SPECIALISED PROCEDURES 1

March 2021 Class

by
Elizabeth G.
 Module outcomes

 By the end of this module, the learner should;

1. Manage patients undergoing specialized diagnostic procedures
2. Manage patients undergoing radiological examinations
3. Manage patients undergoing endoscopic examinations
4. Manage patients scheduled for voluntary medical male circumcision
 Module units:

1. Diagnostic procedures
2. Radiological examinations
3. Endoscopic examinations
4. Voluntary medical male circumcision (VMMC)
 Nursing responsibilities

1. Preparing equipment
 Gathering and preparing equipment is often done by nurses.
 Checking the equipment to ensure it is working properly and is ready for use on
patients.
 Cleaning equipment before and after each use to prevent the spread of
infection.
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2. Preparing patients
 Drawing blood or administering medication prior to testing.
 Collecting specimens, such as sputum or urine samples, and sending them to the
lab.
 Patients may need to have an area sterilized or shaved for a surgical procedure or
the application of electrodes.
 Mentally preparing patients for testing.(refer to hospital policies).
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3. Assist with testing

 Assisting both patients and other health care providers during diagnostic testing.
 They provide patient care during the test which may include administering
medicines when needed.
 Position patients for the examination.
 Transporting patients to and from the diagnostic room.
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4. Monitor patients during testing

 This includes monitoring their current medical condition, especially in those patients deemed
unstable.
 They must check a patient's vital signs (blood pressure, pulse, breathing rate),
 Assess physical condition and keep an eye on any monitors that the patient needs to remain
hooked up to during the tests, such as a heart monitor or ventilator.
 Nurses may also be required to connect or disconnect any monitors or devices that can
interfere with the testing.
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5. Reporting results
 Test results are reported to the patient's doctor, specialists and others in need of the
information by nurses. Results may be phoned in, faxed or sent electronically via a computer.
 It may be the nurse's responsibility to check for the results of the tests as well.
 They may be in charge of entering the results into the patient's medical record.
 Nurses must also notify the patient's physician when abnormal or critical results that require
an immediate response, such as abnormal blood work with critical potassium levels, are
found.
DIAGNOSTIC PROCEDURES
 Introduction

 Diagnostic procedures are examinations that are used to identify an

individual’s specific area of weakness and strength in order to determine a
condition or a disease.
 They include; lumbar puncture, biopsies, paracentesis, cholecystogram,
choloangiogram, venogram, myelogram, hysterosalpingogram, retrograde
pyelogram, endoscopic retrograde cholangiopancreatography (ERCP),
 Dialysis, catheterization, urinary bladder irrigation and stoma care.
 LUMBAR PUNCTURE
 A lumbar puncture (spinal tap) is carried out by inserting a needle into the
lumbar subarachnoid space to withdraw CSF.
Indications
 To obtain CSF for examination in suspicion of meningitis, central nervous
disease.
 To measure and reduce CSF pressure
 To determine presence or absence of blood in CSF
 To administer medications intrathecally
 Contra-indications

 Skin infection at the site of the lumbar puncture

 presence of an intracranial mass lesion
 Uncorrected coagulopathy
 Acute spinal cord trauma
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 The needle is usually inserted into the subarachnoid space between the third and
fourth or fourth and fifth lumbar vertebrae.
 The CSF should be clear and colorless.
 Pink, blood-tinged, or grossly bloody CSF may indicate a subarachnoid
hemorrhage.
 The CSF may be bloody initially because of local trauma but becomes clearer as
more fluid is drained.
 Assisting with lumbar puncture
pre-procedure

1. Explain the procedure to the patient and describe sensations that are likely
during the procedure (ie, a sensation of cold as the site is cleansed with solution,
a needle prick when local anesthetic agent is injected).
2. Obtain a written consent for the procedure.
3. Determine whether the patient has any questions or misconceptions about the
procedure, reassure the patient.
4. Instruct the patient to void before the procedure.
 Positioning
 Position the patient in the lateral recumbent position with hips, knees, and chin
flexed toward the chest in order to open the interlaminar spaces. A pillow can
be used to support the head.
 The sitting position may be a helpful alternative position, especially in obese
patients (easier to confirm the midline).
 In order to open the interlaminar spaces, the patient should lean forward and be
supported by a Mayo stand with a pillow on it, by hunching over the back of a
stool, or by another person.
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Post procedure

 Patient should remain in prone position for 3hrs after the procedure to allow
tissue surfaces along needle track to come back together to prevent CSF
leakage
 Encourage liberal fluid intake
 The specimen should be labeled and sent to the lab with the request form.
 Interpretation of the findings

 Increased CSF pressure can indicate congestive heart failure, cerebral oedema,
subarachnoid hemorrhage, hypo-osmolality resulting from hemodialysis ,
meningeal inflammation, meningitis, hydrocephalus or pseudotumor cerebri.
 Decreased CSF pressure can indicate complete subarachnoid blockage,
leakage of spinal fluid, severe dehydration, hyper osmolality, or circulatory
collapse.
 Lumbar puncture for the purpose of reducing pressure is performed in some
patients with idiopathic intracranial hypertension (also called pseudotumor
cerebri.)
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 The presence of granulocytes is always an abnormal finding

indicating presence of an infection.
 The finding of erythrocytes signifies hemorrhage into the CSF
 Polymerase chain reaction (PCR) has been a great advance in the
diagnosis of some types of meningitis
 Normal CSF pressure is between ( 7-18cmH2o).
 Complications

1. A post lumbar puncture headache, as a result of a leak, the supply of CSF in

the cranium is depleted to a point at which it is insufficient to maintain proper
mechanical stabilization of the brain.
 Post–lumbar puncture headache may be avoided if a
small-gauge needle is used and if the patient remains prone after the procedure.
 A post puncture headache is usually managed by bed rest, analgesic agents,
and hydration.
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2. Herniation of the intracranial contents (brain parenchyma, vascular tissue and

cerebral spinal fluid).
3. Spinal epidural abscess; collection of pus in tissues causing swelling and
inflammation around it.
4. Spinal epidural hematoma; localized collection of blood within tissues.
5. Meningitis.
 Prevention of leakage

 Needle with a small gauge should be used for puncture

 Patient should remain prone for 3hrs or lateral position , if larger
amounts of CSF has been withdrawn(more than 20mls).
 Biopsies

 Biopsies are pieces of tissue taken from the body in order to examine it more
closely.
 Mostly a doctor should recommend a biopsy when an initial test suggests an
area of tissue in the body isn’t normal.
 This area of abnormal tissue is called a tumor or a mass.
 BIOPSIES

 The three most common biopsy methods are the excisional, incisional,
and needle methods;
 Excisional biopsy is most frequently used for easily accessible tumors of the
skin, breast, and upper or lower gastrointestinal and upper respiratory tracts.
 Incisional biopsy is performed if the tumor mass is too large to be removed. In
this case, a wedge of tissue from the tumor is removed for analysis.
 Excisional and incisional approaches are often performed through endoscopy.
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 Needle biopsies are performed to sample suspicious masses that are

easily accessible, such as some growths in the breasts, thyroid, lung,
liver, and kidney. Needle biopsies are most often performed on an
outpatient basis.
 Needle aspiration biopsy involves aspirating tissue fragments
through a needle guided into an area suspected of bearing disease.
 Bone marrow aspiration

 Bone marrow examination refers to the pathologic analysis of samples of

bone marrow obtained by bone marrow biopsy and bone marrow aspiration.
 The aspiration is done by removal of a small amount of this tissue in liquid
form for examination
 Bone marrow is the soft tissue inside bones that helps form blood cells, it’s
found in the hollow part of most bones.
Sites
 Pelvic bone
 Breast bone i.e. over the sternum
 Ribs
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Indications
Bone marrow examination is used in the diagnosis of a number of conditions;
i. Leukemia – a cancer of blood forming tissues.
ii. Anemia
iii. Thrombocytopenia – low platelet level
iv. Pancytopenia – a deficiency of all types of blood cells.
v. Multiple myeloma – a cancer of plasma cells ( B-lymphocytes wbcs capable
of secreting immunoglobulin or antibody that play a significant role in
adaptive immunity).
 Pre-preparations

 Nil per oral 6 hours prior the procedure

 check
on medications that the patient is on, some like aspirin and some
NSAIDS will have to be stopped prior the biopsy
 Explain the procedure to the patient
 Patient signs consent form to show that she understands the benefits and
risks of the biopsy and has agreed to have the test .
 Post-procedure care
 Confine the patient in bed for an hour or longer as ordered by the doctor
 Observe the puncture site for bleeding, if present apply pressure and bandage
 Record the procedure in the patient’s cardex
 Label the specimen and take them to lab with request form
 Advise the patient not to make the biopsy site wet by showering until 24 hrs are
over
 If the bleeding soaks through the dressing, the patient should report to hospital
 They should avoid vigorous activity or exercises for a day or two- this helps
minimize bleeding and discomfort
 Liver biopsy

 Is a procedure where small pieces of liver tissue are removed in order to be sent
to lab for examination
 It’s helpful in the diagnosis of diseases that affect the liver E.g liver cirrhosis
Purpose
i. Diagnosis: this allows establishment of very specific diagnosis
ii. Monitoring: monitoring effectiveness of therapy that the patient is receiving for
a liver disease. It can also provide warning if certain therapies the patients are
receiving are damaging to the liver
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Indications
 Alcoholic liver/ fatty liver/ alcoholic hepatitis
 Elevated liver enzymes of unknown origin
 Jaundice
 Hemochromatosis - excess iron
 Hepatomegaly of undetermined cause
 Autoimmune liver disease –immune system attacks the liver
 Cancers of the liver and non cancerous tumor
 Chronic viral hepatitis
 Liver transplantation- to rule out rejection
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Procedure

