Руководство к практическим занятиям по общему уходу за хирургическими больными (стр. 14 )

The main factors of paralytic intestinal obstruction are sharp swelling of a stomach, absence of a stool and gases (flatulence), absence of peristalsis (on auscultation the so-called "the dead silence" is marked).

Struggle against a paresis of a gastroenteric tract is composed from a complex of actions the part of which is carried out at a stage of operative treatment (an intubation of thin intestine, local anesthesia (blockade) of reflexogenic zones etc.). It is necessary for patient to take a position in a bed with the raised head for reduction of pressure on a diaphragm and improvement of pulmonary ventilation. Full starvation is ordered. The need for water, electrolits, proteins, carbohydrates and vitamins is compensated due to a parenteral feed (see chapter 8). The contents of a stomach of the patient with a paresis of a gastroenteric tract is usually moved with the help of a gastric probe (the technique of stomach sounding is described in chapter 15).

During the operation concerning peritonitis and intestinal obstruction the intestinal probe can be applied to the patient. This probe is a silicon tube of about 1.5-2 m perforated on 2/3 of its length. It is introduced through a nose into a stomach and further into a small intestine. The non perforated part of tube must be in esophagus and pharynx. In the postoperative period it is necessary to watch an intestinal probe carefully to prevent its partial moving from a gastroenteric tract lumen. In this case intestinal discharge can enter in pharynx and be aspirated in respiratory ways. This can cause asphyxia and an aspiration pneumonia.

For decompression of the lower part of a gastroenteric tract into a rectum flatus tubes and an enema are applied (chapter 15). From all kinds of enemas the siphon enemas well washing out a colon lumen and promoting amplification of a peristalsis are often applied. The application of the so-called hypertonic enema - introduction of a hypertonic solution (5% sodium chloride) into a rectum can be effective. The Ognev's enema (10 % sodium chloride, 50 ml of vaseline oil and 50 ml of hydrogen peroxide 3 %) is a variant of a hypertonic enema.

Such methods of struggle against a paresis of intestine as infusion therapy (saline solutions), injections of the drugs stimulating intestinal peristalsis (Proserin, Cerucal), electrostimulation of intestine are applied.

An oral cavity care is important both after emergency, and after scheduled operations on a abdominal organs. Healthy people have its autopurification at chewing firm ch care consists of wiping, washing or an irrigation of mucous and teeth. A teeth can be wiped with a wet cotton tampon with 0,5% sodium bicarbonate. Washing of an oral cavity is carried out with the help of a rubber cylinder of 0,5% sodium bicarbonate, 0,5% hydrogen peroxide, potassium permanganate 1:10000, 0,02% a water solution chlorgecsidin, solution furacillin 1:5000. The patient should take half sit-down position. The breast and neck are closed by an apron, the tray is put under a chin.

Reduction of salivation, infringement of a normal drainage of an oral cavity, the termination of teeth cleaning lead to dryness of the mucous membrane, amplified development of pathogenic microflora. That can cause stomatitis (an inflammation of a mucous membrane of oral cavity), a glossitis (an inflammation of tongue), a gingivitis (an inflammation of gingivas) and a parotitis (an inflammation of a parotid gland) and even worsen the patient’s condition. To prevent these complications it is necessary to carry out hygienic processing of an oral cavity 2 times a day by the technique described above. To stimulate salivation (to improve of a drainage of a parotid gland) it is possible to give the patient acid products (citric juice).

Position of the patient in bed depends on a type of operation. So after a stomach resection the patient is usually put on a back with a little raised head end of a bed. At a gastrectomy (full removal of a stomach or extirpation) the half sit-down position is considered the best one. For a constant decompression of a stomach stump a surgeon introduces the thin probe into a stump through a nose leaving it there for 2-3 days. It is necessary to remember, that the decompression of a stomach after lots of operations on it and a duodenum is a very important manipulation.

The seriously ill category of patients demanding much care is the patients who have undergone operation on intestine. Operations in connection with a cancer and perforation of colon are performed more often. At some patients operations end with by creation of colon fistula (colostomy, artificial anus) in abdominal wall. Change of a bandage with the removed loop of intestine is made on the second day. The lumen of a gut is opened usually on the 3-4 day after operation. After formation of a fecal fistula careful protection of a line of sutures and a surrounding skin against faeces weights are required. Dressings are done not less than 2 times a day with processing of the skin with antiseptics and skin protectors (Lassar's paste, zinc paste). After full formation of colostomy (on the 10-12 day after operation ) a special plastic pouch for gathering faeces is applied.

