Immediate action is mandatory for the nurse. The patient’s life depends on the correctness of actions; this must be remembered. Therefore, it is so important to know the sequence of actions and strictly follow them in the event of a case of anaphylactic shock.

Anaphylactic shock– acute systemic allergic reaction of type I of a sensitized organism to repeated introduction of an allergen, clinically manifested by hemodynamic disturbances with the development of circulatory failure and tissue hypoxia in all vital areas important organs And life-threatening patient.

Medical assistance is provided immediately at the scene of anaphylactic shock.

Pre-medical measures:

1. immediately stop administering the drug and call a doctor through an intermediary, remain with the patient;
2. apply a tourniquet above the injection site for 25 minutes (if possible), loosen the tourniquet for 1-2 minutes every 10 minutes, apply ice or a heating pad to the injection site cold water for 15 minutes;
3. put the patient in horizontal position(with the head end down), turn your head to the side and extend lower jaw(to avoid aspiration of vomit), remove removable dentures;
4. ensure the flow fresh air and oxygen supply;
5. If breathing and circulation stop, perform cardiopulmonary resuscitation in a ratio of 30 compressions per chest and 2 artificial breaths “from mouth to mouth” or “from mouth to nose”;
6. administer a 0.1% solution of adrenaline 0.3-0.5 ml intramuscularly;
7. prick the injection site of the drug at 5-6 points with a 0.1% solution of adrenaline 0.5 ml with 5 ml of a 0.9% sodium chloride solution;
8. provide intravenous access and begin administering 0.9% sodium chloride solution intravenously;
9. administer prednisolone 60-150 mg in 20 ml of 0.9% sodium chloride solution intravenously (or dexamethasone 8-32 mg);

Medical measures:

• Continue administering a 0.9% sodium chloride solution in a volume of at least 1000 ml to replenish the circulating blood volume; in a hospital setting - 500 ml of a 0.9% sodium chloride solution and 500 ml of a 6% solution of Refortan HES.
• If there is no effect, hypotension persists, repeat the administration of a 0.1% solution of adrenaline 0.3-0.5 ml intramuscularly 5-20 minutes after the first injection (if hypotension persists, injections can be repeated after 5-20 minutes), in a hospital setting if possible Cardiac monitoring should be administered intravenously at the same dose.
• If there is no effect, hypotension persists, after replenishing the circulating blood volume, administer dopamine (200 mg of dopamine per 400 ml of 0.9% sodium chloride solution) intravenously at a rate of 4-10 mcg/kg/min. (no more than 15-20 mcg/kg/min.) 2-11 drops per minute to achieve a systolic blood pressure of at least 90 mmHg. Art.
• If bradycardia develops (heart rate less than 55 per minute), inject a 0.1% solution of atropine 0.5 ml subcutaneously; if bradycardia persists, repeat the administration at the same dose after 5-10 minutes.

Constantly monitor blood pressure, heart rate, and respiratory rate.

Transport the patient to the intensive care unit as soon as possible.

You may never have to spend providing assistance with anaphylactic shock for the reason that it will not happen with you. However, the nurse should always be ready for immediate action according to the given algorithm.

Algorithm for a nurse to act in case of anaphylactic shock

Since anaphylactic shock occurs in most cases when parenteral administration medications, first aid is given to patients by nurses in the manipulation room. The actions of a nurse during anaphylactic shock are divided into independent actions and actions in the presence of a doctor.

First, you must immediately stop administering the drug. If shock occurs during intravenous injection, the needle must remain in the vein to ensure adequate access. The syringe or system should be replaced. New system with saline solution should be in every manipulation room. If shock progresses, the nurse should perform cardiopulmonary resuscitation according to current protocol. It is important not to forget about your own safety; use personal protective equipment, for example, a disposable artificial respiration device.

Prevention of allergen penetration

If shock develops in response to an insect bite, measures must be taken to prevent the poison from spreading throughout the victim’s body:

• - remove the sting without squeezing it or using tweezers;
• - Apply an ice pack or cold compress to the bite site;
• - Apply a tourniquet above the bite site, but for no more than 25 minutes.

Patient position in shock

The patient should lie on his back with his head turned to the side. To make breathing easier, free the chest from constricting clothing and open a window for fresh air. If necessary, oxygen therapy should be given if possible.

The nurse's actions to stabilize the victim's condition

It is necessary to continue removing the allergen from the body, depending on the method of its penetration: inject the injection or bite site with a 0.01% solution of adrenaline, rinse the stomach, give a cleansing enema if the allergen is in the gastrointestinal tract.

To assess the risk to the patient's health, it is necessary to conduct research:

1. - check the status of ABC indicators;
2. - assess the level of consciousness (excitability, anxiety, inhibition, loss of consciousness);
3. - examine the skin, pay attention to its color, the presence and nature of the rash;
4. - establish the type of shortness of breath;
5. - count the number of breathing movements;
6. - determine the nature of the pulse;
7. - measure blood pressure;
8. - if possible, do an ECG.

Nurse establishes permanent venous access and begins administering medications as prescribed by the doctor:

1. - intravenous drip of 0.1% solution of adrenaline 0.5 ml in 100 ml of physiological solution;
2. - introduce 4-8 mg of dexamethasone (120 mg of prednisolone) into the system;
3. - after stabilization of hemodynamics - use antihistamines: suprastin 2% 2-4 ml, diphenhydramine 1% 5 ml;
4. - infusion therapy: rheopolyglucin 400 ml, sodium bicarbonate 4% -200 ml.

In case of respiratory failure, you need to prepare an intubation kit and assist the doctor during the procedure. Disinfect instruments, fill out medical documentation.

After stabilizing the patient's condition, he needs to be transported to the allergology department. Monitor vital signs until complete recovery. Teach the rules for preventing threatening conditions.

Section 5. ALGORITHM FOR EMERGENCY MEASURES IN ANAPHYLACTIC SHOCK

Section 4. LIST OF MEDICINES AND EQUIPMENT IN PROCEDURE ROOMS REQUIRED FOR TREATMENT OF ANAPHYLACTIC SHOCK

1. Adrenaline solution 0.1% – 1 ml N 10 amp.
2. Saline solution (0.9% sodium solution chloride) bottles 400 ml N 5.
3. Glucocorticoids (prednisolone or hydrocortisone) in ampoules N 10.
4. Diphenhydramine 1% solution – 1 ml N 10 amp.
5. Eufillin 2.4% solution – 10 ml N 10 amp. or salbutamol for inhalation N 1.
6. Diazepam 0.5% solution 5 – 2 ml. – 2 – 3 amp.
7. Oxygen mask or S-shaped air duct for mechanical ventilation.
8. System for intravenous infusions.
9. Syringes 2 ml and 5 ml N 10.
10. Tourniquet.
11. Cotton wool, bandage.
12. Alcohol.
13. Ice container.

