Care in the early postoperative period briefly. Caring for the elderly after surgery under general anesthesia. An experienced, observant nurse is the doctor’s closest assistant; the success of treatment often depends on her

Concept of postoperative period, his tasks. Uncomplicated postoperative period, characteristics.

The postoperative period is the period from the end of the operation until the patient’s recovery.

It is customary to divide the postoperative period into:

1. Early postoperative period - from the moment the operation is completed until the patient is discharged from the hospital.

2. Late postoperative period - from discharge + 2 months after surgery

3. Long-term postoperative period - until the final outcome of the disease (recovery, disability, death)

The main tasks of medical staff in the postoperative period are:

Preventing the occurrence of postoperative complications is the main task, for which you should:

Recognize postoperative complications in a timely manner;

Provide patient care by a doctor, nurses, orderlies (pain relief, provision of vital functions, dressings, strict implementation of medical prescriptions);

Provide adequate first aid in a timely manner if complications arise.

Complications in the postoperative period:

Bleeding;

Purulent-septic complications from the postoperative side that can result in fistulas and even eventration;

Peritonitis;

Hypostatic pneumonia;

Cardiovascular failure;

Paralytic intestinal obstruction due to intestinal paresis;

Thromboembolism and thrombophlebitis;

Postoperative hernias;

Adhesive intestinal obstruction

Transporting the patient from the operating room to the ward. The patient is transported from the operating room on a gurney to the recovery room, or to the intensive care unit and intensive care. In this case, the patient can be taken out of the operating room only with restored spontaneous breathing. The anesthesiologist must accompany the patient to the intensive care unit or post-anesthesia ward along with at least two nurses.

During transportation of the patient, it is necessary to monitor the position of catheters, drainages, and dressings. Careless handling of the patient can lead to loss of drains, removal of the postoperative dressing, and accidental removal of the endotracheal tube. The anesthesiologist must be prepared for respiratory distress during transport. For this purpose, the team transporting the patient must have a manual Breathe-helping machine(or Ambu bag).

During transportation, intravenous infusion therapy may be carried out (continued), but in most cases, the system for intravenous drip administration of solutions is closed during transportation.

Bed arrangement: all bed linen is changed. The bed should be soft and warm. To warm the bed, 2 rubber heating pads are placed under the blanket, which are applied to the feet after the patient is taken to the operating room. For 30 minutes (no more!) an ice pack is placed on the area of ​​the postoperative wound.

The patient in the post-anesthesia period, right up to complete awakening, should be under constant supervision of medical staff, since in the first hours after surgery the most likely complications associated with anesthesia:

1. Tongue retraction

3. Violation of thermoregulation.

4. Heart rhythm disturbance.

Tongue retraction. In a patient still in a narcotic sleep, the muscles of the face, tongue and body are relaxed. A relaxed tongue can move down and close the airway. Timely restoration of airway patency is necessary by introducing an airway tube, or by tilting the head back and moving the lower jaw.

It should be remembered that after anesthesia the patient must be constantly under the supervision of the medical staff on duty until complete awakening.

Vomiting in the post-anesthesia period. The danger of vomiting in the postoperative period is due to the possibility of vomit flowing into the oral cavity and then into the respiratory tract (regurgitation and aspiration of vomit). If the patient is in a narcotic sleep, this can lead to his death from asphyxia. If an unconscious patient is vomiting, it is necessary to turn his head to the side and clear the oral cavity of vomit. In the recovery room there should be an electric aspirator ready for use, which is used to remove vomit from the oral cavity or from the respiratory tract during laryngoscopy. Vomit can also be removed from the oral cavity using a gauze cloth on a forceps. If vomiting develops in a conscious patient, you need to help him by handing him a basin and supporting his head above the basin. In case of repeated vomiting, it is recommended to administer Cerucal (metoclopramide) to the patient.

Violation of the rhythm of cardiac activity and breathing until they stop, it occurs more often in older people and infants. Respiratory cessation is also possible due to recurarization - repeated late relaxation of the respiratory muscles after muscle relaxation during endotracheal anesthesia. In such cases, it is necessary to be prepared to carry out resuscitation measures and have breathing equipment at the ready.

Violation of thermoregulation. Violation of thermoregulation after anesthesia can be expressed in a sharp increase or decrease in body temperature, severe chills. If necessary, it is necessary to cover the patient, or, conversely, to create conditions for improved cooling of his body.

For high hyperthermia use intramuscular injection analgin with papaverine and diphenhydramine. If even after the administration of the lytic mixture the body temperature does not decrease, use physical cooling of the body by rubbing with alcohol. As hyperthermia progresses, ganglion blockers (pentamine or benzohexonium) are administered intramuscularly.

If there is a significant decrease in body temperature (below 36.0 – 35.5 degrees), warming the patient’s body and limbs with warm heating pads can be used.

Fighting pain in the postoperative period.

Complications associated with pain in the postoperative period.

Prolonged exposure to pain and pain of high intensity lead not only to moral and mental distress, but also to very real biochemical metabolic disorders in the body. Release into the blood large quantity adrenaline ("stress hormone" produced by the adrenal cortex) leads to increased blood pressure, increased heart rate, mental and motor (motor) agitation. Then, as the pain continues, the permeability of the walls of the blood vessels is disrupted, and the blood plasma gradually escapes into the intercellular space. Biochemical changes in the composition of the blood also develop - hypercapnia (increased CO 2 concentration), hypoxia (decreased oxygen concentration), acidosis (increased blood acidity), changes occur in the blood coagulation system. Tied Together circulatory system, all human organs and systems are affected. Pain shock develops.

Modern methods of anesthesia make it possible to prevent dangerous consequences pain due to injuries, surgical diseases and during surgical operations.

The tasks of the medical staff when relieving pain syndrome are::

Reduced pain intensity

Reducing the duration of pain

Minimizing severity side effects associated with pain.

The pain prevention strategy involves:

Limiting the number of punctures, injections, and testing.

Use of central catheters to avoid multiple venous punctures.

Painful procedures should only be performed by trained medical personnel.

Careful dressings, removal of adhesive plaster, drainage, catheters.

Ensuring adequate pain relief before painful procedures

Non-pharmacological methods of pain management:

1.Creation comfortable conditions for the patient

2. Painful procedures should only be performed by an experienced specialist.

3. Maximum breaks are created between painful procedures.

4. Maintaining a favorable (least painful) position of the patient’s body.

5. Limitation of external stimuli (light, sound, music, loud conversation, rapid movements of personnel).

In addition, it is advisable to use cold to reduce pain in the area of ​​the surgical wound. At local application cold reduces the sensitivity of pain receptors. A pack of ice or cold water is placed on the surgical wound.

Pharmacological methods of pain control :

Use of narcotic anesthetics;

Promedol - used as a universal narcotic analgesic after most surgical operations

Fentanyl - in the postoperative period is used in a dose of 0.5 - 0.1 mg with intense pain. Also used in combination with droperidol (neuroleptanalgesia)

Tramadol – has less pronounced narcotic properties, i.e. causes euphoria, addiction and withdrawal symptoms noticeably less than drugs. It is used as a solution subcutaneously, intramuscularly and intravenously, 50 mg per 1 ml (ampoules of 1 and 2 ml).

Use of non-narcotic anesthetics.

Barbiturates - phenobarbital and sodium thiopental have a hypnotic and analgesic effect

Ibuprofen

Metamizole sodium (analgin) is most often used in the postoperative period to reduce the intensity of pain intramuscularly and subcutaneously, (and sometimes intravenously) by injection. Tablet forms are also used, which contain metamizole sodium - sedalgin, pentalgin, baralgin.

Application local anesthetics

In addition to the solutions used for local infiltration and conduction anesthesia, contact anesthetics such as tetracaine cream, instillagel, EMLA cream, lidocaine are used to anesthetize injections, punctures and other painful procedures.

Care and dynamic monitoring of the patient in the postoperative period.

Monitoring and caring for the patient’s skin in the postoperative period

Monitoring a patient's skin after surgery is an important source of information about the state of his health. Sharp pallor of the skin against the background of a drop in blood pressure and tachycardia suggests internal bleeding. The development of yellowness of the skin after surgery on the liver and biliary tract indicates a serious complication associated with obstruction of these tracts. In addition, the skin in the postoperative period is subject to serious testing in patients with poor care. Bedsores develop on it.

The most typical places for bedsores to form: area of ​​the sacrum, shoulder blades, back surface of the heel.

Clinic: redness of the skin from places of mechanical impact on it with clear boundaries, then the appearance of blisters with transparent contents on it, then blueing and blackening of the skin with clear boundaries, the removal of dead tissue tissue with the formation of a deep tissue defect, the bottom of which is bone..

Bedsore - necrosis of an area of ​​soft tissue due to disruption of their blood supply for the following reasons:

Long-term, constant mechanical impact on tissue (lying in an uncomfortable bed in the same position, folds of bed linen);

Microtrauma of the skin (dried bread crumbs turned into emery);

Violation of the innervation of these areas (spinal patient).

Hence, measures to prevent bedsores that affect their causes:

Skin hygiene;

Turning the patient in bed, sitting, monitoring the cleanliness and smoothness of the linen under the patient, using personal care items to eliminate mechanical stress (rubber pad, half inflated);

Periodically wiping the skin in places where bedsores are most likely to form with camphor alcohol;

Treatment of a disease leading to disruption of innervation, massage of the areas of the body most susceptible to bedsores

Treatment of bedsores :

1. Necrectomy - removal of all non-viable tissue within the black borders. A mandatory stage without which further treatment and healing of bedsores is not possible;

2. Wound management according to all the rules for treating a purulent wound. It should be remembered that the ointments used never make the weather. But their correct use helps to cleanse the wound, its granulation and epithelization.

Features of patient care after various surgical operations.

Caring for a patient after thoracic surgery

Strict bed rest.

Semi-sitting position in bed.

Monitoring the tightness of drains.

Monitoring valve operation during passive aspiration pleural cavity according to Bulau.

Determine the amount and nature of discharge through pleural drainage.

Control for intravenous catheter, periodic rinsing of the catheter with heparin solution..

Intravenous administration of blood substitutes and blood products, accurate implementation of other doctor’s prescriptions.

Dressing the wound.

Feeding the patient.

Hygienic care for skin and oral cavity.

Providing defecation and urination.

Monitoring body temperature, blood pressure, pulse rate, respiratory rate.

Caring for a patient after surgery for peritonitis

Strict bed rest.

Removal of stomach contents using a permanent nasogastric tube.

Fowler's position in a functional bed.

Administration of painkillers: analgesics, narcotics, accurate implementation of other doctor’s prescriptions

Caring for an intravenous (peripheral or central) catheter.

Drainage care: periodic dressings, rinsing if necessary.

Control over the amount and nature of drainage discharge.

Dressing the surgical wound.

Care of fistulas (in the presence of colostomy, gastrostomy, intestinal intubation)

If there is a catheter in the epidural space, periodic administration of an anesthetic.

Inhalation of humidified oxygen.

Catheter in the bladder to determine kidney function.

