Paramedic, the role of the paramedic in surgery. Thesis: The role of the paramedic in the prevention of anemia in children of primary and secondary school age

SMOLENSK REGIONAL HEALTH DEPARTMENT

REGIONAL STATE BUDGET

PROFESSIONAL EDUCATIONAL INSTITUTION

"SMOLENSK BASIC MEDICAL COLLEGE

NAMED AFTER K.S. KONSTANTINOVA"

(OGBPOU "Smolensk Basic Medical College named after K.S. Konstantinova")

Specialty 060101 “General Medicine”

Allowed for protection

Deputy Director of HR

A.L. Butsyk

"___"______________20__

GRADUATE QUALIFYING WORK

on the topic: “The role of the paramedic in vaccination”

Students of group 44F

Gorbacheva Irina Vladimirovna

Head of the research and development work: Shestakovskaya G.A.

Reviewer of the thesis: Gerasimov S.A.

Smolensk

Introduction………………………………………………………………………………

I. Theoretical part………………………………………… …….

1. History of the emergence and development of vaccines……………………………..

2. Types of vaccines……………………………………………………….

3. Preventive vaccinations…………………………………….

4. National calendar of preventive vaccinations………….

4.1 Tuberculosis………………………………………………………………

4.2 Hepatitis B…………………………………………………………………………………

4.3 Diphtheria, tetanus, whooping cough (DTP)…………………………………….

4.4 Polio……………………………………………………….

4.5 Measles, mumps, rubella…………………………

4.6 Haemophilus influenzae infection………………………………………………………

4.7 Pneumococcal infection…………………………………………………………………

5. Calendar of preventive vaccinations for epidemic indications………………………….

6. Vaccination of children against the background of diseases and in certain groups of children

7. Methods of administering vaccines…………………………………………….

8. Contraindications to preventive vaccinations………

9. Vaccination reactions and post-vaccination complications……………….

II. Practical part

III. Conclusion

IV. Application

V. List of sources used

INTRODUCTION

In recent years, the situation with infectious diseases has sharply worsened throughout Russia, especially in large cities. High growth is observed in the group of so-called controlled infections. This means that children are more likely to get sick with diphtheria, whooping cough, mumps and other infectious diseases. Scientists attribute this to changes in socio-economic conditions, in other words, to the deterioration of living conditions. But not only! The increase in the incidence of controlled infections is associated with insufficient vaccination coverage of eligible groups of children and adults, and the high frequency of unjustified refusals from vaccinations.

Humanity does not owe the salvation of so many lives to any medical science as vaccinology, which studies the development and use of drugs for the prevention of infectious diseases - vaccine prevention has demonstrated impressive successes and, without a doubt, has proven that it is the most effective means of preventing infectious diseases. One such achievement is the eradication of smallpox in the 20th century. In the near future, the goals of eliminating polio and reducing the incidence of measles, rubella, diphtheria and mumps are set. A wide network of immunization rooms has been created in children's clinics, and vaccination rooms have been opened to immunize children on a paid basis. The legal framework for vaccine prevention has been developed and implemented.

In the coming century, vaccine prevention will play an increasingly important role in protecting the population from infections. It is expected that in the 21st century the calendar of preventive vaccinations will include immunization against 35-40 infections. Today we can say with complete confidence that vaccination is an effective method of preventing a number of infectious diseases.

The purpose of the thesis is to analyze the activities of a paramedic in carrying out vaccination.

Objectives of the thesis:

1. Study the theoretical foundations of the organization of vaccination.

2. Research the activities of a paramedic in the organization of vaccination.

4. Independent analysis of the main provisions of this topic.

5. Study of literature, reference and scientific sources.

6. Summarizing the information received and drawing conclusions on this topic.

Research methods:

1. Theoretical:

· analysis of scientific literature;

· comparative analysis;

· generalization;

2. Empirical:

· document analysis;

· statistical data processing.

I. THEORETICAL PART

1. HISTORY OF THE APPEARANCE AND DEVELOPMENT OF VACCINES

Infectious diseases have plagued humanity throughout history. Taking a huge number of lives, they decided the destinies of people and states. Spreading with enormous speed, they decided the outcome of battles and historical events. Thus, the first plague epidemic described in the chronicles destroyed most of the population of Ancient Greece and Rome. Smallpox, brought to America in 1521 on one of the Spanish ships, claimed the lives of more than 3.5 million Indians. As a result of the Spanish Flu pandemic, more than 40 million people died in 1980-1920, which was 5 times higher than the losses during the First World War.

In search of protection from infectious diseases, people have tried a lot - from spells and conspiracies to disinfectants and quarantine measures. However, it was only with the advent of vaccines that a new era of infection control began.

Even in ancient times, people noticed that a person who had once suffered from smallpox was not afraid of repeated contact with the disease. At the beginning of the 18th century, protection against smallpox was carried out by rubbing liquid from skin blisters. Among those who decided on this method of protection against smallpox were Catherine II and her son Paul, the French king Louis XV. In the 18th century, Edward Jenner was the first doctor to vaccinate people with cowpox to protect them from smallpox. In 1885, Louis Pasteur, for the first time in history, vaccinated against rabies a boy who had been bitten by a rabid dog. Instead of imminent death, this child remained alive.

In 1892, a cholera epidemic swept through Russia and Europe. In Russia, 300 thousand people died from cholera per year. Russian physician V. A. Khavkin, who worked at the Pasteur Institute in Paris, managed to produce a drug, the administration of which reliably protected against the disease. Khavkin tested the vaccine on himself and on volunteers. With mass vaccination, the incidence and mortality from cholera among vaccinated people decreased tenfold. V. A. Khavkin also created a vaccine against plague, which was successfully used during epidemics.

The vaccine against tuberculosis was created by French scientists in 1919. Mass vaccination of newborn children against tuberculosis was started in France only in 1924, and in the USSR such immunization was introduced only in 1925. Vaccination has significantly reduced the incidence of tuberculosis among children.

At the same time, a vaccine against diphtheria, tetanus and whooping cough was created. Vaccination against diphtheria began in 1923, against whooping cough in 1926, and against tetanus in 1927.

The need to create protection against measles was due to the fact that this infection was one of the most common until the 60s of the last century. In the absence of vaccination, almost the entire child population under the age of 3 suffered from measles, and more than 2.5 million children died annually. The first vaccine was created in the USA in 1963; it appeared in the Soviet Union in 1968. Since then, the incidence has decreased by two thousand times.

Today, more than 100 different vaccines are used in medical practice, protecting people from more than forty infections. Vaccination, which saved humanity from epidemics of smallpox, plague, and diphtheria, is today rightfully recognized as the most effective way to combat infection. Mass immunization not only eliminated many dangerous epidemics, but also reduced mortality and disability. In the absence of vaccination against measles, diphtheria, tetanus, tuberculosis, polio, out of 90 million children born annually, up to 5 million died from vaccine-regulated infections and the same number became disabled (i.e., more than 10% of children). More than 1 million children died annually from neonatal tetanus, and from whooping cough: 0.5-1 million children. Among children under 5 years of age, up to 60 and 30 thousand children died annually from diphtheria and tuberculosis, respectively.

After the introduction of routine vaccination in a number of countries, there have been no cases of diphtheria for many years, polio has been eradicated throughout the Western Hemisphere and in Europe, and the incidence of measles is sporadic.

In developing countries, where there are not enough resources for mass vaccination against tetanus infection, the mortality rate is very high. Every year, 128,000 children around the world die from tetanus before reaching their first birthday. It kills 30,000 mothers within a week of giving birth. Tetanus kills 95 people out of 100 cases. In Russia, fortunately, such a problem does not exist, since children under one year old and adults are required to be vaccinated.

Recently, a lot of campaigns have appeared aimed at belittling the role of preventive vaccinations against infectious diseases. It is impossible not to note the negative role of the media in promoting the anti-vaccination program.

Unfortunately, cases of parents refusing all vaccinations for their children have begun to appear. These parents do not understand the danger they are exposing their children to, who are completely defenseless against infections. Good immunity and the vitamins used will not be able to help such children in the event of a real encounter with the causative agent of a serious disease. In these situations, parents are fully responsible for the health and life of their child.

The statement that “there is no evidence that vaccinations have helped humanity win the fight against some dangerous infectious diseases” is not true. Global studies in various countries around the world clearly confirm that the introduction of vaccine prevention has led to a sharp reduction or complete elimination of many diseases.

2. TYPES OF VACCINES

1. Live vaccines contain a weakened viral agent. These vaccines include vaccines against polio, measles, mumps, rubella or tuberculosis. When they are introduced into the body, they begin to multiply. The body's response is that it begins to produce antibodies that fight against infection.

2. Synthetic vaccines are vaccines that are artificially created recognition of pathogenic bacteria.

3. Chemical vaccines. They contain components of cells or other parts of pathogens. Chemical vaccines include some vaccines against whooping cough, Haemophilus influenzae, and meningococcal infection.

4. Toxoids are vaccines that contain an inactivated toxin. They undergo special processing. These are vaccines for diphtheria and tetanus.

5. Inactivated vaccines or “killed vaccines”. They are a microorganism killed under the influence of physical or chemical factors. These vaccines include vaccines against hepatitis A and whooping cough. These vaccines cannot be given frequently.

6. Recombinant vaccines. Genes of the infectious agent that are responsible for the production of protective antigens. Subsequently, it is he who produces and accumulates the necessary antigen. Recombinant vaccines for rotavirus infection and also against viral hepatitis B are known.

3. PREVENTIVE VACCINATIONS

Preventive vaccinations are a method of immunizing children against infectious diseases, when various vaccines are introduced into the body that can lead to the development of immunity. Preventive vaccinations are the administration of vaccines, which are immunobiological preparations. A vaccine is a weakened whole microbe or pathogen. The components of the vaccine cause a specific immune reaction, which is produced by antibodies, against the causative agent of the infectious disease. It is these antibodies that provide protection against infection.

There are 2 types of preventive vaccinations:

1. Planned:

· Hepatitis B;

· Tuberculosis;

· Diphtheria, tetanus, whooping cough (DTP);

· Poliomyelitis;

· Measles, mumps, rubella;

· Haemophilus influenzae infection;

· Pneumococcal infection.

2. Conducted according to epidemic indications:

· Rabies;

· Brucellosis;

· Typhoid fever;

· Hepatitis A;

· Yellow fever;

· Tick-borne encephalitis;

· Q fever;

· Leptospirosis;

· Meningococcal infection;

· Anthrax;

· Tularemia;

· Cholera;

4. NATIONAL CALENDAR OF PREVENTIVE VACCINATIONS

The concept of a vaccination calendar was formed in the 40-50s. last century, when the list of used vaccines increased. Now the number of “calendar” infections in developed countries has increased to 17 (except for vaccinations for epidemic indications). The list of preventive vaccinations of the NKPP of Russia, defined by the Federal Law, includes vaccinations against 12 infections; the right to approve the NKPP is granted to the Ministry of Health of the Russian Federation, which also establishes a list of vaccinations for epidemic indications (vaccinations against hepatitis A and meningococcal infection are included in the NKPP of a number of countries).

The NKPP of Russia is introduced by orders of the Ministry of Health of the Russian Federation, published at significant intervals (1973, 1980, 1997, 2001, 2011, 2014).

In the UK, this work is carried out by the Joint Committee on Vaccination and Immunization, established in 1963. In addition to the main composition, it includes 9 subcommittees on current issues. In Germany, this function is entrusted to the standing committee for vaccination at the Robert Koch Institute. In France, the development of proposals for NCPP is carried out by a vaccination committee of 18 members. In the USA, recommendations on NCPP are developed by the Advisory Committee of the Leading Areas of Vaccinology and Immunoprophylaxis.

The main difference between the National Vaccination Calendar of Russia and the NCPP of developed countries is the absence of vaccinations against rotavirus, papillomavirus infection and chickenpox, meningococcal infection and hepatitis A, as well as the presence of BCG revaccination, the use of whole-cell DTP vaccine, and the absence of a 2nd revaccination against whooping cough. These vaccines (except for hepatitis A) are not yet produced in Russia; their inclusion in the NKPP requires significant material costs.

Since 2012 Vaccinations against pneumococcal infection are introduced into the Immunoprophylaxis Calendar. The planned replacement of the 3rd dose of oral polio vaccine with an inactivated one, taking into account the worsening situation in the world, has been postponed for now. Thus, the Immunoprophylaxis Calendar from 2014 will include 12 infections (vaccinations against Haemophilus influenzae infection remain only for risk groups for now).

Table 1

Calendar of preventive vaccinations in Russia.

First 24h	1st vaccination against viral hepatitis B (including risk groups) (1)
3-7 days	Vaccination against tuberculosis (BCG-M or BCG) (2)
1 month	2nd vaccination against viral hepatitis B
2 months	1st vaccination against pneumococcal infection 1st vaccination against Haemophilus influenzae (children at risk) (4) 3rd vaccination against viral hepatitis B (at risk) (1)
3 months	1st vaccination against diphtheria, whooping cough, tetanus and polio (IPV)
4.5 months	2nd vaccination against diphtheria, whooping cough, tetanus and polio (IPV), pneumococcal and hemophilus influenzae (children at risk) (4)
6 months	3rd vaccination against diphtheria, whooping cough, tetanus, viral hepatitis B, Haemophilus influenzae (children at risk) (4) and polio (OPV)
12 months	Vaccination against measles, rubella, mumps, 4th vaccination against viral hepatitis B (risk groups)
15 months	3rd vaccination against pneumococcal infection (5)
18 months	1st revaccination against diphtheria, whooping cough, tetanus, polio (OPV), Haemophilus influenzae (children at risk) (4)
20 months	2nd revaccination against polio (OPV)
6 years	Revaccination against measles, rubella, mumps
7 years	2nd revaccination against diphtheria, tetanus (ADS-M), revaccination against tuberculosis (BCG) (6)
14 years	3rd vaccination against diphtheria, tetanus (ADS-M), polio (OPV)
Adults	Revaccination against diphtheria, tetanus - every 10 years
Against rubella	Children 1-18 years old, girls 18-25 years old (inclusive) who have not been sick, not vaccinated, vaccinated against rubella once

Continuation of the table. 1

(1) Children born to mothers who are carriers of HBsAg, sick with viral hepatitis B or who have had viral hepatitis B in the third trimester of pregnancy, who do not have test results for markers of hepatitis B, as well as those classified as risk groups: drug addicts, in families in which there is a carrier of HBsAg or a patient with acute viral hepatitis B and chronic viral hepatitis

(2) Vaccination of newborns against tuberculosis is carried out with the BCG-M vaccine; Vaccination of newborns is carried out with the BCG vaccine in subjects of the Russian Federation with incidence rates exceeding 80 per 100 thousand population, as well as when there are tuberculosis patients around the newborn.

(3) When using combined vaccines with a hepatitis component, the introduction of the 2nd dose of hepatitis B vaccine can be delayed by 2-3 months of age.

(4) Children with immunodeficiency conditions or anatomical defects leading to a sharply increased risk of hemophilus influenzae infection; with oncohematological diseases and/or receiving immunosuppressive therapy for a long time; HIV – infected and born from HIV-infected mothers; located in closed preschool institutions (orphanages, orphanages, specialized boarding schools for children with psychoneurological diseases).

For children who have not received the vaccine at 3 months. If vaccinations against hemophilus influenzae were not carried out in the 1st year of life, vaccination is carried out once in the 2nd year of life.

(5) For children who were not vaccinated in the 1st year of life, vaccination is carried out twice with an interval of at least 2 months.

(6) Revaccination against tuberculosis is carried out to tuberculin-negative children not infected with Mycobacterium tuberculosis at age 7.

4.1 Tuberculosis.

Tuberculosis is the most important problem in the world, which has become even more acute with the spread of HIV infection. A third of the world's population is infected with tuberculosis; the incidence of tuberculosis in the world reached its peak in 2004 - 8.9 million new cases (in 1997 - 8.0 million) with 1.46 million deaths. About 15% (and in the countries of South Africa - 50-60%) of all patients are infected with HIV. The failure to control tuberculosis is largely due to the limited protection provided by the BCG vaccine. The incidence of tuberculosis in Russia has increased from 34 in 1991. up to 85.4 per 100,000 in 2002, in 2012 it was 62.77 per 100,000, in children 0-14 - 16.72, among all patients with tuberculosis they make up 4%, and in children there is hyperdynamics due to “small forms”.

Vaccination against tuberculosis is carried out in more than 200 countries, over 150 countries provide it in the first days after the birth of a child. Only 10 countries carry out revaccination. In 2007, 89% of the world's newborns were vaccinated against tuberculosis.

In Russia, mass BCG vaccination is necessary; vaccinating only children from social risk groups, as is the case in countries with low incidence, is not yet acceptable for us, although, taking into account the frequency of BCG osteitis, it is tempting to postpone vaccination in more prosperous areas to an older age.

The BCG vaccine contains both living and non-living microbial cells. In the BCG-M vaccine, the proportion of living cells is higher, which makes it possible to obtain a satisfactory result with a smaller dose and reduce the frequency of adverse reactions. Both vaccines are from the M. bovis substrain - BCG (BCG -1 Russia), which has an average residual virulence with high immunogenicity. Both BCG preparations meet WHO requirements; the preparations are stored at a temperature not exceeding 8 0 C: BCG - 2 years, BCG-M - 1 year.

Vaccination is carried out for practically healthy newborns with the BCG-M vaccine at the age of 3-7 days. The BCG vaccine is used in newborns in regions of the Russian Federation with incidence rates above 80 per 100 thousand. population, as well as in the presence of tuberculosis patients in the environment.

Newborns with contraindications are vaccinated in neonatal pathology departments (stage 2) before discharge, which ensures a high level of coverage and reduces the number of children vaccinated in the clinic. Children who were not vaccinated during the neonatal period should be vaccinated within 1-6 months. life, children over 2 months. vaccinated only if the result is negative. Mantoux.

Revaccination is carried out for tuberculin-negative children under the age of 7 years who are not infected with tuberculosis.

Vaccination of a newborn leads to long-term (up to 10 years or more) preservation of immunity with post-vaccination or infraallergy, followed by the gradual development of more pronounced sensitivity to tuberculin, which slowly fades away over many years. Delaying revaccination to 14 years does not increase the incidence of tuberculosis in children and adolescents in regions with a satisfactory epidemic situation. The refusal of revaccination at 14 years of age in the new National Calendar is long overdue, because its influence on the epidemiological situation is more than doubtful.

Preparing for BCG vaccination. Before vaccination with BCG, the child should be examined by a neonatologist or pediatrician and his health condition should be adequately assessed. If there is a suspicion of any diseases associated with impaired immunity, it is best to postpone vaccination and carry out appropriate tests. In some cases, your doctor may prescribe antihistamines for several days before and after the vaccine.
Contraindication in BCG vaccination is prematurity (as well as intrauterine malnutrition of 3-4 degrees) - birth weight less than 2500 g. The use of the BCG-M vaccine is permissible starting from a weight of 2000 g. Premature babies are vaccinated when their original body weight is restored - the day before discharge. In newborns, withdrawal from BCG is usually associated with purulent-septic diseases, hemolytic disease, and severe damage to the central nervous system.

A contraindication to vaccination is primary immunodeficiency - it must be remembered if other children in the family had a generalized form of BCG-itis or death from an unclear cause (probability of immunodeficiency). WHO does not recommend vaccinating children of HIV-infected mothers until their HIV status is known. Although children perinatally infected with HIV remain immunodeficient for a long time, a decrease in reactivity is fraught with the development of generalized BCG-itis.

It is important to avoid unjustified withdrawal of newborns from BCG, incl. at the second stage of nursing, because the bulk of severe forms of tuberculosis and up to 70-80% of all deaths are registered in unvaccinated children.

Contraindications for revaccination are:

· Immunodeficiency conditions, malignant blood diseases and neoplasms. When prescribing immunosuppressants and radiation therapy, vaccination is carried out no earlier than 12 months after the end of treatment.

· Active or past tuberculosis, infection with mycobacteria.

· Positive or questionable Mantoux reaction.

· Complicated reactions to previous administration of the BCG vaccine (keloid scars, lymphadenitis).

Reactions. At the site of intradermal injection of BCG and BCG-M, an infiltrate of 5-10 mm in size develops with a nodule in the center and a smallpox-type crust, sometimes a pustule or small necrosis with scanty serous discharge. In a newborn, the reaction appears after 4-6 weeks; after vaccination - sometimes already in the 1st week. Reverse development occurs within 2-4 months, sometimes more, 90-95% of grafted people remain with a scar measuring 3-10mm.

Complications are divided into 4 categories:

· Local damage (subcutaneous infiltrates, cold abscesses, ulcers) and regional lymphadenitis.

· Persistent and disseminated BCG infection without lethal outcome (lupus, osteitis).

· Deseminated BCG infection, a generalized lesion with a fatal outcome, which is observed in congenital immunodeficiency.

· Post-BCG syndrome (manifestations of a disease that arose shortly after BCG vaccination, mainly of an allergic nature: erythema nodosum, granuloma annulare, rash).

Efficiency

The BCG vaccine, developed in 1921, is used almost unchanged in our time. Mycobacteria strain BCG-1, multiplying in the body, after 6-8 weeks create long-term immunity to tuberculosis, providing protection (64-78%) from generalized forms of primary tuberculosis, but not protecting against the disease in case of close contact with the bacilli-releasing agent and not preventing the development secondary forms of tuberculosis. There is also evidence that BCG reduces the infection of contacts. A 60-year follow-up of a high-risk group for tuberculosis (US Indians and Eskimos) showed a 52% reduction in the incidence of vaccine recipients over the entire period compared to placebo recipients (66 versus 132 per 100,000 person-years).

4.2 Hepatitis B

Hepatitis B is an acute viral disease characterized by severe damage to liver cells. The first symptoms of the disease resemble those of a common cold or flu, and it happens that hepatitis B is limited exclusively to these manifestations. Subsequently, jaundice (coloring the mucous membranes and skin yellow), nausea and vomiting, as well as dark urine and almost colorless stool are added to the list of symptoms. Bilirubin and liver enzymes increase in the patient’s blood, and characteristic markers of the virus are detected. The mortality rate among patients with hepatitis is low, but there is a high probability of the disease transforming into a chronic form, which usually leads to cirrhosis or liver cancer. It should be noted that in infants, hepatitis B is often asymptomatic, which greatly complicates diagnosis. In addition, the probability of chronic hepatitis in children who became infected in the first year of life is 90%, and in children from one to five years old - 50%.

Hepatitis infection occurs due to direct contact with the blood (or its preparations) of a sick person. That is, the disease is transmitted in the following ways: through contact with a carrier of the infection:

· through shared utensils, touching, handshakes, etc.;

· the so-called vertical route, that is, from the woman in labor to the child, especially if the woman is infected with an active form of the virus or suffered the disease in the last months of pregnancy;

· through shared needles during medical procedures, ear piercing, etc.;

· during transfusion of donor blood (statistically, up to 2% of donors in the world are carriers of hepatitis B);

· in approximately 40% of cases the source of the virus remains unclear.

Preparing for hepatitis B vaccination. Healthy children usually do not require special preparation for vaccination. You just need to measure the child’s body temperature - it should be normal, and in infants a temperature of up to 37.2 can be a variant of the norm. In addition, the pediatrician must adequately assess the child’s condition and make a further decision: prescribe any additional tests or medications, or even give a waiver for vaccination. Some doctors, to be on the safe side, prescribe antiallergic drugs to children as a preparatory step before vaccination. It should be noted that there is no great need for such an event, since not all children are prone to allergies.
Indications. Hepatitis B vaccination is a nationwide program. All newborns and people at risk are susceptible to it. The main indications for hepatitis B vaccination are to reduce the risk of infection and transmission of the virus from person to person. In childhood, children often become infected through:

· breast milk from an infected mother;

· contact with blood, saliva, tears or urine of an infected family member;

· medical manipulations with violation of the integrity of the skin;

· blood transfusion.

However, the following groups of children are at particular risk of infection:

· living in areas with a high level of infection;

· living in families with chronic hepatitis;

· living in children's institutions;

· receiving hemodialysis; children receiving certain blood products.

Contraindications. Vaccination against hepatitis B is contraindicated only for people who are allergic to baker's yeast. This is usually expressed in an allergic reaction to all bakery and confectionery products, kvass, beer, etc. If there is no allergy, but there was a strong reaction to the previous injection, the next dose is not administered. Allergic reactions to other antigens and diathesis are not contraindications, but in this case the allergist must select the appropriate time for the procedure. It is worth refraining from vaccination during the period of an acute cold or other infectious disease until complete recovery. After meningitis, all vaccinations are postponed for six months. In the presence of severe diseases, the timing of vaccinations is chosen, since the pathology of other organs and systems is not a contraindication for vaccination.

Reaction to the vaccine. The hepatitis B vaccine is very simple, that is, it is easily tolerated. Basically, the vaccine causes reactions at the injection site, which include: redness; small nodule; unpleasant sensation at the injection site when making fast and intense movements. These reactions are largely due to the presence of aluminum hydroxide and occur in approximately 10–20% of individuals. Today, the effectiveness of the vaccine is so high that manufacturers are reducing dosages and completely eliminating preservatives, which makes it possible to further minimize adverse reactions.

Complications. Complications of hepatitis vaccination include the following conditions: anaphylactic shock; hives; rash; exacerbation of allergy to dough containing yeast. The frequency of these complications ranges between 1 case in 100,000 and 300,000 - that is, these phenomena are very rare. We often hear that the hepatitis B vaccine increases the risk of multiple sclerosis. A WHO study of 50 countries found no such relationship.

4.3 Diphtheria, tetanus, whooping cough (DTP, ADS-m)

The DPT vaccine protects against diphtheria, tetanus and whooping cough. Contains inactivated toxins of diphtheria and tetanus microbes, as well as killed pertussis bacteria. DTS (diphtheria-tetanus toxoid) is a vaccine against diphtheria and tetanus for children under 7 years of age. Used if DPT vaccine is contraindicated.

ADS-m is a vaccine against diphtheria and tetanus, with a reduced content of diphtheria toxoid. It is used for revaccination of children over 6 years of age and adults every 10 years.

DTP (international name DTP) is a vaccine that produces immunity to three diseases at once - whooping cough, diphtheria and tetanus. Whooping cough is a dangerous disease caused by a bacterium called Bordatella pertussis. Its main symptom is attacks of severe spasmodic cough. Whooping cough is especially dangerous for one-year-old children, as it is fraught with respiratory arrest and complications such as pneumonia. The disease is transmitted from an infected person or carrier of the infection through airborne droplets.

Diphtheria is even more difficult in young patients, the causative agent of which is a special bacterium (diphtheria bacillus), which, among other things, is capable of releasing a toxin that destroys cells of the heart muscle, nervous system and epithelium. Diphtheria in childhood is very severe, with high fever, enlarged lymph nodes and characteristic films in the nasopharynx. It should be noted that diphtheria poses a direct threat to the life of a child, and the younger the child, the more dangerous the situation becomes. It is transmitted through the air (by coughing, sneezing, etc.), or through household contact with an infected person.

Finally, tetanus. The causative agent of the disease is the tetanus bacillus, which can exist in the environment for a very long time and is very resistant to antiseptics and disinfectants. It enters the body through wounds, cuts and other damage to the skin, producing toxins that are dangerous to the body.

Preparing for vaccination. Since the DPT vaccine represents a serious burden on the body, it is very important to properly prepare the baby for immunization.

· Before routine immunization, it is necessary to visit children's specialists, in particular, a neurologist, since most often complications after this vaccination occur in children with disorders of the nervous system.

· It is best to take blood and urine tests to make sure there are no diseases that could complicate the child’s condition after the injection.

· If the baby has suffered any infection (for example, ARVI), then at least two weeks should pass from the moment of absolute recovery until the moment the drug is administered.

· Children who are prone to allergic reactions should be given antihistamines in a maintenance dosage approximately three days before vaccination.

· Immediately before vaccination, the child should be examined by a pediatrician and adequately assess his condition.

Contraindications. There are general and temporary contraindications to DTP vaccination. General contraindications in which a medical exemption for vaccination is given include:

· Progressive disorders of the nervous system;

· Severe reactions to previous vaccinations;

A history of afebrile seizures (that is, those that were not caused by high fever), as well as febrile seizures associated with previous vaccine administrations;

· Immunodeficiency;

· Hypersensitivity or intolerance to any vaccine components.

If you have one of the above disorders, you should definitely consult with specialists, since if some of them are present, children may receive a dose of the vaccine that does not contain pertussis toxoids, which are the main source of severe side effects. Temporary contraindications to DTP vaccination are any infectious diseases, fever and exacerbation of chronic diseases. In such a situation, vaccination should be done no less than two weeks after the child has completely recovered.
Body reactions and side effects. Adverse reactions to DTP vaccination are observed in approximately a third of patients, and the peak of such reactions occurs on the third dose of the vaccine - it is during this period that intensive formation of immunity occurs. The reaction to the vaccine appears within three days after the vaccine is administered. It should be noted that any symptoms that appear after this period are in no way related to vaccination. Normal reactions to the injection, which resolve within two to three days after taking antipyretics and antihistamines, include the following:

· Temperature increase.

· Changes in behavior. The child may be restless, whine and even scream shrilly for several hours: this reaction is usually associated with pain after the injection.

· Redness and swelling at the injection site. A normal reaction is swelling of less than 5 cm and redness of less than 8 cm.

