FOLEY’S CATHETER

• Foley’s catheter is a self-retaining catheter made up of latex.

• It is made to be self-retaining by means of a balloon which should be inflated with saline.

• In cases of intractable epistaxis or bleeding oesophageal varices the balloon is inflated with air.

INDICATIONS

• URINARY:To monitor urine output in case of

shock or renal failure.To differentiate anuria from retention.For urinary incontinence.To give bladder washes (in Cystitis)For suprapubic cystostomy.

• NON-URINARY:To arrest post-nasal bleeding in cases

of intractable epistaxis.To arrest bleeding from oesophageal

varices in case of portal hypertension.

• CONTRAINDICATIONS:In the presence of urethral trauma

• COMPLICATIONS:Injury to urethra or urinary bladder.Inadvertent catheterization of the

vagina may occur.Urinary tract infection in the absence

of aseptic precautions.

PROCEDURE Sedate the patient, if necessary Cleanse the urethral meatus and

penis or the perineal area with povidone iodine solution.

Select the Foley’s catheter of the appropriate size:

8 Fr: newborns10 Fr: most children12 Fr: older children The catheter tip should be well

lubricated.

EQUIPMENT: Sterile gloves - consider Universal Precautions

Sterile drapesCleansing solution e.g. SavlonCotton swabs ForcepsSterile water Foley catheter SyringeLubricant (water based jelly or xylocaine jelly)Collection bag and tubing

POSITION: Place the patient supine with knees flexed.

MALE: Gently grasp and extend the penile shaft to

straighten out the urethral pathway. Hold the catheter near the distal tip and advance

it up the urethra unless resistance or an obstruction is encountered.

If resistance is encountered, select a smaller catheter.

The catheter should be passed into the bladder all the way to the Y-connection.

Inflate the balloon after advancing the catheter all the way to the Y-connection.

Tape the catheter to the child’s leg.

• FEMALE:Carefully spread the labia.A well-lubricated, pre-tested Foley

catheter is introduced into the bladder.

Advance the catheter to its entire length before inflating the balloon.

After withdrawing the catheter, after a dunking sensation is appreciated, secure it with tape.

TO REMOVE THE CATHETER:Attach a syringe and aspirate the salineballoon gets deflated and the catheter can beremoved easily.If this does not succeed, the balloon can bedeflated by: Overinflate the balloon by injecting more saline

till it bursts. Cut the side-channel distal to the outer balloon

and go on cutting it upto the meatus till the balloon gets deflated.

The balloon can be punctured via per-rectal route or suprapubic route.

URINARY DRAINAGE BAG

It is a disposable plastic bag which is marked in millilitres, so as to measure the urine output.

The bag is closed at the upper end and has a plastic tube opening into it.

There is a valve present at the opening of the plastic bag into the drainage bag to prevent urine collected in the drainage tube to re-enter the tube.

The plastic tube (inlet) has a connector at the other end which can be connected to a catheter.

• The bag also has an outlet at the upper end which is usually kept closed, but can be used to empty the contents of the drainage bag by inverting the bag.

• The urinary drainage bag is placed at a lower level than the body to facilitate urine drainage by gravity.

FLATUS TUBE

It is made up of India rubber. It is thick and stout and has a

bulbous rod with two eyes at the tip.

INDICATIONS:Diagnostic use:Diagnosis of intestinal obstructionDiagnosis of volvulus

Therapeutic use:To remove gaseous obstructionIn typhoid lymphaticsIn paralytic ileusIn volvulus

CONTRAINDICATIONS

• Recent rectal or prostatic surgery• Diseases of the rectal mucosa• Immunosuppressed patients

Equipment:a) Take a sterile flatus tube in a bowl.b) Swabstickc) Vaseline bottled) Draw mackintosh and drawsheet.e) Two kidney trays

PROCEDURE:

1) Arrange them in such a manner that it will be comfortable for the patient and handy to work.

2) It will also save the time and energy.3) Explain the procedure to the patient and relatives to

gain their co-operation.4) Provide privacy by putting curtain, so that the patient

will not feel shy.5) To prevent the blanket from getting spoil, fold it and

keep it at the foot site.6) Place the draw mackintosh and draw the sheet under

his waist to prevent the bed from getting wet.7) Give him left lateral position on the bed.8) Loose the garments of the waist and expose only the

necessary portion, so that the patient will not hesitate.

9) Lubricate the flatus tube at eye side, up to 3" to 4" with vaseline to prevent the friction, as the mucus membrane of the rectum is very delicate.

10) Touch the tip of flatus tube to the anus so that the sphincter muscles of the anus constrict and immediately relaxes, at that time insert it in anal canal gently but quickly, keeping the free end of the flatus tube under the lotion in kidney tray.

11) Insert the tube 7 to 10 inches and observe the bubbles and liquid stools in the lotion.

12) When the bubbles are stopped then move the tube little bit inside and outside, and observe for the bubbles. After that remove the tube and keep it in other kidney tray. See that the tube will not touch the floor.