General blood tests, urine tests, biochemical tests blood.

Monitoring body temperature, pulse rate, blood pressure, breathing rate

Patient care after surgery for purulent surgical pathology.

Isolate from “clean” surgical patients.

Antibacterial therapy(antibiotic therapy, nitrofurans, sulfonamides)

Painkillers, sleeping pills.

Immobilization of the affected area of ​​the body, limb...

Dressings, changing wet bandages, replacing drains if necessary.

Intravenous administration of blood substitutes, blood products, detoxification drugs.

Administration of painkillers and sleeping pills.

Monitoring general blood and urine tests.

Monitoring body temperature, pulse rate, breathing, blood pressure.

Caring for urological patients

Dressings, changing wet bandages.

Antibiotic therapy.

Administration of painkillers, antispasmodics or narcotics.

Care of suprapubic drainage (epicystostomy), lumbar drainage (nephrostomy, pyelostomy).

If necessary, flush the drains with antiseptics.

Administration of diuretics (if necessary)

Monitoring diuresis

General urine and blood tests.

Monitoring body temperature, pulse, blood pressure

Caring for patients after cancer surgery.

Painkillers for pain.

Dressing the surgical wound.

If you have fistulas, care for fistulas.

Chemotherapy, radiation therapy as prescribed by the oncologist

Exclusion of physiotherapeutic procedures and massage.

Parenteral nutrition if normal nutrition is not possible.

Optimistic attitude in relationships with the patient.

Gentle information about the nature of the tumor.

Oxygen therapy

To combat hypoxia in postoperative patients, oxygen inhalation is used. Due to the toxicity of pure oxygen, it is given to patients in the form of a gas mixture with air at a concentration of 40–60%. Oxygen inhalation is carried out using a face mask, nasal catheter, and nasal cannula. Tents and endotracheal tubes can also be used for oxygen therapy.

Types of motor (physical) activity modes

Strict bed rest- the patient is forbidden not only to get up, but in some cases even to turn independently in bed.

Bed rest- under the supervision of a nurse or exercise therapy specialist, it is allowed to turn in bed, with a gradual expansion of the regime - to sit up in bed, lower your legs.

Ward regime- You are allowed to sit on a chair near the bed, stand up, and walk around the room for a short time. Feeding and physiological functions are carried out in the ward.

General mode- the patient takes care of himself independently, he is allowed to walk along the corridor, offices, and walk around the hospital grounds.

Movement disorders ( motor activity) can lead to severe changes in the patient’s condition, due to dysfunction of organs, even death.

Purposes of bed rest.

1. Limiting the patient’s physical activity. Adaptation of the body to hypoxic conditions when the need to breathe is disrupted and the cells’ need for oxygen decreases.

2.Reducing pain, which will reduce the dose of painkillers.

3. Restoring strength in a weakened patient.

To give the patient a comfortable physiological position, a functional bed with an anti-decubitus mattress and special devices are needed: pillows of various sizes, bolsters, diapers, blankets, footrests that prevent plantar flexion.

Patient's position in bed :

Position "on your back".

Stomach position.

Side position.

Fowler's position (half-lying and half-sitting) with the head of the bed raised by 45-60 degrees.

Sims' position is intermediate between the "side" and "prone" positions.

53. Features of preparation for operations and postoperative care for elderly and old age.

Preoperative preparation is carried out for all patients. It is performed to a minimum extent only for patients undergoing surgery for emergency and emergency indications.

On the eve of a planned surgical operation, general preoperative preparation is carried out. Her goal:

1. Eliminate contraindications to surgery by examining the patient’s vital organs and systems.

2. Preparation of the patient psychologically.

3. To prepare as much as possible the patient’s body systems, on which the intervention will have the greatest load during the operation and in the postoperative period.

4. Prepare the surgical field.

Preparation procedure:

1.1. General inspection

Every patient admitted to a surgical hospital for surgical treatment must be undressed and the skin of all parts of the body examined. In the presence of weeping eczema, pustular rashes, boils or fresh traces of these diseases, the operation is temporarily postponed and the patient is sent for outpatient follow-up treatment. The operation on such a patient is performed one month after complete cure, because infection can manifest itself at the site of surgery in a patient weakened by surgical trauma.

1.2. History taking

Taking an anamnesis makes it possible to find out and clarify previous diseases, to determine whether the patient suffers from hemophilia, syphilis, etc. In women, it is necessary to clarify the date of the last menstruation, since it has a great impact on the vital functions of the body.

1.3. Laboratory research

Planned patients are admitted to the surgical hospital after laboratory examination at the clinic at your place of residence. They conduct a general blood and urine test, a urine test for sugar, biochemical composition blood and the necessary x-ray examinations of the chest and abdominal organs.

1.4. Clinical observation

It is important for the patient to get to know the attending physician and to establish relationships between them. To completely eliminate contraindications to surgery, choose a method of pain relief and take measures to prevent subsequent complications, it is necessary that the patient fully opens up to the doctor. If special preparation of the patient for the operation is not required, then the preoperative period of the patient in the hospital is usually 1-2 days.

1.5. Psychological preparation of the patient (see above)

1.6. Special Events:

Respiratory preparation

Respiratory organs account for up to 10% of postoperative complications. Therefore, the surgeon should pay special attention to the patient’s respiratory system.

In the presence of bronchitis and emphysema, the risk of complications increases several times. Acute bronchitis is a contraindication to elective surgery. Patients with chronic bronchitis are subject to preoperative sanitation: they are prescribed expectorants and physiotherapeutic procedures.

Cardiovascular preparation

An ECG is performed on all patients over the age of 40, as well as in cases of heart complaints. An examination by a therapist is mandatory for older people. If the heart sounds are normal and there are no changes in the electrocardiogram, no special preparation is required.

Oral preparation

In all cases, before surgery, patients require sanitation of the oral cavity with the assistance of a dentist. Removal of removable dentures immediately before surgery

Preparation gastrointestinal tract

Before a planned operation on the abdominal organs, the patient is given a cleansing enema the evening before the operation. When preparing patients for surgery on the large intestine, it must be cleaned. In these cases, 2 days before the operation, a laxative is given 1-2 times, the day before the operation the patient takes liquid food and is prescribed 2 enemas, in addition, another enema is given on the morning of the operation.

Liver preparation

Before the operation, liver functions such as protein synthetic, bilirubin-excretory, urea-forming, enzymatic, etc. are examined.

Determination of kidney function

During the preparation of patients for surgery and in the postoperative period, the condition of the kidneys is usually assessed by urine tests, functional tests, isotope renography, etc.

Preparation surgical field:

A hygienic bath or shower the day before;

In the morning - shaving the surgical field followed by skin treatment ethyl alcohol;

Increasing the general resistance of the patient's body before surgery.

Increased body resistance contributes to better tissue regeneration and other reparative processes. Drip administration of glucose before surgery must be supplemented with the introduction of nicotinic and ascorbic acids, vitamins B1, B6. For the most severe patients, it is advisable to prescribe anabolic hormones, gamma globulin, plasma, albumin, and blood transfusions.

Each type of pathology requires certain features in preoperative preparation. We will talk about this when studying the corresponding pathology

Preparing patients for gastric surgery

Patients with advanced stomach diseases often experience a deficiency in circulating blood volume, a decrease in blood proteins and a disturbance in metabolic processes in the body.

To replenish proteins, blood, plasma, and albumin transfusions are necessary. Intravenous infusions of 5% glucose solution, sodium and potassium salts, fat emulsion preparations are performed (2-3 liters per day). On the eve of the operation, patients with pyloric stenosis wash their stomach daily with a 0.25% solution of hydrochloric acid before going to bed. Depending on the patient’s condition, preparation lasts 6-14 days. The day before surgery, patients are switched to liquid food (broth, tea). A cleansing enema is given at night, and in the morning on the day of surgery, the liquid is removed from the stomach with a probe.

Preparing patients for operations on the large intestine and rectum.

Except general training weakened patients, which includes blood transfusions, glucose solutions, sodium chloride, vitamins and cardiac medications, it is necessary to cleanse the intestines. The patient is allowed liquid food for two days before surgery. On the first day of preparation, a laxative is given in the morning and an enema is given in the evening. On the second day, a cleansing enema is done in the morning and evening. On the morning of the operation, enemas are not given. 5-6 days before surgery, the patient is prescribed chloramphenicol or kanamycin.

A patient with hemorrhoids is given a laxative a day before, and in the evening the rectum is washed with several cleansing enemas until clean water is obtained.

Preparation for surgery of patients with intestinal obstruction.

Patients with intestinal obstruction most often undergo surgery for life-saving reasons. It should last no more than 3 hours from the moment the patient enters the surgical department. During this time, it is necessary to administer antispasmodics (atropine, papaverine, no-shpu), rinse the stomach, conduct a bilateral perinephric blockade with a 0.25% novocaine solution (60-80 ml), and perform a siphon enema. This eliminates dynamic intestinal obstruction, which will be resolved by the specified measures.

Preoperative preparation includes blood transfusion, polyglucin, sodium chloride, potassium, vitamins C and B1, cardiac medications.

Direct preparation of patients for surgery and rules for its implementation.

On the eve of the operation, the patient takes a bath. Before washing, the doctor pays attention to the skin to see if there are any pustules, rashes, or diaper rash. If detected, the planned operation is cancelled. The surgical site is shaved on the day of surgery to avoid cuts and scrapes that are prone to infection.

Features of the preparation of elderly and senile patients

An ECG and examination by a therapist and other related specialists for concomitant diseases are required;

Treatment concomitant diseases and compensation for the functions of internal organs and systems;

The following features of the body of old people should be taken into account:

Weakened body defenses;

Tendency to develop hypostatic pneumonia;

Tendency to thrombosis and thromboembolism;

Difficulties in contact (hard of hearing, poor vision, memory, etc.;

Typically overweight;

Features of preparing children

Mandatory weighing of the child (emergency room), and adults too (dosage of anesthetics per kg of weight);

Stop feeding 4-5 hours before surgery. Starving a child is contraindicated;

Colon cleansing with enemas;

During gastric surgery - gastric lavage;

Children do not tolerate cooling well;

Specificity in drug dosage;

Difficult contact with the child;

Nutritional features;

Close contact between the surgeon and the pediatrician;

The surgical field is not torn;

The mother's presence at the child's bedside is very important;

Features of preparing patients for emergency operations

The shortest time for preparation;

Minimal additional examinations;

Partial sanitary treatment of the patient, washing or wiping contaminated areas of the body;

Gastric lavage - as directed by a doctor;

Dry shaving of the surgical field

The favorable or unsatisfactory outcome of the operation, as well as the subsequent postoperative period, depends on the preoperative preparation of the patient, including the above observations and studies.

Maximum preparation eliminates the possibility of complications, prepares the patient’s vital organs for surgical intervention, creates a favorable psychological background, elevates the system, and all these factors contribute speedy recovery sick.

Postoperative care for elderly and senile patients

This group of patients is prone to pulmonary complications, therefore, from the first day after surgery, preventive measures are taken to prevent them: exalted position in bed, early turning, alternating jars with mustard plasters, breathing exercises, which ensure good drainage of the tracheobronchial tree. The body of older people is very sensitive to oxygen starvation, so they must breathe humidified oxygen.

