«APPROVED»
At the methodological meeting of
the internal medicine propedeutics
department
Chief of the department
____________prof. Khomazuk T.A.
«
»
2013 y.
Guidelines
For Second-year Students of the Dentist Department
Subgect
Module №
Enclosure module №
Topic №13
Propedeutics of the internal medicine
Course
Faculty
2
The methodic of medical manipulations.
Dnepropetrovsk- 2013
General purpose: To know the methodics of such medical manipulations
improving blood circulation, in patients with gastrointestinal disordes, with
respiratory pathology.
Specific purpose:
1. To know doing of procedures include hot water-bottles, cups, mustard
plasters, compresses, ice bags.
2.To study main principles of care of coughing patients.
3.To know the indications for gastric lavage and technics of using.
4. To know the indications for enemas and technics of using.
Topic content:
Various procedures are used to produce the desired effect on a patient's blood
circulation, both local and general. These procedures include hot water-bottles, cups,
mustard plasters, compresses, ice bags, etc. These procedures have their effect on both
healthy and sick individuals through thermal, mechanical or chemical stimulation. The
skin is the main site of application of these procedures. When irritated, various reflexes
are activated in the skin. Ivan Pavlov showed that during thermal stimulation of the skin,
inhibition develops in the cerebral cortex. For example, sleepiness develops after a warm
bath or even after local application of heat. Thermal effects decrease or even remove
pain, decrease skin sensitivity, and prevent transmission of pathological impulses into
the central nervous system. Temperature stimulants reflectory change the lumen of the
blood vessels to alter the blood distribution in the body. When the cutaneous vessels
dilate, the vessels of the abdominal organs contract, and vice versa, when the skin
vessels narrow, the vessels of the abdominal viscera dilate.
The application of a warming compress is accompanied by local dilation of blood
vessels and enlargement of blood circulation in tissues, that in this area of inflammatory
processes produces painful and resorptional action. The warming compresses are used in
treatment of various local infiltrations, for example, postinjection ones, some diseases of
muscles and joints, chronic inflammatory diseases.
The warming compress can be dry or moist.
The dry warming compress (usual cotton-gauze bandage) is more often
intended for protection of those or other sites of a body or head, for example ntck or ear
from cold exposure.
Moist warming compress is prepared from 4-th layers.
At the beginning a piece of a tissue, moistened with warm water (50-60°C) or
with solution of 40% alcohol is put on a skin (Fig. 62). Then it is coated with a piece of
the oilskin, polyethylene film or of a waxed paper. At last a layer of cotton wool is
placed there. Each subsequent layer of a compress should be bigger, than the previous
one. Above the compress a bandage is placed.
The duration of application of a moist warming compress is 6-8 hours. While
taking off a compress the skin should be sponged with water or alcohol and then wiping
with a towel to prevent maceration of the skin. If there is irritation of the skin, it is better
to avoid further applying of moist compresses.
The contraindications for applying warming compresses are various skin
diseases (dermatitises, furunculosis) and injuries of the skin.
The local warming effect can be received with the help of a heater (hot water
bottle). In its application, reflex dilatation of the blood vessels of the crgans of
abdominal cavity and the relaxation of a smooth musculature, that, in particular, is
accompanied by disappearance of spastic pains will occur. In the treatment of a peptic
ulcer, renal or hepatic colics, radiculitis, the effect of a heater may be painfull.
Hot water bottles in the volume from 1 to 3 liters are more often applied. Before
using the hot water bottles it is filled with hot water (60-70°C) approximately 2/3 of its
volumes, air is carefully evacuated. It is necessary to tightly screw hot water bottle with
a cap and overturn it with the purpose to check this. Before giving it to the patient wrap
it in a towel.
The heaters arc contraindicated in obscure abdominal pains (in such diseases,
as an acute appendicitis, acute cholecystitis, acute pancreatitis), in malignant tumors, in
the first day after a trauma, in outside and interior bleedings, in the patients with the
impaired skin sensitivity, and also in unconscious patients.
The application of a mustard powder is based on the fact that evaporated etheral
oil causes an irritation of a skin receptors and its hyperemia, resulting in a reflex dilation
of blood vessels located deep in the internal organs and it causes resorption of some
inflammatory processes.
Standard mustard plasters are sheets of a dense paper of the size 8612,5 cm,
covered with a layer of the unoiled mustard powder. Mustard plasters are applied on
skin, previously having moistened it with 40'C water, and are taken off after 10 — 15
minutes.
