Early postoperative period. Early postoperative complications and their treatment.


Features care for patients undergoing surgery. Nursing clean dressing . Nursing purulent dressing .


Postoperative period is called the period of treatment the patient from the end of surgery to recovery.


The main tasks facing medical professionals tasks after surgery are:


1 ) the treatment and care of patients ;


2 ) prevention and treatment of possible complications;


3) early rehabilitation.


Postoperative period


Postoperative period - this is time from the operation to recovery and rehabilitation of the patient or transferring him/her to a group of disability. Depending on the severity of the disease, the size and nature of the operation, the postoperative period may last from several days to several months. There are early postoperative period - the first 5-6 days after surgery , late postoperative period - to discharge the patient from hospital ; remote postoperative period - up to a full recovery and restore its ability to work or transfer to disability group .


In the postoperative period should carefully monitor the status and function of major organs and systems as surgery and anesthesia lead to relevant pathophysiological changes in the body. Under the influence of surgery and anesthesia varies the intensity of metabolism : catabolism violated value (accumulation of toxic products in the body due to the collapse of substances and cells) and anabolism (the set of processes to the formation of organic substances - components of cells and tissues).


During the postoperative period , there are three phases (stages ): catabolic , anabolic and reverse development .


Catabolic phase: The duration of this phase - 3 - 4 days. Severity of the disease depends on the severity and volume of operations , type of anesthesia, their duration, intensity of postoperative treatment ( inadequate , unbalanced treatment , presence of complications). It should be noted that the catabolic phase is primarily a defensive reaction of the organism, which aims - to increase resistance due to energy and plastic materials. On one hand, this is due to increased degradation of proteins, fats and carbohydrates , on the other hand formation of a large number of toxic substances , leading to acidosis (changes in acid- base balance ), impaired redox processes in tissues and organs ( liver, kidney , heart , etc. . ) that affects the general condition of the operated patients.

 

Reverse development phase. Duration of - 4 - 6 days. In this period begins active synthesis of protein, fat, glycogen ( carbohydrate material) , the number of energy and plastic materials. Clinical signs of this phase is to improve the general condition of the patient, reduce pain, normalization of body temperature , the appearance of appetite. Improves the cardiovascular system, respiratory system. Restored activity of the gastrointestinal tract, intestinal peristaltic contraction , begin to deviate gases.


Anabolic phase. Clinically, it is characterized as a period of recovery. In this phase improves the health of patients , appetite and normalize the function of internal organs: heart, lungs , liver , kidneys and so on. Duration anabolic phase - 2-5 weeks. Its progress depends on the severity of the disease, the amount transferred surgery , duration of catabolic phase. She completed the restoration of body weight, complete wound healing and tissue maturation reliable postoperative scar formation .


Changes in the patient associated with surgical trauma


 In the postoperative period may develop certain metabolic disorders and functions of internal organs. They usually occur in severely ill after complex operations. After the smaller operations , such as routine hernia or appendectomy , these changes are expressed slightly and do not require special treatment.


1. Disorders of protein metabolism. One of the serious disturbances of homeostasis operated patients is a violation of protein metabolism. In the body of a healthy person weighing 70 kg contains about 10 kg of protein ( 14% of body weight ), which ensures normal functioning of the body. The main violation protein metabolism is the predominance of protein breakdown of their synthesis. Decreasing the amount of protein in the blood ( hypoproteinemia ) is mainly due to the decrease of albumin , which in turn leads to disruption of the ratio of globulins. The main source and intake of protein breakdown in the body's muscles are seriously ill . In these patients occurs muscle weakness, atrophy. The lowest level of protein observed for 5-6 days after surgery , after which he began to be normalized . However, this normalization of protein in the blood is very slow and lasts 10-15 days. To prevent disturbances of protein metabolism in patients with preoperative period is necessary to ensure high calorific protein food , spend transfusion of plasma albumin protein.


2. Disorders of lipid metabolism . In the postoperative period, marked changes occur and fat metabolism . For its correct use mostly fat emulsion ( venolipid , intralipid , emulsan et al. ), Which is the energy source of unsaturated fatty acids ( linoleic , linolenic , arachidonic , etc. .) To ensure normal function of cells , inhibit catabolic processes. It should be noted that the caloric content of fat is 2.5 times higher than that of protein and carbohydrates. Fat emulsion is poured at a rate of 1.5 - 2 grams of fat per 1 kg of the patient.


3. Disorders of carbohydrate metabolism after surgery. In 90 % of patients in the first 2-3 days of sugar in the blood is reduced and there is hypoglycemia . On 3rd,- 4th day observed elevated levels of blood glucose ( hyperglycemia ), sometimes glucosuria , which is associated with an increase in its formation and decreasing absorption. With 2- 3rd day the amount of glucose in the blood is reduced and there is hypoglycemia . Note that the number of substances in the body depends on the intensity of metabolic processes and methods of their separation from the body. This is in violation of carbohydrate metabolism in the body mainly accumulate oxidized products that reduce the alkalinity reserve and affect blood pH. Change the value of blood pH by only 0.3-0.4 IU (normal pH - 7,35-7,45 units ) in any direction leads to marked disturbances of enzymatic activity of redox processes in the body that can result in death patient.
Timely , proper and intensive preoperative preparation , careful nursing, and correction of carbohydrate metabolism (introducing sufficient 5-10% glucose solution with insulin at the rate of 1 IU of insulin on glucose 4-5 g dry ) before and after surgery is the best way prevention of severe carbohydrate metabolism .


4. Disorders of water- electrolyte metabolism cause many complications in patients after surgery. There are three forms of disorders of water metabolism :


 1) there is a real shortage of water due to shortfalls in the body ;


 2) the excess water caused by the mismatch between the intake and output of the body ;


 3) redistribution of water in some parts of the body associated with changing ratios of electrolytes.


After surgery and rehabilitation of the patient distinguish three periods of observation of the patient . After a short period of immediate postoperative surveillance anesthesiologist in restorative House for a full restoration of consciousness and normalization of breathing, blood pressure, pulse, and if there is no evidence for its transfer to the intensive care unit, the patient returned to the general ward . After discharge from the surgical department patient may still require supervision and rehabilitation surgeon. It is provided with a period of outpatient treatment in the clinic, sanatorium or program of gradual recovery of activity in rehab.


Oral Care: After the necessary operations .Early oral care. Dryness of mouth recommended to perform regular rinsing with water and lubricating mucous membrane with Vaseline oil.
To prevent inflammation of the parotid glands, rinse your mouth with warm water and lemon juice. Nursing staff should follow to ensure that patients are regular in cleaning teeth.
Care: All patients must wash daily face and hands. Critically ill are washed by nurses. It is necessary to monitor the purity of the skin severely ill. Contaminated areas are to be immediately washed and wiped.
To prevent pressure sores lying sick enclose inflatable rubber wheels, regularly (2-3 times daily) on consuming area of
​​the bac , pelvis and sacrum camphor alcohol. It is necessary to frequently change the patient's position in bed. When the initial signs of bedsores on altered skin begin, lubricate with 5-10% of potassium permanganate.


To prevent zaprilosti should be regularly cleaned with 0.1 % solution of potassium permanganate and prypudryuvaty talc inguinal and axillary areas , navel , women - may fold under lochnymy glands.


Especially should carefully monitor the purity of the perineum.

