fibrom uterin, partea practica

7/26/2019 Fibrom Uterin, Partea Practica

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CAPITOLUL III Partea Practic

PREZENTAREA CAZURILOR

CAZUL I

DOSAR DE NGRIJIRE

DATE DE IDENTIFICARE:

Nume: D

Prenume: V

Vrsta: 38 de ani

Grua san!uin": A II# R$%

D&mi'i(iu(: Cr'ea# )udetu( D&()*

DATE DE SPITA+I,ARE:

Data intern"rii: -. ianuarie ./-0# &ra -/

Data e1tern"rii: -2 ianuarie ./-0# &ra 8:3/

Dia!n&sti' (a internare: P&(ii4r&mat&5" uterin"

6ier(a5ie end&metria(" aden&mat&as"

Dia!n&sti' (a e1ternare: P&(ii4r&mat&5" uterin"

Te$ni'" &erat&rie: 6isteret&mie t&ta(" 'u ane1e't&mie 4i(atera("

Drena) e(7in

&ti7e(e intern"rii: 9 dureri n eta)u( a4d&mina( ineri&r

9 metr&(a!ie9 'ea(ee# ame;e(i*

SIT ?I SOCIA+>:

Situa;ia ami(ia(": '"s"t&rit"

Num"r '&ii: 3 '&ii

Situa;ia s&'ia(": 'a5ni'"

C&ndi;ii de 7ia;": 4une# (&'uie@te 'u s&;u( @i '&iii# ntr9& 'as" 'u 3 'amerePERSOANE C< CARE IA +EG>T


2/92

Nume: C* I*

Adresa: Cr'ea# )ude;u( D&()

ANTECEDENTE: 6ered&9'&(atera(e: nesemnii'ati7e

Pers&na(e i5i&(&!i'e# at&(&!i'eB:

9 menar$" -.ani# 'i'(u re!u(at: 9 5i(e# (u1 n&rma(

nea!"astm"9 tr&m4&(e4it" n ante'edente at&(&!i'e9 nasteri 39 a7&rturi/

Fa't&rii de ris' ri7ind m&du( de 7ia;": nu 4ea 'aea# nu '&nsuma a('&&(#

nu umea5"# nu are reerin;e 'u(inare*

ISTORIC


3/92

ASPECTE SOCIO+OGICE:

&d de 7ia;": 'u s&;u( @i '&iii

ediu(: rura(

O'ua;ie: 'asni'"

Parti'u(arit";i: ee'tuea5" tre4uri(e 'asni'e# i a'e ("'erea s"9@i a)ute

s&;u( (a !r"din"rit

Pr&4(eme s&'ia(e: nu are*

EHAEN C+INIC GENERA+ ee'tuat de medi'B:

Stare !enera(": u@&r a(terat"Te!umente @i mu'&ase: a(ide 'a(de e(asti'e*

Aaratu( &ste&arti'u(ar: inte!ru din un't de 7edere anat&m&un';i&na(#

4ine &rientat tem&r&9sa;ia(* Nu re5int" ra'turi a(e &ase(&r*

Sistemu( mus'u(ar: t&nus mus'u(ar# '&ntra';ie mus'u(ar" re5ent"*

Aarat resirat&r: s&n&ritate u(m&nar"# murmur 7e5i'u(ar re5ent# t&ra'e

n&rma( '&n&rmat*Aarat 'ardi&7as'u(ar: @&'u( ae1ian re5ent n sa;iu( V inter'&sta(

stn!# artere erieri'e u(sa;i(e# T*A* --// mm6!# u(s KKmin*

Aaratu( di!esti7: re(e1u( de de!(uti;ie este re5ent# a4d&men m&4i( 'u

mi@'"ri(e resirat&rii# durer&s (a a(are n $i&!astru*

Aaratu( ur&!enita(: mi';iuni i5i(&!i'e# (&)" rena(" (i4er"#rini'$i

nea(a4i(i*

SNC re(e1e '&ndi;i&nate @i ne'&ndi;i&nate re5ente# ROT re5ente*

E1amenu( radi&(&!i': (a indi'a;ia medi'u(ui se ee'tuea5" ELG*

OSERVARE INI=IA+>:

Situa;ia (a internare: -K/'m# G KM!# T*A* --// mm6!#

P KK min# T 3K#C# R -2 rmin# 7"5 4un# au5 4un*

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ANANE,A INI=IA+> A ASISTENTEI EDICA+E:

-* Ne7&ia de a resira @i de a7ea & 4un" 'ir'u(a;ie: nea(terat"

resira;ie ritimi'"# am("# r&und"# de ti '&sta( sueri&r

re'7en;a resira;iei este de -2 rmin

u(s KK min

T*A* ma1 --/ mm6!# T*A* min / mm6!

te!umente 'a(de# artere erieri'e u(sati(e

.* Ne7&ia de a 4ea @i a mn'a: nea(terat"

denti;ie 4un"# mu'&as" 4u'a(" @i (im4" r&5 @i umed"*

masti'a;ia este u@&ar"# re(e1 de de!(uti;ie re5ent* &ta de mn'are re5ent"# mese(e sunt rearti5ate uni&rm 3 mese @i .

!ust"riB# -/ &re reaus n&'turn*

nu are reerin;e 'u(inare# '&nsum" -0// m( (i'$ide5i*

3* Ne7&ia de a e(imina: a(terat"

a'ienta re5int" mi';iuni i5i(&!i'e# 9 e 5i# diure5a de -8// m(*

urina de 'u(&are @i mir&s n&rma(e# 6a'id* tran5it intestina( re5ent# - s'aun e 5i*

metr&ra!ii 9 ierderi de sn!e n aara 'i'(u(ui menstrua( n 'antit";i

mi'i de -9./ m( sn!e 5i# 'te .9 3 5i(e* etr&ra!ii(e au a"rut n urm" 'u -

an# (a n'eut 'u de4ut insidi&s# a&i s9au a''entuat*

'i'(u menstrua( 'u (u1 a4undent .// m( sn!e 5i 'u durat" de

90 5i(e 'u sn!e r&@u des'$is*

ritmu( 'i'(u(ui menstrua( este de 3/ 5i(e# u(timu( 'i'(u menstrua( a &st

(a data de 2 ianuarie ./-0*

transira;ii minime*

* Ne7&ia de a se mi@'a @i a a7ea & 4un" &stur": u@&r a(terat"

aaratu( &ste&9arti'u(ar inte!ru*

sistemu( mus'u(ar inte!ru: n&rm&t&n# n&rm&Mineti'*

de(asarea u@&r n!reunat" de durere*

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5/92

* Ne7&ia de a d&rmi @i a se &di$ni: a(terat"

s&mnu( este ne(ini@tit# ntrerut din 'au5a dureri(&r de (a ni7e(u(

$i&!astru(ui*

4&(na7a re5int" an1ietate @i dat&rit" inter7en;iei '$irur!i'a(e# m&ti7

entru 'are se tre5e@te n&atea*

Diminea;a (a tre5ire se simte &4&sit" @i eui5at"*

s&mnu( este insui'ient 'antitati7 @i 'a(itati7*

0* Ne7&ia de a se m4r"'a @i de54r"'a: nea(terat"

4&(na7a se &ate m4r"'a @i de54r"'a sin!ur"*

(en)eria tre4uie adus" (a at* 7e@minte(e sunt a(ese 'u !ust# ade'7ate '(imatu(ui*

K* Ne7&ia de a men;ine temeratura '&ru(ui n (imite n&rma(e: nea(terat"

temeratura '&ru(ui este de 3K#C*

te!umente(e a(ide# '"(du;e*

trasira;ie minim"*

8* Ne7&ia de a i 'urat @i de a9@i r&te)a te!umente(e: nea(terat" a'ienta @i &ate rea(i5a sin!ur" t&a(eta '&ru(ui*

'a7iatatea 4u'a(" re5int" denti;ie a(4"# '&m(et"*

mu'&asa 4u'a(" umed" @i r&5*

un!$ii !ri)ite# t"iate s'urt*

ie(e 'urat"# neted"# 'atie(at"# e(asti'"*

2* Ne7&ia de a e7ita er'i(e(e: a(terat"

stare de a!ita;ie dat&rit" amenin;"rii i5i'e*

a'ies 'risat# an1ietate din 'au5a dureri(&r de (a ni7e(u( $i&!astru(ui*

ertur4area ima!inii desre sine dat&rit" dii'u(t";ii de adatare (a &

s'$im4are '&r&ra(" nde"rtarea uteru(uiB*

-/* Ne7&ia de a '&muni'a 'u semenii: nea(terat"

4&(na7a &ate '&muni'a 7er4a( @i n&n7er4a(*

4&(na7a reer" s" su&rte dureri(e n t"'ere*

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6/92

nu su&rt" s" 7&r4es'" rea mu(t desre 4&a(a sa*

un';i&narea ade'7at" a &r!ane(&r de sim;: a'uitate 7i5ua(" @i auditi7"#

ine;e !ustati7" @i a mir&su(ui# sensi4i(itate ta'ti("*

--* Ne7&ia de a ra'ti'a re(i!ia: nea(terat"

4&(na7a este &rt&d&1"# arti'i" (a s(u)4e(e 4iser'e@ti# are n'redere n

Dumne5eu*

4&(na7a este '&n@tient" de 'eea 'e se ntm(" @i inter7ine &tri7it

'&n7in!eri(&r r&rii*

-.* Ne7&ia de a i uti(: nea(terat"

a'ienta @i a''et" n&ua stare n 'are se !"se@te# m&du( 'um arat"#n";i@area sa*

a'ienta &ate de"@ii anumite m&mente 'riti'e*

-3* Ne7&ia de a n7";a: nea(terat"

4&(na7a re5int" interes entru t&ate materia(e(e 'are des'riu 4&a(a sa*

4&(na7a este '&n@tient" de ne'esitatea &rm"rii de n&i atitudini @i

derinderi '&re'te# ne'esar" &4;inerii unei st"ri de 4ine*-* Ne7&ia de a se re'reea: nea(terat"

a'ienta re5int" interes a;" de a'ti7it";i(e 'urente a(e 7ie;ii*

a'ienta este a'ti7"# interesat" de 'eea 'e se etre'e n )uru( ei# arti'i"

(a a'ti7it";i*

INTERPRETAREA DATE+OR* NEVOI AFECTATE* PRO+EE DE

NGRIJIRE

Ne7&ia de a e(imina: men&metr&ra!ii# transira;ii minime*

Ne7&ia de a d&rmi @i a se &di$ni: s&mn a!itat# (is" &di$n"*

Ne7&ia de a e7ita eri'&(e(e: ne(ini@te# &4&sea(" si$i'"# durere (a ni7e(u(

$i&!astru(ui*

POSII+IT>=I DE EVO+


7/92

Vinde'are: da# rin inter7e;ie '$irur!i'a("

Sta4i(i5are# ame(i&rare: da# rin tratament medi'a(

A!ra7are: da# rin aari;ia '&m(i'a;ii(&r 9 de!enerare $ia(in"# ne'r&4i&5"#

ine';ii# tum&ri ma(i!ne*

De'es: 9

OIECTIVE DE NGRIJIRE:

A* O4ie'ti7e !(&4a(e:

a'ienta s" re7in" (a ni7e(u( 4un de s"n"tate*

a'ienta s" ai4" sta4i(it" 'au5a @i ntinderea (e5iunii# s" ie de a'&rd 'utratamentu( medi'a( res'ris de medi' entru re'""tarea indeenden;ei

un';i&na(e*

s" n;e(ea!" im&rtan;a sita(i5"rii @i s" a''ete s" a'" a;" ima!inii

sa(e '&r&ra(e s'$im4ate*

* O4ie'ti7e intermediare:

s" n;e(ea!" im&rtan;a e1amene(&r '(ini'e @i de (a4&rat&r entrusta4i(irea dia!n&sti'u(ui*

s" ie 'aa4i(" n" (a sr@itu( sita(i5"rii s"9@i re'aete indeenden;a

a;" de ne7&i(e ae'tate @i s" ai4" n'redere n ers&na(u( medi'&9sanitar*

s" n;e(ea!" ne'esitatea re!imu(ui a(imentar# s"9( 'un&as'" @i s"9(

rese'te*

a'ienta s" a''ete s" a'" a;" ima!inii sa(e '&r&ra(e s'$im4ate# s"9@i

a''ete u@&r n&u( statut men&au5a artii'ia(" dat&rit" nde"rt"rii uteru(uiB*

C* O4ie'ti7e se'ii'e:

s" ai4" & resira;ie n&rma("# s" i se asi!ure & 7enti(a;ie '&resun5"t&are

entru re7enirea '&m(i'a;ii(&r u(m&nare*

s"9@i "stre5e ritmu( @i re'7en;a resirat&rie n (imite(e n&rma(e -09

-8rminB*

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8/92

s"9@i men;in" un';ia 'ardi&9'ir'u(at&rie (a ni7e( '&resun5"t&r# s" ai4" &

4un" 'ir'u(a;ie erieri'"*

s"9@i men;in" n (imite &time# 4a(an;a $idr&9e(e'tr&(iti'"*

s" ai4" un s&mn &di$nit&r*

s"9i disar" durerea de (a ni7e(u( $i&!astru(ui*

a'ienta s"9@i mi'@&re5e an1ietatea 'u ri7ire (a:

9 m&dii'area s'$emei '&r&ra(e

9 s'$im4"ri(e r&7&'ate de men&au5" &r;at" 're@terea n !reutate# teama

de a nu mai a7ea '&iiB*

9 teama de ierdere a se1ua(it";ii9 teama de m&arte

COPORTAENT A?TEPTAT* N CE INTERVA+

(a sr@itu( sita(i5"rii# a'ienta re5int" & resira;ie n&rma("# am("# 'u

t&ra'e n&rma( '&n&rmat*

are un s&mn (ini@tit# &di$nit&r*

durerea de (a ni7e(u( $i&!astru(ui a n'etat# a'ienta se mi@'" "r"dii'u(tate (a sr@itu( sita(i5"rii*

a'ienta nu mai este ne(ini@tit"# are n'redere n sine @i n ers&na(u(

medi'&9sanitar*

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9/92

PLAN DE NURSING

Data Nevoia

fundamen

ta

!ertur"at

Dia#no$tic de

nur$in#

O"iective

de nur$in# !re%ente

Tim! Interven&ii

de nur$in#

Evauarea

o"iectiveor

-.*/- A e(imina E(iminareamenstrua("inade'7at" 'antiati7@i 'a(itati7 din 'au5a$iertr&iei 4eni!ne amu@'$iu(ui uterinmaniestat" rinmen&metr&ra!ii*Transira;ii minime*

Pa'ienta s" re5inte &stare de 4ine# de '&n&rti5i'*Pa'ientas"9@imen;in"re!iunea

erinea("'urat"*

. $ 9Asistenta medi'a(" asi!ur" reausu( (aat# &5itie Trende(en4ur!9 Asistenta medi'a("a(i'" ansamentea4s&r4ante @i ( i1ea5" n ##TQ*9 Asistenta medi'a(" s'$im4"

ansamentu( des*9 Asistenta medi'a(" n7a;" a'ientate$ni'i de re(a1are*9 Asistenta medi'a(" r&te)ea5" atu( 'umu@ama @i a(e5"*9 Asistenta medi'a(" a)ut" sau men;inete!umente(e a'ientei 'urate @i us'ate*9 Asistenta 7a ee'tua t&a(eta erinea(a&ri de 'ate &ri este ne7&ie9 Asistenta medi'a(" &4ser7" sn!erarea

7a!ina(" 'antitate# ase't# ritm# (e!"tura'u a(te maniest"riB*

Du" . &re a'ientare5int" & stare de 4ine#de '&n&rt i5i' @i dese'uritate*Te!umente(e sunt us'ate@i 'urate*

A d&rmi sia se &di$ni

Dii'u(tate n a se&di$ni dat&rit"an1iet";ii @i dureriide (a ni7e(u(

Pa'ienta s" 4enei'ie5ede un s&mn'&resun5"t&r 'antitati7@i 'a(itati7 de K98 &reB

-5i 9Asistenta medi'a(" n'ura)ea5" a'ienta s"'&muni'e 'u 'ei din )ur# s"9@i e1rimeem&;ii(e# ri'a# &inii(e*9Asistenta medi'a(" (e '&muni'"

Du" ra'ti'areae1er'i;ii(&r resirat&rii @i'reearea '(imatu(ui(ini@tit# a d&ua 5i a'ienta

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10/92

A e7ita

eri'&(e(e*

$i&!astru(ui#maniestat" rin &rede &di$n"insui'iente 'antitati7@i 'a(itati7

An1ietate dat&rit"amenin;"riiinte!rit";ii i5i'e#ne'un&a@terii

r&!n&sti'u(ui 4&(iimaniestat" rina!ita;ie# a'ies'risat*Dei'it de 'un&@tin;e

ri7ind eri&adare&erat&riemaniestat" rina!itat# a'ies 'risat*

nentrerute*Pa'ienta s" ie a'ti7"#'&&erant" @i s" e1rime& stare de 4ine*

Pa'ienta s"9@i mi'@&re5ean1ietatea# s"

4enei'ie5e de un mediude si!uran;"# s"9@i &at"e1rimea sentimente(e

&5iti7e (e!ate den'rederea de sine*Pa'ientei sa i se adu'" (a'un&stin;" in&rma;iidesre r&'eduri(e

re&erat&rii# s"4enei'ie5e de si!uran;asi$&(&!i'" entrunde"rtarea st"rii dean1ietate*

aar;in"t&ri(&r s" sus;in" m&ra( a'ienta*9Asistenta medi'a(" '(arii'" nen;e(e!eri(e(e!ate de '&nse'in;e(e &era;iei# dentreruerea 7ie;ii se1ua(e# de men&au5"&r;at"*9Asistenta medi'a(" asi!ur" '&ndi;ii demediu ade'7ate entru a e7ita &ri'e eri'&(#aerise@te sa(&nu(# s'$im4" (en)eria de at#7erii'" temerature @i umiditatea din sa(&n*

9Asistenta medi'a(" n'ura)ea5" a'ienta s"'&muni'e 'u 'ei din )ur# s"9@i e1rimeem&;ii(e# ri'a# &inii(e*9Asistenta medi'a(" (e '&muni'"aar;in"t&ri(&r s" sus;in" m&ra( a'ienta*9Asistenta medi'a(" '(arii'" nen;e(e!eri(e(e!ate de '&nse'in;e(e &era;iei# dentreruerea 7ie;ii se1ua(e# de men&au5"&r;at"*9Asistenta medi'a(" asi!ur" '&ndi;ii demediu ade'7ate entru a e7ita &ri'e eri'&(#aerise@te sa(&nu(# s'$im4" (en)eria de at#7erii'" temerature @i umiditatea din sa(&n*9Asistenta medi'a(" in&rmea5" a'ientadesre re!"tirii(e re&erat&rii# desrene'esitatea a'tu(ui '$irur!i'a(# desremen&au5a artii'ia("*

sune '" a a7ut un s&mn&di$nit&r "r" '&@maruri*Pa'ienta a rimitdia!n&sti'u( deP&(ii4r&mat&5" uterin"*

Du" dis'u;ii(e a7ute 'u

asistenta @i 'u mem4riiami(iei# a'ienta @imi'@&rea5" st"ri(e dean1ietate# @i e1rim"ri'a @i em&;ii(e 'u ri7ire(a m&dii'area s'$emei'&r&ra(e*Sunt nde"rtatenen;e(e!eri(e 'u ri7ire (ae7&(u;ia &st&erat&rie# @i

a'ienta n;e(e!ene'esitatea inter7en;iei'$irur!i'a(e*

-3*/-*./-0 Pre!"tirea re&erat&rie:

-* Re'&(tarea sn!e(ui entru rea(i5area ana(i5e(&r de (a4&rat&r*

62


11/92

.* A(imenta;ia este u@&r di!era4i(" n re5iua &era;iei* Seara a'ienta nu mai m"nn'"# e7entua( rime@te & 'an" de 'eai#

ine r")it"# 4rn5" de 7a'i*

3* E(iminare: se rea(i5ea5" & '(ism" seara# naintea &era;iei*

* Anemia: se '&re'tea5" dat&rit" sn!er"ri(&r mi'i 'antitati7 @i reetate# de&are'e sn!er"ri(e redisun (a '&m(i'a;ii

&st&erat&rii: @&'# tr&m4&5e* Se ee'tuea5" transu5ie 'u sn!e i5&!ru# i5&R$*

* Pre!"tirea (&'a(": 'u & sear" naintea &era;iei se n("tur" i(&5itatea u4ian"# se rea(i5ea5" 4aie !enera("# se m4ra'"

4&(na7a 'u (en)erie 'urat"* Re!iunea 'are 7a i suus" inter7en@iei '$irur!i'a(e 7a i e1aminat" da'" n 7e'in"tatea ei e1ist"

un'te de &(i'u(it"# e'5ema# intertri!&9de&are'e a'estea sunt surse de ine';ie &st&erat&rie*

-*/-*./- &ra K://# naintea &era;iei:

se m"s&ar" temeratura# tensiunea arteria("# (usu(# resira;ia*

se rea(i5ea5" & '(ism" e7a'uat&re*

se n("tur" (a'u( de e un!$ii# iar a'ienta este aten;i&nat" s" nu9@i dea 'u ru) e 4u5e# de&are'e# aste( &t i urm"rite

un';ii(e 'ir'u(at&rii @i resirat&rii a '"r&r tu(4urare intra&erat&rie se e7iden;ia5" rin 'ian&5a 4u5e(&r @i un!$ii(&r*

re!iunea e 'are se a'e in'i5ia se de5ine'tea5" 'u a('&&( @i se a'&er" 'u & '&mres" steri("

nainte de intrarea n sa(a de &era;ie# 4&(na7a @i !&(e@te 7e5i'a urinar" @i I se m&ntea5" & s&nd" emanent"*

&ra -/:3/

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12/92

Oera;ia: 4&(na7ei i se rea(i5ea5" aneste5ie !enera(" &4;inut" rin intr&du'erea intrara$idian de N&7&'ain" - @i

Hi(in" . i&(e* A'tu( '$irur!i'a( '&nst" din $istere't&mie t&ta(" 'u ane1e't&mie 4i(atera("* I s9a administrat 4&(na7ei un

(a'&n de sn!e i5&!ru# i5&R$# rin transu5ie e masa &erat&rie*

Pa'ienta a &st trans&rtat" n se';ia de reanimare# unde s9a tre5it (a . &re du" inter7en;ia '$irur!i'a("* A &st

sura7e!$eat" de asistenta medi'a(" @i medi'a( aneste5ist# i s9au urm"rit a'iesu(# 'u(&area te!umente(&r# T*A*# u(su(#

resira;ia# s9a administrat medi'a;ia res'ris"* &(na7a este trans&rtat" a d&ua 5i# -*/-*./-0# n se';ia de !ine'&(&!ie unde

i se a'&rd" n!ri)iri(e &s&erat&rii*

Data Nevoia

fundamenta

!ertur"at

Dia#no$tic de nur$in# O"iective Tim! Interven&ii Evauare

64


13/92

-*/

-

A resire @i a a7ea& 4una 'ir'u(a;ie

Greutate n a resiradat&rit" inter7en;iei'$irur!i'a(emaniestat" rinm&dii'areaam(itudiniiresirat&ri'e# resira;iesueri'ia("# ta$inee*

Pa'ienta s" resire"r" dii'u(tate# s"ai4" un ritmresirat&r re!u(at de-8 rmin# s"9@imi's&re5e ta$ineea*

.$ 9 Asistenta medi'a(" a)ut" a'ienta s"ee'tue5e e1er'i;ii resirat&rii# s" se a@e5e ntr9& &5i;ie ade'7at" s" @i s'$im4e &5i;ia din .n . &re*9 Asistenta medi'a(" &4ser7" 'u(&areaun!$ii(&r# 4u5e(&r @i te!umente(&r @i n&tea5" n&aia de &4ser7a;ie*9 Asistenta medi'a(" ume5e@te aeru( dinn'"ere 'u a" a('&(i5at"*

9 Asistenta medi'a(" asir" se're;ii(e 4r&n@i'e#da'" este 'a5u(9 Asistenta medi'a(" m&nit&ri5ea5" @inre!istrea5" T*A# u(su(# resira;ia#temeratura*

Du" . &re a'ientare5int" t&ra'e n&rma('&n&rmat 'are arti'i"simetri' (a mi@'"ri(eresirat&rii*Ta$ineea s9adiminuat./rminB*

A mn'a @i a 4ea* A(imenta;ieinsui'ient" 'antitati7@i 'a(itati7 din 'au5ainter7en;iei'$irur!i'a(emaniestat" rin$idratare @i indi!estiede a(imente

insui'iente 'antitati7@i 'a(itati7*

Pa'ienta s" iee'$i(i4rat"$idr&e(e't&(iti' (a unni7e( &tim# s"

re5inte mu'&aseumede*

-. $ 9 Asistenta medi'a(" administrea5" n rima 5idu" &era;ie a(imenta;ie arentera("# und

eru5ii 'u !(u'&5" -/9-/ m( @i seri5i&(&!i' 9-/ m(*9 Asistenta a(imentea5" er &s a'ienta 'u 'eai#a"# (im&nad"# 5eam" de '&m&t# ar&1imati7./ m(# administrate din . n . &re 'u (in!uri;an 'antit";i mi'i*

9 Asistenta medi'a(" ee'tuea5" 4i(an;u((i'$ide(&r in!erate @i e(iminate# m&nit&ri5ea5"@i nre!istrea5" arentera(e*

Pa'ienta este $idratat"'&resun5"t&r# re(u1u(de de!(uti ;ie este

resent*9(uide(e arentera(e au&st m&nit&ri5ate @inre!istrate*

65


14/92

A e(imina E(iminare urinar"insui'ient" 'anitati7 @i'a(itati7 d&7edit" rina4sen;a mi';iuniis&ntane dat&rit"inter7en;iei'$irur!i'a(e*

Asi!urarea uneie(imin"ri n&rma(e# nra&rt 'u 'antitateade (i'$ide in!erate @iadministrate

arentera(*Pa'ienta s" ai4" &mi';iune s&ntan"i5i&(&!i'"

re7enirea ine';ieiurinare*

-.$ 9Asistenta medi'a(" 7erii'" ermea4i(itateas&ndei urinare 'are este intr&dus" naintea&era;ieiB @i e7itarea 'ud"rii a'esteia*9Asistenta medi'a(" n'ear'" stimu(areae7a'u"rii# aste(:9Asistenta medi'a(" intr&du'e 4a5inetu( 'a(dsu4 a'ient"# une '&mrese 'a(de e re!iunea

u4ian"*9Asistenta medi'a(" re7ine ine';ia urinar"

rin ee'tuarea de mane7re steri(e*9Asistenta medi'a(" du" nde"rtarea s&ndeiurinare 7erii'" !&(irea 7e5i'ii urinare din n $# n '&ndi;ii(e unui a&rt de (i'$ide in!erate*9Asistenta medi'a(" &4ser7" da'" aar semnede ine';ie*

Du" 0 &re s&ndaurinar" este ermea4i("#ne'udat"*Du" nde"rtareas&ndei urinare see(imin" & 'antitate de-/ m( urin" (a ie'aremi';iune*

