• Before and after each patient contact

• Before handling food and medications

• After coughing, sneezing, or blowing your nose

• After using the toilet

Improper handling of linen results in the transfer of pathogenic organisms through direct contact with the health care provider's clothing and subsequent contact with the patient, patient care items, or other materials in the care environment. Proper linen handling is such an elementary procedure that, in theory, it seems almost unnecessary to mention; however, it is a procedure so frequently and carelessly ignored that emphasis is justified. All linen, whether clean or used, must never be held against one's clothing or placed on the floor. The floors of a health care facility are considered grossly contaminated, and, as such, any article coming in contact with the floor is also contaminated. Place all dirty linen in appropriate laundry bags. Linen from patients having infectious or communicable diseases must be handled in a special manner. Such procedures are discussed in the Nursing Procedures Manual, under the section "Isolation Procedures."

Isolation technique, a medical aseptic practice, inhibits the spread and transfer of pathogenic organisms by limiting the contacts of the patient and creating some kind of physical barrier between the patient and others. In isolation techniques, disinfection procedures are employed to control contaminated items and areas. For purposes of this discussion, disinfection is described as the killing of certain infectious (pathogenic) agents outside the body by a physical or chemical means. Isolation techniques employ two kinds of disinfection practices, concurrent and terminal. Concurrent disinfection consists of the daily measures taken to control the spread of pathogenic organisms while the patient is still considered infectious. Terminal disinfection consists of those measures taken to destroy pathogenic organisms remaining after the patient is discharged from isolation. There are a variety of chemical and physical means used to disinfect supplies, equipment, and environmental areas, and each facility will determine their own protocols based on recommendations of an Infection Control Committee.

Surgical Aseptic Technique

As used in this discussion, surgical aseptic technique is the term used to describe the sterilization, storage, and handling of articles to keep them free of pathogenic organisms. The following discussion will address the preparation and sterilization of surgical equipment and supplies, and the preparation of the operating room for performing a surgical procedure. It should be noted that specific methods of preparation will vary from place to place, but the basic principles of surgical aseptic techniques will remain the same. This discussion will present general guidelines, and individual providers are advised to refer to local instruction regarding particular routines of a specific facility.

Before an operation, it is necessary to sterilize and keep sterile all instruments, materials, and supplies that come in contact with the surgical site. Every item handled by the surgeon and his or her assistants must be sterile. The patient's skin and the hands of members of the surgical team must be thoroughly scrubbed, prepared, and kept as aseptic as possible.

During the operation, the surgeon, surgeon's assistants, and scrub corpsman must wear sterile gowns and gloves and must not touch anything that is not sterile. Maintaining sterile technique is a cooperative responsibility of the entire surgical team. Each member must develop a surgical conscience, a willingness to supervise and to be supervised by others regarding the adherence to standards. Without this cooperative and vigilant effort, an otherwise successful surgical procedure may result in a complete failure if a break in sterile technique goes unnoticed or is not corrected.

Basic Guidelines

To assist in maintaining the aseptic technique, the following principles must adhere to all members of the surgical team:

• All personnel assigned to the operating room must practice good personal hygiene. This includes daily bathing and clothing change.

• Those personnel having colds, sore throats, open sores, and other infections should not be permitted in the operating room.

• Proper operating room attire, which includes scrub suits, gowns, head coverings, and face masks, should not be worn outside the operating room suite. If such occurs, change all attire before re-entering the clean area. (The operating room and adjacent supporting areas are classified as clean areas.)

• All members of the surgical team having direct contact with the surgical site must perform the surgical hand scrub before the operation.

• All materials and instruments used in contact with the site must be sterile.

• The sterile gowns worn by surgeons and scrub corpsmen are considered sterile from shoulder to waist, including the gown sleeves. Only the front of the gown is considered sterile.

• Sterile surgical gloves are considered aseptic. If they are torn, punctured, or have touched an unsterile surface or item, they are considered contaminated.

• The safest, most practical method of sterilization for most articles is steam under pressure.

• Label all prepared, packaged, and sterilized items with an expiration date.

• Use articles packaged and sterilized in cotton muslin wrappers within 28 calendar days.

• Use articles sterilized in cotton muslin wrappers and sealed in plastic within 180 calendar days.

• Unsterile articles must not come in contact with sterile articles.

• Make sure the patient's skin is as clean as possible before a surgical procedure.

• Take every precaution to prevent contamination of sterile areas or supplies by airborne organisms.

Methods of Sterilization

Sterilization refers to the complete destruction of all living organisms, including bacterial spores and viruses. The word sterile means free from or the absence of all living organisms. Any item to be sterilized must be thoroughly cleaned mechanically or by hand, using soap or detergent and water. When cleaning by hand, apply friction to the item by using a brush. After cleaning, thoroughly rinse the items with clean, running water before sterilization. The appropriate sterilization method is determined according to how the item will be used, the material of which the item is made, and the sterilization methods available. Physical methods of sterilization comprise moist heat and dry heat. Chemical methods include gas and liquid solutions.

Physical Methods - Steam under pressure (autoclave) is the most dependable and economical method of sterilization. It is the method of choice for metalware, glassware, most rubber goods, and dry goods. All articles must be correctly wrapped or packaged so that the steam will come in contact with all surfaces of the article. Similar items should be sterilized together, especially those requiring the same time and temperature exposure. Articles that will collect water must be placed so the water will drain out of the article during the sterilization cycle. A sterilizer should be loaded in a manner that will allow the free flow of steam in and around all articles. Each item sterilized must be dated with the expiration of sterility. Sterilization indicators must be used in each load that is put through the sterilization process. This verifies proper steam and temperature penetration.

The operating instructions for a steam sterilizer will vary according to the type and manufacturer. There are a number of manufacturers, but there are only two types of steam under pressure sterilizers. They are the downward displacement and the prevacuum, high-temperature autoclave.

In the downward (gravity) displacement autoclave, air in the chamber is forced downward and out of the bottom discharge outlet as pressurized steam enters from the top of the chamber. The temperature in the sterilizer gradually increases as the steam heats the chamber and its contents. The actual timing does not begin until the temperature is above 245 degrees F (118 degrees C).

The prevacuum, high-temperature autoclave is the most modern and economical to operate and requires the least time to sterilize a single load. By use of a vacuum pump, air is extracted from the chamber before admitting steam. This prevacuum process permits instant steam penetration to all articles and through all cotton or linen dry goods. The sterilization time is reduced to 4 minutes. The temperature in the chamber is rapidly raised and held at 274 degrees F (134 degrees C). Timing the cycle is done automatically.

If the temperature is increased, the sterilization time may be decreased. The following are some practical sterilization time periods:

• 3 minutes at 270°F (132°C)

• 8 minutes at 257°F (125°C)

• 18 minutes at 245°F (118°C)

All operating rooms are equipped with highspeed (flash) sterilizers. Wrapped, uncovered, opened instruments placed in perforated trays are "flash" sterilized for 3 minutes at 270 degrees F (132 degrees C). Sterilization timing begins when the above temperature is reached, not before.

The use of dry heat as a sterilizing agent has limitations. It should be restricted to items that are unsuitable for exposure to moist heat. High temperatures and extended time periods are required when using dry heat. In most instances, this method often proves impractical. The temperature must be 320 degrees F (160 degrees C), and the time period must be at least 2 hours.

Chemical Sterilization - Only one liquid chemical, if properly used, is capable of rendering an item sterile; that chemical is glutaraldehyde. The item to be sterilized must be totally submerged in the glutaraldehyde solution for 10 hours. Before immersion, the item must be thoroughly cleansed and rinsed with sterile water or sterile normal saline. It should be noted that this chemical is extremely caustic to skin, mucous membranes, and other tissues.

