Structure and functions of the therapeutic department. Preparation of antiseptic solutions. Duties of the medical personnel.

 

A hospital is a health care institution providing patient treatment by specialized staff and equipment.

Hospitals are usually funded by the public sector, by health organizations (for profit or nonprofit), health insurance companies, orcharities, including direct charitable donations. Historically, hospitals were often founded and funded by religious orders or charitable individuals and leaders. Today, hospitals are largely staffed by professional physicians, surgeons, and nurses, whereas in the past, this work was usually performed by the founding religious orders or by volunteers. However, there are various Catholic religious orders, such as the Alexians and the Bon Secours Sisters, which still focus on hospital ministry today, as well as several Christian denominations, including the Methodists and Lutherans, which run hospitals.

In accord with the original meaning of the word, hospitals were originally “places of hospitality”, and this meaning is still preserved in the names of some institutions such as the Royal Hospital Chelsea, established in 1681 as a retirement and nursing home for veteran soldiers.

During the Middle Ages hospitals served different functions to modern institutions, being almshouses for the poor, hostels for pilgrims, or hospital schools. The word hospital comes from the Latin hospes, signifying a stranger or foreigner, hence a guest. Another noun derived from this, hospitium came to signify hospitality, that is the relation between guest and shelterer, hospitality, friendliness, hospitable reception. By metonymy the Latin word then came to mean a guest-chamber, guest’s lodging, an inn. Hospes is thus the root for the English words host (where the p was dropped for convenience of pronunciation) hospitality, hospice, hostel and hotel. The latter modern word derives from Latin via the ancient French romance word hostel, which developed a silent s, which letter was eventually removed from the word, the loss of which is signified by a circumflex in the modern French word hôtel. The German word ‘Spital’ shares similar roots.

Grammar of the word differs slightly depending on the dialect. In the U.S., hospital usually requires an article; in Britain and elsewhere, the word normally is used without an article when it is the object of a preposition and when referring to a patient (“in/to the hospital” vs. “in/to hospital”); in Canada, both uses are found.

Some patients go to a hospital just for diagnosis, treatment, or therapy and then leave (‘outpatients’) without staying overnight; while others are ‘admitted’ and stay overnight or for several days or weeks or months (‘inpatients’). Hospitals usually are distinguished from other types of medical facilities by their ability to admit and care for inpatients whilst the others often are described as clinics.

General

The best-known type of hospital is the general hospital, which is set up to deal with many kinds of disease and injury, and normally has an emergency department to deal with immediate and urgent threats to health. Larger cities may have several hospitals of varying sizes and facilities. Some hospitals, especially in the United States, have their own ambulance service.

District

A district hospital typically is the major health care facility in its region, with large numbers of beds for intensive care and long-term care;

Specialized

Types of specialized hospitals include trauma centers, rehabilitation hospitals, children’s hospitals, seniors’ (geriatric) hospitals, and hospitals for dealing with specific medical needs such as psychiatric problems (see psychiatric hospital), certain disease categories such as cardiac, oncology, or orthopedic problems, and so forth. In Germany specialized hospitals are called fachkrankenhaus; an example is Fachkrankenhaus Coswig (thoracic surgery).

A hospital may be a single building or a number of buildings on a campus. Many hospitals with pre-twentieth-century origins began as one building and evolved into campuses. Some hospitals are affiliated with universities for medical research and the training of medical personnel such as physicians and nurses, often called teaching hospitals. Worldwide, most hospitals are run on a nonprofit basis by governments or charities. There are however a few exceptions, e.g. China, where government funding only constitutes 10% of income of hospitals. 

 Specialized hospitals can help reduce health care costs compared to general hospitals. For example, Narayana Hrudayalaya‘s Bangalore cardiac unit, which is specialized in cardiac surgery, allows for significantly greater number of patients. It has 3000 beds (more than 20 times the average American hospital) and in pediatric heart surgery alone, it performs 3000 heart operations annually, making it by far the largest such facility in the world. Surgeons are paid on a fixed salary instead of per operation, thus the costs to the hospital drops when the number of procedures increases, taking advantage of economies of scale. Additionally, it is argued that costs go down as all its specialists become efficient by working on one “production line” procedure.

Teaching

 

A teaching hospital combines assistance to patients with teaching to medical students and nurses and often is linked to a medical school, nursing school or university.

Clinics

The medical facility smaller than a hospital is generally called a clinic, and often is run by a government agency for health services or a private partnership of physicians (iations where private practice is allowed). Clinics generally provide only outpatient services.

Hospitals vary widely in the services they offer and therefore, in the departments (or “wards”) they have. Each is usually headed by aChief Physician. They may have acute services such as an emergency department or specialist trauma centre, burn unit, surgery, orurgent care. These may then be backed up by more specialist units such as:

·         Emergency department

·         Cardiology

·         Intensive care unit

·         Paediatric intensive care unit

·         Neonatal intensive care unit

·         Cardiovascular intensive care unit

·         Neurology

·         Oncology

·         Obstetrics and gynaecology

Some hospitals will have outpatient departments and some will have chronic treatment units such as behavioral health services, dentistry, dermatology, psychiatric ward,rehabilitation services, and physical therapy.

Common support units include a dispensary or pharmacy, pathology, and radiology, and on the non-medical side, there often are medical records departments, release of information departments, Information Management (aka IM, IT or IS), Clinical Engineering (aka Biomed), Facilities Management, Plant Ops (aka Maintenance), Dining Services, and Security departments.

In the modern era, hospitals are, broadly, either funded by the government of the country in which they are situated, or survive financially by competing in the private sector (a number of hospitals also are still supported by the historical type of charitable or religious associations).

 

 

 

Charlotte Regional Medical Center, a for profit hospital in Punta Gorda, Florida

In the United Kingdom for example, a relatively comprehensive, “free at the point of delivery” health care system exists, funded by the state. Hospital care is thus relatively easily available to all legal residents, although free emergency care is available to anyone, regardless of nationality or status. As hospitals prioritize their limited resources, there is a tendency for ‘waiting lists’ for non-crucial treatment in countries with such systems, as opposed to letting higher-payers get treated first, so sometimes those who can afford it take out private health care to get treatment more quickly.^[40] On the other hand, some countries, including the USA, have in the twentieth century introduced a private-based, for-profit-approach to providing hospital care, with few state-money supported ‘charity’ hospitals remaining today.^[41] Where for-profit hospitals in such countries admit uninsured patients in emergency situations (such as during and after Hurricane Katrina in the USA), they incur direct financial losses,^[41] ensuring that there is a clear disincentive to admit such patients. In the United States, laws exist to ensure patients receive care in life threatening emergency situations regardless of the patient’s ability to pay.^[42]

As the quality of health care has increasingly become an issue around the world, hospitals have increasingly had to pay serious attention to this matter. Independent external assessment of quality is one of the most powerful ways to assess this aspect of health care, andhospital accreditation is one means by which this is achieved. In many parts of the world such accreditation is sourced from other countries, a phenomenon known as international healthcare accreditation, by groups such as Accreditation Canada from Canada, the Joint Commission from the USA, the Trent Accreditation Scheme from Great Britain, and Haute Authorité de santé (HAS) from France.

 

 

 

 

 

 

 

 

An outpatient (or out-patient) is a patient who is not hospitalized for 24 hours or more but who visits a hospital, clinic, or associated facility for diagnosis or treatment. Treatment provided in this fashion is called ambulatory care. Sometimes surgery is performed without the need for a formal hospital admission or an overnight stay. This is called outpatient surgery. Outpatient surgery has many benefits, including reducing the amount of medication prescribed and using the physician’s or surgeon’s time more efficiently. More procedures are now being performed in a surgeon‘s office, termed office-based surgery, rather than in a hospital-based operating room. Outpatient surgery is suited best for healthy patients undergoing minor or intermediate procedures (limited urologic, ophthalmologic, or ear, nose, and throat procedures and procedures involving the extremities).

An inpatient (or in-patient), on the other hand, is “admitted” to the hospital and stays overnight or for an indeterminate time, usually several days or weeks (though some cases, such as coma patients, have been in hospitals for years). Treatment provided in this fashion is called inpatient care. The admission to the hospital involves the production of anadmissioote. The leaving of the hospital is officially termed discharge, and involves a corresponding discharge note.

Misdiagnosis is the leading cause of medical error in outpatient facilities. Ever since the National Institute of Medicine’s groundbreaking 1999 report, “To Err is Human,” found up to 98,000 hospital patients die from preventable medical errors in the U.S. each year, government and private sector efforts have focused on inpatient safety.^[1] While patient safety efforts have focused on inpatient hospital settings for more than a decade, medical errors are even more likely to happen in a doctor’s office or outpatient clinic or center.

The inpatient module is designed to take care of all the activities and functions pertaining to Inpatient Management. This module automates the day-to-day administrative actives and provides instant access to other modules, which leads to a better patient care. It provides comprehensive data pertaining to Admission of Patients & Ward Management: Availability of beds, Estimation, Agreement preparation, Collection of advance, planned admission, Emergency admission and so on. The Inpatient module also deals with Ward Management: Shifting from one ward to the other, Bed availability, Surgery, Administration of drugs, nursing notes, charge slip and so on.

A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health careservices in a systematic way to individuals, families or communities.

An individual health care provider (also known as a health worker) may be a health care professional within medicine, nursing, or allied health professions. Health care providers may also be a public/community health professional. Institutions (also known as health facilities) include hospitals, clinics, primary care centres, and other service delivery points. The practice of health professionals and operation of health care institutions is typically regulated by national or state/provincial authorities through appropriate regulatory bodies for purposes of quality assurance.^[1] Together, they form part of an overall health care system.

Antiseptics and Disinfectants: Activity, Action, and Resistance

 

 

Antiseptics and disinfectants are extensively used in hospitals and other health care settings for a variety of topical and hard-surface applications. A wide variety of active chemical agents (biocides) are found in these products, many of which have been used for hundreds of years, including alcohols, phenols, iodine, and chlorine. Most of these active agents demonstrate broad-spectrum antimicrobial activity; however, little is known about the mode of action of these agents in comparison to antibiotics.

Antiseptics and disinfectants are used extensively in hospitals and other health care settings for a variety of topical and hard-surface applications. In particular, they are an essential part of infection control practices and aid in the prevention of nosocomial infections . Mounting concerns over the potential for microbial contamination and infection risks in the food and general consumer markets have also led to increased use of antiseptics and disinfectants by the general public. A wide variety of active chemical agents (or “biocides”) are found in these products, many of which have been used for hundreds of years for antisepsis, disinfection, and preservation . Despite this, less is known about the mode of action of these active agents than about antibiotics. In general, biocides have a broader spectrum of activity than antibiotics, and, while antibiotics tend to have specific intracellular targets, biocides may have multiple targets. The widespread use of antiseptic and disinfectant products has prompted some speculation on the development of microbial resistance, in particular cross-resistance to antibiotics. This review considers what is known about the mode of action of, and mechanisms of microbial resistance to, antiseptics and disinfectants and attempts, wherever possible, to relate current knowledge to the clinical environment.

 It is important to note that many of these biocides may be used singly or in combination in a variety of products which vary considerably in activity against microorganisms. Antimicrobial activity can be influenced by many factors such as formulation effects, presence of an organic load, synergy, temperature, dilution, and test method. 

“Biocide” is a general term describing a chemical agent, usually broad spectrum, that inactivates microorganisms. Because biocides range in antimicrobial activity, other terms may be more specific, including “-static,” referring to agents which inhibit growth (e.g., bacteriostatic, fungistatic, and sporistatic) and “-cidal,” referring to agents which kill the target organism (e.g., sporicidal, virucidal, and bactericidal). For the purpose of this review, antibiotics are defined as naturally occurring or synthetic organic substances which inhibit or destroy selective bacteria or other microorganisms, generally at low concentrations; antiseptics are biocides or products that destroy or inhibit the growth of microorganisms in or on living tissue (e.g. health care personnel handwashes and surgical scrubs); and disinfectants are similar but generally are products or biocides that are used on inanimate objects or surfaces. Disinfectants can be sporostatic but are not necessarily sporicidal.

Sterilization refers to a physical or chemical process that completely destroys or removes all microbial life, including spores. Preservation is the prevention of multiplication of microorganisms in formulated products, including pharmaceuticals and foods. A number of biocides are also used for cleaning purposes; cleaning in these cases refers to the physical removal of foreign material from a surface

 

Considerable progress has been made in understanding the mechanisms of the antibacterial action of antiseptics and disinfectants By contrast, studies on their modes of action against fungi viruses and protozoa have been rather sparse. Furthermore, little is known about the means whereby these agents inactivate prions.

