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General Surgery Department of Russian State Medical University

Chief professor doctor of medicine N.A.Kuznetcov

Peculiarity care
of patients in surgical practice
Lector:
Assistant of General Surgery Department
of medical faculty
c.d.m. Barinov V.E. 1
General Surgery Department of Russian State Medical University

Care of patient or hypurgia is medical


practice securing optimal conditions of
existence ill peoples and prevention
of development different
complications.

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General Surgery Department of Russian State Medical University

Care is art.
Professional care of patent is at the first
maximal
quality care.

Art of care consist of no nursing by patient


with something sickness, but the man have
individual features, character, habit and wishes.

Creation of favorable conditions for


patient, delicate and tactful attitude, readiness
aiding in each minute is obligatory conditions
of qualitative nursing.

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General Surgery Department of Russian State Medical University

Participants of care:

 Doctor
 Nurse
 Hospital attendant
 Kins

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General Surgery Department of Russian State Medical University

Present-day principle of care:


Preventive of Independent
damage

Respect of patient’s
Confidentiality senses and dignity

Infection safety
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General Surgery Department of Russian State Medical University

14 base needs of patient


Model of V. Henderson

Patient needs:

1. Normal breathing
2. To use enough for food and liquid
3. To excrete by-product of life
4. To move and keep active position of body
5. To sleep
6. To dress and undress, choose the clothing by himself.
7. To keep the normal temperature

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General Surgery Department of Russian State Medical University

14 base needs of patient


Model of V. Henderson

Patient needs:

8. To keep hygiene, take care of appearance


9. To provide for personal security
10. Communicate with another people
11. To realize devotions
12. Carry out favorite work
13. To rest
14. To satisfy craving for knowledge

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General Surgery Department of Russian State Medical University

Stages of surgical treatment of patient

 First stage – before operation


(from hospitalization to start the operation)
 Second stage – during operation
(from making incision to put in last stitch)
 Third stage – after operation
(from closing wound to discharge)

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General Surgery Department of Russian State Medical University

Type of sanitary processing:


Full: Partial:

 to take a shower or bath  To wash dirty zone of skin;


 to cut a hair and nails  To change clothing and
 To change clothing and underwear
underwear  Sanitary processing and
 Sanitary processing and accept in deposit personal
accept in deposit personal clothing of patient
clothing of patient;  To reveal of stray
 To reveal of stray;
 Shaving operation zone (30-40
minutes before operation).

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General Surgery Department of Russian State Medical University

Sanitary rules of medical personal include of:

 Washing hands after physical examination of each


patient no less than 2 minutes.
 Daily change of personal towel;
 Protect body by gloves, mask, smocks and full
covered hair cup

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General Surgery Department of Russian State Medical University

Care after operation in surgical ward

 Active support sufficient functional activity


 Prevention and treatment complication from organ and system:
 Respiratory system
 Cardio-vascular system
 Digestive system
 Nervous system
 Early indicates of complication:
 Surprise anxiety,
 Misleading,
 Inadequate conduct
 Change of appearing

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General Surgery Department of Russian State Medical University

Care of respiratory system:

 Complication:
 Standstill pneumonia
 Athelectasis in the lungs
 Lung’s edema
 To keep of adequate lung’s ventilation :
 well-time anesthetization
 To remove a phlegm from bronchial tree
 Breezing practice
 Early activation of patient

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General Surgery Department of Russian State Medical University

Care of digestive system:

 Normalization of intestine movement;


 Care of oral cavity;
 Good recovery in operation zone;
 Normalization of digestion

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General Surgery Department of Russian State Medical University

Care of oral cavity

 Cotton sticks include glycerin,


lemon’s acid, natural extract of
lemon and 0,1% Na-
benzoate
 Help for daily care of oral cavity
 Especial for patients without
consciousness, after difficult
operation, during artificial
ventilation of lungs and patient has
hyperthermia

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General Surgery Department of Russian State Medical University

Nutrition of patient

 Artificial
 Natural

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General Surgery Department of Russian State Medical University

Forced probe feeding

 Oral- or nasal- probe


 Through gastrostoma
 Through ieunostoma

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General Surgery Department of Russian State Medical University

Artificial enteral feeding have been indicate


for patients:

