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40 Enteral (tube) nutrition

If oral feeding is not possible, nutrient solutions can be administered through a tube into the stomach or small intestine (as appropriate) to allow nutrients to undergo natural transformations [I]. The intake of food into the intestinal lumen, in addition to cavity and parietal digestion and absorption of nutrients, provides several advantages. One of them is the trophic effect of tube enteral nutrition on the mucous membrane - the barrier separating intestinal microorganisms from the bloodstream. This circumstance attracts much attention, since the intestine is currently regarded as the entry point for infection that causes sepsis in patients in critical conditions. This chapter begins with an introduction to trophism and below provides practical recommendations for administering enteral nutrition.

TROPHYS AND SEPSIS

One of the most convincing arguments in support of enteral nutrition (versus parenteral nutrition) is that complete rest of the intestine causes atrophy of the intestinal mucosa. Degenerative changes in the intestinal wall occur after just a few days of rest, and they progress despite total parenteral nutrition (intravenously). The effect of enteral nutrition on the structure of the intestinal mucosa is shown in Fig. 40-1 (data obtained in an experiment on animals fed protein-depleted food). The top micrograph shows normal small intestinal mucosa with multiple finger-like projections. These outgrowths are called microvilli. They increase the internal surface of the intestine (with folds, villi and crypts by almost 500 times), which is involved in the absorption of nutrients. The lower micrograph shows changes in the mucous membrane that occurred after 1 week in an animal that received food with a decrease in protein content and insufficient energy value. Degenerative changes range from shortening and atrophy of microvilli to complete destruction of the surface of the intestinal mucosa, which is undesirable under any circumstances.

It is believed that degenerative changes in the mucous membrane in this case are due to the lack of nutrients in the intestinal contents that are normally captured by epithelial cells and used for energy. In this process, proteins to amino acids can play a special role; Moreover, glutamine has been identified as the main “fuel” for the epithelium of the small intestine. Enteral nutrition can also stimulate the release of trophic substances (for example, immunoglobulin A, bile, etc.) and thereby indirectly promote mucosal regeneration.

Destruction of the mucous membrane resulting from the lack of enteral nutrition will lead to impaired absorption of nutrients when it is resumed. This may explain the phenomenon of overeating diarrhea observed after long periods of bowel rest. In this regard, the need to continue enteral nutrition in a volume sufficient to prevent overeating syndrome is obvious.

TRANSLOCATION

The intestinal mucosa also serves as a protective barrier, isolating pathogenic microorganisms located in its cavity from the circulating blood. If this barrier is destroyed, as, for example, shown in Fig. 40-1 (lower microphotograph), then pathogenic microorganisms can invade the mucous membrane, gaining access to the vessels. This process is called translocation. Translocation may be the most important cause of latent sepsis in seriously ill patients, and is regarded as the first step towards multiple organ failure syndrome. This syndrome has a high mortality rate and, according to some researchers, is the main cause of death in patients in critical condition.

The role of enterally administered nutrients in maintaining mucosal barrier function and preventing translocation is currently unknown. However, the existence of this non-nutritive function calls attention to tube feeding as part of the body's antibacterial defense system to help prevent sepsis in critically ill patients. Observations in this area can be summarized as follows:

enteral nutrition is capable of providing the absorption function of the small intestinal mucosa and participating in the maintenance of a protective barrier separating intestinal pathogenic microorganisms from the systemic circulation. Such non-nutritional effects may be as important as the trophic function of enteral nutrition.

TUBE FEEDING GUIDE

INDICATIONS

In the absence of contraindications, total enteral nutrition is recommended in the following situations:

1. Exhausted patients who have not eaten adequately (orally) for the last 5 days.

2. Well-nourished people who fasted for 7 to 10 days.

3. Patients with extensive burns.

4. After subtotal (up to 90%) resection of the small intestine.

5. For external small intestinal fistulas with a small amount of discharge (less than 500 ml/day).

After resection of the small intestine, tube feeding helps in the regeneration of the remaining part of the mucous membrane. Although there is currently no clear specific effect of enteral nutrition in burns, there is reason to believe that it can prevent the occurrence of sepsis and the loss of large amounts of protein from the intestines in burn patients [I].

CONTRAINDICATIONS

Artificial enteral nutrition (in any quantity) through a tube is contraindicated in the following cases:

1. Clinically pronounced shock.
2. Intestinal ischemia.
3. Intestinal obstruction.
4. Refusal of such food by the patient or his guardian, consistent with hospital policy and existing laws.

The following conditions represent relative contraindications to full enteral nutrition, but do not exclude it in a small volume (partial nutrition):

1. Partial intestinal obstruction.

2. Severe intractable diarrhea.

3. External small intestinal fistulas with a discharge volume of more than 500 ml/day.

4. Severe pancreatitis or pancreatic pseudocyst.

In these situations, some patients can be prescribed small-volume enteral nutrition. Its purpose is not to cover energy costs, but to maintain the integrity of the intestinal mucosa.

ENTERAL NUTRITION THROUGH A NAZOENTERAL TUBE (NASOENTERAL TUBE NUTRITION)

Nutrients are usually administered through special tubes passed through the nose into the stomach or duodenum. Initially, the probes were thick (14-16 Charrier units) solid tubes placed in the stomach. Modern probes are much narrower (8 Charrier units), they are more flexible and have a greater length, allowing flashing of the small intestine. Modern tubes are more convenient for patients and reduce the risk of reflux and aspiration pneumonia. The main disadvantage of thin probes is the possibility of asymptomatic tracheal intubation and pneumothorax.

INTRODUCTION OF THE PROBE

To calculate the length of the probe reaching the stomach when inserted through the nose, you need to add up the distances from the tip of the nose to the auricle and from the ear to the xiphoid process. To insert a thin flexible probe, a rigid guide is required to facilitate its passage through the larynx and upper respiratory tract. The narrow tubes easily pass around the inflated cuffs of the endotracheal tubes. Patients who require enteral nutrition are often mentally unstable, so if a probe accidentally gets into the trachea, cough and other signs of intubation may not occur. As a result, the probe can be inserted deep into the lung and (if it is perforated) into the pleural cavity.

CONTROL OF THE PROBE POSITION

The case of the probe getting into the lung is shown in Fig. 40-2 (chest x-ray). The radiopaque end of the thin probe is visible in the right lung. An x-ray examination was performed after a feeding tube was inserted into the patient. In patients in intensive care units, obvious symptoms indicating that the probe has fallen into the trachea are often absent. This emphasizes the need to carry out an appropriate test to monitor the correct position of the tube after each insertion and before starting feeding.

Chest X-ray. Standard practice is to obtain a chest x-ray after each tube insertion. Although this can confirm the intrathoracic position of the probe (see Fig. 40-2), there are exceptions to the rule. For example, a probe visible below the shadow of the dome of the diaphragm may still be in the chest cavity as the posterior costophrenic sinus descends to the level of the body L IY. To accurately determine the location of the probe, it is necessary to have a lateral X-ray, but it is quite difficult to take such X-rays with a patient lying in bed.

Auscultation. A common method for determining the position of the tube is to auscultate the left upper quadrant of the abdomen while introducing air through the tube. A gurgling sound in the hypochondrium confirms the location of the probe in the stomach. However, in this case, errors are possible, since sounds emanating from a probe located in the lower chest can be transmitted to the upper outer quadrant of the abdomen. Currently, auscultation is not considered a reliable way to confirm the correct position of the probe.

Determination of pH of gastric contents. Aspiration of gastric contents can help only if it is acidic. Obtaining secretions with a pH below 3.0 can confirm the placement of the tube in the stomach. However, when using a thin probe, aspiration is often impossible because it collapses under the influence of negative pressure. This circumstance limits the value of the aspiration test.

Conclusion. After each insertion of the probe, it is necessary to monitor its position in one way or another. If fluid with a pH below 3.0 can be aspirated, this can confirm the placement of the tube in the stomach. In other cases, after each insertion of a probe, a chest x-ray must be performed. A direct view is usually sufficient because the possibility of inserting a probe into the posterior costophrenic sinus (as determined by lateral x-rays) is small.

PROBE LOCATION

Nutrient solutions can be administered through a tube directly into the stomach or duodenum, which depends on the decision of the doctor, since there is no convincing evidence of the advantage of one or another position of the tube,

Gastric feeding. Intragastric fluid administration has advantages associated with the reservoir function of the stomach and the diluting effect of its juice. Gastric juice mixed with the nutrient solution can reduce its concentration and therefore reduce the risk of diarrhea. In addition, the buffer tanks of the nutrient solutions are designed in such a way as to prevent stress ulcers and bleeding from the stomach (see Chapter 5). Finally, distension of the stomach with the introduction of a nutrient solution will stimulate the release of trophic substances, such as immunoglobulin A and bile, which help maintain the integrity of the mucous membrane of the stomach and intestines.

The main disadvantage of gastric feeding is the possibility of regurgitation and aspiration of fluid into the lungs. This complication is reported to occur in 1-38% of patients, although its true incidence is difficult to determine. This complication varies significantly in different patient populations: it is greatest in paralyzed patients, as well as in comatose patients.

Duodenal feeding. The supposed benefit of duodenal tube placement is a reduced risk of reflux and aspiration pneumonia. However, there is currently no data to support this view. The negative properties of duodenal feeding include the difficulty of passing the probe through the pylorus and the increased likelihood of diarrhea. If a decision is made about duodenal feeding, then the following techniques can help to pass the probe through the pylorus.

1. Insert the probe at a distance of at least 85 cm from the tip of the nose (in this case it will wrap itself in the stomach), and then wait 24 hours. In 2/3 of cases, during this time the probe itself penetrates the duodenum.
2. If the probe does not spontaneously pass into the duodenum within 24 hours, the patient should be placed on the right side for several hours and then the position of the probe should be checked using x-ray examination.
3. In patients with gastric atony (in particular, with) migration of the probe through the pylorus can be stimulated by metoclopramide (at a dose of 10 mg 15 minutes before insertion of the probe).
4. If all of the above measures fail, fluorography is necessary.

Recommendations. I prefer gastric feeding due to its stated benefits, especially the trophic effect. Additionally, there is no convincing evidence that duodenal feeding reduces the risk of aspiration pneumonia. To detect possible aspiration, we often add food coloring to nutritional solutions and monitor the color of upper respiratory tract secretions.

STARTING TUBE FEEDING

The first task is to make sure that tube feeding is safe at the selected volume and frequency. The second task is to choose the initial feeding regimen and the method of continuing feeding.

