ALGORITHMS OF PRACTICAL SKILLS FOR oscE

BLOOD GROUPS DETERMINATION BY ABO SYSTEM WITH THE HELP OF

MONOCLONAL ANTIBODIES ANTI-A AND ANTI-B

1. Wear safety goggles, rubber gloves

2. Prepare the necessary test instruments (plate, pipettes, glass sticks or
glassware) on the desktop.
3. Apply 1 drop of monoclonal antibodies anti-A and anti-8 to the appropriate
lobes of plate
4. Apply 1 drop of blood sample from a test tube using a plastic pipette, near
each drop of a monoclonal antibodies (blood: reagent - 1: 10)
5. Mix blood and monoclonal antibodies by different ends of a glass stick
6. Continue to mix reagents by shaking the plate for 30 seconds.
7. Stand exposure 2.5 minutes
8. Dispose used materials and gloves, leave the safety goggles on the table
9. Evaluate the agglutination reaction on the plate and write the result of
determined blood group on paper

QUESTIONING SURGICAL PATIENT

1. Introduce yourself to the patient.
2. Confirm patient's name, age and occupation.
3. Explain that you are going to ask him some questions to uncover the cause of his
abdominal pain, and obtain his consent.
4. Ensure that he is comfortable
Presenting complaint and history of presenting complaint
Determine:
• Site of pain e.g. right iliac fossa.
'-- • Onset and progression.
"• G-haracter
, e.g. sharp, dull, aching' burning - allow the patient to use h"1s own words.
 )

• Radiation.
• Associated symptoms and signs.
• Timing and duration.
• Exacerbating and alleviating factors.
• Severity on a scale of .1 to 10.
Ask about:
• Systemic signs and symptoms: fever, jaundice, loss of weight or anorexia, effect on
everyday life.
• Upper GI signs and symptoms: dysphagia, indigestion (heartburn), nausea, vomiting,
haematemesis.
• Lower GI signs and symptoms: diarrhoea or constipation, melaena or rectal bleeding,
steatorrhoea.
• Genitourinary signs and symptoms: frequency, dysuria, haematuria.
• Gynaecological signs and symptoms: length of menstrual period, amount of bleeding,
pain, intermenstrual bleeding, last menstrual period.
Past medical history
• Previous episodes of abdominal pain.
• Current, past, and childhood illnesses.
• Previous hospital admissions and surgery.
Drug history
--. Prescribed medications. Ask specifically about corticosteroids, NSAIDs, antibiotics,
and the contraceptive pill.
• Over-the-counter medication and herbal remedies.
• Recreational drugs.
• Allergies.
Family history
• Parents, siblings, and children. Ask specifically about colon c;mcer, irritable bowel
syndrome, inflammatory bowe! dj~~-~,jaundice, peptic ul~eration, and polyps.
- . ---- -----=- . . ----- ---1- . . . .~- .a:;:: --- - - --

Social history
' .
• Alcohol consumption.
• Smoking.
• Recent overseas travel.
• Tattoos and piercings.
• Employment, past and present.
• Housing.
• Contact with jaundiced patients.
After taking the history
• Ask the patient if there is anything that he might add that you have forgotten to ask.
• Ask the patient if he has any questions or concerns.
• Thank the patient.
• Summarise your findings.