Requirements on trolley:
As for bone marrow biopsy with addition of the following
• Scalpel or blade
• Specimen jar
• Menghini liver biopsy needle
Preparation
a) Ascertain the results of coagulation tests- prothrombin time, partial thromboplastin time,
and platelet count
b) Check for signed consent- confirm that informed consent has been provided
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Preparation cont…

c) Take and record patient’s vital signs immediately before biopsy

d)Explain the procedure to the patient- steps of the procedure, sensations expected,
after-effects expected, restrictions of activity and monitoring procedures to
follow
Steps
1. Support the patient during the procedure
2. Expose the right side of the patients upper abdomen(right hypochondriac)
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3. Instruct the patient to inhale and exhale deeply several times finally to exhale
and to hold breath at the end of expiration(prevents puncturing of the
diaphragm and risk of lacerating the liver is minimized)
4. The physician promptly introduces the biopsy needle by way of the trans
thoracic (inter costal) or trans abdominal (sub costal) route, penetrates the
liver, aspirates and withdraws. The entire procedure is completed within 5-10
seconds.
5. Instruct the patient to resume breathing
Nursing care post procedure
1)Immediately after biopsy, assist the patient to turn onto the right side; place a pillow
under costal margin, and caution the patient to remain in this position, recumbent and
immobile, for several hours.
• Instruct the patient to avoid coughing or straining.
• In this position, the liver capsule at the site of penetration is compressed against the
chest wall, and the escape of blood or bile through the perforation is prevented.
2) Measure and record patients pulse, respiratory rate and BP at 10-15 minutes intervals
for the first hour , then 30 minutes for the next 2hrs, or until the patient stabilizes.
 Changes in vital signs may indicate; bleeding, severe hemorrhage or bile
peritonitis, most frequent complications of liver biopsy.
3)If the patient is discharged after the procedure, instruct the patient to avoid heavy
lifting and strenuous activity for one week.
Complication
 Fever
 Pain, swelling, redness or discharge around needle insertion site
 Chest pains
 Shortness of breathing
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 Fainting or dizziness- sign of possible blood loss

 Nausea and vomiting
 Worsening abdominal pains – bleeding, leakage of bile
 Renal biopsy(needle biopsy of the kidney)

 This is removal of a small piece of kidney tissue for examination. It can be done through;
• Ultra sound guided kidney biopsy
• CT-guided kidney biopsy
• Or surgical biopsy
Indications
1) Protein in urine
2) Unexplained acute renal failure
3) Glomerulopathies (a set of diseases affecting the glomerular)
4) Transplant rejection
Contraindications
 Bleeding tendencies
 Uncontrolled hypertension
 Solitary kidney
 Skin infection at biopsy site
Post biopsy nursing care
 Ask patient to remain in prone position for 1hr and remain on bed rest for 24hrs
to minimize the risk of bleeding
 Vital signs are taken every 15 minutes for the first 1hr, and then with decreased
frequency as indicated.
Note;
 Kidney is a highly vascularized organ, bleeding can occur through the puncture
site and collect in peri-renal space without being noticed leading to shock.
 A clot can form in ureters causing severe pain
 Observe for any signs of shock
 Take post biopsy urine specimen for comparison with baseline
 Hemoglobin level is assessed within 8hrs
 Incase of excessive bleeding;
• Blood transfusion is commenced
• Surgical intervention to control hemorrhage and drainage or’ Nephrectomy is
done
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 Advise patient to avoid strenuous activity and heavy lifting for two
weeks to prevent trigger of delayed hemorrhage
 Patientshould report back in case of any signs or symptoms of
bleeding (hematuria, fainting, dizziness)
 ABDOMINAL PARACENTESIS/ ABDOMINAL TAPPING

 This is the puncture of the abdomen and the withdrawal of fluid that has collected in the
peritoneal cavity.
 The fluid build up is called ascites
 It relieves abdominal pressure and obtains specimen for laboratory analysis.
Indications
i. To find the cause of ascites e. g. infection
ii. To check for certain types of cancer e. g liver cancer
iii. To remove large amounts of fluid that causes pain or difficulty in breathing or that affects
kidney or bowel(intestine) functioning.
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contraindications

 Mild hematologic abnormalities do not increase the risk of bleeding

 The risk of bleeding may be increased if:
 prothrombin time>21 seconds (n is 11.0-12.5sec)
 platelet count< 50,000 per cubic millimeter.
Absolute contraindication is acute abdomen that requires surgery
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Relative contraindications are:

i. Pregnancy
ii. Distended urinary bladder
iii. Abdominal wall cellulitis
iv. Distended bowel
v. Intra-abdominal adhesions
 Patient’s preparation

 Signed consent form

 Prepare patient by providing the necessary information and instructions by
offering re-assurance.
 Instruct the patient to void.
 Gather appropriate sterile equipment and collection of receptacles.
 Placethe patient in upright position on the edge of the bed or in a chair with feet
supported on a stool.
 If the patient is confined in bed use fowlers position.
 Take patients blood pressure
 Nursing action post procedure

 Check rate of drainage and adjust to the required rate of flow

 Return patient to bed or to a comfortable sitting position
 Measure, describe and record the fluid collected
 Label samples of fluid and send them to lab
 Monitor vital signs every 25 minutes for 1hr, every 30 minutes for 2hrs, every
hour for 2hrs and then every 4hrs
 NOTE:

 BP and pulse may change as fluid shift occurs after removal of fluid.
 An elevated temperature is a sign of infection
 Assess for hypovolemia, electrolyte shifts, changes in mental status which may
occur with removal of fluid and fluid shifts and report.
 Check puncture site for leakage or bleeding, leakage of fluid may occur because
of changes in abdominal pressure and may contribute to further loss of fluid if
undetected.
 Leakage suggest a possible site of infection and bleeding may occur in patients
with altered clotting secondary to liver disease.
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Provide patient teaching regarding:

 Need to monitor for bleeding or excessive drainage from puncture site.
 Importance of avoiding heavy lifting or straining.
 Need to change position slowly
 Frequency of monitoring for fever
 THORACENTESIS
 A thoracentesis is a procedure that is done to remove excess fluid
from the pleural space.
 It’s invasive and removes fluid or air from the pleural space for
diagnostic or therapeutic purposes.
 A cannula, or hollow needle, is carefully introduced into the thorax,
generally after administration of local anesthesia.
 Nursing responsibility:

Before the procedure

 Check if the consent form has been completed and signed.
 Assess client for known allergies, especially to local anesthetic.
 Place patient on the proper position. Proper positioning stretches the chest or
back and allows easier access to the intercostal spaces. The nurse can position
the client in one either of the following:
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 Assistthe client to sit on the edge of the bed with the feet supported
and arms and head on a padded over-the-bed table
 Assist the patient to straddle on a chair with his or her arms and head
resting on the back of the chair
 If the client is unable to assume a sitting position, assist him or her to
lie on the unaffected side. Then elevate the head of bed to 30 to 45
degrees
 During the procedure;

 Inform the client of the cold sensation to be felt when antiseptic skin
solution is applied to the puncture site. A stinging sensation is also felt
during the injection of the local anesthesia.
 Instruct
the client to refrain from coughing, breathing deeply or
moving during the procedure to avoid injury to the lung.
 After the procedure

After the needle is withdrawn, apply pressure over the puncture site and
a small, sterile dressing is fixed in place.
 Put the client on bed rest.
 Obtain post-procedure chest x-ray results. The x-ray verifies that
there is no pneumothorax.
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 Record total amount of fluid withdrawn, nature of fluid and its color
and viscosity.
 Ifordered, prepare samples for laboratory evaluation. A specimen
container with formalin may be needed if a pleural biopsy is to be
obtained.
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 Evaluatethe patient at intervals for increased respiration rate,

asymmetric lung movement, vertigo, tightness in the chest area,
uncontrolled cough with blood-tinged mucus, rapid pulse and signs of
hypoxemia.
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 To prevent pulmonary edema and hypovolemic shock after the

procedure, fluid is removed slowly and no more than 1000 ml of fluid
is removed during the first 30 minutes. Also, it is vital to check the
client for complications post-thoracentesis to provide timely
interventions.
RADIOLOGICAL
PROCEDURES
The biliary tree
CHOLECYSTOGRAM

 Cholecystogram is an x-ray procedure used to help evaluate the

gall bladder.
 The test is used to help diagnose disorders of the liver and gall
bladder including cholecystitis, polyps and gallstones.
 For the procedure, a special diet (low fat diet) is consumed a day
prior to the test.
 Contrast tablets are also swallowed the evening before to help
visualize the gall bladder on x-ray.
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 On the morning of the procedure patient avoids eating or drinking anything

 Some people may experience adverse reactions of the contrast, diarrhea,
nausea and vomiting.
CHOLANGIOGRAPHY/CHOLOANGIOGRAM

 Cholangiography is the imaging of the bile duct by x-rays and

an injection of contrast medium..
 There are at least two kinds of cholangiography:
1. Percutaneous Trans-hepatic Cholangiography (PTC):
Examination of liver and bile ducts by x-rays. This is
accomplished by the insertion of a thin needle into the liver
carrying a contrast medium to help to see blockage in liver and
bile ducts.
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2. Endoscopic Retrograde Choledochography (ERC).

