- •The thematic module 1
- •Introduction to surgery. Desmurgy. Aseptics and antiseptics. Features of care of patients in the surgical department. Surgical operation. Practical employment № 1
- •IV. Table of contents of teaching
- •Introduction to surgery
- •V. Reference basis of actions
- •Vі. Tasks for verification of eventual level of knowledges.
- •Vіі. Методика проведения занятия и организационная структура занятия
IV. Table of contents of teaching
Introduction to surgery
Surgery is the region of medicine, studying illnesses and traumas of all regions and organs of still human body, elaborative and applying the special methods medical treatments.
In the word for word translation «surgery» means «handiwork» (from greece cheir – hand, ergon – I operate). Surgery of beginning to develop considerably earlier than other sections of medicine – practically from the origin of humanity. A hunt, wars, were the permanent satellites of man, and he was forced to learn to stop bleeding from a wound, to delete sticking in a body arrows. However, as science she was formed only in XIX century.
The name of doctor of Ancient Greece is well-known Hyppokrat (460-370 B.C.), as of right of considered the father of scientific medicine and surgery. His principle of «Ubi pus ibi evacua» («Seeing a pus, let out») is fundamental in medical treatment of festering-inflammatory diseases.
Large contribution to development of surgery brought in Abu Ali Ibn-Sina, known as Avitsenna (980-1037). The known his labour «Canon of medical science» remained a table book for doctors up to XVII century.
Dominant influence of church in Middle Ages halted development of science, including surgery, and in 1215 was forbidden to be engaged in surgery on that foundation, that christian church «oppositely bloodshed». So surgery was separated from medicine and equated to the workshop of tsiryulnikov. Tsiryulnik (hairdresser) clipped, shaved and «opened a blood».
Universities in Italy (Bolonya), France (Paris) appeared in the epoch of late dark ages, on the medical faculties of which surgery was excluded from teaching. However prohibition to teach surgery could not halt its existence, as patients needed the help of people, which were able to treat wounds, breaks, dislocations, to stop bleeding and other.
Opening of the W. Harvey (1578-1657) system of circulation of blood, based on own and preceding researches on the anatomy of heart and vessels (including on the Vezaliy researches), had the enormous value in development of medicine and surgery. He opened two circles of circulation of blood and proved that no air circulates in the vessels of lights, as was accepted then to consider, and blood.
Surgery as science got official confession in 1719, when the Italian surgeon Lafranshi was invited on the medical faculty of Sorbonna for reading of lectures on surgery.
The Kievo-mogilyanskaya academy (1622) was the first educational establishment on Ukraine, where preparation of theologians, medical workers and other was conducted
In 1755 the Moscow university with a medical faculty and «clinics at a faculty» is opened.
For one century, since a middle XIX century, a such sharp jump happened in development of surgery, that measured up repeatedly surpassed all, that was done for preceding millenniums. In it opening were instrumental XIX – beginning XX centuries, making foundation of subsequent development of surgery: opening of anesthesia, introduction of anesthesia and local anaesthesia to surgery; development and introduction of asepsis in surgical practice; methods of stop of bleeding and filling of blood loss in; completion of forming of modern anatomy, creation of topographical anatomy and perfection of surgical technique.
N.I. Pirogov is deservedly considered leading light of home and foreign surgery (1810-1881). In 18 years he made off the medical faculty of the Moscow university. Beginning in 26 years professorial activity in the Derpt university N.I. Pirogov spared large attention of anatomy, created the applied (topographical) anatomy. He was the virtuoso of surgical technique thanking, as he spoke, to knowledges of anatomy and surgery.
Investment of N.I. Pirogov in surgical science is enormous. He widely inculcated ether anesthesia (executed 10 000 operations to injured), developed his new methods – rectal and endotracheal. To them basic principles of the military field surgery are developed: approaching of medicare to the battle-field, sorting of injured, succession in helping on the stages of evacuation, creation of mobile hospitals. On these principles, providing of medicare in the period of Great Patriotic war was founded 1941-1945 Classic description of traumatic shock belongs to him.
