The role of the nurse in physical rehabilitation. The role of the nurse in the rehabilitation of patients with diseases of the cardiovascular system. Muscular and ligamentous-articular apparatus

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COURSE WORK

Nursing process in the rehabilitation of patients

Student: Akopyan Angela Vladimirovna

Specialty: nursing

Group: 363

Supervisor

Gobedzhishvili Elena Alexandrovna

Stavropol 2014

Introduction

1. Main part

1.1 Rehabilitation of patients with stroke

1.1.1 Etiology, pathogenesis of stroke

1.1.2 Stages of determining a rehabilitation program

1.1.3 Types of rehabilitation programs and conditions of implementation

1.1.4 Types of rehabilitation

1.2 Nursing process

2. Practical part

Literature

stroke vascular nursing rehabilitation

INconducting

The relevance of research.

Rehabilitation of patients who have suffered stroke is an important medical and social problem. This is determined by the frequency of vascular lesions of the brain and its complications. More than 450 thousand strokes are registered annually in Russia; the incidence of stroke in the Russian Federation is 2.5 - 3 cases per 1000 population per year.

Currently, stroke is considered a clinical syndrome of acute vascular damage to the brain. It is the outcome of various pathological lesions of the circulatory system: blood vessels, heart, blood. The ratio of hemorrhagic and ischemic strokes is 1: 4 - 1: 5.

A stroke often leaves behind severe consequences in the form of motor, speech and other disorders, significantly disabling patients, reducing the quality of life of the patients themselves and their immediate relatives. Spontaneous recovery of impaired functions can be supplemented and accelerated by rehabilitation measures.

A modern integrated approach to organizing rehabilitation care for patients who have suffered acute cerebrovascular accident (ACVA) allows up to 60% of post-stroke patients of working age to return to work or another type of active social activity (compared to 20% of patients who have not undergone a system of rehabilitation measures)

Despite positive results in assessing the quality and effectiveness of rehabilitation treatment for patients who have suffered a stroke and organizing the rehabilitation of such a contingent, the existing system does not meet all the needs for it, which requires improvement of organizational forms and methods of work.

The educational and professional level of both primary care nurses and nurses of specialized neurological departments meets modern requirements for the level of training of nursing specialists. The conditions for staged rehabilitation of post-stroke patients help expand the role of nurses, determine the main directions of activities that help improve the patient’s health-related quality of life. All this justifies the need to search for mechanisms that should not be based on intuition, but on purposeful and systematic work, combined with scientific justification, designed to meet the needs and solve the patient’s problems, as well as changing the role of the nurse, taking into account its more rational use, full functioning in modern conditions.

In accordance with the above, a working hypothesis that the use of modern technologies for organizing nursing care in the rehabilitation of patients who have suffered stroke contributes to the rapid restoration of functional independence of patients, improves the quality and efficiency of nursing care.

Goal of the work:

· generalization and systematization of the results of the study of the problem contained in the scientific literature;

· identification of controversial theoretical issues within the framework of the problem under study and argumentation of one’s own approach;

· acquiring skills in processing factual material, presenting it in the form of tables, diagrams, graphs and their analysis.

To achieve this goal, the following tasks were solved:

Carry out therapeutic and diagnostic interventions, interacting with participants in the treatment process (PC2.2.);

Collaborating with interacting organizations and services (PC2.3.);

Use medications in accordance with the rules for their use (PC 2.4.);

Comply with the rules for the use of equipment, equipment and medical products during the diagnostic and treatment process (PC2.5.);

Carry out rehabilitation processes (PC2.7.).

1. Main part

1.1 Rehabilitation of patients with stroke

1.1.1 Etiology, pathogenesis of stroke

Stroke is an acute cerebrovascular accident.

It is an acute deficit in brain function caused by non-traumatic brain injury. Due to damage to cerebral blood vessels, a disorder of consciousness and/or motor, speech, and cognitive impairment occurs. Incidence of cerebral stroke in different countries varies from 0.2 to 3 cases per 1000 population; In Russia, over 300,000 strokes are diagnosed annually. According to world statistics, there is a gradual rejuvenation of patients with cerebral stroke.

Rehabilitation of patients after acute circulatory disorders is aimed at restoring functionality nervous system or compensation for a neurological defect, social, professional and domestic rehabilitation. The duration of the rehabilitation process depends on the severity of the stroke, the extent of the affected area and the topic of the affected area. It is important to begin measures aimed at rehabilitating the patient in the acute period of the disease. They must be carried out gradually, systematically and over a long period of time. When restoring impaired functions, three levels of recovery are distinguished.

The first level is the highest, when the impaired function returns to its original state, this is the level of true recovery. True rehabilitation is possible only when there is no complete death of nerve cells, and the pathological focus consists mainly of inactivated elements. This is a consequence of edema and hypoxia, changes in the conductivity of nerve impulses, and diaschisis.

The second level of recovery is compensation. The concept of “compensation” includes an ability developed during the development of a living organism, which allows, in the event of a dysfunction caused by the pathology of any of its links, this function of the affected structures is assumed by other systems that were not destroyed by the action of a traumatic factor. The main mechanism for compensating functions during stroke is functional restructuring and the inclusion of new structures in the functional system. It should be noted that on the basis of compensatory restructuring it is rarely possible to achieve full recovery functions.

The third level of recovery is readaptation (adjustment). It is observed when the pathological focus that led to the development of the defect is so large that there is no possibility of compensation for the impaired function. An example of readaptation to a long-term severe motor defect can be the use of various devices in the form of canes, wheelchairs, prostheses, and walkers.

In the recovery period after a stroke, it is currently customary to distinguish several periods: early recovery, lasting the first 6 months; the late recovery period includes a period of time from six months to 1 year; and the residual period, after a year. In the early period of rehabilitation, in turn, two periods are distinguished. These periods include a period of up to three months, when the restoration of range of motion and strength in the affected limbs generally begins and the formation of a post-stroke cyst is nearing completion, and from 3 months to six months, when the process of restoration of lost motor skills continues. Rehabilitation of speech skills, mental and social rehabilitation occupy more long time. The basic principles of rehabilitation are identified, which include: early start of rehabilitation measures; systematicity and duration. This is possible with a well-organized, step-by-step construction of the rehabilitation process, complexity and multi-discipline, i.e., the inclusion in the rehabilitation process of specialists in various fields (neurologists, therapists, in some cases urologists, ziologists or neuropsychologists, massage therapists, speech therapists-aphaphysiotherapists, kinesiotherapy (therapeutic physical education), aphasiologists-acupuncturists, occupational therapists, psychologists, social workers, biofeedback specialists); adequacy of rehabilitation measures; The most important principle of rehabilitation of patients after a stroke is the participation of the patient himself, his loved ones and relatives in the process. Effective planning and implementation of restoration programs requires the joint, coordinated efforts of various specialists. In addition to a rehabilitation physician, a specialist in the field of rehabilitation of patients who have suffered a stroke, such a team includes specially trained nurses, physical therapists, a vocational rehabilitation doctor, a psychologist, a speech therapist and a social worker. Moreover, the composition of the team of health workers may vary depending on the severity of the disorders and their type.

1.1.2 Stages of determining a rehabilitation program

1. carrying out rehabilitation expert diagnostics. A thorough examination of the sick or disabled person and the determination of his rehabilitation diagnosis serve as the basis on which the subsequent rehabilitation program is built. The examination includes collecting complaints and medical history of patients, conducting clinical and instrumental studies. A special feature of this examination is the analysis of not only the degree of damage to organs or systems, but also the impact of physical defects on the patient’s life activity and on the level of his functional capabilities.

2. determination of the rehabilitation prognosis - the estimated probability of realizing the rehabilitation potential as a result of treatment.

3. identification of measures, technical means of rehabilitation and services that allow the patient to restore impaired or compensate for lost abilities to perform everyday, social or professional activities.

1.1.3 Types of rehabilitation programs and conditions of implementation

1. stationary program. Carried out in special rehabilitation departments. It is indicated for patients who require constant monitoring by medical professionals. These programs are usually more effective than others, since in the hospital the patient is provided with all types of rehabilitation.

2. day hospital. The organization of rehabilitation in a day hospital comes down to the fact that the patient lives at home and is in the clinic only for the duration of treatment and rehabilitation measures.

3. outpatient program. It is carried out in rehabilitation therapy departments at clinics. The patient is in the clinic department only during rehabilitation activities, for example, massage or exercise therapy.

4. Home program. When implementing this program, the patient takes all treatment and rehabilitation procedures at home. This program has its advantages, as the patient learns the necessary skills and abilities in a familiar home environment.

5. Rehabilitation centers. In them, patients participate in rehabilitation programs and take the necessary medical procedures. Rehabilitation specialists provide the patient and his family members with the necessary information, give advice regarding the choice of a rehabilitation program and the possibility of its implementation in various conditions.

Rehabilitation treatment should begin when the patient is still in bed. Correct position, turns in bed, regular passive movements in the joints of the limbs, breathing exercises will allow the patient to avoid complications such as muscle weakness, muscle atrophy, bedsores, pneumonia, etc. The patient should always maintain physical activity, as it strengthens the patient, and inaction weakens it.

1.1.4 Types of rehabilitation

1. Medical rehabilitation : according to the definition of the WHO expert committee, this is an active process, the goal of which is to achieve complete restoration of functions impaired due to disease or injury, or, if this is unrealistic, the optimal realization of the physical, mental and social potential of a disabled person, his most adequate integration into society

- Physical methods of rehabilitation (electrotherapy, electrical stimulation, laser therapy, barotherapy, balneotherapy);

Mechanical methods of rehabilitation (mechanotherapy, kinesiotherapy);

Non-traditional methods of treatment (herbal medicine, manual therapy, occupational therapy)

Psychotherapy;

Speech therapy assistance;

Technical means of rehabilitation;

2. social rehabilitation arising as a result of damage and disruption of life, restrictions and obstacles to performing social role, considered normal for a given individual.

Social and everyday adaptation:

Social and environmental rehabilitation:

Of course, all these consequences of the disease are interconnected: damage causes disruption of life, which, in turn, leads to social restrictions and a violation of the quality of life. The relationship between the disease and its consequences can be schematically represented as follows:

1.2 Nursing process

The nursing process is the systematic identification of patient and nurse situations and emerging problems in order to implement a plan of care that is acceptable to both parties.

The goal of the nursing process is to maintain and restore the patient's independence in meeting the basic needs of the body.

Achieving the goal of the nursing process is carried out by solving the following tasks:

Creation of a patient information database;

Determining the patient's need for nursing care;

Identification of nursing service priorities;

Providing nursing care;

Assessing the effectiveness of the care process.

The first stage of the nursing process is nursing examination

A nursing examination includes an assessment of the patient's condition, collection and analysis of subjective and objective data on the state of his health.

Having collected the necessary information about the state of health, the nurse should:

1. Gain an understanding of the patient before care begins.

Determine the patient's ability to self-care.

Establish effective communication with the patient.

Discuss care needs and expected outcomes with the patient.

Complete the documentation.

Evaluation of objective data physical condition patient:

Physical data: height, body weight, edema (localization);

Facial expression: painful, puffy, without features, suffering, wary, calm, indifferent, etc.;

Consciousness: conscious, unconscious, clear;

Position in bed: active, passive, forced;

Musculoskeletal system: deformation of the skeleton, joints, muscle atrophy, muscle tone (preserved, increased, decreased);

Respiratory system: frequency breathing movements, characteristics of breathing, type of breathing (thoracic, abdominal, mixed), rhythm (rhythmic, arrhythmic), depth (superficial, deep), tachypnea (rapid, superficial, rhythmic), bradypnea (reduced, rhythmic, deep), normal (16 -18 respiratory movements in 1 minute, superficial, rhythmic);

Blood pressure: in both arms, hypotension, hypertension, normotension;

Pulse: number of beats per minute, bradycardia, tachycardia, arrhythmia, normal (pulse 60-80 beats per minute);

Ability to move: independently, with the help of others.

Evaluation of objective data psychological state patient:

Changes in the emotional sphere: fear, anxiety, apathy, euphoria;

Psychological tension: dissatisfaction with oneself, shame, impatience, depression.

The nurse receives subjective data about the patient’s health during a conversation. These data depend on the patient's emotions and feelings. Information can be provided by relatives, friends, colleagues and health workers if the patient is unconscious, disoriented or the patient is a child.

The quality of the examination performed and the information obtained determines the success of subsequent stages of the nursing process.

The second stage of the nursing process isidentification of nursing problems

Nursing diagnosis-- this is a description of the patient's health status (current and potential), established as a result of a nursing examination and requiring intervention from the nurse.

Nursing diagnosis is aimed at identifying the body's reactions in connection with the disease, can often change depending on the body's response to the disease, and is associated with the patient's ideas about the state of his health.

Nursing diagnoses are associated with disruption of processes:

Movements (decreased motor activity, loss of coordination, etc.);

Breathing (difficulty breathing, productive and non-productive cough, suffocation);

Blood circulation (edema, arrhythmia, etc.);

Nutrition (nutrition significantly exceeding the body’s needs, deterioration of nutrition, etc.);

Behaviors (refusal to take medications, social isolation, suicide, etc.);

Perceptions and sensations (hearing impairment, visual impairment, taste impairment, pain, etc.);

Attention (voluntary, involuntary, etc.);

Memory (hypomnesia, amnesia, hypermnesia, etc.);

In the emotional and sensitive areas (fear, anxiety, apathy, euphoria, negative attitude towards health workers providing assistance and the quality of the manipulations performed, etc.);

Changes in hygienic needs (lack of hygienic knowledge, skills, etc.).

The main methods of nursing diagnosis are observation and conversation. Particular attention in nursing diagnostics is paid to establishing psychological contact and determining the primary psychological diagnosis.

The nurse observes, while talking with the patient, the presence or absence of psychological tension and notes:

Changes in the emotional sphere, the influence of emotions on behavior, mood, state of the body.

When conducting a psychological conversation, one should adhere to the principle of respecting the patient’s personality, guarantee the confidentiality of the information received, and listen patiently to the patient.

After formulating all nursing diagnoses, the nurse establishes their priority, based on the patient's opinion about the priority of providing him with care.

The third stage of the nursing process is planning the goals and scope of nursing care

Setting goals of care is necessary to:

Personal nursing care definitions;

Determining the degree of effectiveness of care.

The patient actively participates in the planning process, the nurse motivates the goals, convincing the patient of the need to achieve them, and together with him determines ways to achieve these goals.

Achieving each goal includes 3 components:

Execution (verb, action).

Criteria (date, time, distance).

Condition (with the help of someone or something).

For example: the patient will perform full range of motion at the elbow joint with the unaffected arm on the tenth day.

The fourth stage of the nursing process --implementation of the nursing care plan

Requirements for implementing the plan

1. Systematic implementation of the nursing care plan.

Coordination of planned actions.

Involving the patient and his family in the process of care.

Recording of care provided.

Providing pre-hospital care according to the standards of nursing practice, taking into account the individual characteristics of the patient.

Accounting for the failure of planned care in the event of a change in circumstances.

Implementation of a nursing care plan in exercise therapy through the use of exercise therapy tools with complex psychophysical training, in various therapeutic options, in different modes of physical activity.

The fifth stage of the nursing process --assessing the effectiveness of planned care

The purpose of summative assessment is to determine the outcome of nursing care. Assessment is ongoing until the patient is discharged.

The nurse collects and analyzes information, draws conclusions about the patient’s response to care, the possibility of implementing the care plan, and new problems.

Key aspects of the assessment:

Achieving the goal, determining the quality of care;

Patient response to quality of care;

Searching for and assessing new problems and patient care needs.

If the goals are achieved and the problem is solved, the nurse notes this in the plan about achieving the goal for this problem, puts a date and signature.

If the goal of the nursing process for this problem is not achieved and the patient continues to need care, it is necessary to re-evaluate, determine the cause of the deterioration or the moment of change in the patient's health status.

It is important to involve the patient in identifying the reasons that prevented the achievement of the goal.

Documentation of the nursing process

The need to document the nursing process is to move from an intuitive approach to patient care to a thoughtful approach designed to meet the patient's care needs.

