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PLAN DE NGRIJIRE

- CAZUL I
Culugerea datelor
1.Date subiective
NUME: C. P.
VR!"A: #$ a%i
!E&: 'e(i%i%
!"ARE CIVIL): c*s*t+,it*
RELIGIE: +,t+-+.*
NA/I0NALI"A"E: ,+(1%*
PREG)"IRE PR02E!I0NAL): 3iceu3
0CUPA/IA: e-ucat+a,e
D0MICILIUL: c+(. Li4+vat5 6u-. Vas3ui
C0NDI/II DE VIA/): bu%e5 3+cuie7te cu s+8u3 7i c+4i3u35 3a cas*5 a(bii su%t sa3a,ia8i.
09I:NUIN/E DE VIA/): %u c+%su(* a3c++35 %u 8i%e ,e;i(5 c+%su(* + ca'ea <i3%ic.
!EMNE PAR"ICULARE: - i%*38i(e: 15=> c(?
- ;,eutate: $# @;?
- ;,u4 sa%;ui%: A II5 RA 4+<itiv?
- %u se 7tie a3e,;ic* 3a %ici u% (e-ica(e%t
2UNC/II VI"ALE: "A B 1C$D EF (( A;
P B G= bD(i%
R B #C ,D(i%
"
F
B C>
F
C
2UNC/II VEGE"A"IVE: - a4etit sc*<ut
- scau% abse%t HC <3eI -iu,e<*- sc*<ut*
- -u,e,e J% '+sa i3iac* -,ea4t*
AN"ECEDEN"E PER!0NALE: - (e%a,Ka 3a 1$ a%i
- + %a7te,e %+,(a3*
- u% av+,t s4+%ta%
- '3u. (e%st,ua3 3a CF <i3e5 $ <i3e5 '*,* -u,e,i
AN"ECEDEN"E AERED0- C0LA"ERALE: %ea;* b+3i i(4+,ta%te.
DA"A IN"ERN)RII: FE.F#.#F1L
OBSERVAII: siste( +ste+- a,ticu3a, i%te;,u5 te;u(e%te i%te;,e5 cu,ate5 sta,e ;e%e,a3*
u7+, a3te,at*.
DIAGNOSTIC MEDICAL: a4e%-icit* acut* '3e;(+%+as*
MOTIVELE INTERNRII: - ;,e8u,i?
- v*,s*tu,i?
- 'eb,* (+-e,at* HC>
F
C I?
- -u,e,e *% '+sa i3iac* -,ea4t*?
- taKica,-ie?
- taKi4%ee?
- ce'a3ee.
ISTORICUL BOLII: Pacie%ta -ec3a,* c* J% u,(* cu $ <i3e au a4*,ut ;,e8u,i3e 7i
v*,s*tu,i3e5 ia, -e #L -e +,e au a4*,ut -u,e,i J% '+sa i3iac* -,ea4t*.
NEV0I A2EC"A"E 09IEC"IVE IMPLEMEN"ARE EVALUARE
0RA >5 FL.F#.#F1#
1INev+ia -e a evita 4e,ic+3e.
D.I. Vu3%e,abi3itatea 'a8* -e
4e,ic+3e?
Du,e,e J% <+%a i%;Ki%a3* cu
i,a-ie,i J% (e(b,u3 i%'e,i+, 7i
Ki4+c+%-,u3 -,e4t.
Risc 4+te%8ia3 -e c+(43ica8ie
i(e-iat* 7i ta,-iv*:
- 4e,it+%ita?
- Ke(+,a;ie 4+st+4e,at+,ie
- +c3u<ie i%testi%a3*?
- 'istu3e?
- evisce,a8ii?
A%.ietate
"A B 1C$DEF (( A;
R B #C ,D(i%
AV B G= bD(i%
-Re-uce,ea a%.iet*8ii
-C+(bate,ea -u,e,ii
-P,eve%i,ea
c+(43ica8ii3+,
4+sibi3e 7i a i%'ec8i3+,
i%te,i+a,e.
- M* 4,e<i%t 4acie%tei 7i asi;u, u% (ic,+c3i(at 'av+,abi3
H te(4e,atu,a ca(e,ei -e a4,+.i(ativ #F
F
C5 u(i-itate5 sa3+%
ae,isit5 3e%6e,ie -e 4at 7i -e c+,4 cu,at*I.
