Руководство к практическим занятиям по общему уходу за хирургическими больными (стр. 13 )

The medical personnel is obliged to provide cleanliness of a body, cloth and bedclothes of the patient, an optimum mode of his feeding, excreta hygiene.

Chapter 12

SUPERVISION AND CARE OF PATIENTS AFTER ABDOMINAL AND THORACIC OPERATIONS

Surgical interventions on abdominal and thoracic organs are most frequent operations now. In common surgery departments the majority of cavity operations are interventions on organs of abdominal cavity. Both planned and urgent abdominal operations are performed in common surgery departments. Planned operations on lungs, heart, esophagus are performed in special departments usually. There are departments of lung surgery, departments of heart and vascular surgery, etc. However urgent patients with a surgical pathology of a thorax, are rather often admitted to common surgery departments, therefore questions of general care of this patients should be known not only by doctors, but by paramedics as well.

Supervision and care of the patients after thoracic operations

Surgical treatment is needed for many lesions of thoracic ch diseases are acute and chronic purulent damages of lungs and pleura, tumors of lung and mediastinum, heart and large vessels defects, illness of a gullet. Operations are performed also at the open and closed traumas of a breast. The patients who have undergone surgical interventions on lungs, gullet, heart and large vessels, frequently are in severe condition and require well organized specialized care.

It is possible to assert, that recovery of patients after thoracic operations equally determines both a well executed (well-made) operation, and high-grade postoperative care.

At the first hours after operations on lung, heart and gullet very serious complications can develop. The nurse should not to leave such patients without supervision even for a minute. It is necessary to take care of character of breathing, pulse, arterial pressure, condition of drainages, body pervision over a bandage is also very important.

The medical personnel must know dangerous symptoms significative of circulatory and respiratory disturbance.

The important characteristics of a patient’s condition with a pathology of respiratory system is the change of frequency, depth and rhythm of breathing. The healthy adult makes 16-18 respiratory movements (breaths) per minute. Normal breathing should be rhythmical, with average depth. One respiratory movement falls on 4 pulse beats. Accelerated deep breathing is observed on emotional excitation, an anemia of brain, irritation of painful and thermal receptors. Accelerated superficial breathing happens at an pneumonia and pleuritis. Faint deep (the so-called stenotic) breathing is observed at narrowing of the top respiratory ways and laryngeal edema. Recurrent breathing testifies patient’s heavy condition observed on heavy blood circulation disorder.

One of the important symptoms of a pathological condition of respiratory tract is cough. Cough is the jerking exhalations accompanying with strong contraction of respiratory muscles. The physiological role of cough consists of an elimination of the particles (lung phlegm, dust) from respiratory ways. Frequent and repeating cough usually testifies of a lung pathology, but can be reflex (at irritation of a pleura, a nasopharynx mucous). Cough can be dry or wet (productive) with a lung phlegm. The character and quantity of a lung phlegm has diagnostic importance. The latter can be mucous, serous, purulent, hemorrhagic. Admixtures of blood in a lung phlegm is called a pneumorrhagia. It is necessary to remember, that the pneumorrhagia sometimes precedes a pulmonary bleeding. Pulmonary blood is scarlet, foamy.

Patients with a surgical pathology of thorax can have such pathologic processes as a pyothorax (accumulation of pus in a pleural cavity), a haemothorax (accumulation of blood), a pneumothorax (accumulation of air), hypodermic emphysema (enter of air in a hypodermic cellular tissue from morbid changed lung) after an operation. At air presence in a hypodermic cellular tissue the symptom of a crepitation (sensation of snow crackle) on palpation of a corresponding site of a body is determined.

For breath relief the patient takes half-sit down position. The in-come of fresh air is necessary. The good effect is given with oxygen therapy. There is an old method of oxygen therapy with applying oxygen cushion. Now oxygen moves into respiratory ways from the centralized system through nasal catheters. Sometimes patients can be put in special oxygen wards or in pressure chambers with the increased air pressure.

Before use it is necessary to sterilize and grease a catheter with vaseline. It is entered through the lower nasal duct and attaches with the help of a plaster. It is necessary to remember, that it is possible to give only the humidified oxygen to upper respiratory ways. Humidifying is done by an admission of oxygen through water. For this aim it is possible to apply special set called Bobrov's jar. That is a tightly closed vessel with a rubber cork. There are 2 apertures in the cork through which tubes are inserted into a vessel: one short, another - long, coming to a bottom of a vessel. The 1/3 of a jar is filled up with water. Oxygen comes along long tube, passes through water and gets away along short tube to nasal catheters.