INJECTIONS
I. The procedure intramuscular (IM) and subcutaneous (SC) injections
• Wash your hands and don gloves.
• Attach a needle to the syringe and draw up the correct volume of the drug, making sure
to tap out and expel any air.
• Dispose of the needle and attach a new needle to the syringe for IM/SC administration.
• Ask the patient to expose his leg and ensure that the target muscle is completely
relaxed.
• Identify landmarks in an attempt to avoid injuring nerves and vessels.
• Clean the exposed site with an alcohol steret two times and allow it to dry.
• Warn the patient to expect a piercing into the skin.
Intramuscular (IM) injection technique
• IM injection site is the gluteal muscle - upper lateral quadrant
• With your free hand, slightly stretch the skin at the site of injection.
• Introduce the needle at a 90 degree angle to the patient's skin in a quick, finn motion.
• Pull on the syringe's plunger to ensure that you have not entered a blood vessel. If you
aspirate blood, you need to start again with a new needle, and at a different site.
• Slowly inject the drug and quickly remove the needle.
Subcutaneous (SC) injection technique
• Bunch the skin between thumb and forefinger, thereby lifting the adipose tissue from
the underlying muscle ('tenting').
• Insert the needle, bevel uppermost, at a 45 degree angle in a quick, firm motion. You are
aiming for the tip of the needle to be in the 'tent'.
• Release the skin.
•Pullon the syringe's plunger to ensure that you have not entered a blood vessel.
• Slowly inject the drug.
Immediately dispose of the needle in the sharps box.
• Apply gentle pressure over the injection site with some cotton wool (the patient may
assist with this).
• Ensure that the patient is comfortable.
• Ask him if he has any questions or concerns.
• Thank him.
• Sign the prescription chart and record the date, time, drug, dose, and injection site of the
injection in the medical records.
II. The procedure of intravenous injections
• Consult the prescription chart and check:
- the identity of the patient
- the prescription: validity, drug, dose, diluent (if appropriate), route of administration,
date and time of administration
- drug allergies
• Check the name, dose and expiry date of the drug on the vial and the name and expiry
date of the diluent.
• Wash your hands and don gloves .
• Attach a 21 G (green) needle to a syringe and draw up the correct volume of the drug,
making sure to tap out and expel any air.
• Remove the needle and attach a new 21 G needle to the syringe .
• Apply a tourniquet to the model arm and select a suitable vein.
• Clean the venepuncture site with an alcohol steret two times.
 I

• Retract the skin with your non-dominant hand to stabilise the vein, tell the patient to
expect a piercing into the skin, and insert the needle into the vein until a flashback is
seen.
• Undo the tourniquet.
• Administer the drug at the correct speed (too fast may cause adverse reactions such as
emesis).
• Withdraw the needle and immediately dispose of it in the sharps box.
• Apply gentle pressure over the injection site using a piece of cotton wool.
• Remove the gloves.

WOUND MANAGMENT
Wound debridement
• Put on a mask
• Clean hand with antiseptic
• Put on rubber gloves
• Clean the skin around the wound with antiseptic three times
• Perform a palpation and instrumental (using a probe) wound revision
• Perform sanation of the wound cavity with antiseptic
• Dry the wound
• Apply an aseptic bandage
• Dispose used tools and materials to container with disinfectant
• Prescribe an emergency tetanus prophylaxis (to speak out in the voice of the need
to introduce tetanus toxoid)
Suturing and stitches removement
• Put on a mask
• Clean hand with antiseptic
• Put on rubber gloves
• Clean the skin around the wound with antiseptic
• Choose the necessary tools for suturing and knot removing (needle holder, needle,
 thread, surgical tweezers, scissors).
• Take the needle and put needle correctly (1/3 of the needle's ear, and 1/3 of the
"nose" of the needle holder) in the needle holder at an angle of 90 degrees
• Take the thread and correctly (long part 2/3 length, short part 1/3 length) tucked in
the needle's ear
• The long edge of the thread should be locked under the fingers of the arm near the
nappy bronchus
• Surgical tweezers fix the edge of the wound and at a distance of I cm from it,
insert the needle perpendicular to the plane of the stitching tissue
• The needle should be carried through the tissues around the circumference of its
curvature through the two edges of the wound symmetrically, while capturing the
same amount of tissue in the stitch.
• Tie thread by three surgical knots, placing them 1 cm from the side of the wound
• Cut off the free ends of the thread, retreating 1 cm from the knot
• Remove the stitches according to the generally accepted method (with the
tweezers, grab the free edges of the threads by pulling them to the top and place
the scissors between the knot and the skin, cut thread and remove it by tweezers)
• Repeat the suturing and stitches removing 2 more times
• Dispose used tools and materials to container with disinfectant

ABDOMINAL EXAMINATION
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Obtain consent to examine his abdomen.
• Wash hands and wear rubber gloves.
• Position the patient so that he is lying flat on the couch, with his arms at his side
and his head supported by a pillow.
• Ask the patient to release the belly of clothing.
• Ask the patient to identify area of pain
 • Ensure that the patient is comfortable.
General inspection

• From the end of the couch, observe the patient's general appearance (age, state of
health, nutritional status, and any other obvious signs).
• Next observe the surroundings, looking in particular for the presence of a
nasogastric tube, intravenous infusion, urinary catheter, drain, or stoma bag.
• Inspect the abdomen for its form, contours, symmetry, involving of anterior
abdominal wall in breathing and any obvious distension, localised masses, scars,
and skin changes. Ask the patient to lift his head up and to cough. This makes
hernias more visible and, if the patient has difficulty complying with your
instructions, suggests peritonism.
Palpation

Before you begin, ask the patient to identify any area of pain or tenderness during
palpation.