 This primarily examines the larger bile ducts within the liver and
the bile ducts outside the liver
 The contrast media is given intravenously
 The procedure is used to locate gall stones within the bile ducts and
identify other causes of obstruction to the flow of bile. E.g strictures
of bile ducts and cancers that may impair normal flow of bile
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Procedure
To do an intravenous cholangiogram, an iodine containing dye is
injected intravenously into the blood
The dye is removed from the blood by the liver which excretes it into
bile.
 The dye is concentrated enough just as it’s secreted into the bile that it
does not need to be further concentrated by the gall bladder in order to
outline bile ducts and any gall stones that may form within them.
several x-rays (radiographs) are taken as the liver excretes the dye
 ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP)

 It is a technique that combines the use of endoscopy and

fluoroscopy to diagnose and treat certain problems of the biliary
or pancreatic ductal systems.
 Through the endoscope, the physician can see the inside of the
stomach and duodenum, and inject dyes into the ducts in the biliary
tree and pancreas so they can be seen on x-rays.
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 ERCP is used primarily to diagnose and treat conditions of the bile ducts,
including gallstones, inflammatory strictures (scars), leaks (from trauma
and surgery), and cancers.
 ERCP can be performed for diagnostic and therapeutic reasons, although
the development of safer and relatively non-invasive investigations such
as magnetic resonance cholangiopancreatography (MRCP) has meant
that ERCP is now rarely performed without therapeutic intent.
 Patients preparation

 Sign an informed consent

 Starve for 8hrs to allow the upper GI to be empty during the procedure
 Withhold any oral medications
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Diagnostic indications
Obstructive jaundice to establish the cause
Chronic pancreatitis - a controversial indication due to widespread
availability of safer diagnostic modalities including endoscopic
ultrasound, high-resolution CT, and MRI/MRCP
Gallstones with dilated bile ducts on ultrasonography
Suspected bile duct tumors
Suspected injury to bile ducts either as a result of trauma or iatrogenic
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Therapeutic indications
◦ Endoscopic sphincterotomy -removal of stones
◦ Dilation of strictures
◦ Insertion of stent(s)
◦ Drain fluid collections
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Contraindications
Recent attack of acute pancreatitis, within the past several weeks.
Recent myocardial infarction.
History of contrast dye anaphylaxis.
Poor health condition for the procedure.
Severe cardiopulmonary disease.
 Complications

 The major risk of an ERCP is the development of pancreatitis

 Gut perforation is a risk of any endoscopic procedure, and is an
additional risk if a sphincterotomy is performed..
 Bleeding.
 Over sedation can result in dangerously low blood pressure,
respiratory depression, nausea, and vomiting.
 There is also a risk associated with the contrast dye in patients who are
allergic to compounds containing iodine.
 VENOGRAPHY

 Is a procedure in which radiograph of the veins is taken after special dye is

injected into the veins.
 Venogram examines the condition of veins and the valves.
 Venogram can show the veins in the legs, pelvis, arms, veins leading to the
heart and veins leaving kidneys.
Sites
1. Dorsal vein of the foot into deep veins
2. Femoral vein to the pelvis
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Purpose
 Check blood clots in the veins
 Assess varicose veins before surgery
 Help physician insert medical device such as stent in a vein
 Guide in treatment of diseased veins
 MYELOGRAM / MYELOGRAPHY
 Thisis a radiologic examination that uses contrast medium to detect
pathology of the spinal cord, including location of spinal cord injury,
cysts and tumors
 The
procedure involves injection of radio opaque dye into cervical or
lumbar spine followed by several x-ray projection
 A myelogram may help find the cause of pain not found by an MRI or
CT scan
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Indications
 The cause of leg or arm numbness, weakness or pain
 Narrowing of the spinal canal (spinal stenosis)
 Tumor or infection causing problems with the spinal cord or nerve roots
 A spinal disc that has ruptured or herniated
 Inflammation of the membrane covering the brain and spinal cord
 Problems with blood vessels to the spine
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Pre procedure care

 Explain the procedure to the patient
 Obtain a signed consent
 Starve the patient before the procedure for the prescribed time
 Remove dentures and metal ornaments or objects
Procedure
 Patient lies prone on the x-ray table with lower extremities tightly secured with straps to the
table
 Skin area is infiltrated with local anesthesia, dye is then injected into the spinal sac, then the
table is slowly rotated into circular motion
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 First down at the head end for 4-6 minutes then rotated up at the head end for the
same duration
 Several more minutes the process is completed. This movement ensures the
contrast has sufficiently worked it’s way through the spinal cord, followed by x-
rays, CT or MRI scans
 If the dye introduced in spinal tap was oil based, the physician conducting the
procedure will remove it after the procedure. If water based dye is used it’s not
removed as it is eventually absorbed by the body
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Post procedure care

 Patient should be in recumbent position for 24hrs with head raised
 Observe for neurologic signs especially headache as a result of CSF leakage
 Encourage the patient to increase fluid intake to enhance dye excretion
 Instruct the patient to avoid strenuous activities and heavy lifting at least a day
after test
 HYSTEROSALPINGOGRAPHY/
UTEROTUBOGRAPHY
 Hysterosalpingography (HSG) is an x-ray study of the uterus and the fallopian
tubes after injection of a contrast agent. The diagnostic procedure is performed
to evaluate infertility or tubal patency and to detect any abnormal condition in
the uterine cavity.
 Sometimes the procedure is therapeutic because the flowing contrast agent
flushes debris or loosens adhesions.
 pre-procedure preparation

 laxatives and an enema may be administered to evacuate the intestinal

tract so that gas shadows do not distort the x-ray findings.
 A mild sedative or an analgesic agent, such as ibuprofen may be
prescribed.
 The patient is placed in the lithotomy position and the cervix is exposed
with a speculum. A cannula is inserted into the cervix and the contrast
agent is injected into the uterine cavity and the fallopian tubes.
 X-rays are taken to show the path and the distribution of the contrast
agent.
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post-procedure
 Some patients experience nausea, vomiting, cramps, and faintness.
 After the test, the patient is advised to wear a pad for several hours, because the
radiopaque contrast agent may stain clothing
 RETROGRADE PYELOGRAGHY

 Is a radiologic technique of examining strictures of the collecting system of the

kidney
 A radio opaque contrast medium is injected through a urinary catheter into the
ureter and the calyces of the pelvis of the kidney using cystoscope
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Indications
 In cases where IVP provides inadequate visualization
 Before extracorporeal shock-wave lithotripsy(to break kidney stones)
 Identification of filling defects e.g. kidney stones and tumors
 During placement of ureteral stents
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Contraindication
 Presence of a urinary infection
 Pregnancy
 Allergy to contrast media
Complications
 Infection
 Perforation of ureter
 Hematuria due to trauma
DIALYSIS
 DIALYSIS

 Dialysis is a mechanical process of removing nitrogenous waste and

excess fluid and other wastes from the blood by imitating the function
of the kidneys.
 Dialysis replaces three main kidney functions;

1. removing waste from the blood

2. removing excess fluid from the blood
3. keeping electrolytes in balance
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TYPES OF DIALYSIS TREATMENT

Hemodialysis
Peritoneal dialysis
Continuous renal replacement therapy
 Continuous renal replacement therapy

 CRRT is a type of blood purification therapy used with patients

who are experiencing AKI.
 During this therapy, patients blood passes through a special filter
that removes fluid and uremic toxins, returning clean blood to the
body.
 Thisis performed over a 24-hour period to allow a patient with
unstable blood pressure and heart rates (termed
hemodynamically unstable) to better tolerate the process.
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 CRRT does not produce rapid fluid shifts, does not require dialysis
machines and can be initiated quickly.
 It is widely used in critical care units
 Hemodialysis

Hemodialysis is used for patients who are acutely ill and require
short-term dialysis and for patients with advanced CKD or ESRD.
Hemodialysis prevents death but does not cure renal disease
The objectives of hemodialysis are to extract toxic nitrogenous
substances from the blood and to remove excess water.
 A dialyzer (also referred to as an artificial kidney) serves as a
synthetic semipermeable membrane, replacing the renal
glomeruli and tubules as the filter for the impaired kidneys.
 Ct…

 In hemodialysis, the blood, laden with toxins and nitrogenous

wastes, is diverted from the patient to a machine, a dialyzer,
where toxins are filtered out and removed and the blood is
returned to the patient.
 Diffusion, osmosis, and ultrafiltration are the principles on which
hemodialysis is based.
 Ct…

SUB TYPES OF HEMODIALYSIS

Acute hemodialysis
 Indicated when there is a high and rising level of serum potassium,
fluid overload, or impending pulmonary edema, increasing acidosis,
pericarditis, and severe confusion.
 It may also be used to remove certain medications or other toxins
from the blood (poisoning or drug overdose).
 Ct…

Chronic hemodialysis(maintenance)
 Indicated in chronic renal failure, known as end-stage renal
disease (ESRD), in the following instances:
 Ct….

