Theme 01

Theme 01

Organization of nurse work of medical post and manipulation room in Pediatric Hospital.

 

Deontological Aspects of Relationships of Health Care Providers With

Pediatric Patients and Their Caregivers.

 

 

Medical deontology is a science about appropriate, about what should be the medical employee and its relations with the patients and their kinsmen. The ethics study the moral norms of the behaviour of person or of the social group. Specifically they distinguish a medical ethics. The concept «medical deontology» is narrower, than concept «medical ethics».

The term «deontology» was entered in scientific turnover in the beginning ХIХ century by the English Philosopher-Benthamite Jeremiah Bentham – for a designation of science about professional behaviour of person. The basic principle of deontology is a conscious submission of personal interests to interests of a society that is to super-personal interests.

It is possible to subdivide the norms of behaviour of medic on the: norms general-cultural (i.e. rules of human dialogue, what are base on the respect to human advantage), norm of the etiquette (i.e. politeness, tactfulness etc., what are base on the habits of cultural behaviour and traditions of dialogue between people), and norm medico-deontological (observance of these norms provides trust of the patient to doctor, in their basis the requirements of medical trade lay).

It is possible among medico-deontological norm, in turn, to allocate the general-medical and special norms. The general-medical norms are observed by all medical employments. The special medical norms are realized in specific conditions of medical specialization, here, accordingly, they are allocated deontology therapeutic, pediatric, surgical, stomatological etc.

The importance of the deontological side in the relations between doctor and the patient grows constantly. It is caused by growing technical, tool equipment of modern medicine, by tendency to differentiation and specialization of medical sciences and, thereof, by excessive concentration of doctor’s attention on the separate struck with illness organs, and systems of the organism.

 

 

Medical Ethics is the study of moral values and judgments as they apply to medicine. Ethical principles heavily govern the practice of medicine and ethical theories form the basis of ethical argument. With high profile cases regarding malpractice of doctors and the recent medical advances in technology, more and more clinical practices are coming under the scrutiny of both the media and the general public. For example, hand-washing was once a common courtesy, but now it could be deemed unethical to not do so. This is a result of the discovery of “superbugs” (e.g. MRSA), which are potentially fatal due to their resistance to available antibiotics, and the public demand for health services to improve their standards.

However, medical ethics is not an exact science. In certain situations it may be difficult to know what is ethically “correct”. Ethical debates commonly arise on medical wards; therefore, a comprehensive knowledge of medical ethics is paramount to deciding the best course of action.

Ethical Theories

Ethical theories can be seen as schools of thought when judging the rightness or wrongness of a proposed action or when choosing from a number of proposed actions. There are two main ethical theories that apply to medical practice:

·                 Consequentialism refers to those moral theories which hold that the consequences of a particular action form the basis for any valid moral judgement about that action.^[4]

·                 Deontology is an approach to ethics that focuses on the rightness or wrongness of actions themselves, as opposed to the rightness or wrongness of the consequences of those actions.

 

Clinical Example A doctor comes out of a room after witnessing a patient suffer a distressing death. The family approach the doctor and ask if he suffered. The doctor lies and says “He went peacefully”. Consequentialist view – this eases the burden of the family at a distressing time. Deontologist view – lying is fundamentally wrong and the family are entitled to the truth.

 

Ethical Principles

The ethical principles that govern medical practice should act as a framework when making medical decisions. When ethical dilemmas arise the best approach is to think through these ethical principles logically and methodically.

 

Beneficence and Non-maleficence[edit]

Beneficence is the act of “doing good” while non-maleficence is the act of “not doing bad”. In practical terms, medical practitioners have an ethical responsibility to strive to do what is in the best interests of their patients. However, it is important to remember that some medical interventions may seem beneficial but may also carry with them the possibility of causing harm. In fact, nearly all medical treatments and procedures, it could be argued, harm the patient in some way, but it is more to do with the magnitude of the benefit versus the magnitude of potential risks.

Clinical Example A doctor has diagnosed an elderly lady with rheumatoid arthritis and wants to prescribe an NSAID to relieve the pain and reduce the inflammation. – Beneficence However, he does not want the patient to develop gastrointestinal bleeding, a common side-effect of NSAIDs, especially in the elderly – Non-maleficence

Autonomy and Consent

Autonomy is the right of a patient to make an informed, uncoerced decision about their own health management. If this principle is disregarded by a medical professional because he/she believes another decision would be better for the patient, then it is termed paternalism. An autonomous decision should never be overruled by a medical professional, but not all decisions are autonomous. For patients to have autonomy, they must have the capacity to receive, retain and repeat the information that is given to them, provided the information is complete and given to them in a manner that they can understand.

 

Clinical Example A patient with breast cancer is told by her oncologist that there are two treatment options, a total mastectomy or a partial mastectomy with radiotherapy. The patient decides to have a total mastectomy – Autonomy An oncologist decides that a patient with breast cancer should receive a total mastectomy – Paternalism

 

Consent is an extension of autonomy and has many types. Implied consent is when a doctor assumes that certain actions or body language from a patient imply that the patient has consented to the planned action of the doctor. Expressed oral consent is when a patient has verbally given the doctor permission to proceed with the intended action. Expressed written consent is documented evidence that the patient has, usually with a signature, given consent to a procedure. Written consent should only be obtained after oral consent. Fully informed consent is consent given after being given all the information about the procedure. When possible, fully informed consent, both written and oral, should be obtained before any procedure, examination or treatment.

Clinical Example A patient with tonsillitis is in the ENT ward and a doctor approaches with a syringe. The patient stretches out her left arm in the direction of the doctor. The doctor takes a sample of her blood. – Implied Consent The doctor then asks if she can take the patient’s blood pressure. The patient says yes. – Expressed oral consent Then the doctor asks the patient to consent for surgery by reading and signing a form consenting to a tonsillectomy after explaining to the patient the risks and benefits of the procedure. The patient reads and signs the document and expresses her wish to have the procedure. – Fully informed written and oral consent

 

Truth-telling

The ethical principle of Truth-telling is the process in which a doctor gives the patient all known information about their health. It allows the patient to be fully-informed and, therefore, allows for the ethical principles of autonomy and consent. A point of note that always needs to be considered is the fact that some patients do not want the information. Therefore it is important to ask the patient if they want to know or not. The only other (extremely rare) occasion when it is acceptable not to tell the patient the truth is when the patient may come to harm when being told, e.g. “If you tell me I have cancer I will kill myself!”.^[8]

 

Confidentiality

The ethical principle of confidentiality ensures that the medical information held about a patient is accessible only to those to whom the patient has given access via autonomous and full-informed consent. In order to achieve trust between medical professionals and their patients, confidentiality must be maintained. Confidentiality may be broken if information shared by the patient refers to a potential danger to public safety or if it is ordered by a court.^[9]

 

Clinical Example A doctor informs a patient that he cannot drive because of his recent diagnosis of epilepsy. The patient agrees but, when driving to work one morning, the doctor sees the man driving. The doctor must inform the local driving authority due to concerns regarding public safety.

 

Preservation of life

The ethical principle of preservation of life is a will to treat a patient’s illness with the aim of prolonging life. After all, most patients want to live longer; most doctors may have joined the profession to save lives. This principle may be overruled if the patient has made a living will stating their desire not to be resuscitated.^]

Justice

Justice refers to the distribution of things and positions of people within society. In a medical setting, justice involves the allocation of health-care resources in a fair way. This may be an equal distribution (egalitarianism) or a maximization of the total or average welfare across the whole society (utilitarianism).

The Four Topic Method

The Four Topic Method is a way to provide a framework in which the clinician faced with an ethical issue to analyze the case in an objective form. The Four topic Method developed by Jonsen, Siegler and Winslade in 1982 includes the following and are aligned with the ethical principles of Autonomy, Beneficence, Non-maleficence, Justice:

·                 Medical Indications ( Beneficence and Non-Maleficence)

·                 Patient Preferences ( Autonomy)

·                 Quality of Life (Beneficence, Non-Maleficence and Autonomy)

·                 Contextual Features ( Justice : Loyalty and Fairness)

 

 

CODE OF ETHICS AND MEDICAL DEONTOLOGY

 

CHAPTER ONE

MAIN PRINCIPLES

 

ARTICLE 1

DEFINITION

The medical deontology is a collection of principles and regulations that the physician (1) must respect during exercising of the profession. The physician’s behavior, even out working time must be excellent according to the dignity this profession requires. The physicians are obligated to recognize the principles and regulations this code  contains.

 

Article 2

Recognition of the Order of Physicians

The physicians must recognize the Order of Physicians as a public entity which represents the common interests of medical professions and regulates the relationships between them in the public interest.

 

Article 3

Recognition of Deontological Code and the Oath of Physician

When any physician registers with the Order of Physicians, he must have full knowledge of Deontological Code and in the same time he takes an oral or written oath, promising to respect it with correctness.

 

Article 4

Duties and mission of the physician

The essential duty is to save the life, to protect the physical and psychological health and relieve the sufferings. The physician relies on science and his consciousness during his human mission to preserve the health, to diagnose and treat the illnesses.

 

Article 5

Medical Aid

The physician must offer the same medical aid without differencing of, age, sex, race, nationality, religion, political opinions, economical health, position on society etc, in the same time respecting the human rights and personality of each individual. In war or disaster time he must immediately engage to offer his assistance, by being available to respective authorities.

 

Article 6

Respect of Tradition

The physician must do anything he is able to respect and protect the highly valued traditions of medical profession, continually respecting a high professional standard and a suitable ethical behavior towards the patient, families and any other person who seeks care.

 

Article 7

Boundaries on professional activity

The physician must not abuse in any case with the circumstances the profession creates. The physician must not use his position for personal benefits and professional purposes.

 

Article 8

Aid on Emergency Cases

Despite the specialty he belongs, the physicians must not refuse to intervene in any place or circumstance to offer emergency care to any person ieed, also seeking the specialized assistance.

 

Article 9

Relationships with colleagues and staff

The physicians must be careful to safeguard the goodwill of medical profession and he also must have correct relationships with colleagues and the rest of medical staff.

 

Article 10

Use of knowledge

The physician must use the knowledge and his capability based on professional independence, autonomy of action and personal responsiveness.

 

Article 11

Professional obligations

The physician has the duty to be updated with the news from science, participate in qualification activities for his professional development. He must precisely assess the patient’s situation based on anamnesis, clinical signs and required examinations.  Iecessity occasions and when possible, he must consult with specialists inside or outside his specialty and execute the consultant’s instructions. He must assist the public to understand health cases and contribute in education and training of other physicians.

 

CHAPTER TWO

PHYSICIAN OBLIGATIONS TOWARDS THE PATIENT

 

 

Article 12

Relationship with the patient

The physician must care for safeguarding the patient’s wellbeing and his own health interest. Relationships between them must rely in respective confidence. The prime principle of these relationships is the freedoms of choice of the physician or institution of care the patient posses.

 

Article 13

Professional Competence

The physician must guarantee commitment and professional competence to the patient. He must confront the diagnosis and treatment problems, dedicating the required time to the patient. He must do his work without ethical and professional gaps, without physical, emotional and material abuse on patient. Based on the level of seriousness, the breaches on this course are penalized according to the provisions of Law No .6815, dated on 01.06.2000 and the Statute of the Order of Physicians.

 

Article 14

Patient’s confirmation on treatment

The physician must respect the patient right on his free will to accept or to refuse the treatment and the recommended type of medical care. If the patient feels unable to offer his confirmation and his representative is not present in emergent medical cases, the physician acts relying on his responsibility for the best possible benefit of the patient.

 

Article 15

Duties to children, old people and handicap people

The physician must engage in care for children, old people, handicap people while exercising his profession especially when he notice that the family or outside family surroundings where he lives, do not offer enough care  for their health.Called to treat a child or minor, the physician must try to get the parent’s approval, relatives or legal representatives. There is an exemption when the case is emergent and it is impossible for the physician to communicate with them. In suspicious cases abuse or maltreatment against the child, the physician is obligated to give notice to the respective body recognized by law.

 

Article 16

Informing the patient

The physician must inform the patient for the progress of examinations and the type of medical treatment, to provide prognosis telling the patient the good sides and bad sides, in order to jointly take the fairest decision for the best treatment. If the patient is under age to judge in an independent minor or mentally unable, the physician is obligated to take the decision of family or foster career and when this is impossible, must be acted on the responsibility of medical consultancy.

 

Article 17

Patient’s right to be informed on results.

The patient has the right to know the truth on his disease and to be informed with all results of analysis and other medical documents. However, if the physician judges that the information damages the health of the patient, then he is not obligated to inform him on the truth or to show him the medical documentation.

 

Article 18

Informing the families

It is a moral duty for the physician to show understanding and share of concern with the families of the patient and must keep them informed on the progress of the patient’s situation. This collaboration counts for the best of the patient.

 

Article 19

Diagnosis and medical procedures

The physician must propose and apply to the patient only those diagnosis proceedings that are needed for the diagnosis, more convincing, and also only the medical treatment that meets the approved standards of the present-day medical science. The physician must be as much as possible rational on economic expenditures, while he is treating the patient according to the common medical practice. The unnecessary examination and treatment proceedings are not permissible, regardless of who covers the expenses for the patient treatment.Article 20 Nonintervention on family matters. The physician must not get involved on personal or family problems of the patient and should not try to influence him, unless it is required by the type of medical treatment.

 

Article 21

Keeping the secret

The data the physician finds out while exercising the duty, are considered as medical secrecy. With the patient consent, the physician is obligated to keep the secret to families and other persons, also after the patient death, apart of those cases where it causes danger for other people’s life and health.

 

Article 22

Secret release

The physician has the right to release the secrets of the patient, on such cases where hiding them risks the life of the patient or where this is required by an institution supported by law. The physician is obligated to not release the identity of the patient, when he uses the medical data on the patient for publicity purposes.

