MINISTRY OF PUBLIC HEALTH OF UKRAINE

O.O.BOGOMOLETS NATIONAL MEDICAL UNIVERSITY

“Approved”
on the methodical meeting of the
Department of General Surgery №2
Head of Department
Professor Ioffe O.Y.

_____________________________

25 August 2021

Academic Guides
for individual work of students to prepare for practical lesson

Academic discipline General Surgery

Module № 1 Introduction to surgery. Desmurgy. Bases of sanitary and
epidemic regimes in surgical clinic. Urgent surgical conditions.
Basical principles of transfuziology, anesthesiology and
reanimatology.
Content module № 1 Desmurgy. Antisepsis. Asepsis. Bleeding. Haemotransfusion.
Traumatic injuries.
Subject of lesson № 1 Desmurgy. Definition. Rules of overlays and types of
bandages. Typical bandages on the upper limb, head, neck,
chest. Desmurgy. Bandages on the abdomen, perineum, lower
limb. Gypsum technology.
Course 3
Faculty Medical

Kyiv-2021
 1. ACTUALITY

Patient care is an integral part of the curative process, especially in the

postoperative period, when most of surgical patients are shut-in, and have wounds
that require dressing.
N. Pirogov noted that every medical worker should be able to properly apply
a bandage, and each surgeon must be a master in this matter. An incorrectly applied
bandage can lead to serious complications, with consequences on the same level as a
poorly performed operation. In addition, the knowledge of desmurgy is necessary
for a doctor of any speciality to provide a first aid to the injured.
Acute dynamic developments of the disease in operated patients require
increased vigilance and responsibility during treatment. Surgical patients don’t self-
recover, they are nursed.
A doctor of any speciality requires the ability to determine the patient's
condition and skillfully organize not only the treatment, but also patient’s care. Care
for operated patients refers to special care conducted like general nursing by nurses,
but this knowledge and these skills are necessary for all physicians. The latter
expands the theoretical horizons of the doctor, helps to bring up the important moral
qualities inherent in the medical profession – a sensitive attitude towards the sick,
humanism, mercy, and loyalty to civic duty.

2. SPECIFIC OBJECTIVES:

• To define the concept of "postoperative period".

• To classify the postoperative period.
• To comprehend the phases of the postoperative period.
• To study the features of care for patients who underwent surgery on the
extremities.
• To study the features of care for patients who underwent surgery on the
abdominal cavity and perineum.
• To study the aspects of caring for patients of orthopedic and traumatological
profile.
• To study the aspects of nutrition in the postoperative period.
• To perform the typical bandages on the abdomen.
• To perform the typical bandages on the perineum.
• To perform the typical bandages onto the extremities.
• To classify hardening bandages.
• To learn the formula of medical plaster (gypsum) and the technology of its
performing.
• To know the healing properties of medical plaster.
• To demonstrate the samples of determination the quality of plaster.
• To summarize the rules of plaster’s technology.
• To know the types of plaster casts.
 • To learn the indications and contrandications to the treatment with the plaster
bandages.
• To study complications in the treatment of medical plaster;
• To organize and to demonstrate the imposition of a plaster bandage.

3. BASIC KNOWLEDGE, SKILLS, NECESSARY FOR THE

STUDY OF THE LESSON:
Names of previous Obtained skills
disciplines
Human anatomy Describe the features of the structure of the outer
integument of a human.
Chemistry Determine the chemical structure of gypsum.
Physics Define and identify the parameters of the physical
impact factors used for the control of the infection.
Propedeutic of internal Care for the patients.
diseases
Microbiology Describe the main groups and properties of bacterial
flora.

4. TASKS FOR THE SELF-WORKING DURING THE PREPARATION

FOR THE LESSON.

4.1 A list of the main terms, parameters, characteristics the student should
learn during the preparation for the lesson:
Term Definition
Aseptic (aseptica) 1. A complex of curative and profilactic measures,
determined to make an organism free from
contamination caused by harmful bacteria, viruses, or
other microorganisms; surgically sterile or sterilized;
(of surgical practice) aiming at the complete exclusion
of harmful micro-organisms.
Antisepsis (antiseptica) A complex of measures reaching the topical
destruction of bacteria, avoiding their growth in the
open wound. The method was developed as an
offshoot of French bacteriologist Louis Pasteur's germ
theory.
A painful, often reddened area of degenerating,
ulcerated skin caused by pressure and lack of
movement, and worsened by exposure to urine or other
irritating substances on the skin. Untreated bed sores
Bed sore
can become seriously infected or gangrenous. Bed
sores are a major problem for patients who are confined
to bed or a wheelchair. They can be prevented by
moving the patient frequently, changing bedding, and
 keeping the skin clean and dry. Also called a pressure
sore, decubitus sore, or decubitus ulcer.
An infection that occurs after surgery in the part of the
body where the surgery took place. Surgical site
infections can sometimes be superficial infections
Surgical site infection
involving the skin only. Other surgical site infections
are more serious and can involve tissues under the skin,
organs, or implanted material.
A fistula is an abnormal, tube-like connection that
forms between two organs or vessels that are lined with
Fistula epithelial cells. Fistulas are generally the result of a
disease condition, but artificial fistulas may also be
surgically created for therapy.
Dressing material with a possible contents of drug
Bandage substance, superimposed and strengthened on the
surface of the patient's body with a curative purpose.
The act of rendering immovable, as by a cast or splint.
Immobilization Fixation (as by a plaster cast) of a body part in order to
(immobilisatio) promote proper healing. The act of limiting movement
or making incapable of movement;
A fluid rich in protein and cellular elements that oozes
out of blood vessels due to inflammation and is
deposited in nearby tissues. The altered permeability of
Exudate blood vessels permits the passage of large molecules
and solid matter through their walls. The vessels seem
to weep, to sweat, in keeping with the Latin "exsudare",
to sweat out, from which exudate is derived.

4.2 Theoretical questions to the lesson:

1. Definition of postoperative period.

2. Classification of the postoperative period.
3. Phases of the postoperative period.
4. Features of care for patients who underwent surgical intervention on the
extremities.
5. Features of care for patients who have undergone surgical intervention on
the abdomen and perineum.
6. Features of care for patients of orthopedic and traumatological profile.
7. Features of nutrition in the postoperative period.
8. Typical bandages on the abdomen.
9. Typical bandage bandages on the perineum.
10. Typical bandages on the extremities.
11. Kinds of bandages that hardened.
12. The formula of medical plaster (gypsum) and its manufacture.
13. Curative properties of medical plaster (gypsum).
14. Samples for the quality of gypsum powder.
 15. Rules of gypsum engineering.
16. Types of gypsum dressings.
17. Indications and contraindications to the treatment of the cast.
18. Complications during the treatment under gypsum dressings.
19. Equipment procurement and imposing cast.

4.3 Practical work (tasks) that are performed on the lesson:

1. Apply bandages to the extremities, perineum and abdomen.

2. Perform samples to check the quality of gypsum powder.
3. Impose and replace aseptic bandage.
4. Prepare a plaster bandage, technique of it’s soaking and applying on to
extremities.
5. Carry out a cleansing enema and setting a gas discharge pipe.
6. Replace underwear in critically ill patients.
7. Replace the bed linen in critically ill patients.
8. Provide the toilet and feeding for the severely ill patients.
9. Pick up the necessary tools to remove the cast.

5. CONTENT OF THE TOPIC

The period of treatment of the patient from the moment the operation ends until
recovery is called postoperative.
The main tasks in the postoperative period are:
1) promotion of regeneration and adaptation processes;
2) prevention, in-time detection, and control of complications;
3) early restoration of working capacity.
The postoperative period begins from the moment of the end of operative
intervention and lasts until the complete recovery of the patient or permanent
disability.
By clinical classification the postoperative period is divided into:
- early (3-5 days)
- late (2-3 weeks);
- recovery (rehabilitation) from 3 weeks to 2-3 months.
Early period is characterized by the direct impact of the injury, the
consequences of anesthesia and the forced position of the patient’s body. The course
of this period is usually typical and does not depend on the type of surgical
intervention. The features of the late or distant periods completely depend on the type
of disease or trauma and from the nature of the surgical procedure.
The phases of the postoperative period:
- catabolic phase: usually lasts 5-7 days. Its course depends on the
severity of the patient's condition in the preoperative period and the traumatic nature
of the operation itself. In this phase, catabolism (increased protein breakdown, and
protein loss can reach significant limits, in case of severe interventions - up to 40
grams per day) increases, tissue acidosis, increased blood flow of catecholamines,
glucocorticoids, aldosterone, and others. Neurohumoral processes lead to changes
in vascular tension, disrupt the processes of microcirculation and oxidation-reduction
reactions.
- Phase of reverse progress: lasts 3-5 days. During this period, the
activity of the sympathoadrenal system decreases, protein metabolism is normalized
(positive nitrogen balance is noted), glycogen and fat synthesis is activated. In this
phase, anabolic processes gradually begin to predominate over the processes of
catabolism.
- Anabolic phase: characterized by active recovery functions excited in the
catabolic phase. This phase activates the nervous system, increases the activity of
growth hormone, increases protein synthesis, glycogen stores are restored. Due to
these processes, regeneration, growth, and development of damaged structures
progresses.

