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Surgical diseases

Surgery deals with diseases for which treatment is applied, mainly, the method of mechanical influence on tissues, often accompanied by their disconnection to detect a pathological focus and its elimination. Improved, surgical practice uses the achievements of the medical spider in anatomy and physiology, pathology, pharmacology and microbiology.
The range of the surgical method in the present time is very wide, in essence it is used for diseases of all organs and tissues of the body: the brain and spinal cord, heart, lungs, esophagus, kidneys, muscles, bone skeleton, etc. Modern operation is a very complicated act, during which the physiological functions of a sick organism are studied. When violations are detected, a wide range of mechanical, physical, chemical and biological measures are used to restore them. The name "surgery", which literally means "handiwork", "craftsmanship", "craft", no longer fully answers its modern content.
The successes of technology and biological sciences have created the conditions for the transformation of surgery, along with therapy, into the main - a very large and complex medical specialty, the need for which is great. Emergency services - emergency stations, trauma centers and traumatology institutes are organized, 24-hour duty in the relevant departments of hospitals is introduced. All this provides early diagnosis, timely transportation of the sick person to a medical institution and providing him with the necessary surgical care on time.
Antiseptic and aseptic. Before the introduction of aseptic and antiseptic methods, postoperative mortality reached 80%: patients died of purulent, putrefactive and gangrenous processes. The nature of decay and fermentation, discovered in 1863 by Louis Pasteur, as an incentive for the development of microbiology and practical surgery, made it possible to assert that microorganisms are also the cause of many wound complications.
Antiseptics implies a set of measures aimed at the destruction of microbes on the skin, in the wound, pathological education or the body as a whole. Isolate the physical, mechanical, chemical and biological antiseptic.
When the physical antiseptic is provided, the outflow from the wound of the infected content is provided and thereby its purification from microbes, toxins and products of tissue decay. This is achieved by the use of tampons made of gauze, drains of rubber, glass, plastic. Hygroscopic properties of gauze are significantly enhanced when it is moistened with hypertensive solutions (5-10% sodium chloride solution, 20-40% sugar solution, etc.).
Apply open methods of treating wounds without bandaging, which leads to air drying of the wound and thus creating unfavorable conditions for the development of microbes. Physical antiseptics include the use of ultrasound, laser beams, physiotherapy procedures.
Mechanical antiseptics are methods for removing infected and non-viable tissues from the wound, serving as the main nutrient medium for microorganisms. These are operations that have received the name of active surgical treatment of brine, as well as toilet wounds. Are of great importance for the prevention of wound infection.
Chemical antiseptics provides substances with bactericidal or bacteriostatic action (eg, sulfanilamide drugs), which have a harmful effect on microflora.
Biological antiseptics constitute a large group of drugs and techniques, the action of which is directed directly against the microbial cell and its toxins, and a group of substances acting indirectly through the human body. So, mainly on the microbe or its toxins are: 1) antibiotics - substances with pronounced bacteriostatic or bactericidal properties; 2) bacteriophages;
3) antitoxins administered, as a rule, in the form of serums (tetanus, antidiphtheria, etc.).
Indirectly through the body, increasing its immunity and thereby enhancing the protective properties, vaccines, toxoids, blood and plasma transfusions, the introduction of immune globulins, methylthiouracil preparations, etc.,
Proteolytic enzymes lyse dead and non-viable nets, promote the rapid purification of wounds and deprive microbial cells of nutrients. According to observations, these enzymes, by changing the habitat of microbes and destroying their membrane, can make the microbial cell more sensitive to antibiotics.
Asepsis. The method of surgical work, ensuring the prevention of the entry of microbes into the surgical wound or their development in it. On all objects surrounding the person, in the air, in the water, on the surface of his body, in the contents of internal organs, etc. There are bacteria. Therefore, surgical work requires compliance with the basic law of asepsis, which is formulated as follows: everything that comes in contact with the wound must be free of bacteria, i.e. Sterile.