13) If the bubbles are observed more then write the result 'good', if not then mark the result 'poor'.

14) Remove the draw sheet and mackintosh. Make the patient comfortable. Do the bed neat

15) Record the date, time and result of flatus tube on the case paper and inform the sister incharge.

TUBERCULIN SYRINGE

It is 1cc syringe with a plastic piston (plastic syringe), or a metal piston ( glass syringe)

USES :

• To administer PPD for Mantoux test.• To administer BCG vaccine.• To adminiter test doses of drugs such as

penicillin.• Provocative Testing – to test for allergens in

Bronchial asthma , atopy.• Insulin injections in Diabetes Mellitus.• Giving small doses of drugs. Eg. Gentamicin,

Phenobarbitone , Digoxin.

MANTOUX TEST

Tuberculin PPD 2 T.U./0.1 ml, solution for injection:1 dose = 0.1 ml contains 0.04 microgram

Tuberculin PPD.– Store at 2°C - 8°C, protected from light

PROCEDURE OF MANTOUX TEST

Diameter of induration Interpretation Action Less than 6mm Negative Previously unvaccinated

individuals may be given BCG provided there are no contraindications.

6mm or greater but less than 15mm

Hypersensitive to tuberculin protein. May be due to previous TB infection, BCG or exposure to atypical mycobacteria

Should not be given BCG

>= 15mm Strongly hypersensitive to tuberculin protein Suggestive of TB infection or disease

Should not be given BCG. Refer for further investigation and supervision which may include chemotherapy.

RESULT INTERPRETATION

BCG Vaccination• It induces primarily cell mediated immunity.• Administered at or soon after birth • Supplied in the form of lypophilised or freeze

dried powder, in a vaccum sealed dark colored multidose vial.

Reconstituted with normal saline. • Extremely sensitive to light and heat. Thus,

cold chain should be maintained.• In lypophilised form, it remains potent for

upto a year at 2-8 ˚C.

• Dose – 0.1ml• Site- convex aspect of left shoulder at the insertion of

deltoid to allow for easy identification of scar.• Route of administration – intradermal• Multiplication of BCG bacilli papule at 2-3 weeks

4-8 mm in size at 5-6 weeks ulceration heals by scarring around 6-12 weeks• Adverse effects – persistent ulcer with delayed healing

ipsilateral axillary or cervical lymphadenopathy, and rarely abscess and sinus formation.

• Positive reaction to tuberculin test 4-12 weeks after immunisation.

SCALP VEIN NEEDLE

• It consists of a metallic needle attached to a plastic tubing.• At the junction of the needle and the tubing, there is butterfly

shaped plastic holder which facilitates easy insertion of the scalp needle into the vein.

• The plastic holder is flexible and colour coded .eg . Black is no 22.

• The commonly used needles are from no 22 to no 24.• There is an inverse relation between the guage number and

the internal diameter.• Higher the guage number , small is the diameter of needle.

Thus 24G needle is smaller in diameter than 22G needle.

USES

• Collection of blood• Infusion of iv fluids, drugs, blood etc.• ABG analysis

LUMBAR PUNCTURE

INDICATIONS :

• Diagnostic :– Infectious

• Meningitis• Encephalitis

– Inflammatory• Multiple Sclerosis• Gullain-Barre syndrome

– Oncologic– Metabolic– Spontaneous

subarachnoid hemorrhage

• Therapeutic :– Analgesia– Anesthesia– Antibiotics– Antineoplastics

CONTRAINDICATIONS :• Increased intracranial pressure– Cerebral herniation– Impending herniation– Possible increased ICP and focal neuro signs

• Coagulopathy• Prior lumbar surgery• Severe vertebral osteoarthritis or degenerative

disc disease• Significant cardiorespiratory compromise• Infection near the puncture site• Space occupying lesion

EQUIPMENT :• Spinal needle

– Less than 1 yr: 1.5in– 1yr to middle childhood:

2.5in– Older children and adults:

3.5in

• Three-way stopcock• Manometer• 4 specimen tubes• Local anesthesia• Drapes• Betadine

PROCEDURE :• Performed with the

patient in the lateral recumbent position.

• A line connecting the posterior superior iliac crest will intersect the midline at approx. the L4 spinous process.

• Spinal needles entering the subarachnoid space at this point are well below the termination of the spinal cord.

• LP in older children may be performed from L2 to L3 interspace to the L5 to S1 interspace.

• At birth, the cord ends at the level of L3.

• LP in infant may be performed at the L4 to L5 or L5 to S1 interspace.

• Position the patient:– Generally performed in the

lateral decubitus position.– A pillow is placed under the

head to keep it in the same plane as the spine.

– Shoulders and hips are positioned. perpendicular with the table.

– Lower back should be arched toward practitioner.

a. Ligament flavum is a strong, elastic, yellow membrane covering the interlaminar space between the vertebrae.

b. Interspinal ligaments join the inferior and superior borders of adjacent spinous processes.

c. Supraspinal ligament connects the spinous processes

• A topical anesthetic (e.g. EMLA cream) can be applied 30 to 60 minutes before performing the puncture to minimize pain on penetration.

