Anexa 2

FIŞĂ SINTETICĂ DE MONITORIZARE A BOLNAVULUI DIALIZAT PERITONEAL -

ANUL ..........
______________________________________________________________________________
| Numele ........................... Prenumele ............................... |
| _ _ _ _ _ _ _ _ _ _ _ _ _ |
| CNP |_||_||_||_||_||_||_||_||_||_||_||_||_| Nr. carnet (pentru bolnavii |
| _ _ _ _ _ _ _ _ |
| incluşi în programele de sănătate) |_||_||_||_||_||_||_||_| |
| _ _ _ _ |
| Număr înregistrare a Fişei de spitalizare de zi SZ |_||_||_||_| |
| Întocmit de ................................................................ |
| (parafa medicului) |
|______________________________________________________________________________|
______________________________________________________________________________
| |Ianuarie | Februarie | Martie | Aprilie | Mai | Iunie |
|_______________________|_________|___________|________|_________|_____|_______|
| Data | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Apetit | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Greutate (kg) | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Presiune arterială | | | | | | |
| (cmHg) | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| - clinostatism | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| - ortostatism | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Semne de | | | | | | |
| hiperhidratare | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Diureză medie (l/zi) | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Ultrafiltrare medie | | | | | | |
| netă (ml/zi) | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Test echilibrare | | | | | | |
| peritoneală*2) | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| DPCA/DPCC | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Sistem | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Nr. schimburi | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Orar schimburi | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Tip soluţie | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Volum | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Starea orificiului de | | | | | | |
| ieşire*1) | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Recomandări | | | | | | |
| - Dietă | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| - Tratament | | | | | | |
| medicamentos | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
| Probleme | | | | | | |
|_______________________|_________|___________|________|_________|_____|_______|
*1) După clasificarea Tdwardowky
22.37;A4;t2
_____________________________________________________________________________
| |Iulie|August |Septembrie|Octombrie|Noiembrie|Decembrie|
|_______________________|_____|_______|__________|_________|_________|_________|
| Data | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Apetit | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Greutate (kg) | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Presiune arterială | | | | | | |
| (cmHg) | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| - clinostatism | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| - ortostatism | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Semne de | | | | | | |
| hiperhidratare | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Diureză medie (l/zi) | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Ultrafiltrare medie | | | | | | |
| netă (ml/zi) | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Test echilibrare | | | | | | |
| peritoneală*2) | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| DPCA/DPCC | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Sistem | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Nr. schimburi | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Orar schimburi | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Tip soluţie | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Volum | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Starea orificiului de | | | | | | |
| ieşire*1) | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Recomandări | | | | | | |
| - Dietă | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| - Tratament | | | | | | |
| medicamentos | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
| Probleme | | | | | | |
|_______________________|_____|_______|__________|_________|_________|_________|
*1) După clasificarea Tdwardowky
Observaţii
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