Equipment
1. Bed linen set (2 pillowcases, duvet cover, sheet).
2. Gloves.
3. Bag for dirty laundry.
Preparation for the procedure
4. Explain to the patient the course of the upcoming procedure.
5. Prepare a set of clean linen.
6. Wash and dry your hands.
7. Wear gloves.
Executing the procedure
8. Lower the rails on one side of the bed.
9. Lower the head of the bed to a horizontal level (if the patient’s condition allows).
10. Raise the bed to the required level (if this is not possible, change the linen, observing the biomechanics of the body).
11. Remove the duvet cover from the blanket, fold it and hang it on the back of the chair.
12. Make sure the clean bedding you prepared is nearby.
13. Stand on the opposite side of the bed that you will be making (on the side of the lowered rail).
14. Make sure that there are no small personal items of the patient on this side of the bed (if there are such items, ask where to put them).
15. Turn the patient on his side towards you.
16. Raise the side rail (the patient can support himself in a side position by holding the rail).
17. Return to the opposite side of the bed, lower the handrail.
18. Elevate the patient's head and remove the pillow (if there are drainage tubes, make sure they are not kinked).
19. Make sure there are no small items of the patient's belongings on this side of the bed.
20. Roll up the dirty sheet with a roller towards the patient’s back and slip this roller under his back (if the sheet is heavily soiled (with secretions, blood), put a diaper on it, so that the sheet does not come into contact with the contaminated area, the patient’s skin and the clean sheet).
21. Fold a clean sheet in half lengthwise and place its central fold in the center of the bed.
22. Fold the sheet towards you and tuck the sheet into the head of the bed using the “corner bevel” method.
23. Tuck the middle third, then the lower third of the sheet under the mattress, placing your hands palms up.
24. Make the roll of the rolled clean and dirty sheet as flat as possible.
25. Help the patient “roll” over these sheets towards you; make sure that the patient is lying comfortably, and if there are drainage tubes, they are not kinked.
26. Raise the side rail on the side of the bed where you were just working.
27. Go to the other side of the bed.
28. Replace the bedding on the other side of the bed.
29. Lower the side rail.
30. Roll up the dirty sheet and place it in a laundry bag.
31. Straighten a clean sheet and tuck it under the mattress, first its middle third, then the upper third, then the lower third, using the method in paragraph 1. 22, 23.
32. Help the patient turn onto his back and lie in the middle of the bed.
33. Tuck the blanket into a clean duvet cover.
34. Adjust the blanket so that it hangs equally on both sides of the bed.
35. Tuck the edges of the blanket under the mattress.
36. Remove the dirty pillowcase and throw it into the laundry bag.
37. Turn a clean pillowcase inside out.
38. Grasp the pillow by its corners through the pillowcase.
39. Pull the pillowcase over the pillow.
40. Elevate the patient's head and shoulders and place a pillow under the patient's head.
41. Raise the side rail.
42. Create a fold in the blanket for the toes.
Completing the procedure
43. Remove gloves and place them in a disinfectant solution.
44. Wash and dry your hands.
45. Make sure the patient is lying comfortably.
Patient eye care
Equipment
1. Sterile tray
2. Sterile tweezers
3. Sterile gauze wipes - at least 12 pcs.
4. Gloves
5. Tray for waste material
6. Antiseptic solution for treating mucous membranes of the eyes
Preparation for the procedure
7. Clarify the patient’s understanding of the purpose and progress of the upcoming procedure and obtain his consent
8. Prepare everything you need
9. Wash and dry your hands
10. Examine the mucous membranes of the patient’s eyes to identify purulent discharge
11. Wear gloves
Executing the procedure
12. Place at least 10 napkins in a sterile tray and moisten them with an antiseptic solution, squeeze out the excess on the edge of the tray
13. Take a napkin and wipe your eyelids and eyelashes with it from top to bottom or from the outer corner of the eye to the inner
14. Repeat the treatment 4-5 times, changing napkins and placing them in the waste tray
15. Wipe the remaining solution with a dry sterile cloth
Completing the procedure
16. Remove all used equipment and then disinfect it
17. Help the patient find a comfortable position
18. Place the wipes in a container with a disinfectant and then dispose of them
19. Remove gloves and place them in a disinfectant solution
20. Wash and dry your hands
21. Make a note in the medical record about the patient’s reaction.
Study of the arterial pulse on the radial artery
Equipment
1. Clock or stopwatch.
2. Temperature sheet.
3. Pen, paper.
Preparation for the procedure
4. Explain to the patient the purpose and progress of the study.
5. Obtain patient consent for the study.
6. Wash and dry your hands.
Executing the procedure
7. During the procedure, the patient can sit or lie (arms are relaxed, arms should not be suspended).
8. Press with 2, 3, 4 fingers (1 finger should be on the back of the hand) the radial arteries on both hands of the patient and feel the pulsation.
9. Determine the pulse rhythm for 30 seconds.
10. Select one comfortable hand for further examination of the pulse.
11. Take a watch or stopwatch and examine the pulsation of the artery for 30 seconds. Multiply by two (if the pulse is rhythmic). If the pulse is not rhythmic, count for 1 minute.
12. Press the artery harder than before to the radius and determine the tension of the pulse (if the pulsation disappears with moderate pressure, the tension is good; if the pulsation does not weaken, the pulse is tense; if the pulsation has completely stopped, the tension is weak).
13. Write down the result.
End of the procedure
14. Inform the patient the result of the study.
15. Help the patient find a comfortable position or stand up.
16. Wash and dry your hands.
17. Record the test results on a temperature sheet (or nursing care plan).
Blood pressure measurement technique
Equipment
1. Tonometer.
2. Phonendoscope.
3. Handle.
4. Paper.
5. Temperature sheet.
6. Alcohol napkin.
Preparation for the procedure
7. Warn the patient about the upcoming study 5 - 10 minutes before it starts.
8. Clarify the patient’s understanding of the purpose of the study and obtain his consent.
9. Ask the patient to lie down or sit at the table.
10. Wash and dry your hands.
Execution
11. Help remove clothes from your arm.
12. Place the patient’s arm in an extended position, palm up, at the level of the heart, muscles relaxed.
13. Place the cuff 2.5 cm above the ulnar fossa (clothing should not compress the shoulder above the cuff).
14. Fasten the cuff so that two fingers pass between the cuff and the surface of the shoulder.
15. Check the position of the pressure gauge needle relative to the zero mark.
16. Find (by palpation) the pulse on the radial artery, quickly pump air into the cuff until the pulse disappears, look at the scale and remember the pressure gauge readings, quickly release all the air from the cuff.
17. Find the place of pulsation of the brachial artery in the area of the ulnar fossa and firmly place the stethoscope membrane on this place.
18. Close the valve on the bulb and pump air into the cuff. Inflate air until the pressure in the cuff, according to the tonometer readings, exceeds 30 mmHg. Art., the level at which the pulsation of the radial artery or Korotkoff sounds ceases to be detected.
19. Open the valve and slowly, at a speed of 2–3 mm Hg. per second, release air from the cuff. At the same time, use a stethoscope to listen to sounds on the brachial artery and monitor the readings of the pressure gauge scale.
20. When the first sounds appear above the brachial artery, note the level of systolic pressure.
21. Continuing to release air from the cuff, note the level of diastolic pressure, which corresponds to the moment of complete disappearance of sounds in the brachial artery.
22. Repeat the procedure after 2–3 minutes.
Completing the procedure
23. Round the measurement data to the nearest even number and write it as a fraction (systolic blood pressure in the numerator, diastolic blood pressure in the denominator).