The most effective method of chemical sterilization presently available is the use of ethylene oxide (ETO) gas. ETO gas sterilization should be used only for material and supplies that will not withstand sterilization by steam under pressure. Never gas sterilize any item that can be steam sterilized. The concentration of the gas and the temperature and humidity inside the sterilizer are vital factors that affect the gas sterilization process.

ETO gas sterilization periods range from 3 to 7 hours. All items gas sterilized must be allowed an aeration (airing out) period. During this period, the ETO gas is expelled from the surface of the item. It is not practical here to present all exposure times, gas concentration, and aeration times for various items to be gas sterilized. When using an ETO gas sterilizer, it is important to be extremely cautious and to follow the manufacturer's instructions carefully.

Preparation of Supplies for Autoclaving

• Ensure that all articles to be sterilized are clean and in good condition and working order.

• Wrap instruments and materials to be autoclaved in double muslin wrappers or two layers of disposable sterilization wrappers.

• When muslin wrappers are routinely used, launder them after each use and carefully inspect them for holes and tears before use.

• When articles are placed in glass or metal containers for autoclaving, place the lid of the container so the steam will penetrate the entire inside of the container.

• The contents of a linen pack are arranged in such a way so the articles on top are used first.

• Label every item that is packaged for sterilization to specify the contents and expiration date.

• Do not place surgical knife blades and suture materials inside linen packs or instrument trays before sterilization.

Instruments

• Wash each instrument after use with an antiseptic detergent solution. When washing by hand, pay particular attention to hinged parts and serrated surfaces. Rinse all instruments and dry them thoroughly.

• Use an instrument washer/sterilizer, if available, to decontaminate instruments and utensils following each surgical procedure.

• Following cleaning and decontamination, leave hinged instruments unclamped and wrapped singly or placed in trays for resterilization.

Glassware

• Inspect all reusable glassware for cracks or chips.

• Wash all reusable glassware with soap or detergent and water after use and rinse it completely.

• When preparing reusable glass syringes:

  • Match numbers or syringe parts.

  • Wrap each plunger and barrel separately in gauze.

  • Wrap each complete syringe in a double muslin wrapper.

• When glassware, tubes, medicine glasses, and beakers are part of a sterile tray, wrap each glass item in gauze before placing it in the tray.

 Suture Materials

Suture materials are available in two major categories: absorbable and nonabsorbable. Absorbable suture materials can be digested by the tissues during the healing process. Absorbable sutures are made from collagen, an animal protein derived from healthy animals, or from synthetic polymers. Nonabsorbable suture materials are those that effectively resist the enzymatic digestion process in living tissue. These sutures are made of metal or other inorganic materials. In both types, each strand of specifically sized suture material is uniform in diameter and is predictable in performance.

Modern manufacturing processes make all suture materials available in individual packages, presterilized, with or without a surgical needle attached. Once opened, do not resterilize either the individual package or an individual strand of suture material. The only exception to this rule involves the use of surgical stainless steel. This material is often provided in unsterile packages or tubes. Individual strands or entire packages must be sterilized before use.

Rubber Latex Materials

• Rubber tubing is to be washed in an antiseptic detergent solution.

• Pay attention to the inside of the tubing. Rinse all tubing well and place it flat or loosely coiled in a wrapper or container.

• When packing latex surgical drains for sterilization, place a piece of gauze in the lumen of the drain. Never resterilize surgical drains.

• Rubber catheters bearing a disposable label must never be resterilized.

• Sterile disposable surgeon's (rubber) gloves are for one time use only and are never resterilized.

Handling Sterile Articles

When you are changing a dressing, removing sutures, or preparing the patient for a surgical procedure, it will be necessary to establish a sterile field from which to work. The field should be established on a stable, clean, flat, dry surface. Wrappers from sterile articles may be used as a sterile field as long as the inside of the wrapper remains sterile. If the size of the wrapper does not provide a sufficient working space for the sterile field, use a sterile towel. Nothing but sterile articles and supplies are placed on this field. Once established, the field is touched only by those persons who have donned sterile gloves. The following basic rules must be adhered to:

• An article is either sterile or unsterile. There is no in-between. If there is doubt about the sterility of an item, consider it unsterile.

• Any time the sterility of a field has been broached, the contaminated field and setup must be replaced.

• Do not open sterile articles until they are ready for use.

• Do not leave sterile articles unattended once they are opened and placed on a sterile field.

• Do not return sterile articles to a container once they are removed from the container.

• Never reach over a sterile field.

• When pouring sterile solutions into sterile containers or basins, do not touch the sterile container with the solution bottle. Once opened, bottles of liquids must be entirely used when first poured. If any liquid is left in the bottle, discard it.

• Never use an outdated article. Unwrap it, inspect it, and if reusable, rewrap it in a new wrapper for sterilization.

Surgical Hand Scrub

The purpose of the surgical hand scrub is to reduce resident and transient skin flora (bacteria) to a minimum. Resident bacteria are often the result of organisms present in the hospital environment. Because these bacteria are firmly attached to the skin, they are difficult to remove. However, their growth is inhibited by the antiseptic action of the scrub detergent used. Transient bacteria are usually acquired by direct contact and are loosely attached to the skin. These are easily removed by the friction created by the scrubbing procedure.

Proper hand scrubbing and the wearing of sterile gloves and a sterile gown provide the patient with the best possible barrier against pathogenic bacteria in the environment and against bacteria from the surgical team. The following is the generally accepted method for the surgical hand scrub:

• Before beginning the hand scrub, don a surgical cap or hood that covers all hair, both head and facial, and a disposable mask covering your nose and mouth.

• Using approximately 6 ml of antiseptic detergent and running water, lather your hands and arms to 2 inches above the elbow. Leave detergent on your arms and do not rinse.

• Under running water, clean your fingernails and cuticles, using a nail cleaner.

• Starting with your fingertips, rinse each hand and arm by passing them through the running water. Always keep your hands above the level of your elbows.

• From a sterile container, take a sterile brush and dispense approximately 6 ml of antiseptic detergent onto the brush and begin scrubbing your hands and arms.

  • Begin with the fingertips. Bring your thumb and fingertips together and using the brush, scrub across the fingertips using 30 strokes.

  • Now scrub all surface planes (4) of the thumb and all surfaces of each finger, including the webbed space between the fingers, using 20 strokes for each surface area.

  • Scrub the palm and back of the hand in a circular motion, using 20 strokes each.

  • Visually divide your forearm into two parts, lower and upper; scrub all surfaces of each division 20 strokes each, beginning at the wrist and progressing to the elbow.

  • Scrub the elbow in a circular motion using 20 strokes.

  • Scrub in a circular motion all surfaces to approximately 2 inches above the elbow.

  • Do not rinse this arm when you have finished scrubbing. Rinse only the brush.

  • Pass the rinsed brush to the scrubbed hand and begin scrubbing your other hand and arm, using the same procedure outlined above.

  • Drop the brush into the sink when you are finished.

  • Rinse both hands and arms, keeping your hands above the level of your elbows, and allow water to drain off the elbows.

  • When rinsing, do not touch anything with your scrubbed hands and arms.

• The total scrub procedure must include all anatomical surfaces from the fingertips to approximately 2 inches above the elbows.

• Dry your hands with a sterile towel. Do not allow the towel to touch anything other than your scrubbed hands and arms.

• Between operations, follow the same hand scrub procedure.

Gowning and Gloving

If you are the scrub corpsman, you will have opened your sterile gown and glove packages in the operating room before beginning your hand scrub. Having completed the hand scrub, back through the door holding your hands up to avoid touching anything with your hands and arms. Gowning technique is shown in figure 5-1 and performed as follows:

• Pick up the sterile towel that has been wrapped with your gown. Touch only the towel.

• Dry one hand and arm, starting at the hand and ending at the elbow, with one end of the towel. Dry the other hand and arm with the opposite end of the towel. Drop the towel.

• Pick up the gown in such a manner that hands touch only the inside surface at the neck and shoulder seams.

