T. KAPITAN PROPAEDEUTICS OF CHILDREN’S DISEASES AND NURSING OF THE CHILD Fourth edition, updated and translated in English Vinnitsa The State Cartographical Factory 0yaK BBK K20 ISBN 978-966-2024-90-6 616-07:616-053.2/.5:61.004.5(075) 57.3 K 20 Reviewers: Sorokman T.V.— MD, professor, head of departmentof pediatrics and medical genetics of Bukovyna State Medical University Pavluk V.P. — MD, Director of Department of Medical Programs of International Fund “Ukraine 3000" Tepexaadeno 2a eudannam: Kanitan T. Tiponenestuxa autaunx xaopo6 3 2ornagom 3a aitemu : (Iiapyaunx ana cTynentie sHuwx MeaHsHHx HasanbHux 3aknazie). — Binanus : 1M «lepxasra kaptorpadiana pa6puxan, 2010, — 868 c. : intocrp. ; Kon. axa. [8 ¢.). Mhapyannx yxaanennit na nigcrasi «llporpamu 3 nponeneaTH4nor, baxyabterceKo! Ta noT nestarpil aaa ctyaewrin BMUNX MeAMUKNX wansanbnnx aaenaaie {I-LV plants axpeavrauim, saraepaoxenil MO3 Ypainn. Tapysnix npnswasenni crygenram (tI xyp MLW MeaHAHnK HaedaMbIOIX JaKRaRtE AA HigFOTORKH 20 ipaKTH'KiX 3aNATE 3 Kypey npone- eaTHKH aitrauitx xBopo6 3 AornagoM 3a aITbMIL Kapitan T. Propaedeutics of children's diseases and nursing of the child : [Textbook for students of higher medical educational institutions] ; Fourth edition, updated and translated in English. / T. Kapitan — Vinnitsa: The State Cartographical Factory, 2010. — 808 pp. «ill. appendix. [ 8 pp]. ISBN 978-966-2024-90-6 This textbook is made on the basis of “Teaching plan in propaedeulical, departmental ‘and hospital pediatrics for students of higher medical educational institutions of III-IV levels of accreditation’, authorized by Ministry of Health of Ukraine. The target audience of this textbook is second and third year students of higher educational institutions trained for Practical classes in propaedeutics of children's illnesses and children care YAK 616-07:616-053.2/.5:61.004,5(075) BBK 57.3 Allights are reserved. This book is protected by copyright No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, ‘mechanical, photocopying or otherwise without the prior permissionof the auther. ‘Any violation is strictly prohibited under the laws of Ukraine © TV Kapitan, 2001-2010 © The State Cartographical Factory, 2010PREFACE Boundaries of scientific understanding and prediction can not be foreseen. D. Mendeleyev Dear colleagues and students! First of all, | would like to express my sincere gratitude for your attention to the previous edition of the book and for all your recommendations concerning the contents. This second edition is as a result of numerous orders for the textbook from different states of the country. All received recommendations and opinions about its contents were taken into consideration. Lately, pediatricians’ tactics and methods of approach concerning children’s examination and care for them have considerably changed, especially the aspects of the evaluation of their physical condition and babies nursing etc. This modern information is given in accordance with recommendations of WHO, and was confirmed by the Ministry of Health of Ukraine (Order # 149 of 20.03.2008). That is why the second edition of “"Propaedeutics of children’s diseases and nursing of the child” is renewed; it contains some innovations and additions. There are some actual issues considered in it: + Methods of the evaluation of children's, physical development (all necessary tables and graphs are given as well as some examples of the obtained results). «The rules of babies nursing and weaning are considerably changed, some correspondent tasks (assignments) are given. Some criteria of the evaluation of psychomotor development of a child are changed and modern ones are given. Besides, this edition gives the new classification of anemia, and considers in details, some modern methods of diagnostics of digestive system diseases as well as diseases of the cardio-vascular system, etc. There is a new chapter "Sense organs". Some supplementary demonstrative colored and black-and- white illustrations are also given. Many foreign students from Vinnitsa National Pirogov Memorial Medical University took an active part in translating this book into English. All of them speak English fluently. | am very grateful to all of them and give their names here with great pleasure: Umoh Enobong Emmanuel (Nigeria) (special thanks to you dear) Saidi Mwishehe Mohamed (Tanzania) Tsidie Matsebula (Swaziland) Kalu John Chimbueze (Nigeria) Ssuubi Games Muwonge (Uganda) 3| also want to mention thankfully, the name of the students who helped me during our work with the first edition: Ticini Joseph, Sanilraj, Hozefa Vaikarya, Thankamony Raja, Siddiqui Mohammad Misbah (all students are from India), Maka Kaino (Tanzania), Prabath Ahangamage (Sri Lanka). As usual, | shall willingly and thankfully accept all your opinions, recom- mendations, wishes and critical remarks, which after thorough studying may be used later on — they will help to make this book better. You may send your remarks and suggestions to my e-mail address: kapitanTV@yandex.ru. Sincerely yours & Crna? a Dr. T. Kapitan~ PREFACE TO THE FIRST EDITION Pediatrics (Greek paidos —a child, iatreia — treatment) is ascience which studies laws of a child's development, rules of his/her feeding, etiology and pathogenesis of children’s diseases and ways of their prophylaxis as well as diagnostics and treatment. Propaedeutics of children’s illnesses (Latin propaedeutica — preliminary training, preparatory training, introduction into science) is basic knowledge of pediatrics, which focuses on the following issues: (a) Age peculiarities of growth, development and formation of all systems of children’s organism. (b) Methods of examination, palpation, percussion, auscultation of internal organs and systems of children. (c) All types of examination of patients with children's diseases. (d) Semiotics of basic lesions in various systems and organism as a whole. (e) Clinical processing of data obtained after general and additional ‘examination of patients. The textbook in propaedeutics of children’s illnesses includes all questions according to the academic plan. The section of child nursing, which is considered simultaneously with propaedeultics of children's illnesses, is added only on the request of both Ukrainian and foreign students of the second and third year of study. Questions are generally simple but foregin students of the second year of study still have problems with Ukrainian or Russian languages. Very often third year students, who know our language better, have no time to master large questions in propaedeutics and child caring simultaneously. Comments of students are taken into account in this edition. The following recommendations and requests are considered: (a) Major ideas of the text are underlined or typed in bold letters. (b) Basically the text is written in the style of enumeration of major issues. (c) With large numbers of demonstrative photos. (4) Examples of writing some case histories, are given (e) Not only normal data of laboratory methods of examination, but also its pathological changes and interpretation of results are given; majority of analyses are realistic in nature. (f) Brief characteristics of the known scientific researches and scientists (their countries and life time) are presented (g) Methods and ways of calculation of all kinds of child's nursing as well 5as different types of problems and their solutions are described. It will greatly help in preparation of students. (h) Brief characteristics of many diseases that comply with the academic plan in propaedeutics of children's illnesses are given. It will greatly help students of the second and third year of study master many symptoms of pathological conditions. (i) In the appendix, there is a sample of case record, percentile tables, dietary tables and basic norm analysis of laboratory inspection of all considered systems. The knowledge of all sections of propaedeutics of children’s illnesses is necessary not only to the pediatricians or the family doctor, but also to each and every doctor. It is not only because in some countries, there is no profession as a doctor-pediatrician. It is because of the fact that very often, when the condition of the child gets worse, especially in case of emergency, parents approach doctors of any specialization for help. And you, the present students, of 3-4 years of study should be able to serve the child and render urgent help. Dear students! At the end of the third year, you will finish studying propaedeutics of children’s illnesses, by then, you should be able to easily understand medical informations, and your knowledge would have reached the first half of your higher medical education. If while reading the textbook, you have any difficulties, which you think are caused as a result of insufficient information, wrongly written texts, or the submitted tables have helped you master the ‘material or on the contrary, complicated things thereby making understanding difficult, etc., | will be very grateful for your advice, recommendation, remarks and criticism and will take them into account in the future. _ Yours faithfully, T. Kapitan a& nn?- Abbreviations and signs in the text AAFT — adhesive-aggregative functions of thrombocytes ACTH — Adrenocorticotropic hormone AD — atopic dermatitis ADH — antidiuretic hormone AIDS — Acquired Immune Deficiency Syndrome ALT — alanine aminotransferase (formely SGPT) ALV — artificial lung ventilation APUD-system — Amine Precursor Uptake and Decarboxylation system ARF — acute renal failure AST — aspartate aminotransferase (formely SGOT) AV — atrioventricular AVIR — Acute viral infections of respiratory tracts AVnode — atrioventricular node BALT — Bronchus associated lymphatic tissue BB — concentration of the buffer basis BE — excess or deficit of buffer systems b.m, — bowel movement BMI — body mass index BP — blood pressure b.p.m. — beats per minute (heart beats) BR — breathing rate BRE — blood routine examination ‘CAT — computerised axial tomography CBC — Complete blood count CDC — Centers for Disease Control CHD — congenital heart diseases Cl — enrculatory insufficiency Cl — Color index CIS — Commonwealth of independent States CNS — central nervous system CO — cardiac output CRF — chronic renal failure CRP — C-reactive protein CSF — cerebrospinal fluid CTTI — cardio-thymo-thoracic index CV — cardiovascular CXR — chest X-ray DBP - diastolic blood pressure DIC-syndrome - Disseminated intravascular clotting syndrome dL deciiiter (100 mL) DPT — diphtheria-pertussis-tetanus EAH - electrical axis of heart FBS _ fasting blood sugar EchoCG echocardiography ECG electrocardiogram ED effective doseENT -— ear, nose and throat ESR - Erythrocyte sedimentation rat FBC. - fuil blood count FSH — follicie-stimulating hormone FTT — Failure to Thrive GH — growth hormone (=somatotropic hormone) GIT -- gastrointestinal tract GIL — ‘Giga per itter’ (=10%L) Hb, hb, Hgb, hgb — hemoglobin HF — heart failure HHV — Human Herpes Virus HIV — Human Immunodeficiency Virus HLA system — Human Leucocyte Antigen 8} HR — heart rate hrs — hours Ht — hematocrit HTN — hypertension 1A — intra-arterial IBW — ideat body weight ICU — intensive care unit .d, — intradermal injections m., IM — intramuscular in r/v — in the range of the vision . IV — intravenously IVC — inferior vena cava IVS — inter-ventricular septum, IL — titre ‘A — left atrum LC PUFA — long chained poly unsaturated fatty acid LIE — teuko-erythroblastic mdex LH — luteinizing hormones LV — left ventricle LVF — left ventricular failure LVH — left ventricular hypertrophy MALT — mucus associated lymphatic tissue meg, Hg — microgram MED — minimum effective dose mg — milligram ml, mL — mitititer mm — millimeter mM — millimote mmol/kg/day — milimote per kg of body weight per day MNP — mononucleus phagocyte system MPN — most probable number MRI — magnetic resonance imaging NBB — Normative buffer base NEFA — nonesterified fatty acids nim — nanometersNPD * neuro-psychological development OFE — Osmotic fragility of erythrocytes PBS — post prandial blood sugar PCG — phonocardiogram PCV — packed red blood cell volume PDA — patent ductus arteriosus PMD — psychomotor development PP — vitaminB,, nicotinic acids (from Pellagre-preventive) PR — pulse rate PRL — prolactin pt — patient PT — prothrombin time RA— right atrium RBC — red blood cell(s) or red blood count RES — reticuloendothelial system RI— respiratory insufficiency RV — right ventricle RVF — right ventricular failure SA node — sinoatrial node SB — Standard bicarbonate of blood SBP — Systolic blood pressure s.¢. — subcutaneous injections SCID — Severe Combined Immuno Deficiency SCM — sternocleidomastoid muscle SES — sanitary-and-epidemiologic station SGOT — serum glutamic oxaloacetic transaminase (see AST) SGPT — serum glutamic pyruvic transaminase (see ALT) SI_— International System of Units (Systeme International d'Units) SV — stroke volume SVC — superior vena cava SLE — systemic lupus erythematosus spp. — plural of species TAR-syndrome — Thrombocytopathy and thrombocytopenia with the Absence of Radial bone TIL —‘Tera per Iter’ (=10"/L) ‘TNF —- tumor necrosis factor TSH — Thyroid stimulating hormone UNICEF — United Nations for International Children’s Emergency Fund USG — Ultrasound cardiography, Ultra sono graphy UVR —— Ultra-Violet Radiation VIP — vasoactive intestinal polypeptide WBC — white blood cell(s) or white blood count WHO -- World Health Organisation [X]-- concentration of any species (°X’ stands for. K* — potassium, Na* — sodium, Ca* — calcium, etc ) il, pL — microliter =~ meanings of synonymsList of abbreviations icable in medicine, their Latit eis and meaning in English language 10mn ‘And ex aqua In water fac, fiat, fant Make, lef be made ‘Gramma, ‘Gram’ Guttae Drops ‘quitatim Drop by drop hora Hour hoc nocte: “Tonight hora somn ‘At bad fime indies Daily Tiquor. ‘liquor, solution. ‘WMisce Mix ‘mane primo. First thingin the moming, ‘more dictor ‘As directed medicamentum ‘Amedicine mane et nocte Moming and ni mixture ‘A mixture noct. nocte: ‘Of the night noct. maneg. nocle maneque ‘Night and moming Non. fep., AF. non repetatur ‘Do not repeat, no refills .p.0. ‘Nothing by mouth. o Octarius: Pint OD. ‘Ocuius Dexter Right eye: OL. ‘Oculus Laevus Left eye omn. bid. Every 2 days ‘omn. bin. Every 2 hours ‘omni. hor. Every hour ‘omn. noct. ‘omni nocte Every night com. Zh. ‘omni quadranta hora Every 15 minutes ‘om. mane vel. noc. | omni mane vel nocte Every morning or night OS. ‘oculus sinister Left eve ‘O.u. ‘oculo ulerque Each eye [part. vi partis vicibus. In divided doses p.c., post. ib. ‘post cibos. ‘After meals, PM. Post Meridien, ‘Afternoon or evening .0. er os By mouth, [pp.a phiala prus aaitata ‘The bottle having first been shaken. [p. per rectum Through the rectum: [p.r.n. pro re nata ‘As needed [pro. rat. aet. ro ratione aetatis ‘According to patient's age Pulv. Pulvis. powder [g.a.d., 4.0.4. ‘quoque allernis die Every other day ad. ‘quoqu Every day Qh. ‘Quisque hora Every hour ‘Q.2h. Every two hours Q.3h. Every three hours aid. ‘quater in die Four times a day ‘quantum libel ‘As much a8 wanted. ‘quantum sulficiat A sufficient quantity ‘A sufficient quantity to make ‘quam voluens ‘As much as you wish Recipe Take, recieve sans, Siné. Without Signa Mark ‘sub cutis ‘Subcutaneously semih. semihora Half an hour 4Signa Label, or fel tbe pnnted ‘singulorum ‘Of each, solutio ‘Solution solve Dissolve ‘semi or Semisse ‘One-half ‘si opus sit ifthere is need. stet, stent, Let it (them) stand statin Al once, immediately subinde, Immediately after ‘sume. Take. ‘Suppositorium “A supposilory syrupus, Syrup. tabella, Tablet ‘Such uch doses Tern die, Three times a day ter in nocte Three times a night ‘unctura Tincture tritura’ Triturate ‘Teaspoonful ‘unguentum- ‘Ointment ut dictum As directed ‘winum ‘Wine While awake:ETHICS AND DEONTOLOGY OF PEDIATRICIANS Deontology is the soul of medicine and the wisdom of healing (cor