From Big Medical Encyclopedia

Patient care. Contents:


of patient care............ 149

Patient care by children..... 151

Patient care of advanced and senile age......... 152

Care of surgical patients. 152 Features of patient care after urological operations.153 Features of patient care after gynecologic operations 153 Care of dental patients............... 154

Care of otorhinolaryngological

patients............ 154

Care of ophthalmologic patients.............. 155

Patient care by skin and venereal diseases....... 156

Care of infectious patients. 156 Care of neurologic patients 156 Care of mentally sick...157 Leaving — set of the actions providing vsesto

early service of the patient, creation of the optimal conditions and a situation promoting favorable disease, bystreyshy recovery facilitate

a niya of sufferings and to prevention of complications, performance of medical appointments.

Philosophy of patient care. At. divide into the general and special. The general At. includes a gigabyte. the maintenance of the room, in Krom is the patient, maintenance ought a gigabyte. conditions of the most sick, care of a convenient bed, its purity and clothes of the patient, catering services of the patient, assistance at meal, a toilet, fiziol. departures etc., accurate and timely implementation of all ordered medical procedures and medicinal appointments, and also continuous overseeing by dynamics of health and a condition of the patient. Features At., caused by specifics of this or that disease or damage, designate the term «special leaving».

At. it is not opposed to treatment (see Therapy), and integrally enters it as a component. Correct At. assumes creation of a favorable household and psychological situation at all stages of treatment. It is under construction on the principles of the guarding mode preserving and sparing mentality of the patient. Any elimination of excessive irritants, ensuring silence, rest, creation of a situation of a cosiness promote maintenance at sick optimistic mood, confidence in a happy end of a disease. Successful performance of numerous actions on At. demands not only the corresponding skills, but also the compassionate attitude towards the patient, sincere generosity. Diseases, physical sufferings generate an acrimony, feeling of alarm, feeling of dissatisfaction, sometimes even a hopelessness, the discontent turned to medical staff or relatives. It is necessary to oppose to this burdensome attitude keenness, a step, ability to encourage, support the patient. It is also important to protect the patient from negatively influencing factors and from excessive attention to the state (see the Deontology medical). Organization U. and its performance in hospital and polyclinic uslov.iya — obligatory and very responsible section of activity of medical staff. In house conditions At. it is carried out by relatives of patients at consultation and under control of medics.

The room intended for the patient shall be spacious, light and, whenever possible, protected from noise, isolated. The abundance of air and light, an optimum temperature schedule indoors exert beneficial effect on an organism at any disease. In the absence of the conditioner the room is aired. In the city air flow in a night vrekhmya since in the afternoon air is more contaminated by dust and gases is preferable (especially in districts of big traffic congestion). For protection of the patient against a cold flow of air during airing of the room his body is well covered with a blanket, and the head — a towel or a scarf, the person leave open. Can be opened by summer of a window round the clock, it is necessary to open transoms (window leaves)

3 — 5 times a day in the winter. Inadmissibly instead of airing to fumigate the room with various flavoring means.

Temperature indoors shall be a constant, within 18 — 20 ° (it is especially important that the room did not cool down by the morning), relative humidity of air — 30 — 60% (see the Microclimate). In need of increase in humidity in the room put vessels with water or put the humidified rags on heating batteries, for reduction of humidity strenuously air the room. The abundance of daylight is necessary for the patient, the view of the sun and the sky favorably influences his mood and a state. Luminous intensity should be reduced only at diseases of eyes and nek-ry diseases of a nervous system. Electric bulbs shall be covered with opaque lamp shades, and leave at night included only in lighting fixtures of low heat (night lamps).

It is necessary to maintain purity of the room carefully. Cleaning it is necessary to carry out at least 2 times a day: window frames, doors, furniture wipe wet rags, wash the floor or wipe with the brush wrapped by wet rags. Carpets, portieres and other objects where dust can accumulate, it is preferable to remove or to shake out or clean often the vacuum cleaner. Noise-protective measures are always necessary: isolation from transport, street and production noise, decrease in loudness of sounding of TVs, radio receivers, etc., a conversation in a low voice.

The correct transportation of the patient is very important. Seriously ill patients are transported carefully, avoiding pushes, on a special chair, a wheelchair or transfer on a stretcher. A stretcher with the patient carries 2 or 4 persons, going without cadence, short steps. On hands and a rearrangement of the patient 1, 2 or 3 persons can carry out carrying. If the patient is transferred by 1 person, then it brings one hand under shovels, another — under hips of the patient; at the same time the patient holds bearing hands for a neck. At a rearrangement of the seriously ill patient from a stretcher on a bed a stretcher puts at right angle to a bed so that the foot end of a stretcher was closer to the head end of a bed. Before a rearrangement of the seriously ill patient check its readiness, existence of bedside accessories and individual objects of leaving for a bed. The podkladny oilcloth, an urinal, a rubber circle, a bed-pan are necessary for seriously ill patients. The bed of the patient shall be the sufficient length and width, with the plain surface convenient and tidy. It is desirable to use a multisection mattress, atop to-rogo put a sheet, if necessary under a sheet enclose an oilcloth. In some cases, napr, at damages of a backbone, under a mattress put a firm board. Such placement of a bed is desirable, a cut allows to approach the patient on both sides, the bed should not be put near sources of heating of the room.

The seriously ill patient help to undress, take off footwear, in special cases if necessary carefully cut clothes.

Change of bed linen by the seriously ill patient needs to be made skillfully, without creating for them an inconvenient pose, forced muscular tension, without hurting. The patient is carefully removed on edge of a bed, the released part of a sheet is skatyvat as bandage, up to a body of the patient; on this part of a bed spread a fresh sheet, on to-ruyu and shift the patient. The sheet can be skatyvat in the direction from legs to the head (if the movements even in a bed are prohibited the patient). At first skatyvat the foot end of a sheet to a waist, enclose a fresh sheet, then remove the replaced sheet from under an upper body, carefully straighten folds of a fresh sheet, its edges attach safety pins to a mattress. During the change of bed linen it is necessary to shake out a blanket.

Changing the seriously ill patient a shirt, bring a hand under his back, lift a shirt to a nape, remove a sleeve from one hand, then with another (if one hand is injured, at first release healthy). Put on a shirt, since a sore hand, then through the head lower it on a back to a sacrum and carefully straighten folds. If the patient absolutely cannot move, put on a shirt baby's undershirt. The linen contaminated by allocations or blood before sending to a laundry is presoaked in the clarified solution of lime chloride (see) also dry up.