Anaphylactic shock - pathological condition, which is based on an immediate allergic reaction that develops in a sensitized body after the re-introduction of an allergen into it and is characterized by acute vascular insufficiency.

Causes: medications, vaccines, serums, insect bites (bees, hornets, etc.).

Most often characterized by a sudden, violent onset within 2 seconds to an hour after contact with the allergen. The faster the shock develops, the worse the prognosis.

Basic clinical symptoms : sudden anxiety, fear of death, depression, throbbing headache, dizziness, tinnitus, feeling of constriction in the chest, decreased vision, “veil” before the eyes, hearing loss, heart pain, nausea, vomiting, abdominal pain, urge to urinate and defecate.

Upon inspection: consciousness may be confused or absent. The skin is pale with a cyanotic tint (sometimes hyperemia). Foam at the mouth and there may be cramps. The skin may have hives, swelling of the eyelids, lips, and face. The pupils are dilated, there is a box sound above the lungs, breathing is hard, dry wheezing. The pulse is frequent, thread-like, blood pressure is reduced, heart sounds are muffled.

First aid for anaphylactic shock:

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WHEN DETECTING PEDICULOSIS:

1. Put on an additional robe and headscarf.

2. Sit the patient in the locker room on a couch covered with oilcloth.

3. Using a cotton swab, treat the patient’s hair:

0.15% karbofos (1 teaspoon per 0.5 liters of water);

0.5% solution of methyl acetophos in half with acetic acid;

0.25% dicresyl emulsion;

20% water-soap suspension of benzyl benzoate;

Lotion "Nittifor";

5% boric ointment;

Soap-powder emulsion (composition: 450 ml shampoo + 350 ml kerosene + 200 ml warm water);

Shampoo "Grincid", bottle 25 ml;

- “Perfolon”, bottle 50 ml.

REMEMBER!

Children under 5 years of age, pregnant and lactating women should not use organophosphorus solutions.

4. Cover your hair with a scarf for 20 minutes (Nittifor lotion - 45 minutes);

5. Rinse your hair with warm water.

6. Rinse with a 6% vinegar solution. Comb with a fine comb for 10 - 15 minutes. If there are lice (pubic lice), treat the hair on the pubis and armpits - rub 10% sulfur or white mercury ointment into the skin.

7. Place the patient’s linen, gown, and nurse’s scarf in a bag and place it in a disinfection chamber! At home - boil in a 2% soda solution for 15 minutes, iron with a hot iron on both sides. Treat outerwear with karbofos and leave for 20 minutes. in a plastic bag, air dry.

8. After disinsection, the room and objects are treated with the same disinfectant solutions.

9. On title page medical records are marked “P” in the upper right corner with a red pencil (monitoring by the guard nurse after 7 days).

10. Fill out the “Emergency Notice of infectious disease» and send it to the regional SES at the patient’s place of residence. Then the patient, accompanied by a nurse, goes to the bathroom to take a hygienic bath or shower.

TRANSPORTATION OF THE PATIENT TO THE DEPARTMENT.

The method of delivering the patient to the department is determined by the doctor depending on the severity of the patient’s condition: on a stretcher (manually or on a gurney), on a chair-gurney, on hand, on foot.

The most convenient, reliable and gentle way to transport seriously ill patients is on a gurney.

It is more convenient for three people to transfer the patient from the couch to the gurney and back.

SEQUENCE OF ACTIONS WHEN TRANSPORTING ON A GROLLER.

1. Place the gurney perpendicular to the couch - the head end of the gurney to the foot end of the couch.

1. All three stand near the patient on one side

2. a) one places his hands under the patient’s head and shoulder blades;

3. b) the second - under the pelvis and top part hips;

4. c) the third - under the middle of the thighs and lower legs.

5. Having lifted the patient, turn 90 degrees towards the gurney with him.

6. Place the patient on the gurney and cover him.

7. Inform the department that a patient has been referred to them in serious condition.

8. Send the patient and his medical record to the department, accompanied by a health care worker.

9. In the department, bring the head end of the gurney to the foot end of the bed, three of us lift the patient and, turning 90 degrees, place him on the bed.

10. If there is no gurney, then 2–4 people carry the stretcher manually. Carry the patient feet first down the stairs, with the front end slightly elevated. The patient is carried up the stairs head first.

SEQUENCE OF ACTIONS WHEN TRANSPORTING A PATIENT ON A CHAIR:

1. The junior nurse tilts the gurney chair forward by stepping on the footrest.

2. Have the patient stand on the footrest, then support the patient in the chair.

3. Lower the wheelchair to its original position.

4. Make sure that during transportation the patient’s arms do not extend beyond the armrests of the wheelchair.

NOTE:

FOR ANY METHOD OF TRANSPORTING A PATIENT TO THE DEPARTMENT, THE ACCOMPANYING MAN IS RESPONSIBLE TO TRANSFER THE PATIENT AND HIS MEDICAL CARD TO THE ROOM NURSE.

WASH THE NURSE'S HAND BEFORE AND AFTER PERFORMING MANIPULATIONS.

Hand washing for nursing staff is a mandatory requirement both before and after performing manipulations.

Sequencing:

1. open the tap and adjust the temperature and water flow;

2. wash the lower third of the left and then the right forearm with soap, rinse off the soap with water;

3. wash with soap left hand and the spaces between the fingers, then the right hand and the spaces between the fingers, rinse off the soap with water;

4. wash the left nail phalanges with soap, then right hand;

5. close the tap without touching it with your fingers;

6. Dry your left hand first, then your right hand (it is advisable to use paper towels for these purposes).

CHANGING LINEN FOR A SERIOUSLY ILL PATIENT

EQUIPMENT: clean linen, waterproof (preferably an oilskin bag for

dirty linen, gloves).

CHANGE OF UNDERWEAR.

ACTION ALGORITHM:

2. Elevate the patient's upper body.

3. Carefully roll the dirty shirt up to the nape of your neck.

4. Raise both the patient’s arms and move the shirt rolled up at the neck

5. over the patient's head.

