1 1 страница Тверская государственная медицинская академия РУКОВОДСТВО К ПРАКТИЧЕСКИМ ЗАНЯТИЯМ ПО ОБЩЕМУ УХОДУ ЗА ХИРУРГИЧЕСКИМИ БОЛЬНЫМИ под редакцией доктора медицинских наук профессора Е.М.Мохова Рекомендуется Учебно-методическим объединением по медицинскому и фармацевтическому образованию вузов России в качестве учебного пособия для студентов медицинских вузов Тверь 2006 2 Составители: проф. Е.М.Мохов, проф. И.А.Котов, доц. М.А.Мурадалиев, доц. В.А.Кадыков, канд. мед. наук В.В.Бельшов, А.В.Львов, С.А.Морозов, канд. мед. наук М.Э.Вишняков, канд. мед. наук Э.М.Аскеров Под редакцией доктора медицинских наук профессора Е.М.Мохова Рецензенты: профессор кафедры хирургии Российского государственного медицинского университета В.А.Горский профессор кафедры хирургических болезней Московского государственного медикостоматологического университета Г.С.Рыбаков Руководство к практическим занятиям по общему уходу за хирургическими больными / под редакцией профессора Е.М.Мохова. – Тверь: Издательство 2004, – 000 с. Руководство подготовлено преподавателями кафедры общей хирургии Тверской государственной медицинской академии. Оно отражает специфику ухода за хирургическими больными в лечебных учреждениях, освещая характер и порядок соответствующих действий медицинского персонала. Руководство предназначено для студентов медицинских вузов. Его содержание соответствует программе по общей хирургии с уходом за хирургическими больными, утвержденной Министерством здравоохранения России. Кафедра общей хирургии Тверской государственной медицинской академии 3 3 страница Tver Sate Medical Academy GENERAL CARE THE MANUAL Edited by professor E.M.Mohov The book is recommended by the Educational and Methodological Association on Medical and Pharmaceutical training of Russia as a textbook for students of Medical Higher Educational Institutions Tver 2006 4 4 страница Russian text Authors: E.M.Mohov, MD; I.A.Kotov, MD; M.A.Muradaliev, V.A.Kadykov; F.V.Lvov, S.A.Morozov; M.E.Vishniakov; E.M.Askerov Edited by professor E.M.Mohov Publisher's readers: V.A.Gorsky, professor,MD, Russian State Medical University G.S.Rybakov, professor,MD, Moskow State Medical Stomatologic University English text Adaptation to English and editing: V.A.Kadykov The manual was written by teachers of general surgery department Tver State Medical Academy. It contains data about general care of patients (nursing) in surgical department of medical establishments. The manual is intended for medical students. It content corresponds to official general surgery curriculum of Russian Public Health Ministry. Chapter 1 THE STRUCTURE, EQUIPMENT AND THE ORGANIZATION OF SURGICAL DEPARTMENT. PROPHILAXIS OF HOSPITAL INFECTIONS Surgical department The surgical department is a part of hospital possessing more then 75 places. Usually in ordinary town hospitals there is one surgical department (40-60 places). As a rule in large medical establishments, as a rule, there are several different surgical departments. One of them must be intended for treatment of patients with purulent diseases and purulent postoperative complications. In such kind of hospitals the specialized surgical departments such as: traumatological, urological, cardiovascular surgery, etc also may be created. For fulfillment of surgical operations there is a special complex of premises named a surgery block. There are two systems of allocation of a surgery block: uncentralized and centralized. At the first one each surgical department has separate surgery block, the second – one block for all surgical departments at the same place. The centralized system is preferable for using in the large hospitals having many surgical departments. The upper floor is usually destined for a surgery block. Except surgery block the surgical department has wards for patients, sister posts, dressing, procedural room, a room for enemas, a doctors' room, a cabinet of the head of department, a room of the senior sister, place for sorting and storage of dirty bed-clothes and subjects for cleaning, canteen. In clinics there are rooms of the professor, the senior lecturer, on es for assistants, and educational rooms. Allocation of patients at a surgical hospital is carried out according to character of their disease and their common condition. So in common surgery department there are two parts. Patients with purulent processes must be placed in separate part of department. In the other part the patients after operations without infectious complications and preparing for scheduling operations are allocated. It is done to prevent distribution of infection. Serious patients are placed in one - double wards, isolators. Especially serious patients are situated into reanimation department intended not only for surgical patients, but also for all other patients demanding intensive treatment (see chapter 14). Wards of surgical department are supplied with the functional beds, which allow the patient to take various positions and move easily. Each patient should have a bedside-table for personal things. For patients with a bed care it is desirable to have elevating little tables. It is necessary that wards were supplied with the alarm device to call up the medical personnel. 6 The sister’s post is usually situated in a corridor to provide the proper review of wards. The distance from a post up to the most distant wards should not be more than 27-30 m. The post is equipped with cases for storage of medicines, subjects for patients’ care. Usually on a post there is also a special table with boxes for documentation (sheets of medical assignments, duty magazines, etc.). Also there should be a panel of alarm system with numbers of wards. Dressings are intended for bandagings and other manipulations. In a common surgery department there are 2 dressing: "pure(clean)" and "purulent" which should be in corresponding parts of department. About the organization of work in dressing and a surgery block it will be told below (see chapter 4). Procedure room (treatment room) is a premise where taking of blood from a vein for analyses, intravenous injection of medicinal substances, preparation of systems for transfusions and infusions, blood typing, performance of individual compatibility blood tests are carried out. Procedural room should have the area not less than 15 sq.m., it must be light, supplied with warm and cold water. Walls and floor should be convenient for mechanical cleaning. The procedural equipment are: a case or a table for storage of medicines; drum-boxes with sterile dressings, syringes, needles; systems for intravenous injections; supports for infusions; test tubes for blood; a set for blood group definition; a refrigerator for storage of blood, serums and medicines. The room for enemas - is a special premise for doing enemas. Here it is possible to do also washing of a stomach, a catheterization of a bladder. In a room the couch is put. It is supplied with the corresponding equipment (the device for enemas, Esmarch's irrigator, probes, rubber tubes etc.). In the same room it is expedient to have a separate bathroom with a toilet bowl. Doctors' room - a workplace of doctors where they perform paper work and hold different conferences. The room of the senior sister is usually used not only as her workplace, but also as a room for storage of medicines and other medical products. Therefore except the common furniture there are places for storage narcotic and strong drugs. Other medicines, and also new syringes, needles, probes, catheters and other subjects are in special cases and shelves. The senior sister deals with many important medical documentations. The organization of reception on hospitalization of patients of a surgical structure 7 The first department where the patient directed to hospitalization comes into is the admitting department (reception). In the usual municipal hospital patients with various deceases are admitted to a reception. In the admitting department is carried out survey, reception, registration, sanitary manipulations and transportation of patients. The admission department usually has the following premises: a hall for visiting, cabinets for examination and diagnostics, a room for registration of patients, sanitary room, ward for observation, procedural, dressing, laboratory for emergency analyses, a room for storage of clothes, a cabinet of the head, a duty doctor cabinet, a lavatory. The surgeon examines the patients in a viewing cabinet. If it is necessary to check up the diagnosis the doctor directs to taking blood analysis appoints analyses of blood, urine and other researches or direct the patient to corresponding experts and special researches. Sometimes diagnosis is not clear. In this case patient is placed in a special observation ward for differential diagnostics. Patients is observed and examined during several hours (not more than three) then the doctor comes to a decision. On the basis of the results of examination of a patient the doctor makes this or that diagnosis. In accordance with indications the patient is hospitalized in a common or the specialized surgical department. If indications for hospitalization are not present, the patient is discharged with medical recommendations. The patient can be discharged home and after some medical procedures which are carried out in reception: a cleaning enema, washing of a stomach, bandaging, injections, etc. Bandagings and small operations are carried out in dressing, other medical manipulations - in the treatment room. Principles of equipment and the organization of work dressing and procedural room, as well as in surgical departments also will be described below. Registration of patients is carried out by the medical nurse. Every patient in hospital has the history case (special medical form), the sister fills in the title page of the case record, and write data on the patient in a log-book of admitted patients. If the patient is discharged from a hospital this fact is also put down into the log-book. The patient accepted for treatment into the hospital, passes through a sanitary inspection room. The sanitary inspection room is intended for carrying out of sanitary processing patients. The question of necessity of sanitary processing is solved by the doctor on duty. Comprehensive sanitary processing consists of a hair-cut, cut of the nails, shaving, taking a shower or a hygienic bath. At first patient should be carefully examined on pediculosis (parasitic disease, infestation of lice). At the present time it is not necessary to carry out the comprehensive sanitary manipulations of all patients because the overwhelming majority of admitting patients keeps 8 hygiene. The sanitary manipulation with the patients who are in a severe state and need the emergency surgical help is not carried out. The technique of sanitary manipulations, and also features of the work with severe state patients in a reception are described more detailed in the chapter 11. After sanitary processing the patient change his cloth. The outer clothes of each patient are placed in a separate plastic bag in storage. Bags are marked and placed on special hangers in the certain order. The list of the things is checked and pasted in the history case. Intrahospital infections Intrahospital infections - are infectious diseases and the wound infections acquired by a patient at a hospital in addition to the basic disease, and also diseases of medical personnel appeared because of the treatment and care of infectious patients. The source of intrahospital infection can be the patient carrying pathogenic microorganisms among patients, the personnel, and also visitors of patients. Occurrence of an intrahospital infection is connected with late revealing and isolation of infectious patients in the hospital , underestimation epidemiological anamnesis concerning infectious diseases transferred before at coming patients, wrong placing of patients in wards, non-keeping measures of detection activators of infectious illnesses among patients and the personnel, default of rules of the current and final disinfection, unsatisfactory sanitary processing of patients. To development of an intrahospital infection decrease in resistance of an organism of patients under influence of basic disease, operative intervention, a blood loss, treatment by immunodepressive drugs promote. On taking the patient to a hospital it is necessary to collect exhaustive data about infectious diseases suffered from before (Botkin's illness, etc.) and about contacts with infectious patients. For this purpose can be made laboratory research of excrements, urine, lung phlegm, blood, a smear from a pharunx, etc. to reveal infectious illness and bacterium carriers. Reception to hospital patients with suspicion on infectious illness or being in contact to infectious patients is performed at isolating wards of admission department. Epidemic trouble is especially concerning air - i.e. drop infections (flu), visiting patients is forbidden. The particular place among intrahospital infections belongs to virus hepatitis B, C, D and HIV In prophylaxis of this disease the extremely careful processing of reusable syringes and needles has great value. In a surgical departments there are specific conditions for occurrence of intrahospital infections, having a strong character. Wounds of surgical patients are an open gate for infections. 9 Modern intrahospital infections in surgical clinics are shown basically by a syndrome of suppurations and septic defeats. There are various agents of purulent infection: staphylococci, streptococci, Proteus, E. coli, bacteria of blue-green pus, etc. Infection agents of gas gangrene are especially dangerous. Sources of pathogenic microorganisms in surgical hospitals are the patients with chronic infection, trophic ulcers, purulent wounds, tracheostomy, colon fistulas, etc. The certain value in occurrence of intrahospital infections is given to the medical and paramedical personnel who can carry pathogenic microorganisms. There are some ways of distribution of intrahospital infections inside the surgical departments: air - drop, contact and implantational ways. Infection is especially dangerous for patients with major defects of integument (burns, scalped wounds, frostbites). The complex of measures to prevent microbes invasion in an operational wound is called an aseptic. Prophilaxis of an intrahospital infection in surgical department base on rules of aseptic. For reduction of air pollution in operational and dressing the medical staff should have special surgical masks, aprons and bootee. There are ultra-violet lamps for disinfection air. For prophilaxis of a contact infection it is necessary to apply special methods of washing hands before operation and an operational field of patient. At operations and bandagings it is necessary to exclude completely an opportunity of microbes’ contamination of wounds from tools, cotton and bandaging. So before to use this things are exposed to sterilization, i.e. full clearing of microbes and their spores. Sterilization in medical establishment is carried out with the help of steam sterilizers, dry heat sterilizers and other methods. With the purpose of prophilaxis of implantational infection all suture materials and endoprosthesises are subjected to sterilization by hard radiation or gas at the factories. An effective measure of prevention of hospital infection is application medical products of disposable using (syringes, needles, infusions sets, intubation tubes, etc.). The correct organization of carrying out the operations and bandagings has great value. Expansion of isolated purulent departments or, at least, presence of separate dressing, "clean" and "purulent", and also discharges of special sisters and doctors for work only with infected patients is the most expedient. Chapter 2. CLINICAL HYGIENE AND RULES OF BEHAVIOUR OF THE MEDICAL PERSONNEL IN SURGICAL DEPARTMENT Hygiene is a part of a medical science which studies influence of life conditions on health of the person. Hygiene solves the following problems: - sanitation of the environment (protection of ground, water and air); 10 - prevention of infectious illnesses; - Creation of the sanitary legislation. The part of hygiene developing specifications and the requirements, directed on maintenance of optimum conditions for treatment of patients and work of medical workers in hospitals refers to as clinical hygiene. Care of patients is based on positions of clinical hygiene. An integral part of the last is the clinical hygiene of the medical personnel. One developing from set of factors among which the most value have hygiene of a nutrition, hygiene of work, personal hygiene, hygiene of clothes. Hygiene of a feed Hygiene of a feed as a part of the common hygiene studies all aspects directly connected to a feed. The primary problem of nutrition hygiene is the scientific basis of the optimum feed. All physical actions and biological processes of the organism use his power resources. Power inputs of people of different trades vary in limits from 3000 up to 5000 kcal/day. Medical workers power inputs on the average are about 3000 kcal/day. For reception of such quantity of power resources it is necessary, that a diet includes: proteins - 118 g, fats - 56 g, carbohydrates – 500 g. Rational and balanced nutrition is determined not only structure of food, but also distribution of daily diet and intervals between meals. Power inputs are high in an operating time. Therefore dinner should take 45-50 % of daily caloric content. For a breakfast should have about 30-35 %, for a supper - 15-20 %. For the personnel working during night and evening time, the breakfast in volume of 25-30 % of daily caloric content, a dinner (2-2,5 hours prior to work) - 40-45 %, a supper - 20 % is recommended. Intervals between breakfast, dinner and supper should not be more than 6-7 hours. The "hungry" secretion stimulates intestine peristalsis with unpleasant sensations otherwise begins. At a four-times meal intervals between receptions should be 4 - 4,5 hours. Changes of a diet result in infringement of the established rhythm of work of a digestive tract. The set of necessary products is developed on the basis of human physiological requirements for various food substances, in view of nutritional value of foodstuff and influence on their structure of culinary processing. It is necessary to take into account also, that food rate value of vegetable products is lower, than products of animal origin. Mixed food is better than separate foodstuff is assimilated. Vitaminization of a feed has great value. The better way is use vitamin-rich foodstuff then artificial vitaminization. Natural vitamins are in a complex with other nutrients that provides their good assimilation. 11 The food factor has important role in development of diseases. Especially frequently it appear on the background of alimentary insufficiency. The person in this case becomes easily susceptible to infectious diseases and unstable to influence of adverse factors of an environment. Alimentary insufficiency (malnutrition) can be caused: - The use of low-calorie, defective food; - Insufficient quantity of food; - Bad assimilation of food substances in a gastroenteric tract; - Infringement of metabolic processes; - Increase in allocation of food substances; - Blocking food substances by antimetabolic substances. For normal physiological processes the water and salt metabolism is very important. Its infringement is result of some pathological syndromes. As an example can be potassium deficiency калия shown as a nausea, muscular weakness, depression, hart problems. In medical establishment normal conditions for nutrition of medical personnel should be created. Hygiene of work Hygiene of work, or professional hygiene studies labour activity of the person and surrounding industrial environment from the point of view of their possible influence on an organism, develops hygienic specifications and actions which purpose of favorable working conditions. Hygiene of work of medical workers investigates influence on an organism of physical, chemical and mental factors of the environment, develops hygienic specifications of the environment (bacterial contamination of operation block, dressings, wards, etc.), studies labour processes and generate physiological, physiological and pathological alterations in an organism, develops a rational mode of work and rest. For the personnel of surgical department the six-hour working day is established. The staff of radiological departments have the five-hour working day, the four-hour working day is established to medical staff in radiation-activity zones. In such way it is possible to achieve increase in labour productivity and at the same time preservation of health of employees. Hygiene of work of the medical personnel depends and on conditions of water supply, the water drain, illumination, heating, etc. Water has important hygienic role but can be source of infectious diseases. The waterway of distribution is most typical for cholera, typhoid, dysentery, hepatitis A. The state of health is influenced by mineral structure of water. For example, lack of iodine causes development of goitre, lack of fluorine promotes development of caries, etc. 12 Personal hygiene Personal hygiene is the branch of common hygiene studying questions of preservation of human health by observance of a hygienic mode of life and activity. To personal hygiene carry the hygienic conditions of a body, linen, clothes, footwear, bed-clothes, kitchen utensils. Rules of personal hygiene of the medical personnel have the specific character connected to character of theirs activity. Special importance for the medical worker has the clean integuments. A minimum the washing of a body once a week is necessary to carry out. Especially careful care should be carried out hands. It is necessary to wash hands before and after manipulations, before and after contact with patient, before reception of food. The medical staff should preserve hands against pollution during all time of day. Nails should be shortly cut. For preventive of hands skin dryness it is necessary to grease it with creams. All dangerous manipulation must be performed with rubber gloves (injections, infusions, bandagings). After contact with infected patients (or suspicious) it should wash hands with antiseptic (for ex. alcohol). It is necessary to watch carefully hygienic condition of hair. Hair accumulate a dust and together with it a plenty of microflora. In surgical department there is a danger of wound contamination by this microflora. Therefore hair should pure, brushed. Care of an oral cavity is carried out with usual way. The medical staff should be undergone the dispensary supervision providing carrying out of routine inspections once in half-year. Hygiene of clothes Clothes and footwear of medical personnel have great important for normal work. In hospital departments it must not be in usual footwear you walk along the street. Hygienic regimen of medical departments demand of this fact. Therefore in medical establishments there is a necessity of carrying of replaceable footwear. These are usual shoes or slippers which the medical personnel of surgical department puts on only in work time. It is the best way to have leather (plastic) replaceable footwear. It must not wear in department felt or woolen slippers as these materials usually strongly become soiled microbes. In the operation theatre visitors must put on cover on slippers (cotton or plastic). In an operating time in operation block and dressing medical personnel must use masks. Improvising masks are made of 4-6 layers of a gauze is more often. Masks of disposable using are issued by the medical industry. Mask should close mouth and nose completely. In such a way the personnel protects wounds of patients from hit of microbes during cough and conversation. 