Algorithms for the actions of a nurse when performing practical manipulations. Algorithms for performing nursing manipulations Quality control of sterilization
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KAZAKHSTAN-RUSSIAN MEDICAL UNIVERSITY
Department of Propaedeutics of Internal Medicine and Nursing
Essay
on the topic of:Algorithm for the action of a nurse during an attack of bronchial asthma
Completed by: Estaeva A.A.
Faculty: “General Medicine”
Group: 210 "B"
Checked by: Amanzholova T.K.
Almaty 2012
Introduction
1. Bronchial asthma. Etiology
3. Status asthmaticus
4. Treatment of bronchial asthma
Conclusion
Introduction
Bronchial asthma is a chronic nonspecific relapsing polyetiological lung disease, formed with the participation of immunological and non-immunological mechanisms, characterized by pronounced hyperresponsiveness of the respiratory tract to specific and nonspecific stimuli and the presence of the main clinical manifestation - attacks of expiratory suffocation with reversible bronchial obstruction due to spasm of smooth muscles, swelling of the mucous membrane and hypersecretion of bronchial glands.
1. Bronchial asthma. Etiology
Bronchial asthma is conventionally divided into 2 forms: infectious-allergic and atonic.
b The infectious-allergic form usually occurs with inflammatory diseases of the nasal pharynx, bronchi and lungs.
b The atopic form develops with increased sensitivity to non-infectious allergens from the external environment.
Bronchial asthma is a disease based on chronic inflammation of the airways, accompanied by changes in the sensitivity and reactivity of the bronchi and manifested by an attack of suffocation, status asthmaticus, or, in the absence of these, symptoms of respiratory discomfort (paroxysmal cough, wheezing and shortness of breath), accompanied by reversible bronchial obstruction against the background of a hereditary predisposition to allergic diseases, extrapulmonary signs of allergy, eosinophilia of blood and (or) sputum.
Two important aspects of the problem can be noted:
· bronchial asthma occurs in waves, that is, periods of exacerbations are followed by remissions, during which the patient experiences virtually no discomfort. The conclusion naturally suggests itself about the need for preventive treatment (to lengthen periods of remission);
· the pathological process is based on chronic inflammation, therefore, anti-inflammatory treatment should be the main therapy.
The first stage of the development of the disease is identified by conducting provocative tests to determine the altered (usually increased) sensitivity and reactivity of the bronchi in relation to vasoconstrictor substances, physical activity, and cold air. Changes in the sensitivity and reactivity of the bronchi can be combined with disorders of the endocrine, immune and nervous systems, which also do not have clinical manifestations and are detected by laboratory methods, most often by performing stress tests.
The second stage of the formation of bronchial asthma does not occur in all patients and precedes clinically pronounced bronchial asthma in 20 - 40% of patients. The condition of pre-asthma is not a nosological form, but a complex of signs indicating a real threat of the occurrence of clinically pronounced bronchial asthma. Characterized by the presence of acute, recurrent or chronic nonspecific diseases of the bronchi and lungs with respiratory discomfort and symptoms of reversible bronchial obstruction in combination with one or two of the following signs: hereditary predisposition to allergic diseases and bronchial asthma, extrapulmonary manifestations of allergic altered reactivity of the body, blood eosinophilia and (or) sputum. The presence of all 4 signs can be considered as the patient having an asymptomatic course of bronchial asthma.
Broncho-obstructive syndrome in patients in a state of pre-asthma is manifested by a strong, paroxysmal cough, aggravated by various odors, with a decrease in the temperature of inhaled air, at night and in the morning when getting out of bed, with influenza, acute catarrh of the upper respiratory tract, from physical exertion, nervous tension and others reasons. The cough subsides or becomes less intense after ingestion or inhalation of bronchodilators. In some cases, the attack ends with the discharge of scanty, viscous sputum.
2. Main manifestation of the disease
The main manifestations of the disease are
· Attacks of suffocation (usually at night) lasting from several minutes to several hours, and in especially severe cases up to several days.
There are three periods in the development of an attack of bronchial asthma:
1. period of harbingers
2. high period
3. period of reverse development of the attack.
The period of precursors begins several minutes, hours, and sometimes even days before the attack. It can manifest itself with various symptoms: burning sensation, itching, scratching in the throat, vasomotor rhinitis, sneezing, paroxysmal cough, etc.
The height of the period is accompanied by a painful dry cough and expiratory shortness of breath. Inhalation becomes short, exhalation is sharply difficult, usually slow, convulsive. The duration of exhalation is 4 times longer than inhalation. Exhalation is accompanied by loud whistling wheezes that can be heard from a distance. Trying to ease breathing, the patient takes a forced position. Often the patient sits with his torso tilted forward, resting his elbows on the back of the chair. Auxiliary muscles are involved in breathing: the shoulder girdle, back, and abdominal wall. The chest is in the position of maximum inspiration. The patient's face is puffy, pale, with a bluish tint, covered with cold sweat, and expresses a feeling of fear. The patient finds it difficult to talk.
With percussion over the lungs, a box sound is detected, the boundaries of relative cardiac dullness are reduced. The lower borders of the lungs are shifted downwards, the mobility of the pulmonary edges is sharply limited. Above the lungs, against the background of weakened breathing, dry, whistling and buzzing rales are heard during inhalation and especially during exhalation. Breathing is slow, but in some cases it can be rapid. Heart sounds are almost inaudible; there is an accentuation of the second tone over the pulmonary artery. Systolic blood pressure increases, the pulse is weak and accelerated. With prolonged attacks of suffocation, signs of insufficiency and overload of the right chambers of the heart may appear. After an attack, wheezing usually disappears very quickly. The cough intensifies, sputum appears, initially scanty, viscous, and then more liquid, which is easier to expectorate.
The period of reverse development can end quickly, without any visible consequences from the lungs and heart. In some patients, the reverse development of the attack continues for several hours or even days, accompanied by difficulty breathing, malaise, drowsiness, and depression. Sometimes attacks of bronchial asthma turn into an asthmatic state - the most common and dangerous complication of bronchial asthma.
3. Status asthmaticus
bronchial asthma help treatment
Status asthmaticus is a syndrome of acute progressive respiratory failure that develops in bronchial asthma due to airway obstruction when the patient is completely resistant to therapy with bronchodilators - adrenergic drugs and methylxanthines.
There are two clinical forms of status asthmaticus:
b anaphylactic
b allergic-metabolic.
The first is observed relatively rarely and is manifested by rapidly progressing (up to total) bronchial obstruction, mainly as a result of bronchospasm and acute respiratory failure. In practice, this form of status asthmaticus is an anaphylactic shock that develops with sensitization to drugs (aspirin, non-steroidal anti-inflammatory drugs, serums, vaccines, proteolytic enzymes, antibiotics, etc.).
Much more common is the metabolic form of status asthmaticus, which develops gradually (over several days and weeks) against the background of exacerbation of bronchial asthma and progressive bronchial hyperreactivity. In the development of this form of status asthmaticus, bacterial and viral inflammatory processes in the respiratory organs, uncontrolled use of beta-agonists, sedatives and antihistamines, or unjustified reduction in the dose of glucocorticoids play a certain role. Broncho-obstructive syndrome in this form of status is mainly determined by diffuse swelling of the bronchial mucosa and retention of viscous sputum. Spasm of bronchial smooth muscles is not the main cause of its occurrence.
There are three stages in the development of status asthmaticus.
Stage I is characterized by the absence of ventilation disorders (compensation stage). It is caused by severe bronchial obstruction, moderate arterial hypoxemia (PaO2 - 60-70 mm Hg) without hypercapnia (PaO2 - 35-45 mm Hg). Shortness of breath is moderate, there may be acrocyanosis and sweating. Characterized by a sharp decrease in the amount of sputum produced. On auscultation, hard breathing is detected in the lungs; in the lower parts of the lungs it can be weakened, with prolonged exhalation, and dry, scattered rales are heard. Moderate tachycardia is observed. Blood pressure is slightly increased.
Stage II - the stage of increasing ventilation disorders, or the stage of decompensation, is caused by total bronchial obstruction. It is characterized by more pronounced hypoxemia (PaO2 - 50-60 mm Hg) and hypercapnia (PaCO2 - 50-70 mm Hg).
The clinical picture is characterized by the appearance of qualitatively new signs. Patients are conscious; periods of excitement may be followed by periods of apathy. The skin is pale gray, moist, with signs of venous congestion (swelling of the neck veins, puffiness of the face). Shortness of breath is pronounced, breathing is noisy with the participation of auxiliary muscles. There is often a discrepancy between noisy breathing and a decreasing amount of wheezing in the lungs. In the lungs, areas with sharply weakened breathing are identified, up to the appearance of “silent lung” zones, which indicates increasing bronchial obstruction. Tachycardia is noted (heart rate 140 or more per minute), blood pressure is normal or low.
Stage III is the stage of pronounced ventilation disturbances, or the stage of hypercapnic coma. It is characterized by severe arterial hypoxemia (Pa02 - 40-55 mm Hg) and pronounced hypercapnia (PaCO - 80-90 mm Hg or more).
The clinical picture is dominated by neuropsychic disorders: agitation, convulsions, psychosis syndrome, delirium, which are quickly replaced by deep lethargy. The patient loses consciousness. Breathing is shallow and rare. On auscultation, sharply weakened breathing is heard. There are no breath sounds. Heart rhythm disturbances up to paroxysmal with a significant decrease in the pulse wave during inspiration and arterial hypotension are characteristic. Hyperventilation and increased sweating, as well as limited fluid intake due to the severity of the patient's condition, lead to hypovolemia, extracellular dehydration and blood thickening. Complications of status asthmaticus include the development of spontaneous pneumothorax, mediastinal and subcutaneous emphysema, and disseminated intravascular coagulation syndrome.
4. Treatment of bronchial asthma
Mild attacks of bronchial asthma are stopped by oral administration of theophedrine or ephedrine hydrochloride or inhalation of drugs from the group of beta-adrenergic agonists: fenoterol (Berotec, Partusisten) or salabutamol (Ventolin). At the same time, distracting means can be used: cups, mustard plasters, hot foot baths. If there is no effect of ephedrine hydrochloride or epinephrine hydrochloride, it can be administered subcutaneously. If there are contraindications to their use, 10 ml of a 2.4% solution of aminophylline in isotonic sodium chloride solution is administered intravenously. Humidified oxygen is also used.
In case of severe attacks and the presence of resistance to beta-adrenergic drugs, therapy consists of slow intravenous administration of aminophylline at the rate of 4 mg/kg of the patient’s body weight. In addition, they provide humidified oxygen.
In case of resistance to beta-adrenergic drugs and methylxanthines, glucocorticoid drugs are indicated, especially in patients who took these drugs in a maintenance dose. For patients who have not received glucocorticoids, 100-200 mg of hydrocortisone is initially administered, then the administration is repeated every six hours until the attack stops. Steroid-dependent patients are prescribed large doses at the rate of 1 mcg/ml, that is, 4 mg per 1 kg of body weight every 2 hours. Treatment of status asthmaticus is carried out taking into account its form and stage.
In case of anaphylactic form, emergency administration of adrenergic drugs is indicated, up to intravenous injection of adrenaline hydrochloride (in the absence of contraindications). Elimination of medications that cause status asthmaticus is mandatory. Sufficient doses of glucocorticoids are administered intravenously (4-8 mg of hydrocortisone per 1 kg of body weight) at intervals of 3-6 hours. Oxygenation is carried out, and antihistamines are prescribed.
