Care of surgically ill children. Abstract general care for sick children in a hospital. Reception department of a general hospital
State Educational Institution of Higher Professional Education of the Federal Agency for Health and Social Development
"Amur State Medical Academy".
Department of General Surgery
L. A. Volkov, A. S. Zyuzko
BASICS OF PATIENT CARE
SURGICAL PROFILE
TEACHING AID FOR STUDENTS OF THE II YEAR
Blagoveshchensk - 2010
The tutorial was prepared by:
L. A. Volkov - K.M.N., Honored Doctor of the Russian Federation, Assistant of the Department of General Surgery, ASMA.
A. S. Zyuzko- K.M.N., Assistant of the Department of General Surgery, ASMA.
Reviewers:
V.V. Shimko - D.M.N., Professor, Department of Faculty Surgery, ASMA.
Yu.V. Dorovskikh - Associate Professor of the Department of Hospital Surgery, ASMA.
The methodological manual was prepared in accordance with the program for patient care in a surgical clinic and aims to create a theoretical basis for the effective development of theoretical material. The manual consists of 15 topics of practical classes, which outline the organization and mode of a surgical hospital, deontological and ethical issues of patient care, aspects of clinical hygiene of the patient and staff, methods of using drugs, especially preparing patients for diagnostic studies and surgical interventions; highlights the basic principles of care for patients with various surgical pathologies and victims of injuries.
Nursing. Types of care. Device, equipment, mode of operation of the reception and diagnostic department. Reception of patients, registration, sanitization, transportation. Deontology in surgery.
Patient care- sanitary gipurgia (Greek hypourgiai - to help, provide a service) - medical activities aimed at alleviating the patient's condition and contributing to his recovery. During patient care, the components of personal hygiene of the patient and his environment are implemented, which the patient is not able to provide himself due to illness. In this case, physical and chemical methods of exposure based on the manual labor of medical personnel are mainly used.
Patient care is divided into general and special.
General care includes activities that are necessary for the patient himself, regardless of the nature of the existing pathological process (nutrition of the patient, change of linen, personal hygiene, preparation for diagnostic and therapeutic measures).
Special care- a set of measures applied to a certain category of patients (surgical, cardiological, neurological, etc.).
Surgical care
Surgical care is a medical activity for the implementation of personal and clinical hygiene in a hospital, aimed at helping the patient to meet his basic life needs (food, drink, movement, emptying the intestines, bladder, etc.) and during pathological conditions (vomiting, coughing, breathing problems, bleeding, etc.).
Thus, the main tasks of surgical care are: 1) providing optimal living conditions for the patient, contributing to the favorable course of the disease; 2) fulfillment of doctor's prescriptions; 3) accelerating the patient's recovery and reducing the number of complications.
Surgical care is divided into general and special.
General Surgical Care consists in the organization of the Sanitary-hygienic and Medical-protective regimes in the department.
Sanitary and hygienic regime includes:
Organization of cleaning of premises;
Ensuring patient hygiene;
Prevention of nosocomial infection.
Therapeutic and protective regime consists in:
Creating a favorable environment for the patient;
Provision of medicines, their correct dosage and use as prescribed by the doctor;
Organization of high-quality nutrition of the patient in accordance with the nature of the pathological process;
Proper manipulation and preparation of the patient for examinations and surgical interventions.
Special care It is aimed at providing specific care for patients with a certain pathology.
Features of care for surgical patients
Features of care for a surgical patient are determined by:
dysfunctions of organs and systems of the body arising as a result of a disease (pathological focus);
the need and consequences of anesthesia;
operating injury.
Particular attention in this contingent of patients should be directed, first of all, to accelerating the processes of regeneration and preventing infection.
The wound is the entrance gate through which pyogenic microorganisms can penetrate into the internal environment of the body.
With all the actions of middle and junior medical personnel in the process of caring for patients, the principles of asepsis must be strictly observed.
Organization of the work of the reception
Reception department of a general hospital
The admission department (reception ward) is intended for receiving patients delivered by ambulance, referred from polyclinics and outpatient clinics, or seeking help on their own.
The Reception Department performs the following functions:
Conducts round-the-clock examination of all sick and injured, delivered or applied to the emergency department;
Establishes a diagnosis and provides highly qualified medical and advisory assistance to all those who need it;
Performs examination and, if necessary, assembles a council of several specialists to clarify the diagnosis;
With an unclear diagnosis, it provides dynamic monitoring of patients;
Produces triage and hospitalization in specialized or specialized departments of the hospital;
Transfers non-core patients and victims after providing them with the necessary assistance to hospitals and departments according to the profile of the disease or injury, or sends them to outpatient treatment at their place of residence;
Provides constant round-the-clock communication with all operational and duty services of the city.
The reception department includes a waiting room, a reception desk, an information desk, examination rooms. The admission department has close functional contacts with laboratories, diagnostic departments of the hospital, isolation rooms, operating rooms, dressing rooms, etc.
the admission department should be located on the lower floors of the medical institution;
it is necessary that there are convenient access roads for ambulance transport from the street;
elevators should be located near the admission department for transporting patients to medical departments;
the premises of the admission department should be finished with moisture-resistant materials (tile, linoleum, oil paint) for ease of sanitization.
Cleaning requirements:
Cleaning of the premises of the admission department must be carried out at least 2 times a day with a wet method using detergents and disinfectants that are allowed for use in the prescribed manner. Cleaning equipment must be labeled and used for its intended purpose. After use, it is soaked in a disinfectant solution, rinsed in running water, dried and stored in a specially designated room. Couches, oilcloths, oilcloth pillows, after examining each patient, are treated with rags moistened with a solution in accordance with the current instructions. The sheets on the couch in the examination room are changed after each patient. In the treatment room, dressing room, as well as in the small operating room, wet cleaning is carried out 2 times a day using a 6% hydrogen peroxide solution and a 0.5% detergent solution or disinfectant. Wheels after use are treated with a disinfectant solution in accordance with the current instructions.
Waiting hall intended for patients and accompanying relatives. There should be a sufficient number of chairs, armchairs, wheelchairs (for transporting patients). Information about the work of the medical department, hours of conversation with the attending physician, a list of products allowed for transfer to patients, and the phone number of the hospital's help desk are posted on the walls. It should indicate the days and hours in which you can visit the sick.
Nurse's office. It registers incoming patients and prepares the necessary documentation. There should be a desk, chairs, forms of necessary documents.
observation room it is intended for examination of patients by a doctor and, in addition, here the nurse conducts thermometry, anthropometry, examination of the pharynx, and sometimes other studies (ECG) for patients.
Examination room equipment:
A couch covered with oilcloth (on which patients are examined);
height meter;
Medical scales;
Thermometers;
Tonometer;
spatulas;
Sink for washing hands;
Desk;
Case history sheets.
treatment room It is intended for providing emergency care to patients (shock, visceral colic, etc.).
Treatment room equipment:
Couch;
Medical cabinet containing: anti-shock first aid kit, disposable syringes, disposable systems, anti-shock solutions, antispasmodics and other medications;
Bix with sterile dressing material, sterile tweezers in a disinfectant solution (for working with Bix);
Bix with sterile gastric tubes, rubber urinary catheters, enema tips.
Operational dressing room designed for small operations (PST of an accidental wound, reduction of dislocation, reposition of simple fractures and their immobilization, opening of small abscesses, etc.).
Sanitary checkpoint, his tasks include:
Sanitary treatment of sick and injured;
Acceptance of clothes and other things of patients, inventory of clothes and things and transfer to storage;
Issuance of hospital gowns.
For the treatment of seriously ill and injured, a bathroom with portable showers is provided. The sanitary checkpoint should have an appropriate set of toilets, sinks, shower rooms, provided for by sanitary standards, taking into account the possibility of a mass influx of victims. For the deceased in the emergency department, a room with a separate entrance should be allocated, where it is provided for the storage of several corpses for a short time (until the morning).
Responsibilities of the Admissions Nurse:
registration of a medical card for each hospitalized patient (filling in the title page, indicating the exact time of admission of the patient, the diagnosis of the referring medical institution);
examination of the skin and hairy parts of the body to detect pediculosis, measurement of body temperature;
fulfillment of doctor's orders.
Responsibilities of the Receptionist:
examination of the patient, determination of the urgency of performing a surgical intervention, the required volume of additional studies;
filling in the medical history, making a preliminary diagnosis;
determining the need for sanitary and hygienic treatment;
hospitalization in a specialized department with a mandatory indication of the type of transportation;
in the absence of indications for hospitalization, the provision of the necessary minimum of outpatient medical care.
A.V. Geraskin, N.V. Polunina, T.N. Kobzeva, N.M. Ashanina ORGANIZATION OF CARE OF CHILDREN IN A SURGICAL HOSPITAL Recommended by the Educational and Methodological Association for Medical and Pharmaceutical Education of Russian Universities as a teaching aid for students studying in the specialty 06010365 - Pediatrics Medical Information Agency Moscow 2012 UDC 616-08:616-053.2:617-089 BBK 51.1(2)2 G37 N.I. Pirogov” of the Ministry of Health and Social Development of the Russian Federation A.V. Geraskin - Head of the Department of Pediatric Surgery; Professor; N.V. Polunina - acting Rector, Professor of the Department of Public Health and Health; corresponding member RAMN; T.N. Kobzeva - Associate Professor of the Department of Pediatric Surgery; N.M. Ashanina - Associate Professor of the Department of Public Health and Health. G37 Geraskin A.V. Organization of care for children in a surgical hospital / A.V. Geraskin, N.V. Polunina, T.N. Kobzeva, N.M. Ashanina. - M.: Medical Information Agency LLC, 2012. - 200 p.: ill. ISBN 978-5-8948-1909-9 The textbook acquaints students who first crossed the threshold of a surgical hospital as medical workers with the organization and mode of operation of the pediatric surgical department, as well as with their job descriptions. The features of child care, the organization of therapeutic feeding of patients, the main medical manipulations in the children's surgical clinic are described. The final chapter is devoted to first aid. For medical students and surgeons. UDC 616-08:616-053.2:617-089 LBC 51.1(2)2 ISBN 978-5-8948-1909-9 © Geraskin A.V., Polunina N.V., Kobzeva T.N., Ashanina N. M., 2012 © Design. OOO "Medical Information Agency", 2012 All rights reserved. No part of this book may be reproduced in any form without the written permission of the copyright holders. Table of Contents Introduction.................................................................. ................................................. ........... 6 Chapter 1. The structure and organization of the work of the pediatric surgical clinic .............................. ......................................... 9 1.1. The structure and organization of the work of the reception ward.................... 9 1.1.1. Structure and mode of operation .............................................................. .. 9 1.1.2. Therapeutic-protective regime of the emergency room. .........23 1.1.3. Sanitary and hygienic regime of the emergency room.......23 1.1.4. The epidemiological regime of the emergency room .............................. 24 1.2. Structure and organization of work of a specialized ward department. Safety..............................................25 1.2.1. Structure and mode of operation .............................................................. ..30 1.2.2. Therapeutic and protective regime. Deontology................................................. ......................43 1.2.3. Sanitary and hygienic regime of the ward department .............................................. ..............47 1.2.4. Epidemiological regime of the ward department ..........56 1.3. Structure and organization of work of the operating unit..............................63 1.3.1. Structure and mode of operation .............................................................. ..63 1.3.2. Therapeutic-protective mode of the operating unit .............................................. ..............72 1.3.3. Sanitary and hygienic regime of the operating unit .............................................. ..............72 1.3.4. The epidemiological regime of the operating unit............................................................... ............74 1.4. The structure and organization of the work of the intensive care unit and intensive care.................................................................. .......................................81 4 Table of contents 1.4.1. Structure and mode of operation .............................................................. 1.4.2. Therapeutic and protective regimen of the intensive care unit and intensive care ............................................. 1.4.3. Sanitary and hygienic regime of the resuscitation and intensive care unit .............................................. 1.4.4. Epidemiological regime of the resuscitation and intensive care unit .............................................. 1.5. Structure and organization of work of a one-day hospital ........ 1.5.1. Structure and mode of operation .............................................................. 1.5.2. Therapeutic and protective regimen of a hospital for one day .............................................. .......... 1.5.3. Sanitary and hygienic regime of a hospital for one day ............................................. .......... 1.5.4. Epidemiological regime of a one-day hospital .............................................................. ........ 81 83 85 85 86 86 88 89 90 Chapter 2. Organization of care for children in a surgical clinic ............................ ........................................... 91 2.1. Age-related anatomical and physiological features of child care in a surgical clinic .................................................................................. 92 2.1.1. Personal hygiene of newborns and infants. ......... 92 2.1.2. Personal hygiene of infants and toddlers .............................................................. .............. 94 2.1.3. Personal hygiene of middle-aged and older children who are on a general regime .............................................. 95 2.1.4. Personal hygiene of patients on strict bed rest .............................................................. ................. 95 2.2. Peculiarities of child care in a pediatric surgical clinic.................................................................. .........................99 2.2.1. Personal hygiene of the child before the operation....................... 99 2.2.2. Peculiarities of child care after abdominal surgery ..............101 2.2.3. Peculiarities of care for children after operations on the organs of the chest cavity ....106 2.2.4. Peculiarities of care for urological patients ..........108 2.2.5. Peculiarities of care for traumatological and orthopedic patients .........................................................108 2.2. 6. Peculiarities of care in the intensive care unit .............................................................. .........113 Chapter 3. Organization of therapeutic feeding of patients in a children's surgical clinic .............................. .........................115 3.1. Organization of feeding of newborns and infants .............................................. ..............................115 3.2. Organization of therapeutic nutrition in older children .............................................. .............................................117 Table of contents 5 Chapter 4. Basic medical procedures for caring for children in a surgical clinic. ................................................. ..........120 4.1. Measurement of body temperature .............................................................. ......120 4.2. Administration of medicinal preparations..............................................124 4.2.1. Types of local treatment ............................................................... ....125 4.2.2. General treatment .................................................................. .................125 4.2.2.1. Enteral administration of drugs .............................................................. .............126 4.2.2.2. Introduction of drugs into the respiratory tract .......................... 127 4.2.2.3. Parenteral administration of drugs....................................127 4.3. Collection of analyzes .................................................. ...............................137 4.4. Determination of blood group and Rh factor .............................. .................................138 Chapter 5. Providing first aid to children .............................................. .142 5.1. Applying bandages. Desmurgy.................................................142 5.2. Stopping external bleeding...............................................149 5.3. Transport immobilization for fractures .........................................150 5.4. First aid for poisoning .............................................................. 