Johari/Nohari Quadrants

diksyunaryo

Ilokano:
Antique - kabsat ni nanang
Decipher - saan nga dobotones
ravine - imneken jay init
begotten - panagimukat manen
who - panagkakantsaw
a one - wala
ham man - saanak nga agululbod
about - nauneg nga banag
stone - agsardeng kan
show - agbugaw manok

Modern English:
school - a place where papa pays and child plays
life insurance - a contract that keeps you poor all your life so that you can die rich
nurse - a person who wakes you up to give you sleeping pills
marrieage - it's an agreement in which a man loses his bachelor degree and a woman gains her masters
divorce - future tense of marriage
father - banker provided by nature
criminal - a person no different from the rest except he gets caught

Gay:
TERMS OF ENDEARMENT
“Girl!”, “Lolah!”, “Ateh!”, “Mamah!”, “Titah!”, “Sister!”, “Mother!”, “Bakla!”

PROPER NOUNS
Ace Sanchez - a top
Aglipay - ugly Pinay ( jowang pokpok na chaka ng mayaman na foreigner )
Ana, Anaconda - ahas, traidor
Anita Linda, Aida - A.I.D.S.
Ate Vangie - gamot pampatulog (Ativan Gang)
Ate Vi - atrebida
Backstreet Boys - cute guys sa likuran mo
Bayombong, Nueva Viscaya - masturbate
Bebang, Mayta - maid
Blusang Itim - mga bakla na gumanda nang maayusan sa parlor
Cathy Santillan, Kate Gomez, Cathy Mora, Cathy Dennis - makati, malibog
Chabelita - chubby
Chanda Romero - tummy (ang laki ng Chanda Romero nung pulis) / an old woman
Chiquito - maliit
Churchill - sosyal
Crayola Khomeni - iyak
Dakota Harrison P! laza - malaki tite
Debbie Gibson - give
Duty Free - maliit ang nota
Ella Mae (Saeson), Ella Fitzgerald, Ella Luansing - state of feeling horny
Eva Kalaw - evak
Felix Bakat - bakat ang tite (sa brief or pants)
Girlie Rodis - babae
Givenchy - give, pahingi
Halls - tsupa
Indiana Jones - hindi sumipot
Janjalani, Pocahontas - bakla na palaging late o indyanera
Jennilyn (Mercado) - cheap, chaka
Joana Paras - asawa
Julanis Morisette, Reyna Elena - umuulan
Julie Andrews - mahuli
Kelvinator, Kelvina - babaeng mataba, sinlaki ng refrigirator
Leticia Ramos Shahani - shabu
Lilet - bading na bagets
Lucita Soriano - loss na, sorry pa
Lucrecia Kasilag - baliw
Luz Clarita, Luz Clarita, Luz Valdez - talo, loss ang beauty
Maharlika, Mahalia Jackson - mahal
Manilyn Reynes - malibog
Miss Nigeria - negra
Murriah Carey, Morayta - mura
Nora Daza - magluto
Oprah Winfrey, O.P.M. - oh, promise me, pangako, utang
Phil Collins - Philcoa
Purita Kalaw Ledesma, Purita Kashiwara, Pureta Malaviga - poor, dukha
Rica Paralejo, Nina Ricci - mayaman
Rita Gomez - naiirita
Ruffa - laklak
Siete Pecados - tsismosa
Thunder Cats - gurang
Tom Jones, Tommy Lee Jones - gutom
Uranus - puwet
Washington D.C. - wala
X-Men - mga dating lalaki
Yayo Aguila - dyahe
Zsa Zsa Padilla - o siya, sige!

ADJECTIVES & ADVERBS
48 years - sobrang tagal
antibiotic - antipatika
balaj, valaj - balahura
bella - boba
bigalou - big
biway, chopopo, guash - gwapo
bongga, bonggakea - super to the max
borta - malaki katawan
boyband - lalaking sintaba ng baboy
buya - nakakahiya
chaka, chuckie, shonget, ma-kyonget, chapter, jupang-pang - ugly
cheapangga, chipipay - cheap, ka-cheapan
chipipay - cheap
chopopo - gwapo
conalei - baklush
daki - dako
dites - dito
doonek - doon
effem - halatang bakla
emena gushung - malanding semenarista
fayatollah kumenis - payat
ganda lang - for free
ganders - maganda
intonses - sira, wasak
jongoloids - bobo
jowa, jowabelles, jowabella - karelasyon, boyfriend o girlfriend
jutay, juts - maliit
kabog, loss - talo!
katagalugan - matagal
katol - mukhang katulong
kirara - pangit / maitim
klapeypey-klapeypey - pumalakpak
krang-krang - hungry (same as Tom Jones)
krung-krung - sira ulo, baliw
lulu, tungril, tetetet - lesbian
mahogany, mashumers, ugmas - mabaho
majubis - mataba / gusgusin
matod - magnanakaw
nakakalurky - nakaka-shock, nakaka-takot
neuro - napaisip bigla, mind-boggler
oblation - walang saplot
otoko - lalakeng lalaki
pamin, paminta, pamentos, pamenthol - discreet gay guy
pinkalou - pink
pranella - praning
quality control - maganda ang quality
sangkatuts - marami, isang katutak
shala - sosyal
shogal - matagal
shokot, bokot - takot
shonga, shongaers, planggana - tanga
shonga-shonga - tanga-tanga
shonget, makyonget - ugly
shontis - buntis
sudems - never
tamalis - tamad
urky - nakakaloka
warla - loka-loka, nawawala sa sarili, nababaliw
wasok - contraction ng “wasak pag pasok”
wiz, waz - wala!
wrangler, thunder(s), tanders, majonders – matanda

