Respiration Types of respiration: external - pulmonary - delivery of oxygen to the blood; internal - the transfer of oxygen from the blood to organs and tissues. - a vital human need, a process that ensures the continuous supply of oxygen to the body and the removal of carbon dioxide and water vapor to the outside.
20 - tachypnea; 20 - tachypnea; 5 Characteristics in a healthy person In pathology Rhythmicity - regularity of inhalations and exhalations at certain intervals rhythmic arrhythmia (respiratory) Frequency - number of breaths per minute > 20 - tachypnea; 20 - tachypnea; 20 - tachypnea; 20 - tachypnea; 20 - tachypnea; title="(!LANG:Characteristics in a healthy personIn pathology Rhythmicity - regularity of inhalations and exhalations at certain intervals rhythmic arrhythmia (respiratory) Frequency - number of breaths per minute 16-20 > 20 - tachypnea;
Respiration Types of shortness of breath: Physiological - in a healthy person during excitement, physical exertion. Pathological: inspiratory - difficult to inhale (foreign body, laryngitis); expiratory - exhalation is difficult (bronchospasm - bronchial asthma); mixed - both inhalation and exhalation are difficult (heart disease). Shortness of breath is a violation of breathing in rhythm, frequency, depth.
Nursing intervention plan for dyspnoea Nursing interventions: Rationale 1. Calm the patient Reduce emotional stress 2. Raise the head of the bed, seat the patient comfortably Ease breathing 3. Provide ventilation, unbutton the collar, fold back the blanket 4. Prohibit the patient from smoking 5. Assist the patient in self-care Comfortable content 6. Monitor the general condition, PS, BP, respiratory rate Early detection of complications 7. As directed by the doctor, provide oxygen supply, administration of drugs Provide treatment
Properties of the pulse Properties (criteria) of the pulse In a healthy pathology Symmetry - the coincidence of pulse waves on both hands symmetrical asymmetric (narrowing or squeezing of the artery) Rhythm - alternation of pulse waves at certain intervals rhythmic arrhythmia Frequency - the number of pulse waves per minute> 80 - tachycardia; 80 - tachycardia; "> 
Blood pressure Systolic blood pressure (normal mm Hg) - maximum - during the contraction of the left ventricle of the heart. Reflects the state of the heart and arterial system. Diastolic (normally 60-90 mm Hg) - minimal - in the phase of relaxation of the left ventricle. Indicates the resistance of blood vessels. Pulse pressure (optimally - 40-50 mm Hg. Art.) - the difference between the indicators of systolic and diastolic blood pressure. Increase - hypertension Decrease - hypotension.
Fainting Factors of occurrence: severe neuropsychic shock (fear, sharp pain, sight of blood), overwork, stuffiness. Subjective sensations before fainting: lightheadedness, dizziness, tinnitus. Objectively: lack of consciousness, pale skin, cold extremities, weak pulse, possible decrease in blood pressure. - short-term loss of consciousness due to acute insufficiency of blood supply to the brain. Plan for nursing interventions for syncope Nursing interventions Rationale 1. Lay the patient horizontally, without a pillow, with legs elevated Ensuring blood flow to the vessels of the head 2. Open the window, unbutton the collar Facilitate breathing 3. Spray the face with cold water, bring ammonia to the nose (at a distance of 15 cm) , pat on the cheeks, call by name Influence on receptors 4. After providing assistance, put the patient to bed for 2 hours, cover, place a heating pad at the feet Prevention of repeated fainting 5. Drink hot coffee, strong tea 6. Determine hemodynamic parameters (PS, BP) Early detection of acute vascular insufficiency 7. In case of low BP, inform the doctor, prepare and administer prescribed drugs Provide treatment
CHAPTER 5
GRADE
FUNCTIONAL STATE
The student must know:
Normal thermometry;
Physiological fluctuations in body temperature;
Maximum mercury thermometer device;
The main properties of the pulse and the factors that affect them;
Places for the study of the pulse;
Normal values of pulse rate, characteristic of rhythm and tension;
Equipment needed to measure blood pressure (BP);
Normal blood pressure values;
Errors that occur when measuring blood pressure;
The normal value of the frequency of respiratory movements.
The student must be able to:
Measure body temperature;
Measure the pulse and determine its properties;
Measure blood pressure;
Concepts and terms:
Blood pressure is the pressure that the blood in an artery exerts on its wall;
bradycardia- heart rate less than 60 in 1 min;
hyperemia- redness;
fever- protective and adaptive reaction of the body, which occurs in response to the action of pathogenic stimuli and is expressed in the restructuring of thermoregulation to maintain a higher than normal level of heat content and body temperature;
ovulation- rupture of the ovarian follicle and the release of a mature egg into the abdominal cavity;
pulse- periodic jerky oscillations of the walls of blood vessels associated with a change in their blood supply and the dynamics of pressure in them during one cardiac cycle;
tachycardia- heart rate more than 100 in 1 min;
thermometry- measurement of human body temperature.
5.1. BODY TEMPERATURE
thermoregulation
The body temperature of a healthy person during the day is subject to slight fluctuations, but does not exceed 37 ° C. Maintaining body temperature at a constant level is provided by neurohumoral regulation of heat production (heat generation) and heat transfer.
The formation of heat in the body occurs as a result of oxidative processes in cells. The higher the intensity of metabolic processes, the greater the heat production. Heat transfer to the environment can be carried out by conduction, heat radiation and evaporation. The body's ability to change the level of heat transfer depends on the network of skin blood vessels, which can quickly and significantly change their lumen. With insufficient heat production in the body (cooling), reflex constriction of the skin vessels occurs and heat transfer decreases. The skin becomes cold, dry, sometimes there is a chill (muscle trembling), which contributes to some increase in heat production by skeletal muscles. With an excess of heat (overheating), a reflex expansion of the skin vessels is observed, the blood supply to the skin increases and, accordingly, the heat transfer by conduction and radiation increases. If these mechanisms of heat transfer are not enough (for example, during a lot of physical work), sweating increases sharply: evaporating from the surface of the body, sweat provides an intensive loss of heat by the body.
In the armpit of a person, the temperature is 36.4-36.8 ° C. The temperature of °C is the maximum (lethal), at which irreversible changes occur at the cellular level, metabolism is disturbed and death occurs. The minimum body temperature at which irreversible processes are also observed is 23-15 "C.
Physiological fluctuations in body temperature during the day in the same person are 0.3-0.5 ° C. In elderly and senile people, the temperature is often lowered (subnormal). The mechanisms of thermoregulation in children are imperfect, and metabolic processes are more intense, due to this, there is an instability of body temperature with large fluctuations during the day. In newborns in the armpit, the temperature is 37.2 "C. When measuring temperature in the rectum, vagina, oral cavity, it is 0.2-0.4 ° C higher than in the armpit. In women, the body temperature of envy from the phase of the menstrual cycle : during the period of ovulation, it rises by 0.6-0.8 ° C. Body temperature rises with intense physical and emotional stress, food intake.During depression, on the contrary, it decreases.
