Orders regulating the work of a nurse in a surgical department. Medical documentation of the surgical department of the polyclinic. Dressing room preparation for further work

1. Order of the Ministry of Health of the USSR No. 408 of 1989 "On measures to reduce the incidence of viral hepatitis in the country."

Epidemiology, clinic, diagnosis, treatment, outcomes, clinical examination of patients with viral hepatitis A, B, delta, etc.

Hepatitis A. Hepatitis A virus (HA) belongs to the picornavirus family, similar to enteroviruses. The HA virus can persist for several months at 4 ° C, for several years at -20 ° C, and for several weeks at room temperature. The virus is inactivated by boiling.

Only one serological type of HA virus is known. Of the determined specific markers, the most important is the presence of antibodies to the HA virus of the Ig M class (HA anti-virus IgM), which appear in the blood serum at the onset of the disease and persist for 3-6 months. Detection of anti-HAV IgM indicates hepatitis A and is used to diagnose the disease and identify sources of infection in the foci.

The GA virus antigen is detected in the feces of patients 7-10 days before clinical symptoms and is used to identify sources of infection.

Antivirus HA IgG is detected from the 3-4th week of the disease and persists for a long time.

The source of infection is patients with any form of acute infectious process.

Forms of the disease: icteric, anicteric, subclinical, inapparent.

The transmission mechanism is fecal-oral. Its implementation occurs through the factors inherent in intestinal infections: water, "dirty hands", food, household items. People are generally susceptible to infection. Immunity after a previous illness is long-term, possibly lifelong.

The incubation period is from 7 to 50 days, on average 15-30 days.

Preicteric period (prodrome period) - acute onset, fever up to 38 ° C and above, chills, headache, weakness, loss of appetite, nausea, vomiting, abdominal pain. There is a feeling of heaviness in the right hypochondrium. The tongue is coated, the abdomen is swollen, the liver reacts to palpation of the abdomen. The duration of this period is 5-7 days. By the end of the preicteric period, the urine becomes dark, beer-colored. The feces are discolored. The sclera is subicterous. The II icteric phase of the disease begins.

Jaundice grows rapidly, a number of symptoms subside, a feeling of heaviness in the right hypochondrium, weakness, and decreased appetite persist. The size of the liver increases, it has a smooth surface, and is compacted. The spleen is enlarged. In the blood - leukopenia, a moderate increase in bilirubin, increased AlAT and AsAT. The icteric period lasts 7-15 days.

The recovery period is characterized by the rapid disappearance of clinical and biochemical signs of hepatitis.

There are no chronic forms of GA.

Anicteric forms of viral hepatitis A have the same clinical (with the exception of jaundice) and biochemical (with the exception of increased bilirubin levels) signs.

Erased forms are those in which all clinical signs are minimally expressed.

Inaparent forms - asymptomatic carriage, which is detected by the appearance of ALT activity in the blood serum and the presence of anti-IgM and IgG.

The diagnosis is established on the basis of clinical data, as well as the detection in the blood serum of antibodies to the HA virus of the immunoglobulin class M (anti-HAV IgM) and class G (anti-HAV IgG) and an increase in the activity of ALT and AST and bilirubin in the blood.

Patients are to be hospitalized in the infectious diseases department of the hospital. Recovery usually occurs within 1 - 1.5 months after discharge from the hospital.

Reconvalescents of HAV are observed in the office of infectious diseases, where they undergo medical examination once a month. They are removed from the register after 3 months in the absence of complaints, normalization of liver size and functional tests.

Treatment, prevention

Mild forms of hepatitis A do not need medical treatment. It is enough to follow a diet, half-bed rest, and drink plenty of fluids; in case of moderate-severe form, the introduction of detoxifying agents is added: a 5% glucose solution is injected intravenously, a solution

Ringer's 500 ml with the addition of 10 ml of a 5% solution of ascorbic acid.

Severe forms are extremely rare: more intensive fluid therapy may be required.

Preventive measures - the introduction of immunoglobulin according to epidemiological indications up to 3.0 ml. Data on immunoglobulin prophylaxis are entered in the registration forms No. 063 / y and 26 / y. The drug is allowed to be administered no more than 4 times at intervals of at least 12 months.

Persons who have been in contact with patients with HAV are monitored (once a week for 35 days).

Hepatitis B (HB) is an independent disease caused by the hepatitis B virus, which belongs to the hepadnavirus family. Extremely stable in the external environment.

The source of hepatitis B are patients with any form of acute and chronic hepatitis B, as well as chronic "carriers" of the virus. The latter are the main sources of infection. The patient can be contagious as early as 2-8 weeks before the onset of signs of the disease.

The incubation period is 6-120 days.

Preicteric period. The disease begins gradually. Patients complain of decreased appetite, nausea, vomiting, constipation, followed by diarrhea. Often worried about joint pain, itching, increase

Transmission mechanism - parenteral:

Through damaged skin and mucous membranes;

Transplantar;

With blood transfusions;

Sexually.

the size of the liver, sometimes the spleen. There is leukopenia in the blood. The activity of the indicator enzymes ALT and ASAT in the blood serum is increased. The duration of this period is from 1 day to 3-4 weeks.

The icteric period is long, characterized by the severity and persistence of the clinical symptoms of the disease, and has a tendency to increase. Jaundice reaches its maximum at 2–3 weeks. There is long-term soreness in the right hypochondrium, the liver is smooth, enlarged. In the blood: leukopenia, lymphocytosis, a significant increase in the level of bilirubin, an increase in ALT and AST in the blood serum.

Typically, acute hepatitis B occurs in a moderate form, often severe forms.

Fulminant (lightning) forms are rare.

Complications: hepatic coma, encephalopathy.

Chronic forms of hepatitis B are common.

The recovalescence period is longer than with HAV; clinical and biochemical signs persist for a long time.

Specific methods of laboratory diagnostics are the presence of HBs antigen (HBSAg), which appears in the blood long before the appearance of the clinical picture of the disease.

To distinguish the state of HBsAg carriage from active infection, it is necessary to study anti-HBsIgM in the blood serum; the absence of such antibodies is characteristic of carriage.

Discharge of convalescents in hepatitis B is carried out according to the same clinical indications as in hepatitis A.

Outcomes of acute viral hepatitis:

Recovery;

Residual effects:

Prolonged convalescence;

Post-hepatitis hepatosplenomegaly.

The ongoing course of the infectious process:

Prolonged hepatitis;

Chronic persistent hepatitis;

Asymptomatic carriage of HBs antigen;

Chronic active hepatitis;

Cirrhosis of the liver;

Primary liver cancer.

Clinical examination

After discharge from the hospital, the patient is examined no later than 1 month later. He is then examined 3, 6, 9 and 12 months after discharge. Deregistration is carried out in the absence of chronic hepatitis and a double negative test for HBsAg, carried out at an interval of 10 days.

Treatment:

Detoxification therapy, depending on the severity of the condition;

Reaferon (recombinant alpha-2 interferon);

Symptomatic treatment.

Prevention is aimed at actively identifying sources of infection; for this, it is necessary to examine the population for the carrier of viral hepatitis B, and, first of all, to examine persons from risk groups.

At-risk groups

1. Donors.

2. Pregnant women.

3. Recipients of blood and its components.

4. Personnel of blood service establishments, hemodialysis, surgery, biochemical laboratories, ambulance stations, intensive care units.

5. Patients at high risk of infection staff of centers for hemodialysis, kidney transplantation, cardiovascular and pulmonary surgery, hematology.

6. Patients with any chronic pathology, long-term inpatient treatment.

7. Patients with chronic liver diseases.

8. The contingent of narcological and dermatovenerologic dispensaries.

Prevention of professional infections:

All manipulations, during which contamination of hands with blood or serum, can occur, are carried out with rubber gloves. During work, all injuries on the hands are sealed with adhesive plaster. Wear masks to avoid splashing blood;

Frequent use of disinfectants should be avoided when handling hands. Surgeons should not use hard brushes to wash their hands;

In case of blood contamination of hands, immediately treat them with a disinfectant solution (1% chloramine solution) and wash them twice with warm water and soap, wipe dry with an individual single-use napkin;

In case of blood contamination, immediately treat the surface of work tables with a 3% solution of chloramine;

Health care workers by birth professional activity contact with blood, are subject to examination for the presence of HBsAg upon admission to work, and then at least once a year.

Prevention of hepatitis during therapeutic and diagnostic parenteral interventions

1.In order to prevent hepatitis B in all health care facilities:

It is necessary to maximize the use of disposable tools;

Strictly follow the rules of disinfection, pre-sterilization cleaning and sterilization of medical equipment;

Medical histories of people who are HBsAg carriers should be labeled.

2. OST of the Ministry of Health of the USSR from 1985 42-21-2-85

Sterilization and disinfection of medical devices.

Methods, means, modes:

Disinfection (methods, means);

Pre-sterilization processing (stages);

Sterilization (methods, modes, means);

Cleaning products from corrosion.

3. Order of the Ministry of Health of the USSR No. 215 of 1979 "On measures to improve the organization and improve the quality of specialized medical care for patients with purulent surgical diseases."

The instructions for the organization and conduct of sanitary and hygienic measures, anti-epidemic regime in the departments of the surgical profile, intensive care wards are described.

4. Order of the Ministry of Health of the Russian Federation No. 295 of 1995 "On the introduction of the rules for the mandatory medical examination for HIV."

The list of employees of institutions and organizations who undergo a medical examination to detect HIV infection during mandatory and periodic medical examinations upon admission to work:

Doctors, nurses and paramedics for the prevention and control of AIDS, directly involved in the examination, diagnosis, treatment and care of persons infected with the immunodeficiency virus;

Doctors, nurses and nurses in laboratories;

Scientists, workers of enterprises for the manufacture of immunobiological preparations, whose work is associated with material containing the immunodeficiency virus.

Rules for conducting compulsory medical examination for the detection of HIV infection.

1. Donors of blood, sperm and other biological fluids, tissues, organs are subject to compulsory medical examination.

2. The study of blood serum for the presence of antibodies to the immunodeficiency virus is carried out in 2 ethane.

Stage I - the total spectrum of antibodies against the antigens of the HIV virus is detected using an enzyme-linked immunosorbent assay.

Stage II - immune blotting is carried out in order to determine antibodies to individual proteins of the immunodeficiency virus.

3. In the event that HIV infection is detected in employees of individual enterprises (the list of organizations is approved by the Government of the Russian Federation), they are subject to transfer to another job that excludes the conditions for the spread of HIV infection.

List of indications for testing for HIV / AIDS in order to improve the quality of diagnostics.

1. Patients according to clinical indications:

Febrile for more than one month;

Having an increase in lymph nodes in two or more groups for more than one month;

With diarrhea lasting more than one month;

With unexplained weight loss;

With lingering and recurrent pneumonia or pneumonia that does not respond to conventional treatment;

With subacute encephalitis;

With fleecy leukoplakia of the tongue;

With recurrent pyoderma;

Women with chronic inflammatory diseases of the reproductive system of unknown etiology.

2. Patients with suspicion or with a confirmed diagnosis of the following diseases:

Addiction;

Sexually transmitted diseases;

Kaposi's sarcoma;

Brain lymphomas;

T cell leukemia;

Pulmonary and extrapulmonary tuberculosis;

Hepatitis B;

Cytomegalovirus infection;

Generalized or chronic forms of herpes simplex;

Recurrent herpes zoster (persons under 60 years of age);

Mononucleosis;

Candidiasis of the esophagus, bronchi, trachea;

Deep mycosis;

Anemia of various origins;

Pregnant women - in the case of taking abortion and placental blood for further use as a raw material for the production of immunopreparations.

Compulsory testing for HIV infection is prohibited.

Patient coding when referring them to HIV testing:

100 - citizens of the Russian Federation;

102 - drug addicts;

103 - homosexual and bisexual;

104 - patients with venereal diseases;

105 - persons with promiscuous sexual intercourse;

106 - persons staying abroad for more than one month;

108 - donors;

109 - pregnant women (donors of placental and abortion blood);

110 - recipients of blood products;

112 - persons who were in places of deprivation of liberty from risk groups;

113 - examined but for clinical indications (adults);

115 - medical staff working with AIDS patients or infected material;

117 - examined for clinical indications (children);

118 - others (indicate contingent);

120 - medical contacts with AIDS patients;

121 - heterosexual partners of HIV-infected people;

122 - homosexual partners of HIV-infected people;

123 - partners of HIV-infected people in intravenous drug injection;

126 - the survey is voluntary;

127 - anonymous survey;

200 - foreign citizens.

5. Order of the Ministry of Health of the USSR No. 1002 dated 09/04/87 "On measures to prevent infection with the AIDS virus."

The following are subject to certification:

Foreigners arriving for a period of 3 months or more;

Russian citizens returning from foreign business trips lasting more than one month;

Persons from risk groups who have received multiple transfusions of blood and blood products, drug addicts, homosexuals, prostitutes;

Citizens who have contacts with sick or virus carriers;

Those wishing to be examined.

6. Order No. 286 of the Ministry of Health of the Russian Federation of 7.12.93 and Order No. 94 of 7.02.97, "On improving the control of sexually transmitted diseases."

For the first time in his life, a patient with an established diagnosis of active tuberculosis, syphilis, gonorrhea, trichomoniasis, chlamydia, ureaplasmosis, gardnerellosis, urogenital candidiasis, anourogenital herpes, genital warts, scabies, trachoma, mycosis of the feet is notified (form) No. 089 /.

The notice is drawn up in each medical institution. The notice is drawn up by a physician. If a diagnosis is established by nursing staff, patients should be referred to a doctor.

To carry out 100% coverage of serological blood tests for syphilis of patients admitted to inpatient treatment, who applied to polyclinics for the first time in a given year, using the express method; tuberculosis, neurological, drug addiction patients, donors - classic serological reactions.

7. Order of the Ministry of Health of the Russian Federation No. 174 of 05/17/99 "On measures to further improve the prevention of tetanus."

Most effective method tetanus prevention is active immunization with tetanus toxoid (AS).

Protection against tetanus in children is created by immunization with DTP-vaccine or ADS-toxoid, in adults - with ADS-M-toxoid or AC-toxoid. The completed course of active immunization includes the primary vaccination and the first revaccination. To prevent tetanus from occurring in the event of injury, emergency prophylaxis is required.

Drugs used for routine active immunization against tetanus:

DTP - adsorbed diphtheria-tetanus pertussis vaccine containing 1 ml of 20 billion inactivated pertussis microbial cells, 30 units of diphtheria and 10 units of tetanus toxoid binding;

ADS-M - with reduced antigen content;

Ac - tetanus toxoid (in 1 ml 20 units).

Drugs used in emergency immunization of tetanus:

AS - adsorbed tetanus toxoid;

IICC - purified horse tetanus serum, one dose of PSS is 3000 ME;

PSCHI - human tetanus immunoglobulin, one dose is 250 ME.

Emergency tetanus prophylaxis is carried out when:

Injuries with violation of the integrity of the skin and mucous membranes;

Burns and frostbite of II-IV degrees;

Community-acquired abortion;

Childbirth outside medical institutions;

Gangrene of any type, carbuncles and long-term abscesses;

Animal bites.

Emergency prevention of tetanus consists in the primary surgical treatment of the wound and the simultaneous specific immunoprophylaxis. It must be carried out as early as possible and up to 20 days from the moment of injury.