153 5.5. First aid for fainting .............................................................. .....153 5.6. Prehospital cardiopulmonary resuscitation (closed heart massage, artificial respiration) ..................................154 Appendix................................................... ................................................. ..................................159 Test tasks .............................. ................................................. ...............................164 Literature .................. ................................................. .................................................194 Introduction 1st-2nd year students starting practical training in clinics , and then to their first production practice, should get acquainted with the structure and organization of work in a children's surgical clinic, issues of deontology of medical personnel, organization and requirements of safety and fire safety, medical and protective, sanitary-hygienic and epidemiological regimes, organization of care children. Without this, the successful work of the future doctor is impossible. Becoming full-fledged medical workers, students must comply with all requirements and legal provisions for working in medical institutions. The doctor must not only perform medical manipulations and follow job descriptions, but also must know, perform, control and be able to teach the rules of care for nurses and junior staff where he will work in the future. The quality of the examination of the patient, the timely diagnosis, the favorable course of the surgical intervention, the course of the postoperative period and recovery depend on properly organized care. Neglect or ignorance of the care of surgical patients can negate the results of the most brilliant and impeccably performed operations. The basic knowledge gained by students in the cycles: biology, chemistry, physics, anatomy, microbiology, physiology, pharmacology, etc., will be necessary to understand the basics of organizing medical and protective, sanitary and epidemiological sick children of all ages. It becomes clear that there is a need for further study of such basic disciplines as: social hygiene, healthcare organization, epidemiology, psychology, etc. A modern large children's clinic is a multidisciplinary institution that provides medical diagnostic, therapeutic and rehabilitation assistance to children with various diseases, both surgical and therapeutic, from the neonatal period to adolescence. Hospitals have long been and remain today the main clinical base for educating students and training future doctors. The modern system of providing medical care provides for the possibility of organizing consultative and diagnostic centers in large children's hospitals, trauma centers for providing outpatient care and specialized departments for hospitalizing patients. The Consultative and Diagnostic Center, equipped with modern equipment, provides highly qualified diagnostic and therapeutic assistance to children with various diseases. The structure of such a center includes the following departments: ultrasound and X-ray, computed tomography, radioisotope diagnostics, endoscopic, laboratory diagnostics. Treatment and diagnostic centers include departments: orthopedic, uronephrology, follow-up observation of newborns, ophthalmology, clinical genetics, cryotherapy, gastroenterology, etc. Medical care for children is provided free of charge upon presentation of a compulsory medical insurance policy (CMI). Round-the-clock emergency care for children is provided at the trauma center. Modern advances in pediatric surgery and anesthesiology have made it possible to open an outpatient surgery center or a one-day hospital to perform planned surgical interventions in children over 1 year old. The organization of the work of a modern pediatric surgical clinic is determined by the goal of providing emergency and planned diagnostic and therapeutic care to children both in outpatient and inpatient settings, the need for rehabilitation and aftercare. 8 Organization of childcare in a surgical hospital In connection with the requirements of the new Federal State Educational Standard for Higher Professional Education in the specialty of Pediatrics, in the process of undergoing educational practice in general childcare of a surgical profile, students should know: types of sanitization of sick children and adolescents, types of fevers, features of observation and care of sick children and adolescents with diseases of various body systems. Students should also be able to: sanitize the patient upon admission to the hospital and during the stay in the hospital, change the patient's underwear and bed linen, treat bedsores; provide care for patients of various ages suffering from diseases of various organs and systems, transportation; measure body temperature, daily diuresis, collect biological material for laboratory research, conduct anthropometry for children and adolescents, various types of enemas, conduct feeding; carry out disinfection and pre-sterilization preparation of medical instruments, materials and means of patient care. Students must have: the skills of caring for sick children and adolescents, taking into account their age, nature and severity of the disease; skills in caring for the seriously ill and agonizing patients. The production practice, carried out after the 1st year, as an assistant to junior medical personnel, should give students the following knowledge and skills. Know: the main stages of the work of junior medical personnel. Be able to: perform manipulations for the care of patients. After the 2nd course - assistant to the ward nurse. Know: the main stages of the work of a ward nurse. Be able to: perform the manipulations of a ward nurse. After the 3rd year - assistant procedural nurse. Know: the main stages of the work of procedural medical personnel. Be able to: perform the manipulations of a procedural nurse. Chapter 1 STRUCTURE AND ORGANIZATION OF THE WORK OF THE CHILDREN'S SURGICAL CLINIC The Children's Surgical Clinic is a complex of functional units designed to receive and keep patients in a hospital, provide them with medical surgical care, prepare for surgery, perform surgery and postoperative care for patients until recovery. The modern children's surgical clinic includes the following structural units: emergency room, specialized surgical departments (urological, orthopedic-traumatological, thoracic, abdominal, emergency and purulent surgery, newborns, planned, cardiological, etc.), functional diagnostic department, operating unit, department resuscitation and intensive care, housekeeping services. 1.1. Structure and organization of work of the emergency room 1.1.1. Structure and mode of operation Any hospital "begins" with the admissions department. The main tasks of the admission department are: 10 Organization of child care in a surgical hospital 1. Registration of documentation for incoming patients, organization of reception and registration of the movement of patients in the hospital as a whole. 2. Initial examination, triage and referral of patients to various departments of a medical institution or for outpatient treatment, provision of emergency outpatient care. 3. Sanitary treatment of patients entering a medical institution. 4. Communication with the ambulance station, FGUZ "Center for Hygiene and Epidemiology" and other medical institutions, notification of relevant institutions about injuries on the street and at home, issuing certificates of incoming patients. To carry out these tasks, the admission department must have qualified personnel, a rational layout, appropriate throughput, medical diagnostic equipment, and medicines. The reception department is located on the first floor with an isolated entrance for receiving patients, has good communication with the medical and diagnostic departments and provides good transportation of patients. Rice. Fig. 1. Half-box of the emergency room Chapter 1. Structure and organization of the work of the children's surgical clinic Pic. 2. Half-box of emergency room for newborns Pic. 3. Dressing room of the emergency room 11 12 Organization of child care in a surgical hospital The admission department includes three sets of premises: 1) general; 2) diagnostic and therapeutic; 3) sanitary pass. Common areas include: lobby, staff room, toilet, etc. Diagnostic and treatment rooms include: boxes for receiving both planned and emergency patients, a treatment room, a clean and purulent dressing room (Fig. 1–3). Sanitary pass includes: dressing room, bathroom and dressing rooms. Operating mode. In the work of the emergency room, a strict sequence is observed: registration of patients, medical examination and sanitization. 1. Registration of patients. For each hospitalized in the admissions department, they enter: a medical card of an inpatient - the main document of a medical institution (medical history) (Fig. 4, 5), a statistical card of a person who left the hospital (Fig. 6, 7), information about the patient is also entered in the admission log sick. All patient data is entered into a computer, an electronic medical record is created. The emergency room nurse fills out the passport part of the inpatient medical record: the child's last name, first name, patronymic, address, age, last name, first name, patronymic and parents' address, compulsory medical insurance policy data, which children's institution the child attends, date and hour of illness, date and hour hospital admissions. Particular attention should be paid to the accurate filling of the date and time of the disease in case of injuries, burns, poisoning, acute conditions requiring surgical treatment. The paperwork is completed with the signature of the child's relatives, certifying their legal consent to perform surgical interventions and various studies, the signature of the doctor and nurse of the emergency room (Fig. 8–10). 2. Medical examination. The duties of the emergency room doctor include making a preliminary diagnosis, assessing the severity of the patient's condition, prescribing an examination, determining the tactics of treatment (hospitalization, observation, emergency surgery, providing outpatient care, etc.) and issuing a medical card for an inpatient. It contains basic information about the patient: complaints, medical history, anamnesis of life with the obligatory indication of data on childhood infections and vaccinations, Chapter 1. Structure and organization of the children's surgical clinic 13 Pic. 4. Title page of the inpatient medical record (case history) 14 Organization of child care in a surgical hospital Pic. Fig. 5. Inner sheet of the medical record of an inpatient (case history) Chapter 1. Structure and organization of the work of a children's surgical clinic Pic. Fig. 6. Statistical map of a patient who left the hospital 15 16 Organization of child care in a surgical hospital Pic. Fig. 7. The reverse side of the statistical map of the patient who left the hospital Chapter 1. The structure and organization of the work of the children's surgical clinic Pic. Fig. 8. Consent of the child's parents to the operation 17 18 Organization of child care in the surgical hospital Pic. Fig. 9. The decision to conduct a medical intervention (operation) without the consent of the patient Chapter 1. The structure and organization of the work of the children's surgical clinic Pic. 10. Consent to anesthetic provision of medical intervention 19 20 Organization of care for children in a surgical hospital allergic reactions, blood transfusions, operations, contacts with infections (according to relatives), objective status. All admitted patients are subjected to thermometry. Emergency patients in the admissions department around the clock perform laboratory blood tests using express diagnostics to determine: the number of leukocytes, ESR, hemoglobin, hematocrit, blood coagulation, acid-base balance, blood sugar, bilirubin, potassium and sodium, prothrombin index. Patients who require emergency surgical treatment, determine the blood type and Rh factor. If necessary, an emergency X-ray and ultrasound examination is performed. Registration of a medical card of an inpatient patient ends with a preliminary diagnosis, appointment of a regimen, examination, treatment, indicating the method of transporting the patient to the department or operating room. The issue of the possibility of allowing the mother to care for the child is being decided (the mother must be healthy and must pass a stool test for the intestinal group to prevent the introduction of an intestinal infection into the department). On the medical card of an inpatient, the time of the patient's admission to the emergency room is noted, and then the time of transfer to the department. If the patient is receiving outpatient care in the emergency room, then detailed records are made in the outpatient register. If the child delivered by ambulance does not need hospitalization, he was provided with outpatient care, a surgical diagnosis was removed, the parents refuse the proposed hospitalization, the child is recorded in the register of admission of patients and refusals of hospitalization. For all patients released from the emergency room who were admitted with abdominal pain older than 3 years (children under 3 years of age are hospitalized without fail), if the diagnosis of acute appendicitis is excluded, an application is sent to the children's clinic for an active visit to the pediatrician at home the next day. Hospitalization in hospitals of patients in need of special inpatient examination and treatment is carried out around the clock in the direction of the doctors of polyclinics, ambulance and emergency departments. Patients with emergency diseases who applied to the emergency department on their own (spontaneous) are also hospitalized. Regardless of whether the children admitted to the hospital are hospitalized or not, they receive emergency care. Children under the age of one year are hospitalized with their mother. Relatives with an older child may be hospitalized if he is in serious condition and needs constant care. If the patient is delivered in an unconscious state due to an accident (traffic or domestic injury, poisoning, etc.), the victim is reported to the police department, and after the initial medical examination, if necessary, the child can be sent without sanitization to the intensive care unit or intensive care unit. therapy, operating room for emergency care. Hospitalization of planned patients - somatically healthy children - is carried out for surgical treatment for a previously established diagnosis (umbilical, inguinal hernia, varicocele, etc.) or for the second stage of treatment in a specialized department. Hospitalization of planned patients is carried out in the morning, in boxes isolated from emergency patients, in order to prevent nosocomial infections. The procedure for registering a planned patient includes checking the necessary documentation and analyzes specified in the permit for the operation (Fig. 11): i referral for hospitalization (referral for hospitalization, rehabilitation treatment, examination, consultation f.057 / y-04); i a detailed extract from the history of the development of the child on the onset of the disease, treatment and examination in a polyclinic, in addition, there should be information about the development of the child, all past somatic and infectious diseases (extract from the medical card of an outpatient, inpatient f. 027 / y) ; i certificate of contacts with infectious patients (valid for 3 days); i the conclusion of the pediatrician on the absence of contraindications for a planned operation; i compulsory medical insurance policy. All analyzes and studies are carried out on an outpatient basis and must comply with the age norm. The doctor of the emergency room, examining the child, must confirm the surgical diagnosis and the somatic health of the child. 11. Voucher for elective surgery Chapter 1. Structure and organization of work of the children's surgical clinic 23 no contraindications to anesthesia and elective surgery. A medical card of an inpatient is issued, the necessary sanitary and hygienic treatment is carried out, and the child is sent to the department. 1.1.2. Therapeutic and protective mode of the emergency room In the emergency room, the first acquaintance of a sick child with the medical situation and staff takes place, here he gets the first impression of the work of a medical institution. Parents with children of various ages seek medical help, from the neonatal period to adolescence. The excitement and anxiety of parents increases the fear of a sick child before a medical institution. The task of the medical staff of the emergency room is to inspire confidence, reassure not only the child, but also adults. Measures aimed at protecting the patient from negative emotions are taken from the first moment of his appearance in the hospital, from the emergency room to the operating room. A friendly, calm conversation with a child on abstract, understandable topics allows you to get in touch with him, calm him down, and distract him from the upcoming unpleasant moments of hospitalization and surgical intervention. A positive psychological attitude of the child will help further accelerate his recovery. 1.1.3. Sanitary and hygienic regime of the emergency room After a medical examination in the sanitary room of the emergency room, the child is hygienically treated. The air temperature in the room should not be below 25 °C. The patient undresses, a thorough examination of the skin and hair is performed. (It is necessary to exclude pediculosis, scabies, infectious rash, etc.). The examining couch should be rigid and covered with a sheet and diaper. The oilcloth of the couch is wiped with a rag moistened with a disinfectant solution after examining the patient. If pediculosis is detected, the patient's clothes are processed in a steam-formalin chamber, and the child's hair is cut and treated with insecticidal preparations, and put on a hospital gown. If the patient's condition allows, he is washed in a bath or shower at a temperature of 35-36 ° C. They cut the nails on the hands and feet (scissors boil for 15 minutes after treating each patient). 24 Organization of child care in a surgical hospital When the patient's condition does not allow taking a bath or shower, partial treatment is performed. The torso and limbs of the child are wiped with a towel moistened with warm water, paying special attention to the treatment of skin folds. The child changes into hospital or home cotton clothes (pajamas, a change of underwear, leather slippers). Sanitary treatment is carried out under the supervision of the nurse on duty of the admission department. Newborn babies are hospitalized in hospital gowns. In the department, a nursing mother is given a daily clean medical gown, comfortable changeable, homemade cotton clothes are needed. A patient with a medical card of an inpatient patient from the admission department to the ward is transported by a nurse or a nurse, depending on the severity of the general condition on foot, on a stretcher, on a wheelchair, on his hands or in an incubator and passes it to the guard nurse. The sanitary and hygienic regime of boxes and examination rooms corresponds to the regime of the ward department. It is necessary to regularly ventilate the premises, air conditioning, twice a day wet cleaning of the premises using disinfectant solutions. (See details in the section on the sanitary and hygienic regime of the ward. ) 1.1.4. Epidemiological mode of admissions In order to prevent the introduction and spread of nosocomial infection, it is necessary to separate flows and reduce contacts of emergency and planned patients to the maximum. Children with suspected surgical disease (acute appendicitis, etc.) with symptoms of a respiratory viral infection, intestinal infection, meningitis, chickenpox and other childhood infections can be admitted to the emergency room. It is necessary not only to make a correct diagnosis and determine the tactics of treating a sick child, but also to prevent infection of others. The admission department of the children's hospital must be boxed. Boxes should be 3-4% of the total number of beds. The most convenient for work are the individual Meltzer-Sokolov boxes, which include an anteroom, a ward, a sanitary unit, and a personnel lock. There is also a special box for hospitalization of newborns (Fig. 12). Chapter 1. Structure and organization of the pediatric surgical clinic 25 Pic. 12. Semi-box of the department of neonatal surgery The child is delivered to the box, where he is examined by a doctor for the first time, a preliminary diagnosis is made and the question of the need for hospitalization or outpatient emergency care is decided. If, during a medical examination, a concomitant infectious disease is detected in a patient, he is sent to a surgical boxed department. In the emergency room, they disinfect all the rooms through which the patient has passed, and all equipment with which he came into contact. An emergency notice filled out by a doctor is sent to the Center for Hygiene and Epidemiology. 