It must be remembered that the rapid administration of large amounts of fluid causes overload of the low-elastic vascular bed and the right side of the heart. In this regard, saline solutions, blood, and blood substitutes are administered intravenously slowly, drip-wise.

Subcutaneous infusions should also be done carefully, because in elderly patients the liquid is poorly absorbed and rapid administration in large quantities causes tissue compression, which can lead to necrosis of areas of the skin. In this regard, the liquid is also administered slowly, dripwise, with the addition of hyaluronidase preparations and the application of warm heating pads to this area. Elderly patients tolerate the introduction of fluid into the rectum better.

In older people, asymptomatic suppuration of the surgical wound without pronounced subjective sensations is much more common. In this regard, frequent dressings are recommended. A complex of vitamins is prescribed. Insufficient skin care contributes to the rapid development of bedsores, which in older people are difficult to treat.

POSTOPERATIVE CARE

What is the role of the nurse in the postoperative period?

From the moment the patient enters the ward from the operating room, the postoperative period begins, which continues until discharge from the hospital. In this period nurse must be especially careful. An experienced, observant nurse is the doctor’s closest assistant; the success of treatment often depends on her. In the postoperative period, everything should be aimed at recovery physiological functions the patient, for normal healing of the surgical wound, and for the prevention of possible complications.

Depending on the general condition of the person being operated on, the type of anesthesia, and the characteristics of the operation, the ward nurse ensures the desired position of the patient in bed (raises the foot or head end of a functional bed; if the bed is an ordinary one, then takes care of the headrest, bolster under the legs, etc.).

The room where the patient is admitted from the operating room must be ventilated. Bright light not allowed in the ward. The bed must be placed in such a way that it is possible to approach the patient from all sides.

What is the postoperative regimen?

Each patient receives special permission from the doctor to change the regimen: different terms allowed to sit down and stand up. Mainly after non-cavitary operations moderate severity, at feeling good the patient can get up near the bed the next day. The nurse should monitor the patient’s first rise from bed and not allow him to leave the room on his own.

How is the patient cared for and monitored after local anesthesia?

It should be kept in mind that some patients have increased sensitivity to novocaine, and therefore after surgery under local anesthesia they may experience general disorders: weakness, drop in blood pressure, tachycardia, vomiting, cyanosis. In such cases, you need to administer 1-2 ml of a 10% caffeine solution subcutaneously, intravenously - 20 ml of 40% glucose, 500-1000 ml of saline. Usually after 2-4 hours all symptoms of intoxication disappear.

How is a patient cared for and monitored after general anesthesia?

After anesthesia, the patient is placed in a warm bed on his back with his head turned or on his side (to prevent the tongue from retracting) for 4-5 hours without a pillow, covered with heating pads. The patient should not be woken up.

Immediately after surgery, it is advisable to place a bag of sand or a rubber bladder with ice on the area of ​​the surgical wound for 4-5 hours. The application of gravity and cold to the operated area leads to compression and narrowing of small blood vessels and prevents the accumulation of blood in the tissues of the surgical wound. Cold soothes pain, prevents a number of complications, and reduces metabolic processes, making it easier for tissues to tolerate circulatory failure caused by surgery. Until the patient wakes up and regains consciousness, the nurse should remain near him constantly, monitoring his general condition, appearance, blood pressure, pulse, and breathing.

How is a patient cared for if vomiting occurs after anesthesia?

In the first 2-3 hours after anesthesia, the patient is not allowed to drink or eat. When vomiting occurs, the patient's head is turned to the side, a tray is placed near the mouth or a towel is placed, the vomit is removed from the mouth so that aspiration (entry into the respiratory tract) does not occur, and subsequently pulmonary atelectasis. After vomiting, wipe the mouth with a damp swab. When vomiting after anesthesia, the effect is provided by the injection under the skin of 1-2 ml of a 2.5% solution of chlorpromazine, 1 ml of a 2.5% solution of diprazine.

How to prevent complications from the respiratory system in the postoperative period?

It is important to prevent pulmonary complications by protecting the patient from cooling during transport from the operating room to the ward. It needs to be covered and wrapped, since in the operating room the air temperature is higher than in the corridors, and during transportation it may be exposed to drafts.

To prevent complications from the respiratory system, it is necessary to take active measures to improve the respiratory process: place cups on the chest and back. Immediately after awakening from anesthesia, it is necessary to force the patient to periodically take deep breaths and exhalations, movements of the upper and lower extremities. The nurse should patiently explain to the patient the need and safety of deep breathing. Patients are asked to inflate rubber balloons and cough. When coughing, the patient should put his hand on the wound area and, holding it, bend his knees.

Which medications prescribed to enhance the depth of breathing?

The administration of narcotic and painkillers is of great importance to enhance the depth of breathing. In order to improve blood circulation and prevent postoperative pulmonary complications, the patient receives camphor oil 2-3 ml up to 3-4 times a day (necessarily heated).

In the ward for severe postoperative patients there must always be an oxygen cylinder and a suction.

How to care for a patient after surgery thyroid gland?

Patients operated on for thyrotoxic goiter are especially unstable and unbalanced, and in the postoperative period they should be protected from any stress. The most comfortable position after thyroid surgery is semi-sitting with the head slightly tilted forward to relax the neck muscles. The nurse on duty monitors the general condition of the patient, the color of the skin, the frequency, filling and rhythm of the pulse, blood pressure, and the condition of the bandage.

A nurse caring for a patient undergoing surgery for thyrotoxic goiter should have boiled syringes ready and necessary medications: camphor, cordiamine, strophanthin, glucose, hydrocortisone, sterile system for intravenous and subcutaneous fluid administration, blood transfusion, oxygen cylinder.

The skin of patients with thyrotoxic goiter is tender, thin, and often after surgery it becomes irritated from smearing with iodine and cleol. In such cases, it is good to lubricate the skin with Vaseline and other indifferent ointments.

What complications are possible after thyroid surgery?

In the coming hours after the operation, the patient may develop a state of acute thyrotoxicosis, which is manifested by increasing anxiety, agitation, redness of the face, increased trembling of the hands and body, increased heart rate, sometimes arrhythmia, and increased temperature. The nurse immediately informs the doctor about this and is actively involved in providing assistance.

Sometimes such patients experience painful cramps of the limbs and face after surgery. They appear as a result of injury or removal of the parathyroid glands, which regulate calcium metabolism. Intravenous administration of calcium chloride is prescribed (10 ml of a 10% solution 2-3 times a day). At the same time, a solution of calcium chloride is prescribed orally, a tablespoon 3-4 times a day.

How is a patient cared for after chest surgery?

Patients after such operations must be placed in specially designated wards, equipped with everything necessary to provide emergency care. Until recovery from anesthesia, the patient should remain in bed without a pillow.

After emerging from the state of anesthesia, the patient is given an elevated position, the most comfortable for breathing, expectoration, the work of the heart. Oxygen therapy (humidified oxygen is supplied) is of great importance. To prevent accumulations of mucus, it is extremely important to promptly suck out the mucus with a catheter or aspirator.

Due to a sharp decrease in the plastic abilities of tissues and weakening of body functions, these patients are especially predisposed to the formation of bedsores, therefore, from the first days after surgery, it is necessary to often change the patient’s position, at least for a short period of time, changing linen at this time, if necessary.

How is drainage monitored postoperatively?

Often after surgery, a rubber drainage tube is left in the cavity of the pleura, and sometimes the pericardium, to evacuate the accumulation of air and fluid. If the discharge from the tube is unusually copious and intensely stained with blood, the nurse should call a doctor to decide on help (you may need surgery to stop bleeding). Violations of the tightness of the drainage are dangerous, which can lead to air suction and compression of the heart and lungs; the condition of the patients worsens, the pulse and breathing become more frequent, and cyanosis appears.

It is very important to ensure that there is no stagnation in the stomach; at the slightest sign of it, a thin probe must be inserted through the nasal passage and the contents of the stomach should be evacuated.

How is a patient cared for after abdominal surgery?

After surgery on the abdominal organs, under local anesthesia, the patient should be put to bed so that the wound is at rest. Unless the surgeon gives special instructions, the most comfortable position is with the head of the bed elevated and legs slightly bent. This position helps relax the abdominal wall, provides rest for the surgical wound, and facilitates breathing and blood circulation.

How is a patient cared for after gastric surgery?

After gastric surgery, the nurse should remember the possibility of severe postoperative bleeding, and such a clear symptom as bloody vomiting is not always present, and bleeding may occur with predominance common symptoms: pallor of the skin, increased heart rate and changes in pulse rate, drop in blood pressure.

How are patients with gastrostomy cared for?

Gastrostomy -: gastric fistula - most often applied in case of obstruction of the esophagus (cancer, cicatricial narrowing as a result of burns, etc.). Through the stoma, food enters directly into the stomach, bypassing the oral cavity and esophagus.

The nurse should ensure that the tube does not fall out, especially in the coming days after the operation, when the canal has not yet formed. If this happens, there is no need to try to insert the fallen tube, since insertion “blindly” can lead to the tube entering the free abdominal cavity rather than into the stomach, which threatens the development of peritonitis. After the fistula is formed and the sutures are removed, the patient must be taught to insert the tube independently. After each feeding, you need to clean the skin around the fistula. To prevent irritation, the skin is lubricated with indifferent ointments (zinc, Lassar paste, etc.).

How is a patient cared for after colon surgery?

Proper nutrition is of great importance. In these patients, it is especially dangerous to load the intestines and cause early peristalsis. The patient must be fed strictly as prescribed by the doctor.

How to care for patients with intestinal fistulas?

In case of intestinal obstruction, sometimes a fistula is placed on the intestine to empty it - either temporarily (if a radical operation is planned in the future to eliminate the cause of the obstruction and subsequent closure of the fistula), or permanently (if the tumor cannot be removed or after removal of the tumor it was not possible to restore natural patency). Depending on the location of the fistula, the nature of its discharge also changes: from a fistula on the small intestine (enterostomy) it will be liquid, and on the distal parts of the large intestine it will look like formed feces (discharge from a fistula of the cecum - cecostoma - is quite liquid). Patients with intestinal fistulas should be frequently bandaged to prevent irritation and inflammation of the skin around the fistula. The bandage must be applied so that it does not slip when moving. Scrupulous adherence to cleanliness is a prerequisite when caring for patients with intestinal fistulas. After each bowel movement, it is good to place a napkin moistened with Vaseline oil on the protruding mucous membrane of the intestine of the unnatural anus, cover it with gauze napkins and cotton wool. It is better to strengthen the bandage with bandages or special bandages. It is not recommended to use cleol or a patch, since the use of adhesive bandages with frequent changes leads to skin irritation and dermatitis.

How to care for the surrounding skin intestinal fistula?

