In medicine the concept "care of the patient " stands as an independent discipline and represents a whole system of measures including correct and well-timed performance of various prescriptions, carrying out of some diagnostic tests, preparation for the certain research, overseeing the condition of the patient, giving the patient first aid and conducting the necessary medical documentation. Quite often the success of the treatment and outcome of the disease are determined by the quality of care. Thus, the care of the patients is an obligatory component of all treatment processes, influencing no small degree of total efficiency.

Patient care is both general and specific.

General care implies carrying out medical and prophylactic procedures irrespective of the character of the particular pathology.

Special care requires carrying out procedures that are specific for a given disease (pulmonological, cardiological, gastroenterological, etc.).

Timely diagnosis, proper treatment, and adequate care are the necessary conditions for the recovery of the patient. To give qualified assistance to the patient, it is necessary to acquire proper medical knowledge and skills.

The profession of the physician involves hard labor, sleepless nights, doubts, tormenting experiences, patience, and self-control. At any time the doctor must be ready to give aid. The successful therapy greatly depends on the authority of the physician. This authority is won not only by selfless labor but also by profound knowledge, because an authoritative physician is always a competent physician.

However, the intense work of physicians and their assistants, becomes useless if medical personnel ignore the rules of doctor-patient relationships. Appropriate conduct of the medical personnel between themselves and with the patients improves the efficacy of prophylaxis and treatment of patients.

Deontology may be defined as the set of rules and principles of medical ethics, which governs a member of the medical profession in the exercise of his professional duties. The deontological principles should be followed by all medical workers. The main object of deontology is the relations between the doctor and the patient, between the nurse and the patient, and also between the physician, the nurse, and the patient.

A hospital is an unusual environment for the patient: a mother may be separated from her child, the child from its parents, etc. Some people may be greatly concerned about their job that they have to abandon. All these circumstances may generate fears and anxieties in the patient. A chronic patient may have psychic disorders. A disease upsets not only his social connections but also his mental equilibrium. Positive relations between the patient and the assistant physician or the midwife may accelerate recovery. The careful attitude of the physician, his assistant or a nurse toward the patient is mandatory for a normal atmosphere at a hospital or any other medical establishment.

The main deontological requirement is high medical skill and a constant drive to improve one's knowledge and skill. A good physician should know all recent advances in medicine and should also be acquainted properly with the problems of the neighbouring medical specialties. The authority of a physician largely depends on his attitude toward the patient. When examining the patient, the physician should show his compassion and interest, show his sympathy for the patient. If you are not serious, the patient will not feel confidence in you, nor in other medical students that might come next.

As soon as the physician has gained as much information as possible about the disease from clinical findings and results of examination, he must do his best to quiet the patient, raise his spirits, and convince him that there are good signs for his recovery, without dwelling on the unfavourable symptoms of the disease.

While prescribing medicines and giving advice, the physician should explain the treatment schedule and its mode of administration. While discussing the case with his colleagues at the patient's bedside, the physician should avoid words and terms that might be unknown to the patient or might be misunderstood by him. An occasional thoughtless word from the physician may impair the mood of the patient, impair his sleep, appetite, and general condition and even may provoke disease. This is called jatrogenic diseases. Even in hopeless cases (cancer with multiple metastases, fatal heart disease, irreversible affection of the liver, or kidneys) the patient believes that he may recover, and the truth should therefore always be concealed from him. The duty of the physician is to persuade the patient by all possible means that his disease may be cured.

Medical deontology implies keeping medical secrets. All that the physician knows about his patient should be kept secret, otherwise the patient will suffer from moral and sometimes material loss. The patient's confidence in his doctor and other medical personnel is an important medical factor: the patient feels safe and believes that everything possible is being done to promote his recovery. This however does not hold for cases where keeping a secret may do harm to other people. For example, if the disease is infectious, the patient should be hospitalized because his isolation arrests the spreading of the disease and provides better conditions for treatment.

The problems of medical deontology are closely connected with professional ethics. The science of morals, rules and requirements for social conduct is known as ethics. Medical ethics implies the morals of medical workers, their attitudes toward each other and toward their patients. If a physician discovers an error in the prescriptions and methods of his predecessor, he must correct it tactfully so that the patient does not lose his faith in medicine and in his recovery.

The patient is usually very sensitive to the attitude of the medical personnel toward him and becomes very grateful to them. In long-standing diseases, and especially due to the special features of their character, some patients become very irritable and capricious. The attending personnel should not become involved in arguments with such patients. Some reassuring words usually help in such situations, but the medical personnel should be persistent in demanding that the patient fulfil medical orders and observe the existing rules.

In other words, each patient requires a special approach in treatment. Unless this is recognized, it is impossible to understand the patient properly and hence it is impossible to give him all possible medical attention.

MEDICAL INSTITUTIONS, ORGANIZATION THEIR WORK

Organization of the medical institution work is determined by the necessity to get medical aid to people.

A policlinic is an independent medicoprophylactic facility or a department at a hospital. A policlinic has some laboratory and diagnostic cervices. Physicians of all specialities receive patients at a policlinic. Laboratory studies, X-ray examinations and other functional studies are carried out at a policlinic. Patients are given there various procedures and treatment. A policlinic carries out prophylactic inspection of the population.

Emergency aid stations provide medical aid in critical cases and accidents. The stations are open to patients 24 hours a day. Many emergency aid stations have their own vehicles (ambulances) equipped with modern equipment and instruments to give emergency aid and resuscitate patients on their way to the hospital.

A hospital is an institution for accommodating patients and supervising their treatment. It has an admissions, medical, and administrative departments.

There are both general and specialized hospitals. The latter treat patients with special diseases, e.g. tuberculosis, infectious diseases, etc. As a rule, those who serve in the army are serviced at a military hospital.

A clinic is a medical institution where patients receive medical attention in stationary conditions. Medical students are educated at clinics. Clinics are also centres of medical research.

A sanatorium is a stationary medical institution where an environment is provided for the sick to recover completely from their illness. As a rule, sanatoria (health resorts) are located in areas with a good climate where mineral water and therapeutic muds are available.

1. Organization of the work of the therapeutic department.

The therapeutic department includes the wards, the study of the manager of each department, the physician's room, the rooms of the senior nurse and the senior nurse-assistent, room for medical procedures, the dining room and scullery, the bath-room, the enema-room, the room for washing and sterilization of the bed-pan , storages of stock, toilets for the patients and medical personnel.

In each department the room for day treatment time of the patients is stipulated.This means that organization of a high-grade care must have correct equipment in the wards. The optimum is when 60 % of the wards in the department are with 4 beds, 20 % — on 2 beds and 20 % — on 1 bed. The wards are furnished with necessary medical equipment and furniture.

Each department is led by the manager of the department. He usually is one of the most experienced doctors, who organizes well-timed inspection and treatment of the patients, monitors the work of the medical personnel, is responsible for the rational use of the bed fund of department, medical equipment and pharmaceuticals.

Physicians immediately carry out inspection and treatment of the patients and check their condition every day.

The senior nurse organizes and monitors the work of the nurses and of the nurse-assistants and of the senior nurse-assistant. She also keeps the medical equipment and pharmaceuticals.

The senior nurse-assistant is responsible for well-timed maintenance of the department with soft and solid stocks, and also body-linens and bed-linens

Ward-nurses working on a post, carry out all prescriptions for the physicians on inspection and treatment of the patients

The procedural nurse carries out certain duties in a room for medical procedures: various injections, collection of blood for biochemical analyses, definition of a blood group together with the physician.

The nurse-assistants provide care for the patients, their power supply and the maintenance of a necessary sanitary condition in the department.

2. Nurse post

Nurse post is the basic place of the work ward-nurse.

The nurse post should be located not far from the wards under observation, or it may be inside the ward if the patient's condition requires special constant observation.

Here there is a table with locked boxes for a storage of the medical documents, a case for storage of medicines, a refrigeration cabinet for the storage of perishable substances. The instruments, dressing material, inflammable substances (alcohol, Ether), the instruments for the patient's care (thermometers, heaters, cupping-glass) are separately kept (Fig.1).

The nurse post should be provided with a telephone and a signal board. A signal board should be installed near the table so that the medical worker remains aware of the situation in the wards.

The post nurses conduct the following documents: leafs of medical prescriptions, temperature sheets, diet- sheets, register of transfer of shifts, register "movements of the patients in the department"(entering to the hospital and discharge from the hospital), special records of the doctor's prescriptions.

3.Organization of the work at the admission department

The patients, directed to hospital, first of all are admitted to the reception-department. There are received and registered of the patients, with the appropriate medical documentation, the medical examination with an establishment of character and gravity of disease, definition of department for the subsequent hospitalization of the patients, giving him if necessary an emergency medical care with cleansing.