The pleural cavity after the thoracic operations is often drained with tubular drainages. The personnel observing patients is necessary to have at least the common information about assignment of drainages and the rules of their work. Plastic (silicon) tubes (diameter about 0.5-1 cm) are applied as drainages.

The lower parts of a pleural cavity are drained after operation to remove liquid contents (blood and an exudate). Usually with this purpose the drainage is entered along back auxiliary line through 7-8 intercostal space. If there is a necessity of air removal, the drainage is entered into the top part of a pleural cavity (usually through 2-nd intercostal space along median clavicle line).

There are two types of drainages: active and passive. Passive drainage is Bulau's drainage. This type is widely used. It works on flap principle. The finger of a thin rubber glove is attached to the end of the draining a pleural cavity tube. The top of finger is cut in a longitudinal direction at a length of 1 cm. The end of a tube together with a finger is located on a bottom of vessel (glass jar) the one quarter of which is filled with an antiseptic. At an inspiration contents of a pleural cavity follow from it along tube through rubber finger. On inhalation the finger is collapsed and block the entry of air & liquid from a vessel into a pleural cavity. The described way of drainage has the advantage of simple performance and does not demand application of any equipment. At present medical industry delivers special disposable bags with the same flap principle.

They apply various sets for active drainages. The simpliest variant of sucking away device is Bobrov's jar (described above). Long tube joins the drainage from a pleural cavity, and short - a special cylinder in the compressed condition (it is possible to use a rubber syringe for enemas). The better choice of active drainage is special electric suction apparatus automatically supporting the low pressure in the system.

The nurse should watch that vessels in which pleural contents are aspirated, were not overflown, and also carefully to take into account the character and quantity of discharged on drainages. It is very important to notice the termination of a drainage functioning or infringement of its hermetics.

If a patient has a bad cough with a plenty of lung phlegm we can apply postural drain. The patient should be laid on a stomach. The pillow is removed, and the foot end of a bed rises on 30-60 sm. The head of the patient should be below a trunk and feet. Thus respiratory ways will be well cleared of blood or lung phlegm.

Nurse’s duties include care of an oral cavity and skin of the patient. The important element of her activity is implementation of active postoperative period. The next day after operation the patient must change his position in a bed, breathe deeply, inflate a children's balloon or a rubber toy, move hands and legs, turn his head. Active movements of upper & lower extremities improve pulmonary ventilation and common hemodynamics. The earlier rising of patients is practised in the majority of surgical clinics. At many operations on lungs, mediastinum, chest wall the patient is allowed to get up the next day after intervention. The nurse should help the patient to get up.

The psychological atmosphere in a department influences greatly the result of operative treatment. The success of operation is promoted by goodwill, the sensitive tender, attentive attitude of the personnel to the operated patients.

Supervision and care of the patients after operations on abdominal cavity.

Patients with a pathology of abdominal organs make a significant part among patients of surgery departments. To the majority of these patients surgical operations are performed. The last can be urgent, emergency and scheduled (planned).

The course of the postoperative period of patients after operative interventions on organs of abdominal cavity, in many respects is determined by a condition of a motor function of a gastroenteric tract. After operations, especially urgent, quite often there comes a paresis of a gastroenteric tract or paralytic intestinal obstruction may occur. This condition is caused by inhibition of a stomach and an intestine motility to its full absence (a paralysis of unstriped muscles). The unstriped muscles of intestinal tube are constantly in tonus and move (peristalsis) on a par.

The direct reasons of a gastroenteric paresis are the peritonitis, pancreatitis, abdominal abscesses, retroperitoneal hematomas and an excessive lesion of abdominal organs at operations (technically difficult, traumatic interventions). As a result of intestinal tube motility inhibition (a relaxation of intestine muscles), the passage of contents slows down or stops completely. As a result hollow organs of a gastroenteric tract dilate and become a pouches without peristalsis, filled with a liquid chyme and gases. Processes of an adsorption in the inflated loops of intestine are sharply inhibited and, on the contrary, process of secretion intensifies. Thus, the rough growth of microflora which distributes from thick intestine to the top portions of an intestinal tube up to a stomach (dysbacteriosis) begins. Microbes cause rotting and fermentation of intestinal contents that increase an intoxication and raises quantity of the gases in intestine. The significant amount of water, electrolytes, proteins, enzymes that cause damage of a homeostasis get into a lumen of intestine.