Assessment of patient physical condition indicators sample. Assessment of the patient's functional state Teacher: Melnik O.N.

Introduction

1. Assessment of the patient’s functional state

2. Admission to a medical institution

3. Patient sanitization

Conclusion

Literature

Introduction

Hospital (lat. stationarius - standing, motionless) is a structural unit of a medical institution (hospital, medical unit, dispensary), intended for the examination and treatment of patients in a round-the-clock (except for day hospital) stay in this institution under the supervision of medical personnel.

The main structural units of the hospital are the emergency department (reception room), medical premises, and the administrative and economic part.

Inpatient care begins in the admissions department. The emergency room is an important diagnostic and treatment department designed for registration, admission, initial examination, anthropometry, sanitary and hygienic treatment of admitted patients and the provision of qualified (emergency) medical care. The success of the patient’s subsequent treatment, and in emergency conditions, his life, depends to a certain extent on how professionally, quickly and organized the medical staff of this department acts. Every arriving patient should feel a caring and friendly attitude towards him in the admission department. Then he will gain confidence in the institution where he will be treated.

Thus, the main functions of the reception department are the following.

Reception and registration of patients.

Medical examination of patients.

Providing emergency medical care.

Determination of the hospital department for hospitalization of patients.

Sanitary and hygienic treatment of patients.

Preparation of appropriate medical documentation.

Transportation of patients.

1. Assessment of the patient’s functional state

The nurse in the reception department measures the temperature and checks the documents of incoming patients; notifies the doctor on duty about the arrival of the patient and his condition; fills out the passport part of the medical history for the patient, registers them in the register of patients undergoing inpatient treatment; enters the patient's passport into the alphabet book; if the patient’s condition is satisfactory, he performs anthropometry (measures height, chest circumference, weighs); quickly and accurately carries out the doctor’s instructions for emergency care, strictly observing asepsis; accepts valuables against a receipt from the patient, explains the procedure for receiving them, and introduces the rules of behavior in the hospital; organizes sanitary treatment of the patient, handing over (if necessary) his things for disinfection (disinfestation); informs in advance (by telephone) the nurse on duty of the department about the patient’s admission; organizes the sending of the patient to the department or accompanies him herself.

To generally assess the patient’s condition, the nurse should determine the following indicators.

General condition of the patient.

Position of the patient.

The patient's state of consciousness.

Anthropometric data.

General condition of the patient

An assessment of the general condition (severity of the condition) is carried out after a comprehensive assessment of the patient (using both objective and subjective research methods).

The general condition can be determined by the following gradations.

Satisfactory.

Moderate weight.

Heavy.

Extremely severe (preagonal).

Terminal (agonal).

State of clinical death.

If the patient is in satisfactory condition, anthropometry is performed.

Anthropometry(Greek antropos - person, metreo - to measure) - assessment of a person’s physique by measuring a number of parameters, of which the main (mandatory) ones are height, body weight and chest circumference. The nurse records the necessary anthropometric indicators on the title page of the inpatient medical record

Measurement results temperature entered into the Individual Temperature Sheet. It is created in the emergency department along with a medical record for each patient admitted to the hospital.

In addition to graphically recording temperature measurement data (scale “T”), it builds curves of pulse rate (scale “P”) and blood pressure (scale “BP”). At the bottom of the temperature sheet, the data for calculating the respiratory rate per minute, body weight, as well as the amount of liquid drunk per day and urine excreted (in ml) are recorded. Data on defecation (“stool”) and sanitary treatment carried out are indicated with a “+” sign.

Nursing staff must be able to determine the basic properties of the pulse: rhythm, frequency, tension.

Pulse rhythm determined by the intervals between pulse waves. If pulse oscillations of the artery wall occur at regular intervals, therefore, the pulse is rhythmic. In case of rhythm disturbances, an incorrect alternation of pulse waves is observed - an irregular pulse. In a healthy person, the contraction of the heart and the pulse wave follow each other at regular intervals.

Heart rate counted within 1 minute. At rest, a healthy person has a pulse of 60-80 per minute. When the heart rate increases (tachycardia), the number of pulse waves increases, and when the heart rate slows (bradycardia), the pulse is rare.

Pulse voltage determined by the force with which the researcher must press the radial artery so that its pulse fluctuations completely stop.

Pulse voltage depends primarily on the value of systolic blood pressure. With normal blood pressure, the artery is compressed with moderate force, so the normal pulse is moderate. With high blood pressure, it is more difficult to compress the artery - such a pulse is called tense, or hard. Before examining the pulse, you need to make sure that the person is calm, not worried, not tense, and that his position is comfortable. If the patient has performed some kind of physical activity (brisk walking, housework), undergone a painful procedure, or received bad news, pulse examination should be postponed, since these factors can increase the frequency and change other properties of the pulse.

Data obtained from examining the radial pulse are recorded in the Inpatient Medical Record, Care Plan, or Outpatient Card, indicating rhythm, frequency, and tension.

In addition, the pulse rate in a hospital facility is noted with a red pencil on the temperature sheet. In column “P” (pulse) enter the pulse frequency - from 50 to 160 per minute.

Blood pressure measurement

Arterial pressure (BP) is the pressure that is formed in the arterial system of the body during heart contractions. Its level is influenced by the magnitude and speed of cardiac output, the frequency and rhythm of heart contractions, and the peripheral resistance of the arterial walls. Blood pressure is usually measured in the brachial artery, where it is close to the pressure in the aorta (can be measured in the femoral, popliteal and other peripheral arteries).

Normal systolic blood pressure values ​​range from 100-120 mmHg. Art., diastolic - 60-80 mm Hg. Art. To a certain extent, they also depend on the person’s age. Thus, in elderly people the maximum permissible systolic pressure is 150 mmHg. Art., and diastolic - 90 mm Hg. Art. A short-term increase in blood pressure (mainly systolic) is observed during emotional stress and physical stress.

By observing breathing, in some cases it is necessary to determine its frequency. Normally, breathing movements are rhythmic. Respiratory rate in an adult at rest it is 16-20 breaths per minute; in women it is 2-4 breaths more than in men. In the lying position, the number of respirations usually decreases (to 14-16 per minute), in an upright position it increases (18-20 per minute). In trained people and athletes, the frequency of respiratory movements can decrease and reach 6-8 per minute.

The combination of inhalation and subsequent exhalation is considered one breathing movement. The number of breaths in 1 minute is called the respiratory rate (RR) or simply the respiratory rate.

