The Ministry of Health of Ukraine Ukrainian Medical Stomatological Academy

Approved at the Department of Propaedeutics to Internal Medicine with Care of Patients meeting on 11 09 2018 Protocol No2 The Head of the Department Professor Yu. Kazakov

METHODICAL INSTRUCTION FOR STUDENTS’ SELF-PREPARATION WORK

Educational discipline Care of patients

Module No 1

Enclosure module No 1

Topic The main principles and organization aspects of care of patients with therapeutic pathology. Organization of the work of therapeutic in-patient departments

Year 2

Faculty medical

1. The topic basis: Care of patients is complex of actions, directed to forming of favorable conditions for successful treatment of the patients and alleviation of their condition and satisfaction of the main requirements of organism. The most important tasks of the care should be directed to activation and support of reserve means of his/her organism during struggle against disease. Actions of care of patients have often decisive importance in successful treatment of the patients and in whole process of their recovery. More often care of patients is realized by middle and junior medical personnel. But despite the fact that actions on care of patients aren’t functional physician duties, every physician must know all peculiarities of care and be able to perform any manipulation or procedure independently, control quality of the work of middle and junior medical personnel, secure realization of all essential manipulations on care in case of absence of the nurse also or in out-hospital conditions. That is why mastering by technique of carrying out manipulations on care of patients with following deontological and esthetical norms is one of the most important link in clinical preparation of future physician. 2. The specific aims:  To become acquainted with structure and functioning of therapeutic in- patient department.  To demonstrate using of the main principles of medical deontology.  To determine essence of care of patients and its role in structure of general- therapeutic actions.  To demonstrate using of skills on observance of treatment-protective regimen  To demonstrate using of skills on securing of sanitary-hygienic regimen of the main subdivisions of therapeutic hospital.  To formulate notion about the main psychotherapeutic approach to the patients.  To demonstrate using of the main moral-deontological principles of medical specialist.  To list functional duties of junior nurse in hospitals.  To acquainted with structure and functioning of therapeutic in-patient department.  To demonstrate using of skills concerning observance of treatment protective regimen.  To demonstrate using of skills on securing of sanitary-hygienic regimen of the main subdivisions of therapeutic hospital.  To acquire skills concerning filling in medical documentation of admitting office.  To carry out anthropometric examination of the patients and count index of body weight.  To become acquainted with patients’ transporting on stretcher, wheel chair, wheel stretcher.  To become acquainted with modern agents for carrying out of sanitary- hygienic cleaning of therapeutic department’s rooms 3. Basic knowledge, experience, skills necessary for studying the topic in connection with other subjects (interdisciplinary integration) : Previous disciplines Obtained skills 1. Anatomy To know human anatomy. 2. Physiology To know physiology of the main systems of organism. 3. Medical psychology To be able to observe principles of ethics and deontology in medical practice. 4. Chemistry To know properties of the main substances, solutions of which are used for prophylactic disinfection

4. Tasks for self-work during preparation to the class. 4.1 List of the main terms, parameters, characteristics, which should be mastered during preparation to the class: Term Definition 1. Care of patients It is complex of actions, directed to forming of favorable conditions for successful treatment of the patients and alleviation of their condition and satisfaction of the main requirements of organism. 2. Medical ethics It is complex of moral criteria, which are used by medical worker during his/her work on support of preservation and strengthening of the health. 3. Medical deontology It is complex of ethical norms and principles of behavior during carrying out of professional duties by medical worker 4. Physician secret Confidential information about patient’s appealing for medical aid, diagnosis, and other information about condition of his/her health and private life, obtained as result of examination and treatment, prophylaxis and rehabilitation.

5. Iatrogeny It is psychogenic disorder, disease or any pathological process, occurred under influence of medical interventions, carried out with diagnostic, treatment or prophylactic purpose 6. «Vocal aseptics» It is necessity of constant control of their behavior by medical personnel - of intonations, looks, gestures, which can be interpreted by the patient incorrectly. 7. Nursing lookout It is the workplace of ward nurse. It is intended for 25-30 post patients, it always takes place near wards, in order to all patients can be under the permanent care of nurse. 8. Transporting of It is transference or transportation of them from the patients admitting office to the medical department, from one medical department to another, or from one hospital to another.

9. Index of body It is ratio of body weight to patient’s squared height (kg/m2). weigh Normally it is 18,5-24,9 kg/m2 .

4.2. Theoretical questions to be answered before class: 1. Historical landmarks of formation of medical aid to the ill men. 2. Determining of role and place of care of patient in treatment-diagnostic process. 3. Structure of care of patients, conditions of its carrying out. 4. Moral-ethical and deontological aspects of forming of medical specialist. 5. The main professional duties of junior medical personnel (junior nurse). 6. The main deontological aspects of medical worker’s activity. 7. Principles of professional subordination in system physician-nurse-junior nurse. 8. Conception of treatment-protective, sanitary and hospital regimens of therapeutic hospital. 9. Role of junior medical personnel in support of treatment-protective and sanitary regimens of therapeutic hospital. 10. Name the role of therapeutic department of hospital. 11. Name the professional duties of medical personnel of therapeutic department. 12. Name the functional role of nursing lookout post. 13. Name the medical documents of therapeutic department. 14. What is the organization of patient’s visits and discharge from a hospital? 15. What is the role of admitting office? 16. What document is filled by the nurse of admitting office? 17. What’s the way of sanitization of hair in patients? 18. What technical equipment is used for transporting of patients? 19. In what case is the form of urgent report filled in? 20. What does the term “anthropometry” mean?

4.3. Practical work (tasks), which should be performed during class: 1. To become acquainted with the main moral-ethical and deontological aspects of carrying out of care of patients, principles of professional subordination. 2. To acquire concepts treatment-protective, sanitary and hospital regimen of therapeutic hospital. 3. To prepare one of disinfectants for prophylactic disinfection. 4. Work in admitting office:  to register patients, admitting to the hospital;  to fill in title page of case history and statistic bond;  to transport patients to hospital’s departments. 5. Carrying out of patient’s anthropometric measurers:  to measure patient’s growth (standing and sitting) by means of auxanometer;  to measure patient’s body weight by means of medical balance;  to calculate index of body weight and to interpret it. 6. Carrying out of actions on securing of sanitary-hygienic regimen of therapeutic department:  to prepare solutions of chlorinated lime and chloramine for moist cleaning of rooms of therapeutic department;  to perform cleaning of therapeutic department’s rooms.

The contents of topic: Text CARE OF PATIENTS Care of patients, hypurgia is complex of actions, directed to forming of favorable conditions for successful treatment of the patients and alleviation of their condition and satisfaction of the main requirements of organism. Care includes giving aid to the patient for provision of his/her organism’s needs in food, water, physical activity, defecation and urination, amelioration during pathological conditions, particularly, in nausea, vomiting, asthma, cough, various pains, etc. Care foresees forming for the patient quiet (easy) moral atmosphere, favorable living and hygienic conditions (optimal temperature, sufficient lighting and ventilation of the wards, comfortable clear bed, necessary minimum of personal hygiene’s objects, alarm system). Peculiarities and volume of care actions depend on general patient’s condition, character and degree of his/her disease’s severity, regimen prescribed by physician. The most important tasks of the care should be directed to activation and support of reserve means of his/her organism during struggle against disease. It is well known, that actions of care of patients have often decisive importance in successful treatment of the patients and in whole process of their recovery. Organizing of favorable conditions of patient’s being in the ward, tactful relations from the side of medical personnel, timely giving of the first medical aid isn’t only obligatory condition of successful treatment, but often these actions play not less role than any difficult medical manipulation or procedure. It is possible to assert without exaggeration that care, organized rationally, in severe ill patients first of all, determines the character of disease’s course mostly. So, for example, by means of different reanimation actions it is possible to help out of apparent death to the patient, to carry out technically difficult operation, but patient can be lost in connection with various complications as result of breach of elementary demands of regimen and non-observance of care actions, in unsatisfactory hygienic conditions, patient’s state in a bed without motion practically. Care of patient plays important prophylactic role in development of some diseases and their complications. So, for example, timely and correct actions of care of skin or care of mucous membrane of oral cavity can check development of trophic and infectious lesions of tissues, inflammatory diseases of oral cavity and gastrointestinal tract. That is why semantologically terms “care” and “treatment” have common origin - from Greek. therapeia, that means both care, and treatment simultaneously. Having the common purpose, - patient’s sanitation, preservation and strengthening (building up) of his/her health, care and treatment are indissoluble between themselves. They are integral essence of general medical process, its interconnected links, supplementing each other. Realization of care actions doesn’t demand only professional skills of technically qualitative carrying out of any manipulation or procedure. Observance of moral-ethic and esthetic norms of relations with ill person plays not less importance. Under influence of the disease patients often become hyper excitable, sensitive, sometimes they express unjust claims, react to surround factors and manifestations of their disease more acutely (more intensively) than in usual conditions. In these conditions skill of medical personnel, including medical student, to be maximally careful, charitable, tactful and sympathetic to the ill person is exceptionally important. Tact, civility, sincere wish to help to the patient in his/her sufferings should be shown in every action of medical worker during carrying out measures on care of patients. It is necessary always to find such methods and means, which can alleviate patient’s condition, to find words for patient’s relief and improvement of his/her mood. Besides, it is necessary to demand of realization of physician’s prescriptions and other necessary medical and diagnostic procedures from patient. Medical worker must engraft faith in curative force of physician’s prescriptions and health-improving possibilities of medicine to every patient, using strong properties of word. The greatest physician of antiquity Hippocrates taught physician in his relations with the patients in the following way: “All necessary actions you carry out calmly and skillfully... It is necessary to inspire patient by means of friendly merry, civil word. If it is necessary you decline patient’s demands strictly and firmly, in other cases - surround patient by love and diversion.” Modern physician must be guided by these wise advices of “medical father” in his/her professional actions. General human features - civility, tact, sympathy and self-sacrifice isn’t important condition of exclusively physician activity only, but they also acquire great importance during realization of duties on care of patients. And vice versa, rudeness, inattention, carelessness, hardness, fastidious, disrespectful relation to the patient can break favorable background of medical process, cause mental trauma to the patient, brake process of recovery and significantly diminish effectiveness of medical measures. Such moral qualities are incompatible with ethical demands to the medical worker. First steps of the students in clinics, their first acquaintance with patient must be connected with mastering of the main rules and demands of medical ethics and deontology by them. Medical ethics is reflection of moral, humanistic principles in the action of medical worker. It forms and regulates norms of moral behavior of physician, nurse, junior nurse, their relations with patients, his relatives and colleagues. Peculiarities of medical ethics, which distinguish it from general one, are determined by specifics of professional action of medical workers and by connected with this factor their peculiar state in society. Deontology (from Greek - deon -due, logos-science) is science about moral duties of medical worker during his/her professional action. Deontology is the part of medical ethics. It reflects moral demands and determines spiritual code of medical worker’s behavior in relations with patients and his/her colleagues. Mastering of medical ethics and deontology is obligatory condition of professional preparation of medical worker. Mastering of rules and demands of medical ethics and deontology goes along difficult way of moral and professional perfection and self-perfection. It is insufficiently presence of vocation or laborious task (work) for their mastering. Combination of both these factors is expedient and important for forming of high level of moral-ethical and deontological preparation of medical worker. Exalted moral features - humanism, sympathy, duty sense, readiness to self-sacrifice, good- will, cultural level, simplicity and modesty - aren’t only desirable, but also very necessary professional qualities of medical worker. That is why mastering by students of norms and rules of medical ethics and deontology aren’t necessary only for their general moral perfection, but also it is obligatory forming part of special, professional physician preparation. Starting from first days of study in medical academy it is necessary to engraft to future physician qualities of men with exalted and pure moral, which should be having spiritual riches, moral purity and physical perfection. Side by side with general progress of society, methods of giving of medical aids to the patients are improves themselves. Technical methods are introduced into different spheres of medical action widely. But regardless of achievements of technical progress in medicine, human contacts, force of personal influence of medical worker to the patient will be always irreplaceable remedies for the patient. And it can’t be shown only in high-specialized aspects of physician action, but also - during carrying out relatively technically simple actions on care of patients. The most important role for realization of demands of medical ethics and deontology belongs to the word. “Word, plant, knife” - it is ancient aphorism, first place belongs to the word. Patient waits sympathetic, fair, encouraging word from the physician, nurse, junior nurse. It can be real medicines, which can influence favorably to the protective force of human organism. That is why words of founder of modern native medicine M.Ya. Mudrov continue to be instant for present medical worker: “... There are mental medicines, which treat body. They are derived from science of wisdom, psychology more often. By means of this art sad person can be encouraged, angry one can become tender, impatient person can regain one’s composure, fearful person can become daring, secretive - frank (open), perplexed - reliable. Strength of mind, which conquers bodily pains, doubt, alarm is inspired by this art”. It is necessary to remember that tender word treats, bad one - cripples. Medical worker always can use word as his/her reliable (effective) accomplice in the struggle against disease. It is necessary to know: it isn’t important only contents, but intonation also. Friendly, calm tone of voice reassures patient, bridles his/her experience, diminishes sense of alarm and confusion. It is necessary to study to take care of patient’s nervous system by means of word. It is necessary to remember always that engaging in an argument with patient and rise of the voice are inadmissible. It is necessary to speak with patient even-temperedly and calmly, even in cases when patient is excited nervously and impetuous in his/her expressions. Careless word can not only offend patient, but also seriously complicate the course of disease. In some cases it cal lead to development of iatrogenic diseases, i.e. diseases, caused by pathological psychical reaction of the patient to the word of medical personnel. Iatrogeny (from Greek iatros - physician, and Latin genes - origin) - frequent occurrence in medico-prophylactic institutions with low (poor) culture and organization of medical process. Relation to word during contact with patients with chronic diseases should be exacting peculiarly. In these persons psychics is depressed, mood is worrying, faith into recovery is absent. If condition of ill person is really severe, for example in malignant diseases, medical worker must keep truth about real disease from the patient, try to support him/her morally. Medical personnel must know the main demands of medical esthetics. Cloth must be tidy. Professional cloth should be convenient and simple by style and doesn’t restrain motions. Inalienable condition of medical esthetics is execution of demands concerning to uniform: clear white washed smock, which cover knees, white shawl or little cap, covered hair, light and comfortable footwear, for example, slippers. Observance of personal hygiene is very important. It is necessary to remember that excessive using of cosmetics can be reflected negatively on the ethical atmosphere of contacts with patients. In medical worker nails must be cut shortly, hands - clear, warm and soft. It needs special care of them. More often care of patients is realized by middle and junior medical personnel (nurses and junior nurses). Last ones take part in carrying out of some simple manipulations on care, and help to the middle medical personnel. But despite the fact that actions on care of patients aren’t functional physician duties, every physician must know all peculiarities of care and be able to perform any manipulation or procedure independently, control quality of the work of middle and junior medical personnel, secure realization of all essential manipulations on care in case of absence of the nurse also or in out-hospital conditions. That is why mastering by technique of carrying out manipulations on care of patients is one of the most important link in clinical preparation of future physician.

Contents of care of patients Depending on character of diseases and peculiarity of actions, care is subdivided into general and special. General care includes actions, which are carried out with purpose forming of optimal conditions for patient’s treatment regardless of specifics of disease. Special care includes such actions, which have specific peculiarities and carried out taking into account diagnosis of disease and individual manifestations of its course. Complex of actions on general care of patients includes the following elements: 1) observance of personnel hygiene, prophylactic of bed sores (pressure sores), hospital catarrhal diseases, hygiene of underwear and bedclothes; 2) securing sanitary-hygienic norms in wards, other rooms (including additional ones), forming favourable microclimatic conditions in the wards, care for timely provision of the patients by the necessaries of care, realization of demands of treatment-protective regimen in department; 3) realisation of physician’s prescriptions (distribution of medicaments, giving injections, applying cups, leeches, mustard plasters, compresses, feeding of severe ill patients, carrying out of oxygen therapy, registration of body temperature, measurement of blood pressure, examination of pulse, collection of samples - for laboratory-diagnostic researches); 4) providing first medical aid in urgent or extreme conditions of organism (faint, collapse, attacks of asthma, cough, bleeding, pains of different localization, dyspeptic signs, arrest of cardiac action and breathing); 5) carrying out of relatively simple medical and diagnostic manioulations and procedures: gastric lavage, using of bedpen, urinal/colostomy bag, hot bottle, ice bag, flatus tube, title bed, giving of cleansing and siphon enema, using of individual oxygen inhalator, preparation of system for intravenous drop introduction of medicaments, sterilization of syringes, needles, forceps, scissors, prophylactics of bed sores; 6) filling in of medical documentation, which concerns to competence of middle medical personnel: temperature chart, direction to laboratory researches, execution of documents for patient’s discharge, writing documents for diet; 7) carrying out of sanitary-elucidative work.

There is wide network of treatment-prophylactic institutions of outpatient and inpatient type. Some patients, with uncomplicated course of disease mainly, get medical aid in out hospital condition (in polyclinics, health units or at home). Medical aid to the patients, which need bed rest is given in hospitals, i.e. in inpatient treatment-prophylactic institutions.  hospital is stationary medical institution where diagnostics and treatment of the patients are carried out. Modern hospital is medical institution with possibilities for diagnostics and treatment of the patients, where conditions for satisfaction of their living and cultural-aesthetic needs are made. Specialized stationary (inpatient) treatment-prophylactic institution, which is part of medical educational or research institution is named clinic (from Greek kline - bed).  clinic - stationary medical institution, where not only diagnostics and treatment is carried out, but also - preparation of physicians and scientific-pedagogical cadres and research work with improvement of diagnostics and treatment of men’s disease

Depending on type, there are following stationary (inpatient) departments of hospitals: therapeutic, surgical, obstetrical, gynaecological, neurological, infectious, orthopaedic, ontological and others. Actions on care are integral part of complex medical service of the patients in the outpatient setting and steady-state ones, but they have the most importance in case of giving medical aid to the hospital (stationary) patients. Hospital or clinic consists of specialized functional departments. The main structural subdivisions of the hospital are: admitting (admission) office, medico- diagnostic complex and administrative-manager part. Medico-diagnostic subdivision consist of treatment and diagnostic rooms, specialized wards or departments, operating rooms, dressing rooms, procedural rooms, wards, rooms for medical personnel (physicians, nurses), places for the rest, dining room and secondary rooms(toilet, bathroom, material storehouse). Depending on patients’ type, every medico-diagnostic subdivision has its peculiarities. So, in stationary (inpatient) departments of therapeutic type operating room and dressing room are absent, and, for example, in reanimation department rooms for patients’ rest are inexpedient. Every department has special places (posts) for duty nurses, who observe patients and carry out physician’s administrations (prescriptions) to them. Apart from duty nurses, there is also procedural nurse, who carries out treatment and diagnostic manipulations and procedures: injections, intravenous infusions, takes blood for biochemical study, carries out gastric and duodenal intubation. Measures on care of patients include securing of work regimen of departments. There are following regimen:  sanitary;  hospital;  treatment-protective SANITARY REGIMEN The sanitary state of therapeutic department includes the following: 1) Allotment of separate bed covered by clean bed-clothes, the individual clean underwear, bed-table for keeping of the personal things, individual clean urinal or bedpan, drinking bowl (if it is necessary ) to every patient; 2) Definite equipment of wards. The therapeutic department includes from 60 to 120 beds. It is considered, that 60% of wards must include 4 beds, 20% includes 2 beds, and 20% - 1 bed according to present day hygienic standards. Distance between beds must be not less than 1 m , because it is comfortable for transporting of patient and for giving the first aid. One patient must occupy not less than 7 m2. The height of ward must not be below than 3-3,5 m, that is one patient must have 22-25 m3 of air. Correlation of area of windows to the floor must be 1:6, the temperature of air in a ward - 18-22o C. It might be as well that every ward has separate toilet. Wards must be well alighted. The walls must be painted by a light oil-paint, because of easy washing them during cleaning. The radiators of heating are also painted by an oil paint. From the hygienic point of view the floor, covered by linoleum, is the best. Ventilation of wards is carried out by air, but conditioning of air is the best method of ventilation. Illumination of wards in evening hours must be carried out by means of mat lamps. Together with general lamps every bed- table must have table lamp. Wards must be equipped properly. Metallic or wooden beds with a spring net covered by a mattress must be there. Wheels with rubber tires are fastened on the bed. Every bed, including free one, must be equipped by a mattress, pillow, sheet, blanket with a blanket cover and towel. On the back of bed, faced to a passage- way, a small list must be fixed, which contains the following data: the surname, name and patronymic of patient, number of diet, date of change of underwear and bed-clothes, special notes on which a medical personnel must pay attention, for example „Don’t put an enema!” (which is written with a red-ink pencil bias); in some hospitals a temperature chart is here. In the bedridden patients under a bed or on a low chair there is an individual urinal and bedpan. On the back of bed, faced to the wall, the towel of patient is hung, bedside tables or bed-tables are placed between beds. Glasses are on them, and in the closed part one can see tooth brush, paste, soapy, comb, eau-de-cologne, paper, pencils, and others, and also small food stock, that do not become spoilt (juices in the hermetically closed tins, biscuits, candies). Drinking bowl, glass with solution for the rinse of mouth must be on a bed- table in seriously ill patients. In a ward there is a general table on which a carafe with the boiled water is put. At this table physician can do records to the case history, to write administrations to the patients for different procedures. It can be used by a nurse during giving medications. Near every bed there are earphones, button of signaling, hung on a cord, which seriously ill patients can use it not changing his/her position. Oxygen must be led to every bed. All wards must have room thermometers. Wards in the department are divided into general wards and wards for seriously ill patients. Wards for seriously ill patients must include usually 1-2 persons. They must have separate toilet. Wards for seriously ill patients are divided into two types: intensive care units and wards for seriously ill patients with the chronic and severe diseases. 3) Illumination of wards. It is known, that a direct sunbeam has bactericidal action, therefore during building hospital the windows of wards are oriented to the south or south-east. In evening hours luminescent lamps are the best illumination, however it is possible to apply electric lamps with a mat plafond; 4) Ventilation. Sufficient ventilation helps to destroy air, polluted by bacteria. Ventilation can be natural. It is achieved by means of regular ventilation of wards and other rooms of department. Ventilation of wards is carried out not less than 3-4 times by means of opening of window leaf (ventilation pane) . Thus it is necessary to watch that there are no draughts, and the bedridden patients must be covered by blanket well. For ventilation of wards it is necessary also to use of conditioners. 5) Heating. An optimum temperature regimen in a winter is 20-21oC, in summer it is 22-24oC. In a winter the central heating is usually used. The disinfection regimen in the department provides the system of the measures, directed to elimination of agents of diseases and creation of conditions, which prevent their distribution in an environment. There are 2 types of disinfection: prophylactic, which is carried out by junior nurses, and final (in an epidemic focus). It is performed by a middle medical personnel and junior nurses of department, and also by specialists of the SES and disinfection stations. Methods of disinfection:  A mechanical method consists in the moist cleaning of room.  Chemical method is the moist cleaning of room with use of different disinfectants, sanitization by the disinfectants matters of crockery, the things of care of patients.  Physical method is divided into: a) thermal, that is boiling or sanitization of different things of patients care, crockery, the underwear and bed-clothes in autoclaves; b) ultraviolet irradiation with the purpose of disinfection of air in wards and procedure rooms. Prophylactic disinfection. In its carrying a considerable place belongs to the moist cleaning of rooms, that is performed with use of different disinfectants. Among them the most valuable disinfectants are chlorine compounds (chlorinated lime, chloramine, lithium hypochloride). Antimicrobial properties of chlorine preparations are cuased by the activity of chloric acid, which is formed during dissolution of the chlorine or its compounds in water. Chlorinated lime (calcium hypochloride) –is shallow powder of white color with a strong smell. It is kept in a dry crock and in place protected from light. It is used: a) in a dry kind – for disinfection of excrements, sputum or scattering in toilets, where the sewage system is absent; b) as different solutions. General rules of preparation of solutions of clorinated lime Solutions are prepared in the enameled or faience crock or in large bottles made from thick dark glass. Crock, where solution is kept, must be very tightly covered by a lid or a cork. Preparation of solutions is usually performed in the special room, which is near the toilet; it is desirable that it’ll be dark or half-dark, walls and floor will be covered by tiles, there will be a shell for washing of hands. Preparation of 10% solution of clarified chlorinated lime: 1 kg of dry chlorinated lime is mixed in the small quantity of water for formation of steady pasty mass. Continuing mixing, the volume of water increases to 10 l. The prepared solution is abandoned in a bowl during 24 hours. Thus during first 4 hours solution needs to be mixed not less than 3 times. Then solution is placed carefully, not shaking sediment, to the bowl from dark glass. You must keep this solution during 5-7 days. Solution has very pungent characteristics and influences on mucous membranes and skin. Therefore during its using the rules of safety must be performed, that is: applying rubber gloves, protective glasses, gauze respirators. Preparation of solution of chlorinated lime for the moist cleaning of rooms.  For preparation of 0,1% solution: 100 ml of 10% solution of chlorinated lime add to 10 l of water and mix well;  For preparation of 0,2% solution: 200 ml of 10% solution of chlorinated lime add to 10 l of water and mix well; Chloramine (N-chlorbenzosoulfonide sodium) is white crystalline powder, which contains 25-29% of active chlorine. 0,2-5% solution of chloramine is used for disinfection. Preparation of solutions of chloramine:  for 0,2% solution – 2 g chloramine, add 1 l of water and shake well;  for 1% solution – 10 g chloramine, add 990 ml of water;  for 2% solution – 20 g chloramine and 980 ml of water;  for 5% solution – 50 g chloramine and 950 ml of water. Water, that is added to chloramine, must have the temperature of 50-60oC. This solution must be kept no more than 5 days. Two-tertiary salt of calcium hypochloride (TTSCH). It is white crystalline powder, that contains from 47% to 52% of active chlorine. 5% solution of TTSCH is usually prepared. A little quantity of water is added to 5 g of dry substance and is mixed . After mixing the rest of water is added, its common quantity must be 950 ml (that is for 10 l of water for the moist cleaning of rooms it is necessary 50 g of TTSCH). It is necessary to keep the prepared solution no more than 5 days. During the work with solution TTSCH precautionary measures must be used (rubber gloves, gauze respirators and others). Soapy-soda solution For preparation of 1% solution you must take 100 g of laundry soap and 100 g of sodium of hydrogen carbonate for 10 l water. Mix well. For preparation of a 2% solution you must take 200 g of laundry soap and 200 g of sodium of hydrogen carbonate for 10 l water. Mix well. Method of the moist cleaning of rooms of department Common rules: 1) The moist cleaning of rooms are carried out by junior nurses (hospital cleaners). 2) An inventory for performing of disinfective measures (buckets, mops, rags and others) must be in the special for this purpose rooms. It is marked and used only in those rooms which it is appointed for (separately for wards and corridors, toilets, dining-rooms, and others). 3) For the moist cleaning different disinfectants are used. Moist cleaning of wards, corridors, and halls is carried out twice a day – after night rest and before sleep. Before the moist cleaning the rooms are swept. Sweeping a floor passes from windows and walls towards the middle of ward and doors. During the moist cleaning patients go out from a ward (except for those, who are bedridden); at this time the room must be aired well. Usually for cleaning we use 0,2% solution of chlorinated lime or 0,5% solution of chloramine. Furniture, window-sills, the radiators of heating are washed or wiped by a moist rag 1 time per three days. Upper parts of walls, ceiling, the plafonds of lighting devices are purged from a dust twice a month. During cleaning special attention is paid to the state of bed tables. There must not be food products, which become spoilt quickly. After the moist cleaning the ultraviolet irradiation of wards is performed. Cleaning of dining-room (buffet) is carried out after every meal. Tailings of food products are collected in the closed buckets or little tank with lids and take away in definite time. Crockery is washed as following: a) water of temperature of 70-80oC is used with addition of mustard, sodium of hydrocarbonate (for deprivation of fat crockery). Water is changed twice; b) after washing crockery must be disinfected by 0,2% solution of clarified chlorinated lime; c) after disinfection a crockery must be cleaned by hot water. The workers of dining-room must perform the rules of the personal hygiene, during the visit of toilet room they must keep their clothes on a workplace. They must take a medical examination before beginning work and every month in the process of work. Baths, shells, toilets, floor must be washed several times every day, and also if they are dirty. 0,5% clarified solution of chloramine or 0,5% solution of two-tertiary salt of calcium hypochloride is used for washing of lavatory pans, urinals, bedpans. Bath is washed after each patient, first of all by warm solution of soap, and then it is rinsed by 0,5% solution of chlorinated lime or 1-2% solution of chloramine. The general cleaning is carried out not rarer than once a week. Except of the moist cleaning of rooms, walls, plinths, bed-tables, refrigerators are washed, plafonds are wiped, ceiling is swept. In the uninfectious department the final disinfection is carried out in cases, when there was the case of acute infectious disease (infectious hepatitis, dysentery, scarlet fever and others). It is directed to complete destroying of causative agent of disease in the department. All rooms, furniture, lighting devices, clothe are disinfected. Sanitization of rooms by the mixture of different disinfectants with using of hydropoultis is the most important method of final disinfection. Final disinfection can be also made by means of the disinfection of surface of objects by wiping or washing with disinfective solutions. Underwear and bed- clothes, blankets, towels, mattresses must be disinfected in the special chambers.

HOSPITAL REGIMEN Contents and amount of hospital regimen is established by administration of hospital (depatment) on the basis of existent typical statute. It determines exact time and consequence of carrying out of definite actions by the patient, manipulations, procedures (wake up, temperature taking, food intake, drugs intake, carrying out of special administrations of physician, rest time, visiting time, sleep). Realization of regimen isn’t important only for organization of efficient work of personnel of clinics or department, but also is inalienable condition for successful treatment of the patient. Hospital regimen, organized correctly, which takes into account rhythms of human biological activity, can be used as one of string factors of treatment process. The main demands of observance of hospital regimen:  Official by the hour regulation of daily regimen of department’s work;  Determining of regulated terms of carrying out of treatment actions, manipulations, procedures;  Establishment of sequence and periodicity of terms of general organization measures, and diagnostic examinations - wake up, taking body temperature, diagnostic examinations, food intake, drugs intake, rest time, visiting time, sleep).

Table 1 gives a tentative regimen for a hospital.

Table 1 Time (h) Procedures 7.00 Wake-up 7.00-7.30 Temperature taking 7.30-8.00 Morning toilet 8.00-8.30 Dispatching medicines 8.30-9.30 Breakfast 9.30-12.00 Physician’s rounds 12.00-14.00 Carrying out medical orders 14.00-14.30 Dinner 14.30-16.30 Afternoon rest 16.30-17.00 Temperature taking 17.00-17.30 Tea 17.30-19.00 Visiting time 19.00-19.30 Dispatching medicines 19.30-20.00 Supper 20.00-21.30 Leisure time 21.30-22.00 Evening toilet 22.00-7.00 Sleep

TRETMENT-PROTECTIVE REGIMEN Hospital regimen foresees realization of treatment-protective regimen. The most important aim of last one is protection of patient’s psychics, affected by disease, from nervous irritations, forming favorable conditions for securing of his/her physical and mental rest. Protection of sensitive patient’s nervous system from excessive irritators forms favorable background for successful treatment, physical and mental rehabilitation. Distinct observance of day regimen, elimination of unfavorable influence of excessive sonic background (loud talk, wrangles, sound motions) has great importance for making treatment-protective regimen. It is necessary to limit appearance of different negative emotions in the patients. They can be caused by unpleasant look of care things (remains of dirt, blood, sputum), poor table appointments, irrational organizing of rest, indistinct work of personnel. Medical personnel should be spoken softly with patients and colleagues, bridling manifestations of emotions. Movements of physician and nurse during giving aid to the patient should be distinct, unfussy and without accompanying significant noise. Professional duties of junior nurses (nurse’s aide) 1. Daily cleaning of wards, toilets, corridors and other rooms of department. 2. Change of patient’s underwear and bed-clothes together with a nurse. 3. Presentation and bearing-out of bed-pans and urinals. 4. Washing, rubdown, washing intimately of seriously ill patients, surveillance after the cleanness of their hair, nails. 5. Bathing of patients together with a nurse. 6. Transporting of patients from the admitting office, and to different diagnostic procedures. 7. Delivery of biological material (blood, urine, excrement) in a laboratory. It is necessary to remember that a junior nurse must not give food to the patients, feed seriously ill patients, wash a crockery, perform the simplest manipulation procedures (to apply mustard plasters, to apply enemas and others).

Relations of nurse and junior nurse 1. Junior nurse is subordinated to the ward nurse. 2. Duties of the junior nurse and nurse are delimited mainly, but they have common actions- change of bedclothes and underwear, washing and transporting of the patient. 3. If junior nurse is busy, nurse can give and take out bedpan, urinal (it’s advisable to put gloves). 4. Instructions, given to the junior nurse by nurse, should be distinct, consistent, non sharp so that junior nurse doesn’t feel she is punished, but her actions are controlled and directed. 5. Nurse must appeal to the junior nurse by name and patronymic.