24. Wipe the phonendoscope membrane with a cloth moistened with alcohol.
25. Write down the study data in the temperature sheet (protocol for the care plan, outpatient card).
26. Wash and dry your hands.
Determination of frequency, depth and rhythm of breathing
Equipment
1. Clock or stopwatch.
2. Temperature sheet.
3. Pen, paper.
Preparation for the procedure
4. Warn the patient that a pulse examination will be performed.
5. Obtain the patient’s consent to conduct the study.
6. Ask the patient to sit or lie down so that you can see the upper chest and/or abdomen.
7. Wash and dry your hands.
Executing the procedure
8. Take the patient’s hand as for examining the pulse, hold the patient’s hand at the wrist, place your hands (yours and the patient’s) on the chest (in women) or on the epigastric region (in men), simulating the examination of the pulse and count the respiratory movements as 30 seconds, multiplying the result by two.
9. Write down the result.
10. Help the patient take a position that is comfortable for him.
End of the procedure
11. Wash and dry your hands.
12. Record the result on the nursing assessment sheet and temperature sheet.
Measuring armpit temperature
Equipment
1. Clock
2. Medical maximum thermometer
3. Handle
4. Temperature sheet
5. Towel or napkin
6. Container with disinfectant solution
Preparation for the procedure
7. Warn the patient about the upcoming study 5 - 10 minutes before it starts
8. Clarify the patient’s understanding of the purpose of the study and obtain his consent
9. Wash and dry your hands
10. Make sure that the thermometer is intact and that the readings on the scale do not exceed 35°C. Otherwise, shake the thermometer so that the mercury column drops below 35 °C.
Execution
11. Examine the axillary area, if necessary, wipe dry with a napkin or ask the patient to do this. In the presence of hyperemia or local inflammatory processes, temperature measurements cannot be taken.
12. Place the thermometer reservoir in the axillary area so that it is in close contact with the patient’s body on all sides (press the shoulder to the chest).
13. Leave the thermometer for at least 10 minutes. The patient should lie in bed or sit.
14. Remove the thermometer. Assess the indicators by holding the thermometer horizontally at eye level.
15. Inform the patient of the results of thermometry.
Completing the procedure
16. Shake the thermometer so that the mercury column drops into the reservoir.
17. Immerse the thermometer in the disinfectant solution.
18. Wash and dry your hands.
19. Make a note of the temperature readings on the temperature sheet.
Algorithm for measuring height, weight and BMI
Equipment
1. Height meter.
2. Libra.
3. Gloves.
4. Disposable napkins.
5. Paper, pen
Preparation and carrying out the procedure
6. Explain to the patient the purpose and course of the upcoming procedure (learning to measure height, body weight and determine BMI) and obtain his consent.
7. Wash and dry your hands.
8. Prepare the stadiometer for use, raise the stadiometer bar above the expected height, place a napkin on the stadiometer platform (under the patient’s feet).
9. Ask the patient to take off his shoes and stand in the middle of the stadiometer platform so that he touches the vertical bar of the stadiometer with his heels, buttocks, interscapular area and the back of his head.
10. Position the patient’s head so that the tragus of the auricle and the outer corner of the orbit are on the same horizontal line.
11. Lower the stadiometer bar onto the patient’s head and determine the patient’s height on the scale along the lower edge of the bar.
12. Ask the patient to get off the stadiometer platform (if necessary, help him get off). Inform the patient about the measurement results and write down the result.
13. Explain to the patient about the need to measure body weight at the same time, on an empty stomach, after visiting the toilet.
14. Check the serviceability and accuracy of medical scales, set the balance (for mechanical scales) or turn it on (for electronic ones), place a napkin on the scale platform
15. Invite the patient to take off his shoes and help him stand in the middle of the scale, and determine the patient’s body weight.
16. Help the patient get off the scale, tell him the result of the body weight test, and write down the result.
End of the procedure
17. Put on gloves, remove the napkins from the stadiometer and scales and place them in a container with a disinfectant solution. Treat the surface of the stadiometer and scales with a disinfectant solution once or twice with an interval of 15 minutes in accordance with the guidelines for the use of a disinfectant.
18. Remove gloves and place them in a container with a disinfectant solution,
19. Wash and dry your hands.
20. Determine BMI (body mass index) -
body weight (in kg) height (in m 2) Index less than 18.5 - underweight; 18.5 - 24.9 - normal body weight; 25 - 29.9 - overweight; 30 - 34.9 - 1st degree obesity; 35 - 39.9 - II degree obesity; 40 and more - III degree obesity. Record the result.
21. Inform the patient’s BMI and write down the result.
Applying a warm compress
Equipment
1. Compress paper.
2. Vata.
3. Bandage.
4. Ethyl alcohol 45%, 30 - 50 ml.
5. Scissors.
b. Tray.
Preparation for the procedure
7. Clarify the patient’s understanding of the purpose and course of the upcoming procedure and obtain his consent.
8. It is convenient to sit or lay down the patient.
9. Wash and dry your hands.
10. Cut off the required piece of bandage or gauze with scissors (depending on the area of application and fold it into 8 layers).
11. Cut a piece of compress paper: 2 cm larger than the prepared napkin around the perimeter.
12. Prepare a piece of cotton wool around the perimeter 2 cm larger than the compress paper.
13. Place the layers for the compress on the table, starting with the outer layer: cotton wool at the bottom, then compress paper.
14. Pour alcohol into the tray.
15. Moisten a napkin in it, lightly wring it out and place it on top of the compress paper.
Executing the procedure
16. Place all layers of the compress simultaneously on the desired area (knee joint) of the body.
17. Secure the compress with a bandage so that it fits tightly to the skin, but does not restrict movement.
18. Note the time of application of the compress in the patient’s chart.
19. Remind the patient that the compress is applied for 6 - 8 hours, give the patient a comfortable position.
20. Wash and dry your hands.
21. 1.5 - 2 hours after applying the compress with your finger, without removing the bandage, check the moisture level of the napkin. Secure the compress with a bandage.
22. Wash and dry your hands.
Completing the procedure
23. Wash and dry your hands.
24. Remove the compress after the prescribed time of 6–8 hours.
25. Wipe the skin in the area of the compress and apply a dry bandage.
26. Dispose of used material.
27. Wash and dry your hands.
28. Make a note in the medical record about the patient's reaction.
Installation of mustard plasters
Equipment
1. Mustard plasters.
2. Tray with water (40 - 45*C).
3. Towel.
4. Gauze napkins.
5. Clock.
6. Tray for waste material.
Preparation for the procedure
7. Explain to the patient the purpose and course of the upcoming procedure and
obtain his consent.
8. Help the patient find a comfortable position, lying on his back or stomach.
9. Wash and dry your hands.
11. Pour water at a temperature of 40 - 45*C into the tray.
Executing the procedure
12. Examine the patient’s skin at the site where the mustard plasters were placed.
13. Immerse mustard plasters one by one in water, allow excess water to drain, and place the side covered with mustard or the porous side on the patient’s skin.
14. Cover the patient with a towel and blanket.
15. After 5–10 minutes, remove the mustard plasters, placing them in the waste material tray.
End of the procedure
16. Wipe the patient’s skin with a damp, warm cloth and dry with a towel.
17. Place the used material, mustard plasters, napkin in the waste material tray, then dispose of it.
18. Cover and place the patient in a comfortable position, warn the patient that he must remain in bed for at least 20 - 30 minutes.
