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Home , Enteral administration, Intradermal injection, Medical thermometer, Oxygen cocktail

The Ministry of Health of Ukraine Ukrainian Medical Stomatological Academy

Approved at the Department of Propaedeutics to Internal with Care of Patients meeting on 09 10 2018 Protocol No4 The Head of the Department Professor Yu. Kazakov

METHODICAL INSTRUCTION FOR STUDENTS’ SELF-PREPARATION WORK

Educational discipline Nurse practice Module No 1 Enclosure module No 1 Topic Duties and actions of ward and procedural nurse of therapeutic department. Year 3 Faculty medical

1. The topic basis:it is very important to know duties and actions of ward and procedural nurse of therapeutic department. Great attention must be given to organization of work of ward and procedural nurse. 2. The concrete aims:  To explain term “lookout post”  To represent documentation, which is filling in by nurse  To explain rules of thermometry and measurement of blood pressure and pulse  To explain rules of maintenance of patients by preparations  To represent documentation of manipulation room

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 structure of the main systems of organism. 2.Physiology To know physiology of the main system of organism, mechanisms of . 3. To know classification of the according to mechanism of therapeutic action, place of action. Doses of medical preparations.

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. Pulse It is rhythmical vibration of the arterial wall caused by the heart contraction. 2. Arterial hypertension It is elevation of systolic pressure over 140 mm and of diastolic over 90 mm Hg 3. Arterial hypotension It is a drop in the systolic pressure below 110 mm and of diastolic below 60 mm Hg

4. lookout post It is the workplace of ward nurse. 5.Venipuncture It is transcutaneous introducing of the needle in the vein 6. Infusion therapy It is therapy by means of intravenous infusions. 7. It is parenteral method of medicaments’ introduction by means of and needles usually.

4.2. Theoretical questions to be answered before class: 1. Name the functional role of nursing lookout post. 2. Name the medical documents of ward nurse and nursein charge of injections and other medical procedures (procedural nurse) of therapeutic department. 3. What are modern methods of measuring of body temperature ? 4. What is ? 5. Tell about palpation of pulse on radial artery. 6. What properties of pulse do you know? 7. List vessels, which can be palpated. 8. What methods of measuring of blood pressure do you know? 9. Tell about auscultatory method of measuring blood pressure by N.Korotkoff. 10. Name “five rights” in administering a drug. 11. What treatment is called “etiotropic”? 12. What treatment is called “pathogenetic”? 13. What treatment is called “symptomatic”? 14. What does “therapeutic dose” mean? 15. What dose “toxic dose” mean? 16. Name the rules of keeping medicinal preparations. 17. Name classification of the medications depending on their route. 18. Name routes of administration for parenteral medications. 19. Name topical preparations. 20. What are methods of sterilization of syringes and needles? 21. What purpose of use of intradermal injections? 22. What places are the most convenient for giving subcutaneous injections? 23. What places are the most convenient for giving intramuscular injections? 24. Why are intravenous injections more responsible manipulations than subcutaneous and intramuscular ones

4.3. Practical work (tasks), which should be performed during class: 1. To take part in work of the ward and procedural (sister in charge of injections and other medical procedures) nurses. 2. To fill in documentations of ward and procedural nurse. 3. To take part in work of procedural (sister in charge of injections and other medical procedures) nurses, giving injections particularly 4. To fill in documentations of procedural nurse.

The contents of topic: Text Professional duties of ward nurse: 1. Careful fulfilling of all administrations of phisician,filling in the administration list accordingwith fulfilling . 2. Preparation of patients for diagnostic examinations (x-ray, endoscopy and others ). 3. Collection of material for examinations (blood, urine, feces) and sending it to the laboratory. 4. Looking for transporting of patients to different diagnostic rooms. 5. Control for providing measures according to sanitary and hygienic regimen and observation of the personal hygiene in patients with serious diseases. 6. According to patients’ feeding: a) drafting of a la carte requirement;b ) control for maintenance of proper diet by the patients ; c) feeding of seriously ill patients; d) control of products, brought by the relatives of patient. 7. Taking bodytemperature (in the morning and in the evening; data recording in a temperature chart). 8. Obligatory presence during phisicians’rounds, accounting to him/her about all changes, that ocurred in the state of patient for a last day, receiving new prescriptions. 9. Hospitalization of patients, verification of rightness of conducting of their sanitization , acquaintance of patient with the rules of internal order. 10. Measuring of arterial pressure, pulse rate, breathing rate, day's diuresis and report of these data to the physician. 11. Correct estimation of the state of patient and giving him/her emergency aid, and calling a doctor if it is necessary. In emergency situations a nurse must give first premedical aid (artificial respiration, indirect massage of heart, and others ). 12. Careful filling in medical documentation. 13. Control for work of junior medical personnel (junior nurses, workers of feeding room). Nursing lookout post and its functional role Nursing lookout post is the workplace of ward nurse. It may include 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: 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) ; 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 Fig.1. Nursing lookout ; d) the devices of patients care; e) post. disinfecting ; f) dressing material.

3. Small table, where drums with sterile material (by cotton wool, bandages) are, jar with disinfecting (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 , 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.

Documents of ward nurse: a) sheet of the medical administration, which is signed by a medical sister after their fulfilling; b) temperature charts; c) journal for passing of duties; d) journalfor movement of patients in the department; e) journalfor registration of drugs; f) journalfor registration of patients with the high temperature of body; g) a la carte requirements to the feeding room ( canteen ) of (in two copies); h) journalfor requirements of medicines; i) journalwith the lists of patients who need any laboratory or instrumental research; j) journalfor registration of list of patients which need consultation of doctors-specialists. 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 temperature of body 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, bed-slippers. 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 medical sister at a morning conference in the department is very important At a lookout post reception and passing of duties are journalized, in which nurses append the signatures about the reception and passing of duty. 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 and vagina – 37,3-37,50С. The lethal (mortal) maximal level of rise of temperature is over 42,50С, minimum – below 330С. There are irreversible violations of exchange of matters and structure of cells, thatincompatibly 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 is necessary so that all 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 oncea week (in the case of necessity, for example, at adiposity, daily or in a day). After every taking ofbody 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. 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.2).

Fig. 2.Palpation of radial artery.

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 mmabove 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. 3).

Fig. 3. 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 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.

Professional duties of sister in charge of injections and other medical procedures (procedural nurse) As a rule, they are experienced and skilled specialists who perform the special medical manipulations: intravenous injections, taking of blood from a vein for the analyses. They can help to doctor during the performing of the special procedures, for example, blood transfusion, pleura or abdominal punctures. Document of procedural cabinet: a) journals 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) journals 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. 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 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 (, 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 . The following methods of administration of medicinal preparations are distinguished: enteral (intestinal), external, parenteral, and by . 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 ( 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 ) (Fig.4).

Fig.4. Sublingual and buccal medications

-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 ), 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.

Fig.5. Parenteral medications

Routes of administration for parenteral medications (Fig.5) include the  subcutaneous route:administration into subcutaneous tissue, under the skin;  intradermal route:administration under the epidermis, into the ;  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, , and small intestine ). The two forms of oral medications are solid and . Solid forms. Solid forms of medication include tablets, capsules, and . (Fig. 6). Tabletsare solid forms of medicinal compounds measured and shaped to a specific dosage and form by the manufacturer. Prolonged-acting (sustained-release) tablets are oral medications specially formulated for gradual absorption. Fast-acting tablets may contain substances such as lactose that speed absorption in the stomach. Entericcoated tablets are oral medications with a hard surface that impedes absorption Fig.6. Solid forms of medication until the medication reaches the small intestine.Some tables must be chewed,whereas other are swallowed whole.

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 (water or juices) before are called powders. Many powders are sold in bulk and must be measured and diluted immediately before administration. Liquid forms. Liquid medications include , 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 is left standing. Therefore, suspensions, such as and magmas ( thick milky suspensions of an inorganic substance), must be shaken before each administration. 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, 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 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). 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 ) 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. or are used for rectal administration of medicines. (Fig.7). Rectal suppositories are shaped like small cigars or cones, 1-1,5 cm in diameter, and are 2,5-4 cm long. A weights 1,1-4 g. When inserted into the rectum, the suppository base has to overcome the resistance of the sphincter muscles.The base material should therefore be solid at normal temperature but melt and dissolve at the temperature of the body, so Fig 7. Rectal suppositories that the active substance can be absorbed by the rectal mucosa. Commonly used bases are 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. Preparations. Topical medication come in different forms, such as: are suspensions of insoluble in water or ingredients dissolved in a thickened liquid ( e.g., calamine ). Creams are oils dispersed in 60 to 80 per cent water to form a thick liquid or soft solid ( e.g., antifungal ). 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 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.

Method of taking blood for general blood analysis

It is necessary to carry out examination of blood at the same time before food intake.The blood is taken from IV finger (ring finger) of the left hand. Before prink finger is disinfected and degreased, rubbing it with cotton, moistened by alcohol and then - by ether (or their mixture). Puncture is carried out by sterilized scarificator or Francke’s needle with changeable sterilized blades. Prink usually is performed into tip of terminal phalanx’ pulp on the depth 2,5-3 mm.First drop, obtained after prink, is taken by filter paper or cotton, moistened by ether. There is the following sequence of taking blood for research: for determination of ESR, Hb, then - for counting of leukocytes, erythrocytes; nurse makessmears. After blood taking finger’s pulp is wrapped by cotton, moistened with ether or alcohol, and pressed to the palm for stop of bleeding.

Blood sugar analysis It is independent analysis (although it can be taken passingly during research of general blood analysis or biochemical blood analysis). Blood for carrying out of analysis must be taken only from vein and only on an empty stomach, and, what’s more, it must be not more than 8 hours from last food intake. Taking of venous blood can be carried out both from finger or vein.

Bacteriological blood research  For bacteriological inoculation it is necessary to take blood from peripheral vein, constant catheter can’t be used as it can be with bacterial pollution  Necessary conditions – presence of sterile gloves of clear hands. Place of venepunction must be treated with 2% iodine solution or other antiseptics. In 1-2 minutes iodine must be removed with 70% alcohol, skin must be dry. Cover of bottle with medium, where blood must be got in, also must be disinfected.  Blood is taken by means of sterile and needle without any contact of hand with place of puncture.  Blood is got in bottle with culture medium through rubber plug, closing it. Don’t pull out plug from the bottle!  If blood is taking for carrying out of several analysis, firstly – into cultural medium.  Blood culture must be added with label with information about patient and sent to the laboratory immediately. If blood taking occurs after finishing of laboratory work, bottles must be placed in thermostat at the temperature +37 ° C.

Injections Injections are given by means of syringes and needles usually. Syringes of different types ( “Record”, Luer, Gane are shown in Fig.1 ) consist of cylinder and sucker. They have different capacity ( from 1 to 20 sm3 and more ). Syringes for injection of tuberculine are thinnest ( one point is 0, 02 ml ). There are special syringes for injectionof insulin; points on the cylinder of thessyringes are marked in units of insulin. Needles, using for injections, have different length ( from 1,5 to 10 sm and more ) and different diameter of open space( from 0,3 to 2 mm ). They must to be sharp. Now so called non-needle injectors are used. They allow to injectintradermaly, subcutaneusly and intramuscularly the medicine without using needles. Fig.1. Types of syringes and needles. Syringes and needles, which we use for injections, must to be sterile certainly. Different methods of sterilization are used for destruction of microbe flora. They are based on effect of certain physical factors. Sterilization of syringes and needles in the autoclaveby means of saturated water steam under pressure 2,5 kg/sm2 and temperature 1380 C and sterilization in dry-air sterilizer by dry hot air are the most optimal and effective methods. Up to now sometimes boiling of syringes and needles is used in daily medical practice. But this method doesn’t secure absolute sterilization as some viruses and bacteria don’t perish besides. In this connection, non-permanent syringes and needles, which secure effective protection from SPID-infection, hepatitis B and C, are ideal. Sterilization by boiling supposes observance of number of rules and certain succession in processing of syringes and needles. After carrying out of injection, syringe and needle are washed by cold flowing water in order to remove the remains of blood and medicine. Needles and syringes in disassembled state are placed for 15 min. in hot ( 500 C ) washing solution , prepared on the basis of50 g washingpowder, 200 ml perhydrol for 9750 ml water. After careful washing in this solution with using “wire brushes”or cotton- gause tampons syringes and needles are rinsed out in flowing water again. Then tests for exposing of tracesof blood and washing substance in the needles and syringes are caried outselectively with purpose of checking the quality of processing. Presence of traces of blood is determined by means of benzidine test. For this purpose some crystals of benzidine are mixed with 2 ml 50% acetic acid solution and 2 ml 3% hydrogen peroxide solution. Some drops of this solution are brought in syringe and passed through needle. Appearance of green colour is evidence of presence of traces of blood in instruments. In thescauses syringes and needles need of repeated processing in order to avoid transmissionof different diseases ( for example, serous hepatitis, SPID ). Traces of washing substance are exposed by means of test with fenolphtalein. Basic reaction, which is gaven by washing solution, causestheappearance of rosy color after addition of some drops of 1% fenolphtalein solution. Boiling of syringes and needles is carried out in sterilizer.Syringes in disassemble state are wraped a gauze serviette, put together with needles, mandrins, forceps, retractors on its metallic grating (Fig.2 ); flooded with distilled or boiled water and boiled during 45 min. Then sterilizator’s cover is taken away and it is put on the table by external surface. Retractors are took out by sterile packer. Sterilizator’s netis raised by retractors and placed across. Syringe is takenbyforceps; needle is put and fixed by forceps too (Fig.3).

Fig.2.Laying of syringes in Fig.3. Succession of assemblage of syringes. sterilizator

Now in accordance with active instruction boiling as method of sterilization isn’t usedin medical institutions ( exept that cases, when it is impossible to use other methods of sterilization because of some reasons). Boiling gave up one’s place to sterilization in dry-air sterilizer and autoclave. Atsterilization by hot air in dry-air sterilizer (at temperature 1800 C during 1 hour) and by water steam in autoclave(during 20 min.) after before-sterilization processing dry syringes (in dissamble state !) and needles are put in packets from special paper (craft-packets). Syringe capacity and date of sterilization are indicated on packets. Packets are put in dry-air sterilizer or steam sterilizer. In the first case control of sterilization is realizedwith the help of sucrose, which on reaching of required temperature is converted from white crystalline powder into dark-brown mass; and in the second case – with the help of benzoicacid, its crystals are exposed fusion at the temperature of sterilization. Before takingdrug in syringe from bottle or ampoule, it is necessary to control its name and to satisfy that preparation is ready. The neck of ampoule or capofbottle are wiped by spirit, ampoule is opened. After this contents of ampoule are taking into the syringe by individual needle. Then this needle is took away and another is put on. With its help injection is carried out. If it is necessary to give an injection in the ward, syringe with taking medicine and cotton rolls, moistened by spirit, are brought on sterile traythere.

Intradermal injections Intradermal injections are used with diagnostic purpose for carrying of tuberculin test Mantoux, different allergic tests and during initial stages of local anesthesia. For giving intradermal injection internal surface of forearm is used usually. It is necessary that needle (it’s advisable short) is syringed in the skin in the small depth (to disappearance of its open space). After this action - content of syringe is injected under acute angle. If technique of giving of injection is correct, we can see tubercle as“lemon peel” on the place of the intradermal injection.

Test on tolerance to antibiotics 1000 Units of antibiotic, dissolved in 0,1 ml of isothonic solution of sodium chloride, are injected in internal surface of forearm. For control isothonic solution of sodium chloride are injected in same area of oppositeforearm. Positive is test, if reddenand swelling are appeared on the place of giving of antibiotic in a some minutes.

Subcutaneous injections Medicines with good absorption in friable subcutaneous fat are injected by means of subcutaneous injections. The most convenient places for subcutaneous injections are external surface of shoulder and thigh, subscapular area; for injecting some medicines (for example, heparin) – lateral surface of abdominal wall(Fig.4). At first the skin is treated by cotton rolls with spirit carefully. Then cutaneous fold is formed by left hand. Ready syringe is took by right hand. After this needle is syringedapproximately in 1/3 its length in base of a triangle, which is made. After puncture of the skin the syringe is put in left hand and syringe’s content is injected Fig. 4. Body areas for giving of slowly. Then a needle is drawn out subcutaneous injections. quickly. The place of injection is wiped by spirit again and pressed by cotton roll.(Fig.5 ).

Fig.5. Technique of subcutaneous injections. Intramuscular injections Medicines, injected intramuscular, are absorpted more quickly than at subcutaneous injections. The best places for giving intramuscular injections (there is well developed muscular layer )are: upper- external quadrant of buttock, front-external surface of thigh, subscapular area (Fig. 6 ). At carrying out of intramuscular injections syringes with needle (its length is 8-10 sm, its open spase is wide ) are placed perpendicularly to skin surface and needle is syringed in the depth of 7-8 sm. In the meantime skin around place of puncture is pressed by left hand. (Fig. 7). It is necessary draw off to oneself piston of syringe before injecting of medicine directly in order to be sure that needle didn’t get into Fig.6. Body areas for giving blood vessel. intramuscular injections. Account of dose and giving of antibiotics Antibioticsare produced in special bottles in the form of powder of certain quantity (in gramm) or unites of activity (UA). For dissolving of antibiotic sterile 0,25% or 0,5% solution of novocain or isothonic solution of sodium chloride are takinginto the syringe, which has capacity of 10 ml (1 ml of solution for every Fig.7. Technique of 100000 UA of antibiotic). Internal part of metallic intramuscular covers is taken off bottle by nipple, rubber stopper is injections. wiped by ethyl spirit and punctured by sterile injection needle, which are connected with syringe with solvent. And concentration of antibiotic in 1 ml is defined from this quantity. After total dissolving of antibiotic, bottle is turned upside-down and necessary dose of antibiotic is taking by inverted motion of piston.

Intravenous injections and drop infusions Intravenous injections are given by means of venipuncture (transcutaneous introducing of the needle in the vein) more often, by means of venisection - more rare. Intravenous injections are more responsible manipulations than subcutaneous and intramuscular ones. They are performed by speciallyinstructed nurse or physician usually as concentration of medicinal substances in the blood after intravenous introducing increasesmore quickly, than in case of use of other methods of introducing of medications. Mistakes during giving of intravenous injections can lead to very serious consequences for the patient. Veins of cubital flex, superficial veins of forearm and manus, sometimes - veins of lower extremities are used for intravenous injections more often. During performing of venipunction small oilcloth pill is placed under elbow of straightened hand of the patient for maximal extension position of the hand. Tourniquet is appliedabove place of supposed puncture (cross-clamped must be only veins, and circulation in arteries must be kept) (Fig. 3). For increasing of filling of the vein, it is necessary to propose to the patient several times to compress and to unclenchmanus. Skin cover in the injection place must be treated by spirit carefully. It is reasonably some to tighten skin of cubital flex by fingers of the left hand. It gives possible to fix the vein and decreases its mobility. Venipuncture is carried out in two stages: at first the skin is punctured and than - vein. In case of well-developed veins puncture of the skin covers and wall of the vein can be performed simultaneously. Correctness of hit of the needle in a vein is defined as appearance of blood drops from the needle. If the needle is connected with syringe already, for the control of its position it is necessary some draw of oneself piston of syringe: appearance of the blood in syringe will confirm right location of the needle. After this tourniquet, applied before, is loosened and medicinal substance is introduced in a vein slowly.

Fig. 8. Technique of intravenous injections.

After removal ofneedle and secondary treatment of the skin covers by spirit place of injection is pressed by sterile cotton roll or pressed bandage is applied on it during 1-2 minutes. Intravenous infusions are used for introduction of large quantity of different solutions (3-5L and more); they are the main method of so-called infusion therapy. Intravenous infusions are used in those cases when it is necessary to recover volume of circulated blood, to normalize water-electrolytic balance and acid-base state of organism, to remove signs of intoxication in severe infectious diseases, poisoning. If it is necessary quickly to introduce medical substance (in shock, collapse, severe haemorrhage), streamed intravenous infusions are used. If medical preparation must introduce into the blood stream slowly, drop infusion must be used. In those cases when question about long (during some days) introducing of large quantity of solutions arises, catheterization of vein (subclavicular more often) or venisection are used. Intravenous infusions are performed by means special system for drop introduction. From the point of view of observance of rules of aseptic and antiseptics it is optimally to use systems of throwaway. Systems of none expendable using are less convenient as they need sterilization in autoclave. Each system in collected state consists of vial with preparation necessary for infusion, short tube with air filter and needle for entering of air into vial, dropper with filter and two tubes, forceps, puncture needle, rubber transitiontube, connecting tube of dropper with puncture needle (Fig. 9).

Fig. 9. Use of system for intravenous drop infusions.

Taken away metal cup from the vial, preliminary wiped it by spirit, it is introduced short needle of the dropper (through it than fluid from vial will be flow) and long needle of artificial airway tube (through which air will be enter in the vial) in the vial. Forceps is applied on tube before dropper; vial is turned upside down and is hanged on the special support abovethe bed at the height 1-1,5m. Besides, we must follow with one’s eyes for end of long needle (artificial airwaytube), which must be in the vial above level of fluid. Dropper is filled by solution in the following way: tube, coming to puncture needle, is raised so that dropper (in turned state) should be on the same level with vial. After taking away of forceps fluid from vial begun flow into the dropper. When it is filled approximately by half, the end of the tube with puncture needle is come down. And fluid will be filling this tube, forcing out air. After forcing out of all air from the system, forceps is applied on the tube (near puncture needle). After puncture of a vein system is connected to puncture needle and necessary rate of entering of fluid (usually 50-60 drops per minute) is established. Infusion is ended when fluid stops to enter from vial to dropper.

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

1. What purpose before measuring of temperature is inguinal pit recommended dry with? a) fromthe hygienical reason; b) in order to thermometer was in morefirm position; c) 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. When measuring of temperature in a rectum is used? a) intestinal bleeding; b) piles; c) tumor of rectum; d) diarrhea; e) exhaustion of organism. 6. 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. 7. Name general signs of solutions, lotions and tinctures: а) all they are used for enteral administration; b) all they are dosed in tea-spoons or table-spoons; c) all they are in same aggregative state. 8. What method of drugs (medicine) introduction is called “parenteral” ? a) mouth route of medication; b) any method of medication, different from the oral route; c) topical route of administration; d) method of medication by means of injection; e) sublingual medication. 9. In what cases are medications administeredenteralyafter a meal ? a) if theyirritate mucous membrane of stomach ; b) if they take part in processes of digestion; c) if they are destroyed by hydrochloric acid of gastric juice and peptic enzymes; 10. Name the enteral medications: a) sublingual; b) intramuscular; c) intravenous; d) optic; e) otic. 11. Name the parenteral medications: a) nasal; b) vaginal; c) rectal; d) pulmonary; e) subcutaneous. 12. Name the topical medications: a) suspensions; b) emulsions; c) elixirs; d) tinctures; e) suppositories. c) remains of washing substance on the syringe; d) rosy colour is colour of reagent. 13. 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. 14. What is sequence of examination of arterial pulse? a) rhythm, rate, synchronization, filling, tension; b) rate, rhythm, synchronization, filling, tension; c) synchronization, rhythm, rate, tension, filling; d) filling, tension, rate, rhythm, synchronization; e) tension, filling, rate, rhythm, synchronization. 15. 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. 16. 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. 17. Who proposed auscultatory method of determining of arterial pressure? a) Riva-Rochi; b) Lang; c) Korotkoff; d) Traube; e) Vinogradov. 18. Name the parenteral medications: f) nasal; g) vaginal; h) rectal; i) pulmonary; j) subcutaneous. 19. After passing of benzidine reagent through syringe and needle, colour of reagent was green.What is appearanceof such colour of reagent about? а) presence of remains of medicines in the syringe; b) presence of remains of blood in the syringe; c) syringe isclean chemicaly; d) there are traces of sodium hydrocarbonatis in the syringe. 20. Some drops of 1% spirit solution of phenolphthaleinare put on internal part of the syringe, which was soaked in the washing solution and rinsed out in flowing water.What is appearance of rosy color evidence about? a) presence of remains of blood in the syringe; b) presence of remains of vitamin B12 after its injection on the syringe; c) remains of washing substance on the syringe; d) rosy colour is colour of reagent. 21. What is the duration of sterilization of syringes and needles in the dry-air sterilizer? а) 45 min.; b) 1 hour; c) 1,5 hour; d) 2 hour. 22. What is the duration of sterilization of syringes and needles in autoclave? a) 20-30 min.; b) 45-55 min.; c) 1 hour- 1,5 hour. 23. It is necessary to make test on sensitivity to penicillin to the patient. How many units of antibiotic’s activity we must give intradermaly? а) 500 Units; b) 1000 Units; c) 2000 Units; d) 3000 Units; e) 4000 Units. 24. What is depth of syringe of injection needle at carrying out of intradermal injection? а) 0,1-0,2 mm; b) 0,3-0,4 mm; c) 0,6-0,8 mm; d) 0,9-1,0 mm. 25. In what cases we can see changing as “ lemon peel” on the skin? a) at rubbinginpeelintheskin; b) at jaundice; c) at use ofacrichine; d) at prolonged use of carrot; e) at carrying out of the intradermal injection in the skin area, which treated by tincture of iodine previously; 26. What is the role of artificial airway tube in the system for intravenous drop infusions? a) forces out fluid from vial with solution; b) obstructs to permeation of air in tubes of system; c) promotes to drop movement of fluid through system. 27. What maximal quantity of medical solution can be introduced in organism during one time by means drop infusion? a) 150 - 200 ml; b) 400 - 500 ml; c) 600 - 800 ml; d) 1000 - 1500 ml; e) 2000 - 3000 ml; f) 4000 - 5000 ml. 28. How many times can sterile system for intravenous drop infusion be used? a) one; b) two; c) three; d) four; e) five; f) more than five.

-with the selective group of right answers – the II-nd level; 1. Name the parenteral medications: a) intradermal; b) oral; c) buccal; d) intra-arterial; e) intraosseous. 2.How are syringes and needles sterilized? a) in autoclave; b) in dry-air sterilizer; c) with use of sterilizing gases; d) by boiling. 3. What areas of body are the most convenient for subcutaneous injections? a) external surface of shoulder; b) internal surface of shoulder; c) external surface of thigh; d) internal surface of thigh; e) subscapular area; f ) lateral surface of abdominal wall. 4. What areas of body are the most convenient for giving of intramuscular injections? a) external surface of shoulder; b) internal surface of shoulder; c) external surface of thigh; d) internal surface of thigh; e) subscapular area. 5.What are indications for use of intravenous infusions? a) decreasing of volume of blood circulation; b) intoxication of organism in infectious diseases and poisoning; c) elevation of arterial pressure; water-electrolytic and acid - base imbalance

-with the selective group of right answers – the II-nd level; 1. What manipulations are performed in a procedure room? а) injections; b) puncture of pleura cavity; c) applying of cupping glasses, mustard plasters; d) medical baths; e) determination of blood type. 2. What medical documents are filled in by ward nurses ? а) journal 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. 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. 4. 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. 5. 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. 6. In what cases is rectal route of medication used? a) if peroral administration is impossible or undesirable? ; b) if it is necessary to give local medical effect; c) if it is necessary to get fast and pronounced effect . 7. In what cases is injection route of medication used? а) if it is necessary to receive fast medical effect; b) if the drug acts very quickly; c) if the drug has a high toxicity; d) if it is necessary to supply exact concentration of a drug in a blood; e) if there are no other ways of a drug introduction. 8. Name the forms of oral medications: a) suspensios; b) cream.; c) gels; d) powders; e) capsules. 9. Name the advantages of the peroral medication: a) medicines can be given in any form; b) medicines can be given under non sterile conditions; c) preparations are slowly absorbed into the blood; d) properties of the medicine are altered by the gastric juice; e) it is difficult to predict the concentration of the medicine in the blood. 10. Name the disadvantages of the peroral medication: a) medicines can be given in any form; b) medicines can be given under non sterile conditions; c) preparations are slowly absorbed into the blood; d) properties of the medicine are altered by the gastric juice; e) it is difficult to predict the concentration of the medicine in the blood. 11. Name the topical medications: a) nasal; b) vaginal; c) rectal; d) pulmonary; e) subcutaneous. 12. Name the parenteral medications: f) intradermal; g) oral; h) buccal; i) intra-arterial; j) intraosseous. 13. Name the forms of oral medications: a) solid; b) liquid; c) antiseptic; d) antibiotics; e) antiinflammatory. 14. Name the categories of the topical medications: a) solid; b) liquid; c) antiseptic; d) antibiotics; e) antiinflammatory. 15. Name the solid forms of oral medications: a) tablets; b) capsules; c) powders; d) syrups; e) solutions. 16. Name the liquid forms of oral medications: a) tablets; b) capsules; c) powders; d) syrups; 17. Name the liquid forms of oral medications: a) suspensions; b) emulsions; c) elixirs; d) tinctures; e) suppositories. 18.Name the topical medications: a) aerosols; b) enemas; c) anesthetics; d) antibiotics; e) antiseptics. 19.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. 20. After the examination of pulse on the radial artery has been finished, it is studied on the following arteries: a) splenic; b) sublingual; c) temporal; d) carotid; e) femoral; f) popliteal; g) subcostal; h) pulmonary.