ORGANIZATION OF WORK OF THERAPEUTIC DEPARTMENT The therapeutic department of hospital is intended for the giving of medical care to the patients with internal diseases, who needs the prolonged medical treatment, examination, carrying out of difficult diagnostic procedures. There are the general therapeutic (unspecialized) departments, which are usually placed in small district hospitals, and the specialized (cardiological, gastroenterological, pulmonological and others) departments in large multi-type hospitals (city, regional). The staff of therapeutic department: 1. The head of department. 2. Hospital physicians (doctors in charge). 3. Head nurse (senior medical sister). 4. Ward nurses. 5. Sisters in charge of injections and other medical procedures (procedural nurses). 6. Junior nurses (nurse-assistants). 7. Workers of dining-room.

The rooms of therapeutic department: 1. The study of the head of department. 2. The physicians room. 3. The rooms of the senior nurse and the senior nurse – assistent. 4. The wards. 5. Nursing lookout post. Equipment of the wards was analysed before and one of nursing lookout post will be analysed in detail later. 6. The rooms for medical procedures: 1) for subcutaneous and intramuscular injections; 2) for intravenous injections, blood transfusions, taking of blood from a vein for the analyses; 3) for performing of the spetial medical and diagnostic procedures- pleural or abdominal punctures (pleurocentesis or abdominocsntesis); 4) for making of gastric lavage, giving of enema. The room for medical procedures must have such equipment: a) cabinet for saving instrumentation and medicines; b) drums with sterile syringes, needles, systems for transfusion of blood and infusion solutions; c) sets of sterile instruments for performing of pleura or abdominal punctures; d) supports for drop intravenous introducing of medicines; e) supports for sterile test tubes, which will used for taking of blood; f) sets for blood grouping; g) refrigerators for saving blood, sterile solutions for intravenous injections, sera, vaccine; h) quartz-mercury lamp; i) several couches; j) electric apparatus for sucking off. 7. The dining room and scullery. 8. The bath-room. 9. The room for washing and sterilization of the bed-pan, storages of stock. 10. Toilets for the patiets and medical personnel.

Nursing lookout post and its functional role Nursing lookout post is the workplace of ward nurse. It is intended for 25- 30 patients, it always takes place near wards, in order to all patients can be under the permanent care of nurse. Usually it is located in a corridor and is separated from it by partition – wooden from below and transparent glass above. The necessary equipment (Fig.1): 1. Table with sliding boxes, which is locked if it is necessary, for saving of case reports, sheets of the medical administration, different medical forms. 2. The special medical cabinets from plastic material for saving: a) medicines; preparations of group “A” (poisonous) and “B” (drastic), preparations for internal using and for the injections are saved separately; b) medical instrumentation (forceps, packers, scissors, scalpels); c) medical thermometers; d) the devices of patients care; e) disinfecting solutions; f) dressing material. 3. Small table, where drums with sterile material (by cotton wool, bandages) are, jar with disinfecting solution (furacillin), with packer dropped in it. 4. Small table with drum, where sterile syringes are. 5. Small table for distribution of medicines with the separations for every patient. 6. Refrigerator, where different tinctures, decoctions, serums, vaccines, are placed. 7. Panel of the light signal system. 8. Telephone. 9. Facilities of emergency illumination. 10. Wash-bowl for washing of hands, soap, clean towel.

Fig. 1. Nursing lookout post

Medical documents of therapeutic department Documents of physician: a) case history (medical card of in-patients); b) card of patients, who are in in-patient department (statistical document); c) medical certificate, which is given to the patient after discharging from a hospital. Documents of ward nurse: a) sheet of the medical administrations, which is signed by a nurse after their fulfilling; b) temperature charts; c) register for passing of duties; d) register for movement of patients in the department; e) register for registration of drugs; f) register for registration of patients with the high temperature of body; g) a la carte requirements to the feeding room ( canteen ) of hospital (in two copies); h) register for requirements of medicines; i) registers with the lists of patients who need any laboratory or instrumental research; j) register for registration of list of patients which need consultation of doctors-specialists. Documents of procedural cabinet (room): a) registers for registration of intravenous injections, blood transfusion, plasma, substitutes and albuminous preparations, taking of blood for biochemical researches, determining of the blood group, resus blood factor, taking of blood for determining of infectious diseases; b) registers for registration of syringes, needles, systems for drop intravenous introducing of different medicines, small bottles with blood, plasma and others; c) different instructions, which are necessary for sanitization of rooms, sterilizations of instruments, grant of help, using in urgency as onset anaphylactic shock, different antiepidemic measures; d) tables of antidotes. Documents of head nurse (senior medical sister): a) register for movement of patients; b) register for registration of drugs; c) register for registration of alcohol; d) register for requirements to the chemist’s shop; e) register for administrative-economic rounds; f) the graphs of work of junior and middle medical personnel, their time-board.

Reception and passing of duties by ward nurses Ward nurse, who came for duties, is to check up the following: a) quality of the morning cleaning of wards and other rooms of department; b) cleanness of underwear and the bed-clothes; c) quality of taking the morning toilet, especially in seriously ill patients; d) the presence of the collected material for the morning analyses, its quality (urine, feces, sputum); e) readiness of patients for diagnostic procedures; f) quality and rightness of the morning prescriptions; g) taking of body temperature and its mark in a temperature chart. At a lookout post nurse on duty checks: reserve and expenditure of medicines, presence of drugs that accordance of their expenditure with a record in the journal for consideration of drugs, presence of necessary documents, temperature charts, sheets of administration, presence of instruments for work . During passing the duties the following things are given: keys from closets, thermometers, hot-water bottles, bedpans, urinals. At the end of duty a nurse must make the report of movement of patients in the department for a previous day. The report of nightly nurse at a morning conference in the department is very important At a lookout post register of reception and passing of duties is filled in. Nurses append the signatures about the reception and passing of duty in this register. Organization of patients visits Permanent admission, in which hours for visit are marked, is given out to the relatives of seriously ill patients (excepting hours of rounds, performing of manipulations, rest). They must dress white medical smocks (gowns). Visitors meet patients, which the bed rest is not prescribed, in the specially organized for this purpose rooms (in the certain time, usually from 17.00 to 19.00). The bedridden patients are visited in a ward. Parcel brought to the patient is controlled by a nurse. It is impossible to give to the patient the boiled sausage, pastries with a cream, can foods, milk, spicery, alcoholic drinks and others. The tested food products must be kept in a refrigerator in polyethylene bags. Information about patient’s condition can be given by a nurse or physician. A physician informs relatives about the state of patient and his/her health in details. Discharging patients from in-patient department Before discharging patients from in-patient department it is necessary to prepare certificate about his/her condition in hospital, sick-list, excerption from a case history, medicines prescription. A head nurse informs the admitting office about discharging, except the names of these patients of the list from a la carte requirements, gives out to the patient the check about handed over clothes and values handed over, kept at storehouse, designs and gives out mentioned above documents to the patient. A patient receives necessary documents, takes away from storehouse with the values and clothes handed over and goes from the department at definite hours, usually after dinner. Patients who are below 18 years old, or those, who are not fully recover, and also the old-age patients go from a hospital only with relatives. Patients, who are not transportable after treatment, are delivered home after discharging by a sanitary transport under control of nurse and in accompaniment of relatives.

ORGANIZATION OF WORK OF ADMITTING OFFICE There are two types of the admitting office. They are: centralized and decentralized. The centralized type is used in multi-field uninfectious hospitals, when the admitting office is localized in the territory of hospital in a separate building, isolated from other departments. The decentralized departments are formed on the base of profile department of hospital (infectious department, maternity hospital). Organization of work in the admitting office is carried out in such sequence: registration of patients, examination by physician, rendering of urgency medical care if it is necessary, anthropometric measuring, sanitization, changing clothes and transporting patient to in-patient department. Registration documents: 1. Inpatient’s card (Case history) (title page is filled in by nurse); 2. Register of patients’ registration; 3. Register for refusals in hospitalization; 4. “Card of patients, who are in in-patient department” (statistical document)) (pasport part and left side are filled in by nurse). During hospitalization of patient in in-patient department in sanitary inspection room of admitting office sanitization is carried out to him/her, which includes such procedures: examination of body for the signs of infectious diseases, scab, trichophytosis; examination of hairy part of head and underwear for the signs of pedicoulosis; if it is necessary cutting of nails, hair, shaving; carrying out of hygienic bath, shower, or rubdown, it depends on the state of patient; changing clothes of patient in clean hospital clothes. A question about the necessity of sanitization and its volume is decided by physician. Then a nurse helps to a patient to put his/her things, clothes in the special bag, fill in a check in two copies describing the name and quantity of things. One copy of check is put into bag, another is put in a case history. A bag with clothes is saved in the special storehouse. Depending on the state of patient and the method of sanitization, administered by physician of admitting office, hygienical bath, shower or rubdown is carried out to the patient. Before the filling of bath it must be washed by 0,5% chlorinated lime solution or 2% chloramine solution. First of all cold water is collected, then the hot water in bath, for avoidance of steam accumulation in the room. Bath is filled with such computation, that water reaches him/her on the level of the nipples. The temperature of water in bath must be 35-400 С. A skin is wiped by a dry towel after bathing. If it is possible, it is better to bathe the patient under a shower which is perclived easier, the patient stands or sits on chair here. If bath and shower are contra-indicated a patient is wiped by warm water with soap. After sanitization a patient dresses clean hospital underwear and slippers. On the title page of сase history a mark about the carried out sanitization is made. The examination of patient on signs of a scabies and pedicoulosis is necessarily carried out in the admitting office. The hair part of head, pubis, inguinal pits and clothes (for the exposure of clothes louse) are examinated. At the examination of head it is possible to see scratching places, crusts that appeared after scratching, eggs of lice (nits) grey-white color, which are very tightly fixed to a hair, especially near its root, lice. At the examination of patient with pedicoulosis such measures are executed: 1. Urgent report about the case of pedicoulosis is filled in and sent to SES at the place of patient’s residence. 2. The note about the incident of pedicoulosis is written on the title page of case history. 3. The clothes of patient are sent to the disinfection chamber. 4. The fight is carried out against lousiness. In sanitary inspection room there is the special set which contains: magnifying glass, reading-lamp, razor, scissors, hairclipper, comb, packed carbofosis, jar with a capacity of one the liter for preparation of solution of carbofosis, 9% solution of vinegar acid, oilcloth for the comb-out of hair and bucket for its incineration, cotton and oilcloth triangular scarf, sack for clothes, glasses, masks, dressing-gown and triangular scarf for a personnel. During carrying out of sanitization of patients with pedicoulosis a nurse strings a mask, puts on to the mitten, additional dressing-gown and triangular scarf. A patient is sat on a couch covered by an oilcloth and process of the hair of head by a 0,15% carbofosis hydro- emulsion solution ( 3 ml 50% solution or 5 ml 30% solution dilute in 1 l of warm water) is made. This solution can be used not longer than 8 hours from the moment of preparation. A hair is covered by cotton, and then by oilcloth triangular scarfs which are wearing during 30 min. Then a hair is washed by warm water, is rinsed by solution of vinegar acid and is combed out above an oilcloth by a close-toothed comb during 9-15 min. Application of carbofosis is contra-indicated for the expectant mothers, the children , who are below 5 years old, and persons with the damage of skin of head . Use 5% boric ointment, 0,25% emulsion of dicrezilis, 0,5% solution of methylacetofosis in identical quantities with vinegar acid and soapy emulsion in these cases. Note “P” is made on the title page of case history, and a patient in 9 days is repeatedly examined. Every case of pedicoulosis the “Urgent report about the infectious disease”(f. 058y) is sent to the sanitary-epidemiological station. Anthropometry Anthropometric examinations of parameters of physical development of man include measuring of growth, body weight, chest and abdominal circumference. Usually anthropometric examinations in the admitting office are carried out by a nurse. Measuring of growth is carried out by means of the special device – stadiometer (Fig.2 ,a, b). Its vertical bar has centimetre points. The horizontally located slat moves along a bar. A patient stands by the back to the bar, very tightly touching it by heels, buttocks, shoulder-blades and back of head. The head of patient must be in such position, that the overhead border of external acoustic meatus and corners of eyes are on one horizontal line. Put plane-table on the head of patient and count points on a scale to the lower border of plane-table. The obtained results are filled in the case history. There growth of seriously ill patient is measured by a centimetre band in recumbency of patient.

Fig. 2. Measuring of growth of the patient a – stadiometer; b – measuring of growth.

Measuring of patient’s body weight is carried out on medical balance which is set and regulated correctly before this procedure (Fig.3). Weighing is carried out on an empty stomach after emptying of urinary bladder and bowels. A patient must be dressed in the underwear only. A patient stands carefully in the middle of platform of balance at the down bar. When it is attained equilibrium, the bar of balance is levitated, the weights are moved on the slats of beam of balance to the left until it will not become at the same level with a control line. Then the bar of balance is down again, and indexes of lower (one point = 1 kg) and upper (one point = 100 g) slats are summed up. The obtained results are filled in the case history. Weighing of patients in hospital is carried out one time a week. Weighing of patients with obesity, the exhausted patients and patients with the edema is carried out twice or three times a week.

Fig3. Weighing of the patient on medical balance

It is reasonably to use index of body weight for objective estimation of body weigh. It is ratio of body weight to its squared height (kg/m2). Its ideal result - 18,5-24,9 kg/m2 . For determining excessive body weight in adult persons we use classification of WHO, 1977 (table 1). Table 1 Determining of body weight Classification Index of body weight, kg/m2 Insufficient body weight To 18,5 Normal body weight 18,5-14,9 Excessive body weight 25 and more Pre-obesity 25-29,99 Obesity: I degree 30-34,99 II degree 35-39,99 III degree More than 40

Measuring of chest circumference is carried out by means of soft centimeter band (Fig.4) from the front of the IV rib (under nipples in men), behind and under the shoulder-blades (scapulas). Thus the hands of patient must be lowered. The chest circumference is measured during maximal inspiration and expiration, and also during the quiet breathing. Measuring of abdominal circumference matters in patients with ascites (measure daily), and also in obesity (measuring is carried out on an empty stomach). A centimeter band is placed in front - on the level of umbilicus, behind - on the level of the ІІІ lumbar vertebra. The obtained results are filled in the case history.

Fig. 4. Measuring of chest circumference

Transporting of patients Transporting of patients is transference or transportation of them from the admitting office to the medical department, from one medical department to another, or from one hospital to another. The type of transporting is determined by physician only, because wrong select type can harm to the patient (for example, with the myocardial infarction, internal bleeding). All patients are divided into transportable and untransportable ones depending on the general state. Transportable patients are the patients, who without harm for the health can move without assistance (patients of the satisfactory state), who can be transported by means of wheel stretcher, wheelchair, carry on stretcher (patients of the state of moderate severity or seriously ill). Untransportable patients are ones, who are in the grave condition, transporting can entail a threat for their life. It is necessary to give such patients exigent (emergency) or reanimation aid. If it was successful, a patient can be transported to the resuscitation, coronary care units or surgical department. Rules of transporting of patients from admitting office to the medical department: 1. Patients of the satisfactory state go to the ward without assistance, but in accompaniment of nurse or junior nurse. 2. Patients of the state of moderate severity are transported to the department on an wheelchair (Fig. 5, a, b). 3. Seriously ill patients are transported on special wheel stretcher (Fig. 6, a,b) covered by a blanket and clean sheet (individual for every patient). 4. If wheel stretcher is absent a patient is carried on stretcher.

Rules of transference of patients on stretcher (Fig.7, a, b, c): 1. Transference of patient is carried out by two hospital aid-men. 2. During transference of patient aid-men don’t must keep in step, their steps must be short. 3. If elevator is absent, and a patient must be transferenced the stairs, you need keep the following rules:  during transporting upwards (Fig.7, b) patient is carried by a head ahead, an aid-man, who goes ahead, holds stretcher on the dropped hands; an aid-man, who goes behind - holds the handles of stretcher on his shoulders.  during transporting downward (Fig.7, c) patient is carried by feet ahead: an aid- men, who go behind, hold stretcher on the dropped hands; an aid-men , who goes ahead, hold the handles of stretcher on his shoulders.

Fig.5.Transporting of the patient on Fig.6. Transporting of the patient on the wheelchair: a- wheelchair; the wheel stretcher: a-wheel stretcher; b-transportation of the patient on the wheelchair b-transportation of the patient on the wheel stretcher

Fig.7. Transporting of the patient on the stretcher: a- on plane surface; b- upwards; c- downward

Rules of shifting of patient from a couch on stretcher or wheel stretcher 1. If area of room is sufficient, the leg end of stretcher is put to the head end of bed (perpendicular position); if the area of room is insufficient, the stretcher is put parallel to the bed. 2. In cause of the perpendicular setting of stretcher ( wheel stretcher ) by three aid-men, one aid-man puts a hand under a head and shoulder-blades of patient, the second aid-man takes patient under a pelvis and upper part of thighs, third one takes patient in the middle of thighs and shins. They raise a patient and lay him on a stretcher simultaneously by the concerted motions. In cause of the perpendicular setting of stretcher by two aid-men (in lying position of patient), one aid-man puts hands under a neck and shoulder- blades of patient, the second one puts hands under loin and knees of patient. Rules of shifting of patients from stretcher (wheel stretcher) into a bed 1. In cause of the perpendicular setting of stretcher or wheel stretcher to the bed, three or two aid-men raise patient and, turning him on 90о, lay into a bed. 2. If stretcher or wheel stretcher is in parallel position to the bed, aid-men, raising the patient, turning him on 180о and lay him into a bed.

Features of transporting of patients with different diseases of internal organs Patients with acute myocardial infarction are carefully transported exceptionally on wheel stretcher or stretcher. Patient with heart failure, with the breathlessness is carried on stretcher or wheel stretcher in position semi-sitting; in the relatively satisfactory state of patients it is possible to transport them on a wheel chair. Patients with a collapse and other types of vascular insufficiency are transported on stretcher or wheel stretcher thus, that the head of patient is below than feet. Patients in the swoon state, in the danger of origin of vomiting, are transported on stretcher or wheel stretcher in position on the back with a returned aside head. Patients with the gastro-intestinal bleeding are transported on the back. An ice-bag is laid on their abdomen.

A. Test tasks to be done: - with a single selective answer - I-st level:

1. What factor promotes to spread of nosocomial infections? a) breach of rules of aseptic and antiseptic in a hospital; b) bedbugs and cockroaches; c) patients with pedicoulosis. 2. How often is it necessary to carry out the moist cleaning of wards? a) daily; b) if it’s necessary; c) if it’s necessary, but not rarer than twice a day. 3. What is the norm of useful area of hospital ward calculating on one patient? a) 4-5 m2 ; b) 6 m2; c) 7 m2 ; d) 8 m2; 4. What does the role of bed-tables? a) for keeping of medicines; b) for keeping of outerwear of patient; c) for keeping of things of the personal hygiene of patient. 5. What does term “special care” mean? a) the care, carried out extra carefully; b) the care, carried out in special conditions; c) the care, which needs presence of highly skilled specialists; d) the care, which foresees additional actions, caused by specific features of disease. 6. Who must to carry out care of patients? a) patient’s kin; b) average and junior medical personnel; c) all medical workers and patient’s kin, and what’s more - every from them has his certain function according to care’s carrying out. 7. Malignant tumor of the stomach is diagnosed in the patient. Eradication of it must be carried out. Patient refuses from operation categorically. What is correct tactics of physician? a) to say true diagnosis to the patient; b) to discharge patient, shrouding true diagnosis from him; c) to say to the patient about presence of other disease (peptic ulcer, polyp of the stomach) in him, which needs to operate; try to persuade patient in necessity of operation. 8. The nurse confused externally similar bottles. She injected the patient Insulin instead Heparin. Therefore acute deterioration of condition of the patient (coma) occurred. How it is possible to estimate action of the nurse? a) medicle offence; b) medical mistake; c) casual oversight. 9. What is normal ward temperature? a) 14-16o C; b) 16-18o C; c) 18-22o C; d) 22-26o C. 10. Normally ventilation of wards is carried out: a) not less than 1 time by means of opening of window leaf (ventilation pane); b) not less than 1-2 times by means of opening of window leaf (ventilation pane); c) not less than 2-3 times by means of opening of window leaf (ventilation pane); d) not less than 3-4 times by means of opening of window leaf (ventilation pane); e) every hour by means of opening of window leaf (ventilation pane). 11. Solution of chloramine must be kept no more than: a) 1 day; b) 3 days; c) 5 days; d) 7 days; e) two weeks. 12. Furniture, window-sills, the radiators of heating are washed or wiped by a moist rag: a) 1 time every day; b) 1 time per two days; c) 1 time per one week; d) 1 time per three days; e) 1 time per one month.

- with the selective group of right answers - II - nd level: 1. What disinfectants are used for the moist cleaning? a) 0,5% solution of chlorinated lime; b) 10% solution of chlorinated lime; c) 1% solution of chloramine; d) 3% solution of peroxide of hydrogen; e) solution of potassium permanganate. 2. What factor promotes to appearance of cockroaches in the hospital departments? a) ill-timed deleting of wastes of meal and unhigh-quality cleaning of rooms of easting establishment; b) cracks in walls and plinths; c) hospital-acquired infections; d) insufficient sanitization of patients. 3. What are the types of disinfection? a) prophylactic; b) bactericidal; c) moisture; d) final. 4. What are the methods of disinfection? a) mechanical; b) biological; c) chemical; d) physical. 5. Professional duties of junior nurses include the following: a) bathing of patients together with a nurse; b) transporting of patients from the admitting office, and to different diagnostic procedures. c) careful filling in medical documentation; d) measuring of arterial pressure, pulse rate, respiratory rate, day's diuresis and report of these data to the physician; e) correct estimation of the patient’s state and giving him/her emergency aid , and calling a physician if it is necessary. In emergency situations a junior nurse must give first premedical aid (artificial respiration, indirect massage of heart, and others); f) delivery of biological material (blood, urine, excrement) to a laboratory; g) making of subcutaneous and intramuscular injections. 6. An optimal temperature regimen in wards: a) in a winter -18-20oC b) in a winter - 20-21oC; c) in summer - 20-22oC d) in summer - 22-24oC; e) in a winter and in summer - 16-18 oC. 7. Common rules of the moist cleaning of rooms of department include the following: a) the moist cleaning of rooms are carried out by junior nurses (hospital cleaners); b) an inventory (stock) for performing of disinfective measures (buckets, mops, rags and others) must be in the special for this purpose rooms; c) stock is marked and used only in those rooms which it is appointed for; d) for the moist cleaning different disinfectants are used necessarily; e) for the moist cleaning different disinfectants are used in a day. 8. Crockery is washed as following: a) water of temperature of 70-80oC is used with addition of mustard, sodium of hydrocarbonate (for deprivation of fat crockery); b) water is changed twice; c) water is changed thrice; d) after washing crockery must be disinfected by 0,2% solution of clarified chlorinated lime; e) after washing crockery must be disinfected by 10% solution of clarified chlorinated lime;

f) after disinfection a crockery must be cleaned by hot water. 9. Relations of nurse and junior nurse are based on the following: a) junior nurse is subordinated to the procedural nurse only; b) junior nurse is subordinated to the ward nurse; c) duties of the junior nurse and nurse are delimited mainly, but they have common actions - change of bedclothes and underwear, washing and transporting of the patient; d) if junior nurse is busy, nurse can give and take out bedpan, urinal (it’s advisable to put gloves); e) instructions, given to the junior nurse by nurse, should be distinct, consistent, non sharp so that junior nurse doesn’t feel she is punished, but her actions are controlled and directed; f) nurse must appeal to the junior nurse by name; g) nurse must appeal to the junior nurse by name and patronymic. 10. A junior nurse must not: a) give food to the patients; b) feed seriously ill patients; c) wash a crockery; d) transport patients from the admitting office, and to different diagnostic procedures; e) to perform the simplest manipulation procedures (to apply mustard plasters, to apply enemas and others);

B. Tasks to be done:

Task 1. Patient F., having treatment in clinics, during walk (airing) exceeded the limits of hospital park’s territory. What is qualification of this breach? a) Patient broke internal regulations of clinics; b) Patient broke treatment-protective regimen; c) Patient broke sanitary regimen.

Task 2. Junior nurse (hospital cleaner) during cleaning of toilet revealed absence of bottle with solution of chlorinated lime and loudly informed duty nurse, which was in contrary end of corridor. What regimen was broken by the junior nurse? a) Treatment-protective; b) Sanitary-hygienic; c) Hospital. Task 3. During rest hour the nurse came in the ward and loudly reproved patient for ill-timed drugs intake. Is nurse’s action correct? Task 4. . Cleaning the wards, junior nurse used stock for toilet. Is her action correct? Task 5. Junior nurse saw that patient with bed rest left ward and is going to the toilet along corridor. What actions should be carried out by junior nurse? Answers for test tasks of the I-st level: 1 - a 7 - c 2 - c 8 - a 3 - c 9 - c 4 - c 10- d 5 - d 1 1 - c 6 - c 1 2 - d

Answers for test tasks of the II-nd level: 1 - a , c 6 - b , d 2 - a , b 7 - a , b , c , d 3 - a , d 8 - a , b , d , f 4 - a , c , d 9 - b , c , d , e , g 5 - a , b , f 1 0 - a , b , c , e

Standards of right answer for tasks: Task 1. a Task 2. a Task 3. No, it isn’t. She roughly broke treatment-protective regimen. Task 4. No,it isn’t. Stock must be used only in proper purpose (separately for wards, corridors, toilets, dinner rooms, etc.) Task 5. Junior nurse must say to the nurse about break of regimen by the patient. Test tasks to be done: - with a single selective answer - I-st level: 1. Document of head nurse (senior nurse) includes: a) register for registration of syringes, needles, systems; b) register for requirements to the chemists shop; c) case history; d) card of patient, who are in in-patient department. 2. A patient, who suddenly felt badly, enters to the admitting office of hospital without appointment card. What will your tactic be? a) to examine a patient, to give him necessary medical aid and to decide a question about tactic of future treatment; b) to call in an ambulance; c) to send a patient for appointment card. 3. A patient with complaints of abdominal pains entered to the admitting office. The general condition of patient is satisfactory. Can he take a hygienic bath? а) it is possible; b) it is impossible; c) it is possible after the exception of acute surgical disease. 4. A patient with suspicion on the gastro-intestinal bleeding (3 hours ago there was “coffee- grounds”) is delivered to the admitting office. He feels subjectively satisfactorily, can move without assistance. How must a patient be transported to the department? a) on a foot, escorted by a nurse; b) on wheel chair; c) only on wheel stretcher. 5. What thermometer the temperature of water of hygienic bath is taken by? a) mercury medical thermometer; b) thermometer on liquid crystals; c) alcoholic thermometer in a case; d) electro-thermometer. 6. What temperature of hygienic bath must be? a) 31-32 oC; d) 37-38 oC; b) 33-34 oC; e) 39-40 oC; c) 35-36 oC; f) 41-42oC. 7. Transporting of infectious patient was carried out by means of wheel stretcher. What actions (concerning wheel stretcher) must be performed after ending of this transporting? a) wheel stretcher must be cleaned with 1:5000 solution of furacilline, soft stock - washed; b) wheel stretcher isn’t disinfected, linen is soaked in 2% solution of chloramine; c) wheel stretcher and linen must be disinfected with 2 % solution of boric acid; d) wheel stretcher is treated with 2% solution of chloramine, linen is disinfected in disinfecting chamber. 8. Nursing lookout post is intended for: a) 10-15 patients; b) 15-20 patients; c) 20-25 patients; d) 25-30 patients; e) 30-35 patients. 9. Every case of pedicoulosis the “Urgent report about the infectious disease”(f. 058y) is sent to: a) infectious hospital; b) the sanitary-epidemiological station; c) every hospital of region; d) the back-ground monitoring station; e) tubercolosis hospital. 10. Normal result of body weight index is: a) 14,5-18,4 kg/m2 ; b) 18,5-24,9 kg/m2 ; c) 25-29,99 kg/m2 ; d) 30-34,99 kg/m2 ; e) 35-39,99 kg/m2 . 11.Measuring of growth is carried out by means of: a) rule; b) tape-measure; c) stadioumeter; d) angle measurer. - with the selective group of right answers - II - nd level: 1. What manipulations are performed in a procedure room? a) injections; b) pleurocentesis (pleural tapping); c) applying of cupping glasses, mustard plasters; d) medical baths; e) blood typing. 2. What medical documents are filled in by ward nurses? a) register for passing of duties; b) medical certificate; c) sheet of the medical administration; d) a la carte requirements to the feeding room; e) card of patients , who are in in-patient department ( statistical document ). 3. The rooms of therapeutic department include the following: a) the study of the head of department; b) the study of substitute of the head of department; c) the physicians room; d) the dining room and scullery; e) the rooms of the senior nurse and the senior nurse – assistent; f) cloakroom; g) the bath-room; h) the wards; i) nursing lookout post. 4. The rooms of therapeutic department include the following: a) the rooms for medical procedures; b) the dining room and scullery; c) the bath-room; d) room for junior nurse; e) the room for washing and sterilization of the bed-pan, storages of stock; f) toilets for the patiets and medical personnel; g) room for visit of patient’s relatives. 5. Equipment of the room for medical procedures includes the following: a) cabinet for saving instrumentation and medicines; b) gastric tube; c) drums with sterile syringes, needles, systems for transfusion of blood and infusion solutions; d) sets of sterile instruments for performing of pleura or abdominal punctures; e) supports for drop intravenous introducing of medicines; f) bed-pens; g) urinals; h) supports for sterile test tubes, which will used for taking of blood. Equipment of the room for medical procedures includes the following: a) Esmarch’s irrigator; b) sets for blood grouping; c) refrigerators for saving blood, sterile solutions for intravenous injections, sera, vaccine; d) quartz-mercury lamp; e) bath; f) several couches; g) electric apparatus for sucking off. 7. Equipment of nursing lookout post includes the following: a) refrigerator, where different tinctures, decoctions, serums, vaccines, are placed; b) supports for sterile test tubes, which will used for taking of blood; c) panel of the light signal system; d) telephone; e) tape recorder; f) facilities of emergency illumination; g) wash-bowl for washing of hands, soap, clean towel. 8. Equipment of nursing lookout post includes the special medical cabinets from plastic material for saving: a) medicines; b) medical instrumentation; c) medical thermometers; d) sterile test tubes, which will used for taking of blood; e) the devices of patients care; f) disinfecting solutions; g) case history of patients; h) dressing material. 9. At the examination of patient with pedicoulosis such measures are executed: a) urgent report about the case of pedicoulosis is filled in and sent to SES at the place of patient’s residence; b) the note about the incident of pedicoulosis is written on the title page of case history; c) the clothes of patient are sent to the disinfection chamber; d) the fight is carried out against lousiness. e) patient is discharged from therapeutic hospital to the infectious hospital. 10. Special set in sanitary inspection room contains (for struggle against pediculosis) the following: a) magnifying glass reading-lamp, razor, scissors, hairclipper, comb; b) packed carbofosis; c) jar with a capacity of one the liter; d) 9% solution of vinegar acid; e) 2 % solution of chloramine; f) oilcloth for the comb-out of hair and bucket for its incineration; g) cotton and oilcloth triangular scarf; h) Esmarch’s irrigator; i) sack for clothes, glasses, masks, dressing-gown and triangular scarf for a personnel. B. Tasks to be done: Task 1. During the taking of hygienical bath a patient complains on nausea, syncope , darkening in eyes, general weakness. Patient is pale. What is tactic of medical personnel? Task 2. A patient is delivered (transported) to a ward on stretcher by the following method: the head end of stretcher is put to the leg end of bed. How was stretcher located correctly? Task 3. A patient is transported to the department on wheel stretcher covered by a fastened on it oilcloth. How correctly wheel stretcher was equipped? Task 4. A patient is lifted on stretcher along the steps to the third floor. Thus the head end of stretcher is returned ahead, and the lower, a bit is heaved up, is in the back end of stretcher. How is carried out transporting of patient correctly? Task 5. Nurse, being at table, fills in passport data of patient in a case history and at the same time suggests to the patient to stand on medical balance. Are her actions correct? Task 6. A patient in the shock state after wounding of abdominal region is delivered to the admitting office of therapeutic clinic. Referring of the absence in the clinic of surgical department, the nurse sent a patient in other clinic, where the specialized surgical department is. Are her actions correct? Answers for test tasks of the I-st level: 1 - b 7 - d 2 - a 8 - d 3 - c 9 - b 4 - c 10- b 5 - c 1 1 - c 6 - c

Answers for test tasks of the II-nd level: 1 - a , b , e 6 - a,b,c,d,f,g 2 - a , c , d 7 - a , c , d , f , g 3 - a,c,d,e,g,h,i 8 - a,b,c,e,f,h 4 - a , b , c , e , f 9 - a , b , c , d 5 - a , c , d , e , h 10- a,b,c,d,f,g

Standards of right answer for tasks: Task 1. To halt the bathing, to lay a patient on a couch, to cover by a sheet, to give to smell the cotton wool moistened by a liquid ammonia, to call a physician. Task 2. No. A stretcher must put so that its leg end was set to the head end of bed. Task 3. No. Wheel stretcher must be covered by a sheet and blanket, which change after transporting of every patient. Task 4. Correctly. Task 5. No. The nurse must preliminary prepare medical balance for weighing; to adjust zero position of balance , to take balance in the extreme left position, to heave fixedness upwards, and then suggest to the patient to unshoe and stand on medical balance for weighing. Task 6. No. A nurse must give urgency medical care to the patient, to fix data about a patient from the words of persons, who accompanied him, and quickly to call a duty physician.

