MEDICAL MANIPULATIONS IN THE PROCESS OF EXAMINATION AND CARE FOR SURGICAL PATIENTS

TRADITIONAL METHODS

The simplest method of examination of patients is anthropometry. This is an examination of the physical development of a person. Height, weight, circumference of the chest, respiratory function (spirometry), muscular forces (dynamometry) are determined. This manipulation is conducted while patient admission to the medical establishment, sanatorium, or rest home. It is obligatory in sanitary establishments unlike to medical hospitals.

Height is measured with an auxanometer. While measuring the height, the patient stands with his back to the post, touching it with his heels, buttocks, shoulder and back of the head. The head is in such position so that the corners of the eyes and the top edge of the external acoustical duct are on one and the same line. The height is determined after lowering the board onto the head with its bottom edge. In some cases height is measured sitting.

Weighing is carried out on medical scales. The patient is weighed at admission to the medical establishment and further no less than once a week, under the same conditions: on an empty stomach, in underwear, after emptying the urinary bladder and intestines. Seriously ill patients are weighed sitting.

Circumference of the chest is measured with a centimeter tape, putting it in the front on the 9th rib under the nipples in men, and in the back under the lower corners of the scapula. Hands are lowered; breathing is voluntary without any deep inhalations and exhalations. Measurements are conducted at the height of inhalation and exhalation.

Spirometry is carried out with the help of a spirometer. The patient takes a deep breath, holds the nose and slowly exhales deeply into a glass tip in the mouth. The tip is sterilized by boiling.

Bed sores prevention. More often bed sores appear on the back of the head, shoulder, spinous process of the vertebra, sacrum, heels, iliac bone, pubis, sternum, etc. The skin on these areas is wiped with a disinfectant solution (camphor spirit, liquid ammonia, cologne, etc.), and a rubber circle covered with an oilcloth is laid under the areas where bed sores are probable. The rubber circle is laid so that the sacrum is inside of it and the bed does not touch it.

Washing the patient. Equipment: jug, dressing forceps, sterile cotton tampons, water or disinfectant solution (КМnО₄, furacillin 1:5,000 etc.). The temperature of the solution should be 35–38°С. While washing under the buttocks, a vessel is laid. The patient lays on his back, legs are bent at the knees, hips are separated. They take the jug in the left hand, and pour the external genitals. A cotton tampon is used to wipe in the direction towards the anus. After that, the surface is dried with dry tampons. In women, syringing is applied with the help of a tip which is entered into the vagina with the depth of 6–7 cm.

Processing the mouth. The mouth of seriously ill patients is processed with the help of a spatula, tweezers and platens damped with a 2% solution of soda or a 5% solution of boric acid, potassium permanganate or warm water.

Processing the eyes. The eyes are washed with the help of sterile gauze tampons moistened in a 3% solution of boric acid. Instillation is performed by a special pipette, the lower eyelid is pulled down by the left hand and a drop is released closer to the nose. After a little waiting, the second drop is released, and the patient is suggested to close his eyes. The rest of the medicine is soaked up with a cotton swab. Ointments are put under the eyelid with a special spatula.

Processing the ears. While forming wax plug in seriously ill patients, drops of peroxide of hydrogen are put in the ear, and then the plug is taken out with the help of a gauze turunda. It is possible to wash away the wax plug with a Furacillin solution. The Janet’s syringe for 150 ml is applied. The patient is seated sideways to the doctor and with his hands he holds a a barrel-like wash-basin under the ear lobe. The auricle is pushed back and upwards. The cannula of the syringe is entered into the external acoustical duct and slowly the piston of the syringe is pressed. When the drug-solution is brought into the ear, the nurse moves the auricle back and upwards, the patient bends his head in the opposite direction, and the medicine is dropped into it, counting the amount of drops; after that the external acoustical duct is closed with a cotton swab.

Care for the nose. For removing scabs from the nose turundas are entered into the nasal entrance, moistened with vaseline oil or glycerin and in some minutes, while rotating them, take them out with the scabs.

Care for the hair. The simplest method is combing, but, as a rule, it is not applied in medical establishments.

Body temperature. The measuring of the temperature is a daily duty of the nurse. The medical thermometer is calibrated from 34 up to 42°С. The mercury column does not fall down by itself, it needs to be shaken down. Thermometers are kept in cups with disinfectant solutions (3% solution of hydrogen peroxide, 0.5% solution of chloramine). Before use the thermometer needs to be wiped with a towel, bring the mercury mark to 35°С and place it under the patient’s armpit, preliminary wiping it with a towel for sweat. The vessel with mercury should be densely touched by the patient’s body. The patient should hold the thermometer for 10 min. For seriously ill patients, it is possible to measure temperature in the rectum, but it is necessary to remember, that the temperature is 0.5–1°С higher there. Before entering the thermometer into the rectum, it is necessary to grease with vaseline. Children’s temperature can be taken in the inguinal wrinkle. The child bends his leg in the hip, so that the wrinkle in the groin will appear. Time of measurement of temperature: 6–7 am and 4–5 pm. While measuring temperature the patient should sit or lie down. With the presence of family the temperature may increase by 1.5–2°С. The temperature is written down in the temperature sheet. In the morning the body temperature is always lower than in the evening.