The admissions department should have a waiting room, registration and inquiry offices, rooms for examination of patients, a room for special medical procedures, and a room for sanitary preparation of the patients.

The patients enter the hospital in several ways:

— according to plan with permit for hospitalization from the polyclinic,

— by the emergency,

— independently.

The patient's name and other personal data are recorded in the admissions department, and then he is examined by the physician.

If a patient is admitted to the hospital according to a preliminary agreement with a policlinic or an outpatient department of another hospital, this means the taking of his case history, primary examination, and sanitary treatment are needed.

If the patient is in a critical condition or even unconscious (hemorrhage, shock, coma, dangerous cardiac arrhythmia, etc.), the patient is not questioned, nor is he given any special sanitary treatment. He is delivered immediately to the resuscitation or operating room, or a specialized department where he is given the necessary medical aid.

With the aim of making a specific diagnosis, the physician of reception-department can invite advice from appropriate experts. In such cases the laboratory and instrumental research will be carried out. In some cases the patient can be in a special diagnostic ward of the reception department within day for specification of the diagnosis. If after examination it is found out that bed care is not necessary, the patient is sent off to the home with proper references, after giving emergency first aid.

The case history is filled in for every patient admitted to the hospital. When recording a case history, the patient reports his name, age, position, address, and the address of his closest relatives. The data and time of admittance to the hospital are also entered in the case history. All this data is also recorded in a special admittance journal.

The nurse records the patient's personal data on a special chart, then the patient's height and weight are measured. The patient is given a superficial examination for possible pediculosis or signs of infectious diseases, and his body temperature is measured. All findings are recorded in the case history and the nurse accompanies the patient to the physician and then gives him sanitary treatment. Finally, the nurse accompanies the patient to the medical department.

The examination of the patient includes not only measuring his height and weight but also the girth of his chest, his muscular strength (dynamometry), and respiratory function (spirometry).

The methods and techniques used to assess the morphological conditions of people are called anthropometry.

The heightof man is measured by a wooden or metal graduated plank fixed in a floor-mounted base (Fig.2).

A horizontal plank slides freely along the vertical plank to read the height. A special collapsible seat is provided to measure the sitting height (the length of the trunk). Another graduated scale starts at the level of the seat. In order to measure the height of a person, he is asked to stand barefoot on the floor plate and to take an erect position so that his back is pressed against the vertical plank; the head should be in a position where the upper edge of the external auditory meatus is level with the outer angle of the eye.

The sliding horizontal plank is then lowered to come in contact with the patient's head and fixed in this position. The patient is asked to step out from the height meter. The lower edge of the sliding plank reads the height. The sitting height is measured in the same way expect that the patient is asked to sit.

The normal height of males varies from 165 to 180 cm and of females from 155 to 170 cm. Deviations on either side are connected with endocrine dysfunction.

Dwarfishnessmay be due to hypofunction of the anterior lobe of the pituitary (nanism) or of the thyroid gland (cretinism).

Gigantismcan be due to dysfunction of the anterior lobe of the pituitary or hypofunction of the sex glands.

Weight is measured on a special medical balance(Fig3).

Weighting should be done in the morning, on a fasting stomach, after defecation and urination. Whenever possible, the patient should be with no clothing or he should wear a light garment. or In order to follow changes in the patient’s weight during treatment (in treatment of asthenia obesity, or edema) repeated weighting should be done in the same conditions (with the patient either undressed or with the same clothes on) in order to rule out the error.

The weight of the human body depends mainly on the height and the girth of the chest. The correlation between these two factors determines the proportionate constitution of man.

Normal weight can be calculated approximately by measuring the man's height and subtracting 100. For example the normal weight of a 180 cm high man should be 80 Kg (180–100).

This in only a tentative method since normal weight varies with age and many other factors. The patient usually loses weight with many diseases, especially those associated with malignant new growth, tuberculosis, acute infections, and gastrointestinal diseases. Fat tissue is lost first, then the patient loses weight at the expense of muscular tissues. Patients with edema gain weight due to retention of moisture in the tissues.

The girth of the chestis measured by a tape passed under the angles of the shoulder blades on the back and across the 4th rib of the chest. The girth should be measured with quiet breathing and hanging hands freely at the patient's sides. The measurements are taken at the height of inspiration and expiration.

Spirometry is the method for determining the respiratory volumes of the lungs, which is necessary for assessing the external respiratory function. The apparatus used for this purpose is called a spirometer. The patient is asked to inhale using maximum effort, and (holding his nose) then to exhale the air into the apparatus through the mouth-piece (Fig.4). The mouth-piece should be washed with soap and water and kept in a sterilizer.

Dynamometry is measuring muscular force using a dynamometer. The patient is asked to squeeze the dynamometer with maximum force: the pointer indicates the muscular strength in kilograms.

Sanitary and hygienic treatment of patients. The amount of sanitary treatment needed depends on the patient's conditions. If the condition of the patient allows it, he receives a shower or a bath. The patient takes off his clothes in the examining room where he is prepared for the bath.

The patient's personal belongings are registered. A copy of the record is placed in the patient's file, while another copy is kept together with the belongings in a storage room. Money and valuables are registered separately by the senior nurse of the admissions department.

A bath is prescribed to clean the patient’s skin from dirt and sweat.

A bath is not recommended for patients with skin diseases, wounds, and for those in a critical condition such as: hypertonic crisis, acute myocardial infarction, acute infringement of a cerebral circulation, tuberculosis in an active phase, the parturient woman, acute surgical pathology. In such cases the patient's skin is rubbed with a tampon, moistened by warm water with soap, then wiped with a dry tampon and the nails of the patients are shortly cut.

The bath should first be washed with hot water and soap and if the previous patient had a skin or infectious disease, the bath should be disinfected (Fig.5).

The patient should be given a clean sponge and after he has taken the bath the sponge should be discarded into a "used sponge" container. Whenever possible, the patient should be given a sterile package containing a clean sponge and underwear.

In order to prevent the water from cooling, the bath should be filled immediately before use. To prevent steaming, the bath should first be filled with cold water and then hot water added to obtain the required temperature, which is measured by a thermometer in a wooden frame.

The water temperature in the bath should be 36-37°C, and the ambient air, 25-28°C.

The head is first washed, then follow the body and the legs. The bath takes 20-25 minutes. The bath is prepared by junior medical personnel, while the assistant physician or the nurse observes the patient's condition.

If the patient's condition does not permit taking a bath, he is given a shower (Fig.6).

The preparations are the same as for a bath. The shower should be taken for 5-10 minutes.

After a bath, the patient has his toe and finger nails cut and is given clean underwear.

Rooms intended for sanitary treatment of patients should be kept clean. The oilcloth covering the cot should be treated with a disinfectant solution (2 per cent chloramine solution). A clean sheet should be used to cover the cot for each new patient.

In detection of pediculosis the special cleansing of the patients will be carried out. Pediculosis is infestation with lice. Lice are associated with poor hygiene, crowded living conditions, and exposure to others with lice. Lice live on the skin, attaching their eggs (nits) to the hair. Itching and scratching are a response to lice bites. Lice are difficult to remove because the nits are attached to the hair by an adhesive substance. Pediculesis capitis,pediculesis pubis (crab lice), clother lice and pediculesis corporis (scabies) are differentiated. (Fig.7).

Scabies refers to infestation of the body. Scabies may be treated with complete bathing, application of topical medication, and washing linen and clothing in very hot water.

Pediculesis capitisamazes a single hair of the head, attaching the nits to a hinge of a hair. There are some ways for dealing with pediculosis capitis. Usually the hair is oiled with a mixture of vegetable oil with kerosene and the head is covered the wax-paper and a triangular scarf for about 8-10 hours. Pediculosis capitis is treated by vigorously massaging the hair and scalp with gamma benzene hexachloride or other special medicines. After that the head is carefully washed out by warm water with soap. For removal of nits within several days the hair is repeatedly combed by fine comb with cotton wool moistened in hot 10 % solution table-Acetum.

Crab lice parasitizes on hair surfaces of pubic area, sometimes amazes a moustache, beard, brow, eyelash or axillary hollows (armpit). For destruction of crab lice the hair section of the affected areas is shaved off. Pediculosis pubis may be more resistive to treatment. The nits are difficult to remove from areas with heavy hair growth. apply the medication to the involved area and leave it on the body 12 to 24 hours. Then bathe the person thoroughly with soap and water. If crab lice are found, emphasize the need for treatment of sexual partners to prevent reinfestation.

Clothes lice,causing affecting the skin are found often in pleats and seams of linen. They are carriers of typhus. The person is thoroughly bathed with soap and water. The linen and clothes of such patients are disinfected in special disinfectant chambers.

The detection of louse must be completely dealt with complete (washing of the patient with soap and water, destruction of insects in linen, bed accessories and inhabited rooms, i.e. disinfection and disinfestation) or partial (washing of the people and disinfection (disinfestation) linen, clothes, footwear).