Factors that cause the heart to beat faster can cause increased depth and speed of breathing. This is physical activity, increased body temperature, strong emotional experience, pain, blood loss, etc. Observation of breathing should be carried out unnoticed by the patient, since he can arbitrarily change the frequency, depth, and rhythm of breathing.

2. Admission to a medical institution

The nurse’s responsibilities also include filling out the title page of the medical history: passport part, date and time of admission, diagnosis of the referring institution, statistical coupon for the admitted patient.

The patient is examined on a couch covered with oilcloth. After each patient is admitted, the oilcloth is wiped with a rag moistened with a disinfectant solution. Patients admitted to the hospital, before being sent to the diagnostic and treatment department, undergo a complete sanitary treatment in the reception department with replacement of underwear. Patients who are indicated for resuscitation and intensive care can be sent to the anesthesiology and intensive care unit without sanitization. A patient entering inpatient treatment must be familiarized in the admission department with the daily routine and rules of behavior of patients, which is noted on the title page of the medical history.

All medical documentation is prepared by the admissions department nurse after examining the patient by a doctor and deciding on his hospitalization in this medical institution, or outpatient appointment. The nurse measures the patient’s body temperature and records information about the patient in the “Logbook of admission of patients (hospitalization) and refusal of hospitalization” (form No. 001/u): last name, first name, patronymic of the patient, year of birth, insurance policy details, home address, from where and by whom it was delivered, the diagnosis of the referring institution (polyclinic, ambulance), the diagnosis of the emergency department, and also to which department it was sent. In addition to registering the patient in the “Patient Reception Register,” the nurse draws up the title page of the “Inpatient Medical Card” (form No. 003/u). Almost the same information about the patient is recorded on it as in the “Hospitalization Log”, and insurance policy data is recorded (in the case of planned hospitalization, it is required when admitting the patient). Here you should write down the telephone number (home and work) of the patient or his immediate family.

Rules for monitoring the patient.

Methods for measuring pulse, blood pressure, respiratory rate, body temperature and monitoring diuresis.

Clinical study of the patient , or an objective examination of the patient ( Status praesens ), allows us to judge the general condition of the body and the condition of individual internal organs and systems. In order for the objective examination of the patient to be complete and systematic, the doctor conducts it according to a specific plan:

General examination of the patient (inspectio);

Palpation (palpatio);

Percussion;

Listening (auscultatio).

Other research methods are also carried out to study the state of all body systems: breathing, blood circulation, digestion, urination, lymphatic, endocrine, nervous, osteoarticular, etc. All diagnostic research methods are divided into basic and additional.

The main clinical methods include: questioning, examination, palpation, percussion, auscultation, measurements. These methods allow you to determine the doctor’s further tactics and select the optimal methods of additional research.

General inspection includes an assessment of the patient’s general condition, his consciousness, position, physique, measurement of body temperature, determination of facial expressions characteristic of certain diseases, as well as assessment of the condition of the skin, hair, visible mucous membranes, subcutaneous fat, lymph nodes, muscles, bones and joints. The data obtained by the doctor during a general examination are of utmost diagnostic importance, allowing, on the one hand, to identify characteristic (although often nonspecific) signs of the disease, and on the other, to give a preliminary assessment of the severity of the pathological process and the degree of functional disorders.
General condition of the patient.

The doctor develops an idea of ​​the patient’s general condition (satisfactory, moderate, severe) throughout the entire examination of the patient, although in many cases such an assessment can be given at the first glance at the patient.

Consciousness.

Consciousness can be clear and confused. There are three degrees of impairment of consciousness:

1) Stupor a state of stupor from which the patient can be brought out of for a short time by talking to him. The patient is poorly oriented in the surrounding environment, answers questions slowly, belatedly.

2) Sopor(hibernation) - a more pronounced disturbance of consciousness. The patient does not react to others, although sensitivity, including pain, is preserved, does not answer questions or answers in monosyllables (yes - no), and reacts to examination.
3) Coma- the patient is in an unconscious state, does not respond to speech addressed to him or to the doctor’s examination. There is a decrease or disappearance of basic reflexes.

Comatose states can be as follows:

Alcoholic coma resulting from alcohol intoxication;

Apoplectic coma - observed with cerebral hemorrhage;

Hypo- and hyperglycemic coma - with pancreatic disease (diabetes mellitus) - depending on the use of antidiabetic drugs and the degree of development of the disease;

Hepatic coma - develops in acute or subacute liver dystrophy, cirrhosis and other conditions;

Uremic coma occurs with acute toxic damage to the kidneys, etc.;

Epileptic coma - observed during epileptic attacks.

There may be irritative disorders of consciousness (hallucinations, delusions) that occur in a number of mental and infectious diseases. An examination can also provide insight into other mental state disorders, such as depression, apathy, agitation, and delirium. In the development of a number of somatic diseases, a large place is currently given to mental factors (psychosomatic diseases), which are not based on organ damage.

Position of the patient.

There are active, passive and forced positions.

Active the position is an opportunity to actively move, at least within the hospital ward, although the patient may experience various painful sensations.

Passive position is a condition when the patient cannot independently change the position given to him.

Forced they call a position that somewhat alleviates the patient’s suffering (pain, shortness of breath, etc.). Sometimes the patient’s forced position is so characteristic of a particular disease or syndrome that it allows a correct diagnosis to be made at a distance.

During an attack of bronchial asthma (suffocation, accompanied by a sharp difficulty in exhaling), the patient takes a forced position, sitting, resting his hands on the back of a chair, the edge of the bed, or his knees. This allows you to fix the shoulder girdle and connect additional respiratory muscles, in particular the muscles of the neck, back and pectoral muscles, which help to exhale.

During an attack of cardiac asthma and pulmonary edema caused by blood overflow of the vessels of the pulmonary circulation, the patient tends to take a vertical position (sitting) with his legs down, which reduces the blood flow to the right side of the heart and makes it possible to somewhat relieve the pulmonary circulation (orthopnea position).

Patients with inflammation of the pleura (dry pleurisy, pleuropneumonia) and intense pleural pain often take a forced position - lying on the affected side or sitting with their hands pressing the chest on the affected side. This position limits the respiratory movements of the inflamed pleura and their friction against each other, which helps reduce pain. Many patients with unilateral lung diseases (pneumonia, lung abscess, bronchiectasis) try to lie on the affected side. This position facilitates the respiratory excursion of a healthy lung, and also reduces the flow of sputum into the large bronchi, which reflexively causes a painful cough.

The patient's physique. When assessing the physique (habitus), they take into account the constitution, body weight and height of the patient, as well as their ratio (weight-height indicators). The patient's constitution (constitution - structure, addition) is a set of functional and morphological characteristics of the body, formed on the basis of hereditary acquired exo- and endogenous factors.