Depending on weight and the nature of a disease to the patient appoint various mode: strict bed (it is not allowed to sit), bed (it is possible to move to beds, without leaving it), on-lupostelny (it is possible to go on the room) and a so-called general regime, at Krom a physical activity of the patient is significantly not limited.

At a bed rest fiziol. departures are carried out in a bed. The patient are given purely washed up and disinfected bed-pan (the special device for collecting excrements), in a cut pour a little water for absorption of smells. The vessel bring iod of a buttock so that the crotch appeared over a big opening, and a tube between hips; at the same time the free hand is enclosed under a sacrum and raise the patient. Having exempted the vessel from excrements, it is carefully washed out hot water and disinfect 3% solution of lysol or chloroamine. The urinal (a vessel for collecting urine) is given also well washed up, warm. After each urination urine is poured out, the urinal is washed out solutions of potassium permanganate and hydrosodium carbonate, weak solution hydrochloric (salt) to - you.

All objects of leaving, necessary tools and stock shall be stored in a certain place and to be ready for application. Bed-pans, urinals, bubbles for ice, hot-water bottles, rubber circles after washing by hot water and rinsings of 3% solution of chloroamine store in special cases. Colonic tubes, probes, catheters and tips of enemas are washed with hot water with soap and boiled within 15 min. Tips of enemas store in the separate marked ware. Beakers, invalid's cups, banks boil. At an opportunity it is recommended to use objects of leaving and tools disposable. Medical stock (beds, stretcher, chairs, wheelchairs, cases, etc.) periodically disinfect 3% solution of lysol and chloroamine, daily wipe with wet rags or wash with soap.

Essential significance is attached to personal hygiene of the patient. The patients coming to a hospital except for being in critical condition, subject a dignity. to processing (a bathtub, a shower or wet rubdown, if necessary — a short hairstyle with disinsection processing of a pilar part of skin). The patients needing assistance are lowered in a bathtub on a sheet or put on the stool put in a bathtub and washed by means of a manual shower. The seriously ill patient rub off a body the tampon moistened with warm water with soap, then water without soap and dry wipe. Nails on hands and legs of the patient shall be shortly cut. In the absence of contraindications it is necessary to take a bath or a shower at least 1 time a week. If the bathtub and a shower are contraindicated, then the body of the patient should be rubbed off daily the cotton plug moistened with boiled or floral water. The face, a neck and an upper part of a trunk need to be washed daily, hands — before each meal, legs — daily before going to bed, at a high bed rest — 2 — 3 times a week. Skin of generative organs and an anus needs to be washed daily, at seriously ill patients — at least 2 times a day. At a podmyvaniye under buttocks of the patient enclose the vessel; the patient during this procedure is in situation on spin with the legs bent in knees. For a podmyvaniye it is convenient to use the Esmarch's irrigator supplied with a rubber tube with the tip having the crane or a clip (see fig. 1 to St. Enemas, t. 10, p. 451). The water jet or weak solution of potassium permanganate is directed to a crotch, by at the same time cotton plug carried out in the direction from generative organs to an anus. Other cotton plug drain skin of a crotch, conducting it in the same direction. This procedure can be performed also using a jug, in to-ry pour warm disinfecting solution.

Axillary areas, inguinal folds, folds of skin under mammary glands, especially at corpulent and at persons with the increased perspiration, it is necessary to wash often in order to avoid development of an intertrigo (see).

The seriously ill patients exhausted and being a long time on a bed rest need especially careful care of skin for the prevention of decubituses (see). For this purpose it is necessary to keep a bed in a strict order (to eliminate roughnesses, to smooth folds of a sheet); it is constant to watch purity of skin, to wipe it 1 — 2 time a day with kakhmforny alcohol, to powder talc; to enclose the rubber circles wrapped by pillowcases under the places which are exposed to pressure (e.g., under a sacrum), to often change position of the patient in a bed (to turn it).

Care of hair of patients consists in washing by their warm water with soap and careful combing; washing of the head is carried out by the seriously ill patient to beds. At the patients who are on a long bed rest at insufficient a gigabyte. care of legs on soles thick horn stratifications as manifestation of a scaly form of an epidermophitia are sometimes formed (see). In such cases mechanical removal of horn masses and after-treatment of skin is recommended by antifungal means (see).

Care of an oral cavity consists in toothbrushing by a toothbrush (at least 2 times a day), rinsing of a mouth after each meal. The seriously ill patient wipe teeth with the wadded ball moistened 0,5% with solution of hydrosodium carbonate, 5% solution of sodium tetraborate (borax), weak

solution of potassium permanganate or the truck-tsillpna. Washing of an oral cavity is made by means of the syringe or a rubber bulb. In order that liquid did not get into airways, the patient is given situation with the head which is a little inclined forward, for the best outflow of liquid delay a corner of a mouth. Apply 0,5% to washing solution of hydrosodium carbonate, 0,9% solution of sodium chloride, 2 — 5% solution of borax, solution of potassium permanganate (1:10 Ltd companies).

Care of ears assumes regular washing by their warm water with soap, careful removal of cerumen impaction from outside acoustical pass by the water jet which is released from a rubber bulb (previously in outside acoustical pass pour in several drops of 3% of solution of hydrogen peroxide).

Care of eyes is necessary in the presence of the allocations which are sticking together eyelashes and eyelids that is more often observed at children. In these cases carefully cotton plug moistened in 2% solution boric to - you, soften and delete crusts. Usually eyes and wash out in the morning the tampon moistened with boiled water in the evening.

Care of a nose is carried out in the presence of allocations and formation of crusts. Crusts delete, previously having softened them a liquid paraffin or glycerin.

Important element U. feeding of seriously ill patients according to the ordered diet and a diet is (see clinical nutrition). Bed patients during meal should give the situation allowing to avoid exhaustion. As a rule, they are given sublime or polusi-dyachy situation. The breast and a neck of the patient are covered with a napkin. The weakened and in a fever patients should be fed during the periods of improvement of a state, in a dropping period. Such patients are spoon-fed, the food (wiped or crushed) given in the small portions. It is not necessary to interrupt a day dream for feeding if the patient has sleeplessness. Allow to drink the seriously ill patient from an invalid's cup.

Patients, to-rye cannot swallow food, transfer to artificial nutrition (see artificial nutrition).