13 Protection appears insufficient at presence at the worker of a respiratory infection, therefore the personnel with acute respiratory diseases is not supposed to work in operational. The basic kind of working clothes of the personnel of surgical department is the medical dressing gown. It is intended for protection of personal clothes against pollution. Dressing gownes are made cotton. There are two types dressing gownes: surgical which are fastened behind, and therapeutic, fastened in front. Sleeves should be short or rolling up. Any decorations on dressing gownes it is not supposed. The dressing gown should be fastened well (not wide open). Instead of a dressing gown it is possible to use a working medical suit from a cotton fabric. Medical workers in surgical department must has also caps covering hair on a head. All medical cloth are stored separately from personal clothes. In surgical department it is not necessary to carry woolen things are capable to accumulate infection and are the source of dust. In dressings and operation theatres with a view of the prevention of infectious pollution of special and personal clothes the personnel use plastic aprons, rubber gloves which after work are disinfected. Carriage of bacilli Carriage of bacilli is a preservation in an organism of the person and allocation in an environment of infecting agents without seen clinical display of disease. In surgical department bacilli carriers purulent microorganisms (staphylococcus, streptococcus, E.coli, etc.) there can be doctors, medical sisters, nurses. At carriers infecting agents are allocated through the same organs and systems, as at obviously expressed clinical forms of disease, for example, at intestinal infections infecting agents are allocated with excrements, at air drop infections - through respiratory ways. Distinguish three categories of bacilli carriers: 1) not was ill in the past; 2) had been ill and becoming after that carriers; 3) got immunity after the transferred illness in the past and becoming carriers as a result of new infection. Bacilli carriers are a potential source of infection. Bacilli carriers among hospital personnel can become the causal factor of mass infections of patients. For preventive transmission of infection medical personnel must undergo periodically examinations. Deontology Medical deontology is a set of ethical standards and behaviour principles of the medical staff at performance of the professional duties. Medical deontology defines rules and forms of mutual relations of the doctor with patients, their relatives, with colleagues. 14 The main point of medical personnel have to care of sick person, attentiveness, readiness to help. The sensitive, attentive and accurate person can carry out these duties only. Personnel relations with the patient are based on mutual respect. The great value has skill to have a conversation with the patient. Tone of conversation should be quiet, convincing. Patients should be named only by name or to use the impersonal polite address. At questions on the diagnosis and the mechanism of action of medical drugs it is necessary to send patients to the attending physician to exclude possible contradictions which can undermine trust of the patient to medical staff. At realization of actions on care to demonstrate squeamishness and neglect to the patient are not allowable. Relations of medical personnel among themselves also have important value. Precise observance of a subordination here is necessary. So duty sister should submit directly to the senior sister and the intern or the doctor on duty. All workers of department should concern to each other benevolently. It is impossible to do sharp remarks on work at the presence of patients. All professional conversations must be in doctors room only. Patient listen doctor and sister talking aiways and can do mistaken interpretation their words. Rather important also the correct contact of the medical personnel with relatives of the patient. Dialogue with them should be under construction on the basis of mutual interest. Chapter 3 CLINICAL HYGIENE OF THE ENVIRONMENT AT SURGICAL DEPARTMENT Environment is the physical, chemical, biological and psychological factors having influence on patients at surgical department during fulfillment of medical actions. These factors are: air volume, air temperature, humidity, air moving, dust, smells, air bacterial contamination, noise and other. About surgical wards It is not recommended to create ward more than on 5 - 6 person. The optimum number of beds in many-placed wards is 4. According to hygienic rules 25 m3 of air should be provided to each adult patient. It is achieved by the area of 7 m2 on one bed at height of a room of 3,5 m. Now many hygienists consider, that the air volume in wards should be within the limits of 40-50 m3 for one patient. Such air volume allows supporting cleanliness and optimum qualitative structure of air. Small chambers are most convenient. In a department it is necessarily to have some wards for one place. 15 The basic parameters of air condition of surgical department Carbonic gas. In premises the contents of carbonic gas is regulated and should not exceed 0,1 %. Falling of its concentration in air is not dangerous, increasing – exerts influence on a person. A plenty of carbonic gas in air of rooms is the proove of their high pollution. Temperature. The important value has maintenance of optimal temperature at surgical department. Heat exchange is one of the basic functions of the human organism. As it is well known the temperature of human body is constant and organism is very sensitive to change of air temperature. Optimal temperature in rooms has to be 18 – 20ºC. Very high air temperature is supplementary load for cardiovascular and respiratory system and may cause the worse feeling of a patient after operations. On the contrary low air temperature may cause a common cold and epidemic situation. And surely common cold burden condition of patients especially after operations. High body temperature can dissemble postoperative complications. Humidity. In atmospheric air there is always some water vapours. Humidity of air influences an organism of the person as: - high humidity of low temperature air raises thermal output; - high humidity of high temperature air complicates thermal output; - low humidity of air having rather low temperature, does not render appreciable influence on health state of a person; - low humidity of high temperature air has an adverse effect on health state of a person, raises loss of moisture by an organism, causes dryness of mucous membranes of the top respiratory ways, dry cough, woolly voice. Movement of air. Except the temperature and humidity the movement of air also influences on heat exchange. Speed of air movement less than 1 m/s is not appreciated by a person. Organism of the patients and furthermore postoperative patients, reacts sensitively on changes of temperature, humidity, movement of air. It is especially sensitive to sudden cooling, draughts. The optimum combination of temperature, humidity and speed of air movement is named a zone of comfort. This optimum combination of parameters cause the best state of health (a condition of thermal balance): air temperature in wards about 20 ° (optimum for patients), speed of air movement about 0,5 m/s and humidity should be 55-65 %. Dust. In atmospheric air of the closed premises there is always a dust. Concentration of a dust in the bottom layers of atmosphere changes in very wide limits: from 0,01 mg/m3 up to tens milligrams on 1m3. During breathing the parts of dust remain in respiratory ways. Some of them settle on the mucous membranes of trachea and bronchial tubes and are released from an organism by action of vibrating epithelium and cough. The parts of dust (finest particles) 16 penetrate into alveoli. In alveoli the parts of motes are exposed to phagocytosis by leukocytes and epithelium cells (epithelium of respiratory bubbles, another - is enveloped by lung phlegm and then released from an organism. Not all kinds of dust particles are equally exposed to phagocytosis by phagocytes. Some part of dust remain in lungs forever. High dust concentration in medical premises isn't allow. Dust can irritate mucosal membranes (of eyes, nose), can cause acute conditions of chronic respiratory diseases. But this is not the main point. Air dust contains a lot of microorganisms (bacteria, viruses, spores, fungi). This dust with microorganisms settles down on a surface and is transferred with air steam. A source of pathogenic microorganisms in air of the closed rooms are the saliva exuded at conversation and cough and bacilli carriers. It is known, that at sneezing about 40 000 drops are formed and an absolutely healthy person exuded in air about 10 000 - 20 000 microbes. Splashes of a liquid at cough, sneezing, conversation can scatter on distance in some meters (so, drops in diameter of 1 mm are scattered in air to distance up to 11 m). Drops of saliva stay in air for a long time period (some hours). Drops of saliva with microorganisms on the floor and other surfaces dry up and can rise up with dust on air. It is necessary to remember, that such microorganisms as staphylococcus, diphtheritic bacillus, tubercular mycobacterium keep viability, being in a dust for tens years. Smells. Smells can influence on the state of health and mood of patients. The person is capable to distinguish up to 10 000 various smells. The source of unpleasant smells in wards may be patients with intestinal and urinal fistulas, with purulent processes, gangrenes and other. Especially it is necessary to tell about harmful influence of tobacco smoking on an organism. On a tobacco smoking there are many strong cancerogenic substances (3,4benzpyren). The harmful influence of smoking on state of lungs, hearts, stomach, vessels is proved. Optimum conditions in surgical department For the prevention of environmental contamination in wards, halls, corridors of surgical department there is a number of rules, which must be kept by medical staff, patients and their visitors. There is a specific system of cleaning premises of surgical department. Only wet cleaning must be done. Kinds of cleaning of surgical wards are a planned, general and current cleaning. Planned cleaning is carried out two times a day. It is recommended to wash the floor with water with detergents and sodium carbonate and after washing to wipe it twice with a damp cloth. Walls up to height of extended hand, windows, window-sills, heating radiators, doors are wiped with wet cloth (water with detergents, hydrate of sodium, liquid ammonia 0,5%) and then 17 with dry cloth. The process of bed cleaning, bedside-tables, tables, chairs, cases is the same. In wards for patients with purulent-septic diseases and postoperative purulent complications a daily cleaning is carried out with obligatory using of disinfectants. General cleaning of wards is performed once a week. A floor, windows, ceiling, walls, beds, furniture and all equipment is washed by disinfectants (3% chloramine solution, 0,5% bleach solution, 0,2% desoxone solution, the mix of 3% hydrogen peroxide and 0,5% a solution of detergent powder). The last mixture does not damage wooden and metal things which are necessary to wipe up to dryness after processing. Now there are many modern disinfectants for surfaces (for example "Septopole", "Javelion", "Presept", "Perform" and so on, see appendix). The furniture with a covering from fabrics is processed with 3% solution of formaldehyde. A current cleaning of floor is performed after bandaging of patients during working day, change of drainages and bed-clothes is necessary, at pollution of floor during those or other manipulations. Such cleaning is especially important in wards for purulent patients. The current cleaning is usually carried out only within the limits of the area which was polluted. After discharging the patients a proper cleaning with the disinfectants of their beds and bedside-table must take place. For a period of cleaning the patients, as a rule, leave the ward. If there are bed case patients, it is necessary to take certain measures: to cover with a towel, sheet or to move a bed from that place to wipe a ceiling, floor or walls. To begin cleaning it is necessary with bedsidetables. It is necessary to dust them. Then it is necessary to dust window-sills, plafonds, beds and other furniture. It is necessary to keep quiet, actions of junior medical staff should not disturb patients. During cleaning it is necessary to open ventilation panes and to air ward but so that there were no drafts. The special attention is given to cleaning the sanitary-engineering equipment. Cleaning of bathrooms should be carried out daily with using disinfectants. Baths, washstands, urinals, bidet, lavatory pan can be processed with the help available modern detergents and disinfectants. It is possible to apply also 1% chloramines, 0,75% chloramines plus 0,5% detergents, 3% hydrogen peroxide plus 0,5% detergents and others (sulfochlorantines, dichlor-1, "Alaminol", "Vapusan"). A toilet should be aired carefully. Brushes and other implements are disinfected by 2% bleach, 1% chloramines, 0,2% sulfochlorantines, 2% dichlor before cleaning the other disinfectants also can be used (see appendix). The cleaning inventory is marked strictly according to the assignment (they are marked: "for cleaning corridors", "for processing toilets" etc.). The marked cleaning inventory is kept in 18 established places and used only according direction. Its usage for the other purposes or cleaning other premises is forbidden. To prevent penetration of infection in wards, especially at purulent department, bactericidal ultra-violet lamps (portable or stationary) are applied. Lamps have to be switched on for 30-40 minutes with breaks not less than 2-3 hours. Inclusion of one lamp during 10-15 minutes reduces number of bacteria in air on 70-80 %. Action radius of ultra-violet lamps is 2-3 m on the average. Ultra-violet irradiation exert bad influence on people’s eyes. During this procedure patients and personal must leave the ward. About ventilation. Two basic systems of air ventilation are applied: natural and artificial. The natural ventilation which is carried out through window, ventilation panes, transoms is more distributed nowdays. The full exchange of air should takes place 4-6 times in an hour. For this purpose the most acceptable is often through airing of chambers (for 10-15 minutes). Artificial ventilation (with different blowers and air-conditioners) is the most effective. Air-conditioner not only provides an exchange of air, but also keeps the temperature and humidity. Artificial ventilation allows to create optimum air exchange in wards, i.e. an exchange of air in volume of 40 m3 in hour on one bed. Such ventilation is especially necessary in postoperative wards (in ward of intensive therapy), and also in burn departments. It is preferable that visitors visit only bed case patients in wards. The bulk of visitors should communicate with patients in halls, in special rooms (see chapter 8). In surgical department it is forbidden to smoke. It was spoken above about the influence of smells. Main sources of unpleasant smells are patients with intestinal fistulas, the purulent and putrid infection. For prevention of unpleasant smells it is necessary to care about this patients carefully (washing, change bandages, change bed-cloth, airing and deodorization). Protection of patients against excessive noise has important value. The degree of intensity noise in hospital depends directly on work and behavior of the personnel. Medical workers should talk in a low voice. It is not necessary to clap the doors, to rattle utensils and cleaning tools. It is necessary to eliminate possible negative emotions in patients which can be caused by sight of medical care subjects (blood pieces of a gauze, syringes and scalpels with traces of blood, basins with dirty bandage and cotton etc.). Chapter 4 19 SANITARY-AND-HYGIENIC MODE IN DRESSING AND THE OPERATIONAL BLOCK. Dressing in surgical department are intended to perform the bandaging and some other manipulations to the patents. It is a measure of prevention of purulent infection distribution in the surgical department there are two dressings: "clean" and "purulent". For dressing with one table the area of 20-22 m2 is provided. The dressing floor and walls should be cover with a tile. The ceiling must be painted with an oil-colour. This measure is done to diminish the dirt and be easily washed with disinfecting substances. Colour of floor, walls and ceiling should be tender, it may be white or with green, blue tinctures. Usually in dressing the bactericidal ultra-violet lamp is present. This lamp is switched on after bandagings to kill microbes in the air. The equipment of the dressing room are: operational universal table common sterilized table (table for sterile instruments and dressings) small tool and dressing table for direct dressing job supports for drum sterilized boxes glass cases for drugs overhead light tanks (vessels, plastic cases) for chemical disinfection of instruments, gloves, cottons and so on. certain sets for wound treatment (for example lasers) In each dressings one special dressing sister works. She prepares a patient for dressing, sterile table, helps to the doctor (gives tools, applies bandages and so on), keeps up the order in dressing, carries out its cleaning. The cleaning is carried out by the same rules, as in operational theatre (see below). Type of work in "clean" dressing: dressing of patient with clean wounds punctures and drainages of pleural cavity novocain blockades puncture biopsy primary treatment of wounds Type of work in "purulent" dressing: dressing of patient with purulent wounds opening of suppurative processes (abscesses, phlegmons) 20 drainages of purulent cavities small amputations (for example fingers) necrectomies In small departments sometimes there is only one dressing. In this case patients after operations with clean wounds are dressed in the first turn and only then - the patients with purulent processes and postoperative purulent complications. The operational block is placed separately from wards. The best conditions may be created in the separate premise connected with the basic bulk by a transition or the lift and connected to resuscitation unit. The modern operational block should include operational theatres, preoperative, sterilizing, material, an equipment room, rooms for medical staff. Every operational theatre should have one operational table. Its area should make up 36-48 m2 at the height of room not less than 3,5 m. It’s expediently even in the rather small departments to have separate operational for emergency and for purulent operations. The operational block is among the premises with the limited access. For maintenance of sterility in the operational block 4 zones are allocated: - zone of a sterile mode (operational, preoperative, sterilizing) - zone of a strict mode (rooms for storage of tools and devices, rooms for the personnel) - zone of the limited mode (technical zone for technical equipment) - zone of the common mode (cabinets of the head, the senior sister, a room for dirty operational cloth, etc.). The ceiling, floor and walls of an operational theatre should rounded to pass each other, to avoid congestions of a dust in the corners and to facilitate cleaning. A ceiling must be painted with white oil-colour, walls and floor are covered with tile. In operational it is necessary to have big light windows focused on the north. The capital equipment operational are: an operational table overhead lamp mobile lamp big sterilized table mobile sterilized table for particular operation special tables (glass or stainless steel) for drugs, antiseptics, suture materials suction apparatus apparatus for artificial ventilation of the lung anesthetic apparatus anesthetic table 21 supports for infusion sets other equipment (diathermy apparatus, lasers, laparoscopic sets, etc.) Preoperative room is destined for preparation of the personnel before an operation. It must be in an adjacent room with an operational theatre. A ceiling, walls and a floor are done the same as in operational theatre. In preoperative place 2-3 washstands with cranes which may