- P+,t -iscu8ii cu 4acie%ta 4e%t,u a J%3*tu,a a%.ietatea 7i 4e%t,u
a-i (*,i J%c,e-e,ea J% ecKi4a -e J%;,i6i,e 7i 4e%t,u a c+3ab+,a cu
aceasta.
- A43ic 4u%;a cu ;Kea8* J% <+%a i%;Ki%a3* 4e%t,u a -i(i%ua
-u,e,ea.
- A-(i%ist,e< 3a i%-ica8ia (e-icu3ui A3;+ca3(i% 2.I5IM5
Met,+c3+,4,a(i- '.I5 IM
- Rec+3te< s*%;e 4e%t,u i%vesti;a8ii -e 3ab+,at+, J% u,;e%8*:
ALG5 ;,u4 sa%;ui% 7i RK5 V!A5 ;3ice(ie.
- La ,ec+(a%-a,ea (e-icu3ui 4,e;*tesc 4acie%ta 4e%t,u
e'ectua,ea ecK+;,a'iei ab-+(i%a3e?
- Me-icu3 i%-ic* i%te,ve%8ia cKi,u,;ica3*.
0RA 11
FF
"A B 1#$DEF (( A;
R B #G ,D(i%
AV B >> bD(i%
Pacie%ta este (ai 3i%i7tit* -i% 4u%ct
-e ve-e,e e(+8i+%a3.
#I Nev+ia -e a ,es4i,a 7i -e a
avea + bu%* ci,cu3a8ie.
DI- Dis4%ee cu 4+3i4%ee
R B #C ,es4D(i%.A%.ietate
- "aKica,-ie G= bD(i%
- Du,e,e J% '+sa i3iac* -,ea4t*
Re-uce,ea -u,e,ii5 a
a%.iet*8ii5 a
taKica,-iei 7i a
4+3i4%eei
Asi;u, 4acie%tei + 4+<i8ie a%ta3;ic*.
Discut cu 4acie%ta 4e%t,u aMi J%3*tu,a a%.ietatea
Ae,isesc sa3+%u35 4*st,e< te(4e,atu,a 7i u(i-itatea c+%sta%te J%
sa3+%.
Mas+, 'u%c8ii3e vita3e 7i 3e %+te< J% 2.0.
Pe%t,u ,e-uce,ea -u,e,ii a43ic 4u%;a cu ;Kea8* J% ,e;iu%ea
i%;Ki%a3* 7i c+(4,ese ,eci 4e ',u%te.
R B #F ,D(i%
AV B >> bD(i%
Pace%ta c+3ab+,ea<* cu ecKi4a -e
J%;,i6i,e.
CI Nev+ia -e a se a3i(e%ta
7i Ki-,ata.
D.I. I%a4ite%8*
- G,ea8* 7i v*,s*tu,i -at+,it*
4,+cesu3ui i%'3a(at+,
Re-uce,ea -u,e,ii5
v*,s*tu,i3+, 7i a
;,e8u,i3+,
- P,e;*tesc (ate,ia3e3e %ecesa,e 7i a6ut 4acie%ta J% ti(4u3
v*,s*tu,i3+,5 sus8i%1%--+ J% 4+<i8ie -e -ecubit 3ate,a35
sus8i%1%-u-i ca4u35 ca4te< 3icKi-u3 -e v*,s*tu,* J% t*vi8a ,e%a3*5
4atu3 'ii%- 4,+te6at cu (u7a(a 7i a3e<* 7i a4+i a-uc 3a cu%+7ti%8*
(e-icu3ui.
- 0'e, 4acie%tei u% 4aKa, cu s+3u8ie a,+(at* 4e%t,u a-7i c3*ti
;u,a.
V*,s*tu,i: 1
G,ea8* 4e,(a%e%t*.
LI Nev+ia -e a-7i 4*st,a
te(4e,atu,a c+,4u3ui J%
3i(ite c+%sta%te H%+,(a3eI
D.I. Ai4e,te,(ie
2eb,* (+-e,at* HC>FC I5
te;u(e%te ,+7ii uscate5
ca3-e5 -at+,it* 4,+cesu3ui
i%'3a(at+,.