Maceration of the skin around the fistula causes excruciating suffering for the patient. The main cause of tissue erosion is the digestive action of the pancreatic enzyme released with intestinal contents (most often in small intestinal fistulas). Therefore, to protect the skin from the action of intestinal contents, lactic acid and sodium bicarbonate are added to pastes and ointments, which helps neutralize trypsin when it comes into contact with the skin. To strengthen the skin and give it greater strength, it is used water solution tannin (10%). This solution is used to lubricate areas of skin affected by dermatitis. Powders of dry tannin, gypsum, talc, and kaolin are used; this forms a crust that protects the skin from enzymes. Intestinal contents, falling on the crust, drain from it (with an open method of treatment) or are absorbed by a bandage covering the fistula.

How is an intestinal fistula cared for after the surgical wound has healed?

After the formation of a fistula and healing of the surgical wound, daily baths are useful to reduce skin irritation around the fistula, which help eliminate the dermatitis that often accompanies fistulas. From this time on, patients are taught to use a colostomy bag.

If feces are retained, an enema may be necessary. The nurse needs to put on gloves, first insert a finger into the overlying part of the patient’s intestine, and then hold the tip and pour in 500-600 ml of water or 150-200 g of vaseline oil, which will cause the passage of feces.

How is a patient cared for after surgery on the anus and rectum?

Some features differ in the care of patients operated on for diseases of the rectum and anus - hemorrhoids, polyps, fissures. All these operations usually end with the insertion of oil tampons and a rubber tube into the rectum. When receiving a patient after surgery, the nurse should know that the bandage can become wet with blood and ointment, so the patient’s bed must be prepared accordingly, not forgetting to protect the mattress with oilcloth. To suppress peristalsis and artificial retention of stool, give opium tincture 7 drops 3 times a day for 5 days, and sometimes longer, depending on the nature of the intervention. During this time, the wound surfaces begin to form granulations, which are a good barrier to infection.

After discontinuation of opium, to facilitate the act of defecation, the patient is given (as prescribed by a doctor) vaseline oil orally, a tablespoon 2-3 times a day.

How is a patient bandaged after surgery on the anus and rectum?

The dressing is usually done on the 3rd day after the operation. It is very painful, as it is accompanied by changing tampons. To reduce pain, 30-40 minutes before the patient is admitted to the dressing room, a solution of pantopon or promedol is injected under the skin, and to make the tampons come off softer and less traumatic, dressings are done after a sitz bath with a solution of potassium permanganate.

In the following days until discharge, after bowel movement, the patient takes a sitz bath, after which he is bandaged. The ward nurse makes sure that the dressing room has everything for such a dressing, since it may be needed at any time, even at night.

What are the features of patient care after biliary tract surgery?

Some specific features distinguish the care of patients undergoing surgery on the liver and biliary tract. These patients often suffer from jaundice, which reduces the ability of the blood to clot - this must be kept in mind in connection with the possibility of postoperative bleeding and, therefore, especially closely monitor the bandage, pulse and blood pressure.

Surgical interventions on the liver and biliary tract lead to a more pronounced limitation of the mobility of the diaphragm, since the liver is located in close proximity to it. Taking this into account, all measures are taken to prevent complications from the lungs - first of all, performing breathing exercises, administering oxygen, using painkillers, etc.

How are patients cared for after laryngeal surgery (tracheostomy care)?

A tracheostomy, or tracheal fistula, is applied in the presence of obstacles located above vocal cords. It is used as one of effective means combating respiratory failure. The main task when caring for such a patient is to maintain the patency of the trachea and tracheotomy tube.

The tube can fill with mucus, which will make breathing difficult, so there should be a suction machine in the room near the patient; so that at any time it can be used to quickly remove the contents of the trachea with a sterile rubber elastic catheter passed through a tracheotomy tube. When suctioning from the tracheobronchial tree, it is imperative to use only a sterile catheter to avoid infection.

With a tracheostomy, the patient cannot speak, which often frightens him, so you need to warn him in advance that the lack of voice is a temporary phenomenon, and also teach talk to the patient while closing the external opening of the tracheotomy tube with your finger.

What complications are possible after a tracheostomy?

Caregivers should be aware of possible complications after tracheostomy. The main one is the development of subcutaneous emphysema, which can occur in cases where the tracheotomy tube is not tightly fixed to the surrounding tissues or, soon after surgery, when the patient moves, it falls out of the trachea, and when inhaling air is forced into the soft tissues, spreading along the fascial gaps. The neck circumference increases, the face becomes puffy. The nurse should point this out to the doctor so that measures can be taken to stop further air entering the soft tissues.

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State Budgetary Educational Institution of Higher Professional Education Volga State Medical University of the Ministry of Health of Russia

Department of Surgical Diseases, Pediatric and Dental Faculty

Research work

on the topic: « Features of patient care in the postoperative period"

Completed by: 1st year student, 5th group

Faculty of Pediatrics

Semchenko Maria Sergeevna

Volgograd 2016

• Introduction
• 1. Basic definitions and concepts
• 1.1 Transporting the patient from the operating room to the ward
• 1.2 Arrangement of the ward
• 2. Complications associated with anesthesia
• 2.1 Tongue retraction
• 2.2 Vomiting in the post-anesthesia period
• 2.3 Impaired thermoregulation
• 3. Fighting pain in the postoperative period
• 4. Caring for a seriously ill postoperative patient
• 5. Prevention of postoperative complications
• 5.1 Control of hyperthermia
• 5.2 Combating gastrointestinal paresis
• 5.3 Combating urinary retention
• 5.4 Preventing bedsores
• 6. Nutrition of the patient
• 7. Recovery period
• 8. Role of medical personnel
• Conclusion
• Bibliography

Introduction

The postoperative period is the time between the end of the operation and the patient’s complete recovery. Its duration varies - from 7-8 days to several months. The course of this period is also different and depends on a number of conditions (surgery, anesthesia, state of health of the patient), especially on complications that sometimes occur after surgery. During this period, careful observation and care of the patient is necessary, since proper care, especially in the first postoperative days, often affects not only the result of the operation, but also the life of the patient. Symptoms not noticed in a timely manner and lack of attentive care often lead to severe complications leading to the death of a patient who underwent the operation well. Any changes in the patient's condition must be reported to the doctor.

Objectives: To study the features of care in the postoperative period. Know the possible complications of the postoperative period and methods of their prevention. Learn to recognize postoperative complications.

Objectives: To study the prevention of bedsores and urinary retention. Will study the peculiarities of nutrition in the postoperative period. To study the care of the oral and nasal cavity of a postoperative patient. Become familiar with the role of medical personnel.

Often after surgical treatment complications arise that complicate the healing process. Therefore, preparing a patient for surgery includes a number of preventive measures, both general and local, aimed at preventing complications, both during surgery and in the postoperative period. Surgery and anesthesia lead to certain changes in the human body, which are general in nature and are a response to surgical trauma. Proper management of the patient in the postoperative period, organizing his stay in the department to perform the necessary manipulations and procedures for the treatment and care of the patient are extremely important for prevention possible complications and favorable treatment results. The favorable outcome of treating a patient in the postoperative period largely depends not only on the adequacy of the operation performed, but also on the knowledge and professional skills of nursing staff. Therefore, mastering practical skills and professional skills in caring for patients who have undergone surgery is important for all employees of the surgical department.

1. Basic definitions and concepts

postoperative patient care

The postoperative period is the time from the moment the patient is removed from the operating table until the wound heals and the disappearance of disorders caused by surgical trauma.

Bedsore is necrosis (necrosis) of soft tissues as a result of constant pressure, accompanied by local circulatory and nervous trophism disorders.

Anesthesia is an artificially induced reversible state of inhibition of the central nervous system, which causes sleep, loss of consciousness and memory (amnesia), relaxation skeletal muscles, reduction or shutdown of some reflexes, and pain sensitivity disappears (general anesthesia occurs).

Regurgitation is the reverse of the normal direction of rapid movement of liquids or gases that occurs in hollow muscular organs during their contraction.

Aspiration is the entry of foreign substances into the airways during inhalation.

Asphyxia is an acutely or subacutely developing and life-threatening pathological condition caused by insufficient gas exchange in the lungs, a sharp decrease in oxygen content in the body and the accumulation of carbon dioxide.

The postoperative period is the period from the end of the operation until the patient’s recovery (or until the patient is discharged from the hospital).

It is customary to divide the postoperative period into three phases:

1. Early phase (early postoperative period) - up to 3-5 days after surgery.

2. Late phase (late postoperative period) - 2 - 3 weeks after surgery.

3. Long-term phase - 3 weeks - 3 months after surgery.

1.1 Transporting the patient from the operating room to the ward

The patient is transported from the operating room on a gurney to the recovery room, or to the intensive care unit. In this case, the patient can be taken out of the operating room only with restored spontaneous breathing. The anesthesiologist must accompany the patient to the intensive care unit or post-anesthesia ward along with at least two nurses.

During transportation of the patient, it is necessary to monitor the position of catheters, drainages, and dressings. Careless handling of the patient can lead to loss of drains, removal of the postoperative dressing, and accidental removal of the endotracheal tube. The anesthesiologist must be prepared for respiratory distress during transport. For this purpose, the team transporting the patient must have a manual breathing apparatus (or an Ambu bag) with them.

During transportation, intravenous infusion therapy may be carried out (continued), but in most cases, during transportation, the system for intravenous drip administration of solutions is closed

1.2 Arrangement of the ward

By the time the operation is completed, everything should be ready to receive the patient. The room is ventilated in advance, beds are prepared with clean linen and the sheets are carefully straightened. After surgery, the patient feels best if no one bothers or irritates him. Therefore, in the room where he is located there should be no noise, conversations, or visitors.

The patient in the post-anesthesia period, until complete awakening, should be under constant supervision of medical staff, since in the first hours after surgery, complications associated with anesthesia are most likely:

2. Complications associated with anesthesia

1. Tongue retraction

2. Vomiting.

3. Violation of thermoregulation.

4. Heart rhythm disturbance.

2.1 Tongue retraction

In a patient still in a narcotic sleep, the muscles of the face, tongue and body are relaxed. A relaxed tongue can move down and close the airway. Timely restoration of airway patency is necessary by introducing an airway tube, or by tilting the head back and moving the lower jaw.

It should be remembered that after anesthesia the patient must be constantly under the supervision of the medical staff on duty until complete awakening.

2.2 Vomiting in the post-anesthesia period

The danger of vomiting in the postoperative period is due to the possibility of vomit flowing into the oral cavity and then into the respiratory tract (regurgitation and aspiration of vomit). If the patient is in a narcotic sleep, this can lead to his death from asphyxia. If an unconscious patient is vomiting, it is necessary to turn his head to the side and clear the oral cavity of vomit.

In the recovery room there should be an electric aspirator ready for use, which is used to remove vomit from the oral cavity or from the respiratory tract during laryngoscopy. Vomit can also be removed from the mouth using a gauze pad on a forceps. If vomiting develops in a conscious patient, it is necessary to help him by giving him a basin and supporting his head above the basin. In case of repeated vomiting, it is recommended to administer Cerucal (metoclopramide) to the patient. Disturbances in the rhythm of cardiac activity and breathing until they stop occur more often in older people and infants. Respiratory cessation is also possible due to recurarization - repeated late relaxation of the respiratory muscles after muscle relaxation during endotracheal anesthesia. In such cases, it is necessary to be prepared to carry out resuscitation measures and have breathing equipment at the ready.