The role of the nurse:

Fulfilling medical prescriptions

Dynamic monitoring of the patient's condition:

Mind control

Functional assessment of the patient's condition

Meeting the patient's nutritional and fluid needs:

Adequate nutrition

Adequate fluid intake

Minimizing physical distress:

Correction of breathing disorders

Thermoregulation control

Hemodynamic maintenance

Minimizing emotional distress

Correction of mental disorders

Reduced risk of secondary complications

Deep vein thrombosis of the lower extremities

Bedsores

Pain and swelling in paralyzed limbs.

Correction of breathing disorders.

Ensuring airway patency by preventing obstruction is a priority in patients with stroke:

In a coma

When vomiting.

The main causes of airway obstruction:

Recession of the tongue root

Aspiration of vomit

Participation of the cough reflex and accumulation of sputum in the tracheobronchial tree.

Prevention of airway obstruction:

Removal of removable dentures

Regular sanitation of the oropharynx

Patient position control

Changing body position

Passive breathing exercises

Adequate nutrition of the patient .

The feeding method depends on the degree of depression of consciousness and the preservation of the swallowing reflex. The diet is expanded with dairy and plant foods containing fiber. The patient eats first in bed (high Fowler position and a special table), as the motor mode expands while sitting at the table. The maximum number of actions should be performed by the patient himself for early restoration of everyday skills.

Thermoregulation control

To maintain thermoregulation function, the following care requirements must be observed:

The air temperature in the room should be within 18°-20°C

It is necessary to ventilate the room

It is unacceptable to use feather beds and thick blankets on the patient’s bed.

Correction of mental disorders

Any mental disorders are accompanied by impairments of memory, attention, emotional instability, loss of control over mental activity. Psycho-emotional disorders can significantly impair the motivation and adequacy of the patient’s behavior, thereby significantly complicating the rehabilitation process. The nurse should:

Explain the nature of the violations to relatives

In agreement with the doctor, limit the patient’s communication in case of severe emotional lability and fatigue

If necessary, repeat instructions multiple times and answer patient questions.

Involve people who evoke positive emotions in treatment and rehabilitation

Don't rush the patient

If cognitive functions are impaired, remind the patient about time, place, significant persons

Motivate the patient to get better.

Pain and swelling in paralyzed limbs. Pain and swelling in paralyzed limbs are treated:

Complete elimination of hanging limbs

Application of pneumatic compression or bandaging with special bandages

Maintaining a sufficient range of passive movements

Periodically giving paralyzed limbs an elevated position.

Prevention of deep vein thrombosis. Deep vein thrombosis of the lower extremities and associated pulmonary embolism are serious problem care for stroke. Patients with stroke most often belong to the group high risk, which makes thrombosis prevention mandatory. In bedridden patients, the speed of blood flow through the vessels slows down, which contributes to increased blood clotting and the development of thrombosis of the leg veins. Most often this occurs in a paralyzed limb.

The nurse should:

Bandage the sore leg with an elastic bandage if the patient has varicose veins

Carry out manual massage (stroking and kneading) from the foot to the thigh

Give a forced position in bed (lying on your back, raise your legs 30°-40° using pillows and bolsters).

Prevention of bedsores. Bedsores are one of the most common problems encountered during the rehabilitation treatment of neurological patients. The occurrence of bedsores is usually accompanied by complications such as pain, depression, and infections. We are talking about damage to soft tissues as a result of improper care: prolonged compression of soft tissues and their injuries during various movements of the patient.

If an immobilized patient is in the same position for a long time (lying in bed, sitting in a wheelchair), then in the soft tissues that are compressed between the surface of the support and the bony protrusions, blood and lymph circulation deteriorates, and the nervous tissue is injured. This leads to dystrophic and later necrotic changes in the skin, subcutaneous fat and even muscles.

The formation of bedsores is promoted by a damp, untidy bed with folds and crumbs.

Frequently shifting the patient to different positions in bed will help avoid the formation of bedsores in the patient. These movements are carried out taking into account the rules of body biomechanics every 2 hours.

To give the patient a comfortable, physiological position, the following are needed: a functional bed, an anti-bedsore mattress, and special devices. Special devices include: a sufficient number of pillows of a suitable size, bolsters from sheets, diapers and blankets, special foot rests that prevent plantar flexion.

The role of the nurse restoration of motor skills :

Classes with patients according to the instructions of a physical therapy methodologist in the evenings and weekends

Treatment by position

Step biomechanics

Dosed walking

Role nurse for restoration of speech, reading and writing skills

Classes with patients as directed by a speech therapist

Pronunciation of sounds and syllables

Speech gymnastics

The role of the nurse in restoring self-care skills

Assess the level of functional dependence

Discuss with your doctor the scope of physical activity and self-care

Provide the patient with devices that facilitate self-care

Fill the deficit with your own actions within reasonable limits without causing embarrassment and helplessness

Organize an occupational therapy complex with the patient’s daily activities (home rehabilitation stand, children’s toys of various levels)

Monitor the patient's condition, avoiding the development of fatigue

Conduct individual conversations with the patient

The role of the nurse in reducing the risk of injury

Organize the environment

Provide additional support

Provide mobility aids

The role of the nurse in dealing with confusion

Patient information

Reminder of recent events

Accompanying the patient to places of treatment and food.

Role nurse for shoulder pain

Training the patient’s relatives in gentle moving techniques and rules for handling a paretic arm

Using Positioning

The role of the nurse prevention of recurrent stroke

Using a protocol on arterial hypertension when working with a patient

Patient involvement in the School of Hypertension

2. Practical part

On October 3, 2014, patient Z., 67 years old, was admitted to the neurological department of the State Budgetary Healthcare Institution SK "SMP" with a repeated diagnosis of "CPNM" Dyscirculatory encephalopathy. She complained of high blood pressure, headaches, dizziness, tinnitus, memory impairment, poor coordination, and unsteady gait.

From the medical history: it began in the afternoon, when headaches, dizziness and increased blood pressure appeared.

From the life history: For 3 years he has been suffering from chronic cerebral circulatory insufficiency, there is no heredity.

1. NURSING EXAMINATION.

Consciousness is clear. Body temperature 36.6? C, pulse 80 beats per minute, blood pressure 150/90 mmHg. Art., respiratory rate 20 per minute, cranial nerve without features, decrease in strength in the left extremities to 3 points, superficial sensitivity

2. IDENTIFYING PATIENT PROBLEMS.

Present problems: Headache, ataxia, dizziness, movement disorders, bad mood, sleep disturbance.

Priority problems: Dizziness, headache, ataxia.

Potential problems: Risk of injury.

Goal: Reduce headaches, alleviate the patient’s condition, increase range of motion.

3. PLANNING PHASE

We carry out injury prevention (use a wheelchair or cane when moving); conversations about the need to adhere to diet and nutrition, work and rest schedules, and taking medications. Preparing the patient for injections.

4. IMPLEMENTATION PHASE OF THE NURSING CARE PLAN.

Ensure night peace, eliminate noise, bright light. Food should be well processed, low-fat.

Convince the patient of the need to systematically take medications to lower blood pressure. (clonidine, capoten)

To strengthen and restore coordination of movement, exercise therapy and gymnastics are indicated. Do it 2-3 times a day for 10-15 minutes.

Limit daily fluid intake to 1 liter. Explain to the patient the need for such a regimen.

Peace. Bed rest, prescribe medications: Aeron, Dedakon.

We monitor compliance with medications and diet.

We conduct professionalilaktikainjuries(use a wheelchair or cane when moving);

We have conversations about the need to follow a diet and nutrition regimen, and take medications.

Preparation patient for injections.

Carry out control ensuring that the patient takes medications in a timely manner (as prescribed by the doctor).

Sleep disturbance: ventilate the room before going to bed, give sleeping pills as prescribed by the doctor

Mental disorders accompanied by memory impairment, attention, emotional instability

The nurse should: explain the nature of the violations to relatives; in agreement with the doctor, limit the patient’s communication with severe emotional lability and fatigue; if necessary, repeat instructions many times and answer patient questions; involve persons who evoke positive emotions in rehabilitation.

conclusions

1. The introduction of the nursing process into the rehabilitation of patients who have suffered a stroke is currently a necessary condition for the provision of professional care for patients, because improves the quality of nursing care and has a real impact on the patient’s health-related quality of life.

2. This model of nursing care determines the nature of nursing care in the format of medical rehabilitation, the goal of which is pathophysiological improvement and improvement of functional abilities, social and everyday activity.

3. The main problems of patients who have suffered a stroke and with whom the nursing staff of the neurorehabilitation department work are: violation of the process of undressing, putting on trousers, putting on a shirt, putting on shoes and socks, violation of hygiene skills (washing the face, combing one’s hair, brushing teeth), and the inability independently carry out the process of moving around the ward, within the department and climbing the stairs; on the part of the psycho-emotional state - reluctance to act, obsessive thoughts and fears, feelings of anxiety.

4. The implementation of modern nursing care technologies makes it possible to increase the satisfaction of participants in the rehabilitation process (nursing staff - patient - medical staff) and make it more effective.

5. Expanding the scope of activity within the professional competence of nurses in neurorehabilitation, in a multi-level system of medical care - contributes to the effectiveness of medical care social rehabilitation.

6. The model of nursing care, centered on the individual and his needs, on the family and society, provides nurses with a wide range of roles and functions to work not only with sick patients, but also with their relatives.

Literature

1. S.V. Prokopenko, E.M. Arakchaa, et al., “Algorithm for the rehabilitation of patients who have suffered a stroke,” Educational and methodological manual.: Krasnoyarsk, 2008 - 40 pages.

2. Rehabilitation science: guidelines for extracurricular work for 3-4 year students in specialty 060109 - nursing/comp. J.E. Turchina, T.R. Kamaeva-Krasnoyarsk: KrasSMU printing house, 2009.-134 pp.

3. Fundamentals of early rehabilitation of patients with acute cerebrovascular accident: Educational and methodological manual on neurology for students of medical universities / ed. ed. IN AND. Skvortsova.- M.: Litterra, 2006.-104 p.

4. Ibatov A.D., Pushkina S.V. - Fundamentals of rehabilitation: Textbook. - M.:GEOTAR-Media, 2007.-160 p.

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Phases of rehabilitation.

In accordance with WHO recommendations, the rehabilitation process is divided into three phases: hospital (inpatient), recovery and maintenance. Within each of these phases, the tasks of each type of rehabilitation are solved to one degree or another.

Hospital (inpatient) phase of rehabilitation. The goal of this phase of rehabilitation is to restore the patient’s physical and psychological condition so that he is prepared to carry out the second phase of rehabilitation in a sanatorium or, if there are contraindications, at home. The tasks of the hospital phase of rehabilitation, implemented in the conditions of a cardiological or therapeutic, or other hospital department, are solved within the framework of each type of rehabilitation.

Sanatorium (second) phase rehabilitation . Upon completion of the hospital phase of rehabilitation, the patient is prepared to complete the recovery phase program, which is usually carried out in rehabilitation centers. This phase of rehabilitation is essentially the boundary between the period when a person is in sick status and his return to the family, to active work, to life’s troubles and difficulties.

The main goal of this phase of rehabilitation is to prepare the patient for an active life - returning to the family, for a rational restructuring of the lifestyle, changing some habits, for the systematic implementation of preventive measures, including secondary prevention. The tasks of physical, mental and other aspects of rehabilitation are solved in this phase at a new level compared to the hospital stage.

Maintenance (third) phase of rehabilitation. Upon completion of the recovery phase, the patient enters the third phase of rehabilitation, the purpose of which is to maintain the level of physical performance achieved in the sanatorium with some increase in some patients, and to complete the psychological rehabilitation of the patient already in the conditions of the resumption of his social life.

A possible factor ensuring the effectiveness of rehabilitation as a whole is the implementation of the principle of continuity between phases, which is achieved by entering complete information about the clinical, physical and psychological status of the patient at each stage of rehabilitation into a staged epicrisis.

The leader in the rehabilitation of therapeutic patients is physical therapy (physical therapy).

Features of the physical therapy method:

impact on a person by physical exercise;

the patient himself actively participates in the process of his treatment and rehabilitation.

Physical education means used in exercise therapy:

physical exercise;

motor modes;

natural factors;
occupational therapy.

Classification physical exercise:

a) gymnastics: general developmental and respiratory, active and passive, without apparatus and on apparatus;

b) applied sports: walking, running, throwing balls, grenades, etc., jumping, swimming, rowing, skiing, skating, etc.;

c) sedentary, active and sports games. Of the latter, in the practice of physical therapy, mainly in sanatoriums, they use towns, volleyball, tennis, and elements of basketball.

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State autonomous professional

educational institution

Republic of Bashkortostan

"Belebeevsky Medical College"

Graduate work

THE ROLE OF THE NURSE IN THE REHABILITATION OF PATIENTS WITH CHRONIC BRONCHITIS

Gataullina Aliya Damirovna

Belebey, 201__

Introduction

Chronic bronchitis is one of the most important health problems, making a significant contribution to the growth of temporary disability, increasing cases of disability and premature mortality (Chuchalin A.G. 2010). In the structure of the prevalence of respiratory diseases, chronic bronchitis occupies a leading position, accounting for more than 55% of the pathology of the respiratory system (Shmelev E.I., 2009). In the last decade, chronic bronchitis has been identified as a separate nosological form, which has the appropriate stages, and new approaches to the interpretation of the disease, methods of its diagnosis and prevention have been formed.

The development of chronic bronchitis is associated with the action of exogenous and endogenous risk factors. Exogenous factors include smoking, occupational pollutants of inorganic and organic nature, environmental and climatic factors, low socio-economic level, some forms of respiratory infection; among endogenous ones are congenital deficiency of alpha-1-antitrypsin, bronchial hyperreactivity, prematurity of the fetus at birth.

Bronchopulmonary diseases are one of the main causes of morbidity and mortality in the population. Since the 60s. In the 20th century, the number of people suffering from chronic nonspecific respiratory diseases, and primarily chronic bronchitis and bronchial asthma, began to increase. A number of authors note that the dynamics of morbidity, disability and mortality of the population due to chronic nonspecific lung diseases (CNLD) has become alarming, doubling every five years.

According to WHO experts, chronic bronchitis is a disease that is accompanied by a cough with sputum production for at least three months a year for two years, provided there are no other respiratory diseases. It is very important that the disease is diagnosed on time; for this it is necessary to take tests and be examined by doctors.

The problem of chronic bronchitis is one of the current problems modern therapy, since the diagnosis of the disease is often made untimely. The incidence of chronic bronchitis in last years increased to 60-65% among all forms of chronic nonspecific lung diseases

Thus, despite the existing work devoted to the study of methods of diagnosis, prevention and rehabilitation of patients with bronchitis, this problem is far from being resolved. Insufficient attention is paid to rehabilitation programs at the outpatient stage, while this stage is the main one in correcting the condition of patients with chronic bronchitis. A feature of chronic bronchitis is steadily progressive airway obstruction associated with a pathological inflammatory response of the airways to damaging particles or gases. Unfortunately, all the knowledge accumulated at the present stage does not contribute to reducing the incidence of this pathology. The particular relevance of the problem is associated with the deterioration of the environmental situation on the planet, the widespread prevalence of tobacco smoking, the influence of occupational hazards, and the late diagnosis of obstructive syndrome.

The main goal of rehabilitation of patients with chronic bronchitis is to achieve stable remission of the disease, which involves the maximum elimination of clinical symptoms of the disease, suppression of the activity of the inflammatory process in the bronchi, improvement of the body's immune reactivity, and normalization of general activity.

The purpose of the work is to study the role of the nurse in the rehabilitation of patients with chronic bronchitis.

The object of the study was nurses and patients of the pulmonology department with chronic bronchitis.

The subject of the study is the content of the nurse’s activities in the rehabilitation of patients with chronic bronchitis.

