Surgical Paper

Kai Tiaki : the journal of the nurses of New Zealand, Volume XXII, Issue 3, 1 July 1929, Page 116

Surgical Paper

Question : 1. — What complications may arise after tonsillectomy, and what immediate treatment would you adopt for them? 1. Asphyxia. Treatment: Place patient on 'side, tongue well forward, jaw pushed hard forward. Sponge-holders with swab to swab away vomit and mucus m mouth. A finger passed to back of mouth and into phaxym will remove obstruction there. 2. Shock. Treatment: Bed warm, extra blankets, hot water bottles, well protected, placed around patient. Raise foot of bed on blocks. Administer one pint normal saline, per rectum. 3. Haemorrhage. Reactionary or Secondary. Treatment: Place patient m recumbent position, one pillow. Give morphine gr. 1/6 hypodermically. Ice rack at root of neck and ice bag over heart. Apply pressure to fossa by passing sponge holders with swab on to back of mouth. The swab may be soaked with adrenalin, hydrochloride 1-1000, or tannic acid, to contract blood vessels. Keep patient reassured and quiet by working quickly and confidently. 4. Earache. Treatment: Place warm oil m meatus, hot water bottle as foment over car. 5. Broncho-Pneumonia or Chec': Affections. Treatment: Place m position easiest

for patient to breathe, semi-recumbent, watching* for dyspnoea. Linseed or antiphlogistine plaster to affected side. 6. Ear Affections. Otitis Media Mastoiditis. Treatment: Watch for symptoms of pain. Rise m temperature or pulse. Notify doctor immediately. Place hot fomentations over ear. Question: 2.— Describe the nursing of a case of empyema following operation. 2. The Room: Nurse patient m bright, sunny room, with shades which can be drawn, and have an abundance of fresh air. Position: Owing to having a local or very light anaesthetic, he is out of anaesthetic almost as soon as operation is completed, and may be propped into position immediately. Nurse m upright position with bolster under knees and turned to the side of the wound so that full drainage may be accomplished. Sleep: Symptoms of pain and difficult breathing having been alleviated, the patient should sleep well at night, but if he does not. sponging, changing position, and dressing wound should produce sleepiness. A sedative such as Dover's pulv. gr. X or morphine gr. 1-6 may be necessary for the first night. Diet: Light nourishing diet is needed and copious fluids are indicated. Wound: A drain will be inserted into wound, and for the first 24 hours a suction apparatus may be fitted to this to draw off pus,

The dressing is changed four-hourly or oftener. Care must be taken that a large safety pin is passed through drainage tube and dressing packed under it to prevent tape slipping into wound. The tube is changed for a smaller sized one m about seven days, and this latter is removed, boiled and reinserted at each dressing. When the discharge is lessening this tube is removed and a rubber dam drain inserted. This remains until discharge has ceased, the object of all three being to ensure the cavity granulating up from the bottom. Encourage the patient to cough whilst doing the dressing to evacuate the pus. Strict asepsis whilst doing dressing is essential. Guard against pocketing of pus by watching position of patient, and condition of wound. Pass a sterile catheter gently into wound, and probe with it to assist pus to escape. Lung Exercise: To assist expansion oi lung exercises are started as soon as .the patient is strong enough. Forcing air by blowing through a tube from one jar to another will assist this. For a child a good whistle or trumpet will achieve the same object. Convalescence: A good bracing climate, tonics, including Cod Liver Oil and plenty of fresh air and sunshine are essential. General Nursing: Includes attention to back and sponging eight-hourly. Securing an evacuation of bowels daily, seeing sufficient quantity of urine is passed daily, care and attention to .mouth and teeth. Keep patient contented and happy and interested. Question : 3. — Describe the nursing of a case of suppuration m the knee joint. Patient nursed m Hat bed with knee m (1) I homas knee splint; (2) Padded back splint or box splint. The object being to keep part at rest. Pressure points would be well padded with cotton wool, and the whole splint firmly slung with bandages, and bandaged and strapped. Pain: There is always some pain m

these cases, and this would be alleviated by hot fomentations four-hourly or twohourly. Sedatives such as Dover's pow(U r gr. x, or Aspirin gr. x, may be needed m severe cases to induce sleep. Wound: Hot foments two-hourly and four-hourly or antiphlogistine plaster placed over sterile dressing. Using full aseptic precautions. As pain and discharge lessens dry dressing changed when necessary is used. General Nursing: Includes attention to bowels and bladder. Good nourishing diet with tonics (as man}' of these cases are T.B. m origin) to build up resistance. 11 yd bathing and general cleanliness. Elderly people must be kept well propped up so that there is no risk of hypostatic pneumonia. Convalescence: Is slow and knee must be kept immobilised for some time after patient is allowed up. To this end a caliper with straps across the knee joint is made and fitted and patient wears this for some weeks. Question: 4. — Give the signs and describe the treatment of post-operative dilatation of the stomach : Signs: (1) Persistent vomiting; (2) Enormous distension of abdomen, stomach outline well defined; (3) Distressed breathing, entirely thoracio, hurried and shallow; (4) Weak pulse, rapid and thready temperature, balling to subnormal as prostration increases ; (6) Pale anxious face, knees drawn up and patient acutely distressed. Treatment: Treat for shock immediately. Extra warmth, bed raised at foot. Salines got ready for both subcutaneous and rectal infusion. Stomach wash out is given immediately. The following things prepared for the doctor : — - Tray, containing: — Stomach tube and lubrication jug of soda bicarbonate solution, one ounce of soda bicarb, to each pint of water. Receptacle for return of contents. Swabs and kidney tray, mackintosh to protect patient and bed. Gown for doctor. Stimulants such as brandy zii for injection or infusion per rectum. Camphor m oil my intromuscularly stry-