• Allow the gown to unfold downward in front of you.

• Locate the arm holes and place both hands in the sleeves, holding your arms out and slightly up as you slip your arms into the sleeves. Another person (circulator) who is not scrubbed will pull your gown on as you extend your hands through the gown cuffs.

• Open the inner glove packet on the same sterile surface on which you opened up the gown. The entire gloving procedure is shown in figure 5-2.

• Pick up one glove by the cuff using your thumb and index finger. Touching only the

• cuff, pull the glove onto one hand and anchor the cuff over your thumb.

• Slip your gloved fingers under the cuff of the other glove. Pull the glove over your fingers and hand, using a stretching side-to-side motion.

• Anchor the cuff on your thumb. With your fingers still under the cuff, pull the cuff up and away from your hand and over the knitted cuff of the gown.

• Repeat the preceding step to finish gloving your other hand.

To gown and glove the surgeon, follow these steps:

• Pick up a gown from the sterile linen pack. Step back from the sterile field and let the gown unfold in front of you. Hold the gown at the shoulder seams with the gown sleeves facing you.

• Offer the gown to the surgeon. Once he or she has the arms in the sleeves, let go of the gown. Be careful not to touch anything but the sterile gown. The circulator will tie the gown.

• Pick up the right glove. With the thumb of the glove facing the surgeon, place your fingers and thumbs of both hands in the cuff of the glove and stretch it outward making a circle of the cuff. Offer the glove to the surgeon. Be careful that the surgeon's bare hand does not touch your gloved hands.

• Repeat the preceding step for the left glove.

Cleaning the Operating Room

Cleanliness in the operating room is an absolute must. Cleaning routines must be clearly understood and carefully followed. The cause of postoperative wound infections have on occasion been traced to the operating room. Since no two patients are alike and all patients have their own "resident" bacteria, every surgical case must be considered contaminated.

At the beginning of each day, all the fixtures, equipment, and furniture in each operating room are damp dusted with an antiseptic germicide solution. During the operation, keep the room clean and orderly at all times. Should sponges be dropped on the floor or if blood or other body fluids spill, clean the area immediately using a disinfectant germicide solution and a clean cloth. Between each operation, clean all used items. The area of the floor occupied by the surgical team is cleaned, using the wet vacuum method. If a wet vacuum is not available, mops may be used if a clean mop head is used following each operation. Gowns and gloves are removed before leaving the room. All linens and surgical drapes are bagged and removed from the room. All trash and deposable items are bagged and taken from the room. All instruments are washed by gloved hands or placed in perforated trays and put through a washer/sterilizer.

At the completion of the day's operations, each operating room should be terminally cleaned using an antiseptic germicide solution with the following tasks accomplished:

• Clean all wall- or ceiling-mounted equipment.

• Clean all spotlights and lights on tracks.

• Thoroughly scrub all furniture used in the room, including the wheels.

• Clean metal buckets and other waste receptacles and, if possible, put them through the washer/sterilizer.

• Clean scrub sinks.

• Machine scrub the entire floor in each room. If a machine is not available, use a large floor brush.

• Suction up the disinfectant germicide solution that is used on the floor, using a wet vacuum. If mops are used, make sure a clean mop head is used for each room. The use of mops in the operating room is the LEAST DESIRABLE method of cleaning.

General Safety Precautions in the Operating Room

Since safety practices are important to emphasize, this section will cover some of the situations that are potentially hazardous and discuss what might be done to eliminate the hazard.

All personnel should know the location of all emergency equipment. This includes drugs, cardiac arrest equipment, and resuscitators. All electrical equipment and plugs must be of the explosion-proof type and bear a label stating such. There should be written schedules of inspections and maintenance of all electrical equipment. Navy regulations prohibit the use of explosive anesthetics in the operating room. These regulations, however do not mean we can lessen our concern for fire and explosion hazards. The surface of all floors in the operating room must provide a path of electrical conductivity between all persons and equipment making contact with the floor to prevent the accumulation of dangerous electrostatic charges. All furniture and equipment should be constructed of metal or of other electrically conductive material and should be equipped with conductive leg tips, casters, or equivalent devices. Periodic inspections should be made of leg tips, tires, casters, or other conductive devices of furniture and equipment. This will ensure that they are maintained free of wax, lint, or other foreign material that may insulate them and defeat the purpose for which they are used. Excess lubrication of casters should be avoided to prevent accumulation of oil on conductive wheels. Dry graphite and graphite oil are preferable lubricants.

Rubber accessories for anesthesia machines should be of the conductive type, should be plainly labeled as such, and should be routinely tested to ensure that conductivity is maintained. It is essential that all replacement items be of conductive material.

All personnel entering the operating room should be in electrical contact with the conductive floor through the wearing of conductive footwear or an alternative method of providing a path of conductivity. Conductive footwear and other personnel-to-floor conductive equipment should be tested on a regularly scheduled basis.

All apparel worn in the operating room should be made of a nonstatic producing material. Fabrics of 100 percent cotton are the most acceptable. Fabrics made of synthetic blends may be used only if they have been treated by the manufacturer for use in the operating room. Wool blankets and apparel made of untreated synthetic fabrics are not permitted in the operating room.

Operating rooms must have adequate airconditioning equipment to maintain relative humidity and temperature within a constant range. The relative humidity should be kept at 55 to 60 percent. This level will reduce the possibility of electrostatic discharge and possible explosion of combustible gases. The temperature should be chosen on the basis of the well-being of the patient. The recommended temperature is between 65 degrees and 74 degrees F. The control of bacteria carried on dust particles is facilitated when the recommended humidity and temperature are maintained.

All oxygen cylinders in use or in storage will be tagged with DD Form 1191, Warning Tag for Medical Oxygen Equipment, and measures will be taken to ensure compliance with instructions 1 through 7 printed on the form. An additional tag is required on all cylinders to indicate "EMPTY," "IN USE," or "FULL." Safety precautions should be conspicuously posted in all areas in which oxygen cylinders are stored and in which oxygen therapy is being administered. This posting should be made so it will immediately make all personnel aware of the precautionary measures required in the area.

All electrical service equipment, switchboards, or panelboards should be installed in a nonhazardous location. Devices or apparatus that tend to create an arc, sparks, or high temperatures must not be installed in hazardous locations unless these devices are of a type approved in accordance with the National Electrical Code. Lamps in a fixed position will be enclosed and will be properly protected by substantial metal guards or other means where exposed to breakage. Cords for portable lamps or portable electrical appliances must be continuous and without switches from the appliance to the attachment plug. Such cords must contain an insulated conductor to form a grounding connection between the electrical outlet and the appliance.

Nutrition

Nutrition is a scientific term applied to the process by which food elements are taken into the body to produce energy for body activity, rebuild body tissue, and assist in regulating all body functions. To meet these body needs, it is essential that a person's diet contain a proper balance of the essential food elements that include carbohydrates, fats, proteins, vitamins, minerals, and water. Because the well-nourished person is generally mentally and physically alert and fairly resistant to disease, dietary intake is an important factor in the diagnostic and therapeutic plan of the consumer who requires a health care service.

Nutritive Substances

Carbohydrates are the most efficient source of energy. They provide work energy for body activities and heat energy for the maintenance of body temperature. Additionally, they are easily metabolized to provide quick energy. They may also be stored in the liver as glycogen to be used by the body when they are needed at a later time. Carbohydrates are divided into two groups-sugars (e.g., in fruits, honey, and jellies) and starches (e.g., bread, potatoes, and rice). When taken in excess, carbohydrates are converted to adipose (fat) tissue and contribute to an overweight condition. When carbohydrates are taken too sparingly, the body metabolized its fats and then its protein resources, and this eventually contributes to undesirable weight loss.

