-1-

Patient Care
Theme N 1
Role of assistant physician in patient care
Care of patients is an indispensable part of their treatment. This includes carrying out
the doctor's orders, maintaining proper hygiene of the patient, his bed, and the ward; assisting the
patient in eating or emptying the bowels, prepеaring him for medical and diagnostic procedures, and
organizing the patient leisure time. These duties are fulfilled by the secondary medical personnel
(an assistant physician , a medical nurse). Patient care is both general and specific. General care implies
carrying out medical and prophylactic procedures irrespective of the character of a particular pathology.
Special care requires carrying out procedures specific for the different diseases (obstetric, urological,
stomatological, etc).
Timely diagnosis, proper treatment, and adequate care are the necessary conditions for the
recovery of the patient. To render qualified assistance to the patient, it is necessary to acquire proper
medical knowledge and skills.
The assistant physician should be able to do the following:
1 - medicate the pharyngeal mucosa, 2 - take smears from the larynx, genital organs, and the
rectum; 3 - apply compresses, mustard plasters, leeches; 4 - take gastric juice and irrigate the stomach;
5 - give enemas of all types and introduce gas - discharge tubes; 6 - give subcutaneous,
intramuscular and intravenous injections of medicinal solutions, and also autohaemo-transfusion;
7 - measure arterial pressure; 8 - give artificial respiration; 9 - give first aid in cases of injuries,
poisoning, frost-bite, etc; 10 - carry out simple functional tests; 11 - catheterize the urinary bladder
with a soft rubber catheter and irrigate the bladders; 12 - perform vaginal irrigation; 13 - irrigate the
ears; 14 - dilute tuberculin for diagnostic purposes.
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The assistant physician working at a hospital should be able to do the following: 1 - take
care of patients and of the wards; 2 - inform the physician about the condition of patients during
routine examinations; 3 - write down and carry out accurately all the physician's orders, 4 - control
the sanitary condition of the wards and the patients; participate in health education of patients; 5 - take
their temperature in the morning and evening; measure arterial pressure, pulse and respiration rate; the
amount of expectorated sputum and excreted urine, and record these finding into the case history;
6 - examine critical patients and take special care of them (washing, feeding, inspecting for bedsores,
etc); 7 - collect material for laboratory analyses (sputum, feces, urine, etc); send it to the laboratory, and
record the findings in the case history; 8 - acquaint newly admitted patients with the hospital
regulations and inspect the food sent to the patient by his relatives; 9 - ensure that the hospital regulations
are observed by the patients, junior hospital personnel, and visitors; 10 - order medicinal
preparations and other materials that may be necessary for the patient's care; order special diets
according to the physician's orders; 11 - receive newly admitted patients and check the quality of
their sanitary treatment.
Your role
As a member of a nursing staff of the hospital, you will play an important part in assisting
professional registered nurses in carrying out both simple and difficult procedures, all of which are
necessary to good patient care. You will be taught to perform some procedures alone and others only
under the supervision of a registered nurse.
All the work you do will be directed toward one goal, the recovery of the patient. If you master
all aspects of every task that is taught during the training program, you will be able to do the things a
patient needs in order to get well.
The basis of science has always been the search for the answer to the question “Why?” You
should follow the same procedure. If you do not understand something, ask questions until you do
understand. Keep asking questions until you are certain you know the answers. It is much better to admit
that you do not understand something than to pretend you know it and consequently make mistakes. In
your work it is important that you study and remember the basic information this book will give you.
Wile you are studying proper nursing technique, you must practice each procedure you learn until you
are sure you can perform it without error. Your patients well-being and comfort, and perhaps some day
even a patient’s life, will depend on your knowing your job and doing it well.
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Theme N 2
MORALS. DEONTOLOGY. MEDICAL DOCUMENTATION.

The science of morals, rules and requirements for soc. conduct is known as ethics.
Medical ethics implies the morals of medical personnel, their attitudes toward each other and toward
their patients.
Diseases of the internal organs affect the patient's psychic state and generate fears and
anxieties. The assistant physician should be very attentive and careful in dealing with their patients.
They should be very patient and tolerant. A calm and confident medical personnel will always increase
the patients belief in recovery.
The appearance of the medical personnel should be reassuring and have a calmative effect.
The assistant physician must accurately and skillfully perform their duties. Their main qualities
should be discipline, accurate performance of the physician's orders.
If a nurse or assistant physician commits an error, he must immediately take measures to
remedy his fault. It is his duty to report to the physician with out being afraid of the repercussions,
because the interests of the patient must be of primary importance to any medical worker.
The assistant physician plays important role in the care and treatment of patients and must
be able to raise the patient's spirits make him believe in the successful treatment of his disease.
Inappropriate behavior of a medical personnel can cause an iatrogenic (Greece iatros =
physician) disease in the patient. Sometimes a careless assistant physician can explain to the patient
the essence his disease or criticize the physician's tactics in a way, that may cause an iatrogenic
disease. The best prophylaxis of iatrogenic diseases is adherence to the rules of
medical ethics; i.e. laws of deontology.
DEONTOLOGY is the science of correct behavior of medical personnel aimed at the
maximum efficacy of treatment, and prevention of harmful consequences of inadequate medical aid.
The main object of deontology are the relationships between the doctor and the patient, between the
nurse and the patient, and also between the physician, the nurse, and the patient.
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Positive relationships between the patient and the assistant physician may accelerate
recovery. The patient's confidence in his doctor and other medical personnel is an important medical
factor: the patient believes that everything possible will be done to promote his recovery.
The patient has confidence in his doctor if his medical secrets are properly kept, if the
doctor shows respect to his patient, and understands his needs and demands. From the very first
minute of his presence in the hospital the patient must feel that his interests are regarded with respect.
The physician should try to know as much as possible about the special qualities of the patient's
character. Each patient requires a special approach in treatment. It is impossible to understand the
patient properly, and hence it is impossible to give him all possible medical attention.
The personality of the doctor and other medical personnel, the performing of their duties and
treatment of their patient, are very important curative factors. But only constant improvement of
professional skill and experience makes it possible to exploit these factors to the fullest.

THE NURSE STATION

The nurse station should be located not far from the observed patient’s wards, or it may be
inside the wards if the patient's condition requires special constant observation. The nurse station should
be provided with a room for medicines and instruments, a file room for the case histories. A signal board
should be installed near the table to control the situation in the ward. A locker for poisonous and strong
medicines should be also provided. The nurse station should be maintained in strict compliance with
hygiene requirements.

MEDICAL DOCUMENTATION
Medical documentation is a means of communication and continuity between
physicians, between the physician and assistants, etc. Medical documentation is necessary to
supervise the work of medical institutions, physicians, nurses and etc. It is also used for planing medico
prophylactic measures for research and training purposes. Medical documentation must therefore be
accurate.
The main medical document is the PATIENT'S CASE HISTORY. It
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should be kept for both in- and out-patients. It is easy to assess the sick rate of the population
by inspecting the case histories. The physician or any other medical personnel can find out the details of
medical treatment prescribed to the patient.
The main document in a hospital is the case history contained the name of the patient, his
complaints, anamnesis (history of present illness and life history) , test result, a diary, and an epicrisis.
When the patient is admitted to the hospital the nurse enters his name and other personal data and the
diagnosis that has been established by the medical institution that refers the patients for
hospitalization. The address and the telephone number of the patient and his closest relatives are also
entered in the case history. The case history should be kept under lock at the department where the
patient is treated. The main entries are made by the physician, while the nurse records information
concerning procedures carried out to the patient.

THE PATIENT'S HOSPITAL RECORD

Patient's Chart. The patient's chart contains the graphic chart and other medical
records gradually introduced over the years. The sheets are kept in an orderly manner in a chart holder.
A typical chart consist of the following items:
Doctor's Notes. These notes are highly confidential and are intended only for physicians.
They include the patient's history and the doctor's progress report about the patient condition.
Doctor's Orders. These orders include the prescriptions and treatment for the patient and
they are also confidential as doctor's notes. They are carefully transcribed by the nurse.
Medication Record. This list contains the information about the medicines prescribed for
the patient.
By law, medicines in a hospital may be administered only by licensed personnel. If the
patient asks you to give him any medicine, tell him that you will speak to the doctor. Then pass the
request along to the charge doctor.
Nurse's Notes. Special forms containing the nurse records: her observations about the
patient's condition, treatment and routine care.
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The nurse assistants will not record observations in these notes, but will be responsible
for reporting to the head nurse about any pertinent signs and symptoms, that they observe.
Personal History. This sheet contains pertinent personal information about the
patient, such as name, address, occupation, marital status, next of kin, date of admission, and room
number.
Graphic Chart. The graphic chart gives a running picture of the vital signs as indicated
by periodic taking of temperature, pulse and respiration. Some induces spaces to record blood
pressure, and intake and out put. The conventional form allows enough space to make entries six
times a day for 1 week.
Laboratory and X-ray Report Sheets. These Forms summarize the results of the
laboratory tests and x-rays administered to the patient.
Clothes Sheet. All the patient's clothes and personal things are listed in this sheet.
Miscellaneous Forms. All signed permission papers, such as anesthesia records,
operative permits, and pathology specimen reports are included in the chart.
Kardex. The Kardex is an important source of information and guidance for all members
of the nursing staff and is maintained separately from the patient's chart. It contains the information
about the medications, treatment and plans for nursing care, is kept one for each patient. The
Kardex derives it's name from the standard method of filling these cards.
A nurse make the various entries on the cards, taking them directly from the doctors
orders. In any event, the Kardex provides valuable ready information concerting medication,
treatments, nursing care plan, and diet.
A Consultation card is given to the patient by the assistant physician, when the patient
is referred to specialist. The conclusion of the specialist is recorded into the patient's case history.
A procedure card is intended to record the procedures done to the patient. A separate
card is given for each kind of medical procedure, where the name of the patient should be written.
A head nurse of each department keeps a book where she records all information
about the admitted patient: his name, the preliminary diagnosis and the verified diagnosis upon
the patient's discharge from the hospital. The head nurse keeps records of all strong and poison
medicines that are prescribed to the patients.
Ward nurses and nurses duty keep records of performed procedures to the patients, of
strong and poisonous medicines given to the patients during the day. The keys from lockers where
group A and B medicines are stored are also given to the new nurse on duty. Both nurses put the
signatures in the log-book in accounts for the use of strong and poisonous medicines.
The head nurse should supervise of changing shifts and report to the physician, in
brief, the condition of the patients, fulfillment of his orders, and the sanitary condition of the
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department. The ward nurse can’t leave her post until her successor begins her work.

Theme N 3
Admission department

The patient is admitted into a hospital through its admissions department, where his
name, age, etc. are registered, the patient is examined preliminarily and appropriately prepared for
treatment. The admission department should be located near the main entrance of the hospital and
be provided with convenient access roads. The admission department should have a waiting room,
registration and inquiry offices, rooms for examination of patients, a room for special medical
procedures, and a room for sanitary treatment of the patients. An admission departments at large
hospitals should be provided with an operating room, a room for reception of the injured, and a
room for x-ray examinations. A special isolation room should also be provided for patients with
infectious diseases, and rooms for accommodating of patients with undiagnosed diseases. These
wards should be provided with private bathrooms. The admission department should be
equipped with a sufficient quantity of wheeled beds, stretchers and gowns for patients.
The hospitalized patients should be treated with care and attentiveness. From the first
minute of his stay in the hospital, the patient must have confidence in its medical staff.
The patient's name and other personal data are recorded in the admission department, and
then he is examined by the physician, and given the appropriate sanitary treatment. The rooms of
the admission department are arranged in the order of these procedures. The assistant physician or
the nurse records the patient's personal data on a special chart, then the patient's height and weight
are measured, the patient is given examination to reveal possible pediculosis (lousiness) or signs of
infectious diseases, and his body temperature is taken. All findings are recorded in the case
history and the nurse accompanies the patient to the physician and then gives him sanitary
treatment. Finally, the nurse accompanies the patient to the medical department. If the patient is in
the critical condition or even unconscious (hemorrhage, shock, coma, dangerous cardiac arrhythmia,
etc.), the patient is not questioned, and sanitary treatment is not carried out. He is delivered
immediately to the resuscitation or operating room, or to the specialized department where he is
given the necessary medical aid. If a patient is admitted to the hospital according to a preliminary
agreement with a policlinic or an out-patient department of another hospital, the patient's condition
allows the taking of his case history, primary examination, and sanitary treatment. When the case
history is recording, the patient reports his name, age, address. Position of the patient, the date and
time of hospitalization is registered too. All these data are also recorded in a special admittance
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journal
The examination of the patient includes not only measuring of his height and weight but
also the girth of his chest, his muscular strength (dynamometry), and respiratory function
(spirometry). The methods and techniques used to assess the morphological conditions of man are
called anthropometry The patient is weighed on medical scales. His weight is determined up on
admittance and not less than once a week during his stay at the hospital. The patient should be
weighed in his underwear in the morning before breakfast, after urination and emptying the
bowels. A normal weight is found by subtracting 100 from the height (in cm). This is only a
tentative method since normal weight varies with age and because of many other factors. The
patient usually loses weight in many diseases, especially those associated with malignant
newgrowths, tuberculosis, acute infections, and gastrointestinal diseases. Fat tissue is lost first, then
the patient loses weight at the expense of muscular tissues. Patients with edema gain weight due
to retention of liquid in the tissues. The girth of the chest is measured by a tape passed under the
angles of the scapulas on the back and across the 4-th rib of the chest. The girth should be measured
with quiet breathing and hanging hands freely at the patient's sides. The measurements are taken at
the height of inspiration and expiration. Spirometry is the method of determining the respiratory
volumes of the lungs, which is necessary for assessing the external respiratory function. The
apparatus used for this purpose is called a spirometer. The patient is asked to inhale with maximum
effort, and (holding his nose clamped) to exhale the air into the apparatus through the mouth-piece.
The mouth-piece should be washed with soap and water and kept in a sterilizer.
Dynamometry is a method of measurement of muscular force using a dynamometer. The
patient is asked to squeeze the dynamometer at a maximum force: the pointer indicates the
muscular strength in kilograms.
Anthropometric measurements are followed by examinations: the physician establishes a
preliminary diagnosis, gives first aid whenever necessary, determines the department in which the
patient should be treated, and also the volume of sanitary preparation and kind of transport before
hospitalization.
Patients with signs of infectious diseases should be isolated into a special room at the
admission department.
Sanitary and hygienic treatment of patients. The amount of sanitary treatment depends on
the patient's conditions. If the patient is in critical condition (bleeding, shock, coma,
etc.), the patient is directed straight to the intensive care unit without sanitary treatment. If
the condition of the patient permits, he take shower or a bath. The patient takes off his clothes in
the examining room where he is prepared for the bath. The water temperature in the bath should
be 36-37 C, and of the ambient air, 25-28 C. The patient's personal things are registered. A copy
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of the record is placed in the patient's file, while another copy is kept together with the things in a
storage room. Money and valuables are registered separately by the head nurse of the admission
department. A bath is prescribed to cleanse the skin of the patient from dirt and sweat. A bath is
contraindicated for patients with skin diseases, wounds, and for those in critical condition. The
patient takes off his clothes in a special room and goes to the bath. The bath should first be washed
with hot water and soap and if the previous patient had a skin or infectious disease, the bath
should be disinfected. The patient should be given a clean sponge and after he has taken the bath
the sponge should be discarded into a "used sponge" container. Whenever possible, the patient
should be given a sterile package containing a clean sponge and underwear. In order to prevent the
water from cooling, the bath should be filled immediately before usage. The patient should assume
a convenient position in the bath so that his back and head rest against the bath wall. The head is
first washed, then follow the body and the legs. During washing, the patient should pay special
attention to those parts of the body where sweat usually accumulates (armpits, the groin, the
perineum, the areas between the toes, and under the breasts in women). The bath is taken during
20-25 minutes. The water temperature should be agreed with the body temperature. The bath is
prepared by the junior medical personnel, while the assistant physician or the nurse observes the
patient's condition. If it worsens (dizziness, pallor), the patient is held out of the bath, placed on a
bed and the physician is called if necessary. If the patient's condition does not permit to take a bath,
he should take a shower. The shower should be taken about 5-10 minutes. If the patient's condition
is of medium gravity or critical, the assistant physician or the nurse should cleanse his body with a
wet towel paying special attention to the sweating areas. After a bath, the patient has his toe and
finger nails cut and is given clean underwear. Rooms intended for sanitary treatment of patients
should be kept clean. The oilcloth covering the cot should be treated with a disinfectant solution (2
per sent chloramine solution). A clean sheet should be used to cover the cot for each patient. Calcium
hypochloride should be used to wash bathrooms.
Transportation of the patients. There are several techniques for transporting of the patients.
The patient can move by himself, by means of a wheeled bed or chair, on a stretcher, or can be
carried by the auxiliary personnel. The physician decides which kind of transportation is most
appropriate. If the patient's condition is satisfactory, the patient walks to the ward by himself
accompanied by junior or auxiliary personnel. Critical patients are carried to the ward on wheeled
stretchers. A clean sheet and pillow are placed on the stretchers and the patient is covered with
a blanket. Sheets and pillow cases should be changed for each patient. If a lift is not available, critical
patients are carried up or down the stairs by nurses who carry them carefully and avoid walking at a
normal pace (to prevent jolting). The patient should be moved with his head in the forward direction.
It is obligatory that the assistant physician or nurse accompany the patient to his ward. Moving from
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the stretchers onto the bed sometimes requires much effort on the part of the patient. The stretchers
are therefore put so that the head end of the bed aligns with the foot of the stretchers. In the admission
department the patient is acquainted with the hospital regulations and informed about his
responsibility for observing them. A special note is made in the case history.

Theme 4.
Medicoprotective regime.
The patient unit. Changing bed clothes.

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

Tentative regimen for a hospital.

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Time, h item
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7.00 -Wake-up
7.00 - 7.30 -Temperature taking
7.30 - 8.00 -Morning toilet
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8.00 - 8.30 -Dispatching medicines

8.30 - 9.30 -Breakfast
9.30 - 12.00 -Physician’s rounds
12.00 - 14.00 -Carrying out medical orders and prescriptions
14.00 - 14.30 -Dinner
14.30 - 16.30 -Afternoon rest
16.30 - 17.00 -Temperature taking
17.00 - 17.30 -Tea
17.30 - 19.00 -Visiting time
19.00 - 19.30 -Dispatching medicines
19.30 - 20.00 -Supper
20.00 - 21.30 -Leisure time
21.30 - 22.00 -Evening toilet
22.00 - 7.00 -Sleep
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-------The patient unit. When a patient is admitted to a hospital, he is placed in a patient unit. This
may be a single unit in a large ward, a unit in a semiprivate room with two to four beds, or a private
room. The most common unit is a semiprivate, two-bed room with a screening curtain between
patients.
The patient unit has furnishings and equipment that will be used in care of a patient.Bed.
Since the patient spends most of his time in bed, the bed is the most important piece of equipment in
the unit. It provides needed comfort and support. It must be adjustable so that the doctor, nurse, and
their personnel may treat and care for the patient in a way that least disturbs him. The hospital bed is
about the same length and width as a single bed at home, but higher. There are several types of
hospital beds. The latest model is a motor-driven, adjustable bed. The adjustable spring
(Trendelenburg spring) permits the back part or knee part be raised or lowered to any desired
position. Siderails or bedrails are standard equipment on most hospital beds. They are a safety device
to protect the patient from falling out. They may also assist the patient in getting some exercise by
raising and lowering himself. In common use today is the so-called Hilow bed, which can be raised
and lowered by a motor-driven or hand-operated mechanism. When it is raised, the nurse and doctor
can work without bending over; when lowered, the patient can get in and out with ease. The hilow
bed can be adjusted to a wide variety of positions for treatment and comport. Control panel on a
Hilow Bed. Observing personal hygiene and cleanliness of the ward and the patient's bed
promote effective treatment. It is necessary to check the bed-clothes for cleanliness and the mattress
is smooth. Patient with grave diseases and those suffering from incontinence of urine or feces should
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be placed on an oil-cloth to prevent contamination of the linen. In case of heavy vaginal discharge
in women, easily replaceable sheets should be used over the oil-cloths, which can be renewed as
frequently as necessary. Critical patients should be put in adjustable beds, special head rests should
be used to hold the patient's head in comfortable position. Two pillows and a blanket (in a blanket
cover) are given to the patient. The bed should be made regularly both before and after sleep.
Changing bed-clothes. Underwear and bed-clothes should be changed not less than once
a week after bath, and also after accidental contamination. There are several techniques by which
underwear and bed-clothes can be changed. If the patient is able to walk, he leaves his bed and the
nurse changes the linens. There are two methods by which bed-clothes are changed for bed-ridden
patients. According to one of them, the used sheet is rolled up on both ends toward the center, the
patient is then raised carefully and the used sheet removed. The clean sheet is first rolled up like the
used one, placed under the patient's waist, and then unrolled in the reverse order. According to
the second method, the patient is carefully moved to one side of the bed and the sheet is rolled up
toward the patient’s back. A clean rolled sheet is placed instead on the bed and unrolled toward the
patient. The patient is then moved onto the clean sheet and the clean sheet is fully unrolled.
To change the underwear of a critical patient, the nurse puts her arm under the patient's back,
helps him to sit up in bed, pulls the gown to the patient's armpits and head, pulls the gown first over
the head and then from the arms. A clean gown is put on in the reverse order: the sleeves first and
the gown is pulled over the head and stretched under the patient. Vests open in the front are used
instead of gowns for bed-confined patients.

Theme #5
PERSONAL HYGIENE OF THE PATIENTS

Care of the patient's skin and prevention of the bedsores.

