General care for children with surgical diseases. Surgical care. Extracurricular independent work of students

Foreword …………………………………………………………………………4

Introduction ……………………………………………………………………………..5

Chapter 1. General care of sick children ………………………………………..6

Chapter 2. Procedures and manipulations of a nurse ………………………20 Chapter 3. Skills of a surgical nurse………………………………………………………………………………………………………………………………………………39 Chapter 4. First aid in case of emergency conditions …………………... 55

Appendix ………………………………………………………………………...65

References ………………………………………………………………...67

FOREWORD

The industrial practice of students is the most important link in the training of a pediatrician; in the structure of the educational program of higher medical educational institutions, much attention is paid to this section of education.

The purpose of this teaching aid is to prepare students of the 2nd and 3rd courses of the pediatric faculty for the internship.

The objectives of the teaching aid are to improve the theoretical knowledge of students, provide information on the correct and high-quality performance of the functional duties of junior and secondary medical personnel, ensure the development of practical skills in caring for sick children, performing nursing manipulations and procedures, providing emergency first aid, filling out medical documentation. .

The content of the practical training of a specialist, set out in the manual, corresponds to the state educational standard of higher professional education in the specialty 040200 "Pediatrics", approved by the Ministry of Education of the Russian Federation on March 10, 2000, the materials of the final state certification of graduates of medical and pharmaceutical universities in the specialty 040200 "Pediatrics", approved by the Ministry of Health of the Russian Federation (2000).

The need to publish this educational and methodological manual is due to the development at the NSMA of a new cross-cutting program of practical training for students of the pediatric faculty with a list of skills and abilities necessary for mastering during the period of practical training. A feature of this publication is the generalization and systematization of modern literary material, a clear presentation of the content of all practical skills in accordance with the approved program. Such publications in NSMA have not been published before.

The manual outlines the content of practical skills and abilities in the course of industrial practice as an assistant to a ward and procedural nurse of a therapeutic and surgical profile, an emergency medical assistant, and measures to provide first aid in the most common emergency conditions in children. The proposed manual is intended for self-preparation of students in the study of the discipline "General child care" and the passage of industrial practice.

INTRODUCTION

This teaching aid consists of 4 chapters.

The first chapter is devoted to the general care of a sick child as an obligatory part of the treatment process. The value of care cannot be overestimated, often the success of treatment and the prognosis of the disease are determined by the quality of care. Caring for a sick child is a system of measures, including the creation of optimal conditions for staying in a hospital, assistance in meeting various needs, the correct and timely fulfillment of various medical prescriptions, preparation for special research methods, carrying out some diagnostic manipulations, monitoring the child's condition, providing a patient with first aid.

Nursing and paramedical staff play a crucial role in ensuring proper care. The junior nurse cleans the premises, daily toilet and sanitization of sick children, assists in feeding the seriously ill and the administration of natural needs, monitors the timely change of linen, the cleanliness of care items. The representative of the middle medical level - the nurse, being an assistant to the doctor, clearly fulfills all the appointments for the examination, treatment and monitoring of a sick child, maintains the necessary medical documentation. The chapters “Procedures and manipulations of a nurse”, “Skills of a surgical nurse” include information on various methods of using drugs, collecting material for research, methods for conducting therapeutic and diagnostic manipulations and procedures, and rules for maintaining medical records. Some aspects of care for surgical patients are highlighted.

The effectiveness of a complex of therapeutic effects depends not only on the proper organization of care and training of medical workers, but also the creation of a favorable psychological environment in a medical institution. The establishment of friendly, trusting relationships, the manifestation of sensitivity, care, attention, mercy, polite and affectionate treatment of children, the organization of games, walks in the fresh air have a positive effect on the outcome of the disease.

A medical worker is obliged in emergency situations to be able to correctly and timely provide first aid. The chapter "First aid in emergency conditions" outlines emergency measures, the implementation of which in full, as soon as possible and at a high professional level is a decisive factor for saving the lives of injured and sick children.

At the end of each chapter, there are control questions for students to independently check their knowledge of theoretical material.

The appendix contains a list of practical skills and abilities of students of the 2nd and 3rd courses of the pediatric faculty during the internship.

Chapter 1. GENERAL CARE OF SICK CHILDREN

Conducting sanitization of patients

Sanitary treatment of sick children is carried out in the admission department of the children's hospital. Upon admission to the hospital, if necessary, patients take a hygienic bath or shower (for more details, see "Hygienic and therapeutic baths"). In case of detection of pediculosis, a special disinsection treatment of the child and, if necessary, underwear is performed. The scalp is treated with insecticidal solutions, shampoos and lotions (20% suspension of benzyl benzoate, Pedilin, Nix, Nittifor, Itax, Anti-bit, Para-plus, Bubil, Reed ”, “Spray-pax”, “Elco-insect”, “Grincid”, “Sana”, “Chubchik”, etc.). To remove nits, separate strands of hair are treated with a solution of table vinegar, tied with a scarf for 15-20 minutes, then the hair is carefully combed out with a fine comb and washed. If scabies is detected in a child, disinsection treatment of clothing, bedding is carried out, the skin is treated with a 10-20% suspension of benzyl benzoate, sulfuric ointment, Spregal, Yurax aerosol.

