ࡱ> 5@ 7bjbj22 ]oXX +===8J=$n=r.>.>.>.>.>```xzzzzzz$kRCF \CC.>.>]]]Cx.>j8.>x]Cx]] 4X.>"> PǾ =6t0NWtWlW `"]```D4=;"=PRACTICAL ON STERILIZATION METHODS, INJECTIONS & TEMPERATURE MEASUREMENT Temperature Measurement Objectives At the end of the practical, the student should be able to, Explain how the human body maintains a core temperature at 37oC Under normal conditions On exposure to cold environments With excess heat production. Measure and record the body temperature accurately using a mercury manometer. Discuss the advantages and disadvantages of different sites of temperature measurement. Explain the clinical significance of body temperature measurement. Man is a homeothermic animal, i.e. he is capable of maintaining a constant body temperature that is independent of the environmental temperature. A person's body temperature is the balance between heat production and heat loss by his body. Man's body temperature is maintained in the following range : 97oF - 99oF Core Temperature is the temperature of the deep tissues of the body. This remains constant usually within ( 1oF (( 0.6oC). Core temperature ranges from 98oF to 98.6oF. (Normal Body Temperature 37oC (36.3 - 37.1oC) 98.4oF (97.3 - 98.8oF) Measurement of Temperature: Equipment : Mercury Manometer or Thermistor (platinum head in the oesophagus) or Thermocouple Sites: Core Temperature - Rectal, Oesophageal, Nasopharyngeal Surface Temperature - Oral, Axillary, Groin Temperature is most often measured using a clinical thermometer (Mercury Manometer) A special thermometer is available for taking the rectal temperature. Precautions - When taking oral temperature, hot or cold drinks should not be taken for at least half an hour prior to recording the temperature. The subject should not breathe through his mouth when taking the oral temperature. As it may take upto five minutes for final temperature equilibrium, the thermometer should be kept in place for this amount of time, or till the temperature recorded remains constant. The thermometer is disinfected with Savlon (the thermometer is kept with its bulb dipped in Savlon solution) Before using, the bulb is wiped with a cotton swab soaked in sterile water, and shaken until all the mercury within the capillary tube reaches the bulb (the point below the constriction in the tube) Place the thermometer in the region where temperature is to be measured (mouth, axilla etc.) Keep the thermometer in place, Sublingually - approx. 2 min. Axilla - approx. 3 -5 min. Groin - approx. 3 -5 min Rectum - approx. 1 min After obtaining the reading, wipe the bulb with cotton wool and replace it in the Savlon solution. Reading : Rectal Temperature = Core Temperature Oral Temperature = Core Temperature - 1oC Axillary Temperature = Core Temperature - 2oC Advantages & Disadvantages : Axillary TemperatureOral TemperatureRectal TemperatureAdvantages : Easy to measure No discomfort to patient Useful in small children Closer to core temperature Useful in adults and older children Less discomfort to patient Easy to measure Very close to Core Temperature Useful in shock states Disadvantages : Varies with environmental temperature Inaccurate in shock states Children may bite