Medicine

ALGORITHM 1

ALGORITHM 1

Taking of patients history

 

Gynaecological anamnesis is taken in such order:

I.                   I.                   Menstrual function.

1.     1.     In what age does the menstruations begin?

2.     2.     In which age do the y become regular?

3.     3.     How many days does the menstruation last?

4.     4.     In how many days does the menstruation repeat?

5.     5.     What quantity of blood is lossed during menstruation?

6.     6.     Are the menstruations regular?

7.     7.     Is menstruation accompanied by the unpleasant feeling?

8.     8.     When the last menstruation was?

9.     9.     Did the character of menstrual function during this disease change?

II.                II.                Sexual function.

1.     1.     In what age does the sexual life begin?

2.     2.     Do you use oral contraceptives? Which exactly? What their efficiency?

3.     3.     Did the character of sexual function during this disease change?

III.             III.             Generative function.

1.     1.     How many pregnancies were?

2.     2.     How did pass each of them, which complications were present? What every pregnancy finished by?

3.     3.     How many births were? How did they pass? Which complications were predent?

4.     4.     How did post-natal periods pass?

5.     5.     How many abortions were? What term of pregnancy did they come in?

6.     6.     How many artificial abortions were?

IV.            IV.            Secretory function.

1.     1.     Is any discharge from sexual ways are present?

2.     2.     What character of discharge? Their color? Smell ?

3.     3.     Does the character of discharge during a menstrual cycle change?

4.     4.     Did a secretory function change during disease ?

 

 

ALGORITHM 2

Calculation pulse rate

 

1. Necessary tool.

Clock or stop-watch

 

2. Position of patient.

 

3. Order.

The patient is in bed or sits on a chair in comfortable position

1.         1.          Switch a stop-watch or mark on a watch the time.

2.         2.         Overcome the left hand of patient by a right hand in the area of radiocarpal joint.  Place a thumb finger on the external surface of joint, and index, mid and nameless – on  internal.

3.         3.         To find the radial artery.

4.         4.         To calculate the frequency of pulse for a 1 minute.

 

5.         5.         To fill in the results in a temperature chart.

 

 

 

 

 

 

 

 

 

 

 

 

 

Pay attention to filling, strenght, rhythm of pulse.

 

Fill in the pulse in a temperature chart by a red pencil.

 

 

 

ALGORITHM 3

Estimation of arterial blood pressure

 

Necessary tool

Tonometer, phonendoscope.

 

Position of patient

 The patient is in bed or sits on a chair near table, an arm is located on the table higher than elbow.

 

Order

1.           1.           To put on the  shoulder of patient a blood pressure cuff so that its lower edge should be present on 2-3 cm above elbow.

2.           2.           To connect a cuff with the bulb of tonometer.

3.           3.           To find  the place of pulsation of radial artery in the area of elbow. To put  phonendoscope into this place.

4.           4.           Close a valve.

5.           5.           Pressing a pear, force air in a cuff.

6.           6.           After disappearance of sound of pulse blows force air still on 2-3 points.

7.           7.           Halt to force air, open a valve and slowly let out air.

8.           8.           Mark a mark on a scale, when with¢there will be the first pulse blow. It is the size of systolic pressure.

9.           9.           Continuing to let out air, mark on a scale a mark which pulse blows disappear on. It is the size of diastolic pressure.

One finger only should pass through the cuff.

 

 

 

 

At pregnant arterial pressure is measured on both hands  

 

 

 

ALGORITHM 4

Inspection of cervix in Sims’ speculum

 

Position of patient

 The gynaecological inspection is helded on a gynaecological arm-chair. A woman lies on the back with half-bent in knee  and heeps.

 

 

Necessary tool

Sims’ speculum, sterile gloves

 

Preparation of patient

 To evacuate urinary bladder and rectum, for some indications - necessary  to perform an evacuant enema.

 

Order

1. 1. By the thumb and index  fingers  of the left hand sexual labias are opened.

2. 2. Speculum is grasped by the right right hand and inserted into  vagina, turning it firstly in oblique,  later in direct position to pudendal cleft. 

3. 3. To put a speculum on the back wall of vagina and slightly press on it.

4. 4. The retractor is inserted in parallel direction inside the vagina and pressing into anterior vaginal wall.

5.                     5.                     The cervix is inspected.

6.                     6.                     After cervical inspection the speculum and retractor are removed in  reverse order: retractor  - at first, then speculum.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALGORITHM 5

Inspection of cervix in Cusco speculum

 

Position of patient

 The gynaecological inspection is performed on a gynaecological arm-chair. A woman lies on the back with half-bent in knee  and heeps.