19. Wash and dry your hands.
20. Make a record of the procedure performed in the patient’s medical record.
Using a heating pad
Equipment
1. Hot water bottle.
2. Diaper or towel.
3. Jug of water T - 60-65°C.
4. Thermometer (water).
Preparation for the procedure
5. Explain to the patient the course of the upcoming procedure and obtain his consent to the procedure.
6. Wash and dry your hands.
7. Pour hot (T - 60–65°C) water into the heating pad, slightly squeeze it at the neck, releasing the air, and close it with a stopper.
8. Turn the heating pad upside down to check the flow of water and wrap it in some kind of swaddling cloth
with a towel.
Executing the procedure
9. Place the heating pad on the desired area of the body for 20 minutes.
End of the procedure
11. Examine the patient’s skin in the area of contact with the heating pad.
12. Pour out the water. Treat the heating pad with a rag generously moistened with a bactericidal disinfectant solution twice with an interval of 15 minutes.
13. Wash and dry your hands.
14. Make a note about the procedure and the patient’s reaction to it in the inpatient’s chart.
Setting up an ice pack
Equipment
1. Ice pack.
2. Diaper or towel.
3. Pieces of ice.
4. Jug of water T - 14 - 16 C.
5. Thermometer (water).
Preparation for the procedure
6. Explain to the patient the course of the upcoming procedure and obtain consent for the procedure.
7 Wash and dry your hands.
8. Place pieces of ice prepared in the freezer into a bubble and fill them with cold water (T - 14 - 1°C).
9. Place the bubble on a horizontal surface to displace air and screw on the lid.
10. Turn the ice pack upside down, check the seal and wrap it in a diaper or towel.
Executing the procedure
11. Place the bubble on the desired area of the body for 20–30 minutes.
12. Remove the ice pack after 20 minutes (repeat steps 11–13).
13. As the ice melts, the water can be drained and pieces of ice added.
End of the procedure
14. Examine the patient’s skin in the area where the ice pack is applied.
15. At the end of the procedure, treat the drained water with a rag moistened with a bactericidal disinfectant solution twice with an interval of 15 minutes.
16. Wash and dry your hands.
17. Make a note about the procedure and the patient’s reaction to it in the inpatient’s chart.
Caring for a woman’s external genitalia and perineum
Equipment
1. A jug with warm (35–37°C) water.
2. Absorbent diaper.
3. Kidney-shaped tray.
4. Vessel.
5. Soft material.
6. Cortsang.
7. Container for discarding used material.
8. Screen.
9. Gloves.
Preparation for the procedure
10. Explain to the patient the purpose and progress of the study.
11. Obtain the patient’s consent to perform the manipulation.
12. Prepare the necessary equipment. Pour warm water into a jug. Place cotton swabs (napkins) and forceps into the tray.
13. Separate the patient with a screen (if necessary).
14. Wash and dry your hands.
15. Put on gloves.
Executing the procedure
16. Lower the head of the bed. Turn the patient to her side. Place an absorbent diaper under the patient.
17. Place the bedpan in close proximity to the patient’s buttocks. Turn her onto her back so that her perineum is above the opening of the vessel.
18. Help to find an optimally comfortable position for the procedure (Fowler’s position, legs slightly bent at the knees and apart).
19. Stand to the right of the patient (if the nurse is right-handed). Place a tray with tampons or napkins in close proximity to you. Secure the tampon (napkin) with a forceps.
20. Hold the jug in your left hand and the forceps in your right. Pour water onto the woman’s genitals, use tampons (changing them) to move from top to bottom, from the inguinal folds to the genitals, then to the anus, washing: a) with one tampon - the pubis; b) second - the groin area on the right and left c) then the right and left labia majora c) the anal area, intergluteal fold Throw used tampons into the vessel.
21. Dry the patient’s pubis, inguinal folds, genitals and anal area with blotting movements using dry wipes in the same sequence and in the same direction as when washing, changing the wipes after each stage.
22. Turn the patient on her side. Remove the bedpan, oilcloth and diaper. Return the patient to the starting position, on her back. Place the oilcloth and diaper in a container for disposal.
23. Help the patient find a comfortable position. Cover her. Make sure she feels comfortable. Remove the screen.
End of the procedure
24. Empty the vessel of its contents and place it in a container with disinfectant.
25. Remove gloves and place them in a waste tray for subsequent disinfection and disposal.
26. Wash and dry your hands.
27. Make a record of the procedure and the patient’s reaction in the documentation.
Catheterization of a woman's bladder with a Foley catheter
Equipment
1. Sterile Foley catheter.
2. Sterile gloves.
3. Clean gloves - 2 pairs.
4. Medium sterile wipes - 5−6 pcs.
6. Jug with warm water (30–35°C).
7. Ship.
10. 10−30 ml of saline or sterile water depending on the size of the catheter.
11. Antiseptic solution.
13. Urinal bag.
15. Plaster.
16. Scissors.
17. Sterile tweezers.
18. Kontsang.
19. Container with disinfectant solution.
Preparation for the procedure
20. Clarify the patient’s understanding of the purpose and course of the upcoming procedure and obtain her consent.
21. Separate the patient with a screen (if the procedure is performed in the ward).
22. Place an absorbent diaper (or oilcloth and diaper) under the patient’s pelvis.
23. Help the patient take the position necessary for the procedure: lying on her back with her legs apart, bent at the knee joints.
24. Wash and dry your hands. Wear clean gloves.
25. Carry out hygienic treatment of the external genitalia, urethra, and perineum. Remove gloves and place them in a container with a disinfectant solution.
26. Wash and dry your hands.
27. Place large and medium sterile wipes into the tray using tweezers). Moisten medium napkins with an antiseptic solution.
28. Wear gloves.
29. Leave the tray between your legs. Spread the labia minora with your left hand (if you are right-handed).
30. Treat the entrance to the urethra with a napkin soaked in an antiseptic solution (hold it with your right hand).
31. Cover the entrance to the vagina and anus with a sterile napkin.
32. Remove gloves and place them in a container for used material.
33. Treat your hands with antiseptic.
34. Open the syringe and fill it with sterile saline or water 10 - 30 ml.
35. Open the bottle with glycerin and pour it into the beaker
36. Open the package with the catheter, place the sterile catheter in the tray.
37. Wear sterile gloves.
Executing the procedure
38. Take the catheter at a distance of 5–6 cm from the side hole and hold it at the beginning with 1 and 2 fingers, the outer end with 4 and 5 fingers.
39. Lubricate the catheter with glycerin.
40. Insert the catheter into the urethral opening 10 cm or until urine appears (direct the urine into a clean tray).
41. Drain urine into a tray.
42. Fill the Foley catheter balloon with 10 - 30 ml of sterile saline or sterile water.
Completing the procedure
43. Connect the catheter to a container for collecting urine (urinal).
44. Attach the urine bag with a plaster to the thigh or to the edge of the bed.
45. Make sure that the tubes connecting the catheter and the container are not kinked.
46. Remove the waterproof diaper (oilcloth and diaper).
47. Help the patient lie down comfortably and remove the screen.
48. Place the used material in a container with disinfectant. Solution.
49. Remove gloves and place them in a disinfectant solution.
50. Wash and dry your hands.
51. Make a record of the procedure performed.
Catheterization of a male bladder with a Foley catheter
Equipment
1. Sterile Foley catheter.
2. Sterile gloves.
3. Clean gloves, 2 pairs.
4. Medium sterile wipes 5-6 pcs.
5. Large sterile wipes - 2 pcs.
b. Jug with warm water (30 - 35°C).
7. Ship.
8. Bottle with sterile glycerin 5 ml.
9. Sterile syringe 20 ml - 1−2 pcs.
10. 10 - 30 ml of saline or sterile water depending on the size of the catheter.