Severe adverse reactions include a significant increase in temperature (up to 40°C) or higher, short-term febrile convulsions, significant local swelling and redness (more than 8 cm), diarrhea, and vomiting. In this case, the child should be shown to a doctor as soon as possible. Finally, in very rare cases (about one in a million), complex allergic reactions are observed: rash, urticaria, Quincke's edema, and sometimes anaphylactic shock. They usually appear in the first 20–30 minutes. after the injection, therefore, during this time it is recommended to stay near the medical facility in order to be able to immediately provide the child with the necessary assistance.

4.4 Poliomyelitis

Poliomyelitis is a serious disease caused by a virus from the enterovirus group. It is transmitted from a sick person or a healthy carrier of the virus through the oral or airborne route, and most often affects children under five years of age. From the gastric tract, microorganisms enter the central nervous system, affecting the gray matter and motor nucleus of the spinal cord, and causing atrophy and deformation of the limbs, paralysis, contractures, etc. The course of polio can vary depending on the form of the disease. The initial stage is usually characterized by fever, gastrointestinal disorders, fatigue, headaches, and convulsions. In unvaccinated patients, the first stage of the disease passes into the second - the above symptoms disappear, but paresis and paralysis of the lower extremities and deltoid muscles appear, and less often - the muscles of the trunk, neck and face. Mortality from polio occurs in 5–20% of cases from paralysis of the respiratory muscles, but even if the patient recovers, he will most likely remain disabled for life. The main danger of polio is that the virus that causes the disease is very volatile and also quite resistant to external influences. Thus, in dairy products it can persist for three months, in water - about four, and in the patient’s stool for about six months.

Vaccination against polio is an effective measure for preventing the disease. It is thanks to preventive measures that in our time there are only isolated cases of polio in those countries where vaccination is not carried out.

Preparing for vaccination. Before vaccination against polio, the child must undergo an examination by a pediatrician who adequately assesses his health condition. Such an examination should be taken especially seriously and attentively in anticipation of vaccination with OPV, that is, “live” drugs.

To permanent contraindications for the use of OPV include:

· AIDS or any other immunity disorders;

· Malignant neoplasms;

· Neurological disorders resulting from previous polio vaccinations;

· Taking drugs that have an immunosuppressive effect.

In addition, “live” vaccines cannot be used by children who live with pregnant women.

In the above cases, there is a high risk of developing vaccine-associated poliomyelitis, so it is recommended that these children be vaccinated with inactivated drugs (IPV). The spectrum of contraindications for IPV is slightly narrower:

· Severe side effects on previous vaccinations;

· Allergy to certain antibiotics: kanamycin, streptomycin, polymyxin B, neomycin.

Finally, temporary contraindications for the administration of both types of vaccines are acute infectious or respiratory diseases, as well as exacerbation of chronic diseases. In this case, vaccination is postponed until the child’s condition normalizes. If immunization is carried out with an oral vaccine, after administration of the drug the child should not be fed or watered for an hour.
Adverse reactions. The response to polio vaccination can vary significantly depending on the type of drug and the child's health. The use of IPV is usually well tolerated, but in some cases the following side effects have been reported:

· Increased excitability and nervousness;

· The appearance of slight redness, swelling or infiltration at the injection site;

· Temperature rises to 38.5o.

Such phenomena, as a rule, go away on their own within a couple of days and do not require seeing a doctor. Normal reactions to OPV, which should not cause much concern, include the following:

· Minor gastrointestinal disorders;

· Mild allergic reactions;

· Nausea, single vomiting.

But a child needs urgent medical attention if the following symptoms appear:

· Unusual lethargy or severe weakness;

· Convulsive reactions;

· Shortness of breath or difficulty breathing;

· The appearance of severe itching, urticaria, etc.;

· The appearance of severe swelling of the limbs and/or face;

· Significant (above 39 0) increase in temperature.

4.5 Measles, mumps, rubella (MMR)

Measles is an infectious disease, the main symptoms of which are characteristic spots that appear first on the mucous membrane of the mouth, and then spread throughout the body. The main danger of measles is that this disease is transmitted very quickly: even direct contact with the carrier is not necessary for infection - it is enough, for example, to be in a room from which a sick person has recently left. In addition, about a third of those who have had measles experience a variety of complications, ranging from pneumonia to myocarditis. The disease is especially difficult in young children - in the Middle Ages, measles was often called the “children's plague.” Moreover, it is very dangerous for pregnant women: in this case, infection is fraught with miscarriages and serious disorders in the fetus.

Rubella also refers to childhood diseases that are unreasonably considered mild and harmless. The course of rubella is a bit like measles or acute respiratory infections: fever, a reddish rash all over the body, as well as enlarged occipital lymph nodes. It poses the greatest risk to adults and pregnant women who do not have immunity to the disease. In such cases, rubella can cause inflammation of the brain, as well as infection of the fetus, most often leading to abortion for medical reasons.

Parotitis popularly known as mumps, since due to damage to the salivary glands the patient has a very specific appearance. The mumps virus is not as active as the causative agents of measles and rubella, so direct contact with the carrier is necessary for infection. However, as in previous cases, mumps is dangerous not because of its course, but because of its complications: inflammation of the gonads (ovaries or testicles, depending on the sex of the child) may cause infertility in the future.

Preparing for vaccination is that the child must first be examined by a pediatrician, determining the presence or absence of any diseases. In addition, you should take general tests (blood and urine), and based on their results, assess the baby’s health status. For some children suffering from allergies, doctors recommend taking antihistamines for several days before and after vaccination. In addition, a child who is often sick for a long time may be prescribed a course of interferon therapy (for example, with the drugs “Viferon” or “Grippferon”) - it begins a few days before the injection and ends 14 days after.
In number contraindications against MMR vaccination include:

· Immunodeficiency conditions (HIV, etc.), or treatment with immunosuppressive drugs;

· Severe reactions to previous vaccinations;

· Intolerance to protein, gelatin, neomycin or kanamycin.

In addition, vaccination should be postponed for at least a month in case of any acute infectious diseases or exacerbation of chronic ones.

Reaction to vaccination and side effects. After the injection, some children may experience the following reactions:

· Swelling and severe compaction at the injection site, which can sometimes exceed 8 cm;

· Increase in temperature (up to 38.5 C);

Skin rash resembling measles;

· Runny nose;

· Diarrhea and/or single vomiting;

· Swelling of the testicles in boys.

Typically, such symptoms do not require serious treatment and disappear after a few days. If a child is prone to febrile convulsions or an increase in temperature seriously worries him, parents need to carefully monitor the baby’s condition and give him an antipyretic. If a rash or swelling of the testicles appears in boys, it is recommended to take paracetamol, and in case of a strong local reaction at the injection site, it is necessary to use blood circulation-improving and hormonal creams and ointments, and sometimes antihistamine therapy.

As for serious complications (Quincke's edema, pneumonia, meningitis, orchitis, etc.), they are observed in very rare, isolated cases.

4.6 Haemophilus influenzae infection

Haemophilus influenzae (HIB) infection is a whole complex of serious diseases caused by Haemophilus influenzae, or as it is also called, Pfeiffer's bacillus. This microorganism is easily transmitted when a patient coughs or sneezes, through common household items (for example, toys, dishes, etc.), and in addition, is present on the nasopharyngeal mucosa in approximately 10% of people. The most common form of Hib infections is acute respiratory infections, but in addition there is a fairly high risk of developing the following diseases and conditions:

Haemophilus pneumonia;

· Inflammation of subcutaneous adipose tissue (purulent cellulite);

· Inflammation of the epiglottis (epiglotitis), which is often accompanied by breathing problems;

· Purulent meningitis;

· Infectious diseases of bones, blood, heart;

· Arthritis and sepsis (quite rare).

The main danger of Hib infections is that children under the age of five are most susceptible to them, especially those who do not receive the necessary antibodies from mother's milk, attend childcare facilities, etc. In addition, due to their structure, 80% of Hemophilus influenzae strains are resistant to traditional antibiotics.

Vaccination against Haemophilus influenzae (Hib) infection Until 2010, immunization against Hib infection in the Russian Federation was not mandatory, but only a recommended measure, but at the end of 2010 it was included in the vaccination calendar at the legislative level. It should be noted that this is normal practice for most developed countries, where this preventive measure has been practiced for many years.

If parents for some reason refuse scheduled vaccinations, vaccination against this infection is strongly recommended for children who are at risk:

· Infants on artificial feeding;

· Premature babies;

· Patients suffering from various immunodeficiencies;

· Children who often catch colds and suffer from acute respiratory infections;

· Children with serious chronic diseases whose body is not able to fight Hib infections at full strength;

· For those who attend or plan to attend preschool institutions.

Preparation preparation for immunization against Hib infections is no different from preparation for other similar preventive measures: the person being vaccinated must undergo examination by a neonatologist or pediatrician, and, if necessary, by other specialists, in particular, by a neurologist. The fact is that it is children with neurological disorders who most often experience complications from various vaccines.

Indications. Prevention of purulent-septic diseases (meningitis, septicemia, epiglotitis, etc.) caused by Haemophilus influenzae type b in children from 3 months of age to 5 years.

Contraindications there are relatively few Hib vaccines; in particular, the list of permanent ones includes the following:

· History of severe allergic reactions to the administration of Haemophilus influenzae vaccine;

· Individual intolerance to tetanus toxoid and other components of the drug.

Relative contraindications (when immunization is recommended to be postponed) are acute infectious diseases, as well as exacerbations of any chronic ailments. In this case, the injection should be given when the child’s condition is completely stabilized.

Complications and side effects. Usually, Haemophilus influenzae vaccines are quite easily tolerated by those vaccinated of all ages, however, in some cases, local and general side effects may develop. These include:

· Redness, swelling, swelling and discomfort at the injection site (about 9% of vaccinated people);

· Fever, tearfulness, general malaise (1% of vaccinated people);

· Enlarged lymph nodes;

· Indigestion.

Each of these reactions does not require medical intervention and goes away on its own within a few days. It is impossible to get one of the forms of hemophilus influenzae infection after immunization, since it does not contain living microorganisms and bacteria.

It should be noted that side effects and complications are caused not by the bacterial antigen itself contained in Hib vaccines, but by the tetanus toxoid, which is also included in their composition. That is, people who are allergic to tetanus vaccine may also have allergic reactions to Haemophilus influenzae vaccines. In any case, parents should carefully monitor the baby’s condition after vaccination, and if any nonspecific symptoms occur, immediately show him to the doctor. Also, for half an hour after the procedure, the child should be under the supervision of qualified specialists.

Efficiency modern Hib vaccines are very high: for example, in developed countries, where routine immunization of the population against this infection has been carried out for a long time, the number of cases has decreased by 85–95%. In addition, this preventive measure can reduce the carriage rate of this bacterium from 40 to 3%.

4.7 Pneumococcal infection

Each of us encounters infections, viruses and bacteria every day, which pose a serious threat to health. One of these bacteria is called pneumococcus, and it poses a particular danger to young children. Since this microorganism is quite specific and highly resistant to medications, in particular antibiotics, one of the ways to protect against it is vaccination, which we will discuss below.

Several years ago, vaccination against pneumococcus in Russia was not a mandatory preventive measure, and was carried out only in certain cases: for example, children suffering from various chronic diseases (bronchitis, heart disease, etc.), diabetes mellitus, HIV-infected children, etc. .d. However, against the backdrop of an increase in the number of diseases caused by pneumococcus, as well as the deterioration of the epidemiological situation in the country, it was decided to introduce vaccination against infections caused by pneumococci into the National Vaccination Calendar starting in 2014.

Preparing for vaccination

Preparation for this vaccination is no different from preparation for other types of vaccination. That is, before administering the drug, the child should be examined by a pediatrician, and, if necessary, by other specialists (for example, a neurologist). In some cases, your doctor may prescribe antihistamines before and after the injection to reduce the risk of severe allergic reactions.
Indications:

· children over 2 years old;

adults over 65 years of age;

· all patients with chronic diseases (damage to the circulatory and respiratory systems, kidneys, chronic renal failure, nephrotic syndrome, diabetes mellitus), absent or non-functioning spleen), congenital and acquired immunodeficiency.

Contraindications. Due to the low reactogenicity of pneumococcal vaccines, there are very few contraindications to immunization. These include:

· Hypersensitivity to individual components of the drug, as well as pronounced allergic reactions to previous administrations of the vaccine;

· First and second trimester of pregnancy.

As for temporary contraindications (that is, cases when it is better to postpone vaccination), these include:

· Presence of any acute diseases;

· Increase in temperature, regardless of its cause;

· Exacerbation of chronic diseases.

In such situations, immunization against pneumococcus is carried out when the patient's condition is completely stabilized.

Possible complications. Since pneumococcal vaccines are new generation drugs and do not contain hazardous preservatives, they very rarely cause severe complications. The most common side effects are:

· Induration (infiltrate) or swelling at the injection site, which may be accompanied by discomfort;

· Increase in temperature to 39o;

· Changes in behavior, lethargy and irritability;

· Decreased appetite;

· Drowsiness or, conversely, worsening sleep.

It should be noted that such reactions were noted in no more than 2–5% of vaccinated people, and went away on their own within 24–48 hours. As for severe complications (very high fever, febrile convulsions, severe allergic reactions), they occur no more often than in 1 case out of 1000.

In any case, in order to eliminate any threat to the child’s life, immediately after the injection he should be under the supervision of specialists for at least half an hour, and it is better for severely weakened and premature children to be vaccinated in a hospital setting. In addition, parents should carefully monitor the condition and well-being of the baby after the injection, and if any nonspecific symptoms occur, immediately show him to a specialist. Read in detail about actions after vaccination aimed at reducing the risk of complications here.

Vaccine effectiveness. All modern pneumococcal vaccines are highly immunogenic, that is, they form lasting immunity to at least 90% of dangerous diseases caused by pneumococci.

5. CALENDAR OF PREVENTIVE VACCINATIONS ACCORDING TO EPIDEMIC INDICATIONS

Introduction

Chapter 1. Theoretical part

1 Definition

2 Classification

3 Etiology

4 Pathogenesis

5 Risk factors

6 Clinic

7 Diagnostics

8 Treatment

9 Prevention

Chapter 2. Practical part

2.1 Study of risk factors in patients

2.2 Methods for diagnosing patients with hypertension

3 Analysis and evaluation of the results of the study of patients with hypertension

2.4 The role of the paramedic in organizing and conducting diagnostic, therapeutic and preventive measures to combat hypertension

Conclusion

Introduction

Relevance. Considering the problem of hypertension, we are faced with a paradox: despite the significant prevalence of this pathology, public awareness about it is very low. According to statistics, only 37.1% of men know that they have hypertension, about 21.6% of them are being treated, and only 5.7% are being treated effectively. Women - about 59% know about the presence of the disease, 45.7% of them are being treated, and only 17.5% are being treated effectively.

Currently, arterial hypertension is considered to be a multifactorial disease, in the development of which both hereditary predisposition and environmental factors and bad habits play a role. Like no other disease, hypertension is a lifestyle disease. Clinical studies indicate the possibility of improving the life prognosis and quality of life of patients with adequate antihypertensive therapy, which is carried out differentially depending on the condition of the target organs, concomitant pathology and other characteristics of the patient.

Our country has positive experience in carrying out prevention programs. Thus, in the former USSR the “All-Union Cooperative Program for the Prevention of Arterial Hypertension” was implemented. As a result of their implementation in the groups of program participants, there was a decrease in overall mortality by 17% and 21%, respectively, the incidence of cerebral stroke by 50% and 38%, and mortality from cardiovascular diseases by 41%. Participation in the educational program forms a correct understanding of the disease, the risk factors for its occurrence and the conditions for its progressive course, which allows the patient to more clearly follow a set of recommendations for a long time, and forms an active life position for the patients themselves and their loved ones in the further process of recovery.

Object area therapy

Object of study - hypertension

Subject of study: Hypertension: analysis of prevalence, role of the paramedic in organizing and conducting diagnostic, therapeutic and preventive measures.

Purpose of the study: To study the role of the paramedic in organizing and conducting diagnostic, therapeutic and preventive measures to combat hypertension.

Research objectives:

Explain the concept and causes of the development of hypertension.

To study the classification and clinical picture of the manifestations of hypertension.

Consider the factors for the development of hypertension.

4. Conduct a study aimed at studying risk factors in clinic patients.

Process and analyze the research results.

6. Select methods for organizing and carrying out diagnostic, therapeutic and preventive measures to combat hypertension.

Analyze the research results and formulate conclusions.

Research methods:

1. Theoretical (study of literary sources)

Empirical (questionnaire)

Chapter 1. Theoretical part

1 Definition

Hypertension (Greek hyper- + tonos tension; synonym: essential arterial hypertension, primary arterial hypertension) is a common disease of unknown etiology, the main manifestations of which are high blood pressure in frequent combination with regional, mainly cerebral, disorders of vascular tone; stages in the development of symptoms; a pronounced dependence of the course on the functional state of the nervous mechanisms of blood pressure regulation in the absence of a visible causal connection of the disease with primary organic damage to any organs or systems. The latter circumstance distinguishes hypertension from symptomatic, or secondary, arterial hypertension.

The prevalence of hypertension in developed countries is high, and it is higher among residents of large cities than among rural populations. With age, the frequency of hypertension increases, and in people over 40 years of age it reaches 20-25% in these countries, with a relatively even distribution among men and women (according to some data, hypertension is more common in women).

In general, ideas about the etiology of hypertension are in the nature of hypotheses, therefore the idea that hypertension belongs to diseases of unknown etiology remains justified.

In the pathogenesis of hypertension, the leading one is a violation of higher nervous activity, which initially occurs under the influence of external stimuli and subsequently leads to persistent excitation of the autonomic pressor centers, which causes an increase in blood pressure.

2 Classification

Over the entire period of studying the disease, more than one classification of hypertension has been developed: according to the appearance of the patient, the reasons for the increase in pressure, etiology, the level of pressure and its stability, the degree of organ damage, and the nature of the course. Some of them have lost their relevance, while others continue to be used by doctors today, most often this is a classification by degree and stage.

There is no uniform systematization, but most often doctors use the classification that was recommended by WHO and the International Society of Hypertension (ISHA) in 1999. According to WHO, hypertension is classified primarily by the degree of increase in blood pressure, of which there are three:

1.The first degree - mild (borderline hypertension) - is characterized by pressure from 140/90 to 159/99 mm Hg. pillar

2.In the second degree of hypertension - moderate - hypertension ranges from 160/100 to 179/109 mm Hg. pillar

.In the third degree - severe - the pressure is 180/110 mm Hg. pillar and above.

You can find classifiers that distinguish 4 degrees of hypertension. In this case, the third form is characterized by pressure from 180/110 to 209/119 mm Hg. column, and the fourth is very heavy - from 210/110 mm Hg. pillar and above. The degree (mild, moderate, severe) indicates solely the level of pressure, but not the severity of the course and condition of the patient.

In addition, doctors distinguish three stages of hypertension, which characterize the degree of organ damage. Classification by stages: stage. The increase in pressure is insignificant and inconsistent, the functioning of the cardiovascular system is not impaired. Patients usually have no complaints. Stage. Blood pressure is high. There is an enlargement of the left ventricle. Usually there are no other changes, but local or generalized narrowing of the retinal vessels may be noted. stage. There are signs of organ damage:

· heart failure, myocardial infarction, angina pectoris;

· chronic renal failure;

· stroke, hypertensive encephalopathy, transient cerebral circulatory disorders;

· from the fundus of the eye: hemorrhages, exudates, swelling of the optic nerve;

· lesions of peripheral arteries, aortic aneurysm.

When classifying hypertension, variants of increased pressure are also taken into account. The following forms are distinguished:

· systolic - only the upper pressure is increased, the lower - less than 90 mm Hg. pillar;

· diastolic - lower pressure is increased, upper pressure - from 140 mm Hg. pillar and below;

· systolic-diastolic;

· labile - blood pressure rises for a short time and normalizes on its own, without medications.

3 Etiology

The main cause of hypertension: repeated, usually prolonged, psycho-emotional stress. The stress reaction is of a pronounced negative emotional nature.

Risk factors for hypertension are divided into manageable and uncontrollable.

Controllable risk factors include: smoking, alcohol consumption, stress, atherosclerosis, diabetes mellitus, excess salt intake, physical inactivity, obesity.

The main factors involved in the development of hypertension:

Excess Na+ causes (among other things) several effects:

Increased transport of fluid into cells and their swelling. Swelling of the cells of the walls of blood vessels leads to their thickening, narrowing of their lumen, increased vascular rigidity and a decrease in their ability to vasodilate.

Disorders of the functions of membrane receptors that perceive neurotransmitters and other biologically active substances that regulate blood pressure. This creates a condition for the dominance of the effects of hypertensive factors.

Disturbances in the expression of genes that control the synthesis of vasodilatory agents (nitric oxide, prostacyclin) by endothelial cells.

Studies have shown that consuming salt in amounts exceeding the physiological norm leads to an increase in blood pressure.

It has been scientifically proven that regular consumption of more than 5 g of salt in food daily contributes to the occurrence of hypertension, especially if a person is predisposed to it. Excess salt in the body often leads to spasm of the arteries, fluid retention in the body and, as a result, to the development of hypertension.

Environmental factors. Factors such as noise, pollution and water hardness are considered risk factors for hypertension.

Occupational hazards are of greatest importance (for example, constant noise, the need for attention); living conditions (including utilities); intoxication (especially alcohol, nicotine, drugs); brain injuries (bruises, concussions, electrical trauma, etc.).

Individual characteristics of the body.

Hereditary history of hypertension is one of the most powerful risk factors for the development of this disease. There is a fairly close relationship between blood pressure levels in first-degree relatives (parents, brothers, sisters). The risk increases even more if two or more relatives have high blood pressure.

Starting from adolescence, the average blood pressure level in men is higher than in women. Sex differences in blood pressure reach their peak in young and middle age (35-55 years). In later life, these differences smooth out, and sometimes women may have higher average blood pressure levels than men. This is due to the higher premature mortality of middle-aged men with high blood pressure, as well as the changes that occur in women's bodies after menopause.

High blood pressure most often develops in people over 35 years of age, and the older the person, the higher their blood pressure numbers. In men aged 20-29 years, hypertension occurs in 9.4% of cases, and in men aged 40-49 years - already in 35% of cases. When they reach 60-69 years of age, this figure increases to 50%. It should be noted that under the age of 40, men suffer from hypertension much more often than women, and then the ratio changes in the other direction.

Currently, hypertension has become much younger and increased blood pressure is increasingly being detected in young people and older people.

The risk of developing hypertension increases in women during menopause. This is due to a hormonal imbalance in the body during this period and an exacerbation of nervous and emotional reactions. According to research, hypertension develops in 60% of cases in women during menopause. In the remaining 40%, blood pressure is also persistently elevated during menopause, but these changes disappear as soon as the difficult time for women is left behind.

Stress is the body's response to the strong influence of environmental factors. There is evidence that various types of acute stress increase blood pressure. It is unknown, however, whether long-term stress leads to long-term increases in blood pressure independent of other factors such as diet or socioeconomic factors. In general, there is insufficient data to definitively say about the cause-and-effect relationship between stress and blood pressure or to calculate the quantitative contribution of this factor to the development of the disease.

It is difficult to find another such habit, about the dangers of which so much has been said and written. The fact that smoking can cause the development of many diseases has become so obvious that even a special term has appeared - “smoking-related diseases”. The cardiovascular system also suffers from nicotine.

Diabetes mellitus is a reliable and significant risk factor for the development of atherosclerosis, hypertension and coronary heart disease. Diabetes mellitus leads to profound metabolic disorders, increased levels of cholesterol and lipoproteins in the blood, and a decrease in the level of protective lipoprotein blood factors.

Atherosclerosis is the main cause of various lesions of the cardiovascular system. It is based on the deposition of fatty masses in the walls of the arteries and the development of connective tissue with subsequent thickening and deformation of the artery wall. Ultimately, these changes lead to a narrowing of the lumen of the arteries and a decrease in the elasticity of their walls, which makes it difficult for blood to flow.

Humanity has long known about the beneficial effects of muscle activity on the condition of the body. During physical activity, there is a sharp increase in energy consumption, this stimulates the activity of the cardiovascular system, trains the heart and blood vessels. Muscle load promotes mechanical massage of the walls of blood vessels, which has a beneficial effect on blood circulation. Thanks to physical exercise, the heart works better, blood vessels become more elastic, and cholesterol levels in the blood decrease. All this inhibits the development of atherosclerotic changes in the body.

Regular physical exercise in the fresh air, adequate to achieve an average level of fitness, is a fairly effective means of preventing and treating arterial hypertension.

Research data indicate that a weight gain of 10 kg is accompanied by an increase in systolic pressure of 2-3 mmHg. and an increase in diastolic pressure by 1-3 mm Hg.

This is not surprising, since obesity is often associated with other listed factors - the abundance of animal fats in the body (which causes atherosclerosis), consumption of salty foods, and low physical activity. In addition, if you are overweight, the human body needs more oxygen. And oxygen, as we know, is carried by blood, so an additional load is placed on the cardiovascular system, which often leads to hypertension.

Scientific studies have established a negative effect of alcohol on blood pressure, and this effect was independent of obesity, smoking, physical activity, gender and age. It is estimated that consumption of 20-30 ml. pure ethanol are accompanied by an increase in systolic pressure by approximately 1 mmHg. and diastolic pressure by 0.5 mmHg.

In addition, addiction occurs, which is very difficult to fight. Alcohol abuse can lead to the development of heart failure, hypertension, and acute cerebrovascular accident.

4 Pathogenesis

A number of factors are involved in the development of hypertension:

· nervous;

· reflex;

· hormonal;

· renal;

· hereditary.

It is believed that psycho-emotional overstrain (nervous factor) leads to depletion of vascular regulation centers with the involvement of reflex and humoral factors in the pathogenetic mechanism. Among the reflex factors, one should take into account the possible shutdown of the depressor effects of the carotid sinus and aortic arch, as well as the activation of the sympathetic nervous system. Among the hormonal factors, the strengthening of the pressor influences of the pituitary-diencephalic region (hyperplasia of the cells of the posterior and anterior lobes of the pituitary gland), excessive release of catecholamines (hyperplasia of the adrenal medulla) and activation of the renal-hypertensive system as a result of increasing renal ischemia (hyperplasia and hypergranularity of the cells of the juxtaglomerular apparatus, atrophy of the interstitial cells of the medulla) are important. kidney substances).

The renal factor in the pathogenesis of hypertension is given exceptional importance, since the excretion of sodium and water by the kidneys, their secretion of renin, kinins and prostaglandins is one of the main mechanisms for regulating blood pressure.

In the circulatory system, the kidney acts as a kind of regulator, determining the value of systolic blood pressure and ensuring, through a feedback mechanism, its long-term stabilization at a certain level (barostat function of the kidney). Feedback in this system is carried out by nervous and endocrine mechanisms of blood pressure regulation: the autonomic nervous system with baro- and chemoreceptors and vascular regulation centers in the brain stem, the reninangiotensin system, the neuroendocrine system (vasopressin, oxytocin), corticosteroids, natriuretic hormone and atrial natriuretic factor . In this regard, a prerequisite for the development of chronic arterial hypertension is a shift in the curve of the dependence of the excretory function of the kidney on the value of systolic blood pressure towards its higher values. This phenomenon is called “kidney switching,” which is accompanied by contraction of afferent arterioles, inhibition of the countercurrent multiplying system of the kidneys, and increased reabsorption of water in the distal tubules.

Depending on the activity of the pressor systems of the kidneys, they speak of vasoconstrictor hypertension with high renin activity in the blood plasma (the tendency to spasms of arterioles is sharply expressed) or hypervolemic hypertension with low renin activity (increased mass of circulating blood). The level of blood pressure is determined by the activity of not only pressor, but also depressor systems, including the kinin and prostaglandin systems of the kidneys, which take part in the excretion of sodium and water.

The role of hereditary factors in the pathogenesis of hypertension has been confirmed by the results of a number of experimental studies. It has been shown, for example, that the excretory and endocrine functions of the kidneys, which regulate blood pressure levels, can be determined genetically. In the experiment, lines of animals were obtained with “spontaneous” arterial hypertension, which is based on defects in the excretory and other functions of the kidneys. The “membrane theory” of primary hypertension is also convincing in this regard, according to which the primary link in the genesis of essential hypertension is a genetic defect in cell membranes with respect to the regulation of the distribution of intracellular calcium, which leads to a change in the contractile properties of vascular smooth muscles, increased release of mediators by nerve endings, and increased activity the peripheral part of the sympathetic nervous system and ultimately to the reduction of arterioles, which results in arterial hypertension and the inclusion of the renal factor (“kidney switch”). Naturally, hereditary pathology of cell membranes does not eliminate the role of stressful situations and psycho-emotional stress in the development of hypertension. Membrane cell pathology can only be a background against which other factors act favorably (Scheme XIX). It is important to emphasize the fact that the renal factor often closes the “vicious circle” of the pathogenesis of hypertension, since developing arteriolosclerosis and subsequent renal ischemia include the renin-angiotensin-aldosterone system.

1.5 Risk factors

The main cause of hypertension: repeated, usually prolonged, psycho-emotional stress. Stress - the reaction is of a pronounced negative emotional nature.

Risk factors for hypertension are divided into manageable and uncontrollable

Uncontrollable risk factors include: heredity, gender, age, menopause in women, environmental factors.

Controllable risk factors include: smoking, alcohol consumption, stress, atherosclerosis, diabetes mellitus, excess salt intake, physical inactivity, and obesity.

