A.L. Vertkin
Ambulance: a guide for paramedics and nurses
Foreword
This guide is devoted to the algorithms for the actions of paramedical personnel: paramedics of the "Ambulance" and nurses of polyclinics and emergency departments of the hospital, on the successful actions of which in the first hours of the development of the disease this or that prognosis depends.
Traditionally, the nurse and paramedic are the first to contact the patient, promptly solving the most important issues of diagnosis, obtaining the necessary additional medical information and performing emergency medical procedures. This requires a detailed understanding of the essence of the emergency and the pathological processes occurring in the body, prognosis, a rational and logical treatment plan, and recognition of the age and social characteristics of the patient. At the same time, it is necessary to show maximum attention to the patient and those around him, to be tactful, to monitor his speech, to empathize - in a word, to observe the principles of medical deontology, to which the authors also devoted many pages.
The manual briefly outlines the basic concepts and definitions adopted in emergency medicine, the main provisions on the status of a paramedic (nurse), the main types of violations of regulations by medical staff of the ambulance service, the rights and obligations of a patient who applied for emergency medical care, the main types of responsibility of medical workers providing emergency help.
What associations arise when perceiving the phrase "emergency care"? Perhaps you represent an accident victim or a patient who is urgently hospitalized with bleeding? But it can also be a patient with an acute vascular accident, poisoning with severe intoxication, respiratory failure due to pneumonia, or a pregnant woman with a threatened miscarriage. Emergency care is needed in a variety of situations and does not depend on the chosen medical specialty. The main thing is to know and be able to prioritize assistance to victims, guided primarily by the nature of the underlying disease or syndrome requiring emergency medical care, and assessing the severity of the condition. In this case, the patient must receive the required and guaranteed medical care, regardless of place of residence, social status and age. In case of mass incidents or simultaneous treatment of several patients, the caregiver must be able to determine the order of assistance. The tasks faced by the paramedic during the execution of the call include determining the patient's need for the need to provide him with emergency assistance, the need for therapeutic and diagnostic measures and determining their scope, resolving the issue of the need for hospitalization and confidentiality of information (medical secrecy) about the state of health (illness) of the patient.
Depending on the severity of the condition, five levels of medical care are distinguished:
Level 1 - resuscitation, for patients in need of urgent medical supervision. Examples are patients with acute coronary syndrome, stroke, asthma, etc.
Level 2 - emergency conditions in which patients need urgent examination and quick help, for example, with injuries of the limbs, hyper- and hypothermia, nosebleeds, etc.
Level 3 - urgent conditions, such as intoxication or respiratory disorders in a patient with pneumonia, pain syndromes during sprains, etc. In these cases, patients can wait for examination and treatment for 30 minutes.
Level 4 - less urgent conditions in which medical care may be delayed, such as otitis media, chronic back pain, fever, etc.
Level 5 - non-urgent conditions that occur in chronic diseases, for example, constipation in the elderly, menstrual syndrome, etc.
Differentiation of these conditions requires an assessment of the reason that led to the request for medical help, a detailed questioning and description of the patient's complaints, familiarization with previous medical documentation, evaluation of the effectiveness of previous therapy, etc. Ultimately, the solution of the above issues ensures greater efficiency of the friendly work of the doctor and the average medical personnel in the provision of emergency medical care.
The team of authors of the leadership is represented by leading specialists of the Moscow State University of Medicine and Dentistry, the Moscow Medical Academy named after I.I. THEM. Sechenov, Russian State Medical University and Samara State Medical University, as well as the station of emergency and emergency medical care named after. V.F. Kapinos of the city of Yekaterinburg, who have been involved in emergency medicine for many years.
General principles of work of nurses and ambulance paramedics
1.1. Collection of information
Target
Collect patient information.
Indications
The need to collect information about the patient.
Contraindications
Equipment
Educational nursing history of the disease, medical documentation.
Possible Patient Problems
1. Unconscious state of the patient.
2. Negative attitude towards the conversation.
3. Distrust of the nurse.
4. Aggressively-excited state of the patient.
5. Decrease or absence of hearing.
6. Violation of speech.
Sequence of actions of a nurse (m/s) to ensure safety
1. Inform the patient of the purpose and progress of the information being collected.
2. Prepare an educational nursing history.
3. Address the patient by name and patronymic.
5. Formulate questions correctly so that they are understandable to the patient.
6. Ask questions sequentially, in accordance with the scheme of the educational nursing case history, observing the deontological rules.
7. Record the patient's responses clearly on the Nursing Nursing Record.
Evaluation of results
Patient information is collected and recorded in an educational nursing history.
1.2. Measurement of body temperature in the armpit and oral cavity of the patient
It is necessary to measure the patient's body temperature and record the result in the temperature sheet. Temperature monitoring is required both during the day and when the patient's condition changes.
Equipment
1. Medical thermometers.
2. Temperature sheet.
3. Marked container for storing clean thermometers with a layer of cotton on the bottom.
4. Marked containers for disinfection of thermometers with disinfectants.
6. Towel.
7. Gauze napkins.
Possible problems for the patient
1. Negative attitude towards intervention.
2. Inflammatory processes in the armpit.
Sequence m/s
Measurement of body temperature in the armpit
2. Take a clean thermometer, check its integrity.
3. Shake the thermometer to t<35 °С.
4. Examine and wipe the patient's armpit area with a dry cloth.
5. Place the thermometer in the armpit and ask the patient to press the shoulder against the chest.
6. Measure temperature for 10 minutes.
7. Remove the thermometer, determine the body temperature.
8. Record the temperature results first on the general temperature sheet and then on the temperature sheet of the medical history.
9. Process the thermometer in accordance with the requirements of the sanitary and epidemiological regime.
10. Wash your hands.
11. Store thermometers dry in a clean thermometer container.
Measurement of body temperature in the oral cavity
1. Inform the patient about the upcoming manipulation and its progress.
2. Take a clean medical thermometer, check its integrity.
3. Shake the thermometer to t<35 °С.
4. Place the thermometer under the patient's tongue for five minutes (the patient holds the body of the thermometer with his lips).
5. Remove the thermometer, determine the body temperature.
6. Register the results obtained first in the general temperature sheet, then in the temperature sheet of the medical history.
7. Process the thermometer in accordance with the requirements of the sanitary and epidemiological regime.
A.L. Vertkin
Ambulance: a guide for paramedics and nurses
FOREWORD
This guide is devoted to the algorithms for the actions of paramedical personnel: paramedics of the "Ambulance" and nurses of polyclinics and emergency departments of the hospital, on the successful actions of which in the first hours of the development of the disease this or that prognosis depends.
Traditionally, the nurse and paramedic are the first to contact the patient, promptly solving the most important issues of diagnosis, obtaining the necessary additional medical information and performing emergency medical procedures. This requires a detailed understanding of the essence of the emergency and the pathological processes occurring in the body, prognosis, a rational and logical treatment plan, and recognition of the age and social characteristics of the patient. At the same time, it is necessary to show maximum attention to the patient and those around him, to be tactful, to monitor his speech, to empathize - in a word, to observe the principles of medical deontology, to which the authors also devoted many pages.
The manual briefly outlines the basic concepts and definitions adopted in emergency medicine, the main provisions on the status of a paramedic (nurse), the main types of violations of regulations by medical staff of the ambulance service, the rights and obligations of a patient who applied for emergency medical care, the main types of responsibility of medical workers providing emergency help.