NOUNS, PRONOUNS AND PREPOSITIONS
adez, andabelz, adesa, anda, ka-andahan, andalucia - pera
akesh, akembang - ako
badet, dinga, dingalou - bading
berru - beer
borlog - tulog, power nap
bottomesa, bottones - a bottom
bufra - boyfriend
carrou, carosa - car
cheese - chismis
chimi, chimini, chimi-aa, chimini-aa - maid
constru - construction workerdaot - ahas, traitor
ditey, ditich, ditraks - dito
feelanga - crush
fiampey - singit, etits, flower
garapata - vaklush na punggok na majubis
gardini - security guardoishi - shabu
gulay, pechay, bilatch, tahong - babae
hada - oral gay sex
hammer - pakonyo effect sa mga prosti or callboy, “pokpok”
havana - mahabang mukha
hipon - maganda ang katawan pero panget
itich, itechlavu - ito
itich-me-how - etits, penis
jipamy - jeep
jowa, jowawis - lover, boy/girlfriend
jubelita - vaklita, batang bading
kat-kat - sosyal na tawag sa katulong
katol, chimay - katulong
kyota - bata
kyotatalet - sanggol
likil, mentos, future - lalaki
merlat, melat, bilat, mujer - babae
nota, notes - penis
pa-uring - a bottom
performance artist - mahilig mag-inarte
potato queen - chink for chinks
red alert - menstruation
rice queen - chink folks who go for white guys (?)
colbam, sholbam - callboy
shulupi - pulubi
shumod, shumodity - tamod
suba, bugarou - cigarette
success story - babae/lalaki na mukhang katulong na may lover na foreigner na masalapikaturay - baklang mukhang katulong na mataray
tayelz - tayo
variables - barya, coins
wigwam - wig

VERBS
bacstroke - bugbugin
bet, fillet - gusto
bionic, bayas, bayis - magjakol
bona, kimbash, uring - tirahin sa pwet
bongkang, shongkang, tsuplukan - kumantot
booking - to hook up with someone
borlog, tulogsi - matulog
dramamin - umaastang lalaki
entourage, enter the dragon - pumasok
getluck - kuhanin
gora, godelya - go
hada, koflang, kops - suck
jeverly, kalaw, erna - dudumi
krompal - sampal, but with an attitude (kasi may kasamang kuko)
lafez, lafang, lafour - kain
nomo-nomo, normok - inom
payola - pay
rampage - rampa
rendez-vous - takbo
shonggal - tanggal
sight - look
strungga - nenok, nakaw
*************************************************
lou
pinkalou - pinkcarou - carchuvalou - common __expressionchiva-lou - hada or bjorangalou - anal sex from the rootword orangapagurlalou - pa-girlchufalou - hada
china
payolachina - paypangitchina - pangitchupachina - blow jobmukachina - face
ra/delya
pagodora, pagodelya - tiredbongadera, bongadelya - ang ganda mo day
grabedora, grabedelya - grabe
*************************************************
one pokels - pisoone hammer - P 100one kiaw - P 1,000
P 1,553 - one kiaw, five hammer, at nyifti three pokels
*************************************************
Spanish - Filipino GaylingoChorizo de Bilbao - penisGrande - malaki
Granada de Espa�a - grabe
*************************************************
ANO ANG BAGONG TAW! AG SA JOWA IN THE NEW MILLENIUM?
It depends.
Pag one-time hada lang: STUDIO CONTESTANT.Pag more than once at frequent ang encounter: MONTHLY FINALIST.Pag nagkaka-develop-an na: GRAND FINALIST.Pag nagsasama na at ibina-bahay: LUCKY HOME PARTNER.Pag call-in callboy: LUCKY TEXT PARTNER lang.
*************************************************
Chorvah has its etymology from the Greek word cheorvamus meaning “for lack of the right word to say”, or “in place of anything you want to express but cannot verbalize”. Ibig sabihin pala, siya ay parang “aloha” sa wikang Hawaiiano, which can mean many, many things. “Chorvah” can be used as:
1. Noun: “ano” / “kwan” / “or something”
- “Ate Glow, kelan yung birthday chorvah ni Big Mike?”
- “Hoy, Vicky ‘to, whatcha gonna wear ba? The sporty or the chinese chorvah mo?
2. Adjective: used if you want to be polite.
- “Ang chorvah naman niyan!”
( So, ano ba? Pangit ba o maganda? Baduy ba or ang arte?)
They will never know what you really mean. How polite!
3. Verb: can replace any verb
- “Chorvah lang ng chorvah!”
Chorvah is such an amazing word, it lets you choose your own adventure. At least you will never be accused of putting words in somebody else’s mouth. If you don’t have anything to say, or you can’t find the right word to say, or you want to say something but you don’t know how to say it, just say CHORVAH!
Variations: Chuvah, Chenes, Chenelyn

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Wound Care

General considerations

The injury: The mechanism of injury is important in assessing the degree of risk of complications of a given wound. For example, the farmer who pierces his foot with a manure-laden pitchfork is at high risk for gas gangrene and sepsis. Management would include extensive local wound care and possible admission to hospital for intravenous antibiotics. Mammalian bites present another risk situation for infection. Is there likely to be a foreign body present in the wound? Does the force of injury suggest there is likely to be extensive trauma to deeper tissues?

The patient: Consider complicating medical conditions such as diabetes, other immunosuppressed states including diabetes or other major organ dysfunction (such as renal or hepatic failure) and peripheral vascular disease. These all may affect both resistance to infection and wound healing itself.

Time of injury: The age of the wound is important in deciding the timing of closure, if at all.

Laceration	Age / Condition	Treatment
Extremity	< 12 hours and “clean”	suture primarily
Extremity	>12 hours older or “dirty”	Older or obviously contaminated or infected lacerations are best left alone for healing by secondary intention or tertiary intention (closure a few days later). Saline soaks and antibiotics usually will be required. If cosmetic or other functional considerations apply, then referral to a plastic surgeon is necessary.
Face	< 24 hours	suture primarily unless obviously infected (rare)

These times are based on common medical practice in Canada. A study of forearm and hand lacerations found that closure within 4 hours had a lower infection rate than more than 6 hours from injury.¹

Consultation: Emergency physicians may consider early referral of certain lacerations to an appropriate surgeon. Indications for referral could include:

• Deep lacerations that involve nerve, tendon (often flexor tendon injuries of the fingers) or bone,
  
• Complex or extensive lacerations that may be challenging to repair or are located in difficult anatomical areas.

Assessment of function and the importance of wound exploration

Assess wounds under optimal lighting with minimal bleeding. Important structures underlying any laceration or contusion should be assumed divided until proven otherwise. Motor, sensory and vascular function must always be assessed.