C+(bate,ea 'eb,ei 7i
4*st,a,ea te(+e,atu,ii
J% 3i(ite 'i<i+3+;ice.
- Asi;u, 4acie%tei c+%-i8ii -e (ic,+c3i(at c+,es4u%<*t+,.
- Ae,isesc ca(e,a.
- Le%6e,ia -e c+,4 7i 4at cu,at* 7i uscat*.
- A43ic 4acie%tei c+(4,ese ,eci 4e ',u%te .
- La i%-ica8ia (e-icu3ui a-(i%ist,e< IM.A3;+ca3(i% 2.I.
"e(4e,atu,a a sc*<ut 3a
CE5FC.
$H Nev+ia -e a se J(b,*ca 7i
-e<b,*ca.
D.I. Di'icu3tate -e a se
J(b,*ca 7i -e<b,*ca .
- Du,e,e
- Ai4e,te,(ie
- A%<ietate
- Aut+%+(ie J%
satis'ace,ea %ev+ii
- A6ut 4acie%ta s* se J(b,ace 7i s* se -e<b,ace cu 3e%6e,ie -e
s4ita3.
- Asi;u, 3e%6e,ie -e 4at cu,at*
0biectiv 4a,8ia3 ,ea3i<at
NEV0IA A2EC"A") 09IEC"IVE IMPLEMEN"ARE EVALUARE
=I Nev+ia -e a e3i(i%a
D.I. E3i(i%a,e i%a-ecvat*
- 03i;u,ie H GFF(3D#LKI
- C+%sti4a8ie abse%8a scau%e3+, -e C
<i3e.
-",a%s4i,a8ii (+-e,ate.
- G,ea8*
- C+(bate,ea +3i;u,iei.
- ",a%<it i%testi%a3 %+,(a3.
- I;ie%* satis'*cut*.
- Dese,vesc 4acie%ta 3a 4at cu 43+sca
4e%t,u satis'ace,ea %ev+i3+, 7i +bse,v
ca%titatea 7i as4ectu3 e3i(i%*,i3+,5 a4+i
%+te< J% 2.0.
- E.43ic 4acie%tei i(4+,ta%8a s4*3*,ii 4e
(*i%i -u4* satis'ace,ea %ev+ii.
- R+; 4acie%ta s* 'ac* e.e,ci8ii -e
,es4i,a8ie 4,+'u%-* 4e%t,u J%3*tu,a,ea
se%<a8iei -e ;,ea8*.
- I%cu,a6e< 4acie%ta 7i Ji e.43ic i(4+,ta%8a
i%;e,*,ii -e 3icKi-e.
- E'ectue< + c3is(* evacuat+a,e.
- Nev+ie 4a,8ia3 satis'*cut*.
- Pacie%ta i%;e,* #FF (3 ceai.
EI Nev+ia -e a se +-iK%i
D.I. !+(% J%t,e,u4t -e cca L +,e.
- 2eb,a
- Du,e,e.
- A%.ietate
- Pacie%ta s* be%e'icie<e -e u%
s+(% c+,es4u%<*t+, ca3itativ 7i
ca%titativ.
- C,ee< u% (e-iu a-ecvat: 3i%i7te5 sa3+%
ae,isit5 3e%6e,ie cu,at*.
- Discut cu 4acie%ta 4e%t,u a-i J%3*tu,a
a%.ietatea.
Pacie%ta este 3i%i7tit*? a,e (a,e J%c,e-e,e
J% ecKi4a -e J%;,i6i,e.
>I Nev+ia -e a 'i cu,at 7i J%;,i6it
D.I. Di'icu3tate J% satis'ace,ea %ev+ii
-at+,it* -u,e,ii5 'eb,ei5 a%.iet*8ii.
Asi;u,a,ea ase4ti<*,ii
te;u(e%te3+, J% ve-e,ea
i%te,ve%8iei cKi,u,;ica3e.