There are 3 main types:

Asthenic, characterized by a transformation of growth over the mass (limbs over the torso, chest over the abdomen). The heart and parenchymal organs of asthenics are relatively small in size, the lungs are elongated, the intestines are short, the mesentery is long, and the diaphragm is low. Blood pressure is often reduced, gastric secretions and peristalsis, intestinal absorption capacity, hemoglobin content in the blood, red blood cell count, cholesterol, calcium, uric acid, and sugar levels are reduced. There is hypofunction of the adrenal glands and gonads, hyperfunction of the thyroid gland and pituitary gland;

Hypersthenic, characterized by a predominance of mass over height. “The body is relatively long”, the limbs are short, the stomach is of considerable size, the diaphragm is high. All internal organs, with the exception of the lungs, are relatively large. The intestines are longer, thick-walled and lighter. Persons of the hypersthenic type are characterized by higher blood pressure, high levels of hemoglobin, red blood cells and cholesterol in the blood, hypermotility and hypersecretion of the stomach. The secretory and absorption functions of the intestine are high. Hypofunction of the thyroid gland and some increased function of the gonads and adrenal glands are often observed;

Normosthenic - characterized by proportional physique and occupies an intermediate position between asthenic and hypersthenic.

The nature of the patient's movements. The nature of movements and gait are noted. Gait disorders occur in various neurological diseases and lesions of the musculoskeletal system. The so-called “duck walk” is observed with congenital hip dislocation.

Skin.

Skin examination should be carried out in good natural light. Skin color can also be determined by congenital characteristics of the body that are not associated with pathology. Thus, pale skin in healthy people is observed with constitutional hypopigmentation of the general integument or with a deep location of the network of skin capillaries, with excessive deposition of fat in the skin, and spasm of skin blood vessels. Skin color should be assessed taking into account race and nationality, living conditions and recreation. There are three races: Caucasian, Mongoloid and Negroid, which differ significantly in skin color (primarily).

The congenital absence of normal pigmentation is called albinism (albus - white), sometimes foci of depigmentation (vitiligo) are found.

Skin rashes are of various types and have important diagnostic value, both for recognizing infectious diseases and allergic and other pathologies.

To assess the nature of a skin lesion, the following terminology is used:

Macula - speck;

Papule - swelling, nodule;

Vesicle - bubble;

Pustule - a blister of pus;

Ulcus is an ulcer.

In various pathological conditions, a staged pattern of rashes may be noted: macula -> papule -> vesicle -> pustule; in other conditions, there is a simultaneous eruption of elements that are polymorphic in nature (maculopustular-vesicular).

In various pathological conditions of congenital and acquired nature, hemorrhagic manifestations are detected on the skin and mucous membranes:

Petechiae are tiny capillary hemorrhages on the skin and mucous membranes of a round shape ranging in size from a point to a lentil. When pressed with fingers, they do not disappear - unlike roseola;

Ecchymoses, or bruises, occur as a result of subcutaneous hemorrhages, their size and number vary widely;

Subcutaneous hematomas are hemorrhages into the subcutaneous tissue with the formation of a cavity filled with coagulated blood. At the beginning, the subcutaneous hematoma has the appearance of a tumor-like formation, the color of which, as it dissolves, changes from lilac-red to yellow-green.

Inflammatory skin lesions can manifest themselves in the form of diaper rash (with the appearance of redness, cracks, maceration and rejection) and pyoderma (pyodermia) - with damage to the skin and subcutaneous tissue by pyogenic microbes (staphylococci - staphylopioderma, streptococci - streptopioderma). There is a peculiar skin reaction that occurs as a result of a violation of the body's reactivity, sensitization of the skin to exogenous and endogenous irritants. The pathological condition of the skin, caused by the increased function of the sebaceous glands, is called seborrhea and is associated with changes in the neuroendocrine reactivity of the body. When examining the skin, attention is paid to its color, moisture, elasticity, condition of the hairline, presence of rashes, hemorrhages, vascular changes, scars, etc.

Skin coloring. A practicing doctor most often encounters several variants of changes in the color of the skin and visible mucous membranes: pallor, hyperemia, cyanosis, jaundice and brownish (bronze) skin color.
Pallor may be due to two main reasons:
1) anemia of any origin with a decrease in the number of red blood cells and hemoglobin content per unit volume of blood;

2) pathology of peripheral circulation: a) a tendency to spasm of peripheral arterioles in patients with aortic heart defects, hypertensive crisis, and certain kidney diseases;
b) redistribution of blood in the body during acute vascular insufficiency (fainting, collapse) in the form of blood deposition in the dilated vessels of the abdominal cavity, skeletal muscles and, accordingly, a decrease in blood supply to the skin and some internal organs.

One should also keep in mind the constitutional features of skin color in persons with an asthenic constitutional type (deep location of capillaries under the skin or their weak development) and individual reactions of peripheral vessels (tendency to reflex spasm) to emotions, stress, cold, which occur even in healthy people .

You should know that pallor of the skin caused by anemia is necessarily accompanied by pallor of the visible mucous membranes and conjunctiva, which is not typical for cases of constitutional pallor and pallor resulting from spasm of peripheral vessels.

Red skin color (hyperemia) may be due to two main reasons:
1) expansion of peripheral vessels:

a) for fevers of any origin;

b) when overheated;

c) after consuming certain drugs (nicotinic acid, nitrates) and alcohol;

d) for local inflammation of the skin and burns;

e) with neuropsychic excitement (anger, fear, shame, etc.);

2) an increase in the content of hemoglobin and the number of red blood cells per unit volume of blood (erythrocytosis, polycythemia); in these cases, hyperemia has a peculiar purple hue, combined with a slight cyanosis of the skin (cyanosis).
One should also keep in mind the tendency to a reddish coloration of the skin in people of the hypersthenic constitutional type.

Cyanosis- bluish discoloration of the skin and visible mucous membranes, caused by an increase in the amount of reduced hemoglobin in the peripheral blood (in a limited area of ​​the body or diffusely). Cyanosis appears if the absolute amount of reduced hemoglobin in the blood exceeds 40-50 g/l. (Recall that the amount of total hemoglobin in the blood of a healthy person ranges from 120-150 g/l).

According to the main reasons, three types of cyanosis are distinguished:
1) central cyanosis develops as a result of insufficient oxygenation of blood in the lungs in various diseases of the respiratory system, accompanied by respiratory failure. This is diffuse (warm) cyanosis of the face, torso, and limbs, often having a peculiar grayish tint;

2) peripheral cyanosis (acrocyanosis) appears when blood flow slows in the periphery, for example, with venous stagnation in patients with right ventricular heart failure.

