Description of the nursing process
Nursing nurse satisfaction with nursing care needs, the implementation of the plan of treatment, which is necessary to determine the value of the results and sorting methods. This process is connected with the client, which requires the implementation of the first of each of the five stages. She allows the customer to perform the following process:
– To collect information about the client in order
– Strong and weak sides of the client properly.
– Measures to help patient tasks determined by the actions of the nurse and the development of individual treatment plan.
– The execution of the plan of treatment.
– Evaluation of the effectiveness of medical treatment plan.
The client at every stage of this process and medical partners will work as a partner of a nurse. At the same time, the customer’s level of participation in the health status of its influence and resources. If possible cooperation or compliance with customer baby unconscious people, the stages of the process is performed by using the client’s family members or person’s helper.
Nursing achievement of the primary goal of a comprehensive science-based health care is to help the nurse to do the creative approach. The idea of the target for the full masculine nurse personal issue and psychomotor skills, and these skills in their work with clients disease is preventable, good health and the completion of the process of restoration of lost functions for creative you need to be able to use discretion.
The first step in the process of nursing to collect data. Customer data and continuous evaluation forms and the primary task of the work of nurses. To collect information on the application of these institutions reflect the theory of nursing. In general, nursing measures with a view to protect the health of people may be exposed to illness or disease or improve the functional activity of the issues deal. Nursing care of the accuracy of completeness of the information on the next steps and depends instead.
Nurse on data collection in the following ways:
– Nursing history, physical assessment, medical and nursing literature leaflets appearance, health care professionals and the client form the basis of the information, including suggestions helper.
Based enter the regular news.
– Evaluation of the data.
– Information about the reports.
Diagnostics – this is evidenced by customers’ problems, changes or causes which lead to the appearance of diseases, as well as the strong and weak sides of the client to analyze the data provider. After the nurse what the problem is with the medical nurse, which is one of the other medical staff determines deal. As a result of the analysis of health nurses satisfied with their ability to solve problems found in the nurse called the diagnosis. A nurse from the stage of diagnosis of the following ways:
– Customer data analysis and interpretation.
– To determine the patient’s disease and the benefits of a solid.
– Nurse diagnosis based regulation (formulation).
The nurse was diagnosed with works such as the rule of the sequence.
Planning is identified by nurses, diagnostic and reduce the problems associated with the health, disability, consideration, and thus allow the correct implementation of nursing actions on the size of the establishment of the functions of the client. In addition, the comprehensive treatment capable of meeting the needs of the customer need for nursing care (1) instead of nursing and medical treatment on the plan. The nurse at the planning stage in the following ways:
– Addressing the priorities.
– Assessment of the client’s objectives and development.
– Nursing measures chooses.
– The nurse’s care plan information.
On the implementation of an improvement plan contains. It is composed of health protection, disease prevention, health promotion and acceleration of repayment and loss of function of all activities carried out by a medical nurse. At this stage of medical nurse in the following ways:
– Nursing care plans on it.
– Stockpiling continued and the necessary amendment to the management plan.
– Documentation works well.
Rating – this is the degree to meet customer needs measure. The nurse and the client’s treatment plan set issues addressed how the size of the creative or determined by factors having a negative effect. Due to the client’s treatment plan, this plan will be continued, changed or stops. If the assessment indicates the need to change nursing care, medical history, diagnosis and medical care it is necessary to consider in detail the compatibility of the data. A nurse in the evaluation process in the following ways:
– The level of implementation of the client, according to guffaw measurement.
– Positive or negative impact on the fulfillment of its task to determine the factors.
– Need to change the plan of nursing care.

Nursing patients control methods carried out in 3 stages:
Check I.Sub’ektiv: asked question.
II. Objective examination: Physical examination methods. Palpation, percussion, and auscultation.
III. Additional methods.
A. Laboratory methods.
V. Instrumental methods of control.
I subjective to check patients for requesting an investigation.
Request to query the patient’s subjective part of the inspection, it is based on dialogue between the doctor and the patient, the doctor, his patients (patients) will be able to get acquainted with, and even about the patient that you want to can.
Asked interrogation room the doctor office. Asked question, which is senile patient, if the patient does not es Welcome to the combination of its observer in the next: parents, relatives seeds paper.
Purpose for requesting the inquiry:
– Information
– Assessment of the origin of the disease
– Identify other sources of information
– To be in the patient’s trust
– To know the scope of knowledge of the behavior of the patient
– Assessment of the patient’s illness and his personal qualities
Asked during the question-a strange, strange people do not need trust between doctor and patient.
