Admission records, re- or multiple admission records should be completed within 24 hours after the patient is admitted to the hospital

Entry and discharge records within 24 hours should be completed within 24 hours after the patient is discharged

Recording of admission deaths within 24 hours should be completed within 24 hours of the patient's death

Including name, gender, age, place of origin, ethnicity, marital status, occupation, date of admission, outpatient (emergency) diagnosis, residential address and telephone number, work unit and telephone number. The date and time of medical history collection, the person providing the history (reliability), the admission diagnosis, and the person recording the medical history. For pediatric patients, the names, occupations, workplaces, and phone numbers of parents should be written down.

Chief complaint: The main symptoms (or signs), location and duration stated by the patient when seeing a doctor

History of current illness: The patient’s detailed information on the occurrence, evolution, diagnosis and treatment of the disease, written in chronological order. The names of drugs, diagnoses and procedures provided by patients must be distinguished by quotation marks.

Past history: A patient’s past health and illnesses. Such as vaccination history, allergy history, blood transfusion history

Personal history: such as living habits and travel history

Marital and childbearing history, menstrual history

family history

Follow the order from outside to inside, from front to back, from shallow to deep, and conduct contrast examination of the affected side.

Oral vestibular examination

Dental and bite examination

Oral and oropharyngeal examination

Expression and consciousness check

Appearance and color inspection

Examination of other facial organs

Examination of the location and nature of lesions

Speech and auscultation examination

ordinary inspection

Lymph node examination: The examiner stands in the right front or rear of the patient, with the patient's head slightly lowered and slightly tilted to the examination side to relax the skin and muscles for easy palpation. According to a certain order, slide and palpate from shallow to deep. The general sequence is: occiput, behind the ear, in front of the ear, parotid gland, cheek, submandibular and submental; along the anterior and posterior edges of the sternocleidomastoid muscle, the anterior and posterior triangle of the neck until the supraclavicular fossa.

Facial shape and joint mobility examination

Masticatory muscle examination/mandibular movement examination/occlusal relationship examination

ordinary inspection

Secretory function test

For lumps that have a fluctuating sensation on palpation or are non-solid and fluid-containing, an injection needle can be used for puncture examination.

For clinical abscess puncture, a thick needle with an outer diameter of 0.9mm (20G) is often used, and for vascular lesions, a thin needle with an outer diameter of 0.7m (22G) is used. Puncture is contraindicated when carotid body tumors or arteriovenous malformations are clinically suspected; when tuberculous lesions are suspected, care should be taken when inserting the needle to avoid the formation of long-lasting sinus tracts due to puncture.

In principle, diagnosis and treatment should be completed in one phase; if biopsy must be performed first to confirm the diagnosis, the biopsy time and treatment time should be as close as possible.

excisional biopsy

excisional biopsy

frozen biopsy

fine needle aspiration biopsy

Automatic cutting needle biopsy

It is mostly used for the examination, diagnosis and treatment of maxillofacial and cervical blood vessels, arteriovenous insufficiency and benign and malignant tumors with rich blood supply, especially the interventional embolization treatment of maxillofacial arteriovenous malformations.

Thyroid cancer and intraoral ectopic thyroid can be diagnosed with 131I or 125I, and 125I has better resolution. 99mTc is mainly used to diagnose malignant tumors of the jaw Salivary gland inflammatory diseases and some tumors can be examined by salivary gland radionuclide imaging

The gold standard for clinical examination of diseases of the salivary gland duct system

High pressure steam sterilization

Boiling sterilization method

dry heat sterilization

chemical sterilization

The straight head of the micro electric grinder and the electric or pneumatic bone drill head can be sterilized with high-pressure steam or formaldehyde steam.

Formaldehyde steam or immersion sterilization of drill needles

The method of formaldehyde steam sterilization is to put the instruments into a closed sterilizer that should contain 36% to 40% formaldehyde. The purpose of sterilization can be achieved after 40 minutes.

For major surgeries related to the oral cavity, periodontal treatment, filling of cavities, removal of residual roots, etc. should be performed first. Also use 3% hydrogen peroxide solution, 1:3000-1:5000 potassium permanganate solution or 0.1% chlorhexidine solution to gargle or rinse.

In the skin removal area or bone removal area, the hair must be shaved at least 15cm around the incision. The skin removal area is disinfected and bandaged with 75% ethanol or iodophor;

The bone retrieval area should be prepared 2 days before surgery, disinfected and bandaged with ethanol once a day, and disinfected again on the morning of surgery.

Disinfection method

Disinfection range

Hole towel laying method

Triangular surgical field draping method

Quadrilateral surgical field draping method

Anatomy

parts

length

For large areas of venous bleeding or scar tissue and extensive bleeding during resection of certain tumors (such as venous malformations, neurofibromas, etc.), warm saline gauze can be used to compress and stop bleeding.

The most commonly used and common method

Superficial tiny blood vessels can be simply clamped

Larger bleeding points need to be ligated with silk thread after clamping, which is called ligation to stop bleeding. Electrocoagulation can also be used to stop bleeding.