The physician, however, cannot rely only on tests of motor or sensory function to rule out injuries to tendon or nerve. Only a small portion of a tendon in the finger, for example, needs to remain intact to maintain function. However, if the patient is sent home with such a partial tendon injury, total rupture may occur when the tendon is stressed.

Note that there is no reliable test for isolating a particular wrist flexor or extensor, because more than one muscle performs the same function.

Therefore, wounds in the vicinity of important structures should be gently explored. If visualisation is difficult or the anatomy complex, then an appropriate surgeon should be consulted.

Tendon, nerve or vascular injuries are all too easy to miss unless due care is taken.

Finger Injuries

Injuries to the fingers and hands account for the majority of such cases. Tendon and nerve injuries of the fingers will now be reviewed, followed by a brief discussion of vascular injuries.

Tendon, nerve or vascular injuries are all too easy to miss unless due care is taken. In addition for testing function, these wounds should be gently explored. Injuries to the fingers and hands account for the majority of such cases.

A tendon is visualized through the open wound margin of this wound of the hand.

Finger Injuries

Tendon and nerve injuries of the fingers will now be reviewed, followed by a brief discussion of vascular injuries.

1. Extensor Tendon Injuries of Fingers: The anatomy of the extensor aponeurosis is depicted in the diagram below. Extension is accomplished through the action of the extrinsic digital extensors, and the interosseous and lumbrical muscles.
   
   Transection or avulsion of the central extensor slip from the base of the middle phalanx may allow the lateral band to slip in a volar direction and assume a PIP flexor action. This produces the classical “boutonniere deformity”. The patient may initially exhibit a full range of motion, including extension.

2. Flexor tendon injuries of fingers: A missed flexor injury of the finger may result in long term disability. The anatomy is depicted in the accompanying diagram. The profundus runs the entire length of the finger and inserts into the distal phalanx. If intact, the finger can move normally, even if the superficialis is divided.
   
   

   Profundus tendon testing of long finger D3	Superficialis tendon testing of long finger D3

   
   The testing of these tendons – both the profundus and the superficialis is shown
   above. The test of the superfialis tendon can only be accomplished with all of the other digits being restrained in extension. Moreover, it is not reliable for the index finger. These tests do NOT replace exploration and visualization of the tendons in the wound.
   
   

3. Digital nerve injuries: The digital nerves exit the hand in the region of the volar web spaces, tracking along the medial or lateral aspects of the fingers.
   
   The digital nerves run immediately adjacent to the flexor tendons.
   
   Numbness or complete loss of feeling is not necessarily noted by the patient immediately even if there is complete transection of the nerve. A peculiar or unusual sensation in the territory of the nerve may be the only subjective description.
   
   If there is digital arterial bleeding, then the digital nerve is likely to be injured.
   
   Sensory testing is best done using two-point discrimination.
   
   If the history or physical findings suggest the possibility of a digital nerve injury, then exploration to visualise the digital nerve is necessary. A referral to a plastic surgeon is necessary. However, digital nerve injuries beyond the level of the DIP joint are not repaired and do not require referral.

4. Vascular Injuries
   Most arterial and venous injuries occur within the traumatised limbs. Early diagnosis is important.
   
   Consider the proximity of the wound to arterial structures. A history of bright red blood spurting from a wound indicates an arterial injury. Often, by the time of evaluation within the Emergency Department, this bleeding has stopped because of vasospasm (or uncommonly because of hypovolemic shock).
   
   The presence of a bruit or thrill frequently indicates a significant vascular lesion. Look for the classic six “P’s” in the distal extremity:
   

   pain
   pallor
   pulselessness
   paresthesia
   paresis
   poikilothermia

   Pulses may or may not be absent depending on the degree of injury.
   
   Venous injuries that are significant may be difficult to diagnose. These usually co-exist with arterial or nerve injuries. Arteriovenous fistula may occur.
   
   Compartment syndrome: Look out for
   1. Passive stretch pain of the muscles within the compartment
   2. Compartment swelling

The involved compartment needs to be released immediately.

Local anesthetics

There are two major groups of local anaesthetics: esters and amines.

1. Esters : procaine (Novocaine), and tetracaine (Pontocaine)
2. Amines: lidocaine (Xylocaine) and bupivacaine (Marcaine).

If a past allergy is reported, an anesthetic from another class can be used. Most often, however, the allergy is to the preservative used in the lidocaine multidose vials. Therefore, one option is to use a single-dose lidocaine preparation that does not contain preservatives.

For routine Emergency room use, a mixture of lidocaine 1%, with or without epinephrine 1/100,000 parts, is recommended. For regional nerve blocks, a 2% solution is used. The lidocaine 2% solution can be combined with equal parts of the Marcaine 0.25% solution to obtain relatively quick, yet longer lasting anaesthesia. The anaesthetic effect of lidocaine lasts less than an hour, but as long as two hours if the epinephrine containing preparation is used. Marcaine’s effect lasts from 12-24 hours. This would be important, for example, in the case of a distal digit amputation, where longer-term anaesthesia is desired. Some patients continue to experience considerable pain even after simple suturing, and Marcaine could significantly reduce such pain.

Epinephrine is commonly used as an adjuvant to reduce bleeding and slow anaesthetic absorption systemically. A noticeable decrease in wound bleeding will be noted in about seven minutes. Epinephrine should be avoided in those patients with vasospastic disorders, those with crush or circumferential extremity injuries, or those on beta-blockers. The use of epinephrine in the fingers, toes or penis has classically been contraindicated, because of its supposed propensity to cause vasospasm in these areas.

A toxic dose of Xylocaine (lidocaine) is 3 mg per kg intravenously; 5 mg per kg when injected without epinephrine into the wound margin, and 7 mg per kg when injected with epinephrine into the wound margin. There is evidence that the toxic dose may actually be much higher than usually quoted. The toxicity of Marcaine is one-quarter that of lidocaine, on a weight to weight basis.

Prior to the administration of local anaesthetics, check the sensory and motor nerve response, and for allergy (very rare). The pediatric literature supports the use of a topical anesthetic such as LET (a combination of lidocaine, epinephrine and tetracaine) prior to needle infiltration to reduce the pain. Slow injection by a small needle (such as a 25, 27 or 30 Gauge) will reduce the pain of infiltration.

