Organization of work dressing
Dressing the nurse is responsible for keeping the asepsis in the dressing room.
Depending on the profile of the department in a clean dressing room, Novocain blockades, diagnostic and therapeutic punctures of the thoracic and abdominal cavity, blood and drug transfusions. In clean dressing, small operations are often performed: application of skeletal traction, removal of tumors of the skin and subcutaneous tissue, primary treatment of small wounds.
Purulent dressings treat purulent wounds, puncture and dissection of abscesses and other manipulations of patients with a purulent infection, including blood transfusion.
Staff working in the dressing, where both pure and purulent dressings are made, should be especially careful and careful not to confuse the tools used to dress clean and purulent patients.
The duties of the dressing nurse include the training of a nurse working in dressing, aseptic and antiseptic rules.
Rules of conduct in dressing
1. A strict order of dressings is established: first clean, for example, after plastic surgery, then conditionally clean, for example, after operations on the abdominal organs, and, lastly, purulent dressings.
2. Patients take off their outer clothing( pajamas, bathrobes), stockings, socks in front of the dressing room, in a specially designated room adjacent to the dressing room.
3. Medical personnel work in masks, clean hospital-provided, easily washable shoes( leather, rubber, etc.), gowns with short sleeves or elbows, cap. A mat, moistened with an antiseptic solution, should be placed at the entrance to the dressing room.
4. The infected dressing is taken only by the instrument, thrown into a bucket with a pedal cover and then destroyed.
Organization of work in the dressing room
The working day begins with the examination of the dressing room. The dressing nurse checks whether the duty staff used night dressing. In case of emergency intervention or unplanned dressing, the used and contaminated dressings are removed into buckets with lids, used tools, washed, soaked in an antiseptic solution. The sister checks, whether floors and furniture are wiped with a damp rag, places биксы with a material, establishes the medicines received the day before from a drugstore.
The dressing sister receives a list of all dressings for the day, sets their order. Firstly, patients are bandaged with a smooth postoperative course( removal of sutures), then with granulating wounds.
After making sure the dressing is ready, the sister starts to process the hands. Previously, she puts on the operating form, carefully hides her hair under a kerchief or hat, shorts her nails, puts on a mask. After processing the hands, the sister dresses. She takes a robe from the bix without touching the edges of the beaks. Carefully unfolding it on outstretched hands, she puts it on, ties up the sleeves of her dressing gown with ribbons and hides the ribbons under her sleeve. He opens the beads and ties a dressing gown to the back of the dressing gown. After that, the nurse puts on sterile gloves and covers the instrument table. To do this, she takes a sterile sheet from the bix and stays it, folded twice, onto the instrument table.
When sterilizing by air in kraft paper, the nurse must find out the date of sterilization beforehand. Products sterilized in kraft paper can be stored for no more than three days. Instruments should be laid out in a certain order, which the dressing nurse chooses herself. Usually the tools are laid out on the left side of the table, the dressing material on the right side, in the middle place special tools and drainage tubes. Here the sister puts sterile cans for novocaine, hydrogen peroxide, furacilin. The right corner of the sister leaves free to prepare stickers and bandages during dressing. A sheet folded in half, the sister closes the instrument table. Preparatory work should be completed by 10:00.
1. Organization of dressings. The nurse calls from the patients' wards, guided by a list compiled by the dressing nurse. Lying patients are transported on a gurney with a blanket and a pillow taken from their bed. Transferring the patient to the dressing table, rolling together
with a blanket and a pillow is taken out beyond the dressing until the end of the dressing. In the dressing room it is much more convenient to work when there are two tables: while the surgeon bandages one patient, the nurse prepares the second patient on the other - puts it on the table, removes the upper bandages. If it is not possible to organize two tables, it is necessary to have two wheelchairs in the dressing room, so that the next patient expects a bandage, lying near the dressing room. Use a wheelchair from the operating room is not allowed. In the absence of two wheelchairs, bandages can be accelerated by alternating bedridden and walking patients. Walking patients take off their outer clothing and go to the dressing table. The ward sister and the nurse help to lay the patient on the dressing table, then close it to the waist with a clean sheet. When dressing, there is a doctor;especially responsible procedures, as well as the first dressing he does personally.
Each dressing consists of five stages:
1) removal of the old bandage and skin toilet;
2) performing manipulations in the wound;
3) protection of the skin and from the discharge from the wound;
4) the imposition of a new bandage;
5) fixing the dressing.