Overseeing by a condition of the patient — an indispensable condition of successful treatment. To the persons which are carrying out At., it is necessary to report to the attending physician about all changes, to-rye occur in a condition of the patient. At the same time it is necessary to pay attention to position of a body of the patient, a condition of mentality, a dream, a look, coloring of skin, emergence on it of rashes, a respiration rate, existence of cough, discoloration and character of urine, a calla, phlegms, to make on the instructions of the doctor thermometry (see) bodies, weighing to measure a ratio of the emitted and drunk liquid and to carry out other special observations.

It is necessary to watch that reception by the patient of drugs strictly corresponded to recommendations of the doctor. For drug intake shall be inside prepared a decanter with boiled water and pure beakers.

The seriously ill patients having diseases of a respiratory organs need to be overturned regularly in a bed in order to avoid hypoventilation (see. Lung ventilation) and other complications, at an asthma (see) it give a pose, convenient for breath (enclose an additional pillow, the roller, use chairs, etc.). For the best otkhozhdeniye of a phlegm the patient is given takae situation, at Krom is carried out more free and full drainage of bronchial tubes. The phlegm is collected in the individual spittoon with the turned stopper which is previously filled on 1/3 chloroamine. To the patient help to master the recommended complex of respiratory gymnastics.

At At. for patients with cardiovascular diseases much attention is paid to providing the recommended mode (bed, restrictedly active or training) that is especially important in an acute stage of a disease when reduction of load of the heart reached by absolute physical and mental rest is necessary. For most of patients situation with the raised upper half of a body is most convenient and physiologic. At emergence at sick fear of death — one of frequent and very burdensome feelings at heart diseases — a certain psychological influence from people around is necessary. Lack at them of a fright and fussiness, right tone in the address to the patient (ability to dispel fear, to encourage and not to be persuasive) create an optimum psychoemotional situation.

Features At. with diseases followed patients. - kish. a path gripes (see), nausea (see), vomitings (see), frustration of a chair are connected with frequent existence at them of abdominal pains (see Locks, Ponosa). At the same time the persons who are looking after the patient shall give him required help — to timely bring a tray or a basin at vomiting, to help to accept a convenient pose, to prepare solution for rinsing of a mouth or for a gastric lavage (see), for an enema (see), to prepare a hot-water bottle or a bubble with ice, to strengthen them over the necessary area of a stomach, to replace timely.

Emetic masses always shall look round medical staff in the diagnostic purposes, impurity of blood, and also emetic masses in the form of a coffee thick shall cause special alarm (see. Gastrointestinal bleeding). During the overseeing by the patient it is necessary to watch his activity, adequacy of behavior (at a liver failure), the sizes of a stomach, defense reaction of a front abdominal wall (see. Muscular protection a symptom), skin color, urine and a calla (see Jaundice).

Patient care by children. Specifics At. for sick children of different age consists in features of direct overseeing by the sick child, communication with it, a technique of collecting of material for laboratory researches, holding medical procedures.

Creation gigabyte. situations for the sick child there is of the general a gigabyte. the installations shown to premises of children's BCs (see. Children's hospital), features of hygiene of the newborn (see) and the baby (see).

The small chambers or boxes (see) closed and opened are necessary for children of early age. At suspicion on inf. a disease the child shall be placed in the isolation center (see) with the special equipment. For mothers hospitalized together with children the bedroom and the dining room shall be allocated. For walks of sick children allocate a verandah or special rooms with constantly open windows. Beds for children of chest age shall have the high going-down or folding walls. In a bed put a rigid mattress from a horsehair, basts, a sea grass. It is impossible to apply mattresses from down or a feather. Under a head enclose a flat small pillow.

Air temperature in chamber for the premature child (see. Premature children) shall be 22 — 26 ° depending on body weight, for full-term — 20 °. Daily systematic airing of chambers is necessary at all seasons of the year. The clothes shall be easy, warm and not constrain movements of the child. For swaddling of premature children it is convenient to use envelopes. Free swaddling is shown to children, with normal function of thermal control irrespective of the weight of their body, age and the location (the open couveuse, a bed).

A basis At. for newborns (and premature) respect for the most strict purity, in some cases — sterility is full-term. Are not allowed to At. for but-voro zhdenny persons with acute and chronic inf. diseases. Carrying woolen things and rings is inadmissible. The personnel are obliged to follow rules of personal hygiene strictly. to work in the gauze mask replaced each 3 hours. Monthly at all employees of department it is necessary to conduct researches of slime from a nose and a pharynx on a carriage of diphtheritic sticks (see Diphtheria), a hemolitic streptococcus (see Scarlet fever), hemolitic staphylococcus (see. Staphylococcal infection). Check of lack of stafilokokk in washout from hands is made also once a month.

The special attention is required by care of an umbilical wound (see the Navel, umbilical area), to-ry shall be carried out in strictly aseptic conditions. Daily make a toilet of the newborn: eyes of a proma

howl the sterile cotton wool moistened in solution of potassium permanganate (1: 10 Ltd companies) or solution of Furacilin (1:5000), in the direction from the outer edge to internal; the nose is cleared the wadded wicks moistened in prokipyachenny vegetable oil; the child is washed, grease skin folds; wash away after each act of defecation.

Daily survey of a pharynx of the sick child is necessary. Every day register temperature, body weight, quantity and quality of excrements, existence of vomiting, vomiting, fits of coughing, asphyxia, spasms. Weigh children in the morning, prior to the first feeding.

At purpose of walk consider the body weight, age of the child, season and local climatic conditions. Premature children can be submitted for walk aged 3 — 4 weeks during the spring and summer period at achievement of the weight of 2100 — 2500 are more senior by them, in autumn and winter — at achievement of weight of 2500 — 3000 g. The first walk of these children shall not exceed 5 — 10 min. in the winter, and in the summer — 20 — 30 min. — 3 weeks age walks are allowed the full-term children with 2 in the winter at air temperature — 10 ° in the absence of wind. If at the child cyanosis, cough amplifies, there is a pallor, concern, walk stops.

The organization of feeding of the sick child demands from personnel of special clearness, consistency and ability. Difficulties of feeding can be caused by an underdevelopment of a sucking reflex, existence of inborn uglinesses, failure of the child from food, unconsciousness, etc. In such cases feeding is made through a gastric tube, through a pipette, from a spoon; apply parenteral (see. Parenteral food) and rectal food.