be opened with an elbow. On a table drum boxes with sterile brushes, napkins, masks are placed. In this room surgeons and sisters wash hands and take in plastic aprons, masks, caps. The operational brigade uses sterile masks and sterile dressing gowns. In material room spirit, gloves, surgical tools and products of medical assignment are kept. Sterilizing it is intended for disinfection, presterilizing clearing and sterilization of products of medical assignment. In the majority of modern hospitals there are available centralized sterilizing, therefore in the operational block only metal tools with the help of dry heat sterilizers are treated. For diminishing the risk of pollution of operational block the persons from outside must not be allowed. There are some simple rules of students behavior in operational theatre. Students must put on medical masks in a corridor and the bootee they have to put on at a preoperative room. Students must not have wool cloth under apron. Long hair must be hidden under cap. In the operational theatre there must not be any divagation, talks and noise. It is not allowed to come in and out very often. Students must take allocation in a specified place. They do not allow to touche operational sheets, doctors gowns and especial operational table. It is disallow to pick up instruments or cotton fallen down on the floor. Students must get off bootee before to come out thw operational block. Cleaning of operational block. is made by damp way (1 % Chloramin, 3 % peroxide of hydrogen from 0,5 % of washing-up liquids, 0,2 % dezoxon-1 and dezoxon -4, 2 % dichloramine-1, alaminol, vapusan, lysaphin etc.: There are following kinds of operational block cleaning: - the current cleaning during operation (nurse select napkins fallen on the floor, tools and wipe the soiled floor); - cleaning after operation; it provides cleanliness of an operational hall before the following patient; - daily cleaning at the end of operational day (wash a floor and walls on height of human growth); - the general cleaning is made under the plan weekly (wash all operational theatre including the ceiling, walls, floor, furniture, etc.); 22 - preliminary cleaning (before to start the work , the horizontal surfaces are wiped). For disinfection of air bactericidal ultra-violet lamps are used. They are placed along walls at height not less than 2 m from a floor or hung to a ceiling. Each lamp makes around a sterile zone in diameter about 2-3 m. After 2-3 hours of work the bactericidal lamps work the contamination of decrease microbes in air on 50-80 %. Ventilation operational is carried out by installations of air conditioning with antimicrobic filters. Cleared air moves in operational under small pressure (air affluent) that is why the air from the nearest rooms does not come. The temperature in operational should not be higher than24°C, optimum humidity of air of 50-65 %. There are so called especially clean operations (transplantation of organs, implantation of valves of heart). For this operations operational theatre with laminar (vertical or horizontal) a stream of sterile air are used. Thus it is required to provide a laminar stream with an exchange of air up to 500 times at one time. Number of microorganisms in such operational is reduced in ten times in comparison with those in standard operational, supplied with conditioners. The vertical stream of air is the best. Also there are special equipment for operational brigade. It is so called body exhaust systems. This set include special isolating suit with helmet under which the fresh air is moved. For especially difficult operations on organs of blood circulation special hyperbaric oxygenation operational theatres are created. Chapter 5 SAFETY ENGINEERING OF CARE IN SURGICAL DEPARTMENT AND THE ROLE OF THE AVERAGE AND PREVENTIVE OF IATROGENIC DESEASES Safety engineering at work with the medical facilities Safety engineering – is a complex of actions and means providing healthy and safe working conditions. In medical practice only the standard technical equipment should be applied. To operate with the medical techniques the specially trained and certificated personnel which state of health supposes performance of the specified works are permitted. Before starting work the personnel has a briefing that is registered in a log-book. In a room where the medical techniques is used, there must be papers with service regulations. The personnel should be provided with protective facilities. 23 More often the incorrect manipulations with devices results in defeat by an electric current. It is necessary to watch correctness of electrical apparatus constantly. Connection and shutdown of equipment has to be fulfilled according to instructions. It is forbidden to demount apparatus or to remove the protective details. Maintenance of devices should be provided by special technical personnel. There are medical apparatus with high voltage: surgical diathermic coagulation devices, defibrillators. These tools must be apply only by specially trained staff. We ought to be cautious when applying the laser technique also. Laser shaft is dangerous for eyes, therefore it is necessary to have protective eye-glass. The contact with light of surgical laser (destruction of tissue) is not allowed. It is necessary to remember that the light of some laser types can be invisible (for example at CO2-laser). The prevention of fires and explosions In medical establishments there is always danger of fire accidents. There is a great number of flammable substances, a plenty of electrical equipment which increases this danger. The principal causes of fires are: - infringements of standing order, - incorrect service of electric devices. To prevent fires it is necessary to follow the rules. All hospital rooms should be equipped with automatic alarm system. Alarm console should be in the reception. The cause of fires may be smoking. Smoking in wards must be strictly prohibited. For smoking it is necessary to allocate a special place (it is a toilet more often), equipped with ashbin and fire extinguishers. In department it is forbidden to use heaters (for example, boil devices). Patients must not use home-made heaters. For needs of patients the hospital administration should provide special stationary equipment for quick boiling of water. The fire in ward can arise at misuse wall and table lamps. It is unallowable to cover those lamps with inflammable material (a newspaper, a napkin, etc.) sometimes it is used to decrease light the intensity of light. Dirty bed-cloth, mattresses, pillows, etc. must be kept in the places not accessible to patients and visitors. In the department all used electric equipment: sockets, switchboards, refrigerators, TVs, etc should always be ready to expluatation. 24 If you apply narcosis with ether it is necessary to remember about the possibility of explosions in operation theatre. At the presence of open fire (sparks of static electricity or electrical tools) ether and oxygen compositions can detonate. However suchlike accident can occur only if this composition is accrued in closed space (for example because of ether blowing). Modern construction of anesthetic apparatus practically excludes such accidents. For prevention of the grave consequences of fires in medical establishments there are certain rules: - keys from all closed rooms and exits from department should be kept in certain places known to the personnel on duty; - exits should not be blocked by any furniture or other objects; - in department it is necessary to have emergency sources of illumination; - fire extinguishers and fireplugs must be in accessible places; - in department should hung out (in corridors) schemes of the patients’ evacuation; At occurrence of a fire the junior medical personnel inform the duty doctor and call up the fire brigade. Further the doctor makes a decision either to evacuate patients from department, or to try to liquidate the fire focus with the help of staff. If there is necessity of evacuation all exits of the department are opened. Patients who can walk should specify the way of evacuation. Bed patients are evacuated on stretchers. It is necessary to know that using lifts at fires is impossible. Prevention of the medical personnel from microbic contamination, allergic diseases and chemical damages On the workplace the medical staff can be exposed to influence of various adverse factors of the environment. In surgical department these factors are: patients with contagious forms of infection (purulent, anaerobic); pathogenic microorganisms pollution of rooms and equipment; contact to different drugs and other chemical substances (agents for cleaning of rooms, processing of tools and other products of medical purpose). The medical worker should remember rules of his personal hygiene, cloth hygiene. High air bacterial contamination of surgical department may be the cause of microbic damages. Hygienic rates of microbic contents in the air are (in brackets for winter): microorganisms in 1m3 – 1500 (4500); hemolytic staphylococcus in 1m3 – 24 (52); hemolytic streptococcus in 1m3 – 16 (36). 25 Content of bacterial air may be reduced with the help of a regular wet cleaning and other measures (see chapter 3). All medical actions must be performed in rubber gloves. This concerns to dressings, injections, infusions, transfusions, blood taking for analyses, etc. Aprons (surgical coat, whites) and mask are also preventing cloth. In dressings, before to start the work the doctor should change his surgical coat on another designed for dressings. Sometimes it is necessary to put on plastic apron preservative from pus and blood pollution. During operations it is expedient to apply special tools for face protection. It can be plastic shields, spectacles. It is well-known that the most dangerous is the blood transmitting infections: hepatitis B, C; HIV; syphilis. Skin injuries during operations or care can be the cause of severe diseases. HIV and hepatitis prophylaxis rules are: in skin injuries it is necessary to get off the gloves immediately and try to squeeze out the blood under the flowing water; to wash skin with the soap and process by spirit; to paint wound with iodine; when the blood gets on the eye mucosa it must be washed immediately with water and then with solution of boric acid (1%); when blood gets on in hit of blood (and other infectious material) on skin it is necessary to remove one by a cotton with 70% spirit or 5% iodine and then to wash skin with flowing waters. If there is an injury by HIV-infected tool it must be made emergency (in the same day, during the first hours) chemoprophylaxis with special antivirus drugs. After 72 hours chemoprophylaxis is useless. Except gloves safety measures are the common medical cloth: changeable dress, cotton aprons, caps, masks. It is necessary to keep all this cloth separately in special box. Tools and other products of medical assignment after using are necessarily disinfected. Right after using the tools are immersed into disinfectant solutions (chloramine, hydrogen peroxide, desoxone, “Alaminol”, “Vapusan”, etc.). Disposable tools are removed after disinfection. Other tools are washed and then presterilisation preparation are carried out. This preparation includes: - soaking in a washing solution; - washing in a washing solution with brush; - washing in water; - washing in distilled water; - drying by hot air at temperature 85 ° before full disappearance of a moisture. 26 Premises for steep of operation sheets and napkins, for presterilization cleaning of tools have to be equipped with combined extract and input ventilation. Prepackaging and preparation of disinfectants it carried out in the exhaust hoods or, at least, in well ventilated rooms. All job with disinfectants is done with rubber gloves and, perhaps, in protective spectacles, masks, respirators. Sequence of washing and disinfection must be kept strictly. It is necessary to keep all solutions in a tight closed vessels. At infringement of an operating mode with disinfectants, non-observance of safety measures and in emergencies the personnel may get general and local poisoning. Chemical solutions can get to skin, eyes, respiratory ways and to stomach. First aid at hit of a disinfectant on a skin is lavish washing the skin with pure water. At defeat by formaldehyde it is better to wash the skin with 5 % solution of liquid ammonia. First aid at a poisoning through respiratory ways consists in immediate removal of the victim from the room into the fresh air or into a well aired room. It is necessary to rinse a mouth and a nasopharynx with water. In case of poisoning with formaldehyde vapors inhalation of water vapors with several drops of liquid ammonia is applied. At hit of a disinfectant or other substance in eyes, 2% solution of soda is necessary to wash out the eyes immediately. First aid at hit of a disinfectant into stomach is washing one with pure water with the use of gastric tube (probe) and Jane's syringe. If chlorine disinfectants get into the stomach it is washed out with 2% hyposulphite and 5-15 drops of liquid ammonia with water, milk, soda inside. At the casual intake of formaldehyde washing of stomach with water and liquid ammonia is usually helpful. Allergic aspects. Various medical drugs and disinfectants can be the cause of allergic reactions and diseases. An allergy - is a condition of the changed immunologic activity of an organism due to increase of his sensitivity repeated influences on any agents. The substance causing an allergy, refers to an allergen. Allergic diseases are the pathological processes when the basis of development is the damage of tissues caused by immune reactions. Allergens may be in air, on medical tools. The iatrogenic pathology Iatrogenic diseases are the diseases which arise at patients as consequence of the preventive, diagnostic and medical actions which are carried out by doctors and other medical workers. In other words, Iatrogenic diseases present any harm or the damage done by medical workers without malicious intention to the patient. Cases of iatrogenic diseases happen due to the actions and behaviour of the average and junior medical personnel not so rare (including during care of patients). 27 To the number of iatrogenic diseases which occur due to the activity of the junior medical personnel, postinjection abscesses belong. Abscess - is the limited suppurative inflammation in tissues. As well as the other purulent processes, abscess is caused by pyogenic bacteria (staphylococcuses, streptococci, etc.). This agent gets into the tissues during the performance of intramuscular or hypodermic injections. It may happen, if the personal uses bad sterilized tools (syringes and needles), injection place is badly prepare and breaks the rules of injections. The cause of postinjection abscess occurrence can be incorrect skin care of the surgical patient. Defects in heavy patients care who are taking place on a confinement to bed, may be the cause of decubital ulcers (bedsores). Decubital ulcer (bedsore) is necrosis of skin and deeper soft tissues, arising at the lying weakened patients on the places, exposed to constant pressure. More often decubital ulcers are formed on sites of a body where the skin adjoins to bone prominences. At the position on a back decubital ulcers usually arise in the fields of the sacrum, spinous process of vertebras, scapulas, heels, elbows and back of the head. To formation of decubital ulcers the dirty wet skin and bed-cloth promote. At first there is redness (hyperemia) of skin, then on this site there are purulent bubbles. Bubbles burst, therefore papillary layer of the skin is exposed. Then mortification all skin thickness and underlying tissues occurs. The purulent infection always joins. Prevention of decubital ulcers is: - the main action is regularly (each 1-2 hours) to change position of the patient; - patient's skin must be clean and dry; - tidy bed (absence of folds, dry and clean sheets, absence of garbage on sheet); - it is obligatory to wipe the skin with solutions of camphoric spirits (1%), salicylic acid (1-2%) or special ointments; - body massage; - immediate washing of body after defecation or urination; - using rubber pneumatic rings and antidecubital mattresses. Iatrogenic damages are possible at a catheterization of a bladder, gastric intubation and enema. In such cases injures of urethra, gullet or rectum correspondingly by catheters and rigid tubes may appear. To avoid such complications, it is necessary to possess good techniques to these manipulations and to adhere the rules and sequence of performance of corresponding techniques strictly. Various tube drainages are used insurgery practice very often. Medical personnel must treat with drainages very carefully. Accidental pulling of this tubes can lead to severe complications after operation. For example moving off tube from common bile duct (after operation on biliary tract) can be the cause of bile peritonitis and moving off the tube from pleural cavity can lead to pneumothorax. 28 To the gross technical errors the leaving of foreign bodies in tissues and cavities during operations and bandagings concerns. This foreign bodies can be gauze napkins, fragments of rubber drainages and even surgical tools. They are the cause of such complications as purulent processes, bleedings, peritonitis, pleuritis, bowel obstruction,etc . Mistakes of the same sort at operations have no direct relation with the general care of patients, however in their preventive maintenance the role of junior medical staff is great enough. Principal cause of the common leaving of foreign bodies in wounds or cavities during operation is thoughtless treatment of executable procedure. Also insufficient qualification of operation participants (surgeons, his assistants and operational sisters); insufficient anesthesia and, as result, restless behavior of the patient take place; small cuts giving insufficient access to object of operation; bad illumination of an operational field; presence of plenty of tools and dressings on operation field. Junior medical personnel should be an active participant of dressings and operations. Immutable rule at the performance of any operation should be careful supervision and control calculation of tools and dressing. Chapter 6 BODY HYGIENE OF THE SURGICAL PATIENT The hygienic condition of a surgical patient body has the major value in prophilaxis and treatment of purulent postoperative complications. This is the basic compound part of the patient hygienic regimen. There are two basic kinds of the patient hygienic regimen: the common regimen and bed regimen. The common regimen doesn't limit moving of patients. The same order is to the persons, suffering not severe diseases, having satisfactory condition (for example the patients requiring for observation during preparation for the scheduled operation, recovering patients). The bed care provides the staying of the patient in bed. There can be three kinds: strict bed; usual bed and active bed. The strict bed care is appointed to the patient with such diseases as gastroenteric bleeding, thromboembolic postoperative complications, in a sharp phase of cardiac infarction, etc. Patients at such regimen lay in bed in the certain position. Change of position should be made by the medical personnel. Independent active turns of a trunk are forbidden. A feeding and physiological needs are carried out with the help of medical workers. The basic purpose of this regimen – is prevention of complications, creation of conditions for 29 tissues regeneration and the greatest possible function reduction of the affected organ. Usual bed care is appointed to the majority of patients with sharp surgical diseases and traumas, and also in the first days after many operations. Patients are allowed to turn sideways, to accept convenient position. Some patients can rise in bed and sit. Active bed regimen is appointed to patients with diseases, requiring rest and stay in bed the greatest part of a day (chronic arterial obliterating diseases of lower extremities, stomach (duodenum) ulcer in the stage of exacerbation, etc.). Patients may get up the bed, leave the ward to go to the canteen and toilet. Hygiene of a body of the surgical patient provide: physiotherapy exercises, a morning toilet, hygienic baths or showers, care of hair, fingers, a mouth, a perineum, etc. Body hygiene of the patient with the common regimen The primary aim of clinical hygiene body actions is maintenance of the skin cleanness. It is known, that the human skin represents a complex organ which carries out functions of protection of an organism from adverse environment influences, regulation functions of metabolism, thermoregulation. Sweating and sebaceous glands excrete sweat and fat adsorbing dust, microbes. Skin folds collect these products which cause an itch. Skin scratches are the cause of dermatitis, pustules, furuncles. Patients must wash his hands and face with soap in the morning and in the evening, clean a teeth, comb hair daily. If a patient has grave condition this procedures must be provided by sisters and nurses. The important hygienic action is wiping off the body of patient in grave condition. It is recommended to carry out one time daily. Procedure is the following: the nurse wipes all body from hands to foot with the wet warm sponge. It doesn’t need to use spirits or something like cologne. One may use deodorants. Every 7-10 days patients must take a hygienic bath or douches. Optimum time for this purpose is the period after day time dream. Common regimen patients can wash themselves. If patient is forbidden to get up sisters can move his to bath-room on wheel-stretcher. If it is possible patient is set to bath with the help of medical staff. Otherwise sisters can wash his directly on wheel-stretcher using a shower. In a bathing room there should be a following equipment: a couch; a storage for pure cloth, tanks for dirty cloth; a table with subjects for shaving and haircutting; a soap; brushes; disposable basts. At absence of the last one it is possible to use usual basts after disinfection. Surely disinfected basts and dirty basts must be kept separately. The internal surface of a bath before use is cleared mechanically (a brush, a bast) and with the help of washing-up liquids. 