Nursing with surgical diseases and injuries of the abdomen

Nursingwith surgical diseases and injuries of the abdomen

This - syndrome that develops as a result of injury or acute disease of the abdomen and its organs, in which the signs are obvious complications, but the underlying disease or oiled so hidden that diagnose the underlying disease is difficult, sometimes impossible. Patients require immediate hospitalization in a specialized department for surgical care.

This set of clinical symptoms that develop when injuries or acute surgical diseases of the abdominal cavity (acute appendicitis, perforated gastric and duodenal ulcers, acute intestinal obstruction, etc..), accompanied by irritation of the peritoneum, and in cases of delay in medical care - peritonitis.

a) sudden or slow the emergence of permanent or cramping pain in the abdomen or in individual areas;b) nausea and vomiting;c) retention of gases and feces;d) limited or widespread muscle tension anterior abdominal wall;e) positive symptom of peritoneal irritation Shchetkin-Blumberg.

1) in all acute diseases and injuries of the abdomen, and even suspected them, urgent need to hospitalize the patient in the surgical ward nearest hospital!

2) before transporting the patient to the hospital should be put to bed, prohibit eating and drinking.

3) is strictly prohibited in these cases to use painkillers or antispasmodic drugs because their effects may mask the true clinical picture of the disease, which negatively affect the reliability of diagnostic and surgical care.

Peritonotis - acute nonspecific inflammation parietal, visceral peritoneum, which is accompanied by a local, or general symptoms, impaired functions of various organs i systems.

Peritonotis occupies the first place among the causes of death from acute surgical diseases of organs of the abdominal cavity. Mortality from peritonitis depends on its form, causes and other factors i ranges from 10% to 70% (V.A. Popov, 1985; O.O. Shalimov, 1991, and others.).

For etiolohgy:1. Primary 2. SecondaryPrimary peritonitis caused by ingestion of microflora in the peritoneum by hematogenous or limfogenous. Secondary peritonitis - a complication of various surgical diseases and injuries   

For reasons of secondary peritonotis:1. Incendiary - caused by the proliferation of the inflammatory process in the organs and tissues of the

abdominal cavity and extraperitoneal space. 2. Traumatic 3. Postoperative 4. perforated For stages:1. Reactive 2. Toxic. 3. Terminal.

The nature of fluid: 1. Serous 2. Fibrinous 3. Festering 4. Putrid 5. Hemoragic6. Mixed.

The nature mikroflory:1. Aerobic (staphylo-streptococcus, intestinal bacillus, and

others.)2. Anaerobic (bacteroid, kokkouse and others.). 3. Mixed (association of various microorganisms).

   Over the course of:1. Acute 2. Chronic 3. Slack.

Most common: Limited - when inflammation of other parts distinguishable

from the peritoneal cavity anatomic structures - the greater omentum, bowel loops. This happens when had good reactivity, low virulentness of the mikroflora. An example would be infiltrate appendicitis, holecystitis, pankreatitis, abscesses various locations.

Unlimited - when the inflammatory process of the family could freely distributed on the peritoneal cavity.

Depending on what, in which areas he peritoneal cavity propagating distinguished: local, diffuse, diffuse, general peritonitis. ? 1. LOCAL. Distributed 1 of 9 anatomic areas of the anterior abdominal wall, adjacent to the family of peritonitis: when appendicitis. - in the right iliac plot: when holecystitis - the right infracostalis plot. 2. DIFFUSE. The inflammatory process includes not only the peritoneum in the family of origin, but also extend to adjacent areas (but not more than 3 anatomic plot). For example, when appendicitis., gynecological peritonitis in the inflammatory process involves the pelvic peritoneum, the right, the left iliac and suprapubic segment.

3. POURED. The inflammatory process spreads more than 3 but not more than 6 anatomical sites. For example, signs of inflammation are found in the lower floor of the peritoneal cavity with appendicitis, sigmoid perforation, intestinal occlusion.

4. GENERAL. Manifestations of inflammation are all over peritoneal cavity.

    When peritonitis one should underline flow

degrees course: I - light degree; II – medium; III-A – severe; III-B - extra severe; IV - terminal.

Reactive (up to 24 h).

Toxic (24-72 h).

Terminal (after 72 hours).

1. Slightly growing pain in the abdomen.   2. Nausea, vomiting, gases delays   3. Change of shape of the abdomen, first tense, then      swollen.

Pozytyvni symptoms Schotkina-Blumberg

Razdolsky Voskresensky Kyulenkampfa

Decreasing of “hepatic percussive area" (metal tympanic sound), "deathly silence" (disappearance of peristaltic noises), with Loteyssens’ symptom (auscultation abdominal listen respiratory and cardiac murmurs).

Toxic scissors: puls growth - lowering rate of the temperature.

Plain radiographyabdominal cavity Kloybers’bowl.

Scheme of formation Kloybers’bowls.

All patients with acute peritonitis refer to the surgical department.

It is strictly forbidden to introduce drugs, analgesics, antispasmodics!