Care of postoperative patients undergoing interventions on the extremities

(fractures, dislocations, diseases), on the abdomen and the perineum.
Specificity of trauma - Orthopedic Department affects the rules of care for
these patients.
In regards to the basis of total patient care in the hospital, they are the same as
in other surgical departments. The importance of compliance increases as the injury
complicates the course of any other disease.
The basis for general care is the monitoring of:
v cardiac activity (pulse, blood pressure measurement, evaluation of
heartpain)
v respiratory function (counting the number of breaths per minute, the
identification of shortness of breath, chest pain while breathing), skin
color;
v function of the digestive system (patients’ feeding, timely bowel
movements, enemas, proper evaluation of various dyspeptic disorders,
excrement collecting for analysis, especially when there is a suspicion of
any bowel disease, and others.);
v function of urinary system (urinary retention, detection of overflow of the
bladder, catheterization, the installation of the persistent catheter, flushing
of urinary bladder, etc.).
Correct assessment of the psychosomatic condition of the patient is essential
in the work of a nurse in traumatology unit: is the patient’s attitude adequate towards
their neighbors in the ward and the medical staff, what’s their attitude towards the
treatment, do they follow the regimen recommended by the doctor.
General care performed by a nurse also includes performing different
injections, infusions, temperature measurement, monitoring the cleanness of the
patient, checking for pediculosis, washing and feeding patients, overlaying dressings,
compresses, accomplishing of cupping glasses, enemas and so on. The nurse should
also be familiar with the basics of rational diet of patients.
With patients recovering from abdominal surgery, or on the perineum, you
need to carefully inspect the area of the abdomen daily for the presence of swelling,
softness, or pain. Monitor the number and nature of the discharge from the drains.
Major complications: a slow resumption of peristalsis, the failure of anastomoses,
concealed bleeding and the formation of abscesses.
 Pay particular attention to the cleanness of the perineum. After defecation,
the crotch region has to be washed with a cotton swab with warm water or antiseptic
solution.

Caring for patients in the early postoperative period.

Some of the patients arrive after the operation to the recovery room or
intensive care units if the operation was performed under general anesthesia. The
majority of patients are under observation in the general wards of traumatology
(surgery) compartment.
After surgery, patients require special attention and gentle care. All patients,
regardless of age, type of anesthesia and the nature of surgery must be carried from
the operating department on a gurney. Nurse with a regular nurse’s help to gently
shift the patient to bed, creating the optimal position of the operated segment. Patients
who underwent surgery under local anesthesia are actively involved in the process of
positioning in bed, making the task easier on the staff.
After surgery performed under general anesthesia, the patient is placed on
their back without a cushion, their head turned to the left, so the tongue doesn’t sink
down and therefore patency of the upper airways is not broken and vomitus doesn’t
overflow the trachea.
After waking up from the anesthesia, and in the next 2-3 hours patients
must not drink. If vomiting occurs, turn the patient's head to the left and keep it so
until the disappearance of the gag reflex. Then, using gauze or towels, the remnants
of vomit should be carefully removed from the mouth and throat, to not let it get into
the respiratory tract.
Sequence of actions in case of vomiting:
1.Put on rubber gloves.
2. Turn the patient on his side, and if it is contraindicated, turn the patient's head on
the left side to prevent aspiration of vomit.
3. Cover the neck and chest with a towel.
4. Put a tray or bowl in the mouth of the patient.
5. After each act of vomiting cleanse the oral cavity with water or 2% sodium
hydrogen carbonate solution, if necessary, aspirate the remnants of vomit from the
mouth via pear-shaped cylinder.
Intoxication with drug substances.
Some patients experience hypersensitivity to local anesthetics (novocaine).
Signs of intoxication - red skin, low blood pressure, vomiting, cyanosis that may
occur during surgery or immediately after it. In case of development of these
symptoms, the nurse should immediately call a doctor.
Impairment of thermoregulation. In some cases, a patient’s
thermoregulation may be damaged. Sometimes even during the anesthesia the patient
has a strong fever. In this case, if it can not be limited with the application of warm
heaters to the feet, a general warming of the body is required.
Chills may be the first sign of other complications in the postanesthetic period
- hyperthermia. In this case, the body temperature may rise to 40-42 and even more.
0

You must remember that the increasing of the patient's body temperature at
1 ° C is followed by by increased heart rate at 8-10 b. / min. If the operated patient's
pulse rate is ahead of the temperature or the temperature decreases, and the pulse rate
 increases, that indicates an adverse course of postoperative period. Such
complication is accompanied by paleness of the skin due to spasm of blood vessels.
Hyperthermia leads to disruption of metabolic processes in tissues and organs. The
accumulation of water in cells may cause swelling of the brain. This complication is
dangerous for the patient's life. In case of hyperthermia, efforts of medical staff
should be directed on the reducing heat production in the body of the patient and
increasing the heat emission at the same time. For this purpose, 4.5 ml of a 50%
solution of analgin are injected. Heat emission increases while cooling by physical
factors, but spasms of the skin blood vessels should be eliminated before. For this
purpose use ganglion-blocking medicine in small doses: 0.5 ml of a 5% solution of
pentamine, 0.5 ml of a 2.5% Hexonium solution (administered intramuscularly).
If after the administration of these drugs, body temperature has not lowered,
resort to physical methods of cooling. Use a fan that creates a constant flow of air
over the patient. In addition, it is recommended to apply plastic bags or rubber
bladder with ice on parts of projections of the large vessels: in the groin, axilla, on the
side surfaces of the neck. With the same purpose the stomach is washed with water
temperature 12-15 ° C, enemas 6-8 ° C saline .
When combined drug effects with the physiological cooling fails during 1.5-2
hours and eliminate the state of hyperthermia.
Caring for patients with motor excitation. Sometimes, on awakening from
anesthesia, patients are too excitable, try to remove the bandage, get out of bed,
tearing their clothes, shout, call someone. This can lead to unforeseen complications:
violation of the integrity of the fragile plaster cast, repeated fractures, ruptures of
muscles and tendons, the displacement of the bone fragments, the divergence of
seams on the skin and the like. Patients in this condition may get injured.
Therefore it is necessary to fix in advance the patient's limbs and torso in bed with the
sheets drawn along or specially sewn strips of cloth.
Postoperative pain. After surgery for 2-4 days, patients experience pain in the
rather intense intervention zone. During this period it is necessary to conduct
appropriate anesthesia. After surgery administered drugs (omnopon, promedol) or
analgesics (ketanov, deksalgin, depiofen, dinnastat Nurofen, Baralginum). Narcotics
nurse enters strictly on prescription.
Skin care and mucous membranes
Patients in the first day after surgery are pale, but the next day the skin usually
becomes normal color. Enhancing skin pallor may indicate internal bleeding.
According to the phenomenon of facial flushing, and fever can be a sign of
pneumonia.
Yellow colour of the skin and sclera indicates pathology of the liver and biliary
tract. Skin should be kept clean, which recumbent patient helps by washing hands and
face, carried partial sanitary skin treatment just like in preparation for an emergency
operation. After each defecation and genital area when patients need to wash away
the contamination.
Equipment for cleaning the patient: a pitcher of warm (30-35 ° C) water, and
then with a solution of water-soluble antiseptic (chlorhexidine, Dekasan, Oktenisept),
forceps, cloth, craft, rubber gloves.
Algorithm steps
1. Wear rubber gloves.
2. Move the sacrum under the patient's left hand, help him raise the pelvis.
3. With your right hand, lift and straighten the pelvis under the oilcloth, on top of which
put the ship and lower the patient's pelvis.
4. Stand to the right of the patient, and holding a jug in his left hand, and forceps with a
cloth - to the right, pour the antiseptic from the pitcher to the area genital tissue at this
time wipe the perineum, the skin around it, making movement from the genitals to
the anus (front to back).
5. Dry the skin of the perineum with another cloth in the same direction, remove the
vessel and oilcloth.

