho% is to #se )+ o* s(i$e s 1 "( is 1 +.

10.At ho#!s %e*(te the esoph+e( )((oo$ $% !e"o5e the t!&tio$ to

ssess he"ostsis. I$ &se o* !e)(ee%i$+0 the )((oo$ &$ )e !ei$*(te%

*o! *#!the! 1- ho#!s )#t s#!+i&( i$te!5e$tio$ )e&o"esi$&!esi$+(' (i7e('.

11.I* the!e is $o )(ee%i$+0 (e5e the esoph+e( )((oo$ %e*(te% )#t (e5e

the t#)e i$ p(&e. De*(te the +st!i& )((oo$ $% !e"o5e ho#!s (te!

i* $o )(ee%i$+ hs o&!!e%.

omplications

1. The t#)e +e$e!((' is #$&o"*o!t)(e *o! the ptie$t. The!e "i+ht )e !e!!e$t

he"o!!h+e *te! )((oo$ %e*(tio$.

. Se!io#s &o"p(i&tio$s !e(te% to #se o* the t#)e "i+ht i$&(#%e esoph+e(

pe!*o!tio$0 is&he"i& $e&!osis o* the esoph+#s %#e to o5e!i$*(tio$ o* the

esoph+e( )((oo$ o! t!&heo)!o$&hi( spi!tio$ o* the +st!i& &o$te$t.

3. I$*(tio$ o* the +st!i& )((oo$ i$ the (o6e! esoph+#s o! i$ $ #$i%e$ti*ie%

hit#s he!$i &$ !es#(t i$ !#pt#!e o* the esoph+#s s &$ o5e!i$*(tio$ o* the

esoph+e( )((oo$.

These &o"p(i&tio$s &$ )e 5oi%e% )' e$s#!i$+ the!e is $o !esist$&e to

i$*(tio$ o* the +st!i& )((oo$0 the ;-!' positio$ is &o!!e&t $% t!&tio$ o$ the

t#)e is $ot e;&essi5e.

. O&&sio$((' the t!&tio$0 espe&i((' i* it is 6ei+hte% s'ste"0 &$ !es#(t i$

"i+!tio$ o* the t#)e i$to the h'poph!'$; !es#(ti$+ i$ p!ti( o! &o"p(ete

i!6' o)st!#&tio$.

2. P!o(o$+e% #se 6ith p!ess#!e o$ the esoph+e( "#&os &$ se "#&os(

$e&!osis $% #(&e!tio$. To 5oi% this0 the esoph+e( )((oo$ &$ )e %e*(te%

*o! *e6 "i$#tes e5e!' ho#!s )#t this "' p!e&ipitte )(ee%i$+.

MC TESTS

11.1 I$ 6ht &o$%itio$ "' ppe! esoph+e( 5!i&es,

. &i!!hosis 6ith po!t( h'pe!te$sio$0

). +st!o-esoph+e( !e*(#;0

&. esoph+itis0

%. hepti& &'st0

e. h'pe!te$sio$.

11. ht is the "ost i"po!t$t &(i$i&( si+$ *o! !#pt#!e% esoph+e( 5!i&es,

. hi+h s'sto(i& )(oo% p!ess#!e0

). he"te"esis0

&. )!%i&!%i0

%. (o6 ho#!(' #!i$!' o#tp#t0

e. )i(i!' 5o"iti$+.

11.3 The &o"p(i&tio$s o* pssi$+ >(7e"o!e t#)e !e ECEPT ONE,

. esoph+e( pe!*o!tio$0

). is&he"i& $e&!osis o* the esoph+#s0


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34

&. p$e#"otho!;0

%. esoph+e( #(&e!tio$0

e. t!&heo )!o$&hi( spi!tio$ o* the +st!i& &o$te$t.

11. The *o((o6i$+ stte"e$ts )o#t the te&h$i


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35

s#!+eo$ &$ t7e it o5e! $% p(&e it i$ the ?e?#$#"0 e.+. %#!i$+ tot(

+st!e&to"' 6ith eso-?e?#$( $sto"osis.

The $so-?e?#$( *ee%i$+ t#)e &$ )e !e"o5e% t the )e%si%e 6he$ $o (o$+e!

$ee%e%.

Co"p(i&tio$s

Co"p(i&tio$s !e !e(te% to i$&o!!e&t p(&e"e$t.

1. Pe!*o!tio$ o* the esoph+#s0 sto"&h0 %#o%e$#"0 ?e?#$#" is !!e )#t

"i+ht (e% to %e5e(op"e$t o* septi& "e%isti$itis i$ &se o* esoph+e(

pe!*o!tio$ $% pe!ito$itis i$ &se o* +st!i& o! %#o%e$( pe!*o!tio$.

2. Lo$+ st$%i$+ $so-+st!i& t#)e "' *&i(itte +st!o-esoph+e(

!e*(#; %#e to "i$ti$e% ope$ &!%i 6ith pote$ti( &o"p(i&tio$ o*

ste$osi$+ esoph+itis.

*. 0astrostomy tubes

Gst!osto"' t#)es e$te! the sto"&h th!o#+h the $te!io! )%o"i$( 6((0 so

the' !e #s#((' p(&e% s#!+i&((' #$%e! (o&( $esthesi o! +e$e!( $esthesi.

I$%i&tio$s

A +st!osto"' t#)e "i+ht )e i$%i&te% *o! $#t!itio$ ! %"i$ist!tio$ o*

"e%i&tio$ i$ ptie$t 6ith &o"p(ete %'sph+i0 #s#((' %#e to $ #$!ese&t)(e

&!&i$o" o* the esoph+#s tht o)st!#&ts the (#"e$.

T'pes o* t#)es

T#)es %esi+$e% spe&i*i&((' *o! #se s +st!osto"' t#)e !e 5i()(e 6ith

)((oo$ tips o! "#sh!oo"s tips $% h5e si$+(e (#"e$.

M$+e"e$t

The +st!osto"' t#)e &$ )e p(&e%, ope!ti5e(' th!o#+h s"(( (p!oto"'0

(p!os&opi&((' o! pe!t$eo#s #$%e! e$%os&opi& +#i%$&e 8PGA:

The +st!osto"' t#)e &$ )e p(&e% to +!5it' %!i$+e o! &$ &ppe% o** $%

#se% o$(' s $ee%e%. The e;it site sho#(% )e &(e$se% %i('.

A*te! the t!&t th!o#+h the )%o"i$( 6(( hs he(e% *o! t (est 1 6ee70 "ost

+st!osto"' t#)es &$ )e !ep(&e% i* the!e is (e7 o! "(*#$&tio$ o* the t#)e.

I* the +st!osto"' t#)e $o (o$+e! is $ee%e% it &$ )e !e"o5e% 6ith +e$t(e

t!&tio$ $% s"(( +#4e )$%+e &$ )e p(&e% o5e! the e;it site #$ti( the

%!i$+e s#)si%es. Most +st!osto"' sites 6i(( &(ose o** 6ithi$ - 6ee7s.

Medical terms definitions

+astrostomy ! opening of the anterior stomach wall to the abdominal skin for

enteral nutrition when oral way is not feasible (e.g. obstructie esophageal

cancer).

+astrotomy * cutting of the gastric wall during surgery

+astrectomy! resection of the stomach (total resection is total gastrectomy#

partial resection is partial gastrectomy).

Cejunostomy tube

The' !e p(&e% i$to the ?e?#$#" th!o#+h the $te!io! )%o"i$( 6((. These !e

i$%i&te% *o! %"i$ist!tio$ o* "e%i&tio$ $% e$te!( *ee%i$+0 6he$ it is $otpossi)(e to pe!*o!" +st!osto"' 8t#"o#!s o* the sto"&h $% %#o%e$#" o!

p!e5io#s +st!i& s#!+e!':.

A ?e?#$osto"' t#)e &$ )e p(&e% t (p!oto"' o! (p!os&opi&(('.

The t#)e &$ )e se!e% i$ the ?e?#$#" 6ith o$(' p#!se-st!i$+ s#t#!e o! 6ith

se+"e$t o* the &thete! t#$$e(e% 6ithi$ the ?e?#$#".