Karavaev V.A. (1811-1892) – surgeon of wide type. In 1840 led the department of faculty surgery at the Kiev university. One of the first (in 1847) applied anesthesia. V.A. Karavaev is executed about 16 000 operations (number striking for the surgeon of preantiseptics period). The row of his works is devoted to the plastic operations at a harelip, rhynoplastic, to amputations. Worked under the direction of N.I. Pirogov in Derpt, considered itself his student. Used large popularity among the population. The utterance of congregant which went to God to pray in large Monastery was saved until now: "I ride to Kiev to God to pray, and Karavaev to worship".
After N.I. Pirogov development of home surgery in a great deal is related to the N.V.Sklifosovsky name (1836-1904). He worked in Kiev, Petersburg, Moscow. N.V.Sklifosovsky to one of the first in Russia began to develop an antiseptic method. The developed to them bone operation on comparison and fixing of bones is known as the «Russian lock».
Volkovich N.M. (1858-1928). In 1882 made off the medical faculty of the Kiev university. In 1903 became the professor of department of hospital surgery. In 1894 first from home surgeons executed laminectomy, offered the cut of front abdominal wall at appendectomy (1898). Large vogue was acquired by the Volkovich tire for the immobilization breaks of shoulder. In 1908 organized Kiev surgical society and was his permanent chairman.
Academician of NAS and AMS of Ukraine N.M. Amosov (1913-2003) – founder of the Kiev institute of cardiovascular surgery, carrying his name now. Thoracal surgery and biocybernetics were basic direction of his science and practical activity, he developed the questions of surgical medical treatment of diseases of easy, heart, artificial circulation of blood, physiology of heart, designs of thinking processes and psyche.
Academician of NAS and AMS of Ukraine A.A. Shalimov (1918-2006) – founder of modern surgical school in Ukraine. In 1972 founded Kiev Institute of clinical and experimental surgery (now Shalimov memorial Institute of surgery and transplantology AMS of Ukraine). With 1980 on 2004 A.A. Shalimov worked as a main surgeon of ministry of health protection of Ukraine. Science and practical activity of him was devoted to development of different directions of surgery: to reconstruction-restoration medical treatment of pathology of gullet, stomach, intestine, liver, bilious channels; corrections of diseases of pancreas, cardiac surgery, surgery of vessels, endovascular surgery, cryosurgery and other.
Success of surgical help is determined by joint work of ambulatory-policlinic surgical separations and surgical permanent establishments. A succession in work is very important here: prestationary inspection of patients, completing of them finish the cure after the extract from permanent establishment and other.
Special seat in the structure of medical establishments is taken by clinical hospitals. Departments of surgery of medical universities, the separations of research institutes work on the base of large surgical permanent establishments and give large help not only in practical work, but main – in organization of surgical work, carrying out research, introduction of scientific achievements of surgery in practice.
Hygiene in surgical permanent establishment.
Hygiene of surgical permanent establishments – undressed hygienes, elaborative hygienical norms and requirements to the location, planning, sanitarno-tehnicheskomu equipment with modern amenities. The sanitary-hygienical and antiepidemic mode of permanent establishments is created with the purpose of providing of optimum terms of stay of patients in permanent establishment, effective conducting of medical measures, providing of favourable terms of labour of medical personnel, prophylaxis and rendition of nosocomial infection harmless.
Patients in surgical establishments are divided on «clean» and «festering», clean and festering surgery is distinguished in this connection.
Clean surgery is engaged in medical treatment of patients without the festering and inflammatory diseases. Festering surgery gives help to the patients at which the reason of disease is an infection. Taking into account possibility of transfer of infection from «festering patients» to «clean», patients with the festering diseases are insulated in the special chambers or separations of festering surgery.
The surgical separation consists of chambers for patients, operating block, bandaging, manipulation cabinet and utility rooms (sanitary knot, bathroom, table, buffet, room for linen, personnel and etc.).