It must be remembered that the axillary and inguinal areas and skin folds under the
breasts must be treated more frequently (especially in obese people), because these
parts of the body often develop diaper rashes, for them apply zinc ointment,
Sudocrem.
Prevention of pulmonary complications . Forced position of patients in bed, a
failure of the drainage function of bronchi, oppression under the influence of drugs
and the respiratory center pertussis reflex - all of this creates the preconditions to
reduce the ventilation in the postoperative period. In this regard, may develop
pneumonia and atelectasis.
For the prevention of complications of such patients as early as possible is
transferred to the active mode, conduct therapeutic breathing exercises, prescribed
oxygen therapy, and alkaline oil inhalation.
Active mode the patient after the operation is active movements of
unoperated limbs within a few hours after the operation. A nurse helps the patient to
sit up in bed and go to the side, if it allows a way of fixing the operated segment.
Some patients after a relatively small volume operation can be allowed off bedrest
within a few hours. Active mode is useful especially for older patients.
Treatment of breathing exercises during postoperation improves blood
circulation, increases lung ventilation, and straightens atelectatic areas of the lung
tissue. After the treatment session, breathing exercises reduced dyspnea, increased
tidal volume, and improved alveolar ventilation.
Expansion to a sufficient light also contributes to periodical breaths into the
tank with one hole, it creates a high resistance. For this purpose it is proposed that
patients inflate rubber balls or rubber rings in a volleyball chamber. This procedure
contributes to the pulmonary pressure, and expands cavernous alveoli.
Inhaled oxygen is conveniently carried out using a nasal catheter, introduced
into the lower nasal meatus. Oxygen must first pass through the humidifier. Aerosols
composed of different mixtures containing soda, antiseptics, mixtures of herbs,
antibiotics.
Oxygenation using oxygen mask. Oxygen pillow - a rubber bag, which has
included a rubber tube with a tap and die. It comprises from 25 to 75 liters of oxygen
to which it is filled with an oxygen cylinder. Before starting, the oxygenation
mouthpiece is wrapped with 2-3 layers of wet gauze for moistening sodium
hydrogencarbonate or rubbing alcohol used oxygen. Then the mouthpiece is pressed
tightly to the mouth of the patient and the open the valve which roughly regulate the
supply of oxygen. Inhaling it is done through the mouthpiece and exhale - nose.
When the amount of oxygen in the bed is significantly reduced, to increase its
 revenues to be pressed on the free arm pillow. After use, the mouthpiece is wiped
twice with a solution of 3% hydrogen peroxide and 70 ° ethyl alcohol.
Violation of bowel function . After any operation under general anesthesia the
patient is not allowed to drink for 2-3 hours. The patient can wet the oral cavity with
boiled water in small portions.
Very often after operations that were performed under general anesthesia, there
is flatulence. Bloated and distended bowel loops hypotonic stomach lift the
diaphragm, which complicates the activity of the heart and lungs. The stagnation of
intestinal contents may also cause intoxication of the patient. In this case, it is
necessity to insert the nasogastral tube to empty the stomach. Also at a doctor's
appointment, laxative rectal suppositories and hypertensive or siphon enema may be
given. The first self-discharge of gases, and also occurrence of peristalsis are
favorable characteristics.
Application technology of nasogastric tube:
Equipment: venting pipe, tube, cerate, petroleum jelly, wipes, rubber gloves.
1. Wear rubber gloves.
2. Lay the patient on his left side.
3. Put a warm vessel under the patient's pelvis oilcloth on the bed.
4. Lubricate the rounded end of the tube with petroleum jelly.
5. With your left hand, spread the patient's buttocks and with rotational movements of
the right hand gently insert the tube into the anus. If the patient can not be rotated to
the side, complete the procedure with the patient on their back with knees bent.
6. Enter the tube into the rectum at 20-30 cm, the outer end of its dipped in the bedpan.
7. Keep the tube in the gut for no more than 2 hours.
8. After completing manipulation of the skin around the anus, wipe or rinse with warm
water and then with Vaseline grease. Wash the vapor tube with warm water and soap,
soak for 30 minutes in a 1% chloramine solution, and boil.
Enemas are shown to stimulate self-defecation in the postoperative period and in
severe constipation, increases intracranial pressure, with hemorrhages into the brain.
Technique of laxative enema:
Material provide: a pear-shaped balloon, the vapor pipe, 100-200 g of an oil
(sunflower or vaseline) heated to a temperature of 34-38 ° C, oil cloth, Janet syringe,
200 ml of 10% sodium chloride solution or a 25% solution of magnesium sulphate or
sodium sulphate, latex gloves.
Oil enema (action algorithm):
1. Wear rubber gloves.
2. Dial a pear-shaped balloon 150 ml of warm vegetable oil.
3. Lubricate the vapor tube with petroleum jelly.
4. Ask the patient to lie on the couch, covered with oilcloth on the left side, with their
knees bent and pulled up to their stomach.
5. Separate the buttocks, enter the vapor tube into the rectum by 20 cm.
6. Pripodklyuchite to the tube pear-shaped balloon, slowly enter the oil.
7. Hold the vapor pipe clamp or flexing it. Fill the air cylinder pripodklyuchite to the
vapor tube and enter into it a little air to push the liquid which has remained in the
vapor tube.
8. Remove the vapor tube.
Hypertonic enema (action algorithm):
1. Wear rubber gloves.
2. Preheat hypertonic sodium chloride solution to 37-38 ° C.
3. Dial a pear-shaped balloon 200 ml of a 10% solution of chloride sodium.
4. Follow steps 3-7 of the previous manipulation.
5. Instruct the patient to hold defecation for 30 min.
Contraindication: anal fissures, hemorrhoids in the acute stage, purulent
inflammation and ulceration in the rectum.
Furthermore, stimulation of peristalsis under the skin gently injected 1 ml of
0.05% solution of neostigmine. Stimulate motility with metoclopramide (Reglan) 2.0
/ m. Also check blood electrolyte levels .
Violation of urination
Often after operations on the abdominal organs, especially in the pelvic organs,
urinary retention occurs. Main reason is the fear of pain while reducing the
abdominal muscles and the inability to empty the bladder lying down. If possible, you
should allow the patient to urinate in the normal position. When urinary retention
occurs, you can put a heating pad in the suprapubic region, or perineum. It is
necessary to try to induce urination reflex. To do this, open the tap with running
water in the room. If no effect is performed catheterization of the bladder is
nessesary to perform:
With the left hand hold the penis in an upright position of the head and slightly
pulling his right hand gently introduce the rubber catheter moistened with sterile
glycerin or paraffin oil into the external opening of the urethra. Gradually, without
any effort to advance the catheter through the channel. Sometimes directly to the
bladder catheter is not covered due to spasm of the sphincter. Therefore, you should
get a little catheter, and then again try to hold it through the sphincter section. After
the cessation of urine through the catheter should be a little push with his left hand on
the area of the bladder above the pubis, to completely clean it. The catheter is then
removed, or left Foley catheter by the physician. If the rubber catheter fails to hold, it
is necessary to pull the metal catheter urine. Men metallic catheter enters a doctor.
Women spend catheterization is not difficult due to the specific structure of the
urinary tract.
Monitoring the state of the dressing on the wound. The duties of the ward
nurse include being responsible for monitoring bandages. An experienced nurse
should know the features of the surgery. If the wound is sewn up tightly or it has
drains, they must be particularly careful to monitor the state of the dressing. It can
soak the release of a wound or blood. On the possibility of bandages soaking is
necessary to tell the patient that he was not frightened. During the duty, a nurse
examines a few times a bandage on the wound, noting the intensity of the discharge
of its odor, color and other characteristics. Excessive soaking bandages in a short
period of time, especially the blood, we must bear in mind the possibility of re-
bleeding from the wound. This happens when the ligature slips after surgery, as well
as surgical interventions carried out under tow when some small vessels are not
ligated. Seeing the rapid soaking bandages blood, the nurse should immediately call a
doctor.
When inflammation, tissue necrosis, or when deep burns may occur arozivnye
so-called bleeding, that is bleeding resulting from the destruction of the vessel wall.
In such cases, the patient has a sudden massive bleeding occurs. Ward nurse should
immediately stop the bleeding, pressing his hand a corresponding main vessel
proximal to the wound bleeding from his legs - in the groin crease, bleeding from his
hands - on the inner surface of the shoulder or in the armpit. Pressing the artery, the
sister sends someone from the staff for the physician. In the case of bleeding in the
hallway separating a prominent place always must hang tourniquet . This should be
aware of all the nurses office and nurses.
Observations of postoperative wound
Possible complications of the surgical wound bleeding, the development of
infection, the divergence of seams.
The primary prevention of infection is steady and clear execution of the rules
of asepsis and antisepsis in the operating period. In the postoperative period, special
attention should be paid to the proper functioning of drainage, as well as comply with
all measures to prevent secondary wound infection (for dressings, wound
examination, treatment in the physiotherapy department).
After surgery to the area of a postoperative wound, permitting plaster bandage,
it is necessary to put an ice pack. Bubble ice promotes narrowing krovonosnih skin
vessels and adjacent tissues and reduces the sensitivity of nerve receptors. It is filled
into small pieces of ice, air is displaced residues tightly sealed lid, is wrapped with a
towel and applied to a wound. It is impossible to pour water into the bubble and
freeze it in the freezer, the ice formed because the surface will be very large, which
can lead to hypothermia wound site. Ice packs can be kept for 2-3 hours, and if
necessary more, but every 20-30 minutes it should definitely take 10-15 minutes. As
the ice will melt in the bladder, the water must be drained, and the ice pieces added.
The day after surgery, most patients show ligation. Ligation patients are in a
low operating or dressing material for dressing should be sterile. If the patient has
been imposed a plaster splint, the last shoot, shoot bandage, the wound is washed
with hydrogen peroxide, antiseptic solutions, dried. After inspection of the wound
drainage operation control aseptic bandage is applied (on ointment base, if
necessary). In the future, we must carefully ensure that the bandage is well laid, not
to the wound was exposed. In the early postoperative period bandage may slightly
leak blood, in which case it new bandages are applied. In the event of a significantly
soaked bandage with blood, this should be reported immediately to the doctor, it may
indicate a complications.
During the first week, dressing should be done every day, and then - on
indication. Also in the prevention of wound infection, antibiotics play a very
important role. But even with the most modern antimicrobials neglect of aseptic and
antiseptic rules is unacceptable.
In the normal course of the processes of regeneration and healing of the
wound, sutures can be removed by 12-14 days.
Complications also refer to divergent seams. This can happen in case of
technical error during the operation, or as a result of melting of purulent wounds.
Prevention and treatment of pressure ulcers
Decubitus - is aseptic necrosis of the skin and tissues below the
microcirculation disorders due to prolonged compression. At the lower extremities