Adverse reactions to local anaesthetics may take several forms.

Adverse Reactions to Local Anaesthetics
Type	Incidence	Mechanism	Symptoms
Vasovagal	Common		nausea, light-headedness bradycardia vasodilatation hypotension syncope
Epinephrine related	Common		“ rash” tremor, headache palpitations abdominal and uterine cramps
Toxic (>3mg /kg IV, >5 mg/kg without epinephrine, > 7 mg/kg with epinephrine)	relatively common	IV leak (? From regional blocks?)	tachycardia arrhythmia CNS excitation, depression seizure, coma
Allergic	rare to amides uncommon to esters	IgE mediated ? methylparaben preservative ? antioxidants (sulphites)	angioedema bronchospasm tachycardia hypotension

If there is doubt about allergy, in minor cases, plain normal saline can be injected into the wound margin to stretch the skin, thereby affording some degree of anaesthesia.

Malignant hyperthermia is now considered NOT to be precipitated by the use of lidocaine. Traditionally, in this setting, an ester has been utilised.

Tetanus prophylaxis - Tetanus vaccination
The tetanus disease itself is a serious one but relatively rare in Canada.

An identifiable acute injury occurs in the majority of cases (70%). Puncture wounds and lacerations account for most cases. Interestingly, approximately one-half of these injuries occurred indoors. Only a small percentage of cases occur in previously properly “immunised” patients. The incubation period is from two days to two months.

Tetanus vaccines must be administered intramuscularly. The anterolateral thigh is recommended in infants and the deltoid muscle in older children and adults. These adsorbed vaccines should not be administered subcutaneously as sterile abscess can form.

Since 1982, all school children in Ontario are required by law to be immunised. As of 1987, it is the law in Ontario that physicians inform their patients of the risks and benefits of immunisation. Adverse reactions to primary immunisation with tetanus toxoid are rare. The booster dose, however, can cause local erythema and swelling. Overuse of tetanus vaccines can lead to Arthus type reactions, urticarial reactions, and angioneurotic edema , and rarely, peripheral neuropathy and anaphylaxis.

Tetanus immune globulin (human) is a passive immunising agent containing preformed antibodies. Serum sickness can occasionally occur especially in the past when the globulin was derived from horse sera.

The decision to administer tetanus prophylaxis in the Emergency room depends on the current immunisation status of the patient and the liability of tetanus contamination in a given wound. In this Emergency Department, the order for a “tetanus booster” usually means that tetanus polio (Salk type) inactivated vaccine is administered.

Several protocols for the administration of tetanus prophylaxis are available.
The Canadian Immunization Guide – 6^th Edition – 2002 is available at

http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/cig-gci/.

Prophylactic oral, IM or IV antibiotics in wound care of routine lacerations
There is NO evidence (based on many clinical studies and a meta-analysis) to support the routine use of prophylactic oral, IM or IV antibiotics to prevent wound infections after closure of routine lacerations. Antibiotics do NOT substitute for proper wound cleansing.
Prophylactic antibiotic treatment is, however, proven to be of value in the treatment of animal and human bites in particular. See D. Special Situations in Wound Care / Mammalian bites
``Use of antibiotics should be individualized based on the degree of bacterial contamination, the presence of infection-potentiating factors, such as soil, the mechanism of injury, and the presence or absence of host predisposition to infection. In general, decontamination is far more important than antibiotics. Prophylactic antibiotics should be used in most human, dog, and cat bites, intraoral lacerations, open fractures, and exposed joints or tendons.`` From Management of lacerations in the emergency department. O. Capellan and J. Hollander Emergency Medicine Clinics of North America. Volume 21, Number 1, February 2003

Suctioning a Tracheostomy

Suctioning a Tracheostomy
The upper airway warms, cleans and moistens the air we breath. The trach tube bypasses these mechanisms, so that the air via the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. The trach tube is suctioned to remove mucus from the tube and trachea to allow for easier breathing. Generally, the child should be suctioned every 4 to 6 hours and as needed. There may be large amounts of mucus with a new tracheostomy. This is a normal reaction to an irritant (the tube) in the airway. The heavy secretions should decrease in a few weeks. While a child is in the hospital, suctioning is done using sterile technique, however a clean technique is usually sufficient for most children at home. If your child has frequent respiratory infections, trach care and suctioning techniques may need to be addressed. Frequency of suctioning will vary from child to child and will increase with respiratory tract infections. Try to avoid suctioning too frequently. The more you suction, the more secretions can be produced.

Care Techniques
Sterile Technique: sterile catheters and sterile gloves
Modified Sterile Technique: sterile catheters and clean gloves
Clean Technique: clean catheter and clean hands
The size of the suction catheter depends on the size of the tracheostomy tube. Size 6, 8 or 10 French are typical sizes for neonatal and pediatric trach tubes. The larger the number, the larger the diameter of the suction catheter. Use a catheter with an outer diameter that is about half the inner diameter of the artificial airway this will allow air to enter around it during suctioning. You can also compute the catheter size with this formula: Multiply the artificial airways diameter in millimeters by two. For example, 8 mm X 2 = 16, so a 16 French catheter. Also see Tracheostomy Sizing Chart for recommended catheter sizes for specific Bivona and Shiley pediatric tracheostomy tubes.
Older children may be taught to suction themselves.

Suction Depths
Shallow Suctioning: Suction secretions at the opening of the trach tube that the child has coughed up.
Pre-measured Suctioning: Suction the length of the trach tube. Suction depth varies depending on the size of the trach tube. The obturator can be used as a measuring guide.
Deep Suctioning: Insert the catheter until resistance is felt. (Deep suctioning is usually not necessary. Be careful to avoid vigorous suctioning, as this may injure the lining of the airway).

Signs That a Child Needs Suctioning
Rattling mucus sounds from the trach
Fast breathing
Bubbles of mucus in trach opening
Dry raspy breathing or a whistling noise from trach
Older children may vocalize or signal a need to be suctioned.
Signs of respiratory distress under Tracheostomy Complications

Equipment
Suction machine
Suction connecting tubing
Suction catheters
Normal saline
Sterile or clean cup
3cc saline ampules (“bullets”)
Ambu bag
Tissues
Gloves (optional for home care, use powder-free gloves)

Procedure

• Explain procedure in a way appropriate for child's age and understanding.