cordium medicine). AF. Bilibin Let's begin with the translation of these words of foreign origin. Ethics (Latin word ethica comes from the Greek word which means custom) stands for the norms of behaviour, set of moral rules of a certain social group. Deontology (Greek word deonto means necessary, required) stands for professional etiquette of medical workers, the principles of behaviour of medical personnel, aimed at the maximal increase of treatment effectiveness. It is the part of ethics which deals with the problems of duty, professional responsibility, all forms of moral requirements and their interdependence. Thus, everyone should obey the rules of ethics, but these norms are somewhat different in various groups of the world's population. Deontology and ethics are connected by certain internal relations: deontology is the part of ethics the norms of which are professional duties of all medical workers Hippocrat was the first to formulate the basic moral and ethic rules of a doctor in his well-known “Oath’, the whole text of which specified the humanism of the ancient scientist and doctor. Aperson can bea bad arfist or unsuccessful writer, but one cannot be a bad doctor. As it follows from practice, a competent doctor and a good doctor is not the same. N.A.Semashko wrote, “A person is turned into a good doctor not only by knowledge. The highly humane attitude to a sick person and the authority, which consists of theoretical knowledge, moral values and practical skill, are also necessary.” However, a good doctor is always a competent doctor. He/she should constantly be on the modern top level of the development of medicine. Besides, he/she should always remember the great meaning of Bekhterev's words who said, “If a patient does not feel better after the conversation with a doctor, this is not a doctor’. Itis possible to state confidently that the problems of ethics and deontoloay among pediatricians are the most complicated ones if we speak about all doctors. It is caused the by the following factors. The younger the child is, the more he/she differs from the adult person in their anatomic-physiological features. As these differences bases the pediatric deontology, it is very hard for a pediatrician to estimate health conditions of a child objectively, it is difficult to make diagnose, choose appropriate treatment and explain all this to the child's parents. Sometimes, the child of the junior as well as of the senior age cannot understand a doctor's question. It is especially important when the patient 1s in 13severe condition. That is why very frequently the doctor should ask questions in the form of conversation, watch the reaction of the child and clear up the situation if any doubts arise. Sometimes, it 1s necessary to rephrase a question making it more understandable and clear for the child | should be objective and have to admit that children of almost any age are afraid of doctors during the first contact with him/her. Therefore, a pediatrician should find such a way of communication that would enable him/her to remove a feeling of fear from the wide-open eyes of the child and make a baby calm While speaking to the child, a pediatrician should always keep smiling and this smile should be kind and frank. It is possible to attract the child of the first year of life with an interesting toy, short rhyme, gentle stroke, etc. Pediatrician should apply various techniques of conversation with different children. Alll this should be aimed at winning the child's trust. The child can often be worried and start crying during the first examination and it is considered normal, but if the child behaves the same may during the second or third examination, it may show that the doctor has not made a personal contact with patient, and thus he/she cannot be viewed as a high-grade pediatrician. Children of the senior age are sometimes inclined to dissimulation: they may be afraid of injections, physiotherapeutic procedures and some methods of examination. They may not understand the danger of their disease and therefore, they may unreasonably conceal the signs of the pathology, in spite of the fact they were already determined during examination. That is why, it is necessary for the pediatrician to be very attentive while talking to the patient, to get into contact with him or her, win his/her trust, not to be in a hurry and sometimes not to be limited with just one professional conversation with the patient. By the way, in Kyiv Rus the word ‘doctor’ had a synonym which is translated into modern language as ‘fo tell ies’, but in ancient times, the word just meant ‘to talk’. So the doctor was considered a person, who has the ability to talk and influence a patient with the help of his words. Complications of different character quite often arise while speaking to parents. While asking questions, speaking to and curing a sick child, it is necessary to realise very well and always keep in mind that children are the dearest people for their parents and that is why neither a mother nor a father can stay calm when their child is ill. involuntarily, they can answer a doctor's questions wrong. They, parents, should be asked very attentively as well and sometimes it is necessary to ask a question more than once. You should be very tolerant and calm at this. Besides, it is necessary to understand that parents are worried and excuse their possible rudeness and harsh words during the conversation if their child is in a severe condition. If you are a wonderful doctor, you will cure the patient, and in that case, very often, the parents ask you to forgive them for their hot temper during 14the first days of treatment. Thus, parents are always worried when their child is ill, and they will behave differently depending on the character of disease. A doctor should always be an intelligent (in fact, in Latin intelligens means informed, clever and competent) and educated person who will understand every relative of the child and help him/her. The following Latin saying describes this situation the best: “Dixi et animam levavi” — “I said and thus | relieved pain’. While questioning it is necessary to observe all the rules of ethics. | will tell you about some unsuccessful cases from my own practice. Earlier in my life as a practitioner, while trying to get use to the rules of addressing children and their parents, | always began my questions with, “Well, what has happened to you, my beauty?” ( all litle children are so beautiful, aren't they?) One day, a parent brought their five-year-old girl for consultation because she had pneumonia, unknown to me, this girl suffered from Down's syndrome and had some anomalies in her physical appearance, and as usual, | automatically asked: “Well, what has happened to you, beaut..." had not finished the last word, when i realised my mistake and there and then, | felt really ashamed. From that moment, when | meet patients and their parents for consultation, | always recall this event involuntarily and try not to repeat the same mistake again. There was another case like that. One day a woman came with a boy of six years old. She looked rather elderly — about 60 or in her early sixties, Being ‘sure of this, while filling in the passport part of the case history, | asked her, “Are you his grandmother?" The look of that sad woman, who was exhausted with the constant diseases of her late-born child, became even older and she replied, ‘He is my son. | am fifty years old”. | blushed, bowed and remembered it for ever. Dear students! Mistake is a father of experience. Learn from other people's mistakes. The most difficult part in personal contact with parents and relatives of the child are cases when medicinal help is not effective. These are malignant diseases, post-traumatic conditions, etc. If we speak about newborn children, we should state that the first babies who were born by mothers of senior age die more often (very often miscarriages, still-born, cases, etc. could have occurred before). It is an unspeakable sorrow to lose a child of school age when he or she became the dearest family member. It is a very difficult moment for the doctor too — he/she must be the first to prepare parents for lethal endings of their child that approaches or to inform them about it when it happened. There are different people among doctors too. And the pediatrician who treated the child 1s sometimes unable to have such a difficult conversation, especially if the doctor 1s young, especially if the doctor is a woman, and also if tl is the first case like this in medical practice of the pediatrician. The rules of ethics, mutual understanding and the desire to help each other should also 15be observed among colleagues in the department. So, taking into account the high level of humanity, such conversations with parents are held by one of the doctors who is your colleague. Parents may be mistaken and think that their child requires more attention of the doctor in comparison with other patients. In that case, it is necessary to explain to them confidently and objectively that their child receives all necessary attention, and that he or she is not the only patient in hospital. To observe all the rules of ethics and deontology, there are some more issues of organization of character which should be taken into account by the future head of the child’s care hospital: (a) There should be at least one colleague of senior age among the staff of the pediatricians if a department is small, or at least a couple of such colleagues in a bigger hospital, whose experience will be necessary in cases of emergency concerning emergency medical treatment and talking to parents if a child is in severe condition. (b) To keep positive deontological relations among all doctors is necessary: * Even if a doctor makes a mistake while curing a child, none of the colleagues should tell the child's relatives about it. Itis not right to ‘lure away’ a patient from his/her doctor. Itis necessary to help your colleagues, especially young ones, in curing patient with a serious disease and not to advertise yourself to parents or to other doctors. No matter what kind of professional reprimand may come form a senior professional to a junior one (a doctor or medical personnel of the medium level), it should not be done in presence of the patients or other employees. While examining any mistake, it is necessary to show maximal care and exclude the abusive and negligent tone, which affects a person's dignity and hurts the doctor who made a mistake. When N.I. Pirogov was relatively young he wrote a book about his mistakes for other medical people to learn them and not to repeat them. He wrote about himself, nobody was humiliated. * As it was already stated above, sometimes, it is necessary for the doctor to be the first who tells the parents about the hopeless condition of their child. (c) Special attention should be paid to the organization of work in the admis- sion department: * There are cases when parents flatly refuse to hospitalize their child; nevertheless, if the disease of the child demands it, it is necessary to do your best convince them to agree to hospitalization; sometimes it is necessary to organize a consultation of several doctors for presenting More convincing proof to the parents, that hospitalization is absolutely 16negessary for successful treatment of their child and it should be carried out in the surgical department or even in the reanimation one. The problems of deontology get special value while examining and working with patients who are in terminal condition. If after the examination of such a child, a doctor still thinks that the diagnosis may be wrong and it may result in inadequate treatment, he/she should by all means ask a senior and more experienced colleagues for help, and if they are absent, he/she should talk even to junior colleagues if only it could help the patient. Such behaviour will never have a negative influence on the doctor's authority. On the contrary, when the patient is cured due to the mutual efforts of the whole team, the authority of the doctor will be incontestable both among patients and among medical personnel. First of all, the parents of the child will be very pleased with the doctor's victory over the illness, which will make the doctor highly respected among the people in future. Sometimes there may be more than one child with their relatives who want to get into the hospital at the same time. Such situations very often irritate parents; in this case it is necessary to excite the children's curiosity with some fascinating books, toys, etc., to explain the situation, and first of all hospitalize the children who need it badly. While working with children and their parents, a pediatrician should always remember that he/she can be provoked, but it is important to remain calm and keep ones feelings to oneself, for this is essential for the succesful treatment of the child. Then, the appropriate contact and attitude of parents to the doctor will appear. However, it is very difficult to do. A.P. Chehov said, “To feel your helplessness at the bed of your patient, to hear the accusation of relatives like ‘he has been doctored to death’ which are at least unfair, to understand your own mistakes and punish yourself for them, as there is no doctor without mistaken, — all this is very, very difficult”. Thus, deontology is a science about aesthetic and intellectual image of a medical doctor, about his humane debt to all people and to every patient separately. And while ‘paying this eternal debt back’, during all his/her professional life, a doctor should be on good professional relations with his/her colleagues in medical departments, keep up humane relations between medical workers and patients and their relatives. A pediatrician should devote him/herself to fight for children’s health from the moment of their birth, achieve high professional level, be an example of self-management, firmness, dignity and respect to the patient. Only when all these norms of ethics and deontology are achieved, the doctor deserves his/her patients’ respect and becomes a specialist of great worth. And to finish this section, 1 want to use the words of A. Kempinskiy: “In medicinal product is the doctor himself”. 