Руководство к практическим занятиям по общему уходу за хирургическими больными (стр. 15 )

Clinical course of wound process

Clinical course of wound process depends on character, localization, the size of a wound, a degree of its microbic contamination, adequacy of treatment and immune properties of an organism. There are two basic kinds of wound healing: healing by a 1st intension and healing by a 2nd intension.

The first type of healing occurs when wound margins are connected (mostly with sutures) and there is no suppurative inflammation. Healing by a secondary intension is observed when wound margins set aside from each other on distance and (or) there is a purulent infection.

At primary healing wounds heal relatively fast. The pain subsides in 2-3 days, the edema the edema and a hyperemia of tissues surrounding a wound decreases in 3-5 days, but cicatrization in depth of a wound occurs more slowly. In first two - three days body temperature may rise up to 37 ° and even 38 °, ESR (erythrocyte sedimentation rate) increases, insignificant leukocytosis takes place. These changes are quickly normalized.

The so-called complicated course of wound process is possible in some cases. The concept " wound infection" covers the infectious processes arising in a wound owing to an invasion of pathogenic microflora on insufficiency of protective reactions of injured tissues or all organism. The wound infection can appear in any wounds - operational and casual. Connection of a wound infection (suppuration of a wound) makes impossible wound primary intension healing.

The main infecting agent of a wound infection is the staphylococcus. Last years the great attention is paid to gram-negative flora, and also non clostridial anaerobic microorganisms (Peptococcus, Peptostreptococcus, B. fragilis).

In a clinical characteristics of wound suppurations there are some variants depending on infecting agents. At a staphylococcal infection the body temperature starts to rise on the 5-7 day. But sometimes the fever is marked already in the first day after operation. The state of patient’s health worsens. Various pains in the field of a wound start to disturb. On wound examination skin hyperemia and edema of a wound margins, morbidity on palpation of surrounding tissues, an infiltration of a hypodermic fatty cellular tissue can be seen. On localization of a suppuration under an aponeurosis or deep fascia the symptoms can be very fuzzy because of the skin and a hypodermic fatty cellular tissue start to react only at distribution of pus to these layers of a wound. This circumstance delays early diagnostics.

At gram-negative flora the general and local symptoms of a suppuration appear on the 3-4 day. At these patients the intoxication, high temperature of a body, tachycardia, a painful syndrome are more expressed.

At anaerobic non clostridial infection caused by non spore-forming microbes, the fever, as a rule, is marked from first day after operation (or wound). The common anxiety of the patient, a sharp pain in the wound, an early extensive edema, expressed tachycardia are marked. Only disclosure of wound margins in some cases does not stop a suppuration. In this case special surgical tactics is needed.

There is also anaerobic clostridial wound infection (Cl. perfringens, Cl. sporogenes, etc.). In such cases during the first hours, less often in the first days after operation severe intoxication, the high body temperature, fever, jaundice, oliguria, tachycardia, dyspnea are detected. Local symptoms are pain in the field of a wound, edema, a crepitation (a characteristic crackling on palpation, significative of gas presence in tissues ), dark blue stains on skin.

High leukocytosis and, what is more important, a lymphopenia which can serve as a parameter of developing complication are characteristic of a wound infection.

The general care and supervision over patients

The need for the general care depends not only on a patient’s condition, but also on localization of a wound. Quite often patients with extensive wounds of the face, or legs are not capable to move, to serve themselves independently and need constant supervision and care of the medical personnel even if they feel themselves well.

Wards with such patients, should be aired regularly & exposed to a ultra-violet irradiation with the help of bactericidal lamps 1-2 times a day during 10-15 minutes. During work of these lamps patients faces are to be covered with a towel for the prevention of eyes lesion. Wet cleaning with disinfectants is carried out 2 times a day.

Patients with extensive purulent wounds stay in bed for a long time. Their bandages are frequently impregnated with wound discharge, the bed-clothes becomes soiled, therefore it is necessary to change it not less than two times a day. To change bed-clothes is more convenient, when the patient is on bandaging.

It is necessary to carry out regular preventive maintenance of decubital ulcers (bedsores) for patients with extensive wounds. For this purpose it is necessary to change their position in bed every 2-4 hours. Areas of a body, exposed to pressure (sacrum, calcaneus tubers, ulnar joints, scapulas) are wiped by camphor spirit or special ointments. The special rubber circle (wrapped up in a cotton) is put under the sacrum. To avoid pressure upon other areas, it is possible to use the rings made of cotton wool.