Agents influencing blood circulation. In connection with the fact that mustard plasters, jars, leeches, compresses, baths can entail heavy complications in patient, the nurse should know well the indications and competently technically performs them.

Mustard plaster. Validity of mustard plasters is determined by their specific smell of mustard oil, and they should not flake off. The sizes of mustard plasters are 12×18 cm. Mustard is put on dense hygroscopic paper in a special manner. It is possible to apply mustard plasters on all areas of the body except for the bottom of feet and palms. Before applying mustard plaster, moisten with water (water temperature no more than 45°С) and put with the mustard underneath for 10–15 min. It is better to put a layer of gauze or thin paper under the mustard plaster, and a towel above. It is necessary to remember that with long-term expositions burns, even of ІІ degree, are possible. After mustard plasters removing, the skin needs to be washed with warm water, wiped dry, and the patient should be wrapped in a warm blanket.

Mustard baths. For a mustard bath the water temperature should be 50°С. 50 g of dry mustard should be used for a bucket of water. Time of exposition is 20–30 min. After a mustard bath the feet are washed by warm water and wiped dry. After a mustard bath the feet are better to put on warm socks.

Cups. There are different kinds of cups: usual — Bier’s cups and wet cups. The amount for one patient can range from 10 to 20. When applying cups, the patient lays on the belly or on the side. A metal core with a cotton swab on the end is moistened with spirit or ether. The unnecessary liquid is pressed out so as not to burn the patient. If the skin is very hairy, it should be shaved or densely greased with vaseline. The cup is held in the left hand close to the patient’s body, with the right hand enter an inflamed tampon into the cup and as soon as it goes out, quickly put the cup on the body. The inflamed tampon can not be held in the cup for a long time, because it makes a cup too hot. The patient’s hair should be covered during this procedure with a towel. The cups are kept on usually 15–20 min. Remove them cautiously: incline to one side, pressing on the skin with a finger. Haemorrhages and oedema are on the skin after cups removing. The skin on the site of exposition is cautiously wiped from vaseline. After use the cups are wiped with spirit and are stored in a special box.

Bloodletting. During bloodletting the patient should lay so as not to see the blood, because it may course fainting. A pillow is put under the ulnar bend so that the upper extremity is straightened at the elbow; they cover the pillow with a towel and oilcloth. The skin is disinfected. Equipment for bloodletting: syringe, needle with a thick tube through which blood goes in graduated utensils. 300– 500 ml of blood is taken from the patient. A tourniquet is put on the patient’s shoulder so that there is a pulse on a.radialis. The patient should gripe and undo his fist several times. The index finger of the left hand fixes the vein, and the right one needles into the skin (the incision of a needle should be directed upwards), then the vein. While piercing the wall of the vein, a typical push is felt. After piercing the walls of the vein, the needle is moved upwards by 2–3 cm. If blood is not drawn from the needle, it is necessary to pull it towards yourself and try again to pierce the vein. During bloodletting it is necessary to watch the patient closely. After bloodletting the ulnar bend is disinfected and bandaged.

Leeches. Special medical leeches are applied. One leech sucks from 6 up to 10 ml of the blood. Usually 6 to 12 leeches are used. It is impossible to put leeches on areas where arteries and veins are close to the skin, because erosive bleeding can occur. The skin, where leeches are applied, is moistened with sweet water. They place the leech in a test tube with its head towards the opening. They put the test tube at the necessary place. They wait until the leech sticks to. The leech sticks to the skin for 30–60 min, and then falls off by itself. If it is necessary to remove it earlier, it is moistened with salt water. It is impossible to tear them off. Aseptic bandages are placed on bleeding sites. Leeches are used one time, and then they are distroyed.

Warming compress. It consists of a piece of dense hygroscopic tissue moistened and pressed, oilcloths or wax papers, cotton and bandage. The warming compress promotes blood flow and resorption of the inflammatory infiltration; it can be put on any part of the body. Each following layer of the compress should be 2 cm wider than the previous one. Firstly the compress is prepared, and then put on any site, fixed with a woolen scarf. Duration of a compress exposition is 10 h. The compress is changed in the morning and in the evening. Solutions for compress: warm water, light solution of vinegar (one teaspoon for 0.5 l of water), vodka, cologne, etc.

