5. Content of the lessons

Introduction to surgery. The first information about the surgical manipulations has appeared at ancient times. For 2-4 thousand years BC various surgical procedures were performed in ancient Egypt, India, Babylon, ancient Greece and Rome, Byzantium and China. From the doctors of this period we can ditinguish Hippocrates, Galen, Celsius, Avicenna, who initiated the scientific surgery. From the Middle Ages physicians may be distinguished Paracelsus, Pare Ambruaz, Vezaliy and others. The rapid development of surgery starts at the 19th century after the discovery by Louis Pasteur agents of surgical infection, and its prevention method of Lister, which was the basis of antiseptics. Development of surgery is associated with such names like Peter the 1st, Lomonosov, Sklifosovskyy, Dyakonov, Pirogov. In Ukraine, the first medical institution was Kiev-Mohyla Academy, founded in 1671 Peter Mogila. In the second half of the nineteenth century surgical clinics of Kharkiv and Kyiv become real centers of surgical science and practice in Ukraine. Teaching surgery is performed here by such famous scientists as V.O.Karavayev, M.M.Volkovych and Y.Shymanovskyy. Many prominent surgeons came from educational institutions of Ukraine, some of them headed surgical department of universities. With such eminent surgeons as Volkovych M.M, Krymov A., Vishnevsky A.A., Petrovsky V.V., I. Ischenko, Kolomiychenko M. are connected organization of new surgical schools in Ukraine.

In 1957, a prominent surgeon Amosov M.M. established in Kiev, the first department of cardiac surgery, and in 1983 - organized the Institute of Cardiovascular Surgery. In 50th years of the previous century begins the formation of anesthesiological service in Ukraine. Anesthetics centers are organized at the leading surgical clinics. In 1957, the department of thoracic surgery was transformed into a Thoracic Surgery Department of the Kiev Institute of improvement of doctors led by Professor A.I.Treschynskyy. Important role in improving diagnosis and surgery for diseases of the abdominal cavity played Institute of Clinical and Experimental Surgery, which was created and headed by Academician Shalimov O.O.

Organization of surgical care in Ukraine. Surgical care is one of the most important forms of health care. The basis of modern surgical care system is inherited from the former USSR. This assistance is organized on a territorial basis and phasing of the population of country from lower stage to higher subordination. The organization provides maximum approximation to the residence of the patient and provides appropriate first regional medical institutions. Organization of surgical care includes ascending, primary health care, skilled and specialized surgical care. Surgical assistance is divided into rapid or emergency that requires patients with acute illnesses and injuries, and planned, carried out for patients with chronic illnesses. Primary emergency medical care for patients with acute surgical diseases and injuries is provided by ambulance, medical items and emergency doctors.

Qualified emergency and planned surgical assistance is provided in general surgical hospitals, central district of city and regional hospitals. Development of surgery led to a selection of self discipline traumatology, orthopedics, oncology, urology, pediatric surgery and others, thus, specialized assistance is available in these departments. Important role in providing skilled and specialized care for the population have a surgical clinic medical universities, which operate on the basis of general surgical departments of city and regional hospitals.

Structure of the surgical clinic Medical institutions, which provide surgical help to patients are divided into 2 types: outpatient and inpatient. To outpatient refer clinics, which have surgical rooms and offices, as well as ambulance and emergency care. Inpatient hospitals include multidisciplinary and specialized clinics. Inpatient hospitals can be designed to provide emergency assistance and to assist in a planned manner. The basis of the surgical inpatient hospital is the principle of respect for the rules of asepsis and antisepsis. It is necessary for prevention traumatic infection, creating conditions for operations, investigation and care of postoperative patients. The main surgical hospital departments are: admission department, medical-diagnostic department and operating unit.