The introduction of drugs is not carried out:

Children who have documentary evidence of routine preventive vaccinations in accordance with age, regardless of the period that has passed after the next vaccination;

Adults who have a document confirming the completion of a full course of immunization no more than 5 years ago.

Only 0.5 ml of AC-toxoid is injected:

Children who have documentary evidence of routine preventive vaccinations, without the last age-related revaccination;

Adults who have a document about the conducted immunization course more than 5 years ago;

Persons of all ages who received two vaccinations no more than 5 years ago, or one vaccination no more than two years ago;

Children from 5 months, military personnel, whose vaccination history is unknown.

Active-passive tetanus prophylaxis:

When carrying out active-passive prophylaxis of tetanus, 1 ml of the AC is injected, then with another syringe into another part of the body of the PSCHI (250 ME) or after the intradermal test IICC (3000 ME);

Active-passive vaccination is carried out for persons of all ages who received two vaccinations more than 5 years ago, or one vaccination two years ago;

Unvaccinated people, as well as people who do not have a documented vaccination warning.

To complete the course of immunization against tetanus in the period from 6 months to 2 years, 0.5 ml of AC or 0.5 ml of ADS-M must be boosted.

Emergency prevention of tetanus for repeated injuries

Persons who received only AS (ADS-M) in case of injury in accordance with their vaccination history, in case of repeated injuries, receive emergency prophylaxis as previously vaccinated, but not more often than once every 5 years.

Emergency prophylaxis of tetanus in radiation-thermal injuries - 1 ml of AC and 250 PSCHI are administered.

Conditions and techniques for emergency tetanus prophylaxis

Considering that after the administration of PSS and preparations containing tetanus toxoid, shock may develop in especially sensitive people, it is necessary to organize medical supervision for each vaccinated person within an hour after vaccination. Before the introduction of the AC, the ampoule is shaken until a homogeneous suspension is obtained. An opened ampoule with AC or PSS can be stored, covered with a sterile napkin, for no more than 30 minutes.

The drug is drawn into a syringe from an ampoule with a long needle with a wide lumen. A different needle is used for the injection. AC is administered in an amount of 1 ml. At the same time, 250 ME PSCHI is injected into another part of the body intramuscularly, in the absence of PSCHI, 3000 MEPSS are injected.

Before the introduction of PSS, an intradermal test with horse serum diluted 1: 100 is mandatory to determine the sensitivity to horse serum proteins (the ampoule is marked in red). An intradermal test is not performed if the victim was tested with 1: 100 diluted antirabies gammaglobulin within 1-3 days before the administration of the PSS.

An individual ampoule, sterile syringes and a thin needle are used to set the sample. Serum diluted 1: 100 is injected intracutaneously into the flexor surface of the forearm in an amount of 0.1 ml. The reaction is taken into account after 20 minutes. The test is negative if the diameter of the edema or redness at the injection site is less than 1 cm. With a negative skin test, the PSS (from the ampoule marked in blue) is injected subcutaneously in an amount of 0.1 ml. If there is no reaction after 30 minutes, the rest of the serum dose is injected with a sterile syringe. During this time, the opened ampoule with PSS should be closed with a sterile napkin.

Emergency prophylaxis by revaccination of the AU

AC is administered in an amount of 0.5 ml in accordance with the instructions for the preparation.

All cases of post-vaccination complications that developed after the use of drugs containing tetanus toxoid, as well as after the administration of PSS or PSCHI (shock, serum sickness, diseases of the nervous system), the medical staff urgently reports to the sanitary and epidemiological station.

8. Order No. 297 of 7.10.97 "On improving measures for the prevention of rabies in humans."

In the Russian Federation, from 5 to 20 cases of human infection with rabies are registered annually. In order to improve the quality of the provision of anti-rabies care and improve measures for the prevention of rabies disease in people, I order:

Organize rabies care centers on the basis of medical and prophylactic institutions that include trauma department;

Conduct annual seminars for medical workers on rabies care for the population and rabies prevention;

Organize mandatory prophylactic immunization against rabies for persons whose professional activities are associated with the risk of contracting the rabies virus;

Exercise strict control over the availability of anti-rabies drugs and the conditions of their storage in health care facilities;

Intensify awareness-raising work among the population, using funds mass media and visual agitation.

Regulation on the center for rabies care

1. It is created on the basis of a medical facility, which has a trauma center or a trauma department.

2. The head of the Center is appointed a traumatologist or surgeon trained in organizing and providing rabies care.

3. The activities of the Center are carried out in contact with health care facilities, centers of the State Sanitary and Epidemiological Supervision, and the veterinary service.

The main tasks and functions of the center:

1. The Center provides coordination, organizational, methodological, advisory and practical assistance to medical institutions in providing medical assistance to persons at risk of infection with the rabies virus.

2. Carries out reception and provision of medical aid to victims of bites, scratching, salivation by animals, persons at risk of infection with the rabies virus.

3. Organizes permanent seminars on training and retraining of specialists, anti-rabies aid to the population.

4. Carries out communication and mutual information with veterinary supervision authorities throughout the serviced territory on the epizootic state of the area.

5. Organizes and conducts sanitary and educational work on the prevention of rabies among the population.

Center rights:

Receive the necessary information from health care facilities, State Sanitary and Epidemiological Supervision Centers, veterinary services;

Submit proposals to health authorities on the improvement and improvement of anti-rabies activities, to attract, if necessary, consultants of various profiles.

Instructions on the procedure for the operation of a medical institution and centers of the State Sanitary and Epidemiological Surveillance for the prevention of rabies diseases

The first medical aid to persons who have applied for bites, scratching, salivation by any animals, as well as persons who have received damage to the skin and the ingress of foreign material on the mucous membranes during cutting and opening of animal carcasses, opening the corpses of people who have died from hydrophobia, are provided by all healthcare facilities.

1. The course of treatment and prophylactic immunization is prescribed immediately and is carried out in trauma centers, and in their absence in surgical rooms or departments:

Wash wounds, scratches, abrasions abundantly with a stream of water and soap (or any detergent), treat the edges of the wound with 70% alcohol or tincture of iodine, apply a sterile bandage. The edges of the wound inflicted on the animal should not be excised or sutured during the first three days, except for injuries that require special surgical interventions for vital signs;

In case of extensive wounds, after preliminary local treatment of the wound, several directing sutures are applied;

In order to stop external bleeding, the bleeding vessels are washed.

2. Emergency tetanus prophylaxis is carried out.

3. The victim is sent to the emergency room or surgical department of the hospital for the appointment and conduct of a course of anti-rabies vaccinations.

4. A telephone message is sent to each applicant and a written "emergency" notification (registration form No. 058u) is sent within 12 hours to the State Sanitary and Epidemiological Surveillance Center, trauma centers.

5. In the absence of trauma centers, surgical rooms and departments must:

In the case of the initial appeal of the victim, provide him with first medical aid, promptly transmit a telephone message, send a written notice (registration form No. 058 / y) to the State Sanitary and Epidemiological Supervision Center (station);

Fill in two copies of the “Card for applying for antirabies help” for each victim (registration form No. 045 / y);

Assign and ensure the course of anti-rabies vaccinations in accordance with the current instructions, including on weekends and holidays;

Provide hospitalization for the following categories of victims:

a) persons who have received severe and multiple bites and bites of a dangerous localization;

b) people living in rural areas;

c) re-vaccinated.

medical history and its management,

assignment sheets,

log,

operational log;

registration logs for narcotic and potent drugs (Regulated by the order of the Ministry of Health of the Russian Federation of November 12, 1997 No. 330 "On measures to improve the accounting, prescription and use of narcotic drugs");

Abnormal service documentation (alphabetical log, analysis log, prescription selection log, etc.)

Organization of the dressing room

In any surgical department, it is necessary to deploy two dressings: "clean" and "purulent", placing them as isolated as possible from each other, from wards and from service units. In departments specialized in the treatment of patients with proctological diseases, anaerobic infections and other diseases associated with massive infection of the environment with highly pathogenic microorganisms, it is advisable to deploy a third dressing room for these groups of patients. Dressings in each of these dressings should be performed first in "cleaner" patients, then in "more purulent" patients. In the last place, patients with putrefactive processes, intestinal fistulas, anaerobic infection are bandaged. This principle of operation ensures the longest possible preservation in the dressing conditions of asepsis and prevents cross-infection between patients.

Instruments and sterile dressing material in the dressing room are stored on a "sterile table" located in the place farthest from the entrance door and dressing tables. The "sterile table" is closed at least once every 6 hours. The dressing nurse treats her hands and puts on a sterile gown as in preparation for an operation, covers the table with two layers of sterile sheets, puts sterile instruments and dressings on it, and covers the table with two layers of sterile sheets. The edges of the sheet are fixed with special linen clamps, for which you can lift the top sheet without touching it and the contents of the table. An oilcloth label is attached to one of these clamps, which indicates the date and time of the last overlapping of the table and the signature of the honey. sister who produced it. Instruments and dressings are supplied from the “sterile table” by the dressing nurse with a sterile instrument (usually a forceps is used), which is stored separately in 6% hydrogen peroxide or on the “sterile table” itself, in the corner, on a specially laid diaper or oilcloth.

Currently, dressing rooms are additionally equipped with UV bactericidal chambers for storing sterile medical instruments. (The Ultra-light camera is designed to store instruments for 7 days).

The dressing room staff wear removable gowns, hats, 4-layer gauze masks and disinfected (non-sterile) rubber gloves. In recent years, due to the increasing incidence of viral hepatitis and HIV, the use of protective glasses or face shields is recommended. Before performing dressings, personnel wash their hands under a tap with soap and then put on gloves. In this case, the hands do not become sterile, therefore, manipulations in the wound are performed only with instruments. Between individual dressings, gloved hands are washed under the tap with soap. If blood or wound fluid has come into contact with the gloves, they must be replaced. Immediately after use, gloves are disinfected in accordance with OST 42-21-2-85. If it is necessary to perform hand manipulations, they are prepared as before the operation, and sterile gloves are put on.

The dressing room should have two washbasins (sinks): “for hands” and “for gloves”. Each should have three labeled towels hanging next to them, which are changed every day: "for doctors", "for a nurse", "for a nurse." This is due to the fact that, due to the production responsibilities, the hands of the junior honey. staff are usually more contaminated than the hands of nurses and doctors, and the requirements for cleanliness of the hands of a dressing nurse are the highest. In the "purulent" dressing room, they additionally put on oilcloth aprons, which the nurse wipes after each dressing with a 3% chloramine solution.

The doctor performing the dressing should not approach the “sterile table”. Instruments and dressings are supplied from it only by the dressing nurse. The doctor takes it from the nurse's forceps without touching the latter. The used dressing material is collected in trays disinfected for 1 hour in a 3% solution of chloramine and placed in a closed container (bucket with a lid), where it is filled with a solution of chloramine to a concentration of 6%, taking into account the volume of the dressing material for 1 hour.

In the dressing room:

preliminary cleaning is carried out before the start of the working day: horizontal surfaces are wiped with a disinfectant solution in order to collect dust that has settled overnight;

cleaning after each dressing: the surface of the dressing table and the floor around it are treated with a disinfectant solution;

daily final wet cleaning using a disinfectant solution, which is used to treat equipment, floors and walls to the height of human growth;

general cleaning is carried out once a week, during which the entire inventory and the room, including the ceiling, are washed using detergents and a 3% chloramine solution.

All dressings must be equipped with powerful (150-300 W) ultraviolet lamps, which must be treated for at least 2 hours a day. It is advisable to leave the UV lamps on during all non-working hours.

health care ………………………………………………… 2

2. Typical instructions for filling out primary forms

medical documentation of treatment-and-prophylactic

(form No. 039-3 / y) ………………………………………… .6

offices (form No. 028 / y) ……………………………… ... 7

hospital (form No. 008 / y) ………………………

2.5 ... 2 ... Temperature sheet (form No. 004 /

y) ………… ... 9

2.5 ... 3 .... "Statistical map of the retired from

hospital "(form No. 066 / y) ……………………

3. The procedure for filling out the "Consolidated record of the doctor

surgical department, office "……………………… .... 11

Appendix ………………………………………………………… ...… 12

List of used literature …………………………… ... …… 13

1. On the approval of forms of primary medical

documentation of healthcare institutions. Order of the USSR Ministry of Health dated 04.10.1980

# 1030 (Extract)

In order to streamline the maintenance and use of primary

medical records in healthcare institutions, bringing

medical documentation to a unified system of forms standards,

ensuring the completeness and reliability of information reflecting

activities of health care institutions.

I APPROVE:

List and samples of forms of primary medical documentation

(annex to the order).

I ORDER:

intradepartmental statistical reporting and streamlining accounting in

bodies, institutions and enterprises of the system of the Ministry

health care of the USSR "and other orders of the Ministry of Health

USSR, published before 1.10.80 in terms of approval of forms of primary

medical documentation, with the exception of orders of the USSR Ministry of Health,

which are approved for experimental work

temporary registration forms, the term of application of which has not expired before 1.10.80

2. Typical instructions for filling out primary forms

medical documentation of treatment-and-prophylactic

institutions in the provision of surgical care.(without laboratory documents) Approved by order of the Ministry

Healthcare of the USSR No. 1030 dated 04.10.80 (Extract)

destination. Inpatient medical record data

allow you to control the correct organization of the treatment process

and are used to issue reference material on request

departmental institutions (court, prosecutor's office, expertise, etc.).

Passport part, diagnosis of the sending institution and diagnosis,

established by doctors upon admission of the patient to the hospital

13. Journal of recording of surgical interventions in the hospital f. 008 / y.

14.Inpatient cards

15. Log of registration of transfusion of transfusion media f. 009 / y.

16.Record of narcotic and psychotropic drugs

17.Measuring instrument calibration log

18.Book of complaints and suggestions

20. Minutes of the meetings of the commission on bonuses

21. Minutes of production meetings and conferences

24. Schedule of the work of the head nurse of the department

25. Curriculum for nurses and nurses

26. Schedules of medical examination by the staff of the department

27.Tables and work schedules of employees of the department

28 Requirements for obtaining medication

29. Journal on the examination of the quality of work of middle and junior medical personnel

30. Journal of registration of advanced training of nurses

31. Journal of subject-quantitative accounting and write-off of medicines

32. Journal of accounting of consumption of alcohol

33. Humanitarian Aid Log

34. Dressing log

35.Systems log

36 syringe register

37. Journal of sterilization of medical instruments

38. Register of material values

39 Administrative Bypass Log

40. Log of quartzing

43. Log book of sanitary and educational work f. No. 38 / u.

44. Patient movement log

45. HIV blood collection register, HBS antigen

47.Blood for alcohol register

48. Journal of the taking of smears in the tank. laboratory

49. Log of the examination of patients for head lice

50. Register of azopyram samples

51. Journal of instruction on labor protection and safety

52. Journal of daily control of occupational health and safety

53. Log of knowledge assessment on safety measures for personnel with electrical safety group 1

54. Log of the arrival and departure from work of employees of the department

55. Nomenclature of cases.

II. Performance indicators and defects characterizing the activities of the 2 surgical department of the hospital for 2 years

Name of indicators and methods of their calculation	Years 2013 2014
Performance indicators
1.Average number of days of bed work per year Number of bed days actually spent by patients per year Average annual beds	307,2	298,7
2.Average duration of treatment The number of bed-days spent by patients per year Number of dropped out patients	7,3	7,3
3.Surgical activity (in%) × 100 Number of used patients from the department	46,6	46,9
4.Mortality (in%) × 100 Number of patients who left the department	2,6	1,77
5. Bed turnover Number of patients used (half the sum of admitted, discharged and deceased) Average annual number of beds		20,5
6.Postoperative mortality (in%) × 100 Number of all operated patients per year	6,9	3,9
Defect rates
1.Discrepancy between clinical and pathological diagnoses (in%) The number of discrepancies between clinical and pathological diagnoses (per year)× 100 Number of postmortem autopsies of the deceased in the surgical department (per year)	6,25	4,3
2.Postoperative mortality in diseases requiring emergency surgical care (in% of the number of operations) The number of deaths from diseases requiring emergency surgical care× 100 Number of operated patients requiring emergency surgical care
3. Intrahospital purulent-septic infection - postoperative complications (in% of the number of operations) × 100 Number of operated patients

Indicators
The number of bed-days spent by patients per year
Average annual beds
Number of discharged patients (discharged + deceased)
Number of operated patients per year
The number of patients used (half the sum of those admitted, discharged and dead)
The number of patients who died per year
The number of deaths after surgery per year
The number of discrepancies between clinical and pathological anatomical diagnoses (per year)
The number of postmortem autopsies of the deceased in the surgical department (per year)
The number of deaths from diseases requiring emergency surgical care
Number of operated patients requiring emergency surgical care
Postoperative complications (per year)

Calculation of indicators for 2013.