GASTRIC CONTENTS RETENTION

In order to ensure the safety of gastric feeding, it is always necessary to do a trial administration of liquid before starting it. Water or isotonic sodium chloride solution in an amount equivalent to an hour's volume of food is administered through the tube over 1 hour. Then the tube is closed for 30 minutes, after which the liquid remaining in the stomach is aspirated. If the amount of liquid is less than half of that introduced, then the feeding regimen is considered appropriate. However, if there is a significant residual volume, it is more advisable to start with small portions. When performing this test, you should never inject all the liquid at once, since this can cause a sharp distension of the stomach with retention of its contents and the formation of a much larger residual volume than with slow administration.

FEEDING METHOD

The generally accepted method is a continuous infusion - for 16 hours every day. Intermittent infusions mimic the natural process of eating to a greater extent, but the volumes required to meet daily requirements are large. As a result, the risk of aspiration and diarrhea increases. Patients can more easily tolerate long-term infusions, which allow them to achieve greater weight gain and positive nitrogen balance.

INITIAL FEEDING REGIME

The traditional approach to tube feeding includes a starter regimen, which consists of first injecting a nutrient solution at a low rate, and then gradually increasing the volume and rate of administration in order to reach the established amount within a few days. The rationale is that the mucous membrane of the digestive tract is given time to regenerate. The main disadvantage of the starter regimen is that it takes time to achieve full nutrition, which is often not available when the patient is initially exhausted.

The value of the starter regimen as a routine practice for all patients was assessed in two clinical studies. One of them was carried out with the participation of healthy people, and the other - patients with inflammatory bowel diseases. Both studies showed that total nasogastric tube feeding can be started immediately (without starter mode) without causing any adverse effects.

Recommendations. The starter mode for gastric feeding may not be necessary, since gastric juice dilutes the nutrient solution and increases tolerance to it. In this regard, the starter regimen is reserved for patients with significant residual gastric volume, a long period of intestinal rest, and a depressed mental state. If the starter regimen is prescribed for gastric feeding, then you can switch to full nutrition after 24 hours. With duodenal feeding, the starter regimen is necessary in all cases.

GASTROSTOMY

Gastrostomy- surgical creation of an external gastric fistula for the purpose of chronic enteral feeding of the patient (especially those patients who periodically remove nasoenteric tubes). It was previously believed that feeding through a gastrostomy tube reduced the risk of aspiration compared with nasogastric feeding, but this is not true. Gastrostomies can be created either traditionally (surgical placement) or using an endoscope. Both methods have their positive and negative sides, including complications. The choice of one method or another usually depends on the experience of each hospital.

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

The percutaneous method was introduced in 1979 as a less expensive alternative to traditional gastrostomy. In Fig. 40-3 demonstrates the currently developed PEG technique using a Foley catheter. Through an endoscope inserted into the stomach, the stomach is inflated in such a way as to bring its anterior wall to the anterior abdominal wall. The beam of light coming from the endoscope is visible on the skin. It indicates the point where the stomach is closest to the anterior abdominal wall. A sheathed guide catheter (9 Charrier units in diameter) is inserted through the skin using the Seldinger technique (see Chapter 4). A Foley catheter is then placed through the sheath into the stomach. Its balloon is inflated, the catheter is pulled back until the balloon is tightly pressed against the wall of the stomach, and then in this position it is sutured to the anterior abdominal wall.

PEG is reported to be quite safe when performed by experienced personnel. The rate of complications known to us varies from 2 to 75%. The most serious complication is leakage of intestinal contents into the abdominal cavity, which can lead to the death of the patient. Due to the potential for complications, gastrostomy should be performed either when there is esophageal obstruction or when long-term enteral nutrition is required.

JUNOSTOMIA

The advantage of jejunostomy is due to the fact that peristalsis of the small intestine is restored immediately after abdominal surgery. The jejunum can be used for immediate feeding after surgery on the esophagus, stomach, bile ducts, liver, spleen and pancreas. The risk of aspiration when feeding through a jejunostomy is very small (although no studies have been done in this area). Main contraindications: enteritis (local and radiation), intestinal obstruction distal to the feeding tube.

Rice. 40-3. Percutaneous endoscopic gastrostomy using a sheathed guide catheter and a Foley catheter.

JUNOSTOMY WITH NEEDLE AND CATHETER

Jejunostomy is performed as an additional procedure at the end of laparotomy. It takes no more than 5-10 minutes. In Fig. Figure 40-4 shows the passage of a jejunostomy catheter. After immobilization, the jejunal loop approaches the anterior abdominal wall. A 14-gauge needle is used to create a tunnel in the jejunal mucosa. After this, a jejunostomy catheter No. 16 is passed through the tunnel to the intestinal lumen and into it at a distance of 30-40 cm. The catheter is brought to the surface of the skin and sutured to it, and its intraperitoneal part is covered from the side of the parietal peritoneum.

Feeding method. The small intestine does not have the reservoir capacity inherent in the stomach. If you do not use the starter regimen, diarrhea will occur. Isotonic nutritional mixture usually diluted to 1/4 of the original concentration and initially administered at a rate of 25 ml/h. The infusion rate is increased by 25 ml/hour every 12 hours until the desired rate is achieved. From this point on, the concentration of the nutrient solution is gradually increased over the next few days. Full enteral nutrition can be achieved using this method after 4 days. Feeding is carried out every 6 hours.

Rice. 40-4.

Complications. The possibility of developing severe complications is high. Only one report indicates a postoperative mortality rate of 8%! The most common causes are diarrhea and occlusion of feeding tubes. Currently, jejunostomy is recommended to be used only as a temporary measure.

PREPARATION OF AN ENTERAL DIET

The number of drugs (nutrient mixtures) for enteral nutrition increases every year. The following considerations will help in choosing a drug for a particular patient.

ENERGY VALUE OF THE PREPARATION

The energy value of each drug is determined primarily by the carbohydrate content. Some examples of drugs with different energy densities (per 1 ml of nutritional mixture):

1.1.0 kcal/ml (Osmolite, Isocal and Ensure preparations);

2.1.5 kcal/ml (Ensure Plus);

3.2.0 kcal/ml (preparations Isocal HCN and Osmolite HN).

Nutritional mixtures with a caloric content of 1 kcal/ml are isotonic to plasma and are intended primarily for administration into the small intestine. Drugs with higher energy density are preferable when fluid volume must be limited. They should be administered primarily into the stomach. The secretions of the latter will dilute nutrient solutions and reduce the risk of diarrhea.

OSMOLALITY

The osmolality of nutrient mixtures varies from 300 to 1100 mOsm/kg H 2 O and is determined by their energy density. Although there is no clear connection between the osmolality of formulas and the occurrence of diarrhea, it is advisable to limit the osmolality of nutritional solutions in patients with diarrhea, either by administering drugs into the stomach or by using isotonic formulas.

The typical American diet recommends that protein account for about 10% of energy expenditure. Most enteral feeding formulas provide protein at 20% of total calories. Compositions with a high protein content (the share of protein energy value is 22-24%) are used in victims with injuries and burns. However, there is no convincing evidence that protein-fortified formulas improve outcome.

1. Protein provides less than 20% of total calories (most drugs).

2. Protein provides more than 20% of the total calories (Sustacal, Traumacal).

PROTEIN COMPOSITION

As is known, intact protein is not absorbed, and its breakdown by proteolytic enzymes occurs, of course, much more slowly than the breakdown of already partially hydrolyzed protein. Preparations containing protein hydrolysates are preferably prescribed for disorders of breakdown and absorption (malabsorption) and diseases associated with the rapid passage of food (for example, short bowel syndrome). There is an opinion that nutritional mixtures with peptides can have an antidiarrheal effect during tube feeding, but this requires confirmation.

1. Intact protein contains drugs Isocal, Osmolite, Ensure.

2. Hydrolyzed protein is contained in Vital and Reabolan preparations.

FAT COMPOSITION

Fats are either long-chain triacylglycerols (TCTs) or medium-chain triacylglycerols (MCTs). TSCs are more easily absorbed than TDCs and are preferred for patients with malabsorption. Most enteral nutrition products contain TDC, but some contain both types of triacylglycerols (eg, Isocal and Osmolite).

PLANT FIBERS

Plant fibers contain many polysaccharides that are resistant to metabolism through normal pathways. There are two types of fibers.

1. Fermentable fibers (cellulose and pectin) are metabolized by intestinal bacteria to form short-chain fatty acids (acetic, propionic and butyric acids). These acids can be used as an energy source for the colon mucosa. This type of fiber delays gastric emptying and may be useful in treating diarrhea.

2. Non-fermentable fibers (lignins) are not broken down by intestinal bacteria and, by changing osmotic pressure, attract fluid into the intestinal lumen. Non-fermentable fibers increase the volume of stool and speed up its movement through the intestines, acting like laxatives (help in the treatment of constipation).

There are currently two commercial enteral nutrition formulas containing plant fibers, each containing equal amounts of both types of fiber:

1. Enrich - 12.5 g fiber per 1 liter.

2. Jevity - 13.5 g fiber per 1 liter.

Preparations containing plant fibers are recommended for chronic tube feeding (although their beneficial effect on diarrhea is variable). Mixtures with plant fibers are contraindicated in patients with liver failure, since fermentable fibers promote the proliferation of bacteria in the colon. Fiber can be added to formulas as Metamucil (contains non-fermentable fiber) or Kaopectate (contains fermentable fiber).

CLASSIFICATION

Liquid nutritional mixtures for enteral nutrition are classified according to the composition of nutrients or ease of absorption. The main characteristics of enteral nutrition formulas are listed below.

Mixed formulas are liquid forms of regular food. In adults who are lactose intolerant, they cause diarrhea.

Indications: They are usually prescribed to elderly patients with a healthy gastrointestinal tract who are unable to feed themselves.

Example: Compleat B (calorie content of the drug is 1 kcal/ml).

Lactose-free formulations: standard preparations used for hospital nutrition. Adults tolerate them more easily than mixed formulas.

Indications: patients with a healthy gastrointestinal tract who are lactose intolerant.

Examples: Isocal, Ensure, Sustacal and Osmolite (energy density of drugs 1 kcal/ml); Sustacal NS and Ensure Plus (calorie content 1.5 kcal/ml); Magnacal and Isocal HCN (calorie content 2 kcal/ml).

Chemically formulated mixtures contain hydrolyzed protein instead of intact protein to aid digestion.

Indications: impaired ability to break down proteins and absorb nutrients.

Examples: Criticare HN, Vital HN, Citrotein, Isotein, Travasorb HN and Precision HN.

Elemental compounds contain crystalline amino acids. Most nutrients are easily absorbed: complete absorption occurs in the initial part of the small intestine.