In these cases, the extraction of oxygen by tissues increases, which leads to an increase in the content of reduced hemoglobin (more than 40-50 g/l), mainly in the distal sections (cyanosis of the tips of the fingers and toes, the tip of the nose, ears, lips). The limbs are cold to the touch due to a sharp slowdown in peripheral blood flow;

H) limited, local cyanosis can develop as a result of stagnation in the peripheral veins when they are compressed by a tumor, enlarged lymph nodes or venous thrombosis (phlebothrombosis, thrombophlebitis).
Jaundice in most cases, it is caused by the impregnation of the skin and mucous membranes with bilirubin with an increase in its content in the blood. According to the main causes of hyperbilirubinemia, three types of jaundice are distinguished:

1) parenchymal (with damage to the liver parenchyma);

2) mechanical (when the common bile duct is obstructed by a stone or compressed by a tumor);

3) hemolytic (with increased hemolysis of red blood cells).

Bronze (brown) skin coloring observed in adrenal insufficiency. Brownish pigmentation usually does not appear diffusely, but in the form of spots, especially on the skin of exposed parts of the body (face, neck, hands), as well as in places exposed to friction (armpits, lumbar region, inner thighs, genitals) and in the skin folds of the palms.

The initial signs of mild jaundice (subictericity) are best identified by examining the sclera, soft palate and lower surface of the tongue.

Subjective information includes an assessment of one’s condition by the patient himself and his non-medical environment: the patient’s complaints about his health, the patient’s opinion about how he manifests a violation of a particular need, the patient’s own feelings regarding problems with his health.

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Orenburg Institute of Railways branch of the federal state budgetary educational institution

higher professional education

"Samara State Transport University"

Orenburg Medical College

PM.04, PM.07 Performing professional work

Junior nurse

MDK 04.03, MDK 07.03

Solving patient problems through nursing care.

Specialty 060501 Nursing

Specialty 060101 General Medicine

Topic: 3.2. Assessment of the patient's functional state Lecture

Developed

Teachers Dryuchina N.V.

Marycheva N.A.

Agreed

at a meeting of the Central Committee

Protocol No._____

from "___"_______2014

Chairman of the Central Committee

Tupikova N.N.

Orenburg 2014

Lesson No. 2 Lecture

Topic: 3.2. Assessment of the patient's functional state

The student must:

Have an ideaabout the methodology of nursing examination.

The student must know:

1. C maintaining objective methods of examining patients.
2. Types of consciousness disorders
3. Types of positions in bed.
4. Types of shortness of breath
5. Types of breathing;
6. Pulse characteristics;

Independent work

Lecture No. 2, answer the control questions.

LECTURE PLAN

1. Rules and techniques for general inspection.
2. Types of consciousness disorders.
3. Types of positions in bed.
4. Types of breathing.
5. Types of shortness of breath.
6. Pulse characteristics.
7. Physiological norms of blood pressure.

LECTURE

1. Contents of objective methods of examining patients.

All information about the patient can be divided into two large groups:

Methods of collecting information
Subjective		Objective
Complaints, questioning the patient	Questioning the patient's non-medical environment	Medical documentation	Patient monitoring	Special honey literature	Questioning honey. environment

1. Subjective informationincludes an assessment of one’s condition by the patient himself and his non-medical environment: the patient’s complaints about his health, the patient’s opinion about how he manifests a violation of a particular need, the patient’s own feelings regarding problems with his health.
2. Objective information

Ι . Subjective information is collected through patient interviews.The interview begins with getting to know the patient: finding out his full name, year of birth, place of residence and work, education, and then sequentially according to the scheme.

The interview also provides an opportunity to observe the patient.Observation is also one of the methods of collecting information. Observing behavior, appearance, relationships with others, m\s determines how much the data obtained during observation is consistent with the data obtained during the conversation.

Having information about the patient, taking advantage of his trust and the disposition of his relatives, the nurse should not forget about the patient’s right toconfidentiality of information.

Scheme of subjective examination of the patient:

1. Reasons for seeking medical help (patient’s current complaints)
2. Source of information.
3. Onset of the disease.
4. Past illnesses and surgeries.
5. Allergy history
6. Heredity.
7. Epidemiological anamnesis.
8. Bad habits.
9. Professional production conditions.
10. Interaction with family members.
11. Attitude to procedures.

1. Reasons for contacting (patient's current complaints).

A) The patient independently expresses his painful sensations and complaints.

Usually the patient is asked the question: “What is bothering you?”, “What are you complaining about?”
Information provided by the patient must be recorded.

B) The patient answers the questions of the nurse (student).

M/s (student) asks questions to systematize and detail the patient’s complaints.

For example, when complaining about pain it is necessary to find out from the patient:

1) localization pain (where it hurts);

2) irradiation pain (spread of pain);

3) time of pain onset;

4) duration (constant, paroxysmal);

5) intensity;

6) nature of pain (stabbing, dull, pressing);

7) reasons that cause or increase pain

At complaints of coughm/s needs to be clarified character of cough (wet, dry),intensity, presence of sputum(if there is, find out its quantity, character, color, smell).

Complaints may be general character (weakness, fatigue, loss of appetite, sleep disturbance, irritability, agitation, headache) andspecific character(pain, shortness of breath, heartburn, nausea, vomiting, stool disorders, urination problems, etc.)

Dyspnea - difficulty breathing, characterized by a violation of the rhythm and strength of respiratory movements. Shortness of breath is a protective physiological adaptation, with the help of which the lack of oxygen is compensated and the accumulated excess carbon dioxide is released.

Heartburn - a burning sensation behind the sternum along the esophagus, caused by acidic gastric contents entering the mucous membrane of the esophagus.

Nausea - an unpleasant sensation in the epigastric region, a feeling of heaviness, sometimes accompanied by paleness of the face, increased sweating, palpitations, salivation and slower breathing movements. Nausea often precedes vomiting.

Vomit - a complex reflex act involving the muscles of the stomach, diaphragm, anterior abdominal wall, as well as the epiglottis and soft palate, which results in the eruption of stomach contents out through the mouth, nasal passages (you must pay attention to the presence of impurities in the vomit: blood, mucus, bile , undigested food; vomit the color of “coffee grounds” indicates gastric bleeding).

Flatulence - bloating, painful distension of the abdomen due to the accumulation of gases in the intestines.