Patients with a high fever have a dry lips, there are labial fissures, causing pain on opening of mouth. In these cases it is necessary to grease lips and corners of a mouth with vaseline oil. To reduce feeling of dryness in a mouth, it is good to use albuminous rinsings (albumen on one glass of warm water).

Patients with deep extensive suppurative wounds may have an arrosion (wall destruction) of large blood vessels. The probability of a bleeding from an amputation stump is very high. The medical personnel should be necessarily informed on such patients. Whenever possible it is not necessary to close wound area with a blanket or a sheet for constant supervision over it. On significant drench of bandages with blood the doctor on duty should be called immediately, and the patient is to be transported into the dressing station. The profuse hemorrhage is the indication for imposing a tourniquet above a place of a bleeding.

Bandaging

Bandagings - the medical and diagnostic procedures used during treatment of wounds, ulcers, burns, frostbites, necrosises, external fistulas, etc.

In the surgical department bandaging is carried out in dressing stations with the use of special tools and a dressings. Bandagings are made by a doctor with the help of a nurse or a nurse under the doctor's control. Frequency of bandagings depends on a phase and character of wound process, quantity of wound discharge. After operations with placing a suture the first bandaging is carried out the next day, the second - in 3 - 4 days and the last one - when sutures are removed. In case of a bandage drench in pus, or any other biological liquid bandaging is done immediately. At purulent wounds bandaging is made daily, and if necessary – several times a day. If wound is cleared (a granulation stage) bandaging is made once in 3-4 days.

Indications to emergency bandaging are:

a drench of a bandage;

severe pain in a wound;

an edema and hyperemia near wound;

rise of a body temperature.

Bandaging begins with removal of bandage from a wound. The further manipulations are done in the following order:

- primary toilet of a skin around of a wound;

- survey of a wound,

- toilet of a wound, performance of diagnostic and medical procedures;

- repeated toilet of a skin;

- bandage application.

Primary toilet of a skin includes cleaning of skin (if it is necessary) with wet cotton and processing it with antiseptics (ethyl spirit, iodine, iodinate, iodopyrone).

During survey of a clean wound it is necessary to reveal symptoms of an infection. Symptoms of a sutured wound suppuration are the skin hyperemia, edema, infiltrates in wound area, sometimes pus between sutures. At an anaerobic infection wound margins are edematous, often without hyperemia. Pressing by a finger does not leave a trace in edematous skin. There are traces of an impression of a bandage, a crepitation. The bare suspicion on presence of the anaerobic infection demands urgent measures.

In the purulent wounds: they are qualified degree of inflammation, quantity of discharge, presence of necrosis, character of granulations. This rate of wound process is basis for applying either methods of treatment.

Conception of the wound toilet concerning purulent wounds. This procedure consists of:

- elimination of the foreign bodies;

- elimination of necrotic tissues;

- elimination of pathological liquids (blood, pus, intestinal contents, etc.);

- washing by antiseptics.

Primarily among antiseptic it is better to use 3% hydrogen peroxide. At contact of this solution with wound the foam clearing of a wound is done, and oxygen has bactericidal effect. After hydrogen peroxide it is necessary to wash the wound with other antiseptics, for example 0.02% water chlorhexidine. Further it is necessary to make diagnostic and medical actions (treatment of a wound by laser radiation, necrectomy, dissection of purulent pouches, placing of a secondary sutures and so on). At local treatment of wounds many chemical antiseptics are used for washing and bandaging:

- 3% hydrogen peroxide;

- furacilline solution (1:5000);

- solution of 0.02% water chlorhexidine;

- 0,25% and 0,5% solutions of silver nitrate;

- methylene blue, brilliant green;

- 10% solution of sodium chloride;

- ointment on a hydrophilic basis (Laevosinum);

- proteolytic enzymes (trypsin, chymotrypsin).

On maceration of a skin by wound discharge it is treated with 5-10% solutions of tannin, 3-5 % solutions of potassium permanganate, 1% a solution of methylene blue or brilliant green and special pastes (Lassar's paste, zinc ointment). For protection of skin it is possible to use also film-forming preparations (Cerigel). In case of occurrence of a secondary bleeding a wound tamponade is applied. The hemostatic tampons are removed not earlier, than in 2 - 4 days after a tamponade.