What associations arise when perceiving the phrase "emergency care"? Perhaps you represent an accident victim or a patient who is urgently hospitalized with bleeding? But it can also be a patient with an acute vascular accident, poisoning with severe intoxication, respiratory failure due to pneumonia, or a pregnant woman with a threatened miscarriage. Emergency care is needed in a variety of situations and does not depend on the chosen medical specialty. The main thing is to know and be able to prioritize assistance to victims, guided primarily by the nature of the underlying disease or syndrome requiring emergency medical care, and assessing the severity of the condition. In this case, the patient must receive the required and guaranteed medical care, regardless of place of residence, social status and age. In case of mass incidents or simultaneous treatment of several patients, the caregiver must be able to determine the order of assistance. The tasks faced by the paramedic during the execution of the call include determining the patient's need for the need to provide him with emergency assistance, the need for therapeutic and diagnostic measures and determining their scope, resolving the issue of the need for hospitalization and confidentiality of information (medical secrecy) about the state of health (illness) of the patient.
Depending on the severity of the condition, five levels of medical care are distinguished:
Level 1 - resuscitation, for patients in need of urgent medical supervision. Examples are patients with acute coronary syndrome, stroke, asthma, etc.
Level 2 - emergency conditions in which patients need urgent examination and quick help, for example, with injuries of the limbs, hyper- and hypothermia, nosebleeds, etc.
Level 3 - urgent conditions, such as intoxication or respiratory disorders in a patient with pneumonia, pain syndromes during sprains, etc. In these cases, patients can wait for examination and treatment for 30 minutes.
Level 4 - less urgent conditions in which medical care may be delayed, such as otitis media, chronic back pain, fever, etc.
Level 5 - non-urgent conditions that occur in chronic diseases, for example, constipation in the elderly, menstrual syndrome, etc.
Differentiation of these conditions requires an assessment of the reason that led to the request for medical help, a detailed questioning and description of the patient's complaints, familiarization with previous medical documentation, evaluation of the effectiveness of previous therapy, etc. Ultimately, the solution of the above issues ensures greater efficiency of the friendly work of the doctor and the average medical personnel in the provision of emergency medical care.
The team of authors of the leadership is represented by leading specialists of the Moscow State University of Medicine and Dentistry, the Moscow Medical Academy named after I.I. THEM. Sechenov, Russian State Medical University and Samara State Medical University, as well as the station of emergency and emergency medical care named after. V.F. Kapinos of the city of Yekaterinburg, who have been involved in emergency medicine for many years.
General principles of work of nurses and ambulance paramedics
1.1. Collection of information
Target
Collect patient information.
Indications
The need to collect information about the patient.
Contraindications
Equipment
Educational nursing history of the disease, medical documentation.
Possible Patient Problems
1. Unconscious state of the patient.
2. Negative attitude towards the conversation.
3. Distrust of the nurse.
4. Aggressively-excited state of the patient.
5. Decrease or absence of hearing.
6. Violation of speech.
Sequence of actions of a nurse (m/s) to ensure safety
1. Inform the patient of the purpose and progress of the information being collected.
2. Prepare an educational nursing history.
3. Address the patient by name and patronymic.
5. Formulate questions correctly so that they are understandable to the patient.
6. Ask questions sequentially, in accordance with the scheme of the educational nursing case history, observing the deontological rules.
7. Record the patient's responses clearly on the Nursing Nursing Record.
Evaluation of results
Patient information is collected and recorded in an educational nursing history.
1.2. Measurement of body temperature in the armpit and oral cavity of the patient
It is necessary to measure the patient's body temperature and record the result in the temperature sheet. Temperature monitoring is required both during the day and when the patient's condition changes.
Equipment
1. Medical thermometers.
2. Temperature sheet.
3. Marked container for storing clean thermometers with a layer of cotton on the bottom.
4. Marked containers for disinfection of thermometers with disinfectants.
6. Towel.
7. Gauze napkins.
Possible problems for the patient
1. Negative attitude towards intervention.
2. Inflammatory processes in the armpit.
Sequence m/s
Measurement of body temperature in the armpit
1. Inform the patient about the upcoming manipulation and its progress.
2. Take a clean thermometer, check its integrity.
3. Shake the thermometer to t<35 °С.
4. Examine and wipe the patient's armpit area with a dry cloth.
5. Place the thermometer in the armpit and ask the patient to press the shoulder against the chest.
The new book by well-known authors presents modern technologies for providing emergency care by paramedical personnel. A fundamentally new form of presentation allowed the authors to make accessible the complex issues of providing care at the prehospital stage in various emergency conditions. Even readers without medical education will understand the original visual information on first aid. The book is intended for students of medical colleges, universities, emergency medical personnel, emergency departments of hospitals and clinics. It is necessary for patients and their families to provide assistance in life-threatening situations.
* * *
The following excerpt from the book Ambulance. Guide for paramedics and nurses (A. L. Vertkin) provided by our book partner - the company LitRes.
Syndromes and diseases of the cardiovascular system requiring emergency care
2.1. Coronary artery disease
Myocardial ischemia occurs due to a mismatch between the supply of myocardium with oxygen and the need for it, which increases with physical or emotional stress. The main cause of coronary heart disease is atherosclerosis of the coronary arteries of the heart, leading to a narrowing of the lumen of the vessels by more than 50%.
In addition to atherosclerosis, the cause of myocardial ischemia can also be: an increase in the demand of the heart muscle for oxygen as a result of significant myocardial hypertrophy (with arterial hypertension, stenosis of the aortic orifice due to valvular damage or hypertrophy of the interventricular septum); narrowing of the lumen of the coronary arteries by thrombi, emboli, etc. Extracardiac factors can provoke or aggravate myocardial ischemia - conditions in which myocardial oxygen demand increases (arterial hypertension, tachyarrhythmia, hyperthermia, hyperthyroidism, intoxication with sympathomimetics, etc.) or oxygen supply decreases (anemia , bronchial obstruction, etc.).
2.2. Acute coronary syndrome
Pathophysiology
IHD occurs with periods of stable course and exacerbations. Unstable angina pectoris, myocardial infarction are acute forms of coronary artery disease and are the consequences of the same pathophysiological process - rupture or erosion of an atherosclerotic plaque in combination with adjoining thrombosis and embolization of distally located areas of the coronary bed. Currently, these conditions are united by the general term ACS - a preliminary diagnosis that allows the doctor to determine urgent therapeutic and diagnostic measures. Based on this, it is necessary to establish clinical criteria that allow the doctor to make timely decisions and choose the most rational treatment. This is based on an assessment of the risk of complications and a targeted approach to the appointment of invasive interventions.
The immediate cause of ACS is acute myocardial ischemia, most often due to rupture or splitting of atherosclerotic plaque with the formation of a thrombus in the coronary artery and increased platelet aggregation. Activated platelets can release vasoactive compounds, leading to segmental spasm near the atherosclerotic plaque and worsening myocardial ischemia.
Causes of an acute decrease in coronary perfusion:
- thrombotic process against the background of stenosing sclerosis of the coronary arteries and damage to the atherosclerotic plaque (in 90% of cases);
- hemorrhage into the plaque, detachment of the intima;
- prolonged spasm of the coronary vessels.
The resulting intense pain causes the release of catecholamines, tachycardia develops, which increases myocardial oxygen demand and shortens the time of diastolic filling of the left ventricle, thus aggravating myocardial ischemia. Another "vicious circle" is associated with a local violation of the contractile function of the myocardium due to its ischemia, dilatation of the left ventricle and further deterioration of the coronary circulation.
After 4–6 hours from the moment of development of myocardial ischemia, the zone of necrosis of the heart muscle corresponds to the zone of blood supply to the affected vessel. With an improvement in coronary blood flow, it is possible to restore the viability of cardiomyocytes. Accordingly, the shorter the duration of myocardial ischemia, the smaller the area of necrosis and the better the prognosis.
term OKS symptoms of an exacerbation of coronary heart disease (pain or other discomfort in the chest) are indicated, suggesting acute myocardial infarction, myocardial infarction (MI) or unstable angina (UA). Includes different types of MI (i.e. MI with and without lifts ST, MI diagnosed by biomarkers, by late electrocardiological (ECG) signs, and NS).
