Patient observation rules.
Methodology for measuring heart rate, blood pressure, respiratory rate, body temperature and diuresis control.
Clinical study of the patient , or an objective study of the patient ( Status praesens ), allows you to judge the general state of the body and the state of individual internal organs and systems. In order for the patient's objective study to be complete and systemic, the doctor conducts it according to a specific plan:
General examination of the patient (inspectio);
Feeling (palpatio);
Percussion (percussio);
Listening (auscultatio).
Other research methods are also carried out to study the state of all body systems: respiration, blood circulation, digestion, urination, lymphatic, endocrine, nervous, osteoarticular, etc. All diagnostic research methods are divided into basic and additional.
The main clinical methods include: interrogation, examination, palpation, percussion, auscultation, measurements. These methods make it possible to determine the further tactics of the doctor, to choose the optimal necessary methods of additional research.
General inspection
includes an assessment of the general condition of the patient, his consciousness, position, physique, measurement of body temperature, determination of facial expressions characteristic of some diseases, as well as an assessment of the condition of the skin, hair, visible mucous membranes, subcutaneous adipose tissue, lymph nodes, muscles, bones, etc. joints. The data obtained by the doctor during a general examination are of major diagnostic value, allowing, on the one hand, to identify the characteristic (although often nonspecific) signs of the disease, and on the other hand, to give a preliminary assessment of the severity of the pathological process and the degree of functional disorders.
The general condition of the patient.
The doctor develops an idea of the general condition of the patient (satisfactory, moderate, severe) throughout the entire examination of the patient, although in many cases such an assessment can be given at the first glance at the patient.
Consciousness.
Consciousness can be clear and confused. There are three degrees of impairment of consciousness:
1) Stupor a state of stunning, from which the patient can be brought out for a short time by talking to him. The patient is poorly oriented in the environment, answers questions slowly, with a delay.
2) Sopor(hibernation) - a more pronounced disturbance of consciousness. The patient does not respond to others, although sensitivity, including pain, is preserved, does not answer questions or answers in monosyllables (yes - no), reacts to examination.
3) Coma-
the patient is unconscious, does not respond to speech addressed to him, to a doctor's examination. There is a decrease or disappearance of basic reflexes.
Comatose states can be as follows:
Alcoholic coma resulting from alcohol intoxication;
Apoplexy coma - observed with cerebral hemorrhage;
Hypo- and hyperglycemic coma - with a disease of the pancreas (diabetes mellitus) - depending on the use of antidiabetic drugs and the degree of development of the disease;
Hepatic coma - develops in acute or subacute liver dystrophy, cirrhosis and other conditions;
Uremic coma occurs in acute toxic kidney damage, etc.;
Epileptic coma - observed with epileptic seizures.
There may be irritative disorders of consciousness (hallucinations, delusions), arising from a number of mental and infectious diseases. Examination can provide insight into other mental disorders, such as depression, apathy, agitation, delirium. In the development of a number of somatic diseases, a large place is currently given to mental factors (psychosomatic diseases), which do not have organ damage in their basis.
The position of the patient.
Distinguish between active, passive and forced position.
Active position is the ability to actively move, at least within the hospital ward, although the patient may experience various painful sensations.
Passive position - a condition when the patient cannot independently change the position given to him.
Forced they call a position that somewhat relieves the patient's suffering (pain, shortness of breath, etc.). Sometimes the forced position of the patient is so characteristic of a particular disease or syndrome that it allows a correct diagnosis to be made at a distance.
With an attack of bronchial asthma (suffocation, accompanied by a sharp difficulty in exhaling), the patient takes a forced position, sitting, resting his hands on the back of a chair, the edge of the bed, knees. This allows you to fix the shoulder girdle and connect additional respiratory muscles, in particular the muscles of the neck, back and pectoral muscles, which help to exhale.
With an attack of cardiac asthma and pulmonary edema caused by blood overflow of the vessels of the pulmonary circulation, the patient seeks to take an upright position (sitting) with his legs down, which reduces blood flow to the right heart and makes it possible to somewhat relieve the pulmonary circulation (orthopnea position).
Patients with inflammation of the pleural layers (dry pleurisy, pleuropneumonia) and intense pleural pain often take a forced position - lying on the sore side or sitting, pressing the chest with their hands on the side of the lesion. This position limits the respiratory movement of the inflamed pleural sheets and friction them against each other, which helps to reduce pain. Many patients with unilateral lung diseases (pneumonia, lung abscess, bronchiectasis) try to lie on their sore side. This position facilitates the breathing excursion of the healthy lung, and also reduces the flow of phlegm into the large bronchi, which reflexively causes a painful cough.
The physique of the patient. Assessing the physique (habitus), take into account the constitution, body weight and height of the patient, as well as their ratio (weight and height indicators). The patient's constitution (constitution - structure, addition) is a combination of functional and morphological characteristics of the body, formed on the basis of hereditary acquired exo - and endogenous factors.
The main types are 3:
Asthenic, characterized by the transformation of growth over mass (limbs over the body, chest over the abdomen). The heart and parenchymal organs in asthenics are relatively small, the lungs are elongated, the intestines are short, the mesentery is long, the diaphragm is low. Blood pressure is often lowered, secretion and gastric motility, intestinal absorption capacity, hemoglobin content in the blood, erythrocyte count, cholesterol, calcium, uric acid, and sugar levels are reduced. There is hypofunction of the adrenal glands and gonads, hyperfunction of the thyroid gland and pituitary gland;
Hypersthenic, characterized by the predominance of mass over growth. "The body is relatively long," the limbs are short, the abdomen is significant, the diaphragm is high. All internal organs, with the exception of the lungs, are relatively large in size. The intestines are longer, thicker and lighter. Persons of the hypersthenic type are characterized by higher blood pressure, high levels of hemoglobin, erythrocytes and cholesterol in the blood, hypermotility and hypersecretion of the stomach. The secretory and absorption functions of the intestines are high. Hypofunction of the thyroid gland, some increase in the function of the gonads and adrenal glands is often observed;
Normosthenic - differs in the proportionality of the physique and occupies an intermediate position between asthenic and hypersthenic.
The nature of the patient's movements. The character of movements, gait are noted. Gait disorders occur in various neurological diseases and lesions of the musculoskeletal system. The so-called "duck gait" is observed with congenital dislocation of the hip.
Skin.
Skin examination should be carried out in good natural light. Skin color can also be due to congenital features of the body that are not associated with pathology. So, pallor of the skin in healthy people is noted with constitutional hypopigmentation of the general cover or with a deep network of skin capillaries, with excessive deposition of fat in the skin, spasm of skin vessels. It is worth evaluating skin color taking into account race and nationality, living conditions and recreation. There are three races: Caucasian, Mongoloid and Negroid, which differ significantly in skin color (first of all).