Ministry of Health and Social Development of the Russian Federation

GENERAL CHILD CARE

WITH SURGICAL DISEASES

Kirov

UDC 616-083-053.2+616-089-053.2(075.8)

BBK 57.3+54.5

Published by decision of the central methodological council of the Kirov State Medical Academy

dated 19.05.2011 (Minutes No. 7)

General care for children with surgical diseases: Textbook for students of medical universities / Comp.: Ignatiev S.V., Razin M.P. - Kirov State Medical Academy, 2011 - 86 p., illustrations: 20 figs., 5 tab., bibliography: 10 sources.

The manual highlights modern concepts of general care for children with surgical diseases, considers the structure and organization of surgical care for children in modern Russia, the most important anatomical and physiological features of the child's body, methods of asepsis and antisepsis, formulates the functional responsibilities of personnel caring for children with surgical diseases, the rules of work in the dressing room and the operating room, a detailed description of the most important medical manipulations and algorithms for preparing children for special methods of examination and surgical treatment are given. The manual is intended for students of medical universities studying in the specialty "Pediatrics".

Reviewers:

Head of the Department of Pediatric Surgery of the Astrakhan State Medical Academy, Doctor of Medical Sciences, Professor A.A. Zhidovinov;

Professor of the Department of Surgical Diseases of Children's Age, Izhevsk State Medical Academy Doctor of Medical Sciences, Professor V.V. Pozdeev.

List of conditional abbreviations
Foreword
1.	Structure and organization of surgical care for children in Russia
1.1	Structure and organization of work of the pediatric surgical clinic
1.2	The structure and organization of the operation of the surgical room of the children's polyclinic
	1.3
2.	Anatomical and physiological features of the child's body
	2.1.	AFO of the skin and subcutaneous fat
	2.2.	AFO of the musculoskeletal system
	2.3.	AFO of the respiratory system
	2.4.	AFO of the cardiovascular system
	2.5.	AFO of the nervous system
	2.6.	AFO of the gastrointestinal tract
	2.7.	AFO of the urinary system
	2.8.	AFO of the endocrine system
	2.9.	AFO of the immune system
	2.10.	Control questions and test tasks
3.	Aseptic and antiseptic
	3.1.	Control questions and test tasks
4.	Functional responsibilities of personnel caring for children with surgical diseases. Work in the dressing room and in the operating room
	4.1.	Control questions and test tasks
5.	The most important medical manipulations
	5.1.	Control questions and test tasks
6.	Preparing children for special methods of diagnosis and treatment
	6.1.	Preparing children for special examination methods
	6.2.	Preparing children for surgery
	6.3.	Control questions and test tasks
List of practical skills and abilities
Situational tasks
Samples of correct answers
List of recommended literature

List of conditional abbreviations

Ig	immunoglobulins
AFO	anatomical and physiological features
GP	general doctor
WMO	secondary debridement
gastrointestinal tract	gastrointestinal tract
IVL	artificial lung ventilation
KOS	acid-base state
CT	CT scan
MRI	Magnetic resonance imaging
ICU	resuscitation and intensive care unit
BCC	circulating blood volume
surfactant	surfactants
PDS	polydioxanone
PHO	primary surgical treatment
SanPiN	sanitary rules and regulations
FAP	feldsher-obstetric station
CVP	central venous pressure
CSO	central sterilization department

Foreword

The basics of general care for children with surgical diseases have their own well-defined features in comparison with the care of an adult patient and the care of a somatically ill child.

The course of care for surgical patients of childhood is very important, as it introduces students to the main principles of the work of a pediatric surgical hospital at the level of a paramedical worker. Students acquire not only theoretical knowledge, but also practical skills in caring for sick children of this profile, so the manual contains a list of practical skills that a student should master. In care, preoperative preparation of the operation and nursing of children after it are of great importance. The most postulate principles of these processes are covered on the pages of our publication.

This textbook is intended for undergraduate students of medical universities. The authors took into account modern domestic and foreign literature data, as well as their personal many years of experience in practical pediatric surgery, so they hope that the material presented in the manual will contribute to a deeper understanding by students of pediatric faculties of the structure and organization of surgical care for children in modern Russia, anatomical - physiological characteristics of the child's body, asepsis and antiseptics, functional duties of the staff, work in the dressing room and operating room, the most important medical manipulations, preparing children for special examination methods and surgical treatment. All possible wishes and criticisms will be received by the authors with understanding and gratitude.