A patient with symptoms of exacerbation of coronary artery disease, according to the nature of ECG changes, can be attributed to one of the two main forms of ACS: with or without segment elevations ST: OKSPST or OKSBPST. The term appeared in connection with the need to choose treatment tactics, in particular thrombolytic therapy with TLT, before the final diagnosis of these conditions. At the same time, it was found that the nature of the necessary emergency intervention is determined by the position of the segment ST relative to the isoelectric line. When moving a segment ST up (rise ST) TLT is effective and therefore indicated. With no lift ST this therapy is ineffective. Thus, if a patient with a clear exacerbation of coronary artery disease from the presence or absence of a rise ST depends on the choice of the main method of treatment, then the selection of two variants of ACS at the first contact with a patient who is suspected of developing ACS is expedient from a practical point of view.
Correlation between the diagnostic terms "ACS" and "MI"
The term "ACS" is used when there is not yet sufficient information for a final judgment about the presence or absence of necrosis foci in the myocardium. The main symptom of ACS is angina pectoris, a sharp pain often described as severe, constricting, radiating to the arm or jaw.
Unstable angina is:
- first-time angina pectoris (within 28–30 days from the moment of the first pain attack);
- progressive angina pectoris (conditionally during the first four weeks). Pain attacks become more frequent, severe, exercise tolerance decreases, anginal attacks appear at rest, the effectiveness of previously used antianginal agents decreases, the daily need for nitroglycenin increases;
- early post-infarction angina pectoris (within 2 weeks from the development of MI);
- spontaneous angina pectoris (the appearance of severe pain attacks at rest, often lasting more than 15-20 minutes and accompanied by sweating, a feeling of lack of air, rhythm and conduction disturbances, and a decrease in blood pressure).
Table 1
table 2
Clinical variants of acute myocardial infarction (AMI)
Inspection
Estimate:
Frequency, depth, nature and quality of breathing;
The degree of consciousness of the patient;
BP and heart rate;
The color of the skin and mucous membranes;
The nature of the pain syndrome, provoking factors and the effectiveness of drugs.
First aid
Call a doctor.
Help the patient lie down on the bed.
Provide oxygen and prepare the patient for intubation and, if necessary, mechanical ventilation.
Establish continuous monitoring of the heart activity, take a 12-lead ECG and a chest X-ray using portable equipment.
Determine the level of troponin and D-dimer using rapid tests
Monitor your fluid intake/excretion and tell your doctor if you pass urine less than 30 ml/hour.
As prescribed by the doctor, conduct adequate pain relief (morphine, nitrates), β-blockers (metaprolol), antiplatelet therapy (cardio aspirin, clopidogrel), administration of anticoagulants (fractionated and unfractionated heparin), oxygen therapy and restoration of coronary perfusion (systemic thrombolysis).
Following actions
Monitor vital signs on a regular basis.
Get blood tests for troponin and D-dimer.
Prepare the patient for pacing, if necessary, for cardioversion.
Prepare the patient for transport.
Preventive measures
Talk to patients about the benefits of a healthy lifestyle, a balanced diet, the need to balance the load with their abilities, take care of their health, maintaining normal weight, smoking cessation and abstinence from alcohol and drugs, especially cocaine.
People with coronary insufficiency and a history of myocardial infarction should take cardio aspirin daily.
2.3. Cardiogenic shock and pulmonary edema
Cardiogenic shock
Pathophysiology
Cardiogenic shock may result from left ventricular dysfunction with reduced cardiac output due to causes such as myocardial infarction, myocardial ischemia, end-stage cardiomyopathy.
Check your pulse.
First aid
Provide additional oxygen supply, prepare the patient for endotracheal intubation, if necessary - for mechanical ventilation (ALV).
Place at least two intravenous catheters for infusion of fluids and medications.
As prescribed by the doctor, put a dropper with:
- intravenous solutions (physiological saline, Ringer's solution);
- colloids;
- blood components;
- vasopressors (dopamine) to improve cardiac output, blood pressure, renal blood flow;
- inotropic drugs (dobutamine) to improve myocardial contractility and cardiac output;
- vasodilators (nitroglycerin, nitroprusside) to improve cardiac output;
- diuretics to avoid edema;
- antiarrhythmic drugs for the treatment of arrhythmias (if necessary);
- thrombolytic agents to restore blood flow in the coronary artery in myocardial infarction.
Following actions
Install a urinary catheter.
Keep track of how much fluid is consumed and excreted hourly.
Prepare the patient for possible surgical aids.
Preventive measures
Explain to the patient the need for regular preventive examinations.
Pulmonary edema
Pulmonary edema is a clinical syndrome of acute heart failure caused by swelling of the lung tissue. Pulmonary edema is often the result of cardiac arrest or other cardiac disorders. Edema can develop both gradually and rapidly. Acute pulmonary edema can cause death.
Pathophysiology
Increased pressure in the pulmonary veins.
Fluid enters the alveoli, which interferes with normal oxygen exchange, causing shortness of breath and hypoxia.
Among the causes of pulmonary edema, myocardial infarction, infectious diseases, hypervolemia, poisoning with toxic gases are noted. Heart disease (such as cardiomyopathy) weakens the heart muscle and can lead to pulmonary edema. Pneumonia and primary pulmonary hypertension can also lead to edema.
Check the patient's vital signs, note the presence or absence of oxygen saturation, increased central venous pressure, decreased cardiac output, and hypotension.
Listen to the lungs for wheezing and decreased breathing.
Listen to the heart (note if the heartbeat is fast).
Note if the jugular veins swell and protrude.
First aid
Provide additional oxygen supply, prepare the patient for endotracheal intubation, if necessary, for mechanical ventilation.
Place the patient on the bed in the Favler position.
Send the blood for analysis of its gas composition.
According to the doctor's indications, enter diuretics, inotropes to increase cardiac contractility, vasopressors to improve contractility; antiarrhythmic agents in case of arrhythmias due to decreased cardiac activity, arterial vasodilators (eg, nitroprusside) to reduce peripheral vascular resistance and workload, morphine to reduce anxiety or improve blood flow.
Following actions
Constantly check the patient's vital parameters.
Prepare the patient for placement of an arterial catheter.
Do an EKG.
Determine the level of BNP or NT-proBNP in the blood.
Install a urinary catheter.
Monitor fluid intake and excretion every hour.
Limit salt and fluid intake in the patient's diet.
Prepare the patient for a chest x-ray and echocardiogram.
Preventive measures
It is necessary to prevent the development of diseases leading to pulmonary edema.
Patients at risk should follow a salt-free diet with fluid restriction in the diet.
2.4. Rupture of the papillary muscle
Rupture of the papillary muscle is a serious condition caused by trauma or myocardial infarction. As a rule, the posterior papillary muscle suffers. The cause of death after myocardial infarction in 5% of cases is papillary muscle rupture.
Pathophysiology
The papillary muscles are firmly attached to the wall of the ventricle.
Contraction of the papillary muscles helps maintain systolic valve closure.
When the papillary muscle ruptures due to injury or infarction, mitral valve insufficiency and rapidly progressive left ventricular failure develop.
Monitor the patient's vital parameters, note the presence or absence of an increase in central venous pressure and pressure in the pulmonary artery.
First aid
Provide additional oxygen supply, prepare the patient for endotracheal intubation, and, if necessary, for mechanical ventilation.
Watch for possible signs of cardiac arrest.
As prescribed by the doctor, give the patient diuretics and inotropic drugs that reduce the load on the heart.
Following actions
Constantly check the patient's vital parameters.
Install a urinary catheter.
Keep the patient calm.
Prepare the patient for diagnostic studies - echocardiogram, chest x-ray, angiogram.
Prepare the patient for surgery if necessary.