bedsores operations are usually formed due to the long stay of the patient in bed, as
well as deficiencies in nursing. Typical places of formation of bedsores portion is the
neck, shoulder blades, the back surface of the elbow, the coccyx . It is in these areas
of the bone located quite superficial and there is a pronounced contraction of the skin
and subcutaneous tissue. Most often, pressure ulcers occur in the elderly and in
patients with microcirculatory disorders (diabetes mellitus, angiopathy, etc.).
Distinguish 4 stages of pressure ulcers :
- The first stage is characterized by decubitus seal tissue at the site of the lesion and
its hyperemia, edema may be observed. In this step, bedsores respond very well to
antibiotic therapy with wound healing drugs.
- The second stage is characterized by the formation of pressure ulcers in the affected
areas of erosions and ulcers. But, at this stage tissue damage has not occurred, and it
is struck solely the top layer of the epidermis. The second stage is also successful
with treatment and well-chosen and carried out the tactics possible sustainable
improvements in patient with bedsores.
- The third stage is characterized by a deep bedsores intense affected tissues that are
under the skin. Damage occurs in the subcutaneous layer, which eventually leads to
irreversible necrotic lesions. This stage is extremely difficult to treat.
- The fourth stage is characterized by excessive necrotic lesions and soft tissue
changes, as well as blood circulation in these areas. Such changes can result,
ultimately, to the whole organism intoxication strongest and further blood poisoning
(sepsis).
Stage of development of pressure sores:
- Step ischemia (tissue become pale, sensitive violated)
- superficial necrosis step (appears swelling, redness, are formed in central
portions necrosis black or brown);
- stage of purulent fusion (associated infection, progressing inflammatory
changes occur pus, process extends deeper, up to necrosis of muscle and bone).
Prevention of bedsores
For the prevention of pressure ulcers in the sick, enclose rubber inflatable
wheels, 2-3 times a day, sections where pressure sores may occur, rub camphor
alcohol, frequently change the patient's position in bed, and massage the patient. The
best way to prevent bedsores is active management in the postoperative period
(possibly getting up early, sitting patients), it also helps in the prevention of
pulmonary embolisms. Widely used are anti-bedsore mattresses with a compressor.
Using the mattress reduces the risk of the formation and development of pressure
sores, and creates favorable conditions for post-surgical and drug therapy.
The treatment of pressure ulcers
All rules of prevention must be observed in the treatment of pressure ulcers
must be observed as it eliminates the etiological cause of pressure ulcers, and
prevents progression of the process.
Local treatment of bedsores depends on the process steps of:
- ischemia stage - the skin was treated with camphor spirit, which causes
vasodilation and improves circulation .
- step surface necrosis - necrotic portion was treated with 1% alcohol solution
of brilliant green. These substances have a tanning effect, promote the
formation of crusts which prevent infection .
- purulent fusion step - treatment takes place according to the principles of
treatment of purulent wounds.
 However, in most cases, pressure sores are a sign of neglect in patient care
and preventing them is the main task of care in the postoperative period.
Caring for patients with fistulas (fistulas) . To protect the skin around the fistula
from irritation it is often washed with soap and water or antiseptic solution, and
cotton-gauze swabs are used instead of wool. After washing, the skin is dried and
children’s cream or Vaseline is smeared around the fistula. If there’s skin irritation -
paste Lassara, zinc or dimedrolovoyu ointment is sprinkled. Upon application of
dressings it is not recommend to close the dressing with kleolom, a tacky adhesive; if
the fistula doctor entered a drain and clogged it, it must be carefully rinsed with an
antiseptic solution. When the drainage has dropped out of the fistula, the nurse does
not have to enter it. Patients with enteric fistulas lose a lot of water and salts, so they
need adequate nutrition and treatment.
For temporary closing a fistula, obturators are used. The easiest obturator can be
made out of two tubes with bottles for solutions. With plugs excised 3- plate
thickness 4 mm, diameter of one is unlimited, and the other (internal) should be 2
times greater than the diameter of the fistula. Both plates are sewn with thick thread
and knotted (in the final form resembles obturator stud). The inner plate is bent and
injected into the fistula, where it is straightened and closing stroke, and stitched on
the outer filaments to tighten the skin, the thread externally binded. On top of the
obturator put a napkin with pasta Lassara.
Patient care in a cast .
The cast - often in the form of trauma immobilization. It is used for fractures,
sprains, soft tissue injuries, sprains and torn ligaments, tendons, muscles,
amputations, after various operations on the bones, joints, tendon-muscular system,
about various diseases and the like.
The vast majority of complications when using plaster cast are the result of its
pressure on the soft tissues of the body. This complication occurs, on the one hand,
when a very tight bandage, on the other - when increased soft tissue edema, and they
are compressed in a dense plaster case. In both cases, there are unpleasant sensations
and pain at the site of a significant fixed limb. The patient complains of tightness,
numbness, aching. Subsequently, the distal portion of the limbs numb, my fingers
turn blue, become cold, due to reduced vascular response time.
When a fabric bandage is tightly superimposed with veins located therein, first
compressed are the lower rounds plaster bandage (Bandage feeling of tightness does
not occur at once), as the drying pressure increases. The upper layers of gypsum
bandage are not completely removed, and dried out rounds lie deeper while yielding
to pressure from the outside. When compression of the tissue surface is disturbed,
venous outflow from the immobilized limb segment leads to stagnation of blood in it,
and the subsequent the growth of the segment volume and swelling. A wall plaster
cast on the rising edema contributes to the compression of already deeper tissues and
may eventually lead to a violation of not only venous, but also blood circulation. This
leads to the so-called ischemic necrosis.
In case of patient complaint to a feeling of a compressed limb in the plaster
bandage, especially when only applying the patch, it is necessary to reduce the factors
that may contribute to further swelling and tissue compression. First of all you need
to create the exalted position of the damaged (or operated) limb; while improving
venous return. If an injured leg, the foot of the bed should be raised with the help of
special supports, such as bus Belair. For a hand it is necessary to suspend it above,
attaching to the edge of the cast or bandage a cord and tying the other end to the
Balkan frame or to a special stand - "pie".
The bandage should be longetnoy razbintovat soft bandage and a few edges to
dissolve splints, relieving the compressed segment of the limb. Deaf plaster bandage
in such a case should be completely cut, the fabric free from pressure. It cannot be
partially cut, as in this case the strangulated segment is not released from
compression. Expecting a favorable effect on the partial cutting, often spend precious
time. After dissection of the cast bred its edges, releasing the limb from the pressure.
It helps to normalize blood circulation, and eliminates the threat of complications.
In some cases, only small areas of soft tissue are compressed, which are the
bone formation: heel bone, the patella, the condyles of the bones in the knee and
elbow, a large swivel femur, anterior superior spines of the pelvis, etc. In order to
prevent these complications when applied, plaster cast listed places are needed to
cover the cotton-gauze pads. This is especially true of thin or malnourished patients
with mild subcutaneous, fat, fiber, as well as elderly patients.
Small soft tissue areas may be squeezed in the plaster cast if at the time of
applying, the patch the wall there are indentations. In such cases, the specific location
bandages are cut out a 'window'.
Under the plaster cast, overlaid with a fresh injury (for example, bone
fractures), blisters can form on the skin. They are filled with blood content, and
appear as a result of impregnation of the liquid portion of blood from the hematoma
to the surface layers of the skin. The occurrence, and even more blistering infection,
can delay the deadline necessary operation or cause complications. The bubble must
be oiled with tincture of iodine. Wall of it in one place to make an incision at the base
should be sterile scissors, remove the contents of the bladder, and settled the
epidermis to treat with antiseptic again. This site belongs to keep open or to cover a
single layer of sterile gauze to quickly dried up and peeled off the peel of the
epidermis.
Skotchkast - a hard polymer bandages (artificial gypsum or plastic), which is
used to fix the damaged parts of the body a variety of injuries. Compared with the
traditional plaster, this modern material is not fragile, it is almost impossible to break,
so may be a small load on the bandage. Thus skotchkast 5 times more durable and
easier to conventional plaster. The dressing based on this polymer bandage allows
skin to "breathe", i.e. passes outwardly skin evaporation and air from the outside,
which prevents an itch, allergy or maceration. Therefore, when using synthetic
gypsum, a backing layer of cotton bandage of this material isn’t used, and thus it is
not afraid of water, and the patient is able to shower and even swim in ponds, and rest
on the beach.
Furthermore, a polyurethane resin is at the base material comprises a substance
that does not stick to the gloves of the bandage, which significantly facilitates the
process of applying gauze dressings, and the structure itself skotchkasta eliminates
the need far fewer layers than the standard gypsum.
At the end of the period of bed rest, patients with fractures of use crutches.
During this period, they complain of increased pain at the site of injury, swelling and
bluish toes, feeling the pressure of the cast. The physician should be aware that in the
first period of regime change, such phenomena are caused by temporary disturbance
of blood circulation in the limb (mostly vein). After mastering the walk on crutches
circulatory insufficiency is gradually taking place. The disappearance of these
phenomena is partly due to the normalization process of callus formation at the
fracture site and the formation of primary adhesions.
nursing, located in the skeletal traction
During the treatment period in traction when the patient is in bed, the nurse:
1. conducts toilet patient perestilanie bed, performs all manipulations
(podkladyvaniem vessel, urinal, formulation of enemas, bladder catheterization,
etc.);
2. constantly monitors the correctness of all the patient's traction
system directs cravings, etc .;
3. conducting prevention of complications associated with the
presence in tissues of metal spokes, the ends of which extend outwardly.
To prevent this complication as abscess spoke at skeletal traction, the nurse
should at the outset of treatment to follow closely the skin in areas of the spokes.
Periodic replacement of sterile gauze balls, processing these places iodine tincture is
a guarantee aseptic passage period skeletal traction. If the patient complains of pain
in the places of the spokes, you need to find out whether there is redness of the skin,
soft tissue tenderness around the spokes and pus. For prophylaxis wet gauze beads
alcohol pipetted (5-8 times a day) is recommended. This simple procedure can easily
be performed by the patient after appropriate instructions.
Changing of bedside. To facilitate this procedure, the bed must be attached to a
Brown frame (so-called "Balkan"). The patient is slightly reduced in the bed, pulling
the frame arms. If he can not take an active part in perestilke bed, you can use one of
the methods described in the following figures.