Literature recommended: Main Sources: 1. Clinical Nursing Skills and Techniques: basic, intermediate and advanced. The C.V.Mosby Company, 1986.- 1296 p. 2. Clinical Skills and Assessment Techniques in Nursing Practice. Scott, Foresman and Company, 1989.- 1280 p. 3. Nursing interventions and clinical Skills. Mosby – year Book, Inc., 1996.- 813 p. 4. Nursing Procedures: Student Version. Springhouse Corporation, 1992.-788 p. 5. Polskaya L.V. Nursing procedures in therapeutic practice.- Simferopol: Universum, 2004. - 192 p. Additional ones: 1. Гребенев А.Л., Шептулин А.А., Хохлов А.М. Основы общего ухода за больными: Учеб. пособие.- M.: Медицина, 1999.- 288 с. 2. Нетяженко В.З., Сьоміна А.Г., Присяжнюк М.С. Загальний та спеціальний догляд за хворими.- К.:Здоров’я, 1993.- 304 с. 3. Щуліпенко І.М. Загальний і спеціальний медичний догляд за хворими з основами валеології/ Навчально-методичний посібник для студентів медичних вузів і учнів медичних ліцеїв. - К.:Кий, 1998.- 384 с. Informational resources 1. Leslie Jennings. Educational movie. “ Roles and Functions of the Nurse”./ Leslie Jennings.2014 2. Касевич Н.М. Основи медсестринства в модулях: навч. посіб. – К.: Медицина, 2009 3. HEAT Inc., Health Education & Training . Educational movie Ethical Issues In Nursing -- Respect: Dignity, Autonomy, and Relationships 2010 Internet resourses 1. http://study.com/academy/subj/science/health-and- nursing.html 2. http://www.moz.gov.ua/ua/portal/dn_20130601_0460. html 3. http://www.nursingworld.org/nursingstandards The Ministry of Health of Ukraine Ukrainian Medical Stomatological Academy

Approved at the Department of Propaedeutics to Internal Medicine with Care of Patients meeting on 11 09 2018 Protocol No2 The Head of the Department Professor Yu. Kazakov

METHODICAL INSTRUCTION FOR STUDENTS’ SELF-PREPARATION WORK

Educational discipline Care of patients Module No 1 Enclosure module No 1 Topic Determination and registration of the main indicators of the patient's life (hemodynamics, respiration, body temperature). Care for patients with fever Year 2 Faculty medical

1. The topic basis: determining of the main indexes of hemodynamics and breathing plays important role in examination of patient and care of patients. These indexes reflect function of the main systems of organism: cardio- vascular and respiratory.It causes topicality problem that is studied. 2. Taking and registration of body temperature have the important diagnostic and prognostic value and they are component parts of patient’s care.

2. The specific aims:

 To explain term “pulse” and method of its examination.  To explain different properties of arterial pulse and give examples.  To list arteries where pulse should be studied.  To explain terms “capillary pulse” and “venous pulse”  To classify types of vascular bleedings and arrests of bleeding  To explain the main rules of arrest of bleeding from arterial and venous bleeding  To explain methods of measuring of blood pressure  To list first before-doctor aid in elevation of blood pressure  To list first before-doctor aid for patients with vascular insufficiency  To list the main indexes of breathing  To list first before-doctor aid in case of cough, dyspnea, asthma (bronchial and cardiac)  Taking and registration of body temperature have the important diagnostic and prognostic value and they are component parts of patient’s care. 3.Basic knowledge, experience, skills necessary for studying the topic in

connection with other subjects (interdisciplinary integration) :

Previous disciplines Obtained skills

1.Anatomy To know human anatomy, cardiovascular and respiratory systems organs particularly.

2.Physiology To know physiology of cardiovascular and respiratory systems.

3. Medical psychology To be able to observe principles of ethics and deontology in medical practice.

4. Latin and medical To know terminology (in Latin transcription): terminology pulse, pulse different, rhythmic pulse, arrhythmic pulse, rapid pulse, slow pulse, tense pulse, soft pulse, thready pulse, large pulse, small pulse, swift pulse.

4. Tasks for self-work during preparation to the class.

4.1 List of the main terms, parameters, characteristics, which should be mastered during preparation to the class:

Term Definition

It is rhythmical vibration of the arterial wall caused by the 1. Pulse heart contraction.

It is difference between systolic and diastolic pressure 2. Pulse pressure

It is elevation of systolic pressure over 140 mm and of 3. Arterial diastolic over 90 mm Hg hypertension

4. Arterial hypotension It is a drop in the systolic pressure below 110 mm and of diastolic below 60 mm Hg

5. Fainting-fits They are short-term losses of consciousness due to a suddenly failure of cerebral blood supply arising most often with the fall of arterial pressure

6. Cough It is one of the most important protective reflexes of the respiratory system, directed to evacuation of sputum or foreign body from bronchi and upper airways.

7. Dyspnea It isdifficult or labored breathing.

8. Asphyxia It is pronounced dyspnea which develops suddenly

9. Asthma It is paroxysmal attacks of dyspnea

It is pathological process, which is characterized by disorder 10. Fever thermoregulation processes and elevation of body temperature.

It is fast lowering body temperature ( during a few hours) 11. Critical lowering from 41-40o C to 37-36o C. of body temperature (crisis)

It is slow lowering body temperature from high to the 12. The litical normal values during 2-3 days. lowering of body temperatur (lysis)

4.2. Theoretical questions to be answered before class:

1. Tell about palpation of pulse on radial artery. 2. What properties of pulse do you know? 3. List vessels, which can be palpated. 4. What does term “capillary pulse” mean? 5. Tell about postive and negative venous pilse 6. What are the main rules of arrest of bleeding from arterial and venous vessels? 7. What methods of measuring of blood pressure do you know? 8. Tell about auscultatory method of measuring blood pressure by N.Korotkoff. 9. Tell about first before-doctor aid for patients with arterial hypertension and vascular insufficiency 10. What the main indexes of breathing do you know? 11. What does term “cough” mean? Tell about first aid in case of the cough. 12. Tell about first before-doctor aid for patients with dyspnea, attack of bronchial or cardiac asthma 13. What are modern methods of body temperature measurement? 14. What is fever? 15. Name the stages of fever. 16. Care of patients with fever depending on its stage.

4.3. Practical work (tasks), whichshould be performed during class:

1. To carry out determining of the main indexes of hemodynamics and breathing (pulse, blood pressure, respiratory rate, depth of breathing, type of breathing, rhythm of breathing). 2. To interpret obtained results. 3. To take part in arrest of bleeding from arterial and venous vessels 4. To take part in giving of first before-doctor aid to the patients with elevation and decreasing of blood pressure, cough, dyspnea, asthma (bronchial or cardiac). 5. To carry out measurement of body temperature. 6. To interpret obtained results its registration in temperature chart 7. To take part in care of patients with fever

The contents of topic:

Text

THE MAIN INDEXES OF HEMODYNAMICS

Examination of Arterial Pulse

Pulse is rhythmical vibration of the arterial wall caused by the heart contraction. The pulse is studied by palpation and by instrumental examination - sphygmography.

Palpation of the pulse is the main method of pulse examination. As a rule, pulse is studied first on the radial artery, since it is superficial and runs immediately under the skin. It can be readily felt between the styloid process of the radial bone and the tendon of the internal radial muscle. The patient’s hand is grasped by the examiner so that the thumb of the right hand is placed on the dorsal side of the arm (near the radiocarpal joint) while the 2nd and 3 rd fingers remain on the frontal side of the arm. As soon as the artery is found, it is pressed against the underlying bone. The pulse wave is felt by the examining fingers as a dilation of the artery. The pulse should be taken in the following order. First the examiner must determine if the pulse can be equally felt on both arms. To that both radial arteries should be palpated simultaneously and the magnitude of pulse wave on both hands compared. Normally itis the same.

The pulse wave on one hand may happen to be lower. It is called pulse different (pulsus differens).It occursin unilateral structural abnormalities, compression by a tumor, or a scar in the brachial or subclavian artery or due to compression of large arterial trunk by the aortic aneurysm, mediastinum tumor, retrosternal goiter, or markedly enlarged left atrium. The smaller pulse wave may lag in time. If the pulse on the two arms is different, its further study should be carried out on that arm where pulse wave is more pronounced.

The following properties of pulse are examined: rhythm, rate tension, filling, size and form (Fig.1).

Fig. 1. Palpation of radial artery.

Rhythm. In healthy subjects, cardiac contractions and pulse waves follow one another at regular intervals. Normally the pulse is rhythmic or regular(pulsus regularis). Arrhythmic or irregular pulse (pulsus irregularis) may be of the patient with extrasystole, atrial fibrillation of heart block II degree. In a case of arrhythmia it is necessary to count up not only pulse on a radial artery, but number of the heart contractions. The difference between number of the heart contractions determined with the heart auscultation and number of the pulse waves is called deficiency of pulse. In can occur in atrial fibrillation and extrasystole.

Pulse rate in normal conditions corresponds to the rate of cardiac contractions and is 60-80 per minute. The pulse rate is counted for 15 seconds if the pulse is rhythmic and for 1 minute if the pulse is arrhythmic.

If the heart rhythm is accelerated (tachycardia) the number of pulse waves increases and the pulse rate increases accordingly (pulsus frequens).

In physiology it develops after meals, physical exertion and emotional stress.

In pathology it occurs in elevated body temperature (the heart rate increases by 8-10 per min per degree over 37º C). Accelerated pulse is a frequent symptom of myocarditis, heart failure, neurosis, anemia and thyrotoxicosis and in many infectious diseases and toxicosis; it can be provoked by some pharmacological preparations (adrenalin, caffeine, and atropine).

Slowed cardiac rhythm (bradycardia) is characterized by a respective slowing of the pulse (pulsus rarus).

In physiology it can occur in well-trained athletes and in sleep.

In pathology slowed pulse occurs in increased intracranial pressure (tumor and edema of the brain, meningitis, cerebral hemorrhage), in myxedema, typhoid fever, jaundice, starvation, lead and nicotine poisoning, and due to effect of quinine and digitalis preparations, or by irritation of receptors of the peritoneum and the internal organ.

Pulse pressure (tension) is determined by the force that should be applied to the pulsating artery to compress it completely. To the end, the artery is pressed by the index and middle fingers before the vessel stops pulsating under 4th finger. This property of pulse depends on the magnitude of the systolic arterial pressure and of the elastic property of the arterial wall.

A normal pulse is therefore of moderate or satisfactory tension.

In the patients with high arterial pressure, atherosclerosis the artery is compressed more difficulty. Such pulse is called hard or high tension pulse (pulsus durus). If the arterial pressure decreases, the artery is easy to compress and the pulse is soft (pulsus mollis).

Pulse volume depends on the stroke volume, on the total amount of circulating blood and its distribution in the body. Filling pulse is showed on volume (diameter) of an artery. It is needed to roll an artery under fingers, not squeezing it. In norm diameter of the pulse artery is 3-5 mm. It is called pulse of satisfactory volume.

If the stroke increases (in patient withhigher fever, lung failure, aortic insufficiency) the pulse is called full (pulsus plenus).

In abnormal circulation, blood loss and dehydration of the body, the pulse volume decreases (pulsus vacuus) or (pulsus filiformis).

Pulse size. The pulse size implies its filling and tension. It depends on the expansion of the artery during systole and on its collapse during diastole.

Pulse wave increases with increasing stroke volume, great fluctuations in the arterial pressure, and also with decreasing tone of arterial wall. This pulse is called large volume pulse or pulsus magnus.It is characteristic of aortic valve insufficiency, in thyrotoxicosis, when the pulse wave increased due to the high difference between systolic and diastolic arterial pressure.

Pulse wave decreases with decreasing stroke volume and amplitude pressure fluctuations during systole and diastole and with increasing tone of the arterial wall. The pulse wave becomes small (pulsus parvus). This is observed in stenosis of the aortic orifice, mitral stenosis, in tachycardia, acute circulatory insufficiency, and acute heart failure.

Pulse formdepends on the rate of change in the arterial pressure during systole and diastole. If much blood is discharged into the aorta during systole and the pressure in the aorta increases rapidly, while during a diastole this pressure quickly falls, the arterial wall will expand and collapse quickly as well. This pulse is called quick pulse (pulsus celer).It is characteristic of aortic insufficiency and for thyrotoxicosis.

Slow pulse (pulsus tardus)is, on the contrary, connected with slow rise and fall of pressure in the arterial system and its small fluctuation during the cardiac cycle. This condition is characteristic of aortic stenosis.

The conclusion: pulse is symmetric, rhythmical, a pulse rate is 60 beats per minute, and it is satisfactory tension and filling. Results of daily pulse rate’s determining are entered into temperature chart. Obtained points are connected one to another by means of red pencil, forming graphic picture of pulse rate’s curve.

After examination of pulse on the radial artery has been finished, it is studied on other vessels, on the temporal, carotid, femoral, popliteal arteries, and arteria dorsalis pedis (Fig.2).

Fig.2 Examination of pulse

Examination of pulse on other arteries is especially important in suspected affections of these arteries (obliterating endocarditis, atherosclerosis of the vessels).

Superficial temporal artery is palpated by pressing it to a temporal bone, slightly forward from an auricle. Consolidation, non-uniformthickening, morbidity of temporal arteries is an attribute of the temporal arteritis (Horton’s disese).

Pulse on a carotid is palpated as follows: the physician (nurse) stands facing to the patient; thumb finger is placed between internal edge of the sternocleidomastoid muscle and the upper edge of thyroid cartilage, other fingers - on a posterolateral surface of a neck (serially at the left and on the right); thumb finger is carefully dipped to occurrence sensation of a pulsation.

Subclavian artery is palpated at the external edge of the sternocleidomastoid muscle above clavicle and in the subclavian fossa.

Axillary artery is palpated in the armpit, the patient is asked to lift the straightened hand. The artery is pressed to the head of a humeral bone.

The humeral artery is palpated slightly medially from the center of the ulnar fold.

The femoral artery is better palpated inlaying position of the patient with the straightened hip under the middle of the inguinal ligament.

The popliteal artery is palpated in the popliteal fossa. The patient lies on an abdomen with the leg bent in a knee joint.

Posterior tibial artery is palpated in the condylar groove slightly posterior and below of the medial anklebone.

The arteria dorsalis pedis is palpated in proximal parts of the first intermetatarsal interspace from the external side of the big toe long extensor.

When the aortic isthmus is constricted (coarctation), the pulse waves in the lower extremities decrease significantly, whereas they remain normal, or even increase, on the carotid arteries and the arteries of the upper extremities. In Takayasu’s disease (pulse less disease), in the presence of obliterating endarteritis of large vessels originating from the aortic arch, the pulse decreases or disappears on the carotid, axillary, brachial, and radial arteries.

Capillary pulse

In order to reveal the capillary pulse, the 3rd or 4th finger nail should be slightly pressed in order to form a small white spot: in normal the color of the border of the white spot is constant. If the margin between the red and blanched part will be seen to ebb and flow with each pulse beat, it is called positive capillary pulse. It can be found in patients with aortic insufficiency and sometimes in thyrotoxicosis.

Venous pulse

Venous pulse is investigated on jugular vein in case of its seen pulsation.

It is hardly noticeable in healthy person and this is called negative venous pulse.Pulsation of jugular vein caused by pulsation of the carotid arteries can be mistaken for the venous pulse. It should therefore be remembered that pulsation of the carotid artery can be seen medially of the sternocleidomastoid muscle, while pulsation of the vein - laterally of this muscle. Moreover, if the vein is pressed by a finger along its course, the transmitted vibrations of the peripheral portions of the vein become more visible. It is called false venous pulse. In genuine venous pulse pulsation of the peripheral portion discontinues and pulsation of internal portion presents. It is called positive venous pulse. Positive venous pulse is observed in tricuspid incompetence, pronounced venous congestion in the systemic circulation, and complete transverse heart block.

Palpation of the abdominal wall veins is carried out in their dilation incase of anastomoses occurrence between portal and cava veins due to a syndrome of a portal hypertension (owing to infringement of blood outflow from portal vein in hepatocirrhosis, thrombosis of the portal vein or its branches, compressing of the portal vein by increased lymphonoduses or tumor). If to press a part of the expanded vein of the abdominal wall with two fingers, superseding blood from it, and then alternately to raise one and other finger, in anastomoses, connecting low and upper cava veins the blood stream goes from below upwards, and in anastomoses, connecting portal vein with low cava vein - from top to down.

First aid in hemorrhages

Hemorrhages (bleedings) are subdivided into arterial, venous,capillary and mixed.

It is necessary to remember that in arterial bleeding color of the blood is vermilion and blood flows as pulsing brook (by pushes); in venous bleeding color of the blood is dark and blood flows continuously.

There are temporary and constantarrests of bleeding. Temporary arrest of arterial bleeding is carried out by means of pressing of bleeding vessel over place of hemorrhage, venous bleeding - lower place of hemorrhage. Pressing by finger (fingers) to the bones is realized in case of lesion of large arterial and venous vessels when it is necessary to control bleeding immediately and gain time for preparation to carrying out of arrest of bleeding by other methods, which can allow performing of patient’s transporting. Besides, digital pressing of bleeding vessel needs making intensive efforts. Even strong men can’t carry out this procedure more than 15-20 minutes.

Arrest of arterial bleeding

Every large arterial vessel has typical places where its digital pressing to the bones is carried out. For example, in bleeding from vessels of temporal area temporal artery is pressed to the zygomatic bone in front of lobule of ear. In severe bleeding from wounds of the head, face and tongue - carotid artery on the neck is pressed to the spinal column.

Application of tourniquet is effective method of temporary arrest of arterial bleeding. This manipulation is indicated in massive arterial bleeding from vessels of extremities only. In case of absence of elastic rubber band tourniquet it is possible to use apprentice material: rubber tube, belt, towel, cord.

Fig. 3. Tourniquet

Rules of tourniquet’s application:

 Tourniquet is applied in lesion of large arterial vessels of extremities;  In case of bleeding from arteries of upper extremity tourniquet should be placed on the upper third part of shoulder; in case of bleeding from arteries of low extremity - on middle third part of shoulder;  Tourniquet is applied on raised extremity: it is placed under place of supposing applying, stretched (if it is rubber); soft pad (bandage, clothers and others) is put under it. Tourniquet is turned around extremity several times (until total arrest of bleeding) so that turns should be placed one to another closely and skin folds between them were absent. Ends of tourniquet are knotted firmly or clamped by means of chain or hook;  Tourniquet should be applied tightly, but tissues of extremity must not be pressed strongly as very server complication are possible;  Time of tourniquet applying must be written in note, fastened to the patient’s clothes, and in medical documents, accompanying patient.  It is impossible to apply tourniquet on the low extremity over 90 minutes, and on the shoulder - over 45 minutes. It is interdicted categorically to apply bandages over tourniquet; last one should be well visible;

Tourniquet, appliedbetimes, cansavelife.

After applying of tourniquet victim (patient) must be transported in medical establishment for final arrest of bleeding immediately. If his/her evacuation is delayed, after critical time tourniquet must be take away or relaxed during 10-15 minutes, and then it must be applied again. During period, when extremity was free from tourniquet, arterial bleeding is prevented by means of digital pressing of artery. Sometimes procedure of relaxing and applying of tourniquet is repeated: in winter - every 30 minutes, in summer - in 45-60 minutes.

Arrest of venous and capillary bleeding

Venous and capillary bleeding from vessels of extremity can be controlled by means of applying of compressive dressing (Fig.4). Some sterile drapes are applied on the wound, thick swab from cotton or bandage is bandaged tightly over drapes. After applying of this dressing, it is necessary to make raised position to the extremity. It is reasonably to put ice bag and little load (for example, little bag with sand) on the area of wound over dressing

Fig. 4. Arrestofvenousbleeding

In case of impossibility of tourniquet’s using in bleeding, threatening to the life, wound should be covered by sterile drapes. Thenbleedingvesselshouldbepressedbythefinger. But it is necessary to remember that it is safer to press vessel out of wound (not in the wound).

It is necessary to remember that only physician carry out tight tamponade.

For temporary arrest of the bleeding in the incident place sometimes maximal flexion of the extremity with its fixation in this position can be used successfully. This method of arrest of bleeding reasonably to use in case of intensive bleeding from wounds, localized in the low parts of extremity. Maximal flexing of extremity is carried out in the joint over wound and extremity is fixed in this position by bandage. So, in injury of forearm and shin extremity is fixed in elbow and knee joints; in bleeding from humeral vessels it is necessary to shift hand behind back maximally and fix; in wound of thigh - the leg is flexed in hip and knee joints and thigh, pressed to the abdomen, is fixed.

Final arrest of bleeding is realized in operating room. In case of nasal bleeding patients must occupy sitting or lying position, his/her hand should be inclined backwards. It is necessary to unbutton his/her collar, put cold compress on the bridge of the nose and nose (changing compress as it gets warm), press soft parts (wings) of the nose by fingers and introduce bit of sterile cotton or gauze, moistened by hydrogen peroxide.

MEASURING OF ARTERIAL PRESSURE

The pressure of the blood in the arterial system varies rhythmically, attaining its maximum during systole and lowering during diastole. Arterial pressure (AP) is proportional to the amount of blood ejected by the heart into the aorta (the stroke volume) and the peripheral resistance. AP is expressed in millimeters of mercury column.

AP can be measured by direct or indirect method. In the direct methodthe needle is introduced directly into the artery and connected to a pressure gauge. This method is mostly used in heart surgery. Three techniques exist to take blood pressure indirectly. These are auscultatory, palpatory and oscillographic.

The palpatory method is only used to take systolic pressure.

The oscillographic method is used to record systolic, mean, and diastolic pressure in the form of an oscillogram and also to assess the tones of the arteries, elasticity of their wall

The auscultatory method is commonly used in medical practice. The method was proposed by N. Korotkoff. A sphygmomanometer is used to read pressure. It consists of mercury or a spring manometer which is connected to a cuff and rubber bulb used to inflate the cuff through a connecting tube.

The pressure in the brachial artery is usually measured. To that end, the arm of the patient is freed from tight clothes and a cuff is attached snugly and evenly onto the arm (a finger - breadth between the cuff and the skin). The cuff, manometer and heart of the patient should be at one level. The inlet socket of the cuff should be directed downward, 2-3 cm above the cubital fossa. The phonendoscope bell is placed over the brachial artery in the cubital fossa; the valve on the bulb is closed. Air is pumped into the cuff until pressure inside it is 30 mm above the level at which the brachial or radial artery stops pulsating. The valve is then opened slowly to release air from the cuff. Using the phonendoscope the brachial artery is auscultated and the readings of the manometer followed. When the pressure in the cuff drops slightly below systolic, tones synchronous with the heart beats are heard. The manometer readings at the moment when the tones are first heard are taken as the systolic pressure, when the tones are not heard it is taken as the diastolic pressure (Fig. 5).

Fig. 5. Measuring of arterial pressure

Korotcoff described 4 phases of sounds that are heard during measurement of AP. I phase in the appearance of the tone over the artery. The II phase is appearance pf the loud tones and murmurs caused by the blood turbulence below the constricted point. The moment when loud tones become audible is designated as the III phase. When pressure inside the cuff equals diastolic one, and the blood flow is no longer obstructed, the pulsation of the vessel suddenly decreases. This moment is characterized by a marked weakening and disappearance of the tones (IV phase).

Results of daily blood pressure measurement (sometimes blood pressure is measured some times a day) are entered into temperature chart.

The normal systolic pressure varies from 110 to 140 mm Hg, and diastolic one - from 60 to 90 mm Hg. The difference between systolic and diastolic pressure is called the pulse pressure (normallyit is 40-50 mm HG). Optimal AP is 120/80 mm Hg.

Mean dynamic blood pressureis constant pressure that might (without pulsation) ensure movement of the blood in the system at the some rate. Normal mean pressure is from 80 to 100 mm Hg. It can nly be determined from an oscillogram. It can approximately be calculated by the following formula:

Pmean= Pdiastolic + 1/3 Ppulse

The lowest pressure is normally observed at rest, before breakfast, in the morning, in conditions under which basal metabolism occurs. This pressure is called basal. When pressure is taken for the 1st time, it may appear slightly higher than actual which is explained by the patient’s response to the procedure. It is therefore recommended that pressure be taken 2-3 times. The last and the least value should be considered the closes to the true pressure. In primary research the AP is measured on both hands, thus on the left hand it can be a little bit higher, than on right.

Elevation of systolic pressure over 140 mm and of diastolic over 90 mm Hg is called arterial hypertension. A drop in the systolic pressure below 110 mm and of diastolic below 60 mm Hg is known as arterial hypotension.

A transient increase of the arterial pressuremay occur during heavy exercise, especially in person who are unaccustomed to it, in excitation after taking alcohol, strong tea or coffee, in heavy smoking or during attacks of intense pain.

Longstanding elevation of arterial pressure occurs in essential hypertension, glomerulonephritis, vascular nephrosclerosis, in certain endocrine diseases.

Systolic pressure alone is sometimes elevated, whereas diastolic pressureremains normal or decreased in thyrotoxicosis, atherosclerosis of aorta.

Increasing of the systolic pressure and marked decreased diastolic pressure occurs in aortic incompetence.

Arterial pressuremay bedecreaseddue to constitutional properties in asthenic person. As a pathological symptom hypotension occurs in many acute and chronic infectious disease, Addison’s disease, and myxedema. A sudden drop in the AP occurs in profuse blood loss, shock, collapse or myocardial infarction.

Decrease of the pulse pressure occurs due to decrease systolic (in aortic stenosis, exudative or adhesive pericarditis, heart failure).

Increase of the pulse pressure owing to primary increase systolic pressure is typical for thyrotoxicosis, atherosclerosis, and aortic insufficiency. Sometimes measurement of pressure on legs is required. For this purpose longer cuff which is imposed on the low third of hip is used. The patient lies on an abdomen; the stethoscope is put in popliteal fossa. It is necessary to remember, that on a femoral artery systolic pressure on 35-40 mm Hg, and diastolic - on 15-20 mm Hg is higher than on a humeral artery. Aortic coarctation is characterized by considerably lower pressure in the femoral arteries compared with the brachial arteries.

First before-doctor aid in elevation of blood pressure

Pulsating, pressing pain, frequently localized in the area of back of the head, is one of the signs of hypertension. Hypertensive crisis is sudden elevation of blood pressure in patients with arterial hypertension, accompanying by headache, dizziness, sometimes-vomiting,flashing of “spots” in front of eyes. In this case it is necessary:

1) To call physician; 2) To measure blood pressure; 3) To lay the patient in a bed with a raised head of the bed, ensuring complete physical and mental rest; 4) To air room; 5) To put mustard plasters on the back of the head and calf muscle; 6) To carry out hot or mustard foot baths, warm baths for the arms; 7) To prepare necessary medicaments (for example, 0,5 % solution of dibasole, 10% solution of magnesium sulfate, 0,01% solution of clonidine, 5% solution of pentamine, lasix (furasemide).

First before-doctor aid forpatients with vascular insufficiency

Acute and chronic vascular insufficiency is distinguished. Shock, collapse, and syncope are the symptoms of acute vascular insufficiency. These signs develop when the amount of circulating blood decreases significantly and the vascular tone diminishes. Nutrition of vital organs, the brain in particular, becomes impaired. The skin of patient with acute vascular insufficiency is pallid, the limbs are cold, the pulse is small and weak, the arterial pressure is low, and the patient is extremely weak.

Fainting-fits are short-term losses of consciousness due to a suddenly failure of cerebral blood supply arising most often with the fall of arterial pressure. The patient feels giddiness, nausea, darkness in the eyes and loss of consciousness. In this case it is necessary:

1) To lay the patient horizontally (without a pillow!), to raise his/her leg; 2) To measure arterial pressure; 3) To air room; 4) To sprinkle the patient’s face and breast with cold water; 5) To bring near the nose of the patient tampon or cotton moistened with ammonium chloride and to wipe the patient’s temples with it; 6) To rub the patient’s breast and temples with your hands; 7) To slap the patient (face) with your palms; 8) To put heaters (hot water bottles) on the patient’s extremities and to cover him/her with a blanket; When consciousness is restored it is necessary to give the patient hot strong and sweet tea or coffee.

Collapse and shock are clinical manifestations of acute vascular failure with sharp dropping of the arterial pressure and impairment in the peripheral circulation. It is observed in myocardial infarction, trauma, acute loss of blood and in allergic conditions.

A patient in a state of collapse should also be placed in the horizontal position, without pillows, to improve cerebral circulation, and the legs should be slightly elevated (or the end of an adjustable bed should be raised). Warmth should be applied to the arms and feet. The arterial pressure should be elevated by subcutaneous administration of caffeine or camphor. If the state of collapse persists (e.g. in myocardial infarction), the patient should be given mesatonum by drop infusion in 5% glucose solution.

Vascular shock is the grave complication of the many serious diseases (trauma, bleeding, myocardial infarction, acute infectious diseases) and is needed in emergency medicine.

FOLLOW-UP OF BREATHING

Observing breathing, it is necessary to determine rate, depth, rhythm of respiratory movements and estimate type of breathing.

Normally respiratory movements are rhythmical. Respiratory rate in adult person at rest is 16-20 per minute, besides, in women it is on 2-4 more than in men. In lying position respiratory rate usually diminishes (to 14-16 per minute), and in vertical one - is increased (18-20 per minute). In trained persons and sportsmen respiratory rate can decrease and reach 6-8 per minute. Superficial breathing usually occurs at rest, and on physical or emotional exertion it is deeper.

Depending on taking part in respiratory movement thorax or abdomen (diaphragm) mainly, there are thoracic (in women mainly), abdominal and mixed types of breathing.

It is necessary to follow-up breathing imperceptibly for the patient, as he/she can change rate, depth and rhythm of breathing arbitrarily.

For determining of respiratory rate it is necessary to take patient’s hand like for examination of pulse on radial artery so as to turn away patient’s attention and to put other hand on thorax (in thoracic type of breathing) or epigastrium (in abdominal type of breathing). Only number of inspirations per minute is counted. Results are entered into temperature chart.

There are potential symptoms associated with respiratory disorders: cough, chest pain, dyspnea, hemoptysis.

A cough is one of the most important protective reflexes of the respiratory system. A cough can be productive and dry. Effective coughing clears the tracheobronchial tree of excessive secretions, particulate matter, and sometimes even large pieces of debris (food).

Care of coughing patients depends on the particular disease. For example, in acute respiratory diseases (acute laryngitis or tracheitis), dry and painful coughs are controlled by medicinal preparations taken per os, or by inhalation of sodium hydrocarbonate and hot stream. Mustard plasters, mustard foot baths, and hot compresses on the chest are used as counter-attractive therapy. An irrigating nonproductive coughin persons without congestion may be appropriately treated with suppressants. Suppressants are drugs that depress a cough reflex. Codeine, which is present in many cough preparations, is generally considered the preferred cough suppressant ingredient. Inappropriate suppression of the cough in a person with respiratory congestion can result in harmful retention of the secretions.

If the cough is moist and the patient expectorates much sputum (bronchiectasis), the patient should assume a position in which he/she can more easily expectorate sputum. Antitussives are given to the patients before night sleep.

Sputum (primarily of tuberculosis patients) can be the source of infection for the surrounding people. The patient should therefore observe the rules of personal hygiene. The tuberculosis patient should abstain from coughing in the immediate vicinity of other people: if he/she is unable to control coughing, he must lake all possible measures to prevent contamination of the surroundings. The patient must not spit on the floor because sputum dries up to become an air-borne source of infection. Sputum should be collected in a bottle with a screw cap containing 3% chloramine. (Fig.6). The collected sputum should be decontaminated by lime chloride or a 5% chloramine solution and discarded into the sewage.

Fig. 6. Bottle for the sputum

Apnea refers to periods during which there is no breathing. This is a serious situation in which brain damage occurs if it is suppressed for more than 4 to 6 minutes.

Under normal conditions, healthy adults breathed approximately 16 to 20 times per minute. During illness, the respiratory rate may vary from normal. Dyspnea is difficult or labored breathing.

Pronounced dyspnea which develops suddenly is called asphyxia. Paroxysmal attacks of dyspnea are called asthma. It can be of pulmonary or cardiac etiology, i.e. bronchial or cardiac asthma, respectively.