30 If the bath is contra-indicated for the patient, he washes under the shower by the same rules, as at washing in a bath. After using the bath it is processed with the help of cleaning compositions and solutions of disinfectants. As the last one it is possible to use chloramin, hydrogen peroxide with detergents, sulfochloratine, etc. Shaving things should be kept clean and after each application to be processed by spirit. Now overwhelming majority of patients use own individual shaving things. It is better to advise applying disposable shaving-sets. Hygiene of a body of the patient with a bed care Hygienic (morning) and respiratory gymnastics are obligatory. The respiratory gymnastics will be, that the patient makes on 5-6 deep breaths of 1 times within each hour. Breaths can be carried out in bed without movements or in a combination to movements of hands, legs, trunks. The personnel actively helps the patient with a bed care at washing of hands and face, rinsing of a mouth and cleaning of a teeth. At a strict bed care it is necessary not less often than 3 times a week to carry out washing patient body. For washing the patient in bed use a jug with warm water, a toilet soap and a basin. At washing a head the basin is put on a bed in its head end. The patient raise, having his head above a basin so as water flew down in a basin. A head is washed a soap, then a soap wash off. Upon termination of washing a head carefully wipe a towel. And limbs and trunk are washed with use of similar receptions. It is possible to wash some bed patients in a bath. For this patient put in a bath on a bedsheet which hold for the head and foot ends. At this procedure it is necessary to watch constantly a condition of the patient in time to help to him. Patients with a bed care require special care of perineum area. At a defecation they should use a rubber or metal bedpan. Individual bedpans are placed on special shelf under the patient’s bed. For patients who can sit, but are not capable to move, are used portable bedpan in the armchair form and a chair with the hole on chair-bottom. After each defecation and urination medical worker carries out a toilet of perineum area of patient (washing). The technique of a washing will be described below (chapter 9). Body wiping is made by a damp towel or napkin. It is possible to use a disinfectant solution. First wipe a neck, skin behind ears, back, waist, forward surface of a thorax, axillary areas, limbs, then skin folds in groin areas and perineum. After wiping skin in the same order dry up a towel. 31 Eyes at the patients who are taking place in a unconsciousness, wash out with the help of the sterile napkin with a warm solution of a boric acid. Ears clear of earwax. For this purpose in acoustic duct by a pipette it is dropped solution of hydrogen peroxide. In an ear put for some minutes and then take out together with earwax a cotton ball. In case of need remove crusts from a nose of the patient. With this purpose in nasal passages enter the gauze turunda with mineral oil or any other oil. In 2-3 minutes turunda with the crusts take from nasal passages. The great value is care of oral cavity. Patients with severe condition can not do usual hygiene procedures often. They can have dry mouth, evident dental deposit; it is worsen drain function of mouth. As the consequences are gingivitis, stomatitis and, perhaps, acute parotiditis. It is necessary wipe patient’s mouth (teeth, tongue, gums) with help gauze and antiseptics (weak liquid of potassium permanganate, 0.5% water chlorhecxidine). If patient can he must to gargle.. At dryness and cracks of lips on them impose a napkin moistened with water. Then lips grease mineral or any other oil. Heavy patients need the prophilaxis of decubitus ulcers (see chapter 5). Chapter 7 HYGIENE OF CLOTH, FOOTWEAR, BED-CLOTH AND PERSONAL THINGS OF PATIENTS. Hygiene of hospital clothes and footwear The hospital clothes should be: - made from cotton or synthetic fabric (woolen things, fur products allocating superfluous quantity of a dust in an environment are not allowed; - easy, convenient, easily removed and put on; - reasonable style and color. In surgical departments there are such specificities as high bacterial pollution, pollution of clothes by the blood and discharge from wounds and cavities. Therefore it is expedient to offer patients the hospital clothes which we can expose to careful disinfection. The standard complete set of clothes includes underwear, a pyjamas (for men) and a dressing gown (for women). However it is allowed own patients clothes which should be clean. After change clothes must exposed of disinfection. A cotton domestic dressing gown for women and a sports suit for men are the most convenient form of personal patients clothes in a hospital. As footwear it should used slippers from a waterproof, easily washed and disinfectant material. Carrying in surgical department of street footwear and slippers from fluffy synthetics or 32 fur is absolutely inadmissible. In order to prevent excessive noise at walking it is more preferable to use footwear with a soft sole. When coming in hospital patient changes his clothes in hospital reception where is the special room for this purpose. Changing clothes in surgical department is not supposed. If relatives will not prefer to take away the patient clothes, it locate to special room for storage of clothes. It is not allowed to hold superfluous clothes and footwear in wards of surgical department. In wards hangers or cases should be for hospital clothes. It is impossible to keep clothes on stools, chairs, bedside-tables. Hygiene of underwear At surgical patients it is expedient to be limited to a minimum of underwear (except for patients with the general regimen), as the last: - always becomes soiled and is a potential source of infectious danger; - demands often replacement enough, that can give trouble to patient with procedure of changing clothes; - frequently it purse up folders and can the reason of decubitas ulcers (bedsores); - to a greater or lesser extent complicates carrying out of hygienic actions and also medical and diagnostic manipulations. In particular it concerns grave condition patients with limited activity. The slightest folders on linen cause them additional sufferings. Except for that action on hygiene of a body at these patients are carried out enough frequently, and even minimal additional disturbance (connected to replacement of linen) it is not desirable. Therefore the heaviest surgical patients (for example, in ICU) frequently are without underwear. Less grave surgical patients from underwear have enough one shirt (or night-dress). It should be convenient, easily replaced. Such shirt should be: - from cotton of light colours; - the simple style (baggy) which is not limiting respiratory movements; - with big wholes for a head and hands; - with a minimum quantity of seams; - without fasteners, buttons; - on length up to the top or average third of hips. Change of underwear is carried out individually as required (at pollution), but in any case not less often than 1 time a week. 33 Patients with a bed care are changed clothes with help of medical staff. To replace at such patient a shirt, it is necessary to bring hands under him sacrum, to grasp edges of a shirt and, cautiously raising a breast, to roll up a shirt from a back to a neck and to shift it to a nape. Then, slightly having raised a head and hands of the patient, it is necessary to take off the rolled shirt all over again from a head, then - from hands. If one hand at the patient is damaged, a shirt remove all over again with healthy, and then from a sick hand. Putting on the patient in a clean shirt make in the reverse sequence: in the beginning pass in sleeves of a hand of the patient, then having collected a shirt in folds, carry out it through a head and straighten along a back under the patient. In surgical department there should be a stock clean bed-clothes and underwear for day. Gathering, sorting and transportation of dirty linen carry out junior medical staff. The medical sisters participating in various medical manipulations and researches, to this are not supposed. Their duties are limited only to the actions directly connected to care by patients (change bed-clothes and underwear). At gathering and sorting of dirty linen the personnel should use separate overalls, a mask, rubber gloves, plastic apron which after each gathering wipe the rags with a disinfectant. At change clothes it accurately collect in bags (from a dense cotton or plastic). It is strictly forbidden to fling second-hand linen on a floor or in open receivers. It results in bacterial contamination of environment. For strongly polluted (pus, excrements) linen it is expedient to use separate capacity (bucket). The collected dirty linen should be taken out from department at once. Delivery clean and sending of dirty linen should be carried out separately, on different carriages. Carriages after each transportation are necessary for disinfecting. Change of underwear at patients should be carried out in process of pollution, but not less often than one time in 7 days. The stock of linen should be at the sister - mistress of department who is responsible for its storage and delivery. If the patient uses the him linen to change it should in due time. The control over change of linen is carried out by the attending physician and the nurse.. Hygiene of bed-clothes The important element of the general care to surgical patients is maintenance for him convenient and clean bed. Creation to the patient of comfortable conditions in bed - the factor rendering serious influence on an outcome of all treatment as a whole. The great value thus has observance of rules of hygiene of bedding and bed-clothes. To bedding concern: - mattresses 34 - pillows - blankets. Pillows should be the sufficient sizes (on width of shoulders of the patient). Two pillows are usually used: bottom and top. The top pillow rests in beds back. The sizes of a blanket should be such that it was possible to cover with it bed completely. It is better to use woolen or flannelette blankets (it is especial flannelette as they are well aired and disinfected). Mattresses in the sizes should correspond to bed. It is important, that the surface of a mattress was absolutely equal. It is desirable for grave patients to use special antidecubital mattresses, which elastic surface precisely models a surface of a patient body. Due to increase in a surface of contact and uniform distribution of loading of all body to the big area specific pressure decreases, that considerably reduces probability of bedsores, promotes a relaxation of all muscles groups. With this purpose mattresses from thick foam rubber, hydromattresses, inflatable multisection pneumomattresses are used. The last, with alternating pressure, can be used for carrying out of easy massage (due to increase and pressure decline in various sections). Disinfection of bedding is carried out in vapor formalin boxes (75 ml of formalin on 30 kg; temperature 57-59 °, an exposition of 45 minutes) and a steam-air method (60 kg on 1м2 the box area, temperature 80-90 °, an exposition of 20 minutes). To bed-clothes concern: - pillowcases - bedsheets - blanket covers - napkins - towels. The bed-clothes is produced from not rough, hygienic fabrics (cotton, linen), white color. Seams, patchs and folds on the surfaces are not supposed on pillowcases and bedsheets. The bedsheet should be sufficient size that the mattress was closed by it from all sides. Edges of a bedsheet should be turned up under a mattress from different directions that the bedsheet was not forced down and were not formed folds. Blanket cover and pillowcases should correspond strictly to the sizes of a blanket and pillows and to not have fasteners, buttons. On a regular basis, not less often 3 times day (in the morning, before day time rest and for the night), it is necessary to re-make bed of the patient, straightening folds, shaking off grits. 35 Change of bed-clothes at surgical patients is carried out individually, as required, but, in any case, not less often than 1 time a week. At grave patients constantly taking place in bed the bed-clothes varies daily, and if necessary - some times in day. Usually change of bed-clothes combine with the next sanitary processing the patient. It is more difficult to change bed-clothes at grave patients. Change of a bedsheet here is carried out by two medical workers and demands the certain skills. There are various ways of change of bed-clothes at such patients. If to the patient is allowed to move in bed, medical personal help him to turn sideways. On a released half of bed it is rolled to patients back a dirty bedsheet and on its place (up to half of bed) straighten a clean bedsheet. On one is shifted the patient, helping him to turn all over again on a back, and then on other side therefore the patient appears laying on a clean bedsheet. After that it is removed a dirty bedsheet and straighten clean on other part of a bed. At patients with a strict bed care a bed re-makes as follows. Since the foot end of a bed, it is rolld a dirty bedsheet under the patient, consistently raising shins, hips, buttocks; simultaneously straighten from below the clean rolled bedsheet. Then one of re-making raises a breast and a head of the patient, and another removes a dirty bedsheet and straightens clean under a back and a head of the patient. Sometimes it more expediently to move the patient on a wheelchair (near a bed) and to re-make bed. In any situation change of bed-clothes by the seriously ill patient should be made with the big care and art. For protection of bed-clothes at patients with wound discharge over of bandages are imposed napkins. At patients with involuntary urination and defecation are used plastic napkins on sheet. Above plastic napkin it must be cotton napkin. For these patients are used rubber bedpans or the special mattresses consisting of three fragments, one of which (average) can be removed for statement on its place of a bedpan. Bed-clothes is disinfected by washing in a laundry by boiling during 30 minutes with detergents. Dirty linen of patients with anaerobic infection and strongly polluted linen must be destroyed with help special muffle furnaces. Hygiene of patients personal things The quantity of personal things at patients in a surgical hospital should be minimum. Private patients things frequently are contaminated by microbs and can be source of infection. It is certainly allowed to have toilet and shaving accessories, towels, underwear, the literature in personal using patients. All things should be kept in bedside-tables or the cases allocated for it, but not on tables, window sills. Storage of things in the bags under a bed is absolutely inadmissible. The patient should not block up ward with a plenty of things, it is necessary to 36 hand over all superfluous things on a hospital starage or to transfer home. It is necessary to disinfect subjects of personal hygiene daily. For this purpose 0,5 % spirit solution chlorhexidine is used. Is inadmissible to keep toilet accessories in plastic packages as in the last the damp environment favorable for microorganisms is quickly created. Women for the period of a presence in a hospital are recommended to limit sharply or absolutely to stop the use of the cosmetics, especially strongly smelling and irritating means. Books in order to prevent microbic pollution are the best way for wrapping up in covers which on an extract should be thrown out. Chapter 8 HYGIENE OF A SURGICAL PATIENT NUTRITION. THE HYGIENIC CONTROL OF PARCELS & VISITS Sanitary-hygienic requirements for public catering, buffets & nutrition management. Preparation of food for in-patients is made in the centralized public catering. The latter is to be placed in a separate building or department. Public catering must be completely isolated from clinical departments. Both patients and medical staff cannot enter the public catering to avoid microbic contamination of food. A menu-apportionment is made for every day. The content of foodstuffs for every portion is exactly defined. The menu must meet the requirements of the directions authorized by the Ministry of Health, and also the main principles of dietary nutrition. Each hospital should have a nutritionist who must watch the menu and process of food preparing. A variety of products should be present in the menu-apportionment. Before food distribution, it must be checked by the so-called quality control commission consisting of a dietitian and the public catering manager. In the evening this duty can be entrusted with doctor on duty. Direct food distribution takes place in buffets of the in-patient department. There should be 2 rooms (area – not less than 9m2) and a washhouse for dishes. A junior nurse works in a buffet. She is busy with patient’s nutrition only and must not care of patients. There are tables for food, shelves for washed utensils and disinfectants and a fridge. Distribution of food is to be done within 2 hours after its preparation (not more!) Food must be hot. The 1st course and hot drinks should have temperature not less than 75°C, the 2nd and 3d courses – from 7 to 14°C. It is strictly forbidden to leave food in buffets after meal. It can’t be mixed up with fresh food. In buffet one can store only bread in cases and butter in a fridge. The ready food from public catering is delivered to a department by the buffet worker on a special hand-cart for food which cannot be used for other purposes. Utensils with tightly closed lids or vacuum flasks 37 should be used for transportation of ready food. Bread should be transported in waterproof bags (not fabric) or closed utensils (buckets, pans). Food distribution to the patients is done by buffet workers and nurses on duty. They should have special dressing gowns with marks “Food Distribution/Delivery”. The senior nurse controls the process of food delivery. The junior medical personnel and relatives are forbidden to take part in food distribution. Feeding of patients with general regime is done in a special room of the in-patient department – a refectory. Tables should be wiped with a damp cloth before meal. After meal damp cleaning of tables, their disinfection with 1% chloramines solution and damp cleaning of floors are made. Patients get food according to their individual diet. Food collection 7 treatment of utensils are carried out after meal. Treatment of utensils is carried out by the buffet worker in a buffet. The utensils should pass triple processing in different parts of a washing bath/ sink with the application of modern detergents. The regime of kitchen utensils treatment: mechanical removal of food remnants by a brush or wooden trowel; washing of utensils in water with addition of 1% soda ash and 0.5% detergent at a temperature of 50°C in the 1st part of a bath; disinfection of utensils by boiling during 15 minutes or immersing for 30 minutes into 0.5% chloramines solution, 0.1% sulfochloantine solution in the 2nd part of a bath; rinsing utensils in hot water at a temperature not lower than 65°C in the 3d part of a bath. Drying of utensils is carried out on racks in vertical position. It is forbidden to dry it with towels. It should be kept in special cupboards. Transportation of food to bed care patients should be done by a nurse. A nurse or patient’s relatives can feed him in a ward. Patients may have their own products. The list of products should be confirmed by the head of the department only by no means – in bed-side tables or between window frames. The senior nurse and a nurse on duty should supervise periodically the sanitary condition of fridges and remove products with the expired period of storage. The products subject to long storage should be kept in bed-side tables in closed containers. The medical personnel is to control the sanitary condition of bed-side tables. Nutritional therapy NT is the feeding of a sick person providing his physiological needs and simultaneously a method of treatment by specially selected and prepared products. The temperature, mechanical and chemical influence of food on the gastrointestinal tract should be taken into consideration. 38 The temperature factor. The most indifferent are dishes with the temperature close to temperature in the stomach cavity – 37-38°C. Dishes of contrast temperature (lower 15° and higher 57-62°) have an irritating effect. The cold dishes taken on an empty stomach increase intestinal peristalsis. Mechanical food influence. It depends on its volume, consistence, degree of crushing, character of thermal processing, quantity of cellulose and connective tissue. The weight of a daily ration makes about 3 kg. It should be divided into 4 feeding portions (the 1st breakfast, the 2nd breakfast, dinner and supper). If maximal mechanical gastrointestinal tract sparing diet is needed the daily feeding can be divided into 5-6 and even 8 meals. Liquid and porridge-like dishes have smaller mechanical influence and are faster evacuated from a stomach than firm and compact. Fried dishes will have the greatest mechanical influence while boiled and prepared on a steam ones will have the least. Besides it is necessary to remember that vegetative products contain a plenty of cellulose, creating additional mechanical effect on the gastrointestinal tract. Chemical food influence. Nutritional substances (acids, alkalis, salts, essential oils, extractive substances) have powerful and ambiguous influence on a gastrointestinal tract, changing its motility and digestive gland secretion. It is necessary to take this fact into consideration at setting a diet for patients with various pathology. The diet is prescribed by the doctor in charge. The nurses should know what diet is prescribed to each patient and to inform them on it. There are different diets recommended at various diseases. All diets are numbered from 1 to 15. The quantity of diets in hospital is defined by its type. The characteristics of all diets used in medicine are given in Appendix. Diets №1,2,5,9,15 are frequently used in surgical practice. Besides feeding of surgical patients can be changed depending on the kind of operative intervention and terms of the postoperative period. Eating and drinking (the so-called principle of “an empty stomach”) are forbidden in the day of operation in order to prevent severe narcosis complications (aspiration of vomitory masses). Hunger is prescribed after operation. Its duration depends on a disease and the character of the operation. At this time needs for water, salts, carbohydrates and amino acids are compensated by parental nutrition. After the hungry period the so-called zero diet (diet №0) is prescribed. The patient is allowed to drink water, broth, kefir, kissel. In 1-2 days the diet correspondent to the character of a disease is prescribed. In special cases there is a necessity for the so-called artificial feeding when patients cannot take food by the usual way. This condition can be at coma, traumas and diseases of maxillofacial area, gastrointestinal fistulas, esophagus disorders, mental diseases. 