Changing of bedside is somewhat more difficult with complicated traction

system (for example, multiple fractures of the limbs and trunk). Here, change the
sheets in such a way. A clean sheet too, rolled into a roll, but not along and across.
Perestilanie begin with headboard. By adopting the pillow, the nurse begins to roll
and across the dirty sheet, immediately rolling out clean. Thus, a clean sheet is first
coated at the head, and then the foot end of the bed. With the described method
perestilaniya bed skeletal traction system is not disturbed.
Feeding habits of patients in the postoperative period
The food in the postoperative period should correspond to the nature of the
disease, the volume of the executed operation, and its flow characteristics. In the first
two days after, any food should be freshly prepared, warm, easily digestible, liquid.
 First courses that allow you to have - is the broth, jelly, yogurt, raw or soft-boiled
eggs, meatballs, steamed, cheese, liquid porridge. After closure of early postoperative
patients without concomitant diseases prescribed total diet № 15. Power some
patients after surgical interventions following:
1) after surgery on the stomach and small intestine within the first 1-2 days recommend
hunger, food is provided at this time only the parenteral administration of glucose
solutions, proteins , etc. 2-3 days prescribed liquid diet - table number 1a, then the
number 16, and starting from the 7th day - pasty food. Ranging from 10-12 days, the
patient is gradually transferred to the common table;
2) The diet of patients after surgery on the abdomen, but without opening the stomach
and intestines must be adjusted to prevent gas formation. Usually give all those
products that comply with the table number 1a, except for milk;
3) after operations on the colon, diet is aimed to ensure that the patient within 4-5 days
there was no stool. With diet excludes foods that contain a lot of fiber - black bread,
vegetables, fruit;
4) at fractures prescribed foods rich in calcium, magnesium and other minerals which
will promote bone regeneration.

Typical bandage on his stomach, perineum, limbs.

On the upper part of the abdomen is possible to impose a helical circular
bandage. For bandaging the lower abdomen is recommended to use a combination of
a spiral with a spica bandage . Since the bandage has a tendency to creep, it can be
attached by several turns through vosmipodibnih nadpleche or form first two straps
which cross at the back, the free ends of which are fixed in front and behind the
initial bandage windings and pressed as follows.

To close the inguinal region , the front and rear surfaces of the thighs,
buttocks and perineum used spica. It is formed vosmividnymi coils, which are held
around the hips so that the crossing of the bandage was carried out on the perineum,
without closing and squeezing the external genitals and the anus. Bandage is
performed from the front-upper edge of the iliac bone to the crotch goes to the hip
opposite leg, rounding his back, returned to the crotch and goes to the back of the
thigh of the other leg, skirting it and random rises in front to the anterior upper edge
of the opposite ilium. Depending on the localization of the damage to the intersection
location can be back, side or front.
 The perineum used spica-type bandage. Widely used T-shaped bandage.
Two pieces of gauze or two pieces wide bandage crosslinked in the form of the letter
"T". Bandage horizontal portion is secured around the waist, and a vertical lead
through the crotch and to reinforce the horizontal, before making the front opening or
incision for free urination. For the same purpose can be used in a bandage-shaped.
First the few circular turns around the trunk of the anterior upper edge of the iliac
bone. Further, the segment is taken masking tape on both sides and cut down the
middle. The uncut portion is applied to the crotch, the dressing ends in front and
behind to throw in hand and tied to the waist belt.

Bandage on upper extremity. Bandages on fingers and wrist. Spiral

bandage used for bandaging fingers. It begins with circular strokes in the wrist, then,
with one finger bandaging, bandages are on the back of the hand to the end of the
finger, spiral wrapping his moves. Spiral bandage in this manner can be applied to all
fingers. Fix it at the wrist.

Brush bandage by 8-type bandages. When bandaging hands together with

fingers bandage on a rotary type. First circular strokes reinforce bandage at the wrist,
and then lead him on the dorsum of the hand to the fingers and then - on the palmar
surface, gradually covering the entire brush. Horizontal strokes bandage brush,
starting from the finger. Secure the bandage at the wrist.

The bandage on the forearm and elbow . Forearm bandage -type of spiral
with excesses. At the elbow bent at an angle diverging or converging impose turtle
bandage. At the elbow joint portion in the unbent state the helical bandage is applied
with the knuckle.
 Various types of bandages on the hands, fingers, forearm, elbow and armpit
bandage shown in the following figures.

Bandages on the lower limb.

The bandage on the knee and hip . Impose on the knee joint when flexed
position turtle bandage , with unbent position - bandage on 8-type : circular turn of
events above and below the knee, oblique - with a crossing point in the popliteal
fossa.

Rotary dressing on the thigh stump is shown in the following figure.

The bandage on the lower leg . Shin superimposed spiral with excesses
bandage to knee level, and wherein the bandage is fixed circular course.
 The bandage on the ankle . Ankle area is covered by a vosmiobraznoy
bandages . In case you need to close the heel portion is used turtle bandage . If you
want to close the bandage the whole foot, resort to turning the bandage. After the
circular course in the ankle bandage are longitudinally from the heel to the big toe,
making moves on the side surfaces of the foot. Then, starting from the toes, foot
bandage with circular strokes.

The bandage on the whole foot without toes. Right foot begin to bandage on
the outside, the left - on the inside. Bandage lead along the outer edge of the right
foot from the heel to the base of the fingers, then go dorsum of the foot to the inner
edge of its circular course and is wrapped ream overlaid as low as possible. Bypass
the heel back and repeat the moves described. Fixing bandages around the seed.

Bandage on hips and groin area are presented in the following figures.