A dyspnetic client is likely to demonstrate rapid, shallow breathing. Dyspnetic patients usually appear to be anxious and worried as they experience inefficient breathing. Dyspnetic persons frequently find some relief if they assume an upright position. The condition of being able to breathe easier in this manner is known as orthopnea. A sitting or standing position uses gravity to lower organs in the abdominal cavity to fall away from the diaphragm. This gives more room for the lungs to expand within the chest, thus taking in more air with each breath.

During attacks of dyspnea or asthma, the patient’s chest should be stripped of all clothing and the patient should be helped to assume a semiprone position to facilitate the respiratory movements. Fresh air should also be admitted to the room (ward) and oxygen given to the patient.

In some cases (bronchial asthma) we can use a special small portable apparatus for inhalation of medicinal preparations with a bronchodilated effect. To that end it is necessary to chake the container, to bring it to the patient’s mouth and to make 2-3 pressing movements during the patient’s deep inhalations (Fig.7).

Fig. 7 Using of inhalator

First before-doctor aid forpatients with attack of cardiac asthma

The attack of cardiac asthma is one of the serious signs of an acute heart failure, which requires emergency medical care. The attack of dyspnea occurs suddenly, respiration often becomes increased often (30-40 per minute), bubbling can be heard at a distance; there is a cough with a liquid pink foamy sputum discharge. The nurse must:

1) measure the arterial pressure;

2) put the patient half sitting (in hypotension) or sedentary (in hypertension) position;

3) give inhalation of oxygen, it must be moistened and passed through the ethanol alcohol to depress formation of the gas bubbles in the respiratory tract. Dyspnea and asphyxia should markedly decrease.

4) We can put a venous tourniquet on the extremity (thus a part of the blood is partially deposited in the extremities, the volume of the circulating blood decreases and the work of a left ventricle is facilitated).

It is possible to utilize rubber bandages or rubber tubes instead of a tourniquet. They are applied simultananeously on three extremities: on legs the tourniquet is applied 15 cm below the inguinal fold, on the arm - approximately 10 cm below the humeral joint. On the extremity instead of a tourniquet, it is possible to apply a tonometer cuff forcing in air and simultaneously utilizing it for the periodic control of the level of arterial pressure. Every 15-20 minutes one of the tourniquets is taken out and it is applied on the free extremity.

Temperature of body, its taking and registration.

Normal body temperature of healthy man is: in an inguinal area 36,4-36,90С; in the cavity of mouth – 37,1-37,30С in a rectum and vagina – 37,3-37,50С.

The lethal (mortal) maximal level of temperature’s rise is over 42,50С, minimum – below 330С. There are irreversible violations of exchange of matters and structure of cells, that incompatibly with the life .

Temperature of body takes twice a day usually in the morning between 7.00 and 9.00 and in the evening – 17.00 and 19.00. Sometimes, for the exposure of the latent rheumatism, tuberculosis, and others body temperature is taken by every 2-4 hours. More often the temperature of body is taken in arm-pit. It is more comfortable in practice, but gives less exact results, than taking it in cavities. Before taking temperature the skin in an inguinal area, especially at strong perspiration, is wiped by the towel, moistened by warm water, alcohol or eau-de-cologne, and then is wiped dry. Setting a thermometer is necessary so that all mercury reservoir from every side very tightly adjoined to the body in the depth of inguinal pit. In order to a thermometer isn’t moved it is necessary to pin the shoulder of patient to the thorax very tightly, and to place a forearm thus, that a palm can be in opposite inguinal pit. It is necessary to watch that underwear isn’t placed between a thermometer and body.

If a patient is in the swoon state, or vice versa, it is necessary that somebody held the patient and the thermometer.

The results of the daily double taking of temperature are written down in the special temperature chart, which is filled for every patient. It has such columns:

1) registration of body temperature by sections: „T” - term of taking, „M” – morning temperature, „Ev” - evening temperature. 2) daily registration: pulse rate , breathing rate, arterial pressure, in the case of necessity – quantity of daily urine, emptying; 3) mass of body of patient is measured once a week (in the case of necessity, for example, at adiposity, daily or in a day). After every taking of body temperature at the proper level of temperature net points which connect by straight lines are filled in. The obtained curve exposes fluctuation of the body temperature for the period of care for a patient.

Fever is a pathological process, which is characterized by violation of processes of thermoregulation and rise of body temperature. Depending on a degree the rises such body temperature are distinguished :

 subfebrile – from 37oC to 38oC;  moderately elevated – from 38oC to 39oC;  high – from 39oC to 40oC;  super high – from 40oC to 41oC;  hyperpyretical – above 41oC. According to duration such types of fever are distinguished:

 short term (ephemeral) – febris ephemera. It is continued during a few hours . It occurs if a flu or respirator viral infections are present.  acute – febris acuta. It is continued during 2 weeks . It is typical for an acute bronchitis, pneumonia.  subacute – febris subacuta. It is continued during 15-45 days . It is typical for rheumatism in the stage of exacerbation, chronic bronchitis.  chronic – febris chronica. It is continued during over 45 days . It is typical for tuberculosis, chronic tonsillitis, sepsis. According to the character of temperature curve such types of fever are distinguished (Fig.1):

Fig.1. Types of fever according to the character of temperature curve:

1-fever of permanent type;

2- fever of remitious type;

3- fever of intermittent type;

4- fever of hectic type;

5- fever of inverted type;

6- fever of turning type;

7- fever of undulating type;

8- fever of irregular type

 Fever of permanent type (constant) – febris continua: the level of temperature is usually high, a difference between the morning and evening body temperature varies from 0,5 o C to 1o C . It is typical for lobar pneumonia, abdominal and rash typhus, rheumatism.  Fever of slowed, remitious type (remittent) – febris remmitens: a difference between a morning and evening temperature varies from 1o C to 2o C or higher sometimes; in the morning the body temperature falls below 38oC, but does not goes down to the normal level. It is typical for the impetiginous diseases, lobular pneumonia.  Fever of intermittent type (interremittent) – febris intermittens: periodic, approximately in the identical intervals of time (from 1 to 3 days), in the most cases the sharp rise of body temperature (more often in the second half of day, sometimes at night) during a few hours with its following lowering to the normal level are observed . It’s typical for a malaria.  The fever is exhausive, hectic type (hectic) – febris hectica: it is the protracted fever with day's fluctuations in a temperature to 4-5oC, with the rise of body temperature to 40-41oC in the evening and at night, and in morning it’s fallen to subfebrile or normal values. These fluctuations of a temperature cause the grave condition of patient. It is observed during a sepsis, impetiginous diseases.  Fever of reverse, perverted, or the inverted type (inverse)– febris inversa: similar to the fever of hectic type, but the maximum of temperature is observed in the morning, and in the evening it falls to normal or subfebrile values. It is typical for a sepsis, seriously forms of tuberculosis.  Fever of turning type (recurrent) – febris recurrens: there is the alternation of many days feverish periods with unfeverish (apirecsic periods ). It’s typical for turning typhus.  Fever of undulating or wave like type (undulant)– febris undulans: there is the gradual rise of body temperature during a definite term with its following lysis and more or less protracted free-fever period. It’s typical for lymphogranulomatosis, brucellosis.  Fever of irregular type – febris irregularis, which is called also febris atipica: there is uncertain duration with wrong and various day's fluctuations of the body temperature in the form of permanent, purgative, intermittent, inverted and other fevers and their different combinations. It’s typical for many diseases, for example rheumatism, chronic bronchitis, cholecystitis.

Stages of fever I. The stage of elevation of body temperature (stadium incrementi). It is continued a few hours, days, weeks.

Pathogenesis is characterized by heat production which exceeds heat emission. Heat emission diminishes as a result of constriction of peripheral vessels, reduction of rush of blood to the skin, inhibition of perspiration, reduction of output of heat by a skin. There is contraction of the unstraited muscles of hair bulbs (so called goose skin appears). Heat production is increased due to activation of exchange of substances in skeletal muscles (retractive thermogenesis) on a background the rising of muscular tone and beginnings of the muscular trampling. As a result of reduction of rush of blood to the skin its temperature goes down, sometimes on a few degrees. It results of excitation of thermoreceptors of skin and chill appears. In reply to it epherental impulses pass to the motive neurons to the center of thermoregulation and trampling of skeletal muscles appears.

Clinical picture. A patient complaints of a chill, head ache, weakness, feeling jaded, pain in muscles, strengthening of palpitation, breathlessness, thirst. Sometimes there is the pallor of skin, cyanosys of extremities. Pulse is accelerated, arterial pressure is normal or increased. Breathing is rapid, superficial. A tongue is coated. Sometimes there is a constipation, retention of urinary excretion . There can be a fainting fit, excitement, delirium, hallucinations.

Care of patients. In this period it is necessary to keep an eye for a pulse, arterial pressure, breathing, state of consciousness, relieving nature, skin. Such patients are usually on the strict bed regime. They must be warmed constantly: covered warmly by a blanket, applied by warm hot-water bottles, received great numbers of hot drinks (tea, fruit drinks, decoctions of wild rose and others). It follows to spare a lot of attention to the feeding of such patients, a food must be liquid or semi-liquid, high- calorie (diet №13). Patients must be fed by small portions 5-6 times a day.

As these patients are on the bed regime, it is necessary to give them a bedpan, bad-slipper in proper time. Cleansing enema must be used at constipation. During the retention of urine, especially in the swoon state of patient, bladder catheterization is done. Care for the state the skin (prophylaxis of bedsores), mouth cavity. After doctor’s advice cardiac medicines are administered, breathing by oxygen is used also.

Measures, which diminish the fever and head ache are : cold water-vinegar washes on a head, ice-bag on a head, sponges down of body of patient by water of room temperature with addition of vinegar, moist shrouding of bare patient and inclusion of ventilator.

In the grave course of hyperthermia, which is not treated by any medical measures, we recommend: applying ice-bags to patient, intravenous administering of the cooled isotonic solution of sodium of chloride, enemas with cold water.

ІІ The stage of saving of stationary temperature of body at a high level stadium fastiguim). It is continued from a few hours to a few weeks, depending on the type of disease and reactivity of organism.

Pathogenesis. Processes of heat production and heat emission are approximately balanced at the beginning of stage. In the future heat emission is increased, prevailing heat production , the temperature of body does not rise. The aggravation of heat emission takes place due to dilatation of peripheral vessels, therefore the paleness of skin gives up one’s place to its redden. In a patient there is feeling of heat. In this period the exchange of substances is disturbed due to the decomposition of carbohydrates is violated, fat, albumens; suction of nutritives diminishes for absence of appetite and violation of secretion of digestive glands, the processes of authointoxication of organism increase.

Clinical picture. A patient complaints of feeling of heat, head ache, pain in muscles, thirst, absence of appetite. A pulse is accelerated. Arterial pressure is normal or decreased. Breathing is rapid, superficial. A tongue is dry, coated by a thick white coat, if the patient has bad care there are chaps. Sometimes there are the phenomena of psychical excitement of patient, dizziness, fainting fit.

The care of patient is the same as during the 1st stage of fever, with definite features. The use of liquid must be more intensive. Besides, if a patient uses sulphanilamide preparations which can precipitate in urine passages as sand or stone, it is necessary to give the alkaline drink (mineral water borgomi, milk with sodium by hydrocarbonates) to him. As much as possible you must limit table-sail. A necessity in vitamins rises in this time, therefore it is necessary to increase the quantity of fruit juices, decoction of wild rose.

A patient often is very excited, therefore it is important to look for him/her attentively. A bed is needed to barrier by lateral walls.

Because of the shortage of saliva secretion in feverish patients often there is dryness of mucus shells of mouth cavity up to formation of crusts and chaps on lips and tongue. Therefore it is necessary to treat a mouth cavity by 3% solution of sodium of hydrocarbonates, by 10% solution of borax in glycerine, to oil lips by a vaseline oil. With the purpose of removing products of exchange from the surface of skin , which were accumulated, and for the improvement of secretory function of skin it is necessary to do the moist sponging down of patient, in good time to change the moist underwear and bed-clothes. Patients in this stage, as a rule, are weak, feeble, are on the bed regime. Therefore it is necessary to give them the bedpan and bad-slipper in proper time.

ІІІ The stage of lowering temperature of body During this stage heat production in an organism decreases and heat emission increases. The lowering in body temperature can take place in two ways – critical and litical.

Critical lowering in of temperature of body (crisis) Patient, as a rule, is in the grave condition. The temperature of body can quickly, during a few hours, lowers from 41-40o C to 37-36o C. In this time there can be a sharp cardiac and vascular weakness (collapse), which can cause death of patient. It manifests a definite clinical picture. Patients complain of weakness, feeling of cold, chill, extremities coldness, thirst, head ache, insomnia, palpitation, breathlessness. At the objective examination the pallor of skin, which later becomes cyanosis and takes shelter by a sticky death-damp is observed. Extremities become cold. A pulse is accelerated, weak pulse (threadlike pulse), arterial pressure decreases, sometimes to the threatening values, breathing becomes rapid and superficial. A patient loses the consciousness, pupils broaden, there can be cramps.

The care of patient in this stage is general and special. General care includes warming by warm hot-water bottles and a plenty of warm drink. Perspiration appears after it, that is why it is necessary to wipe patient by a dry towel, change clothes often in dry clean underwear, to change bed-clothes.

The special care includes the supervision for a pulse, arterial pressure, breathing, state of consciousness, physiology excretions of organism. It is necessary for the improvement of blood supply of brain, the head of patient must be below than feet , therefore it is necessary to take away a pillow, to heave the leg end of bed up on 30-40 sm. On doctor’s advice a medical sister administers cardiac preparations, preparations, which increases arterial pressure (caffeine, sulfocamphocain and others), intravenously administer a lot of liquid (glucose with vitamins, isothonic solution and others), tranquilizer and anticonvulsant preparations.

The litical lowering temperature of body (lysis) from high to the normal values takes place during 2-3 days. The state of patient gradually gets better. In this time he needs a plenty of liquid, high-calorie, rich in vitamins diet, frequent change of underwear and bed-clothes (because of excessive perspiration of patient.

A. Test tasks to be done:

- with a single selective answer - I-st level:

1. What is normal pulse rate in adult person?

a) 70 per minute; b) 60 - 70 per minute; c) 70 - 90 per minute; d) 60 - 80 per minute; e) 50 - 80 per minute. 2. How is recording of the pulse named? a) oscillograpy; b) phlebography; c) sphygmography; d) ballistocardiography; e) capillaroscopy. 3. From which parameter is it necessary to begin studying of properties of pulse?

a) rhythm;

b) rate;

c) filling;

d) tension;

e) synchronization of pulse on both radial arteries.

4. Irregular pulse mainly is typical for:

a) aortic stenosis; b) myocarditis; c) atrial fibrillation; d) exudative pericarditis; e) aortal valvular diseases. 5. What does “Takayasu’s disease” mean?

a) aortic valvular disease;

b) mitral valvular disease;

c) coarctation of aorta;

d) obliterating endarteritis of large vessels originating from the aortic arch;

e) congenital heart disease.

6. What is deficiency of pulse?

a) alternation of large and small waves; b) different pulse on the two arms; c) difference between number of heart contractions determined with the heart auscultation and number of the pulse waves; d) pulse in patients with embryocardia; e) different pulse on upper and lower limbs. 7. Rapid pulse is typical for the following conditions:

a) mixedema; b) starvation; c) elevation of body temperature; d) jaundice; e) heart block. 8. Slow pulse is typical for:

a) mitral valve incompetence; b) mitral stenosis; c) aortic valve incompetence; d) aortic ostium stenosis; e) arterial hypertension. 9. Full pulse (pulsus plenus) is typical for:

a) mitral valve incompetence; b) mitral stenosis; c) arterial hypotensison; d) aortic ostium stenosis. e) aortic valve incompetence. 10. Weak pulse is typical for:

a) hypertensive disease; b) coffee abuse; c) symptomatic arterial hypertension; d) arterial hypotension; e) hemorrhage. 11. Tense pulse (pulsus durus) is typical for:

a) myocarditis; b) pericarditis; c) hypotension; d) hypertensive disease; e) heart failure. 12. Thread pulse (pulsus filiformis) is typical for:

a) arteriosclerosis; b) chronic heart failure; c) acute vascular insufficiency; d) endarteritis; e) hypertensive disease. 13. What is upper limit of arterial pressure in health persons (accordance to WOH)?

a) 120/80 mm Hg; b) 130/90 mm Hg; c) 145/95 mm Hg; d) 155/100 mm Hg; e) 140/90 mm Hg. 14. What is name of apparatus for measuring of arterial pressure?

a) oscillograph; b) pneumotachometer; c) capillaroscope; d) manometer; e) Bobrov’s apparatus. 15. Who proposed auscultatory method of determining of arterial pressure?

a) Riva-Rochi; b) Lang; c) Korotkoff; d) Traube; e) Vinogradov. 16. Who proposed palpatory method of determining of arterial pressure?

a) Korotkoff; b) Obraztsov; c) Riva-Rochi; d) Traube; e) Vinogradov. 17. In case of which disease can minimal pressure be fall to 0?

a) hypertensive disease; b) aortic valve incompetence; c) cardiac-vascular insufficiency; d) mitral stenosis; e) aortic ostium stenosis. 18. In case of which disease can pulse pressure be equal to maximal one:

a) hypertensive disease; b) hypotonic disease; c) aortic valve incompetence; d) vascular insufficiency; e) mitral stenosis. 19. On a femoral artery systolic pressure higher than on a humeral artery on:

a) 15-20 mm Hg; b) 20-25 mm Hg; c) 25-30 mm Hg; d) 30-35 mm Hg; e) 35-40 mm Hg. 20.Name the sign of collapse:

a) loss of consciousness; b) dyspnea; c) cough; d) vomiting; e) asphyxia; f) pain in the heart region; g) edema.

- with the selective group of right answers - II - nd level:

1. When does “pulsus differens” on the radial arteries occur?

a) in case of non-specific aortoarteritis (Takayasu’s syndrome); b) in mitral stenosis; c) in aortic ostium stenosis; d) in hypertensive disease; e) in tricuspid valve incompetence; f) in case of large retrosternal goiter; g) in abnomalities of development of vessels; h) in fever. 2. Whendoes rapid pulse (pulsus frequens) occur?

a) in elevated body temperature; b) in sleep; c) in increased intracranial pressure; d) in myxedema; e) in case of thyrotoxicosis; f) after physical exertion; g) after emotional stress. 3. When is irregular pulse observed?

a) in anaemia; b) in sleep; c) after physical exertion; d) in case of atrial fibrillation; e) in fever; f) in case of extrasystole; g) in heart block II degree. 4. When can thready pulse be observed?

a) after physical exertion; b) in blood loss; c) during shock and collapse; d) in high fever; e) in coffee, strong tea abuse; f) in thyrotoxicosis; g) in alcohol abuse. 5. “Pulsus celer” is typical for:

a) mixedema; b) aortic insufficiency; c) aortic stenosis; d) mitral stenosis; e) thyrotoxicosis; f) coronary heart disease; g) hypertensive disease. 6.Normal pulse is:

a) symmetric; b) arrhythmic; c) rhythmic; d) pulse rate - 70-90 per minute; e) pulse rate - 60 - 80 per minute; f) tension pulse; g) pulsus filiformis; h) satisfactory tension and filling. 7. Positive capillary pulse can be revealed:

a) in thyrothoxicosis sometimes; b) in aortic stenosis; c) in bradycardia; d) in aortic valve incompetence; e) in mitral valve prolapse; f) in atrial fibrillation; g) in hypertrophic obstructive cardiomyopathy. 8. A transient increase of arterial pressure may occur:

a) in essential hypertension; b) in glomerulonephritis; c) during heavy exercise; d) in excitation after taking alcohol; e) in vascular nephrosclerosis; f) in certain endocrine diseases; g) after taking strong tea or coffee; h) in heavy smoking. 9. Decrease of pulse pressure occurs in:

a) aortic stenosis; b) aorctic valve incompetence; c) thyrotoxicosis; d) exudative or adhesive pericarditis; e) heart failure; f) stenocardia (angina pectoris); g) mitral stenosis. 10. Care of the patient with headache (in case of hypertension):

a) to ensure complete physical and mental rest; b) to measure arterial pressure; c) to place mustard plasters on the forehead; d) to place mustard plasters on the back of the heard; e) to give the patient nitroglycerine; f) to sprinkle the patient’s face and breast with cold water. 11. Name the areas for applying tourniquet in cardiac asthma:

a) on neck; b) on manus; c) on the arm, 10cm below humeral joint; d) on the arm, 30cm below humeral joint; e) on legs, 15cm below inguinal fold; f) on legs, 25cm below inguinal fold. 12. In case of the fainting-fit it is necessary:

a) to process a skin by sterile small balls moistened with warm boiled water, and then moistened with a sterile solution of glucose; b) to put patient half sitting position; c) to lay the patient horizontal (by without a pillow), to raise his legs; d) to air premise (room); e) to put venous tourniquet on the extremity; f) to sprinkle the patient’s face and breast with cold water; g) to put mustard plasters on the back of the head; h) to bring near nose of the patient tampon or cotton moistened with ammonium chloride and to wipe the person’s temples with it. 13. Name the typical signs of a fainting-fat:

a) dyspnea; b) loss of consciousness; c) pale skin; d) edemas on the legs and loin; e) cyanosis of the skin; f) pain in the heart region; g) palpitation. 14. Hemorrhages (bleedings) are subdivided into the following:

a) arterial; b) venous; c) lymphatic; d) capillary; e) mixed. 15. In case of nasal bleeding: a) patients must occupy sitting or lying position; b) patients must occupy standing position; c) his/her hand should be inclined backwards; d) it is necessary to unbutton his/her collar, put cold compress on the bridge of the nose and nose (changing compress as it gets warm); e) it is necessary to put warm compress on the bridge of the nose and nose; f) it is necessary to press soft parts (wings) of the nose by fingers; g) it is necessary to introduce bit of sterile cotton or gauze, moistened by hydrogen peroxide; h) it is necessary to introduce bit of sterile cotton or gauze, moistened by alcohol. 16. Normally respiratory rate in adult person:

a) is 20-24 per minute; b) is 16-20 per minute; c) in women is on 2-4 more than in men; d) in men on 2-4 more than in women; e) in lying position usually diminishes, and in vertical one - is increased; f) in vertical position usually diminishes, and in lying one - is increased.

B. Tasks to be done:

Task 1.In patient during taking of the blood from a vein for biochemical researches suddenly nausea, feeling of sharp weakness, darkness in the eyes is appeared. The face became pale; sweat is appeared on the skin. What actions must a nurse perform urgently?

Task 2. During practice in surgery student K. seeing blood suddenly became pale and fell, loosed consciousness. What happened with her? What is correct tactic of a nurse in this case?

Task 3.Patient N. complains of dry cough with feeling burning behind sternum. His temperature was elevated to 38,5º C. What actions can be used for amelioration of the patient?

a) Expectorant (mixture); b) Applying of mustard plasters; c) Oxygen inhalations; d) Applying of leeches; e) Fomentations; f) Cups on the back; g) Hot compress; h) Powder withcodeine; i) Warm milk with sodium hydrogen carbonate.

Task 4. In patient D. attack of expiratory dyspnea appeared. What actions can be used in this case?

a) Hot feet bath; b) Compress with camphor alcohol; c) Oxygen therapy; d) Semi-sitting patient’s position; e) Applying of mustard plasters; f) General hygienic bath.

Literature recommended:

Main Sources:

1. Clinical Nursing Skills and Techniques: basic, intermediate and advanced. The C.V.Mosby Company, 1986.- 1296 p. 2. Clinical Skills and Assessment Techniques in Nursing Practice. Scott, Foresman and Company, 1989.- 1280 p. 3. Nursing interventions and clinical Skills. Mosby – year Book, Inc., 1996.- 813 p. 4. Nursing Procedures: Student Version. Springhouse Corporation, 1992.-788 p. 5. Polskaya L.V. Nursing procedures in therapeutic practice.- Simferopol: Universum, 2004. - 192 p. Additional ones:

1. Гребенев А.Л., Шептулин А.А., Хохлов А.М. Основы общего ухода за больными: Учеб. пособие.- M.: Медицина, 1999.- 288 с. 2. Нетяженко В.З., Сьоміна А.Г., Присяжнюк М.С. Загальний та спеціальний догляд за хворими.- К.:Здоров’я, 1993.- 304 с. 3. Щуліпенко І.М. Загальний і спеціальний медичний догляд за хворими з основами валеології/ Навчально-методичний посібник для студентів медичних вузів і учнів медичних ліцеїв. - К.:Кий, 1998.- 384 с.

Answersfortest tasks of the I-st level:

1 - d 6 - c 11- d 15- c

2 - c 7 - c 12- c 16- c

3 - e 8 - d 13- e 17- b

4 - c 9 - e 14- d 18- c

5 - d 10- d 19- e

20- a

Answers for test tasks of the II-nd level:

1 - b , f, g 5 - b , e 9 - a , d , e 13- b , c

2 - a , e , f, g 6 - a , c , e , h 10- a , b , d 14- a , b , d , e

3 - d , f, g 7 - a , d 11- c , e 15- a , c , d , f, g

4 - b , c 8 - c , d , g, h 12- c , d , f , h 16- b , c , e

Standards of right answer for tasks:

Task 1.

 To put patient on the couch with raised leg end;  To bring near the nose cotton roll, moistened with ammonium chloride;  To stop procedure;  To give to the patient strong sweet tea;  To sprinkle the patient’s face with cold water;  To air room.

Task 2.She has fainting

A nurse must: - To lay the student horizontal (by without a pillow), to raise her

legs;

- To measure arterial pressure; -To air room;

- To sprinkle the student’s face and breast with cold water;

- To bring near the nose of the student tampon or cotton moistened with ammonium chloride and to wipe the person’s temples with it.

- To rub the student’s breast and temples with her hands.

- To slap the student with her palms.

- To put heaters (hot water bottles) on the student’s extremities and to cover her with a blanket.

Task 3. b, g, h, i

Task 4.a, d, e

- with a single selective answer - I-st level:

1. What purpose before measuring of temperature is inguinal pit recommended dry with?

а) from the hygienical reason;

b) in order to thermometer was in more firm position;

с) in order to do not to get the understated results of measuring.

2. Temperature of body, which is measured in the rectum of patient, is 37,10С. How is it possible to describe such temperature?

а) how normal temperature;

b) how moderately elevated temperature;

c) how soubfebrile temperature.

3. Where medical thermometers must be kept in the department?

а) in cases on the nursing lookout post;

b) in a jar on the bottom of which cotton wool is fixed and disinfectant is added;

c) in every patient.

4. What indexes are represented in a temperature chart? а) graphic image of temperature curve;

b) graphic image of temperature curve, curves of pulse, frequency of breathing, arterial pressure, mass of body, diuresis, data of laboratory investigations;

c) graphic image of temperature curve, curves of pulse, breathing frequency, results of medical rounds.

5. In a patient during 2 weeks a morning temperature is kept within the limits of 36,0-36,50С, evening – within the limits of 37,5-38,00С. What type of fever in a patient?

а) slowed, remitious;

b) exhausive, hectic;

c) reverse, perverted or inverted ;

d) intermittent.

6. Why is the permanent type of fever at lobar pneumonia rarely now ?

а) microflora that causes the disease changed ;

b) reactivity of organism of patients changed;

c) antibacterial therapy is actively used from the first days of disease .

7. What thermometer the temperature of water of hygienical bath is taken by? a) mercury medical thermometer; b) thermometer on liquid crystals; c) alcoholic thermometer in a case; d) electro-thermometer. 8. When measuring of temperature in a rectum is used? a) intestinal bleeding; b) piles; c) tumor of rectum; d) diarrhea; e) exhaustion of organism. 9. What maximum levels of fluctuations in the morning and evening temperature are inherent to the permanent form fever? a) 1-1,5 oС; b) 0,5-1 oС; c) 0,3-0,5 oС; 10. Day's fluctuations of temperature of patient are 4-5oC. What form of fever are characteristic such fluctuations for? a) remitious; b) undulating; c) hectic; d) reverse. 11. What processes fluctuations of a temperature in an organism in the morning and evening periods of day are conditioned by? a) by reflex; b) by oxidation-reduction; c) by the synthesis of albumen; d) by heat radiation of body; e) by the biological rhythms of power exchange. - with the selective group of right answers - II - nd level:

1. What conditions can lead to the physiology rise of temperature of body?

а) muscular tension;

b) sleep;

c) the use of meal;

d) emotional stress;

e) infectious diseases.

2. How are the processes of thermoregulation changed in the first stage of fever ?

а) blood vessels of skin constrict;

b) the blood vessels of skin dilatate;

c) heat production in skeletal muscles increases;

d) perspiration increases.

3. How are the processes of thermoregulation changed in the stage of lowering of temperature?

а) heat production in skeletal muscles increases;

b) perspiration increases;

c) the blood vessels of skin dilate;

d) heat production in skeletal muscles diminishes.

4. What care of patients measures is it necessary to carry out in the first stage of fever (stage of rising of body temperature)? а) give to drink hot tea to patient;

b) to cover a patient warmly, to apply him by warm hot-water bottles;

c) to change bed - clothes;

d) to apply a cold compress on a forehead.

5. What care of patients measures is it necessary to carry out in the second stage of fever (stage of saving of maximal temperature)?

а) to warm a patient, to apply by hot-water bottles;

b) to look for rate of pulse and breathing, the level of arterial pressure;

c) to look for the state of central nervous system;

d) to carry out the care of mouth cavity.

6. What care of patients measures is it necessary to carry out in case of the critical lowering of temperature?

а) to look for the state of cardiovascular system carefully ( pulse rate and its filling, level of arterial pressure and others);

b) to change underwear and bed-clothes in good time;

c) to look for the state of mouth cavity;

d) to warm a patient and to give to drink a hot tea;

e) to carry out the prophylaxis of bedsores.

B. Tasks to be done:

Task 1. To the patient with the body temperature 41,3oC febrifuge preparations were administered . In 20 minutes a temperature lower to the norm, but the state of patient became worse: a sharp weakness appeared, a pulse is threadlike, extremities are cold, underwear and bedclothes wet from perspiration What help is needed to the patient?

Standards of right answer for task: 1) Necessarily to cause a doctor, heave leg end of bed on 30-40 sm, to take away a pillow from under a head. To apply a patient by hot-water bottles, to cover by a blanket, to give strong sweet tea. To prepare for injection (for administration of doctor) a 10% solution of caffein-benzoatis sodium, 10% solution of sulfocamphocain. At the improvement of the state to wipe a patient dry, to change underwear and bedclothes. Literature recommended: Main Sources: 1. Clinical Nursing Skills and Techniques: basic, intermediate and advanced. The C.V.Mosby Company, 1986.- 1296 p. 2. Clinical Skills and Assessment Techniques in Nursing Practice. Scott, Foresman and Company, 1989.- 1280 p. 3. Nursing interventions and clinical Skills. Mosby – year Book, Inc., 1996.- 813 p. 4. Nursing Procedures: Student Version. Springhouse Corporation, 1992.-788 p. 5. Polskaya L.V. Nursing procedures in therapeutic practice.- Simferopol: Universum, 2004. - 192 p. Additional ones: 1. Гребенев А.Л., Шептулин А.А., Хохлов А.М. Основы общего ухода за больными: Учеб. пособие.- M.: Медицина, 1999.- 288 с. 2. Нетяженко В.З., Сьоміна А.Г., Присяжнюк М.С. Загальний та спеціальний догляд за хворими.- К.:Здоров’я, 1993.- 304 с. 3. Щуліпенко І.М. Загальний і спеціальний медичний догляд за хворими з основами валеології/ Навчально-методичний посібник для студентів медичних вузів і учнів медичних ліцеїв. - К.:Кий, 1998.- 384 с. Informational resources 1. Leslie Jennings. Educational movie. “ Roles and Functions of the Nurse”./ Leslie Jennings.201 2. Касевич Н.М. Основи медсестринства в модулях: навч. посіб. – К.: Медицина, 2009 3. HEAT Inc., Health Education & Training . Educational movie Ethical Issues In Nursing -- Respect: Dignity, Autonomy, and Relationships 2010 Internet resourses 1. http://study.com/academy/subj/science/health-and- nursing.html 2. http://www.moz.gov.ua/ua/portal/dn_20130601_0460.ht ml 3. http://www.nursingworld.org/nursingstandards 4. Methodical instruction is composed by lecturer Ye. Petrov. Methodical instruction is revised and approved again At the Chair of Propaedeutics of Internal Medicine with Care of Patients meeting On “___” ______200__ year. Protocol №

The Ministry of Health of Ukraine Ukrainian Medical Stomatological Academy

Approved at the Department of Propaedeutics to Internal Medicine with Care of Patients meeting on 11 09 2018 Protocol No2 The Head of the Department Professor Yu. Kazakov

METHODICAL INSTRUCTION FOR STUDENTS’ SELF-PREPARATION WORK

Educational discipline Care of patients Module No 1 Enclosure module No 1 Topic Using of the main types of drugs

Year 2 Faculty medical

1. The topic basis: often consequences of severe diseases in great degree depend on quality of care of patients, timely and honest performance of physician’s prescriptions, forming of favourable regimen of recovery. Medication administration is the cornerstone in the overall plan of nursing care and medical treatment. In practically every health care setting, nurses are responsible for administering medications, and assisting people to use medications safely and properly.