11. Antiseptic solution.
12. Trays (clean and sterile).
13. Urinal bag.
14. Absorbent diaper or oilcloth with diaper.
15. Plaster.
16. Scissors.
17. Sterile tweezers.
18. Container with disinfectant solution.
Preparation for the procedure
19. Explain to the patient the essence and course of the upcoming procedure and obtain his consent.
20. Protect the patient with a screen.
21. Place an absorbent diaper (or oilcloth and diaper) under the patient’s pelvis.
22. Help the patient take the required position: lying on his back with his legs apart, bent at the knee joints.
23. Wash and dry your hands. Wear clean gloves.
24. Carry out hygienic treatment of the external genitalia. Remove gloves.
25. Treat your hands with antiseptic.
26. Place large and medium sterile wipes into the tray using tweezers). Moisten medium napkins with an antiseptic solution.
27. Put on gloves.
28. Treat the head of the penis with a napkin soaked in an antiseptic solution (hold it with your right hand).
29. Wrap the penis with sterile wipes (large)
30. Remove gloves and place them in a container with disinfectant. solution.
31. Treat your hands with antiseptic.
32. Place a clean tray between your legs.
33. Open the syringe and fill it with sterile saline solution or water 10 - 30 ml.
34. Open the bottle with glycerin.
35. Open the catheter package and place the sterile catheter in the tray.
36. Wear sterile gloves.
Executing the procedure
37. Take the catheter at a distance of 5–6 cm from the side hole and hold it at the beginning with 1 and 2 fingers, the outer end with 4 and 5 fingers.
38. Lubricate the catheter with glycerin.
39. Insert the catheter into the urethra and gradually, intercepting the catheter, move it deeper into the urethra, and “pull” the penis upward, as if pulling it onto the catheter, applying a slight uniform force until urine appears (direct the urine into the tray).
40. Drain urine into a tray.
41. Fill the Foley catheter balloon with 10 - 30 ml of sterile saline or sterile water.
Completing the procedure
42. Connect the catheter to a container for collecting urine (urinal bag).
43. Attach the urine bag to your thigh or to the edge of the bed.
44. Make sure that the tubes connecting the catheter and the container are not kinked.
45. Remove the waterproof diaper (oilcloth and diaper).
46. Help the patient lie down comfortably and remove the screen.
47. Place the used material in a container with disinfectant. Solution.
48. Remove gloves and place them in a disinfectant solution.
49. Wash and dry your hands.
50. Make a record of the procedure performed.
Cleansing enema
Equipment
1. Esmarch mug.
2. Water 1 -1.5 liters.
3. Sterile tip.
4. Vaseline.
5. Spatula.
6. Apron.
7. Taz.
8. Absorbent diaper.
9. Gloves.
10. Tripod.
11. Water thermometer.
12. Container with disinfectants.
Preparation for the procedure
10. Explain to the patient the essence and course of the upcoming procedure. Obtain the patient's consent for the procedure.
11. Wash and dry your hands.
12. Put on an apron and gloves.
13. Open the package, remove the tip, attach the tip to Esmarch’s mug.
14. Close the valve on Esmarch’s mug, pour 1 liter of water at room temperature into it (for spastic constipation, the water temperature is 40–42 degrees, for atonic constipation, 12–18 degrees).
15. Mount the mug on a tripod at a height of 1 meter from the level of the couch.
16. Open the valve and drain some water through the nozzle.
17. Using a spatula, lubricate the tip with Vaseline.
18. Place an absorbent diaper on the couch at an angle, hanging into the basin.
20. Remind the patient of the need to retain water in the intestines for 5–10 minutes.
Executing the procedure
21. Spread the buttocks with the 1st and 2nd fingers of your left hand, with your right hand carefully insert the tip into the anus, pushing it into the rectum towards the navel (3–4 cm), and then parallel to the spine to a depth of 8–10 cm.
22. Open the valve slightly so that water slowly flows into the intestines.
24. Invite the patient to breathe deeply into the abdomen.
24. After introducing all the water into the intestine, close the valve and carefully remove the tip.
25. Help the patient get off the couch and walk to the toilet.
Completing the procedure
26. Disconnect the tip from Esmarch's mug.
27. Place used equipment in a disinfectant solution.
28. Remove gloves, place them in a disinfectant solution, and then dispose of them. Remove the apron and send it for disposal.
29. Wash and dry your hands.
30. Make sure that the procedure was effective.
31. Make a record of the procedure and the patient's response.
Carrying out siphon lavage of the intestines
Equipment
3. Gloves.
4. Container with disinfectant solution.
5. A container for collecting wash water for testing.
6. Container (bucket) with water 10 -12 liters (T - 20 - 25*C).
7. Capacity (basin) for draining wash water for 10 - 12 liters.
8. Two waterproof aprons.
9. Absorbent diaper.
10. Mug or jug for 0.5 - 1 liter.
11. Vaseline.
12. Spatula.
13. Napkins, toilet paper.
Preparation for the procedure
14. Clarify the patient’s understanding of the purpose and progress of the upcoming procedure. Obtain consent to carry out the manipulation.
15. Wash and dry your hands.
16. Prepare equipment.
17. Put on gloves and an apron.
18. Place an absorbent diaper on the couch, angle down.
19. Help the patient lie on his left side. The patient's legs should be bent at the knees and slightly brought toward the abdomen.
Executing the procedure
20. Remove the system from the packaging. Lubricate the blind end of the probe with Vaseline.
21. Spread the buttocks with fingers 1 and 2 of your left hand, insert the rounded end of the probe into the intestine with your right hand and push it to a depth of 30–40 cm: the first 3–4 cm - towards the navel, then parallel to the spine.
22. Attach a funnel to the free end of the probe. Hold the funnel slightly inclined, at the level of the patient’s buttocks. Pour 1 liter of water into it from the jug along the side wall.
23. Invite the patient to breathe deeply. Raise the funnel to a height of 1 m. As soon as the water reaches the mouth of the funnel, lower it over the wash basin below the level of the patient’s buttocks, without pouring water out of it until the funnel is completely filled.
24. Drain the water into the prepared container (basin for washing water). Note: The first wash water can be collected in a container for testing.
25. Fill the funnel with the next portion and lift it up to a height of 1 m. As soon as the water level reaches the mouth of the funnel, lower it down. Wait until it is filled with rinsing water and pour it into the basin. Repeat the procedure many times until the rinsing water is clear, using all 10 liters of water.
26. Disconnect the funnel from the probe at the end of the procedure, leave the probe in the intestine for 10 minutes.
27. Remove the probe from the intestine with slow forward movements, passing it through a napkin.
28. Immerse the probe and funnel in a container with disinfectant.
29. Wipe the skin in the anus area (in women, away from the genitals) with toilet paper or wash the patient if helpless.
Completing the procedure
30. Ask the patient how he is feeling. Make sure he feels okay.
31. Ensure safe transportation to the ward.
32. Pour rinsing water into the sewer and, if indicated, carry out preliminary disinfection.
33. Disinfect used instruments and then dispose of disposable ones.
34. Remove gloves. Wash and dry your hands.
35. Make a note in the patient’s medical record about the procedure performed and the reaction to it.
Hypertensive enema
Equipment
3. Spatula.
4. Vaseline.
5. 10% sodium chloride solution or 25% magnesium sulfate
6. Gloves.
7. Toilet paper.
8. Absorbent diaper.
9. Tray.
10. Container with water T - 60°C for heating the hypertonic solution.
11. Thermometer (water).
12. Measuring cup.
13. Container with disinfectant
Preparation for the procedure
15. Before administering a hypertensive enema, warn that pain may occur during manipulation along the intestinal tract.
16. Wash and dry your hands.
17. Heat the hypertonic solution to 38°C in a water bath and check the temperature of the drug.
18. Draw a hypertonic solution into a pear-shaped balloon or into a Janet syringe.
19. Put on gloves.
Executing the procedure
26. Warn the patient that the onset of the effect of a hypertensive enema occurs after 30 minutes.
Completing the procedure
28. Place used equipment in a disinfectant solution.
29. Remove gloves and place them in the disinfectant solution.
30. Wash and dry your hands.
31. Help the patient get to the toilet.
32. Make sure that the procedure was effective.
33. Make a record of the procedure and the patient’s reaction.
Oil enema
Equipment
1. Pear-shaped balloon or Janet syringe.
2. Sterile gas outlet tube.
3. Spatula.
4. Vaseline.
5. Oil (vaseline, vegetable) from 100 - 200 ml (as prescribed by a doctor).
b. Gloves.