B. Tasks to be done: Task 1. Taking into account inability of the patient to swallow pill, administered by physician, a nurse kept the patient without drugs. Is her action correct? Task 2. What are actions of nurse in the case of request of the patient to take medicines later term, explained by physician? Task 3. At thedistribution of the medicines a nurse saw absence of label on the one of the bottles. What must to be her tactic in this situation? Task 4. Accordingto instruction of physician, after carrying out of the massage to the patient nurse got of ointment from the medical cabinet and applied ointment in the skin area. What is defedof the nurse action in?

Task 5. In 25 minutes after simmerof sterilizer, a nurse stopped sterilization of syringes and needles, switced sterilizer from electrical system. Are her actions correct? Task 6. After sterilization of syringes and needles by method of boiling, a nurse raised steriliser’s cover, took out hot syringe and piston from sterilizer by sterile nippers. But she can’t to insert sucker into cylinder. What is her mistake in? Task 7. Student, helping to the nurse to give injection, took just used syringe from her, changed used needle for sterile, took necessary medicines in the syringe and prepared for giving injection. What is his mistake in? Task 4A nurse placed bottle with antibiotic under flow of the hot water for speeding-up of dissolving of antibiotic. Are her actions correct? Task 8. A nurse took in the left hand sterile syringe. By forefinger and big finger of right hand she fixed injection needle in the area before muff carefully, connected needle with cannulasof the syringe. Then she took necessary dose of antibiotic from bottle, wiped injection area by ethyl spirit, got needle with syringe from bottle and gave injection. What actions of the nurse were wrong ? Task 9. Redden and swelling by diameter 1 sm appearedon the patient’s skin after intradermal giving in the area of forearm 1000 Units of penicillin. 1) What is reaction of the patient’s skin? 2) What must to be actions of the nurse? Task 10. A nurse must take one-time dose of 150 000 Un. from bottle having capacity of 500 000 Un. of antibiotic. How it is done? Task 11. A nurse collected 15 ml physiologic saline and 5 ml 2,4 % solution of aminophylline in the syringe with volume 20 ml. After pressing of shoulder tourniquet, she carried out venipuncture and begun to introduce medicine in a vein. What manipulations did she not carry out before infusion?

Standards of right answer (tasks): 1) No. A pill must become powered with the help of the nurse. Then patient must to take this powder, taking some water after one’s medicine. 2)To give medicines to the patient and to secure their timely taking in her-self presence ( or presence of other nurse ) according to instruction of physician. 3)Medicines in the bottle must to be confiscated from use and changed for same with chemist’s label, on which must to be indicated term of its acquisition. 4)Before procedure a nurse must was to wash own hands and to clean skin of the patient carefully. 5)No. Syringes must to be boiled during 45 minutes. 6)In order to piston is insertedinto cylinder of syringe freely, it is necessary to collectassembled syringe after its coolness. 7) It isforbided categorically to carry out more than one injection the same syringe. 8) No. Antibiotic must to be dissolved at room temperature by energetic shaking off bottle with solvent. 9) Needle out of muff mustn’t be taken by hands. It is necessary to use sterile nippers for this. It is impossible to use same needle for taking of medicines and giving of injection 10) The patient has allergic reactiontopenicillin. It is necessary to inform of the physician quickly. Injection of penicillin don’t carry out. 11) To dissolve content of bottle in 10 ml sterile 0,5% novocain solution. To take content of bottle in sterile syringe. 12) She didn’t take away tourniquet from the shoulder. She didn’t draw off to oneself piston of syringe in order to be sure that needle is in lumen of a vein.

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.-788p. 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. NHSlocal. Educational movie “Nurse Mentoring On The Ward” 2010. 2. Health Sciences, University of Southampton. Educational movie . “Life as a Nursing Degree Student .Health Sciences.”/University of Southampton 2013 3. Educational movie “Structure and functions of the therapeutic department. Preparation of antiseptic solutions. Duties of the medical personnel.” 2010

Internet resourses 1. https://www.nursingtimes.net/roles/nurse-managers/the- nurses-role-in-hospital-ward-rounds/5056510.article 2. https://www.ebscohost.com/nursing/benefits/improves- nursing-skills 3. http://www.nursingworld.org/nursingstandards

Methodical instruction is composed by lecturer Ye. Petrov. 200__/200__ academic year. 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 09 10 2018 Protocol No4 The Head of the Department Professor Yu. Kazakov

METHODICAL INSTRUCTION FOR STUDENTS’ SELF-PREPARATION WORK

Educational discipline Nurse practice Module No 1 Enclosure module No 1 Topic Duties of nurse on securing of diagnostic process in therapeutic in- patient department.

Year 3 Faculty medical

1. The topic basis: patients with diseases of digestive and urinary system take great place in structure of patients with therapeutic pathology. That is why students must know duties of nurse in diagnostic process for such patients and be able to use practical skills. 2. The specific aims:  To explain rules of preparation of patient for endoscopic study of digestive tract (esophagogastroduodenoscopy, colonoscopy, proctosigmoidoscopy).  To explain rules of preparation of patient for ultrasonic study of abdominal cavity organs.  To classify types of enemas.  To explain rules of preparation of patient for different types of enemas.  To explain rules of preparing a patient for X-rays of the stomach and intestine.  To explain peculiarities of feces taking for different laboratory researches.  To explain peculiarities of collection of urine for different laboratory researches.  To explain carrying out of examination of gastric secretion.  To classify stimulants of gastric secretion.  To explain carrying out of duodenal content study.  To explain carrying out of gastric lavage.  To explain catheterization of  To explain the main functions of the heart and ECG bioelectrical principles.  To explain rules of preparation of patient for ECG examination and carrying out of ECG recording.  To draw normal ECG.  To compose plane of ECG interpretation.  To explain principles of phonocardiography.  To compose plane of PCG recording.  To explain the main elements of PCG.  To explain essence of echocardiography method, positions of the gauge.  To explain the method of the spirography and pneumotachometry.  To draw the spirogram scheme.  To carry out simplest analysis of respiratory volumes.  To compose plan functional duties of the nurse of functional diagnostics room.

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 structure of the main systems of organism, digestive and urinary particularly. 2. Physiology To know physiology of the main system of organism, digestive and urinary particularly. 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. Endoscopy It is examination of hollow or tubular organs by means direct inspection of internal surface with help of special apparatus-endoscope. 2. Esophagogastroduodenoscopy It is endoscopic research of esophagus, stomach and duodenum 3. Proctosigmoidoscopy It is endoscopic research of sigmoid and rectum. 4. Colonoscopy This method by means of flexible colonoscope enables to study morphological picture of mucus membrane of large intestine and carry out target biopsy over the whole its length.

5. Ultrasound study (echography) This method is based on following: different mediums of organisms have different acoustic properties and differently reflect ultrasound signals, radiated by apparatus. 6. An enema is an injection of liquids into the large intestine through the anus.

7. Electrocardiography It is the method of graphic recording of electric currents generated in the working heart. The curve reflecting the electrical activity of the heart is called the electrocardiogram (abbreviated ECG).

8. Phonocardiorgaphy It is the method of recording sounds generated in the beating heart. Phonocardiography is an essential supplement to the heart auscultation.

9. Ultrasound echography (syn. It is a diagnostic method based on echolocation, ultrasound scan- different reflection of ultrasound waves ning, sonography) that pass at various velocities through tissues and media of various density.

10. Spirography It is the method of graphic recording of the changes in time of the inhaled and exhaled air volume.

11. Pneumotachometry It is determining of peak speeds of air flow (“capacity of inspiration” and “capacity of expiration”) with the help of Votchal’s pneumotachometer.

4.2. Theoretical questions to be answered before class: 1. What are the main rules of patient’s preparation to esophagogastroduodenscopy? 2. What are contraindications to carrying out of esophagogastroduodenscopy? 3. What are indications and contraindications to carrying out of colonoscopy? 4. What are the main rules of patient’s preparation to colonoscopy? 5. What are indications and contraindications to carrying out of proctosigmoido- scopy? 6. Tell about preparation of patient for ultrasonic study of abdominal cavity organs. 7. What types of enemas do you know? Name indications and contraindications for their using. 8. Tell about giving of different types enemas. 9. Tell about preparing a patient for X-rays of the stomach and intestine. 10. Tell about feces taking for laboratory research (general examination of feces, for examination on presence of helminthic eggs, examination on presence of occult blood). 11. What are the main rules of collection of urine for laboratory research (general analysis, Zimnitsky’s test, Nechiporenko’s method, Addis-Kakovsky’ method). Diagnostic importance of different methods. 12. Tell about preparation and carrying out of gastric intubation. Its diagnostic importance. 13. Tell about preparation and carrying out of duodenal intubation. Its diagnostic importance. 14. Gastric lavage: indications, contraindications, its carrying out. 15. Tell about application of colonic tube. 16. Tell about carrying out of catheterization of urinary bladder. 17. Tell about preparation of tubes, catheters and tips to manipulations. 18. What are the main rules of patient’s preparation to electrocardiography? 19. Tell about ECG recording. 20. What stages of ECG interpretation do you know? 21. Tell about filling in the ECG form. 22. Technique of phonocardiogram registration. 23. Tell about analysis of the main element so PCG. 24. Tell about echocardiography: basic principles and carrying out of research. 25. Tell about the method of the spirogram recording and interpretation. 26. What does term “pneumotachometry” mean? 27. Tell about functional duties and rights of the nurse of functional diagnostics room.

4.3. Practical work (tasks), which should be performed during class: a. To take part in patient’s preparation to carrying out of esophagogastroduodenoscopy, colonoscopy, proctosigmoidoscopy and urtrasound research of abdominal cavity organs. b. To prepare necessary equipments for cleansing enema, show method of its carrying out on plaster cast. c. To take part in feces taking for laboratory research (general examination of feces, for examination on presence of helminthic eggs, examination on presence of occult blood). d. To take part in collection of patients’ urine for laboratory research (general analysis, Zimnitsky’s test, Nechiporenko’s method, Addis- Kakovsky’ method) and study of urine. e. To prepare necessary equipments for gastric and duodenal intubation, show methods of their carrying out on plaster cast and take part in real manipulations. f. To prepare necessary equipments for catheterization of urinary bladder, show methods of its carrying out on plaster cast and take part in real manipulations. g. To take part in preparation of tubes, catheters and tips to manipulations. h. To carry out ECG recording and to interpret results. i. To take part in recording of PCG, spirogram, carrying out of PCG, pneumotachometry.

The contents of topic: Text

Preparation of patient for endoscopic study of digestive tract Esophagogastroduodenoscopy Modern flexible esophagogastroduodenoscopes enable to inspect mucous membrane of esophagus, stomach and duodenum, carry out target biopsy, and take cellular material for cytological study. Besides that, they have device for aspiration of gastric contents and forcing of air in it. Contraindications. Constriction of esophagus, expressed cardiopulmonary failure, aortic aneurysm, myocardial infarction, stroke, psychic disorders, evident deformity of spinal column, retrosternal goiter, esophageal varicose veins dilatation and esophageal burn. Research is carried out fasting. Last food intake is in the evening, at 18 o’clock. The day before it is necessary to explain to the patient that safety of procedure’s carrying out depends on his/her behavior. He/she must be warned about impossibility to talk and to swallow saliva during manipulation. Removable dental prosthesis is taken away. 3-5 minutes before beginning of examination pharynx is irrigated by 1-2% tetracaine solution. Patient is laid on universal operating table left lateral decubitus. The nurse controls patient’s position and observes patient’s condition. After examination it is interdicted to eat, drink, and smoke during 1 hour. In case of pharyngeal pains its irrigation by 3% sodium hydrogen carbonate solution is prescribed. After examination apparatus is taken energetically; endoscope’s canal is washed by warm water and is blown by air at beginning, then apparatus is disconnected from illuminator, tube is washed by warm water carefully and treated with 30% ethanol. Endoscopes are kept in hanging condition.

Сolonoscopy Using of flexible colonoscope enables to study morphological picture of mucus membrane of large intestine and carry out target biopsy over the whole its length. Indications. Chronic diseases of large intestine, suspicion to polyps and cancer, intestinal bleedings of unknown reason. Contraindications. II and III stages of heart failure, myocardial infarction, acute cerebral thrombosis, comatose state, shock, acute diseases of abdominal cavity organs with signs of peritonitis, which need surgical intervention, hemophilia. Colonoscopy is carried out after careful cleansing of bowels. Low-roughage diet is prescribed 3-4 days before examination. It is necessary to control presence of daily excrements. Day before examination patient must drink 30-50 ml castor or olive oil at 15 o’clock. In the evening high cleansing enema is used. In the morning, 2 hours before examination, cleansing enema is carried out again. Patients don’t have breakfast during study day. Patient occupies left lateral position with legs, flexed in knees and bent to abdomen. If introduction of colonoscope or its moving forward is difficult, patient’s position is changed. He/she can be turned on back or right side. The nurse constantly observes patient’s condition and move forward apparatus according to physician’s instructions.

Proctosigmoidoscopy Inspection of mucous membrane of rectum and sigmoid is carried out by means of proctosigmoidoscope. Indications: pain in area of rectum, constant constipation, in old and elderly persons particularly, mucus or pus discharge, performing of some manipulations (greasing of fissures, ulcers, polypectomy, taking of bit of mucous membrane for histological study). Contraindications: severe general condition of patient, acute inflammatory and suppurative processes in area of anus, scarry strictures of rectum. In the evening day before performing of proctosigmoidoscopy two cleansing enemas with following introduction of flatus tube are carried out to the patient. Slight supper (tea, biscuits) is given to the patient. In the morning 2 cleansing enemas with interval 30 minutes are carried out again. Then - flatus tube is introduced. It is possible other variant also: in the evening cleansing enema is carried out and in the morning 4 hours before examination enema is used again. If patient has constipation, laxative (30 ml of castor oil) is given to him/her during some days before examination, cleansing enema is carried out every day. The nurse carries out patient’s preparation, controls instruments and helps to the physician to perform research. It is possible running out of washing water, which are delayed in intestine, therefore nurse must prepare basin. Last one is placed to external end of proctosigmoidoscope’s tube. The most convenient patient’s position for introduction of proctosigmoidoscopeis is knee-elbow and knee-shoulder. Patient kneels on the table so, that his/her feet hang down out table’s edge and rests one’s elbows or shoulder on the table. Other patient’s position - right lateral decubitus with little raised (lifted) pelvis. In case of insufficient preparation of the patient research stops and repeated preparation is carried out. After end of examination parts of proctosigmoidoscope, which need sterilization, are disconnected from apparatus, washed by warm flowing water, other parts are treated with 30% ethanol. Proctosigmoidoscopes are kept in complete condition in special places, for example, in surgical safe separately from other diagnostic instruments.

Preparation of patient for ultrasonic study of abdominal cavity organs Ultrasound study (echography), which is used widely for diagnostics of digestive organs diseases, is based on following: different mediums of organisms have different acoustic properties and differently reflect ultrasound signals, radiated by apparatus. It is possible to determine position, form, sizes, structure of different organs of abdominal cavity - of the liver, gall bladder, pancreas, to reveal tumors, cysts by means of echography. Research is carried out, as a rule, fasting, preparation usually is comes to “struggle” against meteorism, as accumulation of gases in intestinal loops make more difficult ultrasound visualization of organs. It includes special diet for prevention meteorism: excluding of raw cabbage, rye bread, milk, etc.; besides 2-3 days before examination it is prescribed activated carbon or carbolen (0,5-1,0 g 3-4 times a day) intake, and (according to indications) - enzymatic drugs intake (for example, festal).

Enemas An enema (clyster) is an injection of liquids into the large intestine through the anus. Cleansing enema The indications for use of a cleansing enema are: 1. constipation; 2. preparation of the parturient women for labor; 3. preparation of the patients for scheduled operations on gastrointestinal tract organs, small pelvis; 4. preparation of the patient for an X-ray examination of gastrointestinal tract organs, of small pelvis, pelvic bones, pelvic region of spinal column; 5. preparation of the patients for endoscopic examination of the intestine; 6. poisoning. Contraindications for use of a cleansing enema are: 1. acute appendicitis; 2. acute inflammatory process in the colon with a predilection to bleeding; 3. fissure of the anus; 4. bleeding from gastrointestinal tract; 5. decay of a tumor of a rectum; 6. first days after operation on gastrointestinal tract organs; 7. propapse 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 27-32ºC, 1,5-2 L. In predilection of a spasmed intestine - temperature of the water - 37-39ºC, in an atony - 18- 20 ºC; 3. Vaseline; 4. support-rack; 5. bedpan; 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 hanging an Esmarch’s irrigator, wach-bowl. The patient following a bed regimen is given this procedure in his 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 1-1,5 L, to unclose (open) the tap, to fill in a rubber tube and tip with some water, to closer the tap. For simplification of removing of the faeces use 25-50 g castor or olive oil, or 25 g 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 patient on his back; a bolster (roller) is put under the patient’s pelvis. The buttocks are moved apart by first and second fingers of the left-hand with rotary movements a hand piece is carefully inserted then parallelly to the spinal column 8-10 cm. In the case where there are folds of mucosa or hemorrhoidal, the hand piece is carefully introduced between them. The tap is than 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 to slow 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 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 feces masses are discharged with water within some minutes. If the clyster has not worked, the procedure can be repeated in some hours. Application of purgative clysters (oil, hypertonic, emulsive) A purgative enema is prescribed for persistent constipation or intestinal paresis when administration of large amount of liquid is ineffective or harmful. Oil and hypertonic saline solutions are used. Oil clyster 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: 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 150-200 ml; 2. Janet’s syringe; 3. colonic tube; 4. Vaseline; 5. oil-cloth; 6. vegetable oil (corn, sunflower, oilve). Before the procedure it is necessary to carry out the psychological preparation of the patient and to explain to him, that after 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 37-38 ºC, then a rubber bulb or Janet’s syringe is filled with oil. An oil-cloth is spread under the patient. The patient is laid in 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 10-15 cm. 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 Glycerin must be added to the tincture of camomile. This mixture is collected in Janet’s syringe or rubber ballon 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 inflamamtory 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 ahypertonic 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 strongsaline 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 sulfate solution. The hypertonic solutions should be warmed up before administration. The patient should not defecate 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 washing confirms the diagnosis of intestinal impatency. For the 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 liters 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 jag, 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 siphonage is repeated until the water returning tot eh funnel is clear. After use, the funnel and the tibes are cleaned. Medicinal clyster A medicinal clyster can be both local and general in action. The clysters of local action (medical microclysters) have anti-inflammatory and enveloping activity and their amount should not exceed 200 ml. They are utilized in inflammatory processes of the large intestine. In clysters of local action oil (30-50 ml warm olive oil), starch (5 g of starch is diluted in 5 ml of cold water and, 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 or a Janet’s syringe provided with a 12-20-cm long rubber endpiece. The patient should try to keep the administered medicine in the intestine for at least 30 minutes. The medicinal solution should be given 20-30 minutes after an evacuant enema. The medicinal clysters of general activity are given in cases when it is impossible to introduce drugs through the mouth or parallelly with it. In this method of introduction the medicines are promptly absorbed into blood through hemorrhoidal 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, Chlorali 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 ), 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 liters) of isotonic sodium chloride or glucose solution to treat intoxication, dehydration, 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 lay on his back during the procedure. The solution in the Esmarch flask through the rectal tube is inserted into the rectum to a depth of 20-25 cm. It is necessary to observe the rate of administration and the 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.

Preparing a patient for X-rays of the stomach and intestine Radiological techniques give reliable information concerning the pathology of the stomach and the intestine. X-rays are used to determine the shape and position of the stomach and the duodenum, and the relief of the mucosa in the stomach and small intestine (in first instance of the duodenum). A barium sulfate suspension (100 g in 100 ml of boiled water) is used for radiological examination of the stomach and the intestine. The ability to absorb X-rays accounts for the use of barium sulfate in roentgenology. The suspension is given to the patient per os. The patient should be specially prepared for X-ray. His stomach and the intestines should be emptied from food remains, liquids, and gases. In the X-ray study of the large intestine, a barium sulfate suspension is usually given by enema before irrigoradioscopy. The patient’s large intestine must be emptied before the procedure. Three days before the examination the patient should be fed a low carbohydrate diet. In cases of meteorism, the patient should be given chamomile tea and activated carbon. On the eve of the examination, the patient is given 30-40 ml of castor oil before his dinner. An enema is given before the night sleep and in the morning before the examination.

Feces taking for laboratory research Feces must be delivered for research at once after defecation, its advisable warm in order to prevent changes in it under influence of microorganisms and enzymes. Feces for examination should be taken in clean, dry glass vessel. It is incorrect and unhygienic collection of feces in matchboxes, paper, little bottle and other inconvenient containers. Accompanying label, where patient’s surname and name, department, ward, purpose of research, date and signature of person, sending feces, is fasten on the container. In order to prevent drying of feces and its forming as source of infection spread by means of flies, it must be kept under cover. A feces for research is taken in the morning after sleep. It is impossible to direct for research feces after enema, intake of medicaments, which influence on intestinal peristalsis (for example, belladonna, pylocarpin), and those ones, which change feces color (iron, bismuth, barium), and also after introduction of suppositories and intake of castor and Vaseline oil. Feces must be without extraneous admixtures, for example urine. For general examination of feces little amount of feces is taken into container by means of wooden stick or spatula, container is covered and appoint to laboratory. For examination on presence of helminthic eggs, feces is taken in three places and warm feces is appointed to laboratory. For feces examination on presence of occult blood patient is prepared during three days, excluding meat, fish, all types of green vegetable, tomatoes and eggs from his/her ration (dietary intake). Medicaments, containing iodine, brome, and iron are canceled. During forth day feces are directed to laboratory. Feces for examination on presence of dysentery are appointed to laboratory in special tube with so called “English mixture”. Only “fresh” feces must be directed to laboratory for examination on presence of protozoa in bowels. It must be examined not later than 15-20 minutes after defecation, as vegetative forms of protozoa are lost quickly in outdoor environment.

Collection of urine for laboratory research General urinalysis Container for urine must be clean, dry, without soup remains, as last one can cause alkaline reaction of urine, which becomes useless for study. Urine is taken in the morning after sleep, amount for research - 100-200 ml. Women before taken urine must be washed (external genital organs). Urine must be decanted from vessel, where women excreted urine into other clean vessel. Now in women urine is taken for analysis from middle portion, i. e. from middle urine flow act. During menstruation it isn’t recommended taking of urine for research; but if it is necessary urine is taken by means of catheter. Before taking urine external genital organs must be treated by disinfectant (potassium permanganate, furacilin). It is necessary to remember that carrying out of catheterization of urinary bladder can be complicated due to getting of bacterial flora (which always is in external part of urethra in quantity) into urinary bladder. Urine must be sent to laboratory during 1 hour after its collection, as it can be infected. If possibility to send urine for research quickly is absent, it should be put in cool place. Urine must be sent to laboratory with accompanying form, where the following information must be present: patient’s surname, name, patronymic, date, name of material, provisional diagnosis and researches, which must be carried out. Determining of daily amount of urine First morning portion is excreted into lavatory (toilet). The next portions are collected in one vessel. Last time urine is taken in the morning of the next day in time, marked the day before. For research of glycosuric character of urine it is taken in definite time: 1st portion - from 9 to 14 o’clock, 2nd - from 14 to 19 o’clock, 3rd - from 19 to 23 o’clock, 4th - from 23 to 6 o’clock, 5th - from 6 to 9th -o’clock. Kakovsky-Addis’ method This method is used for determining of amount of formed elements in urine, which was collected during day. Normally during day it is possible to excrete to 2•106 leukocytes, to 1•106 erythrocytes, and to 2•104 casts. The following is peculiarity of this method: during day urine must be kept in cool place, as formed elements of urine are lysed in case of its long keeping. Nechiporenko’ method By means of this methods amount of formed elements in 1 ml of urine is determined. Middle portion of morning urine is collected in clean vessel. After careful mixing 10 ml of urine is filled into graduated centrifugal tube and centrifuged during 5 minute at 1500 turns/minutes. Sediment and approximately 1 ml of fluid above it are left in tube, they are mixed carefully and Goriayev’ chamber is filled. Formed elements (leukocytes, erythrocytes, casts are counted in 100 large quadrates of chamber with following recalculation according to formula: y•4000•1000 X=------= y•250, 1600•10 where x - number of formed elements in 1 ml of urine; y - number of cells in 100 large quadrates of Goriayev’ chamber; 1600 - number of little quadrates in 100 large; 4000 - volume of one little quadrate (mm3); 1000 - number of mm3 in 1 ml; 10- ratio of volume of centrifuged urine to volume of sediment with fluid above it. Normally: leukocytes - to 4000 in 1ml, erythrocytes - to 1000 in 1ml, casts - to 200. Zimnitsky’ test Day before, in the evening nurse prepares 8 clean containers, on which she glues labels with following information: patient’s surname, department, number of ward, number of portions (1st, 2nd, 3rd, and others), periods (6-9, 9-12 and others) when this container is filled. Before carrying out of research patient must not intake diuretics. Research is carried out at usual water schedule and usual eating pattern. Contraindications for carrying out of test are absent. At 6 o’clock in the morning patient empties urinary bladder, this portion isn’t collected. After this excretion urine is collected in 8 containers to 6 o’clock of the next day. Besides, from 6 to 9 o’clock patient passes urine into 1st container, from 9 to 12 o’clock - into 2nd container, etc. It is necessary to see that patient fills all containers. In case of urine absence during 3 hours empty container is sent to laboratory. If patient passes large amount of urine (polyuria) and one container isn’t enough for him, additional container (on which number of portion, patient’s surname are marked) must be given to him. All 8 portions are sent to laboratory; in every portion volume of urine and its specific gravity are measured.

Examination of gastric secretion Fractional research of gastric secretion is carried out by means of intubation. Thin tube with length 1,5 m and diameter 3-5 mm is used for this purpose. In addition to tube it is necessary to have vials, basins, funnel, syringe with capacity 20 ml and towel. For stimulation of gastric secretion the following can be given to the patients: cabbage juice, 7 % cabbage decoction, broth, bread, caffeine, alcohol and other tests meal (enterally), histamine, pentagastrin and insulin (parenterally). It isn’t recommended to obtain gastric juice by means of tube in case of hypertensive disease II and III stages, cardiac decompensation, nasal respiratory impairment, laryngitis, exacerbation of chronic gastritis or peptic ulcer disease, cholecystitis, esophageal veins dilatation, aortic aneurysm, propensity to bleeding, curvature of cervical- thoracic part of spinal column, pregnancy. Before examination the nurse must say to the patient that the day before procedure his/her supper shouldn’t be had later than 18 o’clock. Amount of food during supper should be limited. It is impossible for patient to drink, take food, take drugs, smoke during day of examination. Research is carried out in the morning. Gastric content is taken in special room. Before beginning of procedure the nurse explains purpose of procedure to the patient, instructs his/her to breath through nose deeply. If nasal meatuses are filled by mucus, it is necessary to clean them. Patient sits on the chair (closely to its back) near table, and slightly inclines his/her head forward. The nurse supports patient’s head by left hand, and introduces tube by means of right hand. Syringe with capacity 20 ml for aspiration of gastric contents must be joined to free end of the tube. Thin tube, moistened with water, is introduced into stomach like thick one. The tube is taken like pen during writing; tube is introduced behind root of tongue, turning it forward and downwards slightly. Due to this manipulation pharyngeal curvature becomes flatter, epiglottis is displaced, and way for tube becomes free. Nurse proposes to the patient to breath by means of nose, to restrain emetic motions, and to spit out saliva into towel. In case of retching patient must put out tube by lips and breathe by nose deeply. Gastric contents are taken at once after introduction of thin gastric tube, than gastric juice is aspirated every 15 minutes during 1 hour. Than test meal is introduced into stomach by means of tube. In 10 minutes 10 ml of gastric contents is taken, and after this manipulation in 15 minutes gastric contents is aspirated completely by means of syringe. In the further gastric contents are aspirated every 15 minutes during 1 hour. Vials with gastric contents are placed in rack (support) in strict succession and vials are directed to laboratory. It is necessary to bear in mind that enteral stimulators of gastric secretion are slight and don’t reflect objective condition of gastric acid-excretion completely; that is why now histamine is used often. Histamine is strongest and physiological stimulator of gastric secretion. But it is necessary remember that in case of hypertensive disease, bronchial asthma, allergic diseases its using is contraindicated. In case of using of histamine as stimulator of gastric secretion - antihistamine drugs (suprastine or dimedrole) must be introduced to the patient 15- 20 minutes before introduction of histamine. Gastric contents is taken fasting, than 0,5 ml of 0,1 % solution of histamine is introduced subcutaneously and every 15 minutes during 1 hours gastric juice is aspirated. Sometimes when histamine is contraindicated, pentagastrine (6 mkg per 1kg of body weight) is used. There are following potential complications, which can occur during aspiration of gastric contents by means of thin tube:  Emetic motions and cough. In this case tube must be taken out, patient must take a rest, attempt to introduce tube into stomach must be repeated. In appearance of cough and emetic motions again - it is necessary to carry out anesthesia of pharyngeal mucous membrane with 2 % solution of Novocain or 1 % solution of tetracaine (pantocaine).  Esophageal spasm and pharyngospasm, can be relief slightly, if through tube to infuse little amount of warm water.  Appearance of fresh blood as streaks. It has relation to affection of little vessels of mucous membrane of esophagus or stomach by tube during its introduction or taking out. In case of appearance of blood in quantity aspiration of gastric contents must be stopped. The tube is taken out carefully; nurse soothes patient, prescribes bed rest, gives 10% solution of calcium chloride enterally, vikasol. Ice bag should be placed on the patient’s abdomen.  Syncope, which can be developed in emotionally labile person in case of blood appearance in gastric contents. In this case research is stopped, patient’s face is washed with cold water, cotton ball, moistened with liquid ammonia is given to the patient to smell. Now pH-metric method of taking of gastric juice by means of tube (on the end of it olive with assembled electrodes is present) is used widely. It gives possibility to determine pH of gastric juice in different portion of the stomach. Radiometric research of gastric juice by means of electronic apparatus, which is introduced in the stomach, is used also.