Congenital absence of normal pigmentation is called albinism (albus - white), sometimes depigmentation foci (vitiligo) are found.
Skin rashes are of a varied nature and are of important diagnostic value, both for the recognition of infectious diseases, and allergic and other pathologies.
To assess the nature of the skin lesion, the following terminology is used:
Macula is a speck;
Papule - swelling, nodule;
Vesicle - vesicle;
Pustule - a bubble of pus;
Ulkus is a sore.
In different pathological conditions, there may be a phased rash: macula -> papule -> vesicle -> pustule; in other conditions, there is a one-stage rash of elements that have a polymorphic nature (spotty-pustular-vesicular).
With various pathological conditions of a congenital and acquired nature, hemorrhagic manifestations on the skin and mucous membranes are revealed:
Petechiae (petechie) - the smallest capillary hemorrhages on the skin and mucous membranes of a rounded shape from a point to a lentil. When pressed with fingers, they do not disappear - unlike roseola;
Ecchymoses (ecchymoses), or bruising, occur as a result of subcutaneous hemorrhages, their size and number vary widely;
Subcutaneous hematomas - hemorrhages in the subcutaneous base with the formation of a cavity filled with coagulated blood. At the beginning, the subcutaneous hematoma looks like a tumor-like formation, the color of which, in the process of its resorption, changes from purple-red to yellow-green.
Inflammatory skin lesions can manifest itself in the form of diaper rash (with the appearance of redness, cracks, maceration and rejection) and pyodermia (pyodermia) - with lesions of the skin and subcutaneous tissue by pyogenic microbes (staphylococci - staphylococcus, streptococci - streptopyoderma). There is a kind of skin reaction resulting from a violation of the body's reactivity, skin sensitization to exogenous and endogenous stimuli. The pathological condition of the skin caused by the enhanced function of the sebaceous glands is called seborrhea and is associated with changes in the neuro-endocrine reactivity of the body. When examining the skin, attention is paid to its color, moisture, elasticity, the condition of the hairline, the presence of rashes, hemorrhages, vascular changes, scars, etc.
Skin coloration. The practitioner is most often faced with several options for discoloration of the skin and visible mucous membranes: pallor, flushing, cyanosis, jaundice, and brownish (bronze) skin color.
Pallor
can be due to two main reasons:
1) anemia of any origin with a decrease in the number of erythrocytes and hemoglobin content per unit of blood volume;
2) pathology of peripheral circulation: a) a tendency to spasm of peripheral arterioles in patients with aortic heart disease, hypertensive crisis, some kidney diseases;
b) redistribution of blood in the body in acute vascular insufficiency (fainting, collapse) in the form of blood deposition in the dilated vessels of the abdominal cavity, skeletal muscles and, accordingly, a decrease in blood circulation in the skin and some internal organs.
It should also be borne in mind the constitutional features of skin color in persons with asthenic constitutional type (deep location of capillaries under the skin or their weak development) and individual reactions of peripheral vessels (tendency to reflex spasm) to emotions, stress, cold, which are found even in healthy people ...
You should know that the pallor of the skin caused by anemia is necessarily accompanied by the pallor of the visible mucous membranes and conjunctiva, which is not typical for cases of constitutional pallor and pallor resulting from spasm of peripheral vessels.
Red skin color (flushing) can be due to two main reasons:
1) expansion of peripheral vessels:
a) with fevers of any origin;
b) when overheated;
c) after using certain drugs (nicotinic acid, nitrates) and alcohol;
d) with local inflammation of the skin and burns;
e) with neuropsychic arousal (anger, fear, shame, etc.);
2) an increase in the content of hemoglobin and the number of erythrocytes per unit of blood volume (erythrocytosis, polycythemia), in these cases, hyperemia has a peculiar purple hue, combined with a slight cyanosis of the skin (cyanosis).
It should also be borne in mind the tendency to reddish color of the skin in persons of the hypersthenic constitutional type.
Cyanosis- bluish coloration of the skin and visible mucous membranes, due to an increase in the peripheral blood (in a limited area of the body or diffusely) in the amount of reduced hemoglobin. Cyanosis appears if the absolute amount of reduced hemoglobin in the blood exceeds 40-50 g / l. (Recall that the amount of total hemoglobin in the blood of a healthy person ranges from 120-150 g / l).
According to the main reasons, there are three types of cyanosis:
1) central cyanosis develops as a result of insufficient oxygenation of blood in the lungs with various diseases of the respiratory system, accompanied by respiratory failure. This is a diffuse (warm) cyanosis of the face, trunk, limbs, often having a peculiar grayish tint;
2) peripheral cyanosis (acrocyanosis) appears when blood flow slows down in the periphery, for example, with venous congestion in patients with right ventricular heart failure.
In these cases, oxygen extraction by tissues increases, which leads to an increase in the content of reduced hemoglobin (more than 40-50 g / l), mainly in the distal regions (cyanosis of the tips of the fingers and toes, the tip of the nose, ears, lips). The limbs are cold to the touch due to a sharp slowdown in peripheral blood flow;
H) limited, local cyanosis can develop as a result of stagnation in peripheral veins when they are compressed by a tumor, enlarged lymph nodes, or with venous thrombosis (phlebothrombosis, thrombophlebitis).
Jaundice
in most cases, it is caused by the saturation of the skin and mucous membranes with bilirubin with an increase in its content in the blood. In accordance with the main causes of hyperbilirubinemia, there are three types of jaundice:
1) parenchymal (with damage to the hepatic parenchyma);
2) mechanical (with obstruction of the common bile duct with a stone or its compression by a tumor);
3) hemolytic (with increased hemolysis of erythrocytes).
Bronze (brown) skin staining observed with adrenal insufficiency. Brownish pigmentation usually manifests itself not diffusely, but in the form of spots, especially on the skin of open parts of the body (face, neck, hands), as well as in places subject to friction (in the armpits, in the lumbar region, on the inner surfaces of the thighs, genitals) and in the skin folds of the palms.
The initial signs of mild jaundice (subicterus) are best detected by examining the sclera, soft palate, and lower surface of the tongue.
Assessment of the functional state of the patient.
Students must:
Have an idea about the technique of nursing examination.
Know:
- rules and techniques for general inspection.
- types of impairment of consciousness.
- types of position in bed.
- Types and periods of fever.
- Patient problems.
Be able to:
- to conduct an objective examination of the satisfaction of the basic needs of the patient;
- to evaluate the data of the patient's physical development;
- to assess the appearance, consciousness of the patient, position in bed, condition of the skin and mucous membranes.
- determine edema, water balance.