1. Passport information call (tug`ilgan, nationality, profession, place of work, address.
2. Complaints:
The main complaints of this organ system dysfunction may be caused.
Additional complaints justified as a result of changes in the general level, and other diseases.
3. Gathering of the disease history:
The disease starts when the patient or their relatives have contacted anyone …?
– How did the disease, the causes of origin of the disease, the patient or the parents, it is linked with what?
– How did the onset of the disease or excitation ?, season.
– What research is conducted and their results?
– What methods of treatment and held in their effect, what?
– How long does the existence of a disability?
4. Collect life history:
Biographyc information (location, the beginning of the learning process, learning, education, social status, physical activity).
– The days of vacation how to use the previous and current living conditions, primarily in the military service, where browser if the reason.
– Genetics: family, close relatives of arterial hypertension, diabetes, alcoholism, tuberculosis, mental disorders, cancerous conditions and availability.
– Diseases suffered throughout his life.
– Working and living conditions (dust, the effect of salt and metals, professional habits protection factor).
– Bad habits: smoking, alcohol, and drug addicts.
– Family and sexual life:
Woman: In the beginning of the menstrual period, hurt the lack of Bomi, never married, pregnancy, abortion be.
M: In Potente, libido:
– Feature of the diet, diet, diet unrestricted tax, food additives, animal fat, fried, consumption of bitter products, weight loss diet, the disease of diet.
Drug hystory: Which drugs frequently and over a long period of time, if the state can not take a drug allergy was observed, her blood, serum day.
Epidemiological history: adverse epidemiological zone of residence and contact with infectious diseases, to be living in unfavorable climatic and geographical zone.
According to the common parts of the body and the eye to forgive
According to forgive, and eye-to think about the general condition of the patient.
Initially, the general view held then, and body parts for special glasses will be forgiven.
Objective: Es Welcome to the patient’s condition, mental health, general appearance, skin, the appearance of the components of the body examined.
Guide: to see all the patients that must be held.
Conditions: bright, warm, quiet room.
1. The status of the patient:
– The patient active- its-kind service.
– Passive mode hard bed ill patients.
– Mandatory status of their patients easier (to reduce the pains, in order to reduce the this mode is selected).
2. Constitution.
– Fatigue – the body long, the size, column width, which size.
Hyperstenic body size, the size throughout the column.
Normostenic proportional to size.
3. The image of the face:
– Pain – is hurt because of dyspnea.
– Korvizor heart failure.
Mitral (dealing Mitralis) – two red yonog`ining (mitral valve faulty).
– Dealing nefritica face and eye lids shishinqiragan, fair (glomerulonephritis, nephrotic syndrome).
– Dealing Hippocratica hurt peritonidida.
‘Moon’ Itsenko Kushengo disease.
Akromegaliyadagi face – nose, chin, long yonog`i.
Bazedov face Ekzophtalm hyperterios tireotoksikos.
– Masked amimik around mouth folds, mouth and eye completely closed system sklerodermiyada.
SKV – both the temple and redness of the nose, across the arc of butterfly character.
– Hundreds of asimmetria facial nerve pare paralich.
1. eye to forgive
Mikrotsefaliya other small razmeri idiotizmda.
Gidrotsefaliya different in size and go head istiskosida.
Makrotsefaliya rickets.
– Carrying head square rickets.
Other optional lest aortic valve insufficiency.
– Bloodshed – typhoid, skarlatina, leukemia, adrenogeneatik allopetsiya.
2. Face:
– Peripheral artery factor arternoskleroz brain vessel sclerosis.
Eye lids dark cyanosis – Bazedov disease, tuberculosis, kidney activity of the adrenal gland failure.
– Pumpkin castors that Lepidus sallow-cholesterol metabolic disorders.
– Hundreds of image changes a variety of different diseases
– Redness of the cheeks of a bilateral lobar pneumonia.
Lips stone (Evergreens Labialis), influenza, and pneumonia.
3. EYE:
Strabismus diplopia epidemic encephalitis, minengit other tumor disease.
Nistagm – Tremble the apple brain disease, diffuse sclerosis.
– Reaction to light – light sensitivity.
– Narrowing of the pupil (micosis) – immediate and poisoning quietly
– The expansion of the the apple’s (midvosis) in a coma, atropine poisoning, agonia.
Ekzoftalm tireotoksikos.
– Covers ptozi eye lids down, one-way, two-way.