Questions on practical skills in educational practice (care of children in a surgical hospital) for students of the 1st year of the pediatric faculty.  Structure of a modern children's surgical clinic. Responsibilities of junior and middle medical personnel in the care of children in a surgical hospital.  Maintenance of medical records in the pediatric surgical clinic.  Equipment and tools for the dressing room, manipulation room, operating room. Responsibilities of junior and middle medical personnel.  Responsibilities of paramedical personnel of a pediatric surgical hospital (urological, traumatological, resuscitation, thoracic departments, department of purulent surgery).  General care of patients in the general pediatric surgical department. Preparing a child for surgery.  Features of transportation of patients depending on the nature, localization of the disease (damage), severity of the condition.  The concept of nosocomial infection. Causes of occurrence, main pathogens, sources, ways of spread of nosocomial infection. A set of sanitary and hygienic measures aimed at identifying, isolating sources of infection and interrupting transmission routes.  Sanitary and hygienic regime in the admission department.  Sanitary and hygienic regime in the surgical department.  Sanitary and hygienic diet of patients.  Sanitary and hygienic regime in the operating unit, wards and resuscitation and intensive care units, postoperative wards and dressing rooms.  Treatment of the operating and injection field, hands, surgical gloves during the operation.  Disinfection. Types of disinfection. The sequence of processing medical instruments. Treatment of incubators for newborns.  Sterilization. Types of sterilization. Storage of sterile instruments and medical products.  Features of sterilization of instruments, suture and dressing material.  Peculiarities of sterilization of surgical gloves, rubber products, fabrics, polymers (probes, catheters, etc.)  Rules for laying dressings, surgical linen in bix. Bix styling types. Indicators.  Antiseptic. antiseptic methods. Control methods. Indicators.  Injections. Types of injections. Local and general complications of injections. Disposal of used balls, needles, syringes.  Rules for taking blood for laboratory testing.  Infusion therapy. Tasks of infusion therapy. The main drugs for infusion therapy, indications for their appointment. Ways of introducing infusion media. Complications.  Indications and contraindications for central venous catheterization. Caring for a catheter placed in a central vein.  Blood transfusion. Types of blood transfusion. Determination of the suitability of canned blood for transfusion.  Technique for determining blood group and Rh factor.  Control studies before transfusion of whole blood (erythrocyte mass) and blood products, methods of conducting.  Post-transfusion reactions and complications. Clinic, diagnostics. Possible ways of prevention.  Nasogastric tube. Probing technique. Indications for nasogastric sounding. Technique. Complications of nasogastric sounding.  Types of enemas. Indications for use Technique. Complications.  Taking material for bacteriological examination. How to store biopsy material.  Features of transportation of patients in a surgical hospital.  Tasks of preoperative preparation, ways and means of its implementation.  Surgery. Types of surgical operations. Position of the patient on the operating table. Intraoperative risk factors for infectious complications.  Postoperative period, its tasks. Care of children in the postoperative period.  Complications of the postoperative period, ways of prevention, combating complications that have arisen.  Care of the skin and mucous membranes of the child in the postoperative period.  Postoperative wound care. Removal of stitches.  Temporary stop of bleeding.  Transportation and immobilization depending on the nature and localization of damage or pathological process.  Pre-hospital care for emergency conditions in children.  Terminal states. Monitoring. Posthumous care.  Assistance in emergencies. Primary resuscitation complex, features of its implementation depending on the age of the child.  Desmurgy. Technique for applying different types of dressings in children of different age groups (see Appendix). APPENDIX Questions on desmurgy for students of the 1st year of the Faculty of Pediatrics I. Headbands:  Hippocratic cap  Hat - cap  Bandage on one eye  Bandage - bridle  Neapolitan bandage  Bandage on the nose II. Bandages on the upper limb:  Bandage on one finger  Bandage on the first finger  Bandage-glove  Bandage on the hand  Bandage on the forearm  Bandage on the elbow joint  Bandage on the shoulder joint III. Bandages on the abdomen and pelvis:  Unilateral spike bandage  Bilateral spike bandage  Bandage on the perineum IV. Bandages for the lower limb:  Bandage for the thigh  Bandage for the shin  Bandage for the knee joint  Bandage for the heel region  Bandage for the ankle joint  Bandage for the entire foot (without grabbing fingers)  Bandage for the entire foot (with grabbing fingers)  Bandage for first toe V. Bandages for the neck:  Bandage for the upper part of the neck  Bandage for the lower part of the neck VI. Bandages on the chest:  Spiral bandage  Cruciform bandage  Dezo bandage Head of the Department of Pediatric Surgery MD. I.N. Khvorostov

Available in formats: epub | PDF | FB2

Pages: 224

The year of publishing: 2012

Language: Russian

The manual discusses the features of caring for children with surgical diseases in a hospital. The structure and organization of the work of the children's surgical clinic, equipment and equipment of various departments are reflected. To consolidate the material and self-test, control questions are given at the end of each chapter.

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THE CONCEPT OF CARE OF SURGICAL PATIENTS

Surgery is a special medical specialty that uses methods of mechanical action on body tissues or a surgical operation for the purpose of treatment, which causes a number of serious differences in the organization and implementation of care for surgical patients.

Surgery- this is a complex targeted diagnostic or, most often, therapeutic action associated with the methodical separation of tissues, aimed at accessing the pathological focus and its elimination, followed by the restoration of the anatomical relationships of organs and tissues.

The changes that occur in the body of patients after surgery are extremely diverse and include functional, biochemical and morphological disorders. They are caused by a number of reasons: fasting before and after surgery, nervous tension, surgical trauma, blood loss, cooling, especially during abdominal operations, a change in the ratio of organs due to the removal of one of them.

Specifically, this is expressed by the loss of water and mineral salts, the breakdown of protein. Thirst, insomnia, pain in the wound area, impaired motility of the intestines and stomach, impaired urination, etc. develop.

The degree of these changes depends on the complexity and volume of the surgical operation, on the patient's initial state of health, on age, etc. Some of them are easily expressed, while in other cases they seem significant.

Regular deviations from normal physiological processes are most often a natural response to surgical trauma and do not partially require elimination, since the homeostasis system independently normalizes them.