Fats are nutritive substances that compose the most concentrated source of energy of all the elements. Similar to carbohydrates, they provide the body with work and heat-energy resources. Fats function as carriers for the fat-soluble vitamins (A, D, E, and K), as padding for the organs and subcutaneous tissue, and as an energy resource when stored as adipose tissue. Common sources of fats are butter, milk, oil, and fatty meats. They are not as easily or quickly metabolized as carbohydrates and in excess contribute to overweight, digestive, and cardiovascular problems.

Proteins are the most important element required by the body for tissue growth, development, maintenance, and repair. They are the main structural unit of all living cells. Proteins are expensive sources of energy, since the body does not maintain reserve stores. Because of this, a constant source of protein is required in the daily diet to avoid a deficiency condition. Some of the best sources of protein are found in meat, fish, eggs, and legumes (e.g., peas and beans).

Vitamins are natural components of most foods and are essential for proper growth and maintenance of health. They are needed by the body in minute amounts but play a vital role in metabolism, helping to convert carbohydrates, fats, and proteins into energy. It should be noted that they do not furnish energy or act as tissue-building materials. Some vitamins can be stored in the body; thus, in some people, vitamin abuse can be dangerous. An example of this is the excessive use of vitamin A. Vitamins are classified as either water-soluble or fat-soluble. Niacin, folic acid, vitamin B complex, and vitamin C are transported throughout the body in water and are classified as water-soluble. These vitamins are not stored in the body to any great extent and excesses in intake are generally excreted by the kidneys. Vitamins A, D, E, and K are transported throughout the body in fats and are called fat-soluble. As stated above, many fat-soluble vitamins are stored in the body.

Although the mineral elements constitute only a small portion of the total body composition, they are essential in the building and maintenance of bones, teeth, and various body systems. Some minerals are found in large amounts in the body. Others, detectable in small amounts, are referred to as trace minerals. Regardless of the quantitative amounts, those mineral essential to support and maintain optimal health are calcium, phosphorus, magnesium, iron, iodine, potassium, sodium, chlorine, sulfur, and fluorine.

For mineral needs to be met satisfactorily, the consumption of each element must be sufficient to cover body tissue requirements and to meet the changing physiological needs due to growth or environmental changes. It was once believed that any diet adequate in other respects would also provide an adequate intake of the essential minerals. This is not true. Different foods vary greatly in their mineral content and the same type of food produced in various geographic localities may differ considerably in the percentage composition of the individual minerals. The differences in an individual's eating habits may also result in considerable variation in the mineral intake.

Water, although not a food, is essential for the maintenance of life and health and is an integral part of most foods. It is by far the largest single constituent of the body, comprising almost two-thirds of the total body weight. Of the substances essential to life, water stands second only to oxygen. Without oxygen, humans can survive only a few minutes; without water, they may survive for a period of hours or a few days, depending upon many circumstances.

Water is the great solvent in the body. All basic body constituents are held in water, and it is the medium in which all chemical reactions take place in the body. It functions as a vehicle for nutrients, secretions, and most body substances; and because it is an essential element of the protoplasm of cells, it serves as a building material for growth and repair.

To maintain metabolic equilibrium, water intake must equal water output. The water loss through urine, feces, skin, and lungs must be replaced by water in food, water from the oxidation of food, and fluid intake. Under normal conditions, thirst is usually an adequate guide of the water requirement. When the body is in negative water balance, the condition known as dehydration results. Among its effects are the following:

• Loss of weight due to reduction in tissue water as well as to breakdown of body substances.

• Disturbance in acid-base balance usually toward the acid side, resulting in acidosis (insufficient water places a heavy burden on the kidneys impairing their ability to eliminate waste products through the urine).

• Elevations in body temperature as a result of reduced circulating fluid and subsequent reduced perspiration.

• Exhaustion and collapse.

Metabolism

As previously stated, one of the important functions of food is to provide the body with heat and energy. This is accomplished through the process of metabolism that functions in the following manner. In the various cells and tissues of the body, food substances, in combination with oxygen taken into the body through the lungs, are burned or oxidized, producing heat and energy. The heat that is generated is used for the control of body temperature, and the energy that is produced provides for the muscular activity and movements of the body.

Caloric Value of Foods

The unit of measure of heat production is the calorie (cal). This is the amount of heat energy that is required to raise the temperature of 1 gram (g) of water 1 degree centigrade (C). In food chemistry and metabolism, the large calorie (kcal) is the unit of energy measurement used. One large calorie is 1000 times the size of a standard calorie. The amount of heat energy in terms of calories resulting from oxidation of foodstuffs is the caloric value of the food. By careful analysis, specific caloric values of the basic organic foods have been determined to be the following:

• 1 g of PROTEIN yields 4 cal.

• 1 g of CARBOHYDRATES yields 4 cal.

• 1 g of FAT yields 9 cal.

Most foodstuffs are not pure basic elements, and the exact caloric value of the various compound foods containing more than one of each of the three basic elements cannot be determined precisely. However, laboratory determinations have provided relative caloric values of most representative foods. The following are a few typical examples:

1 slice of bread or small potato	70 calories
1 pat of butter	45 calories
1 glass of whole milk	170 calories
1 small banana	80 calories
12 peanuts	90 calories
1 average serving of steak or ground beef	200 calories
1 candy bar	300 calories
1 serving of fruit pie	300 calories

It should be noted that alcoholic beverages provide 7 calories for each g of alcohol, but these calories have no nutritional value.

Basal Metabolic Rate

The basal metabolic rate (BMR) is an index of the energy demand of the body for the maintenance of life and body functions under basic conditions. Increased activity requires more fuel and oxygen in proportion to the degree of heat and energy requirements.

The energy requirements of a normal 150-pound man under situation of varying activity are approximated as follows:

Forms of Activity	Calories
8 hours of sleep (60 calories per hour)	480
3 hours of light exercise, going to and from work, etc. (200 calories per hour)	600
8 hours of ward duty (220 calories per hour)	1,760
5 hours of recreation watching television (90 calories per hour x 5 = 450) swimming (500 calories per hour x 5 = 2,500)	450 - 2,500
Total for the day	3,290 - 5,340

To maintain body weight without loss or gain, this individual would have to consume food in amounts and kinds to yield 3,290 to 5,340 calories, depending on his activity. Since we have assumed this man to be a normal individual, without a disease state or glandular imbalance, if he consumed more, he would gain weight; if he consumed less, he would lose weight. This balancing of food intake against energy requirement is the only sound basis of weight control with the maintenance of a balanced diet that ensures adequate amounts of all the essential nutrients.

The Adequate Diet

The three specifications that an adequate diet must have are the following:

• Protein for growth and maintenance of body cells.

• Minerals, vitamins, and water for growth, maintenance, and regulation of body processes.

• Fats and carbohydrates for energy.

No single food can be designated essential for life or health. Most food contains one or more nutrients, but no single one contains all the nutrients in the needed amounts. Therefore, choosing foods wisely means selecting foods that together supply nutrients in the needed amounts.

A food guide called the Four Food Groups has been devised to ensure an adequately balanced, daily diet. The following are the basic four food groups and some major nutrients included in each group:

Grain Group-this group furnishes significant amounts of protein, iron, and many of the B vitamins. Also included are carbohydrates that not only provide a quick-energy source but also supply the body with roughage. Specific foods of this group are all breads and cereals that are whole-grained, restored, or enriched. Many of the cereal products furnish many vitamins and minerals. Additionally, foods such as rice, noodles, macaroni, cornmeal, and grits are also included in this group.

Meat Group-this group provides a major source of protein, iron, and the B-complex vitamins. Included in the meat group are beef, veal, lamb, pork, and the organ nutrients such as liver and kidney. Fish, shellfish, poultry, and eggs are also included in the meat group. Foods such as beans, peas, and nuts are alternative sources of protein, which are categorized in the meat group; however, these nutrients are not as high in protein as are the other foods in the group.

