SURGICAL PROCEDURES

DECCOHAS
Urethral catheterization
INTRODUCTION
Insertion of urinary catheter into the bladder through the
urethra to allow urine to drain from the bladder for collection
INDICATIONS
To drain the bladder for preoperative and post operative
patients
For collect urine for investigations
To accurately measure the urine output in critically ill
patients
To relieve retention of urine
To drain the bladder for required strict immobilization for
trauma
CONTRAINDICATIONS
Gross hematuria.
Evidence of urethral infection.
Gross haematuria
Presence of artificial sphincter
Patient refusal
Suspected or confirmed urethral injury
Urethral strictures
Recent urinary tract surgery
Urethral catheterization
Techniques
Preparation of the patient
Creates good rapport with the patients
Explains the procedure to the patient and obtains consent
 Ensures and maintains privacy and confidentiality
Preparing equipment and supplies
Puts on protective gear
Washes hands with soap and water by using IPC principles
•Prepares following equipment:
Dressing trolley
Catheter bag(Drainage bag)
Sterile gloves
Appropriate size catheter
Sterile Lubricant
Sterile water to inflate balloon
Sterile normal saline
Straps/tape to secure catheter to leg
Waterproof sheet
Urethral catheterization
PERFOMING
Explain to the patient that the procedure may be
uncomfortable but should not be very painful (if it is very
painful, then it could be an obstruction or poor positioning for
placement)
Wash the area with soap and water, retracting the prepuce
to clean the furrow between it and the glans.
Put on sterile gloves and, with sterile swabs, apply a bland
antiseptic to the skin of the genitalia

Lubricate the catheter with generous amounts of soluble gel
but note that, the catheter should remain sterile at all times.
If you are right-handed, stand to the patient’s right, hold the
penis vertically and slightly stretched with the left hand, and
introduce the Foley catheter gently with the other hand
If you are using a Foley catheter, inflate the balloon with 10
–15 ml of sterile water after insertion
Partially withdraw the catheter until its balloon abuts on the
bladder neck
 If the catheterization was traumatic, administer an
antibiotic with a gram negative spectrum.
 Always decompress a chronically distended bladder slowly
(as removing too much urine too quickly could cause
decompensation).
Secure the catheter to the patient's thigh with a wide tape
Change the catheter if it becomes blocked or infected, or as
otherwise indicated.
Ensure a generous fluid intake to prevent calculus formation
in recumbent patients, who frequently have urinary
infections.
Urethral catheterization
Complications
Urinary tract infections
Pain due to traction of the drainage bag
Urethral injury
Paraphimosis
Urine leakage from the urethral meatus
Supra pubic aspiration
Indications
Need for sterile urine collection when urethral catheterization is
not possible
Bladder outlet obstruction due to urethral stricture, injury,
malignancy, or prostate hyperplasia
Contraindications
Non palpable bladder
Patient with bladder cancer
Overlying soft tissue infections of the abdominal wall
Abdominal wall skin trauma
Bleeding disorders
Patient refusal
Abdominal distention
Supra pubic aspiration
Techniques
Preparation of the patient
Creates good rapport with the patients
Explains the procedure to the patient and obtains consent
 Ensures and maintains privacy and confidentiality
Preparing equipment and supplies
Washes hands with soap and water by IPC principles
•Assembles the important equipment
Sterile gauze
Sterile gloves
Antiseptic solutions
Lignocaine for local anaesthetic (2%)
Sterile syringe and needle (10 or 20 ml)
Apron
Supra pubic aspiration
Performing suprapubic puncture
Positions the patient in a supine position
Quickly assesses the extent of bladder distension by
inspection and palpation
Puts on the apron
Washes hands with soap and water with IPC principle
 Puts on sterile gloves
 Cleans the skin over the lower abdomen with antiseptic-
soaked gauze
Supra pubic aspiration
Draws up lignocaine into the syringe
Injects local anaesthesia into the skin to raise a small skin wheal of anaesthetic 2 cm
above the pubic bone
Attaches aspiration needle to a syringe
Holds the aspiration syringe with the dominant hand and places the index and middle
fingers of the nondominant hand on the top of the pubic bone to act as a guide
Directs the aspiration needle just proximal to the middle finger and pushes it in slowly at
a slightly caudal angle 10-20° off perpendicular keeping on aspirating, continuously,
advancing slowly
Advances the aspiration needle slowly while keeps on applying steady aspiration until
sees urine flowing into the syringe
Stops advancing when urine flows into the syringe
Aspirates the appropriate amount of urine
Slowly withdraws the needle
Applies gentle pressure over the puncture site using sterile gauze until no blood/urine
flows from the site
Applies another small sterile gauze over the puncture site and secures it with adhesive
plaster
Supra pubic
aspiration
Discards all wastes in appropriate containers
 Decontaminates reusable equipment and returns in their
appropriate places
Takes off the apron
Takes of the gloves
Washes hands with soap and water
Thanks the patient and refer or consult senior if
appropriately
Documents the procedure in patient’s file/case
note Refers the patient as appropriately
SUPRA PUBIC
CATHETERIZATION
Introduction
Also known as suprapubic cystostomy
Is a surgically created connection between the urinary bladder and the
skin used to drain urine from the bladder in individuals with obstruction
of normal urinary flow.