Excess Na+ in food.

Excess salt in the body often leads to spasm of the arteries, fluid retention in the body and, as a result, to the development of hypertension.

Environmental factors. Factors such as noise, pollution and water hardness are considered risk factors for hypertension. Occupational hazards (constant noise, need for attention) are of greatest importance; living conditions (including utilities); intoxication (especially alcohol, nicotine, drugs); brain injuries (bruises, concussions, electrical trauma, etc.).

Hereditary history of hypertension is one of the most powerful risk factors for the development of this disease. The risk increases even more if two or more relatives have high blood pressure.

High blood pressure most often develops in people over 35 years of age, and the older the person, the higher their blood pressure numbers. Currently, hypertension has become much younger and increased blood pressure is increasingly being detected in young people and older people.

Stress is the body's response to the influence of environmental factors. There is evidence that various types of acute stress increase blood pressure.

Diabetes mellitus is a reliable and significant risk factor for the development of hypertension and leads to profound metabolic disorders, increased levels of cholesterol and lipoproteins in the blood, and a decrease in the level of protective lipoprotein factors in the blood.

Atherosclerosis is the main cause of various lesions of the cardiovascular system. It is based on the deposition of fatty masses in the walls of the arteries and the development of connective tissue with subsequent thickening and deformation of the artery wall. Ultimately, these changes lead to a narrowing of the lumen of the arteries and a decrease in the elasticity of their walls, which makes it difficult for blood to flow.

Obesity. Research data indicate that a weight gain of 10 kg is accompanied by an increase in systolic pressure of 2-3 mm. rt. Art. and an increase in diastolic pressure by 1-3 mm. rt. Art.

Alcohol. It is estimated that consumption of 20-30 ml. pure ethanol are accompanied by an increase in systolic pressure of approximately 1 mm. rt. Art. and diastolic pressure by 0.5 mm. rt. Art.

Thus, acting simultaneously and over a long period of time, the factors described above lead to the development of hypertension (and other diseases). The impact of these factors on a person already suffering from hypertension contributes to the severity of the disease and increases the risk of developing various complications.

1.6 Clinic

The clinical picture of hypertension in the early stages of the disease is not clearly defined, so certain difficulties arise in differentiating this disease from neurocirculatory dystonia. Systolic blood pressure of 140-159 mm Hg is considered borderline. Art. and diastolic - 90-94 mm Hg. Art. Patients complain of a headache of a certain localization (often in the temples, back of the head), accompanied by nausea, flashing before the eyes, and dizziness. Symptoms intensify during a sharp rise in blood pressure (hypertensive crisis). Objectively, they find a deviation of the left boundaries of absolute and relative cardiac dullness to the left, an increase in blood pressure above the corresponding physiological (age, gender, etc.) norm, an increase (during a crisis) in the pulse rate and, accordingly, the heart rate, and often arrhythmia, accent II tone above the aorta, an increase in the diameter of the aorta. The ECG shows signs of left ventricular hypertrophy. During X-ray examination<#"justify">In accordance with the recommendations of the WHO Expert Committee, there are 3 stages of hypertension. Stage (mild) - periodic increase in blood pressure (diastolic pressure - more than 95 mm Hg) with possible normalization of hypertension without drug treatment. During a crisis, patients complain of headache, dizziness, and a feeling of noise in the head. The crisis can be resolved by copious urination. Objectively, only narrowing of arterioles, dilation of veins and hemorrhages in the fundus without other organ pathology can be detected. There is no left ventricular myocardial hypertrophy. Stage (moderate) - stable increase in blood pressure (diastolic pressure - from 105 to 114 mm Hg). The crisis develops against the background of high blood pressure; after the crisis resolves, the pressure does not return to normal. Changes in the fundus of the eye and signs of left ventricular myocardial hypertrophy are determined, the degree of which can be indirectly assessed by X-ray and echocardiographic studies. Currently, an objective assessment of the thickness of the ventricular wall is possible using echocardiography. Stage (severe) - stable increase in blood pressure (diastolic pressure - more than 115 mm Hg). The crisis also develops against the background of high blood pressure, which does not normalize after the crisis resolves. Changes in the fundus compared to stage II are more pronounced, arterio- and arteriolosclerosis develop, and cardiosclerosis joins left ventricular hypertrophy. Secondary changes appear in other internal organs.

Taking into account the predominance of a specific mechanism for increasing blood pressure, the following forms of hypertension are conventionally distinguished: hyperadrenergic, hyporheic and hyperrenin. The first form is manifested by severe autonomic disorders during a hypertensive crisis - a feeling of anxiety, facial hyperemia, chills, tachycardia; the second - swelling of the face and (or) hands with periodic oliguria; the third - high diastolic pressure with severe increasing angiopathy. The latter form is rapidly progressive. The first and second forms most often cause hypertensive crises, respectively, for stages I-II and II-III of the disease.

A hypertensive crisis is considered an exacerbation of hypertension. There are three types of crisis depending on the state of central hemodynamics at the stage of its development: hyperkinetic (with an increase in minute blood volume or cardiac index), eukinetic (with preservation of normal values ​​of minute blood volume or cardiac index) and hypokinetic (with a decrease in minute blood volume or cardiac index). index).

Complications of hypertension: heart failure, coronary heart disease, cerebrovascular accidents, up to ischemic or hemorrhagic stroke, chronic renal failure, etc. Acute heart failure, cerebral circulatory disorders most often complicate hypertension precisely during the development of a hypertensive crisis. Diagnosis is based on anamnestic and clinical data, results of dynamic blood pressure measurements, determination of the boundaries of the heart and the thickness (mass) of the wall of the left ventricle, examination of the vessels of the fundus, blood and urine (general analysis). To determine the specific mechanism of arterial hypertension, it is advisable to study humoral factors of pressure regulation.

Differential diagnosis. It is necessary to differentiate hypertension from symptomatic arterial hypertension, which is one of the syndromes in other diseases (kidney disease, skull injuries, endocrine diseases, etc.).

7 Diagnostics

Diagnosis of hypertension (HTN) and examination of patients with arterial hypertension (AH) is carried out in strict sequence, meeting certain objectives: Determining the stability of the increase in blood pressure (BP) and its degree. Exclusion of the secondary nature of hypertension or identification of its form.

Identification of the presence of other risk factors, CVD and clinical conditions that may affect prognosis and treatment, as well as classifying the patient to a particular risk group. Determining the presence of POM and assessing their severity.

Determination of blood pressure stability and its degree

During the initial examination of the patient, the pressure in both arms should be measured. Subsequently, measurements are taken on the arm where blood pressure is higher. In patients over 65 years of age, with diabetes and receiving antihypertensive therapy, measure blood pressure while standing after 2 minutes. It is advisable to measure the pressure in the legs, especially in patients under 30 years of age. To diagnose the disease, at least two measurements must be taken at least a week apart.

Daily blood pressure monitoring (ABPM)

ABPM provides important information about the state of the mechanisms of cardiovascular regulation, in particular, it reveals such phenomena as daily blood pressure variability, nocturnal hypotension and hypertension, blood pressure dynamics over time and the uniformity of the hypotensive effect of drugs. Moreover, 24-hour blood pressure measurements have greater prognostic value than single measurements.

The recommended ABPM program involves recording blood pressure at intervals of 15 minutes during wakefulness and 30 minutes during sleep. Approximate normal blood pressure values ​​for the waking period are 135/85 mmHg. Art., night sleep - 120/70 mm Hg. Art. with a degree of reduction at night of 10-20%. The absence of a nocturnal decrease in blood pressure or the presence of an excessive decrease should attract the attention of a doctor, because such conditions increase the risk of organ damage.

Although unconditionally informative, the ABPM method is not generally accepted today, mainly due to its high cost.

Once stable hypertension is identified, the patient should be examined to exclude symptomatic hypertension.

The examination includes 2 stages.

The first stage is mandatory research, which is carried out for each patient when hypertension is detected. This stage includes assessment of POM, diagnosis of concomitant clinical conditions that affect the risk of cardiovascular complications and routine methods for excluding secondary hypertension.

Anamnesis collection.

Laboratory and instrumental studies:

general urine analysis;

determination of blood levels of hemoglobin, hematocrit, potassium, calcium, glucose, creatinine;

determination of the blood lipid spectrum, including the level of HDL cholesterol, LDL cholesterol and triglycerides (TG):

electrocardiogram (ECG);

chest x-ray;

fundus examination;

Ultrasound examination (ultrasound) of the abdominal organs.

If at this stage of the examination the doctor has no reason to suspect the secondary nature of hypertension and the available data is sufficient to clearly determine the patient’s risk group and, accordingly, treatment tactics, then the examination can be completed.

The second stage involves research to clarify the form of symptomatic hypertension, additional examination methods to assess POM, and identification of additional risk factors.

Special examinations to detect secondary hypertension.

Additional studies to evaluate concomitant RF and POM. Performed in cases where they may affect the management of the patient, i.e. their results may lead to changes in the level of risk. For example, echocardiography is the most accurate method for detecting LVH, if it is not detected by ECG, and its diagnosis will affect the determination of the risk group and, accordingly, the decision on prescribing therapy.

Examples of diagnostic reports:

Hypertension (or arterial hypertension) 3 degrees, 2 stages. Dyslipidemia. Left ventricular hypertrophy. Risk 3.

Hypertension 2 degrees, 3 stages. IHD. Angina pectoris, functional class 11. Risk 4.

Stage 2 hypertension. Atherosclerosis of the aorta, carotid arteries. Risk 3.

Hypertension 1st degree, 3rd stage. Atherosclerosis of the vessels of the lower extremities. Intermittent claudication. Risk 4.

Hypertension 1st degree, 1st stage. Diabetes mellitus, type 2, moderate severity, compensation stage. Risk 3.

8 Treatment

The regime of work and rest, moderate physical activity, proper nutrition with limited consumption of table salt, animal fats, and refined carbohydrates are important. It is recommended to refrain from drinking alcoholic beverages.

Treatment is complex, taking into account the stages, clinical manifestations and complications of the disease. They use antihypertensive, sedative, diuretic and other drugs. Antihypertensive drugs used to treat hypertension can be divided into the following groups:

· drugs that affect the activity of the sympathetic-adrenal system - clonidine (clonidine, hemiton), reserpine (rausedil), raunatin (rauvazan), methyldopa (dopegit, aldomet), guanethidine (isobarine, ismelin, octadin);

· beta-adrenergic receptor blockers (alprenolol, atenolol, acebutalol, trazicor, visken, anaprilin, timolol, etc.);

· alpha-adrenergic receptor blockers (labetolol, prazosin, etc.);

· arteriolar vasodilators (apressin, hyperstat, minoxidil);

· arteriolar and venous dilators (sodium vitroprusside);

· ganglion blockers (pentamine, benzohexonium, arfonade);

· calcium antagonists (nifedipine, corinfar, verapamil, isoptin, diltiazem);

· drugs that affect water and electrolyte balance (hypothiazide, cyclomethiazide, oxodoline, furosemide, veroshpiron, triamterene, amiloride);

· drugs that affect the activity of the renin-angiotensin system (captopril, enalapril);

· serotonin antagonists (ketanserin).

Given the large selection of antihypertensive drugs, it is advisable to determine the specific mechanism for increasing blood pressure in a patient.

For stage I hypertension, treatment is a course of treatment aimed at normalizing and stabilizing normal blood pressure. They use sedatives (bromides, valerian, etc.), reserpine and reserpine-like drugs. The dose is selected individually. The drugs are given mainly at night. For crises with a hyperkinetic type of blood circulation, beta-adrenergic receptor blockers (anaprilin, inderal, obzidan, trazicor, etc.) are prescribed.

In stages II-III, continuous treatment with constant use of antihypertensive drugs is recommended to ensure that blood pressure is maintained as close as possible to the physiological level. Several drugs with different mechanisms of action are combined at the same time; include saluretics (hypothiazide, dichlothiazide, cyclomethiazide). Combined dosage forms containing saluretics (adelfan-esidrex, sinepres, etc.) are also used. For hyperkinetic type of blood circulation, beta-adrenergic receptor blockers are included in therapy. The use of peripheral vasodilators is indicated. A good effect is achieved by taking hemiton, clonidine, dopegit (methyldopa). In elderly people, during antihypertensive therapy it is necessary to take into account the compensatory value of arterial hypertension caused by the atherosclerotic process developing in them. You should not strive for blood pressure to reach normal, it should exceed it.

In case of a hypertensive crisis, more decisive actions are required. However, it must be remembered that a sharp decrease in blood pressure when stopping a crisis is essentially a disaster for the relationship between the mechanisms of pressure regulation that has developed in a certain way in the patient. During a crisis, the dose of drugs used is increased and drugs with a different mechanism of action are additionally prescribed. In emergency cases, with extremely high blood pressure, intravenous administration of drugs (dibazol, pentamine, etc.) is indicated.

Inpatient treatment is indicated for patients with high diastolic pressure (more than 115 mm Hg), with severe hypertensive crisis and for complications.

Treatment of complications is carried out in accordance with the general principles of treatment of syndromes that cause clinical complications.

Patients are prescribed exercise therapy, electrosleep, and in stage I of the disease, physiotherapeutic methods. In stages 1 and 2, treatment in local sanatoriums is indicated.

1.9 Prevention

The role of nervous mechanisms in the origin of hypertension is evidenced by the following facts: in the vast majority of cases, in patients it is possible to establish in the past, before the onset of the disease, the presence of strong nervous “shocks”, frequent unrest, and mental trauma. Experience shows that hypertension is much more common in people exposed to repeated and prolonged nervous strain. Thus, the huge role of neuropsychiatric disorders in the development of hypertension is indisputable. Of course, personality traits and the reaction of the nervous system to external influences matter.

Heredity also plays a certain role in the occurrence of the disease. Under certain conditions, nutritional disorders can also contribute to the development of hypertension; Gender and age matter. Thus, women during menopause (40-50 years old) suffer from hypertension more often than men of the same age. Increases in blood pressure can occur in women during pregnancy, which can lead to serious complications during childbirth. Therefore, in this case, therapeutic measures should be aimed at eliminating toxicosis. Atherosclerosis of cerebral vessels can contribute to the development of hypertension, especially if it affects certain sections responsible for the regulation of vascular tone.

Renal dysfunction is very important. A decrease in blood supply to the kidneys causes the production of a special substance - renin, which helps to increase blood pressure. But the kidneys also have a so-called renoprivative function, which consists in the fact that the medullary zone of the kidneys produces a substance that destroys compounds in the blood that increase pressure (pressor amines). If for some reason this so-called antihypertensive function of the kidneys is impaired, then blood pressure rises and stubbornly remains at a high level, despite comprehensive treatment with modern means. In such cases, it is believed that the development of persistent hypertension is a consequence of impaired renal function of the kidneys.

Prevention of hypertension requires special attention to nutrition. It is recommended to avoid excessive consumption of meat and fats. The diet should be moderate in calories, with limited protein, fat and cholesterol. This helps prevent the development of hypertension and atherosclerosis.

Overweight people should periodically resort to fasting diets. A known dietary restriction must be consistent with work activity. In addition, significant malnutrition contributes to the development of hypertension, causing changes in the reactivity of the higher parts of the central nervous system. A proper diet without the formation of excess weight should be sufficient to prevent functional disorders of the higher nervous system. Systematic weight control is the best guarantee of a proper diet.

A person suffering from hypertension should be moderate in fluid intake. The normal daily need for water is satisfied by 1-1.5 liters of all water taken per day in the form of liquids, including liquid meals at lunch. In addition, a person receives about 1 liter of liquid from water, which is part of the products. In the absence of heart failure, the patient can afford to take fluid in the range of 2-2.5 liters (preferably no more than 1-1.2 liters). It is necessary to distribute the drink evenly - you cannot drink a lot at once. The fact is that liquid is quickly absorbed from the intestines, flooding the blood, increasing its volume, which increases the load on the heart. It must move more blood than usual until the excess fluid is removed through the kidneys, lungs and skin.

Overwork of a diseased heart causes a tendency to edema, and excess fluid aggravates it even more. The use of pickles should be avoided and table salt should be limited to 5 g per day. Excessive salt consumption leads to disruption of water-salt metabolism, which contributes to hypertension. Alcoholic drinks and smoking also accelerate the development of the disease, so they should be strictly prohibited for patients with hypertension. Nicotine is a poison for blood vessels and nerves.

The appropriate distribution of work and rest hours is of great importance. Long and intense work, reading, mental fatigue, especially in persons predisposed to hypertension, contribute to its occurrence and development.

Particular attention should be paid to physical culture. It is a kind of protective measure that trains the neurovascular system of patients with hypertension, reduces phenomena associated with disorders of the nervous system - headache, dizziness, noise and heaviness in the head, insomnia, general weakness. Exercises should be simple, rhythmic, and performed at a calm pace. Regular morning hygienic exercises and constant walking, especially before bed, lasting at least an hour, play a particularly important role.

Hours spent in nature, outside the city, in the country are very useful. It must be remembered, however, that summer residents should alternate hours of intense work with hours of relaxed, simple movement. Try to avoid prolonged stress in a bent state, try not to garden, but rather spend active recreation in the countryside<#"justify">Conclusions on Chapter I

Hypertension deserves the most serious attention, especially because it leads to a strong decrease, and sometimes to loss of mental and physical performance in adulthood, when a person can bring maximum benefit to society. In addition, hypertension is one of the main obstacles to healthy longevity.

The role of nervous mechanisms in the origin of hypertension is evidenced by the following facts: in the vast majority of cases, in patients it is possible to establish in the past, before the onset of the disease, the presence of severe nervous stress, frequent anxiety, and mental trauma. Experience shows that hypertension is much more common in people exposed to repeated and prolonged nervous strain. Thus, the huge role of neuropsychiatric disorders in the development of hypertension is indisputable. Of course, personality traits and the reaction of the nervous system to external influences matter.

Early detection of psychopathological disorders and their timely correction are important factors that determine the success of rehabilitation measures in patients with hypertension.

In patients with hypertension and cardialgia, psychopathological symptoms are also more pronounced, mainly in the form of hypochondriacal, anxious and hysterical syndrome.

In persons with occupational arterial hypertension and patients with essential hypertension, the following character traits are most often identified: hyperthymicity, sthenicity, demonstrativeness, psychasthenicity and, less often, introversion, cycloidism and rigidity.

Heredity also plays a certain role in the occurrence of the disease. Under certain conditions, nutritional disorders can also contribute to the development of hypertension; Gender and age matter. Increases in blood pressure can occur in women during pregnancy, which can lead to serious complications during childbirth. Atherosclerosis of cerebral vessels can contribute to the development of hypertension, especially if it affects certain sections responsible for the regulation of vascular tone.

Thus, these factors require consideration when constructing an individual plan for the primary prevention of hypertension and rehabilitation of patients.

Chapter 2. Practical part

1 Study of risk factors in patients

After studying the literature on this topic, I decided to find out whether there were risk factors for visitors to the city clinic. I conducted a survey. The study involved 30 people of different ages.

Participants were asked to answer the following questions:

.Your age?

How do you assess the level of your health?

What, in your opinion, is the cause of the development of diseases of the cardiovascular system?

Do your relatives have cardiovascular diseases?

Do you smoke?

Is your life stressful?

Are you prone to obesity?

Do you do physical exercise?

Do you know your normal blood pressure numbers?

Summing up the results of the survey, we can conclude that many people do not comply with the simplest norms of a healthy lifestyle. Some become victims of inactivity (hypodynamia), others overeat with the almost inevitable development of obesity, vascular sclerosis in these cases, and in some - heart disease, others do not know how to rest, be distracted from work and everyday worries, are always restless, nervous, and suffer from insomnia which ultimately leads to numerous diseases of the cardiovascular system. Almost all respondents (91%) smoke, which actively shortens their lives. Thus, city residents have all the risk factors for cardiovascular diseases: smoking, excess weight, physical inactivity, stress, hereditary factors, and lack of awareness of their blood pressure.

This suggests that the city’s paramedics pay little attention to primary prevention; they need to take this problem more seriously, because today the incidence of hypertension in people is very high.

2 Methods for diagnosing patients with hypertension

In order to solve the problems formulated in the work, a survey of patients of both sexes aged from 25 to 75 years was carried out. The study involved 30 people who were divided into two groups:

group 1 - control, which included 15 healthy subjects: 6 women and 9 men (average age - 51.5 years). The group of healthy subjects included people who did not have chronic or acute somatic diseases or diseases of the nervous system, or mental health, and who consented to participate in the study.

group 2 - the main one, which included 15 patients with hypertension: 6 women and 9 men (average age - 48.9 years). In all patients, hypertension occurred with crises. Among the men, 2 were diagnosed with stage I hypertension, 2 with stage II hypertension, and 5 with stage III hypertension. Among the women, 2 had stage I hypertension, one had stage II hypertension, and 3 had stage III hypertension. All patients underwent a comprehensive clinical examination.

The design of the experiment is shown in Table 1.

Table 1

Scheme of constructing an experiment in a group of patients with hypertension

Research methods Age Group of patients Healthy Typological questionnaire G.Yu. Eysenck 25-751515 Cattell's sixteen-factor personality questionnaire 25-751515 Diagnosis of the level of personal frustration (Boiko) 25-751515 Emotional burnout (Boiko) 25-751515 Social maladjustment Leary 25-751515

For statistical processing of the research results, statistical methods zM were used.

3 Analysis and evaluation of the results of the study of patients with hypertension

Clinical research methods included general clinical, cardiological and neurological examinations. Anamnesis data, heredity, previous and concomitant diseases, frequency of nervous stress, bad habits, pregnancy, adherence to the treatment of hypertension and blood pressure control were taken into account. The study of the state of the cardiovascular system included blood pressure control.

The psychological study included:

Identification of extraversion-introversion, assessment of emotional stability-instability (neuroticism);

Assessment of individual psychological characteristics of a person;

Identification of the level of personal frustration and the level of manifestation of emotional burnout;

Study of the mechanisms of social maladjustment.

The most important component of hypertension is emotional disturbances. In our work, we assessed the personality characteristics of patients with hypertension using the following components: extraversion-introversion (Eysenck Questionnaire), individual psychological personality characteristics (Cettell Questionnaire), identifying the level of personal frustration and the level of manifestation of emotional burnout (Boiko Methods), studying the mechanisms of social maladaptation (Leary Method).

Typological questionnaire G.Yu. Eysenck (EPI Questionnaire). The EPI questionnaire contains 57 questions, 24 of which are aimed at identifying extraversion-introversion, 24 others - at assessing emotional stability-instability (neuroticism), the remaining 9 constitute a control group of questions designed to assess the sincerity of the subject, his attitude towards the examination and the reliability of the results.

Cattell's sixteen-factor personality inventory. The Cattell Questionnaire is one of the most common questionnaire methods for assessing individual psychological characteristics of a person both abroad and in our country. It was developed under the guidance of R.B. Cattell and is intended for writing a wide range of individual-personal relationships.

Diagnosis of the level of personal frustration (Boyko). The technique is aimed at a person’s emotional and negative experience of any failure, failure, loss, collapse of hopes, accompanied by a feeling of hopelessness and futility of the efforts made.

Emotional burnout (Boyko). Measuring the level of manifestation of emotional burnout - a psychological defense mechanism in the form of complete or partial exclusion of emotions in response to selected psychotraumatic influences.

Leary's social maladjustment. The technique was created by T. Leary, G. Leforge, R. Sazek in 1954 and is intended to study the subject’s ideas about himself and the ideal “I”, as well as to study relationships in small groups. Using this technique, the predominant type of attitude towards people in self-esteem and mutual assessment is revealed.

At the first stage, subjects in the control and main groups underwent a clinical trial.

An important stage of our study was the study of anamnesis, which allows us to assess the role of factors that take the most significant part in the formation of hypertension. The following indicators of medical history were taken into account: heredity, previous and concomitant diseases, frequency of nervous stress, bad habits, pregnancy, adherence to the treatment of hypertension and blood pressure control. The study of the state of the cardiovascular system included blood pressure control.

Based on the results of the anamnesis collection, the following indicators were identified:

table 2

Comparative analysis of anamnestic data of healthy and hypertensive patients

Groups Heredity Previous, concomitant diseases Nervous stress Bad habits Pregnancy Adherence to disease treatment Blood pressure level control Control (healthy) 426.8% 426.8% 746.9% 960.3% 16.7% 16.7% 213.4% Primary (patients with hypertension) 640, 2%960.3%1280.4%853.6%213.4%1067%15100%

A comparison of the anamnestic data of the subjects in the main and control groups established a significantly higher degree of stress load. If the differences are statistically significant (p<0,05) в группе гипертонических больных она составляла 80,4%, т. е. достоверно выше, чем у здоровых 46,9%. В 53,6% в основной группе, т. е. меньше, чем у здоровых 60,3% (p<0,05) был установлен факт вредных привычек. При исследовании наследственной предрасположенности было показано ее достоверное преобладание в группе больных гипертонической болезни (40,2%) по сравнению с соответствующими показателями у здоровых (наследственная предрасположенность 26,8%) (p<0,05).

When patients with hypertension were admitted to the hospital emergency room, the patients had the following blood pressure indicators and the corresponding severity of the disease.

Table 3

Clinical assessment of disease severity

Severity of the diseasePercentageHypertensive warning 1st grade 27.8Hypertensive warning 2nd grade 20.1Hypertensive warning 3rd grade, risk 4.53.6

Table 4

Associated psychovegetative symptoms

Psychovegetative symptomsPercentagesAsthenia26.8Headaches80.4Psycho-emotional stress53.6Low mood67Depression33.5

At the second stage, subjects in the control and main groups underwent psychological testing.

Analyzing the results obtained, we came to the conclusion that in patients with hypertension the level of social maladaptation is higher than in healthy subjects.

Thus, according to the study, we came to the conclusion that in order to normalize the psychological status of patients with hypertension, it is necessary to carry out psychocorrectional work among patients with hypertension.

2.4 The role of the paramedic in organizing and conducting diagnostic, therapeutic and preventive measures to combat hypertension

Prevention of hypertension, which is a chronic progressive vascular pathology, is a difficult task.

Given its widespread prevalence, a special role in working with patients belongs to paramedics, in particular paramedics. The most important prerequisite for effective treatment is thoughtful individual work with patients. First of all, it is necessary to instill in the patient the need for systematic (and not just when blood pressure increases) taking medications for many years, and also, most importantly, a decisive improvement in their lifestyle, i.e., eliminating, if possible, risk factors for arterial hypertension.

Prevention of hypertension is aimed at early detection of the disease by measuring blood pressure in people over 30-35 years of age during periodic medical examinations carried out at enterprises and institutions. People who are found to have increased blood pressure should be taken under medical supervision. The paramedic working at the paramedic station monitors the blood pressure of these people, actively visits them, and monitors the effect of antihypertensive drugs.

Prevention of hypertension occupies a paramount place in solving the problem of longevity, in maintaining mental and physical performance in adulthood. Thus, it is known that the presence of arterial hypertension shortens life expectancy by an average of 10 years (in the group of people over 45 years of age). Such a frequent complication of hypertension as hypertensive crisis causes a fairly high mortality rate, a high percentage of temporary loss of ability to work and disability. Huge labor losses are caused by another complication - myocardial infarction. It is practically important that the prevention of hypertension and the prevention of coronary artery disease largely coincide.

The most promising is the identification of persons with risk factors, i.e. those people in whom the development of hypertension is highly likely (hereditary burden, abuse of table salt, animal fats, liquids and alcoholic beverages, improper work and rest regime, endocrine changes, intake oral contraceptives).

Primary prevention of hypertension should begin in childhood. It is necessary to organize a medical examination in children's institutions, schools, universities with regular measurement of blood pressure in children and young people 2-3 times a year. This needs to be given special attention at first aid stations, in pre-medical appointment rooms in outpatient clinics, etc.

Primary prevention efforts must take into account all risk factors. Rational muscle load is necessary already in childhood, it is necessary to exclude unjustified exemptions from physical education at school, overfeeding of children and adolescents is unacceptable, especially salt eating (increased consumption of table salt). If moderate hypertension does not cause pain, then only a health regimen should be recommended. Night work, as well as work associated with sudden nervous overloads, bending of the head and torso, and lifting heavy objects, is contraindicated for these persons. It is not recommended for a patient with hypertension to sharply tilt the head or body, as this increases the pressure in the cerebral vessels; You should keep your head as straight as possible or move it slightly back. Overtime work is unacceptable, it is necessary to limit exposure to industrial and household noise as much as possible. Sitting in front of the TV for many hours is contraindicated, especially for elderly obese people after eating. Let us remember that it causes thrombosis of the small veins of the legs. It is necessary to combat hypokinesia.

You should exclude from the diet foods that can increase vascular tone and irritate the nervous system (rich meat soups, fried meat, strong coffee, alcoholic drinks, hot and spicy dishes). The fight against obesity is of great importance. People with excess body weight are recommended to periodically resort to fasting diets. Systematic control of body weight is a necessary prerequisite for a proper diet.

Persons with borderline hypertension should be under medical supervision. Their medical examination is required. Training physical activity is recommended. If within 6-12 months their blood pressure steadily returns to normal or remains in the border zone, then observation is continued for another year. When complaints (headache, insomnia, etc.) appear in people at risk, drug treatment is started, usually 6-blockers and sedatives are prescribed.

