A.V. Geraskin, N.V. Polunina, T.N. Kobzeva, N.M. Ashanina ORGANIZATION OF CHILD CARE IN A SURGICAL HOSPITAL Recommended by the Educational and Methodological Association for Medical and Pharmaceutical Education of Russian Universities as a textbook for students studying in the specialty 06010365 - Pediatrics Medical Information Agency Moscow 2012 UDC 616-08:616-053.2:61 7-089 BBK 51.1(2)2 G37 Authors: teaching staff of the State Budgetary Educational Institution of Higher Professional Education “Russian National Research Medical University named after. N.I. Pirogov" Ministry of Health and Social Development of the Russian Federation A.V. Geraskin - Head of the Department of Pediatric Surgery; professor; N.V. Polunina - acting Rector, Professor of the Department of Public Health and Healthcare; corresponding member RAMS; T.N. Kobzeva - Associate Professor of the Department of Pediatric Surgery; N.M. Ashanina is an associate professor of the Department of Public Health and Healthcare. G37 Geraskin A.V. Organization of child care in a surgical hospital / A.V. Geraskin, N.V. Polunina, T.N. Kobzeva, N.M. Ashanina. - M.: Medical Information Agency LLC, 2012. - 200 p.: ill. ISBN 978-5-8948-1909-9 The textbook introduces students who have crossed the threshold of a surgical hospital for the first time as medical workers with the organization and mode of operation of the children's surgical department, as well as their job descriptions. The features of child care, the organization of therapeutic feeding of patients, and basic medical procedures in a pediatric surgical clinic are described. The final chapter is devoted to first aid. For medical students and surgeons. UDC 616-08:616-053.2:617-089 BBK 51.1(2)2 ISBN 978-5-8948-1909-9 © Geraskin A.V., Polunina N.V., Kobzeva T.N., Ashanina N. M., 2012 © Design. Medical Information Agency LLC, 2012 All rights reserved. No part of this book may be reproduced in any form without the written permission of the copyright holders. Contents Introduction................................................... ........................................................ .......... 6 Chapter 1. Structure and organization of work of the children's surgical clinic................................. ............................................... 9 1.1. Structure and organization of the reception room.................................... 9 1.1.1. Structure and mode of operation............................................................. .. 9 1.1.2. Therapeutic and protective regime of the emergency room. .........23 1.1.3. Sanitary and hygienic regime of the reception area......23 1.1.4. Epidemiological regime of the emergency room......24 1.2. Structure and organization of work of a specialized ward department. Safety precautions...................................25 1.2.1. Structure and mode of operation............................................................. ..30 1.2.2. Therapeutic and protective regime. Deontology................................................. ...........................43 1.2.3. Sanitary and hygienic regime of the ward department.................................................... ...............47 1.2.4. Epidemiological regime of the ward department.........56 1.3. Structure and organization of work of the operating unit................63 1.3.1. Structure and mode of operation............................................................. ..63 1.3.2. Therapeutic and protective regime of the operating unit............................................................ ...............72 1.3.3. Sanitary and hygienic regime of the operating unit............................................................ ...............72 1.3.4. Epidemiological regime of the operating unit.................................................... ..........74 1.4. Structure and organization of work of the resuscitation and intensive care unit.................................................. .......................81 4 Contents 1.4.1. Structure and mode of operation............................................................. 1.4.2. Therapeutic and protective regime of the resuscitation and intensive care unit.................................... 1.4.3. Sanitary and hygienic regime of the resuscitation and intensive care unit.................................... 1.4.4. Epidemiological regime of the intensive care unit.................................................... 1.5. Structure and organization of work of a one-day hospital........ 1.5.1. Structure and mode of operation............................................................. 1.5.2. Therapeutic and protective regime of a hospital for one day.................................................... .......... 1.5.3. Sanitary and hygienic regime of a hospital for one day.................................................... .......... 1.5.4. Epidemiological regime of a hospital for one day.................................................... ....... 81 83 85 85 86 86 88 89 90 Chapter 2. Organization of child care in a surgical clinic..................... ........................................... 91 2.1. Age-related anatomical and physiological characteristics of child care in a surgical clinic.................................................... 92 2.1.1. Personal hygiene of newborns and infants. ......... 92 2.1.2. Personal hygiene of infants and toddlers.................................................... ............. 94 2.1.3. Personal hygiene of middle-aged and older children who are on a general regime.................................................... 95 2.1.4. Personal hygiene of patients on strict bed rest.................................................... ................. 95 2.2. Peculiarities of child care in a pediatric surgical clinic.................................................... ....................99 2.2.1. Personal hygiene of the child before surgery.................................... 99 2.2.2. Peculiarities of caring for children after abdominal surgery.................................................... ...............101 2.2.3. Peculiarities of caring for children after operations on the thoracic organs.................................................... ....106 2.2.4. Features of care for urological patients.........108 2.2.5. Peculiarities of care for traumatological and orthopedic patients..................................................108 2.2. 6. Features of care in the intensive care unit.................................................................... .........113 Chapter 3. Organization of therapeutic feeding of patients in a children's surgical clinic.................................... ........................115 3.1. Organization of feeding of newborns and infants.................................................... ...............................115 3.2. Organization of therapeutic nutrition for older children.................................................... ...............................117 Contents 5 Chapter 4. Basic medical procedures for caring for children in a surgical clinic...... ........................................................ ..........120 4.1. Measuring body temperature................................................................... ......120 4.2. Administration of medications........................................124 4.2.1. Types of local treatment................................................................... ....125 4.2.2. General treatment........................................................ ...................125 4.2.2.1. Enteral administration of drugs................................................................. ...............126 4.2.2.2. Administration of drugs into the respiratory tract.........................127 4.2.2.3. Parenteral administration of drugs...................................127 4.3. Collection of analyzes......................................................... ...............................137 4.4. Determination of blood group and Rh factor.................................... .......138 Chapter 5. Providing first aid to children.................................... .142 5.1. Applying bandages. Desmurgy.............................................142 5.2. Stopping external bleeding...................................................149 5.3. Transport immobilization for fractures....................................150 5.4. First aid for poisoning......................................................... 153 5.5. First aid for fainting.................................................................... .....153 5.6. Prehospital cardiopulmonary resuscitation (closed-circuit cardiac massage, artificial respiration) ..............................154 Appendix................... ........................................................ ................................159 Test tasks................... ........................................................ ........................164 Literature.................... ........................................................ ...................................194 Introduction 1st-2nd year students starting practical training in clinics , and then to their first production practice, must become familiar with the structure and organization of work in a children's surgical clinic, issues of deontology of medical personnel, organization and requirements of safety and fire safety, medical-protective, sanitary-hygienic and epidemiological regimes, organization of care children. Without this, the successful work of a future doctor is impossible. Becoming full-fledged medical professionals, students must comply with all requirements and legal provisions for working in medical institutions. The doctor must not only perform medical procedures himself and follow job instructions, but also must know, carry out, control and be able to teach the rules of care to nurses and junior staff where he will work in the future. The quality of the patient’s examination, timely diagnosis, favorable course of surgery, the course of the postoperative period and recovery depend on properly organized care. Neglect of caring for surgical patients or ignorance of it can negate the results of the most brilliant and impeccably performed operations. The basic knowledge acquired by students in the following cycles: biology, chemistry, physics, anatomy, microbiology, physiology, pharmacology, etc., will be necessary to understand the basics of organizing medical and protective, sanitary and epidemiological regimes, conditions of care in the clinic sick children of different ages. It becomes clear that there is a need for further study of such basic disciplines as: social hygiene, healthcare organization, epidemiology, psychology, etc. A modern large children's clinic is a multidisciplinary institution that provides medical diagnostic, therapeutic and rehabilitation care to children with various diseases, both surgical and therapeutic, from the neonatal period to adolescence. Hospitals have long been and remain today the main clinical base for training students and training future doctors. The modern system of medical care provides for the possibility of organizing in large children's hospitals consultation and diagnostic centers, trauma centers for the provision of outpatient care and specialized departments for hospitalization of patients. The Consultative and Diagnostic Center, equipped with modern equipment, provides highly qualified diagnostic and therapeutic assistance to children with various diseases. Such a center includes the following departments: ultrasound and x-ray, computed tomography, radioisotope diagnostics, endoscopic, laboratory diagnostics. Treatment and diagnostic centers include departments: orthopedic, uronephrological, follow-up care of newborns, ophthalmology, clinical genetics, cryotherapy, gastroenterology, etc. Medical care for children is provided free of charge upon presentation of a compulsory health insurance policy (CHI). 24-hour emergency care for children is provided at the trauma center. Modern advances in pediatric surgery and anesthesiology have made it possible to open an outpatient surgery center or a one-day hospital to perform planned surgical interventions in children over 1 year of age. The organization of the work of a modern children's surgical clinic is determined by the goal of providing emergency and planned diagnostic and therapeutic care to children both in outpatient and inpatient settings, the need for rehabilitation and after-care. 8 Organization of care for children in a surgical hospital In connection with the requirements imposed by the new Federal State Educational Standard for Higher Professional Education in the specialty of Pediatrics, in the process of undergoing training in the general care of surgical children, students must know: types of sanitary treatment of sick children and adolescents, types of fevers, features of observation and care of sick children and adolescents with diseases of various body systems. Students should also be able to: perform sanitary treatment of the patient upon admission to the hospital and during the period of stay in the hospital, change the patient’s underwear and bed linen, treat bedsores; provide care for patients of different ages suffering from diseases of various organs and systems, transportation; measure body temperature, daily diuresis, collect biological material for laboratory research, conduct anthropometry for children and adolescents, various types of enemas, and carry out feeding; carry out disinfection and pre-sterilization preparation of medical instruments, materials and patient care products. Students must have: skills in caring for sick children and adolescents, taking into account their age, nature and severity of the disease; skills in caring for seriously ill and dying patients. Practical training carried out after the 1st year as an assistant to junior medical staff should provide students with the following knowledge and skills. Know: the main stages of the work of junior medical personnel. Be able to: perform patient care procedures. After the 2nd year - assistant ward nurse. Know: the main stages of the work of a ward nurse. Be able to: perform manipulations by a ward nurse. After the 3rd year - assistant procedural nurse. Know: the main stages of the work of procedural medical personnel. Be able to: perform the procedures of a procedural nurse. Chapter 1 STRUCTURE AND ORGANIZATION OF THE WORK OF A CHILDREN'S SURGICAL CLINIC A children's surgical clinic is a complex of functional units designed to receive and maintain patients in a hospital, provide them with medical surgical care, prepare for surgery, perform surgery and postoperative care for patients until recovery. A modern children's surgical clinic includes the following structural units: emergency room, specialized surgical departments (urological, orthopedic traumatology, thoracic, abdominal, emergency and purulent surgery, newborns, elective, cardiological, etc.), functional diagnostic department, operating unit, department resuscitation and intensive care, economic services. 1.1. Structure and organization of work of the reception room 1.1.1. Structure and mode of operation Any hospital “begins” with the emergency department. The reception department is assigned the following main tasks. 10 Organization of child care in a surgical hospital 1. Preparation of documentation for incoming patients, organization of reception and recording of the movement of patients throughout the hospital as a whole. 2. Primary examination, triage and referral of patients to various departments of the medical institution or for outpatient treatment, provision of emergency outpatient care. 3. Sanitary treatment of patients entering a medical institution. 4. Communication with the ambulance station, the Federal State Institution “Center for Hygiene and Epidemiology” and other medical institutions, notifying the relevant institutions about injuries on the street and at home, issuing certificates of incoming patients. To carry out the above tasks, the admission department must have qualified personnel, a rational layout, adequate throughput, diagnostic and treatment equipment, and medications. The admission department is located on the ground floor with an isolated entrance for receiving patients, has good communication with medical and diagnostic departments and provides good transportation of patients. Rice. 1. Half-box of the emergency room Chapter 1. Structure and organization of work of the children's surgical clinic Fig. 2. Half-box of the emergency room for newborns Fig. 3. Dressing room of the emergency department 11 12 Organization of care for children in a surgical hospital The admission department includes three sets of premises: 1) general; 2) diagnostic and therapeutic; 3) sanitary checkpoint. Common areas include: lobby, staff room, toilet, etc. Diagnostic and treatment rooms include: boxes for receiving both planned and emergency patients, a treatment room, a clean and purulent dressing room (Fig. 1–3). The sanitary passage includes: a dressing room, a bathroom and a dressing room. Operating mode. A strict sequence is observed in the work of the reception room: registration of patients, medical examination and sanitary treatment. 