A special entry should be made in the case history and the sanitary and epidemiological station of the district where the pediculosis patient resides. He should be informed so that his family may be inspected and the appropriate disinfection measures be taken if necessary. The time of the report to the sanitary and epidemiological station should be recorded in a special journal of the admissions department.

4. Transportation of the patients

The type of transportation is defined by the physician. The patients in a satisfactory conditionare transported to the department on foot accompanied by a nurse or nurse-assistant

Weak patients, invalids, elderly and senile patientsare transported with a special chair — stretcher (arm-chair, wheel-chair) (Fig.8).

The seriously ill patients are transported on a stretcher-cart in a lying position. (Fig.9).

The stretcher with the patient is carried by 2-4 men. In going upstairs the patient is carried with his head first, in going downstairs the patient is carried with his feet first, raising in both cases the foot end of a stretcher (Fig.10).

If patient is transported by one man, he clasps by one arm the thoracal cell of the patient at the level of the scapulas, and the other arm goes under his femurs. Thus the patient puts his arm around the nurses neck (Fig. 11).

In removing the patient from the stretcher on the bed the stretcher is put perpendicularly to the bed (Fig.13) so that the foot end of the stretcher was towards the head end of the bed or closely parallel to it (Fig.12).

SANITARY — HYGIENIC AND TREATMENT PROTECTIVE REGIMENS OF THE THERAPEUTIC DEPARTMENT

1. Sanitary regimen and its meaning

The necessary maintenance of a sanitary regimen in various hospital rooms plays a huge role in work of a hospital, organization of treatment and care of the patients and prophylaxis of many diseases. Infringement of the needs and rules of a sanitary regimen have frequently led to infection of wards, multiplication of the pathogenic microorganisms and spreading of the various insects. The non-observance of a sanitary regimen will always increase the danger of spreading of nosocomial infections.

Nosocomial infections are infectious diseases arising in the patients in a hospital, or the medical personnel as a result of infringement of the rules of asepsis and antiseptics.

2. Basic demands to organization of a sanitary regimen in hospital

According to hygiene requirements, not less than 7 m2 should be alloted per patient in the common ward and 9 m2 in the separate wards. The optimum beds number in a ward is 3 to 5. Patients in critical conditions should be placed in separate wards with private bathrooms.

Attention should be given to illumination of the wards, since the direct solar beams have bactericidical action. The illumination should be of sufficient intensity, uniform and biologically high-grade on the spectrum. Wards should be illuminated with luminescent lamps or common incandescent lamps with opaque diffusors. A night light should be provided at each bedside, so that the nurse might switch on the light without disturbing the sleep of the other patients in the ward.

It is obligatory to have sufficient ventilation, which is supported by a regular aeration of premises(rooms) or air conditioning.

Rooms should be aired 2 or 3 times a day during the cold season, while in summer the windows should be kept permanently open. Airing is obligatory and should not be left up to patients. Heating should be organized so that it fits the optimal requirement for people in buildings — in winter time was +20oC and in summer time was 23-24oC.

Beds in the room should be spaced at a minimum of 1 metre apart, which is necessary to give convenient access by the medical personnel for examining the patient, and for various procedures. Beds should be nickelplated or oilpainted in order to ensure proper hygiene. Critical patients should be placed in adjustable beds on which the patient can be fixed in any position that might be required. A special night table with drawers for personal belongings should be provided at each bedside. Movable tables should be available for feeding bed-ridden patients. (Fig.14).

3. Treatment-protective regime of the therapeutic department

The patient should be given a regime of physical and psychic rest, according to the teachings of the Russian physiologist Ivan Pavlov. He maintained that the patient's condition improves if he is given rest under conditions that meet the special requirements of his nervous system. The main component of such a protective environment is adherence to the hospital regulations and full mutual understanding between the patient and the medical personnel. A correctly planned schedule for a hospital provides sufficient rest for the patient, regular meals, systematic medical observation, timely fulfilment of all diagnostic and medical procedures.

4. Cleaning hospital premises

The hospital premises(rooms) need to be washed and cleaned with use of disinfectants.

Floor material should be suitable for repeated cleansing with a wet rag. Glazed ceramic tile should be used to cover the walls in the operating room and rooms intended for various procedures.

The cleaning of the wards will be carried out 2 times per day, and also in case of need. The wiping down of the dinnig room will be carried out after each meal time. The general cleaning of all premises will be carried out not less often than once per week. The used stock has proper marks and will be used only for a definite purpose.

Different disinfection solutions can be used. Solutions with chlorine more often will be used than various disinfectants. For preparation of a starting solution of lime chloride it is necessary to take 1 kg of a lime and 10 л of water. We'll obtain10 % solution of chlorine lime. This solution is kept in dark containers. Further this solution varies in concentration and is used for the wet cleaning.

PERSONAL HYGIENE OF THE PATIENT

Observing personal hygiene and cleanliness of the ward and the patient's bed promote effective treatment. It is necessary to check the bedclothes for cleanliness and that the mattress is levelled.

Patients with serious diseases and those suffering from incontinence of urine or faeces should be placed on an oil-cloth to prevent contamination of the linen. In the presence of heavy vaginal discharge in women, easily replaceable sheets should be used over the oilcloth, which can be renewed as frequently as necessary. Critical patients should be put in adjustable beds; special head rests should be used to hold the patient's head in a comfortable position. The bed should be made regularly both before and after sleep.

1. Change bed and body linens

Periodic changing of bed linens promotes patient comfort and prevents skin breakdown. When preceded by thorough hand washing performed using a clean technique, and followed by proper handling and disposal of soiled linens, this procedure helps control nosocomial infections.

If the patient is able to walk, he leaves his bed and the nurse changes his linens.

If the patient can't help you to move or turn himself, devise a turning sheet to facilitate bed making and repositioning. For this aim it is necessary to prepare the clean linen so such that it was rolled along its transverse or longitudinal side.

We can change the linens by 2 methods.

The 1-st method: it is necessary to stand near the headboard on one side. A co-worker stands near the opposite side, facing you. Then you remove the pillow from the bed. Remove the soiled pillowcase and replace it with a clean one. With your co-worker in is necessary to quickly fanfold the bottom sheet from the head of the bed under the patient's shoulders, so that it meets the soiled linen. Then you gradually move toward the foot of the bed and, in one movement, quickly and carefully roll soiled linens and clean linens under the patient's buttocks. After that we can place a pillow under her head for comfort.

If you can't get help and must turn the patient yourself, stand at the side of the bed. Turn the patient toward the rail and, if he's able, ask him to grasp the rail to assist in turning. Then reach over the patient and firmly grasp the opposite rolled edge of the turning sheet. Pull the rolled edge carefully toward you and turn the patient. (Fig.15).

Change soiled linen and clothing as needed, but not less often than once per 10 day.

2. Change of body linens for the seriously ill patient

To do this, first of all, a nurse places her hands under the patient's back, then pulls up the edge of patient's shirt to the nape, then takes it out over the head and releases the patient's hands from the sleeves. If one of the patient's hand is damaged, the healthy hand first is released. The shirt is first put on the damaged hand. Then the shirt is put over the head in the direction of a sacrum of the patient. (Fig.16).

3. Placing the Bedpan and urinal

Bedpen and urinal devices permit elimination by the bedridden patient and accurate observation and measurement of urine and stool by the nurse. Thus patients who need help with elimination are people with fractures, those with hip or knee arthroplasty, patients who have had strokes, postoperative patients, those with severe oxygenation problems, and people who are very weakened by a chronic illness.

A bedpan is used by the female patient for defecation and urination and by the male patient only for defecation; a urinal is used by the male patient for urination. (Fig.17).

The person may need to defecate or void at any time, but the most common times are awakening, before and after meals, before sleep and before any treatments or procedures.

Standard bedpans are available in adult and "pedi" sizes and are usually made of plastic, although metal bedpans are sometimes used.

Placing the bedpan. For this aim it is necessary to obtain the appropriate bedpan. If you're using a metal bedpan, warm it under running water to avoid startling the patient and stimulating muscle contraction. The dry bedpan if necessary can be lightly sprinkled with talcum powder on the edge of the bedpan, to reduce friction during placement and removal.

For a thin patient you can place a linen-saver pad at the edge of the bedpan to minimize pressure on the coccyx. If allowed, the head of the bed is slightly elevated to prevent hyperextension of the spine when the patient raises the buttocks. Then supporting the patient's lower back with one hand the bedpan together with protective linen is placed beneath the buttocks of the patient (Fig 18).

If the patient cannot raise his buttocks, you can lower the head of the bed to horizontal and to help the patient roll onto one side, with buttocks toward you. The bedpan is positioned properly against the buttocks, and then the patient is rolled back onto the bedpan.