The t#)e sho#(% )e *(#she% 6ith /-3/ "( o* 6te! o! s(i$e e5e!' - ho#!s to

"i$ti$ pte$&'.


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36

Co"p(i&tio$s

The' !e !e(te% to i$&o!!e&t p(&e"e$t.

1. Pe!ito$itis "i+ht !es#(t *!o" pe!*o!tio$ o* the )o6e(.

2. O)st!#&tio$ "i+ht %e5e(op %#e to )o6e( (oop !ottio$ !o#$% the

?e?#$osto"' t#)e o! *!o" p!ti( o&&(#sio$ o* the )o6e( (#"e$ )'

t#$$e(e% t#)e.

Blakemore tubes

The' !e #se% i$ ptie$ts 6ith he"o!!h+e *!o" +st!oesoph+e( 5!i&es.

A(tho#+h the >(7e"o!e t#)e is #se% i$*!e


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37

Se(e&tio$ o* the "ost pp!op!ite t#)e o! %!i$ *o! p!ti(! sit#tio$ is )se%

o$ t'pe0 5is&osit' $% 5o(#"e o* *(#i% to )e e5te%.

T'pes o* s#!+i&( %!i$s

1. Ope$ %!i$s

The' !e #se% to est)(ish t!&t )et6ee$ )o%' &5it' $% s7i$ s#!*&e. The'

!e #se% s 6i&7.

D!i$+e is *&i(itte% )' p(&i$+ the %!i$ i$ %epe$%e$t positio$ o* the &5it'

to )e %!i$e%.

Fo! e;"p(e0 %epe$%e$t positio$ o* the pe!ito$e( &5it' is Do#+(s po#&h.

I$ +e$e!(i4e% pe!ito$itis0 to p(&e the %!i$+e t#)es i$ the Do#+(s po#&h is

$ot e$o#+h. S#!+i&( t#)es "#st (so )e p(&e% #$%e! the %iph!+" to 5oi%

spi!tio$ %#e to !espi!to!' "o5e"e$ts0 o* the pe!ito$e( *(#i% *!o" %epe$%e$t

positio$ #p ti(( #$%e! the %iph!+". The *o!"tio$ o* s#)-ph!e$i& )s&ess is

i$ s#&h 6' p!e5e$te%

To p!e5e$t !et!&tio$ o* the %!i$ i$to the 6o#$%0 the %!i$+e t#)e is *i;e% to

the s7i$ #si$+ $o$-)so!))(e s#t#!e o! (!+e s*et' pi$ is p(&e% th!o#+h the

%!i$ )o5e the s7i$.

The %!i$ is &o5e!e% )' thi&7 %!essi$+ to )so!) the %!i$+e *(#i% o! $ osto"'

pp(i$&e )+ &$ )e p(&e% o5e! the %!i$ to &o((e&t %!i$+e.

. C(ose% %!i$s

The' !e t#)es &o$$e&ti$+ )o%' &5it' to se(e% !ese!5oi!.

C(ose% %!i$s !e #se% to %!i$ se!o#s o! )(oo%' *(#i% *!o" %isse&tio$ sites o!

*!o" !o#$% i$t!pe!ito$e( $sto"oses.

The +o( o* these %!i$s is to *&i(itte &opttio$ o* %?&e$t tiss#es $% to

p!e5e$t &"#(tio$ o* se!#" $% the %e5e(op"e$t o* he"to".

he$ p(&e% i$ the pe!ito$e( &5it'0 &(ose% %!i$s !e s#!!o#$%e% )' o"e$t#"

$% othe! tiss#es p!o%#&i$+ &o$t!o((e% si$#s t!&t.

The &(ose% $t#!e o* this %!i$+e %e&!eses the !is7 o* i$t!o%#&i$+ i$*e&tio$

i$to the )o%' &5it' )ei$+ %!i$e%.

The o#tp#t *!o" the %!i$ $% the


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5. A !i+i% %!i$ "' e!o%e th!o#+h the 6(( o* )(oo% 5esse( o! ho((o6

i$testi$( st!#&t#!e. This &o"p(i&tio$ &$ )e "i$i"i4e% )' #si$+ so*t

%!i$s $% !e"o5i$+ %!i$s e!('.

6. E;&essi5e s#&tio$ o$ t#)e &$ (so se $e&!osis o* $e!)'

st!#&t#!es. I$te!"itte$t (o6-(e5e( s#&tio$ is s*e!.

Re"o5(

D!i$s sho#(% )e !e"o5e% 6he$ the' h5e &&o"p(ishe% thei! p#!pose,

- 6he$ the !is7 o* $sto"oti& (e7+e hs psse%0

- 6he$ %!i$+e t#)e is #se% *o! postope!ti5e *(#i% &o((e&tio$ 8)(oo%0

se!#"0 ('"ph: $% it "' )e !e"o5e% 6he$ $o *#!the! %!i$+e

o&!s.

MC TESTS

1.1 Nso-+st!i& t#)e is i$%i&te% i$ the *o((o6i$+ &o$%itio$s ECEPT ONE,

. +st!i& %e&o"p!essio$0

). *ee%i$+ i$ &o" ptie$t0

&. p!ep!tio$ o* the sto"&h *o! +st!i& e$%os&op'0

%. +st!i& (5+e0

e. esoph+itis.

1. Fee%i$+ +st!osto"' t#)e is i$%i&te% i$,

. esoph+e( &$&e! 6ith &o"p(ete %'sph+i0

). +st!i& &$&e!0

&. p'(o!i& ste$osis0

%. %#o%e$( t#"o#!0

e. %#o%e$( #(&e!.

1.3 Fee%i$+ ?e?#$osto"' t#)e is i$%i&te% i$,

. +st!i& &$&e!0

). i(e( )o6e( o)st!#&tio$0

&. )o6e( i$*!&tio$0

%. &o(o$i& &$&e!0

e. !e&t( &$&e!.

1. eh! t#)e is #se% *o!,

. e;te!$( %!i$+e o* the )i(e *!o" the &o""o$ )i(e %#&t0

). e;te!$( %!i$+e o* the p$&!eti& ?#i&e0

&. %!i$+e o* the +st!i& ?#i&e0

%. %!i$+e o* the %#o%e$( &o$te$t0

e. %!i$+e o* the )i(e *!o" the +(( )(%%e!.

1.2 The %epe$%e$t positio$ o* the pe!ito$e( &5it' 6he!e s#!+i&( %!i$+e

sho#(% )e p(&e% is !ep!ese$te% )',

. Do#+(s po#&h0

). p!&o(i& !e+io$0

&. p!%#o%e$( !e+io$0

%. #$%e! t!$s5e!se "eso&o(o$0

e. +st!o-hepti& !e+io$.

6. S#18A A5-

)ndications and general principles of stomas


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The eti"o(o+' o* sto" &o"es *!o" +!ee7 6o!% sto"t "e$i$+ "o#th(i7e

ope$i$+0 p!ti(!(' $ i$&ise% ope$i$+ 6hi&h is 7ept ope$ *o! %i**e!e$t

p#!poses.

E;"p(es o* sto"s,

1.Co(osto"'- ope$i$+ o* the &o(o$ o$to the )%o"i$( s7i$ *o! *e&(%!i$+e.

2. I(eosto"'- ope$i$+ o* the i(e#" o$to the )%o"i$( s7i$ *o! i(e(

%!i$+e.

3. Gst!osto"'- ope$i$+ o* the sto"&h o$to the )%o"i$( s7i$ *o!

*ee%i$+.

4. e?#$osto"'- ope$i$+ o* the ?e?#$#" o$to the )%o"i$( s7i$ *o!

*ee%i$+.

5. T!&heosto"'- ope$i$+ o* the t!&he o$to the $e&7 s7i$ *o! )!ethi$+.

It is o*te$ $e&ess!' to %i5e!t the *e&( st!e" o$to the $te!io! )%o"i$( 6((

5i &o(osto"'.