2. The concrete aims: To know general rules of storage and use of medical preparations   To explain legal and ethical implications of medication preparation and administration  To explain “five rights” in administering a drug  To represent classification of types of medications  To explain of the medications depend on their route  To learn about the term “physiotherapy”, its main task.  To know about main physiotherapy types .  To know more about the advantages of physical therapy and indications for using it. 3. Basic knowledge, experience, skills necessary for studying the topic in connection with other subjects (interdisciplinary integration):

Previous disciplines Obtained skills 1. Anatomy To know human anatomy,organization of the body. 2. Physiology To know the main physiological processes of human organism. 3. Pathological physiology To understand the mechanisms that took place in human’s body with various pathological states.

4. Tasks for self-work during preparation to the class. 4.1 List of the main terms, parameters, characteristics, which should be mastered during preparation to the class

Term Definition 1. Physical therapy It is a health care profession primarily concerned with the (physiotherapy) remediation of impairments and disabilities and the promotion of mobility, functional ability, quality of life and movement potential through examination, evaluation, diagnosis and physical intervention carried out by physical therapists. 2. Hyrudotherapy Using medical leeches and applied with the medical aim of a blood removing and anticoagulative agent.

3. Ingalation Method of treatment using inhale gases (oxygen, nitrous oxide), agents, which is vaporized slightly (ether, chloroform), and aerosols (substances, sprayed little).

4. Oxygen therapy Inspiration of oxygen (inhalation oxygenotherapy)

4.2. Theoretical questions to be answered before class: 1. What is Medication preparation and administration main legal and ethical implications of medication preparation and administration? 2. What are “five rights” in administering a drug? 3. Name classification of medications according to their method or route of administration? 4. Tell about simple medical procedures? 5. How do applicate warming compress ? 6. Tell about the indications and contraindications for applying warming compresses. 7. Tell about the indications and contraindications heaters? 8. Name 5 main types of inhalations. 9. Tell about the indications and contraindications for oxygen therapy. 10. The indications and contraindications for the hyrudotherapy.

4.3. Practical work (tasks), which should be performed during class: 1. To carry out storage and use medical preparation. 2. To make application of a warming and dry compress. 3. To make application of mustard plasters and cupping glasses. 4. To make ntroduction of oxygen into airways. The contents of topic:

Storage and use of medical preparations There are many types of therapeutic effects including the following: surgical treatment, balneological and physiotherapeutic procedures, climatotherapy, etc. But the most common type of treatment is pharmacological therapy, i. e. treatment with medical preparations. Medication administration is the cornerstone in the overall plan of nursing care and medical treatment. In practically every health care setting, nurses are responsible for administering medications, and assisting people to use medications safely and properly. The nurse often encounters people who need special assistance in taking medications. People with special needs include children, disabled people, the elderly, those with neurosensory problems ( people with impaired vision, hearing, or swallowing or alterations in mental status ), and those with chronic pain. In addition, nurses must be knowledgable concerning the pharmacology of medications given, the legal implications involved in the preparation and administration of medications, the techniques of safe medication preparation and administration, and the application of the nursing process when they are caring for individuals receiving medication. Medication preparation and administration has many legal and ethical implications. When you administer medications, you are responsible for developing an up-to-date knowledge base. For each medication that you administer, you should be familiar with the following:  the generic and proprietary names;  the classification;  the normal dose or range of doses;  the route(s) of administration;  the desired action;  common side effects;  toxic and undesired effects;  contraindications and incompatibilities with other medications;  special considerations and nursing implications. You also must be aware of the “five rights” in administering a drug. An important nursing responsibility is adhering to these “five rights”. These are the 1. Right drug 2. Right dose 3. Right route 4. Right time 5. Right person. The use and sale of medications are governed by state laws. Medications are classified as either prescription medications ( medications, including controled substances, that require a physician’s order) or over the counter (OTC) medications (medications that may be purchased without a physician’s order. If medication is intended to eliminate the cause of the diseases, this is called etiotropic treatment. For example, antibiotics act on agents causing infections. Many medicinal preparations act not on the causative agent but on the developing diseases, the cause being uncertain or inactive by the time of treatment. This treatment is called pathogenetic. For example, cardiac glycosides or diuretics are given for circulatory insufficiency. Symptomatic treatment is used to alleviate some symptoms of a diseases , e.g. narcotics are given to relieve pain and sedatives are given for insomnia. Sometimes a patient is given etiotropic, pathogenetic, and symptomatic treatment all at the same time. The effects of medicinal preparation depends, to a considerable degree, on its dose. A single dose means the amount of preparation that is given for one intake. A daily dose implies the amount of the medicine which is to be taken within 24 hours. A total or cumulative dose means the amount of the medicine that is taken by the patient during the entire course of treatment. A therapeutic dose the amount of medicine that causes a pronounced therapeutic effect without causing any pathological deviations in the patient. A toxic dose is the amount of medicine causing symptoms of poisoning. A therapeutic effect depends on the concentration of the medicine which in turn depends on the dose and the body weight of the patient. In this connection a dose is often specified with reference to a kilogram of the patient’s weight. A concrete dose should, in such cases, be calculated for each particular case. Sensitivity of people to medicinal preparations normally varies within a wide range depending on the physiological condition of the body (pregnancy, lactation), nutrition, age, and sex. Age sensitivity to medicinal preparations is especially varied. Apart from their curative effect, medicines can also cause undesirable side- effects. These are biological effects that develop irregularly and cannot be predicted or foreseen. Toxic side effects can develop as a result of over dosage by error or of a suicidal attempt of the patient. Drug addiction is a well known side effect of narcotics. A special group of side effects includes various forms of idiosyncrasy and drug disease. The latter is manifested by a complex of immediate and delayed allergic responses. These nonspecific side effects are the result of individual, congenital or acquired properties of the body. If a patient becomes adapted to a medicinal preparation, its therapeutic dose has to be increased. Some preparations, on the other hand, can be accumulated in the body, and their doses should there-fore be gradually decreased, or the medication should be suspended at intervals to prevent poisoning. Ordering and keeping medicinal preparations During his rounds, the physician prescribes various medicines which he enters in the case history of the patient and in the special prescription sheets. The nurse records these prescriptions in a special notebook according to which medicinal preparations are dispatched to the patients. The prescriptions are also put into a special notebook for nocturnal medication, and also in injection list. The medicinal preparations are ordered according to the physician’s prescriptions. All medicines should he kept in a locked cabinet. It should be located in the nurse’s room, out of patient’s reach, and should always be locked. The special control is required for a storage toxicant, strong and narcotic agents, which are kept in special compartments “A” and “B”. Each case of the application is fixed in special notebook with the patient’s name and the number of the case history. Narcotics are subjected to special care. They are kept in the safe. The key from the safe is kept in the duty doctor. The introduction of narcotic drugs is carried out only in the presence of the physician. External medicines should be kept separately from those administered internally. Medicines with a strong odour (iodoform, lysol) and also flammable substances (alcohol, ether ) should be kept separately from other medicines. Special care should be taken in storing sterile solutions for parenteral administration. If a bottle contains several doses, it should be closed after each use. If there is any doubt about the sterility of a preparation, the medicine should be discarded. Alcoholic and ether solutions, tinctures, and extracts can be stored for a long time because microbes are quickly killed in them. But these substances are quickly evaporated which increases the concentration of the active substance and can thus cause over dosage. Some medicines (salts of silver, bromine and iodine) decompose when exposed to light and they should therefore be stored in dark bottles. The amount of medicines kept in the cabinet should not exceed a storage for 3 or 4 days. Sterile solutions (in containers other than vials) should be stored for not longer than 3 days, while anti-biotic solutions, not longer than 24 hours. Ampouled solutions can be stored for months. An expiration date is usually indicated on the label. Administration of medicines Medications can be classified according to their method or route of administration. The following methods of administration of medicinal preparations are distinguished: enteral (intestinal), external, parenteral, and by inhalation. The choice of the administration mode depends on the particular disease. Each mode has its advantages and disadvantages. Enteral administration implies taking medicines by mouth (per os) or through the rectum (per rectum); or the medicine can be placed under the tongue ( sub lingua ). Peroral administration is the common way of taking medicines. The advantage of the method is that medicines can be given in any form and under non- sterile conditions. The disadvantages are: first, the preparation is slowly absorbed into the blood; second, the properties of the medicine are altered by the gastric and intestinal juices. Since the absorption is slow, it is difficult to predict the concentration of the medicine attainable in the blood and tissues. Classification of the medications depend on their route: - Enteral medication:  oral medication: any medication given by mouth;  sublingual medications: medications placed under the tongue and absorbed into the blood vessels underneath the tongue ( e.g., nitroglycerin );  buccal medications: medication help the inside the mouth against the mucouse membranes of the cheek ( e.g. lozenges ). -Topical medications:agents applied to the skin and mucous membranes for absorption or for local therapy. In addition to administration onto the skin, topical agents include optic medications (medications administered into the eye), otic medications (medications administered into the ear), nasal medications (medications administered into the nose), vaginal medications (medications administered into the vagina), rectal medications (medications inserted or instilled into the rectum), and pulmonary medications (medications inhaled into the respiratory tract). Medications given by the sublingual and buccal routes are also sometimes classified as topical medications. - Parenteral medications are those given by injection with a needle. Parenteral medications are the most rapidly absorbed because they are administered directly into or close to the circulation or into their sites of action. Routes of administration for parenteral medications include the  subcutaneous route:administration into subcutaneous tissue, under the skin;  intradermal route:administration under the epidermis, into the dermis;  intravenous route:administration into a vein;  intra-arterial route:administration into an artery;  intracardiac route:administration into the heart muscle;  intraosseous route: administration into a bone;  intrathecal route:administration into the spinal canal;  epidural route:administration into the space external to the dura mater of the spinal canal. Oral medicationsare absorbed in the gastrointestinal (GI) tract ( i.e., the mouth, stomach, and small intestine ). The two forms of oral medications are solid and liquid. Solid forms. Solid forms of medication include tablets, capsules, and powders. On the other hand, lozenges are tablets that should be completely dissolved in the mouth without chewing. Generally, lozenges exert their therapeutic effects directly on the oral mucosa. Capsules are oral preparations in which one or more medicinal substances are placed inside a small shell, which is usually made of gelatin dissolves in the GI tract and releases the medication for absorption. Capsules are swallowed whole. Dry medications that are mixed with liquids (water or juices) before oral administration are called powders. Many powders are sold in bulk and must be measured and diluted immediately before administration. Liquid forms. Liquid medications include syrups, medications that are blended into a sugared or thick flavored liquid. Be wary of using syrups for people with diabetes, because these preparations often contain sugar. Solutions are homogenous mixtures of liquids and solids. Medications in solution are more likely to be unpalatable and may therefore need to be diluted or followed by liquids. Suspensions are mixtures of solid particles in a liquid medium in which the particles precipitate out when the suspension is left standing. Therefore, suspensions, such as gels and magmas ( thick milky suspensions of an inorganic substance), must be shaken before each administration. Emulsions are suspensions made from fats, oils, or petrolatum suspended in a second liquid. These preparations must also be shaken before measurement and administration. Take care to avoid the client’s aspiration (inhalation) of these substances, because oils and fats cause severe pneumonia if drawn into the lungs. Elixirsare drug preparations in a solvent medium of alcohol and water (a hydroalcoholic medium). Sugar is often added to improve the taste. Like syrups, elixirs mask unpalatable medications and simplify administration. Tincturesare also dissolved in hydroalcoholic medium but are more potent than elixirs. Some tinctures are for topical use only, so it is important to distinguish between oral and topical tincture preparations. It is also important to use tinctures and elixirs cautiously in people who are or may be alcoholic. Oral administration of medicines is not recommended for patients who: a) have impaired swallowing, particularly those with suspected or actual stroke; b) are unconscious, or c) refuse to take medications orally. In such cases, discuss the situation with the person, physician, and pharmacist as appropriate. Explore alternatives such as stopping the medication or administering medication in a more acceptable form or by an alternative route ( e.g., injection or nasogastric tube). Rectal administration of medicines is also popular. It is especially important in cases where peroral administration is unfeasible due to difficult swallowing, in burns of the esophagus, incoercible vomiting, when the patient is unconscious, and in some other cases. In some diseases ( heart failure, diseases of the gastrointestinal tract ) absorption of medicines in the stomach and intestine is either slow or incomplete. Rectal administration is preferred in such cases because due to anastomosis of the hemorrhoidal veins with the iliac veins, the medicine enters the inferior vena cava bypassing the system of the portal vein and the liver. It should be remembered that the absorption power of the rectal mucosa is about 25 per cent lower than that of the small intestine. The rectal dose should therefore be slightly higher than a median therapeutic one, but it should not exceed the permissible single dose. The absence of enzymes in the rectum is a disadvantage: medicines contained in a protein, fat or polysaccharide base cannot penetrate the rectal wall and should therefore be given only locally. Suppositories or enemas are used for rectal administration of medicines. cocoa butter, polyethylene glycols, glycerinated gelatin, etc. Suppositories should be wrapped in water-proof paper and kept in a refrigerator. Topical or external medications are applied to the skin or mucous membranes. Some categories of topical medications include: a) anticeptics for cleaning the skin and mucous membranes; b) local anesthetics; c) antipruritics; d) moisturizers and other soothing agents; e) antibiotics, and f) anti-inflammatory agents. Most topical medications are given for their local effects (i.e., the medication exerts its action in the area around the administration site). Some topical medications, however, exert systemic effects – they are carried via the blood to tissues or organs located away from the area of administration. Nitroglycerin, for example, is absorbed through the skin but affects the coronary blood vessels. Topical Medication Preparations. Topical medication come in different forms, such as: Lotions are suspensions of insoluble powder in water or ingredients dissolved in a thickened liquid ( e.g., calamine lotion ). Creams are oils dispersed in 60 to 80 per cent water to form a thick liquid or soft solid ( e.g., antifungal cream ). Both lotions and creams evaporate when applied, leaving a layer of medication on the skin. They protect and lubricate the skin without blocking evaporation of natural skin moisture. Little of the medication is absorbed. Ointmewnts are semi solid preparations in a fat, oil, wax, or watersoluble base. Ointments contain 25 to 50 per cent water. Petrolatum is a widely used ointment. Ointments are moderately or fully occlusive on the skin and therefore have an emollient or softening effect. Moisture retention also enhances medication absorption of therapeutic agents into the skin. Powders for topical use are mixtures of chemicals in a dry form that are usually dusted onto the skin. They promote dryness by absorbing skin moisture. Powders wear off easily and must be applied more frequently than other topical preparations. Gels are semisolid mixtures that liquify when applied to the skin. After application, gels evaporate quickly and dry to a non occlusive film. Some corticosteroids are supplied in gel form to prevent absorption and systemic effects. Aerosols are liquid or powder medications suspended in a mist, often in alcohol-based spray. These medications are sprayed onto a site at a controlled pressure, leaving a film of active ingredients behind. They are used to treat damaged skin and mucous membranes that are too touch directly. Topical medications are most frequently administered to the mucous membranes of the mouth, vagina, rectum, bladder, and respiratory tract. Simple medical procedures Various procedures are used to produce the desired effect on a patient’s blood circulation, both local and general. These procedures include hot water-bottles, cups, mustard plasters, compresses, ice bags, etc. These procedures have their effect on both healthy and sick individuals through thermal, mechanical or chemical stimulation. The skin is the main site of application of these procedures. When irritated, various reflexes are activated in the skin. Ivan Pavlov showed that during thermal stimulation of the skin, inhibition develops in the cerebral cortex. For example, sleepiness develops after a warm bath or even after local application of heart. Thermal effects decrease or even remove pain, decrease skin sensitivity, and prevent transmission of pathological impulses into central nervous system. Temperature stimulants reflectory change the lumen of the blood vessels to alter the blood distribution in the body. When the cutaneous vessels dilate, the vessels of the abdominal organs contract, and vice versa, when the skin vessels narrow, the vessels of the abdominal viscera dilate. The application of a warming compress is accompanied by local dilation of blood vessels and enlargement of blood circulation in tissues that in this area of inflammatory processes produces painful and resorptional action. The warming compresses are used in treatment of various local infiltrations, for example, postinjection ones, some diseases of muscles and joints, chronic inflammatory diseases. The warming compress can be dry or moist. The dry warming compress (usual cotton-gauze bandage) is more often intended for protection of those or other sites of a body or head, for example neck or ear from cold exposure. Moist warming compress is prepared from 4-th layers. At the beginning a piece of a tissue, moistened with warm water (50-600 C) or with solution of 40% alcohol is put on a skin. Then it is coated with a piece of the oilskin, polyethylene film or of a waxed paper. At last a layer of cotton wool is placed there. Each subsequent layer of a compress should be bigger, than the previous one. Above the compress a bandage is placed. The duration of application of a moist warming compress is 6-8 hours. While taking off a compress the skin should be sponged with water or alcohol and then wiping with a towel to prevent maceration of the skin. If there is irritation of the skin, it is better to avoid further applying of moist compresses. The contraindications for applying warming compresses are various skin diseases (dermatitises, furunculosis) and injuries of the skin. The local warming effect can be received with the help of a heater (hot water bottle). In its application, reflex dilatation of the blood vessels of the organs of abdominal cavity and the relaxation of a smooth musculature, that, in particular, is accompanied by disappearance of spastic pains will occur. In the treatment of a peptic ulcer, renal or hepatic colics, radiculitis, the effect of a heater may be painfull. Hot water bottles in the volume from 1 to 3 liters are more often applied. Before using the hot water bottles it is filled with hot water (60-700 C) approximately 2/3 of its volumes, air is carefully evacuated. It is necessary to tightly screw hot water bottle with a cap and overturn it with the purpose to check this. Before giving it to the patient wrap it in a towel. The heaters are contraindicated in obscure abdominal pains (in such diseases, as an acute appendicitis, acute cholecystitis, acute pancreatitis), in malignant tumors, in the first day after a trauma, in outside and interior bleedings, in the patients with the impaired skin sensitivity, and also in unconscious patients. The application of a mustard powder is based on the fact that evaporated etheral oil causes an irritation of a skin receptors and its hyperemia, resulting in a reflex dilation of blood vessels located deep in the internal organs and it causes resorption of some inflammatory processes. Standard mustard plasters are sheets of a dense paper of the size 8 x 12, 5 cm, covered with a layer of the unoiled mustard powder. Mustard plasters are applied on skin, previously having moistened it with 40o C water, and are taken off after 10 – 15 minutes. Mustard plasters are applied in treatment of neurologic diseases (myosites, neuralgia), catarrhal diseases (bronchites, pneumonia), in angina pectoris (on the left-hand half of thorax ) and headaches (on area of a nape). If the skin is very sensitive mustard plasters should be applied over a thin sheet of paper or gauze. General mustard baths help alleviate catarrhs of the airways, bronchitis or pneumonia, usually in children. Mustard powder should be added to water in the bath, 40-60 g per 10 liters. The solution is passed through a gauze to separate undissolved lumps. The temperature of the water in the bath should be 37-390 C; the procedure should last for 8-10 minutes for adults and 5-6 minutes for children. The patient should be then wiped dry with a warm towel, dressed, and allowed to rest. Cups give stronger vasculodilated activity, than mustard plasters and are applied widely in bronchitis, pneumonia, neuralgias, neuritises, myosites. Cups are represented glass vessels with a spherical bottom and thickened edges of volume 30-70 ml. They are put on the body with well developed muscular and subcutaneous fat, flattening bony formations (subclavial, subscapular, interscapular areas). To avoid burns the skin is preliminarily sponged with vaselinum. Then a burning cotton plug moistened with alcohol is put on the inside of every cup for 2- 3 sec. After that with prompt and vigorous motion the cupping-glasses are moved in a circle of a wide area over the surface of the skin. Due to reduction of the air inside a cup (cupping-glass) slight pulling of the skin occurs. The skin becomes a pink or purple color. Duration of cup application is usually from 10 to 15 minutes. The number of cups depends on the size of the surface to which they should be applied. To take it off, it is enough to press with a finger on the skin near to the edge of the cupping-glass, simultaneously wedging it from the bottom in the opposite side. The patient should then be wrapped in blankets and allowed to lie for 30-60 minutes. If the cups remain attached for a longer time, dark red spots and even vesicles filled with fluid may develop on the skin. The cupping-glasses are contraindicated in tumors, active tuberculosis, pulmonary bleedings, diseases of a skin and its hypersensitivity. Treatment with cold is called cryotherapy. Ice bags are commonly used. Cold causes contraction of the blood vessels, thus decreasing the sensitivity of the peripheral nerves. Cold is applied as a first aid measure for acute inflammation of abdominal organs (acute appendicitis, pancreatitis, cholecystitis, etc.), for hemorrhage, contusion, bone fractures, delirium associated with fever, and also for anesthesia. Moist cold compresses are used for the first hours with injuries, nasal and hemorrhoidal bleedings, high fever. Rolling some layers a piece of a soft tissue, it is moistened with cold water and put on the relevant area of the forehead or bridge (of the nose). As the moist cold compress soon reaches the temperature of the body, it is necessary to change it every 2-3 minutes. For more prolonged local cooling it is more convenient to use an ice-bag, which represents a flat rubber bag with a wide hole filled with small pieces of ice. The ice-bag is expedient, but overcooling should be avoided by to hanging it (above a head or a stomach), making ten-minutes breaks every half an hour. Disinfection of hot water bottles, ice bags, cups After their using they must be washed with running water, dried and twice wiped with any disinfectant solution:  0,2 % desactin;  0,2 % blanidas;  0,5 % corsolex-basic. Hyrudotherapy Medical leeches and applied with the medical aim of a blood removing and anticoagulative agent. The secret of leeches’ saliva contains hirudin - a substance having the ability to brake down coagulation and to prevent thromboses. The indications for the hyrudotherapy: 1. Hypertonic crisis. 2. Stenocardia. 3. Myocardial infarction. 4. Thrombophlebites. 5. Heart failure. Contraindications: 1. Hypotonia. 2. Anemia. 3. Slow blood coagulations. 4. Septic and allergic condition. 5. Taking of anticoagulants. 4-6 leeches are applied on the mastoid processes along a vertical line, 1 cm away from the ear auricle in the hypertonic crisis, on the liver area (right hypochondrium) in the cardiac insufficiency, along the course of the veins in the thrombophlebites. The site of the skin, on which it is necessary to put leeches must be treated, with sterile small balls moistened with warm boiled water, and then moistened with a sterile solution of glucose. One leech should be put in a test tube with the back sucker to the bottom of a test rube. Then a test rube is applied to the body and the leech is directed to the necessary site of the skin. A leech must be released from the rest tube, as soon as it bites through the skin and wavy movement appear in its front part. Under the back sucker it is necessary to put a sterile napkin. It is unadvisable: to put leeches above blood vessels. It can cause a severe bleeding. The leech falls off itself in 0,5-1 hour, after having sucked 5-10 ml of blood. If you need to take off a leech before this time, it is necessary to moisten the area of the front sucker with salty water and it falls off by itself. After the leeches are gone, on the place where they were, it is necessary to apply a dry aseptic dressing with a plenty of cotton wool, which is not removed during the day (24 hours) to prevent bleeding. Ingalation It is possible to inhale gases (oxygen, nitrous oxide), agents, which is vaporized slightly (ether, chloroform), and aerosols (substances, sprayed little). Aerosols are dispersal systems, which consist of gas medium and dense or liquid particles in it. There natural and artificial aerosols. Natural ones include aerosols of air of seaside and mountain resorts, where increased contents of iodine, salts of sea water, phytoncids. Artificial aerosols are made by means of special apparatus (aerosol generators), where dispersal aerosols with medicinal substance are formed. Aerosol generators are subdivided into portable (individual) and stationary (of collective using). Special small portable apparatus is used for inhalation of medicinal preparations with a bronchodilated effect. To that end it is necessary to chake the container, to bring it to the patient’s mouth and to make 2-3 pressing movements during the patient’s deep inhalations. Electroaerosol therapy is kind of aerosol therapy. Electroaerosol is aero- dispersal system, where particles aerosols have free positive or negative electrical charge. Electroaerosols penetrate into airways deeper and kept there longer than non-charged. There are 5 main types of inhalations: vapor, thermomoist, electroaerosol, oil and dry. 1. Active base of vapor inhalation is vapor, which during inspiration causes increased blood flow to mucous membrane of upper airways. It promotes to its functional recovery and relieves pain. Menthol, thymol, eucalypts oil are used for vapor inhalations. Temperature of vapor on respirator’s expiration is 55-62º C. Duration of inhalation is 5-10 minutes. 2. In case of thermomoist inhalation spraying of warmed up liquid mixture occurs. It includes isotonic (0,9%) solution of sodium chloride, hypertonic (2-3%) solution of sodium chloride, 1-2 % solution of sodium hydrogen carbonate. It is possible to include bronchial spasmolytics to it. Temperature of mixture for inhalations is 38-42º C. Duration of procedure depends on spread of spraying of medicaments. 75-200 ml of solution is spent for one inhalation. 3. Aerosols (electroaerosols) with room temperature are used widely in portable inhalators. 2-6 ml of medicaments is spent for one inhalation. 4. Oil inhalations don’t have therapeutic importance only, but - prophylactic one also (in case of professional contact with lead, mercury, chrome, ammonia). During application of oil inhalation mucous membrane of airways is lubricated with thin layer of oil with purpose of its protection from various irritations and prevention of toxins absorption. In case of atrophy of mucous membrane it diminishes feeling of dry mouth. 0,5-1 ml of vegetative oil (olive, eucalypt, peachy) and the same amount of cod-liver oil are used. They are degraded and absorbed in the lungs completely. Duration of inhalation is 5-7 minutes. 5. In case of dry inhalations powder, sprayed in solution is mixed with dry hot air, from which water is evaporated and littlest particles of medicament penetrate into bronchi deeply. Inhalations are indicated for straggle against infection, rarefying of sputum, protection of mucous membrane of airways from irritative action of different factors, for improvement of airways patency. Advantage of inhalation method is in the following: unchanged medicines, bypassing liver, get into area of pathological process directly. Disadvantages of this methods: inaccuracy of dosing, potential irritations of mucous membrane of airways, insufficient getting into area of pathological process in case of airways patency disorder. Contraindications to carrying out of inhalation therapy: hemoptysis, active forms of lung tuberculosis, pneumothorax, neoplasms in bronchi and lungs, III stage of heart failure. Inhalations should be carried out at quiet situation, in 1-1,5 hours after food intake and physical work. During procedure patients must not deflect one’s attention for talk and reading. Dress shouldn’t be tight, in order to have possibility to breath without difficulty. After inhalation it is necessary to have rest during 10- 15 minutes, and in winter period - 30-40 minutes. It isn’t recommended to sing, talk, smoke, take food. In case of lesion of paranasal sinuses patients inspire and expire through nose, without force. In case of lesions of pharynx, larynx, bronchi - after inspire of substance, used for inhalation, it is necessary to hold breath to 2 sec., and then to do maximal expiration, by means of nose desirably. It gives possibility to the part of substance to get into paranasal sinuses due to negative pressure in nasal cavity. Oxygen therapy Great role in inhalation therapy belongs to oxygen therapy. Due to its important role in processes of organism’s vital activity, inspiration of oxygen (inhalation oxygenotherapy) is used in different pathological conditions, which are accompanied with oxygen starvation (hypoxia). Oxygenotherapy is indicated in extreme sates of organism, when severe respiratory impairments (asphyxia, carbon monoxide poisoning, methane poisoning, pulmonary edema, open pneumothorax, laryngospasm) are developed suddenly. Inhalation introduction of oxygen is used in case of numerous chronic diseases also, particularly, of cardiovascular system (angina pectoris, myocardial infarction, heart valvular diseases, hypertensive disease, myocarditis); respiratory apparatus (pmeumonia, pneumosclerosis, pulmonary emphysema, bronchial asthma) ; digestive apparatus (peptic ulcer disease, chronic inflammatory diseases of the liver and biliary tracts, gastritis, pancreatitis, enteritis, colitis, etc.). Oxygenotherapy is used widely in diseases of nervous system, skin diseases, numerous surgical diseases. Introduction of oxygen into airways by means of catheter, which is in nasal meatus is effective method of inhalation oxygenotherapy. Before its transnasal (through nose) introduction catheter should be sterilized by boiling and then - lubricated with sterile Vaseline oil.Catheter is introduced slowly along inferior nasal meatus to the depth of 15 cm by fingers of the right hand. In case of this distance it reaches posterior pharyngeal wall (it is possible to mark visually in opened fauces). Catheter should be fixed to skin face with adhesive plaster with purpose of its stabilization. Position of catheter should be changed, transferring it from one nostril into another one every hour, for prevention of trophic changes of nasal mucous membrane. Oxygen inhalation can be carried out by means of medical face masks also. In case of oxygen giving by means of mask, part of oxygen in air mixture must be fro 40 to 60 %. Mask oxygenotherapy by means of individual oxygen inhalator with regulator of oxygen speed providing and container for its moistening has essential advantage to other methods (Fig. 13). In case of absence of special humidifier - Bobrov’s apparatus, third part of which is filled with water, can be used with this purpose. On average oxygen speed providing in using of mask reaches 4-5 l per 1 minute. It is possible to regulate gas flow, particularly, to increase it to 10 l per minute by means of special inhalator device. But it is necessary to remember that patients’ tolerance to oxygen inhalation in volume more than 5 l per minute isn’t good. It is caused by the following: high gas concentrations result to dryness of mucous membrane of the mouth and airways. In case of absence of regulator oxygen speed moving can be controlled by amount and speed of gas vesicles forming in humidifier. Method of oxygen giving to the patient by means of centralized system of oxygen provision is used often in modern in-patient departments. This system consists of several oxygen bambs, connected one to another by connective reduction system. System is placed in specially equipped apartment, which is built near medical building. Identifying sign of oxygen bombs for medical using is blue color of its cover with mark “M” in its upper part (“M” means “medical”). These signs distinguish medical oxygen from technical. For safe preservation of oxygen bombs room temperature must not be more than 36 º C, and system of central heating must be removed from bombs to the distance not less than 2 meters. Bomb, filled by gas, must contain 40 l of like-gas oxygen, pressed to 150 atm. Special device - reductor- with two manometers is added to bomb. One of them, connected directly to the bomb, determines gas pressure in bomb, other one, connected with camera of low pressure, is intended for regulation of pressure of oxygen, which is given to the patient. Oxygen is given in wards (by means of regulated screw) by centralized system under pressure within limits one-two atm. In case of absence of centralized system of oxygen provision, bombs with medical oxygen is placed in places, which are far from patients and medical personal (basements, ground floors) or in separate places, specially adapted to this purpose. Medical personnel must follow the rules of using them strictly of to prevent detonation of oxygen bombs. It is prohibited to smoke, use electric instruments, kindle fire categorically. During work with bombs it is necessary to remember that pressed gaseous oxygen in case of contact with fatty substances react actively (oxidation reaction); it can causes skin burn, flare and detonation even. That is why in contact with compressed it is necessary to know and to follow rules of safety conditions. It is necessary to remember that persons, on skin and dress of which are present substances with fatty base (lipstick, creams, ointments, pastes, etc.), must not be admitted to contact with bombs. Bombs should be protected from strong pushes, impacts, and commotions. They must be in vertical position and fixed condition by means of metallic hoops or chains, which are fixed to the wall. During opening of bomb’s valve nurse must not turn face in direction of oxygen’s stream to prevent burns of face, of eyes, first of all. In stationary conditions with purpose of inhalation oxygenotherapy oxygen tents are used. Moistened oxygen is given into it by means special system. Necessary temperature (near 20º C) is provided by means of automated coolness system or by means of ice. Expired carbine acid is absorbed by soda lime, which is in special chuck, localized in way of passing of expired air. Duration of patient’s stay in oxygen tent must not exceed 10-15 minutes during beginning of the treatment (adaptation period) with gradual increasing to 30-40 minutes-during final stage. 12-15 sessions of inhalation oxygenotherapy (of oxygen tents) are prescribed mainly for course. Sometimes (in case of carbon monoxide poisoning, pulmonary edema, severe cardiopulmonary decompensation) inhalations of pure oxygen can result to respiratory center depression. In these cases it is more reasonably to inhale carbogen, i.e. gas mixture, which consists of 95% of oxygen and 5 % of carbon dioxide. Inspiration of carbon dioxide, which is in gas mixture, causes stimulation of respiratory center. In case of absence of centralized system oxygen provision it is possible to use oxygenous pillow for oxygen inhalations. Oxygenous pillow is rubberized sack (its capacity is 15 l) with rubber tube, plastic mouthpiece and regulation valve. For filling of pillow by oxygen - at the beginning mouthpiece is separated from hose and tube is connected with reductor of oxygen bomb. Then valve is opened slowly and pillow is filled with gas gradually. After its filling reductor’s valve is closed, inverted going out of gas is stopped up by valve, mouthpiece is put on. In case of pillow using with purpose of moistening of oxygen, it is reasonably to wrap up mouthpiece by moist gauze. Oxygen giving is regulated by means of special valve. During inhalation it is necessary to take mouthpiece on distance 4-5 cm from patient’s mouth to diminish feeling of dryness. It is necessary to mark that oxygenotherapy by means of oxygen pillow isn’t effective method and can be used in case of absence other methods only.