Preventive measures
Tell patients about the benefits of a healthy lifestyle, proper nutrition, proportionate exercise, the need for preventive examinations, maintaining normal weight, smoking cessation, abstinence from alcohol and drugs (especially cocaine).
To prevent papillary rupture of the muscle, fibrinolytic drugs should be used.
2.5. Heart rhythm disorders
Arrhythmias are changes in heart rate and rhythm caused by abnormal electrical activity or automaticity in the heart muscle. Arrhythmias range in severity from mild and asymptomatic (which need not be treated) to catastrophic ventricular fibrillation requiring immediate resuscitation.
Pathophysiology
Arrhythmia may be the result of a change in automatism, missed beats, or abnormal electrical conduction. Other reasons:
Congenital defects in the conduction system of the heart;
Myocardial ischemia or infarction;
Organic heart disease;
drug toxicity;
Violations of the structure of connective tissue;
electrolyte imbalance;
Cellular hypoxia;
Hypertrophy of the heart muscle;
Acid-base imbalance;
emotional stress.
Initial inspection
Measure the frequency, depth, quality of breathing, noting dyspnea and tachypnea.
Determine the degree of consciousness of the patient.
Measure blood pressure and pulse rate on the radial artery and compare its rate and filling.
Get a 12 lead ECG.
First aid
Call a doctor.
Ensure oxygen supply.
If the patient is not breathing, initiate artificial respiration and prepare the patient for endotracheal intubation and mechanical ventilation.
If the patient is pulseless, perform CPR or defibrillate for pulseless ventricular tachycardia or ventricular fibrillation.
As prescribed by the doctor, administer medications (with supraventricular tachycardia and stable hemodynamics, vagal tests may be performed) to treat specific arrhythmias. Administer anticoagulant and antiplatelet therapy. In the presence of an immediate threat to life, electrical impulse therapy (EIT) is indicated for tachyarrhythmia, temporary cardiac pacing (ECS) for bradyarrhythmia. In the absence of an immediate threat to life, decide whether it is necessary to stop the rhythm disturbance, if necessary, conduct medical cardioversion.
Following actions
Monitor the patient's heart rate.
Monitor patient vital parameters including pulse oximetry and cardiac output.
Prepare the patient for pacing, if necessary.
Constantly monitor cardiac output, changes in electrolyte levels, arterial blood gases.
Prepare the patient for cardioversion, electrophysiological testing, angiogram, temporary placement of a cardiac defibrillator, pacemaker, or (if indicated) its removal.
A transcutaneous pacemaker, also called an external or non-invasive pacemaker, delivers electrical impulses through externally applied skin electrodes. A transcutaneous pacemaker is the most convenient option in emergencies because it is gentler than other drugs and can be inserted quickly.
Preventive measures
Ensure adequate oxygenation.
2.6. Pacemaker failure
Failure of the pacemaker occurs due to a malfunction in its work, which leads to a malfunction of the heart.
Pathophysiology
The pacemaker may malfunction due to defective batteries or problems with the transmission of impulses.
As a result, the pacemaker stops sending adequate electrical impulses to cause the heart muscle to contract, or the heart muscle is unable to respond to the electrical stimulus (for example, due to its weakness). Sometimes there are situations when a temporary pacemaker stops functioning correctly.
Lack of electrical stimulation of the heart - The ECG does not show pacemaker activity when it should.
Get an ECG to help determine the cause of the pacemaker failure.
Check the cable connection with X-ray.
If the indicators do not light up, the battery needs to be replaced.
Adjust pacemaker sensitivity.
No response: The EKG shows a pulse, but the heart is not responding.
If the patient's condition worsens, call the doctor and help set up other operating parameters.
If the settings are changed, you need to return them to the desired parameters.
Reduced sensitivity: the work of the pacemaker is visible on the ECG, but it works in the wrong periods.
If the pacemaker is not felt, turn the sensitivity control all the way to the right.
If the pacemaker is not functioning properly, the battery needs to be replaced.
Remove from the room possible sources of disruption of pacemakers.
If the pacemaker cannot be adjusted, call a doctor and turn off the pacemaker. If necessary, reduce the heart rate (HR), use atropine. If necessary, apply cardiopulmonary resuscitation.
Provide supplemental oxygen, prepare the patient for endotracheal intubation or mechanical ventilation if necessary.
When using a temporary pacemaker, check the integrity of the wires, the condition of the battery, and the condition of the pacemaker box for damage.
Check the ECG for pacemaker activity.
Control your pulse. If there is no pulse, the resuscitation actions recommended for such a situation are necessary.
Install an external transcutaneous pacemaker if necessary.
Following actions
Constantly monitor the signs of life and the work of the heart.
Do a 12-line ECG.
Prepare a patient with a permanent pacemaker for reprogramming, changing batteries, or replacing the pacemaker itself.
Preventive measures
Instruct patients with pacemakers about safety precautions, possible malfunctions, and the need to periodically change batteries.
Educate patients with temporary pacemakers about how to use the device.
2.7. Heart failure
Cardiac arrest is the absence of contractions of the heart muscle. The heart stops beating or beats abnormally and does not beat effectively. If circulation is not restored within a minute, cardiac arrest results in loss of blood pressure, brain damage and death.
Scheme 1
Pathophysiology
The electrical signals of the heart are intermittent.
The heart stops beating or the ventricles begin to fibrillate.
Blood does not flow to the brain or other vital organs.
Circulatory and respiratory collapses occur, and death occurs without adequate treatment.
Try to palpate the pulse.
Perform resuscitation.
First aid
Call the doctor and the resuscitation team.
Perform cardiopulmonary resuscitation.
Set up heart rate monitoring.
Prepare the patient for endotracheal intubation and mechanical ventilation.
Administer defibrillation for ventricular fibrillation.
Prepare the patient for procedures (such as temporary pacing) and, as directed by the physician, administer cardiac support medications.
Connect the patient to a ventilator and an automatic pressure monitor and take an ECG
Following actions
Prepare the patient for hemodynamic monitoring.
Constantly check the patient's heart rate and vital signs.
Carry out drug therapy to achieve the desired effectiveness.
Preventive measures
Talk to the patient about a healthy lifestyle, including explaining that for heart health, you need to follow a special diet, avoid stress, exercise regularly, maintain a healthy weight, stop smoking and alcohol.
Patients with a history of ventricular tachycardia or ventricular fibrillation should undergo electrophysiological studies and be fitted with an implantable cardiodefibrillator.
2.8. Tamponade
Cardiac tamponade is a rapid, uncontrolled increase in intrapericardial pressure that impairs diastolic filling and reduces cardiac output. An increase in pressure occurs due to the accumulation of blood or fluid in the pericardial sac. If the fluid accumulates rapidly, urgent measures are needed to prevent death. Slow build-up and pressure build-up (eg, when fluid is shed into the pericardial cavity associated with malignant tumors) may be asymptomatic because the fibrous wall of the pericardial cavity may gradually wear down to store 1 to 2 L of fluid.
Pathophysiology
Fluid enters between the sheets of the pericardium, which leads to mechanical compression of the heart muscle. Heart failure develops. A decrease in the pumping function of the heart impairs the blood supply to tissues.
Causes of cardiac tamponade include:
- pericarditis;
– heart surgery;
- aneurysms;
- penetrating wounds of the heart;
- lung cancer;
- myocardial infarction.
Initial inspection
Check if the patient has classic signs of cardiac tamponade (Beck's triad):
- increased central venous pressure;
- paradoxical pulse (lowering blood pressure when inhaling more than 10 mm);
- muffled heartbeat on auscultation.
Watch to see if the patient is losing consciousness.
Check heart rate and blood pressure (BP).
Do an EKG.
First aid
Help the patient to sit upright and lean forward.
Provide oxygen therapy.
Prepare the patient for endotracheal intubation and, if necessary, mechanical ventilation.