After using the bedpan it is necessary to clean the anal and perineal area with a damp washcloth, to dry well with a towel to prevent irritation and infection.

Do not leave weak or helpless people on bedpans for long periods of time. Being left in this way is demeaning and uncomfortable and may promote skin breakdown by a shearing force on the buttocks.

Contents of the bedpan or urinal are emptied into the toilet, rinsed with-cold water, then disinfected with 2% sol. chloraminum or 0,5% lime chloride. The dry bedpan is returned to the patient's bedside or is kept in the special room.

4. Care of the skin

Skin and appendages (hair and nails) form the integumentary system. Bathing is the obvious way to care for skin.

Bathing cleans the skin, stimulates circulation, provides mild exercise, and promotes comfort. Bathing also allows assessment of skin condition, joint mobility, and muscle strength. Depending on the patient's overall condition and duration of hospitalization, he may have a complete bath not less often than once per week or partial bath daily. A partial bath — including hands, face, axillae, back, genitalia, and anal region — can replace the complete bath for the patient with dry, fragile skin or extreme weakness, and can supplement the complete bath for the diaphoretic or incontinent patient.

Regardless of the method of bathing (shower, tub, bed), the balance between self-care and nurse assistance varies. Some people still need to be bathed in bed.

Bed bathing is indicated primarily for people with restricted mobility (some people with casts, traction, or back problems); limited exertion (some people with heart and respiratory problems); and often for first-day postoperative people who may experience hypotension or are very weak.

In this case the temperature of the ward must be comfortable for the patient, any doors and windows must be closed to prevent drafts. The patient is washed with washcloth moistened with soap and water, then rinsed and dried from up to down (face, neck, chest, arms, abdomen, back and buttocks, legs).

The skin of the patients who are taking placed on a bed regimen, are daily bathed with warm water with addition of the alcohol, using a different part of washcloth. Skin-fold areas are washed, and then dried up especially carefully. (Fig.19).

If it is necessary massage can be used to stimulate blood circulation. Special oil, talcum powder can be used is necessary.

5. Skin breakdown (pressure ulcers bedsores) and their prophylaxis

As their name implies, pressure ulcers result when pressure applied with great force for a short period or with less force over a longer period — impairs circulation, depriving tissues of oxygen and other life-sustaining nutrients. This process damages skin and underlying structures. Untreated, these ischemic lesions can lead to serious infection.

Most pressure ulcers develop over bony prominences, where friction and shearing force combine with pressure to break down skin and underlying tissues. The decubituses are usually developed in those areas, where a muscle tissue is not present or it is present in a very small layer.

Common sites include the sacrum, coccyx, ischial tuberosities, and greater trochanters. Other common sites include the skin over the vertebrae, scapulae, elbows, knees, and heels in bedridden and relatively immobile patients. (Fig.20).

Successful pressure ulcer treatment involves relieving pressure, restoring circulation, and — if possible — resolving or managing related disorders. Ideally, prevention is the key to avoiding extensive therapy. Preventive measures include ensuring adequate nourishment and mobility to relieve pressure and promote circulation.

The prophylaxis of skin breakdown is provided by the constant control of the condition of the bed linen and of the patient's linen. It must be clean, without ridges and seams. Special rubber circles (inflate weakly, that easily change form with the movements of the patient) or special rubber matresses consisting of several chambers are laid under the patient (Fig.21).

The position of the patients is regularly changed by turning him in the bed 8-10 times per day. It is necessary 2-3 times a day to wash skin of the patient with room-temperature water, to rub him with camphor alcohol or other alcohol solution and to powder with Talcum.

Several stages are distinguished in the development skin breakdown:

 skin is paled,

 then it is reddened with occurrence of cyanotic maculae,

 a bubble is generated, then the epidermis is exfoliated with the development of the necrosis of a skin, hypodermic tissue, fascias etc. Skin breakdown is not infrequently complicated by connection with a secondary infection. (Fig.22).

When the skin becomes paled

all prophylaxis measures must be increased.

When the skin becomes hyperemic , it should be treated with a 10 per cent camphor spirit twice a day, and then with a moist towel;

the lesion should be irradiated by a quartz lamp and the condition of the skin closely observed.

If bedsores have developed, they should be treated with a strong solution of potassium permanganate with subsequent application of synthomycin, Vishnevsky or other liniment.

Necrotized tissues must be removed with surgical method. (Fig.23).

6. Hair care

Hair care includes combing, brushing, and shampooing. Combing and brushing stimulates scalp circulation, removes dead cells and debris, and distributes hair oils to produce a healthy sheen. Shampooing removes dirt and old oils and helps prevent skin irritation.

Frequency of hair care depends on the length and texture of the patient's hair, the duration of hospitalization, and the patient's condition. Usually, hair should be combed and brushed daily, and shampooed according to the patient's normal routine. Typically, no more than 1 week, or perhaps 2, should elapse between washings.

Shampooing is not recommended in patients with recent craniotomy, depressed skull fracture, conditions necessitating intracranial pressure monitoring, or other cranial involvement.

If baths are not recommended for the patient, his hair should be washed in his bed.

To this end it is necessary to prepare the next equipment: comb and brush • liquid shampoo (or mild soap, such as castile) • shampoo tray with tubing • washcloth • bath towels • large pitcher and small • basin • linen-saver pads • gloves, if the patient has open scalp lesions • support foot, bucket.

Before shampooing the patient's hair, it is necessary to adjust room temperature and eliminate drafts to prevent chilling the patient.

The wash basin should be placed on the bed on the linensaver pad and the patient's head is positioned over the basin. (Fig.24).

The scalp should be shampooed very thoroughly. The washed hair should be rinsed, dried thoroughly, and combed. (Fig.25).

In order to prevent chilling, the patient's head should be wrapped in a dry towel or a napkin.

In some, we can adjust the shampoo tray as shown in Fig 26.

7. Mouth care

Food that remains between the teeth and in the gum pouches is the substrate upon which microbes readily propagate creating conditions for various complications. The care of the mouth is therefore an important item in the general care of the patient.

Mouth care is given in the morning, at bedtime, or after meals. Mouth care entails brushing and flossing the teeth and inspecting the mouth. It removes soft plaque deposits and calculus from the teeth, cleans and massages the gums, reduces mouth odor, and helps prevent infection. By freshening the patient's mouth, mouth care also enhances appreciation of food, thereby aiding in appetite and nutrition.

Patients who are unable to take care for their mouths should be assisted: their teeth, the gums, and the tongue should be cleansed by a cotton wool pad wet with a 3-4 per cent solution of boric acid, a weak potassium permanganate solution, baking soda solution or warm boiled water. Inflammation develops in the mouth, medicinal preparations should be applied or the mouth should be irrigated.

The patient should assume a semiprone position; an oil-cloth should be placed on his chest, while a kidney-shaped basin should be placed under patient's chin (Fig.27).

For the comatose patient we can insert the bite-block to hold the patient's mouth open during oral care and to protect yourself from being bitten during the procedure.

After completing oral hygiene it is necessary to use a moisturizing agent on the lips (water-soluble lubricant, lip balm, or write petroleum jelly) to prevent dryness and cracking.

8. Eye caree

Heavy, crusted eye secretions make it difficult to open the eyes fully, cause eye irritation and infection, and are aesthetically unappealing. Persons at risk for crusting include people in coma, people with severe liver disease and jaundice, and those with conjunctivitis or other eye infections.

Many elderly people suffer from decreased lubrication of the eye. The resulting dryness can lead to infective displacement of dust and bacteria, which can predispose people to infection. Use of natural tear products can prevent problems in the elderly population.

Although eye care isn't a sterile procedure, asepsis should be maintained as much as possible.

Patients who are unable to care for their eyes should be assisted. To that end it is necessary to take: a sterile kidney — shaped basin, sterile gauze balls, a special solution, if necessary some medicines and pipette.

The patient should assume a semiprone position; an oil-cloth should be placed on his chest, while a kidney-shaped basin should be placed under patient's chin. The patient's eye must be gently wiped with the moistened cotton ball, working from the inner canthus to the outer canthus to prevent debris and fluid from entering the nasolacrimal duct. To prevent cross-contamination it is necessary to use a fresh cotton ball for each wipe until the eye is clean (Fig.28).

In order to remove purulent discharge from the eyes, a 3 per cent boric acid solution, ethoxydinaminoacridine lactate (rivanol), or a weak potassium permanganate solution are used from a rubber bulb or by applying a piece of gauze.

If the eyes are affected by an inflammatory process, medicinal preparations should be used or ophthalmic ointments applied. When putting in eye drops, the nurse pulls down the lower eyelid with the left hand and asks the patient to look upward. Using an ophthalmic pipette, two drops are expressed on the lower conjuctiva, one after another. The medication is never dropped on the cornea. (Fig.29). When the patient shuts the eyes, excess solution is expelled from under the eyelids. It should be absorbed by a cotton ball. The pipette should be rinsed and kept closed until the next use.

