Introduction. The role of a nurse in improving the quality of life of patients suffering from prostate diseases Analysis of problems and quality of life of patients

Stage 1. Identification of the problems of a sick child.

Needs are violated: breathe, eat, sleep, rest, communicate, work, study.
Existing problems:

Respiratory failure due to frequent bronchospasm.

Sleep disturbance and rest due to shortness of breath, discomfort, difficulty breathing in a horizontal position.

Disruption of communication due to shortness of breath during conversation, inability to adequately communicate with peers.

Impaired performance due to hypoxia, shortness of breath.

Potential problems and risk of development:

Atelectasis

emphysema

Pneumothorax

Respiratory failure

heart failure

Death during an attack.

Stages. Planning and implementation of patient care in the hospital.

Purpose of care: to promote the onset of remission, to prevent the development of complications

Nursing process in bronchial asthma.
care plan
1. Provide organization and control over compliance with the regime.
Care implementation:
Independent Interventions: Talk to the patient and/or parents about the causes of the disease, the features of treatment and the prevention of complications. Convince of the need for treatment in a hospital, the implementation of all recommendations.
Motivation:
Creation of a sparing regime of the central nervous system and respiratory organs. Expansion of knowledge.
2. Provide organization and control of nutrition.
Care implementation:
independent interventions. Conducting a conversation with the patient / parents about the features of a hypoallergenic diet, the need for its strict adherence not only in the hospital, but also at home after discharge.
Motivation:
Satisfaction of physiological needs. Prevention of exacerbations.
3. Organization of leisure.
Care implementation:
Independent interventions: Encourage parents to bring their child favorite books, games, etc.

Motivation:
Creation of conditions for compliance with the regime
4. Creation of comfortable conditions in the ward.
Care implementation:
Independent interventions: Monitor wet cleaning and regular ventilation; the regularity of changing bed linen; maintaining silence in the room.
Motivation:
Satisfaction of physiological needs in sleep. Improved breathing.
5. Assistance in carrying out hygiene measures, and eating.
Care implementation:
Independent interventions: Have a conversation about the need for hygiene. Recommend parents to bring toothpaste, comb, clean change of clothes.
Motivation:
Satisfying the need to be clean.
6. Follow doctor's orders.
Care implementation:
Dependent intervention: Carrying out basic therapy.
Independent Interventions: Explain to the patient and/or parents the need for medication. Talk to the patient and/or parents about possible side effects of medications. Teach the patient and/or parents how to use PPIs and other inhalation devices, how to perform picloumetry, and keep a self-monitoring diary.
Monitor the stability of practical skills in the patient/parents. Accompany to diagnostic studies, explaining the purpose and necessity of the conduction. Provide psychological support to the patient and parents.
Motivation:
Normalization of morphological changes in the bronchi and functional parameters. Increasing the level of knowledge.
The effectiveness of treatment. Early detection of side effects of drugs.
7. Provide dynamic monitoring of the patient's response to treatment.
Care implementation:
Independent intervention: Questioning about well-being, complaints, measuring body temperature in the morning and evening; control of respiratory rate, heart rate; the presence and nature of shortness of breath and cough; physiological control. If the general condition worsens, immediately inform the attending physician or the doctor on duty.
Motivation:
Monitoring the effectiveness of treatment and care. Early detection and prevention of complications.

Stage. Evaluation of the effectiveness of care

With proper organization of nursing care, remission occurs, the patient is discharged under the supervision of a pediatrician, allergist, pulmonologist in a children's clinic. The patient and his parents should be aware of the peculiarities of the organization of the regimen, diet, elimination measures, the need for dispensary observation and strict adherence to all recommendations.

Chapter 2. Practical part

Organization of nursing care in case of emergency, an attack of bronchial asthma and assistance in exacerbation of the disease.

While doing practice at MAU City Clinical Hospital No. 14 (st. 22 party congress 15A), in the general therapeutic department where there were patients with various adult pathologies - bronchial asthma (COPD), which was often a concomitant pathology, I observed patients with bronchial asthma and provided nursing process. In the department, I saw 2 posts for receiving patients, 2 treatment rooms, an office for nebulizer therapy (inhalation).

Observation of a patient with an attack of bronchial asthma.

The patient was observed on duty in the children's brigade of the ambulance service on 09.05.2016

A brigade was called to help 11-year-old daughter. Complaints: shortness of breath, feeling short of breath, cough with sputum difficult to separate. From the anamnesis it is known that the girl suffers from bronchial asthma. The child's condition worsened after the girl brought a kitten into the house. Objectively: the child is sitting, leaning forward, leaning on the edge of the bed, speech is difficult (communicates in short phrases), agitated. Auxiliary muscles take part in breathing, breathing is noisy, exhalation is difficult. The skin is pale, cyanosis of the nasolabial triangle. A / D 110-60 mm. rt. Art., HR-84 in 1 min. NPV-32 in 1 min.

Algorithm of emergency care for an attack of bronchial asthma.

Asthma attack - acutely frolicking and / or progressively increasing suffocation, with a sharp decrease in peak expiratory flow rates.

The basis is bronchospasm, swelling of the bronchial mucosa, accumulation of mucus, oxygen deficiency.

Information to help the nurse suspect an emergency:

The patient suffers from bronchial asthma

Spasmodic cough

Expiratory shortness of breath (expiration is difficult), participation in breathing of auxiliary muscles.

Restlessness, pale skin

Forced position of the patient

The nurse must:

Table 1

After medical help

Assessment: Patient's condition

1. Suffocation has decreased and stopped, sputum comes out freely.

After that, hospitalization in the therapeutic (pediatric) department was offered.

Pharmacological analysis of the drugs used

Eufillin 2.4%-10 ml (one ampoule)

pharmacological group.

Adenosinergic agents

Pharmachologic effect.

Antispasmodic, diuretic, bronchodilator.

Indication.

Eufillin is used for bronchial asthma and bronchospasm (sharp narrowing of the lumen of the bronchi) of various causes (mainly to relieve attacks)

Contraindications.

The use of aminophylline, especially intravenously, is contraindicated in case of sharply low blood pressure, paroxysmal tachycardia, extrasystole, epilepsy

Side effects.

Dyspeptic disorders (digestive disorders), with intravenous administration, dizziness, hypotension (lowering blood pressure), headache.

Storage conditions.

List B. In a dark place.

Berodual

pharmacological group.

Bronchodilator drug

Pharmachologic effect.

With the combined use of ipratropium bromide and fenoterol, the bronchodilatory effect is achieved by acting on various pharmacological targets. These substances complement each other, as a result, the antispasmodic effect on the muscles of the bronchi is enhanced and a wide range of therapeutic action is provided for bronchopulmonary diseases accompanied by constriction of the airways.

Indications

Berodual is prescribed for the prevention and symptomatic treatment of chronic obstructive respiratory diseases with reversible bronchospasm:

Bronchial asthma;

Chronic obstructive bronchitis, uncomplicated or complicated by emphysema.
Contraindications.

Hypertrophic obstructive cardiomyopathy;

tachyarrhythmia;

I and III trimesters of pregnancy;

Hypersensitivity to the components of the drug.
Side effects.

Nervousness, fine tremor, dizziness, headache, disturbance of accommodation, changes in the psyche (central nervous system);

Rash, urticaria, angioedema of the lips, tongue and face (allergic reactions);

Tachycardia, palpitations (cardiovascular system);

Vomiting, nausea (gastrointestinal tract);

Cough, local irritation, paradoxical bronchospasm (respiratory system);

Urinary retention, hypokalemia, weakness, increased sweating, convulsions, myalgia (others).

Storage conditions.

Store in a dry, dark place, out of the reach of children, at a temperature not exceeding 30 °C. The drug must not be frozen. Shelf life - 5 years.

Pulmicort ( budesonide 0.25 mg or 0.5 mg)

pharmacological group.

Glucocorticosteroid for local use

Pharmachologic effect.

Glucocorticoid, anti-allergic, anti-inflammatory.

Indication.

Bronchial asthma (as basic therapy; with insufficient effectiveness of beta2-agonists, cromoglycic acid and ketotifen; to reduce the dose of oral corticosteroids), chronic obstructive pulmonary disease (COPD), stenosing laryngotracheitis (false croup)

Contraindications.

Side effects.

Common: Candidiasis of the oropharynx, mild irritation of the mucous membrane of the throat, cough, hoarseness, dry mouth.

Rare: Angioedema; The appearance of bruises on the skin; Bronchospasm; Nervousness, irritability, depression, behavioral disorders; Hypersensitivity reactions of immediate and delayed type, including rash, contact dermatitis, urticaria, angioedema, bronchospasm and anaphylactic reaction; Nausea.

Very rarely (effects associated with the systemic action of Pulmicort): Decrease in bone mineral density, cataracts, glaucoma.

Storage conditions.

Preparations Pulmicort And Pulmicort Turbuhaler should be stored in a cool, dry place with an ambient temperature not exceeding 30 degrees Celsius.

Containers with the suspension inside should be stored only in the original envelope, which protects the drug from light.

Observation 2.

An 18-year-old girl was admitted to MAU GKB No. 14 with wheezing, wheezing at night; asthma attacks from 0 to 3 times a day, the provoking factor of which is contact with the hair of a pet (cat), pungent odor, cold air. Attacks of suffocation are accompanied by a cough with difficult to separate, viscous and viscous sputum.

Objectively: the condition is moderately severe, the situation is forced. The skin is pale, moderate cyanosis of the nasolabial triangle, when talking, shortness of breath appears and intensifies. expiratory nature. ChD-26, ChSS-110

Preliminary diagnosis of the Medical team Smp.

Bronchial asthma of moderate severity, exacerbation.

Survey results:

Blood chemistry.

Bilirubin total 18.7 µmol/l

Amylase 74 s/l

Urea 5.45 mmol/l

Blood sugar 4.3 µmol/l

Protein 53.7 g/l

cholesterol 5.7 mmol/l

General blood analysis.

hemoglobin 124 g/l

leukocytes 4.5

Leukocyte formula:

Eosinophils 9%

Lymphocytes 45%

General urine analysis.

Color golden yellow

transparent

urine pH slightly acidic 6.3

Specific Gravity 1012

Protein - no

Glucose - no

Bilirubin - no

Leukocytes 1-2 in the field of view

General sputum analysis + m / flora + VC

Yellow color

Character - purulent

Consistency - viscous

Leukocytes - 10-15 per field of view

Epithelium - 1-3 in the field of view

VK - not found

M / flora - coccal

Electrocardiogram

The heart rate is sinus. Heart rate = 77 bpm.

R1>R2>R3, transition zone - V2, QRS complex: 0.20 sec.

The S wave is maximum in the AVR.

The R wave is maximum at AVL.

Conclusion: Sinus rhythm, NBPNPG.

Ds clinical.

The main disease: atopic bronchial asthma, moderate severity, exacerbation.

Identified violated needs of the patient

1. The need to sleep

2. The need to work

3. The need to be close to family

4. The need to breathe

5. The need to communicate

6. The need to move

Identified patient problems

1. Real (existing):

Respiratory failure due to difficulty exhaling.

Sleep disturbance due to coughing, shortness of breath, stress, anxiety.

Dysfunction due to shortness of breath, weakness.

Violation of hygiene due to insolvency, general weakness of the body, loss of interest in communication.

Movement disorders due to weakness.

Potential

Risk of developing Status Asthma

The risk of developing an attack of respiratory failure

The risk of developing frequent diseases of the upper respiratory tract, pneumonia, broncho-obstructive syndrome.

Short-term goal: Restore disturbed needs, prevent complications, emergency conditions.

Introduction…………………………………………………………………………...3

Chapter 1. Theoretical and methodological substantiation of the problem of the quality of life of patients……………………………………………………………………..8

1.1. Influence of the quality of life of patients on the state of the thyroid gland in the preoperative period……………………………………………………………….8

1.2. The impact of quality of life on the postoperative condition of patients….8

Chapter 2. Study of the quality of life of patients…………………………….21

2.1. Postoperative care………………………………………………….21

2.2. Nutrition of patients…………………………………………………………….41

2.3. Healthy lifestyle…………………………………………………………45

Chapter 3. The influence of various environmental factors on the condition of patients after surgery ………………………………………………………...55

3.1. Influence of anthropogenic factors ……..…………………………………….55

3.2. Influence of natural environmental factors (sunlight, water)……………71

Conclusion………………………………………………………………………….76

List of used literature………………………………………………...77

Introduction

Endocrine surgery is one of the most intensively developing branches of clinical medicine. This was facilitated not only by the successes achieved in the diagnosis of endocrine diseases, but also by the successes associated with the widespread introduction of new technologies into surgical practice, in particular endovideosurgical ones. At the same time, surgical endocrinology cannot develop unless new data obtained in intensively developing anesthesiology and resuscitation are used.

Recent years are characterized by rapid development of endocrinology. This is due, firstly, to the rapid growth in the number of patients with endocrine pathology. So, according to WHO, for example, 7% of people living on the planet suffer from endemic goiter, and 2-5% of the population of Europe and America suffer from diabetes. There is no significant trend towards a decrease in endocrine morbidity, and the frequency of some diseases is even increasing. Secondly, endocrinology has made great strides in developing a number of fundamental problems: the biosynthesis of hormones and the regulation of these processes, the action of hormones at different levels (including subcellular and molecular levels), the mechanisms of endocrine regulation of genetic, generative and metabolic processes, the relationship between endocrine disorders have been studied. and metabolic disorders. This allows introducing new methods of diagnostics and treatment of endocrine diseases into clinical practice. At the same time, there was a separation of a new medical specialty - endocrine surgery. Many patients with endocrinological diseases are cured only by surgery.

Endocrine surgery (surgical endocrinology) has grown in depth and breadth so much in the last 2-3 decades that it is impossible not to emphasize its interdisciplinary nature. But, according to some scientists, domestic endocrine surgery is still weakly "flowing" into the world.

Undoubtedly, the achievements of anesthesiology and resuscitation of recent days have made it possible to significantly expand the indications for surgical treatment of patients with endocrine pathology - childhood and senile age, pregnant women, patients with severe concomitant diseases and combined lesions of several endocrine glands. A significant number of those in need of planned and emergency surgical treatment are patients with common surgical pathology (acute appendicitis, acute cholecystitis, gastric ulcer), combined with endocrine disorders.

Speaking about the successes of endocrine surgery, it is impossible not to notice that the separation of this area of ​​medicine into an independent specialty, the organization of specialized departments, the professional training of highly qualified surgeons, the thorough development of the methodology for performing operations on the endocrine glands do not adequately solve the problems facing this surgical specialty. Even an impeccably performed surgical operation in patients suffering from endocrine diseases cannot guarantee success if serious mistakes were made in the pre- and postoperative periods, as well as during anesthesia.

In everyday life, caring for the sick (compare - care, take care) is usually understood as helping the patient to meet his various needs. These include eating, drinking, washing, moving, emptying the bowels and bladder. Care also implies the creation of optimal conditions for the patient to stay in a hospital or at home - peace and quiet, a comfortable and clean bed, fresh underwear and bed linen, etc. In such volume care is carried out, as a rule, by the junior medical personnel, and also relatives of the patient. In medicine, the concept of "care for the sick" is interpreted more broadly. Here it stands out as an independent discipline and represents a whole system of activities, including the correct and timely implementation of various medical prescriptions (for example, the administration of drugs by injection, setting cans, mustard plasters, etc.), carrying out some diagnostic manipulations (urine collection , feces, sputum for analysis, gastric and duodenal sounding, etc.), preparation for certain studies (X-ray, endoscopic, etc.), monitoring the patient's condition (including the respiratory, circulatory systems), providing the patient with the first pre-medical assistance (gastric lavage, help with fainting, vomiting, coughing, suffocation, gastrointestinal bleeding, artificial respiration and chest compressions, etc.), maintaining the necessary medical documentation. Many of these manipulations are performed by nurses, and some (for example, intravenous injections, bladder catheterization) by doctors.

"Surgical" stress and postoperative pain increase the load on almost all vital systems of the body. The tension of the functions of these systems, primarily blood circulation and respiration, is manifested by an increase in pressure, tachycardia, heart rhythm disturbance, increased breathing, etc. Other negative aspects caused by pain in the early postoperative period and causing "discomfort" of the patient include: a decrease in motor activity, the patient's inability to cough up sputum and breathe deeply, "forced" position, depressive state.

Improving the results of surgical treatment of patients with endocrine pathology at the present stage is seen in the improvement of preoperative preparation, optimization of anesthesia and postoperative management. The fundamental difference between these patients and those of the general surgical profile lies in the presence of the first gross functional disorders in almost all vital systems and severe metabolic disorders.

The postoperative period, characterized by a pronounced pain syndrome, water-electrolyte and metabolic disorders, disorders of ventilation, gas exchange and the activity of the cardiovascular system, places high demands on the functional reserves of the body, even in general surgical patients. In patients with pathology of the endocrine system, complications can be exacerbated by the upcoming disorders of hormonal homeostasis (thyrotoxic crisis, hypo- and hyperglycemic coma, acute adrenal insufficiency, etc.), therefore, adequate management of these patients is available only to doctors who are well acquainted with the nature of hormonal and metabolic disorders, developing at various stages of surgical treatment. This problem primarily concerns surgeons, anesthesiologists and resuscitators of those medical institutions in which operations are performed on the endocrine glands.

In many ways, the recovery in the postoperative period of patients depends on the care of their loved ones - “It’s even nice to get sick when you know that there are people who are waiting for your recovery, like a holiday.” It largely affects the postoperative condition and lifestyle of the patients themselves. Indeed, “in any illness, not to lose the presence of the spirit and maintain a taste for food is a good sign; the opposite is bad. And even in ancient times it was noticed: "Just as there is a disease of the body, there is also a disease of the way of life."

In this regard, the purpose of our work is to study the rules of postoperative care for patients who underwent surgery on the thyroid gland and their future lifestyle.

To achieve the goal, it is planned to solve the following tasks:

Consider the impact of the quality of life of patients on the state of the thyroid gland in the preoperative period;

To investigate the impact of the quality of life of patients in the postoperative period;

Consider the influence of various environmental factors on the condition of patients after surgery, since “the disease is a healing remedy of nature itself in order to eliminate the disorder in the body; therefore, the medicine comes only to the aid of the healing power of nature.

Chapter 1. Theoretical and methodological substantiation of the problem of the quality of life of patients

1.1. Influence of the quality of life of patients on the state of the thyroid gland in the preoperative period

The thyroid gland is located on the anterior surface of the trachea between the thyroid cartilage and the 5-6th tracheal rings. It consists of two lobes located on both sides of the trachea, interconnected by an isthmus, and has an average mass of 15-20 g. The functional and morphological unit of the thyroid gland is the follicle, in which the synthesis of thyroid hormones - thyroxine (T 4) and triiodothyronine (T 3).

So far, surgical methods have played a leading role in the treatment of thyroid diseases. In patients with diffuse toxic goiter (DTG), surgical treatment is carried out with severe thyrotoxicosis, a significant increase in the thyroid gland, and the absence of the effect of conservative therapy. Indications for surgical treatment are also toxic adenoma, multinodular toxic goiter, nodular non-toxic goiter, thyroid cancer, Riedel's fibrous thyroiditis, purulent thyroiditis. Patients with autoimmune Hashimoto's thyroiditis are operated on if they have symptoms of tracheal compression and "cold nodes" in the thyroid gland.

The thyroid gland is located in the anterior region of the neck in front of the larynx and upper cartilages of the trachea. It consists of two lobes, connected by an isthmus, formed by glandular follicles and their surrounding parafollicular tissue. Follicle cells (thyrocytes) synthesize specific hormones thyroxine (tetraiodothyronine) and triiodothyronine from the amino acid tyrosine and inorganic iodine. The perifollicular tissue synthesizes the non-iodinated thyrocalcitonin hormone.

Thyroxine and triiodothyronine, entering the blood, affect all cells of the body, participate in the regulation of all types of metabolism, growth processes, and differentiation of tissues and organs. These hormones increase the intensity of oxidative processes, stimulate the growth of the body, the development and function of the reproductive system, and the excretion of water. They are involved in the regulation of the development of the nervous system and its excitability, ensure the normal function of the skin.

Hypofunction of the gland, manifested in a lack of hormones during the growth of the body, leads to dwarfism - cretinism, in an adult - to myxedema (swelling of the skin), a decrease in the intensity of metabolism and excitability of the nervous system.

Hyperfunction, manifested by an excess of hormones, leads to an increase in the intensity of metabolism, excitability of the nervous system, an increase in the frequency of heart contractions, and the development of goiter. This disease is called Graves' disease.

Thyrocalcitonin, entering the bloodstream, affects the exchange of calcium and phosphorus in the body. The hormone activates osteoblasts, i.e. participates in the formation of bones, providing calcium deposition in bone tissue and reducing its content in the blood.

