General care of the mentally ill. Features of the work of a nurse on duty in a psychiatric hospital

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Introduction

6. Procedure for distributing medicines

10. The role of the nurse in training family members to care for the sick at home

Conclusion

Bibliography

Introduction

“I, solemnly, before God and in the presence of this assembly, pledge myself: To lead my life in purity and faithfully serve my profession. I will abstain from everything that causes harm and death, and will not take or knowingly give harmful medicine. I will do everything in my power to support and elevate the standard of my profession, and I also promise to keep confidential all personal matters within my care and the family circumstances of patients that become known to me in the course of my practice. I will faithfully strive to assist the physician in his work and devote myself to the well-being of those who have entrusted themselves to my care."

The Commitment of Florence Nightingale.

Mental hospital - inpatient facility healthcare, providing treatment and rehabilitation of persons with mental disorders, as well as performing expert functions, engaging in forensic psychiatric, military and labor examinations. Historians have argued that the first psychiatric hospital arose near the North German city of Elbing or in the Spanish city of Valencia. In 2005, at the congress of the World Psychiatric Association, an opinion was voiced that the first institutions of this kind appeared in the 8th century in the Middle East in Baghdad. It is also known that special hospitals in which the insane were treated existed in Constantinople - one of these hospitals was located at the church of St. Anastasia, who was considered a healer of the mentally ill. Until the 18th century, mentally ill people in Russia were under the care of monasteries. The oldest psychiatric hospital in Russia is sometimes called the Kolmovskaya Hospital; in 1706, Metropolitan Job of Novgorod built a foundling house and an invalid hospital in the Kolmovsky Monastery near Novgorod, where people with mental disorders were kept. In 1779, it was announced that the first Russian special hospital “for the use of the insane” would be opened in St. Petersburg, which a few years later became a department of the Obukhov Hospital. By 1810, fourteen specialized institutions were opened in Russia; by 1860, their number reached forty-three. According to contemporaries, iron chains, “rawhide belts” and straight jackets were used as measures of restraint. Along with other methods of treatment, emetics, hydrotherapy, bloodletting and treatment with leeches were used. In Soviet psychiatry, in contrast to Western psychiatry, which aimed primarily at outpatient treatment, the opposite trend prevailed: an increasing number of hospitals were intensively built.

Modern inpatient care for the mentally ill is provided in specialized psychiatric hospitals. Over the past decade, there has been a clear trend towards a reduction in the number of psychiatric beds. If at the beginning of this century their number in Western countries was 4-6 beds per 1000 population, now this figure in a number of countries has decreased by 2-3 times. The provision of psychiatric beds in different regions of our country varies. On average, this figure is 1.5-2 beds per 1000 population. The work of medical personnel in psychiatric institutions differs from that in other hospitals and has a number of features. These features are mainly due to the fact that many mentally ill people do not understand their painful condition, and some do not consider themselves sick at all. In addition, patients with upset consciousness may experience severe motor agitation. In this regard, special requirements are placed on medical personnel in psychiatric hospitals: constant vigilance, restraint and patience, resourcefulness, sensitive, affectionate attitude and strict individual approach to the sick. Consistency in the work of the entire team of department and hospital employees is of great importance. Since knowledge of all the details of the care and supervision of the mentally ill is a necessary condition work of a nurse or paramedic in a psychiatric hospital, the purpose of this work is to consolidate practical skills in caring for mentally ill people, increasing theoretical knowledge in the field of providing psychiatric care.

1. Structure of mental health care

The concepts of “medical deontology” and “medical ethics” are not identical. The problem of duty is one of the main problems of medical ethics; accordingly, medical deontology is a reflection of ethical concepts, but it has a more pragmatic and specific nature. If medical ethics does not carry specificity due to one or another medical specialty (there is no separate ethics of a therapist, ethics of a surgeon, and so on), then medical deontology has acquired the features of specialization due to its applied nature, the relationship with one or another medical profession (distinguish deontology of a surgeon, gynecologist, pediatrician, oncologist, radiologist, etc.). Consequently, medical deontology is part of medical ethics, a set of necessary ethical standards and regulations for medical workers in the implementation of professional activities. Aspects of deontology are: the relationship of doctors with the patient, the patient’s relatives and doctors among themselves. The basis of relationships is the word, which was known in ancient times: “You need to heal with words, herbs and a knife,” ancient healers believed. A smart, tactful word can lift the patient’s mood, instill in him cheerfulness and hope for recovery, and at the same time, a careless word can deeply wound the patient and cause a sharp deterioration in his health. It is important not only what to say, but also how, why, where to say it, how the one to whom the medical worker is addressing will react: the patient, his relatives, colleagues, etc.

In a psychiatric hospital, depending on the psychiatric vigilance, the following regimes may be provided. Mode “A” is a mode of intensive monitoring of medical personnel for patients with depression, a clouded state of consciousness, patients in the stage of catagonic agitation, etc. Mode “B” is ordinary psychiatric observation, which provides for constant monitoring of nursing staff over the behavior of patients in the department. Mode “B” is a combination of observation with the principles of trust. Here, the patient’s freedom from constraint, the possibility of independently coming and going from medical-labor workshops, as well as free movement within them, are widely used. Mode "G" - open door mode. Maximum freedom for the patient and minimum isolation. Mode "D" - outpatients.

Psychiatric care to the population is provided by the work of a psychoneurological dispensary and a psychiatric hospital. Patients registered at a psychoneurological dispensary and newly identified patients, if necessary, are sent for treatment to a hospital. When hospitalizing patients in a hospital, medical personnel must obtain their consent for hospitalization and treatment. Compulsory treatment is necessary only when the patient is inadequate, unable to be critical of his condition, if he poses a danger to himself and others. A simple psychiatric hospital ward has two halves: a restless one and a calm one. The restless half contains patients with inappropriate behavior in an acute state: delusions, hallucinations, psychomotor agitation, and stupor. Such patients need constant supervision by medical personnel, as they can cause harm to themselves and other people. Patients who need special observation and care are placed in a special ward - an observation room, which is constantly monitored by a nurse and a nurse. In the calm half there are patients during the recovery period, when they have adequate behavior, when they can take care of themselves and are not dangerous to themselves and others. In the department of a psychiatric hospital, all doors are always locked with a key, which is kept only by doctors and nursing staff. Windows must be barred or glass must be unbreakable. Windows should be located so that patients cannot reach them. Medical staff in psychoneurological hospitals must constantly show vigilance, patience, sensitivity, politeness, and attention to patients. Medical workers should avoid wearing bright cosmetics and wearing jewelry (chains, earrings), which can be torn off by patients with psychomotor agitation. Nurses wear a gown and cap. Hair must be tucked under a cap. With patients, despite their behavior, even aggressive, it is necessary to communicate patiently, politely, and kindly.

Often the behavior of psychiatric patients leads to tragedies, so the nurse must be vigilant and never turn her back on the patient. The personal belongings of patients prone to suicide should be regularly checked for the presence of sharp, cutting objects, cuttings, chips, wire, pens, hairpins, matches, hairpins, anything with which the patient can open the door or cause harm to himself and others. The personal belongings of other patients are also periodically inspected. It is better to carry out an inspection of personal belongings when the patient is not in the room (the patient is in the dining room, bathroom, on a walk), this spares the feelings of the patients. If it is necessary to immediately look through the patient's belongings, he is called to the doctor's office or to another place outside the ward. During meals, patients are served food that can only be eaten with a spoon. The room where cutlery (knives, forks) and other items are located should always be closed so that patients cannot freely enter there. In organizing coordinated work psychiatric department The work of a nurse plays an important role, as she carries out not only doctor’s prescriptions, medical manipulations, and patient care, but also helps patients in recovery and rehabilitation. The nurse must be well aware of the number of patients in the department every day, know the patients by name, patronymic, surname, in which wards each of them lies, the reasons for the absence of some of them. She must know about the mental illness of each patient, the characteristics of its course, the state of this moment about the treatment being given to him. The nurse must know what orders the attending physician has made and strictly carry them out at a certain time. Communication between a nurse and patients should be smooth, serious, patient, and caring. You cannot be overly ingratiating and liberal with the sick. It is impossible to single out “favorites” among the patients of the department and pay attention only to them, forgetting about the other patients.

The nurse must strictly monitor the regime in the psychoneurological department, since its maintenance is the key to successful treatment of mental patients. Extraneous conversations in the presence of the patient are prohibited, even if the patient is completely indifferent to his surroundings. Sometimes such a patient, after completing a course of treatment, says that in his presence nurses or orderlies had conversations on the most extraneous topics, which were extremely painful for him to listen to, but he could not speak or move, for example, during a catatonic stupor. Extraneous conversations from staff are no less burdensome for patients who are depressed and melancholy. Patients with delusional ideas of attitude or self-blame often see in these conversations a number of “factors” that, in their opinion, are directly related to them. This can increase the anxiety of patients and disrupt contact with medical personnel. Such patients begin to be suspicious of the nurse and do not take medicine from her. In such cases, they say that the patient “weaves” those around him into his delirium.

In the presence of patients, you cannot discuss the health status of any of them, talk about his illness, or express a judgment about the prognosis. It is strictly forbidden to laugh at the sick or conduct a conversation in an ironic, playful tone. Often, patients with delusional ideas express various assumptions about the reason for their stay in the hospital, complain that they are not being treated, and everything is supposedly being done in order to get rid of them, to kill them. It is necessary to listen carefully and patiently to the patient. One should not strive at all costs to dissuade the patient, but one should not agree with his delusional statements. Sometimes, in order to reassure the patient, the nurse promises him another meeting with his family, a conversation on the phone, but does not fulfill it, i.e., deceives the patient. This is completely unacceptable, as the patient loses confidence in the medical staff. If it is impossible to directly and specifically answer a particular question, you should move the conversation to another topic and distract the patient. It is not recommended to fraudulently place a patient in a hospital: this makes it difficult to contact him in the future, the patient becomes distrustful for a long time, does not say anything about himself, about his experiences, and sometimes becomes embittered. You should not be afraid of the sick, but you should not flaunt excessive courage, as this can lead to serious consequences. Patients often write various letters, statements, and complaints to different institutions. In these letters they outline their “ordeals”, demand that they be examined by a commission, etc. Therefore, before sending, all letters written by patients must be read by a nurse or doctor.