Prepare the patient for an echocardiogram that will visualize accumulated fluid.
Prepare the patient for pericardiocentesis or surgery to improve blood pressure and heart function.
To improve myocardial contractility, administer inotropic drugs as prescribed by a doctor.
Following actions
Prepare the patient for insertion of a catheter into the pulmonary artery.
Constantly check for vital signs of the patient.
Monitor the performance of pericardiocentesis (ventricular fibrillation, vasovagal syncope, coronary artery or heart sac damaged by puncture).
If necessary (in a traumatic situation), prepare the patient for a blood transfusion or thoracotomy to avoid re-accumulation of fluid and restore blood supply.
For warfarin-induced tamponade, give vitamin K.
Watch for a decrease in central venous pressure and a concomitant increase in blood pressure, which indicate a decrease in cardiac compression.
Take steps to stabilize your blood pressure.
Reassure the patient.
Preventive measures
Encourage patients to lead a healthy lifestyle, diet, reduce physical and emotional stress, have regular health check-ups, maintain a healthy weight, and avoid smoking and alcohol abuse.
Warn patients who have undergone manipulation (pericardiocentesis) that after performing the procedures it is necessary to remain in bed for an hour.
2.9. Hypertensive crisis
A hypertensive crisis is manifested by a sharp increase in blood pressure, usually more than 220/120 mm Hg. Art.
Pathophysiology
Scheme 2
First aid
Determine blood pressure, heart rate and respiratory rate.
Do an EKG.
Prepare the patient for placement of an arterial catheter.
Carry out antihypertensive therapy (dihydropyridine calcium antagonists, non-selective β-blockers, ACE inhibitors, centrally acting adrenergic receptor stimulants).
Following actions
Watch for signs of cardiac overload (shortness of breath, bulging jugular veins).
Keep track of the amount of fluid consumed and excreted.
Do a urinalysis to monitor kidney function.
Ask if the patient is seeing double.
Keep quiet. Make sure that the lighting in the ward is dim, dim.
Preventive measures
Tell patients about the benefits of a healthy lifestyle, the need for proper nutrition, reducing fatigue, stress, maintaining a healthy weight, stopping smoking and abstaining from alcohol.
Timely treatment of primary hypertension is necessary.
Conditions that provoke secondary hypertension (for example, Cushing's disease) should be eliminated.
2.10. Occlusion of peripheral arteries
Acute peripheral arterial occlusion - obstruction in a healthy artery or in an artery with progressive atherosclerosis as a result of embolism, thrombosis, trauma. The flow of arterial blood during occlusion is suspended, the distal tissues are deprived of the supply of oxygen. The consequence of such violations are ischemia and infarction of the limb.
Pathophysiology
A clot in a peripheral artery blocks or stops blood flow to a specific area. The oxygen deficient area begins to experience cellular and tissue changes that can lead to necrosis and death. Risk factors include smoking, age, intermittent claudication, diabetes mellitus, chronic arrhythmias, hypertension, hyperlipidemia, and medications that may cause blood clots or emboli (eg, hormonal contraceptives).
Initial inspection
Examine the affected limbs. There are five main signs of occlusion:
Pain is usually severe and sharp pain in an arm or leg (or both legs in a patient with sciatic embolism);
Pulse – decreased or absent arterial pulse on Doppler and reduced or absent capillary refill;
Paresthesia - numbness, tingling, paresis, feeling of cold in the affected limb;
Paleness - color line and temperature demarcation at the level of obstruction;
Paralysis is some degree of paralysis.
Find out if the patient has:
Intermittent lameness;
hypertension;
Hyperlipidemia;
Diabetes;
Chronic or atrial fibrillation.
Also find out:
Does the patient smoke;
Is taking medications that cause blood clots or emboli (such as hormonal contraceptives).
First aid
If acute arterial occlusion is suspected:
Call a vascular surgeon and a cardiologist;
Assign bed rest;
Place the damaged area in a forced position to improve blood access;
Give supplemental oxygen;
Attach an intravenous catheter to the unaffected limb;
Take blood for diagnosis;
As prescribed by the doctor, enter morphine, anticoagulants (heparin, to prevent further thrombosis) and thrombolytics (to lysis of newly formed blood clots).
Following actions
Mark the area on the patient's limb where the pulse is palpable or audible - write down the readings of each pulse measurement, compare the data, immediately inform the doctor about changes.
Note areas of discoloration or mottling on the patient's extremity and inform the clinician of the areas.
Observe swelling tissues after successful thrombolytic therapy.
Check coagulation tests, report readings above normal levels.
Note signs of bleeding.
Prepare the patient for invasive isotope administration and possible angioplasty or surgery such as thrombectomy, arterial bypass, or amputation.
Make sure that the patient's clothing does not restrict the blood supply to the affected area.
Try to prevent injury to the affected area by using soft mattresses, cotton blankets or heel protectors, foot support, and sheepskin.
Do not use heating pads and cooling wraps to avoid thermal damage (burns).
Tell the patient about precautions for bleeding, the effect of anticoagulants and thrombolytics.
Give the patient a diet low in vitamin K.
Preventive measures
Remember that prophylactic anticoagulation is necessary for patients at increased risk of occlusion. Warn patients that smoking cessation may prevent arterial occlusion.
2.11. Ruptured aortic aneurysm
Rupture of an aortic aneurysm is an aortic aneurysm in the form of an intramural canal, which is formed due to tearing of the inner membrane and separation of the vessel wall by blood entering through the defect. Blood enters the walls, separates the layers of the aorta, and creates a blood-filled cavity. It most commonly occurs in the ascending or thoracic aorta, but can also occur in the abdominal region. Acute dissecting aneurysm requires urgent surgical intervention.
Pathophysiology
Blood accumulates in the walls of the aorta, separating its layers.
Under pressure from the blood, the aneurysm expands.
Due to a violation of blood circulation, cardiac activity is disturbed.
Risk factors include hypertension, atherosclerosis, birth defects, and connective tissue diseases such as Marfan's syndrome.
Initial inspection
Check your breathing - depth, frequency, quality.
Check the patient's level of consciousness.
Check the patient's vital parameters.
Check the cardiovascular status, determine whether the patient's peripheral pulse is weak or thready, check the apex of the heart, compare the rate and strength.
Check for a heart murmur.
Ask the patient to describe the nature of the pain (this aneurysm is characterized by pain described as sudden, excruciating, tearing from the inside).
First aid
Constantly monitor the work of the heart, make a 12-line electrocardiogram.
Provide supplemental oxygen, if necessary, apply endotracheal intubation or mechanical ventilation.
To assess blood loss, do a blood test for hemoglobin and hematocrit.
Ensure adequate circulation of blood and fluids to keep the heart working properly.
Apply antihypertensive drugs to reduce blood pressure and normalize systolic.
To relieve pain, apply morphine.
Use an inotropic agent, such as propranolol, to reduce the workload on the heart.
Following actions
Monitor the patient for signs of life at all times.
Watch for changes in the patient's condition. Call your doctor immediately if you experience hypotension, tachycardia, cyanosis, or a thready pulse.
Prepare the patient for an echocardiogram, chest x-ray, magnetic resonance imaging.
To assess the work of the kidneys, it is necessary to do tests (clearance of urea, creatinine, electrolyte levels).
Prepare the patient for surgery.
Preventive measures
During preventive examinations, it is necessary to identify a risk group - patients with hypertension and Marfan's syndrome.
It is necessary to maintain strict control of medication intake so that there is no overdose, control the frequency of ultrasound examinations. Patients with chronic aneurysms should be reviewed every 3–4 months.
2.12. Heart contusion
Cardiac contusion is a contusion of the heart muscle or myocardial contusion caused by blunt trauma to the chest. The heart muscle usually returns to normal function.
Pathophysiology
Trauma to the chest can lead to myocardial contusion due to compression of the heart between the sternum and spine.