on bulb Affected by hot or cold drinks Affected by breathing through the mouth  Aesthetically least acceptable method Needs patient cooperation Rigid tube can break in situ Heat production & Heat loss : The thermostat is the Hypothalamus Heat is produced by, Basal Metabolism Exercise / Emotion Specific dynamic action of food Heat is lost via, Radiation, Conduction (70%) Vapourization of sweat (27%) Respiratory passages (2%) Urine and Faeces (1%) Injections Objectives : At the end of the practical, the student should be able to, Identify apparatus and instruments used to inject substances into the body. Describe the routes of administering injections with examples. Describe how to do a venepuncture. Apparatus and Instruments Hypodermic Syringe Commonly used in clinical practice for collection of blood for investigations and the administration if drugs. Maybe glass or plastic Glass syringes are non disposable and have to be sterilized (hot air oven) Plastic syringes are sterilized chemically and can only be used once. (available with needle). A syringe has three main parts. The Piston, Barrel, and Nozzle. Various sizes are available in order to collect varying amounts of blood (1ml 50 ml)  Needles (Disposable and non-disposable) Needles are available in disposable and non disposable (metal) varieties Disposable variety is safer as disease transmission can occur from frequently used needles (HIV, Hep.B) Needles have a Gauge which corresponds to its internal diameter. The gauge ranges from 18G (very large thick needles) to 27G (very fine thin needles). identified by a colour code Therefore, the larger the Gauge, the finer the needle A needle has two parts, a shank and a beveled edge (reduces pain when puncturing the skin). Intravenous Cannula Is used mainly to introduce fluids / drugs into the body for over long periods of time. Ideal for administering fluids continually (fluid therapy). Can also be used to obtain blood if needed repeatedly. Consists of a needle, connected to a plastic hub (2-way or 3-way), which also has a plastic cap (closing cone), that can be closed when fluids etc. are not being given, as well as a separate injection port. It also has a stylet which helps in introducing the cannula into a vein. There are two flexible wings that are used to anchor the cannula to the skin. Cannulae are also colour coded according to the gauge. They are disposable and are available sterilized with Ethylene Oxide gas. Can be kept in situ for approx. 3 days.  Sterile Lancet Is used to obtain capillary blood for certain investigations. They can be obtained in sterilized packs and are disposable. The lancet has a sharp edge, which is used to prick a subjects earlobe or finger. The first drop of blood is generally discarded. Ideal for blood grouping, PCV measurement etc. Vacuum Syringes (Vacutainer) Is a type of syringe used in the withdrawal of blood, where blood is drawn under a vacuum. Is a very safe and painless method. Especially useful in the collection of blood from patients suspected of having HIV or Hep B infection. Tourniquet Is used to compress the blood vessels in a limb. Often used to obstruct the venous return from a limb to facilitate