Sanitary-epidemic mode of admission department at the

hospital Admission department is part of the hospital in which the transmitting and registration of patients is held, also review, physical examination and initial diagnosis, sanitization, transportation of patients to the medical department, informational work is done here as well. In addition, if necessary in the admission department is provided emergency medical care. At centralized planning system of hospitals, practically all therapeutic and diagnostic departments, including admission department are located in one building. With decentralized (pavilion) system, admission department is located in a separate building or in the same medical building with the resuscitation, therapeutic or surgical department. In some hospitals there is no central admissionsdepartment, and each medical department receives patients themselves. Admission department should be placed near the entrance to the hospital and be easy to transport patients - have paved access paths, wide staircases and doors for the passage of a stretcher. Nurse of admission department prepares documentation for patients entering the hospital. In observation room, the doctor examines the patient; here is done thermometry, and sometimes other surveys (eg, electrocardiography). Patients with undentified diagnosis, place temporarily to the diagnostic rooms, and patients with suspected infectious disease are placed in prison. If necessary, at procedure rooms doctors provide emergency care to patients. Sanitization of patients, who enter to the hospital, is conducted in changing rooms.

Admission of patients in hospital and their registration To the admission department of the hospital patients arrive: 1) if sent by their doctor in case failure of outpatient treatment, the so-called planned hospitalization, 2) by emergency car in case of accidents, injuries, diseases or acute exacerbations of chronic diseases, 3) independently, without referral if the patient became ill on the street and he arrived to the admission department, 4) a transfer from other medical institutions. Depending on the patient's condition they are either hospitalized or provided with first aid and directed to be treated at home. Patients, who need help in the resuscitation department, for example, patients with myocardial infarction, enter the appropriate office, bypassing the admission department. Patients who arrive at hospital get inspected at the admission department by physician for the presence of infectious diseases and lice. The doctor examines the skin, hairy areas of the body, pharynx, and measures body temperature.

After resolving the issue of hospitalization, treatment and sanitary way to transport patient, the nurse at the reception of admission department prepares appropriate medical records: a cover page history (f. 003-u), "Magazine of registration of patients" (f. 001-u.) All data about patient nurse receives from the patient, persons who accompany him, or medical personnel of "emergency." Nurse also fills the "Statistical map of dismissed from the hospital" (f.066-u) that she puts in medical history. All data about patient nurse puts in alphabetical book, which is an important document for reference service.

Sanitary Processing During hospitalization of the patient to a hospital in changing rooms of the admission department is conducted sanitization, which includes the following procedures: a review of the body to detect infectious diseases, scabies, trichophytosis; review of the scalp and clothes of the patient to detect lice, if necessary - cutting of the nails, hair, shaving ; providing of hygienic bathing, showering or sponging, depending on the patient's condition, changing patient in a clean hospital gown. The need for sanitization and its volume solves the doctor. Changing rooms should be equipped with everything necessary for sanitary treatment of the patient: couches, cabinets for clean underwear and a tank for dirty linens, washcloth for washing patients, soap, hair clippers, razors for shaving, scissors, air and water thermometers, washcloth and brushes for the processing of bath, specially selected labeled equipment (buckets, mops) for cleaning and disinfection of premises of changing rooms, and plenty of disinfectant solutions.

Carrying out of treatment of patients with pediculosis is done under the order № 410. In the changing room there is special kit, which includes the following items: magnifying glass, desk lamp, razor, scissors, clipper hair, bushy crest, put up karbofos, quart for solution of karbofos, 10% acetic acid, oilcloth for combing out hair and bucket for its combustion, and oilcloth kerchief, bag for clothes, sunglasses, two masks, gown and kerchief for staff. Depending on the patient's condition and approved by the physician type of sanitization method, patient gets hygienic bath, shower or sponging.

Debilitated patients or those who have been stayed in bed for long time and thus could have fainting, must be accompanied to the bathroom, and stay under control when sitting there and exiting from it. If the patient can not wash himself, nurses wash him. When washing it is necessary to constantly monitor the patient. In case of deterioration of health of the patient (dizziness, palpitations, pain in the heart, pallor) washing should be stopped. If possible, it's better to wash patients in the shower, while patients standing or sitting on a stool. If the tub and shower are contraindicated, patients get wiped with warm soapy water. After sanitization patient wears clean clothes and hospital slippers. On the front page of history nurse makes a note about conducted sanitization.

The room of admission department should be cleaned at least twice a day by wet method using disinfectant solutions (1% solution of chlorine bleach, 0.5% solution of bleach). From the admission department, the patient is transported to the appropriate department of the hospital. Medical department of the hospital consists of rooms for patients, treatment rooms - for injection, manipulation - for setting enemas and performing some other manipulations, pantry, ordynatory rooms (lab for doctors), cabinet of senior nurse, and room for storage of clean linen.