However, the paramedic must convince every patient with hypertension that without eliminating risk factors, drug treatment will give an incomplete and short-lived effect. It is precisely in patients’ lack of understanding of this circumstance, as well as in the irregularity of taking antihypertensive drugs, that lie the reasons for the relatively high incidence of hypertension and its complications, including deaths (stroke, myocardial infarction). The experience of some foreign countries shows that persistent work with patients, individually selected and regular antihypertensive therapy can reduce the incidence of myocardial infarction and hemorrhagic strokes in the population by 20-30%.

Therefore, the paramedic must carry out preventive work with people prone to hypertension in order to reduce the risk of morbidity. Although prevention is also necessary for people with hypertension. It is easier to prevent a disease than to treat it! And the paramedic plays a huge role in this.

Conclusions on Chapter II

Based on an empirical experiment, we can conclude that hypertension has a great impact on personality and largely determines the subject’s behavior.

The emotional sphere of patients with hypertension is characterized by high personal and reactive anxiety, emotional tension, low mood, irritability, and the presence of depressive states, including masked ones.

Patients with hypertension are characterized by a higher level of accentuation in general and in particular of the emotive, anxious, pedantic, cyclothymic and dysthymic types.

Patients with hypertension had a higher level of alexithymia, which acts as an important pathogenetic factor in the formation of psychosomatic pathology

Features of adaptation in psychosomatic disorders are difficult due to the active use of non-adaptive psychological defense mechanisms such as denial, repression, overcompensation and compensation, which do not contribute to the awareness of the presence and complexity of the disease, which leads to chronicity of the disease, as well as disharmonious personality development.

Thus, city residents have all the risk factors for cardiovascular diseases: smoking, excess weight, physical inactivity, stress, hereditary factors, and lack of awareness of their blood pressure.

This suggests that the city’s paramedics pay little attention to primary prevention; they need to take this problem more seriously, because today the incidence of hypertension in people is very high.

Conclusion

Measures to prevent hypertension are the subject of intensive and in-depth research. Hypertension, as observations have shown, is one of the most common cardiovascular diseases in many countries.

Patients with hypertension are more predisposed to the occurrence of atherosclerosis, especially of the arteries of the brain, heart, and kidneys. All this indicates the need for systematic measures of personal and public prevention of this disease and its timely treatment.

Epidemiological studies have shown that in a third of patients, hypertension is hidden.

Hypertension deserves the most serious attention, especially because it leads to a strong decrease, and sometimes to loss of mental and physical performance in adulthood, when a person can bring maximum benefit to society. In addition, hypertension is one of the main obstacles to healthy longevity.

First of all, anyone whose blood pressure is within the high or borderline normal range should think about hypertension. Everyone needs to have information about cases of hypertension in the family.

A person who may develop arterial hypertension, as a preventive measure, needs to reconsider the usual way of life and make the necessary amendments to it. This concerns increasing physical activity; regular outdoor exercise is necessary, especially those that, in addition to the nervous system, also strengthen the heart muscle: running, walking, swimming, skiing.

The diet should be complete and varied, including vegetables and fruits, as well as cereals, lean meats, and fish. Eliminate large amounts of table salt. You should also not get carried away with alcoholic beverages and tobacco products.

A healthy lifestyle, a calm and supportive atmosphere in the family and at work, regular preventive examinations with a cardiologist - this is the entire prevention of hypertension and cardiovascular diseases.

In this work I was:

.The literature on this topic was studied and analyzed, where I found out: risk factors for hypertension, the role of a paramedic in the primary prevention of arterial hypertension.

.A study was conducted to study risk factors for cardiovascular diseases in city residents.

.A leaflet for patients on the primary prevention of arterial hypertension has been developed. (Annex 1)

Having solved the tasks I listed above, I can say that the goal of the thesis has been achieved; I studied the role of the paramedic in the primary prevention of hypertension.

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Annex 1

Memo “Prevention of hypertension”

As a manuscript

PODILSKA

Marina Nikolaevna

for the degree of candidate of sociological sciences

Volgograd - 2013

The work was carried out at the State Budgetary Educational Institution of Higher Professional Education "Volgograd State Medical University" of the Ministry of Health of the Russian Federation

Scientific adviser:	Honored Scientist of the Russian Federation, doctor of philosophical science, Doctor of Law, Professor SEDOVA Natalya Nikolaevna
Official opponents:	Doctor of Philosophy, Professor PETROVA Irina Aleksandrovna, Head of the Department of History and Cultural Studies, Volgograd State Medical University, Ministry of Health of Russia, Volgograd Doctor of Medical Sciences, Honored Doctor of the Republic of Tatarstan, KHISAMUTDINOVA Zuhra Anfasovna, Director of State Autonomous Educational Institution of Secondary Professional Education "Kazan Medical College", Kazan
Leading organization	GBOU VPO "Astrakhan State Medical Academy" of the Ministry of Health of Russia, Astrakhan

Developed evidence-based proposals for improving the organization of emergency medical care at the prehospital stage in a large city in modern socio-economic conditions.

However, an analysis of the literature does not provide a unified idea of ​​the importance and professional role of the paramedic in the structure of the Russian healthcare system, which currently appears in a defragmented form - each of the researchers notes some significant feature, but there is no holistic idea of ​​this role yet. In this regard, it is of practical interest to study in the interdisciplinary field of sociology of medicine the parameters of the professional role of a paramedic in modern Russia, and the prospects for its implementation in the context of healthcare reform. Of particular importance is the definition of the boundaries of professional competence in conditions of competition with a general practitioner, since there is an urgent problem of duplication (cross-performance) of direct responsibilities between these specialists.

The high social significance of the work of a paramedic, on the one hand, and the lack of a scientifically based interpretation of his professional role at all stages of professional development, on the other, give rise to theoretical and practical demand for studying this key figure in the healthcare system and medical education using sociological methods. The sociology of medicine has the necessary scientific apparatus and methodological capabilities in order to integrate knowledge about the profession of a paramedic on a single conceptual basis, analyze his functions as a highly qualified specialist, determine the prestige and significance of this profession for society and develop a forecast for the development of this profession.

Purpose of the study- determine the parameters of the professional role of a paramedic in modern Russia and the prospects for its implementation in the context of health care reform, develop recommendations for increasing the social prestige of a paramedic in modern Russia.

This goal is achieved by solving the following scientific tasks:

1. Justify the methodology of medical and sociological research into the professional role of a paramedic;

2. Characterize the social status of a paramedic in modern Russia;

3. Find out the attitude of current paramedics to their professional role;

4. Explain the motives for choosing the profession “paramedic”;

5. Based on empirical research, create a social portrait of a modern paramedic;

Object of study– paramedic service as an integral part of the social health care institution.

Subject of study– professional role of a paramedic.

Working hypothesis. In connection with the implementation of the National Project “Health”, two hypotheses can be put forward about the role of a paramedic in domestic healthcare:

1. Paramedic is a dying profession. The need for it is decreasing due to: a) the expansion of high-tech types of medical care, during which the paramedic cannot realize his functions and b) in the context of the emergence of the professional role of the family doctor, who takes on part of the paramedic functions.

2. A paramedic is a profession that is widely in demand in modern Russia due to: a) the unstructured nature of rural medicine and the lack of qualified doctors in it and b) due to the fact that the role of a family doctor turned out to be unclaimed in urbanized areas.

These two hypotheses are alternative. To confirm one of them and refute the other, it is necessary to conduct a comprehensive medical and sociological study of the professional role of the paramedic.

Scientific novelty of the research consists in substantiating the medical capabilities and social need to consolidate and expand the professional role of the paramedic in modern Russia in the conditions of the imposed destruction of its professional and humanistic meaning, in developing recommendations for increasing the social status of the paramedic and the effectiveness of his work.

The scientific novelty of the research is revealed in provisions submitted for defense:

1. Currently, in connection with the implementation of the National Project “Health” throughout the Russian Federation, a dual position arises in the professional role of a paramedic in domestic healthcare. On the one hand, due to the expansion of high-tech types of medical care, during the implementation of which the paramedic cannot realize his functions, and in the context of the formation of the professional role of the family doctor, who takes on part of the paramedic functions, the need for the profession of “paramedic” is decreasing. On the other hand, this profession is widely in demand in modern Russia due to the unstructured nature of rural medicine and the lack of qualified doctors in it, and due to the fact that the role of a family doctor has turned out to be unclaimed in urbanized areas.

2. All village residents know that there is a first aid station in their locality. 96.08% of respondents used the services of a paramedic, 63.87% were completely satisfied. In case of illness, 92.44% of the rural population prefer to contact a paramedic, while 21.85% turn only to a paramedic. 75.91% of village residents believe that a woman with work experience, with secondary (48.74%) or higher (27.17%) education can cope better with the duties of a paramedic. 93.56% of rural residents have a negative attitude towards the proposal of the Ministry of Health to close FAPs, and 15.97% believe that the number of FAPs needs to be increased. 20.73% would not want their children to work as a paramedic. Thus, the need for a paramedic as an essential participant in the medical care process is confirmed by objective data from a sociological survey.

3. Health care authorities and, in part, local administrations do not fulfill the task of maintaining the high social status of the paramedic and poorly provide the conditions for him to fulfill his professional role. The social status of a paramedic needs to be strengthened and supported through specific socio-economic measures. Experts consider the following measures to be such measures: provide FAPs with transport, provide them with all the required equipment components, water supply and sewerage, increase the salaries of paramedics, expand the list of manipulations allowed to be performed by paramedics, TFOMS themselves pay not only for initial, but also subsequent visits to patients, send them for internships FAPs of medical college graduates.

4. The choice of the paramedic profession among medical college students is due to the following reasons: the importance of the profession in society, working with people (and all students believe that they know how to work with people), the correspondence of the paramedic’s work to the abilities and character of the students, the work requires constant creativity, and the opportunity for self-improvement. The predominant and most significant motives are: the possibility of the most complete self-realization in this particular activity, the desire for career advancement. The motives remained almost unchanged in importance at the beginning and end of training: the need to achieve social prestige and respect from others, the desire to avoid criticism from a manager or colleagues, the desire to avoid possible punishments and troubles.

5. Social portrait of a paramedic in modern Russia: This is a woman, aged 41 to 55 years, married, with 1-2 children, living in the area for more than 20 years. The total work experience is more than 20 years, the work experience as a paramedic is from 10 to 20 years. The salary is 12,065 ± 3,365 rubles per month. It provides 58.98% ±15.18% of the average family income per person per month. Does not have a clear understanding of how recent health care reforms have affected the work of paramedics. Experiencing difficulties such as the lack or lack of means of communication and transport, low wages, lack of conditions for providing quality care at the first aid station and long working hours. He believes that it is necessary, first of all, to solve the problems of transport for paramedics, equipping and repairing first aid stations, and pharmacy points in rural areas. I am sure that FAPs cannot be reduced, but should be left at the same number, because the rural population is interested in the development of the paramedic service. If possible, if it were possible to “start life over”, I would go back to work as a paramedic, but I doubt that I want to see my child in this profession.

Methodological basis of the study. The study was conducted in the categorical field of sociology of medicine. The methodology of the sociology of medicine allows us to apply an integrative approach to the study of psychological and social factors that determine the nature and specificity of the professional role of a paramedic. The study is based on the theory of social roles and the theory of professionalism by T. Parsons, classical studies of the sociology of medicine, fundamental studies of social roles and factors contributing to the success of role behavior (R. Dahrendorf, R. Linton, D. Moreno, T. Parsons), etc. In some comparisons, the dissertation author relied on data obtained by (2004), (2005), (2009), (2006), (2006) and others. The work used sociological methods: interviewing, questioning and focus group.

Experimental base of the study. To conduct this study, a program was developed to study the demand for a paramedic and his professional role in modern Russia using material from the Volgograd region. The research program included three stages. The first stage is a multiparametric questionnaire (Appendix 1), containing the following scales: nominal, rank, metric. The main goal of this section of the program was to study the population’s satisfaction with the medical care provided by a paramedic, opinions about who copes better with the duties of a paramedic, who respondents prefer - a family doctor or a paramedic, and attitudes towards the proposal of the Ministry of Health of the Russian Federation to close FAPs.

The second stage is interviewing experts (Appendix 2). Information was collected using a specially designed questionnaire.

The third stage is a focus group, presented in the form of successive functional blocks and including a system of tasks to be solved, development of a research methodology, determination of criteria for selecting participants, preparation of premises and equipment, development of a facilitator’s plan, conducting the discussion itself, and writing a report.

Theoretical and practical significance of the work consists of substantiating the need for the professional role of a paramedic as an institutional component of the health care system, proving the advantages of this functional unit compared to the functions of a family doctor that are currently not fully realized, identifying the necessary and sufficient working conditions for first-aid posts, and the expectations of the rural population in the provision of medical care.

The findings of the study can be used by local health authorities to optimize the activities of the Healthcare Modernization Program in the field of paramedic service. This is facilitated by the practical recommendations formulated in the Conclusion of the dissertation. In addition, the research materials can be used in the educational process in medical colleges that train paramedics.

Approbation of the dissertation. The materials and conclusions of the study were presented at scientific forums at various levels (Volgograd, 2010, 2013; Moscow, 2013; Arkhangelsk, 2011; Ufa, 2012, etc.). Based on the results of the study, methodological manuals were developed for the system of advanced training for paramedics: “The professional role of the paramedic in modern Russia” (Volgograd, 2012) and “Sociological monitoring of population satisfaction with the provision of paramedic care” (Volgograd, 2013). The sociological research program developed by the dissertation author is secured by an author's certificate. The study was approved by the Regional Ethics Committee of the Volgograd Region (Research Ethics Commission). Based on the dissertation materials, 10 scientific papers have been published, including four in journals on the Higher Attestation Commission List.

Work structure. The dissertation consists of an Introduction, two chapters, a Conclusion containing Practical Recommendations, a List of References - 206 sources (189 domestic and 17 foreign), a List of Abbreviations and two Appendices. The volume of work is 139 pages.

MAIN CONTENT OF THE WORK

In ADMINISTERED the relevance of the research topic, novelty, practical and theoretical significance of the work are substantiated, its purpose and main scientific objectives are formulated, the degree of development of the problem, the methodological and experimental basis of the research are characterized.

CHAPTER 1 "Paramedic" AS A PROFESSION" consists of two paragraphs, the first of which – “ Methodology for studying the professional role of a paramedic in the sociology of medicine" - An overview of sociological research on the problem of professions is given, works and ideas relating to medical professions are highlighted.

The dissertation author relies on the methodology for studying professions developed by T. Parsons, noting that, despite the well-known criticism against him, no sociologist has yet proposed a clearer and more evidence-based methodology.

At the same time, the dissertation characterizes the current state of development of problems of medical professions in domestic sociology and medicine. Thus, the issues of improving the qualifications of medical workers were considered in the works of Russian researchers: publications by L. V. Vecherkina, etc., as well as Kazan scientists:, and Antonova, the professional development of the personality of mid-level medical workers was studied. In the works of recent years, more attention has been paid to the issues health of medical workers (,), etc.

The sociological aspect of studying a group of paramedical workers is presented in the works of such authors as,

The working and living conditions of paramedical workers were the object of close attention,

One of the important aspects of our research is the study of the labor activity of paramedical workers. In this regard, of particular interest are works on the development of a methodology for studying problems of social and labor activity (Nugaev P. M., etc.). In particular, the monograph by the Kazan sociologist presents the concept of labor activity, which is defined as a special type of social activity, on the one hand, and as a reflection of the subjective component of labor, on the other.

The problem of professional preparedness of doctors of various specialties and paramedics in general medical practice was studied by Artamonova. She tried to determine the role of the paramedic in the system of general medical practice (family medicine) in rural healthcare in modern conditions. It has been established that the structure of providing assistance to the population by paramedics of FAPs in rural areas is very close to the activities of a general practitioner. But, as the dissertation author believes, this may also indicate the interchangeability of two professions, therefore, it is necessary to determine which of them is more socially in demand.

Currently, there are about 5 million paramedical workers working in medical institutions of the Russian Federation, and their supply is 112.7 people. Training, retraining and advanced training of paramedical workers is carried out by 450 institutions of secondary vocational education. It should be noted that despite the generally positive dynamics of growth in the number of medical workers, there is a negative increase in the number of paramedical workers. As a result, there is a decrease in the ratio of doctors and paramedics to 1:2.4, which is significantly lower than in developed countries of the world, where the same indicator is 1:4.0 and higher. This fact is confirmed in the socio-hygienic analysis of nursing in Russia. The data she provides indicates that the state of training of paramedical workers in the country does not satisfy modern society. This conclusion is important because in recent years many medical schools have acquired a new status (medical college) and are training paramedics not only at the basic level, but also at an advanced level.

Analysis of the literature led to the conclusion that the professional role of the paramedic has not been sufficiently studied. Paramedics can be considered as an independent link at the stage of providing first aid to the population in rural areas, in factories, in educational institutions at various levels, or in emergency cases. But their functions are very limited, and all components of the professional role are implemented, practically, only by those who work at the FAP.

IN §1.2 “Social status of the profession “paramedic” in modern Russia" reveals a contradiction in attitude towards the profession of a paramedic on the part of health care organizers and the population that uses paramedic help. The dissertation author provides an overview of regulatory documents regulating the training and professional activities of paramedics. Thus, according to Order No. 000n dated July 25, 2011 “On approval of the nomenclature of positions for medical and pharmaceutical personnel and specialists with higher and secondary vocational education in healthcare institutions” of the Ministry of Health and Social Development of the Russian Federation, a paramedic can hold the following positions: head of a medical and obstetric station , head of the health center, senior paramedic, paramedic, emergency medical assistant, paramedic-driver of an ambulance, paramedic-narcologist, paramedic for receiving emergency medical calls and transferring them to visiting emergency medical teams. The qualification characteristics of positions held by paramedics are regulated by Order No. 000n dated July 23, 2010 “On approval of a unified qualification reference book for positions of managers, specialists and employees, section “Qualification characteristics of positions of workers in the field of healthcare.”

The work of FAPs, where the main contingent of paramedics is concentrated and where the role of paramedics in providing medical care to the rural population remains fully preserved, is discussed separately in the dissertation. It is concluded that in the Russian Federation, rural healthcare is represented mainly by the paramedic level, and the profession of a paramedic fits organically into the role structure of domestic healthcare. Theoretically, the state not only has a need for paramedics, but also the capabilities for their quality training. But the theoretical justification for the need for the paramedic profession and the possibilities for training highly qualified specialists in this industry must be confirmed in practice. Therefore, the main argument for or against the paramedic service is the opinion of the consumers of its services - rural residents. In this regard, a study was carried out of their position on this issue. A sociological survey was conducted of residents of those settlements in the Volgograd region in which there is a paramedic and obstetric station. The number of respondents surveyed was 357 people. Of these, 42.58% are men and 57.42% are women.

They used the services of a paramedic and were completely satisfied - 63.87% of residents (24.65% men and 39.22% women), rather yes - 28.01% (13.45% men and 14.57% women), rather no – 1.12% (0.28% men and 0.84% ​​women), no – 0.28% of residents, and these are only women; found it difficult to answer – 2.80% of residents (1.68% of men and 1.12% of women). 70.59% of respondents turn to a paramedic first, and if he refers them, then to a doctor. 7.56% of respondents go to the doctor without visiting a paramedic. Men turn to a doctor somewhat more often, women - to a paramedic. The population's preferences on the question of who will cope better with the work of a paramedic are presented in Table 1. The survey results revealed that a third of the population (33.66%) wanted their children or one of their children to work as a paramedic; 1.40% (0.56% of men and 0.84% ​​of women) have children already working as paramedics.

Table 1. Whom would rural residents like to see as their paramedic?

Woman with higher education and work experience, %	Woman with secondary specialized education and work experience, %	Young female specialist with higher education, %	Young female specialist with secondary specialized education, %	Male with work experience and higher education, %	Male with work experience and secondary specialized education, %	Young male specialist with higher education, %	Young male specialist with secondary specialized education, %	Difficult to answer, %

Thus, the need for a paramedic as an essential participant in the medical care process is confirmed by objective data from a sociological survey. Moreover, the population believes that it is necessary to improve the working and living conditions of primary health care workers.

And, nevertheless, in the Healthcare Modernization Program there is a tendency to reduce the paramedic corps. Why? The answer to this question is dedicated to CHAPTER 2 “SOCIAL PROBLEMS OF IMPLEMENTING THE PROFESSIONAL ROLE OF A PHYSICAL SHER IN DOMESTIC HEALTHCARE”, where in §2.1 “Attitude of paramedics to their profession (based on the results of the focus group)” An interpretation of expert opinion on the current situation is given. In order to clarify this opinion, a focus group was conducted (03/14/2013). The focus group was conducted at the Department of Ethical and Legal Expertise in Medicine of the Volgograd Scientific Medical Center. The monitor was trained in the sociology of medicine at the Volgograd Social and Humanitarian Center. Handouts – data from a survey of the rural population of the Volgograd region about satisfaction with the work of a paramedic, Internet materials. The material was selected from the Volgograd region. The composition of the group: a monitor, seven paramedics from different regions of the Volgograd region, a postgraduate sociologist, a graduate student from a medical college.

As a result of the focus group, the following answers to the questions posed were received:

1. What is the status of FAPs in modern Russia? According to the Healthcare Modernization Program, FAPs belong to the first level of medical care (“help within walking distance”) and their number should be optimized. They are actually being reduced.

2. How do paramedics evaluate the conditions in which they work? Working conditions do not meet requirements. Many FAPs do not have the necessary things - refrigerators, bars on the windows, normal heating, and in some cases, even running water. Paramedics are not provided with transport. Waste removal is not provided. Most FAPs do not have pharmacies, which forces residents to go to the regional center for medications. The problem of equipping FAP premises and providing transport is a matter for the local administration. The problem of drug supply and waste disposal is a matter for local health authorities. Among these problems, paramedics consider the problem of transport to be the most pressing.

3. How do paramedics evaluate their material and living conditions? The living conditions of paramedics are different, but they do not complain about them. Most of the dissatisfaction is caused by the lack of kindergartens and poor conditions for transporting children to school and to the same kindergartens. Salaries are very low - on average, 5-6 thousand rubles per month. There were additional payments as part of the implementation of the National Health Project, but they have now stopped. Practically, all paramedics run household plots.

4. How do paramedics assess the possibility of professional self-realization? Paramedics consider regular advanced training in the regional center to be positive. Negative: low level of attention to them from doctors (primarily doctors of the Central District Hospital), irregular working hours. Dissatisfaction is caused by the restrictions imposed on the work of a paramedic (the ban on carrying out a number of manipulations that are carried out by nurses). An ethical dilemma is formulated: should a paramedic provide assistance to a patient if he is in dire need of it, but the paramedic does not have the right to perform this manipulation (for example, assisting in childbirth). All paramedics admit that they always provide assistance when they are contacted, but in some cases a) they receive administrative penalties, b) they do not receive payment from the insurance company. Claims also regarding overpayments under compulsory medical insurance: only initial claims are paid. Paramedics note that the process of rejuvenation of personnel in their service in the region has practically stopped.

5. What is the attitude of residents towards the paramedic service? All, without exception, paramedics note the warm attitude of local residents towards them, their help in transport problems, repair work at first aid stations, etc. The dissatisfaction of local residents is caused only by the refusal to carry out some manipulations that the paramedic does not have the right to do and about which you have to go to the regional center.

6. How do health authorities and local administrations view the paramedic service? Health authorities are being neglected. The local administration sometimes helps. What offends paramedics the most is the indifferent and condescending attitude of some doctors at the Central District Hospital, inattention to them when delivering a patient to the hospital, and recommendations of activities that the paramedic does not have the right to carry out while at the same time refusing hospitalization.

7. What would paramedics like to change in their work? The priorities were distributed as follows: to provide FAPs with transport, provide them with all the required equipment components, water supply and sewerage, increase the salaries of paramedics, expand the list of manipulations allowed to be performed by paramedics, pay not only for initial visits to patients, and send graduates of medical colleges for internships at FAPs.

Based on the results of the focus group, it was concluded that the social status of the paramedic remains high in the eyes of patients, but the administrative bodies of the territories, regions, as well as health authorities do not show interest in strengthening it.

IN §2.2 “Motives for choosing a profession and the social portrait of a modern paramedic” the motivational dispositions of medical college students who decided to become a paramedic and the result of their professional choice in the form of a social portrait of a modern paramedic are analyzed. The study involved 139 students aged 18 to 21 years, of which 32 were boys and 107 girls. The following methods were used: “Motivation for Professional Activity” by K. Zamfir, modified by A. Rean, “Measuring Achievement Motivation” by A. Mehrabian, and a method for studying factors of attractiveness of a profession, modified by I. Kuzmina and A. Rean. The first identified feature in the structure of personality motives of modern medical assistant students from the 1st to the 3rd year was the dominance of avoiding failures in 100% of respondents and in 95.12% in the 4th year. The second feature is a decrease in the optimal motivational complex among respondents from the 1st year (48%) to the 4th year (43%). However, the worst motivational complexes with a predominance of negative motivation, observed in the 1st year among 3% of students, are not observed in the 4th year. All this indicates that student activity in mastering a profession is noted by less than half of the respondents. The motives remained almost unchanged in importance at the beginning and end of training: the need to achieve social prestige and respect from others, the desire to avoid criticism from a manager or colleagues, the desire to avoid possible punishments and troubles.

To develop a social portrait of a modern rural healthcare paramedic, we conducted 37 interviews, in which paramedics working at paramedic and obstetric stations in various districts of the Volgograd region participated, while they were undergoing advanced training courses at the State Budgetary Educational Institution of Secondary Professional Education "Medical College No. 1, Volgograd" . All interviewees were women, but this does not mean that there are no male FAP paramedics, just that their number is so small that it does not allow obtaining reliable data.

An analysis of the age structure showed that more than half of the respondents (51.35%) are between 41 and 55 years old, 35.14% are between 31 and 40 years old, and 13.51% are over 55 years old. There were no respondents between the ages of 20 and 30. The vast majority of FAP paramedics are married (89.19%), 8.11% are divorced, 2.70% are widows, and none are unmarried. More than half (51.55%) have 2 children; 37.84% - 1 child; 8.11% - 3 children and 2.70% - more than 3 children; There are no childless paramedics among the respondents. The largest group of respondents (32.43%) are paramedics with a total work experience of more than 20 years and aged from 41 to 55 years. Moreover, 29.73% of this age category have work experience as a paramedic ranging from 10 to 20 years. 94.59% of all respondents have lived in the area for more than 20 years. The salary of a paramedic naturally increases depending on the length of service. At the same time, the respondents provide the majority of their family income. Thus, the salary of a paramedic in the age category from 31 to 40 years with experience from 5 to 10 years is 62.26% of the average family income per person per month; with experience from 10 to 20 years – 65.97%. A paramedic aged 41 to 55 years with 5 to 10 years of experience provides 45.68% of the average family income per person per month; from 10 to 20 years – 55.75%; more than 20 years – 75.52%. Over 55 years old and with more than 20 years of experience – 69.70%. Thus, the largest component (48.65%) of paramedics of working age from 41 to 55 years old with experience from 5 to 20 years or more provides 58.98% ±15.18% of the average family income per person per month.

32.43% of paramedics believe that recent healthcare reforms have affected their work more negatively than positively; rather positive 24.32%; had a positive impact – 2.70%; negative – 8.11%; did not influence at all – 18.92%; found it difficult to answer – 13.51%. The distribution of opinions about what difficulties exist in the work of a paramedic is presented in Table 2.

Table 2. Problems that need to be solved first

Rank place	financial problems of paramedics themselves, %	equipping and repairing health centers, %	transport problem for paramedics, %	problem of pharmacy points in rural areas, %		problem of relationship with the Federal Compulsory Compulsory Medical Insurance Fund, %	revision of paramedic care standards, %

Paramedics believe that rural residents are most interested in the development of paramedic business in Russia, 05%), followed by paramedics themselves (24.32%) and regional health authorities (16.22%). 2.70% found it difficult to answer. Doctors and local administrations, according to paramedics, are not at all interested (0%). However, paramedics are optimistic that the paramedic service in Russia will develop in the future (40.54%). However, there are pessimists and skeptics. Thus, 21.62% believe that it will worsen; 18.92% - will not change, and 18.92% found it difficult to answer.

Based on the results of the interview, a social portrait of a modern paramedic was compiled.

IN CONCLUSION It is noted that the study confirmed the correctness of the second hypothesis of those put forward in the Introduction, and its results allow us to offer the following recommendations.

1. The Ministry of Health needs to resolve the issue of increasing wages for paramedics; expand the list of manipulations allowed to be performed by paramedics. Determine the boundaries of professional responsibility between the GP (general practitioner) and the paramedic, as well as determine the conditions under which the transfer of authority from the GP to the paramedic occurs. The territorial compulsory medical insurance fund will pay paramedics not only for initial visits to patients, but also for repeat ones.

2. Local regional administrations need to strengthen the social status and support of the paramedic through specific socio-economic measures: improve the working conditions of paramedics, according to the requirements; continue to equip FAPs with refrigerators, bars on windows, heating, running water, and most importantly, transport; attract young professionals with various incentive measures: cash supplements, housing, kindergartens and schools for children within walking distance.

3. It is advisable for the chief doctors of the Central District Hospital to carry out explanatory work among doctors about the basics of business culture and relationships in the conditions of fulfilling professional duties by mid-level specialists, as full participants in the diagnostic and treatment process.

4. In order to increase the prestige of the paramedic profession, it would be useful for medical colleges to send graduating students to internships at first aid stations in rural areas.