The human skin performs protective, excretory, heat-regulatory and analytical functions (skin
sensitivity). The excretory and thermoregulatory functions of the skin are realized through
perspiration (excretion of the sweat). Sweat glands excrete water, urea, uric acid, sodium, potassium
and other substances. Healthy individuals at rest excrets about 1 litre of sweat a day. The amount of
sweat excreted by patients with fever increases to 10 litres or more. Hear that is dissipated by a person
with sweat accounts for about 20 percent of his total heat emission, and this percentage increases
significantly in patients with fever. Perspiration is the main thermoregulatory of a human body.
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Perspiration increases significantly in the sick person. The assistant physician and the nurse
should take special care of the patient's skin, because when sweat is evaporated it leaves various
metabolites, which decompose on the skin and irritate it. The skin of the bed-ridden and patients with
fever should be cleansed by water mixed with alcohol (1:1), which has a disinfecting effect. Special
attention should be paid to the cleansing the groin, the perineum, the armpits and the skin under the
breasts (in women), where sweating is especially intense.
Patients confined to bed for prolonged periods of time can have bedsores, which are sites of
necrotized skin due to prolonged compression and, hence, defective nutrition. Bedsores usually occur
on the sacrum, the shoulders, elbows. Bedsores more often affect moist skin. The skin first reddens
and becomes tender, and then foci of necrotization develop. Necrotized tissues are rejected and ulcers
develop which sometimes destroy soft tissues till the bone.
Infection of the injured skin can cause purulation and even blood poisoning.
Bedsores indicate inadequate patient's care.
When the skin becomes hyperemic, it should be treated with a 10 percent camphor alcohol
twice a day, and then a moist towel. The lesion should be treated by a quartz lamp. The condition of
the skin should be observed.
If the bedsores have developed, they should be treated with a strong solution of potassium
permanganate with subsequent application of synthomycin, Vishnevsky or other liniments.
Bedsores can be prevented by regular changing the patient's position during the day, by
straightening folds of his underwear or bedclothes, by keeping the skin clean, by treating it with
disinfectant solutions, especially at the sites where bedsores usually occur, and placing a ring rubber
cushion under the patient. When the first signs of bedsores appear on the sacrum, a ring cushion
should be placed so that the sacrum is spanned over the hole in the cushion. Inflatable mattresses
(airbeds) are now used for prophylaxis of the bedsores. Regular baths and skin washing also prevent
the formation of bedsores. The nurse should help weak patients to wash themselves in the morning.
The patient must wash his hands in the morning, before meals and after defecation and urination.
Patients must wash they feet before night sleep, while critical patients, 2-3 times a week (with the
assistance of the nurse). Awash basin with warm water should be placed on the bed.
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Critical patients with incontinence of urine or feces should be assisted in their beds by giving
them a bedpan. It should be remembered, however, that the prolonged use of a hard bedpan could
also provoke the formation of the bedsores. Inflatable bedpans should be therefore used by patients
that unable to leave their bed.
The external genitalia of women confined to bed should be washed at least once a day (unless
more frequent washing is prescribed). The women should urinate and empty her bowel before
genitalia are washed. Washing should be done with a potassium permanganate solution (1:5000) or2
percent lysoform solution. The women should assume a supine position with her legs flexed and
thighs set apart. A bedpan is placed under the pelvis. Using a forceps and cotton wool, the genitalia
are washed with a jet of the disinfectant solution. The cotton ball should be moved from the genitalia
toward the anus. The external genitalia are then dried by dry cotton wool pad.
In addition to washing the external genitalia, women are also given vaginal irrigation. For
this an Esmarch flask is hanged 1 metre above the bed and is filled with a disinfectant solution. A
glass end-piece is introduced into the vagina along its posterior wall to a depth of 6-8 cm. The patient
lies on her back because part of the disinfectant solution will remain in the vagina. After irrigation is
over, the patient should stay in the same position for about 30-min. The external genitalia should be
dried after the vaginal irrigation. The Esmarch flask should be washed in boiling water; the end-piece
should be sterilized.
Care of the mouth. Food that remains between the teeth and in the gum pouches is the
substrate which microbes readily propagate creating conditions for various complications. The care
of the mouth is important in the general care of the patients.
Patients should brush their teeth in the morning and in the evening, using the same brush to
clean the back of the tongue to prevent putrefaction of the desquamated epithelium. The mouth
should be rinsed after meals to remove food remains.
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Patients who are unable to care of their mouth should be assisted: their teeth, gums, and
tongue should be cleansed by a cotton wool pad wetted with 3-4 percent solution of boric acid twice
a day or sodium hydrocarbonate solution (2 percent). If the inflammatory process developed in the
mouth, medicines should be applied or the mouth should be irrigated. Sterile napkins wetted with a
0.1 per cent furacin, 2 per cent of boric acid. A Janet syringe (or a simple rubber syringe) is used for
irrigating the mouth with disinfectant solution. The patient should assume a semi-prone position; an
oilcloth should be placed on his chest, while the patient should hold a metallic basin.
 -16-

Care of the eyes. In order to remove purulent discharge from the eyes, a 3 percent boric acid
solution is used from a rubber bulb or by applying a piece of gauze. The flowing fluid should be collected
in a basin held by the patient under his chin. The hands of the assistant physician or the nurse should be
clean.
If an inflammatory process affects the eyes, medicines should be instilled or ophthalmic
ointments applied. When instilling eye drops, the nurse pulls down the lower eyelid, two drops are
expressed on the eyeball near the nose, one after another. When the patient shuts the eyes, excess solution
is expelled from under the eyelids. A cotton ball should absorb it. The pipette should be rinsed and kept
closed until the next use. Ophthalmic ointment should be applied to the eye using a glass spatula. The
patient is asked to look up, his lower eyelid is pulled down using a moist cotton wool pad, and the
ointment is transferred from the spatula into the inferior lower conjunctivae fornix (fornix conjunctivae
inferior). The spatula is then pulled carefully in the horizontal direction toward the temple.
Care of the nose and the ears. The patient should clean his ears every morning. To prevent the
obstruction of the ear by the wax in bed-ridden patients, their ears should be cleansed 2 or 3 times a
week. Earwax is usually removed from the ear in the form of small lump. Ear wax can be accumulated
in the auditory meatus and clog it. The meatus should be washed. A 100-150 ml Janet syringe is used
for this purpose. The nurse should stay at the side of the patient. The patient under the ear holds a metal
basin. Using her left hand, nurse pulls the ear up and back, introduces the end-piece of the syringe into
the external meatus with her right hand. Water at the temperature of36-37C is discharged with force in
small portions. The ear should be dried by cotton wool. If this procedure fails, cerol solution: 7-8 drops
(preheated in water) are instilled 2-3 times a day for 2 or 3 days.
Using a pipette makes instillation. The patient should incline his head in the direction of his
healthy ear. The left hand should pull down the ear lobe, and the drops instilled by the right hand. In
order to prevent the spontaneous flow of the fluid from the ear, the patient should keep his head inclined
for 15-20 minutes. The ear should be wiped dry by sterile cotton wool.
If a patient is unable to clean his nose, he must be assisted. A small piece of cotton wool should
be wound around a small stick, wetted with oil, and introduced into the nose. The patient is then asked
to move his head up, and the nurse turns the probe clockwise to remove the crusts. Usage of dry cotton
wool should be avoided since it can provoke nasal bleeding.
Care of the hair. It's necessary to take care to prevent the formation of dandruff. The patient
with dandruff should have his hair washed once a week. Various shampoos and soaps are used for this
purpose. If baths are contraindicated for the patient, his hair should be washed in his bed. The wash basin
 -17-

should be placed on the bed, and the patient's head positioned over the basin. The scalp should be
shampooed especially thoroughly. The washed hair should be rinsed, dried and combed. In order to
prevent chilling, the patient's head should be wrapped in a dry towel or a napkin

Theme 6
NUTRITION OF A PATIENT

The health of a human being, his work capacity, and longevity depend to a great degree on
an adequate nutrition. Nutrition is the vital demand of a living body. Food supplies energy and it is the
building material for cells and tissues. The teaching of correct nutrition is called dietetics. A diet
determines the conditions of nutrition, composition, and quantity of food, which is necessary for both
healthy individuals and the sick. A therapeutic diet means planned nutrition of the patient.
Diet should differ depending on the disease. More food should be given to pregnant,
tuberculosis and asthenic patients, while patients who suffer from in coercible vomiting or hemorrhage
associated with a peptic ulcer must not be given any food; some patients may be restricted in certain
foods, others in water, etc. Diet at hospitals is thus therapeutic. There are 15 therapeutic diets; some
diets have subdivisions. Dietologists (or special nurses at smaller hospitals) ensure the control of
patients’ nutrition. A nutritionist is responsible for the observation of the dietary requirements in
departments.
Oxidation of carbohydrates, proteins, and fats in the body liberates energy. The value of
food from the point of view of potential energy is expressed in kilocalorie (kcal). A kilocalorie is the
amount of heat energy, which is necessary to raise the temperature of one liter of water by 1 C. The
daily
Caloric demand depends on the basal metabolism, energy consumption during exercise, and food
intake. The basal metabolism expresses the energy consumption of a person at rest. The basal
metabolism of a normal adult (male) is about 1700 kcal. About 200 kcal are consumed for digestion,
absorption, and assimilation of the food consumed. The energy expenditures
Depend largely on the character and amount of exercise (at work or at rest). Workers whose job
is not associated with physical effort consume from 2600 to 3000 kcal a day, while the energy demand
increases to 3600-4500 kcal a day for workers performing medium-hard and hard physical labor.
 -18-

The modern concept of quantitative processes occurring during assimilation of nutrients has
been formulated in the idea of a balanced diet. The intake of adequate amounts of food in well-balanced
portions is necessary for normal assimilation of nutrients and normal vital activity of a living body. A
correctly balanced intake of proteins, fats, and carbohydrates is expressed by the ratio 1:1:4, of calcium
and magnesium 1:0.6, and of calcium and phosphorus 1:1.6. When planning any diet, it is necessary to
follow the principles of diet therapy. The physiological standards depend on sex, age, occupation, and
some other factors. The average demands of a person for food and energy (calculated for a balanced
diet) can vary depending on the character of a given disorder. For example, sugar should be restricted in
diabetes mellitus, and proteins in renal insufficiency.
It is necessary to take into account the local and general effects of food on the body. The
local effect of food includes stimulation of the central nervous system through the sensory organs (taste,
vision, and olfaction). When the mechanical, temperature, and chemical effects are changes, the
secretory and the motor functions of the alimentary system also change substantially. The general effect
includes changes in the composition of blood during digestion, which causes changes in the nervous and
endocrine systems.
Important factors of diet therapy are sparing, training, and contrast.
Sparing means exclusion or restriction of intake of mechanical, thermal, or chemical
irritants. It is necessary to avoid hasty suspension of a diet, or its undue prolongation. A prolonged
sparing diet can sometimes cause constipation if the diet was prescribed for diarrhea. A sparing regimen
is
Therefore combined with a training diet, with a gradual increase in the food intake, which is
necessary for readaptation of the bodily systems and metabolic processes. So-called contrast days are
sometimes prescribed: foods, that were formerly excluded from the diet (e.g. salt or sauces), are given.
On the one hand, this stimulates the digestive function, and, on the other hand, it encourages the patient
to believe that he is on the recovering. Fasting days promote withdrawal of residues from the body. They
are especially important in the treatment of obesity.
The chemical composition of food and the way it is prepared, as well as some individual or
endemic features of nutrition should be considered. When prescribing a diet, local traditions and national
habits should be taken into account as well as toleration to certain foods. Diet therapy is ineffective if
the patient does not actively cooperate with his doctor, if he is not convinced of the efficacy of the diet
therapy. Encouraging the patient is, therefore, another important factor.
 -19-

Diet therapy also implies certain requirements for food intake. A healthy person eats 3-4
times a day. Taking food at intervals less than two hours is not recommended since the digestive function
does not recover that soon.

Classification of diets

Special diets are prescribed for postoperative patients during their first days following
surgery of the stomach or intestine, and also for patients in a semi-conscious state. The purpose of a
special diet is to supply the minimum possible amount of food in cases where the intake of solid food is
contraindicated and to prevent meteorism. This diet should be given for 5-6 days and then it should be
gradually expanded. During the 2nd and 3rd days, the patient is given liquid or jelly-like food of readily
and quickly assimilated
Substances (non-fatty bullion, non-sweet stewed fruits or berries, wild rose decoctions and
non-sweet tea). Soft-boiled eggs, mucinous soups, pureed meat or curds should be added on the 4th or
5th day. Food should be given at 2-2,5 hour intervals. The diet should then include pureed porridge;
steam-cooked dishes of pureed boiled meat, poultry or fish, pureed vegetables. Additional preparations
for enteral nutrition are added. Food is given 6 times a day; the first portion is 100 ml and then it is
increased to 200-400 ml.
Diet No.1 is prescribed for acute gastritis, exacerbation of chronic gastritis with normal
secretion or hyper secretion, and gastroduodenal ulcer. The diet is intended to lessen the inflammation
and to promote healing by restricting thermal, mechanical, and chemical irritants. Food that stimulates
gastric secretion is excluded from this diet. Pureed, stream-cooked or boiled food is prepared. Cold or
hot food should be excluded. The food should be physiologically adequate and balanced with respect
to calorific value and chemical composition. Food is given 5-6 times a day; milk, cream or yogurt should
be given before bedtime. Carbonated drinks, coffee, and condiments should be excluded.
 -20-

Diet No.2. This diet is prescribed to patients with chronic gastritis with hyposecretion
(period of exacerbation), chronic colitis, states after acute infections, or in injured chewing apparatus.
The diet is intended to supply adequate nutrition, normalize the secretory and motor functions of the
gastrointestinal tract by moderate thermal and mechanical sparing. The diet is normal with respect to
the chemical composition and calorie intake. The food is mostly crushed or pureed. Cold dishes should
be excluded. The patient should eat 5 times a day. Grape juice, carbonated drinks, canned food,
legumes, milk, and fat should be excluded.
Diet No.3. This is prescribed for constipation caused by inadequate nutrition, for
hemorrhoids and fissures of the anus without pronounced inflammation. The diet is intended to stimulate
the motor function of the intestine. The diet includes vegetables, fruits, berries, bread, and cereals high
In fiber; salted and pickled vegetables and vegetable oils are also included. Cold dishes and
drinks are allowed. The diet promotes peristalsis and evacuation of the bowels. The patient should eat
4-5 times a day. Cold water with honey or sugar is given in the morning and stewed fruits before
bedtime. Coffee, cocoa, and strong tea are excluded. The daily calorie intake - 3000 kcal.
Diet No.4. This diet is prescribed for acute enterocolitis with diarrhea following fasting
days, exacerbation of chronic enteritis, dysentery, after surgery on the intestine. This diet should be
prescribed for 5-8 days. It is intended to minimize chemical and mechanical irritation of the intestine,
to decrease fermentative and putrefactive processes in the intestine. The calorie intake is decreased to
2200 kcal a day (mainly at the expense of carbohydrates and fats). Food containing rough cellular tissue,
spices, salted food, fresh bread, buns, coffee, cocoa, carbonated and cold drinks, grape juice, whole milk
(except in dishes) are prohibited. Food should be steamed, or boiled. Food should be pureed before
intake. The temperature of dishes should not higher than 60 C or below 15 C.
Diet No.5. The diet is prescribed for chronic hepatitis, infectious hepatitis (convalescence
stage), and chronic cholecystitis (without exacerbation). The diet is intended to normalize the function
of the liver and the bile ducts and to stimulate secretion of bile under conditions of normal nutrition. The
diet is characterized by an increased content of proteins and carbohydrates; fats are restricted. The
temperature of food is normal. The daily calorie intake - 3000-3500 kcal. The amount of liquid - 2
liters. Coffee, cocoa, and cold drinks are excluded.
 -21-

Diet No.6. The diet is prescribed for nephrolithiasis with formation of concrements from
salts of uric and oxalic acids, and for podagra (gout). The diet is intended to normalize the purine
metabolism, to decrease formation of uric acid, to shift the reaction of the urine to alkaline. Foods
containing a lot of oxalic acid and purine should be excluded. The intake of fats and proteins is restricted.
The intake of carbohydrates is restricted in obesity. The caloric intake is 2500-2700 kcal a day. The
amount of liquid intake is 2-2.5 liters a day. The patient takes meals 4-5 tames a day. Alkaline mineral
water is widely used. Coffee, cocoa, and strong tea are excluded.
Diet No.7. This is intended for patients with chronic nephritis during the convalescence
period, chronic nephritis (in the absence of exacerbation), and nephropathy of pregnancy. The diet is
intended to decrease hypertension and lessen edema, to decrease the formation of and improve the
withdrawal of rest nitrogen from the body. The amount of proteins is moderately restricted while the
intake of vitamins increased. Food is prepared without salt: 3-6 g of salt is given to the patient. Fish,
mushrooms, and nitrogenous substances are excluded. The temperature of dishes is normal. The caloric
value of the diet is 2800-3000 kcal a day. The amount of liquid is restricted to 1 liter. Food is take 5-6
times a day. Cocoa, strong coffee, mineral waters containing sodium is excluded.
Diet No.8. The diet is prescribed for obesity to decrease fat deposits. The content of
carbohydrates and fats (especially animal fats) is low; the protein content is moderately increased.
Liquid, salt, and appetite stimulators are decreased. The diet is low in calories: 800-1000 kcal per day.
The salt intake is restricted to 5 g and liquid intake to 1-1.2 liter a day. The patient eats 5-6 times a day.
In order to depress the feeling of hunger, the diet is enriched with fiber. Tea, coffee, juices (fruits, berries,
vegetables) are given while lemon drinks, kvass, and grape juice are excluded. Fasting days is prescribed,
when the patient eats only watermelon or the like.
Diet No.9. The diet is prescribed for diabetes mellitus. It is intended to normalize
carbohydrate metabolism and to prevent disorder in fat metabolism, and also to determine tolerance to
carbohydrates. The content of fats and carbohydrates is moderately low. Sugar and sweets are excluded.
The protein intake is slightly increased. Vitamins, lipotropic substances (methionine, lecithin), and
cellular tissue are increased. Sugar substitutes (sorbitol, xylitol) are used. The diet is 2500 kcal per day.
The food is given 5-6 times a day. Grape juice, lemon drinks are excluded.
Diet No.10. The diet is prescribed for heart disease with circulatory insufficiency, and
essential hypertension. The diet should spare the cardiovascular system and promote correction of the
abnormal circulation, facilitate withdrawal of rest nitrogen and under oxidized metabolites. The intake
of fats is moderately decreased. All dishes are salt-free. Salt is given to the patient (4-5 g). Food is
 -22-

given 5 times a day, in equal portions. The daily intake of liquid is 1 liter; the caloric intake is 2500-2800
kcal a day.
 -23-

Diet No.11. The diet is prescribed for tuberculosis of the lungs, anemia, and cachexia. It is
intended to increase the body resistivity to various infections and to improve nutrition in general.
The diet is rich in proteins, fats, carbohydrates, vitamins, calcium, and iron. The calorie intake is
3300-3800 kcal a day. Food is given 5 times a day. Fatty meat or poultry, spicy sauces, a lot of
sweet cream are exceeded.
Diet No.12. This diet is indicated for chronic cardiovascular diseases and rich in
vitamins. Food is taken 5-6 times a day. The caloric intake is 3000 kcal a day.
Diet No.13. The diet is prescribed to patients with acute infectious diseases, tonsillitis,
and after surgery on external organs and tissues. The diet is intended to maintain the strength of the
body, to improve the function of the gastrointestinal tract in acute fever or during the
post-operative period when bed-rest is obligatory. The diet is moderately restricted in fats and proteins;
the caloric value is low while the vitamins and liquid are increased. The intake of rough cellular tissue,
fatty, salted and spicy dishes and condiments is restricted. The temperature of hot dishes should not be
higher than 55 and of cold dishes not lower than 12 C. The daily intake of salt is 8-10 g, of liquid, 2
liters and more. The calorie intake is between 2200 and 2500 kcal. Fruit and berry juices, wild rose
decoction, tea with lemon should be given in large amounts.
Diet No.14. The diet is indicated for nephrolithiasis and pyelocystitis attended by alkalinity
of the urine and precipitation of calcium phosphates (phosphaturia). The diet is intended to shift the
acid-base equilibrium toward acidosis by restricting the intake of alkalizing foods (to prevent
precipitation). Vegetables should be restricted (potatoes, carrots, cabbage, berries); the fat intake is
increased to 120 g a day. The daily liquid intake is 2-2.5 liters and of salt 12-15 g. Food is taken 4-5
times a day. Dairy products, salads, canned food, fruits, and fruit and berry juices are excluded.
Diet No.15. The diet is indicated for patients with various diseases, which do not require
diet therapy (without involvement of the alimentary system). The diet is intended to ensure adequate
nutrition by observing physiological standards of nutrition for appropriate working and living
conditions. The daily intake of proteins is 80-100 g (animal proteins,
 -24-

55-60 per cent), of fat 80-100 g (vegetable fats, 25 per cent) and of carbohydrates, 400- 450 g.
The caloric value of the diet is 2700-3000 kcal / day. The daily intake of salt is 15g; the intake of water
is unlimited. Food is taken 4-5 times a day.