6. Then remove the sleeves. If the patient's arm is injured, then the shirt first

7. remove from the healthy hand, and then from the sick one.

8. Place the dirty shirt in an oilcloth bag.

9. Dress the patient in the reverse order: first put on the sleeves (first on

10. the sore arm, then the healthy one, if one arm is damaged), then

11. Throw the shirt over your head and straighten it under the patient’s body.

R O M N I T E! The patient's linen is changed at least once every 7-10 days, for a seriously ill patient - when soiled. To change the linen of a seriously ill patient, it is necessary to invite 1 - 2 assistants.

CHANGE OF BED LINEN.

There are two ways to change bed linen for a seriously ill patient:

1 way– used if the patient is allowed to turn in bed.

A L G O R I T M ACTIONS:

1. Wash your hands, put on gloves.

2. Unfold the patient, elevate his head and remove the pillow.

3. Move the patient to the edge of the bed and gently turn him onto his side.

4. Roll the dirty sheet along its entire length towards the patient

5. Spread a clean sheet on the vacant part of the bed.

6. Gently turn the patient onto his back and then onto his other side so that he is on a clean sheet.

7. Remove the dirty sheet from the freed part and place it in an oilcloth bag.

8. Spread a clean sheet over the freed part, tuck the edges under the mattress.

9. Place the patient on his back.

10. Place a pillow under your head, if necessary, first change the pillowcase on it.

11. If dirty, change the duvet cover and cover the patient.

12. Remove gloves, wash your hands.

Method 2– used in cases where the patient is prohibited active movements in bed.

A L G O R I T M ACTIONS:

1. Wash your hands, put on gloves.

2. Roll up a clean sheet completely in the transverse direction.

3. Unfold the patient, carefully lift the patient's upper torso, and remove the pillow.

4. Quickly roll up the dirty sheet from the head of the bed to the lower back, and spread a clean sheet on the freed part.

5. Place a pillow on a clean sheet and lower the patient onto it.

6. Raise the pelvis, and then the patient’s legs, move the dirty sheet, continuing to straighten the clean one in the free space. Lower the patient's pelvis and legs and tuck the edges of the sheet under the mattress.

7. Place the dirty sheet in an oilcloth bag.

8. Cover the patient.

9. Remove gloves, wash your hands.

SUPPLYING THE VESSEL TO THE PATIENT

EQUIPMENT: vessel, oilcloth, screen, gloves.

A L G O R I T M ACTIONS:

1. Wear gloves.

3. Rinse the vessel with warm water, leaving some water in it.

4. Place your left hand under the sacrum on the side, helping the patient raise the pelvis, while the patient’s legs should be bent at the knees.

5. Place an oilcloth under the patient’s pelvis.

6. With your right hand, move the vessel under the patient’s buttocks so that the perineum is above the opening of the vessel.

7. Cover the patient with a blanket and leave him alone for a while.

8. After defecation is completed, remove the pan with your right hand, while helping the patient to lift the pelvis with your left hand.

9. After inspecting the contents of the vessel, pour it into the toilet and rinse the vessel hot water. If there are pathological impurities (mucus, blood, etc.), leave the contents of the vessel until examined by a doctor.

10. Clean the patient by first changing gloves and using a clean vessel.

12. Disinfect the vessel.

13. Cover the vessel with oilcloth and place it on a bench under the patient’s bed or place it in a specially retractable device of a functional bed.

14. Remove the screen.

15. Remove gloves, wash your hands.

Sometimes the method of feeding the vessel described above cannot be used, since some seriously ill patients cannot rise in this situation, you can do the following.

A L G O R I T M ACTIONS:

1. Wear gloves.

2. Separate the patient with a screen.

3. Turn the patient slightly to one side, with the patient's legs bent at the knees.

4. Place the bedpan under the patient's buttocks.

5. Turn the patient onto his back so that his perineum is above the opening of the bedpan.

6. Cover the patient and leave him alone.

7. Once the bowel movement is complete, turn the patient slightly to one side.

8. Remove the bedpan.

9. After inspecting the contents of the vessel, pour it into the toilet. Rinse the vessel with hot water.

10. After changing gloves and using a clean vessel, wash the patient.

11. After completing the manipulation, remove the vessel and oilcloth.

12. Disinfect the vessel.

13. Remove the screen.

14. Remove gloves, wash your hands.

NOTE:

In addition to enameled vessels, rubber ones are also widely used. A rubber bed is used for weakened patients, those with bedsores, and urinary and fecal incontinence. Do not inflate the vessel too tightly, as it will put significant pressure on the sacrum. The inflatable cushion of the rubber bed (that is, the part of the bed that will come into contact with the patient) must be covered with a diaper. Men are given a urine bag at the same time as the bedpan.

Sputum collection should be carried out in the presence and with the direct participation of medical personnel.

1. The nurse should explain to the patient the reasons for the examination and the need to cough up not saliva or nasopharyngeal mucus, but the contents of the deep parts respiratory tract what is achieved as a result productive cough that occurs after several deep breaths.

2. It is necessary to warn the patient that he must first brush his teeth and rinse his mouth boiled water, which allows you to mechanically remove the main part of the vegetative oral cavity microflora and food debris that contaminate sputum and make it difficult to process.

3. A nurse wearing a mask, rubber gloves and a rubber apron should be behind the patient, choosing her position so that the direction of air movement is from her to the patient. She should open the sterile sputum collection bottle, remove the cap and hand it to the patient.

a few deep breaths.

5. Upon completion of sputum collection, the nurse should close the bottle with a lid, assess the quantity and quality of the collected material, and enter this data into the referral. The bottle with the collected portion of sputum is carefully closed with a screw cap, labeled and placed in a special container or box for transportation to the laboratory.

Logistics support.

Material for testing for acid-fast mycobacteria is collected in sterile vials with tightly screwed caps. When using sealed vials, MBT is prevented from entering the external environment, and the test material is protected from contamination by widespread substances. environment acid-fast mycobacteria.

Hemoptysis - practically never occurs with tuberculosis in children, and is very rare in adolescents.

Shortness of breath - with early forms tuberculosis does not occur. It can be observed with a pronounced increase in intrathoracic lymph nodes, damage to a large bronchus with a violation of its patency. Shortness of breath is noted with miliary, disseminated tuberculosis, exudative pleurisy, widespread fibrous-cavernous tuberculosis.