17GENERAL QUESTIONS OF PEDIATRICS SERVICE AND NURSING OF THE CHILD The most devastating and wides- pread diseases, against which therapy 1s powerless can be prevented by hygiene. G. Zacharin Pediatricians are a diverse group of doctors of many specialties. Just like the doctors engaged in the treatment of adults, there are surgeons, hematologists, nephrologists, cardiologists, immunologists, etc for children. Among pediatricians, there are very specific specialties which are not present among medical doctors working with adult patients, for example, neonatology — treatment of children from birth to the 28" day of life included. Good organization of work of each medical institution is based not only on high-quality work of a doctor, but also on proper work of assisting medical personnel. Each doctor must know the rules and peculianties concerning the work of all subordinates as well as being able to supervise work in a hospital. The significant part of this unit is meant for comprehension during in-class sessions, while being in pediatric departments of hospitals, occasionally, some issues are to be learnt with the help of medical personnels or a teacher. Finally, acquired knowledge should be backed up in a hospital during summer practice TREATMENT AND PROPHYLACTICAL INSTITUTIONS FOR CHILDREN In Ukraine, there are some types of treatment and prophylactic institutions for children. Pediatric department at a maternity hospital. Pediatric polyclinic is an institution for treatment and prophylaxis of children outside the hospital (at home) before they turn 18 years old (according to current data). The number of polyclinics depends on the population of residential area (the bigger the city, the more polyclinics it has). A polyclinic may be incorporated with children’s hospital and may be an independent institution. The polyciinic is attached to a certain territory which is divided into districts. Children of each district are attended to by a district pediatrician together 18with district nurses. One district should have not more than 800 children, not more than 60 children of one year of age, one pediatrician and one and a half (1,5) district nurses (for two pediatricians, and three nurses). A principle document — “History of the Child's Development” — is compiled by doctor and nurses for each child from his/her birth till he/she turns eighteen years old. This document contains all information about the child's description of life and health condition. “History of the Child's Development” begins with a discharge note from a maternity hospital. If a child arrives from other cities or villages, his parents are obliged to submit available history of development from the place of their previous residence to a polyclinic. When the child turns eighteen years old, the history of development is transferred to a polyclinic which attends to adult patients. “History of the Child's Development" is drafted to ensure the continuity in the activities of various structure of pediatricians working in the polyclinic: due to an exact plan, various specialists consulte all children (e.g neurologist, surgeon, dermatologist, ophthamologist, etc.). Due to the work of all medical personnel, the following basic functions of a polyclinic are performed: 1. Medical work: (a) Medical examination of children performed by a district doctor and Subject specialists in the building of the polyclinic (5 children per working hour). Parents can call doctors, i.e. consultation by a district doctor at the homes of the children (one and a half visit per hour). Conclusion about treatment is made on the basis of check up. If necessity occurs, a child's treatment can be carried out either under home conditions or the patient may be sent to a children’s hospital; all data are put down into the “History of the Child's Development”; in case of hospitalization, all information about treatment (‘Discharge form’) comes from a medical institution to a district doctor after discharge from hospital. 2. The purpose of prophylactic work is prevention of possible diseases and disorders in the development of child: (a) Precautions begin with the antenatal care, 1.e. with visiting a pregnant woman in domestic conditions; a healthy pregnant woman is visited by the district nurse twice: the first time (patronage) between the 20" and 23° week of pregnancy, and for the second time (patronage) between the 32° and 40" week of pregnancy; doctor's patronage (the third) is carried out by the doctor individually if any necessity occurs (abnormal Pregnancy, diseases of a woman, poor living standards, etc.). (b) (© 19(b) Observation of child proceeds after birth: « During first month of life — in-home observation (see “Introduction of neonatology”) * During first year of life — once a month. * During second year of life — once per quarter (quarter = 3 months), i.e. four times per year. * During third year of life — twice a year. * During 4-5 years of life — once a year. ‘* During sixth year of life— twice a year the child is examined by a district doctor and specialists in a polyclinic. Decisions about physical, psychological, intellectual and other parameters of the child's development are made on the basis of these examinations. Ifnecessary, different methods of examination are prescribed; special conversation with mothers carried out, etc. Thus, the "History of Child's Development” contains all information about state of health of growing generation. 3. Anti-epidemical work is a complex of actions aimed at timely diagnosis and prophylaxis of infectious diseases. Basic moments of anti-epidemical work are: (a) Vaccination (b) Observation of vaccinated children, especially if post-vaccination complications (allergic reaction, etc.) are present. (c) Diagnosis and treatment of patients with infectious diseases, and if necessary — their hospitalization. Children’s hospitals for children till 18-years of age are divided into: (a) According to the territory they serve: ‘* Municipal, * District. * Regional. « National. (b) According to the variety of departments: + Multi-departmental (one hospital contains departments of different specialization, i.e. prematurely born department, cardiology department, surgery department, etc.; these are usually regional children’s hospitals). * Specialized (children with one group of particular diseases are cured there, e.g. hospitals for curing infectious diseases, etc.). (c) According to a principle of organization: « Incorporated with a polyclinic. * Without a polyciinic. (4) According to the volume of work (it depends on a number of beds, i.e. a maximum number of patients that can be properly served in a department al the same time. 20(e) Clinic is a hospital where not only medical treatment but also research work and training of students, are carried out. Usually one doctor-pediatrician cures 20 children. In serious and severe cases (for example, in regional hospital, in reanimation department=intensive care unit) the pediatrician cures from 5 to 10 children. In children’s hospital whose main function is medical work, responsibilities of medical personnels include the following stages: * To accept patient and if necessary, to render the urgent help. * To prescribe all necessary analysis and examinations. * To diagnose correctly and quickly. * To carry out all complex of medical measures. * To strengthen the immunity of the child against repeated diseases or possible relapse of chronic pathology. * On the day of discharge, to prepare a “Discharge form’. Dispensary is an institution for treatment and prophylaxis where children with a certain group of diseases (for example, antituberculous, endocrinopathic) are examined, constantly observed and treated if necessary. Children's health centre is an institution for treatment and prophylaxis that are located in appropriate resort zones (in Ukraine it is Crimea, Carpathian Mountains, etc.). Sick children are sent there for the period of 1-3 months or longer if necessary. The children are cured there by specific methods. For example: (a) Climate therapy — a child stays under conditions of seaside climate (it stimulates organism, improves characteristics of blood and raises appetite). (b) Thalassotherapy — treatment by sea water which is effective if there is delay of physical development, diseases of skin, nervous system, respiratory tracts. (c) Mud cure — has anti-inflammatory, de-sensiblization, immunological, etc. effect. (d) Estuary cure — itis very effective in diseases of metabolism, nervous system, rheumatic fever and polyarthnitis. (e) Sand baths — is similar to mud cure. (f) Balneotherapy — is using medical mineral waters that promote treatment of cardiovascular, nervous, urinary and other systems depending on its contents. 21= —— Fig. 1 Orphanage home, A roam for group of children of age 3-4 years old Institutions that also render treatment and prophylaxis, mainly preventive, include: (a) Kindergarten (in Ukraine) are attended by children fram 3 to 6-7 years, when parents are at work. (b) Orphanage home (= children's home) (Fig. 1) is an institution for the children of preschool age (from the first month of life) who for different reasons can not live with their parents (e.g. parents are mentally relarded, parents died, children were abandoned, etc.). Basic statistical data of activity of children's treatment and prophylactic institutions are: Level of birth rete = Number of children born alive during ene year * 1000 Average annual population Number of children dead during the first year of life in a given year *1000 Mortality (= Children's) rate (infant death) = {number of children's death. 2/3 born during the first year of life) 1/3 born alive in the previous year ive in the given year + 22Infant mortality in our country ranges from about 10-15 %e (%he = per mille — a unit of measurement equal to 1/1000 of 100% = 1/10 of 1%). In 1995, this figure was 14.7 %o. During the past 10 years, these parameters have fluctuated and in 2008, it was 10.36 %. Vinnytsia region characterized by one of the lowest rate — 8.18 %e in 2009. However, the infant death rate in Ukraine is approximately 1.5 times lesser than any other country of CIS; but, unfortunately, it is 2-7 times more than in countries of European Union. Number of children dead at the age Death rate of children of 0 to 14 years during the given year aged from0to14years= —~ --- «1000 Average children’s population younger than 14 years General number of diseases registered first Morbidity rate = time in one year *100 Average annual children’s population Number of diagnosis at the direction not Quality of diagnostics at coinciding with clinical diagnosis x 100 prehospitalization stage= ~~ a (i.e. diagnosis made by district Number of patients discharged from the or other doctor of polyclinic) hospital Concept about health of children For estimation of the health of children till 3 years of age, 5 criteria are established: (a) Condition of physical development. (b) Condition of psychomotor devel 23(c) Feeding of the chuld. (d) Functional condition of the main systems. (Respiratory, Cardiovascular, Urinary, etc.) (e) The degree of resistibility and reactan: in nism — i.e. how the child endures possible viral and bacterial diseases (e.g. influenza, bronchitis, etc) Medical report defined the term ‘health’ as a condition where results of all necessary medical examinations have proven the abscence of diseases and traumas. (Order of Ministry of Health of Ukraine Ne 149 from 20.03.2008). However, we should take note that “health” — is (a) state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (WHO). According to current data, some children under 3 years especially due to their social factors can be highlighted by pediatricians into the so-called risk group. These are children from families who find themselves in difficult circumstances (adverse moral and material living conditions). WORK IN THE CHILDREN’S HOSPITAL Reception The child directed to a hospital gets into a reception room where his initial examination will be carried out. The appointment card (= direction letter = referral note) (Fig. 2) may be given by the polyclinic doctor, the specialist, or the family doctor; the patient may be delivered by the ambulance. Only patients in severe condition can be accepted without an appointment card. In an appointment card, the full name, age, permanent address, preliminary diagnosis, if possible — the data of the carried out inspection, and also date, surname of the doctor and a medical seal or a seal of the establishment are given. Besides, with th of preventiv infectious disease in the non-infectious hospital, the information about the child's contact with infectious patients is necessary to be indicated in the appointment card, as well as possible infringements of stool (‘yes' or ‘no’, if ‘yes’ — then we should find when there was a contact with an infected person, as each infectious disease has its own incubation period — this is known by the doctor). At the presence of contact of a patient with a child with infectious diseases (in case of obligatory hospitalization) He/She will be admitted in the special isolation ward or will be transferred to the infectious department. 24: City children's hospital # 3 Appointment card Borody Oleg lv., 2 years old, the address is: Solnitchnaya str., 14/92, goes on hospitalization. The diagnosis: Acute Bronchitis. Iron deficient anemia of 1st degree. The general blood analysis on 14.12.2010: RBC — 3.4 T/L, Hb — 92 g/L, WBC — 10 G/L, ESR — 12 mm/hour. No contact with infectious patients, infringements of stool are not present. 15.12.2010 Sign. and stamp of local doctor Fig. 2 An appointment card to the children’s hospital If the child is delivered into the department without parents (in cases of accident, trauma, sudden significant deterioration of the health state), the information of hospitalization should urgently be told to the parents of the patient or the local police station should be informed for the search of the parents incase the child's health is deteriorated. In children’s medical establishment, there is an independent reception with separate medical personnels (doctors, nurses). In small children’s hospitals, the child is accepted by the doctors on duty in the children’s branch or the pediatricians occupying the post of the doctor on duty in the hospital, sometimes. local doctors do it. Reception of the patient should be carried out according to the following standard obligatory plan 1. Registration — First the nurse fills in the data concerning the patient in the ‘Admission register’ or ‘hospitalization register’, (date, full name, age of the child, the address, the diagnosis in the appointment card) and draws up a passport part in the case history (see Appendix # 1). Simultaneously, the child’s body temperature is measured and later examined by the doctor on duty. The specified order is broken in case when a condition of the patient is severe and demands urgent help. 2. Doctor’s examination (collection of complaints, the anamnesis of diseases and life, the estimation of the child's condition, etc.) 1s carried out in 25approximately 20-30 minutes depending on the disease and seriousness of the condition of the child. Then the doctor (in our country personally) writes down all received data in the case history. At the end of this, the preliminary diagnosis, a plan of the inspection of the patient and his treatment are indicated (the list of medications and medical procedures) 3. After examination by the doctor and the case history 1s filled, the nurse carryies out it e: jent: * First of all, the hygienic condition of the child (by examination of the neck, ears and all surface of the skin, nails on the fingers and toes, as well as the hair) is checked. * Incase of long nails, they should be cut. * At diagnosis of pediculosis, the appropriate processing should be carried out (see pg. 33) * Then, if necessary, according to the prescription of the doctor, the child takes a hygienic bath or shower. Attention! In case of severe condition of the patient, sanitary processing should be carried out only after rendering the urgent help and with the permission 4, After reception, the child is transferred to an appropriate department. The kind of transportation is defined by the doctor depending on the condition of the patient: * If the state of health of the child is satisfactory, then he/she can go to the department independently under the nurse's supervision: ‘* Children of the first-second year of life are carried on hands. * The medical staff transports heavy patients on stretcher, carriages (Fig. 3), etc. «In absence of carriages, lift escalator or elevetor, the child of an advanced age can be transferred on the bed sheets or blanket. Transportation of the patient comes to an end with the case history and the prescription form (the plan of treatment and inspection of the patient): « To.a nurse from the child's department (if a condition of the patient is not severe, in evening-night shift). * To the doctor on duty (in the afternoon; if the condition of the patient is very serious at any time of the day). If the child is under 1 year of age, feeding schedule is also prescribed. Besides, an additional verbal communication with the department about the condition of the hospitalised patient is necessary. 