Performance indicators:

1.Average number of days of bed operation per year = 12288/40 = 307.2

2. Average duration of treatment = 12288/1684 = 7.3

3.Surgical activity = (392/842) × 100 = 46.6

4.Mortality = (44/1684) × 100 = 2.6

5. Bed turnover = 842/40 = 21

6.Postoperative mortality = (27/392) × 100 = 6.99

Defect indicators:

1.Discrepancy between clinical and pathological diagnoses = 2/32 × 100 = 6.25

2.Postoperative mortality in diseases requiring emergency surgical care = (0/101) × 100 = 0

3. Intrahospital purulent-septic infection - postoperative complications = (0/861) × 100 = 0

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Introduction

FamousPolishdoctorwrote:"Whomnottoucheshumanneed,whonotpossessessoftnessinhandling,atwhomnot enoughstrengthwill,toeverywhereandsunewheredominateoverby yourself,thatlet bebetterelectsanotherprofession,forhenevernotbatchildrengoodmedicalan employee ".

SAKHALIN REGIONAL ONCOLOGICAL DISPENSER is a medical and medical institution that unites a 302-bed hospital and a polyclinic.

The head of the medical institution is OVSYANNIKOV. V.G

Chief Nurse - N.A. ZHAROVTSEVA

The medical base of the Oblonkodispensary includes

1-oncology-department of abdominal surgery-40 beds

2-oncology department of head and neck tumors - 40 beds

3-oncology department of gynecological oncology -40 beds

4-oncology-department of thoracic surgery-30 beds

5-Oncology Department of Mammology-40 beds

6th chemotherapy department - 30 beds

7- urological department - 30 beds

8-radiological department

It should be noted that the ONCOLOGICAL DISPENSER is the only one in the entire Sakhalin region and accepts patients from all regions. Oncology is a special "branch" of medicine and requires more ethics in working with patients.

Today, the institution is a close-knit, qualified team capable of using the most high-tech medical equipment in treatment.

Medical workers are able to provide medical care in many areas, not only within the walls of the hospital, but also in extreme conditions, during emergencies, during the period of sports competitions at the federal level.

Surgicalbranchhospital deployed for 40 beds.

In the department, patients receive treatment with pathology from the gastrointestinal tract, trauma with damage to the internal organs of the abdominal cavity and patients with purulent-septic diseases.

Currently, the department is located on the 2nd floor of a 3-storey building. The department includes: 14 wards, of which 5 have 2 beds, the rest have 4, each is equipped with a shower and toilet, a treatment room, a dressing room, 2 manipulation rooms, a sanitary room, a nurse's post, a senior nurse's office, and at the other end of the corridor , there is a staff room and a buffet.

Branchcarries outthe followingfunctions:

Provision of diagnostic, therapeutic and preventive care to patients with oncological diseases;

Provision of advisory assistance to doctors of other departments of a medical organization in solving issues of diagnostics and rendering medical care to patients with oncological diseases;

Development and implementation of measures to improve the quality of medical and preventive work of the department;

Participation in the process of improving the professional qualifications of personnel in the diagnosis and provision of medical care to patients with oncological diseases;

Implementation in clinical practice modern methods diagnostics, treatment and rehabilitation of patients with oncological diseases;

Examination of temporary disability;

Conducting conferences on the analysis of the causes of death in the treatment of patients with oncological diseases in conjunction with the pathological department;

Implementation of sanitary and hygienic and anti-epidemic measures to ensure the safety of patients and staff, to prevent the spread of nosocomial infection;

Maintaining accounting and reporting documentation, submitting reports on its activities in the prescribed manner, collecting data for registers, the maintenance of which is provided for by law.

DressingToabinetsurgicalbranches- it's mine workplace... For the convenience of cleaning, the floor is covered with ceramic-granite tiles, the walls are tiled, the ceiling and doors are painted with light-colored oil paint. There is a centralized supply of cold and hot water, heating, electricity and ventilation. Artificial lighting provided by a fluorescent lamp located above the dressing table and lighting fixtures. The electrical wiring is hidden and there is a ground loop. There are two sinks for washing hands and washing tools. Doors of cabinets and doors are covered with plastic.

Equipmentdressingcabinet: table for instruments and dressings - 1 pc. Ultralight - for storing sterile instruments 1 piece, Drying cabinet for sterilizing instruments 1 piece, Bactericidal lamp - 1 piece; tripod; Hemostatic tourniquets - 2 pcs.; Chairs and stools - 3 pcs.; Bench stands - 2 pcs.; operating table / gynecological chair - 1 pc .; tool cabinet - 1 pc .; medicine storage cabinet - 1 pc .; work table - 1 pc .; table for medical documentation - 1 pc .; forceps for collecting contaminated dressings - 2 pcs .; containers for disinfection solutions - 8 pcs.; buckets for waste of class A and B: dry white bag; medical yellow bag - 2 pcs .; movable reflector lamp - 1 pc .; aprons made of oilcloth and plastic - 4 pcs.; glasses - as a means of eye protection - 4 pcs .; disposable sterile gowns, gloves, hats, masks, shoe covers - in abundance; disposable sterile linen - in abundance; ready-made sterile material - in abundance; containers for the preparation of working solutions of disinfectants, measuring containers for diluting disinfectants, brushes, brushes - for processing tools, a bedside table for storing detergents and disinfectants detergents... Anti-shock and anti-AIDS first-aid kits with instructions for their use, also, next to the office there is a sanitary room for the dressing room, where cleaning equipment for current and general cleaning is located - buckets for washing floors and walls-2 pcs, containers for processing furnishings, surfaces -2 pcs, mops for cleaning floors and walls-2 pcs and containers for diluting disinfectants.

Toolsdressingcabinet: maskites; Volkmann spoons; disposable pleural puncture kits; suture material, anatomical, surgical and claw tweezers - 8 pcs.; hemostatic clamps - 8 pcs.; abdominal scalpels -3 pcs.; pointed scalpels - 2 pcs.; pointed scissors -2 pcs .; sharp-pointed eye scissors - 1 pc .; blunt-pointed scissors, curved along the plane, - 2 pcs.; lamellar hooks - 1 pair; general surgical needle holders - 2 pcs .; different surgical needles - 10 pcs .; forceps - 2 pcs.; long tweezers - 2 pcs.; bulbous and grooved probe - 1 pc .; kidney-shaped trays; different cuvettes - 5 pcs. Sterile disposable dressing trays with ready-made dressing material are also available.

REQUIREMENTS FOR THE POSITIONING OF THE EQUIPMENT OF THE SANDING CABINET.

The dressing room is conventionally divided into two zones: clean and conventionally clean.

In the clean area: place a table with sterile instruments, a dry heat cabinet, a cabinet for medicines and instruments.

In a conditionally clean area: place the rest of the equipment, a nurse's desk, an operating and dressing table, a table with disinfectants, a sink, etc.

RESPONSIBILITY.

The dressing nurse is responsible for:

1.Lack of sanitary and hygienic regime in the dressing room.

2. safety of instrumentation, suture material, equipment.

3. violation of the rules of asepsis.

4. failure and delay of dressings through their own fault.

5. lack of knowledge about the course of dressings.

MydOfficialduties:

In the dressing room, dressing and observation of postoperative wounds are carried out, minor operations and punctures are performed. As well as:

1. The manipulations prescribed by the attending physician are performed, which are allowed to be performed by the nursing staff.

2. Seriously ill patients are accompanied to the ward after the performed manipulations.

3. Instruments and dressings are being prepared for sterilization.

4. Systematic sanitary and hygienic control over the dressing room is carried out.

5. Systematic replenishment, accounting, storage and consumption of medicines, dressings, instruments and linen is provided.

6. The junior medical staff of the dressing room is instructed and their work is supervised.

7. Regulatory medical documentation is kept in accordance with the nomenclature of cases.

8. Collection, disinfection and disposal of medical waste is carried out.

9. Measures are being taken to comply with the sanitary and hygienic regime in the room, the rules of asepsis and antiseptics, the conditions for sterilizing instruments, to prevent post-infectious complications, hepatitis, HIV infection. 10. Immediately inform your immediate supervisor about any industrial accident, signs of an occupational disease, as well as about a situation that poses a threat to the life and health of people. If necessary, perform the functions of an operating nurse when performing simple surgical interventions carried out in a dressing room.

Volumecarried outwork.

My working day begins with an inspection of the dressing room. As a nurse in the dressing room, I check whether the staff on duty used the dressing room at night. In case of emergency intervention or unscheduled dressing, the used and contaminated dressing material is removed into buckets with lids (yellow bag - waste of class "B"), used instruments are soaked in a disinfectant solution.

I check whether wet cleaning has been carried out with the use of disinfectants, I take sterile instruments from the CSO, arrange the beads with the material, install the medicines received from the pharmacy the day before.

I get a list of all dressings for the day, set their order. First of all, I bandage patients with a smooth postoperative course (removal of stitches), then with granulating wounds. After making sure that the dressing room is ready, I start treating my hands.

After processing my hands, I start putting on a sterile gown. Opening the bix lid, I check the indicator. Taking the robe, I gently unfold it, holding the edges of the collar with my left hand on an outstretched hand so that it does not touch the surrounding objects and clothes, I put the robe on my outstretched right hand. With this hand, I take the left edge of the collar and put it on my left hand, pulling it forward and up. The assistant ties the ribbons on the back of the robe. Next, I tie the ribbons on the sleeves, as well as the belt, taking it by the free ends, without touching the robe and hands. After that I put on sterile gloves.

When I put on a sterile gown and gloves, I start preparing a sterile table. A sterile table is being prepared, which is covered with a sterile sheet in one layer, so that it hangs 15-20 cm below the table surface. The second sheet is folded in half and stacked on top of the first. After laying out the tools (material), the table is covered with a sheet (folded in 2 layers), which should completely cover all the items on the table, and is tightly fastened with clamps to the bottom sheet. The sterile table is set for 6 hours. In cases where instruments are sterilized in individual packaging, there is no need for a sterile table or it is covered immediately before manipulation.

Dressings are carried out in a mask, cap and sterile gloves, which are changed for each patient. All items from the sterile table are taken with forceps or long tweezers, which are also subject to disinfection and sterilization.

Analysis of work for the reporting period:

№ p.p	Name:	Quantity:
	Pleural puncture
	Bandaging postoperative patients
	Laparocentesis
	Lancing of purulent parapractitis
	Opening of panaritiums and phlegmon
	Lancing of abscesses
	Applying compresses
	CHOLECISTOMS
	CYSTOMES

2. Knowledge and skills of the certified specialty

During her work, she perfectly mastered the following manipulations:

ь Maintaining medical records.

b Control of compliance with the rules of asepsis and antiseptics in the dressing room.

ь Carrying out cleaning in the dressing room.

b Preparation of linen, dressings, masks for sterilization.

b Preparation of surgical styling.

b Preparation of instruments and equipment for sterilization.

ь Ensuring the patient's infectious safety.

ь Carrying out disinfection in the dressing room.

ь Participation in all types of punctures.

b Acquisition of sets of surgical instruments.

b Preparation of suture material.

b Imposition of all types of bandages.

b Providing different ways hemostasis.

ь Assisting with terminal conditions.

b Modern methods of processing the operating field.

l Performing various types of patient placement on the operating table.

b Use of personal protective equipment.

b Preparation of disinfectants.

ь Submission of instruments during the operation and dressing.

b Collection and disposal. used materials and tools.

Manipulations are performed in a certain sequence: removal of the bandage applied earlier; primary toilet of the skin around the wound; initial examination and toilet of the wound; re-examination of the wound; performing diagnostic or therapeutic procedures; repeated skin toilet, bandaging.

The primary toilet of the skin is made in order to remove blood, pus, etc. from the areas of the skin surrounding the wound (for wounds of the hairy areas of the body, hair is shaved off). The toilet is performed with gauze (or cotton) balls dipped in ethyl alcohol, etc.; the skin is treated in the direction from the edges of the wound to the periphery in order to protect it from contamination and infection.

When examining aseptic wounds with superimposed sutures, pay attention to the appearance of local signs of inflammation (hyperemia, edema, eruption of sutures, necrosis). In the absence of inflammation and necrosis, the wound along the suture line is lubricated with 5% alcohol solution of iodine or 1% alcohol solution of brilliant green, 3-5% solution of potassium permanganate, solution of chlorhexidine bigluconate and apply a dry aseptic bandage from gauze napkins, which are fixed with an aseptic sticker, tubular or regular bandage.

In case of wound suppuration, the sutures are removed in whole or in part, while paying attention to the nature of the discharge. When assessing the wound process, the condition of the wound is of great importance. With the development of a putrefactive infection, the surface of the wound is distinguished by dryness, the absence of granulations, the presence of necrotic tissues, and the gray color of the muscles; crepitus of tissues, indicating the presence of gas in them, is rare. With anaerobic infection, the edges of the wound are edematous, and finger pressure does not leave a mark in the edematous tissues, muscle swelling, traces of the dressing being pressed, eruption of sutures, crepitus are noted. The slightest suspicion of the presence of an anaerobic infection is an alarming signal and requires the adoption of the necessary urgent measures.

Pleuralpuncture: My responsibilities include helping a doctor with a pleurocentesis. Puncture of the pleural cavity is carried out with a diagnostic therapeutic purpose. The patient is placed in a comfortable sitting position, with the shoulder girdle resting on the back of the chair or lying on his side. We treat our hands with 70% alcohol or the CHISTEA skin antiseptic, put on sterile gloves. We treat the puncture site with iodine, alcohol using cotton balls. The doctor conducts local anesthesia with 0.5% novocaine solution. The fluid is aspirated using a disposable pleural puncture kit. After the procedure, we process the puncture site and apply a sterile bandage. We immediately send the pleural contents to the laboratory in a special labeled jar.

INdressingcabinetby meis underwaynextdocumentation:

* Journal of registration and control of the bactericidal installation;

* Log book for general cleaning;

* Sterilization log;

* Journal of quality control of pre-sterilization cleaning (azopyram and phenolphthalein samples);

* Register of dressings;

* Journal of accounting of small surgical operations;

* Biopsy log;

* Log book of dressing and consumables;

* Journal of receiving medications from the head nurse;

* Log of emergency situations.