1.2. Structure and organization of work of a specialized ward department. Safety precautions Each surgical department includes: wards for patients, a dressing room, a treatment room, a physiotherapy room, boxes for isolating patients with suspected concomitant infectious diseases. 26 Organization of child care in a surgical hospital: the office of the head of the department and the elder sister, the intern's room, canteen, canteen, playroom, toilets for patients and medical personnel, potty room, enema room, bathroom, clean and dirty linen, mother's room. The main part of the surgical department are the wards. According to the accepted standards, beds in the wards of surgical departments are placed at the rate of 7 m2 per bed. In children's surgical departments, there are wards for infants (half-boxes for 2–4 beds) (Fig. 13), younger (1–6 years old) and older (Fig. 14), a ward for intensive observation of seriously ill children. Children's institutions have specific requirements. 1. Prevention of nosocomial infection. To this end, 25% of isolation wards are provided for outbreaks of childhood infections and isolation of the sick, impassable ward sections and the possibility of their quarantine. 2. The possibility of evacuation within 15–20 minutes if necessary (a large number of elevators, wide stairs). 3. Allocation of special rooms for classes and games. 4. Allocation of about 20% of additional beds for mothers. Beds in specialized wards are functional or conventional with a spring net, for small children - with rising high nets, for newborns - transparent plastic incubators in the form of a "soap dish". Beds in the wards are placed so that the child can be approached from all sides. Bedside tables are placed between the beds, on which glasses and drinkers can stand. Inside the bedside tables you can store personal hygiene items, books, pencils, easy-to-clean toys. It is strictly forbidden to store food in bedside tables. A common table is set up in the ward, at which the doctor can fill out medical documentation, the sister can use it when distributing medicines, and in her free time, children can sit, study, play at it. A modern surgical department is equipped with a treatment room (Fig. 15), "clean" and "purulent" dressing rooms, which should be located at different ends of the department. For a dressing room with one table, an area of \u200b\u200b22 m2 is provided. In the dressing rooms, there must be a forced-air and exhaust Chapter 1. Structure and organization of the work of the children's surgical clinic Pic. 13. Half box for infants Fig. 14. Ward for older children 27 28 Organization of child care in a surgical hospital Pic. 15. Treatment room of the surgical department ventilation, transoms or air conditioning system, bactericidal lamps. The decoration of the premises and the hygienic regime in them are similar to those in the operating block. In the treatment rooms, blood is taken for analysis, jet intravenous infusions, systems for intravenous drip transfusion are assembled, and preparations are being made for intramuscular injections. Dressing and procedural nurses replenish used materials and medicines in the morning and prepare everything necessary for work at any time of the day until 10 am. Occupational safety of medical personnel and patients Fire safety In children's hospitals, safety rules must be observed especially strictly. All premises of the children's hospital are equipped with a centralized fire warning system, are regularly checked for the presence of fire extinguishing equipment, are equipped with personal life support equipment, and have evacuation schemes in case of emergencies. Medical personnel are regularly briefed. In the operating room, resuscitation and intensive care wards, procedural rooms Chapter 1. Structure and organization of the work of the children's surgical clinic 29 rooms, sterilization rooms, where a large number of electrical appliances are used, there are oxygen supply lines and cylinders with medical gaseous substances. In these rooms, for the purpose of fire safety, non-sparking electrical equipment is used, which is located at a height of 2 m from the floor level, the tightness of the oxygen supply is controlled, and it is forbidden to wear clothes made of synthetic materials. It is forbidden to smoke in the premises of children's hospitals. Electrical safety Electrical outlets, oxygen taps should be out of the reach of children. A large number of modern diagnostic and treatment equipment used in a modern hospital must be correctly connected and grounded according to the instructions. Wet cleaning and disinfection of premises should be carried out with electrical appliances turned off. Turning on and off electrical appliances should only be done with dry hands. Accident protection Both patients and medical personnel must be protected from accidents. Sharp and cutting objects, small parts of toys should be out of the reach of children. The design of windows in the wards should prevent the child from falling out. Children must be under the supervision of medical workers at all times; they are transported to other departments of the hospital for research only by medical personnel. All medicines and disinfectants should be stored in strictly designated places, out of the reach of children, and their misuse should be excluded. Medicines are administered strictly in accordance with the doctor's prescriptions, it is necessary to read the label, check the expiration date, calculate the dose. Instructions for working with medical instruments, medical products, and care items must be strictly observed. It is necessary to observe the rules for their storage, disinfection, sterilization and disposal, as well as protective measures. In the radioisotope diagnostics departments, the instructions for working with radioactive preparations, their storage and disposal must be observed, and the discharge of radioactive substances into the general sewer network is excluded. 30 Organization of care for children in a surgical hospital When operating X-ray equipment (X-ray, endovascular surgery, traumatology rooms), the rooms must have shielding from X-rays, the personnel work in special protective aprons and wear individual dosimeters, regularly undergo a medical examination. Infection protection Protection of patients from nosocomial infection is in compliance with the requirements of the sanitary and epidemiological regime. Medical workers of a surgical hospital who constantly have contact with the blood and other biological fluids of patients must strictly observe the rules for working with sterile gloves, avoid injury during manipulations in order to prevent infection with HIV, hepatitis C, syphilis, etc. All surgical medical personnel are vaccinated against hepatitis B. An essential protective measure is the maximum use of disposable medical items. 1.2.1. Structure and mode of operation When a patient is admitted from the emergency room, the ward nurse is obliged to clearly record the time of admission in the inpatient's medical record, check the quality of sanitary and hygienic treatment, the availability of all necessary documents, indicate the child's place in the ward, show the location of the dining room, toilet and playroom. The sister instructs the patient or relatives about the order of conduct in the department, the daily routine. The ward nurse writes down all admitted, and when discharged, all outgoing patients in the journal "Movement of Patients" of the department. Based on these data, the night shift of each department compiles a summary of the number of patients in the department on a given day, the number of free beds. Centrally, this information is transmitted to the emergency room of the hospital and to the central point of the ambulance station. The ward nurse draws up a card of an inpatient in the department: glues insert sheets for doctors' records, a temperature sheet (Fig. 20), available tests, starts a nursing appointment list (on a special form, the sister takes out during the whole day: the patient's temperature, diet, availability and the nature of vomiting and stool, urination, doctor's appointments) (Fig. 16-19). Chapter 1. Structure and organization of work of the children's surgical clinic Pic. Fig. 16. Appointment sheet of the department of neonatal surgery 31 32 Organization of child care in a surgical hospital Pic. 17. List of appointments of the ward surgical department Chapter 1. Structure and organization of the work of the children's surgical clinic Pic. 18. Appointment sheet of the intensive care unit 33 34 Organization of child care in a surgical hospital Pic. Fig. 19. The reverse side of the appointment sheet of the intensive care unit Chapter 1. The structure and organization of the work of the children's surgical clinic Pic. 20. Temperature sheet 35 36 Organization of care for children in a surgical hospital On the morning bypass at the bedside of patients, nurses report to the head and doctors about the condition of the patients, hand over the shift to the sisters. At the morning meeting in the office of the head, the data on duty are specified, comments are made, the readiness of patients for operations and the sequence of surgical interventions are determined. During the day, the middle and junior medical personnel perform their duties according to the schedule of the surgical department. After the morning round, the medical residents pass to the procedural nurse the medical records of the inpatient with intravenous prescriptions for the current day (jet and drip). The ward nurse checks the prescriptions after bypassing them, enters them into the list of prescriptions, receives all the necessary drugs from the head nurse and fulfills the prescriptions, controls the correctness of their execution. In the medical record of an inpatient patient, doctors always write prescriptions in a certain sequence: i the patient's regimen (strict bed rest, lying on a shield on his back, in an incubator at a certain temperature and humidity, under an oxygen tent, etc.); i diet (do not feed, fractional feeding indicating the amount of food and the number of meals, table A 6, etc.); i intravenous drip infusions; i intravenous jet, including transfusion of blood products; i intramuscular and subcutaneous injections; i enteral appointments; i hygienic bath; i change of linen; i stool (indicated if there was an enema); i urination (control of hourly diuresis); i vomiting; i tests that are taken the next morning. In the evening, patients are transferred to the night shift of nurses, who continue to carry out appointments (including intramuscular injections, intravenous infusions). The night shift of nurses monitors seriously ill patients, assists doctors on duty, checks appointments in the inpatient record and makes changes to the appointment list, prepares dishes for taking tests and submits applications for examinations and analyses. The procedural nurse of the ward department in the morning from 8 to 9 o'clock takes blood from a vein from patients for biochemical tests, and sends them to laboratory, determines the blood group. Then he prepares the treatment room for the current work (necessary medicines, syringes, intravenous infusion systems, sterile material). During the day, he performs appointments for patients: intravenous infusions, infusion therapy, in the presence of a doctor, conducts blood transfusions, intramuscular injections, prepares bix with dressing material (napkins, gauze balls, cotton balls, diapers) for sterilization. Conducts decontamination of used disposable syringes, transfusion systems and dressings before disposal, pre-sterilization processing and sterilization of instruments. By the beginning of the working day, the dressing nurse sets sterile tables with surgical instruments for dressings, prepares bixes with sterile dressings, assists doctors during dressing, supplies the necessary tools, sticks bandages on the seams, and applies medical dressings. Upon completion of the planned work, the dressing nurse conducts pre-sterilization preparation and sterilization of the used instruments, prepares the dressing material for sterilization, soaks the used materials and disposable medical supplies in a disinfectant solution before disposal. Sterile tables in treatment rooms and dressing rooms can be used in emergencies around the clock. Separate dressing rooms for "clean" and "purulent" patients are equipped in specialized departments. Work in the treatment room and dressing rooms is carried out with gloves. In dressing rooms, all efforts should be directed to the maximum reduction of microbes in the wound, reducing the possibility of their penetration into the wound, i.e. obey the laws of antiseptics. There are the following antiseptic methods: mechanical, physical, biological, chemical. Mechanical antiseptic methods consist in the primary surgical treatment of the wound, opening the abscess, washing the purulent cavities. Surgical treatment of the wound includes its dissection, excision of the edges, removal of non-viable tissues and contaminants. Physical methods include: wound drainage, irradiation (UVR), drying. Biological methods include the use of enzymatic preparations (trypsin, acetylcysteine, ribonuclease), as well as hyperimmune sera, gamma globulins, plasmas, toxoids to increase passive and active immunity in the wound in order to quickly cleanse necrotic tissues from necrotic tissues. Used for chemical antiseptics. 1. Inorganic compounds (halides, oxidizing agents, inorganic acids and alkalis, salts of heavy metals). Halides make up a large group of antiseptics used in surgery. This is an aqueous and alcoholic solution of Lugol, iodoform, iodonate. They are used to lubricate the edges of a wound. Oxidizing agents (hydrogen peroxide and potassium permanganate) are used when washing wounds, purulent cavities, and therapeutic baths. Silver nitrate (lapis) is used to treat the fungus of the navel, washing cavities, purulent wounds. 2. Organic compounds (alcohols, aldehydes, phenol, nitrofurans, dyes, organic acids). The most widely used in surgery was ethyl alcohol in the form of 70 and 96% solutions. It is used to disinfect hands, cutting tools. Formaldehyde is used to sterilize optical instruments and prepare a triple solution. Nitrofurans (furacillin, furadonin) are used to wash cavities and wounds. Widespread use for the treatment of small surfaces, skin abrasions found dyes - methylene blue, brilliant green. In modern surgery, complex chemicals (1% dioxidine) are used as antiseptics to wash wounds. The mode of operation and job descriptions of procedural and dressing nurses are equated to those of operating nurses. The work of medical personnel and the regimen of patients are subject to the daily routine of the surgical department 7.00–7.30 7.30–8.00 - lifting patients, measuring body temperature, airing the wards; - toilet of patients, cleaning the department, airing the wards; Chapter 1. Structure and organization of the work of the children's surgical clinic 8.00–9.00 39 - fulfillment of morning appointments, change of nurses and transfer of patients; 8.30–9.00 - preliminary examination by the ward doctor and the head of the department of seriously ill patients and newly admitted; 9.00–9.30 - breakfast of patients, morning conference of doctors; 9.30–11.00 - bypass of the attending physician; 10.00–14.00 - medical and diagnostic work (conducting research, operations, dressings, consultations, making appointments, receiving and discharging patients); 14.00–15.00 - lunch, second cleaning, airing the wards, bypassing the doctor on duty, transferring seriously ill patients on duty; 15.00–16.30 - rest; 16.30–17.00 - body temperature measurement, fulfillment of appointments; 17.00–19.00 - walks, visiting relatives, airing the wards; 19.00–20.00 - dinner, shift of nurses on duty and transfer of patients; 19.15–20.30 - fulfillment of evening appointments, bypassing the doctor on duty; twenty. 30–21.30 - basic cleaning, ventilation of the wards, evening toilet; 21.30–7.00 - sleep, night observation and care of the seriously ill. The work of each unit is determined by the job descriptions of medical personnel. The head of the department directly manages the activities of the staff, determines the direction of the work of the department as a whole, and bears full responsibility for the quality and culture of medical care for patients. The hospital resident (attending physician) is directly responsible for ensuring the examination, treatment and proper care of the patients entrusted to him. In clinical hospitals, professors, associate professors and assistants of departments, postgraduate students, residents, and interns take part in the examination and treatment of patients together with hospital doctors. Students take part in rounds of patients together with teachers. 40 Organization of care for children in a surgical hospital Nursing staff (nurses) under the guidance of a doctor performs appointments and provides care for the patient. The head nurse reports to the head of the department and the head nurse of the hospital. She is subordinated to the middle and junior medical staff of the department. The hospital nurse (guard) is one of the central figures in the surgical department, a junior colleague of the doctor. She reports directly to the resident doctor and the head nurse of the department, and during duty - to the doctor on duty. In her subordination are junior nurses to care for the sick and nurses-cleaners of the wards. Job description of a nurse 1. General provisions 1.1. The nurse belongs to the category of specialists. 1.2. A nurse is appointed to a position and dismissed by order of the head of the institution. 1.3. The nurse reports directly to the head of the department / senior nurse of the department. 1.4. A person who meets the following requirements is appointed to the position of a nurse: secondary medical education in the specialty "Nursing". 1.5. During the absence of a nurse, his rights and obligations are transferred to another official, which is announced in the order for the organization. 1.6. The nurse should know: - the laws of the Russian Federation and other regulatory legal acts on health issues; - the basics of the treatment and diagnostic process, disease prevention; – organizational structure of healthcare institutions; – safety rules for working with medical instruments and equipment. 1.7. The nurse is guided in her activities by: - legislative acts of the Russian Federation; – The Charter of the organization, the Internal Labor Regulations, other regulatory acts of the company; - orders and directives of the management; - this job description. Chapter 1. The structure and organization of the work of the pediatric surgical clinic 41 2. The duties of a nurse The nurse performs the following duties. 2.1. Carries out all stages of the nursing process when caring for patients (initial assessment of the patient's condition, interpretation of the data obtained, care planning, final assessment of the achieved result). 