2 variants are possible here: enteral artificial feeding, i.e. feeding through a probe or through artificial fistula of a stomach; parental nutrition, i.e. intravenous introduction of special medications. 39 Feeding with the help of a gastric probe which can be put through a mouth or a nose is used as an elementary way of enteral nutrition. The food mixture consisting of various liquid and jelly products (milk, eggs, broths) is filled up into a probe with the help of a funnel, Esmarch’s irrigator or Jean’s syringe. Application of special balanced mixtures (diets) intended for enteral nutrition, including proteins (in the form of hydrolyze), fats (vegetable oils), carbohydrates (starch), sets of vitamins, mineral salts and microelements is more adequate. They allow to fulfill the needs of an organism and have a precisely specified power value. Besides, the contents of food components in them varies depending on patient’s condition and types of pathological processes. For example, mixtures of general effect are Kozilat (499 kcal/100gr), Terapin (414 kcal/100gr), Enshur (1.06 kcal/ml), Berlamine (1 kcal/ml), Peptamen (1 kcal/ml). For patients with renal insufficiency the special mixture Nephramine (with the lowered protein content is used). Silicone or polyurethane threadlike catheter probes causing the minimal discomfort of the patient are used for introduction of mixtures. They can be put not only in the stomach (nasogastrally), but also in intestine (nasointestinally), using endoscopic techniques. The best method of administration of a nutritious mixture is using of the special pump, allowing to introduce a solution in the set rate, round the clock and without dyspeptic reactions (nausea, vomit, swelling of a stomach) of the patient. Sometimes a patient cannot take food through a probe (gullet obstruction). In this case gastrostomy is done. It is a formation of stomach fistula (artificial duct between stomach lumen and environment). At feeding through a fistula a nutritious mixture is introduced through fistula into a tube. Thorough care of skin around fistula is necessary for prevention and struggle against maceration and dermatitis, arising owing to influence of digestive juices, rich in enzymes (application of sticky films, processing by pastes, for example Lassar’s paste, zinc paste). For parental nutrition are applied: solutions of pure crystal amino acids – aminofusin, aminosteril, aminosol, infesol; fat emulsions – intralipid, lipovenoze (these preparations contain emulsifying agent with soyabean oil, phospholipids, lecithin; diemeter of fat drops allows them to pass through capillaries without threat of fat embolism); carbohydrates (glucose); water, mineral salts, vitamins, microelements. Hygiene of parcels & visits. Additional foodstuffs can come to patients with parcels from relatives and friends. The parcels should meet certain requirements. The number of parcels is not specially regulated, but it should not exceed reasonable limits. It is necessary to mind the patient’ s opportunity to eat all that is given to him. The congestion of products in a patient’s bed-side table and fridge is 40 inadmissible. Empty containers should be thrown away or given back to relatives regularly to prevent blocking up of bed-side tables and fridges. Transmitted foodstuffs can be dangerous to patients. It is necessary to instruct relatives carefully about the diet prescribed to the patient, regime of food taking/ meal, products harmful to the patient. Parcels with perishable food (for example, sausages and other meat products, salads, pies, cakes) are absolutely inadmissible. It’s better not to send meat and fish canned food, tinned mushrooms, salty and smoked fish to patients. Practically all patient are contra-indicated to irritating components of food (pepper, mustard, horse-radish). To maintain the normal feeding the best way is to give juices, fresh and tinned fruit, fresh vegetables, cookies. Fresh vegetables and fruit are to be washed up at home. It is necessary to deliver them in packages, plastic containers. The patient should wash them again before meal. As for drinks, water, juices and cranberry water are desirable. Alcoholic drinks are strictly forbidden. Visiting patients by their relatives and friends is an important medical factor having medical value. Therefore the organization of visits is very important. They say, a hospital passes 2-3 times more visitors than patients a month. Visitors are considered as an additional source of infection in a hospital. But studies have shown recently that the insignificant number of infectious illnesses only are transferred from visitors. So, it is impossible to limit/ cut or absolutely forbid visits of patients (except for occurrence of any specific conditions at treatment of a patient). Visits have favourable effect on patients, especially children. At a long stay in a hospital patients can develop “mental hospitalism”, which negatively influences the recovery. Support by relatives is really important in such cases. Time for visits should be convenient both for personnel, patients and relatives. On weekdays visitors can come only after 4 p.m. (after dinner-rest of patients). In the first half of the day they may interfere with realization of medical diagnostic process in a department. The visits should be finished at 7 p.m.; after that the evening medical procedures and rounds begin. The question about the number of visiting days a week can be solved differently. In some medical establishments 1-2 days a week are allowed only. It is explained by the following: visitors are a potential source of infection. They interfere with and break the rhythm of work. However on the correct organization of visits these arguments seem to be groundless. It is necessary to allow daily visiting of patients. At cutting visiting days many visitors can sharply worsen sanitary condition of a department and create problems in changing rooms. Not more than 1-2 visitors at once may come to one patient. A lot can complicate the work of the medical personnel. Certainly, visitors are obliged to meet some hygienic requirements. The outer clothes and hats are to be necessarily left in a changing room. Traditionally before entering the department, the medical gown is offered to visitors (a gown for 41 every visitor). Even if they don’t bring superfluous microbes themselves, they may come into contact with microflora existing in a hospital, carrying it to their houses. In the departments with high bacterial contamination (such as purulent, burn) these requirements should be followed strictly. Each visitor should use bootee (plastic cover on footwear). Patients with the common regime can spend time with relatives in specially equipped places: rooms, halls for reception of visitors, halls. In this case many problems connected with sanitary-hygienic condition of department are removed. Rooms for reception of visitors should be equipped with corresponding furniture (chairs, sofas, armchairs, tables), ventilation and illumination according to existing sanitary-hygienic norms. These rooms are exposed to damp cleaning daily before reception of visitors and after it. If the patient is prescribed a bed regime, it is necessary to admit relatives to wards. Visitors are to be warned not to sit down on a patient’s bed, therefore there should be enough chairs and stools. It is necessary to limit the number of visitors (1-2). It is necessary to warn relatives about rules of a department. The question on the relatives admission is closely connected with the problems of visiting of seriously ill patients (for care). This question is solved in each case individually. At deficiency of junior medical staff relatives can give very big help in care for the seriously ill patients, therefore at presence of indications this care should be definitely allowed. The certain share of contingent in the surgical department is made up of dying patients. In this case it is necessary to be guided by principles of humanism and not to limit access of relatives and friends to the patients. Thus, correct organization of patients nutrition, parcels and visits demands rather significant efforts on the part of medical staff and administration of the hospital, assumes sufficient financing of medical establishments and reasonable designing of hospitals. Chapter 9. HYGIENE DISCHARGES OF THE SURGICAL PATIENT Hygiene discharges from a mouth and a nose Patients who are disturbed with cough with discharges of a phlegm, it is necessary to supply with the individual spittoons representing a glass vessel with the screwed up cover. It is necessary to watch, that spittoons were in due time released from a phlegm with their subsequent washing and processing by a disinfectant (chloramine, sulfochloratine, dezoxone, etc.). At patients with lungs chronic suppurative processes it is necessary to find body position which allow the phlegm from a tracheobronchial tree better removed (postural drainage). At unilateral 42 process is a position on healthy side. The position drainage is carried out of 2-3 times day for 2030 minutes. Involuntary ejection of a stomach contents through mouth (sometimes and through nose) refers to as vomitting. The medical staff should not leave the patient during vomitting without supervision as loss of vomit mass in respiratory ways (aspiration) with development of an suffocation (asphyxia) is possible. At vomitting it is necessary to set conveniently the patient, to cover a forward surface of his body with an oilcloth, to put before him on a floor a basin. If the patient cannot sit, him lay sideways or turn on one side a head, to a mouth bring a tray. It is possible to replace one with a towel, a bedsheet, a napkin. The patients who are in unconsciousness, sometimes have regurgitation - a passive outflow of gastric contents in a mouth. Owing to absence of a cough reflex gastric contents can be aspirated. At a regurgitation the head of the patient should be turned on one side and to release the oral cavity from contents with help gauze napkins or a suction device. Vomitting and regurgitation frequently are consequence of gastric (intestinal) contents stagnation because of various pathological conditions (stenosis of an stomach output, intestinal obstruction, a gastroenteric paresis after abdominal operations). In this case there can be indications for gastric probe introduction. A thick gastric probe it can enter through a mouth or nose. After a gastric evacuation a probe is deleted. If necessary procedure is repeated. The thin probe intended for prolonged stay in a stomach, is entered through nasal ducts. After introduction the probe is attached by an adhesive plaster to a nose. The probe is joined to a tube, and tube free end falls to glass vessel for gathering and measurements of gastric contents. One can suck away gastric contents each 2-3 hours (with help a Jean’s syringe). Sisters must take stock of discharge quantity and its nature (the technics of probing is described in chapter 15). At plentiful discharges of slime from a nose the patientt is supplied with disposable paper nasal napkins. Crusts can be deleted from nasal courses with the help gauze with vaseline which is entered in a nasal course, and then by rotary movements it is taken. Hygiene of urination The urinal is necessary for an evacuation of a bladder with a bed rest for the patient. Under laying patient it put oilcloth. It used mail bedpan and femail bedpan. Upon termination of a urination the bedpan and oilcloth it removed. After each urination junior nurse releases urinal from urine, washs out with the help a detergent and disinfects (chloramine and other disinfectants). For removal of a sediment from urinal walls it washed with help the weak solution of hydrochloric acid periodically. Before use a urinal rinse with warm water. 43 Patients with a urine retention (ischuria) can have indications to a catheterization of a bladder (see chapter 15). At an enuresis special urinals are applied. Them carry constantly or put on night (at a night enuresis). The urinal should be washed out and disinfected daily. Hygiene anal discharges At an evacuation of intestines at the bed patient it used bedpans. Bedpans are metal, faience and rubber. Before use it is necessary to rinse a bedpan hot water. One hand of the patient is raised, and another is brought the bedpan under buttocks. The patient is covered with a blanket. After defecation nurse takes from under the patient the bedpan, covers patient with an oilcloth or a paper and take out in a toilet. The patient is washed away with warm 0,01 % a solution of potassium permanganate or any other antiseptic. For this purpose under buttocks again it put bedpan. From a vessel it run water on a perineum, simultaneously processing its with gauze napkin, directing napkin from genitals to anus. After washing patient perineum it wiped a napkin. After use bedpan is washed out a hot detergent and is disinfected immersing for 2 hours in a disinfectant (1% chloramine, 0,2% sulfochlorantine, etc.). Medical staff must use rubber gloves. Features of female hygiene Anatomical features of female body (folded structure of a perineum, communication of abdominal cavity with an environment through genital tracts, menses, more direct and short (than mail) urethra) create danger of an ascending infection and development of inflammatory diseases of genitals and urinal tracts. Preventive maintenance of the given complications is observance by each woman of rules of personal hygiene. These rules provide, a daily hygienic toilet of genitals. In surgical departmentes it is desirable to have a special hygienic room, in which woman could carry out a hygienic toilet of genitals (a room of femail hygiene). The specified room should be equipped bidet or a cabin with ascending douch. In this room it is necessary to have a tank with boiled water, a jug, crystal potassium permanganate (for preparation of a solution), hygroscopic cotton wool, Esmarch’s irrigator, vaginal irrigators. Each woman should daily wash with soap external genitals and anal area by warm water (30-50°C) with the subsequent dry perineums a hygroscopic tampon. Thus movements of hands should be carried out at front to back (from a vulva to anus) to not bring a bacterium to urinogenital area. During a menses 3 times day are necessary to make a hygienic toilet not less 44 often. It is necessary to use boiled water, and it is better - a weak solution antiseptics (0,01% solution of potassium permanganate; boric acid - 1 teaspoon on 1 glass of water, etc.). The patient with bed regimen hygienic procedures do with help medical staff. The medical worker dresses gloves and an oil-cloth apron. 2 times day are necessary to wash away the patient not less often: in the morning and in the evening before dream. If necessary the toilet of external genitals is carried out (intimate washing of patient) more often. Before an intimate washing of patient for preservation of cleanliness of bed under a basin of the patient enclose an oilcloth. An intimate washing of patient is made on bedpan. Except an intimate washing of patient at women frequently is carried out vaginal syringing (irrigation). Syringing is carried out with the help of Esmarch’s irrigator, a rubber tube, crane (or forceps) and a sterile vaginal tip. The vaginal tip represents the bent tube in length approximately 15 sm and thickness about 1 sm with several apertures on lateral surfaces on the end. There are glass and plastic tips. For syringing it is used antiseptic liquids (with temperature 35-36°C, at hot syringings - 39-40°C): the weak solution of potassium permanganate, solution of sodium hydrocarbonate (2 teaspoons on 1 l waters), boric acid (3-4 spoons on 0,5 l waters) which pour in Esmarch’s irrigator, suspended on a support on 70 sm is higher than a level of a bed. The patient lays on bedpan with bent legs. In the beginning wash external genitals. Then cautiously enter a tip in a vagina and carry out it deep into on 6-7 sm in a direction up and behind. Holding with one hand the entered tip, another open the crane, starting up a liquid with the greater or smaller speed. After some medicinal syringings the patient should lie down, that the solution could have longer an effect. Upon termination of procedure perineum is dried carefully. After use irrigator needs to wash up well, in the beginning warm water, then a disinfectant solution. The tip is disinfected with 3 % chloramines or a boric acid, before the use is sterilized. Chapter 10. HYGIENE OF TRANSPORTATION OF THE SURGICAL PATIENT Medical transportation is a moving of patient with various aims (first-aid, performance of medical and diagnostic actions). In hospital it is necessary to transport patient from an reception to surgical department, from surgical department to diagnostic cabinets and back. In surgical department there is a necessity of patient transportation from ward to dressing, procedural, operation theatre and from these rooms to ward. There are not problems if the patient can walk. Then he can moves in 45 hospital independently. However, in some cases it is necessary to attend patients by the junior or average medical personnel (for example aged patients). Bed patients are transported on a stretcher, wheelstretcher and wheelchair. Need two or four persons for bear stretcher with the patient. They should not go march in step that a stretcher were not swings. At rise on a stairs it is necessary to bear patient a head forward, and at descent - foots forward. The patient’s head must be up during transportation. For transportation medical staff must know techniques moving of the patient: 1) from a bed on a wheelstretcher, 2) from a wheelstretcher on an operation table, 3) from an operation table on a wheelstretcher, 4) from a wheelstretcher on a bed. The surgical department is supplied with so-called functional beds. Such bed will consist of four parts: head, two average and foot. With the help of special adaptations it is possible to lift and lower separate parts of a bed, giving to the patient the necessary position. Functional beds have wheels for their easier moving. On small distances the patient can be transported directly on a bed. It is expedient to use the next way of patient moving. The wheelchair is put along a bed near to it. The head end of a wheelchair should be at the head end of a bed. Two or three persons settle down so that the wheelchair was between them and a bed. One brings hands under a head and a thorax of the patient, another - under a waist and the hips. If there are three persons one brings hands under a head and the top third of the thorax, the second - under the bottom third of thorax and under a waist, the third - under the hips. All together pull the patient on a wheelchair. If it is impossible place wheelstretcher along bad the wheelstretcher is put perpendicularly beds so that the foot end of a wheelstretcher was at the head end of a bed. Two or three persons stay along the edge of a bed, lift the patient, turn round him on 90 ° and put on a wheelstretcher. Moving of the patient from a wheelstretcher on an operation table. The personnel settles down along a table from the opposite side from a wheelchair. Under the patient hands bring and pulling him on itself, put on a table. Technique of patient moving from a table on a wheelstretcher usually is same as moving from a bed on wheelstretcher. In ward shift the patient on a bed, applying one of the ways described above. In all cases we must pull patients to wheelstretcher but don’t push. Grave condition patients are quite often transported (from the reception, from operation theatre, etc) with infusion system. To not damage vein wall during transportation it should immobilize upper limb with help any splint (for example Kramer's splint). The separate medical worker should keep infusion bottle and watch infusion system (to avoid tension of tubes). 