1. Podolsk rights of patients in rural areas to quality medical care / , //Social and pension law. – 2013. - No. 2 – 0.55 p.l.

2. Podolsk health risks in the views of students of city colleges / , // Sociology of the city No. 3. – 0.5 p.l.

3. Podolsk ethical professional attitudes of medical workers / , // Bioethics No. 1 (7) – 0.3 pp.

4. Podolskaya ethical relationship between a paramedic and an ambulance doctor // Bioethics No. 2, 3 p. l.

5. Podolskaya portrait of a paramedic in the Volgograd region // Sociology of medicine - healthcare reform. Volgograd: VolSMU Publishing House, 2013. – 0.3 pp.

6. Podolsk role of the paramedic in modern Russia. Volgograd. 2012. – 1.2 p.l.

7. Podolsk monitoring of population satisfaction with the provision of paramedic care. Volgograd. 2013 – 1 p.l.

8. Podolsk study of the level of physical and mental health of students of the State Budgetary Educational Institution of Secondary Vocational Education "Medical College No. 1, Volgograd" / , // The state of health of students of medical and pharmaceutical educational institutions of secondary vocational education, ways to strengthen it. Ufa. 2012 – 0.3 p.l.

9. Podolsk motivation for the profession of a paramedic among students of the specialty “General Medicine” // Humanization of nursing work: science, education, practice. Arkhangelsk: Publishing house of the Northern State Medical University. 2011. – 0.2 p.l.

10. On the need for a sociological study of the professional role of the paramedic in modern Russia // Sociology of medicine - healthcare reform. Volgograd: VolSMU Publishing House, 2010. – 0.3 pp.

PODOLSKAYA MARINA NIKOLAEVNA

PROFESSIONAL ROLE OF THE PHARMACY IN MODERN RUSSIA

dissertation for the degree of candidate of sociological sciences

Signed for publication on August 29, 2013.

Format 60x84x 16. Paper. offset. Times New Roman typeface.

Conditional oven l. 1.0. Circulation 100 copies. Order.

Publishing house of Volgograd State Medical University

Concept for the development of the healthcare system in the Russian Federation until 2020

Rental block

KGBPOU KRASNOYARSK BASIC MEDICAL COLLEGE NAMED AFTER V.M.KRUTOVSKY

GRADUATE WORK

Subject: « The role of the paramedic in the prevention of coronary heart disease"

Group student: 401 Mylnikova Olga Vladimirovna / /

Specialty: 060101 General Medicine

Head: Kuleshova Marina Gennadievna / /

Allow for protection:

Chairman of the cycle commission: /__________/

Grade date

Chairman State

certification commission / /

Introduction

Basics of coronary heart disease.

concept and causes of development of coronary heart disease.

Treatment of coronary heart disease

The role of the paramedic in the prevention of coronary heart disease

2.1 methods for diagnosing patients with coronary heart disease

2.2 analysis and evaluation of the results of the study of patients with coronary heart disease.

Conclusion

Bibliography.

Introduction.

Coronary heart disease is the main problem in the clinic of internal diseases; in WHO materials it is characterized as an epidemic of the twentieth century. The basis for this was the increasing incidence of coronary heart disease in people in various age groups, the high percentage of disability, and the fact that it is one of the leading causes of mortality.

Currently, coronary heart disease in all countries of the world is regarded as an independent disease and is included in<Международную статистическую классификацию болезней, травм и причин смерти>. The study of coronary heart disease has a history of almost two centuries. To date, a huge amount of factual material has been accumulated indicating its polymorphism. This made it possible to distinguish several forms of coronary heart disease and several variants of its course. The main attention is drawn to myocardial infarction - the most severe and common acute form of coronary heart disease. Significantly less described in the literature are forms of coronary heart disease that occur chronically - these are atherosclerotic cardiosclerosis, chronic cardiac aneurysm, angina pectoris. At the same time, atherosclerotic cardiosclerosis, as a cause of mortality among diseases of the circulatory system, including among forms of coronary heart disease, is in first place.

Coronary heart disease has become notorious, becoming almost epidemic in modern society.

Coronary heart disease is the most important problem of modern healthcare. For a variety of reasons, it is one of the leading causes of death among the population of industrialized countries. It strikes able-bodied men (more than women) unexpectedly, in the midst of vigorous activity. Those who do not die often become disabled.

Coronary heart disease is understood as a pathological condition that develops when there is a violation of the correspondence between the need for blood supply to the heart and its actual implementation. This discrepancy can occur when the myocardial blood supply remains at a certain level, but the need for it has sharply increased, or when the need remains, but the blood supply has decreased. The discrepancy is especially pronounced in cases of decreased blood supply and an increasing need for blood flow from the myocardium.

The life of society and the preservation of public health have repeatedly posed new problems for medical science. Most often these are different<болезни века>, which attracted the attention of not only doctors: cholera and plague, tuberculosis and rheumatism. They were usually characterized by prevalence, difficulty of diagnosis and treatment, and tragic consequences. The development of civilization and the successes of medical science have pushed these diseases into the background.

Currently, one of the most pressing problems is undoubtedly coronary heart disease. The criteria for angina pectoris were first proposed by the English physician W. Heberden in 1772. Even 90 years ago, doctors rarely encountered this pathology and usually described it as casuistry. Only in 1910 V.P. Obraztsov and N.D. Strazhesko in Russia, and in 1911 Herrik in the United States of America gave a classic description of the clinical picture of myocardial infarction. Now myocardial infarction is known not only to doctors, but also to the general population. This is explained by the fact that every year it occurs more and more often.

Coronary insufficiency occurs as a result of a lack of oxygen supply to the heart tissue. Insufficient oxygen supply to the myocardium can result from various reasons.

Until the 80s of the 19th century, the prevailing opinion was that the main and only cause of angina pectoris (angina) was sclerosis of the coronary arteries. This was explained by the one-sided study of this issue and its main morphological direction.

By the beginning of the twentieth century, thanks to the accumulated factual material, domestic clinicians pointed to the neurogenic nature of angina pectoris (angina pectoris), although the frequent combination of spasms of the coronary arteries with their sclerosis was not excluded (E.M. Tareev, 1958; F.I. Karamyshev, 1962 ; A.L. Myasnikov, 1963; I.K. Shvatsoboya, 1970, etc.). This concept continues to this day.

In 1957, a group of experts on the study of atherosclerosis at the World Health Organization proposed the term<ишемическая болезнь сердца>to denote an acute or chronic heart disease that occurs as a result of a decrease or cessation of blood supply to the myocardium due to a pathological process in the coronary artery system. This term was adopted by WHO in 1962 and included the following forms:

1) angina pectoris;

2) myocardial infarction (old or fresh);

3) intermediate forms;

4) coronary heart disease without pain:

a) asymptomatic form,

b) atherosclerotic cardiosclerosis.

In March 1979, WHO adopted a new classification of coronary heart disease, which distinguishes five forms of coronary heart disease:

1) primary circulatory arrest;

2) angina pectoris;

3) myocardial infarction;

4) heart failure;

5) arrhythmias.

CHAPTER 1. FEATURES OF CORONARY HEART DISEASE.

concept and reasons for the development of coronary heart disease. -56578524130

Coronary heart disease (ischemia) - this concept includes a whole group of diseases. They are characterized by impaired blood circulation in those arteries that feed the myocardium (heart muscle) - the coronary ones. In connection with the latter, coronary heart disease is often called coronary sclerosis or coronary disease.

There are chronic (symptoms of which are arrhythmia, heart failure, etc.) and acute (the manifestation of which may be myocardial infarction) forms of this disease. Ischemia poses a threat not only to the heart, but also to many other organs and organ systems. Coronary heart disease is directly related to anemia.

One form of coronary heart disease is angina. The main symptoms of angina are a nagging pain behind the sternum, which, however, can spread to the left shoulder and left arm. Other symptoms of angina include a feeling of heaviness and tightness, discomfort and shortness of breath.

Methods for diagnosing coronary heart disease include: a detailed interview with the patient, an electrocardiogram (at rest and after dosed exercise), ultrasound, and laboratory data.

Treatment of coronary heart disease is complex and aimed at minimizing risk factors for the development of complications, as well as eliminating the symptoms of the disease and ensuring the patient’s normal functioning. In difficult cases, surgical treatment is indicated.

Coronary heart disease, in particular angina, should never be treated independently, since this greatly increases the risk of developing such a serious complication of coronary heart disease as myocardial infarction.

Coronary heart disease is one of the most common diseases of this organ. This disease has no boundaries. It is common in both developing countries and economically developed ones. However, statistics indicate that the male part of the population suffers more from coronary heart disease than the female part.

Ischemic disease is associated with anemia. Because of this relationship, the disease got its name, because anemia and ischemia are synonyms. In the case of coronary artery disease, ischemia is directly related to insufficient blood flowing to the heart muscle.

Ischemia can occur even in a healthy person. In this case, they talk about transient cardiac ischemia. This form can occur as a reaction of the body to physical activity, cold or a stressful situation.

Ischemia is a threat to the heart. Practice shows that not only this body. In some cases, a diagnosis of cerebral ischemia is made. In this case, we are talking about a lack of blood circulation in the brain. Sometimes limb ischemia is diagnosed. The cardiovascular and nervous systems of the human body are more susceptible to ischemia.

Atherosclerosis is ischemia of the heart muscle (myocardium). The cause of myocardial ischemia is associated with high cholesterol levels, which results in the accumulation of atherosclerotic plaques in the vessels. The latter leads to a narrowing of the lumen of blood vessels. As a result of this narrowing, blood cannot flow into the organ in the same quantity - sufficient for normal functioning.

Myocardial ischemia is characterized by periods of exacerbation and remission. In this case, we can say that the course of ischemia of the heart muscle follows a sinusoid - periods of exacerbation of the disease alternate with periods when ischemia does not manifest itself at all. But it should be understood that such “asymptomatic” periods are not a reason to refuse treatment for the disease - if a diagnosis is made, then coronary artery disease must be treated in any case.

Pathogenesis

According to modern concepts, IHD is a pathology based on myocardial damage, which is caused by coronary insufficiency (insufficient blood supply). An imbalance between the myocardial blood supply needs and its actual blood supply can be caused by a number of reasons:

Intravascular causes:

Thrombosis and thromboembolism of the coronary arteries;

Atherosclerotic narrowing of the lumen of the coronary arteries;

Spasm of the coronary arteries.

Causes outside the vessel:

Myocardial hypertrophy;

Tachycardia;

Arterial hypertension.

IHD is a group concept that includes both acute and chronic conditions (including those considered as independent nosological forms), which are based on ischemia and the changes in the myocardium caused by it (sclerosis, dystrophy, necrosis), but only in in cases where ischemia is caused by a narrowing of the lumen of the coronary arteries, which is associated with atherosclerosis, or the reason for the discrepancy between coronary blood flow and the needs of the myocardium has not been established.

The formation of an atheroslerotic plaque occurs in several stages. Initially, the lumen of the vessel undergoes virtually no changes. As lipids accumulate in the plaque, ruptures in the fibrous cover occur, accompanied by the deposition of platelet aggregates, which contribute to local fibrin deposits. The newly formed endothelium covers the area where the parietal thrombus is located, which protrudes into the lumen of the vessel, narrowing it. Together with lipid fibrous plaques, almost exclusively fibrous stenotic plaques are formed, which undergo calcification.

As each plaque increases and develops, as well as their number, the degree of stenosis of the lumen of the coronary arteries increases, which largely (although not necessarily) determines the severity of clinical manifestations and the development of coronary heart disease. Narrowing of the artery lumen to 50% of the original width is often asymptomatic. As a rule, pronounced clinical manifestations of the disease appear when this lumen narrows to 70% or higher. The more proximally the stenosis is localized, the greater the mass of the myocardium is affected by ischemia (according to the zone of blood supply). The most severe manifestations of myocardial ischemia occur with stenosis of the main trunk or the mouth of the left coronary artery.

The occurrence of myocardial ischemia often involves a sharp increase in its oxygen demand, thrombosis, or coronary vasospasm. The prerequisites for thrombosis, which occur when the endothelium is damaged, can occur already in the early stages of the development of an atherosclerotic plaque - this is enhanced by the fact that the processes of hemostasis disturbances (and above all, platelet activation) play a significant role in the pathogenesis of IHD and its exacerbation. Platelet microembolism and microthrombi can aggravate blood flow disturbances existing in a stenotic vessel.

Significant atherosclerotic damage to the arteries does not prevent their spasm in all cases. A study of transverse serial sections of affected coronary arteries showed that an atherosclerotic plaque causes concentric narrowing of the artery, which impedes the functional dynamics of its lumen, only in 20% of cases. In 80% of cases, the eccentric location of the plaque is determined, which does not prevent the expansion or spasm of the vessel.

Classification and clinical picture of manifestations of coronary heart disease.

There are numerous variants of clinical manifestations of this disease: sudden cardiac death (SCD), angina pectoris, silent myocardial ischemia (SMI), myocardial infarction (MI), post-infarction cardiosclerosis. There is no generally accepted clinical classification of IHD. This is due to rapidly changing ideas about the mechanisms of development of coronary insufficiency, the presence of a common morphological substrate of various forms of IHD and the possibility of a rapid and often unpredictable transition from one clinical form of this disease to another, the existence of several forms of IHD in one patient (post-infarction cardiosclerosis, angina pectoris, silent ischemia myocardium). The most widely used classification in our country is the classification of the All-Russian Scientific Center of the USSR Academy of Medical Sciences (1984), developed on the basis of the recommendations of WHO experts (1979).

Clinical classification of coronary heart disease (1984)

1. Sudden cardiac death (primary cardiac arrest).

2. Angina.

2.1. Angina pectoris:

2.1.1. New-onset angina.

2.1.2. Stable angina (indicating functional class from I to IV).

2.1.3. Progressive angina (unstable).

2.2. Spontaneous (special, variant, vasospastic) angina.

3. Myocardial infarction.

3.1. Large focal (transmural).

3.2. Finely focal.

4. Post-infarction cardiosclerosis.

5. Heart failure (indicating the form and stage).

6. Heart rhythm disturbances (indicating the form).

Later, another form of IHD was added to this classification - “silent myocardial ischemia” (SMI). The last two forms of IHD in this classification (heart failure, cardiac arrhythmias) are considered as independent variants of the course of the disease and are diagnosed in the absence of other clinical manifestations of IHD in patients (angina pectoris, myocardial infarction, post-infarction cardiosclerosis).

Classification of coronary heart disease

1. Sudden cardiac death.

2. Angina.

2.1. Stable angina pectoris (indicating functional class from I to IV).

2.2. Unstable angina:

2.2.1. New-onset angina (AF).*

2.2.2. Progressive angina (PA).

2.2.3. Early post-infarction or postoperative angina.

2.3. Spontaneous (vasospastic, variant, Prinzmetal) angina. **

3. Silent myocardial ischemia. **

4. Microvascular angina (cardiac syndrome X). 5. Myocardial infarction.

5.1. Myocardial infarction with Q wave (large focal, transmural).

5.2. Myocardial infarction without a Q wave (small focal).

6. Post-infarction cardiosclerosis.

7. Heart failure (indicating the form and stage).

8. Heart rhythm and conduction disorders (indicating the form).

Note:

* - sometimes new-onset angina has a stable course from the very beginning;

** - some cases of silent myocardial ischemia, severe attacks of spontaneous angina can be classified as unstable angina.

The working classification provides for the identification of the main variants of unstable angina, which occupies an intermediate position between stable angina pectoris and MI, characterized by a high risk of MI and mortality (10-20% per year compared to 3-4% per year with stable angina pectoris). ). Many cases of unstable angina, accompanied by relatively short-term (within a few days) negative dynamics of the ECG (depression of the RS-T segment, T-wave inversion, transient rhythm and conduction disturbances) fully correspond to the term “acute focal myocardial dystrophy”, which was widespread in the past in the domestic literature.

It is important to highlight in a special category cases of silent myocardial ischemia (SMI), which is diagnosed using modern instrumental methods of functional research of the heart (stress tests, 24-hour Holter ECG monitoring, myocardial radionuclide scintigraphy with 201T1), but is not accompanied by attacks of angina pectoris characteristic of IHD or peace. The concept of BIM also includes those cases of confirmed ischemic heart disease that are manifested only by nonspecific “frozen” changes on the ECG (depression of the RS-T segment and/or inversion of the T wave) and which were previously often interpreted as manifestations of atherosclerotic diffuse cardiosclerosis.

The working classification of IHD has a clear clinical focus, emphasizing the need to distinguish among patients with IHD a group with a stable and unstable course of the disease, which are based on various pathogenetic mechanisms of the formation of chronic and acute coronary insufficiency. The term acute coronary syndrome (ACS) has become widespread in the last ten years. Currently, this term combines unstable angina, MI without a Q wave, MI with a Q wave. Sudden cardiac death can also be included in this group if it is caused by the presence of coronary artery disease. The basis for combining various clinical forms of IHD was modern research, which convincingly demonstrated that the acute development of these variants of IHD occurs as a result of rupture or disruption of the integrity of an atherosclerotic plaque with subsequent formation of a blood clot in the damaged endothelium of the coronary artery.

The consequences of such thrombotic occlusion and the clinical variant of coronary artery disease depend on the degree and duration of cessation of coronary blood flow, as well as on the severity of collateral circulation. In various types of unstable angina, a platelet (“white”) thrombus is formed, which in most cases undergoes spontaneous thrombolysis. With a longer coronary occlusion (up to 1 hour) and the presence of collaterals, MI without a Q wave (small-focal) develops. With rapid complete and prolonged occlusion (more than 1 hour), a well-fixed, durable coronary thrombus is formed, coronary blood flow is completely stopped and a large-focal (transmural) MI with a Q wave develops. The widespread use of the term ACS in modern cardiological practice only emphasizes the need to pay special attention to any clinical manifestations unstable state of coronary blood flow, which may result in the restoration of the previous level of coronary circulation, or result in the development of MI or sudden cardiac death.

With stable angina pectoris, which is based on slowly progressive stenosis of the proximal coronary artery, inadequate dilatation of the coronary vessels in response to an increase in myocardial oxygen demand and spasm of the coronary arteries, the risk of MI and sudden death is significantly lower than with unstable angina. Among patients with angina, patients with stable angina pectoris and patients with unstable angina pectoris should be distinguished, which differ significantly in the mechanisms of development of coronary insufficiency, the degree of risk of acute MI, and sudden death.

The concept of ACS has important practical significance, since it unites a number of variants of coronary artery disease (unstable angina, small-focal and large-focal MI), in most cases having a common morphological basis - rupture of an atherosclerotic plaque and the formation of a blood clot in the coronary artery. This highlights the possibility of transformation of one clinical form of the disease (unstable angina) into another (MI or sudden death). Modern methods of laboratory and instrumental diagnostics make it possible to identify among patients with coronary artery disease a group of people with so-called spontaneous (vasospastic, variant) angina, silent myocardial ischemia and microvascular angina, which are allocated in the working classification into separate headings.

Any patient with coronary artery disease may fit various categories of clinical classification. A patient with stable angina pectoris may have clinical and instrumental signs of post-infarction cardiosclerosis, heart failure, and arrhythmias. This chapter discusses the clinical presentation, diagnosis, and treatment of stable angina, silent myocardial ischemia, Prinzmetal vasospastic angina, and microvascular angina. In some cases, the last three forms of IHD can become unstable.

Factors in the development of coronary heart disease

The main task of preventing the development of coronary heart disease is to eliminate or minimize the magnitude of those risk factors for which this is possible. To do this, even before the first symptoms appear, it is necessary to adhere to recommendations for lifestyle modification.

Risk factors for coronary heart disease are circumstances the presence of which predisposes to the development of coronary artery disease. These factors are in many ways similar to risk factors for atherosclerosis, since the main link in the pathogenesis of coronary heart disease is atherosclerosis of the coronary arteries. Conventionally, they can be divided into two large groups: modifiable and non-modifiable risk factors for coronary artery disease.

TO modifiable risk factors for coronary heart disease relate:

arterial hypertension (that is, high blood pressure),

diabetes,

increased cholesterol levels in the blood, etc.,

overweight and the nature of the distribution of fat in the body,

sedentary lifestyle (hypodynamia),

poor nutrition.

TO immutable risk factors for coronary heart disease relate:

age (over 50-60 years),

male gender,

complicated heredity, that is, cases of IHD in close relatives,

The risk of coronary artery disease in women will increase with long-term use of hormonal contraceptives.

The most dangerous from the point of view of the possible development of coronary heart disease are arterial hypertension, diabetes mellitus, smoking and obesity. According to literature data, the risk of coronary artery disease with elevated cholesterol levels increases by 2.2-5.5 times, and with hypertension - by 1.5-6 times. Smoking has a very strong influence on the possibility of developing CHD; according to some data, it increases the risk of developing CHD by 1.5-6.5 times.

A noticeable influence on the risk of developing coronary artery disease is exerted by such factors that at first glance are not related to the blood supply to the heart, such as frequent stressful situations, mental stress, and mental fatigue. However, most often it is not the stress itself that is to blame, but its influence on the characteristics of a person’s personality. In medicine, there are two behavioral types of people, they are usually called type A and type B. Type A includes people with an easily excitable nervous system, most often of choleric temperament. A distinctive feature of this type is the desire to compete with everyone and win at all costs. Such a person is prone to inflated ambitions, is vain, is constantly dissatisfied with what has been achieved, and is in constant tension. Cardiologists argue that it is this type of personality that is least able to adapt to a stressful situation, and people of this type develop IHD much more often (at a young age - 6.5 times) than people of the so-called type B, balanced, phlegmatic, friendly. Probability the development of coronary heart disease and other cardiovascular diseases increases synergistically with an increase in the number and “power” of these factors.

Age

For men, the critical milestone is the 55th birthday, for women 65 years.

It is known that the atherosclerotic process begins in childhood. Research results confirm that atherosclerosis progresses with age. Already at 35 years of age, coronary heart disease is one of the 10 leading causes of death in the United States; One in five people in the United States has a heart attack before the age of 60. At the age of 55-64 years, the cause of death in men in 10% of cases is coronary heart disease. The prevalence of stroke is even more related to age. The number of strokes doubles with each decade after age 55; however, about 29% of people affected by stroke are under 65 years of age.

Observational findings show that risk increases with age, even if other risk factors remain in the “normal” range. However, it is clear that a significant increase in the risk of coronary heart disease and stroke with age is associated with those risk factors that can be influenced. For example, a 55-year-old man with a high composite risk factor for coronary heart disease has a 55% chance of developing clinical disease within 6 years, while a man of the same age but with a low composite risk has only a 4% chance of developing coronary heart disease. .

Modification of key risk factors at any age reduces the likelihood of disease progression and mortality due to early or recurrent cardiovascular disease. Recently, much attention has been paid to influencing risk factors in childhood in order to minimize the early development of atherosclerosis, as well as to reduce the “transition” of risk factors with age.

Among the many provisions regarding coronary artery disease, one is beyond doubt - the predominance of males among patients.

In one of the large studies, at the age of 30-39 years, atherosclerosis of the coronary arteries was detected in 5% of men and in 0.5% of women; at the age of 40-49 years, the incidence of atherosclerosis in men is three times higher than in women, at the age of 50-59 years in men it is twice as high; after 70 years, the incidence of atherosclerosis and ischemic heart disease is the same in both sexes. In women, the number of diseases increases slowly between the ages of 40 and 70 years. In menstruating women, coronary artery disease is rarely observed, and usually in the presence of risk factors - smoking, arterial hypertension, diabetes mellitus, hypercholestremia, and genital diseases.

Sex differences are especially pronounced at a young age, and begin to decrease over the years, and in old age both sexes suffer from coronary artery disease equally often. In women under 40 years of age who suffer from pain in the heart area, severe atherosclerosis is extremely rare. At the age of 41-60 years, atherosclerotic changes in women are almost 3 times less common than in men. There is no doubt that normal ovarian function “protects” women from atherosclerosis. With age, the manifestations of atherosclerosis gradually and steadily increase.

Genetic factors

The importance of genetic factors in the development of coronary heart disease is well known: people whose parents or other family members have symptomatic coronary heart disease are at increased risk of developing the disease. The associated increase in relative risk varies widely and may be up to 5 times higher than in individuals whose parents and close relatives did not suffer from cardiovascular disease. The excess risk is especially high if the development of coronary heart disease in parents or other family members occurred before age 55. Hereditary factors contribute to the development of dyslipidemia, hypertension, diabetes mellitus, obesity and, possibly, certain behavioral patterns leading to the development of heart disease.

There are also environmental and learned behavioral structures associated with a certain degree of risk. For example, some families consume excessive amounts of food. Overeating in combination with a low level of physical activity quite often leads to the emergence of a “family problem” - obesity. If parents smoke, their children, as a rule, become involved in this harmful habit. Because of these environmental impacts, many epidemiologists have asked whether a history of coronary heart disease continues to be an independent risk factor for coronary heart disease when other risk factors are adjusted statistically.

Poor nutrition

Most risk factors for the development of coronary heart disease are associated with lifestyle, one of the important components of which is nutrition. Due to the need for daily food intake and the huge role of this process in the life of our body, it is important to know and follow the optimal diet. It has long been noted that a high-calorie diet with a high content of animal fats in the diet is the most important risk factor for atherosclerosis. Thus, with chronic consumption of foods high in saturated fatty acids and cholesterol (mainly animal fat), excess cholesterol accumulates in hepatocytes and, according to the principle of negative feedback, the synthesis of specific LDL receptors in the cell decreases and, accordingly, the uptake and absorption by hepatocytes decreases atherogenic LDL circulating in the blood. This type of nutrition contributes to the development obesity, disorders of carbohydrate and lipid metabolism, which underlie the formation of atherosclerosis.

Dyslipidemia

Increased cholesterol levels and changes in blood lipid composition. Thus, an increase in cholesterol levels by 1.0% (with a norm of 5.0 mmol/l and below) increases the risk of developing a heart attack by 2%!

Numerous epidemiological studies have shown that the plasma level of total cholesterol (TC), low-density lipoprotein cholesterol has a positive relationship with the risk of developing coronary heart disease, while this relationship is negative with the content of high-density lipoprotein cholesterol (HDL). Due to this relationship, LDL cholesterol is called “bad cholesterol” and HDL cholesterol is called “good cholesterol”. The significance of hypertriglyceridemia as an independent risk factor has not been fully established, although its combination with low levels of HDL cholesterol is considered to contribute to the development of coronary artery disease.

To determine the risk of developing coronary heart disease and other diseases associated with atherosclerosis and select treatment tactics, it is enough to measure the concentration of total cholesterol, HDL cholesterol and triglycerides in the blood plasma. The accuracy of predicting the risk of developing coronary artery disease increases markedly if the level of HDL cholesterol in the blood plasma is taken into account. A comprehensive characterization of lipid metabolism disorders is a prerequisite for effective prevention of cardiovascular diseases, which essentially determine the life prognosis, ability to work and physical activity in everyday life of the majority of elderly people in all economically developed countries.

Arterial hypertension

Arterial hypertension - when blood pressure exceeds 140/90 mm Hg st.

The importance of high blood pressure (BP) as a risk factor for the development of coronary artery disease and heart failure has been proven by numerous studies. Its significance increases even more if we consider that 20-30% of middle-aged people in Ukraine suffer from arterial hypertension (AH) and at the same time 30-40% of them do not know about their disease, and those who know are treated irregularly and poorly control blood pressure. It is very easy to identify this risk factor, and many studies, including those conducted in Russia, have convincingly proven that through active identification and regular treatment of hypertension, mortality can be reduced by approximately 42-50%, and mortality from coronary artery disease by 15%.

The need for drug treatment in patients with blood pressure above 180/105 mmHg. does not raise much doubt. As for cases of “mild” hypertension (140-180/90-105 mmHg), the decision to prescribe long-term drug therapy may not be entirely simple. In such cases, as in the treatment of dyslipidemia, one can proceed from an assessment of the overall risk: the higher the risk of developing coronary heart disease, the lower the levels of elevated blood pressure, drug treatment should be started. At the same time, non-drug measures aimed at lifestyle modification remain an important aspect of hypertension control. Also, increased systolic pressure causes hypertrophy of the left ventricular myocardium, which, according to ECG data, increases the development of atherosclerosis of the coronary arteries by 2-3 times.

Diabetes

Diabetes or impaired glucose tolerance, when fasting blood glucose is equal to or greater than 6.1 mmol/L.

Both types of diabetes markedly increase the risk of developing coronary artery disease and peripheral vascular disease, and to a greater extent in women than in men. The increased risk (2-3 times) is associated both with diabetes itself and with the greater prevalence of other risk factors in these people (dyslipidemia, hypertension, BMI). An increased prevalence of risk factors already occurs with intolerance to carbohydrates, detected using carbohydrate loading. "Insulin resistance syndrome" or "insulin resistance syndrome" is being carefully studied. metabolic syndrome": a combination of impaired carbohydrate tolerance with dyslipidemia, hypertension and obesity, in which the risk of developing coronary artery disease is high. To reduce the risk of developing vascular complications in patients with diabetes, it is necessary to normalize carbohydrate metabolism and correct other risk factors. Individuals with stable diabetes types I and II are advised to exercise to improve functional ability.