The sanitary-hygienical mode foresees the observance of norms of capacity of hospital chambers, providing of optimum microclimate, chemical and bacteriological composition of air environment, mode of ventilation and illumination of apartments, delivery of high quality drinking-water, timely and complete deleting and disinfection of wastes, providing of patients with the rational and balanced feed, cleaning up of apartments, eliminations and changes of linen, observances of rules of the personal hygiene and others like that.
The antiepidemic mode of surgical separation is directed on prevention of origin and distribution of nosocomial infection. Basic positions of the antiepidemic mode are regulated by the order №720 (31.07.1978).
Infection – this state of infection of organism by pathogenic microbes, which co-operation between the exciter of disease and macroorganizm in the definite terms of external and internal environments is at.
The sick organism of man or bacterial carrier can be the source of exciter of infection.
Hospital or nosocomial (a term originates from the Greek words of nosos [illness] and komein [to treat], and later from Latin nosocomium [hospital]) infection – it is an infection which strikes a patient at the receipt in a hospital or other medical establishment, and also medical personnel during realization of his professional activity.
It is considered on the whole, that a period by duration 48-72 hours from the moment of receipt testifies to the nosocomial reason of infection. Except for growth there is frequency of complications and death rate, a nosocomial infection is dangerous to those, that often microorganisms resistance to medical preparations come forward the reason of her.
The nosocomial infection can be localized in any part of body, however more frequent than all there are the infections of respiratory tracts, infections of catheters for infusion, infections of urinary tracts and infections of wound surfaces.
Development of nosocomial infection relies on two key factors: weakening of protective functions of organism and colonization by pathogenic or potentially pathogenic bacteria.
The way of distribution of infection foresees the methods of prophylaxis of his transmission. Fauces is the basic reservoirs of nosocomial infection, digestive channel and urinary tracts. In obedience to the results of analysis, 83 % cases of nosocomial pneumonia are related to mechanical ventilation, 97 % cases of infection of urinary tracts is investigation of catheterisation and 87 % cases of primary hematogenic infection are related to catheterisation of central vessels. Nosocomial sinusitis, that multiplies development of nosocomial pneumonia, is observed more frequent at patients with gastric probes.
Basic exciters of nosocomial infection: Staphylococcus aureus (30 %), Pseudomonas aeruginosa (29 %), coagulase-negative staphylococcus (30 %), Escherechia coli (13 %), Acinetobacter (9%), Klebsiella (8 %).
Nosocomial infections divide by hospitals and ambulatory.
Basic ways of transmission of nosocomial infections – aerosol (droplet and air-dust), contact, including parenteralniy, fecal-oral, in particular alimentary; transmissive. Air, hands, are the basic factors of transmission of infection, objects of environment.
Every employee which settles down on work passes complete physical examination, short instructing on conducting of basic sanitary-antiepidemic measures. At the exposure of the opened inflammatory processes or signs of indisposition a personnel is removed from work to complete convalescence, at the exposure of transmitter – organize to sanation. In case of beginning of nosocomial infections the extraordinary medical review of all personnel of separation and bacteriological inspection is conducted on a transmitter. Insulate patients with the exposed nosocomial infection in separate chambers and select a separate personnel and articles of care for them.
In case of beginning of nosocomial infection every case is subject to consideration, registrations with filling of form 058-0 and requires the detailed epidemiology inspection with bringing of epidemiologist of sanepidstation.
The control after the observance of the antiepidemic mode in medical establishments is carried out in obedience to the order of ministry of health protection №720, that foresees the obligatory bacteriological control of the state of air environment, surfaces, quality of sterilization and disinfection.
Prophylaxis of nosocomial infection in permanent establishment:
Sanitary and hygienical measures:
mode of ventilation (ventilation, conditioners, portable air cleaner);
cleaning up of apartments (regularity of conducting, use of disinfectant agents, disinfection of harvest inventory);
disinfection of bed things (disinfection chamber);
complete sets valid for one occasion.