Letters that are obviously painful in their content or contain any absurd statements should not be sent. The nurse should give these letters to the doctor. Letters and notes received by the department must also be read before being distributed to patients. This is done to protect the patient from traumatic news that could worsen his health. Transfers to patients (products and things) should be carefully reviewed so that relatives and friends do not intentionally or unintentionally give the patient something that may be contraindicated for him or even dangerous for him, for example, medicines (especially drugs), alcoholic beverages, needles, blades, pens , matches. The nurse monitors not only the patients in the department, but she must supervise the work of the orderlies and supervise their work. She must ensure that continuity is maintained in the work of the sanitary post between different shifts, so that orderlies are always present in the department. The nurse tells the new shift of orderlies which patients require special attention and care. The work of a nurse is a creative process that includes healing process, which requires knowledge of the disease, its course, and treatment methods. The nurse is responsible for many vital necessary procedures. A nurse in a psychiatric department needs knowledge about the psychology of the patient, the peculiarities of the course of his disease, and there must be an individual approach to each patient. This knowledge is necessary for adequate implementation therapeutic work nurses, because obtaining the consent of a psychiatric patient to carry out a particular procedure or taking medications can be very difficult, due to psychosomatic pathology, delusional symptoms, hallucinations. For mental patients, care and supervision provided by a nurse always remains an important process in treatment. The psychiatric nurse is also the link between the patient and the doctor.

2. Description of mental status in medical records

Determining mental status is the most important part of the process of psychiatric diagnosis, that is, the process of knowing the patient, which, like any scientific cognitive process, should not occur chaotically, but systematically, according to a scheme - from phenomenon to essence. Actively purposeful and in a certain way organized living contemplation of a phenomenon, that is, the determination or qualification of the patient’s real status (syndrome) is the first stage in recognizing the disease. Poor quality research and description of the patient’s mental status most often occurs for the reason that the doctor has not mastered and does not adhere to a specific plan or scheme for studying the patient, and therefore does it chaotically.

Because the mental illness is the essence of a personality illness, then the mental status of a mentally ill person will consist of personal characteristics and psychopathological manifestations, which are conventionally divided into positive and negative. Adopting the conventions, we can say that the mental status of a mentally ill person consists of three “layers” of PNL: positive disorders (P), negative disorders (N) and personal characteristics (P).

In addition, manifestations of mental activity can be conditionally divided into four main spheres of PEPS: 1. Cognitive (intellectual-mnestic) sphere, which includes perception, thinking, memory and attention (P). 2. The emotional sphere, in which higher and lower emotions (E) are distinguished. 3. Behavioral (motor-volitional) sphere, in which instinctive and volitional activity (P) are distinguished. 4. The sphere of consciousness, in which three types of orientation are distinguished: allopsychic, autopsychic and somatopsychic (C).

Table 1. Structural and logical diagram of mental status

Mental activity	Positive disorders (P)	Negative disorders (N)	Personality characteristics (L)
Cognitive sphere (P)	Perception Thinking Attention
Emotional sphere (E)	Lower emotions Higher emotions
Behavioral domain (P)	Instinctive activity Volitional activity
Sphere of Consciousness (C)	Allopsychic orientation Autopsychic orientation Somatopsychic orientation

A description of the mental status is carried out after drawing up an idea of ​​the syndrome that defines the condition, its structure and individual characteristics. The description of the status is descriptive, if possible without the use of psychiatric terms, so that another doctor who turns to the medical history and clinical description could, through synthesis, give this condition his clinical interpretation and qualification. Adhering to the structural-logical scheme of mental status, it is necessary to describe four spheres of mental activity. You can choose any sequence when describing these spheres of mental activity, but you must follow the principle: without completely describing the pathology of one sphere, do not move on to describing another. With this approach, nothing will be missed, since the description is consistent and systematized.

It is recommended to begin the presentation of the mental status with a description of the patient’s appearance and behavior. It should be noted how the patient was brought to the office (he came alone, accompanied, went to the conversation willingly, passively, or refused to come into the office), the patient’s posture during the conversation (stands, sits quietly, moves carelessly or restlessly, jumps up, where- sometimes strives), his posture and gait, facial expression and eyes, facial expressions, movements, manners, gestures, neatness in clothing. Attitude to the conversation and the degree of interest in it (listens with concentration or is distracted, does he understand the content of the questions and what prevents the patient from understanding them correctly).

Features of the patient’s speech: shades of voice (modulation of timbre - monotonous, loud, sonorous, quiet, hoarse, shouting, etc.), rate of speech (fast, slow, with pauses or without stops), articulation (chanted, stuttering, lisp) , vocabulary (rich, poor), grammatical structure of speech (ungrammatical, broken, confused, neologisms), purposefulness of answers (adequate, logical, essentially or not essentially, specific, thorough, florid, one-dimensional, diverse, complete, torn and etc.).

The availability or lack of availability of the patient should be noted. If it is difficult to make contact, reflect what is causing this (active refusal of contact, impossibility of contact due to psychomotor restlessness, mutism, stunning, stupor, coma, etc.). If contact is possible, the patient’s attitude to the conversation is described. It is necessary to emphasize whether the patient actively or passively expresses his complaints, what emotional and vegetative coloring they are accompanied by. It should be indicated if the patient does not complain about his mental state and denies any mental disorders. In these cases, actively questioning the patient, the interpretation given by him of the very fact of being admitted to the hospital is described.

The holistic behavior, the correspondence (inconsistency) of the patient’s actions with the nature of his experiences or the environment is described. A picture of unusual reactions to the environment, contacts with other patients, staff, acquaintances and relatives is given. General characteristics of the individual with an assessment of his condition, attitude towards loved ones, towards treatment, immediate and distant intentions.

Following this, it is necessary to describe the patient’s behavior in the department: his attitude towards eating, medications, staying in the hospital, attitude towards surrounding patients and staff, tendency to communicate or isolate himself. The description of the mental state ends with a presentation of the results of a study of attention, memory, thinking, intelligence and criticism of the patient in relation to the disease and the situation as a whole.

3. Behavior of medical staff with excited, delusional, and depressed patients

Agitation is a complex pathological condition that includes speech, mental and motor components. It can develop against a background of delusions, hallucinations, mood disorders, and be accompanied by confusion, fear and anxiety. When providing care to an agitated patient, the nurse's main task is to ensure the safety of the patient and others. Often, to control anxiety, it is enough to create a calm environment and establish contact with the patient so that he feels safe. At psychotic disorders(delusions, hallucinations) neuroleptics and antipsychotics are used to relieve agitation. The main indication for injections of psychotropic drugs is the lack of patient consent to treatment, since the differences between tablet and injectable forms of drugs relate mainly to the speed of development of the therapeutic effect and, to a lesser extent, the level of sedation achieved. The optimal route of drug administration is intramuscular; intravenous administration of drugs is not necessary, and in some cases physically impossible. Modern standards of therapy suggest the use of tablets (for example, risperidone, olanzapine) and injectable forms of atypical antipsychotics (for example, Rispolept Konsta) as first-line agents in all groups of patients, while traditional antipsychotics remain reserve drugs. In case of decompensation of mental illness in a somatically healthy patient, maximum doses of drugs are used to relieve agitation, if necessary. Typically, olanzapine (Zyprexa) at a dose of 5-10 mg or zuclopenthixol (Clopixol-Acufaz) at a dose of 50 mg is administered intramuscularly. The administration of some antipsychotics (haloperidol, zuclopenthixol, olanzapine, trifluoperazine) is often accompanied by the development of extrapyramidal disorders and requires the parallel use of correctors - antiparkinsonian drugs, such as trihexyphenidyl (Cyclodol, Parkopan, Romparkin). In the absence of atypical antipsychotics, 100-150 mg (4-6 ml of a 2.5% solution) of chlorpromazine (Aminazine) or levomepromazine (Tizercin) can be administered intramuscularly. The administration of antipsychotics requires monitoring blood pressure levels due to the risk of collapse. To prevent orthostatic reactions, the use of antipsychotics in doses exceeding the minimally effective ones should be accompanied by an intramuscular injection of 2.0-4.0 ml of a 25% Cordiamine solution (into the other buttock). Of the tablet drugs, preference is given to risperidone (Rispolept) at a dose of 1-4 mg or clozapine (Azaleptin, Leponex), which has a strong antipsychotic and sedative effect, at a dose of up to 150 mg once.

Temporary fixation of a patient with severe agitation is allowed, subject to mandatory documentation of this procedure by the nurse. In this case, the patient should be under constant supervision of medical personnel. It is important to avoid pinching blood vessels, for which the fixing bandages must be wide enough. According to the Law “On the Police” (1991) and the order of the Ministry of Health of the Russian Federation and the Ministry of Internal Affairs of the Russian Federation “On measures to prevent socially dangerous actions of persons suffering from mental disorders” No. 133/269 of April 30, 1997, law enforcement agencies must provide assistance to doctors in such cases.

Tranquilizers (in particular, benzodiazepines) are most effective for neurotic disorders, in particular panic attacks; their use is also recommended in cases where the diagnosis is unclear. From the group of benzodiazepines, it is optimal to use drugs with a shorter half-life and maximum anxiolytic effect, for example, lorazepam. In case of agitation that develops as a result of deep metabolic disorders (during intoxication, severe infection, etc.), it is also preferable to use benzodiazepine tranquilizers - diazepam at a dose of 10-30 mg (2-6 ml of 0.5% solution) or lorazepam at a dose 5-20 mg (-8 ml of 0.25% solution). It is better not to use neuroleptics in such cases, and if necessary, the dose of the drugs should be reduced.

For agitated depression (with prolonged speech motor excitation), melancholic raptus, intramuscular administration of antidepressants with a sedative effect (in order to potentiate the calming effect), for example, amitriptyline in a dose of 40-80 mg (2-4 ml of a 2% solution) is possible. The drugs of choice for the treatment of psychomotor agitation are sedative neuroleptics, including in combination with diphenhydramine (Diphenhydramine) or promethazine (Diprazine, Pipolfen), or tranquilizers. Tranquilizers should be preferred in the elderly, in the presence of severe somatic diseases, severe hypotension. Medications administered parenterally, but do not neglect their administration orally, thereby affecting the speed of onset of action of the drug. It is necessary to adjust the doses of drugs upward if the patient has previously received psychopharmacotherapy. Haloperidol, zuclopenthixol, olanzapine, trifluoperazine must be prescribed with a corrector - trihexyphenidyl (Cyclodol) at a dose of 2 mg.