1.2. The impact of quality of life on the postoperative condition of patients

Despite significant advances in pain management over the past 10–15 years, postoperative pain syndrome (PPS) continues to be a serious medical problem. At the IV Congress of European Associations for the Study of Pain, held under the motto: "Europe against pain - do not suffer in silence" (Prague, September 2003), it was noted that at least 35% of patients undergoing elective and emergency surgical interventions suffer from postoperative pain. At the same time, in 45-50% of cases, the intensity of pain is moderate and high, and 15-20% of patients note that the intensity of pain exceeded their expectations.

In one of the largest studies (about 20,000 patients of surgical departments in the UK), postoperative pain of moderate intensity was noted on average in 29.7% (26.4–33%) of cases, high intensity - in 10.9% (8, 4–13.4%) cases.

Extensive tissue damage during surgical interventions can induce pathophysiological changes in the peripheral and central parts of the CNS, which lead to the formation of postoperative chronic pain syndrome (CPS). The issue of CPS (essentially iatrogenic suffering) was first raised in the 1990s. It is estimated that the frequency of post-thoracotomy CPS approaches 45%, post-mastectomy - to 35-38%, after "open" cholecystectomy CPS develops in approximately 25% of cases, in patients undergoing surgery for inguinal hernias, the so-called genitofemoral pain syndrome occurs in 10 -12% of cases, etc.

The development of postoperative CHD is a serious medical and social problem, which, among other things, is of great economic importance. According to the estimates of American experts, the cost of treating CHD, which developed in a 30-year-old patient, reaches $1,000,000 by the end of his life. In this regard, the main task of increasing the effectiveness of postoperative analgesia at the present stage is the prevention of chronicity of acute PBS.

A few words about the pathophysiology of acute pain. Zones of hyperalgesia are formed around the surgical wound, i.e. increased pain sensitivity (zones of reduced pain thresholds). There are primary and secondary hyperalgesia. Primary hyperalgesia develops rapidly in the immediate vicinity of the wound, in the area of ​​damaged tissues. The pathophysiological basis of primary hyperalgesia is an excessive increase in the sensitivity (sensitization) of pain receptors (nociceptors). When tissues are damaged, the synthesis of metabolites of arachidonic acid is activated. Sensitization of peripheral nociceptors is due to the action of pain mediators (algogens) released from blood plasma, damaged cells, and also from the endings of C-afferent fibers.

Later, secondary hyperalgesia is formed outside the damage zone. The area of ​​secondary hyperalgesia is located not only around the damage zone, but also at a distance from it. It develops as a result of the activation of the central mechanisms of sensitization of nociceptive neurons located in the posterior horns of the spinal cord. In particular, their excitability, spontaneous electrical activity and sensitivity to mechanical stimulation increase. One of the main mechanisms of central sensitization is the development of the phenomenon of "inflating" the activity of nociceptive neurons of the posterior horns of the spinal cord, which is manifested by a progressive increase in the frequency of action potentials generated by nociceptive neurons in response to repeated stimulation of C-afferents. The "spreading" of the zone of excessive pain sensitivity around the surgical wound is due to the expansion of the receptive fields of the neurons of the posterior horns of the spinal cord. This process takes place over 12–18 hours, which in a significant percentage of cases causes an increase in the intensity of postoperative pain by the 2nd day after surgery.

The development of secondary hyperalgesia not only increases the intensity of the acute pain syndrome, but is also the starting point for its chronicity. At present, causal relationships have been identified between the traumatic nature of the operation, the intensity of PBS, and the likelihood of CPS formation. In particular, it is known that the early development of PBS (during the first 4 hours after surgery), its intense nature and long-term existence are the main risk factors for CPS.

What are the current trends in postoperative pain relief?

Analyzing world experience, at present, several main trends in postoperative pain relief can be distinguished:

1) the increasing use of non-opioid analgesics - non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol. In various European clinics, the frequency of prescribing these drugs as the basis for postoperative pain relief varies from 45 to 99%;

2) limitation of the traditional intramuscular administration of opioid analgesics, due to low efficiency and a significant number of side effects of this technique;

3) widespread use of high-tech methods of pain relief - prolonged epidural analgesia (EA) through the infusion of local anesthetics and opioids, as well as patient-controlled intravenous or epidural analgesia (CPVA and CPEA);

4) multimodal nature of postoperative pain relief, i.e. simultaneous administration of several drugs or methods of pain relief that can affect various mechanisms of pain syndrome formation. For example: paracetamol + NSAID ± opioid or extended-release EA + paracetamol, etc.

Traditionally, systemic administration of opioid analgesics has been considered as the basis of postoperative analgesia. At the same time, these drugs are not the "gold standard" for the treatment of acute pain. According to foreign experts, the effectiveness of pain relief in the traditional prescription of opioids as monotherapy does not exceed 25-30%. The problem is that the effective analgesic dose is often close to that which causes respiratory depression. Currently, in a number of developed countries, the share of opioids in the structure of drugs used for postoperative pain relief does not exceed 15–20%. Although there are exceptions - in Denmark, the use of opioids for medical purposes has increased by 800% over the past 20 years.

The most effective attempts to improve the quality of postoperative opioid analgesia are based on the optimization of drug administration methods. The most modern method is patient-controlled analgesia (CPA), which is most focused on the individual needs of the patient in pain relief. If necessary, by pressing the button on the remote device, the patient himself injects an additional bolus of analgesic, which gives him a sense of independence and confidence, and also facilitates the work of nursing staff.

It must be said that high-tech methods of postoperative analgesia, such as CPA and EA, carried out by means of continuous epidural infusion, in developed countries are collectively used in 35–50% of patients who have undergone surgical interventions. These methods are characterized by high efficiency and comparative safety. The already mentioned large British study analyzed the frequency of respiratory depression with the use of opioids through CPA, as well as with their intramuscular and epidural administration. With CPA, the average frequency of respiratory depression was 1.2% if hypoventilation was used as a criterion, and about 11.5% if the degree of decrease in capillary blood saturation was assessed as a criterion. The corresponding figure for EA with opioids was 1.1% and 15.1%, respectively. For comparison: the traditional intramuscular administration of opioid analgesics was characterized by a 0.8% frequency of respiratory depression when focusing on hypoventilation and 37% (!) When using a decrease in saturation as a criterion. The data obtained indicate that the standard of monitoring for CPA should be pulse oximetry, preferably in combination with capnography.

A very common situation is when a patient in a comfortable condition is transferred from the intensive care unit, where the most modern methods of pain relief, such as CPA and EA, were used for his treatment, to a specialized surgical department - and left alone with pain. Currently, in such situations, it is recommended to transfer patients to anesthesia with intravenous paracetamol, followed by a switch to the tablet form.

The wide development of patient-controlled opioid analgesia in our country is limited by: a) the shortage of infusion pumps with a module for CPA, b) the problems of accounting and writing off opioid analgesics. For example, to perform CPA with Promedol, the infusion pump syringe (60 ml) must be filled with 100 mg of the drug. When writing off 5 ampoules of Promedol per 1 patient per day, questions may arise both from the administration of the clinic and from representatives of structures that control the consumption of narcotic analgesics in medical institutions.

Obviously, in our country, the prospects for the development of CPA (if the appropriate equipment is available) are mainly associated with the use of non-opioid analgesics, in particular NSAIDs and intravenous paracetamol.

The critical importance of tissue inflammation in the mechanisms of central sensitization and, consequently, in the formation of chronic pain is an indication for mandatory inclusion of NSAIDs in the treatment regimen for postoperative pain. For a long period of time, NSAIDs were considered peripheral analgesics capable of suppressing the synthesis of inflammatory mediators, primarily prostaglandins, in tissues through a reversible blockade of cyclooxygenase (COX). Evidence was then obtained for the central action of NSAIDs. In particular, it has been shown that NSAIDs inhibit the thalamic response to nociceptive stimulation and prevent an increase in the concentration of prostaglandins in the cerebrospinal fluid, which inhibits the development of secondary hyperalgesia.

The greatest use is found for drugs that have a form for parenteral administration (diclofenac, ketorolac, ketoprofen, lornoxicam). The disadvantage of diclofenac and ketoprofen is the impossibility of their intravenous administration. Ketorolac and lornoxicam (xefocam) are characterized by the most powerful analgesic effect. It should be noted that the majority of reports of increased bleeding of postoperative wounds, cases of gastrointestinal bleeding and nephrotoxic effects are associated with the use of ketorolac. Lornoxicam, which is able to equally suppress the activity of COX-1 and COX-2, is characterized by a pronounced analgesic and anti-inflammatory effect. In the literature, there are practically no reports of side effects of this drug with its short-term appointment (3-4 days) at a dose of 16-24 mg / day.

Not so long ago, data were obtained on the positive effect of NSAIDs on the survival of patients undergoing major surgical interventions, including those complicated by abdominal surgical infection. Prostaglandin E2 (PGE2) promotes protein breakdown, and this effect is enhanced by fever and sepsis. NSAIDs can reduce muscle loss by inhibiting PGE2 synthesis and reducing protein degradation. Assessing the loss of nitrogen in the postoperative period in patients who underwent long-term EA, it was found that the combination of EA with NSAIDs can reduce nitrogen loss by 75–80% in the first 3 days. after surgery, compared with the control group receiving only EA.

Great hopes were associated with the introduction of selective COX-2 inhibitors into clinical practice. To date, meloxicam, nimesulide, celecoxib, etoricoxib, valdecoxib, and parecoxib (an injectable form of valdecoxib) are available from this group of drugs. Theoretically, selective COX-2 inhibitors should have a clinical advantage over other NSAIDs. While maintaining an analgesic effect comparable to them, they do not suppress the physiological production of prostaglandins by tissues, which should be accompanied by a decrease in the number of side effects inherent in NSAIDs. Unfortunately, theoretical assumptions are not fully confirmed in clinical practice.

Large studies have demonstrated that COX-2 inhibitors have a less clinically significant ulcerogenic effect on the gastrointestinal tract. The VIGOR study found that the incidence of upper GI ulcers decreased from 4.5 cases with naproxen to 2.1 cases per 100 patients per year with rofecoxib. In the CLASS study over a period of 3 to 6 months, the incidence of ulcer complications was 0.76% for celecoxib and 1.45% for ibuprofen or diclofenac. The issue of the benefits of COX-2 inhibitors in patients with additional risk factors for gastrointestinal ulcers remains debatable: older age, concurrent use of aspirin or corticosteroids, the presence of Helicobacter pylori. It has been estimated that the number of patients requiring preferential treatment with COX-2 inhibitors over non-selective NSAIDs for the prevention of ulcer complications is 40-100 per year.

Thus, the appointment of selective COX-2 inhibitors is associated with a lower number of ulcerative lesions of the gastrointestinal tract compared to non-selective NSAIDs, however, this figure remains quite high.

Effects on platelet function and thrombogenic effect
Platelets produce only COX-1, therefore, selective inhibitors of COX-2 do not affect their function. This fact is confirmed clinically by a decrease in blood loss in the intra- and early postoperative period, compared with the use of non-selective NSAIDs. At the same time, it should be noted that in most controlled studies, no significant effect of non-selective NSAIDs on the increase in intraoperative blood loss was found. In this regard, the lack of an antiplatelet effect of COX-2 inhibitors is obviously the basis for their preferential use in patients with hemorrhagic diathesis, concurrent administration of anticoagulants, neuraxial anesthesia, and presumed large blood loss.

In recent years, the question of the highly undesirable thrombogenic potential of selective COX-2 inhibitors has been repeatedly raised. Drugs of this type inhibit the production of endothelial prostacyclin, while maintaining the synthesis of thromboxane by platelets, as well as their ability to aggregate. In the already mentioned VIGOR study, an increased risk of myocardial infarction was found in patients treated with rofecoxib compared with patients who received naproxen. One study looking at the treatment of acute pain with parecoxib followed by valdecoxib for 1–2 weeks in patients undergoing coronary artery bypass surgery found a significant increase in the incidence of cardiovascular complications, renal failure, and problems with sternotomy wound healing. D.Clark et al. in a review on the safety of the use of selective COX-2 inhibitors, noted that to date, COX-2 inhibitors can be recommended only in those conditions where their effectiveness is proven, and only in those patients who have a minimal risk of developing these complications . High risk factors include older age, the presence of cardiovascular and renal diseases. In addition, careful monitoring of the condition of all patients in the process of receiving drugs is necessary.

Not so long ago, rofecoxib was withdrawn from the pharmaceutical market by the manufacturer. The randomized controlled trial APPROVE, investigating the efficacy and safety of rofecoxib, was terminated early because the risk of myocardial infarction was twice as high in the drug-treated group as in patients treated with placebo.

The effectiveness of paracetamol tablets as a postoperative analgesic has been confirmed in a number of studies, the analysis of which is presented in the Cochrane database. The analgesic efficacy of single doses of paracetamol 325, 500, 600/650, 975/1000 and 1000 mg has been proven.

Unlike opioids and NSAIDs, respectively, paracetamol does not have endogenous receptors and practically does not suppress COX activity in the periphery. There is increasing evidence of a central antinociceptive effect of paracetamol. Its probable mechanisms include: a) suppression of COX-2 activity in the CNS (prevention of the development of secondary hyperalgesia), b) suppression of COX-3 activity (the existence of which is assumed and which, apparently, has selective sensitivity to paracetamol), c) increased activity of descending inhibitory serotonergic pathways. Paracetamol prevents the production of prostaglandin at the level of cellular transcription, i.e. regardless of the level of COX activity. Paracetamol is an effective analgesic with potential not far inferior to standard doses of morphine and comparable to therapeutic doses of NSAIDs. The introduction of the intravenous form of paracetamol into the clinic makes the prospects for this drug in postoperative pain relief very encouraging.

The appearance of the intravenous form has significantly increased the value and expanded the indications for the use of the drug as a basic component of multimodal postoperative analgesia. The intravenous form of paracetamol is superior to the tablet form in terms of safety, as it is characterized by a more predictable plasma concentration in the early postoperative period. One study found significant fluctuations in plasma paracetamol concentrations in the early postoperative period, including reaching dangerously high levels with oral versus intravenous administration. Thus, the use of the intravenous form is preferred in high-risk patients, especially those with liver disease. There is convincing evidence for the analgesic efficacy of intravenous paracetamol. In particular, in a study on volunteers, the ability of the drug to reduce the severity of central hyperalgesia was revealed, which confirms the central mechanism of its action.

Currently, 90–95% of surgical patients in Europe receive paracetamol. Usually the drug is administered intravenously during the operation, approximately 30 minutes before the end of the operation, which ensures a calm, painless awakening. As we have already mentioned, the absence of pain during the first 4–5 hours after surgery has a positive effect on the subsequent dynamics of the pain syndrome. Repeatedly 1 g of paracetamol is administered after 4 hours, and then every 6 hours (total dose of 4 g per day). The prescription of the drug is facilitated by the availability of its finished dosage form that does not require dilution (unlike, for example, from lornoxicam). After 1-3 days of intravenous paracetamol use, patients are transferred to its oral form, which is the main analgesic prescribed at discharge from the clinic.

Some experts consider paracetamol as an alternative to NSAIDs, since the drug is comparable to them in terms of analgesic effect, but lacks unwanted side effects. The safety of paracetamol can be illustrated by the recommendations for the use of the intravenous form of the drug for anesthesia in obstetrics, as well as in breastfeeding women or pregnant women undergoing surgery.

As is known, currently up to 35-40% of surgical interventions in the developed countries of the world are performed in a “one day” hospital, and in the USA by 2002 this figure reached 60%. At the same time, special attention is paid to early activation and adequate anesthesia of patients. Pain is the main reason preventing timely discharge and the main reason for repeated visits of patients to the clinic. Currently, the most effective method of pain relief in outpatient practice is considered to be 2-3 intravenous administration of paracetamol (sometimes in combination with NSAIDs) during the period of hospital stay. At discharge, oral forms of the same analgesics are prescribed.

As already mentioned, in a fairly large percentage of cases in patients who have undergone elective and emergency surgical interventions, acute PBS is transformed into a form of neuropathic PBS. The diagnosis of neuropathic pain syndrome is made on the basis of characteristic signs of pain, often of a burning, stinging, or shooting nature, with persistence or even intensification of pain after complete healing of the wound. Another characteristic feature of neuropathic pain is its resistance to opioid analgesics.

The management of acute neuropathic pain is challenging. The main recommendations are carried over from experience in the management of chronic pain and involve the use of anticonvulsants and/or tricyclic antidepressants, which can be difficult in the early postoperative period. In these cases, systemic administration of low doses of lidocaine and/or ketamine can be quite effective. The introduction of these drugs can be carried out in the form of continuous subcutaneous infusion - lidocaine at a rate of 1-1.5 mg / kg / h, ketamine - 5-15 mg / h.

Chapter 2

2.1. Postoperative care

Particular attention in the supervision of patients who underwent surgery on the thyroid gland in the early postoperative period should primarily be given to the prevention of complications. Conventionally, they should be divided into 3 groups:

1) complications associated with the peculiarities of changes in the thyroid gland and trachea, with technical difficulties that arise during the operation and errors made during its implementation;

2) endocrine-metabolic disorders caused by intervention on the thyroid gland;

3) non-specific complications that can develop after any surgical operations.

The first group of postoperative complications is associated with emergency conditions caused by impaired airway patency (up to asphyxia). Among the main causes of asphyxia in patients operated on the thyroid gland are subglottic edema of the larynx, paresis of the vocal cords, hematomas compressing the trachea, and tracheomalacia. In order to timely diagnose these complications and determine the state of the vocal cords, a strict rule in the work of an anesthesiologist should be laryngoscopy performed immediately after extubation of the trachea. If an obstruction is detected at the level of the larynx or trachea, accompanied by severe respiratory disorders, tracheal intubation and mechanical ventilation should be performed. In some cases, tracheal intubation may be technically difficult. In such a situation, they resort to injection ventilation (IVL). IVL is carried out using a special laryngoscope or injection bronchoscope, the blade or tube of which is placed at the entrance to the larynx. In the most severe cases, a ventilation injection tracheotome is used, which is introduced into the larynx to a depth of 0.5 cm along the midline and anterior surface of the neck by puncture of the cricothyroid or cricotracheal membranes. This problem in modern conditions can be solved by high-frequency jet ventilation of the lungs through a microtracheostomy. After normalization of ventilation and gas composition of the blood, the issue of further tactics is decided.

Subglottic edema of the larynx occurs, as a rule, as a result of traumatic intubation or rough surgical manipulations at the time of the release of the thyroid gland in the presence of an endotracheal tube in the trachea.

In adults, it is quickly stopped by intravenous administration of antihistamines, glucocorticoid hormones, lasix, as well as the application of the vocal cords with solutions of hydrocortisone, vasopressors and local anesthetics. In children, subglottic edema of the larynx may persist for several days and require a tracheostomy.

Paresis of the vocal cords is a consequence of one or another damage during the operation of the recurrent nerves. This occurs more often during operations for recurrent goiter, large nodular and retrosternal goiters, as well as in patients who have received thyreostatics for a long time. These drugs increase the blood supply to the thyroid gland, increase the bleeding of its tissues and thereby contribute to poor visibility in the surgical field. With unilateral damage to the recurrent nerve, a hoarse, aphonic voice, difficult stridor breathing, and swallowing disorders occur. Under the influence of drug therapy, including the appointment of prozerin, strychnine, vitamin B 12, physiotherapy and acupuncture, dysphagia, as a rule, stops after 5-7 days, and aphonia - after 2-3 months. If the voice is not restored, later (after 6 months) there are indications for plastic surgery on the larynx. With bilateral damage to the recurrent nerves, acute asphyxia occurs due to paralysis of the vocal cords and complete closure of the lumen of the trachea. Such patients undergo tracheostomy, and later laterofixation of the vocal cords. Postoperative bleeding in patients undergoing surgery on the thyroid gland is manifested mainly by local symptoms. Patients experience swelling in the area of ​​the surgical wound, the neck thickens, its contours are smoothed out, coughing, shortness of breath appear, cyanosis of the face develops. If urgent measures are not taken to eliminate this complication, these symptoms will increase, which can lead to severe asphyxia or vagal cardiac arrest. The rate of development of vital disorders depends on the nature of the bleeding. With arterial bleeding, asphyxia can occur a few minutes after surgery, with venous bleeding it develops gradually over 2-3 hours, with parenchymal bleeding, the symptoms increase slowly over 2-3 days. When diagnosing a growing hematoma, an immediate revision of the surgical wound, removal of blood clots and ligation of bleeding vessels are necessary.