Collecting at children of material for laboratory researches presents difficulties and demands special skills. Children up to 5 — 6 years do not cough up a phlegm. Therefore at the moment when the child coughs, the pallet, holding a root of language, remove a phlegm a sterile tampon, to-ry then enter into a sterile test tube. At babies the phlegm is removed from a stomach by means of the probe entered into a stomach on an empty stomach. Capture of blood for serological, biochemical and other researches is made by a venipuncture (see). Excrements for bacterial. researches collect by the glass tube which is melted off since both ends, to-ruyu will sterilize and enter into an anus. The tube filled with excrements is closed since both ends sterile cotton wool, lowered in a test tube and sent in laboratory. Excrements for a research on eggs collect a worm in purely washed glasswares of the small size. Purely pared down stick of kcal take from 5 — 6 different places, then densely cover ware with white paper (see. Helmintologic methods of a research).

Patient care of advanced and senile age is made taking into account features of the growing old organism, decrease in its adaptive opportunities, an originality of a course of diseases at elderly people and age changes of mentality. Feature of many diseases at elderly people is the atypical sluggish current without the expressed temperature reaction, local changes and rather bystry accession of heavy complications.

Exposure of elderly people inf. to diseases, inflammatory processes obliges to especially careful a gigabyte. to leaving. Elderly people quite often show hypersensitivity to changes of a microclimate, diet and diet, lighting, to noise. Features of mentality and behavior of the old person (emotional instability, easy vulnerability, and at vascular diseases of a brain — falloff of memory, intelligence, criticism, helplessness, and sometimes and slovenliness) require special attention and the patient sympathetic relation of service personnel.

The period of a high bed rest for elderly patients follows at an opportunity to reduce, appointing massage (see) for the fastest return to the usual motive mode and respiratory gymnastics for prevention of congestive pneumonia as soon as possible.

Care of surgical patients is determined by actions but training of the patient for operation,

by the prevention of complications,

to-rye can arise during operation, in the period of an anesthesia and in the postoperative period (see Anesthesia local, the Anaesthesia, the Surgery field, the Postoperative period, the Preoperative period).

From the operating table of the patient transfer to a wheelchair and bring to chamber, watching that during the transportation not to cause to

a polnitelny injury, not to displace the applied bandage, not to break a condition of systems of a transfusion.

The patient after operation remains under observation of experienced personnel before independent awakening from an anesthesia. The head of the patient shall be located low, without pillow. During the developing of postanesthetic vomiting the head is turned on one side. As a result of retraction of language or aspiration of slime the patient can have an asphyxia (see). In these cases it is necessary to push forward a mandible and to extend language, to remove a tampon slime from a throat, to cause a tussive reflex (see Cough).

After awakening the patient is given such situation, a cut is for it the most sparing and does not intrude upon leisure of a wound. E.g., a sublime, semi-sitting position, at Krom respiratory excursions are considerably facilitated, it is recommended after a laparotomy (see), and also after thorax operations. Situation on a stomach is applied by hl. obr. after backbone operations.

It is necessary to aim to begin motive activation of the patient for the purpose of prevention of pneumonia, thromboembolisms and other complications as soon as possible.

Even at a smooth current the postoperative period quite often is followed by the phenomena, not dangerous, but painful for the patient — pain, sleeplessness, thirst, an ischuria and gases, a hiccups, to-rye the most burdensome happen in the first two days after operation. Before the termination of vomiting it is not necessary to allow to the patient to drink because of possible strengthening of vomiting. For an ukhmensheniye of dryness in a mouth the patient is allowed to rinse a mouth. After the termination of vomiting, as a rule, it is possible to give water or rather weak tea in small amounts. Apply analgetics to reduction of pains, impose on area of a wound a bubble with ice, watching that he did not put the strong pressure upon a wound. Sometimes pain causes too hardly or incorrectly applied bandage. In this case it is necessary to cut it or to replace, at an opportunity to replace with a bandage in the form of a sticker. After extremity operations pain can be a consequence of its wrong situation. The good immobilization and sublime position of an extremity reduce pain.

The delay of a mocheotdeleniye is often observed after operations on pelvic bodies, after appendectomy; nek-ry patients cannot urinate in horizontal position. Apply heat on area of a bladder to reduction of a reflex spasm of a sphincter, use pharmaceuticals. In the absence of effect make catheterization of a bladder (see Catheterization of uric ways)] at the same time it is necessary to use preferential soft catheter.

Features of patient care after urological operations. In the first days after mono - or a bilateral nephrectomy (see) for patients establish continuous observation, carefully watch a condition of functions of cardiovascular system, breath, acid-base equilibrium, electrolytic balance for the purpose of timely use in case of need of dialysis (see. Artificial kidney) or hemosorptions (see t. 10, additional materials). Control and provide efficiency of drainages in an operational wound. From the first day apply respiratory gymnastics and gymnastic exercises in a bed.

After operation of removal of a bladder (see the Cystectomy) and changes of ureters in a sigmoid gut (see. At re rubbed about plastics) during the first hours and days pay attention to passability of the tubes intubating ureters removed through an anus. In need of a tube wash out sterile isotonic solution of sodium chloride. In order to avoid a reflux the amount of the liquid entered into a gleam of the intubating tube shall not exceed 5 ml.

Organ-preserving kidney operations often are followed by drainage (see) pelvis or an ureter (separately or at the same time) for the term of 2 — 4 weeks. At At. for the patient during this period it is necessary to monitor smooth functioning of a drainage tube. The termination of functioning of a drainage conducts to flowing of urine in pararenal or retroperitoneal space. For removal of possible clots the tube is washed out sterile isotonic solution of sodium chloride (5 ml).

Looking after patients after bladder and prostate operations shall control carefully passability of drainage tubes, watch that there was no excess of tubes from a postural change of a body of the patient in a bed. Sometimes passability of a drainage is maintained by constant drop irrigation by its solution of Furacilin 1:5000. Do not allow course of urine by a drainage tube, a cut can cause suppuration of a wound, development of phlegmon, maceration of skin around a wound, formation of decubituses and other complications.

At At. for patients, at to-rykh on long terms drainages in a kidney (nefrostom), in the bladder (tsistostom) or ureters brought to skin (ureterokutaneostom) are established, pay much attention a gigabyte. to processing of skin around a drainage opening. Patients are under constant observation of the urologist, to-ry shall determine the frequency of washing of a drainage tube and frequency of its change in each individual case.

Features of patient care after gynecologic operations are in many respects caused by anatomic proximity of generative organs of the woman to bodies of a mocheotdeleniye, a rectum and an anus.

