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Ministry of Health of Republic of Belarus
Education establishment
«The Gomel State medical university»
Chair of Internal Disease №1 with Endocrinology Course
It is discussed at the meeting of chair 30.08.2016
Protocol № ___________
for practical training of foreign students of the 1st course
«Supervision and hygienic care of patients with cardio-vascular diseases»
Theme 7 (Lesson 11; 12):
Time: 6 hours
Chief of chair______________
1. Training and educational goals, motivation for theme learning,
requirements of initial level of knowledge
1.1 Aim of training: Learn how to identify the main features of diseases of the
cardio-vascular system and capture the dynamics of these signs (registration and
evaluation of heart rate, blood pressure (BP), respiratory rate counting, measuring
daily urine); learn the technique of rendering first aid at an attack of angina
pectoris, cardiac asthma, syncope, paroxysmal tachycardia.
1.1Requirements to initial level of knowledge: during the training the student
To know:
1. The main pathological symptoms in diseases of the cardio-vascular system
(heart pain, shortness of breath, dyspnea, edema, palpitations).
2. Methods of determining and diagnostic value of the pulse at the radial artery of
the patient.
3. Methodology and diagnostic value of determination of the water balance (daily
4. The technique of counting the number of breaths.
5. The procedure of providing first aid in a fit of angina pectoris, fainting.
6. The procedure of providing first aid at cardiac asthma.
7. The procedure of providing first aid in paroxysmal tachycardia.
To be able to:
1. Perform blood pressure measurement.
2. Conduct count pulse, respiratory rate.
3. To carry out the control of the water balance.
4. Provide first aid in a fit of angina pectoris, syncope, cardiac asthma, paroxysmal
2. Material equipment of training
1. Tonometer.
2. Stethoscope.
3. Checklist from related subjects
1. Anatomy of the cardiovascular system (CVS).
2. Physiology of the cardiovascular system.
4. Questions on an occupation subject:
Lesson № 11
1. Methods of monitoring and taking care of patients with diseases of the
cardiovascular system.
2. The main complaints in diseases of the cardiovascular system: a faint,
collapse, hypertension, hypotension. Symptoms and first aid.
3. Pain in the heart area, causes. Features of pain of angina pectoris, myocardial
infarction, first aid.
4. Shortness of breath, dyspnea, tachycardia. The mechanism of occurrence,
symptoms, first aid.
5. Monitoring and care of patients with heart insufficiency.
6. Arterial pulse: determining technique study its properties. Technique
determining the carotid pulse.
Lesson № 12
7. Blood pressure measurement: methods of registration of the results.
8. Edema: causes, extent, methods of detection. The concept of water balance,
filling water balance form.
9. Holter-electrocardiogram (H-ECG): the essence of the method, the rules of
behavior of the patient during the study.
10. Features of care of patients at intensive care department.
11. Sanitary and epidemiological regime of intensive care department.
5. Materials for self-preparation:
Lesson №11
1. Methods of monitoring and taking care of patients with diseases of the
cardiovascular system.
Observation and care of patients with cardiovascular disease should be carried
out in two directions.
General measures - measures to monitor and care needed by patients with
diseases of various organs and systems: monitoring of the general state of the
patient, a thermometer, monitor the pulse and blood pressure, the filling
temperature blank, ensuring the personal hygiene of the patient, vessel supply, etc.
Special events - event monitoring and care designed to help patients with
symptoms typical of CVD: pain in the heart and chest, the phenomena of acute and
chronic heart insufficiency, edema, cardiac arrhythmias, and others.
Organization of care for patients with cardiovascular disease has a number of
specific features, due to the severity and complexity of the condition of patients
served. These features require a clear organization of the nurse and her
qualifications. Within a short period of time a nurse has to perform a wide variety
of emergency medical procedures, medical appointments, treatments.
For patients with cardiovascular disorders often requires round the clock
surveillance (general state control, skin, heart rate, blood pressure). A nurse should
immediately tell doctor about the deterioration of the patient's condition, to be able
to provide urgent pre-medical, assistance in case of sudden respiratory
insufficiency, loss of consciousness. A very important condition is the precise
fixing of hemodynamic parameters (heart rate, blood pressure), water balance.
In addition, a variety of medical and technical equipment is often used when
working with such patients. Therefore, the nurse must have the necessary
minimum of technical and laboratory skills, be able to use defibrillators and
oxygen plants. Intercede on duty nurse is obliged to ensure that all machinery and
equipment are in good condition.
2. The main complaints in diseases of the cardiovascular system: a faint,
collapse, hypertension, hypotension. Symptoms and first aid.
In diseases of the circulatory system, patients impose a variety of complaints.
The most commonly observed symptoms such as chest pain, palpitations, shortness
of breath, suffocation, edema, feeling sick disruption of the heart and other.