Thermometry
Body temperature is usually measured with a maximum medical thermometer.
This is a glass tank in which a scale and a capillary are soldered, having an extension filled with mercury at the end. Mercury, heating up and increasing in volume, rises through the capillary to a certain mark on the thermometer scale. The maximum height of the mercury column and determines the name of the thermometer - the maximum. Mercury cannot sink into the tank on its own, as this is prevented by a sharp narrowing of the capillary in the lower part. Return the mercury to the tank by shaking.
The thermometer scale is designed to determine body temperature with an accuracy of 0.1 ° C from 34 to 42 ° C.
Thermometry is usually carried out twice a day: in the morning at 7-8 o'clock and g in the evening at 17-18 o'clock. (between 17 and 21 h). In our country, most often thermometry is carried out in the armpit. For a quick release of the phenomenon (for example, in children's groups) of people with a high temperature, "Termotest" is used - a polymer plate coated with an emulsion of liquid crystals. To measure the temperature, it is applied to the forehead: at 36-37 ° C, the letter N (Norma) glows green on the plate, and above 37 ° C - the letter F (Febris - fever)
Rice. 5-2. Measurement of body temperature in the armpit: a - shaking a medical thermometer; b - checking the thermometer indicators before measuring the temperature; c - preparation of the armpit; d - temperature measurement. The height of the temperature rise is determined by a medical thermometer.
Measurement of body temperature in the armpit (Fig. 5-2)
C. Otherwise, shake the thermometer until the mercury reading is below 35°C.
Make sure that the skin in the patient's armpit is dry. If necessary, wipe it off with a clean gauze pad.
II. Performing a procedure
Examine the axillary region.
Place the thermometer so that the mercury reservoir is in the center of the patient's armpit (fully in contact with the skin).
Ask the patient to press his hand to the chest.
Remove the thermometer from the armpit after 10 minutes and determine its readings.
III.Completion of the procedure
Inform the patient of the thermometry result.
1 Write it down in the ward and individual temperature sheets (in the conditions of an inpatient medical institution) or in an outpatient card.
Immerse the thermometer in a container with a disinfectant (in a healthcare facility).
Wash the hands.
Rinse the thermometer under cold running water after the necessary disinfection exposure, wipe it dry, and put it in a case.
Wash the hands.
Registration of thermometry data
In a medical institution, the names of all patients (by ward), the date and time of temperature measurement (morning, evening) are indicated in the temperature sheet. The temperature measurement results are transferred from the post temperature sheet to the individual temperature sheet (Fig. 5-3). It is entered in the admission department together with the first medical card for each patient admitted to the hospital. In addition to graphical recording of temperature measurement data (T scale), frequency curves (P scale) and blood pressure curves (BP scale) are built in the temperature sheet.
C. The results of daily two-time thermometry are applied with the corresponding points.
The morning temperature is recorded as a blue or black dot in the "y" column, the evening temperature in the "c" column. These points are interconnected, forming the so-called temperature curves, reflecting one or another type of fever in the presence of fever.
5.2. PULSE STUDY
There are venous, arterial and capillary pulses. The arterial pulse is the rhythmic oscillation of the artery wall due to the ejection of blood into the arterial system during one cardiac cycle. The arterial pulse can be central (on the aorta, carotid arteries) or peripheral (on the radial artery, dorsal artery of the foot, etc.).
Soreness" href="/text/category/boleznennostmz/" rel="bookmark">painful procedure, received bad news, pulse examination should be postponed, as these factors can increase the frequency and change other properties of the pulse.
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The pulse on the femoral artery is examined in the inguinal region with the hip straightened with a slight outward turn (Fig. 5-10 a).
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The pulse on the posterior tibial artery is examined behind the internal ankle, pressing the artery against it (Fig. 5-10 b). The pulsation of the artery of the rear of the foot is determined on the dorsum of the foot, in the proximal part of the first interdigital space (Fig. 5-10 c).
Measurement of the pulse on the radial artery (in a hospital setting)
Equipment: clock or stopwatch, temperature sheet, pen, paper.
I.Preparation for the procedure
Explain to the patient the essence and course of the study. Obtain his consent to the procedure.
Wash the hands.
II.Performing a procedure
Note. During the procedure, the patient can sit or lie down. Offer to relax the arm, while the hand and forearm should not be “on weight”.
Press II-IV fingers on the radial arteries on both hands of the patient and feel the pulsation (I finger is located on the back of the hand).
Determine the rhythm of the pulse for 30 s.
Take a watch or a stopwatch and examine the arterial pulsation rate for 30 seconds: if the pulse is rhythmic, multiply by two, if the pulse is non-rhythmic, count the frequency for 1 minute.
Report the result to the patient.
Record the result of determining the rhythm and pulse rate.
Press the artery more strongly than before against 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).
Inform the patient of the test result.
Write down the result.
III.Completion of the procedure
Help the patient to get into a comfortable position or stand up.
Wash the hands.
Mark the results of the study in the temperature sheet (or in the protocol for the care plan).
5.3. BLOOD PRESSURE MEASUREMENT
Arterial pressure is the pressure that is formed in the arterial system of the body during heart contractions. Its level is affected by the magnitude and speed of cardiac output, heart rate and rhythm, peripheral resistance of the walls of the arteries.
The pressure maintained in the arterial vessels in diastole due to their tone is called diastolic. The difference between systolic and diastolic pressure forms the pulse pressure.
Normal systolic blood pressure fluctuates within the limit ah 100-120 mm rt. Art., diastolic - 60-80 mm Hg. Art. To a certain extent, they depend on the age of the person.
So, in the elderly, the maximum systolic pressure is 150 mm Hg. Art., and diastolic - 90 mm Hg. Art. (WHO recommendations, 1999). A short-term increase in blood pressure (mainly systolic) is observed during emotional stress, physical stress. Each person has a certain amount of blood pressure at which he feels good. Such blood pressure is often called "working". In one person, it coincides with normal indicators, in another it is above or below the norm.
Arterial hypertension is a condition in which systolic blood pressure exceeds 140 mm Hg. Art. and/or diastolic blood pressure greater than 90 mm Hg. Art. (as a result of at least three measurements taken at different times against the backdrop of a calm environment; the patient should not take drugs that increase or decrease blood pressure). A decrease in blood pressure below normal is called arterial hypotension.
In everyday practice, blood pressure is most often measured by the sound method proposed in 1905 by a Russian surgeon, using a sphygmomanometer (tonometer) apparatus. The sphygmomanometer consists of a mercury or spring manometer connected to a cuff and a rubber bulb. The flow of air into the cuff is regulated by a special valve that allows you to maintain and smoothly reduce the pressure in the cuff. Currently, electronic devices are used to determine blood pressure by a non-sound method.
Blood pressure readings are more reliable if they are measured using a cuff that matches the circumference of the upper arm (Table 5-1). If a standard 12 cm cuff is used, true BP readings will be recorded in individuals with an arm circumference of 25-30 cm.
