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Surgical Diseases


Surgery deals with diseases, for the treatment of which the method of mechanical action on tissues is used, often accompanied by their separation to detect the pathological focus and eliminate it. Improving, surgical practice uses the achievements of medical spiders in anatomy and physiology, pathology, pharmacology and microbiology.
The range of the surgical method at a pastora time is very wide, in essence it is used for diseases of all organs and tissues of the body: brain and spinal cord, heart, lungs, esophagus, kidneys, muscles, bone skeleton, and so on. A modern operation is a very complex act, during which the physiological functions of a sick organism are studied. When violations are found, a variety of mechanical, physical, chemical and biological measures are applied to their recovery. The name "surgery", which literally means "hands-on", "skill", "craft", no longer fully responds to its modern content.
Advances in technology and biological sciences have created the conditions for the transformation of surgery, along with therapy, into a major one — a very large and complex medical specialty, the need for which is great. Emergency services were organized - ambulance stations, traumatological stations and institutes of traumatology, 24-hour duty was introduced in the relevant departments of hospitals. All this ensures early diagnosis, timely transportation of the patient to the hospital and the provision of the necessary surgical care to him in time.
Antiseptic and aseptic. Before the introduction of aseptic and antiseptic methods, postoperative mortality reached 80%: patients died from purulent, putrid and gangrenous processes. The nature of decay and fermentation, discovered in 1863 by Louis Pasteur, became the impetus for the development of microbiology and practical surgery, and made it possible to assert that microorganisms are also the cause of many wound complications.
Antiseptic means a set of measures aimed at the destruction of microbes on the skin, in a wound, pathological formation or the organism as a whole. Allocate physical, mechanical, chemical and biological antiseptic.
When a physical antiseptic provides for the outflow from the wound of infected contents and thus its purification from microbes, toxins and tissue decomposition products. This is achieved by the use of gauze swabs, drains made of rubber, glass, plastic. The hygroscopic properties of gauze are greatly enhanced by wetting it with hypertonic solutions (5-10% sodium chloride solution, 20-40% sugar solution, etc.).
Open wound treatment methods are used without dressing, which leads to air drying of the wound and thus creating unfavorable conditions for the development of microbes. The use of ultrasound, laser beams, and physiotherapeutic procedures also applies to physical antiseptics.
Mechanical antiseptics are methods for removing infected and non-viable tissues that serve as the main nutrient medium for microorganisms from a wound. These are operations, called active surgical treatment of brine, as well as toilet wounds. They are of great importance for the prevention of the development of wound infections.
A chemical antiseptic provides substances with a bactericidal or bacteriostatic effect (for example, sulfa drugs) that have a detrimental effect on microflora.
Biological antiseptic is a large group of drugs and methods, 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 act: 1) antibiotics - substances with pronounced bacteriostatic or bactericidal properties; 2) bacteriophages;
3) antitoxins, administered, as a rule, in the form of serums (tetanus, anti-diphtheria, etc.).
Indirectly through the body, increasing its immunity and thereby enhancing the protective properties, there are vaccines, toxoids, blood and plasma transfusions, the introduction of immune globulins, methylthiouracil drugs, etc.
Proteolytic enzymes lyse dead and non-viable tissues, promote rapid cleansing of wounds and deprive microbial cells of nutrients. According to the observations of these enzymes, changing the habitat of microbes and destroying their membrane, can make the microbial cell more sensitive to antibiotics.
Asepsis. Method of surgical work, which ensures the prevention of microbes entering the surgical wound or their development in it. On all objects surrounding a person, in the air, in 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 should be free of bacteria, i.e. sterile.
Anesthesiology is the science of pain relief.
The possibility of using the drugs to perform the operation painlessly reduces the complications of surgical treatment and significantly expands their range. Pain stimuli change and rearrange all physiological processes in the body. Its reaction to pain is manifested by impaired 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. Pain relief provides not only relief of pain. The task of the anesthesiologist is to manage the vital functions of the body, identify the causes of their violation in the operated patient, timely warning and elimination before, during and after surgery. Anesthesia - loss of sensitivity arises due to temporary damage to the sensory nerves.