 After damage or operation of oral cavity, larynx, gullet, esophagus


 After operation of stomach and esophagus
 With small intestine fistula;
 With breach act of swallow.
 With hard cranial-brain damage associated with long-time loss of
consciousness and coma
 With inoperable tumor of gullet and esophagus breach of permeability
of this organs

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General Surgery Department of Russian State Medical University

Characteristics of nutrition mixture


 Good assimilation
 Balance of exchangeable and irreplaseble
components.
 Stability during of storing.
 Easy preparation
 High dispersion
 Easy passage through thinly probes
 High calories and food value in 1 ml in
finished mixture

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General Surgery Department of Russian State Medical University

Cardio-vascular complications:

 Cardio-vascular deficit;
 Cardio-vascular accident;
 Thrombosis and embolia.

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General Surgery Department of Russian State Medical University

Prevention of thrombosis and embolic


include of:
 Elastic compression of low extremity using elastic
bandage or special stoking
 Adequate anesthetization
 Physical exercises
 Massage
 Early activation of patient

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General Surgery Department of Russian State Medical University

Causes of thrombosis

Triad of R.Virchov
 damage of vessel wall
 decrease speed of blood flow
 hypercoagulation
Rudolf
Virchow
(1821–1902)
 Morphological and functional damage of vessel
 Change characteristic of blood flow
 Increase the coagulation property of bloods

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General Surgery Department of Russian State Medical University

Patient without
fail must know
how to apply to
elastic bandage

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General Surgery Department of Russian State Medical University

Law of Laplas

In use elastic bandage must take in consideration


distribution of elastic pressure into surface – Law of
Laplas

P = T/ R
Pressure = tension force of bandage / radius
of extremity

For example: segment of the leg who have small radius


(ankle-bone, border of foot, fore surface of shank) degree of
compression higher comparison of low profile segment.

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General Surgery Department of Russian State Medical University

Technique overlay of elastic bandage

high
compression

low
compression

5 = incorrect 4 = correct
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General Surgery Department of Russian State Medical University

Technique overlay of elastic bandage

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General Surgery Department of Russian State Medical University

Rule of apply to elastic bandage

Foot mast bend in 90° angle


Start bandage from toes and it
is obligatory cover heel.
Bandage mast follow from
leg’s form.
Modeling cylindrical form of
extremity

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General Surgery Department of Russian State Medical University

Estimation efficacy of compression

Finger-tips become blue if elastic


bandage formed right.

They restore normal flash-color when a


patient start walk, or release physical
examination (for shank).

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General Surgery Department of Russian State Medical University

Estimation efficacy of compression

Patient mast walk in training conditions


during 20-30 minutes after form elastic
bandage

If in this time period shall arise a pain,


elastic bandage must be corrected.

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General Surgery Department of Russian State Medical University

Physician's control is obligatory when patient


wear elastic bandage

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General Surgery Department of Russian State Medical University

Critical result of
incorrect elastic
compression

This is a way to
amputation of
lower extremity
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General Surgery Department of Russian State Medical University

Comparison of elastic bandage


and hospital compressing
stoking

Compression’s power determine of experience of Normalization of elastic characteristics in production


physician or patient process

Necessity study of patient or participation of  Physician make the selection of type of elastic stoking
physician in form elastic bandage and compression volume. Patient may use this type of
compression himself.
 Difficult chose of compression and fixing on hip  Effective compression on hip, have special
accessories for fixing on skin
Bandage shell unusable after few wash, and need Keeping elastic characteristic during half of year.
replaceable. Don’t lose function after wash in hot water.
 Low compliance.  Consent of patient to use this type of compression

 Low accommodation and esthetical characteristics.  High esthetical characteristics and comfort in use.

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General Surgery Department of Russian State Medical University

Care of hard-ill patient’s skin

 Washing face and hand in warm water with soap


 Daily to throw body warm water
 Washing of hair and foots to less than 2 in week
 Washing groin and perianal region no less then 2 in day
 Prevention of decubates

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General Surgery Department of Russian State Medical University

To move and keep active position of body


(14 needs of patient. Model of V.Henderson)

 Healthy man don’t have a


problem with movement
and change body position

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General Surgery Department of Russian State Medical University

To move and keep active position of body


(14 needs of patient. Model of V.Henderson)
 Change of body position of long-lay patient is most
necessary every 2 hour, including night time.
 Is important condition of decubates prevention

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General Surgery Department of Russian State Medical University

Complications of care to patients


 Primary complication for
long-lay patient is
development of decubares.
 If decubates is
development – care is
insufficient!

