Surgery Lecture - 07 Patient Care

General Surgery Department of Russian State Medical University Chief professor doctor of medicine N.A.Kuznetcov

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

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General Surgery Department of Russian State Medical University

Care of patient or hypurgia is medical practice securing optimal conditions of existence ill peoples and prevention of development different complications.

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General Surgery Department of Russian State Medical University

Care is art. Professional care of patent is at the first maximal quality care. Art of care consist of no nursing by patient with something sickness, but the man have individual features, character, habit and wishes. Creation of favorable conditions for patient, delicate and tactful attitude, readiness aiding in each minute is obligatory conditions of qualitative nursing.

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General Surgery Department of Russian State Medical University

Participants of care: Doctor  Nurse  Hospital attendant  Kins 

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General Surgery Department of Russian State Medical University

Present-day principle of care: Independent

Preventive of damage

Respect of patient’s senses and dignity

Confidentiality

Infection safety 5

General Surgery Department of Russian State Medical University

14 base needs of patient Model of V. Henderson Patient needs: 1. 2. 3. 4. 5. 6. 7.

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

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General Surgery Department of Russian State Medical University

14 base needs of patient Model of V. Henderson Patient needs: 8. 9. 10. 11. 12. 13. 14.

To keep hygiene, take care of appearance To provide for personal security Communicate with another people To realize devotions Carry out favorite work To rest To satisfy craving for knowledge 7

General Surgery Department of Russian State Medical University

Stages of surgical treatment of patient 

First stage – before operation (from hospitalization to start the operation)

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Second stage – during operation (from making incision to put in last stitch)

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Third stage – after operation (from closing wound to discharge)

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General Surgery Department of Russian State Medical University

Type of sanitary processing: Full:    

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

Partial:   

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To wash dirty zone of skin; To change clothing and underwear Sanitary processing and accept in deposit personal clothing of patient To reveal of stray

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General Surgery Department of Russian State Medical University

Sanitary rules of medical personal include of: 

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Washing hands after physical examination of each patient no less than 2 minutes. Daily change of personal towel; Protect body by gloves, mask, smocks and full covered hair cup

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General Surgery Department of Russian State Medical University

Care after operation in surgical ward  

Active support sufficient functional activity Prevention and treatment complication from organ and system: Respiratory system  Cardio-vascular system  Digestive system  Nervous system 

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Early indicates of complication: Surprise anxiety,  Misleading,  Inadequate conduct  Change of appearing 

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General Surgery Department of Russian State Medical University

Care of respiratory system: 

Complication:   

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Standstill pneumonia Athelectasis in the lungs Lung’s edema

To keep of adequate lung’s ventilation :    

well-time anesthetization To remove a phlegm from bronchial tree Breezing practice Early activation of patient

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General Surgery Department of Russian State Medical University

Care of digestive system: Normalization of intestine movement;  Care of oral cavity;  Good recovery in operation zone;  Normalization of digestion 

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General Surgery Department of Russian State Medical University

Care of oral cavity 

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Cotton sticks include glycerin, lemon’s acid, natural extract of lemon and 0,1% Nabenzoate Help for daily care of oral cavity Especial for patients without consciousness, after difficult operation, during artificial ventilation of lungs and patient has hyperthermia

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General Surgery Department of Russian State Medical University

Nutrition of patient

 Artificial  Natural

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General Surgery Department of Russian State Medical University

Forced probe feeding   

Oral- or nasal- probe Through gastrostoma Through ieunostoma

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General Surgery Department of Russian State Medical University

Artificial enteral feeding have been indicate for patients:      

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

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General Surgery Department of Russian State Medical University

Characteristics of nutrition mixture       

Good assimilation Balance of exchangeable and irreplaseble components. Stability during of storing. Easy preparation High dispersion Easy passage through thinly probes High calories and food value in 1 ml in finished mixture 18

General Surgery Department of Russian State Medical University

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

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General Surgery Department of Russian State Medical University

Prevention of thrombosis and embolic include of: 

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

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General Surgery Department of Russian State Medical University

Causes of thrombosis Triad of R.Virchov damage of vessel wall  decrease speed of blood flow  hypercoagulation 

Rudolf Virchow (1821–1902)  Morphological and functional damage of vessel  Change characteristic of blood flow  Increase the coagulation property of bloods

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General Surgery Department of Russian State Medical University

Patient without fail must know how to apply to elastic bandage

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General Surgery Department of Russian State Medical University

Law of Laplas In use elastic bandage must take in consideration distribution of elastic pressure into surface – Law of Laplas

P = T/ R Pressure = tension force of bandage / radius of extremity For example: segment of the leg who have small radius (ankle-bone, border of foot, fore surface of shank) degree of compression higher comparison of low profile segment.

