2. FOLEY’S CATHETER

3. • Foley’s catheter is a self-retaining
catheter made up of latex.
• It is made to be self-retaining by means
of a balloon which should be inflated
with saline.
• In cases of intractable epistaxis or
bleeding oesophageal varices the
balloon is inflated with air.

4. INDICATIONS
• URINARY:
To monitor urine output in case of
shock or renal failure.
To differentiate anuria from retention.
For urinary incontinence.
To give bladder washes (in Cystitis)
For suprapubic cystostomy.

5. • NON-URINARY:
To arrest post-nasal bleeding in cases
of intractable epistaxis.
To arrest bleeding from oesophageal
varices in case of portal hypertension.

6. • CONTRAINDICATIONS:
In the presence of urethral trauma
• COMPLICATIONS:
Injury to urethra or urinary bladder.
Inadvertent catheterization of the
vagina may occur.
Urinary tract infection in the absence
of aseptic precautions.

7. PROCEDURE
 Sedate the patient, if necessary
 Cleanse the urethral meatus and penis
or the perineal area with povidone
iodine solution.
 Select the Foley’s catheter of the
appropriate size:
 8 Fr: newborns
 10 Fr: most children
 12 Fr: older children
 The catheter tip should be well
lubricated.

8.  EQUIPMENT:
Sterile gloves - consider Universal
Precautions
Sterile drapes
Cleansing solution e.g. Savlon
Cotton swabs
Forceps
Sterile water
Foley catheter
Syringe
Lubricant (water based jelly or xylocaine jelly)
Collection bag and tubing
 POSITION: Place the patient supine with
knees flexed.

9.  MALE:
 Gently grasp and extend the penile shaft to
straighten out the urethral pathway.
 Hold the catheter near the distal tip and
advance it up the urethra unless resistance or
an obstruction is encountered.
 If resistance is encountered, select a smaller
catheter.
 The catheter should be passed into the
bladder all the way to the Y-connection.
 Inflate the balloon after advancing the
catheter all the way to the Y-connection.
 Tape the catheter to the child’s leg.

10. • FEMALE:
Carefully spread the labia.
A well-lubricated, pre-tested Foley
catheter is introduced into the bladder.
Advance the catheter to its entire
length before inflating the balloon.
After withdrawing the catheter, after a
dunking sensation is
appreciated, secure it with tape.

11.  TO REMOVE THE CATHETER:
Attach a syringe and aspirate the saline
balloon gets deflated and the catheter can be
removed easily.
If this does not succeed, the balloon can be
deflated by:
 Overinflate the balloon by injecting more
saline till it bursts.
 Cut the side-channel distal to the outer
balloon and go on cutting it upto the meatus
till the balloon gets deflated.
 The balloon can be punctured via per-rectal
route or suprapubic route.

12. URINARY DRAINAGE BAG

13.  It is a disposable plastic bag which is
marked in millilitres, so as to measure the
urine output.
 The bag is closed at the upper end and
has a plastic tube opening into it.
 There is a valve present at the opening of
the plastic bag into the drainage bag to
prevent urine collected in the drainage
tube to re-enter the tube.
 The plastic tube (inlet) has a connector
at the other end which can be connected
to a catheter.

14. • The bag also has an outlet at the upper
end which is usually kept closed, but
can be used to empty the contents of
the drainage bag by inverting the bag.
• The urinary drainage bag is placed at a
lower level than the body to facilitate
urine drainage by gravity.

15. FLATUS TUBE

16.  It is made up of India rubber.
 It is thick and stout and has a bulbous
rod with two eyes at the tip.
 INDICATIONS:
Diagnostic use:
Diagnosis of intestinal obstruction
Diagnosis of volvulus

17. Therapeutic use:
To remove gaseous obstruction
In typhoid lymphatics
In paralytic ileus
In volvulus

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

19.  Equipment:
a) Take a sterile flatus tube in a bowl.
b) Swabstick
c) Vaseline bottle
d) Draw mackintosh and drawsheet.
e) Two kidney trays

20. PROCEDURE:
1) Arrange them in such a manner that it will be
comfortable for the patient and handy to work.
2) It will also save the time and energy.
3) Explain the procedure to the patient and relatives to gain
their co-operation.
4) Provide privacy by putting curtain, so that the patient
will not feel shy.
5) To prevent the blanket from getting spoil, fold it and keep
it at the foot site.
6) Place the draw mackintosh and draw the sheet under his
waist to prevent the bed from getting wet.
7) Give him left lateral position on the bed.
8) Loose the garments of the waist and expose only the
necessary portion, so that the patient will not hesitate.