Mustard plasters are applied in treatment of neurologic diseases (myosites,
neuralgia), catarrhal diseases (bronchites, pneumonia), in angina pectoris (on the lefthand half of thoracal cell) and headaches (on area of a nape).
If the skin is very sensitive mustard plasters should be applied over a thin
sheet of paper or gauze. General mustard baths help alleviate catarrhs of the
airways, bronchitis or pneumonia, usually in children. Mustard powder should be
added to water in the bath, 40-60 g per 10 liters. The solution is passed through a
gauze to separate undissolved lumps. The temperature of the water in the bath
should be 37-39°C; the procedure should last for 8-10 minutes for adults and 5-6
minutes for children. The patient should be then wiped dry with a warm towel, dressed,
and allowed to rest.
Cups give stronger vasculodilated activity, than mustard plasters and are applied
widely in bronchites, pneumonia , neuralgias, neuritises, myositis.
Cups are represented glass vessels with a spherical bottom and thickened edges of
volume 30 — 70 ml. They are put on the body with well developed muscular and
subcutaneous fat, flattening bony formations (subclavial, subscapular, interscapular
areas).
To avoid bums the skin is preliminarily sponged with vaselinum. Then a burning
cotton plug moistened with alcohol is put on the inside of every cup for 2 — 3 sec. After
that with prompt and vigorous motion the cupping-glasses are moved in a circle of a
wide area over the surface of the skin. Due to reduction of the air inside a cup (cuppingglass) slight pulling of the skin occurs. The skin becomes a pink or purple color.
Duration of cup application is usually from 10 to 15 minutes. The number of cups
depends on the size of the surface to which they should be applied. To take it off, it is
enough to press with a finger on the skin near to the edge of the cupping-glass,
simultaneously wedging it from the bottom in the opposite side.
The patient should then be wrapped in blankets and allowed to lie for 30-60
minutes. If the cups remain attached for a longer lime, dark red spots and even vesicles
filled with fluid may develop on the skin. The cupping-glasses are contraindicated in
tumors, active tuberculosis, pulmonary bleedings, diseases of a skin and its
hypersensitivity.
Treatment with cold is called cryotherapy. Ice bags are commonly used. Cold
causes contraction of the blood vessels, thus decreasing the sensitivity of the peripheral
nerves. Cold is applied as a first aid measure for acute inflammation of abdominal
organs (acute appendicitis, pancreatitis, cholecystitis, etc.), for hemorrhage, contusion,
bone fractures, delirium associated with fever, and also for anesthesia.
Moist cold compresses are used for the first hours with injuries, nasal and
hemorrhoidal bleedings, high fever. Rolling some layers a piece of a soft tissue, it is
moistened with cold water and put on the relevant area of the forehead or bridge (of the
nose). As the moist cold compress soon reaches the temperature of the body, it is
necessary to change it every 2 — 3 minutes.
For more prolonged local cooling it is more convenient to use an ice-bag, which
represents a flat rubber bag with a wide hole filled with small pieces of ice (Fig. 67). The
ice-bag is expedient, but overcooling should be avoided by to hanging it (above a head
or a stomach), making ten-minutes breaks every half an hour.
The respiratory system ensures the constant delivery of oxygen to the living
body and removal of carbon dioxide and water from it. The gas exchange process
consists of external and internal (tissue) respiration. External respiration is ensured by
pulmonary ventilation and by the exchange of gases between the atmosphere and the
blood in the lungs.
Care of coughing patients depends on the particular disease. For example, in
acute respiratory' diseases (acute laryngitis or tracheitis), dry and painful coughs are
controlled by medicinal preparations taken per os, or by inhalation of sodium
hydrocarbonate and hot steam. Mustard plasters, mustard fool baths, and hot compresses
on the chest are used as counter- attractive therapy.
Many diseases of the stomach can be caused by poisoning with medicines, bad
foodstuffs, alcohol. The patient complaints on the pain in the stomach, nausea, vomiting,
diarrhoea. In there cases we must make gastric lavage. Its action is to clean the stomach.
The indications for gastric lavage (washing, irrigation):
poisoning with medicines, bad (of poor quality) foodstuffs, fungi, alcohol etc.
poisons(venom); delay of nutrition in the stomach because of pyloric stenosis, atony of a
stomach with the phenomena of stagnation of food masses in it,
Castric lavage is done by using: disinfected gastric rubber tube with external
diameter, irrigation syringe or funnel of a capacity of 0,5-1 L, container(capacity) of 810 L boiled water 28-32° C, 2 % of sodium hydrocarbonate solution (in poisonings with
acids), 0,1 % of a citric acid solution (in poisonings with alkalis);basin or bucket for
irrigation water;a mouth dilator, tongue-holder, forceps, laryngoscope (can be used, if
the patient is in an unconscious state).