Placing of patients:
observance of sanitary norms of equipment of boxing;
equipment of chambers for the patients HIV/AIDS;
isolation of patients with complications.
Rational therapy:
rational antibiotic therapy;
validity of therapy.
Sanitary and antiepidemic mode:
disinfection, presterilization treatment and sterilization of tool (the centralized sterilization separations);
safe feed (control of easting establishment, rational storage of products);
control of health (medical personnel, hospitalized patients).
The observances of general principles of hygiene are the most effective strategies, rules of introduction of catheters and care of them. The presence of rings on fingers diminishes efficiency of hygiene of hands, therefore it is recommended to take them off.
Work of the nurse.
In the work a medical sister (Nurse) is under an obligation to execute the orders and pointing of doctors which she works under the direction of. Each Nurse must be able to provide transportation and carrying from place to place of seriously sicking and injured and in the necessary case to organize their transporting. Nurse must be also able to execute elementary laboratory researches. In circulation with sick Nurse must possess large patience and time, showing high humanism. Nurse, equally as well as other medical staffs, must strictly observe a professional secret.
The senior medical sister of separation submits to the manager by the separation of hospital, manages work of Nurse and junior nurses of separation, controls work of chamber Nurse, organizes drafting by chamber Nurse requirements on medications, bandaging materials, instruments and articles of care of patients, signs them, controls the rightness of consideration and storage of medicines; senior to Nurse looks after the sanitary state economy of separation, after the feed of patients and dr. Senior to Nurse carries out measures on the in-plant training of middle and junior medical personnel of separation. In the difficult case she the first comes to for help chamber Nurse
The chamber medical sister submits to the manager by the separation, senior to Nurse separations and doctor-intern. She is under an obligation to know patients in chambers which after her are fastened, the state of their health, features of flow of disease at them, to carry out the care of patients; to be present at the round of patients with an intern or duty doctor; to take to the patients the temperature of body, on purpose of doctor to determine frequency of pulse, breathing and etc In the case of the sharp worsening in a state of sick Nurse immediately reveals about it to the doctor and gives urgent predoctor help to the patient to arrival of doctor.
Nurse is under an obligation exactly to execute all setting of treating doctor: at delivery to the patients of medicine of Nurse watches after that medicine was accepted in its presence. Nurse collects for research the urine, excrement, mokrotu, takes swabs from a pharynx and nose and other, passes them in a laboratory, watches after the receipt from the laboratory of results of research.
Chamber to Nurse provides the observance of the set internal order and sanitary mode in chambers, watches after the timely receipt of all necessity for the care of patients and their medical treatment. In its duty the work with registration medical documents enters also.
All measures on preparation of operating-room to work are included in the duty of operating medical sister. She must heed after a junior medical personnel and warn a surgeon about violation of asepsis from the side of present persons on the operation (students, doctors and other).
Providing of surgeons is the main duty of operating medical sister by necessary instruments and materials during the operation. She must check up the good condition of tool. To give an instrument to the surgeon it is needed so that not to injure him a hand. An operating medical sister is under an obligation well to know all motion of operation, and if anything to her not clearly, to ask a surgeon about it.
The supervision after that enters in the duty of operating medical sister, that during the operation in an operating wound by a chance a serviette, marbles, some instrument or other foreign body, was not left. It easily can happen at the cavernous operations. In order to avoid it the serviettes and instruments consider both to, and after the operation. In those case, when a surgeon has not the helpers, an operating medical sister can in order of exception execute the function of assistant.
Thermometry. The temperature of body of man remains at any terms in relation to permanent. Maintenance of constancy of temperature of body is provided by the difficult processes of thermoregulation.
The temperature of body of healthy man, measured in an axillary cavity, hesitates within the limits of 36,4-36,8°C. Lethal maximal temperature of body (which death of man comes at) makes 43°C, lethal minimum temperature – 15-23 °C.