The e**(#e$t is &o((e&te% i$ !e"o5)(e p(sti& )+ tt&he% )' %hesi5e to the

)%o"i$( s7i$ !o#$% sto".

Sto"s !e $"e% &&o!%i$+ to the p!t o* the )o6e( ope$i$+ o$to the

)%o"i$( 6((, i(eosto"' o! &o(osto"'.

The "?o!it' o* sto"s !e pe!*o!"e% i$ &$&e! s#!+e!'0 (tho#+h the' !eso"eti"es $e&ess!' i$ i$*(""to!' )o6e( %isese0 si+"oi% %i5e!ti(itis

%isese $% si+"oi% 5o(5#(#s.

Sto"s "' )e pe!"$e$t8 *o! the e$ti!e (i*e: o! te"po!!'.

he!e5e! possi)(e0 the $ee% *o! sto" sho#(% )e $ti&ipte% )e*o!e ope!tio$

$% %issse% 6ith the ptie$t.

Pe!"$e$t sto"s

This is $e&ess!' 6he$ the!e is $o %ist( )o6e( se+"e$t !e"i$i$+ *te!

!ese&tio$ o!0 *o! so"e !eso$0 the )o6e( &$$ot )e !e?oi$e%.

A (e*t &o(osto"' is !e


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40

3. E"e!+e$&' !ese&tio$ i$5o(5i$+ #$p!ep!e% )o6e( 8so(i% *e&es i$ the

(#"e$: o! e(e&ti5e s#!+e!' 6he!e the )o6e( hs $ot )ee$ %e


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5. O)st!#&tio$ o* sto" %#e to e%e" o! *e&( i"p&tio$ - !e(ie5e% )'

e;p(o!tio$ 6ith +(o5e% *i$+e! $% so"eti"es +('&e!i$e s#pposito!ies

o! so*te$i$+ e$e"s.

6. Ret!&tio$ o* spo#t i(eosto"'- !e(ee%i$+ is $ i$e5it)(e p!t o* s#!+e!'.

>(oo% (oss sho#(% )e "i$i"i4e% )ese )(ee%i$+ o)s!es the ope!ti5e *ie(%

$% the (oss hs to )e "%e #p (te!.

1. C(ippi$+ $% (i+tio$

Li+tio$ is o)(i+to!' 6he$ (!+e 5esse(s !e %i5i%e%. I$ o!%e! to "i$i"i4e

he"o!!h+e $' 5esse(s !e +e$e!((' o&&(#%e% )' p!ess#!e (o$e0 the *o!&eps

)ei$+ (e*t o$ *o! o$e "i$#te o! t6o. L!+e! 5esse(s !e


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42

tie% o** 6ith th!e%. C!e sho#(% the!e*o!e )e t7e$ s "#&h possi)(e to

&("p the 5esse( (o$e0 6itho#t t7i$+ #p %?&e$t tiss#e.

Fo! the t'i$+ o** o* )(ee%i$+ poi$ts &(ose &oope!tio$ )et6ee$ s#!+eo$ $%

ssist$t is !eipo(! %ithe!"' is "i$(' #se% *o! *i$e s#!+e!' $% !e


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43

%. "o$opo(! %ithe!"'0

e. (o&( he"ostti& +e$ts

1. ht is the )est 6' to o)ti$ he"osttis *o! (!+e 5esse(s %#!i$+ s#!+e!',

. (o&( p!ess#!e0

). (i+t#!e0

&. "o$opo(! %ithe!"#0

%. )ipo(! %ithe!"'0

e. (o&( he"ostti& +e$ts.

1.3 ht is the )est 6' to &o$t!o( %i**#se s"(( 5esse(s )(ee%i$+ *!o" !6

!e 8(i5e! )e% *te! &ho(e&'ste&to"':,

. (o&( p!ess#!e $% p&7i$+ 6ith !eso!))(e he"ostti& "te!i(s0

). &(ippi$+0

&. (i+tio$0

%. s7 the $esthetist to (o6e! )(oo% p!ess#!e0

e. s7 the $esthetist to +i5e 5it. to the ptie$t.

1. The *o((o6i$+ !e the 6's o* s#!+i&( he"ostsis ECEPT ONE,

. &(ippi$+0

). (i+t#!e0

&. "o$opo(! %ithe!'0

%. )ipo(! %ithe!"'0

e. &o$t!o((e% (o6e!i$+ o* the )(oo% p!ess#!e %#!i$+ s#!+e!'.

1.2 ht is the )est 6' to o)ti$ he"ostsis i$ ptie$t 6ith p&e "7e!0

!e$-S 1< S4#45- 8A#-5)A7

V!io#s t'pes o* s#t#!e !e 5i()(e0 the "ost i"po!t$t %isti$&tio$ )ei$+

)et6ee$ )so!))(e $% $o$-)so!))(e "te!i(s.

The +!o#p &$ )e s#)%i5i%e% i$to "o$o*i("e$t $% po('*i("e$t 8)!i%e%:

"te!i(s. The &hoi&e o* s#t#!e "te!i( %epe$%s #po$ the ts7 t h$%0 the

h$%(i$+


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Mo$o*i("e$t "te!i(s h5e $ e;t!e"e(' s"ooth s#!*&e $% &$ )e p#((e%

th!o#+h the tiss#es 6ith "i$i"( *!i&tio$ this "7es the" esie! to i$se!t $%

!e"o5e the$ po('*i("e$t )!i%e% "te!i(s.

O$ the othe! h$%0 "o$o*i("e$t "te!i(s !e sti**0 sp!i$+' $% "o!e %i**i(tto 7$ot. >!i%e% "te!i(s h5e the )est h$%(i$+


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46

The !ee* 7$ot is +e$e!((' se!e 6ith )!i%e% "te!i(s. It is $ot so 6ith

"o$o*i("e$t "te!i(. The!e*o!e &hie5e se!it' )' #si$+ e;t! th!o6s o! )'

t'i$+ s#!+eo$@s 7$ot.

8ethods of skin suturing

The o)?e&ti5e o* s7i$ s#t#!i$+ is to pp!o;i"te the t e%+es so the' 6i((!pi%(' he(0 (e5i$+ "i$i"( s&!. E%+es to )e ppose% sho#(% h5e )ee$ t

i$ &(e$ (i$e $% t !i+ht $+(es to the s7i$ s#!*&e !++e% $% $+(e% e%+es

sho#(% )e t!i""e%.

The t e%+es sho#(% )e )(e to )e )!o#+ht $et(' to+ethe! $% 6itho#t te$sio$0

othe!6ise the 6o#$% "' )!e7 %o6$ o! the s&! s(o6(' st!et&hes0 +i5i$+ $

#+(' !es#(t.

The $ee%(e sho#(% )e "%e to pss pe!pe$%i(!(' th!o#+h the s7i$ i$ o!%e!

tht i$5e!sio$ o* the e%+es "' )e 5oi%e% $% the stit&hes sho#(% )e tie% 6ith

o$(' s#**i&ie$t ti+ht$ess to )!i$+ the s7i$ e%+es to+ethe! 6itho#t &o$st!i&tio$.

Too ti+ht stit&hes se is&he"i o* the tiss#e $% !es#(t i$ %e('e% he(i$+.

Skin closure techniques

1. Si"p(e i$te!!#pte% s#t#!e

. Ve!ti&( "tt!ess s#t#!es #se% *o! &(os#!e o* "ost (!+e 6o#$%s. Goo% s7i$

ppositio$ )#t te$% to (e5e 6i%e stit&h s&!s.

3. Co$ti$o#s o5e!h$% s#t#!e0 o! si"p(e !#$$i$+ stit&h.

. Co$ti$o#s )($7et s#t#!e0 o! !#$$i$+ (o&7e% stit&h

2. S#)ti(!- #se% *o! &os"eti& ppe!$&e

. Ho!i4o$t( "tt!ess s#t#!e

B. C(os#!e o* s7i$ 6o#$% )' "e$s o* Mi&he( &(ips.

Suture removal

S7i$ s#t#!es sho#(% )e !e"o5e% s soo$ s the 6o#$% is st!o$+ e$o#+h to

!e"i$ i$t&t 6itho#t s#ppo!t. I$ the )%o"e$ this t7es )o#t B %'s0 6hi(e i$

the *&e $% $e&7 - %'s.

