Nursing history card of the child's medical history ready. Educational nursing history. The patient notes a decrease in dizziness when standing up
Name of the medical institution: - GBUZ NSO BSMP No. 2
Receipt date: 12.04.13
Branch : cardiological
Full name (of the patient): G.N.M. Floor: the male
Age: 65 years old
Permanent residence: Novosibirsk city
Place of work, profession, position: pensioner
Emergency phone number: available
Directed by: clinic at the place of residence
Clinical diagnosis: Hypertension 3 stage 2 degree, ischemic heart disease, Hypertensive retinopathy, obesity 2 degree, proteinuria.
The development of a real disease (when he fell ill, what he associates with, how often it exacerbates, what is treated, what the exacerbation is currently associated with):
Considers himself ill for 10 years, notes episodic headaches, heaviness in the back of the head, temples, especially in the morning, dizziness; compressive pain behind the sternum and in the region of the heart, which stop at rest or after taking 1-2 tablets of nitroglycerin. Almost all the time, during the last two years, flies flickering before my eyes. Repeatedly entered the emergency department with hypertensive crises, from where, after the improvement of the condition, he left on his own, without having recovered. He took Papazol, No-shpu, Nitroglycerin, was treated with herbs, bioadditives. A year ago, the state of health worsened, crises became more frequent. In this regard, the patient went to the therapist and was hospitalized.
Intolerance to drugs, food, etc.: denies
Past diseases: Botkin's disease, tuberculosis, sexually transmitted diseases, diabetes, injuries, operations, others:
Among the transferred diseases notes frequent acute respiratory diseases.
Complaints of the patient at the time of examination:
Intense headache, heaviness in the back of the head, compressive pain behind the sternum and in the region of the heart, a feeling of lack of air, dizziness, flies before the eyes, weakness.
NURSING DIAGNOSIS
- 1. Real patient problems :
- 1.1. Priority
- 1. Intense headache in the occipital and temporal regions;
- 2. Shortness of breath of an inspiratory nature
- 3. High blood pressure
- 4. Compressive pain behind the sternum
- 5. Dizziness
- 1.2. Secondary problems
- 1. Nausea;
- 2. Intermittent sleep;
- 3. Decreased appetite;
- 4. Lack of rational nutrition skills;
- 5. Increased sweating;
- 6. Fear for one's health, anxiety about the future;
- 2. Potential Issues :
- 1. High risk of stroke;
- 2. Hypertensive crisis;
- 3. Myocardial infarction;
- 4. Diseases of the respiratory system due to smoking;
- 5. Diseases of the cardiovascular system due to obesity.
NURSING INTERVENTION PLAN FOR A PRIORITY PROBLEM
Problem: Intense headache in the occipital and temporal regions
Purpose of nursing intervention:
Short-term goal: The patient will report a decrease in headache intensity within a few hours of hospital stay;
Long term goal: The patient will not complain of headache by the time of discharge from the hospital.
Dependent nursing interventions:
- 1. Reserpine. Inside 0.10 mg. 1 r / day.
- 2. Winkaton. Inside 0.01 g. 2r / day.
Interdependent Interventions:
- 1. Complete blood count;
- 2. General analysis of urine;
- 3. MRI of the brain.
Independent Nursing Interventions:
The nurse will provide:
- 1. medical and protective regime;
- 2. access to fresh air;
- 3. bed comfort with a raised head end of the bed;
- 4. apply distractions: a cold compress on the forehead, mustard plasters to the calf muscles;
- 5. timely fulfillment of all doctor's prescriptions;
- 6. according to the doctor's prescription, will give an anesthetic;
- 7. leisure of the patient after leaving the acute state;
- 8. preparation for additional examination methods;
- 9. The nurse will talk with relatives and roommates about the need to avoid tedious conversations;
- 10. The nurse will explain to the patient the essence of his disease, talk about modern methods of diagnosis, treatment and prevention.
Goal achieved:
- - The patient noted a decrease in the intensity of headache by the end of 1 day of hospital stay;
- - The patient had no complaints of headache by the time of discharge from the hospital;
DYNAMICS OF DEVELOPMENT OF PATIENT PROBLEMS
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Problem |
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Decreased appetite |
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Sleep disturbance |
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Lack of knowledge about rational nutrition |
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excessive sweating |
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* This work is not a scientific work, is not a final qualifying work and is the result of processing, structuring and formatting the collected information, intended to be used as a source of material for self-preparation of educational work.
General information.
Age: 80 years.
Gender: male.
Home address: Perm, 11, apt. 12
Profession: pensioner
Delivered by: GSSP
Diagnosis at admission: hypertension stage 2, hypertensive crisis.
Complaints.
At the time of curation, the patient has no complaints. At the time of hospitalization, there were complaints of intense, "tearing" headache in the occipital and temporal regions, weakness, dizziness, flies before the eyes and tinnitus. Headache developed acutely, the patient associates it with a significant increase in blood pressure, because. usually does not note headaches with an increase in blood pressure.
Disease history.
He considers himself ill for 25 years, for the first time an increase in blood pressure was detected during a medical examination at the place of work (RZD-driver), an increase in blood pressure was not accompanied by subjective sensations, the level of blood pressure was up to 160/90 mm Hg. Since then, he has adhered to antihypertensive therapy - a constant intake of indapamide and corinfar. During therapy, blood pressure decreased.