Study of duodenal content Duodenal content is studied for determining the bile composition, which in turn is necessary to diagnose affections of the gall bladder and bile ducts. Technique Duodenal content is obtained by probing the duodenum by an elastic rubber tube 3-5 mm in diameter with the metal oval bulb at the end of the tube. The length of the tube is about 150 cm. The tube has a mark at a distance of 45 cm from its distal end (the distance to the stomach), next marks follow at 70 and 80 cm length. The procedure is carried out on a fasting stomach. The patient sits with the slightly opened mouth. The tube is placed in the mouth so that the bulb was at the root of the tongue and the patient is asked to make swallowing movements. The nurse should only slightly promote the independent movement of the tube. If the patient attempts to vomit, he is recommending to breathe deeply through the nose. When, according to the marks, the tube reaches the stomach, the patient walks slowly about for 15-20 minutes and continues the swallowing movements. When the tube is swallowed to the mark of 70 cm, the patient lies on his right side. The hot-water bottle is applied under the right side. The outer end of the tube is lowered into a test tube in the stand placed on a low stool at the head-end of the bed. If the bulb has reached the duodenum, yellow alkaline fluid is gathered in the test tube. In order to check the position of the tube end (if no juice is discharged from the probe) air can be forced into the tube by a syringe. If the probe is inside the stomach, the patient feels the stream of the injected air, and bubbling can be heard. If the tube is in the duodenum, the patient does not feel anything and no sounds are heard. The position of the tube can be most accurately established by X-rays. The correct position of the tube bulb is between the descending and the lower horizontal portions of the duodenum. If the tube is stopped before the pylorus, the patient is given to drink 10 ml warm water with 2-3 g of sodium hydrogen carbonate. The normal duodenal contents discharged from the tube -the 1st phase of examination - - is golden-yellow, slightly viscous, clear and opalescent. If it contains gastric juice, it becomes turbid from precipitating bile acids and cholesterol. This portion is designated by the letter A. This is a mixture of bile, pancreatic and intestinal secretion and the diagnostic value of this fluid is therefore low. Bile A is collected for 10-20 minutes. Then an agent stimulating contraction of the gall bladder is given through the tube. It is usually a warm solution of magnesium sulfate (25-30 ml of 25-33% solution). Less frequently it is vegetable oil, egg yellow, 10% sodium chloride solution, 30-40 ml of a 40% glucose solution or 40% sorbitol solution. It can be hormones cholecystokinin or pituitrin which are given subcutaneously. Following the administration of the stimulant into the duodenum, the Oddi’s sphincter contracts and excretion of bile is discontinued. This is the 2nd phase. Normally it continues 4-6 minutes. The 2nd phase elongates if the tone of the Oddi’s sphincter is increased and shortens in its hypotonia. The 3rd phase starts the excretion of golden-yellow contents of the bile duct and the neck of the gallbladder (portion A1). The 4th phase — portion B — is evacuation of the gallbladder, which is attended by discharge of thicker dark-yellow or brown bile. It becomes greenish when it is congested or if the gall bladder is inflamed. This secretion is associated with contraction of the gall bladder concurrent with relaxation of the bladder and Oddi’s sphincters. Bladder bile is a kind of concentrated liver bile. The wall of the gall bladder has selective absorbability. As a result, the content of bile acids and their salts increases in 5-8 times, and bilirubin and cholesterol increase in 10 times compared with their content in the hepatic bile. of the gall bladder secretes mucin. In accordance with the capacity of the gallbladder, the amount of secreted "B bile" is 30-60 ml during 20-30 minutes. Ample amount of bile indicates its congestion in hypotonic dysfunction of the gallbladder. Small amount of bile indicates hypertonic dysfunction of the gall bladder. Increasing of the time gall bladder evacuation indicates hypokinesia of the gallbladder. Decreasing of the time — is hyperkinesia. The bladder reflex may be absent. The appearance of the reflex after additional giving of the stimulant indicates spasm of the sphincter and the absence of organic obstructs. Persistent absence of the bladder reflex is observed in cholelithiasis, cirrhosis of the gall bladder, obstruction of the bile duct with a stone or an inflammatory process in its mucosa, in contractile dysfunction of the gallbladder. After "B bile" excretion discontinues, "C bile" (hepatic bile) is delivered from the tube. This is the 5th phase of the examination. The golden-yellow "C bile" is considered to be hepatic. If its amount smaller then 30 ml it indicates hypoexcretory function of the liver. If the concentrating capacity of the gallbladder is impaired, it is difficult to differentiate between "A, B and C biles" by color. A methylene blue test (chromodiagnostic probing) is used. The reagent is reduced in the liver to a colorless leucobase, but it oxidizes in the gallbladder again and its color reappears. The patient is given 0,15 g of methylene blue in a in the evening and common probing is performed in the morning. If blue bile is discharged after giving magnesium sulfate, it indicates that it is "B bile". Microscopy of duodenal contents Microscopy of duodenal contents should be carried out immediately after collection of each portion. Leucocytes are decomposed during 5-10 min. Presence of the leucocytes more than 10 in vision field and mucous in "B bile" is considered as a diagnostic sign of inflammatory process - cholecystitis. Such symptoms in "C bile" are typical for cholangitis. Discovery of cholesterol crystals and brown grains of calcium bilirubinate are of great importance. They can be revealed in small quantities (+) in healthy subjects, but large ones (++ or +++) suggest cholelithiasis. Discovery of parasites in bile is of great significance. Lamblia intestinalis occurs frequently, the eggs of liver fluke or Chinese fluke are revealed less frequently. After ending of duodenal intubation tube is washed with flowing water, disinfected during 5 minutes in 1% solution of chloramine and then boiled during 15 minutes.

Gastric lavage Many diseases of the stomach can be caused by poisoning with medicines, bad foodstuffs, alcohol. The patient complains on the pain in the stomach, nausea, vomiting, diarrhea. In these causes we must make gastric lavage. Its action is to clean the stomach. The indications for gastric lavage (washing, irrigation): 1. Poisoning with medicines, bad (of poor quality) foodstuffs, fungi, alcohol etc. poisons (venom); 2. Delay of nutrition in the stomach because of pyloric stenosis; 3. Atony of a stomach with the phenomena of stagnation of food masses in it; 4. Acute gastritis. Contraindications: 1. Stenocardia; 2. Liver cirrhosis; 3. Peptic ulcer of a stomach and duodenum with predilection to gastrointestinal bleeding; 4. Idiopathic hypertension (serious shape). Gastric lavage is done by using: 1. Disinfected gastric rubber tube with external diameter 10mm; 2. Irrigation syringe or funnel of a capacity of 0,5-1 L; 3. Container (capacity) of 8-10 L boiled water 28-32º C; 4. 2% of sodium hydrocarbonate solution (in poisonings with acids), 0,1% of a citric acid solution (in poisonings with alkalis); 5. Basin or bucket for irrigation water; 6. A mouth dilator, tongue-holder, forceps. Laryngoscope (can be used, if the patient is in an unconscious state). Before procedure, it is necessary to carry out a psychological preparation of the patient; if he is conscious to explain to the patient the purpose and order of carrying out the procedure and the rules of behaviour of the patient during procedure. Before the procedure, demountable prostheses (if they are presence) must be taken off. During procedure, the patient is on a chair and leaning against its back. The patient is given an oil-cloth apron to put on. The basin is placed between his legs on the floor. The hands of the patient are fixed in such position, that it does not prevent him carrying out the procedure. If the patient is not able to sit, put him on the left-hand side with his head, lower than his trunk, to decrease the hazard of breathing in lavaged waters. The nurse takes the disinfected sound (tube) with clear hands and measures the length, which is necessary to insert into patient, from an umbilicus up to incisors, up to lobule of the auricle; then it is necessary to moisten the blind end of the sound with water; to ask the patient to open his mouth and to say “a´-a´”. After that the round end of the sound is put on the base of the tongue, the patient is asked to swallow and at this moment a sound is put into esophagus. In the case of vomiting the movement of the sound should be stopped, the patient is advised to cover the sound by lips and to breathe through nose. After some time the procedure is repeated before the sound will be inserted to necessary mark. If the sound enters in the respiratory pathways the patient begins to cough, he is blue and loses his voice. In this case the sound should be immediately taken out, and after the patient becomes quiet, the procedure should be continued (repeated). In the unconscious patient, this procedure is carried out by the doctor - reanimator with the help of a laryngoscope. If the gastric lavage is made with the funnel, it is necessary to sink a funnel up to the level of elbows of the patient and fill it with water; then gradually to lift the funnel above the head and let water enter into the stomach - a volume of 500-600 ml. It is necessary to follow carefully, so that not all water from the funnel reaches the stomach, because in this case water can not be removed from a stomach again. When in the funnel there is small amount water it must be down ward again to the level of the elbows of the patient and lavage of water with mucous and with oddments of nutrition will be removed from the stomach. The amount of discharged water should be approximately equal to the amount of injected water. This procedure should be repeated for several times, to pure (clean) lavaged water. After ending of gastric lavage sound is placed into 1% solution of chloramine, then is washed carefully in flowing hot water, which must be passed thought tube, twisted and strained from above downwards several times. Sterilization of sound and watering can is carried out by means of boiling method during 15-20 minutes, then they are placed in boiled cold water. With the occurrence of some blood in lavaged water the procedure should be stopped and the doctor should be called. The syringe can be used instead of the funnel. In some cases, gastric lavage can be made by a tubeless method. In this case it is necessary to give the patient a drink of 2-3 glassfuls of mineral waters or light pink solution of a potassium permanganate; after that the patient will vomit artificially by pressing the index and medial fingers of one hand on the root of a tongue and irritating the back wall of the pharynx. Thus a gastric lavage is carried out to “pure (clean) lavage waters”. The tubuless method of a gastric lavage is contraindicative with a poisoning with acids, alkalis, benzine, and also patient in an unconscious position.

Application of colonic tube In long standing meteorism the application of a colonic 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. Vaselinum; 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 side, the procedure shouild be carried out in a position with the patient on his spine with bent knees and a little bit apart. The round end of a tube is greased with Vaselinum. The buttocks are apart and slowly with rotary motions a tube is introduced into rectum to a depth 20-30 cm, the outside end is placed in a vessel with water (bedpan). The tube is removed after 30-60 minutes and the anus wiped with a wet cotton pad.

Catheterization of urinary bladder Catheterization of urinary bladder is carried out with purpose of its emptying, its lavage, and introduction of medicament or taking of urine for research. There are various types of catheters. Insertion of catheter to women. Before procedure nurse or physician washes hands with soap carefully, and phalangettes treats with solution of alcohol and iodine. Then she puts sterile rubber gloves and control condition of catheter. Sometimes catheter losses elasticity due to frequent boiling, and it introduction into urinary bladder becomes difficult. Such catheter must be changed. The patient should assume a supine position with her legs, flexed in knees, and the thighs set apart. Nurse or physician stands to the right of patient. The day before intimate washing of women is carried out, if it is necessary (presence of vaginal discharge) - irrigation is carried out. Lips of pudendum are moved apart by left hand, and by right hand - genitals and urethral opening are washed carefully with disinfectant (0,02% solution of furacilin, 0,1% solution of rivanol, 2% solution of boric acid). The cotton ball should be moved from genitals to the anus (to prevent intestinal organisms from contaminating the urethra or vagina). Further female catheter, which is lubricated with sterile Vaseline oil, is taken by means of forceps, external urethral opening is found and catheter is introduced carefully. Forcible introduction of catheter is inadmissible. Insertion of catheter to men. The patient should assume a supine position with her legs, slightly flexed in knees. Urinal or basin, where urine will flow, should be placed between patient’s feet. It is necessary to remember that female catheter is heavier than female one, as male urethra has length 22-25 cm and forms 2 physiological strictures, which hinder to moving of catheter. Catheterization in man is carried out first by means of rubber catheter. If it is impossible it’s moving to urethra, plastic catheter is used and in last place - metallic one. Only physician introduces plastic and metallic catheter. Prepuce of penis is shifted and balanus is exposed. Nurse takes penis below its balanus between III and IV fingers of the left hand, and by means of I and II fingers disjoins external urethral opening. By right hand balanus in area of external opening is treated by means of gauze ball, moisten with disinfectant (like in women). Treatment is carried out once-twice-repeated pressing of gauze ball, without rubbing in contents in external urethral opening. Then by right hand with forceps nurse takes catheter (at distance 5-6 cm from opening) of catheter) from sterile basin. It is the most convenience to take external end of catheter between IV and V fingers of the right hand. Before introduction catheter must be lubricated with sterile Vaseline oil, glycerin. End of catheter is introduced into external urethral opening and, slightly intercepting it, pushed into urethra deeper; penis is pulled upwards by means of left hand as drawing on catheter. It is necessary to do forward motions slowly, pushing catheter during one motion at distance 1-1,5 cm. Speed of catheter’s introduction is increased continually as catheter approaches to proximal part of urethra. When catheter reaches external sphincter, it is possible to feel slight barrier. Sometimes persistent spasm of sphincter can be marked. For its liquidation it is necessary to recommend regain one’s composure, relax, breath deeply to the patient. When catheter reaches urinary bladder, urine begins exuded from it. There are potential complications after catheterization: bleeding, which occurs due to lesion of mucous membrane of urethra; infection of urethra due to non-observance of aseptic rules; urethral fever, which is explained by fast absorption of urine (infected particularly), through affected areas of urethral mucous membrane into blood circulation

INSTRUCTIONS FOR NURSE OF FUNCTIONAL DIAGNOSTICS ROOM Timely and total realization of planned and urgent functional-diagnostic examinations is the main task of nurse of functional diagnostics room. Designation and dismissal are realized by head doctor. In his work nurse follow normative legal deeds and orders: order No642 from 12.08.88, No560 from 31.05.79 “Statute of functional diagnostics room”.

Qualification demands Person, who finished medical college and has special training on functional diagnostics, can be designated nurse of functional diagnostics room.

Functions Room of functional diagnostics, stationary departments and out-patient department are places of work of this nurse. Every day the nurse: - calls patients for examinations and carries out last ones; - works up examination results (calculation, posting, etc.); - fills in necessary information; - sorts out results of examinations according to departments; - works with archive of the room; - controls technical condition of apparatuses of the room; - reports about all revealed shortcomings and remarks; - carried out studying of the nurses.

Functional duties

The nurse of functional diagnostics room must: - follow professional discipline and moral-ethical norms; - fulfill labor personnel arrangement; - improve level of practical qualification; - look after correct exploitation of lighting equipments; - undergo primary and periodical medical examination; - be instructed according to fire safety; - control external state of apparatuses, contacts, wall outlets, plugs, earths. - prepare apparatus to the work; - switch apparatus, ventilation after ending of the work, set to rights work place. Functional rights The nurse of functional diagnostics room has right: - to propose to the head of the room directly; - to take part in discussion of questions, in accordance with post; - to settle within limits of her jurisdiction; - to pick up information from the head of the room and senior nurse.

System of subordination and connection with other official persons - the nurse is subordinated to head of the room and senior nurse of functional diagnostics room. Interrelations  with nurses of functional diagnostics room;  with physicians of in-patient and out-patient departments;  with workers of “Medical techniques” during prophylactic inspection of apparatus and in case of calling of specialist for repairing of apparatuses. Estimation of the work and responsibility  estimation of the work of the nurse of functional diagnostics room is carried out by timeliness and quality of performed examinations.  nurse is responsible personally for timely and qualitative carrying out of patient’s examination, fulfillment of this instructions and instruction according to labor protection. Working place  working place is near different apparatuses of functional diagnostics.

ELECTROCARDIOGRAPHY Electrocardiography is the method of graphic recording of electric currents generated in the working heart. The curve reflecting the electrical activity of the heart is called the electrocardiogram (abbreviated ECG). Before getting acquainted with electrocardiography it is necessary to remember the structure and the functions of the electrical conductive system of the heart. The following main functions of the heart are distinguished. Automaticity is the ability of the heart to initiate electrical impulses in the lack of external irritants. Automatism is peculiar to any part of the cardiac conductive system, except of the middle part of the atrioventricular node. Contractile myocardium is deprived of the automatical function as well. Ionic — exchanging processes in the cell are the base of automatism. The sinoatrial (SA) node or node of Kis-Flak is the fastest and dominant cardiac pacemaker which is located near the area of the vena cava orifice of the right atrium and discharges impulses at the rate of 60-90 times per minute. From S-A node excitation process spreads to the atria along the bundle of Bachmann, Venkebach and Torel and reaches the atrioventricular (AV) node (or Ashoff-Tovar's node). AV node is a secondary pacemaker. It is located in the right atrium between the orifice of the coronary sinus and the area of attaching of the tricuspid valve blade and emits 30 to 40 impulses per min. Having passed through the atrioventricular node the impulse spreads through His bundle then along its branches, which form 3 branches: the right and two left ones. Cells of His bundle are the center of the third order automatism and emit 20 — 30 impulses per min. His bundle branches turn into Purkinjie fibers, which approach each every myofibril and are potential or latent pacemakers. Normally S-A node is a generator of the impulses. Conductivity is the ability of the heart to transmit its impulses from the area of their appearance to the contractive myocardium (fig.1).The function of the excitation conductivity is peculiar both to specialized tissue of the electrical conducting system of the heart and contractive myocardium. Normally the impulse is conducted from one point to another without any loss of intensity. Physiological delay of impulses occurs in the AV node, due to this normal time succession of atria and tides excitation occurs. The wave of excitation spreads from top to bottom in strict succession: the right atrium, the left atrium intraventicular septum, right and left ventricles. The wave of depolarization in the ventricular wall spreads from endocardium to epicardium.

Purkinje System System

Fig. 1. Electrical Conduction System of the Heart

Excitability is the ability of the heart to respond to an impulse. The electric current is generated at time of excitation, recorded by galvanometer and seen as ECG. Contractility is the ability of the cardiac muscle to contract in response to excitation. Contractive myocardium generally possesses this function. The fundamental, that is pumping, function of the heart carried out due to successive contraction of different parts of the heart. Refraction — is the disability of the excited myocardial cells 1 become active again due to the additional impulses. Absolute and relative refraction periods are distinguished. The heart cannot become excited and cannot contract independently on the coming impulse fore during absolute refractority period, which corresponds to the duration of the QRS complex and of the ST segment on ECG. The heart responds 1 the strong excitation during relative refractory period, which corresponds to T wave on ECG. The excitation of the myocardial fiber fully returns to normal during diastole, but its refraction is absent. ECG BIOELECTRICAL PRINCIPLES Motions of the ions of potassium, sodium, calcium chlorine through cellular membrane leads to the occurrence of electric potentials in cardiac muscles. When myocardial fiber is at rest the outer surface of cellular membrane is charged positively and the inner surface is charged negatively. The reason of this condition is higher concentration of cations Na+ and Ca++ on outer surface of cellular membrane. The anions of CI- make the interior surface to be charged negatively. The cell is polarized in these requirements (fig. 2).

Fig. 2. ECG bioelectrical principles

Sodium-potassium pump action results in electrical impulse beginning. The sodium ions move inside the cell transferring positive charge there. Anions of Cl- move from the cell and myocardial fiber gets negative charge. This phenomenon is called the depolarization. At this moment the cell is changed by opposite charges and is called the dipole. The depolarization of one part of a cell raises such processes in the adjacent area. Thus the action potential spreads along all the muscle fiber. The P, Q, R, S waves order arise on ECG in consecutive. During a complete excitement of the heart ventricles a segment ST is recorded on ECG. At the end of the period of excitement the cellular membrane becomes less permeable for cations of Na+ but more permeable for cations K+. The moving potassium from the cell makes a positive charge outside the membrane and the interior surface of the membrane is charged negatively again. These processes are called repolarization (T wave on ECG). These changes occur during the period of systole. When all the outer surface of a membrane is charged positively and the interior one — negatively again, the cell will take starting position. This period is called polarization and corresponds to diastole. The isoelectric line will be registered on ECG.

ECG RECORDING For ECG recording it is necessary to connect the patient with a electrocardiograph with the help of the electrodes. Moist pieces of cloth are placed on the lower third of both arms and both legs, upon which the electrode plates are then placed. The electrodes are connected to the apparatus with special wires of different colors. A red wire is connected to the electrodes on the right arm and a yellow one — to those on the left arm, a green wire — to the left leg and a black wire — to the right one (for the grounding of the patient). The chest electrode is placed successively at 6 positions with the help of the suckers: V1 — right sternal line, the 4-th intercostal space, V2 — left sternal line, the 4-th interspace; V3 — left parasternal line, the 4-th interspace (midway between V2 and V4) V4 - left midclavicular line, the 5-th interspace, V5 — left anterior axillary line, the 5-th interspace, V6 — left midaxillary line, the 5-th interspace. The ECG recording starts with the recording of control millivolt (mV). For that, a button "mV" is pressed and a 10 mm deviation of the beam should be achieved by a current regulator. After that 12-leads ECG are recorded which are moustly applied: • 3 standard or bipolar leads are used to record the potentional difference between 2 points of the electrical field, which are removed off from the heart and placed on the limbs: • lead I ECG is recorded by electrodes placed on the arms; • lead II ECG is taken from the right arm and left leg and • lead III - from the left arm and the left leg. In English-speaking countries these leads are usually denoted by symbols LI; L2; L3 (from word "limb") or by figures 1; 2; 3. • Three augmented unipolar limb leads differ from bipolar limb leads because their potential difference is recorded mostly by one active electrode, which is placed successively on the right arm, left leg and left arm. The other negative electrode is formed by the connection of 2 limb electrodes. They are written down with Latin letters: aVR; aVL; aVF. It means: "a" — augmented; "V" — Vilson (author); "R" — right — right arm; "L" — left — left arm; "F" — foot- left leg. • Six unipolar chest leads record the potential difference between active electrode which is placed on the anterior surface of the chest, and the other indifferent electrode which is formed by connected together 3 electrodes from right arm, left leg and left arm (V1 - V6). One should remember, that: — aVR lead resembles a turned standard lead I: waves P and T are negative, main wave is directed down. — The form of aVL lead is similar to that of standard lead I, and aVF — to standard lead III. — Normally in chest leads R wave increases from V1 to V4, and maximal S wave in V2 decreases to V4. Each lead characterizes the condition of the different areas of the heart. Thus: I; aVL — the anterior wall of the heart, usually anterior wall of the left ventricle; III; aVF — the posterior wall of the left ventricle; II — the anterior and the posterior wall of the left ventricle; V1; V2 - the anterior wall of the right ventricle; V3 — the interventricular septum; V4 — the apex of the heart; V5 ;V6 — the left side of the left ventricle. ECG is usually recorded at a speed of tape moving 50 mm/sec. In this case each millimeter of the curve corresponds to 0,02 second. If ECG is recorded at a speed of 25 mm/sec, each millimeter of the curve corresponds to 0,04 sec. Normal ECG is a specific curve, on which the following elements are distinguished: positive waves P, R and T, negative waves Q and S; PQ, QRS and QRST intervals; ST, TP segments (fig. 3).

Fig. 3. Normal ECG

Amplitude of the waves is measured in "mV" or conditionally in millimeters (if 1 mV=10 mm), the width of the waves and the duration of the intervals are measured in seconds. The measures are made in such a lead where these parameters have the highest size (usually it is the II standard lead). Each of these elements characterizes the time and sequence of excitation of various parts of the myocardium. During diastole the heart does not generate current and an ECG records a straight line (TP segment) which is called isoelectrical one The ECG interpretation can be devided into 5 stages:

THE 1-ST STAGE. Determining of the pacemaker and regularity of the cardiac rhythm. To determine the pacemaker, it is necessary to assess the direction of the exitement along the atria and to establish the relation of P waves to QRS complexes in a standard lead. Normally rhythm is sinus. It is characterized by positive and uniform P waves in a standard lead n, every P wave being followed by a QRS complex. If these signs are absent, the variants of the nonsinus rhythm are diagnosed: 1. Atrial rhythms (from the lower parts of atria) are characterized by negative P waves in the II and III leads, before normal QRS complexes. 2. Junctional rhythms are characterized by the following signs: a) no P waves are seen because they are merged with the constant QRS complexes; b) there are negative P waves are present after the normal QRS complexes. 3. Ventricular rhythm is characterized by: a) the rate is slow (below 40 per minute); b) the QRS complexes are wide and deformative; c) the P waves are not connected with the QRS complexes. For the assessment of the cardiac rhythm regularity it is necessary to measure the duration of RR interval on all leads with a ruler. A rhythm is regular if the RR intervals are equal or their fluctuations do not exceed 0,1 sec. (at a speed of 25 mm/sec, it is 2,5 mm of the curve, at the speed of 50 mm/sec, it is 5 mm of the curve). Greater variations in the length of the RR intervals indicate disorders of cardiac rhythm. It is called an irregular rhythm.

THE 2-ND STAGE. Evaluation of the heart contraction rate. For the calculation of the heart rate it is necessary to determine the duration of the RR interval in seconds, for which its length in millimeters is multiplied by 0,02 sec. or 0,04 sec. (depending on the speed of the tape). If the cardiac rhythm is irregular, first the length of 5 RR intervals is determined, then RR interval is found out and finally the cardiac rate is determined for regular cardiac rhythm. The heart rate (HR) is determined by formula: HR=60 sec/RR interval in sec. In normal the rate of cardiac contraction varies from 60 to 90 per min.

THE 3-D STAGE. The determination of the position of the electrical axis of the heart: aid electrical position of the heart. The electrical axis of the heart (EAH) is the direction of the total electromotive force of the heart. Five positions of electrical heart axis are distinguished: 3 physiological ones: normal, horizontal, vertical and 2 pathological ones: deviation of the electrical axis to the left and deviation of the electrical axis to the right. Electrical axis of the heart is expressed by the degree or is determined visually by the shape of QRS complexes in standard leads. At first it is necessary to exclude a pathological position of the electrical axis. For this the S wave depth in the standard leads is assessed. In deviation of the electrical axis to the left the depth of the S wave is registered in the III standard lead and RI>RII>RIII (fig. 4d).

Fig. 4. The positions of the electrical axis of the heart In deviation of the electrical axis to the right the depth of the S wave is determined in the I standard lead and RIII>RII>RI (fig. 4e). If there is no deep S wave in standard leads we determine one of the physiological positions of the electrical axis by the amplitude of the R wave. For the EAH normal position RII>RI>RIII is characteristic (fig. 4a); for a horizontal position of the EAH RI>RII>RIII is characteristic (fig. 4b); for a vertical position of the EAH of RIII>RII>RI or RII>R III> RI (but always RIII>RI) is characteristic (fig. 4c). These variants of the EAH position can be both in a healthy person and in the patients with ventricular hypertrophy. Deviation of the EAH to the right or to the left, as a rule, is a sign of the pathological changes in the cardiac muscle. Electrical position of the heart depends on its position in the chest in relation to three axises: anterio-posterior, longitudinal; transversal. The electrical position of the heart is determined on aVL and aVF leads. If a deep S wave (S>R) is present in aVL lead, it is characteristic of vertical electrical position of the heart. If a deep S wave is present in aVF lead, this is a horizontal position of the heart. Absence of the deep S waves in these leads testifies the basic or intermediate position of the heart.

THE 4-TH STAGE. Analysis of the intervals. PQ interval shows the time of the spreading of the impulse to the atria, A-V node, His' bundle and it extends from the beginning of the P wave to the beginning of the Q or R wave (if the Q wave is absent). The normal length of the PQ interval is 0,12 — 0,20". Shortened PQ interval (smaller than 0,12 ") can be in premature ventricle contraction Wolf-Parkinson-Wight syndrome. The length of the PQ interval more than 0,2" is called atrioventricular block. Duration of the PQ interval is inversely proportional to a heart rate. QRS interval shows the time of transmission of the electrical impulse along the His bundles and the Purkinje's fiber network and reflects the depolarization of both ventricles. The length of the QRS complex is measured from the beginning of the Q wave to the end of the S wave. The normal QRS interval is 0,06 to 0,lsec. The prolongation of the QRS interval (more than 0,1 sec.) is known as an intraventricular block. The QT interval duration reflects the electrical systole of the ventricles. It extends from the beginning of the Q wave (or the R wave, if the Q wave is absent) to the end of T wave. Its duration fluctuates from 0,35 to 0,44 sec, and depends on the rate of cardiac contractions (in accelerated heart rhythm the QT interval shortens); on the sex (the QT interval is longer in females than in males); on the age, but it does not exceed 0,51 sec. The prolongation of the QT interval is the evidence of pronounced diffuse pathology of the myocardium; it can be in hypercalcemia and central nervous system diseases.

