Руководство к практическим занятиям по общему уходу за хирургическими больными (стр. 9 )

Books in order to prevent microbic pollution are the best way for wrapping up in covers which on an extract should be thrown out.

Chapter 8

HYGIENE OF A SURGICAL PATIENT NUTRITION. THE HYGIENIC CONTROL OF PARCELS & VISITS

Sanitary-hygienic requirements for public catering, buffets & nutrition management.

Preparation of food for in-patients is made in the centralized public catering. The latter is to be placed in a separate building or department. Public catering must be completely isolated from clinical departments. Both patients and medical staff cannot enter the public catering to avoid microbic contamination of food. A menu-apportionment is made for every day. The content of foodstuffs for every portion is exactly defined. The menu must meet the requirements of the directions authorized by the Ministry of Health, and also the main principles of dietary nutrition. Each hospital should have a nutritionist who must watch the menu and process of food preparing. A variety of products should be present in the menu-apportionment. Before food distribution, it must be checked by the so-called quality control commission consisting of a dietitian and the public catering manager. In the evening this duty can be entrusted with doctor on duty.

Direct food distribution takes place in buffets of the in-patient department. There should be 2 rooms (area – not less than 9m2) and a washhouse for dishes. A junior nurse works in a buffet. She is busy with patient’s nutrition only and must not care of patients. There are tables for food, shelves for washed utensils and disinfectants and a fridge. Distribution of food is to be done within 2 hours after its preparation (not more!) Food must be hot. The 1st course and hot drinks should have temperature not less than 75°C, the 2nd and 3d courses – from 7 to 14°C.

It is strictly forbidden to leave food in buffets after meal. It can’t be mixed up with fresh food. In buffet one can store only bread in cases and butter in a fridge. The ready food from public catering is delivered to a department by the buffet worker on a special hand-cart for food which cannot be used for other purposes. Utensils with tightly closed lids or vacuum flasks should be used for transportation of ready food. Bread should be transported in waterproof bags (not fabric) or closed utensils (buckets, pans).

Food distribution to the patients is done by buffet workers and nurses on duty. They should have special dressing gowns with marks “Food Distribution/Delivery”. The senior nurse controls the process of food delivery. The junior medical personnel and relatives are forbidden to take part in food distribution.

Feeding of patients with general regime is done in a special room of the in-patient department – a refectory. Tables should be wiped with a damp cloth before meal. After meal damp cleaning of tables, their disinfection with 1% chloramines solution and damp cleaning of floors are made. Patients get food according to their individual diet. Food collection 7 treatment of utensils are carried out after meal.

Treatment of utensils is carried out by the buffet worker in a buffet. The utensils should pass triple processing in different parts of a washing bath/ sink with the application of modern detergents.

The regime of kitchen utensils treatment: mechanical removal of food remnants by a brush or wooden trowel; washing of utensils in water with addition of 1% soda ash and 0.5% detergent at a temperature of 50°C in the 1st part of a bath; disinfection of utensils by boiling during 15 minutes or immersing for 30 minutes into 0.5% chloramines solution, 0.1% sulfochloantine solution in the 2nd part of a bath; rinsing utensils in hot water at a temperature not lower than 65°C in the 3d part of a bath.

Drying of utensils is carried out on racks in vertical position. It is forbidden to dry it with towels. It should be kept in special cupboards. Transportation of food to bed care patients should be done by a nurse. A nurse or patient’s relatives can feed him in a ward. Patients may have their own products. The list of products should be confirmed by the head of the department only by no means – in bed-side tables or between window frames. The senior nurse and a nurse on duty should supervise periodically the sanitary condition of fridges and remove products with the expired period of storage. The products subject to long storage should be kept in bed-side tables in closed containers. The medical personnel is to control the sanitary condition of bed-side tables.

Nutritional therapy

NT is the feeding of a sick person providing his physiological needs and simultaneously a method of treatment by specially selected and prepared products. The temperature, mechanical and chemical influence of food on the gastrointestinal tract should be taken into consideration.

The temperature factor. The most indifferent are dishes with the temperature close to temperature in the stomach cavity – 37-38°C. Dishes of contrast temperature (lower 15° and higher 57-62°) have an irritating effect. The cold dishes taken on an empty stomach increase intestinal peristalsis.

