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Patient Care

Theme N 1 ROLE OF ASSISTANT PHYSICIAN IN PATIENT CARE

Quality patient care is extremely important in a hospital. The majority of nursing tasks involve physical care of patients, and diagnostic or therapeutic procedures. It includes: assisting the patient with a shower or bath, assisting the patient with dressing, eating or emptying the bowels. The physician writes orders for treatments, medications, or modifications in the patients daily activities for the purpose of controlling symptoms or the cause of the patients disease. For most patients, treatment ordered are those that the nurse performs, such as compresses, dressings, irrigation, and applications of heat or cold. Some treatments are performed by specialists. Orders relating to the patients daily activities usually are the responsibility of the nursing staff (monitoring of elimination, amount of rest or activity, any restriction of food or fluid intake). The tasks nurses are required to perform can be divided into four categories: I. Routine nursing services 1) measuring body temperature 2) taking pulse and measuring blood pressure 3) taking respiration rate 4) feeding patients 5) administering morning and evening care 6) performing postmortem care 7) recording fluid intake 8) applying elastic bandages

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9) collecting sputum, urine and stool specimens 10) II. administering oral medications, injections

Maintenance of patient comfort and hygiene 1) changing beds 2) assisting with patient hygiene, bathing, positioning, and oral hygiene 3) caring for hair and nails, ears and eyes 4) administering bedpans and urinals 5) administering enemas

III.

Maintenance of patient area and equipment 1) cleaning and disinfecting patient units 2) sterilizing instruments, pitchers, and glasses 3) maintaining equipment (wheel-chairs, beds, stretchers) in good condition 4) assembling equipment and supplies for diagnostic or therapeutic procedures

IV.

Messenger services 1) transporting patients to other treatment units 2) bringing patients to the operating room 3) picking up drugs from the pharmacy (except narcotics).

Rules for maintaining a professional appearance: 1) A nurse should be neat, well groomed, and wear appropriate clothing or uniform. 2) Shoes should be clean and polished at all times. 3) Hair regular shampooing. Hair should be not fall onto the uniform or over the face while working. 4) Nails should be short, well manicured and free from dirt. A light soft shade nail polish can be allowed (except in delivery or operating room).

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5) Cosmetics - usually restricted (especially in delivery or operating room). 6) Jewelry is not appropriate, except a wedding ring. 7) Bathe or shower daily ant take necessary precautions against body odors. Use a good deodorant, but without perfume (fragrances may be offensive to patients). 8) Brush your teeth regularly. Your role As a member of a nursing staff of the hospital, you will play an important part in assisting professional registered nurses in carrying out both simple and difficult procedures, all of which are necessary to good patient care. You will be taught to perform some procedures alone and others only under the supervision of a registered nurse. All the work you do will be directed toward one goal, the recovery of the patient. If you master all aspects of every task that is taught during the training program, you will be able to do the things a patient needs in order to get well. The basis of science has always been the search for the answer to the question Why? You should follow the same procedure. If you do not understand something, ask questions until you do understand. Keep asking questions until you are certain you know the answers. It is much better to admit that you do not understand something than to pretend you know it and consequently make mistakes. In your work it is important that you study and remember the basic information this book will give you. Wile you are studying proper nursing technique, you must practice each procedure you learn until you are sure you can perform it without error. Your patients well-being and comfort, and perhaps some day even a patients life, will depend on your knowing your job and doing it well.

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Theme N 2 MORALS. DEONTOLOGY. MEDICAL DOCUMENTATION.

The ethics is known as a science of morals, rules and requirements for social conduct. DEONTOLOGY is the science of correct behavior of medical personnel aimed at the maximum efficacy of treatment, and prevention of harmful are the consequences of inadequate medical aid. The main object of deontology and also between the physician, the nurse, and the patient. Diseases of the internal organs affect the patient's psychic state and generate fears and anxieties. The assistant physician should be very attentive and careful in dealing with their patients. They should be very patient and tolerant. A calm and confident medical personnel will always increase the patients belief in recovery. The appearance of the medical personnel should be reassuring and have a calmative effect. The assistant physician must accurately and skillfully perform their duties. Their main qualities should be discipline, accurate performance of the physician's orders. If a nurse or assistant physician commits an error, he must immediately take measures to remedy his fault. It is his duty to report to the physician with out

relationships between the doctor and the patient, between the nurse and the patient,

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being afraid of the repercussions, because the interests of the patient must be of primary importance to any medical worker. The assistant physician plays important role in the care and treatment of patients and must be able to raise the patient's spirits make him believe in the successful treatment of his disease. Inappropriate behavior of a medical personnel can cause an iatrogenic (Greece iatros = physician) disease in the patient. Sometimes a careless assistant physician can explain to the patient the essence his disease or criticize the physician's tactics in a way, that may cause an iatrogenic disease. The best prophylaxis of iatrogenic diseases is adherence to the deontology. rules of medical ethics; i.e. laws of

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Positive relationships between the patient and the assistant physician may accelerate recovery. The patient's confidence in his doctor and other medical personnel is an important medical factor: the patient believes that everything possible will be done to promote his recovery. The patient has confidence in his doctor if his medical secrets are properly kept, if the doctor shows respect to his patient, and understands his needs and demands. From the very first minute of his presence in the hospital the patient must feel that his interests are regarded with respect. The physician should try to know as much as possible about the special qualities of the patient's character. Each patient requires a special approach in treatment. It is impossible to understand the patient properly, and hence it is impossible to give him all possible medical attention. The personality of the doctor and other medical personnel, the performing of their duties and treatment of their patient, are very important curative factors. But only constant improvement of professional skill and experience makes it possible to exploit these factors to the fullest. THE NURSE STATION The nurse station should be located not far from the observed patients wards, or it may be inside the wards if the patient's condition requires special constant observation. The nurse station should be provided with a room for medicines and instruments, a file room for the case histories. A signal board should be installed near the table to control the situation in the ward. A locker for poisonous and strong medicines should be also provided. The nurse station should be maintained in strict compliance with hygiene requirements. MEDICAL DOCUMENTATION Medical documentation is a means of communication and continuity between physicians, between the physician and assistants, etc. Medical

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documentation

is

necessary

to supervise the work of medical institutions,

physicians, nurses and etc. It is also used for planing medico prophylactic measures for research and training purposes. Medical documentation must therefore be accurate. The main medical document is the PATIENT'S CASE HISTORY. It

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should be kept for both in- and out-patients. It is easy to assess the sick rate of the population by inspecting the case histories. The physician or any other medical personnel can find out the details of medical treatment prescribed to the patient. The main document in a hospital is the case history contained the name of the patient, his complaints, anamnesis (history of present illness and life history) , test result, a diary, and an epicrisis. When the patient is admitted to the hospital the nurse enters his name and other personal data and the diagnosis that has been established by the medical institution that refers the patients for hospitalization. The address and the telephone number of the patient and his closest relatives are also entered in the case history. The case history should be kept under lock at the department where the patient is treated. The main entries are made by the physician, while the nurse records information concerning procedures carried out to the patient. THE PATIENT'S HOSPITAL RECORD Patient's Chart. The patient's chart contains the graphic chart and other medical records gradually introduced over the years. The sheets are kept in an orderly manner in a chart holder. A typical chart consist of the following items: Doctor's Notes. These notes are highly confidential and are intended only for physicians. They include the patient's history and the doctor's progress report about the patient condition. Doctor's Orders. These orders include the prescriptions and treatment for the patient and they are also confidential as doctor's notes. They are carefully transcribed by the nurse. Medication Record. This list contains the information about the medicines prescribed for the patient.

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By law, medicines in a hospital may be administered only by licensed personnel. If the patient asks you to give him any medicine, tell him that you will speak to the doctor. Then pass the request along to the charge doctor. Nurse's Notes. Special forms containing the nurse records: her observations about the patient's condition, treatment and routine care.

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The nurse assistants will not record observations in these notes, but will be responsible for reporting to the head nurse about any pertinent signs and symptoms, that they observe. Personal History. This sheet contains pertinent personal information about the patient, such as name, address, occupation, marital status, next of kin, date of admission, and room number. Graphic Chart. The graphic chart gives a running picture of the vital signs as indicated by periodic taking of temperature, pulse and respiration. Some induces spaces to record blood pressure, and intake and out put. The conventional form allows enough space to make entries six times a day for 1 week. Laboratory and X-ray Report Sheets. These Forms summarize the results of the laboratory tests and x-rays administered to the patient. Clothes Sheet. All the patient's clothes and personal things are listed in this sheet. Miscellaneous Forms. All signed permission papers, such as anesthesia records, operative permits, and pathology specimen reports are included in the chart. Kardex. The Kardex is an important source of information and guidance for all members of the nursing staff and is maintained separately from the patient's chart. It contains the information about the medications, treatment and plans for nursing care, is kept one for each patient. The Kardex derives it's name from the standard method of filling these cards. A nurse make the various entries on the cards, taking them directly from the doctors orders. In any event, the Kardex provides valuable ready information concerting medication, treatments, nursing care plan, and diet. A Consultation card is given to the patient by the assistant physician, when the patient is referred to specialist. The conclusion of the specialist is recorded into the patient's case history.

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A procedure card is intended to record the procedures done to the patient. A separate card is given for each kind of medical procedure, where the name of the patient should be written. A head nurse of each department keeps a book where she records all information about the admitted patient: his name, the preliminary diagnosis and the verified diagnosis patients. Ward nurses and nurses duty keep records of performed procedures to the patients, of strong and poisonous medicines given to the patients during the day. The keys from lockers where group A and B medicines are stored are also given to the new nurse on duty. Both nurses put the signatures in the log-book in accounts for the use of strong and poisonous medicines. The head nurse should supervise of changing shifts and report to the physician, in brief, the condition of the patients, fulfillment of his orders, and the sanitary condition of the department. The ward nurse cant leave her post until her successor begins her work. upon the patient's discharge from the hospital. The head nurse keeps records of all strong and poison medicines that are prescribed to the

Theme N 3 Admission department

The patient is admitted into a hospital through its admissions department, where his name, age, etc. are registered, the patient is examined preliminarily and appropriately prepared for treatment. The admission department should be located near the main entrance of the hospital and be provided with convenient access roads. The admission department should have a waiting room, registration and inquiry offices, rooms for examination of patients, a room for special medical procedures, and a room for sanitary treatment of the patients. An admission departments at large hospitals should be provided with an operating room, a

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room for reception of the injured, and a room for x-ray examinations. A special isolation room should also be provided for patients with infectious diseases, and rooms for accommodating of patients with undiagnosed diseases. These wards should be provided with private bathrooms. The admission department should be equipped with a sufficient quantity of wheeled beds, stretchers and gowns for patients. The hospitalized patients should be treated with care and attentiveness. From the first minute of his stay in the hospital, the patient must have confidence in its medical staff. The patient's name and other personal data are recorded in the admission department, and then he is examined by the physician, and given the appropriate sanitary treatment. The rooms of the admission department are arranged in the order of these procedures. The assistant physician or the nurse records the patient's personal data on a special chart, then the patient's height and weight are measured, the patient is given examination to reveal possible pediculosis (lousiness) or signs of infectious diseases, and his body temperature is taken. All findings are recorded in the case history and the nurse accompanies the patient to the physician and then gives him sanitary treatment. Finally, the nurse accompanies the patient to the medical department. If the patient is in the critical condition or even unconscious (hemorrhage, shock, coma, dangerous cardiac arrhythmia, etc.), the patient is not questioned, and sanitary treatment is not carried out. He is delivered immediately to the resuscitation or operating room, or to the specialized department where he is given the necessary medical aid. If a patient is admitted to the hospital according to a preliminary agreement with a policlinic or an out-patient department of another hospital, the patient's condition allows the taking of his case history, primary examination, and sanitary treatment. When the case history is recording, the patient reports his name, age, address. Position of the patient, the date and time of hospitalization is registered too. All these data are also recorded in a special admittance journal

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The examination of the patient includes not only measuring of his height and weight but also the girth of his chest, his muscular strength (dynamometry), and respiratory function (spirometry). The methods and techniques used to assess the morphological conditions of man are called anthropometry The patient is weighed on medical scales. His weight is determined up on admittance and not less than once a week during his stay at the hospital. The patient should be weighed in his underwear in the morning before breakfast, after urination and emptying the bowels. A normal weight is found by subtracting 100 from the height (in cm). This is only a tentative method since normal weight varies with age and because of many other factors. The patient usually loses weight in many diseases, especially those associated with malignant newgrowths, tuberculosis, acute infections, and gastrointestinal diseases. Fat tissue is lost first, then the patient loses weight at the expense of muscular tissues. Patients with edema gain weight due to retention of liquid in the tissues. The girth of the chest is measured by a tape passed under the angles of the scapulas on the back and across the 4-th rib of the chest. The girth should be measured with quiet breathing and hanging hands freely at the patient's sides. The measurements are taken at the height of inspiration and expiration. Spirometry is the method of determining the respiratory volumes of the lungs, which is necessary for assessing the external respiratory function. The apparatus used for this purpose is called a spirometer. The patient is asked to inhale with maximum effort, and (holding his nose clamped) to exhale the air and water and kept in a sterilizer. Dynamometry is a method of measurement of muscular force using a dynamometer. The patient is asked to squeeze the dynamometer at a maximum force: the pointer indicates the muscular strength in kilograms. Anthropometric measurements are followed by examinations: the physician establishes a preliminary diagnosis, gives first aid whenever necessary, determines the department in which the patient should be treated, and also the volume of sanitary preparation and kind of transport before hospitalization. into the apparatus through the mouth-piece. The mouth-piece should be washed with soap

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Patients with signs of infectious diseases should be isolated into a special room at the admission department. Sanitary and hygienic treatment of patients. The amount of sanitary treatment depends on the patient's conditions. If the patient is in critical condition (bleeding, shock, coma, etc.), the patient is directed straight to the intensive care unit without sanitary treatment. If the condition of the patient permits, he take shower or a bath. The patient takes off his clothes in the examining room where he is prepared for the bath. The water temperature in the bath should be 36-37 C, and of the ambient air, 25-28 C. The patient's personal things are registered. A copy of the record is placed in the patient's file, while another copy is kept together with the things in a storage room. Money and valuables are registered separately by the head nurse of the admission department. A bath is prescribed to cleanse the skin of the patient from dirt and sweat. A bath is contraindicated for patients with skin diseases, wounds, and for those in critical condition. The patient takes off his clothes in a special room and goes to the bath. The bath should first be washed with hot water and soap and if the previous patient had a skin or infectious disease, the bath should be disinfected. The patient should be given a clean sponge and after he has taken the bath the sponge should be discarded into a "used sponge" container. Whenever possible, the patient should be given a sterile package containing a clean sponge and underwear. In order to prevent the water from cooling, the bath should be filled immediately before usage. The patient should assume a convenient position in the bath so that his back and head rest against the bath wall. The head is first washed, then follow the body and the legs. During washing, the patient should pay special attention to those parts of the body where sweat usually accumulates (armpits, the groin, the perineum, the areas between the toes, and under the breasts in women). The bath is taken during 20-25 minutes. The water temperature should be agreed with the body temperature. The bath is prepared by the junior medical personnel, while the assistant physician or the nurse observes the patient's condition. If it worsens (dizziness, pallor), the patient is held out of the bath, placed on a bed and

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the physician is called if necessary. If the patient's condition does not permit to take a bath, he should take a shower. The shower should be taken about 5-10 minutes. If the patient's condition is of medium gravity or critical, the assistant physician or the nurse should cleanse his body with a wet towel paying special attention to the sweating areas. After a bath, the patient has his toe and finger nails cut and is given clean underwear. Rooms intended for sanitary treatment of patients should be kept clean. The oilcloth covering the cot should be treated with a disinfectant solution (2 per sent chloramine solution). A clean sheet should be used to cover the cot for each patient. Calcium hypochloride should be used to wash bathrooms. Transportation of the patients. There are several techniques for transporting of the patients. The patient can move by himself, by means of a wheeled bed or chair, on a stretcher, or can be carried by the auxiliary personnel. The physician decides which kind of transportation is most appropriate. If the patient's condition is satisfactory, the patient walks to the ward by himself accompanied by junior or auxiliary personnel. Critical patients are carried to the ward on wheeled stretchers. A clean sheet and pillow are placed on the stretchers and the patient is covered with a blanket. Sheets and pillow cases should be changed for each patient. If a lift is not available, critical patients are carried up or down the stairs by nurses who carry them carefully and avoid walking at a normal pace (to prevent jolting). The patient should be moved with his head in the forward direction. It is obligatory that the assistant physician or nurse accompany the patient to his ward. Moving from the stretchers onto the bed sometimes requires much effort on the part of the patient. The stretchers are therefore put so that the head end of the bed aligns with the foot of the stretchers. In the admission department the patient is acquainted with the hospital regulations and informed about his responsibility for observing them. A special note is made in the case history.

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Theme 4. Medicoprotective regime. The patient unit. Changing bed clothes.

Medicoprotective regime. The patient should be ensured a regime of physical and psychic rest. The patient's condition is improved 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 hospital schedule provides sufficient rest for the patient, regular meals, systematic medical observation, timely fulfillment of all diagnostic and medical procedures. Tentative regimen for a hospital. -------------------------------------------------------------------------------------------------------------Time, h ---------------7.00 7.00 - 7.30 7.30 - 8.00 8.00 - 8.30 8.30 - 9.30 9.30 - 12.00 14.00 - 14.30 14.30 - 16.30 16.30 - 17.00 17.00 - 17.30 -Wake-up -Temperature taking -Morning toilet -Dispatching medicines -Breakfast -Physicians rounds -Carrying out medical orders and prescriptions -Dinner -Afternoon rest -Temperature taking -Tea 12.00 - 14.00 item -----------------------------------------------------------------------------------------------

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17.30 - 19.00 19.00 - 19.30 19.30 - 20.00 20.00 - 21.30 21.30 - 22.00 22.00 - 7.00

-Visiting time -Dispatching medicines -Supper -Leisure time -Evening toilet -Sleep

The patient unit. When a patient is admitted to a hospital, he is placed in a patient unit. This may be a single unit in a large ward, a unit in a semiprivate room with two to four beds, or a private room. The most common unit is a semiprivate, two-bed room with a screening curtain between patients. The patient unit has furnishings and equipment that will be used in care of a patient.Bed. Since the patient spends most of his time in bed, the bed is the most important piece of equipment in the unit. It provides needed comfort and support. It must be adjustable so that the doctor, nurse, and their personnel may treat and care for the patient in a way that least disturbs him. The hospital bed is about the same length and width as a single bed at home, but higher. There are several types of hospital beds. The latest model is a motor-driven, adjustable bed. The adjustable spring (Trendelenburg spring) permits the back part or knee part be raised or lowered to any desired position. Siderails or bedrails are standard equipment on most hospital beds. They are a safety device to protect the patient from falling out. They may also assist the patient in getting some exercise by raising and lowering himself. In common use today is the so-called Hilow bed, which can be raised and lowered by a motor-driven or hand-operated mechanism. When it is raised, the nurse and doctor can work without bending over; when lowered, the patient can get in and out with ease. The hilow bed can be adjusted to a wide variety of positions for treatment and comport. Control panel on a Hilow Bed. Observing personal hygiene and cleanliness of the ward and the patient's bed promote effective treatment. It is necessary to check the bed-clothes for cleanliness and the mattress is smooth. Patient with grave diseases and those suffering from incontinence of urine or feces should be placed on an oil-cloth to prevent contamination of the linen. In case of heavy vaginal

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discharge in women, easily replaceable sheets should be used over the oil-cloths, which can be renewed as frequently as necessary. Critical patients should be put in adjustable beds, special head rests should be used to hold the patient's head in comfortable position. Two pillows and a blanket (in a blanket cover) are given to the patient. The bed should be made regularly both before and after sleep. Changing bed-clothes. Underwear and bed-clothes should be changed not less than once a week after bath, and also after accidental contamination. There are several techniques by which underwear and bed-clothes can be changed. If the patient is able to walk, he leaves his bed and the nurse changes the linens. There are two methods by which bed-clothes are changed for bed-ridden patients. According to one of them, the used sheet is rolled up on both ends toward the center, the patient is then raised carefully and the used sheet removed. The clean sheet is first rolled up like the used one, placed under the patient's waist, and then unrolled in the reverse order. According to the second method, the patient is carefully moved to one side of the bed and the sheet is rolled up toward the patients back. A clean rolled sheet is placed instead on the bed and unrolled toward the patient. The patient is then moved onto the clean sheet and the clean sheet is fully unrolled. To change the underwear of a critical patient, the nurse puts her arm under the patient's back, helps him to sit up in bed, pulls the gown to the patient's armpits and head, pulls the gown first over the head and then from the arms. A clean gown is put on in the reverse order: the sleeves first and the gown is pulled over the head and stretched under the patient. Vests open in the front are used instead of gowns for bedconfined patients.