Symptoms of cardiovascular diseases that require emergency care are:
1. Faint
2. Collapse
3. Hypertensive crisis.
4. Heart attack.
5. Suffocation
Syncope (from the Greek «synkope») is brief loss of consciousness due to
acute insufficiency occurred cerebral blood flow. Typically, syncope occurs when
strong neuropsychiatric effects (fear, severe pain, the sight of blood), in a stuffy
room, with a strong fatigue. Loss of consciousness often preceded by dizziness,
ringing in the ears, darkening of the eyes, a feeling of faintness, and others. We can
see pale skin and visible mucous membranes, cold extremities, cold clammy sweat,
a sharp decrease of blood pressure, a small thready pulse. Syncope occurs usually
in the vertical position of the patient; as soon as he is in the supine position, the
blood flow to the brain increases, and consciousness is quickly restored. Fainting
usually lasts 20-30 seconds, then the patient wakes up.
Help for fainting is to give a horizontal position with raised legs (for the flow
of blood to the head), exemption from hindering clothing, providing fresh air. You
can rub temple and chest of the patient, sprinkle on the face with cold water, bring
to a nose cotton wool soaked in liquid ammonia (10% ammonia solution) for the
activation of the respiratory center.
Collapse (from the Latin «collapsus».) is the clinical manifestation of acute
circulatory collapse with the fall of vascular tone, decrease the contractile function
of the heart, decreased blood volume (CBV) and a fall in blood pressure (BP). It is
observed in the acute bleeding, myocardial infarction, in orthostasis, infectious
diseases (due to dehydration due to repeated vomiting, diarrhea), poisoning,
overdose of antihypertensive drugs. Clinical manifestations are similar to those in a
swoon, but the collapse is not always accompanied by a loss of consciousness, the
patient can be slow, indifferent to what is happening, the pupils dilate.
Help in the collapse is to give a horizontal position with his head down, the
impact on the reason behind the collapse of the basis, such as elimination of
bleeding, warming, etc. If you want to spend on prescription parenteral volume
replacement by infusion of blood products, the introduction of drugs that increase
the vascular tone (kordiamin, phenylephrine, etc.).
Arterial hypertension (AH) is a pathological syndrome characterized by
elevated blood pressure of systolic > 140 mm Hg, diastolic > 90 mm Hg.
When caring for patients with hypertension need to pay close attention to
compliance with all requirements of the patients and treatment-protective mode,
since negative emotions, neuro-psychological stress, poor sleep can worsen the
Hypertensive crisis (sudden, significant increase of blood pressure) requires
urgent medical intervention and the introduction of antihypertensive drugs, as it
may be complicated by cerebrovascular and coronary circulation. Before arrival of
the doctor patient must ensure complete rest, fresh air, you can make a hot foot
bath and warm bath for the hands (with a water temperature of 37- 40 ° C).
Hypotension (systolic blood pressure reduction of <100 mm Hg, diastolic <60
mm Hg) can also be observed in perfectly healthy people, especially asteniks, but it
can also be a symptom of serious diseases associated with a decrease in cardiac
output , vascular tone (myocardial infarction, bleeding, shock, collapse). Patients
with acute hypotension occurred is necessary to lay, to raise the foot end of the bed
to improve blood flow to the brain, to enter on prescription drugs related
(kordiamin, caffeine, sulfokamfokain, phenylephrine, and others.).
3. Pain in the heart area, causes. Features of pain of angina pectoris,
myocardial infarction, first aid.
Pain in the heart area is not always caused by diseases of the cardiovascular
system. Pain may be the result of diseases of the pleura (dry pleurisy), the spine
and intercostal nerves (spinal osteochondrosis, intercostal neuralgia), myositis
(muscle inflammation), hiatal hernia, and others. These pains are called false
angina. Chest pain associated with disorders of the circulatory system, can be
caused by disorders of the pericardium, aorta, neurotic condition.
Angina, or "angina pectoris" (from the Latin. «Angina pectoris»), there is a
narrowing of the coronary arteries as a result of atherosclerotic lesions, which can
be attached vasospasm. Pain caused by attack stenokardiac mismatch between the
myocardial oxygen demand and possibilities of coronary blood flow, leading to
ischemia, hypoxia, cardiac muscle. It breaks down the metabolism and increased
number of poorly metabolic and insufficient output of unoxidized metabolic
products irritate the sensitive nerve endings in the myocardium, causing the
sensation of pain. In typical cases of angina attack is triggered by physical or
emotional stress. Localized pain behind the sternum, are pressing, burning or
squeezing in nature, accompanied by the fear of death, give (irradiate) in the left
shoulder, the arm, the left side of the neck, the lower jaw. Such pain usually lasts
from 1 to 10 minutes and are themselves alone or in 1-3 minutes after taking
nitroglycerin sublingual tablets. Help the patient during an attack of angina is to
provide a complete rest, reception of nitroglycerin under the tongue (if it is
expedient to give the patient an elevated position) and the least - in the production
of mustard plasters on the heart area.