46 At transportation of patients having intubation tube it is necessary to fix this tube by an adhesive plaster to a head. In this case the doctor - anaesthesiologist must observes of transportation. He should have portable device for artificial lungs ventilation as there is dangerous of patient breath stopping. If patient transportation after operation is fulfiled in the elevator medical staff must be ready for unexpected incidents (stopping of the lift, etc.). In the lift together with such patients there must be a doctor – anaesthesiologist and sister having all necessary tools for intensive care (set of medicines, intubation tubes, laryngoscope, gag, the device for artificial lungs ventilation). Transportation of patients having tubular drainages. Tubular drainages are usually entered at performance of operations on pleural and abdominal cavities. The pleural cavity is frequently drained at a pneumothorax, hemopneumothorax, pleurisy. Tubular drainages in the abdominal cavity are left after operations concerning a peritonitis, cholecystitis, pancreatitis more often. At operations on bile ducts it can be applied the external drainage of the common bile duct. The key in such cases is closing of this tubes. Usually it is used clips, stoppers, forceps. One can to tie in a bungle. Otherwise discharge from drainage tubes dirty environment (pus, blood, bile, etc.). Pleural drainage tubes must be closed very carefully. Tube hermiticity disturbance lead to pneumothorax (air accumulation in pleural cavity) and lung collapse. Furthermore there is dangerous of casual removing of drainage tubes during transportation. Loss of the tubes can be reason of severe complications. So early extraction of the tube from the common bile duct can lead to the bile peritonitis which requires second operation (relaparotomy). It is necessary to watch closely also that drainage tubes during moving the patient did not stretch, did not get under a body of the patient. The extremely undesirable is casual removal of drainages at patient transportation. Before transportation of patients a wheelchair is covered with a clean bedsheet or a blanket. A bedsheet is changed after each patient. After work the wheelchair must be washed up with the help of a detergent and disinfected by two-multiple wiping. Chapter 11 OBSERVATION & CARE OF SURGICAL PATIENTS BEFORE OPERATION & IN THE NEAREST POSTOPERATIVE PERIOD Mechanical treatment on tissues and organs of the patient, made with the medical or diagnostic purposes refers to as operation. Complications are possible after operations and the qualified care of patients is the major factor of the prevention and treatment of complications. 47 Care of surgical patients in a reception ward. The volume and matter of care of surgical patients in a reception ward depends on operation emergency. Urgent operation is an operation made soon after examination of a patient who has a life threatening state. Scheduled (planned) operations can be performed in a certain day and are delayed without damage for patient’s health. Mostly, scheduled patients enter a hospital in a satisfactory condition. Usually they are examines in a polyclinic. Therefore after the examination, a nurse draws up the documents (case history), carries out sanitary processing (if it is necessary) and directs him to the surgical department. Patients requiring an emergent operation need the greatest attention and care. More often they are the patients who cannot do without the intensive help of the medical personnel. The main role in carrying out diagnostic actions and examination over these patients belong to a surgeon. The junior medical personnel follows the instructions of the surgeon under the control over the patient’s condition, participates in patient’s examination and renders help. The nurses take the body temperature; fill in analyses forms; call laboratory assistants, other specialists; transport a patient to diagnostic rooms (X-ray, endoscopic, ultrasonic), the sanitary room, bandaging station; assist the doctor at performance of bandaging and medical manipulations (submits tools, dressings, gloves); give enemas; perform injections and infusions. Sanitary processing (hygienic cleansing) of patients is carried out at pollution of a body and clothes considered his general condition and a kind of disease. Patients are necessarily examined on dermatozoonoses. It is occur pediculosis (parasitogenic skin disease, infestation of lice) and scabies (itch, infestation of scabies acarus). In this case one may cut hair and take special drugs (insect killer). There are following insecticides: - benzylbenzoate (ointment 10-20%, emulsion 20%) - malathion (1% shampoo) - permetrin (solution "Nittyfor") - phenotrin (solution) - "Pedilin" (emulsion with tetrametrin and shampoo with malathion). There are old simple medicines: 10% emulsion of soap and petroleum, 5% boric ointment (only for adults). After applying washing of hair with 9% acid acetate for destruction of nits (parasites eggs) is recommended. After anti-parasitic processing the patient washes himself. His clothes is placed in a special bag and is sent to disinfector. People take a shower. If the patient is not capable of washing himself, a nurse helps him. During washing it is necessary to watch the patient as he can fall, hit or choke with water. Seriously ill patients are rubbed down by a sponge with soap water 48 or other detergents. Patients can be in a very poor condition requiring emergent operation. In this case sanitary processing is not carried out (if there is a direct threat for their life, for example, wound of heart), or carried out in the reduced volume: washing the dirty parts of a body, fast preparation of a place for operation. After sanitary processing the patient is dressed in clean cloth and is transported to a ward. The way of transportation is determined by the doctor. If the patient can go, the nurse, having taken the history case, accompanies him to a ward. If the patient cannot go, he is transported on a wheelchair or wheel-stretcher. In the surgical department the patient must be transferred directly by a nurse on duty with his history case. She determines a place in a ward and follows the doctor’s prescriptions. Sometimes a patient is transported to an operation theatre at once from a reception (for example if he has trauma of internal organs and persistent hemorrhage). Care of the patient before operation in the surgical department In urgent cases (when emergent operation is needed), the patients undergo short-time preoperative preparation. Some patients need intravenous infusions of solutions or hemocorrectors, injections of cardiovascular medicines, etc. Some patients need gastrostolavage (through mouth or nose). The time needed for this preparation can be different and depends on patient’s condition but usually it takes no more than 3 hours. Preparation of a patient’s operational field is one of nurse’s functions. Operational field is a part of body which the doctor will operate on. A nurse shaves hair in a zone of the future incision (without any detergents). After shaving she treats it with alcohol, anesthetic ether, chlorhexidine. In some surgical departments an operational field is closed with a sterile bandage after shaving. After premedication (injection of the medicines raising efficiency of anesthesia) the patient is transported into an operation theatre. Before scheduled operations the patient spend from 1 till 10 days in the department and more depending on the number of examinations and preparation for operation. Functions of the nurse include performance of the examination plan prescribed by the doctor. She fills in forms for blood and urine analyses, biochemical researches; makes orders for examination by tool methods of investigation (X-ray, endoscopic methods) of cardiovascular system, lung, liver, kidneys; transports seriously ill patients to diagnostic rooms; calls doctors-advisers; prepares patients for tool researches. So before X-ray research of a gastroenteric tract and urinary system the nurse gives an enema to the patient in the evening before analysis and in the morning on the day of analysis. 49 She also carries out medical disposals of the doctor: distributes tablets and liquid medical products, makes intravenous, intramuscular and hypodermic injections, feeds severe patients, checks performance of sanitary and hygienic norms by patients. The nurse should warn the patient, that in the evening before operation he should eat much. The patient can take y a glass of tea or juice with a bit of white bread only for supper. In the morning on day of operation the patient must not eat and drink. Besides in the evening and in the morning it is necessary to give cleansing enema. Colon purge is obligatory before any scheduled operation especially for aged patients. Before operation the patient should take a bath or shower and to replace underwear. On the day of operation it is necessary to prepare an operational field. It is done in the same way for emergent surgical interventions. In case of gastric evacuation impairment (for example a stenosis of gastric outlet) on the eve and on day of operation it is necessary to remove gastric contents from a stomach and to make gastrostolavage with sodium bicarbonate. A probe is applied for this purpose(see chapter 15). The patient preparing for operation should be given a sedative to sleep well before an operation. the patient should urinate before an operation. The medical personnel must also remember deontology rules. In accordance with particularity of a used method of treatment (surgical operation) at patients before operative intervention usually is great psychic and emotional excitement. Medical personnel should make verbal contact with a patient and explain him his diagnosis. It is necessary to allow patients to interpret in their own way each word of a doctor and a nurse. Care of the patient after operation in surgical department Time from the termination of operation and till its outcome is called the postoperative period. The nearest or early postoperative period is the first 10-12, sometimes more days after the operation when the patient is kept in a hospital. At this time patients need much care. From an operational table the patient is put on a wheel-stretcher and is transported into a ward. Bed for patients should be ready beforehand. It is covered with clean bedclothes. It should be warm. The body temperature can decrease during the operation because of blood loss and other reasons. The patient is covered with a warm blanket. The first 2-3 days of the postoperative period the patient should spend in resuscitation unit or in intensive care ward where constant supervision is provided (and in case of need - the emergency help). It is important to place the patient in bed in a correct position. The last is determined by the type of operation. There are special functional beds for changing of patient's position. 50 There are many complications in the early postoperative period. In the earliest hours the patient (especially after narcosis) can vomit. Therefore there should be a basin, napkins and tools for the toilet of an oral cavity in a ward. Danger of vomit consists of the patient who can choke if gastric contents will get in respiratory ways. The difficult breathing and asphyxia (suffocation, choking) can be a consequence tongue retraction. At occurrence of respiratory frustration the nurse is obliged to call a doctor immediately. The nurse should take care of the pulse, rhythm and depth of breathing, body temperature, blood pressure. There can be a retention of urine (ischuria) after operations. Thus, the bladder is overflown. The nurse should take the elementary measures on elimination of this complication. Urination can be adjusted, if the patient will try to sit himself down or be up near bed. The positive effect can be received, having applied a hot-water bottle on a bladder area. If this actions do not help, it is necessary to apply bladder catheterization (see chapter 15). The nurse should be able to make bladder catheterization with soft urinary catheter. Rigid (metal) catheters should be applied by doctors only. Some patients need constant urinary catheter (Foley's catheter) after operation. It is necessary to wash out this catheter and bladder periodically with antiseptic solutions (furacilline 1:5000, water solution chlorhexidine 0.5% ). The supervision over a bandage of an operational wounds is also very important. If the wound is sutured completely (without drainages and tampons), the bandage should be dry. It drenches in such cases with blood, pus, serous liquid or can indicate a complication. It is necessary to watch the bandage was not dislocated from the place. In such case the nurse should apply a new bandage (a sterile dressing). After some operations tampons are left in a wound, drainages enter a zone of intervention. Features of supervision over such wounds and care of drainages depend on the character of pathology and kind of the operation. Now in the majority of surgical clinics active conducting of the postoperative period is accepted. At once after operation the patient is suggested moving within beds. Generally earlier rising of patients is practised. The patient should be engaged in respiratory exercises and physical exercises. This work is very useful for prevention of postoperative complications. The medical personnel is obliged to provide cleanliness of a body, cloth and bedclothes of the patient, an optimum mode of his feeding, excreta hygiene. Chapter 12 SUPERVISION AND CARE OF PATIENTS AFTER ABDOMINAL AND THORACIC OPERATIONS 51 Surgical interventions on abdominal and thoracic organs are most frequent operations now. In common surgery departments the majority of cavity operations are interventions on organs of abdominal cavity. Both planned and urgent abdominal operations are performed in common surgery departments. Planned operations on lungs, heart, esophagus are performed in special departments usually. There are departments of lung surgery, departments of heart and vascular surgery, etc. However urgent patients with a surgical pathology of a thorax, are rather often admitted to common surgery departments, therefore questions of general care of this patients should be known not only by doctors, but by paramedics as well. Supervision and care of the patients after thoracic operations Surgical treatment is needed for many lesions of thoracic organs. Such diseases are acute and chronic purulent damages of lungs and pleura, tumors of lung and mediastinum, heart and large vessels defects, illness of a gullet. Operations are performed also at the open and closed traumas of a breast. The patients who have undergone surgical interventions on lungs, gullet, heart and large vessels, frequently are in severe condition and require well organized specialized care. It is possible to assert, that recovery of patients after thoracic operations equally determines both a well executed (well-made) operation, and high-grade postoperative care. At the first hours after operations on lung, heart and gullet very serious complications can develop. The nurse should not to leave such patients without supervision even for a minute. It is necessary to take care of character of breathing, pulse, arterial pressure, condition of drainages, body temperature. Supervision over a bandage is also very important. The medical personnel must know dangerous symptoms significative of circulatory and respiratory disturbance. The important characteristics of a patient’s condition with a pathology of respiratory system is the change of frequency, depth and rhythm of breathing. The healthy adult makes 1618 respiratory movements (breaths) per minute. Normal breathing should be rhythmical, with average depth. One respiratory movement falls on 4 pulse beats. Accelerated deep breathing is observed on emotional excitation, an anemia of brain, irritation of painful and thermal receptors. Accelerated superficial breathing happens at an pneumonia and pleuritis. Faint deep (the socalled stenotic) breathing is observed at narrowing of the top respiratory ways and laryngeal edema. Recurrent breathing testifies patient’s heavy condition observed on heavy blood circulation disorder. 52 One of the important symptoms of a pathological condition of respiratory tract is cough. Cough is the jerking exhalations accompanying with strong contraction of respiratory muscles. The physiological role of cough consists of an elimination of the particles (lung phlegm, dust) from respiratory ways. Frequent and repeating cough usually testifies of a lung pathology, but can be reflex (at irritation of a pleura, a nasopharynx mucous). Cough can be dry or wet (productive) with a lung phlegm. The character and quantity of a lung phlegm has diagnostic importance. The latter can be mucous, serous, purulent, hemorrhagic. Admixtures of blood in a lung phlegm is called a pneumorrhagia. It is necessary to remember, that the pneumorrhagia sometimes precedes a pulmonary bleeding. Pulmonary blood is scarlet, foamy. Patients with a surgical pathology of thorax can have such pathologic processes as a pyothorax (accumulation of pus in a pleural cavity), a haemothorax (accumulation of blood), a pneumothorax (accumulation of air), hypodermic emphysema (enter of air in a hypodermic cellular tissue from morbid changed lung) after an operation. At air presence in a hypodermic cellular tissue the symptom of a crepitation (sensation of snow crackle) on palpation of a corresponding site of a body is determined. For breath relief the patient takes half-sit down position. The in-come of fresh air is necessary. The good effect is given with oxygen therapy. There is an old method of oxygen therapy with applying oxygen cushion. Now oxygen moves into respiratory ways from the centralized system through nasal catheters. Sometimes patients can be put in special oxygen wards or in pressure chambers with the increased air pressure. Before use it is necessary to sterilize and grease a catheter with vaseline. It is entered through the lower nasal duct and attaches with the help of a plaster. It is necessary to remember, that it is possible to give only the humidified oxygen to upper respiratory ways. Humidifying is done by an admission of oxygen through water. For this aim it is possible to apply special set called Bobrov's jar. That is a tightly closed vessel with a rubber cork. There are 2 apertures in the cork through which tubes are inserted into a vessel: one short, another - long, coming to a bottom of a vessel. The 1/3 of a jar is filled up with water. Oxygen comes along long tube, passes through water and gets away along short tube to nasal catheters. The pleural cavity after the thoracic operations is often drained with tubular drainages. The personnel observing patients is necessary to have at least the common information about assignment of drainages and the rules of their work. Plastic (silicon) tubes (diameter about 0.5-1 cm) are applied as drainages. The lower parts of a pleural cavity are drained after operation to remove liquid contents (blood and an exudate). Usually with this purpose the drainage is entered along back auxiliary line through 7-8 intercostal space. If there is a necessity of air removal, the drainage is entered 53 into the top part of a pleural cavity (usually through 2-nd intercostal space along median clavicle line). There are two types of drainages: active and passive. Passive drainage is Bulau's drainage. This type is widely used. It works on flap principle. The finger of a thin rubber glove is attached to the end of the draining a pleural cavity tube. The top of finger is cut in a longitudinal direction at a length of 1 cm. The end of a tube together with a finger is located on a bottom of vessel (glass jar) the one quarter of which is filled with an antiseptic. At an inspiration contents of a pleural cavity follow from it along tube through rubber finger. On inhalation the finger is collapsed and block the entry of air & liquid from a vessel into a pleural cavity. The described way of drainage has the advantage of simple performance and does not demand application of any equipment. At present medical industry delivers special disposable bags with the same flap principle. They apply various sets for active drainages. The simpliest variant of sucking away device is Bobrov's jar (described above). Long tube joins the drainage from a pleural cavity, and short - a special cylinder in the compressed condition (it is possible to use a rubber syringe for enemas). The better choice of active drainage is special electric suction apparatus automatically supporting the low pressure in the system. The nurse should watch that vessels in which pleural contents are aspirated, were not overflown, and also carefully to take into account the character and quantity of discharged on drainages. It is very important to notice the termination of a drainage functioning or infringement of its hermetics. If a patient has a bad cough with a plenty of lung phlegm we can apply postural drain. The patient should be laid on a stomach. The pillow is removed, and the foot end of a bed rises on 30-60 sm. The head of the patient should be below a trunk and feet. Thus respiratory ways will be well cleared of blood or lung phlegm. Nurse’s duties include care of an oral cavity and skin of the patient. The important element of her activity is implementation of active postoperative period. The next day after operation the patient must change his position in a bed, breathe deeply, inflate a children's balloon or a rubber toy, move hands and legs, turn his head. Active movements of upper & lower extremities improve pulmonary ventilation and common hemodynamics. The earlier rising of patients is practised in the majority of surgical clinics. At many operations on lungs, mediastinum, chest wall the patient is allowed to get up the next day after intervention. The nurse should help the patient to get up. 54 The psychological atmosphere in a department influences greatly the result of operative treatment. The success of operation is promoted by goodwill, the sensitive tender, attentive attitude of the personnel to the operated patients. Supervision and care of the patients after operations on abdominal cavity. Patients with a pathology of abdominal organs make a significant part among patients of surgery departments. To the majority of these patients surgical operations are performed. The last can be urgent, emergency and scheduled (planned). The course of the postoperative period of patients after operative interventions on organs of abdominal cavity, in many respects is determined by a condition of a motor function of a gastroenteric tract. After operations, especially urgent, quite often there comes a paresis of a gastroenteric tract or paralytic intestinal obstruction may occur. This condition is caused by inhibition of a stomach and an intestine motility to its full absence (a paralysis of unstriped muscles). The unstriped