This causes capillary hemorrhage, which can range from small (petechial hemorrhage) to profuse (through the full thickness of the myocardium).
If myocardial function is severely impaired, myocardial contusion can become an injury incompatible with life.
Usually the contusion affects the right ventricle (this is due to its location).
Myocardial contusion is usually caused by:
– Accidents (for example, due to hitting the steering wheel), accidents;
- falls from a great height;
- Cardiopulmonary resuscitation.
Check the patient's vital signs, including oxygen saturation.
Examine the injured area.
Find out what the patient's complaints are (whether they include chest pain and similar signs of heart contusion).
First aid
Provide supplemental oxygen.
Watch for cardiac activity and the possible appearance of arrhythmias.
Place the patient in the Fowler position for easier breathing.
Use antiarrhythmics, analgesics and anticoagulants (to prevent blood clots) and cardiac glycosides (to increase contractility).
Following actions
Prepare the patient for central venous catheterization.
Monitor the patient's vital signs, including central venous pressure and pulmonary artery pressure.
Get a 12 lead ECG.
Watch for signs of complications (such as cardiogenic shock and cardiac tamponade).
Take blood for troponin.
Prepare the patient for an echocardiogram, tomography, chest x-ray.
If necessary, prepare the patient for pacemaker insertion.
Preventive measures
Conduct preventive conversations about personal safety, in particular about the need to use seat belts when driving in a car and, if possible, purchase cars with airbags.
2.13. Endocarditis
Endocarditis - infection or inflammation of the inner lining of the heart, lining its cavity and forming the walls of the valves. When the disease affects the valves. If untreated, heart disease develops, which leads to death. With timely treatment, about 70% of patients recover.
Pathophysiology
Infection occurs in the endocardium.
The most common causative agent of the disease is pathogenic bacteria - non-hemolytic streptococci and enterocytes. Also, pathogens can be viruses, rickettsia and fungus.
Infection can affect not only the heart, but also the kidneys, lungs, and central nervous system.
Check the patient's vital signs, including temperature (note the presence of fever).
Examine the skin and mucous membranes for petechiae.
Take an electrocardiogram (note if it shows an arrhythmia).
First aid
Call a doctor.
Provide supplemental oxygen.
Take blood for clinical analysis.
Until the test results are available, conduct antibiotic therapy based on the presence of signs of infection.
Make sure the patient is on bed rest.
Give an antipyretic.
Following actions
Constantly monitor the vital parameters of the patient.
Do a 12-line ECG.
Monitor cardiac activity (signs of inefficient heart function - swelling of the jugular veins, shortness of breath).
Watch for signs of embolism - hematuria, pleural chest pain, paresis.
Take a blood test and check the results - the number of white blood cells, red blood cells, rheumatoid factor.
Based on the results of the urine test, monitor the work of the kidneys.
For 4-6 weeks, carry out antibiotic therapy.
Prepare the patient for echocardiography.
If necessary (in severe, complicated cases), prepare the patient for surgery.
Preventive measures
Patients at risk should be treated with antibiotics before surgery and dental procedures.
It is necessary to maintain personal hygiene, including washing hands thoroughly before eating, after returning from the street, etc. (a separate conversation about personal hygiene should be held with cooks).
2.14. Myocarditis
Myocarditis is inflammation of the myocardium. If left untreated, it poses a serious threat to health. Myocarditis is manifested by signs of impaired myocardial contractility, its excitability and conduction.
Pathophysiology
The heart muscle weakens, signs of cardiac arrest appear.
Usually, only a small part of the muscle is involved in the process, but in complicated cases, inflammation affects the entire heart, which can lead to death.
Initial inspection
Find out if the patient had a viral disease.
Note if the patient feels tired or anxious.
Listen to the heart, note if there are heart rhythm disturbances.
Check the patient's vital parameters, note the presence or absence of hypoxia, temperature rise.
Check if the patient has swelling.
Check for other signs of infection such as fever, red throat, sore eyes, etc.
Ask the patient if he is experiencing chest pain, if so, let him describe the nature of the pain.
First aid
Provide supplemental oxygen.
Continuously monitor the work of the heart.
Take blood for analysis, check for the presence of antiviral antibodies in the blood.
Enter as directed by your doctor:
– NSAIDs to reduce inflammation and pain;
– antibiotics to treat a bacterial infection;
- diuretics to reduce the load on the heart and to prevent the appearance of edema;
- if necessary - antiarrhythmic drugs;
- anticoagulants to prevent embolism;
- corticosteroids and immunosuppressants (used to reduce inflammation, but their use is controversial, limited to life-threatening complications);
- cardiac glycosides to increase the contractile function of the myocardium.
Following actions
Constantly monitor the vital parameters of the patient.
Prepare the patient for diagnosis, including a 12-lead ECG, chest x-ray, echocardiogram, and, if necessary, cardiac muscle biopsy.
If necessary, prepare the patient for the insertion of a pacemaker.
Monitor the patient for signs of cardiac arrest.
Take a blood test for white blood cells, red blood cells, creatine kinase, aspartic transaminase (AST), and lactate dehydrogenase (LDH).
To reduce fluid retention in the body, eliminate sodium from the patient's diet.
Monitor patient compliance with bed rest.
Preventive measures
Talk to patients about the importance of personal hygiene, including washing hands before eating, etc.
Talk about the need to wash food before eating it.
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A.L. Vertkin
Ambulance: a guide for paramedics and nurses
Foreword
This guide is devoted to the algorithms for the actions of paramedical personnel: paramedics of the "Ambulance" and nurses of polyclinics and emergency departments of the hospital, on the successful actions of which in the first hours of the development of the disease this or that prognosis depends.
Traditionally, the nurse and paramedic are the first to contact the patient, promptly solving the most important issues of diagnosis, obtaining the necessary additional medical information and performing emergency medical procedures. This requires a detailed understanding of the essence of the emergency and the pathological processes occurring in the body, prognosis, a rational and logical treatment plan, and recognition of the age and social characteristics of the patient. At the same time, it is necessary to show maximum attention to the patient and those around him, to be tactful, to monitor his speech, to empathize - in a word, to observe the principles of medical deontology, to which the authors also devoted many pages.
The manual briefly outlines the basic concepts and definitions adopted in emergency medicine, the main provisions on the status of a paramedic (nurse), the main types of violations of regulations by medical staff of the ambulance service, the rights and obligations of a patient who applied for emergency medical care, the main types of responsibility of medical workers providing emergency help.
What associations arise when perceiving the phrase "emergency care"? Perhaps you represent an accident victim or a patient who is urgently hospitalized with bleeding? But it can also be a patient with an acute vascular accident, poisoning with severe intoxication, respiratory failure due to pneumonia, or a pregnant woman with a threatened miscarriage. Emergency care is needed in a variety of situations and does not depend on the chosen medical specialty. The main thing is to know and be able to prioritize assistance to victims, guided primarily by the nature of the underlying disease or syndrome requiring emergency medical care, and assessing the severity of the condition. In this case, the patient must receive the required and guaranteed medical care, regardless of place of residence, social status and age. In case of mass incidents or simultaneous treatment of several patients, the caregiver must be able to determine the order of assistance. The tasks faced by the paramedic during the execution of the call include determining the patient's need for the need to provide him with emergency assistance, the need for therapeutic and diagnostic measures and determining their scope, resolving the issue of the need for hospitalization and confidentiality of information (medical secrecy) about the state of health (illness) of the patient.
Depending on the severity of the condition, five levels of medical care are distinguished:
Level 1 - resuscitation, for patients in need of urgent medical supervision. Examples are patients with acute coronary syndrome, stroke, asthma, etc.
Level 2 - emergency conditions in which patients need urgent examination and quick help, for example, with injuries of the limbs, hyper- and hypothermia, nosebleeds, etc.