Cold compresses are applied on the wound. A cotton tissue is moistened with cold water and put on the injured area for 10– 15 min.

Poultices. Applied as an anti-inflammatory agent. Heated up linen seed, chaff, salt or sand are used for this purpose.

Hot-water bags can be rubber and electric. The rubber hot-water bag is a 1.5–2 l reservoir with a screwed top. Hot water is poured into the bag only to 3/4 of the volume, let out the free air and screw on the top. After that, check for tightness by turning the hot-water bottle upside down, wrap in a towel and put on the sore place. It is necessary to periodically observe the skin under the bottle. The bottle is indicated very carefully in cases of abdominal pain (the bag is categorically contraindicated for acute appendicitis).

Ice blister. It is prescribed in bleeding. Usually the round rubber reservoirs with a wide hole and top are used. Crushed ice is put into the reservoir, screw on the top, cover with a towel and put on the body. It is not recommended to use a blister for more than 30 min. After a 2-hour break the exposition can be repeated.

Baths can be sedentary, general, manual, gentle, and medical etc.. If the temperature of a bath is lower than 20°С it is a cold bath, 20–34°С — cool, 34–35°С — indifferent, 36–40°С — warm, 40°С and higher — hot. The nurse should observe for the procedure constantly.

Wiping (sponging). It is applied for treatment of itching and as a tempering. They take 2 bed sheets, wrap up the patient, wipe him with one of them moistened in warm water, then the same patient is repeatedly wrapped up with a cooler bed sheet. After wiping, the skin should be dried with a dry towel.

In the department, the senior nurse writes out the medicines according with to applications of the ward nurses who daily write out the medical assignments from medical histories to special writing-books or sheets, which are individual for each patient, and submit the list of drugs appointed to each patient to the senior nurse.

Drugs which belong to the A and B list are stored separately in special safes. A list of preparations which belongs to the A and B list (soporifics, codeine, platyphyllin, etc.) with instructions of the greatest single and daily doses, should be placed on the inside of the door of the safe. Stocks of narcotics should not exceed a 5-day requirement. Stocks of strong drugs should not exceed a 10-day requirement. Medicines which contain narcotics are subject to an object-quantitative account in a special journal, numbered and stamped. In the log-book of narcotic preparations, each analgesic is given a definite sheet, where the name of the medicines, amount, date of application, surname, name of the patient, number of his case record, amount of used ampoules and any remainder are specified.

There are different methods of giving drugs:

— external — through the skin, mucous membrane, respiratory tracts;

— enteral — through the mouth, under the tongue, through the rectum;

— parenteral — administration of medicine into an organism outside the digestive tract.

External Usage of Drugs

Only fat-soluble drugs are absorbed through the excretory ductules of the lacrimal gland and hair follicles of the skin; therefore the external use of medicines is directed, first of all, at their local action on the skin, mucous membrane or wounded area.

Rubbing — administration of drugs through the skin like liquids or ointments. Rubbing is conducted on the following parts of the skin: the bending surface of the forearm, the back surface of the hips, lateral surfaces of the thorax, abdomen that is such areas where the skin is thinner and not covered with hair. If the hair can be shaven there, it is necessary. The skin should be clean on the rubbed area. The necessary amount of ointment or liquid is put on the skin and rubbed in circular movements until the skin becomes dry. Contra-indications to such a procedure: inflammatory changes of the skin (eczema, dermatites, etc.).

Greasing as a method of different drugs administration is widely applied mainly in skin diseases. Cotton or gauze tampons are moistened in the solution and applied to the skin of the patient with easy longitudinal movements. With the presence of hair, greasing is conducted in the direction of its growth. With purulent diseases, the skin is greased around the focus of damage from periphery to the center.

Plaster is a sticky ointment base of dense consistence covered with impenetrable gauze. The ointment base contains active drugs. Contra-indications to the application of plaster are following: eczema, allergic dermatitis. Before applying a plaster the skin is diligently degreased with medical spirit, and the hair is shaven. They remove the plaster gradually; starting with one edge, which is moistened with spirit.

Powdering or sprinkling with powdery drugs (talc or rice powder) is applied for drying the skin for intertrigo and hyperhidrosis. A powder is applied to the skin on the hyperhidrosis site with a clean cotton tampon.

Aerosol inhalation is appointed to a patient for the improvement of bronchial permeability: dicreasing of sputum viscosity, fight against infection, protection of the respiratory ways mucosa from harmful action of irritating agents. The advantages for administering drugs by way of inhalation are following:

Direct action to the pathological process in the lungs.