 

 

Necessary tool

Cusco speculum, sterile gloves

 

Preparation of patient

To evacuate a urinary bladder and rectum, if it is necessary cleansing enema is made.

 

Order

1.     1.     Sterile gloves are dressed.

2.     2.     By the thumb and index fingers  of the left hand labias major are opened in the lower third.

3.     3.     A speculum is inserted in vagina, placing blades parallel to the pudendal cleft.

4.     4.     After insertion of the speculum inside it is returned on 90 0, blades are opened so that vaginal part of cervix was found between blades.

5. After the cervical inspection blades are removed from vagina.

 

 

 

 

 

 

 

A speculum is fixed by lock in some conditions.

 

 

 

ALGORITHM 6
Taking  smears for cytological examination

 

Position of patient

 A woman lies on a gynaecological arm-chair on the back with half-bent in knee  and heeps.

 

Necessary tool

Cusco or Sims speculum, Folchman’ spool, spatula Eyra or cervix brush for taking smears, pincers, wadding marble, subject slide, sterile gloves.

 

Preparation of patient

1.  1.                      A patient is present on gynaecological arm-chair.

2.  2.                     To insert a gynaecological speculum into a vagina, to examine a speculum.

 

Order

1.The material for research is taken from the  anterior lateral vault making a scrub. To put the material on the slide. 

2. By other instrument (the best – by a brush) the material is taken from cervicolumnar junction – tranzition zone.  For this purpose a brush is rotated into the channel of cervix on 360°. The received material is putted on subject slide, revolving a brush.

 

3. If on the cervix there are some changes, a smear is taken also from the pathologically changed areas exposed during colposcopy.

5. A speculum is removed.

6. The surname of the women is written in the special list, the material is sent to the histological laboratory.

 

Carefully by the wadding marble clutched in pincers, tailings of mucus are taken off from the cervix.

 

 

 

ALGORITHM 7

Taking of smears from a vagina for bacteriological examination

 

Position of patient

 A woman lies on the back with half-bent in knee  and heeps.

 

Necessary tool

Cusco or Sims’ speculum, Folcman’ spoon, Eyraspatula  or cervixbrush for taking smears, pincers, wadding marble, subject slide, sterile gloves.

 

Preparation of patient

 1. The  patient is presented in  gynaecological arm-chair.

2. To insert a gynaecological speculum into a vagina, to examine the cervix in speculum.

 

Order

1. A smear is taken from a posterior fornix, cervical channel and urinary orifice by a vaginal gynaecological spatula, uterine sound or cervixbrush. To put the scrub and to put the material on slide.

2.  A speculum is removed.

3. The surname of the women is written in the special list, the material is sent to the histological laboratory.

 

 

ALGORITHM 8

Taking of smear for gonorrhoea

 

Position of patient

 A woman lies on the back with half-bent in knee  andheeps.

 

Necessary tool

Cusco or Sims’ speculum, Folcman’ spoon, Eyraspatula  or cervixbrush for taking smears, pincers, wadding marble, subject slide, sterile gloves.

 

Preparation of patient

 1. The  patient is presented in  gynaecological arm-chair.

2. To insert a gynaecological speculum into a vagina, to examine the cervix in speculum

 

Order

1. A smear is taken from a posterior fornix, cervical channel and urinary orifice by a vaginal gynaecological spatula, uterine sound or cervixbrush. To put the scrub and to put the material on slide.

2.  A speculum is removed.

3. The surname of the women is written in the special list, the material is sent to the histological laboratory.

 

 

 

 

 

 

 

 

 

ALGORITHM 9

Bimanual (pelvic) examination

 

Position of patient

 A woman lies on the back with half-bent in knee  and heeps.

 

Necessary tool

Sterile gloves

 

Preparation of patient

 1. The patient is present in gynaecological arm-chair (before research urinary bladder and rectum are evacuated).

 

Order

1 With thumb and index fingers of the left hand labia major are spreded.

2. The middle and index fingers of the right hand are inserted into vagina, nameless and little finger are pressed to palm, and thumb finger is facing the pubis.

3. Fingers are placed into anterior fornix, the cervix is pushed backwards.

4. By an external hand carefully press on a anterior abdominal wall in direction  to the fingers, which are located in vagina. If the  uterus is placed in position of anteversio-anteflexio, it will be found between the fingers of external and internal hands.

5. The fingers of internal and external hands are located to the right from an uterus. Right adnexa are examined.

6. The fingers of internal and external hands are located to the left of uterus. The left adnexa are examined.

7. The fingers of right hand are removed from vagina.

 

 

 

 

If a woman is nor delivere,  and vagina is narrow, at research a mid finger is entered at first, the back wall of vagina is pushed back , then an index finger is entered.

