Encyclopedia of Family Medicine

Chapter 16 Home Nursing Technology (1)
The patient's appearance

The occurrence and development of each disease has its own rules and characteristics, and is constantly changing. Many changes in the disease can be observed by the patients themselves and their family members. Understanding these changes is of great significance for the diagnosis and treatment of the disease.Things that often need to be observed and recorded include:

(1) Vital signs: including body temperature, pulse, respiration, and blood pressure.

(2) Consciousness: clear, fuzzy, drowsy or coma.

(3) Weight: Obesity, emaciation, normal, increase or decrease.

(4) Expression: indifference, pain, worry, fear or tranquility.

(5) Gait: Steady, hobbled or assisted walking.

(6) Diet: the quality of appetite, the amount of food and the content of the diet.

(7) Nausea and vomiting: time, frequency, degree, nature and amount.

(8) Swallowing: normal, difficult or painful.

(9) Stool: character, frequency, volume, whether there is constipation or diarrhea.

(10) Urine: frequency, volume, color, and smoothness.

(11) Bleeding: time, color, volume, accompanying symptoms.

(12) Cough: degree, nature, content, presence or absence of phlegm and whether phlegm is thick, color and amount of phlegm.

(13) Voice: Loud, weak or hoarse.

(14) Pain: location, time, degree, nature and accompanying symptoms.

(15) Skin color: flushing, pale, cyanotic or yellow staining, whether the skin has bleeding spots, subcutaneous ecchymosis, rash or lumps.

(16) Eyes: Whether the eyelid is swollen, ptosis, sclera, yellowing or bleeding, pupil size, symmetry, and light response.

(17) Ear: Whether the hearing is normal and whether there is secretion.

(18) Nose: whether it is unobstructed, with or without bleeding and secretions.

(19) Oral cavity: the color of the mucous membrane, the condition of the tongue coating, and whether there is ulcer.

(20) Neck: soft or resistant, stiff.

(21) Posture and signs: whether there is passive or forced position.

(22) Sleep: quiet, restless.

(23) Drug reaction: whether there is any adverse reaction after medication or treatment.

monitoring of vital signs

1.body temperature
Body temperature, often based on oral, rectal or axillary temperature.There are two types of mercury column thermometers commonly used, namely the oral watch and the anal watch, which are made of glass and contain mercury at one end. The scale that rises after the mercury is heated is the body temperature.

[How to operate]
Before measurement: dry the sterilized thermometer with gauze, throw the mercury column below 35°C, and choose the oral cavity, underarm or anus according to the condition and age.

(1) Oral measurement method
Put the mercury end of the mouth surface obliquely under the tongue, make the patient breathe through the nose with closed mouth, do not bite the thermometer with teeth, take it out after 3 minutes, wipe it clean, see the degree of brightness, and record the degree and measurement time.

(2) Underarm measurement
Undo the button of the clothes, dry the armpit, put the mercury end of the thermometer into the deep armpit close to the skin, bend the arm across the chest, clamp the thermometer, take it out after 10 minutes, read the reading and record it.

(3) rectal measurement
Make the patient lie on the side with knees bent, expose the buttocks, lubricate the anal surface with 20% soap or oil, gently insert the mercury tip into the anus for 3-4 cm, take it out after 3 minutes, wipe the anal surface, see the degree and record .

[Precautions]
(1) Before and after measuring body temperature, check whether the thermometer is damaged.When throwing the thermometer, do not touch other objects to prevent the watch from being smashed.

(2) Mental disorders, coma and children cannot measure the oral temperature. When measuring the body temperature of such patients, someone must guard the side and hold the thermometer with their hands to prevent the thermometer from being lost or broken.Oral temperature cannot be measured for those who do not cooperate, have surgery on the mouth and nose, or have difficulty breathing.When eating or applying hot or cold compresses to the cheeks, the temperature should be measured after an interval of 30 minutes.

(3) Diarrhea, rectal or anal surgery patients should not measure rectal temperature; after sitz bath or enema, wait 30 minutes before measuring rectal temperature.

(4) If the patient accidentally bites the thermometer and swallows mercury, he can take a large amount of egg white or milk to combine protein and mercury to delay the absorption of mercury and finally excrete it from the body.Without affecting the condition, eat a lot of crude fiber foods such as leeks to wrap the mercury and reduce absorption. Crude fiber can also stimulate intestinal peristalsis and accelerate the excretion of mercury.

(5) Disinfect the thermometer after use. It is advisable to soak it in alcohol. Do not wash the thermometer in hot water or boil it in boiling water, which will cause explosion.