The agents get to the focus of damage beyond the liver unchanged, which predetermines a high concentration of the drug.

Disadvantages:

Inaccuracy of dosage.

Bad penetration of aerosol into the pathological focus duringacute insufficiency of bronchial permeability.

A possible aerosol causes irritation of the mucous membranes.Steam, thermal and oil inhalations are used in medical practice. For steam inhalation a simple steam inhaler is used. While heating water, the steam that is formed, sucks in the drug and disperses it, creating an aerosol which a glass tube puts into the respiratory tract of the patient. For inhalation, solutions of menthol, eucalyptus, antibiotics are applied. Temperature of the aerosol is 57–60°С. While conducting thermal inhalation, a compressor, which carries out dispersion by the compressed air, is used. The aerosol has the temperature of 39–40°С. For inhalation a 2% solution of house-hold soda in a mix with alkaline mineral waters and solutions of antibiotics are applied. With oil inhalation, the oil, covering with a thin layer the mucous membrane of respiratory tract, protects it from mechanical and chemical agents and prevents the absorption of toxic substances.

Instillation of drops into the ear. Before instillation into the ear, the drops are warmed up to the body temperature because the cold drops irritate the labyrinth and can cause dizziness. A pipette is used for instillation into the ear.

Enteral administration of drugs (through the mouth, under the tongue and into the rectum) is the most popular way of treatment because it is the simplest and most convenient method of taking different medical forms (dragee, tablets, capsules, powders). Disadvantages of this way are incomplete absorption of preparations in the digestive tract, partial or full destruction of the medical forms by the digestive enzymes, inactivation in the liver, impossibility to provide a certain concentration of medicines in the blood.

Tablets, dragee or capsules are put on the root of the tongue and washed down with a drink of water. Taking a powder, the patient unwraps the wrapper, forms it into a groove and pours out the contents onto the root of the tongue, washing it down with water. It is possible to dissolve the powder first in water and then drink it after.

Water solutions, infusions, mixtures, broths are given to patients in graduated beakers.

Spirit infusions, extracts and some medical solutions are appointed in capsules. The necessary amount of drops is measured with the help of a pipette into a beaker, add water, and given to the patient to drink.

Some drugs (validol, nitroglycerine, sex hormones, etc.) are taken under the tongue. The good blood circulation in the mucous membrane of the mouth provides full and fast absorption of medicines. With such administration, a medicine is not destroyed by digestive enzymes and enters the general flow of blood circulation, outside the liver.

Administration of medicines into the rectum is given to patients with intestinal impassability, dysfunction of the act of swallowing and mental patients who refuse to take medicines.

Sometimes administration of medicines is taken place by means of electrophoresis.

Parenteral Administration of Drugs

Injection is the administration of drugs intracutaneously, subcutaneouly, intramuscularly, intravenously, intraarterially, intracostally and into the spinocerebral channel, and in different cavities of a person. The nurse should master the techniques of injections. For drugs, recently, disposable plastic syringes of different volume are used — from 1 up to 20 ml; “Luer” and “Record” syringes were used earlier. In some cases a syringe-tubes (basically in war time) is used. For intravenous injections needles with the length of 5–6 cm and the opening of 0.3–0.5 mm are used. Needles with the length of 3–4 cm and an opening of 0.5–1 mm are used for subcutaneous injections, needles with the length of 8–10 cm and the opening of 0.8– 1.5 mm are used for intramuscular injections. Syringes are stored in special cases, a brass mandrin should be on the tip of the needle. It is necessary to check the passability of needles before the injection. Syringes are assembled with the help of tweezers. The left hand takes the cylinder, the right one inserts the piston into the cylinder. The little finger of the left hand holds the piston, the right one with the help of tweezers puts the top on the needle. Medicines are collected from an ampoule which is hold with the 2–3 fingers of the left hand into a syringe. Before filling the syringe with the medicine, it is necessary to read the name of medicine on the ampoule (!). It is necessary to have two needles always: one for a set of medicines, the other one — for the injection. Medicines are collected into the syringe by suction, pulling the piston.

Intracutaneous administration of drugs. For this purpose it is better to use the anterior surface of the forearm. The needle enters only to the corneal layer of the skin. It is possible to administer intracutaneously only 0.1 ml of solution. After administering, a knoll like lemon peel forms on the skin.

Subcutaneous introduction is applied for fast action drugs. The most convenient for hypodermic introduction are the following areas: external surface of the shoulder or radial edge of the forearm, infrascapular area, anterior external surface of the hip, lateral surface of the abdominal wall and the bottom part of the inguinal areas.

Intramuscular injections are done on the following areas: external top quadrant of the gluteal region (remember the gluteal nerve which passes in the internal quadrant of the gluteus), muscular hips (its external surface), abdominal direct muscles, etc.