Ophtalmic ointment should be applied to the eye using a glass spatula. The patient is asked to look up, his lower eyelid is pulled down using a moist cotton wool pad, and the ointmet is transferred from the spatula end onto the inferior conjuctiva. (Fig. 30).

9. Ears care

The patient should clean his ears during his morning toilet.

If the ears are not kept clean, debris accumulates behind the ear and in the anterior aspect of the external ear. Debris in and around the ears can lead to ulceration and infection. The ear care takes place with their regular washing by warm water with soap, and cleaning of the ear canal by a special cotton swabs.

To prevent the build-up of ear wax in bed-ridden patients, their ears should be cleansed 2 or 3 times a week. Ear wax is usually removed from the ear in the form of small lumps. Ear wax may accumulate in the ear of patients and healthy individuals and clogs the auditory meatus and thus impair drastically the hearing function (Fig. 31).

To remove cerumen from deep in the ear canal, an ear irrigation may be ordered by the physician.

A 100-150 ml Janet syringe is used for this purpose. The patient sits with his side to the nurse and to the source of light. A kidney-shaped basin is held by the patient under the ear auricle. Using her left hand, the nurse pulls the ear up and back, and introduces the end-piece of the syringe into the external meatus with her right hand. Water at a temperature of 36-37°C is discharged with force in small portions.

The jet should be directed onto the superior-posterior wall of the meatus. The ear should then be dried by cotton wool. If this procedure fails, to help the patient, ear wax should be softened by using a soda-glycerol solution: 7-8 drops (preheated in water) are instilled 2-3 times a day for two or three days. The patient should be warned that his hearing may be slightly impaired after the instillation (Fig.32.).

If necessary, medicinal preparation should be instilled into the external auditory canal. The person should be in a sitting position and incline his head in the direction of his good ear. The ear lobe should be pulled down by the left hand, and the drops instilled by the right hand.

The ear and external auditory canal are not considered sterile cavities. Therefore we must use sterile solutions at body temperature. The dose for a child is 3-6 drops per instillation. In order to prevent the spontaneous flow of the fluid from the ear, the patient should keep his head inclined for 15-20 minutes. The ear should then be wiped dry by sterile cotton wool.

10. Nose care

The nose provides a sense of smell and protective functions. Mucoid secretions, cilia, and specialized tissue in the nose aids in controlling temperature, humidity, and entry of foreign particles in the respiratory system. Excessive secretions can impair the sense of smell and obstruct breathing.

If a person is unable to sniff or blow the nose, secretions can become crusted and may obstruct the airways or irritate nasal mucosa. If the sense of smell is impaired, inability to detect food aromas may decrease appetite. Adequate hygiene improves comfort and function of the nose. Liquid nasal secretions are usually removed by blowing the nose. Dry, hardened secretions are usually manually removed. Removal may be all that is needed for effective hygiene, other that cleaning externally opening during bathing.

Some people may need help to clear congestion and protect nasal mucosa. External crusted secretions can be removed with a wet washcloth or a cotton-tipped applicator moistened with water or normal saline. (Fig. 33).

The nose is not considered a sterile cavity. Therefore, a clean technique is adequate for the instillation of nose drops, unless the sinus cavities are involved. The patient must be in a supine or a sitting position, with the head resting back on a pillow. Any other position allows the medication to flow out of the anterior nostrils. Draw up the ordered quantity of solution in the dropper and place it just inside the nostrils. Using a soft dropper, carefully instill the prescribed drops into the nostrils. (Fig.34).

To prevent contamination or sneezing, avoid touching the nasal mucosa with the dropper tip. Instruct the person to keep the head tilted back for several minutes to maximize therapy. Because the nasal passages drain into the back of the mouth and throat, the taste of the medication may be disagreeable, causing discomfort and a desire to expectorate.

11. Perineal care

Perineal care, including the external genitalia and the anal area, should be performed during the daily bath and, if necessary, at bedtime and after urination and bowel movements. The procedure promotes cleanliness and prevents infection. It also removes irritating and odorous secretions, such as smegma, a cheese like substance that collects under the foreskin of the penis and on the inner surface of the labia. For the patient with perineal skin breakdown, frequent bathing followed by application of an ointment or cream aids healing.

The external genitalia of women confined to bed should be washed at least once a day (unless more frequent washing is prescribed). Washing should be done with a weak (1:5000) potassium permanganate solution or a 2 per cent lysoform solution. The woman should assume a supine position with her legs flexed and the thighs set apart. A bedpan is placed under the pelvis. Using forceps and cotton wool, the genitals are washed with a jet of the disinfectant solution. The cotton ball should be moved from the genitalia to the anus to prevent intestinal organisms from contaminating the urethra or vagina (Fig.35).

We must use for the one movement only one washcloth. The external genitalia are then dried by a dry cotton wool pad.

For the cleansing of the legs of the bed ridden patient is necessary to place a basin on the patient's bed, flex the leg at the knee, and to place the foot in the basin (Fig.36). Soak the foot, and then wash and rinse it thoroughly. Remove the foot from the basin, dry it, and clean the toenails. The nails must be periodically cut.

NUTRITION OF PATIENT

The health of a human being, his work capacity, and longivity depends to a great degree on adequate nutrition.

Nutrition is the sum of processes by which a living organism ingests, digests, absorbs, transports, and uses nutrients. With the proper nutritional support, the organism can grow, function, and reproduce. Body defense mechanisms, wound healing, and a variety of other vital processes also require optimal nutrition. We also know that nutritional requirements change with age, disease, activity, and stress.

All foods supply a source of energy to the body in the form of calories. The minimum energy needed by the body to maintain the circulation, respiration, muscle tone, body temperature, and other vital processes is called the basal energy requirement.

People of similar size have similar basal energy needs, but total energy requirement differs greatly because requirements depend on physical activity. The basic energy-yielding nutrients are protein, carbohydrates, and fat. Ideally, daily energy intake is just sufficient to meet the body's requirements. When the intake of calories exceeds energy needs, excess calories are converted into body fat to be stored in fat pads, and the person gains weight. On the other hand, a diet deficient in calories leads to loss of body weight over time. Being either underweight or overweight can endanger life and health.

Carbohydrates are one of the major energy sources in the diets of all people throughout the world. Because carbohydrate is the predominant compound in grains, vegetables, fruits, and other plants, carbohydrate-containing foods are widely available.

Carbohydrates are also the source of dietary fiber. Fiber includes carbohydrates and carbohydrates-like components that our gastrointestinal tracts cannot digest. A definitive benefit of dietary fiber is relief of constipation, a probable benefit is the improved management of chronic diverticular disease. Possible benefits of dietary fiber are a mild reduction in blood cholesterol level, a mild improvement in glucose, tolerance, and the increased success of reduced-calorie weight reduction regimens. Its speculative value is that fiber might reduce the risk of colon cancer.

Dietary fiber can cause adverse effects. Possible adverse effects from increased fiber in the diet are interference with absorption of certain minerals, and flatulence and loose stools during the first few days of increased fiber intake. These consequences are minor, however, and should not be major deterrents to emphasizing fiber-rich foods in the daily diet.

Fatis a combination of fatty acids and glycerol. Its main function is to provide the body with a concentrated source of energy. Fat is also the primary storage form of energy. In fact, this nutrient has almost unlimited storage capacity in the body as adipose tissue. Besides these majors functions, fat also

• acts as an insulator for the body in the form of subcutaneous fat

• transports the fatsoluble vitamins, A, D, E, and K

• maintains cellular function in the form of the essential fatty acid, linoleic acid

• supplies cholesterol, which is necessary for the synthesis of adrenal and sex hormones

• is a vital component of cell membranes.

The major role of proteins is to build tissues and aid in the manufacture of essential substances like enzymes and hormones.

Many energy-producing and tissue-building processes are necessary to maintain life and health. These processes require the participation of a variety of vitamins and minerals that operate as coenzymes or cofactors.

Maintenance of life and health, means that water balance be kept within closely defined limits at all times. Water is an essential nutrient that is basic to life. Its overall balance within thefluid compartments of the body is regulated by various complex physiologic processes.

Meals should be regular and of good quality. The amount of food should be moderate, while the food itself as varied as possible. The daily diet of a healthy individual should include the following:

about 150 g protein, 100 g fats, 400-500 g carbohydrates, 1500-2000 ml liquid, about 10 g table salt, and the appropriate quantity of mineral substances (potassium, calcium, iron, zinc, etc.); the food should also be rich in vitamins.

Factors that influence food intake, dietary paterns, and nutritional status are: appetite, financial status, geography, culture, religion, social circumstances, age, individual preferences, physiologic and other reactions, pregnancy and lactation, the media, use of alcohol and drugs, illness and injury.

