Preoperative and postoperative periods. Preoperative period Preoperative period
Preoperative period - the time from the moment of admission (appeal) of the patient to the medical institution until the start of the operation.
Purpose of preoperative preparation- study of disturbed functions of the body, creation of reserves of the functional capabilities of organs and systems to reduce the risk of surgery and minimal opportunities for the development of postoperative complications.
Stages of the preoperative period:
1) remote; 2) nearest; 3) direct.
Depending on the urgency of the operation, the number of stages may decrease.
Tasks of the preoperative period:
Establishing a diagnosis.
Carrying out additional and special diagnostic studies
dovaniya.
Definition of indications and contraindications for surgery.
4. Determination of the urgency of the operation, its nature
and the choice of method of anesthesia (assessment of operational and anesthetic risk).
16. Preoperative preparation.
17. Prevention of endogenous and exogenous infection.
18. Psychological preparation of patients.
19. Carrying out mandatory and specific preoperative measures
acceptance.
20. Premedication.
10. Transportation of the patient to the operating room.
Diagnosis:
The diagnosis is made on the basis of the patient's complaints, anamnesis of the disease and life, clinical manifestations of the disease, laboratory and instrumental research methods.
Examination of the patient:
Depending on the timing of the operation (scheduled, emergency or urgent), it is necessary to perform a minimum diagnostic examination.
At emergency surgery in patients under 40 years of age
General blood analysis
General urine analysis
At emergency surgery in patients over 40 years of age a minimum examination is required in the scope of:
General blood analysis
General urine analysis
Blood group and Rh factor
Electrocardiogram
Plain chest x-ray
Examination of the anesthesiologist-resuscitator
In addition, according to indications, individual biochemical parameters are taken (for example, blood sugar in a patient with diabetes mellitus) and consultations of narrow specialists are carried out (examination by a cardiologist for chronic heart failure). Additional examination according to indications is individual in nature and should be carried out during emergency surgical treatment within 2 hours.
At elective surgery in all patients The diagnostic minimum includes:
General blood analysis
General urine analysis
Blood group and Rh factor
Blood for markers of viral hepatitis "B" and "C"
Blood for markers of HIV infection
Blood chemistry
Coagulogram
Electrocardiogram
Plain chest x-ray (or fluorography)
Feces on worm eggs
Therapist's examination
Gynecological examination (for women)
Dentist examination
Patients admitted for planned hospitalization should be examined as much as possible at the prehospital stage for chronic sluggish infection (gynecologist, dentist). The volume of instrumental research methods (ultrasound, rectoscopy, colonoscopy, etc.) is decided individually depending on the pathology.
The volume of the diagnostic minimum for urgent surgical intervention should not be less than for emergency. A maximum examination is required in the conditions of the department, based on medical and economic standards for this pathology.
Definition of indications for emergency, urgent and planned surgery. Vital indications to surgery occur with a direct threat to the life of the patient (bleeding, acute diseases of the abdominal organs, purulent-inflammatory diseases, etc.)
Absolute readings to surgery - when failure to perform the operation or its long delay can lead to a condition that threatens the life of the patient. With absolute indications, the treatment of the disease is possible only by surgery (malignant neoplasms, obstructive jaundice, etc.). A long delay in surgery in such cases can lead to the development of complications of the disease or irreversible changes in the affected organ and other systems.
Relative readings to surgery are established for diseases that do not pose a threat to the life of the patient (varicose veins of the lower extremities, benign tumors, etc.) With relative indications, a temporary refusal to operate does not cause significant harm to the patient's health.
In accordance with the indications of the operation by urgency divided into:
- urgent, or emergency(perform immediately or within the first two hours from the moment the patient enters the surgical hospital),
- urgent(produced within 2 days from the moment of hospitalization),
- planned(performed after a detailed examination of the patient on an outpatient basis).
Preoperative period. The concept of indications and contraindications for surgery. Preparation for emergency, urgent and planned operations.
Preoperative period- the time interval from the moment the patient enters the surgical hospital to the moment the surgical intervention is performed.