- Train the patient and his relatives in nursing manipulations.
Work it out:
- technique for measuring growth;
- technique for measuring body weight;
- determination of water balance;
- technique for measuring body temperature;
- Technique for digital and graphic recording of indicators of the patient's functional state.
Fix:
- organizing the collection of objective data.
Location: preclinical practice room.
Time spending: 270 minutes.
Topic: 3.2.1 "Assessment of the functional state of the patient."
Explanatory note.
This development is intended to implement the requirements of the State Standard for the training of nurses on the topic "Assessment of the functional state of the patient"
This educational and methodical complex is compiled according to the program for the discipline Technology of medical services. In the specialty 060109 "Nursing".
The topic "Assessment of the functional state of the patient" is dealt with in the course of studying the basics of nursing, because knowledge of the rules for examining a patient contributes to improving the quality of training of medical workers.
The main goal of the discipline is to give students the necessary theoretical data, skills, to lay the foundation for professional actions.
Currently, in many developing countries, nurses independently try to assess the patient's condition.
To control students' knowledge, situational tasks, test tasks, terminological dictation are offered.
Topic: 3.2.1 "Assessment of the functional state of the patient."
PLAN - CHRONOCARD
1. Organizational moment - 5 minutes
2. Motivation - 10 minutes
3. Introductory control - 10 minutes
4. Explanation of the new material (discussion)
- 50 minutes
5. Break - 10 minutes
6. Independent work under supervision
Teacher - 110 minutes
7. Break - 10 minutes
8. Reinforcement (problem solving, terminological dictation, filling out the temperature sheet) - 30 minutes
9. Final control (tests) - 20 minutes
10. Summing up
Homework (compiling a glossary, solving a problem) - 15 minutes
Topic: 3.2.1 "Assessment of the functional state of the patient."
Equipment of the lesson
Temperature sheet
Thermometer
Stadiometer
Scales (floor electronic, medical)
Pen (blue, black, blue)
Learning module
Didactic material
Topic: 3.2.1 "Assessment of the functional state of the patient."
Literature
Main:
Mukhina S.A., Tarnovskaya I.I. "Theoretical foundations of nursing", "A practical guide to the basics of nursing" Moscow publishing group "GEOTAR-Media" 2009
Obukhovets T.P. "Fundamentals of Nursing: Workshop" Rostov-on-Don "Phoenix" 2004
Lecture by the teacher.
Educational-methodical complexes on discipline topics - 40 pcs.
Additional:
Educational-methodical manual on "Fundamentals of nursing" for students, v. 1.2, edited by A. Shpirna, Moscow, VUNMC 2003
Mukhina S.A., Tarnovskaya I.I. "Atlas of Manipulation Technique" by Mosca 1998
Abramova G.S. Psychology in Medicine - M., 1998
Evplov V. Handbook of the senior (chief) nurse. Rostov-on-Don. Phoenix Publishing House, 2000
Journal "Medical assistance", M., 2000-2008
Journal "Nurse" M., 2000-2008
Sister of Mercy magazine, M., 2001-2008
Journal "Nursing", M., 2000-2008
Information block.
ΙΙ. Objective information - these are observations or measurements carried out by a person collecting information using special methods.
Objective information about the patient, obtained as a result of:
1. examination of the patient;
2.from the patient's medical environment(doctors, m / s, ambulance team);
3.examination of medical records(ambulance card, medical history, examinations, tests) ;
4. study of special medical literature(reference books for nursing, nursing standards, atlas of manipulation techniques, a list of nursing diagnoses, the journal "Nursing") .
The objective method includes:
1.M / s observation of how the patient is meeting his 14 basic vital needs;
2. inquiry of the medical environment;
3. study of medical documentation;
4. study of special medical literature in relation to this patient.
Rules and technique of external examination:
An objective examination of the patient begins with a general examination. This research method gives the nurse the most complete objective information about the patient. Therefore, the m / s should have a good command of this research method.
Observation should be carried out in diffused daylight or bright artificial lighting, and the light source should be on the side, so the contours of various parts of the body are more prominently distinguished.
Introduction
1. Assessment of the functional state of the patient
2. Admission to a medical institution
3. Sanitization of the patient
Conclusion
Literature
Introduction
A hospital (lat. Stationarius - standing, motionless) is a structural subdivision of a medical and preventive institution (hospital, medical unit, dispensary), intended for examination and treatment of patients in a round-the-clock (except for day hospital) stay in this institution under the supervision of medical personnel.
The main structural units of the hospital are the admission department (emergency room), treatment rooms, and the administrative part.
Inpatient care begins at the admission department. The emergency room is an important medical and diagnostic department, designed for registration, admission, initial examination, anthropometry, sanitary and hygienic treatment of incoming patients and the provision of qualified (emergency) medical care. Because of how professionally, quickly and orderly the medical staff of this department acts, to a certain extent the success of the patient's subsequent treatment depends, and in case of urgent (urgent) conditions, his life also depends. Each incoming patient should feel a caring and friendly attitude towards himself in the admission department. Then he will be imbued with confidence in the institution where he will be treated.
Thus, the main functions of the admission department are as follows.
Reception and registration of patients.
Medical examination of patients.
Providing emergency medical care.
Determination of the in-patient department for hospitalization of patients.
Sanitary and hygienic treatment of patients.
Registration of the relevant medical documentation.
Transportation of patients.
1. Assessment of the functional state of the patient
A nurse in the admission department measures the temperature, checks the documents of incoming patients; notifies the doctor on duty about the arrival of the patient and his condition; fills in the passport part of the medical history for the patient, registers in the book of registration of patients who are in inpatient treatment; enters the passport part of the patient into the alphabet book; when the patient is in a satisfactory condition, performs anthropometry (measures height, chest circumference, weighs); quickly and accurately fulfills the doctor's prescription for emergency care, strictly observing asepsis; accepts a receipt from the patient of values, at the same time explains the procedure for obtaining them, introduces the rules of conduct in the hospital; organizes the sanitary treatment of the patient, the delivery (if necessary) of his things for disinfection (disinsection); informs in advance (by phone) the nurse on duty of the department about the patient's admission; organizes the sending of the patient to the department or accompanies him herself.
For a general assessment of the patient's condition, the nurse must determine the following indicators.
The general condition of the patient.
The position of the patient.
The state of consciousness of the patient.
Anthropometric data.
The general condition of the patient
The assessment of the general condition (severity of the condition) is carried out after a comprehensive assessment of the patient (using both objective and subjective research methods).
The general condition can be determined by the following gradations.
Satisfactory.
Medium severity.
Heavy.
Extremely hard (preagonal).
Terminal (agonal).
The state of clinical death.