Theme #5 PERSONAL HYGIENE OF THE PATIENTS

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Care of the patient's skin and prevention of the bedsores. The human skin performs protective, excretory, heat-regulatory and analytical functions (skin sensitivity). The excretory and thermoregulatory functions of the skin are realized through perspiration (excretion of the sweat). Sweat glands excrete water, urea, uric acid, sodium, potassium and other substances. Healthy individuals at rest excrets about 1 litre of sweat a day. The amount of sweat excreted by patients with fever increases to 10 litres or more. Hear that is dissipated by a person with sweat accounts for about 20 percent of his total heat emission, and this percentage increases significantly in patients with fever. Perspiration is the main thermoregulatory of a human body. Perspiration increases significantly in the sick person. The assistant physician and the nurse should take special care of the patient's skin, because when sweat is evaporated it leaves various metabolites, which decompose on the skin and irritate it. The skin of the bed-ridden and patients with fever should be cleansed by water mixed with alcohol (1:1), which has a disinfecting effect. Special attention should be paid to the cleansing the groin, the perineum, the armpits and the skin under the breasts (in women), where sweating is especially intense. Patients confined to bed for prolonged periods of time can have bedsores, which are sites of necrotized skin due to prolonged compression and, hence, defective nutrition. Bedsores usually occur on the sacrum, the shoulders, elbows. Bedsores more often affect moist skin. The skin first reddens and becomes tender, and then foci of necrotization develop. Necrotized tissues are rejected and ulcers develop which sometimes destroy soft tissues till the bone. Infection of the injured skin can cause purulation and even blood poisoning. Bedsores indicate inadequate patient's care. When the skin becomes hyperemic, it should be treated with a 10 percent camphor alcohol twice a day, and then a moist towel. The lesion should be treated by a quartz lamp. The condition of the skin should be observed.

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If the bedsores have developed, they should be treated with a strong solution of potassium permanganate with subsequent application of synthomycin, Vishnevsky or other liniments. Bedsores can be prevented by regular changing the patient's position during the day, by straightening folds of his underwear or bedclothes, by keeping the skin clean, by treating it with disinfectant solutions, especially at the sites where bedsores usually occur, and placing a ring rubber cushion under the patient. When the first signs of bedsores appear on the sacrum, a ring cushion should be placed so that the sacrum is spanned over the hole in the cushion. Inflatable mattresses (airbeds) are now used for prophylaxis of the bedsores. Regular baths and skin washing also prevent the formation of bedsores. The nurse should help weak patients to wash themselves in the morning. The patient must wash his hands in the morning, before meals and after defecation and urination. Patients must wash they feet before night sleep, while critical patients, 2-3 times a week (with the assistance of the nurse). Awash basin with warm water should be placed on the bed.

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Critical patients with incontinence of urine or feces should be assisted in their beds by giving them a bedpan. It should be remembered, however, that the prolonged use of a hard bedpan could also provoke the formation of the bedsores. Inflatable bedpans should be therefore used by patients that unable to leave their bed. The external genitalia of women confined to bed should be washed at least once a day (unless more frequent washing is prescribed). The women should urinate and empty her bowel before genitalia are washed. Washing should be done with a potassium permanganate solution (1:5000) or2 percent lysoform solution. The women should assume a supine position with her legs flexed and thighs set apart. A bedpan is placed under the pelvis. Using a forceps and cotton wool, the genitalia are washed with a jet of the disinfectant solution. The cotton ball should be moved from the genitalia toward the anus. The external genitalia are then dried by dry cotton wool pad. In addition to washing the external genitalia, women are also given vaginal irrigation. For this an Esmarch flask is hanged 1 metre above the bed and is filled with a disinfectant solution. A glass end-piece is introduced into the vagina along its posterior wall to a depth of 6-8 cm. The patient lies on her back because part of the disinfectant solution will remain in the vagina. After irrigation is over, the patient should stay in the same position for about 30-min. The external genitalia should be dried after the vaginal irrigation. The Esmarch flask should be washed in boiling water; the end-piece should be sterilized.

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Care of the mouth. Food that remains between the teeth and in the gum pouches is the substrate which microbes readily propagate creating conditions for various complications. The care of the mouth is important in the general care of the patients. Patients should brush their teeth in the morning and in the evening, using the same brush to clean the back of the tongue to prevent putrefaction of the desquamated epithelium. The mouth should be rinsed after meals to remove food remains. Patients who are unable to care of their mouth should be assisted: their teeth, gums, and tongue should be cleansed by a cotton wool pad wetted with 3-4 percent solution of boric acid twice a day or sodium hydrocarbonate solution (2 percent). If the inflammatory process developed in the mouth, medicines should be applied or the mouth should be irrigated. Sterile napkins wetted with a 0.1 per cent furacin, 2 per cent of boric acid. A Janet syringe (or a simple rubber syringe) is used for irrigating the mouth with disinfectant solution. The patient should assume a semiprone position; an oilcloth should be placed on his chest, while the patient should hold a metallic basin.

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Care of the eyes. In order to remove purulent discharge from the eyes, a 3 percent boric acid solution is used from a rubber bulb or by applying a piece of gauze. The flowing fluid should be collected in a basin held by the patient under his chin. The hands of the assistant physician or the nurse should be clean. If an inflammatory process affects the eyes, medicines should be instilled or ophthalmic ointments applied. When instilling eye drops, the nurse pulls down the lower eyelid, two drops are expressed on the eyeball near the nose, one after another. When the patient shuts the eyes, excess solution is expelled from under the eyelids. A cotton ball should absorb it. The pipette should be rinsed and kept closed until the next use. Ophthalmic ointment should be applied to the eye using a glass spatula. The patient is asked to look up, his lower eyelid is pulled down using a moist cotton wool pad, and the ointment is transferred from the spatula into the inferior lower conjunctivae fornix (fornix conjunctivae inferior). The spatula is then pulled carefully in the horizontal direction toward the temple. Care of the nose and the ears. The patient should clean his ears every morning. To prevent the obstruction of the ear by the wax in bed-ridden patients, their ears should be cleansed 2 or 3 times a week. Earwax is usually removed from the ear in the form of small lump. Ear wax can be accumulated in the auditory meatus and clog it. The meatus should be washed. A 100-150 ml Janet syringe is used for this purpose. The nurse should stay at the side of the patient. The patient under the ear holds a metal basin. Using her left hand, nurse pulls the ear up and back, introduces the end-piece of the syringe into the external meatus with her right hand. Water at the temperature of36-37C is discharged with force in small portions. The ear should be dried by cotton wool. If this procedure fails, cerol solution: 7-8 drops (preheated in water) are instilled 2-3 times a day for 2 or 3 days. Using a pipette makes instillation. The patient should incline his head in the direction of his healthy ear. The left hand should pull down the ear lobe, and the drops instilled by the right hand. In order to prevent the spontaneous flow of the fluid from the

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ear, the patient should keep his head inclined for 15-20 minutes. The ear should be wiped dry by sterile cotton wool. If a patient is unable to clean his nose, he must be assisted. A small piece of cotton wool should be wound around a small stick, wetted with oil, and introduced into the nose. The patient is then asked to move his head up, and the nurse turns the probe clockwise to remove the crusts. Usage of dry cotton wool should be avoided since it can provoke nasal bleeding. Care of the hair. It's necessary to take care to prevent the formation of dandruff. The patient with dandruff should have his hair washed once a week. Various shampoos and soaps are used for this purpose. If baths are contraindicated for the patient, his hair should be washed in his bed. The wash basin should be placed on the bed, and the patient's head positioned over the basin. The scalp should be shampooed especially thoroughly. The washed hair should be rinsed, dried and combed. In order to prevent chilling, the patient's head should be wrapped in a dry towel or a napkin

Theme 6 NUTRITION OF A PATIENT

The health of a human being, his work capacity, and longevity depend to a great degree on an adequate nutrition. Nutrition is the vital demand of a living body. Food supplies energy and it is the building material for cells and tissues. The teaching of correct nutrition is called dietetics. A diet determines the conditions of nutrition, composition, and quantity of food, which is necessary for both healthy individuals and the sick. A therapeutic diet means planned nutrition of the patient. Diet should differ depending on the disease. More food should be given to pregnant, tuberculosis and asthenic patients, while patients who suffer from in coercible

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vomiting or hemorrhage associated with a peptic ulcer must not be given any food; some patients may be restricted in certain foods, others in water, etc. Diet at hospitals is thus therapeutic. There are 15 therapeutic diets; some diets have subdivisions. Dietologists (or special nurses at smaller hospitals) ensure the control of patients nutrition. A nutritionist is responsible for the observation of the dietary requirements in departments. Oxidation of carbohydrates, proteins, and fats in the body liberates energy. The value of food from the point of view of potential energy is expressed in kilocalorie (kcal). A kilocalorie is the amount of heat energy, which is necessary to raise the temperature of one liter of water by 1 C. The daily Caloric demand depends on the basal metabolism, energy consumption during exercise, and food intake. The basal metabolism expresses the energy consumption of a person at rest. The basal metabolism of a normal adult (male) is about 1700 kcal. About 200 kcal are consumed for digestion, absorption, and assimilation of the food consumed. The energy expenditures Depend largely on the character and amount of exercise (at work or at rest). Workers whose job is not associated with physical effort consume from 2600 to 3000 kcal a day, while the energy demand increases to 3600-4500 kcal a day for workers performing medium-hard and hard physical labor.

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The modern concept of quantitative processes occurring during assimilation of nutrients has been formulated in the idea of a balanced diet. The intake of adequate amounts of food in well-balanced portions is necessary for normal assimilation of nutrients and normal vital activity of a living body. A correctly balanced intake of proteins, fats, and carbohydrates is expressed by the ratio 1:1:4, of calcium and magnesium 1:0.6, and of calcium and phosphorus 1:1.6. When planning any diet, it is necessary to follow the principles of diet therapy. The physiological standards depend on sex, age, occupation, and some other factors. The average demands of a person for food and energy (calculated for a balanced diet) can vary depending on the character of a given disorder. For example, sugar should be restricted in diabetes mellitus, and proteins in renal insufficiency. It is necessary to take into account the local and general effects of food on the body. The local effect of food includes stimulation of the central nervous system through the sensory organs (taste, vision, and olfaction). When the mechanical, temperature, and chemical effects are changes, the secretory and the motor functions of the alimentary system also change substantially. The general effect includes changes in the composition of blood during digestion, which causes changes in the nervous and endocrine systems. Important factors of diet therapy are sparing, training, and contrast. Sparing means exclusion or restriction of intake of mechanical, thermal, or chemical irritants. It is necessary to avoid hasty suspension of a diet, or its undue prolongation. A prolonged sparing diet can sometimes cause constipation if the diet was prescribed for diarrhea. A sparing regimen is Therefore combined with a training diet, with a gradual increase in the food intake, which is necessary for readaptation of the bodily systems and metabolic processes. So-called contrast days are sometimes prescribed: foods, that were formerly excluded from the diet (e.g. salt or sauces), are given. On the one hand, this stimulates the digestive function, and, on the other hand, it encourages the patient to believe that

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he is on the recovering. Fasting days promote withdrawal of residues from the body. They are especially important in the treatment of obesity. The chemical composition of food and the way it is prepared, as well as some individual or endemic features of nutrition should be considered. When prescribing a diet, local traditions and national habits should be taken into account as well as toleration to certain foods. Diet therapy is ineffective if the patient does not actively cooperate with his doctor, if he is not convinced of the efficacy of the diet therapy. Encouraging the patient is, therefore, another important factor.

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Diet therapy also implies certain requirements for food intake. A healthy person eats 3-4 times a day. Taking food at intervals less than two hours is not recommended since the digestive function does not recover that soon. Classification of diets Special diets are prescribed for postoperative patients during their first days following surgery of the stomach or intestine, and also for patients in a semi-conscious state. The purpose of a special diet is to supply the minimum possible amount of food in cases where the intake of solid food is contraindicated and to prevent meteorism. This diet should be given for 5-6 days and then it should be gradually expanded. During the 2nd and 3rd days, the patient is given liquid or jelly-like food of readily and quickly assimilated Substances (non-fatty bullion, non-sweet stewed fruits or berries, wild rose decoctions and non-sweet tea). Soft-boiled eggs, mucinous soups, pureed meat or curds should be added on the 4th or 5th day. Food should be given at 2-2,5 hour intervals. The diet should then include pureed porridge; steam-cooked dishes of pureed boiled meat, poultry or fish, pureed vegetables. Additional preparations for enteral nutrition are added. Food is given 6 times a day; the first portion is 100 ml and then it is increased to 200-400 ml. Diet No.1 is prescribed for acute gastritis, exacerbation of chronic gastritis with normal secretion or hyper secretion, and gastroduodenal ulcer. The diet is intended to lessen the inflammation and to promote healing by restricting thermal, mechanical, and chemical irritants. Food that stimulates gastric secretion is excluded from this diet. Pureed, stream-cooked or boiled food is prepared. Cold or hot food should be excluded. The food should be physiologically adequate and balanced with respect to calorific value and chemical composition. Food is given 5-6 times a day; milk, cream or yogurt

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should be given before bedtime. Carbonated drinks, coffee, and condiments should be excluded.

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Diet No.2. This diet is prescribed to patients with chronic gastritis with hyposecretion (period of exacerbation), chronic colitis, states after acute infections, or in injured chewing apparatus. The diet is intended to supply adequate nutrition, normalize the secretory and motor functions of the gastrointestinal tract by moderate thermal and mechanical sparing. The diet is normal with respect to the chemical composition and calorie intake. The food is mostly crushed or pureed. Cold dishes should be excluded. The patient should eat 5 times a day. Grape juice, carbonated drinks, canned food, legumes, milk, and fat should be excluded. Diet No.3. This is prescribed for constipation caused by inadequate nutrition, for hemorrhoids and fissures of the anus without pronounced inflammation. The diet is intended to stimulate the motor function of the intestine. The diet includes vegetables, fruits, berries, bread, and cereals high In fiber; salted and pickled vegetables and vegetable oils are also included. Cold dishes and drinks are allowed. The diet promotes peristalsis and evacuation of the bowels. The patient should eat 4-5 times a day. Cold water with honey or sugar is given in the morning and stewed fruits before bedtime. Coffee, cocoa, and strong tea are excluded. The daily calorie intake - 3000 kcal. Diet No.4. This diet is prescribed for acute enterocolitis with diarrhea following fasting days, exacerbation of chronic enteritis, dysentery, after surgery on the intestine. This diet should be prescribed for 5-8 days. It is intended to minimize chemical and mechanical irritation of the intestine, to decrease fermentative and putrefactive processes in the intestine. The calorie intake is decreased to 2200 kcal a day (mainly at the expense of carbohydrates and fats). Food containing rough cellular tissue, spices, salted food, fresh bread, buns, coffee, cocoa, carbonated and cold drinks, grape juice, whole milk (except in dishes) are prohibited. Food should be steamed, or boiled. Food should be pureed before intake. The temperature of dishes should not higher than 60 C or below 15 C.

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Diet No.5. The diet is prescribed for chronic hepatitis, infectious hepatitis (convalescence stage), and chronic cholecystitis (without exacerbation). The diet is intended to normalize the function of the liver and the bile ducts and to stimulate secretion of bile under conditions of normal nutrition. The diet is characterized by an increased content of proteins and carbohydrates; fats are restricted. The temperature of food is normal. The daily calorie intake - 3000-3500 kcal. The amount of liquid - 2 liters. Coffee, cocoa, and cold drinks are excluded.

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Diet No.6. The diet is prescribed for nephrolithiasis with formation of concrements from salts of uric and oxalic acids, and for podagra (gout). The diet is intended to normalize the purine metabolism, to decrease formation of uric acid, to shift the reaction of the urine to alkaline. Foods containing a lot of oxalic acid and purine should be excluded. The intake of fats and proteins is restricted. The intake of carbohydrates is restricted in obesity. The caloric intake is 2500-2700 kcal a day. The amount of liquid intake is 2-2.5 liters a day. The patient takes meals 4-5 tames a day. Alkaline mineral water is widely used. Coffee, cocoa, and strong tea are excluded. Diet No.7. This is intended for patients with chronic nephritis during the convalescence period, chronic nephritis (in the absence of exacerbation), and nephropathy of pregnancy. The diet is intended to decrease hypertension and lessen edema, to decrease the formation of and improve the withdrawal of rest nitrogen from the body. The amount of proteins is moderately restricted while the intake of vitamins increased. Food is prepared without salt: 3-6 g of salt is given to the patient. Fish, mushrooms, and nitrogenous substances are excluded. The temperature of dishes is normal. The caloric value of the diet is 2800-3000 kcal a day. The amount of liquid is restricted to 1 liter. Food is take 5-6 times a day. Cocoa, strong coffee, mineral waters containing sodium is excluded. Diet No.8. The diet is prescribed for obesity to decrease fat deposits. The content of carbohydrates and fats (especially animal fats) is low; the protein content is moderately increased. Liquid, salt, and appetite stimulators are decreased. The diet is low in calories: 800-1000 kcal per day. The salt intake is restricted to 5 g and liquid intake to 1-1.2 liter a day. The patient eats 5-6 times a day. In order to depress the feeling of hunger, the diet is enriched with fiber. Tea, coffee, juices (fruits, berries, vegetables) are given while lemon drinks, kvass, and grape juice are excluded. Fasting days is prescribed, when the patient eats only watermelon or the like. Diet No.9. The diet is prescribed for diabetes mellitus. It is intended to normalize carbohydrate metabolism and to prevent disorder in fat metabolism, and also

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to determine tolerance to carbohydrates. moderately low.

The content of fats and carbohydrates is

Sugar and sweets are excluded. The protein intake is slightly

increased. Vitamins, lipotropic substances (methionine, lecithin), and cellular tissue are increased. Sugar substitutes (sorbitol, xylitol) are used. The diet is 2500 kcal per day. The food is given 5-6 times a day. Grape juice, lemon drinks are excluded. Diet No.10. The diet is prescribed for heart disease with circulatory insufficiency, and essential hypertension. The diet should spare the cardiovascular system and promote correction of the abnormal circulation, facilitate withdrawal of rest nitrogen and under oxidized metabolites. The intake of fats is moderately decreased. All dishes are salt-free. Salt is given to the patient (4-5 g). Food is given 5 times a day, in equal portions. The daily intake of liquid is 1 liter; the caloric intake is 2500-2800 kcal a day.

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Diet No.11. The diet is prescribed for tuberculosis of the lungs, anemia, and cachexia. It is intended to increase the body resistivity to various infections and to improve nutrition in general. The diet is rich in proteins, fats, carbohydrates, vitamins, calcium, and iron. The calorie intake is 3300-3800 kcal a day. Food is given 5 times a day. Fatty meat or poultry, spicy sauces, a lot of sweet cream are exceeded. Diet No.12. This diet is indicated for chronic cardiovascular diseases and rich in vitamins. Food is taken 5-6 times a day. The caloric intake is 3000 kcal a day. Diet No.13. The diet is prescribed to patients with acute infectious diseases, tonsillitis, and after surgery on external organs and tissues. The diet is intended to maintain the strength of the body, to improve the function of the gastrointestinal tract in acute fever or during the post-operative period when bed-rest is obligatory. The diet is moderately restricted in fats and proteins; the caloric value is low while the vitamins and liquid are increased. The intake of rough cellular tissue, fatty, salted and spicy dishes and condiments is restricted. The temperature of hot dishes should not be higher than 55 and of cold dishes not lower than 12 C. The daily intake of salt is 8-10 g, of liquid, 2 liters and more. The calorie intake is between 2200 and 2500 kcal. Fruit and berry juices, wild rose decoction, tea with lemon should be given in large amounts. Diet No.14. The diet is indicated for nephrolithiasis and pyelocystitis attended by alkalinity of the urine and precipitation of calcium phosphates (phosphaturia). The diet is intended to shift the acid-base equilibrium toward acidosis by restricting the intake of alkalizing foods (to prevent precipitation). Vegetables should be restricted (potatoes, carrots, cabbage, berries); the fat intake is increased to 120 g a day. The daily liquid intake is 2-2.5 liters and of salt 12-15 g. Food is taken 4-5 times a day. Dairy products, salads, canned food, fruits, and fruit and berry juices are excluded.