Whatever the type of microbial cell (or entity), it is probable that there is a common sequence of events. This can be envisaged as interaction of the antiseptic or disinfectant with the cell surface followed by penetration into the cell and action at the target site(s). The nature and composition of the surface vary from one cell type (or entity) to another but can also alter as a result of changes in the environment Interaction at the cell surface can produce a significant effect on viability (e.g. with glutaraldehyde) (ut most antimicrobial agents appear to be active intracellularly The outermost layers of microbial cells can thus have a significant effect on their susceptibility (or insusceptibility) to antiseptics and disinfectants; it is disappointing how little is known about the passage of these antimicrobial agents into different types of microorganisms. Potentiation of activity of most biocides may be achieved by the use of various additives, as shown in later parts of this review.

In this section, the mechanisms of antimicrobial action of a range of chemical agents that are used as antiseptics or disinfectants or both are discussed. Different types of microorganisms are considered, and similarities or differences in the nature of the effect are emphasized. The mechanisms of action are summarized .

 

Summary of mechanisms of antibacterial action of antiseptics and disinfectants

 

 

Target	Antiseptic or disinfectant	Mechanism of action
Cell envelope (cell wall, outer membrane)	Glutaraldehyde	Cross-linking of proteins
	EDTA, other permeabilizers	Gram-negative bacteria: removal of Mg2+, release of some LPS
Cytoplasmic (inner) membrane	QACs	Generalized membrane damage involving phospholipid bilayers
	Chlorhexidine	Low concentrations affect membrane integrity, high concentrations cause congealing of cytoplasm
	Diamines	Induction of leakage of amino acids
	PHMB, alexidine	Phase separation and domain formation of membrane lipids
	Phenols	Leakage; some cause uncoupling
Cross-linking of macromolecules	Formaldehyde	Cross-linking of proteins, RNA, and DNA
	Glutaraldehyde	Cross-linking of proteins in cell envelope and elsewhere in the cell
DNA intercalation	Acridines	Intercalation of an acridine molecule between two layers of base pairs in DNA
Interaction with thiol groups	Silver compounds	Membrane-bound enzymes (interaction with thiol groups)
Effects on DNA	Halogens	Inhibition of DNA synthesis
	Hydrogen peroxide, silver ions	DNA strand breakage
Oxidizing agents	Halogens	Oxidation of thiol groups to disulfides, sulfoxides, or disulfoxides
	Peroxygens	Hydrogen peroxide: activity due to from formation of free hydroxy radicals (·OH), which oxidize thiol groups in enzymes and proteins; PAA: disruption of thiol groups in proteins and enzymes

 

Mechanisms of antiprotozoal action have not been widely investigated. One reason for this is the difficulty in culturing some protozoa (e.g.,Cryptosporidium) under laboratory conditions. However, the different life stages (trophozoites and cysts) do provide a fascinating example of the problem of how changes in cytology and physiology can modify responses to antiseptics and disinfectants. Khunkitti et al.  have explored this aspect by using indices of viability, leakage, uptake, and electron microscopy as experimental tools.

Some of these procedures can also be modified for studying effects on viruses and phages (e.g., uptake to whole cells and viral or phage components, effects on nucleic acids and proteins, and electron microscopy) . Viral targets are predominantly the viral envelope (if present), derived from the host cell cytoplasmic or nuclear membrane; the capsid, which is responsible for the shape of virus particles and for the protection of viral nucleic acid; and the viral genome. Release of an intact viral nucleic acid into the environment following capsid destruction is of potential concern since some nucleic acids are infective when liberated from the capsid , an aspect that must be considered in viral disinfection. Important considerations in viral inactivation are dealt with by Klein and Deforest and Prince et al. , while an earlier paper by Grossgebauer is highly recommended.

AlcoholsAlthough several alcohols have been shown to be effective antimicrobials, ethyl alcohol (ethanol, alcohol), isopropyl alcohol (isopropanol, propan-2-ol) and-propanol (in particular in Europe) are the most widely used Alcohols exhibit rapid broad-spectrum antimicrobial activity against vegetative bacteria (including mycobacteria), viruses, and fungi but are not sporicidal. They are, however, known to inhibit sporulation and spore germination, but this effect is reversible Because of the lack of sporicidal activity, alcohols are not recommended for sterilization but are widely used for both hard-surface disinfection and skin antisepsis. Lower concentrations may also be used as preservatives and to potentiate the activity of other biocides. Many alcohol products include low levels of other biocides (in particular chlorhexidine), which remain on the skin following evaporation of the alcohol, or excipients (including emollients), which decrease the evaporation time of the alcohol and can significantly increase product efficacy . In general, isopropyl alcohol is considered slightly more efficacious against bacteria  and ethyl alcohol is more potent against viruses ; however, this is dependent on the concentrations of both the active agent and the test microorganism. For example, isopropyl alcohol has greater lipophilic properties than ethyl alcohol and is less active against hydrophilic viruses (e.g., poliovirus) Generally, the antimicrobial activity of alcohols is significantly lower at concentrations below 50% and is optimal in the 60 to 90% range.

Little is known about the specific mode of action of alcohols, but based on the increased efficacy in the presence of water, it is generally believed that they cause membrane damage and rapid denaturation of proteins, with subsequent interference with metabolism and cell lysis . This is supported by specific reports of denaturation of Escherichia coli dehydrogenases and an increased lag phase in Enterobacter aerogenes, speculated to be due to inhibition of metabolism required for rapid cell division.

Glutaraldehyde.Glutaraldehyde is an important dialdehyde that has found usage as a disinfectant and sterilant, in particular for low-temperature disinfection and sterilization of endoscopes and surgical equipment and as a fixative in electron icroscopy. Glutaraldehyde has a broad spectrum of activity against bacteria and their spores, fungi, and viruses, and a considerable amount of information is now available about the ways whereby these different organisms are inactivated.

The bacterial spore presents several sites at which interaction with glutaraldehyde is possible, although interaction with a particular site does not necessarily mean that this is associated with spore inactivation. E. coli, S. aureus, and vegetative cells of Bacillus subtilis bind more glutaraldehyde than do resting spores of B. subtilis; uptake of glutaraldehyde is greater during germination and outgrowth than with mature spores but still lower than with vegetative cells. Low concentrations of the dialdehyde (0.1%) inhibit germination, whereas much higher concentrations (2%) are sporicidal. The aldehyde, at both acidic and alkaline pHs, interacts strongly with the outer spore layers ; this interaction reduces the release of dipicolinic acid (DPA) from heated spores and the lysis induced by mercaptoethanol (or thioglycolate)-peroxide combinations. Low concentrations of both acidic and alkaline glutaraldehyde increase the surface hydrophobicity of spores, again indicating an effect at the outermost regions of the cell. It has been observed by various authors that the greater sporicidal activity of glutaraldehyde at alkaline pH is not reflected by differences in uptake; however, uptake per se reflects binding and not necessarily penetration into the spore. It is conceivable that acidic glutaraldehyde interacts with and remains at the cell surface whereas alkaline glutaraldehyde penetrates more deeply into the spore. This contention is at odds with the hypothesis of Bruch , who envisaged the acidic form penetrating the coat and reacting with the cortex while the alkaline form attacked the coat, thereby destroying the ability of the spore to function solely as a result of this surface phenomenon. There is, as yet, no evidence to support this theory. Novel glutaraldehyde formulations based on acidic rather than alkaline glutaraldehyde, which benefit from the greater inherent stability of the aldehyde at lower pH, have been produced. The improved sporicidal activity claimed for these products may be obtained by agents that potentiate the activity of the dialdehyde .

During sporulation, the cell eventually becomes less susceptible to glutaraldehyde (see “Intrinsic resistance of bacterial spores”). By contrast, germinating and outgrowing cells reacquire sensitivity. Germination may be defined as an irreversible process in which there is a change of an activated spore from a dormant to a metabolically active state within a short period. Glutaraldehyde exerts an early effect on the germination process. L-Alanine is considered to act by binding to a specific receptor on the spore coat, and once spores are triggered to germinate, they are committed irreversibly to losing their dormant properties . Glutaraldehyde at high concentrations inhibits the uptake ofL-[¹⁴C]alanine by B. subtilisspores, albeit by an unknown mechanism . Glutaraldehyde-treated spores retain their refractivity, having the same appearance under the phase-contrast microscope as normal, untreated spores even when the spores are subsequently incubated in germination medium. Glutaraldehyde is normally used as a 2% solution to achieve a sporicidal effect ; low concentrations (<0.1%) prevent phase darkening of spores and also prevent the decrease in optical density associated with a late event in germination. By contrast, higher concentrations (0.1 to 1%) significantly reduce the uptake of L-alanine, possibly as a result of a sealing effect of the aldehyde on the cell surface. Mechanisms involved in the revival of glutaraldehyde-treated spores are discussed below (see “Intrinsic resistance of bacterial spores”).

There are no recent studies of the mechanisms of fungicidal action of glutaraldehyde. Earlier work had suggested that the fungal cell wall was a major target site , especially the major wall component, chitin, which is analogous to the peptidoglycan found in bacterial cell walls.

Glutaraldehyde is a potent virucidal agent . It reduces the activity of hepatitis B surface antigen (HBsAg) and especially hepatitis B core antigen ([HBcAg] in hepatitis B virus [HBV]) and interacts with lysine residues on the surface of hepatitis A virus (HAV) . Low concentrations (<0.1%) of alkaline glutaraldehyde are effective against purified poliovirus, whereas poliovirus RNA is highly resistant to aldehyde concentrations up to 1% at pH 7.2 and is only slowly inactivated at pH 8.3 . In other words, the complete poliovirus particle is much more sensitive than poliovirus RNA. In light of this, it has been inferred that glutaraldehyde-induced loss of infectivity is associated with capsid changes . Glutaraldehyde at the low concentrations of 0.05 and 0.005% interacts with the capsid proteins of poliovirus and echovirus, respectively; the differences in sensitivity probably reflect major structural variations in the two viruses .

Bacteriophages were recently studied to obtain information about mechanisms of virucidal action . Many glutaraldehyde-treated P. aeruginosa F116 phage particles had empty heads, implying that the phage genome had been ejected. The aldehyde was possibly bound to F116 double-stranded DNA but without affecting the molecule; glutaraldehyde also interacted with phage F116 proteins, which were postulated to be involved in the ejection of the nucleic acid. Concentrations of glutaraldehyde greater than 0.1 to 0.25% significantly affected the transduction of this phage; the transduction process was more sensitive to the aldehyde than was the phage itself. Glutaraldehyde and other aldehydes were tested for their ability to form protein-DNA cross-links in simian virus 40 (SV40); aldehydes (i.e., glyoxal, furfural, prionaldehyde, acetaldehyde, and benzylaldehyde) without detectable cross-linking ability had no effect on SV40 DNA synthesis, whereas acrolein, glutaraldehyde, and formaldehyde, which formed such cross-links , inhibited DNA synthesis .

Formaldehyde.Formaldehyde (methanal, CH₂O) is a monoaldehyde that exists as a freely water-soluble gas. Formaldehyde solution (formalin) is an aqueous solution containing ca . 34 to 38% (wt/wt) CH₂O with methanol to delay polymerization. Its clinical use is generally as a disinfectant and sterilant in liquid or in combination with low-temperature steam. Formaldehyde is bactericidal, sporicidal, and virucidal, but it works more slowly than glutaraldehyde .

Formaldehyde is an extremely reactive chemical that interacts with protein , DNA , and RNA in vitro. It has long been considered to be sporicidal by virtue of its ability to penetrate into the interior of bacterial spores . The interaction with protein results from a combination with the primary amide as well as with the amino groups, although phenol groups bind little formaldehyde . It has been proposed that formaldehyde acts as a mutagenic agent and as an alkylating agent by reaction with carboxyl, sulfhydryl, and hydroxyl groups . Formaldehyde also reacts extensively with nucleic acid (e.g., the DNA of bacteriophage T2). As pointed out above, it forms protein-DNA cross-links in SV40, thereby inhibiting DNA synthesis . Low concentrations of formaldehyde are sporostatic and inhibit germination . Formaldehyde alters HBsAg and HBcAg of HBV .

It is difficult to pinpoint accurately the mechanism(s) responsible for formaldehyde-induced microbial inactivation. Clearly, its interactive, and cross-linking properties must play a considerable role in this activity. Most of the other aldehydes (glutaraldehyde, glyoxyl, succinaldehyde, and o -phthalaldehyde [OPA]) that have sporicidal activity are dialdehydes (and of these, glyoxyl and succinaldehyde are weakly active). The distance between the two aldehyde groups in glutaraldehyde (and possibly in OPA) may be optimal for interaction of these-CHO groups iucleic acids and especially in proteins and enzymes .

Formaldehyde-releasing agents.Several formaldehyde-releasing agents have been used in the treatment of peritonitis . They include noxythiolin (oxymethylenethiourea), tauroline (a condensate of two molecules of the aminosulponic acid taurine with three molecules of formaldehyde), hexamine (hexamethylenetetramine, methenamine), the resins melamine and urea formaldehydes, and imidazolone derivatives such as dantoin. All of these agents are claimed to be microbicidal on account of the release of formaldehyde. However, because the antibacterial activity of taurolin is greater than that of free formaldehyde, the activity of taurolin is not entirely the result of formaldehyde action .

o-Phthalaldehyde.OPA is a new type of disinfectant that is claimed to have potent bactericidal and sporicidal activity and has been suggested as a replacement for glutaraldehyde in endoscope disinfection . OPA is an aromatic compound with two aldehyde groups. To date, the mechanism of its antimicrobial action has been little studied, but preliminary evidence  suggests an action similar to that of glutaraldehyde. Further investigations are needed to corroborate this opinion.