 The presence of uremic signs and symptoms affecting all body

systems (nausea and vomiting, severe anorexia, increasing
lethargy, mental confusion), hyperkalemia, fluid overload not
responsive to diuretics and fluid restriction.
 An urgent indication for dialysis in patients with chronic renal
failure is pericardial friction rub.
Schematic of a hemodialysis circuit
HEMODIALYSIS MACHINE
 Vascular Access

 Access to the patient’s vascular system must be established to

allow blood to be removed, cleansed, and returned to the patient’s
vascular system at rates between 300 and 800 mL/min.
 Several types of access are available.
 Vascular Access Devices

 Immediate access to the patient’s circulation for acute hemodialysis

is achieved by inserting a double-lumen, non cuffed, large-bore
catheter into the subclavian, internal jugular, or femoral vein by the
physician.
 Thismethod of vascular access involves some risk (eg, hematoma,
pneumothorax, infection, thrombosis of the subclavian vein,
inadequate flow).
SUBCLAVIAN CATHETER
 Arteriovenous Fistula

 Thepreferred method of permanent access is an arteriovenous fistula

(AVF) that is created surgically (usually in the forearm) by joining
(anastomosing) an artery to a vein, either side to side or end to side
 The arterial segment of the fistula is used for arterial flow to the
dialyzer and the venous segment for reinfusion of the dialyzed blood.
This access will need time, (2 to 3 months) to “mature” before it can
be used.
RADIOCEPHALIC FISTULA
 Peritoneal dialysis

 A type of dialysis that uses peritoneum in the abdomen as

the membrane through which fluid and dissolved
substances are exchanged with the blood.
 It is used to remove excess fluid, correct electrolyte
imbalance and remove toxins in patients with kidney
failure.
 Peritoneal dialysis involves surgery to implant a peritoneal
dialysis catheter into the abdomen.
 Ct…

 A specialfluid called dialysate flows into the peritoneum and

absorbs waste out of the blood stream. Once the dialysate
draws waste out of the blood stream it is then drained from the
abdomen.
 The process takes a few hours and it is repeated four to six
times per day.
 This exchange of fluid can be performed while patient is
sleeping or awake
 Types of peritoneal dialysis

 PD can be performed using several different approaches:

 acute intermittent peritoneal dialysis (AIPD)
 continuous ambulatory peritoneal dialysis (CAPD)
 continuous cyclic peritoneal dialysis (CCPD).
 Acute Intermittent Peritoneal Dialysis

 Although PD is not as efficient as hemodialysis in removing

solute and fluid, it permits a more gradual change in the
patient’s fluid volume status and in waste product removal.
 Therefore,
it may be the treatment of choice for the
hemodynamically unstable patient.
 CT..

 It can be carried out manually (the nurse warms, spikes, and

hangs each container of dialysate) or by a cycler machine.
Exchange times range from 30 minutes to 2 hours. A common
routine is hourly exchanges consisting of a 10-minute infusion, a
30-minute dwell time, and a 20-minute drain time.
 Maintaining the PD cycle is a nursing responsibility.
 Continuous Ambulatory Peritoneal Dialysis

 CAPD is performed at home by the patient or a trained caregiver

who is usually a family member.
 The procedure allows the patient reasonable freedom and control
of daily activities but requires a serious commitment to be
successful.
 The patient performs exchanges four or five times a day, 7 days a
week, at intervals scheduled throughout the day.
 Ct…

 Most commonly used is a Y-shaped system, in which a bag

containing dialysate solution comes connected to one branch of
the “Y” and a sterile empty bag is connected to the second branch.
 CAPD works on the same principles as other forms of PD:
diffusion and osmosis.
 Continuous cyclic peritoneal dialysis

 CCPD uses a machine called a cycler to provide the exchanges.

It is programmed as to how much fluid to use and how long
and how many exchanges need to be done.
 Itkeeps track of the total amounts removed and will sound an
alarm if limits are not met.
 CCPD combines overnight intermittent PD with a prolonged
dwell time during the day.
 Ct…

 The peritoneal catheter is connected to a cycler machine every

evening, usually just before the patient goes to sleep for the night.
Because the machine is very quiet, the patient can sleep, and the
extralong tubing allows the patient to move and turn normally
during sleep.
PERITONEAL DIALYSIS
 PRINCIPLES OF DIALYSIS

 Hemodialysis depends upon the basic principles of diffusion, osmosis and

ultrafiltration.
DIFFUSION
 This is the movement of solutes(dissolved particles)across a semi permeable
membrane from regions of high solute concentration to regions of low solute
concentration.
 In hemodialysis the semi-permeable membrane is an artificial membrane located
within the dialyzer. Small molecules that pass through this semi-permeable
membrane e.g urea, creatinine and potassium are removed from blood via
diffusion.
 Ct…

OSMOSIS
 Osmosis is the movement of water from an area of low solute
concentration to an area of high solute concentration or
alternatively from an area of high water concentration to an
area of low water concentration through a semipermeable
membrane.
 An osmotic gradient exist when the osmolarity of the solution
on one side of the membrane differs from the osmolarity of
the solution on the other side of the membrane.
 Ct…

 During the dialysis treatment, the osmotic gradient is manipulated in

order to remove the set amount of plasma water.
 This is how removal of fluid is achieved during the treatment process
of peritoneal dialysis.
 Ct…

ULTRAFILTRATION
 In ultrafiltration, water moves under high pressure to an area of
lower pressure.
 This process is much more efficient than osmosis at water
removal and is accomplished by applying negative pressure or a
suctioning force to the dialysis membrane.
 Indications for dialysis

 Acute/chronic kidney failure

 To remove drugs or poisons from the blood
Contraindications
 Severe intolerance to hemodialysis procedure (severe hemodynamic
instability)
 PROCEDURE/NURSING MANAGEMENT

 Explain the procedure to the patient .

 Prepare dialysis equipment.
 Prime the dialysis lines
 Assessment of the patient to include;
 Fluid status i.e. difference between previous post dialysis weight and current
predialysis weight to get the fluid volume that should be removed.
 Blood pressure, peripheral edema, lung and heart sounds.
 Check on the condition of the vascular access, temperature and skin
condition.
 Positioning the patient in supine position
 Creating vascular access and support the venous site
 Draw initial samples for lab analysis to include the UE/Cr
 Connect the patient to the blood lines
 Injecting heparin loading dose (1,000 to 3,000 IU) into the port on the
arterial line
 Switch the pump on and setting flow rate - at 90 to 120ml/min
 Monitor the patient half hourly.
 Allow the patient to rest, sleep, watch television, or read novels.
 Provide the patient with drinks and meals as required.
 Dialysis takes three to four hours
 After the prescribed dialysis time is over, infuse 500mls of
normal saline to push the blood from the tubings back to the
patient’s system.
 Ct..

 Disconnect the arterial and venous lines from the patient and
apply pressure to prevent bleeding.
 Perform post dialysis assessment to include weight, blood
pressure, temperature, pulse rate and respiration rate.
 Give the patient a return date.
 Complications of hemodialysis

 Hypotension may occur during the treatment as fluid is

removed. -Nausea and vomiting, diaphoresis, tachycardia, and
dizziness are common signs of hypotension.
 Painful muscle cramping may occur, usually late in dialysis as
fluid and electrolytes rapidly leave the extracellular space.
 Ct…

 Dysrhythmias may result from electrolyte and pH changes or from removal of

antiarrhythmic medications during dialysis.
 Air embolism is rare but can occur if air enters the vascular system.
 Chest pain may occur in patients with anemia or arteriosclerotic heart disease .
 Ct….

 Dialysisdisequilibrium; Signs and symptoms include headache, nausea and

vomiting, restlessness, decreased level of consciousness, and seizures.
 Gastric ulcers and other gastrointestinal problems occur from the physiologic
stress of chronic illness, medication, and related problems.
 Disturbed calcium metabolism leads to renal osteodystrophy that produces bone
pain and fractures.
 complications of peritoneal dialysis

 Peritonitis
 Hernias
 Low back pain due to increased intra-abdominal pressure
 Bleeding from tube site in the peritoneum.
 Pulmonary complications like atelectasis, pneumonias, bronchitis.
 Protein loss -peritoneum is permeable to proteins and they are lost
through the dialysate.
 CATHETERIZATION

 Catheterization is the process of inserting a catheter through the urethra

into the urinary bladder for drainage of urine or instillation of drugs
 A catheter is a tube made of vicryl or latex and is inserted into the
urinary bladder to drain urine
 Catheters vary in size, shape, length, material, and configuration. The
type of catheter used depends on its purpose.
 Ct…

 Read on different types of catheters

 146

Indications for Catheterization

 To obtain urine specimen from unconscious patient
 To facilitate accurate measurement of urine in patients who require
strict fluid monitoring
 Urine retention
 To measure urine residue
 Ct…

 To perform bladder washout

 Women with full bladder during 1st and 2nd stages of labor
 Pre and post abdominal or pelvic surgery
 Urinary incontinence
 Preventing infection in a patient with an indwelling
catheter

 Use scrupulous aseptic technique during insertion of the catheter. Use a pre-
assembled, sterile, closed urinary drainage system.
 Toprevent contamination of the closed system, never disconnect the tubing.
The drainage bag must never touch the floor.
 Ifthe collection bag must be raised above the level of the patient’s bladder,
clamp the drainage tube. This prevents backflow of contaminated urine into
the patient’s bladder
 Ct…

 Ensure a free flow of urine to prevent infection. Improper drainage occurs

when the tubing is kinked or twisted.
 To reduce the risk of bacterial proliferation, empty the collection bag at
least every 8 hours through the drainage spout—more frequently if there is a
large volume of urine.
 Avoid contamination of the drainage spout. A receptacle in which to empty
the bag is provided for each patient.
 Ct…

 Never disconnect the tubing to obtain urine samples, to irrigate the catheter,
or to ambulate or transport the patient.
 Never leave the catheter in place longer than is necessary.
 Avoidroutine catheter changes. The catheter is changed only to correct
problems such as leakage, blockage, or encrustations.
 Avoid unnecessary handling or manipulation of the catheter by the patient
or staff.
 Ct…

 Carry out hand hygiene before and after handling the catheter, tubing, or
drainage bag.
 Wash the perineal area with soap and water at least twice a day; avoid a to-
and-fro motion of the catheter. Dry the area well, but avoid applying powder
because it may irritate the perineum.
 152

Complications of Catheterization

 Infection
 Psychological trauma
 Physical trauma
 Discomfort
 Urine incontinence
 Renal failure incase of catheter blockage
Ct….

procedure of catheterization KMTC

procedure manual pg.211
Both male and female catheterization.
 URINARY BLADDER IRRIGATION

 DFn; This is continuous irrigation of the bladder via a 3-way

catheter for the purpose of removing clots and debris post
urology surgery.
 This method is normally used for short periods only in an acute
care setting.
 ct…

 During the procedure postoperatively, patient is placed in high fowlers

position to enhance urethral drainage.
 Irrigation is done using normal saline close to body temperature.
 The drip is infused by gravity through a closed sterile drainage system .
 ct…

 Irrigation helps in prevention of clot formation

 Input and output is recorded , ensuring that the output is not less than the
input.
 This helps to avoid over distention of the bladder and fluid retention.
 The drainage tube should be properly secured to avoid traction on the bladder.
 Ct….