It is recommended to use a cuff 20% wider than the arm diameter and up to 30 cm long. If the cuff is wider, the measurement results will be erroneously low. If it is too narrow, the indicators will be overestimated.
Table 5-1. The dependence of the size and width of the cuff on the circumference of the shoulder
If it is not possible to choose a cuff of the appropriate size, the size of the circumference of the shoulder should be taken into account. When measured on a thin arm, blood pressure will be lower, and on a full arm it will be higher than the true one. The value of systolic blood pressure does not require correction with a shoulder circumference of about 30 cm, diastolic - with a shoulder circumference of 15-20 cm. With a shoulder circumference of 15-30 cm, it is recommended to add 15 mm Hg to the systolic pressure indicator. Art., with a circumference of 45-50 cm - subtract 15-20 mm Hg from the result. Art.
Table 5-2. Dependence of the degree of "false" increase in blood pressure on the circumference of the shoulder in obesity
With an increase in the circumference of the shoulder, a “false” increase in blood pressure is recorded (Table 5-2). In obese individuals, the cuff width should be 18 cm (an idea of \u200b\u200btrue systolic blood pressure can be obtained by measuring blood pressure by palpation of the radial artery, applying a conventional cuff to the forearm).
Blood pressure is usually measured on the brachial artery, in which it is close to the pressure in the aorta (it can be measured on the femoral, popliteal and other peripheral arteries).
In addition to blood pressure monitors, another device called a phonendoscope is needed to measure blood pressure. Before measuring blood pressure, you need to make sure that the membrane - and the tubes of the phonendoscope are not damaged, otherwise there may be interference that makes the study difficult. The whole procedure should last no more than 1 minute. After completing the blood pressure measurement, wipe the membrane with a swab moistened with 70 ° alcohol. °
Attention! Measure blood pressure usually 2-3 times at intervals | in 1-2 minutes, the air from the cuff is released each time § completely.
In addition to the digital recording of blood pressure in the form of a fraction, these measurements are recorded in the temperature sheet in the form of a column, the upper limit of which means systolic, and the lower one - diastolic pressure.
Errors in measuring blood pressure
The most common mistake is related to incorrect cuff selection.
In some cases, in the interval between systolic and diastolic pressure, the intensity of the tones weakens, sometimes significantly. This can be mistaken for an increase in diastolic pressure. However, if you continue to release air from the cuff, the intensity of the tones will again begin to increase, and they will disappear at the level of true diastolic pressure.
If, at the beginning of the study, the pressure in the cuff turns out to be raised only to the level of "intermediate fading of tones", then one can make a mistake in determining the systolic pressure - it will turn out to be significantly underestimated. In order to prevent this error, the pressure in the cuff is raised “with a margin” and, releasing air, continue to listen to the tones on the brachial artery until they disappear completely, and in the presence of the “endless tones phenomenon” (tones heard to zero) - to a sharp muffle .
With a strong pressure on the area of the brachial artery with a phonendoscope, in some patients, tones are heard to zero. In such a situation, one should not press the head of the phonendoscope on the area of the artery, diastolic pressure should be noted by a sharp decrease in the intensity of tones. In some cases, the patient has to measure the arterial
pressure on your own. Nursing staff should be trained
this patient manipulation.
Blood pressure measurement
Equipment: tonometer, phonendoscope, pen, paper, temperature sheet (protocol to the care plan, outpatient card), napkin with alcohol.
I.Preparation for the procedure
Warn the patient about the upcoming study 15 minutes before it starts.
Clarify the patient's understanding of the purpose and course of the study and obtain his consent to conduct.
Select the correct cuff size.
Ask the patient to lie down (if the previous measurements were taken in the “lying” position) or sit down at the table.
Valve "href="/text/category/ventilmz/" rel="bookmark"> valve on the "pear", turning it to the right, with the same hand, quickly inflate the cuff with air until the pressure in it exceeds 30 mm Hg st - the level at which Korotkoff's tones (or pulsation of the radial artery) disappear.
Release air from the cuff at a speed of 2-3 mm Hg. Art. in 1 s by turning the valve to the left. Using a phonendoscope, listen to the tones on the brachial artery. Follow the readings on the manometer scale: when the first sounds (Korotkov sounds) appear, “mark” on the scale and remember the number corresponding to the systolic pressure. Continuing to release air from the cuff, note the amount of diastolic pressure corresponding to the weakening or complete disappearance of the Korotkoff sounds.
Inform the patient of the measurement result.
Repeat the procedure after 2-3 minutes.
III.Completion of the procedure
Round the measurement data to 0 or 5, write it down as a fraction (in the numerator - systolic pressure; in the denominator - diastolic).
Wipe the membrane of the phonendoscope with a cloth moistened with alcohol.
Record the study data in the required documentation.
Wash the hands.
Teaching the patient to measure blood pressure
In many diseases, self-control of blood pressure is a necessary condition for successful treatment. The patient usually needs training in this skill.
Equipment: tonometer, phonendoscope, pen, observation diary.
I.Preparation for the procedure
· Tell the patient that you will teach him how to measure blood pressure.
Determine the patient's motivation and ability to learn.
Clarify with the patient whether he agrees to be trained in measuring blood pressure.
II.Patient Education
Familiarize the patient with the device of the tonometer and phonendoscope.
Warn him that blood pressure can be measured no earlier than 15 minutes after exercise.
Demonstration of cuff application technique. Put the cuff on your left bare shoulder (put it on like a sleeve) 1-2 cm above the elbow bend, having previously rolled up the tube along the diameter of the arm. Clothing should not squeeze the shoulder above the cuff; One finger must pass between the cuff and the upper arm.
Demonstrate the technique of connecting the cuff and the pressure gauge, check the position of the pressure gauge needle relative to the zero mark of the scale.
Insert the phonendoscope into the ears, put the membrane of the phonendoscope at the place where the pulse is detected so that its head is under the cuff.
Demonstrate the technique of using a pear:
Take in the hand on which the cuff, pressure gauge is applied, another “pear” so that fingers I and II can be opened and | close the valve;
Close the valve on the “pear”, turning it to the right, inject air into the cuff after the disappearance of tones by another 30 mm Hg. Art.
Slowly open the valve, turning it to the left, release 8 air at a speed of 2-3 mm Hg. Art. in 1 s. At the same time, using a phonendoscope, listen to Korotkoff sounds on the brachial artery and monitor the readings on the pressure gauge scale. Focus the patient's attention on the fact that the appearance of the first sounds corresponds to the value of systolic pressure, and the transition of loud sounds to deaf or their complete disappearance corresponds to the value of diastolic pressure.
Write the result as a fraction.
Ensure that the patient has learned the technique of measuring blood pressure by asking for a demonstration of the procedure. Provide written instructions if necessary.
Learn to keep an observation diary.
Warn the patient that he should measure blood pressure 2-3 times with an interval of 2-3 minutes.