Real hospitalization is associated with an episode of rapid, significant and persistent increase in blood pressure, not stopped by the usual therapy (hypertensive crisis). On the evening of October 17, the patient felt unwell, measured blood pressure = 170/90 mm Hg, after which he took an enalapril tablet - without effect. Later, the patient's condition worsened: the headache intensified, flickering flies before the eyes and tinnitus appeared - re-measured blood pressure = 190/100 mm Hg. After that, the GSSP team was called (at the time of arrival of the ambulance team - BP = 200/100 mm Hg), which delivered the patient to the emergency department of the GMCH No. 1. At the moment the patient is being treated in the cardiology department of the GMSC No. 1.
Anamnesis of life.
Born in 1931 in Belarus, in a complete family, was the first child, has a younger brother. From early childhood, he grew and developed normally. In terms of mental and physical development, he did not lag behind his peers. From the age of 7 I went to school. After school he graduated from a technical school and a specialized school of locomotive drivers. For 30 years he worked as a machinist (factors of industrial hazard - noise, vibration, intensity of the work process). Retired by age. There is no disability.
Household history: lives in a separate apartment with all amenities, together with his wife, financially secure. Eats 3 times a day a variety of hot food in sufficient quantities at home.
Family history: there were 4 people in the family, has a younger brother (74 years old). Mother died of myocardial infarction, suffered from hypertension. Father and brother did not suffer from an increase in blood pressure. Married, has 2 children (daughters 50 and 55 years old) - children do not have hypertension.
Past illnesses: in childhood, he had chickenpox, ARVI is not often.
She denies tuberculosis, diabetes mellitus, viral hepatitis B, C, sexually transmitted and mental diseases in herself and her relatives.
There were no operations, blood transfusions and its components, the dialysis procedure did not twitch.
Bad habits: denies.
Allergological history: intolerance to the drug "Kordaflex" - redness of the skin. Intolerance to other medicines, household substances and foodstuffs is not noted.
General history.
General state. The general condition is satisfactory, consciousness is clear. The patient is contact. The position is active, there is no desire for orthopnea. Unmotivated changes in body weight, fever has not been noticed lately. Notes flashing "flies" before the eyes and dizziness, which is associated with episodes of increased blood pressure. There is no feeling of "crawling", numbness of body parts, skin itching.
Respiratory system. Breathing through the nose is free. No discharge from the nose. Cough, hemoptysis, chest pain, shortness of breath and asthma attacks are absent.
The cardiovascular system. He notes the presence of headaches with a significant rise in blood pressure (SBP more than 160 mm Hg). There is no pain or discomfort in the chest and in the region of the heart. Palpitations, sensations of fading, "tumbling", turning over in the chest are not noted. There is no shortness of breath at rest and during daily physical activity (lifting to the 5th floor). No attacks of suffocation are noted. General weakness, swelling on the face in the morning and swelling on the extremities do not bother. There is no history of MI, stroke.
The digestive system. Appetite saved. Saturation is normal. He does not notice thirst, the taste in the mouth is normal. Chewing is good. Swallowing, passage of food through the esophagus is free, painless. Belching after eating does not bother. Heartburn, nausea, vomiting are not observed.
There is no bloating. The chair is regular, independent. Feces are formed, brown in color, without remnants of undigested food, mucus, blood and pus. Excretion of feces and gases is free. There is no pain in the anus during defecation. There are no blockages.
urinary system. No pain in the lumbar region. Urination 4-5 times a day, painless. Pollakiuria, nocturia, dysuric phenomena are absent. The color of urine is straw yellow.
Musculoskeletal system. There is no pain in the bones of the extremities, in the joints, spine, or flat bones. There is no swelling of the joints, reddening of the skin over them, an increase in local temperature, morning stiffness, limited volume or inability to move. Pain in the muscles does not notice.
Endocrine system. There are no growth and physique disorders, skin changes, pigmentation, excessive sweating. The hairline is characteristic of this sex. Violations of primary and secondary sexual characteristics are not present. Feelings of heat, no hot flashes. Changes in mood (irritability, anger) are not noted. There are no episodes of palpitations.
Nervous system. Sleep is not disturbed, falling asleep quickly, without taking medications. Sleep deep, no night awakenings. The mood is even, calm. There is no sudden change in mood. Sociable. Memory and attention without impairment. Vision is reduced (hypermetropia) - wears reading glasses "+3", hearing is not impaired. The sense of smell and taste are preserved.
Objective examination.
The patient's condition is satisfactory. Consciousness is clear. The position is active. The patient is contact. Body temperature is normal. Height 178 cm, weight 80 kg, constitutional type - normosthenic. BMI = 25.2 - slightly overweight.
Integuments of physiological coloring, clean, moderate humidity. The elasticity and turgor of the skin are preserved. There is no acrocyanosis. Subcutaneous tissue is moderately expressed, evenly distributed. The thickness of the skin-fat fold is 2 cm. There is no edema, pastosity. Visible mucous membranes are clean, moist, pink. The color of the sclera is white.
Lymph nodes are not palpable.
Musculoskeletal system. The structure of the skeleton is proportional, there are no deformations of the bones. The spine is of normal shape, without pathological curvatures. General muscle development is moderate, muscle strength is preserved. There is no pain on touch.
The joints are of normal configuration, there is no redness and swelling over the area of the joints. The volume of active movements is full. There is no pain on palpation of the joints. The shape of the skull is mesocephalic. Posture is normal, movements in the cervical and lumbar spine are free, painless.
The patient's height is unremarkable. There are no stretch marks on the skin, darkening of the skin is not observed. The patient does not experience increased thirst. The thyroid gland is not enlarged, soft, painless.