Properly organized patient care sometimes remains the only important element in postoperative surgery, which may be quite enough for a complete and quick cure of the patient.

Professional care of patients after operations involves knowledge of both the regular changes in their general condition, local processes, and the possible development of complications.

CARE is one of the important elements in the treatment of the patient, organized on the basis of professional knowledge of possible changes or complications in patients after surgery and is aimed at timely prevention and elimination of them.

The amount of care depends on the condition of the patient, his age, the nature of the disease, the volume of surgery, the prescribed regimen, and the complications that arise.

Nursing is a help to the sick in his infirm state and the most important element of medical activity.

In severe postoperative patients, care includes assistance in meeting the basic needs of life (food, drink, movement, emptying the intestines, bladder, etc.); carrying out personal hygiene measures (washing, prevention of bedsores, change of linen, etc.); help during painful conditions (vomiting, coughing, bleeding, respiratory failure, etc.).

In surgical practice, in patients suffering from pain, who are in fear before or after surgery, care involves an active position on the part of the staff. Surgical patients, especially severe postoperative patients, do not ask for help. Any care measures bring them additional painful discomfort, so they have a negative attitude to any attempts to activate the motor regime, to perform the necessary hygiene procedures. In these situations, personnel must exercise caring, patient perseverance.

An important component of patient care is to create maximum physical and mental rest. Silence in the room where the patients are, a calm, even, benevolent attitude of medical personnel towards them, the elimination of all adverse factors that can injure the patient's psyche - these are some of the basic principles of the so-called medical-protective regime of medical institutions, on which efficiency largely depends treatment of patients. For a good outcome of the disease, it is very important that the patient is in a calm, physiologically comfortable position, in good hygienic conditions, and receives a balanced diet.

The caring, warm, attentive attitude of medical personnel contributes to recovery.

SANITARY PREPARATION OF THE PATIENT FOR OPERATION

The preoperative period occupies an important place in the system of treatment and its organization. This is a certain period of time necessary to establish a diagnosis and bring the vital functions of organs and systems to vital levels.

Preoperative preparation is carried out in order to reduce the risk of surgery, to prevent possible complications. The preoperative period can be very short during emergency operations and relatively extended during elective operations.

General preparation for planned operations includes all studies related to establishing a diagnosis, identifying complications of the underlying disease and concomitant diseases, and determining the functional state of vital organs. When indicated, drug treatment is prescribed, aimed at improving the activity of various systems, in order to lead to a certain readiness of the patient's body for surgical intervention. The result of the upcoming treatment largely depends on the nature and conduct, and ultimately on the organization of the preoperative period.

It is advisable to postpone planned operations during menstruation, even with a slight rise in temperature, a slight cold, the appearance of pustules on the body, etc. Mandatory sanitation of the oral cavity.

The duties of junior and middle staff include sanitary preparation of the patient. It usually starts the evening before the operation. The patient is explained that the operation must be performed on an empty stomach. In the evening, patients receive a light supper, and in the morning they cannot eat or drink.

In the evening, in the absence of contraindications, all patients are given a cleansing enema. Then the patient takes a hygienic bath or shower, he is changed underwear and bed linen. At night, according to the doctor's prescription, the patient is given sleeping pills or sedatives.

In the morning immediately before the operation, the hair from the future surgical field and its circumference is widely shaved, taking into account the possible expansion of access. Before shaving, the skin is wiped with a disinfectant solution and allowed to dry, and after shaving, it is wiped with alcohol. These activities can not be done in advance, as it is possible to infect abrasions and scratches obtained during shaving. A few hours are enough to turn them into a focus of infection with the subsequent development of postoperative complications.

In the morning the patient washes, brushes his teeth. The dentures are taken out, wrapped in gauze and placed in the nightstand. A cap or scarf is put on the scalp. Braids are braided for women with long hair.

After premedication, the patient is taken to the operating room on a gurney, accompanied by a nurse dressed in a clean gown, cap and mask.

For patients admitted on an emergency basis, the volume of sanitary preparation depends on the urgency of the necessary operation and is determined by the doctor on duty. Mandatory activities are emptying the stomach with a gastric tube and shaving the scalp of the surgical field.

HYGIENE OF THE BODY, UNDERWEAR, DISCHARGE OF THE PATIENT

IN THE POSTOPERATIVE PERIOD

The postoperative period is a period of time after the operation, which is associated with the completion of the wound process - wound healing, and stabilization of the reduced and affected functions of life-supporting organs and systems.

Patients in the postoperative period distinguish between active, passive and forced position.

An active position is characteristic of patients with relatively mild diseases, or in the initial stage of severe diseases. The patient can independently change position in bed, sit down, get up, walk.

The passive position is observed in the unconscious state of the patient and, less often, in case of extreme weakness. The patient is motionless, remains in the position that was given to him, the head and limbs hang down due to their gravity. The body slides off the pillows to the lower end of the bed. Such patients require special monitoring by the medical staff. It is necessary from time to time to change the position of the body or its individual parts, which is important in the prevention of complications - bedsores, hypostatic pneumonia, etc.

The patient takes a forced position to stop or weaken his painful sensations (pain, cough, shortness of breath, etc.).