The purpose of the preoperative period is to improve the quality of patient treatment by reducing the risk of surgery and the development of complications.
The preoperative period is divided into two stages:
Stage 1 - diagnostic;
Stage 2 - the actual preoperative preparation.
Tasks of the diagnostic stage.
Make an accurate diagnosis (you can limit yourself to the definition of surgical tactics).
Determine the presence of indications or contraindications for surgery.
Assess the state of the main body systems.
To identify the presence of complications of the disease and concomitant lesions of the patient's organs and systems with the determination of the degree of violation of their function.
Correctly choose the method of surgical intervention and the method of anesthesia.
Tasks of preoperative preparation
Conduct psychological preparation.
To carry out correction of violations of the functions of organs and systems, if it is possible to eliminate the complications of the disease and cure concomitant diseases.
To create in the body the necessary reserve of the functional capabilities of organs and systems, to increase the immunobiological strength of the patient's body.
Carry out general measures that reduce the risk of developing a surgical infection.
The results of the work performed by the surgeon in the preoperative period are summarized in the medical record in the form of an operational epicrisis, which includes: 1) justification of the diagnosis; 2) indications for surgery; 3) operation plan; 4) the type of anesthesia and the estimated degree of operational risk.
The intensity of activities carried out in the preoperative period depends on a number of reasons, first of all, on the type of operation in terms of the urgency of implementation.
In emergency operations, the time of the preoperative period is extremely limited. In this situation, the preoperative period includes either only one stage - the diagnostic stage, when the required minimum of preoperative measures is already carried out in the operating room (vascular catheterization, transfusion therapy, administration of blood products and blood substitutes, etc.) or both stages are carried out in parallel, while the duration of the preoperative the period for emergency operations does not exceed 2 hours (acute intestinal obstruction), widespread peritonitis - no more than 4-6 hours.
In urgent operations, the duration of the preoperative period can vary from 1 to 2 days. The diagnostic stage may include the use of all the diagnostic capabilities of the hospital. There is enough time for intensive care.
With planned operations, the preoperative period will depend mainly on the volume of the upcoming operation and on the characteristics of the organization of the surgical hospital. In some cases, patients can be admitted to the hospital already fully examined in other medical and diagnostic institutions, which minimizes the duration of the patient's preoperative stay in the hospital, in others, the entire diagnostic stage is carried out in the same hospital, where surgery will be performed subsequently.
The diagnostic stage may include all known research methods, on the basis of which the diagnosis is clarified and indications and contraindications for surgery are determined.
Standard minimum examination: complete blood count, biochemical blood test - total protein, transaminases, urea, creatinine, glucose, amylase, etc., blood group and Rh factor, complete urinalysis, ECG, chest x-ray, etc.
indications for operations.
Absolute - (emergency and elective surgery) the treatment of this disease or condition is life threatening and is possible only by surgery; (acute appendicitis, acute destructive cholecystitis, pancreatic necrosis, perforated gastric and duodenal ulcer, acute intestinal obstruction, strangulated hernia, acute aortic dissection, pulmonary embolism).
Relative - (elective surgery):
the disease is treated only surgically, but does not pose an immediate threat to life (cholelithiasis, varicose veins of the lower extremities, benign tumors, Hirschsprung's disease);
the disease can be treated both surgically and conservatively (ischemic heart disease; obliterating diseases of the vessels of the lower extremities).
Contraindications for surgery.
Absolute - shock (a serious condition of the body, close to terminal), except for hemorrhagic with continued bleeding; acute stage of myocardial infarction or cerebrovascular accident (stroke), except for the methods of surgical correction of these conditions, and the presence of absolute indications (perforated duodenal ulcer, acute appendicitis, strangulated hernia)
Relative - the presence of concomitant diseases, primarily the cardiovascular system, respiratory, kidney, liver, blood system, obesity, diabetes mellitus.
Possible constituent elements of preoperative preparation.