Research objectives:

1. Study the theoretical foundations of chronic bronchitis - etiology, clinical pathogenesis, features of physical rehabilitation of patients;

2. Determine the level functional state respiratory system and physical performance of patients with chronic bronchitis in remission before a course of physical rehabilitation;

3. Develop a rehabilitation program for specific patients with chronic bronchitis;

4. Compile a questionnaire on the activities of the nurse of the pulmonology department in the rehabilitation of patients with chronic bronchitis, for patients and nurses;

5. To study the role of nursing activities in the rehabilitation of patients with chronic bronchitis at the inpatient stage of rehabilitation;

6. Assess the effectiveness of the nurse in the rehabilitation of patients with chronic bronchitis.

Chapter 1. General characteristics of chronic bronchitis

1.1 Anatomy and physiology of the respiratory system

The respiratory system or respiratory apparatus in humans consists of the respiratory tract and two respiratory organs- lungs. The respiratory tract, according to its position in the body, is divided into upper and lower sections. The upper respiratory tract includes the nasal cavity, the nasal part of the pharynx, the oral part of the pharynx, and the lower respiratory tract includes the larynx, trachea, bronchi, including the intrapulmonary branches of the bronchi.

The respiratory tract consists of tubes, the lumen of which is maintained due to the presence of a bone or cartilaginous skeleton in their walls. This morphological feature fully corresponds to the function of the respiratory tract - carrying air into the lungs and from the lungs out. The inner surface of the respiratory tract is covered with a mucous membrane, which is lined with ciliated epithelium and contains a significant number of glands that secrete mucus. Thanks to this, she fulfills protective function. Passing through the respiratory tract, the air is cleaned, warmed and moistened. In the process of evolution, along the path of the air stream, the larynx was formed - a complex organ that performs the function of voice production. Through the respiratory tract, air enters the lungs, which are the main organs of the respiratory system. In the lungs, gas exchange occurs between air and blood through the diffusion of gases (oxygen and carbon dioxide) through the walls of the pulmonary alveoli and the blood capillaries adjacent to them.

1.2 Etiology of chronic bronchitis

In the etiology of chronic bronchitis, the main importance is given to the long-term effect of pollutants (volatile substances) and non-indifferent dust on the bronchi, which have mechanical and chemical exposure on the bronchial mucosa.

1. Inhalation of pollutants - impurities of various nature and chemical structure contained in the air that have a harmful irritating effect on the bronchial mucosa (tobacco smoke, dust, toxic fumes, gases, etc.);

2. Infection (bacteria, viruses, mycoplasmas, fungi);

3. Endogenous factors - congestion in the lungs with circulatory failure, secretion of nitrogen metabolism products by the bronchial mucosa in chronic renal failure;

4. Untreated acute bronchitis.

1.3 Pathogenesis of chronic bronchitis

1. Dysfunction of the local bronchopulmonary defense system (decreased function of the ciliated epithelium, decreased activity of o-antitrypsin, decreased production of surfactant, lysozyme, interferon, protective IgA, decreased function of T-suppressors, T-killers, natural killer cells, alveolar macrophages).

2. Development of the classical pathogenetic triad - hypercrinia (hyperfunctioning of the bronchial mucous glands, hyperproduction of mucus), discrinia ( increased viscosity sputum due to changes in its physicochemical properties and a decrease in its rheology), mucostasis (stagnation of viscous, thick sputum in the bronchi).

3. Favorable conditions for the introduction of infectious agents into the bronchi as a result of the action of the above factors.

4. Development of sensitization to microbial flora and autosensitization.

1.4 Clinical symptoms

The most characteristic clinical manifestations of chronic bronchitis are cough with sputum and shortness of breath. At the beginning of the disease, a cough with mucous sputum occurs in the morning. Gradually, the cough begins to bother you throughout the day, intensifying in cold weather; over the years it becomes constant, annoying and painful. The amount of sputum increases, it becomes mucopurulent or purulent. Shortness of breath appears and progresses. The greatest importance in pulmonology is given to chronic bronchitis, as a primarily diffuse process that involves the entire bronchial tree, naturally leading to bronchial obstruction, obstructive pulmonary emphysema and the development of cor pulmonale.

1.5 Methods for studying chronic bronchitis

Laboratory data

1. OAK (complete blood count): with exacerbation of purulent bronchitis, a moderate increase in ESR, leukocytosis with a shift to the left.

2. TANK ( bacteriological examination blood): an increase in the content of sialic acids, fibrin, seromucoid, b2 and g-globulin (rarely) in the blood during exacerbation of purulent bronchitis, the appearance of PSA.

3. OA (general analysis) of sputum: mucous sputum is light in color, purulent sputum is yellowish greenish color, mucopurulent plugs may be detected, with obstructive bronchitis - casts of the bronchi; microscopic examination of purulent sputum reveals many neutrophils. In chronic obstructive bronchitis, there is an alkaline reaction in morning sputum and a neutral or acidic reaction in daily sputum. Rheological properties of sputum: purulent sputum - increased viscosity, decreased elasticity; mucous sputum - reduced viscosity, increased elasticity. In obstructive bronchitis, Kurschmann spirals can be detected.

Instrumental studies:

· Bronchoscopy

· Bronchography:

X-ray of the lungs

· Spirography

Pneumotachometry

Program for examining the functional state of the respiratory system:

Respiratory rate at rest (min)

· Chest excursion (difference between the chest circumference at maximum inhalation and at maximum exhalation, cm)

· Vital capacity of the lungs (the largest volume of air that can be exhaled after maximum inhalation, cm 3).

1.6 Features of the treatment of chronic bronchitis

Therapeutic measures for chronic bronchitis are carried out regularly, over a long period of time, regardless of the stage of the disease. If, during an exacerbation of chronic bronchitis, purulent sputum begins to leave, then antibiotics are prescribed (after determining the microbial pathogen and its sensitivity to them) along with mucolytics and expectorants. If chronic bronchitis is of an allergic nature, it is indicated antihistamines. During an exacerbation, bed rest and drinking plenty of fluids (alkaline mineral water, tea with raspberries) are advisable. Non-drug treatment includes physiotherapy (UHF, electrophoresis, inhalation), breathing exercises, mustard plasters, warm compresses (you can get them from grandma’s mezzanine). medical banks). It is possible to perform bronchial lavage (washing the bronchi with medicinal solutions). The indicator of treatment success is the absence of exacerbation for 2 years.

Chapter 2. The role of the nurse in the rehabilitation of patients

2.1 Basics of rehabilitation of patients with chronic bronchitis

Rehabilitation is a direction of modern medicine, which in its various methods relies, first of all, on the patient’s personality, actively trying to restore the person’s functions impaired by the disease, as well as his social connections.

Rehabilitation measures (RM) for bronchitis can begin to be carried out when the acute process subsides in acute bronchitis and after the exacerbation phase in chronic bronchitis. PM is aimed primarily at increasing general and local resistance bronchial tree, the body's resistance to colds and infectious diseases in the upper respiratory tract. In addition, PM helps to increase blood and lymph circulation, reduce inflammatory changes in the bronchi, restore the drainage function of the bronchi and the mechanism of proper breathing.

Regularly carried out rehabilitation activities can provide medical and, to a large extent, professional rehabilitation for patients with chronic bronchitis. A more accurate assessment of rehabilitation possibilities requires longer periods of observation. As for the social rehabilitation of patients with chronic bronchitis, with steadily increasing respiratory failure, it is apparently futile, which once again emphasizes the need for early rehabilitation therapy for these patients, designed to preserve their professional performance.

The goal of rehabilitation is the effective and early return of sick and disabled people to household and labor processes, to society; restoration of a person’s personal properties. The World Health Organization (WHO) gives a very similar definition of rehabilitation: “Rehabilitation is a set of activities designed to ensure that persons with disabilities as a result of disease, injury and birth defects adapt to new living conditions in the society in which they live.” The term rehabilitation comes from the Latin word habilis - “ability”, rehabilis - “restoration of ability”.

According to WHO, rehabilitation is a process aimed at comprehensive assistance to sick and disabled people so that they achieve the maximum possible physical, mental, professional, social and economic usefulness for a given disease.

Thus, rehabilitation should be considered as a complex, socio-medical problem, which can be divided into several types or aspects: medical, psychological, professional (labor) and socio-economic.

In medical rehabilitation, she plays an important role - the nurse, carrying out the rehabilitation process, performs a wide variety of duties, finding herself in various situations and often changing relationships with the patient and his family. The specificity of the nurse’s role in the rehabilitation of patients is that she must implement not only treatment, but also take part in the implementation of the entire rehabilitation process. The emotional and psychological characteristics of the individual must be taken into account, and the emotional contact of the patient with the nurse is recognized as a necessary element of the rehabilitation process.

It is convenient to describe the entire complex of such relationships through role theory.

2.2 Nurse as caregiver

The nurse provides direct nursing care as needed until the patient or family acquires the necessary nursing skills. To provide complete care, the nurse must be able to: establish psychological contact with the patient and his family, taking into account their personal characteristics to ensure his maximum activity, development of goals and implementation of rehabilitation measures; know and be able to determine the patient's reactions to the disease and problems associated with the disease; know and be able to implement types of nursing interventions aimed at solving assigned problems.

This activity is aimed at:

· Restoration of circulatory and lymph circulation functions, functional state of the bronchopulmonary system, improvement of external respiration function

Maintenance of drainage function and ventilation of the bronchopulmonary system

Improvement of impaired function of the cardiovascular system in chronic nonspecific lung diseases

Stimulation recovery processes in the lungs, allowing to accelerate the resolution of the pathological process

· Normalization of immunity, psycho-vegetative changes, relief of depression

· Correction of hormonal levels

· Treatment and rehabilitation with physical factors of concomitant chronic infection / rhinitis, tonsillitis, sinusitis, otitis

· Strengthening the respiratory muscles and abdominal muscles

· Prevention of complications

The nurse, in this role, provides care by:

1) carrying out physical exercises:

General tonic exercises that improve the function of all organs and systems, activate breathing (moderate and high-intensity exercises are used to stimulate the function of external respiration; low-intensity exercises do not have a training effect on the cardiovascular and respiratory systems);

Special (breathing) exercises that strengthen the respiratory muscles, increase the mobility of the chest and diaphragm; promote stretching of pleural adhesions; reduce congestion in the respiratory system, facilitate the removal of sputum, improve the breathing mechanism, coordination of breathing and movement;

In order to relax tense muscle groups, autogenic training, swinging and swinging movements of the limbs, post-isometric muscle relaxation techniques, physical exercises to relax associative and segmental muscles, therapeutic massage using myofascial release techniques, and segmental reflex massage can be used. Taking into account myofascial changes in muscles, the most effective physical exercises are movements involving segmental and associative muscles.

Breathing music therapy classes. A.N. Strelnikova, in her breathing exercises, suggests actively training only inhalation. She explains this by saying that inhalation is the first, therefore independent action, exhalation is the second, therefore dependent on inhalation. If, simultaneously with inhalation, you make a movement of the external muscles that compress the chest, the internal muscles, the muscles of the organs of movement will be forced to prevent the air from diverging, resist it and develop due to this load. Therefore, inhalation is trained strictly simultaneously with movements that compress the chest.

All breathing exercises in her gymnastics are based on breathing movements that compress the tops of the lungs, so that the air entering inside cannot distort the shape of the lungs, and so that the person doing the exercises can restore it through training, if it is distorted, and activate the muscles of the bases of the respiratory organs.

All movements must be done rhythmically. The rhythm of correct breaths improves the rhythm of gas exchange throughout the body, and by obeying it, sooner or later connections broken by the disease and functions lost due to it are restored.

The gymnastics complex includes exercises such as:

Movement - inhale “hands in front of the chest.” They train the shoulder girdle, i.e. the muscles surrounding the respiratory organs from above, and automatically restores or activates the mobility of the bronchi;

Movement - inhale “lean back”. Brings the activity of the shoulder girdle to the limit and improves coordination of movements from the abdominals to the shoulder girdle during inhalations, including the pectoral and rib muscles very actively; - movement - inhale “sit down.” Contracts the abdominal and pelvic muscles. This prevents the diaphragm from descending during inhalation, therefore, air resistance is organized at the very bottom of the respiratory organs. But since the hands make counter movements, the air cannot rise into the narrow tops of the lungs and distort them: resistance to it is also organized there.

Consequently, the muscles of the respiratory organs resist air throughout their entire length. All exercises should be done energetically, but easily.

In the rehabilitation of patients with chronic bronchitis, the M.F. Health Complex is used. Grinenko is presented with breathing and sound exercises.

2) performing a massage. Massage is part of the complex therapy of chronic bronchitis. It promotes the removal of sputum and has a bronchial relaxant effect. Classic segmental, therapeutic and acupressure. Therapeutic massage is an effective therapeutic and rehabilitation method used to normalize body functions in diseases of the respiratory system. Massage for respiratory diseases is used in complex treatment with therapeutic exercises, physiotherapy, and cupping massage. If there is phlegm, use percussion or vibration massage. At night, a massage is performed with hyperemic ointments and breathing activation. To improve ventilation in various areas lungs, it is very important to choose the optimal position. Breathing when performing therapeutic exercises should be calm and rhythmic. If there is mucus in the bronchi, then after the massage, breathing exercises are performed with prolongation of the exhalation phase.

Cupping massage is also used to help remove mucus when coughing. A 200 ml jar is applied to the skin lubricated with Vaseline. Using a suction cup, make sliding massage movements from the lower back to the cervical spine.

Duration 5-15 minutes. Then the patient is wrapped in a blanket and given a glass of tea with lemon or raspberry. This procedure is carried out every other day. Physiotherapy is used in patients with chronic bronchitis to suppress the inflammatory process and improve the drainage function of the bronchi.

The nurse must know the basics of physical therapy, massage, occupational therapy, methods of monitoring the adequacy of the load, specific to a particular disease, and the method of minor psychotherapy. Having mastered these methods, she is obliged to organize and monitor the adequacy of measures carried out by patients independently. So, for example, when a patient is engaged in exercise therapy procedures, a nurse must monitor the correctness of the procedure and the adequacy of the load received using simple control methods - counting the pulse rate, respiratory rate, measuring blood pressure, observing the patient’s appearance, etc. P.

2.3 Sister as "teacher"

The nurse provides the patient and family with information and assistance in developing the skills needed to return to normal health and achieve independence. The nurse can provide educational information and materials to the patient about his illness or disability, and also provides information about new rehabilitation techniques.

In this role, the nurse must be proficient in:

· relevant knowledge about this disease and correctly convey it to the patient and his family, in a language they understand

· the basics of occupational therapy, which will allow her to tell the patient how best to complete the occupational therapist’s task, and assess the patient’s reaction to the load, promptly suggest stopping it if the reaction is inadequate

· basics of massage

The nurse must be able to teach:

1) the technique of performing effective breathing. Learning to breathe fully and consciously regulate it begins with static exercises; use exercises in rhythmic static breathing, which leads to a slowdown in respiratory movements due to their deepening, while the strength of the respiratory muscles increases and the intercostal muscles are toned. Breathing with additional resistance (inhaling through pursed lips, through a tube, inflating rubber toys) reduces the frequency and increases the depth of breathing, and activates the work of the respiratory muscles. It is recommended to breathe through the nose, as this humidifies and purifies the inhaled air; irritation of the receptors of the upper respiratory tract reflexively expands the bronchioles, deepens breathing and increases blood oxygen saturation.

If it is necessary to spare the affected lung, starting positions are used that limit the mobility of the chest on the affected side (lying on the affected side). Using weights in the form of sandbags when performing breathing exercises helps strengthen the abdominal muscles, intercostal muscles and increase the mobility of the diaphragm. To dose physical activity, change the starting position, tempo, amplitude, degree of muscle tension, number and duration of exercises performed, rest breaks, and include relaxation exercises.

Performing breathing exercises requires compliance with the basic laws of breathing: before any physical activity, it is necessary to remove residual air from the lungs, for which you need to exhale through lips folded into a tube; inhalation is mainly (80%) carried out through the diaphragm, while the muscles of the shoulder girdle should be relaxed; the duration of exhalation should be approximately 2 times or more longer than inhalation; inhalation is carried out when the chest is straightened, exhalation is carried out when it is compressed (for example, when bending over).

Exhalation is usually done by relaxing the muscles involved in inhalation, under the influence of gravity of the chest, i.e. slow exhalation occurs with dynamic yielding work of these muscles. The removal of air from the lungs is ensured by elastic forces lung tissue. Forced exhalation occurs when the muscles that produce exhalation contract; increased exhalation is achieved by tilting the head forward, bringing the shoulders together, lowering the arms, bending the torso, and raising the legs forward.