4. Mouth.
Mouth mucosa condition – aft (the wound), pigmentation, hemorrhage, Philpott spot.
– Milk (redness, sores, swelling, bleeding) – Qin, stomotit, leukemia and diabetes.
– The size of the Tongue – miksedema, Down syndrome, acromegaly.
– Fresh, moist and red tongue ulcer.
– Raspberry shaped the language skarlatina.
– Loss of teats smooth lac (Xanterra), one language, Addison’s disease.
– ‘L’ shaped the language of stomach cancer, pellgra Sprung.
– Language epithelial local thickened leukoplakia, thereto.
1. Nationwide:
– Sleep artery pulsatsia aortic valve insufficiency.
– V. jugularis beating (vena cava) – 3 triple valve insufficiency.
– Enlarged lymph nodes – tuberculosis, limfoleykos limfogranulematos cancer metostas.
– Enlarged thyroid gland – tireotoksikos simple goitre dangerous o`smada.
2. Leather trim:
– Skin whitely anemia.
yellow skin anemia Addison-one.
– Greenish – xloros.
– Prohibit the dangerous anemia.
– The color of milky coffee – acute septic endocarditis.
– Redness of the skin – erythremia.
Cyanosis (skin blue) – circulatory failure, chronic disease lung’s.
Icteric skin color yellow bilirubin metabolism disorders, severe hemolysis.
Brown or brown leather kidney gland failure.
– Breast nipples giperpigmentatsia the earth around the belly white linea – Hyperpigmentation of pregnancy in women.
Depigmentatsiya vitiligo (viteligo) the hotbeds.
– Skin moisture sweating – tuberculosis, malaria tireotokos goitre purulent processes.
– Drying of the skin, diarrhea, vomiting.
– Skin rash – a rash accompanied by a variety of diseases:
1. The type of solution in the field of skin breast red, quartz radiation received in Xining, received nicotinic acid.
2. Rozeola spotty rash, abdominal typhoid, Paratii, hay tif syphilis.
3. Casements rash (krapivnitsa), hives (urticaria), allergic diseases.
4.Purpura skin hemorrhages – Verlgof disease, gemofilia, zinc kapilyarotoksikos.
5.Teil scarring after surgery and pregnancy.
6.Injection kidney heart disease.
8.Mahalliy tumor wounded in violation of local blood and lymph circulation.
1. Muscle System:
– Atrophy of the muscles of the local parallel (paralytic) ileus.
– Folded Butimar swelling, redness, stamping knot, rheumatism, arthritis, gout, osteortros deformation.
2. Breast chest:
– Deforming it, Estella, scoliosis, kifoskolios rachitic.
Emphysematous (barelly) – lung’s chronic disease.
– Paralytic tuberculosis, cancer, kaxeksia.
Henly breast rachitic.
3. abdominal observ:
– Asymmetric abdomen enlarged spleen and liver.
– The same zoom abdomen ascites, flatulence.
– Intravenous and subcutaneous veins around the belly, the expansion of the sides of the abdomen, liver cirrhosis, portal hypertension.
4. Eye: The
– Hand fingers drumly nails the circumference motivated, chronic suppurative disease bronchoectatic disease, kidney abscess, acute septic endocarditic, heart born defects, cirrhosis of the liver.
– The finger of death ” – very catching his fingers, hands and feet – Reina disease.
– The expansion of varicose veins, trophic ulcers, heel shape, the shape of the knee.
Anthropometric subdivided into general and specific.
Nationwide, weight measurement, the Nationwide index weight.
– Special – narrow specialists of their size measure. Gynecologist – skulls, etc.
Size by weight of the dynamics of the diseases are often unavailable.
Purpose: Nationwide, the weight measurement.
Guide: all patients are held.
Necessary conditions: bright, warm room, rostomer, medical scales.
1. Nationwide morning shoe size.
2. Patients rostomer, stand size (ankle back, shins, hips, breast, neck tubercular touch rostomer tourism).
3. Planks exposed.
4. The patient is out of the rail, where he was exposed character.
5. Weight morning size.
6. Patients possible solution should not be the case.
7. Before measured in bladder and intestines should be dismissed.
8. The time scale in size to function properly investigated.
9. The exact size milligrams.
10. The patient should be calm and balance while moving.
Body temperature measurement
There are several different methods of temperature measurement (mercury thermometers, liquid crystal, and an electronic thermometer). Mercury thermometers are still widely applied.