Intravenous introduction of drugs. The techniques is similar to that of bloodletting. More often, for intravenous introduction the ulnar veins, less often — veins on the hand or subclavian veins are used. For administering a large amount of liquid disposable systems are applied. It is possible a jet introduction of liquid into the vein.

Venesection is rarely applied now. It is already a small operation, and it is carried out by surgeons under operational conditions.

Pleural tapping is carried out with diagnostic and medical purposes. For diagnostic tapping a 20-g syringe and a needle of 7– 10 cm in length with the tip of 1–1.2 mm and abruptly oblique end are applied. Prepation for the tapping is the same as for an operation. The patient sits on a chair with his face towards the chair back, hands being in front on the chest. The tapping is carried out in the area between the 7th–9th ribs behind the middle average axillary line to the right or left, other intercostal spaces are possible depending on the purpose.

Puncture of the abdominal cavity is a very important diagnostic and medical method. The needle is the same as in pleural tapping, and the same diligent aseptics are applied. The puncture is done, as a rule, a little below the navel along the middle line.

Paracentesis is a more complicated puncture of the abdominal cavity with the help of a special device — a trocar. The trocar consists of the cylinder with the diameter of 0.3–0.5 cm, in its middle on the handle — a sharp metal tip, which sticks out by 2–3 mm. After disinfecting the skin with subcutaneous fat is anesthetized, with the scalpel only the skin is incision and the trocar is entered the abdominal cavity with rotatory movements. The trocar is held like a spear. After entering the abdominal cavity, the spear is taken out. Through the trocar it is possible to administer a catheter or liquid into the abdominal cavity.

Arthrocentesis — a simple manipulation, but it requires the strictest aseptics. The joint is punctured at the site where there are no main vessels and nerves. The puncture is carried out for diagnosis and administering medicinal substances into the joint.

Paracentesis of the urinary bladder is carried out with acute retention of the urine. It is an emergency or urgent manipulation, and every doctor should master it, irrespectively of his speciality. A thick needle punctures the bladder behind the medium line above the pubis; the skin is moved to the side. The observance of aseptics and anaesthesia is obligatory.

Pulse examination. Elementary medical manipulation. Pulse is examined in a sitting or laying patient by 2–4 fingers. It is impossible to measure the pulse by one finger (and also feel your pulse). Examine the frequency, rhythm, strain and filling of the pulse. Calculation is conducted for 30 s to 1 min.

Measurements of arterial pressure. Korotkov’s method with the help of the Riva—Rocci devices is popular. Recently, truly, a majority of doctors measure arterial pressure with the help of a sphygmomanometer. There is an arrow which specifies the arterial pressure. It’s convenient, portable. Techniques of measurement: the patient sits or lays, a cuff put by 5 cm above the elbow bend. With a stethoscope or phonendoscope, the beating of the pulse on the above the ulnar artery are auscultated. With its disappearance, start releasing slowly air from the cuff. When the beating of the pulse is heard again, this is the systolic pressure, further continue releasing the air until the tones disappearance, this is the diastolic pressure.

Measurement of venous pressure is conducted with the help of the Valdman’s device. The ulnar or clavicular vein is punctured and connected to the device. Venous pressure is measured in millimeters of water column. Normally the VP ranges from 50 to 100 mm of water column. The patient during inspection should lie.

Throat swab. The patient opens his mouth widely. With a spatula they squeeze the root of the tongue, wipe the tonsils with a sterile tampon, then the posterior wall of the throat and arches. The edge of the test tube, where the tampon was placed, is burnt.

Gastric intubation is applied to examine gastric juice, artificial feeding and gastric lavage. For this purpose thick and thin gastric probes are used. If the thick probe is applied — the contents of the stomach flows out itself, during washing with a thin probe, it is necessary to extract with the help of a Janet’s or “Record” syringe. The thick probe is entered through the mouth, the thin one is also possible to enter through the mouth, but it is entered through the nose then it irritates the throat less without retching. The equipment for gastric lavage: a watering can for 1–1.5 l, thick gastric probe (length up to 1.5 m), a jug with water or a Janet’s syringe, solutions (water, 2% solution of soda, 0.1% solution of КМnO₄ (light pink)), oilcloth apron, bucket for water, stomach contents. Techniques of procedure: the patient is sitting, leaning on the back of the chair, the head is inclined forward, knees are separated. Before gastric lavage it is necessary to dispose the patient psychologically and diligently explain him the meaning of the happening, what the patient and doctor should do. The depth for entering the gastric probe is the distance from the front teeth to the navel plus the width of the palm of the patient’s hand.