the withdrawal of blood from a vein (in venepuncture). May vary in type from simple rubber or plastic tubing to Velcro bands and pneumatic cuffs. Routes of Administration There are various routes of administration of substances into the body. The route depends on the site of action and time of action required of a certain drug, substance etc. Methods, Intradermal Injection Subcutaneous Injection Intramuscular Injection Intravenous Injection Intrathecal Injection Intrademal Injection : Injection is made into the skin The needle is kept almost parallel to the skin (approx. 15o) and then inserted into it. Prick only approx. 1 mm deep. A thin needle (25G or 27G) is generally used. Eg. Manteaux Test BCG vaccination Subcutaneous Injection : The substance is injected to the subcutaneous space. The skin is pinched between the forefinger and thumb, taking care not to pinch any blood vessels. The needle is then introduced gently. A short fine needle (25G) is used commonly. Eg. Insulin administration. Intramuscular injection : This technique injects substances directly into a muscle. Common sites are, the Deltoid Muscle and Upper outer quadrant of the buttock. The needle is introduced at an angle of 90o to the skin. Following injection, pressure applied to the area to facilitate drug dispersion and to avoid formation of a haematoma. A thicker, longer needle (21 22 G) is used as the drugs are generally opaque and thick. Eg. Vitamins, Antibiotics, Tetanus toxoid Intravenous Injection : This technique injects substances directly into the vein. The needle is introduced at an angle of approx. 30o - 45o (see technique on venepuncture). Veins in the cubital fossa and dorsum of the hand are used Eg. Antidotes  Intrathecal Injection : Employed to inject substances into the subarachnoid space. Eg. Obtaining CSF for investigation Anaethetics Venepuncture Indications : To obtain venous blood samples for investigation To transfuse intravenous drugs, fluids or blood [In order to insert cannulae to distant sites (eg. Heart)] Sites : Antecubital Fossa Dorsum of the hand and wrist [Femoral vein / Jugular vein] Technique : Explain the procedure, obtain consent and reassure the patient Wash hands thoroughly and wear gloves Determine a suitable, preferably visible vein. A tourniquet is applied proximally to the chosen site. The vein is then made prominent by lightly tapping on it and asking the patient to clench and unclench the fist of that arm. Clean the area with surgical spirit Insert the needle at an angle of 30 45o and feel for the loss of resistance when the vein is entered into. This will be indicated by a flash of blood into the hub of the needle. (In the case of injecting drugs, we should carefully observe the flash of blood into the hub of the needle, and only then, inject the substance into the vein.) Withdraw blood slowly into the syringe taking care not to create bubbles. Remove the tourniquet and slowly withdraw the needle. Apply a cotton swab to the area and elevate the arm or apply pressure to prevent extravasation of blood into the surrounding tissues. Next, cap the needle and remove it from the syringe. Put the blood into a suitable bottle to send for