Tracheomalacia develops with a long-term nodular retrosternal goiter. Due to prolonged compression of the tracheal node, disturbances in its blood and lymph circulation, degenerative changes in cartilage develop. If the operation was performed under local anesthesia, then after enucleation of the nodes or extirpation of the thyroid gland, asphyxia may occur due to the collapse of the walls of the trachea. A similar situation arises immediately after extubation of the trachea, if the operation was performed under endotracheal anesthesia. An emergency tracheostomy may be required, followed by a special reconstructive operation.

Among the endocrine-metabolic disorders that occur in the postoperative period with surgical intervention on the thyroid gland, thyrotoxic crisis, hypothyroidism, and parathyroid insufficiency should be distinguished.

A thyrotoxic crisis is a critical condition that develops in a patient with thyrotoxicosis under the influence of provoking factors and is manifested by a sharp increase in the metabolic, organ and systemic symptoms of thyrotoxicosis. The most common provoking factor is surgery on the thyroid gland. The second most important cause of this condition is an intercurrent infection or inflammatory process, especially in the thyroid gland itself. A thyrotoxic crisis may occur as a result of gross palpation of the thyroid gland, psychoemotional stress, extrathyroidal surgery or trauma, decompensation of diabetes mellitus, pregnancy toxicosis, unreasonable withdrawal of thyreostatics or, conversely, the appointment of iodine-containing drugs, sympathomimetics, insulin to a patient with thyrotoxicosis. There are cases when the crisis was provoked by radioiodine therapy for thyrotoxicosis or thyroid cancer.

It seems obvious that a thyrotoxic crisis should occur more often in severe thyrotoxicosis. But practice shows that it may well occur with moderate and even mild thyrotoxicosis, if the conditions for this have developed, primarily in the presence of an appropriate provoking factor. A stable idea of ​​the acute onset of a crisis also needs to be corrected, since in about a third of cases it develops gradually - within a day or more.

The pathogenesis of thyrotoxic crisis is not fully understood. It is believed that the main pathogenetic factors of the thyrotoxic crisis are, firstly, an abrupt increase in the affinity of adrenergic receptors under the influence of a provoking factor, and secondly, an additional increase in free T3 and T4 in the blood. Not all authors share this theory, pointing out that such an additional increase in thyroid hormones is actually small and statistically unreliable. Apparently, we must agree that increased secretion of thyroid hormones is an essential, but not the only pathogenetic factor of the crisis.

An additional pathogenetic factor of the crisis is cortical-adrenal insufficiency. It has been established that chronic hypersecretion of thyroid hormones is accompanied not only by increased breakdown and excretion of corticosteroids, but also by a qualitative change in their biosynthesis, namely, the predominant formation of less active hormones in the adrenal cortex. As a result, at a certain stage of thyrotoxicosis, a relative cortical-adrenal insufficiency occurs, which naturally worsens with a thyrotoxic crisis. This pathogenetic factor undoubtedly exists, which is confirmed both by relevant studies and by the effectiveness of corticosteroid hormones in its treatment.

It is known how important the dysfunction of the kallikrein-kinin system is in the formation of various pathological reactions. Its activation during a thyrotoxic crisis exacerbates cardiovascular, abdominal, vegetative and other disorders.

In most cases, thyrotoxic crisis has an acute onset. The symptoms of thyrotoxicosis quickly, as if like an avalanche, increase: mental and motor anxiety intensifies, acquiring the character of delirium, the skin becomes even hotter and wetter, tachycardia increases, reaching 150 or more per minute; as a rule, there are atrial fibrillation, severe shortness of breath, signs of heart failure appear and rapidly increase. A mandatory sign of a crisis is a febrile temperature.

The eyes are wide open, the face is masklike, blinking is rare. In bed, patients take a characteristic posture, led by arms and legs. Patients rapidly develop lethargy, confusion, often associated with bulbar symptoms, phenomena of renal and hepatic block. Rapidly progressive cardiovascular failure can lead to death.

Very often an acute abdominal syndrome is formed: nausea, vomiting, diarrhea, pain throughout the abdomen. If a patient with thyrotoxicosis had concomitant diseases (peptic ulcer, cholecystopancreatitis, bronchial asthma, diabetes mellitus, etc.), then the thyrotoxic crisis occurs under the guise of their exacerbation, which greatly complicates the diagnosis.

It is useful to group the leading clinical symptoms of a crisis according to their systemic affiliation, since its clinical picture is usually dominated by some systemic syndrome that determines one of the three main clinical variants of a crisis: cardiovascular, abdominal, and neuropsychiatric. Cardiovascular symptoms: tachycardia, extrasystole and atrial fibrillation, cardiovascular failure, shock. Abdominal symptoms: nausea, vomiting, diffuse pain in the abdomen, diarrhea, liver enlargement, jaundice. Neuropsychic symptoms: muscle hypertonicity with increased tendon reflexes, tremor, convulsions, flaccid paralysis (usually of the legs), mental agitation, manic psychosis, delirium, stupor, coma.

Laboratory and instrumental methods for diagnosing a thyrotoxic crisis are not very informative, since deviations in clinical, biochemical and hormonal analyzes, data from electrocardiographic, sonographic and other studies are either nonspecific or practically do not differ from those in uncomplicated thyrotoxicosis. At the same time, these studies make it possible to verify atypical forms of thyrotoxicosis and crisis, which, as already noted, can occur under the guise of anaphylactic or septic shock, periodic flaccid paralysis, withdrawal syndrome, acute surgical pathology of the abdomen, etc.

Thus, thyrotoxic crisis is characterized by four main pathophysiological phenomena: 1) hypermetabolism with severe hyperthermia, dehydration and electrolyte imbalance; 2) sympathetic-adrenal hyperactivity with cardiac, circulatory and psycho-emotional disorders; 3) cortical-adrenal insufficiency with metabolic, cardiovascular and abdominal disorders; 4) activation of the kallikrein-kinin system, which aggravates all of the listed links of pathogenesis.

These phenomena determine the principles of intensive care for thyrotoxic crisis, which include:

1) blockade of the synthesis of thyroid hormones with the help of Mercazolilum;

2) blockade of secretion of thyroid hormones by iodides;

3) sympathetic blockade with b-blockers;

4) elimination of cortical-adrenal insufficiency;

5) decrease in the activity of kallikrein-kinin systems (kontrykal - 40 thousand units; intravenously in 500 ml of isotonic sodium chloride or glucose solution);

6) symptomatic therapy: intravenous infusion of crystalloid and colloid solutions, the introduction of cardiotropic, sedative, antihistamines, antibiotics, the fight against hyperthermia by physical methods.

Treatment of thyrotoxic crisis should begin with the elimination of tissue hypoxia. Its occurrence is facilitated by the uncoupling effect of thyroid hormones on oxidative phosphorylation, a sharp activation of metabolism under conditions of hyperthermia, associated cardiovascular insufficiency, and excessive work of the respiratory muscles. All these deviations can be eliminated only with the help of mechanical ventilation. For the purpose of sedation and synchronization with a respirator, it is better to use barbiturates (hexenal or thiopental-sodium), since they have some antithyroid toxic effect, as well as diazepam, which reduces the concentration of T 3 in the blood plasma by 30%, and sodium oxybiturate, a practically non-toxic hypnotic, similar in structure to the natural metabolites of the body and has antihypoxic properties. Combining these drugs (for example, 20 ml of 20% sodium oxybiturate intravenously + 200-400 mg hexenal intramuscularly), it is possible to quickly put the patient into a state of medical sleep, after which he is transferred to mechanical ventilation, which is advisable to carry out in the mode of moderate hyperventilation and positive pressure in end of exhalation. It is important that medical sleep allows the use of therapeutic hypothermia. In case of a thyrotoxic crisis, antipyretic therapy (amidopyrine, analgin, reopyrin) is usually ineffective, therefore, physical means of cooling are resorted to (ice packs on the head, inguinal regions, armpits, wrapping with wet sheets, followed by blowing the body with air using fans). At the same time, powerful anti-thyroid therapy is prescribed. It includes an intravenous drip infusion of 10 ml of 10% sodium iodide every 8 hours, the introduction of 60-100 mg/day of mercazolil through a gastric tube. In recent years, lithium chloride (up to 1500 mg intravenously) has been used for this purpose.

To correct hemodynamic disorders, b-blockers are primarily used (obzidan 5-10 mg intravenously every 2 hours). Given that b-blockers have a negative inotropic effect, it is advisable to combine them with the introduction of cardiac glucosides. In order to prevent and treat adrenal insufficiency during therapy with b-blockers, glucocorticoids (300-400 mg of hydrocortisone) are used. If it is impossible to use b-blockers, it is recommended to prescribe reserpine 1 ml of a 0.25% solution intramuscularly every 6-8 hours.

Hypovolemia and electrolyte disorders are corrected by transfusion of colloidal and crystalloid plasma substitutes, fresh frozen plasma, albumin, polarizing mixture. Taking into account the important role of activation of the kallikrein-kinin system in the genesis of cardiovascular disorders, patients with a thyrotoxic crisis are shown the administration of proteolysis inhibitors (kontrykal, trasylol, Gordox). The elimination of microcirculatory disorders is achieved by the use of antiplatelet agents (reopoliglyukin, curantil, tiklid), drugs that improve microhemodynamics (trental).

In order to prevent a thyrotoxic crisis, patients with toxic goiter in the early postoperative period are prescribed iodine preparations (Lugol's solution, 20-30 drops 3 times a day) and thyreostatics (Mercazolil, 10 mg 3 times a day, or its analogues). Along with these drugs, b-blockers (obzidan, anaprilin) ​​are used at a dose of 20-40 mg / day.

Be sure to prescribe b-blockers after surgery to those patients who received them in the process of preoperative preparation. Their abrupt cancellation may be accompanied by acute myocardial ischemia. In addition, in the early postoperative period, they may develop acute adrenal insufficiency, so they need preventive administration of glucocorticoids. Along with these measures, anion therapy is carried out in the early postoperative period, aimed at correcting water and electrolyte disorders, sedation with benzodiazepines and barbiturates, as well as postoperative analgesia.

Thanks to the introduction into clinical practice of modern methods of preoperative preparation, anesthesia and postoperative intensive care, the frequency of thyrotoxic crisis has significantly decreased in recent years. However, this problem is still far from being fully resolved. The slightest errors made by the clinician at any stage of the surgical treatment of patients with toxic goiter (insufficiently thorough preoperative preparation, inadequate anesthesia, traumatic resection of the thyroid gland, large surgical blood loss, respiratory failure in the early postoperative period, etc.) provoke the development of this formidable complication.

New prospects in the treatment of thyrotoxic crisis have appeared in connection with the introduction of plasmapheresis into clinical practice. Plasmapheresis reduces the level of thyroid-stimulating antibodies and leads to a significant decrease in the level of thyroid hormones due to their elimination, which is of exceptional importance in the treatment of thyroid storm.

Hypothyroidism. There are primary hypothyroidism caused by a disease of the thyroid gland itself, secondary - due to insufficient stimulation of TSH and tertiary - with a deficiency of TRH. Primary hypothyroidism is observed in 90-95% of cases, secondary thyroid insufficiency is found much less frequently. The prevalence of this condition in the population is very high and amounts to 3-8% of the total population, and there are more such patients in older age groups. This is associated with a violation of thyroxine deiodination in the periphery in people over 60 years of age, as a result of which not T 3 is formed, but inactive reverse triiodothyronine.

The most common cause of primary hypothyroidism in young and middle-aged people is autoimmune thyroiditis.

A hypothyroid state may result from the treatment of thyrotoxicosis: after thyroid surgery, the use of Mercazolil or radioactive iodine.

Postoperative hypothyroidism is more often observed in a patient with diffuse toxic goiter. This is due to the fact that surgeons, in an effort to avoid recurrence, leave too little functioning parenchyma. The development of postoperative hypothyroidism is largely associated with the severity of autoimmune processes developing in the left thyroid tissue; therefore, preoperative determination of the level of thyroglobulin antimicrosomal antibodies is especially important. If patients undergoing subtotal resection of the thyroid gland for diffuse toxic goiter have a very high antibody titer, then more thyroid tissue should be left during resection than is customary. It is also necessary to leave a larger amount of thyroid tissue in patients who, before surgery for thyrotoxicosis, were treated with I 131 or took antithyroid drugs for a very long time.

In patients with DTG who were preparing for surgery using plasmapheresis, it is necessary to leave 30% less tissue during resection of the thyroid gland than in patients who were given antithyroid drugs in the preparatory period, since plasmapheresis, unlike thyreostatics, does not affect the state of the thyroid parenchyma. influence and does not cause its replacement by connective tissue.

Hypoplasia or aplasia of the thyroid gland is the cause of congenital hypothyroidism, while the remnant of thyroid tissue may be located at the root of the tongue. Violation of the development of the gland may be due to iodine deficiency of the body, resulting in endemic goiter. Finally, hypothyroidism is included in the structure of the autoimmune polyendocrine syndrome, in which there is also a decrease in the function of the adrenal cortex, gonads, and pancreas. Its clinical manifestations progress gradually. Increased accumulation of glucosaminoglycan and, first of all, hyaluronic acid in the interstitium, edema, swelling and loosening of collagen fibers lead to the formation of mucinoid edema. The result is a general or regional swelling (perinephric or periorbital edema, swelling of the hands, feet). Facial features become rough. The volume of extracellular fluid increases by 23-27%. Paleness of the skin and thickening of the dermis and epidermis are to some extent associated with a deterioration in its blood supply and anemia.

The most common disorder of the nervous system in patients with hypothyroidism is hypothyroid encephalopathy. The formation of an organic lesion of the nervous system is facilitated by a sharp inhibition of energy and anabolic processes in the structural components. Deficiency of thyroid hormones leads to a violation of the metabolism of central neurotransmitters - norepinephrine, dopamine, acetylcholine.

Slowness of thinking, lethargy, drowsiness, memory loss are detected in many patients, and the severity of the disorders depends on the severity of the decrease in thyroid function. Speech is slowed down, articulation is difficult, dysarthria is detected due to impaired mobility of the lips and tongue, as well as swelling of the vocal cords, leading to a decrease in timbre and hoarseness of the voice. Impaired adaptation to the changing events of everyday life. Often, patients report dizziness, and the examination reveals elements of cerebellar ataxia.

In severe hypothyroidism, pseudodementia occurs with depression of cognitive functions, impaired social adaptation, and even self-care skills. This condition differs from true dementia by reversibility in the appointment of thyroid hormone replacement therapy.

The defeat of the muscular system - hypothyroid myopathy is manifested by weakness and myotonic phenomena.

Myopathic disorders with a myotonic component in adults are called Hoffmann's syndrome. Characteristic are hypertrophy and compaction of muscles to the touch, soreness, painful cramps - cramps, an increase in the mechanical excitability of muscles during percussion (the phenomena of "roller", "ditch", "thumb"). When performing active movements, the phenomenon of myotonic delay is revealed - the inability to quickly relax the muscles. After squeezing the hand into a fist for 15-30 seconds, the patient cannot sharply straighten his fingers; in order to carry out this movement, he has to overcome the tension of the muscles - the flexors of the fingers and the hand. Unlike true myotonia, in Hoffmann's syndrome, there is no weakening of the delay phenomenon during repeated movements. The severity of the myotonic phenomenon increases in a cold room. Electromyographically, characteristic signs of myotonic changes are not detected, therefore they are referred to as "pseudomyotonic".

Changes in the cardiovascular system begin to appear early. Often patients are disturbed by aching and stabbing pains in the region of the heart, especially with concomitant menopause, post-thyrotoxic encephalopathy, atherosclerosis of the coronary arteries. Shortness of breath is most pronounced with physical exertion. There are cyanosis of the lips, hydremic edema, increased density of arteries, swelling of the jugular veins. A number of patients do not have bradycardia, the absence of which does not exclude hypothyroidism, but, on the contrary, tachycardia. The latter may indicate a compensated stage of heart failure.

Hypothyroidism may be accompanied by angina pectoris. Quite rarely, patients with hypothyroidism develop myocardial infarction.

Chronic inflammatory diseases of the nose that develop in patients with hypothyroidism are caused by swelling of the mucous membrane, and hoarseness is the result of swelling of the vocal cords.

One of the characteristic signs of hypothyroidism are functional and morphological disorders of the gastrointestinal tract. Hypotension of the stomach and atrophy of its mucous membrane, lymphoid infiltration and mucinoid edema of the intestinal wall often develop, and the size of the tongue increases. In connection with atrophy of the gastric mucosa and achlorhydria, there may be disturbances in the metabolism of vitamin B 12.

The frequency and severity of liver damage directly depend on the severity of hypothyroidism. Decompensated hypothyroidism occurs with dysproteinemia, hypercholesterolemia, an increase in the concentration of total phospholipids, the activity of alanine and aspartate aminotransferase, and alkaline phosphatase.

The glomerular filtration rate is reduced, as a result of which there is a danger of prescribing cardiac glycosides to patients with hypothyroidism, since their concentration can reach a toxic level.

Laboratory studies reveal a reduced level of thyroid hormones in the blood, an increase in ESR, hyperuricemia, hypergammaglobulinemia, hypercholesterolemia, a decrease in urinary excretion of hydroxyproline, and the absence of C-reactive protein.

Radiographically, osteoporosis, erosion-like changes in the small joints of the hands and feet can be noted.

Treatment of both primary and secondary hypothyroidism is carried out with thyroid hormone preparations - thyrotoxin and triiodothyronine. With long-term replacement therapy, preference should be given to thyroxine. Its daily dose is 50-150 mcg. Existing combined preparations of thyroxine and triiodothyronine (thyrotom and thyreocomb) are less preferred due to the non-physiological ratio of these hormones: the first contains 10 μg T 3 and 40 μg T 4, the second - 10 μg T 3 and 70 μg T 4. At the same time, for the treatment of hypothyroidism caused by endemic goiter, thyreocomb and iodothyrox are the most effective drugs, since they contain 150 and 130 μg of potassium iodide, respectively.

T 3 cannot be used for hypothyroidism monotherapy, but only in addition to T 4 if it is not effective enough. It should be emphasized that when selecting individual therapy, T 3 should not be prescribed to persons over 60 years of age or suffering from coronary heart disease.

Traditionally, when selecting individual therapy, T 3 is prescribed in relatively small doses, gradually increasing them until a euthyroid state is reached. This avoids a relative overdose with increased sensitivity of the myocardium to hormones in conditions of hypothyroidism. This regimen is indicated for patients with concomitant cardiac pathology and over the age of 55 years. Young patients without a aggravated cardiac history can immediately be given a full dose of the drug (for example, 100-150 mcg per day). Given the long-term excretion of thyroid hormones from the blood, the drug is recommended to be taken 1 time in the morning.

Treatment of patients with hypothyroidism should be carried out taking into account not only the hormonal, but also the immune status. Studies have shown that there is a relationship between the state of immunity and compensation for hypothyroidism. For this purpose, immunomodulating therapy with placenta extract, splenin, human immunoglobulin is used. 1 ml of placental albumin contains more than 16 ng of thyroxine, 620 μg of ACTH, 0.7 miI - follicle-stimulating hormone and 19 miI - luteinizing hormone, as well as 2 MME - chorionic gonadotropin. It has a pronounced immunosuppressive and anabolic effect.

Apparently, a promising direction in the treatment of hypothyroidism may be transplantation of cryopreserved thyroid tissue into the subcutaneous fatty tissue of the anterior abdominal wall. According to thyroid tissue allotransplantation leads to the normalization of the hormonal and immune status of patients with postoperative hypothyroidism and can be considered as an alternative to replacement therapy.

It is natural to develop hypothyroidism after thyroidectomy in patients with thyroid cancer.

Suppressive therapy with thyroid hormones should be given to all patients with differentiated thyroid cancer after surgery. Differentiated forms of thyroid cancer (papillary and follicular) account for more than 90% of all malignant neoplasms of this organ. Due to slow growth, late detection of metastases, patients after surgical treatment and radioiodine therapy require long-term follow-up. Patients are treated with high doses of thyroxine to suppress TSH secretion. The need for TSH secretion is substantiated by the fact that in response to TSH stimulation in differentiated cancer cells, growth and adenylate cyclase activity increase due to the presence of TSH receptors in them. Thus, TSH is a growth factor for the remaining thyroid cells. It was found that the frequency of recurrence of the thyroid gland within 10 years in patients receiving suppressive therapy T 4 was 17% compared with 34% in patients without treatment.