It is achieved by the effect of an anesthetic substance on the brain - general anesthesia (anesthesia) or on the spinal cord (spinal anesthesia), on nerve endings and trunks at the site of operation (local anesthesia), there are other types of anesthesia.
Pathological processes underlying surgical diseases. Although there are many thousands of surgical diseases, they are based on only a few types of pathological processes:
1. Surgical infection - the introduction of microbes into the human body and the development as a result of inflammatory phenomena. The range of diseases is very large - from a simple skin abscess to such severe suffering as diffuse purulent peritonitis or general purulent infection - sepsis.
2. Trauma is a variety of open and closed injuries: bruises, tremors, sprains, compression, fractures, dislocations, electro-damage, wounds, burns, frostbite, ruptures of internal organs and so on.
3. Tumor growth of tissues is fundamental in the occurrence of a variety of tumors that affect individual organs and tissues.
4. Circulatory disorders and associated gangrene, ulcers, fistulas, etc.
5. Developmental abnormalities underlying many diseases.
6. Parasitic diseases that require surgical treatment (echinococcosis, ascariasis, etc.).
Surgical operations: mechanical action on tissues and organs produced to cure a disease, alleviate suffering, or to diagnose.
Operations are divided into bloody, in which the integrity of the skin or mucous membranes is broken, and bloodless (for example, straightening dislocation). There are therapeutic and diagnostic operations. Healing are used most often and are of a different nature depending on the tasks that the surgeon sets itself.
Among them are radical, with the help of which they remove a pathological nidus or organ (for example, appendectomy or cholecystectomy), operations performed to improve the function of the organ, restore normal anatomical relationships (for example, hernia repair) and palliative operations, which are designed to alleviate the suffering of the patient in cases when cure is impossible (for example, gastrostomy with advanced esophageal cancer). Diagnostic include biopsy, puncture of the pleura, joints, air injection into the pleura, renal pelvis, etc., as well as laparotomy, thoracotomy, etc.
According to temporary need distinguish emergency, urgent and non-urgent (planned) operations. Emergency needs to be done immediately: a delay of several hours, and sometimes minutes, threatens the life of the patient or dramatically worsens the prognosis. Such are operations with 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 time due to the steady development of the disease. Thus, it is impossible to delay the operation for malignant tumors for a long time, because continued growth can lead to the formation of metastases. In these cases, the delay is valid only for the time needed to clarify the diagnosis and patient preparation.
Non-urgent surgery (for example, cosmetic) can be performed at any time without prejudice to the health of the patient.
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 clarified, the condition of organs and systems is determined, indications for surgical intervention are set, and the period of preoperative preparation. The time may be of different duration, depending on the degree of urgency and the severity of the upcoming operation. Private preoperative preparation is foreseen, taking into account the specificity of a specific disease (for example, gastric lavage during stenosis of its exit, prescription of hydrochloric acid in achilia, complete bowel cleansing and oral administration of colimycin before colon surgery, chronic inflammation of the lungs, etc.) , and general preparation for all patients who are to undergo surgery (good sleep on the eve of the operation, hygienic bath, wide shaving of the surgical field, limiting in food intake the day of surgery, prevention of vitamin A deficiency and others.).
With a complete outpatient examination and the necessary analyzes, clinical observation of a patient preparing for the most common operation should not be delayed for more than 2-3 days. Planned operations should not be prescribed during menstruation, as these days there is increased bleeding and a decrease in the reactivity of the organism.
The postoperative period begins with the end of the operation until the patient’s ability to work. It is divided into three phases: the first
- early, 3-5 days long, the second - 2-3 weeks, until the patient is discharged from the hospital, the third is remote, until the ability to work is restored.
There is a normal post-operative period, when there are no severe dysfunctions of organs and systems, and complicated (hyperergic), when the body’s response to a surgical trauma is extremely negative and all kinds of postoperative complications develop. Even with a normal course of this period, there are always dysfunctions of almost all organs and systems, and with a complicated one, they are pronounced.
Care of surgical patients.
The specifics of caring for patients with a surgical profile are determined primarily by the fact that the functions of the organs and systems of these patients undergo changes due to the disease (pathological focus), anesthesia and surgery.