26Fig. 3 The carriage Simultaneously we a consider kinds of possible transportation of the (Attention! It may be only if the condition of the patient allows transport nanined * By ambulance. + Sanitary aircraft— by plane, helicopter (in mauntainaus place, for urgent transportation to far distances). + Inemergency cases — any road transport. Except the specified function of a reception room (reception of patients and their hospitalization), it has one more function — the registration of the movement of patients in a medical establishment. With this purpose, the medical staff fills the follawing documents: (a) Hospitalization register. (b) In case parents refuse hospitalization, the data on the patient are written down in special refusal register; besides, at refusal, in some cases (such as infectious disease and severe condition of the child), the doctor in the reception must inform the local doctor and the school where the child studies (the kindergarten) about the situation. (c) Discharged register of the patients. (d) Register of transferring to other hospitals. For example: after significant deterioration of the condition, the patient from the small city hospital is transferred to reanimation department (= department of intensive therapy = intensrve Care Unit — ICU) of the regional chidren's hospital, the child from cardiological branch is transferred 27to surgical branch in connection with the development of acute appendicitis, etc. (e) Register of fatal cases. Itts clear that the list of patients in the 1* journal should be equal to the total amount of patients in the last three registers. Medical department During all the time of stay in a hospital, the child is treated in the medical department. intotal, the hospital may have from 1-2up to 10 and more departments depending on its size. In one children's department, there may be patients with different uncontageous diseases (rheumatic fever, pyelonephritis, gastritis; in the same branch, only in a separate chamber, patients with bronchitis, pneumonia, etc.). There are specialized hospitals in which children with diseases of one system (cardiological, gastroenterological, hematological, etc.) are treated. he main objective of all medical personnel in the department is an operative inspection of the patient, the timely statement of the correct diagnosis and, at an opportunity, the full treatment of the child or (in case of incurable disease) realization of the necessary complex of medical actions for the patient. Structure of the children's department The department consists of isolated ward (= chamber = room — in some countries) sections; for children of the 1* year of life, there should be no more than 24 beds, over one year — not more than 30 beds. In one ward there may be accordingly 1-4 and 4-6 beds. The best for the children of breast-feeding age are box wards, when every child has his own ward which prevents possible infections to other patients. Till this time, in some hospitals, according to the old rule there are wards which may not be very effective half-boxes with wooden- glass partitions only between beds. Hygienic requirements in wards are: The distance between beds should not be less than 1.5 m. Every child should have a personal bedside table and a case for clothes. In each ward, one quartz lamp should be hung. If there is no separate toilet near the ward, then the presence of a washbasin with cold and hot water is necessary. Generally, the structure of the children's department comprises of: * The department manager's room. * Duty room — a room for the doctors work. 28* Argom of the senior nurse. * A post of the attendant nurse (on duty) (Fig. 4); for the convenience of constant supervision, it is often located in corridors of the department; near the table of the nurse, there are some hospital shelves in which the most necessary medicines and medical tools are kept. Fig. 4 A post of the attendant (an duty) nurse * In the department, there is nurse's room for inter-muscular injections, eye dropping and other medical procedures, in which, by obligatory tules, medical products and tools for manipulations are kept in the safe, feffigerator or in usual shelves. + Aseparale (") manipulation raom for intravenous injections. In the branch, usually there is @ special separate room for specific a t ction (for example, ‘for intubation of the patient, acarinate by the ENT-doctor, the urologist, and the gynecologist, etc). * A physical procedure cabinet (inhalation, electrophoresis. etc.). . Adining room. * Arest room for the doctor on duty. . Bathhroom. Altollet (Separate for medical staff and patients). 29Sanitary-and-hygienic and anti epidemical regime Sanitary-and-hygienic and anti epidemic regime is the extensive complex of actions which are carried out by all employees of the medical personnel, and also by patients, the purpose of it is maintaining infecti 7 “The following rules are included into the structure of these actions. As it was mentioned above, in an appointment card, the doctor should specify the data of the contact of the child with infectious patients. Despite of the anamnesis written in the refferal form, a doctor at a hospital to which the patientis reffered, has to enquire on the epidemiological anamnesis ‘once more (see pg. 80). As for the tactics of the doctor in case of the positive anamnesis you, students, already know it. Even if the epidemiological anamnesis of the child 1s not aggravated, the patient needs to be examined carefully in a reception to avoid an infectious pathology. Sanitary procedures which should be primarily carried out at reception lasts during all the time of stay of the patient in a hospital. If mother is in a hospital, then once a week, she will cary out the procedures in place of a nurse. Every week each patient takes a hygienic bath. in the department, bed sheets and clothes should be changed in due time. The frequency of the change depends on the pathology, age of the child and his condition. Furniture and the object of common use (couch and pillow on it) should be covered with polyethylene film which is wiped up by 1% sol. of chloramines oF 0.5% sol. of chloride of lime 2 times after every patient, with an interval of 15 minutes, and after that with water. Sterile disposable film sheets can be used. Simultaneously after every patient, the bed sheet on a couch are changed. The medical staff should observe the rules of preparation and distribution of food, and patients — rules of eating food. Usually, itis prepared in a special room. After delivery to the department, it is possible to keep food stuffs in a separate foom not longer than 2 hours. Portions are given into a dining room through a special window. The utensils are exposed to special processing after use. There should be drinking water for patients. All workers of the department are obliged to observe the rules of personal hygiene, as well as every patient is obliged to carry out all rules of personal hygiene (see pg. 34). 30One of the main anti-epidemic actions is disinfection which helps to prevent the distributions of microbes of illnesses in the hospital and their destruction. The disinfection can be: (a) Preventive. (b) Carried out in the epidemic center which is divided into: * Current. * Final Preventive disinfection is a_complex_of actions for preventing the accumulation and distributions of activators of diseases in the hospital. Preventive disinfection should be carried out by the following ways: 1. Ventilation of wards — four times a day. . Quartz (UVR) wards 2 times for 15 minutes. 3. Vacuum cleaning or shaking out in the fresh air of soft things (e.g. mattresses, blankets, curtains, etc.). 4. The complex of preventive disinfection includes the above mentioned tules of the observance of hygiene by medical staff and patients, and also the rules of preparing and distribution of food. 5. Wiping at least 2 times a day (in some departments — more often, for example, in the infectious one — 4 times a day) the floor, windows, furniture, toys with specially prepared solutions, for example: (a) Chloride of lime (now rarely used) — fine powder of white color, it is necessary to keep it in the dry pack protected from the light; only the patient's excrements are disinfected with this dry powder. Chloride of ime in the liquid form is made and applied as follows: « At the beginning, a special 10% or 20% solution is prepared (so-called ‘clarified’): the necessary quantity of the dry powder (for example, 1 kg to 10 L of 10% solution) is stirred in a smaill amount of water, then gradually, water is added up to the necessary volume (in this case — up to 10 L) and at constant stirring, till the formation of homogeneous mix is achieved. The received structure is covered with a lid. * Approximately in 1 hour, the mix 1s mixed up once more, in 1 hour — once again, and after 1 hour — once again; thus, within the first 3 hours its mixed up 3 more times. * In 24 hours, from the beginning of manufacturing, the ready clarified solution (in this case 10%) 1s poured out and then kept for no more than 7 days in enameled, wooden, metal (protected from corrosion) well-closed basin. if calcul: f nt ~ 500 g of powder and water up to 5L = SL of the 10% solution a1~ 2 kg of powder and water up to 10 L = 10 L of the 20% solution * At work, the so-called working solution 1s used 0.5-1%, which 1s made by the necessary dilution of the clarified solution Exe Ne f calculation ~ 1 L of the 10% main solution + 9 L of water = 10 L of the 1% working solution ~ 1L of the 20% main solution + 19 L of water = 20 L of the 1% working solution ~ 500 mi of the 10% clarified solution + water (up to 10 L) = 10 L of the 0.5% working solution * The working solution can be used no more than 24 hours. * For cleaning windows, the floor, furniture, toys, etc. 0.5% solution of chloride of lime is used. (b) Chioramines B (in dry form, it is a powder of white color) — for usage, 1% solution is made by gradual stirring of the necessary quantity of the powder, first in a small volume of hot water (50-60°C), and then adding more and more water up to the necessary full volume (for example: 50 g of powder and 5 L of water). To store a solution is possible no more than 5 days. (c) Dezaktin — dry powder mixed in water for 1-2 minutes. for the formation of 0.1-2.5% solution which is used for the current and final disinfection. When water temperature is 60°C, there will be an accelerated dissolution of the medium (for concentrations over 0.5%). You can save 24 hours. The current disinfection is a complex of actions for the reduction of infection in the whole room near the centre of the infection. For example: in the child's department (non-infectious) on the 1* floor of ward # 4, a child who is hospitalized for the treatment of pneumonia, suffers from salmonellosis as well; the current disinfection should be carried out on the territory of the whole 1* floor. Three kinds of disinfe f 1. Chemical — for disinfecting toys, furniture, windows, the floor etc. with disinfectant solutions of high concentration — 1% solution of chloride of lime and 2% solution of Chloramines. 2. Physical — boiling subjects (pans, dishes, etc.) in water; the addition of soda or some laundry soap (10-20 g in 1 L of water) is effective. 3. Mechanical — washing the linen, removal of dust and dirt with a damp duster. ___ The final disinfection is an utter elimination of the activator of a disease in the centre of the infection (according to the given example, in ward # 4 it 32is necessary to carry out not current, but final disinfection). Thus, the above mentioned concentrated liquid disinfectant solutions, dry powder are used. Many subjects (footwear, books) are processed in disinfection wards. Louse infestations (= pediculosis) is an attribute of untidiness, infringement of the rules of hygiene by a person, and also non-observance of the sanitary- and-hygienic regimen in a hospital. Let's recollect biology: three kinds of lice can parasitize a person — head, crab (= pubic) and body (= clothes) louse (the name specifies the place of their localization); simultaneously there may be nits (= eggs), larva and mature (= imago). The survey on pediculation is done by the nurse in a reception room. As there are three kinds of lice, the appropriate parts of the body and clothes of the patient are exposed to survey. At detection of pediculosis, medical tactics can be different depending on the condition of the patient: 1. If the child is well (for example, parents brought him/her to the hospital with the purpose of some non urgent operation), he/she is usually sent home for elimination of lice, then hospitalization is allowed. 2. If the child needs hospitalization, but his/her condition is not very serious, in a separate room of a reception, the special processing of the patient should be carried out, then the child is transported to the ward. 3. If the condition of the patient is severe or very severe, first of all, the treatment of the basic disease is carried out, and the processing is made after the improvement of his/her condition and only with the permission of a physician (in this case, it is necessary to observe special rules for the warning of distribution of lice among other patients, especially before processing, — the patient is put into the separate ward, there should be a scarf on his/her head, etc.) The technique of eliminating process of the child at revealing hi : (a) It is possible to shear hair (it is usually done with boys — an ideal momentary way!) or to process the head of the patient with one of solutions used for such a purpose: Lotions ‘Nittifor’'Miloca’, ‘Lanchet’, special shampoos, etc. (b) After processing, the head is wrapped up with a polyethylene bag, then a scarf is put on it; in such position, the child stays for 20-40 minutes (according to the instruction). (c) Then, the head is washed by hot water with laundry soap. (d) The next moment is the most scrupulous one; it is gradual combing of the patient’s hair with a fine-tooth comb with a piece of cotton wool (moistened in 9% vinegar solution). (e) The head is swilled with a lot of water. 33Cut off hair, and the hairs cut should be put on an oilcloth and but. At revealing only nits, it is possible to apply more simple solution: the hair is processed with warm (30°C) 9% solution of vinegar, then for 15-20 minutes, the head is wrapped up with a scarf, after that, the hair is combed out and the head is washed. The clothes on which body lice are revealed should be packed into a polyethylene bag and sent into the chamber for disinfection. RULES OF HYGIENE Special features of the medical personnel hygiene Dear students, surely you know all the rules of personal hygiene of the medical personnel, therefore they are only listed here: « Tidy appearance. * Astandard medical smock (coat). « Acap ora kerchief on a head. * Short nails. « Special hospital footwear which is easily disinfected (for example, leather). Hands well washed up with soap. * To medical sisters and doctors engaged in surgical manipulations, watches, rings, varnish on nails are forbidden. * According to indications (the maternity, infectious department, epidemic of influenza, etc.) a mask is put on; it is necessary to change a gauze mask every 4 hours; at an opportunity, it is better to use disposable sterile masks. Rules of hygiene of patients in the children’s hospital The hygienic condition of the ill child is watched by mother and medical staff of children’s hospital. The rules of personal hygiene of the patient older than 4 year include: 1. Care of the appropriate parts of the head and the trunk: (a) Washing — 2 times a day, in the morning and in the evening, according to indications (intake of food in horizontal position, the child in a serious condition, etc.) the amount of washing procedures should be increased. This, as well as all other procedures, is carried out by a matured child 34himself if he/she is not in a serious condition; the child in a severe condition is washed by his/her mother or nurse. (b) Cleaning teeth with a brush — 2 times a day; itis necessary to teach the child to clean his/her teeth correctly: to move a tooth-brush on the vestibular and the lingual surfaces of teeth from the top downwards and from below upwards from both sides; and on the surfaces of the closure of the teeth. (c) The sick child should rinse his/her mouth after each reception of food, especially during diseases of the mouth (stomatitis, quinsy, pharyngitis); it is rational to rinse the mouth with 1.5%-2.5% of soda or 1% of salt solution. (d) It is necessary to wash ears every day. If there is some ear-wax in the ear canals, the nurse cleans the patient's ears in the following way: 3-5 drops of the 3% solution of hydrogen peroxide or sterile Vaseline oil are instilled into the ear, after which the wax plug is removed with the help of cotton-buds. (e) Eyes are washed without special assignment 2 times a day. If the patient's eyes turn sour, eyelashes stick together, itis necessary to wash the eyes with warm tea of strong concentration (brown color), moving a piece of gauze moistened with tea, from (Attention!) an xter ner the ris (f) As for nostrils, the child of the advanced age usually clears them out himself/herself. With such a purpose, the nurse at first puts cotton-buds, moistened with oil solution (Vaseline, Glycerin) into nasal cavity, then for 2-3 minutes, the head of the child is pushed backwards, and then by rounding movements, clears nostrils. The nostrils are processed one by one. (g) The individual comb should be used for daily care of hair according to their length; to wash the head is necessary not less than 1 time a week. (h) The nails are cut once a week. (i) External genital organs are washed with warm water; to girls with the purpose of prevention of urogenital infections, the washing should be carried out (Attention!) from front to back. (j) Hygienic baths — once a week; duration of a bath for 2year old child is 8-10 minutes, after 2 years of age — 10-20 minutes. 