 The drainage should be continuously replenished

 Monitor for signs of bleeding-look at the color of the drainage.
 Administer pain relievers on time.
 Psychological care should be offered to the patient
 STOMA CARE

 A stoma is an opening in your belly’s wall that a surgeon makes in order for
waste to leave the body if one can’t have a bowel movement through the
rectum.
 An ostomy refers to the actual opening in the abdomen
 A stoma refers to the end of the intestines that is sewn into the ostomy.
 Ct…

 Tocreate a stoma, the doctor pulls part of the small or large intestines
onto the surface of the skin and sew it onto an opening of the abdomen.
 Theintestines end empties waste into an ostomy appliance, which is a
pouch attached to the stoma.
 Stomas are usually round. Red and moist and they measure about 1-2
inches wide.
 Ct…

 Ileostomy is defined as a surgical operation which involves attaching of the

ileum to the abdominal wall to allow for drainage OR a surgically created
opening between the ileum of the small intestine and the abdominal wall to
allow elimination of small bowel effluent
 A colostomy may be placed in any segment of the large intestine (colon),
which will influence the nature of fecal discharge.
 Transverse and descending/sigmoid colostomies are the most common types.
 Indications

 Abdominal-perineal resection for rectal cancer

 Fecal diversion for unresectable cancer
 Temporary measure to protect an anastomosis
 Surgical treatment for inflammatory bowel diseases
 Trauma
 Ischemic bowel
 Congenital conditions.
 Characteristics of a normal stoma

1. A stoma is normally pink-red in color

2. It is always moist and bleeds slightly when rubbed,
3. A stoma has no feeling to touch
4. The stool functions is involuntary
5. Postoperative swelling gradually decreases over several months.
 Nursing care of a patient with a stoma

 Prepare patient preoperatively by explaining the surgical procedure, stoma characteristics, and
ostomy management with a pouching system.
 Postoperatively, monitor the stoma color and amount and color of stomal output every shift;
document, and report any abnormalities.
 Periodically change a properly fitting pouching system over the ostomy to avoid leakage and
protect the peristomal skin. Use this time as an opportunity for teaching.
 Assess peristomal skin with each pouching system change, document findings, and treat any
abnormalities (skin breakdown due to leakage, allergy, or infection) as indicated.
 Ct…

 Teach the patient and/or caregiver self-care skills of routine pouch emptying, cleansing skin
and stoma, and changing of the pouching system until independence is achieved.
 Instruct the patient and family in lifestyle adjustments regarding gas and odor control;
procurement of ostomy supplies; and bathing, clothing, and travel tips.
 Encourage patient to verbalize feelings regarding the ostomy, body image changes, and
sexual issues.
 Ct….

 Normal color: pink-red

 Dusky: dark red: purplish hue (ischemic sign)
 Necrotic: brown or black (signs of necrosis)
 Check for abdominal distention, which reduces blood flow to stoma through mesenteric
tension.
 Monitor intake and output with extreme accuracy
 Irrigate NG tube frequently, as ordered, to relieve pressure and decrease gastric contents.
 Offer continued support to patient and family.
 Stoma complications

1. Muco- cutaneous separation; this is separation between skin and stoma

2. Stomal ischemia
3. Stomal stricture or stenosis (usually a long-term complication).
4. Stomal prolapse; prolapse may occur with any type of stoma but is
most common with loop colostomy.
5. Peristomal hernia.
6. Peristomal skin breakdown from exposure to fecal output, allergic reaction to
products or infection.
RADIOLOGICAL
EXAMINATIONS
 Ct.

 Radiological exams are tests that use radiation to visualize body spaces and
organs to come up with a diagnosis.
 Radiation is transmission of energy in the form of waves through space or
material medium
 There are two kinds of radiation: non ionizing radiation and ionizing radiation
 Non ionizing radiation has enough energy to move atoms in a molecule around
or cause them to vibrate but not enough to remove electrons from atoms.
 Ct…

 Examplesof this kind of radiation are radio waves, visible light, and
microwaves.
 Ionizingradiation has so much energy it removes electrons out of
atoms by a process of ionization
 Ionizing radiations can affect atoms in living things hence pose a
health risk by damaging tissues and DNA in genes
 Examples are x-rays, cosmic particles from space
 X-rays
 X-rays are a type of electromagnetic radiation, just like visible light that can
pass through solid objects including the body.
 They were first discovered by a German physics professor, who studied x-rays
and their ability to pass through human tissues to produce images of the bones
and metals visible on developed film.
 Ct….

 To obtain x-ray images of part of the body, patient is positioned with part
of the body being x-rayed between source of the x-ray and the x-ray film.
 Images appear in shades of black and white ,depending on the type of
tissue the x-ray pass through.
 Ct…

 An x-ray machine sends individual x-ray particles through the

body. The images are recorded on a computer or film.
 Structures that are dense (such as bone) will block most of the x-
ray particles, and will appear white.
 Metal and contrast media (special dye used to highlight areas of
the body) will also appear white.
 Structures containing air will be black, and muscle, fat, and
fluid will appear as shades of gray.
 Ct….

 How to Prepare for the Test

 Before the x-ray check on whether patient may be pregnant, or has an IUD
inserted.
 Remove all jewelry, metal can cause unclear images.
 Patient requires to wear a hospital gown.
 Lead shielding for sensitive areas that do not require x-ray.
 Ct…

 The following are common types of x-rays:

 Abdominal x-ray, Barium x-ray, Bone x-ray, Chest x-ray Dental
x-ray, Skull x-ray Extremity x-ray, Hand x-ray, Joint x-ray.

 Read on above
 Chest X-rays

Indications
 Chest infections to check for pneumonia and pulmonary tuberculosis.
 Major chest trauma to check for pneumothorax and hemothorax
 Acute chest pain to check for pneumothorax, perforated viscus
 Asthma /bronchiolitis not responding to treatment or when diagnosis is unclear
 Chest x-ray procedure

 A patient needs no preparation for a chest x-ray. Though the body is exposed to a
small amount of radiation, no pain is involved and very little risk.
 (However, women should inform their doctor if it is possible that they are
pregnant.)
 The patient will be asked to remove his or her clothing, including all jewelry and
other metal objects that might interfere with the x-rays, and put on a loose gown.
 Lead shielding is used to protect parts of the body that are not being x-rayed,
such as the lower abdomen.
 Ct…

 Most often, the machine used for producing chest x-rays is shaped like a box.
Inside this apparatus will be either film or a digital recording plate.
 The patient will be asked to press his or her chest against the flat surface,
positioned about 6 feet from the x-ray tube which produces the radiation.
 SKULL X-RAY

 A skull x-ray is a picture of the bones surrounding the brain,

including the facial bones, the nose, and the sinuses.
 Preparation and procedure.

 Patient remove any clothing, jewelry, hairpins, eyeglasses, hearing

aids, or other metal objects that might interfere with the procedure.
 Wear a gown
 Position on an X-ray table that carefully places the part of the skull
that is to be x-rayed between the X-ray machine and a cassette
containing the X-ray film.
 Cont.

 Body parts not being imaged are covered with a lead apron
(shield) to avoid exposure to the X-rays.
 The radiologic technologist ask patient to hold still in a certain
position for a few moments while the X-ray exposure is made.
 Cont.

 If the X-ray is being done after an injury, special care will be taken
to prevent further injury. For example, a neck brace may be applied
if a cervical spine fracture is suspected.
 Cont.

 The X-ray beam will be focused on the area to be

photographed.
 The radiologic technologist will step behind a protective
window while the image is taken.
 BONE X-RAYS

 Bone x-ray uses a very small dose of ionizing radiation to

produce pictures of any bone in the body.
 It is commonly used to diagnose fractured bones or joint
dislocation. Bone x-rays are the fastest and easiest way for your
doctor to view and assess bone fractures, injuries and joint
abnormalities.
 Ct...

 This exam requires little to no special preparation.

 Check for possibility of pregnancy
 Remove jewelry and wear loose, comfortable clothing or a gown.
 Risk of x-rays

 X-raysprovide a low dose of radiation that are not found to cause

any immediate health effects.
 The risk from x-rays comes from the radiation they produce. This
risk is relatively small but it increases with cumulative exposure.
 However different x-ray procedures release different quantities of
radiation
 There’s a slight increased risk of developing cancer later in life
after prolonged x-ray exposure.
 Ct….