 

Article 23

Attaining the rights

The physician must make the effort for the patient to attain all the social and material rights offered by law. Any abuse, deceiving or falsification of medical documents is penalized by law.

 

Article 24

Continuity of medical treatment

When the physician takes the leave for a limited period, he is obligated to secure the continuity of medical treatment for his patient by passing him to another physician When the physician believes that the proper conditions of treatment according to the patient situation are falling behind his professional capability and knowledge, then he must undertake measures for the patient to pass him to another physician for treatment, capable to take over this cure.  The recommendation for the colleague or colleagues should be honest, justifiable and documented.

 

Article 25

Change of therapy physician

In case that the patient well informed on the disease and capable to take independent decisions looses the confidence on the physician, the physician is allowed to step down from the continuing of the cure and to recommend medical treatment from another physician or medical institution. Unless this situation is due to the disease and the, physicians obligated to help the patient, this type of action is taken also on cases wherethe patient, in a conscientious way behaves in a rude man, becomes brutal or threatening.

 

Article 26

Medical assistance for convicted people

The physician called or working for an institution where the defended or convicted people are suffering the sentence measures, must not only provide medical aid but also defend the rights and dignity of sick sentenced people and if he is physically or physiologically violated the physician must inform the institutions supported by law.

 

Article 27

Medical treatment and force feeding of convicted people.

The treatment and forced feeding is allowed only on those cases where the sick convicted person is not conscientiously able to decide himself. If an adult is mentally fit, and refuses to eat, the physician must respect it. The physician is categorically prevented to take part on violence and torture against the defended.

 

Article 28

Documentation of actions

All the diagnosis and medical treatment actions the physician takes upon the patient must be described (recorded) on respective medical documents (Clinical card, visiting register, prescriptions, medical reports, recommendation report etc.) that are official administrative, legal and scientific papers. Any abuse, deceive or falsification of them is penalized by law.

 

Article  29

Supply of medical documents

With a request from the patient, families or other institution recognized by law, the physician produces or signs only when he is confident they are genuine certificates, medical report, confirmation letters and other documents. These documents are written in Albanian language but if needed also in foreign languages.Article  30 Patient Complain If patients have complaints on the care or medical treatment, they must have an immediate and appropriate answer.  The physician has the professional responsibility to deal with the complaints in a constructive and honest way.  If during the medical treatment the patient has suffered serious injury, regardless of the reason, it must be fully explained to him and possibly asked forgiven from him on what has happen or if he is under 16 years old to his families.

 

Article 31

Easing the suffering of the dying patient.

Easing sufferings and pain is one of the main duties of the physician. This is particularly important during the treatment of a dying patient. Regardless of the treatment, the physician should try to offer spiritual support, always respecting the wishes and religion of the patient. In the same time the physician must inform the patient’s families and guests about his health state and try to acquire their collaboration on easing the patient’s sufferings.

 

Article 32

Non- encouraging the pace of death

Encouraging the end of life or provoking death is against the medical ethics. If the patient is unconscious, without hope for living, the physician must act according to his personal judgment for the best, based on his professional and moral belief.

 

Article 33

Death of patient.

When the patient dies, the physician must explain to the families the reasons andcircumstances of death. They must be informed on all the details.

 

 

CHAPTER THREE

RELATIONSHIP BETWEEN PHYSICIANTS, PROFESSION AND

INSTITUTION

 

 

Article 34

Reciprocal Respect

The relationship between the colleagues must be based on the principles of reciprocal respect. The physician must behave with honesty with other colleagues, the same as he would like them to behave with him. The physician must not gossip hiscolleagues and must not cause disbelief to the patient about their knowledge and capability.

 

Article 35

Respect to teachers

The physician must show respect and bon sense towards his teachers because of the knowledge, professional capability and mastering skills he gained from them.

 

Article 36

Solidarity between colleagues

If an advice or professional support is requested from a colleague, the physician must be available to provide them genuinely and based on his best knowledge. He must be on solidarity with colleagues who are under unfair allegations.

 

Article 37

The attitude against colleague’ s incorrect behavior.

If the physician becomes aware of a irresponsible behavior of a colleague which may be caused by a medical or ethical wrong doing, he must not discuss those with the patient, families or other colleagues, but instead to discuss with the respective authority of the Order of Physicians.

 

Article 38

Collaborator’s mistakes.

The physician is obligated to make notice of the mistakes that can be done by the collaborators or other assistance staff, treating them carefully, without fingering the dignity of anyone and io way in front of the patient, families, and their guests.

 

Article 39

Rapport with therapy doctor

The physician must undertake medical treatment to a patient coming from another physician, only with the request of this other physician or with the request from the patient himself.  In such case the previous physician must inform the therapy doctor about the diagnosis and treatment recommendation and the clinical assessment he has arried out.

 

Article 40

Professional authority and capability growth

It is the physician’s duty to continually study and follow the new developments of his profession, in order to improve the professional authority and by doing so to offer the patients a high level of medical treatment.

 

Article 41

Professional reputation and moral image.

The physician must retain the reputation and professional independence and must not allow his name to be used on business advertisement for personal benefits. He must avoid the unmerited benefit and boosting his fame with self swollenness with proud. The physician must keep a clear moral image by keeping distance from activities that devalue his responsibility (alcohol, drugs, and other defects not consistent with the moral)

 

CHAPTER FOUR

THE PHYSICIAN ATTITUDE TOWARDS THE HUMAN REPRODUCTION,

CLINICAL AND BIO-CHEMICAL RESEARCH EXPERIMENTS, AND

TRANSPLANTATION OF TISSUE AND ORGANS

 

Article 42

Information on sexual health

In favor of family planning, the physician must support the education and natural techniques and then subsequently those artificial according to the medical knowledge and moral vision. He is obligated to inform the partners about the consequences of special contraceptive measures.

 

Article 43

Care for sexual health

The physician must care for the sexual health of the patient, meaning the improvement of life and personal contacts, medical consultancy and assistance for a healthy sexual development, the care for reproduction and for sexual transferring disease.

 

Article 44

Pregnancy interruption

The physician is prevented to cause pregnancy interruption and to take sterilization apart of those cases acknowledged by law and medical indications.

 

Article 45

Application of supportive reproduction techniques

The physician must be aware that  the application of supportive reproduction techniques, including the fertilization in vitro, during the treatment of partnershipimpossibility to gave birth, makes it necessary for both the partners to understand the basic knowledge of such techniques. It is the physician’s duty to be informed on ethical developments of the form and techniques according to universal accepted concepts recognized by law.   .

The abuse on human embryo for researching purposes is not ethic, acceptable and legally condemned.

 

Article 46

Participation on scientific research

The physician that undertakes research work on preventive, diagnosis and medicalm treatment purposes, must represent the research work plan before a particular independent and competent commission to be appraised on the scientific legal grounds and ethical recognition. He must carefully make aware the persons involved on research about the objective of the research, considering the benefits and possible harm and must seek their approval. If it is impossible to get the approval because of the person’s state, it must be requested form his relatives.

It must be clear to the person involved in research, the right he posses on the possibility for interrupting it. A medical treatment which can be compared to placebo must be only used when according to the scientific data, the patient may benefit and the harmful effects are certainly exempt.

 

Article 47

New methods application

The application of new diagnosis, treatment and preventive methods are allowed only after the project approval and the clinical review by an independent competent commission.    Adoption, realize and the promotion of the methods unsubstantiated by science, causing false hope on the patients and families, is a violation itself of medical ethics. .

 

Article 48

Results reports

The achieved results must be reported by the therapy physician according to the scientific report regulations during a specialist gathering and only after the professional opinion is received; it can be produced to the public at large.

 

Article 49

Examine on heritage

The scientific research on health and heritage, using the relevant technology on genetic substances of human beings are acceptable for diagnosis purposes (prenataldiagnosis in vitro or in utero of genetically disease without damaging the embryo or the mother),   for pharmacy industry purposes with clinical interest (produce of medicaments, hormones, injections, etc), for scientific purposes in studying the DNA sequences in human genes for treating the chromosome defects.

 

Articles 50

Transplantation of tissues and organs from the dead person.

In a case of cerebral death, certainly professionally approved, within the legal framework of the Law no 8193 date 06/02/1997 “The Organ Transplantation”, the physician may maintain organs, body parts or tissue, which may be used for medically treating other patients. The physician who determines the cerebral death must not take part on such proceedings.

 

Article 51

Transplantation of tissues and organs from living persons.

The receiving of tissues and organs from a living donator, adult and mentally fit, is done only when he freely grants approval and in written form, after he is made aware of possible consequences. It is unacceptable the receiving of an organ when such action risks the donator’s life.

 

CHAPTER FIVE

CONDITIONS FOR EXERCISING THE PROFESSION

 

Article 52

Workplace arrangements

The physician must have a suitable workplace and the necessary technical equipments. While exercising the profession as a private, the physician must have only one cabinet. Keeping one more must be done only through authorization from the Regional Council of the Order of Physicians.

 

Article 53

Nonuse of administrative functions

The physician that undertakes administrative functions or appointed on public positions is prevented to use the post to increase the number of clients and other benefits.Article 

 

Article 54

Accepting gifts and money

The physician must not accept material gifts or loans from companies, businesses or individuals trading medicaments and other materials. There are exemptions on financing for conferences, workshops and congresses where the objective is professional qualification.

 

Article 55

Attestation

The physician is allowed to write in prescriptions and documents he produces: –  First name, Surname, address, phone number and visiting time. –  Qualification and specialization –  Recognized Titles and functions by the Order of Physicians. –  Honorific titles recognized by the Republic of Albania.

 

Article 56

Contain of Clinic entrance placard.

The physician writes the first name, surname, titles of recognized specializations and the visiting times. Where the physician is titled with a foreign diploma, he must specify the place and University that issued the diploma or certificate authorizing the exercise of this profession.

 

Article 57

Working contract

The medical exercising in any form, despite the fact it is attached to a private or public institution, is done through written contract, where respective part’ s obligations are determined. Any contract prototype is communicated to the Order of Physicians, which may provide observations within a month.

 

Article 58

Employment of Colleagues

The physician who opens a clinic is allowed to employee in his account other physicians, complying with the licensing regulations.

 

Article 59

Service fees

The pay for service fees is done directly by the patient or by the specified administration or institution. The physician must give explanations on service fees or the cost of care. The pay in advance for the treatment, which may last on several periods, is prevented. When several physicians contribute on diagnosis or treatment, the service fees must be special and individual.

 

Article 60

Organization of Physicians

Any joining or grouping of physicians must be achieved based on a written agreement that respects the independence of anyone. The Regional Council of the Order of Physicians approves the agreements.Any agreement or grouping contract done with a professional objective between physicians in one side and the nurses, chemists etc, in the other should be sent to the Regional Council of the Order of Physicians, which must be review within a month.

 

Article 61

The right for strike

The physician has by constitution the right for strike. But the physicians, by acting based on the science and conscience has the duty to guarantee the service for emergent and necessary care for the patient.

 

CHAPTER SIX

FINAL PROVISIONS

 

Article 62

Respect for the Code.

It is the duty for all the physicians, registered on the Order of Physicians to respect the articles of this code.

 

Article 63

Disciplinary measures

The lack of knowledge on articles of this Code does not exclude the physician from the responsibility derived by the non-realization of ethical and deontological duties described in this Code.Disciplinary measures derived by not applying this Code are determined according to the

Regulatory for Disciplinary Commission of the Order of Physicians.

 

Article  64

Notification of the Order of Physicians about breaches

Members of the Order of Physicians have the right and obligation to notify the respective bodies of the Order of Physician’s for all the breaches of this Code.

 

Article 65

Nullification of the old Code.

The Deontological Code approved by the Ministry for Health in the year 1994 and published in the year 1995 is nullifies.

 

Article 66

Validation

 This code is immediately put into effect.

 

 

STUDENT (PHYSICIAN) – PATIENT  MODELS OF COMMUNICATION

 

No matter how high the achievements and

technical possibilities of the modern medicine are,

 a person will always wait and believe a doctor,

who can listen, approve and sympathize

Antoine de Saint Exupéry

 

One can’t treat the body without treating the soul

Socrates

 

 

Hippocrates wrote: «There are three components in medicine: a patient, a disease and a doctor… It is not easy for a patient to understand why his health gets better or worse; it is the doctor who has to explain him everything». Francic Maenab, the doctor of theology wrote: «The doctor’s behaviour, his speaking manners play a significant role at the first encounter with a patient».

Doctor’s professionalism does not depend only on his knowledge of the etiology and pathogenesis of diseases, the methods of their diagnosis and treatment but also on his ability to consult i.e.: to communicate, teach, advise. The ability of the doctor to communicate determines his relationships with patients. Only by gaining the patient’s trust and confidence, the doctor can get a detailed anamnesis; explain the treatment requirements to patients. An experienced specialist expresses his opinions clearly without causing anxiety. He is able to win patients’ favour and give hope to patients for positive treatment. In the history of medicine trust and confidentiality are the basis for the doctor patient communication.

In the last centuries the role of the doctor lay mostly in mere observation of the natural course of diseases.  Recently patients just entrusted doctors the right to make decisions. Doctors “exceptionally for the patients’ sake” acted as they considered being necessary. It seemed that such approach increased the treatment efficiency: the patient didn’t have any doubts or uncertainties because the doctor took all the responsibility for his care. The doctor did not use to share the information with the patient and hid the unpleasant truth.

Thus, in the realities of the modern world there is a high demand of new models of doctor patient communication.

There are the following communication models between a physician and a patient:

Informative (a loyal physician, absolutely independent patient);

Interpretative (a persuasive physician);

Confidential (faith and mutual consent);

Paternal (a physician as a guardian).