AnilidesThe anilides have been investigated primarily for use as antiseptics, but they are rarely used in the clinic. Triclocarban (TCC; 3,4,4′-triclorocarbanilide) is the most extensively studied in this series and is used mostly in consumer soaps and deodorants. TCC is particularly active against gram-positive bacteria but significantly less active against gram-negative bacteria and fungi (30) and lacks appreciable substantivity (persistency) for the skin . The anilides are thought to act by adsorbing to and destroying the semipermeable character of the cytoplasmic membrane, leading to cell death .

Chlorhexidine.Chlorhexidine is probably the most widely used biocide in antiseptic products, in particular in handwashing and oral products but also as a disinfectant and preservative. This is due in particular to its broad-spectrum efficacy, substantivity for the skin, and low irritation. Of note, irritability has been described and in many cases may be product specific . Despite the advantages of chlorhexidine, its activity is pH dependent and is greatly reduced in the presence of organic matter . A considerable amount of research has been undertaken on the mechanism of the antimicrobial action of this important bisbiguanide

 

Preparation and storage of antiseptic solutions: essential precautions

Antiseptics are disinfectants used for bodily care (disinfecting the skin, wounds and mucosa).

As paradoxical as it may seem, water-based antiseptic solutions may be contaminated by germs when being handled and may become germ cultures, especially in the case of the Pseudomonas aeruginosa (pyocyanic).

Mycobacteria are generally highly resistant to chlorhexidine . Little is known about the uptake of chlorhexidine (and other antiseptics and disinfectants) by mycobacteria and on the biochemical changes that occur in the treated cells. Since the MICs for some mycobacteria are on the order of those for chlorhexidine-sensitive, gram-positive cocci , the inhibitory effects of chlorhexidine on mycobacteria may not be dissimilar to those on susceptible bacteria. Mycobacterium avium-intracellulare is considerably more resistant than other mycobacteria .

Chlorhexidine is not sporicidal (discussed in “Mechanisms of resistance”). Even high concentrations of the bisbiguanide do not affect the viability of Bacillusspores at ambient temperatures , although a marked sporicidal effect is achieved at elevated temperatures . Presumably, sufficient changes occur in the spore structure to permit an increased uptake of the biguanide, although this has yet to be shown experimentally. Little is known about the uptake of chlorhexidine by bacterial spores, although coatless forms take up more of the compound than do “normal” spores .

Chlorhexidine has little effect on the germination of bacterial spores but inhibits outgrowth . The reason for its lack of effect on the former process but its significant activity against the latter is unclear. It could, however, be reflected in the relative uptake of chlorhexidine, since germinating cells take up much less of the bisbiguanide than do outgrowing forms . Binding sites could thus be reduced iumber or masked in germinating cells.

The antiviral activity of chlorhexidine is variable. Studies with different types of bacteriophages have shown that chlorhexidine has no effect on MS2 or K coliphages . High concentrations also failed to inactivatePseudomonas aeruginosa phage F116 and had no effect on phage DNA within the capsid or on phage proteins ; the transduction process was more sensitive to chlorhexidine and other biocides than was the phage itself. This substantiated an earlier finding  that chlorhexidine bound poorly to F116 particles. Chlorhexidine is not always considered a particularly effective antiviral agent, and its activity is restricted to the lipid-enveloped viruses . Chlorhexidine does not inactivate nonenveloped viruses such as rotavirus , HAV , or poliovirus . Its activity was found by Ranganathan to be restricted to the nucleic acid core or the outer coat, although it is likely that the latter would be a more important target site.

Alexidine.Alexidine differs chemically from chlorhexidine in possessing ethylhexyl end groups. Alexidine is more rapidly bactericidal and produces a significantly faster alteration in bactericidal permeability . Studies with mixed-lipid and pure phospholipid vesicles demonstrate that, unlike chlorhexidine, alexidine produces lipid phase separation and domain formation (Table 2). It has been proposed that the nature of the ethylhexyl end group in alexidine, as opposed to the chlorophenol one in chlorhexidine, might influence the ability of a biguanide to produce lipid domains in the cytoplasmic membrane.

Polymeric biguanides.Vantocil is a heterodisperse mixture of polyhexamethylene biguanides (PHMB) with a molecular weight of approximately 3,000. Polymeric biguanides have found use as general disinfecting agents in the food industry and, very successfully, for the disinfection of swimming pools. Vantocil is active against gram-positive and gram-negative bacteria, althoughP. aeruginosa and Proteus vulgaris are less sensitive. Vantocil is not sporicidal. PHMB is a membrane-active agent that also impairs the integrity of the outer membrane of gram-negative bacteria, although the membrane may also act as a permeability barrier . Activity of PHMB increases on a weight basis with increasing levels of polymerization, which has been linked to enhanced inner membrane perturbation .

Unlike chlorhexidine but similar to alexidine (Table2), PHMB causes domain formation of the acidic phospholipids of the cytoplasmic membrane. Permeability changes ensue, and there is believed to be an altered function of some membrane-associated enzymes. The proposed sequence of events during its interaction with the cell envelope ofE. coli is as follows: (i) there is rapid attraction of PHMB toward the negatively charged bacterial cell surface, with strong and specific adsorption to phosphate-containing compounds; (ii) the integrity of the outer membrane is impaired, and PHMB is attracted to the inner membrane; (iii) binding of PHMB to phospholipids occurs, with an increase in inner membrane permeability (K⁺ loss) accompanied by bacteriostasis; and (iv) complete loss of membrane function follows, with precipitation of intracellular constituents and a bactericidal effect.

DiamidinesThe diamidines are characterized chemically as described in Table1been used as antibacterial agents. Their antibacterial properties and uses were reviewed by Hugo ( have dibromopropamidine (2,2-dibromo-4,4-diamidinodiphenoxypropane), and . The isethionate salts of two compounds, propamidine (4,4-diaminodiphenoxypropane and Hugo and Russell . Clinically, diamidines are used for the topical treatment of wounds.

The exact mechanism of action of diamidines is unknown, but they have been shown to inhibit oxygen uptake and induce leakage of amino acids (Table 2), as would be expected if they are considered as cationic surface-active agents. Damage to the cell surface of P. aeruginosa and Enterobacter cloacae has been described .

Halogen-Releasing AgentsChlorine- and iodine-based compounds are the most significant microbicidal halogens used in the clinic and have been traditionally used for both antiseptic and disinfectant purposes.

Chlorine-releasing agents.Excellent reviews that deal with the chemical, physical, and microbiological properties of chlorine-releasing agents (CRAs) are available . The most important types of CRAs are sodium hypochlorite, chlorine dioxide, and the N -chloro compounds such as sodium dichloroisocyanurate (NaDCC), with chloramine-T being used to some extent. Sodium hypochlorite solutions are widely used for hard-surface disinfection (household bleach) and can be used for disinfecting spillages of blood containing human immunodeficiency virus or HBV. NaDCC can also be used for this purpose and has the advantages of providing a higher concentration of available chlorine and being less susceptible to inactivation by organic matter. In water, sodium hypochlorite ionizes to produce Na⁺ and the hypochlorite ion, OCl⁻, which establishes an equilibrium with hypochlorous acid, HOCl . Between pH 4 and 7, chlorine exists predominantly as HClO, the active moiety, whereas above pH9, OCl⁻ predominates. Although CRAs have been predominantly used as hard-surface disinfectants, novel acidified sodium chlorite (a two-component system of sodium chlorite and mandelic acid) has been described as an effective antiseptic .

Surprisingly, despite being widely studied, the actual mechanism of action of CRAs is not fully known (Table 2). CRAs are highly active oxidizing agents and thereby destroy the cellular activity of proteins ; potentiation of oxidation may occur at low pH, where the activity of CRAs is maximal, although increased penetration of outer cell layers may be achieved with CRAs in the unionized state. Hypochlorous acid has long been considered the active moiety responsible for bacterial inactivation by CRAs, the OCl⁻ion having a minute effect compared to undissolved HOCl . This correlates with the observation that CRA activity is greatest when the percentage of undissolved HOCl is highest. This concept applies to hypochlorites, NaDCC, and chloramine-T.

Deleterious effects of CRAs on bacterial DNA that involve the formation of chlorinated derivatives of nucleotide bases have been described . Hypochlorous acid has also been found to disrupt oxidative phosphorylation and other membrane-associated activity . In a particularly interesting paper, McKenna and Davies  described the inhibition of bacterial growth by hypochlorous acid. At 50 μM (2.6 ppm), HOCl completely inhibited the growth ofE. coliwithin 5 min, and DNA synthesis was inhibited by 96% but protein synthesis was inhibited by only 10 to 30%. Because concentrations below 5 mM (260 ppm) did not induce bacterial membrane disruption or extensive protein degradation, it was inferred that DNA synthesis was the sensitive target. In contrast, chlorine dioxide inhibited bacterial protein synthesis .

CRAs at higher concentrations are sporicidal ; this depends on the pH and concentration of available chlorine. During treatment, the spores lose refractivity, the spore coat separates from the cortex, and lysis occurs. In addition, a number of studies have concluded that CRA-treated spores exhibit increased permeability of the spore coat .

CRAs also possess virucidal activity .Olivieri et al.  showed that chlorine inactivated naked f2 RNA at the same rate as RNA in intact phage, whereas f2 capsid proteins could still adsorb to the host. Taylor and Butler  found that the RNA of poliovirus type 1 was degraded into fragments by chlorine but that poliovirus inactivation preceded any severe morphological changes. By contrast, Floyd et al. and O’Brien and Newman  demonstrated that the capsid of poliovirus type 1 was broken down. Clearly, further studies are needed to explain the antiviral action of CRAs.

Iodine and iodophors.Although less reactive than chlorine, iodine is rapidly bactericidal, fungicidal, tuberculocidal, virucidal, and sporicidal.

Although aqueous or alcoholic (tincture) solutions of iodine have been used for 150 years as antiseptics, they are associated with irritation and excessive staining. In addition, aqueous solutions are generally unstable; in solution, at least seven iodine species are present in a complex equilibrium, with molecular iodine (I₂) being primarily responsible for antimictrobial efficacy . These problems were overcome by the development of iodophors (“iodine carriers” or “iodine-releasing agents”); the most widely used are povidone-iodine and poloxamer-iodine in both antiseptics and disinfectants. Iodophors are complexes of iodine and a solubilizing agent or carrier, which acts as a reservoir of the active “free” iodine. Although germicidal activity is maintained, iodophors are considered less active against certain fungi and spores than are tinctures .

Similar to chlorine, the antimicrobial action of iodine is rapid, even at low concentrations, but the exact mode of action is unknown. Iodine rapidly penetrates into microorganisms  and attacks key groups of proteins (in particular the free-sulfur amino acids cysteine and methionine , nucleotides, and fatty acids , which culminates in cell death. Less is known about the antiviral action of iodine, but nonlipid viruses and parvoviruses are less sensitive than lipid enveloped viruses . Similarly to bacteria, it is likely that iodine attacks the surface proteins of enveloped viruses, but they may also destabilize membrane fatty acids by reacting with unsaturated carbon bonds.

 

TO AVOID THE CONTAMINATION OF SOLUTIONS, ESSENTIAL PRECAUTIONS MUST BE TAKEN:

– Make all water-based dilutions either with:

• drinking water from a distributioetwork

• boiled water, previously filtered if necessary or

• water filtered through a well-maintained candle-shaped filter in good condition (brushed and disinfected or boiled once a week).

– Change all water-based solutions once a week at least.

To facilitate this, set one day of the week when all solutions are systematically changed.

– Prepare only small volumes at a time to avoid wastage or temptation to keep expired solutions.

– Never add fresh solution to a residue of out-dated solution (wash the bottles and allow them to dry before refilling them)

– Do not use a cork stopper

Indicate the name and concentration of products on all bottles.

 

 

Weighing a Client, Mobile and Immobile

A client’s weight is an essential piece of data used in monitoring his response to a variety of therapies.

Changes in a client’s weight could necessitate an alteration in the assessment and intervention plans. An accurate weight is important, therefore, to ensure appropriate care

ASSESSMENT

1. Assess the client’s ability to stand independently and safely on a scale. Consider factors requiring the use of a sling scale: the client is somnolent or comatose; paralyzed; too weak to stand; or unsteady

when standing.

2. Determine if clothing is similar to that worn during previous weight measurement to help determine

accuracy of the new weight.

Standing Scale

1. Wash hands.

2. Introduce yourself to client and explain what you would like her to do.

3. Place scale near client.

4. Turn on scale and calibrate to zero.

5. Ask client to step up on the scale and stand still (see Figure 22).

Electronic scale: Read weight after digital numbers have stopped fluctuating.