Carrying outanti-epidemicactivities.

The department has a dressing room for dressing clean and purulent wounds. To do this, it was necessary to isolate the so-called clean and purulent dressings, first of all, clean dressings are carried out. After each dressing of patients with signs of suppuration or with purulent wounds, the sheet on the dressing table is replaced, so we use disposable linen as soon as possible. Bandaging is carried out according to the schedule, which is approved by the head of the department. The schedule is posted in a conspicuous place - on the door of the office.

Prevention of the development of postoperative purulent-septic infections consists of a set of measures aimed at breaking the chain of occurrence of the epidemiological process. One of the important sections of this complex is the observance of the sanitary-hygienic and anti-epidemiological regime in the dressing room.

WorkindressingcabinetwhichIdoingdaily:

1. I process my hands, process them at a hygienic level, put on sterile clothes and open the bix.

2. Using sterile forceps (forceps), gently unfold the lining diaper so that its ends remain inside the bix. Tweezers are stored in a sterile bag, in a sterile bix, tweezers are changed after 1 hour.

3. The sterile table is set for 6 hours of work.

4. An individual dressing kit is covered for each patient. The complete set of laying depends on the dressing profile or minor surgery.

5. After the dressing, all used instruments are placed in a container with a disinfectant for 30 minutes and closed with a lid.

6. After bandaging each patient, the oilcloth of the dressing table is wiped with a rag moistened with a disinfectant solution.

7. Used balls, tampons are disinfected, after which they are collected in disposable plastic bags of yellow color, which, after filling, are sealed and removed from the compartment for disposal.

8. After every 2 hours of intensive work, the dressing room should be closed for 30 minutes to carry out routine cleaning, airing and quartzing. In this case, the sheet on the dressing table is replaced.

9. The work of the dressing room is carried out in accordance with the schedule approved by the head of the department, the schedule is posted on the door of the office.

10. When treating surgical patients with drains: every day, all connecting tubes and jars for the discharge are changed to sterile ones, the used ones are disinfected; jars for the drainage system are not placed on the floor, they are tied to the patient's bed or placed next to them on a stand.

11. Sterile gloves are changed:

In case of contamination with blood or other discharge from the wound and with instrumental dressing - after each patient! Hygienic hand antiseptics is preliminarily carried out.

The sterile dressing tray in the ward can only be covered for one patient!

Asepsis is violated if, during dressing, a sterile napkin is moistened by pressing it against the neck of the bottle or pouring it from the bottle. Pour sterile solution into a glass or tray and submerge the tissue there. If the dressing is ointment, then the napkin should be put in a sterile tray and apply the ointment with a sterile spatula, then give to the doctor.

PREPARATION OF KITS FOR STERILIZATION IN A DRY CABINET.

The cabinet, before placing products in it, is wiped with a solution of a disinfectant twice, with an interval of 15 minutes.

Tools on the grates are placed in one row, with open locks no more than 10 pieces.

180-degree stericons are laid in each laying, 5 pieces for each grate in the middle and on the sides of the grate.

Sterilization time is 60 minutes, after which the instruments are placed in the ULTRALITE STERILE TABLE, which is also treated once a week with a disinfectant, distilled water and 6% hydrogen peroxide.

ALGORITHM OF PREPARATION OF BIX FOR STERILIZATION AND TRANSPORTATION IN CSO.

Bix is ​​wiped with a disinfectant solution twice with an interval of 15 minutes.

The bix is ​​lined with a large napkin, which should hang from the outside by 2/3 of the height of the bix; we put an indicator on the bottom. Products packed in coarse calico or kraft paper are laid vertically or on the edge, the distance between the packages is equal to the thickness of the palm so that steam can evenly penetrate between the products. We put an indicator at 132 degrees in the middle of the bix, cover the product with a large napkin and put another indicator on top, close the bix and attach a tag to the handle on which the material laid in the bix is ​​indicated. The bix windows are open, the bix is ​​delivered to the central office in two bags. When opening the bag, pay attention to the sterilization date, the color of the indicator should be brown. Products in bix must be dry. WET PRODUCTS - NOT STERILE.

GENERAL REQUIREMENTS FOR THE ORGANIZATION OF STORAGE OF MEDICINAL PRODUCTS IN THE DRESSING ROOM ORDER-523 dated 03 07 1968. hospital dressing room organization

Storage of medicines for external and internal use should be carried out on separate shelves, about which the appropriate labeling should be made from the pharmacy, medicines come in finished form with an accurate and clear designation on the label (internal, external).

PACKAGING, DISTRIBUTING, TRANSFERRING, AND ALSO REPLACING LABELS IS PROHIBITED.

SHELF LIFE OF MEDICINAL PRODUCTS MANUFACTURED IN A PHARMACY:

Order of the Ministry of Health of the Russian Federation - 214 of 07.16 1997.

Injection solutions in vials, hermetically rolled up for 30-90 days.

Opened vials 6 hours.

Ointment for 10 days.

Hydrogen peroxide 10 days.

Potassium permanganate 10 days.

ALGORITHM OF ACTIONS FOR ANAPHYLACTIC SHOCK.

Anaphylactic shock is a consequence of an immediate allergic reaction, accompanied by a life-threatening violation of all body systems (respiratory, cardiovascular, nervous, endocrine, etc.). The development of shock is provoked by any drugs (antibiotics, sulfonamides, vitamins, etc.).

CLINICAL SIGNS:

Against the background or immediately after the administration of the drug (serum), etc.

Weakness, dizziness appeared.

Difficulty breathing, feeling short of breath.

· Anxiety, feeling of heat all over the body.

Dry mouth, difficulty swallowing (sometimes vomiting)

· The skin is pale, cold, moist.

· Frequent, shallow breathing.

· Systological pressure 90 mm Hg. and below.

· In severe cases, depression of consciousness and respiration.

· Convulsions appear later, consciousness is darkened.

· The skin is covered with itchy patches (hives).

NURSE TACTICS:

· Call a doctor immediately.

· Give the patient a stable lateral position, raise the leg end.

· Give humidified oxygen.

· Measure blood pressure, heart rate.

· Prepare medications from the first-aid kit.

FIRST AID KIT (ANTI-SHOCK KIT):

1 Adrenaline 0.1% -1.0

3 Isotonic solution of 0.9% sodium chloride

4 Dropper

5 Syringes 5.0 10.0 20.0

6 Rubber harness

PROTECTION OF MEDICAL PERSONNEL FROM INFECTION.

COMPOSITION OF THE FIRST AID KIT IN EMERGENCIES WITH BLOOD.

1 Alcohol 70% -200 ml

2 Alcohol solution of iodine 5% 15 ml

3 bandage sterile 2 pcs

4 Sterile wipes 10 pcs

5 Bactericidal adhesive plaster 5 pcs

A first aid kit for HIV prevention should be kept in a separate, labeled container.

INSTRUCTIONS ON ACTION BY A MEDICAL WORKER IN AN EMERGENCY SITUATION.

In order to avoid infection with parenteral viral hepatitis, HIV infection, the rules for working with stabbing and cutting objects should be observed.

1. In case of cuts and injections, immediately remove gloves, wash hands with soap under running water, treat hands with 70% alcohol, lubricate the wound with 5% iodine solution.

2. If blood or other biological fluids get on the skin, this place is treated with 70% alcohol, washed with soap and water and re-treated with 70% alcohol.

3. If the patient's blood and other biological fluids get on the mucous membranes of the eyes, nose and mouth, rinse the oral cavity with plenty of water and rinse with 70% alcohol, rinse the mucous membrane of the eyes and nose with plenty of water, do not rub !!!

4. If blood and other biological fluids of the patient get on the gown, clothes: take off work clothes and immerse them in a disinfectant solution and in an autoclaving bucket.

5. Start taking antiretroviral drugs as soon as possible for post-exposure prophylaxis of HIV infection.

For the purpose of emergency prevention of HIV infection, azidomycin is prescribed for one month. The combination of azidomycin and lamivudine enhances antiviral activity and overcomes the formation of resistant clamps. If there is a high risk of HIV infection (deep cut, visible blood on damaged skin and mucous membranes from patients infected with HIV), you should contact the territorial AIDS prevention and control centers to prescribe chemoprophylaxis.

Persons exposed to the threat of HIV infection are under the supervision of an infectious disease doctor for 1 year with a mandatory examination for the presence of a marker of HIV infection.

Personnel who had contact with material infected with the hepatitis B virus in different parts of the body according to the scheme 0-1-2-6 months, followed by monitoring of the hepatitis marker (at least 3-4 months, after the administration of immunoglobulin). If contact has occurred in a previously vaccinated health worker, it is advisable to determine anti-HBs in the blood serum. If there is a concentration of antibodies in a titer of 10 IU / L and higher, vaccine prophylaxis is not carried out; in the absence of antibodies, it is advisable to simultaneously administer 1 dose of immunoglobulin and a booster dose of the vaccine.

Qualitativethe controlpercarrying outmanipulations

Qualitative indicators include the results of washings from objects of the external environment, carried out in the surgical department regularly throughout the year. The washings determined the presence of conditionally pathogenic and pathogenic forms, Table No. 1, as well as the sterility of medical instruments and dressings, Table No. 2.

Table No. 1

Conclusion: during the year there was not a single positive result. The department carries out high-quality disinfection according to SanPiN 3.1.5.2826-10, Industry standard 42-21-2-85 and orders No. 288, No. 254.

Table No. 2

Conclusion: During the year there was not a single positive washout for sterility, which indicates high-quality processing and sterilization of medical instruments and dressings.

Table No. 3

Conclusion: during the year there was not a single positive result.

INthe presenttimeforfulfillmentsanitary and antiepidemiologicalregime,Sothe sameforstreamliningworkintreatment-and-prophylacticinstitutionsactsleblowingthe documentsandorders:

NS Industrystandard42-21-2 - 85 determining the methods, means and mode of disinfection and sterilization of medical devices.

NS Order№1204 from 16.11.87, "On the medical and protective regime in medical institutions."

NS AtkazMHUSSRfrom12.07.89 № 408 "On measures to reduce the incidence of hepatitis viruses in the country."

NS Order№ 288 "O Sanitary and Epidemiological the regime of a medical and preventive institution.

NS Federallaw“On the prevention of the spread in the Russian Federation of the disease caused by the human immunodeficiency virus (HIV) from 24.02.95.

NS OrderMHRFfrom26.11.98 G№ 342 "On strengthening measures for the prevention of epidemic typhus and the fight against head lice."

NS OrderMHUSSR№ 254 from 03.09.1991 "On the development of disinfection business in the country."

NS OrderMHRF№ 109 from 21.03.2003 "On the improvement of anti-tuberculosis measures in the Russian Federation."

NS OrderMHRF№ 229 from 27.06.2001, "On the national calendar of preventive vaccinations and the calendar of vaccinations for epidemic indications."

NS SanPiN2.1.3.2630-10 "Sanitary and Epidemiological Requirements for Organizations Performing Medical Activities."

NS SanPiN2.1.7.2730-10 from09.12.10 of the year- "Sanitary and Epidemiological Requirements for Medical Waste Management".

NS SanPiN3.1.5.2826-10 from11.01.11 of the year- "Prevention of HIV infection".

3. Sanitary and educational activities

Work on medical prevention and the promotion of a healthy lifestyle for the population is carried out on the basis of the order of the Russian Federation No. 455 of September 29, 2003. 4 hours of budget time are worked out for medical prevention of the population.

Various forms of work are used: conversations, decoration of health corners, health bulletins, lectures.

I am supposed to work 44 hours a year in health education. The most convenient form of work is conversation. After each conversation I have conducted, I make a note in the log book for conducting sanitary and educational work. I constantly conduct conversations not only with the patient, and their relatives to promote a healthy lifestyle.

One of the main goals of a nurse's work is continuous improvement, adherence to ethics and deontology in relation to patients and colleagues. A nurse must promote the preservation and strengthening of health, and encourage a healthy lifestyle. By virtue of their profession, instill in patients the rules of self-care and hygiene. The significance of these measures prevents chronic diseases and their complications. The study of the activities of nursing staff showed that this category of workers has sufficient work experience, high qualifications, great responsibility and independence.

I carry out sanitary and educational work in the department all the time. I form the patients' need for giving up bad habits, motivation for recovery, the ability and skills to self-control the state of health, to provide first aid in case of an exacerbation. Main topics of conversation:

v Varicose veins of the lower extremities.

v About the dangers of smoking.

v Correct administration of tablet medicines.

v Patient education on how to take care of the calostomy and how to change the colostomy bags.

v Diet for diabetes mellitus.

Health bulletins were issued in 2014 on the topics: "Prevention of hemorrhoids", "Phlegmons" and others.

Conclusion

The hospital is constantly working to improve the qualifications of nurses. Every year, advanced training courses for nurses are held on the basis of the SBMK of the SAKHALIN BASIC MEDICAL COLLEGE. The main nursing staff has qualification categories and work experience of over twenty years.

Once a month, conferences are held on compliance with the sanitary and epidemiological regime in the department, processing equipment and instruments, problems of first aid, etc.

Viewsenhancementsprofessionalqualifications

I improve my professional level by attending nursing conferences, learning new technologies. The department holds monthly thematic conferences, where we are introduced to new means of protection, innovations in dressings or equipment, etc. The department is constantly studying new orders and instructions, as well as classes on topics. For example:

§ Organization of the dressing room work. Bix laying, sterile table setting. Tool processing.

§ Types of desmurgy.

§ Technique for dressing postoperative wounds.

§ Care of stomas (intestinal). Features depending on the place of imposition. Means for leather processing.

§ Care of drainage tubes. Types of drainages. The need to flush drainage tubes.

§ Care for wounds: purulent and clean. Types of dressings.

The nurses of the department are fluent in the technique of central venous catheterization, all types of dressings, medical records, etc. All personnel are instructed every six months with passing sanitary and epidemiological examinations. Instructions are constantly conducted to familiarize themselves with the functional responsibilities of the department employees.

Self-education

In the modern world, there is a sufficient amount of professional literature, which contains all the material that a medical professional needs to know. Thanks to this, self-education becomes available to a wide range of people. The development of communications, the media, the Internet, television makes it possible to perceive new information and use its professional activities. Big choice medical journals for nurses: "nursing", "medical bulletin", "nurse", etc. provides the necessary information from which to learn from other regions of Russia. Attending nursing conferences, seminars, talks, is also an integral part of my self-education.

Planningwork

Every day in the department, the head of the department and the head nurse before the start of the working day hold planning meetings, at which the dressing plan for the day is clarified, all current affairs are discussed, problems are identified and decisions are made to eliminate them.

Mentoring

I conduct training for junior medical personnel on compliance with the rules of the sanitary and epidemiological regime, work with disinfectants, and labor protection rules.

On the basis of the department, students of the medical school undergo practical training. I teach them dressings. I try to ensure that during the practice, future nurses receive basic knowledge and skills of nursing.

Privateprofessionalplan

ь Confirm the qualification category in the specialty "Nursing".

ь Constantly improve your professional level of knowledge, skills and abilities through self-education, participation in general hospital, intradepartmental conferences, technical training, seminars.

ь Actively participate in the life of the department and the hospital.