Chest pain is absent in most children; they may be a manifestation of involvement of the parietal pleura in the process, displacement of the mediastinum during complications. The pain is usually small, intermittent, and associated with breathing.

In the medical history, it is necessary to find out the onset and course of the present disease and the possible connection with any provoking factors. Transferred ARVI, chronic bronchitis, repeated or prolonged pneumonia, sometimes bronchial asthma, exudative pleurisy may be masks of tuberculosis.

First clinical manifestations diseases often increase gradually, less often develop acutely. The disease in children is often asymptomatic and is detected when preventive examinations. Acute course more common in early childhood, asymptomatic - in school, especially from 7 to 11 years. We find out whether the child (teenager) has received aminoglycosides, rifampicin, or fluoroquinolones for this disease. These drugs have an anti-tuberculosis effect and improve the condition and lubricate the clinic.

In the life history, we pay attention to information about anti-tuberculosis vaccinations - their timing, the timeliness of tuberculin tests and their results over time throughout the child’s life. The presence of contact with people and animals sick with tuberculosis and the types of contact are determined.

At the same time, we find out the health status of family members - father, mother, relatives, as well as neighbors, with an emphasis on diseases suspicious for tuberculosis (pleurisy, bronchitis, repeated pneumonia, etc.). It is important to find out the timing and results of the last fluorographic examination of parents and other close relatives. What matters is the family’s living conditions, material security, social adaptation parents, family composition. The nature of tuberculin sensitivity in other children in the family is important. We take into account the presence of diseases in the child that predispose to tuberculosis and the methods of treatment performed.

BCG (Bacillus Calmette-Guérin or Bacillus Calmette-Guérin, BCG) is a vaccine against tuberculosis prepared from a strain of weakened live bovine tuberculosis bacillus (lat. Mycobacterium bovis BCG), which has practically lost its virulence for humans, having been specially grown in an artificial environment.

The activity and duration of immunity to the causative agent of human tuberculosis, Mycobacterium tuberculosis, produced under the influence of the vaccine in the child’s body, has not been studied enough

The components of the vaccine retain sufficiently strong antigenicity to give the vaccine proper effectiveness against the development of bovine tuberculosis (“Pearling disease”)

For atypical forms MAC group (eg Mycobacterium avium) it is known that the incidence rate in Sweden between 1975 and 1985 among unvaccinated children was 6 times higher than among vaccinated children, amounting to 26.8 cases per 100,000.

At the moment, the effectiveness of vaccine prophylaxis against pathogens of mycobacteriosis (for example, Mycobacterium kansasii) has not been sufficiently studied.

Every year there are cases of post-vaccination complications. The disease caused by the BCG strain is called BCGitis and has its own characteristics of the development of the tuberculosis process.

Contraindications:

Prematurity (birth weight less than 2500 g);

· acute diseases(vaccination is postponed until the end of the exacerbation);

· intrauterine infection;

· purulent-septic diseases;

· hemolytic disease newborns of moderate and severe form;

· severe lesions nervous system with severe neurological symptoms;

generalized skin lesions;

· primary immunodeficiency;

· malignant neoplasms;

· simultaneous use of immunosuppressants;

· radiation therapy (vaccination is carried out 6 months after the end of treatment);

generalized tuberculosis in other children in the family;

· HIV infection in the mother.

Tuberculin tests.

Important role Timely detection plays a role in the prevention of tuberculosis. Of great importance in this are fluorographic studies, diaskintest, Mantoux test, bacteriological research diagnostic material, preventive examinations.

Main method early detection Tuberculosis infection in children is systematic tuberculin diagnosis. Its main goal is to study the infection of the population with microbacteria tuberculosis, based on the use of tuberculin tests.

Since 1974, a single tuberculin test has been used - the Mantoux reaction with 2TE. Since 2009 introduced the new kind tuberculin test– Diaskintest.

Mass systematic planned tuberculin diagnostics

Goals of mass tuberculin diagnostics:

· identification of persons newly infected with MBT;

· with hyperrergic and intensifying reactions to tuberculin;

· selection for BCG-M vaccination children aged 2 months and older who did not receive vaccinations in the maternity hospital;

· selection for BCG revaccination;

· early diagnosis tuberculosis in children and adolescents.

According to Order of the Ministry of Health of the Russian Federation No. 109 of March 21, 2003 “On improving anti-tuberculosis measures in the Russian Federation,” tuberculin diagnostics are carried out to all vaccinated children from 12 months of age (except for children with medical and social risk factors) annually, regardless of the previous result.

The fight against tuberculosis is a state priority for Russia, which is reflected in legislative acts, the main of which are:

· Federal Law of June 18, 2001 No. 77 Federal Law “On preventing the spread of tuberculosis in the Russian Federation;

· Decree of the Government of the Russian Federation dated December 25, 2001 No. 892 “On the implementation Federal Law“On preventing the spread of tuberculosis in the Russian Federation”;

· Order of the Ministry of Health of Russia dated March 21, 2003 No. 109 “On improving anti-tuberculosis measures in the Russian Federation”;

Mantoux test

The tuberculin skin test, better known as the Mantoux test or Mantoux test, is used to determine whether the body has been exposed to the tuberculosis bacillus. To do this, intradermally inside forearm is inserted small quantities protein of the pathogen and after 72 hours, based on the immune response, which is manifested by redness and the formation of a tubercle, the result is interpreted.

The Mantoux test can only answer the question of whether there is contact with the causative agent of tuberculosis or not. It is unable to determine whether the infection is active or inactive, and whether you are capable of infecting others. To confirm the diagnosis and determine the form of tuberculosis (open, closed, pulmonary, extrapulmonary), additional studies are carried out.

After a reaction, it is important not to wet or scratch the injection site, and to exclude allergens, as this can lead to a false positive result.

Diaskintest

DIASKINTEST is an innovative intradermal diagnostic test, which is a recombinant protein containing two interconnected antigens - ESAT6 and CFP10, characteristic of virulent strains of Mycobacterium tuberculosis (Micobacterium tuberculosis and Micobacterium bovis).

These antigens are absent in the vaccine strain Micobacterium bovis BCG and in most non-tuberculous mycobacteria, therefore Diaskintest causes immune reaction only against Mycobacterium tuberculosis and does not give a reaction associated with BCG vaccination. Thanks to these qualities, Diaskintest has almost 100% sensitivity and specificity, minimizing the likelihood of developing false-positive reactions, which are observed in 40–60% of cases when using the traditional intradermal tuberculin test (Mantoux test). The technique of performing Diaskintest is identical to the Mantoux test with PPD-L tuberculin, which makes its use accessible to medical staff of medical institutions.

