VASILE BAGHIU

fat in psihologie

msiliere psihologicd

lelizare in terapia

ciholog clinician la

t

Dupa absolvirea in

9i a $colii Postliceale

a a\ut, pAna in 2008,

profesia de asistent

ani, in laboratorul de

l promovarea sdndt5tii

nai recent

-

^{intr-un spital}

bstlicealS Sanitarl din

o activitate de jurnalist,

nia, !v[6ius Wvendi,

r publicat numeroase

1a Medicald gi a realizat

fuataSii. De asemehea,

prelegeri, proiectul

oezie, o culegere de

Jtinr eri ^s mulu i ", _{pr ezent}

siat de burse de crealie

; gi are doi copii.

VASILE BAGHIU

TEORIA $I PRACTICA NURSING

Volumut IV

TEHNICI NURSING

$I ADMINISTRAREA MEDICAMENTEL OR

inregistrarea pacientului, igiena, prevenirea

escarelor,

mobilizarea, alimentalia,

sondaj e,

speHturi, clisme,

pansamentul, bandajul, recoltdri,

inj

ec{ii, perfuzia, transfuzia,

administrarea medicamentelor, diagnostice nursing NANDA-I

care

pot fi

asociate

tehnicilor

llf ^{Ca rtea}

ry Medicati

=:= \1:Jrcala

]

I

:'r: lnreglstra- l^j

elimentalia,'

n. ^r nJ ectlt! II

rostice nursing ]

::..:r.ale,

I

I

I

Mullumiri

t din lucrarea _{,,Tboria Si}

t mele cdtorva persoane.

mu-Schulman _Si solului

tfeite pe toatd perioada

lin SUA a unor manuale

ird

de care actualizarea

,ici nu arfifost posibild.

dd,

care mi-au publicctt

tdinea mea se tndreaptd

leles importanla acestr,ti

plaboratorilor _{sdi de la}

le la $coala Postliceald

fulelepciunea, rdb darect

ne a

ingrijirilor

nursing

lionale NANDA-I, afiatd

i in mediile profesionale

ecialitate din lard, ^care

'vi in Scolile ^lo4 precum

interesul ariitat acestor

n lor la clasd, _{tn Scoala}

i

^vohtm tnaiicte de tipar

d, le sunt reutnoascdtor

lefan, precum _Ei tntregii

d ,-edea intplicat intr-un

urd. Cu atat mai mult le

care

iji

duce ctt greu la

es din partea celorlaltri.

stui efort de actualiza:re

tant,

hgrij

irile nursing.

Vasile Baghiu

CUPRINS

PrefaJd. Despre structura gi conlinutul acestei

car{i...

...11

CAPITOLUL I TEHNICI NURSING I.1. Tehnici de evidenfi ^qi miqcare a

bolnavilor.

...19

Ll.1.Internarea...

...19

I.1.2. E,xternarea

...

..-...22

I.1.3.

Transt-eru1...

...23

t.l.4.Aspecteprivindingrijireapacientilorinstadiutenainal ^qidecesul ...25

I.2. Tehnici pentru asigurarea igienei qi confortului pacientuIui...31

I.2.1. Efectuarea toaletei pe regiuni a bolnavuh-ri imobilizat/ incongtient...3l 1.2.2. ingnjirea ochilor, mucoasei nazale^ urechilor. cavitdlii bucale, unghiilor,

parului...

...-.35

1.2.2.a. ingrijirea

ochilor

...35

1.2.2.b. ingrijirea mucoasei nazale

...

^...37

1.2..2.c. ingrijiLea

urechilor

^...38

1.2.2.d. ingrijirea cavitAtrii bucale

...

...40

L2.2.e. ingrijirea

pdrului

...43

1.2.3. Baia,i

Du9u1...

...45

L2.4. Captarea dejecliilor la

pat...

...,18

1.2.4.a. Captarea urinei

...

...,...48

oEursq 'scrtulqcolq gsearslioceu'I'I'II,

rpQrd Earullocau'I'II

nsEl\.p'I'9'1

lJre

esmrsuel)

rrunrserd ES

E

i:1sEtr{'r'I's'I

ul t rnFSInd

B

rnsEl{ 'q'

I's'I

run-]eredurel

E

il

9

88""""""""'

"

"""'

.,\llpleEer

eleir.l :olrrioun-1 lS

ernleledruel e

ep

€reo1 ur goge.r8 e:leluaze.rda.r

ee.rels-rclrellrr rS

,eelelou .eoJeJllser\

.[.S.J

88""""""""'

IorluoJ ri arunlu,lo

rJIuqaI op

.S.I

98"":""""""

:unpecorcl else3e nf,

p.urlp8e1

ur nus lndrurl

ur ojuor1rluepl

tod U

eluc I_VC1\IV51 Burs:nu

ecrlsou8erq .y.y.1

29...