THE 5-TH STAGE. The analysis of the waves, ST segment and voltage of ECG. The P wave is formed as a result of exitement of both atria (right, then left). Analysis of P wave includes: 1) measuring of the P wave amplitude; 2) measuring of the P wave length; 3) determining the P wave polarity; 4) determining the P wave form. The P wave amplitude is measured from isoline to the wave top, and its duration is measured from the beginning to the end of the wave. Its normal amplitude is 1,5 — 2,5 mm, the duration being 0,08 — 0,1 sec. Prolongation of P wave amplitude is the sign of hypertrophy of the atria, it is described in detail further. Prolongation of P wave is the evidence of the intraatrium conduction disorder. The polarity of P wave shows the direction of the wave excitement and therefore the localization of the pacemaker. Normal P wave is always positive in I; II; aVF; V2 — V6 leads. Sometimes in III, aVL, V 1 leads it can have two-phases, and sometimes in III and aVF leads it can be negative. P wave is always negative in aVR lead. Q wave is conditioned by the process of the itraventricular septum depolarization. For its assessment it is necessary: a) to measure the Q wave amplitude and to compare it with the R wave amplitude on the same lead; b) to measure the duration of the Q wave. In normal it is not deep and often absent in ECG. Wide (more than 0,03 sec.) or deep (more than 1/4 R wave in the same lead) Q wave is pathological, it may indicate the acute myocardial infarction, the cicatrice in myocardium, acute "pulmonary heart" and is assessed together with other signs. The R wave depicts the process of stimuli spreading in both ventricles. In normal it is not reduplicated, its duration being 0,04 sec. R wave amplitude gradually increases from V1 to V4 and then slightly decreases to V5 — V6 leads. R wave usually indicates a voltage of the ECG. For this purpose the amplitude of R waves is measured in standard leads. Normal amplitude is 5 to 15 mm. It is called the voltage is kept. If the amplitude of the highest R wave does not exceed 5 mm in standard leads, or the sum of amplitudes of these waves in all three leads is less than 15 mm, (RI+RII+RIII<15 mm) the ECG voltage is considered decreased. Decreasing of the voltage arises in diffuse affection of the myocardium, exudative pericarditis. R wave reduplication or splitting can occur in case of disturbance of the intraventricular conduction. The negative S wave reflects the terminal excitation of the ventricles. For assessing S wave it is necessary: a) to measure S wave amplitude and to compare it with R wave amplitude in the same lead; b) to pay attention to a possible widening, the jagging or the splitting of the S wave. In normal S wave amplitude varies widely in different ECG leads, but does not exceed 20 mm. In the normal position of the heart in the thorasic cavity the amplitude of the S wave is small (2,5 mm on average) in limb leads, except for aVR lead. The deepest S wave is in the chest leads V1; V2, then it gradually decreases to V4 lead, and S wave is very small or absent in V5 — V6 leads. The appearance of the deep S wave in standard leads indicates the hypertrophy of the ventricles. Equality of the R and S waves in the chest leads ("transition zone") is usually recorded in V3 lead or (rarely) between V2 and V3 or V3 and V4 leads. The T wave reflects the process of the fast terminal repolarization of the ventricular myocardium. In normal T wave is always positive in I; II; aVF; V 2 — V6 leads, TI>TIII, and TV6>TV1. T wave can be positive, double-phased or negative in III, aVL and V1 leads. Normally the T wave is always negative and asymmetrical with the gradual ascending and abrupt descending in aVR lead. Its amplitude is connected with R wave and usually does not exceed 6 mm in standard leads, in chest leads it can reach 15 — 17 mm, its height gradually increasing from V1 to V4 and then decreasing to V5 — V6 leads. Its changes (flat or inverted or two phases) are not specific and can occur in different pathological conditions (ischemia, dystrophy or inflammation of the myocardium, pericarditis or certain drugs' intake (potassium, calcium digitalis, etc). Making diagnosis is possible only on base of complex evaluation of the ECG and clinical data. In case of a changed T wave disturbance of the repolarization is suspected. The ST segment reflects the slow phase of repolarization of the ventricles. For the ST segment analysis it is necessary to place the ruler to isoline (segment TP) and to establish the position of its segment relatively to isoline (higher or lower) in all leads. In normal, ST segment is isoelectrical. The ST segment may be displaced from the isoelectric line to not more than 1 mm. RS-T segment in a healthy person is on the level of isoelectrical line (±0,5 mm) in the limb leads. In normal there can be small displacement of the RS-T segment up from isoline (not exceeding 2 mm) in the V1 — V3 chest leads, and down (not exceeding 0,5 mm) in the V4-6 leads. Displacement of ST segment upper the isoelectrical line can show acute ischemia or myocardial infarction, cardiac aneurism, sometimes it can be in pericarditis or, rarely, in diffuse myocarditis and in hypertrophy of the ventricles. ST segment displaced lower isoelectric line can be of different shape and direction, which has a certain diagnostic importance, namely: — horizontal ST segment depression is often a sign of the coronary insufficiency; — descending ST segment depression of, more expressed in its terminal part, is often observed in the hypertrophy of the ventricles and complete His' bundle blockage; — troughed displacement of this segment as arc, curved downwards, is characteristic of hypokalemia, digitalis intoxication; — ascending ST segment depression is often observed in severe tachycardia. Filling in the ECG form. The electrocardiogram is interpreted as follows: 1. Pacemaker (sinus or nonsinus). 2. Regularity of the cardiac rhythm (regular or irregular). 3. The heart rate. Voltage. 4. Position of the electrical axis of the heart. 5. Determination of 4-th ECG syndroms: a) cardiac rhythm disorders; b) myocardial conduction disorders; c) atrial or ventricular hypertrophy; d) myocardial affections (ischemia, dystrophy, necrosis, cicatrices).

PHONOCARDIOGRAPHY Phonocardiography is the method of recording sounds generated in the beating heart. Phonocardiography is an essential supplement to the heart auscultation. Sounds generated in die heart are recorded on a phonogram as a curve (PCG) by an apparatus known as a phonocardiograph. It consists of a microphone, an amplifier, a system of sound filters, and a recording device. The microphone picks up sounds and converts them into electrical signals. They are amplified and transmitted into the system of sound filters where the sounds are separated by their frequencies (low, medium — and high — frequency sound) for their separate recording. Oscillations of a certain frequency are transmitted to the recording device which draws a curve. For a better interpretation of the phonocardiogram, an electrocardiogram should be taken synchronously.

I tone Fig. 5. Phonocardiogram Phonocardiograms are taken in complete silence with the patient in the lying position; the breath should be hold during the expiration phase. The microphone is placed successively on those sites of the chest where heart: sounds are audible during auscultation, and also on those areas where the sounds can be heard well. Phonocardiograms should be analyzed and diagnosis established only by interpreting the phonocardiogram together with the auscultation findings. A normal phonocardiogram gives a graphic picture of vibrations caused by the first and second heart sounds, with a straight line in between, corresponding to the systolic and diastolic pauses. mitral valve, aortal valve, the valve of the pulmonary trunk and tricuspid valve. The PCG deciphering should be carried out in the sequence of its recording: mitral valve, aortal valve, the valve of the pulmonary trunk and tricuspid valve. The I, II, III, IV sounds are described in turn (fig. 5).

Analysis of the I sound should be carried out only on the recording from the mitral and tricuspid valves. This is conditioned by the I sound origin. The I sound is recorded immediately after R wave at the level of the S wave synchronously with ECG. Three main groups of vibration can be distinguished in the I sound. Initial

I tone

small amplitude vibrations are conditioned by the contraction of the ventricular muscles. Main, central segment of the I sound is formed by the vibrations of the maximal amplitude and conditioned by the closing of the mitral and tricuspid valves. The final part of the I-st sound is small vibrations connected with the opening of the aortic and the pulmonary trunk valves.

Fig.6. Phonocardigram from the heart apex

It is necessary to describe the I sound. At first the amplitude of the I-st sound is measured, then its loudness is characterized. The amplitude of the I sound is the highest at the heart apex and the xiphoid process, where it exceeds 1,5-2 times the amplitude of the II sound. (fig. 6) If the amplitude of the I sound at the heart apex or the xiphoid process 3-4 times exceeds the amplitude of the II sound, it is called an increase of the I sound. (fig. 7b)

soud sound

Fig. 7. Pathological I-st sound

Increase of the I sound at the heart apex may be in case of stenosis of the mitral orifice or in tachycardia. If the amplitude of the I sound has the same amplitude as the II one or smaller, it is called the weakness of the I sound (fig.7a). Decrease of the I sound at the heart apex is observed in insufficiency of the mitral valve and in the affection of the heart muscle (myocarditis, cardiosclerosis, myocardiodystrophy). Decrease of the I sound at the xiphoid processes is obrerved in insufficiency of the tricuspid valve. Then the duration of the I sound is measured. In healthy persons it is 0,1- 0,12 sec. The duration of the I sound increases in the affection of the myocardium and in cardiac conductive system affection. The I sound can be splitt. In this case there is the division of the basic part of the I sound into two complexes occurs, but common duration of the I sound preserved and a pause between both parts of the 1 sound is not more than 0,02 sec. Splitting of the I sound is observed: • in the hypertrophy of the left ventricle in sportsmen;

• in the persons who are occupied in a laborious work; • during a very deep expiration. In case of reduplication of the I sound common duration of the I sound increases and a distance between both apexes is more than 0,07 sec. (fig. 8).

Fig.8.Reduplication of the I-st sound

It occurs in asynchronous contraction of the ventricles (bundle-branch block, hypertrophy of the right ventricle). In atrioventricular block the I sound is reduplicated too, but in this case the pause is recorded between the 1-st and the 2-nd parts of the I-st sound. Further the II sound is described. The most informative points for its analysis are the 2-nd interspace to the right and to the left from the sternum and Botkin-Erb point. This is conditioned by the II sound origin: as the result of the aortal and pulmonary trunk valves closing. The II sound is composed of several vibrations which appear synchronously with the end of the T wave on ECG (valvular and vascular components). Its duration is usually 0,04-0,07 sec.

The amplitude of the II sound is the highest at the base of the heart (aortal or pulmonary trunk valves), where it 1,5-2 times exceeds the amplitude of the I sound (fig. 9).

Fig.9.Phonocardiogram from the aorta

If the amplitude of the II sound at the base of the heart 3-4 times exceeds the amplitude of the I sound, it is called increase of the II sound (fig. 10).

Fig.10. Pathological II sound sound ooundsssound

I II I II

Increase of the II sound over aorta is observed in a high pressure in systemic circulation and atherosclerosis of the aorta. Increase of the II sound over pulmonary trunk is observed in high pressure in pulmonary circulation (mitral diseases, chronic diseases of the lung). If the amplitude of the II sound has the same amplitude as the I one or smaller, it is called the weakness of the II sound. Weakeness of the II sound over aorta is observed in low pressure in systemic circulation (hypotonia) and in aortal valve insufficiency. Weakeness of the II sound over pulmonary trunk is observed in pulmonary trunk valve insufficiency. In normal the amplitude of the II sound on the aorta and the pulmonary trunk is equal. If the amplitude of the II sound is higher on the aorta or pulmonary trunk then this state is characterized as an accent of the II sound on one or another valve. Accent of the II sound is observed in the cases as well as an increase of the II sound. The II sound can be splitted and reduplicated. In these cases the pause between its aortal and pulmonary parts is visible. If the pause does not exceed 0,02-0,03 sec and total duration of the II sound does not change it is called the splitting. It can be observed in healthy persons and in juveniles. Reduplication of the II sound (if the pause exceeds 0,05 sec) is observed in increasing of the blood pressure in systemic circulation (essential hypertension) or in pulmonary circulation (mitral diseases or chronic diseases of the lungs), in the left ventricle extrasystoles, in bundle-branch blocks (fig. 11).

Fig.11.Reduplication of the II sound

True reduplication of the heart sounds must be differentiated from apparent doubling which is connected with the appearance of adventitious sounds. In the latter case the basic sound does not change and another one appears before or after it. The III sound appears as a result of the tonic tension of the ventricular muscles during rapid diastolic filling of the ventricles with the blood from the atria. The III sound is recorded at the heart apex or at the Botkin-Erb point 0,12-0,18 sec after the II sound. Physiological III sound is observed in children and thin youths before 20 years, in sportsmen. In this case the I sound is not changed and other signs of the myocardial affection are absent. Pathological III sound is caused by anomalous vibrations of the ventricles due to diminished resistance of the ventricular walls generated during ventricles filling with the blood at the beginning of the diastole. Appearance of the pathological III sound in combination with the weakened I sound is called protodiastolic gallop rhythm. Both the III and the IV sounds, which are heard as one sound, produce mesodiasfolic gallop rhythm. One of the additional sounds is called mitral valve opening sound (mitral valve opening snap). It is usually recorded in the high frequencies 0,04—0,12 sec later the II sound at the heart apex of the patient with stenosis of the mitral orifice. In this case on PCG snapping I sound at the heart apex and accent of the II sound over pulmonary trunk are observed. Combination of the three mentioned symptoms (snapping I sound, mitral valve opening sound and accent of the II sound over pulmonary trunk) is called triple rhythm. Interval between the II sound and the mitral valve opening sound depends on the pressure in the left atrium. The higher atrial pressure the earlier mitral valve opens during diastole and the interval will be shorter. This regularity is used in mitral stenosis diagnostics. Further the interval Q-I sound is calculated by measuring in milimeters the duration from the beginning Q wave synchronous with ECG to central part of the I-st sound of PCG. In normal it is 0,04—0,06 sec. Its duration increases in mitral stenosis. After the tone characteristics description of murmurs is performed. Phonocardiography is very helpful in interpreting the character of heart murmurs. PCG determines the form of the murmur, amplitude, duration, and relation to cardiac tones (basic and additional), the auscultative zone of high amplitude, the place of irradiation and feequency characteristics. The systolic and diastolic murmurs are distinguished relatively the cardiac tones. Sometimes protodiastolic, mesosystolic and late systolic, pansystolic, protosystolic, pandiastolic, and systolo-diastolic murmurs are distinguished. According to their form the murmurs are divided into increasing, decreasing, rhomboidal and lentiform. Depending on their frequency characteristic the murmurs can be: low- frequency, middle- frequency and high-frequency. The organic systolic murmur merging with the I sound, lasting not less than 2/3 of systole being decreased and registered on the heart apex is characteristic of the mitral valve failure (fig. 12). This murmur is combined with low frequency of the I sound on the apex of the heart and with high frequency (accent) of the II sound on the pulmonary trunk.

Fig. 12. Insufficiency of the mitral valve

Fig. 13. The aortal orifice stenosis

The high amplitude organic systolic murmur, of rhomboidal form on the aorta and not merged with the I sound is characteristic of aortal stenosis (fig. 13). The same murmur but on pulmonary trunk is observed in pulmonary trunk stenosis. The functional systolic murmur is observed in relative failure of the mitral valve, diseases of myocardium, anemia, thyrotoxicosis, high temperature and is characterized by small amplitude and a rhomboidal form. It is mostly expressed on the pulmonary trunk and less frequently on the heart apex, short (less than 2/3 of systole), not merged with the I tone and is not registered on every beat of the heart.

The organic diastolic presystolic murmur of increasing character, merging with the snapping I sound and registered at the heart apex is characteristic of the mitral valve stenosis (fig. 14).

Fig. 14. The mitral valve stenosis stenosis The organic diastolic murmur of decreasing character registered after the II sound on the aorta is observed in the aortic valves insufficiency (fig. 15).

Fig.15. The aortic valves insufficiency The functional diastolic murmur (Flint's murmur) is observed on the heart apex in the aortic valve failure. In this case the organic diastolic murmur on the aorta is combined with low-frequency functional murmur on the heart apex and a weakened I sound.

ECHOCARDIOGRAPHY IN CARDIOVASCULAR DIAGNOSIS

Ultrasound echography (syn. echolocation, ultrasound scanning, sonography) is a diagnostic method based on different reflection of ultrasound waves that pass at various velocities through tissues and media of various density. Ultrasound is now widely used in the diagnosis of internal diseases, such as the diseases of the heart, liver, gall bladder, pancreas, kidneys, the thyroid, etc. The use of echography in cardiology makes it possible to determine the presence and character of heart defects, calcification of the cusps in rheumatism and other changes in this organ. BASIC PRINCIPLES OF ULTRASOUND First attempts to use ultrasound for diagnostic purposes were undertaken more than 35 years ago, but satisfactory technical apparatuses have been devised and introduced into clinical practice only during recent time. Cardiovascular applications of ultrasound rely on the fact that ultrasound, generated by the vibration of piezoelectric crystals at frequencies from 2 to 40 MHz or even higher, can be formed into a beam that a) propagates at a uniform speed through most body tissues and b) is reflected from structures in the body to return to strike the piezoelectric crystal from which il originated, which in turn generates an electrical signal. The advantages of ultrasound are following: it can be used to determine the structure of various organs without producing any harmful effect on the patient; - the procedure is not in the least annoying to the patient; - the examination can be repeated (for example in order to assess the dynamics of the process) without any detriment to the patient; - great diagnostic reliability and the value of data obtained with ultrasound make this method very important; - in comparison with other methods since it needs no contrast, radioactive, or other substances to be given to the patient before the procedure. The time interval between transmission of a burst of ultrasound a few microseconds in duration and generation of an electrical signal by the returning "echo," taken together with the known velocity of ultrasound in the body, allows one to determine the distance along the ultrasound beam from the transducer to a reflecting structure, providing information that can be used to image the heart and large arteries and veins. Increases or decreases between the frequency of the emitted and reflected ultrasound can also be used, according to the Doppler principle, to determine the velocity of the reflecting structure's motion toward or away from the transducer. Use of the Doppler shift to determine the velocity along the ultrasound beam of red blood cells forms the basis of Doppler echocardiography evaluation of blood flow. One - and two-dimensional methods of visualization are used. In the one- dimensional (M-method) echography, ultrasonic waves reflected from the studied object arc converted into electric pulses and delivered onto the vertically deviating plates of an X-ray tube. Whenever several anatomical media, located at different distances from the receiver, arise in the pathway of the ultrasonic beam. The vertical spikes arc fixed on the horizontal scanning in succession, in accordance with the time of arrival of the ultrasonic pulse reflected from this or that object. Since this process is repeated at high frequency, the scanning line with spikes on it appears as a stationary pattern on the oscilloscope, screen. The M-method can be used to measure accurately the distance to the object under examination, to determine its anteroposterior dimensions, and sometimes to obtain information concerning special properties of the structure. The method fails to give complete information on the configuration and the size of the object studied, especially so if the object has irregular form. The two-dimensional method (B-method) gives information about shapes, dimension, and the structure of the object under study. The Doppler effect is used for determining moving objects. Sound or light waves are reflected from the moving objects and return to their source with the changed wave frequency. This change is recorded by a receiving element and converted into an audible signal. Instruments utilizing the Doppler effect as their operating principle work with a continuous single frequency. The ultrasonic Doppler system is used for assessment of the blood circulation parameters. The formed elements of blood (and other moving objects) reflect ultrasonic waves whose frequency is modulated. The modulation frequency is proportional to the velocity of motion of the studied object. Velocity is calculated as the difference between the emitted and received frequencies (Doppler formula). PHYSICAL PROPERTIES OF ULTRASOUND An appreciation of the physical properties of ultrasound that determine the information that can be obtained is valuable to understand the strengths and limitations of various echocardiography modalities. One of these is that the average speed of ultrasound (1540 m/sec in body tissues) determines the frequency with which the cycle of ultrasound transmission and echo reception can be repeated. This ranges from 1000 to 1500 times per second for echocardiograms in adults, in whom cardiac structures may be as far as 20 cm from body surface transducers, to higher frequencies for cardiac imaging in children or for evaluation of relatively superficial arteries or intravascular studies. Nearly instantaneous tracking of rapidly moving structures is obtained when the ultrasound beam interrogates the same portion of the heart or vessel through the cardiac cycle, as in M-mode echocardiography. Alternatively, the beam can be swept mechanically or electronically to create a tomographic slice. Because it is desirable to have at least 50 lines of primary information to produce a good quality 90-degree "sector scan," these can be obtained no more frequently than 20 to 30 times per second for cardiac imaging in adults, Thus, M-mode echocardiography has superior temporal resolution, whereas two-dimensional echocardiography provides superior spatial orientation but at a somewhat slow frame rate. The spatial resolution of echocardiography is influenced by several additional factors. The ability to discriminate two nearby objects along the axis of the echocardiographic beam ("depth resolution") is directly related to the ultrasound wavelength and, hence, is inversely proportional to its frequency. The theoretic limit of depth resolution is about 1 mm at a frequency of 2,25 MHz and 0,5 mm at a frequency of 5 MHz. These limits may be achieved in vivo or even exceeded because of the effect of temporally (M-mode) or spatially (two- dimensional) adjacent lines of echoes to reduce ambiguity about the location of interfaces. High ultrasound frequency thus enhances depth resolution; however, the inverse relation between ultrasound frequency and depth penetration into the body has so far limited transthoracic echocardiography to maximum frequencies between 3 and 5 MHz, whereas frequencies between 7 and 15 MHz or even higher may be used (in-other applications such as imaging the carotid or other superficial arteries transcutaneously, evaluating coronary arteries during open heart surgery, or measuring arterial lumen and wall dimensions and characteristics by catheter-tip ultrasound transducers. The ability to discriminate two objects side-by-side and perpendicular to the ultrasound beam (lateral resolution.) is determined by beam width and the extent to which it is focused. Even under ideal circumstances, lateral resolution is less good than depth resolution with all systems used for cardiovascular ultrasound studies. Difficulties with lateral resolution may cause echoes from solid structures to extend laterally into what should have been echo-free spaces containing blood, overstating the cross-sectional area of the left ventricular myocardium and understating that of the ventricular cavity. Evaluation of blood flow by Doppler echocardiography is also influenced by several properties of ultrasound. The most important of these is that the maximum frequency shift - and, hence, velocity of blood flow that can be accurately detected - is proportional to the frequency with which pulses of ultrasound are repeated. This is no problem in continuous-wave Doppler, where ultrasound is continuously emitted from one transducer and the returning signal is received by another, but this modality has the limitation that the recorded velocity may be due to blood flow at any depth along the ultrasound beam ("range ambiguity"). Range ambiguity is eliminated by pulsed-mode Doppler, in which bursts of ultrasound are emitted intermittently and the returning signal is interrogated at an interval thereafter determined to allow the ultrasound to travel from transducer to target and back. However, the slow pulse repetition frequency this entails may, at greater depths within the heart, limit the maximum velocity that can be resolved to 1 m/sec or less, well within the physiologic range. Color flow Doppler recordings reduce spatial ambiguity even further by displaying blood flow patterns in two- dimensional tomographic slices but suffer from even more severe limitation of the maximum velocity that can be accurately detected.

FUNDAMENTALS OF THE ECHOCARDIOGRAPHY EXAMINATION Fig. 16.Two-dimensional echocardiography: section of chambers of heart and valves with registration of movement of walls left ventricle, left atrium and aorta.

ECHOCARDIOGRAPHY EVALUATION OF CARDIAC STRUCTURES

At performance of Echocardiography the ultrasonic gauge have in barefaced easy area of absolute dullness of heart ("of an acoustic window"). Registration Echocardiography begins from identification of mitral or aortal valve. Then small angular displacement of the gauge a ultrasonic beam direct on other structures of heart. Exists echocardiography, at which the registration is made with the help of the gauge entered in esophagus. At one-dimensional echocardiography the image of structures of heart with development (display) of their movement in time turns out. At a M-mode the thickness of walls and sizes of chambers of heart in time systole and diastole is measured. At two-dimensional echocardiography allows receiving the image of heart in real time. Using different points, in which make research and, changing direction a beam, receive the image of structures of heart. Are applied apical, suprasternal and subcostal of a position of the gauge. Apical the approach allows receiving section all 4 chambers of heart and aorta. Echocardiography is used for estimation: a) haemodinamic; b)the sizes of heart chambers in time of systole and diastole; c) of measurement of thickness of a back wall of the left ventricle; d)measurement of thickness of the interventricular septum; e) a fraction of emission of the left ventricle; f) a gradient of pressure through the narrowed aperture.

More frequently echocardiography is used for diagnostics: a) the heart defects; b) hypertrophic cardiomyopatia; c) pericarditis with effusion; d) infectious endocarditis; e) mycsoma of the atrium; f) intracarclial of blood clots; g) prolapse of valves.

The maximal speeds normal intracardial circulation (m/s): - mitral flow (diastole) 0,6-1,3; - tricuspid a flow (diastole) 0,3-0,7; - pulmonary trunk (systole) 0,6-0,9; - target path left ventricle (systole) 0,7-1,1; - aorta (systole) 1,0-1,7.

For researching the following positions of the gauge are use: parasternal - the gauge after imposing of contact paste on a skin in 3 - 4 intercostal space to the left of the sternum (Fig 17); apical - the gauge over the apex of the heart (Fig. 18); subcostal - the gauge is located in the epigastria (Fig. 19); suprasternal - the gauge is located in jugular fosse. The research will be carried out in 3 planes: a short axis of the heart - perpendicular to the long-axis of heart; a long axis - parallel to the long-axis of the heart; plane of four cha mbers of heart - parallel to the frontal plan and at the level of the long-axis of the heart. The research according to longitudinal axis from left of paras-tarnal access allows to determine following structures: - aorta as two parallel linear structures ( the forward wall passes in the interventricular septum, back - forward cusp of the mitral valve; - in front of aorta there is right ventricle; - behind - left atrium settles down. The back wall left atrium proceeds in a back wall of the left ventricle. The right ventricle is located in front of the interventricular septum, behind - left ventricle. Fig.17. Parasternal long-axis two-dimensional view of the heart in diastole of the ventricles: AAW — anterior aortic wall; PAW — posterior aortic wall.

Fig. 18. Apical 4 - chamber cardiac echogram in diastole (left) and systole (right) of the ventricles

Fig.19. Subcostal long-axis 4 - chamber cardiac view

Fig.20.One-dimensional M-section of chambers heart and valves, through which there passes a ultrasonic beam: RV - right ventricle; LV - left ventricle; LA - left atrium; 1 - the beam passes through the RV, an aperture of aorta (registration of aortal valve) and LA; 2 - beams pass through RV, interventricular septum, shutter of the mitral valve (moving at their opening in an opposite direction); 3 - the beam passes through the RV, interventricular septum, cavity of the left ventricle, back wall of the left ventricle. At the other direction of ultrasound the size left atrium, right ventricle, papillary of a muscle can be determined.

The research on a short axis from left of para-starnal of the approach will usually be carried out at a level of the aortal and mitral valves and the papillary of muscles. Behind of aorta settles down left atrium. A back cusps of the pulmonary valve and forward cusps of the tricuspid valve determined accordingly to the left and to the right of aorta. In front of aorta the bearing path of the right ventricle settles down. In a plane at a level of the papillary muscles on the right settles down posterio-medial and at the left - anterio-lateral papillary muscle. In a plane of a short axis at the level of the mitral valve and its bearing path, right ventricle, the interventricular septum and cross section of the left ventricle settles down. At the center it the cusps, driven in an opposite direction, of the mitral of the valve in middle of the diastole, resemble outlines "fish mouth " are visible. Apical the access allows to receive section of four chambers of heart right ventricleand LV are divided by the interventricular septum. The MV settles down a little bit below, than the tricuspid (Fig.21.). The most important primary measurements and derived variables for assessment of the most common forms of heart disease can be obtained from a relatively simple echocardiographic examination, provided that the ultrasound beam and imaging planes are correctly oriented to cardiac structures and blood flow. Because of the central importance of left ventricular structure and performance, the following discussion will focus on this chamber.

Fig. 21. Apical 4—chamber natural cardiac view

The left ventricle may be thought of as a ellipsoid, relatively circular in short-axis views, with a long axis approximately twice its minor axis. To measure the left ventricular minor axis dimension accurately, it is necessary to orient the two-dimensional echocardiographic tomographic plane from the parasternal (or less commonly the subcostal) window to pass through the interventricular septum and posterolateral left ventricular wall so that a cursor line through the chamber at the level of the junction of the papillary muscle tips and mitral chord on the two- dimensional sector would he perpendicular to the walls. Rotation of the two- dimensional sector approximately 90 degrees to the short-axis projection allows one to measure the true maximum left ventricular diameter and correct wall thickness. If, as commonly occurs in older subjects, the best parasternal window is in a low interspace, left ventricular M-mode dimension and short axis two- dimensional cross-sectional areas should not be measured in the usual fashion, although it may be possible to measure correctly other structures such as the aortic root and left atrium. Instead, a higher interspace should be used even though this may image only a narrow sector that includes the left ventricular minor axis. A major advantage of two-dimensional echocardiographic imaging is its ability to visualize the left ventricular long axis and ventricular wall segments near the apex. To use these measurements to calculate variables such as left ventricular mass and ejection fraction, one must obtain the true (longest) long-axis dimension and visualize the ventricular walls in approximately orthogonal planes-(e.g., apical four - and two-chamber views). The left ventricular long axis is commonly foreshortened in the four-chamber view, as may be seen when the transducer is rotated to the two-chamber view; the ventricular apex is observed to be out of the field of view. The transducer should then be moved infer-olaterally until the left ventricular apex is centered as nearly at the top of the image "fan" in both views as possible. Accurate measurements are obtained when care is taken in recording two dimensional images to visualize the short axis views at an appropriate level (e.g., papillary muscle tips) that demonstrates the smallest cavity diameter or area and the smallest wall thickness, and to record parasternal or apical long axis or two or four chamber views that display the largest cavity diameter and smallest wall thickness.

