Sunteți pe pagina 1din 5

NEVOIA

MANIFESTRI DE
FUNDAMENTAL DEPENDEN
1. A RESPIRA I
A AVEA O BUN
CIRCULAIE
2. A BEA I A
MNCA
3. A ELIMINA

TA-100/70mmHg
P-94b/min,palpitatii
Inapetenta

Varsaturi bilioase
Oprirea tranzitului
intestinal
4. A SE MICA I Fatigabilitate
A AVEA O BUN
POSTUR
5. A DORMI I A Treziri frecvente,
SE ODIHNI
6. A SE MBRCA
A SE DEZBRCA
7. A MENINE
TEMPERATURA
CORPULUI N
LIMITE
NORMALE
8. A FI CURAT,
NGRIJIT, DE A
PROTEJA
TEGUMENTELE
I MUCOASELE
9. A EVITA
PERICOLE
10. A COMUNICA
11. A ACIONA
CONFORM
PROPRIILOR
CONVINGERI
12. A SE
REALIZA
13. A SE
RECREEA
14. A NVA
CUM S-I
PSTREZE
SNTATEA

SURSE DE
DIFICULTATE
Ischemia
miocardului,stare
toxica
varsaturi

PROBLEMA DE
DEPENDEN

GRAD DE
DIFICULTATE

Circulatie alterata
Dependent
Nutritie alterata

Dependent

Eliminare inadecvata
Sindrom ocluziv
Intoleranta la efort
Dureri ,anxietate

Dependent
Alterarea mobilitatii

Dependent

Somn perturbat
Dependent
Independent

Independent
Dificultate in respectarea
normelor de igiena

Intoleranta la efort

Deficit de
autoingriire
Dependent

Dureri
vii,colicative,neliniste

Sindromul ocluziv

Risc de complicatii

Dependent
Independent
Independent
Independent
Independent

Cunotine insuficiente
Lipsa informaiilor.
despre boala si pregatirea
preoperatorie

Deficit de cunotine.
Dependent

EXAMENE PARACLINICE I DE LABORATOR


Valori normale
Hemoleucograma :
leucocite
hemoglobin
hematii
Viteza de sedimentare a
hematiilor (VSH)

4200 8000/mmc
Brbai = 15 2 g%
Brbai =4,5-5,5mil/mm
la 1 or = 1 -10 mm
la 2 ore = 7 -15 mm

Valori reale
12 900/mm3
13,3g%
4,4 mil/mm3
la 1 or = 39 mm
la 2 ore = 77 mm

Timp de sngerare

< 6 min

3 min

Timp de coagulare

8-12 min

9 min

Bilirubina : - total

0,6 -1 mg %

1 mg %

Fibrinogen

200-400 mg %

462 mg%

Glicemie
Uree

80 120 mg %

95 mg%

20-50 mg %

52 mg%

Creatinina : - n snge
Proteinograma :- albumine
- alfa 1 globuline
- alfa 2 globuline
- beta globuline
- gamma globuline

0.6 -1.2 mg %

1,3 mg%

40 - 50 %
4%
8%
12 %
16 - 18 %

45%
4,1%
10,3%
14%
22,8%

7,5 -10 g %

7,2 g %

Na+ = 137-152 mEq/l


K+ = 3,8-5,4 mEq/l
Cl = 94-11mEq/l

Na+ = 122 mEq/l


K+ = 3 mEq/l
Cl = 90 mEq/l

180 280 mg%


74 172 mg%

260 mg%
180 mg%

normal

normal

Proteinele totale
Ionograma sanguin
Colesterol
Trigliceride
Examen de urin

SUPRAVEGHEREA FUNCIILOR VITALE


Data

TA

76 b/min

17 r/min

D: 36,6 C

24.03.2014

D: 130/80
mmHg

Diurez

Scaun

580 ml/24h

Lipsa scaun

696 ml/2h

Lipsa scaun

590 ml/24h

Lipsa scaun

460 ml/24h

Lipsa scaun

750 ml/24h

Scaun
moale

1100
ml/24h

Scaun
normal

960 ml/24h

Scaun
normal

S: 37,3 C

25.03.2014

S: 120/85
mmHg
D: 130/65
mmHg

D: 36,5C
78 b/min

16 r/min
S:37,4C

26.03.2014

S: 130/80
mmHg
D: 130/85
mmHg

D:36,8C
68 b/min

18 r/min
S:36,5C

27.03.2014

S: 120/85
mmHg
D: 120/80
mmHg

D:36,9C
73 b/min

21 r/min
S: 36,2C

28.03.2014

S: 110/85
mmHg
D: 120/80
mmHg

D: 36,6C
78 b/min

17 r/min
S:37,3C

29.03.2014

S: 110/85
mmHg
D: 120/70
mmHg

D: 36,7C
69 b/min

18 r/min
S: 36,6C

30.03.2014

S: 110/80
mmHg
D: 135/80
mmHg

D: 37,3C
67 b/min

17 r/min
S: 36,5C

S: 130/80
mmHg

Perioada

Calea
administrrii

Alimente permise

Alimente
nepermise

25.03.2014

parenteral

26.03.2014

parenteral

27.03.2014

strict parenteral

28.03.2014

oral

Cantiti mici de
lichide

Ceai, compot ,suc


de fructe

29.03.2014

oral

Cantiti mici de
alimente
semilichide

Supe crem

30.03.2014

oral

Cantiti mici de
alimente
semilichide i uor
digerabile

Piureuri de
legume, orez

Evitarea alimentelor
care fermenteaz
( varz,fasole,mazre).
Evitarea alimentelor
care duc la constipaie.

TRATAMENT MEDICAMENTOS
Data
25.03.2014

26.03.2014

Medicamente
Glucoz 10%-1500 ml , Soluie Ringer 500
ml, NaCl 5,8%-40 ml, KCl 7,4%-20 ml
,Vitamina B1,B6-1 fiol, Ca gluconic-1 fiol
Metoclopramid 1 fiol
Glucoz 10%-1500 ml, , Soluie Ringer 500
ml , NaCl 5,80-40 ml ,KCl 7,4%-20 ml,
Vitamina B1,B6 ,Ca gluconic 1 fiol

Mod de administrare
i.v (intravenos)

i.v (intravenos)

Metoclopramid 3fiole/zi
Algocalmin-1 fiol

i.m (intramuscular)

27.03.2014

Glucoz 10%-1500 ml, Soluie Ringer 500


ml , NaCl 5,8%-40 ml ,KCl 7,4%-20 ml ,
Vitamina B1,B6-1 fiol ,Ca gluconic-1 fiol

i.v (intravenos)

Metoclopramid 3fiole/zi

28.03.2014

Algocalmin-1fiol

i.m (intramuscular)

Diazepam 1 fiol-seara
Glucoz 10% ,NaCl 5,8%-40 ml ,Vitamina
B1,B6-1 fiol , Soluie Ringer 500 ml

i.v (intravenos)
i.v (intravenos)
i.m (intramuscular), i.m(intramuscular)

Algocalmin-1 fiol , Diazepam-1fiol seara


29.03.2014

Glucoz 10% ,NaCl 5,8%-40 ml ,Vitamina


B1,B6-1 fiol, Soluie Ringer 500 ml

i.v (intravenos)

30.03.2014

Glucoz 10% ,NaCl 5,8%-40 ml ,Vitamina


B1,B6-1 fiol , Soluie Ringer 500 ml
n caz de infecii la indicaia medicului :

i.v (intravenos)

Ampicilin 1g/6h , Gentamicin 1fiol 12/h

i.v (intravenos)