Anesthesiology is the science of anesthesia.
The possibility with the help of drugs to perform a painless operation allows you to reduce complications in surgical treatment and significantly expand their range. Painful irritations change and rebuild all the physiological processes in the body. His reaction to pain is manifested by disorders of blood circulation, metabolism, respiration, etc., especially pronounced in operations on organs such as the heart, lungs, etc. and in patients weakened by the underlying disease and age-related changes. Anesthesia provides not only relief of pain. The task of an anesthesiologist is to manage the vital functions of the body, to identify the causes of their violation in the operated patient, timely warning and elimination before, during and after the operation. Anesthesia - loss of sensitivity occurs due to temporary damage to sensitive nerves.
Achieved by the action of an anesthetic on the brain - general anesthesia (anesthesia) or the spinal cord (spinal anesthesia), nerve endings and trunks at the site of surgery (local anesthesia), there are other types of anesthesia.
Pathological processes underlying the surgical diseases. Although there are many thousands of surgical diseases, but they are based on a few types of pathological processes:
1. Surgical infection - the introduction into the human body of microbes and development as a result of inflammatory phenomena. The range of diseases is very large - from simple cutaneous abscess to such grievous suffering as purulent peritonitis, or a common purulent infection - sepsis.
2. Injury is a wide variety of open and closed injuries: bruises, concussions, sprains, compression, fractures, dislocations, electrical damage, wounds, burns, frostbites, internal organs tears, etc.
3. Tumor tissue growth is fundamental in the emergence of a variety of neoplasms affecting individual organs and tissues.
4. Blood circulation disorders and associated gangrene, ulcers, fistula, etc.
5. Anomalies of development, underlying many diseases.
6. Parasitic diseases requiring surgical treatment (echinococcosis, ascariasis, etc.).
Surgical operations: mechanical influence on tissues and organs, produced for the cure of the disease, relief of suffering or for the purpose of diagnosis.
Operations are divided into bloody, which breaks the integrity of the skin or mucous membranes, and bloodless (for example, straightening of the dislocation). Distinguish between medical and diagnostic operations. Therapeutic are most often used and have a different character depending on the tasks the surgeon sets for himself.
Among them, radical ones are extracted, with the help of which a pathological focus or organ is removed (for example, appendectomy or cholecystectomy), operations performed to improve the function of the organ, restore normal anatomical correlations (for example, hernia repair) and palliative operations, whose task is to alleviate the sufferings of the patient in cases , When the cure is impossible (for example, gastrostomy with advanced esophageal cancer). Diagnostic ones include biopsy, pleural punctures, joints, blowing air into the pleura, renal pelvis, etc., as well as laparotomy, thoracotomy, etc.
For temporary need, they distinguish between emergency, urgent and non-urgent (planned) operations. Emergency should be done immediately: a delay of several hours, and sometimes even minutes, threatens the life of the patient or sharply worsens the prognosis. Such are the operations for bleeding, asphyxia, acute surgical diseases (especially with perforation of the genital organs), etc.
Urgent are considered operations that can not be postponed for a long period due to the steady development of the disease. So, it is impossible to delay operations for malignant tumors for long, because the continuing growth can lead to the formation of metastases. In these cases, an ostex is permissible only for the time needed to clarify the diagnosis and prepare the patient.
Nerorchnye operations (for example, cosmetic) can be made at any time without damage to the health of the patient.
The preoperative and postoperative periods.
The preoperative period begins from the moment the patient enters the surgical department. It is divided into diagnostic, when the diagnosis is specified, the condition of organs and systems is determined, indications for surgical intervention, and the period of preoperative preparation are put. The time may vary in duration, depending on the degree of urgency and severity of the forthcoming operation. Private preoperative preparation taking into account the peculiarity of the specific disease is envisaged (for example, gastric lavage with stenosis of its outlet, administration of hydrochloric acid in achilias, complete cleansing of the intestine and administration of colimycin inwards before surgery on the large intestine, striving to eliminate perifocal inflammation in chronic suppuration of the lungs, etc.). , And general training for all patients who undergo surgery (a good sleep on the eve of surgery, a hygienic bath, a wide shave of the operating field, restrictions on eating on the day of surgery, prevention of vitamin deficiency, etc.).