1. Registration of patients. For each person hospitalized in the admission department, the following is created: a medical record of an inpatient - the main document of the medical institution (medical history) (Fig. 4, 5), a statistical card of a person leaving the hospital (Fig. 6, 7), information about the patient is also entered in the admission journal sick. All data about the patient is entered into a computer, and an electronic medical history is created. The reception nurse fills out the passport part of the inpatient medical record: the child’s last name, first name, patronymic, address, age, last name, first name, patronymic and address of the parents, compulsory medical insurance policy details, which child care institution the child is visiting, date and hour of illness, date and hour hospital admission. Particular attention should be paid to clearly filling out the date and time of illness in case of injuries, burns, poisoning, and acute conditions requiring surgical treatment. The paperwork is completed with the signature of the child’s relatives, certifying their legal consent to perform surgical interventions and various studies, and the signature of the doctor and nurse of the emergency room (Fig. 8–10). 2. Medical examination. The responsibilities of the emergency room doctor include making a preliminary diagnosis, assessing the severity of the patient’s condition, ordering an examination, determining treatment tactics (hospitalization, observation, emergency surgery, providing outpatient care, etc.) and drawing up a medical record for an inpatient. It contains basic information about the patient: complaints, medical history, life history with the obligatory indication of data on past childhood infections and vaccinations, Chapter 1. Structure and organization of work of a children's surgical clinic 13 Fig. 4. Title page of an inpatient’s medical record (medical history) 14 Organization of care for children in a surgical hospital Fig. 5. Internal sheet of the medical record of an inpatient (medical history) Chapter 1. Structure and organization of work of the children's surgical clinic Fig. 6. Statistical map of a patient who left the hospital 15 16 Organization of child care in a surgical hospital Fig. 7. Reverse side of the statistical map of a patient who left the hospital Chapter 1. Structure and organization of work at a children’s surgical clinic Fig. 8. Consent of the child’s parents to the operation 17 18 Organization of care for children in a surgical hospital Fig. 9. The decision to carry out a medical intervention (operation) without the patient’s consent Chapter 1. Structure and organization of work at a children’s surgical clinic Fig. 10. Consent to anesthetic provision of medical intervention 19 20 Organization of care for children in a surgical hospital, allergic reactions, blood transfusions, operations, contacts with infections (according to relatives), objective status. All admitted patients undergo thermometry. For emergency patients in the emergency department, laboratory blood tests are performed around the clock using the express diagnostic method to determine: the number of leukocytes, ESR, hemoglobin, hematocrit, blood coagulation, acid-base balance, blood sugar, bilirubin, potassium and sodium, prothrombin index. For patients who require emergency surgical treatment, their blood type and Rh factor are determined. If necessary, emergency X-ray and ultrasound examinations are performed. The preparation of a medical record for an inpatient patient is completed by making a preliminary diagnosis, prescribing a regimen, examination, treatment, and indicating the method of transporting the patient to the department or operating room. The issue of the possibility of admitting the mother to care for the child is being decided (the mother must be healthy and must undergo a stool test for intestinal group to prevent the introduction of intestinal infection into the department). On the medical record of an inpatient, the time of the patient's visit to the emergency room is noted, and then the time of transfer to the department. If a patient receives outpatient care in the emergency room, then detailed entries are made in the outpatient register. If a child delivered by ambulance does not require hospitalization, he was provided with outpatient care, the surgical diagnosis was removed, the parents refuse the proposed hospitalization, the child is registered in the register of patients admitted and refusals of hospitalization. For all patients released from the emergency room who were admitted with abdominal pain over 3 years of age (children under 3 years of age are required to be hospitalized), if the diagnosis of acute appendicitis is excluded, an application for an active visit to the pediatrician at home is submitted to the children's clinic the next day. Hospitalization of patients in need of special inpatient examination and treatment is carried out around the clock by referral from clinic doctors, ambulance and emergency care teams. Patients with emergency illnesses who come to the emergency department on their own (by gravity) are also hospitalized. Regardless of whether the children taken to the hospital are hospitalized or not, they are provided with emergency care. Children under one year of age are hospitalized with their mother. Relatives with an older child may be hospitalized if he is in serious condition and needs constant care. If the patient is delivered unconscious due to an accident (transport or household injury, poisoning, etc.), the victim is reported to the police department, and after an initial medical examination, if necessary, the child can be sent without sanitary treatment to the intensive care unit or intensive care unit therapy, operating room for emergency care. Hospitalization of planned patients - somatically healthy children - is carried out for surgical treatment for a previously established diagnosis (umbilical, inguinal hernia, varicocele, etc.) or for the second stage of treatment in a specialized department. Hospitalization of planned patients is carried out in the morning, in boxes isolated from emergency patients, in order to prevent nosocomial infections. The procedure for registering a planned patient includes checking the necessary documentation and tests specified in the voucher for the operation (Fig. 11): i referral for hospitalization (referral for hospitalization, rehabilitation treatment, examination, consultation f.057/u-04); i a detailed extract from the child’s developmental history about the onset of the disease, treatment and examination performed in the clinic, in addition, there must be information about the child’s development, all previous somatic and infectious diseases (extract from the medical record of an outpatient, inpatient patient f. 027/u) ; i certificate of contact with infectious patients (valid for 3 days); i pediatrician’s conclusion about the absence of contraindications to elective surgery; i compulsory health insurance policy. All tests and studies are carried out on an outpatient basis and must correspond to the age norm. The emergency room doctor, when examining the child, must confirm the surgical diagnosis and the child’s physical health, 22 Organization of child care in a surgical hospital Fig. 11. Voucher for a planned operation Chapter 1. Structure and organization of work of a children's surgical clinic 23 no contraindications to anesthesia and planned surgery. A medical record of the inpatient is drawn up, the necessary sanitary and hygienic treatment is carried out, and the child is sent to the department. 1.1.2. Therapeutic and protective regime of the emergency room In the emergency room, the first acquaintance of a sick child with the medical environment and staff occurs, here he gets his first impression of the work of the medical institution. Parents with children of various ages, from newborns to teenagers, seek medical help. The excitement and anxiety of parents increases the sick child’s fear of a medical institution. The task of the medical staff of the emergency room is to inspire confidence and reassure not only the child, but also adults. Measures aimed at protecting the patient from negative emotions are taken from the first moment of his appearance in the hospital, from the emergency room to the operating room. A friendly, calm conversation with a child on abstract topics that are understandable to him allows you to get in touch with him, calm him down, and distract him from the upcoming unpleasant moments of hospitalization and surgical intervention. A child's positive psychological attitude will help speed up his recovery in the future. 1.1.3. Sanitary and hygienic regime of the reception room After a medical examination, the child is hygienically treated in the sanitary room of the reception room. The air temperature in the room should not be lower than 25 °C. The patient undresses and a thorough examination of the skin and hair is performed. (It is necessary to exclude head lice, scabies, infectious rash, etc.). The examination couch should be hard and covered with a sheet and diaper. The oilcloth of the couch is wiped with a rag soaked in a disinfectant solution after examining the patient. When lice is detected, the patient’s clothes are treated in a steam-formalin chamber, and the child’s hair is cut, treated with insecticidal preparations, and dressed in hospital clothes. If the patient’s condition allows, he is washed in a bath or shower at a temperature of 35–36 °C. Fingernails and toenails are cut (the scissors are boiled for 15 minutes after treatment for each patient). 24 Organization of child care in a surgical hospital When the patient’s condition does not allow him to take a bath or shower, partial treatment is performed. The child’s torso and limbs are wiped with a towel moistened with warm water, paying special attention to the treatment of skin folds. The child changes into hospital or home cotton clothes (pajamas, a change of underwear, leather slippers). Sanitation is carried out under the guidance of the duty nurse of the reception department. Newborn babies are hospitalized in hospital gowns. The nursing mother in the department is given a clean medical gown every day; she needs a comfortable change of homemade cotton clothes. A patient with an inpatient medical card is transported from the emergency department to the ward by an orderly or a nurse, depending on the severity of the general condition, on foot, on a gurney, on a wheelchair, in arms or in an incubator and hands him over to the guard nurse. The sanitary and hygienic regime of boxes and examination rooms corresponds to the regime of the ward department. It is necessary to regularly ventilate the premises, air conditioning, and wet cleaning of the premises twice a day using disinfectant solutions. (See details in the section sanitary and hygienic regime of the ward department. ) 1.1.4. Epidemiological regime of the emergency room In order to prevent the introduction and spread of nosocomial infection, it is necessary to separate flows and reduce contacts of emergency and planned patients to the maximum. Children with suspected surgical disease (acute appendicitis, etc.) with symptoms of a respiratory viral infection, intestinal infection, meningitis, chickenpox and other childhood infections may be admitted to the emergency room. It is necessary not only to make a correct diagnosis and determine treatment tactics for a sick child, but also to prevent infection of others. The emergency department of a children's hospital should be boxed. Boxes should make up 3–4% of the total number of beds. The most convenient for work are the individual Meltzer-Sokolov boxes, which include an antechamber, a ward, a sanitary unit, and an airlock for personnel. There is also a special box for hospitalization of newborn children (Fig. 12). Chapter 1. Structure and organization of work of the children's surgical clinic 25 Fig. 12. Half-box of the neonatal surgery department The child is taken to the box, where he is initially examined by a doctor, a preliminary diagnosis is made and the issue of the need for hospitalization or provision of outpatient, emergency care is decided. If, during a medical examination, a concomitant infectious disease is detected in the patient, he is sent to a surgical boxed department. In the emergency room, all rooms through which the patient has passed and all equipment with which he has come into contact are disinfected. An emergency notification filled out by a doctor is sent to the Center for Hygiene and Epidemiology. 1.2. Structure and organization of work of a specialized ward department. Safety precautions Each surgical department includes: wards for patients, a dressing room, a treatment room, a physiotherapy room, boxes for isolating patients with suspected concomitant infectious diseases. Utility rooms - 26 Organization of child care in a surgical hospital: office of the head of the department and the head nurse, resident's room, dining room, buffet, playroom, toilets for patients and medical staff, potty room, enema room, bathroom, clean and dirty linen, mother's room. The main part of the surgical department are the wards. According to accepted standards, beds in surgical wards are located at the rate of 7 m2 per bed. In pediatric surgical departments, there are wards for infants (half-boxes with 2–4 beds) (Fig. 13), younger (1–6 years) and older (Fig. 14), intensive care ward for seriously ill children. There are specific requirements for children's institutions. 1. Prevention of nosocomial infection. For this purpose, 25% of isolation wards are provided for cases of outbreaks of childhood infections and isolation of sick people, impenetrable ward sections and the possibility of their quarantine. 2. Possibility of evacuation within 15–20 minutes if necessary (a large number of elevators, wide staircases). 3. Designation of special premises for activities and games. 4. Allocation of about 20% of additional beds for mothers. The beds in the profile wards are functional or ordinary with a spring mesh, for small children - with rising high meshes, for newborns - plastic transparent "soap box" incubators. The beds in the wards are placed so that the child can be approached from all sides. Between the beds there are bedside tables on which glasses and sippy cups can stand. Inside the bedside tables you can store personal hygiene items, books, pencils, and easy-to-clean toys. Storing food in cabinets is strictly prohibited. A common table is installed in the ward, at which the doctor can fill out medical documentation, the nurse can use it when dispensing medications, and in their free time children can sit, study, and play at it. A modern surgical department is equipped with a treatment room (Fig. 15), “clean” and “purulent” dressing rooms, which should be located at different ends of the department. For a dressing room with one table, an area of ​​22 m2 is provided. Dressing rooms must have a supply and exhaust system Chapter 1. Structure and organization of work of a children's surgical clinic Fig. 13. Half-box for infants Fig. 14. Ward for older children 27 28 Organization of care for children in a surgical hospital Fig. 15. Treatment room in the surgical department with ventilation, transoms or air conditioning system, bactericidal lamps. The decoration of the premises and the hygienic regime in them are similar to those in the operating unit. In the treatment rooms, blood is taken for tests, intravenous infusions are given, systems for intravenous drip transfusion are assembled, and preparations are made for intramuscular injections. Dressing and procedure nurses replenish used materials and medications in the morning and prepare everything necessary for work at any time of the day until 10 a.m. Occupational safety for medical personnel and patients Fire safety In children's hospitals, safety regulations must be strictly observed. All premises of the children's hospital are equipped with a centralized fire warning system, regularly checked for the presence of fire extinguishing equipment, equipped with individual life support equipment, and have evacuation schemes in case of emergency situations. Medical staff are regularly trained. In the operating room, resuscitation and intensive care wards, treatment rooms Chapter 1. Structure and organization of work of a children's surgical clinic, 29 rooms, a sterilization room, where a large number of electrical appliances are used, there are oxygen supplies and cylinders with gaseous substances for medical purposes. In these premises, for fire safety purposes, non-sparking electrical equipment is used, which is located at a height of 2 m from the floor level, the tightness of oxygen connections is controlled, and wearing clothes made of synthetic materials is prohibited. Smoking is prohibited in the premises of children's hospitals. Electrical safety Electrical sockets and oxygen taps must be out of reach of children. A large number of modern diagnostic and treatment equipment used in a modern hospital must be correctly connected and grounded according to the instructions. Wet cleaning and disinfection of premises should be carried out with electrical appliances turned off. Turning electrical appliances on and off should only be done with dry hands. Protection from accidents It is necessary to protect both patients and medical personnel from accidents. Sharp and cutting objects, small parts of toys should be out of the reach of children. The design of the windows in the wards should prevent the child from falling out. Children must be under the supervision of medical workers at all times; they are transported for examinations to other departments of the hospital only by medical personnel. All medications and disinfectants must be stored in strictly designated areas, out of reach of children, and their misuse for other purposes must be prevented. Medicines are administered strictly in accordance with the doctor’s prescriptions; you must read the label, check the expiration date, and calculate the dose. Instructions for working with medical instruments, medical devices, and care items must be strictly followed. It is necessary to follow the rules for their storage, disinfection, sterilization and disposal, and protective measures. In radioisotope diagnostic departments, instructions for working with radioactive drugs, their storage and disposal must be followed, and the discharge of radioactive substances into the general sewer network is prohibited. 