ь Constantly use the library with medical literature on the specifics of the department, as well as read the magazines "Nursing", "Nurse".

b Accept Active participation in training young professionals

Offers

According to the specifics of the department's work, patients are admitted both as planned and urgently. For postoperative patients and patients with amputation of limbs, functional beds, reusable and disposable linens are required.

For patients who have temporarily lost their motor function, individual wheelchairs and crutches are needed.

An important role is played by the employee's appearance; it is necessary to highlight medical gowns and suits.

1. Provide disposable medical products, consumables in full.

2. Computerization of medical records.

3. Continue the planned work on the passage of studies, advanced training of the medical staff of the department.

4. Pay special attention: to the improvement of working and rest conditions, moral and material encouragement of the department employees.

5. Introduce a program for the exchange of experience between nurses from other districts of the Sakhalin Oblast.

Nurse of the dressing room FISCHUK E. B

Senior nurse IVANOVA S.N.

Chief Nurse ZHAROVTSEVA N.A.

Bibliography

1. The official website of the National Library of the Federal State Budgetary Healthcare Institution "YOOMC FMBA of Russia"

2. Petrovskaya S.A. Handbook of the head (senior) nurse. M .: Dashkov and K, 2007.

3. Yu.P. Lisitsyn "Guide to Social Hygiene and Health Organization". 1987.

4. Directory "Prevention of nosocomial infections in the work of nurses." 2010 year.

5. Methodical letters and orders of the Ministry of Health of the USSR and the RSFSR, job description.

6. Barykina N.V., Chernova O.V. Nursing in surgery: workshop. Rostov n / a: Phoenix, 2007.

7. S.I. twins Fundamentals of Nursing. M .: Academy, 2007.

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ORDER No. 720 OF JULY 31, 1978. "ON IMPROVEMENT OF MEDICAL CARE FOR PATIENTS WITH PURULENT SURGICAL DISEASES AND STRENGTHENING OF MEASURES FOR COMBATING INTRAHOSAL INFECTION"

In spite of successes achieved in the treatment of purulent wounds, the problem of surgical and nosocomial infection is of particular importance. Due to the economic instability in the country, a sharp deterioration in health care financing, a reduction in the bed network and the inability to provide full-fledged emergency medical care to surgical patients, an increase in the number of neglected cases of diseases, strict implementation of this order is required.

This order approved 4 instructions:

· Instructions for organizing and conducting sanitary and hygienic measures for the prevention of nosocomial infections in medical institutions (surgical departments, in wards and departments of intensive care and intensive care);

· Instructions for bacteriological control of a complex of sanitary and hygienic measures in medical and preventive institutions (departments of the surgical profile, in wards and departments of intensive care and intensive care);

· Instructions for bacteriological examination to identify carriers of pathogenic staphylococcus and carry out sanitation;

· Instructions for cleaning and disinfecting devices for inhalation anesthesia and artificial lung ventilation.

In this order, due to the high frequency of allergic reactions, it is prohibited to treat the surgeon's hands and the operating field with iodine tincture, it is recommended to replace it with iodine-containing solutions (solutions of iodonate, iodopyrone and others). Permur (C4 formulation, or a mixture of hydrogen peroxide and performic acid) and a 0.5% alcohol solution of chlorhexidine bigluconate have been proposed as an alternative for the treatment of the surgeon's hands and the operating field.

ORDER of the Ministry of Health of the Russian Federation No. 174 OF 05/17/99. “ON MEASURES FOR FURTHER IMPROVEMENT OF PREVENTION OF TETANUS ”

As a result of mass immunization of the population, the incidence of tetanus has significantly decreased and in the last decade has stabilized at low rates - from 0.033 to 0.6 per 100 thousand population. About 70 cases of this infection are registered in the country every year, half of which are fatal.

As a result of targeted active immunoprophylaxis, neonatal tetanus has not been recorded since 1975.

The most effective method for preventing tetanus is active immunization with tetanus toxoid (AC-toxoid). Protection against tetanus in children is usually achieved by immunization with DTP vaccine or DTP toxoid or AC toxoid.

After the completed course of immunization, the human body for a long time (about 10 years) retains the ability to quickly (within 2-3 days) produce antitoxins in response to repeated administration of drugs containing AC-toxoid.

The completed course of active immunization includes the primary vaccination and the first revaccination. To maintain immunity against tetanus at a sufficient level, it is necessary to periodically re-vaccinate with an interval of 10 years by a single injection of drugs containing AC-toxoid.

To prevent tetanus from occurring in the event of injury, emergency prophylaxis is required.

Emergency immunization is carried out differentially, depending on the patient's previous immunization against tetanus by administration of AC-toxoid and ADS-M-toxoid (emergency revaccination), or by means of active-passive immunization by simultaneous administration of AC-toxoid and tetanus toxoid (PSS) or immunoglobulin PSCH).

Emergency active-passive prophylaxis in previously unvaccinated people does not guarantee tetanus prevention in all cases; moreover, it carries the risk of immediate and long-term reactions, as well as complications in response to the administration of PSS. To exclude the repeated administration of PSS in case of new injuries, persons who have received active-passive prophylaxis must necessarily complete the course of active immunization by a single revaccination with AC-toxoid or ADS-M-toxoid.

Drugs used for routine active immunization against tetanus:

n Adsorbed diphtheria-tetanus pertussis vaccine (DTP), containing in 1 ml 20 billion inactivated pertussis microbial cells, 30 flocculating units of diphtheria and 10 units of conjugated (EC) tetanus toxoid.

n Adsorbed diphtheria-tetanus toxoid (ADS), containing 60 diphtheria and 20 EC tetanus toxoids in 1 ml.

n Adsorbed diphtheria-tetanus toxoid with reduced antigen content (ADS-M), containing 10 diphtheria and 10 EC tetanus toxoids in 1 ml.

n Adsorbed tetanus toxoid (AS), containing 20 EC in 1 ml.

Drugs used in emergency immunization of tetanus:

n Adsorbed tetanus toxoid (AS);

n Adsorbed diphtheria-tetanus toxoid with reduced antigen content (ADS-M);

n Equine anti-tetanus horse serum purified concentrated liquid (PSS). One prophylactic dose of PSS is 3000 IU (international units);

n Human tetanus immunoglobulin (TITI). One prophylactic dose of PSI is 250 IU.

Emergency prevention of tetanus is carried out:

n in case of injuries with violation of the integrity of the skin and mucous membranes;

n with frostbite and burns (thermal, chemical, radiation) of the second, third, and fourth degrees;

n with penetrating injuries of the gastrointestinal tract;

n for community-acquired abortions;

n during childbirth outside medical facilities;

n with gangrene or tissue necrosis of any type, long-term abscesses, carbuncles;

n from animal and human bites.

Emergency prevention of tetanus consists in the primary surgical treatment of the wound and the simultaneous specific immunoprophylaxis. Emergency tetanus immunization should be carried out as early as possible and up to 20 days after injury, given the length of the incubation period for tetanus disease.

Prescription of drugs for emergency immunization of tetanus is carried out differentially, depending on the availability of documentary evidence of preventive vaccination or immunological control data, the tension of tetanus immunity, and also taking into account the nature of the injury.

The introduction of drugs is not carried out:

n children and adolescents who have documented evidence of routine prophylactic vaccinations in accordance with age, regardless of the period after the next vaccination;

n adults who have documented a complete course of immunization no more than 5 years ago;

n persons who, according to emergency immunological control, have a tetanus antitoxin titer in blood serum above 1: 160 according to RPHA, which corresponds to a titer above 0.1 IU / ml according to the biological neutralization reaction - PH (protective titer).

Only 0.5 ml of AC-toxoid is injected:

n children and adolescents who have documented evidence of a course of routine prophylactic vaccinations without the last age-related revaccination, regardless of the date of the last vaccination;

n adults who have documented a complete course of immunization more than 5 years ago;

n people of all ages who received two vaccinations no more than 5 years ago, or one vaccine no more than 2 years ago;

n children from 5 months of age, adolescents, conscripts and those who have served in the army fixed time whose vaccination history is not known, and there were no contraindications to vaccination;

n persons who, according to the emergency immunological control, have a tetanus toxoid titer in the range of 1:20 - 1:80 according to the RSPA or in the range of 0.01 - 0.1 IU / ml according to the RN data.

Instead of 0.5 ml of AC, 0.5 ml of ADS-M can be injected if immunization with this drug is necessary.

When carrying out active-passive prophylaxis of tetanus, 1 ml of the AC is injected, then with another syringe into another part of the body - PSCHI (250 IU) or after an intradermal test - PSS (3000 IU).

Active-passive prophylaxis is carried out:

· Persons of all ages who received two vaccinations more than 5 years ago, or one vaccination more than 2 years ago;

· Unvaccinated persons, as well as persons who do not have documentary evidence of vaccinations;

· Persons who, according to the emergency immunological control, have a tetanus antitoxin titer of less than 1:20 according to the RGPA or less than 0.01 IU / ml according to the pH data.

All persons who received active-passive prophylaxis of tetanus, in order to complete the course of immunization in the period from 6 months to 2 years, should be revaccinated with 0.5 ml of AS or 0.5 ADS-M.

Children under 5 months who are not vaccinated for various reasons are injected with only 250 IU of PSSI or (in the absence of PSSI) - 3000 IU of PSS.

Emergency prevention of tetanus for repeated injuries:

Persons who, in accordance with their vaccination history, received only AS (ADS-M) with repeated injuries, receive emergency prophylaxis as previously vaccinated in accordance with the rules, but not more often than once every 5 years.

Contraindications to the use of specific drugs for the emergency prevention of tetanus:

1. The main contraindications to the use of drugs for specific prophylaxis of tetanus are:

n hypersensitivity to the corresponding drug;

n pregnancy (in the first half, the administration of AS (ADS-M) and PSS is contraindicated, in the second half - PSS).

2. In persons who had contraindications to the administration of AS (ADS-M) and PSS, the possibility of emergency prophylaxis with the help of PSCI is determined by the attending physician.

3. The state of alcoholic intoxication is not a contraindication to emergency prophylaxis of tetanus.

After the introduction of PSS or drugs containing tetanus toxoid, in very rare cases, complications may develop: anaphylactic shock, serum sickness.

ORDER of the Ministry of Health of the Russian Federation No. 297 dated 07.10.1997. " ON IMPROVEMENT OF MEASURES FOR THE PREVENTION OF THE DISEASE OF PEOPLE WITH RABY "

In connection with the aggravation of the epidemic situation of rabies in the territory of the Russian Federation in recent years, the threat of the spread of this infection among the population has significantly increased. The number of cases of rabies in animals has doubled in recent years, and the number of people injured by animals has more than doubled. In the Russian Federation, 5 - 20 cases of rabies among humans are annually registered, in the Republic of Belarus 1 - 2 cases.

First medical aid to persons who have applied for bites, scratching, salivation by any animals, as well as persons who have received damage to the skin and contact of infected material on the mucous membranes when cutting and opening carcasses of animals that have died from rabies, or when opening the bodies of people who have died from hydrophobia, all MEDICAL AND PREVENTIVE INSTITUTIONS.

THERAPEUTIC AND PREVENTIVE INSTITUTIONS when handling persons who have been bitten, scratched, salivated by any animals, as well as persons who have received damage to the skin and the ingestion of infected material on the mucous membranes during cutting and opening of carcasses of animals that have died from rabies, or during the autopsy of the corpses of people who died from rabies are required:

· Immediately provide first aid to the victim: rinse abundantly wounds, scratches, abrasions, salivation with a stream of water and soap (or any detergent solution), treat the edges of the wound with 70% alcohol or tincture of iodine, apply a sterile bandage. The edges of the wound inflicted on the animal during the first three days should not be excised or sutured, except for injuries that require special surgical interventions for health reasons;

· In case of extensive wounds, after preliminary local treatment of the wound, several directing sutures are applied;

· In order to stop external bleeding, bleeding vessels are sutured;

· Conduct emergency tetanus prophylaxis in accordance with the instructions for its implementation;

Send the victim to the trauma center (or office), and in his absence - to surgery room or the surgical department of a hospital for prescribing and administering a course of rabies vaccinations;

· Send a telephone message to each applicant and send a written "Emergency notification of an infectious disease" (registration form No. 058 / y) to the state sanitary and epidemiological surveillance center in the area of ​​which this institution is located;

· Inform each victim about the possible consequences of refusal of vaccinations and the risk of rabies, the timing of observation of the animal.

TRAUMATOLOGICAL STATIONS (OFFICES), and in their absence- SURGICAL OFFICES AND SURGICAL DEPARTMENTS ARE OBLIGED TO:

1. In the case of the initial appeal of the victim, provide him with first aid, promptly transmit a telephone message and within 12 hours send an emergency notification (registration form No. 058 / y) to the state sanitary and epidemiological surveillance center in the area of ​​which this institution is located.

2. Fill in the “Card of the person who applied for anti-rabies help” for each victim (registration form No. 045 / y).

3. To prescribe and ensure the course of anti-rabies vaccinations in accordance with the current instructions for the use of anti-rabies drugs, including, without fail, on Saturdays, Sundays and holidays in medical institutions that constantly receive patients around the clock.

4. Ensure hospitalization of the following categories of victims for the course of vaccinations:

· Persons who have received severe and multiple bites and bites of a dangerous localization;

· Persons living in rural areas;

· Re-vaccinated;

· Have a burdened history (neurological, allergic, etc.).

5. Clarify the course of vaccinations on the basis of a message from a veterinary institution on the results of observation of animals or a message from the State Sanitary and Epidemiological Surveillance Center on the results of a laboratory study of a dead or killed animal.

6. Inform the centers of state sanitary and epidemiological supervision:

· In case of moving to another place of residence of the victim who has not completed the course of anti-rabies vaccinations;

· In case of post-vaccination complications;

· About vaccinated who have not completed the course of vaccinations;

· About each case of refusal to vaccinate against rabies.

7. Send copies of all completed "Cards of those who applied for anti-rabies help" to the territorial centers of the state sanitary and epidemiological supervision.

8. Ensure the continuity of the course of anti-rabies vaccinations, if possible, with one batch of vaccine.

9. To issue a refusal to provide anti-rabies care in the form of a patient's receipt, certified by the signatures of 2 doctors and the seal of the healthcare facility.

10. To issue and issue a certificate to the patient about the course of anti-rabies vaccinations, if he has a vaccination certificate, fill out the registration form.

11. Keep records of post-vaccination reactions and complications to the introduction of anti-rabies drugs.

12. Determine the need for antirabies drugs and submit requests for antirabies drugs in a timely manner.

Lecture 3. ASEPTICS

Asepsis - measures aimed at preventing the entry of microbes into the wound. Asepsis in translation from Greek means: A - without, septicos - purulent. Hence, the basic principle of asepsis says: everything that comes into contact with the wound must be free of bacteria, that is, it must be sterile. Any surgical intervention should be performed under sterile conditions, this applies not only to surgery itself, but also to traumatology, ophthalmosurgery, urology, endoscopy and other specialties. Therefore, knowledge of asepsis is mandatory for almost any medical profession.

Microbes can enter the wound both from the inside and from the outside. Endogenous infection is an infection located inside the body or on the skin and mucous membranes. Such an infection can enter the wound by contact, lymphogenous and hematogenous routes. Sources of endogenous infection are carious teeth, foci of chronic infection in internal organs - cholecystitis, bronchitis, pyelonephritis, etc.