Objective: To determine the temperature of the body.
Services: performed in patients with various diseases.
Wine: thermometer should be.
1. temperature before measured thermometer rutty pointer from 350-360 down.
2. Temperature armpit under 51, mouth 31 cavity the correct size during the intestines 11-21.
3. Temperature measurement results.
4. Temperature measured, thermometers shook 350-360, vessel with disinfectant solution will be exposed.
5. Right intestinal measured thermometer temperature processes are stored separately from the other thermometer with rubbing alcohol.
Blood pressure (AU) measurement
BP measurement role in the discovery of a variety of diseases.
Objective: The aim of the indirect method of systolic and diastolic blood pressure measurement.
Guide: the size of all patients.
Conditions: tow tanometrs spring manometer (blood peruse measurement).
AB seat position after 51 Employment Assistance leg muscles, blank mind, did not breath, blood peruse measured talk time support should be flat.
1. The patient’s shoulder is removable.
2. shoulder to shoulder between the artery factor.
3. FG recess 2.5 cm above the shoulder cuff exposed at the bottom of the field.
4. Wrist artery pulse dissapear cuffs marked.
5. Fonendoskop arterial allowed only in the recess on the bracket.
6. Gradually cuff launched into the air.
7. Observed manometer scale basis and fonendoskop heard.
8. Fonendoskop heard the first sound (tone) – the maximum systolic pressure.
9. Fonendoskop sound (Tone) loss in the minimum diastolic pressure.
10. The measuring will be held 3 times (manual) and the average indicator, and the result are removed: hypertension, hypotension, normotonia.
check BPM
The goal: to think about the different features of the pulsar.
1. Patients should be peeled.
2. The doctor checked the patient with his hand pulse to the back of the wrist, the lower branch held by the back of the thumb metacarpal industry will be exposed.
– Pulse simultaneous determination of both manually, if done manually sure that it is the same, and after a manual labels continue.
– With the right hand, 3 finger doctor is viewed with caution arterial blood pressure, cardiovascular evaluation Nationwide palpation and pulse 6.
– Rapid pulse – tireotoksikos, myocarditis, hypertension, intoxication, neuroses, and fever.
– Slow pulse jaundice, a complete blockade of the heart.
– Solid pulse atherosclerosis, hypertensive disease.
– Soft pulse of chronic heart failure, venous insufficiency, anemia, blood loss, hypotonia.
– High and a large pulse of aortic valve insufficiency, tireotoksikos.
(IPI), a narrowing of the aortic pulse, tachycardia, ruptured.
– Pulse holes failure, mitral stenosis.
– Pulse vein thrombosis recognized disease (obliterated endoarterint), aortic koarktatsia support limbs.
Determine the status and structure of the nursing care plan objectively verifiable data for the client’s physical evaluations. Physical history wept during the interview and performed subjective evaluation and can provide new information to verify the information. Which is adjacent medical examiners for nurses discussing a lot about the conduct of physical competition. Physical examinations, medical service order to start off the road and taking into consideration may be the basis for medical treatment, doctors usually perform. Some nurses perform a comprehensive physical verification. In any case, nurses chosen for the purpose of nursing physical examination of all aspects of these subjects.
The doctor to find the cause of the pathology and its nursing physical examination performed by physical competition were completed to determine the client’s functional abilities are different. Neurological deficiency When trying to nurse the ability to perceive how to determine the impact will be. For example, a customer holding a stroke on the ability to understand information and evaluation; Furthermore, its ability to carry out daily tasks also studied.
Nursing physical health status of the purposes of the competition assessment, disease detection and nursing procedures are included on the basis of the information. Practice nurses in medical institutions of different methods for different purposes of evaluation of the physical applied. Heart patient care nursing assessment of the client’s physical, high-tech applied. Rehabilitation nurses, the functional disability and to determine the response of dysfunction on a comprehensive mastery of skills. The heel of nursing experience to assess the physical system includes systematic examination of all its members. The operation of a settlement on the basis of this data or information.
Palpation method is based on the feeling feel. With the fingers of the hand he held, and of course a lot of palms, and all will participate. Palpation or that of a physical property of the members of the dressing occurs, its location, size, shape, surface hardness, mobility.
Objective: The aim of this or that member of the physical nature, he appears playing a role of its size, shape, surface hardness, and mobility.
Guide: All patients are held.
Conditions: warm room, or chamber bed (sofa).
Thyroid acoustical
1. 4 fingers on the soft surface of the doctor will be exposed to the back side of the thyroid gland.