The interpretative model is more suitable for the people with lack of education; the confidential model is likely to be more appropriate for educated people who penetrate into health problems essence.

The paternal model practiced earlier, can disturb a patient’s rights and is not used nowadays with the exception of cases threatening a patient’s life or in case of operative or rehabilitative emergency.

Nowadays a physician and a patient should collaborate; they are supposed to tell the truth to each other and to share the responsibility for treatment efficacy. Such cooperation is usually based on encouragement, understanding, sympathy and respect.

One of the most important conditions to maintain mutual understanding between a physician and a patient is considered to be a sense of support. If a patient realizes that a physician tends to assist, he will be more active during treatment and management.

If a physician displays understanding and a keen interest in a certain case, a person is sure that his or her complaints are taken into consideration. This sense can be strengthened when a physician says “I am listening to you and understand you”, confirming it by the expression of his eyes or nodding assent.

Respect means to acknowledge that every person is of a great value. It should be taken into consideration during the course of taking the history while a physician is learning the life conditions of a patient.

Sympathy for a patient is a clue to close cooperation with him or her. It is worthwhile for a physician to imagine himself as a certain patient. It is also very important to comprehend and estimate the inner picture of the disease, that is to take into consideratioot only a patient’s subjective sensations but it is necessary to pay some attention to his state of health and self-observation including his notion about the disease and its causes.

There are no strict rules of communication between a physician and a patient, though all the health care workers in the world follow the general principles of deontology, medical ethics of health professionals. A patient’s emotional state comfort is considered to be the true criterion of deontology,  that is the test to evaluate its effectiveness.

The oath, which is called Hippocratic, has its roots deep in the past. Later it was transformed into a document containing a few special demands to be followed by physicians, namely:

Keeping a medical secret;

Veto on the actions causing both moral and physical injury to a patient or his relatives;

Devotion to the profession.

The principle “Do not harm” is believed to be one of the most important in a physician’s activity. This ancient Latin statement of medical ethics runs as follows: “primum noocere”. Each doctor is supposed to agree with the words by        Ye.Lambert: “There are patients who cannot be helped, but there are no patients who would never be done harm”. It is known that sometimes treatment seems to be more dangerous than a disease. That concerns the side effects in simultaneous application of a great amount of them including incompatibility between expected benefits and a possible risk due to medical measures.

A PHYSICIAN SHOULD BE ABLE NOT ONLY TO LISTEN TO HIS PATIENT, BUT HE SHOULD BE ABLE TO HEAR HIM.

There is nothing more important than having a skill to hear his interlocutor. The notion “to hear” means to perceive and comprehend the information. Egan wrote: “It is necessary to hear not only by means of the ears, but also by means of the eyes, skin, mind, heart, that is to put the soul into the process. A person does not simply perceive a sound; the words are coloured with certain senses, they are able to stimulate imagination”.

The most important things can be transmitted via intonation, facial expression, gestures, finally through silence.

The ability to hear includes:

Perceiving the information;

Perceiving senses;

Expressing sympathy;

Analysis.

Listen to your patient attentively not interrupting him. If necessary suggest some leading questions, e.g. “You seem to be sad…..”, “You seem to be sad because of……”, “Has anything serious happened?”, etc.

COMMUNICATION

Communication is supposed to be the information exchange among people. There are 5 main aspects of communication:

The person who transmits the message;

The information;

Mode of information transmission;

The person receiving the message;

Answer.

 

The main aspects that make communication easier:

Feeling sympathy for each other;

Mutual understanding;

Due time for communication;

Ability to speak clearly, not digressing from the subject.

 

RECOMMENDATIONS FOR PROVIDING THE MOST EFFECTIVE COMMUNICATION WITH A PATIENT

At the beginning of the interview give a patient a kind smile.

Try to learn the causes of a patient’s subconscious anxiety. Help to solve the problem.

Try to give your patient a piece of advice, e.g. what he should do, expect, how he should behave.

Never remind elderly people about their age, while speaking with them. The conversation shouldn’t be in a hurry. The questions should be asked concretely, requiring only single-valued answer.

Try to avoid giving only oral pieces of advice, write down recommendations as to regimen, diet, medication therapy on a sheet of paper.

 Try to explain the necessity of restriction of contracts with stimuli that damage psychics (excessive informational loading, stresses, etc.).

 

At the first meeting:

smile friendly;

create natural atmosphere;

do not be in a hurry;

focus on a patient;

do not make an interrogation of the conversation, let the patient speak freely.

 

A good doctor possesses:

ability to empathize with;

thoughtfulness;

respectful attitude to the patient;

disquitness about the patient condition;

ability to keep patient confidentiality;

competence;

responsibility;

consideration.

 

A good doctor should:

demonstrate attitude towards the patient with a smile;

speak in a comprehensible language;

not abuse of medical terminology;

give distinct instructions;

avoid ambiguity;

not promise incredible things;

check whether the patient understood the information correctly;

be confident that the patient doesn’t have unaccountable questions any more.

 

Doctor-patient appointments usually have the character of a traditional consultation with several defined stages. A doctor or a patient becomes the main character by turns.

 

Environment plays an important role in the process of communication. Such details as open door of the consulting room or surgery, unfriendly doctor’s facial expression can make a great influence on the patient’s frankness. Hospital surrounding usually does not help with ‘physician-patient’ communication: it can oppress, make the patient feel helpless, because it is difficult to seclude oneself in medical establishments. An excessive doctor’s full time job also is harmful. The following notice was hanging on the Welsh doctor consulting room door: “When it seems to you that I examine a patient too long, think about yourself at this place very soon.”

One more unbreakable rule should be pointed out: a conversation with a patient should be face to face, the presence of a third person is excluded. Data about the patient older than 15 years can’t be notified to extraneous people and even relatives without his\her consent. Keeping patient confidentiality, as you remember, is one of the Hippocratic Oath statements.

A good doctor is associated not only with professionalism, encyclopedic knowledge, calculated decisions and perfect medical procedure technique but with an ability to communicate with a patient. Observations show that experienced doctors pay more attention to anamnesis gathering and physical examination than to instrumental and research findings, which are less important for such physicians. It is proved, that a correct diagnosis is made for 45-50 % of patients on the basis of past history data and for 80 – 85 % on the basis of questionnaire and physical methods of examination. Only for 15 – 20 % patients a profound laboratory and instrumental research is needed to make correct diagnosis.

Unfortunately, doctors possess communicative skills “from time to time”. They are obtained with the years of acquired experience. There are no special courses at medical educational establishments that teach such skills. It’s a pity to see how doctors neglect the conversation with a patient and use only laboratory instrumental diagnostics or carry out only traditional treatment schemes. The art of conversation with a patient, ability to conduct a dialogue with him or her calls for not only a desire to communicate but also some extent talent.

A doctor should possess a delicate psychological sense but regular work of consciousness.

Successfull treatment is possible only in trustworthy human relationships and scientific relationships. To reach this aim a technically equipped doctor should not only treat the patient but communicate with him.

Is it possible to teach how to communicate correctly? Communicative skills can be taught, they can be learnt but they can be forgotten very quickly, if not applied into practice (Aspergen Med Teach, 1999). Communicative skills in relation to particular categories of patients should be worked out to being automatic. Then a doctor will use them in routine and dramatic situations. The use of modern didactic methods of teaching will assist students to master communicative skills with a patient effectively.

Carrying into practice patient-oriented treatment, that implies frequent patient-doctor contacts with high degree confidence formation to the latter, rises the quality of given medical aid to great extent. (Lew in at al. Systematic Cochrane review, 2001).

The application of communication strategies by the teachers and tutors, explanation and control of their usage by the students during practical part of classes at clinical subjects prepares our students for real situations in their future practical activity.

By the initiative of L.Ya. Kovalchuk, PhD, Correspondent-member of Academy of Medical Sciences of Ukraine, professor, Rector of I.Ya. Horbachevsky Ternopil State Medical University “Student (Physician)–Patient” models of communication have been  created.

 

COMPULSORY ELEMENTS OF COMMUNICATIVE SKILLS, WHICH SHOULD BE TAKEN IN TO THE PRACTICAL PART OF THE OCCUPATION IN STUDYING OF CLINICAL DISCIPLINES

 

How to work with the patient:

friendly facial expression  when you see the patient at the first time and during communication

greeting and introducing (name, level of competence, explanation or deciding the reason of consultation, with the informed consent of the patient)

the establishment of trustworthy relationships (friendly facial expression, to show interest, respect and care, corresponding style  of communication)

gathering the anamnesis, reasonable substantiation of carrying corresponding physical methods of examination

the explanation of examination findings and making plan for further actions

conversation accomplishment (verbal and nonverbal components)

 

II. STANDARD ALGORISMS APPLICATION OF USING COMMUNICATIVE      SKILLS IN SUCH SITUATIONS WITH TAKING INTO THE CONSIDERATION THE PECULIARITIES OF CLINICAL DIRECTION ELABORATIONS (SURGERY, INERNAL MEDICINE, OBSTETRICS, GYNECOLOGY, PEDIATRICS, NEUROLOGY AND PSYCHIATRY):

 

while taking the anamnesis

 

while making physical methods of examination and perform medical procedures

 

while informing the examination findings

 

while planing and diagnosing conservative treatment findings

 

while substantiating reasonable surgical intervention

 

while informing about the findings of surgical intervention and possible post-operative complications

 

while informing about the treatment prognosis

 

Objective structural clinical examination ( OSCE ) is not only an instrument for students’ clinical skills assessment, but also for establishment of their communicative abilities.

 

III. COMPULSORY ELEMENTS OF COMMUNICATIVE SKILLS, WHICH SHOULD BE TAKEN INTO THE STRUCTURE (OSCE):

 

Standard model of anamnesis and complaints taking

 

Example:

Complaints and anamnesis taking in children.

Friendly facial expression, smile.

Gentle tone of speech.

Greeting and introducing.

Tactful and calm conversation with sick child and his/her parents.

Further action explanation, (hospitalization and/or examination, etc.).

Conversation accomplishment.

 

Standard model of physical methods of examination and doctors’ procedures

 

Example:

Physical methods of children’s examination

1. Cordial facial expression, smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to a child and to his/her parents, which examination or procedures will be carried out  and get their informed consent.

5. Come in to contact with the child and try to get his/her thrust.

6. Prepare for examination or procedures carrying out (clean warm hands, warm phonendoscope, use a screen if necessary).

7. Perform examination or procedures.

8. Explain examination findings to child’s parents.

9. Conversation accomplishment.

Estimating criteria in objective structural clinical examination (OSCE)

A student gets 1 point in case of correct usage of communicative model and demonstration of perfect clinical skills.

A student gets 0.5 point in case of demonstration of perfect clinical skills and some elements of  communicative model.

A student gets 0 point in case of making  mistakes in both models or in case of serious mistakes in clinical skills performing.

 

PEDIATRIC CLINIC

 

Complaints and anamnesis taking  in new-born and nursing babies

1.Friendly facial expression and smile.

2.Gentle tone of speech.

3.Greeting and introducing.

4. Tactful and calm conversation with the parents of sick child.

5. Explanation of future steps concerning a child (hospitalization, performing some methods of examination, etc.).

6. Conversation accomplishment.

 

Physical methods of examination of new-born and nursing babies

1.Friendly facial expression and smile.

2.Gentle tone of speech.

3.Greeting and introducing.

4. Explain to the parents what examination should be performed and obtain their informed  consent.

5. Prepare for examination (clean and warm hands, warm phonendoscope, etc.).

6. Examination.

7. Explaining the results of examination to baby’s  parents.

8. Conversation accomplishment.

 

Complaints and anamnesis taking  in toddlers and preschoolers (children aged from 1 to 6 years)

1.Friendly facial expression and smile.

2.Gentle tone of speech.

3.Greeting and introducing.

4. By means of game playing find a contact with a child.

5. Tactful and calm conversation with  the parents of sick child.

6. Explanation of future steps concerning the child (hospitalization, some methods of examination, etc.).

7. Conversation accomplishment.

 

Physical methods of examination of toddlers and preschoolers

1.Friendly facial expression and smile.

2.Gentle tone of speech.

3.Greeting and introducing.

4. Explain to the parents what examination should be performed and obtain their informed consent.

5. Find a contact  with a child, try to gain his/her confidence. 

6. Prepare for examination (clean and warm hands, warm phonendoscope, etc.).                                         

7. Examination.

8. Explaining the results of examination to child’s parents.

9. Conversation accomplishment.

 

Complaints and anamnesis taking  in school-age children

1.Friendly facial expression and smile.

2.Gentle tone of speech.

3.Greeting and introducing.

4. Tactful and calm conversation with sick child and his/her parents.

5. Explanation  of the further steps to a child and his/her parents (hospitalization, some methods of examination, etc.).

6. Conversation accomplishment.

 

Physical methods of examination of school-age children

1.Friendly facial expression and smile.

2.Gentle tone of speech.

3.Greeting and introducing.

4. Explain to a child and his/her parents what examinations should be performed and obtain their informed consent.

5. Find a contact  with the child, try to gain his/her confidence. 

6. Prepare youself for examination (clean and warm hands, warm phonendoscope, use the screen if necessary, etc.).

7. Examination.

8. Explaining the results of examination to child’s parents.

9. Conversation accomplishment.

 

Informing about the results of examination

1.Friendly facial expression and smile.

2.Gentle tone of speech.

3.Greeting and introducing.

4. Explain to a child and his/her parents what examinations should be performed and obtain their informed consent.

5. Involve adolescent and his/her relatives into the conversation (compare present examination results with previous ones, clarify whether your explanations are clear for them or not).

6. Conversation accomplishment.

 

Planning and prediction of conservative treatment results

1.Friendly facial expression and smile.