Fasting diets
Fasting diets are prescribed for patients with cardiovascular diseases, diseases of the
alimentary tract, kidneys, and for patients with metabolic disorders. The diet is intended to normalize
metabolism, to promote withdrawal of excess water and sodium. Fasting diets are prescribed for 1-2
days, 1-2 times a week, depending on the given disease and toleration of hunger. One food is
predominantly given to the patient on fasting days and the diets are named accordingly, e.g. fruit diet,
vegetable diet, etc.
A dairy diet is usually used for diseases of the cardiovascular system complicated by
pronounced circulatory insufficiency, essential hypertension, obesity, pyelitis, cystitis, and diseases of
the liver and the bile ducts. The calorie intake is 700-1000 kcal a day.
Curds diet. This is prescribed for pronounced circulatory insufficiency, chronic nephritis
(with edema but without azotemia), and obesity. The daily calorie intake is 1600-1700 kcal.
Apple diet. This is prescribed for obesity, essential hypertension, cardiosclerosis
(accompanied by overweight), chronic nephritis, and chronic pancreatitis. The daily calorie intake is
500-600 kcal.
Stewed-fruit diet. The calorie intake is 750 kcal.
Milk-potato diet. This diet is prescribed for chronic nephritis with edema and azotemia,
for diseases of the cardiovascular system with pronounced circulatory insufficiency, and for various
disease associated with acidosis. The daily caloric intake is 1200-1300 kcal.
Raisins diet. This is prescribed for chronic nephritis with edema and azotemia,
cardiovascular diseases with pronounced circulatory insufficiency.
Tea diet. This diet is indicated for acute enterocolitis and gastritis with hyposecretion.
Meat-vegetable diet. This diet is indicated for obesity.
Water melon diet. The diet is prescribed for nephritis, podagra, and nephrolithiasis with
uraturia.
 -25-

Critical patients should be assisted in their meals. If a patient rejects food (psychic
disorders) or is unable to swallow it (in some diseases of the mouth), the patient is fed food should
be fed through a gastric tube. The tube is passed through the oro- or nasopharynx and slowly farther,
along the posterior wall of the pharynx, into the esophagus. If the tube enters the larynx instead of
the esophagus, the patient starts coughing and air is discharge from the tube during respiration. When
the tube is in the esophagus, a funnel is attached to its outer end and liquid food is poured into the
funnel (broth, cream, milk, fruit juice, etc.). Two or three glasses of liquid food should be given per
meal. If liquid food cannot pass through the esophagus, (because of a burn or tumor), an artificial
fistula is made through which food is poured directly into the patient's stomach.
Patients are sometimes given nutrients by enema or parenterally. A nutrient enema is
done after evacuation of the rectum by a cleansing enema. This done, a warm solution (35-40 C) of
a 5 per cent glucose and 0.85 per cent sodium chloride solution are administered by enema. The
solutions should be given 3-4 times a day in a dose from 100 to 200 ml in each enema. If the patient
does not absorb the solutions, 5-6 drops of opium should be added to them. If the patient's condition
is critical, nutrients should be given parenterally, better by intravenous injections. A 40 per cent
glucose solution is usually given. Blood transfusion is also practical. Blood plasma, its substitutes,
and hydrolysates (hydrolysine, amino peptide, protein hydrolysate), which contain amino acids
and lipofundin, are also given parenterally. From 2 to 3 liters of the solutions are given a day.
Food should be taken under calm and quiet conditions. Nervous excitement impairs
the appetite and in some patients it can be completely lost. A sleeping patient should be awakened
for meals except if he suffers from insomnia. Patients should not be awakened if they were given
narcotics or sedatives.
In order to ensure the required sanitary conditions and nutrition for patients, food
brought to them by their relatives should be inspected. The nurse should check if the food
corresponds to the dietary requirements for the given patient. Refrigerators should be available
where the patients can keep their food. Medical personnel should inspect the quality of food kept in
the refrigerators and night tables.

Theme 7
THERMOMETRY

Patient's temperature should be taken to reveal possible fever. It should be remembered,

however, that an elevated temperature does not always correspond the gravity of the patient's
condition.
Temperature should be measured by a maximum thermometer with a scale graduated in 0.1
 -26-

from 34 to 42 С. The thermometer is called maximum because it reads the maximum temperature
reached and the reading stays unchanged after cooling. A narrowing in the capillary tube prevents
the mercury from descending by gravity to the bulb unless the thermometer is shaken energetically.
Shaking should be done carefully as not to break the thermometer.
Before taking a temperature, reduce the thermometer's reading to below 34-35 С mark. The
thermometer should be kept in the armpit so that the mercury bulb is in close contact with the skin
on all its sides. The patient's armpit should be dry because a wet thermometer reads a lower
temperature. The thermometer should be held for 10 minutes m the armpit or 5 minutes in the mouth.
If the patient is very weak and cannot •hold the thermometer with the required force, he should be
assisted.
If the patient's condition is critical, his temperature is taken by placing the thermometer into
the mouth (under the tongue) or inserting into the rectum. In last case the thermometer should be
coated with vaseline or other oil. The patient should lie on his side, the thermometer being inserted
into the rectum to half its length. The buttocks should be kept tight together. Rectal temperature (and
temperature taken in the mouth) is 0.5-1 degree higher than that taken in the armpit. There are some
contraindications to taking rectal temperature. There are constipation, diarrhea and diseases of the
rectum. After taking the temperature, the thermometer should be washed thoroughly in warm water
and then disinfected in alcohol or some other disinfectant solutions. Temperature in infants should
be measured in the groin. The thermometer is placed in the caudal genital fold, the infant's thigh is
flexed to the abdomen so that the thermometer bulb is hidden in the skin fold.
The temperature is usually taken two times a day at hospitals. The first measurement is done
at 7.00-9.00 and the second at 17.00-19.00. If necessary, the temperature is taken at 3-hour intervals.
The findings are recorded in a temperature chart, where the morning and evening temperatures are
designated by dots, which are then interconnected by a curve. Many diseases have their specific
temperature curves. The temperature curve should be appended to the case history.
In normal individuals temperature varies from 36 to 37 С (as taken in the armpit). The body
temperature is lower in the morning and higher in the evening, the difference usually not exceeding
0.8 С in healthy individuals. A body temperature rises slightly after exercise or meals, or when the
ambient temperature is high. The aged and asthenic patients usually have slightly lower temperatures,
while in children it is usually higher than m adults.
The elevation of body temperature over 37 С m adults is called fever. The degree of
temperature rise is important for evaluating the patient's condition. Accelerated heart and respiration
rates and a fall of the arterial pressure attend fever. Patients complain on chill, headache, dry mouth,
thirst, and absence of appetite and excess perspiration. Metabolism is intensified during fever, while
the amount of perspired liquid may be more than 8 liters a day. As a result of decreased appetite and
 -27-

liquid loss during a fever, the patient sometimes loses significant weight.
Usually, quick and significant elevation of temperature is accompanied by a chill, that
continues from a few minutes to an hour; in rare cases it may continue longer. The blood vessels
contract during chills, the skin turns pallid, and so-called gooseflesh develops. The patient feels cold,
he shivers, his teeth chatter. If the temperature rises gradually, the patient may feel only a slight chill.
If the temperature is high, the skin reddens and the patient feels hot. A rapid drop of temperature is
attended by intense sweating. The morning temperature of the patient with fever is lower than the
evening one.
Three periods of fever are distinguished: 1 - rising temperature; 2 - maximum temperature; 3
- dropping temperature. The first period is characterized by a gradual or abrupt rise of temperature
attended by a chill, cyanosis (blue color) of the lips and the extremities, headache, and subjective
indisposition. During this period the patient should be covered with a warm blanket and given hot
tea. During the second period, headache, vertigo, dryness in the mouth, hyperemia of the skin develop
and in serious cases even delirium and hallucinations. The patient should be given much liquid to
drink (tea with lemon, fruit juice, etc.) because his loss of water is significant. If the delirium or
hallucinations develops at the patient, his bed should be provided with a protective network to
prevent him from falling out of bed. A special post for a nurse should be arranged at his bedside.
There are two types of the third period. The temperature may decrease gradually, during the course
of several days. This termination of fever is called lysis. The patient perspires slightly and his
weakness is moderate. A rapid fall of temperature (within a few hours) is called a crisis. It is attended
by intense perspiration and pronounced weakness. Arterial pressure often drops, the limbs become
cold, and cyanosis develops. Medicines increasing arterial pressure should be given and the patient
should be warmed with hot water bottles.
Temperature may rise to various degrees Temperatures between 37-38 С are called
subfebrile, 38-39 С - moderately high, 39-40 С - high, 40-41 С - very high, and over 41 С -
hyperpyrexial temperatures. Hyperpyrexial fever is attended by severe nervous disorders and
endangers the patient's life.
A correct diagnosis can be established not only according to the degree of temperature
elevation but also by its circadian variations, i.e. by the type of fever. Six major types of fever are
distinguished: 1 - continuous fever (37.5-38.5 С) that persists for several days or weeks with
circadian variation within 1 С. This fever is characteristic of lobar pneumonia and typhoid fever; 2 -
remittent fever; the circadian variations in temperature are significant (usually 1.5-2 С). This fever
is characteristic of tuberculosis, bronchopneumoma, and purulent infections; 3 - intermittent fever;
this is characterized by a sudden rise of temperature to 39-40 С and subsequent fall to normal
temperature during a few hours. The temperature may rise again in 1-3 days.
 -28-

This type of fever is characteristic of malaria; 4 - hectic fever; it is characterized by a rise in

temperature to 39 С and over followed by a sudden fall at the same day to a normal or even subnormal
temperature. This fever is characteristic of sepsis and severe forms of tuberculosis; 5 - inverted fever;
the morning temperature is higher than the evening one; this type of fever is typical of brucellosis,
sepsis, and tuberculosis; 6 -irregular fever; it occurs mostly in influenza, rheumatism- dysentery,
tuberculosis, etc. Temperature swings during the day are quite varied and indefinite in irregular fever.
In addition, there are two forms of temperature curves, i.e. relapsing and undulant. Relapsing
fever is characterized by alternation of pyrexia and apyrexia. It occurs in typhus recurrent. Undulant
fever is characterized by a gradual rise of temperature during several days followed by its gradual
fall. This fever occurs in brucellosis and lymphogranulomatosis. A fever lasting 15 days is called
acute, and over 45 days, chronic.
The condition in which the body temperature is markedly subnormal is called hypothermia.
This often occurs after a critical fall of temperature. Hypothermia (about 35 С) can persist for 1-3
days. The pulse is slow; the subjective condition is satisfactory. Hypothermia occurs also in collapse,
after profuse hemorrhage, in starvation, asthenia, and after a prolonged exposure to cold.
Care of patients with fever. Patients with fever are weak and it is necessary to replenish the
lost water and nutrients. Since appetite of patients with fever is decreased, food should not be
abundant but highly caloric and easily assimilated. It should be rich of vitamins and proteins. A lot
of liquid should be given to the patient in order to replenish the loss of water.
If the perspiration is excessive at the patient. Ins bedclothes and underwear should be changed
several times a day. A dry warm towel should be used to wipe off the sweat during especially
intensive perspiration. Since sweat evaporates from the skin and leaves metabolites on its surface
(salts, urea), the skin should be cleaned by the water mixed with alcohol or vinegar. If the body
temperature is high, the mucosa of the mouth and the lips become dry and cracked. Special care of
the mouth should be carried out. Correct care of the patient's skin helps to alleviate his condition.
The patient with fever should be assisted to evacuate his bowels and the bladder. The pulse
and respiration rate should also be monitored. Special attention should be given to the patient during
a critical fall of temperature that is often attended by a fall in arterial pressure (collapse).
 -29-

Crisis

Lysis
 -30-

Fever continua

Fever remittent
 -31-

Fever intermittent

Fever hectic
 -32-

Fever inversus

Fever irregular
 -33-

Fever recurrent

Fever undulant
 -34-

Theme 8
SIMPLE MEDICAL PROCEDURES

Various procedures are used to produce the desired effect on a patient's blood circulation, both
local and general. These procedures include hydrotherapy, hot water bottles, cups, mustard plasters,
leeches, bloodletting, compresses, ice bags, etc. These procedures have their effect on both healthy and
sick individuals through thermal, mechanical or chemical stimulation. The skin is the main site of
application of these procedures. When irritated, various reflexes are activated in the skin. For example,
a person is sleepy after a warm bath or even after local application of heat. Thermal effects decrease or
even remove pain, decrease skin sensitivity, and prevent transmission of pathological impulses into the
central nervous system. Temperature stimulants reflectorily change the lumen of the blood vessels to
alter the blood distribution in the body. When the cutaneous vessels dilate, the vessels of the abdominal
organs contract, and vice versa, when the skin vessels narrow, the vessels of the abdominal viscera dilate.
The entire body responds to a thermal procedure, but the response is more pronounced at the site
of heat application. Heat applied to the skin draws a lot of blood from the internal organs and the body
temperature thus increases. When the difference between the temperature of the body and the ambient
temperature increases, the body gives off its heat to the environment via irradiation. Heat is also removed
during the evaporation of sweat and expiration of air.
When heat is applied to the heart region, the pulse rate increases. But this occurs not due to the
direct effect of heat on the heart muscle, but because of stimulation of the skin receptors. The respiration
and pulse rate increase when heat is applied to large areas of the body, the effect being especially
pronounced when entire body is exposed to heat. Arterial pressure decreases in such cases. When hot,
the body perspires. The sudorific effect of heat promotes the resolution of exudate in inflammatory
affections. Prolonged application of heat to muscles decreases their tone and fatigue develops.
Cold affects the body in three stages. During the first stage, the skin vessels contract, the skin
becomes pallid, blood flows to the internal organs, and the skin becomes cold. A minute later, the second
stage develops: the cutaneous vessels now dilate, the skin reddens, and becomes warm when touched.
During the third stage, the blood flow slows down; the skin turns blue and cold again.
When cold is applied to the heart region, the pulse rate slows and pain in the heart is alleviated.
The respiration rate first decreases and then increases in the cold, metabolic processes are accelerated
and the production of heat is intensified. Cold increases the excitability of muscles. Application of cold
 -35-

retards development of acute inflammatory processes.

Hydrotherapy. This includes the external application of water, e.g. shower, bath, sponging, and
wet packs. Bath, sponging, douching, and similar simple procedures can be done at home, while more
complicated hydrotherapeutic procedures should be done at special hydrotherapeutic establishments. In
order to protect the patient’s body, water can be poured over the body from a pail. The entire body or
its separate parts can, thus, be strengthened. For overall protection the patient is seated on a low stool
in a bathtub, and 2 or 3 pailfuls of water are poured over him. The temperature of water in the first pail
should be 30-34 C, and in subsequent pails, 2-3 C, lower. Water should flow over the chest and back.
The pail should be held close to the body. The procedure should be done daily, the water temperature
being gradually decreased to 21-22 C. The body should be rubbed dry after the procedure until the skin
reddens slightly.
Rubbing is another hydrotherapeutic procedure. It improves the body and can be used during
fever or neurosis. General and local procedures are distinguished. For a general procedure a bed sheet is
wetted in water at the temperature of 30-32 C, the excess water is wrung out, and the patient is wrapped
in the sheet. The patient first raises his arms above his head, then lower them, the sheet is passed over
the shoulders, and finally fixed on the neck. The patient's entire body is then rubbed energetically
through the sheet. Rubbing continues for 2-3 minutes, then the wet sheet is replaced by a dry one. The
effect can be intensified, if water is first poured over the patient. Local rubbing is prescribed for weak
patients. The naked body is covered with a dry sheet and a blanket, and separate parts of the body are
rubbed with a wet towel (32-34 C).
Packs can be wet or dry, local or general. For a general wet pack, two woolen blankets are placed
on the bed. A sheet is wetted (25-30), the excess water is wrung out and the sheet is placed over the
blankets. The patient is undressed and placed on the sheet with his arms raised. The patient is wrapped
in the sheet; then he is allowed to lower his arms, and is wrapped tightly in the blankets. The head alone
is left uncovered. The patient remains in this position for 30-60 minutes. The procedure is effective in
case of neurosis and early hypertension. Local packs are used for obesity: the patient is wrapped to the
waist or the armpits as in general pack. If a pack is dry, the patient is wrapped in a dry sheet, otherwise
the procedure is the same.
Bath. These may be general or local. Depending on the temperature of water, baths may be cold
(below 20 ), cool (20-33 ), neutral (34-37 C), warm (38-39 C), or hot (40 C and over). According to their
composition, baths may be common (pure water), mineral (containing much salt), gas baths (carbon
dioxide, hydrogen sulfide, radon), medicated baths, etc.
 -36-

For a common bath the tub is filled with water at the required temperature. The patient should
sit in the bath without constraint. His feet should rest against the tub end or, if the patient is small, against
a special device. The medical personnel should observe the patient's condition during the procedure: his
heart and respiration rates should be monitored. Common hot baths accelerate the heart and pulse rate,
intensify the metabolism and sweating, and increase the body temperature. At the same time hot baths
relax the muscles and remove pain. They are used in renal, intestinal, and hepatic colic. Hot bath are
contraindicated in diseases of the cardiovascular system, in hemorrhages, and asthenia. Bath of neutral
temperature have a tranquilizing effect on the patient and are therefore used in case of neurosis and
hyperexcitation.
Local bath differs from general ones in that only some parts of the body (arm, leg, etc.) are in
water. Local bath are prescribed for patients with inflammatory affections of the skin, joints or muscles.
Subwater intestinal irrigations are used in some diseases of the intestine (colitis, constipation,
helminthiasis). A special saddle equipped with pipes connecting it to a source of irrigating liquid and a
suction device is installed in a large bathtub (300-400 litre capacity). Irrigation is carried out in 90-120
minutes after a cleansing enema. The temperature of the bath should be 36-38 C. An end-piece lubricated
with Vaseline is inserted into the rectum and 1.5-2 litres of water at a temperature of 38-39 C are
administered into the intestine from a pressure (suspended) flask. Then the suction apparatus is turned
on. This procedure is repeated from 3 to 4 times, with gradually increasing amounts of the administered
water (to 6-8 litres). The final washings should be clean. The patient is then allowed to rest for 15-30
minutes. All parts of the apparatus should be washed and disinfected after use.
Shower is a medical procedure whereby water falls on the patient's body in one or several jets.
A water jet is controlled by the operator from a control panel. Two factors act on the patient - thermal
and mechanical. Showers can be local or general and the water pressure in the shower jet may be low
(0.3-1 kg/sq. cm), medium (1.5-2 kg/sq. cm), or high (2.5-4 kg, sq. cm). The temperature of water varies
from 15 to 45 C depending on the disease. The mechanical action of the shower depends on the manner
by which water is discharged from the source. Water can be sprayed or fall like rain; it can be given in
needle-thin jets, or in fan-like motions; the shower can be circular or in the form of a simple jet. Showers
of short duration increase the tone of muscles and the vascular system. Prolonged cold and hot showers
decrease excitability of the nervous system and intensify metabolism, while warm showers produce a
quieting effect on the patient. Energetic rubbing should be done after shower (both cold and cool) to
intensify blood circulation in the skin.
Heat is applied for local warming, to accelerate resolution of cutaneous and subcutaneous
 -37-

indurations and also as a pain-relieving remedy. The vessels are dilated and blood supply to the tissues
is increased by application of heat. Heat is prohibited in acute inflammation of the abdominal organs
(appendicitis, cholecystitis, pancreatitis), in hemorrhage, contusions (during the first day), and in
thrombophlebitis.
Heat may be applied in water bottles or electrical heaters.
It is not recommended to apply a hot water bottle directly to the patient's body. It should be
wrapped in a towel or placed over a blanket. In order to prevent pigmentation of the skin due to frequent
application of heat, the skin should be coated with Vaseline or vegetable oil. A very hot water bottle is
contraindicated for children and patients with edema.
Treatment with cold is called cryotherapy. Ice bags are commonly used. Cold causes contraction
of the blood vessels, thus decreasing the sensitivity of the peripheral nerves. Cold is applied as a first
aid measure for acute inflammation of abdominal organs (acute appendicitis, pancreatitis, cholecystitis,
etc.), for hemorrhage, contusion, bone fractures, delirium associated with fever, and also for
anesthesia. Ice or snow is placed in a rubber bag which is wrapped in a towel or sheet and applied to
the injured area. To prevent excessive cooling of the tissues, an ice bag should be applied for no longer
than 20-30 minutes followed by an interval of 10-15 minutes. If the patient has a fever, an ice bag is not
applied directly to the head but is suspended over it.
Mustard plasters are used in acute and chronic diseases of the airways, pneumonia (applied to
the chest and back), in hypertonic crisis (onto the back of the head), and in cardiac pain (on the heart
region). Mustard is contraindicated for skin diseases. Very hot water should not be used in applying
mustard plasters because it destroys the mustard enzymes and the mustard oil is not liberated. Ready-
made plasters should be immersed in warm water and applied to the skin for 10-15 minutes. If the skin
is very sensitive mustard plasters should be applied over a thin sheet of paper or gauze. Frequent
application of mustard may cause pigmentation of the skin. The procedure should last for a maximum
of 15 minutes, after which the mustard should be removed from the skin by warm water.
General mustard baths help alleviate catarrhs of the airways, bronchitis or pneumonia, usually in
children. Mustard powder should be added to water in the bath, 40-60 g per 10 litres. The temperature
of water in the bath should be 37-39 C; the procedure should last for 8-10 minutes for adults and 5-6
minutes for children. The patient should then be wiped dry with a warm sheet, and allowed to rest.
Compresses can be general (wet pack) or local (hot, warming, and cold compresses). General
compresses are given to fortify the patient, in cases of fever and neurosis. A general compress lasting
for 15-20 minutes has an antipyretic effect and stimulates the nervous system. General pack for 20-45
 -38-