During hospitalization, most people receive the general (house, regular) diet. Routine modifications of the house diet include the soft, full liquid, and clear liquid diet. The soft diet is commonly ordered for the person with problems in chewing or digesting the more complex and sometimes "rich" foods in the general house diet. Persons without teeth and those recovering from surgery are excellent candidates for the soft diet. Liquid diets may be used before and after surgery as well as in circumstances in which substantial oral or esophageal lesions make it difficult to manipulate and swallow solid foods. All types of liquids are permitted on the general or full liquid diet, whereas a clear liquid diet provides only tea, broth, gelatin dessert, and other "clear" liquid items. In addition to the modifications, diets are often altered to limit calorie or salt intake.

Patients at hospitals have four meals; patients with heart diseases and peptic ulcer should eat 5 or 6 times a day, at strictly predetermined times. The taste of food and its appearance matter as well. The patient's condition permitting, spices may be added to the food. The temperature of hot dishes should be about 60°, and of cold 10-15°C.

Diet should differ depending on the disease. More food should be given to pregnant, tuberculosis and asthenic patients, while patients who suffer from incoercible vomiting or hemorrhage associated with a peptic ulcer must not be given any food; some patients may be restricted in certain foods, others in water, etc. There are 15 therapeutic diets, some diets have subdivisions. The dietologist ensures the control of patient's nutrition. A nutritionist is responsible for the observation of the dietary requirements in departments. At modern hospitals food is delivered to the department in special heated containers on wheeled carts. Food is delivered to the dinning room or directly to the ward. Walking patients should have their meals at the dinning room.

Critical patients should be assisted in their meals. (Fig.37) Weak patients should be helped to assume a convenient position so as not to become tired during meals. If the patient is unable to sit up in bed, he should be assisted into a semiprone position in an adjustable bed. His neck and chest should be covered with a napkin. Bedridden patients may be fed from special tables. Asthenic patients should be fed by a nurse in small portions. Solid food should be cut into small pieces or crushed. Special cups with a spout are used to give liquid food and drinks.

1. Maintaning Nutrition When Gastrointestinal Function Is Impaired

Ideally, a person can meet all nutritional needs with a regular, balanced diet processed through the normal gastrointestinal route. In some circumstances, however, a person cannot ingest, digest, or absorb sufficient nutrients, and nutritional requirements must be met, on either a temporary or a permament basis, by specialized methods of feeding. Specialized methods of feeding may require bypassing normal anatomic structures in order to provide nutrients.

For a person who cannot eat solid food but who can absorb nutrients from the small intestine, enteral feeding is appropriate.Enteral feeding refers to a special liquid formula that can be given orally or through a tube passed through the nose or mouth into the esophagus and stomach. (Fig.38).

A tube may also be surgically implanted directly through the abdominal wall into the stomach or the small intestine (most frequently, into the jejunum) to provide enteral nutrition. (Fig.39). For persons who cannot eat or absorb enough from the normal gastrointestinal route when fed by tubes, parenteral support (intravenous feedings) may be provided. This is sometimes referred to as peripheral parenteral nutrition (PPN).

Parenteral nutrition. Parenteral fluids that are given to enhance nutrition are introduced directly into the venous system. These fluids usually contain glucose, amino acids, electrolytes, minerals, and vitamins. For persons in good nutritional status but with a temporary inability to absorb nutrients, solutions with amino acids and a low concentration of glucose may be administered for short periods through peripheral veins (PPN). About twice a week, lipid emulsions are given through a Y-tube connection into the intravenous line. However, in situations of major trauma or substantial damage to the gastrointestinal tract when longer-term feedings are needed, more substantial parenteral nutrition may be necessary, and a central venous catheter is placed in a large vein (usually the subclavian) that empties directly into the heart. This type of intravenous line allows the client to receive total parenteral nutrition (TPN). Total parenteral nutrition, or hyperalimentation, is the intravenous provision of total caloric needs, including both amino acids for protein building and lipid emulsions and high concentrations of glucose for calories.

Patients are sometimes given nutrients by enema.A nutrient enema is done after evacuation of the rectum by a cleansing enema. This done, a warm solution (36-40°C) of a 5 per cent glucose and 0.85 per cent sodium chloride solution is administered by enema. The solutions should bo given 3-4 times a day in a dose from 100 to 200 ml in each enema.

2. Characteristics of the diets in some diseases

Diet in the management of liver and gall bladder disease (Diet 5)

Because both the liver and gall bladder have important metabolic functions, diseases of these organs frequently require dietary management. Alcohol is not allowed. Goals of nutritional therapy are correction of fluid and electrolyte imbalances and provision of nutritional support, to encourage healing and limit further damage. Dietary measures include

• a basic high protein diet, if liver damage is not severe

• a low protein diet when liver damage is severe. Because the liver plays a major role in protein metabolism, compromised liver function causes increased blood ammonia levels and coma can result. The amount of protein restriction will vary according to the extent of liver damage

• sodium restriction to 1000 to 2000 mg daily to reduce fluid retention when edema or ascites is present

• a soft diet if esophageal varicose (enlarged veins in the esophagus) develop. Soft foods help to prevent rupture of these blood vessels.

Low fat diets have traditionally been prescribed for people with gall bladder disease. The basis for this recommendation was that fat in the intestine causes the gall bladder to contract and therefore causes pain. The best advice for patients with gall bladder disease is not necessarily to avoid fat but to consume a well-balanced diet and avoid foods, or amounts of foods, that cause pain. Obese people should be encouraged to lose weight, especially if surgery is being considered.

Diet in the management of kidney disease (diet 7)

Diet therapy therefore depends upon the specific disorder. Excessive urinary losses require dietary replacement. Impaired elimination of wastes secondary to a malfunctioning kidney requires a diet that minimizes the buildup of these compounds in the circulation. This diet is low in protein, sodium, and potassium. In addition, fluid intake is restricted.

Three kidney disorders are acute glomerulonephritis, the nephrotic syndrome, and chronic renal failure. Their clinical features and dietary recommendations are summarized in Table 2.

Diet in the management of cardiovascular disease (Diet 10)

Several disorders involving the heart and blood vessels require diet modification as part of therapy for the condition. Beneficial dietary changes include cutting down on cholesterol rich foods, and reducing the saturated fat content in the diet by substituting polyunsaturated fats for saturated fats. Additional general recommendations are to

• restrict fat intake to no more than 30 per cent of total calories in the diet

• restrict cholesterol intake to less than 300 mg/day

• eat frequent meals of fish and poultry, which contain less saturated fat than does meat. For meals that include meat, choose lean cuts and trim the fat

• reduce the amount of saturated fat intake in relation to unsaturated fat intake

• cook with liquid vegetable oils and margarines

• use nonfat milk and nonfat milk products

• eat only two or three egg yolks per week, including those used in cooking.

Congestive Heart Failure. The diet primarily involves mild, moderate, or severe sodium restriction, depending on the amount of edema. The main source of dietary sodium is sodium chloride

People with CHF also receive diuretic therapy which increases urination, thus reducing volume overload. Some diuretics cause potassium depletion. Therefore, it is necessary to promote ingestion of foods containing large amounts of potassium (e.g., orange juice, bananas) or to give potassium supplements.

Diet in the management of metabolic and endocrine disorders (Diet 9)

The diabetic diet is one essential components in the control of diabetes. Methods of dietary management differ from clinic to clinic. Generally, however, emphasis is on regulation of carbohydrate and fat intake in order to avoid large fluctuations in serum glucose levels.

STORAGE AND USE OF MEDICINAL PREPARATIONS

There are many types of therapeutic effects including the following: surgical treatment, balneological and physiotherapeutic procedures, climatotherapy, etc. But the most common type of treatment is pharmacological therapy, i.e. treatment with medicinal preparations.

Medication administration is the cornerstone in the overall plan of nursing care and medical treatment. In practically every health care setting, nurses are responsible for administering medications, and assisting people to use medications safely and properly.

The nurse often encounters people who need special assistance in taking medications. People with special needs include children, disabled people, the elderly, those with neurosensory problems ( people with impaired vision, hearing, or swallowing or alterations in mental status), and those with chronic pain. In addition, nurses must be knowledgable concerning the pharmacology of medications given, the legal implications involved in the preparation and administration of medications, the techniques of safe medication preparation and administration, and the application of the nursing process when they are caring for individuals receiving medication.

Medication preparation and administration has many legal and ethical implications. When you administer medications, you are responsible for developing an up-to-date knowledge base. For each medication that you administer, you should be familiar with the following:

• the generic and proprietary names

• the classification

• the normal dose or range of doses

• the route(s) of administration

• the desired action

• common side effects

• toxic and undesired effects

• contraindications and incompatibilities with other medications

• special considerations and nursing implications

You also must be aware of the "five rights" in administering a drug. An important nursing responsibility is adhering to these "five rights". These are the

1. Right drug

2. Right dose

3. Right route

4. Right time

5. Right person.

The use and sale of medications are governed by state laws. Medications are classified as either prescription medications (medications, including controled substances, that require a physician's order) or over the counter(OTC) medications(medications that may be purchased without a physician's order.