Myocardial infarction. At the head of this very serious disease is necrosis of
a portion of the heart muscle. The most common so-called typical (pain, anginal)
variant of myocardial infarction is characterized by the appearance of pain behind
the breastbone. It is very strong, do not respond (no fixes) rest of nitroglycerin
reception, lasting more than 30 minutes (up to several hours). These pains
accompanied by a sense of fear of death, suffocation, severe weakness, drop in
blood pressure, etc. Such patients also first hours of the disease need urgent
hospitalization in an intensive care unit, is equipped with all necessary equipment
for monitoring (automatic continuous monitoring) of their status and of possible
resuscitation. During the first days the patient is prescribed strict bed rest; During
this period is necessary to control the state of the bed, underwear and bed linen, the
fulfillment of all hygienic procedures, feeding the sick, feeding vessel, urinal, etc.
4. Shortness of breath, suffocation, tachycardia. The mechanism of
occurrence, symptoms, first aid.
Shortness of breath for diseases of the cardiovascular system is one of the
signs of heart insufficiency, which is caused by a progressive decline in contractile
function of the myocardium. Heart insufficiency is characterized by stagnation of
blood in small and large circulation and fluid retention in the body. When dyspnea
of cardiac origin blood accumulates in the pulmonary circulation, and the patient
experiences a painful feeling short of breath at first during exercise and excitement,
as well as the disease progresses - and in quiet.
Suffocation (cardiac asthma), heart insufficiency called suddenly caused a
heavy attack of shortness of breath accompanied by noisy breathing, growing
mostly at night (due to increased vagal nerve, which causes a narrowing of the
coronary vessels). The patient then takes a forced sitting position - the position of
orthopnea. Orthopnea (from the Greek "orthos" -. Straight, "pnoe" - breathing) is
the appearance of shortness of breath and choking the patient when breathing in a
horizontal position, forcing him to take a sitting position with feet lowered down.
In this position, shortness of breath decreases due to the discharge of the
pulmonary circulation, so the blood is deposited in the abdomen and lower
extremities vessels. Asphyxiation may not be the heart of nature. For example, in
atherosclerotic lesions of blood vessels that feed the respiratory center, it may be
the so-called asthma Traube - suffocation of central origin, with which the change
in the patient's posture has no effect on his condition. The attack of cardiac asthma
occurs as a sharp decrease in the contractility of the heart muscle due to its necrosis
(heart attack), inflammation (myocarditis heavy) or overload (hypertensive crisis,
hard physical activity). Pulmonary edema appears the most severe manifestations
of heart insufficiency, when the liquid part of the blood vessel goes through walls
and accumulate in the alveoli. At the same time to the already listed symptoms of
cardiac asthma join bubbling respiration and excretion of pink frothy sputum.
Help with dyspnea is to ensure peace, giving the patient sitting or half-sitting
position (orthopnea), exemption from hindering clothing, provide fresh air,
reception nitroglycerin (unless contraindicated) or antihypertensive agents in the
case of high blood pressure prescribed by a doctor.
Assistance activities in cardiac asthma and pulmonary edema are as follows.
1. Call a doctor immediately.
2. Make the patient sitting position (orthopnea).
3. Give the patient nitroglycerin if the systolic blood pressure of the patient is
not less than 100 mm Hg
4. Start with oxygen therapy (alcohol, antifomsilan) through a mask or nasal
5. Start an active aspiration frothy sputum by electric pumps.
6. After giving the patient sitting position to impose on both legs at 15 cm
below the inguinal crease venous tourniquets (rubber tube or the cuff of
sphygmomanometer) to the deposit of blood in the systemic circulation and delay
its flow to the lungs (venous tourniquets can be imposed in addition also on arms).
You should check that only pinched vein - that arterial pulse below the tourniquet
should be maintained and limb to become cyanotic, but not white. After 15-20
minutes, loosen the harness.
7. Harness should be carried out sequentially in a slow mode (first from one
limb, after a while, from the other, etc.).
8. Permitted the use of hot foot baths.
9. According to doctor’s prescription may be injected narcotic analgesics
(morphine, promedolum), diuretics (furosemide), angiotensin converting enzyme
inhibitors, cardiac glycosides and other essential drugs.
Tachycardia is an ncreased heart rate over 90 beats per 1 minute, perceived as
the sick heart, is often one of the first signs of heart disease (heart insufficient,
heart rhythm disturbances). In case of tachycardia in a patient nurse must
immediately inform the doctor to reassure the patient, give it a comfortable
position, if necessary.
