Ear care and external auditory canal. Instillation of drops into the eyes Cleansing the external auditory canal Algorithm
Purpose: Clean the patient's ears
Indications: Impossibility of self-service.
Contraindications: No.
Possible complications: When using hard objects, damage to the eardrum or external auditory canal.
Equipment:
1. Cotton turundas.
2. Pipette.
3. Beaker.
4. Boiled water.
5. 3% hydrogen peroxide solution.
6. Disinfectant solutions.
7. Containers for disinfection.
8. Towel.
2. Wash your hands.
3. Put on gloves.
4. Pour boiled water into the beaker,
5. Moisten cotton pads.
6. Tilt the patient's head to the opposite side.
7. Pull the auricle up and back with your left hand.
8. Remove the sulfur with a cotton turunda with rotational movements.
9. Treat the beaker and waste material in accordance with the requirements of the sanitary and epidemiological regime.
10. Wash your hands.
Evaluation of what has been achieved. The auricle is clean, the external auditory meatus is free.
Education of the patient or relatives. Advisory type of intervention in accordance with the above sequence of nurse actions.
Notes. If you have a small sulfuric plug, put a few drops of a 3% hydrogen peroxide solution into your ear as directed by your doctor. After a few minutes, remove the cork with a dry turunda. Do not use hard objects to remove wax from the ears.
WASHING HEAD
Purpose: Wash the head of the patient.
Indications:
1. Severe condition of the patient.
2. Impossibility of self-service.
Equipment:
1. Basin for water.
2. Special headrest.
3. Pitcher with warm water (37-38 degrees).
4. Water thermometer.
5. Toilet soap or shampoo.
6. Towel.
7. Oilcloth.
8. Comb with rare teeth.
Possible patient problems:
1. Negative attitude towards manipulation.
The sequence of actions of a nurse with ensuring the safety of the environment:
1. Inform the patient about the upcoming manipulation and its progress.
2. Raise the patient's head and upper body with the mattress.
3. Position the headrest.
4. Place an oilcloth under the patient's neck.
5. Tilt the patient's head back.
6. Substitute the pelvis at the head end of the bed.
7. Wet your hair with warm water.
8. Lather your hair well with soap or shampoo.
9. Rinse hair well with warm water and rinse by lathering twice.
10. Dry the patient's head with a towel.
11. Comb your hair with a sparse comb.
12. Put a dry scarf on your head.
13. Remove the basin, stand and oilcloth.
14. Lay the patient comfortably on the pillow.
15. Wash your hands.
Evaluation of the results achieved: The patient's head is washed:
Possible complications.
1. Head burn when using hot water.
2. Deterioration of the general condition of the patient.
Note: Comb long hair from the ends, and short hair from the root.
CARE OF EXTERNAL GENITAL ORGANS AND PERINEA Purpose: To wash the patient Indications: Lack of self-care. Contraindications: no Equipment: 1. Oilcloths 2. Vessel. 3. A jug of water (temperature 35 - 38 degrees Celsius). 4. Cotton swabs or wipes. 5. Forceps or tweezers. 6. Gloves. 7. Screen Possible problems of the patient: 1. Psycho-emotional. 2. The impossibility of self-care. The sequence of actions of the nurse with ensuring the safety of the environment: When washing men: 1. Inform the patient about the upcoming manipulation and the progress of its implementation. 2. Shield the patient. 3. Put on gloves. 4. Pull back the patient's foreskin to expose the glans penis. 5. Wipe the head of the penis with a cloth soaked in water. 6. Wipe the skin of the penis and scrotum, then dry it. 7. Remove gloves, wash your hands. 8. Remove the screen. When washing women: 1. Inform the patient about the upcoming manipulation and its progress. 2. Shield the patient with a screen. 3. Put on gloves. 4. Lay an oilcloth under the patient's pelvis and place a vessel on it. 5. Help the patient lie down on the vessel with her knees bent and slightly apart. 6. Stand on the side of the patient, holding a jug in your left hand, and a forceps with a napkin in your right, pour warm water (t 35-38 °) on the genitals, and with a napkin make movements from top to bottom from the pubis to the anus, change napkins after each movement from top to bottom. 7. Dry the genitals and perineal skin with a dry cloth. 8. Remove the vessel and oilcloth. 9. Cover the patient. 10. Treat the vessel in accordance with the requirements of the sanitary and epidemiological regime. 11. Remove gloves, wash your hands. 12. Remove the screen. Evaluation of the achieved results: The patient is washed. Education of the patient or his relatives. Advisory type of intervention in accordance with the above sequence of nurse actions. SUPPLY OF VESSEL AND URINE, APPLICATION OF BACKING CIRCLE
Purpose: To give the vessel, the urinal, the backing circle to the patient.
Indications:
1. Satisfaction of physiological needs.
2. Prevention of bedsores.
Contraindications: no.
Equipment:
1. Screen.
2. Vessel (rubber, enamelled).
3. Urine bag (rubber, glass).
4. Backing circle.
5. Oilcloth.
6. A jug of water.
7. Korntsang.
8. Cotton swabs.
9. Napkins, paper.
Possible patient problems:
1. Shyness of the patient, etc.
2. Determination of the degree of lack of self-care.
The sequence of actions of a nurse with ensuring the safety of the environment:
1. Inform the patient about the use - vessel and urinal.
2. Separate him with a screen from others.
3. Put on gloves.
4. Rinse the vessel with warm water, leaving some water in it.
5. Help the patient turn slightly to one side, with the legs slightly bent at the knees.
6. Bring the vessel under the patient's buttocks with your right hand, turn him on his back so that the perineum is above the opening of the vessel.
7. Give the man a urinal.
8. Remove gloves.
9. Cover the patient with a blanket and leave him alone.
10. Adjust the pillows so that the patient is in a semi-sitting position.
11. Put on gloves.
12. Remove the vessel with your right hand from under the patient, cover it.
13. Wipe the anal area with toilet paper.
14. Provide a clean vessel to the patient.
15. Wash the patient, dry the perineum, remove the vessel, oilcloth, help the patient lie down comfortably.
16. Remove the screen.
17. Pour the contents of the boat down the toilet.
18. Treat the vessel in accordance with the requirements of the sanitary and epidemiological regime.
19. Remove gloves, wash your hands.
Evaluation of achieved results:
1. Vessel and urinal are served.
2. The rubber circle is placed.
Education of the patient or his relatives. Advisory type of intervention in accordance with the above sequence of nurse actions.
FEEDING A SERIOUSLY ILL
Goal: Feed the patient.
Indications: Inability to eat independently.
Contraindications:
1. Inability to eat naturally.
2. They are detected during the examination by a doctor and a nurse.
3. High temperature
Equipment.
1. Food (semi-liquid, liquid t-400 C).
2. Dishes, spoons.
3. Drinker.
4. Bathrobe marked "For serving food."
5. Napkins, towels.
6. Container for washing hands.
7. A container of water.
Possible patient problems:
1. Lack of appetite.
2. Intolerance to certain foods.
3. Psychomotor agitation, etc.
4. Mental illness - anorexia.
1. Inform the patient about the upcoming meal,
2. Ventilate the room.
3. Wash your hands with soap.
4. Put on a bathrobe marked "For the distribution of food."
5. Place the patient in a comfortable position.
6. Wash the patient's hands.
7. Cover the patient's neck and chest with a tissue or towel.
8. Bring food to the room.
9. Feed the patient with a spoon in small portions, take your time.
10. Invite the patient to rinse their mouth and wash their hands after eating.
11. Shake the crumbs off the bed.
12. Remove dirty dishes.
13. Remove the gown marked "For serving food",
14. Wash your hands.
Evaluation of the achieved results: The patient is fed.
Education of the patient or his relatives. Advisory type of intervention in accordance with the above sequence of nurse actions.
SETTING CANS
Purpose: Put the banks.
Indications: Bronchitis, myositis.
Contraindications.