Diaskintest is intended for performing an intradermal test in all age groups for the purpose of:

· Diagnosis of tuberculosis, assessment of the activity of the process and identification of persons at high risk of developing active tuberculosis;

· Differential diagnosis tuberculosis;

· Differential diagnosis of post-vaccination and infectious allergies (delayed-type hypersensitivity);

· Assessing the effectiveness of anti-tuberculosis treatment in combination with other methods.

At the moment, this method of diagnosing tuberculosis has been suspended indefinitely due to the incident in Smolensk.

Chemoprophylaxis

Chemoprophylaxis refers to the use of specific anti-tuberculosis (tuberculostatic) drugs by healthy people who are at particular risk of developing tuberculosis to prevent them from developing the disease.

In what cases is chemoprophylaxis prescribed:

· Persons in contact with bacilli shedding individuals, including employees of tuberculosis institutions;

· Persons who have been diagnosed with a tuberculin test;

· Persons with high sensitivity to tuberculin, with so-called “hyperergic” reactions to tuberculin;

· Persons with inactive tuberculosis changes, in whom, due to unfavorable conditions, an exacerbation of the process may occur (deterioration of working and living conditions; nonspecific diseases that weaken the body; pregnancy, postpartum period etc.).

Carrying out chemoprophylaxis:

Chemoprophylaxis is carried out in lesions with fresh, non-massive bacilli excretion 2 times a year for 2-3 months for 1-2 years

In areas with unfavorable epidemiological conditions - 2 times a year for 2-3 months for 2-3 years. According to indications, chemoprophylaxis is carried out for children and adolescents from family contacts with patients with active forms of tuberculosis (once a year for 2-3 months for 1-2 years).

After vaccination or revaccination, chemoprophylaxis is not immediately prescribed, since anti-tuberculosis drugs act on the BCG culture and can weaken the production of immunity. It should be carried out only after 2 months of isolation of the sick or vaccinated person. In cases where isolation is impossible, chemoprophylaxis is immediately prescribed instead of vaccination.

Drug for chemoprophylaxis:

The main drug for chemoprophylaxis is tubazide. Its dose for adults is 0.6 g, for children - 5-8 mg per kg of human weight. All daily dose given in one dose; in the absence or intolerance of tubazide, it is replaced with another drug.

When carrying out chemoprophylaxis, regularity of taking the drug is extremely important. The nurse ensures that the patient takes tubazide in the presence of medical workers or a specially trained sanitary asset. If the patient takes tubazide on his own, the drug is given for a short period of time - 7-14 days. This will allow you to monitor the correct course of treatment and promptly detect side effects. In such cases, the doctor reduces the dosage or stops the drug for a while.

Practical part

ALGORITHMS OF MANIPULATIONS ACCORDING TO THE BASICS OF NURSING

BASIC MANIPULATIONS IN OSD

GROWTH MEASUREMENT No. 1/18

Target: Measure the patient's height and record it on the temperature sheet.

Indications:

Contraindications: The patient's serious condition.

Equipment:

1. Temperature sheet.

Possible patient problems:

The patient is excited.

In the patient serious condition or he is physically disabled (blind, missing a limb), etc.

Disinfect the oilcloth in accordance with current orders and place it on the stadiometer.

Position the patient with his back to the counter so that he touches it with the back of his head, shoulder blades, buttocks and heels.

Tilt your head so that the outer corner of the eye is level with the upper edge of the tragus of the ear.

Lower the bar onto your head and mark your height according to the divisions on the height meter stand.

Record the growth data on the temperature sheet.

Growth data was obtained and the results were recorded on the temperature sheet.

DETERMINATION OF BODY WEIGHT No. 2/19

Target: Measure the patient's weight and record it on the temperature sheet.

Indications: The need to study physical development and as prescribed by a doctor.

Contraindications: The patient's serious condition.

Possible patient problems:

The patient is excited.

Negatively disposed towards interference.

Serious condition.

The sequence of actions of the nurse to ensure the safety of the environment:

Inform the patient about the upcoming procedure and its progress.

Check that the scale is working properly.

Place a clean oilcloth on the scale platform.

Open the shutter of the scale and balance it using a large and small weight.

Close the shutter.

Help the patient stand in the middle of the scale (without shoes).

Open the shutter.

Balance the patient's weight using weights.

Close the shutter.

Help the patient get off the scale.

Record the results in your medical history.

Treat the oilcloth in accordance with the sanitary and epidemiological requirements.

Assessment of achieved results: Weight data was obtained and the results were entered into the temperature sheet.

Teaching the patient or his relatives: Advisory type of intervention in accordance with the sequence of actions of the nurse described above.

RESPIRATORY RATE COUNTING No. 3/20

Indications:

Assessment of the patient's physical condition.

Respiratory diseases.

Doctor's appointment, etc.

Contraindications: No.

Equipment.

Clock with second hand or stopwatch.

2. Temperature sheet.

Possible patient problems: Psycho-emotional (excitement, etc.)

The sequence of actions of the nurse to ensure the safety of the environment:

Have a watch with a stopwatch or a stopwatch ready.

Wash your hands.

Ask the patient to lie down comfortably so that you can see the upper part of the anterior chest.

Hold the patient's hand as you would for a radial pulse so that the patient thinks you are examining their pulse.

Look at the chest: you will see how it rises and falls.

If you cannot see the chest moving, place your hand on the patient's chest and you will feel the movement.

Count the frequency for 1 minute (only the number of breaths).

At the end of the procedure, help the patient sit more comfortably and remove all unnecessary items.

1. Wash your hands.

Record the measurement data on the patient's temperature sheet.

Assessment of achieved results: NPV is calculated and recorded on the temperature sheet.

Notes:

Normally, breathing movements are rhythmic (i.e., repeated at regular intervals). The respiratory rate in an adult at rest is 16-20 per minute, and in women it is 2-4 breaths more often than in men. During sleep, breathing usually becomes less frequent (up to 14 - 16 beats per minute), breathing becomes more frequent when physical activity, emotional excitement.

An increase in respiratory rate is called tachypnea; decrease in respiratory rate - bradypnea; apnea - lack of breathing.

Types of breathing: chest - in women, abdominal - in men, mixed - in children.