30 Organization of care for children in a surgical hospital When operating X-ray equipment (X-ray rooms, endovascular surgery, traumatology), the premises must have X-ray shielding, personnel work in special protective aprons and wear individual dosimeters, and undergo regular medical examinations. Infection protection Protection of patients from nosocomial infection lies in compliance with the requirements of the sanitary and epidemiological regime. Medical workers in a surgical hospital who constantly have contact with the blood and other biological fluids of patients must strictly adhere to the rules of working with sterile gloves, avoid injury during manipulations in order to prevent infection with HIV, hepatitis C, syphilis, etc. All surgical medical personnel are vaccinated against hepatitis B. An essential protective measure is the maximum use of single-use medical supplies. 1.2.1. Structure and mode of work When a patient arrives from the emergency room, the ward nurse is obliged to clearly record the time of admission in the medical record of the inpatient, check the quality of sanitary and hygienic treatment, the presence of all necessary documents, indicate to the child a place in the ward, show the location of the dining room, toilet and playroom. The nurse instructs the patient or relatives about the procedure for behavior in the department and the daily routine. The ward nurse records all admitted patients, and upon discharge, all discharged patients in the department’s “Movements of Patients” journal. Based on these data, the night shift of each department compiles a summary of the number of patients in the department for a given day and the number of free beds. This information is centrally transmitted to the hospital reception room and to the central point of the ambulance station. The ward nurse draws up a card for an inpatient patient in the department: glues insert sheets for doctors’ notes, a temperature sheet (Fig. 20), available tests, creates a nursing list of appointments (on a special form, nurses take out: the patient’s temperature, diet, availability and the nature of vomiting and stool, urination, doctor’s prescriptions) (Fig. 16–19). Chapter 1. Structure and organization of work of the children's surgical clinic Fig. 16. Appointment sheet for the neonatal surgery department 31 32 Organization of care for children in a surgical hospital Fig. 17. Appointment sheet of the ward surgical department Chapter 1. Structure and organization of work of the children's surgical clinic Fig. 18. Prescription sheet for the intensive care unit 33 34 Organization of care for children in a surgical hospital Fig. 19. Reverse side of the appointment sheet of the intensive care unit Chapter 1. Structure and organization of work of the children's surgical clinic Fig. 20. Temperature sheet 35 36 Organization of care for children in a surgical hospital During the morning rounds at the bedside of patients, nurses report to the manager and doctors about the condition of the patients, and hand over their shifts to the nurses. At a morning meeting in the director’s office, duty data is clarified, comments are made, and the patients’ readiness for surgery and the sequence of surgical interventions are determined. During the day, nursing and junior medical staff perform their duties according to the routine of the surgical department. After the morning round, the resident doctors hand over to the procedural nurse the medical records of the inpatient with intravenous prescriptions for the current day (jet and drip). The ward nurse checks the appointments after the round, enters them into the appointment sheet, receives all the necessary medications from the head nurse and carries out the appointments, monitoring the correctness of their execution. In the medical record of an inpatient patient, doctors always write down appointments in a certain sequence: i the patient’s regimen (strict bed rest, lying on a backboard, in an incubator at a certain temperature and humidity, under an oxygen tent, etc.); i diet (do not feed, fractional feeding indicating the amount of food and the number of meals, table A 6, etc.); i intravenous drip infusions; i intravenous jet, including transfusion of blood products; i intramuscular and subcutaneous injections; i enteral administration; i hygienic bath; i change of linen; i stool (indicated if there was an enema); i urination (control of hourly diuresis); i vomiting; i tests taken the next morning. In the evening, patients are transferred to the night shift nurses, who continue to carry out assignments (including intramuscular injections, intravenous infusions). The night shift of nurses monitors seriously ill patients, helps the doctors on duty, checks the appointments in the inpatient chart and makes changes to the appointment sheet, prepares dishes for taking tests and submits requests for studies and tests. The procedural nurse of the ward department in the morning from 8 to 9 o'clock takes blood from a vein from patients for tests: biochemistry, Rh factor, sterility, HIV, hepatitis C, and sends them to laboratory, determines blood type. Then he prepares the treatment room for current work (necessary medications, syringes, intravenous infusion systems, sterile material). During the day, he carries out prescriptions for patients: intravenous infusions, infusion therapy, in the presence of a doctor, conducts blood transfusions, intramuscular injections, prepares bags with dressings (wipes, gauze balls, cotton balls, diapers) for sterilization. Conducts disinfection of used disposable syringes, transfusion systems and dressings before disposal, pre-sterilization treatment and sterilization of instruments. At the beginning of the working day, the dressing nurse sets up sterile tables with surgical instruments for dressings, prepares containers with sterile dressings, assists doctors during dressings, supplies the necessary instruments, sticks bandages on the sutures, and applies therapeutic bandages. Upon completion of the planned work, the dressing nurse carries out pre-sterilization preparation and sterilization of used instruments, prepares dressing material for sterilization, and soaks used materials and disposable medical supplies in a disinfectant solution before disposal. Sterile tables in the treatment and dressing rooms can be used in emergency cases around the clock. In specialized departments, separate dressing rooms are equipped for “clean” and “purulent” patients. Work in the treatment room and dressing rooms is carried out with gloves. In dressing rooms, all efforts should be aimed at maximizing the reduction of microbes in the wound, reducing the possibility of their penetration into the wound, i.e. obey the laws of antiseptics. The following antiseptic methods are distinguished: mechanical, physical, biological, chemical. Mechanical methods of antiseptics consist of primary surgical treatment of the wound, opening the abscess, and washing the purulent cavities. Surgical treatment of a wound includes dissection, excision of edges, removal of non-viable tissue and contaminants. Physical methods include: wound drainage, irradiation (UV), drying. Biological methods include the use of enzymatic drugs (trypsin, acetylcysteine, ribonuclease), as well as hyperimmune serums, gamma globulins, plasmas, toxoids to increase passive and active immunity in the wound in order to quickly cleanse necrotic tissue from necrotic tissue. Used for chemical antiseptics. 1. Inorganic compounds (halogens, oxidizing agents, inorganic acids and alkalis, salts of heavy metals). Halides make up a large group of antiseptic agents used in surgery. This is an aqueous and alcoholic solution of Lugol, iodoform, iodonate. They are used to lubricate the edges of the wound. Oxidizing agents (hydrogen peroxide and potassium permanganate) are used for washing wounds, purulent cavities, and medicinal baths. Silver nitrate (lapis) is used to treat navel fungus, wash cavities, and purulent wounds. 2. Organic compounds (alcohols, aldehydes, phenol, nitrofurans, dyes, organic acids). Ethyl alcohol in the form of 70 and 96% solution is most widely used in surgery. It is used to disinfect hands and cutting tools. Formaldehyde is used to sterilize optical instruments and prepare a triple solution. Nitrofurans (furacillin, furadonin) are used to wash cavities and wounds. Dyes such as methylene blue and brilliant green are widely used for treating small surfaces and skin abrasions. In modern surgery, complex chemicals (1% dioxidine) are used as antiseptics to wash wounds. The work schedule and job descriptions of procedural and dressing nurses are equal to those of operating room nurses. The work of medical personnel and the patients’ routine are subject to the daily routine of the surgical department 7.00–7.30 7.30–8.00 - raising patients, measuring body temperature, ventilating rooms; - toilet for patients, cleaning the department, airing the wards; Chapter 1. Structure and organization of work of a children's surgical clinic 8.00–9.00 39 - fulfilling morning appointments, changing nurses and transferring patients; 8.30–9.00 - preliminary examination by the ward doctor and the head of the department of seriously ill and newly admitted patients; 9.00–9.30 - breakfast for patients, morning conference of doctors; 9.30–11.00 - visit to the attending physician; 10.00–14.00 - diagnostic and treatment work (conducting research, operations, dressings, consultations, fulfilling prescriptions, admitting and discharging patients); 14.00–15.00 - lunch, second cleaning, ventilation of the rooms, rounds of the doctor on duty, transfer of seriously ill patients to duty; 15.00–16.30 - rest; 16.30–17.00 - measuring body temperature, completing appointments; 17.00–19.00 - walks, visiting relatives, airing the rooms; 19.00–20.00 - dinner, change of duty nurses and transfer of patients; 19.15–20.30 - fulfilling evening appointments, visiting the doctor on duty; 20. 30–21.30 - basic cleaning, airing of rooms, evening toilet; 21.30–7.00 - sleep, night observation and care for seriously ill patients. The work of each unit is determined by the job descriptions of medical personnel. The head of the department directly supervises the activities of the staff, determines the directions of work of the department as a whole, and bears full responsibility for the quality and culture of medical care for patients. The hospital resident (attending physician) is directly responsible for ensuring the examination, treatment and proper care of the patients entrusted to him. In clinical hospitals, professors, associate professors and department assistants, postgraduate students, residents, and interns take part in the examination and treatment of patients together with hospital doctors. Students take part in rounds of patients together with teachers. 40 Organization of care for children in a surgical hospital Nursing staff (nurses), under the guidance of a doctor, carry out assignments and provide care to the patient. The head nurse reports to the head of the department and the chief nurse of the hospital. The department's middle and junior medical staff are subordinate to her. A hospital nurse (guard) is one of the central figures in the surgical department, a junior colleague of the doctor. She reports directly to the resident physician and head nurse of the department, and during duty, to the doctor on duty. She is subordinate to junior nurses caring for the sick and ward cleaners. Job description of a nurse 1. General provisions 1.1. A nurse belongs to the specialist category. 1.2. A nurse is appointed to a position and dismissed from it by order of the head of the institution. 1.3. The nurse reports directly to the head of the department/head nurse of the department. 1.4. A person who meets the following requirements is appointed to the position of nurse: secondary medical education in the specialty “Nursing”. 1.5. During the absence of a nurse, his rights and responsibilities are transferred to another official, as announced in the order of the organization. 1.6. The nurse must know: – laws of the Russian Federation and other regulations on health care issues; – fundamentals of the diagnostic and treatment process, disease prevention; – organizational structure of health care institutions; – safety rules when working with medical instruments and equipment. 1.7. The nurse is guided in her activities by: – legislative acts of the Russian Federation; – Charter of the organization, Internal Labor Regulations, other regulations of the company; – orders and instructions from management; – this job description. Chapter 1. Structure and organization of work of a children's surgical clinic 41 2. Job responsibilities of a nurse A nurse performs the following job responsibilities. 2.1. Performs all stages of the nursing process when caring for patients (initial assessment of the patient’s condition, interpretation of the data obtained, care planning, final assessment of the achieved result). 2.2. Performs preventive, therapeutic and diagnostic procedures prescribed by the doctor in a timely and high-quality manner. 2.3. Assists when a doctor performs therapeutic and diagnostic procedures and minor operations in outpatient and inpatient settings. 2.4. Provides emergency first aid for acute diseases, accidents and various types of disasters, followed by calling a doctor to the patient or referring him to the nearest medical institution. 2.5. Administers medications, antishock agents (for anaphylactic shock) to patients for health reasons (if it is impossible for a doctor to arrive to the patient in a timely manner) in accordance with the established procedure for this condition. 2.6. Informs the doctor or manager, and in their absence, the doctor on duty, about all detected serious complications and diseases of patients, complications arising as a result of medical procedures, or cases of violation of the internal regulations of the institution. 2.7. Ensures proper storage, accounting and write-off of medications, compliance with the rules for taking medications by patients. 2.8. Maintains approved medical records and reporting documentation. 3. Rights of a nurse A nurse has the right: 3.1. Receive the information necessary to accurately perform your professional duties. 3.2. Make proposals for improving the work of a nurse and the organization of nursing in the institution. 3.3. Require the head nurse of the department to provide the post (workplace) with equipment, equipment, tools, care items, etc., necessary for the high-quality performance of their functional duties. 42 Organization of child care in a surgical hospital 3.4. Improve your qualifications in the prescribed manner, undergo certification (re-certification) in order to assign qualification categories. 3.5. Participate in the work of professional nursing associations and other public organizations not prohibited by the legislation of the Russian Federation. 