Руководство к практическим занятиям по общему уходу за хирургическими больными (стр. 16 )

The repeated toilet of a skin is carried out with the use of the same methods, as before.

The final stage of bandaging is applying a bandage i. e. covering of a wound leaving tampons, drainages and others with the help of a cotton wool, fixed by glue, a napkin, an adhesive plaster, bandage.

Chapter 14

SUPERVISION AND CARE OF PATIENTS IN RESUSCITATION AND INTENSIVE CARE UNITS

The resuscitation is the section of clinical medicine studying various aspects of life restoring and developing methods of treatment and preventive maintenance of terminal plex of various actions at terminal states for restoration of ability to live of an organism is called reanimation.

Departments of resuscitation and intensive care

In Russia there are reanimation and intensive care units of the general profile and specialized reanimation and intensive care departments.

Reanimation departments of the general profile are organized in large hospitals and intended for treatment of patients with various diseases: a traumatic shock, a massive blood loss, acute circulatory and respiratory insufficiency, etc. Also there are patients in need of intensive care in these units. Sometimes particular postoperative intensive care units are organized in big surgical centers.

The specialized centers and departments of reanimation and intensive care are created for patients with the certain diseases. So, in the toxicological centers patients with various poisonings are taken care of in such units. In coronary care units patients with a acute heart attack, impairment of cardiac rhythm are treated.

Resuscitation departments settle down near the reception to provide fast transportation of patients. There are special wards for primary examination of patients, “shock wards” for most severe patients, wards for the treatment of patients in resuscitation units.

Reanimation departments are equipped with the necessary diagnostic and medical equipment: system for monitoring the major functions of human organism (breath and blood circulation), electrocardiographs, mobile x-ray device, devices for artificial pulmonary respiration and narcosis, defibrillators, cardiostimulators, bronchoscopes, etc. Here can be special conditions for hemodialysis, a hemosorption, a hyperbaric oxygenation, plasmos.

There are sterile instrument tables with sterile syringes, needles, tools, infusion sets in the wards.

The heavy condition of patients demands frequent laboratory researches, therefore the communication of reanimation departments with the express laboratories at any time is provided in hospitals. Besides clinical and biochemical analyses of blood (level of protein, creatinine, urea, glucose, some enzymes), it is often necessary to examine its gas structure, acid-base balance, balance of electrolits.

Peculiarities of care in resuscitation and intensive care units

Care of patients who are kept in departments of intensive therapy, includes all elements of the general and special care (with reference to surgical, neurologic, traumatologic and other patients).

For preventive maintenance of infectious complications in departments of reanimation it is necessary to follow some rules. Medical staff should be examined 2 times a year for carriage of bacilli and be sanified. The visits should be limited as much as possible (medical staff attendance as well). It is necessary to put on sterile dressing gowns, bootees and protective masks. Restriction of contacts of the resuscitation unit personnel with other hospital personnel is necessary. The medical staff should process hands by a disinfectant before each contact with the patient. Disinfection of all equipment of wards should be carried out regularly. After removing the patient from department it is necessary to make strong disinfection of his bedclothes. The effective ventilation and constant bacteriological control of room air is necessary.

Special care is necessary for patients with artificial ventilation of lungs through an intubation tube or through tracheostome. This category require regular (sometimes every 15-20 minutes during several days) careful toilet of tracheobronchial tree. Otherwise the syndrome tracheobronchial obstruction and even asphyxia may develop. Procedure of a tracheobronchial discharge removal is made in sterile gloves. The special sterile (disposable) angular or direct catheter connected through a wye (Y-connector) with vacuum suction apparatus is used, thus one knee of a tee remains open. During inhalation of the patient it is necessary to introduce quickly movement this catheter into intubation tube (or tracheostomy tube) and to advance it through a trachea and bronchial tubes serially in the right and left lung (preliminary having turned a head of the patient to the left or to the right). After that it is necessary to close a finger free aperture of a wye, providing, thus, action suction apparatus, and, rotating a catheter, slowly to take it out. A catheter is washed out by a sterile solution or replaced. Procedure is repeated many times o provide full removal of lung phlegm. The efficiency of procedure increases if vibrating massage of a thorax is made simultaneously.

For prevention of decubital ulcers (bedsores) and hypostatic pneumonia medical staff should change patient’s position every 2 hours (as a rule, in sequence side – back – side), wipe skin tanning substances (camphoric spirit, ethyl spirit), enclose jut gauze and rubber rings under bones. For prevention of decubital ulcers it is better to use special mattresses or beds.