Indications: limited ability to absorb nutrients. Usually prescribed for feeding through a jejunostomy.

Examples: Vivonex and Vivonex T.E.N (drug energy density 1 kcal/ml).

SPECIAL MIXTURES

The diseases and pathological conditions listed below prompted the creation of mixtures of special composition that meet the needs of patients in a given situation.

Hepatic encephalopathy. The drugs used for this disease are rich in branched-chain amino acids (BABC), in particular valine, leucine, etc. Hepatic encephalopathy occurs as a result of the accumulation of aromatic amino acids in the brain (for example, phenylalanine, etc.). ARBCs inhibit the penetration of aromatic amino acids through the blood-brain barrier. Examples: Hepaticaid and Travenol Hepatic.

Trauma/stress. Formulas used for trauma and stress are also rich in ARBC (50% of total amino acids compared to 25-30% in conventional formulas). Their use is justified by the fact that a number of stress hormones promote the hydrolysis of proteins in skeletal muscles, and the introduction of exogenous ARBC prevents the breakdown of proteins for energy. The energy density of the drugs is about 1 kcal/ml; they are very hyperosmolal (up to 900 mOsm/kg H 2 O).

Example: Trauma-Aid HBS.

Kidney failure. Mixtures used for renal failure are rich in essential (essential) amino acids and do not contain additional electrolytes. The destruction of essential amino acids will limit the increase in blood urea nitrogen, as nitrogen will be reincorporated into the non-essential amino acid synthesis cycles.

Examples: Travasorb Renal and Amino Aid.

Respiratory failure. The preparations contain a small amount of carbohydrates and are enriched with fats. They are used to limit CO 2 production in patients with severe pulmonary pathology. Mixtures must provide at least 50% of the total energy value from fat. The main disadvantage of the diet is fat malabsorption and steatorrhea.

Example: Pulmocare.

COMPLICATIONS

Common complications of tube feeding are diarrhea and reflux of gastric contents into the upper respiratory tract. Diarrhea is discussed in detail in Chapter 6. A summary of the data is presented here.

Diarrhea occurs in 10-20% of patients receiving tube enteral nutrition. It is caused partly by osmotic forces, and partly by nutrient malabsorption.

The stool does not contain blood. There are also no signs of sepsis. If you are in doubt about the diagnosis, the following activities and recommendations may help:

1. It is necessary to avoid the use of drugs that inhibit intestinal motility. Most likely, they will not help, but, on the contrary, may contribute to the development of intestinal obstruction.
2. It is necessary to use isotonic nutrient solutions that should be administered into the stomach. It is necessary to exclude any hypertensive drugs added to nutritional mixtures.
3. Do not administer antacids containing magnesium sulfate, as well as other drugs that cause diarrhea (for example, theophylline).
4. Consider using fermentable fibers such as pectin. Fibers of this type delay gastric emptying and help it more effectively reduce the osmotic concentration of nutrient solutions. Pectin can be added to nutrient solutions in the form of either Kaopectate (30 ml 2 or 3 times a day) or unprocessed apple juice (100 ml per daily food ration).
5. For enteric feeding, reduce the rate of administration by 50% and slowly increase it over the next 3-4 days. Try not to dilute the formula because dilution increases the water content of the feces.
6. Start parenteral (intravenous) nutrition to prevent negative nitrogen balance while adjusting enteral feedings.
7. DO NOT STOP TUBE FEEDING as this will make your diarrhea worse in the future when you decide to resume tube feeding.

ASPIRATION

The risk of reflux of gastric contents into the upper respiratory tract is exaggerated. According to some authors, the frequency of documented aspirations varies from 1 to 44%. It was suggested that the frequency of aspirations could be reduced by inserting probes into the small intestine, but this was not confirmed. In patients with an increased likelihood of aspiration occurring (for example, in comatose patients), its diagnosis can be facilitated by adding food coloring to the administered drug: aspiration will lead to a change in the color of the discharge from the upper respiratory tract.

CLOGGED PROBES

Narrow enteral feeding tubes may become obstructed in approximately 10% of patients. The usual reason for this is the formation of a plug from the stuck together nutrient mixture. The possibility of obstruction can be reduced by flushing the tube with 10 ml of warm water before and after each feeding. In between drug administrations, the tube must be filled with water and sealed. If the probe becomes impassable, then several effective ways. As a rule, specially developed solutions are used - Coke Classic, Mountain Dew and Adolf's Meat Tenderiser (papain). Viokase is especially effective. Dissolve 1 Viokase tablet along with 1 tablet of sodium bicarbonate (324 mg) in 5 ml of water and then inject this mixture into the probe and squeeze it for 5 minutes. If this does not help, then the probe must be replaced.

LITERATURE

Rombeau JL, Caldwell MD eds. Enteral and tube feeding, 1st ed., Philadelphia: W.B. Saunders, Co., 1984.

1. A.S.P.E.N. Board of Directors. Guidelines for the use of enteral nutrition in the adult patient. JPEN1987: 11:435-439.

SELECTED WORKS

2. Wilmore DW, Smith RJ, O"Dweyer ST, et al. The gut: A central organ after surgical stress. Surgery 1988; 104:917-923.
3. Deitch EA, Wintertron J, Li MA, Berg R. The gut is a portal of entry or bacteremia. Ann Surg 1987; 205:681-690.
4. Fox AD, Kripke SA, Berman R, Settle RG, Rombeau JL. Reduction of severity of enterocolitis by glutamine-supplemented enteral diets. Surg Forum 987; 38:43-44.
5. Cerra FB. Metabolic manifestations of multiple systems organ failure. Crit Care Clin 1989; 5:119-132.
6. Ramos SM, Lindine P. Inexpensive, safe and simple nasoenteral intubation—an alternative for the cost conscious. JPEN 1986; 30:78-81.
7. Metheny NA, Eisenberg P, Spies M. Aspiration pneumonia in patients fed through nasoenteral tubes. Heart Lung 1986; 15:256-261.
8. Raff MH, Cho S. Dale R. A technique for positioning nasoenteral feeding tubes. JPEN 1987; 11:210-213.
9. Valentine RJ, Turner WW, Jr. Pleural complications of naso-enteric feeding tubes. JPEN 1985; 9:605-607.
10. Rombeau JL, Caldwell MD, Forlaw L, Geunter PA eds. Atlas of nutritional support techniques. Boston: Little, Brown & Co., 1989; 77-106.
11. Rees, RGP, Payne-James JJ, King C, Silk DBA. Spontaneous transpyloric passage and performance of fine-bore polyurethane feeding tubes: a controlled clinical trial. JPEN 1988; 12:469-472.
12. Whatley K, Turner WW, Dey M, Leonard J, Guthrie M. When does metoclopromide facilitate transpyloric intubations? JPEN 1984; g:679-681.
13. Jones BMJ. Enteral feeding: Techniques and administration. Gut 1986; 27(Suppl):47-50.
14. Zarlin EJ, Parmar JR, Mobarhan S, Clapper M. Effect of enteral formula infusion rate, osmolality, and chemical composition upon clinical tolerance and carbohydrate absorption in normal subjects. JPEN 1986: 10:588-590.
15. Rees RGP, Keohane PP, Grimble GK, Forst PG, Attrill H, Silk DBA. Elemental diet administered nasogastrically without starter regimens to patients with inflammatory bowel disease. JPEN 1986: 10:258-262.
16. Koruda M, Geunther P, Rombeau J. Enteral nutrition in the critically ill. Crit Care Clin 1987; 3:133-153.
17. Hassett JM, Sunby C, Flint LM. No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy. Surg Gynecol Obstet 1988; 267:383-388.
18. Gauderer MWL, Stellato TA. Gastrostomies: Evolution, techniques, indications, and complications. Current Probl Surg 1986; 23:660-719.
19. Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: Indications, limitations, techniques, and results. World J Surg 1989; 13:165-170.
20. Ryan JA, Page CP. Intrajejunal feeding: Development and current status. JPEN 1984; 8:187-198.
21. Sarr MG. Needle catheter jejunostomy: An unappreciated and misunderstood advance in the care of patients after major abdominal operations. Mayo Clin Proc 1988; 63:565-572.
22. Adams MB, Seabrook GR, Quebbemen EA, Condon RE. Jejunostomy. Arch Surg 1986; 121:236-238.
23. Heimburger DC, Weinsier RL. Guidelines for evaluating and categorizing enteral feeding formulas according to therapeutic equivalence. JPEN 1985; 9:61-67.
24. Jenkins DJA. Dietary fiber. In: Shils ME, Young VR eds. Modern nutrition in health and disease, 7th ed. Philadelphia:Lea & Febiger, 1988; 52-71.
25. Marcuard CP, Segall KL, Trogdon S. Clearing obstructed feeding tubes. JPEN 1989; 13:81-83.

Target: introduction of nutrients into the body, feeding the patient.

Indications: difficulty swallowing, damage to the tongue, pharynx, larynx, esophagus, after surgery on the esophagus, disorders of the central nervous system, unconsciousness, mental disorders with refusal to eat.

Contraindications: injuries of the esophagus, bleeding of the esophagus and stomach, varicose veins veins of the esophagus.

Equipment:liquid food: sweet tea, fruit juice, raw eggs, butter, milk, cream, fruit juices, jelly, baby nutritional mixtures “Baby”, “Infamil”, etc. in the amount of 600-800 ml., special preparations: enpits,

sterile thin gastric tube, glycerin, funnel or Janet syringe, 30-50 ml of boiled water, phonendoscope, bandage, adhesive plaster, probe plug, 20 g syringe, container with disinfectant. solution, gloves.

I. Preparation for the procedure

1. Collect information about the patient, introduce yourself kindly and respectfully.

2. Explain the essence and course of the upcoming procedure and obtain his consent.

3. Prepare the necessary equipment.

4. Wash and dry your hands and put on gloves.

II. Carrying out the procedure

5. Place the patient in a position comfortable for feeding (sitting, lying, Fowler’s position), cover the chest with a napkin.

6. Examine the skin and mucous membranes of the nasal passages. If necessary, clear the nasal passages of mucus and crusts.

7. Determine the distance to which the probe should be inserted: from the xiphoid process to the upper incisors (upper lip) and to the earlobe, put a mark.

8. Moisten the probe with water or treat it with glycerin.

9. Insert the probe through the nasal passage to the desired depth.

10. Monitor the position of the probe in the stomach: draw 30-40 ml of air into the Janet syringe, attach it to the probe and insert it into the stomach under the control of a phonendoscope (characteristic sounds are heard).

Remember! Without making sure that the tube is in the stomach, do not start feeding.