1. Diseases and damage to the skin at the places of cupping.
2. General depletion of the body.
3. High fever.
4. Motor excitation of the patient.
5. Pulmonary bleeding.
6. Children under 3 years old.
7. Pulmonary tuberculosis.
8. Neoplasms.
9. Others are identified during the examination by a doctor and nurse.
10. Increased skin sensitivity, increased capillary permeability.
Equipment.
1. Tray with 12-15 cans.
2. Vaseline.
3. Alcohol 96° - 70°.
4. Forceps with a cotton swab.
5. Matches.
6. Towel.
7. Napkins.
8. Spatula.
9. Vessel with water.
10. Clean cotton.
Possible patient problems:
1. Fear, anxiety.
2. Negative attitude towards intervention, etc.
The sequence of actions m/s with ensuring the safety of the environment:
1. Inform the patient about the upcoming manipulation and its progress.
2. Check the integrity of the edges of the cans
3. Wash your hands.
4. Place the tray with cans at the patient's bedside.
5. Release the necessary area of the body from clothing,
6. Lay the patient on his stomach, turn his head to the side, cover his hair with a towel.
7. Apply a thin layer of petroleum jelly to the place where the cans are placed and rub it.
8. Prepare the wick and moisten it with alcohol, squeeze out the excess alcohol on the edge of the vial.
9. Close and set aside the bottle of alcohol.
10. Light the wick.
11. Take 1-2 cans in your left hand, a burning wick in the other.
12. Insert a burning wick into the jar without touching the edges and bottom of the jar.
13. Remove the wick from the jar and quickly apply the jar to the skin.
14. Place the required number of jars at a distance of 1-2 cm from each other.
15. Dip the burning wick into a vessel of water.
16. Check the suction tightness of the cans by running your hand over them from top to bottom.
17. Cover the patient with a blanket.
18. Find out how the patient feels after 5 minutes and check the skin reaction (hyperemia)
19. Leave the jars for 10 - 15 minutes, taking into account the individual sensitivity of the patient's skin.
20. Remove the cans by placing your finger under the edge of the can, tilting it in the opposite direction.
21. Wipe the skin with a napkin at the place of canning.
22. Cover the patient and leave him in bed for at least 30 minutes.
23. Treat used cans in accordance with current SER regulations.
Evaluation of the achieved results: There are potential hemorrhages of a rounded shape in the cupping sites.
Education of the patient or his relatives. Advisory type of intervention in accordance with the above sequence of nurse actions.
Note:
1. Banks are placed on the chest in front and behind.
2. You can not put banks on the heart area, sternum, mammary glands, spine, shoulder blades, birthmarks.
3. In case of intensive hair growth, the hair is shaved before the intervention.
Possible complications. Skin burns, skin cuts.
STATEMENT OF LEECHES
Purpose: To put the patient with leeches for hemorrhage or injection of hirudin blood.
Contraindications:
1. Skin diseases.
2. Tendency to bleeding or treatment with anticoagulants.
3. Allergic reactions.
4. Anemia.
Equipment:
1. 6-8 mobile leeches.
2. Test tubes or beakers.
3. Sterile tray.
4. Sterile dressing.
5. Tweezers.
6. Pitcher with hot water (38°-50° C).
7. Cotton swabs.
8. Glucose 40%.
9. Gloves.
10. Alcohol 70%.
11. Towel.
12. Ammonia or sodium chloride solution.
13. Chloramine solution 3%.
14. Shaving machine.
15. Disinfection containers.
16. Hydrogen peroxide solution 3%.
Possible patient problems:
1. Negative attitude towards manipulation.
2. Fear.
3. Disgust for leeches.
The sequence of actions m/s with ensuring the safety of the environment:
1. Inform the patient about the upcoming manipulation and its progress.
2. Place the patient in a comfortable position.
3. Examine the skin at the site of the leeches:
* mastoid processes,
* region of the heart,
* area of the liver,
* coccyx area,
* anus area
* along the thrombosed vein (departing from it 1-2 cm).
4. Shave on the eve, if necessary, the hair at the site of the leeches.
5. Put on gloves.
6. Treat the skin with hot water and rub it until redness.
7. Moisten the place of setting the leeches with a solution of 40% glucose.
8. Grab the head end of the leech with tweezers and place it in a test tube or beaker with the tail end.
9. Bring and attach tightly the hole of the test tube or beaker to the desired area of skin.
10. Watch for wavy movements of the leech so that the leech sticks.
11. Replace the leech with another if it does not stick for a long time.
12. Place a tissue under the rear suction cup.
13. Remove the leech after 30 minutes by rubbing an alcohol swab over its back and place it in a container of sodium chloride.
14. Treat the wounds on the patient's skin with a 3% hydrogen peroxide solution.
15. Apply an aseptic cotton-gauze pressure bandage for 12-24 hours.
16. Remove gloves.
17. Treat used leeches, gloves, dressings in accordance with the requirements of the sanitary and epidemiological regime
18. Wash your hands.
Evaluation of the achieved results: Leeches were delivered.
IMPLEMENTATION OF OXYGEN THERAPY USING THE BOBROV APPARATUS AND OXYGEN PILLOW
Purpose: Give the patient oxygen.
Indications:
1. Hypoxia.
2. Appointment of a doctor.
3. Shortness of breath.
Oxygen delivery through a nasal catheter
Equipment:
1. Sterile nasal catheters.
2. Bobrov's apparatus.
3. Gloves.
4. Adhesive plaster.
5. Distilled water or furacillin (in Bobrov's apparatus).
6. Disinfectant solution and container.
Possible patient problems:
1. Reluctance to accept the procedure.
2. Fear.
The sequence of actions m/s with ensuring the safety of the environment:
1. Inform the patient about the upcoming manipulation and its progress.
2. Put on gloves, take a sterile catheter.
3. Determine the distance to which the catheter should be inserted, it is equal to the distance from the wing of the nose to the tragus of the auricle.
4. Fill Bobrov's apparatus with water or furacillin solution to 1/3 of the volume.
5. Connect the catheter to the Bobrov apparatus.
6. Insert the catheter through the inferior nasal passage to the posterior pharyngeal wall to the length determined above.
7. Make sure that the tip of the inserted catheter is visible when examining the pharynx.
8. Attach the catheter to the patient's cheek or nose with adhesive tape to prevent it from slipping out of the nose or into the esophagus.
9. Open the central supply dosimeter valve and supply oxygen at a rate of 2-3 L/min, monitoring the rate on the dosimeter scale.
10. Ask the patient if he is comfortable.
11. Remove the catheter at the end of the procedure.
12. Remove gloves.
13. Treat the catheter, gloves, equipment in accordance with the requirements of the sanitary and epidemiological regime.
Oxygen supply from an oxygen bag.
Contraindications: No.
Equipment:
1. Oxygen cushion.
2. Funnel (mouthpiece)
3. Gauze napkin.
4. Cotton wool.
5. Alcohol 70%.
6. Disinfectant solution.
The sequence of actions m/s with ensuring the safety of the environment:
1. Inform the patient about the upcoming manipulation and its progress.
2. Wash your hands.
3. Take an oxygen bag filled with oxygen.
4. Clean the funnel with alcohol.
5. Fold the gauze into 4 layers and moisten it with water.
6. Wrap the funnel with gauze and secure it.
7. Attach the funnel (mouthpiece) to the patient's mouth.
8. Open the oxygen bag valve.
9. Roll the pillow evenly from the corner opposite the funnel.
10. Treat the funnel at the end of the procedure in accordance with the requirements of the sanitary and epidemiological regime.
Evaluation of achieved results: The patient received oxygen. His condition has improved.
Education of the patient or his relatives. Advisory type of intervention in accordance with the above sequence of nurse actions.
Note. The introduction of oxygen using an oxygen cushion is not an effective method of oxygen therapy, but is still used in clinics where there is no centralized supply, at home, etc.
APPLICATION OF MUSTARD GARDENS
Purpose: Put mustard plasters.
Indications: Bronchitis, pneumonia, myositis.
Contraindications.