When organizing care for agitated patients, it is necessary to take into account that, regardless of the nosological basis of mental illness, they perform many unnecessary actions, do not give in to persuasion, and resist attempts to calm them down. Most of these patients are characterized by unexpected actions, psychomotor agitation is often accompanied by speech, and patients scream loudly, sometimes senselessly. They are unable to control their actions; under the influence of delusional ideas, perception disorders, or due to upset consciousness, patients often commit actions that pose a danger to them and to others, who cannot always correctly assess the patient’s condition and take into account the possible consequences of his behavior . The acute onset of the disease often causes fear among others. The main task in this case is to establish the nature of the disease and immediately begin providing assistance. When caring for and supervising an agitated patient, first of all it is necessary to ensure the safety of the patient himself and those around him, and to create favorable conditions for the provision of assistance. There should be no strangers in the room in which the patient is located, except for those who will participate in organizing supervision over him, it is necessary to remove piercing, cutting and other objects that can be used as a means of suicide or as a weapon of attack. In no case should a health worker show fear of the patient, treat him carefully, calmly, patiently, but at the same time be firm and decisive. To avoid an unexpected blow or attack, you need to approach the patient from the side, sit him down, put your hands on his hands and try to calm him down, explaining that he is not in danger and his condition will soon pass, etc. Calm conversation often reduces agitation. If it is not possible to establish contact with the patient, it is necessary to resort to medications that relieve agitation. If the patient refuses to take the medicine, it is administered by force. However, the sedation of the patient that occurs under the influence of pharmacological agents is often temporary, and after the cessation of the drug’s effect, agitation occurs with the same force. Reassuring the patient should under no circumstances lull the doctor's vigilance. The basic rules of supervision of a patient suffering from psychosis are thoroughness, continuity and reality. In manic-depressive psychosis, the patient’s behavior in a state of manic excitement is largely due to elevated mood and desire for activity. Usually such a patient can be distracted from unwanted actions. Prohibitions cause anger and irritation in such patients, and the word has a beneficial effect.

Common mistakes: Leaving the patient without proper observation and control over his behavior; Underestimation of the danger of psychomotor agitation for the patient himself and those around him (including failure to attract the help of police officers); Neglect of physical restraint methods; Confidence in the need for only intravenous administration of sedatives, excluding intramuscular and oral routes; the use of correctors when administering neuroleptics that can cause side extrapyramidal disorders.

4. Rules for accepting and handing over duty

Most often, the transfer of duty is carried out in the morning, but it can also be done during the day if one nurse works the first half of the day, and the second - the second half of the day and at night. The nurses receiving and handing over duty go around the wards, check the sanitary and hygienic regime, examine seriously ill patients (have measures been taken to prevent bedsores, change bed and underwear) and sign in the register of reception and transfer of duty, which reflects the total number of patients in the department, the number of seriously ill patients and feverish patients, movement of patients, urgent appointments, condition of medical equipment, care items, emergencies. The log must contain clear, legible signatures of the nurses who accepted and passed duty.

The nurse, checking the prescription sheet, draws up a “portion plan” daily (if there is no dietetic nurse). The portion planner must contain information about the number of different dietary tables and the types of fasting and individual diets. For patients admitted in the evening or at night, the nurse on duty prepares a portion plan. The ward nurses' information on the number of diets is summarized by the department's senior nurse, signed by the head of the department, and then transferred to the catering department.

Register of medicines of list A and B. Medicines included in list A and B are stored separately in a special cabinet (safe). There should be a list of these medications on the inside of the safe. Drugs are usually stored in the same safe, but in a special compartment. Hard-to-find and expensive items are also stored in the safe. The transfer of the keys to the safe is recorded in a special journal. To record the consumption of medicines stored in the safe, special journals are created. All sheets in these magazines should be numbered, laced, and the free ends of the cord should be sealed on the last sheet of the magazine with a sheet of paper indicating the number of pages. This sheet is stamped and signed by the head of the medical department. To record the consumption of each drug from list A and list B, a separate sheet is allocated. This magazine is also kept in a safe. Annual records of medication consumption are kept by the department's senior nurse. The nurse has the right to administer a narcotic analgesic only after the doctor has recorded this prescription in the medical history and in his presence. A note about the injection is made in the medical history and on the prescription sheet. Empty ampoules of narcotic analgesics are not thrown away, but are handed over, along with unused ampoules, to the nurse starting her next duty. When transferring duty, they check the correspondence of the entries in the accounting log (the number of ampoules used and the balance) with the actual number of filled used ampoules. When the entire supply of narcotic analgesics is used, empty ampoules are handed over to the head nurse of the department and new ones are issued in return. Empty ampoules of narcotic analgesics are destroyed only by a special commission approved by the head of the medical department.

A journal of acutely scarce and expensive funds is compiled and maintained according to a similar scheme. The register for writing off alcohol and dressings is located in the treatment room. This magazine is numbered and laced, signed by the head nurse and the head of the department.

A summary of the patients' condition is compiled daily by the night nurse, most often early in the morning, before starting their shift. It contains the names of the patients, their room numbers, as well as their state of health.

5. Features of care for the elderly and frail patients

Care for elderly and senile patients is carried out taking into account the characteristics of the aging body, the decrease in its adaptive capabilities, the uniqueness of the course of diseases in older people and age-related changes psyche. A feature of many diseases in the elderly is an atypical sluggish course without a pronounced temperature reaction, local changes and relatively rapid onset severe complications. The susceptibility of older people to infectious diseases and inflammatory processes requires particularly careful hygienic care. Elderly people often show increased sensitivity to changes in microclimate, diet and diet, lighting, and noise. Features of the psyche and behavior of an old person (emotional instability, slight vulnerability, and in case of vascular diseases of the brain - a sharp decline memory, intelligence, criticism, helplessness, and sometimes untidiness) require special attention and patient, sympathetic attitude of service personnel. The period of strict bed rest for elderly patients should be reduced, if possible, by prescribing massage and physical therapy as early as possible in order to quickly return to normal motor mode (to avoid hypokinesia), as well as breathing exercises to prevent congestive pneumonia.

If he is painfully weak, but can move on his own, then you need to support him when moving, accompany him to the toilet, help with dressing, washing, eating, and keep him clean. Weak and bedridden patients who cannot move must be washed, combed, fed, while observing all the necessary precautions, and the bed must be straightened at least 2 times a day. Weak and bedridden patients may develop bedsores. To prevent them, it is necessary to change the patient's position in bed. This is done to ensure that there is no prolonged pressure on any part of the body. To prevent any pressure, you need to make sure that there are no folds or crumbs on the sheet. A rubber circle is placed under the sacrum to reduce pressure on the area where bedsores most often form. The nurse wipes the areas suspected of bedsores with camphor alcohol.

Particular care must be taken to ensure the cleanliness of the hair, body and bed of such patients. Patients should not be allowed to lie on the floor or collect garbage. If the patient has a fever, you need to put him to bed, measure his temperature and blood pressure, call a doctor, give him something to drink more often, and change his underwear if he sweats.

Patients with severe organic brain damage, with decreased intelligence (criticism, memory), with simultaneous dysfunction of the sphincters Bladder and rectum suffer from urinary and fecal incontinence. Such patients require the most careful care. With prolonged lying and exhaustion, the patient develops bedsores. To avoid this, patients should place rubber inflatable rings under the sheet, immediately change soiled underwear and take hygienic baths as often as possible. At certain times, patients should be offered a bedpan or urine bag, and patients who can move should be taken to the restroom. To prevent bedsores, it is necessary to turn patients more often, carefully straighten the slightest folds in the sheets, and ensure that crumbs do not fall on the bed. As a rule, patients suffering from urinary and fecal incontinence are placed in wards for debilitated patients. The absence of the smell of feces and urine in these wards is an indicator of the conscientiousness of the staff’s work.

6. Procedure for distributing medicines

2. distribute medications only at the patient’s bedside;

3. the patient must take the medicine in the presence of a nurse (except for medicines taken with meals);

4. medications prescribed before meals should be taken 15 minutes before meals; medications prescribed to the patient after meals should be taken 15 minutes after eating; medications prescribed to the patient on an empty stomach should be taken in the morning 20 to 60 minutes before breakfast (anthelminthics, laxatives);

5. sleeping pills should be taken by the patient 30 minutes before bedtime.

In some medical departments In order to save time, nurses lay out medications in advance on trays, divided into cells indicating the patient’s name and room number, and deliver these medications to patients 3 times a day. This procedure for distributing medicines has significant disadvantages:

1. it is impossible to control whether the patient has taken medicine;

2. the individual distribution scheme is not followed (not all medications must be taken 3 times a day (sometimes 4-6 times a day), some before meals, others after or during meals, and others at night;

3. errors are possible (medicines prescribed to one patient, due to the carelessness of the nurse, end up in the cell of another patient);

4. It is difficult to answer patients’ questions about prescribed medications, since the medications are already in the tray without pharmaceutical packaging. The nurse often cannot name the drug, its dose, or the specifics of its action, which causes a negative reaction from the patient and reluctance to take drugs unknown to him.

The nurse does not have the right to prescribe or cancel or replace one remedy with another. The exception is those cases when the patient needs emergency assistance or there are signs of drug intolerance. In any case, the nurse must notify the doctor about any changes in prescriptions. If the medicine is given to the patient by mistake or its single dose is exceeded, you should immediately inform the doctor.

7. Features of treatment of sick children with dementia

Dementia is a decline in intellectual function, usually slowly progressive, in which memory, thinking, logic, the ability to concentrate and learn are impaired, and personality changes often occur. Dementia is often a symptom of mental retardation, schizophrenia and other serious mental pathologies in children. In them, dementia is mostly expressed in a noticeable attenuation of mental abilities, the main one among which is memory, that is, the ability to remember is sharply reduced. It is very difficult for such children to remember even such basic things as their name.

Treatment of dementia in children is a rather lengthy process, it is carried out under the supervision of a psychiatrist, but lasting improvement is not always achieved. Patients with such diseases require daily care. Treatment of dementia in children is carried out taking into account the origin of the disease and the course of the main process. To reduce the rate of development of the disease, a psychiatrist prescribes drugs that improve the metabolism of brain nerve cells and cerebral blood flow. In case of residual organic dementia, preference is given to psychological and pedagogical interviews.

That is, the first step is the diagnosis of dementia, and the second is determining the cause of its occurrence. Overt syndromes do not yet warrant a diagnosis of dementia. If a child’s level of consciousness is significantly impaired and his mental state does not make it possible to adequately assess his mental status, then a diagnosis cannot be made. Sometimes people with dementia show depression, but this is also not a clear symptom of dementia in children, although it may raise suspicions about developing dementia. This depression mainly occurs in the early stages of the disease leading to subsequent dementia. The progression of the disease is accompanied by an inevitable deterioration in mental abilities, but depression is much less common.