5. Monitoring and care of patients with heart insufficiency.
Chronic heart insufficiency (CHI) is characterized by the gradual weakening
of myocardial contractility. Manifested increasing dyspnea (at first during exercise
and later at rest), cyanosis (resulting from a violation of gas exchange and
expressed the most in remote areas of the body - the fingertips, earlobes, lips,
chin), tachycardia, peripheral edema (formed for by slowing down in the
capillaries), enlargement of the liver as a result of venous stasis.
Patients with chronic heart insufficiency, in addition to the regular intake of
drugs (cardiac glycosides, diuretics), also need special care, especially during the
period of decompensation (increase in manifestations of the disease). They must
comply with bed rest, which helps to reduce the load on the affected myocardium
and improvement. To reduce congestion in the pulmonary circulation, the patient
should be given a bed in a raised position with headboard. Inhalation oxygen
mixture is used in case of severe shortness of breath. Daily note respiratory rate
and heart rate, blood pressure, and the measurement results are recorded in the
temperature sheet.
Patients with heart insufficiency often lack the appetite that has to be taken
into account when feeding. Diet "N" usually assigned. As already mentioned
above, such patients receive diuretics, cardiac glycosides, it promotes the excretion
of potassium. Therefore, the diet is required to include foods rich in potassium
(apricots, raisins, etc.)
Long-existing edema lead in some cases to secondary changes of the skin,
which then become thinner, lose their elasticity. Against the background of
physical activity limitation in patients with chronic heart insufficiency is necessary
to pay special attention to the care of the skin, to carry out prevention of bedsores.
It should be remembered that patients are on bedrest and receiving diuretics
should be provided urinal, vessel.
Particular attention should be paid to the state of the water balance in patients
with CHI. In order to combat swelling is limited fluid intake (up to 1 liter per day)
and salt intake (up to 1-1.5 grams per day).
6. Arterial pulse: determining technique study its properties. Technique
determining the carotid pulse.
Arterial pulse (from the Latin «pulsus» -Kick, push) is a periodic oscillations
of the walls of the arteries caused by a change in their blood supply as a result of
the heart. Most often, the pulse is determined on the radial artery in the wrist (the
so-called peripheral pulse), as there is superficial artery and well palpated between
the styloid process of the radius and the tendon of the muscle of internal radiation.
Normally, rhythmic pulse, equally palpable on both hands, its frequency in an adult
at rest is 60-90 per minute.
Engineering studies of the radial pulse
1. The fingers of your hands at the same time cover the wrist of the patient (in
the wrist joints) so that the pads of the index and middle fingers are on the front
(inner) surface of the forearm in the projection of the radial artery. The radial
artery is palpated between the styloid process of the radius and the tendon of the
muscle of internal radiation.
2. Carefully feel the radial artery area, pressing it to the underlying bone with
different strength, with the pulse wave is felt as an extension and attenuation
3. Compare oscillation arterial wall on the right and left hands of the patient.
In the absence of any asymmetry (dissimilarity) further research is carried out on
the pulse of one hand.
4. To determine the frequency of the pulse (if pulse rhythmic) count the
number of pulse waves for 15 seconds and multiply the result by 4; in the case of
calculation of arrhythmia was carried out for 1 min.
5. Enter the data pulse research in the leaf temperature (note the red points,
respectively, the scale of the pulse). If you suspect an occlusive vascular disease of
the lower extremities (sharp narrowing of the arteries (lat «obliteratio» -Erasure,
anti-aliasing), the most common cause which acts atherosclerosis of the aorta and
its branches) pulse is determined on the femoral, popliteal arteries, the vessels of
the foot.
Properties arterial pulse
Define the following properties.
1. Rhythm of pulse - it is assessed by the regularity of successive pulse waves.
If the intervals between them are equal, then the pulse is considered correct
(rhythmic pulse, pulsus regularis), if different - wrong (arrhythmic pulse, pulsus
In atrial fibrillation, heart rate may be greater than the number of pulse waves.
In such cases, a pulse deficit, which necessarily should be calculated. Count the
heart rate when listening to the heart, parallel assistant for the same length of time
counts the pulse rate. For example, a patient with heart rate auscultation 98 heart
tones defined in the minute, and the pulse of the radial artery was 78 per minute,
therefore, pulse deficit is 20.
2. Pulse rate - it is determined by counting the number of pulse waves per
minute. Normally, pulse frequency ranges from 60 to 90 per minute and can vary
widely depending on the sex, age, and body temperature and level of physical
activity. The most common heart rate was observed in newborns. At the age of 2560 years, heart rate remains relatively stable. In women, the pulse more often than
men; in athletes and people trained, as well as in elderly heart rate less. Rapid pulse
occurs in a vertical position, during exercise, increased body temperature, heart
insufficiency, cardiac arrhythmias, etc. A pulse frequency of at least 60 per minute
called rare over 90 min - frequent.