 

 

 

 

ALGORITHM 10

Taking of the history in the pregnant woman

 

I. Anamnesis (in translation from Greek - flashback, reminder) is the taking of information about the origin and motion of disease. At the inspection of pregnant in detail obstetric anamnesis is found out. Finding is added to the individual card of pregnant and postpartum patient. A woman is asked in special order:

1. Passport data. The last name, name, patronymic, age, profession, place of work, address.

2. Reasons, that forced a woman to appeal for the medical help (stopping of menstruation, bloody disharge, increase of frequency of urination, enlargement  of milk glands, pains in a abdomen or back and in.).

3. Domestic anamnesis. Heredity: psychical diseases, alcoholism, drug addiction, lacks of development and other diseases which can be inherited or be had unfavorable influence on development of fetus.

4. Carried more early disease. Rachitis, effecting on deformations of pelvis; infectious diseases which can affect sexual development of girl, illnesses of liver,  heart, lungs.

5. Menstrual function:

1) age of menarhe (the first menstruation);

2) term of establishment of regular menstrual function;

3) duration of cycle;

4) duration of bleeding;

5) type of menstruation - painfull, recurrence, regularity;

6) bloodloss;

7) character of menstruations after the beginning of sexual life, births, abortions;

8) data of the first day of the last menstruation;

 

6.Secretory function:

1) presence of discharge from sexual ways;

2) quantity, character of the discharge (bloody, festering, mucous, watery).

 

7. Sexual function:

1) age of beginning of sexual life;

2) what marriage and his duration;

3) health of man (alcoholism, tuberculosis, gonorrhoea, Syphilis);

4) application of contraceptives, duration, efficiency

5) presence of sterility in anamnesis, its duration, methods of medical treatment.

 

8. Genital function or obstetric anamnesis:

1) quantity of pregnancies;

2) result of every pregnancy: births, abortion, ectopic pregnancy, stillborn, features of motion of pregnancy, births, post-natal period;

3) quantity of living children, their mass at birth, features of development.

9. Gynaecological diseases, operations on the pelvic organs.

10. Motion of the given pregnancy – what term the complications were in, as treated oneself – ambulatory or in permanent establishment, what methods of medical treatment were used.

11. Fetal movement:

а) data of the first fetal movement;

б) intensity and frequency of movement.

 

 

ALGORITHM 11

Leopolds’ maneuvers

 

 

Necessary tool

Not needed

 

Position of patient

 The pregnant lies on the back. The doctor sitting to the right from pregnant.

 

Order

The first maneuver. The hands of both hands very tightly are laid horizontally, in the area of uterine fundus. Carefully press on a uterine fundus.

 

The second maneuver. Both hands are placed on the lateral surfaces of uterus at the level of umbilicus. By turns by a right and left hand palpation of fetal parts is performed. Carefully pressing by hands and fingers of hands on the lateral surfaces of uterus, dense, smooth, wide and shiny part is determined from one side - the back of fetus, from opposite – small parts are palpated .

 

 

The third maneuver. By a right hand presented part of fetus is grasped (large finger from one side and four - from the opposite side of lower segment of uterus). The character of presented part and its station is determined.

 

 

Fourth maneuver.  A doctor is standing towards patient’s feet. The hands of both hands are located on the lateral surfaces of lower uterine segment and carefully try to insert the fingers between presented part and pelvic inlet. 

 

The level of uterine fundus location and part of fetus, located in a fundus, is determined. Gestational age is determined.

 

 

By this maneuver the lie, position,variety, and also uterine tone, quantity of amniotic fluid waters and fetal movement, are  determined.

 

 

Presented part station is determined. 

 

 

 

 

Presented part station is determined.

 

 

 

ALGORITHM 12

Fetal heart tones auscultation

 

Necessary tool

Obstetric stethoscope

 

Position of patient

 The pregnant occupies position, lying on a the back with extended feet.

 

Order

Stetoscope is located on the place of the most clear feeling of fetal movement on the  anterior abdominal wall.  One end of watering-can of stetoscope is very tightly pressed on the pregnant’s abdomen, the second end of stetoscope a doctor puts to the area of ear.

Fetal heart tones are most distinctly listened from the side of the back of fetus, to the left - at the first position, to the right - at the second position, below the umbilicus – at cephalic presentation, above – at breech presentation.

 

The rate of fetal heart tones is  - 120-140per minute.

 

 

 

Tones of heart are double, rhythmic, do not correspond with the pulse of pregnant.