The toilet of external genitals both to, and after an operative measure is carried out by 2 times a day using disinfecting solutions (potassium permanganate 1:10 000, Furacilin 1:5000, etc.) «Under buttocks of the patient enclose the vessel and the cotton plug taken by a packer wash external genitals from top to down, and then dry up a dry tampon. Patients, the Crimea it is authorized to go, carry out a toilet of external genitals to a gigabyte. to the room. According to indications (existence of seams in a vagina or patol. allocations) make syringing of a vagina (see. Vulval syringings) or apply medicinal vulval trays. Seams in a vagina and on a crotch as required are examined and processed solutions of hydrogen peroxide, a dioxidin, spirit solution of iodine, tetraethyl-diamino-triphenyl-carbohydride sulfate or other disinfecting drugs.

Forced stay in a bed complicates recovery of function of an urination. Therefore in the preoperative period it is recommended to teach the patient to urinate in lying situation. After operation with the purpose of simplification of an urination under buttocks of the patient enclose the warmed vessel, in the absence of contraindications place a hot-water bottle on a bottom of a stomach, if necessary make catheterization of a bladder with observance of rules of an asepsis. The number of catheterizations depends on a daily urine (usually enough 3 times in су^кп). For the purpose of prevention of cystitis and the ascending infection after its emptying enter 10 ml of 2% of solution of colloid silver of 1 times a day into a bubble.

Recovery of an urination accelerates at an early rising of patients — in 48 hours after vulval operations, including operations for a rupture of a crotch of the third degree i.e. when the sfinkterolevatoroplastika is made. The early rising is necessary also to prevent development of hypodynamic status. It is necessary to teach patients to rise correctly (in the beginning having turned on a stomach).

Features it is recoverediya functions of intestines depend both on the volume of operation, and on preoperative training of patients. So, after a front colporrhaphy (see), colpoperineoplasties (see), a median colporrhaphy on Lefora (see Lefor — Neygebauera operation) and a vulval hysterectomy release intestines for

the 4th days by means of a cleansing enema. After operations for a rupture of a crotch of the third degree when the sfinkterolevatoroplastika is made, defecation detain to 8 — the 9th day. For this purpose for 3 — 4 days before operation of patients transfer to a probe diet, and on the eve of operation give laxative and cleansing give enemas. The first 3 days are only allowed to drink, and then give liquid food. To the 7th days appoint inside a liquid paraffin (on 30 ml 3 times a day) for the purpose of simplification of defecation.'

Other way assumes cancellation of good nutrition of patients one day before operation, an enteroclysis via the probe entered into a stomach, 10 — 11 l of solution of sea salt (at the rate of 11 g of salt on 1 l of water at t ° 37 °), to-ry enter with a speed of 3 l of 1 hour. In day of operation give an enema cleansing. After operation by the patient it is allowed to drink and during 3 days they receive the parenteral food allowing to compensate deficit of energy resources and plastic substances. For the 4th days of patients translate on probe, and from the 7th day — to a usual diet. Function of intestines is recovered independently on 8 — the 9th days. The patients who underwent an operation for purulent inflammatory processes in appendages of a uterus, a pelviperitonitis, a bartholinitis need to provide care of a wound and functioning of drainages. It is better to use two-pro-svetnye drainage tubes, the ends to-rykh lower in bank with disinfecting solution of ohms.

Care of dental patients. Features At. for stomatol. patients in the postoperative period and at injuries of jaws connected generally with difficulties of reception beggars and drink in the regular way with disturbance of functions of chewing, swallowing, the speech, breath. Patients should give a semi-sitting position, a cut promotes reduction of bleeding and improvement of function of breath, prevents aspiration of slime, blood, pus.

The neck and a breast of the patient for protection from allocations from an oral cavity and from bandages are covered with an oilcloth.

In the first days after operation by the patient it is necessary to prohibit to tell and accustom them to communicate in writing. In 6 — 7 days, on the contrary, it is necessary to induce in every possible way the patient to oral speech. since the speech promotes self-cleaning of an oral cavity.

Hygiene of an oral cavity is important part U. Many patients, and especially those, at to-rykh in an oral cavity are various tires and shiniruyushchy devices (see Shinirova-vaniye in stomatology), cannot independently clear an oral cavity therefore such procedure is carried out by the looking after personnel. It is the best of all to make washing of an oral cavity from an Esmarch's irrigator with an individual tip for each patient, it is possible to use a rubber bulb also. Washing is made warm solution of potassium permanganate in cultivation 1:3000. Before washing it is useful to process an oral cavity solution of hydrosodium carbonate at the rate of 1 table. l. on 1 l of water. Position of the patient during washing — sedentary or semilying. The breast of the patient is closed a waterproof apron. A dental surgery mirror or the pallet hold a cheek and advance a tip in back departments of a threshold of an oral cavity, sending a fluid jet to top and bottom departments of the arch. Then the stream is sent through interdental spaces to an oral cavity. It is necessary to wash out a mouth at least

5 — 6 times a day and it is obligatory after each meal. After washing of an oral cavity start cleaning of tires and orthopedic shiniruyushchy devices. Wipe with the tampon moistened with solution of hydrogen peroxide all spaces between tires and dentitions. This processing should be made behind beforehand. After such processing the oral cavity is washed out again. Removable tires and prostheses are washed with a brush with soap after each meal and before going to bed.

Much attention is paid to feeding of patients since independent meal at them is complicated. Patients are fed by means of an invalid's cup, to-rogo attach a rubber tube 20 — 25 cm long to outlet opening. The end of a rubber tube is entered into back departments of an oral cavity.

Liquid food is entered through a tube in the small portions, regulating giving by crossclamping of a tube. Food requires special machining. After heat treatment products as much as possible crush, pass via the meat grinder, a sieve then part with broth, milk, fruktovm juice to a slivkoobrazny consistence. Food shall not be hotter also than acute. During feeding of the patient accepts a sitting position, and in hard cases — lying with the raised head. Before feeding of the patient cover with an oil-cloth apron not to soil a bandage, clothes and bed linen. In case of impossibility of feeding by means of an invalid's cup resort to food by means of the nosozheludochny probe.

Feeding it is necessary to carry out 4 — 5 times a day by small portions.

After the end of feeding it is necessary to wash out an oral cavity a large amount of solution of hydrosodium carbonate and then solution of potassium permanganate (1:5000) or other disinfecting solution.