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Diet No.15. The diet is indicated for patients with various diseases, which do not require diet therapy (without involvement of the alimentary system). The diet is intended to ensure adequate nutrition by observing physiological standards of nutrition for appropriate working and living conditions. The daily intake of proteins is 80-100 g (animal proteins,

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55-60 per cent), of fat 80-100 g (vegetable fats, 25 per cent) and of carbohydrates, 400- 450 g. The caloric value of the diet is 2700-3000 kcal / day. The daily intake of salt is 15g; the intake of water is unlimited. Food is taken 4-5 times a day. Fasting diets Fasting diets are prescribed for patients with cardiovascular diseases, diseases of the alimentary tract, kidneys, and for patients with metabolic disorders. The diet is intended to normalize metabolism, to promote withdrawal of excess water and sodium. Fasting diets are prescribed for 1-2 days, 1-2 times a week, depending on the given disease and toleration of hunger. One food is predominantly given to the patient on fasting days and the diets are named accordingly, e.g. fruit diet, vegetable diet, etc. A dairy diet is usually used for diseases of the cardiovascular system complicated by pronounced circulatory insufficiency, essential hypertension, obesity, pyelitis, cystitis, and diseases of the liver and the bile ducts. The calorie intake is 700-1000 kcal a day. Curds diet. This is prescribed for pronounced circulatory insufficiency, chronic nephritis (with edema but without azotemia), and obesity. The daily calorie intake is 1600-1700 kcal. Apple diet. cardiosclerosis This is prescribed for obesity, essential hypertension, (accompanied by overweight), chronic nephritis, and chronic

pancreatitis. The daily calorie intake is 500-600 kcal. Stewed-fruit diet. The calorie intake is 750 kcal. Milk-potato diet. This diet is prescribed for chronic nephritis with edema and azotemia, for diseases of the cardiovascular system with pronounced circulatory insufficiency, and for various disease associated with acidosis. The daily caloric intake is 1200-1300 kcal.

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Raisins diet. This is prescribed for chronic nephritis with edema and azotemia, cardiovascular diseases with pronounced circulatory insufficiency. Tea diet. hyposecretion. Meat-vegetable diet. This diet is indicated for obesity. Water melon diet. nephrolithiasis with uraturia. The diet is prescribed for nephritis, podagra, and This diet is indicated for acute enterocolitis and gastritis with

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Critical patients should be assisted in their meals. If a patient rejects food (psychic disorders) or is unable to swallow it (in some diseases of the mouth), the patient is fed food should be fed through a gastric tube. The tube is passed through the oro- or nasopharynx and slowly farther, along the posterior wall of the pharynx, into the esophagus. If the tube enters the larynx instead of the esophagus, the patient starts coughing and air is discharge from the tube during respiration. When the tube is in the esophagus, a funnel is attached to its outer end and liquid food is poured into the funnel (broth, cream, milk, fruit juice, etc.). Two or three glasses of liquid food should be given per meal. If liquid food cannot pass through the esophagus, (because of a burn or tumor), an artificial fistula is made through which food is poured directly into the patient's stomach. Patients are sometimes given nutrients by enema or parenterally. A nutrient enema is done after evacuation of the rectum by a cleansing enema. This done, a warm solution (35-40 C) of a 5 per cent glucose and 0.85 per cent sodium chloride solution are administered by enema. The solutions should be given 3-4 times a day in a dose from 100 to 200 ml in each enema. If the patient does not absorb the solutions, 5-6 drops of opium should be added to them. If the patient's condition is critical, nutrients should be given parenterally, better by intravenous injections. A 40 per cent glucose solution is usually given. Blood transfusion is also practical. Blood plasma, its substitutes, and hydrolysates (hydrolysine, amino peptide, protein hydrolysate), which contain amino acids and lipofundin, are also given parenterally. From 2 to 3 liters of the solutions are given a day. Food should be taken under calm and quiet conditions. Nervous excitement impairs the appetite and in some patients it can be completely lost. A sleeping patient should be awakened for meals except if he suffers from insomnia. Patients should not be awakened if they were given narcotics or sedatives. In order to ensure the required sanitary conditions and nutrition for patients, food brought to them by their relatives should be inspected. The nurse should check if the food corresponds to the dietary requirements for the given patient. Refrigerators should be available where the patients can keep their food.

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Medical personnel should inspect the quality of food kept in the refrigerators and night tables.

Theme 7 THERMOMETRY
Patient's temperature should be taken to reveal possible fever. It should be remembered, however, that an elevated temperature does not always correspond the gravity of the patient's condition. Temperature should be measured by a maximum thermometer with a scale graduated in 0.1 from 34 to 42 . The thermometer is called maximum because it reads the maximum temperature reached and the reading stays unchanged after cooling. A narrowing in the capillary tube prevents the mercury from descending by gravity to the bulb unless the thermometer is shaken energetically. Shaking should be done carefully as not to break the thermometer. Before taking a temperature, reduce the thermometer's reading to below 34-35 mark. The thermometer should be kept in the armpit so that the mercury bulb is in close contact with the skin on all its sides. The patient's armpit should be dry because a wet thermometer reads a lower temperature. The thermometer should be held for 10 minutes m the armpit or 5 minutes in the mouth. If the patient is very weak and cannot hold the thermometer with the required force, he should be assisted. If the patient's condition is critical, his temperature is taken by placing the thermometer into the mouth (under the tongue) or inserting into the rectum. In last case the thermometer should be coated with vaseline or other oil. The patient should lie on his side, the thermometer being inserted into the rectum to half its length. The buttocks should be kept tight together. Rectal temperature (and temperature taken in the mouth) is 0.5-1 degree higher than that taken in the armpit. There are some contraindications to taking rectal temperature. There are constipation, diarrhea and diseases of the rectum. After taking the temperature, the thermometer should be washed thoroughly in warm water and then disinfected in alcohol or some other

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disinfectant solutions. Temperature in infants should be measured in the groin. The thermometer is placed in the caudal genital fold, the infant's thigh is flexed to the abdomen so that the thermometer bulb is hidden in the skin fold. The temperature is usually taken two times a day at hospitals. The first measurement is done at 7.00-9.00 and the second at 17.00-19.00. If necessary, the temperature is taken at 3-hour intervals. The findings are recorded in a temperature chart, where the morning and evening temperatures are designated by dots, which are then interconnected by a curve. Many diseases have their specific temperature curves. The temperature curve should be appended to the case history. In normal individuals temperature varies from 36 to 37 (as taken in the armpit). The body temperature is lower in the morning and higher in the evening, the difference usually not exceeding 0.8 in healthy individuals. A body temperature rises slightly after exercise or meals, or when the ambient temperature is high. The aged and asthenic patients usually have slightly lower temperatures, while in children it is usually higher than m adults. The elevation of body temperature over 37 m adults is called fever. The degree of temperature rise is important for evaluating the patient's condition. Accelerated heart and respiration rates and a fall of the arterial pressure attend fever. Patients complain on chill, headache, dry mouth, thirst, and absence of appetite and excess perspiration. Metabolism is intensified during fever, while the amount of perspired liquid may be more than 8 liters a day. As a result of decreased appetite and liquid loss during a fever, the patient sometimes loses significant weight. Usually, quick and significant elevation of temperature is accompanied by a chill, that continues from a few minutes to an hour; in rare cases it may continue longer. The blood vessels contract during chills, the skin turns pallid, and so-called gooseflesh develops. The patient feels cold, he shivers, his teeth chatter. If the temperature rises gradually, the patient may feel only a slight chill. If the temperature is high, the skin reddens and the patient feels hot. A rapid drop of temperature is attended by intense sweating. The morning temperature of the patient with fever is lower than the evening one.

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Three periods of fever are distinguished: 1 - rising temperature; 2 - maximum temperature; 3 - dropping temperature. The first period is characterized by a gradual or abrupt rise of temperature attended by a chill, cyanosis (blue color) of the lips and the extremities, headache, and subjective indisposition. During this period the patient should be covered with a warm blanket and given hot tea. During the second period, headache, vertigo, dryness in the mouth, hyperemia of the skin develop and in serious cases even delirium and hallucinations. The patient should be given much liquid to drink (tea with lemon, fruit juice, etc.) because his loss of water is significant. If the delirium or hallucinations develops at the patient, his bed should be provided with a protective network to prevent him from falling out of bed. A special post for a nurse should be arranged at his bedside. There are two types of the third period. The temperature may decrease gradually, during the course of several days. This termination of fever is called lysis. The patient perspires slightly and his weakness is moderate. A rapid fall of temperature (within a few hours) is called a crisis. It is attended by intense perspiration and pronounced weakness. Arterial pressure often drops, the limbs become cold, and cyanosis develops. Medicines increasing arterial pressure should be given and the patient should be warmed with hot water bottles. Temperature may rise to various degrees Temperatures between 37-38 are called subfebrile, 38-39 - moderately high, 39-40 - high, 40-41 - very high, and over 41 - hyperpyrexial temperatures. Hyperpyrexial fever is attended by severe nervous disorders and endangers the patient's life. A correct diagnosis can be established not only according to the degree of temperature elevation but also by its circadian variations, i.e. by the type of fever. Six major types of fever are distinguished: 1 - continuous fever (37.5-38.5 ) that persists for several days or weeks with circadian variation within 1 . This fever is characteristic of lobar pneumonia and typhoid fever; 2 - remittent fever; the circadian variations in temperature are significant (usually 1.5-2 ). This fever is characteristic of tuberculosis, bronchopneumoma, and purulent infections; 3 - intermittent fever; this is characterized by a sudden rise of temperature to 39-40 and subsequent fall

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to normal temperature during a few hours. The temperature may rise again in 1-3 days. This type of fever is characteristic of malaria; 4 - hectic fever; it is characterized by a rise in temperature to 39 and over followed by a sudden fall at the same day to a normal or even subnormal temperature. This fever is characteristic of sepsis and severe forms of tuberculosis; 5 - inverted fever; the morning temperature is higher than the evening one; this type of fever is typical of brucellosis, sepsis, and tuberculosis; 6 -irregular fever; it occurs mostly in influenza, rheumatism- dysentery, tuberculosis, etc. Temperature swings during the day are quite varied and indefinite in irregular fever. In addition, there are two forms of temperature curves, i.e. relapsing and undulant. Relapsing fever is characterized by alternation of pyrexia and apyrexia. It occurs in typhus recurrent. Undulant fever is characterized by a gradual rise of temperature during several days followed by its gradual fall. This fever occurs in brucellosis and lymphogranulomatosis. A fever lasting 15 days is called acute, and over 45 days, chronic. The condition in which the body temperature is markedly subnormal is called hypothermia. This often occurs after a critical fall of temperature. Hypothermia (about 35 ) can persist for 1-3 days. The pulse is slow; the subjective condition is satisfactory. Hypothermia occurs also in collapse, after profuse hemorrhage, in starvation, asthenia, and after a prolonged exposure to cold. Care of patients with fever. Patients with fever are weak and it is necessary to replenish the lost water and nutrients. Since appetite of patients with fever is decreased, food should not be abundant but highly caloric and easily assimilated. It should be rich of vitamins and proteins. A lot of liquid should be given to the patient in order to replenish the loss of water. If the perspiration is excessive at the patient. Ins bedclothes and underwear should be changed several times a day. A dry warm towel should be used to wipe off the sweat during especially intensive perspiration. Since sweat evaporates from the skin and leaves metabolites on its surface (salts, urea), the skin should be cleaned by

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the water mixed with alcohol or vinegar. If the body temperature is high, the mucosa of the mouth and the lips become dry and cracked. Special care of the mouth should be carried out. Correct care of the patient's skin helps to alleviate his condition. The patient with fever should be assisted to evacuate his bowels and the bladder. The pulse and respiration rate should also be monitored. Special attention should be given to the patient during a critical fall of temperature that is often attended by a fall in arterial pressure (collapse).

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Crisis

Lysis

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Fever continua

Fever remittent

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Fever intermittent

Fever hectic

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Fever inversus

Fever irregular

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Fever recurrent

Fever undulant

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Theme 8 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 hydrotherapy, hot water bottles, cups, mustard plasters, leeches, bloodletting, 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. For example, a person is sleepy after a warm bath or even after local application of heat. Thermal effects decrease or even remove pain, decrease skin sensitivity, and prevent transmission of pathological impulses into the central nervous system. Temperature stimulants reflectorily 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 entire body responds to a thermal procedure, but the response is more pronounced at the site of heat application. Heat applied to the skin draws a lot of blood from the internal organs and the body temperature thus increases. When the difference between the temperature of the body and the ambient temperature increases, the body gives off its heat to the environment via irradiation. Heat is also removed during the evaporation of sweat and expiration of air. When heat is applied to the heart region, the pulse rate increases. But this occurs not due to the direct effect of heat on the heart muscle, but because of stimulation of the skin receptors. The respiration and pulse rate increase when heat is applied to large areas of the body, the effect being especially pronounced when entire body is exposed

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to heat. Arterial pressure decreases in such cases. When hot, the body perspires. The sudorific effect of heat promotes the resolution of exudate in inflammatory affections. Prolonged application of heat to muscles decreases their tone and fatigue develops. Cold affects the body in three stages. During the first stage, the skin vessels contract, the skin becomes pallid, blood flows to the internal organs, and the skin becomes cold. A minute later, the second stage develops: the cutaneous vessels now dilate, the skin reddens, and becomes warm when touched. During the third stage, the blood flow slows down; the skin turns blue and cold again. When cold is applied to the heart region, the pulse rate slows and pain in the heart is alleviated. The respiration rate first decreases and then increases in the cold, metabolic processes are accelerated and the production of heat is intensified. Cold increases the excitability of muscles. Application of cold retards development of acute inflammatory processes. Hydrotherapy. This includes the external application of water, e.g. shower, bath, sponging, and wet packs. Bath, sponging, douching, and similar simple procedures can be done at home, while more complicated hydrotherapeutic procedures should be done at special hydrotherapeutic establishments. In order to protect the patients body, water can be poured over the body from a pail. The entire body or its separate parts can, thus, be strengthened. For overall protection the patient is seated on a low stool in a bathtub, and 2 or 3 pailfuls of water are poured over him. The temperature of water in the first pail should be 30-34 C, and in subsequent pails, 2-3 C, lower. Water should flow over the chest and back. The pail should be held close to the body. The procedure should be done daily, the water temperature being gradually decreased to 21-22 C. The body should be rubbed dry after the procedure until the skin reddens slightly. Rubbing is another hydrotherapeutic procedure. It improves the body and can be used during fever or neurosis. General and local procedures are distinguished. For a general procedure a bed sheet is wetted in water at the temperature of 30-32 C, the excess water is wrung out, and the patient is wrapped in the sheet. The patient first

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raises his arms above his head, then lower them, the sheet is passed over the shoulders, and finally fixed on the neck. The patient's entire body is then rubbed energetically through the sheet. Rubbing continues for 2-3 minutes, then the wet sheet is replaced by a dry one. The effect can be intensified, if water is first poured over the patient. Local rubbing is prescribed for weak patients. The naked body is covered with a dry sheet and a blanket, and separate parts of the body are rubbed with a wet towel (32-34 C). Packs can be wet or dry, local or general. For a general wet pack, two woolen blankets are placed on the bed. A sheet is wetted (25-30), the excess water is wrung out and the sheet is placed over the blankets. The patient is undressed and placed on the sheet with his arms raised. The patient is wrapped in the sheet; then he is allowed to lower his arms, and is wrapped tightly in the blankets. The head alone is left uncovered. The patient remains in this position for 30-60 minutes. The procedure is effective in case of neurosis and early hypertension. Local packs are used for obesity: the patient is wrapped to the waist or the armpits as in general pack. If a pack is dry, the patient is wrapped in a dry sheet, otherwise the procedure is the same. Bath. These may be general or local. Depending on the temperature of water, baths may be cold (below 20 ), cool (20-33 ), neutral (34-37 C), warm (38-39 C), or hot (40 C and over). According to their composition, baths may be common (pure water), mineral (containing much salt), gas baths (carbon dioxide, hydrogen sulfide, radon), medicated baths, etc. For a common bath the tub is filled with water at the required temperature. The patient should sit in the bath without constraint. His feet should rest against the tub end or, if the patient is small, against a special device. The medical personnel should observe the patient's condition during the procedure: his heart and respiration rates should be monitored. Common hot baths accelerate the heart and pulse rate, intensify the metabolism and sweating, and increase the body temperature. At the same time hot baths relax the muscles and remove pain. They are used in renal, intestinal, and hepatic colic. Hot bath are contraindicated in diseases of the cardiovascular system, in

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hemorrhages, and asthenia. Bath of neutral temperature have a tranquilizing effect on the patient and are therefore used in case of neurosis and hyperexcitation. Local bath differs from general ones in that only some parts of the body (arm, leg, etc.) are in water. Local bath are prescribed for patients with inflammatory affections of the skin, joints or muscles. Subwater intestinal irrigations are used in some diseases of the intestine (colitis, constipation, helminthiasis). A special saddle equipped with pipes connecting it to a source of irrigating liquid and a suction device is installed in a large bathtub (300-400 litre capacity). Irrigation is carried out in 90-120 minutes after a cleansing enema. The temperature of the bath should be 36-38 C. An end-piece lubricated with Vaseline is inserted into the rectum and 1.5-2 litres of water at a temperature of 38-39 C are administered into the intestine from a pressure (suspended) flask. Then the suction apparatus is turned on. This procedure is repeated from 3 to 4 times, with gradually increasing amounts of the administered water (to 6-8 litres). The final washings should be clean. The patient is then allowed to rest for 15-30 minutes. All parts of the apparatus should be washed and disinfected after use. Shower is a medical procedure whereby water falls on the patient's body in one or several jets. A water jet is controlled by the operator from a control panel. Two factors act on the patient - thermal and mechanical. Showers can be local or general and the water pressure in the shower jet may be low (0.3-1 kg/sq. cm), medium (1.5-2 kg/sq. cm), or high (2.5-4 kg, sq. cm). The temperature of water varies from 15 to 45 C depending on the disease. The mechanical action of the shower depends on the manner by which water is discharged from the source. Water can be sprayed or fall like rain; it can be given in needle-thin jets, or in fan-like motions; the shower can be circular or in the form of a simple jet. Showers of short duration increase the tone of muscles and the vascular system. Prolonged cold and hot showers decrease excitability of the nervous system and intensify metabolism, while warm showers produce a quieting effect on the

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patient. Energetic rubbing should be done after shower (both cold and cool) to intensify blood circulation in the skin. Heat is applied for local warming, to accelerate resolution of cutaneous and subcutaneous indurations and also as a pain-relieving remedy. The vessels are dilated and blood supply to the tissues is increased by application of heat. Heat is prohibited in acute inflammation of the abdominal organs (appendicitis, cholecystitis, pancreatitis), in hemorrhage, contusions (during the first day), and in thrombophlebitis. Heat may be applied in water bottles or electrical heaters. It is not recommended to apply a hot water bottle directly to the patient's body. It should be wrapped in a towel or placed over a blanket. In order to prevent pigmentation of the skin due to frequent application of heat, the skin should be coated with Vaseline or vegetable oil. A very hot water bottle is contraindicated for children and patients with edema. 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. Ice or snow is placed in a rubber bag which is wrapped in a towel or sheet and applied to the injured area. To prevent excessive cooling of the tissues, an ice bag should be applied for no longer than 20-30 minutes followed by an interval of 10-15 minutes. If the patient has a fever, an ice bag is not applied directly to the head but is suspended over it. Mustard plasters are used in acute and chronic diseases of the airways, pneumonia (applied to the chest and back), in hypertonic crisis (onto the back of the head), and in cardiac pain (on the heart region). Mustard is contraindicated for skin diseases. Very hot water should not be used in applying mustard plasters because it destroys the mustard enzymes and the mustard oil is not liberated. Ready-made plasters

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should be immersed in warm water and applied to the skin for 10-15 minutes. If the skin is very sensitive mustard plasters should be applied over a thin sheet of paper or gauze. Frequent application of mustard may cause pigmentation of the skin. The procedure should last for a maximum of 15 minutes, after which the mustard should be removed from the skin by warm water. 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 litres. The temperature of water in the bath should be 37-39 C; the procedure should last for 8-10 minutes for adults and 5-6 minutes for children. The patient should then be wiped dry with a warm sheet, and allowed to rest. Compresses can be general (wet pack) or local (hot, warming, and cold compresses). General compresses are given to fortify the patient, in cases of fever and neurosis. A general compress lasting for 15-20 minutes has an antipyretic effect and stimulates the nervous system. General pack for 20-45 minutes decreases the excitability of the nervous system, while 50-60 minute packs have a sudorific effect. General wet pack is done as follows. Woolen blankets are placed on a bed, and covered with a damp sheet. The patient undresses and lies down on the sheet and the nurse wraps him quickly in the sheet and then in the blankets. A cold compress is placed on the patient's head. An oil-cloth is sometimes placed between the sheet and the blankets. The size of the oil-clothe should be the same as that of the sheet. The effect of wet pack has three stages. During the first stage which lasts 15-20 minutes, the sheet warms up to the temperature of the patient's body. During the period the nervous system gets excited and the metabolism intensifies. During the second stage (20-40 minutes) the warming process decreases the excitability of the nervous system and drowsiness develops. Respiration becomes deeper, the pulse slows down and the arterial pressure falls. During the third stage (40-60 minutes) the body becomes overheated, the patient perspires, and the nervous system becomes excited.