The objective of suppressive therapy is to reduce the concentration of TSH in the blood to a level of less than 0.1 mU / l. For this, higher doses of thyroxine are used than for replacement therapy: usually from 2.2 to 2.5 mcg / kg of body weight per day. Thyroxine in such a dose causes thyrotoxicosis, including the development of osteopenia. However, the benefits of preventing tumor recurrence outweigh the negative effects of thyroxine treatment. The highest frequency of recurrence of differentiated thyroid cancer is observed during the first 5 years after surgery. If the patient belongs to a group with a potentially low postoperative risk of tumor recurrence (age less than 50 years in women and less than 40 years in men, the size of the primary tumor is less than 4 cm in diameter, no extracapsular growth), then after 5 years of suppressive therapy in the absence of recurrence tumor dose of thyroxine can be reduced. In this case, the level of TSH in the blood should be in the range of 0.1-0.3 mU / l. Treatment is lifelong. In patients with more aggressive morphological types of cancer (follicular carcinoma, Hürthle cell tumor), as well as with the presence of metastases, the thyroxin dosage should not be reduced and the TSH level should remain below 0.1 mU / l.

hypothyroid coma. In advanced cases, hypothyroidism can transform into a hypothyroid coma, which develops only in a patient with hypothyroidism in any form of the latter. But in the vast majority of cases, this coma occurs with primary hypothyroidism, not only because it affects about 95% of hypothyroid patients, but also because of its more severe course. As a rule, these are patients with autoimmune thyroiditis, less often patients who have undergone thyroid surgery or radioiodine therapy.

Usually, hypothyroid coma develops in untreated or undisciplined patients, among whom women aged 60-80 predominate, in the cold season, under the influence of any provoking and predisposing factors. Most often, such a factor is pneumonia, which in patients with hypothyroidism occurs without fever, tachycardia and leukocytosis, and therefore treatment does not begin in a timely manner. The development of coma contributes to the cessation of thyroid hormone replacement therapy or taking sleeping pills, sedatives, drugs, analgesics, alcohol. Provoking moments are cooling, bleeding, increasing heart failure, myocardial infarction, surgery and trauma, hypoxia, hypotension, hypoglycemia and other stressful situations.

The clinical picture of hypothyroid coma is determined to a decisive extent by the predominance of any damage to organs and systems in a particular case of hypothyroidism. Depending on the severity of functional and morphological disorders, various clinical forms are distinguished; cardiovascular, gastrointestinal, neuropathic, psychopathic, etc. Most often, coma is manifested by acute heart failure or Morgagni-Adams-Stokes syndrome, which is associated with myocardial dystrophy, impaired conduction system of the heart, myxedematous pericarditis. Gastrointestinal form of hypothyroid coma usually proceeds in the form of dynamic intestinal obstruction, less often in the form of acute cholecystopancreatitis. Accompanying hypothyroidism disorders of neuromuscular conduction cause a neuropathic form of hypothyroid crisis, indistinguishable from myasthenic crisis, acute cerebral ataxia or spastic paresis. The psychopathic form of the hypothyroid crisis proceeds according to the type of cerebral crisis, acute hallucinatory-paranoid syndrome, and depressive psychosis. Hypothyroidism is almost always accompanied by hypothermia, which may be the only pathognomonic symptom. In this case, body temperature below 30 C means an unfavorable prognosis. However, it must be remembered that in 15-20% of cases, a hypothyroid crisis occurs with normal or even elevated body temperature, which is associated with a concomitant infectious and inflammatory process.

Breathing is shallow, rare, with long pauses. This nature of breathing, even in conditions of a sharply reduced metabolism, is not able to provide adequate ventilation, which leads to hypoxia and hypercapnia. Hypothyroid coma is accompanied by progressive bradycardia and arterial hypotension. Atony of smooth muscles is manifested by urinary retention syndrome and rapidly developing intestinal paresis, up to dynamic intestinal obstruction. Hypoglycemia is often noted.

Outwardly, the most striking clinical manifestation of coma is the rapidly increasing CNS depression - stupor, prostration, coma, which is caused by a drop in cerebral blood flow, hypoxia and acidosis of the brain due to alveolar hypoventilation and progressive cardiovascular insufficiency. It is the growing weakening of respiratory and cardiovascular activity that becomes the direct cause of death, the frequency of which, even in specialized centers, is at least 50%.

The ECG shows low voltage, prolongation of the P-Q and Q-T intervals, ST depression and T-wave inversion. A blood test reveals hypochromic anemia, relative lymphocytosis, eosinophilia, occasionally monocytosis, and delayed ESR. Increased secretion of ADH, characteristic of hypothyroidism, causes hyponatremia, which can be pronounced. Typical pathobiochemical signs of hypothyroidism are hypercholesterolemia, reaching 20-26 mmol / l, hypoglycemia and increased activity of serum creatine phosphokinase (CPK). Urine with high relative density due to hypernatriuria. The most reliable method for verifying primary hypothyroidism and, therefore, most cases of hypothyroid coma is to determine the concentration of pituitary TSH in the blood. At present, an express method for such an analysis has been developed, which is widely used in a number of countries for total screening of newborns for congenital hypothyroidism. Obviously, this method is quite suitable as a screening test for hypothyroid crisis.

Although the recognition of hypothyroid coma is not very difficult, the very diagnosis of such a diagnosis imposes a great responsibility on the doctor. High doses of thyroid hormones prescribed for the relief of hypothyroid coma, in the event of a diagnostic error, can be fatal for patients with normal thyroid function and who are in a coma caused by another cause.

Treatment of hypothyroid coma begins with a jet intravenous injection of 50-100 mg of hydrocortisone, then another 150-200 mg of this drug is prescribed during the day. This start of treatment is due to the desire to stabilize hemodynamics as soon as possible and to ensure the prevention of possible adrenal insufficiency due to the appointment of large doses of thyroid hormones. Following the introduction of glucocorticoids, thyroid hormones are prescribed. Preference is given to thyroxin as the safest drug in patients with cardiovascular disorders. On the first day, 400-500 mcg of the drug is administered intravenously during a uniform slow infusion. In the following days, the dose is reduced to 50-150 mcg / day. Developing respiratory and blood gas disorders are absolute indications for mechanical ventilation. Infusion therapy provides for the correction of hyponatremia and hypochloremia by transfusion of crystalloid drugs, the elimination of anemia by transfusion of erythrocyte mass and the normalization of glycemia by introducing a glucose solution. Given the pronounced disorders of the circulatory system, infusion therapy should be carried out with great care, and its volume should be controlled by measuring hourly diuresis and CVP. Forced warming of patients with the help of any heat sources is unacceptable, since this can lead to vascular collapse. It is advisable to place the patient in a ward with an air temperature of 25 ° C. Antibiotics are prescribed to prevent possible infectious complications. Metabolic drugs are shown: 4-6 g of nootropil or 20-30 ml of cerebrolysin per day are administered intravenously, Cyto-Mac - 15-30 mg 1-2 times a day, vitamins A, group B, C.

An indicator of the effectiveness of the therapy is primarily an increase in body temperature. As it increases, the dose of thyroxine is gradually reduced (strictly individually in accordance with the state of the circulatory system).

A frequent complication noted in the early postoperative period in patients with thyroid diseases is parathyroid insufficiency.

Speaking about nonspecific complications that occur after surgical interventions on the thyroid gland, one cannot fail to note the possibility of developing pneumonia and suppuration of the surgical wound. In order to prevent them in the early postoperative period, patients are prescribed antibiotics.

Thus, the postoperative period in patients undergoing surgery on the thyroid gland is fraught with the risk of developing various complications that can be the direct cause of death. Their timely recognition, effective prevention, and adequate etio- and pathogenetic treatment are the key to the success of surgical treatment of thyroid diseases.

2.2. Patient nutrition

Serious iodine deficiency in adults leads to a disease called myxedema, apathy - a neuropsychiatric disorder, inactivity, drowsiness, decreased performance (weakness, fatigue), an increase in dementia of the type of endocrine psychosyndrome.

Against this background, the emergence of acute psychotic states, mainly manic and depressive ones, is possible.

To avoid complications associated with an insufficient amount of iodine, you need to provide the necessary amount in the body.

You can stock up on enough iodine:

Eating seaweed,

Grape,

Along with iodine, the body needs proteins (primarily of animal origin), since they contain the amino acid tyrosine, which is indispensable for the formation of thyroid hormones.

If the diagnosis is made in a timely manner, do not be afraid. The doctor prescribes the hormone thyroxine, a drug similar to the hormone produced by the thyroid gland.

It gives a fast and lasting healing effect. It must be remembered that when too high doses of thyroid hormones are used to treat hypothyroidism, the symptoms of hypothyroidism can be replaced by symptoms of hyperthyroidism - in other words, an overdose of the hormone.

In this regard, do not forget to determine the blood levels of thyroxine and triiodothyronine (thyroid hormones T 4 and T 3), as well as the concentration of thyroid-stimulating hormone (TSH) and the titer of autoimmune bodies (AIT), i.e. antibodies to thyroid tissues. Based on this analysis, it can be concluded that a lot or a little hormones are produced by the thyroid gland.

The insidiousness of thyroid diseases is that, on the one hand, they can be asymptomatic for a long time, and when they reveal themselves, it is already difficult to treat them. On the other hand, the characteristic symptoms are similar to those of other diseases. For example, a patient's complaints of increased fatigue are often interpreted by therapists as a heart or other ailment.

Increased activity of the thyroid gland and increased production of thyroxine. The thyroid gland increases, tachycardia occurs, and metabolism increases.

In this disease, carbohydrate metabolism is disturbed, which can lead to type 2 diabetes. The most common cause of hyperthyroidism can be a hereditary predisposition or a pituitary tumor consisting of cells that produce TSH. Hyperthyroidism is rarely due to excess iodine, as excess iodine is excreted by the kidneys if they are working properly.

An increased formation of thyroxine is observed with diffuse toxic goiter.

Treatment for nodular and diffuse goiter of the thyroid gland should be aimed at reducing the functional load on this organ. This will allow the hardware, working in normal mode, not to include its additional capabilities by increasing the functioning elements and to exclude critical situations that manifest themselves locally.

There are two possible ways to achieve this goal:

The introduction of thyroid hormones (thyroid gland) into the body, to fill the increased needs for them,

Elimination of the causes, conditions and factors leading to a high functional load on the thyroid gland (thyroid gland).

The first option is the most common. Endocrinologists usually prescribe hormone replacement therapy. Sometimes the appointment of such drugs is justified by feedback from the pituitary gland, the hormone of which (TSH) stimulates the activity of the thyroid gland while reducing its function. Some experts believe that this is why the thyroid tissue is transformed (an increase and nodulation appears), and mistakenly focus attention in the treatment on suppressing the formation of TSH.

With the use of hormonal drugs, the load on the thyroid gland decreases, and changes (thyroid nodules and a diffuse increase in the volume of the thyroid gland) undergo some reverse development. This is a remarkable indication of the reversibility of pathological (or rather, adaptive) processes in the thyroid gland! But such reversibility is not complete. Firstly, because everything that caused the thyroid gland to get into such a state continues to remain in force and require more hormones. Patients are forced to increase the dose of the drug. Secondly, because as the need for hormones increases, and with an increase in their introduction from the outside (with drugs), there is a gradual decrease in the activity of the thyroid gland, with the possibility of complete atrophy of the organ. Thirdly, due to the fact that after the cessation of the use of hormonal drugs, the reverse development of the nodes occurs.

The use of hormonal drugs may be justified either as a temporary measure (for assessing the state of the thyroid gland, maintaining it in conditions where other treatment is impossible, for diagnostic purposes), or in connection with the surgically removed thyroid gland (due to, for example, malignancy of the node). In the latter case, the use of hormonal drugs becomes mandatory for the rest of your life.

It is important to remember, however, that taking thyroid medications accelerates bone loss (i.e., contributes to osteoporosis) and can lead to changes in heart cells, increasing the risk of atrial fibrillation (a condition bordering on cardiac arrest) in old age. .

Removal of nodes (not rarely, the entire lobe of the thyroid gland) does not exclude the functional load on the thyroid gland, that is, it does not exclude the reason why the thyroid gland has come to such a state. Therefore, the formation of nodes continues. And if one lobe is removed, then thyroid nodules develop in another lobe. And then the surgeons can suggest the next operation. We should not forget about the small but very important parathyroid glands, which are usually located next to the thyroid gland. It is not at all rare that they are removed along with the lobes of the thyroid gland. This can lead to some more trouble.

But, in some cases (for example, the malignancy of the process), the surgical method is forcedly indicated. In this case, the lesser of the “two evils” is chosen (chronic medication).

The second way of treatment should be classified as restorative, since the elimination of the causes, conditions and factors that provoke the functional tension of the thyroid gland (manifested in nodulation and an increase in volume), and leads to a stable restorative transformation of the thyroid tissue. The developed and practically tested method for the treatment of nodular and diffuse goiter of the thyroid gland includes the correction of the energy (calorigenic) state, the restoration of a harmonious balance in the relationship between internal organs, the elimination and / or reduction of the influence of harmful factors, and the functional "maintenance" of the thyroid gland itself. These activities are carried out through reflex action, lifestyle assessment and recommendations for an easy (but necessary) correction of nutrition, a number of habits, and other things that affect the pathology.

2.3.Healthy lifestyle

A huge role in hardening belongs to the natural factors of nature. Among the hardening procedures, a special place should be occupied by air baths, sunbathing and water procedures.

Air baths. For the human body, exposure (in a reasonable combination) to short-wave ultraviolet radiation, visible "white" light and long-wave infrared radiation of the sun is very beneficial. When there is no sun in the winter months beyond the Arctic Circle, the Eskimos have a metabolic disorder. Members of Arctic winter expeditions suffer from edema, high blood pressure, insomnia, fatigue, irritability, and even hair loss. The prolonged absence of sun during the winter months causes a gloomy mood, melancholy and often leads to depression. But as soon as you “recharge” with daylight again, the pain disappears. In spring and summer, these phenomena are not observed.

Dreamin a cool room or outdoors. Sleep in itself is an excellent means of restoring health. And in a cool room or in the air, it acquires additional functions of hardening the body. For greater sleep efficiency in the bedroom, as well as in other areas of the apartment and in training rooms, it is very useful to use ionizers.

Recall that the ionizer purifies the air in a natural way - emitting myriads of negatively charged ions, which attract microscopic particles of dust, smoke, pollen constantly swarming in the air. When using ionizers, the air in the room becomes clean, with a fresh smell, like after a thunderstorm.

Sunbathing. According to P. Bragg's figurative comparison, sunlight is the first doctor: his specialty is heliotherapy, and his prescription is solar energy. Everything on earth, including the animal world, would be lifeless without this energy.

The sun is not only light. Its rays are transformed into human health. Without sunlight, people become pale, weak, anemic. The bactericidal properties of the sun are great. The sun helps to overcome fear, anxiety and stress, gives calm, relaxation, relieves tension, tones, stimulates and heals.

Recall that not so long ago, aristocratic pallor was in fashion, and a tanned face indicated belonging to commoners working in the air. Now bronze, chocolate tan is the most fashionable. A tanned body is a symbol of beauty.

Scientists have proven how important the combination of short-wave ultraviolet radiation with visible "white" light and long-wave infrared radiation is for the human body. But each person has his own “limit” of solar exposure. Dermatologists believe that the darker the skin, the more a person can be exposed to direct sunlight.

atmospheric phenomena. Among the many atmospheric phenomena, we will consider solar radiation, geomagnetic storms and ozone "holes", as they are of the greatest importance for hardening.

Sun rays. They consist of visible, infrared and ultraviolet spectra.

The color of a tan (brown, red, golden or bronze) is determined genetically. The highest quality is a brown tan, which serves as an excellent barrier to the penetration of sunlight into the inner layers of the skin.

The most dangerous for all people are ultraviolet rays. They are divided into two groups: "rays A" and "rays B". "Rays A" cause premature skin aging, sun allergies and enhance the harmful effects of "rays B". "B rays" are the root cause of skin burns, which can later lead to skin cancer or the most dangerous malignant formation - melanoma.

geomagnetic storms. Scientists have noticed that almost all powerful geomagnetic storms coincide with the peak of solar activity (or close to it in time). Solar flares, as one of the manifestations of solar activity, cause a lot of physical phenomena, the consequences of which, including for human health, have not yet been fully studied.

What are the reasons for the meteosensitivity of healthy people is not yet entirely clear. Doctors' assumptions boil down to the following reasons:

Reduced immunity;

hereditary predisposition;

Psycho-emotional discomfort (for example, stress);

Type of nervous system;

Age (acceleration has made significant adjustments).

Russian scientists have developed a new direction in climatology - kerosology (the science of weather) and have identified four medical types of weather: I - the most favorable; II - less favorable; III - bad; IV is the worst. The third and fourth types of weather can be accompanied by cyclones, sharp fluctuations in temperature, pressure, atmospheric electromagnetization, etc. Scientists believe that the weather forecast should indicate its medical type and thus orient the population, especially sick people, not only to appropriate clothing, but and visits to a healthcare provider to temporarily change medications or take other protective actions.

Hardening with cold water. In the 19th century water methods of treatment of doctors A. Salmanov and S. Kneipp were especially popular. If the first preferred hot water, then the second - cold. Dr. S. Kneipp in the book "My hydrotherapy" in the chapter "How to temper yourself" systematized his many years of experience in the treatment of diseases and health promotion. There are many methods of using cold water for healing and hardening procedures, in particular:

Water ionization (inhalation of air for 5-6 minutes half a meter from the strongest jet from the tap; when it breaks against the sink, a cloud of tiny water splashes forms and a microzone of increased ionization appears). The procedure refreshes the blood, facilitates breathing, relieves headaches and vasospasms;

Dousing the head with cold water once a week (douse the head five times from the right ear at the neck to the left ear and then in a circle to the right ear, then dry the hair with a towel and do a light head massage). The procedure contributes to the preservation of thick hair, has a good effect on the eyes and ears;

Applying a towel moistened with cold water and wrung out on the back of the head (this relieves cardiac arrhythmia), then every 2 minutes - successively to the stomach and to the calf muscles.

Among the procedures recommended by S. Kneipp are known: walking barefoot on wet grass, wet stones, freshly fallen snow, in cold water, cold washing of hands, feet, general dousing, foot baths (cold and warm), half-baths (not higher than the middle of the abdomen, approximately to the area of ​​the stomach).

barefoot walking. What is the secret of this tempering procedure? The answer can be found by analyzing the structure and functions of the plantar and dorsal parts of the human moan.

The human foot is entwined with seven powerful ligaments and tendons, surprisingly similar to antique sandals. Historically, the foot has been the link between man and the earth, and civilization has turned it into ordinary props.

So, relatively recently, scientists discovered more than 72 thousand nerve endings, or biologically active points, on the soles of the feet, among which there are especially many heat and cold receptors. They are reflexively connected with all internal organs, the brain, lungs and upper respiratory tract, endocrine glands, etc. In this regard, walking barefoot can be compared with acupressure, i.e. stimulation of intensive activity of almost all muscles, blood supply to the brain and other organs. In addition, the antistatic effect is of great importance, i.e. release of the body from the accumulated electrical charge due to the wearing of synthetic clothing and shoes.

Earth, sand, grass are recognized as the best surfaces for walking barefoot. A particularly great hardening effect is achieved when walking barefoot along the banks of a river, sea, ocean, i.e. when walking is accompanied by washing feet and shins with cold water.

Walking on dewy grass. Dew has always been considered "living water".

A special healing effect is given by daily morning jogging barefoot on dewy grass. For example, with sick feet (abrasions, abrasions, fungus, etc.), a daily run of at least 20 minutes is very useful, after which wet feet should dry themselves. At night they should be treated with fresh potato juice.

It can be concluded that walking barefoot and running on dewy grass develop the body's immunity to severe cooling and colds, and give additional vitality.

Pouring. This is a hard option for hardening the body.

Pouring cold water relieves severe headaches, changes a person's attitude to diseases, eliminates fear of them. The results convince him that the body itself is able to cope with diseases, it is only necessary to awaken protective functions in it.

Hardening with water of contrast temperature. The Scottish technique of hydrotherapy, or a contrast shower, also has a hardening effect - alternate dousing with hot and cold water. Scientific research in this area shows that after a 20-30 second cold shower, you need to spend at least 3 minutes under a very hot shower in order for the body to return to physiological norm. This procedure follows the following scheme: first rinse the body with a hot jet (about 35 ° C), then direct the cold jet to the stomach, buttocks and thighs in a circular motion. This speeds up the metabolic processes in the body.

We can recommend another similar method of hardening with water of a contrasting temperature - alternately lowering the feet into a basin with hot (45 ° C) and cold (15 - 20 ° C) water. The procedure should be completed with a 30-second warming up of the legs and rubbing and massage.

Cold and warm baths. S. Kneipp in the book "My hydrotherapy", in the chapter "How to harden yourself" recommends using a variety of water baths.