Psychological preparation. Should be carried out in all cases when the patient is adequate. The patient has the right to receive the necessary information about the nature of the forthcoming surgical intervention. In addition to communication between the doctor and the patient, pharmacological agents can be used - sedatives, tranquilizers, antidepressants, etc. It is necessary to obtain the patient's consent to the operation with documentary evidence. If the patient is incapacitated, the operation is performed with the consent of the guardian, and according to absolute indications, it can be performed with the presence of a medical consultation. Relatives of the patient can be informed of information only with the consent of the patient.
Preparation of the stomach. With a planned operation - fasting 12 hours before the operation. In case of emergency surgery - sounding of the stomach.
Bladder catheterization (according to indications).
Cleansing enema (according to indications) - during planned operations
Preparation of the operating field. During a planned operation, a complete sanitary and hygienic treatment is carried out. In an emergency operation - shaving the hairline.
Premedication. (sedatives, sleeping pills and narcotic analgesics). The purpose of premedication is to reduce emotional arousal and reactions to external stimuli; creation of optimal conditions for the action of antiseptics; decrease in secretion of glands; neurovegetative stabilization; prevention of allergic reactions to the means used for anesthesia.
When performing urgent, and even more so planned operations, the volume of preoperative preparation can be significantly expanded.
General somatic preparation - treatment of concomitant pathology, correction of violations of the internal environment of the body, sanitation of endogenous foci of infection, etc. Particular attention should be paid to the elimination of anemia, correction of dysproteinemia.
Special preparation - for example, preparation of the colon (slag-free diet, intestinal lavage), sanitation of the bronchial tree in case of purulent lung diseases.
Local preparation - debridement and shaving of the surgical field
Prophylactic antibiotic therapy.
Prevention of thromboembolic complications.
As soon as the patient crosses the border of the operating block, the operating period begins, which consists of the following stages:
laying the patient on the operating table in the appropriate position for each surgical intervention;
introducing a patient into anesthesia or performing local anesthesia;
preparation of the operating field;
performing surgery;
getting the patient out of anesthesia
1. from the moment of illness;
2. from the moment of diagnosis;
3. from the moment of admission to the surgical hospital;
4. - from the moment the indications for surgery are established;
5. from the moment of appointment of the day of the operation.
Select the main factors that determine the duration of the preoperative period:
1. - the condition of the patient;
2. - severity of concomitant diseases;
3. - the nature of the pathological process;
4. -volume and invasiveness of the forthcoming operation;
5. none of the above.
Does the stage of immediate preparation for surgery include?
1. inspection of life support systems;
2. - psychological preparation;
3. rehabilitation of chronic foci of infection;
4. - preparation of the gastrointestinal tract and bladder catheterization;
5. -premedication.
On the day of surgery, with a planned surgical intervention, you should perform:
1. the patient must take a hygienic bath or shower according to indications;
2. change underwear and bed linen;
3. transfuse fresh frozen plasma;
4. - shave the hair in the area of the surgical field;
5. gastric lavage.
What are the goals of the preliminary stage of preoperative preparation?
1. ensure the portability of the operation;
2. reduce the likelihood of intra- and postoperative complications;
3. speed up the healing process;
4. stabilization of the main parameters of homeostasis;
5. - all of the above.
Operations performed according to vital indications are:
1. stomach cancer;
2. lipomatosis;
3. - perforative stomach ulcer;
4. acute cholecystitis;
5. - restrained ventral postoperative hernia.
The principles of increasing the body's resistance to surgical trauma are to carry out:
1. standard preoperative preparation;
2. biostimulation of the body's metabolic functions;
3. adaptation to operational stress;
4. decrease in the reactivity of adaptive-regulatory mechanisms by introducing metabolites of stress-realizing and stress-realizing systems;
5. - all of the above.
The early postoperative period begins:
1. after removing the sutures from the surgical wound;
2. after discharge from the hospital;
3. after rehabilitation;
4. - the first 2-3 days after the operation;
5. after elimination of early postoperative complications.