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General Surgery Department of Russian State Medical University

Technique overlay of elastic bandage

high compression low compression 5 = incorrect

4 = correct 24

General Surgery Department of Russian State Medical University

Technique overlay of elastic bandage

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General Surgery Department of Russian State Medical University

Rule of apply to elastic bandage Foot mast bend in 90° angle Start bandage from toes and it is obligatory cover heel. Bandage mast follow from leg’s form. Modeling cylindrical form of extremity

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General Surgery Department of Russian State Medical University

Estimation efficacy of compression

Finger-tips become blue if elastic bandage formed right. They restore normal flash-color when a patient start walk, or release physical examination (for shank).

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General Surgery Department of Russian State Medical University

Estimation efficacy of compression

Patient mast walk in training conditions during 20-30 minutes after form elastic bandage If in this time period shall arise a pain, elastic bandage must be corrected.

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General Surgery Department of Russian State Medical University

Physician's control is obligatory when patient wear elastic bandage

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General Surgery Department of Russian State Medical University

Critical result of incorrect elastic compression

This is a way to amputation of lower extremity 30

General Surgery Department of Russian State Medical University

Comparison of elastic bandage and hospital compressing stoking 

Compression’s power determine of experience of physician or patient

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Necessity study of patient or participation of physician in form elastic bandage

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Difficult chose of compression and fixing on hip

Bandage

shell unusable after few wash, and need replaceable.

Normalization of elastic characteristics in production process Physician make the selection of type of elastic stoking and compression volume. Patient may use this type of compression himself. Effective compression on hip, have special accessories for fixing on skin 

Keeping elastic characteristic during half of year. Don’t lose function after wash in hot water. 

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Low compliance.

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Consent of patient to use this type of compression

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Low accommodation and esthetical characteristics.

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High esthetical characteristics and comfort in use. 31

General Surgery Department of Russian State Medical University

Care of hard-ill patient’s skin     

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

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General Surgery Department of Russian State Medical University

To move and keep active position of body (14 needs of patient. Model of V.Henderson)

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Healthy man don’t have a problem with movement and change body position

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General Surgery Department of Russian State Medical University

To move and keep active position of body (14 needs of patient. Model of V.Henderson) 

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Change of body position of long-lay patient is most necessary every 2 hour, including night time. Is important condition of decubates prevention

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General Surgery Department of Russian State Medical University

Complications of care to patients 

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

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General Surgery Department of Russian State Medical University

Decubates ( lat.- decubare is laying) Decubates is ulcer due to the pressure on the skin in place where bones locate superficial Decubates appear in consequence of local deficit of microcirculation (ischemia) and as result death of tissue cells (necrosis). To take for grating, that pressure on tissue more than 70 mm. Hg. during 2 hours appear irreversible process in tissue. 36

General Surgery Department of Russian State Medical University

International Committee of Healthcare’s politics and science investigations in 1992 was recommend easy and maximal near of clinical practice classification of decubates. 1 stage

3 stage

2 stage

4 stage

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General Surgery Department of Russian State Medical University

Auriculars

Decubates Occiput Scapulas

Shoulder joint Elbows

Elbow joint

Kreuz

Femoral joint

Ichiadicus hillock

Genus joint

Ancle-bone

Heel Contact places

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General Surgery Department of Russian State Medical University

Internal risk factors of decubates Reversible factors Excess or deficit of body weight Limit volume of movement Anemia Deficit of proteins and vitamin «С» substances Hypotension Disorders of pelvinum organs Neurological disorders Disorders of blood circulation at the periphery Thinly skin Nervousness Consciousness disorders Coma

Irreversible factors

Elderly age

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General Surgery Department of Russian State Medical University

External risk factors of decubates Reversible factors Insufficient hygienic care  Tuck on bad and dress of patient  Поручни кровати  Средства фиксации пациента  Damage of spinal column, abdominal cavity and pelvis  Use a cytostatic treatment  Violation transported rules of patient 

Irreversible factors Extensive,

long-time operation more

than 2 hours

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General Surgery Department of Russian State Medical University

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

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General Surgery Department of Russian State Medical University