7. Toilet paper.
8. Absorbent diaper.
9. Screen (if the procedure is performed in the ward).
10. Tray.
11. Container for heating oil with water T - 60°C.
12. Thermometer (water).
13. Measuring cup.
Preparation for the procedure
14. Provide the patient with the necessary information about the procedure and obtain his consent to the procedure.
15. Place a screen.
16. Wash and dry your hands.
17. Heat the oil to 38°C in a water bath, check the oil temperature.
18. Fill a pear-shaped balloon or Janet’s syringe with warm oil.
19. Put on gloves.
Executing the procedure
20. Help the patient lie on his left side. The patient's legs should be bent at the knees and slightly brought toward the abdomen.
21. Lubricate the gas outlet tube with Vaseline and insert it into the rectum 15–20 cm.
22. Deflate the air from the pear-shaped balloon or Janet syringe.
23. Attach a pear-shaped balloon or Janet syringe to the gas outlet tube and slowly inject the oil.
24. Without unclenching the pear-shaped balloon, disconnect it (Zhanet’s syringe) from the gas outlet tube.
25. Remove the gas outlet tube and place it together with a pear-shaped balloon or Janet syringe in the tray.
26. If the patient is helpless, wipe the skin in the anal area with toilet paper and explain that the effect will occur in 6–10 hours.
Completing the procedure
27. Remove the absorbent diaper and place it in a container for disposal.
28. Remove gloves and place them in a tray for subsequent disinfection.
29. Cover the patient with a blanket and help him find a comfortable position. Remove the screen.
30. Place used equipment in a disinfectant solution.
31. Wash and dry your hands.
32. Make a record of the procedure and the patient’s reaction.
33. Assess the effectiveness of the procedure after 6–10 hours.
Medicinal enema
Equipment
1. Pear-shaped balloon or Janet syringe.
2. Sterile gas outlet tube.
3. Spatula.
4. Vaseline.
5. Medicine 50 -100 ml (chamomile decoction).
6. Gloves.
7. Toilet paper.
8. Absorbent diaper.
9. Screen.
10. Tray.
11. Container for heating the medicine with water T -60°C.
12. Thermometer (water).
13. Measuring cup.
Preparation for the procedure
14. Provide the patient with the necessary information about the procedure and obtain his consent to the procedure.
15. Give the patient a cleansing enema 20–30 minutes before performing a medicinal enema
16. Place a screen.
17. Wash and dry your hands. Wear gloves.
Executing the procedure
18. Heat the medicine to 38°C in a water bath, check the temperature with a water thermometer.
19. Draw chamomile decoction into a pear-shaped balloon or into a Janet syringe.
20. Help the patient lie on his left side. The patient's legs should be bent at the knees and slightly brought toward the abdomen.
21. Lubricate the gas outlet tube with Vaseline and insert it into the rectum 15–20 cm.
22. Deflate the air from the pear-shaped balloon or Janet syringe.
23. Attach a pear-shaped balloon or Janet syringe to the gas outlet tube and slowly inject the medicine.
24. Without unclenching the pear-shaped balloon, disconnect it or the Janet syringe from the gas outlet tube.
25. Remove the gas outlet tube and place it together with a pear-shaped balloon or Janet syringe in the tray.
26. If the patient is helpless, wipe the skin in the anal area with toilet paper.
27. Explain that after the manipulation it is necessary to spend at least 1 hour in bed.
Completing the procedure
28. Remove the absorbent diaper and place it in a container for disposal.
29. Remove gloves and place them in a tray for subsequent disinfection.
30. Cover the patient with a blanket and help him find a comfortable position. Remove the screen.
31. Place used equipment in a disinfectant solution.
32. Wash and dry your hands.
33. After an hour, ask the patient how he feels.
34. Make a record of the procedure and the patient’s reaction.
Insertion of a nasogastric tube
Equipment
2. Sterile glycerin.
4. Syringe Janet 60 ml.
5. Band-Aid.
6. Clamp.
7. Scissors.
8. Probe plug.
9. Safety pin.
10. Tray.
11. Towel.
12. Napkins
13. Gloves.
Preparation for the procedure
14. Explain to the patient the process and essence of the upcoming procedure and obtain the patient’s consent to carry out the procedure.
15. Wash and dry your hands.
16. Prepare equipment (the probe must be in the freezer for 1.5 hours before the procedure).
17. Determine the distance to which the probe should be inserted (the distance from the tip of the nose to the earlobe and down the anterior abdominal wall so that the last hole of the probe is below the xiphoid process).
18. Help the patient assume a high Fowler's position.
19. Cover the patient's chest with a towel.
20. Wash and dry your hands. Wear gloves.
Executing the procedure
21. Liberally treat the blind end of the probe with glycerin.
22. Ask the patient to tilt his head back slightly.
23. Insert the probe through the lower nasal passage to a distance of 15–18 cm.
24. Give the patient a glass of water and a drinking straw. Ask to drink in small sips, swallowing the probe. You can add pieces of ice to the water.
25. Help the patient swallow the probe, moving it into the pharynx during each swallowing movement.
26. Ensure that the patient can speak clearly and breathe freely.
27. Gently advance the probe to the desired mark.
28. Make sure that the probe is located correctly in the stomach: attach the syringe to the probe and pull the plunger towards you; The contents of the stomach (water and gastric juice) should flow into the syringe.
29. If necessary, leave the probe for a long time, secure it to the nose with a plaster. Remove the towel.
30. Close the probe with a plug and attach it with a safety pin to the patient’s clothing on the chest.
Completing the procedure
31. Remove gloves.
32. Help the patient take a comfortable position.
33. Place the used material in a disinfectant solution and then dispose of it.
34. Wash and dry your hands.
35. Make a record of the procedure and the patient’s reaction.
Feeding through a nasogastric tube
Equipment
1. Sterile gastric tube with a diameter of 0.5 - 0.8 cm.
2. Glycerin or petroleum jelly.
3. A glass of water 30 - 50 ml and a drinking straw.
4. Janet syringe or syringe with a volume of 20.0.
5. Band-Aid.
6. Clamp.
7. Scissors.
8. Probe plug.
9. Safety pin.
10. Tray.
11. Towel.
12. Napkins
13. Gloves.
14. Phonendoscope.
15. 3-4 glasses of nutrient mixture and a glass of warm boiled water.
Preparation for the procedure
16. Explain to the patient the process and essence of the upcoming procedure and obtain the patient’s consent to carry out the procedure.
17. Wash and dry your hands.
18. Prepare the equipment (the probe should be in the freezer for 1.5 hours before the start of the procedure).
19. Determine the distance to which the probe should be inserted (the distance from the tip of the nose to the earlobe and down the anterior abdominal wall so that the last hole of the probe is below the xiphoid process).