Before procedure, it is necessary to carry out a psychological preparation of the
patient, if he is conscious. To explain to the patient the purpose and order of carrying out
the procedure and the rules of behaviour of the patient during procedure. Before the
procedure, demountable prosiheses (if they are presence) must be taken off. During
procedure, the patient is on a chair and leaning against its back.
The patient is given an oil-cloth apron to put on. The basin is placed between his
legs on the floor.The hands of the patient are fixed in such position, that it does not
prevent him carrying out the procedure. If the patient is not able to sit, put him on the
left-hand side with his head, lower than his trunk, to decrease the hazard of breathing in
lavaged waters.
The nurse takes the disinfected sonde with clear hands and measures the length,
which is necessary to insert into patient, from an umbilicus up to incisors, up to lobule of
the auricle; then it is necessary to moisten the blind end of the sonde with water; to ask
the patient to open his mouth and to say " a-a". After that the round end of the sonde is
put on the base of the tongue, the patient is asked to swallow and a: this moment a sonde
is put into esophagus. In the case of vomiting the movement of the sonde should be
stopped, the patient is advised to cover the sonde by lips and to breath through the nose.
After some time the procedure is repeated before the sond will be inserted to the
necessary mark.
If the sonde enters in the respiratory pathways the patient begins to cough, he is
blue and loses his voice. In this case the sonde should be immediately taken out. and
after the patient becomes quiet, the procedure should be continued (repeated).
In the unconscious patient, this procedure is carried out by the doctor —
reanimator wiih the help of a laryngoscope. If the gastric lavage is made with the funnel,
it is necessary to sink a funnel up to the level of elbows of the patient and fill it with
water; then gradually to lift the funnel above the head and let water enter into the
stomach — a volume of 500-600 mis. It is necessary to follow carefully, so that not all
water from the funnel reaches the stomach, because in this case water can not be
removed from a stomach. When in the funnel there is a small amount water it must be
down ward again to the level of the elbows of the patient and lavage of water with
mucous and with oddments of nutrition will be removed from the stomach. The amount
of discharged water should be approximately equal to the amount of injected water. This
procedure should be repeated for several times, to pure(clean) lavagic water.
With the occurrence of some blood in lavaged water the procedure should be
stopped and the doctor should be called. The syringe can be used instead of the funnel.
In some cases, gastric lavage can be made by a tubeless method. In this case it is
necessary to give the patient a drink of 2-3 glassfuls of mineral waters or light pink
solution of a potassium permanganate; after that the patient will vomit artificially by
pressing the index and medial fingers of one hand on the root of a tongue and irritating
the back wall of the pharynx. Thus a gastric lavage is carried out to " pure(clean) lavage
waters ".
The main complaints of patients with intestinal diseases are pain,
meteorism (inflation of the abdomen), constipation, diarrhoea, intestinal hemorrhages,
and involuntary defecation. No analgesics or w;imth should be given to a patient with
abdominal pain until its cause is established, because this will interfere with diagnosis
and may txi harmful (e.g. in cases of intestinal haemorrhage or acute appendicii is). If
the pain is caused by spasms of the smooth muscles, spasmolitic drugs or a hot-water
bottle can be used. Meteorism is manifested by inflation and distension of the abdomen.
Food rich in carbohydrates should be excluded from the diet because it intensifies the
fermentation processes in the intestine intensifying gas formation. Activated carbon is
prescribed in such cases: a teaspoonful 3-4 times a day; activated carbon (tablets) and
camomile tea are also helpful.
If the patient has diarrhoea, he should use a bed-pan or some other vessel where
his faeces can be collected for inspection and analysis. The patient should keep his body,
clothes, and bed clean; he should wash his anus after defecation with a 2 per cent boric
acid solution. Since diarrhoea is often the result of an infection (cholera, abdominal
fever, dysentery', etc.), it is necessary to take special precautions even before the
diagnosis is established. To this end the patient should be placed in a separate room and
the faeces and urine should be treated with chlorinated lime (1:2) and kept for an hour
before discharging into the sewage.
Involuntary defaecation occurs in patients with severe affections of the brain,
tumors, or injured rectum. These patients should be placed in separate rooms. A highcaloric and easily assimilated diet is given to the patient because the amount of faeces is
small. A cleansing enema should be given every day. The patient should be placed on a
special bed or a rubber pan. Such patients should be given special sanitary treatment to
their bodies; their clothes, and bed sheets should be changed more frequently.