Treatment of the metabolic form of status asthmaticus depends on its stage and includes oxygen, infusion and drug therapy. In stage I, an oxygen-air mixture containing 30-40% oxygen is used. Oxygen is supplied through a nasal cannula at a rate of 4 l/min for no more than 15-20 minutes every hour. Infusion therapy replenishes fluid deficiency and eliminates hemoconcentration, diluting sputum. In the first 1-2 hours, administration of 1 liter of liquid (5% glucose solution, rheopolyglucin, polyglucin) is indicated. The total volume of liquid for the first day is 3-4 liters, for every 500 ml of liquid 10,000 units of heparin are added, then its dose is increased to 20,000 units per day. In the presence of decompensated metabolic acidosis, 200 ml of 2-4% sodium bicarbonate solution is administered intravenously. In case of respiratory failure, the use of sodium bicarbonate solution is limited. Drug therapy is carried out according to the following basic rules:
1. complete refusal to use beta-agonists;
2. use of large doses of glucocorticosteroids;
3. aminophylline or its analogues are used as bronchodilators.
Massive glucocorticosteroid therapy used for status asthmaticus has an anti-inflammatory effect, restores the sensitivity of beta receptors to catecholamines and potentiates their action. Corticosteroids are prescribed intravenously at the rate of 1 mg of hydrocortisone per 1 kg of body weight per 1 hour, i.e. 1 - 1.5 g per day (with a body weight of 60 kg). Prednisolone and dexazone are used in equivalent doses. In stage I, the initial dose of prednisolone is 60-90 mg. Then 30 mg of the drug is administered every 2-3 hours until an effective cough is restored and sputum appears, which indicates the restoration of bronchial patency. At the same time, oral glucocorticoid drugs are prescribed. After removing the patient from asthmatic status, the dose of parenteral glucocorticoids is reduced daily by 25% to the minimum (30-60 mg of prednisolone per day).
Eufillin is used as a bronchodilator, the initial dose of which is 5-6 mg/kg body weight. Subsequently, it is administered fractionally or dropwise at the rate of 0.9 mg/kg per 1 hour until the condition improves. After this, maintenance therapy is prescribed, aminophylline is administered at a dose of 0.9 mg/kg every 6-8 hours. The daily dose of aminophylline should not exceed 1.5-2 g. Cardiac glycosides are not always advisable to use due to the hyperdynamic circulatory regime in asthmatic status.
To thin out phlegm, you can use simple, effective methods: percussion massage of the chest, drinking hot Borjomi (up to 1 liter).
In stage II of status asthmaticus, the same set of measures is used as in stage I. However, higher doses of glucocorticoid drugs are used: 90-120 mg of prednisolone with an interval of 60-90 minutes (or 200-300 mg of hydrocortisone). It is recommended to inhale a helium-oxygen mixture (helium 75%, oxygen - 25%), lavage under careful bronchoscopy under anesthesia, long-term epidural blockade, inhalation anesthesia.
In stage III of status asthmaticus, patients are treated together with a resuscitator. Progressive impairment of pulmonary ventilation with transition to hypercapnic coma, which is not amenable to conservative therapy, is an indication for the use of mechanical ventilation. When it is carried out through an endotracheal tube, the tracheobronchial tract is washed every 20-30 minutes in order to restore their patency. Infusion and drug therapy are carried out according to the rules outlined above. Glucocorticosteroids are administered intravenously (150-300 mg of prednisolone with an interval of 3-5 hours).
It should be noted that drugs used in the treatment of uncomplicated bronchial asthma are not recommended for use in patients with status asthmaticus. These include beta-adrenergic agonists, drugs with a sedative effect (morphine hydrochloride, promedol, seduxen, pipolfen), cholinergic blockers (atropine sulfate, metacin), respiratory analeptics (corazol, cordiamine), mucolytics (acetylcysteine, trypsin), vitamins, antibiotics, sulfonamides , as well as alpha and beta stimulants.
Patients with status asthmaticus must be hospitalized in intensive care wards or the intensive care unit.
5. First aid for an attack of bronchial asthma
|
actions |
justification |
|
|
Call a doctor |
To provide qualified medical care |
|
|
Calm down, unbutton tight clothes, provide access to fresh air |
Psycho-emotional unloading reduces hypoxia |
|
|
Give an inhaler with Berotec (salbutamol), 1 - 2 puffs of metered dose aerosol |
To relieve bronchospasm. |
|
|
Oxygen therapy with 40% humidified oxygen through nasal catheters |
Reduce hypoxia |
|
|
Give a hot alkaline drink, make hot foot and hand baths. |
Reduce bronchospasm and improve sputum discharge. |
|
|
Pulse monitoring, respiratory rate, blood pressure. |
Condition monitoring. |
Prepare for the doctor's arrival:
A system for intravenous infusion, syringes for intravenous, intramuscular and subcutaneous administration of drugs, a tourniquet, an Ambu bag (for possible mechanical ventilation);
Medicines: prednisolone tablets, 2.4% aminophylline solution, prednisolone solution, 0.9% sodium chloride solution, 4% sodium bicarbonate solution.
Conclusion
Young people get sick more often. Dust, various odorous substances, and some food products have an allergenic effect. Bronchial asthma can also occur after an acute respiratory tract infection, acute bronchitis, pneumonia; sometimes it is preceded by sinusitis and rhinitis. Attacks more often develop in damp, cold weather. Neuropsychic factors may be of some importance.
When caring for patients with bronchial asthma, a nurse should not use creams with a strong smell, perfumes, etc., as all this can provoke an attack.
List of used literature
1. Internal diseases: Textbook / F.I. Komarov, V.G. Kukes, A.S. Smetnev et al.; edited by F.I. Komarova, M.: “Medicine”, 1990.
2. Mukhina S.A., Tarnovskaya I.I. General nursing care. Textbook allowance. - M.: Medicine, 1989.
3. Pautkin Yu.F. Elements of general nursing care. Textbook allowance. - M.: Publishing house UDN, 1988.
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Problem 1
Patient problems
Ø Real:
Fever;
Headache;
Sleep disturbance;
Concern about the outcome of the disease.
Ø Potential: risk of asphyxia by vomit.
Ø Priority: fever.
Care plan
Short term goal: reduce the fever over the next five days to low-grade levels.
Long term goal: normalization of temperature at the time of discharge.
| Plan | Motivation |
| Provide the patient with physical and psychological peace | To improve the patient's condition |
| Organize an individual nursing station to care for the patient | |
| Provide plenty of fluid intake (plenty of alkaline drinks for 2 days) | To prevent dehydration |
| Have a conversation with relatives about providing additional nutrition | To compensate for protein loss and increase defenses |
| Measure body temperature every (2 hours) | To monitor the patient's condition |
| Apply physical cooling methods: cover with a sheet or light blanket, use a cold compress or an ice pack | To reduce body temperature |
| Lubricate your lips with Vaseline oil (3 times a day) | To moisturize the lips |
| Provide liquid or semi-liquid food intake 6-7 times a day | For better absorption of food |
| Provide careful care of the patient’s skin and mucous membranes | For the prevention of inflammatory processes of the skin and mucous membranes |
| Provide a change of underwear and bed linen as needed | To ensure patient comfort |
| Observe the appearance and condition of the patient |
Grade: the patient will note a significant improvement in her health, body temperature is 37.4ºC. The goal will be achieved
Problem 2
1) As a result of torsion of the cyst pedicle, the patient developed an acute abdomen.
Information that may lead the nurse to suspect an emergency condition:
sharp, increasing abdominal pain radiating to the groin and thigh;
·nausea, vomiting;
forced position of the patient;
sharp pain on palpation of the abdomen.
ü call a doctor by phone in order to determine further tactics for examining and treating the patient;
ü put the patient on the couch to give a comfortable position;
ü conduct a conversation with the patient in order to convince her of a successful outcome of the disease and create a favorable psychological climate;
ü observe the patient until the doctor arrives in order to monitor the patient’s condition.
Ticket 2
Problem 1
Patient problems
Ø Real:
Limiting physical activity;
Joint pain;
Fever.
Ø Potential:
Risk of bedsores;
Risk of constipation.
Ø Priority: joint pain.
Care plan
Short term goal: reduce pain within 1–2 days.
Long term goal: the patient will be adapted to his condition at the time of discharge.
| Plan | Motivation |
| Provide the patient with physical and mental peace | To improve the patient's condition |
| Provide a forced position for the patient in bed | To reduce pain |
| Carry out a set of patient care measures | To maintain personal hygiene rules |
| Provide a cold compress to the joint area (as prescribed by a doctor) | To reduce pain |
| Conduct a simple complex of exercise therapy and massage (as prescribed by a doctor) | For the prevention of physical inactivity and bedsores |
| Conduct a conversation with relatives about psychological support for the patient, about a gentle regime of physical activity | To facilitate the patient's adaptation to his condition |
| Have a conversation with mother and child about physical inactivity and its consequences | To prevent physical inactivity |
Grade : The patient's condition will improve significantly, and joint pain will decrease. The goal will be achieved.
Problem 2 Needs violated:
· Highlight
· Work
· Communicate
Maintain normal body temperature
Ticket 3
Problem 1
1) Patient problems:
Nose bleed;
Anxiety;
Hemorrhages on the skin.
Ø Priority issue patient: nosebleed.
Care plan
Short term goal: stop nosebleeds within 3 minutes.
Long term goal: relatives will demonstrate knowledge of ways to stop nosebleeds at home.
Grade : nosebleeds will stop. The goal will be achieved.
Problem 2
1. The woman is threatened with termination of pregnancy.
§ cramping pain in the lower abdomen;
§ spotting and spotting.
2. Algorithm of the nurse's actions:
§ call an ambulance for emergency transportation to a gynecological hospital
§ place the pregnant woman on the couch in order to create physical rest, periodically determine pulse and blood pressure, observe the woman until the doctor arrives, in order to monitor the condition
Ticket 4
Problem 1
1) Patient problems:
Prickly heat;
Changes in the skin in the area of natural folds;
Anxiety;
Violation of a comfortable state due to incorrectly selected clothing.
Ø Priority: prickly heat.
3) Care plan:
Short term goal: reduction of skin rashes within 1–2 days.
Long term goal: The skin rash will disappear or significantly decrease within 1 week.
| Plan | Motivation |
| Ensure patient skin hygiene (rubbing, hygienic bath with a solution of string, chamomile, etc.) | To reduce skin rashes |
| Ensure that the child is dressed according to the ambient temperature (do not overwrap) | |
| Ensure the child sleeps hygienically (only in his own crib, not in a stroller, not with his parents) | To reduce skin rashes and prevent recurrence |
| Conduct a conversation with relatives about the correct washing of underwear (wash only with baby soap, rinse twice, iron on both sides) | To reduce skin rashes and prevent recurrence |
| Carry out hygienic cleaning of the room 2 times a day, ventilate 3 times a day for 30 minutes (room temperature 20-22 o C) | To maintain hygiene and enrich the air with oxygen |
Grade : skin rashes will decrease significantly. The goal will be achieved.
Problem 2
1. Satisfaction of needs is impaired:
· be clean maintain temperature
· move
· dress
· undress
· communicate
avoid danger
2. Patient problems:
Ø Real:
- pain;
Temperature increase;
Concern about the outcome of the burn.
Ø Potential:
Risk of developing sepsis;
The risk of developing infectious metastases in organs and tissues;
Risk of developing acute renal failure;
Risk of developing muscle contractures.
Target: pain reduction, temperature reduction, improvement of the patient’s psycho-emotional state, prevention of contractures.
| Plan | Motivation |
| 1. M/s will follow the doctor’s orders and enter: | to normalize the physiological state and prevent complications |
| - 50% analgin IM; - 1% diphenhydramine subcutaneously; - 2% promedol subcutaneously; - antibiotics intramuscularly; - intravenous blood substitutes; - cardiovascular drugs. | to reduce body temperature to relieve pain to treat infection to normalize hemodynamics, water-salt and electrolyte balance, reduce intoxication to normalize hemodynamics |
| 2. M/s will monitor the patient’s condition: blood pressure, pulse, respiratory rate. | To monitor the effectiveness of doctor’s prescriptions and your actions |
| 3. M/s, as prescribed by the doctor, will insert a permanent urinary catheter and provide care for it. | to control urinary function and prevent infectious complications |
| 4. M/s will provide skin care. | for the prevention of infectious complications and bedsores |
| 5. M/s will assist the patient in eating. | to create psychological comfort |
| 6. M/s will provide a boat. | for emptying the bladder and bowels |
Ticket 5
Problem 1
Ø Real problems:
Lack of self-care associated with lower back pain, headaches, chills;
Lack of knowledge about your disease.