Preoperative preparation should be individual and not last more than 2 hours. In patients with very advanced 4-6 hours

1. Eliminating causes (sources) peritonitis.2.Vydalennya sanation fluid and peritoneal cavity.3.Dekompresiya bowel drainage peritoneal cavity.

ACUTE appendicitis

Clinical classification (V.I. Kolesov, 1959).   I. Acute simple (superficial) appendicitis: a) without general clinical signs and severe, rapidly disappearing, local manifestations;b) with minor general clinical signs and pronounced local manifestations of the disease.   II. Destructive appendicitis (abscess, gangrenous, perforated)a)clinical disease of moderate severity and symptoms of local peritonitis;b)b) with severe clinical signs and local peritonitis.

   III. Complicated appendicitis:a)appendiceal infiltrate;b)b) with appendiceal botch (abscess);c)c) with diffuse peritonitis;d)d) other complications (pylephlebitis, sepsis).

Pathologic classification of acute appendicitis (A.I. Abrikosov, 1957). I. Catarrhal (superficial) appendicitis primary affect. II. Phlegmonous appendicitis: 1. Simple phlegmonous appendicitis. 2. Abscess-ulcerative appendicitis. 3. Apostematoze appendicitis: a) without perforations; b) with perforation.III. Gangrenous appendicitis (primary, secondary) a) without perforation; b) with perforation.   

.    Clinical symptoms and subjective

symptoms

1. Stomachache2. Diarrheal syndrome3. Common symptoms of the disease

1. Restriction of movement in the right hip joint at the course, supports the right hand iliac area, mostly in bed lying on his right side with slightly bent at the hip joint right foot.

2. Tongue often varying degrees of dry and coated with white or gray coating.

3. Body temperature is moderately high (up to 38 0C), rectal temperature - increased by more than one degree of fever (Lenanders’ symptom).

4. Pulse - adequate fever, tachycardia.   

Objektive features (general)

Objektive features (Local)

1. Restrictions breaths anterior abdominal wall in the right iliac region and the right half of the abdomen.2. Hyperstezia skin in the right iliac region.3. Muscle tension anterior abdominal wall in the right iliac region and the right half of the abdomen with superficial palpation, often in combination with high sensitivity and moderate pain.4. Severe local pain on deep palpation in the right iliac region, sometimes radiating to the paraumbilikal and epygastric area.5. Weak peristaltic noises on auscultation abdomen.6. Positive appendicular symptoms.7. Positive symptoms of peritoneal irritation

Atypical forms of acute appendicitis

1. Lumbar and Retroperitoneal.2. Pelvic.3. The medial (mezotseliakal).4. Left-side.

Phases of clinical course-Acute appendicitis in children-Acute appendicitis in the elderly-Acute appendicitis in pregnancy

appendicular perforated diffuse peritonitisappendicular infiltrateappendiceal abscesspylephlebitisliver abscessessepsis

Laboratory and instrumental diagnosis methodTo verify the diagnosis "acute appendicitis" is often used

in clinical practice:  - complete blood count - consider most distinctive

change neutrophilic leukocytosis with a more or less pronounced shift leukocyte formula (appearance of young

forms of neutrophilic leukocytes);    - urinalysis - normal in simple and signs of intoxication (protein, leukocytes) destructive with acute appendicitis.

  Also, for verification of acute appendicitis in some cases you can use survey radiographs of the abdomen, measurement of contact skin temperature or termograms of anterior abdominal wall, an ultrasound of the abdomen, celiocentesis, laparoscopy.

   Differential diagnosis Right-sided basal pleuropneumoniamyocardial infarctionintercostal neuralgiaAcute gastritisphlegmon of the stomachAggravation of peptic ulcerAcute cholecystitisAcute pancreatitisAcute intestinal obstructionAcute mesenteric thrombosisAcute diverticulitis (Meckel)Acute diseases of the female internal reproductive organs (ovarian apoplexy, broken ectopic pregnancy, ovarian cysts distortion, sharp adnexitis, endometritis, pelvioperitonit)Urinary tract (renal colic, pyelonephriti).

 TREATMENTConservative treatment is indicated only when appendiceal infiltrate and includes : 1) restricted driving mode;2) full high-calorie diet with the exception of the intake of foods rich in fiber;3) cold on the right iliac area with existing local signs of peritoneal irritation (0.5-1.5 days), liquidating the past - heat (hot water bottle, UHF)4) complex, the generally accepted principles of antibiotic therapy (preferably parenteral), directed by colonic flora;5) perirenal novocaine blockade of antibiotics a day (3-5 per course)6) detoxification infusion therapy (osmoterapiya, stimulation of diuresis in the early days)7) the stimulation of the body's defenses.   If a positive result of such treatment appendicular infiltrate gradually dissolves (average 1-2 weeks), during this period the volume of conservative treatment adequately reduced. After the elimination of clinical signs of the patient discharged from the hospital with the recommendation within 2-4 months required to perform appendectomy in a planned manner.