2. Usually the clothes and the bed-sheets are changed once a week, in case of necessity (the patient is in horizontal position, after vomiting etc.) it is done the needed number of times. 35Changing clothes of the seriously il! patient should be carried out in the following order: « First, the shirt is removed from the head. + Then — from hands. * The clean shirt is put on first on hands. Then — on the head and trunk. In case of trauma or other damages to the arm, the sleeve at the beginning is removed from the healthy arm, then — from the injured one; and the sleeve is. put on the injured hand at first, and then — on the healthy hand and arm. In practice, the following r d the order of two methods of ch the bedding of the severely ill patient are applied: (a) Perpendicularly, « A bed sheet under the child is rolled up so that two bolsters are made: above the head downwards approximately up to the waist and from below from the legs upwards up to the waist. * The formed double rolled sheet is removed. * Aclean bed sheet in the similar form of two rollers 1s laid under the waist of the child across the trunk. * One roller upwards is spread, to the head (Fig. 5), another — downwards, to the legs of the patient; then the bed sheet is straightened smoothly on the bed. (b)Parallelly, * The patient is put sideways on one side of the bed. * On the other side of the bed, the dirty bed sheets are rolled lengthwise. * On the same side of the bed, but without any dirty bed sheets a cleen sheet is put on (Fig. 6 — A). * The patient is moved on to the clean sheet (Fig. 6 — B). + From the free side of the bed the dirty sheet is taken away, after that the clean one is spread out (Fig. 6 — C). Distinctive rules of hygiene for children of the first year of life 1. The care of the appropriate parts of the head and trunk: (a) Cleaning during the 1" month of life is carried out once a day (in the morning), on the 2°*-3" month and further — two times a day (in the morning and in the evening), warm boiled water is necessary; it is better to wipe the face with cotton wool. Since the 5™ month of life of the child, it is advised to wash him/her with water from the tap (temperature 18-20°C); the nurse or the mother washes the child. 36Fig 5 Method of change of the bedding for the severely ill patiant (perpendicularly) Fig. 6 Methods of changing the bed sheets for the severely #! pahent (in parallel form) Designations are in the text (b) Do.not wipe (!) (the mouth cavity of the baby because of its tendemess and probability of the mucous membrane getting easily traumatized(c) Ears are wiped during face washing, external acoustical canals are cleaned with dry cotton-buds only under indications. (d) Eyes, if necessary, are washed from the external corner towards the internal corner with a piece of gauze moistened with tea. (e) For cleansing of nostrils to the depth of 1-1.5 cm, a sterile cotton strand moistened with stenle Vaseline oil is used (a separate one for each nostril), then the canal is cleaned by quick rounding movements outwards. Attention! Unfortunately, inexperienced young mothers like to use match sticks for this purpose, which often results in trauma of nostrils. Techniques of medical procedures for eyes, ears, the mouth cavity etc. for a one year old child, which are carried out only by the trained nurses, are similar to techniques of all age groups. (f) Nails of elderly children are cut once a week. (g) The younger the child is, the more often it is necessary to wash him/ her, as it is done after every urination and defecation, it is necessary to use only water from the tap. The girl's genitals are washed in the direction from front to back. After that it is necessary to wipe and grease the skin with sterile oil (sunflower, special children’s cream, for example Johnson & Johnson). (h) Obligatory rules for the hygienic bath: * Frequency — the first bath is usually done on the 2 week of life, when the remains of an umbilical cord disappears and the umbilical wound has began to dry: during the 1* half-year — every day, during the 2°¢ half-year — every two days. « The bath is taken at specific times — not earlier than 1 hour after feeding or 40-50 minutes before it, and also 1-1.5 hour before sleep. After bath, the child needs 30 minutes of rest (ie. if the child bathe in the evening and eats for the last time before sleep at 24.00, the best time to bathe him/her is 11 p.m.). * Tubs (plastic, enameled) should be washed well before each bathing, especially for a one month old child, then rinsed with hot water. + Temperature of water: during 1" month = — 37.5-37°C 2-6 months — 37-36.5°C after 6 months — 36.5-36°C * The duration of one bathe during the first year is gradually increased from 3-5 to 10 minutes. * The position of the child: Inder 6 months — the child should be placed in such a position, that the head is a little bit higher than the trunk (water should not get into 38- the external acoustical canals). For this purpose, it is possible to put something under the head part of the tub (there are specially made tubs with the raised head part for it) or to hold the head of the child in the hand. Water is poured up to the nipples of the child, leaving the chest part open. After 6 months — in sitting position. * Step by step procedures: o Twice a week to wash with children's soap all the surface of skin, especially the folds (on the neck, between buttocks, behind ears, axillary, inguinal area, etc). © Raise the child above the water, to rinse him/her with clean water from a separate basin. © To wrap the child in to the sheet quickly to dry up all him/her skin accurately. © To grease folds with sterile oil. © To dress him/her up. 2. Attention! Now a days, most pediatricians (in our country too) think that there is no necessity to swaddle up a baby by a cloth from the first day of life; they recommend just to dress up the child with thin dresses, so that the movements of his/her hands and legs are not restricted (see “Introduction of neonatology”). Both in home conditions and in the children's department, for full observance of the rules of hygiene, the child from birth to 3 months of age should be provided every day with such a necessary complete set of clean linen: * 10-15 babies’ undershirts thin and warm (= first vests = baby's loose jacket). * 20-25 diapers (nappy) or 5-6 pampers (such or other kinds of artificial diapers) and due to the kind of diapers, 15-5 crawlers. « 2-4 hats or scarves «4-5 pairs of socks © 2-4 mittens For 2-3 months of age, the complete set of linen includes: * More amount of crawlers + Bibs By the end of 1" year — stockings. Usually, the swaddling of the child is carried out before each feeding after urination and defecation. At diseases of skin, the quantity of swaddling is increased. 39MEDICAL BATHS Medical baths are carried out according to the prescription of the doctor with medical and preventive purposes. By the level of immersing of th Kk into th , the bath can be: (a) General — the whole body is in the water. (b) Local — a certain part of a body is immersed into the water: * Half bath — only the lower part of the body is in the water (up to the waist) * Sitting — the lower part of the stomach and the upper part of thighs. (legs are outside the water) are immersed into the water. « Hand bath — one or both hands are immersed into the water up to elbows. * Bath for lower extremes — legs are immersed into the water. By the temperature of water, the baths are of. + Hot — 42-40°C «Warm = — 38°C * Indifferent — 37°C *Cool —33-30°C *Cold — —less than 20°C ‘The duration of _bath depends on its purpose and medical need The features of the basic medical baths are submitted in Table 1 All medical baths are carried out only at the prescription of a doctor. Special attention is paid to the patient in a severe condition. To them, as a rule, local baths are prescribed. During all these procedures, the nurse has to be beside. Even in case of the slightest worsening of the condition of the patient (increase in the frequency of breath, increased heart rate, unconsciousness,and anxiety) the procedure is stopped and the doctor is called. DECUBITUS Decubitus (= bedsores) are dystrophic changes of skin and subcutaneous tissues of necrotic-ulcerative character which occur in ints with severe conditions and weak patients lying in a position with fed movement for a long time (e.g. lying in bed or in arm chair). This prevents soft tissues from normal blood supply. In severe cases, necrosis may arise not only in soft tissue but also in periostium and bone tissue. 40Table 1 Medical baths Medical |Methods of carrying out| Bath's _| Time of pro- Bath | indications the procedure effect cedure [Frequency 7 2 3 4 3 6 ‘Starch (100 grams) dis- 7 Allergic | solved in cold water and |Reliavesitch-| 7 4 | man dally Starch bath| diathesis, | poured into 10 itres of | ing, softens | 7-10, | mes daily eczema water of and dries skin eae native days Table spoon of herb Bath tea in 1 glass of boiled i 10-12 extractor | {EIS | Wateris et tor tom |FeteVES RT 719 ios daly Bidens tri- utes for cooling, Dose is | MOetenk | minutes | or on alter- partitea 0.5-1 glass of herb tea native days per 1 bath 10-12 Allergic Relieves itch-| sesenan | dance, |2seemstertea rare | 70, sme eczema land dries skin ° native days 5% solution of Polas- Potassium | Allergic | sium permanganate is | Driesskin | 5 49 | 6-8times permanga- | diathesis, poured into water (heated| and act as an} "10, | on allera- nate bath | eczema | to 37°C)tillit becomes | antiseptic tive days light-pink. Each procedure 1s done No longer serene, (tarnay|Yceasrarpere| sumais | Man Mn jot water | diseases of metabolism, 4-6 times De | aeeese.e [adding hot water. Afar the| S'SPONET™ | hands, | oe ey SPk2'07 "bath, the cid covered | POMS Ino longer tat with warm bianket and hot 10-15 — beverages are given for lags ‘No longer Inflammatory Stimulates than 7 min —| Mustard diseases of |100 grams of mustard per} metabolism, | forhands, | 4-6 tmes bath | respiratory | 10 liters of water promotes |no longer that| every day system sweating | 10-15 — for legs Stimulates | No longer tabolism, | than 7 min- Bath with |Infammator| sey iethods of prepar- | “promotes | utes — for fatract of | ois038e8 Of | ‘ng path with extract of | sweating, | hands, pate latricari ipwatory Bidens tripartitea | used as pan | _no longer ry day chamomilla) system kaller and for | that 10-15 — relaxation | for legs aTable 1 (continuation) 1 2 3 4 3 6 50-200 grams of sodium chionde (lake salt or sea sall) is dissolved in 10 an ites of wator and heated Mies Ota nd eaiat | Stimulates | 10 minutes, | 45 20 Rickets, hy- 36.570 fo Ine Ft | metabolism, | procedure | ines potrophy | Procedure, YS, | promotes | becomes 1 7 rature 1s decreased every 1-2 temperature ws decreased) muscular |minute longer] °YG 1 to.35°C. Afterthe bath. | “tones | mevery2-3| %°¥" the child should be ies washed with fresh water which 1s 1°C lesser than thal used for the bath Rickels, hy- Sedates Potrophy, | > 3 mlof iquid pine ox- Coniferous | "M22" traction (or 1-2 grams of | n° ne” 7-10 | 152000 ont Jand function- ous system, alternative bath powder) is dissolved in 10] minutes al disorders stimulates days tres of water at 36°-37°C of nervous metabolism system 5 ers of liquid or 200 Bath with | Traumas of | oams of condensed con-| Pain killing Salvia offct.| locomotive |%2ms of condensed &< ae 815 12-18 nalis’ | organs | Senate is dissolved in | effect minutes | baths in dee age)] 100 ites of water at sail 35° -37°C. Bed-sores often appear if a child is not taken care of in a proper way. They occur because of disruption of blood circulation in the places that are most intensively pressed against the bed, squeezed or punched. This places include the occipital part, scapulae, sacrum, heels and elbows. Bed-sores arise: « If the child lays on an inconvenient bed. * If bed linen is not changed or smoothed out regularly. * If bed linen is not cleaned or changed after every meal . + If patient's skin is not cleaned with an antiseptic solution. Stages of manifestation of bed-sores include:(in the order of their appearance — see “Illustrated Appendix’, Fig 1): (a) Skin becomes pale. (b) Erythema and edema of skin. (c) Exfoliation of epidermis and formation of vesicle. (d) Necrosis of skin. (e) Infection may accompany the bedsore. 42Attention! It is necessary to remember the order of appearance of bed- sores characteristics, because a doctor should immediately be able to estimate how serious the case is and to choose the appropriate treatment. Taking into account the above-specified reasons, which lead to appearance of bed-sores, it is understood that their prevention process depends on the following procedure: (@) A clean, soft towel (preferably gauze) moistened with disinfectant solution (cologne, vodka, half-spirit solution, camphor spirit; 9% vinegar — 1 table spoon dissolved in 300 ml of water) is to be used not less than twice a day (even more often, if necessary) to wipe the whole skin of the patient, especially at places of skin folds and the above mentioned sites. After that, skin should be wiped dry. (b) You should timely: + Replace linen. * Smooth out (i.e. remove folds) the bed-linen. * Thoroughly remove all the crumbs from the bed linen after each meal. A child should be provided with a convenient bed (the best way is a functional bed (Fig. 210) Change the position of patient from time to time if it is not contraindicated, e.g. to turn patient on the right and then on the left side (it improves blood circulation). Itis good to puta specially made bag containing millet under sacral region. (c) id (e Ne ical it 1. If erythema and edema of the skin is present: * Delicate massage with a dry cloth should be applied (it improves local blood circulation). + UVR (Ultra-Violet Radiation) treatment of the damaged area should be carried out © If skin is macerated (Latin ‘macceratio' means ‘soften’), wash it with soap and cold water then wipe skin with spirit or powder it with baby talcum powder. Water-based ointment like ‘Levomicol’ can also be used. 2. dermis i i vesi — the area is treated by a solution of Viride nitens and covered with dry bandage. 