Norton’s scale Read to intercourse Full – 4

Short – 3

Particle - 2

Absence - 1

Age

Less than 10 year – 4

Less than 30 year - 3

Less than 60 year - 2

More than 60 year – 1

Skin’s state

Healthy skin – 4

Shall skin -3

Damp skin -2

Allergies, chap -1

Accompany illness Absence -4

Hyperglycemia, Anemia – 3

Disseminate sclerosis – 2

Coma. Paresis -1

Physical state

Good -4

Satisfaction-3

Badly -2

Very Badly- 1

Mental states

Distinct – 4

Apathetic – 3

Mishmash consciousness-2

Stupor - 1

Activity

Walk by himself -4 Walk with help – 3

wheelchair – 2

Lay patient -1

Moveness

Full -4

Insignificant limit -3

Significant limit – 2

Absence -1

Incontinent

Abscence -4

Sometime-3

Urine -2

Urine and excrements -1

25 score and less – risk of decubates development

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General Surgery Department of Russian State Medical University

Inspection of skin Examine and feel the skin Chap

Change and color

Cyanosis, redden or pale

Chap and spots

Theoretical substantiation Ageing of skin has influent of defense barrier’s state, decrease of perception of pain and property of immune system. Heal of wound is slow down. Dry skin is more expose to damage Chaps is way for microorganisms into the tissue 43

General Surgery Department of Russian State Medical University

Law of 17 April 2002 г. №123 Extract of law

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

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Sufficient prevention of decubates may be avert this in 80% cases with high risk.

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General Surgery Department of Russian State Medical University

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

Health-and-social-development department of Russian Federation

Law of 17 April 2002 г. №123 «Approve of medical standard «Protocol of treatment a patient. Decubates.»»

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General Surgery Department of Russian State Medical University

Prophylaxis is best treatment! For prophylaxis of decubates is need to keep clear of skin and her humidity: -

Washing of skin make without friction and lump soap Use the liquid soap Keep middle humidity of skin In excessive humidity – wear out, in dryness - damp Use waterproof swaddling band and napkin Change the position of patient each 2 hours, including night time 46

General Surgery Department of Russian State Medical University

Cleaning of skin   

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

Nutrition and dump of skin 

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

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Pink color is protect.

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Skin protect  Protect of damage and sicken skin

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General Surgery Department of Russian State Medical University

Wet hygienic serviettes  

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Big serviettes from gently material, it is read to use It’s use without water and soap, help in prevented decubates from lay patient and support the skin in healthy state. Serviettes is intend for skin cleaning by wipe, before and after operation period, in lay-patient cases and for intimate toilet It’s addition means for prophylaxis decubates with enuresis during change the napkin. Time of procedure no more than 5 minutes 48

General Surgery Department of Russian State Medical University

Cleaning of skin MENALIND®   

Ideal mean for washing lay patient in the bad. Do not need in additional washing. Special mean for prophylaxis decubates for patients who need in long-time badly regimen

Application: For washing of lay patient 10 ml wash liquid dissolve in 1,5 liters of warm water. Wear through skin and drying after procedure. To take a shower according 5 ml. Procedure time no more than 5 minutes.

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General Surgery Department of Russian State Medical University

Nutrition and damp of skin MENALIND®

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Protection of skin from lose the liquid and recovery her elastic property. Ideal mean for nutrition and damp of skin for lay patient.

Application: - drift 15-20 ml liquid on pure skin. - Event drift from skin surface - Time of procedure 5-7 minutes 1 bottle it is enough for 25-30 patient

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General Surgery Department of Russian State Medical University

Skin protect

MENALIND®

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

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General Surgery Department of Russian State Medical University

System of individual methods to enuresis problem Easy state Less than 100 ml of urine during 4 hours Medium state 100-200 ml of urine during 4 hours Hard state 200-300 ml of urine during 4 hours Most hard state more than 300 ml of urine during 4 hours

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General Surgery Department of Russian State Medical University

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General Surgery Department of Russian State Medical University

• Pants with catcher (napkin for adults) • It’s recommended for patient suffer enuresis • adsorbed pillow consist of special absorbent change liquid to gel. •Special molecules is soak up smell and prevent from him dissemination •Many-use clasp is help for change napkin and •Full-indicator is inform when napkin would be change •Three-coat absorbed pillow and T-form is promote to prevention decubates in sacrum zone 54

General Surgery Department of Russian State Medical University

Chain of dressing napkin to the patient

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General Surgery Department of Russian State Medical University

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

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General Surgery Department of Russian State Medical University

Addition means for care the patient 1. 2. 3. 4. 5. 6. 7. 8. 9.

Gauntlet for washing Lining sheet Breastplates Cotton sticks Pallets Mask Latex gloves Smocks Apron for protect clothing

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