The use of an ice pack on the wound in the postoperative period aims to:
1. prevention of infection development;
2. prevention of thrombosis and embolism;
3. prevention of divergence of the edges of the wound;
4. - prevention of bleeding from the wound;
5. -pain reduction.
To prevent thromboembolic complications in the postoperative period, you should perform:
1. After the operation, examine the state of the blood coagulation system;
2. 2 hours before surgery, patients from the thromboprone group should be given heparin
5000 IU intramuscularly;
3. elastic bandaging of the lower extremities before surgery;
4. active behavior of the patient in bed;
5. - all of the above.
For the prevention of postoperative pneumonia apply:
1. intravenous administration of large amounts of solutions;
2. introduction of prozerin;
3. - breathing exercises;
4. - the introduction of painkillers;
5. none of the above.
With urinary retention in the postoperative period, you should perform:
1. cleansing enema;
2. prescribe diuretics;
3. inject intravenously 10 ml of 40% urotropine;
4. - a warm heating pad on the hypogastric region;
5. - catheterization of the bladder.
Which of the noted complications always develop during surgical interventions on the gastrointestinal tract?
1. peritonitis;
2. - paresis of the gastrointestinal tract;
3. flatulence;
4. oliguria;
5. pneumonia.
With paresis of the gastrointestinal tract, you should perform:
1. blockade according to Roman;
2. hypertensive enema;
3. prescribe the introduction of cerucal;
4. intravenously inject hypertonic sodium chloride solution;
5. - all of the above.
Determine the early complications that can develop in the postoperative wound:
1. pain and burning in the wound area;
2. -bleeding from the wound;
3. infiltration in the wound area;
4. ligature fistula;
5. suppuration of the wound.
The uncomplicated course of the postoperative period is characterized by:
1. Duration 1-6 days;
2. positive nitrogen balance;
3. decreased activity of the sympathoadrenal system;
4. restoration of bowel function;
5. - all of the above.
Description of the presentation Preoperative period Preoperative period - slide gap
The preoperative period is the period of time from the moment of diagnosis and indications for surgery to the start of its implementation. It starts from the moment the decision to operate is made. It ends with the patient being taken to the operating room.
The preoperative period is divided into diagnostic ((establishment of the main diagnosis, identification of concomitant diseases - in the case when the diagnosis is specified) -) - in this case, the state of organs and systems is determined, indications for surgery are given and the period of preoperative preparation is determined. Preparatory (Psychological, general sympathetic, special, direct training). The duration of the preoperative period depends on the degree of urgency of the surgical intervention.
Preoperative period Stages Content Long-term (weeks, months, years) Clinical examination, health education work Immediate (weeks) Risk assessment and contraindications Immediate (hours, days) Preoperative preparation (general and special)
Tasks of preoperative preparation: 1. 1. Normalization of the mental state. 2. 2. Normalization of the general somatic state: - of the cardiovascular system; - respiratory systems; - functions of the liver and kidneys; - blood systems. 3. 3. Normalization of metabolism: - protein metabolism; - carbohydrate metabolism; - KShchS and VEB. 4. 4. Prevention of surgical infection: - Sanitation of foci of infection; — immunocorrection; 1. 1. antibiotic prophylaxis. 5. 5. Preparation of the operation area: - general; - special.
The main task of the preoperative period. . The main task of P. p. is to minimize the risk of developing various complications associated with anesthesia and surgical intervention both during surgery and in the immediate postoperative period. P. p. is necessary for a comprehensive examination of the patient, a deep assessment of the function of the main organs and systems, as well as a possible complete corrective therapy of the identified disorders in order to increase the reserve capacity of the body.
Disturbed needs of the patient There is a risk of complications. Drinking - the risk of complications. Highlight - constipation, pain. Breathing is pain. Sleep. Rest - pain syndrome. Move - increased pain. Dressing, undressing - the severity of the condition. risk of developing complications. Maintain a state of pain. To be clean is the severity of the condition, the pain syndrome. Avoid danger - the risk of complications. Communication - isolation in a hospital, the severity of the condition. Self-realization - the severity of the condition, disability.