After training, wipe the membrane and ear ends of the phonendoscope with a ball of alcohol.
Wash the hands.
There are special blood pressure monitors designed specifically for self-monitoring. In the cuff of such a tonometer (Fig. 5-12) there is a “pocket” for fixing the head of the phonendoscope.
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5.4. DETERMINATION OF THE NUMBER OF RESPIRATORY MOVEMENTS
The combination of inhalation and exhalation following it is considered one respiratory movement. The number of breaths per minute is called the respiratory rate (RR) or simply the respiratory rate. Normal breathing movements are rhythmic.
In some cases, it is necessary to determine the respiratory rate. The frequency of respiratory movements in an adult at rest is 16-20 per minute, in women it is 2-4 breaths more than in men (WHO recommendations, 1999). In the "lying" position, the number of breaths usually decreases (up to 14-16 per minute), in an upright position it increases (18-20 per minute). In trained people and athletes, the frequency of respiratory movements can decrease and reach 6-8 per minute.
Factors leading to an increase in heart contractions can: cause an increase in the depth and increase in breathing. These include: physical activity, fever, strong emotional experience, pain, blood loss, etc.
The patient can voluntarily change the frequency, depth, rhythm of breathing, so breathing should be monitored unnoticed. For example, while counting breaths, you can tell the patient that you are examining his pulse (Figure 5-14).
Determination of the frequency, depth, rhythm of breathing (in a hospital)
Equipment: clock or stopwatch, temperature sheet, pen, paper.
I.Preparation for the procedure
Warn the patient that a pulse test will be performed (do not inform the patient that the purity of breathing will be tested).
Wash the hands.
Ask the patient to sit (lie down) more comfortably in order to see the upper part of his chest and (or) abdomen.
II.Performing a procedure
Take the patient by the hand as for the study of the pulse. Observe the excursion of his chest and count the breaths for 30 seconds, then multiply the result by 2.
If it is not possible to observe the excursion of the thoracic tki, then put your hands on the chest (for women) or the epigastric region (for men), simulating a pulse test while continuing to hold your hand at the wrist). Record the results in the accepted documentation.
III.Completion of the procedure
State Autonomous Vocational Educational Institution of the Saratov Region"Engels Medical College of St. Luke (Voino-Yasenetsky)"
LECTURE MATERIAL
ON MDK "TECHNOLOGY OF RENDERING MEDICAL SERVICES"
Specialty: 34.02.01 "Sisterhood"
Qualification: nurse
Compiled by the teacher
Budakaeva B.K.
Considered at the PC meeting
"Sisterhood"
Protocol No. _______
from "___" __________ 20__
PC Chairman __________
LECTURE #1
thermoregulation
thermoregulation called a set of processes of regulation of heat generation and heat transfer. Maintaining a certain balance between these processes provides a relatively constant body temperature in a healthy person.
Heat generation carried out due to oxidative processes in muscles and internal organs: the higher the metabolic rate, the greater it is.
Heat dissipation carried out by conduction, heat radiation and evaporation (sweating).
When the ambient temperature rises the blood vessels of the skin expand, its thermal conductivity and heat radiation increase, sweating increases, which leads to an increase in heat transfer and prevents overheating.
When the ambient temperature drops heat transfer decreases due to a decrease in the thermal conductivity of the skin and narrowing of its blood vessels, heat production increases due to increased contractile activity of skeletal muscles (muscle tremors), which prevents a decrease in body temperature and hypothermia.
Physiological temperature fluctuations
Body temperature, measured in the armpit, is normally 36-37 0 C. Physiological fluctuations during the day are usually 0.1-0.8 0 C. The maximum body temperature is recorded in the afternoon from 17 to 21 hours, and the minimum - early in the morning (from 3 to 6 a.m.). A slight increase in body temperature is observed after eating, with intense muscular work, strong emotional stress.
The normal temperature, measured in the rectum, vagina, oral cavity, is 0.5-0.8 0 C higher than in the armpit.
The lethal (fatal) maximum body temperature is 43 0 C. At this temperature, irreversible metabolic disorders occur. The lethal minimum body temperature is 15-23 0 С.
Physiological fluctuations in body temperature normally do not exceed 1 0 C.
Medical thermometer device
Body temperature is usually measured with a maximum (mercury) medical thermometer. Mercury, heating up and increasing in volume, rises through the capillary, along which the thermometer scale is located. The scale is designed to determine body temperature with an accuracy of 0.1 0 C, for which it has the appropriate divisions.
A medical thermometer can measure body temperature from 34 to 42 0 C. The thermometer is called the maximum, as it shows the maximum height of the mercury column.
Mercury can be returned to the tank only after shaking the thermometer until the mercury column drops below 35 0 С.
Body temperature measurement
The measurement of human body temperature is called thermometry. The temperature is measured more often in the armpit, less often - in the inguinal fold (in children), oral cavity, rectum, vagina.
Thermometry is carried out 2 times a day: in the morning on an empty stomach (from 6 to 9 hours) and in the evening before meals (from 17 to 19 hours). With fever, there is a need for a more frequent measurement of body temperature (every 2-3 hours).
The duration of body temperature measurement in the armpit is 10 minutes, in the oral cavity - 1 minute, in the rectum - 5 minutes.
People who are unconscious, restless or drunk should not take their temperature in the mouth, as they can chew on the thermometer.
temperature sheet
For a graphical representation of daily temperature fluctuations, temperature sheets are compiled into which the results of measuring body temperature are entered. It should be remembered that the division price on the “T” scale of the temperature sheet is 0.2 0 C.
The column "Day of stay" is divided into two halves: "U" (morning), "B" (evening). Morning temperature is fixed with a dot (blue or black paste) in column "Y", evening temperature - in column "B". Connecting the dots results in a temperature curve.
Disinfection of thermometers
After use, medical thermometers are completely immersed in a 3% solution of chloramine for 1 hour. After disinfection, rinse under running water, wipe dry and store in a clean container in a horizontal or vertical position. Cotton wool is placed at the bottom of the tank so as not to break the tank with mercury. Store in a container marked "Clean thermometers".
Care of a febrile patient
An increase in body temperature above 37 0 C is called fever. This is an active protective and adaptive reaction of the body in response to a variety of pathogenic stimuli.
Types of fever
depending on the degree of temperature rise distinguish:
subfebrile fever (37-38 0 С);
moderate or febrile fever (38-39 0 С);
high or pyretic fever (39-40 0 C);
excessive or hyperpyretic (above 42 0 С).
fleeting - lasts several hours;
acute - lasts up to 15 days;
subacute - lasts up to 45 days;
chronic - lasts more than 45 days.
Persistent fever- the temperature is usually high, lasts a long time. Daily fluctuations are observed within 1 0 C. Occurs with lobar pneumonia, typhus and typhoid fever.
Fever laxative (relapsing)- with a temperature difference in the evening and in the morning of more than 1 0 C. characteristic of purulent diseases.