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General Surgery Department of Russian State Medical University

Decubates
( lat.- decubare is laying)
Decubates is ulcer due to the pressure on the
skin in place where bones locate superficial
Decubates appear in consequence of local
deficit of microcirculation (ischemia) and as
result death of tissue cells (necrosis).
To take for grating, that pressure on tissue
more than 70 mm. Hg. during 2 hours appear
irreversible process in tissue.
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General Surgery Department of Russian State Medical University

International Committee of Healthcare’s politics and science


investigations in 1992 was recommend easy and maximal near of
clinical practice classification of decubates.

1 stage 3 stage

2 stage 4 stage

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General Surgery Department of Russian State Medical University

Decubates
Auriculars

Occiput

Scapulas
Shoulder joint
Elbows
Elbow joint

Kreuz
Femoral joint

Ichiadicus hillock
Genus joint

Heel
Ancle-bone 38
Contact places
General Surgery Department of Russian State Medical University

Internal risk factors of decubates


Reversible factors Irreversible factors

Excess or deficit of body weight


Limit volume of movement Elderly age
Anemia
Deficit of proteins and vitamin «С» substances
Hypotension
Disorders of pelvinum organs
Neurological disorders
Disorders of blood circulation at the periphery
Thinly skin
Nervousness
Consciousness disorders
Coma

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General Surgery Department of Russian State Medical University

External risk factors of decubates


Reversible factors Irreversible factors

 Insufficient hygienic care Extensive, long-time operation more


 Tuck on bad and dress of patient
 Поручни кровати than 2 hours
 Средства фиксации пациента
 Damage of spinal column, abdominal cavity

and pelvis
 Use a cytostatic treatment
 Violation transported rules of patient

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General Surgery Department of Russian State Medical University

Norton’s scale
Most important in decubates prevention is detection risk
of this complication. There are many valuation scale in
this aim.
For example:
scale Norton (1962);
• scale Waterlow (1985);
• scale Braden (1987);
• scale Medley (1991) and others.
Nortons’s scale is so easy for use because they is more
popularly among nursing personal

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General Surgery Department of Russian State Medical University

Norton’s scale
Read to intercourse Full – 4 Short – 3 Particle - 2 Absence - 1

Age Less than Less than Less than More than


10 year – 4 30 year - 3 60 year - 2 60 year – 1
Skin’s state Healthy skin – 4 Shall skin -3 Damp skin -2 Allergies, chap -1

Accompany illness Absence -4 Hyperglycemia, Disseminate Coma.


Anemia – 3 sclerosis – 2 Paresis -1
Physical state Good -4 Satisfaction-3 Badly -2 Very Badly- 1

Mental states Distinct – 4 Apathetic – 3 Mishmash Stupor - 1


consciousness-2

Activity Walk by himself -4 Walk with help – 3 wheelchair – 2 Lay patient -1

Moveness Full -4 Insignificant Significant Absence -1


limit -3 limit – 2
Incontinent Abscence -4 Sometime-3 Urine -2 Urine and excrements
-1

25 score and less – risk of decubates development 42


General Surgery Department of Russian State Medical University

Inspection of skin
Examine and feel the skin

Change and color Chap

Cyanosis, redden or pale Chap and spots

Theoretical substantiation
Ageing of skin has influent of defense barrier’s state, decrease of
perception of pain and property of immune system. Heal of wound is
slow down.

Dry skin is more expose to damage

Chaps is way for microorganisms into the tissue


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General Surgery Department of Russian State Medical University

Law of 17 April 2002 г. №123


Extract of law

 Insufficient prevention of decubates has


result in significant increase of direct
medical cost, because developed of
complication as decubates and infection
would be treated in hospital. This increase
the time of hospitalization and need special
drugs and special bandage.

 Sufficient prevention of decubates may be


avert this in 80% cases with high risk.