Diarrhea - loose stools with frequent bowel movements (the frequency and presence of impurities are detected: blood, mucus).

Constipation - prolonged retention of feces in the intestines (duration of constipation is determined).

Polyuria - increase in the daily amount of urine (more than 2 liters).

Oliguria - decrease in the daily amount of urine (less than 500 ml).

Anuria - complete cessation of urine output.

Nocturia - predominance of nighttime diuresis over daytime.

2. Sources of information:patient, patient's family, medical staff, medical documents (underline what is appropriate)

3. Onset of the disease:

Since when does he consider himself sick? ___________ _____________________

When and how did the first manifestations of the disease appear?

The patient’s condition immediately before the illness (were there any mental injuries, overwork, hypothermia, eating errors) ____

Course of the disease (sequence of manifestation and development of individual symptoms; periods of exacerbation and remission, research and treatment methods) __

4. Previous illnesses and operations with dates indicated.

5. Allergy history:

a) drug intolerance;

b) food allergens;

c) household allergens;

It is necessary to find out the nature of the allergic reaction (urticaria, Quincke's edema, etc.).

6. Heredity:the health and cause of death of parents, brothers, sisters are noted; special attention is paid to the pathology relevant to the patient’s disease).

7. Epidemiological history:past infectious diseases, tuberculosis, blood transfusions, injections, surgery, contact with infectious patients over the past 6 months.

1. Bad habits:habitual intoxication (smoking, drinking alcohol, drugs, medications).
2. Professional production conditions:presence of industrial hazards (dust, gas, ionizing radiation, vibration, high temperature, etc.)
3. Ability to satisfy physiological needs.
4. Self-care ability.

Actions	Answer options
General mobility
Mobility in bed	Movable; motionless; limited in movements
Ability to eat	Independently, with the help, through a probe, parenterally
Ability to use the toilet
Ability to cook food	On one's own; with outside help
Ability to inject	Maybe; can't
Keep house	Maybe, maybe not

12. Interaction with family members:support of the patient by relatives (whether present or not).

13.Attitude to procedures:tolerates satisfactorily, well, etc.

II . Objective information- These are observations or measurements made by a person collecting information using special methods.

Objective information about the patient obtained as a result of:

1. examination of the patient;
2. from the patient's medical environment(doctors, m/s, ambulance team);
3. studying medical documentation(amb card, medical history, examination notes, tests);
4. studying special medical literature(care guides, standards of nursing practice, atlas of manipulation techniques, list of nursing diagnoses, journal “Nursing”).

The objective method includes:

1. m/s observation of how the patient satisfies his 14 basic vital needs;
2. questioning the medical environment;
3. study of medical documentation;
4. study of special medical literature regarding a given patient.

1. Rules and techniques of external inspection.

An objective examination of the patient begins with a general examination. This research method gives the nurse the most complete objective information about the patient. Therefore, the m/s must be proficient in this research method.

The patient is examined sequentially by the nurse, starting with monitoring the satisfaction of lower physiological needs. Observation must be carried out in diffuse daylight or bright artificial lighting, and the light source should be located on the side, so the contours of various parts of the body stand out more prominently.

	Consciousness	a) Clear b) Confused (clouded, unclear) c) Stupor (stunning) d) Stupor d) Coma	The patient is completely oriented in the surrounding environment and clearly answers questions. The patient’s indifferent, indifferent attitude towards his condition answers questions correctly, but with some delay. The patient is poorly oriented in his surroundings, sluggishly, slowly answers questions, sometimes not to the point, falls into stupor. Deep confusion of consciousness. The patient is in a state of hibernation. A strong irritant (a shout, an injection) can bring him out of this state for a short time. Complete loss of consciousness. The patient does not react to painful and sound stimuli, there are no reflexes. May develop with severe the course of diabetes mellitus, kidney and liver failure, alcohol poisoning.
	Patient's position in bed	a) active b) passive c) forced	This is the position of the patient when the patient is able to turn around, sit down, and stand up independently (mild course of the disease). A passive position is when the patient is very weak, exhausted, unconscious, usually in bed and cannot change his position without assistance (severe course of the disease). The patient borrows to improve his well-being. For example: In patients suffering from gastric ulcers, pain is relieved by the knee-elbow position. With heart disease, the patient, due to shortness of breath, tends to take a sitting position with his legs dangling. In some diseases, disorders of consciousness are observed, which are based on excitation of the central nervous system. These include delusions and hallucinations (auditory and visual).

V. Types of breathing

External breathing.

Breathing consists of inhalation and exhalation phases, which are carried out at a certain constant rhythm - 16-20 per minute in adults and 40-45 per minute in newborns.

Rhythm of breathing movements- These are breathing movements at certain intervals. If these intervals are the same, breathing is rhythmic; if not, it is arrhythmic. In a number of diseases, breathing can be shallow or, conversely, very deep.

There are three types of breathing:

1. Chest type - respiratory movements are carried out mainly due to contraction of the intercostal muscles. In this case, during inhalation, the chest expands and rises slightly, and during exhalation, it narrows and falls slightly. This type of breathing is typical for women.

1. Abdominal type - respiratory movements are carried out mainly due to contraction of the muscles of the diaphragm and the muscles of the abdominal wall. The movement of the diaphragm muscles increases intra-abdominal pressure and when inhaling, the abdominal wall moves forward. When you exhale, the diaphragm relaxes and rises, which moves the abdominal wall back. This type of breathing is also called diaphragm breathing. It occurs predominantly in men.

3) Mixed type - breathing movements are performed simultaneously with the help of contraction of the intercostal muscles and the diaphragm. This type is most often found in athletes.

If satisfaction of the need to BREATHE is disrupted, shortness of breath may appear, that is, a disturbance in the rhythm, depth or frequency of respiratory movements.

1. Types of shortness of breath.

Depending on the difficulty of one or another phase of breathing, there are three types of shortness of breath:

1) Inspiratory - difficulty breathing. This happens, for example, when a foreign body or any mechanical obstacle gets into the respiratory tract.

2) Expiratory - difficult to exhale. This type of shortness of breath is characteristic of bronchial asthma, when spasm of the bronchi and bronchioles occurs.

3) Mixed - both inhalation and exhalation are difficult. This type of shortness of breath is characteristic of heart disease.

If shortness of breath is pronounced, this forces the patient to take a forced sitting position - this is called shortness of breath. suffocation. In addition to the types of pathological shortness of breath described above, there arephysiological shortness of breath that occurs with significant physical exertion.

If the need to breathe is not satisfied, the frequency of respiratory movements may change. If the frequency of respiratory movements is more than 20, such breathing is called TACHYPNEA, if less than 16 - BRADYPNEA.