 For most x-rays, the risk of cancer or defects is very low. Most experts feel that
the benefits of appropriate x-ray imaging greatly outweigh any risks.
 Young children and babies in the womb are more sensitive to the risks of x-
rays.
 COMPUTED TOMOGRAPHY (CT Scan)

 A CT scan or computed tomography combines x-rays with

computer processing to create detailed pictures of cross sections
of the body to form a 3 dimensional x-ray image.
 This allows the user to see inside the object without cutting.
 Ct…

How Do CT Scans Work?

 They use a narrow X-ray beam that circles around one part of the body. This
provides a series of images from many different angles. A computer uses this
information to create a cross-sectional picture. (Like one piece in a loaf of bread,
this three-dimensional (3D) scan shows a “slice” of the inside of your body.)
 This process is repeated to produce a number of slices
 The computer stacks these scans one on top of the other to create a detailed
image of the organs, bones, or blood vessels of interest.
 Ct…

Preparation for a CT scan

 Avoid eating or drinking a few hours before the procedure.
 Wear a hospital gown and remove any metal objects, such as jewelry.
 During the test, patient lie on a table inside a large, doughnut-shaped CT
machine. As the table slowly moves through the scanner, the X-rays rotate
around the body. It’s normal to hear a whirring or buzzing noise. Movement can
blur the image, so patient is asked to stay very still.
 Ct..

 A special dye called contrast material is needed for some CT

scans to help highlight areas of the body being examined.
 The contrast material blocks X-rays and appears white on
images, which can help emphasize blood vessels, intestines or
other structures
CT SCAN
 Indications for CT scan

 Diagnose infections, muscle disorders, and bone fractures

 Pinpoint the location of masses and tumors (including cancer)
 Study the blood vessels and other internal structures
 Assess the extent of internal injuries and internal bleeding
 Guide procedures, such as surgeries and biopsies
 Monitor the effectiveness of treatments for certain medical conditions,
including cancer and heart disease
 contraindications

 Allergic to contrast agents

 Pregnancy
 Acute renal disease
 MAGNETIC RESONANCE IMAGING (MRI)

 Magnetic resonance imaging (MRI) is a medical imaging technique used

in radiology to form pictures of the anatomy and the physiological processes
of the body.
 AnMRI scan uses a strong magnetic field and radio waves to generate
images of parts of the body that can’t be visualized well with the x-rays, CT
scans or ultrasound.
 Thescanner typically resembles a large tube with a table in the middle,
allowing the patient to slide in.
 Cont.

 MRI does not involve x-rays or the use of ionizing radiations which
distinguishes it from CT Scans.
 Compared with CT scans, MRI scans typically take longer and are louder. In
addition, people with some medical implants or other non-removable metal
inside the body may be unable to undergo an MRI examination safely.
 Indications

 Anomalies of the brain and spinal cord

 Tumors, cysts, and other anomalies in various parts of the body
 Breast cancer screening for women who face a high risk of breast
cancer
 Injuries or abnormalities of the joints, such as the back and knee
 Ct...

 Certain types of heart problems

 Diseases of the liver and other abdominal organs
 The evaluation of pelvic pain in women, with causes including
fibroids and endometriosis
 Suspected uterine anomalies in women undergoing evaluation for
infertility
 This list is by no means exhaustive. The use of MRI technology is
always expanding in scope and use.
 Patients preparation;

 Patient should change into hospital gown

 Remove any metal jewelry or accessories that might interfere with the
machine.
 Receive an injection of intravenous (IV) contrast liquid to improve the
visibility of a particular tissue that is relevant to the scan.
 Earplugs or headphones will be provided to block out the loud noises of the
scanner.
 CT…

 No risks have been noted unless patient is allergic to the contrast dye
NOTE:
CT scans utilize X-rays to produce images of the inside of the body while MRI
(magnetic resonance imaging) uses powerful magnetic fields and radio
frequency pulses to produce detailed pictures of organs and other internal body
structures. CT scans use radiation (X-rays), and MRIs do not.
 ULTRA SOUND

 Ultrasound is a type of imaging that uses high-frequency sound

waves to look at organs and structures inside the body.
 Health care professionals use it to view the heart, blood vessels,
kidneys, liver, and other organs. During pregnancy, doctors use
ultrasound to view the fetus.
 Unlike x-rays, ultrasound does not expose you to radiation.
 Ct....

 During an ultrasound test, patient lie on a table. A special technician

or doctor moves a device called a transducer over part of the body.
 The transducer sends out sound waves, which bounce off the tissues
inside the body. The transducer also captures the waves that bounce
back. The ultrasound machine creates images from the sound waves.
 preparation

 Most ultrasound exams require no preparation. However, there are a

few exceptions:
 For some scans, such as a gallbladder ultrasound, the doctor may
require that one does not eat or drink for up to six hours before the
exam.
 Others, such as a pelvic ultrasound, may require a full bladder. One
may need to drink up to six glasses of water two hours before the
exam and not urinate until the exam is completed.
 Before the procedure.

Before ultrasound begins, patient may be required to do the following:

 Remove any jewelry from the area being examined.
 Remove some or all of your clothing.
 Change into a gown.
 Lie on an examination table
 During the procedure

 Gel is applied on the skin over the area being examined. It helps
prevent air pockets, which can block the sound waves that create
the images. This water-based gel is easy to remove from skin and, if
needed, clothing.
 During the procedure

 A trained ultrasound imaging professional (sonographer) presses a

small, hand-held device (transducer) against the area being studied
and moves it as needed to capture the images.
 The transducer sends sound waves into your body, collects the ones
that bounce back and sends them to a computer, which creates the
images.
 Uses.

 Ultrasou­nd has been used in a variety of clinical settings, including

obstetrics and gynecology, cardiology and cancer detection.
 Obstetrics and Gynecology

 Measuring the size of the fetus to determine the due date

 Determiningthe position of the fetus to see if it is in the normal head
down position or breech
 Checking the position of the placenta
 View the number of fetuses in the uterus
 Checking the sex of the baby (if the genital area can be clearly seen)
 Cont.

 checking the fetus's growth rate by making many measurements over

time
 detecting ectopic pregnancy.
 determining whether there is an appropriate amount of amniotic fluid
cushioning the baby
 monitoring the baby during specialized procedures
 seeing tumors of the ovary and breast
 Cardiology

 Cardiac ultrasound also known as echocardiography

 Itmonitors how the heart chambers are pumping blood through
the heart
 Electrodes are used to check on the heart rhythms and
ultrasound technology to see how blood moves through the
heart.
 Urology

 Measuring blood flow through the kidney

 Can diagnose kidney stones
 Detecting prostate cancer early
 In addition to these areas, there is a growing use for ultrasound as a
rapid imaging tool for diagnosis in emergency rooms. Eg to diagnose
testicular tortion
 Positron emission tomography(PET) scan

 A positron emission tomography (PET) scan is a nuclear medicine

test that creates a roadmap of blood flow in the patient’s body. The
healthcare provider can visualize abnormal blood flow to the
patient’s tissues and organs.
 A radioactive chemical called a tracer and a special camera that
detects the tracer inside the patient’s body are the keys to a PET
scan.
 Ct…

 The healthcare provider administers the tracer into the patient’s veins prior to
the scan. The tracer gives off positrons, which are very small charged particles
that can be detected by the PET scan camera.
 ThePET scan camera takes a series of images, each capturing the position of
positrons in the body. These images are stored and replayed on a computer
screen. Images show the tracer containing blood as the blood makes its way into
organs and tissues, giving the healthcare provider a clear picture of blood flow
within the body.
 Ct…

 The PET scan is ordered to study blood flow and metabolic activity
within a patient’s body.
 Healthcare providers frequently combine results from the PET scan
with the CT scan results to obtain a thorough understanding of how well
tissues and organs are being infused with blood. Sometimes a CT scan
is performed along with a PET scan.
 The tracer contains low level radiation that will rarely lead to tissue
damage. It is rare that a patient will have an allergic reaction to the
tracer.
 Ct…

Before Administering the Test

 The patient is asked to withhold medications 24 hours before the PET scan
 The healthcare provider may ask the patient to decrease his or her dose of
insulin if the patient is diabetic
 Withhold meals for 8 hours.
 Withhold caffein, alcohol and tobacco for 24 hours
 PET scan may not be administered if the patient is pregnant or
breastfeeding.
 How the Test Is Performed

 The patient is administered the tracer intravenously.