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A local warming compress is one of the most common procedures. Its therapeutic effect is based on the uniform warming of tissues. The local effect and also reflectory mechanisms increase blood supply of the tissues, intensify metabolism, and decrease sensitivity to pain. A warming compress is used to accelerate the resolution of inflammatory processes in the skin, subcutaneous cellular tissue, and in the joints. It produces an analgesic effect in dyskinesia of the stomach, intestine, and the gall bladder, and also in colitis. Compresses are contraindicated in furunculosis, some skin disease and injuries. A compress consists of four layers. The first layer is a piece of cloth (folded in two or three) wetted in water at 12-16 C. The excess water is wrung out and the cloth is applied to the skin. A piece of oil-cloth of water-proof paper (2-3 cm larger than the cloth) is placed over the wet cloth. The third layer is cotton wool. It is larger than the second layer. All three layers are tightly fixed to the body by bandaging; the pressure of the bandage should not, however, interfere with normal blood circulation. Sometimes, in order to increase the effect of the compress and to lessen maceration of the skin, a 5 per cent alcohol solution is used instead of water to wet the first layer. A 3-4 per cent sodium hydrocarbonate solution or camphor oil can also be used. A local hot compress produces a strong analgesic effect. A piece of gauze, folded several times, is wetted in water at 50-60 C, the excess water is wrung out, and the gauze is placed on the affected site. An oil-cloth is placed on top, and the compress is covered with woolen fabric. Such a compress should be renewed at 5-10 minute intervals. Leeches are blood-sucking aquatic forms. Their saliva contain hirudin, a substance that retards coagulation of blood. Leeches cannot stand strongly smelling substances. They attach themselves better to warm surfaces. One leech can suck up to 10 ml of blood. Leeches should be kept in glass bottles covered with a piece of gauze. Pond or river water is their normal medium but tap water can also be used, provided it is

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allowed to stand open for 24 hours. The temperature of the water should be from 15 to 20 C. The water should be changed once a day. Only healthy leeches can be used to draw blood from patients. They have a good contraction reflex: when a leech is touched, its body becomes short and resilient. Healthy leeches try to escape from the bottle; they stick to the hand if it is immersed in water. Leeches are indicated in hypertension, thrombosis of the cerebral vessels, concussion of the brain, myocardial infarction, and pre-infarction conditions, thrombophlebitis, and hemorrhoids. Leeches are contraindicated in hemorrhage and hemophilia, anaemia, sepsis, and if there is evidence of decreased blood coagulability. Leeches are applied as follows. Several leeches (more than required) are transferred from their bottle into a smaller vessel (50-100 ml) using pincers; only healthy leeches should be selected. The skin of the patient should be washed without fragrant soaps since leeches are very sensitive to odor. The skin of the patient should then be rubbed to cause a rush of blood or wetted with sweet water: the leech will more readily stick to the skin. If the leech does not stick, it is replaced by another one. From 4 to 10 leeches can be applied simultaneously. When a leech bites the skin and sticks to it, the frontal portion of its body sets in wave-like motion. The vessel can now be removed and sterile cotton wool or a piece of gauze placed under the hind end of the leech. A leech sucks effectively from 30 to 90 minutes. If a leech falls off quickly, it means that its application was ineffective. If a leech does not fall off for a long time, it should not be detached by force, but table salt should be sprinkled on it and the leech will fall off. Used leeches should be killed by placing them in formaldehyde solution. The wounds on the patient's skin bleed for 4-24 hours, and from 10 to 30 ml of blood may seep from each wound. During application of leeches the patient should be resting in a convenient position. After removal of the leeches the wound should be bandaged tightly. Suturing may be necessary in rare cases. The wound should be protected from possible infection

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and the bandage changed daily. If the bleeding does not stop, potassium permanganate or iron sesquichloride solution should be used. If the hemorrhage is stopped, the wound should be treated with alcohol, iodine tincture or hydrogen peroxide and dry bandage applied. Leeches should be applied in the following cases: 1 - to draw blood; 2 - to decrease blood coagulability. In the former case the leeches should be allowed to stay until they draw enough blood, and in the latter case they should be removed immediately after they bite the skin and stick to it. The leeches should not be pulled off, but only touched with cotton wool soaked in iodine tincture or alcohol.

Theme 9 STORAGE AND USE OF MEDICINAL PREPARATIONS

There are many types of therapeutic effects including the following: surgical treatment, balneologic and physiotherapeutic procedures, climatotherapy, etc. But the most common type of treatment is pharmacological therapy, i.e. treatment with medicinal preparations. If medication is intended to eliminate the cause of the disease, this is called etiotropic treatment. For example, quinacrine acts on the causative agent of malaria and antibiotics act on agents causing infection. Many medicinal preparations act not on the causative agent but on the developing disease, the cause being uncertain or inactive by the time of treatment. This treatment is called pathogenic. For example, cardiac glycosides or diuretics are given for circulatory insufficiency. Symptomatic treatment is used to alleviate some symptoms of a disease, e.g. narcotics are given to relieve pain

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and sedatives are given for insomnia. Sometimes a patient is given etiotropic, pathogenic, and symptomatic treatment all at the same time. The effect of a medicinal preparation depends, to a considerable degree, on its dose. A single dose means 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 means the amount of medicine that causes a pronounced 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 the 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. Sometimes treatment is begun with a dose that is 2 or 3 times higher than the doses that follow. This is a priming dose. It is used to ensure a specific concentration of the medicine in the patient's blood, while subsequent doses will only maintain this concentration at the required level. These are called maintenance doses. Most often prescribed are therapeutic doses. They produce an optimum curative effect on the patient. But it should be remembered that, in some cases, these doses become toxic. Sensitivity of a patient to medicinal preparations normally varies within a wide range deranging on the physiological condition of the body (pregnancy, lactation), nutrition, age, and sex. Age sensitivity to medicinal preparations is especially varied. In this connection, several formulas have been derived by which doses can be calculated depending on age. But these formulas are not quite suitable for children. In order to prevent possible errors in calculating doses, a special table is provided in the State Pharmacopoeia of the USSR, where permissible single and daily doses of strong and poisonous medicines are calculated. Apart from their curative effect, medicines can also cause undesirable side effects. These are biological effects that develop irregularly and cannot be predicted or

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foreseen. Toxic side effect can develop as a result of overdose 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 last is manifested by a complex of immediate and delayed allergic responses. These non-specifics side effects are the result of individual, congenital or acquired properties of the body. Idiosyncrasy is an example of such a non-specific side effect. This is a congenital hypersensitivity to certain drugs given even in minimal doses. The phenomenon is caused by a disordered enzymatic metabolism. As distinct from idiosyncrasy, drug disease depends not on the congenital but acquired properties of the body. Drug disease develops because of a specific sensitization of the patient to drugs. Its incidence is rather high. If the 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 therefore be gradually decreased, or the medication should be suspended at intervals to prevent poisoning. The nurse must be sure that the patient takes the medication according to the schedule prescribed by the physician; otherwise a patient may collect several doses of the medicine and then take them all at once. In order to prevent poisoning, the patient should be observed while taking medicinal preparations. If an assistant physician or a midwife commits an error, the physician should immediately be informed in order to correct it. Ordering and keeping medicinal preparations. During these rounds, the physician prescribes various medicines which he enters in the case history of the patient. The assistant physician or 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 the injection list. The medicinal preparations are ordered According to the physician's prescriptions.

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When the nurse obtains medicinal preparations from the drug store, she must check that they comply with the order. All medicines that raise any doubts should be returned to the drug store. Storage of medicines without labels is prohibited! All medicines should be 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 cabinet should be provided with drawers where poisons (List A) and strong medicines (List B) should be kept separately and locked with different keys. The dispatch of poisons should be especially controlled. External medicines should be kept separately from those administered internally. Medicines with a strong odor (iodoform, Lysol) and also flammable Expiration terms depend on the form of medicinal preparations (powder, solution, and mixture), their chemical composition, ambient temperature and humidity, etc. Decoctions and tinctures of plant origin can be stored for only short periods of time, while ampoule solution is intended for prolonged storage. All containers should be tightly closed; they should not be left open to prevent contamination with dust, pathogenic fungi, or microbes. 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 solution, tinctures, and extracts can be stored for a long time because microbe is quickly killed in them. But these substances are quickly evaporated to increase the concentration of the active substance and can thus cause overdose. 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 store for 3 or 4 days. Sterile solutions (in containers other than vials) should be stored for not longer than 3 days, while antibiotic solutions, not longer than 24 hours. Ampoule solution can be stored for months. An expiration date is usually indicated on the label. Medicines intended for substances (alcohol, ether) should be kept separately from other medicines.

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treatment of eye diseases should be kept with special precautions. Eye drops should be kept for only 2 or 3 days. A color change, precipitation of flakes, various deposits and coats, or changes in the odor (ointment) indicates that the medicine is spoiled. When visiting a patient at home, the assistant physician or the midwife should teach relatives how to keep and handle the medicines. Medicines should preferably be kept under a lock and should not be left at the patient's bedside. Strong medicines should not be handled with special care. They must be kept away from children. All medicines should be kept in labeled packages. Administration of medicines. The following methods of administration of medicinal preparations are distinguished: enteral (intestinal), external, parenteral, and by inhalation. The choice of the administration mode depends on the particular disease. Each mode has its advantages and disadvantages. Enteral administration implies taking medicines by mouth (per os) or through the rectum (per rectum); or the medicine can be placed under the tongue (sub lingua). Internal 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: 1, the preparation is slowly absorbed into the blood; 2, 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. Forms suitable for internal use are tablets, powders, pills, aqueous and alcoholic solutions, extracts, decoctions, and mixtures. If a medicine has an unpleasant or bitter taste (quinine) or may irritate the mouth mucosa, or else can affect the teeth (iron preparations), they are given in protective coats or capsules. Junior medical personnel should not be allowed to give medicines to patients. This is applied even more to the patient himself, since he may forget to take medicines or not take them in time. Each case when the patient is given medicines should be recorded in the journal in order to prevent overdose by giving the medicine twice or

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miss a dose. When a powder is taken, it should be unpacked, the paper folded in a kind of a chute, and the powder spilt over onto the tongue. The patient should then drink water. If the taste is unpleasant, a sweet drink should be given, especially to children who resist bitter medicines. A coated tablet or a capsule should be placed on the back of the tongue and swallowed with a large gulp of water. If a patient is unable to swallow a large tablet, he should wet it by taking a small sip of water; the next gulp will then help. Liquid medicines are often given. Aqueous solutions, decoctions, and mixtures are given in graduated glasses (5-20 ml). In the absence of calibrated vessels (at home), the medicine can be given in spoonfuls. A tablespoon can hold about 15 ml, a dessert spoon, 10 ml, and a teaspoon, 5 ml. Alcoholic or ether extracts or tinctures should be measured in drops using a pipette. One gram of water contains 20 drops, 1 g of alcohol, 60 drops, 1 g of ether, 80 drops. A separate pipette should be used to give different medicines. If only one pipette is available, it should be washed with boiled or distilled water after each use. Rectal administration of medicines is also popular. It is especially important in cases where per os administration is unfeasible due to difficult swallowing, in burns of the esophagus, vomiting, when the patient is unconscious, and in some other cases. In some disease (heart failure, diseases of the gastrointestinal tract) absorption of medicines in the stomach and intestine is either slow or incomplete. Rectal administration is preferred in such cases because due to anastomosis of the hemorrhoid veins with the iliac veins, the medicine enters the inferior vein 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.

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Suppositories or enemas are used for rectal administration of medicines. Rectal suppositories are shaped like small cigars or cones, 1-1.5 cm in diameter, and 2.5-4 cm long. A suppository weighs 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 that the active substance can be adsorbed by the rectal mucosa. Commonly used bases are cocoa butter, polyethylene glycol, glycerinated gelatin, etc. Suppositories should be wrapped in waterproof paper and kept in a refrigerator. Before insertion into the rectum, the paper should be stripped off the tip of the suppository, which is then inserted into the anus, while the wrapper remains in the hand. If a medicinal solution is to be administered by enema, the rectum should be cleansed by an evacuate enema. Only few medicines are given sublingually. These are strong medicines like nitroglycerine or sex hormones. Their doses are small. The preparations are quickly absorbed under the tongue without being destroyed by digestive enzymes. medicine is thus involved in the circulation bypassing the liver. External medicines are applied to the skin, eyes, ears, nose, and the vagina. Ointments, emulsions, solutions, suspensions, powders, etc. are applied to the skin. The absorbing power of intact skin is insignificant and only a small part of the fatsoluble substances is absorbed through the sebaceous gland outlets. External medicines are mainly intended for local and reflectory effects. Ointments are mainly given in skin diseases. Ointment is taken on a spatula, spread on folded sterile gauze, and thus applied to skin. The gauss is covered with cotton wool and the entire pack is bandaged. Ointments are sometimes used for Compresses. Irritating substances, such as camphor or salicylic acid, are used when a hyperemic effect is desired. An alcoholic tincture of iodine is used for disinfecting the skin The

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and wounds. Iodine tincture can burn sensitive parts of the skin. Powdering or dusting is used to treat the skin of patients with hidrosis and intertrigo. This procedure is usually done to infants. Skin folds are treated with talcum or rice powder: cotton wool is dipped in powder and applied to the affected Skin. The cotton wool should then be discarded. The same cotton wool may not be dipped into the powder for the second time, even if only one infant or an adult patient is treated with this powder.

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Good penetration of medicines through the skin can only be attained by electrophoresis. Particles of the medicinal solution which is used to wet electrode covers penetrate the skin under the action of direct current to form a depot from which the medicine is then gradually carried away by the blood and lymph. Only certain substances can be administered by electrophoresis. Electric current decomposes some medicinal preparations of complicated composition and only its separate components are deposited in the patient. Medicines can be applied to various parts of the body. The advantage of electrophoresis is that the medicine is gradually supplied from the skin depot to various organs and tissues. Small doses given by electrophoresis lessen side effects of the medicine, while its accumulation in a specific part of the body improves significantly the therapeutic effect in some diseases. Solution and ointments are usually used to treat diseases of the eye. The conjunctiva has a pronounced absorption power. Medicinal solution is administered using a pipette. The lower eyelid is pulled down and the drops are applied to the mucosa at the external canthus. Ointments are applied with a special glass rod or spatula from which the ointment is placed between the conjunctiva and the eyeball. Solutions, powders, ointments, and vapors (amyl nitrite, ammonia) are used to treat ailments of the nose. These substances act locally and reflectorily. Medicinal solutions are instilled into the nose with a pipette. The patient should tilt his head back during this procedure. Ointments are applied to the nasal mucosa with a glass rod. Powders are administered by inhalation: while the powder is being inhaled by the left nostril, the right one should be closed, and vice versa. A pipette is used to administer solutions in the ear. The patient should lie on his side during the procedure. In order to straighten the auditory meatus, the ear auricle is pulled up and back. After the drops have been instilled, the finger should press the ear tragus for deeper penetration of the drops. In order to prevent spillage of the solution, the patient should remain on his side for 20-30 minutes. The

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Acoustic meatus should then be closed with a cotton ball.

Globules, tampons,

powders, and solutions are used for vaginal irrigation and other medicinal applications. Medicinal solutions used for irrigation should be warm and a special end-piece should be used. The medicines are usually intended for local use because the absorbing capacity of the vagina is insignificant. The respiratory system is treated by inhaling aerosols, which pass into the alveoli, bronchioles, fine and large bronchi, the trachea, the larynx and the mouth. In order to increase the depth to which aerosols penetrate and to increase the amount of precipitated medicine, aerosols are charged electrically. Electric aerosolization increases the depth of breathing and decreases hypoventilation by increasing the number of functioning alveoli. As a result, larger amount of Antibiotics, sulfa drugs, mineral water, medicinal preparations reach the inflamed focus ensuring direct contact of the preparation with the causative agent in the lung tissue. broncholytics (euphylline, ephedrine), enzymes, expectorants,

corticosteroids, and other substances are administered by inhalation.

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Theme 10-11 Parenteral administration of preparations

Parenteral administration, i.e. not intestinal, implies injections which may be intracutaneous, heart, joints, bone marrow, cerebrospinal canal, and into the focus of affection. The quick effect of injections accounts for their wide use. When given parenterally, medicine enters the internal media of the body directly, bypassing natural barriers, accelerating the therapeutic effect of medicine and increasing the accuracy of dosage. Ampoule solutions are portable, convenient for storage and transportation. The mass production of ampoule-syringes (ampins) expands the field of application of injections in emergency aid and under field conditions. Although the advantages of parenteral administration of medicines are quite obvious, injections are usually given only to those medicines enterally. Injections are impossible or very difficult in cases of hemophilia, skin diseases, in psychic or nervous excitation, or when the patient fears injections, and also under some other conditions. The main requirement for an injection solution is its sterility. Solutions are sterilized by various methods, e.g. in an autoclave, by tyndallization, and bacterial filtration. Distilled water is the common diluent for injections. If a medicine is insoluble in water (camphor, hormones), vegetable oils are used. Injection solutions are patients who cannot take subcutaneous, intramuscular, intravenous and intraarterial. Solutions may be injected into the pleural or abdominal cavity, into the

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manufactured either in ampoules or vials. An ampoule is a sealed glass vessel. When an ampoule is opened, its contents will not remain sterile and ampouled solutions are, therefore, intended for single use. A vial can be opened and closed again in aseptic conditions and its contents can, therefore, be used in portions. Ampoule solutions come mainly in single doses, while cumulative doses are packaged in vials. Solutions are injected using a needle and a syringe. A syringe is actually a small hand pump by which liquids can be injected or extracted. It consists of a hollow barrel or cylinder and a piston with a knob. The cylinder has a larger opening at one end to admit the piston and a narrower one at the other end to which a needle is attached. The cylinder is graduated. The piston should move freely inside the cylinder but its contact with the walls should be tight. Large hospitals have a special department where all materials and tools are washed and sterilized in autoclaves by steam, dry air or gas. Mechanization and The automation of such procedures save time and ensure reliable sterilization. 'Record' and 'Luer' syringes are commonly used in the Soviet Union. cylinder of the Record syringe is made of glass while its cone, the rim and the piston are stainless steel. The Luer syringe is entirely made of glass. The disadvantage of the Record syringe is the different thermal expansion of its parts since they are made of different materials (glass and steel). Consequently, the cylinder often breaks when boiled or cooled. It is impossible to insert the piston into the cylinder when both are hot. The Luer syringe is devoid of these disadvantages but is brittle and its surfaces wear quickly, breaking the tight seal between the piston and the cylinder walls. An injection needle is a metal tube with a cannule for a syringe at one end and a sharp point at the other. Needles are made of polished stainless steel. The length of a needle varies from 15 to 100 mm, while its diameter is between 0.2 to 2 mm.

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At home needles may be sterilized by boiling in a covered stainless steel container. The needles are placed in a sterilizer over a grating which has handles to remove the grating after sterilization. If a sterilizer needs to be cleaned, it should be washed with soap and soda, and wiped dry. If a coat of fat is detected on a syringe (after oil injections), the syringe should be washed with soap, rinsed in alcohol or ether, and then sterilized. Before placing a needle in a sterilizer, it should be checked for obstruction by passing a mandren or a jet of water through it. Needles should be sterilized without their mandrins and be wrapped in gauze to prevent theyre blunting. Two forceps and hooks (to extract the grating) should also be sterilized. Distilled water is used for sterilizing tools. Water should cover the tools in the sterilizer. Sterilization is more effective in a 2 per cent sodium bicarbonate solution, which prevents damage to the tools and slightly increases the boiling point. Sterilization (boiling) should last from 40 minutes. Hands should be specially treated before giving an injection. The hands are first washed with soap and a brush, then treated with alcohol (paying special attention to the fingers), and then the skin folds near the nails are treated with an alcoholic solution of iodine. After sterilization is completed, the cover is removed and placed on the nurse's desk where there is also a glass with sterile cotton wool, a bottle with alcohol, a vial with iodine tincture, a container for used materials and tools, and a glass with a disinfectant solution where a sterile forceps are kept. Using forceps, the nurse removes the hooks from the sterilizer; and using the hooks she removes the grating (with the sterilized articles) and puts it across the sterilizer. Using the forceps, the nurse unfolds the gauze and removes the necessary syringes and needles. The piston is taken by its handle and the cylinder by its external

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surfaces;

the needle is taken by the cannula.