investigation. Caution : Care should be taken to avoid spillage of possibly infected / contaminated blood onto skin or any other surface Sterilization and Disinfection Objectives : At the end of the practical, the student should be able to, Identify the methods of sterilization and disinfection List the practical applications of sterilization and disinfection in a hospital setup. Sterilization - Is the destruction of the vegetative forms as well as spores of bacteria, viruses and fungi. Disinfection - Is the destruction of only the vegetative forms of organisms. The spores remain intact. Methods of Sterilization                Methods of Disinfection  Halogens - Used in treatment of water supplies Cleaning walls, countertops and furniture As skin disingectants (povidone iodine) Eg. Tincture of Iodine 2.5%I2 or 2.5% KI in 90% alcohol  Methylated spirits - Used as skin disinfectants Eg. 70% Alcohol  Phenolic Derivatives - Eg. Hibitane Chlorhexidine Lysol  Quaternary Ammonium Compounds Used as a pre-operative skin disinfectant in combinatoion with other disinfectants. Not very effective alone Eg. Cetrimide  Soaps and Detergents  Oxidising Agents - H2O2 KMnO4 Physical Methods Chemical Methods Heat Radiation Dry heat Moist heat Red Heat Inoculating wires Points of forceps etc. Hot air oven At 160oC for 1 hour Used for heat resistant glassware and metal instruments Infra red radiation Scissors Instruments that cannot withstand dry heat are sterilized by this method. Eg. Glassware, Syringes Use of ultraviolet rays. For ionizing radiation, x-rays and ( rays are used. Eg. Heat unstable instruments Prepacked disposable items Plastic syringes Catheters Rubber equipment 2% Gluteraldehyde eg. Endoscopes  Barrel Piston Nozzle Bevelled Edge Shank Catheter with steel needle 15o Injection port with protective cap Flexible wings Flashback chamber Closing cone 90o 45o Filtration At temperatures of 100oC Steaming Boiling At temperatures > 100oC Done by steaming under pressure (autoclave) 121oC for 15 min. or 134oC for 3 min. eg. Surgical instruments Dressings At temperatures <100oC Pasteurization of milk Bed linen sterilization Clothes Gloves Gases Liquid Ethylene Oxide Eg. Disposable syringes Micropore and Millipore filters Practical No : 01 KLdo [ \ b c e u   ' ) * ; < C D S T W X t noBƺƺƳƳƬƤƕƕƕƺƺƕ hj~>*hj~B*H*phhj~B*ph j\hj~ jhj~ hj~5\ hj~H*hj~hj~5>*B*CJ\phhj~5>*\hj~5>*CJ\'jhyp5>*CJU\mHnHu82KLdo $ A * +  e  '  & F v^^ & F ^ & F & Fh`hx$a$ 3377' ? W X t u  D E p{| , & F pRv^v8^8 & F & F v^vp^p,LoEq $ $Ifa$  & F v^v & F @  L^ `L0IJe|rZZZrB & F I$If^`I & F pL$If^`L $Ifkd$$IflpF| D !   06    4 la e $If^ & F j$If^`j $If & F I$If^`I & F I$If^`I#>?Yx|rZZrEE & F :$If^`: & F :$If^`: $Ifkd$$Ifl F| D !   06    4 la xE? kd0$$Ifl F| D !   06    4 la  & F Bj$If^`j $If & F :$If^`:Bl <GTU?@\] & Fh`hx & F x^ ^ & F ^ BE<GU@A]op:;<dceyzEIac_`dstrs l#m#######t%u%%%%%L'M'''''''''>+?+..g/t/V0Y0!jhj~>*CJUmHnHu hj~H*hj~5>*\ hj~>*hj~5>*\hj~5>*B*CJ\phhj~jhj~CJUmHnHuF]pD:<dZ & F @0* & F @0*] & F @0*x]^ & F ]^ & F ]^ & F x]^ & F ^bcyEa_abcds & F D#x]^# & F @@ ]@  & F @@ x]@  & F ^ ^ & F @p]pBr @ ^!!! & F D^ & F D#x^# & F \` ] ^ & F \` #x] ^# & F ^  & F D]^!""""""""2#######L$$$%%%t%% @ ^@   & F p^p ^%%u&&&&L''''''H(p((((()?)