2.Gentle tone of speech.

3.Greeting and introducing.

4. Explain to child’s parents the necessity of further treatment directions correctly and accessibly.

5. Discuss with parents and their child the peculiarities of drugs intake, duration of usage, side effects and find out whether they understand your explanations.

6. Conversation accomplishment.

 

Informing about the treatment prognosis

1.Friendly facial expression and smile.

2.Gentle tone of speech.

3.Greeting and introducing.

4. Correct and clear explanation of expected results of treatment.

5. Discuss with the parents and their child the importance of continuous treatment, following the treatment scheme, make sure that your explanations are properly understood.

6. Conversation accomplishment.

 

WORK IN THE CHILDREN’S HOSPITAL

 

 

Reception

The child directed to a hospital gets into a reception room where his initial examination will be carried out.

The appointment card (= direction letter = referral note) may be given by the polyclinic doctor, the specialist, or the family doctor; the patient may be delivered by the ambulance. Only patients in severe condition can be accepted without an appointment card.

In an appointment card, the full name, age, permanent address, preliminary diagnosis, if possible — the data of the carried out inspection, and also date, surname of the doctor and a medical seal or a seal of the establishment are given. Besides, with the purpose of preventive care of an infectious disease in the non-infectious hospital, the information about the child’s contact with infectious patients is necessary to be indicated in the appointment card, as well as possible infringements of stool (‘yes’ or ‘no’, if ‘yes'”— then we should find when there was a contact with an infected person, as each infectious disease has its own incubation period — this is known by the doctor). At the presence of contact of a patient with a child with infectious diseases (in case of obligatory hospitalization) He/She will be admitted in the special isolation ward or will be transferred to the infectious department.

 

City children’s hospital # 3 Appointment card Borody Oleg lv., 2 years old, the address is: Solnitchnaya str., 14/92, goes on hospitalization. The diagnosis: Acute Bronchitis. Iron deficient anemia of 1st degree. The general blood analysis on 14.12.2010: RBC — 3.4 T/L, Hb — 92 g/L, WBC — 10 G/L, ESR — 12 mm/hour. No contact with infectious patients, infringements of stool are not present.   15.12.2010                                                               Sign, and stamp of local doctor

 

If the child is delivered into the department without parents (in cases of accident, trauma, sudden significant deterioration of the health state), the information of hospitalization should urgently be told to the parents of the patient or the local police station should be informed for the search of the parents in case the child’s health is deteriorated.

In children’s medical establishment, there is an independent reception with separate medical personnels (doctors, nurses). In small children’s hospitals, the child is accepted by the doctors on duty in the children’s branch or the pediatricians occupying the post of the doctor on duty in the hospital, sometimes local doctors do it.

Reception of the patient should be carried out according to the following standard obligatory plan

1.               Registration — First the nurse fills in the data concerning the patient in the ‘Admission register’ or ‘hospitalization register’, (date, full name, age of the child, the address, the diagnosis in the appointment card) and draws up a passport part in the case history.

Simultaneously, the child’s body temperature is measured and later examined by the doctor on duty. The specified order is broken in case when a condition of the patient is severe and demands urgent help.

2.               Doctor’s examination (collection of complaints, the anamnesis of diseases and life, the estimation of the child’s condition, etc.) is carried out in approximately 20-30 minutes depending on the disease and seriousness of the condition of the child. Then the doctor (in our country personally) writes down all received data in the case history. At the end of this, the preliminary diagnosis, a plan of the inspection of the patient and his treatment are indicated (the list of medications and medical procedures).

3.               After examination by the doctor and the case history is filled, the nurse carryies out the sanitary processing of the patient:

First of all, the hygienic condition of the child (by examination of the neck, ears and all surface of the skin, nails on the fingers and toes, as well as the hair) is checked.

In case of long nails, they should be cut.

At diagnosis of pediculosis, the appropriate processing should be carried out.

Then, if necessary, according to the prescription of the doctor, the child takes a hygienic bath or shower.

Attention! In case of severe condition of the patient, sanitary processing should be carried out only after rendering the urgent help and with the permission of the doctor.

4.               After reception, the child is transferred to an appropriate department. The kind of transportation is defined by the doctor depending on the condition of the patient:

• If the state of health of the child is satisfactory, then he/she can go to the department independently under the nurse’s supervision.

• Children of the first-second year of life are carried on hands.

• The medical staff transports heavy patients on stretcher, carriages (Fig. 3), etc.

• In absence of carriages, lift escalator or elevetor, the child of an advanced age can be transferred on the bed sheets or blanket.

Transportation of the patient comes to an end with the case history and the prescription form (the plan of treatment and inspection of the patient):

To a nurse from the child’s department (if a condition of the patient is not severe, in evening-night shift).

To the doctor on duty (in the afternoon; if the condition of the patient is very serious at any time of the day).

If the child is under 1 year of age, feeding schedule is also prescribed. Besides, an additional verbal communication with the department about the condition of the hospitalised patient is necessary.

Simultaneously we shall consider kinds of possible transportation of the patient outside the hospital (Attention! It may be only if the condition of the patient allows transport him/her):

• By ambulance.

• Sanitary aircraft— by plane, helicopter (in mountainous place, for urgent transportation to far distances).

• In emergency cases — any road transport.

Except the specified function of a reception room (reception of patients and their hospitalization), it has one more function — the registration of the movement of patients in a medical establishment. With this purpose, the medical staff fills the following documents:

(a)        Hospitalization register.

(b)         In case parents refuse hospitalization, the data on the patient are written down in special refusal register; besides, at refusal, in some cases (such as infectious disease and severe condition of the child), the doctor in the reception must inform the local doctor and the school where the child studies (the kindergarten) about the situation.

(c)        Discharged register of the patients.

(d)         Register of transferring to other hospitals. For example: after significant deterioration of the condition, the patient from the small city hospital is transferred to reanimation department (= department of intensive therapy = Intensive Care Unit — ICU) of the regional children’s hospital, the child from cardiological branch is transferred

to surgical branch in connection with the development of acute appendicitis, etc. (e) Register of fatal cases.

It is clear that the list of patients in the 1^st journal should be equal to the total amount of patients in the last three registers.

 

Medical department

 

 

During all the time of stay in a hospital, the child is treated in the medical department. In total, the hospital may have from 1 -2 up to 10 and more departments depending on its size. In one children’s department, there may be patients with different uncontageous diseases (rheumatic fever, pyelonephritis, gastritis; in the same branch, only in a separate chamber, patients with bronchitis, pneumonia, etc.). There are specialized hospitals in which children with diseases of one system (cardiological, gastroenterological, hematological, etc.) are treated.

The main objective of all medical personnel in the department is an operative inspection of the patient, the timely statement of the correct diagnosis and, at an opportunity, the full treatment of the child or (in case of incurable disease) realization of the necessary complex of medical actions for the patient.

Structure of the children’s department

The department consists of isolated ward (= chamber = room — in some countries) sections; for children of the 1^st year of life, there should be no more than 24 beds, over one year— not more than 30 beds. In one ward there may be accordingly 1-4 and 4-6 beds. The best for the children of breast-feeding age are box wards, when every child has his own ward which prevents possible infections to other patients. Till this time, in some hospitals, according to the old rule there are wards which may not be very effective half-boxes with wooden- glass partitions only between beds.

Hygienic requirements in wards are:  

·                 The distance between beds should not be less than 1.5 m.

·                 Every child should have a personal bedside table and a case for clothes.

·                 In each ward, one quartz lamp should be hung.

·                 If there is no separate toilet near the ward, then the presence of a washbasin with cold and hot water is necessary.

Generally, the structure of the children’s department comprises of:

·                 The department manager’s room.

·                 Duty room — a room for the doctors work.

·                 A room of the senior nurse.

·                 A post of the attendant nurse (on duty); for the convenience of constant supervision, it is often located in corridors of the department; near the table of the nurse, there are some hospital shelves in which the most necessary medicines and medical tools are kept.

·                 In the department, there is nurse’s room for inter-muscular injections, eye dropping and other medical procedures, in which, by obligatory rules, medical products and tools for manipulations are kept in the safe, refrigerator or in usual shelves.

·                 A separate (!) manipulation room for intravenous injections.

·                 In the branch, usually there is a special separate room for specific medical procedures with the purpose of treatment and inspection (for example, for intubation of the patient, examination by the ENT-doctor, the urologist, and the gynecologist, etc.).

·                 A physical procedure cabinet (inhalation, electrophoresis, etc.).

·                 A dining room.

·                 A rest room for the doctor on duty.

·                 Bathhroom.

·                 A toilet (separate for medical staff and patients).

 

 

Sanitary-and-hygienic and anti epidemical regime

Sanitary-and-hygienic and anti epidemic regime is the extensive complex of actions which are carried out by all employees of the medical personnel, and also by patients, the purpose of it is maintaining cleanliness in the medical establishment and anticipation of future epidemics of infectious diseases.

The following rules are included into the structure of these actions.

As it was mentioned above, in an appointment card, the doctor should specify the data of the contact of the child with infectious patients.

Despite of the anamnesis written in the refferal form, a doctor at a hospital to which the patient is reffered, has to enquire on the epidemiological anamnesis once more (see pg. 80). As for the tactics of the doctor in case of the positive anamnesis you, students, already know it. Even if the epidemiological anamnesis of the child is not aggravated, the patient needs to be examined carefully in a reception to avoid an infectious pathology.

Sanitary procedures which should be primarily carried out at reception lasts during all the time of stay of the patient in a hospital. If mother is in a hospital, then once a week, she will cary out the procedures in place of a nurse. Every week each patient takes a hygienic bath.

In the department, bed sheets and clothes should be changed in due time. The frequency of the change depends on the pathology, age of the child and his condition.

Furniture and the object of common use (couch and pillow on it) should be covered with polyethylene film which is wiped up by 1% sol. of chloramines or 0.5% sol. of chloride of lime 2 times after every patient, with an interval of 15 minutes, and after that with water. Sterile disposable film sheets can be used. Simultaneously after every patient, the bed sheet on a couch are changed.

The medical staff should observe the rules of preparation and distribution of food, and patients — rules of eating food. Usually, it is prepared in a special room. After delivery to the department, it is possible to keep food stuffs in a separate room not longer than 2 hours. Portions are given into a dining room through a special window. The utensils are exposed to special processing after use.

There should be drinking water for patients.

All workers of the department are obliged to observe the rules of personal hygiene, as well as every patient is obliged to carry out all rules of personal hygiene.

One of the main anti-epidemic actions is disinfection which helps to prevent the distributions of microbes of illnesses in the hospital and their destruction.

The disinfection can be:

a.               Preventive.

b.              Carried out in the epidemic center which is divided into:

·                 Current.

·                 Final.

Preventive disinfection is a complex of actions for preventing the accumulation and distributions of activators of diseases in the hospital. Preventive disinfection should be carried out by the following ways:

1. Ventilation of wards — four times a day.

2.     Quartz (UVR) wards 2 times a day for 15 minutes.

3.     Vacuum cleaning or shaking out in the fresh air of soft things (e.g. mattresses, blankets, curtains, etc.).

4.     The complex of preventive disinfection includes the above mentioned i ules of the observance of hygiene by medical staff and patients, and also the rules of preparing and distribution of food.

5.     Wiping at least 2 times a day (in some departments — more often, for example, in the infectious one — 4 times a day) the floor, windows, furniture. toys with specially prepared solutions, for example:

(a) Chloride of lime (now rarely used) — fine powder of white color; it is necessary to keep it in the dry pack protected from the light; only the patient’s excrements are disinfected with this dry powder. Chloride of lime in the liquid form is made and applied as follows:

·                 At the beginning, a special 10% or 20% solution is prepared (so-called ‘clarified’): the necessary quantity of the dry powder (for example, 1 kg to 10 L of 10% solution) is stirred in a small amount of water; then gradually; water is added up to the necessary volume (in this case — up to 10 L) and at constant stirring, till the formation of homogeneous mix is achieved. The received structure is covered with a lid.

·                  Approximately in 1 hour, the mix is mixed up once more, in 1 hour— once again, and after 1 hour — once again; thus, within the first 3 hours it is mixed up 3 more times.

·                  In 24 hours, from the beginning of manufacturing, the ready clarified solution (in this case 10%) is poured out and then kept for no more than 7 days in enameled, wooden, metal (protected from corrosion) well-closed basin.

Examples of calculation of the quantity:

~ 500 g of powder and water up to 5 L = 5 L of the 10% solution

~ 2 kg of powder and water up to 10 L = 10 L of the 20% solution

·                 At work, the so-called working solution is used 0.5-1%, which is made

§    by the necessary dilution of the clarified solution. Examples of calculation:

~ 1 L of the 10% main solution + 9 L of water = 10 L of the 1% working solution

~ 1 L of the 20% main solution + 19 L of water = 20 L of the 1% working solution

~ 500 ml of the 10% clarified solution + water (up to 10 L) = 10 L of the 0.5% working solution

·                 The working solution can be used no more than 24 hours.

·                 For cleaning windows, the floor, furniture, toys, etc. 0.5% solution of chloride of lime is used.

(b) Chloramines В (in dry form, it is a powder of white color) — for usage,

1% solution is made by gradual stirring of the necessary quantity of the powder, first in a small volume of hot water (50-60°C), and then adding more and more water up to the necessary full volume (for example: 50 g of powder and 5 L of water). To store a solution is possible no more than 5 days.

(c) Dezaktin— dry powder mixed in water for 1-2 minutes, for the formation of 0.1-2.5% solution which is used for the current and final disinfection. When water temperature is 60°C, there will be an accelerated dissolution of the medium (for concentrations over 0.5%). You can save 24 hours.