The syringe is assembled using

theforceps. The needle is adjusted on the cannula by slightly rotating it. The prepared syringe is then placed on the sterilizer cover. Using a special file (preliminarily held in the flame of a burner) the ampoule tip is cut and then broken off with a piece of gauze wetted with alcohol. If a file is not available, the ampoule tip can be broken with the fingers using a piece of gauze wetted with alcohol. A special cutter is widely used to open ampoules. Used ampoules should not be discarded for several hours because the necessity may arise to check the solution. The needle of the syringe is inserted into the open ampoule, and inclining the ampoule gradually the liquid is sucked into the syringe. When all of the solution passes into the syringe, the syringe is turned with its needle up and air is removed together with excess solution. After the solution has been injected in the patient, the needle and the syringe should be rinsed and placed into a pan for used tools. The hands are then washed again and treated with a disinfectant solution to prepare for another injection. A new syringe and needle should be used for each injection because blood that may remain in the needle may carry infection from one patient to another. Neither can one syringe be used for injecting different solutions because even a small amount of a substance can change the effectiveness of another medicinal preparation. For this reason disposable syringes are now popular. Such a syringe is a plastic bulb with a metal needle welded into it. The syringe is sterile and packed in a sterile bag; it is discarded after use. Subcutaneous (hypodermic) injections and infusions. Since subcutaneous tissue is loose and is permeated with many vessels, comparatively large amount of liquids (about 1 litre) can be administered subcutaneously. The external surfaces of the shoulders, thighs, shoulder blades, and the abdominal region can be used for subcutaneous injections, but the anterior lateral surfaces of the shoulder are

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commonly preferred. Sites devoid of arteries, veins or nerve trunks should be selected. Repeated injections should not be done at one and the same site because it can irritate the skin and cause indurations. The skin should be treated with a cotton ball wetted with alcohol before an injection. The syringe is held in the right (apt) hand while the left hand is used to form a fold of theskin. The skin is punctured from either above or below and the needle inserted to a depth of 1.5-2 cm. In order to minimize pain, the skin should be punctured by a swift movement (without jerking). Once the skin has been punctures, the syringe should be passed to the left hand, while the right hand takes hold of the cylinder (between the 2nd and 3 rd fingers) and the piston is pressed by the thumb to eject the solution. A sterile cotton ball is now pressed to the punctured skin and the needle is quickly removed. A cotton ball or gauze pad wetted with alcohol should be held for a few seconds on the punctured site. Hypodermic infiltration sometimes form after injections of oil solutions. Subsequent injections should therefore be made a certain distance from the former injection site. Intramuscular injections. Preparations injected intramuscularly are quickly absorbed because of the highly developed vascular system ml. and contractivity of skin (calcium muscular fibers. The amount of fluid injected intramuscularly should not exceed 15-20 Substances for intramuscular injections strongly irritate the gluconate, magnesium sulfate) or are slowly absorbed (bicillin, bioquinol). Needles should not be longer than 6-8 cm, and the lumen should be sufficiently large. Pain of puncturing the skin does not depend on the needle's thickness but on its dullness. Injections should be made into the upper lateral quadrant of the buttocks; less frequently into the middle third of the anteroexternal surface of the thigh and into the subscapular muscles. These parts of the body are free from large vessels or nervous trunks. Injections should be given alternately into the right and left sides. The syringe is held in the right hand, near the needle. The needle is inserted with a swift motion,

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perpendicularly to the buttock surface to a depth of 5 cm. Before injecting the solution into the muscle, the piston should be slightly pulled back in order to make sure that the needle has not punctured a vessel. Complications are possible; for example, a needle may break and its tip remain in the tissue. This usually happens if the needle is dull or worn out, or if the muscles contract abruptly at the point of injection. The needle tip should be removed surgically. Another possible complication is selection of the injection site, or the irritating action of the injected preparation on the nerve. Abscesses or surface phlegmons may develop. This complication is connected with infection caused by injection, especially if the patient is asthenic or has a decreased resistance, for example, in diabetes mellitus, obesity, tuberculosis, heart failure. In order to prevent injection infection, special care should be taken during sterilization of tools and instruments, during washing hands of the nurse and the skin of the patient, and also during sterilization of injection solutions. When the first signs of inflammation develop, a warm compress, U-V rays, UHF therapy are prescribed. If an abscess occurs, it should be lanced. Intravenous infusions. intravenously. Medicinal solutions or fluids are often given purpose. The Venesection or venepuncture is performed for this the injury of the nervous trunks due to incorrect

physician himself should perform intravenous infusions. An assistant physician or a nurse may also be allowed to perform this operation provided they are supervised by the physician. Venesection may be performed only by the physician. As a rule, injections are made into the cubital vein, less frequently into the vein of the forearm, and the back of the hand or foot. During venepuncture the patient should lie or sit. His arm should be straight at the elbow, and the elbow should rest against an oil-clothe pillow. Slight pressure is applied by a tourniquet to the shoulder, 5-6 cm above the cubital flexure, to compress slightly the superficial veins without stopping arterial

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circulation. The pulse should be palpable. To ensure a better filling of the veins, the patient is asked to clench and unclench his fist several times. The physician or his assistant must treat their hands with alcohol and the nail folds with iodine tincture. The patient's skin in the cubital fossa or any other site of venesection should be treated with alcohol. A suitable vein is now selected for venepuncture, and the skin is pulled down by the fingers of the left hand to fix the vein. The needle is held in the right hand. The vein is punctured by one or two steps. Using the two-step technique, the needle should be held by the right hand parallel to the vein, with the angled surface upward. The skin is punctured so that the needle first passes parallel to the vein, and then punctures its side. As the needle enters the vein, the one doing the procedure, feels as if it is passingthrough an empty space. When the piston is slightly pulled back, blood fills the cylinder to indicate that the needle has entered the vein. If the patient feels pain at the site of puncture or this site swells slightly, it means that the needle has slipped from the vein and the procedure should be discontinued. A sterile bandage should be placed on the swollen site, and another site selected for the puncture. If the single-step procedure is used, the skin and vein are punctured by one movement after fixing a tourniquet in place. The angle between the needle and the skin should then be gradually decreased as the needle passes along the wall of the vein. Upon termination of the procedure, the needle is extracted and the site of puncture closed with a gauze pad wetted in alcohol. The patient should flex his arm to press the pad to the puncture site and hold his arm in this position for 2 or 3 minutes. If a Dufaut needle is used for venepuncture, a pressing bandage should be applied upon termination of the procedure. Intravenous infusions require the following accessories: a sterile tray to hold the syringe, cotton balls wetted in alcohol, and two needles: a long needle with a large lumen to take medicinal solutions and another needle their contents; the date of expiration and for the actual injection. Ampoules containing the injection solutions should be checked for the transluscency of the time of sterilization should be

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established. The ampoules should then be treated with alcohol, their tips cut off, and their contents taken into the syringe. Before puncturing the vein, the syringe should be checked for the presence of air in it. To that end the syringe should be held with the needle upwards, and the air removed from the syringe together with a small portion of solution. The tourniquet should be removed immediately before injecting the solution into the vein. It is also necessary before the injection to make sure that the needle is in the vein. To that end, the piston should be pulled back slightly: if blood enters the syringe, the medicinal preparation can be injected into the vein. Common solutions should be injected during the course of 1.5-2 minutes, but some solutions, e.g. cardiac glycosides must be injected more slowly. The medicine should be injected by pressing the piston with the thumb of the left hand, or the syringe can be carefully passed over the left hand, and the piston should then be pressed with the thumb of the right hand, the cylinder being held between the 2nd and 3rd fingers of the right hand. If the needle has withdrawn from the vein, as occasionally happens, the site of injection gradually swells. Without removing the needle from under the skin, the expressed solution should be taken back into the syringe, and only then the needle removed. The punctured site should be bandaged and the solution injected into the other arm. Intravenous drop infusions are used in cases of acute blood loss, dehydration, traumas, burns, poisoning, etc. Blood, its substitutes, hypertonic and isotonic solutions, medicines and other fluids are given intravenously by drop infusions. The solution should be warmed to 39-40 C. A special system with a dropper is used for infusions. If venepuncture is unfeasible for some reason, venesection should be used. A widelumen needle is used for the puncture. The rate of infusion is controlled in the range of 20-80 drops per minute. To prevent accidental slippage of the needle from the vein during infusion, the arm should be bandaged to a splint while the outer part of the needle fixed on the arm

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by adhesive tape. The patients condition should be under permanent observation and the infusion system must be controlled constantly. Many solutions for intravenous administration are dispensed in special vials closed with a rubber stopper and a metal cap. If the solution is infused directly from such a vial, two needles should be used, one of which is short (4-6 cm) and the other long (12-15 cm). Using sterile forceps, the metal cap should be removed from the vial (after preliminary treatment with alcohol) and both needles are passed through the rubber stopper. The shorter needle is connected with the rubber tubing of the infusion system, the vial is turned upside down and fixed on a stand. The end of the longer needle is above the liquid level to admit air into the vial: the solution will then flow down into the rubber tubing through the shorter needle. The following complication can occur during infusion: the punctured vein may bleed causing thrombophlebitis: a concentrated solution (e.g. a 10 per cent calcium chloride solution) may get in subcutaneous fat causing local necrosis; a nerve trunk or artery can occasionally be damaged. If air is injected into the vein, it can cause an embolism and the death of the patient. Parenteral administration 1. And else, when syringes are sterilized, a piston and cylinder must be lied separately. 2. Rules of prevecetive preparation syringes and needles before sterilized: 1. After using (injections) syringes and needles are placed into container with 1% chloramin solutions on 1 hours. 2. After this - syringes and needles are washed under a tap water. 3. And are placed into warm washing solution with soap powder and concentrated hydrogen peroxide t - 45-50 certigraduate on 20 minute. 4. After syringes are washed in distillate water with brush, and then are dried.

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Theme 12 OBSERVATION AND CARE OF PATIENTS WITH RESPIRATORY PATHOLOGY

The respiratory system ensures the constant delivery of oxygen to the living body and removal of carbon dioxide and water from it. The gas exchange process consists of external and internal (tissue) respiration. External respiration is ensured by pulmonary ventilation and by the exchange of gases between the atmosphere and the blood in the lungs. During inhalation the respiratory center is excited to activate the respiratory muscles: the lungs are distended, the alveoli opened, and air is forced inside the lungs by the difference of pressure in the alveoli and atmospheric air. During exhalation the respiratory muscles relax, the lungs collapse, and the air pressure inside them becomes higher than atmospheric; the air is, thus, expelled from the lungs. Three types of respiration are distinguished: thoracic, abdominal, and mixed. In thoracic respiration the chest expands mainly anteroposteriorly and laterally. This type of breathing is common for women. During abdominal respiration the chest expands mainly vertically because of the diaphragm. This type of breathing is mainly characteristic of men. Mixed respiration is characterized by the uniform expansion of the chest in all directions. Patients with respiratory ailments complain of pain in the chest, dyspnea, suffocation, cough, expectoration of sputum and blood. Dyspnea is the leading complaint. Pronounced dyspnea which develops suddenly is called asphyxia. Paroxysmal attacks of dyspnea are called asthma. It can be of pulmonary or cardiac aetiology, i.e. bronchial or cardiac asthma, respectively.

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During attacks of dyspnea or asthma, the patient's chest should be stripped of all clothing and the patient should be helped to assume a semiprone position to facilitate the respiratory movements. Fresh air should also be admitted to the room (ward) and oxygen given to the patient. Oxygen therapy is helpful in many disease of the cardiovascular and respiratory system, especially if signs of hypoxia develop. Breathing an air-oxygen mixture quickly alleviates hypoxia. For a better therapeutic effect the mixture should contain about 50 per cent oxygen and be given to breathe for a sufficiently long time. Pure oxygen quickly inhibits the respiratory center, and if inhaled for a long time, the patient may faint and develop convulsions. In this connection, a mixture of 95 per cent oxygen and 5 per cent carbon dioxide is given to inhale for 10-30 minutes in cases of CO poisoning, because carbon dioxide excites the respiratory center. In all cases where the patient is given oxygen his condition should be watched attentively, and inhalation discontinued immediately if the patient complains of unpleasant sensations. Oxygen can be given not only for breathing. It can be given subcutaneously or in oxygen baths; it can be administered in the pleural and abdominal cavity, into the stomach and the intestine; it can be used for irrigating wounds. Oxygen partly compensates for hypoxia and also produces local and reflectory effects. Oxygen for medical use contains 99 per cent pure oxygen and 1 per cent nitrogen. It is kept in cylinders that should be handled with care and protected from blows and jerks. It is necessary to remember that oxygen combines with oils and fats to produce an explosive mixture. The storage temperature should not exceed 35 C. No smoking or open flame are allowed in the room when oxygen cylinders are stored. A jet of pure oxygen directed at the eye can impair vision. Oxygen is given from a bag, an inhaler, or in an oxygen tent. An oxygen bag is provided with a rubber tube fitted with a tap and a funnel. The bag is filled with oxygen from a cylinder (through a reducing valve). Before use, the funnel should be

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treated with alcohol and wrapped in several layers of wet gaze since dry oxygen irritates the airways. The oxygen flow from the bag is controlled by the tap. When only a little oxygen remains in the bag, it can be expressed from it by hand. The disadvantage of an oxygen bag is that is is impossible to control the oxygen concentration and the rate of its delivery into the lungs. Moreover, much oxygen is lost into the environment in the absence of tight contacts. Oxygen can be given through a tube directly from an oxygen cylinder. The cylinders should be kept outside the ward in a special room and delivered to the bed-side by a pipeline. Each oxygen cylinder is provided with a reducing valve which lowers the oxygen pressure from 150 atm to 1.5-5 atm. The cylinder is which controls the oxygen delivery to the patient. Within the hospital, the cylinders should be carried on special shock-absorbing carts. Nasal tubes provided with several openings at the end are used to administer oxygen. A perforated tube is passed into the patient's nose and further into the pharynx to a depth of 15 cm (for an adult). The tube should first be boiled and then coated with Vaseline. When in the pharynx, the tube can be seen (and palpated) in the throat. The outer part of the tube is fixed to the patient's cheek, forehead, or temple by adhesive tape to prevent its slippage from the nose or into the oesophagus. Some patients complain of the pressing feeling in the nose and dryness in the pharynx. The tube should therefore be removed twice a day and a new one passed into the other nostril. To preclude burns, oxygen should be humidified by passing it through water. A bottle filled with water (a part of the Bobrov apparatus) is installed in between the oxygen cylinder and the nasal tube. But humidification is often insufficient because oxygen bubbles can be large. A special filter should therefore be used instead. When a nasal tube is used, the oxygen concentration in the bronchi is about 40 per cent at a rate of gas delivery of 4-5 liters per minute, and about 50 per

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cent at a rate of 6-7 liters per minute. This method is convenient because the patient can take meals and drink during the oxygen therapy. An oxygen tent is indicated in acute and chronic respiratory insufficiency. The oxygen consumption in the tent is high and specially trained personnel is required. The tent is provided with with devices for trapping carbon dioxide, cooling air, and for circulation. A mixture containing 40-50 per cent oxygen is usually supplied in the tent. Oxygen is humidified before delivery into the tent. The composition of the gas mixture in the tent is tent tested regularly with a gas analyzer. Care of coughing patients depends on the particular disease. For example, in acute respiratory diseases (acute laryngitis or tracheitis), dry and painful coughs are controlled by medicinal preparations taken per os, or by inhalation of sodium hydro carbonate and hot steam. Dry cups, mustard plasters, mustard foot baths, and hot compresses on the chest are used as counter-attractive therapy. If the cough is moist and the should assume patient a expectorates much sputum (bronchiectasis), the patient position in which he can more easily expectorate sputum.

Antitussive are given to patients before night sleep. Sputum (primarily of tuberculosis patients) can be the source of infection of the surrounding people. The patient should therefore observe the rules of individual hygiene. The tuberculosis patient should abstain from coughing in the immediate vicinity of other people: if he is unable to control coughing, he must take all possible measures to prevent contamination of the surroundings. The patient must not spit on the floor because sputum dries up to become an air-borne source of infection. Sputum should be collected in a bottle with a screw cap containing a 3 per cent chloramine or 2 per cent potassium permanganate solution (1/4-1/3 full capacity). The collected sputum should be decontaminated by lime chloride or a 5 per cent chloramine solution and discarded into the sewage. In special tuberculosis hospitals the sputum is burnt in special furnaces.

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Haemoptysis is expectoration of blood with sputum. If haemoptysis is not significant, i.e. only streaks of blood can be seen in the sputum, no urgent measures are necessary. If haemoptysis is considerable and associated with pulmonary hemorrhage, the patient should be given completes rest in a semireclining position. The patient should not be allowed to talk. If the hemorrhaging does not stop, the patient is given amino caproic acid: 3-4 per os, 2-4 times a day. A 10 per cent calcium chloride solution is given intravenously. The patient is also given 50-100 ml of a 5 per cent amino caproic acid in isotonic sodium chloride solution, vitamin K, and 20-40 ml of a 10 per cent gelatin solution subcutaneously. Transfusion of blood (100-200 ml) or plasma is very effective. If these measures fail to stop the pulmonary hemorrhage in tuberculosis patient, pneumothorax should be used: gas is injected into the pleural cavity to compless the lung. Antitussive are given in haemoptysis only in those cases where a strong cough may intensify blood spitting. The diet of patients with pulmonary hemorrhage should be rich in and drinks should be cool. Spicy foods and condiments are contraindicated. Inhalation is a method for administering medicines by inhaling them with air. Aerosols of medicinal preparations are used for this purpose. The medicines are dispersed in air or oxygen in apparatuses known as inhalers. These may be small portable ones for individual use or stationary apparatuses intended for inhalation therapy of several patients at a time. Preparations may be inhaled as vapor; volatile substances are given in vapor form (Eucalyptus oil, Menthol). Vapor inhalations can easily be given at home. The medicinal substance solution can also be heated and vaporized for inhalations by the patient. From 25 to 200 ml of a medicinal solution can be given for such an inhalation. Medicinal preparation may be administered by inhalation from a small portable apparatus (from 2 to 6 ml). Oil inhalations are also used for therapeutic and prophylactic purposes. About 0.5 ml of oil or its solution may be given in one inhalation. Vegetable oils are usually used vitamins and easily digestible. Food should be semiliquid and given in small portions. Food

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(olive oil, Eucalyptus oil, peach oil, and others). Special apparatus are used for administering powdered sulpha drugs, antibiotics, vasodilator, and other preparations. Not less than 5 inhalations are given per course. Aerosols are used for inhalation. Aerosol means solution in air. The dispersed particles vary in size from 0.5 to 400 m. High dispersion aerosols (0.5-5 m) are more effective. There are also electric aerosols whose particles bear positive and negative charges which neutralize surface tension. The charge being high, the particle may be destroyed to simple aerosols. Pleurocentesis is used for removal of pleural effusion for medical and diagnostic purposes. Only a physician can perform this operation. Necessary for the operation are: long needles (7-10 cm) of medium caliber (1-1.2 mm) with sharply cut angles and cannulas, thin short needles, syringes (2-5 and 10-20 ml), two or three sterile test tubes and the same number of object glasses for smears, elastic rubber tubes leading to cannulas, hemostatic forceps (with smooth clamps), aspirating devices, alcohol, iodine tincture, collodion, sterile tampons wrapped in sterile cloths, rods with cotton wound around them, and forceps. The physician should disinfect his hands like before an operation, put on sterile mask and (after giving anaesthesia) gloves. Pleurocentesis should be done in the room for medical procedures. The physician outlines by percussion the borders of effusion. X-rays can also be used for this purpose. The patient's condition permitting, he is seated on a chair with his back to the physician. The patient inclines slightly toward the non-involved side in order to broaden the intercostal spaces. The patient's arm (on the involved side) should be placed on his head or the other shoulder. If the patient is unable to sit on a chair, he is assisted in the sitting position in his bed. The safe site for puncture is the 7th or 8th interspace in the posterior axillary line. increase dispersion of aerosols. Charged aerosols uniformly distribute in the airways, and their precipitation is more effective than that of

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The site of puncture should be treated first with alcohol, then iodine tincture, and a local novocaine anaesthesia is then given. The chest wall is punctured by a needle connected to a rubber tube (with a clamp) whose other end is attached to a cannula. The puncture is made above the top edge of the rib since the vessels and nerves run along the edges of the ribs. When the needle passes the tissues and enters the pleural cavity, the physician feels a sudden absence of resistance. A syringe (with the piston completely depressed) in now attached to the cannula of the rubber tube, the clamp is removed, and the piston is pulled carefully. If no liquid enters the syringe, the tube is clamped again, the syringe is disconnected from the tube, and the position of the needle changed by inclining or pulling it slightly back. The aspired pleural fluid should be collected in test tubes for analysis and for preparing smears for microscopy. The tube is now connected to an aspirator, the clamp is removed from the rubber tube, and the effusion is removed from the pleural cavity. The aspirator is a graduated glass vessel of 0.5-2 liter capacity. The neck of the aspirator is closed by a rubber stopper through which two glass tubes are passed; the longer tube is connected to the needle or a trocar by a rubber tubing, while the shorter tube is connected to a pump (by a rubber tube). The rubber stopper is fitted with two metal disks pulled together by a screw at the center. Removal of pleural fluid begins with aspiration of air from the vessel by a pump. The tap on the shorter tube is open while the one on the longer tube (connected to the needle) is closed. The effusion is displaced from the pleural cavity into the vessel by the difference of pressures. When the vessel is full of pleural fluid, the longer tube is clamped, the stopper is removed from the vessel, and the vessel is emptied. The vessel is now stoppered again, the air removed from the vessel and the pleural effusion is aspired again. When all fluid is removed, the clamp on the rubber tube is closed near the needle, the syringe is filled with antibiotic solution, a length of the rubber tube between the needle and the clamp is treated with alcohol and punctured by the syringe needle to inject the antibiotic solution. When the procedure is over, the

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needle used for pleurocentesis is removed by a swift movement, and the point of puncture treated with collodion. If a correctly performed pleurocentesis fails to withdraw any fluid from the pleural cavity, it may indicate pleural adhesion or clogging of the needle lumen with fibrin. In this case, pleurocentesis should be repeated in one or two days. The following complications may arise: 1 - the needle may pass into the pulmonary tissue (blood enters the syringe); 2 - the intercostal vessels or nerves may be injured; 3 embolism may develop if air is admitted into a large vessel through the needle.