Apart from inhalation method, enteral, parenteral and contact methods of oxygen providing are used also. They include subcutaneous introduction of gas, oxygen bathes, introduction of oxygen into stomach and bowels in gaseous condition or as oxygen scum. Last one is mixture of oxygen with water extracts of medical plants with adding of scum-former (white of an egg, peptone). Mechanism of medical action of oxygen, introduced into organism, isn’t based on effect of liquidation of its deficiency in organism (hypoxia)only, but it is caused by reflectory influence of gas to nervous, respiratory and cardiovascular system. Literature recommended: Main Sources: 1. Clinical Nursing Skills and Techniques: basic, intermediate and advanced. The C.V.Mosby Company, 1986.- 1296 p. 2. Clinical Skills and Assessment Techniques in Nursing Practice. Scott, Foresman and Company, 1989.- 1280 p. 3. Nursing interventions and clinical Skills. Mosby – year Book, Inc., 1996.- 813 p. 4. Nursing Procedures: Student Version. Springhouse Corporation, 1992.-788 p. 5. Polskaya L.V. Nursing procedures in therapeutic practice.- Simferopol: Universum, 2004. - 192 p. Additional ones: 1. Гребенев А.Л., Шептулин А.А., Хохлов А.М. Основы общего ухода за больными: Учеб. пособие.- M.: Медицина, 1999.- 288 с. 2. Нетяженко В.З., Сьоміна А.Г., Присяжнюк М.С. Загальний та спеціальний догляд за хворими.- К.:Здоров’я, 1993.- 304 с. 3. Щуліпенко І.М. Загальний і спеціальний медичний догляд за хворими з основами валеології/ Навчально-методичний посібник для студентів медичних вузів і учнів медичних ліцеїв. - К.:Кий, 1998.- 384 с. Informational resources 1. Leslie Jennings. Educational movie. “ Roles and Functions of the Nurse”./ Leslie Jennings.2014 2. Касевич Н.М. Основи медсестринства в модулях: навч. посіб. – К.: Медицина, 2009 3. HEAT Inc., Health Education & Training . Educational movie Ethical Issues In Nursing -- Respect: Dignity, Autonomy, and Relationships 2010 Internet resourses 1. http://study.com/academy/subj/science/health-and- nursing.html 2. http://www.moz.gov.ua/ua/portal/dn_20130601_0460.ht ml 3. http://www.nursingworld.org/nursingstandards

Methodical instruction is composed by lecturer Ye. Petrov. Methodical instruction is revised and approved again At the Chair of Propaedeutics of Internal Medicine with Care of Patients meeting On “___” ______200__ year. Protocol №

The Ministry of Health of Ukraine Ukrainian Medical Stomatological Academy

Approved at the Department of Propaedeutics to Internal Medicine with Care of Patients meeting on 11 09 2018 Protocol No2 The Head of the Department Professor Yu. Kazakov

METHODICAL INSTRUCTION FOR STUDENTS’ SELF-PREPARATION WORK

Educational discipline Care of patients Module No 1 Enclosure module No 1 Topic Questioning of the patient and its role in estimation of patient’s general condition Year 2 Faculty medical

. The topic basis: Initial stage of patient’s examination is questioning. Competent questioning of patient’s complaints, present history, life history (with observance of deontological principles) are reliable orient, allowing to direct diagnostic search to necessary direction often.

2. The specific aims: To Know: o Rules, which must be observed during questioning of the patient. o Method of the questioning of the patient (complaints, present history, life history) To Be Able: o To take patient’s passport data. o To take patient’s complaints. o To observe present history. o To observe life history. 3. Basic knowledge, experience, skills necessary for studying the topic in connection with other subjects (interdisciplinary integration) : Previous disciplines Obtained skills 1. Anatomy To know human anatomy 2. Physiology To know physiology of systems of internal organs 3. Medical psychology To be able to observe principles of ethics and deontology in medical practice 4. Latin and medical To know terminology (in Latin transcription): terminology complaints, present history, life history 5.Philosophy To know concept about terms “object”, “subject”

4. Tasks for self-work during preparation to the class. 4.1 List of the main terms, parameters, characteristics, which should be mastered during preparation to the class: Term Definition 1. Subjective symptoms Are those that cannot be found on examination of the patient 2. Objective symptoms Are those that can be found on examination of the patient 3. Syndrome It is combination of symptoms that are interrelated and give rise to one another 4.2. Theoretical questions to be answered before class: 1. What is the beginning of questioning? 2. What rules must physician observe during questioning of the patient? 3. What are patient’s complaints? 4. Name sequence during questioning of patient’s complaints. 5. What types of complaints do you know? 6. What is “ anamnesis morbi”? 7. What is “anamnesis vitae ”? 8. What are the aims of present history? 9. What are the aims of life history? 10. What does the term “harmful habits” mean?

4.3. Practical work (tasks), which should be performed during class: 1. To carry out inquiring of the patients: complaints, present history and life history 2. To interpret obtained results.

The contents of topic: Text

Questioning The beginning of questioning (interrogatio) is acquaintance with patient. His/her surname, name, patronymic, year of birth, nationality, place of permanent residence and work, education, the main profession, time of hospitalization to the hospital are asked. Then: patient’s complaints , history of emergence and developing of disease and also life history are asked. It is necessary to maintain such rules during questioning of the patient. Situation of the chat must be serene. It is desirable to do questioning tete a tete without strange persons (if interpreter isn’t necessary). During questioning physician must be concentrated maximum, to strain his/her intellect and memory, to write down information of the patient minimum. At first it is necessary to say hello to the patient and to introduce yourself to him first. It is necessary to talk to the patient politely, to look into the patient’s face during conversation, don’t cut short questioning, digressing for other things. In order to have trusting contact with patient, physician must to assess psychological peculiarity of the patient correctly at the beginning of the conversation. It may help to find individual approach to the patient and to win his/her over. It is necessary to carry out questioning single-mindedly. Patient’s story is directed to the necessary course in accordance with accepted sequence. At the same time you can not interrupt patient sharply. It is necessary to give him/her to speak one’s mind fully during each stage of questioning. Asked questions must be clear and intelligible. Tone of conversation must be serious but benevolent. It is necessary to follow your speech. If the patient uses medical term, you must to ask what does he/she mean. It is necessary to keep patience and attentiveness, don’t be fussy and hasty. At the same time it is necessary to show to the patient your competence and self-confidence, but without rush, aplomb, flatness and peremptory in the judgement about disease, particularly during first introduction to the patient. Besides, keeping of deonthological principle is very important for questioning. Questioning of patient Complaints Complaints of patient are subjective symptoms of disease. Certain syndromes or complex of symptoms, which help to allow for organs or systems of internal organs involved in pathological process, are allocated on the base of analysis of complaints. It is necessary to hold certain sequence during questioning of patients’ complaints. At first you ask the patient “ Do you complain of? “ or “ What troubles you?” and give the patient possibility to tell about all signs of disease, which motivates him/her to ask for medical help. It is necessary to group complaints in curtain functional systems and besides to differ main and additional complaints. You must know that the main complaints are named by the patient at first. Then, asking additional questions, it is necessary to work out in detail every complaint of the patient. For example, in a case of the pain it is important to make more exact such its characteristic as localization of the pain, its nature (tightening, pressing, cutting, burning, piercing), intensity (sharp or dull), irradiation (area of spreading), time and speed of appearance; factors causing or increasing pain, accompanying symptoms, duration of pain; factors leading to its disappearance or weakening, for example, peace, certain body position, taking medicine and so on. You must ascertain effect of medicine taking before. In a case of abdominal pain it is necessary to make more exact its connection with taking food or defecation. Like attack, sharp, intolerable pain is named colic. In a case of breathlessness it is necessary to determine its connection with physical exertion and character of breathlessness (inspiratory or expiratory). In a case of cough it is necessary to make more exact its character (permanent or like attack), connection with change of body position or inhaling of irritating agents, is cough moist or dry. Then it is necessary to ascertain presence of other manifestations from side of organ system, which is involved in pathological process (on the base of presented complaints). In conclusion systematic questioning by other systems of organs is carried out: Respiratory system – cough, presence of sputum and its character, hemoptysis, painful breathing, breathlessness and suffocation, expiratory, inspiratory or combined character; Cardiovascular system – pain near or behind breastbone (retrosternal pain), its character, heartbeatings (like attack or constant), intermission in work of heart or feeling of “sinking heart”, breathlessness and suffocations of inspiratory character, which are connected with exertion, edema of legs; Digestive system – pain in certain region of abdomen and its character, heartburn, regurgitation (gaseous, acid, bitter, musty smelling, of food), vomiting (with characteristic of emesis), suppressed or perverted appetite, difficulty at the swallowing food (disphagia), diarrhea, constipation, feeling of rumbling and fluctuation of fluid in bowel, abdominal distension, superfluous evacuation of bowel gas (meteorizm), bitter and metallic smack in the mouth, poor tolerance of milk and dairy products, which is manifested by abdominal distension and diarrhea, changes of feces and their character, foul-smelling from the mouth. Urogenital system – back pain and its character, edema of the face and other body parts, frequent urination, high urine flow or low urine flow, changing of urine’s colour (rosy, brown, cloudy-white); Musculoskeletal system – pain and impairment of mobility of joints and vertebral column, feeling of “morning immovment” or crunch at the motions, muscular weakness, pains in muscles and bones, convulsive contracting of single muscles; General complaints - feeling of fever, chill, excessive disposition to perspire, feeling cold, malaise, general weakness, fatigue, itching of the skin, increased bleeding (skin, gum) or inclination to bleeding (nasal, intestinal, uterine), dryness in the mouth, thirst, emaciation or considerable increase of weight; in case of thirst you must make more exact quantity of liquid, drank by patient during day (24 hours); in case of emaciation you must make more exact, how many kg weight loss is and during which term, is emaciation connected with failing appetite (anorexia). In the course of study of complaints you must order subjective symptoms by gathering of signs, which form certain syndromes.

History of emergence and developing of disease ( present history ) History of emergence and developing of disease is named present history (anamnesis morbi, anamnesis- memoirs, morbus- disease ). During taking of present history it is necessary to ask about debut of diseases at first, then to ask about peculiarities of its progress and further to ask about the cause of consulting of the patient to the physician now. Debut of disease. You must ascertain time of beginning of disease, particularities of its emergence (sharp or gradual beginning), first symptoms and succession of their appearance. It is necessary to make more exact connection of emergence of disease with influence of some pathogenic factors (to patient’s opinion).They are supercooling, intoxication, infection, breach of nutrition, physical overstrain, emotional shock, hereditary factor and others. Then you must ask patient about measures, which he/she undertook at the first signs of disease. Sometimes the patient doesn’t attach importance to symptoms of disease during protracted period and therefore he/she doesn’t consult for medical attendance. If the patient was treated himself/herself, it is necessary to make more exact following: did he/she keep diet? What medicine did he/she take? What was their effectiveness? If the patient consulted for medical attendance, it is necessary examine: “When it was?”, “What examinations were carried out?”, “What were their results?”, “What diagnosis was made?”, “What treatment did the patient receive?”, “What was their effectiveness?”. In the case of positive effect, we must make more exact speed of its appearance and concretize this effect. Peculiarities of course of disease. During this stage of questioning it is necessary to ascertain about course of disease from moment of its emergence to present time: did symptoms , arised at the initial stage, change during past period? Did new signs appear? (what? when?), Was patient examined and treated (at out- patient or in-patient department)?, What methods of examination were carried out?, What diagnosis were made?, What methods of treatment were used? , What their effectiveness was? It is reasonably to use fully patients medical documentation: patient’s card, medical card, extract from case histories, conclusions of carried out out-patient laboratory and instrumental examinations. It is necessary to ascertain general tendency of illness course also: progressive, stable or regressive and also peculiarities of alternation of periods of exacerbation and remission; effect of seasonal and other factors on course of disease. Cause of consulting to the physician ( hospitalization ) now. Ask, when change for the worse of course of disease was come, what it manifested in, what causes the patient connects it with. It is necessary to ascertain, what treatment patient received in connection with come change for the worse of course of disease and what effectiveness of therapy was. Besides that, it is necessary to ask patient, if he/she takes medicines in connection with accompanied chronic diseases, for example, diabetes mellitus.

Life history Life history of the patient or anamnesis vitae (vita- life) is learned in order to expose concrete conditions of life, professional, hereditary, social and other factors, which might be to contribute to emergence and developing of disease and to provoke its exacerbation also. During taking of life history it is reasonably to keep following succession. Childhood, adolescence, youth: birthplace (urban locality or countryside, its climatic-geographical factors, determine where the patient lived else), age of parents at the birth of the patient, their social status, their relative relations, if the child was born in time, what the child was in the family by counting, if there were complications during delivery, conditions of lactation of infant (natural or artificial); how the patient developed and studied at school; did he/she go in for sport and what its type was; didn’t he/she drop behind of coevals in physical development, living conditions of family, relations between parents and patient. Professional history: what educational institution patient graduate from, living conditions during studies, gained profession, age of beginning of work, ability to work, particularities of patient’s labour activities - occupational hazards, physical overstrains, protracted business trips, night shifts, overtime job, stressful and conflict situations, reaction for stress; it is necessary to describe nature of labour activities of every profession line and every place of employment (if patient changed them repeatedly). Living conditions now: housing conditions ( living space, number of residents, communal conveniences, presence of damp, cold, remoteness from place of employment ), level of prosperity, regimen and character of feeding, peculiarities of spending of free time, keeping the rules of personal hygiene. Gynecological history: when menstruations began, their regularity, length, abundance of bleeding, presence of painful feeling, intervals between menstruations, date of the last menstruation, time of the first pregnancy, general number of pregnancies, deliveries, miscarriages and abortions, peculiarities of proceeding of pregnancies and deliveries, age of coming of menopause, presence of gynecological diseases, data of last examination by gynecologist. Old diseases, intoxications, trauma, operations: when they were ( name years chronologicaly ), peculiarities of proceeding, where treatment was and its effect, if blood transfusion was used. Epidemiological history: presence tuberculosis, hepatitis, dysentery and other infectious diseases at patient’s relatives, friends and colleagues in job; patient’s contact with poultry and domestic animals, often use of raw meat, fish, milk; presence of gnawing animals in inhabitable dwelling or place of work, pincers bites at past. Allergological history: allergological diseases of the patient and members of the family of the 1-st relationship degree (parents, brothers, sisters), untolerance of any medicines, food stuffs, inhalation agents, substances, contacting with skill (perfumery, washing powders, lacque-painting materials) by patient, how it manifested (nettle rash or other types of rashes, Quincke’s edema, bronchospasm, anaphylactic shock). It is reasonably to ask what inoculations were done to the patient during month before emergence of disease. Heredity: presence of the same disease in relatives of the 1-st relationship degree; it is necessary to ascertain presence diseases, that are inherited often (for example, diabetes, haemolythic anaemia); if relatives of the 1-st relationship degree died, you must ask cause of death and age. Harmful habits: “does patient smoke?”, “From which age?”, “What? (cigarettes, cigars)”, “How often?”, “Has a patient narcotic habit or excessive drinking habit?”, “Has a patient addiction to frequent use of coffee and tea?”. Self-control material: A. Test tasks to be done: -with a single selective answer – I-st level:

1. What parts does questioning of the patient consist of ? a) allergological, family, hereditary, gynecological history; b) complaints, present history ( history of present illness ), life history; c) physical and mental development, education and labour activities; d) all past diseases in chronical order; e) passport part, complaints, present history, life history. 2. What is succession of questioning ? a) present history, life history, passport part, complaints; b) complaints, passport part, present history, life history; c) life history, present history, passport part, complaints; d) allergological, family, hereditary, gynecological history; e) passport part, complaints, present history, life history. 3. What organ system must the questioning about organs and systems begin from? a) it is without difference; b) from cardiovascular system as system of special importance; c) from that one, which can to be involved in pathological process to judge from patient’s complaints; d) from respiratory system, in winter period particularly; e) from digestive system. 4. What harmful habits is it necessary to inquire during questioning about? a) smoking; b) smoking and alcoholism; c) toxicomania; d) narcomania; e) smoking, alcoholism, toxicomania, narcomania. 5. What conclusion must to be done on the base of data of patient’s questioning? a) general state of the patient is appraised; b) provisional diagnosis is made; c) judge system, interconnection of complaints, character of disease (acute or chronic) are determined; d) treatment is indicated; e) health state of the patient is appraised. 6. What do main patient’s complaints mean? a) complaints, which characterize basic disease; b) complaints, which accompany associated disease; c) general complaints (weakness, feeling ill, decreasing of appetite, bad sleep); d) breathlessness, cough, chest pain, haemoptysis, body temperature rise; e) palpitations, pain behind breastbone, edema, breathlessness. 7. What do general complaints mean? a) complaints, which characterize basic disease; b) complaints, which characterize complications of basic disease; c) complaints, which characterize associated disease; d) complaints, which characterize primary majority diseases (for example, weakness, feeling ill, nervous lability); e) complaints, which are connected with disturbance of function of nervous system. 8. What do secondary (additional) complaints mean? a) complaints, which characterize basic disease; b) complaints, which characterize associated disease; c) complaints, which characterize complications of basic disease; d) general complaints ( weakness, feeling ill, decreasing of appetite, bad sleep); e) complaints except ones, which characterize basic f) pathology. 9. Family history is: a) hereditary history; b) выяснение ascertaining health state of close relatives of the patient ( parents, brothers, sisters ); c) married, got married; for women – beginning of menses, number of pregnancies, delivery, abortions; number of children ; time of coming of climacteric period. d) intolerance of any drugs, products by relatives; e) ascertaining number of marriages during life and health state of all husbands/wives. 10. Hereditary history is: a) ascertaining health state of close relatives of the patient (parents, brothers, sisters); b) intolerance of drugs or products by patient; c) married, got married; for women – beginning of menses, number of pregnancies, delivery, abortions; number of children ; time of coming of climacteric period; 11. Allergological history is: a) study of the health state of close relatives of the patient (parents, brothers, sisters) b) intolerance drugs or products by patient, increased sensitivity to smell; c) married, got married; for women – beginning of menses, number of pregnancies, delivery, abortions; number of children ; time of coming of climacteric period. 12. What is subjective symptom? a) manifestations of diseases, which are exposed by physician during physical examination; b) manifestations of diseases, which are exposed in consequence laboratory examination; c) complaints of the patient; d) information, received thanks to palpation; e) information, received thanks to percussion.

-with the selective group of right answers – the II-nd level;

1. Asked questions to the patient must be: а) plain; b) intelligible; c) with medical term ( in order to show one’s competence ). 2. Epidemiological history includes: a) presence tuberculosis, hepatitis, dysentery and other infectious diseases at patient’s relatives, friends and colleagues in job; b) housing conditions ( living space, number of residents, communal conveniences, presence of damp, cold, remoteness from place of employment); c) level of prosperity, regimen and character of feeding; d) patient’s contact with poultry and domestic animals; e) presence gnawing animals in inhabitable dwelling or place of work. 3. What does the term “ housing conditions “ mean? a) living space; b) number of residents; c) pincers bites at past; d) communal conveniences; e) presence of damp, cold; f) use of raw meat, fish, milk. 4. Present history ( history of present illness ) includes: a) debut of disease; b) hereditary history; c) peculiarities of progress of disease; d) cause of consulting to the physician now; e) harmful habits of the patient. 5. During questioning it is necessary to keep: a) patience; b) fussy; c) attentiveness; d) hasty. 6. Patient’s passport data include: a) home address; b) age; c) full name; d) patient’s habits; e) patient’s complaints. B. Tasks to be done: Task 1. At carrying out of questioning of the patient physician use special medical terminology actively with purpose of show of his professionalizm. Is same tactic right? Task 2. Carrying out questioning of admitted patient, physician gives instructions to nurse (about of other nearest measures ). How do you can to appreciate actions of physician in the present instance and why? Task 3. Physician began taking of life history from professional history. Are his actions correct? Task 4. Physician began taking of present history from question: “ What is the matter now?“. What is his mistake in? Task 5. Physician, studying out-patient card of the patient, admitted to hospital, spoke out negative aloud about of correctness of preceding treatment (in patient’s presence). How do you can to appreciate action of physician and why?

Literature recommended: Main Sources: 1. Introduction to the course of internal diseases. Book 1.Diagnosis: [Textbook/Zh.D. Semidotskaya, O.S. Bilchenko, et al.] Edited by Zh.D. Semidotskaya. -Kharkiv: KSMU, 2005. - 312 p. 2. Kovalyova O.N., Ashcheulova T.V. Propedeutics to Internal Medicine. - Vinnytsya: NOVA KNYHA, 2006. - 424 p. Additional ones: 1. McCombs R.P. Fundamentals of Internal Medicine. A physiologic and clinical approach to disease. - 1971. - 860 p. 1. Гребенев А.Л. Пропедевтика внутренних болезней: Учебник – 5-е изд., перераб. и доп.- М.: Медицина, 2001.- 592 с. 2. Ивашкин В.Т., Султанов В.К. Пропедевтика внутренних болезней: практикум. 2-е изд.- СПб.: Питер, 2003.-544 с.

Standards of right answer (tasks): 1) No, it isn’t. 2) Negative. During examination of the patient physician not be distracted for other things. 3) No. They aren’t. 4)He must to ask about debut of disease at first. 5)Negative. Physician doesn’t must to discredit of other physicians by his expression. He must to keep deontological principles.

Methodical instruction is composed by lecturer Ye.Ye. Petrov.

200__/200__ academic year. Methodical instruction is revised and approved again At the Chair of Propaedeutics of Internal Diseases with care of patients meeting On “____”______200__р. Protocol №_____ The Head of Chair, professor Yu. Kazakov

The Ministry of Health of Ukraine Ukrainian Medical Stomatological Academy

Approved at the Department of Propaedeutics to Internal Medicine with Care of Patients meeting on 11 09 2018 Protocol No2 The Head of the Department Professor Yu. Kazakov

METHODICAL INSTRUCTION FOR STUDENTS’ SELF-PREPARATION WORK

Educational discipline Care of patients Module No 1 Enclosure module No 1 Topic General and special care of severe ill patients and patients with agony Year 2 Faculty medical 1. The topic basis: often consequences of severe diseases in great degree depend on quality of care of patients, timely and honest performance of physician’s prescriptions, forming of favourable regimen of recovery. Condition of severe ill patients can be aggravated in any moment; therefore such patients need constant attention and must be during whole day under supervision of medical personnel.

The course of severe disease in the patients can lead to agonal state. In case of such extreme situation every medical worker must give necessary aid to the patient. For this purpose he/she must be able to use necessary reanimation methods, first of all, carrying out of artificial ventilation and closed-chest cardiac massage.

2. The concrete aims:

 To make general rules of the care of patients with bed rest, severe ill patients and agonizing patients.  To explain how comfortable position of patient in a bed, prophylaxis of bedsores, personnel hygiene, including change of underwear and bedclothes should be performed.  To explain how using of bedpan, urinal and colon tube are carried out.  To represent classification of types of enemas.  To explain methods of enemas giving, indications and contraindications for their using.  To explain peculiarities of nutrition of critical patients, including parenteral nutrition.  To compose plan of feeding of elderly and old age patients.  To interpret conception “reanimation”.  To explain methods of reanimation measures: artificial ventilation and closed-chest cardiac massage.  To interpret conceptions “apparent death” and “death”.  To explain rules concerning to behavior with dead body

3. Basic knowledge, experience, skills necessary for studying the topic in

connection with other subjects (interdisciplinary integration) :

Previous disciplines Obtained skills

2 1. Anatomy To know structure of the main systems of organism

2. Physiology To know physiology of the main system of organism, their changes during aging and dying

3. Medical psychology To be able to observe principles of ethics and deontology in medical practice

4. Tasks for self-work during preparation to the class.

4.1 List of the main terms, parameters, characteristics, which should be mastered during preparation to the class:

Term Definition

1. Bedsores There are at first dystrophic, and then - ulcero-necrotic defects of skin, hypodermic basis, and sometimes - skeletal muscles, appearing in case of long pressing of soft tissues between bones and external objects.

2. Enema An enema is an injection of liquids into the large intestine through the anus.

3. Parenteral nutrition It is nutrition by means of parenteral introduction of different medicaments

4. Agony It is stage of dying, characterized by short activation of mechanisms, directed to support of vital activity processes.

5. Apparent death It is reversible stage of dying, during which external manifestations of organism’s vital activity (respiration,

3 cardiac contractions) disappear, but irreversible changes in organs and tissues don’t occur yet.

6. Death It is stage of dying when it is impossible total recovery of function of different organs.

4.2. Theoretical questions to be answered before class:

1. What external signs are testified about severe condition of the patient?

2. What general rules of care of patients with bed rest, severe patients do you know? 3. What measures according to prophylaxis of bedsores should be carried out? 4. Tell about personnel hygiene of severe ill patients. 5. How it is necessary to care of patients with faecal and urinary incontinence? 6. What types of enemas do you know? Indications and contraindications for their using. 7. Nutrition of sever ill patients. 8. Nutrition of elderly and old age patients. 9. Conception about reanimation. 10. Name the main signs of apparent death and death. 11. Describe method of artificial ventilation and closed-chest cardiac massage. 12. What the main rules concerning to behavior with dead body do you know?

4.3. Practical work (tasks), which should be performed during class:

1. Maintenance of comfortable position of the severe ill patients in a bed. 2. To prepare necessary things and to carry out prophylaxis of bedsores of severe ill patients. 3. To carry out change of underwear and bedclothes of the patient, which has bed rest. 4. To prepare necessary things and to carry out hygiene of oral and nasal cavities, eyes and ears of severe ill patients. 5. To prepare necessary equipments for cleansing enema, show method of its carrying out on plaster cast. 6. To show method of use of bedpan and bed slipper in male and female on plaster cast. 7. To take part in nutrition of the patient, which has bed rest.

4 8. To master method of artificial ventilation and closed-chest cardiac massage on phantom. 9. In case of patient’s death to reveal signs of apparent death and death, and if it is necessary - to take part in transporting of the dead body to morgue.

The contents of topic:

Text

CARE OF SEVERE ILL PATIENTS

Severe ill patients include ones, which have diseases with complicated course and without effective treatment or their prognosis is unfavorable. Condition of such patients often is manifested by deep disturbances of the most important functions of organism - nervous activity, breathing, circulation, digestion, excretion.

Most often severe ill patients have bed rest, but sometimes, in spite of severe character of diseases (malignant neoplasm, radiation sickness, blood diseases, AIDS, some organic diseases of nervous system), during debut period of diseases’ development patients can have usual regimen.

It is better to use functional bed (tilting bed) for severe ill patients.

Condition of severe ill patients can be changed in any moment; therefore they demand constant attention and must be under systematic medical supervision during whole period of severe condition.

Individual post must be organized with purpose of qualitative care of patients. Medical personnel of individual post must regularly observe for patient’s appearance, his/her breathing, pulse, blood pressure, urinary excretion, defecation. Nurse and junior nurse must inform physician immediately about all revealed disturbances.

Severe ill patient, which during protracted period have bed rest need attentive care. Prolonged stay in a bed of these patients can lead to dysfunction of cardio-vascular system, organs of breathing and digestion, cause changes of psychics, appearance of bedsores. For prophylaxis of these pathological states it is necessary to carry out the following actions of general care: periodical change of

5 patient’s position in a bed, timely change of underwear and bedclothes, observance of personnel hygiene, sanitary-hygienic and treatment-protective regimes in the ward. Medical personnel must feed severe ill patients 5-6 times in a day, give food by means of little portions within dietary intake, prescribed by physician.

Food should be given to severe ill patients by means of drinking bowl. In case of unconscious condition parenteral or rectal (by means of enema) feeding are used.

In connection with often disturbances of physiologic excretion severe ill patients need help during urinary excretion and defecation. In case of occurrence of involuntary urination or fecal incontinence an aid in using of bedpan, urinal or colostomy bag should be given to the patients.

Patients in state of excitement need systematic care. They often show excessive physical and psychical activity, hyperexcitability, try to run away from the ward, often create conflict situations and even show intentions of suicide.

In these situations medical personnel must calm of the patient, convince patient to stay in a bed. In case of appearance of convulsions, in order to prevent patient’s falling out from the bed, net or board should be fastened along bed’s free border. Individual post of medical personnel should be organized near such patients. Patients in state of physical and psychical excitement should be isolated from other patients. With this purpose it is expedient to place them in separate ward.

After general characteristics of peculiarities of care of severe ill patients, it is necessary to give information according to skills in detail.

Hygienic requirements to the bed Structure of functional (titling) bed. A bed (Fig.1) consists of three mobile sections, which change the position by means the special devices or handles, they are regulated by a nurse. Now there are comfortable functional beds, where a patient without assistance, not changing position, by means the handles or buttons can change the position. Such beds are equipped by bedside table, a stand for a dropper, sections for bed-slippers and bedpans also (Fig.2). A bed must be equipped by the well tight bed-spring, which forms a flat surface. A mattress is laid on it, which also must be without humps and hollows. It is better, that a mattress was made from dense and thick porolon. And it is better that a porolon mattress consists of 2-3 sections, which we can change at dirtying. Mattress – case, which is

6 usually sewn from dense fabric (tic), must be often ventilated (not rarer than once in two days), and if it is necessary – disinfected. For a patient with incontinence of urine or excrement a rubber or polyethylene oilcloth is laid on all area of the mattress. Bed-sheet is laid above the oil-cloth, the edges of which are tucked under the mattress, because it will not get rolled up. Pillows are placed thus, that lower (from feathers) a bit came forward from under overhead (downy) pillow; the last one must resist in back of bed. White pillow-cases are put on pillows. A fairy-tale or woolen blanket with a blanket cover is used for covering of patient depending on a season. Bed-clothes must be remade daily, in the morning and at night, and if it is necessary more often, it must be changed not rarer once in 7-10 days, and if it is drossy (by urine, excrement) – it must be done at once.

Fig.1. Functional bed Fig.2. Functional bed with section for bed- slipper and bedpan

Change of bed clothes During the change of bed clothes, if terms and state of patient are allow to do it, it is better to put him/her on a chair, or place into other bed or couch. If it is impossible, the change of bed clothes is performed without placing of patient into other place. There are some methods for the change of sheet of the bed- patients.

The 1-st method: It is needed to prepare a clean sheet, which is packaged into bolster along the half length like cylinder. It is necessary to take away a pillow, lifting the head of the patient a little. Patient turning on a side is moved aside on the border of bed. Part of sheet, which was freed, displaces like cylinder along the length of bed, and clean sheet is placed into its place, its free edge must hang down from the border of bed. After it a patient turns on the back, and then on the other side, and occupies part of bed covered by a clean sheet. Take away a muddy sheet and straighten clean. The edges of sheet are tucked under a mattress. A pillow is laid under the head of patient.

The II-nd method: In the cases, when a patient must not come back on a

7 side, the change of sheet is performed across a bed. For this purpose a clean sheet is displaced on a width. Heaving up upper part of body of patient a little, take away pillow and displace a dirty sheet from under a head and back, the prepared clean sheet is unwrapped into its place. A pillow is laid on a clean sheet and head of patient is turned down. Levitating a pelvis by turns, and then thighs and shins of patient, dirty sheet is turned like cylinder and clean one is made up. After it the edges of sheet are earthed up under a mattress.

Hygiene of underwear Underwear must be clean, cotton or flannel. Underwear must be changed not rarer than once in 7-10 days, and in the case of its contamination – at once. Change of underwear in seriously ill patient (Fig.3). A shirt is thrown down as the following: at first by easy motions, which least disturb a patient, a shirt is pulled up behind to the back of head, and in front to the breast. After it, heaving up the hands of patient, a shirt is thrown down through a head, and then hands are freed. Put on shirt in a reverse order: at first on hands, then through a head, then by easy careful motions pull off on the back and breasts and straighten carefully.

Fig.3. Change of underwear It is much comfortable, especially in patients with the myocardial infarction, to change shirt that is opened in front and had not fastening. It is necessary to down it from both shoulders on the back, then to take off from one hand, to draw out from under the back and take off from other hand. If a patient has the damaged hand, a shirt is taken off from it in the last place, and put on – in the first.

Care of skin in seriously ill patients The skin of the patients who are taking placed on a bed regimen, are daily bathed with warm water with addition of the alcohol, using a different part of washcloth. Skin-fold areas are washed, and then dried up especially carefully (Fig.4). If it necessary, massage can be used to stimulate blood circulation. Special oil, talcum powder can be used is necessary.