3. Necrosis of skin demands surgical manipulation — necrotic tissue is removed and the wound is covered with a sterile bandage moistened in 1% solution of KMnO,; the bandage should be changed 2-3 times daily; after that, the clean wound is covered with ointment bandage (sea-buckthorn /= Oleum hippopheae rhamnordes/ oil, emulsion of syntomycini etc.) 43ORGANIZATION OF WORK OF MEDICAL PERSONNEL IN CHILDREN’S DEPARTMENT Pediatricians, medical nurses and hospital cleaners work in children's department in our country. Work of medical nurses and hospital cleaners It is possible to work as a medical nurse after graduating from medical school and also after completing third year of study at a medical college or university. Of course, you — as students — know such cases. However, | am frequently asked at my first class: "Why is it necessary for us to know the work and responsibilities of a nurse? The answer to this question is: “Because it will be you — doctors — who the nurse will contact frequently if he/she feels that he/she does not have enough knowledge relating to techniques of certain medical manipulations, rules of introduction and calculation of dozes of medicines. And it will be a great shame, if a doctor is unable to answer the question asked by a nurse”. Several medical nurses work in a children’s department. They carry out different duties: a senior medical nurse (= matron) supervises the work of all other nurses. Manipulation medical nurse is responsible for giving injections, post medical nurse must distribute medicines to patients, observe all patients, collect samples for analysis from patients, etc. Medical nurse performs physiotherapeutic procedures, etc. Usually in the afternoon, there are more nurses at work, than at night. If emergency situations occur, which may arise anytime, a nurse must know and be able to perform all recommendations of a doctor who treats or a doctor on call. The basic duties of nurses 1. Participation during the process of admitting patients into hospital. 2. Performing all recommendations assigned by a doctor (there is a special prescription form where a doctor has to write all the necessary analysis and manipulations that are to be done) (Fig. 7): (@) Distributing medicines to patients (in case the child is alone in a hospital, a nurse should make sure that he/she takes the medicine on time and correctly). (b) Dropping medicine into eyes, nose and ears. (c) Carrying out different manipulations (e.g. intramuscular, intravenous injections, infusion therapy, etc). 44(4) Measuring weight and height of children. (e) Collecting samples for laboratory analysis from patients (blood, urine, stool, nasal and oral swab, etc.), delivering them to the laboratory. When the analyses are completed, it should be taken by the nurse from the laboratory and attached into the case history. (f) Taking general of tients_and_carryin methods of treatment and examination of patient (feeding the child through a tube, catheterization of urinary bladder,and gastrointestinal tract as well as indirect massage of heart, etc. — all this we will study shortly). (g) Transporting patients for radiography, spirography and other kinds of specific examinations, physiotherapy, consultations with subject specialists, etc., and timely submission of all the results after performed analyses and conclusions with subject specialists to a doctor. (h) Calling specialists for consultation from other _departments_of hospital. (i) Carrying out hydrotherapy for patients and be present during the procedure, if it is assigned by a doctor. (j) Calling ambulance for transportation of patients. 3. Permanent duties of a medical nurse that are carried out daily with no special prescription made by doctor: (a) Filling in medical documentation (except for case histories). (b) Measuring patient's body temperature in the morning and in the evening, sometimes the temperature should be taken every hour (if the patient is in severe condition or undergoes infusion therapy) and sometimes even more often. The data are to be put down into a Temperature sheet (Figs 64 — 66). (c) In some cases, heart rate and blood pressure are measured (sometimes a medical nurse puts down these data into the Temperature sheet of the case history — see Fig. 66) measurement of respiration rate. (¢) Measuring weight and height of children once a week, according to a plan. (e) Reporting every morning to the medical personnel of the department ‘about conditions of patients, especially those who are critically ill or newly hospitalized, and about those whose condition unexpectedly got worse. 4. Be present at general doctor's rounds, where all necessary information about the condition of patients is given. 5. Check if all necessities are delivered into department timely: * Medicines. 45Case history # 1337 at 29 May 2010 Full name Angroniuk Sergeu Age Lyear Body weight = 10kg. PRESCRIPTION FORM Date Date § sfl< Physiotherapy, 3 &|s 5 2|¢% § Examinations, | 3 #| Peres Big 2 Remedy and’ | 3 = 35 curative gym- | = e\s d raster | 3 {5 * é Vitamin ‘Cefazoinum 1] oastigs {2.95 250mg diam | 2295 |General blood test|29 05| ‘Acidum Bronchosan adenosininphos- . 2) Sorqua — |29.05 ‘phoricum 1%. | 22.08 Unnalysis | 29.05 0.5 mlg.d.* IM ‘Suprastinum 3) 4tab.tid* | 2905 Chest X-ray |29 05 during eating Linex 1 caps. td. a.c.* before eating '4.| (open and mix with | 29.05 ECG 30.05] ‘some quantity of sweat water) Consultation of cardiologist {92.95 ‘Soda inhalation AB 29 05] ‘Chest UV Radia- ae 30.05} * refer ‘List of abbreviations applicable in medicine, their Latin expressions and ‘meaning in English language" (pgs. 10-12). Fig. 7 Prescription form + Medical tools and bandage materials. * Food for patients. * Sets of clean bed linen and underwear for patients. 6. Stick to the following rules: (a) Personal hygiene. 46(b) Personal hygiene of patients. (c) Order at the medical nurse's post. (d) Storage of medical products which include: ‘* 2 groups of medical products that are to be stored in special metal boxes as safes with inscriptions ‘A’ and ‘B’ or cabinet. Safe ‘A’ gontains poisonous and narcotic products. Safe ‘B’ is used for strong active remedies. Key to the safe should stay with one of the officially appointed employees of the department (senior medical nurse, head of the department) who bear the legal responsibility for preservation and distribution of medicine. Inside the safe, there should be a list with names of medicines stored in the safe and their daily and single pediatric doses. Itis very important to have a list of antidoses in the medical safe, for the purposes of treating children who might get accidentally overdosed by various pharmaceuticals. All data about delivery and use of these medicines should be timely put down into a special medical register. Medical products with strong smell (e.g., liquid ammonia) and coloring solutions (e.g., iodine, methylenblau) are stored in a separate safe. Other medical products are stored in regular cabinets. The medical nurse at the post looks after them. The medicines in the safe are arranged in order convenience for usage. The order of their arrangement may vary from department to department. Each shelf should have a label with the name of the group of medicines on it — eg., for internal or external use, for injections, etc.; besides, it is convenient to divide them according to their form. For example, internal medicines are produced as tablets, liquids, powders, etc.; it is desirable to put the bigger bottles away from the smaller ones — it will enable you to read the labels on bottles at once. * Additional rules of storing medicines: o It is necessary to keep a steady temperature and humidity of environment where the medicines are kept (for example, some medical products — dry plasma, insulin, herbal decoctions, etc. should be stored in a refrigerator at temperature from +2°C to +10°C, fresh frozen plasma — in a freezer as a frozen substance). o There are medicines (for example, iodine) which should be stored under certain illumination — for this purpose they are stored in dark bottles and in dark places. 47° hould not x , which is always specified on the label of the medicine. If there are visible changes in a normal look of a medicine (dimness, flakes, change of color in liquid medicines; appearance of stains and change of color in tablets; unusual smell of a medicine) is also an indication of the fact that medicines should no longer be used. o Medical remedies should never be stored together with disinfecting solutions. 7. Teach children and their parents the following rules, if necessary: + Working hours of the hospital. * Getting food products from friends and storing them « Taking medicines. * Personal hygiene. * Child care. 8. Supervising the work of a junior medical personnel: © Controlling reception and distribution of food, and if necessary rendering assistance in feeding patients who are in severe conditions. + Supervising their main duty — i.e. keeping children's department of the hospital clean and in order. The basic duties of a junior medical personnel: + Damp cleaning in the medical institution (they should know the frequency of cleaning and contents of the liquid used in different rooms). ‘* Supervision of sanitary conditions of furniture in the ward, corridor, etc. * Sanitary processing of the patients, beginning with the reception. ‘* Helping the child in observing the rules of personal hygiene (combing hair, trimming nails, etc.) * Changing bed covers, bed sheets and patients’ clothes. * Prevention of bedsores. * Necessary medical aid to a serious patient in micturition, defecation (for example, to keep a bedpan). * Helping the nurse in some methods of inspection (collecting urine, stool; measuring of weight and height of the child, etc.).. Work of the doctor-pediatrician in a hospital In every children’s department, there is a managing branch and attending physicians, The basic duties of a doctor-pediatrician of the children’s department include: 48* Admission of the patients (in case of the absence of a separate admitting room). * Daily observation of the patients. * Daily filling up of the case history. * Daily viewing and additional! filling of the list of medicines to be given’ * Consultations with the patient's parents at their request during the whole time of hospitalization, especially during discharge from the hospital (the explanation of the child's condition, acquaintance with the results of inspections, advice, and recommendations). * Inthe morning, obligatory presence at the briefing of medical personnels of the department. * Simultaneously with the nurse — carrying out of some difficult manipula- tions (such as blood transfusion; intravenous introduction of plasma, con- trast substances; punctures, for example, pleural puncture, etc.). * On the day of discharging the child from the hospital, a ‘Discharge form’ is written (the document in which the diagnosis, the prescribed examination, treatment and recommendations are specified); it is given out to the parents or transferred to the children’s polyclinic. Medical documentation of the children’s department Th i = Medi rd of the hospitali jent) — see Appendix # 1. The average medical personne! in the case history fills the following sections: * The passport section. The result of examination on pediculosis. + The result of interrogation on possible infectious diseases (virus hepatitis, tuberculosis). A temperature sheet. Once a week — the information about changing clothes and taking hygienic baths. The nurse should, at the requir ti file in the the following documents into the case history * Results from the laboratory and other (X-ray, ECG, etc.) kinds of inspection. * The conclusion of specialists (ENT specialist, cardiologist, etc.), if the consultation was carried out in other medical establishment (the case history of the child cannot be taken out of the hospital) 49‘The general rules of conducting and keeping of the case history: * The data about the condition of the patient should be recorded daily; * The observance of the form and order of the filling of different sections of the document (we shall learn about this further on, in the course of propaedeutics); * After discharging the child from the hospital, the case history is transferred to the archive, where it 1s stored for 25 years. There is a special register which shows the patients’ movement (the duty of a medical personnel is to write the information into it). Every morning, all medical personnel gather in the staff lounge: the persons who were on duty the previous night and those who must be on duty during the new day. Usually such a gathering in our country is called a '5-minute’ briefing (‘piatikhvilinka’ in Ukrainian). At the beginning of this meeting, the duty doctor reports about the situation in a hospital: * Number of children in the department before the beginning of his/her duty and number of children in the morning. Number of children being admitted. Number of patients discharged. Number of children moved to some other hospital or ward. Number of patients dead or has left the hospital unwarrantly. * Detailed information about the newly admitted children. * The condition of serious patients. + Possible reasons of deterioration of the condition of other children (rise in temperature, problems in defecation, etc.) and maximum help rendered to him/her are described. ‘Then, the nurse on duty reports on all the patients who had some increase in temperature, or whose condition became worse, gives the list of those who did not hand over some analyses with the indication of the reason, possible peculiarities of giving and taking medicines. This information is especially necessary for the attending physician. For example: * After the distribution of patients, the doctor starts the inspection of the child whose situation is most severe (at the absence of such information, the severe patient may be examined by the doctor too late, which may be very dangerous for his/her life, — for example, at 12.00 — 1 p.m.). * The missing analyses should be prescribed repeatedly without any delay; there are methods of the inspection, for example, swab culture on pathogenic flora, when the result comes only within 2-3 days; ie. at the absence of such information from the nurse, the doctor finds out about the missing analysis only after some days. + Incase ofthe unwarranted leaving of the sick child, the attending physician should inform the local or family doctor about that immediately. 50The basic moments of this information are filled in specified registers, the order of their conducting may differ in different departments (an example — see Fig. 8). 22.03.2010 The total number of patients — 28 Including: Under 1 year old — 6 Under 3 years old — 10 Severe patients Borovsky E., 2 years old, 5” ward Fedorova |, § months old, 1* ward Are discharged 1. Ivkina A., 7 months old 2. Vashun A., 3 months old — is moved to the ICU department 3. Bevz P, 1 year old — unwarrantly (!) left Have arrived 1. Ivanov A., 3 years old — ARVI 2 Petrovchuk B., 5 years old — Otitis 3. Fedorova |, 5 months old — Pneumonia Fig. 8 An extract from the register of the patients’ movement (written by the duty personnel) The nurses’ register (or sheet) in different departments can have different names and can be conducted unequally, but the most convenient way, — is a document for duly performance of all medical procedures specially for nurses, nd thi 0 filled in (Fig. 9). 