Care of otorhinolaryngological patients. At various diseases of an outside ear carry out a gigabyte. processing of an auricle and outside acoustical pass by sterile cotton wool, in need of moistened with isotonic solution of sodium chloride, liquid or other paraffin (during removal of crusts), alcohol (at a furuncle). Cleaning of acoustical pass with the cotton wool wound on an ear threaded probe shall be made with care since skin of acoustical pass is very sensitive and easily vulnerable. In the presence of plentiful purulent separated a gigabyte. processing is begun with washing of outside acoustical pass (see Ear irrigation) with the disinfecting solution (Furacilin, Rivanolum, etc.) which is surely warmed up to body temperature. Usually such processing is repeated depending on speed of accumulation patol. contents.

Directly after operation on an ear of the patient stack on the healthy party. After slukhuluch-shayushchy operations (see) for 5 days limit the movements of the head of the patient. For this purpose the head of the patient is fixed a strip of bandage to edges of a bed. It is necessary to observe a bed rest after radical ear operation (see Otitis) 2 days, after slukhuluchshayushchy operation — 5 days. At intracranial complications duration of a bed rest is caused by weight of a current of neurologic and septic complications.

The main objective of treatment after various options of operations on a middle ear is achievement of a full epidermization of walls of a postoperative cavity. It is carried out by systematic care of an auricle, zaushny area and of a wound cavity (release it from patol. contents, suppression in it of microflora, control of an excessive granulation, and if it insufficiently, stimulation of growth of granulations).

At. for the patient with acute or chronic rhinitis (see) later operations in a nasal cavity consists separated and crusts of the nasal courses by a suction, nasal tweezers and the nasal probe at a distance, for the end to-rogo cotton wool is wound: according to indications — washing of a nasal cavity various solutions (isotonic solution of sodium chloride, Ringe-ra solution — Locke, etc.) by means of their instillation and suction.

In the presence of the front or back tamponade of a nose made concerning nasal bleeding (see) or after operation in a nasal cavity At. for the patient consists in control of a condition of tampons, a stop of possible bleeding, especially on a back wall of a throat. The mitella after treatment by its ichor is timely changed. In the first days after paranasal sinuses operation disturbance of a slezoottok is possible. In these cases of 1 — 2 time a day wash out eyes of 2% solution boric to - you and dig in solution of a sulfacetamide sodium (albucid).

After a tonsilectomy (see Tonsillitis) the patient on a wheel-chair is brought to chamber, put to bed, usually on the right side, under a cheek enclose a towel or a sheet, on to-ruyu the saliva which is usually painted by blood shall flow down through a corner of a mouth. In process of the accumulation separated a laying change. Within an hour after operation put cold to a neck, in the field of a corner of a mandible (alternately on both parties), by the same technique, as after paranasal sinuses operation (see). The patient is recommended to lie with a half-open mouth, so that saliva flew down independently. Plentiful allocation on a laying of blood indicates the bleeding from tonsillar niches demanding immediate surgical audit. It is necessary to watch that the patient did not swallow blood (it causes vomiting). After removal of almonds allow the patient

meal in a day — in the beginning semi-fluid or in the form of jelly, acute products exclude.

At the diseases of a throat narrowing its gleam (edematous, inflammatory, tumoral processes, foreign bodys, paralyzes), patients are given situation in a bed with the raised upper half of a trunk. The major part U. control of a condition of external respiration is not to pass signs of strengthening of the stenosis of a throat demanding quite often immediate surgical help. After throat operations careful care of a bandage, a tracheotomic tube and a tracheostoma is necessary (see the Tracheostomy). Usually in a tracheotomic tube pour in 10 drops of isotonic solution of sodium chloride of 4 — 5 times a day for prevention of formation

of crusts. In the first days after operation change of a tracheotomic tube is made daily, if necessary suck away contents

from a trachea. After an extirpation

of a throat (see the Laryngectomy) leaving includes feeding of the patient via the nosopishchevodny probe.

Care of ophthalmologic patients. At. for patients with diseases and damages of an eyeglobe includes creation of emotionally sparing situation for the patient, assistance in self-service, in carrying out a gigabyte. procedures and performance of a number of specific appointments (instillation of drops, mortgaging of ointment, imposing of a bandage approximately, etc.). All manipulations are carried out carefully, without the excessive pressure upon an eyeglobe. The dressing material and medicinal substances applied in ophthalmology shall be sterile.

Washing of eyes is made for the purpose of disinfection of a conjunctival cavity, the removal separated, superficial foreign bodys, at burns. Previously having wiped eyelids with a wet cotton plug, they are moved apart index and a thumb of the left hand and irrigate a conjunctival sac with a stream of solution from an undinka or a rubber barrel, without touching eyelashes. During the procedure of the patient inclines the head, and liquid flows down in a tray, to-ry it keeps under a chin. At an instillation of drops the lower eyelid is delayed a wet tampon, press it to edge of an eye-socket, and released a pipette of 1 — 2 drop of liquid on a mucous membrane of a lower eyelid. At a smykaniye a century surplus of drops follows too much centuries and it is deleted with a cotton plug. In a conjunctival sac there are

no more than 1 drop therefore the instillation

more than 2 drops is inexpedient. Eye drops shall be a room tey-peratura. At an instillation of drops it is necessary to avoid a contact with the end of a pipette of eyelashes of the patient that can lead to infection of all solution in a bottle. A necessary condition is use for each patient of separate pipettes with the subsequent their sterilization.

In order to avoid mistakes at an instillation of drops it is necessary to have them on a tray in a certain order, on kazhdokhm a bottle there has to be a label with exact designation of contents and its concentration. Apply an eye tray to achievement of longer contact with a front piece of an eyeglobe of solutions of nek-ry pharmaceuticals, the configuration of reinforced edges a cut corresponds to edges of an eye-socket. At open centuries and inclined position of the head of the patient of eyes it is irrigated with liquid, a cut the tray is filled.

For the purpose of long influence of nek-ry medicinal substances apply plentifully moistened with solution of medicine thin (2 mm) the wadded turundas put by means of a glass rod in the lower conjunctival arch for 20 — 30 min.

Lotions make moistened with the cold or warmed-up solution (depending on indications) the sterile cotton wool enclosed to the closed centuries to-ruyu replace every 5 min.

Solutions of pharmaceuticals, quite often spirit, apply to greasing of ciliary edge a century after their preliminary degreasing. For this purpose use the cotton plug moistened with solution and wrung out which is hardly reeled up on the probe or the thin end of a glass rod. In order to avoid hit of solution on a conjunctiva and a cornea the lower eyelid is delayed from top to bottom, and upper removed from an eyeglobe easy pressing near edge of a century.