If the patient is in a satisfactory condition, anthropometry is performed.
Anthropometry(Greek antropos - a person, metreo - to measure) - an assessment of a person's physique by measuring a number of parameters, of which the main (mandatory) ones are height, body weight and chest circumference. The nurse registers the necessary anthropometric indicators on the title page of the inpatient's medical record
Measurement results temperature entered in the Individual temperature sheet. He is brought in in the admission department along with a medical card for each patient admitted to the hospital.
In addition to the graphical recording of temperature measurement data (scale "T"), curves of the pulse rate (scale "P") and blood pressure (scale "BP") are plotted in it. In the lower part of the temperature sheet, the data on the counting of the respiratory rate in 1 min, body weight, as well as the amount of liquid drunk and excreted urine (in ml) are recorded. Data on bowel movements ("stool") and sanitization performed are indicated with a "+" sign.
Nursing staff should be able to determine the basic properties of the pulse: rhythm, frequency, tension.
Pulse rhythm determined by the intervals between the pulse waves. If the pulse oscillations of the artery wall occur at regular intervals, therefore, the pulse is rhythmic. In case of rhythm disturbances, an incorrect alternation of pulse waves is observed - an irregular pulse. In a healthy person, the contraction of the heart and the pulse wave follow each other at regular intervals.
Heart rate count within 1 min. At rest, a healthy person has a pulse of 60-80 per minute. With an increase in heart rate (tachycardia), the number of pulse waves increases, and when the heart rate slows down (bradycardia), the pulse is rare.
Pulse voltage determined by the force with which the researcher must press the radial artery to completely stop its pulse oscillations.
The pulse voltage depends, first of all, on the value of systolic blood pressure. At normal arterial pressure, the artery is compressed with moderate force, therefore, the pulse of moderate tension is normal. With high blood pressure, it is more difficult to compress the artery - such a pulse is called tense, or hard. Before examining the pulse, you need to make sure that the person is calm, not worried, not tense, and his position is comfortable. If the patient performed some kind of physical activity (brisk walking, housework), suffered a painful procedure, received bad news, the pulse study should be postponed, since these factors can increase the frequency and change other properties of the pulse.
The data obtained from the study of the pulse on the radial artery is recorded in the "Medical record of an inpatient", a care plan or an outpatient card, indicating the rhythm, frequency and tension.
In addition, the heart rate in an inpatient hospital is marked with a red pencil in the temperature sheet. In the column "P" (pulse) enter the pulse rate - from 50 to 160 per minute.
Blood pressure measurement
Arterial pressure (BP) is the pressure that is generated in the arterial system of the body during heart contractions. Its level is influenced by the magnitude and speed of cardiac output, heart rate and rhythm, peripheral resistance of the arterial walls. Blood pressure is usually measured in the brachial artery, in which it is close to the pressure in the aorta (can be measured in the femoral, popliteal, and other peripheral arteries).
Normal indicators of systolic blood pressure range from 100-120 mm Hg. Art., diastolic - 60-80 mm Hg. Art. To a certain extent, they also depend on the person's age. So, in the elderly, the maximum permissible systolic pressure is 150 mm Hg. Art., and diastolic - 90 mm Hg. Art. A short-term increase in blood pressure (mainly systolic) is observed during emotional stress, physical stress.
Observing breathing, in some cases it is necessary to determine its frequency. Normally, breathing movements are rhythmic. Respiratory rate for an adult at rest it is 16-20 per minute, for women it is 2-4 more breaths than for men. In the "lying" position, the number of breaths usually decreases (up to 14-16 per minute), in the upright position it increases (18-20 per minute). In trained people and athletes, the respiratory rate can decrease and reach 6-8 per minute.
The combination of inhalation and subsequent exhalation is considered one breathing movement. The number of breaths per minute is called the respiratory rate (RR) or simply the respiratory rate.
Factors leading to increased heart rate can cause an increase in depth and rapid breathing. This is physical activity, increased body temperature, strong emotional experience, pain, blood loss, etc. Breathing should be monitored unnoticed by the patient, since he can arbitrarily change the frequency, depth, and rhythm of breathing.
2. Admission to a medical institution
The duties of a nurse also include filling out the title page of the medical history: passport part, date and time of admission, diagnosis of the sending institution, statistical coupon for an admitted patient.
The patient is examined on a couch covered with oilcloth. After receiving each patient, the oilcloth is wiped with a rag moistened with a disinfectant solution. Patients admitted to the hospital, before being sent to the diagnostic and treatment department, undergo complete sanitary treatment in the admission department with the replacement of underwear. Patients who are shown resuscitation measures and intensive care can be sent to the department of anesthesiology and intensive care without sanitization. A patient entering inpatient treatment must be familiarized in the admission department with the daily routine and the rules of behavior of patients, about which a note is made on the title page of the medical history.
All medical documentation is drawn up by the nurse of the admission department after the patient has been examined by a doctor and the decision on his hospitalization in this medical institution, or outpatient appointment. The nurse measures the patient's body temperature and records information about the patient in the "Register of admission (hospitalization) and refusal of hospitalization" (form No. 001 / y): last name, first name, patronymic of the patient, year of birth, insurance policy data, home address, where it was delivered from and by whom, the diagnosis of the sending institution (polyclinic, ambulance), the diagnosis of the admission department, as well as to which department it was sent. In addition to registering the patient in the Patient Admission Log, the nurse draws up the title page of the Hospital Patient's Medical Record (Form No. 003 / y). Almost the same information about the patient is recorded on it as in the "Hospitalization Log", the data of the insurance policy is registered (in the case of planned hospitalization, it is mandatory when admitting the patient). Here you should write down the telephone number (home and office) of the patient or his immediate family.
3. Sanitization of the patient
Sanitization is necessary, first of all, to prevent nosocomial infection.
A nurse supervises the sanitary and hygienic treatment of the patient.
In the examination room, the patient is undressed, examined for pediculosis and prepared for sanitary and hygienic treatment. There is a couch, a table, chairs, a thermometer on the wall (the air temperature in the examination room must be at least 25 ° C).
Stages of sanitary and hygienic treatment of patients.
Examination of the patient's skin and hair.
Cutting hair, nails, shaving (if necessary).
Shower or hygienic bath.
Examination of the patient's skin and hair
Examination of the skin and hair of the patient is carried out in order to identify pediculosis (lice). Various types of lice can be found (head lice - affects the scalp; clothing - affects the skin of the body; pubic - affects the hairy surface of the pubic region, hairy armpits and face - mustache, beard, eyebrows, eyelashes. The presence of nits (lice eggs, which are glued by the female to the hair or fibers of tissue) and the insects themselves; itching of the skin; traces of scratching and impetiginous (pustular) crusts on the skin.