Fever hectic or wasting- temperature fluctuations during the day from 2 to 4 0 C with a rapid drop to the norm and below. Such a drop in temperature is accompanied by debilitating weakness with profuse sweating. It is observed in severe forms of tuberculosis, sepsis and lymphogranulomatosis.
Fever perverted(reverse type of fever) - characterized by a rise in morning temperature to a greater extent than in the evening. Occurs with pulmonary tuberculosis, sepsis.
Intermittent or intermittent fever- the temperature rises to 39-40 0 C and above, followed by a rapid (after a few hours) drop to normal or slightly below normal. Fluctuations are repeated every 1-2 or 3 days. This type of fever is characteristic of malaria.
relapsing fever- a sudden rise in temperature to 40 0 C or more is replaced by its fall after a few days to normal, which lasts for several days, and then the temperature curve repeats. This type of fever is characteristic of relapsing fever.
undulating fever- there is an alternation of a constant increase in temperature with its gradual fall to normal and below normal, followed by a period without fever. Then comes a new increase followed by a decrease in temperature. This type of fever is observed with brucellosis, lymphogranulomatosis.
wrong fever- irregular daily temperature fluctuations of various magnitude and duration. Such a fever is found in rheumatism, dysentery, influenza.
Hyperthermic reaction in patients occurs in 3 periods:
1st period- rise in body temperature (a period of chills) - heat production prevails over heat transfer. Heat transfer is reduced due to the narrowing of the skin blood vessels.
Problems: weakness, malaise, headache, muscle pain, "ache" throughout the body (symptoms of general intoxication). An increase in body temperature and spasm of peripheral vessels cause chills and trembling in the patient, he cannot warm himself. The patient is pale, the skin is cold to the touch.
Nursing interventions:
put to bed, create peace;
warm the patient with heating pads, a warm blanket, hot drinks (tea or milk with honey, herbal preparations);
observe the external condition of the patient, conduct thermometry, control physiological parameters - pulse, blood pressure, respiratory rate.
Problems: fever, headache, weakness, loss of appetite, dry mouth, thirst. Objectively: hyperemia of the face, skin is hot to the touch, cracks on the lips. At high temperatures, disturbances of consciousness, hallucinations, delirium are possible.
Nursing interventions:
monitor patient compliance with strict bed rest (individual nursing post);
to enhance heat transfer, cover the patient with a light sheet, wipe the skin with a solution of vinegar or alcohol, apply an ice pack, apply a cold compress;
soften lips with a cosmetic product;
provide at least 1.5-2 liters of fortified drink (tea with lemon, juices, fruit drinks, mineral waters, rosehip infusion);
feed liquid, semi-liquid and easily digestible food, in small portions 5-6 times a day (diet table No. 13);
control of body temperature, pulse, blood pressure, NPV;
control of physiological functions (especially for diuresis - the amount of urine excreted);
assessment of behavioral response.
favorable option- gradual decrease in body temperature over several days. Such a drop in temperature reaction is called lytic - lysis.
Unfavorable option- aggravating the process of recovery - a rapid decrease in body temperature within a few hours. Such a drop in temperature is called critical - a crisis.
Nursing interventions for lysis:
the patient's condition is not dangerous, does not require special measures, to provide comfortable underwear and bed linen, adequate drinking, peace to restore the physical strength of the body and restful sleep. As the condition improves, the regime of physical activity is expanded.
Patient problems in a crisis- a sharp drop in vascular tone with a decrease in blood pressure. Thready pulse, weakness, drowsiness, cold hands and feet, profuse sticky sweat, pallor of the skin, acrocyanosis (cyanosis of the distal parts of the body), a crisis is dangerous for the development of collapse.
Collapse- the development of acute vascular insufficiency (decrease in vascular tone and a decrease in the mass of circulating blood), a sharp drop in blood pressure, palpitations, dizziness, weakness, lethargy, pallor of the skin.
Nursing interventions in crisis:
create a forced position for the patient in bed - raise the foot end of the bed, remove the pillow;
cover the patient with a blanket;
dry the skin;
warm with heating pads, give hot coffee, strong tea;
pulse control, blood pressure;
prepare drugs to increase blood pressure (caffeine, sulfocamphocaine) and administer as directed by a doctor;
change underwear and bed linen;
ensure patient comfort.
Definition of the term "thermoregulation".
Define the terms "heat generation" and "heat transfer".
Physiological fluctuations in body temperature.
Places for measuring body temperature.
Medical thermometer device.
Rules for measuring body temperature.
Rules for filling out the temperature sheet.
Definition of fever.
List the names of fevers according to the degree of temperature rise.
List the names of fevers according to the duration of the course.
List the types of fevers depending on daily fluctuations in temperature.
Define each period of fever.
List the problems in each period of fever.
Nursing interventions in various periods of fever.
LECTURE #2
TOPIC: "ASSESSMENT OF THE FUNCTIONAL STATE OF THE PATIENT"
Observing the need to breathe
Satisfying the need to breathe provides the human body with the oxygen necessary for its normal functioning.
recognize breathing:
External - delivery of oxygen to the blood.
Internal - the transfer of oxygen from the blood to the organs and tissues of the body.
When assessing breathing, take into account: rhythm, frequency, depth.
Breathing rhythm- regularity of inhalations and exhalations. These are breathing movements at regular intervals. If these intervals are the same - rhythmic breathing, if not - arrhythmic.
Respiratory rate (RR)- the number of respiratory movements in 1 minute is 16-20 on average in adults. NPV depends on:
from the position of the body: lying - NPV 14-16, sitting - 16-18, standing 18-20 in 1 minute;
from physical activity: 12-14 during sleep, increased during exercise. In trained people and athletes, the respiratory rate can reach 6-8 per minute.
Bradypnea - decrease in breathing less than 14 per minute.
Apnea is the absence of breathing.
Dyspnea is a breathing disorder.
There are types of breathing:
Thoracic breathing - typical for women - respiratory movements due to contraction of the intercostal muscles.
Diaphragmatic breathing (abdominal type) - characteristic mainly for men - respiratory movements due to the diaphragm and muscles of the abdominal wall.
Mixed breathing - more often in athletes, the elderly - respiratory movements simultaneously with the help of contraction of the intercostal muscles and the diaphragm.
Shortness of breath may be physiological- with significant physical exertion and pathological- with various diseases.
Types of shortness of breath depending on the difficulty of the respiratory phase:
Inspiratory - inhalation is difficult.
Expiratory - it is difficult to exhale.
Mixed - both inhalation and exhalation are difficult.
Suffocation- pronounced, sudden shortness of breath.
Breathing depth: normal, deep, superficial (determined by the volume of air that a person inhales and exhales with each respiratory movement).
internal breathing
The cardiovascular system ensures the delivery of blood to organs and tissues. Criteria for ensuring internal respiration are indicators of pulse, blood pressure, color of the skin and mucous membranes.
The nature of the pulse depends on the size and speed of the ejection of blood by the heart and the elasticity of the artery wall.