Sometimes shortness of breath has a specific character and a corresponding name:

Kussmaul's breathing;

Breath of Biot;

Cheyne-Stokes breathing.

Types of pathological breathing	Changes in pathological breathing
Kussmaul's Breath	Uniform rare respiratory cycles with deep noisy inhalation and intense exhalation.
Cheyne-Stokes breathing	Characterized by periodic delays in exhalation lasting from several seconds to a minute, shallow breathing in the phase dyspnea , increasing in depth and reaching a maximum on the fifth to seventh breath, then decreasing in the same sequence and moving into the next respiratory pause. Most often it occurs as a consequence of dysfunction of the nerve centers, increased intracranial pressure, and heart failure.
Breath Biota	It is characterized by alternating uniform rhythmic breathing movements and long (up to half a minute or more) pauses. Observed in case of organic brain damage, circulatory disorders, intoxication, shock and other severe conditions accompanied by deep hypoxia brain.

Thus, the criterion (sign) of external respiration is frequency and rhythm. Normal breathing is rhythmic, the respiratory rate is 16-20 per minute.

1. Arterial pulse (Ps) is the oscillation of the arterial wall caused by the release of blood into the arterial system during one cardiac cycle (systole, diastole).

Assessment of the state of the pulse according to its qualities

RHYTHM	FREQUENCY	VALUE		SYMMETRY
This is alternation pulse waves through the limit ny intervals time. If time intervals I'm the same - Ps rhythmic. If the intervals don't have time alone nakovy - P s spasmodic (wrong. Violations heart rhythm called arrhythmias: a) extrasysto- Leah - out of turn new reduction 6) flickering arrhythmia - random chaotic contraction of the heart	This is the number of pulse waves per minute. N = 60-80; more 80 - tachycardia; less than 60 - bradycardia	voltage	filling
				This is the power with whose blood presses on the walls of blood vessels. Determined degree of effort required to compression radial artery to stop fully passing pulse waves. Depends on the value of blood pressure. With increased BP - Ps solid or tense. With reduced nom AD -R s soft . At normal blood pressure - moderate tension.	It's filled- blood vessels. Characterized by the magnitude of cardiac output (i.e., the more blood quality, which enters bloodstream), depends on the contraction titular heart strength in systole period; determined by volume blood, post- drinking in artery P s full - with sufficient cardiac output. P s empty - when volume decreases circulating blood, decreasing heart emission (blood loss).	Good quality pulse symmet- richny on the right and left side bodies.

The magnitude of the pulse is determined by the degree of tension and filling. R s larger - good filling, sufficient tension; R s small - small filling, sufficient voltage; R s thread-like - barely palpable.

1. Physiological norms of blood pressure.

5. BLOOD PRESSURE - (BP) is the pressure of blood on the walls of the arteries. It depends on:

The magnitude and rate of cardiac output

Peripheral resistance of arterial walls

In addition to these main factors, blood pressure is also influenced by the amount of circulating blood, its viscosity, pressure fluctuations in the abdominal and thoracic cavities and many other factors.

Blood pressure reaches its maximum level during contraction (systole) of the left ventricle of the heart. In this case, about 70 ml of blood is pushed out of the heart. This pressure is called systolic. Normally it reaches 100-140 mm Hg. Art. Blood pressure is expressed in millimeters of mercury (mmHg).

During the pause between contractions of the ventricles of the heart (that is, diastole), the walls of the aorta and large arteries begin to contract and push blood into the capillaries. Blood pressure gradually drops and by the end of diastole reaches a minimum value: 60-90 mm Hg. Art. This pressure is called diastolic.

The difference between systolic and diastolic blood pressure is PULSE pressure.

NORMAL blood pressure readings - upper limit 140/90, lower limit 100/60 mm Hg. Art.

An increase in blood pressure is called arterial hypertension. A decrease in blood pressure is called arterial hypotension.

Questions for self-control.

1. Name the methods of nursing examination.

4. List the rules for general inspection.

5. Name the types of consciousness disorders.

6. What types of positions in bed do you know?

7. Name the types of shortness of breath.

8. List the types of breathing.

9. What characteristics of the pulse do you know?

10. Name the physiological norms of blood pressure.

Literature.

Main:

1. Mukhina S.A., Tarnovskaya I.I. Theoretical foundations of nursing: textbook. 2nd ed., corrected. And additional M.: GEOTAR-Media, 2013. 368 p.: ill. 116-148 p.
2. Lecture by the teacher.
3. Obukhovets T.P. fundamentals of nursing / T.P. Obukhovets, O.V. Chernov; edited by B.V. Kabarukhin._Izd. 19th, sr. Rostov n/a: Phoenix, 2013. 766 pp.; ill. (Medicine for you) 143-192 p.

Additional:

1. Educational and methodological manual on “Fundamentals of Nursing” for students vol. 1,2 edited by Shpirna A.I., Moscow, VUNMC 2003module No. 7-8 pp. 147-179.

PAGE 13

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Memo to the nurse.

Assessment of the patient's functional state

· Calculation of the arterial pulse on the radial artery and determination of its properties

Blood pressure measurement

· Respiratory rate counting

Calculation of the arterial pulse on the radial artery and determination of its properties

1. Give the patient a comfortable position;

2. Ask him to relax his hand (the hand should not be suspended);

3. Simultaneously press the patient’s hands with your fingers above the wrist joint (the 2nd, 3rd and 4th fingers should be above the radial artery);

4. Compare the frequency of oscillations of the walls of the arteries on the right and left arms, determining the pulse rhythm;

5. Assess the intervals between pulse waves;

6. Take a stopwatch and count pulse waves;

7. Assess pulse filling;

8. Assess tension (compress the radial artery until the pulse disappears);

9. Register the properties of the pulse (temperature sheet);

10. Tell the patient the result.

Blood pressure measurement

1. Warn the patient about the upcoming procedure 15 minutes before it begins;

3. Place the patient’s arm in an extended position with the palm up (put a cushion under the elbow, or ask the patient to place the clenched fist of the free hand under the elbow);

4. Choose the correct cuff size;

5. Apply a tonometer cuff (the tubes should be at the bottom, the cuff should be at a distance of 2-3 cm above the elbow);