Respiratory system. The shape of the chest is correct, without protrusions and retractions. Both halves evenly participate in the act of breathing. On palpation, painless, moderately resistant, voice trembling is preserved over the entire surface of the lungs. The type of breathing is mixed. With comparative percussion of the lungs over the entire surface of the lung fields, a clear pulmonary sound is determined. Breathing through the nose, free. There is no discharge from the nose. The smell of exhaled air is normal.
Topographic percussion of the lungs:
Line Right Left
l.parasternalis 5 rib-
l.medioclavicularis 6 rib-
l.axillaris anterior 7 rib 7 rib
l.axillaris media 8 rib 9 rib
l.axillaris posterior 9 rib 9 rib
l. scapulars 10 intercostal space 10 intercostal space
l.paravertebralis At the level of the spinous process of the 11th thoracic vertebra
At the level of the spinous process of the 11th thoracic vertebra
The height of the tops of the lungs:
Left Right
Front 5 cm 5 cm
Behind At the level of the spinous process of the 7th cervical vertebra At the level of the spinous process of the 7th cervical vertebra
During auscultation, vesicular breathing is carried out evenly in all parts of the lungs, bronchophony is not changed. No wheezing, no pleural friction noise.
The cardiovascular system. Examination of the region of the heart. When examining the region of the heart, no visible changes were detected: there is no heart hump, there are no curvature and retraction of the chest.
Palpation of the heart area: the apex beat is palpable in the 5th intercostal space along the midclavicular line, without features. There is no heartbeat. Epigastric pulsation, heart trembling is not determined. Pain in the region of the heart during palpation is not observed.
Percussion of the heart:
limits of relative cardiac dullness;
Right 1 cm outward from the right edge of the sternum in the 4th intercostal space
Left On the midclavicular line in the 5th intercostal space
Upper On the third rib on the left l.parasternalis
The width of the vascular bundle is 5 cm.
Diameter of the heart - 14 cm.
Auscultation of the heart: heart sounds are muffled, rhythmic, the rhythm is correct, binomial. The physiological ratio of tones at the top is preserved (I tone is louder than II). Based on the II tone louder than I, the accent of the II tone over the aorta is determined. Noises, splitting of tones are not heard.
Pulse 54 beats per minute, rhythmic, intense, satisfactory filling, the same on the right and left hand. HR-54.
AD 140/90 mm. rt. rt.
The digestive system. Examination of the oral cavity: the lips are moist, the mucous membrane is pink. There are no sores, cracks, rashes on the lips. The tongue is moist and clean. The gums are pink, not loosened, do not bleed, without inflammation. The tonsils do not protrude beyond the palatine arches. Zev is calm. The mucous membrane of the pharynx is moist, pink, clean.
Inspection of the abdomen: the abdomen is symmetrical, the abdominal wall is involved in the act of breathing. There is no visible peristalsis of the stomach and intestines. Above the stomach and intestines, the percussion sound is tympanic. Fluid in the abdominal cavity is not detected (fluctuation symptom is negative).
On superficial palpation, the abdomen is soft and painless. There are no hernial protrusions, divergence of the rectus abdominis muscles. Peritoneal symptoms are negative.
With deep palpation in the left iliac region, a painless, even, densely elastic consistency of the sigmoid colon is determined. The blind and transverse colon are not palpable. Auscultation: intestinal peristalsis is preserved.
Liver and gallbladder. The lower edge of the liver does not come out from under the edge of the costal arch. Kurlov's ordinates 9, 8, 7 cm. Palpation of the liver edge is smooth, even, painless. The gallbladder is not palpable, the projection area is painless, Ortner's and Murphy's symptoms are negative. The spleen is not palpable. The pancreas is not determined by palpation, there is no pain in the areas of Shoffar, Gubergrits-Skulsky.
Urogenital system. There is no smoothness, swelling, redness in the lumbar region. The kidneys are not palpated, palpation is painless, the symptom of concussion of the lumbar region is negative on both sides. Urination is free, there are no dysuric phenomena.
Neuropsychic status. Consciousness is clear, speech is intelligible. The patient is oriented in place, space and time. Sleep is not disturbed, memory is preserved. Vision is weakened (due to the age of the patient), correction with glasses. Hearing saved.
Preliminary diagnosis and its justification.
Main disease: Essential arterial hypertension stage II, 3 degrees, risk 3. Hypertensive crisis from 10/17/2011.
Complication of the underlying disease: no
Concomitant diseases: NRS according to the type of AV block Ist., PRBBB, with the development of bradycardia.
Rationale:
Based on the patient's complaints about the appearance of a severe, "tearing" headache in the occipital region, dizziness, flies before the eyes, tinnitus, and taking into account the severity of the development of these symptoms and the ineffectiveness of the usual antihypertensive therapy, in addition, based on the anamnesis data: an increase in blood pressure to 200/100 mm Hg (according to GSSP) can be diagnosed as a hypertensive crisis.
Based on the patient's complaints of headache in the occipital region, weakness; on the basis of the history of the disease, which states that the patient has been suffering from hypertension for many years (BP = 1700/90 mm Hg); based on the data of the anamnesis of life, which say that the patient's mother suffered from hypertension; based on the data of an objective examination: the expansion of the boundaries of the heart to the left, the accent of the II tone over the aorta - it is possible to make a preliminary diagnosis of the underlying disease: essential arterial hypertension, stage II, stage 3, risk 3. Long duration of the disease, gradual, benign course of the process and the absence of Pathological history data from other organs and systems (kidneys, endocrine organs) make it possible to exclude symptomatic hypertension. The EAH stage was set on the basis of an objective examination: the expansion of the borders of the heart to the left, which indicates damage to the target organs. Degree - set on the basis of anamnestic data: increased blood pressure to 200/100 mm Hg. Risk 3 (high risk group) is based on the presence of target organ damage (extension of the borders of the heart to the left), the age of the patient (over 65 years) and the presence of a aggravated family history (HA in the mother).