When calculating the respiratory rate, pay attention to the depth and rhythm of breathing, as well as the duration of inhalation and exhalation, write down the type of breathing.

PULSE STUDY No. 4/21

Target: Examine the patient's pulse and record the readings on the temperature sheet.

Indication:

Assessment of the state of the cardiovascular system.

Doctor's prescription.

Contraindications: No.

Equipment.

1. Temperature sheet.

Possible patient problems:

Negative attitude towards intervention.

Presence of physical damage.

The sequence of actions of the nurse to ensure the safety of the environment:

Inform the patient about the examination of his pulse, explain the meaning of the intervention.

Cover with your fingers right hand the patient's left forearm, with the fingers of the left hand the patient's right forearm in the area of ​​the wrist joints.

Place your 1st finger on back side forearms; 2, 3, 4th sequentially from the base of the thumb on the radial artery.

Press the artery against radius and feel the pulse

Determine the symmetry of the pulse. If the pulse is symmetrical, further examination can be carried out on one arm. If the pulse is not symmetrical, conduct further examination on each arm separately.

Determine the rhythm, frequency, filling and tension of the pulse.

Count your pulse beats for at least 30 seconds. Multiply the resulting figure by 2. If you have an arrhythmic pulse, count for at least 1 minute.

Record the data obtained on the temperature sheet.

Evaluation of achieved results. The pulse was examined. The data is entered into the temperature sheet.

Teaching the patient or his relatives: Advisory type of intervention in accordance with the sequence of actions of the nurse described above.

Notes:

Places for pulse examination:

radial artery

femoral artery

temporal artery

popliteal artery

carotid artery

artery of the dorsum of the foot.

More often the pulse is examined on the radial artery.

At rest in an adult healthy person pulse rate 60-80 beats per minute.

Increased heart rate (more than 90 beats per minute) - tachycardia.

Decreased heart rate (less than 60 beats per minute) - bradycardia.

The level of independence when performing the intervention is 3.

BLOOD PRESSURE MEASUREMENT No. 5/22

Target: Measure blood pressure with a tonometer on the brachial artery.

Indications: For all sick and healthy patients to assess the state of the cardiovascular system (at preventive examinations, with pathology of the cardiovascular and urinary systems; when the patient loses consciousness, complains of headache, weakness, dizziness).

Contraindications: Congenital deformities, paresis, arm fracture, on the side of the removed mammary gland.

Equipment: Tonometer, phonendoscope, pen, temperature sheet.

Possible patient problems:

Psychological (does not want to know the value of blood pressure, is afraid, etc.).

Emotional (negativity towards everything), etc.

The sequence of actions of the nurse to ensure the safety of the environment:

Standard answers

Ticket 21

Given: Patient N., 37 years old.

Ds: Bronchial asthma moderate severity.

Assigned to: Ultraviolet irradiation.

Questions:

1)

2) What formula should be used to calculate the individual biodose before administering therapy to a given patient?

3) What type of irradiation should be recommended for this pathology?

4)

5)

6) What is the sequence of actions for the nurse to determine the biodose if the patient is undergoing the first procedure? (Algorithm of actions).

Solution:

1)

2) X = t (n – m + 1)

3) Fractional, skin

4) cannot be dosed accurately medicinal substance to carry out the procedure. Medicines may cause reverse effect, i.e. harm.

5)

Patients with mild to moderate severity bronchial asthma, in the absence of exacerbation and severe pulmonary and heart failure, barotherapy is prescribed; start with low pressure corresponding to an altitude of 2000-2500 m, and then 3500 m above sea level; the duration of procedures performed daily or every other day is 1 hour; There are 20 procedures per course of treatment.

6)Algorithm for the nurse to determine the individual biodose:

1. Familiarization with the doctor’s prescription.

2. Selecting a device.

3. Selection of irradiation site.

4. Preparation of the device.

5. Giving the patient the desired position.

6. Inspection of the irradiation site.

7. Wearing sunglasses.

8. Applying the dosimeter to the irradiation area.

9. Fixing it with ribbons to the patient’s body.

10. Covering the surrounding skin with a sheet.

11. Install the device at a distance of 50 cm.

12. Opening the first hole for a specified time.

13. Alternately opening and irradiating subsequent holes for the same time.

14. Removing the dosimeter, stopping irradiation and warning the patient about a visit in 24 hours.

15. Inspection of the irradiation site and counting of erythema stripes.

16. Calculation or recalculation of biodose using the formula.

Standard answers

Ticket 17

Given: Sick.

Ds: Rheumatoid arthritis stop.

Assigned to: Paraffin applications, using the method of immersing baths on both feet, t +55 0 C, duration 40 minutes. Course of 15 procedures.

Questions:

1) The emergence of what urgent situation is it possible with this therapy?

2) What is the peculiarity of the release method for this procedure?

3) What other electrotherapeutic segmental-reflex technique can be recommended for a patient with this diagnosis?

4) What sensations should the patient experience in the bath?

5) The sequence of actions of the nurse during this procedure (Algorithm of actions).

Solution:

1) Increased blood pressure: allow the patient to rest until recovery normal pressure If the blood pressure does not drop, call a doctor after a third party.

Dizziness and headache: give the patient a rest after the procedure, give ammonia if necessary, call a doctor immediately.

2) baths

3) Massage, DDT, electrophoresis of non-steroidal anti-inflammatory drugs, phonophoresis of hydrocortisone, applications of dimexide and Spa treatment have an auxiliary value and are used only for mild arthritis.

4) Pleasant warmth

5) Action algorithm:

1. read the doctor’s prescription.

2. lead the patient into the cabin.

3. help the patient undress.

4. help the patient achieve a comfortable body position.

5. wipe the affected area with a cotton swab and alcohol.

6. measure the t of paraffin.

7. Apply paraffin to the skin.

8. Cover with compress paper.

9. wrap in a blanket.

10. make a note on the physical clock about the duration of the procedure.

11. At the end of the procedure, remove the splint.

12. wipe the treated surface with a damp cloth.

13. Make a note in the accounting and reporting documentation.

14. Invite the patient for subsequent procedures.

Standard answers

Ticket 21

Given: Patient V., 49 years old.

Ds: Chronic bronchitis.

Assigned to: Inhalation therapy.

Questions:

1) What method should be used? this procedure?

2) Is it possible to use this therapy at home? What medicinal substances or herbal infusions, vegetable oils can you recommend?