2.3 Impaired thermoregulation

Violation of thermoregulation after anesthesia can be expressed in a sharp increase or decrease in body temperature, severe chills. If necessary, it is necessary to cover the patient, or, conversely, to create conditions for improved cooling of his body.

For high hyperthermia, intramuscular injection of analgin with papaverine and diphenhydramine is used. If even after the administration of the lytic mixture the body temperature does not decrease, use physical cooling of the body by rubbing with alcohol. As hyperthermia progresses, ganglion blockers (pentamine or benzohexonium) are administered intramuscularly.

If there is a significant decrease in body temperature (below 36.0 - 35.5 degrees), warming the patient's body and limbs with warm heating pads can be used.

3. Fighting pain in the postoperative period

Prolonged exposure to pain and pain of high intensity lead not only to moral and mental distress, but also to very real biochemical metabolic disorders in the body. The release of a large amount of adrenaline into the blood (the “stress hormone” produced by the adrenal cortex) leads to increased blood pressure, increased heart rate, and mental and motor (motor) agitation. Then, as the pain continues, the permeability of the walls of the blood vessels is disrupted, and the blood plasma gradually enters the intercellular space. Biochemical changes in the composition of the blood also develop - hypercapnia (increased CO 2 concentration), hypoxia (decreased oxygen concentration), acidosis (increased blood acidity), changes occur in the blood coagulation system. Connected together by the circulatory system, all human organs and systems are affected. Pain shock develops.

Modern methods of anesthesia make it possible to prevent the dangerous consequences of pain in injuries, surgical diseases and during surgical operations.

4. Caring for a seriously ill postoperative patient

The operated patient cannot take care of himself on the first day; in addition, for fear of complications, he tries to move as little as possible in bed and stops performing personal hygiene. The task of the medical worker is to surround the patient with attention and care, provide him with careful care and at the same time force the patient, in cases where necessary, to actively participate in the prevention of complications and the fight against them. The most severe complications, depending on poor care, are inflammation in the oral cavity (stomatitis), mumps, bedsores, inflammation and diaper rash in the perineum and natural folds of the body.

Oral care. After most operations, the patient suffers from dry mouth and thirst. Immediately after the operation, it is not recommended to give the patient anything to drink due to possible vomiting, therefore, to relieve the severe feeling of dryness, patients are allowed to rinse their mouths with water; for more severe patients, they wipe their teeth, gums, and tongue with a cotton swab on a stick moistened with water. In case of severe dryness, reaching the point of cracking of the lips, tongue, or oral mucosa, they are re-lubricated with petroleum jelly. During some operations, eating by mouth is not allowed for several days; in these cases, it is necessary to sanitize the oral cavity with weak antiseptic solutions (solution of soda, rivanol, potassium permanganate, etc.). In addition, the patient must brush his teeth daily with a brush tooth powder or paste. An important prevention of purulent mumps (inflammation of the parotid gland) is to stimulate the secretion of the gland, achieved by wiping and rinsing the mouth with water with the addition of lemon juice or intensively chewing pieces of rubber or the crust of black bread.

Skin care. The patient's skin should be kept clean; accidentally contaminated areas of the skin should be washed and wiped. Be sure to wash your face and wash your hands repeatedly. Particular care must be taken to monitor the condition of the skin of those surfaces of the body on which the patient lies, in order to prevent bedsores. For the same purpose, everyone who is sick with strict bed rest and those who are unable to turn independently in bed at least 2 times a day, it is necessary to wipe their back (massage) with camphor alcohol. Places of greatest pressure should be inspected and wiped even more often. Of great importance in the prevention of bedsores is placing the patient on inflatable rubber rings, changing the patient’s position in the bed: turning on one side or the other (with the doctor’s permission). At the first signs of the appearance of bedsores, suspicious areas must be tamed with a concentrated solution of potassium permanganate. Tanning with a manganese solution is repeated several times a day. Usually, a combination of all these measures allows you to eliminate incipient bedsores. Developed bedsores are treated by smearing with tincture of iodine, applying an adhesive bandage, bandages with sulfidine and other emulsions. Ultraviolet irradiation has a good effect. In obese patients, in places of natural folds (umbilicus, groin and axillary area, in women - under the mammary glands) diaper rash often occurs. Prevention of this complication is achieved by wiping the affected areas with petroleum jelly or dusting with talcum powder.

Caring for the perineal area. Constant contamination of the skin of the perineum can cause the development of a number of complications ( pustular diseases skin, inflammation of the urinary tract, external genitalia). Therefore, after defecation, hygienic treatment of the perineum should be carried out. Place a vessel under the patient and water the perineum boiled water or a weak solution of manganese, use a cotton swab to treat the perineum and then wipe it dry. In women, hygienic washing of the perineum should also be carried out daily at night. If redness appears, the perineum is powdered with talcum powder or lubricated with petroleum jelly.

5. Prevention of postoperative complications

Prevention of pulmonary complications. In many ways, the prevention of these complications depends on the ability to give the patient a semi-sitting position, when ventilation and blood circulation in the lungs improve. In a sitting position, it is easier for the patient to cough and remove secretions and phlegm accumulated in the bronchi. Relieving pain with drugs, giving cardiac drugs and drugs that facilitate sputum production are important point in the prevention of pneumonia (1 ml of 10% caffeine solution, 3 ml of 20% camphor solution 3 times a day, 2 ml of cordiamine 3 times a day). Much depends on the patient’s activity. The nurse’s task is to teach the patient breathing exercises - to carry out periodically (hourly) 10-15 maximum possible breaths, cough regularly, sometimes overcoming the pain. From the next day after surgery, circular cups or mustard plasters are of great importance in the prevention of pneumonia. The cups are placed on both the front and back surfaces of the chest, sequentially, sometimes in three steps, turning the patient on one side or the other. According to indications from for preventive purposes Penicillin therapy is also carried out.

5.1 Control of hyperthermia

After some surgical interventions, a sharp increase in body temperature is observed on the first day (surgeries on the nervous system, under conditions of hypothermia, etc.). An increase in temperature sharply worsens the patient's condition. Decrease in temperature, decrease discomfort problems that arise in this case are achieved by applying ice packs to the head or area of ​​​​the operation, applying cold compresses to the forehead. For persistent increases in temperature, it is possible to use antipyretics: aspirin, pyramidon, antipyrine, etc. The most effective is intramuscular injection of 5-10 ml of a 4% solution of pyramidon.

5.2 Combating gastrointestinal paresis

Intestinal bloating (flatulence) sometimes worsens the condition so much that the most drastic measures are required to eliminate it. It is very common to insert a gas outlet tube, which temporarily eliminates spasm of the rectal sphincter and facilitates the passage of gases. The intestines are better relieved of gases after a hypertensive enema: 100 ml of a 5% solution of table salt is injected into the rectum using a rubber bulb. Usually, after a few minutes, the enema causes stool and profuse passing of gas. Sometimes a hypertensive enema is combined with the administration of drugs that stimulate peristalsis (1-2 ml of a 0.05% solution of proserin under the skin, up to 50 ml of a 10% solution of table salt intravenously). For severe paresis, a perinephric blockade and a siphon enema are performed (see above). Intestinal paresis is accompanied by atony of the stomach and a sharp expansion of its gases. In these cases, relief of the patient's condition can be achieved by inserting a thin probe into the stomach (through the nose) and pumping out gases and stomach contents with a Janet syringe. Sometimes gastric lavage is added to this warm water through the same probe. In case of uncontrollable vomiting, the probe is left on long time for continuous suction.

5.3 Combating urinary retention

If 10-12 hours after the operation the patient cannot urinate on his own, then it is necessary to carry out a number of measures aimed at achieving independent urination. After simple operations, a patient can be allowed to get up, since some patients cannot urinate while lying down, or taken on a gurney to the restroom. Patients who cannot stand should be allowed to turn on their side or be given a semi-sitting position. Sometimes applying a heating pad to the perineum or a cleansing enema eliminates urinary retention.

5.4 Preventing bedsores

1.Use a functional bed.

2.Use an anti-decubitus mattress or a Clinitron bed.

3. Daily inspect the skin in places where bedsores may form: the sacrum, heels, back of the head, shoulder blades, inner surface of the knee joints, areas of the greater trochanter of the femur, ankles, etc.

4. Place rollers and foam pads in cotton (cotton) covers under areas of prolonged pressure.

5.Use only cotton underwear and bed linen. Straighten wrinkles in laundry, shake off crumbs.

6.Change the patient's position in bed every two hours.

7.Move the patient carefully, avoiding friction and tissue movement, lifting the patient off the bed, or using a back sheet.

8. Do not allow the patient to lie directly on the greater trochanter of the femur in the “side decubitus” position.

9.Wash your skin daily with water and liquid soap, thoroughly rinse off the soap and dry your skin with a soft towel using blotting movements.

10. When performing a general massage, lubricate the skin generously with moisturizing cream.

11. Carry out a light massage of the skin with Solcoseryl ointment in places where it turns pale.

12.Use waterproof diapers and nappies that reduce excessive skin moisture.

13. Maximize the patient’s activity.

14.Teach the patient and relatives how to care for their skin.

15. Monitor the patient’s adequate nutrition: the diet should contain at least 120 g of protein and 500-1000 mg of ascorbic acid per day. 10g of protein is contained in 40g of cheese, in one chicken egg, 55g of chicken meat, 50g of low-fat cottage cheese, 60g of raba.

6. Nutrition of the patient

The patient's body loses a significant amount of fluid both during the operation (blood loss) and shortly after it (sweating, vomiting after ether anesthesia). As a result of this, the patient's body becomes dehydrated, and in the postoperative period the missing amount of fluid must first be replenished. Dehydration of the patient's body often results in painful thirst. After operations under local anesthesia, thirst can be satisfied by giving the patient water, warm or iced tea, mineral water, Tea with lemon, cranberry juice. But this can only be done if the operation was not on the stomach. IN the latter case the patient is usually not allowed to drink on the first day. If it is impossible to administer fluid through the mouth, the missing amount (1-2 liters per day) should be administered in another way. It is possible, if the operation was not on the lower segment of the intestine, to introduce liquid in the form of a saline solution through the intestines (saline enemas of 100 ml of solution every 2-3 hours or drip enema of 500 ml 1-2 times a day). Often introduced saline in the first days after surgery, 500-600 ml under the skin or into a vein 2 times a day. When administering saline and glucose intravenously, large amounts of liquid are used, sometimes up to 2-3 liters or more.

7. Recovery period

The postoperative period is followed by a period of recovery, when the patient leaves the hospital, but cannot yet be considered fully recovered. During this period, the patient, weakened by surgery and prolonged lying down, must beware of all those harmful influences that can easily cause any disease. More than usual, he must beware of cold, overwork, must be careful in food and avoid lifting heavy objects, especially after abdominal operations, since the scar may stretch and a postoperative hernia may form. It is advisable that in the immediate postoperative period (3-4 weeks) the patient remains under medical supervision.