Cast (gypsum)
With conservative and post-operative treatment of fractures, soft tissue
damage is widely used immobilisation using casts, which is the best means for the
external fixation of fragments of limbs.
Method of preparation and cast application was first described by the Dutch
physician A. Mathysen (1852), and in 1854, during the Crimean War, described and
widely started using MI Pies. He also paid great attention to the care of the state of
the plastered limb.
 Plaster immobilization: a constant for the duration of immobilization of the
patient's treatment.
Gypsum Formula: calcium sulfate - CaSO4 ∙ 2H2O. For medical purposes
gypsum treated in factories, where it is subjected to a special burn-off in an oven at a
temperature of 130-150 °. After baking gypsum loses part of its water of
crystallization and is not more than 5.25% (CaSO4 ∙ H2O). Gypsum quality is
directly proportional to correct burn-off.
Currently, the gypsum powder is added to cellulose and a number of other
chemical compounds. The thus obtained composition of the hot impregnated in
dressings, dries and forms a gypsum bandages.
In recent years, new thermoplastic materials, which are used instead of
gypsum ("Skotchkast", "Ortoplast", "Goksel" and others). They are well simulated by
heating to 72-75˚S. These bandages are not afraid of water, when wet not lose their
shape, porosity and are capable of air exchange. Such dressings do not require special
pads.
Medicinal properties of gypsum :
1) reliable immobilization for the period of treatment;
2) adsorption properties (absorbs wound separation)
3) fixing limb fixed contractures;
4) treatment of congenital deformities.
Samples of the quality of gypsum :
1) on strength - the ball diameter is 1.5-2.5 cm Throws from 1.5 m onto the floor -
normally remains intact.;
2) on the flowability - gypsum powder is compressed in a fist - normally should not
remain in the palm of lumps, gypsum wakes up between fingers;
3) on humidity - the heated gypsum on a metal plate with a content above the mirror.
If the gypsum quality, not wet, the mirror will not fog up;
4) at the solidification - is this mass (2 parts water and 3 parts of plaster) which
solidifies for 10-12 minutes at fracture does not crumble;
5) on the viscosity - making a plaster splint (4-5 layers), is applied to the forearm,
after hardening it must preserve giving it a shape, do not crumble, but not delaminate;
6) on the smell - when unsuitability gypsum was mixed with water, the smell of
hydrogen sulfide appears (rotten eggs).
Rules of plaster technique:
1) cast must capture two adjacent joint, and when damaged shoulder, thigh bones or
joints - three;
2) limbs is provided average physiological position;
3) at bony prominences physiological need putting cotton-gauze substrate;
4) The last round plaster bandage should cover prior to ½ or ⅔ width of the bandage;
5) The bandage should be otmodelirovana without constrictions, indentations
uniformly cover without pressing limb;
6) of the foot fingers or hands should be free from dressing to control blood flow to a
segment plastered;
7) possible to apply the pencil on the dressing the date and probable duration of
withdrawal of the cast;
8) applying plaster bandage should not take more than 10-15 minutes.
Types of casts:
 All casts are divided into three major groups: longetnaya bandage , longetno-
circular and circular . Also dressings are divided into: Lining (with cotton) and
bezpodkladochnye (on the hand and forearm), circular (circular) longetnye (4-7
layers of plaster bandage), fenestrated (window over the wound bandage), bridges
(significant damage to soft tissue the joints - two connecting bridges 2-3) koksitnye
(hip), gonitnye, calves feet, corsets and cots (spinal cord injury), thoraco-brachial
hanging circular, "boots".

Indications for treatment with plaster bandages:

1) bone fractures after conservative and surgical treatment;
2) joint damage (removal of dislocations), after the restoration of damaged tendons,
ligaments, muscles;
3) elimination of contractures;
4) treatment of congenital deformities of bone (clubfoot, klishorukost etc.).;
5) bone inflammation (rheumatoid arthritis), joint treatment of tuberculosis, bone
osteolysis;
6) After treating skeletal traction;
7) for preventing the formation of contractures in the treatment of burns;
8) tendovaginitis, bone tumors;
9) prevention of deformations in wounds nerve (n. Radialis, n. Peronaeus communis)
10) Urge gypsum;
11) after plastic gypsum recovery operations.
Contraindications to cast application:
1) anaerobic infection in the wound;
2) has not been carried debridement abscesses, septic heats;
3) combined fractures complicated by burns, frostbite.
Complications in the treatment of plasters:
v bedsores (local compression) in the progression of ischemia edema
available tissues (arterial flow impairment),
v disturbance of venous blood flow, a long compression syndrome, muscle
atrophy, stiffness and contractures (3-4 months), with devolution edema possible
redislokatsiya fragments.
v Children can often get a plaster bandage foreign bodies.
v With an increase in intoxication syndrome, sudden distension limb, severe
pain, swelling above the cast - it can be assumed the development of anaerobic
infections.
v When pulsating pain, hyperthermia, increase in peripheral lymph nodes,
leukocytosis build-up can assume development suppurative inflammation.
Technique preform gypsum material :
1) standard is used bandages, 7-14 cm in width, 4-5 m gypsum splints made from
gauze width 20 cm, length 4-5 m.;
2) gipsovalnom bandage placed on the table, parting edge palm plaster over the
surface of the bandage thickness of 2-3 mm;
3) plaster bandage is rolled into a loose roll from one side, and the splint up (roll the)
from both ends toward the center. Plaster bandages are stored in a dry place.
Imposition of the cast:
1) soaking plaster bandages (splints) was immersed in water at about 20 ° C, where
they are to discharge air bubbles closure (increasing water temperature gypsum
solidification speed faster with decreasing - less) .
2) plaster bandages squeeze with both hands from the ends to the center, to the plaster
is not washed with water;
3) a plaster splint is smoothed in width, was transferred on the injured limb and
secured by conventional bandages - (longetnaya bandage) or fixed with a plaster
bandage (Bandage longetno-circular).

Materials for self-control

6.1 Tests
1. Early postoperative period ends:
A. after removing the sutures from the surgical wound
B. after the elimination of early postoperative complications
C. after wound’s healing
D. after the recovery of the patient's health
E. after the patient's discharge from the hospital
2. Catabolic phase of postoperative period characterized by:
A. reduced decay of protein
B. increase of urine output
C. increase of lung capacity
D. decrease in bloodof glucose levels
E. activation of sympatic adrenal system
3. Recovery phase of uncomplicated postoperative period is characterized by:
A. increased activity sympatic adrenal system
B. negative nitrogen balance
C. up to 2 weeks
D. positive nitrogen balance
E. lasting 2-3 days
4. The use of postoperative pressure bandage on the wound is needed for:
A. preventing of wound dehiscence
B. prevention of thrombosis and embolism
C. remission
D. prevention of infection
E. prevention of bleeding
5. Specific prevention of thromboembolic complications after surgery on the
lower extremities includes:
A. applying of elastic bandages on the low extremity
B. use of anticoagulants
C. light curative exercises
D. early verticalization from bed (if possible)
E. active patient’s movement in bed
6. What is contraindicated by the urinary retention in postoperative period :
A. use of diuretics
B. bladder catheterization
C. warming of the bladder
D. intravenous injection of 10 ml of a 40% hexamine solution
E. hypertonic enema
7. What should be applied for the prevention of postoperative pneumonia:
A. introduction of neostigmine
B. electrophoresis with hydrocortisone
C. breathing exercises
D. increase the amount of fluid
E. nonsteroidal anti-inflammatory drugs
8. Which of these complications are most common after a long and traumatic
interventions on the lower extremities?
A. gangrene of the extremity
B. pneumonia
C. paresis of the gastrointestinal tract
D. thromboembolism
E. anuria
9. What should be used by the paresis of the gastrointestinal tract:
A. laparocentesis
B. paranephral blockade
C. hypotonic enema
D. massive antibiotic therapy
E. administration of physiological sodium chloride solution
10. What is concern to the early postoperative complications after surgery
on the extremities?
A. keloid scar
B. limited movement in joints
C. ligature fistula
D. neurodystrophic syndrome
E. bleeding
11. What is refer to the complications in a long-term period after the
treatment of the fractures?
A. acute osteomyelitis
B. soft tissue abscess
C. fat embolism
D. traumatic shock
E. trophic disorders of the soft tissue
12. Prevention of thromboembolism after surgery:
A. all of the above
B. use of anticoagulants
C. elastic bandaging of the lower extremities
D. useageof antiplatelet agents
E. Early mobilization of patients
13. Specify an event aimed at the prevention of pulmonary complications
in bedridden patients in the trauma unit during the postoperative period:
A. nitrous oxide inhalation
B. cold on the chest
C. appointment of iron supplementation
D. breathing exercises
E. gastric lavage
14. Prevention of postoperative wound festering
A. thick seams on the skin
B. physiotherapy
C. resorbable stitches on a wound
D. wound drainage
E. hermetical bandage
15. What is the main for the bedsore prophilaxy:
A. position of the patient on a hard mattress
B. application of the skid circles
C. changing the patient's position in the bed
D. relay of bed linen every 24 hours
E. wipe of the skin of sea buckthorn oil
16. The time of performing the first dressing after elective surgery on
extremities?
A. on the second day
B. on the same day
C. a week later
D. after the anesthesia
E. on the next day
17. What is refer to medical and hygienic care of the patient?
A. X-ray investigation
B. toilet of patient
C. takingof biological material for the research
D. surgery
E. resuscitation
18. What is refer to the dynamic observation of the operated extremity in
the early postoperative period?
A. circulation in the operated extremity
checking of the blood