20. Help the patient assume a high Fowler's position.
21. Cover the patient's chest with a towel.
22. Wash and dry your hands. Wear gloves.
Executing the procedure
23. Liberally treat the blind end of the probe with glycerin.
24. Ask the patient to tilt his head back slightly.
25. Insert the probe through the lower nasal passage to a distance of 15 - 18 cm.
26. Give the patient a glass of water and a drinking straw. Ask to drink in small sips, swallowing the probe. You can add pieces of ice to the water.
27. Help the patient swallow the probe, moving it into the pharynx during each swallowing movement.
28. Ensure that the patient can speak clearly and breathe freely.
29. Gently advance the probe to the desired mark.
30. Make sure that the probe is located correctly in the stomach: attach the syringe to the probe and pull the plunger towards you; the contents of the stomach (water and gastric juice) should be drawn into the syringe or air should be introduced into the stomach using a syringe under the control of a phonendoscope (characteristic sounds are heard).
31. Disconnect the syringe from the probe and apply a clamp. Place the free end of the probe in the tray.
32. Remove the clamp from the probe, connect the Janet syringe without a piston and lower it to the level of the stomach. Tilt the Janet syringe slightly and pour in food heated to 37–38 °C. Gradually raise until the food reaches the cannula of the syringe.
33. Lower the Janet syringe to the original level and introduce the next portion of food. The required volume of the mixture is administered fractionally, in small portions of 30–50 ml, at intervals of 1–3 minutes. After introducing each portion, clamp the distal portion of the probe.
34. Rinse the tube with boiled water or saline solution at the end of feeding. Place a clamp on the end of the probe, disconnect the Janet syringe and close with the plug.
35. If it is necessary to leave the probe for a long time, secure it to the nose with a plaster and attach it with a safe pin to the patient’s clothing on the chest.
36. Remove the towel. Help the patient find a comfortable position.
Completing the procedure
37. Place used equipment in a disinfectant solution and then dispose of it.
38. Remove gloves and place in a disinfectant solution for subsequent disposal.
39. Wash and dry your hands.
40. Make a record of the procedure and the patient’s reaction.
Gastric lavage with a thick gastric tube
Equipment
1. A sterile system of 2 thick gastric tubes connected by a transparent tube.
2. Sterile funnel 0.5 - 1 liter.
3. Gloves.
4. Towel and napkins are medium.
5. Container with disinfectant solution.
b. Container for analysis of wash water.
7. Water container 10 liters (T - 20 - 25*C).
8. Capacity (basin) for draining wash water for 10 - 12 liters.
9. Vaseline oil or glycerin.
10. Two waterproof aprons and an absorbent diaper if washing is carried out while lying down.
11. Mug or jug for 0.5 - 1 liter.
12. Mouth retractor (if necessary).
13. Language supporter (if necessary).
14. Phonendoscope.
Preparation for the procedure
15. Explain the purpose and progress of the upcoming procedure. Explain that when inserting a probe, nausea and vomiting are possible, which can be suppressed by breathing deeply. Obtain consent for the procedure. Measure blood pressure and count pulse if the patient’s condition allows this.
16. Prepare equipment.
Executing the procedure
17. Help the patient take the position required for the procedure: sitting, pressed against the back of the seat and slightly tilting his head forward (or lay him on the couch in a side position). Remove the patient's dentures, if any.
18. Put on a waterproof apron for yourself and the patient.
19. Wash your hands and wear gloves.
20. Place the pelvis at the patient’s feet or at the head end of the couch or bed if the procedure is performed in the supine position.
21. Determine the depth to which the probe should be inserted: height minus 100 cm or measure the distance from the lower incisors to the earlobe and to the xiphoid process. Place a mark on the probe.
22. Remove the system from the packaging, moisten the blind end with Vaseline.
23. Place the blind end of the probe on the root of the tongue and ask the patient to make swallowing movements.
24. Insert the probe to the desired mark. Assess the patient's condition after swallowing the probe (if the patient coughs, remove the probe and repeat the insertion of the probe after the patient has rested).
25. Make sure that the probe is in the stomach: draw 50 ml of air into the Zhane syringe and attach it to the probe. Introduce air into the stomach under the control of a phonendoscope (characteristic sounds are heard).
26. Attach the funnel to the probe and lower it below the level of the patient’s stomach. Fill the funnel completely with water, holding it at an angle.
27. Slowly lift the funnel up 1 m and control the passage of water.
28. As soon as the water reaches the mouth of the funnel, slowly lower the funnel to the level of the patient’s knees and drain the rinsing water into a basin for rinsing water. Note: The first wash water can be collected in a container for testing.
29. Repeat washing several times until clean wash water appears, using the entire amount of water, collecting the wash water in a basin. Make sure that the amount of the injected portion of liquid corresponds to the amount of rinsing water released.
End of the procedure
30. Remove the funnel, remove the probe, passing it through a napkin.
31. Place used instruments in a container with a disinfectant solution. Pour the rinsing water into the sewer and first disinfect it in case of poisoning.
32. Remove aprons from yourself and the patient and place them in a container for disposal.
33. Remove gloves. Place them in a disinfectant solution.
34. Wash and dry your hands.
35. Give the patient the opportunity to rinse his mouth and escort (deliver) to the ward. Cover warmly and observe the condition.
36. Make a note about the completion of the procedure.
Diluting the antibiotic in a vial and performing an intramuscular injection
Equipment
1. Disposable syringe with a volume of 5.0 to 10.0, an additional sterile needle.
2. A bottle of benzylpenicillin sodium salt, 500,000 units, sterile water for injection.
5. Skin antiseptic.
6. Gloves.
7. Sterile tweezers.
8. Non-sterile tweezers for opening the bottle.
9. Containers with disinfectant solution for disinfecting used equipment
Preparation for the procedure
10. Check with the patient for information about the drug and his consent to the injection.
11. Help the patient find a comfortable lying position.
12. Wash and dry your hands.
13. Put on gloves.
14. Check: syringe and needles tightness, expiration date; medicine name, expiration date on the bottle and ampoule; packaging with tweezers expiration date; packaging with soft material expiration date.
15. Remove the sterile tray from the packaging.
16. Assemble the disposable syringe, check the patency of the needle.
17. Using non-sterile tweezers, open the aluminum cap on the bottle and cut off the ampoule with the solvent.
18. Prepare cotton balls and moisten them with a skin antiseptic.
19. Treat the bottle cap with a cotton ball moistened with alcohol and the ampoule with solvent, open the ampoule.
20. Draw the required amount of solvent into the syringe to dilute the antibiotic (200,000 units in 1 ml of dissolved antibiotic).
21. Puncture the stopper of the bottle with a needle of a syringe with solvent, | add solvent into the bottle.
22. Shake the bottle to ensure complete dissolution of the powder, and draw the required dose into the syringe.
23. Change the needle, displace the air from the syringe.
24. Place the syringe in a sterile tray.
Executing the procedure
25. Determine the site of the intended injection and palpate it.
26. Treat the injection site twice with a napkin or cotton ball with a skin antiseptic.
27. Stretch the skin at the injection site with two fingers or make a fold.
28. Take a syringe, insert the needle into the muscle at an angle of 90 degrees, two-thirds of the way, holding the cannula with your little finger.
29. Release the skin fold and use the fingers of this hand to pull the syringe plunger towards you.
30. Press down on the piston and slowly inject the medication.
End of the procedure
31. Remove the needle, pressing the injection site with a napkin or cotton ball with skin antiseptic.
32. Give a light massage without removing the napkin or cotton ball from the injection site (depending on the drug) and help to stand up.