Indications
Suprapubic catheterization is indicated (when transurethral
catheterization is contraindicated or technically not possible) to relieve
urinary retention due to the following conditions:
Urethral injuries
Urethral obstruction
Bladder neck masses
Benign prostatic hypertrophy (BPH)
Prostate cancer
Management of complicated lower genitourinary tract infection
Long term bladder management i.e Neurogenic bladder
Supra pubic catheterization
Contraindications
Suprapubic catheterization is absolutely contraindicated in the absence of
an easily palpable or ultrasonographically localized distended urinary
bladder
Suprapubic catheterization is relatively contraindicated in the following
situations:
Coagulopathy (until the abnormality is corrected)
Prior lower abdominal or pelvic surgery (potential bowel adherence to the
bladder or anterior abdominal wall; may recommend that a urologist
perform an open cystostomy)
Pelvic cancer with or without pelvic radiation (increased risk of adhesions)
Supra pubic
catheterization
Techniques
Preparation of the patient
Creates good rapport with the patients
Explains the procedure to the patient and obtains consent
 Ensures and maintains privacy and confidentiality
Preparing equipment and supplies
Washes hands with soap and water by IPC principles
•Assembles the important equipment and supplies:
Sterile gauze
Sterile gloves
Antiseptic solutions
Lignocaine for local anaesthetic (2%)
Sterile syringe and needle (10 or 20 ml)
Supra pubic catheterization
Sponge holding forceps
Artery forceps
Kidney dish
Galipots
Sterile linens
Scalpels to fit handle number
Scalpel handle
Mounts sterile gauze on the sponge
Nylon suture
Supra pubic catheterization
PERFOMING
Mounts sterile gauze on the sponge holding forceps and wets it with
antiseptic
Cleans the skin over and around the suprapubic area(lower abdomen)
Palpate the distended bladder and mark the insertion site at the midline
and 2 fingers (4-5 cm) above the pubic symphysis.
The use of ultrasonography is recommended to verify the bladder
location and to ensure that no loops of bowel are present between the
abdominal wall and the bladder
Drapes the area with sterile linens
Draws local anaesthesia into the syringe
Administers a local anaesthetic agent by introducing the needle just into
the skin of the the insertion site
Allows 2-3 minutes for the anaesthetic to take effect
Supra pubic catheterization
Using the blade, make a lateral incision at the insertion site
Use retractor to hold skin edges at site of incision
Use forceps to separate abdominal layers until the bladder is seen and
make a superficial incision on the bladder
Tight a catheter with straight artery forceps and pierce on the
superficial incision made on the bladder
Inflate the balloon with 10 –15 ml of sterile water after insertion
Gently withdraw the catheter to lodge the wings against the bladder
wall
Secure catheter to the skin of anterior abdominal wall with Nylon
suture
Place drain gauze pads at the cystostomy site
Secure catheter to the patient to ensure that the catheter is not
accidentally pulled out by the patient.