Breathing exercises can be used to arbitrarily change the breathing frequency. More often, exercises are used to voluntarily slow down the breathing rate (in this case, it is recommended to count to yourself): the exercise reduces the speed of air movement and reduces the resistance to its passage through the respiratory tract. Increasing breathing increases the speed of air movement, and the resistance and tension of the respiratory muscles increase. If it is necessary to intensify inhalation or exhalation during breathing exercises, randomly change the ratio of inhalation and exhalation time. To ensure complete ventilation of the lungs when learning breathing techniques, you need to master all types of breathing (upper thoracic, lower thoracic and diaphragmatic).

2) The nurse should also teach the patient self-massage. When we talk about self-massage of the chest, we mean massage the front of the chest, the pectoralis major muscles and the intercostal spaces. Women should self-massage their breasts on the upper third of the pectoralis major muscle (above the mammary gland). This massage strengthens and improves the tone of the pectoralis major and minor muscles, which is of great importance for ensuring breathing efficiency.

It is best performed in a sitting position. You should sit so that the hand on the side being massaged rests with the hand and forearm on the thigh, and your head should be tilted towards the muscle being massaged. Thus, with your right hand you need to massage the muscle on the left side of the chest, and with your left hand on the muscle on the right side.

You can do this massage while standing or lying down. When massaging in a lying position, the hand on the massaged side should be placed on the stomach, and the other hand should perform massaging movements.

The first stage is stroking. The hand should be pressed tightly to the body, the thumb should be moved to the side. The direction of movement is from bottom to top, from the center of the chest to the armpit.

The second stage is squeezing, it must be done with the tubercle of the thumb and the base of the palm of one hand above and below the nipple. The direction of movement is from the sternum to the shoulders. Repeat 5-6 times.

The next stage is rubbing. First you should rub the intercostal spaces. The direction of the massaging movements is from the sternum to the shoulders. The technique must be performed with one hand and with weights, pressing the fingertips into the intercostal spaces and performing vigorous straight, circular, spiral and dotted rubbing.

You can perform simultaneous rubbing. In this case, each hand should massage its side of the chest.

Then you should rub the hypochondrium. The direction of movement is from the xiphoid process down and to the sides. This rubbing should be done with the palm of your hand, placing the thumb on top of the ribs and the other four fingers on the bottom. Each hand needs to massage the same side.

It is best to perform this technique in a lying position: bend your legs at the knee and hip joints. This position allows you to relax your muscles as much as possible.

After this, it is necessary to rub the sternum. To do this, you need to slightly spread your fingers and place them to the left of the sternum. Rubbing should be done with the phalanges of the fingers bent into a fist and the base of the palm. The direction of movement is towards the pectoralis major muscle.

The fourth stage is kneading. First, ordinary kneading, then kneading with the phalanges of bent fingers, the pads of four fingers and the base of the palm.

The fifth stage is shaking.

You need to complete the chest massage with light relaxing strokes.

· Teach relatives how to perform acupressure.

For chronic bronchitis, massage of the following points is used:

Hegu is one of the most popular points, known in acupressure as the “hundred disease point”.

Located in the fork between the big and index fingers on the back of the hand at the top of the muscle tubercle;

Dazhui - in the depression under the spinous process of the seventh cervical vertebra;

Tiantu - in the center of the depression above the middle of the jugular notch;

The following acupressure techniques are most accessible to a non-specialist:

Light touch and stroking

Light finger pressure and deep pressure.

Finger pressure during acupressure should be strictly vertical, without displacement. The movement of the finger should be rotating or vibrating, but always non-stop. The stronger the impact on the point, the shorter it should be. Most of the points used are handled with the thumb.

Contraindications:

Acupressure is contraindicated for any tumors, acute febrile conditions, peptic ulcers of the stomach and duodenum, blood diseases, active forms of tuberculosis, pregnancy.

3) Teach how to use a pocket inhaler

2.4 Sister as a “lawyer”

The nurse communicates the patient's needs and desires to other professionals, acting on the patient's behalf. This role requires the communication of complete and accurate information by both the healthcare professional to the patient and the patient to the healthcare professional. Voluntary informed consent means that the patient received complete, reliable information about the state of his health, expected medical intervention, risks of harm to him, alternative methods of treatment in a form accessible to him, and on the basis of this information gave voluntary consent to the planned medical intervention.

A nurse must master the method of minor psychotherapy, since by communicating with patients for a longer time than a doctor, she can achieve more in correcting their psychological status. The nurse is obliged to monitor the timeliness and duration of the patient’s independent activities. She is required to know the methods of providing primary emergency care when the patient’s condition worsens during the evening independent procedures, register and bring to the attention of the doctor about all inadequate reactions of the patient to the load.

2.5 Sister as "advisor"

The nurse acts as a constant and objective assistant to the patient, inspiring him to use functional capabilities, helps the patient recognize and see the strengths of the patient’s personality, organizes the patient’s lifestyle by providing recommendations on nutrition, a healthy lifestyle, and adherence to a work and rest regime, which is favorable for the patient. satisfy his needs.

Patients who, during the rehabilitation process, engage in exercise therapy, occupational therapy, receive massage, etc., can and should continue these activities in the evening. To fully restore health, the nurse advises:

Perform breathing exercises and physical therapy exercises

· fulfill steam inhalations that can be done at home;

· apply physiotherapeutic procedures. Physiotherapy is a treatment by the forces of nature; physical factors can have a local effect on the body through the skin, mucous membrane, various tissues and organs, but even in these cases, due to neuro-reflex influences, they also have a general strengthening effect. The use of physiotherapeutic factors for bronchitis is indicated to enhance immunobiological processes in the body.

Physiotherapeutic methods for bronchitis include: electric field UHF (Ultra High Frequency field), microwave therapy (microwave, in the presence of bronchospasm, electrophoresis of a 5% solution of magnesium sulfate is used, ultraviolet irradiation, calcium chloride electrophoresis on the chest.

· Follow the rules of a healthy lifestyle; you should absolutely not drink alcohol, since alcohol is quickly absorbed in the intestines, distributed by blood throughout the body and, when released through the respiratory tract, irritates the bronchi and increases inflammation.

You should also stop smoking; the worst enemy of the respiratory system is tobacco smoke. This is why quitting smoking in chronic bronchitis is absolutely mandatory. Clinicians have more than once been convinced that patients who quit smoking had an improvement in the course of their disease, and sometimes even a complete recovery.

· Avoid cooling or sudden temperature changes. You should always dress according to the season and take special care not to get your feet wet. In case of bad weather, you need to take a raincoat and umbrella with you. Under no circumstances should you wear clothes that are too warm: a sweaty, unseasoned person may experience an exacerbation of bronchitis more easily. And at the same time, you cannot avoid fresh air or be afraid of walking in cold weather. The main thing is not to overheat or overcool, but cold air itself is necessary. You have to get used to it. And one more warning: when going outside, you should not cover your mouth and nose with a scarf. Water vapor accumulates under it, which cools the bronchi and lungs.

· Harden up. First, for a month in the morning, you need to do dry rubbing of the entire body with a hard terry towel, wash your face alternately with lukewarm and cool water. Over time, over 2-3 months, the temperature of cool water should be increasingly reduced, and warm water should be increased. The next stage of hardening is general water procedures, if permitted by the doctor. You can proceed to taking a shower, first warm and then cool; It's better to do this at night. It is useful to wash your feet daily with water, the temperature of which should gradually decrease. Of course, you can harden yourself only at a time when there is no exacerbation of chronic bronchitis.

A study of rehabilitation methods for patients with chronic bronchitis showed that effective means of rehabilitation are physical therapy, massage and physiotherapeutic methods. The rehabilitation effect of the listed methods is due to the antispasmodic effect of physical factors, increased secretion, dilution and rapid discharge of sputum, increased immune activity of the associated lymphatic system, and improvement of the general condition of the patient. They are prescribed strictly individually and differentiated, taking into account the patient’s age, form, extent of prevalence and severity of the bronchopulmonary process.

Chapter 3. Organization, methods and techniques of research. Research results

The study of VCR was carried out at the Belebeevskaya Central District Hospital in therapeutic department, the purpose of the study was to study the role of the nurse in the rehabilitation of patients with chronic bronchitis

Research objectives:

1. Compile a questionnaire about the activities of a nurse in the pulmonology department in the rehabilitation of patients with chronic bronchitis

2. draw up a questionnaire on the activities of a nurse in the pulmonology department for patients undergoing inpatient treatment;

3. To study the role of nursing activities in the rehabilitation of patients with chronic bronchitis at the inpatient stage of rehabilitation therapy. To achieve this goal, the following methods were used:

· survey of medical workers;

· questioning of patients with chronic bronchitis;

· methods of objective examination of the respiratory organs of patients before and after physical rehabilitation;

· mathematical analysis.

The examinations involved 4 male patients, whose age ranged from 40 to 60 years, diagnosed with chronic bronchitis in remission, who were prescribed a course of physical rehabilitation. The physical rehabilitation program included a complex of therapeutic exercises, which was represented by breathing and sound exercises, carried out daily, 2 times a day (once under control in the morning and in the evening independently). Afterwards, vibration massage and inhalations were carried out.

All subjects had access to physical therapy exercises in accordance with the individual characteristics of their functional state. Sampling was also carried out based on the presence of concomitant diseases (arterial hypertension, coronary heart disease, cerebrovascular accidents and a history of heart attacks) to prevent possible complications during physical therapy and stress testing.

The rehabilitation course was 6 days. After training, patients performed therapeutic gymnastics exercises independently. Inhalations were carried out daily for 6 days, after physical therapy. The course of inhalations consisted of 6 sessions.

To determine the level of competence in rehabilitation activities, a survey was conducted among nurses in the therapeutic department.

To assess the effectiveness of nurses in rehabilitation, a survey was conducted among patients suffering from chronic bronchitis for more than 10 years, their age ranged from 40 to 60 years. 4 patients took part in the survey.

Before using physical rehabilitation means, patients underwent objective examination of the respiratory organs:

Type of breathing (thoracic, abdominal, mixed)

Respiratory rate at rest (movements per minute)

· Stange test (breath holding while inhaling, sec)

· Genchi test (breath holding while exhaling, sec)

Vital capacity of the lungs (the largest volume of air that can be exhaled after maximum inspiration, cm 3)

Table 1. Examination of patients before physical rehabilitation

After an objective examination, a course of physical rehabilitation began according to the drawn up plan:

Table 2. Rehabilitation plan for patients with chronic bronchitis

To carry out physical rehabilitation according to a drawn-up plan, the nurse, as a “teacher,” teaches patients the technique of performing therapeutic exercises, special breathing exercises, and self-massage. The sister, as an “advisor,” advises doing breathing exercises, physical therapy exercises, and steam inhalations, which can be done at home, to fully restore health. The nurse as a “lawyer” - taking into account the needs and desires of the patient, helps to cope with the difficulties that arise during the rehabilitation period, she is obliged to monitor the timeliness and duration of the patient’s independent activities.

Patient rehabilitation plan:

1. Therapeutic exercises (in the morning after sleep, breathing is even, calm, free through the nose):

· Starting position lying on your back. Bend your leg at the knees, pull it to your chest - exhale. i.p - inhale. Repeat 2-3 times at an average pace;

· Starting position: sitting, close one nostril with your finger, inhale, exhale through the second nostril. Pinch the other nostril and do the same;

· Starting position: standing, spread your arms to the sides, make a cross movement with your arms - exhale;

· Starting position sitting, hands on knees. Hands behind your head, bend over - inhale; return to the starting position - exhale. 4-6 times;

· Starting position: sitting, hands on your belt - inhale, pull your knee to your chest with your hands - exhale. One by one. 3-6 times;

· Starting position: sitting, feet shoulder-width apart, hands below. Tilt to the left, try to touch the floor with your left hand, exhale with your right hand to your shoulder; return to the starting position - inhale. The same with a tilt in the other direction. 4-6 times;

· Starting position sitting, arms to the sides - inhale; hands crossed on the ribs, standing up and leaning forward - exhale. 4-8 times;

· Walking with arms raised to the sides as you inhale and lowered as you exhale - 1-2 minutes. with slowing down the pace and lengthening the exhalation - 30 - 60 sec;

2. Special breathing exercises (patients perform independently):

· Starting position: standing, raise your arms up and stretch, standing on your tiptoes - inhale. Lower your hands - exhale, saying - “oo-oo-oo”. A complex of breathing exercises for bronchitis is performed five times;

· Walk in place for two minutes. The arms are raised and spread to the sides, in the rhythm of the step - inhale through the nose. Hands are lowered - a strong exhalation with the sound - “oo-oo-oo”;

· Starting position: standing, legs apart. Alternately swing your arms forward and backward. Inhalations through the mouth are frequent. Exhale through the nose;

· Starting position: standing, legs together. Raise one arm, the other is moved to the side. Inhale through your nose. We change the position of the hands - slow and long exhalation.

3. Self-massage Massage (acupressure of the hegu, dazhui, tiantu points);

4. Physiotherapeutic procedures (ultra high frequency field);

5. Inhalations (nebulizer with berodual).

After physical rehabilitation, an objective examination of the patients was carried out:

Table 3. Examination of patients after physical rehabilitation

Based on the results of an objective examination before and after physical rehabilitation, I concluded that when nurses perform the above roles in the rehabilitation of patients, the indicators of an objective examination of patients noticeably improve.

Questioning among nurses to determine the level of competence in rehabilitation activities. Results:

1) Do you like your profession? (Not really)

2) Do you know what a healthy lifestyle is? (Not really)

3) Do you lead a healthy lifestyle? (Not really)

4)Are you hardening yourself? (Not really)

50% - yes, 50% - no

5) Do you know that your professional activity includes responsibilities for carrying out preventive measures among patients? (Not really)

6) How often do you carry out preventive measures? (I don't spend

1 time per week, 1 time per month, another answer)

90% - 1 time per week

10% - whenever possible

7) Do you know about medical rehabilitation of patients? (Not really)

8) Do you teach patients rehabilitation methods? (Not really)

9) Do you know the basics of massage? (Not really)

10) Do you know the basics of physical therapy? (yes, no)

12) Do you consider the needs and desires of patients when caring for them? (Not really)

13) How do you understand whether patients have mastered the rehabilitation measures carried out with them and how this affected their health? (improvement in the dynamics of their condition, they repeat the methods already given to them independently, I just don’t understand)

80% improvement in the dynamics of their condition

10% repeat the methods given to them independently

10% - I don’t understand at all

14) How do you evaluate the effectiveness of your rehabilitation activities? (satisfactory, good, excellent)

90% - excellent

10% is good

15) What do you think negatively affects your desire to work effectively? (underline as appropriate) great physical and emotional stress, low wages, poorly adapted workplace, monotonous work)

100% - great physical and emotional stress, low wages, poorly adapted workplace)

Questioning among patients to assess the effectiveness of nurses in rehabilitation. Results:

1. How long have you considered yourself to be suffering from chronic bronchitis? (10 - 20 years, 20 - 40 years)

50% - 10-20 years

50% - 20 - 40 years

2. What do you understand a healthy lifestyle means? (I don’t know when there are no bad habits)

50% - I don't know

50% - when there are no bad habits

3. Do you lead a healthy lifestyle?

If yes, what methods do you use?

4. What are your bad habits? (no, smoking, alcohol, household habits, etc.)

50% - smoking

5. How many times a year do you undergo inpatient treatment? (1, 2, 3, 4)

100% - 1-2 times a year

6. After completing the course of treatment, do you feel better? (Yes, no, partially)

10% - partially

7. While on inpatient treatment Do they take preventive measures with you? (conversations, do they give you any advice)

9. Do you know about breathing exercises? (yes, no, I heard something)

10% - heard something

10. Do they teach you breathing exercises? (Not really)

11. Do they teach you self-massage? (Not really)

12. Do you use the methods given to you to restore your health?

(yes, no, I don’t know about them)

100% - I don’t know about them

13. Do you think the advice given helps you? (yes, no, I don’t know, no advice was given)

100% - no advice given

14. Are you satisfied with: communication, care, treatment in a hospital? (yes, no, partially)

90% - good

10% - satisfactory

Based on the results of the survey, I concluded that if we take the nurses of the department as 100%, then 95% fulfill their duties and roles; lead appropriate for medical worker Lifestyle; have skills in rehabilitation methods; provide certain knowledge to patients and their relatives, thereby filling the lack of knowledge about this disease; regularly carry out preventive measures through conversations; approach their activities at a professional level; conscientiously carry out patient care activities taking into account all their wishes and needs. And 5% know about their responsibilities, but their reluctance to work leads to the fact that they only partially fulfill their responsibilities.