The bedpan is applied for emptying the bladder and intestines for bedridden patients. There are enameled and rubber bedpans. Before giving the patient the bedpan it is rinsed with hot water. The nurse, with one hand under the sacrum, helps the patient rise a little, and with the right hand between the separated legs brings the bedpan under the gluteus. Cautiously she takes away the bedpan not to spill its contents on the bed, at once the bedpan is covered with an oilcloth or newspaper and is taken out to the toilet room. After defecation the patient needs to be washed.

Flatus tube is applied in meteorism, delay in emptying the intestines and gases, which happens frequently in patients after operative interventions. The soft rubber thick-walled tube with the length of 30–50 cm and a diameter of 3–4 cm is applied for this purpose. On the part which will enter the rectum it is necessary to make some punched holes. The tubes are boiled, greased with sterile vaseline or other fat; the patient separates his gluteus and with cautious movements the tube is entered into the anus so that 5–6 cm are left externally. The external end of the tube is wrapped in cotton wool or gauze. It can be lowered into a bedpan with water. Hold the tube in the rectum no more than 2 h (avoidance of bedsores).

Enema. In healthy people intestines are emptied once a day. After an operation patients frequently have constipation, in these cases if there are no contraindications, laxatives or enema are used. Also the bowel should be opened before radiographic examination, before operations and abortions. Enema is entering of a liquid into the lower part of the thick intestines. There can be cleaning, siphon, nutrient, medical and drip enemas.

Cleansing enemas are made with Esmarch’s mug (enameled capacity of 1–2 l) with a rubber hose with the diameter of 1 cm and the length of 1.5 m. There is a valve and tip on the end (glass, ebonite or plastic) with the length of 8–10 cm. Technique: the patient lays on the left side with legs bent and brought to the stomach, less often on his back (postoperative patients). The capacity and rubber tube are filled with water, the tip is greased with vaseline, the buttocks are separated, and the tip is entered with the depth of 5–6 cm. The tip is entered, first, upwards and forward, and then rotating towards the sacrum. The tip needs to be entered accurately so not to injure any haemorrhoidal nodes, if there are any, and the mucous membrane. The Esmarch’s mug after opening the valve is lifted up to 1 m, in some cases it is necessary to add 1–2 l of water, constantly watching so that air does not enter the intestines.

After entering water, the patient should keep it for 10 min, lying on his back, and only after that the intestines are emptied into the bedpan or toilet. In some cases it is necessary to use a finger to get feces from the ampoule of the rectum that was stopped up. For increasing the effect of enema a little bit of children’s soap, 2–3 spoons of oil or glycerin, 1–2 spoons of kitchen salt, 30–40 ml of 3% of hydrogen peroxide, chamomile extract with valeriana root, etc. can be added to the water. The temperature of water should be near 20°С.

Siphon enema. When a cleansing enema does not help, a siphon one is applied. It works acccording to the principle of the connected vessels. Structure: a watering can, rubber tube 1.5–3 m in length and 1.5–2 cm of diameter with a control glass without a tip. It is better to use a thick gastric probe for this purpose. The temperature of water is 38°С (warm). Position of the patient is the same as for cleansing enemas. The end of the probe is moved towards the sigmoid intestine as far as possible, supervising its position in the rectum with the index finger. The watering can discended, filled with water and slowly rised up to 1–1.5 m. As the can gots empty, more water is added. As soon as the patient becomes disturbed, the can is lowered and inclined into the bucket where the liquid goes out. This is repeated several times, the amount of water used in a siphon enema is up to 10 l.

Medical enemas are general and local. Microenema — 50–100 ml of solution, the temperature is no less than 40°С. Before applying the medical enema, the cleansing one is done. The microenema contains nonpathogenic, soothing, anticonvulsive, somnolent substances. With the long-term use of medicinal substances, the drip method is applied and the enema is called drip. The speed of introduction is 60–80 drops a min. It is possible to give up to 3 l of liquid a day.

Nutrient enemas are applied when patients cannot be fed by usual methods. Nutritious solutions are entered into the rectum by the drip method (water, amino acids, spirit, glucose, fibers). Volume of nutrient enemas is 250 g, the temperature — 38–40°С, 1–2 times a day.