11. Apply a clamp and disconnect the syringe from the probe. Place the free end of the probe into a container.

12. Before feeding, remove the clamp from the probe, draw liquid food into the Janet syringe and connect it to the gastric tube. The Janet syringe can be replaced with a funnel. In this case, hold the funnel slightly inclined at the level of the stomach and pour the prepared food into it. The higher the funnel, the faster the food flow rate. The required volume of the mixture is administered fractionally, in small portions of 30-50 ml with intervals of 1-3 minutes between them. at a temperature of 37-38°C.

13. After feeding, rinse the tube with water.

14. Close it with a stopper. Secure the end of the tube with an adhesive plaster or a strip of bandage until the next feeding. Before each feeding, you need to make sure that the tube is in the same place. When feeding dairy foods, rinse the tube every 2 hours. Infuse food slowly, start with 5-6 meals a day in small portions, gradually increasing the volume of food introduced and reducing the number of feedings.

15. Inspect the linen in case of replacement.

III. Completing the procedure

16. After feeding, remove the probe and place it in a container with disinfectant. solution.

17. Remove gloves, place them in a container with disinfectant. solution

18. Wash your hands

19. Make a record of the procedure and the patient’s reaction to it in the medical documentation.

Note: The length of time the probe remains in the stomach is determined by the doctor.

Rice. 55. Feeding through the NGZ using a Janet syringe

NUTRITION THROUGH GASTROSTOMY

Gastrostomy - Greek. gaster - stomach, stoma - hole.

A gastric fistula is surgically created for the patient, through which a probe is inserted and food enters directly into the stomach. The amount of food and frequency of feeding is determined by the doctor.

Target: feeding the patient.

Indications: inability to take food in other ways, esophageal obstruction, pyloric stenosis.

Equipment: gastric tube, funnel or Janet syringe, 30-50 ml of boiled water, bandage, adhesive plaster, plug for the tube, containers with disinfectant. solution, gloves, sterile wipes, scissors, gels and ointments as prescribed by a doctor, nutritional mixtures as prescribed by a doctor in the amount of 200-500 ml, temperature 37-40°C; liquid food: sweet tea, fruit drink, raw eggs, butter, milk, cream, fruit juices, jelly, nutritional mixtures containing proteins, fats and carbohydrates, etc.

I. Preparation for the procedure

1. Explain the purpose and course of the upcoming procedure to the patient (who is conscious) and relatives. Tell him what he will be fed.

2. Obtain the patient’s consent to perform the procedure.

3. Help the patient find a comfortable position.

4. Wash and dry your hands.

5. Wear gloves.

II. Executing the procedure

7. Attach a funnel or Janet syringe to the rubber tube.

8. Insert warmed food into the stomach in small portions (50 ml) 6 times a day.

Note: Sometimes the patient is advised to chew the food himself, then dilute it in a glass with liquid and pour it into a funnel in a diluted form. With this feeding option, reflex stimulation of gastric secretion is maintained.

9. After introducing food, rinse the rubber tube with 40-50 ml of boiled water.

10. Clamp the tube with a clamp, disconnect the syringe, and close the tube with a stopper.

11. Make sure the patient feels comfortable.

III. Completing the procedure

12. Place the used instruments in a container with disinfectant. solution.

14. Wash and dry your hands.

Remember! Do not introduce a large amount of liquid into the funnel because due to spasm of the stomach muscles, food can be thrown out through the fistula.

Rice. 56. Feeding through a gastrostomy tube

PARENTERAL NUTRITION

(bypassing the gastrointestinal tract)

Target: restoration of impaired metabolism in case of organic and functional failure of the gastrointestinal tract.

Indications: obstruction of the digestive tract, when normal nutrition is impossible (tumor), after surgery on the esophagus, stomach, intestines, preparing exhausted and weakened patients for surgery, anorexia (lack of appetite), when refusing to eat, uncontrollable vomiting.

Equipment: drip system, sterile tray, sterile gauze pads, adhesive tape, 70% alcohol, sterile cotton balls, protein preparations, fat emulsions, carbohydrate preparations, saline solutions, hypertonic solutions.

Algorithm of actions nurse:

I. Preparation for the procedure

1. Explain the purpose and course of the upcoming procedure to the patient and relatives if he is encountering it for the first time.

2. Obtain the consent of the patient or his relatives for the procedure.

4. Wash (hygienic level) and dry your hands.

5. Wear gloves.

6. Prepare the necessary equipment.

7. Before administration, the agent for parenteral administration is heated in a water bath at 37-38°C.

II. Executing the procedure

8. Fill the system for drip administration of nutrients.

9. Connect the system for intravenous administration to the patient.

Protein preparations:

Amino acids:

· hydrolysine,

· casein protein hydrolyzate

Protein preparations are administered at a rate of 10-20 drops per minute in the first 30 minutes, then 40-60 drops per minute. Faster management is not advisable, since excess amino acids are not absorbed and are excreted in the urine.

Fat emulsions:

Lipofundin S

· intralipid

Fat emulsions are administered in the first 10-15 minutes at a rate of 15-20 drops per minute, then 60 drops per minute.

Administration of 500 ml of the drug lasts approximately 3-5 hours. With the rapid administration of a fat emulsion, the patient may experience a feeling of heat, facial flushing, and difficulty breathing.

Carbohydrate preparations:

· glucose solutions 5-10% - 25%.

Saline solutions (isotonic or physiological):

· 0.9% sodium chloride solution

· 1.5% sodium bicarbonate solution

· 0.9% ammonium chloride solution

· 1.1% potassium chloride solution, etc.

The rate of administration is 30-40 drops per minute.

Hypertonic solutions:

· 2%, 3%, 10% sodium chloride solutions.

The rate of administration is 30-40 drops per minute.

Note: Parenteral nutrition solution can be prepared as needed from available ready-made solutions. 5 and 10% glucose solutions are used as the main ones, to which are added the corresponding amounts of 15, 20, 30, 40 ml of 10% NaCl solution, 20-30 ml of 10% KCl solution, 0.5 -1 ml 25% magnesium sulfate solution, 1-2 ml 10% CaCl solution.

Remember! The rate of drug administration must be strictly observed.

Rice. 57. Parenteral feeding of the patient

III. Completing the procedure

12. Disinfect and dispose of the disposable drip system.

13. Remove gloves and put them in a container with disinfectant. solution followed by disinfection and disposal.

14. Wash and dry your hands

15. Make a record of the procedure and the patient’s reaction to it in the medical documentation.

Probe feeding- one of the types artificial administration nutrients into the body when it is impossible or difficult to eat by mouth. There are intragastric tube feeding, carried out through a nasogastric tube or through a gastrostomy, and intraintestinal, or enteral, tube feeding, carried out using a nasointestinal tube or through a jejunostomy.

Indication for tube feeding are: impaired swallowing in stroke, acute polyradiculoneuritis, myasthenia gravis, brain stem tumors, encephalitis of various etiologies, severe traumatic brain injuries, neurotoxicosis (botulism, tetanus); injuries and operations in the oropharyngeal area; jaw fractures; certain pathological conditions of the digestive tract, for example burns and scar changes in the esophagus, obstruction of the gastric outlet of various etiologies; anorexia associated with chemotherapy, sepsis, extensive burns.

Contraindications: obstruction, paresis or infarction of the intestine, impaired absorption of the small intestine.

For tube feeding food mixtures are used, which can be divided into three groups. The first group includes mixtures prepared from natural products; they undergo highly dispersed homogenization. Homogenized canned meat and vegetable diets are often used. The mixtures are prepared in the hospital catering department. The disadvantages of these mixtures are: imbalance in basic nutrients, inferior vitamin and mineral composition, and high viscosity, which makes it difficult to use through small-section probes.

Complete mixtures specially produced for tube feeding domestic industry (“Inpitan”, “Ovolakt”, etc.) have significant advantages compared to hospital-prepared mixtures. Their composition is precisely known, they have a low viscosity, which facilitates administration through small-diameter probes, they can be prepared within a few minutes, and recording their consumption is very simple. These mixtures fully meet the body's needs for basic nutrients. They are produced from milk proteins, egg whites, vegetable oil, corn syrup with the addition of water- and fat-soluble vitamins, macro- and microelements. Energy value of mixtures: protein - 12-15 -; fats - 30-37 -; carbohydrates 50-55 -. The protein in these mixtures is in high molecular weight form, and therefore they are often called polymeric. Some mixtures (for example, Inpitan) do not contain lactose due to the fact that some patients cannot tolerate it due to impaired breakdown of the latter in the small intestine. The mixtures are produced in liquid and powder form, which are diluted with warm boiled water before use. The energy value of ready-to-use mixtures is 4.18 kJ (1kcal) by 1 ml solution when administered into the small intestine and 4.18-8.36 kJ- when administered into the stomach. Polymer mixtures are indicated for patients without pronounced digestive disorders (impaired chewing and swallowing, anorexia, after surgical interventions on the esophagus and stomach, etc.). They can be used as the only power source for a long time (many months).

The second group is hydrolyzed food mixtures that make up mono- and oligomeric diets. In them, protein and carbohydrates are in hydrolyzed form. These diets contain all (essential and non-essential) amino acids (or protein hydrolysates), simple sugars, oligosaccharides, essential fatty acids, vegetable oils and a wide range of vitamins, macro- and microelements. This group of mixtures is characterized by a low content of ballast substances, high osmoticity and the absence of lactose. They do not require active digestion and are easily absorbed. Available in powder form, which is diluted with water before use according to the recommendations. Hydrolyzed food mixtures are prescribed to patients with impaired digestion (severe insufficiency of exocrine pancreatic function, extensive resections of the small intestine, intestinal fistulas, etc.). Due to the high osmotic nature of diets, side effects such as nausea and dumping syndrome are often observed (see. Postgastroresection syndromes), diarrhea.

The third group is nutritional modules. They consist of any one component - protein, fat, carbohydrate. These drugs are used to add to the basic diet in order to meet the needs of patients who require increased amounts of a particular nutrient. To a certain extent, modules include enpits - dry milk mixtures with high biological value and good digestibility. If necessary, a polymer mixture is prepared on their basis. Enpits are produced by industry in the form of a powder, which is diluted with water to a certain concentration (fatty enpit, antianemic enpit, etc.).

In the table presents the composition of the main mixtures used in tube feeding.