1. Removal of the old bandage, skin toilet. Bandage unwind nurse. Removing the bandage, it can not be twisted, since the lower layers can be infected. Bandages, soaked in blood or pus, do not unwind, but cut with scissors to remove bandages. To remove the adhesive plaster, its strips are wetted, and when peeling off, hold the skin with your hands. A surgeon, making a dressing, removes the sticker with tweezers. To do this, his sister gives him a surgical tweezers. The old sticker is removed along the wound from one end to the other. Removing the bandage across the wound leads to its gaping and pain. When removing the bandage, hold the skin with a spatula, tweezers or gauze ball, preventing it from reaching for the bandage. Strongly adherent bandage is exfoliated with a ball moistened with a solution of hydrogen peroxide or an isotonic solution of sodium chloride. With the wrist and foot, the old adherent bandages should be removed after soaking, if the condition of the wounds allows you to make a hand or foot bath from a warm solution of cadmium permanganate( 1: 4000).Before starting the procedure, the bath is treated with alcohol, or washed with hot water with synthetic detergents. Then, warm water 38-40 ° C is poured into the tub and a few drops of a 30% solution of potassium permanganate are added until an intense pink color is obtained. The limb is immersed for 5 minutes with the bandage. After removing the bandage, the limb is taken out of the water, the bandaging material is picked up by the forceps and dumped into the gas. The surgeon examines the wound and processes it. The bath is washed with hot water with synthetic detergents, washed with disinfectant solutions and stored in a dry form.
If the removal of the bandage caused capillary bleeding, it is stopped, lightly pressing the bleeding place with a gauze ball.
After removal of the sticker, the skin of the skin around the seam or wound is produced. Clean the wound with gauze or cotton balls, first dry, then moistened with a technical ether. For cleaning, you can use a warm soapy water 0.5% solution of ammonia. Pasta Lassara well to remove balls, moistened with vaseline oil. The skin is wiped, starting from the edges of the wound to the periphery, and not vice versa. In this case, the liquid drops should not enter the wound. If there is a significant contamination of the skin around the wound, it is possible to protect the wound surface with a sterile gauze cloth, thoroughly wash the entire limb with soap, and if the wound suppurates, then this procedure must be performed every dressing. After cleansing the skin, it is drained with gauze balls, and then treated with iodine with alcohol, iodinol or other coloring antiseptics. Cleanliness of the skin around the wound is the first condition for successful treatment. In addition to cleaning, treatment causes local hyperemia, which positively affects the trophism of the postoperative suture and accelerates healing.
2. Performing manipulations in the wound. When dressing, the following manipulations are performed: removal of sutures, probing of the seam area, ointment tamponade, washing of purulent cavities.
Sutures can be removed from the nurse in the presence of a doctor. This requires surgical tweezers, scissors and a small napkin. The tweezers are sipped at one end of the threads, tied to the side of the seam line. After 2-3 mm of the subcutaneous part of the silk thread of the white color appears from the depth of the tissues, a sharp scissors brush is introduced under the thread and cross this thread at the surface of the skin. The cut ligature with the knot is easily extracted with tweezers. Each removed seam is placed on a nearby small unfolded small napkin, which, after removing the seams, is folded with tweezers and thrown into the pelvis with dirty material.
Removing the metal brackets. To remove the brackets, you must have a clevis and a clip for the Michel brackets. Instead of a clamp for the brackets, you can use the curved Bilroth clamp. Brushing the jaws or the clamp under the middle bent part of the brace, squeeze the staple with the compression of the tool and, first picking one out of the skin, then the other denticle, remove it. When removing the brace with two surgical tweezers, it is grasped for both ends, unbend and remove the denticles from the skin. After removing stitches or staples, treat the seam line with an antiseptic and make stickers.
3. Protection of the skin from discharge from the wound. Before applying bandages to wounds with intestinal, bile discharge( in the presence of intestinal, bile, pancreatic fistula), the skin in the circumference of the wound should be protected from maceration and irritation. For this purpose, the skin around the wound is smeared with Vaseline, Lassar paste, zinc ointment. Sister with a spatula puts on the skin a thick layer of paste or ointment from the edges of the wound and then for 3-4 cm and gives it a dry.
4. Overlapping the dressing. Aseptic dressing is sufficient for a postoperative aseptic suture. It is a gauze wipe spread over the entire length of the surgical suture, which is covered by another layer of gauze, whose dimensions are 3-4 cm larger. Marl along the periphery is glued. Stitches on the face from the first day can be left without a sticker. Dry aseptic cotton-gauze bandage is used for fresh wounds, after removal of postoperative sutures. On top of the wounds, bandages filled with tampons with hypertonic solution or ointments are applied. If the wound has a drainage tube, then to cut it out, the dressing is cut, draining through the incision. The thickness of the layer of cotton wool depends on the amount of discharge from the wound. The size of the cotton-gauze dressings is determined based on the size of the wound or the post-operative seam, so that its dimensions overlap the seam line by 3 cm. In case of long-term bandages, a layer of gray cotton wool is often applied over the absorbent cotton to prevent the dressing from getting wet.