Catheterization of the bladder. It is applied in urinary retention. It is possible to carry out after reflex empting of the bladder is attempted (we’ve already mentioned it above). Catheterization is the administering of a catheter into the cavity of the bladder. It is a dangerous manipulation, and each doctor should know its technique. There are different types of catheters: soft — rubber and firm — metal, female and male. Before using a catheter it is necessarily to disinfect it. Metal catheters consist of a handle, core and beak with two apertures. A male catheter has the length of 30 cm, female — 12–15 cm and the beak is less curved. The technique of catheter introduction in the woman: the woman is irrigated, with the left hand they separate the labia majora pudendi, and with the right one they enter the catheter through the external aperture of the urethra into the bladder. The metal catheter is held with the hand, the rubber — tweezers. Catheterization in women is relatively easy, in men — difficult. The length of the urethra in men is 20–25 cm and it has two physiologic constrictions. Technique of performance: the patient lies on his back; between the legs there is a urinal. They take the head of the penis in the left hand between the 2nd and 3rd fingers, disinfect it with sublimate or spirit. With the right hand and with the help of tweezers they enter the rubber catheter, disinfected and greased with liquid vaseline. The catheter is held with the help of the 5th finger. Technique of catheterization with a metal catheter: with the left hand take the head of the penis, the straight part of the catheter is directed towards the navel, and the beak downwards. They pull the penis onto the catheter so that the beak covers it completely. After that, the catheter elevates upwards vertically, guided by the flaps on the handle. It is impossible to spare much effort, because the bleeding is possible.

MODERN WAYS OF DIAGNOSIS AND TREATMENT IN SURGERY

Laparoscopy

The method of laparoscopic examination (whether peritoneoscopy, pelvioscopy, etc.) was suggested in 1901 by a Russian doctor D. Ott. However, at first it did not receive a wide spreading and recognition due to a number of reasons, the main of which was the absence of special equipment. Enthusiasts of this method of examination used a thoracoscope, cystoscope for a long time. Recently, laparoscopes with high-wave optics and a conductor of a cold jet of light to examine the organs have appeared. They have completely replaced models of optical tubes existing before. These laparoscopes appeared to be effective enough not only in elective but also in emergency surgery, gynaecology, in detection and differential diagnosis of traumas of the abdominal cavity, pelvis minor and retroperitoneal cavities. Modern laparoscopy works out not only the tasks of visual diagnosis of diseases of the organs of the abdominal cavity, pelvis minor and retroperitoneal cavity. In a combination with instrumental palpation of the abdominal organs, radiographic contrast study of the hepatobiliar and pancreaticoduodenal zones, cholecystostomy and biopsy of cancer suspicious formations and other operations under laparoscopic control (such as cholecystectomy, appendectomy, ovariectomy and even resection of the stomach and removal of the whole large intestines and a lot more) are performed.

Principles and Technique of Complex Laparoscopy

Laparoscopic examination consists of the following stages: preparation of the patient, application of pneumoperitoneum, introduction of trocar and an optical tube, examination of the abdominal cavity, instrumental palpation, target biopsy, photolaparoscopy and the end of the examination. Psychological preparation of the patient: the patient should know what kind of examination will take place and understand its necessity. It is necessary to cleanse the gastrointestinal tract, carry out premedication by administering 1 ml of 2% promedol and 0.5 ml of 0.1% solution of atropine.

Application of pneumoperitoneum: piercing should be done at a distance from the enlarged organs, vascular prexuses and from the possible sites of adhessions. The place of applying pneumoperitoneum should be the place for applying the trocar and optical tube. The best one for this purpose is the point located on the middle line 2–4 cm lower than the navel. There are no vascular formations there, it is convenient for applying imposing pneumoperitoneum, applying the optical device and examining all the organs of the abdominal cavity and pelvis. The pathological formations are seldom observed there, which excludes their wounding.

Introduction of trocar. At the moment of trocar application the patient should tense the abdominal wall so that the doctor can feel the resistance of the aponeurosis of the white line of the abdomen. It is undesirable to cut the aponeurosis, because of hernia formation at this place. It is possible to fix the anterior abdominal wall, which helps in applying the trocar. The trocar should be directed at the angle of 45–60° in relation to the axis of the patient’s body. There is no need to enter the trocar more than 0.5 cm into the depth of the abdominal cavity.

Overview of the organs of the abdominal cavity is carried out consistently. Starting with the right hypochondria, then the left, the pelvic cavity and finish with the right hypochondria again. If the purpose is local or target exam, first of all the area under interest is surveyed.

After the end of the exam and other manipulations in the abdominal cavity, the optical tube is removed, and then through the trocar’s crane gas is let out from the abdominal cavity; one suture is applied on the wound.

Endoscopic Examinations

The development of fibrous optics and the creation on its base of the endoscopic fiberscope in the 60s of XX century is the best achievement of science and technology. The introduction of endoscopic methods of examination in clinical practice determined the progress in many sections of medicine: gastroenterology, pulmonology, obstetrics, gynaecology, urology, pediatrics. The development of special equipment and the application of radiological techniques, electric current, ultrasound, laser and other physical, chemical and biological factors during endoscopic interventions have transformed endoscopy into an independent field of medicine with opportunities of studying the pathogenesis, pathophysiology of diseases, solving diagnostic, tactic and medical tasks. Endoscopy became the property not only of large clinical centers but also the achievement of practical public health services even in regional hospitals. It is necessary to realize that now the qualified work of doctors of many specialties is inconceivable without endoscopic examinations.