Hemostatic factors

A number of epidemiological studies have shown that certain factors involved in blood clotting increase the risk of developing coronary artery disease. These include increased plasma levels of fibrinogen and coagulation factor VII, increased platelet aggregation, and decreased fibrinolytic activity, but are not yet commonly used to determine the risk of developing coronary artery disease. For the purpose of preventive influence on them, drugs that affect platelet aggregation are widely used, most often aspirin in a dose of 75 to 325 mg/day. The effectiveness of aspirin has been convincingly proven in studies on secondary prevention of coronary artery disease. As for primary prevention, aspirin, in the absence of contraindications, is advisable to use only in individuals at high risk of developing coronary artery disease.

Excess body weight (obesity)

Obesity is one of the most significant and at the same time most easily modifiable risk factors for atherosclerosis and coronary artery disease. Currently, convincing evidence has been obtained that obesity is not only an independent risk factor (RF) for cardiovascular diseases, but also one of the links - possibly a trigger - for other RFs, such as hypertension, HLP, insulin resistance and diabetes mellitus. Thus, a number of studies have revealed a direct relationship between mortality from cardiovascular diseases and body weight.

More dangerous is the so-called abdominal obesity (male type), when fat is deposited on the abdomen. Body mass index is often used to determine the degree of obesity.

Low physical activity

In people with low physical activity, CHD develops 1.5-2.4 (on average 1.9) times more often than in people leading a physically active lifestyle. When choosing an exercise program, there are 4 things to consider: the type of exercise, its frequency, duration and intensity. For the purpose of preventing coronary heart disease and promoting health, the most suitable physical exercises are those that involve regular rhythmic contractions of large muscle groups, fast walking, jogging, cycling, swimming, skiing, etc. You should exercise 4-5 times a week for 30-40 minutes, including a warm-up and cool-down period. When determining the intensity of physical exercise acceptable for a particular patient, they proceed from the maximum heart rate (HR) after physical activity - it should be equal to the difference between the number 220 and the patient’s age in years. For people with a sedentary lifestyle without symptoms of coronary artery disease, it is recommended to choose an intensity of exercise at which the heart rate is 60-75% of the maximum. Recommendations for individuals with CAD should be based on clinical examination and exercise test results.

Smoking

Quitting smoking completely has been proven to be much more effective than many medications. Conversely, smoking increases the risk of developing atherosclerosis and increases the risk of sudden death several times.

The connection between smoking and the development of coronary heart disease and other non-communicable diseases is well known. Smoking affects both the development of atherosclerosis and the processes of thrombus formation. Cigarette smoke contains over 4,000 chemical components. Of these, nicotine and carbon monoxide are the main elements that have a negative effect on the functioning of the cardiovascular system.

Direct and indirect synergistic effects of nicotine and carbon monoxide on the progression and severity of atherosclerosis:

reduces plasma high-density lipoprotein cholesterol levels;

increases platelet adhesiveness and the tendency to thrombus formation.

Alcohol consumption

The relationship between alcohol consumption and mortality from coronary artery disease is as follows: non-drinkers and heavy drinkers have a higher risk of death than moderate drinkers (up to 30 g per day in terms of pure ethanol). Despite the fact that moderate doses of alcohol reduce the risk of developing CHD, other effects of alcohol on health (increased blood pressure, the risk of sudden death, impact on psycho-social status) do not allow us to recommend alcohol for the prevention of CHD.

1.4 treatment of ischemic heart disease.

Drugs used in the treatment of coronary heart disease

Antiplatelet agents (acetylsalicylic acid, clopidogrel). Data drugs“thin” the blood, help improve its fluidity, reduce the ability of platelets and red blood cells to adhere to blood vessels, and improve the passage of red blood cells through capillaries.

Beta-blockers (metoprolol, bisoprolol, carvedilol). Data drugs reduce the frequency of contractions of the heart muscle, which leads to the expected result - the myocardium receives the required amount of oxygen. Beta-blockers have a number of contraindications: bronchial asthma, pulmonary insufficiency, chronic lung disease.

Statins and fibrators (lovastatin, simvastatin, atorvastatin, rosuvastatin, fenofibrate). Data drugs designed to reduce blood cholesterol levels. And since the level of cholesterol in the blood of patients diagnosed with coronary heart disease should be approximately 2 times lower than that of a healthy person, therefore, drugs of this group are required to be used in the treatment of coronary heart disease.

Nitrates (nitroglycerin, isosorbide mononitrate). Data drugs used to relieve attacks of angina pectoris. Due to the rapid vasodilating effect on blood vessels, the drugs allow you to get the desired effect in a short time. Medicines from the nitrate group should not be used if blood pressure is low (below 100/60). Headaches and decreased blood pressure are their main side effects.

Anticoagulants (heparin). The a drug has a “thinning” effect on the blood, which facilitates blood flow, stops the development of existing blood clots, and also prevents the formation of new blood clots. A drug administered either intravenously or subcutaneously into the abdomen.

Diuretics (loop diuretics - furosemide, thiazide - hypotazide, indapamide). These drugs are designed to remove fluid from the body, which significantly reduces the load on the myocardium.

The following medications are also used in the treatment of coronary heart disease: angiotensin-converting enzyme inhibitors (enalaprin, captopril, lisinopril), antiarrhythmic drugs drugs(amiodarone), antibiotics and others drugs(ethylmethylhydroxypyridine, mildronate, mexicor, coronatera, trimetazidine).

Mini operation

Treatment of coronary heart disease using endovascular coronary angioplasty (balloon angioplasty, stenting). Currently, gentle interventions in the human body are widely used. The mini-surgery is performed under local anesthesia, and auxiliary instruments are inserted into the artery (usually the femoral artery) through minor punctures in the skin. The entire operation is monitored using an X-ray machine. Such procedures give excellent results and are an alternative to direct surgical intervention in the heart muscle, especially in cases where the patient has certain contraindications to surgery.

Surgical treatment of coronary heart disease

In some cases, surgical treatment is the only option that can save the patient’s life. Coronary artery bypass grafting is a surgical procedure during which the coronary vessels are combined with external vessels. The connection is made in a place where the vessels are not affected by the disease. The operation significantly improves myocardial blood saturation. Coronary artery bypass grafting is a surgical procedure during which the aorta is attached to parts of the coronary arteries. Balloon vascular dilatation is the insertion of a balloon filled with a special substance into the coronary vessels. The inserted balloon allows you to expand the damaged vessel to the required size. The balloon is inserted into the coronary vessel through another large artery (radial, femoral) using a manipulator.

1.6 The role of the paramedic in the prevention of coronary heart disease

Lifestyle modification:

To give up smoking. Complete cessation of smoking, including passive smoking. The overall risk of mortality for those who quit smoking is halved within two years. After 5–15 years, it levels out with the risk of those who have never smoked. If you cannot cope with this task on your own, contact a specialist for advice and help.

Physical activity. All patients with coronary artery disease are recommended to engage in daily physical activity at a moderate pace, such as walking for at least 30 minutes a day, home activities such as cleaning, gardening, and walking from home to work. If possible, endurance training is recommended 2 times a week. Patients at high risk (for example, after a heart attack or with heart failure) need to develop an individual physical rehabilitation program. It must be adhered to throughout your life, periodically changing on the recommendation of a specialist.

Diet. The goal is to optimize nutrition. It is necessary to reduce the amount of solid animal fats, cholesterol, and simple sugars. Reduce sodium (table salt) intake. Reduce the total calorie intake, especially if you are overweight. To achieve these goals, you must adhere to the following rules:

Eliminate or limit as much as possible the consumption of any animal fat: lard, butter, fatty meat.

Limit (or better yet completely eliminate) fried foods.

Limit eggs to 2 per week or less.

Reduce table salt consumption to 5 grams per day (salt in a plate), and in patients with hypertension to 3 or less grams per day.

Limit confectionery products, pastries, cakes, etc. as much as possible.

Increase your consumption of grains, as minimally processed as possible.

Increase the amount of fresh vegetables and fruits.

Eat sea fish at least three times a week instead of meat.

Include omega-3 fatty acids (ocean fish, fish oil) in your diet.

This diet has a high protective effect for blood vessels and prevents further development of atherosclerosis.

Weight loss. The goals of the weight loss program for coronary artery disease are to achieve a body mass index in the range of 18.5 - 24.9 kg/m2 and an abdominal circumference of less than 100 cm in men and less than 90 cm in women. To achieve these indicators, it is recommended to increase physical activity, reduce calorie intake, and, if necessary, develop an individual weight loss program and stick to it. At the first stage, it is necessary to reduce the weight by at least 10% of the original and maintain it.

In case of severe obesity, it is necessary to consult a specialist nutritionist and endocrinologist.

Reduce alcohol consumption. According to the latest WHO recommendations, the amount of alcohol consumed should not exceed one bottle of dry wine per week.

Monitoring key indicators

Arterial pressure. If it is within normal limits, you need to check it twice a year. If your blood pressure is elevated, you should take measures as recommended by your doctor. Very often, long-term use of blood pressure-lowering medications is required. The target blood pressure level is less than 140/90 mmHg in people without underlying medical conditions, and less than 130/90 in people with diabetes or kidney disease.

Cholesterol levels. An annual screening should include a blood test for cholesterol. If it is elevated, it is necessary to begin treatment on the recommendation of a doctor.

Blood sugar. It is necessary to monitor blood sugar levels especially carefully if you have diabetes or are prone to it; in such cases, constant supervision by an endocrinologist is necessary.

CHAPTER 2. RESEARCH PART.

Experimental study of coronary heart disease and its prevention.

Goals of examination for suspected coronary artery disease:

Identify additional risk factors: high blood pressure, blood cholesterol, signs of diabetes, kidney damage

Assess the condition of the heart muscle,

Assess the condition of the coronary arteries,

Select treatment tactics

Predict the need for heart surgery.

Holter ECG monitoring

Used along with stress tests to detect transient myocardial ischemia. The value of this technique lies in the ability to detect transient myocardial ischemia in everyday life. The criterion for myocardial ischemia during Holter ECG monitoring is ischemic ST segment depression of 1 mm or more with a duration of ST segment depression of at least 1 minute and time between individual episodes of at least 1 minute. This is the so-called “1x1x1” rule. The method is particularly useful for identifying episodes of vasospastic or spontaneous ischemia, as well as asymptomatic myocardial ischemia. Asymptomatic myocardial ischemia is often a poor prognostic sign. Considering that Holter ECG monitoring often gives false-positive results in patients without angina, patients with a large number of risk factors for coronary heart disease or with a family predisposition to coronary artery disease, as well as for assessing individual prognosis.

Due to the fact that the ability to detect transient myocardial ischemia by recording an ECG at rest is very limited, stress tests become much more important.

Load tests.

Stress tests provoke myocardial ischemia by increasing myocardial oxygen demand (treadmill test, VEM, dobutamine test) or reducing oxygen delivery to the myocardium (tests with dipyridamole and adenosine). Load tests in the form of a treadmill test or VEM are still the most common research methods. This is a relatively simple and inexpensive way to detect transient myocardial ischemia in patients with suspected coronary artery disease or with an established diagnosis.

The treadmill test has both advantages and disadvantages compared to VEM. The advantage lies primarily in the fact that the load is more physiological and is perceived by the patient as more familiar. In addition, when using the standard Bruce protocol, it is possible to perform a greater load than with VEM and achieve the desired result more quickly. The treadmill test is often used in the USA and relatively rarely in Europe and Russia. Possible reasons for this are the higher cost of the treadmill, which is 2-4 times more expensive than a bicycle ergometer, and its large dimensions.

Load on a bicycle ergometer. In case of positive results of the VEM test, the likelihood of a diagnosis of IHD increases. The higher the initial probability of coronary heart disease, the higher the value of this stress test for the patient’s ability to perform adequate physical activity. The most reliable sign of transient myocardial ischemia with a VEM test is horizontal or oblique ST segment depression of 1 mm or more. The probability of diagnosing coronary artery disease is close to 90% if, during exercise, ST segment depression of the ischemic type reaches 2 mm or more and is accompanied by a typical attack of angina. In patients with an initially high probability of coronary artery disease, detection of myocardial ischemia is more important for assessing the severity of coronary lesions and prognosis.

A positive result of the VEM test in such patients is combined with a significantly higher risk of coronary complications and death (the latter by 3.5–6 times). When the ST segment rises to 1 mm per 3 load steps according to the Bruce protocol, mortality in the group of such patients is less than 1% per year, and when the ST segment rises by more than 1 mm per 1 load step, it exceeds 5% per year.

Due to the relatively low sensitivity of the VEM test for ischemic heart disease, its negative result does not exclude this diagnosis. The rate of false positive results reaches 15%. Numerous studies have reported lower sensitivity of VEM and higher false-positive rates in women compared with men. However, when men and women are stratified according to the prevalence of CAD, the study results are similar. The sensitivity and specificity of the treadmill test and VEM tests are approximately the same. Exercising on a bicycle ergometer poses obvious difficulties for patients who do not have cycling experience. The advantages of VEM include the ability to perform a load both sitting and lying down, which is sometimes necessary according to the research protocol when solving some specific problems. Exercise on a bicycle ergometer and treadmill is a worthy and common test, but from 20 to 40% of patients cannot perform them if necessary due to orthopedic and neurological disorders or vascular diseases of the extremities.

Stress – Echo CG.

A new method widely used in the diagnosis of coronary artery disease. A treadmill or bicycle ergometer, as well as pharmacological drugs, are used as a load.

Stress - ECHO CG using a treadmill or bicycle ergometer competes with radioisotope methods in accuracy and equivalence. This technique should be used if the ECG is initially altered (signs of left ventricular myocardial hypertrophy, intraventricular conduction disturbances, electrolyte disturbances, drug effects, etc.). in these cases, local contractility disorders that occur during the development of myocardial ischemia can be detected using echocardiography. The normal response of the left ventricle to exercise is an increase in the rate of contraction and systolic thickening of the left ventricular myocardium. When ischemia occurs, these indicators can change to varying degrees.

Pharmacological stress ECHO CG is carried out with the aim of provoking and identifying myocardial ischemia, as well as determining the functional state of the myocardium and prognosis in a patient with coronary artery disease.

Indications for stress echo CG are:

Inability to perform a treadmill test or exercise on a bicycle ergometer.

Inability to perform physical activity to the required capacity.

False-positive exercise test results in patients without symptoms of coronary artery disease.

The most commonly used drugs in this test are dobutamine, dipyridamole, adenosine and arbutamine.

The system provides constant monitoring of heart rate, blood pressure, heart rhythm, ECG and ECG signs of myocardial ischemia, and conducts their computer analysis.

Radionuclide stress tests.

Myocardial perfusion scintigraphy with thallium-201 or technetium-99m allows us to identify defects in their accumulation in the myocardium. The capabilities of the method increase significantly when perfusion scintigraphy is combined with physical or pharmacological stress.

The need for this study arises if the patient cannot perform an exercise test, the test has not been brought to diagnostic criteria or its results are questionable, it is impossible to perform a stress echo CG or its conduct does not give the desired result (for example, poor visualization of the lateral wall of the left ventricle with echo CG).

Purpose of the study:

To identify the prevalence of coronary heart disease (stable angina, myocardial infarction) and evaluate the effectiveness of its therapy in the treatment and prevention of coronary artery disease.

Main objectives of the study:

Conduct a study of a representative sample in the regional interdistrict emergency hospital named after. N.S. Karpovich and identify the true prevalence of IHD in it depending on gender and age.

To study the prevalence of cardiovascular risk factors and the frequency of occurrence of their combinations in patients with coronary artery disease.

To determine the effectiveness of drug therapy for patients with coronary artery disease in a representative sample in the regional interdistrict emergency hospital named after. N.S. Karpovich.

To study adherence to therapy of patients with coronary artery disease in a representative sample of the regional interdistrict emergency hospital named after. N.S. Karpovich.

Object of study: patients of the regional interdistrict emergency hospital named after N.S. Karpovich, cardiology department, with coronary artery disease.

Subject of the study: the role of the paramedic in the prevention of coronary artery disease.

Research hypothesis: there is a relationship between the severity of coronary artery disease and the functional state and individual personal characteristics of patients with coronary artery disease, therefore a personal approach is necessary to each person with this disease.

I conducted a study at the regional interregional hospital named after. N.S. Karpovich. The study involved 30 people from the cardiology department. (20 men and 10 women).

A survey was conducted.

2.2 Analysis and evaluation of the results of the study of patients with coronary heart disease.

Based on the results of my research, the following results were revealed:

Diagram No. 1. The number of cases depending on gender.

Based on the results of the study, it can be said that:

The largest number of cases are men 66%, women 44%.

Diagram No. 2. Age of patients with ischemic heart disease.

Thus, we see that the peak incidence of IHD occurs between the ages of 45-60 years.

Diagram No. 3. Risk factors for ischemic heart disease.

So, based on the results of the survey, we can say that. That of all the risk factors, nervous stress takes 1st place 67%, 2nd place is obesity 47%, 3rd place is bad habits 38%, and fourth place is physical inactivity 24%. Taken together, all these factors are very dangerous and lead to many diseases.

Diagram No. 4. Complications of ischemic heart disease.

According to the study, we can conclude that the most common complication of coronary artery disease is heart failure 74%, the second place is myocardial infarction 46% and the third is stroke 39%.

Diagram No. 5. Blood pressure control.

So, as you can see from the graph, the majority of patients with coronary artery disease measure their blood pressure daily (65%), this is good news, but there are also those who do not even know what blood pressure is (7%) and this indicates the incompetence of medical workers. 15% measure blood pressure when they feel unwell, and 23% only when visiting a doctor. I want to say that if each of us tries, the number of people controlling their blood pressure can increase, if not to 100%, then at least to 80%, and then perhaps the number of complications from IHD will decrease.

Based on the results of a survey of patients with coronary artery disease, it becomes clear that women are more restrained in their diet. Men, on the other hand, allow themselves to break their diet and do not want to put up with the fact that they cannot eat fatty and spicy foods.

Diagram No. 7. Adherence to treatment.

Thus, according to the results of the study, you see that not all patients understand that IHD is not a curable disease and that medications must be taken for life; many believe that if they feel well, then they are cured and stop taking medications. So, let's look at the statistics:

53% take medications as prescribed;

Taken for high blood pressure 37%;

Accept when they remember 7%;

They don't accept 3%.

Diagram No. 8. Concomitant psychovegetative disorders

We can conclude that women are still more susceptible to psycho-emotional stress and mood swings. They have a hard time with this diagnosis and therefore require constant monitoring and communication.

Diagram No. 9. Hereditary predisposition.

The undoubted role of genetic burden in the development of many risk factors for coronary artery disease, such as lipid metabolism disorders, arterial hypertension, diabetes mellitus, and obesity, has been proven. In some cases, hereditarily determined features of the anatomy of the coronary vessels, as well as structural changes in the arterial wall, can contribute to the development of coronary artery disease.

Diagram No. 10. Duration of this disease.

Most of the respondents have had this pathology for more than 3 years; in my opinion, such patients need a special approach, because they have already psychologically come to terms with this diagnosis. They especially experience psychological deviations in character, mood swings and loss of strength.

According to the study, we can safely say that a larger percentage of people with this disease do not want to seek medical help at a clinic. Many of them complain about long queues at clinics.

Glossary.

Blood pressure is the blood pressure measured in the arteries. Pressure occurs due to the work of the heart, which pumps blood into the vascular system, and vascular resistance. The value of blood pressure in arteries, veins and capillaries is different and is one of the indicators of the functional state of the body.

Hyperlipidemia (hyperlipoproteinemia, dyslipidemia) - abnormally elevated levels lipids and/or HYPERLINK "https://ru.wikipedia.org/wiki/%D0%9B%D0%B8%D0%BF%D0%BE%D0%BF%D1%80%D0%BE%D1%82% D0%B5%D0%B8%D0%BD" \o "Lipoprotein" lipoproteins in HYPERLINK "https://ru.wikipedia.org/wiki/%D0%9A%D1%80%D0%BE%D0%B2%D1%8C" \o "Blood" blood person. Disorders of lipid and lipoprotein metabolism are quite common in the general population. Hyperlipidemia is an important risk factor for the development of HYPERLINK "https://ru.wikipedia.org/wiki/%D0%98%D0%91%D0%A1" \o "IHD" cardiovascular diseases mainly due to the significant influence cholesterol for development atherosclerosis. In addition, some hyperlipidemias affect the development of acute pancreatitis.

Lipids (from HYPERLINK "https://ru.wikipedia.org/wiki/%D0%94%D1%80%D0%B5%D0%B2%D0%BD%D0%B5%D0%B3%D1%80% D0%B5%D1%87%D0%B5%D1%81%D0%BA%D0%B8%D0%B9_%D1%8F%D0%B7%D1%8B%D0%BA" \o "Ancient Greek" Old Greekλίπος - fat) is a large group of natural organic compounds, including fats and fat-like substances. Simple lipid molecules are composed of alcohol and fatty acids, complex - from alcohol, high-molecular fatty acids and other components. Contained in all living cells.

Lipoproteins (lipoproteins) - class complex proteins, HYPERLINK "https://ru.wikipedia.org/wiki/%D0%9F%D1%80%D0%BE%D1%81%D1%82%D0%B5%D1%82%D0%B8%D1% 87%D0%B5%D1%81%D0%BA%D0%B0%D1%8F_%D0%B3%D1%80%D1%83%D0%BF%D0%BF%D0%B0" \o "Prosthetic group" prosthetic group which are represented by any lipidome. Thus, lipoproteins may contain free fatty acids, neutral fats, phospholipids, and cholesterol.

Cholesterol (HYPERLINK "https://ru.wikipedia.org/wiki/%D0%94%D1%80%D0%B5%D0%B2%D0%BD%D0%B5%D0%B3%D1%80%D0 %B5%D1%87%D0%B5%D1%81%D0%BA%D0%B8%D0%B9_%D1%8F%D0%B7%D1%8B%D0%BA" \o "Ancient Greek" Old Greekχολή - bile and στερεός - solid) - organic compound, natural fatty (lipophilic) alcohol contained in cell membranes all living organisms, with the exception of non-nuclear ones ( prokaryotes).

Atherosclerosis (from Greekἀθέρος - chaff, gruel + σκληρός - hard, dense) is a chronic disease of the arteries of the elastic and muscular-elastic type, resulting from disturbances in lipid and protein metabolism and accompanied by the deposition of cholesterol and some fractions of lipoproteins in the intima of blood vessels. Deposits form in the form of atheromatous plaques. Subsequent growth of connective tissue in them ( sclerosis), and HYPERLINK "https://ru.wikipedia.org/wiki/%D0%9A%D0%B0%D0%BB%D1%8C%D1%86%D0%B8%D0%BD%D0%BE% D0%B7" \o "Calcinosis" calcification the walls of the vessel lead to deformation and narrowing of the lumen up to obstruction (blockage of the vessel). It is important to distinguish atherosclerosis from Mönckeberg arteriosclerosis, another form of sclerotic lesions of the arteries, which is characterized by the deposition of calcium salts in the medial layer of the arteries, diffuseness of the lesion (absence of plaques), development aneurysm(not blockage) of blood vessels.

Pancreatitis ( lat. pancreatitis, from "Ancient Greek" Old Greek πάγκρεας - pancreas+ -itis - inflammation) - group diseases And syndromes, at which it is observed inflammation pancreas. For inflammation of the pancreas enzymes secreted by the gland are not released into duodenum, but are activated in the gland itself and begin to destroy it (self-digestion). Enzymes And toxins which are released are often released into the bloodstream and can seriously damage other organs, such as the brain, lungs, heart, kidneys And liver.

Arterial hypertension (AH, hypertension) - persistent increase blood pressure from 140/90 mm Hg. Art. and higher .

Conclusion.

The problem of chronic coronary heart disease has become one of the most acute social problems faced by humanity in the 20th century. The social significance of chronic ischemic disease is due to the fact that the disease affects people of working age and requires large financial costs for treatment and rehabilitation. Thus, early disability of the working population determined educational work on the prevention of chronic coronary heart disease as the main task of medical workers. The main directions of preventive assistance to the population should be considered: promotion of a healthy lifestyle; explaining the need to reduce body weight by following the recommendations of nutritionists and limiting foods rich in fats and carbohydrates; organizing the work of psychological assistance centers. While working on the topic, modern methods of managing patients with coronary heart disease were studied. A comparative analysis of the incidence of coronary artery disease for the period from 2013 to 2015 showed that there was a significant increase in the number of patients with this pathology. Based on the results of the survey, the following conclusions were drawn: men are more likely to suffer from ischemic heart disease; This pathology affects people mainly aged 50 to 60 years; the majority of patients (76%) are not registered as “D”; exacerbation of the disease in 48% of patients occurs 2 times a year; 58% of patients undergo inpatient treatment once a year; not all patients with exacerbation of the disease undergo hospital treatment; patients following the diet and daily routine recommended by the doctor, the predominant number; the majority of patients do not have a disability group for coronary artery disease (83%); 68% of patients do not have bad habits; 84% of patients control their blood pressure; the majority of patients with coronary artery disease (62%) do not perform a daily complex of exercise therapy; The majority of patients (59%) did not undergo sanatorium-resort treatment. The goal of the thesis was achieved: the role of the paramedic in the prevention of coronary artery disease was determined. Preventive measures that a paramedic carries out as part of his work have the following tasks: promoting a healthy lifestyle among a healthy population; carrying out sanitary and educational work among the population; Conducting conversations with patients about the need to adhere to therapeutic nutrition; training patients suffering from coronary artery disease to perform a daily complex of exercise therapy; training patients suffering from coronary artery disease, as well as those at risk for this disease, in the rules for measuring blood pressure; organizing conversations among patients with coronary artery disease, as well as among the healthy population, about the dangers of alcoholism and smoking; recommend that patients with this nosology adhere to a work-rest regime. recommend avoiding stressful situations. In the course of the work, the following tasks were solved: educational and scientific literature on this topic was studied; the causes and predisposing factors influencing the incidence of chronic cerebral ischemia have been established; statistical data on the incidence of chronic cerebral ischemia for 2013 – 2015 were analyzed; Recommendations have been drawn up for the prevention of chronic cerebral ischemia for patients suffering from chronic cerebral ischemia and for their relatives. The result of this work was the compilation of instructions for patients with chronic cerebral ischemia and their relatives on the topics: risk factors for chronic cerebral ischemia; therapeutic nutrition for ischemic heart disease; exercises for dizziness; special classes to train memory and attention. The paramedic carries out preventive measures as part of his work at the paramedic and obstetric station and health center. The results of the work can be used: in the work of a general practitioner; in carrying out sanitary and educational work; this study can be continued by students of a medical college as part of the study of cognitive impairment in patients suffering from coronary artery disease. Primary prevention of coronary heart disease

Primary prevention of IHD is carried out among people without clinical manifestations of the disease, that is, practically healthy. The main areas of primary prevention of coronary heart disease include:

organization of rational nutrition,

decrease in level cholesterol and blood sugar

body weight control,

normalization of blood pressure,

the fight against smoking and physical inactivity, as well as

organizing the correct daily routine and alternating work and rest.

That is, prevention is aimed at eliminating modifiable risk factors and is not only a personal, but also a national problem.

Proper nutrition is based on the principle of matching calories consumed with calories burned. The approximate diet of a thirty-year-old mental worker should contain no more than 3000 kcal, with protein should be 10-15%, carbohydrates (mostly complex) - at least 55-60%. As you age, you need to reduce your calorie intake by approximately 100-150 kcal every 10 years.