33. Used material and equipment must be disinfected and subsequently disposed of.
34. Take off gloves and throw them into a container with disinfectant.
35. Wash and dry your hands.
36. Ask the patient how he feels after the injection.
37. Make a record of the procedure performed in the patient’s medical record.
Intradermal injection
Equipment
1. Disposable syringe 1.0 ml, additional sterile needle.
2. Medicine.
3. The tray is clean and sterile.
4. Sterile balls (cotton or gauze) 3 pcs.
5. Skin antiseptic.
6. Gloves.
7. Sterile tweezers.
Preparation for the procedure
10. Help the patient find a comfortable position (sitting).
11. Wash and dry your hands.
12. Put on gloves.
16. Prepare 3 cotton balls, moisten 2 balls with skin antiseptic, leave one dry.
Executing the procedure
21. Determine the site of the intended injection (middle inner part of the forearm).
22. Treat the injection site with a napkin or cotton ball with a skin antiseptic, then with a dry ball.
23. Stretch the skin at the injection site.
24. Take a syringe, insert the needle onto the bevel of the needle, holding the cannula with your index finger.
25. Press the piston and slowly introduce the drug with the hand used to stretch the skin.
End of the procedure
26. Remove the needle without cleaning the injection site.
29. Wash and dry your hands.
Subcutaneous injection
Equipment
1. Disposable syringe 2.0 volume, additional sterile needle.
2. Medicine.
3. The tray is clean and sterile.
4. Sterile balls (cotton or gauze) at least 5 pcs.
5. Skin antiseptic.
6. Gloves.
7. Sterile tweezers.
8. Containers with disinfectant solution for disinfecting used equipment
Preparation for the procedure
9. Check with the patient for information about the drug and obtain his consent to the injection.
11. Wash and dry your hands.
12. Put on gloves.
13. Check: syringe and needles tightness, expiration date; medicine name, expiration date on the package and ampoule; packaging with tweezers expiration date; packaging with soft material expiration date.
14. Remove the sterile tray from the packaging.
15. Assemble the disposable syringe, check the patency of the needle.
17. Open the ampoule with the medicine.
18. Draw up the medicine.
19. Change the needle, displace the air from the syringe.
20. Place the syringe in a sterile tray.
Executing the procedure
23. Take the skin at the injection site in the fold.
24. Take a syringe and insert the needle under the skin (at an angle of 45 degrees) two-thirds of the needle’s length.
25. Release the skin fold and use the fingers of this hand to press the piston and slowly inject the medication.
End of the procedure
26. Remove the needle, pressing the injection site with a napkin or cotton ball with skin antiseptic.
27. Used material and equipment must be disinfected and subsequently disposed of.
28. Take off gloves and throw them into a container with disinfectant.
29. Wash and dry your hands.
30. Ask the patient how he feels after the injection.
31. Make a record of the procedure performed in the patient’s medical record.
Intramuscular injection
Equipment
1. Disposable syringe with a volume of 2.0 to 5.0, an additional sterile needle.
2. Medicine.
3. The tray is clean and sterile.
4. Sterile balls (cotton or gauze) at least 5 pcs.
5. Skin antiseptic.
b. Gloves.
7. Sterile tweezers.
8. Containers with disinfectant solution for disinfecting used equipment
Preparation for the procedure
9. Check with the patient for information about the drug and obtain his consent to the injection.
10. Help the patient find a comfortable lying position.
11. Wash and dry your hands.
12. Put on gloves.
13. Check: syringe and needles tightness, expiration date; medicine name, expiration date on the package and ampoule; packaging with tweezers expiration date; packaging with soft material expiration date.
14. Remove the sterile tray from the packaging.
15. Assemble the disposable syringe, check the patency of the needle.
16. Prepare cotton balls and moisten them with a skin antiseptic.
17. Open the ampoule with the medicine.
18. Draw up the medicine.
19. Change the needle, displace the air from the syringe.
20. Place the syringe in a sterile tray.
Executing the procedure
21. Determine the site of the intended injection and palpate it.
22. Treat the injection site twice with a napkin or cotton ball with a skin antiseptic.
23. Stretch the skin at the injection site with two fingers.
24. Take a syringe, insert the needle into the muscle at an angle of 90 degrees, two-thirds of the way, holding the cannula with your little finger.
25. Pull the syringe plunger towards you.
26. Press down on the piston and slowly inject the medication.
End of the procedure
27. Remove the needle; pressing the injection site with a napkin or cotton ball with skin antiseptic.
28. Give a light massage without removing the napkin or cotton ball from the injection site (depending on the drug) and help to stand up.
29. Used material and equipment must be disinfected and subsequently disposed of.
30. Take off gloves and throw them into a container with disinfectant.
31. Wash and dry your hands.
32. Ask the patient how he feels after the injection.
33. Make a record of the procedure performed in the patient’s medical record.
WHEN DETECTING PEDICULOSIS:
1. Put on an additional robe and headscarf.
2. Sit the patient in the locker room on a couch covered with oilcloth.
3. Using a cotton swab, treat the patient’s hair:
0.15% karbofos (1 teaspoon per 0.5 l of water);
0.5% solution of methyl acetophos in half with acetic acid;
0.25% dicresyl emulsion;
20% water-soap suspension of benzyl benzoate;
Lotion "Nittifor";
5% boric ointment;
Soap-powder emulsion (composition: 450 ml shampoo + 350 ml kerosene + 200 ml warm water);
Shampoo "Grincid", bottle 25 ml;
- “Perfolon”, bottle 50 ml.
REMEMBER!
Children under 5 years of age, pregnant and lactating women should not use organophosphorus solutions.
4. Cover your hair with a scarf for 20 minutes (Nittifor lotion - 45 minutes);
5. Rinse your hair with warm water.
6. Rinse with a 6% vinegar solution. Comb with a fine comb for 10 - 15 minutes. If there are lice (pubic lice), treat the hair on the pubis and armpits - rub 10% sulfur or white mercury ointment into the skin.
7. Place the patient’s linen, gown, and nurse’s scarf in a bag and place it in a disinfection chamber! At home - boil in a 2% soda solution for 15 minutes, iron with a hot iron on both sides. Treat outerwear with karbofos and leave for 20 minutes. in a plastic bag, air dry.
8. After disinsection, the room and objects are treated with the same disinfectant solutions.
9. On the title page of the medical history, a mark “P” is made in the upper right corner with a red pencil (monitoring by the guard nurse after 7 days).
10. Fill out the “Emergency Notification of an Infectious Disease” and send it to the district SES at the patient’s place of residence. Then the patient, accompanied by a nurse, goes to the bathroom to take a hygienic bath or shower.
TRANSPORTATION OF THE PATIENT TO THE DEPARTMENT.
The method of delivering the patient to the department is determined by the doctor depending on the severity of the patient’s condition: on a stretcher (manually or on a gurney), on a wheelchair, on a gurney, on foot.
The most convenient, reliable and gentle way to transport seriously ill patients is on a gurney.
It is more convenient for three people to transfer the patient from the couch to the gurney and back.
SEQUENCE OF ACTIONS WHEN TRANSPORTING ON A GROLLER.
1. Place the gurney perpendicular to the couch - the head end of the gurney to the foot end of the couch.
1. All three stand near the patient on one side
2. a) one places his hands under the patient’s head and shoulder blades;
3. b) the second - under the pelvis and upper thighs;
4. c) the third - under the middle of the thighs and lower legs.