1. Diseases and damage to the skin in this area.
2. High fever.
3. Decrease or absence of skin sensitivity.
4. Intolerance to mustard.
5. Pulmonary bleeding.
6. Others are identified during the examination by a doctor and nurse.
Equipment:
1. Mustard plasters tested for suitability.
2. Kidney-shaped coxa.
3. Water thermometer.
4. Water 40 - 45 degrees Celsius,
5. Napkin
6. Towel.
7. Coarse calico or absorbent paper.
Possible patient problems:
1. Reduced skin sensitivity.
2. Negative attitude towards intervention.
3. Psychomotor agitation.
The sequence of actions m/s with ensuring the safety of the environment:
1. Inform the patient about the upcoming manipulation, the course of its implementation and the rules of conduct.
2. Take the required number of mustard plasters.
3. Pour water into the kidney tray (temperature 40 - 45 degrees Celsius).
4. Place the patient in a comfortable position and expose the desired area of the body.
5. Immerse the mustard plaster in water for 5 seconds with the mustard facing up.
6. Take it out of the water, shake it off a little.
7. Attach the mustard plaster tightly to the skin through absorbent paper or calico with the side covered with mustard.
8. Cover the patient with a towel and a blanket on top.
9. Find out the patient's sensations and the degree of hyperemia after 5 minutes.
10. Leave mustard plasters for 5 - 15 minutes, taking into account the individual sensitivity of the patient to mustard.
11. Remove mustard plasters.
12. Cover with a blanket and leave the patient in bed for at least 30 minutes.
Evaluation of the results achieved: There is reddening of the skin (hyperemia) in the places where mustard plasters were placed.
Education of the patient or his relatives. Advisory type of intervention in accordance with the above sequence of nurse actions.
Note. Places for setting mustard plasters:
1. On the chest in front and behind.
2. On the region of the heart with coronary artery disease.
3. On the back of the head, calf muscles.
You can not put mustard plasters on the spine, shoulder blades, birthmarks, mammary glands in women.
ICE PACK APPLICATION
Purpose: Place an ice pack on the desired area of the body.
Indications:
1. Bleeding.
2. Bruises in the first hours and days.
3. High fever.
4. With insect bites.
5. As directed by a doctor.
Contraindications: They are revealed during the examination by a doctor and a nurse.
Equipment:
1. Bubble for ice.
2. Pieces of ice.
3. Towel - 2 pcs.
4. Hammer for crushing ice.
5. Disinfectant solutions.
Safety precautions: Ice is not used as a single conglomerate in order to avoid hypothermia or frostbite.
Informing the patient about the upcoming intervention and the progress of its implementation. The nurse informs the patient about the need to put the ice pack in the right place, about the course and duration of the intervention.
Possible patient problems: Decreased or absent skin sensitivity, cold intolerance, etc.
The sequence of actions m/s with ensuring the safety of the environment:
1. Prepare ice cubes.
2. Place the bubble on a horizontal surface and expel the air.
3. Remove the lid from the bubble and fill the bubble with ice cubes to 1/2 volume and pour 1 glass of cold water 14°-16°.
4. Release the air.
5. Place the bubble on a horizontal surface and expel the air.
6. Screw on the ice pack cap.
7. Wipe off the ice pack with a towel.
8. Wrap the ice pack with a towel in 4 layers (the thickness of the pad is at least 2 cm).
9. Place an ice pack on the desired area of the body.
10. Leave the ice pack on for 20-30 minutes.
11. Remove the ice pack.
12. Take a break for 15-30 minutes.
13. Drain the water from the bubble and add ice cubes.
14. Place an ice pack (as indicated) on the desired area of the body for another 20-30 minutes.
15. Treat the bladder in accordance with the requirements of the sanitary and epidemiological regime.
16. Wash your hands.
17. Keep the bubble dry and open the lid.
Evaluation of the results achieved: The ice pack is placed on the desired area of the body.
Notes. If necessary, an ice pack is suspended above the patient at a distance of 2-3 cm.
HEATING HEATER APPLICATION
Purpose: Apply a rubber heating pad as indicated.
Indications.
1. Warming the patient.
2. As directed by a doctor.
Contraindications:
1. PAIN in the abdomen (acute inflammatory processes in the abdominal cavity).
2. The first day after the bruise.
3. Violation of the integrity of the skin at the site of application of the heating pad.
4. Bleeding.
5. Neoplasms.
6. Infected wounds.
7. Others are identified during the examination by a doctor and nurse.
Equipment:
1. Heating pad.
2. Hot water (temperature 60 - 80 degrees Celsius).
3. Towel.
4. Water thermometer.
Possible problems for the patient: Decrease or absence of skin sensitivity (edema).
The sequence of actions m/s with ensuring the safety of the environment:
1. Inform the patient about the upcoming manipulation and its progress.
2. Take the heating pad in your left hand by the narrow part of the neck.
3. Fill the heating pad with water t° - 60° to 2/3 of the volume.
4. Expel the air from the heating pad by squeezing it at the neck.
5. Screw on the plug.
6. Check for leaks by turning the heating pad upside down.
7. Wipe the heating pad and wrap it in a towel.
8. Apply a heating pad to the desired area of the body.
9. Find out after 5 minutes about the patient's feelings.
10. Stop the procedure after 20 minutes.
11. Examine the patient's skin.
12. Process the heating pad in accordance with the requirements of the sanitary and epidemiological regime.
13. Repeat the procedure after 15-20 minutes if necessary.
Evaluation of the achieved results. The patient notes positive sensations (subjectively). On the skin with which the heating pad came into contact, there is a slight reddening (objectively).
Education of the patient or his relatives. Advisory type of intervention in accordance with the above sequence of nurse actions.
Possible complications. Skin burn.
Note. Remember that the effect of using a heating pad depends not so much on the temperature of the heating pad, but on the duration of its exposure. In the absence of a standard heating pad, you can use a bottle filled with hot water.
APPLICATION OF A WARM COMPRESS
Target. Apply a warm compress.
Indications: As directed by a doctor.
Contraindications.
1. Diseases and damage to the skin.
2. High fever.
3. Bleeding.
4. Other contraindications are identified during the examination by a doctor and a nurse.
Equipment:
1. Napkin (linen in 4 layers or gauze in 6-8 layers).
2. Wax paper.
3. Gray cotton.
4. Bandage.
5. Kidney-shaped coxa.
6. Solutions: ethyl alcohol 40 - 45%, or water at room temperature 38-40 degrees, etc.
Possible patient problems: Negative attitude towards intervention, etc.
The sequence of actions m/s with ensuring the safety of the environment:
1. Inform the patient about the upcoming manipulation and its progress.
2. Wash your hands.
3. Fold the napkin so that its perimeter dimensions are 2 cm larger than the lesion.
4. Soak a washcloth in the solution and wring it out well.
5. Apply to the desired area of the body.
6. Place larger wax paper over the napkin (2 cm on all sides)
7. Place a layer of gray cotton on top of the paper, which completely covers the previous two layers.
8. Secure the compress with a bandage so that it fits snugly against the body, but does not restrict the patient's movements.
9. Ask the patient how they feel after 20 to 30 minutes.
10. Leave a compress (for 8-10 hours - water, for 4-6 hours - alcohol)
11. Remove the compress and apply a dry warm bandage (cotton, bandage).
Evaluation of the achieved results.
1. When removing the compress, the napkin is damp and warm; skin is hyperemic, warm
2. Improving the patient's well-being.
Education of the patient or his relatives. Advisory type in accordance with the above sequence of actions of a nurse.
Note. When applying a compress to the ear in a napkin and paper, make an incision in the middle for the auricle.
MEASUREMENT OF BODY TEMPERATURE IN THE ARMARM AND MOUTH OF THE PATIENT
Purpose: To measure the patient's body temperature and record the result in a temperature sheet.
Indications:
1. Observation of temperature indicators during the day.
2. When the patient's condition changes.
Contraindications: No.
Equipment.