Ø Potential problems:
Risk of acquiring an ascending genital infection;
Risk of developing chronic renal failure;
Risk of allergic reaction.
Ø Priority issue: lack of self-care.
Target: The patient will manage the activities of daily living with the help of the nurse.
| 2. Diet. Table No. 5. Do not limit salt. Increase the amount of liquid to 2.5 - 3 liters using cranberry, lingonberry fruit drinks, decoctions of diuretic herbs, min. waters – “Obukhovskaya”, “Slavyanovskaya”. Carrot juice – 100 ml/day, rosehip decoction. Be sure to include fermented milk products containing live cultures. | Complete nutrition that enhances the body's defenses. Increased urine passage, sanitization of the urinary tract, acidification of urine. Restoration of the renal epithelium. Fighting dysbiosis |
| 3. Creating conditions for frequent emptying of the bladder. | Creating comfortable conditions. Prevention of infections |
| 4. Carry out hygiene measures regularly. | Prevention of urogenital infection |
| 5. Provide care for chills: cover warmly, give warm tea (rosehip decoction), warmers to the feet. | Reduce spasm of skin blood vessels, increase heat transfer |
| 6. Explain to the patient the need to comply with the prescribed regimen, diet and treatment. | Adapt to hospital conditions, include in the recovery process |
| 7. Monitoring well-being, T, blood pressure, heart rate, respiratory rate, diuresis, stool. | Control of state dynamics |
Grade: the patient copes with the activities of daily life with the help of m/s Goal achieved.
Problem 2
Patient problems
Ø Real:
Anxiety due to lack of knowledge about the disease;
Weakness;
Ø Potential:
Risk of developing ketoacidotic coma.
Ø Priority issue: lack of knowledge about the disease (diabetes mellitus).
Target: the patient and relatives will demonstrate knowledge about the disease (symptoms of hypo- and hyperglycemic states, methods of their correction and their effectiveness) in a week.
| Plan | Motivation |
| Conduct a conversation with the patient and relatives about the features of the diet and the possibilities of further expanding it for 15 minutes, 2 times a day for 5 days | To address the lack of knowledge about the disease |
| Conduct a conversation with relatives and the patient about the symptoms of hypo- and hyperstates for 3 days, 15 minutes each | To prevent the occurrence of ketoacidotic coma |
| Conduct a conversation with the patient’s relatives about the need for psychological support throughout his life | To create a child’s feeling of being a full-fledged member of society |
| Introduce the patient's family to another family where the child also has diabetes, but is already adapted to the disease | To adapt the family to the child’s illness |
| Select popular literature about the lifestyle of a person with diabetes and introduce it to relatives | |
| Explain to relatives the need to attend the “School for Diabetes Patients” (if there is one) | To expand knowledge about the disease and its treatment |
Grade : the patient and his relatives will have information about the disease, the child’s feeling of fear will disappear.
Ticket 6
Problem 1
1. The patient, against the background of a hypertensive crisis (BP 210/110), developed acute left ventricular failure (pulmonary edema), as evidenced by shortness of breath, noisy bubbling breathing, cough with pink frothy sputum.
2. Algorithm of actions m/s:
b) ensure a sitting position with legs down to reduce the flow of venous blood to the heart, create absolute peace, free from restrictive clothing to improve breathing conditions;
c) clean the oral cavity from foam and mucus in order to remove mechanical obstacles to the passage of air;
d) provide inhalation of humidified oxygen through ethyl alcohol vapor in order to improve oxygenation conditions and prevent foaming,
e) application of venous tourniquets to the limbs for the purpose of blood deposition; (as prescribed by a doctor)
f) place heating pads and mustard plasters on the shin area for distracting purposes;
h) prepare for the doctor’s arrival: antihypertensive drugs, diuretics, cardiac glycosides;
Problem 2
Patient problems
Ø Real:
Frequent urination;
Fever;
Decreased appetite;
Pain when urinating.
Ø Potential:
Risk of violation of the integrity of the skin in the area of the perineal folds.
Ø Priority issue: Frequent urination.
Short term goal: reduce the frequency of urination by the end of the week.
Long term goal: relatives will demonstrate knowledge of risk factors (hypothermia, personal hygiene, nutrition) by the time of discharge.
| Plan | Motivation |
| Provide dietary nutrition (exclude spicy and fatty foods, the amount of liquid should correspond to the doctor’s recommendation) | To normalize water balance |
| Ensure that the patient's underwear and bed linen are changed as they become dirty | To maintain the patient’s personal hygiene rules |
| Ensure regular washing of the patient and lubrication of the perineum 2-3 times a day with Vaseline oil | To maintain perineal hygiene |
| Provide the patient with a urine bag | To empty the bladder |
| Ensure disinfection of the urine bag | |
| Regular airing of the room 3-4 times a day for 30 minutes | |
| Provide psychological support to relatives and the patient | To relieve suffering |
| Ensure that medications are taken as prescribed by the doctor | To treat the patient |
| Have a conversation with relatives about the need to adhere to diet, personal hygiene, and the need to avoid hypothermia | To prevent complications |
Grade : urination frequency decreased. The goal has been achieved.
Ticket 7
Problem 1
1) Patient problems:
Ø Real problems:
Breathing problems due to lack of oxygen;
Lack of self-care due to weakness, shortness of breath;
Difficulty feeding independently due to pain in the tongue and cracks in the corners of the mouth;
Anxiety about your condition.
Ø Potential problems:
Risk of falling;
Risk of cancer recurrence;
Risk of secondary infection.
Ø Priority issue: risk of developing AHF.
2) Purpose:
a) the patient will demonstrate knowledge about the peculiarities of the regime and nutrition during his illness
b) The patient will cope with daily activities with the help of m/s.
Problem 2
1) Patient problems:
Pain and rashes in the mouth,
Lack of appetite,
Fever,
Inability to eat.
Ø Priority issue: pain and rashes in the mouth.
2) Care plan:
Short term goal: pain and rashes in the mouth will decrease within 3 days.
Long term goal:
| Plan | Motivation |
| Ensure the patient's psychological and physical peace | To improve the condition |
| Provide a nutritious diet | For feeding efficiency |
| Provide oral irrigation with furatsilin solution 1:5000 | To reduce rashes and oral pain |
| Ensure that the mouth is rinsed with a 0.5% novocaine solution before each meal. | |
| Ensure infection control of patient care items and utensils | To maintain infection safety |
| Ensure proper daily routine | To improve the condition |
| Treat the oral cavity with trypsin solution 5-6 times a day | To eliminate inflammatory changes in the oral cavity |
| Conduct a conversation with the patient’s relatives about the nature of the prescribed diet and the need to adhere to it | For the treatment and prevention of complications |
Grade: The patient's condition will improve significantly, pain and rashes in the oral cavity will disappear. The goal has been achieved.
| Diet - table No. 1. Meals 6 - 7 times a day, the last meal - 2 hours before bedtime. Serving volume is no more than 200 ml. Eliminate milk, limit easily digestible carbohydrates. | Provide the necessary nutrients without overloading the gastric stump Prevent complications from the resected stomach |
| Oral care - rinsing with an anesthetic solution 15 - 20 minutes before meals and an antiseptic solution after meals Lubricating cracks with brilliant green, Castellani liquid, Iruksol | Reduce pain when eating and prevent the risk of oral infection Reduce infection, speed up healing |
| Conduct a conversation about the causes of anemia, the principles of its treatment, nutrition for its condition | Adapt the patient and include him in the treatment process |
| Hemodynamic monitoring | Monitoring the patient's condition |
Grade: the patient demonstrates knowledge about the peculiarities of the regime and nutrition, and with the help of m/s copes with self-care. The goal has been achieved.
Ticket 8
Problem 1
1. The patient has an attack of bronchial asthma based on a characteristic forced position, expiratory shortness of breath, respiratory rate - 38 per minute, dry wheezing, audible at a distance.
2. Algorithm of actions m/s:
a) call a doctor to provide qualified medical care;
b) unbutton tight clothing and provide access to fresh air;
c) if the patient has a pocket metered dose inhaler, organize taking the drug (1-2 doses) of salbutamol, Berotek, Novodrina, Becotide, Beclomet, etc., to relieve spasm of bronchial smooth muscles (taking into account previous doses, no more than 3 doses an hour and no more than 8 times a day), use a nebulizer;
d) perform oxygen inhalation to improve oxygenation;
e) prepare for the arrival of a doctor to provide emergency assistance:
Bronchodilators: 2.4% aminophylline solution, 0.1% adrenaline solution;
Prednisolone, hydrocortisone, saline. solution;
f) follow the doctor’s orders.
Problem 2
1) Patient problems:
· belching
· nausea
· eating disorder
· decreased appetite
pain in the right hypochondrium
Impaired bowel movements (constipation)
Ø Priority issue: disturbance of a comfortable state (belching, nausea, vomiting).
2)Care plan:
Short term goal: the patient will notice a decrease in belching, nausea, and vomiting by the end of the week.
Long term goal: the state of discomfort will disappear by the time of discharge.
| Plan | Motivation |
| Ensure compliance with the prescribed diet | To improve the condition |
| Ensure compliance with the daily routine | To improve the condition |
| Create a forced position for the patient in case of pain | To reduce pain |
| Teach the patient how to combat nausea and belching | To eliminate belching and nausea |
| Assist the patient with vomiting | To prevent asphyxia |
| Conduct a conversation with the patient and his relatives about the nature of the diet prescribed to him and the need to comply with it | To improve the condition and prevent complications |
| Provide comfortable conditions for the patient in the hospital | To improve the condition |
Grade: The patient's condition will improve significantly, the symptoms of discomfort will pass, the girl will become cheerful and active. The goal has been achieved.
Ticket 9
Problem 1
1) Patient problems:
A patient suffering from coronary artery disease experienced an attack of angina pectoris, as evidenced by compressive pain radiating to the left arm and a feeling of tightness in the chest.
2) Algorithm of actions m/s:
a) call a doctor to provide qualified medical care;
b) sit down and calm the patient in order to relieve nervous tension and create comfort;
c) unbutton tight clothes;)
d) give a nitroglycerin tablet under the tongue in order to reduce myocardial oxygen demand due to peripheral vasodilation under blood pressure control; give an aspirin tablet 0.5 to reduce platelet aggregation;
e) provide access to fresh air to improve oxygenation;
f) place mustard plasters on the heart area for a distracting purpose;
g) ensure monitoring of the patient’s condition (blood pressure, pulse, respiratory rate);
i) follow the doctor’s orders.
Problem 2
Patient problems
Ø Real:
Frequent abdominal pain;
Eating disorders;
Lack of communication.
Ø Potential:
Risk of peptic ulcers and nervous breakdown.
Ø Priority issue: poor nutrition.
Care plan
Short term goal: demonstration by mother of knowledge of dietary nutrition for her daughter.
Long term goal: rational nutrition of the girl, in accordance with the doctor’s recommendations.
Grade: the patient eats properly. The goal has been achieved.
Ticket 10
Problem 1
1) Stomach bleeding. Information that allows the m/s to recognize an emergency condition:
* vomiting “coffee grounds”;
* severe weakness;
* skin is pale, moist;
* decreased blood pressure, tachycardia;
* history of exacerbation of gastric ulcer.