2.2. Timely and qualitatively performs preventive and medical-diagnostic procedures prescribed by the doctor. 2.3. Assists in the doctor's treatment and diagnostic manipulations and minor operations in outpatient and inpatient settings. 2.4. Provides emergency first aid for acute illnesses, accidents and various types of disasters, followed by a doctor's call to the patient or referral to the nearest medical institution. 2.5. Introduces drugs, anti-shock agents (with anaphylactic shock) to patients for health reasons (if the doctor cannot arrive in time to the patient) in accordance with the established procedure for this condition. 2.6. Informs the doctor or the head, and in their absence the doctor on duty, of all detected serious complications and diseases of patients, complications resulting from medical manipulations, or cases of violation of the internal regulations of the institution. 2.7. Ensures proper storage, accounting and write-off of medicines, compliance with the rules for taking medicines by patients. 2.8. Maintains approved medical records and reports. 3. Rights of a nurse A nurse has the right to: 3.1. Receive the information necessary for the accurate performance of their professional duties. 3.2. Make suggestions to improve the work of a nurse and the organization of nursing in the institution. 3.3. Require from the head nurse of the department to provide the post (workplace) with equipment, equipment, tools, care items, etc., necessary for the quality performance of their functional duties. 42 Organization of child care in a surgical hospital 3.4. Improve their qualifications in the prescribed manner, undergo certification (re-certification) in order to assign qualification categories. 3.5. Participate in the work of professional associations of nurses and other public organizations not prohibited by the legislation of the Russian Federation. 4. Responsibility of a nurse The nurse is responsible for: 4.1. For non-performance and / or untimely, negligent performance of their duties. 4.2. For non-compliance with current instructions, orders and orders to maintain the confidentiality of information. 4.3. For violation of the internal labor regulations, labor discipline, safety and fire safety rules. Job description of a junior nurse for patient care 1. General provisions 1.1. Nursing assistant refers to junior medical staff. 1.2. A person who has a secondary general education and additional training in the courses of junior nurses for patient care is appointed to the position of a junior nurse for patient care. 1.3. The junior nurse for patient care is appointed and dismissed by the chief physician. 1.4. The junior nurse for patient care should know: - techniques for conducting simple medical manipulations; - rules of sanitation and hygiene of patient care; – internal labor regulations; – rules and regulations of labor protection, safety and fire protection; - ethical standards of behavior when communicating with patients. 2. Responsibilities Junior nurse for patient care: 2.1. Assists in the care of patients under the guidance of a nurse. Chapter 1. Structure and organization of the children's surgical clinic 43 2.2. Carries out simple medical manipulations (setting cans, mustard plasters, compresses). 2.3. Ensures cleanliness of patients and rooms. 2.4. Monitors proper use and storage of patient care items. 2.5. Makes a change of bed and underwear. 2.6. Participates in the transportation of seriously ill patients. 2.7. Monitors compliance by patients and visitors with the internal regulations of the healthcare facility. 3. Rights Nursing assistant has the right to: 3.1. Submit proposals on issues related to their activities for consideration by their direct management. 3.2. Receive from the specialists of the institution the information necessary for the implementation of their activities. 3.3. Require the management of the institution to assist in the performance of their duties. 4. Responsibility The junior nurse for patient care is responsible for: 4.1. For improper performance or non-performance of their official duties provided for by this job description, to the extent determined by the labor legislation of the Russian Federation. 4.2. For offenses committed in the course of carrying out their activities - within the limits determined by the administrative, criminal and civil legislation of the Russian Federation. 4.3. For causing material damage - within the limits determined by the current legislation of the Russian Federation. 1.2.2. Therapeutic and protective regime. Deontology The mode of the children's surgical hospital should be organized in such a way as to provide the patient with peace. Everything that can frighten or excite the child should be avoided. The medical-protective regime includes the following elements: 1) transformation of the external hospital environment; 2) prolongation of physiological sleep; 44 Organization of care for children in a surgical hospital 3) elimination of negative emotions and pain; 4) combination of rest mode with physical activity; 5) formation of a positive emotional tone. The transformation of the external hospital environment begins with the creation of a cozy environment: clean bed linen, walls painted in light soft colors, paintings with stories from fairy tales, toys, organization of playrooms. All visual stimuli must be eliminated. Noise control is of the utmost importance in transforming the hospital environment. All staff should speak quietly, telephones should be placed away from the wards, and staff should wear noiseless replacement shoes. Of paramount importance for recovery is a long and full sleep (9 hours at night and 2 hours during the day). At this time, silence should be observed, ventilation of the premises. The windows in the children's departments are opened in such a way that the child could not accidentally fall out of them. During the hours of daytime and nighttime sleep, it is prohibited to clean the premises and carry out medical procedures, except for emergency. The mode of the surgical patient is determined by the attending physician as: i strictly bed rest. The patient lies in bed in a certain position, which is changed by medical personnel. Active rotation of the body is prohibited. Meals and physiological administration are carried out with the help of staff. Breathing exercises and dosed exercise therapy; i bed rest. It is recommended to turn on your side and take a comfortable position. Individuals are allowed to get up in bed, lower their legs, get up and go to the toilet with the help of staff. Moderate exercise therapy. i semi-bed rest. They are allowed to get out of bed several times a day, leave the ward for the dining room and the toilet. Increasing the volume of exercise therapy. i general mode. Staying in bed is limited to the internal daily routine. Walks, classes, games are recommended. Measures aimed at protecting the patient from negative emotions are taken from the first moment of his appearance in the hospital, from the emergency room to the operating room. A friendly, calm conversation with a child on abstract, understandable topics allows him to get in touch with him, calm him down, distract him from the unpleasant moments of hospitalization and surgical intervention. Much attention is paid to the fight against pain: all manipulations are performed under local or general anesthesia. Before the operation, sedatives are prescribed. Some of the pain associated with the disease can be eliminated or reduced. To do this, you need to create “bed comfort” for the patient: it is convenient to put him in bed, given the nature of the disease, change or correct the bandage in time, apply heat or cold. For recovery, it is important not only to create a sparing regimen for the patient's nervous system by providing him with rest, but also training, which should be started as early as possible from the onset of the disease. Massage and physiotherapy exercises are individually assigned. An important feature of the organization of the work of the departments of the children's hospital is the need to carry out educational work there with sick children who are treated in the hospital for a long time. To do this, children's hospitals are allocated the position of a teacher-educator, whose functions include organizing games and school activities, walking in the fresh air in the hospital park. The staff should organize the leisure of patients. Of no small importance in creating a favorable psychological climate in the hospital department is medical deontology. Medical deontology (deon - due) is the doctrine of the principles of behavior of medical personnel. In recent years, due to the technicalization of examination and treatment, some scientists have warned about the danger of dehumanization of medicine and the disappearance of the necessary psychological climate in communication between the doctor and patients. Surgery is not limited to science and technology. Surgery reaches the heights of its capabilities only when it is adorned with the highest manifestations, disinterested care for a sick person and, at the same time, not only about his body, but also about the state of his psyche (N. N., 1946). A humane attitude towards the patient, love for one's profession should be the main features of a medical worker. The appearance and behavior of a medical worker should maintain a high prestige of the profession, an atmosphere of goodwill and mutual assistance should be constantly cultivated in the hospital. Pointless disputes, disrespect, mutual insults are incompatible with work in a medical institution. Doctors should set an example of intelligent treatment of people - colleagues, patients and their relatives. Rough speech, vulgarism, inappropriate laughter and, to be honest, sometimes the vulgarity of some doctors serve as evidence of their insufficient education and discredit the face of medical workers. Working with sick children is difficult, because illness and suffering change the psyche, uncertainty, isolation from parents, oppress the child. A child of any age with a surgical disease accompanied by pain, separated from his parents, in an unfamiliar place, under the threat of an unknown surgical intervention, always experiences a stressful state. The child's perception of the external world is sharper, the reaction to external stimuli is often excessive. Some children become quick-tempered, unbalanced, capricious. In a medical institution, the child must meet the constant friendliness and friendliness, only in this case the treatment will be accompanied by an element of psychotherapy. The attitude of the staff should not injure the patient and should not be the cause of a new iatrogenic disease. Most often, the cause of iatrogenic disease is an unsuccessful or inappropriate statement in the presence of a patient or a medical document that accidentally got to him. Even the Hippocratic Oath provides for the preservation of medical secrecy. To prevent iatrogenesis in the hospital, to prevent unfounded complaints, the following rules have been established: i middle and junior staff and students are not allowed to enter into discussions with patients and their parents about the appropriateness of the prescribed treatment, about the possible outcome of the disease or operation; i no one other than the attending physician is allowed to tell the patient the diagnosis; i medical records of the inpatient and the results of laboratory tests are stored in such a way that the patient could not get acquainted with their content; i information about the state of health of the child is given by the attending physician only during personal contact with the parents, it is prohibited to provide information by phone. Analysis Chapter 1. Structure and organization of the work of the children's surgical clinic 47 diseases during the bypass of the professor, assistant or head of the department are carried out outside the ward. It is not recommended to make comments to medical workers in the presence of patients, as the latter may exaggerate the significance of the mistake made and be frightened. In addition, such remarks undermine the authority of the nurse and further deprive her of the opportunity to have a psychotherapeutic effect on the patient. The relationship between healthcare workers and parents is of no small importance. Parents, not without reason, consider each operation for their child to be difficult. There is a special group of parents that requires increased attention: parents who have lost a child earlier and are deeply traumatized by the misfortune they have suffered; elderly parents with an only child; a mother unable to have another child. These parents react sharply to any deviation in the normal course of the disease in a child. Some parents read specialized literature, know medical terms, but without special knowledge, are prone to dramatization and increased anxiety, which can adversely affect the child's well-being. It is impossible to bring to the attention of parents everything that was said and discussed by doctors on rounds, if it was not intended for parents. It is also impossible to make information about this or that child the property of other parents. In no case should the mother be entrusted with even the simplest manipulations. The parents of the child have the right to refuse any medical manipulation. However, the duty of the medical worker is to explain the need for these manipulations and the consequences that may result from refusing to perform them. Parents should receive exactly the information that can influence their decision, and this information should be presented in a form that is easy to understand. Students, from the moment they start their studies at the clinic, including evening practice, become "medical workers" who are subject to all legal requirements. 1.2.3. Sanitary and hygienic regime of the ward department The sanitary and hygienic regime of any medical and diagnostic unit of the hospital covers compliance with the requirements: 48 Organization of child care in a surgical hospital i hygiene of medical personnel (the strictness of its implementation is determined by the mode of operation of each department); i hygiene of a sick child and relatives caring for him; i hygiene of premises, equipment, environment. Clinical hygiene of medical personnel is obliged to ensure: prevention of infectious diseases and infectious surgical complications in patients, prevention of infection with nosocomial infection of medical personnel and those in contact with them outside the hospital. The main objects of personal hygiene of the personnel in the children's surgical clinic are: the body, secretions, clothing, personal items, premises. Knowledge and ability to comply with the basic hygienic requirements for the state of the body of the medical staff (student) is especially necessary in a pediatric surgical clinic. This also dictates the need for regular preventive examinations and sanitation of medical personnel, the need for preventive examinations and registration of a medical book for students. The theoretical foundations for the appointment and rules for wearing medical hygienic clothing (gown, uniform, personal underwear, caps, masks, shoes) are necessary for the student in order to comply with them and further control them in the process of medical activity. The personal hygiene of medical personnel involves keeping the body clean, hair should be neatly combed, and nails trimmed short. Nail polish is not recommended. Rings must be removed during operation. Perfume and cologne should be used in moderation, and only those that have a mild smell. Moderation in the use of cosmetics and various decorations is dictated by the very nature of the activities of medical personnel. The clothing of the medical staff of the surgical clinic consists of a suit (trousers, short-sleeved shirt or cotton dress) and a gown. The sleeves of the bathrobe are wrapped in such a way that they do not interfere with washing hands. Replaceable shoes should be chosen comfortable, not restricting the foot, not with high heels, silent, it should be easy to wash. When working in the operating room, disposable or cloth shoe covers are put on over the shoes. To work in the treatment room, dressing rooms, operating rooms, medical personnel must wear a cotton or disposable cap and a medical mask. Each department of the hospital has a room with individual lockers for changing clothes for staff in work clothes. When working in a pediatric surgical clinic, students are allowed to work in clean white coats that completely cover personal clothing. You cannot use gowns in which classes were held at the departments of anatomy, microbiology, etc. Personal clothing should be comfortable and clean. Woolen things are removed when working in surgical departments. Replacement shoes are noiseless, always leather. Hand care requires special attention to prevent nosocomial infection. Medical personnel should wash their hands not only before eating and after going to the toilet, but also before and after each medical procedure, before and after each examination of a sick child. To prevent reseeding of microflora, washbasins are equipped with elbow taps, so that they are not taken first with dirty and then with clean hands. For handwashing, use liquid disinfectant soap or finely chopped disposable soap bars. Hands are dried with disposable towels. Hand treatment technique by the staff of the surgical clinic All methods of hand treatment begin with mechanical cleaning - washing hands with soap or various solutions (Fig. 21). First, they wash the palmar, then the back surface of each finger, the interdigital space and the nail bed of the left hand. Similarly wash the fingers of the right hand. Then they sequentially wash the palmar and dorsum of the left and right hand, left and right wrist, left and right forearm (up to the border of the middle and upper thirds). Wipe the nail beds again. In conclusion, the foam is washed off with a jet from the fingers to the elbow, without touching the forearms with the brushes. The water tap is closed with an elbow. After treatment, the hands are wiped with napkins sequentially, starting with the fingers and ending with the forearms. Medical personnel of surgical, resuscitation and obstetric hospitals must strictly protect their hands from contamination. Wash floors, clean the sanitary unit in the apartment, 50 Organization of child care in a surgical hospital Fig. 21. The appearance of the sink for washing hands by the personnel of the surgical department to work in the garden and vegetable garden, clean vegetables with gloves. Frequent washing of hands leads to dry skin, so it must be constantly nourished, lubricated daily after work and at night with cream. In order to prevent the reseeding of microflora by medical staff when working with patients in the departments of neonatal surgery, neonatology, resuscitation and intensive care, along with hygienic treatment of hands, personnel disinfect with skin antiseptics. Manuzhel is applied to the hands at least 3 ml and rubbed into the skin until dry, but not less than 30 seconds before each examination and any manipulation. Sterile medical gloves must be used when working with personnel in the treatment room, dressing room, operating room, when working with blood. In cases where a child sick or infected with HIV, congenital syphilis, hepatitis C is transferred to the surgical department for emergency indications, it is necessary to strengthen measures for the sanitary and hygienic protection of personnel, other patients and the environment from infection. Chapter 1. Structure and organization of the work of the children's surgical clinic 51 All staff with a sick child work only in medical