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Coronary heart disease [Text]: manual / G.V. Pogosova [etc.]; edited by R. G. Oganova; VNOK. - M.: GEOTAR-Media, 2011. - 112 p. 5. Coronary heart disease and diabetes mellitus [Text]: algorithm for diagnosis, prevention and treatment: manual / I. I. Dedov [etc.]; Ministry of Health and Social Development of the Russian Federation, Federal Agency for Health and Social Development, Federal State Institution ERC Rosmedtekhnologii. - M.: Perspective, 2007. - 24 p. The manual describes an algorithm for optimal methods and means of diagnosing coronary heart disease in patients with diabetes, especially in cases of its painless course. Recommendations for the treatment and prevention of coronary heart disease in diabetes mellitus are given. The manual is intended for endocrinologists, cardiologists and can be used as a manual in medical higher education institutions, as well as in advanced training courses for doctors. 6. Cardiac rehabilitation [Text] = Cardiac rehabilitation manual: practical. hands / lane from English edited by J. Niebauer. - M.: Logosphere, 2012. - 328 p. Based on clinical observations, the guide describes the general principles of the development and implementation of physical exercises, highlights issues of nutrition and psychological support for patients, as well as the optimal means of diagnosis and treatment in a particular case. The book presents the most common heart diseases and cardiac rehabilitation programs for patients with coronary heart disease, congenital cardiovascular diseases, persons after cardiac surgery, as well as those suffering from peripheral artery disease. This publication is a unique practical guide for doctors and is aimed at helping to manage patients using measures to optimize their health. 7. Computed tomographic coronary angiography for coronary heart disease [Text]: textbook. allowance / G. E. Trufanov [etc.]; Military medical acad. them. S. M. Kirov; Fed. Center for Heart, Blood and Endocrinology named after. V. A. Almazova. - St. Petersburg. : Elbi-SPb, 2012. - 64 p. The manual outlines recommendations for performing computed tomographic coronary angiography for coronary heart disease. Indications for the study, features of the technique and analysis of the results are considered. CT semiotics of atherosclerotic lesions of the coronary arteries is described. The role and place of the technique in the structure of methods for examining patients with coronary artery disease is determined. The educational and methodological manual has been compiled to assist a practicing radiologist in conducting research, interpreting results and writing conclusions. The textbook can also be useful for cardiologists and students undergoing training in the system of higher postgraduate and additional education. 8. Kosarev, V.V. Clinical pharmacology of drugs used in cardiovascular diseases [Text]: textbook. manual / V.V. Kosarev, S.A. Babanov; Ministry of Health and Social Development of the Russian Federation, State Educational Institution of Higher Professional Education "SamSMU". - Samara: Etching, 2010. - 139 p. The educational manual is intended for the system of university and postgraduate professional education of doctors and is addressed to students of medical, preventive and pharmaceutical faculties, general practitioners, cardiologists, clinical pharmacologists, pharmacists. The textbook outlines the issues of clinical pharmacology of the main classes of drugs used in cardiological practice - antihypertensive, antiarrhythmic, drugs with anti-ischemic, hypolipidemic and antiaggregation effects. Test questions, tests and tasks are presented. 9. Radiation diagnostics of heart and vascular diseases [Text]: national. hands / ch. ed. S. K. Ternovoy, L. S. Kokov; ASMOK. - M.: GEOTAR-Media, 2011. - 688 p. The book outlines the principles of radiation diagnostics of the cardiovascular system at a modern level. The methods of ultrasound, X-ray and magnetic resonance diagnostics of heart and vascular diseases are described in detail in accordance with the nosological forms of diseases of the cardiovascular system. The manual describes in detail radiation semiotics for congenital and acquired heart defects, and discusses diagnostic issues for coronary heart disease in detail. The radiation semiotics of diseases of the cerebral vessels and branches of the aortic arch is presented, and diagnostic research algorithms for atherosclerotic lesions of the aorta and arteries of the extremities are outlined. A separate chapter discusses methods for visualizing an aortic aneurysm and its branches. This volume describes the capabilities of radiation methods in the diagnosis of venous diseases. The diagnostic capabilities of radiation examination methods for varicose veins of the lower extremities, varicose veins of the small pelvis, and varicocele are examined and analyzed in detail. The radiation semiotics of venous thrombosis in the inferior vena cava system is described. Algorithms for radiodiagnosis of such a serious complication as pulmonary embolism are described in detail. A separate chapter is devoted to the possibilities of radiation research methods in the diagnosis of angiodysplasia. The publication is intended for clinical residents, students of the faculty of postgraduate and additional education, undergoing primary specialization or thematic improvement in radiology diagnostics, cardiovascular, X-ray endovascular and general surgery, as well as traumatology. The materials in the manual can also be used in practice by doctors in ultrasound diagnostic departments, radiologists, specialists in computed tomography and magnetic resonance imaging, as well as cardiovascular, x-ray endovascular, general surgeons and traumatologists. 10. MRI in the diagnosis of coronary heart disease [Text]: textbook. allowance / G. E. Trufanov [etc.]; Military medical acad. them. S. M. Kirov; Fed. Center for Heart, Blood and Endocrinology named after. V. A. Almazova. - St. Petersburg. : Elbi-SPb, 2012. - 64 p. The manual outlines recommendations for conducting contrast-enhanced magnetic resonance imaging for coronary heart disease. Indications for the study, features of the technique and analysis of the results are considered. The MRI semiotics of coronary artery disease is described, with emphasis on the assessment of myocardial viability. The role and place of the technique in the structure of methods for examining patients with coronary artery disease is determined. The educational and methodological manual has been compiled to assist a practicing radiologist in conducting research, interpreting results and writing conclusions. The textbook can also be useful for cardiologists and students undergoing training in the system of higher postgraduate and additional education. 11. Rehabilitation for diseases of the cardiovascular system [Text] / ed. I. N. Makarova. - M.: GEOTAR-Media, 2010. - 304 p. Prevention and rehabilitation treatment of patients with diseases of the cardiovascular system is one of the most important areas of domestic medicine. This paper presents the main therapeutic and preventive non-drug methods (diet therapy, psychotherapy, physiotherapy, exercise therapy, massage), which can be used independently or in combination with medications. Particular attention is paid to the clinical and physiological rationale for the use of each method, as well as their role at different stages of treatment. One of the chapters of the book is devoted to sanatorium-resort treatment, which is traditionally considered as the third stage of patient treatment in the “polyclinic-hospital-sanatorium” medical care system. The book is of interest to doctors of various specialties, especially cardiologists, rehabilitation medicine doctors, physiotherapists, psychotherapists, nutritionists, doctors and instructors in physical therapy, and balneologists. 12. Fokin, V. A. MRI in the diagnosis of ischemic stroke [Text]: textbook. manual / V. A. Fokin, S. N. Yanishevsky, A. G. Trufanov; Military medical acad. them. S. M. Kirov; Fed. Center for Heart, Blood and Endocrinology named after. V. A. Almazova. - St. Petersburg. : Elbi-SPb, 2012. - 96 p. The manual is devoted to a new method of radiological diagnosis of ischemic stroke - high-field MRI with the ability to obtain diffusion-weighted and perfusion-weighted images. Based on a review of literature data, the textbook outlines the state and problems of MRI diagnostics of ischemic stroke at the present stage. A separate chapter covers the basics of MRI, MR diffusion and MP perfusion. The MP semiotics of ischemic stroke in different periods is described according to traditional, as well as perfusion- and diffusion-weighted MRI. A separate chapter is devoted to optimizing the technique of MRI of the brain, especially in the acute period of ischemic stroke. Practical recommendations are given for performing MRI when examining patients with suspected ischemic stroke, as well as recommendations for examining severe patients with physical activity. The textbook may be useful for specialists in radiology diagnostics, neurologists and neurosurgeons and students undergoing training in the system of higher postgraduate and additional education. 13. Shchukin, Yu. V. Chronic ischemic heart disease in old and senile age [Text]: scientific and practical. manual / Yu. V. Shchukin, A. E. Ryabov; Ministry of Health and Social Development, State Educational Institution of Higher Professional Education SamSMU Roszdrav, State Institution of Social Development "Geriatric Scientific and Practical Center". - Samara: Volga-Business, 2008. - 44 p. Treatment of chronic ischemic heart disease in elderly and senile people is an important and complex problem. Its importance is determined by the fact that cardiovascular diseases occupy first place in the structure of morbidity; in older people they are more severe and more often lead to death. This manual is based on the NRI of the scientific society of cardiologists and examines the main features of the cardiovascular system in older people, the diagnosis and clinical manifestations of stable coronary artery disease, and the principles of treatment. The manual is intended for general practitioners and therapists. cardiologists, geriatricians. 14. Otto, C. M. Echocardiography review guide: companion to the Textbook of clinical echocardiography [Text] = Echocardiography: reference book / C. M. Otto, R. G. Schwaegler. - Piladelphia: Saunders Elsevier, 2008. - ill. - Index: p. 343-349. This manual introduces the reader to echocardiography. The authors clearly demonstrate the basic principles of echocardiography for all types of heart disease. Modern approaches to echocardiography are covered. The principles of obtaining echocardiographic images and Dopplerography are discussed; transthoracic echocardiogram; transesophageal echocardiography; modern echocardiographic techniques; clinical indications for use; systolic function of the left and right ventricle; diastolic filling and ventricular function; cardiac ischemia; cardiomyopathy and heart disease with hypertension and pulmonary pathologies; pericardial diseases; valve stenosis; valvular regurgitation; valve replacement; endocarditis; intracardiac masses and potential sources of cardiac embolism; echocardiographic examination of the great vessels; congenital heart defects in adults. Full-text online access at www.expertconsult.com will allow readers to consult on this issue and view videos related to each individual case described in the guide. Articles from periodicals 15. Balluzek, M. F. Rational choice of therapy with drugs of metabolic groups for coronary heart disease [Text] / M. F. Balluzek, I. G. Semenova, Yu. A. Novikov // Practical Medicine. - 2013. - No. 3. - P. 124-128. - Bibliography: p. 128 (12 titles). 16. Boytsov, S. A. Mechanisms of reducing mortality from coronary heart disease in different countries of the world [Text] / S. A. Boytsov // Preventive medicine. - 2013. - No. 5. - P. 9-19. - Bibliography: p. 18-19 (43 titles). 17. Bokeria, O. L. Sudden cardiac death and coronary heart disease [Text] / O. L. Bockeria, M. B. Biniashvili // Annals of Arrhythmology. - 2013. - No. 2. - P. 69-79. - Bibliography: p. 78-79 (38 titles). 18. Possibilities of echocardiography with speckle tracking in identifying viable myocardium in patients with chronic coronary heart disease [Text] / M. Yu. Gilyarov [et al.] // Cardiology and cardiovascular surgery. - 2014. - No. 1. - P. 4-9. 19. Gendlin, G. E. Features of antithrombotic therapy in patients with atrial fibrillation and coronary heart disease [Text] / G. E. Gendlin, E. E. Ryazantseva, A. V. Melekhov // Journal of Heart Failure. - 2013. - No. 3. - P. 135-140. - Bibliography: p. 140 (30 titles). 20. Hospital and long-term results of coronary bypass surgery in young patients with acute coronary syndrome [Text] / K. K. Musaev [et al.] // Cardiology and cardiovascular surgery. - 2014. - No. 1. - P. 29-32

Appendix No. 1.

How old are you?

A) less than 40. B) 45-60. B) more than 60.

And husband. B) female

A) yes. B) no.

Heredity

A) burdened. B) not burdened.

Excess weight.

Is there. B) no.

a) stress at work.

b) physical activity

c) I don't work.

Diabetes

Is there. B) no. C) was not examined

Cholesterol level

A) normal. B) tall. B) I don’t know.

Visual impairment

Is there. B) no.

Are you on a diet?

A) no. B) yes. C) I try to stick to it, but sometimes I break it.

Working pressure

B)140 and above/90 and more.

How much does it increase?

A) up to 150 not higher.

B) 190 and above.

What medications are you taking?

History of strokes or heart attacks?

Is there. B) no.

Accompanying illnesses.

A) there are (tell us which ones). B) no.

Do you drink alcohol?

A) happens on holidays.

B) I drink a little every day.

C) I drink often.

D) I don’t drink at all.

Graduate work. The problem of chronic coronary heart disease has become one of the most acute social problems faced by humanity in the 20th century.

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Introduction
Brain diseases are a topical area of ​​clinical medicine and have not only medical but also social significance, as they are one of the leading causes of morbidity, mortality and disability in the Russian Federation. Over the past decade, there has been a significant increase in the number of vascular diseases of the brain in young and middle-aged people, which are difficult to objectify in the early stages, and to treat effectively in the later stages.
Relevance of the topic: annual morbidity and mortality rates from stroke in the Russian Federation (RF) are one of the highest in the world. It is known that in our country about 450-500 thousand people annually suffer one or another type of stroke, i.e. every 1.5 minutes one of our compatriots suffers a cerebral infarction or hemorrhage in the brain. About 500 thousand Russians die every year due to a stroke. In the first month after the disease develops, 35% die, and within a year another 15%.
In the Russian Federation (RF), more than 1 million people live with the consequences of this disease, 80% of them are disabled, of which a third are people of working age. Only every fourth patient returns to work. Stroke affects an increasingly younger population—every fifth person is under 50 years of age. At the same time, mortality rates are higher in patients aged 30 to 50 years. There is a rejuvenation of stroke with an increase in its prevalence in people of working age - up to 65 years.
In the Republic of Bashkortostan, the dynamics of stroke incidence over the past 10 years is characterized by a tendency to increase rates from 1.6 to 2.3 per 1000 people. Moreover, in the structure of general morbidity, the number of cases of hemorrhagic stroke is increasing, which indicates insufficiently effective detection and treatment of arterial hypertension as one of the leading risk factors for the development of acute cerebrovascular accidents.
Thus, stroke is a national medical and social problem, which is why real efforts to organize effective preventive measures and improve the system of providing medical care to patients with a stroke are so significant and important.
Research problem: acute cerebrovascular accidents are a very important problem in neurology and are not only medical, but also social in nature. This is due to the widespread prevalence of stroke among the population, as well as the significant negative consequences for their health.
The purpose of the thesis: to determine the role of the paramedic in the prevention of complications of acute cerebrovascular accidents
Object of study: patients with acute cerebrovascular accidents
Subject of study: the role of the paramedic in the prevention of complications of acute cerebrovascular accidents
Research hypothesis: let us assume that the paramedic’s performance of the main duties in relation to patients with stroke will help increase patients’ awareness of existing risk factors, possible complications and methods of dealing with them
Research objectives:
1. Study the theoretical aspects of acute cerebrovascular accidents
2. To study the role of the paramedic in the prevention of stroke complications.
3. Conduct a comparative analysis of the incidence of stroke in the territory of the city of Tuymazy and the village of FAP. Duslyk, draw conclusions.
4. Conduct a survey among patients who have suffered a stroke and analyze data on the incidence of stroke over the past 3 years.
5. Develop preventive measures aimed at preventing the consequences of strokes and methods of combating existing complications and risk factors.
6. Introduce measures to prevent complications of strokes in the conditions of a paramedic and obstetric station.
Theoretical significance: a comprehensive study of medical awareness about their disease and the presence of complications in stroke patients and existing risk factors was assessed. Preventive materials have been developed for the prevention of stroke complications, which can be recommended for use in a medical and preventive institution.
Practical significance: the introduction of individual training programs for the prevention of stroke complications for rural residents will help establish a trusting relationship with the patient, acquire self-control skills, and will allow for a comprehensive and individual approach to each patient; forms a change in behavior, style and lifestyle, giving up bad habits, improving the prognosis and quality of the residents of the Tuymazinsky district.
Research methods: analysis and synthesis of specialized literature,
Internet resources, personal data, medical documentation, statistical data.
Structure of the work: corresponds to the logic of the study and includes an introduction, a theoretical part, a practical part, a conclusion, a list of references and applications.

CHAPTER 1. Theoretical aspects of acute cerebrovascular accidents

1.1. Concepts of acute cerebrovascular accidents, classification of stroke, pathogenesis, clinical picture

Acute cerebrovascular accidents are a group of clinical symptoms that develop due to an acute disorder of the blood supply to the brain.
Stroke (Late Latin insultus - attack) is an acute disturbance of blood circulation in the brain with the development of persistent symptoms of damage caused by a heart attack or hemorrhage in the brain matter. Transient ischemic attack is a transient disorder of cerebral circulation in which neurological symptoms regress within 24 hours.
This term combines conditions of different etiology and pathogenesis, the implementing element of which is acute vascular catastrophe of both the arterial and venous beds.
Stroke includes acute disorders of cerebral circulation, characterized by the sudden (within minutes, less often - hours) appearance of focal neurological disorders (motor, speech, sensory, coordination, visual, cortical functions, memory) and/or general cerebral disorders (changes in consciousness, headache , vomiting, etc.), which persist for more than 24 hours, or lead to the death of the patient in a shorter period of time due to a cause of cerebrovascular origin.
Classification:
A. Initial manifestations of insufficiency of blood supply to the brain:
1. Initial manifestations of insufficient blood supply to the brain.
2. Initial manifestations of insufficiency of blood supply to the spinal cord.
B. Transient cerebrovascular accidents (24 hours):
1. Transient ischemic attacks (TIA)
2. Hypertensive cerebral crises
B. Stroke:
1. Subarachnoid non-traumatic hemorrhage
2. Hemorrhagic stroke - non-traumatic hemorrhage in the brain (depending on location):
2.1. Parenchymal (in brain tissue)
2.2. Intraventricular (into the ventricles of the brain)
2.3. Subarachnoid (space between the arachnoid and the pia mater)
2.4. Subdural (subdural space of the brain)
2.5.Epidural (the space between the periosteum and the inner surface of the integumentary bones of the skull - most often the parietal)
3. Cerebral infarction (ischemic stroke):
3.1. Cerebral ischemic stroke
3.2. Spinal ischemic stroke
According to the mechanism of development, five main subtypes of ischemic stroke are traditionally distinguished:
1) atherothrombotic - which is based on the formation of a blood clot at the site of an atherosclerotic plaque;
2) embolic - in which emboli from the heart or atherosclerotic plaque of a large vessel are transferred with the bloodstream to smaller cerebral vessels and clog them;
3) lacunar - develops against the background of arterial hypertension, which is characterized by narrowing of small arteries as a result of atherosclerosis;
4) hemodynamic - occurs when two factors are combined: a sharp decrease in blood pressure (BP), due to a temporary deterioration in cardiac activity, stenosis (narrowing) of one of the large vessels of the brain;
5) hemorheological occlusion (blockage) of cerebral vessels occurs with increased blood clotting and (or) hyperaggregation (increased ability to stick together) of platelets.
4. Minor stroke (3 weeks).
5. Consequences of a previous cerebral stroke (more than 1 year).
There are several periods of ischemic stroke:
The most acute period is the first 3 days. Of these, the first three hours were defined as a “therapeutic window”, when it is possible to use thrombolytic drugs for systemic administration. In case of regression of symptoms during the first day, a transient ischemic attack is diagnosed;
acute period - up to 4 weeks;
early recovery period - up to six months;
late recovery period - up to 2 years;
period of residual effects - after 2 years.
Pathogenesis
The main pathogenetic condition of ischemic stroke is insufficient blood flow to a certain area
brain with subsequent development of a focus of hypoxia and necrosis. The limitation of the focus of ischemic stroke is determined
the possibility of developing collateral (bypassing the main artery or vein) blood circulation, which sharply decreases in old age. The need for blood redistribution between different areas of the brain arises
both in physiological conditions of increased functional activity, and in pathology caused by stenosis and thromboembolism of the vascular lumen. The rapid development of collateral circulation is
an important condition for effective cerebral blood flow. High sensitivity of ganglion nerve cells in the brain
to the factor of hypoxia and ischemia determines a short time period of restoration of blood circulation by dilating collateral vessels. Untimely development of collateral
blood circulation leads to the formation of a focus of ischemia with death
brain tissue (Figure 1). The possibility of developing adequate blood flow depends, first of all, on the rate of occlusion of the vessel lumen. Yes, when
high rate of development of vessel blockage (for example, with embolism, focal symptoms are usually observed; on the contrary, with
slow closure of the artery lumen and, accordingly, good
development of collateral circulation, clinical symptoms may be transient). Development of ischemic stroke
often preceded by transient cerebrovascular accidents. The most common occurrence of ischemic stroke is during sleep or immediately after sleep. It often develops
during myocardial infarction.
Hemorrhagic stroke, as a rule, is etiologically caused by hypertension. However, most often it occurs in hypertension in combination with atherosclerosis.
The development of anatomical changes (lipohyalinosis - decreased elasticity of the vessel wall, fibrinoid necrosis - impregnation of affected tissues with fibrin) in the perforating arteries of the brain and the formation of microaneurysms against the background of arterial hypertension are the most common prerequisites for the occurrence of stroke. Hemorrhage occurs due to rupture of the altered perforating
arteries (Figure 2). In this case, the vascular wall is impregnated
blood plasma with disruption of its trophism, formation of microaneurysms, rupture of blood vessels and exit
blood into the brain matter. When an artery ruptures or a microaneurysm (pathological protrusion) bleeding continues from several minutes to several
hours until a blood clot forms at the rupture site. Hemorrhage caused by arterial hypertension is localized mainly in the basins of the perforating arteries of the brain in the area
basal ganglia, thalamus, white matter of the cerebral hemispheres
brain, pons, cerebellum.
Hemorrhages can occur as a hematoma - with
rupture of a vessel or by the type of hemorrhagic impregnation. The hematoma is well demarcated from the surrounding tissues and is a cavity filled with liquid blood and its clots. For hemorrhages
in the brain caused by a ruptured vessel, in 80-85% of cases there is a breakthrough of blood into the subarachnoid space or into the ventricles.

Figure- 1. Ischemic area of ​​the brain

Figure-2. Hemorrhage from a ruptured vessel
Clinic
Ischemic strokes are characterized by a sudden onset with the acute development of persistent (lasting more than 24 hours) focal symptoms (paresis of the muscles of the arms, legs, face, blindness in one eye, speech impairment, sensory impairment, etc.). With a thrombotic stroke, symptoms often develop at night, and the patient already wakes up with paresis or aphasia. If a stroke occurs during the daytime, then gradual progression of the neurological defect is characteristic over several hours.
General cerebral symptoms (headache, depression of consciousness), as a rule, are expressed to a much lesser extent than with cerebral hemorrhage, or are absent. Pronounced cerebral manifestations are more typical for extensive hemispheric ischemic strokes, extensive infarctions of the brainstem, cerebellum - severe ischemic stroke.
- Aphasia (loss of speech)
- Apraxia (violation of purposeful actions, with damage to the left hemisphere)
- Anosognosia (impaired spatial orientation and inattention to the opposite half of space, lack of a critical assessment of one’s defect in case of damage to the right hemisphere).
- Loss of the right and left halves of vision (homonymous hemianopsia) and abduction of the eyeballs towards the lesion. On the side of hemiparesis, weakness of the lower part of the facial muscles of the genioglossus muscle, which pushes out the tongue, is usually observed (manifested when the tongue protrudes, deflecting it towards the paresis).
Clinically, embolic stroke is characterized by a sudden development of symptoms. Sometimes a patient who has rapidly developed paresis falls to the floor without having time to grab the nearest support. The neurological defect is maximal already at the very beginning of the disease; loss of consciousness and epileptic seizures are common. Limited embolic strokes can manifest themselves, for example, as isolated sensory aphasia (in this case, the patient does not understand the speech addressed to him, and his own speech is meaningless). The deterioration of the condition of such patients for the first days after a stroke may be due not only to swelling, but also to hemorrhage in the infarction area.
A characteristic feature of ischemic stroke is the predominance of focal symptoms over cerebral ones.
Among the focal symptoms of ischemic strokes, the development of central hemiparesis (weakness in the arm and leg on one side of the body) is often observed. In the acute stage, as a rule, muscle tone and tendon reflexes in the paralyzed arm and leg are reduced, but the Babinski reflex is detected. Patients with stroke are characterized by an increase in muscle tone, mainly in the flexors of the arm and extensor of the leg, as a result of which a hemiparetic gait develops, the peculiarity of which is that the paretic leg describes a semicircle when walking (circumduction), and the paretic arm is bent and brought to the body.
Hemorrhagic stroke is characterized by a rapid increase in neurological symptoms. The disease occurs more often during the day,
during physical activity or emotional stress
and is manifested by a characteristic combination of cerebral and focal symptoms. Sudden sharp headache, vomiting, impaired consciousness, psychomotor agitation, tachycardia, hemiparesis
or hemiplegia are the most common initial symptoms of hemorrhage. Impaired consciousness ranges from mild stupor,
stupor to deep atonic coma. All reflexes are lost, the breathing rhythm changes, the skin becomes hyperemic,
often profuse sweating, tense pulse, arterial
pressure increased to 180-200 mmHg. and higher. Gaze paresis, anisocoria, divergent strabismus, hemiplegia,
sometimes meningeal symptoms, sensorimotor aphasia. In 10% of cases, generalized epileptic seizures develop. The disease is usually accompanied by
hyperthermia. Hemorrhages from arterial aneurysms are clinically characterized by the rapid development of the meningeal symptom complex: stiff neck, Kernig and Brudzinski symptoms, photophobia, general hyperesthesia, and sometimes disorders
psyche such as confusion, disorientation, psychomotor agitation.
In the acute period, there is an increase in temperature to 38-39°C, signs of increased intracranial pressure - nausea, vomiting, and sometimes congestion in the fundus. Mild symptoms of focal brain damage often develop - paresis of the limbs, speech disorders, sensory disturbances.
Consequences and complications of stroke
The course of a stroke is divided into periods:
1) acute - lasts up to 1 month. after a stroke;
2) restorative - from 1 month. up to 1 year;
3) residual - after 1 year;
It is in the residual period that the consequences of a stroke are formed. In other words, the consequences of a stroke are the result of treatment and recovery after a stroke in the acute and recovery period.
1. Paralysis and paresis - the most common consequences of a stroke are movement disorders, usually unilateral hemiparesis.
2. Changes in muscle tone in paretic limbs - usually this is an increase in spastic tone, much less often - muscle hypotonia (mainly in the leg). Spasticity often increases the severity of motor disorders and tends to increase within 1 month after a stroke, often leading to the development of contractures.
3. Post-stroke trophic disorders: atrophy of the joints of paretic limbs; “painful shoulder syndrome” associated with a violation of the position of the spine with a displacement to the right, left, up or down; muscle atrophy, bedsores. Most often, in patients in the first 2 weeks after a stroke, “painful shoulder syndrome” occurs, in the genesis of which two factors can play a role - trophic disorders (arthropathy) and prolapse of the humeral head from the glenoid cavity due to stretching of the joint capsule, which occurs under the influence of the severity of the paretic hands, as well as due to muscle paralysis.
4. Sensory disturbances – among sensory disturbances, often combined with hemiparesis, the most important is a disorder of muscle-joint sensation - this makes it difficult to restore walking and self-care skills, making it impossible to perform subtle targeted movements.
5. Central pain syndrome - approximately 3% of patients who have had a stroke experience pain of central origin. Thalamic syndrome includes: acute, often burning pain on the half of the body and face opposite the lesion, sometimes intensifying with changes in weather, touch, emotional stress, pressure; reduction of all types of sensitivity; hemiparesis. Thalamic syndrome often does not develop immediately after a stroke, but after several months and tends to further increase pain.
6. Speech disorders. Aphasia is observed in more than a third of patients. There are types of aphasia: motor (impaired own speech), sensory (impaired understanding of the speech of others), amnestic (forgetting individual objects and actions), sensorimotor (impaired own speech and understanding of the speech of others), total aphasia. Another type of speech disorder is dysarthria - a violation of the correct articulation of sounds while maintaining “internal” speech, understanding the speech of others, reading and writing.
7. Violation of higher mental functions - cognitive impairment (decreased memory, intelligence, concentration of attention. The following may also develop: apatico-abulia syndrome (lack of one’s own motivations for activity - abulia), interest in life (apathy), decrease in volitional functions (abulia), depression accompanied by asthenia occurs in 40–60% of post-stroke patients.
8. Visual impairment - most often it is homonymous (one-sided) hemianopsia (loss of the left field of vision with lesions in the right hemisphere of the brain and vice versa). Oculomotor disorders: paresis of the eye muscles, double vision, gaze paresis.
9. Post-stroke epilepsy develops in some patients in 6-8% of cases, within a period of 6 months to 2 years after stroke.
Impaired balance, coordination and statics make it difficult to restore walking functions and self-care skills.

1.2.The role of the paramedic in the prevention of complications of acute cerebrovascular accidents

1.2.1.The role of the paramedic in diagnosing stroke and providing emergency care

The paramedic is the primary link in providing assistance to persons with acute cerebrovascular accidents; he must know the basic principles of providing pre-hospital emergency care at the prehospital stage in order to prevent the development of many complications.
The paramedic must be able to distinguish between cerebral infarction and hemorrhagic stroke, as this is important for providing qualified patient care (Table 1).
Table 1 - Differential diagnostic characteristics of strokes
Factors and symptoms Hemorrhagic stroke Ischemic stroke (cerebral infarction)
History of arterial hypertension Atherosclerosis of cerebral vessels
Age Young and middle Elderly and senile
Onset Acute sudden Slower
Consciousness Sudden or very quickly depressed (to the point of coma) Gradual depression
Headache Very severe Not pronounced
Vomiting Often Unusual
BP Increased Normal
or downgraded
Neck stiffness Characteristic Absent
Facial hyperemia Typical Absent
Liquor Mixed with blood No blood
Pulse and respiration Sudden changes No sudden changes
Anisocoria Characteristic Absent
Retinal hemorrhage Characteristic Absent
Dynamics of condition Progressive deterioration Gradual deterioration
When making a diagnosis, the paramedic must use the standard of first aid - orders. Order No. 930 of November 30. 2009 “On the procedure for organizing monitoring of the implementation of measures aimed at improving the provision of medical care to patients with vascular diseases.” Order No. 389-m “On approval of the procedure for providing medical care to patients with acute cerebrovascular accidents” and the “Guidelines for emergency medical care” emanating from them.
The paramedic conducts an examination and physical examination of the patient: assessment of the general condition, consciousness, breathing; visual assessment: carefully examine and palpate the soft tissues of the head (to identify traumatic brain injury), examine the external auditory and nasal passages (to identify cerebrospinal fluid and hemorrhea); study of pulse rate and rhythm (>60); measures blood pressure (increase); auscultation of the heart: the presence of a murmur of mitral valve prolapse or other cardiac murmurs and takes an ECG.
When examining the neurological status, the paramedic should pay special attention to the presence of the following signs:
o Motor disturbances in the limbs: it is necessary to ask the patient to hold the raised limbs for 10 s, the paretic limb will fall faster (Barre test).
o Speech disorders (dysarthria, aphasia): with dysarthria, the patient’s own speech is unclear, while the understanding of the addressed speech is completely intact, and there is a feeling of “porridge in the mouth”; with aphasia, the patient may not understand spoken speech, and there may be no speech production of his own.
o Disorders of cranial innervation: facial asymmetry (“distortion” of the face when asked to show teeth or smile), dysphagia (swallowing disorders - choking when taking liquid or solid food).
o Sensitivity disorders: when symmetrical areas of the limbs or torso tingle, a unilateral decrease in pain sensitivity is detected.
o Decreased level of consciousness (stunning, stupor, coma).
o Visual field defects (most often hemianopsia - loss of the right or left visual fields in both eyes).
If the paramedic identifies obvious symptoms of acute cerebrovascular accident, he does the following:
- must carry out neuroprotective therapy: Mexidol - intravenously in a stream for 5-7 minutes (4-8 ml) or drip 0.2 g (4 ml) in 100 ml of 0.9% sodium chloride solution; Semax - 2-3 drops of 1% solution in each nasal passage; glycine from 8-10 tablets under the tongue, if the patient is conscious; Ceraxon – 1000 mg (10 ml) IV slowly.
If the patient is unconscious:
- it is necessary to sanitize the upper respiratory tract (remove dentures), ensure free breathing (unfasten the tight collar, avoid hyperextension or excessive bending of the head), turn it on its side to prevent aspiration of saliva and vomit and the further development of aspiration pneumonia.
- oxygen inhalation. Mechanical ventilation is indicated for bradypnea (respiratory rate 35-40 per minute), increasing cyanosis.
- in the presence of arterial hypertension (systolic blood pressure >200 mm Hg, diastolic blood pressure >110 mm Hg), a slow decrease in blood pressure is indicated (by no more than 15-20% of the initial values ​​within an hour, because a sharp decrease or blood pressure below 160/110 mm Hg, dangerous by worsening cerebral ischemia): enalapril 0.625-1.25 mg IV (1-2 ml) in a slow stream;
magnesium sulfate - iv 1000-2000 mg (10-20 ml), administered slowly (the first 3 ml over 3 minutes) over 10-15 minutes;
- if a convulsive syndrome occurs: diazepam IV in an initial dose of 10-20 mg (1-2 ml), subsequently, if necessary, 20 mg IM or IV drip. The effect takes several minutes to develop and varies among patients.
- urgent hospitalization of patients in the intensive care unit or in the neurosurgical department (for hemorrhagic stroke).