@)[){))) h^h @ ^@    2 ^2 ))*=*t**+++k,,,q----0.e.f.g.h.i.j.k. h^h ! & F  p^p & F  `p^p k.l.m.n.o.p..../f/g/x///=0V0Z0\0_0e0i0o0t0w0^ & Fh`h  h^hY0Z0[0\0^0_0d0e0h0i0n0o0s0t0v0w0x0y0{0}0~0000000000000d1e11111222222222222 3 33 3!323Z3c333333344K5L55555jhj~U jchj~ hj~H* hj~>* hj~5\hj~B*ph hj~H*hj~jhj~CJUmHnHu hj~>*CJHw0y0|0}00000000000000000000000000 !001G111111111222=22222222222$a$ & F  D^ ! ,^,`22333333333 3 3 333 3!323338393C3D3M3N3Y3Z3c3$a$ !c3v333333334 4S4k4l4m44444455'5(5:5J5K5   hh^h hK5M5N5U5V5]5^5e5f5t5u5{5|55555555555555555$a$55556666 666K6L6N6~66666666 7!777777hypB*phhyphypB*ph hj~>*H* hj~>* hj~5\ hj~H*hj~566!6+6465666N6z6666666667!7)7*7+7172797:7I7a7 h$a$a7b777777777$a$ h 1h/ =!"#$%zam>_z6;+( zar%KP)sp:"M( UUUUzakW7{y3T( $$If !vh5 5 5 #v :V lp065 4a $$If !vh5 5 5 #v :V l 065 4a $$If !vh5 5 5 #v :V l 065 4a 'Dd _[0  # A2<'kvjZmO' `!'kvjZmO ,fPUKP#&x\ү9]@ADE%gAPa|FD$ɒE2 OD bsćݙ}7ꮙ2(7%zWIKE(Ee!V.D!T1L\Is#uG=Dy;u{)& ;FctJKUޤ;5 cP?k.l3?jCĞF_?EOTKa7)HQb$r1=k:B1=TkD L[SXeZ ]ZF_|d|y(?8wr?o'J'IIF_^6;E7ki!R~qconc4a763292&-05F)34Z 5uYX=ݛ,o0{PO_u!~~Ic O NBtJGڈ`fcYxϬc2[`zrsҘcn1fy39l51fSq-s9c1O Myl`׼c>n̾V@i)I5zԚiz˺ZeU5Z;͓>iFfh(:i8 5c=e|o=dZ$`0ZQvu萹6op;4;#{l*h|fiU=uuYZK[B2FC?'a(TV cړv̙ji:[an1]B,SCt6j43ڟ yɝ<'%#W\J{3Tp|`)埧}Lіj3A%^5ЭpW#Zޫ|DT_`kPp!/ȟRj}EADS޺|vY^TkN2Y=Y>_mSeX%y#xwݲ&mH;dm],k<^t_fh]Β>]#4ק\U_^N5VemYpMQ2NQ 'Rt|t:G)]iLJyGoHuYNӎX#:c 6ƒߘDghDLfQR^c ]axx|_N=Oc8+psAy#2(:_24U]8TtihMW+r< 5d? :ٙހ   PV7~!(S c%1ޣ Tx6> ֛Zwjuٛ赔j9ῴ6 X M?s#tֹV5|Li9c Hc(t֚و^,B*k|3'TWU}~BWX˫ {n@oU'Z+B'YZ}M7@oclmwк>ϡ.p}d.iڈjK8tQ:anOjߨqp pn6=(obT3Q]50~zA*CT8|ד*lP4w|`8,4y0q?PPtT71o}xL+w]_K%0j1qݨzqJ#3|N{Ӈ]F M[z+p, qy e{Y;2 >Vx2׳{ σ&jRs8D+Gvwl,ū.q^\ z.o[zwbni*ܥ܂ICe/z8}u1o=u1h|)}=J>6zz\yx9R.0ni ׸-N=# |gd%C[ڻGpc?dg§Qr?K=8ԅK4=C.BOs~~J4W`ysf·%~#\ |6n 6BC?Øvְ퇆ԛb?F Ns1FRaJ8סPMzVnDQޣ"j9=e +ZQzˮ7,XE**'~ ~|*. ݗa!\PGpM7XP/O0<ɫ]|-M۳lQI|&Uļz̭,#_AuԍғQtn?s.@=(=e7W_Iߟ\i*ܾh*ÆqY+q<ag9lhtTY *s`h_i7z)]Ǫêp<ځ'J ((:_xXB4bmХE?Ezkpi.—I7Ex AmPtTha7bM!ǿM4[TTjLt~Sw*6]Y2ՠ5uOk:-O{M7;_zK7e6[5ʆ }Px_)YtTp!v&%dResȨwK rhj.z/ ߖ6ѣz>δFQ=qݝ/`=B_<gn4nOz?7^ CxayNuuÞ$^h yA6U&`RWO[ES'IR'")a<0^FXcZ: ~<^vc/څ=iv7r<"߸P T~O wK-q^=_Eb8=owbچ>?z>`t= @bg؆18Ç8eg@n1yuSe!܋3w@wQIqx j\|Nwi}C~ɑND psqO&} {./s]ɷOŝPJھ &mTm 3l[vunsom>#fNJѳOە[dWg;9~g(]ωɮ3}=]!'嘰y|Oeu-ɛ\O 40z'eMrǪ<7\ 3Ja[FZh`yuFEkmF5s(+m>ڼJrL^B}GӺ|Bz̜bn-u}!_)o8T9PM㹔f]Koȍ <]Ƴ䍼=lݭ|?)SRzK_&E5¢+Nm/dƒ'~H6V~ƙqP:lG8Z©8ˌwe)a7I1 "2Aw2Q`dzp{%|0<6S +d~ٍ$d7%Jh9%a L%\89g%aEY:IcryIxl,+afN-9w#h+\_s2ՕMod''S3{=f:vwgxYJ8ْ$a*_Ty O{CZӓnog z5WY+} n?'g;=G gzs9ΓÝlE+0n )kg;H稪|M=GW1稟Is4-V378K 8Ó$YQv~-V }0/zmx}Q9E0&E-~~gbDV;qDs._*CI{Rn!{66˞eXѠR \A3AX`8<llT.qs* ܷ l &q@4 $Pan-F@-sD`95p\Zem NnEEmp<#> wVg,/9*@1L!X(JuW2IV1nz|jvk}c{ҘlYD<ēJ<)e'f[V[v9 g&z9eE'PfS:Xщ v@0x67߷ENy 9_:UE3;oR"˝\8b} :Mq5ܗ2NlwRJ,e\ خHqߩ14VϞgTɼnh&(`wZhkxzIlsV_&*+DUq̪*~wZV]57 nGcskf\cv{{{[ȍuw:b,γ Ngtq 99'w/ZEyibs` v~|ֿ <|t nr :u+)@n1p,0F~Iį@qXl1_[{,#uUhl.zibup8rNw̹Kun8~1 |Yhs8,vfE7`TwܒFswrrsw*7qsmwΑeݻda7ݍiewS]q9ǝVs3ͩtsuj:rr;_   ʝf`˝-\UܖO 䓀zjA [?ta;Wts?sb{Pd?&ڋ啶+ruYn`o&f&vkQݶ̊vct3lZ֬d['Z lְ˝(i$jդ_ 2jXfgMI:; R!=kZoXL.lOap}8k-N'|Qa?{L}V bۇk]}A_=W㨯}w}Y\qE;hhB}Bɛ]݅cy?!}('mL״wNo M ሲ+8^yx9w@ރlqKz9wǡ@ލrT8}v8oygyo9cvEhڷ\-IV(;D[1p&i9D;ߺ Cll签 9ǟSAv8oǾ#,R 23kgoڝ|>|uDQΞ(`w/G*G#Q9wRvTގt%.ϛ ˥9U{"kJN!,VOOjNXsZ>a5'+NV}3/oQ}?'Fψyq1D?