Nu au a"rut semen de

ine';ie urinar"*

66


15/92

A se mi@'a Im&4i(itate maniestat"rin !reutateaa'ientei de a semi@'a# de a se ridi'asin!ur" din at# de amer!e# dat&rit" durerii@i a eui5"rii n urmaa'tu(ui '$irur!i'a(*

Pa'ienta s" ai4"t&nusu( mus'u(ar @i&r;" mus'u(ar"*Pa'ienta s"9@imen;in" satis"'ute'e(e(a(te ne7&iundamenta(e# s"

re5inte & &stur"ade'7at" @i

nedurer&as"*

. 5i(e 9Asistenta medi'a(" a)ut" a'ienta s" se a@e5en &5i;ia FO+ER n de'u4it d&rsa( entru ase re7eni resiunea intraa4d&mina(" 'res'ut"*Se une un 4ru a4d&mina( entru sri)in @i'&n&rt su(imentar*9Asistenta medi'a(" a)ut" a'ienta s" ee'tue5ee1er'i;ii i5i'e 'u mem4re(e ineri&are din n &re*9Asistenta medi'a(" s'$im4" &5i;ii(e

a'ientei (a ie'are . &re*9Asistenta medi'a(" ee'tuea5" un masa) u@&r(a mem4re(e ineri&are n sensu( 'ir'u(a;iei dent&ar'ere*9Asistenta medi'a(" a)ut" a'ienta (asatisa'erea ne7&i(&r i5i&(&!i'e a(e&r!anismu(ui*9Asistenta medi'a(" a(i'" tratamentu( (aindi'a;ia medi'u(ui entru disari;ia dureri(&r*

Pa'ienta re5int" &&stur" n&rma(" @i u;indurer&as" (a sr@itu('e(ei de9a d&ua 5i du"&era;ie* S9a rea(i5atmasa) (a mem4re(eineri&are# iar &5i;ia a&st s'$im4at" din d&u"n d&u" &re*

67


16/92

A d&rmi @i a se&di$ni

Dii'u(tatea de a d&rmi@i a se &di$nimaniestat" rin &reinsui'iente de s&mn#s&mn a!itate dat&rit"dureri(&r n urmaa'tu(ui '$irur!i'a(*

Pa'ienta s"4enei'ie5e de uns&mn '&resun5"t&r'antitati7 @i 'a(itati7*

- 5i 9Asistenta medi'a(" n7a;" a'ienta s" ra'ti'e9te$ni'i de re(a1are# e1er'i;ii resirat&rii 'u 3/de minute nainte de 'u('are*9Asistenta medi'a(" &er" a'ientei & 'an" 'u(ate 'a(d nainte de 'u('are# aerise@te sa(&nu(#s'$im4" (en)eria de at @i de '&r*9Asistenta medi'a(" surim" surse(e dedis'&m&rt @i de irita4i(itate*9Asistenta medi'a(" a(i'" tratamentu(

medi'ament&s (a indi'a;ia medi'u(ui*9Asistenta medi'a(" a e1(i'at a'ientei s"9@i'aute &5i;ia 'ea mai 4un" n 'are s" nu

re5inte durere*

Pa'ienta se &di$ne@ten&atea# are un s&mn(ini@tit# 'u & durataar&1imati1 K &re*

A i 'urat @i a9;ir&te)ate!umente(e*

A(terarea te!umente(&rmaniestat" rin (a!"a4d&mina(" dat&rit"inter7en;iei'$irur!i'a(e*

Pa'ienta s" re5intete!umente @imu'&ase 'urate*Pa'ienta s" se7inde'e 'u un minimde dis'&m&rt*

. $

5i(e

9Asistenta medi'a(" ee'tuea5" t&a(eta!enera(" a a'ientei @i i s'$im4" (en)eria de'&r @i de at*9Asistenta medi'a(" n'ee sura7e!$erea

ansamentu(ui imediat du" inter7en;ie# @ira&rtea5" medi'u(ui da'" sn!erea5"*9Asistenta medi'a(" ee'tuea5" s'$im4area

ansamentu(ui# n!ri)irea ("!i(&r s"(areaa'esteia 'u s&(u;ie antiseti'"B @i a(i'" un

ansament n&u*9Asistenta medi'a(" ee'tuea5" 'ur";area @is"(area erineu(ui 'u s&(u;ie steri(" de . &ri

e 5i @i du" ie'are e(iminare# se men;ine5&na us'at" entru a !r"4i 7inde'area*9Asistenta medi'a(" '&ntr&(ea5" tam&ane(e

erinea(e @i &4ser7" 'u(&area# 'antitatea @imir&su( se're;iei e(iminate# @i ra&rtea5"medi'u(ui*

Du" . &re a'ientare5int" te!umente @imu'&ase 'urate* P(a!a a&st 'ur";at" 'u s&(u;ieantiseti'" @i

ansamentu( a &sts'$im4at*Tam&ane(e erinea(eau &st '&ntr&(ate @is'$im4ate*+a ni7e(u( (a!i(&r nuau a"rut semen deine';ie*

68


17/92

9Asistenta medi'a(" administrea5" anti4i&ti'e(a indi'a;ia medi'u(ui entru re7enireaine';iei*9Asistenta medi'a(" i e1(i'" a'ienteiim&rtan;a "str"rii te!umente(&r 'urate (ani7e(u( ("!ii si r&te)area ei*

A e7ita eri'&(e(e Durere (a ni7e(u( (a!iia4d&mina(emaniestat" rin

(ns# a'ies 'risat#dat&rit" inter7en;iei'$irur!i'a(e*

Pa'ienta s"4enei'ie5e desi!uran;" si$&(&!i'"

entru nde"rtareast"rii de an1ietate*Pa'ienta s" n7e;e s"9

@i '&ntr&(e5e durerea*C&m4aterea durerii*

3 5i(e 9Asistenta medi'a(" s"tiue@te ami(ia s"n'ura)e5e a'ienta @i s" men;in" un '(imat de&timism*9Asistenta medi'a(" n'ura)ea5" a'ienta s"'&muni'e 'u a(te 4&(na7e# 'u '&(e!e(e desa(&n*

9Asistenta medi'a(" aerise@te sa(&nu(*9Asistenta medi'a(" n7a;" a'ienta s"9@i'&mrime 'u a(ma (a!a &era;iei atun'i'nd tu@e@te# str"nut" sau @i s'$im4" &5i;ia*9Asistenta medi'a(" administrea5" a'ientei (aindi'a;ia medi'u(ui ana(!eti'e @i tran'$i(i5ante

entru 'a(marea dureri(&r @i asi!urarea unui

Pa'ienta dis'ut" 'u'e(e(a(te 4&(na7e @i 'u'&(e!e(e de sa(&n @i esten'ura)at" de ami(ie*Pa'ienta a n7";atmet&de de '&m4atere a

durerii*Du" administrareaana(!eti'e(&r durerea sediminuea5"*

69


18/92

s&mn de 'e( u;in 892 &re*9Asistenta medi'a(" in&rmea5" a'ienta s"e7ite ri!u( @i e&rtu( i5i'*

A '&muni'a C&muni'are inei'a'e(a ni7e( ae'ti7maniestat" rin a'ies'risat# (ans# re'7entn'$idere n sinedat&rit" neadat"rii (an&ua s'$em"'&r&ra("*

Pa'ienta sea'&m&dea5" 'u n&uaima!ine '&r&ra(" @i'u trauma r&7&'at"de &era;ie# s"

re5inte n'redere nsine @i n 'ei din )ur

entru a a'e a;"situa;iei e1istente*

. $ 9Asistenta medi'a(" a)ut" a'ienta s" n;e(ea!"'" deresia# n!ri)&rarea# sentimentu( deneutin;" sunt n&rma(e @i de a''etat*9Asistenta medi'a(" a)ut" ami(ia @i rietenii s"n;e(ea!" '" a'ienta are ne7&ie s" ien;e(eas" de'i s" se '&m&rte n&rma( 'u ea# s"& sri)ine s"9@i "stre5e uterea de atra';ie# s"ie ea ns"@i*9Asistenta medi'a(" as'u(t" 'u aten;iee1rimarea er'e;ii(&r se1ua(e de '"tre

a'ient"*

9Asistenta medi'a(" dis'ut" 'u a'ienta desre&si4i(u( ima't a( inter7en;iei '$irur!i'a(easura 7ie;ii se1ua(e*

Fami(ia @i rietenii aun;e(es '" tre4uie s" &sri)ine @i s" & a)ute e

a'ient"# s"9i ie a("turi*Du" '&n7ersa;ii(e

urtate a'ientan;e(e!e '" 7ia;a se1ua("nu este a4&(it" 'i d&arntrerut" tem&rar 098s"t"mniB a&i se &atere(ua "r" ni'i &

r&4(em"*

70


19/92

-0*/-

A mn'a @i a 4ea A(imenta;ieinsui'ient" 'antitati7@i 'a(itati7 meniestat"

rin inaeten;"# asteniei5i'" @i si$i'"dat&rit" inter7en;iei'$irur!i'a(e*

Pa'ienta s" sea(imente5e a'ti7 (a

at*Pa'ienta s" ai4" &stare ame(i&rat"*

-. $ 9Asistenta medi'a(" e1(i'" a'ienteine'esitatea a(imenta;iei er &ra(*9Asistenta medi'a(" a)ut" a'ienta s" sea(imente5e sin!ur" 'u su" de (e!umestre'urate# 'eaiuri re'i# 5eam" de '&m&t*9Asistenta medi'a(" '&ntinu" s" a(imente5e

a'ienta arentera( (a indi'a;ia medi'u(ui*

Pa'ienta se a(imentea5"a'ti7* Ca7itatea 4u'a("este inte!r"# mu'&asa

4u'a(" este umeda*

A se mi@'a Im&4i(itate maniestat"rin !reutatea

a'ientei de a se mi@'asin!ur" din 'au5adurerii @i a eui5"rii nurma a'tu(ui'$irur!i'a(*

Pa'ienta s" re5inte& m&4i(itate n&rma("

@i & &stur" ade'7at""r" durei# s" &at"mer!e ns&;it" rinsa(&n*

-.$ 9Asistenta medi'a(" a)ut" a'ienta s" se ridi'edin at# & ns&;e@te n timu( mersu(ui rin

sa(&n*9Asistenta medi'a(" n'ura)ea5" si$i'

a'ienta*9Asistenta medi'a(" administrea5a tratamentu(medi'ament&s res'ris de medi'*

Pa'ienta mer!e sin!ur"dar ne'esit" u@&r sri)in*

A i 'urat @i a9;ir&te)ate!umente(e*

De!radareate!umente(&r @imu'&ase (&rmaniestat" rin (a!"a4d&mina(" din 'au5ainter7en;iei'$irur!i'a(e*

Pa'ienta s" re5intete!umente @imu'&ase 'urate*Pa'ienta s" re5inte& 'i'atri5are 't mairaid" a ("!ii*

. $ 9Asistenta medi'a(" ee'tuea5" t&a(eta!enera(" a a'ientei @i i s'$im4" (en)eria de'&r @i de at*9Asistenta medi'a(" ee'uea5" t&a(eta ("!ii 'us&(u;ii antiseti'e @i a(i'" ansament steri(*9Asistenta medi'a(" rea(i5ea5" s"(area @i'ur";area erineu(ui 'u s&(u;ie steri(" @in(&'uirea tam&ane(&r erinea(e*

Pa'ienta re5int"te!umente @i mu'&ase'urate*+a ni7e(u( ("!ii nu aua"rut semen (&'a(ein(amat&rii*Pa'ienta este & ers&an"

rudenta# @tie e 'at&si4i( s" e7ite

eri'&(e(e*A e7ita eri'&(e(e Durere (a ni7e(u( ("!ii

a4d&mina(e#maniestat" rinirita4i(itate# a'ies'risat# din'au5ainter7en;iei

Pa'ienta s"4enei'ie5e desi!uran;" si$&(&!i'"

entrunde"rtareairita4i(it";ii*

. 5i(e 9Asistenta medi'a(" in&rmea5" a'ienta 'uri7ire (a eti&(&!ia @i e7&(u;ia i4r&mu(uiuterin*9Asistenta medi'a(" m"s&ar" @i n&tea5" n&aia de &4ser7a;ie un';ii(e 7ita(e a(e

a'ientei*

Du" dis'u;ii(e a7utea'ienta n;e(e!ee7&(u;ia i4r&mu(uiuterin*Dureri(e se mi's&rea5"@i sunt mai rare du"

71


20/92

'$irur!i'a(e* C&m4aterea durerii(a ni7e(u( ("!iia4d&mina(e*

9Asistenta medi'a(" administrea5" tratamenu(antia(!i' res'ris de medi'*

administrareatratamentu(ui antia(!i'*

-K-8*/-

A i 'urat @i a9;ir&te)ate!umente(e

De!radareate!umente(&r @imu'&ase(&r#rere5entat" rin (a!"a4d&mina(" dat&rit"inter7en;iei

'$irur!i'a(e*

Pa'ienta s" re5intete!umente @imu'&ase 'urate*Pa'ienta s" re5inte& 'i'atri5are 't mairaid" a ("!ii*

. $ 9Asistenta medi'a(" rea(i5e5" t&a(eta !enera("a a'ientei @i i s'$im4" (en)eria de '&r @i de

at*9Asistenta medi'a(" ee'uea5" t&a(eta ("!ii 'us&(u;ii antiseti'e @i a(i'" ansament steri(*9Asistenta medi'a(" ee'tuea5" s"(area @i

'ur";area erineu(ui 'u s&(u;ie steri(" @is'$im4area tam&ane(&r erinea(e*

Pa'ienta re5int"te!umente @i mu'&ase'urate*+a ni7e(u( a4d&menu(ui

(a!a este 'urat" 'utendin;a sre 'i'atri5are#

"r" semen de ine';ie*

A e7ita eri'&(e(e An1ietate 'u ri7ire (areaari;ia dureri(&rrere5entat" rina'ies 'risat# dat&rit"a'tu(ui '$irur!i'a(*