Level 3 - urgent conditions, such as intoxication or respiratory disorders in a patient with pneumonia, pain syndromes during sprains, etc. In these cases, patients can wait for examination and treatment for 30 minutes.
Level 4 - less urgent conditions in which medical care may be delayed, such as otitis media, chronic back pain, fever, etc.
Level 5 - non-urgent conditions that occur in chronic diseases, for example, constipation in the elderly, menstrual syndrome, etc.
Differentiation of these conditions requires an assessment of the reason that led to the request for medical help, a detailed questioning and description of the patient's complaints, familiarization with previous medical documentation, evaluation of the effectiveness of previous therapy, etc. Ultimately, the solution of the above issues ensures greater efficiency of the friendly work of the doctor and the average medical personnel in the provision of emergency medical care.
The team of authors of the leadership is represented by leading specialists of the Moscow State University of Medicine and Dentistry, the Moscow Medical Academy named after I.I. THEM. Sechenov, Russian State Medical University and Samara State Medical University, as well as the station of emergency and emergency medical care named after. V.F. Kapinos of the city of Yekaterinburg, who have been involved in emergency medicine for many years.
Chapter 1
General principles of work of nurses and ambulance paramedics
1.1. Collection of information
Target
Collect patient information.
Indications
The need to collect information about the patient.
Contraindications
Equipment
Educational nursing history of the disease, medical documentation.
Possible Patient Problems
1. Unconscious state of the patient.
2. Negative attitude towards the conversation.
3. Distrust of the nurse.
4. Aggressively-excited state of the patient.
5. Decrease or absence of hearing.
6. Violation of speech.
Sequence of actions of a nurse (m/s) to ensure safety
1. Inform the patient of the purpose and progress of the information being collected.
2. Prepare an educational nursing history.
3. Address the patient by name and patronymic.
5. Formulate questions correctly so that they are understandable to the patient.
6. Ask questions sequentially, in accordance with the scheme of the educational nursing case history, observing the deontological rules.
7. Record the patient's responses clearly on the Nursing Nursing Record.
Evaluation of results
Patient information is collected and recorded in an educational nursing history.
1.2. Measurement of body temperature in the armpit and oral cavity of the patient
It is necessary to measure the patient's body temperature and record the result in the temperature sheet. Temperature monitoring is required both during the day and when the patient's condition changes.
Equipment
1. Medical thermometers.
2. Temperature sheet.
3. Marked container for storing clean thermometers with a layer of cotton on the bottom.
4. Marked containers for disinfection of thermometers with disinfectants.
6. Towel.
7. Gauze napkins.
Possible problems for the patient
2. Inflammatory processes in the armpit.
Sequence m/s
Measurement of body temperature in the armpit
2. Take a clean thermometer, check its integrity.
3. Shake the thermometer to t<35 °С.
4. Examine and wipe the patient's armpit area with a dry cloth.
5. Place the thermometer in the armpit and ask the patient to press the shoulder against the chest.
6. Measure temperature for 10 minutes.
7. Remove the thermometer, determine the body temperature.
8. Record the temperature results first on the general temperature sheet and then on the temperature sheet of the medical history.
9. Process the thermometer in accordance with the requirements of the sanitary and epidemiological regime.
10. Wash your hands.
11. Store thermometers dry in a clean thermometer container.
Measurement of body temperature in the oral cavity
1. Inform the patient about the upcoming manipulation and its progress.
2. Take a clean medical thermometer, check its integrity.
3. Shake the thermometer to t<35 °С.
4. Place the thermometer under the patient's tongue for five minutes (the patient holds the body of the thermometer with his lips).
5. Remove the thermometer, determine the body temperature.
6. Register the results obtained first in the general temperature sheet, then in the temperature sheet of the medical history.
7. Process the thermometer in accordance with the requirements of the sanitary and epidemiological regime.
8. Wash your hands.
9. Store thermometers clean and dry in a special container for measuring the temperature in the oral cavity.
Evaluation of results
Body temperature is measured (in various ways) and recorded on temperature sheets.
Note
1. Do not take the temperature of sleeping patients.
2. The temperature is measured, as a rule, twice a day: in the morning on an empty stomach (from 7 to 9 o'clock) and in the evening (from 17 to 19). As prescribed by the doctor, the temperature can be measured every 2-3 hours.
1.3. Blood pressure measurement
Target
Measure blood pressure with a tonometer on the brachial artery.
Indications
All sick and healthy patients to assess the state of the cardiovascular system (at preventive examinations, with pathologies of the cardiovascular and urinary systems; with loss of consciousness of the patient, with complaints of headache, weakness, dizziness).
Contraindications
Congenital deformities, paresis, fracture of the arm, measurement on the side of the removed breast.
Equipment
Tonometer, phonendoscope, pen, temperature sheet.
Possible Patient Problems
1. Psychological (does not want to know the value of blood pressure, afraid, etc.).
2. Emotional (negativity towards any action), etc.
2. Place the patient's arm correctly: in an extended position, palm up, the muscles are relaxed. If the patient is in a sitting position, then for better extension of the limb, ask him to place a clenched fist of his free hand under his elbow.
3. Place the cuff on the patient's bare shoulder 2–3 cm above the elbow; clothing should not squeeze the shoulder above the cuff; fasten the cuff so tightly that only one finger passes between it and the shoulder.
4. Connect the pressure gauge to the cuff. Check the position of the pressure gauge pointer relative to the zero mark on the scale.
5. Feel the pulse in the area of the cubital fossa and put a phonendoscope in this place.
6. Close the valve on the bulb and pump air into the cuff: pump air until the pressure in the cuff, according to the pressure gauge, does not exceed 25–30 mm Hg. Art. the level at which the pulsation of the artery ceased to be determined.
7. Open the vent and slowly deflate the cuff. At the same time, listen to the tones with a phonendoscope and follow the readings on the pressure gauge scale.
8. Note the systolic pressure when the first distinct sounds appear above the brachial artery.
9. Note the value of diastolic pressure, which corresponds to the moment of complete disappearance of tones.
10. Record your blood pressure readings as a fraction (the numerator is systolic and the denominator is diastolic), for example, 120/75 mmHg.
11. Help the patient lie down or sit comfortably.
12. Treat the membrane of the phonendoscope with 70% alcohol by wiping twice.
13. Wash your hands.
14. Record the obtained data in the temperature sheet.
Remember! Blood pressure should be measured two or three times on both hands at intervals of 1-2 minutes, the lowest result is considered reliable blood pressure. The cuff must be completely deflated each time.
Evaluation of the results
Blood pressure was measured, the data was entered into the temperature sheet.
1.4. Examination of the patient's pulse and fixing the readings in the temperature sheet
Indications
1. Assessment of the state of the cardiovascular system.
2. Appointment of a doctor.
Contraindications
Equipment
3. Temperature sheet.
Possible Patient Problems
1. Negative attitude towards intervention.
2. The presence of physical damage.
Evaluation of results
The pulse was examined. The data is entered in the temperature sheet.
Sequence of actions m / s to ensure safety
1. Inform the patient about the study of his pulse, explain the meaning of the intervention.
2. Grasp the left forearm of the patient with the fingers of the right hand, the right forearm of the patient in the area of the wrist joints with the fingers of the left hand.
3. Place your first finger on the back of your forearm; second, third, fourth consecutively from the base of the thumb on the radial artery.
4. Press the artery against the radius and feel for a pulse.
5. Determine the symmetry of the pulse. If the pulse is symmetrical, further examination can be carried out on one arm. If the pulse is not symmetrical, carry out further research on each arm separately.
6. Determine the rhythm, frequency, filling and tension of the pulse.
7. Count pulse beats for at least 30 seconds. Multiply the resulting number by two. If there is an arrhythmic pulse, count for at least one minute.
8. Record the obtained data in the temperature sheet.
Notes
1. Places for examining the pulse:
radial artery;
femoral artery;
Temporal artery;
Popliteal artery;
Carotid artery;
Dorsal foot artery.
2. More often, the pulse is examined on the radial artery.
3. At rest, in an adult healthy person, the pulse rate is 60–80 beats per minute.
4. Increased heart rate (more than 90 beats per minute) - tachycardia.
5. Decreased heart rate (less than 60 beats per minute) - bradycardia.
6. The level of independence in the implementation of the intervention - 3.
1.5. Setting up a cleansing enema
goal
Clear the lower part of the large intestine from feces and gases.
Indications
1. Stool retention.
2. Poisoning.
3. Preparation for X-ray and endoscopic studies of the stomach, intestines, kidneys.
4. Before operations, childbirth, abortion.
5. Before the introduction of medicinal enema.
Contraindications
1. Inflammatory diseases in the anus.
2. Bleeding hemorrhoids.
3. Prolapse of the rectum.
4. Tumors of the rectum.
5. Gastric and intestinal bleeding.
6. Acute appendicitis, peritonitis.
Equipment
1. System consisting of: Esmarch's cup, connecting tube 1.5 m long with valve or clamp, sterile rectal tip.
2. Water at room temperature 1–1.5 liters.
3. Oilcloth.
4. Gloves.
6. Apron.
7. Towel.
8. Tripod.
10. Vaseline, spatula.
11. Disinfectant solutions.
12. Tanks for disinfectants.
Possible Patient Problems
1. Psychological discomfort during the procedure.
2. Negative attitude towards this intervention.
Sequence of actions m / s to ensure safety
1. Inform the patient about the upcoming manipulation and its progress.
2. Put on gloves, gown, apron.
3. Pour 1-1.5 liters of water at room temperature (20 °) into Esmarch's mug, with spastic constipation, the water temperature is 40 °, with atonic constipation - 12 °.
4. Fill the system with water.
5. Hang Esmarch's mug on a tripod at a height of 75–100 cm.
6. Lay the patient on his left side on a couch covered with oilcloth hanging into the pelvis.
7. Ask the patient to bend the knees and pull them to the stomach.
8. Bleed the air out of the system.
9. Lubricate the tip with petroleum jelly.
10. Stand to the left of the patient.
11. Spread the patient's buttocks with the left hand.
12. With your right hand, insert the tip into the rectum with light rotational movements, the first 3-4 cm of the tip towards the navel, and then 5-8 cm parallel to the spine.
13. Open the valve (or clamp).
14. Ask the patient at this moment to relax and breathe slowly from the belly.
15. Close the valve or clamp the rubber tube, leaving a small amount of water at the bottom of Esmarch's mug.
16. Remove the tip.
17. Ask the patient to retain water in the intestines for 5-10 minutes.
18. Escort the patient to the restroom.
19. Disassemble the system and immerse it in the disinfectant solution.
20. Remove gloves, apron and gown.
21. Process the disassembled system, gloves, apron and tip in accordance with the requirements of the dignity of the epidemiological regime.
22. Wash your hands.
Evaluation of results
Received feces.
Note
Wash the patient if necessary.
1.6. Preparation for ultrasound and retrograde cystography
goal
Prepare the patient for the study.
Indications
Doctor's appointment.
Sequence of actions m / s to ensure safety
1. Inform the patient about the upcoming manipulation and its progress.
2. Give the patient a towel or tissue.
3. Take the patient on a gurney to the ultrasound and x-ray room.
Evaluation of results
The patient is prepared for the study.
1.7. Determination of body weight
goal
Measure the patient's weight and record it on the temperature sheet.
Indications
The need for a study of physical development and as prescribed by a doctor.
Contraindications
Severe condition of the patient.
Possible Patient Problems
1. The patient is excited.
2. Negatively inclined to interfere.
3. Severe condition.
Sequence of actions m / s to ensure safety
1. Inform the patient about the upcoming manipulation and its progress.
2. Check that the balance is working.
3. Lay a clean oilcloth on the scale platform.
4. Open the balance shutter and balance it with a large and small weight.
5. Close shutter.
6. Help the patient to stand in the middle of the scale platform (without shoes).
7. Open shutter.
8. Balance the patient's weight with weights.
9. Close shutter.
10. Help the patient off the scale.
11. Record the results in the medical history.
12. Process the oilcloth in accordance with the requirements of the sanitary and epidemiological regime.
Evaluation of results
Weight data are obtained and the results are recorded in the temperature sheet.
1.8. Applying an ice pack
Target
Place an ice pack on the desired area of the body.
Indications
1. Bruises in the first hours and days.
2. As directed by a doctor.
Contraindications
They are identified during the examination by a doctor and a nurse.
Equipment
1. Bubble for ice.
2. Pieces of ice.
3. Towel.
4. Hammer for crushing ice.
5. Disinfectant solutions.
Possible Patient Problems
Decrease or absence of skin sensitivity, cold intolerance, etc.
Sequence of actions m / s to ensure safety
1. Prepare ice cubes.
2. Place the bubble on a horizontal surface and expel the air.
3. Fill the bubble 1/2 full with ice cubes and pour one glass of cold water 14 - 16 C°.
4. Place the bubble on a horizontal surface and expel the air.
5. Screw on the ice pack cap.
6. Wrap the ice pack with a towel in four layers (the thickness of the pad is at least 2 cm). Release the air.
7. Place an ice pack on the desired area of the body.
8. Leave the ice pack on for 20-30 minutes.
9. Remove the ice pack.
10. Empty the bubble and add ice cubes.
11. Place an ice pack (as indicated) on the desired area of the body for another 20-30 minutes.
12. Treat the bladder in accordance with the requirements of the sanitary and epidemiological regime.
13. Wash your hands.
14. Store the bladder dry and with the lid open.
Evaluation of results
An ice pack is placed on the desired area of the body.
Education of the patient or his relatives
Advisory type of intervention in accordance with the above sequence of nurse actions.
Sequence of actions m / s to ensure safety
Ice is not used as a single conglomerate to avoid hypothermia or frostbite.
Informing the patient about the upcoming intervention and its progress
The nurse informs the patient about the need to put the ice pack in the right place, about the course and duration of the intervention.
1.9. Carrying out measures to prevent bedsores
Target
Prevention of bedsores.
Indications
Risk of bedsores.
Contraindications
Equipment
1. Gloves.
2. Apron.
4. Bed linen.
5. Lining rubber circle placed in a case.
6. Cotton-gauze circles - 5 pcs.
7. A solution of camphor alcohol 10% or 0.5% solution of ammonia, 1 - 2% alcohol solution of tannin.
8. Pillows filled with foam or sponge.
9. Towel.
Possible Patient Problems
The impossibility of self-care.
Sequence of actions m / s to ensure safety
1. Inform the patient about the upcoming manipulation and its progress.
2. Wash your hands.
3. Put on gloves and an apron.
4. Examine the patient's skin for potential bedsores.
5. Wash these skin areas with warm water morning and evening and as needed.
6. Wipe them with a cotton swab moistened with a 10% camphor alcohol solution or a 0.5% ammonia solution or a 1% - 2% tannin alcohol solution. Wiping the skin, do a light massage with the same swab.
7. Make sure that there are no crumbs, folds on the sheet.
8. Change wet or soiled laundry immediately.
9. Use pillows filled with foam rubber or sponge to reduce pressure on the skin in places where the patient comes into contact with the bed (or place a rubber circle placed in a cover under the sacrum and tailbone, and cotton-gauze circles under the heels, elbows, back of the head) or use anti-decubitus mattress.
10. Remove gloves and apron, process them in accordance with the requirements of the sanitary and epidemiological regime.
11. Wash your hands.
Evaluation of results
The patient has no bedsores.