The patient in a coma should be put on one side for maintenance of respiratory ways patency. The top arm is placed on a pillow or soft cylinder enclosed under a breast. Dental prosthesis is deleted. For prevention of cornea drying in eyes it is necessary to drop 2 - 3 drops of vaseline or peach oil 2 - 3 times a day. The skin is wiped carefully 1-2 times a day, its folds is powdered talc or children's powder. The face is wiped with a damp towel. Sometimes medical personnel makes passive gymnastics for prevention of joint contractures. Infusion solutions should be warm up to the temperature a human body.

The psychological moments have the certain value in resuscitation units. Doctors, nurses and assistant nurses should be able to show sympathy, to keep an atmosphere of amplified attention to the patient, to be cautious in conversations that their talking won’t cause sufferings.

Experience shows, that in resuscitation unit it is necessary to select trained nurses with the experience of work in therapeutic or surgical departments not less than 2-3 years.

Medical aid at terminal states

Critical conditions between life and death are called as terminal states. They are preagonal condition, agonal condition (agony) and clinical death.

The preagonal condition appears on a background of a heavy hypoxia (oxygen insufficiency) of internal organs and is characterized by gradual depression of consciousness, progressing frustration of vital functions (breath and blood circulation).

Symptoms of preagonal state are:

- confused, clouded consciousness;

- falling of arterial pressure (it is not detected);

- tachycardia with thread-like pulse;

- shallow and infrequent breathing (hypopnoea and bradipnoea);

- pale skin and acrocyanosis (cyanosis of finger, lips, auricles of ear)

- some reflexes are kept (eye reflexes).

Expressiveness and duration of the preagonal period can be various. At sudden cardiac arrest (for example, myocardial infarction) the preagonal period is almost absent. At gradual dying on a background of many chronic diseases it can proceed for several hours. The preagonal period comes to an end of a terminal pause (the short-term termination of breath), proceeding from 5-10 sec up to 3-4 min. Then the agonal period (agony) begins.

The agony is characterized by:

- absence of consciousness;

- an areflexia;

- pulse is hardly determined only on carotids;

- bradycardia;

- breathing not only shallow and infrequent but and arrhythmic (Biot’s respiration or Cheyne-Stocks respiration);

The agonal period continues from several minutes (for example, at acute cardiac arrest) till several hours and more (on slow dying) then there clinical death comes.

The clinical death is characterized by:

- unconsciousness;

- absence of breathing;

- absence of cardiac activity;

- wide pupils without light reaction;

- pale skin with acrocyanosis.

After the respiratory and cardiac arrest cells of human body do not die at once. Cells of brain cortex can be alive for 5-6 bcortical nerve centers are more hypoxia-resistants. Other cells of body can stay alive for some hours. Duration of clinical death depends on duration of a preagonal state and an agony: the longer they are, the deeper and more unreversable clinical death is. The clinical death passes into biological death. It is an unreversable state when biological processes in an organism completely stop. So clinical death continues not more than 5-6 min till we can restore/reload function of brain cells.

At early stages all kinds of death (clinical and biological) do not differ from each other (there are the same symptoms - apnoea, stop of blood circulation and coma). Because of reanimation should be done in all cases of sudden death and then in the course of revival one can determine the efficiency of actions and the prognosis for the patient. This rule is not applied to cases with clear external attributes of biological death (livores mortis, rigor mortis). One must not do reanimation in cases of terminal stadium of severe death diseases (cancer; heart insufficiency, renal failure).

The diagnosis of a full stop of breathing is made by visually (absence of respiratory excursions). It is impossible to waste time applying a mirror or a piece of metal to a mouth and a nose. Pulse is to be necessary taken on carotid or femoral arteries only.

Carrying out reanimation it is necessary: 1) to restore patency of airways, 2) to begin artificial respiration, 3) to start cardiac massage as soon as possible.

Patency of airways. The patient should be laid on a back on horizontal rigid surface. Doctor throws back a head of the patient, putting one hand under his neck, and another having on a forehead. It provides an easy approach to a throat and a trachea preventing falling back of a tongue. It is necessary (by means of a cotton napkin (or a handkerchief)) to clean top floors of airways. It is better to use suction apparatus if it is near. It is good to use special air tubes (Safar’s tube, S-shape tube). With the purpose of introduction of an air tubes the mouth of the patient should be opened, and a tube advance to a root of tongue by rotational movements.