1.2.2. The role of the paramedic in the prevention of stroke

The most important prerequisite for effective treatment is: timely provision of emergency qualified medical care to patients with developed acute cerebrovascular accidents and thoughtful individual work with patients with stroke, i.e. elimination, if possible, of risk factors and the development of possible complications of stroke.
A FAP paramedic may encounter stroke not only at the stage of diagnosis and emergency care, but also work with patients to prevent stroke and take part in the rehabilitation of patients after stroke.
The FAP paramedic should know that there are two groups of risk factors for the development of stroke:
1) Modifiable, which can be influenced and reduce the incidence of stroke;
2) non-modifiable, which cannot be changed, but you can, knowing about them, take preventive steps, especially in the presence of other risk factors.
Non-modifiable risk factors:
1. Age - after 55 years, the risk of developing a stroke doubles every 10 years. In the age group over 60 years old, 70% of all stroke cases are registered.
2. Gender - men are more likely to suffer from stroke than women (4:1 ratio).
3. Hereditary predisposition (in first-degree relatives) - the likelihood of developing a stroke increases by 2 times if one of the parents had this disease. It is believed that a hereditary tendency to strokes is more often transmitted through the maternal line.
Modifiable risk factors:
1.Hypertension (35%) - high blood pressure is the most common risk factor for stroke and TIA.
2. Diabetes mellitus - increases the risk of stroke by 3 times. This disease occurs in 8% of the population. In patients with ischemic stroke, diabetes mellitus is observed in 15-33% of cases.
3.TIA or previous stroke - increases the risk of developing a subsequent stroke by 10 times.
4. Obesity (27%) - defined as exceeding the body mass index (BMI) by more than 30 kg/m2. BMI is determined using Quetelet’s formula: body weight (in kilograms) must be divided by height (in meters) squared (Table 2).
Table 2 - Classification of obesity by BMI (WHO)

4. Coronary heart disease - a previous myocardial infarction increases the risk of stroke by 3 times.
5.Disturbance of lipid metabolism - an increase in the content of total cholesterol in the blood (not > 5.2 mmol/l) and low-density lipoproteins in combination with a decrease in high-density cholesterol leads to the development of atherosclerosis of blood vessels.
6. Stenosis of the carotid arteries - severe atherosclerotic lesions of the carotid arteries in the form of vascular stenosis are the cause of 5-7% of cerebrovascular accidents annually.
7. Heart rhythm disturbances - atrial fibrillation, regardless of the cause that caused it, increases the likelihood of a stroke by 3.6 times.
8.Heart failure - regardless of the cause, increases the risk of stroke by 3 times.
9. Smoking (> 20 cigarettes per day) - accelerates the process of vascular damage and increases the influence of other risk factors.
10. Alcohol abuse - chronic alcoholism is a risk factor for all subtypes of stroke.
11. Use of tablet contraceptives (oral contraceptives) containing more than 50 mg of estrogens and postmenopausal hormonal therapy. Taking these medications increases the likelihood of developing cerebrovascular accidents only if there are other risk factors, especially smoking and high blood pressure.
12. Long-term negative psycho-emotional and psychosocial stress (9%).
To combat risk factors for the development of stroke, the FAP paramedic is obliged to: promote a healthy lifestyle; carry out regular health education work among the entire population; actively involve rural residents in undergoing medical examination of the adult population.

1.2.3. The role of the paramedic in the residual period of acute stroke

Due to the possible development of a large number of complications in the residual period of a stroke, patients require appropriate care and an individual rehabilitation plan for each patient. The FAP paramedic must be directly involved in this.
The main tasks of a paramedic in the rehabilitation of patients with stroke:
1. Training patients suffering from stroke and their relatives, as well as persons at risk for this disease, in the rules of measuring blood pressure;
2. Monitor the strictness of taking recommended medications;
3. Train relatives in the prevention of bedsores; the basic principles of passive gymnastics and massage of paralyzed parts of the body;
4. To prevent thromboembolism, relatives of bedridden patients should be advised to purchase compression stockings or bandage their legs with an elastic bandage - this will help minimize the risk of blood clots - thrombi;
5. Conduct a conversation with relatives about the need to maintain a “healthy psychological climate” in the family and that this is the key to more successful restoration of lost functions;
6. Another important point in the rehabilitation of patients with stroke is proper nutrition; the paramedic is obliged to give all the necessary recommendations on nutrition;
7. Conduct conversations with patients about the need to comply with therapeutic exercises, training patients suffering from stroke to perform a daily complex of therapeutic physical training;
8. Organizing and conducting conversations among patients with stroke, as well as among the healthy population, about the dangers of alcoholism and smoking; recommend that patients with this nosology adhere to a work-rest regime, and recommend avoiding stressful situations.
9. Know the basic principles of treatment of stroke, for timely preventive treatment with medications prescribed by a doctor and monitoring the intake of medications by patients who have suffered a stroke.
Basic principles of drug treatment after stroke:
1. Antiplatelet agents: Aspirin cardio as prescribed by a doctor;
2. Lifelong antihypertensive therapy - Captopril as prescribed by a doctor;
3. Antioxidants and Nootropics: Mexiprim, every six months as prescribed by a doctor;
4. Antidepressants: Prozac;
5. Anticoagulants: Fraxiparine, Clexane;
6. B vitamins: Thiamine, Pyridoxine.
Thus, stroke is a very serious health problem, causing harm to the health of patients and leading to the death of patients.
The paramedic must know the standards of diagnosis and emergency care, and know the main risk factors for the development of the disease. To be able to carry out their primary prevention and, in the event of the appearance of patients with acute stroke at the FAP, to participate in their rehabilitation, to know the basic principles of drug treatment of patients with stroke.

CHAPTER 2. Empirical study of the role of the paramedic in the prevention of complications of acute cerebrovascular accidents

2.1.Organization of the base and research methods

Our study was conducted on the basis of the FAP in the village of Duslyk, Tuymazinskaya Central District Hospital of the Republic of Bashkortostan. The study involved 21 patients suffering from stroke. The study was conducted from May 4 to May 13, 2016, which consisted of four research stages.
At the first stage of the study, a comparative analysis of the incidence of stroke in the city of Tuymazy and the village was carried out. Duslyk for 2013-2015.
At the third stage of the study, an analysis was carried out of the degree of awareness of patients about their disease, existing risk factors, existing complications and the degree to which patients followed all the doctor’s prescriptions and recommendations (Appendix A).
After the sociological study, we carried out sanitary and educational work with stroke patients and their relatives, namely: a conversation with stroke patients separately on the complications they had, which provided information about the characteristics of stroke, methods of dealing with risk factors, existing complications and the prevention of recurrences. stroke attacks (Appendix B); conversation with relatives of bedridden patients about the prevention of bedsores and the principles of skin care, recommendations were given on methods of combating pneumonia, in case of disorders of the large intestine (Appendix B). A booklet was also released on the topic “Say no to the consequences of a stroke” to increase patients’ awareness of their disease and the basic principles of preventing complications (Appendix D); memo “20 simple exercises for walking patients who have had a stroke” (Appendix E); A health bulletin has been issued (Appendix K).
At the fourth stage, a repeated analysis was carried out of the degree of awareness of patients about their disease, existing risk factors, complications of a stroke, and the degree to which patients followed all the doctor’s prescriptions and recommendations (Appendix I).
In order to analyze the activities of a paramedic at a medical and obstetric station in the prevention of stroke complications, the subjects were asked to conduct a questionnaire survey.
Questioning as a research method allows you to obtain in a short period of time the maximum possible amount of information about any disease, find out public opinions on certain issues and in other similar cases.

2.2. Comparative analysis of statistical data of stroke patients in the city of Tuymazy and the village of Duslyk

For more complete information about the incidence of stroke and comparative analysis, we studied and analyzed statistical data on the incidence in the city of Tuymazy (Table 3) and the village. Duslyk (Table 6) for the last three years from 2013 to 2015.
Table 3 - Incidence of stroke in the city of Tuymazy for 2013-2015.

Year Registered patients with this disease

Are registered at the dispensary
Total Men Women Diagnosis established for the first time in life
2013 802 641 161 802 643

2014 642 513 129 642 415
2015 844 675 169 844 716
Conclusion: the incidence of stroke in the city of Tuymazy increased sharply in 2015, so in 2013 the number of patients was 802 people, in 2014 - 642 people, and in 2015 already 844 people. It can be assumed that this is due to frequent stressful situations due to the difficult economic situation in the country. Of these, the incidence among men and women is (ratio 4:1), so in 2013 there were 641 men, 161 women; in 2014 there were 513 men, 129 women; in 2015 there were 675 men and 169 women.
Table 4 - Statistical data on the incidence of stroke among people of working age in Tuymazy from 2013 to 2015
2013 2014 2015
Subarachnoid
hemorrhage 6 5 9
Intracerebral and other intracranial hemorrhage 54 36 56
Cerebral infarction 497 410 419
Stroke not specified as hemorrhage or cerebral infarction 9 8 4
Let's present the results obtained in the form of a diagram (Figure 3):
Figure 3. Statistical data on the incidence of stroke among people of working age in Tuymazy from 2013 to 2015
Thus, the number of stroke cases in people of working age in 2013 was 566 people, in 2014 - 459 people, in 2015 - 488 people.
Table 5 - Statistical data on the incidence of stroke among people of retirement age in Tuymazy from 2013 to 2015
2013 2014 2015
Subarachnoid
hemorrhage 1 1 1
Intracranial and other intracranial hemorrhage 30 32 35
Cerebral infarction 138 162 318
Stroke not specified as hemorrhage or cerebral infarction 9 6 3

Let's present the results obtained in the form of a diagram (Figure 4):

Figure 4. Statistical data on the incidence of stroke among people of retirement age in Tuymazy from 2013 to 2015
Thus, the number of stroke cases in people of retirement age in 2013 was 178 people, in 2014 - 183 people, in 2015 - 357 people.
We studied the medical documentation of the FAP: form No. 025/у medical records of an outpatient; dispensary observation log form No. 030/у. The study revealed the following data on the incidence of stroke over the last 3 years from 2013 to 2015, among people living in the village. Duslyk.
Table 6 - Incidence of stroke in the village of Duslyk for 2013-2015.
Diagnosis made for the first time in life Are undergoing follow-up with a diagnosis of stroke Total patients who have had a stroke
2013 5 5 5
2014 7 7 7
2015 7 9 9
Let's present the results obtained in the form of a diagram (Figure 5):

Figure-5. Incidence of stroke in the village of Duslyk for 2013 – 2015.
As can be seen from the data shown in Table 4 and Figure 1, the incidence of stroke in the village of Duslyk is increasing every year. If in 2013 there were 5 people with stroke, in 2014 there were already 7 people, and in 2015 there were 9 people.
Let us present the analysis of the gender composition of identified patients in the form (Table 7):
Table 7 - Gender composition of identified patients
Of which men, of which women
2013 4 1
2014 5 2
2015 7 2
Analyzing the data in Table 7, we see that the incidence of stroke among men is higher than among women. So in 2013, 4 men and 1 woman suffered a stroke, in 2014, 5 men and 2 women, in 2015. 7 men and 2 women.
Now let's present an analysis of the prevalence of stroke types (Figure 6).

Figure- 6. Prevalence of types of stroke from 2013 to 2015 in the village of Duslyk
Analyzing the data in Figure 6, we see that the incidence of ischemic stroke prevails over the incidence of hemorrhagic stroke. So, if the difference between ischemic and hemorrhagic stroke in 2013 is 3 people, then in 2014 and 2015 it is 5 people.
The age composition is presented in Figure 7:

Figure- 7. Age of patients
Thus, of the respondents, 15% of patients aged 30-40 years, 20% of patients aged 40-50 years, 35% of patients aged 50-60 years and 30% of patients over 60 years of age suffered a stroke.
Conclusion: after conducting a comparative analysis of statistical data for the city of Tuymazy, data from outpatient records of patients, a log of dispensary observation and questioning of patients in the village of Duslyk, the following conclusions can be drawn:
1. The incidence of stroke increases with each passing year, we assume that this is due to an increase in the number of people suffering from heart disease, lack of awareness of the population about the risk factors for developing the disease; with insufficient coverage of clinical examination of patients with risk factors for developing the disease. Heredity also plays an important role in the increase in the incidence of stroke.
2. Most often, men suffer strokes than women, perhaps this is due to the fact that men, unlike women, are more susceptible to stress and the harmful effects of bad habits, smoking and alcohol; the presence of sexual intercourse in women also plays an important role the hormone estrogen, which protects the vascular walls and maintains their elasticity until the onset of menopause, on average up to the age of 50.
3. Ischemic stroke develops more often than hemorrhagic stroke, perhaps this is due to age-related changes in the body;
4. The number of stroke patients of working age is increasing; it can be assumed that the “rejuvenation” of stroke is associated with an increase in the number of patients with high blood pressure, frequent stress, the presence of bad habits, and ignorance of risk factors for stroke.

2.3. Characteristics of the paramedic and obstetric station in the village of Duslyk

The medical and obstetric center in the village of Duslyk is the largest in the entire Tuymazinsky district. Consists of: waiting room, paramedic's office, midwife's office, treatment room, storage room for cleaning items. The FAP staff includes three employees: a manager - a paramedic, a paramedic and a midwife, two with the highest category, one excellent student in healthcare. The FAP serves: a school, one kindergarten, a bakery and shops.
Documentation of the paramedic and obstetric station is presented in Appendix G.
Basic orders regulating the work of the paramedic-midwife station. Duslyk.
OST 42-21-2-85 “Sterilization and disinfection of medical products, methods, means, regimes”;
Order No. 770 “On the introduction of an industry standard.” OST 42-21-2-85 "on sterilization and disinfection";
Order No. 170 “On measures to improve the prevention and treatment of HIV-infected people in the Russian Federation”;
Order No. 720 “On improving medical care for patients with purulent surgical diseases and strengthening measures to combat nosocomial infections”;
Order No. 342. “On strengthening measures to prevent epidemic typhus and combat lice”;
3.1.5.2826-10 “Prevention of HIV infection”;
SanPiN 2.1.3.2630-10 Sanitary and epidemiological requirements for organizations engaged in medical activities;
SanPiN 2.1.7.2790-10 Sanitary and epidemiological requirements for the management of medical waste;
Order No. 36. “On improving measures for the prevention of diphtheria.”
The number of population served for 2016 is 2181 people, of which 1063 are men, 1118 are women, 426 are children.
FAP paramedic s. Duslyk is obliged:
1. Conduct outpatient appointments and home care for the assigned population according to the established schedule.
2. Provide urgent and emergency pre-hospital medical care for conditions that threaten human life and health.
3. Carry out the doctor’s prescriptions in a timely manner and in full when organizing dynamic monitoring and treatment of the patient at the place of residence.
4. Carry out dynamic observation, including control over the organization of timely treatment of patients with socially significant diseases (tuberculosis, sexually transmitted diseases, mental and drug addiction diseases, oncological pathology, diabetes mellitus).
5. Participate, under the guidance of doctors from medical institutions, in conducting preventive and dispensary examinations of decreed groups of the population and patients registered at the dispensary. Maintain control charts (form No. 030/u) for dispensary patients in the prescribed manner and ensure their timely attendance at medical specialists, carry out preventive measures among dispensary patients according to the recommendations of doctors.
6. Carry out activities for active early identification of patients and persons with risk factors for the development of diseases: filling out initial patient examination cards + Stage I of targeted medical examination, organizing a fluorographic examination of the attached population, cytological examination of women, measuring blood pressure for persons over 16 years of age, measuring intraocular pressure for persons over 40 years old, etc.
7. Provide patronage to pregnant women (in the absence of a midwife), postpartum women and children under the age of 1 year; carry out dynamic monitoring of children in the first year of life who are at risk, prevent rickets, anemia, promote rational feeding, participate in work with socially disadvantaged families on reproductive health and family planning.
8. Conduct preventive vaccinations for the population in a timely and high-quality manner in accordance with the vaccination calendar; know permanent and temporary contraindications to them.
9. Carry out, under the guidance of doctors from medical institutions and specialists from the Federal State Health Institution, a set of sanitary, hygienic and anti-epidemic measures in the event of an unfavorable epidemiological situation in the service area. Know the clinic of especially dangerous infections and the tactics of nursing staff when identifying them.
10. Regularly conduct door-to-door visits to actively monitor the condition of the assigned population and early detection of diseases, including infectious ones.
The FAP paramedic has the right:
1. Within the limits of their competence, conduct an examination, establish a diagnosis, prescribe treatment, perform medical procedures and preventive measures.
2. Use all approved instructional and methodological materials published by health authorities of the Russian Federation and the Republic of Belarus concerning the activities of the FAP.
3. Make proposals to improve the work of the FAP and improve the system of medical care in the service area.
4. Improve professional qualifications through advanced training courses in postgraduate education institutions at least once every five years in accordance with the established procedure.
5. Enjoy established benefits in accordance with current legislation.

2.3.1. Medical examination of stroke patients at the FAP

Patients with stroke are subject to mandatory medical examination on the basis of Article 46 of Federal Law No. 323 of November 21, 2011 “On the fundamentals of protecting the health of citizens of the Russian Federation.”
A FAP paramedic if the head of a medical organization entrusts him with certain functions of the attending physician, including conducting dispensary observation, in the manner established by order of the Ministry of Health and Social Development of the Russian Federation dated March 23, 2012 No. 252-n.
Depending on the diagnosis, patients belong to one or another dispensary group: patients with transient cerebrovascular accidents with focal neurological symptoms belong to group D III; patients who suffered a cerebral stroke with complete restoration of impaired functions during the first 3 weeks (“minor stroke”) Group DIII; patients with residual effects of cerebral stroke group DIII.
Documentation of medical examination of patients with stroke:
1. The main medical document, which reflects the dynamics of dispensary observation of the patient, is the “Outpatient Medical Card” form No. 025/u; the letter D or the disease code is placed on the spines so as not to confuse this card with another document.
2. For each patient, the “Medical examination record card” form No. 131/u-86 is filled out. It is kept by the local therapist.
3. The “Dispensary Observation Log” form No. 030/u is also filled out.
The FAP paramedic in relation to stroke patients is obliged to:
- conduct dynamic monitoring of patients with stroke 4 times a year;
- organize a doctor’s call 2 times a year;
- motivate patients to recover by conducting preventive conversations with patients and their relatives;
- increase awareness among patients about risk factors and principles of combating them;
- carry out procedures prescribed by a doctor at home (injections);
- provide training to patients and their relatives in the basic principles of care.

2.4. Results before the study

To the question, “From what sources did you receive information about your disease?” The following results were obtained (Figure 8):

Figure- 8. Source of information about stroke
Thus, 50% of respondents were not at all interested in information about stroke, 15% received information from friends or acquaintances, 15% from medical professionals and television shows, and 5% from books or magazines.
After analyzing the personal data, the following results were obtained: to the question “Do you smoke?” 70% of respondents answered that they smoke, 30% do not smoke; to the question “Do you drink alcohol?” 40% of respondents answered “yes, I use”, 60% answered negatively; to the question “are you often exposed to stressful situations”, 45% of respondents answered “often”, 55% “rarely”;
To the question “Do you adhere to the principles of proper nutrition or are you on a diet?” The following results were obtained (Figure 9):

Figure-9. Compliance with the principles of proper nutrition or diet
Analyzing the data in Figure 9, we see that only 25% of the patients surveyed follow the principles of proper nutrition or adhere to a diet, 25% of them sometimes adhere and 40% do not adhere at all.
To the question, “What cardiovascular diseases do you have?” The following results were obtained (Figure 10):

Figure- 10. Presence of cardiovascular disease
Thus, 70% of respondents have a history of hypertension, 20% have had a myocardial infarction, and 10% have arrhythmias.
To the question “Do you have a history of a previous stroke?” The following results were obtained (Figure 11):

Figure- 11. Presence of a previous stroke
As can be seen from the data presented in Figure 11, among the respondents, 10% have a history of stroke, 80% do not.
To the question “Do you follow all the doctor’s prescriptions and recommendations?” the following data were obtained (Figure 12):

Figure- 12. Compliance with doctor’s prescriptions and recommendations
Thus, only 47% of respondents comply with all doctor’s prescriptions.
To the question “Do you perform physical therapy at home and how often?” The following results were obtained (Figure 13):

Figure- 13. Performing physical therapy
Thus, 45% of respondents sometimes perform physical therapy at home, 35% of them do not perform physical therapy at all, and only 20% conduct physical therapy classes.
To the question, “What consequences are you concerned about today?” the following data were obtained (Figure 14):

Figure- 14. Presence of complications
Analyzing the data in Figure 14, we see that 20% of respondents have a complication in the form of sensory disturbances in one half of the body, 15% have sensory disturbances in the arms, another 15% have sensory disturbances, 15% have sensory disturbances in both legs, 15% have impaired speech, reading and writing, 13% of patients have a bad mood and fatigue, 6% of patients have pain of various localization and nature, 6% of patients have congestive pneumonia.
To the question “Do you need help performing basic activities: eating, washing, bathing, dressing, moving?” The following results were obtained (Figure 15):

Figure- 15. Need for outside help
Thus, from Figure 15, we see that 55% of the surveyed patients need help in performing basic activities, 45% do not need outside help.
To the question “Are you willing to learn lost self-care skills?” the following data were obtained (Figure 16):

Figure- 16. Teaching lost skills
Thus, from Figure 16, we see that 40% of the surveyed patients are not willing to learn self-care skills, 60% of them are willing to learn self-care skills.
After the sociological study, we carried out health education work, namely a conversation with patients who had suffered a stroke, which provided information about the characteristics of a stroke (Appendix B); A conversation was held with relatives of stroke patients, where available information about such a formidable complication as bedsores was presented and recommendations for skin care were given (Appendix B). Patients were also provided with booklets on the topic of preventing stroke complications, which describe available information about stroke and the basic principles of preventing complications (Appendix D); a reminder that describes simple physical exercises for the prevention of paresis and contractures (Appendix D); Sanitary Bulletin (Appendix K).

2.5. Results after the study

The main results of the survey of patients after the above measures to prevent stroke complications are presented in Table 8.
Table 8 - Results of patient surveys after the study.
No. Question Result
Yes, % No, % I doubt it
Sometimes, %
1 Do you want to quit smoking and drinking alcohol? 80% 10% 10%
2 Do you fight stress and develop stress resistance? 75% 20% 5%
3 Do you follow the principles of proper nutrition or diet? 60% 30% 15%
4 Do you follow all the prescriptions and recommendations of the doctor and paramedic? 80% 10% 10%
5 Do you control your blood pressure and take medications regularly? 80% 10% 10%
6 Do you perform physical therapy at home regularly? 50% 35% 15%
7 Are you willing to try to learn all the lost skills? 70% 20% 10%
As can be seen from the data given in Table 8, 80% of the subjects want to quit smoking and drink alcohol, fight stress and develop stress resistance in themselves 75% of the subjects, follow the principles of proper nutrition or diet 60% of the subjects, follow all the doctor’s prescriptions and recommendations and 80% of subjects are paramedics, control their blood pressure and take medications regularly for 80% of subjects, regularly perform physical therapy for 50% of subjects, and willingly try to learn all lost skills for 70% of subjects.
Thus, after training, patients know that it is useful to eat right, exercise, and follow all doctor’s prescriptions, as this will help improve health and prevent subsequent complications.
The main goal in the prevention of complications of a stroke in the conditions of the paramedic and obstetric station in the village of Duslyk: preventing recurrent cases of the disease, increasing the ability of patients to work.

Conclusion
Brain diseases are a topical area of ​​clinical medicine and have not only medical but also social significance, as they are one of the leading causes of morbidity, mortality and disability throughout the world. Over the past decade, there has been a significant increase in the number of vascular diseases of the brain in young and middle-aged people, which are difficult to objectify in the early stages, and to treat effectively in the later stages.
The analysis of the studied literature indicates that acute cerebrovascular accidents occupy a leading place among other diseases. The relevance of the study was confirmed and the need for preventive measures in patients with stroke was substantiated. The most important task in the prevention of stroke complications is the family environment, nutrition, adherence to work and rest schedule, blood pressure control, taking all medications prescribed by the doctor, following all the advice and recommendations of the paramedic and doctor on
performing physical therapy and learning all lost skills.
A special role in the prevention of complications of acute cerebrovascular accidents is given to the average medical worker, who must help patients deal with existing and possible consequences and prevent repeated attacks of the disease.
To analyze the role of the paramedic in the prevention of stroke complications, we conducted an empirical study on the basis of the FAP in the village. Duslyk, Tuymazinsky district of the Republic of Bashkortostan.
The study took place in four stages:
At the first stage, we studied statistical data and conducted a comparative analysis of the incidence of stroke in the city of Tuymazy and the village. Duslyk for three years from 2013 to 2015. We came to the following conclusions:
5. The incidence of stroke increases with each passing year, we assume that this is due to an increase in the number of people suffering from heart disease, lack of awareness of the population about the risk factors for developing the disease; with insufficient coverage of clinical examination of patients with risk factors for developing the disease. Heredity also plays an important role in the increase in the incidence of stroke.
6. Most often, men suffer strokes than women, perhaps this is due to the fact that men, unlike women, are more susceptible to stress and the harmful effects of bad habits, smoking and alcohol; the presence of sexual intercourse in women also plays an important role the hormone estrogen, which protects vascular walls and maintains their elasticity until the onset of menopause, on average up to the age of 50.
7. Ischemic stroke develops more often than hemorrhagic stroke, perhaps this is due to age-related changes in the body;
8. The number of stroke patients of working age is increasing; it can be assumed that the “rejuvenation” of stroke is associated with an increase in the number of patients with high blood pressure, frequent stress, the presence of bad habits, and ignorance of risk factors for stroke.
At the second stage, we studied the organization of the work of the FAP village. Duslyk.
At the third stage of the study, an analysis was carried out of the degree of awareness of patients about their disease, existing risk factors, existing complications and the degree to which patients followed all the doctor’s prescriptions and recommendations.
Then we developed preventive measures aimed at preventing the consequences of strokes and methods of dealing with existing complications: a conversation with stroke patients, which provides information about the characteristics of a stroke (Appendix B); conversation with relatives of bedridden patients about the prevention of bedsores and the principles of skin care (Appendix B). Booklets were also published on the topic “Say no to the consequences of a stroke” to increase patients’ awareness of their disease and the principles of preventing complications (Appendix D); memo “20 simple exercises for patients who have had a stroke” (Appendix D); a health bulletin was issued (Appendix K) and implemented in the conditions of the paramedic and obstetric station.
At the fourth stage, a re-analysis of the degree of patient compliance with all doctor’s prescriptions, the degree of control over risk factors and existing complications of a stroke was carried out (Appendix I). Results of repeated questioning: 80% of the subjects want to quit smoking and drinking alcohol, fight stress and develop resistance to stress 75% of the subjects, follow the principles of proper nutrition or diet 60% of the subjects, follow all the prescriptions and recommendations of the doctor and paramedic 80% of the subjects, control their blood pressure and take medications regularly for 80% of subjects, regularly perform physical therapy for 50% of subjects, and willingly try to learn all lost skills for 70% of subjects.
After carrying out a set of preventive measures, the subjects’ awareness of their disease improved, and the number of patients complying with the recommendations of the doctor and paramedic increased.
Based on the results of the study, the following recommendations can be made for the population:
Monitor your blood pressure levels;
Give up bad habits;
Fight excess weight;
Follow the principles of proper nutrition or the diet prescribed by your doctor;
Perform physical therapy exercises regularly;
Build stress resistance in yourself;
Take medications prescribed by your doctor regularly.
Thus, the research hypothesis was confirmed; the paramedic’s performance of the main duties in relation to patients with stroke will help increase patients’ awareness of existing risk factors, possible complications, and methods of dealing with them.
The goal has been achieved, the tasks have been achieved.

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