3. Fill the pulse - it is determined by the blood volume being in the arteries,
and depends on the systolic volume of the heart. With good filling pulse wave is
high, well distinguishable (a full pulse, pulsus plenus), with poor - small, poorly
palpable (empty pulse, pulsus vacuus). Barely perceptible, weak pulse called
filamentous (pulsus filiformis); when it is detected, the nurse should immediately
inform your doctor.
4. The voltage pulse - it is determined by the force that must be applied to the
total cross-clamping the artery. If the pulse disappears at a moderate compression
of the radial artery, then such a pulse is described as satisfactory voltage pulse;
with a strong compression of the pulse is estimated to be busy, with a light - the
absence of stress (soft). According to the voltage pulse can roughly estimate the
blood pressure inside the arteries: a high-pressure pulse tense, or solid (pulsus
durus), low - soft (pulsus mollis).
5. The value of the pulse - it is determined from the total voltage ratings and
filling rate, it depends on the amplitude of oscillations of the arterial wall. There
are a large pulse (pulsus magnus) and low pulse (pulsus parvus).
6. Form pulse - it is determined by the rate of change of volume of the artery
which depends on the speed with which the left ventricle ejects blood into the
arterial system. The rapid expansion and reducing of arteries characteristic of fast
pulse (pulsus celer). This pulse is observed at vice aortic valve, significant nervous
overexcitation. With a slow expansion and reducing artery observed slow pulse
(pulsus tardus), noted in the narrowing of the aortic orifice. Pulse on the right and
left hands can be not the same (different filling and stress) at anomalies of
development, narrowing, external compression of the corresponding radial,
brachial or subclavian arteries. In such cases, the pulse survey conducted
separately on both hands, and to characterize the work of the heart itself - on the
hand, where it will be palpable. Typically, a healthy person exhibit rhythmic pulse
with a frequency of 60-90 per minute, and the satisfactory filling voltage equal
(symmetrical) on both sides.
Technique determining the carotid pulse
In severe the patient's condition evaluated the presence of a pulse in the
external carotid artery.
1. Identify the front of the neck with the most protruding part of the thyroid
2. Push the index and middle fingers on the wall of cartilage laterally, and
install them between the cartilage and the adjacent muscle.
3. Use your fingertips to determine the pulsation of the carotid artery. The
study should be carried out carefully (with one hand), you can not pinch the carotid
artery, as it is rich reflexogenic area and there is a risk of sharp reflex slowing of
heart rate (HR) up to the loss of a sick mind.
Lesson №12:
7. Blood pressure measurement: methods of registration of the results.
Arterial pressure is a pressure in the arterial system which is formed during
the heart. Depending on the phase of the cardiac cycle distinguish systolic and
diastolic blood pressure. Systolic blood pressure, or a maximum occurs in the
arteries after systole of the left ventricle, and corresponds to the maximum lifting
pulse wave. Diastolic blood pressure is maintained in the arteries during diastole
because of their tone and the pulse wave corresponds wears off. The difference
between the values of systolic and diastolic blood pressure is called pulse pressure.
BP depends on the cardiac output, total peripheral vascular resistance, VCB, HR.
Measurement of blood pressure is an important condition for the control method of
hemodynamics in both healthy and sick people. Measurement of blood pressure
can be carried out direct and indirect methods. The direct method involves the
introduction of gauge sensor directly into the bloodstream. This method is used
during catheterization to determine the pressure in the large vessels or heart
cavities. In everyday practice, blood pressure is measured by indirect auscultatory
method proposed in 1905, Russian surgeon Nikolai Sergeyevich Korotkov using a
sphygmomanometer (the unit Scipione Riva-Rocci, also called a tonometer). In
modern scientific epidemiological studies using mercury sphygmomanometers the
so-called "floating zero", allowing to neutralize the effect of atmospheric pressure
on the measurement results. Sphygmomanometer consists of mercury or more
frequently spring manometer, attached to the cuff and the rubber bulb. Air into the
cuff regulated by a special valve that allows to contain and gradually reduce the
pressure in the cuff. BP measured force spring pressure (in mm Hg), which is
passed clockwise, moving the dial with applied millimeter divisions.
Regulation of blood pressure measurement (regulated by the 1 Report of the
Expert Scientific Society for the Study of Hypertension (DAG-1, 2000)):
1. Blood pressure measurement is carried out in a person lying down or sitting
in a chair. In the latter case, the patient should sit on a chair with a straight back,
lean back in his chair, relax your legs and do not cross them, put his hand on the
table. The support back in the chair and the location of your hands on the table
exclude the rise in blood pressure because of the isometric muscle contraction.