(6) Body temperature can be represented by symbols: oral temperature "●", armpit temperature "", anal temperature "".

2.Pulse observation
With the contraction and relaxation of the heart, the pulse can be felt on the superficial artery, which is called the pulse.

The resting pulse of a normal adult is 60-100 beats per minute, which can vary with factors such as age, gender, labor and emotion.Generally, women are faster than men, children are faster than adults, and the elderly are slower. It can temporarily increase during exercise and emotional agitation, and it is slower when resting and sleeping.The pulse rhythm is uniform and the interval time is equal.

When a disease affects the cardiovascular system and causes an abnormal pulse, it can manifest as:
(1) Speed ​​pulse: The pulse rate for adults exceeds 100 beats per minute.

(2) bradycardia: adult pulse rate is less than 60 beats per minute.

(3) Irregular pulse: The pulse is irregular, and the time between pulses varies.

[Measurement methods]
All superficial large arteries close to bones can be used for pulse diagnosis.The most commonly used is the radial artery (the side of the wrist near the thumb), followed by the temporal artery, carotid artery, brachial artery, femoral artery, dorsalis pedis artery, and posterior tibial artery.

[How to operate]
(1) Before diagnosing the pulse, the patient should be kept quiet, take a supine position, put the arm in a comfortable position, stretch the wrist, and put the palm down; if taking a sitting position, ask the patient to bend the elbow to a 90° angle, lay it flat on the table, and place the wrist on the table. Stretch, palms facing down.

(2) When measuring the number, press the fingertips of the index finger, middle finger, and ring finger on the surface of the radial artery. The pressure should be such that the pulse can be clearly felt. Count for half a minute. Multiply the measured pulse rate by 2 to get the pulse rate per minute. pulse rate.Abnormal pulse should be measured for 1 minute.When the pulse is weak and unclear, the heart rate can be counted with a stethoscope for 1 minute instead of palpation.

(3) Note: If the patient has strenuous activities, he should rest for 20-30 minutes before taking the test.The measured results should be recorded and used as information for diagnosis and treatment.

3.Observation of breathing
In the process of metabolism, the human body needs to continuously take in oxygen from the environment and discharge carbon dioxide. This gas exchange between the body and the environment is called respiration.

The normal adult breathing rate is 16-20 breaths per minute.Changes with factors such as age, labor and emotion.It is faster in children, slower in the elderly, faster in labor and emotional agitation, and slower in rest and sleep.Under normal circumstances, the breathing rate and depth are relatively uniform and stable.

The rate, rhythm, and depth of breathing can be altered by disease.

(1) Changes in respiratory rate: Adults who breathe more than 24 times per minute are called increased breathing, which is common in high fever and hypoxia.Breathing less than 10 times per minute, called slow breathing, common in intracranial disease and sleeping pill poisoning.

(2) Changes in respiratory rhythm: respiratory rhythm disorders often occur.

① Tidal breathing: It is a kind of periodic breathing abnormality.The characteristic is that the breathing is shallow and slow at the beginning, and then gradually accelerates and deepens. After reaching the climax, it gradually becomes shallow and slow, and then after apnea for a few seconds, the above symptoms reappear.Repeatedly like this, its breathing movement is in a state of ebb and flow, so it is called tidal breathing.It is more common in central hypoxia.

②Intermittent breathing: The phenomenon of breathing and apnea appear alternately, which is characterized by abruptly stopping breathing after regular breathing several times, and then starting to breathe again after a short period of interruption, and so on and so forth.Common in intracranial lesions and respiratory failure.

(3) Changes in breathing depth
①Deep breathing: It is a deep and regular big breathing, which is more common in metabolic acidosis, such as diabetic ketoacidosis.

② Superficial breathing: It is a superficial irregular breathing, sometimes sighing, seen in dying patients.

(4) Changes in breathing sound

① Cicada-like breathing: There is a high-pitched sound when inhaling, which is mostly caused by the obstruction near the vocal cords, which makes it difficult for air to enter.More common in laryngeal edema, spasm, laryngeal foreign body.

②Snoring breathing: Due to the accumulation of more secretions in the trachea or bronchi, the breathing makes rough snoring sounds, which are more common in deep coma.

(5) Dyspnea: objective manifestations are changes in respiratory frequency, rhythm, and depth.Subjectively, the patient feels insufficient air, labored breathing, chest tightness and irritability, inability to lie flat, cyanosis of lips and nails, fluttering of the nose, mainly due to insufficient gas exchange and hypoxia.Can be divided into:
① Inspiratory dyspnea, inhalation is laborious, and its time is significantly longer than exhalation, resulting in strong contraction of respiratory muscles and three concave signs.Seen in laryngeal edema, laryngeal foreign body.