Patient problems In the preoperative period. Physiological: Termination of vital activity; Pain syndrome; Violation of movement (forced position); Respiratory problems Thirst, dry mouth; Violation of physiological needs (eat, drink, excrete).
The duration of the preoperative period depends on the degree of urgency of the operation, the condition of the patient, his age and the severity of the upcoming surgical intervention. .
Only emergency, urgent operations performed according to vital indications (severe injuries, injury of large vessels, acute appendicitis, strangulated hernia, ectopic pregnancy, perforated gastric ulcer, acute intestinal obstruction, etc.) are allowed with minimal preparation (from several minutes to 1-2 hour), since the delay in the operation in such cases threatens the life of the patient.
Classification of surgical operations 1. 1. According to the purpose of the intervention: - diagnostic (exploratory, trial); - therapeutic radical (combined, extended); palliative; optional (cosmetic, aesthetic, sex correction). 2. 2. According to the deadlines: - urgent / emergency (in the first hours); - urgent / delayed (on the first day); - planned (weeks, months, years). 3. 3. In order of execution: — primary; - repeated (re-) early; later.
Classification by urgency Planned (in the department, in the morning, with tests). Rescheduling a schedule operation does not affect the forecast. Urgent (in the morning, in the department, with tests). It is impossible to postpone such an operation, because this will entail a deterioration in the patient's condition. Emergency - performed in the first 2 hours from the moment the patient enters the hospital. And in conditions that are life-threatening (bleeding, asphyxia, etc.), the intervention is carried out in the shortest possible time.
Preparation for the operation is carried out strictly individually and includes a number of general and special measures: general - - mandatory for each operation; ; special - - are necessary only in preparation for certain operations.
In patients with acute appendicitis, strangulated hernia, with ectopic pregnancy after examination and obtaining consent to the operation, preoperative preparation is limited to the introduction of morphine and cardiac agents; ; patients with severe trauma, injury of large vessels are given anti-shock therapy; ; with intestinal obstruction, physiological saline, 5% glucose solution are infused before surgery; patients with perforation of the abdominal organs are administered serum, plasma or protein blood substitutes.
Immediate preparation of the patient for surgery General principles. Planned operations Emergency operations Preparation of the surgical field. Full sanitary hygienic processing. Dry shaving of hairline. "Empty Stomach". Fasting 12 hours before surgery. Probing of the stomach according to indications. Bowel emptying. Cleansing enema. Not produced. Emptying the bladder. Independent urination. Bladder catheterization according to indications. Premedication. Various means according to a certain scheme. Atropine and narcotic analgesics.
Premedication - the introduction of medications before surgery in order to reduce the frequency of intra- and postoperative complications. Tasks of performing premedication: Reduction of emotional stress; Neurovegetative stabilization; Decreased reactions to external stimuli; Creation of optimal conditions for the action of anesthesia; Prevention of allergic reactions to drugs used in anesthesia; Decreased secretion of glands;
Before operations performed under anesthesia, emptying the stomach with a probe is often required, and in case of acute intestinal obstruction, a siphon enema is also required. . With the so-called planned (non-urgent) operations, the main task of the preoperative period is to minimize the risk of the upcoming operation.
The preoperative period for non-urgent operations (appendectomy in the "cold" period, hernia repair, etc.) usually takes 2-3 days. It takes 10 to 30 days to prepare a patient for pulmonectomy due to a suppurative process of the lung with symptoms of severe intoxication or a patient with malnutrition in cancer of the esophagus, lung, etc., from 10 to 30 days.
General measures are aimed at improving the neuro-somatic state of the patient, increasing the immunobiological strength of the body, combating secondary anemia, dehydration, intoxication, nutritional decline, etc. A number of patients undergo special training for surgery in specialized departments ((clinics, hospitals))
NURSE'S TASKS: Removal and preservation of dentures, rings and other jewelry Applying for premedication control of diuresis. To reduce the risk of aspiration of vomit during anesthesia, patients usually have a light supper the day before surgery and do not receive any food or liquids until after 11:00 pm on the day before surgery.