5. Having lifted the patient, turn 90 degrees towards the gurney with him.
6. Place the patient on the gurney and cover him.
7. Inform the department that a patient has been referred to them in serious condition.
8. Send the patient and his medical record to the department, accompanied by a health care worker.
9. In the department, bring the head end of the gurney to the foot end of the bed, three of us lift the patient and, turning 90 degrees, place him on the bed.
10. If there is no gurney, then 2–4 people carry the stretcher manually. Carry the patient feet first down the stairs, with the front end slightly elevated. The patient is carried up the stairs head first.
SEQUENCE OF ACTIONS WHEN TRANSPORTING A PATIENT ON A CHAIR:
1. The junior nurse tilts the gurney chair forward by stepping on the footrest.
2. Have the patient stand on the footrest, then support the patient in the chair.
3. Lower the wheelchair to its original position.
4. Make sure that during transportation the patient’s arms do not extend beyond the armrests of the wheelchair.
NOTE:
FOR ANY METHOD OF TRANSPORTING A PATIENT TO THE DEPARTMENT, THE ACCOMPANYING MAN IS RESPONSIBLE TO TRANSFER THE PATIENT AND HIS MEDICAL CARD TO THE ROOM NURSE.
WASH THE NURSE'S HAND BEFORE AND AFTER PERFORMING MANIPULATIONS.
Hand washing for nursing staff is a mandatory requirement both before and after performing manipulations.
Sequence of actions:
1. open the tap and adjust the temperature and water flow;
2. wash the lower third of the left and then the right forearm with soap, rinse off the soap with water;
3. wash the left hand and the spaces between the fingers with soap, then the right hand and the spaces between the fingers, rinse off the soap with water;
4. Wash the nail phalanges of the left and then the right hand with soap;
5. close the tap without touching it with your fingers;
6. Dry your left hand first, then your right hand (it is advisable to use paper towels for these purposes).
CHANGING LINEN FOR A SERIOUSLY ILL PATIENT
EQUIPMENT: clean linen, waterproof (preferably an oilskin bag for
dirty linen, gloves).
CHANGE OF UNDERWEAR.
ACTION ALGORITHM:
2. Elevate the patient's upper body.
3. Carefully roll the dirty shirt up to the nape of your neck.
4. Raise both the patient’s arms and move the shirt rolled up at the neck
5. over the patient's head.
6. Then remove the sleeves. If the patient's arm is injured, then the shirt first
7. remove from the healthy hand, and then from the sick one.
8. Place the dirty shirt in an oilcloth bag.
9. Dress the patient in the reverse order: first put on the sleeves (first on
10. the sore arm, then the healthy one, if one arm is damaged), then
11. Throw the shirt over your head and straighten it under the patient’s body.
R O M N I T E! The patient's linen is changed at least once every 7-10 days, for a seriously ill patient - when soiled. To change the linen of a seriously ill patient, it is necessary to invite 1 - 2 assistants.
CHANGE OF BED LINEN.
There are two ways to change bed linen for a seriously ill patient:
1 way– used if the patient is allowed to turn in bed.
A L G O R I T M ACTIONS:
1. Wash your hands, put on gloves.
2. Unfold the patient, elevate his head and remove the pillow.
3. Move the patient to the edge of the bed and gently turn him onto his side.
4. Roll the dirty sheet along its entire length towards the patient
5. Spread a clean sheet on the vacant part of the bed.
6. Gently turn the patient onto his back and then onto his other side so that he is on a clean sheet.
7. Remove the dirty sheet from the freed part and place it in an oilcloth bag.
8. Spread a clean sheet over the freed part, tuck the edges under the mattress.
9. Place the patient on his back.
10. Place a pillow under your head, if necessary, first change the pillowcase on it.
11. If dirty, change the duvet cover and cover the patient.
12. Remove gloves, wash your hands.
Method 2– used in cases where the patient is prohibited from active movements in bed.
A L G O R I T M ACTIONS:
1. Wash your hands, put on gloves.
2. Roll up a clean sheet completely in the transverse direction.
3. Unfold the patient, carefully lift the patient's upper torso, and remove the pillow.
4. Quickly roll up the dirty sheet from the head of the bed to the lower back, and spread a clean sheet over the freed part.
5. Place a pillow on a clean sheet and lower the patient onto it.
6. Raise the pelvis, and then the patient’s legs, move the dirty sheet, continuing to straighten the clean one in the free space. Lower the patient's pelvis and legs and tuck the edges of the sheet under the mattress.
7. Place the dirty sheet in an oilcloth bag.
8. Cover the patient.
9. Remove gloves, wash your hands.
SUPPLYING THE VESSEL TO THE PATIENT
EQUIPMENT: vessel, oilcloth, screen, gloves.
A L G O R I T M ACTIONS:
1. Wear gloves.
3. Rinse the vessel with warm water, leaving some water in it.
4. Place your left hand under the sacrum on the side, helping the patient raise the pelvis, while the patient’s legs should be bent at the knees.
5. Place an oilcloth under the patient’s pelvis.
6. With your right hand, move the vessel under the patient’s buttocks so that the perineum is above the opening of the vessel.
7. Cover the patient with a blanket and leave him alone for a while.
8. After defecation is completed, remove the pan with your right hand, while helping the patient to lift the pelvis with your left hand.
9. After examining the contents of the vessel, pour it into the toilet and rinse the vessel with hot water. If there are pathological impurities (mucus, blood, etc.), leave the contents of the vessel until examined by a doctor.
10. Clean the patient by first changing gloves and using a clean vessel.
12. Disinfect the vessel.
13. Cover the vessel with oilcloth and place it on a bench under the patient’s bed or place it in a specially retractable device of a functional bed.
14. Remove the screen.
15. Remove gloves, wash your hands.
Sometimes the method described above for raising the bedpan cannot be used, since some seriously ill patients cannot lift themselves up. In this situation, you can proceed as follows.
A L G O R I T M ACTIONS:
1. Wear gloves.
2. Separate the patient with a screen.
3. Turn the patient slightly to one side, with the patient's legs bent at the knees.
4. Place the bedpan under the patient's buttocks.
5. Turn the patient onto his back so that his perineum is above the opening of the bedpan.
6. Cover the patient and leave him alone.
7. Once the bowel movement is complete, turn the patient slightly to one side.
8. Remove the bedpan.
9. After inspecting the contents of the vessel, pour it into the toilet. Rinse the vessel with hot water.
10. After changing gloves and using a clean vessel, wash the patient.
11. After completing the manipulation, remove the vessel and oilcloth.
12. Disinfect the vessel.
13. Remove the screen.
14. Remove gloves, wash your hands.
NOTE:
In addition to enameled vessels, rubber ones are also widely used. A rubber bed is used for weakened patients, those with bedsores, and urinary and fecal incontinence. Do not inflate the vessel too tightly, as it will put significant pressure on the sacrum. The inflatable cushion of the rubber bed (that is, the part of the bed that will come into contact with the patient) must be covered with a diaper. Men are given a urine bag at the same time as the bedpan.
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:
Nosebleed;
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 proper 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;
Increase in temperature;
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 that the patient is regularly washed and the perineum is lubricated 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.
d) 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 for carrying 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 arms 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:
Wet 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;
· lie 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 (calling an ambulance is possible 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 individual means of care (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 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 the level of anxiety, her mood has improved somewhat, she knows what kind of life she should lead 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.
Measuring body temperature in the armpit
1. Examine 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.Register 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 golden-yellow liquid 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, and 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 diuresis.
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 the left hand, spread the patient’s buttocks, and with the 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 are gases and the patient feels full, it is necessary to lower the mug below the couch and raise it again after the gases have 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.
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.
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 person, 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?