2. Algorithm of the nurse's actions:
a) Call the on-duty general practitioner and surgeon to provide emergency assistance (the call is possible with the help of a third party).
b) Place the patient on his back with his head turned to the side to prevent aspiration of vomit.
c) Place an ice pack on the epigastric area to reduce the intensity of bleeding.
d) Prohibit the patient from moving, talking, or taking anything orally to prevent an increase in bleeding intensity.
e) Observe the patient; periodically determine pulse and blood pressure before the doctor arrives in order to monitor the condition.
f) Prepare hemostatic agents: (5% solution of e-aminocaproic acid, 10 ml of 10% calcium chloride solution, dicinone 12.5%)
Problem 2
1) Patient problems:
Ø Real:
Malnutrition (hunger);
Vomiting, regurgitation.
Ø Potential:
Risk of dystrophy;
Risk of asphyxia during aspiration of vomit.
Ø Priority issue: malnutrition (hunger).
2) Care plan:
Short term goal: organize the child’s correct diet by the end of the week.
Long term goal: demonstration by the mother of knowledge of rational feeding of the child.
| Plan | Motivation |
| Ensure rational feeding of the child; keeping the child's daily routine | To improve the condition |
| Teach mom the rules of feeding | To improve the condition and prevent possible complications |
| Teach the mother the rules of care for vomiting and regurgitation | To prevent asphyxia |
| Observe the appearance and condition of the child | For early diagnosis and timely provision of emergency care in case of complications |
| Weigh the child daily | To control the dynamics of body weight |
| Psychologically prepare the mother to carry out the necessary diagnostic procedures for the child | To improve the condition of mother and child |
Grade : The patient's condition will improve significantly and an increase in body weight will be noted. The goal will be achieved
Ticket 11
Problem 1
1. The patient developed an attack of suffocation.
Information that may lead the nurse to suspect an emergency:
· feeling of lack of air with difficulty exhaling;
· non-productive cough;
· position of the patient with a bend forward and emphasis on the hands;
· an abundance of dry whistling rales audible at a distance.
2. Algorithm of the nurse’s actions:
· M/s will call a doctor to provide qualified medical care.
· M/s will help the patient take a position with a forward bend and emphasis on her hands to improve the functioning of the auxiliary respiratory muscles.
· M/s will use a pocket inhaler with bronchodilators (Asthmopent, Berotec) no more than 1-2 doses per hour to relieve bronchospasm and ease breathing.
· M/s will provide the patient with access to fresh air, oxygen inhalation to enrich the air with oxygen and improve breathing.
· M/s will provide the patient with hot alkaline drinks for better sputum discharge.
· The nurse will place mustard plasters on the chest (if there is no allergy) to improve pulmonary blood flow.
· M/s will provide parenteral administration of bronchodilators (as prescribed by the doctor).
· M/s will provide monitoring of the patient’s condition (pulse, blood pressure, respiratory rate, skin color).
Problem 2
1) Patient problems:
Ø Real:
Moist cough;
Sleep and appetite disorders;
Fever.
Ø Potential: risk of suffocation and shortness of breath.
Ø Priority issue: wet cough.
2) Care plan:
Short term goal: the patient will notice an improvement in sputum production by the end of the week.
Long term goal: the patient and relatives will demonstrate knowledge of the nature of the cough at the time of discharge.
| Plan | Motivation |
| Ensure that you drink plenty of alkaline fluids | |
| Ensure that simple physical procedures are carried out as prescribed by a doctor | To improve sputum discharge |
| Teach the patient cough discipline and provide an individual spittoon | To comply with infection safety regulations |
| Give the patient the prescribed drainage for 10 minutes 3 times a day (time depends on the age of the child) | To improve sputum discharge |
| Ensure frequent ventilation of the room (30 minutes 3-4 times a day). If necessary, oxygen therapy | To prevent suffocation and shortness of breath |
| Ensure that you take medications as prescribed by your doctor | To treat the patient |
| Visually inspect sputum daily | To identify possible pathological changes |
Grade : The patient's condition will improve, coughing attacks will be less frequent. The goal will be achieved.
Ticket 12
Problem 1
1. A patient with lung cancer began to have pulmonary hemorrhage.
Information to suspect pulmonary hemorrhage:
· Scarlet foamy blood is released from the mouth during coughing;
· The patient has tachycardia and decreased blood pressure.
2. Algorithm of the nurse's actions:
· M/s will ensure that an ambulance is immediately called to provide emergency medical assistance.
· M/s will give the patient a semi-sitting position and provide a container for the released blood.
· M/s will provide complete physical, psychological and verbal rest to reassure the patient.
· M/s will apply cold to the chest to reduce bleeding.
· M/s will monitor the patient’s condition (pulse, blood pressure, respiratory rate).
· M/s will prepare hemostatic agents.
· M/s will follow the doctor’s orders.
Problem 2
1) Patient problems:
Eating disorders (decreased appetite);
Violation of skin integrity (cracks in the corners of the mouth);
Impaired bowel movements (tendency to constipation).
Ø Priority issue: eating disorder (appetite).
2)Care plan:
Short term goal: demonstration by the mother of knowledge about proper nutrition of the child by the end of the week.
Long term goal: The patient’s body weight will increase by the time of discharge, and the hemoglobin content in the blood will increase.
| Plan | Motivation |
| Diversify the patient’s menu with foods containing iron (buckwheat, beef, liver, pomegranates, etc.) | To increase hemoglobin content in the blood |
| Feed the patient in small portions 5-6 times a day with warm food | For better absorption of food |
| Aesthetically design your meals | To increase appetite |
| With the doctor’s permission, include delicious tea, sour fruit drinks, and juices in your diet | To increase appetite |
| If possible, involve the patient’s relatives in feeding him | For feeding efficiency |
| Provide walks in the fresh air, physical exercise 30-40 minutes before meals, massage, gymnastics | To increase appetite |
| Have a conversation with relatives about the need for good nutrition | To prevent complications |
| Weigh the patient daily | To control the patient's body weight |
Grade : By the time of discharge, the patient’s body weight will increase and the hemoglobin content in the blood will increase. The goal will be achieved.
Ticket 13
Problem 1
1. Fainting.
Rationale:
· sudden loss of consciousness while taking a blood test from a young man (fright);
· no significant changes in hemodynamics (pulse and blood pressure).
2. Algorithm of medical actions. sisters:
Call a doctor to provide qualified assistance;
· lay with legs elevated to improve blood flow to the brain;
· provide access to fresh air to reduce brain hypoxia;
· provide exposure to ammonia vapor (reflex effect on the cerebral cortex);
· ensure control of respiratory rate, pulse, blood pressure;
· as prescribed by a doctor, administer cordiamine and caffeine in order to improve hemodynamics and stimulate the cerebral cortex.
Problem 2
1) Patient problems:
Impaired bowel movements (constipation);
Eating disorders;
Anxiety.
Ø Priority issue: impaired bowel movement (constipation).
2)Care plan:
Short term goal: the patient will have stool at least once a day (time varies individually).
Long term goal: relatives know methods to prevent constipation.
| Plan | Motivation |
| Provide a sour-milk-vegetable diet (cottage cheese, kefir, vegetable broth, fruit juices and purees) | |
| Ensure sufficient fluid intake (fermented milk products, juices) depending on appetite | To normalize intestinal motility |
| Try to develop a conditioned reflex in the patient to defecate at a certain time of day (for example, in the morning after eating) | For regular bowel movements |
| Provide massage, gymnastics, air baths | To improve the general condition of the patient |
| Provide a cleansing enema and gas tube as prescribed by a doctor | For bowel movements |
| Record daily stool frequency in medical records | To monitor bowel movements |
| Teach relatives about dietary habits for constipation | To prevent constipation |
| Recommend expanding the physical activity regime | To normalize intestinal motility |
Grade : The patient's stool returns to normal (once a day). The goal will be achieved.
Ticket 14
Problem 1
1) Patient problems:
Ø Real:
Itching of the skin;
Decreased appetite;
Bad dream.
Ø Potential:
High risk of infection associated with compromised skin integrity.
Ø Priority issue– itching of the skin.
2) Care plan:
Short term goal: the patient will notice a decrease in itching by the end of the week.
Long term goal: skin itching will significantly decrease or disappear by the time of discharge.
Grade : skin itching has decreased significantly. The goal has been achieved.
Problem 2
1. As a result of non-compliance with the diet, the patient developed an attack of renal colic.
Information that may lead the nurse to suspect an emergency:
Sharp pain in the lumbar region radiating to the groin area;
Frequent painful urination;
Restless behavior;
Pasternatsky's sign is sharply positive on the right.
2. Algorithm of the nurse’s actions:
Call an ambulance to provide emergency assistance (an ambulance can be called with the help of a third party);
Apply a warm heating pad to the lower back to relieve pain;
Use techniques of verbal suggestion and distraction;
Monitoring pulse, respiratory rate, blood pressure;
Observe the patient until the doctor arrives to monitor the general condition.
Ticket 15
Problem 1
1) Patient problems:
Changes in the skin as a result of metabolic disorders and poor nutrition;
The child does not eat properly due to the mother’s ignorance of the rules for feeding babies;
Difficulty in nasal breathing due to nasal discharge.
Ø Priority issue: poor nutrition of the child due to the mother’s lack of knowledge about rational feeding.
2)Purpose: In 1-2 days the mother will tell you about her child’s nutritional habits.
Grade: the mother will identify foods intolerant to the child and organize a hypoallergenic diet for him. The goal has been achieved.
Problem 2
1) Patient problems:
ü cannot take care of himself due to general weakness and the need to remain in bed;
ü thirst and dry mouth, disrupts drinking regime;
ü sleeps poorly;
ü experiences tension, anxiety and worry due to an unclear prognosis of the disease;
ü the risk of aspiration of vomit due to the fact that the patient is in bed in a supine position and exhaustion.
Ø Priority issue patient: cannot care for himself due to general weakness and the need to remain in bed.
2) Target: The patient will cope with activities of daily living with the help of a nurse until the condition improves.
| Plan | Motivation |
| 1. M/s will provide physical and mental peace, bed comfort | |
| 2. M/s will monitor the patient's compliance with bed rest. Recommends an elevated position in bed or a side position | To improve overall well-being and increase diuresis |
| 3. M/s will provide complete, fractional, easily digestible nutrition, with limited salt, liquid and animal protein in accordance with diet No. 7 | To increase the body's defenses, reduce the load on the urinary system |
| 4. M/s will provide personal care products (glass, vessel, duck), as well as means of emergency communication with the post | To create a comfortable state |
| 5. The nurse will provide hygienic care for the patient (partial sanitary treatment, washing, changing bed and underwear) | To prevent secondary infection |
| 6. M/s will help the patient organize leisure time | Improvement of mood, activation of the patient |
| 7. M/s will monitor hemodynamic indicators, physiological functions, evaluate their quantity, color and smell of urine | For early diagnosis and timely provision of emergency care in case of complications. To monitor renal excretory function |
Grade: the patient copes with daily activities with the help of the nurse, notes a significant improvement in well-being, and demonstrates knowledge of compliance with the regime and diet. The goal has been achieved.
Ticket 16
Problem 1
1) Patient problems:
Decreased appetite;
Irrational feeding due to the mother’s lack of knowledge about proper nutrition of the child;
Anxious dream.
Ø Priority issue: irrational feeding due to the mother’s lack of knowledge about the proper nutrition of the child.
2) Purpose: the mother will freely navigate issues of rational feeding and organize proper nutrition for the child.
Grade: the mother is fluent in the issues of rational nutrition of the child, demonstrates knowledge about the importance of iron in the treatment of anemia. The goal has been achieved.