Theme 13 OBSERVATION AND CARE OF PATIENTS WITH CARDIOVASCULAR PATHOLOGY

Patients with disease of the cardiovascular system complain of heart and retro sternal pain; they also complain of palpitation and intermission in the heart work, dyspnea, and edema, a feeling of discomfort in the right hypochondrium, dyspepsia, and headache. Pain in the heart region is a serious complaint and its cause must always be revealed. Pain can be the result of heart diseases (angina pectoris, myocardial infarction, neurosis, etc.), of pleurisy, intercostal neuralgia, injured ribs, etc. Cardiac pain varies in its character, severity, duration, localization, and paths of radiation. Patients with cardiac neurosis complain of pain in the heart apex; the pain is prolonged, it becomes more severe during excitement, and can be abated by sedatives. Pain developing in angina pectoris arises during walking, exercise, or as the patient leaves a warm rooms and is exposed to the cold. The pain is usually localized in the retro sternal region, continues for a few minutes and is quickly alleviate by nitroglycerin or validol. Pain associated with myocardial infarction differs substantially from pain associated with

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angina pectoris. It is more severe, lasts for a few hours or even days, and is not alleviated by nitroglycerine or validol (methyl valerate). Pain of uncertain etiology and also protracted attacks of angina pectoris may suggest myocardial infarction. First aid to such patients (before the arrival of the physician) should include validol on a lump of sugar (or a tablet) or 1-2 drops of a 1 per cent nitroglycerin solution. Validol and nitroglycerin act within 1-2 minutes. Mustard plasters or leeches on the heart region are also effective in alleviating heart pain. If the cause of pain in the heart region is unknown, gastric lavage is contraindicated even in the presence of abdominal pain, nausea, and vomiting. cases. Dyspnea is a most common complaint in circulatory insufficiency. The degree of dyspnea varies. At first dyspnea develops during exercise when ascending stairs, and abates when the exercise is discontinued. In cases of more pronounced circulatory insufficiency, dyspnea develops during slight exercise, when the patient talks, and even when at complete rest. Edema associated with heart diseases is another symptom of circulatory insufficiency. If edema is pronounced, bedsores soon develop. Since nutrition of the skin affected by edema is reduced, the bedsores quickly purulate. Injections should not be given into edematous subcutaneous tissue because absorption of solutions is slow and infection can easily penetrate the body through the leaking punctured skin. Proper care of patients with cardiovascular insufficiency is an important factor in their treatment. Inhalation of oxygen has a favorable effect on their condition: dyspnea and asphyxia markedly decrease. It is necessary that the air in the ward should be fresh, of normal temperature and humidity. For patients with pronounced circulatory insufficiency prolonged bed-rest is often prescribed, and the bed linen should therefore be free from knots that might press on the patient's body. The bed should be made in the morning, before the day nap and night sleep. The auxiliary personnel must take These symptoms often occur in-patients with myocardial infarction. Lavage of the stomach is dangerous in such

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special care of the patient's body. The patient should be assisted in changing his position in his bed in order to prevent the formation of bedsores or thrombosis (blood coagulation) in the vessels of the legs and the pelvis. It should be remembered that prolonged bed-rest may cause blood congestion in the lungs and pneumonia. Dyspnea and asphyxia are reduced if the upper portion of the patients body is slightly raised. This can easily be done using an adjustable bed. If such a bed is not available, a regular bed can be rearranged by using special head- and footrests. Since a bed-ridden patient spends little energy, his diet should be less caloric (about 2300 kilocalorie) but contain more vitamins C and B. Liquid and salts should be restricted since their excess provokes the formation of edema. The daily intake of salts should not exceed 5 g during the first three days of the patient's hospital stay; then the salt ration can be increased to 7-10 g. Potassium salts have a diuretic effect and therefore potato, cabbage, figs, dried apricots, and other foods containing a lot of potassium should be given to the patient. Karell's diet increases diuresis too: the patient is given 100-150 ml of milk six times a day. Edema is latent during early stages of cardiac failure. It can only be revealed by decreased diuresis (amount of excreted liquid) and increasing body weight, while the water intake remains unchanged. Keeping this in view, patients with circulatory insufficiency should be weighed daily and their daily consumption and excretion of liquid (soup included) controlled. This helps assess the efficacy of treatment. It should also be remembered that a patient without a fever loses from 0.5 to 1 liter of liquid by sweating, about 200 ml with respiration, and about 100 ml with feces. The loss of liquid by sweating increases significantly in-patients with fever. The excreted urine should be measured daily and the findings recorded in the case history. When latent edema is discovered, daily and nocturnal diuresis should be determined. Daily diuresis includes urine excreted from 8.00 to 20.00 and the nocturnal from 20.00 to 8.00. In normal individuals the nocturnal

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diuresis is smaller than the daily one. In the presence of latent edema the nocturnal diuresis is, on the contrary, greater. Bloodletting (phlebotomy) and oxygen therapy is often prescribed for patients with circulatory insufficiency. In the presence of pronounced edema, especially in ascites, the amount of food intake should be strictly controlled because the appetite may be markedly decreased. It is also necessary to make sure that the patient follows the doctor's orders concerning limited salt and liquid intake. If the patient complains of constipation, cathartics and enema (hypertonic or oil) are indicated. In the presence of pronounced ascitis, which is difficult to manage with medicinal preparations, abdominal puncture (paracentesis) is recommended. Abdominal puncture is used in rare cases for the diagnostic study of the ascitic fluid. A special instrument (troacar) is used for puncturing the abdominal wall. The procedure requires the following: a syringe (with a 0.5 per cent novocaine solution), a basin for collecting the withdrawn fluid, a scalpel, a needle holder with a needle and a silk thread, and a towel or a sheet to wrap the abdomen during paracentesis. The urinary bladder should be emptied before the procedure. The patient should assume a sitting position. The site of puncture is treated with alcohol and iodine tincture, and local novocaine anesthesia is administered. The abdominal wall is then punctured at the median line midway between the navel and the pubis, or by the edge of the rectus abdominis muscle (at the same level). After the trocar has been passed through the abdominal wall, the mandrin is removed from the trocar and the fluid withdrawn. A towel is tightly wrapped around the abdomen to prevent a possible faint. If the fluid outflow stops, the patient's position should be changed: the intestine or the omentum thus moves away from the trocar and withdrawal of the fluid is resumed. When the procedure is over, the punctured site is sutured and the amount of the fluid withdrawn estimated. In some cases a pressing bandage will be sufficient after removal of the trocar. The abdomen should be bandaged tightly and the patient placed in bed. Part of the withdrawn fluid is sent to the laboratory for examination.

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Care of patents with vascular insufficiency. Acute and chronic vascular insufficiency is distinguished. Stock, collapse, and syncope are the symptoms of acute vascular insufficiency. These signs develop when the amount of circulating blood decreases significantly and the vascular tone diminishes. Nutrition of vital organs, of the brain in particular, becomes impaired. The skin of patients with acute vascular insufficiency is pallid, the limbs are cold, the pulse is small and weak, the arterial pressure is low, and the patient is extremely weak. Examination of the pulse shows the condition of the patients' vascular tone. Pulse is the vibration of the arterial walls caused by the passage of blood injected into the arteries by heart contractions. The radial artery at the distal end of the forearm (near the wrist) is the most convenient place to feel the pulse. The thumb is placed on the back of the forearm, while the other fingers are placed on its anterior surface to feel the radial artery. The fingers should not press the patients wrist since the blood will thus be displaced from the artery and the next pulse wave will not be detectable. If the artery is not easily palpable, the fingers should feel across the wrist, since the artery may be displaced toward either side, or on the contrary, may be located in the middle of the wrist. If the artery is impalpable due to some abnormality, the pulse on the other arm should be felt. The filling, rate, rhythm, and pressure of the pulse should be assessed. The pulse rate is determined by counting the number of pulse waves during one minute (or at least during 30 seconds, with subsequent doubling of the finding). When the pulse is slow, the beats should be counted during the course of two minutes. The pulse rate should be entered in the case history (or a temperature graph). The normal pulse rate of an adult is 60-80 per minute; in athletes it may be from 50 to 60. During sleep the pulse decreases by about ten beats per minute. The pulse rate in women is 7-8 beats higher than in men. In neonates it is 130-140 beats per minute; in a 4-6-year-old child the pulse rate is 90-100, in children aged 8-10 it is 85-90 per minute. The pulse rate increases during exercise, nervous strain, and fever. When the

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body temperature increases, the pulse rate increases 10-15 beats per each degree centigrade. The pulse rate corresponds to the rate of heart contractions. A pulse rate below 60 per minute is called bardycardia, and over 90, tachycardia.

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The pulse rhythm is usually regular in normal individuals. It means that all pulse waves are equal and follow one another at regular intervals. If the pulse waves differ in their magnitude and follow at irregular intervals, this condition is called arrhythmia. There exist many types of cardiac arrhythmia, but extra systole and fibrillation are the most common. Extra systole is characterized by intermissions (dropped beat) which are followed by a prolonged (compensatory) pause. Fibrillation of the heart is characterized by the absence of any regularity in frequency and magnitude of the pulse wave. If the cardiac output is small, the pulse wave does not reach the peripheral portions of the arteries and the pulse thus becomes undetectable. A difference between the number of heart contractions and the pulse rate thus appears, which is known as a pulse deficit. This is the sign of a severe heart disease. Arterial pressure depends on the force of the heart contraction and the vascular tone. Increased arterial pressure is called hypertension, and decreased pressure is called arterial hypotension. Arterial pressure is measured by a tonometer or a Riva-Rocci sphygmomanometer. The patient may sit or lie during this procedure. The patient elbow. places his straightened in the arm conveniently on a table where the sphygmomanometer is installed. A cuff is placed on his upper arm, 2-3 cm above the The pulsating vein elbow flexure is found and the bell of a phonendoscope is placed over the vein tightly but without exerting extra pressure. Air is now pumped into the cuff by a rubber bulb. As the brachial artery is compressed by the inflated cuff and the tonomether readings increase, the pulse beats should be heard in the stethoscope. The cuff should be inflated until the pulse is no longer heard. The pressure in the cuff is now gradually released and when the first sound is heart through the stethoscope, the mercury column should be read. This is the maximum arterial pressure. When the pulsating sounds disappear, the manometer reading should be taken again: this is the minimum arterial pressure.

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The maximum pressure, otherwise known as systolic pressure, corresponds to the blood pressure during left ventricular systole when pressure in the arteries is the highest. Minimum, or diastolic pressure, is the blood pressure during diastole of the left ventricle. The difference between the maximum and minimum blood pressure is called the pulse pressure. Arterial pressure varies within a wide range depending on age, condition of the nervous system, physical strain, etc. The average maximum pressure at rest is 115-125 mm Hg and the minimum 60-80 mm Hg; the average pulse pressure is 50-60 mm Hg. The findings are recorded in the form of a fraction where the numerator is the maximum and the denominator the minimum blood pressure. Errors in measuring arterial pressure are due mainly to improper technique or defects in the apparatus. Errors may also arise from the fact that once the tone has appeared it may suddenly disappear and then reappear again. Treatment of acute vascular insufficiency depends on the cause of the disease and on the gravity of the patient's condition. If a patient experiences a syncope, he should be placed in the horizontal position, without pillows, to ensure a better blood supply to the brain. The patient's clothing should be loosened and ammonia given to smell. If these measure do not help, caffeine and camphor should be given subcutaneously. A patient in a state of collapse should also be placed in the horizontal position, without pillows, to improve cerebral circulation, and the legs should be slightly elevated (or the end of an adjustable bed should be raised). Warmth should be applied to the arms and feet. The arterial pressure should be elevated by subcutaneous administration of caffeine, camphor, phenylephrine hydrochloride or norepinephrine. If the state of collapse persist (e.g. in myocardial infarction), the patient should be given phenylephrine hydro-chloride or norepinephrine by drop infusion in a 5 per cent glucose solution.

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Patient experiencing a hypertonic crisis (arterial pressure above 200/120 mm Hg) are prescribed absolute bed-rest. Dry cups or mustard plasters are applied along the sides of the spine. If this does not help, 400-600 ml of blood is to be removed and 4-6 leeches applied (on the mastoid processes along a vertical line, 1 cm away from the ear auricle). Leeches should not be applied closer to the ear because the veins are there superficial and severe bleeding may be provoked.

Theme 14 CARE OF CRITICAL PATIENTS

A critical patient requires special care night and day. In order to give him quiet and to spare other patients from negative emotions, a seriously ill patient should be placed in a separate room (for one, or at the most, two patients). The patient can rest here at any time that may suit his best, for he may suffer from insomnia due to pain or for some other reasons. Since the patient is bed-ridden, maximum comfort must be provided for him. An adjustable bed will suit this purpose best of all. His condition permitting, the patient should be turned in his bed as frequently as needed to prevent formation of bedsores. The linen should be straightened as well. Whenever it is necessary to carry the patient, special rules should be followed. A critical patient requires special care during transportation. Feeding a critical patient is a problem as well because appetite may be absent or he may experience an aversion to food. If the patient has difficulties with swallowing, food should be given through a nasogastric tube; large amounts of glucose are infused intravenously (40 %) or subcutaneously (5 %). Since critical patients are weak, only very close relatives should be admitted to visit them. If the patient is unconscious, a nurse should sit by his bedside. If a

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critical patient is overexcited, he may be furious, may attempt suicide, etc. The bed of such patients should be guarded by a net. When in a state of delirium, the patient may be dangerous to the surrounding people. These patients should be kept in a psychiatric ward irrespective of their will. If the patient resists actively, he should be approached and immobilized carefully as not to harm him and to preclude possible damage to the surrounding people. To decrease hyper excitation, 25-50 ml aminazine and 0.3 g barbamyl should be given 2-3 times a day; aminazine injections should also be given. Critical patients with myocardial infarction, apoplexy, or other diseases should be placed in wards where their condition is carefully observed: their pulse and respiration rate are monitored, and their heart action controlled (ECG) so that necessary measures might be taken timely to preclude possible complications. These wards should be equipped with all instrumentation that might be necessary for observing and treating such patients. Apparatus for electrical stimulation of the heart should also be available. A nurse for the individual care of a critical patient may sit by the patient's bedside both in the hospital and at home. Only experienced personnel should be allowed to care for critical patients. The physician's assistant or a nurse should observe the patient constantly and take appropriate care of him. The nurse must see if the patient feels comfortable in his bed. The position of the bed in the room should ensure an easy approach to the patient. All items that may be necessary for the patient's care, such as a bed-pan, an oxygen bag, or a drinking glass, should be within easy reach of the nurse. A sterilizer with a syringe and injection needles, alcohol, medicines, sterile materials, etc. should be kept on a separate table. The nurse should constantly observe the rate and character of the patient's pulse and respiration, the color of his skin and mucosa, body temperature, and the character of the patient's excrements. All changes in the patient's condition should be reported to the physician. The patient's mouth and skin need special care. In the

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morning the nurse should cleanse the patient's teeth and tongue, wash his mouth cavity, sponge the face and body. The patient's clothes and linen should be changed frequently and all creases smoothed. Feeding a critical patient requires special skill. If the patient is unable to raise his head, he may choke on liquid food, even if given from a special cup with a spout. A transparent polythene tube (20-30 cm long, with a diameter of 8-10 mm) should be attached to the spout of a cup and placed in the mouth (on the tongue root or in the gap behind the last molar). Liquefied food should be fed carefully to prevent possible choking. The patient should be fed 4-5 times a day. The temperature of the food should be 35-40 C. The evacuatory function of the intestine should be monitored. If feces are retained for two days, an evacuant enema should be given. If the patient does not urinate, he should be catheterized once or twice a day. If the patient suffers from severe pain, the physician may prescribe narcotics (morphine and the like). During her duty hours the nurse keeps hourly records of her observations and all procedures that are conducted. She records in log-book all complaints of the patient, his pulse and respiration rate, arterial feeding, volumes of excretions (sputum pressure, temperature, time of included). Defecation should also be

recorded in the book; the presence of blood in the patient's excrements must be noted; blood-stained excretions should be left for examination of the physician. The patient's condition or malignant prognosis of his state must not be discussed at the patient's bedside even if the patient is unconscious, because loss of consciousness may only be apparent and the patient may grasp the content of the conversation. This especially holds for patients with apoplexy. The assistant physician must be tactful with the patient's relatives. He should not reassure them unreasonably but must make them believe that everything is being done to save the patient. Proper care is the best proof of this declaration.