Pa'ienta s" n;e(ea!"'" starea ei s9aame(&irat# '"rese'tnd re!imu(i!ien&9dieteti' estemiedi'at" aari;ia'&m(i'a;ii(&r*

. $ 9Asistenta medi'a(" administrea5" tratamentu(antia(!i' res'ris de medi'*9Asistenta medi'a( e1(i'" a'ientei '" ris'u(aari;iei '&m(i'a;ii(&r &st&erat&rii este mi'#ar&ae ine1istent*9Asistenta medi'a(" e1(i'a ne'esitateare!imu(ui i!ien&9dieteti'*

Pa'ienta este (ini@tit" nri7in;a rearti;ieidureri(&r @i'&m(i'a;ii(&r &st&erat&rii @i a n;e(esne'essitate re!imu(uii!ien&9dieteti'*

-2*/-*

A i 'urat @i a9tir&te)ate!umente(e*

De!radareate!umente(&r @imu'&ase(&rmaniestat" rin (a!"a4d&mina(" din 'au5a

inter7en;iei'$irur!i'a(e*

Pa'ienta s" re5inte& 'i'atri5are 't mairaid" a (a!ii#s'&aterea ire(&r'$irur!i'a(e*

. $ 9Asistenta medi'a(" ee'tuea5" t&a(eta ("!ii&erat&rii 'u s&(u;ii antiseti'e*99Asistenta medi'a(" ee'tuea5" s'&atereaire(&r '$irur!i'a(e 'u mu(t" ruden;"*9Asistenta medi'a(" ee'tuea5" s"(area @i

'ur";area erineu(ui 'u s&(u;ie steri("*

+a ni7e(u( a4d&menu(ui#(a!a este 'urat"#'i'atri5at"# "r" semende ine';ie*

A n7";a Dei'it de 'un&@tin;erere5entat rinin&rma;ii insui'ienteasura '&n7a(es'en;ei#a satisa'erii ne7&i(&e

Pa'ienta s" @tie s" seadate5e n ami(ie @in n&ua '&munitate'u n&ua sa ima!ine'&r&ra("# s"9@i

. $ Asistenta medi'a(" e1(i'" a'ientei @iami(iei n 'e a '&nstat inter7en;ia '$irur!i'a("@i (a 'e m&dii'"ri s" se a@tete men&au5aBs" 'un&as'" ee'te(e teraiei $&rm&na(e# s"a''ete '" s("4i'iunea# &4&sea(a# irita4i(itatea

Pa'ienta @tie n 'e a'&nstat inter7en;ia'$irur!i'a(" @i (a 'em&dii'"ri s" se a@tetemen&au5"# ee'te(e

72


21/92

sa(e# a tratamentu(ui dere'uerare*

asume r&(urise'ii'e 't mai'urnd &si4i(*

@i (nsu( sunt n&rma(e n timu('&n7a(es'en;ei*Pa'ienta s" @tie s" e7ite re(a;ii(e se1ua(e#ridi'area !reut";i(&r# '&ndu'ereaaut&turismu(ui sau @ederea re(un!it" nma@in"# a(te r&rtiri n" (a ar&4areamedi'u(ui 098 s"t"mniB*S n;e(ea!" @i s" a''ete '" starea de'&n7a(es'en;" in'(ude 4"i ar;ia(e# (a1ati7e @i

medi'amete n 'a5 de dis'&m&rt# &di$n"#diet" e'$i(i4rat"# e7entua( &(&sirea unui

&rt)artier*S" @tie '" "tarea @i s'$im4area tam&nu(ui

erinea( de . &ri e 5i este n&rma(# dar '"tre4uie s" ra&rte5e medi'u(ui sn!erarea#'antitatea m"rit"de se're;ie sau se're;ii urtmir&sit&are* S" @tie '" entru une(e emei ar

utea i nenesare 2 s"t"mni93 (uni entru ase sim;i e(e nse(e# re7enirea dein5nd de &serie de a'&ri '&ndi;ie i5i'"# 7rst"#menta(itate# atitudine a;" de 4&a("# atitudineaami(iei @i a rieteni(&r*

teraiei $&rm&na(eB*

-2*/-*

E1ternarea

73


22/92

ROLUL DELEGAT AL ASISTENTEI 'EDICALE

DATA DENU'IREA ANALIZEI (ALORIREALE

(ALORINOR'ALE

-3*/- 6EOG+OINA

+E


23/92

DATA TRATA'ENT TE'PERATUR

)* PULS* TA*

RESPIRA+IE

-*/- ORA ,-./-OPERA+IA

DUP) OPERA+IE 0Du! o!eratie

Atr&in" -

D&rmita( -'

Nesd&na( -

+Xstenan -

Arduan .

66C

i&i(in -

Etarusi(at .

FentanX( 3

Transu5ie de sn!e

A II R$%

Sardena( .

Ami'i(in" 3!

Pr&sta$(in .

Diiridam&( .

A(!&'a(min 3

Fen&4ar4ita( -

Ser i5i&(&!i' 2Y

K/ m(

G(u'&5" -/

K/ m(

O.

i&stin 0

3* C

min

2 mm6!

-2 rmin

-*/- Ami'i(in" 3! -!8$B

Diiridam&( dr*

A(!&'a(min 3

N&r(&1a'in . t4

i&stin .

Ser i5i&(&!i' 2Y -// m(

G(u'&5" -/ -// m(

3K* C

28 min

-3/K mm6!

.. rmin

75


24/92

-0*/- Ami'i(in" 3 !

Diiridam&( dr*

3K C

K0 min

9ur&4i(in&!en

9i!men;i 4i(iari

9eite(ii

n&rma(

a4sen;i

eite(ii (ate#r&tunde# rare# mu'us

re5ent re'7ent&1a(at de Ca

90 m! Y

a4sen;i

rare

-3*/- EHAENEPARAC+INICE

ELG9

interretare

m&r&(&!i'

n&rma(

76


25/92

A(!&'a(min 3

N&r(&1a'in . t4

Tr&m4&st& . t4

6eat&tr&m4in !e(

-3/K/ mm6!

-8 rmin

-K*/- Ami'i(in" 3!

Diiridam&( dr*

A(!&'a(min 3

N&r(&1a'in . t4

Tr&m4&st& . t4

6eat&tr&min !e(

30*K C

K min

-.0 mm6!

-K rmin

-8*/- Ami'i(in" 3 !

Diiridam&( dr*

A(!&'a(min 3

N&r(&1a'in . t4

Tr&m4&st& . t4

6eat&tr&m4in !e(

30*0 C

KK min

-3/K/ mm6!

-0 rmin

77


26/92

EPICRIZA

&(na7a# D*V# n 7rst" de 38 de ani# se internea5" e data de -. ianuarie

./-0# entru urm"t&are(e simt&me: dureri n eta)u( a4d&mina( ineri&r#

metr&ra!ie# 'ea(ee# ame;e(i# n se';ia de !ine'&(&!ie 'u dia!n&sti'u( de

&(ii4r&mat&5" uterin"*

+a e1amenu( &4ie'ti7 se &4ser7" un a4d&men m&4i( 'u mi@'"ri(e

resirat&rii# durer&s (a a(are n $i&!astru# se re'&(tea5" sn!e @i urin" entruana(i5e(e de (a4&rat&r* Se administrea5" tratament medi'ament&s# iar 4&(na7a se

r&!ramea5" entru inter7en;ie '$irur!i'a(" e data de - ianuarie ./-0 &ra

-/*3/*

Este re!"tit" re&erat&r e data de -3 ianuarie ./-0*

Inter7en;ia '$irur!i'a(" s9a "'ut su4 aneste5ie !enera(" r&'edeu(

&erat&r a de'urs n '&ndi;ii 4une# "r" '&m(i'a;ii e masa &erat&rie* &(na7eii s9a administrat un (a'&n de sn!e i5&!ru i5&R$# &st&erat&r entru

'&re'tarea anemiei*

Te$ni'a &erat&rie: 6istere't&mie t&ta(" 'u ane1e't&mie 4i(atera("*

Pa'ienta este sta;i&nar" & 5i n se';ia de reanimare# du" 'are re7ine n

se';ia de !ine'&(&!ie unde s9au ee'tuat n!ri)iri(e &st&erat&rii iar stare

!enera(" s9a ame(i&rat*Se e1ternea5" e data de -2 ianuarie ./-0 &ra 8*3/ (a indi'a;ia medi'u(ui#

'u urm"t&are(e re'&mand"ri:

e7itarea e&rturi(&r i5i'e tim de . (uni*

e7itarea re(a;ii(&r se1ua(e 098 s"t"mniB# @edere re(un!it" n ma@in"

sau '&ndu'erea aut&turismu(ui*

re5entarea (a '&ntr&( du" & (un" de 5i(e*

78


27/92

&di$n" re(un!it" @i diet" e'$i(i4rat" se 7&r e7ita (e!ume(e 'u 'e(u(&5"

!reu di!esti7": ma5"re# as&(e# 7ar5"B* Se indi'" r&duse (a'tate# (ate# sue

'a(de# 'arne s(a4"# aste "in&ase# '&nsumarea a ./// m( (i'$ide 5i(ni'*

Pa'ienta @tie n 'e a '&nstat inter7en;ia '$irur!i'a(" @i (a 'e s'$im4"ri s"

se a@tete men&au5aB# 'un&a@te ee'te(e teraiei $&rm&na(e# a''et" '"

s("4i'iunea# &4&sea(a# irita4i(itatea @i (nsu( sunt &4i@nuite n timu(

'&n7a(es'en;ei*

Pa'ienta n;e(e!e @i a''et" '" starea de '&n7a(es'ent" in'(ude 4"i

ar;ia(e#(a1ati7e @i medi'amente n 'a5 de dis'&n&rt# &di$n"# diet" e'$i(i4rat"#

e7entua( &(&sirea unui &rt)artier*Pa'ienta @tie '" "tarea @i s'$im4area tam&nu(ui erinea( de . &ri e 5i

este n&rma(# dar '" tre4uie s" ra&rte5e medi'u(ui sn!erarea# 'antitatea 'res'ut"

de se're;ie sau se're;ii urt mir&sit&are*

Pa'ienta @tie '" entru une(e emei ar utea i ne'esare 2 s"t"mni 9 3

(uni entru a se sim;ii din n&u e(e nse(e# re7enirea dein5nd de & serie de

a't&ri '&ndi;ie i5i'"# atitudine a;" de 4&a("#menta(itate# 7rst"# atitudineaami(iei @i a rieteni(&rB*

Pa'ienta este mu(;umit" de n!ri)iri(e a'&rdate de ers&na(u( medi'&9

sanitar e eri&ada intern"rii*

79


28/92

CAZ II

DOSAR DE NGRIJIRE


Nume:

Prenume: G

Vrst": 30 ani

Grua san!uin": /I R$%

D&mi'i(iu(: strada Re7&(u;iei# num"ru( -

DATE DESPRE SPITA+I,ARE:

Data intern"rii: ./ ianuarie ./-0# &ra 2*3/*

Data e1tern"rii: .K ianuarie ./-0# &ra 8*//*

Dia!n&sti' (a internare: Susi'une de i4r&m uterin

Dia!n&sti' (a e1ternare: Fi4r&m uterin

Te$ni'" &erat&rie: 6istere't&mie su4t&ta(" interane1ia("

&ti7e(e intern"rii: 9 dureri $i&!astri'e

9 men&metr&ra!ie

9 ame;e(iSIT ?I SOCIA+>:


Num"r '&ii: . '&ii

Situa;ia s&'ia(": mana!er

C&ndi;ii de 7ia;": 4une# (&'uie@te 'u s&;u( @i '&iii ntr9& 'as" 'u 3 'amere

PERSOANE C< CARE SE IA +EG>T


29/92

Nume: *+

Adresa: CRAIOVA# strada Re7&(u;iei# num"ru( -

ANTECEDENTE:

6ered&9'&(atera(e: nesemnii'ati7e

Pers&ane(e i5i&(&!i'e# at&(&!i'eB: menar$a -. ani

a a7ut & inter7en;ie '$irur!i'a(" n -28.

aendi'e't&mie

n '&i("rie a a7ut: 7ari'e("# &rei&n

na@teri .

a7&rturi /Fa't&rii de ris' ri7ind m&du( de 7ia;": '&nsum" &'a5i&na( 'aea# nu

'&nsum" a('&&(# nu umea5"# nu are reerin;e 'u(inare*

ISTORIC


30/92

Re!im a(imentar: re!im nr*- &st&erat&r n rima 5iB# tretat se

di7ersii'"# a)un!nd n 5iua de e1ternare (a & a(imenta;ie n&rma("# e7itndu9se

7ar5a# as&(ea# ma5"rea*

ASPECTE PSI6O+OGICE:

Stare de '&ntien;": '&n@tient"# '&muni'" 7er4a(

C&m&rtament: ne(ini@tit

&d de internare: este adus" de ami(ie

Parti'u(arit";i: durerea & n!ri)&rea5"


&d de 7ia;": 'u s&;u( @i '&iiiediu(: ur4an

O'ua;ie: mana!er

Parti'u(arit";i: ee'tuea5" tre4uri(e 'asni'e# i a'e ("'ere s"9@i a)ute s&;u(

(a es'uit*

Pr&4(eme s&'ia(e: 9

EHAEN C+INIC GENERA+ ee'tuat de medi'B: Starea !enera(": u@&r a(terat"