Balance scale: Slide the larger weight into the notch most closely approximating the client’s

weight. Slide the smaller weight to the notch such that the balance rests in the middle.Add

the two numbers to read the client’s weight.

6. Ask client to step down and assist client back to the bed or chair, if necessary.

7. Wipe scale with appropriate disinfectant.

8. Wash hands.

 

zhovtuha

ikterichnost sclera

Dark brown color of the skin may occur when the adrenal insufficiency. Skin color reminds intense tan, more pronounced in the open areas.

Spots on the face and increased pigmentation of the white line of the abdomen, breast nipple may be signs of pregnancy. There are cases when the skin lacks pigment (albinism). Often identified foci of depigmentation as white spots – (vitiligo).

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Skin moisture determined by the function of the sweat glands . Excessive moisture of the skin can occur in healthy people at high ambient temperature ( bath, hot shop ), with hard work , with emotional overload.

Excessive sweating can occur at the critical high temperature reduction ( under the influence of drugs or spontaneously ) , tuberculosis (night sweats exhausting ) , introducing diseases , septic conditions . Excessive sweating can occur in thyrotoxicosis , neurocirculatory dystonia.

Excessive dryness of the skin can be a sign of dehydration ( for diarrhea , uncontrollable vomiting ) , with excess fluid excretion by the kidneys (diabetes , diabetes insipidus ) . Dry skin may depend on medication (atropine ) , be a sign of hypothyroidism ( myxedema ) , when accompanied by an increased reduction of turgor skin keratinization .

Elasticity (turgor) determined by the content of fluid in the tissues , as the blood supply . This property is determined by palpation of the skin on the forearm when two fingers ( thumb and forefinger), and take the skin in the crease , and then release it . A healthy person’s skin fold quickly straightened . On examination, the elasticity is retained rounded contours , rounded body. Decrease in skin turgor examination revealed the severity of wrinkles on the face and neck , sunken eyes . Fold of skin on palpation straightened slowly. This may be a sign of dehydration , rapid weight loss , senile atrophy of the skin .

On examination of the skin may occur scars : on the thighs and abdomen after pregnancy , deep, close connection with subordinate layers , is a sign of suffering tuberculous lymphadenitis , or syphilitic lesions , postoperative scars indicate migrated in the past surgery or injury .

Skin rash (eruptio) are important for the diagnosis of infectious diseases , pathology of blood .

 

Skin rash (eruptio) are important for the diagnosis of infectious diseases, pathology of blood.

 

 

 

Roseola (roseola) – spotty rash 2-3 mm in diameter, which disappears when pressed. Often identified on the abdomen and lower chest (typhoid fever, paratyphoid, syphilis).

 

 

Erythema (erythema) – vidmezhena sharply from healthy tissue hyperemic portion slightly rises above the healthy skin. Can manifest itself in the face, allergic reactions, septic conditions. Erythematous patches in the localization on the nose in the form of butterflies, aggravated by exposure to the sun cause suspicion lupus erythematosus. Chervonofioletovoe (violet) coloring of the upper eyelid to diagnose dermatomyositis.

 

 

 

 

Hair. The distribution of body hair has sex differences. Besides the absence of beard, mustache and a weaker growth of hair on the body, women have more differences in the growth of pubic hair. In women, hair growth is bounded above by a horizontal line, while men grow hair in the midline to the navel. The absence of these differences may be due to dysfunction of the gonads.

 

Excessive hair growth (hypertrichosis or hirsutism) can be a sign of adrenal tumors or testicular acromegaly. Hypotrichosis often genetically or medically dependent. Hair loss (alopecia) can be caused by trauma, hypothyroidism, thallium intoxication, scleroderma, fungal diseases, syphilitic lesions, systemic lupus erythematosus.

 

Nails. Lack of polish can be a congenital anomaly that is associated with ichthyosis or result of trauma. Due habits nibbling nails can manifest lack of the free edge of the nail with his inequality. Unusually long and narrow nails detect Marfan syndrome.

 

 

 

 

 

 

The development of the subcutaneous tissue depends on the constitutional features of the person , age, gender . In addition to assessing the degree of development when viewed from subcutaneous tissue ( overly – , medium-, ill-defined ) , determined by palpation skinfold thickness , capturing lower blade angle in women or in the left hypochondrium or middle third of the arm with two fingers in men skin area of 5 cm and squeeze it between your fingers. If this fold of skin is so thin that through it well tangible opposite finger , it means that the subcutaneous tissue is poorly developed , if the fingers probed lightly – medium developed, if the fingers do not felt – strongly developed (excessive fat deposition ) . Skinfold thickness to better identify with the help of a compass dimensional ( 1 cm in men , women up to 2 cm ) .

Uniform deposition of fat in the subcutaneous basis can occur in healthy people leading a sedentary lifestyle , excessive eat fats and carbohydrates . Uneven deposition of fat is often a manifestation of endocrine diseases or disorders of the neuroendocrine regulation ( deposition of fat on the face , neck, shoulder girdle with thin limbs with Cushing’s disease ) .

 

 Cushing’s disease

 

Edema (oedema) caused by accumulation of fluid in the tissues. On examination, the skin shiny, smoothed fossa and bony prominences . When edema is stretched and strained skin looks clear. When expressed edema top layer of skin can peel off the accumulation of fluid in the blisters that burst to form ulcers. On examination, the skin over the swelling visible imprints of clothing, footwear . To identify edema fingertips pressed against the skin to the bone basis , leads to the formation of pits that slowly straighten . In ambulant patients with edema looking at dorsum of the foot or on the surface of the tibia perednomedialny . In patients who are on bedrest , swelling easier to spot in the lumbosacral region . Under general edema should seek their cause : heart disease, kidney disease, malnutrition . This may show signs of accumulation of fluid in the serous cavities ( peritoneal , pleural , cardiac cavity shirts ) and subcutaneous tissue (anasarca). Local swelling asymmetrical , often caused by disorders of blood and lymph circulation ( vein thrombosis , with compression of the lymphatic ducts tumor or enlarged lymph nodes ) . Local swelling may be a manifestation of an allergy ( angioedema of the face, neck), local inflammatory process.

 

 

 

 

 

Lymph nodes. On examination can only be detected significantly increased lymph nodes at the same time pay attention to the changes in the skin over them ( redness, fistula formation ) . More detail the state of nodes can be estimated by palpation. A healthy person’s lymph nodes were not enlarged and not palpable.

Consistently performed palpation of the cervical , submandibular , and over – the subclavian , axillary , elbow , inguinal and popliteal lymph nodes . Lymph nodes were palpated palmar surface of the fingers and deeper palpation performed fingertips . Determine the amount of nodes , their consistency , tenderness , mobility, zluchenist with the surrounding tissues , fluctuation , the scars on them. Systemic lymphadenopathy characteristic of hematological diseases ( chronic lymphocytic leukemia, Hodgkin’s disease ) , HIV , syphilis. Local lymph node enlargement may be a response to the inflammatory process ( submandibular when dental caries or inflammation of the tonsils ) or metastasis ( supraclavicular lymph nodes increase in the left gastric tumors ) .

Muscle. Assess the degree of their development , with the feeling discover soreness. Muscle development makes it possible to judge the overall condition of the patient : the debilitating diseases can manifest muscle atrophy , decrease their strength . Available on isolated muscle atrophy from stroke paralyzed limbs. Muscle strength was investigated using a dynamometer ( for each hand separately). The study was conducted three times and record the best result. Averages of the right hand men of 40-45 kg, 30-35 kg in women , the left hand is less than 5-10 kg .

The class strength ( muscle strength back extensors ) define spring dynamometer . Analyzed rises on support plus , which is attached to the chain dynamometer , and without bending the arms and legs slowly unbent , does removing the chain. In men, the rate of 130-150 kg, 80-90 kg in women .

Overview of the hands and feet . Hands in a healthy person straight. To determine this examinee pulls them forward , palms up and connects so that little fingers touching. If this does not touch your elbows hands , so they are straight . otherwise indicate X -shape.

 

Legs can be straight, O- or X -shaped . Straight leg upright touching heels , inner ankles , calves , and internal vyrostkami entire surface of the thighs. Legs O- shaped touch only the upper thighs and heels , X -shaped – in the hips, internal femoral condyles and diverge in the calves and heels . The distance between the hip vyrostkami at About -shape between your heels and with X -shape of more than 5 cm indicates a significant deviation from the norm leg shape . Stops can be flattened and flat. Disproportionately large feet reveal in acromegaly .

Examination of joints and locomotor apparatus begin with a detailed examination of the affected joints. Each joint has its inherent shape. With the development of pathological processes in the joints change their appearance .

Mild these changes – change the contours of the joints ( the smoothness of its contours) , swelling of the joints – a total loss of its natural shape due to edema and joint effusion is palpation . Chronic inflammatory processes in the joints cause deformation and stable defiguratsiya joints ( spherical deformation of the knee more often in juvenile rheumatoid arthritis , fusiform – Tuberculous , clavate – syphilis ) .

Deformation interphalangeal joints of the hands due to bone growths characteristic of deforming osteoarthritis , ulnar deviation of the fingers of the joint – for rheumatoid arthritis.

 

Deformed joints are the cause of establishing a false limbs, especially the lower. At various joint diseases may occur varus placement of the knee, (O-shaped legs) or valgus – (X-shaped legs).

 

 

Examination joints should pay attention to the condition of symmetric joint , where you can make a comparison , if he is not involved in the pathological process .

Increased skin temperature is a manifestation of the inflammatory process, its active phase . Lowering the temperature is a sign of spastic state or regional vascular occlusion due to vascular disease . To determine the temperature of the back surface of the skin brush should be attached to the joint area for a moment. Longer application can compare the temperature of the patient and the investigator. Compare the temperature of the skin over the symmetrical joints. In symmetric affected joints compared temperature femur, tibia and knee or shoulder, elbow and forearm . A healthy person’s knee and elbow joints have a lower temperature than the femur and tibia , respectively, and if the temperature of the hip, knee and lower leg is the same, it indicates a pathological process in the joint.

Head . Significant changes in the size of the skull often detected during the inspection of children: an enlarged skull in hydrocephalus , microcephaly with reduced . Rectangular shape of the head is often a sign of childhood rickets . Certain diagnostic importance is the position of the head. Limited mobility or complete immobility of her reveal osteochondrosis , ankylosing спондилоартрит.Покачивание head in the anteroposterior direction in synchronism with the heartbeat possible aortic insufficiency (with pale skin and observed pulsation of the carotid arteries in the neck – “dance carotid ” ) . Twitching of the head or body parts can be a sign of a nervous tic or chorea minor .

Overview of the face. Expression in good health calm, intelligent , cheerful, with the disease – a martyr .

With fever – a person excited , skin red , shiny eyes (facies febrilis).

Puffy face is in renal disease (facies nephritica), frequent attacks of bronchial asthma and coughs hoarsely , local venous stasis as a result of mediastinal tumor process or general agreement pericarditis ( due to compression of the superior vena cava ) may be allergic origin ( angioedema ) .

In heart failure, face puffy, pale yellow with a bluish tint , mouth half open , lips cyanotic , eyes droop (face corvisart ) . Cyanotic blush on the cheeks, bluish coloration of the mucous lips and nose tip legkozhovtushni sclera stenosis of the left atrioventricular opening (facies mitralis).

 

 

Cautious , anxious , frightened face , dilated eye slits , frightened eyes bulging shiny – the patient’s face in thyrotoxicosis (f. Basedovica).

When miksedeme contrary, puffy face , eyes narrowed the gap , the hair on the outer half of the eyebrows are missing, nose and lips thickened and pale skin . Enlarged protruding nose , lower jaw , eyebrows , frontal mounds , thick lips can diagnose acromegaly . The same features, but softer expressed, sometimes in women during pregnancy. Intense red, rounded like a full moon face with the growth of beards and mustaches in women can manifest in Cushing’s disease . In severe chronic liver person is tired , yellow skin and mucous membranes . “Butterfly” on the nose (erythema on the nose or in the cheek or brow , not necessarily symmetric ) appears in systemic lupus erythematosus . In systemic sclerosis mask-like face , amimichnoe , waxy skin , taut , shiny, hard taken in the fold , half-open eyes , lips delicate , mouth slit narrowed , surrounded by wrinkles in the form of a pouch . Dark purple erythema and periorbital edema on the face detected with dermatomyositis .

Eyes .

 

On examination, pay attention to the width of the eye slits , state age , conjunctiva, sclera, cornea and pupil . Uneven eye slits may be due to the omission of a century due to paralysis of the oculomotor nerve or bleeding or syphilitic brain damage . Narrowed eye slits can be kidney disease , myxedema , expanded – with thyrotoxicosis . Sign of myasthenia gravis is the inability in the evening to raise the upper eyelids , so that the eyeballs remain partially or completely closed. ” Bags ” under the eyes can be the first sign of acute nephritis or arise in paroxysms of coughing , after insomnia in healthy people – after eating salty , peppery dishes. Dark color of the eyelid may occur with adrenal insufficiency , hyperthyroidism ; limited yellow spots on the eyelid skin ( xanthomas ) in the pathology of lipid metabolism , liver diseases. Retraction of both eyeballs show with peritonitis , cholera , significant dehydration in moribund patients.