Foot baths. They are divided into cold and warm. A cold foot bath closes the calf muscles, reaching the subcutaneous folds. Healing and hardening effects are achieved if you stand in the water for 1-4 minutes. This activates the flow of blood to the legs from the upper parts of the body, especially from the head and chest area. Most often, this procedure is used when a person does not tolerate full or half baths. For people in good health, cold foot baths are a means of hardening the body, they eliminate fatigue, promote an even mood and restful sleep.

Half baths. They belong to the hardening procedure. Cold water fills the bath just above the middle of the abdomen, covering the stomach area. You can take the procedure in three positions: standing, kneeling and sitting. The last position is typical for half-baths recommended by S. Kneipp.

Cold half-baths can help with weakness and diseases in the abdomen, with hemorrhoids, colic from gas formation, and also with hypochondria.

Full baths. They can be cold and warm, for healing and hardening. The treatment takes place in two positions: standing or lying down. In the second case, water covers the body up to the region of the heart, and the upper part of the body is washed with hands or a coarse thick towel. Full baths with cold water significantly help in hardening the body. They cleanse, refresh the skin, increase its functionality, strengthen the body. The frequency of taking such baths in winter should not exceed one or two times a week, and the duration of stay in the bath should be 1 minute. Before taking a bath, the body should be warm, preferably hot, even sweaty. S. Kneipp believed that the more a person sweated, the higher the effect of hardening with cold water. Those who sweat do not need to go to bed immediately; it is better to sit in the bath and quickly wash the upper body, and only then plunge for a few seconds to the neck. After that, you should immediately go out and dress quickly, without drying yourself. Over the next 15 minutes, it is necessary to perform exercises (preferably in the air) in order to dry and warm up.

To harden cold baths, you must first prepare, gradually accustoming the body to the cold. In addition, before taking a bath, it is recommended to perform long and intense exercises. But one should not be afraid of hardening procedures. A pleasant feeling will follow the first unpleasant sensation, and that which gave rise to fear will gradually become a need.

With mental and physical overload, the warmest baths are taken with a solution of sea or table salt. Immersion in water should be as deep as possible,

Swimming in the reservoirs. Regular bathing in cold water, according to British scientists, helps fight viral infections, stimulates blood circulation and even increases sexual activity.

You should swim in familiar and specially equipped places where the location of cold springs, places of strong current, whirlpools, underwater snags, etc. is known.

Winter swimming. Winter swimming has become quite popular in recent years. However, it received a disturbing experimental assessment: this process is a very dangerous occupation, leading to a rapid waste of vitality and a reduction in life expectancy. Cold causes the outflow of blood from the skin to the internal organs, while blood is equally necessary for the whole body. Indeed, in order for the body to be strong and hardy, its normal circulation is necessary. Years of winter swimming and swimming in icy water can lead to stoop, stiffness in the joints and other defects. Cold enhances the work of the endocrine glands and primarily the adrenal cortex, which maintain a constant body temperature and resistance to sudden cold. At first winter swimming, the activity of the adrenal cortex is stimulated, but with regular exercise it weakens. Summarizing the experience of "walruses", it is possible with some caution to recommend hardening procedures in the hole. Although the "walruses" believe that cold treatment will give results twice as fast as the traditional one (in a warm bed), since in the ice hole the body's immune system instantly and intensively turns on and quickly overcomes a cold.

Bathingin the sea. Sea water contains compounds of potassium, calcium, magnesium. Coastal air is saturated with iodine and bromine. The saltier the sea, the more useful the coast in the air. Air ions are not only useful for the lungs. They strengthen the immune system, i.e. heal the body.

The sea has a great effect on the nervous system of a person who is tired of stress, restores the emotional state, has a strong psychotherapeutic effect, and positively affects mental balance.

Walking along the seashore hardens the body, swimming helps patients with osteochondrosis of the spine, with diseases of the joints. The main thing is not to bring the skin to the state of "goose". After swimming in the sea, it is better not to take a shower, since the "salt coat" is very good for the skin; it promotes an even tan. It is enough to rinse your hair with fresh water, dry yourself with a towel and apply moisturizing creams or lotion to the body once a day.

Exercisesin water. In recent decades, such areas as water aerobics, aquodance, aquomotion and other health-improving types of swimming have appeared. They solve many problems of physical improvement, as well as hardening of the body. The aquatic environment almost completely eliminates the problem of injury risk: a person’s body weight in water is one tenth of the real one, this significantly reduces the load on muscles and joints and allows you to train and strengthen those muscles and ligaments, which under normal conditions are involved with great difficulty.

Chapter 3. The influence of various environmental factors on the condition of patients after surgery

3.1. Influence of anthropogenic factors (air pollution, water pollution, influence of heavy metals, radiation)

Heavy metals still remain one of the priority groups of pollutants that have both local and regional and global distribution. Their entry into the aquatic environment is associated with natural and anthropogenic sources.

The importance of trace elements in the implementation of human vital functions has already been proven for many elements (manganese, zinc, molybdenum, fluorine, iodine and selenium), for others (chromium, nickel, vanadium, tin, arsenic, silicon) it is probable. The main criterion by which macroelements are distinguished from microelements is the body's need for an element, determined in mg / kg of mass per day. All of these trace elements in the body function either in the form of hydrated ions, or, like iron, in the form of coordination compounds.

Among the pollutants of the biosphere, which are of the greatest interest for various quality control services, metals (primarily heavy, that is, having an atomic weight of more than 40) are among the most important. This is largely due to the biological activity of many of them. The physiological effect of metals on the human and animal organism is different and depends on the nature of the metal, the type of compound in which it exists in the natural environment, and also its concentration. Many heavy metals exhibit pronounced complexing properties. Thus, in aqueous media, the ions of these metals are hydrated and are able to form various hydroxo complexes, the composition of which depends on the acidity of the solution. If any anions or molecules of organic compounds are present in the solution, then the ions of these metals form various complexes of various structures and stability.

In the series of heavy metals, some are extremely necessary for the life support of humans and other living organisms and belong to the so-called biogenic elements. Others cause the opposite effect and, getting into a living organism, lead to its poisoning or death. These metals belong to the class of xenobiotics, that is, alien to living things. Specialists in environmental protection have identified a priority group among toxic metals. It includes cadmium, copper, arsenic, nickel, mercury, lead, zinc and chromium as the most hazardous to human and animal health. Of these, mercury, lead and cadmium are the most toxic.

Possible sources of biosphere pollution with heavy metals include ferrous and non-ferrous metallurgy enterprises (aerosol emissions that pollute the atmosphere, industrial effluents that pollute surface waters), mechanical engineering (copper plating, nickel plating, chromium plating, cadmium plating), battery processing plants, and road transport.

It is known that the effect of ionizing radiation on people is the destruction of living cells of the body, which can lead to varying degrees of disease, and in some cases, death. To assess the effect of ionizing radiation on a person, two main characteristics must be taken into account: ionizing and penetrating abilities.

It has long been known that the degree of radiation (radiation) damage depends on the dose received and the time during which the person was exposed to radiation. It must be understood that not every dose of radiation is dangerous for humans. Everyone gets x-rays, x-rays of a tooth, a stomach, a broken arm, we watch TV, fly an airplane, conduct a radioisotope study - in all these cases we are exposed to additional radiation. But these doses are small, and therefore not dangerous. Large doses received in a short period of time or over a long period of time can cause severe radiation injury. In this regard, it is important to assess the radiation situation at the enterprise.

The mechanism by which radiation causes changes in living tissues is unknown, but the first stage of these changes seems to be ionization, the removal of orbital electrons from the atom.

The ionized state of the atom lasts only an insignificant fraction of a second, then the electron is captured again, recombination occurs, and the atom returns to its normal state. However, within a short period of ionization, chemical splits or compounds can occur that set in motion a chain of events that cause severe biological damage.

The energy of particles or beams determines the number of ionization they can cause. The distribution of ions in the tissue depends on the nature of the radiation.

When J 131 is found in the human thyroid gland, all b-radiation is absorbed in this organ, with the exception of b-particles released by atoms less than 2 mm away from the surface of the gland. On the other hand, no more than 10% of the g-ray energy is absorbed in the thyroid gland. The radiation absorbed by the gland cannot be measured by instruments located outside the body. Therefore, the study of in vivo thyroid function with radioactive iodine is always based on the measurement of g-rays.

The dose of b- or g-rays received by the tissue is expressed as the energy absorbed per 1 g of tissue. Roentgen (r) - the unit of dose of x-rays or g-rays, determined by the number of ion pairs formed per 1 g of air, represents an energy absorption of 93 ergs per 1 g of tissue. The unit of dose of b-rays, the physical equivalent of the roentgen (fair), is usually defined as the absorption of 93 ergs per 1 g of tissue.

It is impossible to measure the dose of radiation released inside the tissue; however, some data on this can be obtained. The corresponding formula for calculations can be found in the literature. Two factors alter the radiation dose calculations made using the standard formula: 1) the distribution of the isotope in the thyroid gland is not strictly uniform, and 2) not all of the isotope remains in the gland to decay there with a physical half-life of 8 days.

In a normal gland and in toxic diffuse goiter, the distribution of the isotope does not appear to be macroscopically as “spotty” as in nodular goiter (Fig. 3.1.1.), but the distribution is still uneven throughout the gland and in each follicle. Part of the radioactive iodine is included in the hormone and secreted at a rate that depends on the secretory activity of the gland. In the standard formulas, the physical half-life must therefore be replaced by the effective half-life, which is the time required for the amount of J 131 actually remaining in the iron to be halved. This effective half-life depends on both the physical breakdown and the excretion of the resulting hormone. In euthyroid individuals, the effective half-life ranges from 7 to 8 days; in hyperthyroid patients - from 3 to 8 days; in 80% of hyperthyroid patients it is 5-7 days. The effective half-life cannot be calculated by formula and must be determined for each patient individually by repeated measurements of radioactivity over the thyroid gland at regular intervals after the administration of radioactive iodine.

This biological half-life is equal to the number of days required for half of the injected isotope to disappear from the gland by biological processes rather than by physical decay. Therefore, a correction for physical decay must be introduced into the calculations. If the effective half-life were exactly the same as the physical half-life (8 days), there would be no secretion and the biological half-life would be infinite.

The biological half-life, calculated from the effective half-life values ​​given above, varies from 56 days to infinity in euthyroid individuals, and is 5 days or more in hyperthyroid patients, averaging 24 days.

To determine the dose of radiation received by the tissue, the weight of the gland, the amount of absorbed J 131 and the effective half-life must be determined.

Small black dots are depositsJ 131 . Note the cluster of dots in Fig. b. a - normal thyroid gland of a 6-year-old child, SW. 200; b - non-toxic nodular goiter, SW. 125.

The last two quantities can be measured; it is much more difficult to determine the weight of the gland, but in any particular series of cases, provided that all determinations of size are made by the same person, the error will be constant and the results will be comparable.

The result is not a fair per gram, and a fair is not a unit related to weight. If a gland receives an average dose of 100 FE, this means that a gram of gland absorbs 9300 ergs of energy. Iron weighing 20 g, which receives a dose of 160 fair from 20 \ac located inside it and not excreted iodine, absorbs 160 X 93 X 20 or 297,600 ergs. A gland weighing 50 g, which receives the same dose from 50 mc J 131 located in it, absorbs a total of 160 X 93 X 50, or 837,000 ergs.

There are several clinical questions related to the dosage problem.

In the clinical use of J 131 and the calculation of the dose of radiation produced by radioactive iodine, it is important to determine: 1) the dose received by the functioning thyroid tissue or tissue of metastatic thyroid cancer, and 2) the dose received by other tissues or organs and the body as a whole.

The dose received by the thyroid gland can be directly calculated from the above formulas. Irradiation occurs at a constantly decreasing intensity, for about 3 weeks (this time is 3-4 effective half-lives). The maximum dose of radiation received from radioactive iodine in the gland can be greater than the dose of radiation received from x-ray therapy, since x-rays must pass through the skin and subcutaneous tissues, which must be protected from irreversible damage.

The total exposure of the body occurs during the time when the isotope circulates in the blood, so that for a given amount of J 131 the dose of radiation will depend on the volume of the body and on the rate of purification of the blood from the isotope. The formulas for calculating the dose received by the thyroid gland are not applicable for calculating the exposure received by the body as a whole. However, physicists have come to the conclusion that the dose of radiation received by the body as a whole is 0.5-1.0 g for each millicurie introduced. Such exposure is only dangerous when large therapeutic doses are used to treat cancer or to suppress thyroid function in heart disease. In the case of heart disease, the dose of radiation is probably given only once, and the possible damaging effect can be ignored. With the repeated administration of large doses for metastatic thyroid cancer, the total exposure of the body can seriously affect the hematopoietic organs.

Irradiation of tissues and organs other than the thyroid gland occurs essentially due to the high absorption of J 131 or high clearance of radioactive iodine from the blood during the first day after administration. The possibility of selective accumulation of J 131 in other organs, even at lower concentration levels than that which exists in the tissue of the thyroid gland, has not been confirmed in patients.

High local concentrations are found in the gastrointestinal tract during the first hours after absorption, as well as in the kidneys during excretion, and probably in the salivary glands, which are also the organ of iodine excretion. Measurements of the radioactivity of urine, blood, gastric contents and saliva have found that the radiation that the corresponding organs receive per unit weight is not more than the total dose of radiation received per unit weight by the body as a whole. However, “large local areas, such as the gastric mucosa, renal tubules, salivary glands, can receive several times more radiation per unit weight than the body as a whole. Since the kidneys and gastric mucosa are quite radioresistant, one should not expect serious damage to them. Irradiation of the salivary glands can cause dry mouth, usually temporary; with repeated administrations of large doses, this dryness may become permanent.

Selective accumulation of J 131 in other organs at a higher concentration than the concentration in the blood was not detected either by external measurement or by autopsy. The concentration of J 131, higher than its concentration in the blood, was found only in various parts of the gastrointestinal tract, which removes iodine and excretes thyroid hormone. The concentration in the gonads is not high enough to cause genetic damage; data obtained from 4 autopsies of the ovaries, 4 autopsies of the testicles and 5 autopsies of non-specialized gonads showed that the concentration of J 131 in the gonads in no case was as high as the concentration in the blood. The doses of radiation received by both the thyroid gland and the body as a whole vary greatly, and approximate limits for single doses of J 131 are shown in Table. 3.1.1.

Table 3.1.1.

Received irradiation with the introduction of single doses of J 131

Reintroduction of radioactive iodine. The above data refer to a single dose of J 131 . But often, for the purposes of diagnosis and therapy, repeated administration of radioactive iodine is desirable. This issue requires special discussion. Tissues are known to recover to a certain extent after exposure to radiation, so the net effect of two doses administered at a certain interval of time is probably not the same as that produced by a double dose administered at the same time. However, most experiments on the quantitative study of tissue repair after irradiation were carried out with radium rays or x-rays, when all cells of a given group received essentially the same dose; little is known about the recovery of the thyroid after a dose of radioactive iodine. It is possible that in the thyroid gland, different follicles function at different times; this can alter the response of thyroid tissue to radiation.

Radiation at any level can never be considered harmless, so it should never be used unless some improvement is expected in the patient's condition. This applies to both diagnostic and therapeutic applications of x-rays and radioisotopes; at the same time it is necessary to enter probably smaller doses. Most diagnostic tests can be performed with 15 ms J 131 or less, provided that sufficiently sensitive measuring instruments are used. With the introduction of such doses, one cannot object to three to four or more samples per year. Samples that require the introduction of more than 50 mc J 131 should be repeated only if there is an urgent need. For diagnostic purposes, apparently, you can enter no more. 100 m c in year; however, a final decision regarding the maximum allowable dosage can only be made after additional experimental and clinical data are obtained.

When treating toxic goiter, the total dosage should be minimal. The full effect of a single dose may not appear for up to 3 months. Subsequent doses need not be as large as the first, especially when there is a certain decrease in the size of the gland.

The possibility of repeating the dose in the treatment of cancer should be considered individually for each patient. The decision regarding the dose depends on the degree of absorption of J 131 by metastases and the degree of damage caused by J 131 in the hematopoietic organs. Large doses are probably contraindicated in cases where the number of leukocytes is below 3000 or the number of platelets is below 100,000. However, in order for J 131 to have an effect, its concentration in cancer tissue must be at least 30 times higher than the concentration in the blood. This should be taken into account when choosing a dosage. Tumor volume and iodine uptake by the tumor are also important in determining dosage. For example, a spinal metastatic tumor estimated at 100 cc in volume and absorbing 5 ms from a 100 ms dose had a J 131 concentration of 50 ms per gram of tissue. Blood 24 hours after the administration of such a dose rarely detects a concentration of 1 m With per 1 cm 3. Thus, in this case, it was possible to treat the tumor with radioactive iodine. In another patient with chest metastases in the form of a "snowball", the total volume of the tumor was, apparently, more than 500 cm 3 . 48 hours after the administration of 100 me J 131, 85% of this dose was excreted, the remaining 15 mc, apparently, was distributed equally between the body fluids and the tumor. In this case, cancer treatment with J 131 was not possible. If the external score shows that the activity over the thoracic cell is 15-20 times greater than the activity over the control area, for example over the thigh, then cancer treatment with J 131 is possible. If this ratio is only

Methods for removing radioactive excreta. Since most of the administered dose of radioactive iodine is rapidly excreted, where urine samples are collected, appropriate arrangements should be made for disposal of the urine. If urine is not collected and allowed to enter the sewer directly, there is a health hazard to sewer workers or a risk of entry into the water supply.

The National Committee for Radiation Protection approved the following recommendations regarding the removal of radioactive waste: 1) when a single dose not exceeding 25 mc is administered to patients, there are no restrictions on the removal of urine, 2) when a dose exceeding 25 mc is administered, the patient should be hospitalized until until the content of J 131 in the body is reduced to 25 mc. The amount of urine that can be allowed to drain into hospital sewer lines depends on the average daily flow of water through these lines; the decision on this issue is made by the radiation safety inspector of the institution.

There are no restrictions on the removal of the urine of a patient who has received repeated small doses of J 131, provided that the content of J 131 in the body never reaches 25 mc and that the patient is the only one in this institution receiving such doses of a radioactive substance. If there are several such patients, general hospital sewage should be tested.

Carcinogenic agents are numerous and varied in nature; carcinogenic agents, for example, are x-rays, hormones, viruses, and chemicals. One guideline indicates that approximately 25% of the chemicals that have been tested for carcinogenic properties have these properties.

Most of the experiments on the study of chemical carcinogenic agents were carried out on mice. The results of the action of a given chemical substance in any animal species vary considerably depending on the conditions of administration of this substance and the duration of its action. Differences in efficacy are even more pronounced when comparisons are made across species; in fact, attempts to chemically produce cancer in monkeys have been completely unsuccessful.

By analogy with other life processes, a complex mechanism must be involved in the occurrence of cancer. In all cases, a large number of different factors must act simultaneously or sequentially in order to cause cancer. Thus, exposure to a specific carcinogen in an animal or human is unlikely to cause cancer in the absence of other conditions necessary for this.

A carcinogen can be seen as an external factor contributing to cancer, although some substances normally found in the body act in a similar way, such as bile acids, triple hormones, and estrogens. All of them, under appropriate experimental conditions, cause the formation of malignant tumors, in addition, in an intact organism there is an internal factor on which the occurrence of cancer depends; such a factor, apparently, lies in the genetic structure of the cell nucleus. This factor may act by influencing future cell generation. This factor provides the appearance of a genetic substance with an inherent ability of stability and instability, so that it determines to some extent the effectiveness of any specific carcinogen in the formation of cancer. Its existence has been shown in experiments with inbreeding mice, in which mice susceptible or resistant to tumors were obtained at will.

There is also a third factor that has to do with the development and non-development of cancer. This last factor, which for convenience can be called anti-carcinogenic, changes the effect of the carcinogen and regulates its formation. For practical purposes, thyroxine can be considered as such an anticarcinogen. In mice, marked suppression of thyroxine production by goitrogenic substances or irradiation of the thyroid causes pituitary hypertrophy and apparently an excess production of thyroid-stimulating hormone. Prolonged action of excess thyrotropin in turn causes hypertrophy of the thyroid gland, benign adenoma and thyroid cancer. Introduced with food, thyroidin prevents the occurrence of these consequences of the introduction of goitrogenic substances.

Numerous clinical data that x-rays and radium are carcinogenic factors have been obtained in the study of diseases in radiologists, who in the past worked without precaution and protection from the effects of radiation. Such a study shows that, under certain conditions, X-rays cause skin epithelioma and bone sarcoma. In all these cases, it is difficult or impossible to estimate the true dose received by the tissues: the effect of radiation has continued for a long time; while the tissues received an unknown amount of radiation. It is possible that in these cases, relatively large amounts of radiation acted on tissues that were already the site of pathological disorders.