Activities before the operation On the eve of the operation, the patient is prescribed a shared bath or shower and change linen. When washing, again pay attention to the skin of the whole body - are there any pustules, rashes, diaper rash, etc. On the day of the operation, the surgical field is shaved; 30-40 minutes before the operation, morphine with atropine and other medications are administered as prescribed by the anesthesiologist. Before the operation, the patient is asked to urinate. The patient is delivered to the operating room necessarily on a stretcher, accompanied by a ward sister.
The most important element of P. p. is the psychological preparation of the patient. As a rule, patients want to receive comprehensive answers to questions related to the nature of the disease, the validity of the operation and its features, the danger to health or disability, etc. The patient must be confident in the high professional competence of the surgeon and in the successful outcome of the operation.
Test-reference control Preoperative preparation begins from the moment: a) a diagnosis is made that requires an operation and a decision is made on its implementation; b) admission of the patient to the surgical department for the operation; c) both answers are correct;
Test reference control In the preoperative period, the following stages are distinguished: a) one; b) two; at three o'clok;
Reference test The psychological problem of the patient before the operation: a) pain: b) fear: c) inability to pay for the operation:
Test-reference control Violated needs in preparation for gastric resection surgery: a) violated the need to move; b) the need to eat is violated; c) the need to sleep is disturbed;
Test reference control Premedication on the day of surgery includes the introduction of: a) Promedol solution 2% - 1 ml, atropine solution 0.15, diphenhydramine solution - 1% - 1 ml. b) a solution of analgin 50% - 2 ml, phenobarbital - 0.1 ml, aspirin - 0.5 ml; c) aspirin - 0.5, diphenhydramine solution 1% - 1.0.
Test reference control Premedication is prescribed before surgery: a) 2 hours; b) 4 hours; c) 30 -45 minutes;
Test reference control Cleansing enema is carried out before the operation: a) emergency: b) planned: c) does not matter;
Situational tasks Task No. 1 There is a patient with a diagnosis of "stomach disease" in the surgical department. The patient is concerned about epigastric pain not associated with eating. I have lost 8 kg in the last 3 months. He notes a decrease in appetite, an aversion to meat food, a feeling of fullness in the stomach after eating. Sometimes he vomits for relief. The examination revealed that the tumor is located in the pyloric part of the stomach. On the round, the doctor told the patient that he was going to have an operation, after which the patient began to worry, in a conversation with his sister, he expressed fears that he was unlikely to undergo the operation, since his friend allegedly died from such an operation.
Situational tasks Tasks: 1. What special and additional research methods were performed for the patient to confirm the diagnosis. 2. List the satisfaction of what needs is impaired in the patient. 3. Identify the patient's problems, prioritize, formulate goals. 4. Plan nursing interventions with motivation. 5. Make a plan for preparing the patient for surgery.
Situational tasks 1. What special and additional research methods were performed for the patient to confirm the diagnosis. When examining a patient, R-graphy of the stomach with barium, FGDS with biopsy, ultrasound of the liver, pancreas are performed.
Situational tasks 2. List the satisfaction of what needs is violated in the patient. Violation of the satisfaction of needs - to be healthy, eat, excrete, avoid danger, work.
Situational tasks 3. Define the patient's problems, highlight the priority, formulate goals. Patient problems. Real: weight loss; loss of appetite; vomit; fear of the upcoming operation; Priority problem: - fear of the upcoming operation. The goal is that by the time of the operation, the patient will feel safe during and after the operation.