minutes decreases the excitability of the nervous system, while 50-60 minute packs have a sudorific
effect.
General wet pack is done as follows. Woolen blankets are placed on a bed, and covered with a
damp sheet. The patient undresses and lies down on the sheet and the nurse wraps him quickly in the
sheet and then in the blankets. A cold compress is placed on the patient's head. An oil-cloth is sometimes
placed between the sheet and the blankets. The size of the oil-clothe should be the same as that of the
sheet. The effect of wet pack has three stages. During the first stage which lasts 15-20 minutes, the sheet
warms up to the temperature of the patient's body. During the period the nervous system gets excited
and the metabolism intensifies. During the second stage (20-40 minutes) the warming process decreases
the excitability of the nervous system and drowsiness develops. Respiration becomes deeper, the pulse
slows down and the arterial pressure falls. During the third stage (40-60 minutes) the body becomes
overheated, the patient perspires, and the nervous system becomes excited.
A local warming compress is one of the most common procedures. Its therapeutic effect is based
on the uniform warming of tissues. The local effect and also reflectory mechanisms increase blood
supply of the tissues, intensify metabolism, and decrease sensitivity to pain. A warming compress
is used to accelerate the resolution of inflammatory processes in the skin, subcutaneous cellular tissue,
and in the joints. It produces an analgesic effect in dyskinesia of
the stomach, intestine, and the gall bladder, and also in colitis. Compresses are contraindicated
in furunculosis, some skin disease and injuries.
A compress consists of four layers. The first layer is a piece of cloth (folded in two or three)
wetted in water at 12-16 C. The excess water is wrung out and the cloth is applied to the skin. A piece
of oil-cloth of water-proof paper (2-3 cm larger than the cloth) is placed over the wet cloth. The third
layer is cotton wool. It is larger than the second layer. All three layers are tightly fixed to the body by
bandaging; the pressure of the bandage should not, however, interfere with normal blood circulation.
Sometimes, in order to increase the effect of the compress and to lessen maceration of the skin, a 5 per
cent alcohol solution is used instead of water to wet the first layer. A 3-4 per cent sodium hydrocarbonate
solution or camphor oil can also be used.
A local hot compress produces a strong analgesic effect. A piece of gauze, folded several times,
is wetted in water at 50-60 C, the excess water is wrung out, and the gauze is placed on the affected site.
An oil-cloth is placed on top, and the compress is covered with woolen fabric. Such a compress should
be renewed at 5-10 minute intervals.
Leeches are blood-sucking aquatic forms. Their saliva contain hirudin, a substance that retards
 -39-

coagulation of blood. Leeches cannot stand strongly smelling substances. They attach themselves better
to warm surfaces. One leech can suck up to 10 ml of blood. Leeches should be kept in glass bottles
covered with a piece of gauze. Pond or river water is their normal medium but tap water can also be
used, provided it is allowed to stand open for 24 hours. The temperature of the water should be from 15
to 20 C. The water should be changed once a day.
Only healthy leeches can be used to draw blood from patients. They have a good contraction
reflex: when a leech is touched, its body becomes short and resilient. Healthy leeches try to escape from
the bottle; they stick to the hand if it is immersed in water.
Leeches are indicated in hypertension, thrombosis of the cerebral vessels, concussion of the
brain, myocardial infarction, and pre-infarction conditions, thrombophlebitis, and hemorrhoids. Leeches
are contraindicated in hemorrhage and hemophilia, anaemia, sepsis, and if there is evidence of decreased
blood coagulability.
Leeches are applied as follows. Several leeches (more than required) are transferred from their
bottle into a smaller vessel (50-100 ml) using pincers; only healthy leeches should be selected. The skin
of the patient should be washed without fragrant soaps since leeches are very sensitive to odor. The skin
of the patient should then be rubbed to cause a rush of blood or wetted with sweet water: the leech will
more readily stick to the skin. If the leech does not stick, it is replaced by another one. From 4 to 10
leeches can be applied simultaneously.
When a leech bites the skin and sticks to it, the frontal portion of its body sets in wave-like
motion. The vessel can now be removed and sterile cotton wool or a piece of gauze placed under the
hind end of the leech. A leech sucks effectively from 30 to 90 minutes. If a leech falls off quickly, it
means that its application was ineffective. If a leech does not fall off for a long time, it should not be
detached by force, but table salt should be sprinkled on it and the leech will fall off. Used leeches should
be killed by placing them in formaldehyde solution. The wounds on the patient's skin bleed for 4-24
hours, and from 10 to 30 ml of blood may seep from each wound.
During application of leeches the patient should be resting in a convenient position. After
removal of the leeches the wound should be bandaged tightly. Suturing may be necessary in rare cases.
The wound should be protected from possible infection and the bandage changed daily. If the bleeding
does not stop, potassium permanganate or iron sesquichloride solution should be used. If the hemorrhage
is stopped, the wound should be treated with alcohol, iodine tincture or hydrogen peroxide and dry
bandage applied.
Leeches should be applied in the following cases: 1 - to draw blood; 2 - to decrease blood
 -40-

coagulability. In the former case the leeches should be allowed to stay until they draw enough blood,
and in the latter case they should be removed immediately after they bite the skin and stick to it. The
leeches should not be pulled off, but only touched with cotton wool soaked in iodine tincture or alcohol.

Theme 9

STORAGE AND USE OF MEDICINAL PREPARATIONS

There are many types of therapeutic effects including the following: surgical treatment,
balneologic and physiotherapeutic procedures, climatotherapy, etc. But the most common type of
treatment is pharmacological therapy, i.e. treatment with medicinal preparations.
If medication is intended to eliminate the cause of the disease, this is called etiotropic
treatment. For example, quinacrine acts on the causative agent of malaria and antibiotics act on agents
causing infection. Many medicinal preparations act not on the causative agent but on the developing
disease, the cause being uncertain or inactive by the time of treatment. This treatment is called
pathogenic. For example, cardiac glycosides or diuretics are given for circulatory insufficiency.
Symptomatic treatment is used to alleviate some symptoms of a disease, e.g. narcotics are given to
relieve pain and sedatives are given for insomnia. Sometimes a patient is given etiotropic, pathogenic,
and symptomatic treatment all at the same time.
The effect of a medicinal preparation depends, to a considerable degree, on its dose. A single
dose means the amount of the medicine, which is to be taken within 24 hours. A total or cumulative dose
means the amount of the medicine that is taken by the patient during the entire course of treatment.
A therapeutic dose means the amount of medicine that causes a pronounced in the patient. A
toxic dose is the amount of medicine causing symptoms of poisoning. A therapeutic effect depends
on the concentration of the medicine, which in turn depends on the dose, and the body weight of the
patient. In the connection a dose is often specified with reference to a kilogram of the patient's weight.
A concrete dose should, in such cases, be calculated for each particular case. Sometimes treatment is
begun with a dose that is 2 or 3 times higher than the doses that follow. This is a priming dose. It is used
to ensure a specific concentration of the medicine in the patient's blood, while subsequent doses will
only maintain this concentration at the required level. These are called maintenance doses.
 -41-

Most often prescribed are therapeutic doses. They produce an optimum curative effect on the
patient. But it should be remembered that, in some cases, these doses become toxic. Sensitivity of a
patient to medicinal preparations normally varies within a wide range deranging on the physiological
condition of the body (pregnancy, lactation), nutrition, age, and sex. Age sensitivity to medicinal
preparations is especially varied. In this connection, several formulas have been derived by which doses
can be calculated depending on age. But these formulas are not quite suitable for children. In order to
prevent possible errors in calculating doses, a special table is provided in the State Pharmacopoeia of
the USSR, where permissible single and daily doses of strong and poisonous medicines are calculated.
Apart from their curative effect, medicines can also cause undesirable side effects. These are
biological effects that develop irregularly and cannot be predicted or foreseen. Toxic side effect can
develop as a result of overdose by error or of a suicidal attempt of the patient. Drug addiction is a well-
known side effect of narcotics. A special group of side effects includes various forms of idiosyncrasy
and drug disease. The last is manifested by a complex of immediate and delayed allergic responses.
These non-specifics side effects are the result of individual, congenital or acquired properties of the
body. Idiosyncrasy is an example of such a non-specific side effect. This is a congenital hypersensitivity
to certain drugs given even in minimal doses. The phenomenon is caused by a disordered enzymatic
metabolism. As distinct from idiosyncrasy, drug disease depends not on the congenital but acquired
properties of the body. Drug disease develops because of a specific sensitization of the patient to drugs.
Its incidence is rather high.
If the patient becomes adapted to a medicinal preparation, its therapeutic dose has to be
increased. Some preparations, on the other hand, can be accumulated in the body, and their doses should
therefore be gradually decreased, or the medication should be suspended at intervals to prevent
poisoning.
The nurse must be sure that the patient takes the medication according to the schedule
prescribed by the physician; otherwise a patient may collect several doses of the medicine and then take
them all at once. In order to prevent poisoning, the patient should be observed while taking medicinal
preparations. If an assistant physician or a midwife commits an error, the physician should immediately
be informed in order to correct it.
Ordering and keeping medicinal preparations. During these rounds, the physician prescribes
various medicines which he enters in the case history of the patient. The assistant physician or the nurse
records these prescriptions in a special notebook according to which medicinal preparations are
dispatched to the patients. The prescriptions are also put into a special notebook for nocturnal
 -42-

medication, and also the injection list. The medicinal preparations are ordered
According to the physician's prescriptions.
When the nurse obtains medicinal preparations from the drug store, she must check that they
comply with the order. All medicines that raise any doubts should be returned to the drug store. Storage
of medicines without labels is prohibited! All medicines should be kept in a locked cabinet. It should
be located in the nurse's room, out of patient's reach, and should always be locked. The cabinet should
be provided with drawers where poisons (List A) and strong medicines (List B) should be kept
separately and locked with different keys. The dispatch of poisons should be especially controlled.
External medicines should be kept separately from those administered internally. Medicines with a
strong odor (iodoform, Lysol) and also flammable substances (alcohol, ether) should be kept separately
from other medicines.
Expiration terms depend on the form of medicinal preparations (powder, solution, and
mixture), their chemical composition, ambient temperature and humidity, etc. Decoctions and tinctures
of plant origin can be stored for only short periods of time, while ampoule solution is intended for
prolonged storage. All containers should be tightly closed; they should not be left open to prevent
contamination with dust, pathogenic fungi, or microbes. Special care should be taken in storing sterile
solutions for parenteral administration. If a bottle contains several doses, it should be closed after each
use. If there is any doubt about the sterility of a preparation, the medicine should be discarded.
Alcoholic and ether solution, tinctures, and extracts can be stored for a long time because
microbe is quickly killed in them. But these substances are quickly evaporated to increase the
concentration of the active substance and can thus cause overdose. Some medicines (salts of silver,
bromine and iodine) decompose when exposed to light and they should therefore be stored in dark
bottles. The amount of medicines kept in the cabinet should not exceed a store for 3 or 4 days. Sterile
solutions (in containers other than vials) should be stored for not longer than 3 days, while antibiotic
solutions, not longer than 24 hours. Ampoule solution can be stored for months. An expiration date is
usually indicated on the label. Medicines intended for treatment of eye diseases should be kept with
special precautions. Eye drops should be kept for only 2 or 3 days. A color change, precipitation of
flakes, various deposits and coats, or changes in the odor (ointment) indicates that the medicine is
spoiled.
When visiting a patient at home, the assistant physician or the midwife should teach relatives
how to keep and handle the medicines. Medicines should preferably be kept under a lock and should
not be left at the patient's bedside. Strong medicines should not be handled with special care. They
 -43-

must be kept away from children. All medicines should be kept in labeled packages.
Administration of medicines. The following methods of administration of medicinal
preparations are distinguished: enteral (intestinal), external, parenteral, and by inhalation. The choice of
the administration mode depends on the particular disease. Each mode has its advantages and
disadvantages.
Enteral administration implies taking medicines by mouth (per os) or through the rectum (per
rectum); or the medicine can be placed under the tongue (sub lingua). Internal administration is the
common way of taking medicines. The advantage of the method is that medicines can be given in any
form and under non-sterile conditions. The disadvantages are: 1, the preparation is slowly absorbed into
the blood; 2, the properties of the medicine are altered by the gastric and intestinal juices. Since the
absorption is slow, it is difficult to predict the concentration of the medicine attainable in the blood and
tissues.
Forms suitable for internal use are tablets, powders, pills, aqueous and alcoholic solutions,
extracts, decoctions, and mixtures. If a medicine has an unpleasant or bitter taste (quinine) or may irritate
the mouth mucosa, or else can affect the teeth (iron preparations), they are given in protective coats or
capsules.
Junior medical personnel should not be allowed to give medicines to patients. This is applied
even more to the patient himself, since he may forget to take medicines or not take them in time. Each
case when the patient is given medicines should be recorded in the journal in order to prevent overdose
by giving the medicine twice or miss a dose. When a powder is taken, it should be unpacked, the paper
folded in a kind of a chute, and the powder spilt over onto the tongue. The patient should then drink
water. If the taste is unpleasant, a sweet drink should be given, especially to children who resist bitter
medicines. A coated tablet or a capsule should be placed on the back of the tongue and swallowed with
a large gulp of water. If a patient is unable to swallow a large tablet, he should wet it by taking a small
sip of water; the next gulp will then help.
Liquid medicines are often given. Aqueous solutions, decoctions, and mixtures are given in
graduated glasses (5-20 ml). In the absence of calibrated vessels (at home), the medicine can be given
in spoonfuls. A tablespoon can hold about 15 ml, a dessert spoon, 10 ml, and a teaspoon, 5 ml. Alcoholic
or ether extracts or tinctures should be measured in drops using a pipette. One gram of water contains
20 drops, 1 g of alcohol, 60 drops, 1 g of ether, 80 drops. A separate pipette should be used to give
different medicines. If only one pipette is available, it should be washed with boiled or distilled water
after each use.
 -44-

Rectal administration of medicines is also popular. It is especially important in cases where

“per os” administration is unfeasible due to difficult swallowing, in burns of the esophagus, vomiting,
when the patient is unconscious, and in some other cases. In some disease (heart failure, diseases of the
gastrointestinal tract) absorption of medicines in the stomach and intestine is either slow or incomplete.
Rectal administration is preferred in such cases because due to anastomosis of the hemorrhoid veins with
the iliac veins, the medicine enters the inferior vein Cava bypassing the system of the portal vein and
the liver. It should be remembered that the absorption power of the rectal mucosa is about 25 per cent
lower than that of the small intestine. The rectal dose should therefore be slightly higher than a median
therapeutic one, but it should not exceed the permissible single dose. The absence of enzymes in the
rectum is a disadvantage: medicines contained in a protein, fat or polysaccharide base cannot penetrate
the rectal wall and should therefore be given only locally.
Suppositories or enemas are used for rectal administration of medicines. Rectal suppositories
are shaped like small cigars or cones, 1-1.5 cm in diameter, and 2.5-4 cm long. A suppository weighs
1.1-4 g. when inserted into the rectum; the suppository base has to overcome the resistance of the
sphincter muscles. The base material should therefore be solid at normal temperature but melt and
dissolve at the temperature of the body, so that the active substance can be adsorbed by the rectal mucosa.
Commonly used bases are cocoa butter, polyethylene glycol, glycerinated gelatin, etc. Suppositories
should be wrapped in waterproof paper and kept in a refrigerator. Before insertion into the rectum, the
paper should be stripped off the tip of the suppository, which is then inserted into the anus, while the
wrapper remains in the hand. If a medicinal solution is to be administered by enema, the rectum should
be cleansed by an evacuate enema.
Only few medicines are given sublingually. These are strong medicines like nitroglycerine or
sex hormones. Their doses are small. The preparations are quickly absorbed under the tongue without
being destroyed by digestive enzymes. The medicine is thus involved in the circulation bypassing the
liver.
External medicines are applied to the skin, eyes, ears, nose, and the vagina. Ointments,
emulsions, solutions, suspensions, powders, etc. are applied to the skin. The absorbing power of
intact skin is insignificant and only a small part of the fat-soluble substances is absorbed through the
sebaceous gland outlets. External medicines are mainly intended for local and reflectory effects.
Ointments are mainly given in skin diseases. Ointment is taken on a spatula, spread on folded
sterile gauze, and thus applied to skin. The gauss is covered with cotton wool and the entire pack is
bandaged. Ointments are sometimes used for
 -45-

Compresses. Irritating substances, such as camphor or salicylic acid, are used when a hyperemic
effect is desired. An alcoholic tincture of iodine is used for disinfecting the skin and wounds. Iodine
tincture can burn sensitive parts of the skin.
Powdering or dusting is used to treat the skin of patients with hidrosis and intertrigo. This
procedure is usually done to infants. Skin folds are treated with talcum or rice powder: cotton wool is
dipped in powder and applied to the affected
Skin. The cotton wool should then be discarded. The same cotton wool may not be dipped into
the powder for the second time, even if only one infant or an adult patient is treated with this powder.
Good penetration of medicines through the skin can only be attained by electrophoresis.
Particles of the medicinal solution which is used to wet electrode covers penetrate the skin under the
action of direct current to form a depot from which the medicine is then gradually carried away by the
blood and lymph. Only certain substances can be administered by electrophoresis. Electric current
decomposes some medicinal preparations of complicated composition and only its separate components
are deposited in the patient. Medicines can be applied to various parts of the body. The advantage of
electrophoresis is that the medicine is gradually supplied from the skin depot to various organs and
tissues. Small doses given by electrophoresis lessen side effects of the medicine, while its accumulation
in a specific part of the body improves significantly the therapeutic effect in some diseases.
Solution and ointments are usually used to treat diseases of the eye. The conjunctiva has a
pronounced absorption power. Medicinal solution is administered using a pipette. The lower eyelid is
pulled down and the drops are applied to the mucosa at the external canthus. Ointments are applied with
a special glass rod or spatula from which the ointment is placed between the conjunctiva and the eyeball.
Solutions, powders, ointments, and vapors (amyl nitrite, ammonia) are used to treat ailments
of the nose. These substances act locally and reflectorily. Medicinal solutions are instilled into the nose
with a pipette. The patient should tilt his head back during this procedure. Ointments are applied to the
nasal mucosa with a glass rod. Powders are administered by inhalation: while the powder is being
inhaled by the left nostril, the right one should be closed, and vice versa.
A pipette is used to administer solutions in the ear. The patient should lie on his side during
the procedure. In order to straighten the auditory meatus, the ear auricle is pulled up and back. After
the drops have been instilled, the finger should press the ear tragus for deeper penetration of the drops.
In order to prevent spillage of the solution, the patient should remain on his side for 20-30 minutes. The
Acoustic meatus should then be closed with a cotton ball. Globules, tampons, powders, and
solutions are used for vaginal irrigation and other medicinal applications. Medicinal solutions used for
 -46-

irrigation should be warm and a special end-piece should be used. The medicines are usually intended
for local use because the absorbing capacity of the vagina is insignificant. The respiratory system is
treated by inhaling aerosols, which pass into the alveoli, bronchioles, fine and large bronchi, the trachea,
the larynx and the mouth. In order to increase the depth to which aerosols penetrate and to increase the
amount of precipitated medicine, aerosols are charged electrically. Electric aerosolization increases the
depth of breathing and decreases hypoventilation by increasing the number of functioning alveoli. As a
result, larger amount of medicinal preparations reach the inflamed focus ensuring direct contact of the
preparation with the causative agent in the lung tissue. Antibiotics, sulfa drugs, broncholytics
(euphylline, ephedrine), enzymes, expectorants, mineral water, corticosteroids, and other substances are
administered by inhalation.