• Sit beside the patient and use the palmar surface of your fingers to lightly palpate
in all nine regions of the abdomen, beginning with the region furthest away from
any pain or tenderness.

• By flexing and extending your metacarpophalangeal joints, palpate for tenderness,

rebound tenderness, guarding, and rigidity. Keep looking at the patient's face for
any signs of discomfort.
Order of palpation:
L Pain in the right iliac region:
The left iliac area - the left lateral - the right lateral - the left subcostal - right subcostal -
epigastric - umbilical - suprapubic region - right iliac area
IL Pain in the left iliac region:
The right iliac region - left lateral - right lateral - left subcostal - right subcostal -
~pigastric - umbilical - suprapubic - left iliac area
III Pain in the epigastric region:

The left iliac area - right iliac region - left lateral - right lateral - left subcostal - right
subcostal - umbilical - suprapubic - epigastric
 I

IV. Pain in the right subcostal area:

The left iliac area - right iliac region - left lateral - right lateral - left subcostal -
epigastric - umbilical - suprapubic - right subcostal
NB! The painful area should be palpated the last.
• Detennine the symptom of peritoneal irritation in the place of greatest pain.
Technique: Slowly press the abdominal wall with your hand, and then quickly remove
the hand. A positive symptom is the increase in pain when take off the arm from the
abdominal wall. Negative symptom is the absence of increased pain when take off the
arm from the abdominal wall.
• Cover up the patient and thank him. Enquire about and address any concerns that
he may have.
• Summarise your findings and offer a differential diagnosis.

TRAUMA
I.Arterial bleeding arrest by tourniquet application
1. Put on rubber gloves
2. Put the patient on the couch
3. Prepare the area of the limb to overlaying the tourniquet - protect the skin with a soft
gauze bandage.
4. Give the affected limb an elevated position.
5. Slide injured limb through the loop of tourniquet
6. Place the tourniquet proximally from wound on 5-8 cm (maximum 10 cm) .
7. After placing the tourniquet on the limb, pull free running end of band tightened
securely fasten it back on itself
8. Twist the windlass until bleeding stops
9. Lock the windlass in a place with a clip (special bracket).
10. Check the absence of pulse on the peripheral artery of the affected limb
11. Secure strap, note the time of the tourniquet applying (hours, minutes) on strap.
,Before time, write the capital letter "T" (tourniquet, time), which is a signal to the staff
that the wound has a tourniquet attached.

l
12 · Make sure that the tourniquet is not attached to the joint, to the place of the bone

fracture. Try not to apply a tourniquet in the middle third of the shoulder and in the
region of the popliteal area - there is possibility of nerves damage.
NB! The tourniquet is not superimposed on the middle third shoulder and in the
upper third of the shin - the danger of nerves injury
II. Temporary bleeding arrest from a.femoralis., a.poplitea, a.carotis communis,
a.axillaris by digital pressure on blood vessels.
1. Wear rubber gloves
2. Put the patient on his back
3. Perform temporary bleeding arrest by digital pressure on blood vessels.
Technique
3.1.Bleeding from a.femoralis:
Pulsation of a.femoralis is to be found at the point corresponding to the edge between
median and internal thirds of the inguinal ligament. At this point, the digital pressure on
a.femoralis should be applied towards horizontal pubic ramus.
3.2. Bleeding from a.poplitea:
Pulsation of a.poplitea is to be found at the hollow of the knee. The digital pressure on
a.poplitea should be applied at the top of the hollow of the knee towards the posterior
surface of tibia.
3.3. Bleeding from a.brachia/is:
With the right hand grab the forearm and elevate it, bending the arm in the elbow joint
approximately at an angle of 80 °;
With the left hand grab the victim's shoulder so that the first to fourth fingers are on the
inner furrow of the brachial muscle, and the thumb - on the opposite side of the shoulder;
Press the brachial artery to the humerus by four fingers of left arm
3.4. Bleeding from a.carotis communis:
Pulsation of a.carotis communis is to be found in the middle of the internal part of m.
Stemocleidomastoideus (projection of the upper edge of the thyroid cartilage). At this
point, the digital pressure on a.carotis communis should be applied towards the carotid
tubercle of the transverse process of the cervical vertebra VI.
 ,J
I
I

/ 4. Estimate effectiveness of bleeding arrest-bleeding stop.