2. Both support Neck exposed at the back of the thumb.
3. After a visit to the doctor, the patient swallows several actions at the same time palpation.
4. The thyroid gland acoustical made his presence blood system nodes, mobile tariffs.
Breast chest acoustical
1. Palpation is done with both hands, hand, symmetrical on both sides of his hands will be exposed. On the front of the patient to the doctor.
2. Doctor’s hand, breast thorax lateral (side) side pressed the same application related to this sector.
3. In the left hand below the right breast chest shovel the other hand, is being placed on the field in front of the same is properly viewed.
4. The right hand on the left breast below the chest shoveling other hand, is being placed on the field in front of the same to the public.
5. Young children breast chest elasticity. Breast elasticity pleural transudat chest, exudates, tumor, the lungs declines tissue solid.
Fluctuations in the volume
This method of sound given to the surface of the breast chest unnoticed.
The order of performance:
1. Application hands collar being placed on the field of surface and groundwater, and the ‘P’ letter-holder means (tractors, four, forty) prescribed.
2. After palms breast by 4-qovurg`achaga chest exposed, the ‘R’ protection is prescribed to say the words.
3. The patient’s hand, arising allowed only in the doctor’s hand auxiliary line, the letter ‘r’ words said.
4. So back to the patient after the doctor the doctor turned up support breast clamps, and the process is repeated.
5. The patient’s breast on the application of hybrid, the two away from each other breast, the doctor, his hands behind breast clamps, and repeats the process again.
6. breast on a process to be performed. Usually breast thorax should be symmetric vibrations of sound in the same areas.
Sound vibrations lungs pressed tissue increases, pleural gas, liquid gathered lungs tissue declines in thickness.
Good luck Biff acoustical
Objective: Good luck to pummel his field, the power to determine the size of the resistance.
1. The doctor on the palm of his right hand on the patient’s chest should feel my luck Turkish.
2. At the same time, he spat on 4-5 ribs bone, fingers armpit EU average armpit ground should be line.
3. The base is determined by the luck to pummel the three finger loose ends outside the field pushes luck to directed end.
4. There is no limit, area, height, strong resistance is evaluated.
5. Good luck Biff adults 5 range of ribs Lmedoclavicularis 1-1.5 cm inside, the age of children is worthy of all places.
Profit acoustical
This is a method to estimate abdominal cavity physical.
2 allocate the same palpation:
a) Surface or relative.
b) deep palpation.
Abdominal surface acoustical
Objective: Local defense, hurt, subcutaneous derivatives applies in order to compare the field and symmetric.
1. The patient lies in the back, waist and clothing feet, handsknee broken hand is pulled across the body.
2. doctor to bend the fingers of his right hand half of the patient’s stomach, deep left field and caution in print, without the patient diverted fingers clockwise direction, if you hurt the industry says, her hand palpation .
3. After the doctor left hand VLAN up, will continue palpation.
4. The area under the left rib palpable.
5. palpable epigastric.
6. Right palpable rib underground.
7. Abdominal right flanks palpation.
8. Right lower quadrant palpable.
9. The middle part of the abdomen and the lower middle part of the abdomen (bladder) end of palpation.
10. The opposition of the abdominal wall, is hurt. Generally, it should be soft pains.
Abdominal deep acoustical
This palpation method V.P.Obraztsov conducted.
1. acoustical depth of the sigmoid colon. The four fingers parallel to the sigmoid should be waged.
2. The skin pinch with your fingers to breathe, and breathing out with your fingers on the back wall of the abdomen (line spine drug) to push progressive manner.
Carrying out his hand from the inside out and from top to bottom must be pushed.
1. S-shaped colon, to its surface, mobility, joint pains, blood system determined (usually located in the area of the left side of softness).
2. After palpable to see the resumption of the right-hand side of the intestine. Deep breathing and the back of a hand, the other hand, the right iliac fossa deep palpation to see the rectum assessment. According to the generally intestine 3-4 cm soft, sometimes a little realized the presence of the gas, the less active.
3. To the left of the small intestine after the right-hand side, from the bottom up palpation.
4. The rise coverage intestine began 2-3 cm above the umbilicus, slowly carried down the (right to left). Typically, men with groin of 1 cm, 1-3 cm below the females.
5. Rise up colon (left) and fly (left) has been implemented by parts V.X.Vasilenko Bimanual method palpation .
liver acoustical
The surface of the liver using acoustical boundary edge, texture, and joint pains.