Theme 10-11
Parenteral administration of preparations

Parenteral administration, i.e. not intestinal, implies

injections which may be intracutaneous, subcutaneous, intramuscular, intravenous and intraarterial.
Solutions may be injected into the pleural or abdominal cavity, into the heart,
joints, bone marrow, cerebrospinal canal, and into the focus of affection.
The quick effect of injections accounts for their wide use. When given parenterally, medicine
enters the internal media of the body directly, bypassing natural barriers,
accelerating the therapeutic effect of medicine and increasing the accuracy of dosage. Ampoule
solutions are portable, convenient for storage and transportation. The mass production of ampoule-
syringes (ampins) expands the field of application of injections in emergency aid and under field
conditions.
Although the advantages of parenteral administration of medicines are quite obvious, injections
are usually given only to those patients who cannot take medicines enterally.
Injections are impossible or very difficult in cases of hemophilia, skin diseases, in psychic or
nervous excitation, or when the patient fears injections, and also under some
other conditions.
The main requirement for an injection solution is its sterility. Solutions are sterilized by various
methods, e.g. in an autoclave, by tyndallization, and bacterial filtration.
Distilled water is the common diluent for injections. If a medicine is insoluble in water
 -47-

(camphor, hormones), vegetable oils are used. Injection solutions are manufactured either in ampoules
or vials. An ampoule is a sealed glass vessel. When an ampoule is opened, its contents will not remain
sterile and ampouled solutions are, therefore, intended for single use. A vial can be opened and closed
again in aseptic conditions and its contents can, therefore, be used in portions. Ampoule solutions
come mainly in single doses, while cumulative doses are packaged in vials.
Solutions are injected using a needle and a syringe. A syringe is actually a small hand pump by
which liquids can be injected or extracted. It consists of a hollow barrel or cylinder and a piston with a
knob. The cylinder has a larger opening at one end to admit the piston and a narrower one at the other
end to which a needle is attached. The cylinder is
graduated. The piston should move freely inside the cylinder but its contact with the walls should be
tight.
Large hospitals have a special department where all materials and tools are washed and
sterilized in autoclaves by steam, dry air or gas. Mechanization and automation of such procedures save
time and ensure reliable sterilization.
'Record' and 'Luer' syringes are commonly used in the Soviet Union. The cylinder of the Record
syringe is made of glass while its cone, the rim and the piston are stainless steel. The Luer syringe is
entirely made of glass. The disadvantage of the Record syringe is the different thermal expansion of
its parts since they are made of different materials (glass and steel). Consequently, the cylinder often
breaks when boiled or cooled. It is impossible to insert the piston into the cylinder when both are hot.
The Luer syringe is devoid of these disadvantages but is brittle and its surfaces wear quickly, breaking
the tight seal between the piston and the cylinder walls.
An injection needle is a metal tube with a cannule for a syringe at one end and a sharp point at
the other. Needles are made of polished stainless steel. The length of a needle varies from 15 to 100
mm, while its diameter is between 0.2 to 2 mm.
At home needles may be sterilized by boiling in a covered stainless steel container. The needles
are placed in a sterilizer over a grating which has handles to remove the
grating after sterilization. If a sterilizer needs to be cleaned, it should be washed with soap and soda,
and wiped dry. If a coat of fat is detected on a syringe (after oil injections), the syringe should be
washed with soap, rinsed in alcohol or ether, and then sterilized. Before placing a needle in a sterilizer,
it should be checked for obstruction by passing a mandren or a jet of water through it. Needles should
be sterilized without their mandrins and be wrapped in gauze to prevent they’re blunting. Two forceps
and hooks (to extract the grating) should also be sterilized.
 -48-

Distilled water is used for sterilizing tools. Water should cover the tools in the sterilizer.
Sterilization is more effective in a 2 per cent sodium bicarbonate solution,
which prevents damage to the tools and slightly increases the boiling point. Sterilization (boiling)
should last from 40 minutes.
Hands should be specially treated before giving an injection. The hands are first washed with
soap and a brush, then treated with alcohol (paying special attention to the
fingers), and then the skin folds near the nails are treated with an alcoholic solution of iodine.
After sterilization is completed, the cover is removed and placed on the nurse's desk where there
is also a glass with sterile cotton wool, a bottle with alcohol, a vial with iodine tincture, a container for
used materials and tools, and a glass with a disinfectant solution where a sterile forceps are kept.
Using forceps, the nurse removes the hooks from the
sterilizer; and using the hooks she removes the grating (with the sterilized articles) and puts it across the
sterilizer.
Using the forceps, the nurse unfolds the gauze and removes the necessary syringes and needles.
The piston is taken by its handle and the cylinder by its external surfaces; the needle is taken by the
cannula. The syringe is assembled using theforceps. The needle is adjusted on the cannula by slightly
rotating it. The prepared syringe is then placed on the
sterilizer cover.
Using a special file (preliminarily held in the flame of a burner) the ampoule tip is cut and then
broken off with a piece of gauze wetted with alcohol. If a file is not
available, the ampoule tip can be broken with the fingers using a piece of gauze wetted with alcohol.
A special cutter is widely used to open ampoules. Used ampoules should not be discarded for several
hours because the necessity may arise to check the solution. The needle of the syringe is inserted into
the open ampoule, and inclining the ampoule gradually the liquid is sucked into the syringe. When
all of the solution passes into the syringe, the syringe is turned with its needle up and air is removed
together with excess solution. After the solution has been injected in the patient, the needle and the
syringe should be rinsed and placed into a pan for used tools.
The hands are then washed again and treated with a disinfectant solution to prepare for another
injection.
A new syringe and needle should be used for each injection because blood that may remain
in the needle may carry infection from one patient to another. Neither can one syringe be used for
injecting different solutions because even a small amount of a substance can change the effectiveness of
 -49-

another medicinal preparation. For this reason disposable syringes are now popular. Such a syringe is a
plastic bulb with a metal needle welded into it. The syringe is sterile and packed in a sterile bag; it is
discarded after use.
Subcutaneous (hypodermic) injections and infusions. Since subcutaneous tissue is loose and
is permeated with many vessels, comparatively large amount of liquids (about 1 litre) can be
administered subcutaneously. The external surfaces of the shoulders, thighs, shoulder blades, and the
abdominal region can be used for subcutaneous injections, but the anterior lateral surfaces of the
shoulder are commonly preferred. Sites devoid of arteries, veins or nerve trunks should be selected.
Repeated injections should not be done at one and the same site because it can irritate the skin and
cause indurations.
The skin should be treated with a cotton ball wetted with alcohol before an injection. The syringe
is held in the right (apt) hand while the left hand is used to form a fold of theskin. The skin is punctured
from either above or below and the needle inserted to a depth of 1.5-2 cm. In order to minimize pain,
the skin should be punctured by a swift movement (without jerking). Once the skin has been
punctures, the syringe should be passed to the left hand, while the right hand takes hold of the cylinder
(between the 2nd and 3rd fingers) and the piston is pressed by the thumb to eject the solution. A sterile
cotton ball is now pressed to the punctured skin and the needle is quickly removed. A cotton
ball or gauze pad wetted with alcohol should be held for a few seconds on the punctured site.
Hypodermic infiltration sometimes form after injections of oil solutions. Subsequent injections should
therefore be made a certain distance from the former injection site.
Intramuscular injections. Preparations injected intramuscularly are quickly absorbed because of
the highly developed vascular system and contractivity of muscular fibers. The amount of fluid
injected intramuscularly should not exceed 15-20 ml. Substances for intramuscular injections strongly
irritate the skin (calcium gluconate, magnesium sulfate) or are slowly absorbed (bicillin, bioquinol).
Needles should not be longer than 6-8 cm, and the lumen should be sufficiently large. Pain of
puncturing the skin does not depend on the needle's thickness but on its dullness. Injections should
be made into the upper lateral quadrant of the buttocks; less frequently into the middle third of the
anteroexternal surface of the thigh and into the subscapular muscles. These parts of the body are free
from large vessels or nervous trunks. Injections should be given alternately into the right and left sides.
The syringe is held in the right hand, near the needle. The needle is inserted with a swift motion,
perpendicularly to the buttock surface to a depth of 5 cm. Before injecting the solution into the muscle,
the
 -50-

piston should be slightly pulled back in order to make sure that the needle has not punctured a vessel.
Complications are possible; for example, a needle may break and its tip remain in the tissue.
This usually happens if the needle is dull or worn out, or if the muscles contract abruptly at the point of
injection. The needle tip should be removed surgically. Another possible complication is the injury
of the nervous trunks due to incorrect selection of the
injection site, or the irritating action of the injected preparation on the nerve. Abscesses or
surface phlegmons may develop. This complication is connected with infection caused by injection,
especially if the patient is asthenic or has a decreased resistance, for example, in diabetes mellitus,
obesity, tuberculosis, heart failure. In order to prevent injection infection, special care should be
taken during sterilization of tools and instruments, during washing hands of the nurse and the skin of
the patient, and also during sterilization of injection solutions. When the first signs of inflammation
develop, a warm compress, U-V rays, UHF therapy are prescribed. If an abscess occurs, it should be
lanced.
Intravenous infusions. Medicinal solutions or fluids are often given intravenously. Venesection
or venepuncture is performed for this purpose. The physician himself should perform intravenous
infusions. An assistant physician or a nurse may also be allowed to perform this operation provided
they are supervised by the physician. Venesection may be performed only by the physician. As a
rule, injections are made into the cubital vein, less frequently into the vein of the forearm, and the back
of the hand or foot. During venepuncture the patient should lie or sit. His arm should be straight at the
elbow, and the elbow should rest against an oil-clothe pillow. Slight pressure is applied by a tourniquet
to the shoulder, 5-6 cm above the cubital flexure, to compress slightly the superficial veins without
stopping arterial circulation. The pulse should be palpable. To ensure a better filling of the veins, the
patient is asked to clench and unclench his fist several times. The physician or his assistant must treat
their hands with alcohol and the nail folds with iodine tincture. The patient's skin in the cubital fossa or
any other site of venesection should be treated with alcohol. A suitable vein is now selected for
venepuncture, and the skin is pulled down by the fingers of the left hand to fix the vein. The needle is
held in the right hand.
The vein is punctured by one or two steps. Using the two-step technique, the needle should be
held by the right hand parallel to the vein, with the angled surface upward. The skin is punctured so
that the needle first passes parallel to the vein, and then punctures its side. As the needle enters the
vein, the one doing the procedure, feels as if it is passingthrough an empty space. When the piston
is slightly pulled back, blood fills the cylinder to indicate that the needle has entered the vein. If the
 -51-

patient feels pain at the site of puncture or this site swells slightly, it means that the needle has slipped
from the vein and the procedure should be discontinued. A sterile bandage should be placed on the
swollen site, and another site selected for the puncture.
If the single-step procedure is used, the skin and vein are punctured by one movement after
fixing a tourniquet in place. The angle between the needle and the skin should then be gradually
decreased as the needle passes along the wall of the vein. Upon termination of the procedure, the needle
is extracted and the site of puncture closed with a gauze pad wetted in alcohol. The patient should flex
his arm to press the pad to the puncture site and hold his arm in this position for 2 or 3 minutes. If a
Dufaut needle is used for venepuncture, a pressing bandage should be applied upon termination of
the procedure.
Intravenous infusions require the following accessories: a sterile tray to hold the syringe, cotton
balls wetted in alcohol, and two needles: a long needle with a large lumen to take medicinal solutions
and another needle for the actual injection. Ampoules containing the injection solutions should be
checked for the transluscency of their contents; the date of expiration and the time of sterilization
should be established. The ampoules should then be treated with alcohol, their tips cut off, and their
contents taken into the syringe. Before puncturing the vein, the syringe should be checked for the
presence of air in it. To that end the syringe should be held with the needle upwards, and the air removed
from the syringe together with a small portion of solution. The tourniquet should be removed
immediately before injecting the solution into the vein. It is also necessary before the injection to make
sure that the needle is in the vein. To that end, the piston should be pulled back slightly: if blood
enters the syringe, the medicinal preparation can be injected into the vein. Common solutions should be
injected during the course of 1.5-2 minutes, but some solutions, e.g. cardiac glycosides must be
injected more slowly.
The medicine should be injected by pressing the piston with the thumb of the left hand, or
the syringe can be carefully passed over the left hand, and the piston should then be pressed with the
thumb of the right hand, the cylinder being held between the 2nd and 3rd fingers of the right hand. If the
needle has withdrawn from the vein, as occasionally happens, the site of injection gradually swells.
Without removing the needle from under the skin, the expressed solution should be taken back into
the syringe, and only then the needle removed. The punctured site should be bandaged and the solution
injected into the other arm.
Intravenous drop infusions are used in cases of acute blood loss, dehydration, traumas, burns,
poisoning, etc. Blood, its substitutes, hypertonic and isotonic solutions, medicines and other fluids are
 -52-

given intravenously by drop infusions. The solution should be warmed to 39-40 C. A special system
with a dropper is used for infusions. If venepuncture is unfeasible for some reason, venesection
should be used. A wide-lumen needle is used for the puncture. The rate of infusion is controlled in
the range of 20-80 drops per minute.
To prevent accidental slippage of the needle from the vein during infusion, the arm should be
bandaged to a splint while the outer part of the needle fixed on the arm by adhesive tape. The patient’s
condition should be under permanent observation and the infusion system must be controlled
constantly.
Many solutions for intravenous administration are dispensed in special vials closed with a rubber
stopper and a metal cap. If the solution is infused directly from such a vial, two needles should be used,
one of which is short (4-6 cm) and the other long (12-15 cm). Using sterile forceps, the metal cap
should be removed from the vial (after preliminary treatment with alcohol) and both needles are passed
through the rubber stopper. The shorter needle is connected with the rubber tubing of the infusion
system, the vial is turned upside down and fixed on a stand. The end of the longer needle is above the
liquid level to admit air into the vial: the solution will then flow down into the rubber tubing through
the shorter needle.
The following complication can occur during infusion: the punctured vein may bleed causing
thrombophlebitis: a concentrated solution (e.g. a 10 per cent calcium chloride solution) may get in
subcutaneous fat causing local necrosis; a nerve trunk or artery can occasionally be damaged. If air is
injected into the vein, it can cause an embolism and the death of the patient.

Parenteral administration
1. And else, when syringes are sterilized, a piston and cylinder must be lied separately.
2. Rules of prevecetive preparation syringes and needles before sterilized:
1. After using (injections) syringes and needles are placed into container with 1% chloramin
solutions on 1 hours.
2. After this - syringes and needles are washed under a tap water.
3. And are placed into warm washing solution with soap powder and concentrated hydrogen peroxide
t - 45-50 certigraduate on 20 minute.
4. After syringes are washed in distillate water with
brush, and then are dried.
 -53-

Theme 12
OBSERVATION AND CARE OF PATIENTS
WITH RESPIRATORY PATHOLOGY

The respiratory system ensures the constant delivery of oxygen to the living body and
removal of carbon dioxide and water from it. The gas exchange process consists of external and
internal (tissue) respiration. External respiration is ensured by pulmonary ventilation and by the
exchange of gases between the atmosphere and the blood in the lungs. During inhalation the
respiratory center is excited to activate the respiratory muscles: the lungs are distended, the alveoli
opened, and air is forced inside the lungs by the difference of pressure in the alveoli and atmospheric
air. During exhalation the respiratory muscles relax, the lungs collapse, and the air pressure inside
them becomes higher than atmospheric; the air is, thus, expelled from the lungs.
Three types of respiration are distinguished: thoracic, abdominal, and mixed. In thoracic
respiration the chest expands mainly anteroposteriorly and laterally. This type of breathing is common
for women. During abdominal respiration the chest expands mainly vertically because of the
diaphragm.
This type of breathing is mainly characteristic of men. Mixed respiration is characterized by the
uniform expansion of the chest in all directions.
Patients with respiratory ailments complain of pain in the chest, dyspnea, suffocation,
cough, expectoration of sputum and blood. Dyspnea is the leading complaint. Pronounced dyspnea
which develops suddenly is called asphyxia. Paroxysmal attacks of dyspnea are called asthma. It
can be of pulmonary or cardiac aetiology, i.e. bronchial or cardiac asthma, respectively.
During attacks of dyspnea or asthma, the patient's chest should be stripped of all clothing
and the patient should be helped to assume a semiprone position to facilitate the respiratory
movements. Fresh air should also be admitted to the room (ward) and oxygen given to the patient.
Oxygen therapy is helpful in many disease of the cardiovascular and respiratory system,
especially if signs of hypoxia develop. Breathing an air-oxygen mixture quickly alleviates hypoxia.
For a better therapeutic effect the mixture should contain about 50 per cent oxygen and be given to
breathe for a sufficiently long time. Pure oxygen quickly inhibits the respiratory center, and if inhaled
for a long time, the patient may faint and develop convulsions. In this connection, a mixture of 95 per
cent oxygen and 5 per cent carbon dioxide is given to inhale for 10-30 minutes in cases of CO
 -54-

poisoning, because carbon dioxide excites the respiratory center. In all cases where the patient
is given oxygen his condition should be watched attentively, and inhalation discontinued immediately
if the patient complains of unpleasant sensations.
Oxygen can be given not only for breathing. It can be given subcutaneously or in oxygen
baths; it can be administered in the pleural and abdominal cavity, into the stomach and the intestine;
it can be used for irrigating wounds. Oxygen partly compensates for hypoxia and also produces local
and reflectory effects. Oxygen for medical use contains 99 per cent pure oxygen and 1 per cent nitrogen.
It is kept in cylinders that should be handled with care and protected from blows and jerks. It is
necessary to remember that oxygen combines with oils and fats to produce an explosive mixture. The
storage temperature should not exceed 35 C. No smoking or open flame are allowed in the room when
oxygen cylinders are stored. A jet of pure oxygen directed at the eye can impair vision.
Oxygen is given from a bag, an inhaler, or in an oxygen tent. An oxygen bag is provided
with a rubber tube fitted with a tap and a funnel. The bag is filled with oxygen from a cylinder (through
a reducing valve). Before use, the funnel should be treated with alcohol and wrapped in several layers
of wet gaze since dry oxygen irritates the airways. The oxygen flow from the bag is controlled by the
tap. When only a little oxygen remains in the bag, it can be expressed from it by hand. The
disadvantage of an oxygen bag is that is is impossible to control the oxygen concentration and the
rate of its delivery into the lungs. Moreover, much oxygen is lost into the environment in the absence
of tight contacts.
Oxygen can be given through a tube directly from an oxygen cylinder. The cylinders should
be kept outside the ward in a special room and delivered to the bed-side by a pipeline. Each oxygen
cylinder is provided with a reducing valve which lowers the oxygen pressure from 150 atm to 1.5-5 atm.
The cylinder is which controls the oxygen delivery to the patient. Within the hospital, the cylinders
should be carried on special shock-absorbing carts.
Nasal tubes provided with several openings at the end are used to administer oxygen. A
perforated tube is passed into the patient's nose and further into the pharynx to a depth of 15 cm (for
an adult). The tube should first be boiled and then coated with Vaseline. When in the pharynx, the
tube can be seen (and palpated) in the throat. The outer part of the tube is fixed to the patient's cheek,
forehead, or temple by adhesive tape to prevent its slippage from the nose or into the oesophagus.
Some patients complain of the pressing feeling in the nose and dryness in the pharynx. The tube
should therefore be removed twice a day and a new one passed into the other nostril.
To preclude burns, oxygen should be humidified by passing it through water. A bottle filled
 -55-

with water (a part of the Bobrov apparatus) is installed in between the oxygen cylinder and the nasal
tube. But humidification is often insufficient because oxygen bubbles can be large. A special filter
should therefore be used instead. When a nasal tube is used, the oxygen concentration in the bronchi
is about 40 per cent at a rate of gas delivery of 4-5 liters per minute, and about 50 per cent at a rate
of 6-7 liters per minute. This method is convenient because the patient can take meals and drink during
the oxygen therapy.
An oxygen tent is indicated in acute and chronic respiratory insufficiency. The oxygen
consumption in the tent is high and specially trained personnel is required. The tent is provided with
with devices for trapping carbon dioxide, cooling air, and for circulation. A mixture containing 40-50
per cent oxygen is usually supplied in the tent. Oxygen is humidified before delivery into the tent.
The composition of the gas mixture in the tent is tent tested regularly with a gas analyzer.
Care of coughing patients depends on the particular disease. For example, in acute
respiratory diseases (acute laryngitis or tracheitis), dry and painful coughs are controlled by
medicinal preparations taken per os, or by inhalation of sodium hydro carbonate and hot steam. Dry
cups, mustard plasters, mustard foot baths, and hot compresses on the chest are used as
counter-attractive therapy. If the cough is moist and the patient expectorates much sputum
(bronchiectasis), the patient should assume a position in which he can more easily expectorate sputum.
Antitussive are given to patients before night sleep.
Sputum (primarily of tuberculosis patients) can be the source of infection of the surrounding
people. The patient should therefore observe the rules of individual hygiene. The tuberculosis patient
should abstain from coughing in the immediate vicinity of other people: if he is unable to control
coughing, he must take all possible measures to prevent contamination of the surroundings. The
patient must not spit on the floor because sputum dries up to become an air-borne source of infection.
Sputum should be collected in a bottle with a screw cap containing a 3 per cent chloramine or 2 per
cent potassium permanganate solution (1/4-1/3 full capacity). The collected sputum should be
decontaminated by lime chloride or a 5 per cent chloramine solution and discarded into the sewage.
In special tuberculosis hospitals the sputum is burnt in special furnaces.
Haemoptysis is expectoration of blood with sputum. If haemoptysis is not significant, i.e. only
streaks of blood can be seen in the sputum, no urgent measures are necessary. If haemoptysis is
considerable and associated with pulmonary hemorrhage, the patient should be given completes rest
in a semireclining position. The patient should not be allowed to talk. If the hemorrhaging does not
stop, the patient is given amino caproic acid: 3-4 per os, 2-4 times a day. A 10 per cent calcium chloride
 -56-

solution is given intravenously. The patient is also given 50-100 ml of a 5 per cent amino caproic acid
in isotonic sodium chloride solution, vitamin K, and 20-40 ml of a 10 per cent gelatin solution
subcutaneously. Transfusion of blood (100-200 ml) or plasma is very effective. If these measures
fail to stop the pulmonary hemorrhage in tuberculosis patient, pneumothorax should be used:
gas is injected into the pleural cavity to compless the lung. Antitussive are given in haemoptysis
only in those cases where a strong cough may intensify blood spitting.
The diet of patients with pulmonary hemorrhage should be rich in vitamins and easily
digestible. Food should be semiliquid and given in small portions. Food and drinks should be cool.
Spicy foods and condiments are contraindicated.
Inhalation is a method for administering medicines by inhaling them with air. Aerosols of
medicinal preparations are used for this purpose. The medicines are dispersed in air or oxygen in
apparatuses known as inhalers. These may be small portable ones for individual use or stationary
apparatuses intended for inhalation therapy of several patients at a time. Preparations may be inhaled
as vapor; volatile substances are given in vapor form (Eucalyptus oil, Menthol). Vapor inhalations
can easily be given at home. The medicinal substance solution can also be heated and vaporized
for inhalations by the patient. From 25 to 200 ml of a medicinal solution can be given for such an
inhalation. Medicinal preparation may be administered by inhalation from a small portable apparatus
(from 2 to 6 ml). Oil inhalations are also used for therapeutic and prophylactic purposes. About 0.5 ml
of oil or its solution may be given in one inhalation. Vegetable oils are usually used (olive oil,
Eucalyptus oil, peach oil, and others). Special apparatus are used for administering powdered
sulpha drugs, antibiotics, vasodilator, and other preparations. Not less than 5 inhalations are given
per course.
Aerosols are used for inhalation. Aerosol means solution in air. The dispersed particles vary
in size from 0.5 to 400 m. High dispersion aerosols (0.5-5 m) are more effective. There are also
electric aerosols whose particles bear positive and negative charges which neutralize surface tension.
The charge being high, the particle may be destroyed to increase dispersion of aerosols. Charged
aerosols uniformly distribute in the airways, and their precipitation is more effective than that of simple
aerosols.
Pleurocentesis is used for removal of pleural effusion for medical and diagnostic purposes. Only
a physician can perform this operation. Necessary for the operation are: long needles (7-10 cm) of
medium caliber (1-1.2 mm) with sharply cut angles and cannulas, thin short needles, syringes (2-5 and
10-20 ml), two or three sterile test tubes and the same number of object glasses for smears, elastic
 -57-

rubber tubes leading to cannulas, hemostatic forceps (with smooth clamps), aspirating devices, alcohol,
iodine tincture, collodion, sterile tampons wrapped in sterile cloths, rods with cotton wound around
them, and forceps. The physician should disinfect his hands like before an operation, put on sterile
mask and (after giving anaesthesia) gloves.
Pleurocentesis should be done in the room for medical procedures. The physician outlines
by percussion the borders of effusion. X-rays can also be used for this purpose. The patient's condition
permitting, he is seated on a chair with his back to the physician. The patient inclines slightly toward
the non-involved side in order to broaden the intercostal spaces. The patient's arm (on the involved
side) should be placed on his head or the other shoulder. If the patient is unable to sit on a chair, he is
assisted in the sitting position in his bed. The safe site for puncture is the 7th or 8th interspace in the
posterior axillary line.
The site of puncture should be treated first with alcohol, then iodine tincture, and a local
novocaine anaesthesia is then given. The chest wall is punctured by a needle connected to a rubber
tube (with a clamp) whose other end is attached to a cannula. The puncture is made above the top edge
of the rib since the vessels and nerves run along the edges of the ribs. When the needle passes the
tissues and enters the pleural cavity, the physician feels a sudden absence of resistance. A syringe (with
the piston completely depressed) in now attached to the cannula of the rubber tube, the clamp is
removed, and the piston is pulled carefully. If no liquid enters the syringe, the tube is clamped
again, the syringe is disconnected from the tube, and the position of the needle changed by inclining
or pulling it slightly back. The aspired pleural fluid should be collected in test tubes for analysis and
for preparing smears for microscopy. The tube is now connected to an aspirator, the clamp is
removed from the rubber tube, and the effusion is removed from the pleural cavity.
The aspirator is a graduated glass vessel of 0.5-2 liter capacity. The neck of the aspirator is
closed by a rubber stopper through which two glass tubes are passed; the longer tube is connected to
the needle or a trocar by a rubber tubing, while the shorter tube is connected to a pump (by a rubber
tube). The rubber stopper is fitted with two metal disks pulled together by a screw at the center.
Removal of pleural fluid begins with aspiration of air from the vessel by a pump. The tap on
the shorter tube is open while the one on the longer tube (connected to the needle) is closed. The effusion
is displaced from the pleural cavity into the vessel by the difference of pressures. When the vessel is
full of pleural fluid, the longer tube is clamped, the stopper is removed from the vessel, and the vessel
is emptied. The vessel is now stoppered again, the air removed from the vessel and the pleural effusion
is aspired again. When all fluid is removed, the clamp on the rubber tube is closed near the needle,
 -58-

the syringe is filled with antibiotic solution, a length of the rubber tube between the needle and the
clamp is treated with alcohol and punctured by the syringe needle to inject the antibiotic solution.
When the procedure is over, the needle used for pleurocentesis is removed by a swift movement,
and the point of puncture treated with collodion.
If a correctly performed pleurocentesis fails to withdraw any fluid from the pleural cavity, it
may indicate pleural adhesion or clogging of the needle lumen with fibrin. In this case, pleurocentesis
should be repeated in one or two days. The following complications may arise: 1 - the needle may pass
into the pulmonary tissue (blood enters the syringe); 2 - the intercostal vessels or nerves may be injured;
3 - embolism may develop if air is admitted into a large vessel through the needle.