Modern endoscopes are created on the basis of fibrous optics. Flexibility made them safe and effective, providing wide practical application. The most rapid period of new endoscopes introduction fell on 60–70-s of the XX century, their amount increased. The most widespread are endoscopes from the companies “Olympus” (Japan) and “ASM” (USA).

Ultrasound Diagnosis in Surgery

In clinical medicine ultrasound diagnosis began to be applied at the beginning of the 50s of the XX century. That time the equipment intended for revealing cracks in metal objects. For the next four decades there was a rapid development of ultrasound diagnosis, technical improvements, which allowed to extend diagnostic opportunities of ultrasound devices. Today one can say with certainty that ultrasound researches have occupied one of leading places in modern clinical medicine.

Cryosurgery

The application of cold together with medicinal herbs and bloodletting is the oldest in the history of mankind method of treatment. In the works of the “Father of Medicine” — Hyppocrates — the medical effects of local application of cold to stop bleedings in wounds and traumatic oedema are described in details. Cold is the oldest anesthetizing agent. In the Middle Ages military surgeons used it as anaesthesia during surgical operations.

Despite the fact that cryosurgical treatment of different damages to the skin began a long time ago, the rapid development of cryosurgery in the modern meaning of this term became possible only as a result of technical progress and the opportunity to create complicated modern devices for cryogenic destruction in the depth of tissues and organs of a patient. Cryosurgery is widely applied in neurosurgery, ophthalmology, othorhinolaryngology, gynaecology, and urology. The first cryosurgical operation in the former USSR was conducted in 1962 by I. Kooper, and A. Li in 1961 offered the device like a metal probe through which liquid nitrogen is able to enter directly the pathologically changed organs — their parts, mucous membranes, skin. In 1971, Laberopulos proposed a cryoscalpel.

E. E. Sandomirsky and coauthors (1979), А. І. Paches and coauthors (1978), V. M. Zaporozhan (1982) and many other authors, who studied the peculiarities of influence of low temperatures onto the organs and tissue with different kinds of pathology, showed that cryosurgery is a physiologic and sparing method of treatment, which is exsanguinate, painless, less traumatic, has high technical opportunities, absence of complications, which allows to use it in medical practice.

Application of Laser Beams in Surgery

At the beginning of 60-s of the XX century, due to the researches of the Nobel Prize winners N. G. Basov and A. M. Prokhorov and their American colleagues C. Tauns and A. Shavlov, the new principle of increasing radiowaves with the help of a bundle of “active” molecules was investigated. The optical quantum generator, which operates on a crystal of artificial ruby was created.

The essence of the laser action consists in the following: during the activity of a powerful light flash created by a pumping light, the active substance turns to the excited condition. In a certain time period (105–106 s) a part of the excited atoms comes back to the initial condition, thus releasing light quantum. Due to numerous reflection from resonator’s mirrors the amount of collisions of photons with active substance increases, therefore an avalanche of light quantum, which after achieving a certain capacity escapes as a bright light impulse with a very high concentration of energy, forms.

The first working laser plant was designed in the USA in 1960. Since the studying of the biological interaction of laser radiation with biological objects has started. Researches concluded that the laser beam can be manipulated with high accuracy, influencing areas of tissues of any size, groups of cells, endocellular structures, for example, the nucleus of a cell, etc.

First, the laser was applied mainly in oncology, ophthalmology and some other fields of surgery and subsequently received wide recognition in medicine.

Ultraviolet Irradiation of Blood

The first positive results from clinical application of irradiation by ultra-violet rays became possible after the invention of the first device for irradiation of blood (E. K. Knott). In 1928 for the first time in the world, the reinfusion of irradiated blood was conducted in a patient after a septic abortion, which was treated earlier without success. After this therapy the patient recovered. Since the 80s, ultra-violet irradiation of blood (UVIB) has been widely applied in medical establishments. For irradiating blood, lamps, which radiate ultra-violet rays both of the short and mixed type, are used. The reinfusion of irradiated blood promotes the pain disappearance, wounds healing, the general state of health improves, working ability increases, sleep and the body temperature normalizes. The method has no complications and contraindications and has the following action:

— bactericidal, antibacterial;

— anti-inflammatory;

— desintoxication;

— stimulates oxidation-reduction reactions, reduces hypoxia in tissue;

— raises the resistance of an organism to infections; — stimulates phagocytosis, etc.