P,e;*tesc 4acie%ta 4e%t,u i%te,ve%8ia
cKi,u,;ica3* 4,i%: 4,e;*ti,e 'i<ic* 7i
4siKic*5 4,e;*ti,e 3+ca3* 4,i%: e4i3a,e5
s4*3a,e5 -e;,esa,e5 ba-i6+%a,e cu ti%ctiu,*
-e i+- a ab-+(e%u3ui.
C+%-uc 4acie%ta 3a sa3a -e +4e,a8ie
4e%t,u i%te,ve%8ia cKi,u,;ica3*.
La i%-ica8ia (e-icu3ui a-(i%ist,e<
Dia<e4a( N '.
M*s+, 'u%c8ii3e vita3e 7i 3e %+te< J% 2.0.
Pacie%ta este ecKi3ib,at* 4siKic?
Acce4t* i%te,ve%8ia cKi,u,;ica3*.
C1(4u3 +4e,at+, este 4,e;*tit.
"A B 1#FDEF (( A;.
AV B G= bD(i%.
R B 1G ,D(i%

RAPORT DE PREDARE

ZIUA I !reo!erator
La scKi(ba,ea tu,ei 4,e-au 4acie%ta C.P. ca,e va 'i +4e,at* 3a +,e3e 1=
FF
.
C1(4u3 +4e,at+, este e'ectuat.
Eva3ua,ea 'u%c8ii3+, vita3e este e'ectuat*.
Pacie%ta %u a 4,e<e%tat c+(43ica8ii 4+st +4e,at+,ii:
NEV0IA A2EC"A") 09IEC"IVE IMPLEMEN"ARE EVALUARE
0RA >
FF
5 F$.F#.#F1#
1INev+ia -e a evita 4e,ic+3e
D.I. Vu3%e,abi3itatea 'a8* -e
4e,ic+3e
- Du,e,e H 43a;a +4e,at+,ieI
- Risc 4+te%8ia3 -e c+(43ica8ii
i(e-iate 7i ta,-ive:
-Ae(+,a;ie 4+st+4e,at+,ie
- Evisce,a8ii
Risc 4e%t,u i%'ecta,ea 43*;ii
+4e,ate
- Re-uce,ea -u,e,ii
-P,eve%i,ea c+(43ica8ii3+,
- P+,t -iscu8ii cu 4acie%ta J% ve-e,ea J%;,i6i,i3+,
4,+;,a(ate
- Asi;u, + 4+<i8ie a%ta3;ic* 4acie%tei5 -e -ecubit
-+,sa3 '*,* 4e,%*
- Asi;u, u% (ic,+c3i(at 'av+,abi3 4acie%tei
- M+bi3i<e< 4asiv 4acie%ta
- Ae,isesc sa3+%u3
- M+%it+,i<e< 'u%c8ii3e vita3e
- Pause< 43a;a +4e,at+,ie
- A-(i%ist,e< 3a i%-ica8ia (e-icu3ui a%tia3;ice:
A3;+ca3(i% '.I5 IM 7i a%tibi+tice- Pe%ici3i%* 1FFFFFF
U.I. 3a = +,e
0RA 1#
FF
- Du,e,i -i(i%uate
- Nu 4,e<i%t* c+(43ica8ii 4+st +4e,at+,ii
"A B 11FDEF (( A;
AV B >F bD (i%
R B #F ,D(i%
#I Nev+ia -e a 'i cu,at 7i J%;,i6it
D.I. I%ca4acitatea -e a-7i
satis'ace %ev+i3e -e i;ie%*
I%te,ve%8ia cKi,u,;ica3*
- Pacie%ta s* 4,e<i%te
te;u(e%te 7i (uc+ase
cu,ate 7i 4a%sa(e%te cu,at
a43icate
- Discut cu 4acie%ta J% ve-e,ea c+%7tie%ti<*,ii
u,(*t+a,e3+, teK%ici ce u,(ea<* s* i 3e a43ic
- E'ectuea<* t+a3eta 4a,8ia3* a 4acie%tei 3a 4at
- E'ectue< 4a%sa,ea 43*;ii +4e,at+,ii J% c+%-i8ii -e
ase4sie
Pacie%ta este cu,at* 7i se c+(4+,t* bi%e