5. Fixation of the dressing is done by bandaging, gluing or using a reticular bandage bandage. Sister with a cotton swab soaked in a glue, lubricates the skin along the edges of the applied bandage 3-4 cm wide. The skin around the wound should be clean-shaven and degreased with alcohol. After drying the glue, a piece of gauze, which is 4 cm wider and longer than the applied bandage, is applied from above, stretching over the corners. Marl tightly pressed to the skin. Its non-glued edges are cut with scissors. When fixing with an adhesive plaster, the surgeon pulls the edges of the wound with his hands and keeps them in the desired position, and the sister tears the strip of the desired length from the roll of the adhesive patch, without touching the patch of the hand that lies on the wound. Glue usually 1-3 strips. To the wound does not disperse, it is necessary to make strips of sufficient length, capturing at least 10 cm of healthy skin. Thus, the total length of the strip is 20-22 cm. Over the transverse bands parallel to the wound, two longitudinal strips are laid, receding from the edge of the wound by 3-5 cm.
A properly applied bandage usually relieves the patient. Even if the dressing is accompanied by painful procedures and manipulations, the pains caused by them quickly subsided.
It is necessary to pay attention to the patient's complaints, to increase pain after dressing. Most often they are associated with a tightly bandaged dressing, sometimes a skin burn with careless application of iodine, but there may be more serious causes, for example, secondary bleeding with the formation of an expanding hematoma. At the end of the dressing, you need to make sure of the strength of the label. When moving and dressing, the patient is assisted by ward sisters and sanitary attendants dressing. The nurse should ensure that patients enter only on call and do not stay after the dressing.
After every dressing, the oilcloth on top of the sheet is wiped with a disinfectant solution. In case of accidental ingress of pus on the floor, the nurse immediately wipes the floor with a mop moistened with a disinfectant solution.
Dressings of patients with purulent wounds. Purulent dressings begin only after the dressing sister will check up, whether all pure dressings are finished and whether there were no untethered purulent patients. During work with purulent patients, the staff wears specially designed gowns, gloves and aprons. The ambulance delivers the patient to the dressing room, places it under the oilcloth, taking into account the possibility of spreading pus, inserts a kidney basin to the wound or puts several layers of lignin or sterile cotton wool to prevent pus and rinsing liquids from getting into the table. Before opening the abscess, the nurse shaves her hair in the field of the operating field and, at the doctor's instruction, puts the patient in a comfortable position. Dressings of purulent wounds, both primary and secondary( arising from suppuration of operating and traumatic wounds) are of the same type. Treatment of purulent wounds and dressings, in particular, are based on an understanding of the general patterns of a purulent process that has three phases:
• an inflammation phase that includes two periods - vascular changes( hyperemia, edema) and wound cleansing;
• reparation phase( formation and maturation of granulation tissue);
• phase of epithelialization and reorganization of the rumen.
After removing the dressing and toilet of the skin around the wound, the sister gives one after another a few dry gauze balls. Pus is not washed, but slightly pressed balls to the surface of the wound, like blotting paper. Used balls, soaked in pus, are thrown into the pelvis. On the instructions of the doctor, the sister gives several balls moistened with hydrogen peroxide, and then again the dry balls to drain the formed foamy mass. Then, similarly, the nurse gives the surgeon balls, moistened in a solution of furacilin, and then dry balls to completely drain the wound.
If necessary, the dressing sister prepares gauze turunda. Turundu length of 20-30 cm dressing sister takes the edge of the lead, wraps around his lips using tweezers and immerses it in a jar with 10% sodium chloride solution, where it easily unwinds and extracts after impregnation. When extracting the turunda, the excess solution of the sister squeezes into the jar with tweezers. After that, she fixes the free end of the turunda with tweezers and tweezers give the doctor who takes the turunda with his tweezers. To lay the turunda and fill it with a cavity, the doctor must have a buttoned probe. The sister of the turunda holds the weight with her korntsanga. The surgeon gradually introduces the turunda with a probe into the purulent cavity, while the nurse continues to support it, intercepting the corncang in the right place. Over the turundum with hypertonic solution apply a few napkins, also moistened in this solution.
Currently, ointments are actively used on a water-soluble basis - levosin, levomecol, sorbilex, etc. Tampons with similar ointments do not adhere to the bottom of the wound, easily melt at a temperature of 37 ° C.Apply these ointments to the first phase of the purulent process, helping to cleanse wounds from nonviable tissues, suppress microflora. Use as a tampon impregnated with ointment, or injected in an amount of 10-15 ml with a syringe through a catheter or micro-irrigator. In the presence of lean purulent discharge and the appearance of granulations, that is, in the second phase of the purulent process, it is necessary that the drugs used reliably protect the granulation tissue from superinfection and provide conditions for the epithelization of wounds. Usually, ointments that do not have an irritating effect are used: Vishnevsky ointment, Vinilin( Shostakovskii's balm), sea buckthorn oil, Kalanchoe, methyluracil ointment, solcoseryl gel, sintomycin emulsion, etc. The order of wetting turundas and napkins and feeding them to the doctor is the same. Well protect the granulation of the wound from the damaging effect and contribute to the process of epithelization foam-forming aerosols( cimezole, tozoze), when used, the antimicrobial aerosol preparation almost completely remains on the wound surface, and thus a sufficient concentration is created. When excessive granulations appear, the doctor is given a small cotton swab moistened with a solution of silver nitrate( lapis), to cauterize the granulations.