On examination, the conjunctiva can see her pallor , which correlates with the level of hemoglobin in the blood is a sign of its redness inflammation in viral and bacterial infections , can manifest petechiae ( in hypertensive crisis , protracted septic endocarditis ) . Examining the sclera can detect them inekovanist vessels (coughing , asthma attack , infectious diseases ) , it is easier to detect jaundice color is a manifestation of jaundice.

Corneal reflex is checked by touching a piece of paper to the cornea , resulting in an immediate closing of the eyes . Bilateral absence of corneal reflex may be a sign of a coma , narcotic sleep ; unilateral absence of such a reflex may be at defeat triple nerve.

On examination, the pupils pay attention to their size , symmetry , reaction to light. Pupillary discover in uremia , tumors, inflammatory diseases and hemorrhage inside the skull , with morphine and nicotine poisoning . When aortic aneurysm or tumor compressing the cervical sympathetic ganglion , can manifest unilateral contraction of the pupil on the affected side . Such a unilateral constriction of the pupil may be in people with long working monocle (jewelers , watchmakers ) . Dilated pupils show in comas (except uremia and bleeding in the brain ) , in cases of poisoning by atropine or its instillation into the conjunctival sac for ophthalmoscopy , in botulism , clinical death in moribund patients. Rhythmic pulsation pupils (narrowing and expanding them) synchronous with the heart beat can be a sign of aortic insufficiency .

The reaction of pupils to light is checked as follows : two palms doctor closes his eyes tightly subject (you can turn) and monitors or narrowed pupils and how quickly it happened when they hit the light . In a healthy person under the influence of pupillary light is instantaneous and the reaction is estimated to be living . Weakly expressed or absent response to light may be in coma, drug poisoning , atropine .

Strabismus occurs when paralysis of the eye muscles ( lead poisoning , botulism , diphtheria ), and lesions of the brain or its membranes .

Nose. On examination, evaluate the shape , size, color of skin local , state nasal breathing . Disproportionately large nose ( with thick lips , big cheekbones ) is a sign of acromegaly : not as sharp when he increased myxedema . Pointed nose is a sign of a sharp depletion , dehydration, systemic scleroderma . Red nose with a bluish tint can be a sign of alcoholism. Curvature of the nose may be the result of injury ( boxers ), and a saddle shape – a sign of syphilis. Erythematous rash on the nose or atrophic scars testify in favor of lupus . Herpetic eruptions on the wings of the nose can be with pneumonia , then it turns out that the wings of the nose involved in breathing ( inspiratory rise , fallen down during exhalation ) . Nasal obstruction is often a sign of inflammation in the nasal passages and sinuses , accompanied by the growth of polyps or a deviated septum , and the patient is always open or half-open mouth.

Ears . Cyanotic color of their skin is a sign of cardiopulmonary failure, pallor earlobes is a sign of anemia , tubercles yellow-white color on the inner surface of the ear can detect gout .

Mouth. Dry chapped lips covered brown crusts are more often for serious infectious diseases accompanied by fever . Mucosal cyanosis of the lips is a sign of heart failure. Cold sores on the lips reveal a fever , viral infection , inflammation of the lungs .

 

Examination first pay attention to the size and shape of it: increased fat tongue may be a manifestation of myxedema, acromegaly, an allergic reaction, his tumor or trauma. Smooth tongue with atrophied papillae detected by gastric disease. Dryness of the tongue with cracks her bleeding indicates the plight of the patient. Imprints of teeth on the side surface of the tongue is a sign of increasing it, and small scars – a consequence of traumatic bites in epileptic seizures.

 

 

Hives (urticaria) – round or oval red blisters on the skin, similar to those at the sting . Often a manifestation of allergies can manifest in the human liver .

Cold sores (herpes) – vesicles with a diameter of 0.5 to 1 cm, which initially contain clear and then cloudy liquid . A few days later the bubbles burst , exposing eroded area . Often detected on the lips and nose wings ( with pneumonia , respiratory infection ) or along the nerve branches ( shingles) .

Bleeding in the skin ( haemorrhagiae ) – can be of different sizes : point ( petechiae ) , linear ( ecchymosis ) , massive ( hematoma ) . Unlike the rash they do not disappear when pressed , eventually change their color (red changes to green and then yellow). The presence of purpura may be a sign of hypovitaminosis , dysfunction or decrease in platelet count , liver diseases.

On the skin of the upper half of the body may appear excessive dilation of the capillaries and arterioles (teleangiectasia) – spider veins , which are a sign of inflammatory activity in the liver or liver cirrhosis and failure arise from inactivation in the liver sudinnoaktivnih substances cause dilation of small vessels .

On the anterior abdominal wall , on the shins and thighs can be seen irregularly dilated veins that are visible through the skin. These are signs of venous blood outflow ( genetically determined in the propagation of lower limb veins ) or by increasing the pressure in the portal vein ( liver cirrhosis ) . Varicose veins (varices) on the legs can cause certain areas of thrombosis , followed by the entry of blood clots in the blood flow in the pulmonary circulation ( pulmonary artery branches thromboembolism ) , so finding them may be the key for the diagnosis of this disease.

Atrophy (atrophia) – skin becomes thinner, easily injured, loses its normal pattern. May be a sign of senile atrophy , discoid lupus erythematosus , lipodystrophy after insulin injections .

Erosion (erosia) – the most superficial violation of the integrity of the skin due to rupture of vesicles with herpes or other rashes , exposing the shiny red surface.

Cracks (fissura) – linear damage in the dermal layers of the epidermis often with hyperkeratosis , hypovitaminosis ( in the corners of the mouth ) .

Ulcers (ulcus) – deep skin damage to the papillary layer. Often the result of traumatic injury , burns, malnutrition ( for varicose veins propagation ) .

Tremors tip extended language detected in hyperthyroidism, alcoholism , its deviation in the direction (deviation ) – with hemiplegia due to cerebrovascular accidents . Complete inspection of the oral cavity and pharynx detailed examination of the tonsils.

Neck . On examination, pay attention to its height : for patients with emphysema is characterized by a short neck , head looks when planted on the chest . Swollen veins in the neck is a sign of congestion due to heart failure, as well as the difficulty of outflow of blood from the superior vena cava with mediastinal tumors , pericardial effusion , adhesive mediastinoperikarditi . On examination, you can see the pulsation of the carotid arteries ” carotid dance ” with severe aortic insufficiency .

Enlargement of the thyroid gland can be uniform and then discover when inspecting round neck or isolation may increase one of its destiny ( adenoma ) .

 

 

 Thorax . Conducting a general examination of the chest in women pay particular attention to the state of the mammary glands. Observed standing with his hands down , and then picks them up. Symmetry control mammary glands did not change their path, no protrusion or pits on the surface , have not changed nipples ( pay attention to their symmetry , the presence of these secretions or dried crusts) . In the supine position the examinee palm conduct palpation of both glands , defining properties of tissues between the toes and chest . Upon detection of the seal detail its localization (in which quadrant ) value , texture , motility , the presence of enlarged lymph nodes. Fingertips palpate clockwise each gland (the patient alternately puts his hand behind his head and a corresponding shoulder cushion or roller ) . Thumb and forefinger squeeze the nipple : the transparent or spotting womaeeds inspection oncologist.

 

 

Pronounced kyphoscoliosis spine

Inspection of the abdomen . A healthy person’s belly jutting slightly right and left half of it symmetrical , navel retracted rib arc slightly outlined . People with asthenic constitution abdomen may be retracted. In the horizontal position of the subject stomach should be level with the chest . With insufficient development of abdominal muscles in the upright position of the patient exhibit sagging belly. Increasing the size of the stomach may be due to the excessive development of subcutaneous fat, accumulation of gas in the intestines ( flatulence ) , accumulation of fluid in the abdomen (ascites ) , the presence of tumors , cysts. To clarify the reasons for the increase belly review complement palpation and percussion , which should be carried out in the horizontal and vertical positions of the patient. With obesity abdominal wall thickened , navel drawn around it rises and anterior abdominal wall . Edema of the abdomeavel remains retracted , anterior abdominal wall testovatoy consistency clicking finger leaves a trace , traces remain of the belt, rubber bands , clothes. When this swelling occur in other areas of the body .

 

Thermometry

Fever – is typical pathological process which is characterized by a change in temperature increase and thermoregulation of the body, regardless of the ambient temperature. In the evolution of fever emerged as a reaction to infection , and therefore, in addition to fever , during this process there are other phenomena that are typical of infectious disease. Intoxication and samoperegrivannya create a complex picture in which the phenomenon of damage combined with defensively .

Fever must be distinguished from hyperthermia. Last develops due to external or internal body heating . Febrile thermoregulation center is rebuilt so that it allows you to actively raise the body temperature to a higher level . In hyperthermia the body temperature rises despite attempts thermoregulation center to keep it at a normal level.

Iormal thermoregulation performed reflexively . At the periphery (skin , internal organs ) is cooling and thermal receptors that perceive temperature fluctuations internal and external environment and from which the information comes in the thermoregulation center , located in the hypothalamus. Neurons are here have direct and sensitive to both heat and cold . Integration of temperature signals and the temperature of the hypothalamus produces effector impulses travel mostly along the sympathetic nerves and determine the state of metabolism , the intensity of the peripheral circulation , trembling, shortness of breath. Fever begins with a change of this reflex mechanism and setting the temperature at a different, higher , level.

1. Stage fever . A characteristic feature of this stage is the predominance of heat over the emissivity (A > B). I must not think that in this period lost control over the regulation of heat. In contrast, the reference temperature ” setpoint ” actively shifted upward , and all the mechanisms of heat production and heat rearranged so as to keep the body temperature at the highest level . Firstly , heat transfer is limited , and this mechanism is critical. Peripheral vessels constrict , decreasing the influx of warm blood to the peripheral tissues , decreases sweating and evaporation. In addition, all other paths are blocked by the heat output – radiation, conduction , convection . Muscle contraction occurs hair follicles , increasing insulation and as a result – the appearance of ” goose bumps .”

Increase heat production is achieved by boosting metabolism in muscle ( contractile thermogenesis ) due to increased muscle tone and muscle tremors . Muscular tremors associated with spasm of the peripheral vessels. Due to the decrease in blood flow , skin temperature decreases sometimes by several degrees. Thermoreceptors excited , you feel cold – shivering. In response, the thermoregulation center sends efferent impulses to the motor neurons – there trembling.

Simultaneously, the amplified and thermogenesis , i.e. heat generation in the organs such as liver , lung, brain. This is the result of nerve trophic action on the tissue , resulting in activated enzymes , increased oxygen consumption and heat production . In thermal homeostasis unbalance viznachealnu may play a role as humoral factors . It is known that some bacterial toxins have the ability to separate the oxidation and oxidative phosphorylation and thereby contribute to the formation of heat. This additional thermogenesis can accelerate temperature increase in stage I of fever.

2 . Body temperature rises up until it reaches the reference temperature, ” set point .” At this level, it is still some time (hours, days), there comes a stage of high standing temperature. In this heat production again comes into equilibrium with the emissivity (A = B) , although higher than normal temperature. The patient feels a surge of heat (fever ) . Increases not only the temperature of the internal organs , but also the temperature of the skin.

Keeping the temperature at a higher level due to the fact that under the influence of leukocyte pyrogen changes ” set point ” thermoregulation center . At this level restarts mechanism to maintain constant temperature with characteristic oscillations in the morning and evening, the amplitude of which is significantly higher than that iormal.

New level of temperature fluctuations during its days are determined by several factors, including the crucial amount of pyrogens and sensitivity to them thermoregulatory centers . Furthermore, the system is set to the heat output power , accuracy and reliability of a functional and trophic innervation, forming substances disconnectors and, finally , the presence of energy in the body of the stock material , particularly fat. In malnourished people infectious diseases can occur without fever . In children, it develops rapidly, old – slowly , to a low level .

By raising the body temperature rise in the second stage rozrizyanyut fever following :

a) low-grade – up to 38 0 C;

b ) moderate – 38-39 0 C;

c) high – 39-41 0 C;

g ) giperpiretichesky – more than 41 0 C.

Stage temperature reduction. Upon termination of pyrogens thermoregulation center is restored , set point temperature drops to normal levels. The heat accumulated in the body, derived as a result of vasodilation of the skin, the appearance of frequent sweating and breathing.

Reducing the temperature may be gradual , lytic (several days) or rapid critical. In the latter case, it may happen too sudden vasodilatation , and in combination with intoxication may occur life-threatening collapse.