Problem 2
1) Patient's problems:
ü cannot care for himself due to the need to remain in bed and general weakness;
ü cannot sleep in a horizontal position due to ascites and increased shortness of breath;
ü the patient cannot independently cope with the stress caused by the disease;
ü complains of lack of appetite;
ü risk of violation of skin integrity (trophic ulcers, bedsores, diaper rash);
ü risk of developing atonic constipation.
Ø Priority issue patient: cannot care for himself due to the need to remain in bed and general weakness.
2)Purpose: The patient will cope with daily activities with the help of the nurse until her condition improves.
| Plan | Motivation |
| 1. M/s will ensure compliance with bed rest | To improve renal blood flow and increase diuresis |
| 2. M/s will conduct a conversation with the patient and his relatives about the need to follow a salt-free diet, control daily diuresis, count the pulse, and constantly take medications. | To prevent deterioration of the patient’s condition and the occurrence of complications; reducing anxiety levels |
| 3. The nurse will ensure that the client has an elevated position in bed, using a functional bed and foot rests whenever possible; will provide bed comfort | Easier breathing and better sleep |
| 4. M/s will provide access to fresh air by ventilating the room for 20 minutes 3 times a day | To enrich the air with oxygen |
| 5. The nurse will provide feeding to the patient, personal hygiene measures in the ward, the ability to carry out physiological functions in bed, and the patient’s leisure time. | Satisfying the basic needs of the body |
| 6. M/s will ensure that the patient is weighed once every 3 days | To control the reduction of fluid retention in the body |
| 7. M/s will provide calculation of water balance | To control negative water balance |
| 8. M/s will observe the patient’s appearance, pulse, blood pressure | To monitor the patient’s condition and possible deterioration of the condition |
Grade: the patient notes a decrease in anxiety levels, her mood has improved somewhat, she knows what kind of life should be led with this disease. The goal has been achieved.
Ticket 17
Problem 1
1) Patient problems:
Inability to feed the child due to decreased appetite and insufficient milk supply from the mother;
Anxious sleep;
Insufficient weight and height gain;
Violation of physiological functions due to insufficient nutrition.
Ø Priority issue: inability to feed the child due to decreased appetite and insufficient milk supply from the mother
2)Purpose: normalize nutrition by the end of 3 weeks.
| Plan | Motivation |
| 1. M/s will conduct control feeding | to determine the dose of sucked milk, determine weight deficiency and resolve the issue of hypogalactia |
| 2. M/s will determine the age-specific daily and single dose of milk, supplementary feeding dose | to identify nutritional deficiencies and correct them |
| 3. For the first time (1 week), the m/s will recommend fasting nutrition (feeding in fractional doses, reducing the amount of food, reducing the time between feedings) | to determine food tolerance |
| 4. As prescribed by the doctor, the m/s will tell the mother about the child’s water regime | to replenish the missing amount of nutrition |
| 5. As prescribed by the doctor, the m/s will have a conversation with the mother about prescribing corrective supplements in the child’s diet | In order to eliminate the deficiency of proteins, fats, carbohydrates |
| 6. M/s will monitor the child’s weight daily | To decide on the adequacy of dietary therapy |
Grade: the mother is fluent in the issues of rational nutrition of the child, demonstrates knowledge about the diet and nutrition correction. When conducting anthropometry, positive dynamics in weight gain and height are observed.
The student demonstrates to the mother the correctly chosen method of teaching additional methods of warming the baby.
Problem 2
1) Patient problems:
ü cannot take food and liquid, sleep or rest due to severe heartburn;
ü does not know about the dangers of taking soda in large quantities for heartburn;
ü decreased appetite.
Ø Priority issue: cannot eat, drink, sleep or rest due to severe heartburn.
2)Purpose: the patient will not suffer from heartburn during his hospital stay.
Ticket 18
Problem 1
1) Patient problems:
Ø Real problems:
Lack of self-care due to weakness, dizziness;
Lack of information about the disease.
Ø Potential problems:
1. The risk of trophic changes in the skin due to its dryness and decreased immunity.
2. Risk of developing heart failure.
Ø Priority issue: lack of information about the disease.
2)Purpose: By the end of the conversation with the m/s, the patient will understand how to eat properly and what regimen to follow for this disease.
| Plan | Motivation |
| Reduce the load on the myocardium, reduce the risk of injury |
| Replenish iron deficiency, get enough protein |
| Reduce skin dryness, reduce the risk of injury |
| Include in the treatment process and ensure reliable test results |
| Control of state dynamics |
Grade: the student clearly explains the principles of diet therapy for her illness.
Problem 2
1. Acute stomach. Suspicion of acute appendicitis.
2. Algorithm of actions m/s:
Ticket 19
Problem 1
1) Patient problems:
Ø Real problems:
Lack of self-care due to severe weakness, fever;
Inability to feed independently due to pain in the mouth and throat;
Lack of communication due to severe weakness, sore throat;
Lack of information about the disease, examination and treatment.
Ø Potential problems:
Risk of falling;
Risk of developing acute heart failure;
Risk of developing a temperature crisis;
Risk of secondary infection;
Risk of developing bedsores;
Risk of developing massive bleeding and hemorrhage;
Risk of thrombosis of the subclavicular catheter.
Ø Priority issue: lack of self-care as a consequence of severe weakness and fever.
2)Purpose: the patient will cope with daily activities with the help of m/s.
| Plan | Motivation |
| Mode - bed Position in bed - with raised headboard Boxed ward (aseptic block). | Prevention of acute heart failure Prevention of secondary infection |
| Diet: parenteral nutrition as prescribed by a doctor. The infusion rate is determined by the doctor. | Impossibility of enteral nutrition, need to obtain nutrients |
| Skin care: change body positions every hour, with simultaneous treatment of the skin with an antiseptic solution and a light massage, change bed and underwear when soiled (sterile underwear) Anti-decubitus pads under the sacrum, heels, elbows | Prevention of bedsores and infections |
| Oral care: rinsing the mouth with antiseptic solutions (furacilin, chlorophyllipt, decoction of St. John's wort, yarrow), novocaine every 2–3 hours. Treating teeth with cotton swabs and 2% soda solution | Reduce inflammation and pain in the mouth. Prevent the spread of infection. Provide a feeling of comfort. |
| Care for chills: cover warmly, use heating pads in bed. Do not apply to the body! | Expand skin blood vessels and increase heat transfer. Prevent increased hemorrhages. |
Prevention of congestive pneumonia:
| Avoid congestion in the lower parts of the lungs. Improve pulmonary ventilation. Destroy pathogenic microorganisms. |
| Caring for the subclavian catheter. Skin care around the catheter is according to the standard. For a heparin lock - heparin is 2 times less than the standard. | Prevention of infection. Prevention of bleeding. |
| Conduct a conversation with the patient, taking into account the severity of her condition, in verbal and non-verbal ways, informally on a friendly level. Explain the need for bed rest, prescribed treatment, examination, and the benefits of parenteral nutrition. | Adapt to hospital conditions. Fill the information gap. Get reliable survey results. Include in the treatment process. |
| * If there is no aseptic block, the patient is placed in a separate room. Cleaning with disinfectants means every 4 hours with quartz chamber. Staff put on a sterile gown upon entering the room. Ventilation only with air conditioning | Prevention of infection |
| Monitoring hemodynamics, temperature, skin condition, diuresis, stool | Condition assessment |
Grade: The patient copes with daily activities with the help of m/s.
Problem 2
1. Frostbite of the IV and V fingers of the right hand, I-II degree.
2. Algorithm of actions m/s:
Ticket 20
Problem 1
1) Patient problems:
* high risk of falling due to dizziness;
* does not understand the need for bed rest;
* risk of fainting;
* risk of acute heart pain.
Ø Priority issue: high risk of falling.
2) Target: there will be no fall.
Related information.
Standard answers
Ticket 21
Given: Patient N., 37 years old.
Ds: Bronchial asthma of moderate severity.
Assigned to: Ultraviolet irradiation.
Questions:
1)
2) What formula should be used to calculate the individual biodose before administering therapy to a given patient?
3) What type of irradiation should be recommended for this pathology?
4)
5)
6) What is the sequence of actions for the nurse to determine the biodose if the patient is undergoing the first procedure? (Algorithm of actions).
Solution:
1)
2) X = t (n – m + 1)
3) Fractional, skin
4) It is impossible to accurately dose the medicinal substance for the procedure. Medicines can cause the opposite effect, i.e. harm.
5)
Patients with mild to moderate bronchial asthma, in the absence of exacerbation and severe pulmonary and heart failure, are prescribed barotherapy; start with low pressure corresponding to an altitude of 2000-2500 m, and then 3500 m above sea level; the duration of procedures performed daily or every other day is 1 hour; There are 20 procedures per course of treatment.
6)Algorithm for the nurse to determine the individual biodose:
1. Familiarization with the doctor’s prescription.
2. Selecting a device.
3. Selection of irradiation site.
4. Preparation of the device.
5. Giving the patient the desired position.
6. Inspection of the irradiation site.
7. Wearing sunglasses.
8. Applying the dosimeter to the irradiation area.
9. Fixing it with ribbons to the patient’s body.
10. Covering the surrounding skin with a sheet.
11. Install the device at a distance of 50 cm.
12. Opening the first hole for a specified time.
13. Alternately opening and irradiating subsequent holes for the same time.
14. Removing the dosimeter, stopping irradiation and warning the patient about a visit in 24 hours.
15. Inspection of the irradiation site and counting of erythema stripes.
16. Calculation or recalculation of biodose using the formula.
Standard answers
Ticket 17
Given: Sick.
Ds: Rheumatoid arthritis of the feet.
Assigned to: Paraffin applications, using the method of immersing baths on both feet, t +55 0 C, duration 40 minutes. Course of 15 procedures.
Questions:
1) What emergency situation is possible during this therapy?
2) What is the peculiarity of the release method for this procedure?
3) What other electrotherapeutic segmental-reflex technique can be recommended for a patient with this diagnosis?
4) What sensations should the patient experience in the bath?
5) The sequence of actions of the nurse during this procedure (Algorithm of actions).
Solution:
1) Increased blood pressure: give the patient a rest until normal pressure is restored; if blood pressure does not decrease, call a doctor after a third party.
Dizziness and headache: give the patient a rest after the procedure, give ammonia if necessary, call a doctor immediately.
2) baths
3) Massage, DDT, electrophoresis of non-steroidal anti-inflammatory drugs, phonophoresis of hydrocortisone, dimexide applications and spa treatment are of auxiliary value and are used only for mild arthritis.
4) Pleasant warmth
5) Action algorithm:
1. read the doctor’s prescription.
2. lead the patient into the cabin.
3. help the patient undress.
4. help the patient achieve a comfortable body position.
5. wipe the affected area with a cotton swab and alcohol.
6. measure the t of paraffin.
7. Apply paraffin to the skin.
8. Cover with compress paper.
9. wrap in a blanket.
10. make a note on the physical clock about the duration of the procedure.
11. At the end of the procedure, remove the splint.
12. wipe the treated surface with a damp cloth.
13. Make a note in the accounting and reporting documentation.
14. Invite the patient for subsequent procedures.
Standard answers
Ticket 21
Given: Patient V., 49 years old.
Ds: Chronic bronchitis.
Assigned to: Inhalation therapy.
Questions:
1) What method should be used to carry out this procedure?
2) Is it possible to use this therapy at home? What medicinal substances or herbal infusions, vegetable oils can be recommended?
3) What devices for inhalation therapy are currently used at home? What is their feature?
4) What other physical procedures can inhalation therapy be combined with for this pathology?
5) What is the sequence of actions of the nurse when performing this procedure?
Solution:
1) For inhalation, the patient is seated in a chair for free breathing in a comfortable position and through a respiratory mask, fixed together with the generator on the table, for 5-10 minutes. They give you an aerosol of the desired composition to inhale.