Care of patients with a general regime after surgery is reduced mainly to the organization and control over their compliance with hygiene measures. Severely ill patients with bed rest need active assistance in caring for the body, linen and in the implementation of physiological functions.

The competence of medical personnel includes the creation of a functionally advantageous position for the patient, conducive to recovery and prevention of complications. For example, after surgery on the abdominal organs, it is advisable to position with a raised head end and slightly bent knees, which helps to relax the abdominal press and provides peace to the surgical wound, favorable conditions for breathing and blood circulation.

To give the patient a functionally advantageous position, special head restraints, rollers, etc. can be used. There are functional beds, consisting of three movable sections, which allow you to smoothly and silently give the patient a comfortable position in bed with the help of handles. The legs of the bed are equipped with wheels for moving it to another place.

An important element in the care of critically ill patients is the prevention of bedsores.

A bedsore is a necrosis of the skin with subcutaneous tissue and other soft tissues, which develops as a result of their prolonged compression, disorders of local blood circulation and nervous trophism. Bed sores usually form in severe, weakened patients who are forced to be in a horizontal position for a long time: when lying on the back - in the region of the sacrum, shoulder blades, elbows, heels, on the back of the head, when the patient is positioned on his side - in the region of the hip joint, in the projection of the greater trochanter femur.

The occurrence of bedsores is facilitated by poor patient care: untidy maintenance of the bed and underwear, uneven mattress, crumbs of food in the bed, prolonged stay of the patient in one position.

With the development of bedsores, reddening of the skin, soreness first appears on the skin, then the epidermis is exfoliated, sometimes with the formation of blisters. Next, necrosis of the skin occurs, spreading deep into and to the sides with the exposure of muscles, tendons, and periosteum.

To prevent bedsores, change the position every 2 hours, turning the patient, while examining the places of possible occurrence of pressure sores, wiping with camphor alcohol or another disinfectant, performing a light massage - stroking, patting.

It is very important that the bed of the patient is tidy, the mesh is well stretched, with a smooth surface, a mattress without bumps and depressions is placed on top of the mesh, and a clean sheet is placed on it, the edges of which are tucked under the mattress so that it does not roll down and does not gather into folds.

For patients suffering from urinary incontinence, feces, with abundant discharge from wounds, it is necessary to put an oilcloth across the entire width of the bed and bend its edges well to prevent contamination of the bed. A diaper is laid on top, which is changed as needed, but at least every 1-2 days. Wet, soiled linen is changed immediately.

A rubber inflatable circle covered with a diaper is placed under the sacrum of the patient, and cotton-gauze circles are placed under the elbows and heels. It is more efficient to use an anti-decubitus mattress, which consists of many inflatable sections, in which the air pressure changes periodically in waves, which also periodically changes pressure on different areas of the skin in waves, thereby producing a massage, improving skin blood circulation. When superficial skin lesions appear, they are treated with a 5% solution of potassium permanganate or an alcohol solution of brilliant green. Treatment of deep bedsores is carried out according to the principle of treatment of purulent wounds, as prescribed by a doctor.

Change of bed and underwear is carried out regularly, at least once a week, after a hygienic bath. In some cases, linen is changed additionally as needed.

Depending on the condition of the patient, there are several ways to change bed and underwear. When the patient is allowed to sit, he is transferred from bed to a chair, and the junior nurse makes the bed for him.

Changing a sheet under a seriously ill patient requires a certain skill from the staff. If the patient is allowed to turn on his side, you must first gently raise his head and remove the pillow from under it, and then help the patient turn on his side. On the vacated half of the bed, located on the side of the patient's back, you need to roll up a dirty sheet so that it lies in the form of a roller along the patient's back. On the vacated place you need to put a clean, also half-rolled sheet, which in the form of a roller will lie next to the roller of the dirty sheet. Then the patient is helped to lie on his back and turn on the other side, after which he will be lying on a clean sheet, turning to face the opposite edge of the bed. After that, the dirty sheet is removed and the clean one is straightened.

If the patient cannot move at all, you can change the sheet in another way. Starting from the lower end of the bed, roll the dirty sheet under the patient, lifting his shins, thighs and buttocks in turn. The roll of the dirty sheet will be under the patient's lower back. A clean sheet rolled up in the transverse direction is placed on the foot end of the bed and straightened towards the head end, also raising the lower limbs and buttocks of the patient. A roller of a clean sheet will be next to a roller of a dirty one - under the lower back. Then one of the orderlies slightly raises the head and chest of the patient, while the other at this time removes the dirty sheet, and straightens a clean one in its place.

Both ways of changing the sheet, with all the dexterity of the caregivers, inevitably cause a lot of anxiety to the patient, and therefore it is sometimes more expedient to put the patient on a gurney and make the bed, especially since in both cases it is necessary to do this together.

In the absence of a wheelchair, you need to shift the patient together to the edge of the bed, then straighten the mattress and sheet on the freed half, then transfer the patient to the cleaned half of the bed and do the same on the other side.

When changing underwear in seriously ill patients, the nurse should bring her hands under the patient's sacrum, grab the edges of the shirt and carefully bring it to the head, then raise both hands of the patient and transfer the rolled shirt at the neck over the patient's head. After that, the hands of the patient are released. The patient is dressed in the reverse order: first they put on the sleeves of the shirt, then throw it over the head, and, finally, straighten it under the patient.