EVALUATION OF OTHER CARDIAC STRUCTURES AND PARAMETERS Standardized transthoracic echocardiographic examination allows quantitative or semiquantitative assessment of other cardiac structures. Mitral and aortic valve morphology and motion are best assessed in long- and short-axis views. Aortic root size is determined by measuring its maximum diameter at the sinuses of Valsalva at end diastole in long axis views; left atrial diameter or area is measured in the long-axis or apical four-chamber view at end systole. Apical four- chamber views, medially displaced parasternal long-axis recordings, and short-axis views are used to assess the right-sided chambers and tricuspid valve. Multiple views are needed to determine the presence, degree of loculation, and accessibility from the body surface of pericardial effusion. Use of suprasternal notch and subcostal windows allows additional assessment of the aortic arch and descending and upper abdominal aorta in many patients. - ECHOCARDIOGUAPHIC EVALUATION OF HEART VALVES

AORTIC VALVE The root of aorta, initial part of an ascending aorta and left atrium is good determined in a plane of a long axis from of parastarnal access (Fig. 22). In one-dimension echocardiography the aorta represents as two parallel linear Echo-signal, driven forward to the gauge in the period of the systole and to the back in time of the diastole. Echo-signal of aortal cusps settle down between reflections of walls of aorta. The diameter of aorta is measured during opening cusps of the aortal valve - in the beginning of the systole of LV. In time of the systole of cusps miss and form "box", in time of the diastole they are closed as a line. The disclosing of cusps achieves 1,8-2,3 see.

Fig. 22. Parasternal long-axis two-dimensional view of the heartin diastole and systole- Aortic cusps are closed in diastole of the left ventricle, in systole they are opened.

The anterio-posterior size of left atrium (LA) is determined from an outside surface of a back wall of aorta up to of the endocardial surface of a back wall of LA in the end of the systole of LV, that corresponds to the period of the closed cusps of the aortal valve and maximal distance of atrium walls. MITRAL VALVE Echocardiography of a forward shutter mitral of the valve has the M- figurative form. The back shutter mitral of the valve goes with smaller amplitude and has the W-figurative form. The typical sites (point) Echocardiography of a forward shutter mitral of the valve designate by the letters. Allocate point's A, C, D, E, F.

Fig.23. Echocardiogram of the forward shutter of the mitral valve: A - the maximal opening of shutters of the mitral valve in time of the systole of left atrium, C - closing of shutters in time of systole of left ventricle, D -- beginning of the diastole and the opening of shutters of the mitral valve, E - maximal opening of shutters, F - moderate covering of shutters in a phase of slow filling of ventricular.

In M-mode investigation the anterior cusp of the MV has a M-like configuration but posterior cusp of the MV - resembles W. Point C is corresponds to the period of the closing of MV in beginning of diastole, point D - to period of opening of the anterior cusp, point E is corresponds to the maximal its opening in phase of quickly filling of LV. Point F is corresponds to the period of early closing of MV in quick filling, point A - to the maximal opening of the MV in systole of the LA (Fig.24.).

Fig. 24. M-mode echogram of the mitral valve. Determination of the slopes amplitude C-D, D-E and early diastolic opening (E-F)

At echocardiography the following signs should be measured (Fig. 25.): - amplitude of MV moving (C-D); - amplitude of moving (D-E); - general amplitude of MV moving (C-E); - speed of early diastolic closuring (E-F); - duration of systole and diastole.

Fig. 25. Measurement of the anterior MV leaflet velocity movement in diastole: D-E - 398 mm/sec, E-F - 123 mm/sec, F-A - 138 mm/sec, A-C - 258 mm/sec.

TRICASPID VALVE The forward cusps of the TV on 1-d echocardiography in diastole remind the letter M, and back cusps the letter W, similar to the image of the MV. In a M-mode the speed early both late diastolic disclosing and covering of a forward cusps of the TV is determined. Visualization of the right ventricle is carried out from of parastarnal access on a long and short a-xis, and also from of the apical and subcostal position. The definition of mobility of a forward wall and parameters of haemodinamic of the right ventricle is identical to research of the LV. Doppler ECHO-CG allows to determine circulation of blood through the TV, and in a color mode determined a jet circulation of blood. PULMONARY ARTERY AND ITS VALVE The visualization of the PT and cusps of its valve is achieved by of parastarnal of scanning in a short axis at a level of aorta and LV and from of the subcostal access (Fig. 26).

Fig. 26 Parasternal short-axis scanning the basis of the heart with the visualization of pulmonary valve (PV). Thus in the beginning receive the image of the PT with cusps of the valve in 2-d a mode, then, directing a beam on a researched cusps and switching the device on a M-mode, receive the image of cusps necessary for measurement of the necessary parameters. More often the back cusps, less often - forward is registered. EVALUATION OF LEFT VENTRICULAR STRUCTURE

Two methods of making M-mode echocardiographic left ventricular measurements are currently in widespread use. The first of these to be proposed, the Penn method, is commonly used to measure left ventricular mass. The thickness of the echocardiographic lines representing endocardial interfaces is excluded from wall thickness measurements and is included in chamber dimensions by the Penn convention. The more recent recommendations of the American Society of Echocardiography, in which all measurements arc made from leading edge to leading edge, have been widely adopted and may be used for measurement of left ventricular mass and other variables. End-diastolic measurements (made at the peak of the R wave of the simultaneous ECG by the Penn convention and at the QRS onset according to the American Society of Echocardiography) can* be used to calculate left ventricular mass by anatomically validated formulas and to estimate left ventricular chamber volumes. Measurement of left ventricular mass requires use of primary echocardiographic measurements in variants of the cube-function formula that have been regression-corrected by comparison with postmortem data. Although left ventricular mass is, overall, the best measure of myocardial cell size (since the number of cardiac myocytes remains relatively constant after infancy in humans), valuable information about concentric hypertrophy due to hypertension or aortic stenosis can also be obtained by calculating "relative wall thickness" as 2PWT/LVID. Left ventricular mass, wall thicknesses, and chamber volume may also be measured by two-dimensional echocardiography. Two methods for determination of left ventricular mass by two-dimensional echocardiography have been anatomically validated. The simpler of these methods employs an ellipsoid model then requires measurement of the left ventricular long axis and of the cross-sectional area (CSA) of left ventricular myocardium and cavity in short-axis projection. Left ventricular chamber volume is calculated by the long-axis length-short-axis area method is 5/6 (long-axis length x cavity CSA), and ventricular mass is derived from the dif- ference between this volume and the total volume of the ventricular cavity plus myocardium calculated in the same way. The other method of two-dimensional echocardiography determination of left ventricular mass utilizes a truncated ellipsoid formula that corresponds more precisely to the shape of this chamber but requires more complex computations.

Evaluation of ventricular performance Systolic function of a symmetrically contracting ventricle, such as in patients with uncomplicated hypertension, can be easily assessed by measurement of the fractional shortening between end diastole and end systole of the left ventricular internal dimension. If ventricular wall motion is uniform, fractional shortening is closely correlated with global left ventricular ejection fraction and is a simple substitute for it. Left ventricular chamber volume at end diastole and end systole, calculated by the above methods or by several others, may be used to derive the left ventricular stroke volume and ejection fraction more directly, but with a greater time requirement. Regional left ventricular function can be assessed semi- qualitatively from two-dimensional short-axis and long-axis views and apical two- and four-chamber views using the 14-segment classification or the 16-segment one recommended by the American Society of Echocardiography. In these systems, motion of each segment is graded as normal, hypokinetic, akinetic, or dyskinetic. A numerical score from 1 (normal) to 4 (dyskinetic) is assigned to each segment's motion, which when averaged provides a summary measure of left ventricular function that is inversely related to left ventricular ejection fraction. The pattern of left ventricular diastolic filling can be assessed by measurement of transmural blood flow during the early and late phases of ventricular filling. The normality of early diastolic ventricular relaxation may be assessed, albeit indirectly, by measuring the peak flow velocity in early diastole ("E" velocity) or the integral of early diastolic flow. Similarly, the peak 1 luw velocity in late diastole ("A" velocity) and the integral of late diastolic flow will be increased by enhanced venous return or atrial Starling forces and diminished by impaired left ventricular compliance. Interpretation of Doppler findings as abnormal must be undertaken with caution because normal values are influenced by both subject age and echocardiographic technique (the E/A ratio declines with age in normal adults and is lower when measured at the mitral anular plane than at the level of the mitral orifice), whereas filling rates of diseased ventricles are affected by the level of atrial pressure.

THE METHOD OF THE SPIROGRAM RECORDING AND INTERPRITATION Spirography (lat. spiro- to inspirate+greek. grapho- to write) is the method of graphic recording of the changes in time of the inhaled and exhaled air volume. An apparatus which is used for the registration of the ventilative indices changes is called spirograph. Spirography reveals the respiratory insufficiency long before its clinical symptoms become apparent, establishes its type, character and degree, and can be used to follow up functional changes in the respiratory system in the course of the disease and under the effect of treatment. Spirograph connected to the patient records all respiratory oscillations. We can determine the main lung volumes and indices of lung ventilation if the scale of the spirograph and the speed of tape moving are known. Depending on the spirogram incline level the consumption is determined.

E — an examined A — CO2 absorbation R — recording arrangement C — clamp V — capacity.

Fig. 27 . The spirograph structure scheme

For the external respiratory function examination the apparates of the closed type are used mainly where inspiration and expiration is performed through the apparatus capacity (fig. 27). Spirography should be taken on an empty stomach, after 30 minutes resting. The patient sits down, takes a tube into the mouth compressing it with his lips. The clamp is put into the nose. Then the patient inspires oxygen which is filled in the apparatus before the procedure starts and exhales carbonic dioxide, which is absorbed in special part of the spirograph. The amplitude movement with the air volume is recorded on the paper under the influence of inhalation and exhalation expiration. Displacement of the curve on 1 mm corresponds to 20 ml of the inhaled oxygen (the coefficient of the scale — CS). The speed of tape moving is 50 mm/min. The spirogram recording succession: • at first the patient breathes calmly during 3-5 min; • then maximal deep inspiration and maximal deep expiration is performed (VC); • after several calm respiratory movements the patient makes deep , holds breathing during 2 sec. and then the fast exhalation is made (FEVC); • then the patient breathes maximally deeply and quickly during 15 sec. (MLV). After taking the curve (fig.28 ) calculation of the indices is made. All indices should be expressed not only in their absolute quantity but in percentage to the proper value as well which is taken for 100%.

Fig. 28. The spirogram scheme

All respiratory volumes are divided into several groups:

I. THE LUNG VOLUMES 1. RV — the respiratory volume is the volume of air inspired and expired during normal breathing. On the site of the calm breating recording not less than three different in size respiratory cycles (big, small and middle). They are measured in mm, summarized and devided by the number of measured v/aves. An average number received in that way s multiplied by CS. Normally it is 500 ml on the average varying from 300 to 900 ml or 100+20% of RV proper. (Proper values are taken from special tables. For example "Instrumental methods of the respiration and blood circulation examination".— Brudnaya N. E., Shitova E. O.: K., 1984.). RV decreases in restrictive type of lung insufficiency. RV increases in obstructive type of lung insufficiency, after psychical exertion, and in trained sportsmen as well (in combination with low respiratory rate). 2. The vital capacity (VC) is the greatest volume of air that can be expired from the lungs after a maximal inspiration. For calculation of VC the distance from the point of maximal inhalation (A) before the point of maximal exhalation (B) is measured (fig. ) and is multiplied by CS (20). Normally VC is 3-5 L, or ±20% of the proper indices. It varies considerably depending on sex, age, height and weight. VC proper could be determined by the formula: VC=(0,052 x height) — (0,028 x age) — 3,2. VC decreases in restrictive type of lung insufficiency (decreasing of the amount of the functional lung tissue), in the processes, which limit straightening of the chest and the lung mobility (pleural effusion, deformation of the chest, ascites), in different nervous and psychical diseases, which are accompanied by common asthenia. VC can be divided into three parts: amplitude of the middle part is RV, distances lying above and below are inspiratory and expiratory reserve volumes. 3. The inspiratory reserve volume (IRV) is the maximal volume of air that can be inspired after a normal inspiration. Normally IRV constitutes more than 50% of VC. IRV decreases in restrictive type of lung insufficiency. 4. The expiratory reserve volume (ERV) — is the volume of air which can be expired by maximal effort after a normal expiration completion. Normally it is 25-35% of VC. ERV often decreases in obstructive type of lung insufficiency, usually accompanied by emphysema. II. THE PULMONARY VENTILATION INTENSITY INDICES 1. Respiratory rate (RR) — is calculated by a number of respiratory movements during 1', (this is 5 cm of the curve) which is recorded in calm breathing. Normally it is 10 — 20 respirations per/min. RR decreases in the obstructive type of pulmonary insufficiency. RR increases in the restrictive type of lung insufficiency, on psychical exertion, in fever and intoxications. 2. Minute volume (MV) is the amount of air ventilated by the lungs during 1 minute. MV is calculated by multiplying the respiratory volume by respiratory rate. Normally it is 4—8 L, on the average is 5 L/min or ±20% of proper values. MV increases in the organism requiring more oxygen and it is realized by acceleration and deepening of respiration. Increasing MV can be in lung, heart and blood diseases as a compensatory reaction to the oxygen insufficiency. This is an objective sign of the dyspnoea and the first sign of the lung and heart insufficiency. In the compensatory respiratory mechanism decreasing MV will be normal or decreased. MV decreases in trained people, in myxoedema and in the respiratory centre depression. 3. Maximal lung ventilation (MLV) is the amount of air that can pass through the lungs in maximal effort of the respiratory system. MLV is calculated by multiplying the amount of the deepest respiratory movement by their middle amplitude and by CS and by 4, because during this probe the patient maximally deeply and fastly breathes only 15 second. Normally MLV is 80-200 L/min or +20% of its proper value. Proper MLV can be found in a special table or calculated by the formula: MLV = 35 x VC. Considerably decreasing MLV in combination with normal or slightly decreased VC is characteristic of obstructive type of lung insufficiency. Normal or slightly decreased MLV in combination with considerably decreased VC is characteristic of restrictive type of lung insufficiency. 4. Respiratory reserve (Rr) is determined by a formula Rr=MLV- MV. In healthy persons Rr 15-20 times exceeds MV and forms more than 85% of MLV. This index characterizes functional possibilities of the respiratory system and is decreased in lung insufficiency.

III. THE RESPIRATORY ACT MECHANIC INDICIES 1. Forced expiratory vital capacity (FEVC) is the amount of the air, which should be exhaled in forced expiration after deep inhalation. (Votchal — Tiffenean probe). During FEVC recording the speed of the tape moving is changed before 1200 mm/min. The calculation of FEVC is made by the following method (fig. ): from the point of the breath stopping on the height of the inhalation (point F) horizontal line 1 cm in length is drawn (point G), then from the point G perpendicular is dropped until crossing with spirogram (point H). A distance GH is measured in mm and multiplied by CS. In healthy persons FEVC is 80% of the VC, mainly due to the increased resistance of fine bronchi to the passing of air. FEVC decreases in obstructive type of lung insufficiency.

IV. THE LUNG VENTILATION EFFECIENCY INDICIES

1. Oxygen consumption coefficient (CO2C) is the amount of oxygen, which the lungs absorb for 1 minute. CO2C is calculated by the following method: along a low edge of the curve in the distance of the calm breathing incline line is drawn, which connects the lower peak of the waves. The other line is drawn strictly horizontally. One builds a triangle ABC (fig. ). The side "BC" is linear measure of the amount of oxygen, which was absorbed by the lung for 3 minutes. Distance "BC" is multiplied by CS and divided on 3. Normally CO2C is 250-300 ml/min. CO2C characterizes the level of the basic metabolism. Increasing CO2C is the sign the respiratory apparatus reserve possibility depression. 2. Oxygen usage coefficient (CO2U) shows how much oxygen the patient uses from 1 litre of air in millilitre. For the oxygen usage coefficient calculation it is necessary to divide CO2C by MV: CO2U = CO2C (ml): MV(L) Normally it is 25—60 ml/L. Increasing CO2U occurs in trained people as the sign of more economical ventilation. Decreasing CO2U is the sign of the decreased lung ventilation effectiveness and difficulty of oxygen diffusion through the lung membrane. It can be present in lung and heart insufficiency, voluntary hyperventilation. By to spirogram we can determine the degree and type of lung failure. LUNG FAILURE is the inability of the respiratory system to provide the organism with oxygen fully. 3 types of disordered lung ventilation are distinguished: obstructive, restrictive and mixed (combined). The restrictive type of ventilation disorder occurs in limited lung ability to expand and to collapse. It can be in pneumosclerosis, pneumonia, emphysema, hydro- and pneumothorax, massive pleural adhesions, kyphoscoliosis, ossification of the costal cartilages, limited mobility of the ribs. These conditions are in the first instance attended by a limited depth of the maximum of possible inspiration. In other words, the vital capacity of the lungs and RV decrease together with the maximal lung ventilation, but the dynamics of the respiratory act is not affected: when it is necessary the respiratory rate may be increased, for the purpose of respiratory compensation. The obstructive type is characterized by a difficult passage of air through the bronchi due to their constriction. It can be in bronchitis, bronchial asthma, spasm or compression of the trachea or large bronchus by a tumor. Spirography shows a marked decrease in the FEVC, RR, MLV and increase in the RV. The mixed or combined type includes the signs of the two previous disorders, often with prevalence of one of them; this type of disorder occurs in long-termed diseases of the lungs and the heart. Depending on relation of the obtained indices to the proper values 3 degrees of lung failure are distinguished: early (I degree.); moderate (II degree.) and severe (III degree.). In the I degree obtained indices differ from a proper on 21-40%; in the II degree — 41-60%; in the III degree — more than 60%. Spirogram data are necessary to be compared with clinical signs of the lung failure. Thus in the I- degree of the lung failure patients complain of dyspnoea, which becomes evident only on moderate or significant physical exertion. The respiratory rate at rest is normal, after moderate physical exercise it increases by 10-15 respirations. Spirography reveals changes in the lung ventilation intensity and lung volumes indices. VC and (or) FVC decrease by 21-40% in comparison with proper values. In the II degree, the dyspnoea develops during a light exercise, cyanosis is revealed on examination. In addition, spirography reveals disorder of the ventilation efficiency (CO2C and CO2U). VC and (or) FVC decrease by 41-60% of proper values. In the III degree dispnoea and cyanosis are revealed at rest. On examination the participation of the additional muscles in respiratory act (nose wings, intercostal muscles) is observed. The signs of heart failure (oedema, the liver increase, accelerated pulse) are revealed. VC and (or) FVC decrease by more than 60% of proper ones.

PNEUMOTACHOMETRY Pneumotachometry is carried out with the help of Votchal’s pneumotachometer. Peak speeds of air flow (“capacity of inspiration” and “capacity of expiration”) are determined during this procedure. In healthy persons these indices must not be less than 4 L/sec. This investigation is simple method, which differs disturbance of ventilation according to restrictive and obstructive type. In case of restrictive type of disturbance of ventilation “capacity of inspiration” and “capacity of expiration” are decreased equally. In obstructive type “capacity of expiration” is decreased mainly.

A. Test tasks to be done: -with a single selective answer – I-st level; 1. Name the indications for giving of medicamental clyster with general action: a) myocardial infarction; b) suspicion on an intestinal obstruction; c) comatose state; d) constipation in the seriously ill patient; e) introduction of medicine, bypassing the liver. 2. Name the indications for the colonoscopy: a) serious cardiopulmonary failure; b) gastroduodenal bleeding; c) aortic aneurysm; d) chronic diseases of colon; e) poisoning. 3. Name the contraindications for gastric lavage: a) poisoning with medicines, alcohol, bad foodstuff; b) stenocardia; c) unconscious position ; d) first day after operation of gastrointestinal organs; e) poisoning with acids, alkalies, benzine. 4. Name the indications for the using of colonic tube: a) chronic decompensatory cardiovascular failure; b) meteorism; c) shock; d) absence of effect after cleansing enema; e) paresis of intestine after surgical operations. 5. Name the equipment for the application of purgative clysters: a) bedpan with water; b) 2 thick gastric tubes with length of 1 meter; c) rubber ballon capacity of 150-200 ml; d) funnel with the capacity of 0,5-1 L; e) funnel with the capacity not less than 1 L. 6. Name the indications for giving of the medicamental clyster with general action: a) introduction of medicine, bypassng the liver; b) acute appendicitis; c) for compensation of major losses of fluid by an organism during vomiting; d) for compensation of major losses of fluid by an organism during diarrhoea; e) chronic appendicitis. 7. How much water is it necessary for a siphon clyster? a) 1,5-2 L; b) 5-10 L; c) 10-12 L; d) 50-100 ml; e) 200-500 ml. 8. Name the indications for a siphon clyster: a) chronic decompensatory cardiovascular failure; b) meteorism; c) shock; d) absence of effect after cleansing enema; e) paresis of intestine after surgical operations. 9. Name the contraindications for giving a cleansing enema: a) preparation of the patients for X-ray examination of the gastrointestinal organs; b) acute appendicitis; c) poisoning; d) constipation; e) chronic appendicitis. 10. What is colonoscopy? a) endoscopic survey of esophagus, stomach and duodenum; b) endoscopic survey of esophagus; c) endoscopic survey of stomach; d) endoscopic survey of small intestine; e) endoscopic survey of large intestine. 11. Name the indications for a siphon clyster: a) myocardial infarction; b) suspicion on an intestinal obstruction; c) comatose state; d) constipation in the seriously ill patient; e) introduction of medicine, bypassing the liver. 12. What are the contraindications for gastroduodenoscopy? a) liver cirrhosis; b) constipation; c) preparation of parturient woman for labor; d) idiopathic hypertension III-d stage; e) delayed food in stomach because of pyloric stenosis; 13. Name the contraindications for a gastric lavage: a) atony of stomach with stagnation of food masses; b) peptic ulcer of stomach and duodenum with predilection to gastrointestinal bleeding; c) preparation of the patients for operations; d) acute gastritis; e) preparation of the patients for endoscopic examinations of intestine. 14. Name the equipment for the application of colonic tube: a) bedpan with water; b) 2 thick gastric tubes with length of 1 meter; c) rubber ballon capacity of 150-200 ml; d) funnel with the capacity of 0,5-1 L; e) funnel with the capacity not less than 1 L. 15. What is gastroduodenoscopy? a) endoscopic survey of esophagus, stomach and duodenum; b) endoscopic survey of esophagus; c) endoscopic survey of stomach; d) endoscopic survey of small intestine; e) endoscopic survey of large intestine. 16. Name the indications for siphon clyster: a) serious cardiopulmonary failure; b) gastroduodenal bleeding; c) aortic aneurysm; d) chronic diseases of colon; e) poisoning. 17. Name the indications for application of emulsive clyster: a) myocardial infarction; b) suspicion on an intestinal obstruction; c) comatose state; d) constipation in the seriously ill patient; e) introduction of medicine, bypassing the liver. 18. What temperature of water must be for cleansing enema in atony of intestine? a) 28-32oC; b) 37-39oC; c) 18-20oC; d) 20-30oC; e) 38-45oC. 19. How much medicine is it necessary for microclyster? a) 1,5-2 L; b) 8-10 L; c) 10-12 L; d) 50-100 mL; e) 200-500 mL. 20. Name the indications for application of cleansing enema: a) serious cardiopulmonary failure; b) gastroduodenal bleeding: c) aortic aneurysm; d) chronic diseases of colon; e) poisoning. 21. Name the indications for application of hypertonic clyster: a) fissure of an anus; b) steady constipation; c) prolapse of rectum; d) inflammatory and ulcerative processes in a large intestine; e) atonic constipation. 22. Name the contraindications for colonoscopy: a) diseases of esophagus, stomach and duodenum; b) hemophilia; c) intestinal bleeding; d) acute respiratory infectious; e) acute diseases of abdominal cavity with the sign of peritonitis. 23. What temperature of water must be for cleansing enema in spastic colitis? a) 28-32oC; b) 37-39oC; c) 18-20oC; d) 20-30oC; e) 38-45oC. 24. What temperature of water must be for gastric lavage? a) 28-32oC; b) 37-39oC; c) 18-20oC; d) 20-30oC; e) 38-45oC. 25. Name the indications for application of cleansing enema: a) preparation of the patients for X-ray examination of the gastrointestinal organs, kidney, spinal column; b) acute appendicitis; c) for compensation of major losses of fluid by an organism during vomiting; d) for compensation of major losses of fluid by an organism during diarrhoea; e) chronic appendicitis. 26. Name the indications for colonoscopy: a) diseases of esophagus, stomach and duodenum; b) hemophilia; c) intestinal bleeding; d) acute respiratory infectious; e) acute diseases of abdominal cavitys with the sing of peritonitis. 27. How much water is it necessary for a gastric lavage? a) 1,5-2 L; b) 8-10 L; c) 10-12 L; d) 50-100 mL; e) 200-500 mL. 28. Name the indications for application of hypertonic clyster: a) chronic decompensatory cardiovascular failure; b) meteorism; c) shock; d) absence of effect after cleansing enema; e) paresis of intestine after surgical operations. 29. Name the indications for gastroduodenoscopy: a) serious cardiopulmonary failure; b) gastroduodenal bleeding; c) aortic aneurysm; d) chronic diseases of colon; e) poisoning. 30. Name the contraindications for giving a cleansing enema: a) poisoning with medicines, alcohol, bad foodstuff; b) stenocardia; c) unconscious position; d) first day after operation of gastrointestinal organs; e) poisoning with acids, alkalies, benzine. 31. What temperature of water must be for cleansing enema in normal functioning of intestine? a) 28-32oC; b) 37-39oC; c) 18-20oC; d) 20-30oC; e) 38-45oC. ECG 1. In what cases is ECG - rhythm called as “regular”? a) the R-R interval’s fluctuation does not exceed 10 %; b) the R-R interval’s fluctuation does not exceed 0,1 sec.; c) the R-R interval’s fluctuation exceeds 0,1 sec.; d) the R-R interval’s fluctuation exceeds 0,2 sec.; e) the R-R interval’s fluctuation exceeds 0,3 sec.; 2. What is regular sinus rhythm? a) inverted P wave following by QRS complex always; b) upright P wave following by QRS complex always; the R-R duration fluctuates from 0,15 to 0,45 sec.; c) upright P wave following by QRS complex always; the R-R fluctuation does exceed 0,10 sec.; d) different by its form and amplitude P wave following by QRS complex always; e) P wave doesn’t always following by QRS complex; the P-Q interval fluctuates from 0,25 to 0,35 sec. 3. In which place of cardiac conductive system does activation impulse appear normally? a) in sinoatrial (sinus) node; b) in atrioventricular node; c) in the left bundle-brand; d) in the right bundle-branch; e) in cardiac conductive myocytes (Purkinje fibers). 4. What does “P wave of sinus origin” mean? a) P wave isn’t always before every QRS complex; b) P wave hidden in QRS complex; c) upright P wave following by QRS complex always; the P waves configuration is equal; d) P wave following by QRS complex always; P wave is different by amplitude; e) inverted P wave before every QRS complex. 5. What ECG - interval is used for determining of heart rate? a) P-Q; b) QRS; c) QRST; d) R-R; e) T-P. 6. R-R interval registers: a) intraatrial conduction; b) intraventricular conduction; c) vebtriculoatrial conduction; d) duration of cardiac cycle; e) ventricular contractions. 7. The heart rate is normally: a) 60-80 per minute; b) 40-60 per minute; c) 90-120 per minute; d) 120-240 per minute; e) 30-40 per minute; 8. How can the ECG voltage be measured ? a) by means of measuring of R wave amplitude in I standard lead; b) by means of measuring of R wave amplitude in II standard lead; c) by means of measuring of S wave amplitude in II standard lead; d) by means of determining of the sum of the R waves amplitude in I, II and II standard leads; e) by means of measuring of R wave amplitude in chest leads. 9. In which standard lead is the highest voltage of waves observed normally? a) I; b) II; c) III; d) III at the height of inspiration; e) III at the height of expiration. 10. Decreased ECG voltage signifies about: a) deviation of electrical axis of the heart; b) tachycardia; c) polytopic rhythm; d) myocardial hypertrophy; e) inflammatory and sclerotic changes in myocardium. 11. Electrical axis of the heart deviates to the left when: a) the highest R wave is in I lead, the lowest S wave is in III lead; b) the highest R wave is in III lead, the lowest S wave is in I lead; c) the highest R wave is in II lead; d) the highest R wave is in III lead; e) the highest R wave is in I lead. 12. Electrical axis of the heart deviates to the right when: a) the highest R wave is in I lead, the lowest S wave is in III lead; b) the highest R wave is in III lead, the lowest S wave is in I lead; c) the highest R wave is in II lead; d) the highest R wave is in I lead; e) the highest R wave is in III lead. 13. Electrical axis of the heart doesn’t deviate (normal position) when: a) the highest R wave is in I lead, the lowest S wave is in III lead; b) the highest R wave is in III lead, the lowest S wave is in I lead; c) the highest R wave is in II lead; d) the highest R wave is in I lead; e) the highest R wave is in III lead. 14. What is the angle α value on ECG in persons of normosthenic type? a) 0 - 30°; b) 31 - 70°; c) 71 - 90°; d) 91 - 180°; e) 0 - (-180°). 15. What is the angle α value in case of horizontal position of the electrical axis of the heart? a) 0 - 30°; b) 31 - 70°; c) 71 - 90°; d) 91 - 180°; e) 0 - (-180°). 16. What is the angle α value in case of vertical position of the electrical axis of the heart: a) 0 - 30°; b) 31 - 70°; c) 71 - 90°; d) 91 - 180°; e) 0 - (-180°). 17. What the angle α value on ECG is typical for sinistrogram? a) 0 - 30°; b) 31 - 70°; c) 71 - 90°; d) 0 - (-180°); e) 90 - (+180°). 18. What the angle α value on ECG is typical for dextrogram? a) 0 - 30°; b) 31 - 70°; c) 71 - 90°; d) 0 - (-180°); e) 90 - (+180°). 19. What does wave P represent on ECG? a) activation of atria; b) activation of ventricles; c) contraction of atria; d) contraction of ventricles; e) activation of bundle-branches. 20. What conductivity does QRS complex register? a) atrioventricular; b) intraventricular; c) intra-atrial; d) conductivity along right bundle-branch; e) conductivity along left bundle-branch. 21. What does wave T represent on ECG? a) activation of atria; b) activation of ventricles; c) direction of the electrical axis of the heart; d) repolarization of both ventricles; e) contraction of atria. 22. In which lead wave T is always inverted? a) in I standard; b) in II standard; c) in III standard; d) in aVR; e) in aVF. 23. In which chest lead of ECG inverted T wave can be observed in adult persons normally? a) V1; b) V2; c) V3; d) V4; e) V5. 24. In which lead P wave is always inverted? a) I standard; b) II standard; c) III standard; d) aVR; e) aVF. 25. I standard lead registers predominantly potential of: a) right atrium; b) right ventricle; c) interventricular septum; d) anterior wall of the left ventricle; e) posterior wall of the left ventricle. 26. III standard lead registers predominantly potential of: a) right atrium; b) right ventricle; c) interventricular septum; d) anterior wall of the left ventricle; e) posterior wall of the left ventricle. 27. From which parts of the heart potentials are 5 and 6 chest leads registered? a) right atrium; b) lateral wall of the left ventricle; c) right ventricle; d) interventricular septum; e) heart apex. 28. What interval is called as “electrical systole of the heart”? a) P - Q; b) Q - T; c) QRS; d) R - R; e) P - P. 29. The normal P wave duration is: a) 0,02 - 0,03 sec.; b) 0,03 - 0,04 sec.; c) 0,04 - 0,06 sec.; d) 0,06 - 0,10 sec.; e) 0,12 - 0,18 sec. 30. The normal duration of the QRS complex is: a) 0,02 - 0,05 sec.; b) 0,06 - 0,10 sec.; c) 0,16 - 0,20 sec.; d) 0,21 - 0,30 sec.; e) 0,30 - 0,40 sec. 31. Lead I is obtained by connecting electrodes from: a) upper extremities; b) lower extremities; c) right arm and left leg; d) left arm and left leg; e) left arm and right leg. 32. Lead II is obtained by connecting electrodes from: a) upper extremities; b) lower extremities; c) right arm and left leg; d) left arm and left leg; e) left arm and right leg. 33. Lead III is obtained by connecting electrodes from: a) upper extremities; b) lower extremities; c) right arm and left leg; d) left arm and left leg; e) left arm and right leg. 34. How many chest leads must be during registration of biopotentials of the heart? a) 3; b) 20; c) 6; d) 1; e) 9. 35. Where is V4 position of the chest electrode? a) fourth intercostal space, right sternal border; b) fourth intercostal space, left sternal border; c) along left anterior axillary line; d) interspace in which apex is located; midclavicular line. e) along left posterior axillary line. 36. What chest lead corresponds to transition zone normally? a) V1; b) V2; c) V3; d) V4; e) V5. 37. What is sign of transition zone at ECG? a) chest lead, in which amplitudes of R wave and S wave are equal; b) standard lead, in which amplitudes of R wave and S wave are equal; c) augmented unipolar leads, in which amplitudes of R wave and S wave are equal; d) chest lead, in which R wave amplitude is more than S wave amplitude; e) chest lead, in which R wave amplitude is less than S wave amplitude. 38. What standard lead looks like aVL lead? a) I; b) II; c) III; d) III at the height of inspiration; e) III at the height of expiration. 39. What lead of ECG is mirror reflection of the I standard lead? a) aVL; b) aVF; c) V4; d) aVR; e) V6. 40. Method of ultrasound research of different structures of the heart is named: a) electrocardiography; b) phlebography; c) spyrography; d) sphygmography; e) echocardiography. 41. Registration of intracardial blood flows by means ultrasound is named: a) electrocardiography; b) phlebography; c) spyrography; d) sphygmography; e) Dopplercardiography. 42. What is “movable object” in Dopplercardiography? a) blood plasma; b) lymph; c) muscles of the heart; d) blood corpuscles; e) cusps of the valves. 43. Method of registration of sound effects, which appear during action of the heart, is named: a) phonocardiography; b) phlebography; c) spyrography; d) sphygmography; e) echocardiography. 44. What must be registered together with PCG? a) phlebography; b) electrocardiography; c) spyrography; d) sphygmography; e) echocardiography. 45. The method of graphic recording of the changes in time of the inhaled and exhaled air volume is called: a) pneutachometry; b) pneumotachography; c) spirometry; d) spirography; e) roentgenography. 46. An apparatus which is used for the registration of the ventilative indices changes is called: a) pneumotachograph; b) spirograph; c) pneumotachometer; d) spirometer; e) tomograph. 47. The method of graphic recording of the changes in time of the inhaled and exhaled air volume is called: a) pneutachometry; b) pneumotachography; c) spirometry; d) spirography; e) roentgenography. 48. An apparatus which is used for the registration of the ventilative indices changes is called: a) pneumotachograph; b) spirograph; c) pneumotachometer; d) spirometer; e) tomograph. 49. At first in the spirogram recording succession: a) maximal deep inspiration and maximal deep expiration are performed; b) after several calm respiratory movements the patient makes deep inhalations, holds breathing during 2 sec. and then fast exhalation is made; c) the patient breathes calmly during 3 – 5 min; d) the patient breathes maximally deeply and fastly during 15 sec. 51. Normally the respiratory volume on the average is: a) 300 ml; d) 900 ml; b) 500 ml; e) 1000 ml. c) 700 ml; 52. The greatest volume of air that can be expired from the lungs after a maximal inspiration is called: a) inspiratory reserve volume; b) expiratory reserve volume; c) respiratory volume; d) vital capacity; e) maximal lung ventilation. 53. Normally vital capacity is: a) 1-2 L; d) 500 ml; b) 3-5 L; e) 4-8 L. c) 5-7 L; 54. Normally respiratory rate is: a) 10-20 respiratory movements per/min; b) 15-25 respiratory movements per/min; c) 25-30 respiratory movements per/min; d) 30-35 respiratory movements per/min; e) 60-80 respiratory movements per/min. 55. Normally minute volume is: a) 2-4 L; d) 10-12 L; b) 4-8 L; e) 1-2 L. c) 8-10 L; 56. Amount of air that can pass through the lungs in maximal effort of the respiratory system is called:: a) vital capacity; b) minute volume; c) forced expiratory vital capacity; d) maximal lung ventilation; e) respiratory reserve. 57. Normally maximal lung ventilation is: a) 20-60 L/min; d) 200-380 L/min; b) 40-80 L/min; e) 400-600 L/min. c) 80-200 L/min;