S#t#!es sho#(% !e"i$ i$ p(&e i* the!e is $' %$+e! o* 6o#$% sep!tio$.

Fo! !e"o5( o* the s#t#!e0 pi&7 #p 6ith *o!&eps o$e t e$% $% p#(( to e;pose p!t o* the stit&h *!o" the s7i$ $% the$ t *(#sh 6ith the tiss#e s#!*&e so

tht the e;pose% (e$+th o* the s#t#!e0 6hi&h is pote$ti((' i$*e&te%0 %oes $ot

h5e to pss th!o#+h the tiss#es.

MC TESTS

12.1 A)so!))(e s#t#!es !e o*te$ #se% to 5oi% the $ee% *o! !e"o5(0 ECEPT

ONE,

. Mi$o! s7i$ ope!tio$s0

). S#!+e!' i$ 7i%s0

&. Ci!"&isio$s0

%. Vse&to"ies0

e. He!$i !epi!.

12. The "i$ %5$t+e o* s'$theti& s#t#!e "te!i(s is,

. The' p!o5o7e (itt(e o! $o i$*(""to!' !e&tio$0

). Goo% h$%(i$+0

&. Goo% )so!))i(it'0

%. Opti"( %#!tio$ o* st!e$+th0

e. P!o5o7e $ i$te$se i$*(""to!' !e&tio$.

12.3 ht is t!#e )o#t "o$o*i("e$t "te!i(s,

. The' h5e $ i!!e+#(! s#!*&e0


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). The' &$ )e p#((e% th!o#+h the tiss#e 6ith "i$i"( *!i&tio$0

&. The' h5e the )est h$%(i$+


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48

C#t 6ith the tips o* the s&isso!s *o! &!&' !the! th$ #si$+ the &!#t&h 6hi&h

6i(( !#$ the !is7 o* %"+i$+ tiss#es )e'o$% the ite" )ei$+ %i5i%e% $% 6i((

(so %i"i$ish &!&'.

%issecting forceps

Ho(% +e$t(' )et6ee$ th#") $% !i$+ *i$+e!s0 the "i%%(e *i$+e! p('i$+ the

pi5ot( !o(e.

T6o "i$ t'pes o* *o!&eps !e 5i()(e0 toothe% *o! to#+he! tiss#e s#&h s

*s&i o! s7i$0 $% $o$-toothe% 8t!#"ti&: *o! %e(i&te tiss#es s#&h s )o6e(

$% 5esse(s. Ne5e! &!#sh tiss#es 6ith the *o!&eps )#t #se the" to ho(%

"$ip#(te tiss#es 6ith +!et &!e $% +e$t(e$ess.

+aemostats artery forceps"

Ho(% he"ostts i$ si"i(! "$$e! to s&isso!s.

P(&e o$ 5esse(s #si$+ the tips o* the ?6s 8the +!ip (esse$s to6!%s the ?oi$t o*the i$st!#"e$t:.

Se!e positio$ #si$+ the !t&het (o&7. Le!$ to !e(ese the he"ostt #si$+ eithe!

h$%. Fo! the !i+ht h$% ho(% the *o!&eps s $o!"((' the$ +e$t(' *#!the!

&o"p!ess the h$%(es $% sep!te the" i$ p($e t !i+ht $+(es to the p($e o*

&tio$ o* the ?oi$t.

Co$t!o( the *o!&eps %#!i$+ this "$oe5!e to p!e5e$t the" *!o" sp!i$+i$+ ope$

i$ $ #$&o$t!o((e% "$$e!.

Fo! the (e*t h$%0 ho(% the *o!&eps #se the th#") $% i$%e; *i$+e! +!spi$+ the%ist( !i$+ $% the !i$+ *i$+e! !esti$+ o$ the #$%e!s#!*&e o* the $e! !i$+ $%

+e$t(' &o"p!ess the h$%(es $% sep!te the" +i$ t !i+ht $+(es to the p($e

o* &tio$ t7i$+ &!e to &o$t!o( the *o!&eps s 'o# %o so.

3eedle holder

G!sp the $ee%(e ho(%e!s i$ si"i(! "$$e! to s&isso!s.

Ho(% the $ee%(es i$ the tip o* the ?6s )o#t t6o-thi!%s o* the 6' (o$+ the

&i!"*e!e$&e0 $e5e! t its 5e!' %e(i&te poi$t.

Se(e&t the $ee%(e-ho(%e! &!e*#(('. Fo! %e(i&te0 *i$e s#t#!i$+ #se *i$e sho!t-

h$%(e% $ee%(e-ho(%e! $% $ pp!op!ite $ee%(e.

S#t#!i$+ t %epth !eet6ee$ th#") $% "e%i#s *i$+e!0

&. >et6ee$ th#") $% !i$+ *i$+e!0

%. >et6ee$ th#") $% (itt(e *i$+e!0

e. >et6ee$ i$%e; $% !i$+ *i$+e!.


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1.3 Ho6 is &o!!e&t(' ho(% s&(pe( *o! *i$e s7i$ i$&isio$,

. Li7e 7$i*e t)(e0

). >et6ee$ th#") $% !i$+ *i$+e!0

&. >et6ee$ th#") $% "e%i#s *i$+e!0

%. >et6ee$ th#") $% (it((e *i$+e!0

e. Li7e pe$.

1. Ho6 is &o!!e&t(' ho(% s&(pe( *o! !o#ti$e s7i$ i$&isio$,

. Li7e 7$i*e t)(e0

). Li7e pe$0

&. >et6ee$ th#") $% i$%e; *i$+e!0

%. >et6ee$ th#") $% !i$+ *i$+e!0

e. >et6ee$ th#") $% (itt(e *i$+e!.

1.2 ht is the #se o* $ $to"i&( *o!&eps,

. G!spi$+ po$e#!osis0

). G!spi$+ s7i$0

&. G!spi$+ %e(i&te tiss#es0

%. Ret!&ti$+ the tiss#es0

e. C#tti$+.

&. $5-1$-5A#)2- A5-

Ope!tio$s sho#(% )e &!!ie% o#t #$%e! opti"( &o$%itio$s to e$s#!e the )est

possi)(e !es#(t *o! the ptie$t.

P!epe!ti5e i$5esti+tio$s, 6hi&h tests $% 6h'

ardiovascular system

A$ ECG 6i(( %i+$ose is&he"i& he!t %isese $% %'s!h't"is.

The i$&i%e$&e o* si(e$t is&he"i is si+$i*i&$t $% is&he"i& he!t %isese is

sso&ite% 6ith "$' othe! ptho(o+i&( &o$%itio$s s#&h s &e!e)!o5s(!

%isese0 h'pe!te$sio$0 %i)etes.

A p!eope!ti5e ECG o$ (( ptie$ts o5e! the +e o* / is !e&o""e$%e%.

U$%e! the +e o* /0 $ ECG sho#(% )e &!!ie% o#t i$ the *o((o6i$+ &o$%itio$s,

- histo!' o* &hest pi$s0 p(pittio$s0

- sho!t$ess o* )!eth o$ e;e!tio$0

- s#%%e$ *i$ti$+

- h'pe!te$sio$

- histo!' o* he!t %isese

- st!o$+ *"i(' histo!' o* he!t %isese

- he5' s"o7e!

5espiratory system

I* the ptie$t is $o!"((' *it )#t hs &o#+h o! &o(%0 it is sto"!' to postpo$e

s#!+e!' #$ti( he is )ette!. This is )ese +e$e!( $esthesi ses so"e


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te(e&tsis 8(5eo(! &o((pse:0 6hi&h i$ the p!ese$&e o* &o-e;isti$+ #ppe!

i!6' i$*e&tio$ "' (e% to )!o$&hop$e#"o$i.