Situational tasks 4. Make a plan for nursing interventions with motivation. 4. Planning: Motivation M / s daily for 5 -10 minutes. will discuss with the patient his fears and worries. - provide moral support; M / s, answering the questions of the patient, will acquaint him with the methods of anesthesia, the plan of preoperative preparation, the course of the postoperative period. - to instill confidence in the patient that all the actions of health workers are aimed at preventing complications during anesthesia and the postoperative period; M / s will introduce the patient to a patient who has successfully undergone such an operation. back up your words with the lips of the one who underwent the operation; M / s will provide moral support to relatives. - provide moral support to loved ones; M / s organizes the leisure of the patient. - distract the patient from thoughts about an unfavorable outcome; By the time of the operation, the m / s will make sure that the patient has overcome fear. - evaluate your actions;
Situational tasks 5. Make a plan for preparing the patient for surgery. Preoperative preparation plan: Feed a light supper in the evening on the eve of the operation, warn the patient not to eat or drink in the morning. Do a cleansing enema at night. As prescribed by the doctor at night, take sleeping pills. In the evening, carry out a complete sanitization. On the morning of the operation: take the temperature; cleansing enema; shave the surgical field; as prescribed by the doctor, rinse the stomach through a tube; before premedication, invite the patient to urinate; carry out premedication; bring the patient on a gurney to the operating room; .
Situational tasks Task No. 2. The patient was operated on for mechanical obstruction. After the operation, a tumor of the sigmoid colon was found and a colostomy was placed. On the 2nd day after the operation, the bandage began to get wet with intestinal contents. The patient is upset, depressed, she is worried about the attitude of relatives towards her. She believes that she will be a burden to the family of her daughter, with whom she lives. Most of all, she is worried about the presence of an intestinal fistula. She doubts that she will be able to provide care for the skin in the area of the fistula.
Situational tasks Tasks: 1. What skin changes in the fistula area can occur with poor care? 2. List the satisfaction of what needs is impaired in the patient. 3. Formulate the patient's problems, identify the priority problem and goals. 4. Plan nursing interventions with motivation. 5. Pick up drugs to protect the skin around the fistula. 6. Assemble a set of instruments for abdominal surgery.
The preoperative period is the period from the moment the patient enters the hospital and before the start of the operation.
PREOPERATIVE PREPARATION OF PATIENTS
LECTURE #9
Most of the patients who enter the surgical department undergo surgery. From the moment of admission to the hospital, the preoperative period begins, during which efforts are aimed at reducing the risk of surgery, preventing complications that may occur during and after it.
Goals of preoperative preparation:
o Ensure tolerability of surgical trauma;
o Reduce the likelihood of intra- and postoperative complications;
o Speed up the healing process.
Tasks of preoperative preparation:
· Psychological preparation;
Stabilization of the main parameters of homeostasis, if necessary, primary preoperative detoxification;
Preparation of the respiratory tract and gastrointestinal tract;
· Preparation of the operating field;
Emptying the bladder
· Premedication.
There are two stages in the preoperative period:
Ø Diagnostic or stage of preliminary preparation for surgery (from the moment the patient enters the hospital until the appointment of the day of surgery);
Ø The stage of immediate preparation (from the moment the day of the operation is set to the start of the operation).
The preparatory stage includes:
· Statement / specification of the diagnosis;
Examination of the life support systems of the body;
Identification of concomitant diseases;
· Assessment of the risk of surgical intervention;
· Correction of revealed violations of the functions of organs and systems, rehabilitation of chronic foci of infection, stimulation of the mechanisms of resistance (resistance) of the body.
The morale of patients admitted for surgery is significantly different from the state of patients hospitalized for conservative treatment, since the operation is a great physical and mental trauma. It is important that from the first minutes of admission, starting from the emergency department and ending with the operating room, the patient feels the clear work of the medical staff. He looks and listens to everything around him, is always in a state of tension, turns primarily to the middle and junior medical staff, seeks their support. Calm behavior, gentle treatment, a calming word spoken in time are of exceptionally great importance. The indifferent attitude of the sister, the negotiations of the staff about personal, irrelevant things in the presence of the patient, the inattentive attitude to requests and complaints give the patient reason to doubt all further measures, alarm him. The talk of medical personnel about the poor outcome of the operation, death, etc., has a negative effect. Medical personnel, with all their behavior, must arouse the patient's disposition and trust. The patient's recovery depends not only on a technically well-performed operation, but no less on careful preoperative preparation; in some cases, the care of a surgical patient decides his fate. Nursing staff not only must know how to fulfill the doctor's prescription, but must understand why this prescription is made, how it is useful for the patient, and what harm the patient can do if he does not comply with certain doctor's prescriptions. Only he can prepare the patient well for the operation, who will carry out the doctor's prescriptions not automatically, but consciously, understand the essence of the measures taken.