8. Role of medical personnel

The main tasks of medical staff in the postoperative period are:

- Preventing the occurrence of postoperative complications is the main task, for which you should:

- recognize postoperative complications in time;

- provide care for the patient by a doctor, nurses, orderlies (pain relief, provision of vital functions, dressings, accurate implementation of medical prescriptions);

- provide adequate first aid in a timely manner in case of complications.

An experienced, observant nurse is the doctor’s closest assistant; the success of treatment often depends on her.

Depending on the general condition of the person being operated on, the type of anesthesia, and the characteristics of the operation, the ward nurse ensures the desired position of the patient in bed (raises the foot or head end of a functional bed; if the bed is an ordinary one, then takes care of the headrest, bolster under the legs, etc.)

The room where the patient is admitted from the operating room must be ventilated and clean. Bright light in the room is unacceptable. The bed must be placed in such a way that it is possible to approach the patient from all sides. These requirements are fulfilled by junior medical personnel.

Conclusion

Thus, the postoperative period is very important for the patient’s recovery. During this period, the patient is at risk of complications. There are many measures to create maximum peace for the patient. Of great importance are measures to eliminate pain both during operations and in the postoperative period, and during other manipulations, as well as attention to the mental state of the patient, his well-being, and experiences (mental prevention). All this creates a protective treatment regimen for patients.

Bibliography

1. Kolb L.I., Leonovich S.I., Yaromich I.V. General surgery. - Minsk: Higher school, 2008.

2. Evseev M. A. “Patient care in a surgical clinic” Publisher: GEOTAR-Media, 2010

3. Gritsuk I.R. Surgery. - Minsk: New Knowledge LLC, 2004.

4. Dmitrieva Z.V., Koshelev A.A., Teplova A.I. Surgery with the basics of resuscitation. - St. Petersburg: Parity, 2002.

5. Dvoinikov S.I. Fundamentals of Nursing. M.: Medicine, 2005

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Determination of the postoperative period

At the end of the operation, the patient is transferred to a gurney, transported to the ward and placed on a bed, depending on the severity of the condition; the patient can be placed in a postoperative or intensive care ward with an individual post. In the intensive care unit, equipment must be prepared to provide necessary assistance- artificial ventilation device, tracheostomy kit, defibrillator, means for infusion therapy, medications (adrenaline, ephedrine, calcium chloride, etc.) Before admitting the patient, the room must be cleaned, ventilated, prepared clean, without folds, linen in cold time of year, warmed with heating pads. During transportation to the ward, as well as before complete awakening from narcotic sleep, there should be a nurse anesthetist or an anesthesiologist next to the patient, since during the awakening stage after the use of muscle relaxants, recurarization may occur with respiratory or cardiac arrest. In these cases, repeated tracheal intubation and artificial ventilation are performed, and in case of cardiac arrest, closed massage is performed.

It is better to place the operated patient on a functional bed, which allows for a comfortable position, or, if this is not available, on a backboard. In order to improve blood flow to the brain, the patient's position in bed during the first two hours is on his back, without a pillow, and after recovery from anesthesia he is given a position depending on the nature of the operation. Changing body position in the first hours after surgery is allowed only with the permission of the doctor. The most comfortable position is on the right side, which facilitates the work of the heart and improves function digestive tract, the likelihood of vomiting decreases. After surgery on the chest and abdominal cavities, a semi-sitting position is necessary; it prevents congestion in the lungs, facilitates breathing and cardiac activity, and promotes better rapid recovery bowel functions. To ensure that patients do not move to the foot end of the bed, it is necessary to place their limbs on a persistent footrest.

To improve drainage of the abdominal cavity, pouch of Douglas, and pelvic organs, a position with a raised head end (Fowler's position) is used. After operations on the spine, as well as after some interventions on the brain, the patient takes a position on his stomach; if the operation was on the thoracic or lumbar spine, a soft cushion is placed under the chest.

We must always remember that any position of the patient, even comfortable and optimal, must be changed as early and often as possible (with the doctor’s permission), which will help reduce postoperative complications, increase the overall tone of the body, and improve blood circulation.

For postoperative patients, the nurse performs everything necessary appointments doctor Administers intramuscular or subcutaneous painkillers: on the first day after surgery, every 3 hours, narcotic analgesics (promedol, omnopon solutions), and on subsequent days, non-narcotic analgesics (analgin, baralgin) as needed. The patient is connected to the system and blood products, means for correcting the internal environment of the body and other drugs are administered intravenously. The nurse monitors the main systems and organs, and if changes are detected, she independently provides assistance or calls a doctor.

Postoperative wound care

An ice pack or, less commonly, a bag of loose material (sand) should be placed on the postoperative wound site to prevent bleeding. An ice pack helps to constrict blood vessels in the skin, as well as adjacent tissues, and reduce the sensitivity of nerve receptors. It is filled with small pieces of ice, the remaining air is squeezed out, the lid is tightly closed, wrapped in a towel and applied to the wound. You cannot pour water into a bubble and freeze it in the freezer, since the surface formed ice will be very large, which can lead to hypothermia of the wound area. The ice pack can be kept for 2-3 hours, and more if necessary, but every 20-30 minutes it must be taken away for 10-15 minutes. As the ice in the bubble melts, the water must be drained and pieces of ice added.

If a bag with a weight is placed on the wound, it performs a function similar to a compressive bandage - it presses the vessels on the surface and in the depths of the wound. After use, the tissues are soaked in a disinfectant solution, washed and sterilized, the loads are cleaned of blood and wound secretions, wiped with a solution of chloramine (chlorantheine), and then placed in plastic bags for a day, where cotton balls moistened with a 10% formaldehyde solution are placed. When caring for a wound in cases where the bandage has slipped, the nurse should correct it. When the bandage quickly becomes saturated with blood, bandaging it is contraindicated; you must call a doctor. The next day after the operation, it is necessary to bandage the wound, examine and palpate. If the course of the postoperative process is favorable, dressing is rarely performed so as not to injure the granulations. The sutures are removed in two stages, usually on days 7-8, and in some operations on days 11-12.

Cardiovascular care

In the early postoperative period, the nurse measures the patient's pulse and blood pressure hourly. When measuring the pulse, attention is paid to its frequency, rhythm, filling and tension. It must be remembered that an increase in the patient’s body temperature by 1 ° C is accompanied by an increase in heart rate by 8-10 beats. /Min. If the operated patient's pulse rate is faster than the temperature or the temperature decreases and the pulse quickens, this indicates an unfavorable course of the postoperative period. After surgery, the patient may develop collapse - acute vascular insufficiency. The patient is pale, cold extremities, significant tachycardia, arterial hypotension.

Nurse's procedure for collapse:

Call a doctor immediately

Provide the patient with strict rest, horizontal position in bed, without a pillow, with legs slightly elevated

Cover the patient with a blanket and apply warm heating pads to his feet.

Provide access to fresh air or oxygen inhalation

Prepare the necessary medications: strophanthin, mezaton, a bottle of saline, etc.

Gastrointestinal Care

After any operation under anesthesia, the patient is allowed to drink after 2-3 hours. After surgery on the digestive organs, drinking is allowed for much longer (for example, after surgery on the intestines - 1-2 days). The patient can moisten the mouth with small portions of boiled water and lemon. To prevent stomatitis, the oral cavity is treated with a solution of potassium permanganate (1:5000), 2% boric acid solution (Fig. 3.3). To increase salivation, it is recommended to suck a lemon. If the tongue is severely dry, lubricate it with a mixture of glycerin and lemon juice or a solution of citric acid. If the patient cannot care for his mouth on his own, the nurse should help him brush his teeth. Very often after operations on the gastrointestinal tract, bloating occurs. In this case, it is necessary to insert a gas outlet tube into the patient. Hypertonic or siphon enemas can also be performed as prescribed by a doctor. The first spontaneous passage of gases, as well as the appearance of peristalsis, are favorable signs. A common manifestation of complications of the postoperative period from the digestive organs is vomiting.

Medical personnel should help the patient cope with this complication.

Sequence of actions for a nurse when vomiting

If the condition allows, it is necessary to sit the patient down and put an oilcloth apron on him.

Place a basin or bucket at your feet.

Hold the patient's head while vomiting by placing your palm on his forehead.

After you stop vomiting, have the patient rinse their mouth with water and dry their face with a towel.

Leave the vomit until the doctor arrives. If the patient is unconscious or his condition is so severe that he cannot be seated, the nurse’s sequence of actions when vomiting is as follows:

Wear rubber gloves.

Turn the patient on his side, and if this is contraindicated, turn the patient's head to the left side to prevent aspiration of vomit.

Cover your neck and chest with a towel.

Place a plastic tray or basin in the patient's mouth.

After each act of vomiting, treat the oral cavity with water or 2% sodium bicarbonate solution; if necessary, suck out the remaining vomit from the mouth using a pear-shaped balloon.

Laxative enemas are indicated to stimulate spontaneous bowel movements in the postoperative period, as well as for severe constipation, increased intracranial pressure, and cerebral hemorrhages.

Laxative enema technique

Material support: pear-shaped cylinder, gas outlet tube, 100-200 g of oil (sunflower, hemp or vaseline), heated to a temperature of 34-38 ° C, oilcloth, Janet syringe, 200 ml of 10% sodium chloride solution

Contraindications: anal fissures, hemorrhoids, purulent and ulcerative inflammatory processes in the rectum. Complications do not arise if the technique is followed. Using a pear-shaped balloon, a mixture of the following composition: 20 ml of a 10% sodium chloride solution, 20 ml of glycerin and 20 ml of a 1% hydrogen peroxide solution is injected into the rectum. After administration of the solution, patients should lie down for 10-15 minutes on their left side to prevent leakage of the mixture.

Nutrition of patients during the postoperative period

Nutrition in the postoperative period must correspond to the nature of the disease, the volume of the operation performed, as well as the peculiarities of its course. In the first two days after any operation, food should be freshly prepared, warm, and liquid. first courses that allow you to eat are broths, jelly, yogurt, raw or soft-boiled eggs, steamed cutlets, cheese, liquid porridge. After the end of the early postoperative period, patients without accompanying diseases are prescribed general diet No. 15. Nutrition after some surgical interventions is as follows:

) after operations on the stomach and small intestine, fasting is recommended for the first 1-2 days; food during this time is provided only parenteral administration solutions of glucose, proteins, etc. After 2-3 days, a liquid diet is prescribed - table No. 1a, then No. 16, and starting from the 7th day - porridge-like food. Starting from 10-12 days, the patient is gradually transferred to the general table

) the diet of patients after interventions on the abdominal cavity, but without opening the stomach and intestines, should be adjusted to prevent gas formation. Provide all products that meet table No. 1a, except dairy

) after operations on the colon, the diet is aimed at ensuring that the patient does not have stool for 4-5 days; foods containing a lot of fiber are excluded from the diet - brown bread, vegetables, fruits

) after some operations on the oral cavity, esophagus, as well as weakened and unconscious patients, artificial nutrition can be provided through a catheter or through a gastrostomy tube, if it is placed on the stomach, and in some cases, using an enema. Let us dwell in more detail on some types of nutrition for patients.