If medication is intended to eliminate the cause of the disease, this is called etiotropic treatment. For example, antibiotics act on agents causing infections. Many medicinal preparations act not on the causative agent but on the developing disease, the cause being uncertain or inactive by the time of treatment. This treatment is called pathogenetic. For example, cardiac glycosides or diuretics are given for circulatory insufficiency. Symptomatic treatment is used to alleviate some symptoms of a disease, e.g. narcotics are given to relieve pain and sedatives are given for insomnia. Sometimes a patient is given etiotropic, pathogenetic, and symptomatic treatment all at the same time.

The effect of a medicinal preparation depends, to a considerable degree, on its dose. A single dose means the amount of preparation that is given for one intake. A daily dose implies the amount of the medicine which is to be taken within 24 hours. A total or cumulative dose means the amount of the medicine that is taken by the patient during the entire course of treatment. A therapeutic dose means the amount of medicine that causes a pronounced therapeutic effect without causing any pathological deviations in the patient. A toxic dose is the amount of medicine causing symptoms of poisoning.

A therapeutic effect depends on the concentration of the medicine which in turn depends on the dose and the body weight of the patient. In this connection a dose is often specified with reference to a kilogram of the patient's weight. A concrete dose should, in such cases, be calculated for each particular case.

Sensitivity of people to medicinal preparations normally varies within a wide range depending on the physiological condition of the body (pregnancy, lactation), nutrition, age, and sex. Age sensitivity to medicinal preparations is especially varied.

Apart from their curative effect, medicines can also cause undesirable side-effects. These are biological effects that develop irregularly and cannot be predicted or foreseen. Toxic side effects can develop as a result of over dosage by error or of a suicidal attempt of the patient. Drug addiction is a well known side effect of narcotics.

A special group of side effects includes various forms of idiosyncrasy and drug disease. The latter is manifested by a complex of immediate and delayed allergic responses. These nonspecific side effects are the result of individual, congenital or acquired properties of the body.

If a patient becomes adapted to a medicinal preparation, its therapeutic dose has to be increased. Some preparations, on the other hand, can be accumulated in the body, and their doses should there-fore be gradually decreased, or the medication should be suspended at intervals to prevent poisoning.

1. Ordering and keeping medicinal preparations

During his rounds, the physician prescribes various medicines which he enters in the case history of the patient and in the special prescription sheets. The nurse records these prescriptions in a special notebook according to which medicinal preparations are dispatched to the patients. The prescriptions are also put into a special notebook for nocturnal medication, and also the injection list. The medicinal preparations are ordered according to the physician's prescriptions.

All medicines should he kept in a locked cabinet. It should be located in the nurse's room, out of patients' reach, and should always be locked.

The special control is required for a storage toxicant, strong and narcotic agents, which are kept in special compartments "A" and "B". Each case of their application is fixed in special notebook with the patient's name and the number of the case history. Narcotics are subjected to special care. They are kept in the safe. The key from the safe is kept in the duty doctor. The introduction of narcotic drugs is carried out only in the presence of the physician.

External medicines should be kept separately from those administered internally. Medicines with a strong odour (iodoform, lysol) and also flammable substances (alcohol, ether) should be kept separately from other medicines.

Special care should be taken in storing sterile solutions for parenteral administration. If a bottle contains several doses, it should be closed after each use. If there is any doubt about the sterility of a preparation, the medicine should be discarded.

Alcoholic and ether solutions, tinctures, and extracts can be stored for a long time because microbes are quickly killed in them. But these substances are quickly evaporated which increases the concentration of the active substance and can thus cause over dosage. Some medicines (salts of silver, bromine and iodine) decompose when exposed to light and they should therefore be stored in dark bottles. The amount of medicines kept in the cabinet should not exceed a storage for 3 or 4 days. Sterile solutions (in containers other than vials) should be stored for not longer than 3 days, while anti-biotic solutions, not longer than 24 hours. Ampouled solutions can be stored for months. An expiration date is usually indicated on the label.

2. Administration of medicines

Medications can be classified according to their method or route of administration. The following methods of administration of medicinal preparations are distinguished: enteral (intestinal), external, parenteral, and by inhalation.

The choice of the administration mode depends on the particular disease. Each mode has its advantages and disadvantages.

Enteral administration implies taking medicines by mouth (per os) or through the rectum (per rectum); or the medicine can be placed under the tongue (sub lingua). Peroral administration is the common way of taking medicines. The advantage of the method is that medicines can be given in any form and under non-sterile conditions. The disadvantages are: first, the preparation is slowly absorbed into the blood; second, the properties of the medicine are altered by the gastric and intestinal juices. Since the absorption is slow, it is difficult to predict the concentration of the medicine attainable in the blood and tissues.

Classification of the medications depend on their route:

- Enteral medication:

 oral medication: any medication given by mouth.

 sublingual medications: medications placed under the tongue and absorbed into the blood vessels underneath the tongue (e.g., nitroglycerin)

 buccal medications: medication help the inside the mouth against the mucouse membranes of the cheek (e.g., lozenges) (Fig.40).

- Topical medications: agents applied to the skin and mucous membranes for absorption or for local therapy. In addition to administration onto the skin, topical agents include optic medications (medications administered into the eye), otic medications (medications administered into the ear), nasal medications (medications administered into the nose), vaginal medications (medications administered into the vagina), rectal medications (medications inserted or instilled into the rectum), and pulmonary medications (medications inhaled into the respiratory tract).

Medications given by the sublingual and buccal routes are also sometimes classified as topical medications.

- Parenteral medications are those given by injection with a needle. Parenteral medications are the most rapidly absorbed because they are administered directly into or close to the circulation or into their sites of action.

Routes of administration for parenteral medications (Fig.41) include the

• subcutaneous route: administration into the subcutaneous tissue, under the skin

• intradermal route: administration under the epidermis, into the dermis

• intramuscular route: administration into a muscle

• intravenous route: administration into a vein

• intra-arterial route: administration into an artery

• intracardiac route: administration into the heart muscle

• intraosseous route: administration into a bone

• intrathecal route: administration into the spinal canal

• epidural route: administration into the space external to the dura mater of the spinal canal.

Oral medications are absorbed in the gastrointestinal (GI) tract (i.e., the mouth, stomach, and small intestine). The two forms of oral medications are solid and liquid.

Solid forms. Solid forms of medication include tablets, capsules, and powders. (Fig. 42).

Tablets are solid forms of medicinal compounds measured and shaped to a specific dosage and form by the manufacturer. Prolonged-acting (sustained-release) tablets are oral medications specially formulated for gradual absorption. Fast-acting tablets may contain substances such as lactose that speed absorption in the stomach. Entericcoated tablets are oral medications with a hard surface that impedes absorption until the medication reaches the small intestine. Some tablets must be chewed, whereas others are swallowed whole. On the other hand, lozenges are tablets that should be completely dissolved in the mouth without chewing. Generally, lozenges exert their therapeutic effects directly on the oral mucosa.

Capsules are oral preparations in which one or more medicinal substances are placed inside a small shell, which is usually made of gelatin dissolves in the GI tract and releases the medication for absorption. Capsules are swallowed whole.

Dry medications that are mixed with liquids (water or juices) before oral administration are called powders. Many powders are sold in bulk and must be measured and diluted immediately before administration.

Liquid forms. Liquid medications include syrups, medications that are blended into a sugared or thick flavored liquid. Be wary of using syrups for people with diabetes, because these preparations often contain sugar.

Solutions are homogenous mixtures of liquids and solids. Medications in solution are more likely to be unpalatable and may therefore need to be diluted or followed by liquids

Suspensions are mixtures of solid particles in a liquid medium in which the particles precipitate out when the suspension is left standing. Therefore, suspensions, such as gels and magmas (thick milky suspensions of an inorganic substance), must be shaken before each administration.

Emulsions are suspensions made from fats, oils, or petrolatum suspended in a second liquid. These preparations must also be shaken before measurement and administration. Take care to avoid the client's aspiration (inhalation) of these substances, because oils and fats cause severe pneumonia if drawn into the lungs.

Elixirs are drug preparations in a solvent medium of alcohol and water (a hydroalcoholic medium). Sugar is often added to improve the taste. Like syrups, elixirs mask unpalatable medications and simplify administration.

Tinctures are also dissolved in a hydroalcoholic medium but are more potent than elixirs. Some tinctures are for topical use only, so it is important to distinguish between oral and topical tincture preparations. It is also important to use tinctures and elixirs cautiously in people who are or may be alcoholic.