The current disinfection is a complex of actions for the reduction of infection in the whole room near the centre of the infection. For example: in the child’s department (non-infectious) on the 1^st floor of ward #4, a child who is hospitalized for the treatment of pneumonia, suffers from salmonellosis as well; the current disinfection should be carried out on the territory of the whole 1^st floor.

Three kinds of disinfection are applied:

1.               Chemical — for disinfecting toys, furniture, windows, the floor etc. with disinfectant solutions of high concentration — 1% solution of chloride of lime and 2% solution of Chioramines.

2.               Physical — boiling subjects (pans, dishes, etc.) in water; the addition of soda or some laundry soap (10-20 g in 1 L of water) is effective.

3.               Mechanical— washing the linen, removal of dust and dirt with a damp duster.

The final disinfection is an utter elimination of the activator of a disease in the centre of the infection (according to the given example, in ward # 4 it

is necessary to carry out not current, but final disinfection). Thus, the above mentioned concentrated liquid disinfectant solutions, dry powder are used. Many subjects (footwear, books) are processed in disinfection wards.

Louse infestations (= pediculosis) is an attribute of untidiness, infringement of the rules of hygiene by a person, and also non-observance of the sanitary- and-hygienic regimen in a hospital.

Let’s recollect biology: three kinds of lice can parasitize a person — head, crab (= pubic) and body (= clothes) louse (the name specifies the place of their localization); simultaneously there may be nits (= eggs), larva and mature (- imago).

The survey on pediculation is done by the nurse in a reception room. As there are three kinds of lice, the appropriate parts of the body and clothes of the patient are exposed to survey.

At detection of pediculosis, medical tactics can be different depending on the condition of the patient:

1.               If the child is well (for example, parents brought him/her to the hospital

with the purpose of some non urgent operation), he/she is usually sent home for elimination of lice, then hospitalization is allowed.

2.               If the child needs hospitalization, but his/her condition is not very serious,

in a separate room of a reception, the special processing of the patient should be carried out, then the child is transported to the ward.

3.               If the condition of the patient is severe or very severe, first of all, the

treatment of the basic disease is carried out, and the processing is made after the improvement of his/her condition and only with the permission of a physician (in this case, it is necessary to observe special rules for the warning of distribution of lice among other patients, especially before processing, — the patient is put into the separate ward, there should be a scarf on his/her head, etc.).

The technique of eliminating process of the child at revealing head lice:

(a)             It is possible to shear hair (it is usually done with boys — an ideal momentary way!) or to process the head of the patient with one of solutions used for such a purpose: Lotions ‘Nittifor’, ‘Miloca’, ‘Lanchet’, special shampoos, etc.

(b)             After processing, the head is wrapped up with a polyethylene bag,

then a scarf is put on it; in such position, the child stays for 20-40 minutes (according to the instruction).

(c)             Then, the head is washed by hot water with laundry soap.

(d)             The next moment is the most scrupulous one; it is gradual combing of the patient’s hair with a fine-tooth comb with a piece of cotton wool (moistened in 9% vinegar solution).

(e)             The head is swilled with a lot of water.

Cut off hair, and the hairs cut should be put on an oilcloth and burnt. At revealing only nits, it is possible to apply more simple solution: the hair is processed with warm (30°C) 9% solution of vinegar, then for 15-20 minutes, the head is wrapped up with a scarf, after that, the hair is combed out and the head is washed.

The clothes on which body lice are revealed should be packed into a polyethylene bag and sent into the chamber for disinfection.

Special features of the medical personnel hygiene

Dear students, surely you know all the rules of personal hygiene of the medical personnel, therefore they are only listed here: 9 Tidy appearance.

•                   A standard medical smock (coat).

•                   A cap or a kerchief on a head.

•                   Short nails.

•                   Special hospital footwear which is easily disinfected (for example, leather).

•                   Hands well washed up with soap.

•                   To medical sisters and doctors engaged in surgical manipulations, watches, rings, varnish oails are forbidden.

•                   According to indications (the maternity, infectious department, epidemic of influenza, etc.) a mask is put on; it is necessary to change a gauze mask every 4 hours; at an opportunity, it is better to use disposable sterile masks.

 

ORGANIZATION OF WORK OF MEDICAL PERSONNEL IN CHILDREN’S DEPARTMENT

Pediatricians, medical nurses and hospital cleaners work in children’s department in our country.

Work of medical nurses and hospital cleaners

Several medical nurses work in a children’s department. They carry out different duties: a senior medical nurse (= matron) supervises the work of all other nurses. Manipulation medical nurse is responsible for giving injections, post medical nurse must distribute medicines to patients, observe all patients, collect samples for analysis from patients, etc. Medical nurse performs physiotherapeutic procedures, etc.

Usually in the afternoon, there are more nurses at work, than at night. If emergency situations occur, which may arise anytime, a nurse must know and be able to perform all recommendations of a doctor who treats or a doctor on call.

The basic duties of nurses

1.               Participation during the process of admitting patients into hospital.

2.               Performing all recommendations assigned by a doctor (there is a special prescription form where a doctor has to write all the necessary analysis and manipulations that are to be done):

 

Case history # 1337 at 29 May 2010 Full name Andronjuk Sergeu

Age 1 year                                    Body weight 10 kg

 

 

 

PRESCRIPTION FORM

 

(a)                              Distributing medicines to patients (in case the child is alone ,in a hospital, a nurse should make sure that he/she takes the medicine on time and correctly).

(b)                              Dropping medicine into eyes, nose and ears.

(c)                              Carrying out different manipulations (e.g. intramuscular, intravenous injections, infusion therapy, etc).

(d)     Measuring weight arid height of children.

(e)    Collecting samples for laboratory analysis from patients (blood, urine, stool, nasal and oral swab, etc.), delivering them to the laboratory. When the analyses are completed, it should be taken by the nurse from the laboratory and attached into the case history.

(f)      Taking general care of the patients and carrying out complicated methods of treatment and examination of patient (feeding the child through a tube, catheterization of urinary bladder,and gastrointestinal tract as well as indirect massage of heart, etc. — all this we will study shortly).

(g)    Transporting patients for radiography, spirography and other kinds of specific examinations, physiotherapy, consultations with subject specialists, etc., and timely submission of all the results after performed analyses and conclusions with subject specialists to a doctor.

(h)    Calling specialists for consultation from other departments of hospital.

(i)      Carrying out hydrotherapy for patients and be present during the procedure, if it is assigned by a doctor.

(j)   Calling ambulance for transportation of patients.

3.                Permanent duties of a medical nurse that are carried out daily with no special prescription made by doctor:

(a)   Filling in medical documentation (except for case histories).

(b)     Measuring patient’s body temperature in the morning and in the evening, sometimes the temperature should be taken every hour (if the patient is in severe condition or undergoes infusion therapy) and sometimes even more often. The data are to be put down into a Temperature sheet (Figs 64 — 66).

(c)     In some cases, heart rate and blood pressure are measured (sometimes a medical nurse puts down these data into the Temperature sheet of the case history —see Fig. 66) measurement of respiration rate.

(d)  Measuring weight and height of children once a week, according to a plan.

(e)   Reporting every morning to the medical personnel of the department about conditions of patients, especially those who are critically ill or newly hospitalized, and about those whose condition unexpectedly got worse.

4.                Be present at general doctor’s rounds, where all necessary information about the condition of patients is given.

5.                Check if all necessities are delivered into department timely:

§        Medicines.

§        Medical tools and bandage materials.

§        Food for patients.

§        Sets of clean bed linen and underwear for patients.

6.               Stick to the following rules:

•          Personal hygiene of patients.

•          Order at the medical nurse’s post.

•          Storage of medical products which include:

§   2 groups of medical products that are to be stored in special metal boxes as safes with inscriptions ‘A’ and ‘B’ or cabinet. Safe ‘A’ contains poisonous and narcotic products. Safe ‘B’ is used for strong active remedies. Key to the safe should stay with one of the officially appointed employees of the department (senior medical nurse, head of the department) who bear the legal responsibility for preservation and distribution of medicine. Inside the safe, there should be a list with names of medicines stored in the safe and their daily and single pediatric doses. It is very important to have a list of antidoses in the medical safe, for the purposes of treating children who might get accidentally overdosed by various pharmaceuticals. All data about delivery and use of these medicines should be timely put down into a special medical register.

§   Medical products with strong smell (e.g., liquid ammonia) and coloring solutions (e.g., iodine, methylenblau) are stored in a separate safe.

§    Other medical products are stored in regular cabinets. The medical nurse at the post looks after them. The medicines in the safe are arranged in order convenience for usage. The order of their arrangement may vary from department to department. Each shelf should have a label with the name of the group of medicines on it — e.g., for internal or external use, for injections, etc.; besides, it is convenient to divide them according to their form. For example, internal medicines are produced as tablets, liquids, powders, etc.; it is desirable to put the bigger bottles away from the smaller ones — it will enable you to read the labels on bottles at once.

§   Additional rules of storing medicines:

§    It is necessary to keep a steady temperature and humidity of environment where the medicines are kept (for example, some medical products — dry plasma, insulin, herbal decoctions, etc. should be stored in a refrigerator at temperature from +2°C to +10°C, fresh frozen plasma — in a freezer as a frozen substance), o There are medicines (for example, iodine) which should be stored under certain illumination — for this purpose they are stored in dark bottles and in dark places.

§    The medicine should not be used after the expiration date, which is always specified on the label of the medicine. If there are visible changes in a normal look of a medicine (dimness, flakes, change of color in liquid medicines; appearance of stains and change of color in tablets; unusual smell of a medicine) is also an indication of the fact that medicines should no longer be used, o Medical remedies should never be stored together with disinfecting solutions.

7.                 Teach children and their parents the following rules, if necessary:

•                   Working hours of the hospital.

•                   Getting food products from friends and storing them.

•                   Taking medicines.

•                   Personal hygiene.

•                   Child care.

8.                 Supervising the work of a junior medical personnel:

•                   Controlling reception and distribution of food, and if necessary rendering assistance in feeding patients who are in severe conditions.

•                   Supervising their main duty — i.e. keeping children’s department of the hospital clean and in order.

 

The basic duties of a junior medical personnel:

•                   Damp cleaning in the medical institution (they should know the frequency of cleaning and contents of the liquid used in different rooms).

•                   Supervision of sanitary conditions of furniture in the ward, corridor, etc.

•                   Sanitary processing of the patients, beginning with the reception.

•                   Helping the child in observing the rules of personal hygiene (combing hair, trimming nails, etc.).

•                   Changing bed covers, bed sheets and patients’ clothes.

•                   Prevention of bedsores.

•                   Necessary medical aid to a serious patient in micturition, defecation (for example, to keep a bedpan).

•                   Helping the nurse in some methods of inspection (collecting urine, stool; measuring of weight and height of the child, etc.).

 

Work of the doctor-pediatrician in a hospital

In every children’s department, there is a managing branch and attending physicians.

The basic duties of a doctor-pediatrician of the children’s department include:

•  Admission of the patients (in case of the absence of a separate admitting room).

•   Daily observation of the patients.

•   Daily filling up of the case history.

•   Daily viewing and additional filling of the list of medicines to be given).

•   Consultations with the patient’s parents at their request during the whole time of hospitalization, especially during discharge from the hospital (the explanation of the child’s condition, acquaintance with the results of inspections, advice, and recommendations).

•   In the morning, obligatory presence at the briefing of medical personnels of the department.

•   Simultaneously with the nurse — carrying out of some difficult manipula­tions (such as blood transfusion; intravenous introduction of plasma, con­trast substances; punctures, for example, pleural puncture, etc.).

•   On the day of discharging the child from the hospital, a ‘Discharge form’ is written (the document in which the diagnosis, the prescribed examination, treatment and recommendations are specified); it is given out to the parents or transferred to the children’s polyclinic.

Medical documentation of the children’s department

 

The case history (= Medical record card of the hospitalized patient)

The average medical personnel in the case history fills the following suctions:

•  The passport section.

•  The result of examination on pediculosis.

•  The result of interrogation on possible infectious diseases (virus hepatitis, tuberculosis).

•  A temperature sheet.

•   Once a week — the information about changing clothes and taking hygienic baths.

The nurse should, at the required time, file in the the following documents InlQ the case history :

•   Results from the laboratory and other (X-ray, ECG, etc.) kinds of inspection.

•  The conclusion of specialists (ENT specialist, cardiologist, etc.), if the consultation was carried out in other medical establishment (the case history of the child cannot be taken out of the hospital).

The general rules of conducting and keeping of the case history:

•The data about the condition of the patient should be recorded daily;

•The observance of the form and order of the filling of different sections of the document (we shall learn about this further on, in the course of propaedeutics)

•After discharging the child from the hospital, the case history is transferred to the archive, where it is stored for 25 years.

There is a special register which shows the patients’ movement (the duty of a medical personnel is to write the information into it). Every morning, all medical personnel gather in the staff lounge: the persons who were on duty the previous night and those who must be on duty during the new day. Usually such a gathering in our country is called a ‘5-minute’ briefing. At the beginning of this meeting, the duty doctor reports about the situation in a hospital:

•Number of children in the department before the beginning of his/her duty and number of children in the morning.

•Number of children being admitted.

•Number of patients discharged.

•Number of children moved to some other hospital or ward.

•Number of patients dead or has left the hospital unwarrantly.

•Detailed information about the newly admitted children.

•The condition of serious patients.

• Possible reasons of deterioration of the condition of other children (rise in temperature, problems in defecation, etc.) and maximum help rendered to him/her are described.

Then, the nurse on duty reports on all the patients who had some increase in temperature, or whose condition became worse, gives the list of those who did not hand over some analyses with the indication of the reason, possible peculiarities of giving and taking medicines.

This information is especially necessary for the attending physician.