The practical significance of the study of the role of the nurse in the rehabilitation of patients with chronic bronchitis lies in the possibility of using it in practice for organizing nursing activities to carry out rehabilitation measures for patients.

1. Performing the role of a nurse, as a person providing care, provide care as follows:

· Ensure regular ventilation in the room where the patient is;

· Avoid the presence of strong odors in the room (cosmetics, deodorants, etc.) so as not to provoke a coughing attack.

· Provide therapeutic nutrition that promotes, more quick treatment inflammation, improves immunity, supports the functioning of the heart and blood vessels, and also relieves the digestive system

· Provide plenty of fluids up to 2 liters per day;

· Monitor the performance of physical exercises:

General tonic;

Special exercises

Various breathing exercises aimed at correcting the prevailing pathological process;

· Supervise the massage. The nurse must know the basics of physical therapy, massage, occupational therapy, methods of monitoring the adequacy of the load, specific to a particular disease, and the method of minor psychotherapy;

2. Performing the role of a nurse as a “teacher,” the nurse must be able to teach:

1) technique of performing effective breathing;

2) The nurse should also teach the patient self-massage;

3) Teach relatives how to perform acupressure;

3. Performing the role of a nurse as a “lawyer,” the nurse is obliged to monitor the timeliness and duration of the patient’s independent studies. She must master the methods of providing primary care if the patient’s condition worsens during the evening independent procedures, register and bring to the attention of the doctor about all inadequate reactions of the patient to the load.

4. Performing the role of a nurse as an “adviser”, for the complete restoration of health, the nurse advises:

1) perform breathing exercises and physical therapy exercises;

2) perform steam inhalations, which can be done at home;

3) Follow the rules of a healthy lifestyle; you should absolutely not drink alcohol, since alcohol is quickly absorbed in the intestines, distributed by blood throughout the body and, when released through the respiratory tract, irritates the bronchi and increases inflammation;

4) You should also stop smoking; the worst enemy of the respiratory system is tobacco smoke. This is why quitting smoking in chronic bronchitis is absolutely mandatory. Clinicians have more than once been convinced that patients who quit smoking had an improvement in the course of their disease, and sometimes even a complete recovery;

5) Avoid cooling and sudden temperature changes. You should always dress according to the season and especially take care not to get your feet wet;

Analysis of the literature used:

I used the material (from a book/textbook/online resource):

1. Grinenko M.F. Physical education and sports/M.F. Grinenko. - M.: The path to health. It is in it that the health complex in the rehabilitation of patients with chronic bronchitis, which is represented by breathing and sound exercises, is described in more detail;

2. Popov S.N. Therapeutic physical culture: Textbook. /S.N. Popov. - M.: Academy, because it more specifically describes the concepts of exercise therapy and rehabilitation, means of exercise therapy, general requirements for the method of using physical exercises, exercise therapy for diseases of the respiratory system, the basics of the method of exercise therapy for diseases of the respiratory system;

3. Shchetinin M.N. Breathing gymnastics by A. N. Strelnikova / M.N. Shchetinin. -M.: Metaphor, this book contains the most complete description of all Strelnikova’s breathing exercises, how to perform them correctly for chronic bronchitis and various diseases;

4. Epifanov V.A. Regenerative medicine: textbook / V.A. Epifanov. - M.:GEOTAR-Media. This textbook outlines the basics of restorative medicine as an independent branch of medical science and practice. Methods for diagnosing and researching the functional state of the body are covered in detail. The influence of health-improving physical culture on the human body is considered.

course work, added 11/25/2011

Bronchial asthma as a chronic disease, its clinical symptoms. Duration of asthma attacks. The role of respiratory tract infections and environmental distress in the occurrence of bronchial asthma. Actions of a nurse during an attack.

presentation, added 12/26/2016

Signs, symptoms and diagnosis of chronic obstructive pulmonary disease. Classification, indications for hospitalization for illness. Treatment regimens for chronic obstructive bronchitis and emphysema. Strategy of applied antibacterial therapy.

presentation, added 10/23/2014

thesis, added 07/20/2015

Job description defining the duties, rights and responsibilities of an operating nurse. Participation of the nurse in preparation for the operation. Features of the sanitary and epidemiological regime. Nursing activities in teaching and counseling patients.

course work, added 12/21/2010

The main symptoms and signs of cholelithiasis, its causes. Methods for diagnosing the disease. Complications and consequences of gallstone disease. Determination of indications and contraindications for surgery. The role of the nurse in the preoperative period.

thesis, added 05/20/2016

Responsibilities and rights of an operating room nurse according to the job description. Basic regulatory documents regulating the activities of a surgical nurse. General rules of conduct for nurses during surgery.

presentation, added 04/01/2015

Study of types and methods of transmission of infectious diseases of the respiratory system. Description of influenza, acute respiratory infections, sore throat, diphtheria, measles, whooping cough. Prevention of these diseases, as well as provision of first-aid care by a nurse.

course work, added 10/30/2014

Etiology, clinical picture, classification, purulent-inflammatory diseases of the abdominal organs, principles and approaches to their diagnosis. Organization of the work of the surgical department. Preoperative preparation for purulent peritonitis, the role of the nurse.

The purpose of this work is to identify the role of the nurse in rehabilitation

patients who have suffered an ischemic stroke.

The set goal is specified by the research objectives, which

are to:

Define ischemic stroke and identify the main factors

contributing to its development;

Give a classification of stroke, consider its clinical picture and

Talk about the features of treatment and prevention of ischemic stroke;

To reveal general issues of rehabilitation of patients who have suffered ischemic

To characterize the nursing process for ischemic stroke;

Analyze the activities and role of the nurse in the process

rehabilitation of patients after ischemic stroke.

decreased blood flow to an area

brain with the appearance of an ischemic zone and

death of neurons (nerve cells).

Stage 1 (inpatient) – rehabilitation begins in the neurological

department where the patient is delivered by an ambulance team (18-21 days).

Stage 2 – rehabilitation in specialized rehabilitation facilities

hospitals where the patient is transferred 3-4 weeks after a stroke.

This stage may have different options depending on the severity

Stage 3 – outpatient rehabilitation in a polyclinic setting

rehabilitation center or recovery rooms of a clinic.

10. Stages of the nursing process for ischemic stroke

The goal of stage 1 is to determine the patient's need for care. When assessing

sources of information are: the patient himself, his family, medical personnel,

Stage 2 – making a nursing diagnosis. The goal of stage 2 is to identify problems

patient and their identification (real or potential problem).

Stage 3 – stage of planning the rehabilitation process. Stage 3 goal –

drawing up a care plan together with the patient to solve his problems. Plan

care consists of goals that must be individual, realistic,

measurable, with specific deadlines for achievements.

Stage 4 – implementation of planned rehabilitation measures. Stage 4 goal –

carry out a nursing intervention designed to achieve a goal. At

work in the department, goal achievement is carried out jointly with others

Stage 5 – assessment of the effectiveness of the rehabilitation measures carried out.

At this stage, the nurse, taking into account the patient’s opinion, independently

evaluates the quality of his actions in the rehabilitation process, notes the achievements

whether the set goals have been achieved completely, partially or not, indicating

reasons for possible failures

ischemic stroke consists of:

Carrying out medical prescriptions;

Functional assessment and dynamic monitoring of the condition

Meeting the patient's needs for adequate nutrition and

Minimizing physical and emotional distress;

Correction of breathing disorders;

Correction of mental disorders;

Reducing the risk of secondary complications;

Prevention of deep vein thrombosis of the lower extremities, bedsores,

pain and swelling in paralyzed limbs

The role of the nurse in the rehabilitation of a patient after a stroke

Stroke can be characterized as an acute violation of intracerebral circulation, accompanied by persistent focal and general brain symptoms, which persist for more than 24 hours and develop due to the death of brain matter. According to WHO (World Health Organization), this is one of the leading causes of mortality in European countries, and in the structure of overall mortality in Russia it ranks second after heart disease. The incidence of stroke over the past two decades has increased from 1.3 to 7.7 cases per 1000 adults, especially in large administrative centers. This increase is caused by an increase in the life expectancy of modern humans and the percentage of senile and elderly people in the modern population. It is extremely important that among the surviving patients they become disabled, and the fate of each of them depends on the people around them, since they need expensive medical and social rehabilitation and the care of loved ones. The incidence of stroke increases with age. Thus, according to world data, the annual incidence rate at the age of 40

49 years old is 2 cases per 1000, and from 50 to 60 years old it is 0.9, and over 60 years old it is 15.4. The negative role of strokes is the deterioration of the quality of life of older people, and, as a result, there is a need for help from relatives, medical and social workers due to the development of motor and mental disorders.

minor stroke - regression of symptoms occurs within 3-4 weeks,
mild to moderate severity - without disorders of consciousness with a predominance of focal neurological symptoms.
severe stroke - with depression of consciousness, signs of cerebral edema, disruption of the activity of other organs and systems

2. According to the localization of the outbreak:

left hemisphere - speech, counting, writing, movement in the right limbs are impaired,
right hemisphere - the perception of shape, size, position in space, movement in the left limbs is impaired,
stem - consciousness, swallowing, breathing, blood circulation, thermoregulation are impaired, often leading to death.

3 By the nature of brain changes

ischemic - occurs due to blockage of an artery by a thrombus or atherosclerotic plaque,
hemorrhagic - occurs as a result of hemorrhage into the substance of the brain or under the meninges during a hypertensive crisis, rupture of a modified vessel (aneurysm);
combination of ischemic damage with hemorrhage.

Causes of the disease and their prevention. A stroke develops against the background of an existing vascular pathology(atherosclerosis, arterial hypertension, their combinations) and some other diseases (diabetes, blood diseases and others). The immediate causes of stroke include sharp, rapidly occurring fluctuations in blood pressure (BP) during physical activity, psycho-emotional stress, heavy food, alcohol consumption and/or heart rhythm disturbances.

arterial hypertension,
hypercholesterolemia and atherosclerotic artery disease.
cardiac arrhythmias, which significantly increase the risk of ischemic stroke due to the formation of blood clots in the cavities of the heart,
increased blood clotting and polycythemia,
diabetes mellitus leading to failure arterial wall and contributing to the progression of atherosclerosis,
excessive salt intake, leading to increased blood pressure,
smoking, regardless of what type of smoke and how it enters the body,
physical inactivity leading to increased body weight,
unfavorable living, socio-economic conditions and low educational level of patients are accompanied by more frequent development arterial hypertension. Solving these problems is the task of public policy

Unregulated risk factors include

Floor. The incidence of men after 60 years of age increases sharply compared to the incidence of women
Age. With age, the risk of developing a stroke significantly increases due to the gradual accumulation and increase of negative factors in age - 1.5 per 1000, and in the age group of 60 and older - about 20 people per 1000 population.
Heredity. The condition of the vascular wall, blood pressure level, etc. are inherited, which, in combination with external unfavorable factors, can lead to a stroke. Based on this, in persons with unfavorable heredity, close attention should be paid to preventive measures.

Preventive measures aimed at combating regulated risk factors (primary prevention) imply a mass strategy, including extensive health education work aimed at familiarizing the population with risk factors and combating them. The main burden in this work is borne by family nurses. Monitoring blood pressure levels and learning how to measure it are of utmost importance. It can be reduced by a combination of hygienic measures (quitting smoking, maintaining an adequate rest and work regime, regulated physical activity) and systematically taking medications. However, in older people, a sharp decrease in blood pressure leads to a deterioration in blood supply to the brain, so the regimen and dosage of the drug must be strictly followed. A healthy, balanced diet allows you to maintain a constant body weight and fight high cholesterol levels. Food should be easily digestible. enriched with vitamins and vegetable fats. Four meals a day are optimal, last appointment no later than 19 o'clock. Animal fats are removed from the diet and replaced with vegetable fats, meat with fish, if necessary, use special drugs that lower cholesterol levels, eliminate salt, increase the amount of fresh fruits and vegetables rich in fiber consumed. Drug preventive measures include antihypertensive therapy , taking drugs that regulate lipid metabolism, antiplatelet agents as prescribed by a doctor.

1. Syndrome of impaired consciousness

Productive ones include delusions, hallucinations and other types of mental disorders that can develop with cerebral hemorrhage.

Unproductive ones include a feeling of stupor, stuporous state and coma.

Stupefaction is characterized by an increase in the threshold of perception, patients are lethargic, inhibited, indifferent, their answers are monosyllabic, they poorly focus on the topic of conversation, quickly become exhausted, disoriented, questions asked to the patient have to repeat phrases several times and pronounce them louder.
Stupor is characterized by a lack of speech contact, pathological drowsiness, while the eyes remain open to sound and painful stimuli.
Coma is characterized by “unawakenability”, lack of opening the eyes to stimuli, lack of motor activity, possible presence of uncoordinated protective movements (to pain), and in the terminal stage vital functions (breathing, blood circulation) are disrupted.

2. Movement disorder syndrome

paralysis (plegia) - complete loss of limb function,
paresis - partial loss of limb function.

In the acute period of a stroke, the tone of the affected muscles is usually reduced, and muscle hypotension is observed. Subsequently, muscle tone increases, spastic paresis develops up to the formation of the characteristic posture of a patient who has suffered a stroke, figuratively called “the hand asks, the leg squints/- - flexion in the elbow and radiocarpal joints and extension in the ankle and knee joints.

pain (headache, pain in paralyzed limbs).
decreased physical activity and ability to self-care due to paralysis (paresis),
difficulty communicating due to speech disorders;
psycho-emotional disorders (fear, anxiety, restlessness, depression) associated with helplessness and fears for one’s future.

The course of different types of stroke has some characteristics.

emergency nature - medical care in the so-called “therapeutic window” (the first 3-6 hours from the onset of the disease) allows to reduce the number of complications and improve the outcome of treatment,
intensity - at first, patients are in the intensive care unit, focusing on all the causes that led to the development of stroke;
complexity - treatment of conditions that directly threaten the patient’s life, prevention of complications, early rehabilitation.
phasing - conditionally, patient management is divided into the following stages: pre-hospital, inpatient, rehabilitation

Before emergency assistance arrives, the patient is positioned so that the head is above the plane of body support. The pillows should be placed so that the elevation starts from the level of the shoulder blades. You should unbutton the patient's collar and make sure that clothing does not interfere with free breathing. First of all, the false jaws, if any, are removed. According to the recommendations of the National Stroke Association, if a patient’s blood pressure increases, it is necessary to give him the usual antihypertensive medications, while not allowing a sharp decrease in blood pressure (so as not to cause rapid growth of the stroke focus and damage to large areas of the brain). Blood pressure should be stabilized within mm above the normal level.

diagnostics (type of stroke, reasons for its development), the results of which determine the choice of drug therapy,
correction of basic body functions, therapy of neurological disorders,
prevention of complications acute period stroke,
early rehabilitation

Nursing care. The responsibilities of a nurse include

initial assessment of the patient’s condition and risk factors for complications,
drawing up a nursing care plan for the patient,
monitoring the patient's condition and risk factors for complications.

In the acute period of stroke, the main measures are aimed at improving the general physical condition of the patient, preventing conditions associated with immobility, identifying neurological deficits and, in accordance with preserved capabilities, improving motor, speech, sensory functions, psycho-emotional state, restoring self-care and stereotypical household skills, prevention of recurrent stroke.

treatment of complications and concomitant diseases;
prevention of recurrent stroke.
correction of psycho-emotional disorders.