In case of detection of pediculosis, a special sanitary and hygienic treatment of the patient is carried out; the nurse makes an entry in the "Journal of examination for pediculosis" and puts a special mark ("P") on the title page of the medical history, and also reports the detected pediculosis to the sanitary-epidemiological station.
If head lice is not detected, the nurse helps the patient to undress, then fills in two copies of the "Admission receipt" (form No. 1-73), which indicates a list of things, their brief description. One copy of the receipt is put into the "Medical record of an inpatient", the second is attached to the things sent to the storage room.
Then the patient, accompanied by his sister, goes to the bathroom. The washing of the patient can be done by a nurse or a nurse under the supervision of a nurse. Depending on the patient's condition, sanitization can be complete (bath, shower) or partial (wiping, washing). The patient is washed with a washcloth and soap: first the head, then the body, upper and lower extremities, groin, perineum.
The duration of the procedure is no more than 20 minutes. The presence of a nurse is mandatory, she is always ready to provide first aid in case of a possible deterioration of the patient's condition.
To perform rubdown, the patient is placed on a couch covered with oilcloth. Sponge moistened with warm water, wipe the neck, chest, hands. Dry these parts of the body with a towel and cover them with a blanket. In the same way, they wipe the stomach, then the back and lower limbs.
After sanitization, the patient is put on clean hospital underwear, a dressing gown (pajamas), and slippers. Sometimes you are allowed to use your own linen, which must be changed according to the hospital's schedule.
All data on the treatment of an admitted patient must be recorded in the medical history so that the ward nurse can repeat the treatment in 5-7 days.
admission patient
In case of a serious condition of the patient, he is taken to the intensive care unit or the intensive care unit without sanitary and hygienic treatment.
Conclusion
The main tasks of the admission department of a medical institution are: 1 Reception, examination by the doctor on duty, initial clinical examination, sanitization and subsequent referral of patients to the appropriate department; 2 Provision of emergency medical care to all patients in need; 3 Organization of discharge of patients from the hospital and their transfer to other medical institutions; 4 Identification, registration and analysis of defects in the provision of medical care to patients at the pre-hospital stage and the development of measures to prevent them. Examination and treatment of the patient begins from the moment he is admitted to the emergency department and includes: clinical examination in the emergency department by the doctor on duty; performing the necessary laboratory, functional, X-ray and other studies; conducting, if necessary, consultations of specialist doctors and councils; implementation of urgent medical measures.
Compliance with the sanitary and epidemiological regime in the admission department is an integral part of the sanitary and epidemiological regime of the hospital and provides for the following measures.
Mandatory sanitary and hygienic treatment of incoming patients.
Emergency notification of the sanitary and epidemiological service (by phone and by filling out a special form) and providing all necessary measures if an infectious disease, food poisoning, or head lice is detected in a patient.
Regular thorough damp cleaning of rooms and surfaces of objects.
The use of various methods of disinfection (boiling, the use of disinfectant solutions and ultraviolet radiation).
Literature
1. Mukhina S.A., Tarnovskaya I.I. A practical guide to the subject from "Fundamentals of Nursing". Tutorial. - M.: Rednik, 2002- 35s.
2. Oslopov V.N., Bogoyavlenskaya O.V. General patient care in a therapeutic clinic. Tutorial. Publisher: GEOTAR-Med. - M .: - 24s.
3. Directory of general practitioner. In 2 volumes. / Ed. Vorobieva N.S. –M .: Publishing house Eksmo, 2005- 26 p.
4. Yaromich I.V. Nursing. Study guide / 5th ed. LLC "Onyx 21st century", 2005-24s.
Elements of hygienic patient care: the concept of hygienic care, skin care and prevention of pressure sores, rules for the care of hair, ears, eyes, nose, oral cavity and dentures.
Hygienic care for patients is the main component of the treatment and protective regime of the hospital department. He is unchanging includes care of skin, hair, nails, ears, eyes, nose, oral cavity and dentures (if any). It should be regular and observed by all patients on their own or carried out with the help of service personnel.
Skin care. Skin care is an integral part of hygienic care for the sick, disabled, elderly and elderly people. Cleanliness of the skin is essential for its normal functioning and prevention of various skin diseases and conditions. Secretion of sebaceous and sweat glands, dust, horny scales contribute to skin pollution. So necessary daily to carry out morning and evening toilet: washing, washing, washing hands before meals and after using the toilet. In addition, in patients on bed and strict bed rest, it is necessary to wash and wipe dry daily. places of formation of diaper rash... These include: axillary and groin areas, folds of skin under the breasts and on the abdomen in obese people, and other folds. Take a bath or shower at least 1 time per week. If the patient is motionless or there are contraindications, it is necessary to perform a wet rubdown.
Bedsore- it deep lesions of the skin and soft tissues up to their death as a result of prolonged squeezing... Pressure ulcers can form wherever there are bony protrusions. With the patient's position on the back these are the sacrum, heels, shoulder blades, sometimes the back of the head and elbows. At position sitting these are the ischial tubercles, feet, shoulder blades. When lying down on belly these are the ribs, knees, toes from the back, the crests of the ilium. Signs bedsores is an the appearance of a pale area of the skin, then a bluish-red color without clear boundaries, then the epidermis sloughs off, bubbles form. Further, tissue necrosis occurs, spreading deep into the tissues and to the sides. Grade I- limited to the epidermal and dermal layers. The skin is not broken. There is a stable hyperemia with cyanotic-red spots, which does not disappear after the cessation of pressure. Treatment is conservative. Grade II- shallow superficial violations of the integrity of the skin, extending to the subcutaneous fat layer. Persistent hyperemia with cyanotic-red spots remains. Detachment of the epidermis occurs. Treatment is conservative. Grade III- complete destruction of the skin in its entire thickness to the muscle layer with penetration into the muscle itself. Surgical treatment. Grade IV- damage to all soft tissues. The formation of a cavity with damage to the underlying tissues (tendons, up to the bone). Surgical treatment.
TO predisposing factors include: disorders of local blood circulation, innervation and tissue nutrition. The occurrence of pressure ulcers contribute to poor patient care, untidy maintenance of bed and underwear, an uneven mattress, food debris in bed and, in general, a long stay of the patient in one position. Treatment carried out in accordance with the degree of tissue damage. Grades I and II are treated by rubbing the formed pressure ulcers 1-2 times a day with 5-10% potassium permanganate solution, 5% iodine solution, 1% brilliant green solution and applying a dry bandage. III and IV degrees of pressure ulcers are treated by a surgeon: dead tissue is removed, an ointment bandage is applied with solcoseryl, honey, Vishnevsky's ointment, etc., quartzing, aerosol preparations are prescribed.