I* the s#!+i&( &o$%itio$ is (i*e th!ete$i$+ the$ it &$$ot )e %e*e!!e%. I$ this

sit#tio$ it is $e&ess!' to opti"i4e the pe!iope!ti5e stte #si$+ $ti)ioti&s0

o;'+e$0 )!o$&ho%i(to!s $% &hest ph'siothe!p'.

Ro#ti$e &hest-;-!' is o*te$ poi$t(ess e;e!&ise.

It is o* 5(#e i* the!e is histo!' o* p!e5io#s p#("o$!' %isese o! ph'si&(

si+$s i$%i&te si+$i*i&$t ptho(o+'.

A(( i$5esti+tio$s "#st )e ?#sti*ie% )' $ e;pe&ttio$ tht the !es#(t &o#(% )e

)$o!"(.

P!eope!ti5e i$5esti+tio$s !e $ot s&!ee$i$+ e;e!&ise *o! the +e$e!(

pop#(tio$.

Blood

E$s#!e tht the ptie$t is $ot $e"i&.

Do )(oo% he"o+(o)i$ esti"tio$ $% *#(( )(oo% &o#$t )e*o!e e5e$ "i$o!

s#!+e!'.

I* the ptie$t is $e"i& postpo$e $ e(e&ti5e p!o&e%#!e #$ti( it is i$5esti+te%

$% &o!!e&te%.

I* $ e"e!+e$&' ope!tio$ is $e&ess!'0 &o!!e&t the $e"i )' t!$s*#sio$ o*

6ho(e )(oo% o! p&7e% &e((s.

E;&(#%e )(oo% %isese $% )(ee%i$+ te$%e$&ies0 espe&i((' i* the ptie$t is

?#$%i&e% o! hs (i5e! %isese. Vit"i$ i$?e&tio$s 1 "+0 9 ho#!('0 "' )e

!e


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51

M($#t!itio$ is (i$7e% to postope!ti5e "o!)i%it' $% "o!t(it'. The!e is

!e%#&e% !esist$&e to i$*e&tio$ $% poo! 6o#$% he(i$+.

These &o"p(i&tio$s !e o)se!5e% i$ ptie$ts #$%e!+oi$+ !%iothe!p' o!

&he"othe!p'0 i$ %i)etes0 o(%e! ptie$ts $% those 6ho !e i""#$o%epp!esse%

o! o$ (o$+-te!" ste!oi%s.

E;"i$e $% 6ei+h the ptie$t.

Is the!e e5i%e$&e o* 6ei+ht (oss, (oose s7i$ *o(%0 +#$t ppe!$&e.

As7 ho6 the 6ei+ht (oss &"e )o#t, !e!!e$t 5o"iti$+0 pi$ o$ eti$+0

%i!!he0 (oss o* petite. Loss o* 1/= is &&epte% s e5i%e$&e o* "($#t!itio$.

>o%' "ss i$%e; is &((te% G 8+: o5e! hei+ht se$e*its o* $#t!itio$( s#ppo!t,

- i""#$e &o"pete$&e i$&!eses

- 6o#$% $% $sto"oti& he(i$+ i"p!o5e 6he$ ()#"i$ (e5e(s pp!o&h

$o!"(it'.

- s#!5i5( *!o" s#!+i&( &o"p(i&tio$s is "o!e (i7e('.

)ndications for nutritional support;

- p!eope!ti5e(' i$ "($o#!ishe% ptie$ts

- e;&e!)tio$s o* i$*(""to!' )o6e( %isese

- sepsis $% "?o! s#!+i&( &o"p(i&tio$s

- e;te$si5e )#!$s o! t!#"

- !%ioK&he"othe!p' *o! &$&e!s.

5outes for nutritional support

I* GI t!&t is 5i()(e0 #se it.

1. O!( !o#te, *oo% p!ep!tio$s $% s#pp(e"e$ts &$ )e +i5e$ i*

s6((o6i$+ is possi)(e $% GI t!&t is *#$&tio$i$+.

. E$te!( !o#te, NG t#)es0 +st!osto"' *ee%i$+ t#)e0 ?e?#$osto"' t#)e

i$ ptie$ts 6ith *#$&tio$i$+ s"(( )o6e(.

St!t )' &o$ti$#o#s(' i$*#si$+ t 2 "(Kh0 +!%#((' i$&!esi$+ to 1// "(Kh.

3. P!e$te!( !o#te,

- pe!iphe!( 5ei$ *ee%i$+ is #se*#( i$ the sho!t te!". Ptie$ts 6ith

"($#t!itio$ *o! "(i+$$t %isese "' )e$e*it *!o" p!eope!ti5e

$#t!itio$ o* this 7i$%.

- tot( p!e$te!( $#t!itio$ 5i &e$t!( 5ei$ is i$%i&te% 6he$ othe!

"etho%s o* *ee%i$+ !e eithe! i"possi)(e o! #$s#it)(e.

Most ptie$ts !e


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TOTAL 2// "( 2// "(

Eater depletion

Mi(% 6te! %ep(etio$ is 6he$ the %e*i&it is (.

Si"pto"s $% si+$s, thi!st0 o(i+#!i0 %!' to$+#e.

Mo%e!te 6te! %ep(etio$ 6he$ the %e*i&it is 3 (.

Si"pto"s $% si+$s, 6e7$ess $% t&h'&!%i

Se5e!e 6te! %e*i&it is 6he$ the %e*i&it is (.

Si"pto"s $% si+$s, (o6 >P0 hi+h #!e0 h'pe!$t!ie"i.

Eater e!cess

Si"pto"s $% si+$s, he%&he0 &o$*#sio$0 &o$5#(sio$s.

3atrium depletion

This is %#e to 6te! o5e!(o%.

S'"pto"s $% si+$s, *i$ti$+0 post#!( h'pote$sio$0 o(i+#!i.

Se5e!e h'po$t!ie"i, sho&70 se5e!e h'pote$sio$0 hi+h #!e0 (o6 N0 &o$*#sio$0

&o".

3atrium e!cess

The i$te!stiti( &o"p!t"e$t e;p$%s (e%i$+ to &(i$i&( e%e".

$otassium depletion

This is %#e to %ep(eti$+ %i#!eti&s0 p'(o!i& ste$osis.

S'"pto"s $% si+$s, 6e7$ess0 $o!e;i0 i(e#s0 &!%i& !!h'th"is.

ECG- T 65e *(tte$i$+

$otassium e!cess

Mo!e th$ B.2 ""o(K( (e%s to "#s&(e p!('sis0 &!%i& !!h'th"is 6ith

pe7e% T 65es o$ ECG.

I$ s#!+i&( ptie$ts it is sso&ite% 6ith te !e$( *i(#!e0 "ssi5e tiss#e

%ist!#&tio$ 8&!#sh o! )#!$s i$?#!ies: 6he$ (e7s o#t o* 'he t!#"ti4e%

tiss#es.

T!et"e$t, 2/ + +(#&ose12 U i$s#(i$ +i5e$ s !pi% i$*#sio$1// "( o* 9.=

so%i#" )i&!)o$te / "( &(&i#" +(#&o$te 1/= o5e! 2 "i$.

I* it *i(s the$ %i('sis is %5is)(e.

MC TESTS

1B.1 The )e$e*its o* $#t!itio$( s#ppo!t0 p!eope!ti5e(' 6he$ "?o! s#!+e!' isp($$e%0 !e ECEPT ONE,

. i""#$e &o"pete$&e i$&!eses0

). (ess postope!ti5e pi$0

&. 6o#$% he(i$+ i"p!o5es 6he$ ()#"i$ (e5e(s pp!o&h $o!"(it'0

%. $sto"oti& he(i$+ i"p!o5es0

e. s#!5i5( *!o" s#!+i&( &o"p(i&tio$s is "o!e (i7e('.

1B. he$ sho#(% $ot $#t!itio$( s#ppo!t )e #se%,

. p!eope!ti5e(' i$ "($o#!ishe% ptie$ts0

). sepsis $% "?o! s#!+i&( &o"p(i&tio$s0

&. o(% ptie$ts #$%e!+oi$+ &ho(e&'ste&to"'0

%. e;te$si5e )#!$s o! t!#"0

53


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53

e. !%ioK&he"othe!p' *o! &$&e!s.