1. Medical thermometers.
2. Temperature sheet.
3. Containers for storing clean thermometers with a layer of cotton on the bottom.
4. Tanks for disinfection of thermometers.
5. Disinfectant solutions
6. Clock.
7. Towel.
8. Gauze napkins.
Possible patient problems:
1. Negative attitude towards intervention.
2. Inflammatory processes in the armpit.
The sequence of actions m/s with ensuring the safety of the environment:
Measurement of body temperature in the armpit.
1. Inform the patient about the upcoming manipulation and its progress.
2. Take a clean thermometer, check its integrity
<35 градусов Цельсия.
4. Examine and wipe the patient's armpit area with a dry cloth.
5. Place the thermometer in the armpit and ask the patient to apply it with his hand.
6. Measure temperature for 10 minutes.
7. Remove the thermometer, determine the body temperature.
8. Record the temperature results first on the general temperature sheet and then on the temperature sheet of the medical history.
9. Process the thermometer in accordance with the requirements of the sanitary and epidemiological regime.
10. Wash your hands
11. Store thermometers dry in a clean thermometer container.
Measurement of body temperature in the oral cavity.
1. Inform the patient about the upcoming manipulation and its progress.
2. Take a clean medical thermometer, check its integrity.
3. Shake the thermometer to t<35 градусов Цельсия.
4. Place the thermometer under the patient's tongue for 5 minutes (the patient holds the body of the thermometer with his lips).
5. Remove the thermometer, determine the body temperature.
6. Register the results obtained first in the general temperature sheet, then in the temperature sheet of the medical history.
7. Process the thermometer in accordance with the requirements of the sanitary and epidemiological regime.
8. Wash your hands.
9. Store thermometers clean and dry in a special container for measuring the temperature in the mouth.
Evaluation of the achieved results. Body temperature is measured (in various ways) and recorded on temperature sheets.
Education of the patient or his relatives: Advisory type of intervention in accordance with the above sequence of actions of the nurse.
Note.
1. Do not take the temperature of sleeping patients.
2. The temperature is measured, as a rule, twice a day: in the morning on an empty stomach (from 7 to 9 o'clock) and in the evening (from 17 to 19). As prescribed by the doctor, the temperature can be measured every 2-3 hours.
SELECTION OF APPOINTMENTS FROM CASE HISTORY
Target. Select appointments from the medical history and record in the appropriate documentation.
Indications: Doctor's appointment.
Contraindications: No.
Equipment:
1. Medical history.
2. Sheets of appointments.
3. Sheets for the distribution of medicines.
4. Magazine for injections, intravenous infusions,
5. Journal of consultations.
The sequence of actions m/s with ensuring the safety of the environment:
1. Choose appointments from the medical history daily at a time convenient for the nurse, free from patient care, after completing the rounds of all patients by doctors and recording appointments in the medical history.
2. Select appointments for the procedural nurse and write them down in the injection log.
3. Choose a separate appointment for consultations, research and enter them in the appropriate journals.
4. Make sure you understand your notes when handing over the watch.
Evaluation of the achieved results. Prescriptions are selected from the medical history and transcribed into the appropriate documentation.
LAYOUT AND DISTRIBUTION OF MEDICINES
FOR ENTERAL USE
Target. Prepare medicines for distribution and reception by patients.
Indications: Doctor's appointment.
Contraindications. They are identified during the examination of the patient by a nurse.
Equipment:
1. Appointment sheets.
2. Medicines for internal use.
3. Mobile table for the layout of medicines.
4. Beakers, pipettes (separately for each bottle with drops).
5. Container with boiled water.
6. Scissors.
7. Disinfectant solutions.
8. Capacity for disinfection.
9. Towel.
Possible patient problems:
1. Unreasonable refusal.
2. Vomiting.
3. Allergy.
4. Unconscious state.
The sequence of actions m / s with ensuring the safety of the environment.
When administering drugs by mouth:
1. Wash your hands and dry them dry.
2. Read the prescription sheets carefully.
3. Read carefully the name of the drug and dosage on the package, check it with the prescription sheet.
4. Pay attention to the expiration date of the medicinal product.
5. Arrange the prescribed medicines into cells for each patient at one time.
6. Do not leave medicines on the bedside tables at the patient's bedside (with the exception of nitroglycerin or validol).
7. Inform the patient about the medicines prescribed to him, about the rules for taking them and about possible side effects.
8. Make sure that the patient takes the prescribed medications in your presence.
9. Process used beakers and pipettes in accordance with the requirements of the sanitary and epidemiological regime.
Evaluation of the achieved results: Medicines are laid out in accordance with prescription lists and their timely intake by patients is ensured.
Education of the patient or his relatives: Advisory type of intervention in accordance with the above sequence of actions of the nurse.
Notes.
1. You can not replace the drug with another without the consent of the doctor.
2. Do not store medicines without labels.
3. Before taking the powder by the patient, dilute it first with water.
4. Give aqueous solutions (potions, decoctions, infusions) from a spoon (1 tablespoon - 15 g, 1 dl - 10 g, 1 tsp - 5 g) or a beaker.
5. Any repackaging of medicines is prohibited.
USE OF MEDICINES BY INHALATION METHOD THROUGH THE MOUTH AND NOSE
Purpose: To teach the patient the technique of inhalation using an inhalation balloon.
Indications: Bronchial asthma (to improve bronchial patency).
Contraindications: Detected during the examination of the patient.
Equipment:
1. Inhaler with a medicinal substance.
2. Inhaler without medicinal substance.
Possible patient problems:
1. Fear before using an inhaler or drug.
2. Decrease in intellectual abilities, etc.
3. Difficulty inhaling when the drug is administered through the mouth.
The sequence of actions m/s with ensuring the safety of the environment:
1. Inform the patient about the use of the inhaler.
2. Inform the patient about the drug.
3. Check the name and expiration date of the medicinal substance.
4. Wash your hands.
5. Demonstrate the procedure to the patient using an inhalation balloon without drugs.
6. Seat the patient.
7. Remove the protective cap from the mouthpiece of the can.
8. Turn the aerosol can upside down.
9. Shake the can
10. Take a deep breath.
11. Take the mouthpiece of the can in your mouth, tightly clasping it with your lips.
12. Take a deep breath through your mouth and at the same time press down on the bottom of the can.
13. Hold your breath for 5-10 seconds.
14. Remove the mouthpiece from your mouth.
15. Breathe out calmly.
16. Disinfect the mouthpiece.
17. Invite the patient to independently perform the procedure with an inhaler filled with a medicinal substance.
18. Close the inhaler with a protective cap.
19. Wash your hands.
Evaluation of the results achieved: The patient correctly demonstrated the technique of inhalation using an inhalation balloon.
Note: The number of inhalations is determined by the doctor. If the patient's condition allows, then it is better to do this procedure while standing, since the respiratory excursion is more effective.
INTRODUCTION OF DRUGS THROUGH THE RECTAL
Purpose: The introduction of liquid medicines into the rectum.
Indications. By doctor's prescription.
Contraindications. No.
Equipment.
1. Packaging of the suppository.
2. Screen.
3. Gloves.
4. Capacity for disinfection.
5. Disinfectants.
6. Towel.
7. Oilcloths.
Possible patient problems:
1. Psychological.
2. The impossibility of self-care.
The sequence of actions m/s with ensuring the safety of the environment:
1. Inform the patient about the upcoming manipulation and its progress.
2. Remove the suppository package from the refrigerator,
3. Read the name and expiration date.
4. Fence off the patient with a screen (if he is not alone in the ward).
5. Place an oilcloth under the patient.
6. Lay the patient on the left side with legs bent at the knees,
7. Put on gloves.
8. Open the shell in which the suppository is packed without removing the suppository from the shell.
9. Ask the patient to relax, spread the buttocks with one hand, and insert the suppository into the anus with the other (the sheath will remain in your hand).
10. Invite the patient to take a comfortable position for him.
11. Remove gloves.
12. Treat them in accordance with the requirements of the sanitary and epidemiological regime.
13. Remove the screen.
14. Wash your hands.
Evaluation of the achieved results: Suppositories are introduced into the rectum.