4. Responsibility of the nurse The nurse is responsible for: 4.1. For failure to perform and/or untimely, negligent performance of one’s official duties. 4.2. For failure to comply with current instructions, orders and instructions to maintain confidentiality of information. 4.3. For violation of internal labor regulations, labor discipline, safety and fire safety rules. Job description of a junior nurse for patient care 1. General provisions 1.1. A junior nursing nurse is one of the junior medical staff. 1.2. A person with secondary general education and additional training in courses for junior nurses in patient care is appointed to the position of junior nurse for patient care. 1.3. The junior nurse for patient care is appointed and dismissed by the chief physician. 1.4. A junior nursing nurse should know: – techniques for performing simple medical procedures; – rules of sanitation and hygiene of patient care; – internal labor regulations; – rules and regulations of labor protection, safety and fire protection; – ethical standards of behavior when communicating with patients. 2. Job responsibilities of the Junior Nurse for Patient Care: 2.1. Assists in patient care under the direction of a nurse. Chapter 1. Structure and organization of work of the children's surgical clinic 43 2.2. Performs simple medical procedures (placement of cups, mustard plasters, compresses). 2.3. Ensures that patients and premises are kept clean. 2.4. Ensures proper use and storage of patient care items. 2.5. Changes bed and underwear. 2.6. Participates in the transportation of seriously ill patients. 2.7. Ensures that patients and visitors comply with the internal regulations of the healthcare facility. 3. Rights The junior nurse for patient care has the right: 3.1. Submit proposals on issues of their activities for consideration by their immediate management. 3.2. Receive from the institution’s specialists the information necessary to carry out its activities. 3.3. Demand that the management of the institution provide assistance in the performance of their official duties. 4. Responsibility The junior nurse for patient care is responsible: 4.1. For improper performance or failure to fulfill one’s job duties as provided for in this job description, within the limits determined by the labor legislation of the Russian Federation. 4.2. For offenses committed in the course of carrying out their activities - within the limits determined by the administrative, criminal and civil legislation of the Russian Federation. 4.3. For causing material damage - within the limits determined by the current legislation of the Russian Federation. 1.2.2. Therapeutic and protective regime. Deontology The regime of a children's surgical hospital should be organized in such a way as to ensure peace for the patient. Anything that might frighten or worry the child should be avoided. The medical and protective regime includes the following elements: 1) transformation of the external hospital environment; 2) extension of physiological sleep; 44 Organization of child care in a surgical hospital 3) elimination of negative emotions and pain; 4) combination of rest and physical activity; 5) formation of a positive emotional tone. The transformation of the external hospital environment begins with creating a cozy environment: clean bed linen, walls painted in light soft colors, paintings with scenes from fairy tales, toys, organization of playrooms. All visual stimuli must be eliminated. Noise control is extremely important in transforming the hospital environment. All staff must speak quietly, telephones are installed away from the wards, and staff must wear silent, removable shoes. Long and full sleep (9 hours at night and 2 hours during the day) is of utmost importance for recovery. During this time, silence and ventilation of the premises should be maintained. Windows in children's departments open in such a way that a child cannot accidentally fall out of them. During the hours of daytime and night sleep, cleaning the premises and performing medical procedures is prohibited, unless absolutely necessary. The regimen of a surgical patient is determined by the attending physician as: i strictly bed rest. The patient lies in bed in a certain position, which is changed by medical personnel. Active turns of the body are prohibited. Nutrition and physiological functions are carried out with the help of staff. Breathing exercises and dosed exercise therapy; i bed rest. It is recommended to turn on your side and take a comfortable position. Individuals are allowed to rise in bed, lower their legs, stand up and go to the toilet with the help of staff. Moderate exercise therapy. i semi-bed rest. You are allowed to get out of bed several times a day, leave the room to go to the dining room and toilet. Increasing the volume of exercise therapy. i general mode. Staying in bed is limited by the internal daily routine. Walks, activities, and games are recommended. Measures aimed at protecting the patient from negative emotions are taken from the first moment of his appearance in the hospital, from the emergency room to the operating room. A friendly, calm conversation with a child on abstract topics that are understandable to him allows you to get into contact with him, calm him down, and distract him from the unpleasant moments of hospitalization and surgical intervention that are facing him. Much attention is paid to the fight against pain: all manipulations are performed under local or general anesthesia. Before the operation, sedatives and sedatives are prescribed. Some pain associated with the disease can be eliminated or reduced. To do this, you need to create “bed comfort” for the patient: place him comfortably in bed, taking into account the nature of the disease, change or correct the bandage in time, apply heat or cold. For recovery, it is important not only to create a gentle regime for the patient’s nervous system by providing him with rest, but also to train, which should be started as early as possible from the onset of the disease. Massage and physical therapy are prescribed individually. An important feature of the organization of the work of departments of a children's hospital is the need to carry out educational work there with sick children who are being treated in a hospital for a long time. For this purpose, children's hospitals allocate a position for a teacher-educator, whose functions include organizing games and school activities, and outdoor walks in the hospital park. The staff must organize leisure time for patients. Medical deontology is of no small importance in creating a favorable psychological climate in a hospital department. Medical deontology (deon - due) is the doctrine of the principles of behavior of medical personnel. In recent years, due to the technologicalization of examination and treatment, some scientists have warned about the danger of dehumanization of medicine and the disappearance of the necessary psychological climate in communication between doctors and patients. Surgery is not limited to science and technology. Surgery reaches the heights of its capabilities only when it is decorated with the highest manifestations, selfless care for a sick person and, at the same time, not only for his body, but also for the state of his psyche (Petrov N. N., 1946). A humane attitude towards the patient and love for his profession should be the main features of a medical worker. The appearance and behavior of a medical worker should maintain the high prestige of the profession; the hospital should constantly cultivate an atmosphere of goodwill and mutual 46 Organization of child care in a surgical hospital. Pointless disputes, disrespect, and mutual insults are incompatible with working in a medical institution. Doctors should set an example of intelligent treatment of people - colleagues, patients and their relatives. Rude speech, vulgarisms, inappropriate laughter and, to be honest, sometimes the vulgarity of some doctors serve as evidence of their lack of education and discredit the face of medical workers. Working with sick children is difficult, because illness and suffering change the psyche, uncertainty, isolation from parents, and depress the child. A child of any age with a surgical disease accompanied by pain, separated from his parents, in an unfamiliar place, under the threat of an unknown surgical intervention, always experiences a stressful state. The child’s perception of the outside world is more acute, and the reaction to external stimuli is often excessive. Some children become hot-tempered, unbalanced, and capricious. In a medical institution, the child should be met with constant friendliness and friendliness, only in this case the treatment will be accompanied by an element of psychotherapy. The attitude of the staff should not injure the patient and should not cause a new iatrogenic disease. Most often, the cause of an iatrogenic disease is an unsuccessful or inappropriate statement in the presence of a patient or a medical document that accidentally came into his possession. Even the Hippocratic Oath provides for the preservation of medical confidentiality. To prevent iatrogenic behavior in the hospital and to prevent unfounded complaints, the following rules have been established: i middle and junior staff and students are not allowed to enter into discussions with patients and their parents about the appropriateness of the prescribed treatment, the possible outcome of the disease or operation; i no one other than the attending physician is allowed to inform the patient of the diagnosis; i inpatient medical records and laboratory test results are stored in such a way that the patient cannot become familiar with their contents; i information about the child’s health status is provided by the attending physician only during personal contact with the parents; provision of information by telephone is prohibited. Analysis Chapter 1. Structure and organization of work of a children's surgical clinic 47 diseases during the round of a professor, assistant or head of department is carried out outside the ward. It is not recommended to make comments to medical workers in the presence of patients, as the latter may exaggerate the significance of the mistake and become frightened. In addition, such comments undermine the authority of the nurse and further deprive her of the opportunity to provide a psychotherapeutic effect on the patient. The relationship between health care workers and parents is important. Parents, not without reason, consider every operation on their child difficult. There is a special group of parents that requires increased attention: parents who have previously lost a child and are deeply traumatized by the misfortune they suffered; middle-aged parents with an only child; a mother deprived of the opportunity to have another child. These parents react sharply to any deviation in the normal course of the disease in the child. Some parents read specialized literature and know medical terms, but without special knowledge, they are prone to dramatization and increased concern, which can negatively affect the child’s well-being. You cannot bring to the attention of parents everything that was said and discussed by doctors during rounds if it was not intended for parents. You also cannot make information about a particular child available to other parents. Under no circumstances should you entrust even the simplest manipulations to your mother. The child's parents have the right to refuse any medical procedures. However, it is the responsibility of the medical professional to explain the need for these manipulations and the consequences that may result from refusing to perform them. Parents should receive exactly the information that may influence their decision, and this information should be presented in a form that is easy to understand. Students, from the moment they begin their clinical studies, including evening practice, become “medical workers” who are subject to all legal requirements. 1.2.3. Sanitary and hygienic regime of a ward department The sanitary and hygienic regime of any diagnostic and treatment unit of a hospital covers compliance with the requirements: 48 Organization of child care in a surgical hospital i hygiene of medical personnel (the severity of its implementation is determined by the operating mode of each department); i hygiene of the sick child and relatives caring for him; i hygiene of premises, equipment, environment. Clinical hygiene of medical personnel is obliged to ensure: prevention of infectious diseases and infectious surgical complications in patients, prevention of nosocomial infection of medical personnel and those in contact with them outside the hospital. The main objects of personal hygiene of personnel in a children's surgical clinic are: body, secretions, clothing, personal belongings, premises. Knowledge and ability to comply with basic hygienic requirements for the body condition of medical staff (students) is especially necessary in a pediatric surgical clinic. This also dictates the need for regular preventive examinations and sanitation of medical personnel, the need for preventive examinations and registration of a medical record for students. The theoretical basis for the purpose and rules of wearing medical hygienic clothing (gown, uniform, personal underwear, cap, mask, shoes) are necessary for the student in order to comply with them and subsequently monitor them in the process of medical practice. Personal hygiene of medical personnel involves keeping the body clean, hair should be neatly combed, and nails should be trimmed short. Painting your nails with nail polish is not recommended. The rings must be removed during operation. Perfume and cologne should be used in moderation, and only those that have a mild odor. Moderation in the use of cosmetics and various jewelry is dictated by the very nature of the activities of medical personnel. The clothing of the medical staff of the surgical clinic consists of a suit (trousers, short-sleeve shirt or cotton dress) and a robe. The sleeves of the robe are wrapped in such a way that they do not interfere with washing your hands. Replacement shoes should be chosen that are comfortable, do not restrict your feet, do not have high heels, are silent, and are easy to wash. When working in the operating room, disposable or fabric shoe covers are worn over shoes. To work in the treatment room, dressing rooms, operating rooms, medical personnel must wear a cotton or disposable cap and a medical mask. Each department of the hospital has a room with individual closets for changing staff into work clothes. When working in a pediatric surgical clinic, students are allowed to work in clean white coats that completely cover their personal clothing. You cannot use gowns that were used for classes at the departments of anatomy, microbiology, etc. Personal clothing should be comfortable and clean. Woolen items are removed when working in surgical departments. Replaceable shoes are silent, always leather. Hand care requires special attention to prevent hospital-acquired infections. Medical personnel must wash their hands not only before eating and after visiting the toilet, but also before and after each medical procedure, before and after each examination of a sick child. To prevent reseeding of microflora, washbasins are equipped with elbow taps, so that they are not handled first with dirty and then with clean hands. For hand washing, use liquid disinfectant soap or finely chopped disposable soap pieces. Hands are dried with disposable towels. Hand treatment technique for surgical clinic personnel All hand treatment methods begin with mechanical cleaning - washing hands with soap or various solutions (Fig. 21). First, wash the palmar surface, then the back surface of each finger, the interdigital space and the nail bed of the left hand. The fingers of the right hand are washed in the same way. Then sequentially wash the palmar and back surfaces of the left and right hand, left and right wrist, left and right forearm (to the border of the middle and upper thirds). Wipe the nail beds again. Finally, wash off the foam from your fingers to your elbow with a stream, without touching your forearms with your hands. The water tap is closed with the elbow. After treatment, hands are wiped with napkins sequentially, starting with the fingers and ending with the forearms. Medical personnel in surgical, intensive care and obstetric hospitals must strictly protect their hands from contamination. Wash the floors, clean the sanitary unit in the apartment, 50 Organization of child care in a surgical hospital Fig. 21. Appearance of the hand-washing sink for the staff of the surgical department to work in the garden and vegetable garden, peeling vegetables