muscles of intestinal tube are constantly in tonus and move (peristalsis) on a par. The direct reasons of a gastroenteric paresis are the peritonitis, pancreatitis, abdominal abscesses, retroperitoneal hematomas and an excessive lesion of abdominal organs at operations (technically difficult, traumatic interventions). As a result of intestinal tube motility inhibition (a relaxation of intestine muscles), the passage of contents slows down or stops completely. As a result hollow organs of a gastroenteric tract dilate and become a pouches without peristalsis, filled with a liquid chyme and gases. Processes of an adsorption in the inflated loops of intestine are sharply inhibited and, on the contrary, process of secretion intensifies. Thus, the rough growth of microflora which distributes from thick intestine to the top portions of an intestinal tube up to a stomach (dysbacteriosis) begins. Microbes cause rotting and fermentation of intestinal contents that increase an intoxication and raises quantity of the gases in intestine. The significant amount of water, electrolytes, proteins, enzymes that cause damage of a homeostasis get into a lumen of intestine . The main factors of paralytic intestinal obstruction are sharp swelling of a stomach, absence of a stool and gases (flatulence), absence of peristalsis (on auscultation the so-called "the dead silence" is marked). Struggle against a paresis of a gastroenteric tract is composed from a complex of actions the part of which is carried out at a stage of operative treatment (an intubation of thin intestine, local anesthesia (blockade) of reflexogenic zones etc.). It is necessary for patient to take a position in a bed with the raised head for reduction of pressure on a diaphragm and improvement of pulmonary ventilation. Full starvation is ordered. The need for water, electrolits, proteins, 55 carbohydrates and vitamins is compensated due to a parenteral feed (see chapter 8). The contents of a stomach of the patient with a paresis of a gastroenteric tract is usually moved with the help of a gastric probe (the technique of stomach sounding is described in chapter 15). During the operation concerning peritonitis and intestinal obstruction the intestinal probe can be applied to the patient. This probe is a silicon tube of about 1.5-2 m perforated on 2/3 of its length. It is introduced through a nose into a stomach and further into a small intestine. The non perforated part of tube must be in esophagus and pharynx. In the postoperative period it is necessary to watch an intestinal probe carefully to prevent its partial moving from a gastroenteric tract lumen. In this case intestinal discharge can enter in pharynx and be aspirated in respiratory ways. This can cause asphyxia and an aspiration pneumonia. For decompression of the lower part of a gastroenteric tract into a rectum flatus tubes and an enema are applied (chapter 15). From all kinds of enemas the siphon enemas well washing out a colon lumen and promoting amplification of a peristalsis are often applied. The application of the so-called hypertonic enema - introduction of a hypertonic solution (5% sodium chloride) into a rectum can be effective. The Ognev's enema (10 % sodium chloride, 50 ml of vaseline oil and 50 ml of hydrogen peroxide 3 %) is a variant of a hypertonic enema. Such methods of struggle against a paresis of intestine as infusion therapy (saline solutions), injections of the drugs stimulating intestinal peristalsis (Proserin, Cerucal), electrostimulation of intestine are applied. An oral cavity care is important both after emergency, and after scheduled operations on a abdominal organs. Healthy people have its autopurification at chewing firm food. Such care consists of wiping, washing or an irrigation of mucous and teeth. A teeth can be wiped with a wet cotton tampon with 0,5% sodium bicarbonate. Washing of an oral cavity is carried out with the help of a rubber cylinder of 0,5% sodium bicarbonate, 0,5% hydrogen peroxide, potassium permanganate 1:10000, 0,02% a water solution chlorgecsidin, solution furacillin 1:5000. The patient should take half sit-down position. The breast and neck are closed by an apron, the tray is put under a chin. Reduction of salivation, infringement of a normal drainage of an oral cavity, the termination of teeth cleaning lead to dryness of the mucous membrane, amplified development of pathogenic microflora. That can cause stomatitis (an inflammation of a mucous membrane of oral cavity), a glossitis (an inflammation of tongue), a gingivitis (an inflammation of gingivas) and a parotitis (an inflammation of a parotid gland) and even worsen the patient’s condition. To prevent these complications it is necessary to carry out hygienic processing of an oral cavity 2 times a day by the technique described above. To stimulate salivation (to improve of a drainage of a parotid gland) it is possible to give the patient acid products (citric juice). 56 Position of the patient in bed depends on a type of operation. So after a stomach resection the patient is usually put on a back with a little raised head end of a bed. At a gastrectomy (full removal of a stomach or extirpation) the half sit-down position is considered the best one. For a constant decompression of a stomach stump a surgeon introduces the thin probe into a stump through a nose leaving it there for 2-3 days. It is necessary to remember, that the decompression of a stomach after lots of operations on it and a duodenum is a very important manipulation. The seriously ill category of patients demanding much care is the patients who have undergone operation on intestine. Operations in connection with a cancer and perforation of colon are performed more often. At some patients operations end with by creation of colon fistula (colostomy, artificial anus) in abdominal wall. Change of a bandage with the removed loop of intestine is made on the second day. The lumen of a gut is opened usually on the 3-4 day after operation. After formation of a fecal fistula careful protection of a line of sutures and a surrounding skin against faeces weights are required. Dressings are done not less than 2 times a day with processing of the skin with antiseptics and skin protectors (Lassar's paste, zinc paste). After full formation of colostomy (on the 10-12 day after operation ) a special plastic pouch for gathering faeces is applied. Peculiarity of operations on biliary tract is leaving of tubular drainages and pledget (tampon) in an abdominal cavity. The medical personnel should watch a condition of a bandage. If patient has tampon the bandage get wet through with serous or hemorrhagic liquid. If the bandage get wet through with blood, bile or pus sister must inform about this to the doctor on duty. The control over the character and quantity of discharge contents from abdominal cavity on a tubular drainage is carried out in the same way. Sometimes the drainage of biliary ducts (choledochus) with a thin tube can be applied during an operation. Then bile quantity is registered by the nurse. Bile can be intriduced back into a stomach with the help of a nasogastral probe. Patients ill with jaundice need careful supervision of medical staff. It is necessary to reveal the coming hepatic insufficiency: euphoria, lethargy, sleepiness. After various abdominal operations there can be different complications demanding emergent medical intervention. One of the dangerous complications is the gastric or intestinal bleeding. Indices: vomit with blood, sloppy tarry stool (melena), scarlet blood in stool. Other complication is the early adhesive intestinal obstruction caused by peritoneal adhesions that compress intestine. Characteristic symptoms of this complication are the periodic spasmodic pain in a stomach, vomit, swelling of a stomach. Presence of similar symptoms is the indication to immediate examination by the surgeon. 57 The attentive attitude of medical staff to patients is an indispensable condition for maintenance of good current of the postoperative period. Chapter 13 SUPERVISION AND CARE OF PATIENTS WITH EXTENSIVE WOUNDS Wound - lesion of integrity of a skin or mucous membranes, and frequently underlying tissues and organs, caused by traumatic influence. Classification of wounds Depending on causes wounds are divided into operational and casual. Operational (conditionally sterile) wounds are formed in aseptic conditions in operational theatres or dressings. Other wounds refer to casual wounds (arisen at home, at factory, on road and in accidents). Superficial wounds with damage only of superficial layers of skin and mucous membrane are called abrasion (scratch). Abrasions can be wide and linear. According to type of damaging tools wounds are divided into pierce, gunshot, crashed, lacerated, contused, bite, cut, saber, scalped wounds. The cut wound has equal, parallel borders, the length of it is more than depth, and damages of tissues around of a wound are insignificant. The pierced wound has the small external sizes, but deep narrow wound channel. The sabre wound can be similar to cut, but, as a rule, is deeper and is surrounded with unviable tissues. The bite wounds result from bites of an animal or man. They are characterized by extensive microbic contamination on account of to oral microflora and, as a rule, are complicated by suppuration. Besides at bites an animal (carnivores), in an human organism the rabies virus can get. Lacerated wounds are characterized by significant destruction of tissues with formation of haemorrhages and hematomas. types of lacerated are scalped, contused and crushed wounds. The scalped wounds are characterized with skin detachment on the big extent without (enough with) skin damages. They are the result of hair hit in moving mechanisms or of extremity (at lesion of vehicle wheel). Contused and crushed wounds are characterized by extensive damages of tissues and development of their traumatic necrosis; are sometimes accompanied by full avulsion (abjunction) a segment of extremity. Gunshot wounds are the hardest type of damages. There are such wounds as а) tangential when the wound channel has no top wall; b) blind when there is only an entrance aperture and a shell jams in body; c) perforating when both input wound and output wound openings are present. There are also the penetrating wounds described by damage of all wall layers of any cavity (pleural, abdominal, skulls, joint), and not penetrating. 58 In addition to there are conjoined, multiple and combined lesions. Conjoined lesion is a damage (cold steel arms, bullet or fragmentation) of several adjacent organs or anatomic areas by a one shell. Multiple wound is a damage of two and more anatomic formations or organs by several shells of one kind (for example, bullets or knife). Combined damage is a mechanical lesion (wound) in combination of various other hitting factors (for example, ionizing radiation, chemical substances, burns, frostbite, pathogenic microorganisms). There can be foreign bodies in a wound: pieces of clothes, ground, glass and shells (bullet, fragmentation). All foreign bodies are contaminated with microorganisms. Here we speak about primary microbe contamination. Microbes can get in a wound during its treatment. In this case we speak about secondary bacterial contamination of a wound. Clinical course of wound process Clinical course of wound process depends on character, localization, the size of a wound, a degree of its microbic contamination, adequacy of treatment and immune properties of an organism. There are two basic kinds of wound healing: healing by a 1st intension and healing by a 2nd intension. The first type of healing occurs when wound margins are connected (mostly with sutures) and there is no suppurative inflammation. Healing by a secondary intension is observed when wound margins set aside from each other on distance and (or) there is a purulent infection. At primary healing wounds heal relatively fast. The pain subsides in 2-3 days, the edema the edema and a hyperemia of tissues surrounding a wound decreases in 3-5 days, but cicatrization in depth of a wound occurs more slowly. In first two - three days body temperature may rise up to 37 ° and even 38 °, ESR (erythrocyte sedimentation rate) increases, insignificant leukocytosis takes place. These changes are quickly normalized. The so-called complicated course of wound process is possible in some cases. The concept " wound infection" covers the infectious processes arising in a wound owing to an invasion of pathogenic microflora on insufficiency of protective reactions of injured tissues or all organism. The wound infection can appear in any wounds - operational and casual. Connection of a wound infection (suppuration of a wound) makes impossible wound primary intension healing. The main infecting agent of a wound infection is the staphylococcus. Last years the great attention is paid to gram-negative flora, and also non clostridial anaerobic microorganisms (Peptococcus, Peptostreptococcus, B. fragilis). In a clinical characteristics of wound suppurations there are some variants depending on infecting agents. At a staphylococcal infection the body temperature starts to rise on the 5-7 day. 59 But sometimes the fever is marked already in the first day after operation. The state of patient’s health worsens. Various pains in the field of a wound start to disturb. On wound examination skin hyperemia and edema of a wound margins, morbidity on palpation of surrounding tissues, an infiltration of a hypodermic fatty cellular tissue can be seen. On localization of a suppuration under an aponeurosis or deep fascia the symptoms can be very fuzzy because of the skin and a hypodermic fatty cellular tissue start to react only at distribution of pus to these layers of a wound. This circumstance delays early diagnostics. At gram-negative flora the general and local symptoms of a suppuration appear on the 34 day. At these patients the intoxication, high temperature of a body, tachycardia, a painful syndrome are more expressed. At anaerobic non clostridial infection caused by non spore-forming microbes, the fever, as a rule, is marked from first day after operation (or wound). The common anxiety of the patient, a sharp pain in the wound, an early extensive edema, expressed tachycardia are marked. Only disclosure of wound margins in some cases does not stop a suppuration. In this case special surgical tactics is needed. There is also anaerobic clostridial wound infection (Cl. perfringens, Cl. sporogenes, etc.). In such cases during the first hours, less often in the first days after operation severe intoxication, the high body temperature, fever, jaundice, oliguria, tachycardia, dyspnea are detected. Local symptoms are pain in the field of a wound, edema, a crepitation (a characteristic crackling on palpation, significative of gas presence in tissues ), dark blue stains on skin. High leukocytosis and, what is more important, a lymphopenia which can serve as a parameter of developing complication are characteristic of a wound infection. The general care and supervision over patients The need for the general care depends not only on a patient’s condition, but also on localization of a wound. Quite often patients with extensive wounds of the face, or legs are not capable to move, to serve themselves independently and need constant supervision and care of the medical personnel even if they feel themselves well. Wards with such patients, should be aired regularly & exposed to a ultra-violet irradiation with the help of bactericidal lamps 1-2 times a day during 10-15 minutes. During work of these lamps patients faces are to be covered with a towel for the prevention of eyes lesion. Wet cleaning with disinfectants is carried out 2 times a day. Patients with extensive purulent wounds stay in bed for a long time. Their bandages are frequently impregnated with wound discharge, the bed-clothes becomes soiled, therefore it is 60 necessary to change it not less than two times a day. To change bed-clothes is more convenient, when the patient is on bandaging. It is necessary to carry out regular preventive maintenance of decubital ulcers (bedsores) for patients with extensive wounds. For this purpose it is necessary to change their position in bed every 2-4 hours. Areas of a body, exposed to pressure (sacrum, calcaneus tubers, ulnar joints, scapulas) are wiped by camphor spirit or special ointments. The special rubber circle (wrapped up in a cotton) is put under the sacrum. To avoid pressure upon other areas, it is possible to use the rings made of cotton wool. Patients with a high fever have a dry lips, there are labial fissures, causing pain on opening of mouth. In these cases it is necessary to grease lips and corners of a mouth with vaseline oil. To reduce feeling of dryness in a mouth, it is good to use albuminous rinsings (albumen on one glass of warm water). Patients with deep extensive suppurative wounds may have an arrosion (wall destruction) of large blood vessels. The probability of a bleeding from an amputation stump is very high. The medical personnel should be necessarily informed on such patients. Whenever possible it is not necessary to close wound area with a blanket or a sheet for constant supervision over it. On significant drench of bandages with blood the doctor on duty should be called immediately, and the patient is to be transported into the dressing station. The profuse hemorrhage is the indication for imposing a tourniquet above a place of a bleeding. Bandaging Bandagings - the medical and diagnostic procedures used during treatment of wounds, ulcers, burns, frostbites, necrosises, external fistulas, etc. In the surgical department bandaging is carried out in dressing stations with the use of special tools and a dressings. Bandagings are made by a doctor with the help of a nurse or a nurse under the doctor's control. Frequency of bandagings depends on a phase and character of wound process, quantity of wound discharge. After operations with placing a suture the first bandaging is carried out the next day, the second - in 3 - 4 days and the last one - when sutures are removed. In case of a bandage drench in pus, or any other biological liquid bandaging is done immediately. At purulent wounds bandaging is made daily, and if necessary – several times a day. If wound is cleared (a granulation stage) bandaging is made once in 3-4 days. Indications to emergency bandaging are: a drench of a bandage; severe pain in a wound; an edema and hyperemia near wound; 61 rise of a body temperature. Bandaging begins with removal of bandage from a wound. The further manipulations are done in the following order: - primary toilet of a skin around of a wound; - survey of a wound, - toilet of a wound, performance of diagnostic and medical procedures; - repeated toilet of a skin; - bandage application. Primary toilet of a skin includes cleaning of skin (if it is necessary) with wet cotton and processing it with antiseptics (ethyl spirit, iodine, iodinate, iodopyrone). During survey of a clean wound it is necessary to reveal symptoms of an infection. Symptoms of a sutured wound suppuration are the skin hyperemia, edema, infiltrates in wound area, sometimes pus between sutures. At an anaerobic infection wound margins are edematous, often without hyperemia. Pressing by a finger does not leave a trace in edematous skin. There are traces of an impression of a bandage, a crepitation. The bare suspicion on presence of the anaerobic infection demands urgent measures. In the purulent wounds: they are qualified degree of inflammation, quantity of discharge, presence of necrosis, character of granulations. This rate of wound process is basis for applying either methods of treatment. Conception of the wound toilet concerning purulent wounds. This procedure consists of: - elimination of the foreign bodies; - elimination of necrotic tissues; - elimination of pathological liquids (blood, pus, intestinal contents, etc.); - washing by antiseptics. Primarily among antiseptic it is better to use 3% hydrogen peroxide. At contact of this solution with wound the foam clearing of a wound is done, and oxygen has bactericidal effect. After hydrogen peroxide it is necessary to wash the wound with other antiseptics, for example 0.02% water chlorhexidine. Further it is necessary to make diagnostic and medical actions (treatment of a wound by laser radiation, necrectomy, dissection of purulent pouches, placing of a secondary sutures and so on). At local treatment of wounds many chemical antiseptics are used for washing and bandaging: - 3% hydrogen peroxide; - furacilline solution (1:5000); - solution of 0.02% water chlorhexidine; - 0,25% and 0,5% solutions of silver nitrate; 62 - methylene blue, brilliant green; - 10% solution of sodium chloride; - ointment on a hydrophilic basis (Laevosinum); - proteolytic enzymes (trypsin, chymotrypsin). On maceration of a skin by wound discharge it is treated with 5-10% solutions of tannin, 3-5 % solutions of potassium permanganate, 1% a solution of methylene blue or brilliant green and special pastes (Lassar's paste, zinc ointment). For protection of skin it is possible to use also film-forming preparations (Cerigel). In case of occurrence of a secondary bleeding a wound tamponade is applied. The hemostatic tampons are removed not earlier, than in 2 - 4 days after a tamponade. The repeated toilet of a skin is carried out with the use of the same methods, as before. The final stage of bandaging is applying a bandage i.e. covering of a wound leaving tampons, drainages and others with the help of a cotton wool, fixed by glue, a napkin, an adhesive plaster, bandage. Chapter 14 SUPERVISION AND CARE OF PATIENTS IN RESUSCITATION AND INTENSIVE CARE UNITS The resuscitation is the section of clinical medicine studying various aspects of life restoring and developing methods of treatment and preventive maintenance of terminal states. Complex of various actions at terminal states for restoration of ability to live of an organism is called reanimation. Departments of resuscitation and intensive care In Russia there are reanimation