Enteral nutrition

Enteral nutrition includes feeding through a gastric tube, gastrostomy tube or enema

Feeding technique

Materials: sterile thin rubber probe with a diameter of 0.5-0.8 cm, Vaseline or glycerin, Janet funnel or syringe, liquid food (sweet tea, fruit drink, raw eggs, broth, etc.), rubber gloves

Action algorithm

Wear rubber gloves.

Treat the probe with Vaseline (glycerin).

Insert the probe through one of the nasal passages to a depth of 15 cm

Locate the probe. If the procedure is carried out correctly, the end of the probe should be in the nasopharynx. If the end of the probe has moved forward, it must be placed against the back wall throats.

Bend the patient's head slightly forward and right hand push the probe forward. If the patient does not choke or air is not sucked out of the probe, the probe is in the esophagus. Insert it another 10-15 cm.

Connect the free end of the probe to a funnel (Janet syringe)

Slowly pour the cooked food into the funnel

Then pour in clean water (rinsing the probe) and disconnect the funnel (Zhanet syringe).

Secure the outer end of the probe in the area of ​​the patient's head so that it does not interfere with him. The tube is not removed during the entire feeding period, which can last 2-3 weeks.

Nutrition through a gastrostomy tube. When feeding a patient through a gastrostomy tube (a tube inserted into the stomach through the anterior abdominal wall), a funnel is connected to its free end and a small amount of food is first introduced - 50 ml 6-7 times a day, and then the volume of administration is gradually increased to 300-500 ml, decreasing the multiplicity. Sometimes the patient is allowed to chew food, then dilute it in a glass with liquid, and pour it into a funnel in a diluted form.

Nutrition through an enema. Using an enema, 300-500 ml of a nutrient solution heated to 37-38 ° C - 5% glucose solution, amino acid solution, physiological solution - is injected dropwise through the rectum. You can carry out similar feeding using a pear-shaped rubber balloon, but the single volume of the injected solution should be small.

Parenteral nutrition

This type of nutrition is used after operations on the stomach, esophagus, intestines and for some other conditions. For this procedure, it is necessary to introduce into the body the basic nutrients proteins, fats, carbohydrates, water, salts and vitamins. among protein preparations, hydrolysine, casein protein hydrolyzate, alvesin, etc. are most often administered; from fatty acids - lipofundin, intralipid; from carbohydrates - 10% glucose solution. To replenish the body with mineral salts, it is necessary to introduce up to 1 liter of electrolytes per day. Medicines for parenteral nutrition administered intravenously. Before administration, they must be heated in a water bath to body temperature (37-38 ° C). It is necessary to monitor the speed of drug administration. Thus, protein preparations are administered at a rate of 10-20 drops per minute in the first 30 minutes, and then gradually over 30 minutes the rate of administration is increased to 60 drops per minute. Other agents are administered in a similar manner. With faster administration of protein preparations, a feeling of heat, facial flushing, and difficulty breathing may occur.

Skin and mucous membrane care

Patients are pale on the first day after surgery, but the next day the skin, as a rule, acquires a normal color. Increasing pallor of the skin may indicate internal bleeding. The phenomenon of hyperemia of the facial skin, as well as an increase in body temperature, may be a sign of pneumonia. Yellowness of the skin and sclera indicates pathology of the liver and bile ducts. The skin must be kept clean, for which the bedridden patient is helped to wash his face and hands, and a partial sanitization skin in the same way as in preparation for emergency surgery. After each act of defecation, as well as when the genital area of ​​patients is contaminated, it is necessary to wash it.

Technique for washing the patient

Material support: a container with warm (30-35 ° C) water or a weak solution of potassium permanganate, a forceps, a napkin, a vessel, rubber gloves.

Action algorithm

Wear rubber gloves.

Place your left hand under the patient’s back and help him raise his pelvis.

With your right hand, lift and straighten the oilcloth under the pelvis, place the bedpan on top of it and lower the patient’s pelvis.

Stand to the right of the patient and, holding the jug in your left hand and the forceps with a napkin in your right, pour the antiseptic from the jug onto the genital area, while using the napkin to wipe the perineum and the skin around it, moving from the genitals to the anus.

Dry the skin of the perineum with another napkin in the same direction, remove the vessel and oilcloth.

Bedsores. Bedsores form in places prolonged compression soft tissues They are localized mainly in the areas of the shoulder blades, sacrum, greater trochanter or heels, their formation is facilitated by trophic disorders, metabolism, exhaustion, wetting of the skin with urine, sweat, wound contents, the presence of folds in the bed linen, food crumbs after feeding, infrequent repositioning, poor skin care

The first sign of bedsores is pale skin followed by redness.

Subsequently, swelling, necrosis and detachment of the epidermis and skin necrosis appear

Prevention of bedsores:

change the patient's position several times a day,

straighten, shake the sheet so that there are no folds and crumbs,

seriously ill patients need to place an inflatable rubber circle under the sacrum 5-6 times a day, it is necessary to wipe the skin in those areas that come into contact with the bed: camphor alcohol, cologne, a weak solution of vinegar (1 tablespoon acetic acid for 200-300 ml of water),

If the skin is red, rub it periodically with a dry towel,

check the skin of the back and buttocks daily,

regularly wash the patient with soap and water, wipe with talcum powder,

place bags of millet and flax seeds under the sacrum, cotton-gauze rings under the heels,

Constantly massage the back and sacrum.

Respiratory care

dangerous complication postoperative period from the respiratory system is congestive pneumonia. To prevent it, a semi-sitting position in bed and getting up early after surgery are recommended. In addition, it is necessary to combat intestinal flatulence, which will promote normal lung excursion.

From the very first days after the operation, it is necessary to force the patient to breathe deeply and do breathing exercises several times a day. He should cough up phlegm. Also shown are Percussion and vibration massage chest, therapeutic exercises, use of cupping and mustard plasters. Positive result gives inflation of rubber chambers, children's toys, breathing through a mask of an anesthesia apparatus connected to a tube, which is immersed in water to a depth of 7-10 cm.

Oxygen therapy

In the postoperative period, severely ill patients often have to undergo oxygen therapy. This can be done through a centralized supply of oxygen, using an oxygen pillow or cylinder.

With centralized oxygen supply, oxygen cylinders are kept in a special room and oxygen is supplied through a system of tubes to dosimeters, where it is humidified and supplied to the patient through a nasal catheter or nasal cannula.

Technique for inserting a nasal catheter

Wear rubber gloves.

Boil the catheter and lubricate it with sterile Vaseline.

Insert the catheter into the lower nasal passage and further into the pharynx - to a depth of 15 cm. The tip of the inserted catheter should be visible when examining the pharynx.

Secure the outer part of the catheter with an adhesive tape on the cheek so that it does not descend into the esophagus.

Open the tap of the dosimeter and supply oxygen at a rate of 2-3 l/min, controlling the speed on the scale.

Nasal cannula insertion technique

Wear rubber gloves.

Insert the ends of the cannula into the patient's nostrils.

Using an elastic bandage (retainer) for the head, secure the cannula so that it does not cause discomfort to the patient.

Attach the nasal cannula to a source of humidified oxygen with the desired concentration and flow rate.

Ensure that the oxygen tubes have sufficient mobility and secure them to clothing.

Check the condition of the cannula every 8 hours and ensure that the humidifying container is always full.

Periodically inspect the nasal mucosa and ears patient to identify possible skin irritations.

In small hospitals where there is no centralized supply of gases, it can be supplied directly from oxygen cylinder, the oxygen contained in the ward is explosive, and therefore when working with cylinders you must follow safety rules

The cylinder must be installed in a metal socket and secured with straps or a chain.

The cylinder must be located no closer than 1 m from the heating system.

The cylinder must be protected from direct sunlight.

Release gas from the cylinder only through a reducer on which a pressure gauge is installed, which allows you to control the oxygen pressure at the outlet.

It is prohibited to use cylinders and reducers whose service life has expired.

Do not lubricate your hands with greasy cream when working with an oxygen cylinder.

Oxygenation using an oxygen pillow. An oxygen bag is a rubberized bag that includes a rubber tube with a tap and a mouthpiece. It contains from 25 to 75 liters of oxygen, which is filled from an oxygen cylinder. Before oxygenation begins, the mouthpiece is wrapped in 2-3 layers of wet gauze; sodium bicarbonate or sodium bicarbonate is used to humidify the oxygen. medical alcohol Then the mouthpiece is pressed tightly to the patient’s mouth and the tap is opened, with the help of which the oxygen supply is approximately regulated. Inhalation is done through the mouthpiece through the mouth, and exhalation through the nose. When the amount of oxygen in the pillow decreases significantly, to increase its supply, it is necessary to press the pillow with your free hand. After using the mouthpiece twice wipe with a 3% solution of hydrogen peroxide or ethyl alcohol This method of oxygenation is considered the least appropriate due to large losses of oxygen, as well as the inability to dose it accurately and evenly

Urinary system care

Often after operations on the abdominal organs, especially on the pelvic organs, urinary retention occurs. The main reason is the fear of pain when contracting the abdominal muscles and the inability to urinate while lying down. If possible, the patient should be allowed to urinate in his normal position. If you have urinary retention, you can place a heating pad on the suprapubic area or perineum. It is necessary to try to induce urination reflexively. To do this, you need to open the running water tap in the room and pour warm water over the genitals of the patient lying on the bed. If there is no effect, bladder catheterization is performed.

Bibliography

postoperative period bedsore prevention

1. Struchkov V.I., Struchkov Yu.V. General surgery. M.: Medicine, 1988.

Timofeev N.S., Timofeev N.N. Asepsis and antiseptics. Leningrad: Medicine, 1980.

Usov D.V. Selected lectures on general surgery. Tyumen. 1995.

Textbook on general surgery. / Ed. Chernova V.N. M.: Book, 2003.

Khoronko Yu.V., Savchenko S.V. Handbook of Emergency Surgery. Rostov-on-Don: Phoenix, 1999.

The postoperative period is the period from the moment of the operation until the restoration of the patient’s ability to work (recovery) or his transfer to disability (loss of ability to work).

Regardless of the nature of the surgical intervention performed, in the postoperative period it is necessary to carry out a number of measures that will allow the patient to more easily cope with the changes in the body that develop after the operation. Among these activities, the following should be highlighted:

a) The patient is transported from the operating room to the intensive care unit on a gurney in a supine position. The gurney must be adapted to conveniently transfer the patient onto the bed.

b) Giving the patient a position in accordance with the nature of the surgical intervention performed and/or in accordance with the pathological process:

 position on the back without a pillow, head turned to the side - after anesthesia to prevent cerebral hypoxia and aspiration of vomit from the respiratory tract;

 lateral position is allowed after the patient’s condition has been stabilized;

 Fowler’s position (half-sitting) is used for operations on the gastrointestinal tract;

 prone position - after surgery on the brain and spine;

- during operations on lower limbs patients are placed on Beler splints.