The peripheral pulse is easier to palpate on long sections of the artery where they pass over the surface of the bone. In adults, the pulse often found on the radial artery. Also palpated on the temporal, carotid, brachial, femoral, popliteal arteries, on the dorsal artery of the foot.
arterial pulse- These are oscillations of the arterial wall due to the release of blood into the arterial system.
Pulse characteristic
Pulse rhythm - determined by the intervals between pulse waves. If the pulse oscillations of the artery wall occur at regular intervals, then the pulse is rhythmic. With rhythm disturbances, an irregular alternation of pulse waves is observed - arrhythmia.
Pulse rate- it is calculated within 1 minute. At rest, a healthy person has a pulse of 60-80 beats per minute. With an increase in heart rate (HR) (tachycardia), the number of pulse waves increases, a frequent pulse appears, and with a slow heart rate (bradycardia), the pulse is rare.
Voltage- determined by the force with which it is necessary to press the radial artery so that its pulse oscillations completely stop. The voltage of the pulse depends on the magnitude of the systolic pressure.
If blood pressure is normal, the artery is compressed with moderate effort, so the pulse is normal with moderate tension. With high blood pressure, it is more difficult to compress the artery - such a pulse is called tense or hard. In the case of low blood pressure in the artery, it contracts easily - the pulse is soft.
Filling the pulse It is characterized by the filling of the artery with blood and depends on the magnitude of cardiac output, that is, on the amount of blood that is released into the systole into the arterial system, as well as on the total amount of circulating blood in the vascular system. If the cardiac output is normal, the pulse is full. with circulatory failure, a large loss of blood, the filling of the pulse decreases and is called empty.
Pulse value depends on voltage and content. If the tension is firm or moderate, and the filling of the total value in this case will be large. If the voltage is soft, and the filling of the empty value will be small.
Sometimes the magnitude of the pulse waves can be so small that it is difficult to determine. Such a pulse is called threadlike.
Blood pressure (BP) is the pressure of the blood on the walls of the arteries. It depends on the magnitude of cardiac output and the tone of the arterial wall.
Distinguish blood pressure:
Systolic blood pressure (normally ranges from 140 to 100 mm Hg) - the maximum pressure of circulating blood on the walls of the artery during contraction of the left ventricle of the heart, which reflects the integrity of the heart and arterial system.
Diastolic blood pressure (normally ranges from 100 to 60 mm Hg) - the minimum pressure of circulating blood on the arterial walls in the phase of relaxation of the left ventricle of the heart, which speaks of vascular resistance.
Pulse pressure - the difference between systolic and diastolic pressure, optimal 40-50 mm Hg. Art.
Normal blood pressure readings:
The upper limit is 140/90 mm Hg. st
Lower limit 100/60 mm Hg. Art.
An increase in blood pressure is arterial hypertension.
Lowering blood pressure - arterial hypotension.
BP numbers determine the individual characteristics and lifestyle of a person.
Factors leading to a decrease in blood pressure:
age (infants have low blood pressure);
the use of drugs;
decrease in the volume of circulating blood (bleeding, extensive burns);
age;
an increase in the total volume of circulating blood;
feeling of fear, anxiety, positive and negative emotions, stress, reaction to the doctor (white coat hypertension);
physical pain;
increased consumption of table salt;
vasoconstrictors;
atherosclerosis, obesity, kidney disease;
after smoking, drinking alcohol.
Control questions
Describe the need to breathe.
List the parameters that are taken into account when assessing breathing.
Describe the rhythm, frequency and depth of breathing.
Definition of the concept of "shortness of breath".
List the types of dyspnea.
Define the term "pulse".
List the places of palpation of the peripheral pulse.
Describe the arterial pulse.
Definition of "blood pressure".
Describe systolic and diastolic blood pressure.
List the factors that lead to a decrease in blood pressure.
List the factors that lead to an increase in blood pressure.
Assessment of the general condition of the patient includes such concepts as the state of consciousness, the position of the patient in bed, the condition of the skin and mucous membranes, the concept of pulse, blood pressure and respiration.
Assessment of the state of consciousness, types of consciousness.
There are several states of consciousness: clear, stupor, stupor, coma.
Stupor (stupor) - a state of stunning. The patient is poorly oriented in the environment, answers questions sluggishly, late, the answers are meaningless.
Sopor (subcoma) - the state of hibernation. If the patient is brought out of this state by a loud response or braking, then he can answer the question, and then again fall into a deep sleep.
Coma (complete loss of consciousness) is associated with damage to the center of the brain. In coma, muscle relaxation, loss of sensitivity and reflexes are observed, there are no reactions to any stimuli (light, pain, sound). Coma can be with diabetes mellitus, cerebral hemorrhage, poisoning, severe liver damage, kidney failure.
In some diseases, disorders of consciousness are observed, which are based on the excitation of the central nervous system. These include delusions, hallucinations (auditory and visual).
Assessment of the patient's activity mode, types of position.
Types of position of the patient in bed.
- 1. active position - they call such a position when the patient is able to independently turn around, sit down, stand up, serve himself.
- 2. passive position - the position is called when the patient is very weak, emaciated, unconscious, usually in bed and cannot change his position without outside help.
- 3. forced position - a position in bed that the patient himself occupies to alleviate his suffering, reduce painful symptoms (cough, pain, shortness of breath). In patients suffering from exudative pericarditis, the pain and breathing of the patient is relieved by the knee-elbow position. With heart disease, the patient, due to shortness of breath, tends to take a sitting position with legs dangling.
Assessment of the condition of the skin and mucous membranes.
Examination of the skin allows you to: reveal discoloration, pigmentation, peeling, rash, scarring, hemorrhage, bedsores, etc.
The change in skin color depends on the thickness of the skin, the lumen of the vessels of the skin. The color of the skin may change due to the deposition of pigments in its thickness.
- 1. pallor of the skin and mucous membranes can be permanent and temporary. Paleness can be associated with chronic and acute blood loss (uterine bleeding, peptic ulcer), it can be with anemia, fainting. Temporary pallor can occur with spasm of skin vessels during fright, cooling, during chills.
- 2. abnormal redness of the skin depends on the expansion and overflow of small blood vessels of the skin (observed during mental arousal). The red color of the skin in some patients depends on the large number of red blood cells and hemoglobin in the blood (polycythemia).
- 3. cyanosis - a bluish-purple color of the skin and mucous membranes is associated with an excessive increase in carbon dioxide in the blood and a lack of saturation with oxygen. Distinguish between general and local. General develops with cardio and pulmonary insufficiency; some congenital heart defects, when part of the venous blood, bypassing the lungs, mixes with arterial; in case of poisoning with poisons (Berthollet salt, aniline, nitrobenzlol), which convert hemoglobin into methemoglobin; in many lung diseases due to the death of their capillaries (pneumosclerosis, emphysema). Local - developing in separate areas, may depend on blockage or compression of the veins, more often on the basis of thrombophlebitis.