should wear gloves. Frequent hand washing leads to dry skin, so it must be constantly nourished by lubricating it with cream every day after work and at night. In order to prevent the re-seeding of microflora by medical staff when working with patients in the departments of neonatal surgery, neonatology, resuscitation and intensive care, along with hygienic hand treatment, staff carry out disinfection with skin antiseptics. Apply at least 3 ml of Manugel to the hands and rub into the skin until dry, but for at least 30 seconds before each examination and any manipulation. When personnel work in the treatment room, dressing room, operating room, or when working with blood, it is necessary to use sterile medical gloves. In cases where, for emergency reasons, a child sick or infected with HIV infection, congenital syphilis, or hepatitis C is transferred to the surgical department, it is necessary to strengthen sanitary and hygienic protection measures for personnel, other patients and the environment from infection. Chapter 1. Structure and organization of work of a children's surgical clinic 51 All personnel work with a sick child only in medical gloves (it is necessary to ensure their integrity, avoid punctures and cuts), use disposable syringes, medical products and care items. Used disposable products are soaked separately from others in disinfectant solutions before disposal. Bed linen and diapers must be soaked in disinfectant solutions after use. The patient is provided with personal eating utensils, bottles for milk and water. After use, they are also soaked separately from the rest of the dishes in disinfectant solutions and sterilized in a dry-heat oven. Surgical instruments used in the treatment of such a child are thoroughly disinfected and sterilized with the obligatory amidopyrine test. The medical staff of the surgical clinic is vaccinated against hepatitis B prophylactically. Sanitary and hygienic treatment of the ward department. Each ward must have a sink for washing, a mirror, and a tank for used diapers. The wards must be maintained in exemplary order; they must be comfortable, spacious, light and clean. The walls in the chambers are painted with light oil paint. In the evening, the chambers are illuminated with electric light. Night lights are equipped for illumination at night. Based on the tasks of creating an optimal microclimate and preventing secondary infection, the requirements for lighting, heating, and ventilation of surgical hospital premises are determined. The optimal temperature in the wards is about 20 °C, in the dressing room and bathrooms it is slightly higher - 25 °C. Sunlight has a beneficial effect on the functioning of the human body and a detrimental effect on pathogens. The chambers should be well lit and oriented to the southeast or southwest. The optimal ratio of window area to floor area in the wards is 1: 6, dressing room 1: 4. The optimal relative air humidity is 55–60%. Good ventilation is an indispensable condition for maintaining a chamber. The most perfect ventilation is achieved by air conditioning units with bacterial filters. Regular ventilation of the room significantly reduces microbial contamination of the air. Air exchange should be at least four times per hour. Hygienic air standards in a ward per patient are 27–30 m3. Supply and exhaust ventilation using air filters should be used in the wards. Types of cleaning of a surgical hospital include daily, twice a day wet cleaning of premises and equipment, routine cleaning after dressings. It is advisable to immediately vacate patients with a general cleaning of the room after all patients are discharged from the box. Cleaning should always be damp, using a soap and soda solution. Equipment for wet cleaning (bucket, mop, rag) are marked, used only for a specific room, disinfected after use and stored in a special room. After each patient is discharged, the bed and bedside table are wiped with a rag, generously moistened with a disinfectant solution, and covered with clean bed linen. General cleaning of the department is carried out weekly. The premises are first cleared of equipment, inventory and tools. The room and all equipment are wiped with a sterile rag, generously moistened with a disinfectant solution, or irrigated with a hydraulic remote control. The equipment is wiped, then the room is closed and after one hour it is washed with water and a rag. When cleaning, staff wear clean gowns, shoes, and masks. After disinfection, the room is irradiated with ultraviolet light, including bactericidal irradiators, for 2 hours. The hospital's sanitary service regularly flushes equipment, rooms, and air intakes, monitoring the quality of cleaning. In the intensive care units, surgery and therapy of newborns, and maternity hospitals, in order to prevent nosocomial infections, general cleaning, routine repairs and disinfection were introduced twice a year for 2 weeks with mandatory bacteriological control in the future. Disinfection Disinfection is the second most important measure for the prevention of nosocomial infections after sanitization. For the purpose of air disinfection, irradiation with ultraviolet rays is used. The bactericidal lamp is turned on in the dressing room an hour before the start of surgery or dressing, during breaks, after completion of procedures and after cleaning. Germicidal lamps should not be turned on while people are in the premises, as this can lead to radiation burns. Chemical disinfectants are widely used for treating premises, equipment, equipment, instruments, anesthesia and breathing apparatus, personnel hands and gloves, used syringes, dressings, disposable linen, and patient care items. They are also used to treat sanitary facilities, laboratory and food utensils, toys, shoes, ambulance transport, etc. Currently, a large number of disinfectants are commercially produced, each of which has its own instructions for use. They are subject to a number of requirements: a wide range of bactericidal action, no toxic effect on humans, no damaging effect on tools and devices, rubber products. The operating mode of disinfectants is determined by the area of ​​their application (tools, room surfaces, medical devices, medical waste, care products) and instructions for use. Disinfection is carried out by wiping, irrigation, soaking, and immersion. Disinfection of instruments. Domestic and imported disinfectants are used: amixan, disinfectant-forward, aniozyme DD1, which have antimicrobial activity against various gram-negative and gram-positive microorganisms, including pathogens of nosocomial infections (Escherichia coli and Pseudomonas aeruginosa, staphylococcus, streptococcus, fungi of the genus Candida, hepatitis viruses , HIV, adenovirus, etc.). The disinfection regime combined with pre-sterilization cleaning of medical products (instruments, endoscopes, anesthesia and respiratory equipment, etc.) includes the following stages. 1. Soaking at a temperature not lower than 18 ° C with complete immersion for 15–60 minutes in the working solution (from 1.2 to 3.5%) and filling the cavities and channels of products (glass, metal, plastic, rubber) with it. , such as endoscopes and instruments for them, anesthesia and breathing apparatus - 54 Organization of child care in a surgical hospital round, anesthetic hoses. The concentration of the solution and the duration of exposure depend on the drug and the type of product and are indicated in the instructions for use. 2. Washing each product in the same solution in which the soaking was carried out using a brush, brush, napkin, product channels, using a syringe for 1–3 minutes. 3. Rinsing with running water (channels using a syringe) - 3 minutes. 4. Rinse with distilled water - 2 minutes. For similar purposes, disinfectants can be used: diabak, mistral. The quality of pre-sterilization cleaning of medical devices is controlled by performing an amidopyrine or azopyrine test for the presence of residual blood. Disinfection of medical waste is carried out to prevent nosocomial infections and environmental contamination. Disposable medical products (syringes, needles, blood transfusion systems, gloves, probes, etc.), dressings, disposable underwear, etc. before disposal are treated by soaking in solutions: amixan 2% - 30 min, hypostabil 0.25% - 60 min. Disinfection of reusable waste collection containers is carried out daily (amiksan 0.5% - 15 min), disinfection (between) body containers for collecting medical waste, car bodies is carried out according to the regime of surface treatment by wiping or irrigation. Disinfection of indoor surfaces (floors, walls, etc.), furnishings, beds, incubators, surfaces of apparatus, instruments, equipment, and ambulance transport is carried out by wiping with a rag soaked in a solution of the product at a consumption rate of 100 ml/m2 of surface. There is no need to rinse the working solution of the product (amiksan) from surfaces after disinfection. Treatment of objects by irrigation is carried out using special equipment, achieving uniform and abundant wetting. The application rate for irrigation is 300 ml/m2 (hydraulic control, automax) or 150 ml/m2 for spraying (quasar). Excess disinfectant after application by irrigation is removed with a rag. Patient care items and toys are immersed in the solution or wiped with a rag moistened with the solution (amic-Chapter 1. Structure and organization of work of a children's surgical clinic 55 san 0.25% - 15 min). At the end of the disinfection period, they are washed with water. The dishes are freed from food debris and completely immersed in a disinfectant solution (amiksan 0.25% - 15 min) at the rate of 2 liters per set. After disinfection is completed, the dishes are washed with water for 5 minutes. Laboratory glassware is disinfected by soaking in a 0.5% amixan solution for 15 minutes. Sanitary equipment (baths, sinks, toilets, vessels, pots, etc.) are treated with a solution of the product (amiksan 0.25% - 15 minutes) using a brush or brush, and after disinfection is completed, it is washed with water. The consumption rate of the product by wiping is 100 ml/m2, by irrigation - 150–300 ml/m2 of surface. Cleaning material (mops, rags) is soaked in a solution of the product (amixan 0.5% - 15 minutes), after disinfection is completed, rinsed and dried. To treat surfaces associated with blood and for general cleaning of premises, the following solutions are used: diabac 3.5% - 60 min, amixan 1% - 60 min, disinfectant-forward 0.5% - 60 min (wiping, irrigation). Precautionary measures Persons under 18 years of age, persons with hypersensitivity to chemicals and chronic allergic diseases are not allowed to work with disinfectants. Contact of the product and working solutions with mucous membranes, skin, and eyes is not allowed. Containers containing the product solution must be tightly closed. All work with the product and working solutions must be carried out with rubber gloves protecting your hands. Disinfection of indoor surfaces by wiping can be carried out without personal respiratory protection and in the presence of patients. When treating surfaces using the irrigation method, it is recommended to use personal protective equipment: for hands - rubber gloves, for respiratory organs - universal respirators and for eyes - sealed goggles. After disinfection by irrigation is completed, it is recommended to carry out wet cleaning and ventilation in the room. 56 Organization of child care in a surgical hospital When carrying out work, it is necessary to observe the rules of personal hygiene. Smoking, drinking and eating is prohibited. After work, wash exposed areas of the body (face, hands) with soap and water. If a product leaks or spills, collect it with a rag; cleaning must be done with rubber gloves and rubber shoes. Environmental protection measures must be observed: do not allow undiluted product to enter surface or ground water and sewer systems. Disinfectants are stored in special cabinets and rooms inaccessible to children, and separately from medications to prevent their accidental use for other purposes. First aid measures for accidental poisoning Amixan is low-hazard, but if precautions are not followed, irritation of the mucous membranes, respiratory organs (dryness, sore throat, cough), eyes (tearing, pain in the eyes) and skin (hyperemia, swelling) is possible. If signs of irritation of the respiratory system appear, you should stop working with the product, immediately remove the victim to fresh air or transfer to another room, and ventilate the room. Rinse your mouth and nasopharynx with water; subsequently, prescribe rinsing or warm-moist inhalations with a 2% sodium bicarbonate solution. If the product gets into the stomach, give the victim several glasses of water with 10–20 crushed tablets of activated carbon to drink. Do not induce vomiting. If the product gets into your eyes, you should immediately rinse them thoroughly under running water for 10–15 minutes, drip in a 30% sodium sulfacyl solution and immediately consult a doctor. If the product gets on the skin, rinse off the product with plenty of water and lubricate the skin with an emollient cream. 1.2.4. Epidemiological regime of the ward department The working conditions of a modern children's surgical clinic, where complex surgical interventions are performed, including on newborns, requiring intensive care Chapter 1. Structure and organization of work of a children's surgical clinic 57 and resuscitation aids, are especially in dire need of the strictest adherence to epidemiological regimen and prevention of both importation from outside and the development of nosocomial infection. When people stay indoors for a long time, the microclimate changes, the content of water vapor in the air increases, its temperature rises, unpleasant odors appear, and bacterial pollution of the air and room increases. A sick child is a source of bacterial contamination of the environment. Antibacterial drugs used in modern pediatric surgical and intensive care units lead to the emergence of hospital-acquired, highly pathogenic strains of microorganisms. Colonization of newborns with hospital strains occurs on days 3–4 of hospital stay, and in adults on days 7–10. The children's surgical clinic performs a large number of surgical interventions, including minor surgery (suturing wounds, opening boils and abscesses, etc.), injections, and blood transfusions. There is a need to organize strict sanitary and epidemiological measures to prevent infections spread through blood (HIV, hepatitis, syphilis, etc.) both among patients and among staff. Organization of disinfection and disposal of medical waste is necessary to prevent environmental contamination and prevent outbreaks of infectious diseases. In connection with the above, the most stringent requirements are imposed on compliance with the epidemiological regime in a children's surgical hospital, implemented in three areas: 1) clinical examination of personnel; 2) rational placement of patients; 3) organizing cleaning of the department. The doctor must not only perform medical procedures himself and follow job descriptions, but also know and be able to teach the rules of disinfection and sterilization to nurses and orderlies where he will work, and monitor the correctness of their implementation. The placement, layout, and structure of the work of a children's surgical hospital are subject to one requirement - the prevention of nosocomial infections and purulent complications in surgical patients. Strict isolation is carried out during the admission and placement of planned and emergency patients, patients with purulent surgical infection, and the allocation of departments for newborns. The structural units of each ward department (ward, catering unit, sanitary room, “clean” and “dirty” linen, treatment room, etc.) have their own requirements for the sanitary and epidemiological operating regime. Particularly strict requirements are imposed on the operating unit, dressing rooms, intensive care units and neonatal surgery. The use of disposable syringes, fluid transfusion systems, probes and catheters, and care items plays a significant role in the prevention of nosocomial infections. Different departments of a surgical clinic require different quality levels of sanitary and epidemiological treatment: sanitization, disinfection, asepsis (sterilization). Etiology of nosocomial infection. Clinical studies have shown that there are no specific pathogens of surgical infection. Microorganisms that can be isolated from a purulent-inflammatory focus are a wide range of opportunistic and even saprophytic bacteria. Some of these microorganisms are permanent members of the endogenous human flora, for example Staphylococcus epidermidis, fecal streptococcus or Escherichia coli. Other pathogens are found in humans inconsistently (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas aeruginosa, etc.). Staphylococci. Streptococci. The natural habitat of coccal flora (staphylococcus, streptococcus) in humans is the anterior sections of the nasal cavity. Due to the ability to form capsules under unfavorable conditions, these microorganisms are well preserved in the external environment. They tolerate drying well and remain viable for a long time in dry dust. Direct sunlight kills them only after a few hours. On the walls of hospital rooms and windows, these microorganisms remain viable for up to 3 days, in water - 15–18 days, on woolen fabrics - about 6 months. When heated to 70–80 °C in liquid, they die within 20–30 minutes. Disinfecting solutions in working concentrations have a detrimental effect on them (chloramine - 5 minutes, phenol - 15 minutes, sublimate - 30 minutes). The contamination of environmental objects with pathogenic coccal flora is closely related to the degree of human contact with these objects. Chapter 1. Structure and organization of work of a children's surgical clinic 59 It has been established that the source of coccal infection is a person (a patient or a carrier of the bacteria). Bacterial carriage of pathogenic coccal flora by medical personnel is of great epidemiological importance. This leads to the constant release of bacteria into the external environment and secondary contamination of the skin, hair, clothing of the bacteria carrier and surrounding objects. Enterobacteriaceae (Escherichia coli, Klebsiella, Pseudomonas aeruginosa, Proteus, etc.) are gram-negative rods that are widespread in nature. Many types of enterobacteria are inhabitants of the intestines. Hospital pathogenic strains can accumulate and even multiply in places of high humidity (sinks, taps, soap dishes, wet towels, etc.), in some solutions. Violation of the rules for hand washing by medical personnel is of epidemiological significance in the spread of gram-negative infection. Pathogenesis. From a general biological position, the principle of unity of the organism and the external environment is manifested by the normal symbiosis of humans, animals and plants with the world of microbes. The microflora of the intestines, respiratory tract, and skin is an expression of this symbiosis. There is not a single species in nature that does not support other species. The essence of symbiosis is the mutual adaptation of the organism and the microbe, which ensures their mutual biological interests in relation to nutritional factors, reproduction, on the one hand, and immunity, on the other. Infectious disease is not just about protecting and fighting. This is a biologically unique process of adaptation, most often ending in a new form of symbiosis between the organism and the microbe. The pathological expression of symbiosis is autoinfection (endogenous infection). This option serves the “interests” of the microbe, strengthens its existence as a species, especially since with the end of the autoinfection, carriage, as a rule, does not stop, and the tendency to relapse sometimes increases (sore throat, erysipelas, pneumonia). Autoinfectious (endogenous) diseases include: nasopharyngitis, tonsillitis, appendicitis, colitis, chronic constipation, bronchitis, bronchopneumonia, cystitis, pyelonephritis, conjunctivitis, dermatitis, furunculosis, otitis media, cholecystitis, osteomyelitis, and many types of sepsis. Exogenous infections are caused by the entry into the body from the external environment of microorganisms for which the given organism has not developed sufficient immunity or this immunity is shaken in its physiological basis. For the occurrence of infectious bacterial and viral diseases, the following principle remains in force: microorganisms entering the internal environment of the body cause an infectious disease not because this is their absolutely unchanged property (to be a pathogen), but because a given individual, located in given conditions (nutrition) , exchange, age, climate), these microorganisms encounter conditions favorable for their development. This is also facilitated by the proper reactivity (excitability) of the body, determined by the state of the individual’s nervous system. In nature, there is no special type of “pathogenic” microbes, but at the same time there are many ways to make an immune organism susceptible, and vice versa. Microbes have a high coefficient of variability and adaptability, replacing several microbial generations over the course of hours and days, acquiring pathogenic properties. The complex of reactions in an infectious disease can be complete and contain the entire sum of morphological, physiological, clinical and immunological signs (“manifesting” forms of infectious diseases). The same complex may be less complete, many, even essential signs may drop out of it (outpatient forms of infection), typical manifestations may be absent, to the point that the infectious disease may be outwardly completely invisible (“silent” infection). Such a “silent” infection should be recognized as a fact of great practical epidemiological importance. The carriage of pathogenic microbes is not a purely mechanical process of entering the body and carrying this or that infection; There is no doubt that carriage is essentially the same biological process of interaction between a microbe and an organism, which determines the so-called “silent” infection (I.V. Davydovsky). Contact of the body with certain microorganisms is characterized by the term contamination. The contaminating microorganism can be isolated in cultures from the surface of the skin or mucous membranes. This microorganism will not always find favorable conditions for itself and will cause the development of an infectious process. Under favorable conditions (availability of nutrients, conditions for reproduction, competitive struggle of various microorganisms for possession of ecological niches, state of the local immune system, genotype), the process of colony formation occurs, the proliferation of bacteria on the mucous membranes of the digestive tract. , respiratory tract, genitourinary tract, on the skin. This process is called colonization. In cases where the bacterial flora reaches a threshold, critical level, conditions arise for the translocation of bacteria into the internal environment of the body with the development of an infectious process. An important factor that disrupts the barrier function and increases the permeability of mucous membranes to bacterial flora is the influence of various stress factors (surgical trauma, blood loss, hypoxia, inadequate anesthesia, prolonged artificial ventilation, resuscitation aids, invasive diagnostic methods). A factor that seriously influences the variability of the bacterial flora, causing the emergence of highly pathogenic strains in surgical and intensive care units, is antibiotic therapy. It leads to a change in the main causative agent of purulent infection, which can be traced at intervals of several to tens of years. Thus, the fact that streptococci are replaced by staphylococci under the influence of penicillin therapy is well known. Then, as a result of the widespread use of semi-synthetic penicillins, there was a decrease in the frequency of staphylococcal diseases, and gram-negative bacteria took first place in the etiology of surgical infections (especially postoperative complications). In recent years, there has again been a tendency towards an increasing role of gram-positive coccal bacteria, especially Staphylococcus epidermidis and Streptococcus, strains of which are characterized by multiple antibiotic resistance. Transmission of infection from bacteria carriers and patients can occur in a variety of ways: 1) airborne droplets (when talking, coughing) or airborne dust (with dust particles containing pathogenic bacteria); 2) contact (in contact with contaminated environmental objects or the hands of personnel). 62 Organization of child care in a surgical hospital Significant secondary pollution of the environment is caused by violations of the rules for wearing masks by staff, errors in compliance with the sanitary regime (insufficient hand cleaning, improper use of various sterile solutions, etc.). Studies have shown that more than half of patients in surgical departments are colonized by nosocomial strains of microorganisms after 10 days of stay. A direct relationship was revealed between the frequency of bacterial carriage, the number of long-term hospital patients, the frequency of seeding of pathogenic microorganisms from the operating room air, on the one hand, and the percentage of postoperative suppuration, on the other. The epidemiological regime in a surgical hospital is carried out in three areas: medical examination of personnel, rational placement of patients, organization of cleaning of the department. Clinical examination of the staff of the surgical department (examination by a therapist, dentist, otolaryngologist), annual fluorography of the chest, blood tests for RW, HIV, hepatitis, stool culture for intestinal group, throat smear for diphtheria, quarterly examination for carriage of pathogenic staphylococcus (throat and nose) are important in the prevention of hospital infections. Bacteria carriers are subject to additional examination by a dermatologist and ophthalmologist. If chronic diseases of the skin, nasopharynx, ears, eyes, teeth are detected - the source of staphylococcal infection - employees are released from work in the operating room and sent for treatment. If pathogenic staphylococcus is detected in the nasopharynx, sanitation is carried out: rinsing the throat and instilling solutions of chlorophyllipt, furatsilin, potassium permanganate, and staphylococcal bacteriophage into the nose for 6–7 days. The use of antibiotics for the purpose of sanitizing staphylococcal carriers is unacceptable, since it gives only a short-term effect and contributes to the formation of antibiotic-resistant species of bacteria. After the sanitation, repeat swabs are taken from the throat and nose. Permanent carriers of pathogenic strains that cannot be sanitized are proposed to be removed from work in the operating unit, intensive care units, neonatal surgery, and maternity wards. All students starting work in clinics are required to undergo a preventive medical examination and obtain a medical record. Chapter 1. Structure and organization of work of the children's surgical clinic 63 1.3. Structure and organization of work of the operating unit 1.3.1. Structure and mode of operation The operating unit is the “heart” of the surgical clinic. It includes: operating rooms, preoperative, sterilization, material, equipment rooms, blood transfusion room. It also includes awakening rooms, rooms for operating nurses, head nurses, anesthesiologists on duty, and the head of the department. In the centralized operating unit, each specialized department has its own operating room. An operating room is allocated for emergency round-the-clock work. The operating room is located isolated from the wards, catering unit and sanitary facilities, and the emergency operating room and emergency purulent surgery operating room are located away from the clean planned operating rooms. The operating room is a restricted access area. It includes two main zones - sterile and clean. The so-called sterile zone includes: preoperative (Fig. 22), operating room, sterilization and washing room and hardware room. The entrance to the sterile area is marked on the floor with a red line (10 cm wide). This area is entered only in surgical underwear. The clean area contains a material room, an instrumental room, an anesthesia room, a dressing room for doctors and nurses, a protocol room, and an express laboratory. A vestibule is provided between the clean and sterile areas, which reduces the possibility of infections entering the operating room. The sterile area includes an operating room (Fig. 23) with one operating table with a ceiling height of at least 3.5 m, a width of 5 m, and an area of ​​36–48 m2. It is recommended to decorate the operating room with durable, waterproof and easy to clean material. The ceiling, floor and walls should blend into each other in a rounded manner to prevent dust from accumulating in the corners, reduce air stagnation and make cleaning easier. Floors must be durable, seamless, smooth and easy to wash and clean (linoleum, epoxy resin). To avoid accidents due to the formation of sparks and fire when metal tools fall and hit a stone floor, the use of ceramic tiles and marble is not recommended. The ceiling is painted with white oil - 64 Organization of child care in a surgical hospital Fig. 22. Preoperative. The hands are treated with surgical paint, the walls are finished with facing tiles in greenish or pale blue tones. For fire safety purposes, utility lines in the operating unit must be closed. It provides power supply from two independent sources and a centralized supply of oxygen, nitrous oxide and vacuum. To prevent an explosion as a result of the accumulation of flammable gases, all switches and sockets are located at a height of 1.6 m from the floor and must have a spark-proof housing. All objects that accumulate static electricity, including the operating table, are grounded. To eliminate external interference to the operation of electronic devices, shielding of the operating room or loop grounding is carried out. Chapter 1. Structure and organization of work in a children's surgical clinic 65 Operating rooms should have large, bright windows oriented to the north or northwest. In the operating room, two types of artificial lighting are used - general and local. The main equipment of the operating room includes: 1) operating table; 2) shadowless ceiling lamp; 3) shadowless mobile lamp; 4) apparatus for diathermocoagulation (electronic knife); 5) anesthesia machine; 6) anesthesia table (anesthesia kit, medications); 7) large table for tools; 8) mobile table for tools; 9) auxiliary instrument table (for sterile suture material, a set of cutting instruments in a disinfectant solution, cleol, iodine, etc. ); 10) bixes on stands, equipped with a pedal device; Rice. 23. Operating room. Preparing a child for surgery 66 Organization of child care in a surgical hospital 11) wall-mounted bactericidal lamps; 12) electronic tracking systems; 13) defibrillator; 14) stands for infusion solutions. The sterilization and washing room is located next to the operating room and is connected to it by a window with sliding glass for the transfer of sterile instruments. Usually they wash in it, and if necessary, they sterilize instruments. If there is a central sterilization department in the operating unit, only occasionally used instruments are sterilized. The preoperative room is intended to prepare personnel for surgery (see Fig. 22). It is separated from the operating room by a wall with observation windows, and from the corridor by a vestibule. In the preoperative room there are 2-3 washbasins with taps for opening with the elbow. Mirrors and an hourglass are mounted above them. In the preoperative room there is a table on which there are sterile brushes and napkins for washing hands, a forceps in a triple solution, and boxes with the inscription “Sterile masks”. To disinfect hands, installations with an antiseptic solution and basins with stands are installed. Medicines and instruments are stored in the built-in cabinets. In the material room, surgical and suture material is prepared for sterilization. Alcohol, gloves, medicines and other items are stored here. Boxes with sterile materials are stored in separate cabinets. The instrumentation includes the basic “Operational Set” and instruments for specialized departments (newborns, thoracic, urological, orthopedic traumatology, endoscopic, etc.). In addition, sets of sterile instruments are being prepared for puncture and catheterization of central veins, venesection, tracheostomy, pleural puncture, and primary resuscitation. Operating linen includes surgical gowns, caps, sheets, diapers, and towels. It is painted dark green, indicating that it belongs to the operating unit. For sterilization, surgical linen is placed in boxes in sets (3 gowns, 3 sheets, 3 diapers). After filling the bix, the edges of the sheet lining it are folded one on top of the other. A robe is placed on top of it, and several gauze napkins and a diaper are placed on it. This allows the operating nurse, after washing her hands, to dry them and put on a sterile gown without exposing the rest of the linen and material. Chapter 1. Structure and organization of work in a children's surgical clinic 67 Special clothing consists of a cap, surgical suit (shirt and trousers), shoe covers and an apron. The operating suit is painted, like the operating linen, dark green. Walk in a surgical suit outside the operating unit or use colored underwear in other departments of the medical institution