Of greatest importance is an exogenous infection that enters the wound from the external environment. There are 3 ways of transmission of exogenous infection:

1. Airborne droplets - the infection enters the wound from the air, with saliva splashes, when coughing, sneezing, etc.

2. Contact path - the infection enters the wound from objects in contact with the wound.

3. Implantation route - the infection enters the wound from materials left in the body or wound during surgery: drains, catheters, suture material, vascular prostheses, artificial materials, etc.

Airborne Infection Prevention

Prevention of airborne infection primarily depends on the correct organization of the surgical department, dressing rooms, operating rooms. In the surgical department, the wards should be for 2 - 4 beds, the area for 1 bed should be at least 6.5 - 7.5 square meters. Floors, walls, furniture in wards should be easily cleaned and disinfected. In small hospitals, like a district hospital, there is 1 surgical department, but it is necessary to separate the "purulent" from the "clean" patients, ideally have 2 dressings - for purulent and clean dressings. In dressing rooms it is necessary to work in dressing gowns, caps, masks.

Asepsis should be especially carefully observed in the operating unit. The operating unit must be separate from other parts of the hospital. The operating unit consists of operating rooms, preoperative rooms, and utility rooms for personnel. In the operating room, the floor and walls should have a smooth surface, preferably tiles, which can be easily disinfected. Before the operation, the operating team completely changes into sterile overalls; students must visit the operating rooms in clean coats, caps, masks, shoe covers, without woolen clothes, with neatly hidden hair. The operating room must adhere to the redline rule. Operating rooms are cleaned using a wet method. Distinguish:

preliminary cleaning - before the operation;

routine cleaning - carried out during the operation;

daily cleaning - after the end of the operation;

general cleaning - carried out once a week.

To reduce bacterial pollution of the operating room air, air purifiers and bactericidal lamps are used.

Prevention of contact infection

This section includes the treatment of the surgeon's hands and the operating field, sterilization of surgical instruments, sterilization of linen and dressings.

The surgeon's hands are treated in 2 stages: mechanical cleaning and disinfection. Mechanical cleaning consists in washing hands under running water with soap and a brush for 2 - 5 minutes. Hand disinfection can be done in several ways:

1. Until recently, the most widespread was the treatment of the surgeon's hands according to Spasokukotsky - Kochergin: after washing, the hands are treated in 2 basins with a 0.5% solution of ammonia, for 5 minutes in each basin. Then hands are wiped dry and treated with 96% alcohol for 5 minutes. Due to the duration of processing, this method is rarely used at present.

2. Treatment of the surgeon's hands with chlorhexidine-bigluconate: after washing, the hands are dried, treated twice for 3 minutes with napkins moistened with 0.5% alcohol solution of chlorhexidine-bigluconate.

3. Treatment of the surgeon's hands with a solution of pervomur (a mixture of formic acid and hydrogen peroxide): after washing, the hands are treated in a basin with a 2.4% solution of pervomur for 1 minute.

4. Treatment of the surgeon's hands according to the Davletov method: after washing, the hands are treated with Davletov's solution (a mixture of 0.1 normal hydrochloric acid solution and 33% alcohol).

5. Accelerated methods of processing the hands of the surgeon: methods of Brun and Alfeld using 96% and 70% alcohol.

After treating the hands with any method, the surgeon puts on sterile rubber gloves.

The processing of the operating field consists in hygienic processing and disinfection of the skin in the area of ​​the operating access. Hygienic treatment consists in washing the patient, shaving hair in the area of ​​the forthcoming surgical intervention.

Most often, the disinfection of the operating field is carried out according to Grossikh-Filonchikov: the operating field is widely treated twice with 5% tincture of iodine, then twice with 70% alcohol solution, after which the operating field is covered with sterile sheets.

In addition, the operating field can be treated with iodonate, iodopyrone, 0.5% alcoholic solution of chlorhexidine-bigluconate.

Sterilization of surgical instruments consists of pre-sterilization processing and sterilization itself.

Pre-sterilization treatment: after the operation, instruments contaminated with blood are soaked in a washing solution, then washed under running water with a brush, rinsed in distilled water, dried at a temperature of 85 degrees.

Sterilization:

By boiling: produced in special sterilizers, boilers, with the addition of soda. Nowadays it is rarely used, mainly for the sterilization of rubber, PVC and silicone tubes, non-cutting instruments. Metal tools and glass products are boiled for 20 minutes, rubber products - 10 minutes.

Sterilization with dry steam: carried out in special dry-heat ovens at a temperature of 180 degrees for 60 minutes.

Chemical method: small instruments (needles, scalpel blades) and plastic products can be sterilized in 6% hydrogen peroxide solution for 360 minutes at 18 degrees, or for 180 minutes at 50 degrees.

Processing of endoscopes, catheters is carried out:

in steam-formalin chambers;

ethylene oxide (gas method);

solutions of the "sidex" type;

triple solution.

Sterilization of surgical drapes and dressings

Surgical linen and dressings are sterilized by autoclaving - in special bixes, which are placed in autoclaves. Linen and material are sterilized at a temperature of 120 degrees under a steam pressure of 1.1 atmospheres for 45 minutes, or at a temperature of 132 degrees under a steam pressure of 2 atmospheres for 20 minutes.

Prevention of implantation infection

Suture sterilization

silk sterilization: Kocher method - skeins of silk are washed in warm water and soap, dried, defatted in ether for 12-24 hours, then placed in 70% alcohol for 12-24 hours, after which they are boiled for 10 minutes. Store in hermetically sealed jars in 96% alcohol, which is changed every 7 days.

sterilization of nylon and lavsan: carried out by autoclaving.

sterilization of catgut: Sitkovsky method - in iodine vapor; ray method - gamma irradiation.

sterilization of atraumatic ligatures: in a factory way by gamma irradiation.

Control over pre-sterilization treatment

In order to control for the presence of residues of the washing solution, an amidopyrine or phenolphthalein test is carried out, for the presence of blood residues - a benzidine or ortho-toluidine test. If there are residues of cleaning solution or blood, a discoloration of the control solutions appears.

Sterilization control: based on the color change of test indicators; on the melting effect of some chemical compounds; by direct thermometry; by bacteriological control.

During autoclaving, together with the sterilized products, sealed glass cones with chemical compounds are placed in bixes: powders of urea, benzoic acid with fuchsin, which melt at temperatures above 120 degrees.

During sterilization in dry ovens, thermal indicators are used that change color when the temperature reaches 180 degrees, or direct thermometry using thermometers built into the sterilizers.

Control over the sterility of the suture material, dressing material, linen, the surgeon's hands and the operating field is carried out by periodic inoculation of washes or samples of suture material - bacteriological control.

Lecture 4. ANTISEPTICS

One of the important sections of general surgery is the topic "Antiseptics". Without dwelling on the history of antiseptics, it should only be noted that the founder of antiseptics is considered to be the English surgeon Lister, who proposed carbolic acid for treating wounds, the surgeon's hands and instruments.

So, antiseptic is a set of measures aimed at destroying microorganisms in a wound, in a pathological focus and in the body as a whole. Antiseptics can create either unfavorable conditions for the development of infection, or have a detrimental effect on microorganisms.

Distinguish between mechanical, physical, chemical, biological and mixed antiseptics. Let's consider each of them separately.

Mechanical antiseptic- this is the use of mechanical methods that help to remove foreign bodies, non-viable and necrotic tissues from the wound, which are a good environment for the reproduction of microorganisms. In general, any accidental wound is considered infected, but not every wound festers. This is due to the fact that for the development of infection in the wound, a certain concentration of microbes is required: 100,000 microbial bodies per 1 g of tissue. This is a critical level of wound contamination.

However, the infection can develop in the wound and with less bacterial contamination, for example, with diabetes mellitus, anemia, general weakening of the patient, suppression of immunity, etc.

Therefore, any accidental injury must be treated. Thus, the main method of mechanical antiseptics is the surgical debridement of the wound. Primary surgical treatment of the wound consists in excision of the edges and bottom of the wound. At the same time, the microbial contamination of the wound is significantly reduced.

In addition, the treatment of the wound with a stream of liquid belongs to mechanical antiseptics. A jet of liquid under high pressure washes away foreign bodies, pus and microorganisms.

Mechanical antiseptics also includes wound drainage with rubber strips and tubes, this is the so-called passive wound drainage, when pus flows out of the wound by gravity, passively.

Application of methods of active drainage of wounds. Unlike passive drainage, in this case, to improve the outflow from the focus, a vacuum source is used: an electric suction, a vacuum pump, a microcompressor, etc. There are two types of active drainage: first, active-aspiration drainage, when a drainage tube is connected to a suction; secondly, flow-aspiration drainage, when an antiseptic solution is introduced into the focus through one tube, the other tube is connected to the suction, thus constant irrigation of the focus is performed.

Physical antiseptic Is the application of physical factors. These include:

1. Application of a high-energy (surgical) laser. Moderately defocused laser beam evaporates necrotic tissue, pus. After such treatment, the wound becomes sterile, covered with a burn scab, after which the wound heals without suppuration.

2. The use of ultrasound - sound with a frequency above 20 kHz causes the effect of cavitation, that is, the action of high-frequency shock waves that have a fatal effect on microorganisms.

3. The use of physiotherapeutic procedures - UFO, quartzing, UHF, electrophoresis, etc.

Chemical antiseptic- the use of chemicals that have a bactericidal effect (retarding the development and reproduction of microbes).

There are many chemical antiseptics, they are divided into the following groups:

I. Group of halogens:

1.chloramine B: used for washing purulent wounds 1-2% solution, for hand disinfection - 0.5% solution, for current disinfection of premises - 2% solution;

2. iodine alcohol solution 5-10%;

3. iodine preparations: iodonate 1% solution, iodinol 1% solution, iodopyrone 1% solution.

II. Oxidants:

1. A solution of hydrogen peroxide. On contact with the wound, hydrogen peroxide decomposes with the release of oxygen, forming a copious foam. The antiseptic effect of hydrogen peroxide is explained by both a strong oxidative effect and mechanical cleaning wounds from pus and foreign bodies;

2. Perhydrol - contains about 30% hydrogen peroxide, it is used to prepare a solution of pervomur;

3. Potassium permanganate ("potassium permanganate"): used for washing wounds 0.1% solution, for washing the mouth and stomach 0.01% solution.

Oxidants are especially effective for anaerobic and putrefactive diseases.

III. Acids:

1. Boric acid - in the form of a powder, and in the form of a 4% solution for washing wounds. It is especially effective for Pseudomonas aeruginosa infection.

2. Formic acid - used to prepare a solution of pervomur (for treating the surgeon's hands).

3. Hydrochloric acid - 0.1% hydrochloric acid solution is part of Davletov's solution.

IV. Aldehydes:

1.formaldehyde;

2. lysoform;

3. formalin.

V. Phenols:

1.carbolic acid;

2. Ichthyol, used in the form of an ointment.

Vi. Alcohols: ethyl alcohol 70% and 96% solutions, for treating the edges of wounds, treating the hands of the surgeon and the operating field.

Vii. Hypertonic solutions:

1. Hypertonic solution (10% sodium chloride solution);

2. 30% urea solution;

3.40% glucose solution.

The disadvantage of hypertonic solutions is their rapid inactivation due to dilution with wound exudate.

VIII. Dyes:

1. Methylene blue 1-3% alcohol solution;

2. Brilliant green ("brilliant green");

3. Rivanol.

IX. Heavy metal salts:

1. Silver nitrate: 0.1 - 0.03% aqueous solution is used for washing purulent wounds and bladder; 1 - 2% solutions and ointments are used for cauterization of granulations, in the treatment of fistulas.

2. Sublimate (mercury dichloride) is a strong poison. A solution of 1: 1000 or 1: 2000 is used for processing instruments and gloves. Not currently in use due to toxicity.

3. Silver salts: collargol and protargol.

H. Detergents: These are potent surfactants.

1. Chlorhexidine bigluconate. A 0.5% alcohol solution is used to treat the surgeon's hands, and a 5% aqueous solution is used to treat wounds and abdominal cavity with peritonitis.

2. Zerigel: used to treat the hands of the surgeon. When applied to the hand, a film is formed that can be removed with alcohol.

3. Rokkal 10% and 1% aqueous solutions.

XI. Derivatives of nitrofurans:

1. Furacillin - for treating wounds, instruments, washing cavities;

2. Furadonin, furazolidone - uroantiseptics;

3. Furagin is an antiseptic for intravenous administration.

Biological antiseptic: These include:

1. Antibiotics;

2. Enzymes;

3. Bacteriophages;

4. Serums;

5. Immunoglobulins.

Antibiotics:

1. Penicillin group: benzylpenicillin, bicillin 1, 3, 5. Semisynthetic penicillins: methicillin, oxacillin, ampiox, carbenicillin.

2. Group of tetracyclines: tetracycline, oxytetracycline, morphocycline, biomycin.

3. Group of chloramphenicol: chloramphenicol, syntomycin.

4. Macrolides: erythromycin, oleandomycin, sigmamycin.

5. Aminoglycosides: kanamycin, gentamycin, amikacin, brulamycin, heramycin, sisomycin.

6. Group of cephalosporins: seporin, kefzol, cloforan, ketacef.

7. Rifamycins: rifamycin, rifampicin, rifadin.

8. Antifungal antibiotics: nystatin, levorin, amphoterricin.

9. Other antibiotics: lincomycin, polymyxin, ristomycin, and others.

10. Class of thienamycins: new antibiotics with the broadest spectrum of action. The representative is thienam, effective for both gram-negative and gram-positive aerobes and anaerobes.

Enzymes: They have a necrolytic, bactericidal, anti-inflammatory effect. These include:

1. Chymotrypsin;

2. Trypsin;

3. Himopsin;

4. Terrilitin;

5. Enzymes in ointments: Iruxol;

6. Immobilized enzymes - introduced into the dressing material, they act for 24 - 48 hours.

Bacteriophages: Staphylococcal, streptococcal, Pseudomonas aeruginosa, Proteus, combined, etc.

Serums:

1. Antistaphylococcal;

2. Antitetanus (PSS);

3. Anti-gangrenous, etc.

Immunoglobulins:

1. Gamma globulin;

2. Influenza;

3. Staphylococcal.

Preparations of natural origin:

1. Chlorophyllipt - a mixture of chlorophylls;

2. Ectericide: obtained from fish oil;

3. Baliz: obtained from saccharomycetes.

Sulfonamides:

1. Streptocide;

2. Sulfadimezin;

3. Sulfalene;

4. Urosulfan;

5. Sulfadimethoxine;

6. Sulfapyridazine;

7. Biseptol.

Ointment antiseptics:

In surgery, 2 types of ointments are used: 1 - on a fatty and petrolatum-lanolin basis (syntomycin, Vishnevsky ointment, furacillin, etc.); 2 - water-soluble ointments (levosin, levomikol). The best for purulent processes are water-soluble ointments. They, firstly, contain an antibiotic (chloramphenicol), and secondly, they have a high osmotic activity, exceeding the activity of a hypertonic solution by 10-15 times, while their activity lasts for 20-24 hours.

Routes of administration of antiseptics:

1. Enteral administration - through the gastrointestinal tract. In this way, antibiotics and sulfonamides are administered.

2. External use - for the treatment of wounds: in the form of powder, ointment, solution.

3. Cavity introduction - into the joint cavities, into the abdominal, pleural cavities.

4. Parenteral administration (intravenous, intra-arterial).

5. Endoscopic introduction - through the bronchoscope into the bronchi, into the cavity of the lung abscess; through a fibrogastroscope - into the esophagus, stomach, duodenum.

