caz1 ocluzie intestinala

8/12/2019 caz1 ocluzie intestinala

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PREZENTAREA CAZULUI 2 DE BOAL

CULEGEREA DATELOR:

NUME:MPRENUME:PDOMICILIU: Moca, Judeul IaiVRSTA: 8SE!: MDATA INTERN"RII: #$%&%'#(

DATA E!TERN"RII:')%&%'#(DIA*NOSTIC LA INTERNARE: Oclu+ie i-e.-ial/ 01i 2ol2ulu. ileal 0e 31id/MOTIVELE INTRN"RII: 4 co.-i0aie 4 -1a+i- i-e.-ial a0.e- 4 du1e1i a3do5iale i-e.e 4 61eu1i, 2/1./-u1iANAMNE7A:

a%A-ecede-e 9e1edo4cola-e1ale: e.e5iica-i2e3% A-ecede-e 0e1.oale: 9e0a-i-/ c1oic/ -o;ic/c% Codiii de 2ia/ i de 5uc/: 3ued% Co50o1-a5e-e: eu5/-o1

ISTORICUL


2/14

Si.-e5ul e12o., edoc1i, o16ae de .i5: OTS, ROT 3ila-e1al

E!AMENE RADIOLO*ICE4 1adio61aie a3do5ial/ .i50l/ Gi2ele 9id1oae1ice de di5e.iui 5edii4 eco61aie a3do5ial/: ica- e0al0a3il, .0leo5e6alie, coleci.- /1/ calculi,

1iic9i 3ila-e1al /1/ 5odiic/1i, 0ac1ea. /1/ 5odiic/1i eco61aice

E!AMENE DE LA


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IDENTIFICAREA PROBLEMELOR DE DEPENDEN


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NEVOIAFUNDAMENTAL

DIAGNOSTIC DENURSING

MANIFESTRI DEDEPENDEN

SURSA DE DIFICULTATE

1. A RESPIRA I AAVEA O BUNCIRCULAIE

Al-e1a1ea 1e.0i1aieida-o1i-/a;ie-/ii,du1e1ii

Re.0i1aie.u0e1icial/

4a;ie-a-e4du1e1e de0ede-

2. A BEA I AMNCA

Ali5e-aieiadec2a-/

*1eu1i,V/1./-u1iIa0e-e/

4li0.a 0o-ei de5ca1e da-o1i-/2/1./-u1ilo1

de0ede-

3. A ELIMINA Al-e1a1ea

eli5i/1ilo1i-e.-iale

A3.ea .cauelo1 i

a 6a+elo1 i-e.-ialede 5ai 5ul-e +ileCo.-i0aie

4.id1o5 oclu+i2

45o3ili-a-e1edu./ de0ede-

4. A SE MICA IA AVEA O BUNPOSTUR

Di5iua1ea5o3ili-/ii

S-a1e 6ee1al/al-e1a-/

4du1e1e4.l/3iciue de0ede-

5. A DORMI I A

SE ODINI

Tul3u1/1i ale

.o5ului 5aie.-a-e01i i.o5ie

A;ie-a-e 4a;ie-a-e

4.-1e.4du1e1e

de0ede-

!. A SE "MBRCAA SE DEZBRCA

Diicul-a-e = a .e=531/ca i de+31/ca.i6u1

Du1e1e a3do5ial/i-e./

4.l/3iciue4du1e1e de0ede-

#. A MENINETEMPERATURACORPULUI "N

LIMITENORMALE

4

ide0ede-

$. A FI CURAT%"NGRI&IT

Diicul-a-ea de a4iaco1da =61iBi1i de

Te6u5e-e i5ucoa.e e=61iBi-e

4di5iua1ea5o3ili-/ii,


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ANALIZA DATELOR u15a cule6e1ii da-elo1 a5 .-a3ili- 0e1-u13a1ea u15/-oa1elo1 e2oie uda5e-ale:

#%Ne2oia de a 1e.0i1a i de a a2ea o 3u/ ci1culaie

'%Ne2oia de a 3ea i de a 5ca$ Ne2oia de a eli5ia

(%Ne2oia de a .e 5ica i de a a2ea o 3u/ 0o.-u1/

&%Ne2oia de a do15i i de a .e odi9ii

?%Ne2oia de a .e =531/ca i de+31/ca

>%Ne2oia de a i cu1a- i =61iBi-8%Ne2oia de a e2i-a 0e1icolele

)%Ne2oia de a .e 1ec1ea

#%Ne2oia de a =2/a cu5 ./4i 0/.-1e+e .//-a-ea%


6/14

PLAN DE "NGRI&IRE 13.(5.2(14 ) 14.(5.2(14

N*+,-/*0--

D-6,7- /* 86-9-* O-*-+* I6*+*6;--


7/14

# 5l, Ri6e1 & 5l4cli.5/ e2acua-oa1e4Ad5ii.-1a1e Mio.-i

$ 0e +iN*+,- /* 7*=-@ @- /*+* , >6?,7>

I5o3ili+a1e da-o1i-/du1e1ilo1 a3do5ialei-e.e = 9i0ocod1uld1e0-

A5elio1a1eadu1e1ii

ABu-a1ea 0acie-ului./ eec-ue+e 5ic/1iale 5e531elo1ae+a1ea ace.-uia=-14o 0o+iie c- 5aicoo1-a3il/E2i-a1ea e.ca1elo1 cu.al-ele .0ecialea-ie.ca1e

Ad5ii.-1a1e de NoS0a ' 0e +i, Piae ',Mial6i # i5

Du1e1ea .4aa5elio1a-

N*+,- /* /,=- @- /* 7* ,/-6-

Tul3u1/1i de .o55aie.-a-e 01i i.o5ie,1ic/, .-1e.