Theme 13
OBSERVATION AND CARE OF PATIENTS
WITH CARDIOVASCULAR PATHOLOGY

Patients with disease of the cardiovascular system complain of heart and retro sternal pain;
they also complain of palpitation and intermission in the heart work, dyspnea, and edema, a feeling of
discomfort in the right hypochondrium, dyspepsia, and headache.
Pain in the heart region is a serious complaint and its cause must always be revealed. Pain
can be the result of heart diseases (angina pectoris, myocardial infarction, neurosis, etc.), of pleurisy,
intercostal neuralgia, injured ribs, etc. Cardiac pain varies in its character, severity, duration,
localization, and paths of radiation. Patients with cardiac neurosis complain of pain in the heart apex;
the pain is prolonged, it becomes more severe during excitement, and can be abated by sedatives. Pain
developing in angina pectoris arises during walking, exercise, or as the patient leaves a warm rooms and
is exposed to the cold. The pain is usually localized in the retro sternal region, continues for a few
minutes and is quickly alleviate by nitroglycerin or validol. Pain associated with myocardial infarction
differs substantially from pain associated with angina pectoris. It is more severe, lasts for a few hours
or even days, and is not alleviated by nitroglycerine or validol (methyl valerate).
Pain of uncertain etiology and also protracted attacks of angina pectoris may suggest
myocardial infarction. First aid to such patients (before the arrival of the physician) should include
validol on a lump of sugar (or a tablet) or 1-2 drops of a 1 per cent nitroglycerin solution. Validol and
nitroglycerin act within 1-2 minutes. Mustard plasters or leeches on the heart region are also effective
in alleviating heart pain. If the cause of pain in the heart region is unknown, gastric lavage is
 -59-

contraindicated even in the presence of abdominal pain, nausea, and vomiting. These symptoms often
occur in-patients with myocardial infarction. Lavage of the stomach is dangerous in such cases.
Dyspnea is a most common complaint in circulatory insufficiency. The degree of dyspnea
varies. At first dyspnea develops during exercise when ascending stairs, and abates when the exercise
is discontinued. In cases of more pronounced circulatory insufficiency, dyspnea develops during slight
exercise, when the patient talks, and even when at complete rest.
Edema associated with heart diseases is another symptom of circulatory insufficiency. If
edema is pronounced, bedsores soon develop. Since nutrition of the skin affected by edema is reduced,
the bedsores quickly purulate. Injections should not be given into edematous subcutaneous tissue
because absorption of solutions is slow and infection can easily penetrate the body through the leaking
punctured skin.
Proper care of patients with cardiovascular insufficiency is an important factor in their
treatment. Inhalation of oxygen has a favorable effect on their condition: dyspnea and asphyxia
markedly decrease. It is necessary that the air in the ward should be fresh, of normal temperature and
humidity. For patients with pronounced circulatory insufficiency prolonged bed-rest is often prescribed,
and the bed linen should therefore be free from knots that might press on the patient's body. The bed
should be made in the morning, before the day nap and night sleep. The auxiliary personnel must take
special care of the patient's body. The patient should be assisted in changing his position in his bed in
order to prevent the formation of bedsores or thrombosis (blood coagulation) in the vessels of the legs
and the pelvis. It should be remembered that prolonged bed-rest may cause blood congestion in the lungs
and pneumonia. Dyspnea and asphyxia are reduced if the upper portion of the patient’s body is slightly
raised. This can easily be done using an adjustable bed. If such a bed is not available, a regular bed can
be rearranged by using special head- and footrests.
Since a bed-ridden patient spends little energy, his diet should be less caloric (about 2300
kilocalorie) but contain more vitamins C and B. Liquid and salts should be restricted since their excess
provokes the formation of edema. The daily intake of salts should not exceed 5 g during the first three
days of the patient's hospital stay; then the salt ration can be increased to 7-10 g. Potassium salts have
a diuretic effect and therefore potato, cabbage, figs, dried apricots, and other foods containing a lot of
potassium should be given to the patient. Karell's diet increases diuresis too: the patient is given 100-150
ml of milk six times a day.
Edema is latent during early stages of cardiac failure. It can only be revealed by decreased
diuresis (amount of excreted liquid) and increasing body weight, while the water intake remains
 -60-

unchanged. Keeping this in view, patients with circulatory insufficiency should be weighed daily and
their daily consumption and excretion of liquid (soup included) controlled.
This helps assess the efficacy of treatment. It should also be remembered that a patient without
a fever loses from 0.5 to 1 liter of liquid by sweating, about 200 ml with respiration, and about 100 ml
with feces. The loss of liquid by sweating increases significantly in-patients with fever. The excreted
urine should be measured daily and the findings recorded in the case history. When latent edema is
discovered, daily and nocturnal diuresis should be determined. Daily diuresis includes urine excreted
from 8.00 to 20.00 and the nocturnal from 20.00 to 8.00. In normal individuals the nocturnal diuresis is
smaller than the daily one. In the presence of latent edema the nocturnal diuresis is, on the contrary,
greater.
Bloodletting (phlebotomy) and oxygen therapy is often prescribed for patients with
circulatory insufficiency. In the presence of pronounced edema, especially in ascites, the amount of
food intake should be strictly controlled because the appetite may be markedly decreased. It is also
necessary to make sure that the patient follows the doctor's orders concerning limited salt and liquid
intake. If the patient complains of constipation, cathartics and enema (hypertonic or oil) are indicated.
In the presence of pronounced ascitis, which is difficult to manage with medicinal
preparations, abdominal puncture (paracentesis) is recommended. Abdominal puncture is used in rare
cases for the diagnostic study of the ascitic fluid. A special instrument (troacar) is used for puncturing
the abdominal wall. The procedure requires the following: a syringe (with a 0.5 per cent novocaine
solution), a basin for collecting the withdrawn fluid, a scalpel, a needle holder with a needle and a silk
thread, and a towel or a sheet to wrap the abdomen during paracentesis. The urinary bladder should be
emptied before the procedure. The patient should assume a sitting position. The site of puncture is treated
with alcohol and iodine tincture, and local novocaine anesthesia is administered. The abdominal wall is
then punctured at the median line midway between the navel and the pubis, or by the edge of the rectus
abdominis muscle (at the same level). After the trocar has been passed through the abdominal wall,
the mandrin is removed from the trocar and the fluid withdrawn. A towel is tightly wrapped around the
abdomen to prevent a possible faint. If the fluid outflow stops, the patient's position should be changed:
the intestine or the omentum thus moves away from the trocar and withdrawal of the fluid is resumed.
When the procedure is over, the punctured site is sutured and the amount of the fluid withdrawn
estimated. In some cases a pressing bandage will be sufficient after removal of the trocar. The abdomen
should be bandaged tightly and the patient placed in bed. Part of the withdrawn fluid is sent to the
laboratory for examination.
 -61-

Care of patents with vascular insufficiency. Acute and chronic vascular insufficiency is
distinguished. Stock, collapse, and syncope are the symptoms of acute vascular insufficiency. These
signs develop when the amount of circulating blood decreases significantly and the vascular tone
diminishes. Nutrition of vital organs, of the brain in particular, becomes impaired. The skin of patients
with acute vascular insufficiency is pallid, the limbs are cold, the pulse is small and weak, the arterial
pressure is low, and the patient is extremely weak.
Examination of the pulse shows the condition of the patients' vascular tone. Pulse is the
vibration of the arterial walls caused by the passage of blood injected into the arteries by heart
contractions. The radial artery at the distal end of the forearm (near the wrist) is the most convenient
place to feel the pulse. The thumb is placed on the back of the forearm, while the other fingers are placed
on its anterior surface to feel the radial artery. The fingers should not press the patient’s wrist since the
blood will thus be displaced from the artery and the next pulse wave will not be detectable. If the artery
is not easily palpable, the fingers should feel across the wrist, since the artery may be displaced toward
either side, or on the contrary, may be located in the middle of the wrist. If the artery is impalpable due
to some abnormality, the pulse on the other arm should be felt. The filling, rate, rhythm, and pressure of
the pulse should be assessed.
The pulse rate is determined by counting the number of pulse waves during one minute (or
at least during 30 seconds, with subsequent doubling of the finding). When the pulse is slow, the beats
should be counted during the course of two minutes. The pulse rate should be entered in the case history
(or a temperature graph). The normal pulse rate of an adult is 60-80 per minute; in athletes it may be
from 50 to 60. During sleep the pulse decreases by about ten beats per minute. The pulse rate in women
is 7-8 beats higher than in men. In neonates it is 130-140 beats per minute; in a 4-6-year-old child the
pulse rate is 90-100, in children aged 8-10 it is 85-90 per minute. The pulse rate increases during
exercise, nervous strain, and fever. When the body temperature increases, the pulse rate increases
10-15 beats per each degree centigrade.
The pulse rate corresponds to the rate of heart contractions. A pulse rate below 60 per minute
is called bardycardia, and over 90, tachycardia.
 -62-

The pulse rhythm is usually regular in normal individuals. It means that all pulse waves are
equal and follow one another at regular intervals. If the pulse waves differ in their magnitude and follow
at irregular intervals, this condition is called arrhythmia. There exist many types of cardiac
arrhythmia, but extra systole and fibrillation are the most common. Extra systole is characterized by
intermissions (dropped beat) which are followed by a prolonged (compensatory) pause. Fibrillation
of the heart is characterized by the absence of any regularity in frequency and magnitude of the
pulse wave. If the cardiac output is small, the pulse wave does not reach the peripheral portions of
the arteries and the pulse thus becomes undetectable. A difference between the number of heart
contractions and the pulse rate thus appears, which is known as a pulse deficit. This is the sign of a
severe heart disease.
Arterial pressure depends on the force of the heart contraction and the vascular tone.
Increased arterial pressure is called hypertension, and decreased pressure is called arterial hypotension.
Arterial pressure is measured by a tonometer or a Riva-Rocci sphygmomanometer. The patient may
sit or lie during this procedure. The patient places his straightened arm conveniently on a table
where the sphygmomanometer is installed. A cuff is placed on his upper arm, 2-3 cm above the elbow.
The pulsating vein in the elbow flexure is found and the bell of a phonendoscope is placed over the
vein tightly but without exerting extra pressure. Air is now pumped into the cuff by a rubber bulb.
As the brachial artery is compressed by the inflated cuff and the tonomether readings increase, the pulse
beats should be heard in the stethoscope. The cuff should be inflated until the pulse is no longer
heard. The pressure in the cuff is now gradually released and when the first sound is heart through the
stethoscope, the mercury column should be read. This is the maximum arterial pressure. When the
pulsating sounds disappear, the manometer reading should be taken again: this is the minimum arterial
pressure.
 -63-

The maximum pressure, otherwise known as systolic pressure, corresponds to the blood
pressure during left ventricular systole when pressure in the arteries is the highest. Minimum, or
diastolic pressure, is the blood pressure during diastole of the left ventricle. The difference between
the maximum and minimum blood pressure is called the pulse pressure. Arterial pressure varies within
a wide range depending on age, condition of the nervous system, physical strain, etc. The average
maximum pressure at rest is 115-125 mm Hg and the minimum 60-80 mm Hg; the average pulse
pressure is 50-60 mm Hg. The findings are recorded in the form of a fraction where the numerator
is the maximum and the denominator the minimum blood pressure.
Errors in measuring arterial pressure are due mainly to improper technique or defects in
the apparatus. Errors may also arise from the fact that once the tone has appeared it may suddenly
disappear and then reappear again.
Treatment of acute vascular insufficiency depends on the cause of the disease and on
the gravity of the patient's condition. If a patient experiences a syncope, he should be placed in
the horizontal position, without pillows, to ensure a better blood supply to the brain. The patient's
clothing should be loosened and ammonia given to smell. If these measure do not help, caffeine and
camphor should be given subcutaneously.
A patient in a state of collapse should also be placed in the horizontal position, without
pillows, to improve cerebral circulation, and the legs should be slightly elevated (or the end of an
adjustable bed should be raised). Warmth should be applied to the arms and feet. The arterial pressure
should be elevated by subcutaneous administration of caffeine, camphor, phenylephrine hydrochloride
or norepinephrine. If the state of collapse persist (e.g. in myocardial infarction), the patient should be
given phenylephrine hydro-chloride or norepinephrine by drop infusion in a 5 per cent glucose solution.
Patient experiencing a hypertonic crisis (arterial pressure above 200/120 mm Hg) are
prescribed absolute bed-rest. Dry cups or mustard plasters are applied along the sides of the spine. If
this does not help, 400-600 ml of blood is to be removed and 4-6 leeches applied (on the mastoid
processes along a vertical line, 1 cm away from the ear auricle). Leeches should not be applied closer
to the ear because the veins are there superficial and severe bleeding may be provoked.

Theme 14
CARE OF CRITICAL PATIENTS
 -64-

A critical patient requires special care night and day. In order to give him quiet and to
spare other patients from negative emotions, a seriously ill patient should be placed in a separate room
(for one, or at the most, two patients). The patient can rest here at any time that may suit his best, for
he may suffer from insomnia due to pain or for some other reasons.
Since the patient is bed-ridden, maximum comfort must be provided for him. An
adjustable bed will suit this purpose best of all. His condition permitting, the patient should be turned in
his bed as frequently as needed to prevent formation of bedsores. The linen should be straightened as
well. Whenever it is necessary to carry the patient, special rules should be followed. A critical patient
requires special care during transportation. Feeding a critical patient is a problem as well because
appetite may be absent or he may experience an aversion to food. If the patient has difficulties with
swallowing, food should be given through a nasogastric tube; large amounts of glucose are infused
intravenously (40 %) or subcutaneously (5 %).
Since critical patients are weak, only very close relatives should be admitted to visit them.
If the patient is unconscious, a nurse should sit by his bedside. If a critical patient is overexcited, he
may be furious, may attempt suicide, etc. The bed of such patients should be guarded by a net. When in
a state of delirium, the patient may be dangerous to the surrounding people.
These patients should be kept in a psychiatric ward irrespective of their will. If the patient
resists actively, he should be approached and immobilized carefully as not to harm him and to preclude
possible damage to the surrounding people. To decrease hyper excitation, 25-50 ml aminazine and 0.3
g barbamyl should be given 2-3 times a day; aminazine injections should also be given.
Critical patients with myocardial infarction, apoplexy, or other diseases should be placed
in wards where their condition is carefully observed: their pulse and respiration rate are monitored,
and their heart action controlled (ECG) so that necessary measures might be taken timely to
preclude possible complications. These wards should be equipped with all instrumentation that
might be necessary for observing and treating such patients. Apparatus for electrical stimulation of
the heart should also be available.
A nurse for the individual care of a critical patient may sit by the patient's bedside both in the
hospital and at home. Only experienced personnel should be allowed to care for critical patients.
The physician's assistant or a nurse should observe the patient constantly and take appropriate care of
him. The nurse must see if the patient feels comfortable in his bed. The position of the bed in the
room should ensure an easy approach to the patient. All items that may be necessary for the patient's
care, such as a bed-pan, an oxygen bag, or a drinking glass, should be within easy reach of the nurse.
 -65-

A sterilizer with a syringe and injection needles, alcohol, medicines, sterile materials, etc. should
be kept on a separate table.
The nurse should constantly observe the rate and character of the patient's pulse and
respiration, the color of his skin and mucosa, body temperature, and the character of the patient's
excrements. All changes in the patient's condition should be reported to the physician. The patient's
mouth and skin need special care. In the morning the nurse should cleanse the patient's teeth and
tongue, wash his mouth cavity, sponge the face and body. The patient's clothes and linen should be
changed frequently and all creases smoothed.
Feeding a critical patient requires special skill. If the patient is unable to raise his head, he
may choke on liquid food, even if given from a special cup with a spout. A transparent polythene
tube (20-30 cm long, with a diameter of 8-10 mm) should be attached to the spout of a cup and placed
in the mouth (on the tongue root or in the gap behind the last molar). Liquefied food should be fed
carefully to prevent possible choking. The patient should be fed 4-5 times a day. The temperature of the
food should be 35-40 C.
The evacuatory function of the intestine should be monitored. If feces are retained for two
days, an evacuant enema should be given. If the patient does not urinate, he should be catheterized once
or twice a day. If the patient suffers from severe pain, the physician may prescribe narcotics (morphine
and the like).
During her duty hours the nurse keeps hourly records of her observations and all procedures
that are conducted. She records in log-book all complaints of the patient, his pulse and respiration
rate, arterial pressure, temperature, time of feeding, volumes of excretions (sputum included).
Defecation should also be recorded in the book; the presence of blood in the patient's excrements must
be noted; blood-stained excretions should be left for examination of the physician.
The patient's condition or malignant prognosis of his state must not be discussed at the
patient's bedside even if the patient is unconscious, because loss of consciousness may only be apparent
and the patient may grasp the content of the conversation. This especially holds for patients with
apoplexy. The assistant physician must be tactful with the patient's relatives. He should not reassure
them unreasonably but must make them believe that everything is being done to save the patient. Proper
care is the best proof of this declaration.
Care of patients in the terminal condition. The terminal state develops due to various
causes (profuse bleeding, damning, strangulation, apoplexy, etc.) and consists of preagonal
condition, agony, clinical death and biological death.
 -66-

The preagonal condition is characterized by confused consciousness or its complete

loss; the pulse and arterial pressure are difficult to determine, respiration is superficial, the skin is
pallid, the mucosa cyanotic. Agony is the pangs of death; the patient is unconscious, the eye reflexes
are absent, the pulse on the carotids is small, respiration pathological, the vital functions are profoundly
deranged. Agony may continue from a few minutes to several hours. The processes in the cerebral
cortex fade, the body temperature drops, and the pulse becomes thready. General convulsions develop
and the sphincter are paralyzed. The face is covered with a cold sweat, the nose is pointed, the
cornea turns cloudy. A patient in the agonal state should be removed from the general ward to spare
the emotions of other patients.
Death is the cessation of life activity in the body. Clinical (apparent) and biological
(functional) deaths are distinguished. A patient in the state of clinical death can be revived. Clinical
death is characterized by the absence of respiration, arrest of the heart action, and dilation of the
pupils. But thanks to anaerobic glycolysis, basal metabolism is still maintained in the body for 4 to 7
minutes. Biological death, which follows the clinical one, is characterized by irreversible changes in
the central nervous system. The muscles become relaxed and the body temperature falls to the ambient
temperature. Livores mortes later develop on the dependent parts of the corpse.
Closed chest cardiac massage (indirect) can be carried out during clinical death when the
vital activity of the body can be restored. The massage is effective when the heart either stops or
fibrillates. Massage should be combined with artificial respiration in the ratio of 3:1 or 4:1. In
cases with acute blood loss the patient should be given donor blood or its substitutes, ntravenously and
intra-arterially. The patient is placed on a rigid and level surface; his legs should be slightly raised.
The operator places the heel of one hand, with the heel of the other on top of it, on the lower third of
the sternum and applies pressure at a rate of 60-80 per minute. The sternum should yield 3-6 sm. If
the pressing force is insufficient, the operator should use the weight of his body to increase the
thrust. The sternum presses the heart against the spine to express blood from it chambers into the aorta
and the pulmonary arteries. As the pressure is removed, the chest expands and the heart relaxes; its
chambers are filled with blood from the veins. If the massage is effective, a pulse becomes determinable
on the carotid and femoral arteries; the maximum pressure can thus increase to 60-90 mm Hg.
Adrenaline, noradrenaline, mesaton, gluconate or chloride of calcium are given intra-venously or
intra-arterially. If closed chest cardiac massage does not help, the chest is opened surgically (if
the patient is in the operating room) and the heart is given a direct massage.
Excess pressure on the chest in indirect massage can cause fracture of the ribs and injuries
 -67-

of the lungs, liver or other organs.