IN childhood dementia and mental retardation are related concepts. Dementia, most often, is a consequence of various diseases, so it should only be treated by a specialist, a psychiatrist and a neurologist.

Pharmacological treatment of dementia involves the use of drugs from the group of psychostimulants, for example, caffeine (Caffeine-sodium benzoate), mesocarb (Etimizol, Sidnocarb). Herbal remedies used include tonic preparations: eleutherococcus, ginseng, lemongrass, leuzea and a number of others.

These drugs affect the central nervous system and increase endurance during mental and physical stress; they are low-toxic and patients tolerate them well.

Nootropic drugs include: Noocetam, Nootropil, Lucetam, Piracetam, animal brain hydrolyzate drug - Cerebrolysin.

8. Patients with a disorder of consciousness

The most important sign of twilight states is a sudden loss of consciousness. Usually without apparent reason, without any precursors, a change in consciousness occurs in which the patient’s behavior begins to be determined by acutely occurring hallucinatory-delusional phenomena of a frightening nature. Outwardly, patients seem to have changed little, often their activity remains consistent, which immediately makes it possible to distinguish these conditions from delirium. However, the very first question addressed to the patient or the word spoken to him shows that the patients are disoriented: they do not understand where they are, do not recognize the people around them, cannot name the date, month, year, do not remember their name and the names of people close to them. The patients’ speech is coherent and grammatically correct, but at the same time it is impossible to talk with them. They do not answer questions, they themselves do not expect an answer to their statements. They speak without addressing anyone, as if to themselves. Characterized by relative uniformity of the condition with pronounced affective disorders in the form of anger, tension, melancholy and fear, senseless rage. In more rare cases, the depth of twilight disturbance of consciousness is less pronounced, orientation is preserved to a certain extent, delusions and hallucinations may not be expressed. Outwardly ordered behavior is observed, but affects of fear, anger, tension, attacks of sudden aggressiveness and cruelty are possible (dysphoric type of twilight state). A special danger of the twilight state is that, despite outwardly orderly behavior, patients can commit unexpected severe aggressive actions, attacking others, destroying everything in their path. Twilight states are distinguished by aggressiveness and cruelty.

Twilight states can alternate with epileptic seizures, be the only manifestation of epilepsy, recur periodically or occur only once. When caring for a patient with epilepsy, it should be remembered that due to their unique character, they often enter into long-term conflicts with other patients, which can lead to aggression; the nurse must be able to distract the patient in time and calm him down. However, if the patient still remains angry and tense, it is necessary to bring this to the attention of the doctor. During dysphoria, which can last for several hours, the patient does not need to be contacted often, or sought to be involved in any activities, since at this time he is irritated and angry. It is better to give him complete rest while continuing to monitor his condition.

It is necessary to ensure the safety of the patient and others, to prevent dangerous actions caused by fear, anxiety, and excitement. Therefore, measures to monitor the patient are of paramount importance, especially in acute hallucinatory states. To reduce agitation, aminazine (2-4 ml of a 2.5% solution) or tizercin (2-4 ml of a 2.5% solution) is administered intramuscularly or the same drugs orally at 100-200 mg per day.

With continued use of aminazine or tizercin, the doses of which can be increased as prescribed by a doctor to 300-400 mg per day, they are combined with drugs that selectively act against hallucinations: triftazine up to 20-40 mg per day, or haloperidol up to 15-25 mg per day day, or trisedil up to 10-15 mg per day intramuscularly or orally in the same or slightly higher doses, or etaprazine up to 60-70 mg per day.

In addition to supervising patients, the nurse monitors their implementation of hygienic measures, and if the patient refuses food, she uses tube feeding. The nurse should also carefully monitor whether the patient is taking medications by examining the patient's mouth after administering medications.

9. Caring for patients with disorders of will. Tube feeding

In the departments, as a rule, there are helpless patients who require the most careful systematic care. This group includes patients with catatonic and depressive stupor, with severe organic brain damage in the presence of paralysis or profound dementia, physically weak patients, etc. They often cannot eat on their own, they need to be fed and watered by hand. Physically weak patients, as well as in cases of swallowing disorders, should be given mostly liquid food, in small portions, slowly, as patients can easily choke. It is necessary to monitor the cleanliness of linen and bed. Periodically, for this purpose, patients should be covered with a bed. Cleansing enemas are used to empty the intestines. Patients who are allowed to stand must be taken to the toilet. In case of urinary retention (more often observed with catatonia), it must be released using a catheter. It is important to carefully examine (at least 1-2 times a week) skin patients, as they easily develop bedsores and diaper rash. Particular attention should be paid to the area of ​​the sacrum and buttocks. When the first signs of bedsores appear - persistent redness of the skin - the patient should be placed on a rubber circle and the skin should be systematically wiped with camphor alcohol. The oral cavity, especially if the patient does not drink or eat and is fed through a tube, should be periodically rinsed. You need to strictly monitor the cleanliness of your hair (it is better to cut it short).

Patients who refuse to eat require a lot of attention from the staff. Refusals to eat can have different origins: catatonic stupor, negativism, delusional attitudes (ideas of poisoning, self-blame), imperative hallucinations that prohibit the patient from eating. In each case, you must try to find out the reason for refusing to eat. Sometimes, after persuasion, the patient begins to eat on his own. Some patients trust only one of the employees or a relative to feed themselves. Patients with symptoms of negativism sometimes eat if you leave food near them and move away. Taking insulin on an empty stomach often helps, resulting in an increased feeling of hunger. In some cases, the staff manages to feed the patient, overcoming slight resistance.

If all the measures taken do not lead to positive results, the patient has to be fed artificially through a tube. To carry out this activity, it is necessary to prepare: 1) a rubber probe (hole diameter is about 0.5 cm, one end is rounded, with two side holes, the other is open); 2) a funnel onto which the open end of the probe is placed; 3) petroleum jelly or glycerin to lubricate the probe before insertion; 4) a nutritional mixture, which includes 500 grams of milk, 2 eggs, 50 grams of sugar, 20-30 grams of butter, 5-10 grams of salt and vitamins (the nutritional mixture should be warm); 5) two glasses boiled water or tea; 6) clean rubber balloon; 7) matches; 8) mouth dilator. When everything is prepared, the patient is placed on the couch on his back. Usually the patient resists, so 2-3 orderlies have to restrain him. The end of the probe is lubricated with Vaseline or glycerin and inserted through the nose. Usually, the probe, without much effort, passes well through the nasal passage into the nasopharynx, then into the esophagus and reaches the stomach; for this, the probe must be inserted to a length of about 50 cm. When the probe passes in the nasopharynx area, the patient reflexively experiences separate vomiting movements, in addition, the patient himself may tend to push the probe out. At this time, there may be short-term breath holdings, the patient blushes and tenses. In such cases, it is recommended to cover the patient’s mouth for a while and tell him to breathe through his nose and swallow. If the patient has difficulty breathing, cyanosis of the face, or increased agitation, the probe must be quickly removed. Before introducing the nutritional mixture, you must finally make sure that the tube is in the stomach. An indicator of this is the following: 1) the patient breathes freely; 2) the flame of a burning match brought to the funnel does not deviate to the side and through the funnel you can hear the sound of stomach peristalsis; 3) the introduction of air into the funnel using a balloon causes noise in the stomach area, reminiscent of rumbling.

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Depression.

Syndromes associated with emotion disorders

Depressive syndrome

Depression is one of the most common disorders in both psychiatric and

general somatic practice(3-6% in the population).

The basis of the depressive syndrome is the depressive triad, which includes painful

low mood, ideation and psychomotor disturbances in the form of general lethargy.

A painfully low mood is a structurally heterogeneous formation.

There are three main components of the emotional component of the depressive syndrome:

sad, anxious and apathetic. They are in a dynamic relationship with each other, but, as

As a rule, at a certain period of time or in certain cases one of them predominates.

The daily rhythm of depressive disorders is very characteristic. Melancholy and apathy usually reach

maximum severity in the morning, anxiety is more variable and often worsens towards

In general, ideation disorders in depressive syndrome are characterized by

known fixation of experiences on a certain topic, narrowing the volume of free

associations and changing their pace (usually slowing down). In some severe cases, comprehension

situations, memory and attention impairments are so pronounced that the condition resembles a picture

dementia. Depending on the nature of the low mood, some features are possible

ideation disorders (see below).

Psychomotor depressive disorders, to an even greater extent than ideation disorders, are associated with

dominant mood, which is especially clearly visible in expression. General

behavioral and volitional activity is usually reduced (hypobulia).

Along with the main “triad” signs, the structure of the depressive syndrome includes

psychopathological phenomena closely related to emotional disorders themselves.

One of the most common disorders in depression is somatopsychic and

somatovegetative disorders. According to their own

clinical manifestations they are diverse, changeable and closely related to the leading hypothymic

condition. They can act as the first signs of incipient depression or, when

insufficiently expressed hypothymia, play the role of so-called somatic equivalents.

Depressive syndrome includes a variety of somatoneurological disorders,

the main manifestation of which (especially in the acute period) is the so-called triad

Protopopova: tachycardia, mydriasis, constipation, essentially indicating a disturbance in activity

vegetative nervous system in the form of sympathicotonia. Somatic manifestations of depression are also

include amenorrhea, weight loss, dyspepsia, various localizations pain, etc.

Depressive depersonalization may occupy a significant place in the structure of depression,

experienced as “mournful insensibility”, “a feeling of loss of feelings”, impoverishment, inferiority

emotional life. The most common and, as a rule, the most significant for

Patients are experiencing the loss of natural feelings for loved ones. Feelings are also possible

loss of emotional attitude towards the environment with indifference to work, to activities, to

entertainment; ability to rejoice (anhedonia); responsiveness to sad events;

abilities for compassion, etc. The experiences of oppression of “vital emotions” are especially painful:

feelings of hunger, thirst, satiety and pleasure when eating, sexual satisfaction,

feelings of bodily comfort, “muscular joy” and fatigue when physical activity;

natural negative emotional tone of pain. Often present

experiences of loss of the sense of sleep, “depersonality”, “feeling of absence of thoughts”, “speech without

thoughts”, “detachment” in communication, “soullessness”, etc. Greatest representation

depersonalization of this kind is usually inherent in depression of moderate depth, without pronounced

lethargy.