1B.3 S'"pto"s $% si+$s o* 6te! %ep(etio$ !e ECEPT ONE,

. o(i+#!i0

). h'po$t!ie"i0

&. (o6 )(oo% p!ess#!e0

%. h'pe!$t!ie"i0

e. hi+h #!e.

1B. S'"pto"s $% si+$s o* potssi#" %ep(etio$ !e0 ECEPT ONE,

. 6e7$ess0

). $o!e;i0

&. i(e#s0

%. o$ ECG0 pe7e% T 65e0

e. o$ ECG- T 65e *(tte$i$+.

1B.2 ht is $ot t!#e )o#t s'"pto"s $% si+$s o* potssi#" e;&ess,

. T 65e *(tte$i$+ o$ ECG0

). "#s&(e p!('sis0

&. &!%i& !!h'th"is0

%. pe7e% T 65es o$ ECG0

e. Potssi#" o* B.2 ""o(K(

?. $1S#1$-5A#)2- 18$7)A#)13S

0astrointestinal problems

1. P!('ti& i(e#s

A*te! )%o"i$( s#!+e!' $o!"( )o6e( so#$%s %isppe! )o#t 9 ho#!s #s#(('

!et#!$i$+ o$ the thi!% o! *o#!th %'.

Postope!ti5e i(e#s is %#e to p!('sis o* the "'e$te!i& p(e;#s $% is o* t6o

t'pes, i$testi$( i(e#s 8the &o""o$est: $%te +st!i& %i(ttio$.

I(e#s 6i(( (so o&! *o((o6i$+ pe!ito$itis0 )%o"i$( t!#" $%

i""o)i(i4tio$. It "' )e p!o(o$+e% i$ h'pop!otei$e"i& $% h'po7(ie"i&

ptie$ts.

S'"pto"s

- )%o"i$( %iste$sio$ $% 5o"iti$+0

- )se$t )o6e( so#$%s.

I$testi$( i(e#s #s#((' sett(es 6ith pp!op!ite t!et"e$t.

Ate +st!i& %i(ttio$ is $ e"e!+e$&'.

A $so+st!i& t#)e "#st )e psse% i""e%ite(' to p!e5e$t i$h(tio$ o* +st!i&

&o$te$t0 h'po5o(e"i o! +st!i& !#pt#!e.

A $so+st!i& t#)e 6i(( e"pt' the sto"&h o* *(#i% $% +s.

Mi$ti$ &o$ti$o#s spi!tio$.

E$s#!e %e


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54

E$s#!e $i( o!((' *o! ho#!s )e*o!e s#!+e!'.

E;&(#%e "e&h$i&( ses $% i(e#s. Gi5e &e$t!( $tie"eti&s.

he$ pe!siste$t0 pss NG t#)e0 &o!!e&t h'%!tio$ $%e(e&t!o('te %ist#!)$&es.

3. Di!!he

Di!!he "' o&! *o((o6i$+ $ i(e#s o! i$ sso&itio$ 6ith &o$ti$#i$+ sepsis.

It "' (so *o((o6 spe&i*i& p!o&e%#!es s#&h i(eo-$( $sto"osis0 t!#$&(

5+oto"' $% he"i&o(e&to"ies.

A(so !e"e")e! the possi)i(it' o* i$*e&tio$0 pse#%o"e")!$o#s &o(itis is esi('

*o!+otte$.

T!et"e$t

I%e$ti*' the se,

- !e&t( $% US to e;&(#%e pe(5i& )s&ess

- stoo( (t#!e to e;&(#%e $ i$*e&tio#s %i!!he

- )%o"i$( !' *o! o)st!#&ti5e (esio$s.

Rep(&e (ost *(#i%s $% +i5e $tipe!ist(iti& %!#+s 8&o%ei$e phosphte0 (o"oti(:.

4. Co$stiptio$

It is &o""o$(' e$&o#$te!e% *te! e(e&ti5e s#!+e!'0 p!ti(!(' i$ the e(%e!('.

T!et"e$t

E$s#!e %e


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55

Seere sepsis is defined as sepsis associated with organ dysfunction#

hypoperfusion or hypotension.

-rgan dysfunction ariables1

- rterial hypoxemia

- cute oliguria

- reatinine 3 ;.0 mgBC 3:. or aP99 3/0 secs)

- 9hrombocytopenia (platelet count 7:00#000- &yperbilirubinemia (plasma total bilirubin 3 ;.0 mgP is the 7e' to )(oo% (oss.

T!et"e$t

- !ise the (e+s0 est)(ish $ i5 i$*#sio$

- pp(' p!ess#!e to o)5io#s e;te!$( )(ee%i$+ poi$ts

- !ep(&e (ost )(oo% 5o(#"e 6ith &o((oi%s *(#i% 85o(#5e$0 he"&&e( o!%e;t!$ B/: #$ti( 6ho(e )(oo% is 5i()(e.

- !!$+e *o! the ptie$t to !et#!$ to thet!e i* $e&ess!' 8to (i+te

)(ee%i$+ so#!&e:.

- &!!' o#t &o+#(tio$ s&!ee$0 &(otti$+ *&to!s "' )e !ep(&e% 6ith

*!esh *!o4e$ p(s"

- "es#!e #!i$e 5o(#"e.

56


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56

Eound infection

o#$% i$*e&tio$ !e"i$s o$e o* the "ost &o""o$ &o"p(i&tio$s i$ the s#!+i&(

ptie$t %espite %5$&es i$ septi& s#!+i&( p!&ti&e $% *te! %e&%es o*

p!o+!esses i$ $ti)ioti& the!p'.

It is !e(te% to the t'pe o* s#!+e!' &!!ie% o#t0 %epe$%i$+ 6hethe! the s#!+i&(

p!o&e%#!e is &(ssi*ie% s &(e$0 pote$ti((' &o$t"i$te%0 &o$t"i$te% o! %i!t'.

C(ssi*i&tio$ o* ope!ti5e p!o&e%#!e )se% o$ %e+!ee o* "i&!o)i(

&o$t"i$tio$,

1. C(e$ p!o&e%#!e is &o$si%e!e% 6he$ the ope!tio$ is e(e&ti5e0 $ot

e"e!+e$t0 $o$-t!#"ti&0 the 6o#$% is p!i"!i(' &(ose%0 6he$ the!e is

$o te i$*(""tio$ $% $o )!e7 i$ te&h$i


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57

Se5e!it' o* 6o#$% i$*e&tio$,

- "i$o! i$*e&tio$ i* the!e is %is&h!+e 6itho#t &e((#(itis o! %eep tiss#e

%est!#&tio$0

- "?o! i$*e&tio$ i* the %is&h!+e o* p#s is sso&ite% 6ith tiss#e)!e7%o6$0 p!ti( o! tot( %ehis&e$&e o* the %eep *s&i( ('e!s o* the

6o#$%0 o! i* s'ste"i& i(($ess is p!ese$t.

Ris7 *&to!s o* 6o#$% i$*e&tio$,

- he"to" *o!"tio$0

- %i)etes0 poo! $#t!itio$0

- !e%#&e% i""#$it' $% %!#+s 8ste!oi%s:

- tiss#e h'po;i

T!et"e$t,

- $ti)ioti&s !e i$%i&te% 6he$ the!e is &e((#(itis o! i""#$o%e*i&ie$&'.

- s#t#!e sho#(% )e !e"o5e%

- !e(ese p#s i* p!ese$t )' ope$i$+ the 6o#$% to p!o5i%e %ee*o!e 3

"o$ths "o!e the$ 32= 6i(( !ei$*!&t0 *te! 3 "o$ths 12= $% *te!

"o$ths o$(' =.

- P!eope!ti5e $ti&o+#(t$ts $% $tip(te(et %!#+s "' )e o* 5(#e

- +i5e pp!op!ite "e%i&( t!et"e$t to ptie$ts 6ith $+i$ o!