In Ophthalmolum. to practice widely use ointments, emulsions and gels, to-rye prolong effect of medicinal substance and reduce friction a century about a front surface of an eyeglobe. At a mortgaging of these dosage forms of the patient shall look up. The left hand delay a lower eyelid, apply with the wide end of a sterile glass rod a small amount of ointment on an inner surface of a century, holding a stick parallel to its edge, after a smykaniye the century a stick is extended.

Use of medicamentous drugs in the form of powder make by a stryakhivaniye since the wide end of a glass rod on an inner surface of a lower eyelid after procrastination it from top to bottom. Soluble eye medicinal films of 1 times a day enter tweezers into a conjunctival sac.

Care of eyes includes use of thermal procedures, cold and revulsives (bloodsucker). Apply the warming compress — to-ruyu from above cover imposing on the closed eyelids of the gauze napkin moistened with warm boiled water with compresseal paper or a thin oilcloth. Spirit and the poluspirto-Vyya compresses in eye practice do not apply. Dry heat is used in the form of the eye hot-water bottles or

bottles with a capacity about 15 — 20 ml filled with hot water of temperature not higher than 80 °. Lying on one side, the patient touches a hot-water bottle with the sore eye covered with a napkin within 30 min. Cold is appointed after a stupid injury and in the postoperative period. Pieces of ice or a cold water are placed in the rubber bubble wrapped in a napkin and put to a superciliary arch, avoiding pressure approximately.

On the eve of operation with vskrytiyelg an eyeglobe to the patient cut eyelashes. Just before operation it is necessary to remove dentures. After the end of operation to the patient apply a bandage both eyes (binocular) or one eye (monocular) depending on the nature of surgery. At first close eyelids a vatnomarlevy small pillow, to-ruyu fix then the bintovy bandage or strips of an adhesive plaster 0,5 cm wide located in parallel, at an angle to each other or crosswisely. If there is a need of imposing of a compressing bandage, then under a wadded and gauze small pillow place a dense cotton roll according to the place where it is necessary to make a compression, and then apply a bintovy bandage. Sometimes apply special metal eye gauzes.

The patient brought from the operating room to chamber on a wheelchair shall be on a high bed rest, terms to-rogo are defined by the nature of surgery. Postoperative At. includes an immobilization of the head of the patient, prevention of cough and vomiting. Later 6 — 8 hours after operation of the patient it is possible to feed with liquid or kashitseobrazny food. After cancellation of a bandage or a sticker apply special curtains to protection of the operated eye. They are trained from bandage or pieces of a gauze 7 — 8 cm wide, 14 — 16 cm long, fold double and thrown through a bintovy bandage in one tour around the head or fixed to a forehead an adhesive plaster.

Patient care by skin and venereal diseases. The patients suffering from skin diseases demand special leaving, features to-rogo depend on character and a stage of a disease. In the period of an acute inflammation of skin it is necessary to refrain from hydrotherapeutic procedures since moistening of skin (a bathtub, a shower, wiping by a wet towel) can do harm, promoting strengthening of an inflammation and exudation. At the nek-ry skin diseases (e.g., eczema, dermatitis) which are followed by acute inflammatory the phenomena and subjective feelings (burning, itch), for their reduction on doctor's orders by the becoming wet surfaces of skin impose lotions (see) from the knitting disinfecting solutions. Solutions for lotions shall be stored in the refrigerator, they should be taken out only before the procedures. After subsiding of an inflammation at absence a moknutiya it is possible to begin local hygienic washings of skin and local bathtubs. For cleaning of skin, removal from its surface of crusts and scales, a secret grease and sweat glands it is possible to use warm water, the tanning and disinfecting solutions. At the diseases which are followed by an itch, especially in the field of generative organs and an anus, washings by hot broth of a camomile have favorable effect (or local bathtubs). If at the patient perspiration of feet is noted (see the Hyperhidrosis), at care of it it is necessary to provide daily foot baths with cool water. In addition to local (sedentary, foot), apply also the general bathtubs. The last, as well as a warm shower, it is possible to carry out at the extended, chronically proceeding dermatosis (psoriasis, diffusion neurodermatitis, etc.). Heat baths, causing an active hyperemia, promote permission of infiltration of skin. For treatment of skin diseases use various ointments, creams, pastes. Greasing of skin is made a wadded and gauze tampon, the pallet or a palm. The remains applied with to lay down. the purpose of pastes and ointments delete from the surface of skin with the tampon moistened with warm vegetable oil (peach, sunflower, etc.). The listed actions for care of skin shall be carried out only according to recommendations of the dermatologist.

At treatment of patients with infectious skin diseases precautionary measures are necessary. In order to avoid spread of pustulous rash of patients with a pyoderma it is impossible to wash in a bathtub or under a shower. Skin around the centers of defeat it is necessary to rub off daily carefully 2% salicyl, boric or camphoric alcohol. Patients with a pyoderma should change next-to-skin and bed linen, and also a towel daily. The linen which was in the use is subject to boiling, outerwear — disinfection in a dezkamer. Also it is necessary to arrive with clothes of the patient with a mange and fungus diseases of skin. Disinfection are subject a blanket, a mattress, a pillow and all objects of use, to-rymi patients with a mange, mycosis used (see Disinfection).

At At. for patients of veins. diseases it is necessary to observe especially carefully the measures warning a possibility of transmission of infection. For patients with syphilis allocate the insulator or special department, the marked ware. The used dressing material from sore veins. diseases burn. Dirty linen is subject to obligatory boiling, outerwear — disinfection. In venerol. department it is necessary to make daily careful wet cleaning of all chambers and offices, to wipe door handles and other objects of the general use with soap water or solution of chloroamine. Carry especially carefully out special cleaning of rooms where carry out by the patient a gigabyte. procedures.

Care of infectious patients. Great value at At. for inf. by the patient it is allocated for the actions directed to prevention of intrahospital infections (see). Special attention is paid epid. to the mode in department and to carrying out the current disinfection (processing of ware, linen, cleaning of rooms, disinfection of emetic masses, a calla and urine).

To personnel it is reasonable for work in a hospital to have a special hospital dress or a suit, atop to-rogo put on a dressing gown. Hair close a cap or a kerchief. At At. behind sick intestinal infections it is necessary to wash hands with warm water with soap after implementation of each procedure. Processing of vessels and dirty linen is carried out in rubber gloves, to-rye disinfect after each procedure. In departments of respiratory infections the personnel work in the four-layer gauze mask closing a mouth and a nose, replaced each 3 — 4 hours.