Peculiarity of operations on biliary tract is leaving of tubular drainages and pledget (tampon) in an abdominal cavity. The medical personnel should watch a condition of a bandage. If patient has tampon the bandage get wet through with serous or hemorrhagic liquid. If the bandage get wet through with blood, bile or pus sister must inform about this to the doctor on duty. The control over the character and quantity of discharge contents from abdominal cavity on a tubular drainage is carried out in the same way. Sometimes the drainage of biliary ducts (choledochus) with a thin tube can be applied during an operation. Then bile quantity is registered by the nurse. Bile can be intriduced back into a stomach with the help of a nasogastral probe.

Patients ill with jaundice need careful supervision of medical staff. It is necessary to reveal the coming hepatic insufficiency: euphoria, lethargy, sleepiness.

After various abdominal operations there can be different complications demanding emergent medical intervention. One of the dangerous complications is the gastric or intestinal bleeding. Indices: vomit with blood, sloppy tarry stool (melena), scarlet blood in stool. Other complication is the early adhesive intestinal obstruction caused by peritoneal adhesions that compress intestine. Characteristic symptoms of this complication are the periodic spasmodic pain in a stomach, vomit, swelling of a stomach. Presence of similar symptoms is the indication to immediate examination by the surgeon.

The attentive attitude of medical staff to patients is an indispensable condition for maintenance of good current of the postoperative period.

Chapter 13

SUPERVISION AND CARE OF PATIENTS WITH EXTENSIVE WOUNDS

Wound - lesion of integrity of a skin or mucous membranes, and frequently underlying tissues and organs, caused by traumatic influence.

Classification of wounds

Depending on causes wounds are divided into operational and casual. Operational (conditionally sterile) wounds are formed in aseptic conditions in operational theatres or dressings. Other wounds refer to casual wounds (arisen at home, at factory, on road and in accidents). Superficial wounds with damage only of superficial layers of skin and mucous membrane are called abrasion (scratch). Abrasions can be wide and linear.

According to type of damaging tools wounds are divided into pierce, gunshot, crashed, lacerated, contused, bite, cut, saber, scalped wounds.

The cut wound has equal, parallel borders, the length of it is more than depth, and damages of tissues around of a wound are insignificant. The pierced wound has the small external sizes, but deep narrow wound channel. The sabre wound can be similar to cut, but, as a rule, is deeper and is surrounded with unviable tissues. The bite wounds result from bites of an animal or man. They are characterized by extensive microbic contamination on account of to oral microflora and, as a rule, are complicated by suppuration. Besides at bites an animal (carnivores), in an human organism the rabies virus can get. Lacerated wounds are characterized by significant destruction of tissues with formation of haemorrhages and hematomas. types of lacerated are scalped, contused and crushed wounds. The scalped wounds are characterized with skin detachment on the big extent without (enough with) skin damages. They are the result of hair hit in moving mechanisms or of extremity (at lesion of vehicle wheel). Contused and crushed wounds are characterized by extensive damages of tissues and development of their traumatic necrosis; are sometimes accompanied by full avulsion (abjunction) a segment of extremity. Gunshot wounds are the hardest type of damages. There are such wounds as а) tangential when the wound channel has no top wall; b) blind when there is only an entrance aperture and a shell jams in body; c) perforating when both input wound and output wound openings are present.

There are also the penetrating wounds described by damage of all wall layers of any cavity (pleural, abdominal, skulls, joint), and not penetrating.

In addition to there are conjoined, multiple and combined lesions. Conjoined lesion is a damage (cold steel arms, bullet or fragmentation) of several adjacent organs or anatomic areas by a one shell. Multiple wound is a damage of two and more anatomic formations or organs by several shells of one kind (for example, bullets or knife). Combined damage is a mechanical lesion (wound) in combination of various other hitting factors (for example, ionizing radiation, chemical substances, burns, frostbite, pathogenic microorganisms).

There can be foreign bodies in a wound: pieces of clothes, ground, glass and shells (bullet, fragmentation). All foreign bodies are contaminated with microorganisms. Here we speak about primary microbe contamination. Microbes can get in a wound during its treatment. In this case we speak about secondary bacterial contamination of a wound.