At this stage, rehabilitation means (physiotherapy, kinesiotherapy, occupational therapy) are more widely used in connection with the improvement in the general condition of the patient. Much attention is paid to solving problems associated with stable pathological conditions. The main problems of the patient during this period are movement disorders associated with spastic hemiparesis and the formation of pathological posture, pain associated with increased muscle tone. headache, difficulty communicating associated with speech disorders, depressive state The goal of treatment at this stage is maximum adaptation of the patient to the neurological deficit by using the remaining functions, increasing the ability to self-care, solving social problems of the patient and his family. The main role in solving these problems is played by the family nurse. Her tasks include:

active patronage of post-stroke patients at home,
receiving patients on an outpatient basis,
running specialized schools for post-stroke patients,
organization of hospitalization at home (for non-hospitalized patients or those in need of continued treatment after inpatient stages

Particular attention at the outpatient stage is paid to the prevention of recurrent strokes, including

good nutrition and physical activity,
combating risk factors,
regular visits to the doctor,
daily intake of antiplatelet agents (aspirin, chimes) and a course of medications that improve cerebral circulation (Instenon, Actovegin, Fezam).

monitors blood pressure, pulse, and, if necessary, monitors ECG.
checks the patient's observation diary of his condition.
helps the patient understand the medication regimen, draws up a memo for the patient, writes down the medications the patient takes without a doctor’s prescription;
monitors the timely delivery of tests, if necessary, writes out a referral for tests or independently collects samples,
assesses the ability for self-care over time, plans nursing interventions in accordance with the identified problems of the patient

For ease of observation, patients are divided into three observation groups.

General observation group - patients with 1

2 risk factors that require monitoring by a family doctor or geriatrician. The tasks of the nurse are to carry out health education work, identify risk factors through questioning, provide advice on their correction, and teach methods of monitoring one’s condition.

A high-risk group for stroke - patients who have more than two risk factors for stroke, they should be observed by a family doctor and consulted with a neurologist once every six months. The nurse invites patients to a scheduled appointment, conducts classes at the patients’ schools (according to risk factors), for example, at school diabetes mellitus, a school for patients with arterial hypertension, before a planned visit, sends the patient for tests (clinical blood test, prothrombin, sugar, lipid spectrum blood). As prescribed by the doctor, sends the patient to a day hospital or organizes hospitalization at home

A group of patients who have suffered a stroke, are observed by a family doctor and are referred for examination to a neurologist once every 3 months or when their condition worsens. This group actively conducts secondary prevention activities and conducts classes at the school for post-stroke patients.

A special aspect of secondary prevention of strokes is maintaining a school for post-stroke patients. Classes are organized for outpatients, as well as relatives caring for post-stroke patients at home, and are conducted jointly by a neurologist and a specially trained nurse.

selection of patients and their formation into groups (for example, by duration of stroke, by neurological defect, etc.);
conducts practical classes in physical therapy, teaches the patient to monitor his condition, together with the patients draws up a personal card for the post-stroke patient, including information about the duration of the stroke, medications taken, existing other diseases, usual blood pressure levels, contact numbers;
gives lectures on combating the main risk factors for stroke, rules of behavior for patients who have suffered a stroke, nutritional therapy;
if necessary, refers patients for consultation to a psychotherapist, psychologist, physiotherapist,
calls patients for routine examinations to a neurologist,
maintains medical records

Patients who have suffered an acute cerebrovascular accident will need care from loved ones for several years, especially patients who have become “prisoners” of their apartment or room. For such patients and their relatives, the help of a visiting nurse is necessary. The visiting nurse must clearly understand and instill in her ward that a victim of acute stroke can not only develop his speech or motor skills, but also expand the scope of his self-care, as well as perform simple independent work.

select a separate bright room, remove unnecessary furniture, remove carpets, hide wires to prevent injuries, arrange furniture so that the patient can independently move from bed to chair, to the table and then select unbreakable dishes. If the patient is bedridden, then ensure the most comfortable approach to the bed to provide care for the patient. Explain to relatives the rules of care, teach them how to use auxiliary means (bed, bolsters, sippy cup). The patronage nurse should familiarize relatives with the specifics of caring for post-stroke patients, features of diet and drinking regime, and teach simple methods monitoring the patient’s condition, measuring blood pressure and pulse, and an algorithm of measures if the patient’s condition worsens.

Stages of nursing care after stroke

Timely and correctly provided medical care for a cerebral stroke is the key to preserving the life and health of the patient. The nursing process occupies an important place at all stages of treatment and rehabilitation of a person with this pathology. Mid-level medical workers must not only carry out doctors’ orders. They have own algorithm management of patients after acute cerebrovascular accident (ACI) or transient form of the disease (PTI). In many ways, the speed of recovery of the victim and the quality of his further social adaptation depend on the nurses.

Types and stages of the nursing process

The entire list of activities that are carried out in the process of nursing care can be divided into three groups:

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Dependent activities that are performed after receiving physician orders.
Independent procedures provided for by the rules and not requiring the approval of superior specialists.
Interdependent manipulations - prescribed by a doctor and carried out by a nurse, but after some actions have been performed by other personnel.

In the intensive care ward or rehabilitation department for patients after a violation of the blood supply to the brain, nurses act strictly according to the established scheme:

the patient is examined to determine the extent of the lesion, assess the general condition, and identify potential complications;
a preliminary nursing diagnosis(impaired movement, speech, sensitivity, vital important functions, asthenia);
an action plan is drawn up, independent of the doctor’s instructions, in order to ensure the patient’s life and speed up the process of his recovery;
implementation of assigned tasks in the process of interaction with other medical personnel;
assessment of the results of the work done, which is carried out taking into account the goals set at the very beginning.

A separate stage of a nurse’s work during a stroke is the need to communicate with the patient himself and his relatives. The specialist must be competent, open and accessible. The patient’s mood and his body’s response to the treatment procedures depend on his actions in this direction.

Download the video course “Life after a stroke”

A step-by-step rehabilitation program after a stroke at home. The video course is indispensable for patients who have suffered a stroke and their relatives. Contents of the program.

Nurse's responsibilities when caring for a patient with stroke

The importance of nursing care for acute cerebrovascular accidents is due to the fact that at each stage of therapy a lot of unforeseen problems can arise. The general condition of the patient and the speed of his recovery depend on the nurse’s observation and her reaction. Nursing staff must monitor the victim’s vital signs and their dynamics. In an unstable situation, data must be taken every 2-3 hours and changes reported to the attending physician.

During treatment and rehabilitation, the victim is required to receive drug treatment in the form of injections, droppers, oral forms of drugs. The nurse must not only distribute pills to the wards and put in IVs, but also make sure that the patient receives the necessary product. After a stroke, there are frequent cases of changes in consciousness in victims. Some of them may rip out IVs, forget to take medications, or even hide them.

Early nursing work

The acute period after a stroke is critical for the patient, regardless of whether he had a hemorrhagic or ischemic form of pathology. Over the course of several days, mid-level medical staff perform manipulations aimed at reducing the risk of death of the patient and the likelihood of his developing complications. High-quality care in the future will also affect the speed of recovery of lost or altered skills.

Monitoring vital signs and functions

The first action at this stage is to prevent respiratory arrest. In a patient admitted to the hospital, it is necessary to examine the oral cavity and free it from vomit, dentures, and, if necessary, eliminate the retraction of the tongue. Sanitation of the mouth and pharynx should be carried out daily. If necessary, passive breathing exercises are performed.

In addition, it is necessary to ensure compliance with the following points:

feeding the patient in case of impaired motor functions (through a tube or from a spoon);
maintaining water balance;
hemodynamic control;
assessment and correction of the victim’s mental state;
pain relief and elimination of tissue swelling;
control of heart rate and blood pressure.

The frequency of all manipulations is established by a resuscitator or other senior specialist. The nurse should immediately report any changes in the patient's condition to the doctor.

Prevention of complications

An important point in the planning stage is drawing up a list of actions aimed at preventing the occurrence of additional problems. First of all, the nurse must strictly follow the doctor’s orders. This will allow the patient to recover from a critical condition faster and prevent him from developing a second stroke.

Other preventive manipulations are aimed at preventing:

bedsores - increased attention is paid to the personal hygiene of a bedridden patient, the treatment of potentially problem areas, regular changes in body position;
thrombosis of the lower extremities - tightly bandaging the legs and giving the lower part of the body an elevated position;
pneumonia - turning the patient over every 2.5 hours to prevent congestion;
urinary tract infections - use disposable diapers or regularly wash the bladder if you have an indwelling catheter.

In some cases, a stroke leads to dysfunction pelvic organs. Then, to satisfy the patient’s natural physiological needs, catheterization and enema procedures are performed. These manipulations are also performed by nurses.

Features of the rehabilitation stage

At the end of the critical period, the patient’s recovery process after stroke begins. The nurse takes an active part in it. She continues to carry out many of the already listed manipulations to monitor the victim’s condition and prevent complications. This list includes procedures aimed at restoring motor, speech and social activity of a person. Often, mid-level medical staff are responsible for conducting basic physical therapy exercises and massage.

A nurse must be a good psychologist, because she has to communicate with the patient and his loved ones. During the process of care, she is able to push the victims to perform some self-care manipulations.

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During the restoration of walking, you need to influence the main components that form walking. Contents of the program.

As a person returns to physical activity, nursing care includes walking and strengthening self-care skills after working with specialized specialists.

Outpatient care and medical examination

The period of rehabilitation of patients after a stroke does not end with discharge from the hospital or specialized center. The program developed by specialists will give maximum effect, if you continue to use it at home. Recovery, which can take months, requires outside supervision. Most often, these responsibilities fall on the shoulders of mid-level medical staff.

During this period, the responsibilities of nurses are as follows:

patronage visits to patients at home to monitor their general condition and implement the rehabilitation scheme;
assisting the doctor in managing outpatient appointment people who have had a stroke and are at risk of having another stroke;
providing information to the patient’s relatives in order to prevent complications and relapses;
drawing up instructions for stroke victims based on the recommendations of the attending physician;
control of dispensary reception of patients assigned to a medical institution.

Nursing care for patients who have suffered a stroke is important at all stages of working with the victim. People who have suffered a severe shock, do not feel confident in their own body and their strengths, need constant support. Help, tips and attention from an experienced nurse can return patients to the right mood. This will ensure a smoother exit from the critical period and increase the efficiency of the recovery phase.

Nursing process for stroke

Since a stroke is a lesion of the cerebral cortex through hemorrhage or ischemic necrosis, depending on the location of the process, a person loses the ability to perform certain functions. They may involve loss of social and professional abilities, but also affect vital functions.

During the treatment of the disease and the rehabilitation period, the nurse helps ensure the fulfillment of lost functions. Let's take a closer look at the nursing process for stroke.

Types of nursing care

The nurse is often only a performing staff member. Usually the attending physician or council gives appointments and prescribes the necessary procedures. But in addition to the doctor’s instructions, nursing staff have their own instructions and responsibilities, regardless of the instructions.

The nursing process is divided into:

dependent interventions - following doctor's orders;
independent interventions - performing duties that do not require doctor's approval;
interdependent interventions - the prescription of recommendations by a doctor and the implementation of the latter by a nurse after some manipulations by nursing staff.

Stages of the process

A nurse in a stroke department always has a clearly defined plan of action, and always follows the established canons. The nursing process in the treatment of stroke has 5 stages.

Initial examination of the patient and assessment of his condition. At this stage, the nurse determines the extent of the damage and what care the patient needs. For a complete picture, a carefully collected anamnesis will help: complaints or the neurological condition of the patient himself, a description of the loss of functions by relatives, a previous examination by a doctor and an anamnesis of diseases in the medical history, medical workers.
Preliminary nursing diagnosis. After collecting the information, the nurse determines the degree of inhibition of vital body functions and the degree of paresis of the limbs. And against the background of the collected picture, he distinguishes between potential and real problems, in the fight against which outside help is needed.
Planning stage. After determining the extent of the damage, the nurse develops a plan to combat the identified symptoms to ensure the patient’s vital functions and a speedy recovery. The goals and objectives set must be achievable, clearly defined with specific tasks and deadlines.
Execution phase. At this stage, the nurse, interacting with other employees and specialists, implements the planned plan. Read more about possible actions below. This step, in fact, is performed throughout all periods of treatment (from the acute period to rehabilitation).
Evaluating the effectiveness of the work done. The final stage is carried out almost throughout the entire period of therapy to achieve the goal. The work performed should be assessed by the nurse herself, but it is important to take into account the patient’s opinion.

The last stage can be assessed in three gradations:

goal accomplished;
the goal is partially achieved;
the goal was not achieved.

In case of incomplete or non-achievement of the set objectives, nursing staff must indicate the reason that prevented the plan from being fully implemented.

General rules of nursing care during the execution phase

At different periods of therapy, the nurse encounters various problems related to the patient's health that need to be eliminated.

Throughout the entire period of treatment, the nursing staff carries out the doctor’s orders, which consist of administering droppers with medicine, intramuscular and intravenous injections. It is important to monitor the intake of tablet medications, since many patients with stroke are in the hospital with limb paresis of varying degrees. That is, they will not be able to take the drug on their own. Slight retardation and a degree of consciousness “stunning” are also possible. There are no physical reasons for the inability to take the medicine, but there are mental disorders. Also, atherosclerotic dementia (against the background of physiological signs of aging) can play a cruel joke on short-term memory.

In addition to monitoring drug therapy, the nurse is responsible for dynamic data. Physiological functions (stool, diuresis) are monitored daily, body temperature and blood pressure are measured twice a day. If the patient's condition is unstable, blood pressure is measured in both arms every 3 hours, since a possible recurrent stroke or a possible post-stroke infarction may be primarily indicated by increased unstable blood pressure. The pulse in the main arteries, its discrepancy with the heart rate, and the frequency of respiratory movements are monitored.

Until the condition stabilizes, the nurse monitors the level of consciousness. All data is recorded on a prescription sheet, which is then transferred by the doctor to the medical history.

Functions of a nurse in the early period

The acute period is the most difficult for the patient. It is in these few days that the fate of the patient is decided, reducing the risk of mortality and the degree of restoration of lost functions.

This period requires the greatest dedication and care from the nurse to the patient. First of all, for the average medical personnel The following questions should come first:

security respiratory function and prevention of apnea;
ensuring nutritional and hydration balance;
prevention of secondary complications and recurrent stroke;
reducing the risk of thrombosis of the veins and arteries of the lower extremities;
hemodynamic control;
control and relief of pain and swelling in paralyzed limbs;
control and correction of the patient’s mental state;
prevention of bedsores and moisturizing of the skin;
ensuring the functional ability of the pelvic organs;
minimizing emotional and physical stress on the body.

Providing vital functions

The first step is to prevent apnea or aspiration. To do this, immediately after admission to the hospital, the nurse must check the oral cavity for the presence of dentures, vomit, and retraction of the root of the tongue. The reason for the lack of breathing may be a violation of the cough reflex with further accumulation of bronchial secretions in the bronchi.

To resolve such issues, you must follow some rules:

sanitation of the oral cavity or tracheostomy with removal of secretions from the trachea and bronchi;
Adoption special provision(Trendelenburg) with the head end lowered and the head turned to the left;
periodically performing passive breathing exercises.

If motor functions are impaired, the nurse is also involved in nutrition. If there are stem symptoms, and there is a violation of consciousness and the swallowing reflex, then the patient needs to have a nasogastric tube placed. Every 4 hours, the nurse feeds the patient liquid homogeneous food using a syringe through a tube. If a patient has paresis of the limbs, the nurse simply helps the patient eat regular food.

Hydration consists of parenteral and enteral infusions. With their help, water balance is maintained taking into account physiological losses.

Prevention of complications

First of all, to avoid a recurrent stroke, it is necessary to stay with the patient around the clock, strictly follow the doctor’s instructions and ensure maximum emotional and physical peace. In case of increased blood pressure or complaints from the patient, immediately contact a doctor and provide emergency assistance.

To avoid the development or occurrence of vascular thrombosis of the lower extremities, you need to tightly bandage your legs with an elastic bandage. Lack of movement and the impossibility of early activation due to the high risk of recurrent cerebrovascular accident require tight bandaging. It wouldn't hurt to give the limb an elevated position. Using pillows or bolsters, elevate the limb at an angle of 30°. It will also reduce swelling and improve circulation.

Preventing bedsores is a big part of a nurse's work. special place. This needs to be given due attention and not neglected. It is advisable to adhere to the following:

observe the rule of daily change of underwear;
change bed linen when soiled;
observe the rules of hygiene in relation to the patient and wipe the areas of contact with camphor alcohol;
every 2 hours, in the absence of independent movement, change the patient’s position (frequently used positions: lying on the back, on the stomach, on the side, the “frog” position, the Fowler and Sims position);
place special cushions under the sacrum, heels and shoulder blades.