Milk Group-this group supplies the body with calcium, some high quality protein, and vitamins, especially A and riboflavin (B2). Foods included in this group are whole, evaporated, skim, and dry milk. Also included are butter, buttermilk, ice cream, and a wide variety of cheeses.

Vegetable/Fruit Group-this group provides a major source of vitamins and minerals. Almost all the body's vitamin C requirements and half of its vitamin D requirements are furnished by this group. Such foods as cantaloupe, grapefruit, oranges, strawberries, and green peppers are good sources of vitamin C. Apricots, peaches, asparagus, carrots, broccoli, brussel sprouts, spinach, and sweet potatoes are excellent sources of vitamin D. Each day the healthy adult requires 4 servings from the grain group, 2 from the meat group, 2 from the milk group, and 4 from the vegetable/fruit group for a nutritious healthful diet.

Diet Therapy

An important part of the total health care management of the patient is the dietary plan. Basically, a patient's diet therapy consists of either a regular or special diet. The goals of both categories are to provide for either a normal life cycle, or special dietary requirements that are necessary for treating disease or injury and for rehabilitating the patient. Regular diets are planned in accordance with an individual's specific life style, such as found among pediatric, adult, maternal, or geriatric populations. Special diets, commonly called therapeutic diets, are planned or changed in one or a combination of the following methods:

• Modification of total calories

• Modification of consistency

• Modification of levels of nutrients

• Elimination of specific foods

• Preparation methods

An individual's nutritional care consists of the following four essential elements: assessment, planning, implementation, and evaluation. All of these elements are necessary for the successful provision of effective health care. Assessment provides the health care team with an estimate of the patient's nutritional status upon admission and provides a basis for planning diet therapy during hospitalization. Dietary implementation and monitoring guide the health care team in evaluating and adjusting both optimal calorie and nutritional intake. These contribute to the patient's total care by reducing tissue healing time, decreasing susceptibility to infection, and providing for an optimal physical and biochemical status.

To summarize briefly, the overall objectives of planned and implemented diet therapy are to:

• Prevent nutritional deficiency

• Improve and maintain the very best nutritional status

• Aid the maintenance and re-establishment of a positive state of well-being in persons with a medical or physical problem

• Identify problems associated with over-nutrition and undernutrition and decide when these problems put a patient at a high nutritional risk.

The Medical Patient

For purposes of this discussion, the term medical patient will be considered as any person who is receiving diagnostic, therapeutic, and supportive care for a condition that is not managed by surgical, orthopaedic, psychiatric, or maternity-related therapy. This is not to infer that patients in these other categories are not treated for medical problems. Many surgical, orthopaedic, psychiatric and maternity patients do have secondary medical problems that are treated while they are undergoing management for their primary condition. Although many medical problems can be treated on an outpatient basis, this discussion will address the hospitalized medical patient. It should be noted that the basic principles of management are essentially the same for both the inpatient and outpatient.

The medical management of the patient generally consists of laboratory and diagnostic tests and procedures, medication, food and fluid therapy, and patient teaching. Additionally, for many medical patients, particularly during the initial treatment phase, rest is a part of the prescribed treatment.

Test and Procedures

A variety of laboratory and diagnostic tests and procedures are commonly ordered for the medical patient. Frequently, the hospital corpsman is assigned to prepare the patient for the procedure, collect the specimens, or assist with both the procedure and specimen collection. Whether a specimen is to be collected or a procedure is to be performed, the patient needs a clear and simple explanation about what is to be done and what the patient can do to assist with the activity. Often the success of the test or procedure is dependent upon the patient's informed cooperation. When collecting specimens, the hospital corpsman must complete the following:

• Collect the correct kind and amount of specimen at the right time.

• Place the specimen in the correct container.

• Label the container completely and accurately. This often differs somewhat for each facility and local policies should be consulted.

• Complete the laboratory request form accurately.

• Record on the patient's record and other forms, as appropriate, the date, time, kind of specimen collected, the disposition of the specimen, and anything unusual about the appearance of the specimen or the patient during the collection.

When assisting with a diagnostic procedure, the hospital corpsman must understand the sequence of steps of the procedure and exactly how his or her assistance can best be provided. Since many procedures terminate in the collection of a specimen, the above principles of specimen collecting must be followed. Following the completion of a procedure or specimen collection, it is the responsibility of the assisting hospital corpsman to ensure that the patient's safety and comfort have been attended to, the physician's orders are accurately followed, and that any supplies or equipment used are appropriately disposed of.

Medications

A major form of therapy for the treatment of illness is the use of drugs. It is not uncommon for the medical patient to be treated with several drugs. As members of the health care team, hospital corpsmen assigned to preparing and administering medications are given a serious responsibility demanding constant vigilance, integrity, and special knowledge and skills. The preparation and administration of medications were addressed in great detail in the Hospital Corps School curriculum. Chapter 6 of the Nursing Procedures Manual is devoted entirely to medications. These references and the continued inservice training devoted to medication administration at all medical facilities support the importance of accurate preparation and administration of drugs.

An error, which also includes omissions, can seriously affect a patient, even to the point of causing death. Each hospital corpsman is responsible for his or her own actions, and this responsibility cannot be transferred to another. No one individual is expected to know all there is to know about all patients and medications. However, in every health care environment, the hospital corpsman has access to other health care providers who can assist in clarifying orders, explaining the purposes, actions, and effects of drugs, and in general answering any questions that may arise concerning a particular patient and his or her medications. There should be basic drug references available to all personnel handling medications, including the Physicians' Desk Reference and a hospital formulary. As a hospital corpsman, it is your responsibility to consult these members of the team and these references for assistance in any area in which you are not knowledgeable or whenever you have questions or doubts. You are also responsible for knowing and following local policies and procedures regarding the administration of medications.

Food and Fluid Therapy

An entire section of this chapter addressed the subject of nutrition. The following will be a brief discussion on food and fluid as it relates specifically to the medical patient. Loss of appetite, food intolerance, digestive disturbances, lack of exercise, and even excessive weight gain influence a medical patient's intake requirements. Regardless of their medical problem, patients have basic nutritional needs that frequently differ from those of the healthy person. As a part of the patient's therapeutic regimen, food is usually prescribed in the form of a special diet. Regardless of the kind of diet prescribed, the patient must understand why certain foods are ordered or eliminated and how compliance with the regimen will assist in his or her total care. It is the responsibility of the corpsman to assist the patient in understanding the importance of the prescribed diet and to ensure that accurate recording of the patient's dietary intake is made on the clinical record.

In many disease conditions, the patient is unable to tolerate food or fluids or may lose these through vomiting, diarrhea, or both. In these cases, replacement fluids as well as nutrients is an important part of the patient's medical management. On the other hand, there are several disease conditions in which fluid restrictions are important aspects of the patient's therapy. In both of these instances, accurate measurement and recording of fluid intake and output must be carefully performed. Very frequently this becomes a major task of the staff hospital corpsman.

Patient Teaching

Earlier in this chapter, under "Health Education," the goals and principles of patient teaching were addressed. When taken in the context of the medical patient, there are some general areas of patient teaching needs that must be considered, particularly as the patient approaches discharge from an inpatient status. They include the following:

• Follow-up appointments

• Modification in daily living activities and habits

• Modification in diet, including fluid intake

• Medications and treatment to be continued after discharge

• Measures to be taken to promote health and prevent illness

Rest

The primary reason for prescribing rest as a therapeutic measure for the medical patient is to prevent further damage to the body or a part of the body when the normal demand of use exceeds the ability to respond. However, prolonged or indiscriminate use of rest, particularly bed rest, is potentially hazardous. Some of the common complications occurring as a result of prolonged bed rest are:

• Circulatory problems, such as development of thrombi and emboli, and subsequent skin problems, such as decubiti.

• Respiratory problems, such as atelectasis and pneumonia.

• Gastrointestinal problems, such as anorexia, constipation, and fecal impactions.