21. 9) Lubricate the flatus tube at eye side, up to 3" to 4" with vaseline to
prevent the friction, as the mucus membrane of the rectum is very
delicate.
10) Touch the tip of flatus tube to the anus so that the sphincter muscles
of the anus constrict and immediately relaxes, at that time insert it in
anal canal gently but quickly, keeping the free end of the flatus tube
under the lotion in kidney tray.
11) Insert the tube 7 to 10 inches and observe the bubbles and liquid
stools in the lotion.
12) When the bubbles are stopped then move the tube little bit inside
and outside, and observe for the bubbles. After that remove the tube
and keep it in other kidney tray. See that the tube will not touch the
floor.
13) If the bubbles are observed more then write the result 'good', if not
then mark the result 'poor'.
14) Remove the draw sheet and mackintosh. Make the patient
comfortable. Do the bed neat
15) Record the date, time and result of flatus tube on the case paper
and inform the sister incharge.

22. TUBERCULIN SYRINGE
It is 1cc syringe with a plastic piston (plastic
syringe), or a metal piston ( glass syringe)

24. USES :
• To administer PPD for Mantoux test.
• To administer BCG vaccine.
• To adminiter test doses of drugs such as
penicillin.
• Provocative Testing – to test for allergens in
Bronchial asthma , atopy.
• Insulin injections in Diabetes Mellitus.
• Giving small doses of drugs. Eg. Gentamicin,
Phenobarbitone , Digoxin.

25. MANTOUX TEST
Tuberculin PPD 2 T.U./0.1 ml, solution for
injection:
1 dose = 0.1 ml contains 0.04 microgram
Tuberculin PPD.
– Store at 2°C - 8°C, protected from light

26. PROCEDURE OF MANTOUX TEST

27. Diameter of induration Interpretation Action
Less than 6mm Negative Previously unvaccinated
individuals may be given
BCG provided there are no
contraindications.
6mm or greater but less Hypersensitive to tuberculin Should not be given BCG
than 15mm protein. May be due to
previous TB infection, BCG
or
exposure to atypical
mycobacteria
>= 15mm Strongly hypersensitive to Should not be given BCG.
tuberculin protein Refer for further
Suggestive of TB infection investigation
or and supervision which may
disease include chemotherapy.

28. BCG Vaccination
• It induces primarily cell mediated immunity.
• Administered at or soon after birth
• Supplied in the form of lypophilised or freeze
dried powder, in a vaccum sealed dark colored
multidose vial.
Reconstituted with normal saline.
• Extremely sensitive to light and heat. Thus,
cold chain should be maintained.
• In lypophilised form, it remains potent for
upto a year at 2-8 ˚C.

29. • Dose – 0.1ml
• Site- convex aspect of left shoulder at the insertion
of deltoid to allow for easy identification of scar.
• Route of administration – intradermal
• Multiplication of BCG bacilli papule at 2-3
weeks 4-8 mm in size at 5-6 weeks
ulceration heals by scarring around 6-12
weeks
• Adverse effects – persistent ulcer with delayed
healing ipsilateral axillary or cervical
lymphadenopathy, and rarely abscess and sinus
formation.
• Positive reaction to tuberculin test 4-12 weeks
after immunisation.

30. SCALP VEIN NEEDLE
• It consists of a metallic needle attached to a plastic tubing.
• At the junction of the needle and the tubing, there is butterfly
shaped plastic holder which facilitates easy insertion of the
scalp needle into the vein.
• The plastic holder is flexible and colour coded .eg . Black is no
22.
• The commonly used needles are from no 22 to no 24.
• There is an inverse relation between the guage number and
the internal diameter.
• Higher the guage number , small is the diameter of needle.
Thus 24G needle is smaller in diameter than 22G needle.

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

33. LUMBAR PUNCTURE

34. INDICATIONS :
• Diagnostic : • Therapeutic :
– Infectious – Analgesia
• Meningitis
• Encephalitis – Anesthesia
– Inflammatory – Antibiotics
• Multiple Sclerosis
– Antineoplastics
• Gullain-Barre syndrome
– Oncologic
– Metabolic
– Spontaneous
subarachnoid
hemorrhage

35. CONTRAINDICATIONS :
• Increased intracranial pressure
– Cerebral herniation
– Impending herniation
– Possible increased ICP and focal neuro signs
• Coagulopathy
• Prior lumbar surgery
• Severe vertebral osteoarthritis or degenerative
disc disease
• Significant cardiorespiratory compromise
• Infection near the puncture site
• Space occupying lesion

36. EQUIPMENT :
• Spinal needle
– Less than 1 yr: 1.5in
– 1yr to middle childhood: 2.5in
– Older children and adults:
3.5in
• Three-way stopcock
• Manometer
• 4 specimen tubes
• Local anesthesia
• Drapes
• Betadine

37. PROCEDURE :
• Performed with the
patient in the lateral
recumbent position.
• A line connecting the
posterior superior iliac
crest will intersect the
midline at approx. the
L4 spinous process.
• Spinal needles entering
the subarachnoid
space at this point are
well below the
termination of the
spinal cord.

38. • LP in older children may
be performed from L2 to
L3 interspace to the L5 to
S1 interspace.
• At birth, the cord ends at
the level of L3.
• LP in infant may be
performed at the L4 to L5
or L5 to S1 interspace.