B. control and registration of volume of infusional therapy and

dedicated patient fluid
C. measuring of intraocular pressure
D. control of blood pressure, pulse
E. thermometry
19. The toilet of uncomplicated postoperative wound includes:
A. dilution of the wound edges for the inspection
B. changing of dressings and applying of antiseptic solutions on the
wound’s edges
C. all of the above
D. wound drainage
E. injection of antibiotics around of the wounds
20. Excessive long-term immobilization of the fracture may bed a cause:
A. pseudarthrosis
B. hemarthrosis
C. interposition of the soft tissues
D. contractures
E. epiphysiolisis
21. To make it easier to remove the plaster bandage, the cut line should be
moistened with:
A. ether
B. hypertonic sodium chloride solution
C. castor oil
D. alcohol
E. turpentine
22. What should be done by the appearance of swelling and pain in the
fracture’s region after the application of circular plaster bandage:
A. injection of diuretic
B. cut the bandage in length and dilute its edge
C. apply a hot compress
D. fix the extremity in upwards position
E. injection of painkillers
23. The most frequent pulmonary complications in the postoperative
period are:
A. bronchiectasis
B. pneumonia
C. fat pulmonary embolism
D. bronchitis
E. bronchial asthma
 24. Control X-ray for the first time after the application of a plaster cast,
performed:
A. during the first day
B. in three weeks
C. after 10-14 hours
D. on 6-8 day
E. in 2-3 days
25. What is refer to the plaster immobilization:
A. cap
B. Kramer’s splint
C. spica bandage
D. sling bandage
E. longuet
26. What kind of rules of the cast application allows you to control the
blood circulation in the extremity?
A. keep free of the cast fingertips
B. providing a physiological position of the limbs
C. creating conditions for further skeletal traction
D. prevent torsion of bandage’s tours
E. immobilization of the adjacent joints
27. The position of the patient in the bed in postoperative period after the
general anesthesia?
A. the head is on the pillow
B. lower extremities lifted up
C. head turned to the side without a pillow
D. Fowler’s position
E. the patient is on the side
28. Patient may drink after general anesthesia:
A. immediately after the operation
B. in 2-3 hours
C. After 1 hour
D. in 6 hours
E. after 12 hours
29. The hyperthermia can be a cause of the next severe complication in
postoperative period:
A. cephaledema
B. pulmonary edema
C. asphyxia
D. pneumonia
E. postoperative bleeding
30. The temperature of the cooling enemas when hyperthermia occurs in
postoperative should be:
A. 10-12 degrees
B. 2-4 degrees
C. 18-20 degrees
D. 6-8 degrees
E. 14-16 degrees
31. What is allow to the alveolar ventilation with the aim of prevention of
pulmonary complications in trauma patients:
A. expiration into the reservoir with a one hole
B. hot compress on the chest
C. oxygen inhalation
D. active movements in not operated extremity
E. breathing exercises
32. What can be used to stimulate the peristalsis in the postoperative
period?
A. gentamicin
B. proserine
C. morphine
D. heparin
E. analgin
33. Early postoperative period is…. after the operation:
A. 3-5 days
B. 10-12 days
C. 1 Week
D. 2 weeks
E. 1-2 days
34. Late postoperative period is… after the operation :
A. up to 10 days
B. 2-3 weeks
C. up to 2 months
D. 4 weeks
E. 5-6 days
 35. Duration of the catabolic phase of the postoperative period?
A. 5-7 days
B. 1 day
C. up to 2 weeks
D. 2-4 days
E. 8-10 days
36. Duration of the recovery phase of postoperative period?
A. 3-5 days
B. 8-10 days
C. 1 month
D. two month
E. up to 2 weeks
37. What does allow to the tasks in the early postoperative period in
trauma patients?
A. all of the above
B. pain preventing
C. Correction of fluid and electrolyte balance, detoxication therapy
D. restoration of the cardiovascular and respiratory systems
E. bed sore prevention
38. The terms of the removing of the sutures in trauma patients?
A. 5-7
B. 18-20
C. 3
D. 12-14
E. 8-10
39. Raising of the body temperature on 1 ° C is accompanied to
increasingof the heart rate to:
A. 1-2 beats / min.
B. 3-4 beats / min.
C. 5-7 beats / min.
D. 8-10 beats / min.
E. 12-14 beats / min.
40. What should be used for the prevention of thromboembolic
complications in trauma patients?
A. anticoagulants
B. strophanthin, phenylephrine, physiological sodium chloride solution
C. oxygen therapy
D. painkillers and anticoagulants
E. horizontal position in bed, without a pillow, with a few raised legs
41. Who did first describe the preparation and technique of the cast
application?
A. Kocher
B. Dzhanelidze
C. Hippocrates
D. Pirogov
E. Mathiesen
42. Who was the first? who has used the medical plaster in practice?
A. Dzhanelidze
B. Pirogov
C. Kocher
D. Hippocrates
E. Mathiesen
43. By cast To what kind of immobilization refers the medical plaster
(gypsum)?
A. therapeutic
B. preserving
C. intermediate
D. rehabilitation
E. temporal
44. What is the chemical formula of gypsum after the roasting?
A. CaSO4 ∙ H2O
B. C2H5OH
C. CuSO4 ∙ H2O
D. CaCl2
E. HCl
45. What does lose the plaster after the roasting?
A. sulfuric acid
B. water
C. free oxygen
D. hydrogen ions
E. calcium
46. What does refer to the medicinal properties of gypsum?
A. treatment of noncurable dislocations
B. fixation of unstable fractures
C. early rehabilitation
D. reliable immobilization of the period of treatment, rest
E. treatment of habitual dislocation
47. The probe to the quality of gypsum when made the ball with a diameter
up to 2.5 cm?
A. strength
B. the smell
C. the solidification
D. humidity
E. on flowability
48. When it used the fire, the metal plate and the mirror for the checking
of quality of gypsum?
A. the solidification
B. strength
C. humidity
D. the smell
E. on flowability
49. What does refer to the rules of cast application?
A. toes or hands should be free from bandages
B. the last round of plaster bandages must be covered prior to ½ or ⅔
of the bandage width
C. extremity should be provided the to thephysiological position
D. cast must capture two adjacent joint, and when damaged shoulder,
thigh bones or joints - three
E. all of the above
50. What kind of rule of cast application may be ignored?
A. cast must capture two adjacent joint, and when damaged shoulder,
thigh bones or joints - three
B. toes or hands should be free from bandages
C. the imposition of a plaster cast should not take more than 10-15
minutes
D. dressing should be modeled without constrictions, indentations,
evenly cover without pressing limbs
E. application of a pencil on a bandage to overlay and probable
duration of withdrawal of the cast
51. That refers to the testimony of cast treatment?
A. fractures after conservative and surgical treatment
B. all of the above
C. inflammatory bone diseases (rheumatoid arthritis), joint treatment
of tuberculosis, bone osteolysis
D. treatment of congenital bone deformities (clubfoot, klishorukost)
E. after treatment with skeletal traction
52. Indications for treatment with plaster bandages are:
A. not cut cellulitis, purulent heats
B. Combined complicated fractures burns
C. frostbite
D. anaerobic infection in the wound
E. inflammation of the tendon sheath (tendovaginitah)
53. For what should be left free from the cast tips of fingers and toes?
A. to monitor the blood circulation in the injured limb
B. for possible early rehabilitation
C. for the prevention of bone fragments redislokatsii
D. for the prevention of contractures
E. to prevent prolonged compression syndrome
54. What should be assumed to be the temperature for soaking plaster
bandages?
A. 10 degrees
B. 20 degrees
C. 15 degrees
D. 5 degrees
E. 30 degrees
55. How long will harden the plaster ?
A. 5-7 min.
B. 14-16 min.
C. 2-3 min.
D. 10-12 min.
E. 20 minutes.
56. The cast is finally dry after:
A. 4 hours
B. 72 hours
C. 6-12 hours
D. 2 hours
 E. 24-72 hours
57. What measures are used in the stage of ischemia bedsores?
A. the use of proteolytic enzymes
B. blistering showdown
C. treatment with 5% solution of potassium permanganate
D. treatment with 1% alcohol solution of brilliant green
E. Skin treatment with camphor spirit
58. What kind of measures are used for pressure ulcers in stage of
superficial necrosis?
A. necrectomy
B. Skin treatment with camphor spirit
C. antibiotic
D. treatment with 1% alcohol solution of brilliant green
E. the use of proteolytic enzymes
59. What kind of drug has a local pharmacological anti-inflammatory and
anti-edema effect?
A. alcoholic chlorhexidine
B. heparin ointment
C. Skin treatment with camphor spirit
D. gel "Troxevasin"
E. dimexide
6.2 Case Studies
1. The patient ,72 y.o. in the trauma unit at skeletal traction due the
fracture of the femur. We know that he has the diabetes mellitus for many
years. Body weight reduced, dry skin, the mobility is limited. Rate the degree
of risk of development of bed sores.
A. very high
B. high
C. the danger zone
D. risk zone
E. low risk
2. During the dressing after surgery on the hand, suddenly patient has
felt nausea, a feeling of severe weakness, darkening in the eyes. Face became