With full outpatient examination and necessary analyzes, clinical observation of the patient preparing for the most common operation should not be delayed for more than 2-3 days. Scheduled operations should not be prescribed during menstruation, as these days there is increased bleeding and reduced reactivity of the body.
The postoperative period begins from the moment of the termination of the operation to the restoration of the patient's capacity for work. It is divided into three phases: the first
- early, duration 3-5 days, the second 2-3 weeks, until the patient is discharged from the hospital, the third - distant, before the restoration of work capacity.
The normal course of the period after the operation is normal, when there are no serious violations of the functions of organs and systems, and complicated (hyperergic), when the reaction of the body to surgical trauma is extremely negative and all sorts of postoperative complications develop. Even in the normal course of this period, there are always abnormalities in almost all organs and systems, and in case of a complicated one they are sharply expressed.
Care of surgical patients.
Features of care for patients with surgical profile are determined primarily by the fact that the functions of organs and systems of these patients undergo changes due to a disease (pathological focus), anesthesia and surgery.
Postoperative wounds are the entrance gates through which pyogenic microorganisms can enter the body. Therefore, attention should be directed primarily to preventing the development of infection and the acceleration of regeneration processes. It is important to observe the condition of the bandage (stickers), not to let it slip and expose the postoperative suture.
If, for one reason or another, the dressing has been drenched with blood, or other detachable from the wound, it is necessary to inform the surgeon to make a dressing. It is allowed to work only with sterile instruments, use only sterile dressings. If drainage pipes are supplied, it is necessary to monitor the nature and quantity of the drainage system that separates them, etc.,
You should always keep in mind the possibility of sudden bleeding from a postoperative wound. It occurs at an early time after surgery, usually with slippage of the ligation imposed on the vessel, or rejection of a thrombus from a vessel that is not ligated (ligation). When infection of a postoperative wound, bleeding is caused by purulent melting of large vessels. If the wound is sewn tightly, the blood draining from the vessel accumulates in the tissues, a swelling is formed, the area of ​​the incision increases in volume, deforms, the skin can change color, etc. The caregiver must first notice the beginning festering of the wound. The patient in such cases usually complains of the appearance of throbbing pain in the wound. There is an increase in body temperature, in the wound area there is swelling, redness of the skin, etc.
The neuropsychic sphere of surgical patients is undoubtedly traumatized. Like the disease itself, it is often difficult, and the upcoming anesthesia and surgery, associated with fear of consequences and fear of a dysfunctional outcome. All this is accompanied by a prolonged, significant overstrain of internal forces. There are no people who calmly refer to the need to undergo an operation: the only difference is that some can, and others do not, contain their experiences without showing them.
Increased nervous excitability, insomnia, pain, etc., lead, not so rarely, to the development of postoperative psychoses, which may prove dangerous for the patient's life, if this opportunity is not taken into account and appropriate measures are not taken.
It is also necessary to remember the possibility of postoperative paresis and paralysis. All this requires much attention to the neuropsychic state of the surgical patient already in the preoperative period. In these cases, prophylactic importance is provided by calm explanatory conversations with the patient, it is not bad to place in the ward near him a convalescent person who successfully underwent similar surgical intervention, it is advisable to visit a person who has long had an operation and feels well.
Violations of the functions of the cardiovascular system and anemia caused by blood loss are often noted in severe surgical patients, they can lead to a decrease in blood pressure, including acute (collapse). Forced lying position, low mobility attract venous stasis, thrombosis and embolism. Often there is an increasing anemia (for various reasons), usually accompanied by hypoxemia (oxygen starvation): there is pallor, cyanosis, etc.