One of the characteristic signs of depression is ideas of low value and self-blame. IN

depending on the severity and clinical variant of depression, they can manifest themselves in the form

psychologically understandable experiences of low self-esteem and ideas of low value that

may be unstable, changeable, and often depend on the situation; super valuable ideas that are already

characterized by persistence, low variability, loss of direct connection with the situation; crazy ideas.

hypochondria, etc.

Various sleep disorders, the nature of

which is closely related to the nature of hypothymia. With melancholy, shortened sleep is noted, early

awakening, a feeling of not being fully “awake” in the morning; with anxiety - difficulty

falling asleep, insomnia, combined with frequent awakenings in the middle of the night; with apathy -

increased drowsiness, shallow night sleep.

Desire disorders are also characteristic of depressive syndrome

violations. Their manifestations depend on the leading affect. So, for example, when sad and

apathetic affect, suppression of appetite is noted (often combined with aversion to food

or lack of taste sensations), sexual desire (up to complete depression). At

In an anxious state, on the contrary, there may be an increase in drives.

Particular attention should be paid to suicidal manifestations in depression. According to the latest

according to WHO, suicide occupies one of the first places as a cause of death, along with cardiovascular

vascular diseases, cancer and accidents. One of

common reasons committing suicide are depression (up to 15% of depressions end in attempts

suicide). Suicidal tendencies in depression have varying degrees of development,

persistence and intensity depending on the nature of depression. Suicide risk is higher in

cases of mild and moderate depression, as well as those “open” to influence

environmental influences and personal attitudes of patients. Suicide attempts are more common in early

the early morning hours, as well as at the beginning and end of the depressive phase. Motives prevail

caused by real conflicts, experiences of one’s own change, depressive

depersonalization, feeling of mental pain. With deep

in depression, delusional ideas of guilt and hypochondriacal

megalomanic delirium (Cotard's syndrome). At the height of the development of a depressive state, it is possible

impulsive suicides. Suicidal attempts are more often made with anxiety and melancholy

affect, at the initial stages of development of depressive phases, in patients with asthenic,

sensitive and hysterical personality traits in premorbid. Severity of depression

conditions varies significantly - from mild (subdepression) to severe, occurring in the form of

psychosis. Depending on the combination and/or dominance in the clinical picture of different

components of the depressive “triad” and “non-triadic” manifestations are distinguished by a variety of

clinical variants of depressive syndrome, the most common of which are as follows.

Melancholic (sad, classical, endogenous) depression is represented by a triad in

the form of a painfully low mood with a melancholy component; slow pace

thinking; psychomotor retardation (up to depressive stupor). Oppressive,

hopeless melancholy is experienced as mental pain, accompanied by painful physical

sensations in the region of the heart, epigastrium (“precardiac melancholy”). Present, future and past

seem gloomy, everything loses its meaning and relevance. There is no desire for activity.

Motor disorders in melancholy depression are presented in the form of sadness or even

frozen gaze, suffering facial expressions (“mask of grief”), dejected or frozen posture

(depressive stupor), lowered arms and head, gaze fixed on the floor. By appearance

these patients look very aged (characterized by a decrease in skin turgor, which makes it

wrinkled). Daily fluctuations in the condition are possible (easier in the evening than in the morning). Characteristic

ideas (even delusional) of self-abasement, guilt, sinfulness, hypochondriacal. They can

suicidal thoughts and tendencies arise, which indicate the extreme severity of depression.

Sleep disorders are manifested by insomnia, shallow sleep with frequent awakenings in the first

half the night, disturbance of the sense of sleep. Melancholic depression is characterized by a variety of

somatoneurological disorders, the main manifestation of which (especially in the acute period)

is Protopopov's triad. In addition, cardiac rhythm disturbances are possible.

ma, pronounced weight loss (up to 15-20 kg per short term), pain, in women - violation

menstrual cycle, often amenorrhea. Significant decrease in desires: lack of appetite and/or

taste of food, depression of sexual function, decreased instinct of self-preservation (suicidal

trends). Sometimes stupor is suddenly replaced by a fit of excitement - an explosion of melancholy

(melancholic raptus). In this state, patients can bang their heads against the wall, tear out

eyes, scratch your face, jump out of a window, etc. Melancholic syndrome is characteristic of

clinical picture of MDP, affective attacks in schizophrenia.

Anxious depression is characterized by a depressive triad with the experience of anxiety and

motor restlessness, up to motor excitation (agitated depression).

Ideation disorders in anxiety are characterized by an acceleration of the pace of thinking with

instability of attention, constant doubts, intermittent, sometimes poorly legible

speech (up to verbalizations), disordered, chaotic thoughts. Patients express

ideas of self-accusation, repent of the “wrong” actions of the past, rush about, groan. Experiences

are more focused on the future, which seems terrible, dangerous,

painful. With anxious depression, the gaze is restless, darting, with a hint of tension,

facial expressions are changeable, a tense sitting posture with swaying is typical, with severe anxiety -

restlessness. At the height of anxiety and agitated depression, the risk of suicide is especially high.

attempts. Agitated and anxious depression do not have nosological specificity, although

It should be noted that in elderly patients they occur more often.

Apathetic depression: the absence or decrease in the level of

motives, interest in the environment (in severe cases - in life in general), emotional

reactions to ongoing events, indifference, decreased vitality (anergic

depression), insufficiency of volitional impulses with the inability to overcome oneself, to make an effort

over oneself, make a certain decision (abulic version). Psychic dominates

inertia (“mental weakness”, “life by inertia”). Ideation disorders in apathetic

variant are characterized by a depletion of associations, a decrease in their brightness and sensory coloring,

impaired fixation ability

and arbitrary direction of attention and thinking. Ideas of worthlessness or guilt are observed

rarely, feelings of self-pity and envy of others dominate. For apathetic depression

the look is indifferent, calm, sedentary, sleepy; game slowed down facial muscles,

facial expressions of boredom, indifference, and indifference are typical; movements are sluggish, relaxed, slow.

Somatovegetative symptoms are mild. Suicidal tendencies are rarely observed. U

Some patients also experience psychomotor retardation with slowed movements, speech

products; they stop taking care of themselves, lie in bed, complete

immobility (stupor). Such variants are called adynamic (inhibited) depression.

Asthenodepressive syndrome is characterized by moderately severe symptoms

depressive triad and severe asthenic disorders in the form of increased

fatigue and exhaustion, irritable weakness, hyperesthesia. Asthenodepressive

syndromes are observed in a very wide range of non-psychotic diseases.

Depressive-hypochondriacal syndrome is characterized by the dominance of somatic

symptoms of depression with moderate severity of the depressive triad. In addition, patients

express the belief that they suffer from severe, incurable somatic

disease, and therefore actively visit and undergo examinations in medical

institutions. Depressive-hypochondriacal syndromes are observed in a wide range of diseases.

Depressive-paranoid syndrome: depressive symptoms are expressed to varying degrees,

up to deep lethargy; at the same time, patients experience anxiety, formulate

delusional ideas of persecution, poisoning, which tend to be systematized. This

the syndrome has no nosological specificity.

Cotard's syndrome (melancholic paraphrenia) is a complex depressive syndrome,

including depressive experiences and hypochondriacal ideas of an enormous nature

and denial. The sick consider themselves great sinners, they have no justification on earth, because of them

all humanity suffers, etc. With Cotard's nihilistic delirium, patients express

hypochondriacal delirium (all their insides, bones rot, from them

there is nothing left, they are infected with a “terrible” disease and can infect the whole world, etc.).

Cotard's syndrome is observed rarely, mainly in schizophrenia, involutional

melancholy.

Depressive-depersonalization syndrome is a variant of the depressive syndrome in which

in the clinical picture, the leading place is occupied by depressive depersonalization (see above).

Atypical (“masked”, “larved”, “vegetative”, “somatized”,

hidden) depressions are characterized by the dominance of somatopsychic, somatovegetative

disorders or other psychopathological “masks”. With these types of depression, actually

low mood is present in an erased form or is completely absent (“depression without

depression"). The manifestations in the form of somatic “masks” are of greatest importance. These states

most often observed in the practice of doctors of other specialties (up to 60-80% of such patients are not

come to the attention of psychiatrists). According to various authors, patients with such

depression accounts for about 10-30% of all chronic patients general medical practice. ABOUT

The following signs indicate that these conditions belong to depression: phasicity

courses with seasonal (spring-autumn) relapses; daily fluctuations in symptoms;

hereditary burden of affective disorders; presence of affective

history of (manic and depressive) phases; absence of organic causes of suffering,

confirmed by objective examination (“negative” diagnosis); long-term observation

from doctors of another specialty in the absence of a therapeutic effect from long-term treatment;

positive therapeutic effect antidepressants. Depression is more common with

disorders of the cardiovascular and respiratory systems, often qualified by therapists

as “vegetative-vascular dystonia” or “neurocirculatory dystonia”. Less commonly observed

“masks” in the form of gastrointestinal pathology (various dyspeptic manifestations and

abdominal pain). In addition, within the framework of such depressions, periodic

insomnia, lumbago, toothache, nocturia, sexual dysfunctions, etc.

The work of medical personnel in psychoneurological institutions differs from that in other hospitals and has a number of features.

These features are mainly due to the fact that many patients do not understand their painful condition, and some do not consider themselves sick at all.

In addition, a number of patients with a disordered state of consciousness show a picture of sharp motor agitation. Therefore, special requirements are imposed on medical personnel in psychiatric hospitals: constant vigilance, restraint and patience, sensitive and affectionate attitude, resourcefulness and a strictly individual approach to the patient. Consistency in the work of the entire team of hospital department employees is of great importance.

Knowledge of all the details of the care, supervision and service of mentally ill people is an absolutely necessary condition for the work of a nurse or paramedic in a psychiatric institution.

This section is devoted to this topic. First of all, we should dwell on what should be the behavior of medical personnel in the department and their attitude towards the mentally ill.

Firstly, the nurse is obliged to know all the patients in the department well: to know not only the last name, first name and patronymic of the patient, in which ward and where exactly he is lying, but also his mental state for the current day; the number of patients in the department and which of them and for what reason are outside the department. It is necessary to pay Special attention for patients requiring special observation and care. The sister learns about this during a departmental round, which is done by a doctor, from nursing diaries and during five-minute meetings. Secondly, you need to know exactly all the prescriptions made by the doctor and strictly follow them at the specified time.

All patients should be treated seriously, politely, kindly and sympathetically.

To think that patients do not understand and do not appreciate this is a deep misconception. However, one should not go to the other extreme: be overly affectionate, sweet in dealing with patients, or talk to them in a lisping tone. This can irritate and worry patients.