&o$+esti5e &!%i& *i(#!e.

I$ ptie$ts 6ho $ee% e"e!+e$&' s#!+e!'0 the !is7 o* s#!+e!' is ?#sti*i)(e.

%eep venous thrombosis

DVT is hi+hest i$ ptie$ts o5e! / 'e!s o(% 6ho #$%e!+o "?o! s#!+e!'.

Postope!ti5e i$&!ese i$ p(te(ets &o#p(e% 6ith 5e$o#s e$%othe(i( t!#" $%

stsis (( &o$t!i)#te 8Vi!&ho6@s t!i%:. I* $o p!oph'(;is is +i5e$0 3/= o*

s#!+i&( ptie$ts 6i(( %e5e(op DVT $% /01-/0= 6i(( %ie *!o" p#("o$!'

th!o")o-e")o(is" 8PTE:.

Hi+h !is7 *&to!s,

- Pe(5i& s#!+e!'

- Hip !ep(&e"e$t s#!+e!'

- M(i+$$t %isese

- Co$t!&epti5e pi( (s

58


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58

- P!e5io#s histo!' o* DVT ot PTE

- O(%e! ptie$ts s the i$&!ese o* DVT is ("ost (i$i! 6ith %5$&i$+

+e.

- Othe! *&to!s, o)esit'0 %i)etes "e((it#s0 po('&'the"i0 5!i&ose 5ei$s0

&!%i& $% !espi!to!' %isese.

C(i$i&( %i+$osis,

- p'!e;i t B-9 %'s postope!ti5e(' is o*te$ the *i!st si+$. It "' )e

sso&ite% 6ith pi$0 s6e((i$+ o* the (e+ $% !ise i$ s7i$ te"pe!t#!e.

- Ho""$s si+$ p!ese$t, pi$ i$ the &(* o$ *o!&e% *(e;io$ o* *oot.

T!et"e$t

Lo6 "o(e(! 6ei+ht hep!i$e *o! 1/ %'s0 e$o;p!i$e 8&(e;$e: - 1 "+K+

t6i&e %i(' o! $%!op!i$ 8 *!;ip!i$e: /01 "(K1/ + t6i&e %i('.

Not $e&ess!' to "o$ito! &o+#(tio$ %#!i$+ LMH t!et"e$t.

A*te! 9 %'s0 sso&ite to LMH0 o!( $ti&o+#($t s#&h s 6!*!i$ 1 t) o*

"+ *o! t6o %'s the$ &!!' o$ 6ith 6!*!i$e o$(' *o! "o$ths.

The %ose o* 6!*!i$e is t!i""e% *te! the p!oth!o")i$e ti"e.

P!e5e$tio$

I%e$ti*' the hi+h !is7 ptie$t

Metho%s o* p!e5e$tio$,

- "e&h$i&(, #se o* e(sti& sto&7i$+s $% i$te!"itte$t pe!ope!ti5e p$e#"ti&

&(* &o"p!essio$.

- "e%i&tio$,

- (o6 %ose LMH, s#)t$eo#s0 //#K7+ 1 ho#!s p!eop. the$ 9 o!

1 ho#!(' #$ti( "o)i(e.

- De;t!$ B/, st!te% o$ i$%#&tio$ o* $estheti&0 !epet the!e*te! i*

$e&ess!'.

- A(te!$ti5e +e$ts, spi!i$0 &(opi%!o+e( 8p(5i;:.

MC TESTS

19.1 N#se $% 5o"iti$+ s &o"p(i&tio$s o* postope!ti5e pe!io% "i+ht NOT

)e %#e to,

. $estheti& +e$ts0

). $(+esi&s0

&. &o$stiptio$0

%. i$testi$( i(e#s0

e. "e&h$i&( o)st!#&tio$.

19. ht is NOT &(i$i&( *et#!e !e+!%i$+ ptie$t 6ith postope!ti5e

)(ee%i$+,

. the ptie$t is !est(ess0 &o(% $% &(""'0

). %e&!esi$+ p#(se !te0

&. i$&!esi$+ p#(se !te0

%. p((o!0

e. si+hi$+.

19.3 ht is NOT !is7 *&to! *o! 6o#$% i$*e&tio$ s postope!ti5e

&o"p(i&tio$,

. he"to" *o!"tio$0

). &(e$ s#!+e!'0

&. %i)etes0

59


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59

%. poo! $#t!itio$0

e. !e%#&e% i""#$it' $% %!#+s 8ste!oi%s:.

19. ht is the )est thi$+ to %o i$ +!oss(' i$*e&te% postope!ti5e 6o#$%,

. pp('i$+ i&e )+0

). &h$+e %!essi$+s th!ee ti"es %i('0

&. s#t#!e !e"o5e% to !e(ese p#s0

%. $tipi!eti&s0

e. pi$ 7i((e!s.

19.2 ht is NOT hi+h !is7 *&to! *o! %eep 5e$o#s th!o")osis s

postope!ti5e &o"p(i&tio$,

. pe(5i& s#!+e!'0

). "(i+$$t %isese0

&. &o$t!&epti5e pi((s0

%. p!e5io#s histo!' o* %eep 5e$o#s th!o")osis o! p#("o$!' th!o")e")o(is"0

e. 'o#$+ ptie$t 6ith )o%' "ss i$%e; o* /.

. E143% A5-

Dis!#ptio$ o* tiss#e i$te+!it'0 6hethe! s#!+i&( o! t!#"ti&0 sti"#(tes se!ies

o* &e(#((! $% "o!pho(o+i& e5e$ts tht &$ !es#(t i$ spo$t$eo#s 6o#$%

&(os#!e.

I"pi!"e$t o* $o!"( he(i$+0 espe&i((' )' i$*e&tio$0 is "?o! so#!&e o*

s#!+i&( "o!)i%it'0 P!o&esses o* 6o#$% he(i$+.

1. Epithe(i4tio$ - )e+i$s 6ithi$ 1 ho#!s *!o" i$?#!'0 is the p!o&ess )' 6hi&h

s#!*&e &o5e!i$+ o* the 6o#$% is !esto!e% )' &o")i$tio$ o* &e(( "i+!tio$

$% "#(tip(i&tio$. he$ $ !e is %e$#%e% o* epithe(i#" the "!+i$( &e((s

%i5i%e "i+!te &!oss the )!e !e.

. P!o(i*e!tio$ o* *i)!o)(sts )e+i$s t pp!o;i"te(' the *o#!th%'. Fi)!o)(sts

"i+!te i$to the 6o#$%0 p!o(i*e!te $% p!o%#&e e;t!&e(#((! "t!i; i$&(#%i$+

&o((+e$. >#%%i$+ o* $e6 &pi((!ies *!o" e;isti$+ 5e$#(es p!o%#&es !e%0

)ee*' s#!*&e &((e% +!$#(tio$ tiss#e.

3. Mt#!tio$ o* the 6o#$% st!ts %#!i$+ the thi!% 6ee7 $% is &h!&te!i4e% )'

$ i$&!ese i$ 6o#$% st!e$+th 6itho#t $ i$&!ese i$ the "o#$t o* &o((+e$.

St!e$+th is +i$e% )' &o((+e$ !e"o%e((i$+ 6ith $ i$&!ese i$ &!oss-(i$7i$+ $%

i"p!o5e% &o((+e$ (i+$"e$t (o$+ (i$es o* te$sio$. The i$&!ese i$ te$si(e

st!e$+th p(te#s *te! 1 'e! t B/-9/= o* i$t&t s7i$.

The s(ope o* the "t#!tio$ !5e is steepest %#!i$+ the *i!st -9 6ee7s.

Co$t!&tio$ is $ i"po!t$t &(i$i&( *et#!e i$ ope$ 6o#$%s.

A*te! -3 %'s0 "'o*i)!o)(sts ppe!0 si$+ the 6o#$% i$s to "o5e to6!%

e&h othe!0 si+$i*i&$t(' !e%#&i$+ the 6o#$% !e.