Postoperative wounds are entry gates through which pyogenic microorganisms can enter the body. Therefore, attention should be directed primarily to prevent the development of infection and accelerate the processes of regeneration. It is important to monitor the state of the dressing (stickers), do not allow it to slide off and expose the postoperative suture.
If for one reason or another the dressing is soaked with blood, or other wound discharge, it is necessary to inform the surgeon to do the 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, etc.
You should always keep in mind the possibility of sudden bleeding from a postoperative wound. It occurs early after surgery, usually when a ligature is placed on a vessel, or a thrombus is removed from a vessel that is not ligated (ligated). At infection of a postoperative wound bleeding is caused by purulent fusion of large vessels. If the wound is tightly sewn up, then the blood pouring from the vessel accumulates in the tissues, swelling is formed, the incision area increases in volume, deforms, the skin can change color, etc. The caregiver must be the first to notice the beginning suppuration 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, swelling, redness of the skin, etc. appears in the wound area.
The neuropsychic sphere of surgical patients is undoubtedly traumatized. Like the disease itself, often severe, and the upcoming anesthesia and surgery are associated with fear of the consequences and fear of a dysfunctional outcome. All this is accompanied by a long, significant overstrain of internal forces. There are no people who are calm about the need to undergo an operation: the only difference is that some can, and others do not, hold back their experiences without showing them.
Increased nervous excitability, insomnia, pain, etc., do not, rarely, lead to the development of postoperative psychosis, which can be dangerous for the patient’s life if this possibility is not considered and appropriate measures are not taken.
It is also necessary to remember about the possibility of postoperative paresis and paralysis. All this requires great attention to the neuropsychological state of the surgical patient already in the preoperative period. In these cases, quiet explanatory conversations with the patient are of preventive importance; it is a good idea to place a convalescent patient who has safely undergone such a surgical procedure in the ward next to him, it is advisable to visit a person who has long had an operation and feels good.
Disorders of the cardiovascular system and anemia caused by blood loss, are often observed in severe surgical patients, they can lead to a decrease in blood pressure, including acute (collapse). Forced recumbency, low mobility entail venous congestion, thrombosis and embolism. Often there is increasing anemia (for various reasons), usually accompanied by hypoxemia (oxygen starvation): pallor, cyanosis, etc. appear.
In the postoperative period, the functions of the respiratory organs undergo changes, especially pronounced during operations on the chest and its organs, on the abdominal wall and abdominal organs. In connection with pain in the area of ​​operation, the restriction of respiratory movements is usually noted, pulmonary ventilation is reduced, one or another degree of hypoxemia is observed. Immobility or low mobility of patients, especially when standing on the back, in elderly and senile age leads to venous congestion in the lungs, impaired coughing up of sputum, which accumulates in the bronchi and contributes to the development of hypostatic, atelectatic postoperative pneumonia. In addition, operations on the organs of the abdominal and chest cells are often extensive, traumatic, and are accompanied by damage to a large number of blood vessels, in which numerous small thrombi are formed, creating conditions for postoperative thromboemia. Oxygen deficiency, shortness of breath, pneumonia, pleurisy - this is an incomplete list of complications that threaten the surgical patient with respiratory organs.
An important caregiver care for patients to prevent this possibility. Patients with the risk of pulmonary complications are better to lay on a functional bed.
The doctor and sister should not spare time to teach the postoperative to breathe deeply, to cough and to keep him lying in bed with an elevated position of the body. In cases of oxygen starvation, it is necessary to take care of oxygen therapy. It should be remembered that in most cases, postoperative pneumonia is the result of ignoring the rules of nursing.
The functions of the digestive organs are impaired in all postoperative patients, but especially sharply after operations on the abdominal organs. Intoxication caused by disease and surgical trauma primarily affects cells with the most differentiated function (nerve and glandular), including those "responsible" for the work of the digestive organs, the secretion of digestive juices.
Следствием отклонений является: потеря аппетита, расстройство пищеварения (поносы), понижение перистальтики или даже ее отсутствие, приводящее к запорам и др. Чтобы наладить работу кишечника, надо придерживаться ряда требований. До нормализации функций слюнных желез - обязательна тщательная санация полости рта. 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.
Интоксикация. 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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