8

Fig.4. Care of skin in seriously ill patients Washing of seriously ill patients is performed not rarer than two times a day, and if it is necessary - more often. A face is wiped by a soft sponge or wadding tampon or soft towel moistened by warm water. Then a face is wiped by a dry towel. Washing of hands in seriously ill patients. Hands of seriously ill patients are washed not rarer than three times a day, and if it’s necessary - more often. For this purpose a bowl is put near a patient (Fig.5), warm water is taken into pitcher and it spilled over the hands of patient. If a patient can soap hands, he/she does it and washes off soap without assistance. As for immobile patient nurse soaps hands and washes off soap by a right hand, and by the left hand she waters the hands of patient from pitcher.

Fig.5.Washing of hands in seriously ill patient

Washing of legs in seriously ill patients. Patients, who walk without assistance, wash legs with soap every evening, in seriously ill patients it is done by a nurse (Fig.6). She turns away the lower end of mattress, a bowl with warm water

9 puts on a bed-spring and dips the feet of patient into it. By a lathery sponge she wipes interphalangeal intervals carefully and washes other areas of legs (to the middle of shin) with soap, by a dry towel wipes interphalangeal intervals at first, and then - whole surface of legs. In case of presence of fungus defeats of skin of feet these places are wiped by any antifungous ointment or solution.

Fig.6. Washing of legs in seriously ill patient

Care of hair in seriously ill patients. Hair of seriously ill patients is washed in a bed (Fig.7).

Fig.7. Washing of hair in seriously ill patient

For this purpose the head end of mattress is earthed up under the shoulders of patient, under a head and shoulders the special support is placed, do it so that the head of patient was heaved up and lean back. A bowl is put under a head. The warm boiled water is poured from pitcher on the hair of patient. For head washing liquid shampoo or soap-suds are used. After washing the hair is wiped and combed. If a hair is fat, it is washed once a week, if hair is normal or dry – once for 10-14 days. Combing of hair. If a patient can not comb without assistance, it must be done by a nurse twice a day. Every patient must has his own/her own comb. A

10 short hair is combed from a root to the tips. A long hair is combed gradually, beginning from tips. Prophylaxis of bedsores and fight against them. In the loosened immobile patients, especially those, who occupy passive position in a bed (for example, inparalyzed), disturbances of feed of muscles and skin are appeared quickly. Bedsores (decubitus) appear – at first dystrophic, and then ulcero-necrotic defects of skin, hypodermic basis, and sometimes - skeletal muscles. More often the bedsores arise up in those places, where layer of skin and hypodermic basis is the thinnest and where bony projections (prominences) are located close: on the back of head, shoulder-blades, sacrums, shins, elbows, heels. It is necessary to remember that formation of bedsores is the sign of bad care of patient. Stages of formation of bedsores. First of all a skin becomes pale, it reddens farther, then acquires the cyanotic colouring. After it a skin again becomes pale, swells up, bubbles appear on it, at first pale-yellow (due to transsudate and lymph), then bubbles are filled with a hemorrhagic liquid and burst. There is a shallow ulcer (erosion), which in absence of medical treatment becomes deeper and can cause necrosis of muscles. In severe cases through such ulcer it is possible to see a bone. Bedsores become site of entry for an infection usually; first of all they can be the reason of origin of sepsis, death can occur as a result. The danger of formation of bedsores grows in those diseases which are characterized by breaking of trophism (feed) of tissues. These are, for example, diabetes, different lesions of cerebrum and spinal cord (stroke, inflammation, trauma), atherosclerotic lesion of different arteries, trombophlebitis. Performing of prophylactic measures. With the purpose of prophylaxis of bedsores it is necessary to activate position of patient in a bed constantly. For this purpose every 2-3 hours, except the night, the patient must be returned on different sides, leaving him/her in this position during a few minutes. It is necessary to change position of patient not less than 8-10 times a day. It is necessary to look after the cleanness of underwear and bedclothes, carry out the rules of hygiene. Places which are the most vulnerable to the origin of bedsores need to cleanse by warm water with soap very often, to wipe by a camphor spirit (alcohol), eau-de-cologne, water with vinegar, to oil by a Vaseline oil, to sprinkle by talc. Under sacrums and coccyx it is necessary to underlay a bit inflated (that it easily changed the form at motions of patient) rubber circle (Fig.8), or rubber bedpan, on which pillow-case put on. There are also small rubber circles, that they are put under elbows and heels (Fig.9). With the same purpose a fabric mattress or bed-pillow, filled to the oaten either by a linen husk or inflatable rubber mattress are used. Last one has original design: every 3-5 minutes pressure of air in its separate chambers changes automatically and pressure of mattress on different points of body changes; it gives a positive effect.

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Fig.8. The use of rubber circle

Fig.9. The use of small rubber circles

Medical treatment of bedsores. It is necessary to remember that to treat bedsores far more difficult, than to prevent their formation. The methods of medical treatment depend on the stage of bedsores. 1) At stage of formation of hyperemia or paleness and edema of skin (without breaking of its safety) the affected places are cleansed by quartz lamp, a skin is wiped by a camphor spirit, vinegar, eau-de-cologne or strong solution of potassium permanganate. 2) At the stage of formation of bubbles, which didn’t burst yet, the affected places are treated by diamond green or a 70% ethyl spirit, camphor spirit or strong solution of potassium permanganate. 3) At the stage of formation of skin-deep ulcers we use: diamond green, sea- buck thorn oil, synthomycin emulsion. An aseptic bandage is imposed on an ulcer. 4) Deep bedsores are processed thus: turunda, which is moistened by hypertensive solution, is inserted into bedsore, and an aseptic bandage is applied. After cleaning of bedsore from necrotic masses the bandages with Vishnevsky ointment, 1% synthomycin emulsion, 10% streptocid ointment, sea- buck thorn oil are used.

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Fig.10. Intimate washing of the patient

Intimate washing and irrigation of seriously ill patients. Intimate washing of seriously ill patients is carried out not rarer than two times a day; and also after every act of urination or defecation (Fig.10). For this purpose nurse must have jug by a capacity not less than 2 l or Esmarch’s irrigator, warm water of temperature of 30-35o C with weak solution of potassium permanganate, packer, a few large wadding tampons. Before intimate washing rubber gloves are put on. An oilcloth is put on a sheet under lower parts of patient’s body. Warm dry metallic or bit inflated rubber bedpan is put under buttocks. The legs of patient are bent in knees and are moved apart. Warm water is poured from Esmarch’s irrigator or jug on the area of genitals. Genitals, inguinal folds and area of anus are wiped by a wadding tampon as a following: genitals are washed at first, then inguinal folds and area of anus. It is so necessary to do in order to add not an infection to the urino-genital organs. The area of perineum is wiped by a dry tampon in the same direction. If there are intertrigoes in folds, they must be oiled by Vaseline oil or sprinkled by talc. Irrigation must be done to the women, who have vaginal discharge. Esmarch’s irrigator is taken for this purpose, water warmed-up to the temperature of 30-35oC with weak solution of potassium permanganate or furacillin fills in it. An irrigator is suspended on 1 m higher than level of bed or fastened on a support (stand). Rubber gloves are put on and ill patient is irrigated. For this purpose lips of pudendum are disjoined by two fingers of the left hand and the sterile vaginal tip smeared by Vaseline oil is carefully entered in vagina on a depth 5-7 cm. Holding a tip, the faucet of Esmarch’s irrigator is slightly opened. After irrigation the area of perineum is wiped by a dry wadding tampon. The use bedpan and urinal. Seriously ill patients are incapable of using toilet without assistance. They must do all physiology “necessities” in a bed, using a bedpan and urinal, for this purpose a nurse helps them. A bedpan and urinal are placed on low stool under a bed or in the specially mounted seat of tilting bed. During using of a bedpan or urinal, patient, if he/she is in a general ward, must be partitioned off from other patients by a screen.

13 The use of a bedpan. A bedpan is metallic with the enameled coverage (Fig.11, a), made of delftware (Fig.11, b) or rubber (Fig.11, c).

Fig.11. Types of bedpan: а- metallic with the enameled coverage; b- made of delftware; c- rubber

Fig. 12.The use of the bedpan

A metallic bedpan more often has a flat round form with the large round or oval opening from above and small opening in a tube, which goes out from a lateral surface. To the patient it is given disinfected, dry and warm, with little quantity of warm water. A rubber bedpan is inflated by means of leg pump. It is given more often to debilitated patients, patients with bedsores, and also patients with urinary and fecal incontinence, because it can be under a patient during prolonged period. A bedpan is used thus (Fig.12): a dry rubber oilcloth is put under a patient, a bedpan is put under buttocks, a nurse puts a hand under the sacrums of patient, his/her pelvis rises here, the arcuated in knees legs of patient are disjoined into sides, a bedpan is put under the buttocks of patient thus, that a perineum found oneself above its large opening, and a tube was between the thighs of patient towards knees. After the act of defecation a bedpan is taken out. For this purpose a nurse lifts the pelvis of patient again, takes the tube of bedpan and takes out it in direction, to the opposite underlying. A bedpan is emptied in a toilet, and in the sanitary room it is washed by hot water, disinfected by 1-2% solution of chlorinated lime or 3% solution of chloramine. Patient is washed by warm water.

14 For patients, who move by wheelchair by means of nurse, and also for patients who move by invalid chair, the special devices on lavatory pans in toilets, in order to patients could hold them by hands .

The use by urinal. It is necessary to know that most patients can not urinate without assistance because of a bashfulness or inconvenience. To help them there are the following methods: a bedpan must be dry and warm, on its bottom there must be a little of warm water, warm water is poured to urino-genital organs, a warm hot-water bottle is placed on pubis, tap with water is turned, that a patient will heard the sound of its flow. If patient and after it will not be able to urinate without assistance, it is necessary to carry out catheterization of the urinary bladder. Urinal has elongated form; it ends with a short tube with opening (Fig.13, a, b).

Fig.13. Urinals: a-male; b - female

Male and female urinals differ by the structure of watering-can. Male urinal has a short tube from above; female urinal has a watering-can with the incurved edges on the end of the more horizontal located and wider tube.

Warm dry urinal is placed between the legs of patient. To the women urinal put thus, that opening of urine was above the watering-can of tube. Male penis is entered into opening of tube. After the act of urination urinal is taken up, its contents are outpoured in lavatory pan. In a sanitary room urinal is washed by warm water, disinfected by 3% solution of chloramine.

Care of mouth cavity in seriously ill patients. A nurse carries out toilet of mouth cavity to seriously ill patients twice a day, and after each of meal. For this purpose she uses the small rubber bulb, filled with weak antiseptic solution, forceps or packer, spatula, wadding balls , gauze serviettes, the warm boiled

15 water or one of antiseptic solutions ( 5% solution of boric acid, 2% solution of sodium of hydrogen carbonate, weak solution of potassium permanganate). At first oral cavity is rinsed out by solution, then a tongue carefully wiped, taking off fur from it by the gauze serviette, moistened by one of solutions. After it the teeth are wiped by other tampon, pulling a cheek by the spatula. After this procedure a patient rinses out a mouth by warm water. If a patient can not rinse a mouth without assistance, a nurse carries out irrigation (washing) of oral cavity by the Janet’s syringe, rubber bulb, or Esmarch’s irrigator. Except it, it is necessary to prepare a oilcloth apron, tray, spatula, one of antiseptic solutions ( 2% solution of boric acid – 1 tea-spoon for glass of water, solution of peroxide of hydrogen – 1 tea-spoon for glass of water, solution of furacillin 1:5000 and so on.).

Semi-sitting position with some lop-sided ahead head is given to the patient, that a liquid doesn’t get into respiratory tract. Neck and breasts are closed by a oilcloth apron, and under a chin put a tray, which patient or the nurse holds. A nurse pulls by a spatula by turns right and left cheeks and irrigates a mouth cavity by the stream of liquid. Under pressure of liquid there is the mechanical washing of lobules of meal. A patient must take out dentures before bed, to wash by water by tooth brush and save till morning in glass with water. In the morning, before putting it is necessary to wash them by water. Care of eyes in seriously ill patients. Measures about the care of eyes include the double washing of patient for a day. If in a patient there was conjunctivitis (inflammation of mucous membrane of eye) and purulent discharge from eyes are appeared, it is necessary to wash eyes by a sterile wadding tampon, moistened by 2% solution of boric acid. A tampon must be individual for every eye. Washing eyes must be done in direction from the external corner of eye to the nose, so that not bring an infection to the nasolacrimal canal. Care of ears in seriously ill patients. Cleaning of external auditory meatus in seriously ill patients is carried out by a nurse. 3% solution of hydrogen peroxide or camphor spirit (alcohol) is instilled (applied by dropping) into the ear for softening of ear-wax. Cotton wool is winded on a thin probe with thread, by the left hand nurse pulls auricle a bit back and upwards, by right - carefully brings a probe into an auditory meatus and by easy circulating motions clears an ear. It is necessary also to wipe a skin in a fold on the back surface of auricle, near the place of its transition into a mastoid process, because maceration and fungus lesions of skin can arise in this place in seriously ill patients. Care of nasal cavity in seriously ill patients. In seriously ill patients a nurse must daily release nasal passages (meatuses) from scabs that appear there. For this purpose it is necessary to do two wadding tourounda, to smear them by a Vaseline oil or glycerin. Nurse carefully brings tourounda into both nasal passages and holds

16 them there during 2-3 min. By circulating motions, wadding tourounda together with scabs take out. Using of colonic tube In long standing meteorism the application of a colonic tube (flatus tube) is indicative. To that end it is necessary: 1. A thick-walled colonic tube of a length of 30-40 cm and an outer diameter of 10 mm; 2. Vaseline; 3. Oil-cloth; 4. Bedpan. Under the patient’s pelvis an oil-cloth is placed. The patient is laid on the right side with the legs, moved toward the stomach. If the patient cannot be laid on his/her side, the procedure should be carried out in a position with the patient on his/her spine with bent knees and a little bit apart. The round end of a tube is greased with Vaseline. The buttocks are apart and slowly with rotary motions a tube is introduced into rectum to depth 20-30 cm, the outside end is placed in a vessel with water (bedpan). The tube is removed after 30-60 minutes and anus wiped with a wet cotton pad (Fig. 14).

Fig. 14. The application of a colonic tube

Enemas An enema (clyster, clysis) is an injection of liquids into the large intestine through the anus. The indications for use of a cleansing (purgative) enema are: 1. Constipation; 2. Preparation of the parturient women for labor; 3. Preparation of the patients for scheduled operations on gastrointestinal

17 tract organs, small pelvis; 4. Preparation of the patient for X-ray examination of GIT organs, of small pelvis, pelvic bones, pelvic region of spinal column; 5. Preparation of the patients for endoscopic examinations of the intestine; 6. Poisoning. Contraindications for use of a cleansing enema are: 1. Acute appendicitis; 2. Acute inflammatory processes in the colon with a predilection to bleeding; 3. Fissure of the anus; 4. Bleeding from the gastrointestinal tract; 5. Decay of a tumor of a rectum; 6. First days after operation on GIT organs; 7. Prolapse of the rectum. For the cleansing enema it is necessary: 1. An Esmarch’s irrigator (glass, enameled, rubber) capacity 1-2 L, with a tip (hand piece) and a tap; 2. Water with a temperature of 27-32º C, 1,5-2L. In predilection of a spasmed intestine - temperature of the water - 37-39 º C, in an atony - 18-20 º C; 3. Vaseline; 4. Support-rack; 5. Bedpen; 6. Bucket or basin; 7. Oil-cloth. If the state of the patient allows, the procedure of the cleansing enema will be carried out in a special toilet room, where there is a couch, support -rack for handing a Esmarch’s irrigator, wash-bowl. The patient following a bed regimen is given this procedure in his/her bed. For the procedure it is necessary: To set up the Esmarch’s irrigator on a support of a height of 1 m above the patient, to pour out some water at a proper temperature, and about 1-1,5L, to unclose (open) the tap, to fill in a rubber tube and tip with some water, to close the tap. For simplification of removing of the faeces use 25-50g castoric or olive oil, or 25g of shaving soap which can be added in the water. After that the tip with Vaseline is greased. The patient is laid on the left-hand side with the legs, pulled to a stomach; if the patient cannot turn, the procedure is carried out in a position with the patient on his back; a bolster (roller) is put under the patient’s pelvis. The buttocks are moved apart by 1st and 2nd finger of the left-hand with rotary movements a hand piece is carefully inserted into the anal hole; at first in a direction of the umbilicus 3-4cm, then parallely to the spinal column 8-10cm. In the case where there are folds of mucosa or hemorrhoidal, the hand piece is carefully introduced between them (Fig 15).

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Fig. 15. The cleansing enema

The tap is then opened. The liquid should flow gently from the flask. If the liquid does not pass from the flask, the position of the end-piece in the rectum should be changed slightly, or the pressure increased by raising the flask to a higher position. If the patient complains of pain, the flask should be lowered toslow down the rate of water outflow. If the end-piece becomes clogged with faeces, it should be cleaned and introduced again. If the faeces are hard, they should be removed from the rectum by a finger or a spatula. The administered liquid reaches remain parts of the large intestine to intensify peristalsis and to cause the urge to defecate. The patient should retain the administered liquid for 5- 10 minutes. Then the patient empties his intestine into a toilet. If the procedure is carried out in the bed it is necessary, to promptly give the patient a bedpan. The cleansing enema is considered to be effective, if some faeces masses are discharged with water within some minutes. If the clyster has not worked, the procedure can be repeated in some hours. After procedure tip should be separated from system and placed into 1% chloramines solution, then - be boiled during 15 min. An Esmarch’s irrigator is washed, wiped and kept in cabinet, which is in the room for carrying out of enemas. Application of purgative clysters (oil, hypertonic, emulsive) A purgative enema is prescribed for persistent constipation or intestinal paresis when the administration of large amounts of liquid is ineffective or harmful. Oil and hypertonic saline solutions are used. The purgative effect of an oil clyster is based on the fact that the oil envelops the faeces and facilitates its excretion. By the action of intestinal microflora and juice the oil is partially split and fatty acids, formed as a result of this process, have a weakening and irritating effect on the intestinal wall, which promotes a recommencing of a normal peristalsis. The indications for application of an oil clyster are:

19 1. Steady or atony constipation; 2. Inflammatory and ulcerative processes of the large intestine. For using the oil clyster it is necessary to take: 1. A rubber ballon capacity of 150-200ml; 2. Janet’s syringe; 3. Colonic tube; 4. Vaseline; 5. Oil-cloth; 6. Vegetable oil (corn, sunflower, olive). Before the procedure it is necessary to carry out the psychological preparation of the patient and to explain him, that after the procedure he should stay in bed for some time. It is better to give this procedure of some hours in the evening, so that the act of defecation may take place in the morning. Oil is warmed up in a water bath to a temperature of 37-38º C, then a rubber bulb or Janet’s syringe is filled with oil. An oil-cloth is spread under the patient. The patient is laid on the left-hand side with the legs, moved towards the stomach. The anal orifice is exposed and an oiled colonic tube is introduced into the rectum by rotary movements to a depth of 10-15cm. Janet’s syringe is connected with a tube and oil is inserted into the rectum. The patient must lie down quietly to keep the oil in a rectum. Emulsive clyster The emulsive clyster is applied in constipation to the seriously ill patients. You need 1 table spoonful of camomile is pour with one glassful of well boiled water. It is kept 15-20 minutes and then filtered. The yolk of an egg, teaspoon of sodium hydrocarbonate and 2 table spoons of Glycerine must be added to the tincture of camomile. This mixture is collected in a Janet’s syringe or rubber balloon and injected into rectum. Evacuation of faeces from an intestine will occur in 15-20 minutes. Hypertonic clyster A hypertonic clyster is indicative in: 1. Atonic constipation; 2. Paresis of an intestine after surgical interventions on the organs of the abdominal cavity. Contraindications for giving of a hypertonic clyster are: 1. Acute inflammatory and ulcerative diseases of the inner section of the intestine; 2. A fissure in the field of an anus. The action of a hypertonic clyster is osmotic character: for dilution of a hypertonic salt solution up to isotonic concentration in a lumen of the rectum through an intestinal wall, an intercellular fluid intensively enters and dilutes the faeces. Also, the strong saline solution stimulates peristalsis, and as a result of such combined action, in 20 minutes evacuation of faeces from the intestine occurs. A hypertonic saline enema consists of 50 - 100 ml of a 10 % sodium chloride solution or a 25 % magnesium sulphate solution. The hypertonic solutions

20 should be warmed up before administration. The patient should not defaecate for 15-30 minutes after the enema. Siphon enema A siphon enema is given when an evacuant enema and laxatives are ineffective to remove putrefactive material, poisons and toxic substances from the intestine and also for the diagnosis of intestinal obstruction. The absence of gas bubbles in the washings confirms the diagnosis of intestinal impatency. For siphon clyster the following equipment is needed: 1. 2 thick gastric tubes of length 1 meter with an inner diameter not less than 10 mm and connected to a glass tube and a funnel with the capacity not less than 1 L; 2. 10-12 litres of water of room temperature; 3. A jug or a mug; 4. A bucket for lavaged waters; 5. An oil-cloth, apron, Vaseline. The siphon clyster is a serious treatment for the patient, therefore it is necessary during the procedure to watch carefully the patient’s condition. The patient assumes the same position as for a cleansing enema. The tip of the rectal tube is coated with Vaseline and gradually inserted into the rectum to a depth of 20-25 cm. The funnel is held slightly above the patient’s body. Water is poured into the funnel from a jug and the funnel is raised 50 cm above the patient’s body. When the liquid level in the funnel descends to the funnel’s apex, the funnel is lowered over the basin and held in this position until the liquid containing intestinal material rises to its initial level. The liquid is then discarded into the basin. Clean water is poured into the funnel and the siphoning is repeated until the water returning to funnel is clear. After use, the funnel and the tubes are cleaned (Fig. 16)

Fig.16. A siphon enema

Medicamental clyster A medicamental clyster can be both local and general in action. The clyster of local action (medical mycroclysters) have anti-inflammatory and enveloping activity and their amount should not exceed 200 ml. They are utilized in inflammatory process of the large intestine. In clysters of local action oil (30-50 ml warm olive oil), starch (5g of starch is diluted in 5 ml of cold water and,

21 stirring, add 100 ml of boiled water) and others, can be used. These are antispastics, antibiotics, sulpha drugs, antiparasitary preparations, and some others. A tepid solution (50-200 ml) is administered by a rubber bulb (Fig. 17) or Janet injector provided with a 12-20-cm long rubber endpiece (Fig. 18). The patient should try to keep the administered medicine in the medicine in the intestine for at least 30 minutes. The medicinal solution should be given 20-30 minutes after an evacuant enema.

Fig. 17. Medicamental clyster

Fig 18. Medicamental clyster

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The medicinal clysters of general activity are given in cases, when it is impossible to introduce drugs through the mouth or parallely with it. In this method of introduction the medicines are promptly absorbed into blood through haemorrhoidal veins, bypassing (passing) the liver. For general influence on an organism small volumes of medicines (up to 200 ml) can be introduced in medical microclysters. For example, Chloral hydras (1 g of the drug is diluted in 25 ml of 0,9% solutions of a sodium chloridum and then add 25 ml of starch paste), apply in cramps and severe excitement to the patient. A drop enema, or simply drip, is used for giving a large amount (up to 2 litres) of isotonic solution of sodium chloride or glucose solution to treat intoxication, dehydratation, etc. The apparatus includes Esmarch flask rubber tubing, a dropper, a glass tube, and a rectal tube. The rectal tube has lateral openings. The rate of liquid administration is controlled by a clamp. The patient should lie on his back during the procedure. The solution in the Esmarch flask through the rectal tube is inserted into the rectum to depth of 20-25 cm. It is necessary to observe the rate of administration and temperature of the solution. Contraindications for all types of clysters are:  acute inflammatory processes in the area of the anus;  malignant tumors of the rectum in a stage of decay;  gastrointestinal bleedings;  acute abdomen.

Nutrition of critical patients Critical patients should be assisted in their meals. Weak patients should be helped to assume a convenient position so as not to become tired during meals. If the patient is unable to sit up in bed, he should be assisted into a semiprone position in an adjustable bed. His neck and chest should be covered with a napkin. Bedridden patients may be fed from special tables. Asthenic patients should be fed by nurse in small portions. Solid food should be cut into small pieces or crushed. Special cups with a spout are used to give liquid food and drinks. Parenteral nutrition. For persons who cannot eat or absorb enough from the normal gastrointestinal route when fed by tubes, parenteral support (intravenous feedings) may be provided. This is sometimes referred to as peripheral parenteral nutrition (PPN). Parenteral fluids that are given to enhance nutrition are introduced directly into venous system. These fluids usually contain glucose, amino acids, electrolytes, minerals, and vitamins. For persons in good nutritional status but with a temporary inability to absorb nutrients, solutions with amino acids and a low concentration of glucose may be administered for short periods through peripheral veins (PPN). About twice a week, lipid emulsions are given through a Y-tube connection into the intravenous line. However, in situations of major trauma or substantial damage to the gastrointestinal tract when long-term feedings are needed, more substantial parenteral nutrition may be necessary, and a central venous catheter is placed in a 23 large vein (usually the subclavian) that empties directly into the heart. This type of intravenous line allows the client to receive total parenteral nutrition (TPN). Total parenteral nutrition, or hyperalimentation, is the intravenous provision of total caloric needs, including both amino acids for protein building and lipid emulsions and high concentrations of glucose for calories.

GERIATRIC CARE Today, more people live to an old age than ever before. Although 40% of people over age 65 may occasionally require a stay in an extended care facility, only 5% of elderly people require long-term supervised care; the rest can maintain their independence. However, about 80% of elderly people have at least one chronic health problem – usually arthritis, heart or respiratory disease, hypertension, or impaired vision or hearing. These problems often occur simultaneously, straining the patient's and his family's ability to cope. The part of medicine studies the aging organism is called gerontology. Geriatrics is the part of gerontology which studies the illness of the elderly (60-74 years old) and senile (over 75 years old) people. Psychosocial, physiologic, and biological changes normally occur during aging. Age-related changes in body function may affect drug action and we must, improve compliance and avoid adverse reactions and loss or impairment of the urinary or anal sphincter control. Incontinence may be transient or permanent. Contrary to popular opinion, urinary incontinence is not a disease and not part of normal aging. It may be caused by confusion, dehydration, fecal impaction, or restricted mobility. It's also a sign of various disorders, such as prostatic hyperplasia, bladder calculus, bladder cancer, urinary tract infection, cerebrovascular accident, diabetic neuropathy, multiple sclerosis, spinal cord injury, and urethral stricture. It may also result from urethral sphincter damage after prostatectomy. What's more, certain drugs including diuretics, hypnotics, sedatives, anticholenergics, antihypertensive, and alpha antagonists, may trigger urinary incontinence. Urinary incontinence is classified as acute or chronic. Acute urinary incontinence results from disorders that are potentially reversible, such as delirium, dehydration, urine retention, restricted mobility, fecal impaction, infection or inflammation, drug reactions, and polyuria. Chronic urinary incontinence occurs as four distinct types: stress, overflow, urge, or functional incontinence. With stress incontinence, leakage results from sudden physical strain, such as a sneeze, cough, or quick movement. It overflow incontinence, urine retention causes dribbling because the distended bladder cannot contract strongly enough to force a urine stream. In urge incontinence, the patient cannot control the impulse to urinate. Finally, functional (total) incontinence results when urine leakage occurs even though the bladder to cognitive or environmental factors, such as mental impairment or lack of appropriate or timely care. Fecal incontinence, the involuntary passage of feces, may occur gradually (as it does in dementia) or suddenly (as does in spinal cord injury). It most commonly results from fecal stasis and impaction secondary to reduced activity,

24 inappropriate diet, or untreated painful anal conations. It can also result from chronic laxative use, reduced fluid intake, and neurologic deficit. Pelvic, prostatic or rectal surgery can also cause fecal incontinence as can medications, including antihistamines, psychotropic, and iron preparations. Not usually a sign of serious illness, fecal incontinence can seriously impair an elderly patient's physical and psychological well-being. Patients with urinary or fecal incontinence should be carefully assessed for underlying disorders (Fig.19-20).

Fig. 19. Care of the patients with the fecal incontinence Most can be treated – some can be cured. Treatment aims to control the condition through bladder or bowel retraining or other behavior management techniques, diet modification, drug therapy, and possibly. Corrective surgery for urinary incontinence includes transurethral resection of the prostate in men, repair of the anterior vaginal wall or retropelvic suspension of the bladder in women, urethral sling, and bladder augmentation. For urinary and fecal incontinence effective hygienic care is necessary to prevent skin breakdown and infection.

Fig. 20. Care of the patient with the urinal incontinence

25 The patient or his assistant must clean the perineal area frequently, and apply a moisture barrier cream. This controls foul odors as well. The psychological problems resulting from incontinence include social isolation, loss of independence, lowered self-esteem, and depression. If the patient has such a problem as constipation we can advise him to consume a fiber-rich diet, with raw, leafy vegetables (such as carrots and lettuce), unpeeled fruits (such as apples), and whole grains (such as wheat or rye breads and cereals). It is necessary to teach the elderly patient to gradually eliminate laxative use, because using laxative agents to promote regular bowel movement may have the opposite effect – producing either constipation or incontinence over time. Regular exercise helps to regulate bowel mobility. Even a non ambulatory patient can perform some exercises while sitting or lying in bed. Four of five persons over age 65 have one or more chronic disorders. This helps explain why elderly patients consume more drugs than any other age-group. Although elderly adults represent only 12% of the population, they take 30% to 40% of the prescription drugs issued. Drug therapy for elderly patients presents a special set of problems based on age-related changes. These changes affect drug metabolism, absorption, distribution, and excretion. The changes also have therapeutic compliance. Physiologically, aging alters the body composition and triggers changes in the digestive system, liver, and kidneys. As the body ages body structures and systems change. This affects how the body responds to medications. Some changes that commonly and significantly affect medication administration follow.

Body composition As a person grows older, his total body mass and lean body mass tend to decrease while body fat tends to increase. These factors affect the relationship between a drug's concentration and solubility in the body. Digestive system Decreases in gastric acid secretion and GI motility lead to the body's decreased ability to absorb many drugs well. This can cause problems with certain drugs – for example, digoxine, whose narrow therapeutic range is tied closely to absorption. Hepatic system Advancing age reduces blood supply, and certain liver enzymes become less active. As a result, the liver loses some of its ability to metabolize drugs. With reduced liver function come more intense drug effects, as higher levels of a drug remain in circulation. It increases the incidence of drug toxicity. Renal system Kidney function diminishes with age. This alone may impair drug elimination by 50 % or more. In many cases, decreased kidney function leads to increased blood levels of certain drugs. In turn, these changes may affect the drugs dosage and administration techniques. Even though the elderly patient receives the

26 optimum drug dosage, he's still at risk for an adverse drug reaction. Ongoing physiologic changes, poor compliance with the drug regimen, and greater drug consumption contribute to elderly patients experiencing twice as many adverse reactions as younger patients. In fact, about 40% of the people who experience adverse drug reactions are over age 60. Signs and symptoms of adverse drug reactions (such as confusion, weakness, and lethargy) are typically blamed on the disease. If the adverse reaction is unidentified or misidentified, the patient will probably continue taking the drug. To compound the problem, if the patient has multiple physical dysfunctions or adverse drug reactions, or both, he may consult several doctors or specialists who- unknown to one another - may prescribe more drugs. If the patient's drug history remains uninvestigated and if the patient takes additional non prescribed drugs to relieve common complaints (such as indigestion, dizziness, and constipation), he may innocently fall into a pattern of inappropriate and excessive drug use. Known as "polypharmacy", this pattern imperils the patient's safety and the drug regimen's effectiveness as well. Although many drugs can cause adverse reactions, most serious reactions in elderly patients result from relatively few drugs. Commonly, these reactions result from diuretics, antihypertensives, digitals glycosides, corticosteroids, sleeping aids, and nonprescription drugs. Finally, the elderly patient may have difficulty complying with his drug regimen. Hearing and vision deficits, forgetfulness, the need for multiple drug therapy, poor understanding of dosage and directions, and various socioeconomic factors (such as poverty or social isolation) combine to make treatment a special problem. Ensuring successful treatment requires involving family members, the pharmacist, and other caregivers in supervision and teaching tailored to the patient's needs. Common signs and symptoms of adverse reactions to medications include hives, impotence, incontinence, stomach upset, and rashes. Elderly patients are especially susceptible and may experience serious adverse reactions such as orthostatic hypotension, altered mental status, anorexia, dehydration, blood disorders, and tardive dyskinesia. Additional adverse reactions, such as anxiety, confusion, and forgetfulness may be dismissed as typical elderly behaviors rather than recognized as drug effects. Orthostatic hypotension Marked by light-headache ness or faintness and unsteady footing, orthostatic hypotension occurs as a common adverse response to antidepressant, antihypertensive, antipsychotic, and sedative medications. To prevent accidents, such as falls, warn the patient not to sit up or get out of bed too rapidly. Instruct him to call for assistance in walking if he feels dizzy or faint. Altered mental status Agitation or confusion may follow ingestion of alcohol or anticholinergic, antidiuretic, antihypertensive, and antidepressant medications. Paradoxically,

27 depression is a common effect of antidepressant medications. Anorexia This is a warning sign of toxicity - especially from digitalis glycosides such as digoxin. That's why the doctor usually prescribes a very low initial dose. Dehydration If the patient's taking diuretics, such as hydrochlorothiazide, be alert for dehydration and electrolyte imbalance. Monitor blood levels and provide potassium supplements as ordered. Oral dryness results from many medications. If anticholinergic medications cause dryness, suggest sucking on sugarless candy for relief. Blood disorders If the patient takes an anticoagulant, such as warfarin, watch for signs of easy bruising or bleeding (such as excessive bleeding after tooth brushing). Easy bruising or bleeding may be signs of other problems such as blood dyscrasias or thrombocytopenia. Drugs that may cause these reactions include several antineolpastic agents such as methotrexate, antibiotics like nitrofurantoin, and anticonvulsants such as valproic acid and phenytoin. A patient who bruises easily should report this to his doctor immediately. Tardive dyskinesia Characterized by abnormal tongue movements, lip pursing, grimacing, blinking, and gyrating motions of the face and extremities, this disorder may be triggered by psychotropic drug such as halopiridol or chlorpromazine. The nurse or family member must help the patient to take prescribe medications, to prevent any complications of the drug therapy. For that aim a plastic box with four section medication compartments marked ''breakfast'', ''lunch'', and ''bedtime'' helps of the patient to see whether he's taken all the medications prescribe for one day. The lids may also be embossed with braille characters if needed. Falls are a major cause of injure and death among elderly people. In fact, the older the person, the more likely he'll die of a fall or its complications. In people aged 75 or older, falls account for three times as many accidental deaths as motor vehicle accidents. Factors that contribute to falls include lengthy convalescent periods in elderly patients, higher risks of incomplete recovery, and increasing physical disability. Once impaired, equilibrium takes longer to be restored in elderly people than in younger adults. And naturally, loss of balance increases the risk of falling. Besides causing physical harm, injuries from falls can trigger psychological problems, leading to losses in self-confidence and hastening dependency and a move to a long-term care facility or nursing home. Falls may be accidental and caused by environmental factors, such as poor lighting, slippery throw rugs, or highly waxed floors. But frequently, falls result from physiologic factors such as temporary muscle paralysis, vertigo, orthostatic (postural) hypotension, central nervous system lesions, dementia, failing vision, or decreased strength and coordination. For fall prevention it is necessary:

28  to correct potential dangers in the patient's room. Position of the call light or bell so that he can reach it without getting out of bed. Provide adequate night-time lighting;  to place the patient's personal belongings and assistive aids – purse, wallet, books, tissues, urinal commode, cane or walker – within easy reach;  to instruct him to rise slowly from a supine position to avoid possible dizziness and loss of balance;  to lower the bed to its lowest position so the patient can easily reach the floor when he gets out of bed. This also reduces the distance to the floor in case he falls;  to advise the patient to wear nonskid footwear.