-with the selective group of right answers – the II-nd level; 1. Name the reasons of hematemesis: a) exacerbation of a peptic ulcer of stomach; b) bleeding of stomach ulcer; c) acute pancreatitis; d) poisoning with caustic alkaline; e) poisoning with substandard nutrition. 2. Name the indications for application of a cleansing enema: a) liver cirrhosis; b) constipation; c) preparation of parturient woman for labor; d) idiopathic hypertensia III-d stage; e) delayed food in stomach because of pyloric stenosis. 3. Name the equipment for siphon clyster: a) bedpan with water; b) 2 thick gastric tubes with length of 1 meter; c) rubber ballon capacity of 150-200 ml; d) funnel with the capacity of 0,5-1 L; e) funnel with the capacity not less than 1 L. 4. Name the reasons of hematemesis: a) liver cirrhosis; b) insult; c) carcinoma of a stomach; d) hypertonic crisis; e) varicose phlebectasia of an esophagus. 5. Name the indications for gastric lavage: a) poisoning with medicines, alcohol, bad foodstuff; b) stenocardia; c) constipation; d) first day after operation of gastrointestinal organs; e) poisoning with acids, alkalies, benzine. 6. Name the contraindications for giving a hypertonic clyster: a) fissure of an anus; b) steady constipation; c) prolapse of rectum; d) inflammatory and ulcerative processes in a large intestine; e) atonic constipation. 7. Name the contraindications for colonoscopy a) myocardial infarction; b) suspicion of an intestinal obstruction; c) comatose state; d) constipation in seriously ill patient; e) introduction of medicine, bypassing the liver. 8. Name the reasons of vomiting: a) exacerbation of peptic ulcer of stomach; b) bleeding ulcer of stomach; c) acute pancreatitis; d) poisoning with caustic alkaline; e) poisoning with substandard nutrition. 9. Name the indications for application of cleansing enema: a) atony of stomach with stagnation of food masses; b) peptic ulcer stomach and duodenum with predilection to gastrointestinal bleeding; c) preparation of the patients for operations; d) acute gastritis; e) preparation of the patients for endoscopic examinations of intestine. 10. Name contraindicates for a tubeless method of a gastric lavage: a) poisoning with medicines, alcohol, bad foodstuff; b) stenocardia; c) unconscious position; d) first day after operation of gastrointestinal organs; e) poisoning with acids, alkalies, benzine. 11. What are the contraindications for gastroduodenoscopy? a) serious cardiopulmonary failure; b) gastroduodenal bleeding; c) aortic aneurysm; d) chronic diseases of colon; e) poisoning. 12. Name the reasons for vomiting: a) liver cirrhosis; b) insult; c) carcinoma of a stomach; d) hypertonic crisis; e) varicose phlebectasia of an esophagus. 13. Name the indications for gastric lavage: a) atony of stomach with stagnation of food masses; b) peptic ulcer stomach and duodenum with predilection to a gastrointestinal bleeding; c) preparation of the patients for operations; d) acute gastritis; e) preparation of the patients for endoscopic examinations of intestine. 14. What are the contraindications for gastroduodenoscopy? a) diseases of esophagus, stomach and duodenum; b) hemophilia; c) intestinal bleeding; d) acute respiratory infectious; e) acute diseases of abdominal cavity with the sing of peritonitis. 15. Name the equipment for application of colonic tube: a) rubber tube of the length 70 cm; b) Esmarchs irrigaton container with capacity of 1-2 L; c) funnel with the capacity of 0,5-1 L; d) vaseline; e) rubber tube of the length 30-40 cm; 16. Name the indications for the application of oil clyster: a) fissure of an anus; b) steady constipation; c) prolapse of rectum; d) inflammatory and ulcerative processes in a large intestine; e) atonic constipation. 17. Name the contraindications for giving a cleansing enema: a) diseases of esophagus, stomach and duodenum; b) hemophilia; c) intestinal bleeding; d) acute respiratory infectious; e) acute diseases of abdominal cavitys with the sing of peritonitis. 18. Name the contraindications for colonoscopy: a) chronic decompensatory cardiovascular failure; b) meteorism; c) shock; d) absence of effect after cleansing enema; e) paresis of intestine after surgical operations. 19. Name the contraindications for giving a gastric lavage: a) liver cirrhosis; b) constipation; c) preparation of a parturient woman for labor; d) idiopathic hypertension III-d stage; e) delayed food in stomach because of pyloric stenosis. 20. Name the contraindications for giving a cleansing enema: a) fissure of an anus; b) steady constipation; c) prolapse of rectum; d) inflammatory and ulcerative processes in a large intestine; e) atonic constipation. 21. Name the equipment for application of cleansing enema: a) rubber tube of the length 70 cm; b) Esmarchs irrigaton container with capacity of 1-2 L; c) funnel with the capacity of 0,5-1 L; d) vaseline; e) rubber tube of the length 30-40 cm. 22. Name the main complaints of patients with affection of stomach: a) pain; b) abdominal pain; c) regurgitation; d) nausea; e) diarrhoea. 23. Name the main complaints of patients with intestinal diseases: a) vomiting; b) bleeding; c) constipation; d) meteorism; e) involuntary defecation. 24. Name the reasons for vomiting: a) exacerbation of peptic ulcer; b) acute pancreatitis; c) poisoning; d) insult; e) hypertonic crisis. 25. Name the reasons for hematemesis: a) tumor of brain; b) carcinoma of a stomach; c) liver cirrhosis; d) varicose phlebectasia of an esophagus; e) ulcerative colitis. 26. The following signs are typical for peritoneal pains: a) cramp-like or aching character; b) acute, sharp character; c) distinct localization; d) indistinct localization, diffuse pains; e) increase of the pains during motions; f) pains are accompanied by tension of abdominal muscles. 27.There are the following contraindications for gastric lavage: a) gastric bleeding; b) late period after chemical burn of pharynx, esophagus; c) cerebral impairment; d) myocardial infarction; e) pyloric stenosis; f) chronic hepatic failure with development of uremic gastritis. ECG -with the selective group of right answers – the II-nd level; 1. The normal P wave is always upright in the following leads: a) I; b) II ; c) III; d) aVL; e) aVR; f) aVF; g) V1; h) V2 - V6. 2. The normal Q wave’s signs are the following: a) its amplitude in all leads except aVF is not more than ¼ of the R wave amplitude; b) its amplitude in all leads except aVR is not more than ¼ of the R wave amplitude; c) its amplitude in all leads except aVR is not more than ½ of the R wave amplitude; d) its amplitude in all leads except aVF is not more than ½ of the R wave amplitude; e) its duration is 0,03 sec.; f) its duration is 0,3 sec.; g) it is inverted in I, II, III, aVL, aVF, V4 - V6 leads; h) it may be deep and wide in the V3 lead. 3. The normal R wave’s signs are the following: a) its amplitude is 15 - 25 mm; b) its amplitude is 5 - 15 mm; c) it is recorded in all standard and augmented limb leads. d) in the aVF lead R wave may be low or even absent; e) in the chest leads R wave amplitude increases from V1 to V4, and than slightly decreases in V5 and V6 leads; f) in the chest leads R wave amplitude decreases from V1 to V4, and than slightly increases in V5 and V6 leads. 4. The normal S wave’s signs are the following: a) it is inverted; b) it is upright; c) its amplitude is not exceed 30 mm; d) its amplitude is not exceed 25 mm; e) in the limb leads its amplitude is low, except aVR lead; f) in the chest leads S wave amplitude increases from V1, V2 to V4, and in V5,V6 leads its amplitude is not low; g) in the chest leads S wave amplitude decreases from V1, V2 to V4, and in V5,V6 leads its amplitude is very low or S wave may be even absent. 5. The normal T wave’s signs are the following: a) its duration is 0,06 - 0,12 sec.; b) its duration is 0,12 - 0,16 sec.; c) its amplitude is 1,2 - 2,4 mm; d) its amplitude is 0,4 - 1,1 mm; e) its amplitude is 2,5 - 6 mm; f) the normal T wave is always upright in III, aVL and V1 leads; g) the normal T wave is always upright in I, II, aVF, V2 - V6; h) TI< T III, TV6< TV1. 6. In the ECG conclusion it is necessary to note following: a) the cardiac rhythm pacemaker; b) regularity of the cardiac rhythm; c) the pulse rate; d) the heart rate; e) position of the electrical axis of the heart; f) the width of vascular bundle; g) configuration of the heart; h) presence of the four ECG syndromes. 7. What is diagnostic value of phonocardiography? a) diagnostics of heart valvular diseases; b) revealing of prolapse of mitral valve; c) definition and addition of auscultation data; d) revealing of changes of sounds; e) estimation of state of myocardium in patients with ischemic heart disease, myocarditis, cardiomyopathy; f) definition of character of cardiac murmurs; g) revealing of the fluid in pericardial cavity. 8. Rules of taking of phonocardiography include the following: a) complete silence in the room; b) sitting position of the patient; c) semi-sitting position of the patient; d) lying position of the patient; e) holding breath during the inspiration phase; f) holding breath during the expiration phase; g) dark room. 9. Spirography should be taken: a) on an empty stomach; b) in 1 hour after meal; c) after 5 minutes resting; d) on exertion; e) after 30 minutes resting. 10. The lung volumes include: a) respiratory rate; b) respiratory volume; c) vital capacity; d) maximal lung ventilation; e) respiratory reserve. 11. The lung volumes include: a) inspiratory reserve volume; b) expiratory reserve volume; c) respiratory reserve; d) forced expiratory vital capacity; e) minute volume. 12. Vital capacity includes: a) respiratory volume; b) minute volume; c) inspiratory reserve volume; d) expiratory reserve volume; e) maximal lung ventilation; f) forced expiratory vital capacity. 13. The pulmonary ventilation intensity indices include: a) respiratory rate; b) vital capacity; c) minute volume; d) maximal lung ventilation; e) respiratory volume; f) respiratory reserve. 14. The lung ventilation efficiency indices include: a) oxygen consumption coefficient; b) maximal lung ventilation; c) vital capacity; d) oxygen usage coefficient; e) forced expiratory vital capacity. 15. There are such types of disordered lung ventilation: a) obstructive; b) constructive; c) restrictive; d) constrictive; e) mixed. 16. Signs of the I- degree lung failure are: a) dyspnea develops during a light exercise; b) cyanosis is revealed on examination; c) dyspnea, which becomes evident only on moderate or significant physical exertion; d) spirography reveals disorder of the ventilation efficiency (CO2C and CO2U); e) vital capacity and (or) forced expiratory vital capacity decrease by 21-40% in comparison with proper values; f) dispnea and cyanosis are revealed at rest; g) spirography reveals changes in the lung ventilation intensity and lung volumes indices.

B. Tasks to be done: Task 1. During giving of siphon enema nurse paid attention that water doesn’t flow from funnel, lifted high. What actions she must carry out? Task 2. After carrying out of cleansing enema nurse washed tip with flowing water and put it in cabinet together with tube for gastric lavage. Is her action correct? Task 3. The nurse proposed to the patient to occupy prone position, introduced tip of enema, treated by ethanol, into anal orifice (anus), 6 cm deep, filled Esmarch’s irrigator with water (0,5 l), warmed up to 60º C and began to introduce fluid into bowels. What are her mistakes? Task 4. During introduction of thick gastric tube (for gastric lavage) patient took on a bluish tint and began to suffocate. What is the reason of this complication? What is tactic of the nurse? Task 5. Nurse said to the patient to occupy right lateral decubitus, and places soft cylinder and hot-water bag under right hypochondrium. Are all these manipulations correct? Task 6. Emergency team came to call to the patient, used large dose of somnifacients (soporifics). Patient is without consciousness. How must gastric lavage be carried out? Answers for test tasks of the I-st level: 1 - e 11- b 21- e 2 - d 12- d 22- e 3 - b 13- b 23- b 4 - b 14- a 24- a 5 - c 15- a 25- a 6 - a 16- e 26- c 7 - c 17- d 27- b 8 - d 18- c 28- e 9 - b 19- d 29- b 10- e 20- e 30- d 31- a

Answers for test tasks of the II-nd level: 1 - b , d 10- c , e 19- a , d 2 - b , c 11- a , c 20- a , c , d 3 - b , e 12- b , d 21- b , d 4 - a , c , e 13- a , d 22- b , c , d 5 - a , e 14- b , d 23- c , d , e 6 - a , d 15- d , e 24- a , b , c , d , e 7 - a , c 16- b , d , e 25- b , c , d 8 - a , c , e 17- c , e 26- b , c , e , d 9 - c , e 18- a , c 27- a , b , c , d

Standards of right answer for tasks: 1) She must several times to lift and lower funnel, to change position of tube in bowels little (to put out or push forward deeper). In case of absence of effect, it is necessary to take out tube, wash it and repeat procedure. 2) No, it isn’t. Tips for enema must be sterilized and kept separately in special container. 3)Patient must be occupying left lateral decubitus with flexed legs.  The tip of enema must be lubricated with Vaseline or glycerin before introduction into rectum.  The depth of tip’s introduction into rectum must be near 10 cm.  Temperature of water, used for giving enema, must not be more than 40ºC. 4) The tube got into larynx or trachea (it isn’t in esophagus!). It is necessary to take out tube immediately. 5) No, they aren’t. Soft cylinder should be placed under pelvis. 6) Gastric lavage to the patient, which is without consciousness, in absence of cough and laryngeal reflexes, must be carried out only after preliminary intubation of trachea (by physician or doctor’s assistant) - for prevention of aspiration of fluid.

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.-788p. 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. Tungtunghospital.Educational movie. “ A better experience, a painless endoscopy!” / Tungtunghospital.2013 2. Nick Smith. Educational movie . “The basics of the ECG in 5 min”/ Nick Smith. 2014 3. SAIT. Educational movie. “Diagnostic Medical Sonography” / SAIT. 2011 Internet resourses

1. http://www.moz.gov.ua/ua/portal/dn_20130601_0460.ht ml 2. http://www.nursingworld.org/nursingstandards 3. http://www.ferris.edu/HTMLS/colleges/alliedhe/Nursing/ Standards-of-Professional-Nursing-Practice.htm

Methodical instruction is composed by lecturer Ye. Petrov. 200__/200__ academic year. 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 09 10 2018 Protocol No4 The Head of the Department Professor Yu. Kazakov

METHODICAL INSTRUCTION FOR STUDENTS’ SELF-PREPARATION WORK

Educational discipline Nurse practice Module No 1 Enclosure module No 1 Topic Moral-ethical and legislative bases of nurse business in Ukraine Year 3 Faculty medical

Hours – 1 1. The topic basis: the role of moral-ethical principals, norms and values for realization of the professional duties by nurses is very important. That is why every future physician (he/she must know nurse duties also!) should know ethical and legislative bases of nurse business, The ICN code of ethics for nurse and Ethical Code of nurse of Ukraine, particularly. 2. The specific aims:  To explain ethical principles of nurse business.  To explain The ICN code of Ethics for Nurse.  To explain essence of Ethical Code of Nurse of Ukraine.  To tell Florence Nightingale Pledge  To be able to observe principles of ethics and deontology in medical practice. 3. Basic knowledge, experience, skills necessary for studying the topic in connection with other subjects (interdisciplinary integration) : Previous disciplines Obtained skills 1. Care of patients To know and to be able to carry out care of patients of therapeutic department. 2. History of medicine To know the main historical periods of nursing business’s organizing and the greatest persons, Florence Nightingale, particularly. 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. Nurse ethics It is moral aspects of nurse business, which are component of nurse business and are “in the heart” of professional calling (vocation) of the nurse.

2. Moral It is principles, valuables and standards, which are kept by men during his/her daily life and behaviour.

3. Ethics It is studying of these principles, valuables and standards.

4. Principles It is main and basic points of view. It is idea about good and just things, which must be carried out.

5. Valuables It is idea about good and just things, which must be carried out.

6. Standards It is rules of behaviour, reflecting of valuables.

4.2. Theoretical questions to be answered before class: 1. Tell about ethical principle of nurse business. 2. Tell about Ethical Code of Nurse of Ukraine. 3. Tell about The ICN Code of Ethics for Nurse. 4. To tell Florence Nightingale Pledge 5. What is moral and legislative responsibility of the nurse to the society? 6. What are guaranties and protection of legal rights of the nurse?

4.3. Practical work (tasks), which should be performed during class: 1. To observe principles of ethics and deontology in medical practice.

The contents of topic: Text

ETHICAL PRINCIPLES OF NURSE BUSINESS

Nurse ethics - is moral aspects of nurse business, which are component of nurse business and are “in the heart” of professional calling (vocation) of the nurse. Nurse ethics is closely connected with historical aspects of nurse business, functional duties and theses about nurse, her social status and theoretical conceptions, which are basic in nurse business. There are definitions of following terms (according to “LEMON”, WHO, 1996):  Moral - principles, valuables and standards, which are kept by men during his/her daily life and behaviour.  Ethics - studying of these principles, valuables and standards.  Principles - main and basic points of view.  Valuables - idea about good and just things, which must be carried out.  Standards - rules of behaviour, reflecting of valuables. In literature the following questions are discussed: is it possible to delimit nurse and medical ethics? Does approach of the nurse to ethical aspects during daily work from physician’s one isolated? Nurse ethics sees its difference from medical ethics in purposive direction of its action on professional care of patients, which gives to the nurse independence during work together with physicians. These two methods of action (of nurse and physician) are different and are realized in different conditions. Just therefore duties of nurses differ from physician’s duties and ethical aspects are manifested differently. As for history of this question, we can remind that conditions and functions of the nurse in XIX and XX centuries were differ greatly. Taking into account foregoing, we can assert confidently that nurse business and nurse ethics have deep traditions, basis of which is works of Florence Nightingale. XIX century for nurses was century of subjugation of nurses to their preceptor, physicians mainly. The maximal function, which must be carried out by the nurse, was function of obedient performance of physicians’ prescriptions without any objection. But in XX century (during last decades particularly) and at the beginning of XXI century level of nurse preparation increased significantly. Teaching of the nurses was improved and such discipline as scientific researches in nurse business appeared at first. It promotes to formation of basis of nurse knowledge, nurse theories and nurse models. So, nursing business now goes out on other, independent place in system of public health service. In many countries of world and on international level spiritual role and place of nurse business in many kinds of social activities is written down in so called Code of Ethical Rules of Nurse Business. E. Bandman (1985) proposes following functions or aim of ethical norms of nurse business: 1. To give information to society about nurses understand and take confidence and responsibility, which are given to them. 2. To determine actions of the nurse in relation to patient, colleagues, nurse profession and society. Deontology is part of nurse ethics. This term was proposed at first by Kant. It is derived from Greek word “deon”, which means men must do. From point of view of nurse business, deontology considers problems, which answers the question: how nurse must behave oneself in concrete situations during her work? Ethical Code of the nurse of Ukraine answers this question.