2. Measure the blood pressure is recommended in 1-2 hours after a meal and
not earlier than 1 hour after drinking coffee and smoking.
3. The cuff (rubber inner part of it) sphygmomanometer should cover at least
80% of the arm circumference and covering 2/3 of its length.
4. It is necessary to make at least three measurements at intervals of not less
than 5 minutes. For the value of BP are taking the average value calculated from
the obtained in the last two measurements. According to the classical method of
measuring blood pressure WHO is not accepted in clinical practice, it is measured
three times at intervals of not less than 5 minutes, and in the history of the disease
are entered lowest blood pressure (cited according to vice-president of RAMS
academician AI Martynov, 2000).
BP measurement technique
1. Offer the patient a comfortable position (lying or sitting on a chair); His
hand must lie freely, palm up.
2. Apply the patient's shoulder cuff sphygmomanometer at its heart (the
middle of the cuff should roughly correspond to the level of the fourth intercostal
space) so that the bottom edge of the cuff (with space rubber tube output) was
about 2-2.5 cm above the elbow, and between the shoulder of the patient and the
cuff could be held one finger. At the same time the middle cuff balloon must be
exactly above the palpable artery and the location of the rubber tube should not
interfere with auscultation of the arteries. Improper cuff may lead to the imposition
of artificial blood pressure change. Deviation from the position of the middle of the
cuff of the heart level to 1 cm leads to a change in blood pressure by 0.8 mm Hg .:
raise blood pressure in the cuff position below the level of the heart, and
conversely, a decrease in blood pressure when the cuff position above the heart
3. Connect the tube with a cuff pressure gauge tube (using mercury (most
accurate), pressure gauge).
4. Set the left hand fingers in ulnar fossa of the brachial artery (it is found
from the pulsation), the right hand with a closed valve compressing the pears into
the cuff rapidly to pump air and determine the level at which the pulsation of the
brachial artery disappears.
5. Slightly opening the valve and slowly let the air out of the cuff, stethoscope
set in the cubital fossa of the brachial artery.
6. With the valve closed by compressing a rubber bulb to the cuff quickly to
pump air unless gauge pressure in the cuff does not exceed 20-30 mm Hg. Art. the
level at which disappears in the brachial artery pulsation (ie, slightly above the
expected value of systolic blood pressure). If the air in the cuff is slowly injected,
breach of venous outflow can cause the patient severe pain and "lubricate" the
sonority of tones.
7. Slightly opening the valve and slowly let out (play off) the air from the cuff
at a rate of 2 mm Hg 1 sec (delay deflation lowers blood pressure values), while
conducting listening (auscultation) of the brachial artery.
8. Mark on the pressure gauge value corresponding to the appearance of the
first sounds (Korotkoff sounds caused by the blows of pulse wave) - systolic blood
pressure; the value of the gauge, in which the sounds disappear, corresponds to the
diastolic blood pressure.
9. Release all the air from the cuff by opening the valve, then disconnect the
joint rubber tubes and remove the cuff to the patient's arm.
10. Add to notepad BP values obtained in the thermal sheet in the form of red
bars respectively scale AD. The value of blood pressure rounded to the nearest 2
mm Hg
Blood pressure can be measured as oscillographic method (there are special
devices for measuring blood pressure by this method), which allows, in addition to
blood pressure indicators to evaluate more and the state of the vascular wall,
vascular tone, blood flow velocity. When a computer signal processing while also
calculated the value of shock, cardiac volume, total peripheral vascular resistance
and, importantly, they meet each other. Normal systolic blood pressure for an adult
ranges from 100-139 mm Hg. Art, diastolic -. 60-89 mmHg Increased blood
pressure is considered at the level of 140/90 mmHg and above (hypertension), low
- less than 100/60 mm Hg (Hypotension). The sharp increase in blood pressure
called a hypertensive crisis, which, in addition to a rapid rise in blood pressure,
manifest severe headache, dizziness, nausea and vomiting. If the values of systolic
and diastolic blood pressures fall into different categories, the higher category set.
The terms "normal" and "elevated" levels of blood pressure, initially being the
result of consensus (ie, according to the doctors' decision), and now continues to be
to some extent arbitrary. Clearly distinguish between normal and abnormal blood
pressure has not been possible. As the outcome of today's large population-based
studies (design of so-called evidence-based medicine) as regards the relationship of
occurrence of cerebral stroke and myocardial infarction on the levels of blood
pressure and the effect of antihypertensive therapy for the prevention of the
boundaries of these levels are constantly shifting in the direction of smaller and
smaller sizes.