3) What devices for inhalation therapy are currently used at home? What is their feature?

4) What other physiotherapy procedures can be combined with? inhalation therapy with this pathology?

5) What is the sequence of actions of the nurse when performing this procedure?

Solution:

1) For inhalation, the patient is seated in a chair for free breathing in a comfortable position and through a respiratory mask, fixed together with the generator on the table, for 5-10 minutes. They give you an aerosol of the desired composition to inhale.

2)

3) Compression inhaler CN-231, Machold inhaler with essential oils, inhaler

4) Electrosleep, DDT, method No. 124: Inhalation of electric aerosols, inductothermy with light feeling heat the area of ​​the adrenal glands, while an inductor-cable in the form of a spiral of 2-3 turns is applied at the level of T 10 - L 4, DVM on the lung area, NMP, UHF using a bitemporal technique, phonophoresis, dry carbon dioxide baths, the use of electroacupuncture and electropuncture, as well as the cauterization method (ju), in particular with wormwood cigarettes.

Algorithm of a nurse's actions when conducting inhalation therapy.

1. Familiarize yourself with the doctor’s prescription (type of inhalation, composition of the inhalation mixture, its quantity, duration of the procedure);

Preparing for the patient procedure:

1. Instruct the patient about behavior and breathing during the procedure;

2. Fill the inhaler container with medicine;

3. Seat the patient at the inhaler;

4. Make sure it is ready;

Carrying out the procedure:

1. Turn on the inhaler.

2. Make sure the patient’s behavior and breathing are correct.

3. Monitor the patient.

4. In case allergic reactions(cough, choking) stop the procedure and call a doctor.

End of the procedure:

1. Turn off the inhaler.

2. Remove the tip and sterilize.

3. Invite the patient to rest for 10-15 minutes.

4. Warn the patient about unwanted smoking, loud talking and cooling for 2 hours.

Standard answers

Ticket 20

Given: Patient V., 49 years old.

Ds: Acute bronchitis.

Assigned to: Inhalation therapy (alkaline inhalations).

Questions:

1) Select a device for the procedure to this patient, if there are devices “AIR-2” and “Vulcan”; Why?

2) What alkaline solutions can be used?

3) Is it possible to use this therapy at home? What medicinal substances or herbal infusions, vegetable oils can be recommended?

4) What devices for inhalation therapy are currently used at home? What is their feature?

5) What method should be used to perform this procedure?

Solution:

1) It is better to use the Vulcan device for acute bronchitis, because This ultrasonic nebulizer, the penetration depth and speed of aerosol particles on this device are greater than on the AIR-2 device.

2) For inhalation, you can use an alkaline solution of 1-3% baking soda solution, sea water, salt-alkaline mineral waters.

3) The procedure is possible at home. Eucalyptus, rose, lavender, coriander, sage, anise

4 ) CN-231 compression inhaler, Machold inhaler with essential oils, inhaler

UN-231 ultrasonic, easy to use.

5 ) For individual inhalation, the patient is seated in a chair in a comfortable position for free breathing and through a respiratory mask, attached together with the generator to the back of the chair or on the table, for 5-10 minutes. Allow the patient to inhale an electrical aerosol of the desired composition.

TONSILS

Standard answers

Ticket 17

Given: Patient S., 44 years old.

Ds: Chronic tonsillitis.

Assigned to: Ultrasound therapy on the tonsil area.

Questions:

1) What tests should this patient undergo before the appointment? ultrasound therapy?

2) What method will be used for this procedure and what is its intensity?

3) Write down the settings on the front panel of the machine that you need to set before starting the procedure.

4) What other physiotherapy procedures can phonophoresis be combined with for this pathology?

5) What is the sequence of actions of the nurse when performing ultrasound therapy.

Solution:

1) Before prescribing an ultrasound, it is necessary to do a blood test to determine platelets.

2) The procedure technique is stable for the tonsil area, in two fields per submandibular region, intensity – 0.2-0.4 W/cm 2, continuous mode for 5 minutes. on each side, on ointment: analgin 50%

aa 25.0

petrolatum

1) UV, UHF, microwave, cryotherapy, inhalation, the use of helium-neon laser with cryotherapy, intralacunar irradiation, Laser physiotherapy and laser puncture for acute and chronic tonsillitis can be carried out using a pulsed semiconductor laser on gallium arsenide with a wavelength of 0.89 μm, a power density at the end of the emitter up to 7 mW.

4) Continuous mode, intensity 0.2 - 0.4 W/cm2. Duration 3 -5 minutes.

5) Algorithm of the nurse’s actions when conducting ultrasound therapy:

1. Read the doctor’s prescription.

2. Invite the patient into the cabin.

Preparing the patient for the procedure:

1. Instructing the patient about sensations and behavior during the procedure.

2. Exposing the area of ​​the procedure.

3. Laying (seating) the patient.

4. Application of contact medium.

Preparation of the device:

1. Selection and activation of the desired emitter.

2. Consecutive switching on of the device in the specified mode and intensity.

3. Checking the operation of the emitter.

4. Inclusion of procedure hours.

Carrying out the procedure:

1. Labile technique with moving the emitter or stable technique with fixation of the emitter.

End of the procedure:

1. Turn off the device.

2. Remove the contact medium from the skin.

3. Make a note on the procedure card about the procedure.

Standard answers

Ticket 20

Given: Patient M., 37 years old.

Ds: Chronic bronchitis.

Assigned to: General ultraviolet irradiation (starting from 1/4 biodose), every other day. Course of 15 procedures.

Questions:

1) What emergency situation is possible during this therapy?

2) What other segmental reflex techniques can be recommended for the treatment of this disease?

3) What other local irradiation techniques can be recommended for this pathology?

4) What method of irradiation should be recommended for this pathology?

5) What are the disadvantages of this procedure?

6) What method should be used to carry out this procedure?

Solution:

1) Insufficient eye protection for patients and staff can lead to the development of acute conjunctivitis due to burns of the conjunctiva and cornea of ​​the eye by UV rays. Severe violations of safety precautions may result in skin burns.

Electrical injuries (immediately stop the manipulation, turn off the switch, pull the wires away from the patient with a dry rope, pull him away without touching the patient’s body /only by the clothes/, call a doctor through a third party, psychological help, give valerian extract, give tea, cover warmly; in severe cases: mechanical ventilation + indoor massage hearts + ammonia. If it doesn’t help, then the patient is taken to intensive care and hospitalized.