Artificial respiration is given according to several methods. The most effective of them are
now considered the mouth-to-mouth or mouth-to-nose techniques. Before giving artificial
respiration, dental prostheses, if any, should be removed from the patient's mouth and the mouth
cleaned from vomit. Mouth-to-mouth artificial respiration is done as follows. The patient should
be in the supine position, his head tilted back. The mouth and the nose of the patient may be covered
with a piece of gauze. The rescuer takes a deep breath, places his mouth over the patient's pinches the
patient's nostrils, and blows the air forcefully into his lungs. From 1000 to 1500 ml of air is, thus, blown
into the lungs of an adult. The expiration of the patient is passive occurring as the chest collapses.
The rate of artificial respiration should be 16-20 breaths per minute. A special S tube of firm
rubber is used to facilitate the artificial mouth-to-mouth respiration. It is placed into the patient's
mouth (to the tongue's root) and acts as an air duct. If the patient's mouth is closed tightly,
mouth-to-nose respiration should be given. The patient is supine, his mouth is closed when the air is
blown into his lungs. When the air is exhaled, the mouth is half open. Artificial respiration is usually
given together with closed chest cardiac massage. One rescuer performs artificial respiration, while
the other - indirect massage on the heart. Each breath should be followed by 4 or 5 thrusts on the
chest.
There are specially equipped ambulance cars for rendering urgent medical aid to patients
with myocardial infarction, apoplexy, shock, poisoning or other life-threatening conditions.
Apparatuses for giving artificial respiration and electrical stimulation of the heart should also be
available in the ambulance. All necessary measures should be taken in the ambulance during the
transportation of the patient to the hospital. The patient should be transported to a large hospital
which has an intensive care unit. The patient is brought directly to this department without any
formalities in order to give all possible aid as soon as possible.
Biological death. Clinical (apparent) death is followed by biological (functional) death.
The physician certifies the moment of death and makes an appropriate entry into the case history
where he records the date and time of death.
The dead body is undressed, placed on its back, the lower jaw is pulled up to the skull, and
the eyelids are lowered; the body is covered with a sheet and left in bed for two hours. The name of the
deceased and the number of his case history are written in ink on his thigh. The dead body is
delivered to the pathologoanatomical department with a special note indicting the name of the
deceased, the number of his case history, the diagnosis, and the date of death. The deceased may be
 -68-

delivered to the patholoanatomical department only after positive signs of death develop: rigor mortis,
postmortem lividity, softening of the eye-balls, etc. If the patient dies at home, the physician certifies
the death and issue a certificate where he indicates the cause of death.
All patients who die in a hospital should undergo a postmortem examination (autopsy)
at a pathologoanatomical department. All valuables should be removed from the dead body and
handed over to relatives before delivering the cadaver to the postmortem department. If the valuables
cannot be removed, a special note should be made in the case history, and the body sent to the
mortuary with these valuables on.

Themes 15-16

CARE AND OBSERVATION OF PATIENTS WITH

ALIMENTARY DYSFUNCTION

Complaints of patients with diseases of the digestive system are quite varied and depend on
the part of the digestive tract that is pathologically affected.
Patients with disease of the mouth cavity (teeth caries, stomatitis, gingivitis) complain
of pain, have difficulty in chewing, and decreased or increased salivation. The bacterial flora of the
mouth in stomatitis is activated to cause severe inflammation of the mucosa. If salivation is decreased,
the mouth mucosa is inflamed which promotes the development of stomatitis or intensifies the existing
inflammation.
The mouth is inspected while the patient is in the sitting position. The physician asks the
patient to open his mouth, and moves his lips and cheeks aside with a spatula (disinfected by boiling).
After the tonsils and the posterior wall of the pharynx have been inspected, the root of the tongue is
depressed with the spatula and the patient is asked to say 'Ah'. Adequate illumination is necessary
during examination of the mouth cavity, the tonsils, and the pharynx. Any reflector can be used for this
purpose. Smears of the mucosa of the mouth, nose, or throat are taken with sterile cotton swab. The
patient sits facing the light source with his mouth wide open. The root of the tongue is pressed by
a spatula held in the left hand, while a smear is taken from the pathological focus with a cotton swab
in the right hand. When a smear is taken from the nose, the thumb of the left hand should lift slightly
the tip of the patient's nose. The swab taken from the sterile test tube should not touch the external
surfaces of the nose. The smear should first be taken from one and then from the other nostril.
 -69-

Test tubes containing the smear on swabs should be sent to the laboratory immediately.
They should be labeled indicating the patient's name, age, ward, and department in the hospital, date,
the name of the material, and the purpose of its testing. The mouth cavity should be cleansed daily in
many disease of the mouth itself or the gastrointestinal tract, in circulatory insufficiency, and in some
other diseases. The teeth of the patient should be cleansed and the mouth rinsed. Mouth mucosa
should be treated with medicinal solutions in some diseases. A cotton ball is taken by pincers,
wetted in the appropriate medicinal solution, and applied to the affected site with the help of a
spatula. Patients with afflictions of the stomach complain of poor appetite, regurgitation, heartburn,
nausea, vomiting, abdominal pain, and bleeding.
Care of patients. In a vomiting patient the respiration rate decreases, heart rate increases,
arterial pressure falls, and the nervous system becomes excited. The patient's condition permitting,
he should sit on the side of the bed with his feet on the floor. A basin should be placed between his
fee. When vomiting stops, the patient should rinse his mouth, drink two or three gulps of cold water,
and lie in bed. A warm water bottle should be placed on his feet and the patient covered with a
blanket. If blood is present in the vomited material, no drink should be given to the patient.
If the patient is unable to sit in his bed, the pillow should be removed from under his head,
and the head turned so that the vomit does not get into his airways. A little basin or a towel should be
placed at the angle of his mouth. If the vomit gets in the airways, coughing is induced by the refectory
mechanism. The cough is followed by a forced inspiration and the vomit may penetrate the deeper
parts of the airways and the lungs. The patient can thus die or develop aspiration pneumonia.
The condition of the patient with haematemesis is drastically impaired due to the loss of
blood. The patient is weak, he experiences dizziness and nausea; his arterial pressure falls. A
physician should be summoned in such cases. The patient should be placed in bed and an ice bag applied
to the epigastrium. Neither dinks nor medicines should be given per os. Injections of 10 ml of a 10 per
cent calcium gluconate (or chloride) and a 5 per cent aminocapronic acid solution (intravenously) and
20-40 ml of a 10 per cent gelatin solution (subcutaneously) are indicated. The pan for collecting the
vomited material should be clean because extraneous admixtures can mislead the physician, and the
results of the laboratory analysis will be unreliable. The order that should be followed in delivery of
the vomit to the laboratory should be same as for other excretions of the patient. The vomited material
should be disinfected like feces. When a patient is attacked by vomiting, the nurse should stay at his
bedside and summon the physician.
Lavage of the stomach 0is done for therapeutic and diagnostic purposes. It is indicated in
 -70-

chronic gastritis and stenosed pylorus, uraemia, intestinal obstruction, chemical and food poisoning.
Contraindications are esophageal and gastric bleeding, burns of the mouth and pharynx mucosa, angina
pectoris, and myocardial infarction. Gastric lavage is done using a glass funnel with a capacity of about
1 liter and a 1 meter long rubber tube (1 sm. in diam.).The tube is connected by a glass tube to a thick
70-80 cm long gastric tube with a diameter of about 1 cm. One end of the gastric tube is rounded
and has two oval openings, one above the other. Water for lavage (6-10 liters) should be warmed
to 30-35 C. A jar and a basin for washing are also required. The gastric tube should be disinfected
by boiling and its potency checked before use. The patient is given an oil-cloth apron to put on and
is seated in a chair. The basin is placed between his legs on the floor. During the procedure the patient
should not throw back his head, bite the tube or touch it with his hands. If the patient has removable
dental prostheses, they should be removed before the procedure. The nurse stands by the right side of
the patient, while her assistant by the patient's left side. The nurse grasps the gastric tube at about 10
cm distance from its rounded tip and places this length into the patient's mouth so that the tip of tube
is on the root of the tongue. The patient is asked to swallow repeatedly: the tube passes into the
oesophagus and farther into the stomach. The tube's progress should be assisted either by the right
hand or by the left and right hands alternately. A vomiting reflex often expels the tube from the
throat. The tube should in such cases be removed and a new attempt made after a while. If this
procedure proves ineffective, the Gunther method should be used: the back of the tongue is pressed
down with the index finger and the tube is carefully introduced into the oesophagus. The depth of
immersion is controlled by the mark on the tube which indicates that the tube has reached the stomach.
When the tube is in the stomach, the funnel is attached to it via the glass and rubber tubes.
The funnel is held below the stomach level and water or a potassium permanganate solution is poured
into it. The funnel with the liquid is now raised gradually above the patient's head to pass the
liquid into the stomach. The funnel is then lowered and the liquid returns from the stomach into the
funnel. Care should be taken that some liquid remains in the funnel, since otherwise it would
be difficult to withdraw it from the stomach. The washing are discarded into the basin, a fresh
portion of solutions is poured into the funnel, and the procedure is repeated. Lavage should be continued
until washing waters are clear.
If the patient is unconscious, a thin tube is introduced through the nasal cavity. The one
doing the procedure must make sure that the gastric tube reaches the stomach by a test aspiration
using a syringe. Water is injected into and withdrawn from the stomach using a Janet syringe or a
common 20-40 ml injector. The stomach should be emptied as fully as possible.
 -71-

Under home conditions, if a gastric tube is not available, the patient is given 4-8 glasses of
water to drink and the back of his pharynx is then irritated to provoke vomiting. The procedure is
repeated several times.
Diagnostic lavage of the stomach is indicated in cases when tuberculosis of the airways
or stomach cancer is suspected. Tuberculosis mycobacteria can be found in the washing in cases of
tuberculosis and cancer cells in gastric cancer. Diagnostic lavage should be performed on an empty
stomach. A then gastric tube with 5 or 6 openings at the distal end is swallowed by the patient (a length
of 45-50 cm), or the tube is introduced through the nose. A syringe with an isotonic sodium chloride
solution is attached to the outer end of the tube and the solution is injected into the stomach and
then withdrawn from it. The procedure is repeated several times using the same solution so as to obtain
the higher concentration of gastric mucus in the washing. The washing are poured into a clean
container and sent to the laboratory.
A gastric tube is used also to assess the gastric acid output and the evacuatory function of
the stomach. One-time obtaining of gastric juice by a thick tube is now considered inexpedient since the
intensity of gastric secretion varies not only in patients but in healthy individuals as well. Moreover,
there are some contraindications to using a thick tube because it provokes vomiting and staining.
At the present time a thin tube (5 mm outer and about 3 mm inner diameter) is used for
fractional obliging of gastric juice. This is an elastic rubber tube with lateral openings at the distal
end. Since the tube is soft it cannot be forced into the stomach, but should be swallowed by the
patient. If swallowing provokes vomiting, the tube should be passed through the nose. The patient
should remove any artificial teeth and sit on a chair. The leading end of the tube should be wetted
with water and placed into the patient's mouth beyond the tongue root. The patient is then asked to
swallow the tube.
When the tube reaches the stomach, a clamp is placed on its outer end to prevent the
spontaneous withdrawal of gastric acid. According to Leporsky, the gastric secretion of a fasting
stomach is withdrawn first. Then four 15-minute portions are taken. The patient is now given a test
meal (a caffeine solution, 7 per cent cabbage decoction, 300 ml of a 5 per cent alcohol solution). A
stimulant (histamine, insulin, pentagastrin) in sometimes given parenterally. Ten minutes after the
administration of the gastric secretion stimulant a 10 ml portion is withdrawn. Then in 15 minutes
the stomach is emptied. Then five 15-minute specimens of pure gastric juice are taken. If secretion
is provoked by parenteral administration of a stimulant, four 15-minute portions of the gastric juice are
collected within an hour. Each portion is collected in a separate vessel and the volume is marked. All
 -72-

specimens are then delivered to the laboratory.

Preparing a patient for x-rays of the stomach and small intestine. Radiological
techniques (roentgenoscope and roentgenography) give reliable information concerning pathology
of the stomach and the intestine. X-ray has remained an important method of examination in
gastroduodenal pathology. X-rays are used to determine the shape and position of the stomach and
the duodenum, and the relief of the mucosa in the stomach and small intestine (in the first instance
of the duodenum). A barium sulphate suspension (100 g in 100 ml of boiled water) is used for
radiological examination of the stomach and the intestine. The power to absorb x-rays accounts for
the use of barium sulphate in roentgenology. The suspension is given to the patient per os.
The patient should be specially prepared for x-ray (either roentgenoscope or
roentgenography). His stomach and the intestine should be emptied of food remains, liquids, and gases.
Two days before the examination the patient's diet should be free from food that can cause flatulence,
e.g. rye bread, milk, or potatoes. In order to decrease flatulence, 2-3 days before the examination
the patient should be given a warm camomile tea (one table-spoonful in a glass of water). On the
eve of the examination, and also in the morning before the procedure, the patient should be given a
cleansing enema. Only an empty stomach can be examined by x-rays, and the patient is therefore
warned that he should abstain from eating (liquids or solids) 6-8 hours before the x-ray examination.
Duodenal probing is done for both diagnostic and therapeutic purposes. Many diseases of
the bile ducts and the gall bladder are attended by bile congestion. When a duodenal tube enters the
gall bladder, it contacts reflectorily to eject its contents into the duodenal lumen. Bile specimens are
important diagnostically.
 -73-

Taking specimens of duodenal contents is indicated: 1 - for withdrawal of the bile

congested in the gall bladder; 2 - for administration of medicines into the duodenum; 3 - for laboratory
examinations of bile; 4 - for artificial nutrition of patients with non-healing ulcers of the stomach.
Duodenal probing is contraindicated in: 1 - exacerbation of gastric ulcer;
2 - cancer of the oesophagus and stomach; 3 - angina pectoris and myocardial infarction;
4 - heart failure; 5 - acute cholecystitis and cholelithiasis.
A 1.5m long rubber tube with a diameter of 4-5 mm is used for the purpose. The distal end
of the tube mounts a metal olive with several perforations. The tube bears three marks to indicate the
distance from the teeth to the entrance to the stomach (50 cm), to the pylorus (70 cm), and to the middle
of the duodenum (90 cm). The tube should be washed and boiled after each use. If an infectious
disease is suspected, the tube should be disinfected for 2 hours in a disinfectant solution.
Two or three days before the procedure, the patient should be fed a diet free from foods
causing intense fermentation in the intestine. Medicines which relieve spasms of the gall bladder and
bile ducts (belladonna, no-spa) should be given. On the eve of the procedure, the patient should be
given a cleansing enema. The procedure should be done before breakfast. Dental prosthesis, if any,
should be removed. The conditions in the room are important. Preferably a special room should be
provided for the purpose, or the patient should at least be separated from others by a screen. The patient
must be observed during the entire procedure.
The procedure is as follows. The patient sits on the bed, unbuttons his collar, unfastens
his belt, and takes hold of the pan with the duodenal tube. The patient himself, or assisted by the nurse,
places the tube olive at the root of the tongue and makes several swallowing movements with his
mouth closed. The patient should breathe deeply and swallow together with the saliva. As soon as
the tube descends to the first mark to indicate that it has entered the stomach, the patient is placed
on his right side and a hot water bag is put under the right hypochondrium. The swallowing should
now be resumed until the tube is passed to the second mark. Swallowing should be gradual since
otherwise the tube may coil up in the stomach.
As the tube moves in the stomach, the gastric contents should be aspired into a special vessel
by syringe. The passage of the tube through the pylorus into the duodenum should agree with the
periodic opening of the pylorus. If the pylorus is contracted or affected by a spasm, it becomes
impassible for the tube. In order to accelerate the tube's passage through the pylorus, 1 ml of a 0.1 per
cent atropine solution should be given subcutaneously and the upper abdomen massaged. If the
pylorus spasm is due to gastric hyper acidity, the gastric juice should be aspired by a syringe, or a
 -74-

glass of a 1-3 per cent sodium hydro carbonate (baking soda) solution given per os.
In some cases the necessity arises to check the position of the olive tip. The best
visualizing technique is x-ray. The position of the tube's tip can also be determined tentatively by the
aspirate. If the olivetip is inside the stomach, the aspired liquid is cloudy and acid: litmus paper turns
red. The gastric contents may be green and react alkaline (litmus paper turns blue) to indicate that
the tube's olive is in the duodenum. Still another method consists in injecting air by a syringe: if the
olive is in the stomach the patient fells bubbling. No sound can be heard if the tube is in the duodenum.
If the olive has entered the duodenum, the aspirate is clear yellow; it reacts alkaline (A
bile). This is a mixture of bile, gastric juice, and pancreas secretion. A stand with test tubes is placed by
the patient's bedside and the duodenal contents are collected in them. B bile (bile from the gall
bladder) is obtained after stimulation with 40-60 ml of a warm (39-40 C) 25 per cent magnesium
sulphate solution or 20 ml of vegetable oil, which are administered to the patient through the tube. The
gall bladder contracts upon this stimulation while the Oddi sphincter relaxes to admit B bile into the
duodenum. B bile is dark brown and tenacious. Part of the B bile collected is used for a culture.
After the gall bladder has been emptied, a clear bile is drained again. This is a mixture
of fluids secreted by the intra hepatic ducts, the hepatic bile, or simply C bile. If the bile is to be
examined for the presence of lamblia, the obtained specimens should immediately be sent to the
laboratory, because when the bile cools, the parasites become immobile and hence undetectable by
microscopy.
Modern examination of the duodenal contents if often a multi step procedure. In the
presence of motor dysfunction of the gall bladder and the bile ducts (biliary dyskinesia), and also in the
presence of inflammation, antibiotics and other medicinal solutions are administered through the tube
after taking C bile. In the presence of excess fermentative and putrefactive process in the intestine,
lavage can also be performed through the tube. To this end, mineral water at a temperature of 39-40 C
is passed through the tube for 10-15 minutes. During the first lavage 1 liter of water is used, this
quantity increasing to 2-4 liters in subsequent irrigations.
Preparing the patient for x-ray of the gall bladder and the bile ducts. The x-ray study
of the gall bladder is called cholecystography. It can be done with the administration of radiopaque
substances (per os or intravenously). The x-ray study of gall bladder and the bile ducts is called
cholecystocholan-giography. Radiopaque material is given only by intravenous routes in this
procedure. Bilitrast, cholevid are given per os and bilignost intravenously. The presence of iodine
accounts for the x-ray opacity of these substances. When given per os or intravenously, radiopaque
 -75-

substances first enter the liver and then (through the bile ducts) the gall bladder.
Cholecystography is used for determining the shape and position of the gall bladder,
its motor function, and also is cases when bile stones are suspected. Cholecystography is
contraindicated in pronounced circulatory insufficiency, severe liver affections, acute nephritis, and
hypersensitivity to iodine. No special regimen or diet is necessary before this procedure. If the
patient is likely to develop constipation, he should be given a cleansing enema on the eve or in the
morning of the day of the procedure. Since the highest concentration of bilitrast in the gall bladder
is attained 15 hours after the administration, the preparation should be given 18-19 hours before the
procedure (on the eve of the examination). Bilitrast is given in 1-1.5 g doses at 20-minute intervals. The
total dose is 3-3.5 g. Each dose should be given with a glass of sweet tea. At 22.00 the patient is given
100 ml of a 40 per cent glucose solution. X-ray pictures are taken the next morning at 9.00 or 10.00.
By another method the patient is given a cleansing enema at 18.00 or 19.00, then 3-3.5 g bilitrast,
and placed on his right side for 30 minutes. The patient is given porridge or vegetable puree, and a
cup of tea with bread for a supper. Before night sleep, the patient is given 5-7 drops of an opium tincture
and a tablespooful of activated carbon. The x-ray examination is conducted in the morning, at 9.00 or
10.00, after an overnight fast. If the shadow of the gall bladder is absent, another picture is taken
in three hours. If the shadow is visible, two or three egg yolks are given to the patient and another
picture is taken in 90 minutes. Possible side-effects of billignost are nausea, vomiting, or nettle rash.
If the results of cholecystography with per oral administration of radiopaque preparations
are negative, cholecystocholangiography with intravenous administration is used to study the bile
ducts and for a rapid diagnosis of colic.
Contraindications for cholecystocholangiography are the same as for cholecystography. A
cleansing enema is given to the patient on the eve of the examination, and preparations that might
affect the motor function of the gall bladder (opium, cholagogics, etc.) are not administered.
The radiopaque preparation is given intravenously. The patient should be preliminarily
tested for sensitivity to iodine by administrating 1-2 ml of a 20 per cent solution of the
preparation on the eve of the examination. If side-effects are absent, 30-40 ml of the preparation
(preheated to normal body temperature) are injected. The preparation is injected slowly, over the course
of 4-6 min. Side-effects are more likely to occur with rapid administration (nausea, vomiting, heat, fall
of the arterial pressure). In emergency cases the patient's sensitivity to the preparation is tested
immediately before the examination: 1-2 ml of a 20 per cent bilignost solution is administered, and if
there are no adverse reactions for 2-3 min the remaining quantity (30-40 ml) of the solution is injected.
 -76-