Te!umente @i mu'&ase: a(ide 'a(de esasti'e

Aaratu( &ste&arti'u(ar: inte!ru din un't de 7erere anat&m&9un';i&na(#

4ine &rientat tem&r&9sa;ia(* Nu re5int" ra'turi a(e &ase(&r* Sistemu(

mus'u(ar: t&nus mus'u(ar# '&ntra';ie mus'u(ar" re5ent"*

Aarat resirat&r: s&n&ritate u(m&nar"# murmuru( 7e5i'u(ar re5ent#


Aarat 'ardi&7as'u(ar: @&'u( ae1ian re5ent n saiu( V inter'&sta(

stn!# artere erieri'e u(sati(e# T*A*-.0 mm6!*

Aaratu( di!esti7: re(e1u( de de!(uti;ie este re5ent# a4d&men m&4i( 'u

mi@'"ri(e resirat&rii# durer&s (a a(are n $i&!astru# a4d&men 'u 'i'atri'e

&st&erat&rie# aendi'e't&mie*

82


31/92

Aaratu( ur&!enita(: mi';iuni i5i&(&!i'e# (&)" rena(" (i4er"# rini'$i

nea(a4i(i*

SNC re(e1e '&ndi;i&nate @i ne'&ndi;i&nate re5ente# ROT re5ente*

E1amenu( radi&(&!i': (a indi'a;ia medi'u(ui se ee'uea5" ELG*

OSERVARE INI=IA+>:

Situa;ia (a internare: -0 'm# G02 M!# TA-.0 mm6!# P20

min#T30*KC# R.. rmin# 7"5 4un# au5 4un*

ANANE,A INI=IA+> A ASISTENTEI EDICA+E:

-* Ne7&ia de a resira @i a a7ea & 4un" 'ir'u(aie: u@&r a(terat" re'7en;a @i am(itatea resira;iei este m&dii'at" dat&rit" durerii*

e'7en;a resira;iei .. rmin*

nu ne'esit" a&rt de &1i!en*

u(s 20 min*

T*A ma1 -. mm6!# T*A min 0 mm6!*

te!umente(e @i mu'&ase a(ide# artere erieri'e u(sati(e*.* Ne7&ia de a 4ea @i de amn'a: nea(terat"

denti;ie 4un"# "r" r&te5" dentar"*

mu'&as" 4u'a(" @i (im4" r&5 @i umed"*

masti'a;ia este u@&ar"# re(e1 de de!(uti;ie re5ent*

&t" de mn'are re5ent"# 3 mese5i @i . !ust"ri# 2 &re reaus n&'turn#

nu are reerin;e 'u(inare# '&nsum" -// m( (i'$ide5i*


a'ienta re5int" mi';iuni i5i&(&!i'e# 39 e 5i# diure5a de -K/ m( de

mir&s @i 'u(&are n&rma("*

tran5it intestina( re5ent# - s'aun e 5i*

men&ra!ii ierderi de sn!e n '&ntinuarea 'i'(u(ui menstrua( n

'antit"i mi'i de -9./ m(5i*

83


32/92

'i'(u( menstrua( 'u (u1 a4undent .// m( sn!e5i 'u durat" de 90

5i(e'u sn!e r&@u des'$is*

ritmu( 'i'(u(ui menstrua( este de 3/ de 5i(e# u(timu( 'i'(u menstrua( a

&st (a data de - ianuarie ./-0*

transira;ii minime


aaratu( &ste&9arti'u(ar inte!ru*

sistemu( mus'u(ar inte!ru:n&rm&tn&rm&Mineti'*

de(asarea u@&r in!reunat" de durere*

* Ne7&ia de a d&rmi @i de a se &di$ni: a(terate s&mnu( este ne(ini@tit# ntrerut din 'au5a dureri(&r de (a ni7e(u(

$i&!astru(ui# este insui'ient 'antitati7 @i 'a(itati7*

4&(na7a re5int" an1ietate @i astenie i5i'" si si$i'"*

0* Ne7&ia de a se m4r"'a @i de54r"'a: nea(tert"

4&(na7a se &ate m4r"'a @i de54r"'a sin!ur" dar 'u e&rturi*

(en)eria tre4uie adus" (a at*K* Ne7&ia de a men;ine temeratura '&ru(ui n (imite n&rma(e: nea(terat"

temeratura '&ru(ui este de 30*KC*

te!umente(e a(ide#'"(du;e*

8* Ne7&ia de a i 'urat @i de a9@i r&te)a te!umente(e: nea(terat"

a'ienta @i &ate ee'tua sin!ur" t&a(eta '&ru(ui*

'a7itatea 4u'a(" re5int" denti;ie a(4"# '&m(et"*

mu'&asa 4u'a(" umed" @i r&5*

un!$ii n!ri)ite# t"iate s'urt*

ie(e n!ri)it"# neted"# 'atie(at"# e(asti'"*

2* Ne7&ia de a e7ita eri'&(e(e: a(terat"

stare de a!ita;ie dat&rit" amenin;"rii i5i'e*

a'ies 'risat# an1ietate dat&rit" dureri(&r de (a ni7e(u( $i&!astru(ui*

an1ietate dat&rit" inter7en;iei '$irur!i'a(e

84


33/92




nu d&re@te s" dis'ute desre 4&a(a sa*


4&(na7a este &rt&d&1"# arti'i" (a s(u)4e(e 4iseri'e@ti# are n'redere n

Dumne5eu*

4&(na7a @i d" seama de 'eea 'e se ntm(" @i a';i&nea5" '&n&rm

'&n7in!eri(&r r&rii*

-.* Ne7&ia de a i uti(: nea(terat" a'ienta @i a''et" n&ua stare n 'are se !"se@te# m&du( 'um

arat"#n"ti@are sa*

a'ienta &ate tre'e este anumite m&mente 'riti'e*

-3* Ne7&ia de a n7";a: nea(terat"


-* Ne7&ia de a se re'rea: nea(terat" a'ienta re5int" interes a;" de a'ti7it";i(e 'urente a(e 7ie;ii*

a'ienta este a'ti7"# interesat" de 'eea 'e se etre'e n )uru( ei# arti'i"

(a a'ti7it";i*

INTERPRETAREA DATE+OR* NEVOI AFECTATE* PRO+EE DE

NGRIJIRE*

Ne7&ia de a resira @i a a7ea & 4un" resira;ie: u@&ar" ta$inee# u@&ar"

ta$i'ardie*

Ne7&ia de a e(imina: men&metr&ra!ii# transira;ii minime*

Ne7&ia de a d&rmi @i a se &di$ni: s&mn a!itat# (is" &di$n"*

Ne7&ia de a e7ita eri'&(e(e: a!ita;ie# &4&sea(" si$i'"#durere (a ni7e(u(

$i&!astru(ui*

85


34/92

POSII+IT>=I DE EVO+


35/92

s"9@i "stre5e un';ia 'ardi&'ir'u(ar" (a ni7e( '&resun5"t&r# s" ai4" &

4un" 'ir'u(a;ie erieri'"*

s"9@i men;in" n (imite &time# 4a(an;a $idr&e(e'tr&(iti'"*

s" ai4" un s&mn &di$nit&r*

s"9i disar" durerea de (a ni7e(u( $i&!astru(ui*

a'ienta s"9@i mi'@&re5e an1ietatea 'u ri7ire (a:

9 m&dii'area s'$emei '&r&ra(e

9 s'$im4"ri(e determinate de men&au5a &r;at" 're@terea n

!reutate# teama de a nu mai a7ea '&iiB*

9 teama de ierdere a se1ua(it";ii*9 teama de m&arte*


(a sr@itu( sita(i5"rii# a'ienta re5int" & resir;ie n&rma("# '&m(e1"#

'u t&ra'e n&rma( '&n&rmat*

are un s&mn (ini@tit# &di$nit&r* durerea de (a ni7e(u( $i&!astru(ui a n'etat# a'ienta se mi@'" "r"

dii'u(tate (a sr@itu( sita(i5"rii*

a'ienta nu mai este a!itat"# are n'redere n sine @i n ers&na(u(

medi'&9sanitar*

87


36/92

PLAN DE NURSING

Data Nevoia

fundamenta

!ertur"at

Dia#no$tic de nur$in# O"iective

de nur$in# !re%ente

Tim

!

Interven&ii

de nur$in#

Evauarea

o"iectiveor

./*/- A resire @i a a7ea& 4un" 'ir'u(a;ie

Greutate n a resiramaniestat" rinm"rirea re'7en;ei

resira;iei ta$ineeB..rmin dat&rit"dureri(&r de (a ni7e(u($i&!astru(ui*

Pa'ienta s" re5interesira;ie n&rma("-09-8rminB @i s"

ie s'$i(i4rat" si$i'*

. $ 9 Asistenta medi'a(" asi!ur" un sa(&n 4ineaerisit# ns&rit# n 'are se men;ine &temeratur" '&nstant" de -89./C*

9Asistenta medi'a(" asi!ur" &5i;ie anta(!i'"a'ientei*9Asistenta medi'a(" n7a;" a'ienta s"&(&seas'" te$ni'i de re(a1are# s" insire

r&&und*9Asistenta medi'a(" m"s&ar" @i n&tea5" in&aia de &4ser7a;ie un';ii(e 7ita(e a(e

a'ientei*9Asistenta medi'a(" re'&(tea5" sn!e n7ederea ee'tu"rii ana(i5e(&r de (a4&rat&r*9Asistenta medi'a("# (a indi'a;ia medi'u(ui#administrea5" a'ientei tratament antia(!i'*

Du" . &re a'ientaresir" mai u@&r#re'7en;a resira;iei

s'ade (a -2 rmin#te!umente(e @imu'&ase(e sunt'&(&raten&rma(i5i(&!i'# u;in

a(ide anemie din'au5a sn!e(ui

ierdutB*


Greutate n a se &di$nirere5entat" rin &reinsui'iente de s&mn#

s&mn ntrerut# a!itatdat&rit" dureri(&r de (ani7e(u( $i&!astru(ui*

Pa'ienta s"4enei'ie5e de uns&mn '&resun5"t&r

K92&reB*Pa'ienta s" iea'ti7"# '&&erant" @is" e1rime & stare de

4ine# 'u t&nusu( i5i'@i si$i' 4un*

-. $ 9Asistenta medi'a(" &er" a'ientei & 'an" 'u(ate 'a(d nainte de 'u('are# i su!erea5"

a'ientei s" a'" & 4aie 'a(d" nainte de

'u('are*9Asistenta medi'a(" identii'" 'are sunta'ti7it";i(e a!reate de a'ient" @i e(a4&rea5"mreun" 'u a'easta un r&!ram de a'ti7itate'are s" '&resund" st"rii a'ientei*9Asistenta administrea5" medi'a;ia res'ris"de medi'*

Du" -. &rea'ienta are uns&mn4un

nentrerut'antitati7 @i'a(itati7*

88


37/92

A e(imina E(iminare menstrua("@i 7a!ina("ne'&resun5"t&aremaniestat" rin$em&ra!ii nere!u(atesur7enite ntre d&uamenstre su''esi7e @i$em&ra!iimenstrua(ere(un!ite

dat&rit" i4r&mu(uiuterin*

Pa'ienta s" re5inte& stare de 4ine# de'&n&rt i5i' @ise'uritate s" ai4" &stare de 4ine si$i'*

.$ 9Asistenta medi'a(" asi!ur" reausu( (a at#a(i'" ansamente a4s&r4ante @i ( i1ea5"n ##TQ*9Asistenta medi'a(" s'$im4" ansamentu(des*9Asistenta medi'a(" n7a;" a'ienta te$ni'ide re(a1are*9Asistenta medi'a(" r&te)ea5" atu( 'umu@ama @i a(e5"*

9Asistenta medi'a(" administrea5" sedati7e(a indi'a;ia medi'u(ui*

Du" . &re a'ientare5int" & stare de4ine de '&n&rt i5i'@i de si!uran;"*

A e7ita eri'&(e(e An1ietate r&7&'at" dene'un&a@terea

r&!n&sti'u(ui 4&(ii @ia ne'un&a@teriimi)(&a'e(&r demi'@&rare a dureri(&rmaniestat" rin e'ies'risat# ne(ini@tedat&rit" inter7en;iei'$irur!i'a(e*

Pa'ienta s"4enei'ie5e de unmediu de si!uran;" @ide & si!uran;"

si$&(&!i'" entrun("turarea st"rii dean1ietate# s" iein&rmat" desre

r&'eduri(ere&erat&rii*

. $ 9Asistenta medi'a(" asi!ur" un mediu der&te';ie si$i'" ad'7at st"rii de 4&a(" aa'ientei# n'ura)ea5" a'ienta s" '&muni'e'u 'ei din )ur# s"9@i e1rime em&;ii(e# ne7&i(e#ri'a# &inii(e*9Asistenta medi'a(" s"tuie@te ami(ia s" &sus;in" m&ra( e a'ient"*9Asistena medi'a(" a)ut" @i determin"

a'ienta s" arti'ie (a (uarea de'itii(&rri7ind n!ri)iri(e*9Asistenta medi'a(" une n (e!"tur" a'ienta'u a(te 4&(na7e 'are au ne'esitat inter7en;ie'$irur!i'a(" iar '&na(es'en;a are un mersa7&ra4i(*9Asistenta medi'a(" m"s&ar" @i n&tea5" n&aia de &4ser7a;ie un';ii(e 7ita(e*

Pa'ienta este . &remai (ini@tit"#n'ear'" s"'&n(u're5e 'u'adre(e medi'a(e#n;e(e!e ne'esitateainter7en;iei'$irur!i'a(e*

89


38/92

.-*/-*./-0 Pre!"tirea re&erat&rie:

-* Re'&(tarea sn!e(ui entru rea(i5area ana(i5e(&r de (a4&rat&r*

.* A(imenta;ia este u@&r di!era4i(" n re5iua &era;iei* Seara a'ienta nu mai m"nn'"# e7entua( rime@te & 'an" de 'eai#

ine r")it"# 4rn5" de 7a'i*

3* E(iminare: se ee'tuea5" & '(ism" seara# naintea &era;iei*

* Anemia: se '&re'tea5" din 'au5a sn!er"ri(&r mi'i 'antitati7 @i reetate# de&are'e sn!er"ri(e redisun (a '&m(i'a;ii

&st&erat&rii: @&'# tr&m4&5e* Se rea(i5ea5" transu5ie 'u sn!e i5&!ru# i5&R$*

* Pre!"tirea (&'a(": 'u & sear" naintea &era;iei se nde"rtea5" i(&5itatea u4ian"# se a'e 4aie !enera("# se m4ra'"

4&(na7a 'u (en)erie 'urat"* Re!iunea 'are 7a i suus" inter7en@iei '$irur!i'a(e 7a i e1aminat" da'" n 7e'in"tatea ei e1ist"

un'te de &(i'u(it"# e'5ema# intertri!&9de&are'e a'estea sunt surse de ine';ie &st&erat&rie*

..*/-*./-0 &ra 2//# naintea &era;iei:

se m"s&ar" temeratura# tensiunea arteria("# (usu(# resira;ia# se rea(i5ea5" & '(ism" e7a'uat&re*

se nde"rtea5" (a'u( de e un!$ii# iar a'ienta este anun;at" s" nu9@i dea 'u ru) e 4u5e# de&are'e# aste( &t i

urm"rite un';ii(e 'ir'u(at&rii @i resirat&rii a '"r&r tu(4urare intra&erat&rie se e7iden;ia5" rin 'ian&5a 4u5e(&r @i un!$ii(&r*

re!iunea e 'are se a'e in'i5ia se de5ine'tea5" 'u a('&&( @i este a'&erit" 'u & '&mres" steri("* nainte de intrarea n sa(a de &era;ie# 4&(na7a @i !&(e@te 7e5i'a urinar" @i I se m&ntea5" & s&nd" emanent"*

&ra -.//

90


39/92

Oera;ia: 4&(na7ei i se ee'tuea5" aneste5ie !enera(" &4;inut" rin intr&du'erea intrara$idian de N&7&'ain" - @i

Hi(in" . i&(e* A'tu( '$irur!i'a( '&nst" din $istere't&mie t&ta(" 'u ane1e't&mie 4i(atera("* I s9a administrat 4&(na7ei un

(a'&n de sn!e i5&!ru# i5&R$# rin transu5ie e masa &erat&rie*

Pa'ienta a &st trans&rtat" n se';ia de reanimare# unde sa tre5it (a &ra 3 du" inter7en;ia '$irur!i'a("* A &st

sura7e!$eat" de asistenta medi'a(" @i medi'a( aneste5ist# i s9au urm"rit a'iesu(# 'u(&area te!umente(&r# T*A# u(su(#

resira;ia# s9a administrat medi'a;ia res'ris"* &(na7a este trans&rtat" a d&ua 5i .3*/-# n se';ia de !ine'&(&!ie unde i se

a'&rd" n!ri)iri(e &s&erat&rii*

Data Nevoia

fundamenta

!ertur"at

Dia#no$tic de

nur$in#

O"iective

de nur$in# !re%ente

Tim! Interven&ii

de nur$in#

Evauarea

o"iectiveor

91


40/92

.3*/- A resire @i a a7ea& 4una 'ir'u(a;ie

Dii'u(tate n a resiradat&rit" inter7en;iei'$irur!i'a(emaniestat" rinm&dii'areaam(itudiniiresirat&ri'e#resira;ie sueri'ia("#u@&ar" ta$inee*

Pa'ienta s" ai4"resira;ie n&rma(" @ite!umente(e @imu'&ase(e s" ie'&(&rate i5i(&!i'# s"ai4" un ritmresirat&r re!u(at -09-8rmin*

. $ 9Asistenta medi'a(" a)ut" a'ienta s"rea(i5e5e e1er'i;ii resirat&rii# s" sea@e5e ntr9& &5i;ie ade'7at" s" @is'$im4e &5i;ia din . n . &re*9Asistenta medi'a(" &4ser7" 'u(&areaun!$ii(&r# 4u5e(&r @i te!umente(&r @i (en&tea5" n &aia de &4ser7a;ie a

a'ientei*9Asistenta medi'a(" m&nit&ri5ea5" @i

nre!istrea5" T*A# u(su(# resira;ia#temeratura*

Du" . &rea'ienta resir"mai u@&r @i re5int"te!umente @imu'&ase mai u;in

a(ide*Ta$ineea s9ami'@&rat*

A mn'a @i a 4ea A(imenta;iene'&resun5"t&are'antitati7 @i 'a(itati7dat&rit" inter7en;iei'$irur!i'a(emaniestat" rin$idratare @i indi!estiede a(imenteinsui'iente 'antitati7@i 'a(itati7*

Pa'ienta s" iee'$i(i4rat"$idr&e(e'tr&(iti' (aun ni7e( &tim @i s"

re5inte mu'&saeumede

-. $ 9Asistenta medi'a(" administrea5" nrima 5i du" &er;ie a(imenta;iearentera("# instituind eru5ii 'u!(u'&5" -/9-// m( @i ser i5i&(&!i'9-// m(*9Asistenta medi'a(" a(imentea5" er &s

a'ienta 'u 'eai# a"# (im&nad"# 5eam"de '&m&t# ar&1imati7 3// m(#administrate din . n . &re 'u (in!uri;an 'antit";i mi'i*9Asistenta medi'a(" ee'tuea5"

4i(an;u( (i'$ide(&r in!erate @i e(iminate

Pa'ienta estee'$i(i4rat"'&resun5"t&r$idr&e(e'tr&(iti'#

re5int" mu'&aseumede*F(uide(e arentera(eau &stm&nit&ri5ate @inre!istrate*

A e(imina E(iminare urinar"insui'ient" 'antitati7rere5entat" rina4sen;a mi';iunii

Asi!urarea uneie(imin"ri n&rma(e# nra&rt 'u 'antitateade (i'$ide in!erate

-. $ 9Asistenta medi'a(" 7erii'"ermea4i(itatea s&ndei urinare 'areeste intr&dus" naintea &era;ieiB @ie7itarea 'ud"rii a'esteia*

Du" 0 &re s&ndaurinar" este

ermea4i("#ne'udat"*

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41/92

s&ntane din 'au5ainter7en;iei'$irur!i'a(e*

@i administratearentera(*Pre7enirea ine';ieiurinare*Pa'ienta s" ai4" &mi';iune s&ntan"*

9Asistenta medi'a(" re7ine ine';iaurinar" rin ee'tuarea de mane7resteri(e*9Asistenta medi'a(" du" nde"rtareas&ndei urinare 7erii'" !&(irea 7e5i'iiurinare din n &re# n '&ndi;ii(eunui a&rt de (i'$ide in!erat*9Asistenta medi'a(" &4ser7" aari;iasemne(&r de ine';ie*

Du" nde"rtareas&ndei urinare see(imin" & 'antitatede -/ m( de urin"(a ie'are mi';iune*Semne(e de ine';ieurinar" nu aua"rut*


Greutatea de a d&rmi@i ntreruereas&mnu(ui din 'au5adureri(&r n urmaa'tu(ui '$irur!i'a(#maniestat" rin 7aiet#&re insui'iente des&mn*

Pa'ienta s"4enei'ie5e de uns&mn '&resun5"t&r'antitati7 @i 'a(itati7@i de un '&n&rt i5is@i si$i'*

- 5i 9Asistenta medi'a(" a(i'" te$ni'i den!ri)ire ne'esare &4;inerii unei st"ride 4ine i5i' @i si$i': aerise@tesa(&nu(# s'$im4" (en)eria de at*9Asistenta asi!ur" a'ientei & &5i;ie'&re't"9Asistenta n7a;" a'ienta te$ni'i dere(a1are @i e1er'i;ii resirat&riirea(i5ate 'u 3/ de minute nte de s&mn*9Asistenta surim" surse(e dedis'&m&rt @i irata4i(itate*9Asistenta a(i'" tratamentu(medi'ament&s (a indi'a;ia medi'u(ui*

Pa'ienta se&di$ne@te n&atea#s&mnu( iind(ini@tit# 'u & durat"de 0 &re*

A i 'urat si a9;ir&te)a te!umente(e

De!radareate!umente(&r

rere5entat" rin(a!" a4d&mina("dat&rit" inter7en;iei'$irur!i'a(e*

Pa'ienta s" re5intete!umente @i

mu'&ase 'urate*Pa'ienta s" se7inde'e 'u un minimde dis'n&rt @i "r"'&m(i'a;ii*

. $

5i(e

9Asistenta medi'a(" rea(i5ea5" t&a(eta!enera(" a a'ientei @i ii s'$im4"

(en)eria de '&r @i de at*9Asistenta medi'a(" ee'tuea5"s'$im4area ansamentu(ui# n!ri)irea

("!i(&r s"(area a'esteia 'u s&(u;ieantiseti'"B @i a('" un ansament n&u*9Asistenta medi'a(" rea(i5ea5"'ur";area @i s"(area erineu(ui 'u

Du" . &rea'ienta re5int"

te!umente @imu'&ase 'urate*P(a!a a &st'ur";at" 'u s&(u;ieantiseti'"#

ansamentu( a &stn(&'uit# (a ni7e(u(

93


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s&(u;ie steri(" de . &ri e 5i du"ie'are e(iminare# se men;ine 5&na'urat" entru a !r"4ii 'i'atri5area*9Asistenta medi'a(" '&ntr&(ea5"tam&ane(e erinea(e @i &4ser7"'u(&area# 'antitatea @i mir&su( se're;ieie(iminate# @i ra&rtea5" medi'u(ui*9Asistenta medi'a(" administrea5"

entru re7enirea ine';iei (a indi'a;ia

medi'u(ui# Ami'i(in" -!5i*

("!ii nu aua"rutsemne deine';ie*

A e7ita er'i'&(e(e Durere (a ni7e(u(("!ii a4d&mina(e#maniestat" rinirita4i(itate# a'ies'risat# dat&rit"inter7en;iei'$irur!i'a(e*

Pa'ienta s"4enei'ie5e desi!uran;"

si$&(&!i'" entrunde"rtarea st"rii dean1ietate# n7";area

a'ientei s"9@i'&ntr&(e5e durerea @is" (ute m&tri7a ei*

3 5i(e 9Asistenta s"tuie@te mem4rii ami(ieis" n'ura)e5e a'ienta @i s" men;in" un'(imat de &timism*9Asistenta n'ura)ea5" a'ienta s"7&r4eas'" 'u a(te a'iente# 'u '&(e!e(ede 'amer"9Asistenta medi'a(" aerise@te sa(&nu(#& n7a;" e a'ient" sa9@i '&mrime 'u

a(ma (a!a &era;iei aun'i 'ndtu@e@te# strnut" sau @i s'$im4"

&5i;ia*9Asistenta medi'a(" entru a 'a(madureri(e @i a asi!ura un s&mn &di$nit&rde 'e( u;in 892 &re de s&mn# (aindi'a;ia medi'u(ui# se dministrea5"ana(!eti'e @i tran'$i(i5ante*

Pa'ienta dis'ut" 'u'e(e(a(te a'iente @in7a;" met&de de'&m4atere adurerii*Du" administrareade ana(!eti'edurerea semi'@&rea5"*

94


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A '&muni'a C&muni'are inei'a'e(a ni7e( ae'ti7maniestat" rin a'ies'risat# (ans# re'7entn'$idere n sinedat&rit" nea'&m&d"rii(a n&ua s'$em"'&r&ra("*

Pa'ienta s" sea'&m&de5e 'u n&uaima!ine '&r&ra(" @i'u traumadeterminat" de&era;ie# s" re5inten'redere n sine @in 'ei din )ur entrua a'e a;" situa;iei

e1istente*

. $ 9Asistenta medi'a(" a)ut" a'ienta s"n;e(ea!" '" deresia# n!ri)&rarea#sentimentu( de neutin;" sunt n&rma(e@i de a''etat*9Asistenta medi'a(" a)ut" ami(ia @i

rietenii s" n;e(ea!" '" a'ienta arene7&ie s" ie n;e(eas" de'i s" se'&m&rte n&rma( 'u ea# s" & sri)ines"9@i "stre5e uterea de atra';ie# s" ie

ea ns"@i*9Asistenta medi'a(" as'u(t" 'u aten;iee1rimarea er'e;ii(&r se1ua(e de'"tre a'ient"*9Asistenta medi'a(" '&muni'" 'u

a'ienta desre &si4i(u( ima't a(inter7en;iei '$irur!i'a(e asura 7ie;iise1ua(e*

Fami(ia @i rieteniiau '&n@tienti5at '"tre4uie s" & sri)ine@i s" & a)ute e

a'ient"*Du" dis'u;ii(e

urtate a'ientade7ine'&muni'ati7"* *

.*/- A mn'a @i a 4ea Astenie i5i'" @isi$i'" dat&rita uneia(imenta;iiinsui'iente# a!ita;iemaniestat" rininaeten;" n urmaa'tu(ui '$irur!i'a(*

Pa'ienta s" sea(imente5e a'ti7 (a

at*Pa'ientei s" i seame(i&re5e starea!enera("*

-. $ 9Asistenta medi'a(" e1(i'" a'ienteine'esitatea a(imenta;iei*9Asistenta medi'a(" a)ut" 4&(na7a s"se a(imente5e sin!uru 'u su" de(e!ume stre'urat"# 'eaiuri re'i# 5eam"de '&m&t# su'uri*9Asistenta medi'a("# (a indi'a;iamedi'u(ui# '&ntinua s" a(imenete5e

a'ienta arentera(*

Pa'ienta sea(imentea5" a'ti7 (a

at*

A se mi@'a Im&4i(itatemaniestat" rindii'u(tatea a'ienteide a se mi@'a# de a seridi'a din at sin!ur"