Dynamics of changes in body temperature during fever can be represented as the temperature curve . Temperature curve at a fever always consists of three parts – the head , the high standing and drop, but each of them as a whole and the curve may have their own characteristics, inform the doctor about the patient’s condition and have differential diagnostic value . Its character depends on the pathogen and the reactivity of the organism.

On the nature of the temperature curve can affect biological features of the pathogen , such as cyclicality of its development in the blood. In this regard, the temperature curve in malaria – intermittent (febris intermittens). Thus, when vivax (malaria tertiana) febrile seizures occur in a day, whereby the temperature rises sharply and held at a height of between 30 – 60 minutes to 2 – 3 hours and then returned to its initial level and can even be lower than it.

Dependence of the temperature curve of the pathogen is clearly seen as the example of typhoid fever during the return (febris recurens). Spirochete Obermeyer with phagocytosed makrofagotsity and multiplies them. As accumulation in cells spirochetes break through the barrier of mononuclear phagocytes and blood filled . This contributes to an attack of fever lasts 6-8 days , after which the temperature decreases and the critical period comes apyrexia also takes 6 – 8 days. Seizures can be repeated .

Febrile biorhythms depend not only on the pathogen , but also on the patient’s body , on the capacity of the immune system to respond to antigenic stimuli from the nervous and endocrine system and metabolism . It should be noted that due to the use of antibiotics and other drugs , temperature curves largely lost its typicality .

Thermometry – the measurement of human body temperature . Body temperature is relatively constant internal environment , the maintenance of which the complex processes of thermoregulation. Body temperature constancy is ensured that the amount of heat that is generated in the body ( heat production ) because of oxidative processes in the muscle and viscera power to the quantity of heat which gives body to the external environment ( heat ) . The higher the intensity of metabolic processes , the more heat production . Giving the body heat is through evaporation from the surface of the skin and respiratory tract , heat radiation and heating the surrounding air ( teploprovedeniya ) . Temperature stability ( temperature homeostasis ) regulated by a special thermoregulatory center located in the brain and coordinated interaction of the nervous , endocrine and cardiovascular systems and excretory organs . Body’s ability to change the level of heat transfer depends mainly on the network located in the skin blood vessels, which can quickly change their clearance . If insufficient heat production in the body (or cooling) reflexively constrict blood vessels of the skin and reduces heat . The skin becomes cold , dry, sometimes a muscle tremors , which increases heat production. Conversely, when excess heat (or overheating ) reflexively apply skin vessels , increases blood supply and therefore increases the heat loss by radiation and teploprovedeniya . If these mechanisms are insufficient heat , then sharply increased sweating : evaporates from the surface of the body , sweat provides intense body heat loss . Violation of mechanisms of heat as a result of external or internal causes can lead to a reduction , and often kpovysheniyu body temperature – fever.

In a healthy person under the armpit temperature ranges 36,4-36,8 ° C, in the rectum by 1 ° C above. Lethal maximum body temperature 42,5 ° C. The irreversible changes of protein structures . Minimum lethal body temperature fluctuates between 15-23 ° C. Possible physiological fluctuations . Thus, the temperature measured in the rectum , vagina, inguinal fold , mouth, turns on 0,2-0,4 ° C higher than the armpit. Children ‘s body temperature is slightly higher ( iewborns , it reaches 37,2 ° C under the arm ) , aged opposite – reduced . In women, the temperature depends on the phase of the menstrual cycle : during ovulation , it increases by 0,6-0,8 ° C. Diurnal variation in body temperature 0,1-0,6 ° C. The maximum temperature recorded in the second half of the day , between 17 – th and 22 th hours , and the minimum – at dawn between the third and 6th hours.

 

 

 

Level of body temperature depends on the disease, or determined by reaction of the patient pathological factor. Therefore, measurement of body temperature (thermometers) may be of diagnostic value.

Measured body temperature maximum medical thermometer. This glass tank where soldered scale and capillary having an extension at the end, filled with mercury. When heated, the mercury rises in the capillary, remaining at the level maximizing cooling and even so called maximum thermometer.

 

 

Electronic thermometer

 

 

 

mercury thermometer

Made to measure the temperature in the armpit , mouth (oral temperature) , rectum (rectal temperature). Before measuring the thermometer is shaken to the mercury dropped into the tank. To do this, grab the top of the thermometer into a fist so that the middle of it was between the thumb and forefinger , and repeatedly shaken . When shaking uncooled thermometer mercury column breaks are possible , which should be eliminated by repeated shaking. Before the measurement of temperature is necessary to examine the axilla (to avoid local inflammatory processes) and wipe dry her of underwear or a towel. End of the thermometer with the mercury reservoir is placed in the armpit , for which the patient must take a hand. The thermometer is placed so that the mercury reservoir on all sides in contact with the body. To thermometer slipped , the patient’s hand tightly lead to chest, in debilitated and ill hand fixes sister . Temperature measurement lasts at least 10 min. Between the thermometer and the body should not be underwear .

When measuring the temperature in the rectum thermometer smeared with Vaseline or other grease. The patient lies on her side and the thermometer is introduced into the rectum to a depth of 6-7 cm after the introduction of the thermometer buttocks of the patient closer to each other , which ensures its fixation . 5 min hold the thermometer . Rectal thermometers are used in neonates , malnourished patients and Exhausted . It should not be used in inflammatory processes in the rectum , diarrhea , bleeding from the cracks or hemorrhoidal veins , as well as instituting patient. After each measurement temperature thermometer wash with warm soapy water and disinfect ( 1:1000 mercuric chloride or alcohol ) .

When measuring the temperature of the thermometer in the mouth is placed under the tongue and the teeth are fixed . Children often measured temperature in the inguinal crease. For this purpose the leg is bent at the hip joint , so that the thermometer is in the crease formed . After measuring the temperature of a patient thermometer thoroughly washed with warm running water and immersed for 15-20 min in the dark glass disinfectant ( Dexon 0.1 % or 1% chloramine ) , then wiped well and shaking off label mercury below 35 ° C give another patient.

In the hospital the body temperature was measured twice a day: between 6th and 8th hours of the morning and 16 in the 18 hours of the day . The patient then lies or sits . Prescribed by a doctor , to catch the maximum temperature rise during the day, it was measured every 2-3 hours. The obtained data were recorded in the temperature log , and then transferred to individual air leaf glued to the map of the inpatient . Temperature sheet is one of the mandatory forms of medical documentation. In it, except for temperature , blood pressure is recorded , the amount of fluid , the amount of daily urine output , the body weight of the patient , the intervention (puncture of the pleural cavity , etc.). The results of each designated point temperature at the intersection of the temperature indicators and the date and time ( morning, evening ) measurements . Broken line from the junction of these points is called the temperature curve has specific characteristics in certain diseases .

 

 

For the rapid detection of people with increased body temperature in a big team used polymer -coated plates emulsion of liquid crystals ” TERMOTEST .” The plate applied to the skin of the frontal region . At a temperature of 36-37  C on plate green light letter “N” (Norma), and at temperatures above 37  C – the letter “F” (Febris). Level of temperature increase is determined medical thermometer .

Elektrotermometriia – body temperature measurement using sensors to various parts of the body . Method is much less inertia , easy to loose , restless patients in children. The sensors are connected with an arrow on the scale of the deviation which determines the body temperature of the patient. In intensive care units in the monitoring system used thermometric individual blocks. With an increase in body temperature of range audible or visual alarm . The method allows for daily , and if necessary longer, the registration of temperature fluctuations .

With simultaneous measurement of rectal and skin temperature gradient increase of temperature due to lower skin temperature detected in acute circulatory failure ( collapse) and with different variants of shock ( cardiogenic shock, myocardial infarction ) .

Human disease can manifest decrease or increase in temperature. Lowering the temperature below 36 ° C are found in patients with :

– A reduced function of the thyroid gland;

– In the collapse ;

– Supercooling ;

– Starvation ;

– The elderly and old age;

– In agony and in a state of clinical death.

A moderate increase in temperature may be under physiological conditions ( intense muscular work, at the height of digestion) . Temperature rises over

37 ° C in pathological states called fever or fever.

By increasing the degree of distinction :

– Low-grade (37-38  C)

– Moderately elevated (38-39  C)

– High (39-41  C)

– Excessively high temperatures (above 41 C   

Degree rise in temperature determines the features of patient care .

Important is to define the daily temperature fluctuations or fever . The following types of fevers.

1. Fever constant type : (febris continua) body temperature is set to high figures , lasts a long time , its daily fluctuations do not exceed 1  C. Can be a sign of pneumonia, typhoid fever.

2 . Relapsing fever , laxative : (febris remittens) with a difference in temperature during the day 1-2  C without reducing it to normal levels. Observed in tuberculosis, introducing diseases .

3 . Intermittent fever , intermittent (febris intermittens). There is a brief sudden increase in temperature to 39-40  C and rapid decline to normal levels. Fever, repeated after 2-3 days, may be a sign of malaria.

4 . Hectic fever or exhausting (febris hectica) – high temperature rise with a sharp 3-4  C to reduce it to a normal level , or even lower , with debilitating sweating. Observed in tuberculosis, sepsis , chlamydia .

5 . Reverse type of fever (febris inversus), when the morning temperature is higher and decreases in the evening. May be a sign of sepsis , tuberculosis, brucellosis .

6. Undulating fever (febris undulans): there is a periodic increase in temperature, followed by its reduction to the normal period and normal body temperature . May be a sign of Hodgkin’s disease , brucellosis .

 

Figure 1-9 . Different types of temperature curves . Figure 1-7 Fever : Fig. 1 – constant, Fig. 2 – laxative , Fig . 3 – intermittent , Fig . 4 . – Hectic , Fig . 5 – return ; Figure 6 – wavy , Fig . 7 – bad . Fig . 8. Crisis . Fig . 9. Lysis .

Care of patients with fever is determined by its stage . There are three stages of fever :

I – increase in body temperature ( this step is characteristic predominance of heat over the emissivity )

II – constantly elevated temperature ( characterized by a balance between heat production and heat loss )

III – decrease in body temperature ( heat production decreases and increases its efficiency ) .

Clinical manifestations of the first stage is muscle tremors , chilliness, muscle aches , headache , malaise, pallor or cyanosis sometimes limbs. The skin is cold to the touch, takes the form of ” goose ” . The duration of this stage from a few hours to 2-5 days. The patient should be put to bed , warm ( impose heaters , drink hot tea, hide an extra blanket ) . Patients with fever should be on strict bedrest and exercise physiological needs in bed.

In the second stage of fever is stabilized at a high level , are only its fluctuations during the day. Increased heat production and heat dissipation are in dynamic equilibrium . Significantly reduced muscular tremors , pale skin redness changes . The patient may complain of headache, feeling of heat , thirst , dry mouth , loss of appetite . Skin is hot , red , eyes shining . At higher temperatures possible delirium ( delirium ) . Signs of intoxication delirium is the appearance of features in the behavior of the patient: anxiety , crying, moaning, repeating the same questions to the staff , refusal of food , increased sensitivity to noise and light . The patient then starts to doze off in silence lies with eyes wide open , staring considering painting mereschatsya him . Excitation can occur : the patient falls from bed can make an attempt to run out into the street or jump out of the window. Facial expression of fear and anxiety. He submitted ghost pictures , animals that are attacking him. Delirium is a dangerous strain on the cardiovascular system and the possible danger to the patient’s life and actions of the people around them .

In such cases, set the individual post .

The bed is placed further away from the window and so had access to it from all sides. Chamber of take away all unnecessary objects , especially sharp and cutting . Nurse monitors pulse , blood pressure, respiration , skin color and performs medical purposes. Headache on the forehead of the patient can put a cold compress soaked in a solution of vinegar (2 tablespoons per 0.5 liters of water ) linen napkins, towels or make cold wrap . On the forehead of the patient put a napkin or towel wrapped ice pack .

Instead of a bubble of cold water or ice is used , if necessary in a dry ice bags “Penguin” , which is pre-cooled in a freezer . The effect of these sacs remains 2-3 h , they can be applied to the area of the large vessels of the neck , elbow bends. You can put cold compresses , which make using towels or lineapkins folded in quarters and soaked in vinegar mixed with water or water diluted 1:1 with alcohol. Napkin twisting well , shake and apply to head in the frontal and temporal lobes . Poultice dries quickly and needs to be replaced every 8-10 minutes . Control the pulse frequency and the blood pressure value . Often the cardiovascular system (especially in elderly patients ) is crucial in the prognosis of the disease , so it is necessary to introduce a timely manner designed cardiac or vascular agents.

Temperature and its significant fluctuations cause depletion of the patient. To increase the resistance of the organism , it is necessary to give the patient digestible foods high energy value in the form of a liquid or semi (diet number 13). Due to the significant decrease in appetite , food should be frequent ( 5-6 times ), and the food should be given in small portions , better watch setback . For detoxification patient requires a large amount of liquid in the form of fruit and berry juices , mineral water degassed . This reduces the concentration of toxic products in the blood. Introduction provides a large amount of liquid vigorous detoxificatioot only the kidneys , but also due to sweating skin and mucous membranes. Restriction of salt in the diet also reduces fluid retention in the body , increases urine .