• Wash hands.


• Set up equipment and connect suction catheter to machine tubing.


• Pour normal saline into cup.


• Put on gloves (optional).


• Turn on suction machine (suction machine pressure for small children 50-100mm Hg, for older children/adults 100-120mm Hg)


• Place tip of catheter into saline cup to moisten and test to see that suction is working.


• Instill sterile normal saline with plastic squeeze ampule into the trach tube if needed for thick or dry secretions. Excessive use of saline is not recommended. Use saline only if the mucus is very thick, hard to cough up or difficult to suction. Saline may also be instilled via a syringe or eye dropper, which is less expensive than single dose units. Recommended amount per instillation is approximately 1cc.


• Gently insert catheter into the trach tube without applying suction. (Suction only length of trach tube - premeasured suctioning. Deeper insertion may be needed if the child has an ineffective cough.)


• Put thumb over opening in catheter to create suction and use a circular motion (twirl catheter between thumb and index finger) while withdrawing the catheter so that the mucus is removed well from all areas. Avoid suctioning longer than 10 seconds because of oxygen loss. Note: Some research has shown that by applying suction both going in and then out of the tube takes less time and therefore results there is less hypoxia. Also, there are now holes on all sides of the suction catheters, so twirling is not necessary.


• Draw saline from cup through catheter to clear catheter.


• For trach tubes with cuffs, it may be necessary to deflate the cuff periodically for suctioning to prevent pooling of secretions above trach cuff.


• Let child rest and breathe, then repeat suction if needed until clear (allow at least 30 seconds between suctioning).


• Oxygenate as ordered (extra oxygen may be given before and after suction to prevent hypoxia).


• Some children need extra breaths with an Ambu bag (approximately 3 - 5 breaths). Purposes of bagging: hyperoxygenation, hyperinflation, and hyperventilation of the lungs. However, this is usually not needed for stable children with no additional respiratory problems.


• The child's mouth or nose may also be suctioned, if needed after suctioning the trach, then dispose of that catheter (do not put same catheter back into trach).


• Dispose of suction catheter, saline and gloves, turn off machine. In home care, catheters may sometimes be used more than once before disposal or cleaning if child need frequent suctioning. Keep tip of catheter sterile, and store into original package.


• A bulb syringe may be used between suctioning if the child is able to cough up some secretions on his/her own.


• Be aware of color, odor, amount and consistency of the secretions and notify doctor of changes in secretions.

Pulmonary Concepts In Critical Care

Airway Management

AIRWAY MANAGEMENT

1. HUMIDIFICATION – heated cascade
   provides 100% humidification of inhaled gases. Ensure
   systemic hydration is monitored to help keep secretions
   thin.


2. AEROSOL THERAPY – nebulizers
   delivering aerosols increase secretion clearance and
   liquefy mucus; nebulizers may become a source of
   bacterial contamination.


3. CUFF MANAGEMENT – essential for
   prevention of necrosis and aspiration. Two different cuff-inflation
   techniques are currently used:


4. Minimal leak technique (ML) – inject
   air into cuff until no leak is heard and then withdrawing
   the air until a small leak is heard on inspiration. (Problems
   are related to maintaining PEEP, aspiration around the
   cuff, and increased movement of the tube.)


5. Minimal occlusive volume technique (MOV)
   – inject air into cuff until no leak is heard, then
   withdrawing the air until a small leak is heard on
   inspiration, and then adding more air until no leak is
   heard on inspiration. (Problems are related to higher
   cuff pressures than ML technique.) Use only if patient
   needs a seal to provide adequate ventilation and/or is at
   high risk for aspiration.


6. Monitor cuff pressures at least q. 8 h.
   Maintain pressure 18 to 22 mm Hg (25 to 30 cm H2O.
   Greater pressures decrease capillary blood flow in
   tracheal wall and lesser pressures increase risk of
   aspiration. Do not routinely deflate cuff.


7. POSTURAL DRAINAGE & POSITIONING (see
   respiratory references).


8. Key Point: Pneumonia = "Good lung
   down position"


9. ARDS = prone positioning for improved
   oxygenation


10. SUCTIONING – perform as sterile
    procedure only when patient needs it and not on a routine
    schedule. Observe for hypoxemia, atelectasis,
    bronchospasms, cardiac dysrhythmias, hemodynamic
    alterations, increased intracranial pressure, and airway trauma.

ENDOTRACHEAL/ TRACHEAL SUCTIONING PROCEDURE

OBJECTIVES:

The nurse performs endotracheal and tracheostomy suctioning to:

1. Maintain a patent airway.


2. To improve oxygenation and reduce the work of
   breathing.


3. To remove accumulated tracheobronchial secretions
   using sterile technique.


4. Stimulate the cough reflex.


5. Prevent pulmonary aspiration of blood and gastric
   fluids.


6. Prevent infection and atelectasis.

EQUIPMENT:
Sterile normal saline

Suction source

Ambu bag connected to 100% O2

Clear protective goggles/mask or face shield

Sterile gloves for open suction

Clean gloves for (in-line) closed suction

Sterile catheter with intermittent suction control port or In-line
suction catheter

PROCEDURE:

1. Wash hands. Reduces transmission of
microorganisms.

2. Assess patient’s need for
suctioning. Since endotracheal suctioning can be hazardous
and causes discomfort, it is not recommended in the absence
of apparent need.

Coarse breath sounds

Coughing; increased respirations

Increased PIP on ventilator

3. Don goggles and mask or face shield.
Potential for contamination

4. Turn on suction apparatus and set vacuum
regulator to appropriate negative pressure. Recommend 80-120
mmHg; adjust lower for children and the elderly. Significant
hypoxia and damage to tracheal mucosa can result from
excessive negative pressure.

5. Prepares suction apparatus. Secure one
end of connecting tube to suction machine, and place other
end in a convenient location within reach.

6. Use in-line suction catheter or open
sterile package (catheter size not exceeding one-half the
inner diameter of the airway) on a clean surface, using the
inside of the wrapping as a sterile field.

