Observation of the most important indicators of the patient's condition

  • Observation of the most important indicators of the patient's condition

    Examination of the patient

    Some research methods are necessarily included in the general clinical examination plan. Mainly these are the following methods of examination: anthropometry, measurement of blood pressure, body temperature with the calculation of the possible nature of the temperature curve, general blood and urine tests, helminth feces analysis, chest X-ray, electrocardiography for persons over 40 years old.

    Laboratory diagnostics includes an extensive set of methods for studying cellular and chemical composition;physico-chemical and biological properties of tissues and body fluids, immunity indices, as well as methods for detecting pathogens. The method of laboratory study is compiled in accordance with the conclusions drawn from the general survey. However, some types of laboratory diagnosis need to be carried out regardless of the likely disease. For example, in a hospital environment, in addition to general blood tests, urine, feces for eggs of worms, each patient is given blood for Wasserman's reaction, as well as for the quantitative content of glucose, bilirubin, cholesterol, urea. This makes it possible to identify some diseases that are asymptomatic in the initial stage of the disease.

    Measurement of growth

    Manipulation is conducted to assess and control the physical development of children, adolescents and adults;by appointment of a doctor;at suspicion on disturbance of functions of a pituitary body. Required inventory: vertical growth meter, accounting documentation, oilcloth, container with disinfectant solution.

    Growth measurement standing

    Spread the oilcloth( napkin) on the platform of the growth meter.

    The nurse, standing to the side of the gauge, raises the folding seat, moves the measuring bar above the patient's height. Then the patient( without shoes and headgear) stands on the platform of the growth meter. In this case, he must touch the scale with four points: the back of the head, shoulder blades, buttocks, heels.

    The position of the head is checked on the line connecting the outer corner of the eye and the upper edge of the ear, it should be horizontal. The measuring strip is lowered on the patient's head and pressed against the measuring scale of the rostomer. The readings are taken on the right( light) side of the scale of the growth meter after the patient descends from the site of the growth meter. Then the folding seat is closed and the bar is lowered.

    These measurements are entered in the accounting records. The glue is placed in a disinfectant solution.

    Growth measurement in sitting position

    The nurse is located on the side of the growth meter. On the folding seat spread oilcloth. The measuring strip is raised above the patient's height. The patient sits on the folding seat, touching it with three points: the back of the head, shoulder blades, buttocks. The head is fixed in a position where the line connecting the outer corner of the eye and the upper edge of the ear should be horizontal. The measuring strip is lowered on the patient's head and pressed against the scale of the growth meter. The readings are taken on the left( dark) side of the scale of the growth meter after the patient rises from the folding seat of the growth meter. The bar is lowered, the measurement data is recorded in the accounting records. The glue is placed in a disinfectant solution.

    Body weight measurement

    This procedure is performed in the morning on an empty stomach after the bowel and bladder have been emptied.

    The measurement of body weight is performed to assess physical development. It is carried out according to the doctor's prescription, in order to control the physical development of children, adolescents, adults;with diseases of the urinary, cardiovascular, endocrine systems.

    Medical scales, accounting documentation, oilcloth, rubber gloves, container with disinfectant solution are needed for the study.

    Before carrying out the measurement it is necessary to adjust the balance: open the lock of the lock, check the balanced state of the balance beam.

    If the movable rocker is below the stationary one, the adjusting nut is turned anti-clockwise, if higher, then clockwise until equilibration. When the adjustment is completed, the shutter of the lock is closed. Put an oilcloth on the platform of the scales. The patient in underwear, without shoes, with the lock locked, stands on the center of the weighing platform. Initially, kilogram weights are set up to the patient's specified approximate weight. Having opened the lock of the lock, the balance arms are balanced by the movement of gram weights. The lock of the lock is closed. The patient descends from the weighing platform, recorded indications are recorded in the records. The glue is soaked in a disinfectant solution.

    Measurement of the chest circumference

    It is carried out in order to control the physical development of children, adolescents, adults, as prescribed by the doctor for respiratory system diseases.

    A centimeter loop with a loop and records are required for the study.

    The patient should undress, stand upright and spread his arms out to the sides. A centimeter tape covers the patient's chest( while the nurse with his right hand holds the loop, and the left - the free edge of the tape).The tape is applied on the following landmarks: in front of children and men on the lower edge of the sucking-in circles, and in women - at the upper edge of the IV rib, above the breast glands behind the lower corners of the scapula.

    Then the patient should lower his hands, take the maximum breath. The nurse, at the same time, reads to the patient the readings taken at maximum inspiration. Then the patient exits the maximum exhalation, and the nurse reads the readings on the centimeter tape in this position.