1. The patient lies in the back, waist and peeled, hands across the body of a knee buckling hands reciprocal.
2. The lower limit of the percussion liver.
3. The sole of the left-hand flank lower playback (XI-XII under rib), rib spread of thumb and will not be published.
4. The right hand side of the plate correctly in the abdominal muscle wall of the abdomen exposed, the finger past the bottom border of the liver will be exposed.
5. breath brings you pinch the skin to the doctor (after the fingers of the hand), the patient is prescribed to take a deep breath.
6. breathing down the lower edge of the liver, stems from the fact that the fingers.
7. If unavailable in the lower border of the liver (palpation can not be verified), 1-2 cm more important to exude a finger over and over again, so that, to the lower edge of the liver palpation has taken the process is repeated.
8. Generally, the lower edge of the liver is soft, round, flat, almost intuitive.
Kidney acoustical
Usually the big kids, adults people kidney acoustical seen. Small children, infants, gidronefros polikictos tumordisease, nefroptos kidney acoustical can be seen.
For size, surface, texture, weight.
1. The patient is lying in a horizontal position, to be free hands to keep the abdomen and legs, blowing the chest hands. Frachning left hand plates, the patient’s right back on the field, across the spine XII rib throughout toes exposed.
2. The doctor left hand is rolled over the right edge of the rectus abdominal abdomen. These grants allowed only in semi-bent fingers on the corner of the arc rib.
3. When it comes to one of the two hands, the patient is prescribed to take a deep breath.
4. At the same time the lower part of kidney’s down, gaining apparent.
5. Breathe of general right hand fingers into the deep abdominal cavity on the left hand side.
6. If you suspect kidney its shape, size, surface and changes evaluated.
divorced acoustical
The body of the meeting:
1. The patient’s right side and placed the head bends forward looking chest lies in the chest with his left hand, bent at the elbow in a breast free. abdominal Press release . Frachning left hand on the left breast area of the chest between the VII and XII rib auxiliary requested to start (to limit movement).
2. The doctor fingers of his right hand slightly bent, abdominal surface of the iliac branch, on the corner of the arc rib called.
3. The patient, a doctor with the right hand wall of the abdomen, in your pocket.
4. After the doctor, the patient will pay to take a deep breath.
5. breathing spleen palpation, the fingers of the right hand molding (apparent).
Typically, spleen palpation, the invisible.
Lymph nodes acoustical
These lymph nodes size, texture, mobility weight.
1. Which group of lymph nodes palpation should be done in this area, the muscles loose. Lymph nodes acoustical with both hands at the same time, the indicator and is performed with the middle finger felt.
2. palpation of lymph nodes evaluated as follows:
– The amount (number);
– Size (size);
– Consistence;
– Mobility;
– The sensitive relationship with the surrounding tissues (weight).
3. Palpation in order to be performed in the following order:
Jag` underground;
– The mental underground;
– Nationwide;
Collar surface and underground;
– Neck;
Armpit underground;
– FG;
– Thoracic;
– Groin;
– Underneath the laptop.
Joints acoustical
Palpation link traumatic arthropathy configurations, the noise level liquid.Mode:
1. acoustical hurt, swelling, fever, local joint liquid, crepitus.
2. Active and passive joint’s try to limit the movement in the level of activity will be evaluated.
3. Active and passive doctor intolerably taken on joint, its crepitus (rattling) can be detected.
4. Bo`g`imdagi pernartikulyar Ge.
Members studied percussion internal organs, physical method, which is based on the body surface to see the tale.
Objective: To limit or be members, resized, depending on the type of PCI sound card members about the changes in their symmetrical Vikram PCI compared with one voice.
Guide: respiratory tract, heart and blood vessels, liver, spleen limit their configuration, size, and their pathological changes, abdominal cavity fluid (ascites).
Conditions: warm, quiet room, the hiring of foreigners, the patient should be off the waist.
Lung’s comparative percussion
Objective: lung’s symmetric PCI compared with one voice in the field.
1. The top and bottom of the left and right hand collar areas held by both left and right in the field of percussion and voices are compared with one another. Usually lungs PCI sound. pathology:
Inbox lungs emphysema, bronchial asthma.
– Rupture of the tympanic lungs abscess and pus discharging bronx lit sector.
Muffled pneumonia, bleeding.
2. And just behind the top of the breast and shoulder in the field of underwater sounds on the right and on the left side of the symmetric fields, compared with one another.