Bile ducts are visible 10-15 minutes after administration; the picture becomes more distinct
in 25-40 min. The gall bladder becomes visible in 40-45 min. The maximum opacity of the gall
bladder is attained in 90 min. In 24 hours the radiopaque preparation fills the large intestine (through
which its main bulk is excreted). The preparation is usually well tolerated by patients. Some patients
may experience dizziness, chills, nausea, vomiting, a drop in arterial pressure, and fever. These
phenomena subside spontaneously. If necessary, oxygen can be given to breathe, or 1 ml of a 5
per cent ephedrine solution injected subcutaneously. If the patient has a history of allergic reactions,
he should be given diphenylhydramine hydrochloride or some other antihistamine preparation
(pipolphen, suprastin) 2 or 3 days before the procedure.
Care of patients with intestinal dysfunction. The main complaint of patients with
intestinal diseases are pain, meteorism (inflation of the abdomen), constipation, diarrhoea, intestinal
hemorrhages, and involuntary defecation.
No analgesics or warmth should be given to a patient with abdominal pain until its cause
is established, because this will interfere with diagnosis and may be harmful (e.g. in cases of intestinal
hemorrhage or acute appendicitis). If pain is caused by spasms of smooth muscles, peroral or
subcutaneous administration of atropine or belladonna is indicated often together with other
analgesics, e.g. morphine or promedol.
Meteorism is manifested by inflation and distension of the abdomen. Food rich is
carbohydrates should be excluded from the diet because it intensifies the fermentation processes in
the intestine intensifying gas formation. Activated carbon is prescribed in such cases: a
teaspoonful 3-4 times a day; activated carbon (tablets) and camomile tea are also helpful. Cleansing
enemas give considerable relief to the patient. If these methods prove ineffective, a 50-cm long
rubber tube with a diameter of 1 cm should be inserted into the rectum to a depth of 20-30 cm. The
rounded tip of the tube, which has lateral openings, should first be coated with Vaseline. The other
end of the tube is placed in a bed-pan in order to protect the linen from occasional soiling by the
intestinal contents. An oil-cloth can be used for the same purpose. The tube is removed after 30-60
minutes and the anus wiped with a wet cotton pad.
If the patient has diarrhoea, he should use a bed-pan or some other vessel where his feces can
be collected for inspection and analysis. The patient should keep his body, clothes, and bed clean; he
should wash his anus after defecation with a 2 per cent boric acid solution. Since diarrhoea is often
the result of an infection (cholera, abdominal fever, dysentery, etc.), it is necessary to take special
precautions even before the diagnosis is established. To this end the patient should be placed in a
 -77-

separate room and a rug wetted with a disinfectant solution placed at the threshold.
The patient's plates, glasses, and silverware should be washed with soap and soda,
boiled for 15 minutes, and kept separately from others. All objects that are used for his care should
also be washed with soap and hot water. Linens should be collected in a special bin fitted with a cover
and then boiled for 15 minutes with soap and soda. The bed-pan should be washed in a disinfectant
solution, rinsed in water, closed with a cover, and placed on a sheet of paper which should be burned
after each use. The feces and urine should be treated with chlorinated lime (1:2) and kept for an hour
before discarding into the sewage. Food remains should be treated in the same way.
The room and other premises where the patient may touch various objects should be
cleaned two or three times a day using a wet rag. The floor should be washed with hot water, soda,
and soap. The door handles, taps, w.c. pans and floor in the lavatory should be treated with a
disinfectant solution. The patient's room and the rooms for common use should be aired several times
a day. The personnel who take care of infectious patients or those suspected of having infectious
diseases should wear overalls made of easily washable fabric. After contact with the patient or after
washing his plates and silverware and the bed-pan, or after cleaning the rooms, the worker should
wash his hands with soap using a brush. When the attending personnel leave the room or other premises
where the patient is present, they should take off their overalls and wipe their feet on the rug wetted
with the disinfectant solution.
Constipation is a retention of stools for more than two days. Constipation is managed with
a special diet, cathectic, and cleansing enemas. The number of daily defalcation should be counted
and the amount of feces in each defecation assessed. In some patients a considerable amount of
hardened feces accumulates in the rectum. An enema is useless in such cases and the feces should be
removed manually. A rubber glove lubricated with oil should be used for the purpose. A bed-pan is
placed under the patient's pelvis and the finger is inserted into the rectum to remove the hardened feces.
If not removed in due time, the feces harden even more and press on the intestinal wall, causing sores.
A cleansing (evacuant) enema should be given after this manual procedure.
If intestinal hemorrhage develops (which is manifested by tarry stools), the patient should
stay in bed, and the physician should be informed. A ice-bag should be placed on the abdomen and
100-200 ml of compatible blood infused. If this does not help, surgery is indicated. During the course
of the first 24 hours, the patient should abstain from food. The intake of liquids should also be
limited. Cold or slightly warmed semiliquid food should be given. Peroral administration of medicines
should be suspended.
 -78-

Hemorrhage may be only slight in peptic ulcer, in cancer and some other diseases, and
blood traces in the feces can only be detected in the laboratory. When hemorrhage is suspected the
patient should be given a meat-free diet for three days before the examination, since meat can be
responsible for a positive occult blood test. Feces are not tested for blood if the patient is suffering
from gum or nasal bleeding, or hemorrhage after tooth extirpation.
Involuntary defecation occurs in patients with severe affections of the brain, tumors,
or injured rectum. These patients should be kept in separate rooms. A high-caloric and easily
assimilated diet spares the patient because the amount of feces is small. A cleansing enema should be
given every day. The patient should be placed on a special bed or a rubber pan. Such patient should be
given special care with frequent sanitary treatment of their body; their clothes and sheets should
be changed more frequently.
Enema. An enema is an injection of liquids into the large intestine through the anus.
Enema is indicated to remove bowel contents, to administer medicines, nutrients, or radiopaque
substances (barium sulphate) for x-ray examinations. Evacuant, purgative, drop, and nutrient enemas
are distinguished.
An evacuant enema is given for constipation, poisoning, before labor in women, before
x-rays of the abdomen or the pelvic organs, and before giving medicinal or nutrient enemas. An
evacuant enema is contraindicated in gastric and intestinal hemorrhage, ulceration of the large
intestine or the rectum, hemorrhoids, cancer of the rectum or the large intestine, purulent and
ulcerative processes in the large intestine or the anus, in acute appendicitis and peritonitis, and in
rectal prolapse.
Pure water is used for an evacuant enema (1-2 liters). To increase the cleansing effect,
a camomile tea and 2-3 tablespoonfuls of glycerol or Vaseline oil should be added. The water
temperature for atonic constipation should be 15-20 C and for spastic constipation, 37-39 C. An
Esmarch flask is filled with water and its tap opened to displace air from the tube. The tap is then
closed and the flask hanged from a stand at a height of 1-1.5 meter. The patient lies on his side at the
edge of his bed and flexes his thigh on the abdomen. An oil-cloth should be placed under the patient.
A rubber, glass or ebonite end-piece is used. The left hand is used to separate the buttocks,
while the end-piece lubricated with Vaseline is inserted into the rectum by the right hand and rotated
slightly about its axis until it reaches a depth of 10-12 cm. The end-piece should first be moved toward
the umbilicus, and then posteriorly, parallel to the coccyx. The tap is now opened.
The liquid should flow quietly from the flask. If the liquid does not pass from the flask, the
 -79-

position of the end-piece in the rectum should be changed slightly, or the pressure increased by raising
the flask to a higher position. If the patient complains of pain, the flask should be lowered to slow down
the rate of water outflow. If the end-piece becomes clogged with feces, it should be cleaned and
introduced again. If the feces are hard, they should be removed from the rectum by the finger or a
spatula. The administered liquid reaches the remote parts of the large intestine to intensify peristalsis
and to cause the urge to defecate. The patient should retain the administered liquid for 5-10 minutes.
A purgative enema is prescribed for persistent constipation or intestinal paresis when the
administration of large amounts of liquid is ineffective or harmful. Oil and hypertonic saline solutions
are used.
An oil enema is indicated for pronounced constipation when hardened feces are
accumulated in the rectum, and also in inflammatory and ulcerative processes in the large intestine
and the rectum. Sunflower seed oil, olive oil, Vaseline oil or linseed oil are used for the purpose.
Oil penetrates the space between the feces and the intestinal wall to facilitate the discharge of the
feces. Oil also produces a mild irritating effect on the intestinal wall decreasing inflammation
and promoting the normalization of peristalsis. From 50 to 100 ml of oil is required for an enema. The
temperature of the oil should be 37-39 C. A Janet injector or a rubber bulb with a tube are used for a
while after the procedure. The purgative effect should occur within 8-12 hours.
After use the tools should be washed with hot water and sodium bicarbonate, and bioled.
Hypertonic saline enema. This consists of 50-100 ml of a 10 per cent sodium chloride
solution or a 25 per cent magnesium sulphate solution. The enema is given in intestinal paresis and
oedema of the intestinal wall. The enema is contraindicated in ulceration of the large intestine and
fissures of the anus. The hypertonic solution should be warmed up before administration.
The tools used for the purpose are the same as for giving an oil enema. The patient should not
defecate for 15-30 minutes after the enema.
A siphon enema is given when an evacuant enema and laxatives are ineffective to remove
putrefactive material, poisons and toxic substances from the intestine and also for the diagnosis of
intestinal obstruction. The absence of gas bubbles in the washing confirms the diagnosis of intestinal
impotency.
A siphon enema requires a 1-2 liter glass funnel and piping: a 1.5-m long rubber tube, a
short glass tube, and rectal tube. A jar, a basin and an oil- cloth are also required. Water (10-15 liters)
should be warmed up before use. The patient assumes the same position as for an evacuant enema.
The tip of the rectal tube is coated with Vaseline and inserted into the rectum to a depth of 20-25 cm.
 -80-

The funnel is held slightly above the patient's body. Water is poured into the funnel from a jar and
the funnel is raised. When the liquid level in the funnel descends to the funnel's apex, the funnel
is lowered over the basin and held in the position until the liquid containing intestinal material rises
to its initial level. The liquid is then discarded into the basin. Clean water is poured into the funnel
and siphon age is repeated until the water returning to the funnel is clear. After use, the funnel and the
tubes are cleaned.
Medicinal solutions that are given by enema are usually of local action. These are
antispatics, antibiotics, sulpha drugs, antiparasitary preparations, and some others. A tepid solution
(50-200 ml) is administered by a rubber bulb or a Janet injector provided with a 12-20-cm long rubber
end-piece. The patient should try to keep the administered medicine in the intestine for at least 30 min.
The medicinal solution should be given 20-30 minutes after an evacuant enema.
A drop enema, or simply drip, is used for giving a large amount (up to 2 liters) of isotonic
sodium chloride or glucose solution to manage intoxication, dehydration, etc. The apparatus includes
an Esmarch flask, a rubber tubing, a dropper, a glass tube, and a rectal tube. The rectal tube has
lateral openings. The rate of liquid administration is controlled by a clamp. The patient should lie on
his back during the procedure. The solution in the Esmarch flask should be 41-42 C. The rectal tube
is inserted into the rectum to a depth of 20-25 cm. It is necessary to observe the rate of administration
and the temperature of the solution.
Preparing a patient for an x-ray study of the large intestine. A barium sulphate
suspension is usually given by enema before irrigoradioscopy. The patient's large intestine must be
emptied before the procedure. Three days before the examination the patient should be fed a low
carbohydrate diet. It cases of meteorism, the patient should be given camomile tea and activated carbon.
On the eve of the examination, the patient is given 30-40 ml of castor oil before his dinner. An enema
is given before the night sleep and in the morning before the examination. A rectal tube is inserted into
the rectum 30 minutes before the examination to release gases. A barium suspension is used as a
radiopaque material. It is prepared from 200 g of barium sulphate and 10 g of tannin in 1 liter of water.

Theme#17-18

OBSERVATION AND CARE OF PATIENTS WITH URINARY DISORDERS

Patients with diseases of the urinary system usually complain of lumbar pain, edema, headache,
urinary disorders, deranged vision, nausea, vomiting, and fever.
 -81-

Patients with renal dysfunction and diseases of the urinary tract require special care. Patients
with acute nephritis may develop severe complications and should therefore be hospitalized. Patients
with chronic nephritis require hospitalization only during exacerbation and those with acute nephritis
should stay in bed. If this condition is not observed, various complications are likely to develop and the
patient's recovery is delayed. Water, salt, and protein should be restricted in the diet of patients with
renal disease. The diet should be rich in vitamins. Fasting days, when the patient eats only apples, stewed
fruits, etc. should be prescribed.
Uremia is severe poisoning of the body with rest nitrogen, which is not removed efficiently by
the kidneys. Products of protein decomposition (urea, uric acid, and creatinine) accumulate in the
patient's blood.
Protein should be restricted to 20-40 g a day. The intake of meat, fish, and dairy products should
be limited as well. The permissible amount of protein should come from eggs and boiled meat. Potatoes
and sweets are recommended. Intravenous injections of 300-400 ml of a 5 per cent glucose solution are
given. In the presence of acidosis, the patient should be given 150-200 ml of a 4 per cent sodium
hydrocarbonate solution; vitamins are given per Os.
The renal function is assessed by the diluting and concentrating power of the kidneys. The
amount of urine excreted during a specified period of time is called diuresis. The daily diuresis is the
amount of urine excreted during 24 hours. The average daily diuresis of a healthy human is 1.5 litre.
Some diseases are attended by a decreased diuresis, which is called oliguria. A complete cessation of
urination is called anuria. Polyuria (increased diuresis) attends rapidly resorbing edema. A healthy
individual urinates from 4 to 6 times a day. The urine is excreted in a uniform jet. Frequent urination
(usually in small portions) is called pollakiuria and occurs in inflammatory affections of the urinary
ducts.
The concentration of the urine is determined by its specific gravity. Normal specific gravity of
urine varies from 1.010 to 1.030, depending on the diet. The concentration of the urine increases in
oliguria, because the residues are dissolved in a decreased volume of the urine. The specific gravity of
the urine varies from 1.030 to 1.040 in oliguria, while in polyuria it varies between 1.008 and 1.010. If
the concentrating power of the kidneys is affected, the specific gravity of the urine remains low even in
oliguria. The liquid elimination by the kidneys is disturbed.
The Zimnitsky test. Its advantage over other urine tests is that it can be carried out without
interfering with the patient's usual regimen. The test is carried out during the course of twenty-four
hours. At 6.00 or 7.00 in the morning the patient urinates and discards the urine. Then he collects the
 -82-

urine at 3-hour intervals: a total of 8 specimens. The volume and the specific gravity of each 3-hour
portions of the urine are measured in the laboratory. The volumes of the urine passed during the day and
night are compared. The daytime diuresis of a normal individual is about two times greater than the
nocturnal diuresis. The specific gravity of the daytime urine fluctuates from 1.005 to 1.028. Nocturnal
diuresis, called nycturia, prevails in renal dysfunction. The specific gravity of the urine in pronounced
renal failure changes very little (isohyposthenuria).
Care of patients with urinary retention or incontinence. Retention of the urine (ischuria) is a
pathological condition characterized by the inability of the kidneys to excrete the urine due to an obstacle
in the ureters or urethra. The passage of the urine may be obstructed by stones, tumors, cicatricial
contractions in the ureter or in the urethra. The urine may be retained due to nervous regulatory disorders
of the excretory function. Postlabour ischuria can develop after parturition. This is due to decreased
muscular tone, edema of the neck of the urinary bladder, or injury to the urinary bladder by the foetal
head. Ischuria can be acute or chronic, complete or partial, with or without painful tenesmus. A healthy
individual passes the urine in a full and strong jet. In the presence of partial retention, the jet thins and
weakens or the urine passes by drops.
When taking care of the patient, it is necessary to count his urination and to measure the volumes
of the passed urine. Special attention should be given to patients whose central nervous system is affected
and in whom the urinary bladder may be paralyzed simultaneously with the spasm of the sphincter.
Overdistension of the bladder may in this case cause is repture. If the patient retains the urine for 6 hours
after parturition or surgery, all measures should be taken to release the urine. Sometimes the patient
should be left alone or be assisted into the sitting position. A water bag may be placed on the lower
abdomen, or the patient may be given an enema of tepid water, or a bath. If these measures fail to help
the patient, he/she should be given an injection of pituitrin or magnesium sulfate. If this does not help
either, the urinary bladder should be catheterized.
Flexible and metal catheters are distinguished. A soft catheter is a 25-30-cm long rubber tube
with a diameter from 0.3 to 1 cm. The tip of the tube is rounded and fitted with lateral openings. Metallic
catheters are divided into male and female ones. Both are provided with handles and beaked tips. The
rounded tip has one or two oval openings. The male catheter is 25-30 and the female about 15 cm long.
The beak of the male catheter is longer than that of the female catheter. Metal, rubber, and plastic
catheters are sterilized by the boiling. Rubber catheters should be sterilized in formaldehyde vapor. Since
formaldehyde irritates the urethral mucosa, the catheters should then be rinsed in distilled water.
Catheterization can be carried out for diagnostic and therapeutic purposes. Catheterization is
 -83-

contraindicated in injuries and acute inflammation of the urethra or the urinary bladder. Sterilized
catheters, forceps, and cotton balls soaked in disinfectant solution are placed in a sterile through before
the procedure. Sterile glycerol, or a special paste, and a urine receptacle should also be prepared. The
patient lies on his back with the legs slightly flexed and separated. The urine receptacle should be placed
between the patient's thighs. The genitals should be washed with water and disinfected with cotton ball
wetted with a mercury dichloride or ethoxydiaminoacridine lactate solution. The rounded tip of a soft
catheter should be held with the forceps, and the catheter's outer end, by the fingers. The glans penis is
held by the left hand and the tip of the catheter is inserted into the urethra using the right hand. The
catheter is then pushed forward into the bladder by the forceps until urine starts flowing from the
catheter.
When catheterizing women, the one performing the procedure should stand by the patient's right
side. The labia major are separated, the orifice of the urethra disinfected, and the catheter inserted until
urine emerges. The catheter should be removed slightly before all the urine is withdrawn so that the
remaining urine can wash the urethra after extraction of the catheter.
Sometimes the urinary bladder is irrigated with medicinal solutions during catheterization.
Potassium permanganate, silver protein, colloid silver or other solutions are used for the purpose. The
sterile solution (0.4-1 litre) is preheated to 38- 39 C and placed in an Esmarch flask. The tube is clamped
and the flask suspended. After catheterization and withdrawal of the urine, the catheter (usually a rubber
one) is connected to the tubing of the Esmarch flask and 100-400 ml of the solution are passed into the
bladder. The catheter is then disconnected from the tubing and the solution is allowed to flow from the
bladder. The procedure is repeated several times.
Urinary incontinence is a morbid state in which the patient does not feel the urge to urinate and
passes the urine involuntarily. Incontinence usually attends affections of the brain, unconscious
conditions, neurosis, and diseases of the urinary bladder. Constant excretion of the urine causes
maceration of the skin, bedsores, and soiling of underwear and linens.
Patients with urinary incontinence should be examined to establish the cause of incontinence and
to manage it. A urinal should be put in the bed of such patients. The urinals should be emptied at least
three times a day and washed with soap and warm water. Once a day the urinal should be disinfected
with a potassium permanganate solution. Walking patients should be given special urinals which they
can carry about. The urinals (both male and female) and made of rubber, nylon or other material and
comprise a special urine trap, which is attached to the lower part of the trunk, and a receptacle which is
attached to the thigh. A well-fitted urinal does not interfere with the patient's movements or routine
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work.
Preparing a patient for x-ray of the urinary system. Excretory (intravenous) urography is a
common radiographic study of the urinary tract. Solutions (50-60 per cent) of bilignost, verographin, or
urographin are used as opaque media for urography. The informative value of the studies depends on
the effective evacuation of gas and feces from the intestine, the renal function, and some special features
of the disease. To prevent possible allergic reaction of the patient to iodine preparations used as the
radiopaque medium, his sensitivity to a particular preparation should be tested on the eve of the
examination. To this end, 1 ml of the preparation is injected intravenously and the immediate and
delayed responses are observed. If an allergic reaction develops, the examination should not be
conducted. Immediately before the examination, the region of the kidneys and the bladder should be x-
rayed to check if the intestine in this region is emptied. On the eve of the urographic study, and also two
hours before the examination, the patient should be given a cleansing (evacuate) enema. If the patient
is predisposed to constipation, he should be given laxatives (rhubarb, buckhorn). Chamomile tea or
activated carbon should be given in meteorism. The patient should empty the urinary bladder
immediately before the procedure.
The radiopaque preparation is warmed to body temperature and injected into the cubital vein
during the course of 3-5 minutes. The first 2-3 ml should be injected at an especially slow rate and the
condition of the patient observed carefully. If any allergic reaction develops (nasal discharge, sneezing,
nettle rash), the injection should be discontinued immediately without removing the needle from the
vein in order to infuse glucose or isotonic saline solution. When given intravenously, radiopaque
material is rapidly excreted by the kidneys. The pelvis, ureters, and the urinary bladder can be seen on
x-rays.
The radiopaque substance can be administered directly into the pelvis through the urinary ducts.
This method is called retrograde (ascending) pyelography. Special catheters and a cystoscope are used
for the administration of the radiopaque medium into the pelvis. Special marks on the catheter are
important for controlling the depth of its insertion: a normal depth to catheterize the pelvis is 24-28 cm
from the orifice. Warm solution of urographin (20 ml 60%) is slowly administered through the catheter.
Cystoscopy is the examination of the urinary bladder from inside using a cystoscope. Before
introducing the cystoscope, it should be checked that it is in good condition. The caliber of the
cystoscope should be selected to comply with the lumen of the urethra. The cystoscope should be coated
with ample sterile glycerol, and a few drops of glycerol should be introduced into the orifice of the
urethra. The beak of the cystoscope should be passed into the urethra very slowly until it enters the
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urinary bladder.