7. Prepares catheter and prevents
transmission of microorganisms. Catheter exceeding one-half
the diameter increases possibility of suction-induced hypoxia
and atelectasis.

8. Prepare catheter flush solution.With in-line
catheter use sterile saline bullets to flush catheter. With
regular suctioning set up sterile solution container and
being careful not to touch the inside of the container, fill
with enough sterile saline or water to flush catheter.

9. With in-line suction catheter use clean
gloves. With regular suctioning, done sterile gloves.
Maintain sterility. Universal precautions. In regular
suctioning the dominant hand must remain sterile throughout
the procedure.

10. Pick up suction catheter, being careful
to avoid touching nonsterile surfaces. With nondominant hand,
pick up connecting tubing. Secure suction catheter to
connecting tubing. Maintains catheter sterility. Connects
suction catheter and connecting tubing

11. Ensures equipment function. Check
equipment for proper functioning by suctioning a small amount
of sterile saline from the container. (skip this step in in-line
suctioning)

12. Remove or open oxygen or humidity
device to the patient with nondominant hand. (skip this step
with in-line suctioning). Opens artificial airway for
catheter entrance. Have second person assist when indicated
to avoid unintentional extubation.

13. Replace O2 delivery device or reconnect
patient to the ventilator. Hyperoxygenate and hyperventilate
via 3 breaths by giving patient additional manual breaths on
the ventilator before suctioning. Hyperoxygenation with 100%
O2 is used to offset hypoxemia during interrupted oxygenation
and ventilation. Preoxygenation offsets volume and O2 loss
with suctioning. Patients with PEEP should be suctioned
through an adapter on the closed suction system.

14. Without applying suction, gently but
quickly insert catheter with dominant hand during inspiration
until resistance is met; then pull back 1-2 cm. Catheter is
now in tracheobronchial tree. Application of suction pressure
upon insertion increases hypoxia and results in damage to the
tracheal mucosa.

15. Apply intermittent suction by placing
and releasing dominant thumb over the control vent of the
catheter. Rotate the catheter between the dominant thumb and
forefinger as you slowly withdraw the catheter. With in-line
suction, apply continuous suction by depressing suction valve
and pull catheter straight back. Time should not exceed 10-15
seconds. Intermittent suction and catheter rotation prevent
tracheal mucosa when using regular suctioning methods. Unable
to rotate with closed- suction method.

16. Replace oxygen delivery device.
Hyperoxygenate between passes of catheter and following
suctioning procedure. Replenishes O2. Recovery to base PaO2
takes 1 to 5 minutes. Reduces incidence of hypoxemia and
atelectasis.

17. Rinse catheter and connecting tubing
with normal saline until clear. Removes catheter secretions.

18. Monitor patient’s cardiopulmonary
status during and between suction passes. Observe for signs
of hypoxemia, e.g. dysrhythmias, cyanosis, anxiety,
bronchospasms, and changes in mental status.

19. Once the lower airway has been
adequately cleared of secretions, perform nasal and oral
pharyngeal or upper airway suctioning. Removes upper airway
secretions. The catheter is contaminated after nasal and oral
pharyngeal suctioning and should not be reinserted into the
endotracheal or tracheostomy tube.

20. Upon completion of upper airway
suctioning, wrap catheter around dominant hand. Pull glove
off inside out. Catheter will remain in glove. Pull off other
glove in same fashion and discard. Turn off suction device.
Reduces transmission of microorganisms.

21. Reposition patient. Supports
ventilatory effort; promotes comfort; communicates caring
attitude.

22. Reassess patient’s respiratory
status. Indicates patient’s response to suctioning

23. Dispose of suction liners and
connecting tubing, sterile saline solution every 24 hours and
set up new system. Decreases incidence of organism
colonization and subsequent pulmonary contamination.
Universal precautions.

PRECAUTIONS:

1. Minimize suctioned-induced atelectasis and hypoxemia:

a. Avoid using catheters larger than one-half the
diameter of the airway.

b. Administer one or more postsuctioning
hyperinflations, using manual or sigh breaths on the
ventilator or ambu bag if not ventilated.

2. Maintain rigorous sterile technique when suctioning the
intubated patient. Impaired pulmonary defense systems and
invasive instrumentation of the pulmonary tract predisposes
these patients to colonization and infection. Never use same
catheter to suction the trachea after it has been used in the
nose or the mouth.

3. Limit the frequency of suctioning and avoid, as much as
possible, catheter impaction in the bronchial tree when the
patient is anticoagulated or when hemorrhage from suction-induced
trauma is evident.

4. Minimize the frequency and duration of suctioning when
patient is on positive end-expiratory pressure (PEEP) greater
than 5 cm or continuous positive airway pressure (CPAP).
Small suctioning-induced changes may have profound effects on
these marginally oxygenated patients.

5. Maintain awareness of the limitations of ET/tracheal
suctioning. Maneuvers and catheter design have been proposed
to increase the likelihood of passage into the left bronchus;
however, these have been shown to be of limited success.
Because the left main stem bronchus emerges from the trachea
at the 45-degree angle from the vertical, suction catheters
are almost inevitable passed into the right bronchus (when
they pass the carina) despite head-turning, etc.

6. The use of saline installations for loosening
secretions has been controversial and recent research shows
that in fact it is detrimental and poses a greater risk of
pneumonia for the patient.

RELATED CARE:

1. Include strategies to move secretions through
peripheral airways. These measures are: appropriate hydration
and adequate humidification of inspired gases (to keep
secretions thin); coughing and deep breathing; frequent
position changes (may need rotation bed); chest
physiotherapy; and bronchodilating agents as ordered.

2. Monitor the patient carefully during ET/tracheal
suctioning for ectopic dysrhythmias aggravated by suction-induced
hypoxemia and other dysrhythmias, particularly conduction
disturbances, related to catheter irritation of vagal
receptors within the respiratory tract (requires immediate
cessation of suctioning and hyperoxygenation).

POTENTIAL COMPLICATIONS

Hypoxemia

Atelectasis

Dysrhythmias

Nosocomial pulmonary tract infection

Sepsis

Mucosal trauma with increase secretions

Cardiac arrest

Verification of ET Tube Placement

The American College of Emergency Physicians endorses the following principles regarding the confirmation of endotracheal tube placement in the emergency department or in the out-of-hospital setting.

