Features of care and monitoring of neurological patients

Care for neurological patients has some specific features: systematic monitoring of the patient's condition, careful and timely performance of medical appointments, recording of heart rate, respiration, blood pressure and temperature and recording of the obtained data in the observation sheet. The patient's condition during the first day is monitored every 30-60 minutes. The data of observation and performance of medical appointments are recorded in a card consisting of the following graphs: date, day, hour, minute, pulse rate, respiration, blood pressure, temperature, water balance, volume of fluid administered to the patient and the volume of fluid allocated, state of consciousness. A separate graph is used to record the performance of appointments( transfusion of blood and its substitutes, the introduction of various drugs, overturning the patient, giving moistened oxygen, bladder catheterization, etc.).

Skin care

It is very important when caring for patients who are unconscious to monitor the skin condition. In bedridden patients, as a rule, skin nutrition is affected. Fixed position in bed for several hours causes local disturbance of blood circulation, leads to tissue ischemia and the formation of pressure sores. The first signs of the appearance of pressure sores are redness and maceration. Most bedsores are formed in the nape of the neck, scapula, sacrum, buttocks, heels. As prophylactic measures for the emergence of pressure sores, the patient should be turned in bed every 2-3 hours, gently massage the skin and wipe it with a 33% solution of alcohol or camphor alcohol, and regularly put the patient on a rubber circle covered with a diaper for several hours. So that there are no folds on the sheet, its corners are tied to the legs of the bed. When maceration of the skin is prescribed ultraviolet irradiation, lubrication with a 2% solution of manganese. Bedsores can be formed in paralyzed patients( with stroke, myelitis, tumors, traumatic spinal cord injury, etc.) after several hours in the same position under unfavorable conditions( wet bed, folds).

There are four stages of pressure sores:

• necrosis;

• formation of granulations;

• epithelialization;

• formation of a trophic ulcer.

When necrosis, the nurse must free the wounds from the necrotic masses, eliminate the wounds and "pockets".To do this, topically apply antiseptics( rivanol solutions - 1: 1000, 1: 500, furatsilina solution - 1: 4200), antibiotics and ultraviolet irradiation of the wound.

In the stage of granulation formation, it is necessary to create conditions that will help fill the wound with granulation tissue. At the same time, ozokerite and dirt are applied.

In case of severe neurological diseases, paralysis and paresis, warmers should not be used, as if they are disturbed, they can lead to a burn. Burns in these patients heal badly, they can develop a septic process and appear flexion contracture( stiffness) in the paralyzed lower limb.

A nurse is obliged to monitor the cleanliness and frequency of changing bed linen. Sheets need to be changed frequently. Change of bed linen for seriously ill patients is carried out in the following way: the patient is put on the edge of the bed or is carefully turned, or gently moved to the edge, a dirty sheet is removed from the free part of the bed and the oilcloth is wiped. A clean sheet, folded into a roll, is rolled out on the free part of the bed. The patient is turned over to the half-covered, cleaned completely dirty sheet and spread to the end clean. It is necessary to change linen quickly, without causing, but the opportunity, the patient no inconvenience.

Oral Care

A neurological patient, especially in a serious or unconscious state, needs careful oral care. With a weakening of the body's defenses, even ordinary oral flora can become pathogenic and cause gingivitis, stomatitis and inflammation of the parotid gland( parotitis).It is necessary to wipe the oral cavity 2-3 times a day with a 2-4% solution of boric acid, 3% hydrogen peroxide solution, mucous membrane moisten with alkaline water, remove food debris. This can be done with a cotton swab dipped in the above solutions. A wet tampon can be held with a surgical instrument - a forceps or a long tweezers. If the patient has a bad mouth, you can put the glove on one hand, on the index finger, wind a clean cloth moistened with the solution, and thoroughly treat the mouth cavity manually.

Under certain conditions, for example, in cases of craniocerebral trauma, hemorrhagic stroke, consciousness is often disturbed, and in some cases there is a violation of external respiration;in such cases impose a tracheostomy. Inspired air through the tracheostomy tube or un-moistened oxygen dries the mucous membrane of the trachea and bronchi, which can lead to the development of tracheitis, bronchitis, pneumonia. Therefore, it is necessary to make sure that the gas mixture inhaled through the tracheostomy tube is warm and moist. Every 1-2 hours the output part of the tracheostomy tube should be rinsed, 2-3 drops of a 5% solution of soda with antibiotics should be instilled in the trachea and at least 5-6 times a day using a soft polyethylene tube to suck the mucus from the trachea through the tracheostomy. The dressing around the tracheostomy tube should be dry and clean. These measures improve pulmonary ventilation and increase the oxygen content in the blood.