For very sick patients, there are special shirts (undershirts) that are easy to put on and take off. If the patient's arm is injured, first remove the shirt from the healthy arm, and only then from the patient. They put on the sick hand first, and then the healthy one.

In severe patients who are on bed rest for a long time, various disorders of the skin condition may occur: pustular rash, peeling, diaper rash, ulceration, bedsores, etc.

It is necessary to wipe the skin of patients daily with a disinfectant solution: camphor alcohol, cologne, vodka, half alcohol with water, table vinegar (1 tablespoon per glass of water), etc. To do this, take the end of the towel, moisten it with a disinfectant solution, wring it out slightly and begin to wipe it behind the ears, neck, back, front surface of the chest and in the armpits. Pay attention to the folds under the mammary glands, where diaper rash can form in obese women. Then dry the skin in the same order.

A patient who is on bed rest should wash his feet two or three times a week, placing a basin of warm water at the foot end of the bed. In this case, the patient lies on his back, the junior nurse lathers his feet, washes, wipes, and then cuts his nails.

Severely ill patients cannot brush their teeth on their own, therefore, after each meal, the nurse must treat the patient's mouth. To do this, she alternately takes the patient’s cheek from the inside with a spatula and wipes the teeth and tongue with tweezers with a gauze ball moistened with a 5% solution of boric acid, or a 2% solution of sodium bicarbonate, or a weak solution of potassium permanganate. After that, the patient rinses his mouth thoroughly with the same solution or just warm water.

If the patient is not able to rinse, then he should irrigate the oral cavity with Esmarch's mug, rubber pear or Janet's syringe. The patient is given a semi-sitting position, the chest is covered with an oilcloth, a kidney-shaped tray is brought to the chin to drain the washing liquid. The nurse alternately pulls the right and then the left cheek with a spatula, inserts the tip and irrigates the oral cavity, washing away food particles, plaque, etc. with a jet of liquid.

Severely ill patients often experience inflammation on the oral mucosa - stomatitis, gums - gingivitis, tongue - glossitis, which is manifested by reddening of the mucous membrane, salivation, burning, pain when eating, the appearance of ulcers and bad breath. In such patients, therapeutic irrigation is performed with disinfectants (2% chloramine solution, 0.1% furatsilin solution, 2% sodium bicarbonate solution, a weak solution of potassium permanganate). You can make applications by applying sterile gauze pads soaked in a disinfectant solution or painkiller for 3-5 minutes. The procedure is repeated several times a day.

If the lips are dry and cracks appear in the corners of the mouth, it is not recommended to open the mouth wide, touch the cracks and tear off the crusts that have formed. To alleviate the patient's condition, hygienic lipstick is used, lips are lubricated with any oil (vaseline, creamy, vegetable).

Dentures are removed at night, washed with soap, stored in a clean glass, washed again in the morning and put on.

When purulent secretions appear that stick together the eyelashes, the eyes are washed with sterile gauze swabs moistened with a warm 3% solution of boric acid. The movements of the tampon are made in the direction from the outer edge to the nose.

For instillation of drops into the eye, an eye dropper is used, and for different drops there should be different sterile pipettes. The patient throws his head back and looks up, the nurse pulls back the lower eyelid and, without touching the eyelashes, without bringing the pipette closer to the eye than 1.5 cm, instill 2-3 drops into the conjunctival fold of one and then the other eye.

Eye ointments are laid with a special sterile glass rod. The eyelid of the patient is pulled down, an ointment is laid behind it and rubbed over the mucous membrane with soft movements of the fingers.

In the presence of discharge from the nose, they are removed with cotton turundas, introducing them into the nasal passages with light rotational movements. When crusts form, it is necessary to first drip a few drops of glycerin, vaseline or vegetable oil into the nasal passages, after a few minutes the crusts are removed with cotton turundas.

Sulfur that accumulates in the external auditory canal should be carefully removed with a cotton swab, after having dripped 2 drops of a 3% hydrogen peroxide solution. To drip drops into the ear, the patient's head must be tilted in the opposite direction, and the auricle pulled back and up. After instillation of drops, the patient should remain in a position with his head tilted for 1-2 minutes. Do not use hard objects to remove wax from the ears because of the risk of damage to the eardrum, which can lead to hearing loss.

Due to their sedentary state, seriously ill patients require assistance in carrying out their physiological functions.

If it is necessary to empty the intestines, the patient, who is on strict bed rest, is given a vessel, and when urinating, a urinal.

The vessel can be metal with an enamel coating or rubber. The rubber vessel is used for debilitated patients, in the presence of bedsores, with incontinence of feces and urine. The vessel should not be tightly inflated, otherwise it will exert significant pressure on the sacrum. When giving the ship to the bed, be sure to put an oilcloth under it. Before serving, the vessel is rinsed with hot water. The patient bends his knees, the nurse brings his left hand to the side under the sacrum, helping the patient raise the pelvis, and with her right hand places the vessel under the patient's buttocks so that the perineum is above the opening of the vessel, covers the patient with a blanket and leaves him alone. After defecation, the vessel is removed from under the patient, its contents are poured into the toilet. The vessel is thoroughly washed with hot water, and then disinfected with a 1% solution of chloramine or bleach for an hour.