• During intubation, direct visualization of the endotracheal tube passing through the vocal cords into the trachea constitutes firm evidence of correct tube placement, but should be verified with additional techniques.
• Verification of endotracheal tube placement should be completed in all intubated patients, and reconfirmation of endotracheal tube position should be done in all patients when their clinical status changes, or when there is any concern about proper tube placement.
• Standard physical examination methods, such as auscultation of lungs and epigastrium, visualization of chest movement, and fogging in the tube, are not sufficiently reliable to exclude esophageal intubation in all situations.
• Verification techniques include capnometry, esophageal detection devices, and revisualization with direct laryngoscopy.
• End-tidal CO2 detection, either qualitative, quantitative, or continuous, is the most accurate and easily available method to monitor correct endotracheal tube position in patients who have adequate tissue perfusion.
• Pulse oximetry and esophageal detector devices are not as reliable as end-tidal CO2 determinations in patients who have adequate tissue perfusion.
• For patients in cardiac arrest, and for those with markedly decreased perfusion, when end-tidal CO2 does not confirm tracheal intubation, other methods of confirmation, such as direct visualization, should be done.

Casting and Splinting

General Casting Techniques The general principles of cast application are demonstrated in this video showing the application of a short arm cast.

Casts and splints for various injuries or regions of the body

Click on the thumbnails to view movies.
Note: Due to size, some movies may take a few minutes to load.

	Vietnam Sling How to apply a Vietnam sling for shoulder injuries.
	Sugar tong splint How to apply a sugar tong splint for a fracture of the humerus.
	Posterior slab for the elbow How to apply a long arm posterior slab splint.
	Ulnar gutter splint How to apply an ulnar gutter splint.
	Colles’ wrist fracture cast How to apply a cast for a reduced Colles’ fracture.
	Short arm cast How to apply a short arm cast.
	Volar slab How to apply a volar slab splint to the forearm.
	Thumb spica cast How to apply a thumb spica cast.
	Boxer’s cast How to apply a cast for a boxer’s fracture.
	Thumb gutter splint How to apply a thumb spica gutter splint.
	Long leg cast How to apply a long leg cast.
	Cylinder cast how to apply a long leg cylinder cast for fractures of the patella.
	Short leg cast How to apply a below knee non-weight bearing cast
	Posterior slab for the ankle How to apply a below knee posterior slab splint
	Short leg walker cast How to apply a below knee walking cast
	Walking heel application How to apply a walking heel to a below knee cast.

Cast removal How to use a cast saw to safely remove a cast.

©2003 Department of Emergency Medicine, University of Ottawa

Urinary Catheter Insertion

Introduction
The ability to insert a urinary catheter is an essential skill in medicine.
Catheters are sized in units called French, where one French equals 1/3 of 1 mm. Catheters vary from 12 (small) FR to 48 (large) FR (3-16mm) in size.
They also come in different varieties including ones without a bladder balloon, and ones with different sized balloons - you should check how much the balloon is made to hold when inflating the balloon with water!


Universal precautions
The potential for contact with a patient's blood/body fluids while starting a catheter is present and increases with the inexperience of the operator. Gloves must be worn while starting the Foley, not only to protect the user, but also to prevent infection in the patient. Trauma protocol calls for all team members to wear gloves, face and eye protection and gowns.


Indications
By inserting a Foley catheter, you are gaining access to the bladder and its contents. Thus enabling you to drain bladder contents, decompress the bladder, obtain a specimen, and introduce a passage into the GU tract. This will allow you to treat urinary retention, and bladder outlet obstruction.
Urinary output is also a sensitive indicator of volume status and renal perfusion (and thus tissue perfusion also).
In the emergency department, catheters can be used to aid in the diagnosis of GU bleeding.
In some cases, as in urethral stricture or prostatic hypertrophy, insertion will be difficult and early consultation with urology is essential.


Contraindications
Foley catheters are contraindicated in the presence of urethral trauma. Urethral injuries may occur in patients with multisystem injuries and pelvic factures, as well as straddle impacts. If this is suspected, one must perform a genital and rectal exam first. If one finds blood at the meatus of the urethra, a scrotal hematoma, a pelvic fracture, or a high riding prostate then a high suspicion of urethral tear is present. One must then perform retrograde urethrography (injecting 20 cc of contrast into the urethra).


Equipment
Sterile gloves - consider Universal Precautions Sterile drapesCleansing solution e.g. SavlonCotton swabs ForcepsSterile water (usually 10 cc)Foley catheter (usually 16-18 French)Syringe (usually 10 cc)Lubricant (water based jelly or xylocaine jelly)Collection bag and tubing


Procedure
Insertion of an urinary catheter in a female

Insertion of an urinary catheter in a male


Review the female anatomy in more detail
Review the male anatomy in more detail

1. Gather equipment.
2. Explain procedure to the patient
3. Assist patient into supine position with legs spread and feet together
4. Open catheterization kit and catheter
5. Prepare sterile field, apply sterile gloves
6. Check balloon for patency.
7. Generously coat the distal portion (2-5 cm) of the catheter with lubricant

8. Apply sterile drape
9. If female, separate labia using non-dominant hand. If male, hold the penis with the non-dominant hand. Maintain hand position until preparing to inflate balloon.
10. Using dominant hand to handle forceps, cleanse peri-urethral mucosa with cleansing solution. Cleanse anterior to posterior, inner to outer, one swipe per swab, discard swab away from sterile field.
11. Pick up catheter with gloved (and still sterile) dominant hand. Hold end of catheter loosely coiled in palm of dominant hand.
12. In the male, lift the penis to a position perpendicular to patient's body and apply light upward traction (with non-dominant hand)
13. Identify the urinary meatus and gently insert until 1 to 2 inches beyond where urine is noted
14. Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check actual balloon size)
15. Gently pull catheter until inflation balloon is snug against bladder neck
16. Connect catheter to drainage system
17. Secure catheter to abdomen or thigh, without tension on tubing
18. Place drainage bag below level of bladder
19. Evaluate catheter function and amount, color, odor, and quality of urine
20. Remove gloves, dispose of equipment appropriately, wash hands
21. Document size of catheter inserted, amount of water in balloon, patient's response to procedure, and assessment of urine

Complications
The main complications are tissue trauma and infection. After 48 hours of catheterization, most catheters are colonized with bacteria, thus leading to possible bacteruria and its complications. Catheters can also cause renal inflammation, nephro-cysto-lithiasis, and pyelonephritis if left in for prolonged periods.
The most common short term complications are inability to insert catheter, and causation of tissue trauma during the insertion.
The alternatives to urethral catheterization include suprapubic catheterization and external condom catheters for longer durations.