gloves (it is necessary to monitor their integrity, avoid punctures and cuts), use disposable syringes, medical products and care items. Used disposable products are soaked separately from others in disinfectant solutions before disposal. Bed linen, diapers after use are subject to mandatory soaking in disinfectant solutions. The patient is allocated personal utensils for food, bottles for milk and water. After use, they are also soaked separately from the rest of the dishes in disinfectant solutions and sterilized in a dry-heat cabinet. Surgical instruments used in the treatment of such a child are thoroughly disinfected and sterilized with the obligatory amidopyrine test. The medical staff of the surgical clinic is vaccinated against hepatitis B. Sanitary and hygienic treatment of the ward Each ward should have a sink for washing, a mirror, a container for used diapers. It is necessary to maintain exemplary order in the wards, it must be comfortable, spacious, light and clean. The walls in the wards are painted with light oil paint. In the evening, the wards are illuminated by electric lights. Nightlights are provided for lighting at night. Based on the tasks of creating an optimal microclimate and preventing secondary infection, the requirements for lighting, heating, and ventilation of the premises of a surgical hospital are determined. The optimum temperature in the wards is about 20 °C, in the dressing room and bathrooms it is slightly higher - 25 °C. Sunlight has a beneficial effect on the vital activity of the human body, a detrimental effect on pathogens. Chambers should be well lit, oriented to the southeast or southwest. The optimal ratio of the window area to the floor area in the wards is 1: 6, the dressing room is 1: 4. The optimal relative humidity is 55–60%. Good ventilation is an indispensable condition for the maintenance of the ward. The most perfect ventilation is achieved by air conditioning units with bacterial filters. Re- 52 Organization of care for children in a surgical hospital regular ventilation of the room significantly reduces the microbial contamination of the air. Air exchange should be at least four times per hour. The hygienic norms of air in the ward per patient are 27–30 m3. In the wards, supply and exhaust ventilation with the use of air filters should be used. Types of cleaning of the surgical hospital include daily, twice a day wet cleaning of rooms and equipment, current cleaning after dressings. It is expedient to carry out a one-time box laying of patients with a general cleaning of the premises after all patients have been discharged from the box. Cleaning should always be damp, using a soap and soda solution. Wet cleaning equipment (bucket, mop, rag) is marked, used only for a specific room, disinfected after use and stored in a special room. After each patient is discharged, the bed and bedside table are wiped with rags abundantly moistened with a disinfectant solution and covered with clean linens. General cleaning of the department is carried out weekly. The room is previously freed from equipment and inventory, tools. The room and all equipment are wiped with a sterile rag, abundantly moistened with a disinfectant solution, or irrigated from a hydraulic console. The equipment is wiped, then the room is closed and after one hour it is washed with water and rags. When cleaning, the staff puts on clean gowns, shoes, masks. After disinfection, the room is irradiated with ultraviolet light, including bactericidal irradiators for 2 hours. The sanitary service of the hospital regularly flushes equipment, rooms, air intakes, controlling the quality of cleaning. In the intensive care units, surgery and therapy of newborns, maternity hospitals, in order to prevent nosocomial infections, general cleaning, maintenance and disinfection were introduced twice a year for 2 weeks with mandatory bacteriological control in the future. Disinfection Disinfection is the second most important measure for the prevention of nosocomial infection after sanitization. For the purpose of air disinfection, irradiation is used. The bactericidal lamp is turned on in the dressing room one hour before the start of the operation or dressing, during breaks, after the end of the procedures and after cleaning. Germicidal lamps should not be turned on while people are indoors, as this can lead to radiation burns. Chemical disinfectants are widely used for the treatment of premises, inventory, equipment, tools, anesthesia and breathing apparatus, personnel hands and gloves, used syringes, dressings, disposable underwear, patient care items. They also process sanitary facilities, laboratory and food utensils, toys, shoes, ambulances, etc. Currently, a large number of disinfectants are commercially produced, each of which has its own instructions for use. They are subject to a number of requirements: a wide range of bactericidal action, the absence of toxic effects on humans, the absence of a damaging effect on tools and devices, rubber products. The mode of operation of disinfectants is determined by the scope of their application (tools, room surfaces, medical devices, medical waste, care products) and instructions for use. Disinfection is carried out by wiping, irrigation, soaking, immersion. Instrument disinfection. Domestic and imported disinfectants are used: amixan, disinfectant-forward, aniozyme DD1, which have antimicrobial activity against various gram-negative and gram-positive microorganisms, including pathogens of nosocomial infections (Escherichia and Pseudomonas aeruginosa, staphylococcus, streptococcus, fungi of the genus Candida, hepatitis viruses , HIV, adenovirus, etc.). The mode of disinfection combined with pre-sterilization cleaning of medical devices (instruments, endoscopes, devices for anesthesia and breathing equipment, etc.) includes the following steps. 1. Soaking at a temperature not lower than 18 ° C with complete immersion for 15-60 minutes in a working solution (from 1.2 to 3.5%) and filling it with cavities and channels of products (glass, metal, plastic, rubber) , such as endoscopes and instruments for them, anesthetic and breathing apparatus, anesthetic hoses. The concentration of the solution and the duration of exposure depend on the drug and the type of product and are indicated in the instructions for use. 2. Washing each product in the same solution in which soaking was carried out with a brush, brush, napkin, product channels, using a syringe for 1–3 minutes. 3. Rinsing with running water (channels with a syringe) - 3 min. 4. Rinsing with distilled water - 2 min. For similar purposes, disinfectants can be used: diabac, mistral. The quality of pre-sterilization cleaning of medical devices is controlled by setting an amidopyrine or azopyrine test for the presence of a residual amount of blood. Disinfection of medical waste is carried out in order to prevent nosocomial infections and environmental contamination. Single-use medical products (syringes, needles, blood transfusion systems, gloves, probes, etc.), dressings, disposable underwear, etc., are soaked in solutions before disposal: amixan 2% - 30 min, hypostabil 0.25% - 60 min. Disinfection of reusable waste collectors is carried out daily (amiksan 0.5% - 15 min), disinfection (between) body containers for collecting medical waste, car bodies is carried out according to the mode of surface treatment by wiping or irrigation. Disinfection of surfaces in rooms (floor, walls, etc.), furnishings, beds, couveuses, surfaces of apparatuses, instruments, equipment, ambulance transport is carried out by wiping with a rag soaked in a solution of the agent at a consumption rate of 100 ml / m2 of the surface. Washing off the working solution of the agent (amiksan) from the surfaces after disinfection is not required. Processing of objects by irrigation is carried out using special equipment, achieving uniform and abundant wetting. The consumption rate of the product for irrigation is 300 ml/m2 (hydraulic control, automax) or 150 ml/m2 for spraying (quasar). Excess disinfectant after application by irrigation is removed with a rag. Patient care items, toys are immersed in a solution of the product or wiped with a rag moistened with a solution (amik-Chapter 1. Structure and organization of the work of a children's surgical clinic 55 dignity 0.25% - 15 min). At the end of the disinfection exposure, they are washed with water. The dishes are freed from food debris and completely immersed in a disinfectant solution (amiksan 0.25% - 15 minutes) at the rate of 2 liters per 1 set. At the end of disinfection, the dishes are washed with water for 5 minutes. Laboratory glassware is disinfected by soaking in 0.5% amixan solution for 15 minutes. Sanitary equipment (baths, sinks, toilet bowls, vessels, pots, etc.) is treated with a solution of the agent (amiksan 0.25% - 15 min) with a brush or ruff, after disinfection it is washed with water. The consumption rate of the agent by the wiping method is 100 ml/m2, by the irrigation method - 150–300 ml/m2 of the surface. Cleaning material (mops, rags) is soaked in a solution of the product (amiksan 0.5% - 15 minutes), after disinfection, rinsed and dried. For the treatment of surfaces associated with blood, and for general cleaning of the premises, solutions are used: diabac 3.5% - 60 minutes, amixan 1% - 60 minutes, disinfection forward 0.5% - 60 minutes (wiping, irrigation). Precautions Persons under 18 years of age, persons with hypersensitivity to chemicals and chronic allergic diseases are not allowed to work with disinfectants. Contact of means and working solutions with mucous membranes, skin, eyes is not allowed. Containers with a solution of the agent must be tightly closed. All work with the agent and working solutions must be carried out with the protection of hands with rubber gloves. Disinfection of indoor surfaces by wiping can be carried out without personal respiratory protection equipment and in the presence of patients. When treating surfaces by irrigation, it is recommended to use personal protective equipment: for hands - rubber gloves, respiratory organs - universal respirators and eyes - sealed goggles. At the end of the disinfection by the method of irrigation in the room, it is recommended to carry out wet cleaning and ventilation. 56 Organization of child care in a surgical hospital When carrying out work, it is necessary to observe the rules of personal hygiene. Smoking, drinking and eating is prohibited. After work, open areas of the body (face, hands) should be washed with soap and water. In case of leakage or spillage of the product, collect it with a rag, cleaning must be carried out in rubber gloves and rubber shoes. Measures to protect the environment must be observed: do not allow undiluted product to enter surface or ground water and sewage. Disinfectants are stored in special cabinets and rooms out of the reach of children, and separately from medicines to prevent their accidental misuse. First aid measures in case of accidental poisoning Amixan is not dangerous, but if precautions are not followed, irritation of the mucous membranes, respiratory organs (dryness, sore throat, cough), eyes (lacrimation, pain in the eyes) and skin (hyperemia, swelling) is possible. If signs of irritation of the respiratory system appear, work with the product should be stopped, the victim should be immediately removed to fresh air or transferred to another room, and the room should be ventilated. Rinse mouth and nasopharynx with water; subsequently prescribe rinsing or warm-moist inhalations with a 2% solution of sodium bicarbonate. If the drug enters the stomach, give the victim a few glasses of water with 10-20 crushed activated charcoal tablets to drink. Do not induce vomiting. If the product gets into the eyes, immediately rinse them with plenty of water for 10–15 minutes, drip a 30% solution of sulfacyl sodium and immediately consult a doctor. In case of contact with the skin, it is necessary to wash off the product with plenty of water and lubricate the skin with a softening cream. 1.2.4. The epidemiological regime of the ward department The working conditions of a modern children's surgical clinic, where the most complex surgical interventions are performed, including in newborns requiring intensive care regimen and prevention of both introduction from outside and the development of nosocomial infection. When people stay indoors for a long time, the microclimate changes, the content of water vapor in the air increases, its temperature rises, unpleasant odors appear, and bacterial pollution of the air and the room increases. A sick child is a source of bacterial pollution of the environment. Used in modern children's surgical and intensive care units, antibacterial drugs lead to the emergence of hospital highly pathogenic strains of microorganisms. Colonization of newborns with hospital strains occurs on the 3rd–4th day of hospital stay, in adults - on the 7th–10th day. In the children's surgical clinic, a large number of surgical interventions are performed, including minor surgery (suturing wounds, opening boils and abscesses, etc.), injections, transfusions of blood products. There is a need to organize strict sanitary and epidemiological measures to prevent infections spread through the blood (HIV, hepatitis, syphilis, etc.) both among patients and among staff. The organization of disinfection and disposal of medical waste is necessary to prevent environmental contamination and outbreaks of infectious diseases. In connection with the foregoing, the most stringent requirements are imposed on compliance with the epidemiological regime in a children's surgical hospital, implemented in three areas: 1) medical examination of personnel; 2) rational placement of patients; 3) organizing the cleaning of the department. The doctor must not only perform medical manipulations and follow job descriptions, but also know and be able to teach the rules of disinfection and sterilization of nurses and orderlies where he will work, control the correctness of their implementation. The placement, layout, structure of the work of a children's surgical hospital is subject to one requirement - the prevention of nosocomial infections and purulent complications in surgical patients. Strict isolation is carried out at the reception and placement of planned and emergency patients, patients with purulent surgical infection, the allocation of departments for newborns. The structural subdivisions of each ward department (ward, catering unit, sanitary room, “clean” and “dirty” linen, procedural, etc.) have their own requirements for the sanitary and epidemiological regime of work. Particularly stringent requirements are imposed on the operating unit, dressing rooms, intensive care units and neonatal surgery. The use of disposable syringes, fluid transfusion systems, probes and catheters, and care items plays a significant role in the prevention of nosocomial infection. Different departments of the surgical clinic require different quality levels of sanitary and epidemiological treatment: sanitization, disinfection, asepsis (sterilization). Etiology of nosocomial infection. Clinical studies have shown that there are no specific causative agents of surgical infection. Microorganisms that can be isolated from a purulent-inflammatory focus are a wide range of opportunistic and even saprophytic bacteria. Some of these microorganisms are permanent representatives of the human endogenous flora, such as Staphylococcus epidermidis, Streptococcus fecalis, or Escherichia coli. Other pathogens are found intermittently in people (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas aeruginosa, etc.). Staphylococci. Streptococci. The natural habitat of the coccal flora (staphylococcus, streptococcus) in humans is the anterior parts of the nasal cavity. Due to the ability to form capsules under adverse conditions, these microorganisms are well preserved in the external environment. They tolerate drying well and remain viable in dry dust for a long time. Direct sunlight only kills them after a few hours. On the walls of hospital wards and windows, these microorganisms retain their viability for up to 3 days, in water for 15–18 days, and on woolen fabrics for about 6 months. When heated to 70–80 °C in a liquid, they die within 20–30 min. Disinfectant solutions in working concentrations have a detrimental effect on them (chloramine - 5 minutes, phenol - 15 minutes, sublimate - 30 minutes). The contamination of pathogenic coccal flora of environmental objects is closely related to the degree of human contact with these objects. Chapter 1. Structure and organization of the work of the children's surgical clinic 59 It has been established that the source of coccal infection is a person (a patient or a bacteriocarrier). Of great epidemiological importance is the bacteriocarrier of pathogenic coccal flora by medical personnel. This leads to the constant release of bacteria into the external environment and the secondary contamination of the skin, hair, clothes of the bacteriocarrier and the surrounding objects. Enterobacteria (E. coli, Klebsiella, Pseudomonas aeruginosa, Proteus, etc.) are Gram-negative rods widely distributed in nature. Many types of enterobacteria are inhabitants of the intestine. Hospital pathogenic strains can accumulate and even multiply in places of high humidity (sinks, taps, soap dishes, wet towels, etc.), in some solutions. Epidemiological significance in the spread of gram-negative infection is a violation of the rules for the treatment of hands by medical personnel. Pathogenesis. From a general biological position, the principle of the unity of the organism and the external environment is manifested by the normal symbiosis of man, animals and plants with the world of microbes. The microflora of the intestines, respiratory tract, skin is an expression of this symbiosis. In nature, there is not a single species at the expense of which other species would not live. The essence of symbiosis consists in the mutual adaptation of the organism and the microbe, which ensures their mutual biological interests in relation to factors of nutrition, reproduction, on the one hand, and immunity, on the other. Infectious disease is not just defense and struggle. This is a biologically peculiar process of adaptation, most often ending with a new form of symbiosis between the organism and the microbe. The pathological expression of symbiosis is autoinfection (endogenous infection). This option serves the "interests" of the microbe, strengthens its existence as a species, especially since with the end of autoinfection, the carriage, as a rule, does not stop, and the tendency to relapse sometimes increases (tonsillitis, erysipelas, pneumonia). Autoinfectious (endogenous) diseases include: nasopharyngitis, tonsillitis, appendicitis, colitis, chronic constipation, bronchitis, bronchopneumonia, cystitis, pyelonephritis, conjunctivitis, dermatitis, furunculosis, otitis, cholecystitis, osteomyelitis, many types of sepsis. Exogenous infections are caused by the entry into the body from the external environment of microorganisms, in respect of which the given organism has not developed sufficient immunity or this immunity has been shaken in its physiological basis. For the occurrence of infectious bacterial and viral diseases, the following principle remains valid: microorganisms entering the internal environment of the body cause an infectious disease not because it is their absolutely unchanged property (to be the causative agent), but because in a given individual under given conditions (nutrition) , exchange, age, climate), these microorganisms meet favorable conditions for their development. This is facilitated by the proper reactivity (excitability) of the body, determined by the state of