You cannot give obvious preference and pay special attention to one patient and neglect another. This also does not go unnoticed and causes fair discontent.

It is necessary to monitor the business situation in the department, the implementation of the established daily routine, and avoid loud conversations among the staff, since silence when treating neuropsychiatric patients is a very important and necessary condition.

Medical personnel must be neat and smart. The robe must be clean and well ironed, fastened with all buttons. You should wear a white scarf on your head, tucking your hair under it. Men are recommended to wear a white cap on their heads. Department staff should not wear beads, earrings, brooches or other jewelry while working, as these items interfere with holding an excited patient and can be torn off by such a patient.

In cases where patients begin to experience motor or speech agitation or a sudden change in condition generally occurs, the nurse is obliged to immediately notify the attending or duty doctor about this. Nursing staff are not allowed to independently prescribe medications or procedures, or move patients from one room to another or even within the same room.

Extraneous conversations in the presence of the patient are prohibited, even if the patient is completely indifferent to everything around him. Sometimes such a patient, after completing a course of treatment, says that in his presence, his sisters or nannies talked about the most extraneous topics, which he found extremely painful to listen to, but he could not speak or move (the patient had, for example, a catatonic stupor). Such extraneous conversations of patients in a depressed and melancholy state are no less burdensome. Patients with delusional ideas of attitude or self-blame often see in these conversations a number of “facts” that, in their opinion, are directly related to them. This can increase the anxiety of patients and disrupt contact with medical personnel. Such patients begin to be suspicious of their sister and stop taking medicine from her. In such cases, they say that the patient “weaves” those around him into his delirium.

In the presence of patients, you cannot discuss the health status of any patient, talk about his illness, or make judgments about the prognosis. It is strictly forbidden to laugh at the sick or conduct a conversation in an ironic, playful tone.

Often patients with delusional ideas express various kinds assumptions about the reason for their stay in the hospital, complaining that they are not being treated, and everything is supposedly being done in order to get rid of them, to kill them. In these cases, you need to listen carefully and patiently to the patient. One should not strive at all costs to dissuade the patient, but one should not agree with his delusional statements. Most often in these cases, one has to tell the patient that all his assumptions are wrong, his fears are completely unfounded and that he needs treatment, since He is sick. The patient, as a rule, is not satisfied with this answer and immediately asks a question about the date of his discharge from the hospital. The patient should be advised to consult their doctor with this question. It is usually very difficult to talk about the exact timing of discharge in the treatment of mental illness, since during the treatment process additional time may be needed for certain activities or a deterioration in the patient’s health may occur. You need to talk about the timing of discharge only approximately, so that no disputes or conflicts arise later. Only a few days before discharge can you name the exact date.

Sometimes, in order to reassure the patient, one of the medical staff promises him an unscheduled meeting with his relatives, a conversation on the phone, but then does not fulfill his promises, i.e., in other words, deceives the patient. This is completely unacceptable, since as a result the patient loses trust in others. If for some reason it is impossible to directly and specifically answer a particular question, you should, if possible, move the conversation to another topic and distract the patient. It is also not recommended to fraudulently place a patient in a hospital. This makes further contact with the patient difficult; he remains distrustful of others for a long time, does not talk about himself (isolated), about his experiences, and sometimes becomes embittered towards the staff.

You should not be afraid of the sick, but you should not flaunt unnecessary courage, as this can lead to serious consequences. Let us give an example demonstrating how caution should not be neglected when communicating with a patient. During a conversation in the office, a patient in a delirious state turned to one of the inexperienced doctors and invited him to go out into the corridor to talk one-on-one. All the patient's behavior pointed to his delusional attitude towards the doctor. The patient and the doctor (contrary to the advice of other employees) went out into the corridor, where the patient immediately attacked the doctor and struck him several times.

We must not forget about possible sudden (impulsive aggressive) actions of patients directed against staff or other patients. In general, aggressive actions of patients towards medical personnel are a rare phenomenon. Under no circumstances should you be offended or angry with patients for their aggressive intentions or actions, as they are associated with the disease.

After recovery, you can often hear the patient asking you to forgive him for his behavior in the past.

If there is a quarrel or fight among the patients, the nurse must take urgent measures to separate the patients (for this it is necessary to invite orderlies, and if there are not enough of them, then conscious patients) and immediately inform the doctor about this. In the presence of patients, you should not justify the behavior of one or blame the other.

Patients often approach the staff with a number of requests. Many of them are quite doable. But before you do this, you need to take into account all the possible consequences, i.e. be careful. For example, a patient with schizophrenia with delusional ideas physical impact and poisoning, after the treatment she began to feel much better, but the delirium did not completely disappear, which she carefully hid (dissimulated). In the evening, this patient asked her sister for a safety pin in order to thread the elastic through her panties. They gave her a pin. Soon after this, the doctor called discovered that the patient had a facial injury, as she tried to “zip” her mouth so that at night “they would not open it and pour toxic substances into her.”

Patients often write all kinds of letters, statements, complaints to various institutions, in which they set out all their “ordeals”, demand that they be examined by a commission, etc. To ensure that such statements do not leave the hospital, all letters written by patients are must be read by a nurse or doctor. Letters that are obviously painful in their content or contain any absurd statements should not be sent. The nurse should give these letters to the doctor. Letters and notes received by the department must also be read before being distributed to patients. This is done in order to protect the patient from certain traumatic news that could worsen their health. Food and clothing deliveries to patients should be carefully reviewed so that relatives and friends, intentionally or unintentionally, do not give the patient anything that may be contraindicated for him, or even dangerous for him, for example, medicines (especially drugs), alcoholic drinks, needles, razor blades , pens, matches.

The nurse must know in every detail the duties of the orderlies and monitor their work, remembering the inadmissibility of removing the sanitary post without providing a replacement. The nurse must give instructions to the new shift of orderlies entering their post as to which patients require strict supervision, especially nursing care. These most often include patients in depressed state, hallucinating patients, patients with delusions, especially with delusions of physical influence and persecution, patients with epilepsy with frequent seizures or periodic attacks of disorder of consciousness, physically weak patients who refuse to eat, and some others.

The most vigilant supervision and observation of such patients is the best way to avoid accidents (suicide, self-torture, escape, attack on others). These patients should not disappear from the sight of the orderlies for even a minute. If a suicidal patient covers his head with a blanket, it is necessary to approach him and open his face, since there are cases of attempts to commit suicide under the blanket. When measuring temperature, care must be taken to ensure that the patient does not harm himself with the thermometer or swallow it for the purpose of suicide. If the patient goes to the restroom, the orderly must monitor the patient’s behavior through the window. Supervision should not weaken day or night; in the ward where such patients are usually placed (observation ward), there must be sufficient light at night.

When dispensing medications, you should not leave the patient until he takes it, since some, for one reason or another, do not want to be treated (delusional interpretation, fear, negativism), having received the powder or tablet, throw them away or even accumulate them to take a large dose at once for the purpose of poisoning. If suspicions of this kind arise, you need to inspect the patient’s belongings and bed, which, however, should be done from time to time in relation to many patients. Inspection of things, so as not to insult or offend the patient, must be done during walking hours or while the patient is in the bath. If an urgent examination is necessary, the patient is offered to take a bath or invited to the doctor’s office for a conversation.

Suicidal (suicidal) or mentally retarded patients sometimes collect pieces of glass, nails, and pieces of metal while walking in the garden, so orderlies must monitor the behavior of patients during walks. The area is systematically thoroughly cleaned.

Patients should not carry matches with them. For those who smoke matches, the orderly snores. In this case, it is necessary to carefully observe that the patient does not throw a burning cigarette on the bed or cause burns to himself, which is sometimes done by patients in a depressed or delirious state.

Patients should not have long pencils, penknives, hairpins or hairpins.

The patient is shaved by a barber in the presence of an orderly; For this it is better to use a safety razor. These precautions are necessary because there are isolated cases when a patient snatches a razor from the hands of staff and causes serious injury to himself. Patients are not given knives and forks during meals. Food is prepared in advance in such a way that it can be eaten using only a spoon. The cupboard where knives and other items are stored must always be locked. Sick people are not allowed to enter there.

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Ministry of Health of the Russian Federation

State budgetary educational institution of higher professional education

"Smolensk State Medical University"

Department of Propaedeutics of Internal Diseases

Rabstract

Subject:Features of caring for patients with mental illness

Completed by: Lanovenko Y.S.

Smolensk 2016

When treating mentally ill patients, their care is of no small importance. Caring for patients with mental disorders has a number of specific features. First of all, you need to consider that you are dealing with a person who, due to illness, cannot control his emotions and actions. Therefore, the caregiver of a mentally ill patient must be constantly alert to prevent the occurrence of possible episodes of aggression or seizure. It is also impossible to do without such qualities as patience, vigilance and resourcefulness, since in the treatment of mental illness it is very important to provide the necessary help in a timely manner and be able to react correctly in the current situation. Caring for patients should consist not only of physical, but also of moral support. Therefore, a person caring for a mentally ill person must be polite, friendly, affectionate and sympathetic. When caring for patients with mental illness, it should be taken into account that many of them cannot care for themselves. The patient must be provided constant help in solving seemingly simple issues: washing, dressing, eating and even getting out of bed. The same measures are used as for patients with somatic diseases. Patients with agitation, thoughts of suicide (suicidal), as well as stuporous and unkempt patients are prescribed bed rest. Typically, such patients are placed in special observation wards with a constant, 24-hour observation post. Monitoring patients in a psychiatric hospital has a number of goals: first, to protect the patient from wrong actions, both in relation to himself and in relation to other persons; secondly, to prevent possible suicide attempts. Monitoring the course of the disease is of great importance, since often when mental illness the patient's condition during the day or night can be completely different. Patients are monitored by a doctor and nurses.

In addition to bed rest and observation, care for the mentally ill includes adherence to a daily routine, which must strictly correspond to the treatment being provided. Morning toilet for weak, stuporous and agitated patients is carried out by the staff.

A nurse in a psychiatric department must know what hallucinations, delusions and delusional ideas, paranoia, manic, depressive, apathetic and catatonic states are in order to quickly navigate, help the patient not harm others and himself, dissuade him in time from something, but if it fails, invite a doctor.

For patients in a psychiatric hospital, they try to create conditions under which the necessary peace would be ensured. Noise as a strong irritant, especially with prolonged exposure, depletes the human nervous system. It is known that noise is tiring and healthy person, causes him a headache, increases his pulse rate, etc. It is clear that noise and bustle have a particularly harmful effect on a mentally ill person. Mentally ill people cannot stand noise; this causes their headaches to worsen, irritability appears, outbursts of agitation occur, and the symptoms of the disease may worsen.