 

For easy defecation perineal area is washed with Watt tion swab with warm water or a 0.1 % solution of potassium permanganate. Women should wash crotch at night.
The time when the patient is allowed to get out of bed , depending on the severity and nature of the operation, his condition and the postoperative course. In satisfactory condition and no complications after appendectomy hernia he is allowed you to get out of bed the 2 -3rd day. After a complicated operation (resection of gastric , cholecystectomy , and others .) - 5 - 7th day as directed by medical doctor .ovarian cancer. After operations on the thoracic organs, the limbs fractures , injury to blood vessels, nerves , etc. Have allowed lyayetsya in different terms individually for each patient.
Supervision of dressing is one of the major responsibilities among medical personnel. We must watch closely well connected areas lying and if wound is exposed. If dressing MAT nulasya and the wound is exposed , you should immediately make a bandage . For bundle may leak a little blood in the first days after the opera wrong. In these cases lightly grease it with an alcoholic solution of iodine and pidbyntovuyut When the bandages blood leakage should immediately call a doctor and make arrangements for sleep nennya bleeding.


Change fold in 2nd 3rd day to control the operation wound and 7th 8th day for removal of sutures. When nahno yenni ligation often do depending on the wound and in bundles .


Removing stitches: Sutures are removed in most patients after 7 -8th day , children can be removed earlier (5 -6th) day after the operations. In elderly and debilitated patients stitches removed later - on 10-12 -day .


Patients eating after surgery: Feeding/eating of patient after operation depends on the nature of it. With operations in the abdominal organs, usually during the first day are not allowed to drink.
In further for 5-7 days patients are prescribed liquids, easily digestible food (soup, pureed soups , yogurt , liquids, pudding , soft boiled egg , etc.). . Diet set depending on the nature of the disease and surgery. So, after surgery for gallbladder prescribed hepatic diet, after surgery for gastric ulcer illness prescribed ulcer diet, etc.
To relieve thirst rubbed her lips and mouth on moist cotton wool.
After operations on the stomach and intestines at day 2, patients are allowed digested drink warm water a teaspoon per hour. On day 3 patients can eat soup, pudding, soft boiled egg in the next few days - liquid cream of wheat, pureed soups. Rusk allow 5 -6th day.
After operations on the gallbladder and liver in patients with hepatic disease, denote diet. Patients can eat from the 2- 3rd day, a small portion of the liquid, pureed food.
The diet of patients after operations on the small intestine is: can drink on the 2nd day in small portions. On the 5th -7th days give liquid food (soup, soft boiled egg, jelly , etc. ). Rusk allow 7 -8th day.
After operations on the colon patients prescribed genus tion , easily digestible food for 5-7 days. In the same period for delayed emptying give tincture of opium (5-10 countries Pelmo 3 times a day).
During the first day the patient after appendectomy lyayutsya allowed to drink from the 2nd day prescribed liquid foods , dry re, with the 3- 4th day - white bread.
After removal of the hernia operations on the extremities patient appoints overall diet.
After radical surgery for esophageal region patients are on parenteral nutrition for 5 days. On the 6th day they are allowed to drink small sips and then gradually prescribed liquid food.
The diet of patients after operations on the chest, the lungs and heart is composed of a liquid , easily digestible food with plenty of protein, carbohydrates and vitamins. During the first 3-5 days amount of food should be limited to prevent complications of the heart and gastrointestinal tract.
After operations on the lungs by 5 -7th day if no complications appoint overall diet.


Direct postoperative care


Recognition and treatment of major life threatening complications that may occur during this period are functional duty doctor NICU with a surgeon.
Airway obstruction airways should always be kept free and clear.

 

The main causes of obstruction following.


1. Retraction of the tongue may occur in unconscious patients after general anesthesia. Loss of muscle tone leads to retraction of the tongue to the posterior pharyngeal wall and can increase masticatory muscle spasm when exiting unconsciousness . Complicating factor in the various manipulations of anesthesia may be injury of the tongue or soft tissues of the mouth or throat.


2. Foreign bodies such as dentures and broken teeth, secretions and blood, stomach contents or intestines - frequent sources of airway obstruction . Before the surgery, dentures should be removed and taken precautions to prevent aspiration of gastric contents.


3. Laryngospasm may occur with mild loss of consciousness and grow with insufficient anesthesia.


4. Laryngeal edema may occur in young children after traumatic attempts at intubation or infection.


5. Compression of the trachea may occur during surgery on the neck and is particularly dangerous for hemorrhage after thyroidectomy or reconstruction of vessels.


6. Bronchial obstruction and bronchospasm may develop due to the ingress of foreign body aspiration or irritating substance , it could be an allergic reaction to a medication or complications of asthma.
Attention doctors should be directed at identifying and eliminating the causes of airway obstruction as a matter of extreme urgency. With good patency of airways hypoxia may be due to complications from postventylyatsiynymy mismatch between ventilation and perfusion . At that usually do well anesthesiologists , ventilation lung gas mixture with a high oxygen content. Determine blood gas analysis .


Myocardial ischemia.

Postoperative heart failure may increase in the early period , especially in patients with a history of previous heart disease, myocardial ischemia . Patients with ischemia may complain of squeezing chest pain . In the period of recovery of consciousness may be the only symptom of hypotension. If suspected ischemia, ECG performed immediately and the measures for continuous monitoring of cardiac activity ( Cardiomonitoring ).


Respiratory failure. Respiratory failure is defined as the inability to maintain normal partial pressure of oxygen and carbon dioxide (PO2 and PCO2) in arterial blood. Determination of blood gas composition - the source of its early recognition and should be conducted in the dynamics in patients with previous respiratory diseases. Normal PO2 - more than 13 kPa at age 20 , falling to 60 to about 11.6 kPa; respiratory failure accompanied by a value less than 6.7 kPa. In cases of severe hypoxemia clinically manifested cyanosis of skin and mucous membranes , with independent breathing - severe shortness of breath.


Other specific problems . For specific groups of patients should include careful ongoing monitoring , for example, patients who are subject to such operations as thyroidectomy , adrenalectomy , and other interventions against diabetes and require replacement therapy and careful monitoring of blood pressure and plasma electrolytes . Patients who had undergone surgery on the neck, should be observed in terms of accumulation of blood in the wound ( hematoma ), which may cause fast-paced asphyxia .


Features postoperative period in patients with senile .


Senile people require special attention and care. The reaction to the disease process they delayed and less pronounced resistance to drugs is usually reduced. In the elderly significantly reduced pain sensation and therefore emerging complications may occur bezsymptomnno . It is therefore necessary to carefully listen to the patient himself assesses the development of the illness , and therefore change the treatment and mode.
Usually about elderly patients gavage , drainage, depriving them of mobility are removed as soon as possible , minimize the intravenous infusion. They were soon lifted out of bed after surgery for abdominal , lower limbs, which is the prevention of many complications. These patients are waiting for surgery "reasonable approach to their specific needs ."

 

POSTOPERATIVE MANAGEMENT IN GENERAL SURGICAL CHAMBER
 
TOTAL CARE . After returning to the ward regularly, almost every hour or every 2 hours check is made
​​, monitoring heart rate, blood pressure and respiratory rate . Patients who underwent complex surgery on the stomach or intestines , shown hourly emissions control by nasogastric tube , urine output and discharge from the wound. Observations by a nurse under the supervision of a doctor who treats or another surgeon ( if necessary, and other consultants ). Permanent medical supervision is removed when the patient is stabilized.

In most medical institutions examination of patients by medical personnel to the state of his condition , health and dynamics of basic life functions carried out in the morning and evening. Trouble that suddenly appears , disorientation , inappropriate behavior or appearance - often the earliest signs of complications. In these cases, pay attention to the state of general hemodynamics and respiration , pulse , temperature and blood pressure levels. All data is monitored and recorded in history. The need for conservation of probes , catheters is decided on the basis of monitoring of renal function and bowel fullness of chest excursion and effective cough. Thoroughly researched chest, sputum examined .
Lower limbs examined in terms of the appearance of swelling , pain calf muscle , changes in skin color. In patients receiving intravenous fluids, controlled liquid equilibrium. Daily measurement plasma electrolytes . Intravenous infusion terminated as soon as the patient begins to drink liquids on their own. A few days fasting in the first days after the operation cannot bring a lot of damage , but enteral ( probe ) or parenteral nutrition is always necessary if the strike lasts more than a day .
For some patients, painful and depressing problem after surgery may be insomnia, and it is important to recognize and promptly treat such patients (including silence , the mode of communication with staff and relatives ).