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 05/19/2011 (protocol No. 7)

General care for children with surgical diseases: A textbook for students of medical universities / Compiled by: Ignatiev S.V., Razin M.P. – Kirov State Medical Academy, 2011 - 86 p., ill.: 20 figures, 5 tables, bibliography: 10 sources.

The manual highlights modern concepts of general care for children with surgical diseases, examines the structure and organization of surgical care for children in modern Russia, the most important anatomical and physiological features of the child’s body, aseptic and antiseptic methods, formulates the functional responsibilities of personnel caring for children with surgical diseases, rules for working in the dressing room and operating room, a detailed description of the most important medical procedures 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, Izhevsk State Medical Academy, Doctor of Medical Sciences, Professor V.V. Pozdeev.

© S.V. Ignatiev, M.P. Razin, Kirov, 2011

© State Educational Institution of Higher Professional Education Kirov State Medical Academy of the Ministry of Health and Social Development of Russia, Kirov, 2011

List of abbreviations

Preface

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

The course in caring for pediatric surgical patients is very important, as it introduces students to the basic principles of working in a pediatric surgical hospital at the level of a nursing assistant. Students acquire not only theoretical knowledge, but also practical skills in caring for sick children of this profile, therefore the manual contains a list of practical skills that a student must master. In nursing, preoperative preparation for the operation and nursing of children after it are of great importance. The most postulative principles of these processes are highlighted on the pages of our publication.

This textbook is intended for junior students of medical universities. The authors took into account modern domestic and foreign literary 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, anatomy -physiological characteristics of the child’s body, asepsis and antiseptics, functional duties of staff, work in the dressing room and operating room, the most important medical procedures, preparing children for special methods of examination and surgical treatment. All possible wishes and critical comments will be received by the authors with understanding and gratitude.

State educational institution of higher professional education of the Federal Agency for Health and Social Development

"Amur State Medical Academy".

Department of General Surgery

L. A. Volkov, A. S. Zyuzko

NURSING FUNDAMENTALS

SURGICAL PROFILE

TEACHING MANUAL FOR SECOND YEAR STUDENTS

Blagoveshchensk - 2010

The tutorial was prepared by:

L. A. Volkov - K.M.N., Honored Doctor of the Russian Federation, assistant at the Department of General Surgery of the ASMA.

A. S. Zyuzko- K.M.N., assistant at the Department of General Surgery, ASMA.

Reviewers:

V.V. Shimko - D.M.N., Professor of the Department of Faculty Surgery of ASMA.

Yu.V. Dorovskikh - Associate Professor, Department of Hospital Surgery, ASMA.