$f3ǿSo7W|Kċb/&_/aY"P|/ȗwRQr iqpwm8=~r8{ʗIYD0A4go p9KE}/qタM=?N.$SnV"p3ʄ3LB>(ʄ[(d3ODʱg^L[یgP dLq~PwI96Eg ]FnCP _LsmtctkC?}J{$sm$sgYJ\̵iV䟟[)smE2U2זESr\2sm sm|%2kCf-yd;N\2smɿQڬuwd3sm|g3sm|g3sm|g3sm|g3sm%\f\f\f\f\fK6>̵96>̵96>̵96>̵96>̵}kK^k'dDh-E"H"Z$BDh-E"Hv"H>"G$D#}DH>r>"#Ȝ*\N@N Heading 2$ @&^ 5>*\J@J Heading 3$@&5>*B*CJ\phH@H Heading 4$$@&a$ B*CJphDAD Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List 4@4 Header  !4 @4 Footer  !@T@@ Block Text ] ^DC@"D Body Text Indent 2 ^2 HR@2H Body Text Indent 2 ^$*5?K^<?GOWfm'#+St/   ;<=Z\&B()*+EHKMNOVWZ]h$*5?K^<?GOWfm'#+St  //n2KLdo$A*+e '?WXtuDEp{| , L o    E q   0 I J e # > ? Y x   B l  <GTU?@\]pD:<dZbcyEa_abcdsBr@^2LtuLH p !?!@![!{!!!!"="t""###k$$$q%%%%0&e&f&g&h&i&j&k&l&m&n&o&p&&&&'f'g'x'''=(V(Z(\(_(e(i(o(t(w(y(|(}((((((((((((((((((((((((((()G)))))))))***=************+++++++++ + + +++ +!+2+3+8+9+C+D+M+N+Y+Z+c+v++++++++, ,S,k,l,m,,,,,,--'-(-:-J-K-M-N-U-V-]-^-e-f-t-u-{-|-----------------..!.+.4.5.6.N.z........./!/)/*/+/1/2/9/:/I/a/b////////000000 0 0 0 0 0 0 00 0 0 0 0000 0000000000000 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 000 00000000 0 0 0000? 0? 0\ 0\o 0\o 0\o 0\o 0\o0o 0o 0o 0o 0o 0o 0o 0o0o 0o 0o 0o 0o 0o 0o 0o 0o0o0o0o0o 0o 0o 0o 0o 0o 0o0o 0o 0o 0o 0o0o 0o 0o 0o 0o0o00 0 0 0 0 000000000000000000000000000000000 0 0 0 0 0 0 0 0 0  0  0  0  0  0  0  0  0  0  0  0  0  0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (0 0o&0o& 0o& 0o&00000800000000000000000000000000000000080000000000000000000 0 0 00000000000000000000@0My000e0M900'0M900'0M900'0M900'0M90 0'0M90 0'0000000000M900000M90000000000M90#0'00M90&0'0M900'0M900'0M900'0M900'0M900'0M90 0'0M90 00M90 0'0M900'0M9000M9000M9000M900'0M90B0'0M90D0'0000M90I0'0000000M90Q0'000000M90X0'0M90Z0'0M90\0'00M90_0'0M9000HM900M900M900M900BY057&.4' ,ex]!%)k.w002c3K55a77 !"#$%'()*+,-/0123567  lk?r$m>_z6;+i"nr$r%KP)sp:"Minr$kW7{y3Tin 鏾f3Π U n@ %j( (  `  c $' `  c $& `  c $/ `  c $. `  c $8 `  c $7 `  c $= `   c $@ `   c $ >  `   c $ <  HB  @ C D$HB   C D#HB @ C D4HB  C D3NB  S D: NB  S D;NB  S D1N  3  ?  ZB  s *DZB  s *DZB  s *DZB  s *DZB  s *DZB  s *DZB  s *D  b d"(+ [ #"  t * :# #" d"`$+` !#, 8#" !!*tb # 8G0*A50%3,,9Tb " C G$bm,0b ! TG0*A$Narrow horizontal!#$6zZ <( 9 <( ) BNCQDE(F 8YCNN&Cp8"Q @   #" .''`b  c $G <(x`b  c $G0*H~`b   c $GE`L y ' 7y 'fB * s *Dyy'$fB + s *Dy'y'fB , s *D{%%!fB - s *D{''fB . s *Dy&&&fB / s *Dy$$fB 0 s *D{##/fB 1 s *D{""/fB 2 s *Dyr!r!VfB 3 s *D~B B )fB 5 s *D{ r ; s * %"n($  r < s * &(()  r = s *q%2(: `B >B c $D#D% `B ?B c $D6$q#%q# `B @B c $D#/)&/) *N F(O)5 p  t Uw7(8 Y# #" F4w(5lb S 05Nb  3 G0*4H!5T  BlC(DE|F44@h-xU*Xlsz 8T(Pt^Rl0 LKJOXK$G@4n(3 @          #" 4#5  BfCDELF$ 4-DUTcb*aX9@Gt 8S9Rf-@      #" 5#6Nb  3 G0*$4E!G5Zb  S G 20!4`B  c $D0846  BCNDE4F '(3PHrKNC9/  @    #" A4!4`B  c $D!T3!G4`B  c $D04 00"z + 1!3 3 #" ( 1!{3H2  # + 1!3H2  # C 1!~3  BtCjDE(F U tjmgXcHZ8Q!E6 ' @   #" % 2 73  0BwCDEF< U U%%C8?9/>%>>+5?i z(4@KU_lptppppppYpBp(pp wsodU&F/%25@            #" $ Y2 /3  BlCBDE(F lgZK'<2BBB/* @   #" ( I2 2fB  s *D!0!1%`B  c $D 0!0""  BCDEdF,my$3Q]i[Ek*{5Tc3yOk{Yj@        #" !0" 2ZB  S D!0!1ZB  S D!0!1B2   >"n1x"1B2   V"1"K1B2   "1W"2 z !1?$3 3 #"  1"3N  3  Uz"1?