chnine gi 1-20. Hypodermically should be m readiness m case the doctor requires them. Question : 5. — Give the most common causes of restlessness, and the loss of sleep within forty-eight hours of operation, and describe the nursing methods to alleviate this condition : Causes: (1) Vomiting; (2) Flatulence, causing* distension; (3) General discomfort due to strange surroundings, position patient has to adopt for special operations; (4) Position of needles injected subcutarieously ; (5) Discomfort caused by catheter m rectum m a continuous rectal infusion ; (6) Pain round wound due to distension ; (7) Dressing pulling on sutures ; (8) Discomfort due to heat rumpled drawsheet ; (9) Inability to pass urine. Treatment : 3 and 8. Sponge patient with warm water, change night dress and put on a fresh clean one, change drawsheet, see that it was free from wrinkles. Modify position as much as allowed, and shake pillows and replace them comfortably. Have knees flexed m abdominal operations sufficiently to take strain off abdomen, limbs involved m operation elevated and supported on pillows. Place hot water bottle at patient's feet, and see that she was comfortably warm but not unduly so, and treat other conditions. 1. Vomiting: (1) Soda bicarb, m warm water will clean stomach out, and vomiting should cease (2) lodine m ii m one ounce water; (3) Iced black coffee will also relieve this condition. 2. Flatulence: (1) Soda Bicarbonate with essence of pepperment m ii m five ounces water ; (2) Bismuth and soda z ss (half an ounce) ; (3) Carminative mixture containing ginger. 4. Position of Subcutaneous Needles: Remove and boil and re-insert (if necessary) m a different place, preferably where there is much loose tissue. Leave out for few hours if allowed. (Full aseptic precautions necessary).

5. Discomfort Caused by Catheter m Rectum: Remove and leave out for four hours, provided patient is taking fluids per mouth. Re-insert at that time, seeing that infusion is correct temperature (110 deg. F. to 115 deg. F.). Pass flatus tube to allow ain T flatus to escape. 6. Pain Round Wound: Would automatically disappear when flatulence relieved. 7. Dressing Pulling on Sutures: In a septic wound dressing could be changed. In an aseptic wound this condition would be a small matter if patient were otherwise comfortable, and it would be wiser not to torch the wound. 9. Inability to Pass Urine: One could try such local measures as hot packs to abdomen, hot drink, irrigation of pubes with warm water, turning on taps. If these fail catherisation with strict asepsis may be performed, should relieve patients immediately. Question : 6. Describe the location m the body of the following: — (a) Appendix. (b) Antrum of Highmore. (c) Astragalus. (d) Sigmoid. (c) Pancreas. 6. A. Appendix: Is at the blind end of the caecum which is the first portion of large bowel, and commences from ilebvaecal valve. Caecum is about three inches m length, and lower end is blind portion. 6. Antrum of Highmore: Is cavity m each superior maxilla just above' the canine teeth m upper jaw. It communicates with nasal cavity. C. Astragulus: Is bone with which tibia and fibula articulate to form ankle joint. D. Sigmoid: Ts the last portion (all but three inches forming rectum) of large intestine, and as its name implies is S shaped. Forms part of the pelvic colon.

E. Pancreas: Has head and tail. Head commences at cardiac end of stomach, tail runs along just beneath stomach. Its duct enters duodenum at duodenal papilla and it is just m front and above the transverst colon. The head is just above splenic flexune of colon. Spleen lies adjacent to it.

* * * * EXAMINER'S COMMENTS ON SURGICAL PAPER, JUNE, 1929. I consider the surgical papers on the whole show a definite general improvement m the educational standard of the nurses since I last carried out the examination. The knowledge displayed showed also some definite improvement, but as usual the standard varies very considerably. There were some really excellent papers though often spoilt by one weak question, very often the anatomical one. The first question was on the whole well answered, but.patchy. The second question was almost invariably very well answered. The third question was poorly answered, the need for efficient and complete rest and nursing from that point of view being generally insufficiently stressed. The fourth question was not well answered —many of the nurses hav-

ing no knowledge whatever of the condition. The fifth question was fairly well answered, though often showing surprising lack of power of observation m the most frequent occurrences m a nurse's life. The sixth question was not answered by man)' nurses, preference being given to the seventh. The sixth was badly answered on the whole, and the seventh moderately answered. The instruction of the nurses seemed to have been very good, and the details of nursing treatment were obviously well known to most of the nurses. The best paper is well worthy of publication, and though not so full m many questions as some of the others, was easily the best balanced and most free from errors. A general idea of the practical nursing' proficiency of the different candidates m say, three classes, would be of great value to the examiner m deciding" the border line papers giving him the power of swaying the marks by, say 3 or 4, m either direction if the report re general work and efficiency warranted it. It seems a pit}' to fail a nurse poor at examinations when just on the borderline if m her work she was more than usually efficient.