pale, sweat has appeared on the skin. What kind of following measurements
should be done urgently?
A. --
B. put a patient on the couch with the lowered feet
C. put the patient in a chair
D. put a patient on the couch with uppered feet
E. put a patient on the couch with a raised head
3. The patient, 62 y.o. is in the postoperative room of the trauma unit.
The strict bed rest was appointed to him. What kind of drug will use the
nurse for the prevention of pressure ulcers?
A. 2% sodium hydrogencarbonate solution
B. 10% camphor solution of alcohol
C. 3% hydrogen peroxide solution
D. 1: 5000 solution of furacillin
E. 70% ethanol
4. Patient L., 45 y.o. treated in the trauma unit due the open fracture of
the humerus, the patient is assigned to intramuscular antibiotic. 2 hours after
the injection the patient complains of itching and redness at the injection’s
site. What kind of complication is observing?
A. infiltrate
B. phlegmon
C. abscess
D. paresis
E. allergic reaction
5. Patient L., 65 y.o. was treated in the trauma unit. Objectively: the
patient is a long time in bed. Position - passive. Detachment of the epidermis,
blisters are observed in the sacral area. What kind of drug shold be used for
the treatment.
A. iodine alcohol solution of 5%
B. ethyl alcohol 70%
C. 1% Brilliant green
D. camphor alcohol 10%
E. chlorhexidine
6. The patient 26 y.o. in the trauma unit, immediately after the surgery
has the body temperature rose to 38.2 ° C. He feels the chills, severe
weakness, headache. What kind of care must be used in the I period of fever?
A. warm the patient
B. impose thepatient with the heaters of cold water
C. disclose of the patient
D. apply an ice pack to his head
E. give a cool drink
7. Patient 38 years is in the trauma unit in the early postoperative period
(the operation was under general anesthesia). He hasn’t urination for 12
hours. The bladder catheterization should be done. Specify the solution for
the lubricationof the catheter prior to it’s insertion.
A. sterile solution of boric acid
B. sterile solution of Dekasan
C. 70% ethanol
D. a sterile solution of potassium permanganate
E. sterile glycerol
8. Female, 65 y.o. stays during 3 weeks in the traumatological
department. She is very loose, there is a long time in bed. Nurse has noticed
bubbles on the sacral region during the replacement the patient’s underwear.
What should be done?
A. cleaned with 70% ethanol
B. lubricate 5-10% potassium permanganate solution
C. lubricate the brilliant green
D. lubricated with 1% solution of salicyl alcohol
E. grease 10% camphor solution of alcohol
9. A woman with a 10-year-old boy turned to you in connection with the
fact that the child complains on the pain in the right elbow. 6 days ago, in the
ambulance the infected abrasions on the elbow were processed and
bandaged. By the examination you have determined a little cyanosis on the
right forearm and wrist, swelling of the subcutaneous veins, even with raised
extremity. What happened? How can you help this child?
A. crush syndrome. conduct hemodialysis
B. phlegmone of the upper extremity. antibiotics
C. compression of the extremity due the bandage with the blocking of
blood circulation. Loosen the bandage or change it to a new
D. elbow bursitis. Conservative treatment
E. purulent arthritis. joint’s drainage
10. It has the patient in the emergency room with the incised wound of the
palmar surface of the middle third of the right forearm. According to the
patient, the wound caused him 1.5 hours ago after the conflict with the
unknown on the street. The primary surgical debridement was performed
and primary sutures were applied. The nurse put a bandage, tied the knot the
ends of the bandage over the wound. After that the patient has injected
subcutaneously 1.0 ml of tetanus toxoid and 3000 IU antitetanus serum.
Where the mistake was made?
A. 1.0 ml of tetanus toxoid
B. it was not necessary to apply the primary sutures
C. wound debridement was performed
D. entered of toxoid subcutaneously
E. bandage was positioned over the wound
11. The patient 68, has the trophic ulcer measuring 1.5 x 2 cm necrotic
bottom skin erythema and tenderness around on the the inner surface of the
lower third of the right tibia. The ulcer was treated with an antiseptic
solution, allowed to dry, covered with a cloth ointment "Iruxol". What kind
of bandage you should apply?
A. Velpeau bandage
B. spiral bandage with excesses bandage
C. circular
D. spicate
E. turtle
12. The patient undergone to the phlebectomy on the right thigh due the
varicose veins. The sutured wound was processed with 1% solution of
iodonat and closed with napkins. What is necessary to impose a bandage on
the lower limb to secure the dressing?
A. spiral bandage with excesses bandage
B. spicate
C. sling
D. occlusive
E. Velpeau bandage
13. Patient P., 24 years, was operated due the purulent elbow bursitis. The
joint’s bag was washed with antiseptic solution, drained with napkin
moistened with hypertonic sodium chloride solution, covered with gauze.
How do you fix the dressing?
A. crusiform bandage
B. circular patch
C. turtle bandage
D. spica
E. spiral bandage with excesses bandage
14. Patient S., 36 years old, suffered during the road accident. There is a
large ruble-laceration on the outer surface of the right shoulder joint. Signs
of humerus fracture are present. What kind of dressing should be imposed as
the first aid?
A. Crusiform
B. Desault
C. turtle
D. spicate
E. circular
15. Patient S., aged 53, operated due the acute ascending thrombophlebitis
of the superficial veins on left lower limb with the localization of blood clots
in the leg and in the lower third of the thigh. What kind of physical activity
may be allowed during the first day after the operation?
A. general regime
B. strict bed rest
C. early ambulation
D. bed rest
E. half-bed rest
16. Patient K., 49 years old, underwent surgery for acute ascending
thrombophlebitis of superficial veins of the left lower extremity. During the
operation the satisfactory retrograde blood flow from the femoral vein was
not achieved. What kind of physical activity may be allowed within three
days after the operation?
A. common mode.
B. bed rest
C. half –bed mode
D. strict bed rest.
E. early ambulation
17. Patient G., 20 years, 8 days ago admitted to the trauma department
with traumatic injury of the neurovascular bundle and the humerus bone in
the lower third of the right shoulder. After surgical intervention right upper
limb is immobilized by a plaster splint. In what sequence it is advisable to
carry out change of underwear to the patient?
A. sequence does not matter
B. remove the shirt from the back, chest, dump it over his head,
successively removed from the patient, and then with a healthy hand
C. remove the shirt from the back, chest, dump it over his head,
consistent with a healthy shoot, and then with a sore hand
D. sequence: chest, back, head, the affected limb, and then healthy
E. sequence: chest, back, head, healthy limb, and then struck
18. Patient A., 38 years old, who has underwent to the resection of
stomach due the gastric ulcer, has complains on expressed excessive
salivation and bad smell of breath. What is the prevention of mechanical
parotitis due the insertion of nasogastric tube?
A. use of gentle mechanical food
B. UHF-therapy on the parotid region
C. half-alcocholic compresses on the parotid region
D. antibiotic
 E. sanitation of the oral cavity (teeth cleaning, rinsing with antiseptics)
19. Patient L., 59 years old, the 5th day after the gastric resection. During
the day complaining about the feeling of bloating and abdominal distension.
Objectively: increase of the size of the abdomen. Percussion: over all
abdomen the presence of tympanic sound that does not change when you
change the patient's position. Symptoms of peritoneal irritation is not
revealed. Auscultation: weak peristaltic noises. Indicate the most likely
complication of the underlying disease.
A. spastic bowel obstruction
B. obesity
C. flatulence
D. diffuse peritonitis
E. ascites
20. Patient D., 62 years old, is being treated at the Department of
Abdominal Surgery, on the 5th day after the gastric resection, the meteorism
was diagnosed . Carbolen was used throughout the day (3 tablets x
3 times a day) and was not effective. What are the priority measures to
eliminate such complications?
A. chill on the stomach area
B. injection of antispasmodics
C. cleansing enema
D. gastric lavage
E. gas discharge tube

7. RECOMMENDED LITERATURE
1. M. Townsend. Sabiston textbook of surgery.-16th ed

2. S.I. Shevchenko. Surgery: text-book for English medical students/S.I.Shevchenko /

-Kharkov: KSMU, 2000.-344 p.

3. A. Butyrsky. Общая хирургия (с алгоритмами ухода за хирургическими

больными ): для студентов, обучающихся на английском языке.-Симферополь:
КГМУ, 2004.-478 с.

4. O. Dronov. Lecture Course of General Surgery/ O. Dronov -K/: Medinform, 2011/-

343 p.

5. R. Kushnir. General surgery/ Lectures.-Ternopil: Ukrmedknyha, 2005.-308 p.