Functions of the respiratory system undergo changes in the postoperative period, especially pronounced in operations on the chest and its organs, on the abdominal wall and organs of the abdominal cavity. In connection with the pain in the area of ​​the operation, there is usually a restriction of respiratory movements, pulmonary ventilation decreases, and this or that degree of hypoxemia is observed. Immobility or low mobility of patients, especially with the position on the back, in the elderly and elderly, leads to venous stasis in the lungs, a violation of the expectoration of the sputum, which accumulates in the bronchi and promotes the development of hypostatic, atelectatic postoperative pneumonia. In addition, surgery on the organs of the abdominal and thoracic cells is often extensive, traumatic and accompanied by damage to a large number of blood vessels in which numerous small thrombi form, creating conditions for thromboemo-olic postoperative pneumonia. Oxygen deficiency, dyspnea, pneumonia, pleurisy - this is an incomplete list of complications, which threatens the surgical patient from the respiratory organs.
An important concern of the caretaker for the patient is to prevent this possibility. Patients with a risk of pulmonary complications better to mend the functional bed.
The doctor and sister should not spare the time to teach the aftercare to breathe deeply, cough and watch that he is lying in bed with an elevated position of the trunk. At the phenomena of oxygen starvation, care must be taken to carry out oxygen therapy. It should be remembered that in most cases, postoperative pneumonia is the result of ignoring the rules of patient care.
Functions of the digestive system are violated in all postoperative patients, but especially dramatically after operations on the abdominal organs. From the intoxication caused by the disease and surgical trauma, the cells with the most differentiated function (nerve and glandular), including those "responsible" for the work of the digestive organs, the secretion of digestive juices, primarily suffer.
The consequence of deviations is: loss of appetite, indigestion (diarrhea), a decrease in peristalsis or even its absence, leading to constipation, etc. To adjust the intestine, we must adhere to a number of requirements. Before the normalization of the functions of the salivary glands - a thorough sanitation of the oral cavity is mandatory. Для восстановления желудочно-кишечной секреции - вкусная, разнообразная, богатая витаминная диета. При застое в желудке содержимого - его промывание, очистительные клизмы. До восстановления перистальтики кишечника - его стимулирование фармакологическими препаратами.
Нарушения водносолевого обмена. Обильные, повторные рвоты, экссудация, поносы приводят к значительной потере организмом больного воды и солей: выраженное обезвоживание и обессоливание требуют возмещения.
Intoxication. Все больные с гнойным очагом страдают от двойной интоксикации: продуктов жизнедеятельности бактерий и некротического распада тканей, вызванных воспалительным процессом. Причем ткань при каждой операции травмируется дополнительно. Количество распадающихся тканей, а следовательно и степень послеоперационной интоксикации, определяются объемом оперативного вмешательства. Известно, что даже после небольших операций у больных наблюдается плохое самочувствие, бессонница, небольшое повышение температуры, изменение состава крови, ухудшение аппетита и тд.
Чем больше операция, а следовательно больше разрушенных тканей, тем выраженное и длительнее сохраняются симптомы интоксикации. Они усиливаются с развитием нагноения в операционной ране. Учитывая это, принимают меры по дезинтоксикации (обильное питье, оксигенотерапия, обеспечение оттока распада и др.).