 The patient lies on a table.
 The patient may be given a blindfold or earplugs to wear during the scan.
 Electrocardiogram electrodes are placed on the patient, if the patient’s heart
is being studied.
 The PET scan camera moves around the patient.
 Ct…

 The patient might be asked to tell a story or read during the scan, if the
patient’s brain is being studied.
 The healthcare provider or PET scan technician is outside the PET scan
room and is able to speak to the patient through an intercom and see the
patient through a window.
 The patient must drink lots of fluid for a full day to flush the tracer from
the patient’s body
 The test takes 3 hours and the results are ready immediately
 Ct…

 Normal: Normal blood flow

No growth
No blockage
Normal metabolic activity
 Abnormal: Unexpected blood flow
The existence of a growth
A blockage is identified
Unusual metabolic activity
VOLUNTARY MALE MEDICAL
CIRCUMCISION
(VMMC)
 Voluntary male medical circumcision

 Voluntary male medical circumcision (VMMC) is the removal of all or part of

the foreskin of the penis by a trained healthcare professional.
 Thisreduces heterosexual male vulnerability to HIV infection by approximately
60%.
 VMMC can have a major impact on HIV epidemics in high prevalence settings.
 Ct…

 Male circumcision can be performed for medical reasons or as part of

traditional or religious practices. It can be performed for therapeutic reasons to
correct pathological conditions such as phimosis, paraphimosis…, for elective
purposes such as improved hygiene, prevention of HIV and STI’S and
aesthetic preferences.
 The most common type of circumcision is the elective, done on adolescents- at
least 10 years old and above under local anesthesia. This is based on the
evidence of safety and clients capacity to assent and co-operate.
 Ct…

 Traditional foreskin cutting has been widely performed for religious and cultural
reasons, often within two weeks of birth or at the beginning of adolescence, as a
rite of passage into adulthood.
 Mechanism through which male circumcision reduces HIV infection:
 The primary target cells through which HIV enters the body are immune system
target cells with CD4 receptors, including Langerhans cells. These cells are
present in high density in the epithelium of the inner foreskin and are close to the
surface.
 Ct…

 In a study done, HIV uptake by cells from the mucosal surface of the foreskin
was seven times more efficient than uptake by cells from tissue of the female
cervix.
 The highly vascularized foreskin mucosa and the mucosa at the frenulum are
prone to tearing and bleeding during intercourse. These microinjuries allow easy
entry of HIV into the bloodstream.
 A factor that further facilitates transmission of the virus is the presence of an
ulcerative sexually transmitted infection— such as herpes simplex, chancroid or
syphilis.
 Ct…

 Research has indicated that there’s a high concentration of anaerobic bacteria

which cause inflammation at the foreskin.
 Epidemiology of VMMC

 In the mid-2000s, male circumcision was found to reduce the female-to-male

sexual transmission of HIV by 60%.It remains the only one-off intervention that
reduces the risk of HIV infection and is highly cost-effective.
 Since 2007, the World Health Organization (WHO) and UNAIDS have
recommended voluntary medical male circumcision (VMMC) as a key
component of combination HIV prevention in countries with a high HIV
prevalence and low levels of male circumcision. As a result, 14 countries in East
and Southern Africa were identified as priority countries and initiated programs
to expand the provision of male circumcision
 Ct…

 These countries include; Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique,

Namibia, Rwanda, south Africa, Eswatini, Tanzania, Uganda, Zambia and Zimbabwe.
 In 2016/17, South Sudan was subsequently identified as high priority country for
VMMC programs, taking the total to 15.
 This massive public health intervention called for 80% coverage of male circumcision
by 2016 in the original 14 priority countries.
 This was estimated that achieving this coverage would cost US$1.5 billion but would
lead to savings of US$16.5 billion by 2025 due to averted HIV treatment and care costs.
It is also estimated that reaching 80% coverage in the 14 countries would prevent up to
3.4 million new HIV infections.
 Ct…

 By the end of 2017, over 18.5 million men in the priority countries had been
medically circumcised. Of this total, 4 million voluntary circumcisions were
performed in 2017 alone.
 A new VMMC target was set in the United Nations ‘2016 Political Declaration
on HIV and AIDS’ to reach 25 million young men in priority countries with
VMMC by 2020.
 A subsequent WHO/UNAIDS VMMC strategic framework set the goal of
reaching 90% of 10-29 year olds in priority countries with VMMC by 2021.
 To reach this coverage level, 5 million young men in the priority countries will
need to undertake voluntary circumcision every year.
 Ct…

 Factors that deter men from undergoing VMMC include; fear of pain,
perception of low HIV risk, poor parental or social support and a preference for
traditional, ‘rites of passage’ circumcision, which carries a cultural significance
in some communities.
 Benefits of male circumcision in HIV prevention

 Reduced rates of urinary tract infections in childhood

 Prevents inflammation of the glans penis (balanitis).
 It becomes easy to maintain penile hygiene
 Reduce the risk of human papilloma virus and resultant lower risk of penile
cancer.
 There’s reduced risks of some sexually transmitted infections (STI’S),
especially the ulcerative diseases such as chancroid and syphilis .
 Ct…

 Circumcision prevents the potential development of scar tissue on the foreskin,

which may lead to phimosis(inability to retract the foreskin) and paraphimosis
(swelling of the retracted foreskin).
 Reduced risk of infection with HIV.
 Reduced risk of cancer of the cervix in female sex partners
 Risks of VMMC

 The safety of the procedure mainly depends on the settings and the expertise of
the provider. When performed in clinical settings, under aseptic conditions, by
well trained, adequately equipped facility, then the risks are reduced;
 Infection at the site of the circumcision.
 Excessive bleeding.
 Hematoma (formation of blood clots under the skin).
 Adverse reactions to the anesthetics used during the circumcision
 Ct….

 Meatitis (inflammation of the opening of the urethra)

 Increasedsensitivity of the glans penis for the initial months after the
procedure.
 Pre- procedure preparation

 Before circumcision is done, the clients needs to have pre- procedure

preparation which should include;
 HIV testing
 Actions to reduce the risk of acquiring HIV
 Timing of the proposed male circumcision procedure
 The male circumcision service package and its benefits
 What to expect during circumcision procedure and the adverse effects
 Ct…

 The offer of partial protection against HIV

 Convectional or devise based circumcision methods available in the clinic
 Eligibility criteria for circumcision and exclusion criteria
 Post procedure wound care
 Tetanus toxoid vaccination as per the national policy
 Then take focused medical history to determine any contraindications
 Ct…

 Perform focused physical examination to rule out any signs of immunodeficiency

for example: unexplained weight loss, recurrent opportunistic infections.
 Focused general examination will include;
• vital signs
• body weight
• check for signs of anemia
• skin health
• examination of the penis
 Basic surgical skills required for safe circumcision

 Preparing a sterile operating field and maintaining sterility

 Handling tissue safely
 Handling needles and other sharp instruments safely
 Placing surgical stitches (sutures)
 Tying knots
 Stoppingbleeding by vessel ligation, suture transfixion or diathermy
(haemostasis)
 Setting up and safely using diathermy
 Circumcision specific skills (preparation)

 Prepare the skin and drape the client before the procedure
 Give injectable local anesthesia using subcutaneous ring block or dorsal nerve
block, or both
 Retract the foreskin and manage adhesions
 Mark the line for circumcision
 Realign tissue and skin after the procedure
 Avoid damaging the urethra by having proper understanding of the anatomy of
the frenulum and knowing the relationship between the frenulum and the
underlying urethra
 Ct…

 Perform the forceps-guided method of circumcision

 Perform the dorsal slit method of circumcision
 Perform the sleeve resection method of circumcision
 Dress the wound
 Ensure that there is good recordkeeping and reporting
 Operative procedure

 There are different methods of male circumcision to include;

 Forceps guided
 Dorsal slit
 Sleeve resection
 1.Forceps guided

 The forceps-guided method should not be used in adolescent boys under the
age of 15 years or in any male who has adhesions—or in any male whose tip of
the glans cannot be clearly identified by palpating the foreskin—because of
difficulty identifying the glans and the risk of glans amputation.
 Ct….

 STEP 1. Prepare skin, drape skin and administer anesthetic agents

 STEP 2. Retract the foreskin and separate any adhesions.
 STEP 3. Mark the line of the incision and skin orientation marks.
 STEP 4. Grasp the foreskin at the 03:00 o’clock and 09:00 o’clock or 06:00
o’clock and 12:00 o’clock positions with two artery forceps. Place these forceps
on the natural apex of the foreskin to help ensure that there is equal tension on the
inside and outside surfaces of the foreskin. If this is not done correctly, there is a
risk of leaving too much of the inner (mucosal) layer of the foreskin or removing
too much skin on the shaft.
 Ct…

 STEP 5. Put sufficient tension on the foreskin to pull the skin mark so that it is
just distal to the glans. Taking care not to catch the glans, apply a long, straight
forceps across the foreskin just proximal to the mark, with the long axis of the
forceps going from the 12:00 o’clock to the 06:00 o’clock position.
 Before completely locking the forceps, feel the glans to check that it has not
been accidentally caught in the forceps; then, lock it until the click sound is
heard.
 If there is any doubt about whether the glans has been caught in the forceps, do
not proceed with the forceps-guided method.
Placing the forceps to guide the male circumcision
 Ct…

 STEP 6. Using a scalpel, cut away the foreskin flush with the distal side of the
forceps (the side of the forceps towards the outside or tip of the foreskin).
 Cutting in one smooth, decisive motion is safer and leads to better cosmetic
outcomes. The forceps protects the glans from injury; nevertheless, particular
care is needed at this stage.
Forceps-guided method: cutting off the foreskin
 Ct…

 STEP 7. Pull back the skin to expose the raw area. Using a dry gauze swab,
compress the area for two to three minutes.
 Clip any bleeding vessels with artery forceps. Take care to catch the blood
vessels as accurately as possible and to not grab large amounts of tissue. Larger
blood vessels should be underrun with a suture and ligated.
 Take care not to place hemostatic stitches too deeply. Diathermy, if it is
available, may be used for smaller blood vessels.
Applying artery forceps to blood vessels to stop bleeding, and using a suture to
underrun the blood vessel
 Ct….