Care after operations on the abdominal cavity.


Anterior abdominal wall and stomach examined daily to detect excessive swelling, muscle tension, pain, wound conditions - leakage from the wound or where drainage is . The main types of complications in this group of patients: slow recovery of intestinal peristalsis , anastomotic failure , bleeding or abscess formation .


The presence of intestinal noises , self discharge gas and the appearance of stool indicates restore peristalsis. If after the intervention was delivered nasogastric tube , he kept open constantly ( which facilitates discharge of gases) and allows further draining the intestines. Passive drainage may be supplemented by continuous or periodic suction content. The probe is kept to a decrease in the amount of hourly aspiration and can be removed when there is self- discharge gas and there is a chair (usually 5-6 days). Nasogastric tube causing inconvenience to the patient and should not be kept for longer than necessary.


Care early.

 

Frequent dressing is not always necessary in the treatment of surgical wounds , after planned operations in the absence of pronounced pain in the wound, the normal temperature of the patient wound may look back in 1-2 days , and it should be inspected daily in detecting even small signs of infection: redness , swelling , increasing pain .


Draining wounds are done to prevent the accumulation of fluid or blood and allows you to control any selection - with anastomotic failure , congestion of lymph or blood. Many surgeons in recent years prefer to use a closed suction drainage system with a small force of aspiration (eg , corrugated suction drainage produced by the domestic industry ) after operations on vessels. Usually drain is removed when the amount of fluid received each day , reduced to a few milliliters.


Skin sutures are traditionally not removed until such time as the wound is not healed completely. Terms of healing depends on many factors. Thus, appropriate early removal of sutures or parentheses around the neck or face (3-4 days) to prevent the formation of unsightly scars . Then sutures can be pasted sticky strips (like plaster ) to prevent differences and better healing. In exposed areas (face , neck, upper and lower limbs) are preferred epidermis seams imposed absorbent or non-absorbent synthetic fibers . If the wound is infected , you will need to remove one or more joints prematurely , the wound edges are raised , running drainage.


The difference between the edges of the wounds of the abdominal wall is rare and mostly in patients who underwent surgery for a malignant tumor. This process is supported by factors such as hypoproteinemia , vomiting , prolonged paresis of the intestines and stomach swelling, wound infection site and pulmonary complications.
To distinguish the wound edges abrupt discharge from the wound a large number of serous fluid. On examination, the wound is evistseratsiya with protruding loop of intestine or omentum fragment . In these cases, the operating conditions of the internal organs and reduce a wound stitched seams node .
 
Early postoperative complications

 
Intravenous injection of irritant drugs or solutions may cause bruising , hematoma , phlebitis or venous thrombosis. Intravenous catheters are installed in large veins should be securely sealed to prevent air embolism. Arterial catheters or accidental needle punctures the artery - the most common cause of injury . This can lead to arterial occlusion and even gangrene , since most damage is diagnosed late.


Paresis nerve can be caused by stretching or compression of the main nerve trunk or extravascular administration corrosive solution. The most frequently damaged nerve is the ulnar nerve in the elbow fossa, radial nerve in the shoulder and brachial plexus in the supraclavicular area.


Development nerve paresis may occur in a difficult position the patient on the operating table - long limbs or local compression of compression with the patient on the side or stomach . Compliance with precautions to prevent nerve paresis of the limbs in the early postoperative period.
 
CARDIO- PULMONARY COMPLICATIONS . In the early postoperative acute heart failure is the most frequent complication . In patients with coronary artery disease or valve defects, arrhythmias after major surgery can be observed phenomena heart failure. The reason for its growth can be excessive in volume intravenous fluid infusion in the early postoperative period, which can be avoided by carrying out monitoring of central venous pressure. Treatment of heart failure is to avoid the further fluid overload, heart prescribing diuretics and drugs.


Once the patient recovers full consciousness after anesthesia , the major problems of the respiratory system can be a collapsed lung and pulmonary infection. PotentiaL factors in their development may reduce the mobility of the diaphragm , general lethargy, abdominal tension and pain in the wound. Prevent the occurrence of complications explain the need to rotate the patient in bed, breathe deeply and cough . Great importance is attached physiotherapy, coughing and deep breathing with simultaneous appointment of small doses of analgesics . This abdominal wall in the region of the wound must be supported by a temporary bandage . Bronchospasm is acquired by inhalation bronchodilator drugs, and hypoxia treated with oxygen through a mask or nasal tube. Antibiotic therapy administered after sending sputum for bacteriological examination .
 
RENAL FAILURE. Acute renal failure after surgery may result from prolonged renal hypoperfusion , which may result in hypovolemia, sepsis or transfusion of incompatible blood . Patients with previous renal disease and jaundice are particularly susceptible to ischemia of the kidneys and more likely to develop acute renal failure. The importance of monitoring hourly urine output necessitates bladder catheterization for all patients who performed major surgery, as well as those at risk of renal failure.


Early recognition and treatment of bacterial and fungal infections are also important in preventing renal failure. Acute renal failure is characterized by oliguria , combined with low specific gravity of urine (less than 1010) . Oliguria in combination with high concentrations of urine suggests that kidney function is good but it is receiving inadequate blood supply . This is an indication for the introduction of more liquid. Rapid infusion of saline increased urine output in these patients, a thorough examination eliminates the cause of hypovolemia (eg , bleeding ).

 

Terms of dressings. Dressings


Requirements for dressings should be the same as the operating (bright room, the ceiling of which shall be painted with oil paint, walls and floor are lined with tiles).


In the dressing to maintain cleanliness. Table for instruments and dressings cover as well as in the operating room (Fig. 12.13).


Tools submit forceps. Ligation is carried out only by means of an instrument to. Instruments are sterilized into the dressing room or sterilizing operating unit. Dressings should be provided with a central cold and warm water. The optimum temperature should be 18-20
C. In the dressing should not be foreign objects, clothe, except for the dressing table, table for instruments and dressings, cabinets for medical supplies and instruments and chairs for patients. In a dressing must consider the degree of cleannes wounds of patients. Patients with complications, purulent wounds bandaged in the least. At the end of the day conducting wet cleaning bandages and irradiation with ultraviolet rays .Were in surgical wards, usually has two dressings - for "clean them" and "septic" patients.


Required bandages medical nurse :


1. Performs assigned doctor- intern manipulations are allowed to perform nurse .


2. Accompanies seriously ill after manipulations performed in the ward.


3. Strictly adhering to the rules of asepsis and antisepsis.


4. Prepares and sterilization sterilize bandages and instruments commentaries according to the operating instructions.


5. Provides a systematic bacteriological control harness binding material, tools, facilities of bandages rooms.


6. Provides regular updating, recording, storing and controlling of spending medicines, tools and clothes.


7. Instructs nurses dressings and monitor its performance.


8. Keeps accounting records.


9. Systematically increase their professional qualifications.


10. Participates in health - educational work.


Infection control of the surgical hospital.


In order to prevent festering disease and compliance with sanitary hygienic bacteriological laboratory sanitary station, which is subject to a medical institution, shall once in 15-20 days bacteriological control of air pollution (operating, dressings, Chambers), quality control disinfection
, treatment of hands of personnel ,sterile surgical material and instruments.