② Expiratory dyspnea, exhalation is laborious, the time is significantly longer than inhalation, more common in asthma.

③ Mixed dyspnea, inhalation and exhalation are laborious, and the breathing frequency increases and becomes superficial.More common in pulmonary infectious diseases.

[Measurement methods]
(1) Always measure respiration after measuring the pulse, and still press the hand on the patient's wrist to divert the patient's attention.

(2) Observe the ups and downs of the patient's chest or abdomen, taking one breath and one breath.

(3) Observe the depth and rhythm of breathing, multiply by 2 after counting for half a minute for adults and children.If the breathing is irregular, count to 1 minute, and the baby counts to 1 minute.

(4) When a critically ill patient's breathing is weak and difficult to observe, a little cotton can be placed in front of the patient's nostrils, and the blowing of the cotton can be observed and counted.Record the number of breaths in 1 minute.

4.Observation of blood pressure
When blood flows in a blood vessel, the lateral pressure on the blood vessel wall is called blood pressure.Take millimeters of mercury (mmHg) or kilopascals (kPa) as the unit, 1kPa=7mmHg.

When the heart contracts, blood flows into the aorta, and the arterial pressure is the highest at this time, which is called the systolic pressure; when the heart relaxes, the arterial wall elastically returns to its original position, and the pressure in the arterial tube drops to the lowest level, which is called the diastolic pressure.The difference between systolic and diastolic blood pressure is called pulse pressure difference.

Normal adult blood pressure, at rest, the systolic blood pressure is 90-140mmHg, the diastolic blood pressure is 60-90mmHg, and the pulse pressure difference is 30-40mmHg.Normally it remains relatively constant.However, there may be small changes due to the influence of various factors:

(1) Age and gender: Pediatric blood pressure (belonging to the physiological characteristics of children).Before middle age, the blood pressure of women is 5~10mmHg lower than that of men, and there is no difference after middle age.

(2) The influence of time and sleep on blood pressure: Generally, the blood pressure is higher in the evening than in the early morning. When the rest and sleep are not good, the blood pressure increases slightly.

(3) Environmental changes: In a cold environment, blood pressure can rise; in a high-heat environment, blood pressure can drop.

Blood pressure changes when various factors affect cardiac output, peripheral resistance, arterial wall elasticity, and circulating blood volume.

(1) Hypertension: A systolic blood pressure of 10 mmHg or above and a diastolic blood pressure of 90 mmHg or above is called high blood pressure.

（2）临界高血压：指血压值在正常和高血压之间。收缩压高于140而低于160mmHg，或舒张压高于90而低于95mmHg，定为临界高血压。

(3) Hypotension: Diastolic blood pressure lower than 50, systolic blood pressure lower than 90mmHg is hypotension.

[Measurement methods]
(1) Measurement site: It is usually measured at the brachial artery of the cubital fossa of the upper limb, and the fossa artery of the lower limb can also be removed.

(2) Materials: sphygmomanometer, stethoscope.

(3) Operation method:
①Before the measurement, let the patient rest for 15 minutes to eliminate the influence of fatigue or stress on blood pressure.

②Let the patient take a sitting or lying position, expose the right or left arm, roll up the sleeves to the shoulders, and the cuffs should not be too tight, so as not to affect the blood flow. .

③Put the sphygmomanometer flat, drive out the air in the cuff, and wrap it around the middle of the upper arm evenly without any folds. The tightness should fit a finger.If it is too tight, the blood vessel will be compressed before the gas is injected, so that the measured blood pressure will be low; if it is too loose, the air bag will be in the shape of a balloon, and the effective measurement area will be narrowed, so that the measured blood pressure will be high.The middle part of the air bag should face the elbow fossa, so that the pressure is just on the artery when inflated, and the lower edge of the cuff is 2~3 cm away from the elbow fossa, and the end is neatly inserted into the inner ring, and the mercury tank switch is turned on.