Hyperthermia care

Patients with craniocerebral trauma with serious impairment of consciousness often have cases of fever. Therefore, ice bubbles wrapped in a napkin are used to cool the body, they are placed on the heart area and large main vessels, underarm cavities, inguinal and popliteal areas, the elbow fold area. Bubbles with ice and put on the head of the patient. Hypothermia reduces the intensity of cellular metabolism, the phenomenon of cerebral edema and intracranial hypertension, and also reduces the need for brain matter in oxygen.

Care for acute disorders of the cerebral circulation

Regardless of the nature of the cerebral stroke, medical personnel must follow several rules:

• ensure that the patient is lying on his back;

• Remove removable teeth from the mouth as far as possible;

• In case of vomiting, the patient should be turned on his side and cleaned of the mouth cavity from the vomit to avoid aspiration and the subsequent development of aspiration pneumonia;

• In case of worsening of the condition, take necessary medications, inhale oxygen, systematically suck off mucus from the oral cavity and nasopharynx;

• to prevent pneumonia, bedsores;

• if you urinate incontinently, you need to have a bladder catheterization;

• if the patient is overly excited, an enema with chloral hydrate( 30-40 ml of 4% solution) should be made;

• transportation of patients in extremely serious condition is allowed only in exceptional cases, as this can worsen their condition.

A nurse should distinguish between two main types of cerebral stroke: hemorrhagic and ischemic;in addition, you need to know about transient disorders of cerebral circulation, based on spasms of cerebral vessels. These disorders occur with atherosclerosis of the cerebral vessels, hypertension, arterial hypotension( a decrease in cardiac activity, blood loss), increased viscosity and coagulability of the blood, with cervical osteochondrosis.

With common cerebral crises, headache, head noise, dizziness, nausea or vomiting, blushing or redness of the skin, tension or loss of pulse, elevation or lowering of blood pressure, upsetting of consciousness.

With localized cerebral crises, focal symptomatology prevails over cerebral palsy, and this is manifested by paresis or paralysis, speech disorders, paresthesia. In such cases, the patient must be laid, create conditions for him to rest. At high arterial pressure, make bloodletting( up to 100 ml of blood from the elbow of the elbow), put leeches on the mastoid process, mustard on the back of the neck or the calf muscle region. Apply antispasmodic and hypotensive drugs: 2 ml of 2% solution of papaverine in 10-20 ml of 40% glucose solution intravenously, dibazol 2-5 ml of 1% solution subcutaneously;10 ml of a 25% solution of magnesium sulfate on a 0.25% solution of novocaine intramuscularly;at an arterial hypotension - intimate or cardiac agents: kardiamin, camphor, a solution mezatona, korglikona 0,06% in 20% -solution of a glucose intravenously. With a headache, analgesics.

Hemorrhagic stroke. Most often it occurs suddenly in hypertensive disease or atherosclerosis, strong emotional or physical stress. Spilled blood destroys the brain tissue, causes the phenomenon of cerebral edema, which leads to an increase in intracranial pressure. There is a severe headache, hyperemia of the face and mucous membranes, vomiting, increased blood pressure and body temperature, sopor, coma, psychomotor agitation, signs of focal lesions( hemiparesis and hemiplegia), blood may appear in the cerebrospinal fluid. Characteristic disorders of breathing and cardiovascular activity. In such cases, it is necessary to put mustard plaques on the back of the head, with a high blood pressure, a strained pulse and a crimson-red face to make a bloodletting( 100-300 ml).On the head put a bubble with ice for several hours with interruptions for 1-2 hours. Apply coagulants: vikasol, calcium gluconate. In the presence of elevated blood pressure - dibazol, papaverine, hypothiazide;introduce a lytic mixture - aminazine 2.5% - 2 ml;Dimedrol 1% - 2 ml;Promedol 2% - 1 ml;Novocaine 0.5% - 50 ml, Glucose 10% - 300 ml. Dehydrating agents: glycerol, lazix, novorit;intramuscular - magnesia. In disorders of breathing, tracheostomy.

Ischemic stroke. More often it occurs in old age against the backdrop of atherosclerosis of the vessels of the brain and arterial hypotension, increased coagulability of the blood. Often it occurs during sleep. The development of stroke is associated with the presence of a thrombus, embolus and cerebral vascular insufficiency. Characteristically, the presence of precursors of a stroke, which may appear in a few hours, so the nurse should be observant and, perhaps, even once again ask the patient if he has a darkening in the eyes, dizziness, weakness, transient numbness of the limbs. The skin of the face at the time of the already developed ischemic stroke will be pale, the pulse is weak, the blood pressure is lowered, the body temperature is normal, the cerebrospinal fluid is not changed. In the first hours of the onset of a stroke, if there is a weak cardiac activity, heart means are used: camphor, cordyamine, korglikon;for removal of spasm of cerebral vessels - intravenous injection of 10 ml of a 2.4% solution of euphyllin in 10 ml of 40% glucose solution. Assign inhalation of carbogen, in order to reduce the formation of thrombus - dicumaril, syncumar, heparin, fibrinolysin. In the presence of paresis or paralysis, it is advisable to massage, physiotherapy exercises: initially - passive movements in the paralyzed limbs, and with the restoration of muscle strength - active movements. LFK combine with a light massage. With an increase in muscle tone apply midokalm. After two weeks, resorption therapy is used: solutions of potassium iodide( 0.5-2% solution of 1 tablespoon 2-3 times a day after meals for 3-4 weeks);intramuscularly aloe( 1-2 ml every other day, number 15-20).