Heart failure: first aid: call a doctor after the 3rd person, cardiac massage + mechanical ventilation, medication (Norepinephrine IV + 2 - 5 ml of 5% calcium chloride, additionally injected 8% sodium bicarbonate 1.5 - 2 ml per 1 kg of body weight.

Burns: Calm the patient, call a doctor if necessary (depending on the degree of the burn), treat the tank with solution, apply a dry or lubricated bandage.

2)a) SMT – variable mode. Electrodes paravertebral, in the interscapular region. 3-4 RR for 5 minutes, modulation frequency – 70-80 Hz, depth – 50%. Course – 12 procedures, daily.

b) Ca 2+ electrophoresis using the “collar” method (according to A.E. Shcherbak), daily. Course of 10 procedures. The “collar” is moistened with a CaCl 2 solution.

A collar-shaped electrode S = 600-800 cm 2 is placed on the back in the area of ​​the shoulder girdle and in front in the subclavian region, the second rectangular electrode S = 300-400 cm 2 is in the lumbosacral region.

V) Electrophoresis of Ca 2+ using the “general electrophoresis according to Vermeule” method: a pad with a 2-5% CaCl 2 solution is placed in the interscapular area and connected to one of the electrodes. And two other double electrodes are placed on the area calf muscles and connect to the other pole. J = 0.05 mA

3) Electrosleep, DDT, method No. 124: Inhalation of electric aerosols, inductothermy with a slight sensation of warmth in the area of ​​the adrenal glands, while an inductor-cable in the form of a spiral of 2-3 turns is applied at the level of T 10 - L 4, DVM on the area of ​​the lungs, NMP, UHF at bitemporal technique, phonophoresis, dry carbon dioxide baths. The use of electroacupuncture and electropuncture, as well as the cauterization method (ju), in particular with wormwood cigarettes, is of particular importance.

4) Patients in the phase of fading exacerbation and remission of bronchial asthma are successfully prescribed therapeutic exercises with an emphasis on individually selected breathing exercises, exercises in the pool (water temperature 37-38 ° C), as well as different kinds therapeutic massage.

5) At misuse, violation of dosage and safety rules, ultraviolet irradiation can have a damaging effect, both local and general. Therefore, when carrying out phototherapeutic, and especially ultraviolet, procedures, it is necessary to strictly and accurately follow the doctor’s instructions.

When dosing and carrying out ultraviolet irradiation strictly necessary! Individual approach to the patient, due to the fact that the light sensitivity of different people, different areas of the skin and even perception by the same people medical procedures V different time Years and individual periods of life differ significantly and have individual fluctuations.

UVR can have a damaging effect if the dosage is exceeded, as well as with increased and pathological sensitivity to UV rays.

Insufficient eye protection for patients and staff can lead to the development of acute conjunctivitis due to burns of the conjunctiva and cornea of ​​the eye by UV rays.

Some diseases can be aggravated under the influence of ultraviolet radiation.

6) For bronchitis, two fields are irradiated. The first field - the anterior surface of the neck and the area of ​​the upper half of the sternum - is irradiated with the patient positioned on his back, a pillow is placed under the back, and the head is slightly tilted back. Radiation dose – 3 biodoses. Second field – back surface neck and upper half of the interscapular region - irradiated with the patient lying on his stomach. A pillow is placed under the chest, the forehead rests on folded hands. Radiation dose – 4 biodoses. Irradiation is carried out after 1-2 days. The course of treatment is 5-6 procedures.

Standard answers

Ticket 1

Given: Patient S., 25 years old.

Ds: ARVI (dry cough, sore throat, runny nose, weakness, T 0 37.2)

Assigned to: Ural Federal District.

Questions:

1) What emergency situation is possible during this therapy?

2) Is it possible to appoint a UFO?

3) By what method and with what doses should this procedure be administered?

4) What scheme of general ultraviolet irradiation should this procedure be carried out?

5) What are the disadvantages of this procedure?

6) What is the sequence of actions of the nurse when conducting ultraviolet radiation?

Solution:

1) Electrical injuries (immediately stop the manipulation, turn off the switch, pull the wires away from the patient with a dry rope, pull him away without touching the patient’s body /only by the clothes/, call a doctor through a third party, psychological help, give valerian extract, give tea, cover warmly; in case of severe degrees: mechanical ventilation + closed cardiac massage + ammonia. If this does not help, then the patient is taken to intensive care and hospitalized.

Cardiac arrest: first aid: call a doctor first, cardiac massage + mechanical ventilation, medication (Norepinephrine IV + 2 - 5 ml of 5% calcium chloride, additionally administered 8% sodium bicarbonate 1.5 - 2 ml per 1 kg of body weight .

Burns: Calm the patient, call a doctor if necessary (depending on the degree of the burn), treat the tank with solution, apply a dry or lubricated bandage.

2) Irradiation with ultraviolet rays can be prescribed short-wave or integral spectrum to the area of ​​the tonsils, nasal mucosa and pharyngeal mucosa.

3)a) Impact on the tonsils: the patient is sitting on a chair (preferably a screw chair), the mouth should be at the level of the tube. A removable tube with an oblique cut is installed on the irradiator and it is inserted deep into the mouth, directing the rays to one or the other tonsil. The patient holds the protruding tongue with a gauze pad and monitors through the mirror so that the root of the tongue does not interfere with the procedure. Each time it is necessary to irradiate only half back wall pharynx (to avoid repeated irradiation of the same areas). The irradiation dose is 1-5 biodoses (1-5 minutes or more) for the integral spectrum and 1-2 biodoses (3-6 minutes) for irradiation with short-wave rays. Irradiation is carried out daily or every other day, 3-5 irradiations per course of treatment.

b) Impact on the mucous membrane of the pharynx: to irradiate the posterior wall of the pharynx, the rays are directed at it through a removable tube with a wide opening. Dose – 2 biodoses.

V) Impact on the nasal mucosa: the patient is seated on a chair facing the lamp, slightly tilting his head back. The nasal mucosa is irradiated through a tube with a small hole, inserting it shallowly into each nostril. Radiation dose – 2-3 biodoses. Irradiate daily or every other day. The course of treatment is 2-5 irradiations.

4) Accelerated scheme.

Number of biodoses Distance from lamp, cm

5) It is impossible to accurately dose the medicinal substance for the procedure. Medicines can cause the opposite effect, i.e. harm

Action algorithm