Plentiful sweating at critical temperature drop demands frequent change of linen from patients. Pay attention to a mental condition of in the fever patients in connection with possibility inf. psychosis, in particular a delirium (see. Delirious syndrome).

Features At. at separate inf. diseases — see the Typhoid, the Dysentery, Malaria and other articles devoted separate nozol. to forms.

Care of neurologic patients. At diseases of a nervous system often there are heavy motive disorders, disturbances of sensitivity, the speech, disorder of function of pelvic bodies, convulsive attacks are possible. Specifics are defined by it At. for neurologic patients.

At a stroke (see), and also at acute neuroinfections it is necessary to take measures for the prevention of quite often arising life-threatening complications from the very beginning: pneumonia, formations of decubituses, inflammations of urinary tract. Development of pulmonary complications is promoted by constant position of the patient on spin and hit in respiratory tracts of slime from a nasopharynx. For the prevention of these complications of the patient follows often (each 2 hours) carefully to turn; it is necessary to clear several times a day a mouth and a throat «the false tampon moistened boric to - that, to apply otsa-syvatel. Are important fight against an atony of intestines and an ischuria.

At patients with motive disturbances of cerebral genesis the paralyzed extremities in order to avoid muscular contractures stack in a certain situation (see Paralyses, paresis). The paralyzed hand is put on a pillow so that the shoulder joint and a hand were at one level in the horizontal plane, a hand take aside, it shall be straightened, and the brush is turned palm up with the straightened divorced fingers. For deduction of an extremity in such situation use sacks with sand and longetka. The paralyzed leg is stacked as follows: under

a knee joint enclose the roller from cotton wool, foot is held at an angle by 90 °C the help of rubber draft or an emphasis in a wooden box. In situation on a healthy side the paralyzed hand lies or along a trunk, or is bent at an angle 90 ° on a pillow; the leg is bent in a hip and knee joint, under it enclose a pillow. Position of the patient on spin and on one side is changed by each 2 — 3 hours. Depending on a condition of the patient the doctor appoints passive and active gymnastics and massage in certain terms. In process of recovery of movements it is necessary to pay the main attention to that patients included the affected extremities as self-service as soon as possible.

In the presence by sick speech frustration (see Aphasia) it is recommended to place, whenever possible, them in chambers with patients, at to-rykh function of the speech it is kept and to give classes with the logopedist. During an epileptic seizure (see Epilepsy) for the prevention of injuries it is reasonable to enclose a pillow or any soft things under the head of the patient. Hands and legs of the patient should be held, protecting them from a bruise. For the prevention of a bite of language and lips the pallet or edge of a towel is recommended to insert sideways into a mouth. It is desirable to turn the head aside that saliva freely flew down. It is necessary to undo a collar of a shirt.

Diseases of a spinal cord often are followed by the lower paraplegia (see) or a paraparesis of legs, dysfunction of pelvic bodies, trophic disturbances (see the Trophicity), it is frequent — development of decubituses. In similar cases from the first days of a disease careful care of skin is necessary. On a mattress and a sheet there should not be folds. Under the body parts which are exposed to pressure it is necessary to enclose a rubber rubber ring. Several times a day it is necessary to change position of the patient, to wipe skin with camphoric alcohol. For the prevention of contractures (see) it is necessary to watch position of legs, to stack them in the necessary situation, to fight against an otvisaniye of feet. Feet establish at right angle to a shin by means of an emphasis, removable splints are sometimes imposed. At an ischuria carry out repeated catheterization of a bladder in the conditions of a strict asepsis and using means of antiseptics, at an incontience of urine apply an urinal. At a delay of a chair cleansing enemas are shown.

Care of mentally sick. Mentally patients in certain states are not capable to manage the actions, to give themselves to them the report, in behavior they are guided by painful experiences, cannot estimate the condition. Thereof such patients can be dangerous to people around, for themselves or to become helpless, to suffer from accident. Therefore At. behind mentally sick it is accompanied by supervision of their behavior and observation * behind their state. The observation which is carried out by personnel is necessary also for identification of symptoms of mental disorders, assessment of a mental state, action of the applied methods of treatment. In psychiatric-tsakh the system of supervision and overseeing by patients depending on their state is developed.

Strict supervision is exercised for patients with the dulled consciousness or with heavy painful experiences (nek-ry forms of nonsense and hallucinations), under influence to-rykh the patient can suffer itself (attempts to suicide, autotomy, persistent failure from food, etc.), to cause damage to people around or aims at escape. At strict supervision patients contain in special chamber under the round-the-clock observation of personnel and can leave this chamber (for a toilet, procedures, etc.) only accompanied by personnel.

The doubled watch can be carried out in usual chambers for patients, to-rye require close attention of personnel due to the need to note displays of mental disorders, a possibility of the complications caused both by the course of the disease, and the applied methods of treatment connected with. The doubled watch is appointed according to somatic indications, and also helpless and weak patients. Other patients are under the general observation of personnel.

With development of system of rehabilitation of mentally sick the step differentiated mode of observation is developed. In a crust, time this mode began to be used more widely. The most high (restrictive) security differs from strict supervision in the fact that the freedom of movement within department, but under continuous observation of personnel is provided to the patient. Besides, there is a mode of the differentiated observation, the mode of open doors and partial hospitalization (as a day or night hospital, house issues, etc.). The mode of observation is combined with to lay down. the mode guarding (including bed), sparing and activating (with wide use of work therapy, cultural therapy, etc.).

Work in mental health facilities (hospitals, polustatsiona-ra, clinics) imposes high requirements to personnel and is accompanied by constant and considerable tension. In all situations the personnel shall keep endurance and calm, never to raise the voice, not to answer attacks of patients, to patiently listen to complaints and painful statements, not to disprove them, but also not to assent to patients. Supervision and patient care need to be carried out so that not to offend their advantage, at the same time to keep constant vigilance, especially during reception by patients of food, procedures, a bypass of doctors, walks, a toilet, appointments to the family.

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V. P. Baskakov (gin.), V. P. Bisyarina (ped.), L. E. Brodov (inf.), A. F. Darenkov (Urals.), P. I. Laptev (ostomies.), M. N. Li-zanets, V. G. Mazurov (hir.), A. E. Lichno (psikhiat.), D. K. Lunev (not BP.), N. A. Butt (oft.), V. T. Palchun (ENT specialist.).