Lung’s topographic percussion
Topographic percussion lung’s exude and lower lungs tour, the area of the crane.
To determine the lower limit of the lung’s
Lung’s border lines across the bottom of the left and right hand.
Plessimetr finger between the ribs from ribs allowed only in parallel and 1-qovurg`a between done down across lines.
1. L. medioclavicularis (secondary line) is determined by the lower limit of the Nationwide lung’s
2. And just before the finger plessimetr armpit underground line (L. Axillaries’ ant) will be exposed, and across the line, is determined by the lower limit of the left and right hand lung’s (standard on the right and on the left side rib 7).
3. Right and left rear armpit underground line is determined by the lower limit of the Nationwide lung’s (normal 8-qovurg`a both sides).
4. The right and left hand across the back armpit underground line is determined by the lower limit of the lung’s (9 ribs norm).
5. The right and left side of the front line is determined by the lower limit of the Nationwide lung’s (standard on both the 10-qovurg`a).
6. spine line is determined by the lower limit of the Nationwide lung’s (normal 11-cutters vertebrae).
To determine the excursion of the lungs
1. Previous armpit underground or across the Middle armpit underground line is determined by the lower limit of the patient’s quiet mode lung’s and marked with a special pen.
2. The prescribed keep the patient takes a deep breath and breathing, as well as across the line above the lower limit of the lung’s identified, marked with a pen.
3. After full breath of the patient, with a pen and repeat the above process.
Typical (normal) up and down to the lower limit of the lung’s 3-4 cm, 6-8 cm (tour) drift. Reduction in the excursion lungs emphysema, bronchial asthma, lungs, pneumonia, pleurisy patients.
To determine the area of the crane
1. Finger plessimetr the left and right side trapetion be allowed only in the front middle part of the muscle.
2. After the finger here (trapetion muscles medium) inside the lungs sound clear a hollow with pen and percussion sounds.
3. Spread out between the same parties percussion, with a pencil. Both sectors the range distance measurement on this – then called. Normally, the area of 5-6 cm. Lungs expand emphysema lungs of silica is reduced.
Relative to define the boundaries of the heart
A relative of the heart limit its real limit (size).
1. Initially, the upper limit of the diaphragm. line on the right-hand side a hollow sounds percussion throughout the Middle East, the 1-qovurg`aga up chocks, 4-qovurg`a equivalent the range.
2. The point support rib finger perpendicularly, parallel to the skull of curtailing my percussion lungs will continue until the sound sounds a hollow PCI sound, which appeared on the earth (and curtailing norm of 1 cm on the right-hand side of the skull). Chronic bronchial diseases of the lungs, kidney artery stenosis of the left hole atrioventrikulyar eksudat prevrit enlarged heart right direction.
3. In the left middle armpit underground line 5-qovurg`a curtailing the range bone on the left side of the percussion, and the left border (normal secondary 1.5 cm inside the line to the left). Mitral valve insufficiency, aortic stenosis hole, eksudat enlarged left side of the heart pericardium.
4. In the left parasternal line to go down to the Nationwide percussion (1 rib the ranges) and a hollow sound, which appears at the upper limit. 3 of the normal adult L.parasternalis sinistra from ribs (between 2 rib). Atrioventrikulyar hole on the left of the stenosis, eksudat enlarged heart pericardium up.
5. The rise of the heart to determine the cross section of the left and right sides of the border together. Norman 11-13 cm. aortic hole configuration aortic stenosis, mitral configuration of the mitral valve insufficiency.
6. Heart (belly) underground armpit fossa for curtailing the upper limit to the bone to the skull of curtailing the bottom line and armpit held a hollow percussion sounds (heart).
7. In the heart of an extensive 2-qovurg`a for curtailing the range bones on the right and left by the percussion equivalent collar secondary line to the left. Norman 5-6 cm. enlarged aortic aneurysm, kidney artery aneurysms, and atherosclerosis.
To determine the absolute limits of the heart
Equivalent to the absolute limit covered by the lungs with the heart of the heart.
1. found on the right-hand limit of the relative of the heart, and also the method of percussion to complete a hollow will continue to hear the sound.
2. inside the left border of the relative slow heart beat percussion method to absolute continue a hollow sounds.
3. In the upper limit of the relative found further down the road, to complete a hollow will continue to sound percussion .
4. In a normal heart (right, left, top) absolute 1 cm beyond the boundaries of the relative inside.
Cure of liver percussion
On the method of curing liver percussion liver size of 3 is set to be held.