Pa'ienta s"n";i@e5e &m&4i(tate n&rma(" @i& &stur" ade'7at"#"r" dureri*

. $ 9Asistenta medi'a(" a)ut" a'ienta ntimu( mersu(ui*9Asistenta medi'a(" n'ura)ea5" si$i'

a'ienta# administrea5" tratamentu(medi'ament&s res'ris de medi'*

Pa'ienta se &atede(asa sin!ur" darare ne7&ie de u;ina)ut&r*

95


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din 'au5a durerii @i aeui5"rii n urmaa'tut(ui '$irur!i'a(*

A i 'urat @i a9tir&te)a te!umente(e

De!radareate!umente(&r# !reutaten a se ee'tuan!ri)iri(e de i!ien"#maniestat" rin (a!"a4d&mina(" dat&rit"

inter7en;iei'$irur!i'a(e*

Pa'ienta s" re5intete!umente @imu'&ase 'urate*Ci'atri5area ("!ii s"ie 't mai raid"*

. $

3 5i(e

9Asistenta medi'a(" rea(i5ea5" t&a(eta!enera(" a a'ientei @i i s'$im4"(en)eria de '&r @i de at*9Asistenta medi'a(" ee'tuea5"

a'ientei t&a(eta ("!ii 'u s&(u;iiantiseti'e @i a(i'" ansament steri(#

ee'tuea5" s"(area @i 'ur";areaerineu(ui 'u s&(u;ie steri("*

Pa'ienta re5int"te!umente @imu'&ase 'urate*

Nu au a"rut semende ine';ie (ani7e(u( ("!ii*

A e7ita eri'&(e(e Irita4i(itate dat" de(a!a &erat&riemaniestat" rinan1ietate a;" de &

&si4i(" '&m(i'a;iedat&rit" a'tu(ui'$irur!i'a(*

Pa'ienta s"4enei'ie5e desi!uran;"

si$&(&!i'" entrunde"rtarea st"rii dean1ietate*

. 5i(e 9Asistenta medi'a(" in&rmea5"a'ienta 'u ri7ire (a eti&(&!ia @ie7&(u;ia i4r&mu(ui uterin*9Asistenta m"s&ar" @i n&tea5" n &aiade &4ser7a;ie un';ii(e 7ita(e a(e

a'ientei*9Administrea5" tratamentu( antia(!i'

res'ris de medi'*

Dureri(e sunt din 'en 'e mai rare du"administrareamedi'amente(&r iar

a'ienta reu@e@te s"@i (e '&ntr&(e5e *Pa'ienta '&muni'"'u 'e(e(a(te

a'iente*..0*/- A i 'urat si a9ti

r&te)a te!umente(eDii'u(tate n a seee'tua n!ri)iri(e dei!ien"# maniestat"

rin (a!" a4d&mina("

dat&rit" a'tu(ui'$irur!i'a(*

Pa'ienta s" re5intete!umente @imu'&ase 'urate*Pa'ienta s" re5inte

& raid" 'i'atri5area ("!ii*

. $

. 5i(e9Asistenta medi'a(" ee'tuea5"

a'ientei t&a(eta ("!ii 'u s&(u;iiantiseti'e @i a(i'" ansament steri(*9Asistenta medi'a(" erea(i5e5" t&a(eta

!enera(" a a'ientei @i i s'$im4"(en)eria de '&r @i de at*

Pa'ienta re5int"te!umente @imu'u&ase n!ri)ite*+a ni7e(u(

a4d&menu(ui (a!aeste 'urat"# "r"semne de ine';ie*

A e7ita eri'&(e(e An1ietate 'u ri7ire (areaari;ia dureri(&rmaniestat" rin a'ies'risat# dat&rit"

Pa'ienta s" n;e(ea!"'" starea ei s9aame(i&rat# '"rese'tnd re!imu(

- 5i 9Asistenta medi'a(" administrea5"tratamenu( antia(!i' res'ris de medi'*9Asistenta medi'a(" e1(i'" a'ienteine'esitatea re!imu(ui i!ien&9dieteti'*

Pa'ienta a n;e(esim&rtan;are!imu(ui i!ien&9dieteti'*

96


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a'tu(ui '$irur!i'a(* i!eien&9dieteti' estemiedi'at" aari;ia'&m(i'a;ii(&r*

.K*/- A i 'urat De!radareate!umente(&rrere5entat" rin

(a!" a4d&mina(" din'au5a inter7en;iei'$irur!i'a(e*

Pa'ienta s" re5inte& 'i'atri5are 't mairaid" a ("!ii*

. $ 9Asistenta medi'a(" ee'tuea5" t&a(eta("!ii&erat&rii 'u s&(u;ii antiseti'e*9Asistenta medi'a(" ee'tuea5"s'&aterea ire(&r '$irur!i'a(e 'u mu(t"

ruden;"*9Asistenta medi'a(" ee'tuea5"

s"(area @i 'ur";area erineu(ui 'us&(u;ie steri("*

+a ni7e(u(a4d&menu(ui# (a!aeste n!ri)it" 'utendin;e sre'i'atri5are*

A n7";a Dei'it de 'un&@tin;edesre aut&n!ri)ireadu" e1ternaremaniestate rin'un&@tin;e insui'ienteasura '&n7a(es'en;ei#a satisa'erii ne7&i(&rsa(e# @i a tratamentu(uide re'uerare*

Pa'ienta s" n;e(ea!"t&ate restri';ii(# dieta'&ntr&(u( durerii @i(imitarea a'ti7it";iise1ua(e*

. $ 9Asistenta medi'a(" edu'" a'ienta @iami(ia*C&nta'tu( se1ua( 7a i ermisdu" 98 s"t"mni* Este (imitat e&ru(i5i'# nu ur'" e s'"ri -9. s"t"mni#a&i se a'&m&dea5" tretat n"a)un!e (a n&rma(*9Se (imitea5" mun'a !rea n!&s&d"rie# nu ridi'" &4ie'te !re(e s"t"mni*9Se administrea5" ./// m( (i'$ide5i*9Da'" rea'erea este (ent" @i a'ienta

re5in" e4r"# se anun;" medi'u(*9Se administrea5" ana(!e5i'e entru

'a(mare @i '&ntr&(u( durerii*9Pa'ienta 7a '&nsuma un re!ima(imentar 4&!at n r&teine*

Pa'ienta @i ami(iaau n;e(eim&rtan;are!imu(ui i!ien&9dieteti'# n 'e a'&nstat inter7en;ia'$irur!i'a(" @i (a 'es'$im4"ri s" sea@tete men&au5"artii'ia("# ee'te(eteraiei$&rm&na(eB*

.K*/- E1ternare

97


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ROLUL DELEGAT AL ASISTENTEI 'EDICALE

DATA DENU'IREAANALIZEI

(ALORIREALE

(ALORINOR'ALE

.-*/- 6EOG+OINA

+E


47/92

PROTEINE TOTA+E

EHAEN DE

96

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99


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DATA TRATA'ENT TE'PERATUR)*

PULS* TA*

RESPIRA+IE

./*/- P&(idin 31.

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100


49/92

.3*/- Ami'i(in" -! 1

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101


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EPICRIZA

&(na7a# *G# n 7rst" de 30 ani# se internea5" e data de ./ ianuarie

./-0# entru urm"t&are(e simt&me: men&metr&ra!ie# dureri $i&!astri'e#

ame;e(i# sen5a;ii de !reutate @i 4a(&nare n a4d&men# n se';ia de !ine'&(&!ie# 'u

dia!n&sti'u( de i4r&m uterin*

+a e1amenu( '(ini' &4ie'ti7 se &4ser7" un a4d&men m&4i( 'u mi@'"ri(e

resirat&rii# durer&s (a a(are n $i&!astru# 'u 'i'atri'e &st&erat&rie:

aendi'e't&mie* Se re'&(tea5" tratament medi'ament&s*

&(na7a r"sunde (a tratamentu( medi'ament&s# dar ne'esit" inter7en;ie

'$irur!i'a(" e data de .. ianuarie ./-0*

Este re!"tit" re&erat&r*

Inter7en;ia '$irur!i'a(" s9a "'ut su4 aneste5ie !enera(" r&'edeu(

&erat&r a de'urs n '&ndi;ii 4une# "r" '&m(i'a;ii e masa &erat&rie* &(na7ei

i s9a administrat un (a'&n de sn!e rin transu5ie e masa &erat&rie @i a(te .(a'&ane de sn!e re&erat&r entru '&re'tarea anemiei*

Te$ni'a &erat&rie: 6istere't&mie su4t&ta(" interane1ia("*

Pa'ienta este sta;i&nar" & 5i n se';ia de reanimare# du" 'are re7ine n

se';ia de !ine'&(&!ie unde s9au "'ut n!ri)iri(e &st&erat&rii iar stare !enera("

s9a ame(i&rat*

Se e1ternea5" (a indi'a;ia medi'u(ui# 'u urm"t&are(e re'&mand"ri: e7itarea e&rturi(&r i5i'e tim de . (uni*

re5entarea (a '&ntr&( du" & (un" de 5i(e*

re!im a(imentar: se 7&r e7ita (e!ume(e 'u 'e(u(&5" !reu di!esti7"

ma5"re# as&(e# 7ar5"B* Se indi'" r&duse (a'tate# (ate# sue 'a(de# 'arne s(a4"

de as"re# aste "in&ase*

Pa'ienta @tie n 'e a '&nstat inter7en;ia '$irur!i'a(" @i (a 'e s'$im4"ri sase a@tete men&au5a artii'ia("B# 'un&a@te ee'te(e teraiei $&rm&na(e# a''et"

102


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'" s("4i'iunea# &4&sea(a# irita4i(itatea @i (nsu( sunt &4i@nuite n timu(

'&n7a(es'en;ei*

Pa'ienta @tie s" e7ite re(a;ii(&r se1ua(e# ridi'area !reut";i(&r# @ederea

re(un!it" n ma@in" sau '&ndu'erea aut&turismu(ui# a(te e&rturi# n" (a

ar&4area medi'u(ui 98 s"t"mniB*

n;e(e!e @i a''et" '" starea de '&n7a(es'en;" in'(ude 4"i ar;ia(e# (a1ati7e

@i medi'amente n 'a5 de dis'&n&rt# &di$n"# diet" e'$i(i4rat"#e7entua( &(&sirea

unui &rt)artier*

?tie '" "tarea @i s'$im4area tam&nu(ui erinea( de . &ri e 5i este

n&rma(# dar '" tre4uie s" ra&rte5e medi'u(ui sn!erarea# 'antitatea 'res'ut" dese're;ie sau se're;ii urt mir&sit&are*

?tie '" une(e emei ar utea i ne'esare 2 s"t"mni 93 (uni entru a se

sim;ii din n&u e(e nse(e# re7enirea dein5nd de & serie de a't&ri '&ndi;ie

i5i'"# atitudine a;" de 4&a("# menta(itate#7rst"# atitudinea ami(iei @i a

rieteni(&rB*

Pa'ienta este mu(;umit" de n!ri)iri(e a'&rdate de ers&na(u( medi'&9sanitar e eri&ada intern"rii*

CAZ III

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DOSAR DE NGRIJIRE


Nume: I

Prenume: D

Vrst": K ANI

Grua san!uin": A II R$%

D&mi'i(iu(: CRAIOVA# strada Cara'a(# nr* -3

DATE DESPRE SPITA+I,ARE:

Data intern"rii: -- e4ruarie ./-0# &ra 2/-*

Data e1tern"rii: -K e4ruarie ./-0# &ra --*

Dia!n&sti' (a internare: Fi4r&mat&5" uterin" $em&ra!i'"

Dia!n&sti' (a e1ternare: Fi4r&mat&5" uterin" $em&ra!i'"

Te$ni'a &erat&rie: 6istere't&mie t&ta(" 'u ane1e't&mie t&ta("

&ti7e(e intern"rii: 9 metr&ra!ie

9 ame;e(i# 'ea(ee

9 dureri n eta)u( a4d&mina( ineri&r

SIT ?I SOCIA+>:


Num"r '&ii: '&ii

Situa;ia s&'ia(": 'asier"C&ndi;ii de 7ia;": 4une# (&'uie@te 'u s&;u( @i 'ei '&ii ntr9& aartament

'u 'amere

PERSOANE C< CARE =INE +EG>T


53/92

Pers&na(e i5i(&!i'e# at&(&!i'eB: menar$a -0 ani# 'i'(u re!u(at# 90 5i(e# (u1

n&rma(# na@teri# a7&rturi/*

Fa't&rii de ris' ri7ind m&du( de 7ia;": '&nsum" a('&&(# 4ea 'aea#

&'a5i&na(# nu umea5"# nu are reerin;e 'u(inare*

ISTORIC


54/92

Starea de '&n@tien;": '&n@tient"#'&muni'" 7er4a(*

C&m&rtament: ne(ini@tit*

&d de internare: este adus" de s&;*

Parti'u(arit";i: durerea @i $em&ra!ia & n!ri)&rea5"*


&d de 7ia;": 'u s&;u( @i 'ei '&ii

ediu(: ur4an

O'ua;ia: 'asier"

Parti'u(arit";i: rea(i5e5" tre4uri(e 'asni'e# i a'e (a'ere s" mear!"

mreun" 'u ami(ia n e1'ursii (a sr@itu( s"t"mnii*Pr&4(eme s&'ia(e: 9

EHAEN C+INIC GENERA+ ee'tuat de medi'B:

2 Stare !enera(": a(terat"

Te!umente @i mu'&ase: e(asti'e# 'a(de# a(ide*

Aaratu( &ste&arti'u(ar: inte!ru @i m&4i( din un't de 7edere anat&m&9

un';i&na(# 4ine &rientat tem&r&9sita(* Nu re5int" ra'turi a(e &ase(&r*Sistemu( mus'u(ar: t&nus mus'u(ar# '&ntra';ie mus'u(ar" re5ent"

Aarat resirat&r: s&n&ritate u(m&nar"# murmuru( 7e5i'u(ar re5ent#


Aarat 'ardi&7as'u(ar: @&'u( ae1ianre5ent n satiu( V inter'&sta(

stn!# artere erieri'e u(sati(e# T*A*-/K/ mm6!# u(s2K min*

Aarat di!esti7: re(e1u( de de!(uti;ie este re5ent# a4d&men m&4i( 'u

mi@'"ri(e resirat&rii# durer&s (a a(are n $i&!astru# tran5it intestina( re5ent*

Aarat ur&!enita(: mi';iuni i5i&(&!i'e# s&ntane# (&)" rena(" (i4er"#

rini'$i nea(a4i(i*

SNCre(e1e '&ndi;i&nate @i ne'&ndi;i&nate re5ente # ROT re5ente*

E1amenu( radi&(&!i' (a indi'a;ia medi'u(ui se ee'tuea5" ELG*

OSERVARE INI=IA+>:

-* Ne7&ia de a resira si a a7ea & 4un" 'ir'u(a;ie: u@&r a(terat"

106


55/92

2 re'7en;a @i am(itudinea reira;ie sunt m&dii'ate dat&rit" durerii*

re'7en;a resira;iei# dat&rit" st"rii &st nar'&ti'e este de .3 rmin

ta$ineeB*

nu ne'esit" a&rt de &1i!en

u(s 2K min ta$i'ardieB*

T*A* ma1 -/ mm6!# T*A min K/ mm6!*

'&(&ra;ia te!umente(&r @i mu'&ase(&r este a(id"# artere erieri'e

u(sati(e*

.* Ne7&ia de a 4ea @i a mn'a: nea(terat"

denti;ie 4un"# "r" r&te5" dentar"* 'a7itate 4u'a(" inte!r"# nu re5int" edenta;ie# mu'&as" de 'u(&are r&5#

!in!ii(e sunt aderente (a din;i*

re(u1u( de de!(uti;ie este re5ent# di!estia este (ent"*

&t" de mn'are re5ent"# mese(e sunt rearti5ate uni&rm 3 mese @i .

!ust"riB*

nu are reerin;e 'u(inare se $idratea5" n&rma(# 'u -//9./// m( (i'$ide5i# rin '&nsum de

su'uri# sue @i a"*


a'ientare5int" mi';iuni i5i&(&!i'e s&ntane n num"r de 9 e 5i#

diure5a de -K// m(*

urina de 'u(&are @i mir&s n&rma(e# 6a'id *

tran5it intestina( re5ent# - s'aun e 5i*

metr&ra!ii9 ierderi de sn!e n aara 'i'(u(ui menstrua( n 'antit";i mi'i

de -9./ m(5i# 'te .93 5i(e* etr&ra!ii(e au a"rut n urm" 'u 8 (uni# (a n'eut

'u de4ut insidu&s# a&i sau intensii'at*

'i'(u( menstrua( 'u (u1 a4undent .// m( sn!e5i 'u durat" de K98 5i(e

'u sn!e de 'u(&are r&@u des'$is*

107


56/92

ritmu( 'i'(u(ui menstrua( este de .8 5i(e# u(timu( 'i'(u menstrua( a &st

(a data de .3 ianuarie ./-0*

transira;ii minime*


aarat &ste&9arti'u(ar inte!ru @i m&4i(# 'eea 'e i ermite a'ientei

indeenden;" t&ta(" n mi@'are*

sistemu( mus'u(ar inte!ru: n&rm&t&n# n&rm&Mineti'*

de(asarea u@&r n!reunat" de durere*

* Ne7&ia de a d&rmi @i a se &di$ni: a(terat"

s&mnu( este ne(ini@tit# ntrerut din 'au5a dureri(&r de (a ni7e(u($i&!astru(ui# este insui'ient 'antitati7 @i 'a(itati7*

4&(na7a re5int" an1ietate @i dat&rit" inter7en;iei '$irur!i'a(e# m&ti7

entru 'are se tre5e@te n&atea* Diminea;a (a tre5ire se simte &4&sit" @i eui5at"

si$i'*

0* Ne7&ia de a se m4ra'a @i de54r"'a: nea(terat"

4&(na7a se &ate m4r"'a @i de54r"'a sin!ur"# reernd & 7estimenta;iu@&ar" @i '&m&d"*

(en)eria tre4uie adus" (a at*

7e@minte(e sunt a(ese 'u !ust# ade'7ate '(imatu(ui*

K* Ne7&ia de a men;ine temeratura '&ru(ui n (imite n&rma(e:nea(terat"

temeratura '&ru(ui este de 30*C*

te!umente(e a(ide# '"(du;e*

transira;ie minim"*

8* Ne7&ia de a i 'urat @i de a9@i r&te)a te!umente(e: nea(terat"

a'ienta @i &ate rea(i5a sin!ur" t&a(eta '&ru(ui*

'a7itatea 4u'a(" re5int" denti;ie a(4"*

mu'&asa 4u'a(" este inte!r"# umed" @i r&5# &se(e na5a(e (i4ere*

un!$ii t"iate s'urt# n!ri)ite*

a'ienta re5int" te!umente 'urate# netede# e(asti'e# n&rma( i!mentate*

108


57/92

2* Ne7&ia de a e7ita eri'&(e(e: a(terat"

stare de a!ita;ie din 'au5a amenin;"rii i5i'e*

(ns# a'ies 'risat# an1ietate dat&rit" dureri(&r (a ni7e(u( $i&!astru(ui*

ertur4area ima!inii desre sine dat&rit" dii'u(t";ii de adatare (a &

s'$im4are '&r&ra(" nde"rtarea uteru(uiB*




nu su&rt" s" 7&r4eas'" rea mu(t desre 4&a(a sa*

un';i&narea ade'7at" a &r!ane(&r de sim;: ine;e !ustati7" @i amir&su(ui# sensi4i(itate ta'ti("*


4&(na7a este de re(i!ie &rt&d&1"# are n'redere n Dumne5eu# dar nu

arti'i" (a s(u)4e(e 4iseri'e@ti*

4&(na7a este '&n@tient" de a'eea se ntm(" @i a';i&nea5" '&n&rm

'&n7in!eri(&r r&rii*-.* Ne7&ia de a i uti(: nea(terat"

a'ienta @i a''et" n&a stare n 'are se !"se@te# m&du( 'um arat"#

n";i@area sa*

a'ienta se simte inuti(" @i '&m(e1at" de atu( '" nu &ate i a("turi

de ami(ie

a'ienta &ate de"@ii anumite m&mente 'riti'e*-3* Ne7&ia de a n7";a: nea(terat"


4&(na7a d&re@te s" a(e 't mai mu(te in&rma;ii de e7&(u;ie &st

&erat&rie# de a'eea une mu(te ntre4"ri

4&(na7a este '&n@tient" de ne'esitatea &rm"rii de n&i atitudini @i

derinderi '&re'te# ne'esar" &4;inerii unei st"ri de 4ine*

-* Ne7&ia de a se re'rea: nea(terat"

109


58/92

a'ienta este a'ti7"# intersat" de 'eea 'e se etre'e n )uru( ei# arti'i"

(a a'ti7it";i @i i (a'e &arte mu(t sa 'iteas'a r&mane de dra!&ste*

a'ienta re5int" interes a;" de a'ti7it";i(e 'urente a(e 7ie;ii*

INTERPRETAREA DATE+OR* NEVOI AFECTATE*

PRO+EE DE NGRIJIRE

Ne7&ia de a resira @i a a7ea & 4un" 'ir'u(a;ie: u@&r" ta$inee# u@&ar"

ta$i'ardie*

Ne7&ia de a e(imina: transira;ii minime# metr&ra!ii*

Ne7&ia de a d&rmi @i a se &di$ni: (isa &di$nei# an1ietate# s&mn a!itat#

insui'ient 'antitati7 @i 'a(itati7*Ne7&ia de a e7ita eri'&(e(e: ne(ini@te# &4&sea(" si$i'"# durere (a ni7e(u(

$i&!astru(ui*

POSII+IT>=I DE EVO+


59/92

s"9@i re'aete indeenden;a a;" de ne7&i(e ae'tate# s" ie 'aa4i(" n"

(a sr@itu( sita(i5"rii @i s" ai4" n'redere n ers&na(u( medi'&9sanitar*

s" n;e(ea!" ne'esitatea re!imu(ui a(imentar# s"9( 'un&as'" @i s" i(

rese'te*

a'ienta s" a''ete s" a'" a;" ima!ini sa(e '&r&ra(e m&dii'ate# s"9@i

a''ete u@&r n&u( statut men&au5a artii'ia(" dat&rit" nde"rt"rii uteru(uiB*

C* O4ie'ti7e se'ii'e:

2 s" ai4" & resira;ie n&rma("# s" i se asi!ure & 7enti(a;ie '&resun5"t&are

entru re7enirea '&m(i'a;ii(&r u(m&nare*

s"9@i men;in" ritmu( @i re'7en;a resirat&rie n (imite n&rma(e -09-8rmin*

s"9@i "stre5e un';ia 'ardi&9'ir'u(at&rie (a un ni7e( '&resun5"t&r# s"

ai4" & 4un" 'ir'u(a;ie erieri'"*

s"9@i men;in" n (imite &time# 4a(an;a $idr&e(e'tr&(iti'"*

s" ai4" un s&mn (ini@tit&r*

s"9i disar" durerea de (a ni7e(u( $i&!astru(ui* a'ienta s"9@i mi'@&re5e an1ietatea 'u ri7ire (a:

9 s'$im4area s'$emei '&r&ra(e*

9 s'$im4"ri(e determinate de men&au5a &r;at" m"rirea n !reutateB# teama de

ierdere a se1ua(it";ii# teama de m&arte*


2 (a sr@itu( sita(i5"rii# a'ienta re5int" & resira;ie n&rma("# am("# 'u


durerea de (a ni7e(u( $i&!astru(ui a (uat sr@it# a'ienta se mi@'" "r"

!reutate (a sr@itu( sita(i5"rii*

a'ienta nu mai este a!itat"# are n'redre n sine @i n ers&na(u(

medi'&9sanitar*

111


60/92

PLAN DE NURSING

Data Ne7&ia

undamenta("

ertur4at"

Dia!n&sti' de

nursin!

O4ie'ti7e

de nursin! re5ente

Tim Inter7en;ii

de nursin!

E7a(uarea

&4ie'ti7e(&r

-/*/.* A resira @i aa7ea & 4un"'ir'u(a;ie

Greutate n aresiramaniestat" rin

're@tereare'7en;eiresira;ieita$ineeB.3rmin din 'au5adureri(&r de (ani7e(u($i&!astru(ui*

Pa'ienta s" re5interesira;ie n&rma("-0-8rminB @i s" ie

e'$i(i4rat" si$i'#an1ietatea s" disar"*

. $ 9Asistenta medi'a(" asi!ur" unsa(&n 4ine aerisit# ns&rit# n'are se men;ine & temeratur"

'&nstant" de -89./C*9Asistenta medi'a(" asi!ur"&5i;ie anta(!i'" a'ientei*Asistenta medi'a(" n7a;"

a'ienta s" &(&seas'" te$ni'ide re(a1are# s" insire

r&&und*9Asistenta medi'a(" m"s&ar" @in&tea5" in &aia de &4ser7a;ieun';ii(e 7ita(e a(e a'ientei*Asistenta medi'a(" re'&(tea5"sn!e n 7ederea ee'tu"riiana(i5e(&r de (a4&rat&r*9Asistenta medi'a("# (aindi'a;ia medi'u(ui

administrea5" tratamentantia(!i'*

Du" . &re a'ienta resir"mai u@&r# re'7en;aresira;iei s'ade (a ./ rmin#

te!umente(e @i mu'&ase(esunt '&(&raten&rma(i5i(&!i'# u;in a(ide*

A e(imina E(iminaremenstrua(" @i7a!ina("ne'&resun5"t&are maniestat" rin

Pa'ienta s" re5inte &stare de 4ine# de '&n&rti5i' @i si!uran;" s" ai4"& stare de 4ine si$i'*

.$ 9Asistenta medi'a(" asi!ur"reausu( (a at#a(i'" ansamentea4s&r4ante @i ( i1ea5"n ##TQ*

Du" . &re a'ienta re5int"& stare de 4ine# de '&n&rt @ise'uritate*

112


61/92

$em&ra!iinere!u(ate#a'i'(i'e# sur7enitentre d&uamenstre su''esi7edin 'au5ai4r&mu(ui uterin*

9Asistenta medi'a("s'$im4" ansamentu( des*9Asistenta medi'a(" n7a;"

a'ienta te$ni'i de re(a1are#& (ini@te@te n (e!"tur" 'u

4&a(a sa @i i e1(i'" s'&u(inter7en;ii(&r*9Asistenta medi'a("

r&te)ea5" atu( 'u mu@ama

@i a(e5"*9Asistenta medi'a("# (aindi'a;ia medi'u(ui#administrea5" sedati7e


Greutate n a se&di$nimaniestat" rin&re insui'ientede s&mn# s&mnntrerut# a!itatdat&rit" dureri(&rde (a ni7e(u($i&!astru(ui*

Pa'ienta s" 4enei'ie5ede un num"r de &re des&mn '&resun5"t&areunu adu(t K92 &reB# s"ie a'ti7"# '&&erant" @is" e1rime &a

fibrom uterin, partea practica

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