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%ifferent ways of wound healing

1. P!i"!' i$te$tio$ 6o#$% he(i$+ !e*e!s to &(os#!e o* 6e((-

pp!o;i"te% tiss#es 8the 6o#$% e%+es !e )!o#+ht to+ethe!0 ppose%0

$% the$ he(% i$ p(&e )' "e&h$i&( "e$s, %hesi5e st!ips0 stp(es o!

s#t#!es:.

. Se&o$%!' i$te$tio$ 6o#$% he(i$+ !e*e!s to 6o#$%s (e*t ope$0 )ese

o* the p!ese$&e o* i$*e&tio$0 e;&essi5e t!#" o! s7i$ (oss0 $% the

6o#$% e%+es &o"e to+ethe! $t#!((' )' "e$s o* +!$#(tio$ $%

&o$t!&tio$.

3. De('e% p!i"!' &(os#!e !e*e!s to pp!o;i"tio$ o* 6o#$% e%+es *te!

i$iti( ope$ t!et"e$t. >&te!i( &o#$ts i$ &o$t"i$te% ope$ 6o#$%s

!e !e%#&e% *te! -2 %'s. o#$% e%+es !e )!o#+ht to+ethe! t )o#t

-2 %'s0 )e*o!e +!$#(tio$ tiss#e is 5isi)(e.

-mergency wound care

Histo!' $% ph'si&( e;"i$tio$

The ptie$t "#st )e e;"i$e% *o! othe! i$?#!ies tht "' $ot )e i""e%ite('

pp!e$t.

Ne#!o(o+i& $% 5s(! i$te+!it' sho#(% )e ssesse% %ist( to the site o* i$?#!'.

The $e#!o(o+i& e;"i$tio$ "#st )e pe!*o!"e% p!io! to i$*i(t!tio$ o* $estheti&

+e$ts.

1. o#$% &(e$si$+

The *i!st step i$ 6o#$% &!e is to &(e$se the 6o#$% $% s#!!o#$%i$+ s7i$ i$

p!ep!tio$ *o! e;"i$tio$ $% &(os#!e.

I$ +e$e!(0 6o#$%s &$$ot )e &(e$se% %e


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The %e&isio$ to &(ose 6o#$% %epe$%s o$ &(i$i&( ?#%+"e$t o* the %e+!ee o*

&o$t"i$tio$ p!ese$t.

o#$%s tht !e &(e!(' i$*e&te% o$ p!ese$ttio$ sho#(% )e (e*t ope$ *o! %e('e%

&(os#!e o! he(i$+ )' se&o$% i$te$tio$.

A*te! - ho#!s *!o" i$?#!'0 6o#$% hs hi+h !is7 o* &o$t"i$tio$.

A ?#%+"e$t "#st )e "%e *te! ssess"e$t o* the "e&h$is" o* i$?#!'0 the

p!ese$&e o* &o$t"i$i$+ "te!i( o! s#)?&e$t *!&t#!e0 the ppe!$&e $% the

(o&tio$ o* the 6o#$%.

Antibiotics prophyla!is

I$ the #$i$*e&te% "i$o! so*t-tiss#e 6o#$%0 "ost st#%ies %e"o$st!te $o

%5$t+e i$ %"i$iste!i$+ p!oph'(&ti& $ti)ioti&s.

A *e6 spe&i*i& e;&eptio$s i$&(#%e ptie$ts 6ith &!%i& 5(5e %isese o!

p!ostheses $% o!thope%i& p!ostheses.

A$ti)ioti&s !e (so i$%i&te% *o! hi+h-!is7 6o#$%s 8o(%0 %eep0 %e5it(i4e%: o! i$

the &o"p!o"ise% host.

Co$t"i$te% 6o#$%s #s#((' &$ )e "$+e% 6ith %e)!i%e"e$t $% ((o6e% to

&(ose )' se&o$%!' i$te$tio$ 6itho#t the #se $ti)ioti&s.

I$%i&tio$s *o! $ti)ioti& #se i$&(#%e &(i$i&((' i$*e&te% 6o#$%s o! he5'

&o$t"i$tio$ 6ith *e&es0 s(i5 o! 5+i$( se&!etio$s.

A$ti)ioti& #se %oes $ot ((o6 &(os#!e o* 6o#$% tht 6o#(% othe!6ise )e (e*t

ope$.

A possi)(e e;&eptio$ is the &o$t"i$te% 6o#$% i$ the hi+h(' 5s(! s7i$ o*

the he% $% *&e s#&h 6o#$% is &(ose% i""e%ite(' o6i$+ to &os"eti&

&o$si%e!tio$,

#etanus infection

Tet$#s is se% )' to;i$ p!o%#&e% )' the $e!o)i& o!+$is" C(ost!i%i#"

tet$i.

This i$*e&tio$ is &h!&te!i4e% )' sps" o* the 5o(#$t!' "#s&(es $% "'


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62

A ptie$t 6ith %i!t' 6o#$% 6ho hs $e5e! )ee$ i""#$i4e% sho#(% )e +i5e$

pssi5e i""#$i4tio$ 6ith h#"$ tet$#s i""#$e +(o)#(i$e i$t!"#s(!('.

The p!ote&tio$ pe!io% hs h(*-(i*e o* 1 "o$th.

The *i!st %ose o* tet$#s to;oi% "' )e +i5e$ t the s"e ti"e )#t sho#(% )e

+i5e$ t sep!te i$t!"#s(! site.

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o)st!#&tio$0 pp!op!ite i$te!5e$tio$ to eithe! !e5s(!i4e the %ist( (e+ o! to

((o6 he(i$+ *te! "p#ttio$ "' )e i$%i&te%.

3. Poo! (e#7o&'te *#$&tio$ i$ %i)eti&s "' i"pi! 6o#$% he(i$+ $% the

i""#$e !espo$se to i$*e&tio$.

E;"i$tio$

Assess the e;te$t $% se5e!it' o* the 6o#$%.

The pe!iphe!( &i!(tio$ sho#(% )e ssesse% )' e;"i$tio$ o* the pe!iphe!(

p#(ses o! &pi((!' !e*i((.

Note the (e5e( o* se$so!' (oss0 i* $'.

P($t! #(&e!s e;te$%i$+ to "ett!s( he%0 (e5i$+ e;pose% &!ti(+e is

t'pi&( o* so &((e% "( pe!*o!$s #(&e!.

Osteo"'e(itis i$ the ph($; o! "ett!s( is &o""o$.

E;"i$e 6e) sp&es *o! "'&oti& i$*e&tio$0 6hi&h &$ (e% to s7i$ *iss#!es tht

p!o5i%e po!t( o* e$t!' *o! )&te!i.

U$i$*e&te% 6o#$%s !e t!ete% )' %e)!i%e"e$t $% %!essi$+.

C!e*#( t!i""i$+ o* &((#ses $% $i(s is he(p*#(.

Re5s(!i4tio$ "' i"p!o5e &i!(tio$. C(ose *o((o6-#p is esse$ti(.

)nfected wounds

I$*e&tio$s !e po(i"i&!o)i( $% &$ i$&(#%e e!o)i& &o&&i0 )&i((i $%

$e!o)es. Ptie$ts sho#(% )e hospit(i4e% $% t!ete% 6ith )!o% spe&t!#"

i$t!5e$o#s $ti)ioti&s.

No$ 5i)(e tiss#e sho#(% )e &o"p(ete(' %e)!i%e% $% )s&esses sho#(% )e

%!i$e%.

A)so(#te $o$-6ei+ht )e!i$+ is &!#&i( *o! he(i$+.

Co$t!o( )(oo% s#+! !epete%('.

%ressings

F#$&tio$ o* %!essi$+s

D!essi$+s se!5e the *o((o6i$+ *#$&tio$s,

-p!ote&tio$ *!o" t!#"

- i""o)i(i4tio$

- &o"p!essio$

- )so!)tio$ o* %!i$+e

- p!ote&tio$ *!o" )&te!i( &o$t"i$tio$

- estheti&s.

I$ ope$ 6o#$%s0 %!essi$+s &$ (so i% i$ %e)!i%e"e$t.

I$ s#!+i&

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