Control of microbial contamination of air in operating and bandages conducted once a month. Dirty air in the chamber and rebandaging can be determined using sedimentation, filtration and method of the shock wave of air. Sedimentation principle of the method is that the microorganisms that are in the air, settle on a horizontal surface. For this study, using Petri dishes with nutrient medium (2% agar), which are within 15 minutes are left open in predefined locations operating or tied. After that, the Petri dish is placed in an incubator for 24 h and count up of colonies that grew. Filtration method of research inlines in the draw of 10-40 liters of air through special absorbers with sterile fluid. The principle of the shock wave is that soaked through the apparatus of air strikes the surface containing nutrient medium above , so that bacteria trapped in it. Air samples were carried out using the apparatus Krotov.


In the operating number of colonies of microorganisms on 1m3 of air. You must not to exceed 500 hours and 1000 - both during and after operating hours. For dressings and preoperative may be no more than 1,000 to bosom to 1m3 in the air to work. In addition, the sample volume of 250 liters of air should not be plazmokoagulations hemolytic staphylococcus.


Quality control of disinfection carried out suddenly, without the person, 1-2 times a month. Sterile cotton swab moistened with sterile isotonic sodium chloride solution or 1% hyposulfite of lead washed away the 10 subjects, the area should be flush 200-300 cm3. Satisfaction assessment provide disinfection in the absence of growth of E. coli, Proteus, Pseudomonas aeruginosa, Staphylococcus aureus and Streptococcus.


Crops with it usually spends elder sister of operating so that the staff did not know when and from whom he will serve. Drill results should be discussed and compares the frequency of postoperative complications. This control improves the quality of hand washing and reduced personnel in the number of postoperative complications.


In addition to the mandatory daily monitoring the effectiveness of sterilization in an autoclave (dressings, linen) using standard vials or sulfur which is necessary every 10 days seeding with sterilized material. Particular attention should be given to the quality of sterilization same material. Crops of silk, catgut should be performed prior to sterilization and its storage at least once in 10 days.


To control the sterility of hands of medical personnel, dressings and suture material eldest sister should be operating a special journal.


To identify and sanitation carriers of pathogenic 1-2 times a year to all employees of the surgical department do swabs from the nose and throat swabs special . Revealed carriers of pathogenic infections dignity without fail. In the absence of positive outcomes from treatment of chronic inflammatory diseases of the upper respiratory tract and oral cavity an employees transferred to another job.

Activities nurse in the postoperative period

Postoperative period, phase


Postoperative period - this time from the operation to convalescence and rehabilitation of the patient or transfer it to a group of disability.


Depending on the severity of the disease, the size and nature of operations afteroperation period can last from several days to several months.


There are early postoperative period - the first 5-6 days after surgery , late postoperative period - to discharge the patient from hospital ; remote postoperative period - up to a full recovery and restore its performance or shiping a group of disability.


Postoperatively should carefully monitor the status and function of major organs and systems as surgery and anesthesia lead to relevant pathophysiological changes in the body. Under the influence of surgery and anesthesia varies the intensity of metabolism, catabolism violated ratio (pro accumulation of toxic products in the body due to the collapse of substances and cells) and anabolism (aggregate of processes to the formation of organic substances - compositioning parts of cells and tissues).


During the postoperative period, there are three phases (stages): catabolic, anabolic and reverse development.


Catabolic phase. The duration of this phase - 3-4 days. Severity of dependence live on the severity of the disease, the volume of transactions , type of anesthesia, their duration, intensity postoperative treatment ( inadequate , unbalanced treat tion , the presence of complications). It should be noted that the catabolic phase is primarily a defensive reaction of the organism, which aims - to increase resistance to organism by energy and plastic materials. On the one hand, this is due to increased degradation of proteins, fats and carbohydrates , on the other hand - formed a large number of toxic substances , leading to acidosis (change in acid- base balance ), impaired redox processes in tissues and organs (liver , kidney heart, etc. . ) that affects the general condition of the patient operated .


Phase reverse development. Duration of - 4-6 days. This period begins active synthesis of protein, fat, glycogen (carbohydrate meals), the number of energy and plastic materials. Clinical signs of this phase is to improve the general condition of the patient, reduce pain, normalization of body temperature, the appearance of appetite. Activity of cardiovascular system gets better, respiratory system. Restored activity of the gastrointestinal tract, appear peristaltic reductions of intestine ,gases begin to depart.


Anabolic phase. Clinically, it is characterized as a period convalescence.In this phase improves the health of patients, appetite and normalize the function of internal organs: heart, lungs, liver, kidneys and so on. Duration anabolic phase - 2-5 weeks.of course depends on the severity of the disease, the amount transferred surgery, duration of catabolic phase. It is completed reduction in body weight, complete wound healing, ripening of connecting fabric and reliable postoperative scar formation.


Changes in the patient associated with surgical
injury

Postoperatively, the individual may develop metabolic disorders and functions of internal organs. They usually arise in critically ill after complex operations. After the smaller operations, such as routine hernia or appendectomy, these changes are expressed slightly and do not require special treatment.


Disorders of protein metabolism. One of the serious disturbances of homeostasis operated patients is a violation of protein metabolism.


In the body of a healthy person weighing 70 kg contains about 10 kg of protein (14% of body weight), which ensures the normal functioning of the organism. The main violation protein metabolism is the predominance of protein breakdown of their synthesis. Decreasing the amount of protein in the blood (hypoproteinemia) taken place mainly due to the decrease in albumin, which in turn leads to disruption of their relationship with the globulins. The main sources of fracture flow and protein breakdown in the body's muscles are seriously ill.


In these patients occurs muscle weakness, atrophy. The lowest level of protein in the blood observed for 5-6 days after surgery, after which he began normalized. However, this normalization of protein in the blood taken palce very slowly and lasts 10-15 days. To prevent disturbances of protein metabolism in patients with preoperative period is necessary to ensure high calorific protein food, spend plasma transfusion, albumin, protein.


Disorders of lipid metabolism. In the postoperative period, marked changes occur and fat metabolism. For its correct use mostly fat emulsion (venolipid , intralipid , emulsan et al. ), Which are sources of fracture energy of unsaturated fatty acids ( linoleic , linolenic, arachidonic , etc. .) To ensure normal function of cells, inhibit catabolic processes.


It should be noted that the caloric content of fat is 2.5 times higher than that of protein and carbohydrates. Fat emulsion poured at the rate of 1.5-2 grams of fat per 1 kg of the patient.
Disorders of carbohydrate metabolism after surgery. In 90 % of patients in the first 2-3 days of sugar in the blood is reduced and there is hypoglycemia. With 3-4 days observed elevated levels of blood glucose (hyperglycemia), sometimes glucosuria that due to a decrease in its formation and assimilation. Note that the number of substances in the body depends on the intensity of metabolic processes and methods of their separation from the body.


This is in violation of carbohydrate metabolism in the body mainly accumulate oxidized products that reduce the alkalinity reserve and affect blood pH. Change the value of blood pH by only 0.3-0.4 IU (normal pH - 7,34 -7,45 units ) in any direction leads to marked disturbances of enzymatic activity of redox processes in the body that can result in death patient.


Timely , proper and intensive preoperative preparation, careful nursing and correction of carbohydrate metabolism (introducing sufficient 5-10% glucose solution with insulin at the rate of 1 IU of insulin on glucose 4-5 g dry ) before and after the operation is the best way to prevent severe forms of carbohydrate metabolism .


Disorders of water- electrolyte metabolism is the cause of many complained in patients after surgery. There are three forms of violation of water exchange : 1) there is a real shortage receipt due to insufficient water in the body , and 2) the excess water caused by the mismatch between revenues and elimination of the body 3) reallocation of water in some areas of body connected with the of ochanging relations of electrolytes. Normal necessity of human need in water ranging from 2,000 to 2,500 ml, depending on body weight, age, sex and some other factors. Metabolic disturbances water can manifest dehydration (dehydration) or hypehydration. Remember that a person identifies a day by the kidneys to 1.5 liters of water through the lungs - 400-500 ml through the skin - 500 ml and through the intestines - 200 300 ml. To determine the necessary amount of water for dehydration propose to use the formulation Rendall.