Preoperative preparation of patients consists in a complex of measures. In some cases, they are reduced to a minimum (for emergency and urgent operations), and for elective operations, they should be carried out more carefully.
Activities carried out to prepare patients for surgery can be divided into - - are common, i.e. mandatory before each operation,
· Hygienic bath or shower;
Change of underwear and bed linen,
Shaving hair in the surgical area (strictly on the day of surgery, but no more than 6 hours between shaving and surgery),
Cleansing enema,
· Emptying the bladder.
- special, special, which must be carried out only in preparation for certain operations.
Specific activities include:
o Gastric lavage (upper GI surgery)
o Siphon enema (colon surgery, etc.)
TO basic research scheduled patients include:
measurement of height and weight of the patient,
determination of blood pressure,
clinical analysis of blood and urine,
· blood chemistry,
a coagulogram
blood test for hepatitis markers, RW, HIV.
determination of blood group and Rh factor,
x-ray / fluorography of the chest,
Ultrasound of the abdominal organs,
· Examination by an ENT doctor, a dentist - sanitation of foci of chronic infection.
Examination of feces for eggs of worms.
At emergency operations sufficient premedication (injection of a solution of morphine or promedol), shaving the surgical field and emptying the stomach from the contents. In patients with severe injuries, it is necessary to immediately begin anti-shock measures (pain relief, blockades, transfusion of blood and anti-shock fluids). Before surgery for peritonitis, intestinal obstruction, emergency measures should be taken to combat dehydration, detoxification therapy, correction of salt and electrolyte balance. These activities should begin from the moment the patient arrives and should not cause a delay in the operation.
When preparing a patient for a planned operation, the diagnosis should be clarified, comorbidities should be identified that can complicate, and sometimes even make the operation impossible. It is necessary to establish foci of endogenous infection and, if possible, sanitize them. In the preoperative period, the function of the lungs and heart is examined, especially in elderly patients. Debilitated patients require preoperative transfusion of protein drugs and blood, as well as the fight against dehydration. Much attention should be paid to the preparation of the nervous system of the patient before the operation.
The risk of surgical intervention is based on accounting for:
ü Age;
ü The functional state of the vital systems of the body;
ü The severity of the underlying and concomitant diseases;
ü The urgency and volume of the operation.
Operational risk criteria:
q I degree risk- a somatically healthy patient undergoing a small planned surgical intervention (opening of abscesses, diagnostic procedures).
q Risk II A degree– somatically healthy patients undergoing more complex planned surgical intervention (appendectomy, cholecystectomy, operations to remove benign tumors, etc.)
q Risk III B degree- patients with relative compensation of life support systems and functions of internal organs undergoing minor elective surgeries indicated in the category "risk I degree".
q Risk III A degree– patients with full compensation of life support systems and functions of internal organs, undergoing complex, extensive intervention (gastric resection, gastrectomy, operations on the colon and rectum, etc.)
q Risk III B degree– patients with subcompensation of life support systems and functions of internal organs, undergoing minor surgical interventions.
q Grade IV risk– Patients with a combination of deep, general somatic disorders (acute or chronic, caused, for example, by myocardial infarction, trauma, shock, massive bleeding, diffuse peritonitis, endogenous intoxication, renal and hepatic insufficiency, etc.), undergoing major or extensive surgical interventions, which, in In most cases, with the listed pathology, they are performed on an emergency basis or even for vital (vital) indications.
q Grade V risk(allocated to a separate degree by some clinics, but not included in the mandatory classification) - patients with decompensation of life-support organs and functions of internal organs, with surgical intervention in which there is a high risk of death on the operating table, and in the early postoperative period.
