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Practical Procedures
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Preparing a patient for a procedure

Laying a cart
Local anesthetic

  Laying a cart

Setting up a cart is a vital skill. It should be performed meticulously to ensure a sterile field.

  • Collect all the equipment you need for a given procedure. You will commonly need the following:
    – a dressing pack
    – a green (21-gauge) needle to draw up lidocaine and to inject it into deeper tissue
    – an orange (27-gauge) needle to administer local anesthetic to the skin
    – 10-ml and 20-ml syringes
    – packets of gauze
    – iodine or chlorhexidine cleaning solution; check that your patient is not allergic to iodine
    – surgical tape
    – sterile gloves
    – a hazardous material container
  • Ask for help. You will need another pair of hands later.
  • Place all of the items except for the dressing pack on the bottom shelf of your cart and take the cart to the patient's bedside.
  • Explain to the patient the procedure you are about to perform.
  • Position the patient and yourself so that you are both comfortable. Procedures always take longer than expected.
  • Place an incontinence pad under the patient. This protects the bed and the patient from any blood and cleaning solution that you spill. The patient and nursing staff will thank you!
  • Open the dressing pack with the tips of your fingers. Trying not to touch more than the corners, open the outer packaging. There will be another package inside, together with paper towels and a yellow bag. Take out the yellow refuse bag and stick it on the end of the cart.
  • Peel open the orange needle package and drop the contents onto sterile paper without actually touching it. Repeat for all of the other items you might need (needles, gloves, gauze, syringes, etc.).
  • Wash your hands thoroughly. Dry them with paper towels and put on your gloves. Your hands are now sterile and you cannot touch anyone or anything that is not sterile – this includes any part of the patient you have not cleaned with iodine or chlorhexidine.

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  Local anesthetic
  • Ask your assistant to pour the cleaning solution into the pot on your cart.
  • Clean the appropriate area on your patient using gauze or cotton, applying the cleaning solution in a circular motion, working from the center of the area outwards. Give yourself a large clean area. Do not go over where you have been with the same swab. Go over it again with a new swab if necessary. This area is now sterile and you can touch it. Cover any remaining part of the patient that is not sterile, and that you might touch accidentally, with drapes or with the sterile sheet in the dressing pack.
  • Ask your assistant to show you the bottle of local anesthetic and to confirm its name, strength, and expiration date.
  • Draw up the lidocaine in a 10-ml syringe. The maximum dose of 1% lidocaine is 20 ml; for 2% lidocaine, it is 10 ml.

Note: Never use lidocaine plus adrenaline when suturing extremities (fingers, toes, and noses).

  • Attach an orange needle to the syringe and puncture the skin fairly superficially, into the dermis near the site you want to anesthetize. Enter at a 45° angle, aspirate back on the syringe to check that you are not in a blood vessel and inject 1–2 ml of lidocaine. A small "bleb" will appear, allowing you to push the needle in further and deeper. Aspirate as you go, and continue to inject the local anesthetic along the line of the cut or where you will suture.
  • Once you have injected superficially, remove the orange needle and replace it with a green one to anesthetize more deeply, aspirating before you inject throughout. This time, enter the skin at a 90° angle.
  • Allow the anesthetic to work. Often, the reason patients sometimes complain of pain after receiving a local anesthetic is because the anesthetic has not had time to work.

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There are many ways to suture (ask any surgeon), and the best way to learn is by watching and then doing. We will not go into further details here.

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When you have finished your procedure, do the following:

  • Ensure that all your sharps are disposed of in a hazardous material container. This is your responsibility alone.
  • Clean the patient with normal saline and some clean swabs. Make sure that all of the cleaning solution and blood are cleaned off.
  • Discard the incontinence pad.
  • Put green drapes and gowns in the laundry basket. Make sure that all other disposable items are cleaned up and put in your yellow bag. Put the yellow bag in the appropriate place and replace all other items. If you are lucky, your assistant will help, but don't make that assumption.

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