39. • Position the patient:
– Generally performed in
the lateral decubitus
position.
– A pillow is placed under
the head to keep it in the
same plane as the spine.
– Shoulders and hips are
positioned. perpendicular
with the table.
– Lower back should be
arched toward
practitioner.

40. a. Ligament flavum is a strong,
elastic, yellow membrane
covering the interlaminar
space between the
vertebrae.
b. Interspinal ligaments join
the inferior and superior
borders of adjacent spinous
processes.
c. Supraspinal ligament
connects the spinous
processes

41. • A topical anesthetic (e.g. EMLA cream) can be
applied 30 to 60 minutes before performing the
puncture to minimize pain on penetration.
• Either a sitting or lateral decubitus position can
be used .
• Monitor the patient visually and with pulse
oximetry for any signs of respiratory difficulty as
a result of assumed position.
• The subarachnoid space must be entered below
the level of spinal cord termination.
• The spine should be flexed maximally to
increase spacing between spinous processes.

42. • The patient’s back should be carefully prepared and
draped using provided disinfecting solution and
drapes.
• Orient yourself anatomically and find the L4 spinous
process at the level of iliac crests
• Palpate a suitable interspace distal to this level.
• Infiltrate 2% Lidocaine subcutaneously (without
epinephrine to prevent cord infarction should it be
introduced into the cord by accident) with a fine
needle.
• A field block can be applied injecting into and on
either side of the interspinous ligaments.
• Identify the two spinal processes in between which
the needle will be introduced, penetrate the skin
and slowly advance the tip of the needle at about
10 degrees cephalad (i.e. toward the patient’s
umbilicus).

43. • Remove the stylet and check for clear fluid will flow
from the needle when the subarachnoid space has
been penetrated.
• The ligaments offer resistance to the needle, and a
“pop” is often felt as they are penetrated.
• Withdraw the needle leaving the tip in, recheck the
landmarks and slowly progress the needle again.
• Measure the opening pressure using the manometer
by attaching it via a stopcock to the spinal needle.
• Normal opening pressure ranges from 10 to 100 mm
H2O in young children and 60 to 200 mm H2O after
eight years of age

44. • CSF volume of 1cc obtained in 3 tubes.
• In the neonate, 2ml in total can be safely
removed.
• In an older child 3 to 6 ml can be sampled
depending on the child’s size.
• Tube 1 is used for determining protein and
glucose
• Tube 2 is used for microbiologic and cytologic
studies
• Tube 3 is for cell counts and serologic tests for
syphilis

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

46. BONE MARROW ASPIRATION

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

48. CONTRAINDICATIONS :
• Hemorrhagic disorders such as congenital
coagulation factor deficiencies (eg,
hemophilia), disseminated intravascular
coagulation and concomitant use of
anticoagulants.
• Skin infection or recent radiation therapy at
the sampling site.
• Bone disorders such as osteomyelitis or
osteogenesis imperfecta.

50. PROCEDURE :
• Obtain consent from a parent or guardian.
• If the posterior iliac crest is the chosen site, patients
are generally placed in the lateral decubitus position
or the prone position
• Sterilize the site with the sterile solution
• Place a sterile drape over the site, and administer
local anesthesia, letting it infiltrate the skin, soft
tissues, and periosteum.
• After local anesthesia has taken effect, make an
incision through which the bone marrow aspiration
needle can be introduced .

53. • If a guard is present, should be removed before starting
bone marrow aspiration, to ensure adequate depth of
penetration..
• In general, the needle should be advanced at an angle
completely perpendicular to the bony prominence of
the iliac crest.
• Once the needle passes through the cortex and enters
the marrow cavity, it should stay in place without being
held.
• Once the periosteum has been penetrated, pressure is
used to advance the needle through the cortex and
rotate the needle in a semicircular motion, alternating
clockwise and counterclockwise movements.

54. • If the patient is in the lateral position, the hip may
be stabilized with the other hand to get a better
feel for the position and depth of the needle.
• The thumb of this hand can be to mark the
desired site and to prevent accidental
repositioning of the needle.
• A slight give will be felt, after which you will feel
that the needle is fixed solidly within the bone.
• Remove the stylet and aspirate approximately 1
ml of unadulterated bone marrow into a syringe.
• Specimen is taken and is assessed for the
presence of bony spicules.

55. • If the specimen shows spicules, the specimen
should be used to make smear slides immediately.
• If spicules are sparse or are not present, a new
sample should be obtained from a slightly
different site.
• The needle is left in place and sequential syringes
are filled that have been prepared with heparin or
other anticoagulants or preservatives, depending
on the requirements for specific studies to
withdraw samples for additional analysis.
• Then remove the needle, either after reinserting
the stylet or with the syringe attached.

56. COMPLICATIONS :
• Hemorrhage
• Infection
• Persistent pain at the marrow site
• Retroperitoneal hematomas
• Trauma to neighboring structures (e.g.,
lacerations of a branch of the gluteal artery)
and soft tissues