III. Arrest of venous bleeding by pressure bandage
l. The position of the victim - on the back or sitting in a comfortable position for him
2. Position of the rescuer - opposite to victim for observing the face of the patient (to see
if he does not hurt) and the whole dressing surface
3. Put on rubber gloves
4. Elevate the injured extremity by using a roller-pillow.
5. Cover the wound with a sterile gauze napkin
6. Put pressure element over the sterile gauze napkin (packed bandage)
7. Apply a circular bandage, exercising maximum pressure on the wound:
• Take free end of the bandage to the left hand, and its rolled part to the right hand.
• Untwist the bandage around the limb from left to right (along the clockwise
direction), with fixation of bandage's end by first two rounds.
• The first two rounds of bandage should completely cover each other to secure the
end of the bandage well, and each subsequent round should partially cover the
previous, fixing it.
• The last 2 rounds of bandage, as well as the first two, are superimposed on each
other, then the bandage is cut along, tie the knot at both ends (it is not necessary to
break the bandage, since one end can break)
8. Estimate the effectiveness of stopping the bleeding - no bleeding
Iv. Immobilization of the upper limb with a pneumatic splint.
1. Extract pneumatic splint from the package. Untight the buckle and put splint under the
injured upper limb (fixation place).
2. Upper limbs provide a comfortable physiological position - the shoulder is diverted to
50 ° and forward to 30 °, bend in the elbow by 90 °, fingers bend to 60 °.
3. The splint apply in accordance with the position and contour of the fixed place. If
necessary, the hand is fixed using a bandage through a healthy forearm so that no
traumatic shock occurs.
4. Put gauze or cotton between skin and splint.
5. Fasten splint.
 I
1•
- - - - •• -~ -
/4 Open the valve by tu .
7. Inflate the r .
nung the air tube b
Ycounter clockwise.
sp mt using a pum d
8 It· P, an reverse the tube to close the valve.
. is necessary to observe the co ..
the color of . u<litton of the limb - check the warm fingers and assess
the skm - the pre f
circulato d' . sence O cyanosis. It is necessary for the prevention of
ry isorders m the extremity
9. In the case of fracture s Of the forearm bones 2 joints should be fixated - the elbow and
· t £or the shoulder - three joints: shoulder, elbow and ray wrists.
the radial-wrist j om,
l O· When unlocking, open the valve, and further, by releasing the lightning, the lock from
the upper limb is removed.
V. Immobilization of the upper limb with a pneumatic splint.
1. Extract pneumatic splint from the package.
2. Unclip the buckle and place splint under the injured lower limb (place of fixation),
necessarily from below, or put the victim on the deployed splint with an injured lower
limb.
3. The splint apply in accordance with the position and contour of the fixed place.
4. Put gauze or cotton between skin and splint.
5. Give the limb an average physiological position - move the thigh by 10 °, the leg bend
in the knee joint by 10-15 °, the foot - by 90 °.
6. Fasten splint
7. Close the buckle.
8. Open the valve by twisting the air tube by counter clockwise.
9. Inflate the splint using a pump, and reverse the tube to close the valve.
10. It is necessary to observe the condition of the limb - check the wann fingers and
assess the color of the skin - the presence of cyanosis. It is necessary for the prevention of
circulatory disorders in the extremity.
11. The splint must necessarily seize two joints in the shin bones (knee and ankle-foot) or
three joints with fractures of the femur (hip+ knee+ ankle-foot)
VI. Application of occlusive bandage in case of open pneumothorax
1. Position of victim - sitting on chair. Position of rescuer - in opposite to patient
2. Open the individual bandage package - take the package to the left hand that the free
edge is on top, with the right hand grab the cuted edge and tear off it, extracting the
contents from package;
3• Cover the wound by sterile internal side of package wrap - the sterile side of the
package should tightly close the wound with a protrusion along the edge of 4 to 5 cm.
The edges of the wrap should be hermetically tucked to the skin.
4. Then put the two pads on the package with a side that is not stitched with a colored
thread on the rubberized shell.
5. Fixate pads to the thorax by circular bandage
6. Check the effectiveness of application the bandage - no symptoms of an increase in
pneumothorax and no increase in the area of subcutaneous emphysema.