The concomitant diagnosis was HRS according to the type of AV block I stage, PRBBB, with the development of bradycardia, based on the anamnesis data (Holter monitoring in 2007 and 2009), as well as an objective examination (pulse 54 beats per minute).
Patient examination plan.
1. ECG (in the emergency department) - to exclude MI. The appearance of characteristic changes: ST depression, monophasic curve - signs of the most acute and acute stages.
2. Tropanin test - to rule out MI. A positive test indicates the presence of troponin in the blood, which is a consequence of damage to myocardiocytes.
3. KLA - clinical minimum - to determine the presence of anemia, signs of inflammation.
4. OAM - clinical minimum - allows you to suspect a pathology of the kidneys, to determine the need for further examination of the kidneys.
5. BHC - determination of the level of glucose and total cholesterol in the blood, which is mandatory due to the age of the patient and the presence of CCC damage in him; ALT, AST, LDH - definition of cytolysis syndrome in the myocardium.
6. Coagulogram - platelet count, clotting time and duration of bleeding, fibrin - to assess hemostasis and the risk of thromboembolic complications.
7. Daily monitoring of blood pressure - determination of blood pressure fluctuations during the day, the level of blood pressure during sleep and wakefulness, rest and exercise.
8. Holter monitoring - in connection with the presence of NRS in the anamnesis, to clarify the form and degree of rhythm disturbance. Determination of ECG signs of NRS.
9. Echocardiography - to determine changes in the structure (wall thickness, valves) and function (contractile: the presence of foci of hypokinesia, determination of ejection fraction and residual diastolic volume) of the heart.
10. Ultrasound of the heart - visual examination of the heart + Doppler mapping - to determine the blood flow and the presence of regurgitation.
11. UZDG BCA - determination of cerebrovascular accident and the degree of violation.
12. Examination of the fundus - consultation of an oculist - to determine specific changes in the vessels of the retina.
Survey results.
Tropanin test (10/17/2011)
negative
UAC (10/18/2011):
Erythrocytes 4.61 x 1012/l (4.5-5.5 x 1012/l)
Hemoglobin 146 g/l.
Color indicator 31 pg.
Leukocytes 4.9 x 109/l (4-6 x 109/l)
Segmented 48% (63%)
Lymphocytes 49% (23%). -
Monocytes 3%.
ESR 7 mm/h.
OAM(10/18/2011):
The color is light yellow.
The reaction is acidic.
Specific gravity 1015.
Protein negative.
Sugar negative.
Leukocytes 1-2 in the field of view.
Erythrocytes 0-1 in the field of view.
Epithelium flat 2-3 in the field of view.
Conclusion: the specific gravity of urine is reduced, which may indicate chronic pyelonephritis, however, it is impossible to make such a diagnosis based on the OAM result alone, so it is necessary to conduct a Zemnitsky study to determine the concentration function of the kidneys.
Biochemical blood test (10/19/2011):
Total cholesterol 6.0 mmol/l (0.00-5.2).
Glucose 5.78 mmol / l (3.89-5.83).
Creatinine 80.7 µmol/l (63.6-110.5)
Microreaction to syphilis (20.10.2011):
Negative.
ECG from 10/18/2011:
Conclusion: sinus rhythm, bradycardia, AV blockade of the I degree, pronounced EOS deviation to the left. Complete blockade of the right leg of the bundle of His. Blockade of the anterior - upper branching of the left leg of the bundle of His. Focal changes on the lower wall of the left ventricle are not excluded.
ECG from 10/21/2011:
EchoCG of the heart from 10/25/2011:
Substantiation of the main clinical diagnosis.
The main diagnosis: Essential arterial hypertension stage II, stage 3, risk 3 is based on: complaints, anamnesis, physical examination, instrumental and laboratory data.
Complaints, medical history and physical examination confirming the main diagnosis are given above.
In addition, the diagnosis is confirmed by the data of instrumental studies: EOS shift to the left is a sign of left ventricular hypertrophy.
Stage II is based on the data of an objective examination (see above), in addition, during the ECG - signs of LV hypertrophy, which was also confirmed by echocardiography of the heart.
Grade 3 is based on the history, physical examination (see above).
Risk 3 is based on the history, physical examination (see above) and instrumental analysis data: ECG signs of left ventricular hypertrophy.
Complications: no
Concomitant diseases: NRS type AV blockade Ist., PRBBB, with the development of bradycardia, blockade of the anterior - upper branching of the left leg of the His bundle was set on the basis of anamnesis, objective examination (see above). In addition, the diagnosis is confirmed by the data of monitoring carried out in the GMSCH No. 1.
differential diagnosis.
Recognition of hypertension does not present any significant difficulties. It is much more difficult to determine the cause of the increase in blood pressure. This patient has essential arterial hypertension, it should be differentiated from secondary (symptomatic) hypertension.
Renal - with parenchymal nephropathy (chronic pyelonephritis, glomerulonephritis, polycystic kidney disease, amyloidosis of the kidneys, connective tissue diseases); with renovascular nephropathy (atherosclerosis, aortoarteritis, fibromuscular dysplasia of the renal arteries, blockage of the renal arteries by a thrombus or embolism); with tumors of the kidneys producing renin.