Education of the patient or his relatives: Advisory type of intervention in accordance with the above sequence of actions of the nurse.
ASSEMBLY OF THE SYRINGE FROM THE STERILE TRAY AND THE STERILE TABLE, FROM THE KRAFT PACKAGE
Objective: Collect the syringe.
Indications. The need to administer a medicinal substance to a patient as prescribed by a doctor,
Equipment.
1. Sterile tray, table, kraft bag.
2. Sterile bix.
3. Tweezers, tray.
4. Sterile container with disinfectant solution for sterile tweezers.
5. Sterile bottle with 70 degree alcohol (AHD or other antiseptics).
6. Sterile syringes and needles.
7. Sterile tweezers.
The sequence of actions m/s with ensuring the safety of the environment:
1. Treat your hands.
2. Check the tag on the bix.
3. Put the date of opening the bix and signature, open the bix, check the indicator.
4. Take a calico package with tweezers from the bix.
5. Remove 1 tweezer from the calico package and place it in a sterile tray.
6. Remove the calico package with syringes and needles from the bix.
7. Check the tag on the package.
8. Open the outer packaging with your hands.
9. Take sterile tweezers in your right hand and open the inner package.
10. Remove the syringe barrel from the package.
11. Transfer it to your left hand, holding the middle of the cylinder.
12. Take the syringe plunger by the handle with tweezers with your right hand
13. Using tweezers, insert the plunger into the syringe barrel.
14. Take the needle by the cannula with your right hand with tweezers.
15. Put the needle with tweezers on the under-needle cone of the syringe, without touching the tip of the needle with your hands.
16. Place the tweezers in a container with a disinfectant solution.
17. Rub the cannula of the needle to the under-needle cone of the syringe with the fingers of your right hand.
18. Check the patency of the needle.
19. Place the finished syringe on the inside of the calico packaging or sterile tray.
20. The syringe is ready to draw the medication.
Evaluation of the achieved results. The syringe is assembled.
SET OF MEDICINES FROM AMPOULES AND VIALS
Purpose: To collect medicinal substance.
Indication: The need to administer a medicinal substance to the patient as prescribed by the doctor,
Contraindications: No.
Equipment:
1. Ampoules or vials with a medicinal substance.
2. Sterile syringe and needle.
3. Sterile tweezers,
4. Sterile bix with balls and napkins.
5. 70-degree alcohol.
6. Nail file.
7. Sterile tray.
A set of medicinal substance from an ampoule.
1. Prepare the right medicine.
2. Check the expiration date of the medicine and its dosage on the package, paying attention to the method of administration.
3. Pay attention to the transparency and color of the medicine.
4. Shake the ampoule lightly so that all the solution is in its wide part.
5. Take sterile tweezers in your right hand.
6. Remove the ball from the sterile bix with sterile tweezers, moisten it with 70 degree alcohol.
7. Treat the narrow part of the ampoule with a ball of alcohol.
8. Place the narrow part of the ampoule on the pad of the index finger of the left hand on the ball.
9. Take a nail file and file the narrow part of the ampoule.
10. Break off the tip of the ampoule with a ball and throw it into the tray,
11. Place the opened ampoule on the table.
12. Take the prepared syringe in your right hand, holding the needle sleeve with the 2nd finger, the cylinder with the 1st, 3rd and 4th fingers, the piston with the 5th.
13. Take the prepared ampoule in your left hand between the 2nd and 3rd fingers ("fork"),
14. Carefully insert the needle into the ampoule.
15. Hold the cylinder with the first and fifth fingers of the left hand, and the needle sleeve with the 4th.
16. Grasp the handle of the syringe with the 1st, 2nd, 3rd fingers of your right hand.
17. Pull the piston towards you.
18. Take the correct amount of medicine.
19. Put the ampoule on the table.
20. Change the needle to the correct needle for this injection.
21. Rub the needle to the cone with the fingers of your right hand.
22. Take the syringe in your left hand, holding the needle cannula with your 2nd finger, the cylinder with your 3rd and 4th fingers, and the plunger with your 5th.
23. Turn the syringe vertically upwards and remove air from it while holding the cannula of the needle.
24. Place the syringe on a sterile tray and cover it with a sterile napkin, or leave the syringe on the sterile part of the inner calico packaging and cover it with a sterile part.
Evaluation of the results achieved: The prescribed medicinal substance was drawn into a syringe,
ANTIBIOTIC DILUTION
Goal: Dilute antibiotics.
Indications: As directed by a doctor.
Contraindications: Individual intolerance.
Equipment:
1. The syringes are sterile.
2. Sterile needles for intramuscular injections and for a set of medicinal substances.
3. Sodium chloride solution 0.9%, sterile.
4. Balls are sterile.
5. Alcohol 70%.
6. Vials with antibiotics.
7. Tray for dumping.
8. Nail files.
9. Tweezers are not sterile (or scissors).
10. Sterile tweezers.
11. Towel.
The sequence of actions m/s with ensuring the safety of the environment:
1. Wash your hands and treat with a ball of alcohol.
2. Take the antibiotic vial.
3. Read the inscription on the bottle (name, dose, expiration date).
4. Open the aluminum cover in the center with non-sterile tweezers.
5. Rub the rubber stopper with a ball of alcohol.
6. Take an ampoule with a solvent of 0.9% sodium chloride solution, read the name again.
7. Treat the ampoule with a ball of alcohol.
8. File and open the solvent ampoule.
9. Draw the correct amount of solvent into the syringe at the rate of 1 ml (0.5 ml) of solvent for every 100,000 units. antibiotic.
10. Take the vial and inject the collected solvent into it.
11. Disconnect the syringe, leave the needle in the vial.
12. Shake the vial with the needle until the antibiotic is completely dissolved.
13. Put the needle with the vial on the needle cone of the syringe.
14. Lift the vial upside down and draw the contents of the vial or part of it into the syringe.
15. Remove the vial with the needle from the needle cone of the syringe.
16. Put on and secure the needle for intramuscular injection on the needle cone of the syringe.
17. Check the patency of this needle by passing a little solution through the needle.
Evaluation of the achieved results: Antibiotics are diluted.
Education of the patient or his relatives: Advisory type of intervention in accordance with the above sequence of actions of the nurse.
Similar information.
INDICATIONS: For hygienic purposes.
Patient preparation: Explain the essence of the procedure.
Nurse training: Dressed in uniform, gloves.
Patient position: Sitting or lying on your side.
EQUIPMENT.
Tray, sterile cotton swabs, sterile pipettes, warm water (3% hydrogen peroxide solution)
ALGORITHM.
2. Drop 2-3 drops of a 3% hydrogen peroxide solution warmed up to body temperature into the ear canal.
3. Remove sulfur accumulating in the passage with cotton turundas, making circular movements (it is advisable to tilt the patient's head in the opposite direction).
4. The toilet is held with several cotton turundas until the turunda is clean.
5. Wash your hands.
Washing the ear canal
INDICATIONS. Sulfur plug (as prescribed by a doctor).
Patient preparation: Explain the essence of the procedure.
Nurse training: Dressed in uniform, gloves.
EQUIPMENT.
Sterile: a tray, cotton turundas, gauze wipes, a pipette, Janet's syringe; 3% hydrogen peroxide solution and furacillin solution (warm the solutions to body temperature), oilcloth, tray for used material.
ALGORITHM.
1. Pull the auricle back and up, tilting the patient's head in the opposite direction.
2. Drop 2-3 drops of 3% hydrogen peroxide into the ear canal for 2 minutes.
3. Draw furacillin, heated to body temperature, into Janet's syringe.
4. Lay an oilcloth on the patient's shoulder, let him hold the kidney-shaped tray.
5. With Janet's syringe, pressing the piston, rinse the ear canal to clean water.
6. Dry the ear canal with cotton turundas with rotational movements.
7. Wash your hands.
b) Instillation of drops in the ear
INDICATIONS. Inflammation of the middle ear (as prescribed by a doctor).
EQUIPMENT.
Tray, pipette, medicine, prescription sheet.