Composition of mixtures for tube feeding on 4186 kJ (1000kcal)

Nutrients included in the mixture	Type of mixture
	"Inpitan"	"Ovolakt"	enpit protein	enpit fatty
Protein, G
Fat, G
Carbohydrates, G
Minerals, mg:
manganese
Vitamins, mg:
folic acid
cobalamin
pantothenic acid

In all cases tube feeding you should start with caution, constantly observing how the patient tolerates it. The amount of mixture administered per day is determined by the patient’s condition; as a rule, it is 125.4-188.1 kJ (30-45kcal) by 1 kg body weight. In the first 2-3 days, the concentration of the food mixture is reduced to 2.09 kJ (0,5kcal/ml), and the volume is up to 1000-1200 ml at an injection rate of 40-50 ml/h(into the small intestine). If such a regime tube feeding does not cause side effects (flatulence, diarrhea, abdominal pain, etc.), then the rate of administration and the volume of the food mixture are gradually increased. Subsequently, in accordance with the tolerance and needs of the body, the concentration of the food mixture is increased.

Such mixtures can be administered using a conventional drip system. However, it is not possible to maintain a constant infusion rate. Using modern peristaltic pumps for tube feeding ensures supply of a given volume of mixture at the required speed in various modes.

Nasogastric tube feeding it is more physiological to carry out in an intermittent (fractional) mode, when within 10-40 min enter 120-480 ml mixtures followed by intervals from 1 to 8 h. The mixture is introduced into the intestine in a constant drip mode in a volume of 30-50 ml by 1 kg body weight per day.

In many clinics for tube feeding Rubber and polyvinyl chloride probes, which have a number of negative properties, are still used. Firstly, these probes have a large outer diameter (5-6 mm), which causes inconvenience to the patient. In addition, polyvinyl chloride probes harden upon contact with nutritional mixtures and secretions of the digestive canal, which can result in bedsores of the intestinal wall and its perforation. Therefore, they can be administered only for 3-4 days.

Modern polyurethane and silicone probes have an outer diameter of 2.6-3.2 mm, do not harden for several months, are well tolerated by patients and cause almost no complications. Length of nasogastric tube 70-80 cm, nasojejunal - 120-140 cm. The transnasal probe is inserted in the usual way (see. Probing of the stomach). In addition, the probe is passed intraoperatively or using an endoscope (next to the endoscope or through the biopsy channel). In comatose patients, a probe with a mandrin is directed into the esophagus using a laryngoscope. Control of the correct position of the probe is carried out by suctioning the gastric contents with a syringe, quickly introducing air with simultaneous auscultation of noise in the epigastric region, or x-ray. To prevent clogging of the probe with the frozen nutrient mixture, it must be washed 20 ml boiled water every 4-6 h and immediately after stopping the administration of the mixture. If the probe becomes clogged, it should be replaced.

There are three types of complications possible tube feeding: from the gastrointestinal tract - reflux, vomiting, aspiration, diarrhea, flatulence (due to high speed of administration, the use of hyperosmolar, lactose-containing, bacterially contaminated mixtures); associated with the probe - incorrect installation, twisting of the probe, rupture of its wall, blockage, bedsore of the nasopharynx wall, intestines, perforation, bleeding (when using large-diameter polyvinyl chloride probes); metabolic - hypo- and hyperkalemia, hyperglycemia, electrolyte disturbances, the so-called tube feeding syndrome (a combination of hypertonic dehydration, hypernatremia, hyperchloremia, hyperosmolarity and hyperammonemia due to prolonged use of hyperosmolar mixtures and lack of constant monitoring of water and electrolyte balance).

Tube feeding of children is carried out through tubes with a diameter of 1.7-2.6 mm and length 40-60 cm. Taking into account the small volume of the stomach and the functional characteristics of the gastrointestinal tract, the nutritional mixture is administered at a speed of 5 to 60 ml/h. The volume of nutritional mixture for children of the first 2 years of life is 100-75 ml by 1 kg body weight per day, over 2 years - 75-50 ml by 1 kg body weight per day. Use adapted mixtures (see. Baby food products) and diet (see. Nutrition) according to the child’s age.

Bibliography: Bratus V.D., Butylin Yu.P. and Dmitriev Yu.L. Intensive care in emergency surgery, p. 112, Kyiv, 1989; Popova T.S. and Tamazashvili T.Sh. Enteral tube feeding of surgical patients. Surgery, No. 3, p. 120, 1986, bibliogr.; Sysoev Yu.A. and Nesterin M.F. Enteral nutrition, Issue. nutrition, No. 3, p. 3, 1985, bibliogr.; Tsatsanidi K.N. and others. Mixtures for enteral nutrition during operations on the gastrointestinal tract. Surgery, No. 3, p. 119, 1987, bibliogr.

Indications:

Tube diets are prescribed for maxillofacial operations and injuries, cancer of the oral cavity, pharynx, esophagus, burns, scar changes, resection of the esophagus, craniocerebral operations, trauma, tumors and other brain lesions with impaired nervous regulation of chewing and swallowing, in an unconscious state , coma, liver failure, kidney failure, diabetes mellitus, stomach diseases with its obstruction, severe burn disease, sepsis and other diseases with an extremely weakened condition of the patient.

Purpose of the diet: provide nutrition to patients who cannot eat food in the usual way due to impaired chewing and swallowing due to obstruction of the upper gastrointestinal tract, unconsciousness or a sharply weakened state.

General characteristics of the diet: Diets consist of liquid and semi-liquid (cream-like consistency) foods and dishes passed through a tube directly into the stomach or small intestine. Dense foods and dishes are ground and diluted with liquid, taking into account the nature of the mixture (boiled water, tea, broth, vegetable decoctions, milk, juice of fruits and vegetables, etc.). Individual products, after grinding through a meat grinder, are rubbed through a grinding machine or a thick sieve and filtered through a fine sieve. a sieve to prevent the ingress of hard-to-grind parts (meat veins, fiber fibers, etc.) And this includes cold and hot foods and drinks. The temperature of the food is 45-50°C, since cooling makes the food viscous and difficult to pass through the probe. In the absence of contraindications, diets are physiologically complete in chemical composition and energy value with a varied range of products. In most cases, the tube (h) diet is based on type of diet No. 2 (No. 2z) or type of diet No. 1 (No. 1z) - for concomitant diseases of the digestive organs (peptic ulcer, severe gastritis, etc.). For other concomitant or underlying diseases (diabetes mellitus, circulatory failure, liver, kidney, etc.), diets appropriate for the given disease are used according to the above principles of the tube diet.

Chemical composition and calorie content of diets No. 2z and 1z: Proteins - 100-110 g (65% animal), fats - 100 g (25-30% vegetable), carbohydrates - 350-400 g, table salt - 10-12 g (No. 1z) or 15 g (No. 2z), free liquid - up to 2.5 l. The mass of the dense part per serving is no more than 250-300 g. The energy value of the diet is 2700-2800 kcal.

Diet: 5-6 times a day.

Bread. 150 g of crackers from wheat bread (or butter), 50 g from rye bread; for diet No. 1z - only wheat or cream. After thorough grinding, add to liquid food.

Soups. In low-fat meat, fish broth, vegetable broth with thoroughly pureed and well-cooked permitted vegetables and cereals or cereal flour; pureed soups from meat and fish; milk soups with pureed vegetables and cereals; from pureed fruits and semolina. Soups are seasoned with creamy or vegetable oil, cream, sour cream. For diet No. 13, meat and fish broths are not used.

Meat, poultry, fish. Low-fat types and varieties: from the softest parts of beef carcass, rabbit, poultry. Liver. Free from fat, fascia, tendons, skin (poultry), skin and bones (fish). Boiled meat and fish are passed through a meat grinder with a fine grid twice and rubbed through a thick sieve. Meat and fish purees (soufflé) are mixed with pureed garnish and brought to the desired consistency by adding broth (diet No. 2z), vegetable or cereal (diet No. 1z) broth. Thus, meat and fish dishes are served mixed with side dishes. On average, 150 g of meat and 50 g of fish per day.

Dairy products. On average, per day 600 ml of milk, 200 ml of kefir or other fermented milk drinks, 100-150 g of cottage cheese, 40-50 g of sour cream and cream. If you are intolerant to milk, replace it with fermented milk and other products. Mashed cottage cheese, in the form of cream, soufflé; curd cheeses. Rub with milk, kefir, sugar until the consistency of sour cream.

Eggs. 1-2 pieces per day soft-boiled; for steam protein omelettes - 3 egg whites.

Cereals. 120-150 g of semolina, oatmeal, oatmeal, oatmeal, rice, buckwheat, Smolensk. Cereal flour. Porridges are pureed, liquid, with milk or broth (diet No. 2z). Boiled mashed vermicelli.

Vegetables. 300-350 g per day. Potatoes, carrots, beets, cauliflower, zucchini, pumpkin, and limited green peas. Thoroughly mashed and well boiled (mashed potatoes, soufflé). White cabbage and other vegetables are not used.

Snacks. Do not use.

Fruits, sweet dishes and sweets. Ripe fruits and berries - 150-200 g per day. In the form of pureed purees and compotes (as a rule, passed through a meat grinder and rubbed through a sieve), jellies, mousses, jelly, decoctions, juices. Decoctions of dried fruits. Sugar - 30-50 g, honey (if tolerated) - 20 g per day.

Sauces. Do not use.

Beverages. Tea, tea with milk, cream; coffee and cocoa with milk; juices of fruits, berries, vegetables; decoctions of rose hips and wheat bran.

Fats. Butter - 20 g, vegetable oil - 30 g per day.

Sample diet menu No. 14.

1st breakfast: soft-boiled egg, liquid milk semolina porridge - 250 g, milk - 180 g.

2nd breakfast: apple puree - 100 g, rosehip decoction - 180 g.

Lunch: oatmeal soup with vegetables in pureed meat broth - 400 g, mashed meat with potato semi-liquid milk puree - 100-250 g, compote decoction - 180 g.

Afternoon snack: pureed cottage cheese with milk - 100 g, jelly - 180 g.

Dinner: pureed rice soup with broth - 250 g, boiled fish soufflé - 100 g, carrot puree - 200 g.

At night: kefir.

Additions.

1. Specialized industrial products are intended for tube feeding: Nutrizon, Berlamin, etc. Patients with lactose (milk sugar) intolerance may experience nausea, bloating, and loose stools when using milk-based tube feeding products. In these cases, low-lactose mixtures are used. Intolerance to dairy products is revealed by interviewing the patient or his relatives. Liquid ready-to-use products are the easiest to use.