Endocrine - with pheochromocytoma; primary hyperaldosteronism (Conn's syndrome); extra-adrenal chromaffin tumors; cider Itenko-Cushing; hyperparathyroidism; thyrotoxicosis.
Hemodynamic - with coarctation of the aorta; open ductus arteriosus; insufficiency of the aortic valve; complete atrioventricular block; congestive heart failure.
Neurogenic - with increased intracranial pressure (tumor, brain injury, stroke); encephalitis, meningitis.
Drug (iatrogenic) - as a result of taking contraceptives containing estrogens, glucocorticosteroids, non-steroidal anti-inflammatory drugs, ephedrine, or the withdrawal of antihypertensive drugs (eg, clonidine, beta-blockers).
Toxic - with alcohol abuse; acute lead poisoning, etc.
This patient does not have the above listed clinical signs. From this we can conclude that the patient suffers from essential arterial hypertension.
Treatment of the disease.
General principles of treatment:
A. non-drug treatment.
1. Diet with salt restriction (less than 6 g / day), restriction of fats and easily digestible carbohydrates, body weight correction, avoiding the use of whole milk products, meat with fatty layers, confectionery products, eliminating solid fats such as butter, processed cheeses, animal fats, chocolate; fish dishes are shown, especially marine;
2. Refusal to drink alcohol and tobacco.
3. Physical activity in training mode.
4. Compliance with the regime of work and rest.
5. Other methods of non-drug treatment: auto-training, acupuncture, physiotherapy (electrosleep), herbal medicine.
Non-drug treatment is indicated for all patients. In the early stages of the disease and with a slight increase in blood pressure, it can normalize blood pressure without drug correction.
B. Drug therapy.
1) Blockers of slow calcium channels (nifedipine, amlodipine, verapamil, etc.). The mechanism of action of this group of drugs is to inhibit the entry of calcium ions into the cell during the period of membrane depolarization, which leads to a negative inotropic effect, a decrease in heart rate, a decrease in the automatism of the sinus node, a slowdown in atrioventricular conduction, and prolonged relaxation of vascular smooth muscle cells (mainly arterioles). Slow calcium channel blockers are divided into dihydropyridine derivatives (nifedipine), phenylalkylamines (verapamil), benzothiazepines (diltiazem).
2) -blockers (propranolol, atenolol, bisoprolol, metoprolol, carvedilol, oxprenolol). The antihypertensive effect of β-blockers is associated with a competitive blockade of 1-adrenergic receptors of the heart, as well as with a decrease in renin secretion, an increase in the synthesis of rejuvenating PGs, and an increase in the secretion of atrial natriuretic factor. Also, drugs of this group reduce heart rate and inhibit myocardial contractility). -blockers are divided into selective 1- and non-selective 1-2-blockers. Also, drugs in this group are divided into those with internal sympathomimetic activity (oxprenalol, pindolol, acebutolol), not having such activity (propranalol, nadolol, atenolol, betaxolol, bisoprolol, metoprolol), having a vasodilating effect (carvedilol, celiprolol, nebivolol).
3) Diuretics. For the treatment of hypertension, the following are used: thiazides and thiazide-like diuretics (hydrochlorothiazide, indapamide, clopamide); loop diuretics (furosemide, bumetanide, pyretanide); potassium-sparing diuretics (spronolactone, triamterene, amiloride). The mechanism of the hypotensive action of diuretics is that an increase in the excretion of sodium ions in the urine leads to a decrease in plasma volume, venous return of blood to the heart, cardiac output and peripheral vascular resistance, which causes a decrease in blood pressure.
4) ACE inhibitors are divided into active substances (captopril, lisinopril) and prodrugs (enalapril, ramipril, cilazapril, trandolapril). The mechanism of action of this group of drugs is to block the conversion of inactive angiotensin I to active angiotensin II under the influence of ACE, which leads to a weakening of its vasoconstrictor action, a decrease in the formation of aldosterone and fluid retention in the body, resulting in a decrease in blood pressure.
5) Angiotensin II receptor blockers (losartan, irbesartan, candesartan, eprosartan, valsartan). The mechanism of their action is to block receptors for angiotensin II, which leads to the impossibility of implementing its pressor effect on the vessels and, as a result, leads to a decrease in peripheral vascular resistance and blood pressure.
For relief of hypertensive crisis
S. Natrii chloridi 0.9% - 200 ml
S. Kalii chloridi 10% - 10.0 ml intravenous drip.
S.Magnii sulfati 25% - 3.0 ml
ACE inhibitors (inhibit angiotensin-converting enzyme and, as a result, disrupt the formation of renin, help reduce pressure):
Rp.: Ramitren - 0.0025
D.t.d N 30 in caps.
S. Take 1 tablet 1 time daily after meals.
Rp.: Enalaprili 0.01
D.t.d N 20 in tab.
S. Take 1 tablet 2 times daily.
Antiplatelet agents (to thin the blood and facilitate its passage through the microvasculature):
Rp.: Kardiomagnili 0.075
D.t.d. No. 20 in tab.
S. Take 1 tablet 1 time daily after dinner.
Cardiomagnyl-combined agent contains: Acetylsalicylic acid 75 mg, Magnesium hydroxide 15.2 mg. It has an antiplatelet effect, is a non-steroidal anti-inflammatory agent. Thromboxane A2 under the influence of acetylsalicylic acid (ASA) decreases as a result of selective inhibition of its synthesis, which reduces the aggregative ability of platelets. Magnesium hydroxide has a protective effect on the gastric mucosa, which is important when taking ASA.