Ligation of well-known or thick blood vessels to stop bleeding

external carotid artery ligation

Regional suturing to stop bleeding

Hypothermic anesthesia (body temperature lowered to about 32°C) can effectively reduce the blood volume of surrounding tissues

During the operation, the systolic blood pressure was reduced to about 10kPa (80mmHg)

Generally, about 30 minutes is appropriate, and it is contraindicated for patients with cardiovascular disease.

For fine-level dissection or separation of solid adhesion scar tissue, the instruments used are scalpels and surgical scissors.

This method causes little tissue damage and requires delicate and accurate movements. It should generally be performed under direct vision.

For the separation of normal muscle and loose connective tissue and the removal of encapsulated benign tumors

It is mainly performed with vascular forceps. It can also use knife handles, fingers, gauze, etc. It can be performed under indirect vision, which will cause great damage to the tissue.

On the basis of complete hemostasis, strict and correct alignment sutures are performed layer by layer from deep to shallow in order to achieve primary healing.

The tissues on both sides of the incision must be in good contact and correctly aligned; each layer must be sutured separately.

The tissue on both sides should be equal and symmetrical to avoid dead space, otherwise blood or fluid will accumulate, which will not only delay the healing process, but also easily lead to infection.

Sutures should be performed under no or minimal tension to avoid wound dehiscence and excessive scarring after healing. Determine the appropriate needle distance and margin according to the nature, site and intraoperative conditions of the surgery

The order of suturing should be the free side first and then the fixed side. On the contrary, it is easy to tear the tissue. This point should be followed when suturing intraoral mucosal flaps and free skin grafts or flaps.

When suturing the skin of the face and neck, in addition to involution sutures along the incisions of depressed wrinkles to make the scars consistent with the depth of the wrinkles, it is generally necessary to prevent involution and excessive eversion of the wound edges to avoid infection and obvious scars after healing. The suture should cover the entire thickness of the skin. When the skin edge is thin, part of the subcutaneous tissue should also be brought in. When inserting the needle, the needle tip should be perpendicular to the skin, and the distance between the needles on both sides of the skin incision should be equal to or slightly smaller than the subcutaneous distance.

The distance between the skin suture needle entry point and the wound edge (margin) and the suture spacing density (needle pitch) should be based on the principle of keeping the wound edge in contact with each other without cracks.

There should be no other tissue sandwiched between the sutured tissues to avoid affecting healing.

The tightness of the knot after sewing should be moderate

Avoid excessively long straight sutures in functional parts (such as corners of the mouth, lower eyelids, etc.) to avoid linear shrinkage of scars after healing, causing tissue and organ displacement.

Choose the right suture

In situ wound suturing method

Tension-relieving wound suturing

Sutures in special circumstances

Infected or contaminated wound

Wounds that exude a lot of fluid

Wounds with dead space

Wounds with incomplete hemostasis

According to the principle of drainage

sheet drainage

Yarn drainage

tubular drainage

Negative pressure drainage

Drainage time

Drainage site

Drainage fixation

refers to a wound that has not been invaded by bacteria

Face and neck surgical wounds

Refers to wounds that occur under non-sterile conditions

Wounds connected to the oral cavity, nasal cavity or intraoral surgery wounds; Wounds caused by various injuries. For example, the injury time is short and the stratomycetes have not invaded the deep tissue to cause purulent inflammation.

Wounds where bacteria have invaded, multiplied, and caused acute inflammation, necrosis, and suppuration, and wounds where surgery is performed under these circumstances

Abscess incision and drainage, osteomyelitis focus removal of the jaw

When removing drainage from a sterile or contaminated wound or when infection is suspected

When the dressing slips and cannot protect the wound

When there is a large amount of purulent secretion or exudate from the wound

When there is bleeding from the wound or suspected hematoma

When the wound is bandaged too tightly, affecting breathing or causing pain

When observing wound healing and skin flap nutrition

When the wound is not clean and hinders normal healing

Other situations should be determined according to different surgical requirements

It should be completed before the morning ward round to facilitate observation of the changes in the wound on the previous day.

The ideal location for dressing change is a specially designed dressing room. For patients who cannot get up and move around, dressing can be changed at the bedside

Protect the surgical area and wound, prevent contamination or secondary infection, and avoid further damage

Keep warm, stop bleeding, reduce edema and pain

Prevent or reduce fracture displacement

Fix the dressing to prevent it from falling off or shifting

When cleaning the wound and dressing it, attention should be paid to aseptic operation

When wrapping the bandage around the submandibular area and neck, special attention should be paid to maintaining a clear airway

The bandage should be smooth, close-fitting, and moderately tight

The wound in the parotid gland area should be bandaged with a certain amount of pressure and should be flexible to avoid salivary fistulas.

For incision and drainage wounds, appropriate pressure should be used for the first bandage to facilitate hemostasis.