Patients in a coma in the first day of food can not be given. If the patient swallows, with the help of a drinker, it is necessary to inject liquid( tea, juices) in small portions. In swallowing disorders, food and liquid can enter the bronchi. Therefore, feeding is carried out through a probe inserted into the stomach through the mouth or lower nasal passage. If the patient is unconscious for several days, he is also fed through a probe. When you insert the probe, you can use a laryngoscope. Before you feed the nutrient mixture through the probe, you need to make sure that the probe is in the stomach. If during vomiting there is vomiting, then the patient's head must be turned aside, clean the mouth of the vomit. When popperhivanii patient should be fed "kiseleobraznoy" food - kissel, liquid semolina porridge, kefir. It should be remembered that a heavy neurological patient needs to be fed more often, in small portions, with interruptions. We must ensure that the patient does not choke, not tired, otherwise he can refuse to eat. You can drink from a drinker or a teaspoon, tea should not be hot. Food should be high in calories, rich in vitamins, contain meat, dairy products, vegetables, fruits.

It must be remembered that in people in a coma, when feeding through a probe, aspiration very often occurs, therefore, in the early days of a coma, only parenteral nutrition should be used. Exclusively for parenteral nutrition, patients are rapidly depleted, and feeding through the probe begins on the third day. As parenteral nutrition, use isotonic sodium chloride solution intravenously or subcutaneously in the thigh, slowly, not more than 500-600 ml per one session. For a better absorption at the injection site, a warm heating pad is applied for a short time through the diaper. The total amount of liquid administered on the first day should not exceed 1 liter, and in the subsequent, when administering dehydration therapy, at least 2-3 liters are administered. In addition, 300 ml of 40% glucose are injected intravenously, 8-10 units of insulin and 500 ml of vitamin C, vitamins of group B,( 50-100 ml intramuscularly) are added to it. In patients in a coma, the digestive and acid-forming functions of the stomach and digestive glands are suppressed, so gastric juice and extractive co -ogenic substances can be used. Given that patients can be depleted, on the fifth day, at the doctor's discretion, anabolic steroid hormones( methyl-androstenediol, nerobol) can be prescribed. Nutrition of patients should be high-calorie: 3000-4000 kcal per day, of which 95-120 g of protein, 550-700 g of carbohydrates, 40-60 g of fats. In the case of paresis of the muscles of the pharynx and larynx, a gastrostomy is applied.

Bladder catheterization

With certain diseases of the central nervous system( cerebrovascular disease, brain and spinal cord tumors, myelitis, trauma of the spine and spinal cord), disorders of the pelvic organs occur-the retention or incontinence of urine and feces.

In an unconscious patient with urinary retention, it is necessary to determine the filling of the bladder. By palpation and percussion, the contours of the bladder are revealed, the upper border of which can reach the navel, if it is full. With anuria, the bladder is empty. When urine retention is used, a catheter is used, which is performed with a sterile catheter( preferably rubber).Sex organs are pretreated with solutions of antiseptics. In case of repeated catheterization for the prevention of urinary infection, the bladder should be washed with antiseptics or antibiotics. If the patient is shown a permanent catheterization, the catheter is inserted into the bladder and the free end is lowered into the jar with the antiseptic. In a number of patients in severe chronic conditions, acute renal failure may occur. The main treatment for renal failure is the appointment of a rational diet for calories, the composition of fats, carbohydrates, salts and the amount of water introduced into the body. It is necessary to know that in acute renal failure, corticosteroid hormones are not prescribed.

Gastric lavage

With renal failure, the gastrointestinal tract and skin take over the excretory function. Therefore, patients wash the stomach with 2-8 liters of a weak solution of sodium hydrogencarbonate 1-2 times a day.

Cleanses

Siphon enemas are placed for lavage of the intestine. At high levels of residual nitrogen and urea in the plasma, the question is raised whether the patient undergoes hemodialysis or peritoneal dialysis.

Laxative enemas are used for stool retention. If the usual enema does not cause bowel movement, make oil enemas( 100 ml of vegetable oil or Vaseline) or enema from a 30% solution of magnesium sulphate. Of laxatives, sulfate magnesia is prescribed for 20-30 g per reception, rhubarb for 0.5 g three times a day, vaseline oil for 1 tbsp.l.3 times a day. Correctly adjusted care is of great importance in the prevention of severe complications and promotes rapid recovery and recovery of work capacity.