Calcium antagonists (block the entry of calcium ions into the cardiomyocyte, thus reducing its ability to develop mechanical stress, and, consequently, reducing myocardial contractility):
Rp.: Amlodipini 0.005
D.t.d. No. 20 in tab.
S. Take 1 tablet 1 time per day.
A derivative of dihydropyridine is a blocker of "slow" calcium channels of the II generation. It has a long-term dose-dependent hypotensive effect due to a direct vasodilating effect on vascular smooth muscles. With arterial hypertension, a single dose provides a clinically significant decrease in blood pressure for 24 hours. It does not cause a sharp drop in blood pressure, a decrease in exercise tolerance, or left ventricular ejection fraction. Reduces the degree of left ventricular myocardial hypertrophy, has anti-atherosclerotic and cardioprotective effects. It does not affect myocardial contractility and conduction, does not cause a reflex increase in heart rate, inhibits platelet aggregation, increases glomerular filtration rate, and has a weak natriuretic effect.
Potassium and magnesium preparations. To normalize the electrolyte balance in the body, it helps to normalize the heart rhythm and reduce the oxygen starvation of the heart muscle.
Rp.: Asparcami 0.375
D.t.d. No. 50 in tab.
S. Take 1 tablet 3 times daily.
Stage epicrisis.
80 years old (10.03.2011) has been hospitalized in the cardiology department of the KMSCH No. 1 since October 17, 2011 with a diagnosis of essential arterial hypertension stage III, stage 3, risk 3. Hypertensive crisis from 10/17/2011. Complications: no. Concomitant diseases: NRS according to the type of AV block Ist., PRBBB, with the development of bradycardia.
The patient was admitted on an emergency basis with a GSSP team with complaints of intense, "tearing" headache in the occipital and temporal regions, weakness, dizziness, flies before the eyes and tinnitus.
From the anamnesis: he has been ill for 25 years, for the first time an increase in blood pressure was detected during a medical examination at the place of work, an increase in blood pressure was not accompanied by subjective sensations, the level of blood pressure was up to 160/90 mm Hg. Since then, he has been on antihypertensive therapy. During therapy, blood pressure decreased.
In 2007, he was examined by the Holter monitoring method - a violation of the heart was revealed in the form of AV blockade of the I degree, a complete blockade of the right leg of the His bundle.
In 2009, he underwent an examination at the City Clinical Hospital No. 4 of the city of Perm (in the direction of a district cardiologist). During the examination, episodes of AV blockade of I, II degree were revealed, in combination with a complete blockade of the right bundle branch block with the development of bradycardia up to 32 beats. in min.
During hospitalization, the following studies were carried out. Tropanin test (10/17/2011) - negative. KLA (October 18, 2011): moderate lymphocytosis was detected. OAM (10/18/2011): decreased specific gravity of urine.
Biochemical blood test (10/19/2011): increase in total cholesterol.
Microreaction to syphilis (20.10.2011): negative.
ECG from 10/18/2011: sinus rhythm, bradycardia, AV blockade of the I degree, pronounced EOS deviation to the left. Complete blockade of the right leg of the bundle of His. Blockade of the anterior - upper branching of the left leg of the bundle of His. Focal changes on the lower wall of the left ventricle are not excluded.
ECG from 10/21/2011:
Conclusion: sinus rhythm, heart rate 76 beats. per minute, AV block II degree, an increase in the QT interval. Complete blockade of the right leg of the bundle of His.
EchoCG of the heart from 10/25/2011:
Conclusion: US signs of aortic atherosclerosis, LV hypertrophy. Type 1 LV diastolic dysfunction. Fibrous changes in the cusps of the AC and MC.
The following treatment was carried out: hypertensive crisis was stopped (intravenous administration of magnesium sulfate and potassium chloride), amlodipine -5 mg - 1 time per day in the evening, enalapril - 10 mg - 2 times a day, cardiomagnyl - 75 mg - 1 time per day after meals, asparkam - 0.375 mg - 1t 3 times a day.
Against the background of the treatment, the patient's condition improved: headache and dizziness disappeared, blood pressure decreased. At the time of the last day of curation, the patient does not present any active complaints.
Observation at the district cardiologist;
Dieting with salt restriction, restriction of fats and easily digestible carbohydrates, avoiding the use of whole milk products, meat with fatty layers, confectionery products, eliminating solid fats such as butter, processed cheeses, animal fats, chocolate; fish dishes are shown, especially marine;
Physical activity in the training mode;
Compliance with the regime of work and rest;
Systematic control of blood pressure - 2 times a day and with deterioration of health.
Continue systematic antihypertensive therapy: Enalapril - 10 mg - 1 tablet 2 times a day in the morning and evening; Amlodipine - 5 mg - 1 tablet 1 time per day in the evening; with a crisis increase in pressure - Captopril - 25 mg - 1 tablet, if necessary - 1 more tablet.
Continue taking antiplatelet agents: cardiomagnyl 75 mg - 1 tablet 1 time per day after meals.
Taking potassium and magnesium preparations: asparkam - 0.375 mg - 1 tablet 3 times a day.
Consultation with a cardiac surgeon in connection with a heart rhythm disorder, deciding on the installation of an artificial pacemaker.
List of used literature.