Гиподинамия (недостаточная подвижность) нарушает кровообращение, ведет к застоям крови, гипостазам, тромбозам, эмболиям, уменьшает вентиляцию легких, усиливает гипоксемию (кислородное голодание), ухудшает все функции пищеварительных органов, вызывает атрофию мышц и т.д. Недостаточная подвижность хирургических больных может быть вынужденной (многочисленные тяжелые переломы, другие травмы, обширные операции и т.д.) или связанной с общей слабостью, вызванной болезнью. Она в значительной степени усиливает все послеоперационные нарушения функций органов и систем и может быть первопричиной многих тяжелых осложнений. Осознавая это, врач и ухаживающий персонал должны принимать самые активные меры для ее устранения, используя разнообразные методы активных и пассивных движений больного - лечебную физкультуру, массаж, приспособления, помогающие больному садиться и пр. Гимнастика, проведенная утром после подъема, улучшает работу всех органов и систем организма и, что особенно важно, устраняет застойные очаги кровообращения, неминуемо возникающие во время сна. Утреннюю зарядку могут проводить по существу все хирургические больные, она не показана только особо тяжелым по указанию лечащего врача. Ходячие больные могут выполнять упражнения стоя, средней тяжести - сидя на стуле, а лежачие - лежа в кровати.
Важно выполнять весь комплекс движений для всех групп мышц и суставов в определенной последовательности и с достаточной нагрузкой. Примерной схемой проведения утренней зарядки продолжительностью 12-15 минут может быть следующая.
Для мышц и суставов головы и шеи ( в течение 3-4 мин.): а) наклоны головы вперед, назад, влево и вправо (8-10 раз); 6) повороты головы вправо и влево (8-10 раз); в) вращательные движения головы справа налево и наоборот (8-10 раз).
Для мышц рук и плечевого пояса: а) выбрасывание рук в стороны, вверх и вперед с распрямлением их и приведением к туловищу со сгибанием в локтевых суставах (10 раз); б) вращение вытянутых рук спереди назад и сзади вперед (10 раз); в) схватывание руками туловища спереди (выдох) и разведение их в стороны (вдох) (8-10 раз); г) движения в лучезапястных суставах - сгибание и разгибание по 10-15 раз и вращение предплечья (15-20 раз); д) сжимание пальцев в кулак и разгибание их по 10-15 раз.
Для мышц и суставов позвоночника: а) сгибание и разгибание вперед, назад, вправо и влево; б) вращение позвоночника вправо и влево с вытянутыми в стороны руками; в) сгибание позвоночника вперед с доставанием пола кончиками пальцев (8-10 раз).
Для мышц и суставов нижних конечностей: а) ходьба на месте с максимальным сгибанием в коленных и тазобедренных суставах; б) поочередное движение прямой ноги вперед и назад с одновременным движением прямых рук в этом же направлении по 10-12 раз каждой ногой; в) поочередное вращательное движение правой и левой вытянутой ноги спереди назад и сзади вперед по 10-12 раз каждой ногой.
Во время упражнений следует следить за вдохом и выдохом.
Естественно, что часть движений нельзя выполнять лежа в кровати или сидя на стуле. В этих случаях их следует заменить другими или совсем исключить. Важно только следить за тем, чтобы все 4 группы мышц получали достаточную нагрузку.
Что касается мышц туловища, брюшного пресса, то они активно работают при упражнении рук, ног и позвоночника, а дыхательные мышцы - во время вдоха и выдоха.
Уход за кожей и профилактика пролежней. Помимо общих правил содержания постели и белья, необходимо помнить о периодическом изменении положения больного с тем, чтобы одни и те же места тела не подвергались длительному сдавливанию, особенно у истощенных больных. Туалет кожи и санация возможных очагов инфекции на ней имеют особое значение. Наличие гнойных прыщей, фурункулов и других гнойных очагов служит противопоказанием для проведения плановой операции, а при экстренных неотложных вмешательствах значительно ухудшает прогноз. Нередко, особенно у пожилых больных, р кожных складках, в подмышечных впадинах, в пахах и на промежности отмечаются дерматиты, вызванные грибками.
В предоперационном периоде все эти процессы должны быть излечены. Помимо обязательных ежедневных гигиенических ванн при особо упорных грибковых поражениях необходимо протирать складки кожи спиртом и припудривать присыпками, содержащими тонко размельченный нистатин или леварин.

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