For every 25-30 beds of general hospital stands nursing post. It should be placed close to the rooms which are served. Post of the nurse should be equipped with a desk, cupboard for storage of medicines, medical instruments, safe storage of drugs (lists A and B), moving table to distribute drugs, a preparation table for the various manipulations, a refrigerator for storage of perishable items. The work of nursing post is organized according to hospital reigime. During the day the nurse takes the prescription of the doctor, preparing patients for various researches and accompanies them in diagnostic laboratories, distributes medication, does required injections, helps to feed the seriously ill patients. An important aspect of nursing is the acceptance and delivery of duty.

Nurse may not leave the post until it reaches its next change. Nurse who took the place of previos nurse, together with the one, who finished, bypass rooms, check sanitary status of the rooms, pay special attention to seriously ill patients. Nurse, which delivers duty, reports about the changes in the state of these patients during the duty, talks about the volume of appointments made, emphasizing those appointments that have to be done during the next duty.

Hygiene of the patient. Prevention of pressure sores.

Before entering the hospital patient gets sanitization. The department provides the patient with a set of clean bed linen. In the morning after the night of sleep walking patients get washed at the special toilet, and lying patients get washed by nurses: patients who can sit in bed, get poured water from a pitcher on their hands and they wash themselves, brush their teeth, and lying patients get wiped only (face, hands ) with moistened towel or cloth. Severely ill patients after surgery should have inspected the mouth, nose, eyes. Mouth is rinsed with 1% solution of potassium permanganate or sodium bicarbonate, and the teeth and gums nurse get rubbed with a cotton-gauze ball.

Eyes of patients are washed with cotton-gauze ball, dipped in digested water or isotonic sodium chloride solution, and in case of presence of bacterial inflammation of the conjunctiva in the bag last are instilled solution or made an ointment containing sulfonamides (eg, 20-30% sulfatsil-sodium) or antibiotics. Walking patients shave themselves independently, and lying patients get shaved by barber, keeping all preventive measures against infection. For walking patients at the toilets (separate for men and women) are created conditions for washing after defecation and for washing in the evening and morning of the genital area. Lying patients get washed by nurses. Along with cleaning the skin from contamination, seriously ill patients get washed in areas of bone appearances - buttocks, shoulder blades, spine, five - rubbed with camphor alcohol (ethyl or 60%). This prosedure, as well as frequent patient turning in bed, smoothing out the sheets underneath (smoothing out the wrinkles on it), etc. are important steps to prevent bed sores.

Weekly patients get new clean underwear and bed sheets and get washed. Linen, contaminated by traumatic or other secretions, change by request. Patients should always be based on clean and dry laundry. To prevent bed sores seriously ill patients, especially of elder age, patients with diabetes need to underlay under the buttocks, rubber wheels, and under five - cotton-gauze or foam pads, it's necessary often turn them, changing body position. In recent years, to prevent bedsores widely used special air mattresses and other multi sectional. Patients, especially with obesity, must be observed and prevented dermatitis and infection of the skin by rubbing inguinal folds, the folds on the abdomen and under the breasts by 56-70% ethyl alcohol, to sprinkle these places with talc or tooth powder or - by the appearance of skin disease - get lubricated with ointment zinc oxide paste or paste of Lassar.

The positioning of patient in bed should be physiological, i.e., to provide the most relaxation of all muscle groups. This reduces the energy costs of his body and promotes optimal performance of the functions of all organs and systems. This meets the requirements of the position on the back with a slight lifting of the head and feet. It's forbidden to put leg across another leg for laying patients, because it promotes the development of thrombosis of leg vessels. In some states the patient with prolonged nausea and vomiting, especially after anesthesia, is put on his back, with a little turning aside his head. In the horizontal position (without raising the head end of the bed) should also be patients with bleeding and anemia after bleeding. This position promotes blood flow (oxygen) to the brain and heart. Conversely, patients with respiratory failure shoud have half-sitting position (orthopnea). With increased head lay also patients after operations on organs of the oropharynx and neck.