... ...0re1u0lur1u eir.rnuir3e6.g.;.1

08""""""""'

p1e:e1ueled Elerrgrg€ erieluerurly

.q.Z.t.l

81.""""""'':"

elelotlto pll?trurul?

erielueurrly .e.2.r.1

8/""""""""'

qletcglilB erie1uaurr1y.7.7.1

9L""""""""'

g,r.rsed e1e:n1uu

urfelueurly

I.V.I .c.

IL"''

'"""""'

g^rlru qlernluu uriulueurlv.q.

I.r.I

9L...

alereua3 elcadsy.e.

I.r.t

9L..,...

.. .

. ..

BIEmleuerielueurrly.l.y.l

9L"

"""""""

rnlnAuuloq elieluauue

pulrprd lrluqol

.r.l

0L""""""""'

"""

inpuuorred lnpodsuerl

.q.V.L.I

89""""

""""

"'

rnlnluerced eolezrlrqol

.e.f J

t.I

eerezi1tqo1,u rS Inilodsuurl rnlnluerced

89""""""""'

.y.g.1

99""""""""'

"""'llqncep toltriucrldruor ap e

role.rgJso ealrue.,\ald nes

.r.f.I

S9""""""""

.'....'...(pcluourouSoled /Eieiro;

,prrsed

'q'rr1cu) ied ur mln,reuloq rerfrzod

ee-re^rosqo is rrlerd ,rl.1cedsu eaJ,nre^g

.z.E.J

""""""""

t9

"""

'...

cleioLro8 elccdsy .lrqnrap

eltunrza_I op

I.E.l

,9""""""""'

...1r8un1a.rd InlrqnJop

ap

alu8a1 giucJldruoJ

roun uerrue,lard

nrluad

lJIuq{

.t.I

29"""""""

""""

mlt\euloq rupls r:rdrrsu rerueiqlnJ ololceJE .9.2.I

9S"" "'

e1 ted

llzrlrqour

rnlntueroud

d:oc r-l

ep reualuey uerequrrr{Js .J.S.Z.I

SS""""""

".'...

lezrlrqour .

lnluercrd 1ed nc ep rerraluel

eerequrqrs

q.g.Z.l

t9"

"""""""

luerced '

ted ep prg

reueluel eerequtqrs

.e.g.Z.l

tE""

""" ""

dloc ep 1ed rS

ep rar:elue1 BoleqLurqrs .g.Z.l

29...

.... ...

lolrfiuEs;e,r uerulde3 .p.r.e.I

I9...

relnds eo;clde

).c.t.z.I

6F...,...

eleceJ.rolrrreleu uerrlciu3 .q.r.a.l

49 51

I.5. 1.a. \lisularea. notarea" intcrpletarea qi reprczentat.ca crafi

ci

a temperaturii in foaia de

temperaturd...

...88

I.5.1 .b. N{Isurarea. uotarca. intcrfretarea gi reprczcntar-ea graficii a pulsului in foaia dc tcrnperatlrri ...

...

...93

1.5. 1.c. N{dsurarea. ltotarea. itterpletarea gi reprezentar-ea grafi

ci

a presir-rnii sdngelr"ri in loaia de temperatura (tensiunea arteriall - T.A.)

...

...91

I.5. 1.d. Mdsurarea. 1lotarea, interpreiarea gi reprezentarea graficd a respiraliei in foaia de ten.rperatur6

...

...101

I.5.2. Observarea gi notarea elimindrilor patologice: expectoralia.

vdrsdturi1e....

...105

1.5.2.b.

Virsdturile....

...106

I.6. Sondaje,

spilituri, clisme

...109

I.6.1. Sondajul gastric

aspilatir,...

...109

I.6.2. Spdl5tura

gastric5....

...113

I.6.3. Sondajul vezical la femeie gi

barbat...

...117

I.6.4.

Spdldruravezicald

...121

I.6.5. Clisma

evacuatoare...,...

...124

I.7. Pansamente,

bandaje

...130

1.7.1. Pansarnentul

...

...130

1.7.2.

Bandajul...