2)
3) Compression inhaler CN-231, Machold inhaler with essential oils, inhaler
4)
Electrosleep, DDT, method No. 124: Inhalation of electric aerosols, inductothermy with a slight sensation of warmth in the area of the adrenal glands, while an inductor-cable in the form of a spiral of 2-3 turns is applied at the level of T 10 - L 4, DVM on the area of the lungs, NMP, UHF at bitemporal technique, phonophoresis, dry carbon dioxide baths. The use of electroacupuncture and electropuncture, as well as the cauterization method (ju), in particular with wormwood cigarettes, is of particular importance.
Algorithm of a nurse's actions when conducting inhalation therapy.
1. Familiarize yourself with the doctor’s prescription (type of inhalation, composition of the inhalation mixture, its quantity, duration of the procedure);
Preparing for the patient procedure:
1. Instruct the patient about behavior and breathing during the procedure;
2. Fill the inhaler container with medicine;
3. Seat the patient at the inhaler;
4. Make sure it is ready;
Carrying out the procedure:
1. Turn on the inhaler.
2. Make sure the patient’s behavior and breathing are correct.
3. Monitor the patient.
4. In case of allergic reactions (cough, choking), stop the procedure and call a doctor.
End of the procedure:
1. Turn off the inhaler.
2. Remove the tip and sterilize.
3. Invite the patient to rest for 10-15 minutes.
4. Warn the patient about unwanted smoking, loud talking and cooling for 2 hours.
Standard answers
Ticket 20
Given: Patient V., 49 years old.
Ds: Acute bronchitis.
Assigned to: Inhalation therapy (alkaline inhalations).
Questions:
1) Select a device to carry out the procedure for this patient, if there are devices “AIR-2” and “Vulcan”; Why?
2) What alkaline solutions can be used?
3) Is it possible to use this therapy at home? What medicinal substances or herbal infusions, vegetable oils can be recommended?
4) What devices for inhalation therapy are currently used at home? What is their feature?
5) What method should be used to perform this procedure?
Solution:
1) It is better to use the Vulcan device for acute bronchitis, because This is an ultrasonic inhaler, the penetration depth and speed of aerosol particles on this device are greater than on the AIR-2 device.
2) For inhalation, you can use an alkaline solution of 1-3% baking soda solution, sea water, salt-alkaline mineral waters.
3) The procedure is possible at home. Eucalyptus, rose, lavender, coriander, sage, anise
4 ) CN-231 compression inhaler, Machold inhaler with essential oils, inhaler
UN-231 ultrasonic, easy to use.
5 ) For individual inhalation, the patient is seated in a chair in a comfortable position for free breathing and through a respiratory mask, attached together with the generator to the back of the chair or on the table, for 5-10 minutes. Allow the patient to inhale an electrical aerosol of the desired composition.
TONSILS
Standard answers
Ticket 17
Given: Patient S., 44 years old.
Ds: Chronic tonsillitis.
Assigned to: Ultrasound therapy on the tonsil area.
Questions:
1) What tests should this patient undergo before prescribing ultrasound therapy?
2) What method will be used for this procedure and what is its intensity?
3) Write down the settings on the front panel of the machine that you need to set before starting the procedure.
4) What other physiotherapy procedures can phonophoresis be combined with for this pathology?
5) What is the sequence of actions of the nurse when performing ultrasound therapy.
Solution:
1) Before prescribing an ultrasound, it is necessary to do a blood test to determine platelets.
2) The procedure technique is stable for the tonsil area, two fields for the submandibular area, intensity – 0.2-0.4 W/cm 2, continuous mode for 5 minutes. on each side, on ointment: analgin 50%
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1) UV, UHF, microwave, cryotherapy, inhalation, the use of helium-neon laser with cryotherapy, intralacunar irradiation, Laser physiotherapy and laser puncture for acute and chronic tonsillitis can be carried out using a pulsed semiconductor laser on gallium arsenide with a wavelength of 0.89 microns, power density at the end of the emitter up to 7 mW.
4) Continuous mode, intensity 0.2 - 0.4 W/cm2. Duration 3 -5 minutes.
5) Algorithm of the nurse’s actions when conducting ultrasound therapy:
1. Read the doctor’s prescription.
2. Invite the patient into the cabin.
Preparing the patient for the procedure:
1. Instructing the patient about sensations and behavior during the procedure.
2. Exposing the area of the procedure.
3. Laying (seating) the patient.
4. Application of contact medium.
Preparation of the device:
1. Selection and activation of the desired emitter.
2. Consecutive switching on of the device in the specified mode and intensity.
3. Checking the operation of the emitter.
4. Inclusion of procedure hours.
Carrying out the procedure:
1. Labile technique with moving the emitter or stable technique with fixation of the emitter.
End of the procedure:
1. Turn off the device.
2. Remove the contact medium from the skin.
3. Make a note on the procedure card about the procedure.
Standard answers
Ticket 20
Given: Patient M., 37 years old.
Ds: Chronic bronchitis.
Assigned to: General ultraviolet irradiation (starting from 1/4 biodose), every other day. Course of 15 procedures.
Questions:
1) What emergency situation is possible during this therapy?
2) What other segmental reflex techniques can be recommended for the treatment of this disease?
3) What other local irradiation techniques can be recommended for this pathology?
4) What method of irradiation should be recommended for this pathology?
5) What are the disadvantages of this procedure?
6) What method should be used to carry out this procedure?
Solution:
1) Insufficient eye protection for patients and staff can lead to the development of acute conjunctivitis due to burns of the conjunctiva and cornea of the eye by UV rays. Severe violations of safety precautions may result in skin burns.
Electrical injuries (immediately stop the manipulation, turn off the switch, pull the wires away from the patient with a dry rope, pull him away without touching the patient’s body /only by the clothes/, call a doctor through a third party, psychological help, give valerian extract, give tea, cover warmly; in case of severe degrees: mechanical ventilation + closed cardiac massage + ammonia. If this does not help, then the patient is taken to intensive care and hospitalized.
Cardiac arrest: first aid: call a doctor first, cardiac massage + mechanical ventilation, medication (Norepinephrine IV + 2 - 5 ml of 5% calcium chloride, additionally administered 8% sodium bicarbonate 1.5 - 2 ml per 1 kg of body weight .
Burns: Calm the patient, call a doctor if necessary (depending on the degree of the burn), treat the tank with solution, apply a dry or lubricated bandage. 
2)a) SMT – variable mode. Electrodes paravertebral, in the interscapular region. 3-4 RR for 5 minutes, modulation frequency – 70-80 Hz, depth – 50%. Course – 12 procedures, daily.
b) Ca 2+ electrophoresis using the “collar” method (according to A.E. Shcherbak), daily. Course of 10 procedures. The “collar” is moistened with a CaCl 2 solution.
A collar-shaped electrode S = 600-800 cm 2 is placed on the back in the area of the shoulder girdle and in front in the subclavian region, the second rectangular electrode S = 300-400 cm 2 is in the lumbosacral region.
V) Electrophoresis of Ca 2+ using the “general electrophoresis according to Vermeule” method: a pad with a 2-5% CaCl 2 solution is placed in the interscapular area and connected to one of the electrodes. And the other two double electrodes are placed on the area of the calf muscles and connected to the other pole. J = 0.05 mA
3) Electrosleep, DDT, method No. 124: Inhalation of electric aerosols, inductothermy with a slight sensation of warmth in the area of the adrenal glands, while an inductor-cable in the form of a spiral of 2-3 turns is applied at the level of T 10 - L 4, DVM on the area of the lungs, NMP, UHF at bitemporal technique, phonophoresis, dry carbon dioxide baths. The use of electroacupuncture and electropuncture, as well as the cauterization method (ju), in particular with wormwood cigarettes, is of particular importance.
4) Patients in the phase of fading exacerbation and remission of bronchial asthma are successfully prescribed therapeutic exercises with an emphasis on individually selected breathing exercises, exercises in the pool (water temperature 37-38 ° C), as well as various types of therapeutic massage.
5) If used incorrectly, dosage and safety rules are violated, ultraviolet irradiation can have a damaging effect, both local and general. Therefore, when carrying out phototherapeutic, and especially ultraviolet, procedures, it is necessary to strictly and accurately follow the doctor’s instructions.
When dosing and carrying out ultraviolet irradiation, it is strictly necessary! An individual approach to the patient, due to the fact that the light sensitivity of different people, different areas of the skin and even the perception of medical procedures by the same people at different times of the year and certain periods of life differ significantly, have individual fluctuations.
UVR can have a damaging effect if the dosage is exceeded, as well as with increased and pathological sensitivity to UV rays.
Insufficient eye protection for patients and staff can lead to the development of acute conjunctivitis due to burns of the conjunctiva and cornea of the eye by UV rays.
Some diseases can be aggravated under the influence of ultraviolet radiation.
6) For bronchitis, two fields are irradiated. The first field - the anterior surface of the neck and the area of the upper half of the sternum - is irradiated with the patient positioned on his back, a pillow is placed under the back, and the head is slightly tilted back. Radiation dose – 3 biodoses. The second field - the back surface of the neck and the upper half of the interscapular region - is irradiated with the patient lying on his stomach. A pillow is placed under the chest, the forehead rests on folded hands. Radiation dose – 4 biodoses. Irradiation is carried out after 1-2 days. The course of treatment is 5-6 procedures.
Standard answers
Ticket 1
Given: Patient S., 25 years old.
Ds: ARVI (dry cough, sore throat, runny nose, weakness, T 0 37.2)
Assigned to: Ural Federal District.
Questions:
1) What emergency situation is possible during this therapy?
2) Is it possible to appoint a UFO?
3) By what method and with what doses should this procedure be administered?
4) What scheme of general ultraviolet irradiation should this procedure be carried out?
5) What are the disadvantages of this procedure?
6) What is the sequence of actions of the nurse when conducting ultraviolet radiation?
Solution:
1) Electrical injuries (immediately stop the manipulation, turn off the switch, pull the wires away from the patient with a dry rope, pull him away without touching the patient’s body /only by the clothes/, call a doctor through a third party, psychological help, give valerian extract, give tea, cover warmly; in case of severe degrees: mechanical ventilation + closed cardiac massage + ammonia. If this does not help, then the patient is taken to intensive care and hospitalized.
Cardiac arrest: first aid: call a doctor first, cardiac massage + mechanical ventilation, medication (Norepinephrine IV + 2 - 5 ml of 5% calcium chloride, additionally administered 8% sodium bicarbonate 1.5 - 2 ml per 1 kg of body weight .
Burns: Calm the patient, call a doctor if necessary (depending on the degree of the burn), treat the tank with solution, apply a dry or lubricated bandage.
2) Irradiation with ultraviolet rays can be prescribed short-wave or integral spectrum to the area of the tonsils, nasal mucosa and pharyngeal mucosa.
3)a) Impact on the tonsils: the patient is sitting on a chair (preferably a screw chair), the mouth should be at the level of the tube. A removable tube with an oblique cut is installed on the irradiator and it is inserted deep into the mouth, directing the rays to one or the other tonsil. The patient holds the protruding tongue with a gauze pad and monitors through the mirror so that the root of the tongue does not interfere with the procedure. Only half of the back of the throat should be irradiated each time (to avoid repeated irradiation of the same areas). The irradiation dose is 1-5 biodoses (1-5 minutes or more) for the integral spectrum and 1-2 biodoses (3-6 minutes) for irradiation with short-wave rays. Irradiation is carried out daily or every other day, 3-5 irradiations per course of treatment.
b) Impact on the mucous membrane of the pharynx: to irradiate the posterior wall of the pharynx, the rays are directed at it through a removable tube with a wide opening. Dose – 2 biodoses.
V) Impact on the nasal mucosa: the patient is seated on a chair facing the lamp, slightly tilting his head back. The nasal mucosa is irradiated through a tube with a small hole, inserting it shallowly into each nostril. Radiation dose – 2-3 biodoses. Irradiate daily or every other day. The course of treatment is 2-5 irradiations.