25.03.2010 Injections im. Antibiotics Vitamins ‘efotaxinum B, 5" ward Sidorov N. — 0.25 b.i.d. 6" ward Petrov A. — 0.25 Li.d. 8 ward Borisov |. — 0.5 b.i.d. Amicacinum 1* ward Lajkova O. — 100 mg b i.d. 4” ward Leshchin Z. — 50 mg b.1.d. General blood test 4 ward Laykova O. 4° ward Petrenko J. X-ray of respiretory system 5° ward Sidorov N 2° ward Mazur A. — 0.5 mL 3” ward Zocev E. — 0.5 mL 9” ward Vetrova I. — 1.0mL 3” ward Lesovenko N. — 0.5 mL 9 ward Sizov U. — 1.0 mL Inspection General urinalysis 1" ward Virovkin L 3 ward Sokolova I. Ultra sound of heart 3” ward Lesovenko N Fig. 9 An extract from the nurses’ register (sheet) 51In the register the attendant nurse on duty daily, sometimes 2 umes a day, makes the following extract of the sheet of the assignments (with mentioning the surname of the child): © Intramuscular injections (there may be a list according to the groups of medicines, the time of introduction, the wards, etc.) © The list of necessary analyses. + Assignments for the inspection and the appropriate preparation for the procedure. + The list of consultations, etc. The register book of the department (Fig. 10) in which the information on hospitalization of patients and their discharge is registered, has the following vertical columns: + Number. + Number of the case history. * Date of hospitalization. * Full name. * Age. * Address. + By whom he/she was refered from. + The diagnosis during hospitalisation. + The final diagnosis (at discharge). * Date of discharg * When he/she is discharged to: home, transferred to some other department, fatal case. + Number of days in the department (In Russian and Ukrainian — Kia and Sg). Attention! The first and last days are considered as 1 day; for example — if patient arrived on 2.02.2010, and was discharged on 7.02.2010, the number of days — 5. The _register-book of infectious patients in pediatrics is of special importance because infectious diseases (measles, scarlet fever, pertussis J= whooping cough/, etc.) are most frequent among children. The diseases of such character develop not later than 3 weeks after the contact of the child with the infectious patient. Therefore, the patient who is hospitalised into the children’s department, for example, with pneumonia, but was in contact with the infected patient 7 days before, is dangerous for 2 more weeks. Probably, the infectious disease will be shown in him/her, but may be, the child was not infected — it is not known by anybody. Such a child cannot be put into a usual ward. Here, the doctor solves the problem individually: A patient whose condition is not 522 3 Sz s | t2 ; | 2] Zee 38 a 33 sl? 8| 2) gs Ss| 28 es = < 3 gfe 2s £|3 3 2 | 23 g5| 2 [25 g = a is 2 é 35 Koval Victory | Doctor from| Acute 131] 131 [8.2 inna |108+ street, | te depart, ACU | pneumo-|28.°2:) Home | 23 vanovna| 24/75 | ment mia Youth: ARVI. \Oleksien-| 16 02 05.01.) Av- Rhinitis. 07 02. |Infection| 132} 132 Joo y0},K© Olea | 2509 | enue, [AMPUANCE| ‘Neuro. MENMBS! So46 [hospital] 1 Petrovich aig toxicosis Fig. 10 An extract from register of the department very severe can be treated at home, but a severe one — put into a separate isolated disease will be shown in him/her, but may be, the child was not infected — it is not known by anybody. Such a child cannot be put into a usual ward. Here, the doctor solves the problem individually: A patient whose condition is not very severe can be treated at home, but a severe one — put into a separate isolated ward and at presence of symptoms of an infectious disease — directed to the infectious hospital. However, in each case, the information on the patient like this is entered into the above-mentioned register-book of infectious patients named above. In the emergency messages book, the cases of emergency character are recorded (ie. demanding urgent finding out of the reason of the occurrence and prevention of spreading out the pathology (infectious disease, poisoning, dangerous reaction to vaccination, medicines). The information on these cases should be reported urgently to SES (sanitary-and-epidemiologic station). RULES OF DRUG ADMINISTRATION There are some ways of the medicinal administration: 4. Enteral (= oral) — introduction of medicines through gastrointestinal ‘act (GIT) * Peroral. * Per rectum. 532. Parenteral — introduction of medicines by injection with skin damage: © Intradermal, + Subcutaneous. © Intramuscular. * Intravenous. 3. mm 2 * Manual application of the preparation on derma and mucous membranes. * Electrophoresis. * Inhalations. Enteral Peroral (= Per os, p.o.) administration of medicines in pediatrics does not cause any complication in children of older age. With this purpose, as well as in adult, medicines are used in the form of tablets, capsules, granules, powders and liquids. At the time of prescribing medicines, the doctor (or nurse) should explain the rules of taking the medicines: * How many times a day, sometimes, it is necessary to specify the time of reception (some medicines are given only in the morning or in the evening). * Connection with_meals— most medications are given after meal (for reduction of their irritating influence on the mucous membrane of the stomach), some of them should be used a. (i.e. before meal Sometimes 45-50 min ite) me + Some peculiarities are possible. For example, Solutan should be taken with some milk; as for Mucaltinum it is better to dissolve it in water and to add a little sugar. Usually, the preparation is put on the root of the tongue, and then, the child takes some drinks of water or other liquid tasty for him/her, simultaneously with which the medicine is swallowed. As for children of early age, especially during the first 2 years, itis difficult to give them a medication per os. It is strictly not recommended to do it by force (1), Recently, this problem has been solved by preparing medicines in the form of syrups. If syrup doesn't help, then the medicine should be crumbled and mixed with a little amount sugar and water, or dissolved in some tasty liquid. The technique of giving medicine is: taking some medicine in a spoon, place the child in almost a vertical position, close his/her nose and the child opens mouth in reply to this and medicine is put in the mouth, then a favourite drink is given. 54is as follows: is an administration of a suppository through the rectum, * The child of an older age is made to lie sideways, with legs bent in knee and hip joints, the nurse by one hand moves buttocks apart, with another hand she put the suppository deep enough as the anus gets closed. Then for the prevention of slipping out of the suppository, il is necessary lo compress buttocks near the anus for some minutes. * The child of early age can be put on the back, with legs lifted upwards, and further on, the technique of administration js. similar to the above description. Parenteral methods For parenteral administration of medicine, a syringe is used, it consists of a.culndes.a Diston. the cone of which is located at the end of cylinder and le whi fix ie tothe sharp. aid, i$ Called aS cannula — see Fig. 11 Jast few years with the purpose of are used. Syringes are different depending on: + Yolume_and_application — special for insulin and tuberculin, we use a 1 mL syringe. (on the syringe, the measure of volume is indicated in mL and UA), widely used are— on 2 ml, 5 ml, 10 mL, 20 mL, and more voluminous syringes (for example, 60 mL); sation of th at th the syringe or eccentric. Needles also differ — in length. diameter. the cut of angle at the end. In our days, for the use of any needle with any syringe, the diameter of the cone in all syringes and diameter of the cannula in all needles are identical. The kind of syringe and needle depends on the volume and consistency of the medicine, and also on the way of its introduction. 55 Fig. 11 Structure of synnge and needle Designations. a — the cylinder, ce b — the piston, cannula of the needle: — the needle of ‘buttertly’ typeThe general rules and order of parenteral administration: (a) The place of injection depends on its kind; however, it 1s always that part of skin which contains the least amount of nerve fibres and blood vessels (except for intravenous injections). (b) During injection, periosteum should not be damaged. (c) For prevention of mistake, it is necessary to read the labe ampule or the bottle, to pay attention to the kind of medication, doze, expiry date. (d) tis good to wash your hands; even at small injury of skin — to process it with spirit; the presence of purulent damages on the skin is a contra- indication for the injection; after processing of hands do not touch anything. (e) Put a needle on the syringe. (f) Take some medicine into t volume (if the ampule or the bottle are placed above the needle — the liquid flows from the top downwards, if it is under the needle — the liquid rises from below upwards). (g) Always change a needle to a clean one. (h) Lift up the needle, slightly let some liquid out so that air could go out from the needle (thus, the superfluous amount of medicine will be removed) ()) Before the first injections, it is necessary to prepare the child psychologically for this procedure, not deceiving (1) him/her. (j) The child should be kept into motionless position on the bed which relaxes the muscles and promotes the best administration of the liquid; child should be held by mother. (k) Process the place of the injection with 70% ethyl alcohol, ether, or 5% tincture of iodine. (l) Inject the needle approximately to 1/2-2/3 of its lengths — in case the cannula is broken in the place of connection, it will be possible to take it out without operation. If the needle is put till cannula in that case, the broken part enters the tissues, that will demand surgical intervention. (m) The preparation is entered with the certain speed which depends on the following factors: + Less amount of liquid entered — demands a higher speed. * Consistence of medicines — thicker medications are more slowly injected. + Morbidity of a preparation — very painful medicine are not entered quickly, but also not very slowly.+ Fhe purpose of the procedure — here, the speed is specified by the doctor. (n) The needie is taken away, and the place of the injection is wiped by spirit (0) Repeated injections are not done in the same place. Dear students! The best way to learn this is not theoretically, but practically! Intradermal injections (i.d.): From the name itself, it is clear that the medication is to be administered in skin. Features of the technique: (a) The place of the injection is the internal surface of the forearm or external surface of the shoulder. (b) The needle and a syringe are of the least sizes, it is better to use the syringe with the eccentric arrangement of the cone of a tip. (c) The skin is processed with spirit or ether. (d) The needle is placed with its cut directed upwards at an acute angle to the skin and injection is done intradermally. (e) If the medicine is entered correctly, a so-called symptom ‘of lemon peel’ is observed — the skin towers a little, a papule is formed, and many pits are formed (this reminds the peel of lemon). Mostly, such injections are done forthe diagnostic purpose. For example, for determination of the allergic reaction of an organism to antibiotic. Antibiotic is injected into the skin in the lower third of forearm in lower concentration (diluted). In 20 minutes, the size of hyperemia around the place of the injection is visually evaluated. Normally, reddening is absent or its diameter does not exceed 1 cm. If it is more — the preparation is contra-indicated for the child. In order determine to the condition of migration of water (and sodium) in tissues, i.e. the hydrophilia of the tissues, the Mc Clure-Aldrich test is carried out (the U.S. doctor and the biochemist of the 20" century): 0.2 mL of isotonic solution is injected with a thin syringe in the region of the top half of forearm. The time of resorption of the papule with ‘lemon peel’ is taken into account, which normally depends on age: © Under 1 year ofage | — 15-20 minutes + 1-5 years — 20-30 minutes * Over 5 years — 40-60 minutes The evaluation of the analysis: (a) The time is lower than normal (1.e. accelerated resorption) — this 1s a sign of edema of tissues of different character (cardiac, renal, etc ); 57if the edema of this kind can not be observed, then, tt is refered to as ‘pitting’ edema (see pg. 471), and can be established by means of this method. (b) The time is higher than normal (i.e. slow resorption) — this is a sign of dehydration of the organism. Subcutaneous injection (s.c.) is refered to, when the medicine is fered under the skin. Features of the technique: (a) Places of the injection — top % of the shoulder, bottom % of the forearm, stomach, under the scapula, external surface of thigh. (b) Needles and syringes — are both of different sizes. It is better to use syringes with eccentric arrangement of the tip of the cone. (c) The skin is processed with spirit or iodine. (d) With the 1* and the 2° fingers of one hand, skin and subcutaneous tissue are slightly pinched (a fold is formed at this) and stretched upwards a little. (e) The needle is placed at an acute angle to the skin and 1-2 cm of it is entered deep into the skin. (f) Draw the piston back and check the possibility that the needle has been injected in a vessel — if blood is not present, then the medicine can be injected. During intramuscular injection (i.m., IM) the medicine is injected into a muscle. It is one of the most widespread parenteral method. The advantage of intramuscular injections in comparison with subcutaneous is the quick absorption of the medicine due to lot of blood and lymphatic vessels in muscles. Features of the technique are as follows: (a) The place of the injection is the top external quarter of the buttock and the top anteroexternal quadrant of the thigh. (b) Needles are long, of average diameter and syringes are of different volume. (c) The skin is wiped with spirit or iodine. (d) The needle is placed at an angle of 90° to the skin and is entered into, on a depth of 2-3 cm. (e) A possible inadmissible introduction of the needle into a blood vessel is checked and at the absence of blood the medicine is injected. (f) For quick and better absorption of the preparation after injection, it is effective to carry out massage in the place of the injection or put a warm hot-water bottle. 58Complications and necessary medical tactics 1. Infiltration — hardening in the place of the injection — arises when a large number of injections are done in closely located points, and also in case of the voilation of the rules of aseptics. Itis determined by palpation, and the child often complain about pain in the place of injection and a dangerous attribute is reddening of the skin in the place of infiltration. ‘+ Warming by means of the compress (semi-alcoholic or with heparin). * ‘lodine network’ (Fig. 12)— a ‘picture’ in the form af grid is drawn at the place of the injection with cotton bud moistened with 2% solution of iodine. * Ultra-Violet Radiation. 2. Hemorrhage and bleeding arise mostly in case, when the end of a needle injures a blood vessel, Probably, there may be a blood disease that enhance bleeding, which demands special inspection of the child Medical tactics’ * The nurse has to bandage this place pressing the bandage firm to the skin. * To inform the doctor immediately. 3. Damage of nerve fibers occurs as a result of wrongful choice of place for injection, The child experiences a sharp pain which feels like an electric shock. Further on, the attributes of the voilation of functions of the injured nerve develops. There may be a condition of anaphylactic shock The tactics of the nurse is to stop the injection and to call the doctor. 4. Allergic reaction develops as a result of the influence of the medication administered on the child and is expressed with the following clinical features. e * Sites of hyperemia of different sizes and forms on different areas of the body. + Fever. — + Rise in body temperature, * Nausea, vomiting, “The tactics of the nurse is to call a doctor Fig. 12 odine netwark'm the top immediately. ‘extemal quadrant of the nght buttock 595, At the voulation of techniques of admnistration, the medicine can get into the surrounding region — for example, embolism of the branches of pulmonary arenes with the particles of oil solutions which have got into a vein during their intramuscular or subcutaneous injection. 