For example:

•                   After the distribution of patients, the doctor starts the inspection of the child whose situation is most severe (at the absence of such information, the severe patient may be examined by the doctor too late, which may be very dangerous for his/her life, — for example, at 12.00 — 1 p.m.).

•The missing analyses should be prescribed repeatedly without any delay; there are methods of the inspection, for example, swab culture on pathogenic flora, when the result comes only within 2-3 days; i.e. at the absence of such information from the nurse, the doctor finds out about the missing analysis only after some days.

• In case of the unwarranted leaving of the sick child, the attending physician should inform the local or family doctor about that immediately.

 

The nurses’ register (or sheet) in different departments can have different names and can be conducted unequally, but the most convenient way.

In the register the attendant nurse on duty daily, sometimes 2 times a day, makes the following extract of the sheet of the assignments (with mentioning the surname of the child):

• Intramuscular injections (there may be a list according to the groups of medicines, the time of introduction, the wards, etc.).

• The list of necessary analyses.

• Assignments for the inspection and the appropriate preparation for the procedure.

• The list of consultations, etc.

 

The register book of the department in which the information on hospitalization of patients and their discharge is registered, has the following vertical columns:

§     Number.

§     Number of the case history.

§     Date of hospitalization.

§     Full name.

§     Age.

§     Address.

§     By whom he/she was refered from.

§     The diagnosis during hospitalisation.

§     The final diagnosis (at discharge).

§     Date of discharge.

§     When he/she is discharged to: home, transferred to some other department, fatal case.

§     Number of days in the department. Attention! The first and last days are considered as 1 day: for example — if patient arrived on 2.02.2010, and was discharged on 7.02.2010, the number of days — 5.

 

The register-book of infectious patients in pediatrics is of special importance because infectious diseases (measles, scarlet fever, pertussis /= whooping cough/, etc.) are most frequent among children. The diseases of such character develop not later than 3 weeks after the contact of the child with the infectious patient. Therefore, the patient who is hospitalised into the children’s department, for example, with pneumonia, but was in contact with the infected patient 7 days before, is dangerous for 2 more weeks. Probably, the infectious disease will be shown in him/her, but may be, the child was not infected — it is not known by anybody. Such a child cannot be put into a usual ward. Here, the doctor solves the problem individually: A patient whose condition is not very severe can be treated at home, but a severe one — put into a separate isolated disease will be shown in him/her, but may be, the child was not infected — II is not known by anybody. Such a child cannot be put into a usual ward. Here, the doctor solves the problem individually: A patient whose condition is not very severe can be treated at home, but a severe one — put into a separate isolated ward and at presence of symptoms of an infectious disease — directed to the infectious hospital. However, in each case, the information on the patient like this is entered into the above-mentioned register-book of infectious patients named above.

In the emergency messages book, the cases of emergency character are recorded (i.e. demanding urgent finding out of the reason of the occurrence and prevention of spreading out the pathology (infectious disease, poisoning, dangerous reaction to vaccination, medicines). The information on these cases should be imported urgently to SES (sanitary-and-epidemiologic station).

 

RULES OF DRUG ADMINISTRATION

 

There are some ways of the medicinal administration:

1.     Enteral (=oral) — introduction of medicines through gastrointestinal It net (GIT):

♦   Peroral.

♦   Per rectum.

2.    Parenteral — introduction of medicines by injection with skin damage:

♦      Intradermal.

♦      Subcutaneous.

♦      Intramuscular.

♦      Intravenous.

2.   Through derma and mucous membranes without their damage:

♦      Manual application of the preparation on derma and mucous membranes.

♦      Electrophoresis.

♦      Inhalations.

 

Enteral

Peroral (= Per os, p.o.) administration of medicines in pediatrics does not cause any complication in children of older age. With this purpose, as well as in adult, medicines are used in the form of tablets, capsules, granules, powders and liquids. At the time of prescribing medicines, the doctor (or nurse) should explain the rules of taking the medicines:

© How many times a day, sometimes, it is necessary to specify the time of reception (some medicines are given only in the morning or in the evening).

© Connection with meals— most medications are given after meal (for reduction of their irritating influence on the mucous membrane of the stomach), some of them should be used a.c. (i.e. before meals). Sometimes 45-50 minutes prior to a meal.

© Some peculiarities are possible. For example, Solutan should be taken with some milk; as for Mucaltinum it is better to dissolve it in water and to add a little sugar.

Usually, the preparation is put on the root of the tongue, and then, the child takes some drinks of water or other liquid tasty for him/her, simultaneously with which the medicine is swallowed.

As for children of early age, especially during the first 2 years, it is difficult to give them a medication per os. It is strictly not recommended to do it by force (!). Recently, this problem has been solved by preparing medicines in the form of syrups. If syrup doesn’t help, then the medicine should be crumbled and mixed with a little amount sugar and water, or dissolved in some tasty liquid.

The technique of giving medicine is: taking some medicine in a spoon, place the child in almost a vertical position, close his/her nose and the child opens mouth in reply to this and medicine is put in the mouth, then a favourite drink is given.

Per rectum (p.r.) is an administration of a suppository through the rectum.

The technique is as follows:

•    The child of an older age is made to lie sideways, with legs bent in knee and hip joints, the nurse by one hand moves buttocks apart, with another hand she put the suppository deep enough as the anus gets closed. Then for the prevention of slipping out of the suppository, it is necessary to compress buttocks near the anus for some minutes.

•    The child of early age can be put on the back, with legs lifted upwards, and further on, the technique of administration is similar to the above description.

 

Parenteral methods

 

For parenteral administration of medicine, a syringe is used, it consists of a cylinder, a piston, the cone of which is located at the end of cylinder and u needle which is fixed on the cone. Recollect! The end of the needle opposite lu the sharp end, is called as cannula — see.

 

 

 

a — the cylinder;

b _ the piston;

c — cannula of the needle’

d—the needle of ‘butterfly’type

 

During last few years with the purpose of pi< mention of infectious diseases and spreading gl AIDS plastic disposible syringes “Luer” are used.

Syringes are different depending on:

•                   Volume and application — special for insulin and tuberculin, we use a 1 mL syringe. (on the syringe, the measure of volume is indicated in mL and UA), widely used are — on 2 mL, 5 mL, 10 mL, 20 mL, and more voluminous syringes (for example, 60 mL);

•                   The location of the cone at the centre of the syringe or eccentric.

Needles also differ— in length, diameter, IIIo cut of angle at the end.

The general rules and order of parenteral administration:

(a)     The place of injection depends on its kind; however, it is always that part of skin which contains the least amount of nerve fibres and blood vessels (except for intravenous injections).

(b)     During injection, periosteum should not be damaged.

(c)     For prevention of mistake, it is necessary to read the label on the ampule or the bottle, to pay attention to the kind of medication, doze, expiry date.

(d)     It is good to wash your hands; even at small injury of skin — to process it with spirit; the presence of purulent damages on the skin is a contra­indication for the injection; after processing of hands do not touch anything.

(e)     Put a needle on the syringe.

(f)       Take some medicine into the syringe a little bit more than the necessary

volume (if the ampule or the bottle are placed above the needle — the liquid flows from the top downwards, if it is under the needle — the liquid rises from below upwards).

(g)     Always change a needle to a clean one.

(h)     Lift up the needle, slightly let some liquid out so that air could go out from the needle (thus, the superfluous amount of medicine will be removed).

(i)       Before the first injections, it is necessary to prepare the child psychologically for this procedure, not deceiving (!) him/her.

(j)   The child should be kept into motionless position on the bed which relaxes the muscles and promotes the best administration of the liquid; child should be held by mother.

(k)   Process the place of the injection with 70% ethyl alcohol, ether, or 5% tincture of iodine.

(I)   Inject the needle approximately to 1/2-2/3 of its lengths — in case the cannula is broken in the place of connection, it will be possible* to take it out without operation. If the needle is put till cannula in that case, the broken part enters the tissues, that will demand surgical intervention.

(m) The preparation is entered with the certain speed which depends on the following factors:

•           Less amount of liquid entered — demands a higher speed.

•          Consistence of medicines — thicker medications are more slowly injected.

•          Morbidity of a preparation — very painful medicine are not entered quickly, but also not very slowly.

•           The purpose of the procedure — here, the speed is specified by the doctor.

(n) The needle is taken away, and the place of the injection is wiped by spirit.

(o) Repeated injections are not done in the same place.

 

Intradermal injections (i.d.): From the name itself, it is clear that the medication is to be administered in skin.

Features of the technique:

(a)     The place of the injection is the internal surface of the forearm or external surface of the shoulder.

(b)     The needle and a syringe are of the least sizes, it is better to use the syringe with the eccentric arrangement of the cone of a tip.

(c)     The skin is processed with spirit or ether.

(d)     The needle is placed with its cut directed upwards at an acute angle to the skin and injection is done intradermally.

(e)     If the medicine is entered correctly, a so-called symptom ‘of lemon peer is observed — the skin towers a little, a papule is formed, and many pits are formed (this reminds the peel of lemon).

Mostly, such injections are done for the diagnostic purpose. For example, for determination of the allergic reaction of an organism to antibiotic. Antibiotic In Injected into the skin in the lower third of forearm in lower concentration (diluted). In 20 minutes, the size of hyperemia around the place of the injection h visually evaluated. Normally, reddening is absent or its diameter does not exceed 1 cm. If it is more — the preparation is contra-indicated for the child.

In order determine to the condition of migration of water (and sodium) In tissues, i.e. the hydrophilia of the tissues, the Mc Clure-Aldrich test is < ferried out (the U.S. doctor and the biochemist of the 20^th century): 0.2 mL of isotonic solution is injected with a thin syringe in the region of the top half of luruarm. The time of resorption of the papule with lemon peel’ is taken into fi« count, which normally depends on age:

•                   Under 1 year of age — 15-20 minutes

•                   1-5 years — 20-30 minutes

•                   Over 5 years — 40-60 minutes

I lie evaluation of the analysis:

(a) The time is lower thaormal (i.e. accelerated resorption) — this is a sign of edema of tissues of different character (cardiac, renal, etc.); if the edema of this kind caot be observed, then, it is refered to as ‘pitting’ edema (see pg. 471), and can be established by means of this method.

(b) The time is higher thaormal (i.e. slow resorption) — this is a sign of dehydration of the organism.

 

Subcutaneous injection (s.c.) is refered to, when the medicine is administered under the skin.

Features of the technique:

(a)     Places of the injection— top 14 of the shoulder, bottom of the forearm, stomach, under the scapula, external surface of thigh.

(b)     Needles and syringes — are both of different sizes. It is better to use syringes with eccentric arrangement of the tip of the cone.

(c)     The skin is processed with spirit or iodine.

(d)     With the 1^st and the 2^nd fingers of one hand, skin and subcutaneous tissue are slightly pinched (a fold is formed at this) and stretched upwards a little.

(e)     The needle is placed at an acute angle to the skin and 1-2 cm of it is entered deep into the skin.

(f)       Draw the piston back and check the possibility that the needle has been injected in a vessel — if blood is not present, then the medicine can be injected.

 

During intramuscular injection (i.m., IM) the medicine is injected into a muscle. It is one of the most widespread parenteral method. The advantage of intramuscular injections in comparison with subcutaneous is the quick absorption of the medicine due to lot of blood and lymphatic vessels in muscles.

Features of the technique are as follows:

(a)     The place of the injection is the top external quarter of the buttock and the top anteroexternal quadrant of the thigh.

(b)     Needles are long, of average diameter and syringes are of different volume.

(c)     The skin is wiped with spirit or iodine.

(d)     The needle is placed at an angle of 90° to the skin and is entered into, on a depth of 2-3 cm.

(e)     A possible inadmissible introduction of the needle into a blood vessel is checked and at the absence of blood the medicine is injected.

(f)       For quick and better absorption of the preparation after injection, it is effective to carry out massage in the place of the injection or put warm hot-water bottle.

 

Complications and necessary medical tactics

 

1.                Infiltration — hardening in the place of the injection — arises when a large number of injections are done in closely located points, and also in case of the voilation of the rules of aseptics.

It is determined by palpation, and the child often complain about pain in the place of injection and a dangerous attribute is reddening of the skin in the place of infiltration.

Medical tactics:

§     Warming by means of the compress (semi-alcoholic or with heparin).

§     Iodine network^[2] (Fig. 12)— a ‘picture’ in the form of grid is drawn at the place of the injection with cotton bud moistened with 2% solution of iodine.

§     Ultra-Violet Radiation.

2.                Hemorrhage and bleeding arise mostly in case, when the end of a needle injures a blood vessel. Probably, there may be a blood disease that onhance bleeding, which demands special inspection of the child.

Medical tactics:

§     The nurse has to bandage this place pressing the bandage firm to the skin.

§     To inform the doctor immediately.

3.                Damage of nerve fibers occurs as a result of wrongful choice of place for injection/The child experiences a sharp pain which feels like an electric ‘.liock. Further on, the attributes of the voilation of functions of the injured nerve develops.

There may be a condition of anaphylactic shock.

The tactics of the nurse is to stop the injection and to call the doctor.

 

‘Iodine network’in the top external quadrant of the right buttock

 

At the voilation of techniques of administration, the medicine can get into the surrounding region — for example, embolism of the branches of pulmonary arteries with the particles of oil solutions which have got into a vein during their intramuscular or subcutaneous injection.

5.                Abscess — suppuration in the place of the injection— is the result of rude voilation of the rules of asepsis, demands surgical treatment.

Medical terminology: the word Infusion‘ means parenteral administration of plenty of liquid into a patient with diagnostic or medical purpose. Infusions can be intra-arterial, intravenous, intraportal, subcutaneous, etc. Infusions are divided into stream (- set) and droplet ones considering the administering speed.

Intravenous infusions (= injections) (i.v., IV) when medicines are injected into peripheral veins, and this procedure is mostly applied at a serious condition of the child, however they can be carried out during scheduled treatment.