Constipation is a rctension of stools for more than two days. Constipation is
managed with a special diet, cathertics, and cleansing enemas. In some patients a
considerable amount of hardened faeces accumulates in the rectum. An enema is
useless in such cases and the facces should be removed manually. A rubber glove
lubricated with oil should be used for the purpose. A bed-pan is placed under the
patient's pelvis and the finger is inserted into the rectum to remove the hardened
faeces. If not removed on time, the faeces will harden even more and press on the
intestinal wall, causing sores. A cleansing enema or syphon clyster should be given
alter this manual procedure.
Enemas. An enema is an injection of liquids into the large intestine through the
anus. The indications for use of a cleansing enema are: constipaton; preparation of
the parturient women for labor; preparation of the patients for scheduled operations on
gastrointestinal tract organs, small pelvis; preparation of the patient for an X-ray
examination of GIT organs, of small pelvis, pelvic bones, pelvic region of the spir al
column, preparation of the patients lor endoscopic examinations of the intestine;
poisoning.
For the cleansing enema it is necessary: an Esmarch's irrigator (glass,
enameled, rubber) capacity 1-2 L, with a tip (hand piece) and a tap; water with a
temperature of 27-32C, 1,5-2 L. If the state of the patient allows, the procedure of the
cleansing enema will be carried out in a special toilet room, where there is a couch,
support — rack for hanging a Esmarch's irrigator, wach-bowl. The patient following a
bed regimen is given this procedure in his bed.
To set up the Esmarch's irrigator on a support of a height of lm above the patient,
to pour out some water at a proper temperature, and about l-l,5L, to unclose (open) the
tap, to fill in a rubber tube and tip with some water, to close the tap. For simplification of
removing of the faeces use 25-50 g castoric or olive oil, or 25 g of shaving soap which
can be added in the water. After that the tip with Vaselinum is greased. The patient is
laid on the left- hand side with the legs, pulled to a stomach; if the patient cannot turn,
the procedure is carried out in a position with the patient on his back, a bolster (roller) is
put under the patient's pelvis. The buttocks are moved apart by I-st and II fingers of the
left-hand with rotary movements a hand piece is carefully inserted into the anal hole; at
first in a direction of the umbilicus 3-4 cm, then parallelly to the spinal column 8-10 cm.
In the case where there are folds of mucosa or hemorrhoidal, the hand piece is carefully
introduced between them. The tap is then opened. The liquid should flow gently from
the flask. If the liquid does not pass from the flask, the position of the end-piece in the
reeturr should be changed slightly, or the pressure increased by raising the flask to a
higher position. If the patient complains of pain, the flask should be lowered to slow
down the rate of water outflow. If the end-piece becomes clogged with faeces, it should
be cleaned and introduced again. If the faeces are hard, they should be removed from the
rectum by a finger or a spatula. The administered liquid reaches the remain parts of the
large intestine to intensify peristalsis and to cause the urge to defecate. The patient
should retain the administered liquid for 5-10 minutes. Then the patient empties his
intestine into a toilet. If the procedure is carried out in the bed it is necessary, to promptly
give the patient a bedpan. The cleansing enema is considered to be effective, if some
faeces masses are discharged with water within some minutes. If the clyster has not
worked, the procedure can be repeated in some hours.
Recommended Reading:
1. Diseases and disorders : a nursing therapeutics manual / Marilyn Sawyer
Sommers, Susan A. Johnson, Theresa A. Beery.—3rd ed.
2. Учебное пособие для иностранных студентов медицинских вузов,
обучающихся на английском языке / Мостовой Ю.М, Демчук А.В.,
Константинович Т.В.-1-е издание. - Винница:, 2009.
3. Clinical Nursing Skills and Techniques: basic, intermediate and advanced.
The C.V. Mosby Company, 1986.-1296 p.
4. Clinical Skills and Assessment Techniques in Nursing Practice. Scott,
Foresman and Company, 1989.-1280 p.
5. Emergency Nursing: priciples and practice. The C.V. Mosby Company,
1985.-715p.
6. Instructor's Manual for Fundamentals of Nursing, J.B. Lippincott Company
Philadelphia, 1989.-120 p.
7. Nursing interventions and clinical Skills. Mosby — year Book, Inc., 1996.813p.
8. Nursing Procedures: Student Version. Springhouse Corporation,1992.788 p.