Supra pubic catheterization
All patients who undergo suprapubic tube placement
should be referred to a urologist for correction of the
underlying disease as well as routine cystostomy tube care.
Do not change a newly inserted catheter for 4 weeks; this
allows the catheter tract to become established.
Subsequently inserted tubes should be changed at least
once a month to decrease infections.
Supra pubic catheterization
Complications
Gross hematuria
Postobstruction diuresis
Urosepsis
Intra-abdominal visceral organ injuries(bowel perforation)
Mucopurulent discharge around the exit site
Renal calculi formation
SPLINT
Applying splint to an injured
limb
Introduction
Splinting techniques are used to treat musculoskeletal
system abnormalities
Indications
Indications for splinting include the following:
Temporary immobilization of sprains, fractures, and reduced
dislocations
Control of pain
Prevention of further soft-tissue or neurovascular injuries
To decrease swelling
Applying splint to an injured limb

Contraindications
There are no absolute contraindications for the use of splints
in the emergency setting or in the field to stabilize for
transport.
Relative contraindications include the following:
Impending compartment syndrome
Neurovascular compromise
Developing or active reflex sympathetic dystrophy
Applying splint to an injured
limb
Creates good rapport with the patient
Ensures and maintains privacy and confidentiality
Discusses the procedure with the patient and obtain informed
consent
Puts on protective gears
Wash hand with water and soap by using IPC principles
Assesses the fracture
Places padding
Applies rigid materials long enough to extend at least from
above the fractured site to below it
Ties the splint into place using any of the following: pack
straps, rope, clothing, belts, triangular bandages
Applying splint to an injured limb
Puts the leg straight
Places the splinting material along the underside of the limb
so that it extends from above the fractured site to below it
Folds the splinting material up around the sides of the limb
Thanks the patient and washes hands with soap and water
Documents the procedure in the patient’s file and refers the
patients for further management
Immobilizing Fractures
Applying an arm
sling
 Applying an arm sling to injured forearm
 Creates good rapport with the patient
 Ensures and maintains privacy and confidentiality
 Discusses the procedure with the patient and obtain
informed consent
 Washes hands with soap and water by IPC principle
 Supports the injured forearm approximately parallel to the
ground with the wrist slightly higher than the elbow
 Places an open triangular bandage between the body and
the arm, with its apex towards the elbow
 Extends the upper point of the bandage over the shoulder
on the uninjured side
 Brings the lower point up over the arm, across the shoulder
on the injured side to join the upper point and ties firmly
with a reef knot
 Ensures the elbow is secured by folding the excess bandage
over the elbow, securing it with a safety pin
 Thanks the patient and washes hands with soap and water
 Document the procedure in the patient’s file and refers the
patients if appropriately
Applying an elevated sling to
an injured shoulder
 Creates good rapport with the patient
 Ensures and maintains privacy and confidentiality
 Discusses the procedure with the patient and obtain
informed consent
 Supports the victim’s arm with the elbow beside the body
and the hand extended towards the uninjured shoulder
 Places an opened triangular bandage over the forearm and
hand, with the apex towards the elbow
 Extends the upper point of the bandage over the uninjured
shoulder
 Tucks the lower part of the bandage under the injured arm,
brings it under the elbow and around the back and extends
the lower point up to meet the upper point at the shoulder
 Ties firmly with a reef knot
 Secures the elbow by folding the excess material and
applying a safety pin, and then ensure that the sling is
tucked under the arm giving firm support
 Thanks the patients and washes hands with soap and water
 Documents the procedure in the patient’s file and refers the
patients for further management as appropriately
Applying a collar and cuff to
an injured upper arm or rib
 Creates good rapport with the patient
 Ensures and maintains privacy and confidentiality
 Discusses the procedure with the patient and obtain informed
consent
 Washes hand with water and soap by using IPC
 Allows the elbow to hang naturally at the side and places the