and intensive care units of the general profile and specialized reanimation and intensive care departments. Reanimation departments of the general profile are organized in large hospitals and intended for treatment of patients with various diseases: a traumatic shock, a massive blood loss, acute circulatory and respiratory insufficiency, etc. Also there are patients in need of intensive care in these units. Sometimes particular postoperative intensive care units are organized in big surgical centers. The specialized centers and departments of reanimation and intensive care are created for patients with the certain diseases. So, in the toxicological centers patients with various 63 poisonings are taken care of in such units. In coronary care units patients with a acute heart attack, impairment of cardiac rhythm are treated. Resuscitation departments settle down near the reception to provide fast transportation of patients. There are special wards for primary examination of patients, “shock wards” for most severe patients, wards for the treatment of patients in resuscitation units. Reanimation departments are equipped with the necessary diagnostic and medical equipment: system for monitoring the major functions of human organism (breath and blood circulation), electrocardiographs, mobile x-ray device, devices for artificial pulmonary respiration and narcosis, defibrillators, cardiostimulators, bronchoscopes, etc. Here can be special conditions for hemodialysis, a hemosorption, a hyperbaric oxygenation, plasmos. There are sterile instrument tables with sterile syringes, needles, tools, infusion sets in the wards. The heavy condition of patients demands frequent laboratory researches, therefore the communication of reanimation departments with the express laboratories at any time is provided in hospitals. Besides clinical and biochemical analyses of blood (level of protein, creatinine, urea, glucose, some enzymes), it is often necessary to examine its gas structure, acid-base balance, balance of electrolits. Peculiarities of care in resuscitation and intensive care units Care of patients who are kept in departments of intensive therapy, includes all elements of the general and special care (with reference to surgical, neurologic, traumatologic and other patients). For preventive maintenance of infectious complications in departments of reanimation it is necessary to follow some rules. Medical staff should be examined 2 times a year for carriage of bacilli and be sanified. The visits should be limited as much as possible (medical staff attendance as well). It is necessary to put on sterile dressing gowns, bootees and protective masks. Restriction of contacts of the resuscitation unit personnel with other hospital personnel is necessary. The medical staff should process hands by a disinfectant before each contact with the patient. Disinfection of all equipment of wards should be carried out regularly. After removing the patient from department it is necessary to make strong disinfection of his bedclothes. The effective ventilation and constant bacteriological control of room air is necessary. Special care is necessary for patients with artificial ventilation of lungs through an intubation tube or through tracheostome. This category require regular (sometimes every 15-20 minutes during several days) careful toilet of tracheobronchial tree. Otherwise the syndrome tracheobronchial obstruction and even asphyxia may develop. Procedure of a tracheobronchial 64 discharge removal is made in sterile gloves. The special sterile (disposable) angular or direct catheter connected through a wye (Y-connector) with vacuum suction apparatus is used, thus one knee of a tee remains open. During inhalation of the patient it is necessary to introduce quickly movement this catheter into intubation tube (or tracheostomy tube) and to advance it through a trachea and bronchial tubes serially in the right and left lung (preliminary having turned a head of the patient to the left or to the right). After that it is necessary to close a finger free aperture of a wye, providing, thus, action suction apparatus, and, rotating a catheter, slowly to take it out. A catheter is washed out by a sterile solution or replaced. Procedure is repeated many times o provide full removal of lung phlegm. The efficiency of procedure increases if vibrating massage of a thorax is made simultaneously. For prevention of decubital ulcers (bedsores) and hypostatic pneumonia medical staff should change patient’s position every 2 hours (as a rule, in sequence side – back – side), wipe skin tanning substances (camphoric spirit, ethyl spirit), enclose jut gauze and rubber rings under bones. For prevention of decubital ulcers it is better to use special mattresses or beds. The patient in a coma should be put on one side for maintenance of respiratory ways patency. The top arm is placed on a pillow or soft cylinder enclosed under a breast. Dental prosthesis is deleted. For prevention of cornea drying in eyes it is necessary to drop 2 - 3 drops of vaseline or peach oil 2 - 3 times a day. The skin is wiped carefully 1-2 times a day, its folds is powdered talc or children's powder. The face is wiped with a damp towel. Sometimes medical personnel makes passive gymnastics for prevention of joint contractures. Infusion solutions should be warm up to the temperature a human body. The psychological moments have the certain value in resuscitation units. Doctors, nurses and assistant nurses should be able to show sympathy, to keep an atmosphere of amplified attention to the patient, to be cautious in conversations that their talking won’t cause sufferings. Experience shows, that in resuscitation unit it is necessary to select trained nurses with the experience of work in therapeutic or surgical departments not less than 2-3 years. Medical aid at terminal states Critical conditions between life and death are called as terminal states. They are preagonal condition, agonal condition (agony) and clinical death. The preagonal condition appears on a background of a heavy hypoxia (oxygen insufficiency) of internal organs and is characterized by gradual depression of consciousness, progressing frustration of vital functions (breath and blood circulation). Symptoms of preagonal state are: - confused, clouded consciousness; 65 - falling of arterial pressure (it is not detected); - tachycardia with thread-like pulse; - shallow and infrequent breathing (hypopnoea and bradipnoea); - pale skin and acrocyanosis (cyanosis of finger, lips, auricles of ear) - some reflexes are kept (eye reflexes). Expressiveness and duration of the preagonal period can be various. At sudden cardiac arrest (for example, myocardial infarction) the preagonal period is almost absent. At gradual dying on a background of many chronic diseases it can proceed for several hours. The preagonal period comes to an end of a terminal pause (the short-term termination of breath), proceeding from 5-10 sec up to 3-4 min. Then the agonal period (agony) begins. The agony is characterized by: - absence of consciousness; - an areflexia; - pulse is hardly determined only on carotids; - bradycardia; - breathing not only shallow and infrequent but and arrhythmic (Biot’s respiration or Cheyne-Stocks respiration); The agonal period continues from several minutes (for example, at acute cardiac arrest) till several hours and more (on slow dying) then there clinical death comes. The clinical death is characterized by: - unconsciousness; - absence of breathing; - absence of cardiac activity; - wide pupils without light reaction; - pale skin with acrocyanosis. After the respiratory and cardiac arrest cells of human body do not die at once. Cells of brain cortex can be alive for 5-6 minutes. Subcortical nerve centers are more hypoxia-resistants. Other cells of body can stay alive for some hours. Duration of clinical death depends on duration of a preagonal state and an agony: the longer they are, the deeper and more unreversable clinical death is. The clinical death passes into biological death. It is an unreversable state when biological processes in an organism completely stop. So clinical death continues not more than 5-6 min till we can restore/reload function of brain cells. At early stages all kinds of death (clinical and biological) do not differ from each other (there are the same symptoms - apnoea, stop of blood circulation and coma). Because of reanimation should be done in all cases of sudden death and then in the course of revival one can 66 determine the efficiency of actions and the prognosis for the patient. This rule is not applied to cases with clear external attributes of biological death (livores mortis, rigor mortis). One must not do reanimation in cases of terminal stadium of severe death diseases (cancer; heart insufficiency, renal failure). The diagnosis of a full stop of breathing is made by visually (absence of respiratory excursions). It is impossible to waste time applying a mirror or a piece of metal to a mouth and a nose. Pulse is to be necessary taken on carotid or femoral arteries only. Carrying out reanimation it is necessary: 1) to restore patency of airways, 2) to begin artificial respiration, 3) to start cardiac massage as soon as possible. Patency of airways. The patient should be laid on a back on horizontal rigid surface. Doctor throws back a head of the patient, putting one hand under his neck, and another having on a forehead. It provides an easy approach to a throat and a trachea preventing falling back of a tongue. It is necessary (by means of a cotton napkin (or a handkerchief)) to clean top floors of airways. It is better to use suction apparatus if it is near. It is good to use special air tubes (Safar’s tube, S-shape tube). With the purpose of introduction of an air tubes the mouth of the patient should be opened, and a tube advance to a root of tongue by rotational movements. Artificial respiration. Now the effective expiratory types of artificial respiration are (from mouth to mouth and from mouth to nose). They are based on rhythmical inflation of air in respiratory ways of the patient. Having made a deep breath, doctor presses himself to patient mouth and blows air with effort. To prevent outflow of air a nose of the patient is closed with the cheek or a hand. At height of an artificial breath the forcing of air stops, there is a passive exhalation. Intervals between separate respiratory cycles should make not less than 5 sec (12 cycles per 1 minutes). On breathing through a nose a mouth of the patient is closed, doctor does inhalations through nose. This job is very hard for doctor. Therefore if it is possible it’s better to use special hand respirators (Ambou’s bag) which improves a physiological & hygienic basis of artificial ventilation of lungs. Cardiac massage. The main symptom of cardiac arrest - absence of pulse on a carotid (femoral) artery. The compression of a cardiac musle between vertebral column and sternum results in transfer of small blood volumes from the left ventricle in greater circulation, and from right - in lesser circulation. Patient must lie on hard surface. Doctor puts one palm on another and makes pressure upon a breast in a point located on 2 fingers (3-4 cm) higher than a xiphoid. Depth of chest deflection must be 4-5 cm, frequency not less than 60 compressions per 1 minute. Criterion of correct massage - precisely determined artificial pulse wave on a carotid (femoral) 67 artery. If revival is carried out by one person after two forcings of air 15 compressions are made. If there are two persons a ratio ventilation - massage makes 1 : 5. After recovery of spontaneous hart activity massage must be stopped, but artificial ventilation should be continued till restoration of spontaneous breath. Efficiency of reanimation actions is controlled not less than once per one minute. Except for occurrence of pulse on carotids there should be narrowing pupils, reduction of pallor and cyanosis if reanimation is effective. If it is inefficient (absence of pulse, wide pupils with loss of their reaction to light, absence of breath) reanimation actions are stopped in 25-30 minutes after the beginning. If blood circulation is restored, artificial ventilation of lungs must be proceeded The most often complication of the closed massage of heart is ribs (rarely sternum) fractures. They are especially difficult for avoiding at elderly patients whose thorax loses elasticity and becomes rigid. There are damages of lungs, hearts, ruptures of a liver, a spleen, a stomach less often. Chapter 15. DRAINAGE OF HOLLOW ORGANS THROUGH NATURAL APERTURES Hollow organs are drained at disturbance of their permeability, for evacuation of contents and introduction of medicinal substances. Probing of the top parts of a gastroenteric tract The oesophagus, stomach, duodenum and underlaying parts of small intestine are drained with the help of rubber or plastic probes. There are thick and thin gastric probes which are soft plastic tubes with various diameters. On an external surface of these tubes marks on distance 40, 50 and 60 sm from its end are usually rendered. For duodenum probing the thin probe with metal olive is used. The duodenal probe also has 3 marks on distance 55, 70 and 90 sm from the end. Probing is carried out by sister or doctor in operation theatre, wards or procedurals in position of the patient on back or on the right side. The patient is covered with an oil-cloth apron. The probe is greased with vaseline (vaseline oil). The medical worker carrying out procedure enters the probe in patient oral cavity. When the probe end will reach the root of tongue, to the patient it is suggested to do swallowing movements. Simultaneously probe advances further. In result tube will penetrate at first into the gullet, and then in the stomach. Thin probe can be entered through the bottom nasal duct. In this case the probe end passes through epipharynx, oropharynx and next - to oesophagus. 68 The purpose of applying a probe can be both single evacuation of a stomach contents (stomach washing) and prolonged evacuation. For first aim the thick probe which is entered through a mouth is more often is used. For prolonged evacuation the thin probe entered through a nose is used. It can be left in a stomach for removal of contents for some days. Its external end is fixed by a plaster on the patient’s face. Through a glass adapter the probe is joined with a rubber or plastic tube which end falls to the graduated vessel with a small amount of an antiseptic. The vessel should be below level of a bed. Marks on tube surface show distance from teeth to probe end. For a drainage of a gullet (at the person of average height) the probe is entered on depth of 15-20 sm from a forward teeth. At leading in depth of 40-42 sm (up to the first mark) the probe arrive at cardial part of a stomach. If the probe has gone down on depth about 50 sm (up to the second mark) then its end is at the body of a stomach. At depth of about 60 sm (up to the third mark) the probe reaches the pylorus. If probe hit in the stomach appear gastric contents. For a drainage of duodenum the duodenal probe is entered at first on 50-60 sm (up to the first mark) that the end of a probe appeared in the lowermost part of the stomach. The sister removes stomach contents by syringe. To pass through the pylorus to duodenum the probe should be on depth about 70 sm from teeth (up to the second mark). For a drainage of small intestine it is used special perforated plastic tube about 1,5-2 m long. Such probe type can be entered only during laparotomy. Enemas and flatus tube Enema is medical procedure at which through rectum various liquids with the medical or diagnostic purposes are entered. Medical enemas are applied for colon content evacuation, washing, medicinal influence on it and on organism as a whole. Accordingly enemas refer to cleansing, siphon, medicinal, diagnostic, saline, laxative. Introducing of a liquid at performance is made with the help of simple devices. Those can be either the pear-shaped rubber cylinder (balloon) or a special vessel (named an irrigator) with joined rubber tube in length of 1,5 m supplied with the crane (or a clip, forceps) and a tip (glass, plastic, rubber) on the tube end. Contraindications to enemas are the gaping of anus, rectal prolaps, acute diseases of anal area, acute colon bleeding, severe common condition of the patient demanding full rest. Cleansing enemas it is given at constipations, before operations and radiological researches of abdominal organs. For an enema usual water of room temperature is used. Water in volume from 0,5 up to 1,5 л is poured in the irrigator, tube is filled (air removal) then the crane is 69 closed (or tube is pressed by a clip). Bed is covered with an oilcloth. The patient should lay on the left side, with bended in hip and knee joints legs. The tip is greased with vaseline. The tip is entered in anus. First it directs up and forward (in relation to a vertical axis of a body) and after it will promote on 3-4 sm, - up and behind. Depth of the tip penetration should be about 10-12 sm. After that the crane ia opened for start-up of a liquid. The siphon enema is applied for deep colon washing and as medical procedure at some kinds of intestinal obstruction. One can use water or antiseptic solutions and lytic substances (sodium benzoate, soda, potassium permanganate, etc.). It is better use warm water (25-35°C). Patient position and equipment are same as cleansing enema but it is not used rigid tip abd tube mast be thick (not less 1 sm in internal diameter). The filled irrigator is lifted up on height of 1-1,5 m (one can hang on a support). The tip is entered in rectum on 25-30 sm from anus. Water will penetrate into rectum. When the water level will reach to the irrigator bottom, it lower down below bed level. The water passes together with content in the irrigator. The crane is closed, dirty water is removing, is poured clean water and irrigator is lifted on support. Such cycles should be about 5-10. Laxative enemas are used for colon stimulation at constipations. To laxative enema are applied vegetable oil in quantity about 100 ml, and also pure glycerin (5-20 ml). Before using oil is warmed up preliminarily till 38-40 °. Commonly it is used a pear-shaped balloon. Stool usually appears in 10-12 hours. Medicinal enemas are applied for local and common influences. Local drugs are used for reduction of rectal mucous membrane inflammation. Medicinal enemas for the common influence are done with the purpose of administration of water, medicines, salts, nutrients. Before procedure the cleansing enema is given. Medicines for local influence enter in the rectum in small volume (15-100 ml) with the help of rubber balloon or a syringe through catheter. Medicinal enemas for the common influence are usually done by drop way. An irrigator connected to drop system, is filled in and one begin irrigation slowly (40-80 drops in one minute). After medicinal enema patient should lay not less than 1 hour. Before diagnostic enema it is necessary to prepare colon. On the eve the patient should get laxative, and for one hour before research - cleansing enema. Diagnostic enema is applied for contrast colon investigation. As the contrast remedy barium sulfate is used (200-300 g in 500 ml of water). Irrigator is filled with contrast in volume 1.5-2 liters. The soft tube is entered in rectum on depth of 12-15 sm. At accumulation of gases in intestines it is applied artificial flatus removal. With this purpose in rectum on depth of 15-20 sm the thick rubber tube greased with vaseline is entered. Its external end should be on 5-6 sm outside from anus. Flatus tube can be left at some hours. 70 Bladder catheterization One of kinds of the drainage of hollow organs is the bladder catheterization - entering of urine catheter in the urethra and through it in a bladder with the purpose of evacuation of urine, its washing at diseases, local medicine influence and capture of urine for research. At bladder catheterization it is used various catheters - tubes, made of elastic materials (for example, rubbers) or metal. There are soft catheters (rubber, plastic) and rigid (metal). Catheters differ on size, form and caliber. Soft catheters is applied more often. If necessary prolonged bladder drainage it is possible to use special types: Petzer’s catheter (for bladder fistulas), Foley’s catheter. Contraindications to the catheterization are the acute inflammation of urethra, fresh its damage, acute inflammation of the prostata gland (prostatitis), acute inflammation of epididymis. The catheterization is made in patient position on back. Under buttocks one can put a firm pillow or same thing. Urine catheters must be sterilized. Now it is used disposable sterilized catheters. Medical staff must put on rubber gloves. Before catheterization it is carried out washing by an antiseptic solution of external urethral opening. Female catheterization is rather simple technique beyond depending on catheter types. Catheter greased with oil is entered in an external urethral opening. Curved tip of the metal catheter should be inverted up. Male catheterization can be not easy task sometimes. At first it is necessary to try soft catheter. Before catheterization the medical worker washes with help an antiseptic solution external urethral opening and balanus. Penis is kept in vertical position. The catheter is entered in urethra and moves. Occurrence urine from the catheter specifies that it has penetrated into bladder. Catheterization by rigid catheter is more difficult. There are special technique of this catheterization. During this catheterization can be severe complications: damage of urethra or bladder. Soft male catheter can uses a medical sister. Rigid catheter can use only doctor. Catheter type Foley is used usually for prolonged catheterization. Technique of catheterization is same as any soft catheters. Foley’s catheter can be in bladder during many days and even months. Medical staff must wash this catheter with help antiseptics every day to prevent urinal infection.