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
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 -
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-
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-
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
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
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-
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-
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
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
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 -
where E - lack of electrolytes ; m - weight of the
patient, kg 0,2 - coefficient ;
K1 - normal content of cations in plasma , 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-
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-
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-
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 or 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
depends 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 Bronchiolitic 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 ,
sulfanilamidni 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. Medical 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 embolism 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 with 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 temperatures .
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 with 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 , dimedrolu 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-
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
controlls 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-
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
Quality control of disinfection carried out suddenly,
without the personnel, 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.