Nurse training: Dressed in uniform.
Patient preparation: Explain the essence of the procedure.
Patient position: Lying on your side or sitting.
ALGORITHM.
1. Check that the name of the drops matches the doctor's prescription.
2. Warm up the drug to a body temperature of 37 ° C.
3. Dial the required number of drops.
4. Tilt the patient's head in the opposite direction, and pull the auricle back and up.
5. Drop 2-3 drops of the drug into the external auditory canal.
6. After instillation of drops, the patient should remain in a position with his head tilted for 1-2 minutes.
ADDITIONAL INFORMATION:
1. Cold drops irritate the labyrinth and can cause dizziness, vomiting, orthostatic shock.
2. Washing the external auditory canal should be carried out strictly according to the doctor's prescription.
3. Used medical instruments are processed according to order 197.
PROFESSIOGRAM № 35
NOSE CARE
(toilet of the nasal cavity, washing, instillation of drops)
I. JUSTIFICATION.
Compliance with the rules of personal hygiene is one of the most important places in the complex of measures for patient care. The need for care of the nasal cavity arises in the presence of secretions with the formation of crusts on the mucous membrane of the nasal cavity. This manipulation is carried out in order to improve the process of breathing through the nasal cavity.
Nasal toilet
INDICATIONS. Discharge of mucus, crusts in the nose.
Nurse training: Dressed in uniform, gloves.
Patient preparation: Explain the essence of the procedure.
Patient position: lying or sitting.
EQUIPMENT. Tray, cotton turundas, vaseline oil.
ALGORITHM.
1. Ask the patient to tilt their head back slightly.
2. With cotton swirls, gently remove mucus from the nasal passages with rotational movements.
3. Crusts can be removed from the nasal passages with cotton swabs moistened with oil and left in the nasal passages for 2-3 minutes.
4. Remove gloves, wash your hands.
Washing the nasal cavity
INDICATIONS. Inflammatory processes in the nasal cavity
doctor's prescription).
Nurse training. Dressed in uniform, gloves.
Patient preparation. Explain the essence of the procedure.
Patient position: sitting.
EQUIPMENT: Tray, rubber bulb, furacillin solution 1:5000, prescription sheet.
ALGORITHM.
1. Warm the furacillin solution to body temperature (37-38 o C).
2. Ask the patient to take a deep breath in and out and hold the breath for a few seconds.
3. Spray the spray solution into the nasal cavity (if it is not available, inject a small amount of liquid with a rubber bulb).
4. The poured liquid is poured into the mouth and collected in a tray that the patient holds in his hands.
5. After the end of the procedure, the patient should blow his nose, alternately pinching one half of the nose, then the other.
6. Wash your hands.
7. Record the procedure in the Medical Record.
Instillation of drops in the nose
INDICATIONS. Inflammatory diseases of the nasal cavity (as prescribed by a doctor).
Nurse training: Dressed in uniform, clean hands.
Patient preparation: Explain the essence of the procedure.
Patient position: Lying or sitting with head thrown back.
EQUIPMENT: Sterile pipette, cotton turundas, medicine, prescription sheet.
ALGORITHM.
1. Check that the name of the drops matches the doctor's prescriptions.
2. Cleanse the nasal passages with cotton turundas.
3. Draw the required number of drops into the pipette.
4. Lift the tip of the patient's nose.
5. Ask the patient to tilt their head towards the instillation.
6. Drop 3-4 drops into the lower nasal passage (ask the patient to press the nostril).
7. Repeat the procedure for the other nostril.
8. Wash your hands.
9. Make a record of the performed procedure in the "Medical record".
ADDITIONAL INFORMATION.
Warn the patient that they may taste or smell the drops.
PROFESSIOGRAM № 36
CARRYING OUT THE TOILET OF THE SERIOUSLY ILL
(hair washing, nail trimming, foot washing)
Washing head
INDICATIONS. For hygienic purposes, in the absence of independent skills and limitation of physical activity.
Nurse training: Dressed in uniform, gloves.
Patient preparation: Explain the essence of the procedure.
Patient position: Lying.
EQUIPMENT. Shampoo, soap, warm water 10 l, basin, towel,
oilcloth, gloves.
ALGORITHM.
1. Raise the head end of the functional bed so that the patient's head hangs over the edge of the functional bed.
2. Place an oilcloth or diaper under the patient's shoulders and neck.
3. Wash your hair with warm water and shampoo over the basin; lather your hair well and wipe the skin under the hair.
4. Rinse your hair with water and dry with a towel.
5. Comb your hair well from the roots.
6. After washing the head, in order to avoid hypothermia, put on a scarf or towel on the patient's head.
Nail care
INDICATIONS.
activity.
Nurse training. Dressed in uniform, gloves.
Patient preparation. Explain the essence of the procedure.
Patient position: Lying.
EQUIPMENT. Water container, soap, hand cream, scissors, nail file, tray, towel.
ALGORITHM.
1. Add a little liquid or ordinary soap to a container of warm water, dip the patient's hand for 2-3 minutes.
2. Alternately removing your fingers from the water and, wiping them, carefully trim your nails, leaving 1-2 mm from the outer edge of the nail plate, file your nails, rinse the brush, wipe dry.
3. Process the second brush.
4. Place the patient's foot in a container with warm water and soap for 3-5 minutes, treat the nail plates in the same way as on the hands. Rinse the foot, wipe dry.
5. Treat the second foot.
6. Do not cut your toenails too short as this may damage the skin. Always cut your nails straight across.
foot washing
INDICATIONS. Lack of independent skills and motor
activity.
Nurse training: Dressed in uniform, gloves.
Patient preparation: Explain the essence of the procedure.
Patient position: Lying.
EQUIPMENT. Basin, soap, towel.
ALGORITHM.
1. Add a little liquid or ordinary soap to a basin of warm water and lower the patient's foot for 2-3 minutes.
2. Wash the lower leg, foot, interdigital spaces.
3. Dry your feet with a towel, especially between the toes.
4. Wash the second foot in the same way.
ADDITIONAL INFORMATION.
Hair is washed 1 time in 6-7 days; legs - 2-3 times a week; nails are trimmed as needed, at least once a month.
PROFESSIOGRAM № 37
Ambulance. A guide for paramedics and nurses Vertkin Arkady Lvovich
1.12. Cleansing the external auditory canal
goal
Clean the patient's ears.
Indications
Impossibility of self-service.
Contraindications
Possible Complications
When using hard objects, damage to the eardrum or external auditory canal.
Equipment
1. Cotton turundas.
2. Pipette.
3. Beaker.
4. Boiled water.
5. 3% hydrogen peroxide solution.
6. Disinfectant solutions.
7. Containers for disinfection.
8. Towel.
Possible Patient Problems
Negative attitude towards intervention, etc.
Sequence of actions m / s to ensure safety
1. Inform the patient about the upcoming manipulation and its progress.
2. Wash your hands.
3. Put on gloves.
4. Pour boiled water into a beaker.
5. Moisten cotton pads.
6. Tilt the patient's head to the opposite side.
7. Pull the auricle up and back with your left hand.
8. Remove the sulfur with a cotton turunda with rotational movements.
9. Treat the beaker and waste material in accordance with the requirements of the sanitary and epidemiological regime.
10. Wash your hands.
Evaluation of results
The auricle is clean, the external auditory meatus is free.
Notes
If you have a small sulfuric plug, put a few drops of a 3% hydrogen peroxide solution into your ear as directed by your doctor. After a few minutes, remove the cork with a dry turunda. Do not use hard objects to remove wax from the ears.
Patient or family education
Advisory type of intervention in accordance with the above sequence of nurse actions.