$3&Tr  C GX  n!1"2*Zr B S LGX  n!2"3%B2   L#2#2!jZ 0" v3  0" v3`B  c $D" y2" 2$ZB B S D 1 10ZB B S D33 ZB  S D0&<3+  BCDELF$ e~Ek77zmxykMB7x8T6L@      0v3  BC|DE4F  9]++qkx| @    #" 0l3  rBC1DEF~(1@  01B2   ,V1f1B2   81r1 B2   >2xP2Bb    / 0:ZB  S D: ": 0ZB  S D " 0 B2   = ! "1  B<CDE(F  uZ7'$/8< @   #" 7 H!s "  B6CDE(F 4361,h!H3 @   #" r B! ""NR  3 L o! !dh '*7 %# Mh#" z p6}!9 3  #" 'h)7Hb  # G!p6}!9H"  # G0*78H"  # G0*A!7^!8H"  # G0* 7!8H"  # G0* 7 8H"  # G0*3 7P 8H"  # G0*78Nb  3 G0* ;(#)4z k5P!K7 3  #" (H)Hb  # G!k5P!K7H"  # G0*!#6+!7H"  # G0*a A6 .7H"  # G0*6 7Nb  3 G0* A())`B  c $D ))`B  c $D *m*Nb  3 G0* (2B)T  BlC(DE|F4 4@h-xU*Xlsz 8T(Pt^Rl0 LKJOXK$G@4n(3 @          #"  (5*  BfCDELF$  4-DUTcb*aX9@Gt 8S9Rf-@      #"  (u*Nb  3 G0* (@)Zb  S G  P( )`B  c $D P(P(  BCNDE4F '(3PHrKNC9/  @    #" P()`B  c $D )=)`B  c $D P(S("z + 1!3 3  #" x($)XH2  # + 1!3H2  # C 1!~3  BtCjDE(F鏾 tjmgXcHZ8Q!E6 ' @   #" v(((  0BwCDEF<鏾鏾 %%C8?9/>%>>+5?i z(4@KU_lptppppppYpBp(pp wsodU&F/%25@            #" u((#  BlCBDE(F lgZK'<2BBB/* @   #" x((fB  s *D ))*`B  c $D (S)(  BCDEdF, my$3Q]i[Ek*{5Tc3yOk{Yj@        #" )FL*V`B  c $D )K)"`B   c $D )S)*H2   #  )*H2   #  *)*H2   #  )&*OZ (,*x $  (,*xZ  S 鏾 #)9,*x`r  c $GX  ()`r B c $t5GX  (T)5N2  3  ))|f 0" v3 3  's(UZB  S D" y2" 2ZB B S D 1 1ZB B S D33ZB  S D0&<3  BCDELF$ e~Ek77zmxykMB7x8T6L@      0v3  BC|DE4F  9]++qkx| @    #" 0l3  xBC1DEF~(1@  01B2   ,V1f1B2   81r1B2   >2xP2Hb  #  r((o`B  c $D ((`B  c $D ((H2   #  ( ( ! B<CDE(F  uZ7'$/8< @   #" (( " B6CDE(F 4361,h!H3 @   #" ((TR # C  (( ` & c $  ` ( c $ ` ) c $ ` * c $ ` + c $ NB ,@ S D NB -@ S DNB .@ S D NB /@ S DNB 0@ S D^T h.)1 ?#" TB : C D(h.(1N" 1 3 G0* U#/)0  2 c FA" Light horizontalU#/#0N 3 3  U#0#L0ZB 4B S D Z0#Z0ZB 5B S D /#/ZB 6 S D 0V0#ZB 7B S D 00ZB 8B S D 3030TB ;B C DH!h.(h.TB <B C DH!1(1 = BChDE4F g&9VTq PIh @    #" O0O!1 > BChDE4F g&9VTq PIh @    #" q.`!/ TB @ c $Df3oHB A C Df B s * TB C c $Df3oHB D C Df E s * TB F c $Df3o!HB G C Df H s *  ` K c $% HB L C D"f M s *E H N # D) N O 3 F HB P@ C DCHB Q C DAHB S C DBHB T@ C D,HB U C D+` V c $2 ` W c $0 HB X@ C D*HB Y C D)` Z c $9 NB [ S D6NB \ S D5` ] c $ -  NB ^ S D(HB _@ C DHHB ` C DGHB a C DNHB b C DMHB c C DLHB d C DKHB e C DJHB f C DIXT  ;( j#"  h 0!hS"`? h( !N i 3 a&;(B S  ?H0(  B C D @:cdyEFGHab_srtLV(W(X(Z(\(](_(`(a(b(c(e(f(g(i(j(k(l(m(o(p(q(r(t(u(w(y(z(}(((((((((((())***/j"^!t htt@ t@ Jst@ wt@ Jt@ t@ t@[r9!tp>G" t&G"tZt,t. t-4 t(LE$ t)Mb!t/t*<M#t0mDt+rd#t% Oxt-tIt?"ZtAtBTbt@-CtD8*8RtE'CtCx%%tGB%tHtFxtLZ;t  Kt@   it@Kl"7t@nPt@ Pt@^JJtYtX(tU wtT;t]k"`t@ EWt@bt@WQ{!t@j't@Vlt@.t@;.ut@\t[ftE 't@'t@Z!t@,,\t@$ $ :t@ 4t@ ECt@ A 4 t@(I#t@ %mt@Q OrtS O tPO tN r$tM4  otO?t`t_ tf te td tc tb tatDT  /  /8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsplace 4@4<  L R   s { 061=qx&,LSO[js 4 @ L N u ! !3!5!I!T!U!Z!<%I%')4)6)>)G)I)))))))))))**j*v******* +++S,U,,,,,+-9-;-=-f-n-..I/K/b/k///?Hu, ; Z c     GSq +7L O 3&?&&&''("(G)J)c)i)))))** +++w++S,V,m,,,,;-=-{........I/L/////3333333333333333333333333333333333333333AE, e Y  B @pcy7s* + + + ++++!+1+3+7+9+B+D+L+N+X++,S,k,,&-(-I-N-T-V-\-^-d-f-s-u-z-|-----------------.../)/+/0/2/8/:/`/b////// +++//User1User1User1User1User1User1User1User1User1Dr.Yamuna RajapakseS ĘM ҚU Қ;FOT.)d{.)F(c%4rC9(^tVg|/n6Қ<:0p@ JXerKĘ}RZ`frژJZe\"LWj9joH?