Lesson 6.7: Inhaler Teaching, Spacers, and Wound Care
Teaching a skill to a patient is a combined procedure and communication station. The examiner assesses clarity, demonstration, and checking of understanding. The principle: do not just tell, demonstrate, then watch the patient do it, then correct any errors.
Inhaler Types and Key Teaching Points
| Device | Key Teaching Points | Common Errors to Correct |
|---|---|---|
| MDI (Pressurised Metered Dose Inhaler) | Shake well. Breathe out fully. Seal lips. Breathe in slowly, press canister once, continue inhaling. Hold breath 10 seconds. | Too fast an inhalation. Pressing before or after starting to breathe in. Not holding breath afterwards. |
| MDI + Spacer | Shake MDI. Attach to spacer. Breathe out away from spacer. Press once. Take one slow deep breath or 5 tidal breaths. Hold 10 seconds. Wash spacer monthly in soapy water — drip dry, do not wipe. | Using spacer with DPI (incorrect). Pressing more than once per breath. Failing to wash spacer. |
| DPI (Turbohaler, Accuhaler, Ellipta) | Load device as per type. Deep, fast inhalation required — no propellant sound confirms activation. No shaking. No spacer. | Breathing in too slowly. Forgetting to load the device. Using a spacer. |
| Breath-actuated MDI (Autohaler) | Device fires automatically on inhalation. No coordination needed. Audible click on activation. Seal lips, breathe in. | Not sealing lips. Not breathing in deep enough to trigger. |
After any steroid inhaler: always advise the patient to rinse their mouth and spit — this prevents oral thrush.
Wound Assessment — Before Suturing
- Time since injury: <6 hours ideal for primary closure. >6–8 hours carries higher infection risk.
- Mechanism: crush injuries, bites, and contaminated wounds may not be suitable for primary closure.
- Depth: does it involve deep structures (tendon, nerve, bone)?
- Neurovascular status distal to the wound.
- Tetanus status: when was their last booster?
- Allergies: lidocaine, latex, antiseptics.
Simple Interrupted Suture — Technique
- Explain procedure and obtain consent. Position comfortably.
- Clean wound with 0.9% saline or chlorhexidine. Remove any foreign bodies.
- Local anaesthesia: lidocaine 1% (without adrenaline in fingers, toes, penis, nose, ears). Infiltrate around wound edges. Wait 2–3 minutes.
- Drape wound. Open suture pack aseptically.
- Load needle in holder at the swaged point (90–120 degrees from tip).
- Evert wound edges slightly. Enter skin at 90 degrees, 3–4 mm from wound edge.
- Pass needle through both sides in one movement. Tie instrument knot — square knot, 5 mm tails. Suture every 5–8 mm.
- Final check: wound closed, no gaps, even tension. Cover with sterile non-adherent dressing. Document.
Suture Removal Timing
| Location | Removal |
|---|---|
| Face | 3–5 days (highly vascular, cosmetically sensitive) |
| Scalp | 7–10 days |
| Trunk and extremities | 7–10 days |
| Over joints (knees, elbows) | 10–14 days — high mechanical stress |
| Hands and feet | 10–14 days |
Tetanus Prophylaxis
| Situation | Action |
|---|---|
| Clean wound, fully vaccinated (5 doses) | No action needed. |
| Clean wound, incomplete vaccination | Complete vaccination course. No immunoglobulin. |
| Tetanus-prone wound, fully vaccinated | One booster dose (dTaP/IPV) if last dose >5 years ago. |
| Tetanus-prone wound, unknown or incomplete | Full vaccination course + tetanus immunoglobulin (TIG) 250 units IM at a different site. |
Tetanus-prone wound: >6 hours old, puncture wound, devitalised tissue, contaminated with soil/manure/faeces, compound fracture, animal bite.
Wound aftercare counselling: keep dry 24–48 hours, then gentle washing with soap and water. Watch for signs of infection: increasing redness, warmth, swelling, pus, red streaking, fever, or wound opening — return if any of these develop.