hand extended towards the shoulder on the uninjured side
 Forms a clove hitch by forming two loops –one towards you,
the other away
 Puts the loops together by sliding the handsunder the loops
and closes with a ‘clapping’ motion, ties the clove hitch on the
wrist
 Slides the clove hitch over the hand and gently pulls it
firmly to secure the wrist, extends the points of the
bandage to either side of the neck, and firmly ties with a
reef knot
 Allows the arm to hang naturally
 Ensures that the sling is not compromising circulation to
the hand
 Checks for distal circulation often
 Thanks the patient and washes hands with soap and water
 Documents the procedure in the patient’s file and refers
the patient for further management if appropriate
INCISION AND
DRAINAGE
Incision and
Drainage
INTRODUCTION
Are minor surgical procedures to release pus or pressure built up
under the skin , such as from an abscess, boil
INDICATIONS
Abscess that does not resolve despite conservative measures
Large abscess (>5mm)
Palpable, fluctuant abscess
CONTRAINDICATIONS
There are no absolute contraindications for incision and drainage
If the patient’s physical condition is compromissed, stabilization to
render him or her fit for anaesthesia should be carried out before
procedures are undertaken
Incision and Drainage
Creates good rapport with the patient
Explains the procedure to the patient and obtains consent
Ensures and maintains privacy
Preparing equipment and supplies
Puts on protective gear
Washes hands with soap and water by using IPC principles
•Prepares following equipment:
Drum of sterile gauze
Pair of surgical gloves
Appropriate antiseptic
Bandage
dhesive plaster
Receiver
Incision and Drainage
Washes hands with soap and water by using IPC principles
Puts on sterile gloves
Opens tray and checks equipment for completeness:
Scalpel handle
Sponge holding forceps
Artery forceps
Sinus forceps
Kidney dish
Galipots
pair of scissors Sterile linens
Scalpels
Incision and Drainage
Mounts sterile gauze on the sponge holding forceps and
wets it with antiseptic
Cleans the skin over and around the abscess
Drapes the area with sterile linens
Draws local anaesthesia into the syringe
Administers a local anaesthetic agent by introducing the
needle just into the skin of the dome of the abscess Avoids
puncturing the abscess at this point of the procedure
Allows 2-3 minutes for the anaesthetic to take effect
Incision and Drainage
Mounts the scalpel onto the appropriate scalpel handle
Tests if the area is well anaesthetized
Incises the skin over the abscess making a simple linear incision through the total
length of the abscess conforming to the natural skin folds
Drains all the pus from the abscess cavity
Probes the abscess cavity with a sinus forceps to break up all the loculations if
any
Irrigates the abscess cavity copiously with sterile normal saline solution until all
visible pus is removed
Packs the cavity with gauze soaked in antiseptic (povidone iodine or eusol) and
leaves a tail of about 1 cm of packing to serve as drainage and facilitate its removal
NOTE: Avoids packing the cavity too tightly, since excessive pressure may cause
tissue necrosis
Applies dry sterile gauze to cover the wound and secures it with either bandage
or adhesive plaster
Clears the working areas and leaves it clean
Discards all wastes in appropriate containers
Incision and Drainage
 Decontaminates all reusable equipment/instruments and
returns to their appropriate places
Takes off the apron
Takes of the gloves
Washes hands with soap and water
Thanks the patient
Documents the procedure in the patient’s file/case note
Surgical and social
toilet
Creates good rapport with the patient
Discusses the procedure with the patient and obtains
informed consent
Ensures and maintains privacy
Puts on protective gears
Preparing equipment and supplies
Washes hands with soap and water with IPC principle
Assembles important equipment and supplies:
Sterile swabs/gauze
Antiseptic
Surgical and social toilet
Sponge holding forceps
Artery forceps
Warm normal saline
Sterile and clean gloves
Basin/receiver
Local anaesthesia
 Syringes
Kidney dish
 Gallipot
Surgical and social toilet
Performing social wound toilet
Washes hands with soap and water
Puts on sterile gloves Positions patient accordingly
Shaves hair around the wound if necessary
Puts drapes around the wound area
Cleans the skin around the wound with antiseptic
Applies local anaesthesia around the wound and deep
enough to anaesthetize the tissues below the wound
Surgical and social toilet
Cleans the wound thoroughly with running water and antiseptic