Often, high temperature cracks occur body lips and corners of the mouth which must be lubricated with oil or vaseline glycerol. Sterilized spatula and tweezers with enough sterile gauze napkins placed on a sterile tray. The medicine is poured into a petri dish . Sandwiched tweezers cloth moistened with medications. The patient was asked to open his mouth and, using the spatula, discover the affected spot mucosa. Applied thereto dampened cloth drugs . For each location of the lesion using fresh sterile cloth . Mouth rinse or wipe with a weak solution of sodium bicarbonate . Bedridden patients requires careful skin care, which will help to prevent bedsores. In case of constipation give enema . Sick in bed and fed ship urinal . When winding Chamber beware drafts patient should tuck , and a head cover with a towel. Care should be taken that the patient did not drop a blanket. During the period of fever the patient is prescribed bed rest .

During the period of decline in body temperature ( stage III ) can be different , because it can happen quickly or slowly. A slow decrease in temperature for a few days called lysis. Fast during the day (often for 5-8 h ) , lower temperature with higher values ​​iormal and even subnormal called crisis.

Critical temperature reduction can be accompanied by acute circulatory failure manifested by excessive sweating , pale skin sometimes with cyanosis , decreased blood pressure , increased heart rate and a decrease in its content , until the appearance of filamentous . Extremities become cold to the touch , the skin clammy , cold sweat. At a critical decrease in body temperature of the patient nurse controls properties pulse and blood pressure value . If necessary, apply the tools of intensive care , emergency administration of vascular agents ( phenylephrine , caffeine , epinephrine hydrochloride). The patient is placed at the feet warmers , clean pillow under the head or raise the lower end of the bed , give drink hot tea or coffee. With the sudden deterioration of the patient should call the doctor on duty . When excessive sweating patient wipes , change of underwear and bed linen . At night, leave a few spare pairs of underwear to replace wet .

During lytic reduction of body temperature patient feels general weakness. After the temperature has fallen , it usually falls asleep. The patient’s condition improved. He expanded the motor mode , designate high calorie diet .

alleged problems

Hyperpyrexia or hyperthermia – it is too high ( above 41 ° C) increase in body temperature , which can lead to serious condition of the patient, or even death.

Hyperpyrexia : can manifest syncope , agitation, delirium , fever. Reduce fever and pain : cold water and vinegar lotion on his head an ice pack on his head, wiping the patient’s body with room temperature water with vinegar, wrapping wet naked patient , exposure of the patient and the fan switch .

When hyperthermia heavy flow is not exposed to therapeutic measures , recommend: taxation patient ice packs , the introduction of chilled isotonic sodium chloride solution , enema with cold water.

Physical methods of dealing with hyperthermia include:

– Air baths outdoors ( even in winter ) , a body blow by a fan

– Wet wrapping the entire body of the patient, sometimes in combination with the inclusion of the fan ;

– Sponging the body with water and vinegar , cold compress ( vinegar- water on the head );

– The application of ice packs , which are placed on the head, on the areas where there are large vessels (liver, upper third of the front of the thigh );

– Taxation of the whole body ice packs ;

– The use of enemas with cold (10-15 ° C) water.

 

hed from the body (otherwise it threatens cerebral edema ) .

The physical methods also relates gastric lavage with cold water , the introduction of up to 10-20 ml of 4-8 ° C solution of glucose.

Drugs are administered by a doctor. Certainly parenterally administered analginum diphenhydramine .

 

Therapeutic and diagnostic service can be only for hospital and clinic and include various profile labolatoriyi, classrooms (ECG renhtenivskyy, physical therapy, exercise therapy, massage and etc..).

Hospitals as a structural element to be a pharmacy, pathological department (SIDS).

By administrative economic part is easting, storage, laundry (if they are not centralized in the city), Technical Department, disinfecting camera etc.

Based on the basic functions and features of Typical traditional model of hospital release following main structural parts statsianaru: admissions department, profiling medical departments, special treatments, diagnostic service departments and others.

 

Admissions department hospital hospital can be centralized (for all hospitals) or decentralized (to some special structural parts thereof. 

The primary goals of the admissions department:

1. Acceptance of patients, the diagnosis and of the need for hospitalization.

2. Registration of patients and bypass traffic in the hospital.

3. Medical sorting patients.

4. Providing if necessary emergency care.

5. Sanitization of patients (in some cases).

6. Serving ovidkovoho center on the status of patients.

 

Independent employ staff on duty doctors foster establishing offices in hospitals with 500 beds or more, and the number of beds in likarnyahz less alternate turns all residents Hospital.

In hospitals with 200 beds and more staff in admissions is a doctor – zaviduyuchyyviddilennyam and middle and junior medical staff. If there are staff positions independent physicians in the emergency department, patients incoming from the hours of doctors offices, in addition to the admissions department physicians, residents inspect the relevant departments.

In krupnyhbahatoprofilnyh hospitals clock duty in the emergency department provides a team of doctors, consisting of a surgeon, travmotoloha, physician and radiologist.

Other doctors (gynecologist, urologist, neurosurgeon, nervopatoloh etc.). Duty, usually in the relevant specialized departments and if necessary their cause in the admissions department at kosultatsiyu.3

After examination of the patient with the admissions department or sent to a specialized (if diagnosed) or diagnostic department (House), which is structurally and geographically in the admissions department.

 

One of the functions of the hospital the hospital is fighting nosocomial infections, whose presence complicates treatment leads to utyazhelinnya proceeds and increased provodzhenosti treatment.

For the purpose of combating nosocomial infections in the emergency department allocated diagnostic chamber – for short stay patients temperature to diagnosis. Upostupayuchyh patients and their relatives gather detailed epidemiological history. With revenue of children compulsory Help SES on child transferred infectious diseases and contact with infectious patients.

 

2. Medical (health) department

The most optimal number of beds in large hospitals vidddilenni taken 60-70 lizhok.V presence of such offices is the most optimal states required set prymishen more opportunities to install modern machines, equipment and so on.

Medical office linked to general hospitals dopomizhnymymedychnymy and economic services, and in large hospitals – from general hospitals for clinical and other laboratories.

States department of hospital medical staff utvoryuyutysya depending on the number of beds, type and profile of the institution. The main structure in a regular hospital department are dominant head office, doctor-intern, nurse, nurse, sister-mistress.

In large departments are subordinate: head nurse, Sister mistress, directly responsible for the economic state department.

In surgical wards senior operating nurses. The immediate treatment in hospital are doctors – ordynatyry. In one post doctors – ordynatyra have an average of 25 beds with some variations depending on the profile of the hospital.

Work in the office in the morning begins with a morning conference, called “p’yatyhylynky.”

Daily registrar office receives information from night duty medical personnel about the condition of patients, prognosis Enrolling patients, familiarity with laboratory, radiographic and other studies conducted bypass patients, accompanied by a nurse. After bypassing the doctor proceeds to therapeutic and diagnostic procedures. In surgical wards operations are designed to schodennho surgeons often bypass patients, and in some cases bypass surgeons spend their sick after working in the operating room.

After this the doctors filled history of surgical patients.

History hvoryby is very important in the overall rate of patients in the hospital – is an important medical document.

There are several main functions of history 

1. He has great practical value – it covered the basic medical and diagnostic information about the patient. It shows the flow dynamics of the disease.

2. It has practical value for students, residents, graduate nurses.

3. Has scientific value. Many clinical and anatomical conclusions based on data history.

4. Legal value – in some cases death basic document is the chief witness protection insults or doctor, medical staff, when you need a forensic investigation.

 At discharge, patients ordinator is epicrisis – a short statement on the course of the disease and the time of discharge.With a history of illness discharged and deceased resident introduces the head of department.3. Performance inpatient (hopital)care

For the analysis of hospital use diverse indicators. In the most cnservative stimates are widely used over 100 different indicators inpatient care. A number of indicators can be grouped as reflecting determining areas of functioning hospital. In particular, vydilyayutb indicators describing: 

– Provision of public inpatient care,

– Load of medical staff

– Logistical and medical security,

– Use of hospital beds,

– The quality of inpatient care and its effectivenes. 

a) zabezpechennist, accessibility and structure of inpatient care 

1. The number of beds per 10,000 inhabitants

2. Admission rate per 1000 inhabitants

3. Availability of beds separate profiles per 10,000 inhabitants

4. Structure of beds;

5. Structure hospitalized on profiles

6. Level hospitalization pediatric population

7. The need for inpatient care per 1 inhabitant per year (number of bed-days), which accounts for 1 inhabitant per year in the area:

 b) load of medical staff

8. The number of beds at the first position in the changing doctor, nurses

9. Manning hospital doctors (nurses)

10. Feature medical office

11. Index of labor efficiency in hospitals

c) Performance of beds.

12. Average number of beds per year (bed occupancy during the year)

13. The average length of stay of the patient in bed

14. Turnover bed

15. Average downtime bed

16. Dynamics of hospital beds and others.

d) The quality and efficiency of inpatient care

17. Загальнолікарнянийпоказник litalnosti

18. Structure of deceased patients: an account of beds, in separate groups of diseases and certain forms of lymphoma

19. Proportion of deaths in the first day

e) Quality of surgical hospital

20. Postoperative litalnist

21. The frequency of postoperative complications

22. Structure of operating procedures

23. Rate surgical activity

24. Dynamism being operated on in hospital

25. Indicators of emergency surgical care

e) Results of inpatient care

26. Proportion hospitalized planning iekstrenno

27. Seasonality hospitalization

28. Distribution Enrolling patients in the days (Hourly days) and other indicatorsHospital admissions department consists of (centralized or decentralized), specialized wards departments, operational units and others.

Therapeutic and diagnostic service can be only for hospital and clinic and include various profile laboratories, classrooms (ECG, X-ray, physical therapy, exercise therapy, massage, etc.)..

Hospitals as a structural element to be a pharmacy, pathological department (SIDS).

By administrative economic part is easting, storage, laundry (if they are not centralized in the city), Technical Department, disinfection camera etc.

Based on the basic functions and typical features of the traditional model of hospital release following main structural parts of the hospital: admissions department, profiling medical departments, special treatments, diagnostic service departments and others.

Admissions department hospital hospital can be centralized (for all hospitals) or decentralized (to some special structural parts thereof).

The primary goals of the admissions department:

1. Acceptance of patients, the diagnosis and of the need for hospitalization.

2. Registration of patients and bypass traffic in the hospital.

3. Medical sort patients.

4. Providing if necessary emergency care.

5. Sanitization of patients (in some cases).

6. Serving as a reference center on the status of patients.

Independent employ staff on duty doctors foster establishing offices in hospitals with 500 beds or more, and in hospitals with less number of beds alternate turns all residents Hospital.

In hospitals with 200 beds or more in state admissions is a doctor – Head of Department, as well as middle and junior medical staff. If there are staff positions independent physicians in the emergency department, patients who enter the hours doctors offices, in addition to the admissions department physicians, residents inspect the relevant departments.

In large multidisciplinary hospitals clock duty in the emergency department provides medical team consisting of a surgeon, trauma, physician and radiologist.

Other doctors (gynecologist, urologist, neurosurgeon, neurologist, etc.). Duty, usually in the relevant specialized departments and if necessary their cause in the admissions department for advice.

After examination of the patient with the admissions department or sent to a specialized (if diagnosed) or diagnostic department (House), which is structurally and geographically in the admissions department.

One of the functions of the hospital hospitals are combating intra-hospital infection, whose presence complicates treatment leads to an adverse outcome and increased duration of treatment.

For the purpose of combating intra-hospital infections in the emergency department allocated diagnostic chamber – for short stay patients temperature to diagnosis. In

Patients who come to the hospital and their relatives gather detailed epidemiological history. At admission children must help SES on child transferred infectious diseases and contact with infectious patients.

Medical (health) department

The most optimal number of beds in the department of a large hospital accepted the presence of 60-70 beds. In these offices is the most optimal states required set of premises, more opportunities for installation of modern equipment, technology and so on.

Medical office linked to the general hospital for medical and ancillary commercial services, and in large hospitals – from general hospitals for clinical and other laboratories.

States department of hospital medical staff formed depending on the number of beds, type and profile of the institution. The main structure in a regular hospital department are dominant head office, doctor-intern, nurse, nurse, sister-mistress.

In large departments are subordinate: head nurse, Sister mistress, directly responsible for the economic state department.

In surgical wards senior operating nurses. The immediate treatment in hospital are doctors – interns. In one post doctors – Resident had an average of 25 beds with some variations depending on the profile of the hospital.

Work in the office in the morning begins with a morning conference, called “p’yatyhvylynky.”

Daily registrar office receives information from night duty medical personnel about the condition of patients, prognosis of those admitted patients, familiarity with laboratory, radiographic and other studies conducted bypass patients, accompanied by a nurse. After bypassing the doctor proceeds to therapeutic and diagnostic procedures.