    The following measurements are carried out in a quiet state, for which the patient is asked to slowly say his / her name. The received results are entered in the accounting documentation. The difference between the readings with the maximum inspiration and maximum expiration corresponds to the range of the chest.

    Muscle strength measurement

    It is carried out according to the doctor's prescription for the purpose of controlling the physical development of children, adolescents, adults.

    The procedure requires a dynamometer and accounting documentation. The nurse is obliged as much as possible intelligibly to explain the algorithm of carrying out dynamometry.

    The dynamometer needle must be locked in position 0. The patient, standing straight, takes the dynamometer in the right arm, the muscles must be on the movable dynamometer strap. The patient withdraws his right hand to the side, moves it forward and maximally squeezes his fingers. It is necessary to take readings and return the arrow of the dynamometer to the mark of 0. The muscular strength of the right hand is measured twice more. The maximum result is entered in the accounting documentation. A similar procedure is performed when measuring the muscular strength of the left arm.

    Measurement of the vital capacity of the lungs

    The physician prescribes control over the physical development of children, adolescents, adults;diseases of the respiratory system.

    Nurse, in advance explaining the patient the algorithm of manipulation, thoroughly washes his hands, puts on gloves. Taking a sterile tweezers, open the container for clean mouthpieces. The replaceable mouthpiece should be taken out with a sterile tweezers over the edge with the shoulder, the container should be closed. The mouthpiece is fixed on a spirometer. Combine the zero division of the scale with the arrow, rotating the moving part of the spirometer. The spirometer is given to the patient so that his fingers do not block the spirometer fan. The replaceable mouthpiece on the spirometer is covered with a sterile gauze napkin. Then the patient is asked to turn his head to the side and take a deep breath, then exhale. Then the patient should inhale again, take the mouthpiece of the spirometer in his mouth, tightly wrap his lips, clutching his nose, slowly exhale all the air. Record the spirometer scale readings, return the zero division to the arrow in the above way. Repeating the survey twice, the maximum result is recorded in the accounting records. The used napkin and replaceable mouthpiece are placed in a disinfectant solution.

    Heart rate measurement

    The pulse test is performed to evaluate the functional state of the cardiovascular system. It is performed according to the doctor's prescription for diseases affecting the condition of the cardiovascular system.

    The nurse sits in front of the patient. The forearm and the patient's brush should be relaxed. The nurse takes the patient's hands, lying freely with the palms down, with the right hand left, the left hand with the right. At the base of the patient's thumb, the person who examines II, III, IV with fingers probes the pulsating radial artery. Having felt a pulse, slightly squeeze the artery with fingers, so that it is clearly palpated.

    The pulse characteristic is given by one hand at a synchronous pulse( synchronism is the coincidence of pulse strokes on both hands).

    Heart rate characteristics:

    • rhythm of pulse - uniform alternation of pulse waves. Arrhythmic is the pulse, in which the alternation of pulse waves is uneven;

    • heart rate - the number of pulse beats per minute.

    With a rhythmic pulse, it is necessary to count the number of strokes in 15( 30) seconds and multiply by 4( 2), with an arrhythmic pulse, the number of strokes is counted in 1 minute. The norm is 60-80 beats per minute, over 80 strokes - tachycardia, below 60 beats per minute - bradycardia.

    A nurse must prepare a set for this manipulation in advance:

    • dry air spirometer;

    • a set of clean exchangeable mouthpieces;

    • sterile tweezers;

    • sterile gauze wipes;

    • medical gloves;

    • disinfectant solution;

    • accounting records.

    The pulse voltage is directly proportional to the force that must be applied to completely stop the pulsed oscillations of the radial artery. There are moderate, intense, mild pulse.

    Filling the pulse - filling the arteries with blood. There are a complete, weak and threadlike pulse.

    In the temperature sheet, the measurement results are as follows: heart rate - horizontally with dots of red color, date - in vertical. The connection of the points gives a "curve of the dynamics of the pulse frequency".

    It is carried out to determine the functional state of the cardiovascular system, with diseases of the cardiovascular and endocrine systems. To perform this manipulation you need a tonometer and a phonendoscope.

    During the measurement, the patient should sit or lie, his unbent hand should be freely laid with the palm up. The tonometer is placed at the same level as the patient's arm.

    The cuff is wrapped around the naked shoulder 2-3 cm above the elbow fold, but do not overtighten - between the cuff and the patient's skin, the finger should be placed, and the cuff tubes should be directed down the lateral surface of the forearm. Check the connection of the cuff tubes to the manometer of the device. On the ulnar fold, palpation is determined by pulsation of the ulnar artery. At this point, apply the phonendoscope tightly, but without pressure. With the valve of the canister closed, air is gradually pumped up to 20 mm Hg. Art.higher than the expected blood pressure level of the patient.

    The valve is opened and, slowly releasing the air, is marked on the scale of the manometer:

    • the first heard tone, which indicates the level of systolic pressure on the scale of the manometer;

    • the last heard tone - the level of diastolic pressure.

    Pulse pressure is determined by calculating the difference between systolic and diastolic pressure.

    Next, disconnecting the tubes, remove the cuff from the patient.

    In the temperature sheet, the result is marked in the form of a shaded rectangle of red color, the upper boundary of which is the systolic pressure level, and the lower boundary is the diastolic level.

    It is carried out with a diagnostic purpose, in a planned order 2 times a day - in the morning from 6.00 to 8.00 and in the evening from 17.00 to 19.00, and also according to the doctor's prescription.

    To perform this procedure, the following kit is necessary: ​​medical mercury thermometer, gloves, watch, pen, temperature sheet, gauze pad, containers with antiseptic solution.

    A nurse washes her hands, puts on gloves and wipes the patient's dry axilla with a napkin. Preliminary check the integrity of the thermometer and shake off the mercury to below 35 ° C.The thermometer is placed in the axillary region of the patient so that there is no undergarment between the mercury tank and the body.

    The patient is asked to press his shoulder against the chest. Indications are evaluated after 10 minutes. Then shake the mercury below 35 ° C.The thermometer, napkin, and gloves are put in appropriate containers with a disinfectant. Wash your hands. The measurement results are entered in the individual patient temperature sheet with blue dots. When all points are connected, a "temperature curve" is obtained.

    To determine life-threatening conditions of the patient, as well as pathological changes in physiological functions that can not be recognized by simple observation of the patient due to the suddenness and rapidity of their occurrence, a method of constantly monitoring a number of parameters of human physiological functions using specialized devices equipped with monitors is used. This method is called monitor monitoring. Monitoring is performed on such indicators as heart rate, respiratory rate, heart rate, arterial and venous pressure, body temperature, cardiac output, electrocardiogram and electroencephalogram, gas content in blood and exhaled air, blood pH, etc.

    Monitoring observationappoints a doctor, and carries out his average medical staff.

    Nurses of specialized departments, wards and intensive monitoring posts, resuscitation units are required to undergo special training in monitoring monitoring and resuscitation.

    For monitor monitoring, several types of monitors are used:

    • tracking;

    • registering;

    • equipped with an alarm triggered when the value of the monitored indicator deviates beyond the limits set by the doctor;

    • equipped with microprocessors capable of storing, analyzing and interpreting the results of measurements for a certain period of time and containing information on changes in the given indicators in graphical or tabular form.

    The most common monitoring of the main functions of the heart with stationary bedside cardiac monitors. Cardiac monitors allow monitoring of ECG and other parameters of cardiac activity simultaneously in several patients from a central monitor post. The central monitor post is located in intensive care units, in intensive care units, toxicological units, in operating and postoperative wards, in micro-pediatric units, etc. Control over a large number of indicators is difficult, so one or two of the most significant at the moment are monitored.

    There are monitors that do not require special cable connection to the central monitor post, they are used in any ward as a mobile bedside ECG monitor for monitoring of seriously ill patients.

    Long-term monitoring monitoring with portable monitors is also common. Portable monitors are required for registration with the diagnostic purpose of ECG, AD, or other indicators both in hospital and in community settings for 24-48 hours. This type of monitoring monitoring allows you to compare the indicators of interest with the patient's complaints, subjective feelings, the level of his physical activity, various processes of vital activity( such as sleep, nutrition, etc.) and, if necessary, adjust the therapy in a timely manner.

    After the doctor appoints a monitoring monitor, the nurse of the monitor post connects the patient to the monitor by attaching electrodes or other sensors of the monitor system, starts the device, checks the quality of the electrical contacts, and begins visual observation of the monitor's parameters.

    The monitor post can not be left by a nurse without an appropriate replacement( under no circumstances).

    If the dynamic of the parameter being investigated or an automatic alarm is triggered, the nurse is obliged:

    • to immediately register the investigated indicator;

    • promptly, skillfully analyze and evaluate the prognostic significance of the detected changes;

    • immediately inform the doctor about the detected changes in the parameter under study;

    • If necessary, urgently call the patient on duty to the emergency resuscitation team. Throughout the entire period of resuscitation, both monitor indicators and therapeutic and diagnostic measures are documented, indicating the exact time of their conduct.