the nervous system of the individual. In nature, there is no special kind of "pathogenic" microbes, and at the same time, there are many ways to make an immune organism susceptible, and vice versa. Microbes have a high coefficient of variability and adaptability, replacing several microbial generations over the course of hours and days, acquiring pathogenic properties. The complex of reactions in an infectious disease can be complete and contain the entire sum of morphological, physiological, clinical and immunological signs (“manifesting” forms of infectious diseases). The same complex may be less complete, many, even essential signs may fall out of it (outpatient forms of infection), there may be no typical manifestations, to the point that the infectious disease may be outwardly completely invisible (“deaf” infection). Such a “silent” infection should be recognized as a fact of great practical epidemiological importance. The carriage of pathogenic microbes is not a purely mechanical process of getting into the body and carrying by the latter one or another infection; there is no doubt that carriage is, in essence, the same biological process of interaction between the microbe and the organism, which determines the so-called "deaf" infection (I.V. Davydovsky). The contact of an organism with certain microorganisms is characterized by the term contamination. The contaminating microorganism can be isolated in crops from the surface of the skin or mucous membranes. Not always this microorganism will find favorable conditions for itself and become the cause of the development of the infectious process. Under favorable conditions (the availability of nutrients, conditions for reproduction, competitive struggle of various microorganisms for the possession of ecological niches, the state of the local immune system, genotype), the process of colony formation, reproduction of bacteria on the mucous membranes of the digestive tract occurs. , respiratory tract, genitourinary tract, on the skin. This process is called colonization. In those cases when the bacterial flora reaches a threshold, critical level, conditions arise for the translocation of bacteria into the internal environment of the body with the development of an infectious process. An important factor that disrupts the barrier function and increases the permeability of the mucous membranes for bacterial flora is the influence of various stress factors (surgical trauma, blood loss, hypoxia, inadequate anesthesia, prolonged mechanical ventilation, resuscitation aids, invasive diagnostic methods). A factor that seriously affects the variability of the bacterial flora, causing the emergence of highly pathogenic strains in surgical and intensive care units, is antibiotic therapy. It leads to a change in the main causative agent of purulent infection, which can be traced at intervals of several to tens of years. Thus, the fact of displacement of streptococci by staphylococci under the influence of penicillin therapy is well known. Then, as a result of the widespread use of semisynthetic penicillins, the frequency of staphylococcal diseases decreased, and gram-negative bacteria came to the fore in the etiology of surgical infection (especially postoperative complications). In recent years, there has again been a tendency towards an increase in the role of gram-positive coccal bacteria, especially epidermal staphylococcus and streptococcus, strains of which are characterized by multiple antibiotic resistance. The transmission of infection from bacteria carriers and patients can be carried out in a variety of ways: 1) airborne (when talking, coughing) or airborne dust (with dust particles containing pathogenic bacteria); 2) contact (in contact with contaminated objects of the environment or the hands of personnel). 62 Organization of child care in a surgical hospital Violations of the rules for wearing masks by staff, errors in observing the sanitary regime (insufficient hand treatment, improper use of various sterile solutions, etc.) lead to significant secondary environmental pollution. Studies have shown that more than half of patients in surgical departments after 10 days of stay in them are colonized by nosocomial strains of microorganisms. A direct relationship has been found between the frequency of bacterial carriage, the number of long-term hospitalized patients, the frequency of seeding of pathogenic microorganisms from the air of the operating room, on the one hand, and the percentage of postoperative suppuration, on the other. The epidemiological regime in a surgical hospital is carried out in three areas: medical examination of personnel, rational placement of patients, organization of cleaning of the department. Clinical examination of the staff of the surgical department (examination by a general practitioner, dentist, otolaryngologist), annual chest fluorography, blood tests for RW, HIV, hepatitis, stool culture for the intestinal group, a swab from the throat for diphtheria, a quarterly examination for carriage of pathogenic staphylococcus (crops from the throat and nose) are important in the prevention of nosocomial infection. Bacteriocarriers are subject to additional examination by a dermatologist and ophthalmologist. Upon detection of chronic diseases of the skin, nasopharynx, ears, eyes, teeth - the source of staphylococcal infection - employees are released from work in the operating room and sent for treatment. If pathogenic staphylococcus is detected in the nasopharynx, sanitation is carried out: rinsing the throat and instilling solutions of chlorophyllipt, furatsilin, potassium permanganate, staphylococcal bacteriophage into the nose for 6–7 days. The use of antibiotics for the purpose of sanitation of staphylococcal carriers is unacceptable, as it gives only a short-term effect and contributes to the formation of antibiotic-resistant bacterial species. After the sanitation, repeated swabs are taken from the pharynx and nose. Permanent carriers of pathogenic strains that are not amenable to sanitation are proposed to be removed from work in the operating unit, intensive care units, neonatal surgery, and maternity wards. All students starting to work in clinics are required to undergo a preventive medical examination and issue a medical book. Chapter 1. Structure and organization of the children's surgical clinic 63 1.3. Structure and organization of work of the operating block 1.3.1. Structure and mode of operation The operating unit is the "heart" of the surgical clinic. It includes: operating rooms, preoperative, sterilization, material, equipment rooms, a blood transfusion room. It also includes awakening rooms, rooms for operating sisters, an older sister, anesthesiologists on duty, and a department head. In the centralized operating block, each specialized department has its own operating room. An operating room is allocated for emergency round-the-clock work. The operating unit is located in isolation from the wards, catering unit and sanitary units, and the emergency operating room and operating room for emergency purulent surgery are located away from clean elective operating rooms. The operating block belongs to the premises with limited access. It includes two main zones - sterile and clean. The so-called sterile zone includes: preoperative (Fig. 22), operating room, sterilization-washing and hardware. The entrance to the sterile area is marked on the floor with a red line (10 cm wide). This zone is entered only in operating underwear. In a clean area, there is a material, instrumental, anesthetic, dressing room for doctors and nurses, protocol, express laboratory. Between the clean and sterile zones, a vestibule is provided, which reduces the possibility of infections entering the operating unit. The sterile zone includes an operating room (Fig. 23) for one operating table with a ceiling height of at least 3.5 m, a width of 5 m, and an area of 36–48 m2. It is recommended to finish the operating room with a durable, waterproof and easy-to-clean material. Ceiling, floor and walls should flow into each other in a rounded manner to eliminate dust accumulation in the corners, reduce air stagnation and facilitate cleaning. Floors must be durable, seamless, even and easy to clean and clean (linoleum, epoxy). To avoid accidents due to the formation of sparks and fire when metal tools fall and hit the stone floor, the use of ceramic tiles, marble is not recommended. The ceiling is painted with white oil. 22. Preoperative. Treatment of hands with surgical paint, walls are finished with facing tiles of greenish or pale blue tones. For the purpose of fire safety, engineering communications in the operating unit must be closed. It provides for power supply from two independent sources and a centralized supply of oxygen, nitrous oxide and vacuum. To prevent an explosion due to the accumulation of combustible gases, all switches and sockets are located at a height of 1.6 m from the floor and must have a spark-proof housing. All items that accumulate static electricity, including the operating table, are grounded. To eliminate external interference with the operation of electronic devices, screening of the operating room or loop grounding is carried out. Chapter 1. Structure and organization of the work of the children's surgical clinic 65 Operating rooms should have large bright windows oriented to the north or northwest. In the operating room, two types of artificial lighting are used - general and local. The main operating room equipment includes: 1) operating table; 2) shadowless ceiling lamp; 3) shadowless mobile lamp; 4) apparatus for diathermocoagulation (electroknife); 5) anesthesia machine; 6) anesthesia table (anesthetic kit, medicines); 7) a large table for tools; 8) mobile tool table; 9) auxiliary instrument table (for sterile suture material, a set of cutting instruments in a disinfectant solution, cleol, iodine, etc. ); 10) bixes on stands, equipped with a pedal device; Rice. 23. Operating room. Preparing a child for surgery 66 Organization of child care in a surgical hospital 11) wall bactericidal lamps; 12) electronic tracking systems; 13) defibrillator; 14) racks for infusion solutions. The sterilization and washing room is located next to the operating room and communicates with it by a window with sliding glasses for the transfer of sterile instruments. Usually they wash in it, if necessary, they sterilize the instruments. If there is a central sterilization department in the operating unit, only occasionally used instruments are sterilized. The preoperative room is intended to prepare personnel for the operation (see Fig. 22). It is separated from the operating room by a wall with viewing windows, and from the corridor by a vestibule. In the preoperative room, 2–3 wash basins with taps for opening with the elbow are placed. Mirrors and an hourglass are attached above them. In the preoperative room, a table is placed on which there are sterile brushes and napkins for washing hands, forceps in a triple solution, biks with the inscriptions "Sterile masks". For disinfection of hands, installations with an antiseptic solution, basins with stands are installed. Medicines and instruments are stored in built-in cabinets. In the material room, the preparation of the operating and suture material for sterilization is carried out. Alcohol, gloves, medicines and other items are stored here. Bixes with sterile materials are stored in separate cabinets. The toolkit includes the main "Operating Kit" and tools for specialized departments (newborns, thoracic, urological, orthopedic, endoscopic, etc.). In addition, sets of sterile instruments are being prepared for puncture and catheterization of central veins, venesection, tracheostomy, pleural puncture, and primary resuscitation. Operating linen includes surgical gowns, caps, sheets, diapers, towels. It is painted in dark green, indicating belonging to the operating unit. For sterilization, the surgical linen is placed in the biks in sets (3 gowns, 3 sheets, 3 diapers). After filling the bix, the edges of the sheet lining it are wrapped one on top of the other. A dressing gown is laid on top of it, and several gauze napkins and a diaper are placed on it. This allows the operating sister, after washing her hands, to dry them and put on a sterile gown without opening the rest of the linen and material. Chapter 1. Structure and organization of the work of the children's surgical clinic 67 Special clothing consists of a cap, operating suit (shirt and trousers), shoe covers and an apron. The operating suit is dyed, as well as the operating linen, in a dark green color. Walking in an operating suit outside the operating room or using colored underwear in other departments of the medical institution
Foreword …………………………………………………………………………4
Introduction ……………………………………………………………………………..5
Chapter 1. General care of sick children ………………………………………..6
Chapter 2. Procedures and manipulations of a nurse ………………………20 Chapter 3. Skills of a surgical nurse………………………………………………………………………………………………………………………………………………39 Chapter 4. First aid in case of emergency conditions …………………... 55
Appendix ………………………………………………………………………...65
References ………………………………………………………………...67
FOREWORD
The industrial practice of students is the most important link in the training of a pediatrician; in the structure of the educational program of higher medical educational institutions, much attention is paid to this section of education.
The purpose of this teaching aid is to prepare students of the 2nd and 3rd courses of the pediatric faculty for the internship.
The objectives of the teaching aid are to improve the theoretical knowledge of students, provide information on the correct and high-quality performance of the functional duties of junior and secondary medical personnel, ensure the development of practical skills in caring for sick children, performing nursing manipulations and procedures, providing emergency first aid, filling out medical documentation. .
The content of the practical training of a specialist, set out in the manual, corresponds to the state educational standard of higher professional education in the specialty 040200 "Pediatrics", approved by the Ministry of Education of the Russian Federation on March 10, 2000, the materials of the final state certification of graduates of medical and pharmaceutical universities in the specialty 040200 "Pediatrics", approved by the Ministry of Health of the Russian Federation (2000).
The need to publish this teaching aid is due to the development at the NSMA of a new cross-cutting program of practical training for students of the pediatric faculty with a list of skills and abilities necessary for mastering during the period of practical training. A feature of this publication is the generalization and systematization of modern literary material, a clear presentation of the content of all practical skills in accordance with the approved program. Such publications in NSMA have not been published before.
The manual outlines the content of practical skills and abilities in the course of industrial practice as an assistant to a ward and procedural nurse of a therapeutic and surgical profile, an emergency medical assistant, and measures to provide first aid in the most common emergency conditions in children. The proposed manual is intended for self-preparation of students in the study of the discipline "General child care" and the passage of industrial practice.
INTRODUCTION
This teaching aid consists of 4 chapters.
The first chapter is devoted to the general care of a sick child as an obligatory part of the treatment process. The value of care cannot be overestimated, often the success of treatment and the prognosis of the disease are determined by the quality of care. Caring for a sick child is a system of activities, including the creation of optimal conditions for staying in a hospital, assistance in meeting various needs, the correct and timely implementation of various medical prescriptions, preparation for special research methods, carrying out some diagnostic manipulations, monitoring the child's condition, providing a patient with first aid.
Nursing and paramedical staff play a crucial role in ensuring proper care. The junior nurse cleans the premises, daily toilets and sanitizes sick children, assists in feeding the seriously ill and administering natural needs, monitors the timely change of linen, and the cleanliness of care items. The representative of the middle medical level - the nurse, being an assistant to the doctor, clearly fulfills all the appointments for the examination, treatment and monitoring of a sick child, maintains the necessary medical documentation. The chapters “Procedures and manipulations of a nurse”, “Skills of a surgical nurse” include information on various methods of using drugs, collecting material for research, methods for conducting therapeutic and diagnostic manipulations and procedures, and rules for maintaining medical records. Some aspects of care for surgical patients are highlighted.
The effectiveness of a complex of therapeutic effects depends not only on the proper organization of care and training of medical workers, but also the creation of a favorable psychological environment in a medical institution. The establishment of friendly, trusting relationships, the manifestation of sensitivity, care, attention, mercy, polite and affectionate treatment of children, the organization of games, walks in the fresh air have a positive effect on the outcome of the disease.
A medical worker is obliged in emergency situations to be able to correctly and timely provide first aid. The chapter "First aid in emergency conditions" outlines emergency measures, the implementation of which in full, as soon as possible and at a high professional level is a decisive factor for saving the lives of injured and sick children.
At the end of each chapter, there are control questions for students to independently check their knowledge of theoretical material.
The appendix contains a list of practical skills and abilities of students of the 2nd and 3rd courses of the pediatric faculty during the internship.
Chapter 1. GENERAL CARE OF SICK CHILDREN
Conducting sanitization of patients
Sanitary treatment of sick children is carried out in the admission department of the children's hospital. Upon admission to the hospital, if necessary, patients take a hygienic bath or shower (for more details, see "Hygienic and therapeutic baths"). In case of detection of pediculosis, a special disinsection treatment of the child and, if necessary, underwear is performed. The scalp is treated with insecticidal solutions, shampoos and lotions (20% suspension of benzyl benzoate, Pedilin, Nix, Nittifor, Itax, Anti-bit, Para-plus, Bubil, Reed ”, “Spray-pax”, “Elco-insect”, “Grincid”, “Sana”, “Chubchik”, etc.). To remove nits, separate strands of hair are treated with a solution of table vinegar, tied with a scarf for 15-20 minutes, then the hair is carefully combed out with a fine comb and washed. If scabies is detected in a child, disinsection treatment of clothing, bedding is carried out, the skin is treated with a 10-20% suspension of benzyl benzoate, sulfuric ointment, Spregal, Yurax aerosol.
THE CONCEPT OF CARE OF SURGICAL PATIENTS
Surgery is a special medical specialty that uses methods of mechanical action on body tissues or a surgical operation for the purpose of treatment, which causes a number of serious differences in the organization and implementation of care for surgical patients.
Surgery- this is a complex targeted diagnostic or, most often, therapeutic action associated with the methodical separation of tissues, aimed at accessing the pathological focus and its elimination, followed by the restoration of the anatomical relationships of organs and tissues.