Removes any loose foreign materials from the wound
Rinses the wound with warm normal saline
Holds any bleeders with artery forceps while cleaning the wound
to prevent further bleeding
Dries the wound with sterile gauze
Packs the wound with Vaseline gauze
Removes gloves
Washes hand with soap
Thanks the patient
Refers the patient as appropriately
Wound Stitching
 Creates good rapport with the patient
 Discusses the procedure with the patient and obtains informed consent
 Ensures and maintains privacy
 Preparing equipment and supplies
 Washes hands with soap and water by using IPC principle
 Assembles important equipment and supplies:
 Sterile swabs/gauze
 Antiseptic
 sponge holding forceps
 Artery forceps
 Absorbable suture with round bolded needle
 Non-absorbable suture with cutting needle
 Needle holder
 Warm normal saline
 Sterile and clean gloves
 Basin/receiver
 Sterile drapes
 Local anaesthesia
 Syringes
 Scalpels
 Kidney dish
 Gallipot
 Apron
 Scalpel holders (BP handle) number 3 and 4
 Pair of scissors
 Toothed dissecting forceps
 Washes hand with soap and water
 Wears protective gears
 Infiltrates local anesthesia
 Picks up the needle holder with the dominant hand Holds
the toothed dissecting forceps with the non-dominant hand
 Picks up the needle with the toothed dissecting forceps and
mounts it on the needle holder, approximately two-thirds of
the way along its length from its tip
 Picks up the wound edge and everts it, holding it slightly
raised by using the toothed dissecting forceps.
 Pierces the skin from outside at a reasonable distance from
the wound edge
 Ensures most part of the needle is visible to the other side
of the skin edge, and then releases the needle from the
needle holder
 Remounts the needle on the needle holder and releases the
skin edge from the dissecting forceps.
 Picks up the other skin edge with the toothed dissecting
forceps and everts it a bit
 Pierces the skin edge from inside at reasonable distance from
the edge just as he/she did on the other edge of the skin
NOTE Avoids trapping a lot of subcutaneous tissue within the
sutures that may prevent the edges from proper apposition
 Releases the needle from the holder without moving the
forceps, then remounts the it on the side that the needle has
emerged from the wound
 Pulls most of the suture (thread) through the wound, leaves a
length of suture about 3–5 cm on the first edge of the wound
 Positions the needle holder parallel to the wound, raised a
few centimetres above
 Winds the longer length of suture (needle end) on the
proximal twice, clockwise around the needle holder;
holding the suture and not the needle
 Grasps the short end of the suture with the needle holder,
pulling it through the two loops just created, so that the
short end now lies on the first edge of the wound and the
long length on the other edge
 Ensures that this ‘tie’ or ‘throw’ is lying against the skin
Releases the needle from the holder
 Winds the long length of suture once anticlockwise around
the needle holder
 Again, grasps the short end of the thread with the needle
holder, pulling it through the single loop just created (again
crossing hands)
 Ensures that this throw is also lying flat, thus creating a
‘squared’ knot resembling a reef knot
 Checks that the knot does not resemble a slipknot Winds
the suture once clockwise around the needle holder
pulling the short end through the loop to lock the knot
 Cuts the two ends of thread 5 mm away from the knot
Repeats the interrupted suturing until the wound is
adequately apposed
 Ensures that the wound edges are opposed correctly and not
overlapping
 Cleans the area around the wound with antiseptic and dries it with
sterile dry gauze
 Covers the sutured wound with dry sterile gauze and secures the
gauze with adhesive plaster
 Thanks the patient and instructs on care of the site as well as the day
of suture removal
 Discards all wastes in appropriate containers
 Decontaminates all reusable equipment/instruments and returns in
their appropriate places
 Takes off the apron and gloves
 Washes hands with soap and water
 Documents the procedure in patient’s file/case
Removing Stitches
 Creates good rapport with the patient
 Ensures and maintains privacy and confidentiality
 Discusses the procedure with the patient and obtain informed consent

 Assembles the following equipment and supplies: Toothed dissecting

forceps
 A pair of scissors
 Artery forceps
 Handle for surgical blade
 Surgical blade
 Cotton and gauze swabs
 Antiseptics
 Sterile gloves