1. The right down the middle line percussion, sound a hollow percutaneously. The liver is considered the upper limit of 1.
2. After looking up the same across the line abdominal bo`g`iq percussion sounds. This is the lower limit of the first two (upper and lower), points (9 + 2 cm norm).
3. Prior to the first point above the middle line perpendicular towards the holding, the size of the liver is the point of intersection of two lines 2 (limit) is the first point.
4. And just across the line and belly up towards the percussion sounds to bo`g`iq, this is the second of the border 2 points (2-border points 1 and 2). Normally, the line 8 + 2 cm.
5. Rib across the arc of the left hand, from the outside inward, a hollow percutaneous percussion sounds. It determines the earth, and her 2-connecting point of the upper sides of the border. Normally, lines 7 + 2 cm. border of the liver, hepatitis, liver exinokok, anemia, enlarged collagenosis. Shrinking liver cirrhosis.
These methods are physical methods of investigation; the body is formed based on the sound.
Objective: The main and additional noise and interference, heart tones, noise, hear the rhythm of the heart pathological means to identify and assess.
Guide: To check the respiratory and cardiovascular system.
Conditions: warm quiet room, fenondoskop stethoscope.
lungs auscultation
1. Fenondoscop’s the ureter into the tip of the ear. Stethoscope or fenondoskop heated and then allowed only to hear the sphere.
2. The end of the hearing lung’s (of the area). Lung’s symmetrical right and left of the area which is considered one of the most frequently heard.
3. Before left hand, between rib 4 heard.
4. Armpit gaining ground listening the back of the head.
5. listening to the breast surface, underground and the range on the right-hand and left-hand one of those viewed heard the case without bowing down before head to the patient hands folded on the front the chest are looked on.
6. The act of breathing of the patient’s 2-3 (breathing) will be heard and the public. Norman lungs vesicular breathing sounds.
– Vesicular breathing weakened physiological breast chest thicken, fat people who (giperstenics).
– Increased physiological vesicular breathing people thin (astenic). Eroded.
– Lungs emphysema, bronchial asthma, clamor ligament narrow, narrow trachea between major bronchi tumor, the foreign objects.
– Strengthening vesicular breathing pathological bronchospasm.
– Increased bronchial pneumonia respiratory Croupous 2-stage.
Amphora respiration – lungs abscess burst misplacement (abscess pus discharging area).
– Metallic breath – pnevmotoraks.
– Stenotic respiratory trachea, a major narrowing of the bronchial tubes.
– Dry wet – acute, chronic bronchitis, pneumonia, bronchial asthma lungs emphysema.
– Wet wet lungs tissue inflammation bronchitis.
Krepitation – pneumonia, tuberculosis, infarction.
– Pleural friction noise – Dry bleeding.
1. First, find the luck to palpation method oversight.
2. Good luck Biff mitral valve (normal, where I tone) sounds, dystonia (mitral valve insufficiency) and diastolic (mitral stenosis), noise is heard. I tone can be characterized as follows:
I Clapsly ton mitral stenosis.
– I was weak tone of mitral valve insufficiency.
Rhythm (the rhythm of quail) – I tone ventricular expansion myocardial failure of the separation of the hypertrophied myocardium, myocardial infarction, kardiomiopatia decompensated porok.
3. After the right hand 2-qovurg`a hear a projection of bone curtailing between edge of the aorta. At the same time, the second tone. Systolic (aortic stenosis), provocative diastolic function (aortic valve insufficiency) II tone accent (hypertension) is heard.
4. curtailing the bones on the left side II between rib lungs artery projection (2 points) will be heard. Here, the second tone, diastolic noise is heard. II ton divided ears 3-part rhythm (singing quail) – mitral stenosis holes played.
5. curtailing bone 3 triple valve (4 points), and the systolic function (3 triple valve insufficiency) and diastolic (narrowing of the hole in the right atrioventrikuluar stenosis).
6. Botkin Airbus points (5 points)
Curtailing bones on the left side of the 3-qovurg`a between projection of 3 aortic valve. II tone, noise and diastolic aortic insufficiency. A / B – Various changes of the pulse is also different.
Control questions
1. The purpose of the Nursing physical examination?
2. Nursing patients questioning how is it done?
3. The need to pay attention to what to collect from the patient’s history?
4. What images do you know?
5. skin changes indicative of how kasallshiklardan?
6. palpation procedures and their significance?
7. The rule of percussion and its significance?
8. auscultation procedure and rules, and their significance?