The changes that occur in the body of patients after surgery are extremely diverse and include functional, biochemical and morphological disorders. They are caused by a number of reasons: fasting before and after surgery, nervous tension, surgical trauma, blood loss, cooling, especially during abdominal operations, a change in the ratio of organs due to the removal of one of them.
Specifically, this is expressed by the loss of water and mineral salts, the breakdown of protein. Thirst, insomnia, pain in the wound area, impaired motility of the intestines and stomach, impaired urination, etc. develop.
The degree of these changes depends on the complexity and volume of the surgical operation, on the patient's initial state of health, on age, etc. Some of them are easily expressed, while in other cases they seem significant.
Regular deviations from normal physiological processes are most often a natural response to surgical trauma and do not partially require elimination, since the homeostasis system independently normalizes them.
Properly organized patient care sometimes remains the only important element in postoperative surgery, which may be quite enough for a complete and quick cure of the patient.
Professional care of patients after operations involves knowledge of both the regular changes in their general condition, local processes, and the possible development of complications.
CARE is one of the important elements in the treatment of the patient, organized on the basis of professional knowledge of possible changes or complications in patients after surgery and is aimed at timely prevention and elimination of them.
The amount of care depends on the condition of the patient, his age, the nature of the disease, the volume of surgery, the prescribed regimen, and the complications that arise.
Nursing is a help to the sick in his infirm state and the most important element of medical activity.
In severe postoperative patients, care includes assistance in meeting the basic needs of life (food, drink, movement, emptying the intestines, bladder, etc.); carrying out personal hygiene measures (washing, prevention of bedsores, change of linen, etc.); help during painful conditions (vomiting, coughing, bleeding, respiratory failure, etc.).
In surgical practice, in patients suffering from pain, who are in fear before or after surgery, care involves an active position on the part of the staff. Surgical patients, especially severe postoperative patients, do not ask for help. Any care measures bring them additional painful discomfort, so they have a negative attitude to any attempts to activate the motor mode, to perform the necessary hygiene procedures. In these situations, personnel must exercise caring, patient perseverance.
An important component of patient care is to create maximum physical and mental rest. Silence in the room where the patients are, a calm, even, benevolent attitude of the medical staff towards them, the elimination of all adverse factors that can injure the patient's psyche - these are some of the basic principles of the so-called medical-protective regime of medical institutions, on which the effectiveness largely depends treatment of patients. For a good outcome of the disease, it is very important that the patient is in a calm, physiologically comfortable position, in good hygienic conditions, and receives a balanced diet.
The caring, warm, attentive attitude of medical personnel contributes to recovery.
SANITARY PREPARATION OF THE PATIENT FOR OPERATION
The preoperative period occupies an important place in the system of treatment and its organization. This is a certain period of time necessary to establish a diagnosis and bring the vital functions of organs and systems to vital levels.
Preoperative preparation is carried out in order to reduce the risk of surgery, to prevent possible complications. The preoperative period can be very short during emergency operations and relatively extended during elective operations.
General preparation for planned operations includes all studies related to establishing a diagnosis, identifying complications of the underlying disease and concomitant diseases, and determining the functional state of vital organs. When indicated, drug treatment is prescribed, aimed at improving the activity of various systems, in order to lead to a certain readiness of the patient's body for surgical intervention. The result of the upcoming treatment largely depends on the nature and conduct, and ultimately on the organization of the preoperative period.
It is advisable to postpone planned operations during menstruation, even with a slight rise in temperature, a slight cold, the appearance of pustules on the body, etc. Mandatory sanitation of the oral cavity.
The duties of junior and middle staff include sanitary preparation of the patient. It usually starts the evening before the operation. The patient is explained that the operation must be performed on an empty stomach. In the evening, patients receive a light supper, and in the morning they cannot eat or drink.
In the evening, in the absence of contraindications, all patients are given a cleansing enema. Then the patient takes a hygienic bath or shower, he is changed underwear and bed linen. At night, according to the doctor's prescription, the patient is given sleeping pills or sedatives.
In the morning immediately before the operation, the hair from the future surgical field and its circumference is widely shaved, taking into account the possible expansion of access. Before shaving, the skin is wiped with a disinfectant solution and allowed to dry, and after shaving, it is wiped with alcohol. These activities can not be done in advance, as it is possible to infect abrasions and scratches obtained during shaving. A few hours are enough to turn them into a focus of infection with the subsequent development of postoperative complications.
In the morning the patient washes, brushes his teeth. The dentures are taken out, wrapped in gauze and placed in the nightstand. A cap or scarf is put on the scalp. Braids are braided for women with long hair.
After premedication, the patient is taken to the operating room on a gurney, accompanied by a nurse dressed in a clean gown, cap and mask.
For patients admitted on an emergency basis, the volume of sanitary preparation depends on the urgency of the necessary operation and is determined by the doctor on duty. Mandatory activities are emptying the stomach with a gastric tube and shaving the scalp of the surgical field.
HYGIENE OF THE BODY, UNDERWEAR, DISCHARGE OF THE PATIENT
IN THE POSTOPERATIVE PERIOD
The postoperative period is a period of time after the operation, which is associated with the completion of the wound process - wound healing, and stabilization of the reduced and affected functions of life-supporting organs and systems.
Patients in the postoperative period distinguish between active, passive and forced position.
An active position is characteristic of patients with relatively mild diseases, or in the initial stage of severe diseases. The patient can independently change position in bed, sit down, get up, walk.
The passive position is observed in the unconscious state of the patient and, less often, in case of extreme weakness. The patient is motionless, remains in the position that was given to him, the head and limbs hang down due to their gravity. The body slides off the pillows to the lower end of the bed. Such patients require special monitoring by the medical staff. It is necessary from time to time to change the position of the body or its individual parts, which is important in the prevention of complications - bedsores, hypostatic pneumonia, etc.
The patient takes a forced position to stop or weaken his painful sensations (pain, cough, shortness of breath, etc.).
Care of patients with a general regime after surgery is reduced mainly to the organization and control over their compliance with hygiene measures. Severely ill patients with bed rest need active assistance in caring for the body, linen and in the implementation of physiological functions.
The competence of medical personnel includes the creation of a functionally advantageous position for the patient, conducive to recovery and prevention of complications. For example, after surgery on the abdominal organs, it is advisable to position with a raised head end and slightly bent knees, which helps to relax the abdominal press and provides peace to the surgical wound, favorable conditions for breathing and blood circulation.
To give the patient a functionally advantageous position, special head restraints, rollers, etc. can be used. There are functional beds, consisting of three movable sections, which allow you to smoothly and silently give the patient a comfortable position in bed with the help of handles. The legs of the bed are equipped with wheels for moving it to another place.
An important element in the care of critically ill patients is the prevention of bedsores.
A bedsore is a necrosis of the skin with subcutaneous tissue and other soft tissues, which develops as a result of their prolonged compression, disorders of local blood circulation and nervous trophism. Bedsores usually form in severe, weakened patients who are forced to be in a horizontal position for a long time: when lying on the back - in the region of the sacrum, shoulder blades, elbows, heels, on the back of the head, when the patient is positioned on his side - in the region of the hip joint, in the projection of the greater trochanter femur.
The occurrence of bedsores is facilitated by poor patient care: untidy maintenance of the bed and underwear, uneven mattress, crumbs of food in the bed, prolonged stay of the patient in one position.
With the development of bedsores, reddening of the skin, soreness first appears on the skin, then the epidermis is exfoliated, sometimes with the formation of blisters. Next, necrosis of the skin occurs, spreading deep into and to the sides with the exposure of muscles, tendons, and periosteum.
To prevent bedsores, change the position every 2 hours, turning the patient, while examining the places of possible occurrence of pressure sores, wiping with camphor alcohol or another disinfectant, performing a light massage - stroking, patting.
It is very important that the bed of the patient is tidy, the mesh is well stretched, with a smooth surface, a mattress without bumps and depressions is placed on top of the mesh, and a clean sheet is placed on it, the edges of which are tucked under the mattress so that it does not roll down and does not gather into folds.
For patients suffering from urinary incontinence, feces, with abundant discharge from wounds, it is necessary to put an oilcloth across the entire width of the bed and bend its edges well to prevent contamination of the bed. A diaper is laid on top, which is changed as needed, but at least every 1-2 days. Wet, soiled linen is changed immediately.
A rubber inflatable circle covered with a diaper is placed under the sacrum of the patient, and cotton-gauze circles are placed under the elbows and heels. It is more effective to use an anti-decubitus mattress, which consists of many inflatable sections, the air pressure in which periodically changes in waves, which also periodically changes the pressure on different parts of the skin in waves, thereby producing a massage, improving skin blood circulation. When superficial skin lesions appear, they are treated with a 5% solution of potassium permanganate or an alcohol solution of brilliant green. Treatment of deep bedsores is carried out according to the principle of treatment of purulent wounds, as prescribed by a doctor.
Change of bed and underwear is carried out regularly, at least once a week, after a hygienic bath. In some cases, linen is changed additionally as needed.
Depending on the condition of the patient, there are several ways to change bed and underwear. When the patient is allowed to sit, he is transferred from bed to a chair, and the junior nurse makes the bed for him.
Changing a sheet under a seriously ill patient requires a certain skill from the staff. If the patient is allowed to turn on his side, you must first gently raise his head and remove the pillow from under it, and then help the patient turn on his side. On the vacated half of the bed, located on the side of the patient's back, you need to roll up a dirty sheet so that it lies in the form of a roller along the patient's back. On the vacated place you need to put a clean, also half-rolled sheet, which in the form of a roller will lie next to the roller of the dirty sheet. Then the patient is helped to lie on his back and turn on the other side, after which he will be lying on a clean sheet, turning to face the opposite edge of the bed. After that, the dirty sheet is removed and the clean one is straightened.
If the patient cannot move at all, you can change the sheet in another way. Starting from the lower end of the bed, roll the dirty sheet under the patient, lifting his shins, thighs and buttocks in turn. The roll of the dirty sheet will be under the patient's lower back. A clean sheet rolled up in the transverse direction is placed on the foot end of the bed and straightened towards the head end, also raising the lower limbs and buttocks of the patient. A roller of a clean sheet will be next to a roller of a dirty one - under the lower back. Then one of the orderlies slightly raises the head and chest of the patient, while the other at this time removes the dirty sheet, and straightens a clean one in its place.
Both ways of changing the sheet, with all the dexterity of the caregivers, inevitably cause a lot of anxiety to the patient, and therefore it is sometimes more expedient to put the patient on a gurney and make the bed, especially since in both cases it is necessary to do this together.
In the absence of a wheelchair, you need to shift the patient together to the edge of the bed, then straighten the mattress and sheet on the freed half, then transfer the patient to the cleaned half of the bed and do the same on the other side.
When changing underwear in seriously ill patients, the nurse should bring her hands under the patient's sacrum, grab the edges of the shirt and carefully bring it to the head, then raise both hands of the patient and transfer the rolled shirt at the neck over the patient's head. After that, the hands of the patient are released. The patient is dressed in the reverse order: first they put on the sleeves of the shirt, then throw it over the head, and, finally, straighten it under the patient.
For very sick patients, there are special shirts (undershirts) that are easy to put on and take off. If the patient's arm is injured, first remove the shirt from the healthy arm, and only then from the patient. They put on the sick hand first, and then the healthy one.
In severe patients who are on bed rest for a long time, various disorders of the skin condition may occur: pustular rash, peeling, diaper rash, ulceration, bedsores, etc.
It is necessary to wipe the skin of patients daily with a disinfectant solution: camphor alcohol, cologne, vodka, half alcohol with water, table vinegar (1 tablespoon per glass of water), etc. To do this, take the end of the towel, moisten it with a disinfectant solution, wring it out slightly and begin to wipe it behind the ears, neck, back, front surface of the chest and in the armpits. Pay attention to the folds under the mammary glands, where diaper rash can form in obese women. Then dry the skin in the same order.
A patient who is on bed rest should wash his feet two or three times a week, placing a basin of warm water at the foot end of the bed. In this case, the patient lies on his back, the junior nurse lathers his feet, washes, wipes, and then cuts his nails.
Severely ill patients cannot brush their teeth on their own, therefore, after each meal, the nurse must treat the patient's mouth. To do this, she alternately takes the patient’s cheek from the inside with a spatula and wipes the teeth and tongue with tweezers with a gauze ball moistened with a 5% solution of boric acid, or a 2% solution of sodium bicarbonate, or a weak solution of potassium permanganate. After that, the patient rinses his mouth thoroughly with the same solution or just warm water.
If the patient is not able to rinse, then he should irrigate the oral cavity with Esmarch's mug, rubber pear or Janet's syringe. The patient is given a semi-sitting position, the chest is covered with an oilcloth, a kidney-shaped tray is brought to the chin to drain the washing liquid. The nurse alternately pulls the right and then the left cheek with a spatula, inserts the tip and irrigates the oral cavity, washing away food particles, plaque, etc. with a jet of liquid.
Severely ill patients often experience inflammation on the oral mucosa - stomatitis, gums - gingivitis, tongue - glossitis, which is manifested by reddening of the mucous membrane, salivation, burning, pain when eating, the appearance of ulcers and bad breath. In such patients, therapeutic irrigation is performed with disinfectants (2% chloramine solution, 0.1% furatsilin solution, 2% sodium bicarbonate solution, a weak solution of potassium permanganate). You can make applications by applying sterile gauze pads soaked in a disinfectant solution or painkiller for 3-5 minutes. The procedure is repeated several times a day.
If the lips are dry and cracks appear in the corners of the mouth, it is not recommended to open the mouth wide, touch the cracks and tear off the crusts that have formed. To alleviate the patient's condition, hygienic lipstick is used, lips are lubricated with any oil (vaseline, creamy, vegetable).
Dentures are removed at night, washed with soap, stored in a clean glass, washed again in the morning and put on.
When purulent secretions appear that stick together the eyelashes, the eyes are washed with sterile gauze swabs moistened with a warm 3% solution of boric acid. The movements of the tampon are made in the direction from the outer edge to the nose.
For instillation of drops into the eye, an eye dropper is used, and for different drops there should be different sterile pipettes. The patient throws his head back and looks up, the nurse pulls back the lower eyelid and, without touching the eyelashes, without bringing the pipette closer to the eye than 1.5 cm, instill 2-3 drops into the conjunctival fold of one and then the other eye.
Eye ointments are laid with a special sterile glass rod. The eyelid of the patient is pulled down, an ointment is laid behind it and rubbed over the mucous membrane with soft movements of the fingers.
In the presence of discharge from the nose, they are removed with cotton turundas, introducing them into the nasal passages with light rotational movements. When crusts form, it is necessary to first drip a few drops of glycerin, vaseline or vegetable oil into the nasal passages, after a few minutes the crusts are removed with cotton turundas.
Sulfur that accumulates in the external auditory canal should be carefully removed with a cotton swab, after having dripped 2 drops of a 3% hydrogen peroxide solution. To drip drops into the ear, the patient's head must be tilted in the opposite direction, and the auricle pulled back and up. After instillation of drops, the patient should remain in a position with his head tilted for 1-2 minutes. Do not use hard objects to remove wax from the ears because of the risk of damage to the eardrum, which can lead to hearing loss.
Due to their sedentary state, seriously ill patients require assistance in carrying out their physiological functions.
If it is necessary to empty the intestines, the patient, who is on strict bed rest, is given a vessel, and when urinating, a urinal.