• Urinary tract problems, such as retention, infection, or the formation of calculi.

• Musculoskeletal problems, such as weakness, atrophy, and the development of contractures.

• Psychological problems, such as apathy, depression, and temporary personality changes.

The key concept in the therapeutic management of the patient on prolonged bed rest is the prevention of complication resulting from this one aspect of the total care regimen. Awareness of the potential hazards is the first step in prevention. Alert observations of skin condition, respirations, food and fluid intake, urinary and bowel habits, evidence of discomfort, range of motion, and mood are critical elements that provide data indicating impending problems. When this data is properly reported, the health care team has time to employ measures that will arrest the development of preventable complications.

The Surgical Patient

Surgical procedures are classified into two major categories: emergency and elective. Emergency surgery is that required immediately to save a life or maintain a necessary function. Elective surgery is that which, in most cases, needs to be done but can be scheduled at a time beneficial to both the patient and the provider. Regardless of the type of surgery, every surgical patient requires specialized care at each of four phases. These phases are classified as preoperative, operative, recovery, and postoperative. The following discussion will address the basic concepts of care in each phase.

Preoperative Phase

Before undergoing a surgical procedure, the patient must be in the best possible psychological, spiritual, and physical condition. Psychological preparation begins the moment the patient learns he or she is going to have an operation. The physician is responsible for explaining the surgical procedure to the patient, including the events that can be expected afterward. Since other staff personnel reinforce the physician's explanation, all members of the team must know what the physician has told the patient. In this manner, they are better able to answer the patient's questions. All patients approaching surgery are fearful and anxious. The staff can assist in reducing this fear by instilling confidence in the patient regarding the competence of those providing care. The patient should be given the opportunity and freedom to express any feelings or fears concerning the proposed procedure. Even in an emergency, it is possible to give a patient and the family psychological support. Often this is accomplished simply by the confident and skillful manner in which the administrative and physical preoperative preparation is done.

People who face operations are often afraid. This fear can be related to fear of anesthesia, body disfigurement, pain, and even death. Frequently, religious faith is a source of strength and courage for these patients. If a patient expresses a desire to see a clergyman, every attempt should be made to arrange a visit.

Except in emergencies, the administrative preparation usually begins the day before surgery. Since the step-by-step procedure is clearly delineated in the Nursing Procedures Manual, in the section titled "Preoperative Care," the entire procedure will not be repeated here. The Request for Administration of Anesthesia and for Performance of Operations and Other Procedures (SF 522) will be addressed here. This document identifies the operation or procedure to be performed, has a statement written by the patient indicating in lay terms a description of the procedure, and includes signatures of the physician, patient, and a staff member who serves as a witness. SF 522 must be completed before any preoperative medications are administered. If the patient is not capable of signing the document, a parent, legal guardian, or spouse may sign it. It is customary to require the signature of a parent or legal guardian if the patient is under 21 years of age, unless the patient is married or a member of the Armed Forces. In these latter two cases, the patient may sign his or her own permit, regardless of age.

Normally, the physical preparation of the patient begins in the late afternoon or early evening the day before surgery. As with the administrative preparation, each step is clearly stated in the Nursing Procedures Manual. Also, listed under "Skin Preparation," you will find a description of both the purpose and procedure for performing the preoperative shave.

Preoperative teaching is an important part of the total preparation. The exact time that preoperative teaching should be initiated greatly depends upon the individual patient and type of surgical procedure. Most experts recommend that preoperative instructions be given as close as possible to the time of surgery. Appropriate preoperative instructions given in sufficient detail and at the proper time greatly reduce operative and postoperative complications.

Operative Phase

The operative, or intraoperative phase as it is sometimes called, begins the moment the patient is taken into the operating room. Two of the major factors to consider at this phase are positioning and anesthesia.

Positioning

The specific surgical procedure will dictate the general position of the patient. For example, the lithotomy position is used for a vaginal hysterectomy; whereas, the dorsal recumbent position is used for a herniorrhaphy. Regardless of the specific position the patient is placed in, there are some general patient safety guidelines that must be observed. 

• When positioning a patient on the operating table, remember the following:

• Whether the patient is awake or asleep, place the patient in as comfortable position as possible.

• Strap the patient to the table in a manner that

  • allows for adequate exposure of the operative site.

  • is secure enough to prevent the patient from falling, but does not cut off circulation or contribute to nerve damage.

• Secure all extremities of the patient in a manner that will prevent them from dangling over the side of the table.

• Pad all bony prominences to prevent the development of pressure areas or nerve damage.

• Make sure the patient is adequately grounded to avoid burns or electrical shock to either the patient or the surgical team.

Anesthesia

One of the greatest contributions to medical science was the introduction of anesthesia. It relieves unnecessary pain and increases the potential and scope of many kinds of surgical procedures. Therefore, health care providers must understand the nature of anesthetic agents and their effect on the human body.

Anesthesia may be defined as a loss of sensation that makes a person insensible to pain, with or without loss of consciousness. Some specific anesthetic agents are discussed in the "Pharmacology and Toxicology" chapter of this manual. Health care providers must understand the basics of anesthesiology as well as the specific drug's usage.

Regional Anesthesia - The two major classifications of anesthesia are regional and general. Regional anesthetics reduce all painful sensations in a particular area of the body without causing unconsciousness. The following is a listing of the various methods and a brief description:

• Topical anesthesia is administered topically to desensitize a small area of the body for a very short period.

• Local blocks consist of the subcutaneous infiltration of a small area of the body with a desensitizing agent. Local anesthesia generally lasts a little longer than topical.

   

• Nerve blocks consist of injecting the agent into the region of a nerve trunk or other large nerve branches. This form of anesthesia blocks all impulses to and from the injected nerves.

   

• Spinal anesthesia consists of injecting the agent into the subarachnoid space of the spinal canal between the third and fourth lumbar space or between the fifth lumbar and first sacral space of the spinal column. This form of anesthesia blocks all impulses to and from the entire area below the point of insertion, provided the patient's position is not changed following injection of the agent. If the patient's position is changed, for example, from dorsal recumbent to Trendelenburg's, the anesthetic agent will move up the spinal column and the level of the anesthesia will also move up. Because of this, care must be exercised in positioning the patient's head and chest above the level of insertion to prevent paralysis (by anesthesia) of the respiratory muscles. In general, spinal anesthesia is considered the safest for most routine major surgery.

   

• Epidural blocks consist of injecting the agent into the epidural space of the spinal canal at any level of the spinal column. The area of anesthesia obtained is similar to that of the subarachnoid spinal method. The epidural method is frequently used when continuous anesthesia is desired for a prolonged period. In these cases, a catheter is inserted into the epidural space through a spinal needle. The needle is removed, but the catheter is left in place. This provides for continuous access to the epidural space.

   

• Saddle blocks consist of injecting the agent into the dural sac at the third and fourth lumbar space. This form of anesthesia blocks all impulses to and from the perineal area of the body.

   

• Caudal blocks consist of injecting the agent into the sacral canal. With this method, anesthesia is obtained from the umbilicus to the toes.

General Anesthesia - General anesthetics cause total loss of sensation and complete loss of consciousness in the patient. They are administered by inhalation of certain gases or vaporized liquids, intravenous infusion, or rectal induction. The induction of inhalation anesthesia is divided into four stages. These stages and the body's main physiological reaction in each phase are explained below and depicted in figure 5-3.

• Stage 1 is called the stage of analgesia or induction. During this period, the patient experiences dizziness, a sense of unreality, and a lessening sensitivity to touch and pain. At this stage, the patient's sense of hearing is increased and responses to noises are intensified (fig. 5-3).

   

• Stage 2 is the stage of excitement. During this period, there is a variety of reactions involving muscular activity and delirium. At this stage, the vital signs show evidence of physiological stimulation. It is important to remember that during this stage the patient may respond violently to very little stimulation (fig. 5-3).