1. Mukhin N.A., Moiseev V.S. Internal diseases, Moscow 2006
2. Kukes V.G. Clinical pharmacology, Moscow 2008
3. Grebenev A.L., Propaedeutics of internal diseases, Moscow "Medicine", 1995.
Department of Cardiology Ward 6
Full name Chernyshev Sergey Prokopevich
Gender m Age (full years) 67
Permanent residence: Chistopol, Academician K. d. 7-14
Place of work disabled person of the 3rd group
Sent to the hospital for emergency indications: no,
Type of transportation: can go
Height 160 Weight 70 BMI 27.34
Allergy No
Source of information patient, family, medical records, staff
Medical diagnosis angina pectoris
Complaints of the patient at the time of curation pain in the region of the heart, shortness of breath during exercise
Identification of risk factors
3. The nature of nutrition fractional full
4. Bad habits
Smoking: No
Alcohol consumption: No
Physiological Data
Skin color pallor
Rashes No
Edema No localization
2. Breathing and circulation
Respiratory rate 18 min.
Cough: No
Phlegm: No
Addition:
Pulse characteristics frequent, rhythmic, intense
Blood pressure on the peripheral arteries: 170/100
left hand 170/100 right hand 173/100
Addition
3. Digestion
Appetite: reduced
Swallowing: normal
Diet adherence No
Addition:
Urination: free
Urination frequency: day 8 night 2
Incontinence: No
Addition:
Bowel function:
Regularity/Frequency: 2
Chair decorated
Addition:
5. Motor activity
Dependency: partial
Applied walking aids: Yes
What kind of devices are used: cane
Does a health worker need help? Yes
Addition:
6. Sleep, rest
Night sleep duration 7
Daytime sleep duration 2
Body temperature at the time of examination 36.5
Addition:
Addition:
Addition:
Is there a risk of falling: No
Addition:
9. Existing (real) problems of the patient pain in the heart area, shortness of breath on exertion
10. Priority problem(s) shortness of breath on exertion
11. Potential problems in the development of myocardial infarction
PATIENT CARE PLAN
Name of the patient
Patient problems
The goal is short-term, term - pain in the heart area stops within 3 days
The goal is long-term, the term is the absence of complications
A set of exercises for angina pectoris
Sitting on a chair, bend your legs at the knees at a right angle and place them shoulder-width apart, hands on your knees. Deep breathing 2-3 times. Exhalation is lengthened.
Squeeze and unclench your fingers into a fist 8-10 times. Breathing is arbitrary. The pace is average.
Bend your legs at the knees at a right angle and place them shoulder-width apart; hands on the belt.
Alternately bend and unbend the legs in the ankle joints 8-10 times. Breathing is arbitrary. The pace is average.
Bend your legs at the knees at a right angle and place them shoulder-width apart, hands on your belt. Raise your arms up, to the sides, bend - inhale, return to the starting position - exhale, 2-3 times. The pace is slow.
Sitting on the edge of a chair, bend your knees at a right angle and place them shoulder-width apart, lower your arms. Alternately put the leg on the knee of the other leg 2-3 times - exhale, return to the starting position - inhale. You can support the lower leg with runes. The pace is slow.
Bend your legs at the knees at a right angle and place them shoulder-width apart, hands on your belt. Alternately take your hands back and make circular movements with them 2-3 times. When abducting and raising the arm - inhale, return to the starting position - exhale. The pace is slow.
After that, get up, walk slowly for 4 minutes, stop, take 2-3 deep breaths and exhale.
Further exercises - in a standing position.
Spread your legs shoulder-width apart, hands holding on to the back of the chair. Half squat - exhale, return to the starting position - inhale. Repeat 3-4 times. The pace is slow.
Spread your legs shoulder-width apart, lower your arms. Then pull them forward and part them to the sides - inhale. Lower your hands - exhale, 2-3 times, the pace is slow.
Feet together, hands holding on to the back of the chair. Alternately 2-3 times take the leg to the side. Breathing is arbitrary. The pace is slow.
Spread your legs shoulder-width apart, put your fingers on your shoulders. Circular movements in the shoulder joints; repeat 2-3 times in each direction. The pace is slow. Breathing is arbitrary.
Put your legs together, hands on your belt. Deep breathing 2-3 times.
The following exercises are performed while sitting on a chair.
Bend your legs at the knees at a right angle and spread them shoulder-width apart, lower your arms. Alternately stretch the leg forward. Raise your arms to the sides - inhale. Return to the starting position - exhale, 3-4 times. The pace is slow.
Sitting on a chair, bend your legs at the knees at a right angle and place them shoulder-width apart. Fingers to shoulders. Breeding the elbows to the sides - inhale, return to the starting position - exhale, 3-4 times. The pace is slow.
Sitting on a chair, bend your legs at the knees at a right angle and place them shoulder-width apart, put your hands on your knees. Simultaneously bend and unbend the legs in the ankle joints, 3-4 times. The pace is slow. Breathing is arbitrary.
Sitting on a chair, put your legs together, put your hands on your belt. Alternately take your hands to the sides - inhale, return to the starting position - exhale. 2-3 times. The pace is slow.
Sitting on a chair, put your legs together, put your hands on your hips. Deep breathing 2-3 times.
3.2. Nursing patient follow-up card No. 2
Medical organization Central District Hospital
Department of Cardiology Ward 11
Full name Yarullin Marat Fatykhovich
Gender and Age (full years) 68
Permanent residence: Kargali, st. Checkpoint 9a
Place of work, disabled person of the 3rd group
Who directed the sick self-conversion
Sent to the hospital for emergency indications: yes, 3 hours after the disease;
Type of transportation: on a wheelchair,
Height 170 Weight 80 BMI 27
Allergy: No
Source of information (underline): patient, family,
Medical diagnosis of hypertension
Complaints of the patient at the time of curation headache, dizziness, shortness of breath aggravated when walking
Identification of risk factors
1. The mode of work and rest does not work
2. Living conditions living in favorable conditions
3. The nature of nutrition is fractional, not complete
4. Bad habits
Smoking: No
Alcohol consumption: No
5. There are no production hazards
6. No chronic diseases
Physiological Data
1. Condition of the skin and subcutaneous fat
Physiological skin color
Rashes No
The nature of the rash.