The vessel can be metal with an enamel coating or rubber. The rubber vessel is used for debilitated patients, in the presence of bedsores, with incontinence of feces and urine. The vessel should not be tightly inflated, otherwise it will exert significant pressure on the sacrum. When giving the ship to the bed, be sure to put an oilcloth under it. Before serving, the vessel is rinsed with hot water. The patient bends his knees, the nurse brings his left hand to the side under the sacrum, helping the patient raise the pelvis, and with her right hand places the vessel under the patient's buttocks so that the perineum is above the opening of the vessel, covers the patient with a blanket and leaves him alone. After defecation, the vessel is removed from under the patient, its contents are poured into the toilet. The vessel is thoroughly washed with hot water, and then disinfected with a 1% solution of chloramine or bleach for an hour.
After each act of defecation and urination, patients should be washed away, otherwise maceration and inflammation of the skin are possible in the area of the inguinal folds and perineum.
Washing is carried out with a weak solution of potassium permanganate or other disinfectant solution, the temperature of which should be 30-35 ° C. For washing, you need to have a jug, forceps and sterile cotton balls.
When washing away, a woman should lie on her back, bending her legs at the knees and slightly spreading them at the hips, a vessel is placed under the buttocks.
In the left hand, the nurse takes a jug with a warm disinfectant solution and pours water on the external genitalia, and with a forceps with a cotton swab clamped into it, movements are made from the genitals to the anus, i.e. top down. After that, wipe the skin with a dry cotton swab in the same direction, so as not to infect the anus into the bladder and external genitalia.
Washing can be done from an Esmarch mug equipped with a rubber tube, a clamp and a vaginal tip, directing a stream of water or a weak solution of potassium permanganate to the perineum.
Men are much easier to wash. The position of the patient on the back, legs bent at the knees, a vessel is placed under the buttocks. Cotton, clamped in a forceps, wipe the perineum dry, lubricate with vaseline oil to prevent diaper rash.
POSTOPERATIVE WOUND CARE
The local result of any operation is a wound, which is characterized by three major features: gaping, pain, bleeding.
The body has a perfect mechanism aimed at wound healing, which is called the wound process. Its purpose is to eliminate tissue defects and relieve the listed symptoms.
This process is an objective reality and occurs independently, passing through three phases in its development: inflammation, regeneration, reorganization of the scar.
The first phase of the wound process - inflammation - is aimed at cleansing the wound from non-viable tissues, foreign bodies, microorganisms, blood clots, etc. Clinically, this phase has symptoms characteristic of any inflammation: pain, hyperemia, swelling, dysfunction.
Gradually, these symptoms subside, and the first phase is replaced by the regeneration phase, the meaning of which is to fill the wound defect with young connective tissue. At the end of this phase, the processes of constriction (tightening of the edges) of the wound begin due to fibrous connective tissue elements and marginal epithelization. The third phase of the wound process, scar reorganization, is characterized by its strengthening.
The outcome in surgical pathology largely depends on the correct observation and care of the postoperative wound.
The process of wound healing is absolutely objective, takes place independently and is worked out to perfection by nature itself. However, there are reasons that impede the wound process, inhibit the normal healing of the wound.
The most common and dangerous cause that complicates and slows down the biology of the wound process is the development of infection in the wound. It is in the wound that microorganisms find the most favorable living conditions with the necessary humidity, comfortable temperature, and an abundance of nutritious foods. Clinically, the development of infection in the wound is manifested by its suppuration. The fight against infection requires a significant strain on the forces of the macroorganism, time, and is always risky in terms of generalization of the infection, the development of other serious complications.
Infection of the wound is facilitated by its gaping, since the wound is open to the ingress of microorganisms into it. On the other hand, significant tissue defects require more plastic materials and more time to eliminate them, which is also one of the reasons for the increase in wound healing time.
Thus, it is possible to promote the speedy healing of a wound by preventing its infection and by eliminating the gap.
In most patients, gaping is eliminated during the operation by restoring anatomical relationships by layer-by-layer suturing of the wound.
Care of a clean wound in the postoperative period comes down primarily to measures to prevent its microbial contamination by a secondary, nosocomial infection, which is achieved by strict adherence to well-developed asepsis rules.
The main measure aimed at preventing contact infection is the sterilization of all objects that may come into contact with the surface of the wound. Instruments, dressings, gloves, underwear, solutions, etc. are subject to sterilization.
Directly in the operating room after suturing the wound, it is treated with an antiseptic solution (iodine, iodonate, iodopyrone, brilliant green, alcohol) and closed with a sterile bandage, which is tightly and securely fixed by bandaging or with glue, adhesive plaster. If in the postoperative period the bandage is tangled or soaked with blood, lymph, etc., you must immediately notify the attending physician or the doctor on duty, who, after examination, instructs you to change the bandage.
With any dressing (removing the previously applied dressing, examining the wound and therapeutic manipulations on it, applying a new dressing), the wound surface remains open and, for a more or less long time, comes into contact with air, as well as with tools and other objects used in dressings. Meanwhile, the air of the dressing rooms contains significantly more microbes than the air of operating rooms, and often other rooms of the hospital. This is due to the fact that a large number of people are constantly circulating in the dressing rooms: medical staff, patients, students. Wearing a mask during dressings is mandatory in order to avoid droplet infection with saliva splashes, coughing, and breathing on the wound surface.
After the vast majority of clean operations, the wound is sutured tightly. Occasionally, between the edges of the sutured wound or through a separate puncture, the cavity of the hermetically sutured wound is drained with a silicone tube. Drainage is performed to remove wound secretions, remnants of blood and accumulating lymph in order to prevent wound suppuration. Most often, drainage of clean wounds is performed after breast surgery, when a large number of lymphatic vessels are damaged, or after operations for extensive hernias, when pockets in the subcutaneous tissue remain after the removal of large hernial sacs.
Distinguish passive drainage, when the wound exudate flows by gravity. With active drainage or active aspiration, the contents are removed from the wound cavity using various devices that create a constant vacuum in the range of 0.1-0.15 atm. Rubber cylinders with a sphere diameter of at least 8-10 cm, industrially manufactured corrugations, as well as modified aquarium microcompressors of the MK brand are used as a vacuum source with the same efficiency.
Postoperative care for patients with vacuum therapy, as a method of protecting an uncomplicated wound process, is reduced to monitoring the presence of a working vacuum in the system, as well as monitoring the nature and amount of wound discharge.
In the immediate postoperative period, air may be sucked in through skin sutures or leaky junctions of tubes with adapters. When the system is depressurized, it is necessary to create a vacuum in it again and eliminate the source of air leakage. Therefore, it is desirable that the device for vacuum therapy had a device for monitoring the presence of vacuum in the system. When using a vacuum of less than 0.1 atm, the system ceases to function on the very first day after the operation, since the tube is obturated due to thickening of the wound exudate. With a degree of rarefaction of more than 0.15 atm, clogging of the side holes of the drainage tube with soft tissues is observed with their involvement in the drainage lumen. This has a damaging effect not only on the fiber, but also on the young developing connective tissue, causing it to bleed and increase wound exudation. A vacuum of 0.15 atm allows you to effectively aspirate the discharge from the wound and have a therapeutic effect on the surrounding tissues.
The contents of the collections are evacuated once a day, sometimes more often - as they are filled, the amount of liquid is measured and recorded.
Collection jars and all connecting tubes are subjected to pre-sterilization cleaning and disinfection. They are first washed with running water so that no clots remain in their lumen, then they are placed in a 0.5% solution of synthetic detergent and 1% hydrogen peroxide for 2-3 hours, after which they are washed again with running water and boiled for 30 minutes.
If suppuration of the surgical wound has occurred or the operation was originally performed for a purulent disease, then the wound must be carried out in an open way, that is, the edges of the wound must be parted, and the wound cavity drained in order to evacuate pus, and create conditions for cleaning the edges and bottom of the wound from necrotic tissues .
Working in the wards for patients with purulent wounds, it is necessary to adhere to the rules of asepsis no less scrupulously than in any other department. Moreover, it is even more difficult to ensure the asepsis of all manipulations in the purulent department, since one must think not only about not contaminating the wound of a given patient, but also about how not to transfer the microbial flora from one patient to another. “Superinfection”, that is, the introduction of new microbes into a weakened organism, is especially dangerous.
Unfortunately, not all patients understand this and often, especially patients with chronic suppurative processes, are untidy, touch the pus with their hands, and then wash them poorly or not at all.
It is necessary to carefully monitor the condition of the bandage, which should remain dry and not contaminate the linen and furniture in the ward. Bandages often have to be bandaged and changed.
The second important sign of a wound is pain, which occurs as a result of an organic lesion of nerve endings and in itself causes functional disorders in the body.
The intensity of pain depends on the nature of the wound, its size and location. Patients perceive pain differently and react to it individually.
Intense pain can be the starting point of collapse and development of shock. Severe pains usually absorb the patient's attention, interfere with sleep at night, limit the patient's mobility, and in some cases cause a feeling of fear of death.
The fight against pain is one of the necessary tasks of the postoperative period. In addition to the appointment of medications for the same purpose, elements of a direct impact on the lesion are used.
During the first 12 hours after surgery, an ice pack is placed on the wound area. Local exposure to cold has an analgesic effect. In addition, cold causes contraction of blood vessels in the skin and underlying tissues, which contributes to thrombosis and prevents the development of hematoma in the wound.
To prepare the “cold”, water is poured into a rubber bladder with a screw cap. Before screwing the lid on, the air must be expelled from the bubble. Then the bubble is placed in the freezer until completely frozen. The ice pack should not be placed directly on the bandage; a towel or napkin should be placed under it.
To reduce pain, it is very important to give the affected organ or part of the body the correct position after the operation, in which maximum relaxation of the surrounding muscles and functional comfort for the organs are achieved.
After operations on the abdominal organs, a position with a raised head end and slightly bent knees is functionally beneficial, which helps to relax the muscles of the abdominal wall and provides peace to the surgical wound, favorable conditions for breathing and blood circulation.
The operated limbs should be in an average physiological position, which is characterized by balancing the action of antagonist muscles. For the upper limb, this position is the abduction of the shoulder to an angle of 60 ° and flexion to 30-35 °; the angle between the forearm and shoulder should be 110°. For the lower limb, flexion at the knee and hip joints is made up to an angle of 140 °, and the foot should be at a right angle to the lower leg. After the operation, the limb is immobilized in this position with splints, a splint, or a fixing bandage.
Immobilization of the affected organ in the postoperative period greatly facilitates the patient's well-being by relieving pain, improves sleep, and expands the general motor regimen.
With purulent wounds in the 1st phase of the wound process, immobilization helps to delimit the infectious process. In the regeneration phase, when the inflammation subsides and the pain in the wound subsides, the motor mode is expanded, which improves the blood supply to the wound, promotes faster healing and restoration of function.
The fight against bleeding, the third important sign of a wound, is a serious task of any operation. However, if for some reason this principle turned out to be unrealized, then in the next few hours after the operation, the bandage gets wet with blood or blood flows through the drains. These symptoms serve as a signal for an immediate examination of the surgeon and active actions in terms of revision of the wound in order to finally stop the bleeding.
Questions on practical skills in educational practice (care of children in a surgical hospital) for students of the 1st year of the pediatric faculty. Structure of a modern children's surgical clinic. Responsibilities of junior and middle medical personnel in the care of children in a surgical hospital. Maintenance of medical records in the pediatric surgical clinic. Equipment and tools for the dressing room, manipulation room, operating room. Responsibilities of junior and middle medical personnel. Responsibilities of paramedical personnel of a pediatric surgical hospital (urological, traumatological, resuscitation, thoracic departments, department of purulent surgery). General care of patients in the general pediatric surgical department. Preparing a child for surgery. Features of transportation of patients depending on the nature, localization of the disease (damage), severity of the condition. The concept of nosocomial infection. Causes of occurrence, main pathogens, sources, ways of spread of nosocomial infection. A complex of sanitary and hygienic measures aimed at identifying, isolating sources of infection and interrupting transmission routes. Sanitary and hygienic regime in the admission department. Sanitary and hygienic regime in the surgical department. Sanitary and hygienic diet of patients. Sanitary and hygienic regime in the operating unit, wards and resuscitation and intensive care units, postoperative wards and dressing rooms. Treatment of the operating and injection field, hands, surgical gloves during the operation. Disinfection. Types of disinfection. The sequence of processing medical instruments. Treatment of incubators for newborns. Sterilization. Types of sterilization. Storage of sterile instruments and medical products. Features of sterilization of instruments, suture and dressing material. Peculiarities of sterilization of surgical gloves, rubber products, fabrics, polymers (probes, catheters, etc.) Rules for packing dressings, surgical linen in bix. Bix styling types. Indicators. Antiseptic. antiseptic methods. Control methods. Indicators. Injections. Types of injections. Local and general complications of injections. Disposal of used balls, needles, syringes. Rules for taking blood for laboratory testing. Infusion therapy. Tasks of infusion therapy. The main drugs for infusion therapy, indications for their appointment. Ways of introducing infusion media. Complications. Indications and contraindications for central venous catheterization. Caring for a catheter placed in a central vein. Blood transfusion. Types of blood transfusion. Determination of the suitability of canned blood for transfusion. Technique for determining blood group and Rh factor. Control studies before transfusion of whole blood (erythrocyte mass) and blood products, methods of conducting. Post-transfusion reactions and complications. Clinic, diagnostics. Possible ways of prevention. Nasogastric tube. Probing technique. Indications for nasogastric sounding. Technique. Complications of nasogastric sounding. Types of enemas. Indications for use Technique. Complications. Taking material for bacteriological examination. How to store biopsy material. Features of transportation of patients in a surgical hospital. Tasks of preoperative preparation, ways and means of its implementation. Surgery. Types of surgical operations. Position of the patient on the operating table. Intraoperative risk factors for infectious complications. Postoperative period, its tasks. Care of children in the postoperative period. Complications of the postoperative period, ways of prevention, combating complications that have arisen. Care of the skin and mucous membranes of the child in the postoperative period. Postoperative wound care. Removal of stitches. Temporary stop of bleeding. Transportation and immobilization depending on the nature and localization of damage or pathological process. Pre-hospital care for emergency conditions in children. Terminal states. Monitoring. Posthumous care. Assistance in emergencies. Primary resuscitation complex, features of its implementation depending on the age of the child. Desmurgy. Technique for applying different types of dressings in children of different age groups (see Appendix). APPENDIX Questions on desmurgy for students of the 1st year of the Faculty of Pediatrics I. Headbands: Hippocratic cap Hat - cap Bandage on one eye Bandage - bridle Neapolitan bandage Bandage on the nose II. Bandages on the upper limb: Bandage on one finger Bandage on the first finger Bandage-glove Bandage on the hand Bandage on the forearm Bandage on the elbow joint Bandage on the shoulder joint III. Bandages on the abdomen and pelvis: Unilateral spike bandage Bilateral spike bandage Bandage on the perineum IV. Bandages on the lower limb: Bandage on the thigh Bandage on the shin Bandage on the knee joint Bandage on the heel region Bandage on the ankle joint Bandage on the entire foot (without gripping fingers) Bandage on the entire foot (with gripping fingers) Bandage on first toe V. Bandages for the neck: Bandage for the upper part of the neck Bandage for the lower part of the neck VI. Bandages on the chest: Spiral bandage Cruciform bandage Dezo bandage Head of the Department of Pediatric Surgery MD. I.N. Khvorostov