6. Connect the pressure gauge to the cuff;

7. Check the position of the pressure gauge needle;

8. Determine the pulsation in the ulnar fossa with your fingers, apply the phonendoscope membrane to this place;

9. Close the bulb valve, force air into the cuff until the pulsation in the ulnar artery disappears;

10. Open the valve, slowly releasing air, listening to the tones, and monitor the reading of the monometer;

11. Note the number of appearance of the first beat of the pulse wave (corresponds to systolic blood pressure);

12. Note the disappearance of sounds (corresponds to diastolic blood pressure);

13. Release all the air from the cuff;

14. Assess the result of blood pressure height and pulse pressure;

15. Report the result to the patient;

16. Register the result (temperature sheet).

Respiratory rate counting

1. Warn the patient about the procedure;

2. Give the patient a comfortable position;

3. Take the patient’s hand as for examining the pulse;

4. Place your hand and the patient’s hand on the patient’s chest (for thoracic breathing) or epigastric region (for abdominal breathing), simulating a pulse examination;

6. Assess the frequency of respiratory movements.

7. Explain to the patient that his respiratory rate has been counted;

8. Record the data in the temperature sheet.

Body temperature measurement

Body temperature is an important indicator of our health. As soon as the thermometer crosses the 37 degree mark, it’s time to think about whether there are any problems. From time to time, the body temperature may rise slightly, but if the values ​​​​are already clearly above 37.2, and the temperature does not want to “fall”, and other symptoms and complaints appear, then it is time to consult a doctor. Measuring body temperature is a fairly simple process and we have all been familiar with it since childhood. Many people have a medical thermometer or a simple glass thermometer at home. It is inexpensive and quite accurate, but differs from new thermometers in the time it takes to measure temperature. New digital thermometers have already been appreciated by many, especially parents with small children. This thermometer allows you to accurately and, most importantly, quickly find out the temperature. Unfortunately, if the batteries that power this miracle of medical technology run out and require replacement, this is not always reflected in a timely manner on the thermometer itself. For this reason, thermometer readings can sometimes be incorrect, which means do not forget to compare them with the readings of a regular thermometer at least once a month. Thermometers that can measure body temperature on the forehead or ear have similar characteristics.

Most often, body temperature is measured in the armpit. To do this, you need to hold the thermometer about 7 minutes. However, many doctors believe this method is not accurate enough. Another option would be to measure the temperature in the mouth, but even here the readings can be inaccurate and may be affected by breathing, timing of meals, or even smoking. Also, putting an old glass thermometer in your mouth can be downright dangerous, and of course this option is not suitable for children and people with an unbalanced psyche. The most accurate option is to measure the temperature in the rectum and ear canal using a special thermometer. It should be noted that the temperature in the rectum differs from the temperature in the armpit by approximately 0,3-0,6 degrees. The temperature sheet is used in hospitals, where the patient's condition is constantly monitored. Body temperature is measured at least 2 times per day (morning and evening), and sometimes more often. The data is entered into a sheet and sometimes a graph is drawn point by point for clarity. Each such document is created for an individual patient. Additionally, data is indicated when measuring blood pressure, pulse, respiratory rate, and weight. In some cases, data is entered on the daily amount of urine and fluid consumed, etc. The temperature sheet must include the patient’s full name and card number.