It is now widely used BP monitoring using noninvasive automatic instruments
for continuous registration of blood pressure in an outpatient setting. The principle
of operation of most of them is based on a classic cuff blowing at preset intervals
by a microprocessor, which is suspended at the patient over his shoulder. At the
same auscultatory method (by Korotkov) determining the blood pressure of 38% is
used in devices for monitoring blood pressure, oscillometric (by Маrеу) - 30% of
vehicles, in other devices - combined method. Recommended daily program
monitoring of blood pressure involves the registration of blood pressure at intervals
of 15 minutes during the waking period and in 30 minutes - during sleep.
In some cases, great importance is the measurement of blood pressure in the
arteries of the lower extremities (eg, coarctation of the aorta - a congenital
narrowing of the aorta when there is a significant reduction in blood pressure in the
femoral arteries compared to the shoulder). To measure blood pressure in the
femoral artery of the patient should be put on the stomach of the subject to impose
on the thigh cuff and listen to the popliteal artery in the popliteal fossa. The normal
blood pressure values measured in the femoral artery must not differ significantly
from the brachial artery blood pressure.
Table 1 - Classification of blood pressure levels (mmHg.). (ESH / ESC, 2003,
WHO, 1999).
Categories AH
Optimal blood pressure
Systolic blood pressure
Diastolic blood pressure
Normal blood pressure
Hypertension 1st severity
Hypertension 2nd severity
Hypertension 3rd severity
Note. 1. If the levels of systolic and diastolic blood pressure correspond to the
different categories, the level of blood pressure of a person belongs to a higher
2. In isolated systolic hypertension can also be divided into three degrees of
severity depending on the level of systolic blood pressure, diastolic blood pressure
given less than 90 mm Hg. Art.
3. The above classification of blood pressure levels is applicable only to
persons who are not receiving antihypertensive drugs. How to classify
hypertensive patients who receive antihypertensive drugs, experts ESH-ESC,
unfortunately, do not indicate.
8. Edema: causes, extent, methods of detection. The concept of water
balance, filling in water balance form.
Edema during heart insufficiency is the result of stagnation of blood in the
systemic circulation and fluid retention in the body. Cardiac edemas are located
mostly on the legs when the patient walks, or in the sacrum, lumbar, shoulder
blades, if the patient lies. The skin in the area of edema becomes smooth, shiny,
and taut, when it pressure it formed a long time to straighten out pit. In advanced
cases of heart insufficiency, fluid (transudate) may accumulate in the serous
cavities, leading to the formation of ascites, hydrothorax, hydropericardium.
Ascites (from the Greek «askites» -. Like a bloated fur Edematous) is
accumulation of fluid in the abdomen ("dropsy" belly).
Hydrothorax (from the Greek «hydor» -. Water, liquid, «thorakos» - chest) is
accumulation of fluid in the pleural cavity.
Hydropericarditis (+ hydro pericardium) is accumulation of fluid in the
pericardial cavity.
Anasarca (from the Greek «ana» -. Around, «sarcus» - meat) is widespread
edema. Initially Anasarca termed «hydor ana sarcus» (from the Greek «hydor» -.
Liquid), which meant "the liquid around the" meat ", ie body. " Subsequently, the
word «hydor» ceased to be used and widespread edema briefly were designated as
«ana sarcus» - anasarca.
Particular attention should be paid to the state of the water balance in patients
with chronic heart insufficiency. In order to combat swelling is limited fluid intake
(up to 1 liter per day) and salt intake (up to 1-1.5 grams per day).
Control of water balance.
Objectives: To identify the hidden edema, determining the amount allocated
per day of urine, assessment of the adequacy of therapy, primarily diuretic.
Necessary equipment:
1. Medical weigher.
2. Clean dry 2 or 3-liter jar.
3. Graduated vessel.
4. The blank accounting water balance.
5. Temperature blank.
1. The day before to warn the patient about the upcoming procedure and the
rules of the urine collection, to give it details of the entries in the list taking into
account the water balance.
2. At 6 o'clock in the morning to wake the patient, so that he urinated in the
toilet on their own, or to release him to the urine catheter; this portion of the urine
does not take into account.
3. All subsequent urine sample to 6 am the next day inclusive of the patient
should be collected in a jar.
4. During the day, the patient or nurse accounting are introduced in the body
fluid in milliliters, including drunk (first dish is 75% liquid) and the entered
5. Using a graduated vessel count the number of allocated urine per day.
6. The measurement data recorded in a special graph of the temperature blank,
or a separate sheet accounting fluid balance and weight (Figure).
Sheet registration and patient fluid balance weight.
Accounting fluid balance and weight form
Patient Name
in Drinking,
Evaluation of the water balance
1. Calculate how much liquid should stand out in the urine. The amount of
urine, which should stand out (normal), determined by the formula: the number of
the incoming liquid (including not only the water content in the food, but also
parenteral solutions) multiplied by 0.8 (80%).