Care and prevention of bedsores. Organize bed, mattress, aids, food, drink. Take into account not only physiological, but also social, psycho-emotional needs of the patient. Conduct a current assessment of the condition of the skin at least 1 time a day (in the morning). Change the position of the patient every two hours, lifting him above the bed, laying him alternately on the right or left side, stomach. Examine daily the skin in places of possible formation of pressure ulcers: sacrum, heels, ankles, shoulder blades, elbows, occiput, greater trochanter of the femur, inner surfaces of the knee joints. Daily wash the places of possible formation of pressure ulcers 2 times a day (morning and evening) with warm water and neutral soap: wipe dry with a towel (make blotting movements, wiping dry with a towel); treat with a napkin dipped in warm camphor alcohol or ethyl alcohol (40 °); apply a protective cream or sprinkle with powder; to rub soft tissues in places of possible formation of pressure ulcers with massage techniques. Do not massage in the area of protruding bone areas. Shake crumbs off sheets after feeding. Eliminate unevenness, eliminate folds on bedding and underwear. This must be done every 2 hours. Change wet or soiled laundry immediately. Determine the quantity and quality of food consumed. Food should contain at least 120 g of protein. Ensure adequate fluid intake per day, at least 1.5 liters. Use a foam rubber circle in a pillowcase under the patient's sacrum and foam rubber circles under the patient's elbows and heels, an anti-decubitus mattress. They eliminate pressure on the skin. Encourage the patient to change position in bed using crossbars and other devices. Encourage the patient to be active if he can walk. For urinary incontinence: change diapers every 4 hours. For men, use urine bags. For fecal incontinence: change diapers immediately followed by washing.
Hair care. Men get their hair short and wash their hair once a week during a hygienic bath. Hair should be combed daily to remove dust and dandruff. To do this, take a fine comb. Short hair is combed from roots to ends, and long hair is divided into strands and slowly combed from ends to roots, trying not to pull them out. A comb dipped in a vinegar solution is good at combing out dandruff and dust. Shampooing, nail clipping are carried out once every 7 days.
Ear care. Caring for healthy ears is expressed in regular washing with warm water and soap. Under no circumstances should you clean the external ear canal with sharp objects! This can damage the eardrum or the wall of the ear canal. If a sulfur plug has formed, it is removed.
Eye care Pour sterile vaseline oil into one beaker, and furacilin solution into the other in order to maintain asepsis. Using a pair of tweezers, moisten a ball with vaseline oil, pressing it lightly against the sides of the beaker. Take the ball in your right hand and rub one eyelid in the direction from the outer corner of the eye to the inner one (softening and detachment of purulent crusts is ensured). Wipe the eyelid with a dry ball in the same direction (removal of exfoliated crusts is ensured). Moisten the ball in the furacilin solution in the same way and repeat rubbing in the same direction (eye treatment with antiseptic agents is provided). Repeat rubbing 4-5 times with different balls in order to maintain infectious safety. In the presence of pus-like discharge in the corners of the eyes (treatment of the conjunctival cavity is provided)
Nose care In a seriously ill person, a large amount of mucus and dust accumulates on the nasal mucosa, which makes breathing difficult and aggravates the patient's condition. Weakened patients cannot free the nasal passages on their own, therefore, the attendant must remove the formed crusts daily. Take the turunda with tweezers, moisten it in petroleum jelly, squeeze it slightly (infectious safety is observed). Transfer the turunda to the right hand and introduce it with rotational movements into the nasal passage for 1-3 minutes, lifting the tip of the patient's nose with the left hand (softening of the crusts in the nasal passages is ensured). Remove the turunda with rotational movements from the nasal passage (crusts are removed from the nasal passages).
Caring for dentures Ask the patient to remove the dentures and place them in a special cup. Bring a cup with dentures, a toothbrush, toothpaste, a large napkin, and a towel to the sink. Place a large napkin on the bottom of the sink. Open the water tap. Use a paper towel and moisten the toothbrush with cool water. Apply toothpaste to it, thoroughly brush your dentures, holding them in your hands above the sink, directing the brush away from you. Rinse dentures under running water.
23 Elements of physiotherapeutic patient care: segmental reflex therapy and its types (setting mustard plasters, compresses, application of dry heat and cold), hydrotherapy.
Segmental reflex therapy- impact on the skin in order to change the functional state of organs and body systems.
To her simplest methods include: the use of cans, mustard plasters, compresses, a heating pad and an ice bladder, as well as various methods of hydrotherapy.
Hydrotherapy- external use for therapeutic, prophylactic and rehabilitative purposes of water in the form of baths, showers, douches and rubdowns, as well as swimming in the pool.
Rubdown, douche. You can start with local influences (arms, legs, back, chest), and then move on to general influences. The procedures are carried out with water at a temperature of 32-34 0 C, with each subsequent procedure lowering it by 1-2 0 C to 18-20 0 C. The procedures are carried out daily or every other day. The course of treatment is 15-30 procedures. Dousing and rubdowns are carried out with aim hardening, increasing efficiency, physical activity of a person.
Souls. Various kinds showers: rain, needle, dust (descending), intermediate (ascending) and jet (Charcot, Scottish, fan), circular. The effect of showers depends on the water temperature and pressure. Cold and hot showers lasting 1-3 minutes - refresh, tone up the cardiovascular and muscular systems; warm lasting 2-3-5 minutes - reduce excitability, cause relief of muscle spasms, improve sleep; high pressure showers(2-3 atm) have an exciting effect. Souls are prescribed daily or every other day. The course is 15-20 procedures.
Healing baths. Depending on the temperature water: 1.cold (up to 20 0 С) - duration 1-3 minutes; 2. cool (up to 33 0 С) - duration 1-3 minutes; Therapeutic action: tones up, increases metabolism, stimulates the central nervous system, enhances the contraction of smooth muscles. 3.individual (34 0 -36 0 С) - duration 20-30 minutes; Therapeutic action: light toning and refreshing effect. 4. warm (37 0 -39 0 С) - duration 5-10 minutes; Therapeutic action: reduces pain, relieves muscle tension, has a calming effect on the central nervous system, improves sleep. 5. hot (40 0 -42 0 C) - duration 5-10 minutes; Therapeutic action: increases perspiration, enhances metabolism.
Depending on immersion in water: general - immersion to the xiphoid process; half-bath - immersion to the navel; local - immersion of individual parts of the body.
Depending on the composition of the water: fresh; aromatic - pine extract, sage, turpentine emulsion, mustard, herbal decoctions; medicinal; gas - oxygen, carbon dioxide, nitrogen, radon; mineral - salts of iodine, bromine, sodium sulfide.