- 4. jaundice - staining of the skin and mucous membranes due to the deposition of bile pigments in them. With jaundice, yellow coloration of the sclera and hard palate is always observed, which distinguishes it from yellowing of another origin (sunburn, the use of quinacrine). Icteric coloration of the skin is observed with an excess content of bile pigments in the blood. There are the following forms of jaundice:
- a) subhepatic (mechanical) - in case of violation of the normal outflow of bile from the liver to the intestine through the bile duct when it is blocked by a gallstone or tumor, with adhesions and inflammatory changes in the bile ducts;
- b) hepatic - if the bile formed in the cell enters not only the bile ducts, but also into the blood vessels;
- c) suprahepatic (hemolytic) - as a result of excessive formation of bile pigments in the body due to a significant breakdown of red blood cells (hemolysis), when a lot of hemoglobin is released, due to which bilirubin is formed.
- 5. bronze - or dark brown, characteristic of Addison's disease (with a lack of function of the adrenal cortex).
Increased pigmentation can cause skin discoloration. Pigmentation is local and general. Sometimes there are limited areas of pigmentation on the skin - freckles, birthmarks. Albinism is the partial or complete absence of pigmentation, the absence of pigmentation in certain areas of the skin is called vitiligo.
Skin rashes - the most characteristic rashes occur with skin, acute infectious diseases.
Skin moisture depends on perspiration. Increased humidity is observed with rheumatism, tuberculosis, diffuse toxic goiter. Dryness - with myxedema, sugar and non-sugar diabetes, diarrhea, general exhaustion.
Skin turgor - its tension, elasticity. It depends on the content of intracellular fluid, blood, lymph and the degree of development of subcutaneous fat.
Pulse and its characteristics.
The arterial pulse is the rhythmic oscillation of the artery wall due to the ejection of blood into the arterial system during one contraction of the heart. There are central (on the aorta, carotid arteries) and peripheral (on the radial, dorsal artery of the foot and some other arteries) pulse.
For diagnostic purposes, the pulse is also determined on the temporal, femoral, brachial, popliteal, posterior tibial and other arteries.
Most often, the pulse is examined in adults on the radial artery, which is located superficially between the styloid process of the radius and the tendon of the internal radial muscle.
When examining the arterial pulse, it is important to determine its frequency, rhythm, filling, tension and other characteristics. The nature of the pulse depends on the elasticity of the artery wall.
Frequency is the number of pulse waves per minute. Normally, in an adult, the pulse is 60-80 beats per minute. An increase in heart rate over 85-90 beats per minute is called tachycardia. A heart rate slower than 60 beats per minute is called bradycardia. The absence of a pulse is called asicitolia. With elevated body temperature on GS, the pulse increases in adults by 8-10 beats per minute.
The rhythm of the pulse is determined by the interval between pulse waves. If they are the same, the pulse is rhythmic (correct), if they are different, the pulse is arrhythmic (incorrect). In a healthy person, the contraction of the heart and the pulse wave follow each other at regular intervals. If there is a difference between the number of heartbeats and pulse waves, then this condition is called a pulse deficit (with atrial fibrillation). The counting is carried out by two people: one counts the pulse, the other listens to the heart sounds.
The filling of the pulse is determined by the height of the pulse wave and depends on the systolic volume of the heart. If the height is normal or increased, then a normal pulse (full) is felt; if not, then the pulse is empty.
The voltage of the pulse depends on the value of arterial pressure and is determined by the force that must be applied until the pulse disappears. At normal pressure, the artery is compressed with a moderate effort, therefore, the pulse of moderate (satisfactory) tension is normal. At high pressure, the artery is squeezed by strong pressure; such a pulse is called tense. It is important not to make a mistake, since the artery itself can be sclerotic. In this case, it is necessary to measure the pressure and verify the assumption that has arisen.
At low pressure, the artery is squeezed easily, the voltage pulse is called soft (non-stressed).
An empty, relaxed pulse is called a small filiform.
The data of the pulse study are recorded in two ways: digitally - in medical records, journals, and graphically - in the temperature sheet with a red pencil in the column "P" (pulse). It is important to determine the division value in the temperature sheet.
Counting the arterial pulse on the radial artery and determining its properties. arterial comatose patient pulse
Places for probing the pulse - temporal, carotid, radial, femoral, popliteal artery.
Get ready: stopwatch.
Action algorithm:
- 1. Lay or seat the patient in a comfortable position
- 2. grab the patient's hand with the right hand in the area of the wrist joint
- 3. Feel for the pulsating radial artery, on the palmar surface of the forearm, at the base of 1 finger.
- 4. Press the artery (not hard) with 2,3,4 fingers
- 5. Count the number of pulse beats in 1 minute - this is the pulse rate
- 6. Determine the voltage of the pulse - the force necessary to stop the pulsation by pressing on the wall of the artery.
- 7. Determine the filling of the pulse - with good filling, a clear pulse wave is felt under the finger, with poor filling, the pulse wave is not clear, poorly distinguishable.
Poor filling of the pulse (“threaded pulse”) indicates a weakening of the heart muscle. Tell your doctor immediately!
Determination of blood pressure.
Blood pressure is the pressure that blood exerts on the wall of the arteries. It depends on the force of contraction of the heart and the tone of the arterial wall. There are systolic, diastolic and pulse pressure.
Systolic is the pressure during systole of the heart, diastolic pressure at the end of diastole of the heart.
The difference between systolic and diastolic pressure is called pulse pressure.
The norm of pressure depends on age and ranges in an adult from 140/90 to 110/70 mm Hg.
An increase in blood pressure is called hypertension (hypertension) and a decrease in blood pressure is called hypotension (hypotension).
Blood pressure is usually measured once a day (if necessary, more often) and noted digitally or graphically in the temperature sheet.
The measurement is made with a tonometer, which consists of a pressure gauge with a rubber pear, a cuff.
Indications:
- 1. Assessment of the general condition;
- 2. Diagnosis of cardiovascular and other diseases;
Prepare: phonendoscope, tonometer.
Technique:
- 1. seat the patient or lay down, calm down.
- 2. Expose the upper limb.
- 3. Apply cuff for 3-5cm. above the elbow.
- 4. Apply the phonendoscope to the elbow and feel the pulsation.
- 5. Pump air with a bulb until the pulsation disappears (20-30 mmHg above the patient's normal blood pressure).
- 6. Gradually reduce the pressure in the cuff by slightly opening the pear valve.
- 7. when the first sound appears, remember the number on the pressure gauge scale - systolic pressure.
- 8. Keep deflating the balloon evenly.
- 9. note the number on the pressure gauge scale at the last perceptible sound - diastolic pressure.
- 10. Repeat blood pressure measurement 2-3 times on one limb and take the arithmetic mean.
- 11. A digital record of blood pressure is made in the medical history, and a graphic record is made in the temperature sheet.
Breath monitoring.