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General Surgery Department of Russian State Medical University

Single-use hygienic
devices and prophylactic cosmetic is
recommend for care of patient.
Who is recommend?

Health-and-social-development department of Russian Federation

Law of 17 April 2002 г. №123


«Approve of medical standard
«Protocol of treatment a patient. Decubates.»» 45
General Surgery Department of Russian State Medical University

Prophylaxis is best treatment!


For prophylaxis of decubates is need to keep clear of skin and her
humidity:

- Washing of skin make without friction and lump soap


Use the liquid soap
- Keep middle humidity of skin
In excessive humidity – wear out, in dryness - damp
- Use waterproof swaddling band and napkin
- Change the position of patient each 2 hours, including night time

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General Surgery Department of Russian State Medical University

Cleaning of skin

 Blue color is cleaning


 Care of skin always starting to cleaning
 This is important to next nutrition and dump of skin

Nutrition and dump of skin


 Yellow color is nutrition and dump
 Pantenol and keratin keep humidity of skin and support natural energetic balance, smooth out
wrinkles

 Pink color is protect.


Skin protect
 Protect of damage and sicken skin

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General Surgery Department of Russian State Medical University

Wet hygienic serviettes

 Big serviettes from gently material, it is


read to use
 It’s use without water and soap, help in
prevented decubates from lay patient
and support the skin in healthy state.
 Serviettes is intend for skin cleaning by
wipe, before and after operation period,
in lay-patient cases and for intimate
toilet
 It’s addition means for prophylaxis
decubates with enuresis during change
the napkin.
 Time of procedure no more than 5
minutes

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General Surgery Department of Russian State Medical University

Cleaning of skin
MENALIND®

 Ideal mean for washing lay patient in the bad.


 Do not need in additional washing.
 Special mean for prophylaxis decubates for patients who need in long-time badly regimen

Application:

For washing of lay patient 10 ml wash liquid

dissolve in 1,5 liters of warm water.


Wear through skin and drying after
procedure.
To take a shower according 5 ml.
Procedure time no more than 5 minutes.

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General Surgery Department of Russian State Medical University

Nutrition and damp of skin


MENALIND®

 Protection of skin from lose the liquid and


recovery her elastic property.
 Ideal mean for nutrition and damp of skin
for lay patient.

Application:
- drift 15-20 ml liquid on pure skin.
- Event drift from skin surface
- Time of procedure 5-7 minutes

1 bottle it is enough for 25-30


patient

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General Surgery Department of Russian State Medical University

Skin protect
MENALIND®

 Air foam making poured coat on skin surface. This


is protect skin from urine and excrements during 6
hours.
 This is ideal mean for protect of skin long-lay
patient in possible decubates developed place.
 Irreplaceable mean for patients suffer by enuresis
Application:.
 Shake up bottle and spray on clean and dry skin
 Procedure time about 5 minutes.

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General Surgery Department of Russian State Medical University

System of individual methods to enuresis


problem

Easy state
Less than 100 ml of urine during 4 hours

Medium state
100-200 ml of urine during 4 hours

Hard state
200-300 ml of urine during 4 hours

Most hard state


more than 300 ml of urine during 4 hours 52
General Surgery Department of Russian State Medical University

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General Surgery Department of Russian State Medical University

• Pants with catcher (napkin for adults)


• It’s recommended for patient suffer enuresis
• adsorbed pillow consist of special absorbent change liquid to gel.
•Special molecules is soak up smell and prevent from him
dissemination
•Many-use clasp is help for change napkin and
•Full-indicator is inform when napkin would be change
•Three-coat absorbed pillow and T-form is promote to prevention
decubates in sacrum zone

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General Surgery Department of Russian State Medical University

Chain of dressing napkin to the patient

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General Surgery Department of Russian State Medical University

•Adsorbed swaddling band.


•It is recommend for individual hygiene for patients suffer
from enuresis or additional protect furniture and underwear
•Adsorbed swaddling band consist of unraveling cellulose
•External side don’t slide on surface and form a plaits too.

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General Surgery Department of Russian State Medical University

Addition means for care the patient

1. Gauntlet for washing


2. Lining sheet
3. Breastplates
4. Cotton sticks
5. Pallets
6. Mask
7. Latex gloves
8. Smocks
9. Apron for protect clothing

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