ETHICAL CODE OF NURSE OF UKRAINE Nurses of Ukraine has adopted this Code, taking into account great value moral-ethical norms in public health service, important role of the nurse as representative of one of the mass medical professions in the society, and also, following modern ethical-normative documents of international medical organizations. PART 1. GENERAL THESISES CLAUSE 1. The nurse as personality The following factors are organically combined in the life and activity of the nurse: lofty professionalism, humanity and charity, deep understanding of public value of her works, complex comprehensive care of patients and relieving of their suffering, recovering of health and rehabilitation, contribution to fortifying of health and prophylaxis of diseases, readiness “to give oneself” to choose profession, even in most difficult conditions. Ethical Code reflexes moral level of the nurse, her ideology; its task is increasing of prestige and authority of nurse profession in society, contribution to development of nurse business in Ukraine. PART 2. NURSE AND PATIENT CLAUSE 1. The nurse as personality Ethical basis of the nurse is humanity and charity, respect to inalienable rights of man and citizen. Recovery and improvement of patient’s health is the greatest reward for the nurse for her work. In her activity nurses of Ukraine must follow to international declarations about rights of man, Constitution and laws of Ukraine, public moral values, principles and norms of professional ethics and spiritual property of our national culture. CLAUSE 2. Nurse and patient’s right to qualitative medical care The nurse reasonably to her competence must provide to any patients: man, woman, children, old man, newborn or moribund men. The nurse bears moral responsibility to patient, colleagues, society for her activity. CLAUSE 3. Professional competence - the main condition of nurse activity The nurse must always carry out her duties professionally, according to standard of activity the nurse, worked out by Ministry of Health of Ukraine. Professional demands include creative attitude to her duties, ability to orient quickly in information, to choose the most important from it, to improve constant her special knowledge and skills, to increase her standard of culture. The nurse must be competent to relation to moral and legal rights of the patient. The nurse keep highest standards in nurse practice’s sphere taking into account real situations, following to demands of laws of Ukraine, principles of professional ethics. The nurse bears the responsibility for performance of her professional duties. CLAUSE 4. Respect to the patient, humane relation to the patient The nurse must respect patient’s rights to relieving of suffering, she doesn’t have right to promote to patient’s suicide. The nurse must act within the limits of her competence in order to defend patient’s rights, proclaimed by WHO and International medical association. Patient has right to different conveniences, which guarantee secret his individual peculiarities during examinations, diagnostic and medical procedures. Only persons, who are necessary for carrying out of medical interventions, may be present. In exceptional and peculiar situations diagnostic and medical procedures, operative interventions in case of urgent patient’s condition can be carried out despite of representative persons. The nurse in these cases must follow inalienable man’s rights, laws of Ukraine and greatest interests of the patient. CLAUSE 5. Respect of human dignity, needs and values of the patient During work and behaviour the nurse must be standard of lofty culture, civility, modesty and accuracy. Relations with patients must be protecting psychic of the patient maximally. The nurse must treat patient with sympathy and attentively, keep oneself in different situations, be correct during address to the patient. The nurse doesn’t must lower the dignity of the patient during carrying out manipulations. The nurse must respect individual dignity of the patient, his individual needs and values. Such factors as patient’s race, religious views or absence of them, ethnic origin, social or family status, sexual guidance, age or health condition don’t must influence on qualitative medical care. The nurse doesn’t have right to interfere in personal patient’s life without his knowledge and will, excluding those cases when it is related to professional necessity exclusively. CLAUSE 6. First of all - don’t affect The nurse constantly must remember about realization ancient ethical principle of medicine: “first of all - don’t affect” (Lat. -“noli nocere”), being maximally attentive and careful during nurse interventions and carrying out medical prescriptions. Performing interventions, which can negatively influence on the patient, the nurse must foresee security measures and preventive actions according to prevention of complications. CLAUSE 7. The nurse and patient’s right to information The nurse must respect patient’s rights to receipt of information about condition of his health, possible risk and advantage of methods of diagnostics and treatment. Taking into account that information about disease belongs to the physician, the nurse (as member of medical brigade, serving of the patient) has moral right to inform patient only after coordination with physician. The nurse has right to conceal from the patient professional information only in that case, if she is sure this information causes seriously damage to him. CLAUSE 8. The nurse and patient’s right to agreement on medical intervention or refusal from it The nurse must respect right of the patient or his representative (when she have to deal with children or psychically incapable patient) to agree with medical intervention or to refuse from it. The nurse must be sure that the patient agrees or refuses voluntarily and deliberately. Moral and professional duty of the nurse is (reasonably of her qualification) explanation of results of refusal from medical intervention to the patient. Refusal of the patient doesn’t must negatively influence on attitude towards him of medical workers. CLAUSE 9. Duty to keep professional secret Medical secret has moral and juridical aspect. Nurses don’t have right to spread during performing professional duties known for them information about disease, intimate and family sides of the patient’s life. For spreading of professional secret the nurse is morally and legally responsible. The nurse has right to reveal confidential information about the patient to other person only in case of patient’s agreement. CLAUSE 10. The nurse and dying patient The nurse must have knowledge, skill in extent of palliative aid. It gives possibility to relief suffering to dying person. The nurse must give dying patient and his family psychological support. Euthanasia, i.e. act of premeditated stop of patient’s life, done according to patient’s will or his relatives’ request, is held to be unethical. The nurse must respect dyed patient. During body treatment religion and cultural traditions must be taking into account. The nurse must respect citizen’s rights concerning to postmortem examination. CLAUSE 11. The nurse as participant of scientific researches and educational process Participation of the nurse in research work, studying of scientific, and reference literature has great value in her self-completion. PART 3. THE NURSE AND HER PROFESSION CLAUSE 12. Respect to her own profession Professional duty of the nurse concerning to the patient, his relatives and colleagues on the work is complex actions, directed to patient’s recovery, and also behavior of the nurse in concrete situation, occurring in medical practice. The nurse must control her actions constantly, be punctual, keep rules of personal hygiene, support authority and reputation of her profession. The nurse must have good psychological preparation, can control herself and concrete situations impractical activity. Right and duty of the nurse is assertion of one’s moral, economical and professional independence. CLAUSE 13. The nurse and colleagues The nurse must respect her teachers. One of the necessary conditions for the nurse is culture of contacts in collective. The nurse must respect colleagues, taking into account their opinions, knowledge, experience, convictions; she must be careful, sympathetic, tactful, just in relations to one’s colleagues. The nurse must help to colleagues by profession reasonably of one’s knowledge and skills. High professionalism of the nurse is important moral factor of friendly collegial interrelations of nurse and physician. CLAUSE 14. The nurse and shady medical practice The nurse must know legal standards, regulating nurse business, system of public health, methods of treatment, permitted by legislation. The nurse must uphold interests of patient and society, if she revealed illegal, unethical and incompetent medical practice. In this case the nurse has right applied to state public health organs, association of the nurses of Ukraine. PART 4. THE NURSE AND SOCIETY CLAUSE 15. Moral and legal responsibility of the nurse to society Care for health and life of citizens trusts to the nurse. Society demands nurses have to do this important work honestly discharge one’s duty with sense of high responsibility, improve their professional knowledge. The nurse must be responsible for all slips, which occurred as result of inattention, criminal indifference, and mature abuse. Moral duty of the nurse is care for intelligibility and high quality of nurse aid to population. The nurse must take active part in medical-sanitary education of population. The nurse must help in improvement of struggle methods against diseases, prevent patients, organs of power and society about ecological dangerous, bring in one’s substantial contribution in organizing of rescuing service. CLAUSE 16. Supporting of nurse business Moral duty of the nurse is close contribution to development of reform of nurse business in Ukraine. The nurse must support independence, integrity of nurse business, its autonomy, pay attention of the society and mass media to necessities use moral-psychological supporting of family, relatives, friends, colleagues and also any religious worship. Euthanasia, i.e. act of conscious stop of patient’s life, performed according to patient’s will or request of his relatives, is considered unethical. The nurse must treat to died patient with respect. During body’s processing religious and cultural traditions must be taking into account. The nurse must respect citizen’s rights concerning postmortem examination. CLAUSE 17. Guaranties and protection of legitimate rights of the nurse The nurse have rights of legitimate protection of self respect, physical inviolability and right to help during carrying out of her professional duties both in time of peace and in time of war. Standard of living of the nurse must tally with status of her profession. Amount of fee of nurse with private practice must tally with amount and quality of provided medical aid, level of her competence with taking into account of specific circumstances of each concrete case. Free of charge aid to the patients with severe circumstances is approved ethically. Nurses don’t must be forced to work in unfavorable conditions. Securing of conditions of nurses’ professional activity must meet demands of labour protection. PART 5. PROFESSIONAL NURSE ORGANIZATIONS CLAUSE 18. Responsibility of professional nurse organizations Professional nurse organizations are responsible for explanation and supporting of ethical behavior of the nurse. Realization of these tasks demands professional medical organizations were sympathetic to rights, necessities and legal interests of patients and nurses. CLAUSE 19. Interconnection and co-operation among professional nurse organizations Association of nurses of Ukraine can organize its societies all over Ukraine. Organization of connection and co-operation among association of nurses of Ukraine, its territorial subsidiary (societies) and other organizations of nurses is inalienable step to direction of guaranteeing of ethical behavior of nurses. PART 6. ACTION OF ETHICAL CODE OF THE NURSE OF UKRAINE. RESPONSUBILITY FOR ITS BREACH AND PROCEDURE OF ITS REVISION CLAUSE 20. Action of Ethical Code Demands of Code are obligatory for all nurses of Ukraine. Physicians and nurses, which teach at medical college and nurse faculties of medical high educational establishments, must acquaint of students with Ethical Code of nurses of Ukraine. Physicians and nurses, which teach at educational establishments, must set an example to students by their behavior. CLAUSE 21. Responsibility for breach of Ethical Code The nurses are responsible for breach of Ethical Code of nurse of Ukraine. The following punishments can be applied to members of Association of nurses of Ukraine for breach of ethical standards of Code: 1) reproof; 2) warning about incomplete professional conformity; 3) stopping of membership in association during 1 year; 4) summons in local and central leading organs of public health service about facts of breach. CLAUSE 22. Revision and interpretation of Ethical Code Right to revision of Ethical Code of nurses of Ukraine and interpretation of its separate theses belongs to Ministry of Health of Ukraine according to coordination with Association of nurses of Ukraine.

THE ICN CODE OF ETHICS FOR NURSES An international code of ethics for nurses was first adopted by the International Council of Nurses (ICN) in 1953. It has been revised and reaffirmed at various times since, most recently with this review and revision completed in 2005.

PREAMBLE Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal. Inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status. Nurses render health services to the individual, the family and the community and co-ordinate their services with those of related groups.

THE ICN CODE The ICN Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct. ELEMENTS OF THE CODE 1. NURSES AND PEOPLE The nurse’s primary professional responsibility is to people requiring nursing care. In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected. The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment. The nurse holds in confidence personal information and uses judgement in sharing this information. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse also shares responsibility to sustain and protect the natural environment from depletion, pollution, degradation and destruction.

2. NURSES AND PRACTICE The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning. The nurse maintains a standard of personal health such that the ability to provide care is not compromised. The nurse uses judgement regarding individual competence when accepting and delegating responsibility. The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence. The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.

3. NURSES AND THE PROFESSION The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. The nurse is active in developing a core of research-based professional knowledge. The nurse, acting through the professional organisation, participates in creating and maintaining safe, equitable social and economic working conditions in nursing.

4. NURSES AND CO-WORKERS The nurse sustains a co-operative relationship with co-workers in nursing and other fields. The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person.

SUGGESTIONS FOR USE OF THE ICN CODE OF ETHICS FOR NURSES The ICN Code of Ethics for Nurses is a guide for action based on social values and needs. It will have meaning only as a living document if applied to the realities of nursing and health care in a changing society. To achieve its purpose the Code must be understood, internalised and used by nurses in all aspects of their work. It must be available to students and nurses throughout their study and work lives.

APPLYING THE ELEMENTS OF THE ICN CODE OF ETHICS FOR NURSES The four elements of the ICN Code of Ethics for Nurses: nurses and people, nurses and practice, nurses and the profession, and nurses and co-workers, give a framework for the standards of conduct. The following chart will assist nurses to translate the standards into action. Nurses and nursing students can therefore:  Study the standards under each element of the Code.  Reflect on what each standard means to you. Think about how you can apply ethics in your nursing domain: practice, education, research or management.  Discuss the Code with co-workers and others.  Use a specific example from experience to identify ethical dilemmas and standards of conduct as outlined in the Code. Identify how you would resolve the dilemmas.  Work in groups to clarify ethical decision making and reach a consensus on standards of ethical conduct.  Collaborate with your national nurses’ association, co-workers, and others in the continuous application of ethical standards in nursing practice, education, management and research.

Element of the Code # 1: NURSES AND PEOPLE

Practitioners and Educators and National Nurses’ Managers Researchers Associations

Provide care that respects In curriculum include Develop position human rights and is references to human statements and guidelines sensitive to the values, rights, equity, justice, that support human rights customs and beliefs of all solidarity as the basis and ethical standards. people. for access to care.

Provide continuing Provide teaching and Lobby for involvement of education in ethical learning opportunities nurses in ethics review issues. for ethical issues and committees. decision making.

Provide sufficient Provide Provide guidelines, information to permit teaching/learning position statements informed consent and the opportunities related to and continuing education right to choose or refuse informed consent. related to informed treatment. consent.

Use recording and Introduce into Incorporate issues of information management curriculum concepts of confidentiality and privacy systems that ensure privacy and into a national code of confidentiality. confidentiality. ethics for nurses.

Develop and monitor Sensitise students to Advocate for safe and environmental safety in the importance of healthy environment. the workplace. social action in current concerns.

Element of the Code # 2: NURSES AND PRACTICE

Practitioners and Educators and National Nurses’ Managers Researchers Associations

Establish standards of Provide teaching/learning Provide access care and a work setting opportunities that foster to continuing that promotes safety and life long learning and education, through quality care. competence for practice. journals, conferences, distance education, etc.

Establish systems for Conduct and disseminate Lobby to ensure professional appraisal, research that shows links continuing education continuing education and between continual opportunities and quality systematic renewal of learning and competence care standards. licensure to practice. to practice.

Monitor and promote the Promote the importance Promote healthy lifestyles personal health of nursing of personal health and for nursing professionals. staff in relation to their illustrate its relation to Lobby for healthy work competence for practice. other values. places and services for nurses.

Element of the Code # 3: NURSES AND THE PROFESSION

Practitioners and Educators and National Nurses’ Managers Researchers Associations

Set standards for nursing Provide teaching/learning Collaborate with others practice, research, opportunities in setting to set standards for education and standards for nursing nursing education, management. practice, research, practice, research and education and management. management.

Foster workplace Conduct, disseminate and Develop position support of the conduct, utilise research to advance statements, guidelines dissemination and the nursing profession. and standards related utilisation of research to nursing research. related to nursing and health.

Promote participation in Sensitise learners Lobby for fair national urses’ to the importance social and associations so as to of professional economic working create favourable nursing associations. conditions in socio-economic onditions nursing. Develop for nurses. position statements and guidelines in workplace issues.

Element of the Code #4: NURSES AND CO-WORKERS

Practitioners and Educators and National Nurses’ Managers Researchers Associations

Create awareness Develop understanding of Stimulate of specific and the co-operation with overlapping functions and roles of other other related disciplines. the workers. potential for interdisciplinary tensions.

Develop work-place Communicate nursing Develop awareness systems that ethics to of ethical issues of support common other professions. other professions. professional ethical values and behaviour.

Develop mechanisms to Instil in learners Provide guidelines, safeguard the individual, the need to position statements family safeguard the and discussion or community individual, family fora related to when their care is or community when safeguarding endangered by care is endangered people when their health care by health care care is endangered personnel. personnel. by health care personnel.

DISSEMINATION OF THE ICN CODE OF ETHICS FOR NURSES To be effective the ICN Code of Ethics for Nurses must be familiar to nurses. We encourage you to help with its dissemination to schools of nursing, practising nurses, the nursing press and other mass media. The Code should also be disseminated to other health professions, the general public, consumer and policy-making groups, human rights organisations and employers of nurses.

GLOSSARY OF TERMS USED IN THE ICN CODE OF ETHICS FOR NURSES

Co-worker Other nurses and other health and non-health related workers and professionals.

Co-operative A professional relationship based on collegial relationship and reciprocal actions, and behaviour that aim to achieve certain goals.

Family A social unit composed of members connected through blood, kinship, emotional or legal relationships.

Nurse shares A nurse, as a health professional and a citizen, with society with society initiates and supports appropriate action to meet the health and social needs of the public.

Personal health Mental, physical, social and spiritual wellbe- ing of the nurse.

Personal Information obtained during professional information contact that is private to an individual or family, and which, when disclosed, may violate the right to privacy, cause inconvenience, embarrassment, or harm to the individual or family.

Related groups Other nurses, health care workers or other professionals providing service to an individual, family or community and working toward desired goals.

THE FLORENCE NIGHTINGALE PLEDGE I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and I will hold in confidence all personal matters committee to my keeping and family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavour to aid the physician in this work, and devote myself to the welfare of those committees to my care.

A. Test tasks to be done: - with a single selective answer - I-st level: 1. Principles: a) idea about good and just things, which must be carried out; b) main and basic points of view; c) rules of behaviour, reflecting of valuables; d) valuables and standards, which are kept by men during his/her daily life and behaviour. e) deontology. 2. Moral: a) main and basic points of view; b) principles, valuables and standards, which are kept by men during his/her daily life and behaviour; c) rules of behaviour, reflecting of valuables. d) idea about good and just things, which must be carried out; e) deontology. 3. Term “deontology” was proposed at first by: a) Florence Nightingale; b) K. Marx; c) I. Pavlov; d) E. Kant; e) N.Pirogov. 4. The nurse constantly must remember about realization the following ethical principle of medicine (Clause 6 of Ethical Code of Nurse of Ukraine): a) “who diagnoses well, treats well”; b) “first of all - don’t affect”; c) “risk is noble action”; d) “repetition is mother of study”. 5. Is euthanasia, i.e. act of premeditated stop of patient’s life, ethical? (Clause 10 of Ethical Code of Nurse of Ukraine): a) only done according to patient’s will; b) only done according to patient’s relatives’ request; c) no, it isn’t. 6. How many principal elements that outline the standards of ethical conduct does the ICN Code of Ethics for Nurses have? a) two; b) three; c) four; d) five; e) six. 7. An international code of ethics for nurses was first adopted by the International Council of Nurses in: a) 1913; b) 1945; c) 1953; d) 1965; e) 2005.

- with the selective group of right answers - II - nd level: 1. In her activity nurses of Ukraine must follow to: a) international declarations about rights of man; b) Constitution and laws of Ukraine; c) public moral values, principles and norms of professional ethics; d) spiritual property of national culture. 2. For her activity the nurse bears moral responsibility to: a) patient; b) colleagues; c) family; d) society. 3. Professional demands to the nurse include the following: a) creative attitude to her duties; b) ability to orient quickly in information, to choose the most important from it; c) to improve constant her special knowledge and skills; d) qualitative treatment of the patient; e) to increase her standard of culture. 4. The nurse must (Clause 13 of Ethical Code of Nurse of Ukraine): a) respect her teachers; b) respect colleagues; c) always to carry out physician’s instruction; d) taking into account colleagues’ opinions, knowledge, experience, convictions; e) be careful, sympathetic, tactful, just in relations to one’s colleagues. 5. The following punishments can be applied to members of Association of nurses of Ukraine for breach of ethical standards of Code: b) reproof; c) warning about incomplete professional conformity; d) downgrading to junior nurse; e) stopping of membership in association during 1 year; f) summons in local and central leading organs of public health service about facts of breach. 6. Nurses have the following responsibilities (Preamble of the ICN Code of ethics for nurses): a) to promote health; b) to control work of junior nurses; c) to prevent illness; d) to restore health; e) to alleviate suffering; f) to assist to the physician. 7. Nursing care is respectful of and unrestricted by considerations of: a) age; b) colour; c) creed; d) culture; e) disability or illness; f) gender. 8. Nursing care is respectful of and unrestricted by considerations of: a) sexual orientation; b) nationality; c) politics; d) race; e) social status. 9. There are the following elements of the ICN Code: a) nurses and people; b) nurses and practice; c) nurses and patient’s relatives; d) nurses and the profession; e) nurses and co-workers; f) nurses and junior nurses. 10. Practitioners and managers (according to element 1 of the ICN Code: Nurse and people): a) provide care that respects human rights and is sensitive to the values, customs and beliefs of all people; b) introduce into curriculum concepts of privacy and confidentiality; c) lobby for involvement of nurses in ethics review committees; d) provide continuing education in ethical issues; e) provide sufficient information to permit informed consent and the right to choose of refuse treatment; f) use recording and information management systems that ensure confidentiality; g) develop and monitor environmental safety in the workplace; h) advocate for safe and healthy environment. 11. Educators and researches (according to element 2 of the ICN Code: Nurse and practice): a) establish standards of care and a work setting that promotes safety and quality care; b) provide teaching /learning opportunities that foster life long learning and competence for practice; c) conduct and disseminate research that shows links between continual learning and competence to practice; d) lobby to ensure continuing education opportunities and quality care standards; e) promote the importance of personal health and illustrate its relation to other values. f) monitor and promote the personal health of nursing staff in relation to their competence for practice; g) provide access to continuing education, through journals, conferences, distance education,etc. 12. National Nurses’ Associations (according to element 3 of the ICN Code: Nurse and profession): a) set standards for nursing practice, research, education and management; b) provide teaching/learning opportunities in setting standards for nursing practice, research, education and management; c) collaborate with others to set standards for nursing education, practice, research and management; d) develop position statements, guidelines and standards related to nursing research; e) lobby for fair social and economic working conditions in nursing. Develop position statements and guidelines in workplace issues; f) sensitise learners to the importance of professional nursing associations. 13. National Nurses’ Associations (according to element 4 of the ICN Code: Nurse and co-workers): a) stimulate co-operation with other related disciplines; b) develop awareness of ethical issues of other professions; c) develop understanding of the roles off other workers; d) communicate nursing ethics to other professions; e) develop workplace systems that support common professional ethical values and behavior; f) provide guidelines, position statements and discussion for related to safeguarding people when their care is endangered by health care personnel. Answers for test tasks of the I-st level: 1 - b 2 - b 3 - d 4 - b 5 - c 6 - c 7 - c

Answers for test tasks of the II-nd level: 1 - a , b , c , d 10- a , d , e , f 2 - a , b , d 11- b , c , e 3 - a , b , c , e 12- c , d , e 4 - a , b , d , e 13- a,b , f 5 - a , b , d , e 6 - a , c , d , e 7 - a,b,c,d,e,f 8 - a , b , c , d , e 9 - a , b , d , e

Literature recommended: Main Sources: 1. The ICN Code of Ethics for Nurses.- Geneva, 2005.- 9 p. 2. Ruth Backman Murrey, Judith Proctor Zentner. Nursing Assesement and Health Promotion Strategies Through the Zife span. Appleton and Lange. - California, 1985. 3. Craven, Ruth F. Fundamentals of nursing. - Philadelphia, 1992. 4. Bradeley, Jean C. Communications in the nursing context. Appleton- century-crofts (Norwalk, Connecticut), 1986. 5. Fundamentals of nursing. The art and science of nursing care. J.B. Zippincott Company, Philadelphia, 1990. 6. Polskaya L.V. Nursing procedures in therapeutic practice.- Simferopol: Universum, 2004. - 192 p. Additional ones: 1. Лемон. Учебные материалы по сестринскому делу. ВОЗ, Европейское региональное бюро. Соpenhagen, Denmark, 1996. 2. Лойко В.В. Філософія, суть та зміст сестринської справи.- Полтава, 1999.-43 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. 4. Taylor C., Lillis C., Lemore P. Fundamentals of Nursing. – Philadelphia: J.B. Lippincott Company, 2003. – 1000 p. Informational resources 1. John J. Maggio. Educational movie “The five ethical principles” /John J. Maggio 2015 http://my.brainshark.com/6-the-five-e 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://www.moz.gov.ua/ua/portal/dn_20130601_0460.ht ml 2. http://www.nursingworld.org/nursingstandards 3. http://www.ferris.edu/HTMLS/colleges/alliedhe/Nursing/ Standards-of-Professional-Nursing-Practice.htm

Methodical instruction is composed by lecturer Ye. Petrov. 200__/200__ academic year. Methodical instruction is revised and approved again At the Chair of Propaedeutics To 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 09 10 2018 Protocol No4 The Head of the Department Professor Yu. Kazakov

METHODICAL INSTRUCTION FOR STUDENTS’ SELF-PREPARATION WORK

Educational discipline Nurse practice Module No 1 Enclosure module No 1 Topic Organizing of work and duties of the nurse of the main structural parts of therapeutic in- patient department Year 3 Faculty medical

Hours – 2 1. The topic basis: Actuality of topic is determined by considerable prevalence of therapeutic pathology that often requires medical treatment in stationary establishments of the proper type. Therefore students must be expressly oriented towards the organization of work of medical personnel in these establishments, nurse particularly. 2. The specific aims:  To tell about structure and functions of therapeutic in-patient department.  To represent duties of medical personnel of therapeutic in-patient department, of nurse particularly (including admitting office).  To represent list of documentation, filling in by the nurse of therapeutic in- patient department.  To explain rules of keeping of medical preparations.  To explain duties of the nurse according to supporting of treatment protective and sanitary - hygienic regimen of the therapeutic department.

3. Basic knowledge, experience, skills necessary for studying the topic in connection with other subjects (interdisciplinary integration) : Previous disciplines Obtained skills 1. Care of patients To know and to be able to carry out care of patients of therapeutic department. 2. Medical biology To know main lice, pubic lice, clothes lice. 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. The centralized type of admitting It is type of admitting office when last office one is localized in the territory of hospital in a separate building, isolated from other departments (used in multi- field uninfectious ) 2. The decentralized admitting office This type is formed on the base of profile department of hospital (infectious department, maternity hospital).

3. Patient’s anthropometry It includes measuring of growth, mass of body, circumference of thorax and abdomen. 4. Sanitary-hygienic regime It foresees order of carrying out of sanitary-hygienic actions, which is regulated distinctly. 4. Treatment-protective regime It is regime, which is established by hospital administration on the bases of typical instructions. It regulates distinct time and sequence of carrying out of any actions, procedures, manipulations in relation of the patient.

4.2. Theoretical questions to be answered before class: 1. What are structure and functions of therapeutic in-patient department? 2. What are the main parts of therapeutic hospital? 3. What are the main duties of the nurse of therapeutic department? 4. What is medical document of therapeutic department, filling in by the nurse particularly? 5. Tell about organization of work of admitting office. 6. Tell about keeping medicinal preparations. 7. What are basic demands to organization of a sanitary regimen in hospital? 8. Treatment-protective regime of the therapeutic department. 4.3. Practical work (tasks), which should be performed during class: 1. To work in different structural parts of therapeutic in-patient department.

The contents of topic: Text Organization of work of medical personnel in stationary medical establishments of therapeutic type The therapeutic department of hospital is intended for the giving of medicare by a patient 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 (cardiologic, gastroenterologic, pulmonologic and others) departments in large multi-type hospitals (city, regional). The staff and rooms of therapeutic department are analyzed during practice “Care of patient”.

Professional duties of senior, middle and junior medical personnel of in- patient departments Professional duties of the head of department. It is the most experienced physician, who manages all medical process in the department, makes rounds, advises ward physicians, controls work of middle medical personnel (nurses) and junior nurses. Professional duties of hospital physician (doctor in charge). Patients are directly treated in permanent wards. A rightness and timeliness of implementation by the middle and junior medical personnel of manipulation and diagnostic treatments, filling in medical documentation are constantly controlled. Measures, concerned patients care, are determined as: a) method of transporting; b) type of ward where a patient will be treated; c) type of sanitization of patient; d) position of patient in a bed, using functional bed; e) decision of problem concerning the character of patient feeding and type of diet. The types of medical treatment, concerned patients care, are administered, but they are fulfilled by the nurse (cups, mustard plasters, compresses and others). The volume of diagnostic manipulations, which are performed with participation of nurse is determined (duodenal intubation, taking of urine and others). The classes are constantly taken with a middle and junior medical personnel with the purpose of the their qualifications’ increasing, and also sanitary-educational work among patients and their relatives. Professional duties of senior nurse (medical sister). All middle and junior medical personnel of department submits to her. She fulfills important functions, providing following: a) rational organization of work of middle and junior medical personnel; b) the graphs of duties, replacement of medical sisters and junior nurses which out of work; c) systematic supplying the department by medicines, equipment and facilities of patients care; d) sanitary-epidemic regimen in the department; rightness of saving and consideration of drastic medicines; e) rational feeding of patients; f) consideration of patients who enter the department and are discharged from; g) the control for fulfilling the doctors administrations by the nurses and others . Professional duties of ward nurse 1. Careful fulfilling of all administrations of physicians, filling in the administration list according with fulfilling. 2. Preparation of patients for diagnostic examinations (x-ray, endoscopy and others ). 3. Collection of material for examinations (blood, urine, feces) and sending it to the laboratory. 4. Looking for transporting of patients to different diagnostic rooms. 5. Control for providing measures according to sanitary and hygienic regimen and observation of the personal hygiene in patients with serious diseases. 6. According to patients feeding: a) drafting of a la carte requirement; b ) control for maintenance of proper diet by the patients ; c) feeding of seriously ill patients; d) control of products, brought by the relatives of patient. 7. Taking body temperature (in the morning and in the evening; data recording in a temperature chart). 8. Obligatory presence of doctor at the rounds, accounting to him/her about all changes, that happened in the state of patient for a last day, receiving new prescriptions. 9. Hospitalization of patients, verification of rightness of conducting of their sanitization, acquaintance of patient with the rules of internal order. 10. Measuring of arterial pressure, pulse rate, breathing rate, day's diuresis and report of these data to the doctor. 11. Correct estimation of the state of patient and giving him/her emergency aid, and calling a doctor if it is necessary. In emergency situations a nurse must give first premedical aid (artificial respiration, indirect massage of heart, and others). 12. Careful filling in medical documentation. 13. Control for work of junior medical personnel (junior nurses, workers of feeding room).

Professional duties of sister in charge of injections and other medical procedures As a rule, they are experienced and skilled specialists who perform the special medical manipulations: intravenous injections, taking of blood from a vein for the analyses. They can help to doctor during the performing of the special procedures, for example, blood transfusion, pleura or abdominal punctures. Professional duties of junior medical sister (junior nurses) 1. Daily cleaning of wards, toilets, corridors and other rooms of department. 2. Change of patient’s underwear and bed-clothes together with a medical sister. 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, to feed seriously ill patients, to wash a crockery, to perform the simplest manipulation procedures (to apply mustard plasters, to apply enemas and others).

Medical document of therapeutic department Document 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. Document of ward nurse: a) sheet of the medical administration, which is signed by a medical sister after their fulfilling; b) temperature charts; c) journal for passing of duties; d) journal for movement of patients in the department; e) journal for registration of drugs; f) journal 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) journal for requirements of medicines; i) journals with the lists of patients who need any laboratory or instrumental research; j) journal for registration of list of patients which need consultation of doctors-specialists. Document of procedural cabinet: a) journals 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) journals 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. Document of senior nurse (medical sister): a) journal (register) for movement of patients; b) journal for registration of drugs; c) journal for registration of alcohol; d) journal for requirements to the chemist’s shop; e) journal for administrative-economic rounds; f) the graphs of work of junior and middle medical personnel, their time-board.

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 a doctor, rendering of urgency medical care if it is necessary, anthropometric measuring, sanitization, changing clothes and transporting patient to in-patient department. 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, trichophytia; 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 a doctor. 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 a doctor of admitting office, hygienic 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 reach him/her on the level of the nipples. The temperature of water in bath must be 35-400С. 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. During 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 medical sister 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- 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 case. 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, mass of body, circumference of thorax and abdomen. Usually anthropometric examinations in the admitting office are carried out by a medical sister. Measuring of growth is carried out by means of the special device – auxanometer (Fig.1). 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 auditory passage-way 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. 1. Measuring of growth of the patient a – auxanometer. 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.2). 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 in-patients 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.