④ Put on the stethoscope and feel the pulse point of the brachial artery on the inner side of the elbow fossa.Put the head of the stethoscope close to the brachial artery in the cubital fossa, press gently, fix it with your hand, close the valve screw cap on the airbag with the other hand, hold the infusion balloon and inflate into the cuff until the brachial pulsation sound disappears, and then increase the pressure by 20~ 30mmHg, then slowly release the valve at a speed of 2~5mmHg per second to make the mercury column drop slowly, and pay attention to the scale indicated by the mercury column.When the pressure in the cuff gradually drops to be equal to the contraction force of the heart, the blood can pass through the compressed artery when the heart contracts, and the first pulse is heard from the stethoscope. At this time, the scale pointed by the mercury column is the contraction. pressure.Then the fluctuating sound continued to exist and increased. When the pressure in the cuff was equal to the diastolic pressure, the beating sound suddenly weakened or disappeared, and the scale indicated by the mercury column was the diastolic pressure.

⑤Record the measured value, and record it in fractional form, that is, systolic blood pressure/diastolic blood pressure mmHg.When dictating blood pressure values, the systolic pressure should be read first, followed by the diastolic pressure.

[Precautions]
(1) Before measuring, check whether the mercury column of the sphygmomanometer is blocked and whether it is kept at the "0" point.Whether the rubber tube and the balloon are leaking.

(2) The cuff should not be too wide or too narrow, so as not to affect the value.

(3) The "0" point of the sphygmomanometer should be at the same level as the brachial artery and the heart, and the same horizontal line should be maintained when sitting or lying down. high.

(4) If the blood pressure is unclear or abnormal, the measurement should be repeated, and the gas in the cuff should be exhausted first, so that the mercury column drops to the "0" point, wait for a while, and then measure until it is accurate.Otherwise, continuous pressurization for a long time will block the circulation of the limbs, make the patient feel uncomfortable, and affect the measured value.

(5) For patients who need to closely observe changes in blood pressure, try to set the time, location, body position, and sphygmomanometer, so that the measurement can be relatively accurate and conducive to disease monitoring.

(6) For hemiplegic patients, it should be measured on the arm of the unaffected side, because the blood circulation of the affected side is hindered, and the blood pressure cannot be truly reflected.

(7) Pay attention to prevent errors caused by the sphygmomanometer itself, such as insufficient mercury, the measured blood pressure may be low.

Collection of laboratory specimens

In addition to clinical symptoms and signs, laboratory tests are also an indispensable and important method for disease diagnosis. Whether the test results are correct or not is closely related to the collection of specimens.

Specimens that are often sent for testing include excrement, secretions, vomit, blood, body fluids and exfoliated cells.Through the inspection of specimens, to a certain extent, we can understand the normal physiological phenomena and pathological changes of the body, and combined with others, it plays an important role in determining the diagnosis, observing the condition, and formulating preventive measures.On the contrary, improper collection of specimens can affect the accuracy of test results, and even delay diagnosis and treatment.Therefore, it is extremely important to collect specimens and send them for examination. The collection of specimens in home care mainly focuses on stool, urine and sputum.

1. Collection of stool samples

Stool tests are helpful for the diagnosis of digestive tract diseases and parasitic diseases. According to different test items, there are different requirements for collecting stool samples.

(1) Routine stool examination: The specimens are required to be fresh. After the patient defecates, pick out broad bean stools with a small bamboo stick and put them in a clean plastic box or plastic cup.For diarrhea patients with pus and blood in the stool, the part containing pus, blood and mucus should be picked.If it is a water sample, it should be placed in a container for testing.

(2) Fecal occult blood test: Three days before the test, the patient should fast from meat, liver, blood, a large amount of chlorophyll food and iron-containing medicines, so as to avoid false positive reactions and affect the diagnosis of the disease.

(3) Specimens of parasites and eggs: multiple parts of fresh stool should be collected and sent for examination in time.The sample size should be about 10 grams when checking for amoeba.

(4) Cultivate specimens: Instruct the patient to defecate in the bedpan, use a sterile cotton swab to collect a little pus, blood or mucus in the feces, put it in a culture test tube and send it for testing immediately, or use a sterile cotton swab dipped in normal saline, and insert it from the anus for about 6~ 7 cm, turn it gently, take out a little stool, put it into a sterile test tube, cover it and send it for testing.

2.collecting urine samples

Collect urine samples for physical, chemical, bacteriological and microscopic examination:
(1) Urine routine: ask the patient to collect about 100ml of the first urine in the morning and leave it in a clean container for examination.

(2) 12-hour or 24-hour urine specimen: instruct the patient to start urine retention after emptying the bladder at 7:24 in the morning. A larger container is required, and the 7-hour urine should be kept in the container, and the last time will be discharged at 12:7 the next morning. Urine, send all urine for testing.If the urine is left for 7 hours, it will start from [-]:[-] pm to [-]:[-] am the next morning.

(End of this chapter)