Pacie-ul ./01e+i-e u.o5 cali-a-i2i ca-i-a-i2

A.i6u1a1ea uuicli5a- de lii-e =.alo, =de0/1-a1eaac-o1ilo1 ca1eelii-e.c 3ola2ul

Ad5ii.-a1e deDia+e0a5 .ea1a # i5,A;ia1 # co50

Pacie-ul a a2u- u.o5 lii-i-

N*+,- /* 7*8= @-/*

Diicul-a-ea = a .e =531/cacau+a-/ de du1e1ilea3do5iale

Pacie-ul ./ie ca0a3il ./.e =61iBiea.c/.i6u1

ABu-a1ea0acie-ului ./ .e=531ace i de+31acela e2oie ,01e6/-i1ea 0e-1u

e;a5ee1adiolo6ice ieco61aice

Pacie-ul e.-e.c9i53a- = leBe1iecu1a-/

N*+,- /* 0-> @-86-9-

Diicul-a-e = a4.i ace-oale-a co10o1al/ .i6u1da-o1i-/ 2/1.-ei =ai-a-e idu1e1ii

Pacie-ul ./01e+i-e5ucoa.e i-e6u5e-ecu1a-e, i-e61e

A.i6u1a1ea i6ieeico10o1ale 0e1e6iui, .c9i53a1ealeBe1iei de 0a- i deco10, 01e2ei1ea

Pacie-ul e.-e cu1a-i =61iBi-

?&


8/14

e.ca1elo1, eec-ua1ede 5a.aB 1ela;a-

N*+,- /*

*+-?*-,


9/14

La co-1a2i+i-/ 5edicul cu1a- *,=6/ -6*+*6;-* ->--*.

A o.- io15a- 5edicul ae.-e+i.- ca1e a eec-ua- -< ?*6*7*- 1e+ul-a- Ri.c ASA II% P-*6>< 7*=6 ;-C,67-=;=6>< I60,= ?*6> 6*7*-*.

da-a de #&%(%'#( di5ieaa a o.- -1a.0o1-a- 0acie-ul = .alo Te1a0ie I-e.i2/ 0e-1u 01e6/-i1e 01eo0e1a-o1ie ude a o.-0e1u+a- cu & 5l Ri6e1%S4a -1a.e1a- 0acie-ul = .al/, a 01i5i- ae.-e+ie 6ee1al/, a o.- o0e1a- 01i o0e1aie cla.ic/%

PLAN DE "NGRI&IRE POSTOPERATOR 2 -


10/14

Toale-a 0a1ial/0acie-Su01a2e69e1e d1e

Ali5e-aie 9id1ic/

F1a;i0a1i/ .c,(5l;'+iVi-


11/14

45oi-o1i+a1e eli5i/1i45o3ili+a1e 0acie-

ANEE

SUPRAVEGEREA FUNCIILOR VITALE

D TA P R T D->*24 S>6

13.(4.2(14##8& 556

>&35i #815i $>,&C && 5l Li0./

14.(4.2(14#'8 556

>?35i #>15i $?,(C ?& 5l Li0./

15.(4.2(14 ##> 556 ??35i #815i $?,8C >$ 5l Scaue 5oi

1!.(4.2(14 ##8& 556 >'35i #?15i $?,?C >& 5l Scau o15al

1#.(4.2(14 #'8 556 >(35i #815i $>,$C 8$ 5l Scau o15al

ALIMENTAIA BOLNAVULUI

P*-,/ C


12/14

13.(4.2(14 o1al/ Ca-i-/i 5ici de lic9ideE+-*


13/14

i 0/.-1e+e 0o+iia idica-/ de5edicPe-1u 1adio61aie a3do5ial/ .e

aea+/ 0acie-ul = o1-o.-a-i.5 cu0ie0-ul a01o0ia- de ec1a .au deca.e-a ca1e 0oa1-/ il5ul i 2a ii.-1ui- ./ eec-ue+e c-e2a 5ic/1ide 1e.0i1aie, ia1 1adio61aia .e ace= a0ee, du0/ o i.0i1aie 01oud/

oaia de o3.e12aie%R/-,0-* /,=-6


14/14

P 6dLI,6,= 76+-6 NaQ #$>4#&

Q $,84&,(Cl )(4##5

NaQ #($ 5ElQ ?,8 5ElCl 88 5El

>'

caz1 ocluzie intestinala

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