cu 4,ivi,e 3a atitu-i%ea 'a8* -e J%;,i6i,i3e
i;ie%ice
CI Nev+ia -e a se a3i(e%ta 7i
Ki-,ata
D.I. Di'icu3tate -e a se a3i(e%ta
7i Ki-,ata
0 a3i(e%ta,e 7i + Ki-,ata,e
ca3itativ* 7i ca%titativ*
c+,es4u%<*t+a,e 3a + <i -u4*
i%te,ve%8ia cKi,u,;ica3*
P+,t -iscu8ii cu 4acie%ta 7i + J%cu,a6e< s* c+%su(
3icKi-e:
- ceai %eJ%-u3cit
- c+(4+t
- su4* -e <a,<avat
Pacie%ta a,e + t+3e,a%8* -i;estiv* bu%* 7i
este ecKi3ib,at* e(+8i+%a3
LI Nev+ia -e a e3i(i%a
D.I.Diu,e<* %+,(a3*
H1$FF(3D#L K I
",a%s4i,a8ii (+-e,ate
Re'u<* s* (ea,;* 3a t+a3et*
-i% tea(a -e a %u se -escKi-e
43a;a +4e,at+,ie
Re3ua,ea t,a%<itu3ui
i%testi%a3
- P+,t -ive,se -iscu8ii cu 4acie%ta 4e%t,u (i7ca,e
- A6ut 4acie%ta s* (ea,;* 3a t+a3et* 4e%t,u
satis'ace,ea %ev+ii
- 0bse,v 7i %+te< -iu,e<* J% 2.0.
- Pacie%ta a,e t,a%<it i%testi%a3 4e%t,u
;a<e
- U,i%ea<* %+,(a3 1$FF (3D#L K
- !cau% %+,(a3.
$I Nev+ia -e a -+,(i 7i a se
+-iK%i.
D.I.I%ca4acitatea -e a se
+-iK%i
- s+(% J%t,e,u4t
- -u,e,e
- -isc+%'+,t ab-+(i%a3
- Pacie%ta s* be%e'icie<e -e
u% s+(% e'icie%t ca3itativ 7i
ca%titativ su'icie%t
- Re-uce,ea -u,e,ii
C,ee< u% (e-iu a-ecvat:3i%i7te5 ate%ua,ea -u,e,ii5
asi;u,a,ea u%ei i;ie%e c+,4+,a3e c+,es4u%<*t+a,e.
Asi;u, 4acie%ta cu 3e%6e,ie -e c+,4 7i 4at cu,at* 7i
c+%'+,tabi3*.
"e(4e,atu,* 7i u(i-itate a-ecvate J% sa3+%.
P+<i8i+%e< 4acie%ta c1t (ai c+%'+,tabi3.
Ae,isesc sa3+%u3.
R+; 4acie%ta s* se ,e3a.e<e citi%- + ,evist* sau
4,ivi%- 3a te3evi<+,.
!tabi3esc cu 4acie%ta u% +,a, -e s+(% 7i +-iK%*.
A-(i%ist,e< 3a i%-ica8ia (e-icu3ui u% A3;+ca3(i%
IM H'.II J%ai%te -e cu3ca,e 4e%t,u a -i(i%ua -u,e,ea
7i 4e%t,u ca 4acie%ta s* aib* u% s+(% c1t (ai 3i%i7tit
Pacie%ta este (ai 3i%i7tit*5 a,e J%c,e-e,e J%
ecKi4a -e J%;,i6i,e 7i a -+,(it + +,a J%
ti(4u3 <i3ei.
=I Nev+ia -e a se J(b,*ca 7i
-e<b,*ca.
D.I. Di'icu3tate J% e'ectua,ea
(i7c*,i3+, %ecesa,e
J(b,*c*,ii 7i -etb,*c*,ii.
- Du,e,e
- A%.ietate
- M+bi3i<a,ea activ*.
- Ca3(a,ea -u,e,ii.
- I%-e4e%-e%8* J%
satis'ace,ea %ev+ii
- A6ut 4acie%ta s* se -e43ase<e 7i s* 'ac* -ive,se
e.e,ci8ii?
- Discut cu 4acie%ta 4e%t,u a 3ua + 4+<i8ie a-ecvat*
J% 4at?