Hygiene to the patients can be properly granted only if thee is hygiene of his bed, bedding, clothes, apparel, equipment care and transportation, that is all that surrounds the patient. Bedside daily are wiped clean with wet cloth and periodically disinfected with 3% solution of bleach or lizolom. Winders and litters should be cleaned, and in case of contamination of fluids should be disinfected. An important and technically complex is the change of underwear and bed linen of seriously ill patients. It's often done by nurses. Hygiene of the lying patient also means providing support to the special dishes for the timely implementation of the physiological acts - bowel movements and urination, retention of which negatively affects the physical condition of the patient, especially in the nervous and cardiovascular systems, as well as mental state.

Urinal dish in a pure condition is kept under the bed of the patient so that he could use it himself (and especially for the seriously ill - even on a single bedside table), covered with clean cloth. Bedpans are stored in a desinfected way in special cabinets or on shelves in the toilet. Nurses, who are serving patients during defecation or urination, work the appropriate attire - oilcloth or plastic apron, rubber or plastic gloves. After finishing the nurse immediately removes the vessel or urinal and, covering with the oilcloth, refers to the bathroom, where immediately pour into the toilet or leave to review by physician or get disinfected. After this same sister is washing the patient, wipes around the anal opening the skin and then removes the oil cloth. In the absence of patient of self-defecation he needs a cleansing enema. This procedure is done by the nurse. After the enema defecation occurs at the same sanitation provision as an independent.

Patients, especially older men, after abdominal surgery often have delayed urination. In cases where the patient has the urge to urinate, and urine can not be produced more than 6 hours, should be entered the bladder catheter to withdraw it. But this procedure should be directed by a doctor. It should strictly observe the rules of asepsis. Nurses during patient care in the implementation of defecation and urination use oilcloth, aprons and disposable gloves, which are then destroyed. Important role in ensuring of the quality of care play a teaching of nurses by more experienced nurses with special education, respectful attitudes for them from the doctors, caring for them.

Transportation of patients and hygiene of the transport.

Seriously ill patients and patients, who can not move by themselves, with the admission department of the hospital, carry the wards on chairs for sitting or lying, respectively. Winders for lying patients should be covered with a plastic or oilcloth covered mattress that after each use is wiped with bleach solution of 3%. Patients who can not walk, but do not require the supine position, are carried on a stroller for seated patients.

In the absence of litter for lying patients or inability of using it because of the peculiarities of the disease (of the patient), the patient is transported on a stretcher. In and out of operating roomand, patients are carried on chairs of surgical departments. These vehicles have high sanitary requirements: they must be clean and stored in special local places, covered with pure white cloth or white cloth of patient.

Two or three men move the seriously ill patient out of the bed or operating table on chairs and on the contrary. If three men involved in this process, it's done in the following way: one brings his hands under his head, the second - on the back, and the third is supporting legs. If the patient is moved by two men, they both are on the side of the patient and take it - one, raising his hands at the bottom of the head and chest, and the second - in the pelvis and legs. We must take into account the localization of abnormal cells (lesions, wounds, etc.) on the body of the patient and place arms respectively. Especially attentive and careful it’s necessary to be during transportation of patients in a state of unconsciousness (coma, state of narcotic sleep, etc.), because sharp change of position may cause or breach airway (asphyxia), or injury in cervical spine with paralysis of center of phrenic nerve, which will cause asphyxia.

Nutrition and feeding of patients.

Fedding of patients (along with special medical measures) is an important therapeutic measure, a prerequisite for effective treatment. The disease always leads to metabolic disorders, in particular, to enhancing of catabolic processes - the processes of decomposition and vice versa, to decrease anabolic, restorative. Shift of the the equilibrium exchange toward disintegration and material flow reduces the functional capacity of cells, organs and body tissues, including protective and causes accumulation in the body of harmful intermediate decomposition products and residual substances, creating unfavorable conditions for overcoming illness and recovery.