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-1.jpg" alt="> Assessment of the patient’s functional state">!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-2.jpg" alt=">Assessment of functional status is a physical examination of the patient to determine level of activity of the main"> Оценка функционального состояния – это физическое обследование пациента с целью определения уровня деятельности основных систем организма. Медсестра проводит общий осмотр пациента по следующему плану: 1. Общее состояние пациента 2. Оценка сознания 3. Положение пациента в пространстве (в постели) 4. Оценка кожных покровов 5. Выявление отеков 6. Антропометрия 7. Изучение свойств дыхания, пульса 8. Измерение АД 9. Термометрия 10. Физиологические отправления.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-3.jpg" alt=">1. General condition of the patient: § satisfactory - clear consciousness , functions of vital organs regarding"> 1. Общее состояние пациента: § удовлетворительное – сознание ясное, функции жизненно важных органов относительно компенсированы (не нарушены), ЧДД, ЧСС в пределах нормы, пациент обслуживает себя сам. § средней тяжести - сознание ясное, иногда оглушенное, сохранена способность к самообслуживанию, функции жизненно важных органов нарушены, но это не представляет опасности для жизни.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-4.jpg" alt=">§ severe – consciousness is often impaired, functions of vital organs So broken that it's"> § тяжелое – сознание чаще нарушенное, функции жизненно важных органов Нарушены настолько, что это представляет опасность для жизни. § крайне тяжелое – сознание угнетено, возможно кома, дыхание нарушено, резкое нарушение жизненно важных функций, крайне высокий риск для жизни пациента.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-5.jpg" alt="> 2. The patient’s consciousness: 1. Clear - the patient is adequate navigates the environment"> 2. Сознание пациента: 1. Ясное – пациент адекватно ориентируется в окружающей обстановке, конкретно и быстро отвечает на вопросы. 2. Помрачненное – пациент отвечает на вопросы правильно, но с опозданием. 3. Ступор – оцепенение, пациент на вопросы не отвечает или отвечает не осмысленно. 4. Сопор (спячка) – пациент не реагирует на окружающую обстановку, не выполняет никаких заданий, не отвечает на вопросы. Из сопорозного состояния пациента удается вывести с большим трудом, применяя болевые воздействия (щипки, уколы и др.), при этом у пациента появляются мимические движения, отражающие страдание, возможны и другие двигательные реакции как ответ на болевое раздражение.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-6.jpg" alt=">5. Coma (deep sleep) - a life-threatening condition between life and death, characterized by:"> 5. Кома (глубокий сон) - угрожающее жизни состояние между жизнью и смертью, характеризующееся: а) потерей сознания, б) резким ослаблением или отсутствием реакции на внешние раздражения, в) угасанием рефлексов до полного их исчезновения, г) нарушением глубины и частоты дыхания, д) изменением сосудистого тонуса, е) учащением или замедлением пульса, ж) нарушением температурной регуляции.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-7.jpg" alt=">3. Position of the patient in bed: Active position is the ability to actively move around"> 3. Положение пациента в постели: Активное положение - это возможность активно передвигаться по крайней мере в пределах больничной палаты, хотя при этом пациент может испытывать различные болезненные ощущения. Пассивное положение - пациент не может самостоятельно изменить приданное ему положение.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-8.jpg" alt=">Forced position - a position that alleviates the patient’s suffering (pain , shortness of breath, etc."> Вынужденное положение - положение, которое облегчает страдания пациента (боль, одышку и т. п.). Иногда вынужденное положение пациента настолько характерно для того или иного заболевания или синдрома, что позволяет на расстоянии поставить правильный диагноз.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-9.jpg" alt="> 4. Assessment of the skin 1. Skin color In a healthy person human skin is light pink in color."> 4. Оценка кожных покровов 1. Цвет кожи У здорового человека кожа светло-розовой окраски. Нормальная окраска кожи зависит от кровенаполнения ее сосудов, количества пигмента (меланина) и толщины кожного покрова. В патологии: Выраженная Гиперемия Цианоз Иктеричность бледность (покраснение) (синюшность) (желтушность) § акроцианоз § диффузный Ц.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-10.jpg" alt=">2. Skin elasticity. It depends on the state of skin colloids , degree of blood filling, content in"> 2. Эластичность кожи. Она зависит от состояния коллоидов кожи, степени кровенаполнения, содержания в ней жидкости (кровь, лимфа, вода). В норме кожа гладкая, плотная, упругая и легко захватывается в складку, которая затем быстро разглаживается. В патологии: Снижение эластичности кожи: кожа дряблая, морщинистая. Такая кожа, собранная в складку, медленно расправляется. § при старении, § относительном исхудании, § недостаточности кровообращения, § длительном обезвоживании организма. Уплотнение кожного покрова: исчезновение его подвижности вследствие плотного прилегания кожи к подлежащим слоям ткани, невозможность сжать ее в складку. Причина: дерматофиброз - процесс превращения дермы, а иногда и гиподермы в компактную фиброзную ткань.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-11.jpg" alt=">3. Skin moisture. Normally, the skin has moderate moisture , depending on the allocation"> 3. Влажность кожи. В норме кожа обладает умеренной влажностью, зависящей от выделения пота. В патологии: Гипергидроз - повышенная влажность (потливость) § при неврозах, неврастении, сильном эмоциональном волнении, § при повышенной функции щитовидной железы (гипертиреоз), § при лихорадке. Различают: локальный Г. и диффузный Г.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-12.jpg" alt=">Dry skin § with impaired trophism of skin tissue, § with muscle wasting, § with"> Сухость кожи § при нарушении трофики тканей кожи, § при мышечной гипотрофии, § при хронических заболеваниях § обезвоживании.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-13.jpg" alt=">4. Presence of rashes on the skin. Normal skin is clean , no rashes. In pathology: Appearance"> 4. Наличие высыпаний на коже. В норме кожа чистая, высыпаний нет. В патологии: Появление различных высыпаний: пятна, папулы, везикулы, пустулы. Причины: § кожные инфекционные заболевания (корь, краснуха, ветряная оспа и т. д.) § аллергические реакции.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-14.jpg" alt=">5. Violation of the integrity of the skin. Normally, the skin is intact , without damage. In pathology:"> 5. Нарушение целости кожных покровов. В норме кожа целостная, без повреждений. В патологии: Появление царапин, ссадин, ожоговых поверхностей, ран, пролежней, рубцов.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-15.jpg" alt="> 5. Detection of edema Edema is an excess accumulation of fluid in"> 5. Выявление отеков Отек – это избыточное скопление жидкости в мягких тканях или полостях организма человека. Классификация отеков: 1. Кардиальный 1. Наружные 2. Почечный 2. Внутренние 3. Венозный 4. Лимфатический 5. Аллергический 6. Травматический 7. Воспалительный!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-16.jpg" alt="> 6. Conducting anthropometry 1. Height 2. Weight 3 Calculation of body mass index:"> 6. Проведение антропометрии 1. Рост 2. Вес 3. Расчет индекса массы тела: ИМТ= масса тела (кг) рост (м 2) Выраженный дефицит массы: менее 16, 0 Дефицит массы: 16 -18, 5 Норма: 18, 5 – 25, 0 Избыточный вес: 25, 0 – 30, 0 Различные степени ожирения: 30, 0 и более. Кахексия - это крайнее истощение организма, которое характеризуется общей слабостью, резким снижением веса, активности физиологических процессов, а также изменением психического состояния пациента.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-17.jpg" alt=">7. Assessment of breathing properties: Rate: free D. Rhythm"> 7. Оценка свойств дыхания: Оценить: свободное Д. Ритм дыхания: Затрудненное Д. ритмичное аритмичное Наличие кашля, одышки, Частота дыхательных движений: патологических типов 1. N – 16 -20 в минуту 2. Брадипноэ - регулярное, уряженное дыхание реже 16 в мин. 3. Тахипноэ - регулярное, учащенное дыхание чаще 20 -22 в мин. 4. Апноэ – отсутствие дыхания. Глубина дыхания: умеренно глубокое поверхностное Тип дыхания: грудное Д. Брюшное Д. Смешанное Д.!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-18.jpg" alt="> 8. Assessment of pulse properties (Ps) Pulse - periodic jerky vibrations (impacts) of the wall"> 8. Оценка свойств пульса (Ps) Пульс – периодические толчкообразные колебания (удары) стенки артерии в момент выброса крови из сердца при его сокращении. В N пульс симметричен на обеих руках. Свойства пульса: Ритм Частота Наполнение Напряжение Величина § ритмичный § 60 -80 уд/мин. § Полный § Умеренного § большой § аритмичный § Брадикардия § Пустой напряжение § малый § Тахикардия § Твердый § Нитевид- § Мягкий ный Также определяют дефицит пульса. Дефицит пульса – это разница между числом сердечных сокращений и числом пульсовых волн за 1 минуту ЧСС > частота пульса!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-19.jpg" alt=">9. Blood pressure (BP) is the pressure which turns out to be the speed of blood flow in"> 9. Артериальное давление (АД) – это давление, которое оказывается скоростью тока крови в артерии на ее стенки в результате работы сердца. Систолическое Диастолическое Пульсовое давление N 100 -139 N 60 -89 N 40 -50 мм. рт. ст. !!! Подготовка пациента к измерению АД, техника измерения и оценка результатов регламентированы приказом МЗ РФ от 24. 01. 2003 № 4 «О мерах по совершенствованию организации медицинской помощи больным с артериальной гипертонией в РФ» .!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-20.jpg" alt=">10. Thermometry is the measurement of body temperature. Normal : t From the body, measured at"> 10. Термометрия - это измерение температуры тела. В норме: t С тела, измеренная на коже 36, 0 – 36, 9 С В патологии: 1. Гипотермия – понижение: t С тела ниже 36, 0 С. 2. Гипертермия (лихорадка) – повышение температуры тела (37, 0 С и выше).!}

Src="https://present5.com/presentation/3/-100429674_437458032.pdf-img/-100429674_437458032.pdf-21.jpg" alt=">11. Assessment of physiological functions Assessment of the act of urination and defecation">!}