Statement of mustard plasters.Indications: laryngitis, tracheitis, bronchitis, pneumonia, myositis, angina pectoris, hypertensive crisis, neuralgia, etc. Measure the temperature of the water for wetting mustard plasters (40-45 ° C). Hot water should not be used for mustard procedures, because it destroys the mustard enzyme and the mustard oil will not be excreted. Soak the mustard plasters in water for 5 seconds. each. Shake off and apply the mustard plaster on the desired area of the skin with mustard down, put a towel on top. Places of setting mustard plasters: a) circular - on the chest area, except for the breast, nipples; b) collar - on the upper shoulder girdle in hypertensive crisis; c) on the area of the heart - for pain in the heart in women - around the breast, in men - except for the nipples, as well as on the place of projection of pain (more often on the sternum area). Cover the patient with a blanket. Keep the mustard plasters for 10-15 minutes. Remove the mustard plasters, dump them into the waste tray. Wipe the patient's skin with a damp warm gauze cloth, wipe dry. To exclude an allergic reaction, and if there is no allergic reaction between the mustard plasters and the skin, lay gauze soaked in water and squeezed out. It is strictly forbidden to put mustard plasters on paper, because at the same time, the direct irritating effect of mustard oil on the skin is lost. Help the patient put on the linen, put it in a comfortable position. Cover the patient, recommend bed rest (30-60 minutes).
Application of compresses.Compress- medical multilayer bandage. Compresses there are: dry, wet (cold, hot, warming, medicinal), general and local.
Cold compress setting.Target: cause cooling of the skin and constriction of blood vessels, have an analgesic effect. Indications : second period of fever, nosebleeds, first hours after injury, etc. Moisten a napkin in cold water, squeeze out, fold in several layers. Apply the tissue to the skin surface. Moisten the second napkin in a container with cold water, squeeze out, fold in several layers. Replace the first napkin with the second. Change of napkins should be done every 2-3 minutes. The duration of the entire procedure depends on the patient's condition (5-60 minutes).
Setting a hot compress.Target: cause an intense local increase in blood circulation, have a resorbing and analgesic effect. Moisten a napkin in hot water, wring out, fold in several layers. Apply the tissue to the skin surface. Put an oilcloth on top of the napkin, then a layer of cotton wool. Fix the compress with a bandage. The duration of the procedure is 10 minutes.
Setting a warming compress.Indications : local inflammatory processes in the skin, subcutaneous fat, joints, middle ear, bruises on the second day after injury. Moisten a napkin in water or an alcohol solution, squeeze out, fold in several layers. Apply the tissue to the skin surface. Put a larger compress paper on top of the napkin, then a layer of cotton wool that completely covers the previous 2 layers. Fix the compress with a bandage. The duration of the procedure is 6-8 hours. After 1.5-2 hours, check the moisture content of the bottom napkin. After the required time has elapsed, remove the compress, dry the skin with a napkin. Cover the patient or apply a dry warm bandage.
Heating pad supply.Warmer Is dry heat. The effectiveness of its action depends, first of all, on the duration of the procedure, and not on the temperature of the water. Indications : hypertensive crisis, pain syndrome, chronic foci of inflammation. Fill the heating pad with hot water to 2/3 of its volume, then, squeezing it at the neck and laying it horizontally, displace the air from it. Screw on the plug and, turning the neck down, check for leaks. Wrap the heating pad with a towel so that it does not fall out of it during the procedure. The surface of the towel warmer that is applied to the body should be smooth and not wrinkled. Apply a heating pad to the desired area of the body for 20 minutes.
Ice bladder feed.Ice pack Is dry cold. Indications : acute inflammatory processes in the abdominal cavity, the first day after injury, severe fever, postoperative and postpartum period, bleeding. Fill the bubble with ice cubes prepared in the freezer and fill them with cold water. A uniform filling of the ice bubble is achieved. Frostbite may occur on an area of the body when using an ice bladder frozen in the freezer. Screw on the ice bubble cap by placing the bubble on a horizontal surface and expelling the air. Water, displacing air, should be at the bubble cap. Wrap the bubble in a towel so that it does not fall out of it during the procedure. The surface of the bubble in the towel that is applied to the body should be smooth and not wrinkled. Apply the bubble to the desired area of the body for 20 minutes.
Watching your breath, special attention should be paid to changing the color of the skin, determining the frequency, rhythm, depth of DD and assessing the type of breathing. Respiratory movement carried out by alternating inhalation and exhalation. The number of breaths in 1 min. called NPV. In a healthy adult, the rate of DD at rest is 16-20 per minute, in women it is 2-4 breaths more than in men. NPV depends not only on gender, but also on body position, state of the nervous system, age, body temperature, etc.
Calculation of heart rate and measurement of blood pressure.Distinguish arterial, capillary and venous pulse. Arterial pulse - these are rhythmic oscillations of the artery wall caused by the release of blood into the arterial system during one heartbeat. More often, the pulse is examined in adults on the radial artery. By examining the arterial pulse, important to define his frequency, rhythm, filling, voltage and other characteristics. The nature of the pulse also depends on the elasticity of the artery wall. Frequency- this is the number of pulse waves in 1 min. Normally, a healthy adult has a pulse of 60-80 beats. in min. Increased heart rate more than 85-90 beats. in min. called tachycardia. Reducing the heart rate less than 60 beats. in min. called bradycardia. The absence of a pulse is called asystole. Pulse rhythm determined by the intervals between the pulse waves. If they are the same, the pulse is rhythmic (correct), if they are different, the pulse is arrhythmic (incorrect). Pulse filling is determined by the height of the pulse wave and depends on the systolic volume of the heart. If the height is normal or increased, then a normal pulse (full) is felt; if not, then the pulse is empty. Pulse voltage depends on the value of blood pressure and is determined by the force that must be applied until the pulse disappears. With normal blood pressure, the artery is compressed with moderate force, so it is normal pulse of moderate(satisfactory) stresses... With high blood pressure, the artery is compressed by strong pressure - this pulse is called tense... With low blood pressure, the artery is easily compressed, the voltage pulse is called soft(relaxed). An empty, unstressed pulse is called small threadlike.
Arterial is called the pressure that is formed in the arterial system of the body during contractions of the heart and depends on complex neuro-humoral regulation, the magnitude and speed of cardiac output, the frequency and rhythm of heart contractions and vascular tone. Distinguish systolic and diastolic pressure. Normally, blood pressure fluctuates depending on age, environmental conditions, nervous and physical stress. In an adult, the rate of systolic pressure ranges from 100-105 to 130-135 mm Hg. (allowable - 140 mm Hg); diastolic - from 60 to 85 mm Hg (permissible - 90 mm Hg), pulse pressure is normally 40-50 mm Hg. With various changes in the state of health, deviations from normal blood pressure are called arterial hypertension, or hypertension, if the pressure is high. Lowering blood pressure - arterial hypotension or hypotension.