4) Accelerated scheme.
Number of biodoses Distance from lamp, cm
5) It is impossible to accurately dose the medicinal substance for the procedure. Medicines can cause the opposite effect, i.e. harm
Action algorithm
1. Familiarize yourself with the physiotherapist’s prescription.
4. Examine the skin surface at the site where the electrodes are applied.
5. Ask the patient to remove metal objects from the affected area.
6. Install the capacitor plates as prescribed by the doctor.
7. Warn the patient that during the procedure he will feel slight warmth in the treatment area.
8. Check the grounding of the device.
9. Turn the voltage regulator to the first position.
10.Press the control key.
11.Turn the adjustment knob to set the indicator arrow in the red sector area.
12.After 3 minutes. Turn the power control knob and set the intensity of exposure prescribed by the doctor.
13.Check the presence of the electric field of the indicator.
14. Mark the time of the procedure on the physical clock.
15.At the end of the procedure, the power control knob is moved to the extreme left position.
16.Move the voltage knob to the “off” position.
17.Remove the capacitor plates from the patient.
18.Wipe the plates with 70 alcohol.
19. Make a note in the accounting and reporting documentation.
20. Invite the patient to subsequent procedures.
3) The operating factor is an alternating electric field of ultra-high frequency, which has the ability to penetrate and spread to great depths in body tissues.
5)
6) Electrical injuries (immediately stop the manipulation, turn off the switch, pull the wires away from the patient with a dry rope, pull him away without touching the patient’s body /only by the clothes/, call a doctor through a third party, psychological help, give valerian extract, give tea, cover warmly; in case of severe degrees: mechanical ventilation + closed cardiac massage + ammonia. If this does not help, then the patient is taken to intensive care and hospitalized.
Option No. 11
Given: Patient, 30 years old.
Ds: Neck furuncle in the infiltration stage.
Assigned to: Microwave therapy.
Questions: 1) How to position the electrodes correctly?
2) What is the sequence of actions when carrying out
procedures on the Luch-2 device?
3) Is it possible to use this therapy at home?
6) What emergency situation is possible during this therapy?
Solution:
1) Emitters, in size and shape corresponding to the size and outline of the area to be affected, are installed near the area of influence, a gap of 5-7 cm. Intensity of exposure - with a feeling of weak or moderate heat, duration 10-20 minutes, procedures are carried out daily, course of 10 procedures.
2) Action algorithm:
1. Read the doctor’s prescription.
2. Invite the patient into the cabin for a physical procedure.
3. Help the patient find a comfortable position.
4. Ask the patient to free the irradiated area from clothing and metal objects.
5. Install the desired emitter.
6. Warn the patient that during the procedure he will feel slight warmth in the treatment area.
7. Check grounding.
8. Connect the power cord to the connector available on the device.
9. Plug in.
10.Move the power control knob to the extreme left position.
11.Press the power button.
12. Start a physiotherapy timer.
13.Set on it the procedure time specified in the appointment.
14.Slowly begin to turn the power control knob to the right.
15. Focus on the patient’s sensations.
16.The emitter is installed above the patient’s body with an air gap of 3-5 cm.
17. At the end of the procedure, when the timer sounds, press the power button.
18.After the procedure, the emitter is wiped with a solution of 70 alcohol.
19. Invite the patient to subsequent procedures.
20. Make a note about the procedure performed in the physical card and journal.
3) the procedure is possible at home.
1. Not all medicinal substances can be used for its implementation,
2. It is impossible to accurately dose the medicinal substance,
3.A large concentration of drugs is not created. substances in the depot,
4. Sometimes there is an opposite effect of the drug and direct current.
5) In the body, the current propagates along the path of least ohmic resistance (through intercellular spaces, blood and lymphatic vessels, membranes of nerve trunks, muscles). Through intact skin, the current passes mainly through the excretory ducts of the sweat glands. In a living organism, the electrical conductivity of tissue is not a constant value. Tissues that are in a state of edema, hyperemia, saturated with tissue fluid or inflammatory exudate have higher electrical conductivity than healthy ones.
Electrical conductivity depends on the state of the nervous and hormonal systems.
The passage of current through biological tissues is accompanied by physicochemical changes that underlie the primary effect of galvanization on the body. The current is supplied to the patient’s body through contact-applied electrodes. During galvanization, the correct location of the electrodes “Cathode - Anode” is more important. So, when galvanizing the head, when located in the forehead area, the Anode reduces the excitability of the brain, and when located in the Cathode area, it increases the excitability.
6) Electrical injuries (immediately stop the manipulation, turn off the switch, pull the wires away from the patient with a dry rope, pull him away without touching the patient’s body /only by the clothes/, call a doctor through a third party, psychological help, give valerian extract, give tea, cover warmly; in severe cases: mechanical ventilation + closed cardiac massage + ammonia. If this does not help, then the patient is taken to intensive care and hospitalized.
Cardiac arrest: first aid: call a doctor first, cardiac massage + mechanical ventilation, medication (Norepinephrine IV + 2 - 5 ml of 5% calcium chloride, additionally administered 8% sodium bicarbonate 1.5 - 2 ml per 1 kg of body weight .
Burns: Calm the patient, call a doctor if necessary (depending on the degree of the burn), treat the tank with solution, apply a dry or lubricated bandage.
Option No. 12
Given: Patient, 30 years old.
Ds: boil of the right forearm.
Assigned to: UHF therapy.
Questions: 1) By what method, with what capacitor plates can this method be carried out?
2) What is the dose of UHF therapy?
3) In what order should this procedure be carried out? (algorithm of action of the nurse).
4) What are the disadvantages of this procedure,
5) How is the supplied current applied to the patient's body?
6) What emergency situation is possible during this therapy?
Measuring body temperature in the armpit
1. Inspect the armpit, wipe the skin with a napkin
Dry axillary area.
2. Remove the thermometer from the glass with the disinfectant solution. After
disinfection, the thermometer should be rinsed with running water and
wipe dry thoroughly.
3. Shake the thermometer so that the mercury column drops to below 35 0C.
4. Place the thermometer in the armpit so that the mercury reservoir is in contact with the patient’s body on all sides; Invite the patient to press his shoulder tightly to his chest (if necessary, the medical professional should help the patient hold his arm).
5. Remove the thermometer after 10 minutes and remember the readings.
6. Shake the thermometer until the mercury drops below 35 0C.
7. Place the thermometer in a container with a disinfectant solution.
8. Record the thermometer readings on the temperature sheet.
Blood pressure measurement
Execution Sequence
2. Explain the essence and course of upcoming actions.
3. Obtain the patient's consent to the procedure.
4. Warn the patient about the upcoming procedure 15 minutes before it
5. Prepare the necessary equipment.
6. Wash and dry your hands.
7. Give the patient a comfortable position, sitting or lying down.
8. Place the patient’s arm in an extended position with the palm up, placing a cushion under the elbow.
9. Place the tonometer cuff on the patient’s bare shoulder 2-3 cm above the elbow bend so that 1 finger passes between them. The cuff tubes face down.
10. Connect the pressure gauge to the cuff, securing it to the cuff.
11. Check the position of the pressure gauge needle relative to the “0” scale mark.
12. Determine the pulsation in the ulnar fossa with your fingers and apply a phonendoscope to this place.
13. Close the bulb valve, pump air into the cuff until the pulsation in the ulnar artery disappears +20-30 mm Hg. Art. (slightly higher than expected blood pressure).
14. Open the valve, slowly release air, listening to the tones, and monitor the pressure gauge readings.
15.Note the number of appearance of the first beat of the pulse wave, corresponding to systolic blood pressure.
16.Slowly release air from the cuff.
17. “Note” the disappearance of tones, which corresponds to diastolic blood pressure.
18.Release all the air from the cuff.
19.Repeat the procedure after 5 minutes.
20.Remove the cuff.
21.Place the pressure gauge in the case.
22. Disinfect the head of the phonendoscope using the double
wiping with 70% ethyl alcohol.
23.Evaluate the result.
24.Tell the patient the measurement result.
25.Record the result in the form of a fraction (in the numerator - systolic pressure, in the denominator - diastolic) in the necessary documentation.
Arterial pulse measurement
1. Establish a trusting relationship with the patient.
2. Explain the essence and progress of the procedure.
3. Obtain the patient’s consent to the procedure
4. Prepare the necessary equipment
5. Wash and dry your hands
6. Give the patient a comfortable position, sitting or lying down.
7. At the same time, grasp the patient’s hands with your fingers above
wrist joint so that the 2nd, 3rd and 4th fingers are over the radial artery (2nd finger at the base of the thumb). Compare the vibrations of the artery walls in the right and left arms.
8. Count pulse waves in the artery where they are best expressed for 60 seconds.
9. Assess the intervals between pulse waves.
10. Assess pulse filling.
11. Compress the radial artery until the pulse disappears and evaluate the pulse tension.
12. Register the properties of the pulse on the temperature sheet graphically, and in the observation sheet - digitally.
13. Inform the patient about the results of the study.
14. Wash and dry your hands.
Measurement of respiratory rate.
Execution sequence:
1. Create a trusting relationship with the patient.
2. Explain to the patient the need to count the pulse and obtain consent.
3. Take the patient's hand as for examining the pulse.
4. Place your and the patient’s hands on the chest (for thoracic breathing) or epigastric region (for abdominal breathing) of the patient, simulating a pulse examination.
6. Assess the frequency, depth, rhythm and type of breathing movements.
7. Explain to the patient that his respiratory rate has been counted.
8. Wash and dry your hands.
9. Record the data in the temperature sheet.
The calculation of respiratory rate is carried out without informing the patient about the respiratory rate study.
Height measurement
Execution order:
1. Place a replaceable napkin on the stadiometer platform (under the patient’s feet).
2. Raise the stadiometer bar and invite the patient to stand (without shoes!) on the stadiometer platform.
3. Place the patient on the stadiometer platform; the back of the head, spine in the area of the shoulder blades, sacrum and heels of the patient should fit tightly to the vertical bar of the stadiometer; the head should be in such a position that the tragus of the ear and the outer corner of the orbit are on the same horizontal line.
4. Lower the stadiometer bar onto the patient’s head and determine the height on the scale along the lower edge of the bar.
5.Help the patient leave the stadiometer platform and remove the napkin.
Determination of the patient’s body weight (weight)
Execution order:
1. Place a replaceable napkin on the scale platform (under the patient’s feet).
2. Open the shutter of the scales and adjust them: the level of the balance beam, at which all the weights are in the “zero position,” must coincide with the control mark – the “nose” of the scales on the right side.
3.Close the shutter of the scale and invite the patient to stand (without shoes!) in the center of the scale platform.
4.Open the shutter and determine the patient’s weight by moving the weights on the two bars of the rocker arm until the rocker arm is level with the control mark of the medical scale.
5.Close the shutter.
6.Help the patient get off the scale and remove the napkin.
7.Record the measurement data.
Gastric lavage
Indications: It is carried out for therapeutic and diagnostic purposes, as well as to eliminate the remains of poor-quality products and other substances from the stomach. Necessary equipment: gastric tube with two holes, funnel, pelvis.
To determine the length of the probe, use the following formula:
I= L – 100 (cm), where I is the length of the probe, L is the height of the patient, cm.
The tube is inserted to a predetermined length into the stomach. Confirmation that the tube is in the stomach is the cessation of the urge to vomit. After inserting the probe, a funnel is attached to the outer end, then the funnel is raised up and filled with a 2% sodium bicarbonate solution, after which it is lowered below the level of the stomach to remove gastric contents and this is repeated until clean lavage water comes out of the stomach. The amount of rinsing water in the basin should approximately correspond to the volume of liquid introduced through the funnel.