6. Endolymphatic injection - into the lymphatic vessels and nodes. So, endolymphatic antibiotic therapy for peritonitis is widely used in surgery.

Lecture 5. LOCAL ANESTHESIA

Despite the widespread use in modern medicine of intravenous and intubation anesthesia, local anesthesia does not lose its importance. In daily work, the surgeon repeatedly uses local anesthesia, both for small-scale interventions and for therapeutic purposes.

The purpose of local anesthesia is to eliminate pain in a limited area by blocking nerve endings and nerve trunks while maintaining consciousness.

Depending on the method of administration of the anesthetic drug, the following types of local anesthesia are distinguished:

1. Surface anesthesia - achieved by lubricating the skin and mucous membranes. Surface anesthesia is used in ophthalmology - by instilling an anesthetic, in ENT practice - by lubricating or irrigating with a 0.5-2% solution of dicaine. Contact anesthesia is widely used in airway interventions (bronchography, bronchoscopy) and in fibrogastroscopy. In these cases, the anesthetic is applied to the oropharyngeal mucosa by irrigation. As an anesthetic for contact anesthesia, 2 - 5% cocaine solutions, 0.5 - 2% dicaine solutions, 0.5 - 2% pyromecaine solutions are used. Analgesia occurs in 2 to 3 minutes and lasts 20 to 30 minutes. It should be noted that these anesthetics are highly toxic, so they are used in small doses.

2. Infiltration anesthesia - based on soaking the tissues in the area of ​​the future surgical access with an anesthetic solution. Most often, 0.25 - 0.5% solutions of novocaine are used as an anesthetic.

Technique: first, novocaine is injected intradermally with a thin needle, while this area of ​​the skin turns white, takes the form of a "lemon crust". A similar "lemon peel" is created throughout the future skin incision. Then, with a thicker and longer needle, a solution of novocaine is injected into the subcutaneous tissue, then into the muscle and deeper tissues.

A type of infiltration anesthesia is local infiltration layer-by-layer anesthesia, or the "creeping infiltrate" method. The method was proposed by A.V. Vishnevsky.

Technique: intradermally with a thin needle a "lemon crust" is created, then novocaine is injected under pressure into the subcutaneous tissue. Then an incision is made in the skin and adipose tissue, then novocaine is injected under the aponeurosis. This is how the incision and the layer-by-layer tight introduction of novocaine alternate. The total amount of safely administered novocaine can reach 1.5 - 2 liters. Currently, this method is most often used by surgeons for simple operations (appendectomy, hernia repair, removal of benign tumors, sectoral resection of the mammary gland, and others).

3. Conduction anesthesia - based on the interruption of conduction along the nerve trunk. More concentrated solutions of novocaine are used: 1% solution of 5 - 10 ml, 2% solution of 3 ml. Conductive anesthesia is used:

With amputation of the thigh for anesthesia of the sciatic nerve;

In dentistry - when removing teeth (blockade of the mandibular nerve);

In operations on the fingers of the hand, mainly in panaritiums, the Oberst-Lukashevich method is used: at the same time, a tourniquet is applied to the base of the finger, and a 1 - 2% solution of novocaine is injected distally along the lateral surfaces of the finger along the nerve trunks. After 5 minutes, the entire finger is anesthetized.

with fractures of the ribs, with intercostal neuralgia, blockade of intercostal nerves is performed. In this case, 10 - 15 ml of 0.5 - 1% novocaine solution is injected under the lower edge of the rib. To lengthen the analgesic effect of intercostal blockade, alcohol can be added to novocaine - this is the so-called alcohol-novocaine blockade.

4. Intraosseous anesthesia - used in operations on the extremities. Technique: with an elevated position of the limb, a tourniquet is applied to it. Below the tourniquet, the skin, tissue and periosteum are anesthetized, then a Bir's needle with a mandrel is taken, the soft tissues are pierced, the cortical bone is pierced with rotational movements by 1 - 1.5 cm to the spongy substance. The mandrain is removed, and 50 - 150 ml of a 0.25% solution of novocaine is injected. From the spongy substance, novocaine is absorbed into the venous system and anesthetizes the segment of the limb distal to the tourniquet.

5. Local intravenous and intra-arterial anesthesia: rarely used in operations on the extremities. Technique: with an elevated position of the limb, 2 tourniquets are applied to it - above and below the site of operation. 50 - 100 ml of 0.5% novocaine solution is injected into one of the veins between 2 tourniquets. After the operation, the peripheral tourniquet is first removed, then carefully - the central tourniquet.

6. Spinal anesthesia: a type of conduction anesthesia where an anesthetic solution is injected into the subarachnoid space of the spinal canal. Spinal anesthesia is performed during operations on the lower extremities and pelvic organs. Use a solution of novocaine 2% - 5 ml, 5% - 2 ml, solution of sovcaine 1% to 1 ml.

Spinal anesthesia is dangerous, complications are possible: damage to the spinal cord, collapse, when the anesthetic spreads up to the level of the 4th thoracic vertebra, paralysis of the intercostal muscles and diaphragm is possible, which can lead to respiratory arrest. Therefore, spinal anesthesia is performed at a level not higher than 3-4 lumbar vertebrae, and in patients with low blood pressure it is contraindicated.

7. Epidural (epidural) anesthesia: is a type of conduction anesthesia. Technique: anesthetic solution is injected into the epidural space - this is a narrow gap in the spinal canal, only 3 - 5 mm wide, located between the inner surface of the bone canal and the dura mater. The anterior and posterior roots of the spinal nerves exit through the epidural space. As an anesthetic used 2 - 3% solution of trimecaine 10 - 30 ml, 0.3% solution of dicaine 20 - 25 ml. Anesthesia occurs in 20 - 30 minutes and lasts 1 - 3 hours. To lengthen the anesthetic effect, after puncture of the epidural space, a catheter can be left in it, followed by fractional administration of the anesthetic.

Contraindications: the presence of infection in the area of ​​the epidural puncture, low blood pressure, shock, diseases of the central nervous system, pathology of the spine.

8. Novocaine blockade. For a number of diseases or injuries, novocaine blockade is indicated for good pain relief. The effect of such blockages depends on the blockade of nerve endings and trunks, as well as due to the action of novocaine on the regulatory processes of the central nervous system. Varieties (main):

Paranephral blockade according to A.V. Vishnevsky: 80 - 120 ml of 0.25% novocaine solution is injected into the perirenal tissue. It is performed for acute pancreatitis, acute cholecystitis, intestinal obstruction, postoperative paresis and intestinal paralysis.

Cervical vagosympathetic blockade: it is performed for chest injuries, for ischemic heart disease.

Blockade of the round ligament of the liver: performed with acute cholecystitis, acute pancreatitis.

Intra-pelvic block according to Shkolnikov: performed for fractures of the pelvic bones.

Blockade of bone fractures: in case of bone fractures, 30-50 ml of 0.5-1% novocaine solution is injected into the hematoma area.

Dangers and complications of local anesthesia

1. Allergic reaction to anesthetic, up to anaphylactic shock. Therefore, it is necessary to study the allergic history well before anesthesia.

2. Toxic effect of anesthetic - in case of drug overdose.

3. Collapse.

4. Erroneous use of other solutions instead of anesthetic: hypertonic solution (leads to skin necrosis), alcohol (leads to tissue necrosis). To prevent this complication, the surgeon must carefully read the label on the vial, the date of preparation and the concentration of the anesthetic. Previously opened bottles are prohibited to use.

5. When anesthetics enter the vessels, rapid intoxication develops - pallor of the skin, cold sweat, drop in blood pressure, loss of consciousness, up to respiratory arrest.

6. Post-injection infiltrates and abscesses after novocaine blockade - if the rules of asepsis are not followed.

Anesthesia is an artificially induced reversible condition in which the body's reactions to surgical trauma and other stimuli are temporarily turned off or reduced. Under anesthesia, consciousness is turned off, pain is suppressed, muscles relax, reflexes disappear or decrease. The functions of the medulla oblongata are preserved, therefore, spontaneous breathing and heart function are preserved. All drugs used for anesthesia have therapeutic and toxic effects. Toxic effect - in case of an anesthetic overdose. Therapeutic action is the dosage of the anesthetic, which achieves pain relief. The range of therapeutic action is the difference between doses that determine the therapeutic and toxic effects of anesthetics. The wider the range of therapeutic action of the anesthetic, the safer and more convenient its use.

According to the method of administration of anesthetics, inhalation and non-inhalation anesthesia are distinguished.

Inhalation - anesthesia by introducing an anesthetic through the respiratory tract:

a) mask;

b) intubation.

Non-inhalation - anesthesia by introducing anesthetics, bypassing the respiratory tract: a) intravenous; b) rectal; c) intramuscular; d) neuroleptanalgesia; e) ataralgesia.

Non-inhalation anesthesia.

Distinguish between intravenous, intramuscular, rectal anesthesia, neuroleptanalgesia, ataralgesia.

Intravenous anesthesia - carried out by the introduction of anesthetics into the venous bed. The drugs are used:

Derivatives of barbituric acid: sodium thiopental, hexenal. They are produced in the form of a powder, 1 g each, before use they are dissolved in saline, 2 - 5% solutions are prepared. They are introduced slowly, at a dose of 3-10 mg / kg of the patient's weight. Barbiturates, especially thiopental sodium, can cause bronchospasm, depression of the respiratory center. Therefore, with intravenous anesthesia, it is imperative to have a ventilator on hand. They are used for small operations, and most often as an induction anesthesia before intubation anesthesia. The duration of intravenous anesthesia is 10-15 minutes.

Propanidide (sombrevin) is administered slowly intravenously at a dose of 5-10 mg / kg body weight. Duration 4 - 6 minutes. Used for short-term interventions. Recently, it is rarely used due to the high frequency of allergic reactions and anaphylactic shock.

Predion (viadril) - powder, diluted with saline to 0.5 - 1.5% solution. Used in a dose of 12 - 15 mg / kg body weight, duration of anesthesia 40 - 60 minutes.

Ketamine (calypsol, ketalar) - can be used both intravenously and intramuscularly. The dosage is 2 mg / kg, anesthesia occurs in 15 - 30 seconds and lasts for 30 - 40 minutes. Kalipsol has a hallucinogenic effect.

Sodium oxybutyrate (GHB) - use a 20% solution at a dose of 50 to 200 mg / kg of patient weight. Anesthesia occurs in 10 to 15 minutes and lasts 2 to 4 hours.

Intramuscular anesthesia - by introducing an anesthetic (most often calypsol) intramuscularly, when performing small operations, especially in pediatric practice. The dose of calypsol for intramuscular administration is 6-8 mg / kg of body weight.

Rectal anesthesia - by introducing an anesthetic (in the form of a suppository) rectally. Used when examining the abdomen in children with suspected acute surgical pathology of the abdominal organs.

Neuroleptanalgesia - the combined administration of antipsychotics and analgesics. Neuroleptic - droperidol, use 5-10 ml of 0.25% solution. The analgesic is fentanyl, this is a narcotic analgesic, it exceeds the effect of morphine by 100 times, therefore, its weak concentration is used - 0.005% solution, 1 - 2 ml is injected. The duration of the action is 15 - 30 minutes.

Ataralgesia - This is anesthesia, which is based on the achievement of a state of ataraxia ("numbness") and severe anesthesia with the help of sedatives, tranquilizers and analgesics. Ataractic is used - sibazone (diazepam, seduxen, relanium) at a dose of 10-20 mg intravenously, and an analgesic - dipidolor, 2 times stronger than morphine, acts for 4-6 hours.

Inhalation anesthesia

Mask anesthesia - rarely used, more often as a stage before intubation anesthesia, or when it is impossible to intubate the trachea.

Intubation anesthesia - based on the introduction of vapors or gaseous anesthetic into the respiratory tract, directly into the trachea (endotracheal anesthesia) or into one of the main bronchi (endobronchial anesthesia).

Stages of intubation anesthesia: 1 - premedication; 2 - induction anesthesia; 3 - muscle relaxation; 4 - tracheal intubation; 5 - basic anesthesia; 6 - extubation.

Premedication: begins on the eve of the operation with the appointment of sedatives, mainly barbiturates. 30 minutes before the operation, appoint: atropine 1 ml - in order to reduce secretion and salivation and to prevent reflex cardiac arrest; narcotic analgesics: promedol, omnopon, morphine and others - to reduce the pain threshold and reduce the amount of anesthetics; antihistamines: diphenhydramine, suprastin, diprazine and others - in order to prevent bronchospasm, fall in blood pressure, reduce allergic reactions. In emergency cases, premedication is performed directly on the operating table by intravenous administration of these drugs.

Introductory anesthesia: by the introduction of anesthetics (hexenal, sodium thiopental) intravenously (intravenous anesthesia).

Muscle relaxation: muscle relaxation is achieved by the use of muscle relaxants. There are short-acting muscle relaxants - ditilin (listenone, miorelaxin) 1 - 2% solution at a dose of 1.5 mg / kg of patient weight, duration 4 - 5 minutes; long-acting muscle relaxants: tubocurarine, diplacin, navulon, arduan - their action begins in 3 - 5 minutes and lasts 30 - 45 minutes.

Tracheal intubation: performed after complete relaxation of the muscles and cessation of spontaneous breathing. For tracheal intubation, a laryngoscope is required, with which the epiglottis is pushed back, after which the glottis is shown. The intubation tube is inserted through the glottis into the trachea, the cuff is inflated, which prevents the contents of the stomach from entering the respiratory tract.

Basic anesthesia: anesthesia can be maintained with intravenous anesthetics (then only mechanical ventilation is carried out through the endotracheal tube), or it can be carried out by inhaling the anesthetic through the endotracheal tube.

Extubation: the endotracheal tube is removed after spontaneous breathing has been restored.

Drugs for anesthesia.

Liquid inhalation preparations:

Ether for anesthesia - has a wide range of therapeutic action, low toxicity.

Ftorotan - 4 - 5 times greater than the effect of ether, but just as toxic.

Gaseous inhalation drugs:

Nitrous oxide ("laughing gas") - used in a mixture with oxygen in a ratio of 4: 1, low toxicity.

Cyclopropane - Used in a mixture with oxygen. In a mixture with nitrous oxide and oxygen, it is explosive, therefore the use of an electrocoagulator or a laser is impossible.

Stages of inhalation anesthesia

Stage 1 - stage of analgesia: comes in 3 - 5 minutes from the beginning of anesthesia. It is characterized by a decrease in the level of pain reactions and loss of consciousness (the so-called "rausch-anesthesia"). Breathing is calm, eye and corneal reflexes are preserved. At this stage, it is possible to perform small operations.

Stage 2 - arousal stage: comes in 6 - 8 minutes, duration 2 - 3 minutes. It is characterized by complete loss of consciousness, increased breathing rate, tachycardia, increased motor activity, increased muscle tone, dilated pupils, reaction to light is preserved. Operations are not possible at this stage.

Stage 3 - surgical: subdivided into levels.

The first level (3/1) - the excitement passes, the breathing is calm, the muscles relax, the pupils are narrowed, the pulse is normalized.

The second level (3/2) is characterized by shallow breathing, the pupils are narrow, the reaction to light is weak or absent, the pressure and pulse are stable, the muscles are relaxed.

The third level (3/3) - characterized by rapid breathing, tachycardia, decreased blood pressure, lack of reflexes, pupils are dilated. Further deepening of anesthesia threatens death. Therefore, the optimal depth of anesthesia is levels 3/1 and 3/2.