- 0 'ac s* J%8e3ea;* c* i(+bi3itatea este + sta,e
t,ec*t+a,e 7i c* J% cu,1%- va 4utea ,e3ua (e,su3
%+,(a3?
- La i%-ica8ia (e-icu3ui a-(i%ist,e< a%tia3;ice.
Pacie%ta (e,;e ;,eu J% 4+<i8ia a43icat*5
(e%8i%1%-u-7i cu (1%a 43a;a +4e,at*.
EI Nev+ia -e a-7i (e%8i%e
te(4e,atu,a c+,4u3ui J%
3i(ite3e %+,(a3e.
D.I. Ai4e,te,(ie
- "e;u(e%te ,+7ii5 uscate 7i
ca3-e.
- A%.ietate
- 2eb,a -e ,es+,b8ie
- C+(bate,ea 'eb,ei 7i a
a%.iet*8ii.
Ae,isesc J%c*4e,ea5 -iscut cu 4acie%ta5 a43ic
c+(4,ese ,eci 4e ',u%te 4e%t,u a -i(i%ua 'eb,a.
Ca3cu3e< bi3a%8u3 i%;esta- e.c,eta 4e #L K.
A-(i%ist,e<5 3a i%-ica8ia (e-icu3ui5 (e-ica8ia
a%tite,(ic* 7i a%tii%'ec8i+as*: A3;+ca3(i% 'I IM 7i
,es4ectiv Pe%ici3i%a 1FFFFFF U.I. 3a = K.
2eb,a se (e%8i%e 3a CE5$FCH sub'eb,i3itate
I
>I Nev+ia -e a c+(u%ica.
D.I. C+(u%ica,e i%a-ecvat*
3a %ive3 a'ectiv.
Pacie%ta s*-7i e.4,i(e
%ev+i3e5 s* 4+at* c+(u%ica
e'icie%t 3a %ive3 a'ectiv.
P+,t -iscu8ii cu 4acie%ta 4e%t,u a t,ece -e aceast*
sta,e.
0 J%cu,a6e< s*-7i e.4,i(e e(+8ii3e sau %ev+i3e 7i s*
c+(u%ice cu cei -i% 6u,u3 s*u.
E.43ic 4acie%tei i(4+,ta%8a acu(u3*,ii -e %+i
cu%+7ti%8e J% ceea ce 4,ive7te a'ec8iu%ea sa.
0 a%t,e%e< J% -i'e,ite activit*8i H citit5 4,ivit 3a
te3evi<+,I ca,e s* Ji -ea se%ti(e%tu3 -e uti3itate.
P,ev*- i%t,eve-e,ea cu cei -,a;i.
0biectiv 4a,8ia3 ,ea3i<at.
Pacie%ta (a%i'est* i%te,es 4e%t,u a
c+(u%ica 7i a,e J%c,e-e,e J% ecKi4a -e
J%;,i6i,e 7i J% 4e,s+a%e3e a4,+4iate.
RAPORT DE PREDARE
ZIUA a" II a " !o#to!erator$e
La scKi(ba,ea tu,ei 4,e-au 4acie%ta C.P. cu sta,e ;e%e,a3* u7+, a3te,at* -at+,it* i%te,ve%8iei
cKi,u,;ica3e.
Pacie%ta 4,e<i%t*: - 'eb,* (+-e,at* CE5#
F
C.
- te;u(e%te 7i (uc+ase u7+, c+3+,ate?
- "A B 1#FDEF (( A;?
- AV B G# bD(i%
- R B 1> ,D(i%.
",ata(e%t (e-ica(e%t+s: - Pe%ici3i%*: 1FFFFFF U.I. 3a = +,e?
- A3;+ca3(i% '.I IM.
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RAP0R" DE PREDARE
ZIUA a- III a 4+st+4e,at+,ie
P,e-au 4acie%ta C.P. cu sta,e ;e%e,a3* bu%*5 a'eb,i3*.
Pacie%ta a,e t,a%<it i%testi%a3 4,e<e%t.
A( eva3uat 'u%c8ii3e vita3e: "A B 11$D=F (( A;.
AV B E> bD(i%.
R B 1> ,D(i%.
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F
B CE51
F
C.
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