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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 № ___________ METHODICAL REVIEW for practical training of foreign students of the 1st course Subject: «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 should 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 diuresis). 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 tachycardia. 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 disease. 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 catheter. 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 artery. 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 irregularis). 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 cartilage. 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 level. 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 (mmHg) <120 Diastolic blood pressure (mmHg) <80 Normal blood pressure High normal blood pressure 120–129 130–139 80–84 85–89 Hypertension 1st severity 140–159 90–99 Hypertension 2nd severity 160–179 100–109 Hypertension 3rd severity >180 >110 Isolated systolic >140 <90 hypertension 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 category. 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. Procedure: 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 parenterally. 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 Date Entry vein in Drinking, eaten Excreting Fluid balance Weight dynamics 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 daily. Unauthorized movement and the movement of patients with septic infections from ward to ward, or to other offices is prohibited. 6. LITERATURE 1. Fundamentals of nursing: Proc. Benefit / LV Roman'kov [et al.]. - Minsk .: Elaida, 2012. - 200 p. 2. comb, AL Fundamentals of general care medical patients / AL. Comb, AA Sheptulin. - M .: Medicine, 1991. 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