After each act of defecation and urination, patients should be washed, otherwise maceration and inflammation of the skin are possible in the area of the inguinal folds and perineum.

Washing is carried out with a weak solution of potassium permanganate or other disinfectant solution, the temperature of which should be 30-35 ° C. For washing, you need to have a jug, forceps and sterile cotton balls.

When washing away, a woman should lie on her back, bending her legs at the knees and slightly spreading them at the hips, a vessel is placed under the buttocks.

In the left hand, the nurse takes a jug with a warm disinfectant solution and pours water on the external genitalia, and with a forceps with a cotton swab clamped into it, movements are made from the genitals to the anus, i.e. top down. After that, wipe the skin with a dry cotton swab in the same direction, so as not to infect the anus into the bladder and external genitalia.

Washing can be done from an Esmarch mug equipped with a rubber tube, a clamp and a vaginal tip, directing a stream of water or a weak solution of potassium permanganate to the perineum.

Men are much easier to wash. The position of the patient on the back, legs bent at the knees, a vessel is placed under the buttocks. Cotton, clamped in a forceps, wipe the perineum dry, lubricate with vaseline oil to prevent diaper rash.

POSTOPERATIVE WOUND CARE

The local result of any operation is a wound, which is characterized by three major features: gaping, pain, bleeding.

The body has a perfect mechanism aimed at wound healing, which is called the wound process. Its purpose is to eliminate tissue defects and relieve the listed symptoms.

This process is an objective reality and occurs independently, passing through three phases in its development: inflammation, regeneration, reorganization of the scar.

The first phase of the wound process - inflammation - is aimed at cleansing the wound from non-viable tissues, foreign bodies, microorganisms, blood clots, etc. Clinically, this phase has symptoms characteristic of any inflammation: pain, hyperemia, swelling, dysfunction.

Gradually, these symptoms subside, and the first phase is replaced by the regeneration phase, the meaning of which is to fill the wound defect with young connective tissue. At the end of this phase, the processes of constriction (tightening of the edges) of the wound begin due to fibrous connective tissue elements and marginal epithelization. The third phase of the wound process, scar reorganization, is characterized by its strengthening.

The outcome in surgical pathology largely depends on the correct observation and care of the postoperative wound.

The process of wound healing is absolutely objective, takes place independently and is worked out to perfection by nature itself. However, there are reasons that impede the wound process, inhibit the normal healing of the wound.

The most common and dangerous cause that complicates and slows down the biology of the wound process is the development of infection in the wound. It is in the wound that microorganisms find the most favorable living conditions with the necessary humidity, comfortable temperature, and an abundance of nutritious foods. Clinically, the development of infection in the wound is manifested by its suppuration. The fight against infection requires a significant strain on the forces of the macroorganism, time, is always risky in terms of generalization of the infection, the development of other serious complications.

Infection of the wound is facilitated by its gaping, since the wound is open to the ingress of microorganisms into it. On the other hand, significant tissue defects require more plastic materials and more time to eliminate them, which is also one of the reasons for the increase in wound healing time.

Thus, it is possible to promote the speedy healing of a wound by preventing its infection and by eliminating the gap.

In most patients, gaping is eliminated during the operation by restoring anatomical relationships by layer-by-layer suturing of the wound.

Care of a clean wound in the postoperative period comes down primarily to measures to prevent its microbial contamination by a secondary, nosocomial infection, which is achieved by strict adherence to well-developed asepsis rules.

The main measure aimed at preventing contact infection is the sterilization of all objects that may come into contact with the surface of the wound. Instruments, dressings, gloves, underwear, solutions, etc. are subject to sterilization.

Directly in the operating room after suturing the wound, it is treated with an antiseptic solution (iodine, iodonate, iodopyrone, brilliant green, alcohol) and closed with a sterile bandage, which is tightly and securely fixed by bandaging or with glue, adhesive plaster. If in the postoperative period the bandage is tangled or soaked with blood, lymph, etc., you must immediately notify the attending physician or the doctor on duty, who, after examination, instructs you to change the bandage.

With any dressing (removing the previously applied dressing, examining the wound and therapeutic manipulations on it, applying a new dressing), the wound surface remains open and for a more or less long time comes into contact with air, as well as with tools and other objects used in dressings. Meanwhile, the air of the dressing rooms contains significantly more microbes than the air of operating rooms, and often other rooms of the hospital. This is due to the fact that a large number of people are constantly circulating in the dressing rooms: medical staff, patients, students. Wearing a mask during dressings is mandatory in order to avoid droplet infection with saliva splashes, coughing, and breathing on the wound surface.

After the vast majority of clean operations, the wound is sutured tightly. Occasionally, between the edges of the sutured wound or through a separate puncture, the cavity of the hermetically sutured wound is drained with a silicone tube. Drainage is performed to remove wound secretions, remnants of blood and accumulating lymph in order to prevent wound suppuration. Most often, drainage of clean wounds is performed after breast surgery, when a large number of lymphatic vessels are damaged, or after operations for extensive hernias, when pockets in the subcutaneous tissue remain after the removal of large hernial sacs.

Distinguish passive drainage, when the wound exudate flows by gravity. With active drainage or active aspiration, the contents are removed from the wound cavity using various devices that create a constant vacuum in the range of 0.1-0.15 atm. Rubber cylinders with a sphere diameter of at least 8-10 cm, industrially manufactured corrugations, as well as modified aquarium microcompressors of the MK brand are used as a vacuum source with the same efficiency.