There is some evidence that leukemia is more common in Japanese who were exposed to the atomic bomb than in Japanese of the same age group who were less or not exposed to radiation. Similarly, leukemia is more common in radiologists than in the general population. In mice, lymphoblastomas have been artificially induced using X-rays. It has been suggested that, simultaneously with radiation, there may be a factor or factors that enhance the direct effect of radiation on cells that are sensitive to it.

The carcinogenic effect of radioactive isotopes is, in general, qualitatively the same as that of X-rays and radium. The effectiveness of the carcinogenic action varies quantitatively depending on the energy of the isotope, the half-life, its localization in the body, the rate of excretion, the uniformity of its distribution and the magnitude of the total dose administered. Radium is an alpha emitter, which, upon entering the body, is primarily fixed in the bones. There is no adequate method to enhance the mobilization and excretion of this element once it has been fixed in the body; consequently, radium is permanently localized in specific tissue, which is then continuously exposed to radiation. Persons whose body contains radium are exposed throughout their lives, since the half-life of radium is 1590 years. Despite this, not a single case of cancer has been registered in a person in whose body less than 0.9 mc of radium was fixed.

Carcinogenesis due to exposure to radiation in humans. In general, the conditions under which penetrating and ionizing radiation has caused cancer in humans are limited. These conditions are:

1) Chronic exposure of normal tissues and organs, such as
skin, bones, lungs, hematopoietic system and lymphoid formations
undefined amounts of radiation over a long period
time. Examples are illnesses in early radiographers, in workers who coated watch dials with radium, in miners in the cobalt mines of Schneeberg and the uranium mines of Joachimschthal.

2) Action on normal tissues such as skin and bones, large
amounts of radiation exceeding the endurance and regenerative capacity of these tissues. The resulting cancer appears to be similar in origin to the cancer that occurs in burn scars after a latency period of many years. Cancer, as a late consequence of the action of radiation, has become less common as more accurate methods for measuring radiation dosages have become available and the acceptable level for normal organs and tissues has been better defined.

3) Irradiation of precancerous diseases such as nodular goiter, sea skin or giant cell bone tumor.

4) Acute exposure of the whole body, for example, as it happened
the Japanese during the atomic bombing.

Humans have not been observed to develop cancer after irradiation, except under the circumstances just listed. Thyroid cancer has also not been seen as a consequence of irradiation for cancer of the larynx; no malignant tumor was observed in the soft tissues or bones of the pelvis as a result of intensive radiation for cervical carcinoma.

In a conventional radiological examination, carried out for diagnostic purposes, the body receives local or entire area exposure, or both, of the order of 0.05-9 g. In general, this exposure exceeds the exposure received by the body from the diagnostic use of radioactive isotopes. However, the amount of radiation received during treatment with radioactive iodine is greater than the amount received during diagnostic radiological procedures and is comparable to the amount of radiation received during X-ray or radiotherapy. The carcinogenicity of therapeutic doses of radioactive iodine, apparently, is equal in terms of the degree of carcinogenicity of radiation used in general therapeutic radiology, in particular in the therapeutic use of x-rays and radium; radioactive iodine is carcinogenic under the same conditions.

Animal experiments show that certain amounts of antithyroid substances or radioactive iodine can cause the subsequent formation of a benign adenoma or carcinoma of the thyroid gland, or both. Clinical evidence, however, suggests that the likelihood of developing thyroid cancer as a result of radioactive iodine treatment for toxic and non-toxic goiter or as a result of the use of radioactive iodine for diagnostic purposes is small, although not excluded.

If therapeutic doses of radioactive iodine are used indiscriminately in nodular goiter, a certain number of cases of subsequent thyroid cancer can be expected; here it should be taken into account that the number of cases of spontaneous occurrence of thyroid cancer is sharply increased in the presence of nodular goiter. This is less true for toxic nodular goiter; in the presence of toxic nodular goiter, cancer is observed less frequently than in non-toxic nodular goiter.

In the final analysis, the observations relating to the formation of cancer in general, and to the occurrence of cancers with the use of radioactive iodine in particular, indicate that one external carcinogen without other contributing influences does not cause clinical cancer.

3.2. Influence of natural environmental factors

The approach of summer always worries those who know that something is wrong with it. This concern is supported not only by relatives and friends, but also by general practitioners and even endocrinologists. But what about in reality? Is the sun's rays harmful to the thyroid gland?

We can say the following. In the case of the thyroid gland, all prohibitions to be in a place open to the sun are most often associated with a lack of knowledge and excessive precaution.

In medical practice, from time to time one hears from patients concerns about traveling to southern resorts and staying under the rays of the sun. Usually they talk about how doctors, warning against extremely unpleasant consequences, strongly prohibit thermal procedures, the south and sunbathing.

Most patients love and are drawn to warmth. For example, when visiting the bath, they make the water hotter, and relatively more often than other people they like to warm themselves by the fireplace, heater, etc. And this behavior is not accidental. The more pronounced the insufficiency of activity from the thyroid gland, and, accordingly, the more pronounced the manifestations, the more the person feels the desire to warm up.

This is due to the fact that thyroid hormones are involved in providing the body with energy that enters it with food. In other words, energy processes in the cells of all organs can proceed only with the participation of thyroid hormones. This energy is spent by the body not only to meet the needs of life and maintain a stable body temperature. It is necessary for active recovery processes in chronic diseases and to overcome the damaging effects of cold. That is why external heat significantly reduces the functional load on the thyroid gland.

In case of critical situations, the body's need for energy and, accordingly, for thyroid hormones increases. An overstrain of the cells of the organ develops. A group of such cells can change their state and be perceived by ultrasound of the thyroid gland as a nodular formation. As a rule, these are the so-called colloid nodes. Of all the nodular forms, they occur most frequently and are benign. These nodes do not degenerate into malignant ones. Sometimes an overstrain of all thyroid cells provokes a general increase in the organ. In this case, we speak of diffuse goiter. But all these changes indicate only one thing - the thyroid gland intensely provides the body with hormones involved in maintaining a constant heat balance in the body.

All this indicates the need for patients with hypothyroidism or prehypothyroidism to restore their health in the southern resorts! This is a direct indication to stay in the south!

If you are characterized by chilliness, the level of blood pressure is from 110/70 mm Hg. Art. and below, there are laboratory signs of hypothyroidism, and there are no nodes in the thyroid gland or they are colloidal, then you can travel south without any fear. Moreover, the warmth of the south will have a beneficial effect on the thyroid gland and the entire body.

But for patients with symptoms and with thyroid adenoma, rest in the so-called central Russia, or other places with a temperate climate, is better suited.

What medical factors of southern resorts are especially valuable? First of all, it's warm. Earth warmed by the sun, sand, buildings, benches, roads and paths leading to the coast, excessively warm air, with a breeze wafting from the water, an evening saturated with gentle warmth and a morning that has not had time to completely cool down from a hot day - all this is a useful atmosphere for patients with hypothyroidism.

Of course, summer in the south does not happen without sweltering heat. Even a healthy person does not easily endure the prolonged midday heat. Therefore, during this period of the day, it is better for both healthy and sick people to be in a ventilated room, under a canopy, in the shade of spreading trees or gazebos covered with greenery. You can sleep a little, read or do what you love. It is important to try to move walking, swimming, fishing and other being in an open place at the beginning of the day before 11.00 and in the afternoon, somewhere after 16.00. At the same time, it is important not to forget to saturate the body with water. It is recommended to drink chilled water without gas. Patients with hypothyroidism are very useful natural mineral water with a high content of bicarbonates and a small amount of chlorides. Watermelons can be used as sources of water. In addition, watermelons are useful for hypothyroidism due to their saturation with sugars.

To facilitate the tolerance of high temperatures, it is recommended to periodically take a cool, but not cold shower or bathe in natural reservoirs. It is important to remember that you should not overcool yourself during such water procedures.

Among summer thermal natural factors, psammotherapy is used in physiotherapy - treatment with heated sand. You can use this treatment on your own. But the patient must be sure of the purity of the sand, apply this influence in a dosed manner and with the participation of one of the companions or good friends. Of course, this kind of thermal procedures increases the tension of the neurovegetative and cardiovascular systems. Therefore, contraindications to this practice should also be taken into account - coronary heart disease, arterial hypertension, etc. To exclude negative consequences, the use of local sand baths is permissible. For example, wrapping pleasantly with hot sand only hands or feet. You can walk barefoot on hot sand if the sand does not burn, but has a warming sensation. Such heating of the feet is very useful, since it is the plantar surface that is both the place of active entry of temperature influences into the body, and the reflex zone, functionally associated with the neck area. No wonder they say: "If you cool your feet, your throat hurts."

Staying in the south is abundantly saturated with solar influence. It is also one of the important resort factors. But the scorching solar radiation forces them to wear panama hats and light clothing, and some to use protective cosmetics. At the same time, almost every vacationer strives to dress in an even southern tan by the end of the holiday period. Whether it is harmful to a thyroid gland?

You can answer briefly. Indications and contraindications for solar insolation are the same as for healthy individuals. Therefore, excessive presence "under the sun" should be limited.

For the convenience of individual dosing of tanning, modern electronic technologies offer so-called "tanning meters". These are convenient sensors for monitoring ultraviolet radiation. They are somewhat reminiscent of cute children's watches. In addition to a watch and a thermometer, they have a solar activity controller and an electronic adjustment system for an individual skin phototype. The device every ten minutes determines the dose of ultraviolet influence and timely informs the owner of the "tanning meter" with a sound signal about the need to limit the sunbath. Manufacturers make them light, beautiful in the south and waterproof.

Of course, everything in life can be done by instruments. But in life, uncontrollable situations often await us.

Therefore, we do not measure the water we drink in milliliters. We drink as much as is required to quench our thirst. And we eat as much as we want.

With tanning, we tend to focus on the sensations of reddened skin. Everything should be in moderation. Light up a little.

Natural sunlight is helpful. They have a healing power. But this improvement must be dosed. Don't rush to burn. But you should not be afraid of the southern sun either. There is no need to protect the thyroid gland with various scarves, tying them around the neck. This will not only create inconvenience, but also close important reflex zones from therapeutic influence.

Conclusion

Summarizing our work, we can draw the following conclusions.

Achievements in anesthesiology and resuscitation of recent days have made it possible to significantly expand the indications for surgical treatment of patients with endocrine pathology - childhood and senile age, pregnant women, patients with severe concomitant diseases and combined lesions of several endocrine glands. A significant number of those in need of planned and emergency surgical treatment today are patients with common surgical pathology (acute appendicitis, acute cholecystitis, gastric ulcer), combined with endocrine disorders.

Speaking about the quality of life of patients in the postoperative period, it should be noted that acute postoperative pain is still a serious problem in surgery, is difficult to treat and tends to become chronic. Modern achievements in the pharmacotherapy of pain can improve the effectiveness of pain relief, the quality of life of patients in the postoperative period, and also reduce the likelihood of chronic acute PBS. At present, postoperative analgesia has a multimodal character, non-opioid analgesics, which are characterized by high efficiency and safety, play a significant role.

The combination of pain medications, a healthy lifestyle and a healthy diet allow patients who have undergone thyroid surgery to return to a normal lifestyle and improve its quality.

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38. 12. Huereg W. C Am. J. Med., 1950, 8, 355.

39. 13. Kaplan H.S. J. nat. Cancer Inst., 1949, 10, 267.

40. 14. Lawrence J.S. Private message.

42. Nicoloff J.T. Thyroid storm and myxedema coma // Amer. J. Med. Clin. North. - 1985. -Vol. 65.- P. 1005.

43. 19. Siberstein H. Radium poisoning. A survey of the literature dealing with the toxicity and metabolism of absorbed radium, 1945. (U. S. Atomic energy commission, AECD, 2122).

44. 20. Speert H., Quimby E.H., Werner S.C. Surg. Gynec. Obstet., 1951, 93, 230.

At the turn of the 20th and 21st centuries, mechanization and automation of production led to physical inactivity of a significant part of humanity, which, in turn, was caused by an imbalance in energy consumption, a change in the course of a number of biochemical processes and an increase in body weight among the population of economically developed countries. In general, this problem is becoming one of the global ones, affecting all countries. Therefore, the problem of obesity in our time is becoming increasingly relevant and begins to pose a social threat to people's lives. This problem is relevant regardless of social and professional affiliation, area of ​​residence, age and gender. The significance of the problem of obesity is determined by the threat of disability in young patients and a decrease in overall life expectancy due to the frequent development of severe comorbidities.

Social and technogenic factors of society have contributed in recent decades to an increase in the prevalence of overweight. But it should be noted that this problem is not only and not so much medical as social - both in terms of the genesis and factors of its development, and due to the coverage of a significant part of the population and due to the specifics of the social status of overweight people. Most of these individuals suffer from more than just illness and limited mobility; they have low self-esteem, depression, emotional distress and other psychological problems due to prejudice, discrimination and exclusion in society. Assessment of the quality of life of patients allows us to solve such problems as determining the effectiveness of known methods of treatment; stratification of patients into groups and determination of differentiated tactics of treatment and diagnosis, search for new methods of treatment and rehabilitation aimed at improving the course of the disease.

The social aspect of the problem lies in the fact that there are certain objective limitations in the life of such people, there are multiple factors of social deprivation of these people. Gaps in social opportunities between overweight and non-overweight people are steadily growing, which worsens the social well-being of overweight people. The solution of this issue is possible only through not so much highly specialized as a wide range of medical and social measures.

Purpose of the work: to study the quality of life of patients with overweight and obesity in the socio-economic conditions of a large industrial region in comparison with the control group.

Materials and methods. 674 people were interviewed, the respondents were divided into two groups - the control group (150 - with a normal BMI (18.5-25 kg/m2) and the main group (524 - BMI over 25 kg/m2).

The survey tools included a system of indicators that can be conditionally combined into the following content blocks: self-assessment of the quality of life and socio-economic status; factors affecting social well-being and health status, social well-being; value orientations and behavioral stereotypes in relation to health and orientation towards a culture of self-preserving behavior.

When processing and analyzing data, we used such approaches as highlighting meaningful results, summarizing indicators within blocks, establishing inter-block links to highlight the most significant of them. Relationships were described on the basis of one-dimensional, two-dimensional and correlation analyses. To identify internal relationships, more complex methods were used: multivariate and factor analyzes, which made it possible to identify hidden variables that are important for characterizing the quality of life and attitudes towards health, frustration factors.

Results. An analysis of the correlation dependences of the degree of obesity on key parameters of the quality of life was carried out. In the examined group of patients, a wide variability of total indicators of quality of life was observed at different values ​​of the body mass index.

The results of the study indicate differences in the perception of health-related problems, depending on gender and age, and the degree of obesity. The vast majority of respondents from the main group (64%) noted that being overweight strongly affects their health. With rather high assessments of feelings of happiness and cheerfulness, expressed by 26% of the respondents of the main group of agreement with the statement that they have excellent health, 21% noted that they were very nervous over the past 4 weeks, 14.1% noted severe depression, only 24% noted that most of the time they feel calm and peaceful. Excess weight, according to the overwhelming majority, primarily affects physical well-being, respondents quite often note pain and discomfort in the head (73.2%), loss of strength (71.7%), 59.1% - sleep disturbance.

A fairly significant part of the respondents notes the impact of excess weight on the psycho-emotional state: 34.6% emphasize the loss of interest in usually pleasant activities, 48% - a feeling of depression in the morning, 27.7% - note that the future generally seems gloomy to them, and they do not wait nothing good from him, 36.6% focus on the fact that being overweight hinders professional fulfillment to a certain extent, so additional efforts are required to get started (36.6%).

It is necessary to focus on the fact that among women there are much higher those who believe that being overweight contributes to the formation of low self-esteem, those who experience a feeling of insecurity and fear of being rejected. 35.8% of men agreed with the statement that self-esteem due to weight is not what it could be, among women 74% agree with this statement. 44% of women feel insecure about their weight, among men this figure is much lower - 23.2%. More than half of women agree that they do not like themselves precisely because they are overweight.

Along with being overweight, 62.2% of respondents noted that they suffer from hypertension, 20.5% - angina pectoris, 65.4% - osteochondrosis, 60.2% - joint diseases, 25.6% - diabetes mellitus, 2.4% noted hypothalamic syndrome. 85.5% believe that they are overweight and 7.9% noted that they are not overweight. 32.7% noted that they were overweight in childhood.

55% of obese patients noted a significant limitation when performing heavy loads, while among non-obese patients this was 26%. Moderate exercise was performed without restrictions by 80% in the non-obese group and only 60% in the obese group. At the same time, differences in responses in assessing difficulties in performing light loads (lifting and carrying a bag of groceries) did not differ significantly, although there was also a trend towards greater difficulties in the obese group. The same trend was observed when assessing the difficulty in climbing several flights of stairs. Significant restrictions were equally rare in both groups, but in the absence of obesity, almost 86% of patients did not report any restrictions, while the presence of obesity was associated with a moderate restriction in climbing one flight of stairs and the proportion of patients without restrictions was 65%.

Most of the respondents took measures to beat themselves from being overweight. Among the most popular means that were used for weight loss, diets are in the first place, fasting and fasting days are in the second position, loads and gymnastics are in the third position, nutritional supplements are in the fourth, 6.7% practiced separate meals. In terms of age, it should be noted that young respondents are more focused on using diets, fasting days and fasting for weight loss (35, 25 and 22%, respectively) and do not resort to drugs, unlike the older generation.

Conclusions. The results obtained allow us to assume the existence of a relationship and the influence of overweight and obesity on the quality of life indicators, since it is obesity that can be one of the factors responsible for the decrease in the quality of life compared to the control group and determining the processes of social adaptation and the possibility of social realization. At the same time, there is an effect on the quality of life of other factors that reduce the effects of obesity. Potential factors are age and duration of weight-related disease, which are inversely related to obesity rates and are determinants of quality of life.

The results of the study show that the majority of respondents consider health in the current socio-economic conditions to be an enduring value on which many things in this life depend: material well-being, a happy family life, career advancement. Satisfactory assessments prevail in self-assessments of health and prospects for improving the condition; in patients with obesity, assessments of the state of health are much more pessimistic and less satisfied with the state compared to the control group.

It is necessary to reorient public opinion in the direction of social recognition of obesity as a disease and the need for social support for obese people. It can be argued that overweight people constitute one of the most massive communities in the atypical social risk group, united by the unity of their lifestyle and lifestyle, life chances, their social problems and differs from other categories included in the risk group by greater latency. these problems, non-recognition on the part of society and the state of the very fact of deprivation of this category, as well as the specificity and diversity of possible ways to overcome social infringement.

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Budgetary institution of health care of the Omsk region

"Clinical Medical and Surgical Center of the Ministry of the Omsk Region"

The role of a nurse in improving the quality of life of patients suffering from prostate diseases

Baranova Svetlana Alexandrovna

ward nurse

urology department

Introduction

Chapter 1. Quality of life and quality of nursing care

1.1 Psychological aspect of nursing

1.2 Health education in nursing

Conclusions for chapter 1

Chapter 2. Research methodology

2.1 Analysis of the incidence of prostate diseases in the urological department of the "Clinical Medical and Surgical Center"

2.2 Indicators of the quality of life of patients identified at the initial stage of the study

Conclusion on chapter 2

Chapter 3

3.1 Problems of patients suffering from prostate diseases

3.2 Evaluation of the implementation of the developed leaflets in the daily work of a nurse

Chapter 3 Conclusion

Conclusion

List of used literature

Applications

Introduction

nursing prostatic urological medical

The relevance of research. According to the literature and statistics, prostate diseases are widespread, tend to increase in incidence and occur in men at any age. The most common of these are prostatitis, benign prostatic hyperplasia (the old name is prostate adenoma) and prostate cancer.

“Prostatitis affects 30-75% of young and middle-aged men. At the same time, the highest proportion of morbidity is recorded in people of the most able-bodied and sexually active age - 20-40 years old.

“After 50 years, prostate adenoma affects every second, after 60 years - 75%, over 70 years - 80-90%. Pronounced clinical manifestations occur only in 30-40% of cases.

"Prostate cancer ranks first among all oncourological diseases in men over 50 years of age and ranks second in terms of mortality among all malignant tumors in Russia and the United States" .

Prostate diseases significantly reduce the quality of life of patients, make it very difficult, and sometimes even impossible. Symptoms such as urination disorders, disorders in the genital area cause patients a lot of anxiety, disrupt their usual way of life and ability to work. The chronic course of prostate diseases, the need for surgical treatment, long-term treatment - all this often leads the patient into a depressed state, he ceases to believe in recovery. Depressed mood significantly worsens the course of the disease.