When observing breathing, special attention should be paid to changing the color of the skin, determining the frequency, rhythm, depth of respiratory movements and assessing the types of breathing.
Respiratory movements are carried out by alternating inhalation and exhalation. The number of breaths in 1 minute is called the respiratory rate (RR).
In a healthy adult, the rate of respiratory movements at rest is 16-20 per minute, in women it is 2-4 breaths more than in men. The NPV depends not only on gender, but also on the position of the body, the state of the nervous system, age, body temperature, etc.
Breathing monitoring should be carried out imperceptibly for the patient, as he can arbitrarily change the frequency, rhythm, depth of breathing. NPV refers to heart rate on average as 1:4. With an increase in body temperature on GS, breathing quickens by an average of 4 respiratory movements.
Possible changes in the nature of breathing.
Distinguish between shallow and deep breathing. Shallow breathing may be inaudible at a distance or slightly audible. It is often combined with pathological rapid breathing. Deep breathing, heard at a distance, is most often associated with a pathological decrease in breathing. There are 2 types of breathing:
- Type 1 - chest in women;
- type 2 - abdominal in men;
- Type 3 - mixed.
With a disorder in the frequency of the rhythm and depth of breathing, shortness of breath occurs. Distinguish inspiratory shortness of breath - this is breathing with difficulty inhaling; expiratory - breathing with difficulty exhaling; and mixed - breathing with difficulty inhaling and exhaling. Rapidly developing severe shortness of breath is called suffocation.
Normal respiratory movements are from 16 to 20 per minute.
Get ready: stopwatch.
Action algorithm:
- 1. lay the patient down.
- 2. With your right hand, take the patient's hand as for determining the pulse.
- 3. Place your left hand on your chest (for women), or on your stomach (for men).
- 4. count the number of breaths in one minute (1 - one breath = 1 inhale + 1 exhale).
1. Assessment of the functional state of the patient
The nurse in the admission department measures the temperature, checks the documents of incoming patients; notifies the doctor on duty about the arrival of the patient and his condition; fills in the patient's passport part of the medical history, registers in the register of patients undergoing inpatient treatment; enters the passport part of the patient in the alphabetical book; in a satisfactory condition of the patient, it performs anthropometry (measures height, chest circumference, weighs); quickly and accurately fulfills the appointment of a doctor for emergency care, strictly observing asepsis; accepts valuables against a receipt from the patient, while explaining the procedure for obtaining them, introduces the rules of conduct in the hospital; organizes the sanitization of the patient, the delivery (if necessary) of his belongings for disinfection (disinfestation); informs in advance (by phone) the nurse on duty of the department about the admission of the patient; organizes the transfer of the patient to the department or accompanies him herself.
For a general assessment of the patient's condition, the nurse should determine the following indicators.
* General condition of the patient.
* Position of the patient.
* The state of consciousness of the patient.
* Anthropometric data.
General condition of the patient
An assessment of the general condition (the severity of the condition) is carried out after a comprehensive assessment of the patient (using both objective and subjective research methods).
The general state can be determined by the following gradations.
* Satisfactory.
* Moderate.
* Heavy.
* Extremely heavy (pre-agonal).
* Terminal (agonal).
* State of clinical death.
If the patient is in a satisfactory condition, anthropometry is performed.
Anthropometry (Greek antropos - man, metreo - measure) - assessment of a person's physique by measuring a number of parameters, of which the main (mandatory) are height, body weight and chest circumference. The nurse registers the necessary anthropometric indicators on the title page of the medical record of the inpatient
The results of temperature measurement are recorded in the Individual temperature sheet. It is entered in the admission department along with a medical card for each patient entering the hospital.
In addition to graphical registration of temperature measurement data (T scale), it builds curves for pulse rate (P scale) and blood pressure (BP scale). In the lower part of the temperature sheet, data are recorded for counting the respiratory rate in 1 min, body weight, as well as the amount of fluid drunk per day and excreted urine (in ml). Data on defecation (“stool”) and sanitization carried out are indicated by a “+” sign.
Nursing staff should be able to determine the basic properties of the pulse: rhythm, frequency, tension.
The rhythm of the pulse is determined by the intervals between pulse waves. If the pulse oscillations of the artery wall occur at regular intervals, then the pulse is rhythmic. With rhythm disturbances, an irregular alternation of pulse waves is observed - an arrhythmic pulse. In a healthy person, the contraction of the heart and the pulse wave follow each other at regular intervals.
The pulse rate is counted for 1 min. At rest, in a healthy person, the pulse is 60-80 per minute. With an increase in heart rate (tachycardia), the number of pulse waves increases, and with a slow heart rate (bradycardia), the pulse is rare.
The voltage of the pulse is determined by the force with which the researcher must press the radial artery so that its pulse fluctuations completely stop.
The voltage of the pulse depends primarily on the magnitude of systolic blood pressure. With normal blood pressure, the artery is compressed with a moderate effort, therefore, the pulse of moderate tension is normal. With high blood pressure, it is more difficult to compress the artery - such a pulse is called tense, or hard. Before examining the pulse, you need to make sure that the person is calm, not worried, not tense, his position is comfortable. If the patient has done some kind of physical activity (brisk walking, housework), had a painful procedure, received bad news, the pulse examination should be postponed, since these factors can increase the frequency and change other properties of the pulse.
The data obtained from the study of the pulse on the radial artery is recorded in the "Medical record of the inpatient patient", care plan or outpatient card, indicating the rhythm, frequency and tension.
In addition, the pulse rate in an inpatient medical institution is marked with a red pencil in the temperature sheet. In the column "P" (pulse) enter the pulse rate - from 50 to 160 per minute.
Blood pressure measurement
Arterial (BP) is the pressure that is formed in the arterial system of the body during heart contractions. Its level is affected by the magnitude and speed of cardiac output, the frequency and rhythm of heart contractions, and the peripheral resistance of the walls of the arteries. Blood pressure is usually measured in the brachial artery, in which it is close to the pressure in the aorta (can be measured in the femoral, popliteal and other peripheral arteries).
Normal systolic blood pressure ranges from 100-120 mm Hg. Art., diastolic -- 60--80 mm Hg. Art. To a certain extent, they depend on the age of the person. So, in the elderly, the maximum systolic pressure is 150 mm Hg. Art., and diastolic - 90 mm Hg. Art. A short-term increase in blood pressure (mainly systolic) is observed during emotional stress, physical stress.
Watching the breath, in some cases it is necessary to determine its frequency. Normal breathing movements are rhythmic. The frequency of respiratory movements in an adult at rest is 16-20 per minute, in a woman it is 2-4 breaths more than in men. In the "lying" position, the number of breaths usually decreases (up to 14--16 per minute), in an upright position it increases (18-20 per minute). In trained people and athletes, the frequency of respiratory movements can decrease and reach 6-8 per minute.
The combination of inhalation and exhalation following it is considered one respiratory movement. The number of breaths per minute is called the respiratory rate (RR) or simply the respiratory rate.
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