Nasogastric Tube Insertion

Indications
By inserting a nasogastric tube, you are gaining access to the stomach and its contents. This enables you to drain gastric contents, decompress the stomach, obtain a specimen of the gastric contents, or introduce a passage into the GI tract. This will allow you to treat gastric immobility, and bowel obstruction. It will also allow for drainage and/or lavage in drug overdosage or poisoning. In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration, as well as for assessment of GI bleeding. NG tubes can also be used for enteral feeding initially.

Contraindications
Nasogastric tubes are contraindicated in the presence of severe facial trauma (cribriform plate disruption), due to the possibility of inserting the tube intracranially. In this instance, an orogastric tube may be inserted.

Complications
The main complications of NG tube insertion include aspiration and tissue trauma. Placement of the catheter can induce gagging or vomiting, therefore suction should always be ready to use in the case of this happening.

Universal precautions:
The potential for contact with a patient's blood/body fluids while starting an NG is present and increases with the inexperience of the operator. Gloves must be worn while starting an NG; and if the risk of vomiting is high, the operator should consider face and eye protection as well as a gown. Trauma protocol calls for all team members to wear gloves, face and eye protection and gowns.

Equipment:
All necessary equipment should be prepared, assembled and available at the bedside prior to starting the NG tube. Basic equipment includes:
Personal protective equipmentNG/OG tubeCatheter tip irrigation 60ml syringeWater-soluble lubricant, preferably 2% Xylocaine jellyAdhesive tapeLow powered suction device OR Drainage bagStethoscope Cup of water (if necessary)/ ice chipsEmesis basinpH indicator strips

Procedures:

1. Gather equipment



2. Don non-sterile gloves



3. Explain the procedure to the patient and show equipment



4. If possible, sit patient upright for optimal neck/stomach alignment



5. Examine nostrils for deformity/obstructions to determine best side for insertion



6. Measure tubing from bridge of nose to earlobe, then to the point halfway between the end of the sternum and the navel



7. Mark measured length with a marker or note the distance



8. Lubricate 2-4 inches of tube with lubricant (preferably 2% Xylocaine). This procedure is very uncomfortable for many patients, so a squirt of Xylocaine jelly in the nostril, and a spray of Xylocaine to the back of the throat will help alleviate the discomfort.



9. Pass tube via either nare posteriorly, past the pharynx into the esophagus and then the stomach.Instruct the patient to swallow (you may offer ice chips/water) and advance the tube as the patient swallows. Swallowing of small sips of water may enhance passage of tube into esophagus.If resistance is met, rotate tube slowly with downward advancement toward closes ear. Do not force.



10. Withdraw tube immediately if changes occur in patient's respiratory status, if tube coils in mouth, if the patient begins to cough or turns pretty colours



11. Advance tube until mark is reached



12. Check for placement by attaching syringe to free end of the tube, aspirate sample of gastric contents. Do not inject an air bolus, as the best practice is to test the pH of the aspirated contents to ensure that the contents are acidic. The pH should be below 6. Obtain an x-ray to verify placement before instilling any feedings/medications or if you have concerns about the placement of the tube.



13. Secure tube with tape or commercially prepared tube holder



14. If for suction, remove syringe from free end of tube; connect to suction; set machine on type of suction and pressure as prescribed.



15. Document the reason for the tube insertion, type & size of tube, the nature and amount of aspirate, the type of suction and pressure setting if for suction, the nature and amount of drainage, and the effectiveness of the intervention.

- Partially pre-freezing the tube can ease its passage. - Infants can suck on a pacifier during the procedure. - Don’t rely on a cuffed endotracheal tube to prevent passage into the trachea – be sure and confirm placement using the above methods.

Ana Physio Summary

Lecture Note Index

Lecture Number	Topic
0	The Game of Science
1	Chemical Background: Atoms and Molecules
2	Solutions, Ions and pH
3	Biological Macromolecules
4	Enzymes and Metabolism
5	Cells: Structure and Function
6	Cell Division
7	DNA, RNA and Heredity: Genetic Code
8	DNA and Heredity: Transcription and Translation
9	Membrane Structure & Function
10	Membrane Electricity
11	The Action Potential: Nerves
12	Synapses and Neuromuscular Junctions
13	Muscle Contraction: the Sarcomere
14	Muscle Contraction: Mechanics
15	Cardiovascular System: Circulation
16	Cardiovascular System: the Heart as a Pump
17	Cardiovascular System: Electrical Activity and EKG
18	Respiration: Anatomy and Mechanics
19	Respiration: Gas Exchange in Alveoli
20	Oxygen Carriage in Blood
21	Control of Physiological Functions: Homeostasis
22	Physiological Adjustment to Exercise
23	The Skin and Temperature Control
24	Central Nervous System: Anatomy and Organization
25	CNS: Special Centers
26	Autonomic Nervous System
27	CNS: Learning and Memory
28	Cranial Nerves
29	Sensory Physiology
30	Eye and Vision
31	Ear and Hearing
32	Endocrines: Survey and General Principles
33	Endocrines: Pituitary Gland & Hypothalamus
34	Endocrines: Control of Ca and Phosphate
35	Endocrines: Control of Blood Glucose
36	Endocrine Disorders
37	Kidney: Filtration, Secretion, Reabsorption
38	Kidney: Regulation of Salt & Water
39	Regulation of Blood pH: Kidney & Lungs
40	How the Body Handles Drugs: Kidney and Liver
41	Digestion: Basic Processes
42	Digestion: Protein, Carbohydrates, Fats & Other Nutrients
43	Immune System
44	Reproduction: Why Sex?
45	Reproduction: Female System
46	Reproduction: Male System
47	Reproduction: Fertilization & Development