In surgical wards intended operations are often surgeons to daily bypass patients, and in some cases bypass surgeons spend their sick after working in the operating room.

Then doctors fill history of surgical patients.

The medical history is of great importance in the overall rate of patients in the hospital – is an important medical document.

There are several main functions of history:

 

1. He has great practical value – it covered the basic medical and diagnostic information about the patient. It shows the flow dynamics of the disease.

2. It has practical value for students, residents, graduate nurses.

3. Has scientific value. Many clinical and anatomical conclusions based on data history.

4. Legal value – in some cases death basic document is the chief witness protection insults or doctor, medical staff, when you need a forensic investigation.

 

At discharge, patients ordinator is epicrisis – a short statement on the course of the disease and the time of discharge.

With a history of illness discharged and deceased resident introduces the head of department.

Performance inpatient (hospital) care

 

For the analysis of hospital use diverse indicators. In the most conservative estimates are widely used over 100 different indicators inpatient care. A number of indicators can be grouped as reflecting determining areas of functioning hospital. In particular, emphasize indicators that describe:

 

– Provision of public inpatient care,

12. The average number of beds per year (bed occupancy during the year)

13. The average length of stay of the patient in bed

14. Turnover bed

15. Average downtime bed

16. Dynamics of hospital beds and others.

d) The quality and efficiency of inpatient care

17. General-hospital mortality rate

18. Structure of deceased patients: an account of beds, in separate groups of diseases and certain forms of lymphoma

19. Proportion of deaths in the first day

e) Quality of surgical hospital

20. Postoperative mortality

21. The frequency of postoperative complications

22. Structure of operating procedures

23. Rate surgical activity

24. Dynamism being operated on in hospital

25. Indicators of emergency surgical care

e) Results of inpatient care

26. Proportion hospitalized planning and emergency

27. Seasonality hospitalization

28. Distribution of patients admitted on weekdays (by hours of the day) and other indicators

 

Physician of any specialty in practice to analyze their activity over time, which allows to identify the positive aspects and shortcomings in the work of a unit doctor of medical facility. Therefore, students need to know the structure, content, an annual report.   Health is the greatest social and individual value for significant impact on the processes and outcomes of economic, social and cultural development of the country’s demographic situation and the state of national security is an important social criterion of the degree of development and well-being of society. SHC in many urban cities provide specialized integrated hospital and health part in the villages – the central district and regional hospitals.

SHC by WHO definition – this aid maintenance special character, more subtle and complex than assistance provided by a general practitioner, including the assistance of specialized services in the direction of the primary units of medical service.

In the “Basic Law of Ukraine on Health SHC treated as specialized health care provided by doctors who have a specialization and can provide more qualified advice, diagnosis, prevention and treatment than general practitioners.

This difference in the treatment of secondary health care in the “Basic Law of Ukraine” and WHO because today is not prepared enough general practitioners and family physicians, and working in primary care doctors, mostly physicians.

SHC in many urban cities provide specialized integrated hospital and health part in the villages – the central district and regional hospitals.

Urban multidisciplinary hospital for about a third of secondary health re. 

The main objectives of the hospital is:

– Provision of specialized clock inpatient care in sufficient quantity;

– Testing and introduction of modern methods of diagnosis, treatment and prevention;

– Comprehensive restorative treatmet;

         – Examination of disability;

          – Hygienic education of the population.

Most urban hospitals merged with the clinic, but there are separate specialized hospital.

Power hospital depends on the availability of beds.

Depending on the number of beds and are determined by the states of the various services of doctors, nurses. 

To provide secondary health care for the urban population orders MH of Ukraine № 33 from 23.02.2000, the office staff is set depending on the number of beds.

Number of beds per 1 physician rate ranges from 12 (hematologic) to 40 (tuberculosis, for patients with osteo-articular tuberculosis).

Brief look at some profiles:

15 beds for 1 post doctor typical midwife (obstetrician), allergists, cardiology (Department of heart attacks), neurological department for neurologists, neurosurgeons, doctors, surgeons proctologist.

20 beds for 1 post doctor – gynecological gastrointestinal, infectious, neurological, oncology, orthopedics, trauma, ENT, ophthalmology.

In addition to the main specialists in some offices additionally introduced positions other doctors (ieurological for patients with cerebrovascular accident – 1 post therapist for 60 beds in proctological – 0.5 positions oncologist).

Establish positions as medical diagnostic and therapeutic support services, radiologists, endoscopists, laboratory technicians, doctors, physiotherapists and others.

Depending on the number of beds in the department established the post of head offices;

 

– 60 (9 profiles – internal medicine, neurology, surgery, cardiology, traumatology);

 

 -50 (6 profiles – SURGICAL, STI, TB);

 

-40 (14 profiles – gastroenterology, cardiology, and others.)

 

-25 (3 profiles – surgically-thoracic, obstetric, observational, pathology of pregnancy).

 

Admissions Department provides the procedure for referral to hospital and provides:

 

– Registration of patients admitted to hospital and discharged, filling the passport of hospital patient medical record;

 

– Diagnosis;

 

– Justification for hospitalization;

 

– Providing emergency care wheeeded;

 

– Sanitize;

 

– The taking material for laboratory studies, rapid diagnosis, X-ray and functional studies, the definition of the profile of a specialized department;

 

– Registration failures in hospitalization for determining causes;

 

– Providing background information for hospitalized patients.

 

 

Structure of the hospital multidisciplinary hospital:

 

 

 

For the implementation of established staff of doctors and nurses.

 

In the emergency department physician familiar with the medical documentation, conducting examination, provide necessary first aid and guide the patient to the appropriate department.

 

In urban multidisciplinary hospitals can be deployed in various specialized departments, depending on the capacity of the hospital, in the presence of doctors, and the distribution of branches between the city and district hospitals.

 

Basically this: therapy, cardiology, surgery, trauma, Otorhinolaryngological department. Set units not regulated by law.

 

Secondary specialized health care to rural population is provided in district hospitals.

 

The leading institution is – central district hospitals that serve as organizational and medical centers in the organization and quality of care.

 

Heads work CRH chief physician. Which is both the chief doctor of the district. He supervises health, is responsible for the organization of medical assistance, medical diagnostic, preventive, administrative, administrative and financial activities of the hospital.

 manages medical and ancillary diagnostic department of a hospital, is responsible for the organization and quality of medical diagnostic process in a hospital, for keeping records, examination of sick leave, subject to sanitary and epidemiological rules and regulations examines the activities of departments hospital.

 

Deputy chief physician with expertise sick: responsible for the organization and implementation of all measures for the examination. It controls the validity and correctness issue and continuation sheets disability, examines the incidence of TVP on clinic attached to factories and issuance of medical certificate and also examines cases of differences expertise and solutions MCC MSEK.

 

Home nurse hospital directly subordinate to the head physician and his deputy from the medical unit. It organizes and supervises the work of middle and junior medical staff using medical implements measures to improve skills, chairs the Board of Nursing hospital controls correct accounting, distribution and storage of drugs, dressings.

 

The main objectives of CRH:

 

– Direct provision of primary outpatient care population county seat and endowment station;

 

– Provision of specialized outpatient care to the entire population area;

 

– Provision of specialized inpatient care to the entire population area;

 

– Providing quick and prompt medical care; 

– Introduction and practice of the PSI area of ​​modern methods and means of prevention, diagnosis and treatment;

 – Organization of advice; 

– Organizational guidance work of all district health facilities, as well as monitoring their activities;

– Development and implementation of measures aimed at improving the quality of health care; 

– The development, organization and implementation of measures for training medical personnel, and management of medical personnel and logistical resources;

 – Planning, financing and organization of logistics of health district;

 – Training of health personnel, district and local health care facilities.

 

In the second stage of fever is stabilized at a high level , are only its fluctuations during the day. Increased heat production and heat dissipation are in dynamic equilibrium . Significantly reduced muscular tremors , pale skin redness changes . The patient may complain of headache, feeling of heat , thirst , dry mouth , loss of appetite . Skin is hot , red , eyes shining . At higher temperatures possible delirium ( delirium ) . Signs of intoxication delirium is the appearance of features in the behavior of the patient: anxiety , crying, moaning, repeating the same questions to the staff , refusal of food , increased sensitivity to noise and light . Then the patient begins to doze off in silence lies with eyes wide open , staring considering painting mereschatsya him . Excitation can occur : the patient falls from bed can make an attempt to run out into the street or jump out of the window. Facial expression of fear and anxiety. He submitted ghost pictures , animals that are attacking him. Delirium is a dangerous strain on the cardiovascular system and the possible danger to the patient’s life and actions of the people around them .

In such cases, set the individual post .

The bed is placed further away from the window and so had access to it from all sides. Chamber of take away all unnecessary objects , especially sharp and cutting . Nurse monitors pulse , blood pressure, respiration , skin color and performs medical purposes. Headache on the forehead of the patient can put a cold compress soaked in a solution of vinegar (2 tablespoons per 0.5 liters of water ) linen napkins, towels or make cold wrap . On the forehead of the patient put a napkin or towel wrapped ice pack .

Instead of a bubble of cold water or ice is used , if necessary in a dry ice bags “Penguin” , which is pre-cooled in a freezer . The effect of these sacs remains 2-3 h , they can be applied to the area of the large vessels of the neck , elbow bends. You can put cold compresses , which make using towels or lineapkins folded in quarters and soaked in vinegar mixed with water or water diluted 1:1 with alcohol. Napkin twisting well , shake and apply to head in the frontal and temporal lobes . Poultice dries quickly and needs to be replaced every 8-10 minutes . Control the pulse frequency and the blood pressure value . Often the cardiovascular system (especially in elderly patients ) is crucial in the prognosis of the disease , so it is necessary to introduce a timely manner designed cardiac or vascular agents.

Temperature and its significant fluctuations cause depletion of the patient. To increase the resistance of the organism , it is necessary to give the patient digestible foods high energy value in the form of a liquid or semi (diet number 13). Due to the significant decrease in appetite , food should be frequent ( 5-6 times ), and the food should be given in small portions , better watch setback . For detoxification patient requires a large amount of liquid in the form of fruit and berry juices , mineral water degassed . This reduces the concentration of toxic products in the blood. Introduction provides a large amount of liquid vigorous detoxificatioot only the kidneys , but also due to sweating skin and mucous membranes. Restriction of salt in the diet also reduces fluid retention in the body , increases urine .

Often, high temperature cracks occur body lips and corners of the mouth which must be lubricated with oil or vaseline glycerol. Sterilized spatula and tweezers with enough sterile gauze napkins placed on a sterile tray. The medicine is poured into a petri dish . Sandwiched tweezers cloth moistened with medications. The patient was asked to open his mouth and, using the spatula, discover the affected spot mucosa. Applied thereto dampened cloth drugs . For each location of the lesion using fresh sterile cloth . Mouth rinse or wipe with a weak solution of sodium bicarbonate . Bedridden patients requires careful skin care, which will help to prevent bedsores. In case of constipation give enema . Sick in bed and fed ship urinal . When winding Chamber beware drafts patient should tuck , and a head cover with a towel. Care should be taken that the patient did not drop a blanket. During the period of fever the patient is prescribed bed rest .

During the period of decline in body temperature ( stage III ) can be different , because it can happen quickly or slowly. A slow decrease in temperature for a few days called lysis. Fast during the day (often for 5-8 h ) , lower temperature with higher values ​​iormal and even subnormal called crisis.

Critical temperature reduction can be accompanied by acute circulatory failure manifested by excessive sweating , pale skin sometimes with cyanosis , decreased blood pressure , increased heart rate and a decrease in its content , until the appearance of filamentous . Extremities become cold to the touch , the skin clammy , cold sweat. At a critical decrease in body temperature of the patient nurse controls properties pulse and blood pressure value . If necessary, apply the tools of intensive care , emergency administration of vascular agents ( phenylephrine , caffeine , epinephrine hydrochloride). The patient is placed at the feet warmers , clean pillow under the head or raise the lower end of the bed , give drink hot tea or coffee. With the sudden deterioration of the patient should call the doctor on duty . When excessive sweating patient wipes , change of underwear and bed linen . At night, leave a few spare pairs of underwear to replace wet .

During lytic reduction of body temperature patient feels general weakness. After the temperature has fallen , it usually falls asleep. The patient’s condition improved. He expanded the motor mode , designate high calorie diet .

alleged problems

Hyperpyrexia or hyperthermia – it is too high ( above 41 ° C) increase in body temperature , which can lead to serious condition of the patient, or even death.

Hyperpyrexia : can manifest syncope , agitation, delirium , fever. Reduce fever and pain : cold water and vinegar lotion on his head an ice pack on his head, wiping the patient’s body with room temperature water with vinegar, wrapping wet naked patient , exposure of the patient and the fan switch .

When hyperthermia heavy flow is not exposed to therapeutic measures , recommend: taxation patient ice packs , the introduction of chilled isotonic sodium chloride solution , enema with cold water.

Physical methods of dealing with hyperthermia include: