The GAH Toolbox

Preface

The GAH Clinical Guidelines Toolbox is an orientation manual that will familiarize clinicians who have recently joined the hospital with the following:

Orientation to the Hospital – the first part , which must be read to understand the backgroundof the work
Commonly seen problems
Investigative methods available for diagnostics
Common nursing orders
Interventions/medications available for various disorders as currently used in the hospital

The manual assumes that clinicians will rely on their clinical skills of history taking and physical examination to arrive at a presumptive diagnosis or differential diagnosis.

The manual will summarize how each diagnosis is typically investigated and treated. Guidelines take into account our clinical experience, local resources, local cultural sensitivities, established guidelines, and evidence from medical literature. No attempt has been made to describe surgery or procedures with equipment not available in the hospital. In general, the cost of investigations and treatments are a central consideration in clinical-decision-making.

The GAH toolbox is in constant flux - new investigational tools and medical treatments are added as needed. The reader’s input in keeping the Toolbox up to date is highly valued.

Every attempt has been made to ensure accuracy of information and doses. Please advise if any errors or omissions are encountered in the manual. The investigation and treatment protocols serve as guidelines only. Care for each patient should be individualized as appropriate.

References are generally from Current Medical Diagnosis 2019 (CMDT), The Green Book ( Primary Orthopedics) , the Blue Book ( Primary Anesthesia),Oxford Handbook and Medscape.

Thanks are due to Kannan of the MIS team at ASHWINI for getting the manual published.

Editors

June 2020

1st Edition – March 2007 Editors: Dr Nandakumar Menon, Shylaja Devi,Mrudula Rao
2nd Edition – Sept 2009 Editors: Dr Nandakumar Menon, Shylaja Devi,Mrudula Rao
3rd Edition – Nov 2011 Editors:Drs.Gopal Menon, Nandakumar Menon, Shylaja Devi,Mrudula Rao & Abraham Tharakan
4th Edition – May 2016 Editor: Drs. Nandakumar Menon, Sheldon Rao, Royson DSouza, Mrudula Rao & Kathryn Boyd
5th Edition – June 2020 Editor: Drs. Nandakumar Menon, Paul Heron, Mrudula Rao, John Stephen, Veena Shesadiri, Namrita George

TYPICAL NURSING ORDERS

Diet Normal diet Renal diet Liquid diet Lactose-free diet Kangi water (rice water) Kangi water with salt Ragi (cereal beverage) Sattumavu (ragi + peanut/lentils) Eggs (specify frequency)	Activity Activity as tolerated Bedrest Incentive spirometry	Vitals signs ‘TPRBPO2 sat’: Temp Pulse Resp BP,Oxygen saturation Frequency: typically tid – qid or q6h ( as needed)
Dressings Dressing changes are typically once daily. Dirty dressing are done in the Dirty OT usually at the end of the day to minimise nosocomial infections.	Intravenous Fluids Standard solutions include RL, NS, D5W, DNS, Kidral supplied in 500 ml bottles. See table for composition.	Acceptable Abbreviations ac : before meals bid or bd : twice a day cc : cubic centimeter hs or qhs : at bedtime IM : intramuscular IV : intravenous mg : milligrams ml : milliliter od or qd : once daily pc : after meals po : by mouth pr : per rectum prn or SOS : as needed qds or qid : four times a day q6h : every 6 hours exactly stat : at once tds or tid : three times a day AF : after food 1-0-0 : one tablet in morning 1-0-1 : one tab morning / eve 1-1-1 : one tab morn / aft / eve

Intravenous Fluids
Standard solutions include RL, NS, D5W, DNS, Kidral supplied in 500 ml bottles. See table for composition.

Solution	Na	K	Cl	HCO3	Ca	Cal
Ringer’s Lactate	130	5	110	29	2
Normal Saline		154		154
5% Dextrose						200
5% Dextrose Saline	154		154			200
Kidral/Pedilyte*	26	20	21			200

Cal: Calories in Units mmol/L or Cal/L
*Kidral also contains Mg 3, Acetate 23,
PO4 3 (Osm/L 346)

Typical Maintenance IV Rate:
Adults: 50-100 ml/hr
Pediatrics:
4 ml/kg/hr for 1st 10 kg
2 ml/kg/hr for 2nd 10kg
1 ml/kg/hr for additional kg
OR
1st 10kg – 100ml/Kg/day
2nd 10 kg – 50ml/Kg/day
3rd 10 Kg – 20ml/kg/day
Example: Maintenance IV rate for 25kg child is
65 ml/hr or 1000+500+100=1600ml in 24hrs

Typical IV bolus:
Adults: 250-1000 ml over 1 hour
Pediatrics: 10 ml/kg over 1 hour

Oral rehydration salt:
Kanji water with salt is the
commonest rehydrating fluid.
ORS is used if you suspect
hypokalemia or if kanji is unavailable
Measuring Ins and outs:
Urinary (Foley) catheter