The methodological manual was prepared in accordance with the program for caring for patients in a surgical clinic and is aimed at creating a theoretical basis for the effective development of theoretical material. The manual consists of 15 topics of practical lessons, which outline the organization and regime of a surgical hospital, deontological and ethical issues of patient care, aspects of clinical hygiene of the patient and staff, methods of using medications, features of preparing patients for diagnostic studies and surgical interventions; The basic principles of care for patients with various surgical pathologies and victims of trauma are covered.

Nursing. Types of care. Design, equipment, operating mode of the reception and diagnostic department. Reception of patients, registration, sanitary treatment, transportation. Deontology in surgery.

Patient care– sanitary hypourgia (Greek hypourgiai – to help, to provide a service) – medical activity aimed at alleviating the patient’s condition and promoting his recovery. During patient care, components of the personal hygiene of the patient and his environment are implemented, which the patient is not able to provide himself due to illness. In this case, physical and chemical methods of exposure are mainly used based on the manual labor of medical personnel.

Nursing care is divided into general And special.

General care includes measures that are necessary for the patient himself, regardless of the nature of the existing pathological process (nutrition of the patient, change of linen, ensuring personal hygiene, preparation for diagnostic and therapeutic measures).

Special care– a set of measures applied to a certain category of patients (surgical, cardiological, neurological, etc.).

Surgical care

Surgical care is a medical activity for the implementation of personal and clinical hygiene in a hospital, aimed at assisting the patient in satisfying his basic life needs (food, drink, movement, bowel movements, bladder, etc.) and during pathological conditions (vomiting, cough, breathing problems, bleeding, etc.).

Thus, the main objectives of surgical care are: 1) providing optimal living conditions for the patient, conducive to a favorable course of the disease; 2) fulfilling doctor’s orders; 3) accelerating the patient’s recovery and reducing the number of complications.

Surgical care is divided into general and special.

General surgical care consists in organizing sanitary-hygienic and medical-protective regimes in the department.

Sanitary and hygienic regime includes:

Organization of cleaning of premises;

Ensuring patient hygiene;

Prevention of nosocomial infection.

Therapeutic and protective regime is:

Creating a favorable environment for the patient;

Providing medications, their correct dosage and use as prescribed by a doctor;

Organization of high-quality nutrition for the patient in accordance with the nature of the pathological process;

Proper manipulation and preparation of the patient for examinations and surgical interventions.

Special care is aimed at providing specific care for patients with a certain pathology.

Features of caring for surgical patients

Features of caring for a surgical patient are determined by:

dysfunctions of organs and body systems arising as a result of a disease (pathological focus);

the need and consequences of pain relief;

surgical trauma.

Particular attention in this group of patients should be directed, first of all, to accelerating the processes of regeneration and preventing infection.

The wound is an entrance gate through which pyogenic microorganisms can penetrate into the internal environment of the body.

In all actions of nursing and junior medical personnel in the process of caring for patients, the principles of asepsis must be strictly observed.

Organization of the work of the reception department

Reception department of a multidisciplinary hospital

The emergency department (emergency room) is intended to receive patients delivered by ambulance, referred from clinics and outpatient clinics, or who sought help on their own.

The reception department performs the following functions:

Conducts round-the-clock examinations of all sick and injured persons delivered or applied to the emergency department;

Establishes a diagnosis and provides highly qualified medical and advisory assistance to everyone in need;

Conducts an examination and, if necessary, assembles a council of several specialists to clarify the diagnosis;

If the diagnosis is unclear, provides dynamic monitoring of patients;

Performs triage and hospitalization in specialized or specialized departments of the hospital;

Transfers non-core patients and victims after providing them with the necessary assistance to hospitals and departments according to the profile of the disease or injury or refers them to outpatient treatment at the place of residence;

Provides constant round-the-clock communication with all operational and duty services of the city.

The reception department includes a waiting room, a registration desk, an information desk, and examination rooms. The admissions department has close functional contacts with laboratories, diagnostic departments of the hospital, isolation wards, operating rooms, dressing rooms, etc.

the admission department should be located on the lower floors of the medical institution;

it is necessary that there are convenient access roads for ambulance transport from the street;

Elevators should be located near the emergency department to transport patients to medical departments;

The reception area should be decorated with moisture-resistant materials (tiles, linoleum, oil paint) for ease of sanitary processing.

Cleaning requirements:

Cleaning of the premises of the reception department must be carried out at least 2 times a day using a wet method using detergents and disinfectants approved for use in the prescribed manner. Cleaning equipment must be labeled and used for its intended purpose. After use, it is soaked in a disinfectant solution, rinsed in running water, dried and stored in a specially designated room. After examining each patient, couches, oilcloths, oilcloth pillows are treated with a rag moistened with a solution in accordance with the current instructions. The sheets on the couch in the examination room are changed after each patient. In the treatment room, dressing room, as well as in the small operating room, wet cleaning is carried out 2 times a day using a 6% hydrogen peroxide solution and a 0.5% detergent solution or disinfectant solution. After use, gurneys are treated with a disinfectant solution in accordance with the current instructions.

Waiting room intended for patients and their accompanying relatives. There should be a sufficient number of chairs, armchairs, and gurneys (for transporting patients). On the walls are posted information about the work of the medical department, hours of conversation with the attending physician, a list of products allowed for transfer to patients, and the telephone number of the hospital helpline. The days and hours during which patients can be visited should be indicated here.

The duty nurse's office. It registers incoming patients and prepares the necessary documentation. There should be a desk, chairs, and forms of necessary documents.

Examination room is intended for examination of patients by a doctor and, in addition, here a nurse conducts thermometry, anthropometry, examination of the pharynx, and sometimes other studies (ECG) for patients.

Examination room equipment:

A couch covered with oilcloth (on which patients are examined);

Height meter;

Medical scales;

Thermometers;

Tonometer;

Spatulas;

Hand wash sink;

Desk;

Case history forms.

Treatment room intended for providing emergency care to patients (shock, visceral colic, etc.).

Treatment room equipment:

Couch;

A medical cabinet containing: an anti-shock first aid kit, disposable syringes, disposable systems, anti-shock solutions, antispasmodics and other medications;

Bix with sterile dressing material, sterile tweezers in a disinfectant solution (for working with Bix);

Bix with sterile gastric tubes, rubber urinary catheters, tips for enemas.

Surgical dressing room is intended for minor operations (primary surgical treatment of an accidental wound, reduction of a dislocation, reposition of simple fractures and their immobilization, opening of small abscesses, etc.).

Sanitation checkpoint, his tasks include:

Carrying out sanitary treatment of sick and injured people;

Acceptance of clothes and other things of patients, inventory of clothes and things and transfer for storage;

Issuance of hospital clothes.

To treat seriously ill and injured patients, a bathroom with portable shower sinks is provided. The sanitary checkpoint must have an appropriate set of toilets, sinks, and showers, provided for by sanitary standards, taking into account the possibility of a mass influx of victims. For the deceased, a room with a separate entrance should be allocated in the reception department, where several corpses can be stored simultaneously for a short time (until the morning).

Responsibilities of the admission department nurse:

registration of a medical card for each hospitalized patient (filling out the title page, indicating the exact time of admission of the patient, the diagnosis of the referring medical institution);

examination of the skin and hairy parts of the body to identify head lice, measuring body temperature;

fulfilling doctor's orders.

Responsibilities of the emergency department doctor:

examination of the patient, determining the urgency of surgical intervention, the required amount of additional research;

filling out a medical history, making a preliminary diagnosis;

determining the need for sanitary treatment;

hospitalization in a specialized department with mandatory indication of the type of transportation;

in the absence of indications for hospitalization, provision of the necessary minimum of outpatient medical care.

Available in formats: EPUB | PDF | FB2

Pages: 224

Year of publication: 2012

Language: Russian

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

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Questions on practical skills in educational practice (child care in a surgical hospital) for first-year students of the Faculty of Pediatrics.  Structure of a modern pediatric surgical clinic. Responsibilities of junior and nursing staff in caring for children in a surgical hospital.  Maintaining medical records in a pediatric surgical clinic.  Equipment and instruments for dressing, manipulation, and operating rooms. Responsibilities of junior and nursing staff.  Responsibilities of nursing staff in a children's surgical hospital (urological, traumatological, intensive care, thoracic departments, purulent surgery department).  General patient care in a general pediatric surgical unit. Preparing the child for surgery.  Features of transporting patients depending on the nature, location of the disease (damage), severity of the condition.  The concept of nosocomial infection. Causes of occurrence, main pathogens, sources, ways of spreading nosocomial infection. A set of sanitary and hygienic measures aimed at identifying and isolating sources of infection and interrupting transmission routes.  Sanitary and hygienic regime in the reception department.  Sanitary and hygienic regime in the surgical department.  Sanitary and hygienic diet for patients.  Sanitary and hygienic regime in the operating unit, wards 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. Sequence of processing of medical instruments. Treatment of incubators for newborns.  Sterilization. Types of sterilization. Storage of sterile instruments and medical products.  Features of sterilization of instruments, sutures and dressings.  Features of sterilization of surgical gloves, products made of rubber, fabrics, polymers (probes, catheters, etc.)  Rules for placing dressings and surgical linen in the bin. Types of bix styling. 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 drawing blood for laboratory testing.  Infusion therapy. Objectives of infusion therapy. The main drugs for infusion therapy, indications for their use. Routes of administration of infusion media. Complications.  Indications and contraindications for central venous catheterization. Caring for a catheter installed in a central vein.  Blood transfusion. Types of blood transfusion. Determining 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 implementation.  Post-transfusion reactions and complications. Clinic, diagnostics. Possible ways of prevention.  Nasogastric tube. Probing technique. Indications for nasogastric intubation. Technique. Complications of nasogastric intubation.  Types of enemas. Indications for use Technique of implementation. Complications.  Taking material for bacteriological examination. Procedure for storing biopsy material.  Features of transporting patients in a surgical hospital.  Objectives 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. Caring for children in the postoperative period.  Complications of the postoperative period, ways of prevention, combating the complications that have arisen.  Care of the child’s skin and mucous membranes in the postoperative period.  Postoperative wound care. Removing stitches.  Temporary stop of bleeding.  Transportation and immobilization depending on the nature and location of the injury or pathological process.  First aid for emergency conditions in children.  Terminal states. Monitoring. Post-mortem care.  Providing assistance in emergency situations. Primary resuscitation complex, features of its implementation depending on the age of the child.  Desmurgy. Techniques for applying various types of dressings in children of different age groups (see appendix). APPENDIX Questions on desmurgy for first-year students of the Faculty of Pediatrics I. Headbands:  Hippocratic cap  Cap - cap  Bandage on one eye  Bandage - frenulum  Neapolitan bandage  Bandage on the nose II. Bandages for the upper limb:  Bandage for one finger  Bandage for the first finger  Bandage-glove  Bandage for the hand  Bandage for the forearm  Bandage for the elbow joint  Bandage for the shoulder joint III. Bandages on the abdomen and pelvis:  One-sided spica bandage  Double-sided spica bandage  Bandage on the perineum IV. Bandages for the lower limb:  Bandage on the thigh  Bandage on the shin  Bandage on the knee joint  Bandage on the heel area  Bandage on the ankle joint  Bandage on the whole foot (without gripping the toes)  Bandage on the whole foot (with gripping the toes)  Bandage on the first toe V. Neck bandages:  Upper neck bandage  Lower neck bandage VI. Chest bandages:  Spiral bandage  Cruciform bandage  Deso bandage Head of the Department of Pediatric Surgery, MD. I.N. Khvorostov