Mechanical food influence. It depends on its volume, consistence, degree of crushing, character of thermal processing, quantity of cellulose and connective tissue. The weight of a daily ration makes about 3 kg. It should be divided into 4 feeding portions (the 1st breakfast, the 2nd breakfast, dinner and supper). If maximal mechanical gastrointestinal tract sparing diet is needed the daily feeding can be divided into 5-6 and even 8 meals. Liquid and porridge-like dishes have smaller mechanical influence and are faster evacuated from a stomach than firm and compact. Fried dishes will have the greatest mechanical influence while boiled and prepared on a steam ones will have the least. Besides it is necessary to remember that vegetative products contain a plenty of cellulose, creating additional mechanical effect on the gastrointestinal tract.

Chemical food influence. Nutritional substances (acids, alkalis, salts, essential oils, extractive substances) have powerful and ambiguous influence on a gastrointestinal tract, changing its motility and digestive gland secretion. It is necessary to take this fact into consideration at setting a diet for patients with various pathology. The diet is prescribed by the doctor in charge. The nurses should know what diet is prescribed to each patient and to inform them on it. There are different diets recommended at various diseases. All diets are numbered from 1 to 15. The quantity of diets in hospital is defined by its type. The characteristics of all diets used in medicine are given in Appendix.

Diets №1,2,5,9,15 are frequently used in surgical practice. Besides feeding of surgical patients can be changed depending on the kind of operative intervention and terms of the postoperative period. Eating and drinking (the so-called principle of “an empty stomach”) are forbidden in the day of operation in order to prevent severe narcosis complications (aspiration of vomitory masses). Hunger is prescribed after operation. Its duration depends on a disease and the character of the operation. At this time needs for water, salts, carbohydrates and amino acids are compensated by parental nutrition. After the hungry period the so-called zero diet (diet №0) is prescribed. The patient is allowed to drink water, broth, kefir, kissel. In 1-2 days the diet correspondent to the character of a disease is prescribed.

In special cases there is a necessity for the so-called artificial feeding when patients cannot take food by the usual way. This condition can be at coma, traumas and diseases of maxillofacial area, gastrointestinal fistulas, esophagus disorders, mental diseases. 2 variants are possible here: enteral artificial feeding, i. e. feeding through a probe or through artificial fistula of a stomach; parental nutrition, i. e. intravenous introduction of special medications.

Feeding with the help of a gastric probe which can be put through a mouth or a nose is used as an elementary way of enteral nutrition. The food mixture consisting of various liquid and jelly products (milk, eggs, broths) is filled up into a probe with the help of a funnel, Esmarch’s irrigator or Jean’s syringe.

Application of special balanced mixtures (diets) intended for enteral nutrition, including proteins (in the form of hydrolyze), fats (vegetable oils), carbohydrates (starch), sets of vitamins, mineral salts and microelements is more adequate. They allow to fulfill the needs of an organism and have a precisely specified power value. Besides, the contents of food components in them varies depending on patient’s condition and types of pathological processes. For example, mixtures of general effect are Kozilat (499 kcal/100gr), Terapin (414 kcal/100gr), Enshur (1.06 kcal/ml), Berlamine (1 kcal/ml), Peptamen (1 kcal/ml). For patients with renal insufficiency the special mixture Nephramine (with the lowered protein content is used).

Silicone or polyurethane threadlike catheter probes causing the minimal discomfort of the patient are used for introduction of mixtures. They can be put not only in the stomach (nasogastrally), but also in intestine (nasointestinally), using endoscopic techniques. The best method of administration of a nutritious mixture is using of the special pump, allowing to introduce a solution in the set rate, round the clock and without dyspeptic reactions (nausea, vomit, swelling of a stomach) of the patient.

Sometimes a patient cannot take food through a probe (gullet obstruction). In this case gastrostomy is done. It is a formation of stomach fistula (artificial duct between stomach lumen and environment). At feeding through a fistula a nutritious mixture is introduced through fistula into a tube. Thorough care of skin around fistula is necessary for prevention and struggle against maceration and dermatitis, arising owing to influence of digestive juices, rich in enzymes (application of sticky films, processing by pastes, for example Lassar’s paste, zinc paste). For parental nutrition are applied: solutions of pure crystal amino acids – aminofusin, aminosteril, aminosol, infesol; fat emulsions – intralipid, lipovenoze (these preparations contain emulsifying agent with soyabean oil, phospholipids, lecithin; diemeter of fat drops allows them to pass through capillaries without threat of fat embolism); carbohydrates (glucose); water, mineral salts, vitamins, microelements.