The severity of the subcutaneous fat layer
BMI assessment overweight
Edema No
Addition
2. Breathing and circulation
Respiratory rate 16 min.
Cough: No
Phlegm: No
The nature of sputum, if present:
Addition:
Characteristics of the pulse is filled
Blood pressure in the peripheral arteries:
left hand 160/70 right hand 160/70
Addition
3. Digestion
Appetite: not changed
Swallowing: normal
Flatulence (bloating): No
Compliance with the prescribed diet: No
Addition:
4. Physiological functions
Bladder function:
Urination: free,
Urination frequency: day 7 night 2
Incontinence: No
Addition:
Bowel function:
Regularity/Frequency:
The chair is decorated
Addition:
5. Motor activity
Dependency: absent,
Applied walking aids: No
What kind of devices are used: crutches, cane, walker, handrails (underline)
Does a health worker need help? No
Addition:
6. Sleep, rest
Night sleep duration 8
Daytime sleep duration 1
Addition (disturbed sleep, interrupted sleep, daytime sleepiness, insomnia at night):
7. Ability to maintain normal body temperature
Body temperature at the time of examination
Addition:
8. Ability to maintain security
Are there visual impairments: No
Addition:
Is there a hearing impairment: No
Addition:
Is there a risk of falling: No
Addition:
9. Existing (real) problems of the patient headache, dizziness, shortness of breath aggravated by walking
10. Priority problem(s) headache
11. Potential problems risk of complications
PATIENT CARE PLAN
Name of the patient Yarullin Marat Fatykhovich
Patient problems
The goal is short-term, term - the headache stops within 3 days.
The goal is long-term, the term is a complete recovery by discharge
Additional Research Sheet 1
Students Ulyanenko Natalia
Speciality nursing
Well 2Group 03051384
Name of health facility- MBUZ "City Clinical Hospital No. 1"
Branch- therapeutic ward - 4
Type of transportation: can go
1. Surname, name, patronymic of the patient: Ivlev Dmitry Konstantinovich
2. Gender: male 3. Age 50 years old (04.10.1964)
4. Permanent residence: Belgorod region, Belgorod, Koneva street, 12, apt. 4.
5. Place of work, position: IP "Blagovest", accountant
6. Who referred the patient: MSCH
7. Medical diagnosis: Atherosclerosis of the thoracic aorta
2.3. The first stage of the nursing process - EXAMINATION
SUBJECTIVE EXAMINATION
1. The patient's current complaints about pressing and burning pains in the chest, as well as wheezing in the throat.
2. Since when does he consider himself sick: He considers himself sick for 3 years.
3. What does he associate his disease with: Associated with stress and malnutrition.
4. Last deterioration: last 5 days.
5. Past diseases, operations: missing.
6. Risk factors:
allergic anamnesis: not weighed down
heredity: not weighed down
smoking: YES NO;
alcohol: YES (moderately, redundant), NO;
drugs: YES, NO;
hypodynamia: YES,NO;
obesity:YES,NO;
frequent stressful situations: in the family and at work;
occupational hazards: none.
7. Nutrition:
appetite: elevated;
dietary compliance: YES, NO;
food predominates in the diet: spicy, fatty, fried, meat;
daily fluid intake: 1.5 l
8. Capable of independently:
eat;
use the toilet;
wash;
move;
dress;
communicate.
9. Life support resources:
underestimates the severity of the condition;
relation to religion: YES, NO;
family support: YES, NO;
patient support outside the family: YES, NO.
OBJECTIVE EXAMINATION
1. Consciousness:clear, frustrated, missing.
2. Position in bed:active, passive, forced.
3. The state of severity of the patient: satisfactory, moderate,
heavy, extreme.
4. Condition of the skin and mucous membranes:humidity, dryness
color: pallor;
defects: none
edema: missing.
5. Musculoskeletal system
joint function: saved.
6. Body temperature:36,8 .
7. Height:168 .
8. Weight: 89 .
9. Chest circumference: inhale ______, exhale ______,
chest excursion _______.
10. Respiratory system:
NPV: 18 per minute;
type of breathing: abdominal;
depth of breathing: superficial;
breathing rhythm: rhythmic;
nature of shortness of breath: mixed.
11. Cardiovascular system:
pulse: frequency 68 bpm;
rhythm: rhythmic;
voltage: moderate;
filling: full;
magnitude: big;
HELL: 135/105 mmHg st.
12. Gastrointestinal tract:
dental condition: caries;
removable dentures: YES, NO;
tongue coated: YES, NO;
smell from the mouth: YES, NO;
nature of the vomit: missing;
the presence and nature of the stool: constipation;
bloating: YES, NO;
involuntary excretion of feces: YES, NO.
13. Urinary system:
urination: painless;
urine color: usual;
transparency: transparent;
daily amount of urine: norm.
14. Endocrine system:
visible enlargement of the thyroid gland: YES, NO.
15. Nervous system:
dream: restless;
gait disturbance: YES, NO.
THE PATIENT IS DAMAGED
Avoid danger, be healthy, sleep, work.
2.4. The second stage of the nursing process is PATIENT PROBLEMS,
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