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From the book The Newest Book of Facts. Volume 1. Astronomy and astrophysics. Geography and other earth sciences. Biology and medicine author Kondrashov Anatoly Pavlovich From the book The Complete Guide to Nursing author Khramova Elena Yurievna the author Drozdova M V From the book ENT diseases: lecture notes the author Drozdova M V From the book ENT diseases: lecture notes the author Drozdova M V From the book ENT diseases: lecture notes the author Drozdova M V From the book Beauty for those who are over ... Big Encyclopedia author Krasheninnikova D. From the book Home Guide of the most important tips for your health author Agapkin Sergey NikolaevichOuter ear infection An infection can develop in the outer and middle ear. An outer ear infection (sometimes called swimmer's ear) is an inflammation of the outer ear canal, the part of the ear that runs from the eardrum to the outer ear.
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Purpose: Clean the patient's ears
Indications: Impossibility of self-service.
Contraindications: No.
Possible complications: When using hard objects, damage to the eardrum or external auditory canal.
Equipment:
1. Cotton turundas.
2. Pipette.
3. Beaker.
4. Boiled water.
5. 3% hydrogen peroxide solution.
6. Disinfectant solutions.
7. Containers for disinfection.
8. Towel.
Possible patient problems: Negative attitude towards intervention, etc.
The sequence of actions of a nurse with ensuring the safety of the environment:
1. Inform the patient about the upcoming manipulation and its progress.
2. Wash your hands.
3. Put on gloves.
4. Pour boiled water into the beaker,
5. Moisten cotton pads.
6. Tilt the patient's head to the opposite side.
7. Pull the auricle up and back with your left hand.
8. Remove the sulfur with a cotton turunda with rotational movements.
9. Treat the beaker and waste material in accordance with the requirements of the sanitary and epidemiological regime.
10. Wash your hands.
Evaluation of what has been achieved. The auricle is clean, the external auditory meatus is free.
Education of the patient or relatives. Advisory type of intervention in accordance with the above sequence of nurse actions.
Notes. If you have a small sulfuric plug, put a few drops of a 3% hydrogen peroxide solution into your ear as directed by your doctor. After a few minutes, remove the cork with a dry turunda. Do not use hard objects to remove wax from the ears.
End of work -
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Algorithms for manipulations on the basics of nursing
Algorithms for manipulations on the basics of nursing.
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All topics in this section:
Height measurement
Purpose: To measure the patient's height and record it on the temperature sheet. Indications: The need for a study of physical development and as prescribed by a doctor. Contraindications
Determination of body weight
Purpose: To measure the patient's weight and record it on the temperature sheet. Indications: The need for a study of physical development and as prescribed by a doctor. Contrapoka
Respiratory rate counting
Purpose: Calculate the NPV in 1 minute. Indications: 1. Assessment of the physical condition of the patient. 2. Diseases of the respiratory system. 3. Appointment of a doctor, etc.
Pulse study
Purpose: To examine the patient's pulse and record the readings in the temperature sheet. Indication: 1. Assessment of the state of the cardiovascular system. 2. Appointment
Blood pressure measurement
Purpose: To measure blood pressure with a tonometer on the brachial artery. Indications: All patients and healthy to assess the state of the cardiovascular system (for prophylactic
Hand treatment before and after any manipulation
Purpose: To ensure the infectious safety of the patient and medical staff, the prevention of nosocomial infection. Indications: 1. Before and after the manipulation.
Preparation of washing and disinfecting solutions of different concentrations
Purpose: Prepare a 10% bleach solution. Indications. For disinfection. Contraindications: Allergic reaction to chlorine-containing preparations. Equipment:
Carrying out wet cleaning of the hospital premises with the use of disinfectant solutions
Purpose: To carry out a general cleaning of the treatment room. Indications: According to the schedule (once a week). Contraindications: No. Equipment:
Inspection and implementation of sanitization in case of detection of pediculosis
Purpose: To examine the hairy parts of the patient's body and, if pediculosis is detected, to carry out sanitization. Indications: Prevention of nosocomial infection. prot
Implementation of full or partial sanitization of the patient
Purpose: To carry out full or partial sanitization of the patient. Indications: As directed by a doctor. Contraindications: Severe condition of the patient, etc. O
Registration of the title page of the "medical record" of an inpatient
Objective: To collect information about the patient and prepare the title page of the educational and inpatient medical history. Indications: To register a newly admitted patient to the hospital.
Transportation of the patient to the medical department
Purpose: Safely transport the patient depending on the condition: on a stretcher, wheelchair, on his hands, on foot, accompanied by a health worker. Indications: State of the patient
Making the bed for the patient
Goal: Prepare the bed. Indications: The need to prepare a bed for the patient. Contraindications: No. Equipment: 1. Bed.
Change of bed and underwear
Purpose: Change bed and underwear for the patient. Indications: After sanitization of the patient and in seriously ill patients as it gets dirty. Contraindications: No
Carrying out measures to prevent bedsores
Purpose: To prevent the formation of bedsores. Indications: Risk of pressure sores. Contraindications: No. Equipment: 1. Gloves. 2. Far
Oral, nose and eye care
1. Oral care. Purpose: To treat the patient's oral cavity. Indications: 1. Severe condition of the patient. 2. The impossibility of self-care. Etc
Washing head
Purpose: Wash the head of the patient. Indications: 1. Severe condition of the patient. 2. Impossibility of self-service. Contraindications: Detected in the process
Care of the external genitalia and perineum
Purpose: To wash the patient Indications: Lack of self-care. Contraindications: no Equipment: 1. Oilcloths 2. Vessel. 3. A jug of water (t
Submission of the vessel and the urinal, the use of a lining circle
Purpose: To give the vessel, the urinal, the backing circle to the patient. Indications: 1. Satisfaction of physiological needs. 2. Prevention of bedsores.
Artificial feeding of the patient through a gastrostomy
Goal: Feed the patient. Indications: Obstruction of the alimentary and cardia of the stomach. Contraindications: Pyloric stenosis. Equipment. 1. In
Feeding a seriously ill patient
Goal: Feed the patient. Indications: Inability to eat independently. Contraindications: 1. Inability to eat naturally.
Canning
Purpose: Put the banks. Indications: Bronchitis, myositis. Contraindications. 1. Diseases and damage to the skin at the places of cupping. 2. General exhaustion
Setting up leeches
Purpose: To put the patient with leeches for hemorrhage or injection of hirudin blood. Indications: As directed by a doctor. Contraindications: 1. Skin diseases.
Implementation of oxygen therapy using the Bobrov apparatus and an oxygen cushion
Purpose: Give the patient oxygen. Indications: 1. Hypoxia. 2. Appointment of a doctor. 3. Shortness of breath. Oxygen delivery through a nasal catheter
The use of mustard plasters
Purpose: Put mustard plasters. Indications: Bronchitis, pneumonia, myositis. Contraindications. 1. Diseases and damage to the skin in this area. 2. High
Applying an ice pack
Purpose: Place an ice pack on the desired area of the body. Indications: 1. Bleeding. 2. Bruises in the first hours and days. 3. High fever.
Heating pad application
Purpose: Apply a rubber heating pad as indicated. Indications. 1. Warming the patient. 2. As directed by a doctor. Contraindications: 1. PAIN in the
Applying a warm compress
Target. Apply a warm compress. Indications: As directed by a doctor. Contraindications. 1. Diseases and damage to the skin. 2. High fever.
Measurement of body temperature in the armpit and oral cavity of the patient
Purpose: To measure the patient's body temperature and record the result in a temperature sheet. Indications: 1. Observation of temperature indicators during the day.
Selection of appointments from the medical history
Target. Select appointments from the medical history and record in the appropriate documentation. Indications: Doctor's appointment. Contraindications: No. Equipment:
Layout and distribution of medicines for enteral use
Target. Prepare medicines for distribution and reception by patients. Indications: Doctor's appointment. Contraindications. Detected during the examination of the patient
The use of drugs by inhalation through the mouth and nose
Purpose: To teach the patient the technique of inhalation using an inhalation balloon. Indications: Bronchial asthma (to improve bronchial patency). Contraindications:
Assembling a syringe from a sterile tray and a sterile table, from a kraft bag
Objective: Collect the syringe. Indications. The need to administer a medicinal substance to the patient as prescribed by the doctor, Equipment. 1. Sterile tray, table, craft
A set of medicines from ampoules and vials
Purpose: To collect medicinal substance. Indication: The need to administer a medicinal substance to the patient as prescribed by the doctor, Contraindications: None. Equipping
Breeding antibiotics
Goal: Dilute antibiotics. Indications: As directed by a doctor. Contraindications: Individual intolerance. Equipment: 1. Sterile syringes.