 Puts on protective gears
 Washes hands with soap and water by IPC principles
 Puts on clean gloves
 Uses a swab and antiseptic to clean and sterilize the sutures Grasps one tail of
the suture with forceps and pull gently towards one side of the wound, elevating
the knot
 Cuts the opposite side of the suture with stitch-cutters or fine suture scissors
immediately below the knot
 Pulls the suture out of the tissue towards the opposite side of the wound
 Cleans the wound with antiseptics
 Assesses the woundThanks the patient
 Discards all wastes in appropriate container
 Decontaminates used equipment and clean the area
 Removes gloves and wash hands with soap and water
 Documents the findings in the patient’s file
Applying Bandagin
 Creates good rapport with the patient
 Ensures privacy and confidentiality
 Discusses the procedure with the patient and obtain informed consent
 Assembles the followings equipment and supplies: Scissor
 Cotton
 Gauze
 Elastic fabric or linen
 Washes hands with soap and water
 Uses open-weave material to allow ventilation, elastic bandages to secure
dressings and support soft tissue injuries like sprains, or crepe bandages
to firmly support the injured joints
 Keeps the rolled part of the bandage above the injury and the unrolled
part below the injury
 Makes two straight turns in the bandage around the injury
to hold the end in place
 Works up the limb, winding the bandage from the inside to
the outside in spiraling turns making sure that each new
turn covers one third to two thirds of the previous one
 Finishes with one straight turn and secure the end of the
bandage
 Thanks the patient and washes hands with soap and water
 Documents the procedure in patient’s file
ADMINISTERING LOCAL ANAESTHESIA
 Administering Local Anaesthesia
INTRODUCTION
Production of anesthesia(temporary loss of sensation) by inhibiting excitation of
nerve endings or by blocking conduction in peripheral nerves.
Examples; Lidocaine,Bupivacaine,Ropivacaine,Procaine
INDICATIONS
Minor surgical procedures
CONTRAINDICATIONS
Patient allergic reactions
Techniques
Preparation of the patient
Create good rapport
Gives a full explanation to the patient (in language) about the procedure
Asks for consent
Takes relevant history and ask the patient if she/he has experienced any of
adverse reaction to local anaesthetic
Ensures privacy
Administering Local
Anaesthesia
•Washes hands with soap and water using IPC principles assembles the
following equipment and supplies
A trolley
Cleaning solution
10-mL syringe
Appropriate needle for drawing up local anaesthetic from ampoule/vial
Appropriate needle for infiltration
Swabs
Appropriate local anaesthetic (e.g. Lignocaine ampoule 1 – 2%)
Administering Local Anaesthesia
PERFORMING
Calculates and avoids exceeding the maximum safe dose of the chosen
agent
Washes hands with soap and water using IPC principles
Prepares the trolley as a sterile field
Puts on protective gear
Positions the patient comfortably, with the area to be infiltrated on a
secure surface
Ensures that the field is adequately lit
Cleans the skin adequately with anappropriate antiseptic solution and
allows to dry
Drapes the patient with a sterile linen to create a sterile field
Administering Local Anaesthesia
Draws local anaesthesia from the ampoule/vial
Pierces the skin at an angle of approximately 45° using by another
needle (do not use the same needle you used to draw anaesthetic)
Aspirates to make sure that you are not infiltrating intravenously
Pushes on the plunger without moving the needle to infiltrate with
approximately 0.5–2 ml of local anaesthetic
Asks the patient if he/she is having any tingling or numbness around the
mouth, or is feeling light-headed or dizzy
Advances the needle subcutaneously, avoiding superficial veins, until
the tip is at the edge of the wheal just created
Administering Local
Anaesthesia
Aspirates once more before injecting further solution
Injects more solution until the skin area is fully infiltrated, or
the maximum safe dose has been reached
Inserts the needle into deeper tissues through the
subcutaneous wheal and until infiltration is complete if
deeper anaesthesia is required
Allows time for the local anaesthetic to work before
attempting further procedures
Discontinues injection and assesses the client
Documents the procedure in patient’s file
Administering Local Anaesthesia
Complications
Pain on injection site
Hematoma
Infection
Drug toxicity due to overdosing of local anaesthesia
Drug interaction
Hypersensitivity reaction(allergic reactions)