   

• Stage 3 is called the surgical or operative stage. There are four planes to this stage. It is the responsibility of the anesthetist or anesthesiologist to determine which plane is optimal for the procedure. The determination is made according to specific tissue sensitivity of the individual and the surgical site. Each successive plane is achieved by increasing the concentration of the anesthetic agent in the tissue (fig. 5-3).

   

• Stage 4 is called the toxic or danger stage. Obviously, this is never a desired stage of anesthesia. At this point, cardiopulmonary failure and death can occur. Once surgical anesthesia has been obtained, the health provider must exercise care to control the level of anesthesia. Plane 4 of stage 3 is demonstrated by cardiovascular impairment that results from diaphragmatic paralysis. If this plane is not corrected immediately, stage 4 quickly ensues (fig 5-3)

Recovery Phase

For purposes of this discussion, the recovery phase consists of the period that begins at the completion of the operation and extends until the patient has recovered from anesthesia. The recovery phase generally takes place in a specialized area called the recovery room. This unit is usually located near the operating room and has access to the following:

• Surgeons and anesthesiologists or anesthetists

• Nurses and Hospital Corps personnel who are specially prepared to care for immediate postoperative patients

• Special equipment, supplies, medication, and replacement fluids

From the time of admission to the point of discharge, routine care in the recovery room consists of the following:

• Measuring temperature and vital signs

  • Take immediately upon admission and as ordered by the physician thereafter.

• Maintaining airway patency

  • Patients having an artificial airway in place will automatically expel it as they regain consciousness.

  • Have a mechanical suction apparatus available to remove excessive excretions from the patient's airway.

• Ensuring the integrity of dressings, tubes, catheters, and casts

  • Locate the presence of any of the above.

  • Make notations regarding all drainage including color, type, and amount.

  • Immediately report the presence of copious amounts of drainage to the nurse or physician.

• Monitoring intravenous therapy (including blood and blood components)

  • Make notations including type of infusion, rate of flow, and condition of the infusion site.

  • Observe patients receiving blood or blood components closely for untoward reactions.

• Monitoring skin color changes

  • Check dressings and casts frequently to ensure they are not interfering with normal blood circulation to the area.

  • Notify the physician or nurse of general skin color changes that may indicate airway obstruction, hemorrhage, or shock.

• Assessing level of responsiveness

  • For general anesthetics, check for orientation to the environment each time vital signs are taken.

  • For regional anesthetics, check for return of sensory perception and voluntary movement each time vital signs are taken.

• Observing for side effects of the anesthetic agent. Each agent has the potential for causing specific side effects. Some common major side effects that may occur following the administration of both spinal and general anesthesia consist of the following:

  • Spinal

    • Hypotension/shock

    • Respiratory paralysis

    • Neurological complications

    • Headache

  • General

    • Cardiac arrest

    • Respiratory depression

    • Bronchospasm/laryngospasm

    • Diminished circulation

    • Hypotension/shock

    • Vomiting/aspiration

Postoperative Phase

After the patient's status has stabilized in the recovery room, a physician will order his or her transfer to another area in the facility. Generally, this transfer is to the unit that the patient was assigned to preoperatively. Since both surgery and anesthesia have unavoidable temporary ill effects on the normal physiological functions, every effort must be made to prevent postoperative complications. From the time the patient is admitted to the recovery room to the time he or she has recovered from the operation, there are definite goals of care that guide the entire postoperative course. These goals are as follows:

• Promoting respiratory function

• Promoting cardiovascular function

• Promoting renal function

• Promoting nutrition and elimination

• Promoting fluid and electrolyte balance

• Promoting wound healing

• Encouraging rest and comfort

• Encouraging movement and ambulation

• Preventing postoperative complications

The physician will write orders for postoperative care that are directed at accomplishing the above goals. Although each patient's orders will be based on individual needs, there will be some common orders that apply to all patients. These orders will center around the promotion of certain physiological functions and areas addressed in the following paragraph.

Respiratory function is promoted by encouraging frequent coughing and deep breathing. Early movement and ambulation also help to improve respiratory function. For some patients, oxygen therapy may also be ordered to assist respiratory function. Cardiovascular function is assisted by frequent position changes, by early movement and ambulation, and, in some cases, by intravenous therapy. Renal function is promoted by adequate fluid intake and early movement and ambulation. Nutritional status is promoted by ensuring adequate oral or correct intravenous intake and by maintaining accurate intake and output records. Elimination functions are promoted by adequate diet and fluid intake. Postoperative patients should be advanced to a normal dietary regimen as soon as possible, since this too promotes elimination functions. Early movement and ambulation also helps to restore normal elimination activities. In addition to various medications and dressing change procedures ordered by the physician, wound healing is promoted by good nutritional intake and by early movement and ambulation. Rest and comfort are supported by properly positioning the patient, providing a restful environment, encouraging good basic hygiene measures, ensuring optimal bladder and bowel output, and promptly administering pain-relieving medications. Early movement and ambulation are assisted by ensuring maximum comfort for the patient and providing the encouragement and support for ambulating the patient, particularly in the early postoperative period. As indicated in the above discussion, the value of early movement and ambulation, when permissible, cannot be overemphasized.

During the early postoperative phase, the major complications to be guarded against are respiratory obstruction, shock, and hemorrhage. As the patient progresses in the postoperative period, other complications to avoid are the development of pneumonia, phlebitis and subsequent thrombophlebitis, gastrointestinal problems ranging from abdominal distention to intestinal obstruction, and finally wound infections. Accurate implementation of the physician's orders and careful observation, reporting, and recording of the patient's condition will contribute markedly to an optimal and timely postoperative recovery course for the patient.

The Orthopedic Patient

General Care

Patients on the orthopedic service are those who require treatment for fractures, deformities, and diseases or injuries of some part of the musculoskeletal system. Some patients will require surgery, immobilization, or both to correct their condition. The basic principles and concepts of care for the surgical patient will apply to orthopedic patients. The majority of patients not requiring surgical intervention will be managed by bed rest, immobilization, and rehabilitation. Many of the basic concepts of care of the medical patient are applicable for orthopedic patient care. In the military, the usual orthopedic patient is fairly young and in good general physical condition. For these patients, bed rest is prescribed only because his or her admitting condition limits other kinds of activity.

Immobilization

Rehabilitation is the ultimate goal when planning the orthopedic patient's total management. Whether the patient requires surgical or conservative treatment, immobilization is often a part of the overall therapy. Immobilization may consist of applying casts or traction, or using equipment, such as orthopedic frames or Circ-O-Lectric beds. During the immobilization phase, simple basic patient care is extremely important. Such things as skin care, active-passive exercises, position changes in bed (as permitted), good nutrition, adequate fluid intake, regularity in elimination, and common basic hygiene not only contribute to the patient's physical but also psychological well-being.

Lengthy periods of immobilization are emotionally stressful for patients, particularly those who are essentially healthy except for the limitations imposed by their condition. Prolonged inactivity contributes to boredom that is frequently manifested by various kinds of acting out behavior. Often, the unoccupied orthopedic patient experiences exaggerated levels of pain. Orthopedic pain is commonly described as sore and aching. Because this condition requires long periods of treatment and hospitalization, the wise management of pain is an important aspect of care. Constant pain, regardless of severity, is energy consuming. You should make every effort to assist the patient in conserving this energy. There are times when the patient's pain can and should be relieved by medications. There are, however, numerous occasions when effective pain relief can be provided by basic patient care measures such as proper body alignment, change of position, use of heat or cold (if permitted by a physician's orders), back rubs and massages, and even simple conversation with the patient. Meaningful activity also has been found to help relieve pain. Whenever possible, a well-planned physical/occupational therapy regimen should be an integral part of the total rehabilitation plan.