• Either a sitting or lateral decubitus position can be used .

• Monitor the patient visually and with pulse oximetry for any signs of respiratory difficulty as a result of assumed position.

• The subarachnoid space must be entered below the level of spinal cord termination.

• The spine should be flexed maximally to increase spacing between spinous processes.

• Extensive neck flexion, however, should be avoided to minimize a chance of respiratory compromise.

• Make sure the hips and shoulders are aligned & are perpendicular to the bed surface.

• The patient’s back should be carefully prepared and draped using provided disinfecting solution and drapes.

• Orient yourself anatomically and find the L4 spinous process at the level of iliac crests

• Palpate a suitable interspace distal to this level. • Infiltrate 2% Lidocaine subcutaneously (without

epinephrine to prevent cord infarction should it be introduced into the cord by accident) with a fine needle.

• A field block can be applied injecting into and on either side of the interspinous ligaments.

• Identify the two spinal processes in between which the needle will be introduced, penetrate the skin and slowly advance the tip of the needle at about 10 degrees cephalad (i.e. toward the patient’s umbilicus).

• Remove the stylet and check for clear fluid will flow from the needle when the subarachnoid space has been penetrated.

• The ligaments offer resistance to the needle, and a “pop” is often felt as they are penetrated.

• Withdraw the needle leaving the tip in, recheck the landmarks and slowly progress the needle again.

• Measure the opening pressure using the manometer by attaching it via a stopcock to the spinal needle.

• Normal opening pressure ranges from 10 to 100 mm H2O in young children and 60 to 200 mm H2O after eight years of age

• CSF volume of 1cc obtained in 3 tubes.• In the neonate, 2ml in total can be safely

removed.• In an older child 3 to 6 ml can be sampled

depending on the child’s size. • Tube 1 is used for determining protein and

glucose• Tube 2 is used for microbiologic and cytologic

studies• Tube 3 is for cell counts and serologic tests for

syphilis

COMPLICATIONS :

• Herniation• Cardiorespiratory compromise• Pain• Headache (36.5%)• Bleeding• Infection • Subarachnoid epidermal cyst• CSF leakage

BONE MARROW ASPIRATION

INDICATIONS :

• Diagnostic : - Idiopathic Thrombocytopenic Purpura - Aplastic Anemia - Leukemia - Megaloblastic Anemia - Infections e.g. Kala Azar - Storage disorders e.g. Gaucher’s disease - PUO - Myelofibrosis• Therapeutic : - Bone Marrow Transplantation

CONTRAINDICATIONS :

• Hemorrhagic disorders such as congenital coagulation factor deficiencies (eg, hemophilia), disseminated intravascular coagulation and concomitant use of anticoagulants.

• Skin infection or recent radiation therapy at the sampling site.

• Bone disorders such as osteomyelitis or osteogenesis imperfecta.

PROCEDURE :• Obtain consent from a parent or guardian.• If the posterior iliac crest is the chosen site, patients

are generally placed in the lateral decubitus position or the prone position

• Sterilize the site with the sterile solution• Place a sterile drape over the site, and administer

local anesthesia, letting it infiltrate the skin, soft tissues, and periosteum.

• After local anesthesia has taken effect, make an incision through which the bone marrow aspiration needle can be introduced .

• If a guard is present, should be removed before starting bone marrow aspiration, to ensure adequate depth of penetration..

• In general, the needle should be advanced at an angle completely perpendicular to the bony prominence of the iliac crest.

• Once the needle passes through the cortex and enters the marrow cavity, it should stay in place without being held.

• Once the periosteum has been penetrated, pressure is used to advance the needle through the cortex and rotate the needle in a semicircular motion, alternating clockwise and counterclockwise movements.

• If the patient is in the lateral position, the hip may be stabilized with the other hand to get a better feel for the position and depth of the needle.

• The thumb of this hand can be to mark the desired site and to prevent accidental repositioning of the needle.

• A slight give will be felt, after which you will feel that the needle is fixed solidly within the bone.

• Remove the stylet and aspirate approximately 1 ml of unadulterated bone marrow into a syringe.

• Specimen is taken and is assessed for the presence of bony spicules.

• If the specimen shows spicules, the specimen should be used to make smear slides immediately.

• If spicules are sparse or are not present, a new sample should be obtained from a slightly different site.

• The needle is left in place and sequential syringes are filled that have been prepared with heparin or other anticoagulants or preservatives, depending on the requirements for specific studies to withdraw samples for additional analysis.

• Then remove the needle, either after reinserting the stylet or with the syringe attached.

COMPLICATIONS :

• Hemorrhage • Infection• Persistent pain at the marrow site• Retroperitoneal hematomas• Trauma to neighboring structures (e.g.,

lacerations of a branch of the gluteal artery) and soft tissues