Technique for duodenal intubation
1. Explain to the patient the procedure for the procedure.
2. Sit the patient correctly: leaning on the back of the chair, tilt your head forward.
3. Place a towel on the patient’s neck and chest; if there are removable dentures, they must be removed.
5. Carefully place the blind end of the probe on the root of the patient’s tongue and ask him to make swallowing movements.
6. When the probe reaches the stomach (50 cm mark on the probe), apply a clamp to its free end.
7. Place the patient on the couch without a pillow on his right side, asking him to bend his knees, and place a warm heating pad under his right side on the liver area.
8. Ask the patient to continue swallowing the probe for 20-60 minutes until the 70 cm mark.
9. Lower the end of the probe into the test tube, remove the clamp: if the olive of the probe is in the initial part of the duodenum, a golden-yellow liquid begins to flow into the test tube.
10.Collect 2 - 3 test tubes of incoming liquid (portion A - duodenal bile), apply a clamp to the end of the probe.
11. Lay the patient on his back, remove the clamp and inject a heated irritant (40 ml of 40% glucose, magnesium sulfate or sorbitol) through the probe with a syringe to open the sphincter of Oddi, apply the clamp.
12.After 10-15 minutes, ask the patient to lie on his right side again, lower the probe into the next test tube and remove the clamp: a thick, dark olive-colored liquid should flow in (portion B - from the gallbladder), which is released within 20-30 minutes.
13. When a transparent liquid of golden yellow color begins to be released (portion C - liver bile), lower the probe into the next test tube and collect it for 20 - 30 minutes.
14.After completing the procedure, carefully remove the probe and immerse it in a container with a disinfectant solution.
15. All three portions of bile in warm form, along with the direction, are sent to the laboratory for diagnosis.
Preparing a patient for a urine test
1.Explain to the patient the purpose and rules of the study.
2. On the eve of the study, the patient must limit the consumption of foods (carrots, beets), and refrain from taking medications prescribed by the doctor (diuretics, sulfonamides).
3. Do not change your drinking regime the day before the test.
4. The day before and on the day of urine collection, it is necessary to toilet the patient’s external genitalia.
Determination of daily diuresis
Purpose: diagnosis of hidden edema.
Indications:
Monitoring a patient with edema;
Detection of hidden edema, swelling swelling;
Monitoring the effectiveness of diuretics.
Necessary equipment: medical scales, measuring glass
graduated container for urine collection, water balance sheet.
Execution sequence:
1. Establish a trusting relationship with the patient, evaluate him
ability to independently carry out the procedure. Ensure that the patient can perform a fluid count.
2. Explain the purpose and progress of the study and obtain the patient’s consent to the procedure.
3. Explain to the patient the need to adhere to the usual water, food and physical regime.
4. Make sure that the patient has not taken diuretics for 3 days before the study.
5. Give detailed information about the order of entries in the water balance sheet, make sure you are able to fill out the sheet.
6. Explain the approximate percentage of water in food to make it easier to account for water balance.
7. Prepare equipment.
8. Explain that at 06.00 it is necessary to flush urine into the toilet.
9. Collect urine after each urination into a graduated container and measure urine output.
10. Record the amount of liquid released on the accounting sheet.
11. Record the amount of liquid you drink on the record sheet.
12.Explain that it is necessary to indicate the time of administration or administration
liquid, as well as the time of liquid release in the water balance sheet during the day, until 06.00 the next day.
13.At 06.00 the next day, hand over the registration sheet to the nurse.
14. Determine to the nurse how much fluid should be excreted in the urine (normal).
15.Compare the amount of fluid released with the amount of calculated fluid (normal).
18. Make entries on the water balance sheet.
Procedure for distributing medicines
Medicines are prescribed only by a doctor. Before dispensing medications, the ward nurse must:
1. Wash your hands thoroughly.
3. Check the expiration date of the medicinal substance.
4. Check the prescribed dose.
5. Monitor the patient’s intake of the drug (it
must take the medicine in the presence of a nurse).
6. If the drug is prescribed to be taken several times a day, then the correct time intervals should be observed.
7. Drugs taken on an empty stomach are given to the patient in the morning 20-60 minutes before breakfast, taken before meals - 15 minutes before meals, taken after meals - 15 minutes after meals. Medicines should only be stored in the packaging supplied from the pharmacy.
When taking tablets, dragees, capsules, pills, the patient places them on the root of the tongue and washes them down with water. If the patient cannot swallow the tablet whole, it can be crushed first (the exception is tablets containing iron, which must be taken whole). Dragees, capsules, pills are taken unchanged. The powder is poured onto the root of the patient’s tongue and washed down with water. Potions and decoctions are prescribed in a tablespoon (15 ml), teaspoon (5 ml) or dessert spoon (10 ml). It is more convenient to use a graduated beaker.
Oxygen therapy
The indication for oxygen therapy is the elimination of hypoxia of various origins. There are inhalation, non-inhalation (extrapulmonary) and hyperbaric methods of oxygen supply. The most common are inhalation methods of oxygen administration. Inhalation of oxygen (oxygen mixtures) is carried out using oxygen masks, caps, tents and awnings, catheters, and a ventilator. Hyperbaric oxygenation is carried out using pressure chambers and is the therapeutic use of oxygen under a pressure of more than 1 atm. The oxygen therapy regimen can be continuous or in sessions of 20-30-60 minutes.
Rules for oxygen therapy:
1. Ensure airway patency before administering oxygen.
2. Strictly observe the oxygen concentration (the most effective and safe oxygen concentration is 30-40%).
3. Provide oxygen humidification through the thickness of the sterile liquid using the Bobrov apparatus, where the height of the humidifying liquid should be 15 cm.
4.Provide oxygen warming.
5.Control the time of oxygen supply.
6. Observe safety precautions when working with oxygen and monitor airway patency.
7. Monitor breathing and heart rate, oxygen tension in the blood based on the patient’s condition or on the monitor.
Catheterization of the bladder with a soft catheter
Indications:
Acute urinary retention for more than 6 – 12 hours;
Taking urine for examination;
Bladder lavage;
Administration of drugs.
Contraindications:
Damage to the urethra;
Acute inflammatory processes of the urethra and bladder;
Acute prostatitis.
Security:
Soft catheter;
Anatomical tweezers (2 pcs.);
Kornzang;
Latex gloves;
Furacilin solution 1: 5000;
Napkins;
Sterile petroleum jelly;
Container for collecting urine;
Oilcloth lining;
Antiseptic solution for washing;
Containers with disinfectant solution.
Male bladder catheterization
Patient preparation:
2. Ensure patient isolation (use of a screen).
3. Clarify with the patient’s understanding of the purpose and course of the upcoming procedure, obtain his consent, and exclude contraindications.
4. Wear a mask and gloves.
5. Place the patient on his back with his knees slightly bent and legs apart.
6. Place an oilcloth with a diaper under the patient’s buttocks. Place the vessel on top of the protruding edge of the oilcloth.
7. Prepare equipment and stand to the right of the patient. Take a sterile napkin in your left hand and wrap it around the patient’s penis below the head.
8.Stand to the right of the patient, take a sterile napkin in your left hand, wrap the penis below the head.
9. Take the penis between the 3rd and 4th fingers of your left hand, lightly squeeze the head, and use the 1st and 2nd fingers to push back the foreskin.
10.Take a gauze swab with tweezers held in your right hand, moisten it in a solution of furatsilin and treat the head of the penis from top to bottom, twice, from the urinary tract to the periphery, changing tampons.
11. Pour a few drops of sterile petroleum jelly into the open external opening of the urethra.
12. Change tweezers.
Performing the procedure:
1. Take the catheter with sterile tweezers at a distance of 5 - 6 cm from the side hole, circle the end of the catheter over the hand and pinch it between the 4th and 5th fingers (the catheter is located above the hand in the form of an arc).
2. Fill the catheter with sterile petroleum jelly to a length of 15-20 cm above the tray.
3.Insert the catheter with tweezers (with your right hand), the first 4-5 cm, holding the head of the penis with 1 - 2 fingers of your left hand.
4. Using tweezers, grab the catheter another 3-5 cm from the head and slowly immerse it into the urethra to a length of 19 - 20 cm.
5. Simultaneously lower the penis with your left hand towards the scrotum, which helps move the catheter along the urethra, taking into account the anatomical features.
6. When urine appears, immerse the peripheral end of the catheter in a urine collection container.
End of the procedure:
1. Carefully remove the catheter with tweezers in the reverse order after the stream of urine has stopped.
2. Place the catheter (if a reusable one was used) in a container with a disinfectant solution.
3. Press on the anterior abdominal wall above the pubis with your left hand.
4. Remove gloves and place them in a container with disinfectant solution.
5. Wash and dry your hands.
6. Provide physical and psychological rest to the patient.
Catheterization of a woman's bladder
Execution sequence:
1. Establish a friendly relationship with the patient.
2. Ensure isolation of the patient (use of a screen).
3. Clarify with the patient’s understanding of the purpose and course of the upcoming procedure, obtain her consent, and exclude contraindications.
4. Wear a mask and gloves.
5. Place the patient on her back with her knees slightly bent and her legs apart.
6. Spread the labia with your left hand, and use tweezers to take gauze wipes moistened with furatsilin solution with your right hand.
7. Treat the urethra from top to bottom, twice, between the labia minora, changing napkins.
8. Dump the wipes into a disinfectant solution and change the tweezers.
9.Grab the catheter with tweezers (with your right hand) at a distance of 5 - 6 cm from the side hole, like a writing pen.
10.Look the outer end of the catheter over the hand and hold it between the 4th and 5th fingers of your right hand.
11.Drench the catheter with sterile petroleum jelly.
12.Spread the labia with your left hand, and with your right hand carefully insert the catheter into the urethra 4-6 cm until urine appears.
13. Lower the free end of the catheter into a urine collection container.
End of the procedure:
1. Press with your left hand on the anterior abdominal wall above the pubis when urine begins to come out drop by drop.
2. Carefully remove the catheter after urine flow from it has stopped.
3.Dump the catheter into a container for disinfection.
4. Take off gloves and place them in a container with a disinfectant solution.
5.Wash and dry your hands.
6. Provide physical and psychological peace to the patient.
Cleansing enema
Indications: prescribed to relieve the intestines of feces and gases during constipation and to prepare the patient for endoscopic methods
examinations, X-ray methods for examining the abdominal organs.
Necessary equipment: for a cleansing enema, use water at a temperature of 37-39ºС (liquid volume 1 - 1.5 l), an Esmarch mug, a rubber tube 1.5 m long, a plastic tip.
Execution sequence:
1. Establish a friendly relationship with the patient.
2. Pour 1.0-1.5 liters of water at room temperature -20-22ºC into Esmarch’s mug; for atonic constipation - water t 12ºC (to stimulate intestinal motor activity), for spastic constipation - water t 40ºC (to relieve spasm of the intestinal muscles).
3. Hang Esmarch's mug on the stand and lubricate the sterile tip with Vaseline.
4. Open the valve on the rubber tube and fill it with water (bleed out the air). Close the valve.
5. Place the patient on his left side with his knees bent and legs slightly brought toward his stomach on a couch covered with oilcloth hanging into the pelvis.
6. Using the 1st and 2nd fingers of your left hand, spread the patient’s buttocks, and with your right hand carefully insert the tip into the anus 3-4 cm towards the navel, then to a depth of 8-10 cm parallel to the spine.
7. Open the valve slightly - water will begin to flow into the intestines (if there is gas and the patient feels full, it is necessary to lower the mug below the couch and raise it again after the gas has passed). Introduce the required volume of liquid into the intestines.
8. Close the valve and carefully remove the tip.
9. Leave the patient in the left lateral position for 10-15 minutes.
10.The patient empties his bowels into the toilet or bedpan.