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Care of patients in the terminal condition. The terminal state develops due to various causes (profuse bleeding, damning, strangulation, apoplexy, etc.) and consists of preagonal condition, agony, clinical death and biological death. The preagonal condition is characterized by confused consciousness or its complete loss; the pulse and arterial pressure are difficult to determine, respiration is superficial, the skin is pallid, the mucosa cyanotic. Agony is the pangs of death; the patient is unconscious, the eye reflexes are absent, the pulse on the carotids is small, respiration pathological, the vital functions are profoundly deranged. Agony may continue from a few minutes to several hours. The processes in the cerebral cortex fade, the body temperature drops, and the pulse becomes thready. General convulsions develop and the sphincter are paralyzed. The face is covered with a cold sweat, the nose is pointed, the cornea turns cloudy. A patient in the agonal state should be removed from the general ward to spare the emotions of other patients. Death is the cessation of life activity in the body. Clinical (apparent) and biological (functional) deaths are distinguished. A patient in the state of clinical death can be revived. Clinical death is characterized by the absence of respiration, arrest of the heart action, and dilation of the pupils. But thanks to anaerobic glycolysis, basal metabolism is still maintained in the body for 4 to 7 minutes. Biological death, which follows the clinical one, is characterized by irreversible changes in the central nervous system. The muscles become relaxed and the body temperature falls to the ambient temperature. Livores mortes later develop on the dependent parts of the corpse. Closed chest cardiac massage (indirect) can be carried out during clinical death when the vital activity of the body can be restored. The massage is effective when the heart either stops or fibrillates. Massage should be combined with artificial respiration in the ratio of 3:1 or 4:1. In cases with acute blood loss the patient should be given donor blood or its substitutes, ntravenously and intra-arterially. The patient is placed on a rigid and level surface; his legs should be slightly raised. The

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operator places the heel of one hand, with the heel of the other on top of it, on the lower third of the sternum and applies pressure at a rate of 60-80 per minute. The sternum should yield 3-6 sm. If the pressing force is insufficient, the operator should use the weight of his body to increase the thrust. The sternum presses the heart against the spine to express blood from it chambers into the aorta and the pulmonary arteries. As the pressure is removed, the chest expands and the heart relaxes; its chambers are filled with blood from the veins. If the massage is effective, a pulse becomes determinable on the carotid and femoral arteries; the maximum pressure can thus increase to 60-90 mm Hg. Adrenaline, noradrenaline, mesaton, gluconate or chloride of calcium are given intra-venously or intra-arterially. If closed chest cardiac massage does not help, the chest is opened surgically (if the patient is in the operating room) and the heart is given a direct massage. Excess pressure on the chest in indirect massage can cause fracture of the ribs and injuries of the lungs, liver or other organs. Artificial respiration is given according to several methods. The most effective of them are now considered the mouth-to-mouth or mouth-to-nose techniques. Before giving artificial respiration, dental prostheses, if any, should the mouth cleaned from vomit. be removed from the patient's mouth and

Mouth-to-mouth artificial respiration is done as follows. The patient should be in the supine position, his head tilted back. The mouth and the nose of the patient may be covered with a piece of gauze. The rescuer takes a deep breath, places his mouth over the patient's pinches the patient's nostrils, and blows the air forcefully into his lungs. From 1000 to 1500 ml of air is, thus, blown into the lungs of an adult. The expiration of the patient is passive occurring as the chest collapses. The used to facilitate rate of artificial respiration should be 16-20 breaths per minute. A special S tube of firm rubber is the artificial mouth-to-mouth respiration. It is placed into the patient's mouth (to the tongue's root) and acts as an air duct. If the patient's mouth is closed tightly, mouth-to-nose respiration should be given. The patient is supine,

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his mouth is closed when the air is blown into his lungs. When the air is exhaled, the mouth is half open. Artificial respiration is usually given together with closed chest cardiac massage. One rescuer chest. There are specially equipped ambulance cars for rendering urgent medical aid to patients with myocardial infarction, apoplexy, shock, poisoning or other life-threatening conditions. Apparatuses for giving artificial respiration and electrical stimulation of the heart should also be available in the ambulance. All necessary measures should be taken in the ambulance during the transportation of the patient to the hospital. The patient should be transported to a large hospital which has an intensive care unit. The patient is brought directly to this department without any formalities in order to give all possible aid as soon as possible. Biological death. Clinical (apparent) death is followed by biological (functional) death. The physician certifies the moment of death and makes an appropriate entry into the case history where he records the date and time of death. The dead body is undressed, placed on its back, the lower jaw is pulled up to the skull, and the eyelids are lowered; the body is covered with a sheet and left in bed for two hours. The name of the deceased and the number of his case history are written in ink on his thigh. The dead body is delivered to the pathologoanatomical department with a special note indicting the name of the deceased, the number of his case history, the diagnosis, and the date of death. The deceased may be delivered to the patholoanatomical department only after positive signs of death develop: rigor mortis, postmortem lividity, softening of the eye-balls, etc. If the patient dies at home, the physician certifies the death and issue a certificate where he indicates the cause of death. All patients examination (autopsy) who at a die in a hospital should undergo a postmortem pathologoanatomical department. All valuables performs artificial respiration, while the other indirect massage on the heart. Each breath should be followed by 4 or 5 thrusts on the

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should be removed from the dead body and handed over to relatives before delivering the cadaver to the postmortem department. If the valuables cannot be removed, a special note should be made in the case history, and the body sent to the mortuary with these valuables on.

Themes 15-16 CARE AND OBSERVATION OF PATIENTS WITH ALIMENTARY DYSFUNCTION

Complaints of patients with diseases of the digestive system are quite varied and depend on the part of the digestive tract that is pathologically affected. Patients with disease of the mouth cavity (teeth caries, stomatitis, gingivitis) complain of pain, have difficulty in chewing, and decreased or increased salivation. The bacterial flora of the mouth in stomatitis is activated to cause severe inflammation of the mucosa. If salivation is decreased, the mouth mucosa is inflamed which promotes the development of stomatitis or intensifies the existing inflammation. The mouth is inspected while the patient is in the sitting position. The physician asks the patient to open his mouth, and moves his lips and cheeks aside with a spatula (disinfected by boiling). After the tonsils and the posterior wall of the pharynx have been inspected, the root of the tongue is depressed with the spatula and the patient is asked to say 'Ah'. Adequate illumination is necessary during examination of the mouth cavity, the tonsils, and the pharynx. Any reflector can be used for this purpose. Smears of the mucosa of the mouth, nose, or throat are taken with sterile cotton swab. The patient sits facing the light source with his mouth wide open. The root of the tongue is pressed by a spatula held in the left hand, while a smear is taken from the pathological focus with a cotton swab in the right hand. When a

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smear is taken from the nose, the thumb of the left hand should lift slightly the tip of the patient's nose. The swab taken from the sterile test tube should not touch the external surfaces of the nose. The smear should first be taken from one and then from the other nostril.

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Test tubes containing the smear on swabs should be sent to the laboratory immediately. They should be labeled indicating the patient's name, age, ward, and department in the hospital, date, the name of the material, and the purpose of its testing. The mouth cavity should be cleansed daily in many disease of the mouth itself or the gastrointestinal tract, in circulatory insufficiency, and in some other diseases. The teeth of the patient should be cleansed and the mouth rinsed. Mouth mucosa should be treated with medicinal solutions in some diseases. A cotton ball is taken by pincers, wetted in the appropriate medicinal solution, and applied to the affected site with the help of a spatula. Patients with afflictions of the stomach complain of poor appetite, regurgitation, heartburn, nausea, vomiting, abdominal pain, and bleeding. Care of patients. In a vomiting patient the respiration rate decreases, heart rate increases, arterial pressure falls, and the nervous system becomes excited. The patient's condition permitting, he should sit on the side of the bed with his feet on the floor. A basin should be placed between his fee. When vomiting stops, the patient should rinse his mouth, drink two or three gulps of cold water, and lie in bed. A warm water bottle should be placed on his feet and the patient covered with a blanket. If blood is present in the vomited material, no drink should be given to the patient. If the patient is unable to sit in his bed, the pillow should be removed from under his head, and the head turned so that the vomit does not get into his airways. A little basin or a towel should be placed at the angle of his mouth. If the vomit gets in the airways, coughing is induced by the refectory mechanism. The cough is followed by a forced inspiration and the vomit may penetrate the deeper parts of the airways and the lungs. The patient can thus die or develop aspiration pneumonia. The condition of the patient with haematemesis is drastically impaired due to the loss of blood. The patient is weak, he experiences dizziness and nausea; his arterial pressure falls. A physician should be summoned in such cases. The patient should be placed in bed and an ice bag applied to the epigastrium. Neither dinks nor medicines should be given per os. Injections of 10 ml of a 10 per cent calcium

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gluconate (or chloride) and a 5 per cent aminocapronic acid solution (intravenously) and 20-40 ml of a 10 per cent gelatin solution (subcutaneously) are indicated. The pan for collecting the vomited material should be clean because extraneous admixtures can mislead the physician, and the results of the laboratory analysis will be unreliable. The order that should be followed in delivery of the vomit to the laboratory should be same as for other excretions of the patient. The vomited material should be disinfected like feces. When a patient is attacked by vomiting, the nurse should stay at his bedside and summon the physician. Lavage of the stomach 0is done for therapeutic and diagnostic purposes. It is indicated in chronic gastritis and stenosed pylorus, uraemia, intestinal obstruction, chemical and food poisoning. Contraindications are esophageal and gastric bleeding, burns of the mouth and pharynx mucosa, angina pectoris, and myocardial infarction. Gastric lavage is done using a glass funnel with a capacity of about 1 liter and a 1 meter long rubber tube (1 sm. in diam.).The tube is connected by a glass tube to a thick 70-80 cm long gastric tube with a diameter of about 1 cm. One end of the gastric tube is rounded and has two oval openings, one above the other. Water for lavage (6-10 liters) should be warmed to 30-35 C. A jar and a basin for washing are also required. The gastric tube should be disinfected by boiling and its potency checked before use. The patient is given an oil-cloth apron to put on and is seated in a chair. The basin is placed between his legs on the floor. During the procedure the patient should not throw back his head, bite the tube or touch it with his hands. If the patient has removable dental prostheses, they should be removed before the procedure. The nurse stands by the right side of the patient, while her assistant by the patient's left side. The nurse grasps the gastric tube at about 10 cm distance from its rounded tip and places this length into the patient's mouth so that the tip of tube is on the root of the tongue. The patient is asked to swallow repeatedly: the tube passes into the oesophagus and farther into the stomach. The tube's progress should be assisted either by the right hand or by the left and right hands alternately. A vomiting reflex

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often expels the tube from the throat. The tube should in such cases be removed and a new attempt made after a while. If this procedure proves ineffective, the Gunther method should be used: the back of the tongue is pressed down with the index finger and the tube is carefully introduced into the oesophagus. The depth of immersion is controlled by the mark on the tube which indicates that the tube has reached the stomach. When the tube is in the stomach, the funnel is attached to it via the glass and rubber tubes. The funnel is held below the stomach level and water or a potassium permanganate solution is poured into it. The funnel with the liquid is now raised gradually above the patient's head to pass the liquid into the stomach. The funnel is then lowered and the liquid returns from the stomach into the funnel. Care should be taken that some liquid remains in the funnel, since otherwise it would be difficult to withdraw it from the stomach. The washing are discarded into the basin, a fresh portion of solutions is poured into the funnel, and the procedure is repeated. Lavage should be continued until washing waters are clear. If the patient is unconscious, a thin tube is introduced through the nasal cavity. The one doing the procedure must make sure that the gastric tube reaches the stomach by a test aspiration using a syringe. Water is injected into and withdrawn from the stomach using a Janet syringe or a common 20-40 ml injector. The stomach should be emptied as fully as possible. Under home conditions, if a gastric tube is not available, the patient is given 4-8 glasses of water to drink and the back of his pharynx is then irritated to provoke vomiting. The procedure is repeated several times. Diagnostic lavage of the stomach is indicated in cases when tuberculosis of the airways or stomach cancer is suspected. Tuberculosis mycobacteria can be found in the washing in cases of tuberculosis and cancer cells in gastric cancer. Diagnostic lavage should be performed on an empty stomach. A then gastric tube with 5 or 6 openings at the distal end is swallowed by the patient (a length of 45-50 cm), or

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the tube is introduced through the nose. A syringe with an isotonic sodium chloride solution is attached to the outer end of the tube and the solution is injected into the stomach and then withdrawn from it. The procedure is repeated several times using the same solution so as to obtain the higher concentration of gastric mucus in the washing. The washing are poured into a clean container and sent to the laboratory. A gastric tube is used also to assess the gastric acid output and the evacuatory function of the stomach. One-time obtaining of gastric juice by a thick tube is now considered inexpedient since the intensity of gastric secretion varies not only in patients but in healthy individuals as well. Moreover, there are some contraindications to using a thick tube because it provokes vomiting and staining. At the present time a thin tube (5 mm outer and about 3 mm inner diameter) is used for fractional obliging of gastric juice. This is an elastic rubber tube with lateral openings at the distal end. Since the tube is soft it cannot be forced into the stomach, but should be swallowed by the patient. If swallowing provokes vomiting, the tube should be passed through the nose. The patient should remove any artificial teeth and sit on a chair. The leading end of the tube should be wetted with water and placed into the patient's mouth beyond the tongue root. The patient is then asked to swallow the tube. When the tube reaches the stomach, a clamp is placed on its outer end to prevent the spontaneous withdrawal of gastric acid. According to Leporsky, the gastric secretion of a fasting stomach is withdrawn first. Then four 15-minute portions are taken. The patient is now given a test meal (a caffeine solution, 7 per cent cabbage decoction, 300 ml of a 5 per cent alcohol solution). A stimulant (histamine, insulin, pentagastrin) in sometimes given parenterally. Ten minutes after the administration of the gastric secretion stimulant a 10 ml portion is withdrawn. Then in 15 minutes the stomach is emptied. Then five 15-minute specimens of pure gastric juice are taken. If secretion is provoked by parenteral administration of a stimulant, four 15-minute portions of the gastric juice are collected within an hour. Each portion is collected in a

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separate vessel and the volume is marked. All specimens are then delivered to the laboratory. Preparing a patient for x-rays of the stomach and small intestine. Radiological techniques (roentgenoscope and roentgenography) give reliable information concerning pathology of the stomach and the intestine. X-ray has remained an important method of examination in gastroduodenal pathology. 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 the first instance of the duodenum). A barium sulphate suspension (100 g in 100 ml of boiled water) is used for radiological examination of the stomach and the intestine. The power to absorb x-rays accounts for the use of barium sulphate in roentgenology. The suspension is given to the patient per os. The patient should be specially prepared for x-ray (either roentgenoscope or roentgenography). His stomach and the intestine should be emptied of food remains, liquids, and gases. Two days before the examination the patient's diet should be free from food that can cause flatulence, e.g. rye bread, milk, or potatoes. In order to decrease flatulence, 2-3 days before the examination the patient should be given a warm camomile tea (one table-spoonful in a glass of water). On the eve of the examination, and also in the morning before the procedure, the patient should be given a cleansing enema. Only an empty stomach can be examined by x-rays, and the patient is therefore warned that he should abstain from eating (liquids or solids) 6-8 hours before the x-ray examination. Duodenal probing is done for both diagnostic and therapeutic purposes. Many diseases of the bile ducts and the gall bladder are attended by bile congestion. When a duodenal tube enters the gall bladder, it contacts reflectorily to eject its contents into the duodenal lumen. Bile specimens are important diagnostically.

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Taking specimens of duodenal contents is indicated: 1 - for withdrawal of the bile congested in the gall bladder; 2 - for administration of medicines into the duodenum; 3 - for laboratory examinations of bile; 4 - for artificial nutrition of patients with non-healing ulcers of the stomach. Duodenal probing is contraindicated in: 1 - exacerbation of gastric ulcer; 2 - cancer of the oesophagus and stomach; 3 - angina pectoris and myocardial infarction; 4 - heart failure; 5 - acute cholecystitis and cholelithiasis. A 1.5m long rubber tube with a diameter of 4-5 mm is used for the purpose. The distal end of the tube mounts a metal olive with several perforations. The tube bears three marks to indicate the distance from the teeth to the entrance to the stomach (50 cm), to the pylorus (70 cm), and to the middle of the duodenum (90 cm). The tube should be washed and boiled after each use. If an infectious disease is suspected, the tube should be disinfected for 2 hours in a disinfectant solution. Two or three days before the procedure, the patient should be fed a diet free from foods causing intense fermentation in the intestine. Medicines which relieve spasms of the gall bladder and bile ducts (belladonna, no-spa) should be given. On the eve of the procedure, the patient should be given a cleansing enema. The procedure should be done before breakfast. Dental prosthesis, if any, should be removed. The conditions in the room are important. Preferably a special room should be provided for the purpose, or the patient should at least be separated from others by a screen. The patient must be observed during the entire procedure. The procedure is as follows. The patient sits on the bed, unbuttons his collar, unfastens his belt, and takes hold of the pan with the duodenal tube. The patient himself, or assisted by the nurse, places the tube olive at the root of the tongue and makes several swallowing movements with his mouth closed. The patient should breathe deeply and swallow together with the saliva. As soon as the tube descends to the first mark to indicate that it has entered the stomach, the patient is placed on his right side and a hot water bag is put under the right hypochondrium. The

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swallowing should now be resumed until the tube is passed to the second mark. Swallowing should be gradual since otherwise the tube may coil up in the stomach. As the tube moves in the stomach, the gastric contents should be aspired into a special vessel by syringe. The passage of the tube through the pylorus into the duodenum should agree with the periodic opening of the pylorus. If the pylorus is contracted or affected by a spasm, it becomes impassible for the tube. In order to accelerate the tube's passage through the pylorus, 1 ml of a 0.1 per cent atropine solution should be given subcutaneously and the upper abdomen massaged. If the pylorus spasm is due to gastric hyper acidity, the gastric juice should be aspired by a syringe, or a glass of a 1-3 per cent sodium hydro carbonate (baking soda) solution given per os. In some cases the necessity arises to check the position of the olive tip. The best visualizing technique is x-ray. The position of the tube's tip can also be determined tentatively by the aspirate. If the olivetip is inside the stomach, the aspired liquid is cloudy and acid: litmus paper turns red. The gastric contents may be green and react alkaline (litmus paper turns blue) to indicate that the tube's olive is in the duodenum. Still another method consists in injecting air by a syringe: if the olive is in the stomach the patient fells bubbling. No sound can be heard if the tube is in the duodenum. If the olive has entered the duodenum, the aspirate is clear yellow; it reacts alkaline (A bile). This is a mixture of bile, gastric juice, and pancreas secretion. A stand with test tubes is placed by the patient's bedside and the duodenal contents are collected in them. B bile (bile from the gall bladder) is obtained after stimulation with 40-60 ml of a warm (39-40 C) 25 per cent magnesium sulphate solution or 20 ml of vegetable oil, which are administered to the patient through the tube. The gall bladder contracts upon this stimulation while the Oddi sphincter relaxes to admit B bile into the duodenum. B bile is dark brown and tenacious. Part of the B bile collected is used for a culture.

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After the gall bladder has been emptied, a clear bile is drained again. This is a mixture of fluids secreted by the intra hepatic ducts, the hepatic bile, or simply C bile. If the bile is to be examined for the presence of lamblia, the obtained specimens should immediately be sent to the laboratory, because when the bile cools, the parasites become immobile and hence undetectable by microscopy. Modern examination of the duodenal contents if often a multi step procedure. In the presence of motor dysfunction of the gall bladder and the bile ducts (biliary dyskinesia), and also in the presence of inflammation, antibiotics and other medicinal solutions are administered through the tube after taking C bile. In the presence of excess fermentative and putrefactive process in the intestine, lavage can also be performed through the tube. To this end, mineral water at a temperature of 39-40 C is passed through the tube for 10-15 minutes. During the first lavage 1 liter of water is used, this quantity increasing to 2-4 liters in subsequent irrigations. Preparing the patient for x-ray of the gall bladder and the bile ducts. The x-ray study of the gall bladder is called cholecystography. It can be done with the administration of radiopaque substances (per os or intravenously). The x-ray study of gall bladder and the bile ducts is called cholecystocholan-giography. Radiopaque material is given only by intravenous routes in this procedure. Bilitrast, cholevid are given per os and bilignost intravenously. The presence of iodine accounts for the x-ray opacity of these substances. When given per os or intravenously, radiopaque substances first enter the liver and then (through the bile ducts) the gall bladder. Cholecystography is used for determining the shape and position of the gall bladder, its motor function, and also is cases when bile stones are suspected. Cholecystography is contraindicated in pronounced circulatory insufficiency, severe liver affections, acute nephritis, and hypersensitivity to iodine. No special regimen or diet is necessary before this procedure. If the patient is likely to develop constipation, he should be given a cleansing enema on the eve or in the morning of the day of the procedure. Since the highest concentration of bilitrast in the gall bladder

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is attained 15 hours after the administration, the preparation should be given 18-19 hours before the procedure (on the eve of the examination). Bilitrast is given in 1-1.5 g doses at 20-minute intervals. The total dose is 3-3.5 g. Each dose should be given with a glass of sweet tea. At 22.00 the patient is given 100 ml of a 40 per cent glucose solution. X-ray pictures are taken the next morning at 9.00 or 10.00. By another method the patient is given a cleansing enema at 18.00 or 19.00, then 3-3.5 g bilitrast, and placed on his right side for 30 minutes. The patient is given porridge or vegetable puree, and a cup of tea with bread for a supper. Before night sleep, the patient is given 5-7 drops of an opium tincture and a tablespooful of activated carbon. The x-ray examination is conducted in the morning, at 9.00 or 10.00, after an overnight fast. If the shadow of the gall bladder is absent, another picture is taken in three hours. If the shadow is visible, two or three egg yolks are given to the patient and another picture is taken in 90 minutes. Possible side-effects of billignost are nausea, vomiting, or nettle rash. If the results of cholecystography with per oral administration of radiopaque preparations are negative, cholecystocholangiography with intravenous administration is used to study the bile ducts and for a rapid diagnosis of colic. Contraindications for cholecystocholangiography are the same as for cholecystography. A cleansing enema is given to the patient on the eve of the examination, and preparations that might affect the motor function of the gall bladder (opium, cholagogics, etc.) are not administered. The radiopaque preparation is given intravenously. The patient should be preliminarily tested for sensitivity to iodine by administrating 1-2 ml of a 20 per cent solution of the preparation on the eve of the examination. If side-effects are absent, 30-40 ml of the preparation (preheated to normal body temperature) are injected. The preparation is injected slowly, over the course of 4-6 min. Side-effects are more likely to occur with rapid administration (nausea, vomiting, heat, fall of the arterial pressure). In emergency cases the patient's sensitivity to the preparation is

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tested immediately before the examination: 1-2 ml of a 20 per cent bilignost solution is administered, and if there are no adverse reactions for 2-3 min the remaining quantity (30-40 ml) of the solution is injected. Bile ducts are visible 10-15 minutes after administration; the picture becomes more distinct in 25-40 min. The gall bladder becomes visible in 40-45 min. The maximum opacity of the gall bladder is attained in 90 min. In 24 hours the radiopaque preparation fills the large intestine (through which its main bulk is excreted). The preparation is usually well tolerated by patients. Some patients may experience dizziness, chills, nausea, vomiting, a drop in arterial pressure, and fever. These phenomena subside spontaneously. If necessary, oxygen can be given to breathe, or 1 ml of a 5 per cent ephedrine solution injected subcutaneously. If the patient has a history of allergic reactions, he should be given diphenylhydramine hydrochloride or some other antihistamine preparation (pipolphen, suprastin) 2 or 3 days before the procedure. Care of patients with intestinal dysfunction. The main complaint of patients with intestinal diseases are pain, meteorism (inflation of the abdomen), constipation, diarrhoea, intestinal hemorrhages, and involuntary defecation. No analgesics or warmth should be given to a patient with abdominal pain until its cause is established, because this will interfere with diagnosis and may be harmful (e.g. in cases of intestinal hemorrhage or acute appendicitis). If pain is caused by spasms of smooth muscles, peroral or atropine or belladonna is indicated morphine or promedol. Meteorism is manifested by inflation and distension of the abdomen. Food rich is carbohydrates should be excluded from the diet because it intensifies the fermentation processes in the intestine intensifying gas formation. Activated carbon is prescribed in such cases: a teaspoonful 3-4 times a day; activated carbon (tablets) and camomile tea are also helpful. Cleansing enemas give considerable subcutaneous administration of often together with other analgesics, e.g.