Although the nurse does not treat patients on her own, her role in their treatment is very large. Being all the time near the patient, the nurse notices all the changes that occur in his condition, knows how to calm him down and alleviate his suffering. The work of a nurse, if it is carried out at a high professional level, increases the patient's confidence in a favorable outcome of treatment, teaches the patient to live with his illness more fully, thereby improving his quality of life. However, in the domestic literature, there are very few scientific publications with an analysis of the dynamics of the quality of life of patients suffering from prostate diseases in connection with the nursing care provided to them. It is necessary to identify patterns and relationships between improving the quality of life of patients suffering from prostate diseases and improving the quality of nursing care provided to them.

Object of study.

The object of the study is the problems of patients suffering from diseases of the prostate gland, which serve as an indicator of the deterioration in the quality of life of patients.

Subject of study.

The subject of the study is the formation of nurse's knowledge about the problems of patients suffering from prostate diseases, the creation on their basis of leaflets for patients aimed at improving the quality of nursing care provided to them.

Purpose of the study.

Identification of patterns and relationships between improving the quality of life of patients suffering from prostate diseases and improving the quality of nursing care provided to them.

Research objectives:

1. Identify and analyze the problems of patients suffering from prostate diseases.

2. Create, based on them, memos for patients and implement them in the daily work of a nurse.

3. To analyze the effectiveness of the introduction of the developed memos into the daily work of a nurse.

Hypothesis.

The quality of life of patients suffering from prostate diseases directly depends on the quality of nursing care provided to the full extent and in an accessible form for the patient, namely in the form of an individual conversation with the patient with handing memos on the main problems of patients.

Research stages:

1. To identify the problems of patients suffering from prostate diseases using the developed questionnaire.

2. Theoretical analysis of the problems of patients suffering from prostate diseases.

3. In the practical part, create and implement reminders for patients in the daily work of a nurse.

4. To analyze, using a previously developed questionnaire, the effectiveness of introducing reminders for patients into the daily work of a nurse.

Research methods:

1. Historical method.

2. Method of observation.

3. Sociological method.

4. Logical method.

theoretical significance.

Identification of the pattern and relationship between improving the quality of life of patients suffering from prostate diseases and improving the quality of nursing care provided to them contributes to the development of further research in the field of improving the quality of nursing care provided to these patients and patients with other diseases in order to improve the quality of life of these patients.

Practical significance.

The knowledge gained in the course of this work about the problems of patients suffering from diseases of the prostate gland, the developed leaflets for patients, the developed questionnaires for determining the problems of these patients, can be used in the practical work of nurses of urological departments. They will help improve the quality of nursing care provided to patients suffering from prostate diseases, as well as improve the quality of life of patients with these diseases.

Chapter 1.Quality of life and quality of nursing care

Preserving the health of the population and improving the quality of life is a strategic task of the government's state policy.

"Health is a complex concept defined by the World Health Organization as a state of complete physical, mental and social well-being". Appropriate indicators are used to assess the “health” category: healthy life expectancy and quality of life.

Quality of life, according to the definition of the World Health Organization, "a person's complex perception of his position in life in the context of the culture and value system to which he belongs" . That is, the quality of life is an integral characteristic of the physical, psychological, emotional and social functioning of a person (healthy or sick), based on his subjective perception of the features and characteristics of the environment.

The medical concept of quality of life includes, first of all, those indicators that are associated with the state of human health. That is, the medical aspects of the quality of life should be understood as the impact of the manifestations of the disease itself and the limitation of the functional ability that occur as a result of the disease, as well as the impact of treatment on the daily activities of the patient. Thus, the patient's quality of life can serve as a criterion for the quality of medical care provided to him and can be measured using various questionnaires, scales, and indices.

"The quality of medical care is a set of characteristics that confirm the compliance of the provided medical care with the existing needs of the patient (population), his expectations, the current level of medical science and technology" .

The quality of nursing care is such properties of nursing care, due to which the patient is satisfied with its provision in general, as well as satisfied with its result and the process of its provision. And also, the quality of nursing care is the fulfillment by a nurse of functional duties in strict accordance with the legal documentation, that is, her professional competence.

To understand the importance of nursing care in the process of improving the effectiveness of medical care, the following “characteristics of nursing care are used:

1. professional competence;

2. availability;

3. effectiveness of nursing intervention;

4. interpersonal relationships;

5. efficiency;

6. continuity, that is, consistency and continuity in receiving nursing care;

7. safety - means ensuring a safe hospital environment;

8. convenience, which implies not only comfort and cleanliness, but also conditions that ensure the patient's maximum possible independence in the implementation of physiological needs.

The external component of the quality of nursing care is the correspondence between the need and perception of nursing care, which is characterized by the concept of "satisfaction". The organization, content and results of nursing care must meet the expectations and needs of patients and their relatives, as well as the nurses themselves.

“Improving the quality of nursing care is possible with the effective interaction of a professionally competent nurse and the patient (his relatives) in positive socio-psychological, logistical, organizational and economic conditions of a single legal space in the presence of a stable positive motivation of the patient (relatives) for recovery ( maintaining health).

1.1 The psychological aspect of nursing

The work of a nurse has its own characteristics. First of all, it involves the process of interaction with patients and their relatives, the purpose of which is to improve the quality of nursing care provided.

When communicating with a patient, a nurse should remember that any disease is a fairly strong factor that causes stress (a process that leads to tension in all functional systems of the body), and this inevitably affects his mental state. The nurse should be able to timely assess the patient's neuropsychic state and, if possible, have a fruitful and positive impact on the patient in the process of communicating with him.

In order for the process of the relationship between a nurse and a patient to be effective, it is necessary to study the psychological aspects of such a relationship.

Of particular importance for effective and conflict-free interaction is communicative competence, that is, the ability to establish and maintain the necessary contacts with people. At the same time, communicative competence implies not only the presence of certain psychological knowledge, but also the formation of some special skills: the ability to establish contact, listen, “read” non-verbal communication language, build a conversation, formulate questions. It is also important that the nurse owns her own emotions, knows how to maintain confidence, “control her reactions” and behavior in general. No less important are the qualities of a nurse, such as the desire to help and empathy, which are the necessary qualities of any medical worker.

Effective communication is impossible without trust. For the manifestation of the patient to the nurse, the first impression that the patient has when meeting with her matters. At the same time, the actual facial expressions of the nurse, her gestures, tone of voice, facial expression, as well as the appearance of the nurse are important.

Throughout the illness, the patient needs psychological support and the maximum satisfaction of all his psychological needs. The nurse's knowledge of the laws of psychology, ethical and deontological principles, combined with professional skills, allows providing better care to patients, even in the most difficult situations.

1.2 Sanitary and educational work in nursingbnews

"Sanitary and educational work in a medical institution is a complex of differentiated, targeted sanitary and educational measures that provide for the hygienic education of various contingents of the population and are organically related to activities" . Health education is part of a complex of preventive and therapeutic measures carried out with patients and the professional duty of all medical workers.

The purpose of hygienic education in a medical institution is to increase the effectiveness of therapeutic and preventive measures by actively informing and educating patients. In accordance with the informative tasks, sanitary and educational work is carried out at all stages of the patient's stay in the hospital.

Since the nurse spends more time with the patient than other medical workers, most of the health education work falls on her. The main method in this case is a conversation between a nurse and a patient. During these conversations, the nurse should take into account the patient's attitude towards their disease and ensure that this attitude is adequate.

An adequate attitude to one's illness is distinguished by the awareness of one's illness and the recognition of the need to take measures to restore health. Such patients take an active part in carrying out diagnostic and therapeutic measures, consciously and clearly follow the recommendations of the doctor, which contributes to a speedy recovery and eliminates complications of the disease.

There are many variants of the patient's inadequate attitude to his disease - from denying the very fact of the disease to excessive attention to his health and exaggeration of the symptoms of the disease. Inadequate attitude to one's disease significantly complicates the communication of medical workers with such a patient, increases the risk of complications, increases the duration of treatment, and often leads to a chronic course of the disease.

Carrying out sanitary and educational work with the patient, the nurse is obliged to build her conversations in such a way as to solve the problems of a particular patient, ensure the completeness, accessibility and consolidation of oral material, with the help of memos, brochures, re-sessions and conversations. A competently conducted conversation with the patient contributes to a more adequate attitude of the patient to his disease, improves the quality of medical care and the quality of life of the patient.

Conclusions for chapter 1

Improving the quality of medical care is a priority for the modernization of healthcare. Nursing care plays an important role in the process of improving the effectiveness of medical care. The patient's quality of life is an indicator of the patient's health and an important criterion for the quality of medical care. Studying the quality of life of patients allows you to identify the advantages or disadvantages of the medical care provided to the patient.

Competent conduct of health education work by a nurse and the availability of knowledge and skills of effective communication by a nurse improves the quality of nursing care provided to the patient, which in turn improves the quality of medical care provided to him and the quality of life of patients.

Chapter 2. Research methodology

The study was carried out in stages on the basis of the urological department of the Clinical Medical and Surgical Center.

At the first stage, in accordance with the purpose and objectives of the undertaken study and by summarizing the data of the medical literature on this issue, analyzing medical records, personal observations of patients, a questionnaire (Appendix 2) was developed to assess the quality of life of patients suffering from prostate diseases. A survey of the control group of patients was conducted, in the amount of 50 patients undergoing treatment. The results of the survey made it possible to identify the main problems of patients suffering from prostate diseases and to assess the availability, completeness and quality of nursing care provided to them.

Based on the analysis of the results obtained during the survey, as well as the generalization of medical literature data on this issue, the analysis of medical records, personal observations of patients, leaflets for patients were developed (Appendices 3 - 10), and introduced into the daily work of the nurse of the urological department of the Clinical Medical -surgical center.

At the final stage of the study, among the patients of the experimental group, in the amount of 50 people, it was analyzed, using a previously developed questionnaire, the effectiveness of introducing the developed leaflets for patients into the daily work of nurses in the urological department.

2.1 Analysis of the incidence of prostate diseases in the urological department of the Clinical medical and surgical centerntra"

"Clinical Medical and Surgical Center" is a multidisciplinary hospital complex with a capacity of 820 beds, which has 48 specialized departments and 1,547 employees. The Clinical Medical and Surgical Center provides outpatient and inpatient care to employees of transport enterprises and their families, combatants and their families, residents of the Omsk District, the Omsk Region and the Central Administrative District.

The Urology Department was opened in 1984. The department is located on the fifth floor of the inpatient building of the hospital and has 30 beds in a round-the-clock hospital and 10 beds in a day stay. Hospitalization in the department is carried out in a planned manner in accordance with the plan of bed-days. The main direction in the work of the department is highly specialized care for patients with various diseases of the male reproductive system of any degree of complexity.

Analyzing the data on the incidence of prostate diseases, shown in Diagram 1 (Appendix 1), we can draw the following conclusions: the number of treated patients in 2010 increased compared to 2009: the number of prostatitis increased by 22 people, the number of prostate adenomas increased by 40 people, and the number of patients with prostate cancer increased by 5 people. These figures indicate an increase in the incidence of prostate diseases. Also, in diagram 1 (Appendix 1), it can be seen that the number of adenomectomy and TUR performed in the department in 2010 increased by 21 operations compared to 2009, which is also associated with an increase in the incidence of benign prostatic hyperplasia and an increase in the population aged over 60 years old.

The proportion of the incidence of prostate diseases in the urological department in 2010, according to diagram 2 (Appendix 1), was 37%: prostatitis accounted for 15.9%; the proportion of prostate adenomas was 18.6%: and the proportion of prostate cancer was 2.5%. Thus, the number of patients suffering from prostate diseases is more than a third of all patients treated in the department in 2010.

2.2 Showquality of life of patientsidentified at the initial stage of the studyOvaniya

The objectives of the survey were to identify the problems of patients in the control group and assess the availability, quality and completeness of nursing care provided to them. In accordance with these tasks and by summarizing the data of the medical literature on this issue, analyzing medical records, personal observations of patients, a questionnaire was developed to assess the quality of life of patients suffering from prostate diseases (Appendix 2).

The survey involved 50 patients of the control group who were treated in the urological department of the Clinical Medical and Surgical Center.

The survey data, as seen in Diagram 3 (Appendix 1), showed a satisfactory quality of life in 14% of patients, a poor quality of life in 36% of patients, and a terrible quality of life in 50% of patients.

At the same time, 86% of patients noted late referral to a specialist doctor; 68% of patients noted urination disorders that were very disturbing to them; 84% of patients noted a lack of information about their disease and 45% of patients noted difficulties in self-care during treatment and / or in the postoperative period; and also, 78% of patients had various psychological problems: a feeling of fear and anxiety about the outcome of the operation and treatment, a feeling of uncertainty and anxiety about their health, a feeling of inconvenience and embarrassment due to the stoma and during medical procedures (diagram 4 in Appendix 1).

Also, the results of the survey reflect the level of patient satisfaction with the quality of nursing care. Diagram 5 (Appendix 1) shows that 50% of respondents rated the attitude of nursing staff towards patients as benevolent, 27% - as satisfactory, 18% of patients noted the indifference of nursing staff, and 5% of patients noted the rude attitude of nursing staff towards patients.

Nursing care, the indicators of which are shown in Diagram 6 (Appendix 1), was received in full by 38% of patients, 30% of patients rated nursing care as satisfactory, 27% of patients received nursing care not in full, and 5% of patients did not receive nursing care at all care.

Advisory nursing care was positively assessed by 45% of patients, 15% of patients rated it as satisfactory, 30% of patients needed additional information, 10% of patients received advisory nursing care in an inaccessible form (diagram 6 in Appendix 1).

The results obtained indicate that the majority of 86% of the examined patients in the control group have a low level of quality of life and 78% of patients have various psychological problems. Also, from the data obtained, it can be seen that a significant percentage of patients are not satisfied with the quality of nursing care.

Based on these data, it was concluded that it is necessary and extremely urgent to improve the quality of life of patients suffering from prostate diseases, as well as to improve the quality of nursing care provided to them. For this purpose, leaflets for patients suffering from prostate diseases were developed and introduced into the daily work of nurses of the urological department of the Clinical Medical and Surgical Center, developed on the basis of the problems of these patients identified during the study.

Conclusion on chapter 2

According to the analysis of the incidence of prostate diseases in the urological department of the "Clinical Medical and Surgical Center", we see that among all hospitalized patients in 2010, the percentage of patients suffering from prostate diseases was 37%, and we also see that the incidence rates for the period from 2009 to 2010 grew (chart 1 - 2 in Appendix 1). This confirms the relevance of the study.

The results of a survey of the control group of patients revealed a low level of quality of life of patients and a significant dissatisfaction of these patients with the quality of nursing care (diagram 3 - 6 in Appendix 1). Based on these data, it was concluded that it is necessary and extremely urgent to improve the quality of life of patients suffering from prostate diseases, as well as to improve the quality of nursing care provided to them. For this purpose, leaflets for patients suffering from prostate diseases were developed and introduced into the daily work of nurses of the urological department of the Clinical Medical and Surgical Center.

Headsa 3.The role of the nurse in patient caresuffering from prostate diseases

The social significance and relevance of improving the quality of life of patients suffering from prostate diseases is justified by a significant decrease in the quality of life of such patients. Symptoms such as urination disorders, disorders in the genital area cause patients a lot of anxiety, disrupt their usual way of life and ability to work. The chronic course of prostate diseases, the need for surgical treatment, long-term treatment - all this often leads the patient into a depressed state, he ceases to believe in recovery. Depressed mood significantly worsens the course of the disease.

The nurse is almost constantly in contact with the patient and takes an active part in the process of restoring his health, since it is she who continuously monitors him, fulfills all the doctor's instructions, and carries out medical procedures. Also, the direct and main duty of the nurse is the constant and comprehensive care of patients, which is aimed at alleviating the patient's suffering, speedy recovery and prevention of complications. Helping to restore the health of patients, the nurse, thereby improves their quality of life.

Fulfilling all the doctor's prescriptions and constantly monitoring patients, the nurse timely reveals hidden symptoms or changes in the patient's condition, side effects of medicines or medical procedures. This, in turn, allows you to timely adjust the treatment of patients suffering from prostate diseases, and, if necessary, provide emergency medical care.

Carrying out sanitary and educational work with the patient, the nurse builds her conversations in such a way as to solve the problems of a particular patient, ensure the completeness, accessibility and consolidation of the oral material, with the help of memos, brochures, repeated classes and conversations. The nurse provides early and adequate activation of patients and the performance of breathing and therapeutic exercises after surgical interventions, diet, helps the patient in mastering the skills of self-care and care for the cystostomy, and, if necessary, teaches the patient's relatives how to care for him. A competently conducted conversation with the patient contributes to a more adequate attitude of the patient to his disease, improves the quality of medical care and the quality of life of the patient.

The psychological aspect in the work of a nurse is to create psychological comfort for patients suffering from prostate diseases. This requires the nurse to have the knowledge and skills of effective communication, the communicative competence of the nurse. The main methods used by the nurse are talking with patients and observing them. The nurse, talking with the patient, instills in the patient confidence in the correctness of the procedures performed, talks about his illness, about the treatment process, distracts him from negative thoughts about his state of health, inspires him with vigor and faith in recovery. At the same time, the patient is provided with psychological support: he can discuss his problems, feel that he is not alone, that he is understood, the patient develops confidence and active assistance in the treatment process. It is the nurse who helps patients suffering from diseases of the prostate gland to adapt to the environmental conditions of the department and a rich program of therapeutic measures that require a certain emotional and physical stress from the patient. At the same time, the nurse shows friendly participation, care and patience, since the patient, as a rule, experiences fear, anxiety, depression due to forced dependence on others.

The nurse plays the same important role in restoring the health of patients and improving their quality of life as the attending physician. But the volume of activities performed by her is greater than that of a doctor, since the nurse not only provides nursing care and supervision, but is also the direct executor of the doctor's prescriptions, an intermediary between the patient, his relatives and the attending physician. The work of a nurse, if it is carried out at a high professional level, significantly improves the quality of life of the patient, increases the efficiency of medical care provided to the patient, reduces the risk of complications and accelerates the rehabilitation of patients.

3.1 Problems of patients suffering from diseasesAthyroid gland

In order to improve the quality of nursing services provided in the urology department, taking into account the nursing process, purposeful actions of the nurse are needed to address the violated needs of the patient. Each violated need is a problem for the patient, therefore, work was carried out to identify the problems of patients suffering from prostate diseases. Further, based on the analysis of the results obtained during the survey, as well as the generalization of medical literature data on this issue, the analysis of medical documentation and personal observations, an analysis of the identified problems was carried out.

In the analysis of problems, patients suffering from prostate diseases were divided into two groups:

A. Patients in need of examination and conservative treatment;

B. Patients requiring surgical treatment.

A. Problems of patients requiring examination and conservative treatment:

I.Priority issues:

1. Pain in the lower abdomen and in the perineum, constant and / or during urination;

2. fever;

3. sleep disorders associated with frequent urge to urinate;

4. acute urinary retention;

5. sexual disorders.

II.Real problems:

1. feeling of discomfort and embarrassment due to urination disorders;

2. anxiety about the upcoming examination due to a lack of knowledge about the upcoming examination and behavior during the examination;

3. a feeling of insecurity and anxiety about one's health, due to a lack of knowledge about one's disease;

4. feeling of fear and anxiety about the negative result of the examination due to anxiety for one's health;

5. feelings of anxiety due to the need to change lifestyle.

III.Potential problems:

1. the risk of developing complications of the disease.

2. state of depression, despair and hopelessness associated with the detection of cancer.

C. Problems of patients suffering from prostate diseases requiring surgical treatment:

I. priority issuesare potential problems in the postoperativeAndone period:

1. risk of shock due to the condition after surgery;

2. the risk of nausea, vomiting due to the condition after surgery;

3. pain in the area of ​​the postoperative wound,

4. hyperthermia due to the condition after surgery;

5. pain and cramps due to impaired patency of the irrigation system;

6. the risk of developing bedsores due to prolonged stay in a forced position;

7. risk of congestion in the lungs;

8. risk of postoperative complications: bleeding, suture divergence, infection;

9. the risk of developing thrombotic processes in the venous system due to the condition after surgery;

II. Real problems:

1. feeling of fear and anxiety about the upcoming surgery due to a lack of knowledge about behavior in connection with the upcoming surgery;

2. lack of self-care due to a decrease in motor activity due to surgery;

3. embarrassment and inconvenience due to an unpleasant odor in ostomy patients;

4. feeling of discomfort with the urethral catheter;

5. maceration of the skin in the presence of epicystostomy;

6. decrease in motor and physical activity associated with weakness after surgery;

7. violation of the diet due to the condition after the operation;

8. violation of the regimen of defecation due to bed rest;

9. a feeling of fear and anxiety for one's health due to a lack of knowledge about one's disease;

10. feelings of fear, anxiety and insecurity associated with hospitalization;

11. feelings of insecurity and confusion about discharge due to lack of knowledge about post-discharge behavior and the presence of an epicystostomy.