TS = (1 -t 40 t -) x 20 % of body weight of the patient Ht min.


where TS - water scarcity , l;


Ht min. - Hematocrit of the patient ; m - weight of the patient , kg.


Thus, for patients with a body weight of 70 kg and measure hematocrit 45 % of it is: (1 - 40/45) x 14 = 1.68 liters.


In surgery often have to deal with the syndrome IOM dehydration. Thus providing 4 degrees of dehydration: a) moderate - loss of water is 2-5% body weight, and b) significant - water loss is 5-7 % of body weight, c) maximum - the loss of water - 7.10 % d) terminal degree of dehydration - over 10% of patients.


Disorders of water balance is closely connected with the violation of the electrolyte exchange.


To correct the content of Na (135-145 mmol / l ), K (3,8-5,1 mmol / l ), Ca (2,1-2,7 mmol / l ), Mg (0,8-1,2 mmol / l) also use different formulas .


E = m x 0,2 x ( K1 - K2 )


where E - lack of electrolytes ; m - weight of the patient, kg 0,2 - coefficient ;


K1 - normal content of cations in plasma , mmol / l, K2 - the content of cations in plasma of patient mmol / l.


To correct hypocalemia use 7.5 % solution of potassium chloride, 1 ml of 7.5% KCl solution containing 1 mmol of potassium.


It should be noted that the implementation of the pathogenetic treatment of postoperative , especially in critically ill , is only possible with the support of a stable water- electrolyte balance , full of energy and plastic providing body through a full parenteral and enteral nutrition , with adequate protein , essential amino acids vitamins, fatty acids, trace elements.


Changes in the blood may occur: reduction of erythrocytes, hemoglobin, leukocytosis, leukocyte shift (the number of neutrophilic leukocytes and decreases lymphocytes and eosinophils).


At the same time there is a change of blood coagulation properties, manifested increased activity coagulation (fibrinogen, prothrombin, thromboplastin, proaktseleryn et al.) And inhibition of systemic anticoagulation themes of blood, which creates conditions for the emergence of dangerous postoperative complications them - embolism and thrombosis.


To correct anemia and transfusion of hemostatic used erythrocytes- packaged, leukocyte, platelet, plasma, fibrinogen,denote with anticoagulant therapy ( fraksyparyn , heparin, pelentan et al. ).

The role of the nurse in the care of the organization and conduct of postoperative


Postoperative treatment of patients to be active, you must include early ambulation with bed system of physical therapy, nutrition and correction of disturbed functions.


Important role in the prevention of postoperative suppuration and provide timely healing wounds. In seriously ill patients with reduced regenerative processes (pyloric stenosis, cancer, peritonitis, etc. .) To prevent divergence of the wound and eventration should be immediately after the operation sense to wear a special belt, bandage or tie operated.


Extremely large role in the recovery of patients in the postoperative period belongs surgical nurse. Proper and timely implementation of medical appointments and sensitivity to patients and create conditions for their speedy recovery.


All surgical patients after surgery can be divided into three groups:


patients with stable as functions of vital organs (normal hemodynamics , respiration , etc.). , which is usually placed in the recovery room;


patients with labile state of the vital functions that are characterized by unstable hemodynamic and respiratory and the need for intensive treatment ;


patients in critical condition with severe disorders of the cardiovascular , respiratory, nervous system , and others . Without resuscitation in these patients, death can occur, often they are unconscious. They not only need intensive treatment, but careful maintenance.


In modern hospitals severe postoperative patients (second and third group) is concentrated in specialized intensive care and resuscitation.


Intensive therapy involves complex therapeutic interventions aimed at normalization of homeostasis, prevention and treatment of acute disorders of vital functions. Resuscitation - a set of measures aimed at restoring or replacing suddenly lost the heart, lungs and metabolism in patients who are in critical condition.
After treatment and improvement of the patients they are moved or postoperative general surgical ward office. House for postoperative patients should be large (up to 2-3 pers.). In the House should be centralized supply of oxygen and a set of tools, devices and drugs to intensive care and resuscitation (Fig. 17).
 
To provide maximum peace and physiological provision of patients placed on functional bed covered with pure linen. It is better to put the patient in a warmed bed (with hot-water bottle ).It is necessary to monitor the cleanliness of bed linen. For warnings pressure ulcers patient is put on a rubber wheel or a special Mamatic mattress.


To replace the bed linen patient first turn it on its side of the bed in the liberated take away sheet in roll (from the edge of the bed to the patient). After that, the patient returned to a clean sheet, component is dirty and deploying roller clean sheets, covering all bed Fig. 18).
 
 In large surgical departments to monitor and care for their sick operation companies allocate a separate post. The nurse monitors and records the main functional parameters: heart rate, respiration, blood pressure, temperature, amount drunk and highlighted (in urine, stool, discharge from the wound) fluid. At the same time pay attention to the general condition of the patient ( calm, excited, in general , etc. .) , Color ( cyanotic , pale pink , etc. . ) Temperature.

In severe operated patients, especially in the early days it takes diligent oral care. Dryness of the tongue, mouth recommend spending topical rinse with water and smearing mucosal mass vaseline scrap. To prevent inflammatory processes in the mouth (dental abscess, mumps, dental) should brush your teeth, rinse your oral cavity warm water with lemon juice, a weak solution of potassium permanganate, to conduct massage submandibular, with salivary glands. All patients must daily face wash, hand. Seriously sick washing his younger nurses. Men should shave. Skin illness to be clean. Contaminated areas of the body should be immediately washed. In patients with full to prevent diaper rash should be regularly cleaned and lubricated pidpahvynni and groin, navel, women - folds under the breasts 0.1 % solution of potassium permanganate, tetracycline, levomitsetynovoy ointment. Persons specially careful to monitor the purity of the perineum. After each act of defecation perineal area should be washed with warm water or 0.1 % potassium permanganate solution or aqueous chlorhexidine, kutasep -dent and other cloth and dry. Women need to cleaning at the night, using aqueous solutions of weak antiseptics. To take patients out of bed depends on their general condition, severity and nature of a previous operation. It starts with lowering the legs and seat illness nd in bed at a normal state of health can pick it up on their feet.


When satisfactory and normal continuation postoperative period after hernia, appendectomy patients can get up to 2 -3rd day. After complex operations (gastric resection, cholecystectomy, bowel resection, etc.). Patients should raise 5-6 days as directed by the ovarian cancer. After surgery on the limbs, blood vessels, chest and other deter- wool allow in different terms, for each individual patient.


If you are caring for postoperative patients is important to supervise the bandage. Should be carefully supervised to ensure that the bandage is not leaked blood, slid off, not exposed wound.


When the bandages blood leakage should call a doctor immediately and take steps to stop the bleeding (with significant bleeding crush injury, put the ice pack, the burden - a bag of sand, etc.). .


With clean wounds are well healed, the bandage changed on the second day after surgery and for 7-8 days after removal of the sutures. When festering ligation is carried out more frequently wound clean, antiseptic wash and drain.
 
Extremely important valuation in predicting the course, particularly early postoperative period, should observe the oc- er function.
Removal of sutures in most sick people performed on 7- 8th day, the people who do not have power, elderly patients - 10 -12th day. Children can removes seams s for 5 to 6 days after surgery (Fig. 19).


The cardiovascular system
. On the cardiovascular of the system is judged in terms of pulse, blood pressure, colouring of skin. Slowdown and increased pulse pressure (40-50 beats per minute) may indicate a violation of the central nervous system due to brain edema, meningitis.


Often,frequent and reduce heart rate (over 100 beats per minute) on a background of low blood pressure, pale skin may be a manifestation of acute heart failure secondary shock or hemorrhage.