Elimination of pain and swelling in a paralyzed limb is mainly achieved by the above methods of preventing limb thrombosis. In addition, every day the nurse performs a certain amount of passive movements with paralyzed limbs, which will help improve circulation, lymphatic drainage and prevent arthropathies.

Normalization of physiological functions

A stroke can impair the functions of the pelvic organs. This may manifest itself as sphincter weakness due to central paresis and urinary and fecal incontinence or reflex retention and inability to defecate.

To normalize diuresis, a catheter is installed. For women, the procedure is performed by nurses. If the patient is a man, then the case is left to the urologist due to the complexity of the structure (turns and strictures) of the male urethra.

As for stool, most often patients develop intestinal paresis with further constipation. To solve the problem, nurses immediately do enemas. And after the condition has normalized (excessive straining can provoke a repeat case of hemorrhagic stroke), you can help with gentle laxatives (Duphalac).

Nurse's work during rehabilitation

After the body’s functionality is restored and a stable state is established, the rehabilitation period begins. At this stage, motor activity, speech abnormalities, and the mental sphere are more restored. Restore social, everyday and, if necessary, professional ability to work as much as possible.

The nurse at this stage also takes an active part, and the fulfillment of assigned tasks depends even more on the organization of the work of nursing staff.

To restore motor activity, the nurse performs physical therapy in the evenings and on weekends, monitors individual work the patient above himself, helps the patient move.

In the recovery of mental and sensorineural disorders, the nurse acts as a teacher, following the instructions of the speech therapist. She re-teaches the patient to read, write, pronounce sounds and then sentences.

Organizing a work and rest schedule will help restore everyday working capacity, that is, renew self-care skills. The nurse must tactfully distribute active and passive loads and be a support for the patient. Supporting the patient from the moral and physical side will help a quick recovery.

Before discharge, the nurse talks with relatives about further care, activities and special diet.

The role of the nurse in the rehabilitation of a patient after a stroke in a hospital setting

General characteristics of stroke as an acute cerebrovascular accident. Etiology, classification, clinical picture, diagnosis of stroke. Nursing process plan for stroke in the hospital setting. Manipulations performed by a nurse.

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STATE BUDGET EDUCATIONAL

INSTITUTION OF SECONDARY VOCATIONAL

EDUCATION OF THE CITY OF MOSCOW

"MEDICAL COLLEGE No. 5

DEPARTMENT OF HEALTH OF THE CITY OF MOSCOW"

Completed by: 4th year student, group 42

Head: Turakhanova N.V. PM teacher

Candidate of Medical Sciences

Today, about 9 million people in the world suffer from cerebrovascular diseases. The main place among them is stroke.

Every year, cerebral stroke affects from 5.6 to 6.6 million people and claims 4.6 million lives; mortality from cerebrovascular diseases is second only to mortality from heart disease and tumors of all localizations and reaches economically developed countries 11-12%. The annual mortality rate from strokes in the Russian Federation is one of the highest in the world (175 per 100 thousand population).

There is a rejuvenation of stroke with an increase in its prevalence in people of working age - up to 65 years. Morbidity and mortality rates from stroke among people of working age in Russia have increased over the past 10 years by more than 30%.

The early 30-day mortality rate after a stroke is 34.6%, and approximately half of those affected die within a year. Another disaster associated with stroke is that it is the leading cause of serious loss of functional capacity, regardless of age, gender, ethnic origin, or country. Stroke turns out to be the leading cause of disability in the Russian population; 31% of patients who have suffered it require outside help, another 20% cannot walk independently, only 8% of surviving patients are able to return to their previous work. Stroke imposes special obligations on the patient’s family members, significantly reducing their work potential, and places a heavy socio-economic burden on society.

Cerebrovascular diseases cause enormous damage to the economy, taking into account the costs of treatment, medical rehabilitation, and losses in production.

Thus, stroke is a state medical and social problem Therefore, real efforts to organize effective preventive measures and improve the system of providing medical care to patients with a stroke are so significant and important.

Study of nursing activities in caring for patients with stroke.

Nursing process in the treatment of patients with stroke in a hospital setting.

The effectiveness of nurse participation in the treatment of patients with stroke in a hospital setting.

1. Based on a theoretical study of literature sources, identify and study risk factors for stroke, classification, variants of the clinical course of the disease, main treatment methods and possible complications.

2. Explore the role of the nurse in ensuring the quality of life of patients who have suffered a stroke.

3. Conduct a practical study of nursing participation in the treatment of patients with stroke in a hospital setting.

4. Analyze the research results.

1. Analysis of literary sources.

2. Observation from practice of two patients with stroke.

stroke cerebral circulation sister

Chapter 1. Stroke

Stroke is an acute cerebrovascular accident (ACVA), characterized by the sudden (within minutes, hours) appearance of focal and/or cerebral neurological symptoms, which persist for more than 24 hours or lead to the death of the patient in a shorter period of time due to cerebrovascular pathology. Stroke includes cerebral infarction, cerebral hemorrhage and subarachnoid hemorrhage, which have etiopathogenetic and clinical differences. Taking into account the time of regression of neurological deficit, transient cerebrovascular accidents (neurological deficit regresses within 24 hours, unlike the stroke itself) and minor stroke (neurological deficit regresses within three weeks after the onset of the disease) are especially distinguished. Vascular diseases of the brain occupy second place in the structure of mortality from diseases of the circulatory system after coronary heart disease.

b genetic predisposition;

b increased content blood lipids, obesity;

b arterial hypertension;

b heart disease;

b diabetes mellitus;

Ischemic stroke (cerebral infarction)

Ischemic strokes are divided into:

With ischemic stroke, there is an integration of hemodynamic and metabolic disorders that occur at a certain stage of circulatory failure. Chemical cascade reactions that occur in all areas of the brain (especially damaged ones) lead to changes in neurons, astrocytosis and activation of glia, and disruption of the trophic supply of the brain. The outcome of cascade reactions is the formation of a cerebral infarction. The severity of ischemic stroke is primarily determined by the depth of the decrease in cerebral blood flow, the duration of the preperfusion period and the extent of ischemia. The area of the brain with the most pronounced decrease in blood flow (less than 10 ml/100 g/min) becomes irreversibly damaged within 6-8 minutes from the onset of the first clinical symptoms. The formation of most of the cerebral infarction zone ends within 3-6 hours from the moment the first symptoms of a stroke appear.

Hemorrhagic strokes are divided into the following types of hemorrhages:

b) meningeal (subarachnoid, subdural, epidural);

Parenchymal hemorrhages most often occur with hypertension, as well as with secondary hypertension associated with kidney disease or endocrine glands. Less commonly, they develop with vasculitis, connective tissue disease (lupus erythematosus), sepsis, after traumatic brain injury, with hemorrhagic diathesis, uremia. Hemorrhage in the brain develops more often as a result of rupture of a vessel and much less often due to increased permeability of the vascular wall. There are hematomas and hemorrhagic impregnation of brain tissue.

The cause of subarachnoid hemorrhage is most often the rupture of an intracranial aneurysm, less often - the rupture of vessels altered by an atherosclerotic or hypertensive process.

By nature they distinguish:

Ischemic stroke - occurs due to a blood clot or atherosclerotic plaque in the arteries.

· hemorrhagic stroke - occurs as a result of hemorrhage into the substance of the brain or under the meninges during a hypertensive crisis, rupture of a modified vessel.

Along the flow they distinguish:

According to severity they are distinguished:

b Mild to moderate severity - without disorders of consciousness with a predominance

focal neurological symptoms.

b Severe - with depression of consciousness, signs of cerebral edema, disruption of the activity of other organs and systems.

There is also a separate form of stroke - small stroke (in which neurological symptoms completely disappear after 3 weeks).

Most often occurring as people age. A persistent increase in blood pressure contributes to the weakening of the walls of small cerebral vessels and the development of microaneurysms, the rupture of which leads to hemorrhage into the brain substance. The spilled blood forms a hematoma, which can increase in size over several minutes or hours until a blood clot forms at the site of the rupture of the vessel. In hemorrhage associated with arterial hypertension, hematomas are often localized in the deep parts of the brain, mainly in the area of the internal capsule, where nerve fibers pass that connect the motor and sensory zones of the cerebral cortex with the trunk and spinal cord.

Symptoms of intracerebral hemorrhage:

· The patient may fall and lose consciousness;

· The patient's face becomes purple-red or bluish;

· breathing rare, deep;

Parenchymal hemorrhage is characterized by:

· intense pain in the head;

· depression of consciousness (up to coma);

Hemorrhage into the intrathecal space of the brain. In 80% of cases, spontaneous subarachnoid hemorrhage is caused by rupture of an intracranial aneurysm. More rare reasons yavl. trauma, intracranial artery dissection, hemorrhagic diathesis. SAH manifests itself as sudden, intense pain in the head.

At the moment of rupture of an aneurysm, the following is observed:

Half of the patients experience transient headaches within 2-3 weeks associated with compression of adjacent structures by the aneurysm, for example, dilated pupils caused by compression of the oculomotor nerve.

1.3 Clinical picture

Stroke can manifest as cerebral and focal neurological symptoms. General cerebral symptoms of stroke vary. This symptom may occur in the form of impaired consciousness, stupor, drowsiness, or, conversely, agitation, and may also occur momentary loss consciousness for a few minutes. A severe headache may be accompanied by nausea or vomiting. Sometimes dizziness occurs. A person may feel a loss of orientation in time and space. Possible vegetative symptoms: feeling of heat, sweating, palpitations, dry mouth.

Against the background of general cerebral symptoms of a stroke appear focal symptoms brain damage. The clinical picture is determined by which part of the brain is affected due to damage to the blood vessel supplying it.

If a part of the brain provides the function of movement, then weakness in the arm or leg develops, including paralysis. Loss of strength in the limbs may be accompanied by a decrease in sensitivity in them, impaired speech, and vision. These focal stroke symptoms are mainly associated with damage to the area of the brain supplied by the carotid artery. Muscle weakness (hemiparesis), speech and pronunciation disorders, decreased vision in one eye and pulsation of the carotid artery in the neck on the affected side are characteristic. Sometimes there is unsteadiness of gait, loss of balance, uncontrollable vomiting, dizziness, especially in cases where the blood vessels supplying the areas of the brain responsible for coordinating movements and a sense of body position in space are affected. “Spotty ischemia” occurs in the cerebellum, occipital lobes and deep structures and brain stem. Attacks of dizziness in any direction are observed when objects rotate around a person. Against this background, there may be visual and oculomotor disturbances (strabismus, double vision, decreased visual fields), unsteadiness and instability, deterioration in speech, movements and sensitivity.

1. MRI - allows you to see changes in brain tissue, as well as the amount of damaged cells caused by a stroke.

2. Doppler examination of the carotid arteries - The study allows you to see the condition of the arteries, namely, to see the damage to the vessels by atherosclerotic plaques, if any.

3. Transcranial Doppler study - ultrasound examination of cerebral vessels, which provides information about the blood flow in these vessels, as well as about their damage to fatty plaques, if any.

4. Magnetic resonance angiography - similar to an MRI study, only in this study more attention is paid to the vessels of the brain. This study provides information about the presence and location of a blood clot, if any, and also provides information about the blood flow in these vessels.

5. Cerebral angiography - this procedure involves injecting a special contrast agent into the vessels of the brain, and then using X-rays we obtain images of the vessels. This study provides data on the presence and location of blood clots, aneurysms and any vascular defects. This study is more difficult to perform, unlike CT and MRI, but is more informative.

6.ECG - Used in this case to detect any disturbances in heart rhythm (cardiac arrhythmias), which may cause the development of a stroke.

7. Cardiac echocardiogram (Echo-CG) - ultrasound examination of the heart. Allows you to detect any abnormalities in the functioning of the heart, as well as detect defects in the heart valves, which can cause blood clots or blood clots, which in turn can cause a stroke.

8. Biochemical analysis blood - this analysis necessary to determine two main indicators:

1. Blood glucose - necessary to establish an accurate diagnosis, since very large or very little content Blood glucose levels can trigger the development of stroke-like symptoms. And also for diagnosing diabetes mellitus.

2. Blood lipids - this analysis is necessary to determine the content of cholesterol and lipoproteins high density, which can become one of the causes of stroke.

On-site diagnostics:

It is possible to recognize a stroke on the spot, immediately; For this, three main techniques for recognizing stroke symptoms, the so-called “USP” are used. To do this, ask the victim:

· U - smile. With a stroke, the smile may be crooked, the corner of the lips on one side may be directed downward rather than upward.

· Z - to speak. Say a simple sentence, for example: “The sun is shining outside the window.” With a stroke, pronunciation is often (but not always!) impaired.

· P - raise both hands. If your arms don't rise at the same rate, this could be a sign of a stroke.

Additional diagnostic methods:

· Ask the victim to stick out his tongue. If the tongue is curved or irregular in shape and falls to one side or the other, then this is also a sign of a stroke.

· Ask the victim to stretch his arms forward, palms up, and close his eyes. If one of them begins to involuntarily “move” sideways and downwards, this is a sign of a stroke.

If the victim finds it difficult to complete any of these tasks, you must immediately call an ambulance and describe the symptoms to the doctors who arrived at the scene. Even if the symptoms have stopped (transient cerebrovascular accident), there should be one tactic - emergency hospitalization; elderly age, coma are not contraindications to hospitalization.

There is another mnemonic rule for diagnosing a stroke: U.D.A.R.:

· U - Smile After a stroke, the smile becomes crooked and asymmetrical;

· D - Movement Raise both arms and both legs up at the same time - one of the paired limbs will rise slower and lower;

· A - Articulation Say the word “articulation” or several phrases - after a stroke, diction is disrupted, speech sounds inhibited or simply strange;

· R - Decision If you find violations in at least one of the points (compared to the normal state), it’s time to make a decision and call an ambulance. Tell the dispatcher what signs of a stroke (STROKE) you have found and a special resuscitation team will arrive quickly.

b Vascular thrombosis;

b Pneumonia;

Bedsores - Necrosis of soft tissues, which is accompanied by poor circulation.

Vascular thrombosis is a blockage of a blood vessel by a blood clot. As a result, blood does not flow to certain parts of the body. Thrombosis often goes unnoticed.

Inflammation of the lungs - Appears due to a violation of the function of expectoration of sputum accumulating in the lungs.

Paralysis - The patient is unable to move the limbs of the arms and legs;

Coma - Manifests itself in a prolonged loss of consciousness. The person does not respond to the stimulus, breathing is impaired, and he loses the ability to brain activity, loses some brain functions.

Death - after hemorrhagic - mortality exceeds 80% of all cases, after ischemic - up to 40%, after subarachnoid hemorrhage - from 30% to 60%.

1.6 First aid for stroke

1) In case of a stroke, it is most important to take the person to specialized hospital as quickly as possible, preferably within the first hour after symptoms are detected. It should be borne in mind that not all hospitals, but only a number of specialized centers are equipped to provide proper modern stroke care. Therefore, attempts to independently transport a patient to the nearest hospital during a stroke are often ineffective, and the first action is to call emergency services for medical transport.

2) Before the ambulance arrives, it is important not to allow the patient to eat or drink, since the swallowing organs may be paralyzed, and then food entering the respiratory tract can cause suffocation. At the first signs of vomiting, the patient's head is turned to the side so that the vomit does not enter the respiratory tract. It is better to lay the patient down with pillows under his head and shoulders, so that the neck and head form a single line, and this line makes an angle of about 30° to the horizontal. The patient should avoid sudden and intense movements. The patient is unbuttoned from tight, obstructive clothing, his tie is loosened, and his comfort is taken care of.

3) In case of loss of consciousness with absent or agonal breathing, cardiopulmonary resuscitation is started immediately. Its use greatly increases the patient's chances of survival. Determining the absence of a pulse is no longer a necessary condition for starting resuscitation; loss of consciousness and absence of rhythmic breathing are sufficient. The use of portable defibrillators further increases survivability: when in a public place (cafe, airport, etc.), first aid providers need to ask the staff if they have a defibrillator or nearby.