Postoperative care for patients with vacuum therapy, as a method of protecting an uncomplicated wound process, is reduced to monitoring the presence of a working vacuum in the system, as well as monitoring the nature and amount of wound discharge.

In the immediate postoperative period, air may be sucked in through skin sutures or leaky junctions of tubes with adapters. When the system is depressurized, it is necessary to create a vacuum in it again and eliminate the source of air leakage. Therefore, it is desirable that the device for vacuum therapy had a device for monitoring the presence of vacuum in the system. When using a vacuum of less than 0.1 atm, the system ceases to function on the very first day after the operation, since the tube is obturated due to thickening of the wound exudate. With a degree of rarefaction of more than 0.15 atm, clogging of the side holes of the drainage tube with soft tissues is observed with their involvement in the drainage lumen. This has a damaging effect not only on fiber, but also on young developing connective tissue, causing it to bleed and increase wound exudation. A vacuum of 0.15 atm allows you to effectively aspirate the discharge from the wound and have a therapeutic effect on the surrounding tissues.

The contents of the collections are evacuated once a day, sometimes more often - as they are filled, the amount of liquid is measured and recorded.

Collection jars and all connecting tubes are subjected to pre-sterilization cleaning and disinfection. They are first washed with running water so that no clots remain in their lumen, then they are placed in a 0.5% solution of synthetic detergent and 1% hydrogen peroxide for 2-3 hours, after which they are washed again with running water and boiled for 30 minutes.

If suppuration of the surgical wound has occurred or the operation was originally performed for a purulent disease, then the wound must be carried out in an open way, that is, the edges of the wound must be parted, and the wound cavity drained in order to evacuate the pus, and create conditions for cleaning the edges and bottom of the wound from necrotic tissues .

Working in the wards for patients with purulent wounds, it is necessary to adhere to the rules of asepsis no less scrupulously than in any other department. Moreover, it is even more difficult to ensure the asepsis of all manipulations in the purulent department, since one must think not only about not contaminating the wound of a given patient, but also about how not to transfer the microbial flora from one patient to another. “Superinfection”, that is, the introduction of new microbes into a weakened organism, is especially dangerous.

Unfortunately, not all patients understand this and often, especially patients with chronic suppurative processes, are untidy, touch the pus with their hands, and then wash them poorly or not at all.

It is necessary to carefully monitor the condition of the dressing, which should remain dry and not contaminate the linen and furniture in the ward. Bandages often have to be bandaged and changed.

The second important sign of a wound is pain, which occurs as a result of an organic lesion of nerve endings and in itself causes functional disorders in the body.

The intensity of pain depends on the nature of the wound, its size and location. Patients perceive pain differently and react to it individually.

Intense pain can be the starting point of collapse and development of shock. Severe pains usually absorb the patient's attention, interfere with sleep at night, limit the patient's mobility, and in some cases cause a feeling of fear of death.

The fight against pain is one of the necessary tasks of the postoperative period. In addition to the appointment of medications for the same purpose, elements of a direct impact on the lesion are used.

During the first 12 hours after surgery, an ice pack is placed on the wound area. Local exposure to cold has an analgesic effect. In addition, cold causes contraction of blood vessels in the skin and underlying tissues, which contributes to thrombosis and prevents the development of hematoma in the wound.

To prepare the “cold”, water is poured into a rubber bladder with a screw cap. Before screwing the lid on, the air must be expelled from the bubble. Then the bubble is placed in the freezer until completely frozen. The ice pack should not be placed directly on the bandage; a towel or napkin should be placed under it.

To reduce pain, it is very important to give the affected organ or part of the body the correct position after the operation, in which the maximum relaxation of the surrounding muscles and functional comfort for the organs are achieved.

After operations on the abdominal organs, a position with a raised head end and slightly bent knees is functionally beneficial, which helps to relax the muscles of the abdominal wall and provides peace to the surgical wound, favorable conditions for breathing and blood circulation.

The operated limbs should be in an average physiological position, which is characterized by balancing the action of antagonist muscles. For the upper limb, this position is the abduction of the shoulder to an angle of 60 ° and flexion to 30-35 °; the angle between the forearm and shoulder should be 110°. For the lower limb, flexion at the knee and hip joints is performed up to an angle of 140 °, and the foot should be at a right angle to the lower leg. After the operation, the limb is immobilized in this position with splints, a splint, or a fixing bandage.

Immobilization of the affected organ in the postoperative period greatly facilitates the patient's well-being by relieving pain, improves sleep, and expands the general motor regimen.

With purulent wounds in the 1st phase of the wound process, immobilization helps to delimit the infectious process. In the regeneration phase, when the inflammation subsides and the pain in the wound subsides, the motor mode is expanded, which improves the blood supply to the wound, promotes faster healing and restoration of function.

The fight against bleeding, the third important sign of a wound, is a serious task of any operation. However, if for some reason this principle turned out to be unrealized, then in the next few hours after the operation, the bandage gets wet with blood or blood flows through the drains. These symptoms serve as a signal for an immediate examination of the surgeon and active actions in terms of revision of the wound in order to finally stop the bleeding.