2. In tube diets, you can use food concentrates and canned food, except for snack foods (dry and condensed milk and cream, dry skim milk, natural canned vegetables for supplements; concentrates of third courses - jelly, creams, etc.) It is most advisable to use children's products and dietary nutrition with a balanced and standard chemical composition, which facilitates the preparation of the necessary diets. These products are made in the form of purees or homogenized, or are in a powdered state, convenient for dilution with liquids: canned meat, fish, vegetables, fruits, dry milk and acidophilus mixtures, dry milk-cereal mixtures, milk jelly, etc. Homogenized canned food can be combine with specialized tube feeding products, creating highly nutritious and convenient mixtures for tube diets. To prepare for the introduction of canned food through a tube, water, broths, and liquid mixtures of specialized tube feeding products are used.

3. For tube diets you can for a short time use a simplified nutritional mixture of the following composition (for a day): milk - 1.5 l, vegetable oil - 10 g, sugar 150 g, eggs - 4 pieces. The mixture contains 67 g of animal protein, 110 g of easily digestible fats, 220 g of simple carbohydrates; 2100 kcal. The mixture is distributed into 5 doses. 100 mg of ascorbic acid is introduced into it.

In contact with

To feed the patient through a nasogastric tube (enteral, tube feeding ) Various mixtures are used, mucous broth, jelly, tea, milk, butter, juices, cream, as well as infant formula, special preparations for enteral nutrition (protein, fat). Feeding is carried out 5-6 times a day.

Indications: injuries of the tongue, pharynx, larynx; diseases of the medulla oblongata with swallowing disorders.

Equipment:

· sterile thin disposable rubber probe with a plug with a diameter of 5-8 mm;

· glycerin;

· syringe with a capacity of 20 ml;

· liquid food in the amount of 600-800 ml, t = 38-40º C;

· phonendoscope, adhesive plaster, safety pin, tray, syringe, towel, clip, clean gloves, 100 ml boiled water.

Sequence of actions when feeding a patient through a nasogastric tube.

1. Explain the procedure to the patient. Warn him 15 minutes in advance that a meal is coming.

2. Determine the distance to which the probe should be inserted (height in cm minus 100).

3. Treat the end of the probe with glycerin.

4. Assist the patient into a high Fowler's position.

5. Cover the patient's chest with a napkin.

6. Wash your hands.

7. Insert the probe through the lower nasal passage to a depth of 15-18 cm.

8. Instruct the patient to continue swallowing the tube into the stomach.

9. Fill the syringe with air, attach it to the probe, and inject air.

10. Place the head of the phonendoscope over the stomach area: if you hear “gurgling sounds,” the probe is in the stomach.

11. Secure the probe with an adhesive tape on the back of the nose.

12. Clamp the probe with a clamp, placing the free end of the probe in the tray.

13. Heat the food mixture in a water bath to 38-40° C.

14. Connect the syringe to the gastric tube so that the plunger handle is directed upward. Remove the clamp, slowly introduce the prepared food (300 ml are administered over 10 minutes).

15. Rinse the probe with water.

16. Disconnect the syringe.

17. Close the free end of the probe with a stopper and secure it to the patient’s clothing with a safety pin.

18. Make sure the patient feels comfortable.

19. Remove everything unnecessary.

23. Wash your hands. Make a feeding record.

Feeding the patient through a gastrostomy (fistula) created surgically.

Indications: obstruction of the esophagus.

A probe is inserted into the stomach through the fistula, through which food is infused. A funnel is attached to the free end of the probe and heated food is introduced into the stomach in small portions (50-60 ml) 5-6 times a day. Gradually, the volume of administered fluid increases by 250-500 ml, and the number of feedings is reduced to 4 times a day. The nurse must take care of the gastrostomy, ensure that its edges are not contaminated with food, for which, after each feeding, clean the skin around the fistula, lubricate it with Lassar paste and apply a sterile dry bandage.

Feeding patients using nutritional (drip) enemas. Nutrient enemas are given only after the rectum has been emptied of its contents. For better absorption, solutions heated to a temperature of 37-38 0 C are injected into the rectum - a 5% glucose solution, aminopeptin (a drug containing a full set of amino acids). The need for drip enemas may arise with uncontrollable vomiting or severe dehydration. Up to 200 ml of solution is administered simultaneously 2-3 times a day. A small amount of liquid can be administered using a pear-shaped rubber balloon.

Parenteral nutrition is prescribed to patients with symptoms of obstruction of the digestive tract, when normal nutrition is impossible, after surgery on the esophagus, stomach, intestines, when exhausted, weakened patients, in preparation for surgery. For intravenous administration, protein hydrolysis products are used (casein hydrolyzate, fibrosol, aminopeptin, aminokrovin, polyamine), fat emulsion (lipofundin, intralipid, aminoplasmol, lipoplus, LST 3-omega FA), as well as a 5-10% glucose solution, 0.9 % isotonic sodium chloride solution. About 2 liters are administered per day. Protein solutions are heated to a temperature of 37-38 0 C in a water bath and administered intravenously. In the first 30 minutes, administer at a rate of 10-20 drops per minute, then, if well tolerated, the rate of administration is increased to 30-40 drops. The administration of 500 ml of the drug lasts 3-4 hours. It is necessary to administer various components simultaneously for parenteral nutrition.

BODY TEMPERATURE AND ITS MEASUREMENT

In a healthy person, body temperature is normally maintained during the day at a certain level with fluctuations within small limits of 36-36.9 0 C due to three factors: heat production, heat transfer, and thermoregulation.

Heat production- the result of biochemical processes, as a result of which, during the biochemical oxidation of nutrients, energy is released, which is converted into heat. Thus, the higher the intensity of oxidative processes, the higher the temperature. Heat generation occurs in all organs and tissues, but with varying intensity. The highest heat generation is in muscles (up to 60% of all energy), liver (up to 30%), kidneys (up to 10%) and much lower in connective tissue, bones, cartilage. The intensity of heat generation depends on the reactivity of the body, age, gender, emotional state and the person’s lifestyle, time of day, ambient temperature, type of clothing the person is wearing.

Heat dissipation– the result of physical processes: heat radiation, convection, heat conduction and evaporation. Up to 80% of heat loss occurs through sweating. Heat radiation occurs mainly through the skin, gastrointestinal tract, lungs, and kidneys. Convection - the movement and movement of air heated by heat - occurs through the contact of moving molecules of gas and liquid with the body. Thermal conduction is a mechanism for transferring heat to substances in contact with the human body. However, it must be taken into account that air and clothing are poor heat conductors. Heat transfer is also enhanced due to the evaporation of moisture from the surface of the skin and respiratory tract.

Thermoregulation- a complex process of ensuring constant body temperature. The mechanism of thermoregulation is triggered when the intensity of blood transfer to the body surface changes and depends on the ambient temperature. The thermoregulation system includes: peripheral thermoreceptors (skin and blood vessels), a central thermoreceptor “thermostat” (hypothalamus), the thyroid gland and adrenal glands. When there is excess heat (or when the body is overheated), a reflex dilation of skin vessels is observed, its blood supply increases and, accordingly, heat transfer through heat conduction, heat radiation and evaporation due to sharply increasing sweating increases.

To increase heat transfer, you should: maintain optimal ambient temperature; to increase evaporation, give plenty of fluids; to improve heat conduction, it is necessary to free the patient from clothing; toilet the skin; Apply a cold compress and use an ice pack. When there is insufficient heat production by the body (or when it cools), the vessels reflexively narrow, which reduces heat transfer. At the same time, the skin becomes dry, cold, chills appear (muscle tremors - rhythmic contraction of skeletal muscles), which corresponds to an increase in heat production by skeletal muscles (metabolic rate increases 5 times). Thus, the mechanism of thermoregulation ensures the temperature constancy of the internal environment of the body, which is necessary for the normal course of metabolic processes.

MEASURING BODY TEMPERATURE

The concept of “body temperature” is conditional, since body temperature at different points on the surface of the human body ranges from 24.4 °C on the foot to 36.6 °C in the armpit. Physiological temperature fluctuations in the morning and evening average 0.3°-0.5 °C, somewhat lower in the morning and higher in the evening. The temperature may rise slightly after physical stress, eating, or emotional stress. Elderly and senile people have a slightly lower body temperature than young and middle-aged people. In young children, body temperature is unstable with large fluctuations during the day. In women, body temperature is determined by the phases of the menstrual cycle. In summer, body temperature is usually 0.1 - 0.5 °C higher than in winter. Lethal temperature is the temperature of the human body at which structural changes in cells and irreversible metabolic disorders occur. Lethal maximum temperature 43°C, minimum 15-23°C.

Body temperature is measured on the skin (in natural folds - armpits, inguinal folds) and on mucous membranes (oral cavity, rectum, vagina). Most often, the temperature is measured in the armpit. Normal body temperature values:

· in the armpit - on average 36.4° C, fluctuations from 34.7° C to 37.7° C;

· in the oral cavity - on average - 36.8° C, fluctuations from 36° C to 37.3° C;

· in the rectum - on average 37.3°C, fluctuations from 36.6°C to 37.7°C.

Body temperature in the hospital is measured 2 times a day - in the morning, after sleep, on an empty stomach at 7 - 8 o'clock (since body temperature is minimal at 3-6 o'clock in the morning) and in the evening, after a day's rest before dinner at 17 - 18 o'clock (since At this time body temperature is maximum).

In some cases (as prescribed by a doctor), the temperature is measured every 3 hours - which is called temperature profile measurement. If the temperature needs to be measured more often, the doctor indicates the required time interval when assigning a temperature profile.

Body temperature is measured with a maximum medical thermometer, an electric thermometer, a “thermotest”, and an infrared thermometer.

Maximum medical thermometer has a body made of thin glass, one end of which is occupied by a reservoir of mercury. A capillary, sealed at the other end, extends from it. Mercury, heating up and increasing in volume, rises through the capillary along which the thermometer scale is located. The scale is designed to determine body temperature with an accuracy of 0.1°C. A medical thermometer can measure temperatures from 34°C to 42°C. The thermometer shows the maximum height of rise of the mercury column and is therefore called maximum. Mercury cannot fall into the tank on its own, because... this is prevented by a sharp narrowing of the capillary in its lower part. You can return mercury to the reservoir only after shaking the thermometer until the mercury column drops below 35° C.

After measuring the temperature, the thermometer is disinfected by complete immersion in a tray with a disinfectant solution (a gauze napkin must be placed at the bottom of the tray). Never wash the thermometer with hot water.

Due to the fact that some patients may experience skin allergic reactions to disinfectants, after disinfection, thermometers must be rinsed under running water, wiped and stored dry in a glass with cotton wool at the bottom.

Safety precautions when working with a thermometer. The thermometer is made of thin glass and care must be taken when handling it. Before measuring the temperature, you must ensure its integrity.