CARE OF PATIENTS WITH AGONY Dying ant its periods Death is irreversible stop of organism’s activity. States, which are border-line between life and death, are named terminal (Lat. terminalis - final). Such states include process of dying also. This process involves all organs and systems of organism gradually. There are several stages of dying. Preagonal state occurs on the background of severe hypoxia of internal organs. It is characterized by gradual oppression of consciousness, progressive respiratory and circulatory impairments (decrease of blood pressure, rapid breathing and cardiac contractions, which are changed to rare ones, etc.). Expressiveness and duration of preagonal period can be different. So, in case of sudden cardiac arrest (for example, due to severe cardiac rhythm disturbances in patients with acute myocardial infarction) preagonal period is absent nearly, whereas in gradual dying in case of many chronic diseases it can last during some hours. Preagonal period is ended by terminal pause (short stop of breathing). Its duration is from 5-10 sec. to 3-4 min. After it agonal period (agony) occurs. Agony (Gk agony - struggle) is characterized by short activation of mechanisms, directed to support of vital activity processes. A first some elevation of blood pressure, increase of cardiac rate, sometimes - short (till some minutes) recovery of consciousness due to disinhibition of subcortical centers are marked. Then seeming improvement of condition fast changes again into sharp falling of blood pressure (to 10-20 mm Hg), rare rhythm of cardiac contractions (to 20-40 per minutes), severe respiratory disorders with rare, short and deep respiratory movements, loss of consciousness. Pain sensitivity disappears, corneal, tendinous and skin reflexes are lost, general tonic convulsions are observed, involuntary urination and defecation occur, body temperature decreases. Duration of agonal period is from some minutes (for example, in acute cardiac arrest) to some hours and more (in slow dying), then apparent death occurs. Apparent death is reversible stage of dying, during which external manifestations of organism’s vital activity (respiration, cardiac contractions)

29 disappear, but irreversible changes in organs and tissues don’t occur yet. Usually duration of this period is 5-6 minutes. It is possible total recovery of organism’s vital activity during directed terms. After apparent death irreversible changes in tissues (at first in cells of cerebral cortex) occur. It causes condition of death (biological death), when it is impossible total recovery of function of different organs. Duration of period of apparent death depends on type of dying, its length, age of died person, body temperature in dying. So, by means of deep artificial hypothermia (lowering of men’s body temperature to 8-12º C) it is possible prolongation of apparent death’s condition to 1-1,5 hours. Coming of death is verified both to the stop of breathing and cardiac activity, and on the base of appearance of so-called “significant signs of death”: falling of body temperature lower than 20º C, forming of “cadaveric spots” in 2-4 hours after cardiac arrest (they occur due to blood accumulation in lower body parts), development of cadaveric rigidity (consolidation of muscular tissue). Stages of dying according to Kubler-Ross A dying client has a variety of opinions concerning death, and the client’s wishes should, if possible, be followed. Clients may choose to die at home, in a hospital or nursing, or in a hospice. The stages of dying, much like the stages of grief, may overlap, and the duration of any stage vary from as little as a few hours to as a period of months. The process varies from individual to individual. Some individuals may be in one stage for such a short time it seems a stage was skipped. Sometimes an individual returns to a previous stage. According to Kubler-Ross, the stages of dying are: 1) denial and isolation; 2) anger; 3) bargaining; 4) depression; 5) acceptance. Denial and isolation. In the denial and isolation stage, the client denies that he or she will die, may repress what is discussed, and may isolate self fro reality. The client may think, “They made a mistake in the diagnosis. May be they mixed my records with someone else’s”. Anger. The client expresses rage and hostility in the anger stage and adopts a “why me” attitude. “Why me? I quit smoking and I watched what I eat. Why did this happen to me?” Bargaining. The client tries to barter for more time. “If I can just make it to my son’s graduation I will be satisfied. Just let me live toll then”. Many clients will put their personal affairs in order, make wills, and fulfil last wishes such as trips, visiting relatives, and so forth. It is important to meet these wishes, if possible, because bargaining helps clients move into later stage of dying. Depression. In the depression stage, the client goes through a period of grief before death. The grief is characterized by crying and not speaking much. “I waited all these years to see my daughter gets married. And now A may not re here to see her walk down the aisle. I can’t bear the thought of not being there for the wedding

30 - and to see my grandchildren”. Acceptance. When the stage of acceptance is reached, the client feels state of tranquillity and peace. The client has accepted death and is prepared to die. The client may think, “I’ve tied up all those ends - made the will, made arrangements for my daughter to live with her grandparents. Now I can go in peace knowing everyone will be fine”. Conception about reanimation Potential reversible of agonal period and period of apparent death and possibility in a number of cases of total recovery of greatest functions of organism lead to necessity of work up of wide complex of measures, promoting to resuscitation of organism. Reanimation is use of complex of different measures for recovery of organism’s vital activity. Reanimation is carried out in many diseases and conditions: sudden cardiac arrest (in acute myocardial infarction, electrical injury, etc.), acute respiratory standstill (in closure of trachea by foreign body, drowning and others), organism’s poisoning by different venoms, severe traumas, loss of blood, significant acid-base disturbances, acute renal and hepatic failure, etc. Reanimation should not be carried out in following situations: when more than 8 minutes pass from moment of apparent death, if lesions of important for life organs (at first of brain) occur, if all compensatory reserves of organism are exhausted (for example, in last stage of malignant tumors, taking its course with extreme emaciation (cachexia). Reanimation is the most effective in those cases, when it is carried out in specialized departments, equipped by special apparatus. Now there are three types of reanimation departments: general reanimation departments, postoperative intensive care departments and specialized reanimation departments. Artificial ventilation and closed-chest cardiac massage Artificial ventilation is change of air in the patient’s lungs by means of artificial way with purpose of maintenance of gas exchange in case of impossibility or insufficiency of natural breathing. Necessity of carrying out of artificial ventilation appears in disturbances of central regulation of breathing (for example, in cerebral impairment, brain edema), lesion of nervous system and respiratory muscles, taking part in respiratory act (in poliomyelitis, tetanus, poisoning by some venoms), severe pulmonary diseases, (status asthmaticus, extensive pneumonia) and others. In these cases different instrumental methods of artificial ventilation (with use of automatic respirators) are applied widely. They allow to maintain gas exchange in the lungs during long period. Artificial ventilation often is measure of acute care in following states: asphyxia (suffocation), drowning, electric injury, heat stroke and sunstroke, different poisoning. In indicated situations artificial ventilation by means of so- called “expiratory methods” (from mouth into mouth and from mouth into nose) is used often. The most important condition of successful use of expiratory methods of artificial ventilation is previous maintenance of airways’ patency. Ignoring of this

31 rule is the main cause of ineffectiveness of use of artificial ventilation methods “from mouth into mouth” and “from mouth into nose”. Poor patency of airways most often is caused by falling back of root of tongue and epiglottis as result of relaxation of masticatory musculature and transfer of lower jaw in unconscious patient’s condition. Recovery of airway’s patency are reached by maximal throwing back head (its extension in atlanto-occipital joint) with moving forward of lower jaw so that chin occupy the highest position and by introduction of special bended artificial airway into patient’s pharynx through the mouth. During carrying out of artificial ventilation (Fig. 21) patient should be in dorsal decubitus; neck, thorax and abdomen of the patient should be free from pressing clothes (collar got unbuttoned, necktie is loosed, and belt got unbuttoned). Patient’s oral cavity got free from saliva, mucus, vomit mass. Then one hand is placed on parietal area of patient and other hand - under neck, and patient’s head is thrown back. If patient’s jaws are constricted closely, mouth is opened, moving forward lower jaw and pressing on its angles by index fingers.

Fig. 21. Technique of artificial ventilation

In case of use of method “from mouth into nose” person, providing aid, closes patient’s mouth, lifting a little lower jaw, and after deep inspiration carries out energetic expiration, clasping patient’s nose by lips. In use method “from mouth into mouth”, on the contrary, patient’s nose is closed and expiration is done into patient’s mouth, which should be covered by gauze or handkerchief preliminarily. Then patient’s mouth and nose are opened slightly, and after this manipulation passive expiration of the patient occurs. Person, providing aid, during this time takes away his/her head and does 1-2 inspiration. Movements (excursions) of patient’s thorax during moment of artificial inspiration and passive expiration serve as a criterion for correct carrying out of artificial ventilation. In absence of excursion of thorax it is necessary to ascertain and remove causes (poor patency of airways, insufficient volume of inflated air, slight sealing between reanimator’s mouth and nose or mouth of the patient). Rate of artificial ventilation should be 12-18 artificial inspirations per minute.

32 In emergency situations artificial ventilation can be carried out also by means of so called “hand respirators”. In correct use these methods of artificial ventilation are possible to maintain gas exchange in patient’s lungs during long time (to several hours). The main reanimation measures include also cardiac massage, which is rhythmic pressing of the heart, carrying out with purpose of recovery of its activity and supporting of circulation in organism. Now closed-chest cardiac massage is used mainly; open-chest cardiac massage, realizing by means of direct pressing of the heart, is used when necessity of its carrying out occurs during organs of thorax operation with opening of thoracic cavity (thoracotomy). During closed-chest cardiac massage pressing of the heart between sternum and backbone occurs. Due to this action blood passes from right ventricle into pulmonary artery and from left ventricle - into systemic circulation. It leads to restoration of blood circulation in brain and coronary arteries and can promote to renewal of independent cardiac contractions. Closed-chest cardiac massage is indicated in cases of sudden stop or sharp deterioration of cardiac activity, for example, in cardiac arrest (asystolia) or ventricular fibrillation in patients with acute myocardial infarction, electric injury, etc. Besides, the following signs are used as landmarks for beginning of carrying out of closed-chest cardiac massage: sudden stop of breathing, absence of pulse on carotids, accompanying by dilation of pupils, paleness of skin, loss of consciousness. Closed-chest cardiac massage usually is effective when it is begins during early term after stop of cardiac activity. Besides, its carrying out (by inexperienced person even) right after occurrence of apparent death often brings success more than manipulations of expert in resuscitation, carried out later 5-6 minutes after cardiac arrest. Directed circumstances cause necessity of good knowledge of technique of closed-chest cardiac massage and ability to carry out it in emergency situations. Before carrying out of closed-chest cardiac massage (Fig. 22) the patient is placed in dorsal decubitus on the firm surface (ground, couch). If patient is in a bed, he should be placed on the floor (in absence of firm couch) in such cases. Patient got free from street-clothes, his belt got unbuttoned (in order to avoid of trauma of liver).

33 Fig. 22. Technique of closed-chest cardiac massage

The palm of person, providing emergency cover, is placed on the lower third part of sternum; other hand is placed above it. It is important so that both hands were straightened in elbow joints and located perpendicularly to surface of sternum; both palms should be straightened maximally in radiocarpal articulations, i.e. with fingers, raised above thorax. In such position pressing on the lower third part of sternum is produced by proximal (initial) parts of palms. Pressing on the sternum should be carried out by means of fast pushes, and what’s more - hands should be taken away from sternum after every push. Force of pressing, necessary for displacement of the sternum (within 4-5 cm), is provided both by hands’ effort and by body weight of men, carrying closed-chest cardiac massage. That is why in case of position of patient on couch, person, providing emergency cover, should be standing on support; and in those cases when patient is lying on the ground or floor - on knees. Usually rate of closed-chest cardiac massage is 60 pressings per minute. If closed-chest massage is carried out parallelly to artificial ventilation (by two persons), it is necessary to try to do 4-5 pressings of the chest for one artificial inspiration. If closed-chest massage and artificial ventilation are carried out by one man, after 8-10 pressings of thorax he makes 2 artificial inspirations. Effectiveness of closed-chest cardiac massage should not be controlled rare than 1 time during minute. Besides, it is necessary to pay attention to appearance of pulse on carotids, constriction of pupils, recovery of independent breathing in the patient, elevation of blood pressure, diminishing of paleness or cyanosis. If medical apparatus and medicaments are present, carrying out of closed-chest cardiac massage is added by intracardial introduction of 1 ml of 0,1% solution of adrenaline (epinephrine) or 5 ml of 10% solution of calcium chloride. In cardiac arrest sometimes it is success for renewal of its action by means of sharp fist blow to center of the sternum. In revealing of ventricular fibrillation, defibrillator is used for renew of regular rhythm. In ineffectiveness of cardiac massage (absence of pulse on carotids, maximal dilation of pupils with loss of their reaction for light, absence of independent breathing) it must be stop, usually in 20-25 min. after beginning. Fractures of the ribs and sternum are the most often complication during carrying out of closed-chest cardiac massage. It is very difficult to elude of their appearance in elderly patients when thorax losses elasticity and becomes rigid. Lesions of the lungs, heart, ruptures of liver, spleen, stomach occur rarer. Technically correct carrying out of closed-chest cardiac massage, strict dosing of force of pressing to the sternum are promote to prevention of directed complicated.

The rules of behavior with dead body When a client dies, the nurse’s responsibilities include care of the client’s body, care of the family, and discharging specific legal responsibilities. The latter involve ensuring that a death certificate is issued and signed by a physician, labeling the body, and reviewing organ donation arrangements (if any).

34 The death certificate. Laws require that a death certificate be prepared for each patient who has died. The laws specify needed information. Death certificates are sent to local health departments, which compile many statistics from the information. The physician’s signature is required on the certificate, as well as that of the pathologist, the coroner, and others in special cases. The nurse’s responsibility is to ensure that a death certificate has been signed by the physician. Care of the body. After the client has been pronounced dead by a physician, the nurse is responsible for preparing the body for discharge. The body is placed in normal anatomic position to avoid pooling of blood, and soiled dressings are replaced and tubes are removed. If an autopsy is to be performed, tubes should not be removed. The eyes must be closed by gently pressing on the lids with fingertips. It is usually unnecessary and wash the body; the mortician generally attends to this. Some religions strictly forbid the washing, while others must have it performed by a special person. In cultures in which the family’s washing the body of the deceased is considered the last service a family can give a loved one, the family should be given the supplies needed and allowed to be alone in the room with the body. All the patient’s valuables must be collected to prevent loss. It is the nurse’s legal responsibility to place identification lags on both the shroud or garment the body is clothed in and on the ankle to ensure that the body can be identified even if it is separated from the shroud. The nurse should also place ensure that these are received by the mortician. Each tag should include the deceased patient’s name, room number, department, date and time of death, and physician’s name. The body is covered with a clean sheet, placed on the morgue stretcher, and taken to the morgue. The client’s body may have to be placed in the hospital’s morgue refrigerator if mortuary arrangements were not made before the client’s death. The importance of proper and complete identification cannot be overstressed. If the client died following certain communicable diseases, the body may require special handling to prevent the spread of the disease. Requirements for such handling are usually specified by local law and are contingent on the disease- causing organism, mode of transmission, and other characteristics.

Self-control material:

A. Test tasks to be done:

- with a single selective answer - I-st level:

1. What does term “terminal state” mean?

a) state of apparent death;

35 b) agonal period; c) period of dying; d) border-line state between life and death. 2. Why during carrying out of artificial ventilation it is necessary to throw back patient’s head? a) in order to placing of reanimator’s (physician’s) mouth to nose or mouth of the patient was more comfortable; b) in order to maintain patency of airways; c) in order to form good sealing (making air tight) between reanimator’s (physician’s) mouth and nose (or mouth) of patient during carrying out of artificial inspiration. 3. In which position should reanimator’s (physician’s) hands be during carrying out of closet-chest massage?

a) maximally straightened in radiocarpal and cubital articulations; b) slightly bended in cubital articulations and maximally straightened in radiocarpal ones; c) slightly bended in cubital articulations and some straightened in radiocarpal ones; 4. What amount of fluid for irrigation should be prepared for siphon enema?

a) 1-1,5 l; b) 50-100 ml; c) 5-6 l; d) 10-12 l. 5. What does term “parenteral nutrinutrition” mean?

a) nutrition, which realized by means of artificial way; b) introduction of any mixtures with purpose of feeding; c) introduction of any substances, escaping gastro-intestinal tract with purpose of feeding. 6. What is the basic role of functional bed?

a) it allows to give to the patient the most advantageous and comfortable for him position; b) it is possible easily and quickly to move it; c) it facilitates implementation of functions of medical personnel for care and medical treatment. 7. Can be bedsores at the forced sitting position of patient?

a) can not, as bedsores appear only in case of patient’s supine position, prone position or lateral recumbent position; b) can in the area of ischium tubercles;

36 c) can not, as at sitting position between bone appearances and mattress there is the large layer of subcutaneous fat and muscular tissue. 8. Why is it not impossible to inflate a bed-slipper too strongly?

a) it will break quickly; b) it will be dificult to give to it in a bed steady position; c) it must change the form at motions of patient. 9. The increased fragility and slight falling out of hair is marked in seriously ill patient. Does he need to comb a hair?

a) necessarily and very often; b) to try not to comb a hair generally; c) to comb as usually, but use large comb. 10. Why is it not appropriate to put more than 1-2 drops of medical solutions in eyes?

a) eye drops contain the drastic matters (substances); b) conjunctive cavity doesn’t contain more than 1 drop of solution; c) a plenty of liquid affects unfavorably to the state of conjunctiva. 11. What appliance is used for putting of drops in an ear?

a) syringe by a capacity 1 ml; b) pipette; c) Jane’t syringe; d) dropper; e) glass capillary. 12. How must the cleanness of mattress in a patient with irretention of urine and excrement be kept?

a) on a mattress lay an oilcloth and underlay its ends under a mattress; b) a muddy mattress is changed by clean one; c) a mattress is regularly cleared after every emptying of patient. 13. What is optimal correlation of rate of blowing and pressing on thorax during carrying out of artificial ventilation and closed-chest massage?

a) 1:1; b) 1:2; c) 1:3; d) 1:4; e) 1:5. 14. What position of the patient should be during carrying out of reanimation measures - artificial ventilation (from mouth to mouth) and closed-chest massage?

37 a) on the right side with head moved back; b) semisitting on wheelchair or tilting bed; c) dorsal decubitus. 15. How often the head of patient, being at bed rest, should be washed?

a) 2-3 times per a day; b) every day once; c) one time per two days; d) one time per a week; e) twice during month. 16. What is purpose of use of bedpans?

a) prophylaxis of bedsores; b) prevention of meteorisms; c) bowel emptying.

- with the selective group of right answers - II - nd level:

1. What symptoms are significant signs of death (biological)?

a) stop of breathing; b) stop of cardiac activity; c) appearance of “dead body spots”; d) decreasing of skin temperature lower than 20º C; e) appearance of cadaveric (postmortem) rigidity. 2. Contraindications for carrying out of reanimation:

a) late terms (more than 8 minutes) after appearance of apparent death; b) presence of organs’ lesions, incompatible with life; c) renal and hepatic coma; d) cerebral impairment with loss of consciousness; e) last stage of oncologic diseases. 3. How correctness of carrying out of artificial ventilation should be controlled?

a) during carrying out of artificial inspiration dilation of patient’s thorax must occur; b) during passive expiration of the patient collapse of thorax must occur; c) during carrying out of artificial inspiration “inflated” patient’s checks must be marked. 4. What are causes of insufficient effectiveness of artificial ventilation?

a) rate of artificial ventilation isn’t more than 12-14 per minutes;

38 b) absence of patency of airways; c) poor sealing between reanimartor’s (physician’s ) mouth and patient’s nose; d) insufficient volume of air, passed into patient’s airways. 5. What signs do testify about effectiveness closed-chest massage?

a) pulse on carotid arteries appears; b) pupils are constricted; c) pupils are dilated; d) blood pressure is elevated; e) independent breathing is recovered. 6. Indicate peculiarities of the course of diseases in elderly and old age patients:

a) combination of several diseases in the one patient; b) quiescent and poor-symptomatic course of diseases; c) susceptibility (inclination) to development of complications; d) significant expressiveness of clinical signs. 7. Indicate peculiarities of actions of medicaments in elderly patients in comparison to persons of young age:

a) faster absorption in digestive tract; b) slower absorption in digestive tract; c) faster excretion of medicaments from the organism; d) slower excretion of medicaments from the organism; e) more often development of side and toxic effects; f) more rare development of side and toxic effects. 8. What psychological peculiarities are typical for elderly and old patients?

a) often talks about past time; b) often talk about present and future time; c) decrease of memory for recent events; d) increased sociability; e) unsociability. 9. Name the main cases of disturbances of night sleep in elderly and old patients: a) diluvia in urologic diseases; b) sleep during day time; c) breach of treatment-protective regimen in in-patient department; d) sedative and sleeping drugs addiction; 10. Name the main causes of mischance accidents with elderly and old age patients:

a) visit of bathroom without medical personnel; 39 b) weak vision and diminished hearing; c) disturbance of coordination and imbalance; d) significant motion activity; e) poor illumination of wards and corridors; f) absence of devices for support in public places. 11. In what the negative consequences of long presence of elderly age patients in a bed are?

a) dangerous of development of stagnant signs in the lungs; b) possibility of occurrence of thromboembolism as complication; c) difficulty of urination and intensification of constipation; d) growth of signs of heart failure. 12. What measures do you use as the most important during care of elderly and old age patients?

a) care of skin; b) prophylaxis of constipation; c) control of urination; d) often thermometry; e) exercise therapy (curative gymnastics). 13. In case of which diseases of elderly and old age patients urinary incontinence can occur?

a) diseases of urinary bladder; b) chronic renal failure; c) cerebral impairment; d) senile dementia. 14. From which actions it is expediently to begin struggle against constipation in persons of elderly and old age?

a) vegetative purgative medicines intake; b) saline purgative medicines and castor oil intake; c) using of cleansing enemas; d) enriching of food ration by vegetables and fruits; e) increasing of patient’s motion activity. 15. What recommendation of diet can be given to elderly and old age patients? a) limitation of contents of light-assimilated in the food; b) limitation of contents of animal fats in the food; c) limitation of dietary salt consumption; d) diminishing of contents of proteins in the food; e) limitation of liquid consumption. 16. What measures should be carried out in meteorism?

40 a) introduction of colon (flatus) tube; b) limitation of products, rich for dietary fiber and starch in dietary intake; c) use of absorbed carbon, carminative herbs; d) gastric lavage; e) use of enzymatic drugs. 17. Indications for cleansing enemas: a) stool retention (constipation); b) poisonings; c) prenatal period; d) ulcerative lesions of large intestine; e) first days after operations on organs of abdominal cavity; f) preparation to endoscopy and X-ray examination of colon; g) intestinal bleeding. 18. What is purpose of using of saline enema? a) introduction of liquid in organism; b) emptying of intestine in atony constipation; c) emptying of intestine in spastic constipation; d) struggle against edemas. 19. In which cases siphon enema is used? a) for diagnostics of intestinal obstruction; b) for treatment of intestinal obstruction; c) for exsiccosis (fluid loss) with purpose of introduction of fluid; d) before medicinal enema; e) in poisoning. 20. What tip is introduced into rectum in case of siphon enema?

a) plastic or glass, length - 10-12 cm; b) rubber, length- 10-12 cm; c) rubber, length - 20-30 cm; d) thick gastric tube or intestinal tube. 21. Medicinal enemas are:

a) microclysters more often; b) used for introduction of medicines, which are good absorbing in large intestine; c) used for local influence on mucous membrane of rectum and sigmoid; d) used for treatment of intestinal obstruction. 22. In which cases artificial feeding of the patients by means of gastrostomy is carried out?

a) in disorders of swallowing after cerebral impairments; b) after esophageal operations; c) in inoperable tumors of esophagus;

41 d) in traumas of jaws; e) in case refusal to take food in psychical diseases. 23. In which cases artificial feeding of the patients by means of nasogastral tube is carried out?

a) in burns, inoperable tumors of esophagus and pharynx; b) after esophageal operations; c) in disorder of swallowing; d) in fractures of jaws; e) in unconscious conditions.

B. Tasks to be done:

Task 1. Patient C. is in bed. He can’t turn without assistance, to raise a head, hands, legs. How is such position named?

Task 2. The state of patient D. is grave. He is not allowed to move. How many times a day must patient’s underwear and bed clothes be changed?

Task 3. In a ward, where seriously ill patients are, it is necessary to realize ventilation, but many patients object to this. What is the tactic of nurse?

Task 4. Seriously ill patient complain of dryness in a nose, origin of scabs. How to help a patient?

Task 5. In seriously ill patient K. consciousness is lost suddenly, breathing and cardiac contractions stop. Skin covers are pale and cyanotic. Pupils are dilated. It was passed 3 minutes from moment of stop of breathing and cardiac contractions. What is name of this state? What measures should be carried out first?

42 Task 6. In patient R. consciousness and breathing are absent, pulse isn’t palpated, heart sounds aren’t auscultated, skin is pale, muscles are relaxed, lower jaw is loose-hanging, pupils are dilated and irresponsive to light. Body is cold, big cyanotic spots are on the shoulders and back. What is state in this patient? Is it reasonably carrying out of reanimation measures?

Task 7. Patient S. was admitted to reanimation department with loss of consciousness. Breathing is slow, shallow. During every inspiration the head leans back, mouth is opened widely. Pulse is thready, 40 beats per minute, blood pressure is 30/15 mm Hg, body temperature is 34,5 ºC. Involuntary urination occurs. Is it necessary to carry out reanimation measures to the patient and what kind of aid the patient does need in?

Task 8. The nurse placed bedpan under buttocks of patient, which is at bed rest. After defecation she raised pelvic part of the patient, took out bedpan, covered it by oilcloth, poured out contents in toilet, washed bedpan by hot water carefully and then washed it by 2% solution of chloramine. Was procedure carried out completely?

Task 9. After carrying out of cleansing enema the nurse washed tip by flowing water and placed it in cabinet near gastric tube. Is her action correct?

Task 10. Changing dirty linen to seriously ill patients, a nurse detects the redness on sacral bone. What elements of care are needed to the patient?

Task 11. Performing a morning toilet, a nurse paid attention, that in a patient in an external auditory meatus (passage-way) there are a lot of sulphur. How to get it rid of?

Answers for test tasks of the I-st level:

43 1 - d 7 - b 12- a

2 - b 8 - c 13- d

3 - a 9 - c 14- c

4 - d 10- b 15- d

5 - c 11- b 16- c

6 - a

Answers for test tasks of the II-nd level:

1 - c , d ,e 12- a , b ,c ,e 22- b ,c

2 - a , b ,e 13- a ,c , d 23- c , d ,e

3 - a , b 14- a , d ,e

4 - b ,c , d 15- a , b ,c

5 - b , d ,e 16- a , b ,c ,e

6 - a , b ,c 17- a , b ,c ,f

7 - b , d ,e 18- b , d

8 - a ,c ,e 19- a , b ,e

9 - a , b ,c 20- c , d

10- a , b ,c ,e ,f 21- a , b ,c

11- a , b ,c

44

Standards of right answers for tasks:

Task 1. Passive.

Task 2. Necessarily.

Task 3. The nurse must in a polite form explain for the healthful value of ventilation of wards to the patients, to conceal seriously ill patients by a blanket and realize ventilation.

Task 4. For this purpose it is necessary to do two wadding tourounda, to smear them by a Vaseline butter or glycerin. Carefully bring tourounda into both nasal passages (meatuses) and hold them there during 2-3 min. By circulating motions wadding tourounda together with scabs take out.

Task 5. Apparent death.

Reanimation measures - closed-chest cardiac massage and artificial ventilation should be carried out first.

Task 6. Death (biological).

No, it isn’t.

Task 7. No, it isn’t

Intensive medicament therapy should be given to the patient.

45 Task 8. No, it wasn’t. It is necessary to carry out hygienic treatment of perineum.

Task 9. No, it isn’t. Sterilized tips for enema must be kept separately in special container.

Task 10. During stage of formation of hyperemia affected places must be cleansed by quartz lamp, a skin is wiped by a camphor spirit, vinegar, eau-de-cologne or strong solution of potassium permanganate. Except for it, there are expedient next antibedsore measures: change patient’s position, observance of rules of hygiene of bed and linen, underlying of rubber circle, on which pillow-case dresses, under sacrum and coccyx. Task 11. It is necessary carefully to delete sulphur, that accumulated in an external auditory meatus (passage-way) by a wadding tampon, preliminarily instilled 2-3 drops of 3% solution of hydrogen peroxide in an external auditory meatus (passage-way).

Literature recommended:

Main Sources:

1. Clinical Nursing Skills and Techniques: basic, intermediate and advanced. The C.V.Mosby Company, 1986.- 1296 p. 2. Clinical Skills and Assessment Techniques in Nursing Practice. Scott, Foresman and Company, 1989.- 1280 p. 3. Nursing interventions and clinical Skills. Mosby – year Book, Inc., 1996.- 813 p. 4. Nursing Procedures: Student Version. Springhouse Corporation, 1992.-788 p. 5. Polskaya L.V. Nursing procedures in therapeutic practice.- Simferopol: Universum, 2004. - 192 p. Additional ones:

1. Гребенев А.Л., Шептулин А.А., Хохлов А.М. Основы общего ухода за больными: Учеб. пособие.- M.: Медицина, 1999.- 288 с. 2. Нетяженко В.З., Сьоміна А.Г., Присяжнюк М.С. Загальний та спеціальний догляд за хворими.- К.:Здоров’я, 1993.- 304 с. 3. Щуліпенко І.М. Загальний і спеціальний медичний догляд за хворими з основами валеології/ Навчально-методичний посібник для студентів медичних вузів і учнів медичних ліцеїв. - К.:Кий, 1998.- 384 с.

Informational resources:

1. Leslie Jennings. Educational movie. “ Roles and Functions of the Nurse”./ Leslie Jennings.2014 2. Касевич Н.М. Основи медсестринства в модулях: навч. посіб. – К.: Медицина, 2009

46 3. HEAT Inc., Health Education & Training . Educational movie “Ethical Issues In Nursing -- Respect: Dignity, Autonomy, and Relationships” /2010 Internet resourses:

1. http://study.com/academy/subj/science/health-and- nursing.html

2. http://www.moz.gov.ua/ua/portal/dn_20130601_0460.ht ml 3. http://www.nursingworld.org/nursingstandards

Methodical instruction is composed by lecturer Ye. Petrov.

Methodical instruction is revised and approved again

At the Chair of Propaedeutics of Internal Medicine with Care of Patients meeting

On “___” ______200__ year.

Protocol №

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