Performing intradermal injections
Purpose: To introduce intradermally medicinal substance. Indications: As directed by a doctor. Contraindications: Revealed during the examination. Equipment:
Performing subcutaneous injections
Purpose: Inject the drug subcutaneously. Indication: As prescribed by a doctor. Contraindication: Individual intolerance to the administered medicinal substance.
Performing intramuscular injections
Purpose: To administer the drug intramuscularly. Indications: As prescribed by the doctor, in accordance with the list of appointments. Contraindications. Detected during maintenance
Performing intravenous injections
Purpose: Inject a drug into a vein using a syringe. Indications: The need for a rapid action of the drug, the inability to use another route of administration for this
Installing a gas tube
Purpose: To remove gases from the intestines. Indications: 1. Flatulence. 2. Atony of the intestine after surgery on the gastrointestinal tract. Contraindications. Bleeding. Main
Setting up a cleansing enema
Purpose: To clear the lower part of the large intestine from feces and gases. Indications: 1. Stool retention. 2. Poisoning. 3. Preparation for radiologists
Setting a siphon enema
Target. Rinse the intestines. Indications. The need for bowel lavage: 1. In case of poisoning; 2. As directed by a doctor; 3. Preparation for ki surgery
Setting a hypertonic enema
Purpose: To deliver a hypertonic enema and cleanse the intestines from feces. Indications: 1. Constipation associated with intestinal atony. 2. Constipation with general edema
Setting up an oil enema
Purpose: Enter 100-200 ml of vegetable oil 37-38 degrees Celsius, after 8-12 hours - the presence of a chair. Indications: Constipation. Contraindications: Detected during the examination
Setting microclysters
Purpose: To introduce a medicinal substance 50-100 ml of local action. Indications: Diseases of the lower part of the colon. Contraindications: Detected during the examination
Catheterization of the bladder with a soft catheter in women
Purpose: To remove urine from the patient's bladder using a soft rubber catheter. Indications: 1. Acute urinary retention. 2. As directed by a doctor.
Colostomy care
Purpose: To care for the colostomy. Indications: The presence of a colostomy. Contraindications: No. Equipment: 1. Dressing material (napkins, gauze,
Caring for patients with a tracheostomy tube
Objective: To care for the tracheostomy tube and the skin around the stoma. Indications: Presence of a tracheostomy tube. Contraindications: No. Equipment: 1. Percha
Preparing the patient for endoscopic methods of studying the digestive system
Purpose: To prepare the patient for examination of the mucous membrane of the esophagus, stomach, duodenum 12. Indications: As directed by a doctor. Contraindications: 1. Stomach
Preparation of the patient for X-ray and endoscopic methods of examination of the urinary system
Preparation for intravenous urography. Purpose: To prepare the patient for the study. Indications: Doctor's appointment. Contraindications: 1. Intolerance to iodine preparations
Taking blood from a vein for research
Purpose: To puncture a vein and take blood for examination. Indications: As directed by a doctor. Contraindications: 1. Excitation of the patient. 2. Seizures
Taking a smear from the throat and nose for bacteriological examination
Purpose: To take the contents of the nose and throat for bacteriological examination. Indications: Doctor's appointment. Contraindications: No. Equipment: 1. Steril
Taking urine for general analysis
Purpose: Collect the morning portion of urine in a clean and dry jar in the amount of 150-200 ml. Indications: As directed by a doctor. Contraindications: No. Equipment:
Registration of directions for various types of laboratory research
Objective: Correct direction. Indications: Doctor's appointment. Equipment: Forms, labels. Sequence of actions: On the referral form to the laboratory
Urine sampling according to Nechiporenko
Purpose: Collect urine from a medium portion in a clean, dry jar in an amount of at least 10 ml. Indications: As directed by a doctor. Contraindications: No. Equipment: 1. Bank
Taking urine for a sample according to Zimnitsky
Goal: Collect 8 portions of urine during the day. Indications: Determination of the concentration and excretory function of the kidneys. Contraindications: Detected during the examination
Taking urine for sugar, acetone
Purpose: To collect urine per day for testing for sugar. Indications: As directed by a doctor. Contraindications. No. Equipment: 1. Clean dry container
Collection of urine for daily diuresis and determination of water balance
Purpose: 1. Collect urine excreted by the patient per day in a three-liter jar. 2. Keep a sheet of daily records of diuresis. Indications: Edema. Contraindication
Taking sputum for general clinical analysis
Purpose: Collect sputum in the amount of 3-5 ml in a clean glass dish. Indications: In diseases of the respiratory system. Contraindications: Determined by the doctor.
Taking sputum bacteriological examination
Purpose: Collect 3-5 ml of sputum in a sterile container and deliver to the laboratory within an hour. Indications: Doctor's appointment. Contraindications: Detected during the examination of the patient
Stool collection for scatological examination
Purpose: Collect 5-10 g of feces for scatological examination. Indications: Diseases of the gastrointestinal tract. Contraindications: No. Equipment:
Taking feces for protozoa and helminth eggs
Purpose: Collect 25-50 g of feces for protozoa and helminth eggs in a dry glass jar. Indications: Diseases of the gastrointestinal tract. Contraindications: No.
Taking urine for bacteriological examination
Purpose: Collect urine in a sterile container in an amount of at least 10 ml in compliance with aseptic rules. Indications: 1. Diseases of the kidneys and urinary tract.
Taking feces for bacteriological examination
Purpose: Collect 1-3 g of feces in a sterile tube. Indications: Infectious diseases of the gastrointestinal tract. Contraindications: Detected during the examination
Transportation of blood to the laboratory and laying on the form No. 50
Purpose: To ensure the delivery of blood to the laboratory. Indications: As directed by a doctor. Contraindications: No. Equipment: For transporting blood: 1. Ko
Helping a patient with vomiting
manipulation nurse patient Purpose: To help the patient with vomiting. Indications: Patient vomiting. Contraindications: No. Equipment: 1. Capacity
Conducting a study of the secretory function of the stomach with parenteral irritants
Purpose: Collect gastric juice for research in 8 clean jars. Indications: Diseases of the stomach - gastritis, peptic ulcer. Contraindications: Detected in
Carrying out duodenal sounding
Purpose: Obtaining 3 servings of bile for research. Indications: Diseases: gallbladder, bile ducts, pancreas, duodenum. Proti
Preparing the body of the deceased for transfer to the pathology department
Purpose: Prepare the body of the deceased for transfer to the pathoanatomical department. Indications: Biological death ascertained by a doctor and registered in a hospital card
Drawing up a portioner
Purpose: To make a portioner. Indications: Providing meals to patients in the hospital. Contraindications: No. Equipment: 1. Appointment sheets.
Accounting and storage of poisonous, narcotic, potent medicinal substances
Purpose: Storage of medicinal substances of group "A" in a safe and keeping strict records. Indications. The presence of poisonous, narcotic, potent L.V. in the department. Contra
Collection of information
Purpose: To collect information about the patient. Indications: The need to collect information about the patient. Contraindications: No. Equipment: Teaching Nursing History b
Patient education in sublingual drug administration
Purpose: To teach the patient the technique of taking sublingual medicines. Indications: Heart attack. Contraindications: No. Equipment:
Rules for working with a sterile bix and tray
Purpose: Prepare a sterile injection tray. Indications: Necessity to work in sterile conditions. Contraindications: No. Equipment: 1. St
Preparing for ultrasound
Purpose: To prepare the patient for the study. Indications: Doctor's appointment. Contraindications: Acute skin lesions over the examined organ, bruises, etc.
Use of a spittoon
Purpose: To teach the patient how to use the spittoon. Indications: Presence of sputum. Contraindications: No. Equipment: 1. Spittoon jar made of dark