All the work of the staff in the department of a psychiatric hospital is organized and carried out so that it is quiet and in no case is any noise allowed, so that nothing disturbs the patients. Thus, in conditions of peace and quiet, the brain of a mentally ill person is protected from the action of harmful stimuli on it. To create peace, all newly admitted patients must stay in bed for a certain time as prescribed by the doctor. Keeping the patient in bed calms him down and preserves his strength, allowing him to be better observed.

The correct alternation of wakefulness and sleep ensures a person’s normal functioning of his brain and protects the brain’s nerve cells from exhaustion. This is why a strictly established daily routine can be so useful; It is clear that a clearly established daily routine is especially indicated for mental patients undergoing treatment in a psychiatric hospital. For this purpose, in the departments of a psychiatric hospital, a daily schedule is established that is mandatory for all patients, with precise indications of the hours of morning rise, meals, walks, medical work, cultural entertainment, sleep, etc. Such a precisely established regimen helps patients quickly restore the normal activity of their nervous system. If the patient goes to bed and gets up according to a schedule, at certain hours, then he gets used to falling asleep at set hours, his brain receives the necessary rest during sleep. If the patient goes to bed and gets up at different hours, then his rest is disordered and insufficient. Following a strict daily routine by patients regulates their behavior. Only accurate adherence to the daily regimen will lead to successful treatment of patients. On the contrary, any violation of the routine leads to disruption of treatment measures and complicates the work of medical personnel.

Sanitary and hygienic procedures for mentally ill patients

All patients must be kept clean and washed regularly, in addition, they may be prescribed hygienic and medicinal baths. When taking a hygienic bath, you need to quickly and thoroughly wash the patient, starting with the head, then dry him with a sheet and quickly dress him. At medicinal bath They watch the clock to ensure that the patient does not overstay the appointed time. Monitor the condition of patients in the bath (general appearance, complexion). Special supervision is carried out for patients with epilepsy. Patients are accompanied to and from the bathroom by a nurse. Weak patients should be washed, combed, fed, monitored physiological functions, and a vessel and duck should be served in a timely manner. If the patient walks under himself, he should be washed in a timely manner, wiped dry and put on clean underwear; For such patients, an oilcloth is placed under the sheet. Bedsores may appear in bedridden patients; in order to prevent them, the patient's position in bed is often changed. Make sure there are no folds or crumbs. A rubber circle is placed under the sacrum, and the reddened areas are lubricated with camphor alcohol. If a bedsore has formed, lubricate it with Vishnevsky ointment; if it suppurates, treat it with napkins moistened with dioxidine. Keep your mouth, skin, and nails clean.

Caring for depressed patients

When caring for depressed patients, they are strictly monitored both day and night: they must be accompanied to the toilet, washroom, or bathroom. They inspect clothes and bedding to see if there are any dangerous objects hidden in them. Medicines are allowed to be taken only in the presence of a sister, so that the patient does not hoard them for the purpose of suicide. Make sure that such patients take food in a timely manner. Depressed patients need peace. All kinds of entertainment worsen his condition, and there is no need to persuade him to watch TV. Depressed patients often have constipation; they are given enemas in a timely manner. psychiatric paranoia depressive

Caring for patients in a state of agitation

Restless patients are placed in special departments, where there are wards for the severely anxious and the weakly anxious. If the patient is very agitated, then the medical staff must remain calm. We must strive to gently and affectionately calm the patient and switch him to another thought. If the patient begins to bang his head against the wall, he is restrained and sedatives are used.

Restraint is done like this: the patient is placed on his back in an extended position, two nurses stand on either side of the bed - two hold the arms and two hold the legs. You can use a blanket or sheet to hold it. You cannot hold the patient by the ribs, put pressure on the stomach, or touch the face. It is better to stand on the sides of the bed to avoid kicking the patient. Do not sit on the patient's legs while restraining him. In case of dangerous excitement, you should approach the patient holding a blanket and mattress in front of you, to soften a sudden blow from the patient. Each situation depends on the nature and degree of arousal. Restraint techniques are learned through practice under the guidance of a physician and experienced nurses. After intramuscular administration of neuroleptics to a restless patient, sleep occurs. The patient is turned onto his stomach, his head is turned to the side and held during injections. If the patient again tries to jump out of bed, run, or attack, a course of antipsychotics is prescribed. Restless patients are prescribed long warm baths (water temperature 37--38 °C). The patient is taken to the bath; they come from behind, take his hands and quickly cross them in front, under the chest; at the same time, the medical staff and the orderly stand to the side so that the patient does not kick.

There are six types of psychomotor agitation.

1. Hallucinatory-paranoid, occurs in hallucinatory-paranoid states. The patient defends himself from enemies and attacks them. Persuasion does not work here. Sedatives are used.

2. Depressive agitation occurs in a depressive state. The patient hits the wall, scratches his face, and bites. Here, kind words can help, psychotropic antidepressants are additionally prescribed, and the patient can be held with the participation of one orderly.

3. Manic agitation in manic-depressive psychosis. Against the background of talkativeness and noisiness, the patient may attack others. Persuasion is not used, only psychotropics in combination with narcotic drugs.

4. Excitement in a state of delirium (due to infections, alcohol or other poisoning). The patient jumps up, runs, drives someone away from him. There is an expression of fear on his face. Words can have an effect on the patient; sleeping pills and cardiac medications are used.

5. Catatonic excitation in catatonic states. The patient's movements are absurd, his speech is incoherent. The staff's words have no impact. Retention is required; antipsychotics are used in combination with sedatives.

6. Excitement during a twilight state of consciousness occurs in patients with epilepsy. He fights fire and experiences terrible events. The patient is dangerous and attacks others. Words are useless; they hold the patient back. You must approach carefully, try to grab the patient by the limbs, put him in bed and hold him until the attack ends. An enema of chloral hydrate helps. Recently, epilepsy with a twilight state is rare.

There are similarities and differences in caring for neurological and mental health patients. The goal is one - to alleviate the suffering of patients, improve their well-being and help them recover faster or achieve long-term remission. Work is associated not only with physical, but also with mental stress, but if you achieve success, then the work will not seem hard and difficult.

Bibliography

1. Directory of a paramedic, edited by Professor A.N. Shabanova "Medicine" 1976

2. Handbook of Psychiatry, second edition, revised and expanded, edited by A.V. Snezhnevsky MOSCOW "MEDICINE" 1985

3. Article "Care for patients with mental disorder", year 2009

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Types of supervision of mental patients

In accordance with the mental state of the patient, supervision of one kind or another is established over him.

Strict supervision is prescribed for patients who pose a danger to themselves or others. These are patients with suicidal intentions, showing aggressively destructive tendencies or seeking to escape. They are kept in a supervisory (observation) ward, in which a permanent medical post is on duty around the clock. When taking a shift, medical personnel must especially carefully monitor the presence of these patients and carefully check their bed, since patients often try to hide cutting and piercing objects or homemade keys in a mattress or pillow. Transfers to patients are also carefully checked. The supervisory chamber is also illuminated at night, and the lighting must be sufficient for supervision. The patient leaves the observation room only with accompanying persons.

Enhanced monitoring of patients is also carried out in general wards. The duty nurse is warned about the need for especially careful supervision of some patients and a detailed reflection of their behavior in the department diary. Typically, enhanced observation is prescribed in cases where it is necessary to clarify the characteristics of painful manifestations (the nature of the seizures, the characteristics of the patient’s contact with others, the presence of fluctuations in his structure, the correspondence of his complaints about insomnia to reality, etc.) with pronounced variability in the patient’s condition. Patients with somatic pathology, physically weakened, as well as patients for whose treatment active methods are used (insulin therapy, administration of neuroleptics, ECT) require enhanced monitoring. how various kinds of complications may arise in this case.

General observation is prescribed in cases where the patient does not need strict supervision and enhanced monitoring. Patients enjoy freedom of movement inside from division, go out in groups accompanied by a nurse, and are actively involved in labor processes outside the department.

Patients who are assigned a free regime (usually those who are recovering) are given the right to freely leave the department, they are allowed home leave, and they wear their own clothes.

Prevention of suicide attempts Suicide attempts are especially common in depressed patients. They are also observed in patients with delusional experiences under the influence of hallucinations (<<голоса» приказывают больному выпрыгнуть из окна, нанести себе смертельное ножевое ранение и т. п.). Иногда, особенно при шизофрении, суицидальные действия совершаются немотивированно, импульсивно. Такие поступки всегда трудно предсказать. Следует помнить, что больные, склонные к импульсивным действиям, всегда нуждаются в строгом надзоре.

The nurse should know which diseases are most often accompanied by suicidal intentions and behavior. Any suicidal manifestations require serious treatment. Sometimes they think that the patient’s suicidal expressions are hysterical, demonstrative in nature, but, firstly, the diagnosis could be erroneous, and behind the hysterical symptoms there may be hidden real deep depression with melancholy and anxiety, and, secondly, even pain prone to hysterical reactions Noah can “outplay”, and a demonstrative suicide attempt will lead to his death.

As a rule, patients hide suicidal intentions. Only an experienced worker manages to determine their presence in a patient, sometimes by looking at individual traits of his behavior. The patient's wary attention to what is happening around him, his attempts to grab any piercing or cutting objects, shoelaces, or the desire to cover himself with a blanket should always cause concern among the staff. A psychiatrically competent nurse knows that during the depressive phase of MDP, the patients’ mood always worsens in the morning, and therefore intensifies monitoring of them at this time. A convenient time for a suicide attempt occurs when an emergency occurs in the ward. This should be remembered and the level of supervision of patients with suicidal intentions should not be reduced in these cases. The nurse should also be aware that depression with suicidal ideation sometimes occurs after treatment with antipsychotic drugs.

If, nevertheless, a suicide attempt is realized, you should, without leaving the post, call a doctor and take all necessary measures - remove the patient from the noose, stop the bleeding, start artificial respiration, rinse the stomach, etc., depending on the type of suicidal action.

Prevention of aggressive actions by patients is largely associated with the fight against agitation. In this case, the staff’s knowledge of the behavioral characteristics of patients determined by the course of their illness is essential. Thus, aggressive and destructive actions are typical for patients with schizophrenia, who are prone to impulsive actions under the influence of hallucinatory-delusional experiences. The ability to express aggression is characteristic of patients with epilepsy accompanied by dysphoria. These aggressive actions may be directed at other patients or one of the employees.