For the prevention and treatment of secondary shock using facilities are against shock means; transfusion of blood components - packed red blood cells , washed red blood cells, plasma, albumin , blood substitutes - polyglucin , zhelatynolyu the introduction of cardiac preparations, tonics .


Respiratory. In the postoperative period, under the influence of anesthesia, static position in bed , impaired diaphragm excursion decreasing via ventilation , there is frequent and shallow breathing, accumulated phlegm in the bronchi , trachea . This condition can result in pneumonia, formation of pustules. This is why it is important to prevention of these complications ca- active movement since the early days, breathing exercises, Inga -tion moist oxygen, antibiotics.


Urinary system. Normally a day person produces about 1500 ml of urine (40-50 ml per hour). Reduced renal function may be at cation intoxication, leading to oliguria (reduced urine) and anuria (complete cessation of urine). Often urinary retention may occur when using morphine, omnopon.


Digestive Tract.
Any surgery is displayed on the function of the digestive system, even if the operation is not performed on them. In the case of this pathological condition are important viscero -visceral reflexes braking action of the central nervous system is limited by the activity of the patient. Important information can be obtained already in the review of the tongue.Thick, brown patches on the tongue dry and cracked it can be observed in peritonitis, prolonged paresis of the intestine. When dry tongue with crack we recommend rinsing and wiping mouth soda solution (1 teaspoon per cup of water), 2% boric acid peroksydom hydrogen (2 teaspoons per cup of water) solution of potassium permanganate 1:400, lubricating glycerin, antibacterial ointments.

In seriously sick people may develop stomatitis, parotitis (inflammation of the parotid gland). To increase salivation (saliva) in water add lemon juice and cranberry juice. You can assign 3 drops of 1% pilocarpine solution under the tongue. Important features of lesions of the digestive system may be nausea and vomiting. First, you need to figure out the cause. For them it is necessary to eliminate sensing, gastric lavage soda solution. Good effect can be obtained in the appointment of Atropine, Dimedrol, Tserukalu, Raglan.

Nursing assessment of bowel motility .


All surgery on abdominal organs, usually accompanied by impaired motor-evacuation of bowel function, as manifested paresis, abdominal symptoms and functional intestinal obstruction.


These complications occur in any elective surgery, particularly when urgent interventions for mechanical intestinal obstruction, Perforated ulcer or other abdominal diseases accompanied by peritonitis. The patient is observed bloating , nausea , vomiting (often intestinal contents dark green with non pleasant smell ), in addition, such patients have delayed gases chair. In this group of patients booming intoxication, dehydration
, the general state gets worse .The nurse should carefully monitor the status of patients undergoing surgery for gastrointestinal tract, and with the deterioration of a doctor . Important is the assessment of motor- evacuation function of the bowel auscultation of the abdomen. The appearance peristalsis (grunts) Bowel indicates reduction of its muscular wall. No evidence of paralysis of motility in the muscular wall of the intestine and the development of functional intestinal obstruction. To prevent such obstruction , especially in patients with severe diseases of the belly cavity complicated by peritonitis, while conducting operations intubation of intestine thin vinyl chloride tube with a diameter of 1-2 cm.


With a thin endotracheal probe conducted decompression in intestine to remove stagnant toxic contents.


An important aspect of caring for such patients is to count the daily amount of fluid released through the probe. The loss of fluid to replenish makes adequate number parentally. When removing stagnant quiche content, it is appropriate to wash small intestinal lumen (300 - 400 ml) dose of warm isotonic sodium chloride (1-1.5 liters per procedure). The nurse must monitor the status of the probe and the discharge from it. In the absence of passive drainage nurse should regularly every 2-3 hours to carry out extraction of intestinal contents with a syringe or electric pumps Janet. To combat pathogenic intra colonic micro flora and stimulate intestinal contractions should be 3-4 times a day administered oxygen probe (250-300 cm3) using a syringe Janet. Subject to these rules bases decompression postoperative period runs smoothly without lack however enteroplegia : bloating, belching , hiccups , vomiting, labouring breath
.


In patients with intestinal intubation should be periodically Auscultation of abdomen to determine the time of occurrence of peristaltic contractions of intestine. Objective evidence that the appearance of peristalsis is periodic allocation light of intestinal contents through a tube, self discharge gases chair, improving well-being of the patient. Motor function intestine is usually restored 3 - 4th , at least on the fifth day after surgery . The probe is removed at 6- 7th day. Remove probe
put at to its end within 5-10 minutes because it can curl,to displace. When removing the probe may occur in patients with nausea, urge to vomit. Decompression of the small intestine is a very effective method of prevention and treatment after functional obstruction in operating of the functional uncommunicating of intestine. It is an indispensable tool in the operative treatment of general peritonitis, strangulation intestinal obstruction (vulvulus, intussusception ), unloading joints with bowel resection .


Quite often, the success of surgical intervention and restoration of motor activity
in the intestine depends on the method of drainage in the belly cavity, which provides a complete selection of fluid ( exudate , pus , etc. .) From the abdominal cavity . Drainage is usually carried in two or three vinyl chloride pipes diameter 0.5-2 cm ( Fig. 20).
It is important to care for drainage , they should be extended and placed in separate containers ( bottles from the solutions). For the normal outflow of fluid from the abdominal area corresponding to the patient should be given the status o
r barely raise his head on the side , back , etc. .
The nurse must monitor and control cross drainage selection
of them (number, character). The emergence of the drainage tube of blood is a sign of postoperative bleeding, stomach or intestine contents and; lack of anastomotic sutures . Drainage lasts from 3-4 to 5-7 days in some cases longer. Drainage should be removed promptly as they can cause pressure sores ulcers, bleeding , and create conditions for adhesions in the abdominal cavity.


Remove the drain tube should be gently and slowly , it is necessary to remove ligature which records up to the skin of the patient. After removal
of dried tubes you should also monitor the status of dressing anterior abdominal wall, as there may be bleeding , exudate.


Features feeding patients. Feeding patients after surgery depend
s on the size and nature of the surgery.


Feeding patients carried out only with the permission and under the supervision of a physician .


After surgery on the upper gastrointestinal tract (
in the stomach ), the first two days the patient is prohibit from the use any liquids or food. Allow only wet the lips , tongue digested water using a teaspoon , wrapped with gauze . On the third day after the operation the patient can drink mineral water ( without gas ) " Luzhanska ", " Myrgorodska " soda water. Feeding patients begin the restoration of peristalsis in the intestine. Allows the use of fresh yogurt, pudding, clear soup , semolina , fresh eggs, etc. . (table number 0). On the fourth day the patient is prescribed number table 1a or 1b number . Under normal postoperative period patient gradually expanding diet with 12-13 day appointed common table ( 15).


After surgery the duodenum , small intestine sick the first two days is not received enteral nutrition. He carried parenteral nutrition : introduction of a 5 % glucose solution with insulin, blood ( albumin, Protein , blood plasma ), blood substitutes. On the third day appointed table number 0 ( yogurt, pudding , broth ) with 4-5 days - table number 1a ( mechanically and chemically gentle food) , further improvement of the general condition of the patient with the 10- 12th day it is transferred to the common table .


After surgery, non- violation of the integrity of the gastrointestinal tract ( cholecystectomy, surgery on the pancreas , spleen ) in the first two days too exclusive enteral nutrition in the presence of postoperative intestinal paresis ( viscero- visceral ref
lex ) and the development of functional intestinal obstruction. With the end of the 2 -3rd day so patients prescribed yogurt, jelly , table number 1a. On the fourth day of the appointment table number 13 ( pureed soup with crackers , pudding , etc.). . We must remember especially feeding of patients after surgery for colon. In the first two days it was no different from feeding patients during operations on the small intestine. Assign food that contains fiber, with the expectation that within 4-5 days the patient was not a chair. At the same time , to reduce the motility of the colon is prescribed to patients with 8-10 drops of infusion ing opium a day.