 

 

 

ALGORITHM 13

Estimation of uterine height and circumference of the abdomen

 

Necessary tool

Centimeter’ tape

 

Position of patient

 The pregnant occupies position lying on he back with extended feet.

 

Order

1.                 1.                 By a right hand, beginning of centimeter  tape is fixed to the middle of the symphysis. The end is touch in a midline to the uterine fundus.  The left hand determines the uterine height. It is marked on the tape. 

2.                 2.                 The onset of centimeter’s tape is taken by the left hand, a tape is stretched out under the back of pregnant at the level of iliac spines, at the  level of umbilicus for estimation of circumference of the abdomen

 

 

ALGORITHM 14

Determination of the expected fetal weight

For determination of the expected weight of fetus (EFW) it is necessary to know the height of standing of uterine fundus (UF) and circumference of abdomen(AC) of pregnant.

Volscov’ formula:

EFW = UF x AC 

For example: UF= 32 cm, AC = 100 cm. Multiply: 32х100, we received 3200cm. The expected weight of fetus is 3200 g.

Yacubova’ formula:  EFW= (AC+UF) : 4 x 100

For example:  UF= 32 sm, AC = 100 sm. Adding 32+100, we get 132, dividing on 4, we get 33, multiply on 100, we have the expected fetal weight – 3300 g.

 

ALGORITHM 15

Determination of gestational age of the pregnancy and probable day of delivery

1. from data of WOH a date which we get is considered the date of births, deducting 3 calendar months backwards from the 1th day of the last menstruation;

2. on a method Negele: from the 1th day of the last menstruation to deduct 3 calendar months and add 7 days. For example: date of beginning of the last menstruation – on January, 26. We add 7 days – we get on February, 2. From February, 2 we deduct backwards 3 months. Term of births – on a November, 2.

3. Date of non-permanent sexual intercourse. If to the number, when sexual intercourse happened, to add 273 days, the got number will be considered the date of the expected births.

4. Date of ovulation. For determination of term of births it is needed from the first day  of the expected menstruation which did not come, to take away 14 days and to the got number add 273 days.

5. Date of the first feeling of motions of fetus. That to get the date of births in primapara, to the day of the first feeling of motions of fetus to add 20 weeks, and inmultipara  - 22 weeks.

 

 

ALGORITHM 16

Perineal protective maneuvers

 

Necessary tool

Sterile serviette

 

Position of patient

Patient in labor lies on the back on a bed or occupies any comfortable for her position

 

Order

1.        1.        Prevention of preterm fetal head extension.  .

A doctor places the palm of the left hand on symphysis and fingers are located on the presented head. During pushing efforts the fingers flexed fetal head.

 

2.                            2.                            The delivery of the fetal head in the pauses of pushing efforts by increasing of vaginal opening.  In pauses between pushing efforts the thumb and index fingers of the right  hand extend teh vulvar muscles.  These two moments of obstetric help are performed on duty.

 

3.                            3.                            Decreasing of perineal tension by borrowing the tissues from the upper parts of the sexual organs  to the lover.

During pushing efforts the thumb finger of the right hand from  the one side and the four fingers from the other side on the region of sexual organs make the fold from skin to decrease tension on the perineal region.

4. Regulating of pushing efforts.

In the moment when the fetal head is delivered to the level of parietal tubes a midwife asks the womal in labor deeply to breathe the opened mouth. Fetal head is delivered in this moment.

After delivery of fetal head sucking of mucus from respiratory tracts is performed.

 

5.     5.     Delivery of the shoulders.

A doctor takes the fetal head for mento-temporal region by the hands of both hands and apply downward supporting of the fetal head till formation of the fixative point between upper part of anterior shoulder and lover symphysis.  After – upwards supporting for firstly delivery of posterior shoulder.  After – the index fingers of both hands inserted from the side of the back under the arms of fetus and send his trunk  up for delivery.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALGORITHM 17

Manual placental separation and removal

 

Necessary tool

Sterile gloves, sterile napkin

 

Position of patient

 Woman in labor lies on the back on a bed

The abdomen of patient is covered by a sterile napkin

Order

1. By the index and thumb fingers of the left hand the pudendal cleft is opened .

2. The right hand  is helding in cone enter in a vagina.

3. On an umbilical cord a hand is brought into the cavity of uterus, find the placental edge.

4. The left hand in this moment takes place on the uterine fundus and helps right.

5. Pulverulent motions of the right hand  entered between a placenta and wall of uterus,  a placenta is separated from the wall of uterus.