Prevention of aggression is possible with proper organization of monitoring of patients and reporting to the doctor the curtailing features of their behavior. A patient prone to aggressive manifestations is transferred to a closed ward and given appropriate treatment. It is important to stop conflicts between patients at the very beginning, to prevent the possibility of communication between patients who are hostile towards each other.

Preventing escapes requires identifying patients prone to them. These are most often patients undergoing compulsory treatment, or patients experiencing delusional experiences and not critical of the circumstances that led to their hospitalization. Usually they try to gain the trust of the staff and achieve small assignments that allow them to get somewhat out of control. In order to escape, patients stock up on, if possible, non-hospital clothing, and make all kinds of keys and master keys. Such patients require strict supervision; they should not be removed from the department unless absolutely necessary and without proper accompaniment. Their bed should be carefully monitored, and when transferring a shift, pay attention to the condition of the windows in the room. These patients should not be allowed to wash windows, and when ventilating the room you need to keep an eye on them and not let them near the window.

The department's diary is kept by nurses on duty and contains data on round-the-clock monitoring of patients. The diary sheets are filled out every day and contain a list of shifts of medical personnel on duty, lists of patients requiring special monitoring (separately - those prone to suicidal actions, aggression, escape, somatically weakened, refusing to eat); general lists of patients by ward. The diary records each movement of the patient from ward to ward as directed by the doctor. A separate column is reserved for the notes of the doctor on duty during his night rounds of the hospital or a special call to the department. Records of nurses on duty should reflect the characteristics of patients’ behavior, their actions, and statements; patients' body temperature, appetite, physiological functions, night sleep. Excitement states and measures taken are described in detail. The nurse keeping a diary must remember that in some cases the diary, like the medical history, becomes an important document for the investigator and the court. Therefore, everything that happens during a shift must be recorded objectively, correctly, and with a time stamp.

Arriving at work, the head of the department and the attending physicians get acquainted with the entries in the diary and sign it.

Prescriptions are carried out by procedural, chlorpromazine and insulin nurses. This is one of the most important moments in the work of the department. The procedural nurse does not have the right to delegate the dispensing of medications to another employee. She must also ensure that the patient not only receives the medicine from her, but also takes it immediately. This is very important, because for delusional reasons, patients try not to take the medicine, considering it a poison for themselves, or, with depression, they try to accumulate large quantities of potent drugs to carry out suicidal actions. It is also necessary to take into account the possibility of orthostatic collapse in patients taking antipsychotics. They occur when the body changes from horizontal to vertical, and therefore, after taking antipsychotics, patients should lie in bed for at least 30 minutes.

Refusal of patients to eat. The reasons for refusing to eat may vary. Some patients refuse to eat for delusional reasons, for example, they claim that the food is poisoned, or (in cases of depression) that they are unworthy of it; others do so under the influence of hallucinatory experiences. Sometimes refusing food is a method of suicide; among hysterical psychopaths it often serves

display of demonstrative behavior. The reasons for refusing to eat must be known to the medical worker so that in a conversation with the patient he can argue and justify their incorrectness and discrepancy with reality. In this case, the patient should be convinced of the harmfulness of such behavior for himself and for his loved ones. Sometimes you can try to penetrate the world of the patient's painful experiences without challenging them. For example, a patient with delusional ideas of poisoning can change the plate of food. Health care providers should be aware of the main reasons for food refusal. Thus, some delusional patients refuse food brought from home, but eat sick food, others eat eggs only after making sure that there are no traces on their shell of any toxic substance being introduced into the egg.

If the patient cannot be persuaded to start eating, he is prescribed small doses of insulin (4-8 units subcutaneously). Usually, insulin causes a strong feeling of hunger, however, if the patient still has not eaten after this, he should be given intravenous glucose to avoid hypoglycemia.

In order to combat food refusal, especially with catatonic negativism, disinhibition with barbamyl is used. Intravenously (slowly!) Inject 5-8 ml of a 5% barbamyl solution with 1-2 ml of a 10% caffeine solution. For a short period (15-20 minutes), patients disinhibit, become more accessible, and develop an appetite. This time is enough to feed the patient.

If these measures are unsuccessful and if the patient is starving for a long time, as evidenced by the appearance of the smell of acetone from his mouth (usually after 3-4 days of persistent refusal to eat), they proceed to feeding the patient through a tube. Artificial feeding is carried out with the patient lying down. Removable dentures are removed from the mouth. The end of the probe is lubricated with glycerin, and the probe is inserted through the nose or mouth.

We can talk about the passage of the probe into the stomach through the pharynx and esophagus if it has sunk to the 50-centimeter mark. If the probe gets into the respiratory tract, choking, coughing occurs, breathing becomes difficult, and the skin turns blue. You can finally make sure that the probe is inserted into the stomach using a simple technique. A burning match is brought to the funnel inserted into the outer end of the probe. If the match does not go out and the flame does not deflect, then the probe is not in the respiratory tract, but in the stomach. First, about a glass of water or tea is introduced through the tube, and then a heated special nutritional mixture (milk or broth, raw eggs, butter, sugar, salt, fruit and vegetable juices). Thus, tube feeding provides the patient with the required amount of energy, necessary fats, proteins, carbohydrates, and vitamins. After making sure that there is no longer any nutritional mixture in the probe, it is removed with a quick movement. The total amount of nutritional mixture introduced using a probe is 1-1.5 liters. Tube feeding is carried out once a day.

Features of caring for patients in a state of catatonic stupor. Patients in a state of catatonic stupor due to a tendency to impulsive actions and aggressive destructive actions are placed in the observation ward. Due to negativism, stuporous patients themselves do not tell the staff about the pain they experience and do not present somatic complaints. Therefore, the nurse, when taking a shift, must carefully examine the body of such patients so as not to miss any injury or abrasion that may become infected due to the reduced reactivity of the body of such patients. Persons receiving injections should carefully examine and palpate the injection sites, since infiltrates resulting from injections are more successfully cured if treatment is started in a timely manner. In patients receiving a course of treatment with antipsychotics, it is advisable to warm the injection sites prophylactically.

A patient in a state of stupor in the morning needs to be washed, combed and brushed his teeth. Such patients must be systematically shown to the dentist. Untidy patients are given hygienic baths, bed linen and underwear are changed as often as possible. When drooling, it is necessary to wipe the patient's mouth, chin, and skin to prevent maceration. Stuporous patients should be bathed more often than others. In the evening the patient is undressed, washed and put to bed.

Patients in a state of stupor often experience disturbances in the functioning of the intestines and urinary disorders, which also require the attention of staff. For constipation, cleansing enemas are given; for urinary retention, the patient is catheterized. The nurse can check the degree of bladder filling by lightly palpating the anterior abdominal wall in its lower parts and percussion.

Care for somatically weakened patients. These patients require special attention and monitoring of cardiac activity, breathing, basic physiological effects, and careful thermometry. Often at night they experience states of impaired consciousness that require timely relief of psychomotor agitation in accordance with the prescriptions of the attending or duty doctor and constant monitoring of patients.

Somatically weakened patients who are constantly in bed are often untidy in physiological matters. You should systematically check whether they are lying in a bed soiled with excrement, periodically take them, if possible, to the toilet or put a bedpan and do a cleansing enema. For urinary incontinence, place a urinal wrapped in gauze in the bed. The following hygienic measures are systematically carried out: toileting the oral cavity and body, washing the skin of the body, washing women 2 times a day. The latter is carried out as follows: an oilcloth and a bedpan are placed under the buttocks, and then the patient is washed using a rubber tube with warm water or a solution of potassium permanganate; After this, the patient is wiped with a dry gauze cloth in the direction from the genitals to the anus.

Obese or emaciated patients need to frequently wash and dry the skin in the groin, axillary and buttock folds, in the navel area, for women - under the mammary glands, and then sprinkle with talcum powder.

To prevent bedsores, you need to ensure that bedding and underwear are clean and dry, without rough scars, that they are changed frequently, and that there are no crumbs in the bed after eating. If reddened areas appear on the skin, they are wiped with camphor alcohol and vinegar. The appearance of bedsores is dangerous, since in weakened patients, due to the low reactivity and insufficient resistance of their body, sepsis can easily develop.

If a patient has an elevated body temperature, he should be isolated from other patients. We must make sure that without opening the alley, it does not lie under the window in a draft. If the patient has a chill, you need to cover him well, give him a warm drink, and put a heating pad at his feet. With a critical decrease in body temperature, a collaptoid state may occur and psychomotor agitation may occur. In these cases, cardiac and sedatives are prescribed (in small doses).

Walking patients play an important role in the regime of a psychiatric department. They are carried out in special landscaped walking gardens and under the careful supervision of staff. Before starting a walk, the nurse responsible for it must make sure that the possibility of patients escaping from the walk site is excluded, and that there are no sharp objects there. The walking garden is equipped with benches and tables for board games. There are several beds there for physically weakened patients.

The list of patients going for a walk is controlled by a doctor. The responsible nurse receives and hands over patients by name after the walk. If the patient's mental state changes, he is not taken out for a walk that day. Staff are informed about patients prone to escape or self-harm. It is necessary to ensure that dangerous objects, alcoholic beverages, etc. are not passed through the kindergarten fence to patients.

Some patients, in accordance with their mental state and only with the permission of the attending physician and the head of the department, are allowed to walk independently around the hospital premises. In terms of rehabilitation activities, cultural outings of specially selected groups of patients, accompanied by employees, to the cinema, theater, and museum are organized.

Visits between patients and relatives are organized in a special room (visitor's room) and on the days and hours allocated for them. The patient goes on a date with the permission of the attending physician. Before a visit, you need to check the patient’s appearance - is he neatly dressed, shaved, etc. Visits take place in the presence of division staff, who ensure that prohibited items (matches, knives, forks, alcoholic drinks) are not given to patients. The content of food transfers is controlled; transfer of perishable products is not allowed. Relatives should not be allowed to overfeed patients, as this leads to a decrease in their appetite, dysfunction of the stomach and intestines. The department employee tactfully monitors the patient’s conversation with relatives, since sometimes relatives, especially those who are uncritical of the patient’s painful condition, with their statements contribute to the fact that he is worried and excited. The doctor also controls the patient’s correspondence. Letters from patients reflecting their painful experiences should not leave the department; they are pasted into the medical history.

Patients are also not given letters whose content could worsen their mental state.

The staff of the department should not allow any transmission of letters or notes from patients or their relatives and friends to them, bypassing the doctor.

patient supervision medical stupor

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