It should be noted that the majority of patients suffering from prostate diseases requiring surgical treatment undergo a thorough preliminary examination and receive a course of drug treatment. Therefore, such patients have problems in both the first (A) group and the second (B) group.

3. 2 Evaluation of the implementation of the developed memoriesyatokin everyday worknurse bot

The objectives of the survey were to identify the problems of patients in the experimental group and assess the availability, quality and completeness of nursing care provided to them. And the purpose of this survey: to identify the dynamics of the indicators assessed in the experimental group of patients compared with the indicators of the control group.

The survey involved 50 patients of the experimental group suffering from diseases of the prostate gland, who were treated in the urological department of the "Clinical Medical and Surgical Center", after the introduction of instructions for patients into the daily work of the nurse (Appendix 3 - 10).

The survey data, as we see in Diagram 7 (Appendix 1), showed a satisfactory quality of life in 53% of patients, a poor quality of life in 27% of patients, and a terrible quality of life in 20% of patients.

At the same time, as can be seen in Diagram 8 (Appendix 1), 83% of patients reported late visits to a specialist doctor; 57% of patients noted urination disorders that were very disturbing to them; 80% of patients noted the presence of pain in the postoperative period and 31% of patients noted difficulties in self-care in the postoperative period; and also, 56% of patients had various psychological problems: a feeling of fear and anxiety about the outcome of the operation and treatment, a feeling of uncertainty and anxiety about their health, a feeling of inconvenience and embarrassment due to the stoma and in the postoperative period.

The results of the survey also reflect the level of satisfaction of patients with benign prostatic hyperplasia with the quality of nursing care. The attitude of nursing staff to patients was rated by 70% of respondents as benevolent, 20% - as satisfactory, 8% of patients noted the indifference of nursing staff, and 2% of patients noted the rude attitude of nursing staff towards patients (diagram 9 in Appendix 1).

Nursing care, the indicators of which are shown in Diagram 10 (Appendix 1), was received in full by 70% of patients, nursing care was rated as satisfactory by 25% of patients, 5% of patients received nursing care not in full.

Advisory nursing care was positively assessed by 75% of patients, 15% of patients rated it as satisfactory, 10% of patients need additional information (diagram 10 in Appendix 1).

Chapter 3 Conclusion

The nurse plays the same important role in restoring the health of patients and improving their quality of life as the attending physician. The work of a nurse, if it is carried out at a high professional level, significantly improves the quality of life of the patient, increases the efficiency of medical care provided to the patient, reduces the risk of complications and accelerates the rehabilitation of patients.

Patients suffering from prostate diseases often need not only conservative treatment, but also surgical treatment. Therefore, these patients have many different problems that reduce their quality of life. Knowledge of these problems by a nurse should improve the quality of nursing care provided.

The data obtained during the survey of the experimental group indicate a significant positive dynamics in the estimated indicators of the quality of life of patients, compared with the indicators assessed earlier in the control group.

Indicators of satisfactory quality of life of patients in the experimental group increased by 39% compared with the indicators of the questionnaire conducted earlier in the control group (diagram 11 in Appendix 1).

As can be seen in Diagram 12 (Appendix 1), among the indicators of “patient problems”, special attention should be paid to the decrease in the indicators “psychological problems” and “difficulties in self-care” by 14% and 22%, respectively, as well as a significant decrease in the indicator “lack of information about their disease” by 25% in the experimental group compared with the indicators of the questionnaire conducted earlier in the control group.

There is a positive dynamics in the results of the indicator "attitude of nursing staff to patients" in the experimental group compared with the results in the control group: 20% more patients of the experimental group rated it as benevolent (diagram 13 in Appendix 1).

Significantly improved indicators of the "quality of nursing care" in the experimental group compared with the same indicators of the survey of the control group, which is reflected in diagrams 14 and 15 (Appendix 1). Full coverage was received by 32% more patients in the experimental group than in the control group (diagram 14 in Appendix 1). And advisory nursing care in full in the experimental group was received by 30% more patients than in the control group (diagram 15 in Appendix 1).

Conclusion

The positive dynamics of the indicators that determine the quality of life of patients suffering from prostate diseases and the quality of nursing care provided to them undoubtedly indicates a direct dependence of these indicators on the introduction of the developed leaflets for patients into the nurse's work, which in turn improved the quality of nursing care provided. Thus, the quality of life of patients suffering from prostate diseases directly depends on the quality of nursing care provided to the full extent and in an accessible form for the patient, namely in the form of an individual conversation with the patient with handing memos on the main problems of patients.

To further improve the quality of nursing care in the urology department and improve the quality of life of patients suffering from prostate diseases - we think it is necessaryOsmoke:

1. To organize in the department a “Health School for patients with epicystostomies and nephrostomies”.

2. Organize a postoperative ward in the department.

3. Organize a "Health Corner" focused on highlighting topical problems of prostate cancer in the department.

4. To develop and implement in the work of the nurse of the urological department a memo on various aspects of prostate diseases to increase the level of knowledge of patients about these diseases.

5. To develop and implement in the work of the nurse of the urological department the standards for conducting conversations with patients before and after surgical interventions.

List of used literature

1. Sadykov G.M. Chronic abacterial prostatitis. - J. Urology. - 2010, No. 6. - P.11.

2. Website: www.vitosan.ru. - Causes of diseases of the prostate gland.

3. Chudnovets I.Yu., Gatilov A.V., Borosenets N.V. The first experience of laparoscopic prostatectomy. / Innovative technologies in urology: VIII regional scientific-practical conference of Siberian urologists. - Omsk, GOU OMGMA MZOO. - 2009. - S. 195-196

4. Sopina Z.E., Fomushkina I.A. Quality management of nursing care: textbook. - M.: GEOTAR. Media. - 2009. - S. 176

5. Gensh N.A. Handbook of rehabilitation. - Rostov-on-Don: Phoenix. - 2008. - S. 348

6. Skuryagina E.A. Business etiquette in the work of a nurse. - J. Nursing. - 2007, No. 8. - S. 36-37

7. Tysenchuk O.N. Learning to prevent conflicts. - J. Nursing. - 2007, No. 8. - S. 46

8. Orlova T.A. Caring for stoma patients. - J. Nursing. - 2008, No. 6. - S. 38-40

9. Samoilenko V.N. Ethical principles of nursing. - J. Nursing. - 2009, No. 1. - pp. 14-16

10. Samoilenko V.N. Active triangle: nurse - patient - society. - J. Nursing. - 2009, No. 3. - S. 21-23

11. Maslova V.N., Makarova I.A. Organization of health schools. - J. Nursing. - 2010, No. 1. - S. 35-37

12. Gaboyan Ya.S., Logvinova O.V. Organization of the activities of nursing staff in the department of nursing care on the basis of the city clinical hospital No. 64. - M .: Zh. Nurse. - 2006, No. 6. - p.7-9

13. Stepanov V.V. On the state of scientific research on the organization of the work of nursing staff. - J. Head nurse. - 2006, No. 1. - pp. 87-92

14. Nursing. Professional disciplines: Textbook. / Ed. G.P. Kotelnikova. - Rostov-on-Don: Phoenix, ed. 2nd. - 2007. - S. 697

15. Turchina Zh.E., Myagkova E.G. Nursing in geriatrics: Textbook. - Rostov-on-Don: Phoenix. - 2006. - S. 215

16. Dmitrieva Z.V., Teplova A.I. Theoretical foundations of nursing in surgery. - M.: SpecLit. - 2010. - S. 319

17. Paleev N.R. Nursing: The Complete Nurse's Guide. - M.: Esmo. - 2009. - S. 544

18. Ivanyushkin A.Ya. Biomedical ethics. Textbook for medical schools, medical colleges, faculties of the VSO. - M.: Moscow. - 2010 - p. 112

19. Kuleshova L.I. Fundamentals of nursing: theory and practice. Part 2. - Rostov-on-Don: Phoenix. - 2008 - p. 411

20. Kozlova L.V. Fundamentals of Rehabilitation for Medical Colleges. - Rostov-on-Don: Phoenix. - 2011 - p. 475

21. Barykina N.V. Nursing in surgery: textbook. - Rostov-on-Don: Phoenix. - 2010. - S. 447

22. Barykina N.V. Nursing in surgery: workshop. - Rostov-on-Don: Phoenix. - 2009. - S. 460

23. Filatova S.A. Gerontology: textbook. - Rostov-on-Don: phoenix. - 2009. - S. 510

24. Tleptserishev R.A. Economics and health management: a textbook. - Rostov-on-Don: Phoenix. - 2009. - S. 623

25. Rudenko A.M. Psychology for medical specialties. - Rostov-on-Don: Phoenix. - 2009. - S. 634

26. Turkina N.V. General nursing: a textbook. - M.: Moscow. - 2007. - S. 550

27. Sprints A.M. Fundamentals of Nursing: A Handbook. - M.: SpecLit. - S. 463

28. Sprints L.M. Medical psychology with elements of general psychology. - M.: SpecLit. - 2009. - S. 447

29. Pugachev A.G. Urology: textbook. - M.: MIA. - 2008 - p. 248

30. Balabanova A.N. Features of nursing care for geriatric patients with diseases of the kidneys and urinary tract. - M.: GOU VUNMTs. - 2008 - p. 128

31. Rodoman V.E. Diseases of the prostate gland: A guide for physicians. - M.: MIA. - 2009. - S. 672

32. Alyaev Yu.G., Grigoryan V.A., Gadzhieva Z.K. Urinary disorders. - M.: Litera. - 2006. - S. 208

33. Shcheplev P.A. Prostatitis. - M.: Medpress. - 2007. - S. 224

34. Pushkar D.Yu. radical prostatectomy. - M.: Medpress-inform. - 2009. - S. 172

Annex 1

Diagram 1. Analysis of the incidence of prostate diseases in the urological department of the "Clinical Medical and Surgical Center".

Diagram 2. The proportion of the incidence of prostate diseases in the urological department of the "Clinical Medical and Surgical Center" in 2010.

Posted on http://www.allbest.ru/

Posted on http://www.allbest.ru/

Diagram 3. Assessment of the quality of life of patients suffering from prostate diseases in the control group.

Diagram 4. Problems of patients suffering from prostate diseases in the control group.

Diagram 5. The ratio of nursing staff to patients in the control group.

Diagram 6. Evaluation of the quality of nursing care according to the assessment of patients in the control group

Diagram 7. Assessment of the quality of life of patients suffering from prostate diseases in the experimental group.

Diagram 8. Problems of patients suffering from prostate diseases in the experimental group.

Diagram 9. The ratio of nursing staff in the assessment of patients in the experimental group.

Diagram 10. Evaluation of the quality of nursing care by patients in the experimental group.

Diagram 11. Dynamics of quality of life indicators in patients suffering from prostate diseases.

Diagram 12. Dynamics of indicators of problems of patients suffering from diseases of the prostate gland.

Diagram 13. Dynamics of indicators of patients' assessment of the attitude of nursing staff to patients.

Diagram 14. Dynamics of indicators of patient assessment of care provision

Diagram 15. Dynamics of indicators of evaluation of consultative nursing care by patients.

Appendix 2

Questionnaireto assess the quality of lifepatients sufferingdiseases presentAthyroid gland

Dear patient, I ask you to answer a few of my questions in connection with my research work to assess the quality of life of patients suffering from prostate diseases.

I. Identification of patient problems:

II. Patient satisfaction levelestvomnursing pomOcabbage soup:

III. Criteria for assessing the quality of life of patients suffering from diseasesAbody gland:

Thank you for your attention!

Annex 3

Memo 1

REMINDER FOR THE PATIENT

"HOW TO PREPARE

TOPROSTATE RESEARCH"

* How to prepare for an ultrasound of the bladder and prostate in men?

1. The examination is performed with a full bladder, so it is necessary not to urinate before the examination for 3-4 hours

2. Drink 1 liter of non-carbonated liquid 1 hour before the procedure.

3. Before a transrectal examination of the prostate (TRUS), it is necessary to make a cleansing enema.

* ABOUTWhat should you know when taking a PSA blood test?

1. The analysis is given in the morning, on an empty stomach. Do not take the test after eating!

2. Within 3-4 days prior to the analysis, it is necessary to refrain from sexual intercourse, cycling, and taking alcoholic beverages.

3. If the doctor performed a prostate massage, cystoscopy or bladder catheterization, then it is advisable to wait at least 2 weeks before taking the test

4. If you have had a prostate biopsy - at least a month.

5. When evaluating the results of the analysis by a doctor, you must inform about all the medications you take, as well as about previously discovered prostate diseases (prostatitis, adenoma)

6. Otherwise, the results may be misinterpreted.

What preparation is needed before a prostate biopsy?

If you are planning to have a prostate biopsy:

* Do not plan anything for this day and stay at home.

* It is necessary to pass urine in advance for a general analysis and for sowing.

* Stop taking aspirin at least 7 days before the biopsy.

* If you are taking indirect anticoagulants (Sinkumar, Thrombostop,

Pelentan, etc.), it is necessary to warn the doctor about this in advance and stop taking them 3-4 days before the biopsy, after which, on the eve of the biopsy, donate blood to determine the prothrombin time and prothrombin index.

* On the evening before the biopsy, as well as on the morning of the biopsy, you need to give yourself a cleansing enema. It is better to refrain from eating after 7 - 8 pm on the eve of the biopsy.

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27043 0

In recent years, to assess the level of socio-economic well-being of individuals, social groups of the population, the population, the availability of basic material goods to them, the concept of "quality of life" has increasingly been used. The World Health Organization (1999) proposed to consider this concept as the optimal state and degree of perception by individuals and the population as a whole of how their needs (physical, emotional, social, etc.) are met in order to achieve well-being and self-realization.

Based on this, we can formulate the following definition: the quality of life is an integral assessment by an individual of his position in the life of society (in the system of universal values), as well as the correlation of this position with his goals and capabilities.

In other words, the quality of life reflects the level of comfort of a person in society and is based on the sin of the main components:
. living conditions, i.e. the objective, independent of the person himself side of his life (natural, social environment, etc.);
. lifestyle, i.e. the subjective side of life created by the individual himself (social, physical, intellectual activity, leisure, spirituality, etc.);
. satisfaction with conditions and lifestyle.

At present, more and more attention has been paid to the study of the quality of life in medicine, which made it possible to delve deeper into the problem of the patient's attitude to his health. There was even a special term "quality of life associated with health", which means an integral characteristic of the physical, psychological, emotional and social state of the patient, based on his subjective perception.

The modern concept of studying the quality of life associated with health is based on three components.

1. Multidimensionality. The quality of life associated with health is assessed by characteristics, both associated and not associated with the disease, which makes it possible to differentially determine the impact of the disease and treatment on the patient's condition.

2. Variability in time. The quality of life associated with health varies over time depending on the condition of the patient. Data on the quality of life allow for constant monitoring of the patient's condition and, if necessary, to correct therapy.

3. Participation of the patient in the assessment of his condition. This component is especially important. The patient's self-assessment of health-related quality of life is a valuable indicator of his general condition. Data on the quality of life, along with the traditional medical opinion, allow a more complete picture of the disease and the prognosis of its course.

The methodology for studying the quality of life associated with health includes the same stages as any medical and social research. As a rule, the objectivity of the results of the study depends on the accuracy of the choice of method.

The most effective method for assessing the quality of life at present is a sociological survey of the population by obtaining standard answers to standard questions. Questionnaires are general, used to assess the quality of life associated with the health of the population as a whole, regardless of pathology, and special, used for specific diseases. Questionnaires used for these purposes are subject to certain requirements. They should be:
. universal (covering all parameters of health-related quality of life);
. reliable (to record the individual characteristics of the quality of life associated with health for each respondent);
. sensitive (mark any significant changes in the health of each respondent);
. reproducible (test-retest);
. easy to use;
. standardized (to offer a single version of standard questions and answers for all groups of respondents);
. evaluative (to quantify the parameters of health-related quality of life).

A correct, from the point of view of obtaining reliable information, study of the quality of life associated with health is possible only when using questionnaires that have passed validation, i.e. who have received confirmation that the requirements imposed on them correspond to the tasks set.

The advantage of general questionnaires is that their validity has been established for various nosologies, which allows for a comparative assessment of the impact of various medical and social programs on the quality of life of patients suffering from both individual diseases and belonging to different classes of diseases. At the same time, the disadvantage of such statistical tools is their low sensitivity to changes in health status, taking into account a single disease. Therefore, it is advisable to use general questionnaires in epidemiological studies to assess the health-related quality of life of certain social groups of the population, the population as a whole.

Examples of general questionnaires are the SIP (Sickness Impact Profile) and the SF-36 (The MOS 36-ltem Short-Form Health Survey). The SF-36 questionnaire is one of the most popular. This is due to the fact that, being general, it allows assessing the quality of life of patients with various diseases and comparing this indicator with that of a healthy population. In addition, the SF-36 allows respondents to be aged 14 and over, unlike other adult questionnaires that have a minimum threshold of 17 years of age. The advantage of this questionnaire is its brevity (contains only 36 questions), which makes its use quite convenient.

Special questionnaires are used to assess the quality of life of patients with a particular disease, the effectiveness of their treatment. They allow capturing changes in the quality of life of patients that have occurred over a relatively short period of time (usually 2–4 weeks). Special questionnaires are used to evaluate the effectiveness of treatment regimens for a particular disease.

In particular, they are used in clinical trials of pharmacological preparations. There are many special questionnaires, such as AQLQ (.Asthma Quality of Life Questionnaire) and AQ-20 (20-Item Asthma Questionnaire) for bronchial asthma, QLMI (Quality of life after Myocardial Infarction Questionnaire) for patients with acute myocardial infarction, etc.

The work on the development of questionnaires and their adaptation to various linguistic and economic formations is coordinated by an international non-profit organization for the study of the quality of life - the MAPI Institute (France).

There are no single criteria and standard norms for health-related quality of life. Each questionnaire has its own criteria and rating scale. For certain social groups of the population living in different administrative territories, countries, it is possible to determine the conditional norm of the quality of life of patients and subsequently compare it with it.

An analysis of international experience in the use of various methods for studying the quality of life associated with health allows us to raise a number of questions and point out typical mistakes made by researchers.

First of all, the question arises, is it appropriate to talk about the quality of life in a country where many people live below the poverty line, the public health system is not fully funded, and the prices of medicines in pharmacies are not affordable for most patients? Most likely not, because the availability of medical care is considered by WHO as an important factor affecting the quality of life of patients.

The second question that arises when studying the quality of life is whether it is necessary to conduct a survey of the patient himself or is it possible to interview his relatives? When studying the quality of life associated with health, it is necessary to take into account the fact that there are significant discrepancies between the quality of life indicators assessed by the patients themselves and "outside observers", such as relatives and friends. In the first case, when relatives and friends overdramatize the situation, the so-called “bodyguard syndrome” is triggered. In the second case, the "benefactor's syndrome" is manifested, when they overestimate the real level of the patient's quality of life. That is why in most cases only the patient himself can determine what is good and what is bad in assessing his condition. Exceptions are some questionnaires used in pediatric practice.

A common mistake is the attitude to the quality of life as a criterion for the severity of the disease. It is impossible to draw conclusions about the effect of any method of treatment on the patient's quality of life, based on the dynamics of clinical indicators. It is important to remember that quality of life is not assessed by the severity of the course of the process, but by how the patient tolerates his illness. So, with a long-term illness, some patients get used to their condition and stop paying attention to it. In such patients, an increase in the level of quality of life can be observed, which, however, will not mean remission of the disease.

A large number of clinical research programs are aimed at choosing optimal algorithms for the treatment of various diseases. At the same time, the quality of life is considered as an important integral criterion for the effectiveness of treatment. For example, it can be used to compare the quality of life of patients suffering from stable exertional angina who underwent a course of conservative treatment and underwent percutaneous transluminal coronary angioplasty before and after treatment. This indicator can also be used in the development of rehabilitation programs for patients who have undergone serious illnesses and surgeries.

The importance of assessing the quality of life associated with health as a prognostic factor has been proven. Data on the quality of life obtained before treatment can be used to predict the development of the disease, its outcome and, thus, help the doctor in choosing the most effective treatment program. The assessment of quality of life as a prognostic factor can be useful in the stratification of patients in clinical trials and in the choice of an individual treatment strategy for a patient.

An important role is played by studies of the quality of life of patients in monitoring the quality of medical care provided to the population. These studies serve as an additional tool for evaluating the effectiveness of the medical care organization system based on the opinion of its main consumer, the patient.

Thus, the study of health-related quality of life is a new and effective tool for assessing the patient's condition before, during and after treatment. Extensive international experience in studying the quality of life of patients shows its promise in all areas of medicine.

O.P. Shchepin, V.A. Medic