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relief to the patient. If these methods prove ineffective, a 50-cm long rubber tube with a diameter of 1 cm should be inserted into the rectum to a depth of 20-30 cm. The rounded tip of the tube, which has lateral openings, should first be coated with Vaseline. The other end of the tube is placed in a bed-pan in order to protect the linen from occasional soiling by the intestinal contents. An oil-cloth can be used for the same purpose. The tube is removed after 30-60 minutes and the anus wiped with a wet cotton pad. If the patient has diarrhoea, he should use a bed-pan or some other vessel where his feces can be collected for inspection and analysis. The patient should keep his body, clothes, and bed clean; he should wash his anus after defecation with a 2 per cent boric acid solution. Since diarrhoea is often the result of an infection (cholera, abdominal fever, dysentery, etc.), it is necessary to take special precautions even before the diagnosis is established. To this end the patient should be placed in a separate room and a rug wetted with a disinfectant solution placed at the threshold. The patient's plates, glasses, and silverware should be washed with soap and soda, boiled for 15 minutes, and kept separately from others. All objects that are used for his care should also be washed with soap and hot water. Linens should be collected in a special bin fitted with a cover and then boiled for 15 minutes with soap and soda. The bed-pan should be washed in a disinfectant solution, rinsed in water, closed with a cover, and placed on a sheet of paper which should be burned after each use. The feces and urine should be treated with chlorinated lime (1:2) and kept for an hour before discarding into the sewage. Food remains should be treated in the same way. The room and other premises where the patient may touch various objects should be cleaned two or three times a day using a wet rag. The floor should be washed with hot water, soda, and soap. The door handles, taps, w.c. pans and floor in the lavatory should be treated with a disinfectant solution. The patient's room and the rooms for common use should be aired several times a day. The personnel who take

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care of infectious patients or those suspected of having infectious diseases should wear overalls made of easily washable fabric. After contact with the patient or after washing his plates and silverware and the bed-pan, or after cleaning the rooms, the worker should wash his hands with soap using a brush. When the attending personnel leave the room or other premises where the patient is present, they should take off their overalls and wipe their feet on the rug wetted with the disinfectant solution. Constipation is a retention of stools for more than two days. Constipation is managed with a special diet, cathectic, and cleansing enemas. The number of daily defalcation should be counted and the amount of feces in each defecation assessed. In some patients a considerable amount of hardened feces accumulates in the rectum. An enema is useless in such cases and the feces should be removed manually. A rubber glove lubricated with oil should be used for the purpose. A bed-pan is placed under the patient's pelvis and the finger is inserted into the rectum to remove the hardened feces. If not removed in due time, the feces harden even more and press on the intestinal wall, causing sores. A cleansing (evacuant) enema should be given after this manual procedure. If intestinal hemorrhage develops (which is manifested by tarry stools), the patient should stay in bed, and the physician should be informed. A ice-bag should be placed on the abdomen and 100-200 ml of compatible blood infused. If this does not help, surgery is indicated. During the course of the first 24 hours, the patient should abstain from food. The intake of liquids should also be limited. Cold or slightly warmed semiliquid food should be given. Peroral administration of medicines should be suspended. Hemorrhage may be only slight in peptic ulcer, in cancer and some other diseases, and blood traces in the feces can only be detected in the laboratory. When hemorrhage is suspected the patient should be given a meat-free diet for three days before the examination, since meat can be responsible for a positive occult blood test.

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Feces are not tested for blood if the patient is suffering from gum or nasal bleeding, or hemorrhage after tooth extirpation. Involuntary defecation occurs in patients with severe affections of the brain, tumors, or injured rectum. These patients should be kept in separate rooms. A high-caloric and easily assimilated diet spares the patient because the amount of feces is small. A cleansing enema should be given every day. The patient should be placed on a special bed or a rubber pan. Such patient should be given special care with frequent sanitary treatment of their body; their clothes and sheets should be changed more frequently. Enema. An enema is an injection of liquids into the large intestine through the anus. Enema is indicated to remove bowel contents, to administer medicines, nutrients, or radiopaque substances (barium sulphate) for x-ray examinations. Evacuant, purgative, drop, and nutrient enemas are distinguished. An evacuant enema is given for constipation, poisoning, before labor in women, before x-rays of the abdomen or the pelvic organs, and before giving medicinal or nutrient enemas. An evacuant enema is contraindicated in gastric and intestinal hemorrhage, ulceration of the large intestine or the rectum, hemorrhoids, cancer of the rectum or the large intestine, purulent and ulcerative processes in the large intestine or the anus, in acute appendicitis and peritonitis, and in rectal prolapse. Pure water is used for an evacuant enema (1-2 liters). To increase the cleansing effect, a camomile tea and 2-3 tablespoonfuls of glycerol or Vaseline oil should be added. The water temperature for atonic constipation should be 15-20 C and for spastic constipation, 37-39 C. An Esmarch flask is filled with water and its tap opened to displace air from the tube. The tap is then closed and the flask hanged from a stand at a height of 1-1.5 meter. The patient lies on his side at the edge of his bed and flexes his thigh on the abdomen. An oil-cloth should be placed under the patient.

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A rubber, glass or ebonite end-piece is used. The left hand is used to separate the buttocks, while the end-piece lubricated with Vaseline is inserted into the rectum by the right hand and rotated slightly about its axis until it reaches a depth of 10-12 cm. The end-piece should first be moved toward the umbilicus, and then posteriorly, parallel to the coccyx. The tap is now opened. The liquid should flow quietly 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 feces, it should be cleaned and introduced again. If the feces are hard, they should be removed from the rectum by the finger or a spatula. The administered liquid reaches the remote parts of the large intestine to intensify peristalsis and to cause the urge to defecate. The patient should retain the administered liquid for 5-10 minutes. A purgative enema is prescribed for persistent constipation or intestinal paresis when the administration of large amounts of liquid is ineffective or harmful. Oil and hypertonic saline solutions are used. An oil enema is indicated for pronounced constipation when hardened feces are accumulated in the rectum, and also in inflammatory and ulcerative processes in the large intestine and the rectum. Sunflower seed oil, olive oil, Vaseline oil or linseed oil are used for the purpose. Oil penetrates the space between the feces and the intestinal wall to facilitate the discharge of the feces. Oil also produces a mild irritating effect on the intestinal wall decreasing inflammation and promoting the normalization of peristalsis. From 50 to 100 ml of oil is required for an enema. The temperature of the oil should be 37-39 C. A Janet injector or a rubber bulb with a tube are used for a while after the procedure. The purgative effect should occur within 8-12 hours.

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After use the tools should be washed with hot water and sodium bicarbonate, and bioled. Hypertonic saline enema. This consists of 50-100 ml of a 10 per cent sodium chloride solution or a 25 per cent magnesium sulphate solution. The enema is given in intestinal paresis and oedema of the intestinal wall. hypertonic solution should be warmed up before administration. The tools used for the purpose are the same as for giving an oil enema. The patient should not defecate for 15-30 minutes after the 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 impotency. A siphon enema requires a 1-2 liter glass funnel and piping: a 1.5-m long rubber tube, a short glass tube, and rectal tube. A jar, a basin and an oil- cloth are also required. Water (10-15 liters) should be warmed up before use. The patient assumes the same position as for an evacuant enema. The tip of the rectal tube is coated with Vaseline and 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 jar and the funnel is raised. When the liquid level in the funnel descends to the funnel's apex, the funnel is lowered over the basin and held in the 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 siphon age is repeated until the water returning to the funnel is clear. After use, the funnel and the tubes are cleaned. Medicinal solutions that are given by enema are usually of local action. These are antispatics, antibiotics, sulpha drugs, antiparasitary preparations, and some others. A tepid solution (50-200 ml) is administered by a rubber bulb or a Janet The enema is contraindicated in ulceration of the large intestine and fissures of the anus. The

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injector provided with a 12-20-cm long rubber end-piece. The patient should try to keep the administered medicine in the intestine for at least 30 min. The medicinal solution should be given 20-30 minutes after an evacuant enema. 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 manage intoxication, dehydration, etc. The apparatus includes an Esmarch flask, a rubber tubing, a dropper, a glass tube, and a rectal tube. The rectal tube has lateral openings. The rate of liquid administration is controlled by a clamp. The patient should lie on his back during the procedure. The solution in the Esmarch flask should be 41-42 C. 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. Preparing a patient for an x-ray study of the large intestine. A barium sulphate 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. It cases of meteorism, the patient should be given camomile 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. A rectal tube is inserted into the rectum 30 minutes before the examination to release gases. A barium suspension is used as a radiopaque material. It is prepared from 200 g of barium sulphate and 10 g of tannin in 1 liter of water.

Theme#17-18 OBSERVATION AND CARE OF PATIENTS WITH URINARY DISORDERS

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Patients with diseases of the urinary system usually complain of lumbar pain, edema, headache, urinary disorders, deranged vision, nausea, vomiting, and fever. Patients with renal dysfunction and diseases of the urinary tract require special care. Patients with acute nephritis may develop severe complications and should therefore be hospitalized. Patients with chronic nephritis require hospitalization only during exacerbation and those with acute nephritis should stay in bed. If this condition is not observed, various complications are likely to develop and the patient's recovery is delayed. Water, salt, and protein should be restricted in the diet of patients with renal disease. The diet should be rich in vitamins. Fasting days, when the patient eats only apples, stewed fruits, etc. should be prescribed. Uremia is severe poisoning of the body with rest nitrogen, which is not removed efficiently by the kidneys. Products of protein decomposition (urea, uric acid, and creatinine) accumulate in the patient's blood. Protein should be restricted to 20-40 g a day. The intake of meat, fish, and dairy products should be limited as well. The permissible amount of protein should come from eggs and boiled meat. Potatoes and sweets are recommended. Intravenous injections of 300-400 ml of a 5 per cent glucose solution are given. In the presence of acidosis, the patient should be given 150-200 ml of a 4 per cent sodium hydrocarbonate solution; vitamins are given per Os. The renal function is assessed by the diluting and concentrating power of the kidneys. The amount of urine excreted during a specified period of time is called diuresis. The daily diuresis is the amount of urine excreted during 24 hours. The average daily diuresis of a healthy human is 1.5 litre. Some diseases are attended by a decreased diuresis, which is called oliguria. A complete cessation of urination is called anuria. Polyuria (increased diuresis) attends rapidly resorbing edema. A healthy individual urinates from 4 to 6 times a day. The urine is excreted in a uniform jet. Frequent urination (usually in small portions) is called pollakiuria and occurs in inflammatory affections of the urinary ducts.

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The concentration of the urine is determined by its specific gravity. Normal specific gravity of urine varies from 1.010 to 1.030, depending on the diet. The concentration of the urine increases in oliguria, because the residues are dissolved in a decreased volume of the urine. The specific gravity of the urine varies from 1.030 to 1.040 in oliguria, while in polyuria it varies between 1.008 and 1.010. If the concentrating power of the kidneys is affected, the specific gravity of the urine remains low even in oliguria. The liquid elimination by the kidneys is disturbed. The Zimnitsky test. Its advantage over other urine tests is that it can be carried out without interfering with the patient's usual regimen. The test is carried out during the course of twenty-four hours. At 6.00 or 7.00 in the morning the patient urinates and discards the urine. Then he collects the urine at 3-hour intervals: a total of 8 specimens. The volume and the specific gravity of each 3-hour portions of the urine are measured in the laboratory. The volumes of the urine passed during the day and night are compared. The daytime diuresis of a normal individual is about two times greater than the nocturnal diuresis. The specific gravity of the daytime urine fluctuates from 1.005 to 1.028. Nocturnal diuresis, called nycturia, prevails in renal dysfunction. The specific gravity of the urine in pronounced renal failure changes very little (isohyposthenuria). Care of patients with urinary retention or incontinence. Retention of the urine (ischuria) is a pathological condition characterized by the inability of the kidneys to excrete the urine due to an obstacle in the ureters or urethra. The passage of the urine may be obstructed by stones, tumors, cicatricial contractions in the ureter or in the urethra. The urine may be retained due to nervous regulatory disorders of the excretory function. Postlabour ischuria can develop after parturition. This is due to decreased muscular tone, edema of the neck of the urinary bladder, or injury to the urinary bladder by the foetal head. Ischuria can be acute or chronic, complete or partial, with or without painful tenesmus. A healthy individual passes the urine in a full and strong jet. In the presence of partial retention, the jet thins and weakens or the urine passes by drops.

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When taking care of the patient, it is necessary to count his urination and to measure the volumes of the passed urine. Special attention should be given to patients whose central nervous system is affected and in whom the urinary bladder may be paralyzed simultaneously with the spasm of the sphincter. Overdistension of the bladder may in this case cause is repture. If the patient retains the urine for 6 hours after parturition or surgery, all measures should be taken to release the urine. Sometimes the patient should be left alone or be assisted into the sitting position. A water bag may be placed on the lower abdomen, or the patient may be given an enema of tepid water, or a bath. If these measures fail to help the patient, he/she should be given an injection of pituitrin or magnesium sulfate. If this does not help either, the urinary bladder should be catheterized. Flexible and metal catheters are distinguished. A soft catheter is a 25-30-cm long rubber tube with a diameter from 0.3 to 1 cm. The tip of the tube is rounded and fitted with lateral openings. Metallic catheters are divided into male and female ones. Both are provided with handles and beaked tips. The rounded tip has one or two oval openings. The male catheter is 25-30 and the female about 15 cm long. The beak of the male catheter is longer than that of the female catheter. Metal, rubber, and plastic catheters are sterilized by the boiling. Rubber catheters should be sterilized in formaldehyde vapor. Since formaldehyde irritates the urethral mucosa, the catheters should then be rinsed in distilled water. Catheterization can be carried out for diagnostic and therapeutic purposes. Catheterization is contraindicated in injuries and acute inflammation of the urethra or the urinary bladder. Sterilized catheters, forceps, and cotton balls soaked in disinfectant solution are placed in a sterile through before the procedure. Sterile glycerol, or a special paste, and a urine receptacle should also be prepared. The patient lies on his back with the legs slightly flexed and separated. The urine receptacle should be placed between the patient's thighs. The genitals should be washed with water and disinfected with cotton ball wetted with a mercury dichloride or ethoxydiaminoacridine lactate solution. The rounded tip of a soft catheter should be

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held with the forceps, and the catheter's outer end, by the fingers. The glans penis is held by the left hand and the tip of the catheter is inserted into the urethra using the right hand. The catheter is then pushed forward into the bladder by the forceps until urine starts flowing from the catheter. When catheterizing women, the one performing the procedure should stand by the patient's right side. The labia major are separated, the orifice of the urethra disinfected, and the catheter inserted until urine emerges. The catheter should be removed slightly before all the urine is withdrawn so that the remaining urine can wash the urethra after extraction of the catheter. Sometimes the urinary bladder is irrigated with medicinal solutions during catheterization. Potassium permanganate, silver protein, colloid silver or other solutions are used for the purpose. The sterile solution (0.4-1 litre) is preheated to 38- 39 C and placed in an Esmarch flask. The tube is clamped and the flask suspended. After catheterization and withdrawal of the urine, the catheter (usually a rubber one) is connected to the tubing of the Esmarch flask and 100-400 ml of the solution are passed into the bladder. The catheter is then disconnected from the tubing and the solution is allowed to flow from the bladder. The procedure is repeated several times. Urinary incontinence is a morbid state in which the patient does not feel the urge to urinate and passes the urine involuntarily. Incontinence usually attends affections of the brain, unconscious conditions, neurosis, and diseases of the urinary bladder. Constant excretion of the urine causes maceration of the skin, bedsores, and soiling of underwear and linens. Patients with urinary incontinence should be examined to establish the cause of incontinence and to manage it. A urinal should be put in the bed of such patients. The urinals should be emptied at least three times a day and washed with soap and warm water. Once a day the urinal should be disinfected with a potassium permanganate solution. Walking patients should be given special urinals which they can carry about. The urinals (both male and female) and made of rubber, nylon or other material and

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comprise a special urine trap, which is attached to the lower part of the trunk, and a receptacle which is attached to the thigh. A well-fitted urinal does not interfere with the patient's movements or routine work. Preparing a patient for x-ray of the urinary system. Excretory (intravenous) urography is a common radiographic study of the urinary tract. Solutions (50-60 per cent) of bilignost, verographin, or urographin are used as opaque media for urography. The informative value of the studies depends on the effective evacuation of gas and feces from the intestine, the renal function, and some special features of the disease. To prevent possible allergic reaction of the patient to iodine preparations used as the radiopaque medium, his sensitivity to a particular preparation should be tested on the eve of the examination. To this end, 1 ml of the preparation is injected intravenously and the immediate and delayed responses are observed. If an allergic reaction develops, the examination should not be conducted. Immediately before the examination, the region of the kidneys and the bladder should be x-rayed to check if the intestine in this region is emptied. On the eve of the urographic study, and also two hours before the examination, the patient should be given a cleansing (evacuate) enema. If the patient is predisposed to constipation, he should be given laxatives (rhubarb, buckhorn). Chamomile tea or activated carbon should be given in meteorism. The patient should empty the urinary bladder immediately before the procedure. The radiopaque preparation is warmed to body temperature and injected into the cubital vein during the course of 3-5 minutes. The first 2-3 ml should be injected at an especially slow rate and the condition of the patient observed carefully. If any allergic reaction develops (nasal discharge, sneezing, nettle rash), the injection should be discontinued immediately without removing the needle from the vein in order to infuse glucose or isotonic saline solution. When given intravenously, radiopaque material is rapidly excreted by the kidneys. The pelvis, ureters, and the urinary bladder can be seen on x-rays.

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The radiopaque substance can be administered directly into the pelvis through the urinary ducts. This method is called retrograde (ascending) pyelography. Special catheters and a cystoscope are used for the administration of the radiopaque medium into the pelvis. Special marks on the catheter are important for controlling the depth of its insertion: a normal depth to catheterize the pelvis is 24-28 cm from the orifice. Warm solution of urographin (20 ml 60%) is slowly administered through the catheter. Cystoscopy is the examination of the urinary bladder from inside using a cystoscope. Before introducing the cystoscope, it should be checked that it is in good condition. The caliber of the cystoscope should be selected to comply with the lumen of the urethra. The cystoscope should be coated with ample sterile glycerol, and a few drops of glycerol should be introduced into the orifice of the urethra. The beak of the cystoscope should be passed into the urethra very slowly until it enters the urinary bladder.