A medical thermometer may be broken during operation. It is the mercury vapor that is dangerous (they are a nephrotoxic poison), and not the mercury itself, which, when dropped, spreads into small balls.

Demercurization is a set of measures for disinfecting premises contaminated with metallic mercury or its vapors.

To carry out demercurization it is necessary:

Stop people's access to the premises or to the place of mercury spill, provide ventilation;

Report to the senior m/s or the doctor on duty;

Wear personal protective equipment (respirator, rubber gloves, safety glasses) in accordance with labor safety instructions when working with mercury-containing products No. 33/08;

Organize work to carry out primary demercurization.

If mercury spills, it must be collected immediately.

To avoid rubbing mercury into the floor and spreading it throughout the room, collecting mercury drops begins from the periphery of the contaminated area and moves to the center. Spilled droplet-liquid mercury should first be carefully collected with an iron scoop, and then transferred to a receptacle made of unbreakable glass or thick-walled glassware, previously filled with a solution of potassium permanganate.

Mercury can be removed from the cracks and recesses of droplets using strips of foil; very small droplets can be collected with damp foil or newsprint.

Individual drops of mercury should be collected using a pipette, syringe, or rubber bulb.

Treat the area where the mercury was spilled with a soap-soda solution (4% soap solution in a 5% soda ash solution), followed by rinsing with clean water. Ventilate the room.

The collected mercury must be placed in a hermetically sealed glass container and sent for disposal.

Sequence of actions when measuring body temperature in the armpit.

Equipment : thermometer, temperature sheet, clock, pen.

1.Explain to the patient the meaning of the upcoming procedure and obtain his consent.

2.Check that the thermometer is not damaged.

3.Wipe the thermometer dry.

4. Make sure that the thermometer reading is below 35°C; if the reading is higher, the thermometer needs to be shaken.

5.Wipe the patient’s armpit dry, because wet skin distorts thermometer readings.

6.Inspect the axillary area. If there is hyperemia or signs of local inflammation, it is impossible to measure body temperature in this area of ​​the body, because The thermometer reading will be higher.

7. Place the thermometer reservoir in the armpit so that there is full contact with the skin (press the shoulder to the chest) and the thermometer is in the center of the armpit.

8.After 10 minutes, remove the thermometer.

9.Record the thermometer readings on the temperature sheet.

10. Shake the thermometer until all the mercury drops into the reservoir.

11. Immerse the thermometer in the disinfectant solution.

When performing thermometry in the rectum, the patient lies on his left side. The thermometer is lubricated with Vaseline and inserted into the lumen of the rectum to a depth of 2-3 cm. When measuring body temperature in the inguinal fold (in a child), the leg is bent at the hip joint.

When measuring body temperature in the oral cavity, the thermometer is placed under the tongue to the right or left of the frenulum. If there are removable dentures, they are removed first. The mouth must be closed during the procedure.

"Thermostat"- a polymer plate coated with a liquid crystal emulsion. It is used to measure temperature more often in pediatric practice by placing a plate on the forehead. At a temperature of 36-37° C, the letter N is displayed ( Norma) green color, at temperatures above 37° C - letter F ( Febris) Red.

Infrared thermometer- a household ear thermometer, with which the body temperature in the ear is recorded by measuring the intensity of thermal radiation from the eardrum and surrounding tissues. In 1 second, the device makes 8 measurements, and the highest of them is displayed on the display. The device is most often used in pediatric practice.

Electric thermometer- a device for measuring body temperature by placing clamps on the earlobe, the distal phalanx of the finger. Temperature readings are displayed along with other indicators (pulse, capillary blood flow, etc.).

The measurement data is entered into a temperature sheet, where a temperature curve is plotted. The “price” of one division on the “T” scale of the temperature sheet is 0.2°C. Morning and evening temperatures are marked with a dot and, respectively, in columns “U” and “B” along the abscissa. By connecting the points, a temperature curve is obtained that reflects one or another type of fever if there is a fever.

FEVER AND ITS TYPES

Fever- a symptom of many diseases, which serves as an important indicator of their activity. It plays an important role in protecting the body from infection. Fever is an increase in body temperature above 38°C when measured in the armpit.

The following degrees of temperature increase are distinguished:

· 37-38 °C - low-grade fever;

· 38-39 °C - moderately elevated, febrile;

· 39-41 °C - high, pyretic;

· over 41 °C - excessively high, hyperpyretic.

Depending on the duration of the fever, it can be:

· fleeting - a few hours;

Acute - for several days;

Subacute - up to 45 days;

· chronic - more than 45 days.

Depending on daily temperature fluctuations, the following types of fevers are distinguished.

1. Constant fever: the temperature is constantly high throughout the day, lasts a long time, its daily fluctuations do not exceed 1°C. Occurs with lobar pneumonia, typhoid and typhus, and influenza.

2. Remitting (remitting) fever: characterized by daily temperature fluctuations exceeding 1°C, with a minimum daily temperature above 37°C. It is observed in purulent diseases (abscess, empyema of the gallbladder, wound infection), malignant neoplasms.

3. Intermittent (intermittent) fever: the temperature rises to 39-40 °C and above, followed by a rapid (after several hours) drop below 37 °C. Oscillations are repeated after 48-72 hours. Characteristic of malaria (three-, four-day), cytomegalovirus infection, infectious mononucleosis, purulent infection (ascending cholangitis).

4. Relapsing fever: a sudden rise in temperature to 40°C or more is followed by a drop after a few days to normal, which lasts for several days, and then the temperature curve repeats. Characteristic of relapsing fever.

5. Undulating fever: there is an alternation of a constant increase in temperature over several days with a gradual drop to normal or less than normal, followed by a period without fever. Then the temperature rises again and gradually decreases. Characteristic of lymphogranulomatosis, brucellosis.

6. Perverted fever: characterized by a rise in morning temperature to a greater extent than in the evening. Occurs in pulmonary tuberculosis and sepsis.

7. Hectic (debilitating) fever - a rise in temperature during the day by 2-4 ° C with a rapid drop to normal or below. Repeated 2-3 times a day. A drop in temperature is accompanied by debilitating weakness and profuse sweating. It is observed in severe forms of tuberculosis, sepsis, and lymphogranulomatosis.

There are three stages during a fever.

Stage I- the stage of temperature increase, when heat production prevails over heat transfer. Skin blood vessels spasm, sweating decreases, the patient is pale, cooling of the surface layer of the skin reflexively causes trembling, a feeling of cold - chills. Sweating and evaporation are inhibited. Patients experience increased breathing and heart rate.

An increase in temperature by 1 0 C leads to an increase in heart rate by 8-10 beats per minute, and respiration by 4 respiratory movements per minute. Nagging muscle pain, general malaise, and headache may occur.

Help . It is necessary to provide the patient with peace, put him to bed, cover him well with a blanket, put heating pads at his feet, give him hot tea, drug therapy as prescribed by the doctor. The main thing is to warm the patient in order to eliminate vascular spasm and trembling.

Stage II- stage of constantly elevated temperature. It is characterized by a predominant balance of the processes of heat production and heat transfer. At this stage, chills and muscle tremors weaken, sweating increases, spasm of skin vessels decreases and disappears, so that the pallor of the skin is replaced by their hyperemia. During fever, toxic products are absorbed into the blood, so the nervous, cardiovascular, digestive, and excretory systems suffer.

Patients complain of general weakness, headache, insomnia, lack of appetite, pain in the lumbar region, in the heart, dry mouth, cracks appear in the corners of the mouth and on the lips. Patients develop tachycardia, tachypnea, and sometimes a decrease in blood pressure (BP) may be observed. At the height of the fever, some patients may develop delirium and hallucinations, and in young children - convulsions and vomiting.

Help.At high temperature If there is a threat of convulsions, delirium, or hallucinations, an individual nursing station is established. At the same time, the nurse constantly monitors the patient’s condition and behavior, counts pulse, blood pressure, respiratory rate (RR), measures temperature every 2-3 hours, prevents bedsores, and gives enemas for constipation. . Patients' mouths should be irrigated with a 2% soda solution, cracked lips should be lubricated with petroleum jelly, a 10% solution of borax in glycerin, or baby cream. At this stage, the patient must be “cooled down”; he must be dressed in something light, but not undressed; he cannot be wrapped up. A cool, vitamin-rich drink is given. Considering that the patients are intoxicated, the nurse gives them a large amount of liquid, fruit juices, fruit drinks, mineral water (with gas removal). Feeding patients is carried out 5-6 times a day, in small portions, table No. 13 is prescribed, during periods of lower temperature - table No. 15.

Stage III- stage of temperature drop. It is characterized by a decrease in heat production and an increase in heat transfer (peripheral blood vessels dilate, sweating increases significantly, evaporation increases due to an increase in respiratory rate), due to the cessation of the action of pyrogens on the thermoregulation center. A gradual decrease in body temperature over several days is called lysis (lytic decline); a sharp drop in body temperature over a few hours is called a crisis.

The crisis can be complicated by acute vascular insufficiency - collapse. It is manifested by severe weakness, profuse sweating, pallor and cyanosis of the skin, a drop in blood pressure, increased heart rate and a decrease in its filling up to thread-like.

Help with collapse:

· raise the foot end of the bed by 30-40 degrees, remove the pillow from under the head;

· call a doctor through a third party;

· cover the patient with heating pads, cover him, give him strong hot tea;

· administer medications (as prescribed by a doctor): cordiamine, caffeine, sulphocamphocaine;

· When the condition improves, wipe the patient dry, change underwear and bed linen.

With a lytic decrease in temperature, as a rule, there is a gradual improvement in the general condition of the patient. He is prescribed diet No. 15 and his physical activity is expanded.

In a healthy person, the number of respiratory movements per minute (RR) ranges from 16 to 20, averaging 18 respiratory movements per minute. The action of one inhalation and exhalation is called the breathing movement. Rapid breathing - tachypnea - respiratory rate more than 20 per minute - observed at high temperature, decreased respiratory surface of the lungs, pulmonary edema. Decreased breathing - bradypnea - respiratory rate less than 16 per minute - is observed in diseases of the brain and its membranes, with obstacles to the entry of air into the lung (compression of the trachea by a tumor).

Arterial pulse- These are periodic vibrations of the walls of the arteries caused by the contraction of the heart. The pulse is determined by palpation on the arteries, most often on the radial one. During palpation, the following properties of the pulse are studied:

frequency, rhythm, tension, filling, magnitude.

Pulse rate determined by counting the number of pulse waves per minute. The pulse rate fluctuates in newborns between 130 - 140 beats per minute, in 3 - 5 year old children - 100 beats per minute, in 7-10 year old children - 85-90 beats per minute, in adults - 60 - 80 beats per minute, in the elderly - less than 60 beats per minute.