Therefore, energy consumption of the body due to illness should be compensated in any way. There are two ways. The main of them for most patients are natural, enteral (flow of nutrients through the mouth and intestines). The second way is extraintestinal or parenteral nutritional energy substance that is introduced, bypassing the intestines, in the bloodstream, intravenously. The last way is stimulated. It is used when a patient can not eat because of severe condition or it is contraindicated food given the nature of the illness and surgery (because it can lead to complications, such as food intake in the first days after surgery on the esophagus, stomach or intestines). Along with it, so many patients because of violations of various body functions, including digestion, so high energy costs and poor appetite that even possible enteral nutrition is insufficient for last recharge deficit. In this case, additionally prescribe parenteral nutrition.

Parenteral nutrition is performed by nurses s intended and under strict medical supervision. Medical (ward) nurses hold a special type of enteral nutrition - throughzonding. It is based on entering the stomach or small intestine, even in a tube of liquid supplements - broth, milk, a mixture of glucose and milk and eggs and more. It is prescribed to patients who have bowel function, but interferes with normal eating pathology esophagus or stomach or duodenum (stricture or esophageal burns, stomach ulcers, particularly with stenosis, duodenal fistula or even jejunum), and patients in serious condition (faint etc.).  Walking patients eat in hospital cafeterias. Lying patients eat with help of ward nurses at the bedside. Staff who cares for them, should be disciplined, to work in special robe, put on a mask and rubber gloves, to observe strict sanitation. After each contact with a patient snurse have to disinfect hands (2% solution of chlorine bleach, 0.02% chlorhexidine or 70% ethyl alcohol) and then thoroughly wash them with soap and water. In modern hospitals, especially large (clinical) are increasingly used utensils and disposable instruments (polymer and plastic products), which is much easier for nursing and prevents the spread of hospital infection.

Asepsis and antisepsis.

Observations of the Hungarian obstetrician-gynecologist Ignaz Zemelveis and the great Russian surgeon M.I.Pirohov allowed to conclude "that patrurient’s fever" is caused by cadaverous poison, the cause of suppurations is "miasma" that are transmitted from one patient to another through the laundry, air, bondage material. They suggested methods of prevention: handwashing obstetricians with bleach solution before the test, sorting separating patients with purulent wounds and clean wounds, ethanolic solution of iodine, silver nitrate. English surgeon Joseph Lister proposed use of 3% solution of carbolic acid to reduce germs in the wound, at the hands.

Antisepsis is a complex of facilities and activities aimed at killing germs in the wound tissues and cavities that surround it. Chemical antisepsis - is the use of chemicals to prevent infection and control it. Characteristics of the main antiseptic substances: - Halides (iodine solution 3-5% alcohol, iodofores (yodopiron, povidone-iodine) are used for treatment of surgical field, hands, wounds). A solution of 2-10% chlorine bleach is used to disinfect instruments and gloves, 0.5% chlorhexidine is used to treat wounds; - Oxidizing agents (hydrogen peroxide 3.1% potassium permanganate is used for washing wounds ulcers, burn surfaces);

- Dyes - brylliant green 2.1% metelen blue; - 70-90% ethyl alcohol; - Acids and bases of boric acid 2-3%, formic; - The last in a mixture of hydrogen peroxide is a part of the solution C4. - Salts of heavy metals (nitric acid 1-5% silver, protargol solution); - Nitrofurans (furatsilin, furamagum) are used to treat local infections; - Sulfanilomid drugs, fluoroquinolones, antibiotics, large groups of drugs are used mainly for chemotherapy in the form of local, oral and paranteral treatment.

Antiseptic solutions should be used taking into account the sensitivity of microorganisms, the reaction of adjacent tissues. Work of surgery department and operating room shall march strictly to operating requirements of Sanitary and Epidemiological which controls for sterility premises, equipment, bondage and suture materials, instruments and current control of sterilization and more.

Asepsis is a system of measures to prevent getting of pathogenic organisms in the wound cavity, blood vessels, and development of infection in the body during operations, research and medical procedures. It includes a range of different measures: organizational and technical, hygienic, physical and chemical. Depending on the source of penetration of pathogenic microflora is divided into exogenous and endogenous. Exogenous is air, drip, airborne, contact (implantation). Prevention of exogenous infection consists of rational construction and location of hospitals, organizational, technical and safety measures. The basis of chemical and physical aseptic disinfection and sterilization are all in contact with the operating wound (of things and tools).