Oral administration of medicines is not recommended for patients who:

a) have impaired swallowing, particularly those with suspected or actual stroke,

b) are unconscious, or

c) refuse to take medications orally. In such cases, discuss the situation with the person, physician, and pharmacist as appropriate.

Explore alternatives such as stopping the medication or administering medication in a more acceptable form or by an alternative route (e.g., injection or nasogastric tube).

Rectal administration of medicines is also popular. It is especially important in cases where peroral administration is unfeasible due to difficult swallowing, in burns of the esophagus, incoercible vomiting, when the patient is unconscious, and in some other cases. In some diseases (heart failure, diseases of the gastrointestinal tract) absorption of medicines in the stomach and intestine is either slow or incomplete. Rectal administration is preferred in such cases because due to anastomosis of the hemorrhoidal veins with the iliac veins, the medicine enters the inferior vena cava bypassing the system of the portal vein and the liver. It should be remembered that the absorption power of the rectal mucosa is about 25 per cent lower than that of the small intestine. The rectal dose should therefore be slightly higher than a median therapeutic one, but it should not exceed the permissible single dose. The absence of enzymes in the rectum is a disadvantage: medicines contained in a protein, fat or polysaccharide base cannot penetrate the rectal wall and should therefore be given only locally.

Suppositories or enemas are used for rectal administration of medicines. (Fig. 43).

Rectal suppositories are shaped like small cigars or cones, 1-1.5 cm in diameter, and are 2.5-4 cm long. A suppository weighs 1.1-4 g. When inserted into the rectum, the suppository base has to overcome the resistance of the sphincter muscles. The base material should therefore be solid at normal temperature but melt and dissolve at the temperature of the body, so that the active substance can be absorbed by the rectal mucosa. Commonly used bases are cocoa butter, polyethylene glycols, glycerinated gelatin, etc. Suppositories should be wrapped in water-proof paper and kept in a refrigerator.

Topical or external medications are applied to the skin or mucous membranes. Some categories of topical medications include:

a) antiseptics for cleaning the skin and mucous membranes,

b) local anesthetics,

c) antipruritics,

d) moisturizers and other soothing agents,

e) antibiotics, and

f) anti-inflammatory agents.

Most topical medications are given for their local effects (i.e., the medication exerts its action in the area around the administration site). Some topical medications, however, exert systemic effects — they are carried via the blood to tissues or organs located away from the area of administration. Nitroglycerin, for example, is absorbed through the skin but affects the coronary blood vessels.

Topical Medication Preparations. Topical medication come in different forms, such as:

Lotions are suspensions of insoluble powder in water or ingredients dissolved in a thickened liquid (e.g., calamine lotion).

Creams are oils dispersed in 60 to 80 per cent water to form a thick liquid or soft solid (e.g., antifungal cream). Both lotions and creams evaporate when applied, leaving a layer of medication on the skin. They protect and lubricate the skin without blocking evaporation of natural skin moisture. Little of the medication is absorbed.

Ointments are semi solid preparations in a fat, oil, wax, or watersoluble base. Ointments contain 25 to 50 per cent water. Petrolatum is a widely used ointment. Ointments are moderately or fully occlusive on the skin and therefore have an emollient or softening effect. Moisture retention also enhances medication absorption. Hence, ointments provide the most effective vehicle for absorption of therapeutic agents into the skin.

Powders for topical use are mixtures of chemicals in a dry form that are usually dusted onto the skin . They promote dryness by absorbing skin moisture. Powders wear off easily and must be applied more frequently than other topical preparations.

Gels are semisolid mixtures that liquify when applied to the skin. After application, gels evaporate quickly and dry to a nonocclusive film. Some corticosteroids are supplied in gel form to prevent absorption and systemic effects.

Aerosols are liquid or powder medications suspended in a mist, often in an alcohol-based spray. These medications are sprayed onto a site at a controlled pressure, leaving a film of active ingredients behind. They are used to treat damaged skin and mucous membranes that are too painful to touch directly.

Topical medications are most frequently administered to the mucous membranes of the mouth, vagina, rectum, bladder, and respiratory tract.

THERMOMETRY

Temperature refers to the hotness or coldness of a substance. Some living species are able to self-regulate the temperature of their body while others are warmed and cooled by conditions in the enviromment. Humans are homeo-thermic that is, they are warm-blooded and maintain body temperature independently of their environment.

It has been observed that environmental and physiological processes occur in repeated cycles of time. Some events in humans, appear to recur at 24-hour intervals. This cycling pattern is referred to as circadian (meaning nearly every 24 hours) rhythm. Predictable fluctuations in measurements of body temperature and blood pressure are examples of functions that exhibit a circadian rhythm.

The body temperature of a healthy person is maintained within a fairly constant range by the hypothalamus in the central nervous system. This structure is located at the base of the brain and plays an important role as the body's thermostat. It normally allows the body temperature to vary only approximately 1 degree throughout the day. This constancy is referred to as the point. The set point can be altered by the body's response to infectious agents, allergens, and inflamed tissue.

The hypothalamus has two parts: the anterior hypothalamus which controls heat dissipation, and the posterior hypothalamus that governs heat conservation. Thus, the set point is maintained by a balance of mechanisms involving heat production and heat loss. The following are examples of ways in which the body's thermal balance is maintained:

• Heat is produced through the metabolism of food. More heat is produced when the metabolism is increased, and less when the metabolism is decreased.

• Heat production is increased by the body's secretions of epinephrine, nonepinephrine, and thyroxin.

• Exercise produces heat through muscle contraction.

• The body's surface, but not its internal structures, gains and loses heat physically from the sun, wind, and humidity in the environment.

• Heat is transferred primarily through physical processes of radiation, convection, evaporation, and conduction.

• Heat is lost in small amounts through the urine, faeces, and the process of warming and exhaling inspired air.

• Changes in vascularity of the skin modify body temperature. When blood is directed to the skin through dilated vessels, heat loss is increased, when the skin vessels contract, heat is conserved.

• The contraction of smooth muscles when gooseflesh occurs, and the involuntary movement of skeletal muscles when shivering is present, produce heat and promote the circulation of blood that has been warmed through this process.

In physiological conditions temperature of a body of healthy persons changes within the limits of 36,4 — 37,0o C. Variations normally occur in each person, and a range of 0,3 o C to 0,6 o C (0,5 o F to 1,0 o F) from the average normal temperature is considered to be within normal limit. For instance, body temperature is usually about 0,6 o C lower in the early morning than in the late afternoon and early evening. This variation tends to be somewhat greater in infants and children. Current research indicates that the peak elevation of a person's temperature will occur in late afternoon, between 4pm and 7 pm. However, wider variations from the average temperature have been found to be normal for certain persons. Newborns and young children normally have a higher body temperature than adults. The body's internal organs require a fairly constant inner or core temperature for optimal functioning, whereas the surface and periphery of the body can fluctuate widely while gaining or losing heat.

2. THERMOMETRY

Throughout the world, various authors have attempted to find a definition of nursing which puts emphasis on why activities are performed rather than limiting attention to what is done – the observable tasks – and the following definition by Virginia Henderson is one of the most frequently quoted: “Nursing is primarily assisting the individual (sick or well) in the performance of those activities contributing to health, or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge”. It is likewise the unique contribution of nursing to help the individual to be independent of such assistance as soon as possible. ( Henderson, 1960).

Nursing process is central to nursing actions in any setting. It is an efficient method of organizing thought processes for clinical decision-making and problem-solving, when planning and delivering patient care. In its early developmental years, nursing did not seek or have the means to control its own practice. Florence Nightingale, in discussing the nature of nursing, observed that “nursing has been limited to signify little more than the administration of medicines and the application of poultices” ( Nightingale, 1859).

While this societal attitude has persisted into the present, the nursing profession has been working to define what it is that uniquely characterizes what nurses do that other healthcare providers do not do, and to identify nursing’s body of professional knowledge.

The nursing profession has identified a problem-solving process that “combines the most desirable elements of the art of nursing with the most relevant elements of systems theory using the scientific method”. This Nursing Process was introduced in the 1950s as a three-step process of assessment, planning, and evaluation based on the scientific method of observing, measuring, gathering data, and analyzing the findings.

Years of study, use, and refinement have led nurses to expand the nursing process to five concrete steps which provide an efficient method of organizing thought processes for clinical decision-making, problem-solving, and the delivery of higherquality, individualized patient care. According to the steps of the nursing process, when a patient enters the healthcare system, the nurse

Finally, after these interventions have been carried out, the nurse evaluates the effectiveness of the plan of care in reaching the desired outcomes and goals to determine whether or not the problems have been resolved and the patient is ready to leave the system. If the identified problems remain 6 unresolved, further assessment, additional problem identification, alteration of outcomes and goals, and /or changes of interventions is required.