Fig 2. Weighing of the Fig3. Measuring of patient on medical circumference of balance thorax

Measuring of circumference of thorax is carried out by a soft centimetre band (Fig.3) from the front of the IV rib (under nipples at men), behind and under the shoulder-blades. Thus the hands of patient must be lowered. The circumference of thorax is measured during maximal breath, and also during the quiet breathing. Measuring of circumference of stomach matters in patients with ascites (measure daily), and also at obesity (measuring is carried out on an empty stomach). A centimetre band is imposed at the level of belly-button, behind the level of the ІІІ lumbar vertebra. The obtained results are filled in the case history. Transporting. Transporting of patients – this 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 a doctor 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 on wheel stretcher, to 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 or reanimation aid. If it was successful, a patient can be transported to the reanimation, cardiological or surgical departments. 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 wheel chair (Fig.4, a,b). 3. Seriously ill patients are transported on special wheel stretcher (Fig.5, 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.

Fig.4.Transporting of the patient on Fig.5. Transporting of the patient on the wheelchair: a- wheelchair; the wheel stretcher: a-wheel b-transportation of the patient on the stretcher; wheelchair b-transportation of the patient on the wheel stretcher

Fig.6. Transporting of the patient on the stretcher: a- on plane surface; b- upwards; c- downward

Rules of transference of patients on stretcher(Fig.6, 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 their 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 their shoulders.

Rules of shifting of patient from a couch on stretcher or wheel stretcher 1. If the field of room is sufficient, the leg end of stretchers is put to the head end of bed (perpendicular position); if the field of room is insufficient , the stretcher are 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 overhead part of thighs, third 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 puts hands under low back 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 1. Patients with the sharp myocardial infarction are carefully transported exceptionally on wheel stretcher or stretcher. 2. Patient with cardiac insufficiency, 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 litter. 3. Patients with a collapse and other types of vascular insufficiency patients are transported on stretcher or wheel stretcher thus, that the head of patient is below than feet. 4. Patients in the swoon state, at the danger of origin of vomiting, are transported on stretcher or wheel stretcher in position on the back with a returned aside head. 5. Patients with the gastro-intestinal bleeding are transported on the back. An ice- bag is laid on their abdomen .

Keeping medicinal preparations 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 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.

Sanitary regimen and its meaning The necessary maintenance of a sanitary regimen in various hospital rooms plays a huge role in work of a hospital, organization of treatment and care of the patients and prophylaxis of many diseases. Infringement of the needs and rules of a sanitary regimen have frequently led to infection of wards, multiplication of the pathogenic microorganisms and spreading of the various insects. The non- observance of a sanitary regimen will always increase the danger of spreading of nosocomial infections. Nosocomial infections are infectious diseases arising in the patients in a hospital, or medical personnel as a result of infringement of the rules of asepsis and antiseptic. Basic demands to organization of a sanitary regimen in hospital According to hygiene requirements, not less than 7m2 should be allotted per patient in the common ward and 9m2 in the separate wards. The optimum beds number in a ward is 3 to 5. Patients in critical conditions should be placed in separate wards with private bathroom. Attention should be given to illumination of the wards, since the direct solar beams have bactericidical action. The illumination should be of sufficient intensity, uniform and biologically high-grade on the spectrum. Wards should be illuminated with luminescent lamps or common incandescent lamps with opaque diffusers. A night light should be provided at each bedside, so that the nurse might switch on the light without disturbing the sleep of the other patients in the ward. It is obligatory to have sufficient ventilation, which is supported by regular aeration of premises (rooms) or air conditioning. Rooms should be aired 2 or 3 times a day during the cold season, while in summer the widows should be kept permanently open. Airing is obligatory and should not be left up to patients. Heating should be organized so that it fits the optimal requirement for people in building - in winter time was +200 C and summer time was 23-240 C Beds in the room should be spaced at a minimum of 1 metre apart, which is necessary to give convenient access by the medical personnel for examining the patient, and for various procedures. Beds should be nickelplated or oilpainted in order to ensure proper hygiene. Critical patients should be placed in adjustable beds on which the patient can be fixed in any position that might be required. A special night table with drawers for personal belongings should be provided at each bedside. Movable tables should be available for feeding bed-ridden patients.

Treatment-protective regime of the therapeutic department The patient should be given a regime of physical and psychic rest, according to the teaching of the Russian physiologist Ivan Pavlov. He maintained that the patient condition improves if he is given rest under conditions that meet the special requirements of his nervous system. The main component of such a protective environment is adherence to the hospital regulations and full mutual understanding between the patient and the medical personnel. A correctly planned schedule for a hospital provides sufficient rest for the patient, regular meals, systematic medical observation, timely fulfilment of all diagnostic and medical procedures. 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

Cleaning hospital premises The hospital premises (rooms) need to be washed and cleaned with use of disinfectants. Floor material should be suitable for repeated cleansing with a wet rag. Glazed ceramic tile should be used to cover the wall in the operating room and rooms intended for various procedures. The cleaning of the wards will be carried out 2 times per day, and also in case of need. The wiping down of the dinning room will be carried out after each meal time. The general cleaning of all premises will be carried out not less often than once per week. The used stock has proper marks and will be used only for a definite purpose. Different disinfection solutions can be used. Solutions with chlorine more often will be used than various disinfectants. For preparation of a starting solution of lime chloride it is necessary to take 1 kg of a lime and 10 L of water. We’ll obtain 10% solution of chlorine lime. This solution is kept in dark containers. Further this solution varies in concentration and is used for the wet cleaning.

A. Test tasks to be done: -with a single selective answer – I-st level; 1.Document of senior medical sister includes: a) journal for registration of syringes, needles, systems; b) journal 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 , enter to the admitting office of hospital without direction. What will your tactic be? а) to examine a patient, to give him necessary medical aid and to decide a question about tactic of future treatment; b) to cause a machine „first-aid”; c) to send a patient for direction. 3. In a patient ,who was admitted for hospitalization, clothe lice are revealed in the admitting office . What are your actions? а) to say “no” to the patient in hospitalization; b) to carry out the repeated washing of patient with soap in bath, to send the clothes of patient to the desinfection chamber; c) to carry out sanitization, that includes the hair-cutting of hair of head ( if it is possible), processing of hair by the mixture of kerosene with an oil, a next washing of head with the use of a hot 10% solution of vinegar acid ; 4. A patient with complaints of a stomach-ache entered to the admitting office. The general state of patient is satisfactory. Can he take a hygienical bath? а) it is possible; b) it is impossible; c) it is possible after the exception of sharp surgical disease. 5. A patient with suspicion on the gastro-intestinal bleeding (3 hours ago there was vomiting by maintenance of type “offee-grounds”) is delivered to the admitting office. 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 nurse-assistant’s arms; c) only on wheel stretcher. 6. What do the duties of senior medical sister of department include ? а) performing of the most responsible sisterly manipulations; b) control for work of ward nurse, writing out of requirements on medicines; с) control for providing of department by a hard and soft inventory, bed -сlothes. 7. Which solution is used for disinfection of bath after sanitization of patient? a) 0,5% the clarified solution of chlorinated lime; b) 0,5% solution of hexachlorane; c) 2% solution of chloramine; d) 0,5% solution of chloramine; e) 0,5% solution of carbofosis. 8.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. 9.Which temperature of hygienical 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. 10.How must the formation of steam at preparation of hygienical bath be prevented? a) to turn off ventilation; b) to hang above bath the opened crockery with salt acid; c) to prepare bath by the means of successive pouring of cold, and then hot water; d) to hang a dry sheet above bath. 11.What disinfectants are used for the moist cleaning? a) 0,5% solution of chlorinated lime; b) 10% solution of chlorinated lime; c) 5% solution of chloramine; d) 3% solution of peroxide of hydrogen; e) solution of potassium permanganate. 12.How often is it necessary to realize the moist cleaning of wards? a) daily; b) if it’s necessary; c) if it’s necessary, but not rarer than twice a day. 13.What time the first moist cleaning of wards must be finished to? a) to 7.00 b) to 8.00 c) to 9.00 d) to 10.00 e) it is not regulated. 14 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 15. The patient should be given a regime of physical and psychic rest, according to the teaching of: a) S. Botkin; b) I. Pavlov; c) N. Strazhesko; d) E. Kant; e) V. Vasilenko. -with the selective group of right answers – the II-nd level: 1. What manipulations are performed in a procedure room? а) injections; b) puncture of pleura cavity; c) applying of cupping glasses, mustard plasters; d) medical baths; e) determination of blood type. 2. What medical documents are filled in by ward nurses? а) journal 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.Choose hygienic norms in relation to the ward of therapeutic department: a) the height of room must not be below than 2,5-3 m.; b) the height of room must not be below than 3-3,5 m.; c) distance between beds must be not less than 1 meter; d) distance between beds must be not less than 0,5 meter; e) correlation of area of windows to the floor is 1:6; f) correlation of area of windows to the floor is 1:8. 4. What are the types of disinfection? a) prophylactic; b) bactericidal; c) moisture; d) final. 5. What are the methods of disinfection? a) mechanical; b) biological; c) chemical; d) physical. 6. Professional duties of senior nurse (medical sister) include the following: a) rational organization of work of middle and junior medical personnel; b) carrying out of special medical manipulations: intravenous injections, taking of blood from a vein for the analyses. c) the graphs of duties, replacement of nurses and junior nurses which out of work; d) preparation of patients for diagnostic examinations (x-ray, endoscopy and others ). e) systematic supplying the department by medicines, equipment and facilities of patients care; f) the control for fulfilling the doctors administrations by the nurses and others; g) taking body temperature (in the morning and in the evening; data recording in a temperature chart); h) help to physician during the performing of the special procedures, for example, blood transfusion, pleura or abdominal punctures. 7. Professional duties of ward nurse include the following: a) careful fulfilling of all administrations of physicians, filling in the administration list according with fulfilling. b) preparation of patients for diagnostic examinations (x-ray, endoscopy and others ). c) help to physician during the performing of the special procedures, for example, blood transfusion, pleura or abdominal punctures. d) collection of material for examinations (blood, urine, feces) and sending it to the laboratory. e) looking for transporting of patients to different diagnostic rooms. f) control for providing measures according to sanitary and hygienic regimen and observation of the personal hygiene in patients with serious diseases. g) control for work of junior medical personnel (junior nurses, workers of feeding room). i) carrying out of special medical manipulations: intravenous injections, taking of blood from a vein for the analyses. 8. Document of ward nurse includes the following: a) temperature charts; b) journal for passing of duties; c) journal for movement of patients in the department; d) case history (medical card of in-patients); e) journal for registration of drugs; f) journal 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) journal for registration of alcohol; i) journal for requirements to the chemist’s shop. 9. During 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) urgent report about the case of pedicoulosis is filled in and sent to infectious regional hospital; c) the note about the incident of pedicoulosis is written on the title page of case history ; d) the clothes of patient are sent to the disinfection chamber; e) the fight is carried out against lousiness; f) stop hospitalization of the patient during 24 hours. Answers for test tasks of the I-st level: 1 - b 11- a 2 - a 12- c 3 - c 13- c 4 - c 14- b 5 - c 15- b 6 - b 7 - a 8 - c 9 - c 10- c

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

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 to a ward on stretcher by such 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 . 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? Task 7. A patient admitted to the admitting office in the state of heavy cardiovascular insufficiency. What level of sanitization is necessary to patient? Standards of right answer for tasks: 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 cause a doctor. 2) No. A stretcher must put so that their leg end was set to the head end of bed. 3) No. Wheel stretcher must be covered by a sheet and blanket, which change after transporting of every patient . 4) Correctly. 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. 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 cause a duty doctor. 7) Partial sanitization by sponging down of face, the opened parts of trunk by a towel, the moistened water solution of table vinegar acid . In case of sharpening of cardiovascular insufficiency to send patient to the reanimation department quickly, without sanitization.

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.-788p. 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. Educational movie “Therapeutic Nurse-Client Relationship: Maintaining Boundaries” 2015 2. Educational movie “Structure and functions of the therapeutic department. Preparation of antiseptic solutions. Duties of the medical personnel.” 2010

Internet resourses 1. http://www.moz.gov.ua/ua/portal/dn_20130601_0460.ht ml 2. http://www.nursingworld.org/nursingstandards 3. http://www.ferris.edu/HTMLS/colleges/alliedhe/Nursing/ Standards-of-Professional-Nursing-Practice.htm

Methodical instruction is composed by lecturer Ye. Petrov. 200__/200__ academic year. 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 09 10 2018 Protocol No4 The Head of the Department Professor Yu. Kazakov

METHODICAL INSTRUCTION FOR STUDENTS’ SELF-PREPARATION WORK

Educational discipline Nurse practice Module No 1 Enclosure module No 1 Topic Peculiarities of the work of procedure unit of therapeutic department and duties of nurse concerning its maintenance.

Year 3 Faculty medical

Hours – 2 1. The topic basis: Complex treatment of patients, side by side with medicament therapy, includes using of various factors and methods of physical influence to organism. Different methods, which is used with this purpose (mustard plasters, cupping glasses, compresses, hot water bottles, ice bag, etc.) acts reflectory to circulation, nervous system, promotes to positive dynamics of disease and to patient’s recovery. 2. The concrete aims:  To represent duties and rights of nurse of procedure unit.  To compose rules of maintenance of medical instruments in procedure unit.  To classify the main types of compresses, explain mechanism of their action.  To explain technique of using of cups, mustard plasters, hot bottle, ice bag  To explain treatment and disinfection of multi-use facilities  To explain essence of hyrudotherapy.  To explain rules of using of portable (individual) and stationary inhalators.  To explain technique of giving of moistened oxygen and using of oxygenous pillow.

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 structure of the main systems of organism, respiratory and cardiovascular particularly. 2. Physiology To know physiology of the main system of organism, respiratory and cardiovascular particularly. 3. Medical biology To know structure of leeches

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. Mustard plasters It is leaf of solid paper, having rectangular form (8 x 12,5 cm), one side of which is covered with thin layer of dry powder of mustard. 2. Cups It is glass vessels with round bottom and thickened edges with capacity 30-70 ml. 3. Compress It is treatment thermal or cold procedure with using of multi-layered dressing. There are dry and moist compresses. Last one can be hot and cold. 4. Ice bag It is flat rubber bag with wide opening, which is filled with little bits of ice.

5. Hyrudotherapy It is using of medical leeches with treatment purpose.

4.2. Theoretical questions to be answered before class: 1. What are the main duties and rights of procedural unit nurse? 2. Tell about organization of work of the procedural unit nurse. 3. What are indications and contraindications to applying of different types of compresses? 4. What are indications and contraindications to applying of hot water bottle? 5. Mechanism of cups’ action. Indications and contraindications. 6. Tell about cryotherapy. 7. Tell about disinfection of hot water bottles, ice bags, cups 8. Hyrudotherapy: indications, contraindications, technique of its carrying out. 9. Inhalation: indications, contraindications, technique of its carrying out. 10. What term “oxygenotherapy” mean? 11. Indications for carrying out of oxygenotherapy, its technique. 4.3. Practical work (tasks), which should be performed during class: 1. To take part in work of procedural unit of therapeutic department. 2. To show carrying out of simple medical procedures on plaster cast. 3. To prepare necessary facilities for applying of different compresses and carry out procedure. 4. To apply cups, mustard plasters to the patients (if it is necessary). 5. To fill hot water bottle and apply to the patients (if it is necessary). 6. To fill ice bag and apply to the patients (if it is necessary). 7. To take part in treatment and disinfection of multi-use facilities. 8. To take part in procedure of using of stationary inhalators by patients. 9. To show correct using of portative inhalators to the patient. 10. To fill oxygenous pillow correctly. 11. To take part in giving of moistened oxygen to the patient.

The contents of topic: Text

Organization of the work of nurse of procedure unit

One of the nurse-expert, having complete average (speciality “Nursing business”), length of service - 3 years and more and special preparation, which allows holding this post, is nominated to post of the nurse of procedural unit. She is nominated and got one’s discharge by head doctor according to acting laws. She is subordinated directly to head nurse of hospital, the head of department, and senior nurse of department. In his work she follows directives of higher ranking officials and this Instruction. Duties 1. Carrying out of procedures, prescribed by physician, if their performing by average medical personnel is permitted. Besides, she must follow rules aseptics and antiseptics. 2. Aid during carrying out of manipulations, which must be carrying out by physician only. 3. Providing first medical aid, reanimation according to her role. 4. Maintenance of procedural unit action according to profile of department. 5. Taking of orders for procedures in ward nurses, establishment of their performing sequence, consulting with hospital doctor about this question. 6. Maintenance of complete good working of apparatuses and instruments, which are in room, presence of sterile material, medicaments. 7. Timely composition of application for instruments, equipment, medicaments and their taking in accordance with established order. 8. Strict following to demands of infection control in procedure room. • Sanitary- hygienic demands to room, equipment. • Personal hygiene and clothes. • Sanitary-anti-epidemic regimen of the work. • Standards of disinfection and sterilization. • Following to rules of aseptics and antiseptics during carrying out of procedures. 9. Timely and correct filling in medical documentation in accordance with form of documentation of procedural unit, established in hospital. 10. Observance of moral-legal norms of professional contacts. 11. Observance of labor order, labor discipline. 12. Systematic improving of professional qualification by means of taking part in conferences for average medical personnel, organized in hospital and department. 13. Carrying out of sanitary-elucidative work. Rights 14. The nurse of procedural unit has right: 15. In case of absence of physician to provide emergency before-doctor cover to the patients. 16. To improve professional qualification during special courses. 17. To demand following to rules of aseptics and antiseptics from personnel during work in procedural unit. 18. To obtain information, necessary for carrying out of her duties. Responsibility She is responsible for nonfulfilment of duties according to this instruction and internal regulations of hospital. The nurse of procedural unit is responsible for: 19. Total correctness of apparates and instruments, entrusted to her. 20. Sanitary condition of procedural unit. 21. Timely and qualitative carrying out of procedures and manipulations. 22. Observance of rules of labor protection and safety conditions and anti- fire safety.

Hygiene of procedural nurse and demands to her appearance

Procedural nurse must be example of cleanness and accurateness. She must constantly to maintain body cleanness, to have hygienic bath not rarer than one time a week, and in case of excessive sweating - more often, look after hands carefully, to wash them before food intake and after visit to toilet, before and after every medical manipulation. Nails must be cut shortly and without nail polish. In case of dryness of hands’ skin, it should be lubricated with hand cream and any oil. It is possible to prepare mixture of glycerin (3/4) with liquid ammonia (1/4). Tidiness of dress with taking into account standard form. Coming to the work, she must change one’s dress for clean, smoothed down smock. Footwear must be changed for clean shoes, noiseless during walking and disinfected well. Before procedural unit she must cover starched cap. Hair must be collected under cap accurately. Make-up must be moderate, ornaments - simple. Rings and bracelets must be taking away before beginning of the work. Nurse must not have smell of perfume, tobacco, onion, garlic, fish (allergic reactions to smells occur in some patients). Accurate, slim nurse causes confidence in patient and he becomes calm and more confident in her presence. For prevention of nosocomial infection the nurse must: - separately keep street-clothes and special clothes; - not exceed hospital’ territory in special cloth; - not wear special cloth in non-working hours.

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 (Fig.1).

Fig.1. Moist warming compress 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 (Fig.2). 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 (Fig. 3).

Fig.2. Warming compress Fig.3. Warming compress 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.

Fig.4. Hot water bottle 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. (Fig.4). 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. (Fig. 5). 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.

Fig. 5. Mustard plasters

Fig. 6. Cups

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) (Fig. 6). 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 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 (Fig. 7). 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.

Fig. 7. Ice bag

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 (Fig. 8)

Fig.8. Medical leeches

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 (Fig. 9)

Fig. 9. Placing leeches

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.

INHALATION It is possible to inhale gases (oxygen, nitrous oxide), agents, which is vaporized slightly (ether, chloroform), and aerosols (substances, sprayed little).

Fig. 10. Using of portable inhalator: 1-valve, 2-inhalator, 3-reservour, 4- inhalation from individual inhalator

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) (Fig. 10) 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.

Fig. 11. Ultrasound inhalation

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 (Fig. 11). 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 oxygenotherapy. 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 (). 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 (Fig. 12) is effective method of inhalation oxygenotherapy.

Fig. 12.Oxygen inhalation by means of catheter a-general appearance of reduction system and system for moistening of oxygen; b- schematic picture of technique of catheter introduction throughnasal meatus; c- fixating of catheter, introduced into nasal meatus; d- general appearance of the patient with catheter, introduced through mouth

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.

Fig. 13. Methods of oxygen moistening: a-by means of Bobrov’s apparatus; b -by means of individual inhalator; b- inhalation of moistened oxygen

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 ( Fig.14.).

Fig. 14. Centralized system of oxygen provision a- connection of oxygen bombs; b-transporting of oxygen bombs; c, d, e, f - stages of using of oxygen bombs

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 (Fig. 15) . 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.

Fig.15. Taking of oxygen in oxygen pillow a-general appearance of oxygen pillow; b- technique of oxygen taking from bomb.

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) (Fig. 16).

Fig. 16. Apparatuses for forming of oxygen cocktail (oxygen scum): a-for individual using; b- for group using 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.

A. Test tasks to be done: -with a single selective answer – I-st level; 1. What is the duration of the moist warming compress application? a) 24 hour; b) 6 – 8 hour; c) 1 hour; d) 15 hour; e) 2 hour. 2. What is normal respiratory rate of healthy adults in rest state? a) 10 - 15; b) 16 - 20; c) 21 - 25; d) 26 - 30; 3. What is cause of irritating action of mustard plasters? a) organic acids; b) phenol combinations; c) etheral oils; d) alcohol; e) camphor oils. 4. How often must the moist cold compress be changed? a) every 2 – 3 min.; b) as soon as it will be dry; c) every 10 – 15 min. 5. How correctness of applying of moist warming compress must be checked up? a) in 1 – 2 hour compress is taken off and its state is checked up; b) in 1 – 2 hour finger is pushed under compress and state of its internal layer is determined; c) in 1 – 2 hour you must ask about subjective feelings of patient. 6. What is duration of cup application? a) 5-10 min.; b) it must be individual for every patient; c) it must be determined according to change of skin colour under cups. 7. What is the most optimal concentration of oxygen in air-oxygen mixture? a) 15 – 20 %; b) 40 – 60 %; c) 75 – 80 %; d) 95 %. 8. What is purpose of moistening of oxygen during ? a) prevention of its excessive loss; b) keeping the rules of safety conditions; c) prevention of toxic effect of oxygen for organism. 9. What must be speed of oxygen giving by means of individual inhalator normally? a) 2-3 L per minute; b) 4-5 L per minute; c) 6-7 L per minute; d) 8-9 L per minute; e) 9-10 L per minute. 10. What is value of medical oxygen pressure in oxygen bomb? a) 150 atm. b) 80-100 atm; c) 110-140 atm; d) 160-200 atm; e) 220-240 atm. 11. By means of which device decrease of oxygen pressure to necessary level is made before its inhalation? a) reductor; b) manometer; c) system of tubes branching; d) Bobrov’s apparatus; e) chamber for moistening. 12. What is purpose of moistening of oxygen during oxygen therapy? a) for better uptake by the lungs; b) for ionization of oxygen; c) for dininishing of drying action of oxygen in relation of mucous membrane of airways; d) for better uptake of oxygen by tissues. 13. What complications can occur in applying of ice bag? a) skin vesicles (bubbles); b) rupture of infiltrate; c) induration of infiltrate; d) skin ulcer. 14. Irritative action of mustard plasters is caused by: a) terpens; b) organic acids; c) essential (volatile)oils; d) phenol compounds; e) alcohol. 15. How many leeches on average can be applied on area of right hypochondrium in patient with heart failure during one procedure? a) 2-3; b) 4-6; c) 7-9; d) 10-12; e) 13-15. 16. Patient D. complains of elevation of temperature to 38,5º C, dry cough with feeling of burning behind sternum. What procedures can be used for improvement of patient’s condition? a) expectorant mixture; b) applying of mustard plasters; c) oxygen inhalation; d) using of leeches; e) cold compress.

-with the selective group of right answers – the II-nd level; 1. What are the contraindications for the heaters? a) spastic pains; b) obscure abdominal pain; c) in postinjection infiltrates; d) malignant tumours; e) first day after a trauma. 2. What are the contraindications for warming compress ? a) various skin diseases; b) spastic pain; c) injures of the skin; d) interior bleeding; e) postinjection infiltrates. 3. What are the contraindications for cupping-glasses? a) bronchites; b) tumors; c) pulmonary bleeding; d) pneumonia; e) diseases of a skin. 4. When are mustard plasters utilized? a) in bronchites; b) at the first hours in injuries; c) in angina pectoris; d) in nasal bleeding; e) in headache. 5. When is the ice-bag utilized? a) in initial stage of acute diseases (acute appendicitis, pancreatitis etc.); b) in angina pectoris; c) for bone fractures; d) in headache; e) in internal bleedings. 6. When is oxygenotherapy used? a) in hemoptysis; b) in chronic obstructive pulmonary disease; c) in pulmonary edema; d) in dry cough; e) in myocardial infarction. 7. When is moist cold compress utilized? a) in bronchitis; b) in angina pectoris; c) at the first hours after injuries; d) in nasal bleedings; e) in headache. 8. What are distinctive signs of oxygen bombs with medical purpose? a) blue colour of bomb; b) dark colour of bomb; c) mark “M” on bomb; d) presence of reduction system. 9. Acute bronchitis is diagnosed in patient with complaints of dry cough. What procedures can be recommended to him? a) ice bag; b) leeches; c) warming compress (hot compress); d) cold compress; e) mustard plasters; f) cups (cupping glasses). 10. Skin disease eczema was revealed on the skin of thorax in patient R. Using of which procedures is contraindicated to this patient? a) cups; b) mustard plasters; c) warming compress; d) leeches; e) hot water bottle; f) ice bag. 11. When it is possible to apply cold compress? a) asthma attack; b) renal colic; c) headache; d) purulent infiltrate; e) bleeding; f) intraarticular haemorrhage due to traumatic lesion. 12. Where it isn’t possible to apply cups? a) lumbar area; b) heart area; c) mammary gland; d) backbone; e) subclavicular area; f) skin of face. 13. When applying of mustard plasters is contraindicated? a) dry cough; b) inflammation of trachea (tracheitis); c) pneumonia; d) second-degree skin burn; e) first-degree skin burn; f) skin radiolesion; g) cancer of the lungs; h) bleeding wound. 14. What are signs of correct single-use applying of mustard plasters? a) appearance of little vesicles (bubbles) on the skin; b) reddening of the skin; c) appearanc eof pigmentation; d) absence of skin reddening; e) feeling of heat in area of applying of mustard plasters. 15. Name signs of mustard plasters, unfit for using: a) absence of mustard oil smell; b) sharp smell of mustard oil; c) falling of mustard from surface of mustard plaser.

B. Tasks to be done: Task 1. There is intensive abdominal pain, which is accompanied by nausea and vomiting in patient R. A nurse applied hot heater on the patient’s abdomen for relieving the pain. Is her action correct? Task 2. For applying of cups a nurse prepared such things: cups, cotton wool, ethyl alcohol, vaseline oil, tray. What is absent in this list? Task 3. Relatives brought hot broth to the patient with hemoptysis. What must the nurse do? Task 4. A nurse prepared for applying of cups following things: cups, wick, ether, cotton-wool, matches. What is her mistake? Task 5. A nurse applied moist cold compress to the patient for 10 min. Is her action correct? Why? Task 6. Patient S. complaints of strong cough because of acute catarral disease. What help for this patient must be?

Answers for test tasks of the I-st level: 1 - b 9 - b 2 - b 10- a 3 - c 1 1 - a 4 - a 12- c 5 - b 13- c 6 - a 14- c 7 - b 15- c 8 - c 16- b

Answers for test tasks of the II-nd level: 1 - 10- a , b , c , d , e 2 - 11- c , e , f 3 - 12- b , c , d , f 4 - 13- d , e , f , g, h 5 - 14- b , e 6 - 15- a , c 7 - 8 - a , c 9 - c , e

Standards of right answer for tasks: 1)No, it isn’t. During abdomen pain in patient nurse must not carry out any actions before examination and instructions of physician. 2)Metallic rod (Kocher’s clamp, forceps); matches (cigarette lighter). 3)A nurse must forbid giving hot broth to this patient. 4)Use of ether for applying of cups is forbidden categorically. 5)No, it isn’t. As the moist cold compress soon reaches the temperature of the body, it is necessary to change it every 2 – 3 minutes. 6) -Use of inhalation of sodium hydrocarbonate and hot steam; - mustard plasters, mustard foot baths, and hot compresses on the chest must be used as counter attractive therapy.

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.-788p. 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. Intersurgical. “ Oxygen Therapy Training” 2. Tungtunghospital.Educational movie. “ A better experience, a painless endoscopy!” / Tungtunghospital.2013 3. Nick Smith. Educational movie . “The basics of the ECG in 5 min”/ Nick Smith. 2014 4. SAIT. Educational movie. “Diagnostic Medical Sonography” / SAIT. 2011 Internet resourses

1. http://www.moz.gov.ua/ua/portal/dn_20130601_0460.ht ml 2. http://www.nursingworld.org/nursingstandards 3. http://www.ferris.edu/HTMLS/colleges/alliedhe/Nursing/ Standards-of-Professional-Nursing-Practice.htm

Methodical instruction is composed by lecturer Ye. Petrov. 200__/200__ academic year. Methodical instruction is revised and approved again At the Chair of Propaedeutics of Internal Medicine with Care of Patients meeting On “___” ______200__ year. Protocol №