Basic therapy for stroke

Normalization of external respiration and oxygenation function

· Sanitation of the respiratory tract, installation of an air duct. At pronounced violations gas exchange and level of consciousness to ensure patency of the upper respiratory tract, endotracheal intubation is performed for the following indications:

· Patients with acute stroke should be under pulse oximetry monitoring (blood saturation O 2 not lower than 95%). It should be taken into account that ventilation can be significantly disrupted during sleep.

· If hypoxia is detected, oxygen therapy should be prescribed.

· In patients with dysphagia, decreased pharyngeal and cough reflexes an oro- or nasogastric tube is immediately installed and the issue of the need for intubation is decided due to the high risk of aspiration.

Antihypertensive therapy for ischemic stroke.

Blood pressure control in a patient with ischemic stroke, during and after reperfusion therapy (thrombolysis), is achieved with the following drugs:

It is also possible to use the following drugs to lower blood pressure: captopril (Capoten, Captopril tablet), or enalapril (Renitek, Ednit, Enap) orally or sublingually, IV slowly over 5 minutes.

It is also possible to use the following drugs: bendazole (Dibazol) - i.v. clonidine (Clonidine) IV or IM.

Reducing cerebral edema

· Stabilization of systolic blood pressure at the level. rt. Art. Maintaining normoglycemia (3.3-6.3 mmol/liter), normonatremia (mmol/liter), plasma osmolality (mosm), hourly diuresis (more than 60 ml per hour) at an optimal level. Maintaining normothermia.

· Raising the head end of the bed by 20-30%, eliminating compression of the neck veins, avoiding turning and tilting the head, relieving pain and psychomotor agitation.

· Prescription of osmodiuretics is carried out with increasing cerebral edema and the threat of herniation (i.e. with increasing headache, increasing depression of consciousness, neurological symptoms, development of bradycardia, anisocoria (inequality in the size of the pupils of the right and left eyes)), and is not indicated in a stable condition sick. Glycerin or glycerol, mannitol are prescribed. To maintain the osmotic gradient, it is necessary to replace fluid losses.

· If osmodiuretics are ineffective, it is possible to use 10-25% albumin (1.8-2.0 g/kg body weight), 7.5-10% NaCl (100.0 2-3 times a day) in combination with hypertonic solutions of hydroxyethyl starches (Refortan 10% ml/day).

· Tracheal intubation and artificial ventilation in hyperventilation mode. Moderate hyperventilation (normally - tidal volume ml/kg of ideal body weight; respiratory rate per minute) leads to a rapid and significant decrease in intracranial pressure, its effectiveness remains for 6-12 hours. However, long-term hyperventilation (more than 6 hours) is rarely used, since it causes a decrease in cerebral blood flow can lead to secondary ischemic damage to the brain substance.

If the above measures are ineffective, non-depolarizing muscle relaxants (vecuronium, pancuronium) are used. sedatives(diazepam, thiopental, opiates, propofol), lidocaine (Lidocaine hydrochloride solution d/in.).

Drainage of cerebrospinal fluid through a ventriculostomy (drainage installed in the anterior horn of the lateral ventricle), especially in conditions of hydrocephalus, is effective method reducing intracranial pressure, but is usually used in cases of monitoring intracranial pressure through the ventricular system. Complications of ventriculostomy include the risk of infection and hemorrhage into the ventricles of the brain.

For single convulsive seizures, diazepam is prescribed (IV 10 mg in 20 ml of isotonic sodium chloride solution), and again, if necessary, after a minute. When stopping status epilepticus, diazepam (Relanium), or midazolam 0.2-0.4 mg/kg IV, or lorazepam 0.03-0.07 mg/kg IV is prescribed, and again, if necessary, later.

If ineffective: valproic acid 6-10 mg/kg IV for a minute, then 0.6 mg/kg IV dropwise up to 2500 mg/day, or sodium hydroxybutyrate (70 mg/kg in an isotonic solution at a rate of ml/ min).

If ineffective, thiopental IV bolus mg, then IV drip at a rate of 5-8 mg/kg/hour, or hexenal IV bolus 6-8 mg/kg, then IV drip at a rate of 8-10 mg/kg /hour.

If these drugs are ineffective, stage 1-2 surgical anesthesia is performed with nitrous oxide mixed with oxygen in a 1:2 ratio for 1.5-2 hours after the end of the convulsions.

Nausea and vomiting

For persistent nausea and vomiting, metoclopramide (Cerucal), or domperidone, or thiethylperazine (Torekan), or perphenazine, or vitamin B 6 (pyridoxine) is prescribed intravenously.

For psychomotor agitation, diazepam (Relanium) mg IM or IV, or sodium hydroxybutyrate mg/kg IV, or magnesium sulfate (Magnesium sulfate) mg/hour IV, or haloperidolmg IV or IM are prescribed. In severe cases, barbiturates.

For short-term sedation, it is preferable to use fentanyl mcg, or thiopental sodium mg or propofolmg. For procedures average duration and transportation to MRI, morphine 2-7 mg, or droperidol 1-5 mg is recommended. For long-term sedation, along with opiates, you can use sodium thiopental (bolus 0.75-1.5 mg/kg and infusion 2-3 mg/kg/hour), or diazepam, or droperidol (boluses 0.01-0.1 mg/hour). kg), or propofol (bolus 0.1-0.3 mg/kg; infusion 0.6-6 mg/kg/hour), to which analgesics are usually added.

Adequate nutrition of the patient

Should be started no later than 2 days from the onset of the disease. Self-feeding is prescribed in the absence of impaired consciousness and the ability to swallow. In case of depression of consciousness or impaired swallowing, tube feeding is performed with special nutritional mixtures, the total energy value of which should be kcal/day, daily amount of protein 1.5 g/kg, fat 1 g/kg, carbohydrates 2-3 g/kg, water 35 ml/kg, daily amount of fluid administered is at least ml. Tube feeding is carried out if the patient has uncontrollable vomiting, shock, intestinal obstruction or intestinal ischemia.

Change in muscle tone

After the development of a stroke, the muscle tone in the arms and legs changes, with higher tone in the flexors in the arms, and in the extensors in the legs. If you do not start movement in the spastic limbs in time and do not give them a functionally advantageous position, then contractures may develop leading to the formation of a posture Wernicke-Mann.

The correct position of the limb begins to be given 2-3 days after the stroke.

In the supine position: the arm is straightened at the elbow and wrist joints, supinated, the shoulder is laid aside, the fingers are straightened, the first finger is laid to the side, the leg is slightly bent at the knee, the foot should be extended at an angle of 90 degrees and placed in a special boot or resting into the headboard.

In the position on the healthy side: the paralyzed limbs should be bent on the floor and laid on a pillow, the healthy leg should be slightly bent and set back, the hand of the paralyzed arm should be extended and laid on the pillow. To avoid rolling down the patient, 1-2 pillows should be placed under the back.

1.8 Stroke prevention

Prevention of strokes consists of maintaining a healthy lifestyle, timely detection of concomitant diseases (especially arterial hypertension, heart rhythm disturbances, diabetes mellitus, hyperlipidemia) and their adequate treatment.

1. Prevention of the development of atherosclerosis. It is necessary to follow a diet, regularly monitor blood cholesterol levels, and take lipid-lowering medications as prescribed by a doctor if lipid metabolism disorders are detected.

2. Regular physical activity is necessary to prevent the development of obesity, type 2 diabetes and hypertension.

3. Stop smoking. Smoking increases the risk of developing cardiovascular disease and atherosclerosis, which leads to stroke

4. Reduction of hyperlipidemia.

5. Fight stress. Unfavorable factors worsen the patient's condition.

To reduce the irritating effect of the drug on the stomach, use aspirin in a coating that does not dissolve in the stomach (thrombo-ASS) or prescribe antacids.

If doses of aspirin are ineffective, anticoagulants (warfarin, neodicoumarin) are prescribed.

Depends on the etiology and course of the underlying vascular disease, on the nature and rate of development of the pathological process in the brain, on the localization and extent of the lesion, as well as on complications.

A poor prognostic sign for hemorrhagic stroke is a deep degree of impairment of consciousness, especially early development coma. The appearance of oculomotor disturbances, hormetonia, decerebrate rigidity or diffuse muscle hypotonia, the presence of a disorder of vital functions, pharyngeal paralysis, and hiccups is unfavorable. The prognosis worsens with poor physical condition of patients, especially due to cardiovascular insufficiency.

Forecast ischemic stroke more severe in case of extensive hemispheric infarctions that developed as a result of acute blockage of the intracranial part of the internal carotid artery, accompanied by disconnection of the arterial circle of the brain, and blockage of the middle cerebral artery, as well as with extensive infarctions of the brain stem due to acute occlusion of the vertebral and basilar arteries. Signs of general cerebral edema and secondary damage to the brain stem, and general circulatory disorders are unfavorable prognostically. The prognosis is more favorable for limited brainstem infarctions, in young people and in satisfactory general condition of the cardiovascular system.

Complete restoration of lost functions is not always achieved. Currently, stroke is the leading cause of disability.

Chapter 2. Practical part

2.1 Nursing process plan for stroke in a hospital setting

The goal of the nursing process for stroke is to create for the patient the conditions necessary for recovery, prevent complications, alleviate suffering, and also provide assistance in fulfilling needs that he cannot fulfill himself at the time of illness.

· Conduct subjective and objective examinations of the patient.

· Identify the violated needs, real and potential problems of the patient.

The nurse carries out:

b Primary assessment of the patient’s condition and risk factors for complications;

b Training the patient and relatives in care and self-care;

b selection of patients and their formation into groups (for example, by duration of stroke, by neurological defect, etc.);

ь conducts practical classes in physical therapy, teaches the patient to monitor his condition, together with the patients draws up a personal card for the post-stroke patient, including information about the duration of the stroke, medications taken, existing other diseases, usual blood pressure levels, contact numbers;

ь gives lectures on combating the main risk factors for stroke, rules of behavior for patients who have suffered a stroke, nutritional therapy;

ь if necessary, refers patients for consultation to a psychotherapist, psychologist, or physiotherapist;

ь calls patients for routine examinations with a neurologist

ь maintains medical documentation;

Nursing Diagnosis Syndrome:

b Syndrome of movement disorders (paralysis, paresis, loss of coordination).

b Sensory impairment syndrome (numbness of the face, arms, legs).

b Speech impairment syndrome (difficulty pronouncing words, impairment of one’s own speech and understanding of others).

b Asthenia (increased fatigue, weakness, irritability, sleep disturbance).

Nursing intervention plan:

Ш Monitor blood pressure, pulse

Ш Carry out ECG monitoring.

Ш Check the patient's observation diary of his condition.

Ш Help the patient understand the medication regimen

Ш Draw up a memo for the patient, write down the medications that the patient takes without a doctor’s prescription;

Ш monitor the timely delivery of tests, if necessary, write out a referral for tests or independently collect samples,

Ш to assess the ability to self-service over time

Ш Conduct control of transferred products by relatives or other close people to inpatients

Ш Teach the patient relaxation techniques to relieve tension and anxiety

Ш Conduct a conversation with the patient/family.

Observation from practice:

A 75-year-old patient is hospitalized in the neurological department with a diagnosis of cerebral infarction in the territory of the right middle cerebral artery. Left-sided hemiparesis. The patient is conscious, there is weakness in the left extremities. He is inactive independently, needs outside help and care.

The patient underwent the following examinations

· General blood analysis

· Blood test for RW

MRI of the brain

· Chest X-ray

· Ultrasound of neck vessels

The patient is on bed rest. The nurse helps in meeting physiological needs (if necessary, carries out catheterization of the bladder) and carrying out hygienic measures. Carries out the prevention of bedsores, the development of pneumonia, and transports the patient for examinations.

A gentle diet was prescribed with the exception of animal fat, carbohydrates and table salt. The nurse helps the patient eat.

If necessary, provides tube feeding

Infusion therapy is carried out

intravenous drip (Cavinton 4.0 NaCl 200.0)

Intramuscular injections (ethamsylate 2.0; piracetam 5.0; combilipen)

Tablet drugs (Enap 10 mg x 2 times; thrombo ACC 50 mg)

The role of the nurse in this case is to set up a drip system and intramuscular injections. Help with taking pills. Monitors the patient’s condition after taking medications and promptly informs the doctor about the patient’s adverse reactions to the drug.

Algorithms of manipulations performed by a nurse

Algorithm of actions when installing an intravenous system

1. Wear gloves

2. Treat the area of the elbow bend measuring 10*10 cm with a sterile ball of alcohol

3. Treat the area of the punctured vein with a second ball of alcohol

4. Remove excess alcohol with a dry ball

5. Apply a tourniquet and ask the patient to use his fist

6. Puncture with a sterile needle from the system into the vein; if blood appears, place a sterile napkin under the needle

7. Remove the tourniquet and ask the patient to unclench his fist.

8. Connect the system to the needle cannula and open the clamp on the system

9. Secure the needle coupling to the skin with adhesive tape

10.Adjust the flow rate of drops (as prescribed by the doctor)

11. Cover the venipuncture site with a sterile napkin.

12. Apply a clamp to the system or close the valve on the system at the end of infusion therapy

13.Apply a sterile ball to the puncture site and remove the needle from the vein

14.Ask the patient to bend the arm at the elbow joint for 3-5 minutes

15. Throw the used syringe, needle, balls, gloves into a safe disposal box (KBU)

Technique for performing intramuscular injection:

1. soap, individual towel

3. ampoule with medicine

4. file for opening the ampoule

5. sterile tray

6. tray for waste material

7. disposable syringe with a volume of ml

8. cotton balls in 70% alcohol

9. skin antiseptic (Lizanin, AHD-200 Special)

10. Covered with a sterile napkin, a sterile patch with sterile tweezers

12. first aid kit “Anti-HIV”

13. containers with disinfectant. solutions (3% chloramine solution, 5% chloramine solution)

Preparation for manipulation:

1. Explain to the patient the purpose and course of the upcoming manipulation, obtain the patient’s consent to perform the manipulation.

2. Treat your hands at a hygienic level.

3. Assist the patient into the desired position.

Intramuscular injection technique:

1. Check the expiration date and tightness of the syringe packaging. Open the package, assemble the syringe and place it in a sterile patch.

2. Check the expiration date, name, physical properties and dosage of the drug. Check with the assignment sheet.

3. Take 2 cotton balls with alcohol with sterile tweezers, process and open the ampoule.

4. Fill the syringe with the required amount of the drug, release the air and place the syringe in a sterile patch.

5. Put on gloves and treat the ball with 70% alcohol, throw the balls into a waste tray.

6. Use sterile tweezers to place 3 cotton balls.

7. Treat a large area of skin with the first ball in alcohol centrifugally (or in the direction from bottom to top), treat the puncture site directly with the second ball, wait until the skin dries from the alcohol.

8. Throw the balls into the waste tray.

9. Insert the needle into the muscle at an angle of 90 degrees, leaving 2-3 mm of the needle above the skin.

10. Place your left hand on the piston and inject the medicinal substance.

11. Press a sterile ball to the injection site and quickly remove the needle.

12. Check with the patient how he is feeling.

13. Take the 3rd ball from the patient and escort the patient.

Patients with movement disorders

When serving patients, it is worth remembering to perform the manipulations competently and accurately.

Depending on the severity of the paresis, the patient will need partial support or full movement for him.

The nurse should prevent possible trauma to the patient:

· Ensure unhindered movement.

· Teach the patient how to use it correctly aids for movement

· Train balance and walking skills

· To prevent the patient from falling out of the bed, it must be equipped with side backrests.

· Do not hold the patient by the neck - this can lead to injury

· Do not pull on the sore arm - this can lead to dislocation shoulder joint

· Do not lift the patient by the armpits - this will injure the shoulder of the affected arm and cause pain

Observation from practice:

A patient aged 60 years was admitted to the neurological department. Diagnosed with stroke.

Sakh has been suffering for 10 years. diabetes

Upon examination, the patient is conscious. Complaints of dizziness, nausea. He tries to pronounce words with difficulty, but understands spoken speech. Movement in the right arm and right leg is impaired. The patient has difficulty remembering current events. There is visual impairment in both eyes. Blood pressure 180/140, pulse 80, t37.1C.

· Movement of arms and legs is impaired

Difficulty with current events

Priority problem: dizziness, nausea, vomiting, impaired movement of arms and legs

Goal: To alleviate the patient’s condition, ensure proper discharge of vomit, restore limb movement, perception of events and visual function

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