6. Abscess — suppuration in the place of the injection — is the result of rude voilation of the rules of asepsis, demands surgical treatment. Medical terminology: the word ‘infusion’ means parenteral administration of plenty of liquid into a patient with diagnostic or medical purpose. Infusions can be intra-arterial, intravenous, intraportal, subcutaneous, efc. Infusions are divided into stream (= jet) and droplet ones considering the administering speed. Intravenous infusions (= injections) (i.v.,1V) when medicines are injected into peripheral veins, and this procedure is mostly applied at a Serious condition of the child, however they can be carried out during scheduled treatment, A place of injection: * For children of the first years of life, veins in the area of radio-carpel {OILS are Used (this piace is the best for being fixed in the immovable position during droplet administration), less often — uinar vessels and subcutaneous veins of the head (Fig, 13) as well as an area around the ankle joint are used. © Inoiger children injections are made into ulnar (Fig. 14) and radio-carpel regions, less often — ang talocrural joints Features of the technigue of intravenous. jet infusion as follows: 1. Needies — long, of a large diameter, with @ short cut on the end, syringes — of big diameter. 2. The skin is processed with spirit or ether. 3. Al the beginning, it is necessary to press the skin above the place of injection with a finger or a whole hand (the nurse-assistant usually does that, or to put a tourniquet on), 4. The neeale is placed at the surface of @ skin at @ particular angle, along the current of venous blood and pushed deep into untill Fig. 13 Jntravenaus dnp-feed inta a piercing of one wail of vein [an_ attribute of subcutaneaus vein of the head. getting 19 a vein is the occurrence of blood in 60the cannula af the needle; sometimes (at condensation of blood and dehydration of the organism) blood may nat appear]; in thatcase, itis possible toentera sterile cotton strand — if the needle is in the vein, the tip of the strand will redden. Some nurses make injections at once, with a needle fixed to syringe: in such case the entrance in a vein is _ determined by pulling the piston back where by blood will appear in the liquid in inside the syringe, A skilled nurse usually gets into @ vein on first trial; otherwise, it is Necessary, not to pull the needle out of the skin, but to pull it back a little | injections is chosen. bit and try to enter the same or other vein; in case of failure, the needie is drawn out and the place is pressed with a cotton tampon, moistened in _ spirit; then some other place for iv, ZL 5. As for stream infusions, usually, , some medical products are injected Fig. 14 Intravenous droplet infusion. by several syringes which are serially Designations are in the text inserted into the needle placed into a vein; as the medicines work practically fast they are injected slowly (1). 6. During one iv. i 7. After accurate removal of the Soete fon the skin, the place of the injection is processed with spirit, then for intion of bleedin sin: is put In order to administer greater volume of medicines, intravenous droplet infusion are applied when the liquid does not get into a vein, but the current of its adjusted by drops which can be seen. At the beginning, a dripper system is prepared (Fig. 15), the structure of which consists of: 1. Adripper in the form of plastic tube having the following parts: * A special tap (Fig. 15 -— A) which can block a tube and, therefore, regulate the speed of dripping medicines 61« The expanded part — of a dripper (Fig. 15 — B) at the bottom of which a ‘stagnant lake of liquic’ is formed, where the liquid from the Upper part of the tube will drip with the visual speed: the speed of the frequency of drops per minute, either its reduction or increase 1s adjusted by the above mentioned special tap ‘The upper part of the tube ends in a needle which is inserted into a bottle with medicinal bquid. * Althe bottom of the tube, there is a soft rubber site (Fig. 15 -C) or closed ‘hole’ with a special filter, with a cannula on its edge. which is puton a needle in the vein; through the rubber part, the additional medical products are entered by jet infusion after closing the tap hence stopping droplet introduction. 2. Astand on which the bottle with medicine (Fig. 14 — A} is placed upside dawn, for changing the pressure of liquid, the stand can be moved upwards or downwards by a special regulator (Fig. 14 — B). For the appropriate movement of the liquid downwards, apart from the needie of a dripper, one more needie should be inserted with its cannula open into the air, named among medical personnels as ‘air-needie’ (Fig. 14 — C). Dear students! Refer laws of physics. 3. The needle in a vein — the older the child is, the wider and longer the needle is used. In pediatrics, the so-called ‘butterfly-needies which are weil fixed in im- Fig. 15 System of intravenous droplet infusion. Designati ions are in the text 62 movable position are very if it is necessary to repeat injections atimes; for such iv. injections, we can use a Special thin plastic catheters which contains _a__needie with different _diameters_with cannulae on the external end (eVenflone etc.). At first, they are entered togetner into thevein, then, the needle is removed and a thin cannula remains in the vein (for 3-5 days), practically limiting the movement of the hand of the patient. Sometimes, we can use a surgical method of inserting a catheter. S (a) The bottle with liquid is prepared, placed on a stand; the ‘air-needle’ is inserted. (b) The dripper is connected to the bottle. (c) Then, the tube is lifted upwards for a short time, in such a way that the upper part of the dripper is below, then the liquid fills approximately the half of the dripper. And the tube placed downwards at once — the liquid passes through the whole tube up to the cannula. Special attention should be given, if air is present in the tube — it should be removed (1) (d) The tap is closed, and the lower end of the tube usually fixed to the stand for a short time. (e) The needle is entered into a vein. (f) The tube is joined to a needle — for preventing the entrance of little amount of air into a vein at this short moment, the liquid from the dripper should flow and some amount of blood from the vein should come out. (g) The frequency of drops is determined according to the prescription of the doctor — from 10-12 up to 60 per minute. (h) The needle is fixed — a sterile wadded tampon is put under it, and the needle is fixed to the skin with an adhesive plaster. (i) As infusion lasts for some hours, sometimes, during the day, the extremity is fixed in an immovable position, it is especially important for children of an early age. Usually, a splint (a hard plate) is placed under extremities, they are bandaged (do_not close the lower part of the tube and the needle!) and also fixed by a clip to the pillow or mattress, rubber cord may be used if bandage is not available (above the cotton wool on the hand), tie them to the frame of the bed To little children, sedative medicines are given, according to the doctor's prescription. Attention! Nowadays, only the disposable dripper is used, which in case of long infusion, should be replaced by a new dripper in 24 hours. Complications of intravenous injections and medical tactics 1. Infiltration — it is formed, if the medicines enters surrounding tissues through the injured vein or at wrong infusion, outside the vein. The tactics of the nurse is using a warm compress. 632. Hemorrhage and bleeding — are formed at significant damage and puncture of a blood vessel from two sides and at some blood diseases. 3. Air embolism — entering of some amount of air into the vein as a result of professional mistakes, this demands urgent medical assistance. Air embolism due to a considerable amount of air results in an irreversible condition of the patient which can lead to a lethal outcome. 4. Phlebitis is an inflammation of the walls of vein into which the medicine is injected by means of infusion. Clinical attributes — pain and hypere The principal causes are: (a) Infringement of the rules of sterility. (b) Long (more than 3 days) presence of the catheter in a vein. (c) Formation of blood clots in a vein may be in the following cases: * If necessary, the movement of liquid through a needle can be stopped for some time. For this purpose, a mandrin is inserted into the needle. Cannula can be closed with a special stopper, etc. However, a long delay of intravenous infusion promotes the formation of blood clots. op prophylaxtion of the thrombosis in veins (attention, which simultaneously prevents the thrombosis of needles or catheter) a so-called ‘heparin lock’ can be used — into a needle (catheter), 1 mL of the following contents are administered — heparin and 0.85% solution of sodium chloride in the ratio of 1:9, after that, the catheter (or the needle) is closed for the necessary time. « Very slow droplet infusion — 7-8 drops per minute. + The temperature of the medicinal liquid lower than body temperature of the patient — is mostly observed at the infusion of plasma, albumin and blood, which were stored in a refrigerator. Hence, such liquids before the infusion should be warmed up to 37°C. The treatment of phlebitis is to remove the needle, and put a compress with heparin ointment along the vein. jia of skin on a course of vein. 5. Allergic reaction. 6. The infringement of the rules of administration, when the medication enters into surrounding tissues — for example, if, during intravenous administration of calcium chloride, it happens that CaCl, spills outside of vein, necrosis of the tissues will occur. 64‘Other ways Manual application of preparations on the skin is carried out by different ways — putting bandages with medicinal ointment on the skin, simple greasing of the skin with medicine or rubbing ointments, on the skin with tips of the fingers. As for the mucous membranes of eyes, nose and external acoustical passages, the medicines are applied in the form of drops from a sterile (I) i as ointment. The basic features are: 1. Eyes — liquid medical products are dripped into the eye by the nurse in the following way (Fig. 16). The medicine is taken into a sterile pipette. The lower eyelid is accurately pulled downwards and from the pipette, one drop of the medicine is dripped closer to the internal corner of the eye. Attention! The.oipsite should not touch the eve itself Itis better for the child to look aside Incase of prescription of eye ointment, itis put on the mucous membrane of ‘the eye with a special glass blade (the lower eyelid is pulled downwards at this). Then, the child closes the eye and ointment is spread with accurate massage enhanced by the movements over the eyelid. 2. The nose — at the beginning, nasal passages are cleaned toy sneezing or with cotton-tipped appliances). The position of the child is half sitting, the extremities are fixed, and the neck 1s bend a little back and towards the filling nasal passage. 2-3 drops of the medicine are allowed to enter, and the head should be © 7 in this position for some minutes. Then, the head is turned to the opposite side slightly and the same procedure is done in the second nostril 3, External acoustic duct (Fig. 17) — the child is laid on the site opposite to the ear into which the medicine must be dropped, the acoustic duct is cleared. The F lobe of the ear is pulled downwards (forthe Fig. 16 Technique of using eye drops 65older child — downwards and aside) to the level of the acoustic duct. Afterwhich 5-6 drops of medicine — warmed (!) up to 37°C — are entered. After that, the child should stay in such a position for 20 minutes. Electrophoresis is the admunisir the influence of electric current (Fig 18). (a) (b) () (d) as follows: ‘A special lining is processed with the necessary medicinal product depends on the disease, which will penetrate through the skin (according to the doctor's prescription). The lining is placed on the necessary area of skin (itis also prescriped by the doctor, for example, at lung disease — on the chest, at those of the gallbladder — in the area of the right subcostal, at maxillary sinusitis — on the upper jaw). Then, electrodes are laid on the lining and also on one site of the skin, connected to the network with certain voltage, and for 10 minutes under the influence of the weak electric current (the force of the current is observed by the nurse), medicine will penetrate constantly into the organism af the child. After the procedure, the child should slay on the bed well covered for 30 minutes. The_action of electrophoresis depends on the action of the medical product. Inhalation is the _metnod of introduction of medicines into respiratory tract by breathing some aerosols from a special device The method is applied during diseases medicine doctor. In the inhaler, the medicine is crushed, warmed up and immediately allocated through the tube at the end of which there is a mouthpiece, placed to the mouth of the patient (Fig. 19). af respwatory tract. The is prescribed by the In case of inhalation, trunk and Fig, 17 Technique of dripping medicine extremities of a small child are into acouste duct 66Fig. 18 Electrophoresis Fig. 19 Inhalation fixed, the nose is directed to the tube of the inhaler. This procedure is painless; nevertheless children are usually afraid of it and cry, that may cause mother's anxiety and refusal of inhalation, The crying of the child is not dangerous. Besides, during his/her crying, the child makes a deeper breath which promotes the penetration of medicine into the inner pars of respiratory tract. Sometimes, contraindication to inhalation of a child of early age with laryngeal stenosis is of great concern (the procedure can cause edema of the respiratory tract). Duration of inhalation is 5-10 minutes.PERIODS OF THE CHILD'S LIFE Time does nat change, but only improves us Frisch The reasons for the division of human ontogenesis into periods in childhood are: Constant growth and development of the child. Anatomical and physiological, functional and psychological signs in the child's body during different days, months and years of his life. i periods of a child's life are divided inta two stages. This period continues during 270 days sea the moment of fertilization up until child birth. As to determine the exact date of fertilization is impossible, in practice it is considered that the gestational period prolongs for 280 days (= 40 weeks), starting from the first day of the last menstrual cycle of the mother. Intrauterine period is subdivided into following phases: a, Embryonal growth phase — from the moment of fertilization up until 2 manths. ba b. Placental growth phase (= fetal = phase) — from the 3” month up to the end of pregnancy. , Embryonal growth phase — is charac- terized by the highest rate of tissue differen- \ tiation. Its major feature is organogenesis ¥ (formation of almast all internal organs of the ‘ future child). The pathological impact of exo- | genic or endogenic factors could cause em- S| bryopathies (Severe defects of the anatomi- iy cal development) during this period (Fig. 20). Wa The embryonal growth phase of pregnancy is considered as a critical stage of human development — i.e, this period contains the maxi Sit i agenda senenoet res mat of the developing congenital (congemtal absence or grass Shortening /aplasia/ of the Ja, Placentary growth phase — undergoes Te ornare limps’ the Maturation of all systems and organs, 68 Fig. 20 Embryopathy. The exact