A place of injection:

§     For children of the first years of life, veins in the area of radio-carpel joints are used (this place is the best for being fixed in the immovable position during droplet administration), less often — ulnar vessels and subcutaneous veins of the head as well as an area around the ankle joint are used.

§   In older children injections are made into ulnar and radio-carpel regions, less often — and talocrural joints.

Features of the technique of intravenous jet infusion as follows:

1.                      Needles— long, of a large diameter, with a short cut on the end, syringes — of big diameter.

2.                      The skin is processed with spirit or p ether.

3.                      At the beginning, it is necessary to press the skin above the place of injection with i a finger or a whole hand (the nurse-assistant I usually does that, or to put a tourniquet on).

4.                      The needle is placed at the surface of I a skin at a particular angle, along the current of venous blood and pushed deep into untill piercing of one wall of vein [an attribute of getting to a vein is the occurrence of blood in the cannula of the needle; sometimes (at condensation of blood and dehydration of the organism) blood may not appear]; In that case, it is possible to enter a sterile cotton strand — if the needle is in the vein, the tip of the strand will redden.

Some nurses make injections at once, with a needle fixed to syringe; in such case the entrance in a vein is determined by pulling the piston back where by blood will appear in the liquid in inside the syringe.

A skilled nurse usually gets into a vein on first trial; otherwise, it is necessary, not to pull the needle out of the skin, but to pull it back a little bit and try to enter the same or other vein; in case of failure, the needle is drawn out and the place is pressed with a cotton tampon, moistened in spirit; then some other place for i.v. injections is chosen.

5. As for stream infusions, usually, some medical products are injected by several syringes which are serially inserted into the needle placed into a vein; as the medicines work practically fast, they are injected slowly (!).

6. During one i.v. injection, not more than 50 mL can be entered.

7. After accurate removal of the needle from the skin, the place of the Injection is processed with spirit, then for prevention of bleedings, a sterile pressing bandage is put on.

In order to administer greater volume of medicines, intravenous droplet infusion are applied when the liquid does not get into a vein, but the current of it is adjusted by drops which can be seen.

At the beginning, a dripper system is prepared, the structure of which consists of:

1.   A dripper in the form of plastic tube having the following parts:

♦      A special tap which can block a tube and, therefore, regulate the speed of dripping medicines.

♦      The expanded part— of a dripper at the bottom of which a ‘stagnant lake of liquid’ is formed, where the liquid from the upper part of the tube will drip with the visual speed; the speed of the frequency of drops per minute, either its reduction or increase is adjusted by the above mentioned special tap.

♦      The upper part of the tube ends in a needle which is inserted into a bottle with medicinal liquid.

♦                         At the bottom of the tube, there is a soft rubber site or closed ‘hole’ with a special filter, with a cannula on its edge, which is put on a needle in the vein; through the rubber part, the additional medical products are entered by jet infusion after closing the tap hence stopping droplet introduction.

2.    A stand on which the bottle with medicine (Fig. Intravenous infusion – A) is placed upside down, for changing the pressure of liquid, the stand can be moved upwards or downwards by a special regulator (Fig. Intravenous infusion – B).

For the appropriate movement of the liquid downwards, apart from the needle of a dripper, one more needle should be inserted with its cannula open into the air, named among medical personnels as ‘air-needle’ (Fig. Intravenous infusion – C).

 

Intravenous infusion

 

3. The needle in a vein — the older the child is, the wider and longer the needle is used.

In pediatrics, the so-called ‘butterfly’-needles which are well fixed in im­movable position are very convenient vein, then, the needle is removed and a thin cannula remains in the vein (for 3-5 days), practically limiting the movement of the hand of the patient.

Sometimes, we can use a surgical method of inserting a catheter. So:

(a)                         The bottle with liquid is prepared, placed on a stand; the ‘air-needle’ is inserted.

(b)                         The dripper is connected to the bottle.

(c)                         Then, the tube is lifted upwards for a short time, in such a way that the

upper part of the dripper is below, then the liquid fills approximately the half of the dripper. And the tube placed downwards at once — the liquid passes through the whole tube up to the cannula. Special attention should be given, if air is present in the tube — it should be removed (!).

(d)                         The tap is closed, and the lower end of the tube usually fixed to the stand for a short time.

(e)                         The needle is entered into a vein.

(f)                          The tube is joined to a needle — for preventing the entrance of little

amount of air into a vein at this short moment, the liquid from the dripper should flow and some amount of blood from the vein should come out.

(g)                         The frequency of drops is determined according to the prescription of the doctor — from 10-12 up to 60 per minute.

(h)                         The needle is fixed — a sterile wadded tampon is put under it, and the needle is fixed to the skin with an adhesive plaster.

(i)                           As infusion lasts for some hours, sometimes, during the day, the extremity is fixed in an immovable position, it is especially important for children of an early age. Usually, a splint (a hard plate) is placed under extremities, they are bandaged (do not close the lower part of the tube and the needle!) and also fixed by a clip to the pillow or mattress, rubber cord may be used if bandage is not available (above the cotton wool on the hand), tie them to the frame of the bed. To little children, sedative medicines are given, according to the doctor’s prescription.

Attention! Nowadays, only the disposable dripper is used, which in case of long infusion, should be replaced by a new dripper in 24 hours.

Complications of intravenous injections and medical tactics

2.  Infiltration— it is formed, if the medicines enters surrounding tissues Ihrough the injured vein or at wrong infusion, outside the vein. The tactics of the nurse is using a warm compress.

3.  Hemorrhage and bleeding — are formed at significant damage and puncture of a blood vessel from two sides and at some blood diseases.

4.  Air embolism — entering of some amount of air into the vein as a result of professional mistakes, this demands urgent medical assistance. Air embolism due to a considerable amount of air results in an irreversible condition of the patient which can lead to a lethal outcome.

5.  Phlebitis is an inflammation of the wails of vein into which the medicine is injected by means of infusion.

Clinical attributes — pain and hyperemia of skin on a course of vein.

The principal causes are:

§  Infringement of the rules of sterility.

§  Long (more than 3 days) presence of the catheter in a vein.

§  Formation of blood clots in a vein may be in the following cases:

ü      If necessary, the movement of liquid through a needle can be stopped for some time. For this purpose, a mandrin is inserted into the needle. Cannula can be closed with a special stopper, etc. However, a long delay of intravenous infusion promotes the formation of blood clots.

ü      For prophylaxtion of the thrombosis in veins (attention, which simultaneously prevents the thrombosis of needles or catheter) a so-called ‘heparin lock’ can be used — into a needle (catheter), 1 mL of the following contents are administered — heparin and 0.85% solution of sodium chloride in the ratio of 1:9, after that, the catheter (or the needle) is closed for the necessary time.

ü      Very slow droplet infusion — 7-8 drops per minute.

ü      The temperature of the medicinal liquid lower than body temperature of the patient— is mostly observed at the infusion of plasma, albumin and blood, which were stored in a refrigerator. Hence, such liquids before the infusion should be warmed up to 37°C.

ü      The treatment of phlebitis is to remove the needle, and put a compress with heparin ointment along the vein.

6.  Allergic reaction.

7.  The infringement of the rules of administration, when the medication enters into surrounding tissues — for example, if, during intravenous administration of calcium chloride, it happens that CaCI₂ spills outside of vein, necrosis of the tissues will occur.

 

Measurement of respirations

Respirations are evaluated for (1) rate (number per minute), (2) rhythm (regular, irregular or periodic), (3) depth (deep or shallow) and (4) quality (effortless, automatic, difficult, laborated). A nurse also notes the character of breath sounds based on inspection without the aid of auscultation, such as noisy, grunting, snoring, or heavy.

 

 

 

 

Examination of a pulse

 

A pulse is a rhythmic fluctuations of arteries walls, caused by emission of blood into arterial bed and changes of blood pressure in it during systole and diastole. With each contraction the left ventricle ejects a volume of blood (a stroke volume) into the aorta and then into the arterial tree. A pressure wave moves rapidly through the arterial system where it can be felt as the arterial pulse. The spreading of a pulse wave depends on the ability of arteries walls to elastic extension and contraction.

 

Properties of pulse  on artery: symmetry (synchronous or asynchronous), frequency (accelerated, slowed, the pulse rate),  rhythm (rhythmic, arhythmic), tension (of moderate tension, dull, soft), feeling (full, empty), size (high, small, thready), character (quick, slow), pulse deficiency (indicate the number of missing waves per min).

 

 

 

 

 

 

 

Blood pressure measuring

 

Blood pressure in the arterial system varies with the cardiac cycle, reaching a systolic peak and diastolic trough, the levels of which are measured by sphygmomanometer. The difference between systolic and diastolic pressures is known as the pulse pressure.

 

 

 

 

 

Ambulatory blood pressure monitoring (ABPM) is a method of taking regular blood pressure readings, usually over a 24-hour period, as patients conduct their normal activities. A special, automatic blood pressure monitor is used, and patients are asked to keep a diary or log of their activities during the day.

 

 

Ambulatory blood pressure monitoring is usually used when a physician suspects that a patient is suffering from “white coat hypertension.” This is a condition in which high blood pressure occurs only in the physician’s office as a result of stress and anxiety.

However, there are a number of other situations that might cause a physician to recommend ambulatory blood pressure monitoring. These include patients who do not respond to medication and patients with symptoms such as fainting (syncope). In addition, ABPM has been found to be a more accurate predictor of patients at high risk of a cardiac event than then other blood pressure monitoring methods.

Ambulatory blood pressure monitoring is distinguished from home blood pressure testing. Home monitoring systems are gaining in popularity. Relatively inexpensive, they allow people to take their own blood pressure at various times throughout the day. Though this can yield valuable information, there are several drawbacks when compared to ambulatory blood pressure monitoring.

ABPM uses specialized equipment to measure blood pressure at regular intervals, 24 hours a day. This information is combined with a written log to aid in the diagnosis and/or treatment of conditions related to blood pressure.

Ambulatory blood pressure monitoring (ABPM) is a method of taking regular blood pressure readings over a 24- or 48-hour period. This is accomplished with a special device that is worn at all times and measures blood pressure automatically, recording the readings.

Studies have shown that ABPM is a valuable tool in the diagnosis of several conditions.  It is also beneficial for adjusting doses of medication for high blood pressure and even predicting cardiac events in certain patients.

Blood pressure is a measure of the force, or tension, of the blood against the walls of the arteries. High blood pressure puts an added workload and strain on the heart, whereas low blood pressure (hypotension) can lead to fainting (syncope). High blood pressure (hypertension) is a very common disease in America. It is considered a major risk factor for heart attacks and strokes. 

Blood pressure is measured with the use of an arm cuff (sphygmomanometer) and expressed as systolic pressure over diastolic pressure. Systolic pressure is the highest level of the blood’s pressure within the artery walls and corresponds to the contraction of the ventricle. Diastolic pressure is the lowest pressure at which blood stays within the aorta. Both are measured in millimeters of mercury (mmHg).

In most cases, blood pressure is measured in a physician’s office. In recent years, blood pressure measuring equipment has become available that allows people to measure their blood pressure easily and affordably at home. In addition, monitoring equipment is often found in public places, such as grocery stores and pharmacies. However, all of these approaches have certain disadvantages that make ABPM an attractive option for some individuals. For example, in the case of blood pressure measurements at a physician’s office, many people suffer from  “white coat hypertension,” or high blood pressure as a result of anxiety connected to the blood pressure test itself. Similarly, the at-home tests and those completed out of a medical setting may be inconsistent and unreliable.

By contrast, the ABPM measures blood pressure at regular intervals throughout the monitoring period, including at night when the patient is asleep. It then records these measurements. Coupled with an activity diary, the ABPM can give a physician a very accurate picture of factors that may be affecting a patient’s blood pressure, such as exercise, eating, medications and certain forms of heart disease.

This information is useful for a variety of reasons. For example, it may help the physician adjust the dosages of antihypertensive medication. Many studies have shown that blood pressure spikes in the morning, right around the time that 24–hour antihypertensives are at their weakest. Thus, heart attacks and strokes may be more likely to occur in the morning. An ABPM could help identify this situation, and the physician could adjust the patient’s medication accordingly. Studies have also shown that ABPM may be a better predictor for certain cardiac events than other methods of measuring blood pressure.

The special ABPM blood pressure monitor is automatic, lightweight (about 1 pound or less) and quiet. It consists of an arm cuff, a tiny computer and a small compressor to inflate the arm cuff. The compressor and computer are generally worn on a belt around the waist with a tube leading up to a cuff placed on the upper arm. The monitor is programmed to automatically inflate the cuff at specific intervals during the ABPM period, usually every 15 to 30 minutes. In cases of recurring  fainting, measurements may be taken as frequently as every seven to eight minutes.

The frequency of measurements may be programmed differently during the night to minimize the disturbance to a patient’s sleep. The schedule also adjusts for the fact that changes in blood pressure are less dramatic when the patient is at rest. There are two basic techniques that can be used with the monitor cuff to read a patient’s blood pressure. Some monitors use one or both of the following techniques:

 

CARE OF PATIENTS WITH CARDIOVASCULAR PATHOLOGY

Patients with diseases of the cardiovascular system complain of heart pain; palpitation and intermissions in the heart’s action, dyspnea, edema, a feeling of discomfort in the right hypochondrium, headache, or fainting-fits.

Pain in the heart region is a serious complaint and its cause must always be revealed. Pain can be the result of heart diseases (angina pectoris, myocardial infarction, myocarditis), of pleurisy, intercostal neuralgia, injured ribs, etc. Cardiac pain varies in its character, duration, localization and irradiation.