After operations not related to the gastrointestinal tract ( resection of the lung, thyroid , etc.). , In the first 1-2 days the patient is prescribed number table 1a or 1b number in the future - table number 15.

Postoperative complications, Nursing diagnosis , treatment, prevention


Important role in healing the patient is nursing ,
intravenously diagnosis and treatment of postoperative complications. For their expression of nursing require careful maintenance .


In terms of occurrence of all complications are divided into early and late . Early - a complication arising in the first 48 hours after surgery. These include acute respiratory failure , bleeding from the wound , acute cardiovascular failure, etc. .

Later - a complication that occur within 48 hours after surgery. These include abscesses , peritonitis, pressure ulcers, thromboembolism , and others.
In the postoperative care of patients with particular attention should be paid to the patient's body temperature , heart rate monitor , arterial pressure, depth and frequency of breathing, as postoperative wound drainage tubes.


Complications of the nervous system. The main complications are pain, sleep disorders, mental .


Pain after surgery is observed in all patients. Strength , intensity and duration of pain sensation depends on the surgery , his trauma , duration of the nervous system. Particularly strong and intense pain observed after major surgeries on abdominal and thoracic cavities. To reduce the pain during the first 2-3 days after surgery prescribed analgesics, drugs ( 50 % solution analoghinu , 3-5 ml baralgin , omnopon , ketolonh , Promedolum et al. ).


A possible complication after surgery is the development of shock prevention Coy which are rational preoperative preparation , good anesthesia , high surgical technique the surgeon closely monitored and supervised operations Rowan patients.


Sleep disorders occur, usually due to excessive excitability of nervous and mental disturbances patient, severe pain reaction of postoperative complications after ; intoxication. Such patients prescribed sedatives (phenobarbital - 0.1 ; etaminal sodium - 0,3, Barbamyl - 0.3 ) psyhosedatyvni drugs ( chlorpromazine 2.5 % - 1 ml propazyn 2.5 % - 2 ml haloperidol 0.5 % - 1 ml droperidol 0.25% - 5.10 ml , etc.).


Mental disorders observed in patients after a particularly emotional trauma operations , as well as alcoholics and drug addicts. Patients are excited , their behavior is unjustified, it is messy , there may
be hallucinations . These disorders can occur immediately after surgery or later. Postoperative psychosis not only violate the normaling the postoperative period , but also endangering the lives of disroho . With the development of psychosis should always be at the bedside . In his excitement the physician and the patient tied to the bed. To calm patient sedative drugs appointmentis used enema with a solution of chloral hydrate (20-40 ml 5%). Treatment of patients with psychosis must conduct involving a psychiatrist.


Complications of the respiratory system. In the post-operative period by reducing the frequency and depth of pulmonary ventilation, accumulation of Bron
chiolitic content induced rules may result in various complications : congestive pneumonia, atelectasis , bronchitis , pleurisy, acute respiratory insufficiency adequacy . Occurs in patients with cough, shortness of breath, increased body temperature (37-38,5 C), headache , sweating. Auscultation of the lungs can listen weakened breathing and moist rales. For percussion - dullness pulmonary sound.


For the prevention of pulmonary complications in the first days after the operation the patient should be given a functional ( half-sitting ) position in bed , make breathing exercises (Fig. 21), breathing exercises (Fig. 22), massage , inhalations, physiotherapy. Patients should be protected from supercooling, hard cover in bed.


For the treatment of pneumonia prescribe antibiotics , sulfa
nilamidni preparations , expectorant, cardiac facilities , inhalation of oxygen. At development of respiratory insufficiency apply breathing with the help of artificial ventilation of lights . Patients with complications of respiratory treated with lung , the development of respiratory failure involving intensive care


Complications of the cardiovascular system. Most complications arise in the form of acute cardiac and vascular disease. Complications can arise both during surgery and in the near future after it.


Acute cardiac and vascular insufficiency manifested by a sharp deterioration of the patient, accelerated heart rate, lower blood pressure. With delayed diagnosis and to help cardiac arrest can occur . There are two forms of cardiac arrest : asystole (Full stop this August ) and ventricular fibrillation - uncoordinated contraction of myofibrils . In each of these cases a person who provides first aid is 4-5 min for diagnosis and restore circulation. Me
dical assistants must in these cases immediately begin cardiac massage and artificial respiration at once "mouth to mouth ", "mouth -to-nose " or via Ambu bag with a frequency of 12-15

 

vuvan a minute and call a doctor. To restore cardiac activity using 0.1 % solution of epinephrine diluted in 5 ml isotonic sodium chloride or glucose. With the same purpose using digoxin 0.02 % - 1 ml tselanid 0.02 % - 1 ml strofantin 0.05 % - 1 ml korhlyukon 0.06 % - 1 ml. Horo necks effect is the use of ephedrine, mezatona , norepinephrine, dopamine.


To prevent these serious complications should be carefully prepare for surgery , systematically , as necessary , to enter cardiac facilities during surgery and after . As a result of heart failure patients may develop pulmonary edema. In his warning to patients administered glycosides, 2.4% aminophylline solution to 20 ml of 40 % glucose , diuretics prepared, impose venous tourniquet on the limb.


The most threatening complication of vascular insufficiency is embo
lism and thrombosis of large vessels. Most developing pulmonary embolism . Blocked the main trunk of the pulmonary artery or its branches may be caused by a blood clot ( embolus ) , brought over from the peripheral blood tension of veins and septic embolus from the heart cavities . Sometimes drops of fat embolism or air. Often the source of pulmonary embolism artery ( 85%) venous system is the inferior vena cava and lower extremities ( varicose disease , heart failure, forced position in bed , old age , etc.). . In most cases, pulmonary embolism develops suddenly . There is chest pain, shortness of breath, sudden cyanosis , collapse, loss of consciousness. The ECG show signs of right heart overload and diffuse myocardial hypoxia . Treatment consists of rapid intravenous administration of large doses of fibrinolysin (20-40 thousand units ) in combination with 10-20 thousand units of heparin (10 000 IU of heparin 20 000 IU fibrinolysin ), streptokinase 750 000 IU ; streptodekazy 1.5 million units. To prevent thrombosis patients administered heparin, Fraksim - Parin , fenilina , pelentan and other anticoagulants. Described isolated cases of successful operations with removal of pulmonary emboli without Heine embolectomy .


In particular embolism pulmonary artery branches developing myocardial legene , patients complain of severe pain in the chest, cough with bloody discharge w
ith sputum, shortness of breath, general weakness. When renthenolotech examination showed darkening of the affected areas of the lung . For the treatment of pulmonary infarction is also prescribed fibrinolytics , anticoagulants , antibiotics, sulfa drugs , cardiac drugs.
Often the complexity of the vessels is thrombosis, thrombophlebitis their causes is Varicose veins violation coagulation properties of blood, slow blood flow and so on. Thrombosis ( blocked ) and inflammation of the vein thrombophlebitis occurs . Mostly it is the fault peared in the veins of the lower extremities, it can develop into superficial and profound veins. When thrombophlebitis of superficial veins observed inflammatory infiltrate , consolidation along the veins, redness , increased temperature of the body. For deep vein thrombosis of the lower extremities is characteristic swelling of the limbs , pain in the projection of deep vein leg , increased body temperatur
es .


For the prevention of postoperative embolism , thrombosis, thrombophlebitis should be actively treated patients after surgery to prevent dehydrated
in the body to monitor the status of blood coagulation (time and duration of the blood leakage, coagulation , tromboelastohrama ). With increased ability of blood to clot to assign anticoagulants and prothrombin reduce to 70% for 10-15 days after surgery. In the presence of varicose veins of the lower extremities should be elastic stockings or bind ing . In the presence of thrombophlebitis prescribed increased limb position ( roller, tire Belera ), oil- balsamic dressing (ointment embr Nevsky ) Troxevasin , hlivenol , heparin, fraksyparyn et al.

After reducing inflammation in each case decides the vortex issue further treatment of thrombophlebitis (physiotherapy, operational treatment).


Complications of the digestive system. The most common complication after surgery are nausea and vomiting. Quite often they arise reflexly due to anesthesia and manipulation of the organs w
ith zealous cavity during surgery (Fig. 23).
If vomiting nurse should take
note in Dumpling and turn the head of the patient aside for prevention of ingress vomit in the airway. For prophylaxsis differences and exit wounds of the internal organs ( eventration ) impose on the abdomen give a special bandage, belt interrelation prostyrad scrap . At overflow gastro to enter probe to empty and wash it with warm 0.5-1% sodium carbonate solution . If vomiting reflex effect is a good destination metoclopramide or its analogues , Reglan , Reglan , Prymperanu et al.


For the prevention of vomiting after surgery on the stomach and intestines should spend the first 2-3 days of decompression of the stomach using a thin zones conducted through the nasal passage. The nurse must monitor the status of the probe (or it functions ) and the discharge from it. In the presence of stagnant stomach contents were washed with warm soda solution to the " pure ".

Gastric lavage in the postoperative period, the nurse in guilty done under medical supervision.


Hiccups occur, usually after surgery on the abdominal cavity nyny and has a reflex character due to irritation of the phrenic or vagus nerve. Often the cause of hiccups is fullness or development subdiaphragmatic abscess ( abscess ). If the stomach is full , it should immediately release the contents and rinse . Good effect observed by metoclopramide , atropine sulfate, chlorpromazine , d
imedrolu et al. In some cases, conduct vahosympatychnu cervical block or blockade of the phrenic nerve above the clavicle . If no hiccups at- derecognised as it progresses, it may indicate the formation of ulcers in an abdominal regionor development of peritonitis.


Flatulence (bloating ). The reasons it may be due to migration postoperative paresis , the development of peritonitis, abdominal abscesses formation in cavity .


To eliminate flatulence should: 1 ) periodically raise the patient to put the gas tube into the rectum, or conduct a cleansing enema the night hiperto (150-200 ml of 5% sodium chloride solution ) intravenously 40-50 ml of 10% sodium chloride solution , 1 - 2 ml of 10 % solution subcutaneously proserine 2 ) in lingering flatulence to do siphon enema (10-12 liters of water) . In some cases, conduct perirenal blockade , electroplating solar plexus , put enema Ohnevyj (30 ml glycerol , 30 ml of 3% hydrogen peroxide solution , 30 ml of 10 % solution of sodium chloride dy and 150 ml of water).


Diarrhea .There are various reasons Akhil (reducing the acidity of gastric contents ) , intestinal dysbiosis , peritonitis. Treatment should be aimed at eliminating the cause
.


Complications of genitourinary system. The most common complications are ishuriya - urinary retention, bladder infection and kidney failure , anuria - retention of urine by the kidneys. Ishuriya mainly arises from the viscero- visceral reflex after surgery on the organs of the belly cavity . Often the patient can not urinate while lying in bed. Therefore , if no specific contraindications, the patient should be allowed
to urinate sitting or standing. Calls may be effective heater to the area of the bladder , perineum , cleansing enema . If no effect is carried out bladder catheterization in compliance with the rules of asepsis .


Terms of dressings . Dressings .


Requirements for dressings should be the same as the operating ( bright room , the ceiling of which shall be painted with oil paint , walls and floor are lined with tiles ).


In the dressing to maintain cleanliness. Table for instruments and dressings cover as well as in the operating room (Fig. 12.13 ).


Tools submit forceps . Ligation is carried out only by means of the tool. Instruments are sterilized into the dressing room or sterilizing operating unit . Dressings should be provided with a central cold and warm water. The optimum temperature should be 18-20
C. In the dressing should not be foreign objects , clothes , except for the dressing table , table for instruments and dressings , cabinets for medical supplies and instruments and chairs for patients. In a dressing must consider the degree of cleaning wounds of patients. Patients with complications, purulent wounds bandaged in the least. At the end of the day conducting wet cleaning bandages and irradiation with ultraviolet rays ( kvartsevaniya ). Were in surgical wards , usually has two dressings - for " clean them " and " septic " patients.
 
Required bandages
medical nurse :


1. Performs assigned doctor- intern manipulations are allowed to perform nurse .


2. Accompanies seriously ill after manipulations performed in the ward.


3. Strictly adhering to the rules of asepsis and antisepsis.


4. Prepares and sterilization sterilize bandages and instruments commentaries according to the operating instructions .


5. Provides a systematic bacteriological control of sling - binding material, tools ,
bandages apartment .


6. Provides regular updating , recording , storing and controll
s the expense of medicines, dressings , tools and clothes.


7. Instructs nurses dressings and monitor its performance.


8. Keeps accounting records .


9. Systematically increase their professional qualifications .


10. Participates in health - educational work .


Infection control of the surgical hospital.
In order to prevent suppurative diseases and observance of sanitary - hygienic bacteriological laboratory sanitary station, which is subject to a medical institution, shall once in 15-20 days bacteriological control of air pollution ( operating, dressings, Chambers ), quality control disinfection treatment arms personnel, sterile surgical material and instruments.


Control of microbial contamination of air in operating and sling - binding conducted once a month. Dirty air in the chamber and bandaging can be determined using sedimentation , filtration and method -tion of the shock wave of air. Sedimentation principle of the method is that the microorganisms that are in the air , settle on a horizontal surface. For this study, using Petri dishes with nutrient medium (2% agar ), which are within 15 minutes are left open in predefined locations operating or tied tion . After that, the Petri dish is placed in an incubator for 24 h and pidrahovu tion of colonies that grew . Filtration method of research in lies in the draw of 10-40 liters of air through special absorbers with ste
rilized liquid. The principle of the shock wave is that soaked through the apparatus of air strikes the surface containing nutrient medium above , so that bacteria trapped in it. Air samples were carried out using the apparatus Krotov .


In the operating number of colonies of microorganisms on 1m3 of air
.You must not to exceed 500 hours and 1000 - both during and after operating hours . For dressings and preoperative may be no more than 1,000 to bosom to 1m3 in the air to work. In addition, the sample volume of 250 liters of air should not be plazmokoahulyatsiynoho hemolytic staphylococcus .


Quality control of disinfection carried out suddenly, without the person
nel, 1-2 times a month. Sterile cotton swab moistened with sterile isotonic sodium chloride solution or 1% hyposulfite of flush - drive the 10 subjects , the area should be flush 200-300 cm3. Satisfaction assessment disinfection allow growth in the absence of E. coli , Proteus, Pseudomonas aeruginosa, Staphylococcus aureus and Streptococcus .


Crops with it usually spends elder sister of operating so that the staff did not know when and from whom he will serve . Drill results should be discussed and
compare with the frequency of postoperative complications. This control improves the quality of handwashing staff and reduce the number of postoperative complications.


In addition to the mandatory daily monitoring the effectiveness of sterilization in an autoclave ( dressings , linen ) using standard
ampules or sulfur which is necessary every 10 days seeding with sterilized material. Particular attention should be given to the quality of sterilization - seam material. Crops of silk, catgut should be performed prior to sterilization and its storage at least once in 10 days.


To control the sterility of hands of medical personnel, dressings , sutures first and oldest operating sister should have a special journal.
To identify and sanitation carriers of pathogenic 1-2 times a year to all employees of the surgical department do swabs from the nose and throat swabs special . Revealed carriers of pathogenic infections dignity without fail. In the absence of positive results from the treatment of chronic inflammatory diseases of the upper respiratory tract and oral cavity in workers transferred to another job.