Surgical treatment1. Appendectomy.2. Disclosure of appendiceal abscess3. Operation about appendiceal peritonitis

appendectomy

appendix bed drainage

.    appendicular infiltrate Subjective symptoms

1. Moved one attack of acute appendicitis a few days ago with subsequent improvement in the general condition2. Moderate, slight constant pain in the right iliac region, which can be slightly strengthened by movement and coughing

Objective signs: 1. grade body temperature (up to 38,0-38,50 C) 2. adequate body temperature Tachycardia 3. in the right iliac region (or other, depending on the location and position

of the appendix in the background of the patient expressed varying degrees of tension in the muscles of the abdominal wall and inflammatory signs of peritoneal irritation palpable determine tumor formation of irregular shape with more or less clear outline, not quite smooth surface, tight, little or immobile, painful, ranging from 3-4 to 10-12 cm, the same tumor formation can be determined by vaginal or rectal examination

4. moderate leukocytosis with a slight shift of the leukocyte formula and increased ESR.

Therapeutic tactics

   Conservative treatment includes restricted driving mode;Full high-calorie diet with the exception of a diet of foods rich in fiber; cold on the right iliac area with existing local signs of peritoneal irritation (0.5-1.5 days), liquidating the past - heat (hot water bottle, UHF) complex, antibiotic therapy (preferably parenteral), directed by colonic flora; perirenal novocaine blockade of antibiotics a day (3-5 per course), detoxification infusion therapy (osmoterapiya, stimulation of diuresis in the early days), stimulation of the body's defenses.

   If a positive result of such treatment appendicular infiltrate gradually dissolves (average 1-2 weeks), during this period the volume of conservative treatment adequately reduced. After the elimination of clinical signs of the patient discharged from the hospital with the recommendation within 2-4 months required to

perform appendectomy in a planned manner.    

appendiceal abscess

Signs: 1 amplification and spread of local pain (subjectively and objectively)2 deterioration of general condition (fever, malaise, intoxication)3 hectic body temperature at hourly measurements, sometimes fever4 appearance or growth characteristics of peritoneal irritation in the area of infiltration5 may appear symptom fluctuations palpation infiltrate through the anterior abdominal wall or vaginal (rectal) study6 marked increase in white blood cell count and leukocyte formula shift7 signs of abscess abdominal ultrasound examination

Chronic appendicitisclassification1. Primary - pathological changes in the appendix develop gradually without signs of acute attacks. 2. Secondary: - residual (residual) - pathological changes appear after an attack of acute appendicitis, appendiceal infiltrate, appendiceal abscess; -recurrent - if it does occur repeated acute attacks.

Clinical symptoms   Subjective symptoms: - Of past acute appendicitis (not operated), appendicular infiltrate (abscess) - Pain in the right iliac region is very diverse character in the beginning, due to eating, physical activity of the patient, periodicals, intensity;-Variable, moderate (or minor) signs of the passage of intestinal contents, intestinal motility;-No signs of inflammation .   Evidence: - Pain on deep palpation in the right iliac region (in the area of location of the appendix) - The absence of local signs of inflammation and signs of peritoneal irritation;- Possible (not pathognomonic) positive appendiceal symptoms

1. Acute cholecystitis easy.2. Acute uncomplicated destructive of local

nevidmezhovanym peritonitis.3. Acute destructive cholecystitis complicated: a) bile

peritonitis (without visible perforation), b) ruptured bile peritonitis in para-vezykal infiltrate, d) paravezykal abscess, e) jaundice, e) septic cholangitis, g) acute pancreatitis.

4. Most surgeons destructive acute calculous cholecystitis is classified (called) as acute obstructive cholecystitis

Clinical classification of acute cholecystitis

gallbladder calculus

It is almost always abdominal catastrophe!

Acute pancreatitis –inflammation of the pancreas

International classification of acute pancreatitis I. Acute pancreatitis: a) light b) severe.

II. Acute pancreatitis Acute interectitsial fluid accumulation (in the tissue of the pancreas and parapankreatychniy tissue).III. Necrotizing pancreatitis: a) sterile b) infected.IV. Genuine pancreatic cyst.V. Pancreatic abscess.1.Clinico-anatomical forms: a) edematous pancreatitis (pancreatic necrosis abortive), b) fatty pancreonecrosis c) hemorrhagic necrotizing pancreatitis.2. Distribution necrosis: a) local (focal) lesions gland b) subtotal lesions gland c) total defeat cancer.3.Flow: a) abortion b) progressive.4. Periods disease: a) the period of hemodynamic disorders and pancreatic shock, b) the period of functional impairment of parenchymal organs c) period dystrophic and septic complications.

The feature of clinic acute pancreatitis is a paradoxical relationship

Intensity functional features (pain, vomiting, retention of feces and gases).

Early manifestations of common features (shock, collapse, fear of change facial features, local cyanosis, shortness of breath, cold sweat, pulse, temperature).

Relative poverty physical symptoms:

Review - bloating, palpation - soft belly, percussion - tympanitis, effusion, auscultation - quietly .

The access through lig. hepato-gastricum

The access through root of lumbar-colon

ripples

The access through the provision of lumbar-colon greater omentum

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