²<rĘx 0}R)*| h ^`OJQJo(h ^`OJQJo(oh   ^ `OJQJo(h \ \ ^\ `OJQJo(h ,,^,`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh ll^l`OJQJo(Hh^h`OJPJQJ^Jo(-H ^`OJQJo(oH(p^(`OJPJQJ^Jo(-H @ @ ^@ `OJQJo(H ^`OJQJo(oH ^`OJQJo(H ^`OJQJo(H ^`OJQJo(oH PP^P`OJQJo(h^`.h@^`o(-hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L.h^`.hh^h`o(-hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L.h88^8`.h^`.h L ^ `L.h  ^ `.hxx^x`.hHLH^H`L.h^`.h^`.hL^`L.Hr^r`CJOJQJo(H pp^p`OJQJo(oH @ @ ^@ `OJQJo(H ^`OJQJo(H ^`OJQJo(oH ^`OJQJo(H ^`OJQJo(H PP^P`OJQJo(oH   ^ `OJQJo(H8^8`OJPJQJ^Jo(-H pp^p`OJQJo(oH @ @ ^@ `OJQJo(H ^`OJQJo(H ^`OJQJo(oH ^`OJQJo(H ^`OJQJo(H PP^P`OJQJo(oH   ^ `OJQJo(Hh^h`OJPJQJ^Jo(-H ^`OJQJo(oH pp^p`OJQJo(H @ @ ^@ `OJQJo(H ^`OJQJo(oH ^`OJQJo(H ^`OJQJo(H ^`OJQJo(oH PP^P`OJQJo( h^ `o(- ^`OJQJo(o ^`OJQJo( h h ^h `OJQJo( 8 8 ^8 `OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o xx^x`OJQJo(hv^h`CJOJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(h  ^h `o(- ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(   ^ `OJQJo( ^`OJQJo(o !!^!`OJQJo(h^`.h^`QJo(-hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L.h88^8`.h^`.h L ^ `L.h88^8`.hxx^x`.hHLH^H`L.h^`.h^`.hL^`L.h^`o(-h ^`OJQJo(oh   ^ `OJQJo(h \ \ ^\ `OJQJo(h ,,^,`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh ll^l`OJQJo(h^`.h^`.hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L.Hh^h`OJPJQJ^Jo(-H ^`OJQJo(oH(p^(`OJPJQJ^Jo(-H @ @ ^@ `OJQJo(H ^`OJQJo(oH ^`OJQJo(H ^`OJQJo(H ^`OJQJo(oH PP^P`OJQJo(Hh^h`OJPJQJ^Jo(-H^`.H pp^p`OJQJo(H @ @ ^@ `OJQJo(H ^`OJQJo(oH ^`OJQJo(H ^`OJQJo(H ^`OJQJo(oH PP^P`OJQJo(h88^8`.h^`.h L ^ `L.h  ^ `.hxx^x`.hHLH^H`L.h^`.h^`.hL^`L.Hh^h`OJPJQJ^Jo(-H ^`OJQJo(oH pp^p`OJQJo(H @ @ ^@ `OJQJo(H ^`OJQJo(oH ^`OJQJo(H ^`OJQJo(H ^`OJQJo(oH PP^P`OJQJo(\^`o(- ^`OJQJo(o   ^ `OJQJo( \ \ ^\ `OJQJo( ,,^,`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o ll^l`OJQJo(Hh^h`OJPJQJ^Jo(-H ^`OJQJo(oH pp^p`OJQJo(H @ @ ^@ `OJQJo(H ^`OJQJo(oH ^`OJQJo(H ^`OJQJo(H ^`OJQJo(oH PP^P`OJQJo(Hh^h`OJPJQJ^Jo(-H ^`OJQJo(oH(p^(`OJPJQJ^Jo(-H @ @ ^@ `OJQJo(H ^ `OJPJQJ^Jo(-H ^`OJQJo(H ^`OJQJo(H ^`OJQJo(oH PP^P`OJQJo(@^`o(- ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(^`o(- TT^T`OJQJo(o $ $ ^$ `OJQJo(   ^ `OJQJo( ^`OJQJo(o ^`OJQJo( dd^d`OJQJo( 44^4`OJQJo(o ^`OJQJo(Z`;<:d{OTC9(erKS <r}RJZeo6U M xR)*|p@ALWj Jg|/(c%         ?G ?G2      8^                        :        ?G        ?G        8^        :        8^         R!#                8^                 ?G ?G      ?G                 ?G        8^        ?G        ?G ?G: ?G    8^        8^        j~yp I > /@P/@@UnknownGz Times New Roman5Symbol3& z Arial?5 z Courier New;Wingdings?Wingdings 3"qhzfETFPl$Nl$N!24d** 3QH(?yp0PRACTICAL ON STERILIZATION METHODS, INJECTIONS &NECUser1l                   Oh+'0  ,8 T ` l x1PRACTICAL ON STERILIZATION METHODS, INJECTIONS &.0RACNECECECNormalAUser1A80rMicrosoft Word 10.0@6u"_@ָ@E@ˮ l$՜.+,0( hp  J'pura UniversitySN*A 1PRACTICAL ON STERILIZATION METHODS, INJECTIONS & Title  !"#$%&'()*+,-./012345679:;<=>?@ABCDEFGHIJKLNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry FPӾ Data 8)1TableMWordDocument]oSummaryInformation(DocumentSummaryInformation8CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q