6. Sipping by the left hand for an umbilical cord,  placenta is drawn out,  a right hand still remains in an uterus. 

7. By a right hand the cavity of uterus is inspected once again,  that to make sure in absence of tailings of placenta.

8. We get a hand out of cavity of uterus.

 

 

 

The back side of palm is to be turned to the sacrums

 

 

 

 

 

 

 

 

 

 

 

ALGORITHM 18

Measuring of external sizes of pelvis

 

 

Necessary tool

Pelvimeter

 

Position of patient

 The pregnant occupies position, lying on a bed on the back with extended feet.

 

Order

Distantia spinarum - is measured between liac spines. It has 25-26 cm.

Distantia cristarum  - is measured between the prominent points of iliac bones In has 28-29 cm.

Distantia trochanterica - is measured between the prominent parts of trochanter major.  It has 30-31 cm.

External Conjugate is measured from the middle of symphysis til fossa suprasacralis. It has  20-21 cm.

 

 

The formula of pelvis is written down so:

25-28-31-20cm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Solovjov Index  - the average circumference of the radiocarpal joint.

It has 14-16 cm. An index is used for estimation of thickness of pelvic bones.

 

ALGORITHM 19

Measuring of internal pelvic sizes 

 

Necessary tool

Pelvicometer, centimeter tape, sterile gloves.

 

Position of patient

 The pregnant lies on a gynaecological arm-chair.

 

Order

1.                                  1.                                  To perform vaginal research.

2.                                  2.                                  During research to rich by the middle finger of right hand of sacral promontorium.

3.                                  3.                                  By the index finger of the left hand to mark a point on right, near lower symphysis touches a palm.

4.                                  4.                                  To show a right hand out of vagina.

5.                                  5.                                  To measure distance from the end of middle finger to the noted point by pelvicometer or centimeter tape.

6.                                  6.                                  For estimation obstetric conjugate, from the received sizes minus 2 cm.

The diagonal con’yogatou can be measured only at patients with a contracted pelvis.

In normal pelvis - doctor cannot reach the promontorium of the sacrum..

 

 

 

ALGORITHM 20

Primary care of new-born

 

Patient’ position

Patient lies on a Rahmanov’ bed on the back.

 

Note

Necessary tool

Sterile gloves

 

Stages of conducting

Technique of conducting of primary care of new-born

Note

1. Reception of  new-born

1.     1.     A nurse takes a child lays it out on the mother’ abdomen

2.     2.     Dries a child by a preliminary warmed-up sterile diaper.

3.     3.     Dresses a little cap and socks on the child.

4.     4.     Covers by a dry clean diaper and blanket.

 

The contact of child with the abdomen of mother is conducted with the purpose of contact “skin to the skin” and creation of “thermal chainlet”.

2. Estimation of new-born after a scale Apgar.

In the first minute after birth of neonatologist, and in the case of his absence an obstetrician estimates new-born after a scale Apgar.

 

3. I stage of the care of umbilical cord

1.     1.     To change gloves by sterile.

2.     2.     Through 1 min after the birth of child to impose 2 sterile clamps on an umbilical cord.

3.     3.     By sterile scissors to cut an umbilical cord between clamps.

Treatment of umbilical cord by antiseptic is not conducted.

4. The first applying to the breasts.

During 30 min after birth is conducted the first applying of child to the mother’ breasts.

 

5. Measuring of temperature

Through 30 min after birth a nurse takes the temperature of child body by an electronic thermometer in an axylary area

 

6. Conducting of prophylaxis of ophthalmia

 

 

 

 

At the end of the first hour after conducting of contact of mother and child “eyes in eyes” a midwife repeatedly  change gloves by sterile and conducts the prophylaxis of ophthalmia by the applying the 0,5% erythromicyni or a 1% tetracycli ointment on the child conjunctive.

 

7. Contact the “skin to the skin”

The contact the “skin to the skin” proceeds in a maternity hall at least 2 hours on condition of the satisfactory state of mother and child.

 

8. The ІІ stage of treatment of umbilical cord

1.     1.     A child is carried on the warmed table for new-born.

2.     2.     On an umbilical cord 0,3-0,5 cm from an umbilical ring impose a sterile clips.

3.     3.     An umbilical cord is opened.

 

 

9. Weighing, determination of antropometric indexes of child.

 

After completion of contact “skin to the skin” nurse weighs a child, growth is measured, circumference of head, thorax.

 

10. Primary medical review and transferring in a ward.

 

1.     1.     Neonatologist, and at his absence the obstetrician conduct a primary medical examination.

2.     2.     A midwife dresses to the child clean movable indicators, little cap, socks, gloves.

3.     3.     Cover a child together with mother by a blanket and transferred in the ward of common staying of mother and child.