The pulse rate is subject to changes, and may increase or decrease.

Increased heart rate - tachycardia, rapid pulse, more than 80 beats per minute, observed with infectious fever, increased thyroid function, cardiovascular failure, etc.

Decreased heart rate - bradycardia, rare pulse, less than 60 beats per minute, observed with reduced thyroid function, with a concussion, etc.

When body temperature rises by 1 0 C, the pulse increases by 8 - 10 beats per minute.

Pulse rhythm. Normally, the pulse is rhythmic - the pulse waves are equal in strength and intervals. Various types of deviations from this are called arrhythmias (arrhythmic pulse) - the magnitude of the pulse waves and the intervals between them are different.

Types of rhythm disturbances (arrhythmias):

a) extrasystole - an extraordinary contraction of the heart, followed by a long (compensatory) pause. In this regard, the pulse rate in patients is determined strictly in one minute, because the pause can be in the middle and at the end of this minute.

b) atrial fibrillation - determined when the pulse waves are different in strength and intervals, occurs when the myocardium is damaged (cardiosclerosis, heart defects). Moreover, some heart contractions are so weak that the pulse wave does not reach the periphery and is not palpable. A difference is created between the number of systoles and the number of pulse waves - a pulse deficit.

Pulse deficiency is the difference between the number of heartbeats and pulse in the same minute. The pulse deficit is determined by two people simultaneously for one minute by listening to the heart (counting the number of systoles) and palpating the pulse (counting the number of pulse waves). The greater the pulse deficit, the worse the prognosis.

For example:

Heart rate – 110 per minute

R – 90 per minute

20 – pulse deficit

Pulse filling– the volume of blood in the artery. Depends on the ejection of blood during systole. If the volume is normal or increased (with good filling), the pulse is full. If the volume is reduced (weak filling - due to blood loss) - the pulse is empty.

Pulse voltage– blood pressure on the walls of the artery. Depends on the value of blood pressure. With high blood pressure, the pulse is hard and tense; with low blood pressure, the pulse is soft and thread-like.

Pulse value– the total indicator of pulse filling and tension.

a) a pulse of good filling and tension is called large;

b) a pulse of weak filling and tension is called small;

c) thread-like pulse - the magnitude of the waves is so small that they are difficult to detect.

In the medical history, the pulse is noted daily with a number and graphically in blue ink on the temperature sheet.

For heart rate values ​​from 50 to 100, the “price” of the division in the sheet is 2, and for heart rate values ​​of more than 100, it is 4.

Arterial pressure - blood pressure on the artery wall. Depends on the magnitude of cardiac output and vascular tone. The method for measuring blood pressure is called tonometry, which was developed by N.S. Korotkov.

There are systolic (max) blood pressure, when the first sound is heard, and diastolic (min) blood pressure, when the sounds stop.

The difference between systolic and diastolic pressure is called pulse pressure.

The value of blood pressure depends on:

─ state of the nervous system;

─ age;

─ time of day.

Normal blood pressure numbers range: systolic from 140 to 100 mm Hg; diastolic from 90 to 60 mm Hg. The proper blood pressure figures characteristic of a given age can be determined by the formula: blood pressure max = 90 + n, where n is the patient’s age.

Blood pressure in the hospital is measured once a day (more often if indicated), the result is noted in the medical history in the temperature sheet graphically with a column of red paste (value of 1 division = 5 mm Hg).

High blood pressure – hypertension (arterial hypertension). Low blood pressure – hypotension (arterial hypotension).

SIMPLE PHYSIOTHERAPY

Physiotherapy("therapy"-therapy - treatment, " phisio"- physio - nature, influencing factors) call the healing effect on the human body for therapeutic purposes of various natural physical factors: water, heat, cold, light, electricity, electromagnetic field, ultrasound, etc. The therapeutic effect of the simplest physiotherapeutic procedures occurs due to the close connection between internal organs and individual areas of the skin that have a common innervation. The impact occurs through the skin, blood, blood vessels, and nerve receptors on the function of a deep-lying organ. For example, by influencing reflexogenic zones you can relieve headaches, lower blood pressure, etc.

The simplest physiotherapy includes:

· hydrotherapy;

· mustard plasters;

· medical banks;

· ice pack;

· warmer;

· compresses;

· hirudotherapy.

Benefits of simple physiotherapeutic procedures:

· centuries of experience and observations;

· effectiveness proven by scientific research;

· low risk and virtually no side effects;

· active participation of the patient;

· great confidence of the patient in the simplest physiotherapeutic procedures;

· ability to focus on patient problems.

Before you begin performing simple physiotherapy manipulations, you must complete the following: nursing activities.

Explain the essence of the procedure to the patient;

· obtain consent for the procedure;

· prepare the patient (morally and psychologically);

· prepare equipment for the procedure;

· observe infection safety of the patient and healthcare worker;

· observe safety precautions when performing simple physical procedures;

· perform physical procedures strictly according to the algorithm.

HYDROTHERAPY. HEALING BATHS

Water is an invaluable gift of nature, without which the existence of life on Earth is unthinkable.

Hydrotherapy(hydrotherapy) - external use of water with medicinal and preventive purpose. For this purpose, the following is carried out:

· therapeutic baths (general and local: foot and hand);

· dousing;

· rubbing, wiping;

· bathing;

· wet wrapping (wrap).

Classification of baths according to temperature conditions.

1. Cold (up to 20°C) and cool (up to 33°C) general baths have a tonic effect, increase metabolism, stimulate the function of the cardiovascular and nervous systems. Their duration is no more than 1 - 3 minutes.

2. Warm baths (37 - 38°C) reduce pain, relieve muscle tension, have a calming effect on the central nervous system, and improve sleep. Their duration is 5 - 15 minutes.

3. Hot baths (40 - 45°C) increase sweating and metabolism. Their duration is 5 - 10 minutes.

4. Indifferent baths (34 - 36°C) cause a slight tonic and refreshing effect. Their duration is 20 - 30 minutes.

According to the composition of water, medicinal baths can be:

· simple (fresh) - from fresh water;

· aromatic - from water with aromatic substances introduced into it;

· medicinal – with the addition of medicinal components;

· mineral – with mineral waters and gases (hydrogen sulfide, carbon dioxide, radon, with mineral water, etc.).

Sequence of actions when assisting a patient during hydrotherapy.

1. After thorough treatment, the bathtub is filled first with cold water and then with hot water (to avoid steam in the bathroom).

2. The water temperature is measured with a water (alcohol) thermometer. It is lowered into the bath for one minute and, without removing it from the water, the thermometer readings are determined on a scale.

3. The patient is immersed in water (if a general bath is prescribed - up to the xiphoid process, if a half-bath - up to the navel).

4. A towel should be placed under the patient’s head, and a stand should be placed at the feet (to support the legs).

5. It is necessary to monitor the patient's condition. If the condition changes (the patient turns pale, the skin becomes cold, chills, headache, dizziness, rapid increase in heart rate, palpitations, shortness of breath appear), the nurse should immediately stop the procedure and inform the doctor.

6. After completing the procedure, the patient should rest for at least 30 minutes.

MUSTARD PLASTERS

The mechanism of action of mustard plasters is due to the influence of essential mustard oil, which causes dilation of skin vessels, a rush of blood to the corresponding area of ​​the skin and a reflex dilation of blood vessels in deeper tissues and organs. Mustard plasters also have absorbent, analgesic and distracting effects.

Indications for use: inflammatory diseases of the respiratory tract (tracheitis, bronchitis, pneumonia), hypertensive crisis, angina pectoris, myositis, neuritis.

Contraindications: various skin diseases, fever (above 38 0 C), pulmonary hemorrhage, sharp decrease or absence of skin sensitivity, malignant neoplasms.

Sequence of actions during the procedure.

Equipment: tray with water (40-45 0 C), napkin, water thermometer, towel or diaper, fresh mustard plasters suitable for use.

1. Make sure the mustard plasters are suitable (the specific smell must be retained).

2. Ask the patient to lie down in bed and examine his skin.

3. Measure the temperature of the water in the tray with a water thermometer.

4. Shake the mustard plaster package horizontally to distribute the powder evenly throughout all cells of the package.

5. Lower the bag, without changing position, into the tray of water for a few seconds.

6. Remove the mustard plaster from the water and apply the porous side of the bag tightly to the patient’s skin.

7. Cover the patient with a towel and blanket.

8. Mustard plasters are kept for 5 - 15 minutes. Every 2 - 3 minutes, bending back the edge of the mustard plaster, inspect the skin reaction for the presence of hyperemia.

9. As soon as the skin turns red, remove the mustard plasters.

10. Dry the skin with a dry cloth and cover the patient warmly again.

11. Ask the patient to lie down for 30 minutes and not go outside for two hours.

During the procedure, there may be a skin burn with the formation of blisters (with prolonged exposure to mustard plasters).

There are other mustard procedures: mustard wraps, baths (general and local), mustard compress.

MEDICAL BANKS

Medical cups are placed on those areas of the skin where the muscle-fat layer is significantly pronounced. Using the circular method, banks are placed on chest from behind, bypassing the spine, shoulder blades and kidney area. Banks along the spine are placed in one row on both sides in case of hypertensive crisis or hypertension.

The mechanism of action of medical cups is based on the creation of a vacuum in the jar. It sticks to the skin, and under it, as well as in deeper organs, blood and lymph circulation increases, tissue nutrition improves, as a result of which inflammatory foci resolve faster. In addition, in places there is a rupture of blood vessels with the release of biologically active substances (histamine, serotonin), which have an anti-inflammatory effect. Banks also act as a distraction.

Indications: inflammatory diseases of the respiratory tract (tracheitis, bronchitis, pneumonia), hypertensive crisis, osteochondrosis, neuralgia, radiculitis.

Contraindications: pulmonary hemorrhage, pulmonary tuberculosis, malignant neoplasms, various rashes and skin lesions, general exhaustion of the body, agitation of the patient, high fever, age under three years.

Sequence of actions when placing cans.

Equipment: cotton wool, a clamp, a forceps (or a metal rod with a thread at the upper end for cotton wool), clean dry jars with edges checked for integrity (10 - 20 pcs.), Vaseline, alcohol (or cologne at home), spatula, matches , towel or diaper, napkins.

Preparation for the procedure. Wash medical jars warm water or wipe them with alcohol. Place them at the patient's bedside. Make a filter using cotton wool for a forceps.

1. Explain to the patient the essence of the procedure.

2. Place the patient in a comfortable position. When placing the cans