Cast Fabrication

As mentioned previously, immobilization is often a part of the overall therapy of the orthopedic patient; casting is the most common and well-known form of long-term immobilization. In some instances, a corpsman may be required to assist in applying a cast or be directed to apply or change a cast. In this section, we will discuss the method of applying a short- and long-arm cast, and a short-leg cast.

In applying any cast, the basic materials are the same: webril or cotton bunting, plaster of Paris, a bucket or basin of tepid water, a water source (tap water), protective linen, gloves, a working surface, a cast saw, and seating surfaces for the patient and the corpsman. Some specific types of casts may require additional material.

Short-Arm Cast - A short-arm cast extends from the metacarpal-phalangeal joints of the hand to just below the elbow joint. Depending on the location and type of fracture, the physician may order a specific position for the arm to be casted. Generally, the wrist is in a neutral (straight) position with the fingers slightly flexed in the position of function.

Beginning at the wrist, apply three layers of webril. Then apply webril to the forearm and the hand, making sure that each layer overlaps the other by a third as shown in figure 5-4. Check for lumps or wrinkles and correct any by tearing the webril and smoothing.

The plaster of Paris is then dipped into the water for approximately 5 seconds. Gently squeeze to remove excess water, but do not wring out. Beginning at the wrist (fig. 5-4C) wrap the plaster in a spiral motion overlapping each layer by one-third to one-half. Smooth out the layers with a gentle palmar motion. When applying the plaster, make tucks by grasping the excess material and folding it under as if making a pleat. Successive layers cover and smooth over this fold. When the plaster is anchored on the wrist, cover the hand and the palmar surface before continuing up the arm (figs. 5-4D and 5-4E). Repeat this process until the cast is thick enough to provide adequate support, generally 4 to 5 layers. The final step is to remove any rough edges and smooth the cast surface. The ends of the cast are turned back and covered with the final layer of plaster, and the plaster is set for approximately 15 minutes and then trimmed with a cast saw as needed.

Long-Arm Cast - The procedure for a long-arm cast is basically the same as for a short-arm cast except the elbow is maintained in a 90 degrees position, the cast begins at the wrist and ends on the upper arm below the axilla, and the hand is not wrapped.

Short-Leg Cast - In applying a short- leg cast, seat the patient on a table with both legs over the side, flexed at the knee. Instruct the patient to hold the affected leg, with the ankle in a neutral position (90 degrees). Make sure that the foot is not rotated medially or laterally. Beginning at the toes, apply webril (figs. 5-5A, 5-5B, and 5-5C) in the same manner as for the short-arm cast, ensuring that there are no lumps or wrinkles. Apply the plaster beginning at the toes (fig. 5-5E), using the same technique of tucks and folds and smoothing as for the short-arm cast. Before applying the last layer, expose the toes and fold back the webril. As the final step, apply a footplate to the plantar surface of the cast using a generous thickness of plaster splints secured with one to two rolls of plaster (fig. 5-5F). This area provides support to the cast and a weight-bearing surface when used with a walking boot.

Whenever a cast is applied, you must provide the patient with written and verbal instruction for cast care and circulation checks, i.e., numbness, cyanosis, tingling of extremities, and instruct him or her to return immediately should any of these conditions occur. When a leg cast is applied, the patient must also receive instructions in the proper usage of crutches. The cast will take 24 to 48 hours to completely dry and must be treated gently during this time. Since plaster is water-soluble, the cast must be protected with a waterproof covering when bathing or during wet weather. Nothing must be stuck down the cast, i.e., coat hangers, as this can cause bunching of the padding and result in pressure sores. If swelling occurs, the cast may be split and wrapped with an ace bandage to alleviate pressure.

Cast Removal

A cast can be removed in two ways: by soaking in warm vinegar/water solution until it dissolves or in the usual way by cutting. To remove by cutting, cast cutters, spreaders, and bandage scissors are necessary. Cuts are made laterally and medially along the long axis of the cast and are widened with the use of spreaders. The padding is then cut with the scissors.

The Terminally Ill Patient

The terminal patient has many needs that are basically the same as those of other patients: spiritual, psychological, cultural, economic, and physical. What differs in these patients may be best expressed as the urgency to resolve the majority of these needs within a limited time frame. Death comes to everyone in different ways and at different times. For some patients, death is sudden following an acute illness. For others, death follows a lengthy illness. Death not only affects the individual patient; it affects family and friends, staff, and even other patients. Because of this, it is essential that all health care providers understand the process of dying and its effect on all people.

People view death from their individual and cultural value perspectives. An individual's personal perception of death often affects their moral and religious attitude toward it. Many people find the courage and strength to face death through their religious beliefs. These patients and their families often seek support from representatives of their religious faith. In many cases, patients who previously could not identify with a religious belief or the Supreme Being concept may indicate (verbally or nonverbally) a desire to talk with a spiritual representative. There will also be patients who throughout the whole dying experience will neither desire nor need spiritual support and assistance. In all these cases, it is the responsibility of the health care provider to be attentive and perceptive to the patient's needs and provide whatever support personnel that may be required.

An individual's cultural system influences behavior patterns. When we speak of cultural systems, we refer to certain norms, values, and action patterns of specific groups of people to various aspects of life. Dying is an aspect of life and is often referred to as the final crisis of living. In all of our actions, culturally approved roles frequently encourage specific behavior responses. For example, in the Caucasian, Anglo-European culture a dying patient is expected to show peaceful acceptance of his/her prognosis; the bereaved is expected to communicate grief. When people behave differently, the health care provider frequently has difficulty responding appropriately.

Within the last 10 years or so, a theory of death and dying has developed that provides all persons involved with the experience highly meaningful knowledge and skills. In this theory of death and dying (as formulated by Dr. Elizabeth Kubler-Ross in her book On Death and Dying), it is suggested that most people (both patients and significant others) go through five stages: denial, anger, bargaining, depression, and acceptance. The first stage, denial, is one of nonacceptance. "No, it can't be me, there must be a mistake!" It is not only important for the health care provider to recognize the denial stage with its behavior responses but also to realize that some people maintain denial up to the point of impending death. The next stage is anger. This is a period of hostility and questioning "Why me?" The third stage is bargaining. At this point, people revert to a culturally reinforced concept that good behavior is rewarded. Patients are often heard stating "I'd do anything if I could just turn this thing around." Once the patient realizes that bargaining is futile, they quickly enter the stage of depression. In addition to grieving because of his or her personal loss, it is at this point that the patient becomes concerned about his or her family and "putting affairs in order." The final stage comes when the patient accepts death as reality and is prepared for it. It is usually at this time that the patient's family requires more support than the patient.

Despite the fact that each of us expects to die and expects all others to die, there is no easy way to discuss death. To the strong and healthy, death is a frightening thought. The fact that sooner or later everyone dies does not make death easier. There are no procedure books that tell health care providers "how to do" death. The "how to" will only come from the individual health care provider who understands that patients are people. More than any other time in life, the dying patient needs to be treated as an individual person, not a thing, a number, or a disease.

An element of uncertainty and helplessness is almost always present when death occurs. Assessment and respect for the patient's individual and cultural value system are of key importance in planning the care of the dying. As health care personnel, we often approach a dying patient with some feelings of uncertainty, helplessness and anxiety. We feel helpless in being unable to perform tasks that will keep the patient alive; uncertain that we are doing all we can do to either make the patient as comfortable as possible or to postpone or prevent death altogether. We feel anxious about how to communicate effectively with patients, their family, and even among ourselves. This is a normal response since any discussion about death carries a high emotional risk for the patient as well as the health care provider. Nevertheless, communicating can provide both strength and comfort to all if done with sensitivity and dignity, and it is sensitivity and dignity that is the essence of all health care services.

Approved for public release; Distribution is unlimited.

The listing of any non-Federal product in this CD is not an endorsement of the product itself, but simply an acknowledgement of the source. 

Operational Medicine 2001

Health Care in Military Settings

This web version is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

Contact Us  ·  ·  Other Brookside Products