2. Compare the volume of discharged liquid to the expected amount
(calculated according to the formula). Water regard balance as a negative, if the
liquid is allocated less than expected in the calculation of the formula, and as a
positive - if allocated more fluid. Positive water balance indicates the descent of
edema and efficacy of treatment, negative is about the rise of edema and
ineffective diuretic therapy.
When large amounts of fluid accumulation in the abdominal cavity for
therapeutic and diagnostic purposes is performed abdominal puncture
(paracentesis). When it is executed, care must be taken as fast (one-stage) the
removal of large amounts of fluid can cause collapse.
9. Holter-electrocardiogram (H-ECG): the essence of the method, the rules
of behavior of the patient during the study.
Holter ECG (named after American researcher Norman J. Holter, who first
used it in 1961.) is a dynamic electrocardiography - it is a long, often daily, check
the ECG, carried out off-line, in-patient, out-patient, in conditions as close as
possible to the daily life of the subject.
Because research is carried out without the medical staff monitoring, so
patient enough to explain the rules of conduct during Holter ECG monitoring.
During the study, it is prohibited:
- Carrying out of water treatments;
- Conducting physical therapy;
- Use elektro-warmmaker ;
- Touch the device;
- It is necessary to restrict the use of mobile phone.
In the study period, the patient is given an individual blog. The diary is
introduced while taking medicines, mealtime, occupation (beginning and end).
Always fixed sensation (pain, shortness of breath, irregular heart function, heart
rate etc.) That occur during the monitoring.
10. Features of care of patients at intensive care department.
The peculiarity of care at intensive care units is a constant monitoring of the
appearance, heart rate and blood pressure. Leave them for a long time without
supervision is prohibited. Since they are all the time in bed, it is necessary that it be
easy and clean.
The peculiarities of care also includes a change in body position, frequent
change of linen, giving rubber circle under the sacrum and other measures for the
prevention of bedsores. Feed should be often for the seriously ill, be small
portions. Food should be warm and liquid, it is impossible to raise a patient's head,
at the end of a feeder cup wear rubber tube is introduced into the patient's mouth,
feeding cup is raised and lowered - the food in the amount of one drink enters the
mouth. If the patient is unconscious, it is powered by the parenteral route (the
introduction of nutrient solutions through a vein).
A nurse should monitor the physiological settings of the patients, as they have
often paralysis of the pelvic organs and involuntary urination, defecation. In such
cases, under the buttocks need to put a rubber boat, under the sheet - oilcloth.
In the morning the nurse must make a full suite of seriously ill: wipe the teeth
and tongue, mouth wash, wash patients face, wipe the whole body, undercut. Then,
with the help of cleaner needed make a bed linen.
The nurse must be able to read from the equipment controlling some
parameters of life of patients who are in the ICU ward. At the slightest deviation is
necessary to inform doctor immediately.
11. Sanitary and epidemiological regime of intensive care department.
Intensive care unit should be separated from the rest of vestibule equipped
with a source of ultraviolet radiation. Doors should be kept closed.
Students, doctors, consultants, etc. before entering the intensive care unit put
on a mask, remove the hair under the hat, put on shoe covers on top of the shoe. At
the exit from the intensive care unit sets a container with a lid for the collection of
used workwear. Entrance to the office in street shoes prohibited. All appliances,
cell phones and other items imported and introduced into the intensive care unit,
must be decontaminated.
Used dressings and medical instruments, used when working with patients
intensive care unit, is collected in specially marked containers and disinfected after
manipulating one of the regulated practices. The wet cleaning is carried out indoors
using disinfectants, whereupon one of the decontaminated air regulated methods.
Before entering the patient from the operating room to the intensive care unit,
recovery room, before hospitalization, after discharge or transfer to another branch
of the bed, a nightstand, a holder for bedpan and others. Disinfect. Bed veiled
disposable bedding or reusable undergone treatment chamber for treatment for
vegetative forms of microorganisms. If possible, observe the principle of cyclical
filling chambers.
For patients with septic infections are allocated separate blocks (sections),
which is stationary mounted ultraviolet germicidal irradiators closed. In the wards
for patients with GSI staff working in labeled coats, masks, caps, are replaced
Unauthorized movement and the movement of patients with septic infections
from ward to ward, or to other offices is prohibited.
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2. comb, AL Fundamentals of general care medical patients / AL. Comb, AA
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3. Oslopov, VN General nursing care in a therapeutic clinic: Tutorial / VN
Oslopov, OV Epiphany. - M .: GEOTAR - Media. 2008.
4. Skvortsov VV Fundamentals of Nursing: a tutorial / Skvortsov VV - Rostov n /
D .: Feniks.2008
Head of the department of Internal Diseases No.1
with Endocrinology Course,
PhD, assist. of Professor
E.G. Malaeva