 STEP 8. (Optional, extra step) The forceps-guided method leaves a broader

cuff of mucosal skin than other surgical methods, and many providers trim this
to leave a narrower cuff.
 If this additional step is done, do not trim too close to the coronal sulcus. Leave
approximately 0.5–0.6 cm of cuff, so sutures can be safely placed.
 Also, do not trim close to the base of the frenulum, as this makes it difficult to
control bleeding from the frenula artery .
Optional, extra step in forceps-guided method
 Ct…

 (A) Appearance of the inner layer (mucosal layer) cuff after removal of the
foreskin
 (B) application of a curved forceps to stabilize the cuff prior to trimming with
scissors
 (C) the cuff after trimming with scissors
 Ct…

 STEP 9. Place a horizontal mattress suture at the frenulum. When placing the
frenulum suture, take care not to take too deep a bite because the urethra is just
underneath the base of the frenulum.
 Also, take care to align the midline skin raphe with the line of the frenulum.
Horizontal mattress suture at the frenulum (06:00 o’clock position)
Arrows showing the alignment of the midline skin raphe on the shaft of
the penis with the line of the frenulum
 Ct…

 STEP 10. Place a vertical mattress suture opposite the frenulum, in the 12:00
o’clock position.
 Place the suture so that there is an equal amount of skin on each side of the
penis, between the 12:00 o’clock and 06:00 o’clock positions.
 Place two further vertical mattress stitches in the 03:00 o’clock and 09:00
o’clock positions.
Placing a vertical mattress suture at the 12:00 o’clock position
Stabilizing the penis during suturing

 The penis is stabilized

by an assistant
holding two artery
forceps (see arrows)
attached to the long
end of the sutures at
the 06:00 o’clock and
12:00 o’clock
positions.
 Ct…

 STEP 11. After placing sutures at the 06:00, 12:00, 03:00 and 09:00 o’clock
positions (principal sutures), place two or three simple sutures in the gaps
between them and the technique of simple interrupted sutures is applied.
Placement of simple sutures between the mattress sutures

 Two or three
simple sutures are
placed between
the principal
mattress sutures
 Ct…

 STEP 12. Once the procedure is finished, check for bleeding. If there is bleeding
and care has been taken with shaft hemostasis, then the bleeding is likely to be
from the skin edges, which typically stops within a short period of time after
pressure has been applied to it with a gauze swab.
 If bleeding seems to be coming from deeper in the wound, then remove a few or
all of the skin stitches and reinspect the penis shaft to locate the source of the
bleeding.
 It is always better to make sure bleeding has stopped than to take a risk. Once
bleeding has stopped, apply a dressing to the wound.
standard dressing

The dressing should be

left on for 24–48 hours.
The use of adhesive tape
has the advantage of
applying mild, constant
pressure while allowing
the penis to stay in place.
From this point, the client
will undergo post-
procedure assessment.
 2. Dorsal slit method of male circumcision

 STEP 1. Prepare skin, drape the skin and administer anesthesia.

 STEP 2. Retract the foreskin and remove any adhesions.
 STEP 3. Mark the intended line of incision Make the skin mark just distal to
the prominence of the corona (further towards the tip of the penis). The mark
should have a V shape on the ventral side (frenular side), with the point of the
V towards the glans.
 Note the line of the ventral midline raphe, and if there is any deviation from
the midline, make additional orientation marks at the 03:00, 12:00 and 09:00
o’clock positions.
Marking the incision line for the dorsal slit procedure
 Ct…

 STEP 4. Apply artery forceps at the 03:00 o’clock and 09:00 o’clock positions,
to the apex of the foreskin meatus.
 Take care to apply the artery forceps to the foreskin so that there is equal tension
on the inner and outer aspects of the foreskin.
 The purpose of this step is to ensure that there is correct tension on the inner and
outer parts of the foreskin.
Applying forceps to the foreskin
 Ct….

 STEP 5. Keeping tension on the previously applied 03:00 o’clock and 09:00
o’clock forceps, place two artery forceps on the foreskin at the 11:00 o’clock
and 01:00 o’clock positions by taking 1–2 cm of foreskin between the forceps’
blades.
 Check that the inside blades of the two artery forceps are lying between the
glans and foreskin, and the blades have not been inadvertently passed up the
urethral meatus.
Placing artery forceps at the 11:00 o’clock and 01:00 o’clock positions
 Ct…

 STEP 6: keeping the 11.00,1.00, 3.00 and 9.00 o’clock forceps in position,
apply forceps at 6.00 o’clock position, take 1cm bite of the fore skin. The tip of
the outside blade of the forceps should nearly reach the apex.
 The 6.00 o’clock forceps is placed accurately and not too far inside because the
cut to remove the foreskin should be made between the inner layer of the fore
skin and the frenulum
 If cut is made too close to the base of the frenulum, then there’s is increased
risk of bleeding from the frenular artery which is difficult to control and may
lead to the risk of urethral damage during attempts to control this bleeding.
 Ct…

 Once the 6.00 o’clock forceps is in position, the 3.00 o’clock and 9.00 o'clock
tensioning forceps are removed leaving 3 forceps in position; 11.00, 1.00, and
6.00 o’clock.
Forceps at the 06:00 o’clock position, with the inner blade nearly
reaching the fold of the frenulum

 The forceps at 11:00

o’clock and 01:00
o’clock positions are
under tension to
display the interior of
the foreskin meatus
 Ct…

 STEP 7. Between the two top artery forceps (11:00 o’clock and 01:00 o’clock),
apply forceps at the 12:00 o’clock position and close it tightly to crush the line
of the dorsal slit. This crushing helps to reduce bleeding when the dorsal slit is
made.
Applying forceps at 12:00 o’clock position to crush the foreskin before
making the dorsal slit.
 Ct…

 STEP 8. Remove the 12:00 o’clock crushing forceps and, using dissection
scissors, make a cut along the middle of the crushed foreskin (the dorsal slit)
up to the previously marked incision line.
 STEP 9. Make the circumferential cut to remove the foreskin. Starting at the
12:00 o’clock position, the circumferential cut is made using scissors, first in
one direction and then the other.
Cutting the dorsal slit
Cutting of the circumferential at the foreskin
Cutting of the circumferential at the foreskin
 Ct…

 STEP 10. If any ragged edges remain, they can be trimmed, however, always
take care to leave approximately 0.5–0.6 cm of skin proximal to the corona for
suturing. Also, take care to not trim or cut into the deeper tissue of the shaft of
the penis, particularly in the area of the frenulum.
Trimming the inner (mucosal) layer of the foreskin
 Ct…

 STEP 11. Stop any bleeding, and proceed with suturing, as described in Steps
7–11 of the forceps-guided method.
 STEP 12. Check again for bleeding and manage as needed, as described in
Step 12 of the forceps-guided method. Once there is no bleeding, apply a
dressing.
Tips for dorsal slit male circumcision
 When resecting the foreskin, keep looking at the inner foreskin to
ensure that not too much skin is removed.
 Take particular care at the 06:00 o’clock frenular position.
 3. Sleeve resection method of male circumcision

 The sleeve resection method requires a higher level of surgical skill and takes
slightly longer than other methods. If diathermy is available, the procedure
can be virtually bloodless, and the cosmetic results are better than with the
other two techniques.
 However, there is more room for surgical error either by cutting too far into
deeper tissue when making the two circular incisions or by cutting too deeply
when dissecting the skin flap free.
 Ct…

 STEP 1. Prepare skin, drape the skin and administer anesthetic agent(s).
 STEP 2. Retract the foreskin and remove any adhesions. If the foreskin
does not retract easily, it may be necessary to make a partial dorsal slit.
 STEP 3. Two separate lines of incision must be marked, referred to here as
the outer and inner lines of incision. First, mark the intended outer line of
the incision and, draw orientation marks. The skin mark should be made
just distal to the prominence of the corona (that is, further towards the tip of
the penis). On the ventral side (frenula side), the mark should have a V
shape, with the point of the V towards the glans.
Marking the line of the outside cut, at or just below the corona
Marking the V on the ventral side of the penis
 Ct…

 STEP 4. Retract the foreskin and mark the inner (mucosal) incision line 1–1.5
cm proximal to the corona. At the frenulum, the incision line crosses horizontally.
Marking the inner incision line
 Ct…

Step 5. Using a scalpel, make incisions along the marked lines, taking care to cut
through the skin to the subcutaneous tissue but not deeper. As the incision is made,
the assistant should retract the skin and keep it under tension with a moist gauze
swab.
 An artery forceps should be applied to any vessel that is bleeding significantly;
the vessel should then be tied or secured with an underrunning suture. Bleeding
from small vessels can be stopped with diathermy, if available. If the cut has not
been made too deeply, most bleeding will be from the edges of the skin and can
be stopped by placing a simple pressure over the bleeding with a gauze swab;
diathermy should not be used near the skin edge.
Incising along the marked line
Incising the V-shaped line on the underside of the penis
Completed incisions leaving a sleeve of foreskin
 Ct…

 STEP 6. Using a pair of scissors, cut the skin vertically between the proximal
and distal incisions at the 12:00 o’clock position.
Cutting the skin between the outer and inner incisions
 Ct…

 STEP 7. Hold the sleeve of the foreskin under tension with two artery forceps
and dissect the skin from the shaft of the penis using dissection scissors.
 The plane of dissection should be just beneath the skin and the superficial
connective tissue, leaving the deeper fascia (Buck’s fascia) in place.
Dissecting the sleeve of skin away from the shaft of the penis
 Ct….

 STEP 8. Stop any bleeding and close the skin incision with sutures.
 STEP 9. Check for bleeding again, and manage bleeding as needed. Once
there’s no bleeding, apply a firm dressing.