The normal temperature of body, measured in a rectum, vagina, inguinal fold, cavities of mouth, turns out on 0,2-0,4 °C higher, than in a axillary cavity. Almost at all people it is possible to find out day's fluctuations in the temperature of body, making usually 0,1-0,6 °C. Maximal temperature of body is registered in the second half of day (18 hours), and minimum – it is early in the morning (6 hours).
Measuring of temperature of body carries the name of thermometry (from Greek therme – warmly, metreo – to measure) which is conducted by a medical mercury thermometer. Temperature of body is most often taken in a axillary cavity, rarer – in an inguinal fold (at children), cavity of mouth, to the rectum and in a vagina.
Duration of measuring of temperature makes 10 mines. Thermometry is conducted, as a rule, 2 times per a day: in the morning at 6 o'clock and in the evening at 18 o'clock. In a number of cases, for example, at the fever there is a necessity in more frequent measuring of temperature of body (through each 2-3 hours).
For the graphic image of day's fluctuations in a temperature bodies make temperature charts on which by the proper points the results of daily twice thermometry are inflicted. These points are connected between itself, forming the so-called temperature curves reflecting one or another its type at the fever.
Injections. Introduction of medicinal matters is named the injection by their special festering under constraint on a different environment of organism. Depending on it the intradermic, hypodermic, intramuscular and intravenous injections are distinguished. On the special testimonies endarterial, intrapleural, endostal, intracardial introduction of medications is applied.
The injection methods of introduction of medications are applied in those situations, when it is required quickly to attain a necessary effect, for example, at medical treatment of the urgent states. High speed of receipt of medicinal matters in a blood and exactness of their dosage is thus provided, and the required concentration of preparation in a blood thanks to the repeated injections is supported enough long time.
The injections are usually conducted by syringes and needles. So-called unneedle injectors which allow to enter intradermic apply presently, hypodermic and intramuscular medicinal matter without application of needles. Action of unneedle injector is based on power of stream of the liquid given under definite pressure, to penetrate through skin covers.
The intradermic injections are used in diagnostic purposes for raising of the tuberculin reaction Mantu, different allergic tests, and also on initial stages during conducting of local anaesthesia. For implementation of intradermic injections the internal surface of forearm is chosen usually.
By the hypodermics the medicinal matters which are well sucked in in a loose hypodermic cellulose are entered. Are the most comfortable place for the hypodermics outward surface of shoulder and thigh, subscapular region and, for introduction of some preparations (for example, heparin), – lateral surface of abdominal wall.
The medicinal preparations entered intramuscular are sucked in quick, than at the hypodermics. For conducting of intramuscular injections more frequent all are chosen by places, where well enough a mishechniy layer is developed: upper-external quadrant of buttock, anterior-external surface of thigh, subscapular region.
The intravenous injections more frequent than all are produced by vein punction (penetrate skin introduction of needle to the vein), rarer – with the use of vein section (dissection of road clearance of vein). The intravenous injections are more responsible manipulations, than hypodermic and intramuscular injections, and they are executed usually by a doctor or specially trained medical sister, as concentration of medicinal matters in a blood after intravenous introduction grows considerably quick, than at application of other methods of introduction of medications. Errors during conducting of intravenous injections can have the most serious consequences for a patient.
Intravenous inflowings are applied for introduction to the organism of a sick plenty of different solutions (3-5 l and more); they are the basic method of the so-called infuzion therapy. Intravenous inflowings are applied in those case, when it is necessary to recover the volume of circulatory blood, to normalize water-electrolyte balance and acid-basic state of organism, to remove the phenomena of intoxication at the heavy infectious diseases, poisoning. If it is necessary quickly to enter the medicinal matter (at shock, collapse, heavy blood loss), use stream intravenous inflowings. If medicinal preparation must enter of the circulatory system river-bed slowly, tiny introduction is applied. In those situations, when a question about the protracted (during a few days) introduction of plenties of solutions gets up, catetherisation of veins is applied.
Intravenous inflowings are carried out by the special system for tiny introduction.