The bed must be equipped with devices that will facilitate the patient’s movements (trapeze bars, reins, tables).

c) Restoration of body functions ( respiratory system, cardiovascular system, blood circulation, digestive system, excretory system).

The main points of postoperative intensive care are: adequate pain relief, maintenance or correction of gas exchange, ensuring adequate blood circulation, correction of metabolic disorders, as well as prevention and treatment of postoperative complications.

The fight against postoperative pain has great value in the postoperative period. The intensity of pain is directly dependent on the nature and extent of the surgical intervention, as well as on the state of the patient’s neuropsychic status. The mental trauma caused by the operation and the pain experienced by the patient lead to metabolic disorders in the body, the development of postoperative acidosis, and dysfunction of the excretory organs.

Postoperative pain usually appears 1-1.5 hours after operations performed under local anesthesia, or after the return of consciousness in patients after anesthesia. Usually, narcotic analgesics (promedol, omnopon, morphine) are used to relieve these pains. However, after major traumatic operations, the use of even large doses of these drugs does not provide complete pain relief. Moreover, the use of large quantities of these drugs leads to depression of the respiratory center, which creates conditions for the development of postoperative pneumonia and pulmonary embolism.

Monitoring the state of breathing deserves special attention, since breathing disorders in the postoperative period, under certain conditions, can have an adverse effect on postoperative course. After lengthy operations and long-term anesthesia, it may sometimes be necessary to use mechanical artificial respiration in order to normalize the concentration of blood gases, as well as to facilitate respiratory “work” for a patient who limits breathing movements due to fear of pain. In some cases, it may be necessary to use oxygen through a nasal catheter.

In the postoperative period, patients experience an increase in sweating, increased breathing, increased temperature, etc., as a result of which the loss of water through the extrarenal route increases. Therefore, patients with normal hydration on the day of surgery should be given no more than 1.5 l/m of fluids - from 35 to 40 ml per 1 kg of body weight (maintenance dose, except for replacing natural losses), on the first postoperative day (as well as on subsequent days) 1.5 l/m of fluid is prescribed as a maintenance dose.

Wherein special attention should be given to the increased excretion of waste products in the urine due to increased catabolism. It must be borne in mind that, for example, in patients after gastrectomy, 3-4 g (and in case of skull injuries - even 13 g) more nitrogen is released than in healthy individuals with the same body length and weight. This requires, for example, with a relative density of urine of the order of 1.025, more fluid administration: from 160 to 220 or 700 ml of water.

Monitoring the patient by medical personnel on duty is an important activity in the postoperative period. Along with dynamic clinical observations pulse rate, breathing pattern, blood pressure, temperature, state of the nervous system, skin color determine other parameters that will help identify deviations specific to a particular patient (for example, central venous pressure, as well as dynamic control for urine output).

After surgery on the abdominal organs, it is necessary to regularly examine the abdomen, including auscultation, to ensure that intestinal motility has been restored. To stimulate intestinal activity, especially after laparotomy, electrical and drug stimulation is performed, and it is recommended to insert a gas tube into the rectum. In addition, postoperative atony of the gastrointestinal tract can be caused by potassium deficiency (as well as postoperative psychoses).

G) Hygiene measures are of great importance for preventing the development of various complications in the postoperative period. Among them, it is necessary to note wiping the skin with camphor alcohol in long-term patients (prevention of bedsores), treatment of the oral cavity (prevention of mumps), changing bed and underwear in cases of vomiting, involuntary urination, contamination of linen with discharge from cavities, blood.

e) Monitoring the condition of postoperative sutures for timely detection of complications - bleeding or suppuration in the wound, eventration of organs, etc.

Measures that ensure rapid healing of the surgical wound include: compliance with the rules of asepsis, antiseptics, and antibiotic prophylaxis. In this case, local treatment with antibiotics is more likely to be indicated, especially for washing, for example, a purulent focus and for cleansing the abdominal cavity with diffuse peritonitis.

f) The nutrition of patients should correspond to the nature of the surgical intervention. It should be remembered that the sooner the patient begins to receive from food all the nutrients necessary for the vital functions of his tissues, the sooner there will be no need to administer them parenterally. The following rules must be observed: carbohydrates must be introduced immediately, if possible from 150 to 250 g / day. WITH good effect Use sugar-containing substances that are absorbed by the body without insulin, for example, xylitol, sorbitol, fructose. The pathophysiological prerequisite for switching to oral administration of fluids and nutritional substances for nutritional correction should be the normalization of gastric emptying and restoration of intestinal resorption in its distal parts.

g) Active management of the postoperative period is of great importance for the prevention of serious postoperative complications - thromboembolism, pneumonia. Active management of the postoperative period is understood as a set of measures, including early movement of the patient in bed, early getting up (in the first 24-48 hours after surgery), physical therapy, early nutrition.

An active method of managing patients in the early postoperative period improves blood circulation and accelerates the process of regeneration of tissues in the patient’s body, helps restore normal urination and improves intestinal function. In addition, getting up early improves lung function.

h) Prevention of complications and combating them.

All complications arising in the postoperative period can be divided into three large groups

Complications in the organs and systems on which surgery was performed (complications of the main point of the operation). Complications of the first group include: secondary bleeding, development of purulent processes in the area of ​​surgical intervention and in the postoperative wound, dysfunction of organs after intervention on them (impaired patency of the gastrointestinal tract, biliary tract);

Complications in organs that were not directly affected by surgery:

1) complications from the patient’s nervous system: sleep disturbance, mental disorders (up to the development of postoperative psychosis);

2) complications from the respiratory system: postoperative pneumonia, bronchitis, pulmonary atelectasis, pleurisy, accompanied by the development respiratory failure. Prevention measures: early activation of patients, early therapeutic breathing exercises, clearing the airways of mucus;

3) complications from the organs of the cardiovascular system can be either primary, when there is the appearance of heart failure due to disease of the heart itself, or secondary, when heart failure occurs against the background of a severe pathological process developing in the postoperative period in other organs (severe purulent intoxication, postoperative blood loss, etc.);

4) complications from the gastrointestinal tract are often functional in nature. These complications include the development of dynamic obstruction of the gastrointestinal tract that occurs after laparotomy;

5) complications from the urinary organs do not occur so often in the postoperative period, due to the active behavior of patients after surgery. These complications include: delayed urine production by the kidneys - anuria, urinary retention - ischuria, the development of inflammatory processes in the kidney parenchyma and in the bladder wall.

79. Terminal states. Signs of clinical and biological death.

TERMINAL STATES. Terminal conditions include stages (phases) of the body’s vital activity bordering on death (pre-agony, terminal pause, agony, clinical death), when independent correction is no longer possible deep violations basic life functions. The terminal state is initial stage post-resuscitation period. In fact, any disease can lead to a terminal condition.

Preagonia- this is, first of all, severe arterial hypotension, accompanied first by tachyarrhythmia, tachypnosis and pathological types of breathing, and then by bradyarrhythmia and bradypnea with the simultaneous inclusion in the act of breathing of all auxiliary muscles with active exhalation, euphoria or progressive depression of consciousness against the background of deepening total tissue ischemia and organs. During this phase, the basic functions of the body are, to a certain extent, imperfectly regulated by the cerebral cortex.

Terminal pause, lasting up to 3-4 minutes, occurs after turning off all levels of regulation above the medulla oblongata. In this phase, sharp depression of the respiratory center (apnea) and bradyarrhythmia are observed.

Then the respiratory center restores its activity, which characterizes agony phase - last stage dying, when the functions of organs and systems are regulated by the disordered activity of the bulbar centers. In this case, sinus automatism is restored for a short time, heart contractions increase, blood pressure slightly increases, and breathing also increases. However, a significant improvement in gas exchange does not occur due to an imperfect act of breathing: an almost simultaneous contraction of the muscles of inhalation and exhalation. During the agony phase, some dying people regain consciousness. However, the price of such an “outburst” of restoration of vital activity is the subsequent complete extinction of vital functions. Main clinical manifestations agony:

Complete persistent loss of consciousness;

Inadequate atonal breathing;

Convulsions;

Bradyarrhythmia with activation of pacemakers of the II, III orders and subsequent asystole or sudden ventricular fibrillation;

A decrease in blood pressure, determined on the brachial artery in the form of a single dull blow at the level of 40-30 mm Hg. Art.;

Pulse only on main arteries- carotid and femoral.

Clinical death- a reversible phase of dying, characterized by a certain viability of brain cells with the cessation of spontaneous breathing and minimally effective blood circulation. Duration clinical death at normal external temperature - no more than 4 minutes. In conditions of hypothermia, in the absence of convulsions, the duration of clinical death in children is slightly longer.

Diagnostic criteria for clinical death:

1. Pale or marble-cyanotic skin.

2. Lack of consciousness (the person does not respond to shouting, pain, shaking).

3. Absence of pulse in the carotid arteries (lack of blood circulation).

4. Pupil dilation, lack of reaction to light. It is known, for example, that dilation of the pupils is observed already in the second minute of clinical death and indicates that half of the possible life of brain cells has already passed. It should be borne in mind that in cases of poisoning with drugs, sleeping pills, organophosphorus compounds, and in clinical death under conditions of hypothermia, narrow pupils are observed.

5. Lack of breathing.

There is no need for instrumental methods for diagnosing clinical death (auscultation of the heart and lungs, ECG or EEG recording), as this leads to loss of time for possible resuscitation. This kind of research is advisable and necessary only if resuscitation measures are simultaneously performed, and in no case should they interfere with their implementation. The time factor for the start of resuscitation measures plays a huge role and is especially important for the full subsequent psychoneurological rehabilitation of a revived patient.

If resuscitation measures are not carried out or are ineffective, then 10-15 minutes after clinical death occurs biological death (an irreversible condition when the body is revived as biological system impossible).

Diagnostic criteria for biological death:

1. All signs of clinical death.

2. Clouding and drying of the cornea, symptom “ cat eye” - stretching the pupil vertically when squeezing eyeball horizontally (early signs).

3. Rigor spots and rigor mortis (late signs).

If obvious signs of biological death are detected (ineffectiveness of cardiopulmonary resuscitation for at least 30 minutes, repeated cardiac arrest during resuscitation), as well as in some cases of documented reluctance of relatives in resuscitation of patients, the doctor ascertains biological death, records all its signs, explains the situation relatives, and in cases of violent death, reports the incident to the police.

Cardiopulmonary resuscitation is not indicated when brain death is determined by a council of doctors in a hospital setting during the treatment of a patient. An emergency physician has the right to establish brain death in cases of open craniocerebral injury and gross crushing of brain tissue or dismemberment of the torso.

Any person (sick or injured) in terminal state Cardiopulmonary resuscitation is necessary, which consists of performing artificial respiration (ALV), closed massage heart (pacing and (or) defibrillation), correction of metabolic disorders and prevention of irreversible damage to the central nervous system.

Indications for resuscitation are signs of clinical death - lack of consciousness, lack of pulsation of the carotid arteries, and breathing.