Daily water balance is the ratio between the amount of fluid introduced into the body and the amount of fluid excreted from the body during the day. It takes into account the liquid contained in fruits, soups, vegetables, etc., as well as the volume of parenterally administered solutions. Grade:positive water balance indicates the effectiveness of treatment and the convergence of edema. Negative- an increase in edema or ineffectiveness of the dose of diuretics.
Possible changes in breathing patternsDistinguish breathing shallow and deep ... Shallow breathing may be inaudible from a distance or slightly audible. It is often combined with a pathological increase in respiration rate. Deep breathing, heard at a distance, is most often associated with a pathological shortness of breath.
TO physiological types of breathing relate chest, abdominal and mixed types. In women, chest breathing is more often observed, in men - abdominal. TO pathological types of breathing include: big breath of Kussmaul- rare, deep, noisy (with deep coma); breath of biott- periodic breathing, in which there is a correct alternation of the period of superficial DD and pauses of equal duration (from several minutes to a minute); Cheyne-Stokes breath- characterized by a period of increase in the frequency and depth of breathing, which reaches a maximum on the 5-7th breath, followed by a period of decrease in the frequency and depth of breathing and another long pause of equal duration (from several seconds to 1 minute). With a disorder of the frequency, rhythm and depth of breathing occurs dyspnea - a subjective feeling of difficulty breathing, accompanied by an unpleasant sensation of lack of air. Distinguish physiological and pathological shortness of breath: inspiratory dyspnea- This is breathing with shortness of breath; expiratory- breathing with difficulty exhaling; and mixed- breathing with difficulty inhaling and exhaling. Rapidly developing severe shortness of breath is called suffocate . Asphyxia - it is the cessation of breathing due to the cessation of oxygen supply. Asthma - it is an attack of suffocation or dyspnea of pulmonary or cardiac origin.
Swelling - a condition that develops with excessive accumulation of fluid in the body with certain diseases of the cardiovascular, urinary and other systems. Diuresis the process of formation and excretion of urine is called. Daily diuresis is called the total amount of urine excreted by the patient during the day. Daily urine output in adults ranges from 800 ml to 2000 ml.
When implementing care and monitoring of patients with gastrointestinal dysfunction necessary:
Ø to know the peculiarities of the psychological status of such patients and be able to correctly assess it;
Ø observe ethical and deontological principles in dealing with patients;
Ø monitor the observance of the correct regimen of physical activity, personal hygiene, nutrition and diet;
Ø be able to correctly assess the most important symptoms of dysfunction of the gastrointestinal tract;
Ø be able to provide assistance in case of emergency conditions: poisoning, vomiting, bleeding from the gastrointestinal tract, etc.;
Ø be able to perform various medical and diagnostic procedures and measurements: put an enema, a gas outlet tube, rinse the stomach, collect the necessary diagnostic material (urine, feces, vomit), etc.
Breathing Types of breathing: external - pulmonary - delivery of oxygen to the blood; internal - the transfer of oxygen from the blood to organs and tissues. - a vital human need, a process that ensures the continuous supply of oxygen to the body and the removal of carbon dioxide and water vapor outside.
20 - tachypnea; 20 - tachypnea; 5 Characteristics In a healthy person In pathology Rhythm - regularity of inhalation and exhalation at regular intervals rhythmic arrhythmia (respiratory) Frequency - number of breaths per minute> 20 - tachypnea; 20 - tachypnea; 20 - tachypnea; 20 - tachypnea; 20 - tachypnea; title = "(! LANG: Characteristics of a healthy person In pathology Rhythm - regularity of inhalation and exhalation at regular intervals; rhythmic arrhythmia (respiratory) Frequency - number of breaths per minute 16-20> 20 - tachypnea;
Breathing Types of shortness of breath: Physiological - in a healthy person with excitement, physical exertion. Pathological: inspiratory - difficulty breathing (ingress of a foreign body, laryngitis); expiratory - difficult exhalation (bronchospasm - bronchial asthma); mixed - both inhalation and exhalation are difficult (heart disease). Shortness of breath is a violation of breathing in terms of rhythm, frequency, depth.
Nursing intervention plan for shortness of breath Nursing interventions: Rationale 1. Calm the patient Reduce emotional stress 2. Raise the head of the bed, comfortably seat the patient Ease breathing 3. Provide ventilation, unbutton the collar, fold back the blanket 4. No smoking for the patient 5. Help the patient self-care Comfort Contents 6. Monitor the general condition, PS, BP, NPV Early detection of complications 7. As prescribed by a doctor, supply oxygen, administer medications Provide treatment
Pulse properties Pulse properties (criteria) In a healthy person In pathology Symmetry - coincidence of pulse waves on both hands symmetric asymmetric (narrowing or squeezing of an artery) Rhythm - alternation of pulse waves at certain intervals rhythmic arrhythmia Frequency - number of pulse waves per minute> 80 - tachycardia; 80 - tachycardia; "> 
Blood pressure Systolic blood pressure (normal mm Hg) - maximum - during the contraction of the left ventricle of the heart. Reflects the condition of the heart and arterial system. Diastolic (normally 60-90 mm Hg) - minimal - in the phase of relaxation of the left ventricle. Indicates vascular resistance. Pulse pressure (optimal - 40-50 mm Hg. Art.) - the difference between the indicators of systolic and diastolic blood pressure. Increase - hypertension Decrease - hypotension.
Fainting Factors of occurrence: severe neuropsychic shock (fright, sharp pain, sight of blood), overwork, stuffiness. Subjective sensations before fainting: lightheadedness, dizziness, tinnitus. Objectively: lack of consciousness, pale skin, cold extremities, weak pulse, possibly lowering blood pressure. - short-term loss of consciousness due to acute inadequacy of blood supply to the brain. Nursing intervention plan for fainting Nursing interventions Rationale 1. Place the patient horizontally, without a pillow, raising the legs Ensuring blood flow to the vessels of the head 2. Open the window, unfasten the collar Relieve breathing 3. Spray the face with cold water, bring ammonia to the nose (at a distance of 15 cm) , pat on the cheeks, call by name Effect on the receptors 4. After helping, put the patient to bed for 2 hours, cover, put a heating pad at the legs Prevention of repeated fainting 5. Give the patient hot coffee, strong tea 6. Determine the hemodynamic parameters (PS, BP) Early detection of acute vascular insufficiency 7. In case of low BP, inform the doctor, prepare and administer the prescribed medications Providing treatment
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