Stage 4 - Awakening stage: characterized by the termination of inhibition processes in the cerebral cortex. Coming out of anesthesia resembles the process of entering anesthesia, but in the opposite direction.

Complications of anesthesia

1. Complications when entering anesthesia - damage to the epiglottis, vocal cords, intubation of the esophagus.

2. Sudden cardiac arrest. The reasons are cardiac arrhythmias, asystole, ventricular fibrillation. In case of cardiac arrest, it is necessary to stop the operation, start an indirect cardiac massage, intracardiac injection of 1 - 2 ml of adrenaline solution, 10 ml of 10% calcium chloride solution, and defibrillation of the heart. If ineffective, direct cardiac massage by thoracotomy or diaphragmotomy (if the abdominal cavity has already been opened).

3. Acute pulmonary edema - due to acute left ventricular failure. It is characterized by increased breathing rate, cyanosis of the skin and mucous membranes, the appearance of a foamy liquid from the trachea. In acute pulmonary edema, it is necessary to suction fluid from the trachea, inhalation of oxygen through alcohol, mechanical ventilation, hormone therapy, diuretics, narcotic analgesics.

4. Mechanical asphyxia with acute hypoxia is possible due to obstruction of the trachea or bronchi with vomit, broken tooth, denture, crown and others. It is characterized by cyanosis of the skin, dark blood flows out of the wound, blood pressure falls.

Complications after anesthesia

1. Acute myocardial infarction.

2. Acute cardiovascular failure.

3. Recurarization - due to the release of muscle relaxants from the depot into the bloodstream, the muscles of the diaphragm and chest relax again, and respiratory arrest is possible.

4. Retraction of the tongue with asphyxiation.

5. Mendelssohn's syndrome - in the case of regurgitation, that is, getting the acidic contents of the stomach into the tracheobronchial tree, aspiration pneumonia develops, which is difficult to treat.

6. Hypostatic pneumonia, lung atelectasis.

7. Thrombosis, thrombophlebitis.

8. Thromboembolism of the pulmonary artery - due to the separation of a thrombus in the inferior vena cava system, with full or partial occlusion of the main trunk

Special methods of anesthesia

1. Artificial hypothermia - allows you to perform open heart surgery.

2. Electroanalgesia - the effect on the brain of an electric current of certain parameters.

Lecture 7. BLEEDING. METHODS TO STOP BLEEDING

Bleeding is the outpouring of blood from the bloodstream into the external environment or internal organs. Normally, a person has about 4 - 5 liters of blood, of which 60% circulates through the vessels, and 40% is in the blood depot (liver, spleen, etc.). The loss of 1/3 of the blood is life-threatening, but patients can die with less blood loss if it expires quickly. Men tolerate blood loss worse, women are more adapted to blood loss.

Classification:

By the nature of bleeding:

1. Arterial - a pulsating stream of scarlet blood;

2. Venous - slow flow of dark blood;

3. Capillary - slight bleeding from the entire surface of the wound, stops on its own;

4. Parenchymal - a type of capillary bleeding from the parenchymal organ (liver, spleen, bone marrow), but unlike capillary, parenchymal bleeding does not stop on its own.

Because of:

1. Post-traumatic - as a result of injury or wounds, including operating rooms;

2. Arrosive - due to erosion of the vessel wall by a pathological process: stomach ulcer, disintegrating tumor, purulent fusion of tissues and walls of blood vessels;

3. Diapedetic - bleeding without damaging the integrity of the walls of blood vessels - with blood diseases (hemophilia), vitamin deficiency (scurvy), etc.

By the nature of communication with the external environment: distinguish between external, internal and latent bleeding.

1. External - blood flows directly into the external environment, so it is easy to diagnose.

2. Internal - the bleeding blood has no communication with the external environment. Varieties: bleeding in the body cavity and tissue.

In the body cavity:

a) into the abdominal cavity - hemoperitoneum, most often with damage to the parenchymal organs;

b) into the pleural cavity - hemothorax, more often with rib fractures or stab wounds;

c) in the joint cavity - hemarthrosis;

d) into the cavity of the heart bag - hemopericardium, the accumulation of a significant amount of blood in the pericardial cavity causes compression of the heart - cardiac tamponade.

In body tissues:

a) hemorrhage - diffuse tissue saturation with blood;

b) hematoma - the accumulation of blood in the tissues with the formation of a cavity;

3. Latent - the bleeding blood has indirect communication with the external environment. Its varieties:

a) gastrointestinal bleeding (peptic ulcer, esophageal varicose veins, erosive gastritis, etc.), manifested by vomiting of "coffee grounds" or tarry stools, that is, "chalk".

b) pulmonary hemorrhage - manifested by hemoptysis;

c) bleeding from the urinary tract - hematuria.

In certain cases (with a profuse nature of bleeding), hidden bleeding becomes apparent.

By the time of occurrence:

1. Primary - bleeding immediately after injury or spontaneous damage to the walls of blood vessels;

2. Early secondary - bleeding in the first hours after vascular injury due to thrombus rejection, with an increase in blood pressure, as a result of slipping or eruption of ligatures from the vessels;

3. Late secondary - bleeding a few days, a week or even more after damage to the vessel due to purulent fusion of tissues and vessel walls.

Clinic:

Bleeding is manifested by local and general symptoms.

Local symptoms:

With external bleeding, blood is poured into the external environment, and by the nature of the bleeding, it is easy to determine its appearance.

When bleeding into the abdominal cavity, symptoms of irritation of the peritoneum, dullness in the sloping places of the abdomen, the symptom of "Vanka-vstanka" develop.

When bleeding into the pleural cavity (hemothorax), there is compression of the lung, shortness of breath, dullness of percussion sound, weakening of breathing during auscultation.

With gastrointestinal bleeding, nausea, vomiting of "coffee grounds" or tarry stools are noted.

Common symptoms:

Pallor of the skin, cold sweat, weakness, dizziness, fainting, dry mouth, flashing "flies" before the eyes, palpitations, tachycardia, falling blood pressure.

Additional methods for diagnosing bleeding:

1. Complete blood count: drop in the number of erythrocytes, hemoglobin, hematocrit.

2. FGS with suspected bleeding from the esophagus, stomach, duodenum.

3. Digital examination of the rectum: traces of black stool - with bleeding from the upper digestive tract (esophagus, stomach, 12 - duodenum and jejunum), or scarlet blood - with bleeding of the lower gastrointestinal tract (ileum, colon, rectum).

4. Sigmoidoscopy and fibrocolonoscopy for suspected bleeding from the colon.

5. Ultrasound: the accumulation of fluid in the sloping places of the abdominal cavity is revealed.

6. Puncture of the posterior fornix of the vagina in women: blood is detected during ectopic pregnancy, ovarian apoplexy, rupture of the ovarian cyst.

7. Puncture of the pleural cavity in 7 - 8 intercostal spaces with hemothorax.

8. Laparocentesis, laparoscopy: if intra-abdominal bleeding is suspected.

Complications of bleeding:

1. Hemorrhagic shock;

2. Necrosis of organs deprived of blood supply;

3. Formation of false aneurysms;

4. Formation of false cysts;

5. Compression of vital organs with blood: brain, heart, lungs, etc .;

6. Organization of spilled blood with the development of adhesions;

7. Infection with hematomas: the outflowing blood is a good breeding ground for microorganisms;

8. Chronic anemia - anemia, with long-term small blood loss: stomach ulcer, uterine bleeding, etc.

Methods for stopping bleeding:

There are methods of temporary and permanent stopping of bleeding.

Temporary:

1. Imposition of a tight (pressing) bandage;

2. Elevated position of the limb;

3. Maximum flexion of the limb in the joint;

4. Finger pressing of the vessel to the bone;

5. Imposition of Esmarch's tourniquet. Requirements: a lining is placed under the tourniquet, the application time is 2 hours in the summer, 1.5 hours in the winter, an accompanying note is attached to the tourniquet indicating the application time. After the expiration of 1, 5 - 2 hours, the tourniquet is removed for 10 - 15 minutes, then applied again, but for 60 minutes in summer, 30 minutes in winter. Due to the fact that the tourniquet squeezes not only the damaged vessel, but also all the vessels feeding the limb, which is fraught with irreversible ischemic changes distal to the tourniquet, the use of the tourniquet is now considered a forced method when it is impossible to stop bleeding in other ways.

6. Tight wound tamponade;

7. Applying hemostatic clamps during the operation;

8. Blackmore inflated probe for esophageal bleeding;

9. Temporary shunting of large vessels with PVC or glass tubes to maintain blood supply to the limb at the time of transportation.

Final:

1. Mechanical;

2. Physical (thermal);

3. Chemical;

4. Biological.

Mechanical:

1. Ligation of the vessel in the wound;

2. Sewing (ligation) of the vessel during: a) if it is impossible to ligate the vessel in the wound, b) if there is a threat of purulent fusion of the vessel in the wound;

3. Prolonged wound tamponade;

4. Vascular suture (lateral, circular);

5. Vascular plastic (autovenous, synthetic prosthesis).

Physical (thermal): due to exposure to low and high temperatures.

Low: a) ice bladder - with capillary bleeding; b) in case of gastric bleeding - gastric lavage with cold water with pieces of ice; c) cryosurgery - local freezing of tissues with liquid nitrogen, especially during operations on parenchymal organs.

High: a) a tampon moistened with hot saline solution to stop parenchymal bleeding; b) electrocoagulator; c) laser scalpel.

Chemical:

Calcium chloride, dicinone, adrenaline, pituitrin, epsilon-aminocaproic acid.

Biological:

For local use: tamponade of wounds with a hemostatic sponge, fibrin film, allogenic materials "Alloplant" and "Bioplant", a strand of the greater omentum, muscle, Tachocomb film

For general hemostatic action: blood transfusion (especially fresh citrate, even better direct blood transfusion), transfusion of plasma, platelet mass, fibrinogen, the use of vitamin "C", vitamin "K" or vicasol.

Lecture 8. BLOOD GROUPS. BLOOD TRANSFUSION

The widespread use of blood transfusion is characteristic of modern surgery. Blood transfusion is an operation of tissue (blood) transplantation from a healthy person (donor) to a patient (recipient) for a therapeutic purpose. Blood transfusion without fatal complications became possible after the discovery of blood groups (1901 Landsteiner, 1906 Yanovsky) and the Rh factor (1940 Landsteiner and Wiener).

There are 4 main blood groups: 1 - 2 - 3 - 4. They differ in the content of agglutinogens A and B and agglutinins a and b... Agglutinogens, or antigens A and B, are found in red blood cells. Agglutinins, or antibodies a and b are in the blood plasma. When agglutinogen A meets with agglutinin a, as well as agglutinogen B with agglutinin b there is an isohemagglutination reaction - this is the gluing of the erythrocytes of one person when they are mixed with the serum of another person.

Blood groups have the following composition:

Group 1: No agglutinogens, there are agglutinins a and b (O a b);

Group 2: contains agglutinogen A, agglutinin b(BUT b);

Group 3: contains agglutinogen B, agglutinin a(IN a);

Group 4: contains agglutinogens A and B, no agglutinins (ABo).

Previously, they adhered to Ottenberg's law, according to which erythrocytes of donated blood are glued together. According to this law, the recipient with the first group was allowed to transfuse donor blood of only 1 group, the recipient with the second group - donated blood of 2 and 1 groups, recipient

did not come into force Edition from 15.11.2012

Name document	ORDER of the Ministry of Health of the Russian Federation of 15.11.2012 N 922n "ON APPROVAL OF THE PROCEDURE FOR PROVIDING MEDICAL CARE TO THE ADULT POPULATION UNDER THE" SURGERY "PROFILE
Type of document	order, order, rules, standard
Host body	Ministry of Health of the Russian Federation
Document Number	922H
Date of adoption	01.01.1970
Date of revision	15.11.2012
Registration number in the Ministry of Justice	28161
Date of registration with the Ministry of Justice	17.04.2013
Status	did not come into force
Publication	At the time of inclusion in the database, the document was not published
Navigator	Notes (edit)

ORDER of the Ministry of Health of the Russian Federation of 15.11.2012 N 922n "ON APPROVAL OF THE PROCEDURE FOR PROVIDING MEDICAL CARE TO THE ADULT POPULATION UNDER THE" SURGERY "PROFILE

Appendix 7. RULES FOR ORGANIZING THE ACTIVITIES OF THE SURGICAL DEPARTMENT

1. These Rules establish the procedure for organizing the activities of the surgical department, which is a structural subdivision of a medical organization.

2. The surgical department of a medical organization (hereinafter referred to as the Department) is created as a structural unit of a medical organization.

3. The department is headed by a head who is appointed and dismissed by the head of the medical organization, which includes the department.

4. A specialist is appointed to the position of the head of the Department and a surgeon who meets the qualification requirements for specialists with higher and postgraduate medical and pharmaceutical education in the field of health care, approved by order of the Ministry of Health and Social Development of the Russian Federation of July 7, 2009 N 415n, in the specialty "surgery".

5. The structure and staffing of the Department are approved by the head of the medical organization, in which the department is created, and are determined based on the volume of medical and diagnostic work and bed capacity, taking into account the recommended staffing standards provided by Appendix No. 8 to the Procedure for the provision of medical care to the population in the "surgery" profile, approved by this order.

6. The equipment of the Department is carried out in accordance with the equipment standard stipulated by Appendix No. 9 to the Procedure for the provision of medical care to the population in the "surgery" profile, approved by this order.

observation room;

doctors' office;

wards for patients, including single rooms (isolation wards);

operating or operating unit;

dressing room;

dressing room (for purulent wounds);

procedural;

dressing (plaster);

manager's office.

Zakonbase: In an electronic document, the numbering of paragraphs corresponds to the official source.

nursing;

senior nurse's office;

a room for storing medical equipment;

The premises of the hostess sister;

pantry and handout;

dining room;

Room for collecting dirty linen;

shower and toilet for medical workers;

showers and toilets for the sick;

room for sanitization;

sanitary room.

8. The main functions of the Branch are:

provision of specialized, including high-tech, medical care by performing operations using surgical (including microsurgical) methods based on standards of medical care;

preparation and carrying out of diagnostic procedures in stationary conditions;

Mastering and introduction into clinical practice of modern methods of diagnosis, treatment, rehabilitation and prevention of diseases and conditions requiring treatment by surgical methods;

development and implementation of new medical technologies related to the treatment of patients with diseases in the "surgery" profile;

development and implementation of measures aimed at improving the quality of medical and diagnostic work in the department of surgery;

Rehabilitation of patients with diseases in the "surgery" profile in stationary conditions;

examination of temporary disability;

Providing advisory assistance to medical specialists from other departments of a medical organization on the prevention, diagnosis and treatment of diseases and pathological conditions that require treatment by surgery methods;

maintenance of accounting and reporting documentation, provision in the prescribed manner of reports on the activities of the Branch, the maintenance of which is provided for by the legislation of the Russian Federation.

9. To ensure its activities, the Department uses the capabilities of the medical diagnostic and auxiliary units of the medical organization, which includes the Department.

10. The department can be used as a clinical base of medical educational institutions of secondary, higher and additional professional education, as well as scientific organizations.

Appendix N 8
to the Procedure for the provision of medical
assistance to the adult population according to the profile
"surgery" approved by order
Ministry of Health
Russian Federation
dated November 15, 2012 N 922н