Retrosternal pain of a pressing character, arises during walking, exercise, nerve stress associated with angina pectoris or myocardial infarction. It occurs due to insufficient myocardial blood circulation. The nurse before the arrival of the physician must give first aid to such patient. It is necessary:

To set or to lay down the patient, to ensure complete physical and mental rest.

To give the patient Nitroglycerinum ( 1 tablet under the tongue or 1-2 drops 1% of Nitroglycerin Solution on sugar) or Validol tablets.

To put mustard plaster on the heart area.

Dyspnea is a most common complaint in circulatory insufficiency. The degree of dyspnea varies. At first dyspnea develops during exercise when ascending stairs, and abates when the exercise is discontinued. In cases of more pronounced circulatory insufficiency, dyspnea develops during slight exercise, when the patient talks, and even when at complete rest.

The attack of dyspnea (cardiac asthma) is one with serious signs of an acute heart failure, which requires emergency medical care. The attack of dyspnea occurs suddenly, respiration often becomes increased often (3(M0 per minute), bubbling can be heard at a distance, there is a cough with a liquid pink foamy sputum discharge. The nurse must:

–                 measure the arterial pressure;

– put the patient half sitting (in hypotension) or sedentary (in hypertension) position;

– give inhalation of oxygen, it must be moistened and passed through the ethanol alcohol to depress formation of the gas bubbles in the respiratory tract. Dyspnea and asphyxia should markedly decrease.

We can put a venous tourniquet on the extremity (thus a part of the blood is partially deposited in the extremities, the volume of the circulating blood decreases and the work of a left ventricle is facilitated).

It is possible to utilize rubber bandages or rubber tubes instead of a tourniquet. They are applied simultaneously on three extremities: on legs the tourniquet is applied 15 cm below the inguinal fold, on the arm — approximately 10 cm below the humeral joint. On one extremity instead of a tourniquet, it is possible to apply a tonometer cuff forcing in air and simultaneously utilizing it for the periodic control of the level of arterial pressure. Every 15-20 minutes one of the tourniquets is taken out and it is applied on the free extremity.

Edema associated with heart diseases is another symptom of circulatory insufficiency. If edema is pronounced, the liquid is collected into the body cavities (abdominal, pleural, pericardial).

Proper care of patients with cardiovascular insufficiency is an important factor in their treatment. It is necessary that the air in the ward should be fresh, of normal temperature and humidity. For patients with pronounced circulatory insufficiency, prolonged bed-rest is often prescribed, and the bed linen should therefore be free from knots that might press on the patient’s body, to prevent the formation of bedsores. It should be remembered that prolonged bed-rest may cause blood congestion in the lungs and pneumonia.

A position of the patient in bed must be with the raised head. This reduces dyspnea and facilitates the respiration of the patient. It is necessary to control the daily urine and the amount of liquid that is drinked and injected parenterally. The daily urine should not be less than 70-80% of the consumed liquids. If the patient discharges less urine than he consumes (negative diuresis) it means that a part of liquid is deposited in the organism, the edemas are enlarged and the liquid is collected in cavities. If the amount of urine discharged per day is equal to the total amount of consumed liquid, this means positive diuresis. Edemas and the amount of liquid in the cavities will reduce.

In chronic heart failure the patients as a rule have got the expressed trophic changes of the skin, especially marked, in the field of edemas: on legs, the loin, scapulas, due to affection of the skiutrition. Decubituses easily occur in these places.

The patient should follow a light diet, high caloric, with inclusion of a cellulose with a large amount of vitamins and appreciable restriction of salt and liquids.

It is necessary to stimulate the work of the intestine: in case of constipations, if it is necessary to give the patient a hypertonic or oil enema (clyster).

A headache can be a sign of many diseases, requiring emergency aid. Pulsating, pressing pain , frequently localized in the area of back of the head is one of the signs of hypertension. In this case it is necessary:

To lay the patient in bed with a raised head of the bed , ensuring complete physical and mental rest.

To measure arterial pressure.

To air the room.

To put mustard plasters on the back of the head and calf muscle or the hot foot baths, warm baths for the arms can be used to redistribute circulation. It is possible to do a blood- letting or to put a medical leeches.

 

Сhildren’s temperature measuring

 

 

Body temperature changes during the day. Usually it is higher in the after­noon than in the early morning. If a child is very active, his/her temperature may be higher thaormal. Fever is a protec­tion for the body. A rise in body temper­ature above normal (usually 36.6° C=98.6° F axillary temperature) lets you know that there may be an infection somewhere in the body. Fever also helps the body fight the infection. Someone has a fever if the body temperature is higher than 37° C=100° F (oral) or 37.5° C=100.4° F (rectal temperature).

Where to Take the Temperature:

Temperatures measured rectally are the most accurate.  Temperatures measured orally, by electronic pacifier, or by ear canal are also accurate if done properly.  Temperatures measured in the armpit are the least accurate, but they are better thao measurement.  

Age less than 3 months old (90 days old):

An armpit temperature is preferred for reasons of safety and is adequate for screening.  If the armpit temperature is above 99°F (37.2°C), check it with a rectal temperature.  The reason you need to take a rectal temperature for young infants is that if they have a true fever, they need to be evaluated immediately.

Age less than 4 or 5 years old:

A rectal or electronic pacifier temperature is preferred.  An axillary (armpit) temperature is adequate for screening if it is taken correctly.  An ear thermometer can be used after 6 months old.

Age older than 4 or 5 years old:

Take the temperature orally (by mouth) or by ear thermometer.

How To Read A Thermometer:

There are two types of glass thermom­eters, oral and rectal. The only difference between the two kinds is the shape of the silver tip. A rectal thermom­eter has a short rounded tip. It is shaped this way to prevent any damage to the rectum. The oral thermometer has a lon­ger slender tip. Either can be used for an axillary temperature.

While holding the clear (or white) end of the thermometer at eye level, slowly turn the thermometer until you can see the silver line (mercury) (Fig. 1). The lower numbers on the thermometer will be on the left. The amount the mercury moves from left to right will depend on your child’s temperature. The highest number that the silver line reaches is the right temperature. Before using the ther­mometer, make sure it reads 96° F or less. If not, while holding the clear end, shake the thermometer sharply above a soft sur­face, such as a bed or sofa, in case it should fall. Look at the reading again. If it is below 35.5° C=96° F, measure the tempera­ture. If not, repeat the shaking until the reading is below 35.5° C=96° F.

Equipment: Glass thermometer, clock/watch.

 

How To Measure Axillary Temperature

Measuring temperature in the axilla (armpit) is the safest way to check if your child has a fever.

Tell the child that you are going to measure his temperature.

Wash your hands.

Have the thermometer and watch ready.

Look at the thermometer to make sure it is reading below 35.5° C=96° F.

Place the thermometer under the child’s arm. The thermometer’s silver
tip should rest in the center of your child’s armpit.

 Hold the child’s arm firmly against his body.

Look at the time.

The thermometer must remain in place for 7 to 10 minutes. This may seem like a long time. To help make the time seem to go faster, read a
story or watch television with the child. Make sure you hold the thermometer securely.

Remove the thermometer and read.

Praise the child for his help.

Write down the thermometer reading and the time of day.

 

How To Measure Oral Temperatures

By 5 or 6 years of age, a child can understand how to safely hold the ther­mometer in his mouth. If the child has had something to eat or drink, wait 15 minutes before you measure an oral tem­perature.

Tell the child why you want to mea­sure his temperature.

Wash your hands.

Have the thermometer and watch ready.

Look at the thermometer to make sure it is reading less than 35.5° C=96°F.

Place the thermometer in the child’s mouth, far back under the tongue. Tell him to breathe through the nose and not to talk.

Make sure the child does not bite the thermometer.

Look at the time.

Tell the child that the thermometer must stay in place for 2 to 3 minutes. Read a story or watch TV with him.

Remove the thermometer and read.

Praise the child for his help.

Write down the thermometer reading and the time of day.

 

How To Measure Rectal Temperatures

Note that rectal temperatures should not be taken if the child has diarrhea or is less than 1 year old. In taking a child’s temperature, use the following proce­dure:

Tell the child that you are going to measure his temperature.

Wash your hands.

Have the thermometer and watch ready (and a clean diaper if needed).

Look at the thermometer to make sure it is reading less than 35.5° C=96°F.

Measure 2.5 cm (1 inch) on the thermometer.

Place the child on his stomach (Fig. 3), on one side with the upper leg bent, or on back with both legs up.

Dip the thermometer’s silver tip in a lubricant such as petroleum jelly (Vaseline).

Place the silver end of the thermometer into the child’s anus.

Do not insert the thermometer any further than 2.5 cm (1 inch).

Look at the time.

Hold the thermometer in place for 2 to 3 minutes. Always hold the child so that he cannot twist around.

Remove the thermometer and read.

Praise the child for his help.

Wash your hands with soap and water Count to 10 while washing, then rinse with clear water and dry.

Write down the thermometer reading and the time of day.

 

How to Take a Digital Electronic Pacifier Temperature

Have your child suck on the pacifier until it reaches a steady state, and you hear a beep.

This usually takes 3 to 4 minutes.

Your child has a fever if the pacifier temperature is above 100°F (37.8°C)

Nursing care of the child with elevated body temperature.

Body temperature changes during the day. Usually body temperature is higher in the after­noon than in the early morning. If a child is very active, his/her temperature may be higher than normal. Fever is a protec­tion for the body. A rise in body temper­ature above normal (usually 36.6° C or 98.6° F) lets you know that there may be an infection somewhere in the body. Fever also helps the body fight the infection. Someone has a fever if the body temperature is higher than 37° C (100° F) (oral or axillary temperature) or 37.5° C or 100.4° F (rectal temperature).

Clinical signs of increased temperature:

flushed skin, increased respiration and heart rates,

malaise,

“glassy look” to eyes.

You should measure a child’s temper­ature:

When he feels warm to your touch.

When the child is not acting like him­self.

Before calling your health professional to say that the child is sick.

Call your health professional as soon as possible if:

(1) the child has a temper­ature higher than 39.5° C(105° F) 

(2) a fever (oral or axillary temperature above 37° C(100° F) or 37.5° C (100.4° F) rectally) is present and the child:

Is less than 2 months of age.

Has a stiff neck, severe headache, stomach pain, persistent vomiting, purple spots on his skin, or earache with the temperature.

Has a serious illness in addition to the fever.

Is confused or delirious.

Has had a convulsion.

Has trouble breathing after you have cleaned his nose.

Is hard to awaken.

Seems sicker than you would expect.

Cannot be comforted.

Has a temperature that continues to rise after medicine has been given.

Call your health professional during of-ice hours if:

The temperature is between 104° F and 105° F, especially if the child is less than 2 years old.

Burning or pain with urination.

The fever has been present for more than 72 hours.

The fever has been present for more than 24 hours without a known cause.

The fever went away for more than 24 hours, then returned.

The child has a history of febrile sei­zures.

You have some questions.

Table  shows the average normal temperature standards for well adults at various bodv sites.

 

 

Not only elevated temperature itself, but also its circadian variations are very importamt for diagnosing the diseases. Variations of temperature during the day determine the type of fever. The following main types of fever are differentiated.

1. Constant fever (febris continua) — within day the difference between morning and evening temperature does not exceed 1°C, morning temperature smaller than evening one. It is observed in patients with acute lobar pneumonia or II stage typhoid fever.

2. Remittent fever (febris remittems): the daily fluctuations of the temperature exceeds 1 C and the morning’s lowest temperature being over 37 °C, the morning temperature smaller than evening one. It often occurs in tuberculosis, purulent diseases, III stage typhoid fever and lobular pneumonia.

3. Intermittemt fever (febris intermittens), the daily fluctuations of the temperature exceed 1 °C, morning temperature smaller  than  evening  one.   The  body  temperature  alternates

regularly between a period of fever and a period of norma] temperature. It occurs in malaria.

4. Hectic fever (febris hectica): the temperature rises sharply (by 2 ° — 4 C) and drops to normal and subnormal level, that is often accompanied by excessive sweating, morning temperature smaller than evening one. It usually occurs in grave pulmonary tuberculosis, suppuration, sepsis and lymphogranulomatosis.

5. Inverse fever (febris inversus) is type of fever, when morning temperature is higher than evening. It sometimes occurs in sepsis, tuberculosis and brucellosis.

6. Irregular fever (febris irregularis) — the fever, when cicardian variations are varied and irregular. It often occurs in rheumatism, endocarditis, sepsis, tuberculosis.

According to the temperature curve recurrent (relapsing) and undulate (Malta) fever are distinguished.

7. Reccurent fever (febris reccurens) — is characterized by alternation of fever and afebrile periods. It occurs in relapsing fever.

8, Undulant fever (febris undulans) — is characterized by periodic elevation of the temperature followed by its drop. It often occurs in brucellosis and lymphogranulomatosis.

 

Care plan

The most important thing to remem­ber is not to bundle up the child with extra clothes and blankets. Dress him in light clothing. This will help cool him by letting air circulate and heat leave the body.

When a fever is present, it increases the amount of liquid that is needed by the body. It is important to encourage the sick child to drink fluids. Some things that may help encourage him to drink are:

straws,

small cups instead of a big glass,

popsicles,

jello,

soft drinks with the fizz removed (stale). The carbonation can be removed by leaving the soft drink un­covered, by warming the soda in a mi­crowave or on a stove, or by stirring in ½ teaspoon sugar.

 

Medicines should not be used rou­tinely to lower the temperature. If the child is uncomfortable and the fever needs to be treated with more than light clothes and increasing fluids, then drugs can be used.(Acetaminophen brand names: Panadol, Tylenol; tablets: Chewable Anacin 3, Chewable Tylenol, Chewable Junior Strength Tylenol).

 

 

Materials for preparing to the practical class were drawn up by assistant professor T.A. Kovalchuk, M.D.