...135

CAPITOLI'I,II

INVESTIGATII NURSING Ir.1. Recoltarea produselor bio-patologice pentru examene de labor:ator....14l II.1.1. Recoltarea sdngelui prin punc]ie venoas6 pentru examene biochimice, hematologice, serologice; bacteriologice ... - ^{:-.,, .} -:lui in pat (activi, . '.,, ' '... '...65

' _.

...65

...68

'7< '..',.,....,...,...] 5

...7 5 ..,,.'...,...75

'',

.,,..,,..,..,...'..]6

. ...78

...;...78

...80

:.: il

tirnpul sar.r in ...85

...88

:

.:crr in lbaia

o+

o4

68 10

82

88

.:..i1;ur

ot€oj'9AJ ep

irtrs:nu :op:1ft:iu1

t-..:

.i:llri

9lsl.l'9Al nJ

l-,:rs:nu.roplli$u1

:

,raillo n) .

Plsrl f AI

.

- --

-'r'r-'lJos€

lori u

c-lEJ

r:

-.:irp

!1sI-1 11J

'I Al

-:. '-

r.-.: a:ezt1t1n nlluacl

j

-,.,..,1 .

epi'elsrl 'a',\l eluiumuep Is ecglceds

prqsou8elP Bisl'I 'I AI

8

ZOZ"""'""""

""

BrduotoueEyg'7'9:111

I02""""""""

"""""""'erlelettul

'l'g'Itl

102...:..'.'.

.'...-...

IlrolBJldser

roM,

lasEoJnru BlBJBrdns ad

rolaluaururJparu BarBJlsluppv'g'IJJ

g6I""""

redcafui

€cruqel'undocs'e{tugep :('6'1) gcnurepu4ut edcalul

'S'S'ru

""""'

961

ledcefur ecruqel 'r:ndocs

'e[Iugep :('3'g) pleuancqns

udcelul 'r'S'm

161""

rerfcetur Ecruqel'rrndocs 'edlugep

:('ry'f

p.reyncr.rurr*, erfcelul 'g'g'III

99I"""""""'

purn8ues Blzrgsuer1 punud.pzeq

sp eredag

'q'I'S'm

g S

" I

" "

"

".'

" "

"

"

" "

"'

?suouelu4ul utzry:ed

put,,r gze ud

aradeg' qep

e' Z'

ll1

g'

gg1""""'rerfcefur zcruqal'undocs 'adrugep

:(1'1) gseouelurlut

etlcelul'Z'9'III

0gI''"""""""""""""'pluroluaJed

apc JolaluaruuJlpe- ad

,rrurlslrprpv'S'11I

g1I"""""""'

"'

EIBroelucedrolaluoruualperuEarurlsluluipv'l'rrr

9L1""""""

luqds Jolaluaruut.Ipeu ug

FllntJ.rc .oluauruclpaur

ErIpuoJ ap

'g'III

stI"""""".''

"""""""'ElBuElncsuErl eJs4slurups

eelB] 'g'z'm ap

tLl''""""""'

"""""""""

plere1ue;ed ere4srurup€

ep Bal€3

'Z'Z'II

2L1"""""""'

"

plEraluo eJB4smrrups

eeluc ep

'I'z'm

ZLl""""""aturlslulrupu

IIfc ep

u a.ra8alu

IIralIrJ ap

5a.rurls.rulrupB ep

Igf,'ZTII

I 0L

" "

""

"',"'

Joletueruecrper.u BeJ€4sru[xpe

gzeq ep uJ

eppEell'

l' z'

ilI

691"""""""""""""""""

'

"""""rololuarrrErJperu

oJErlsIuFupB u

3p

epreuaS.qn8ar

.qro1;ugep ;3

aluetualg 'I'I11

UO'IXI\ISNYf, IOSNI VEUYUISINII,\I(IY

III TNTOIIdYJ

y91"""""""'

JollJnlpsJB^

BaJulloJau'z'JI

99I""""""""

"""

g8eld urp eluelnrnd

rolriie;ces pelelloce5

'g'l'II

891"""""""

"'ctSolot:aiceq'cr8o1o1rc

rrerrexo rurluad tolr-rds

eerellocer luur8uue3 rnlnlepnsxe Be"relloce5

't'I'II

2SI"""""""".""" '

loleloqel

ep

"""""""

291

erreurexe mluod

e1ece1 tolrr.rElpLlr

eelu1looe6

'['l'lI

LbI"""""""'

roluroqelcpJrroluexen-rluedraur;neo]Bllocc5'Z'I'JJ

...t41

...152

...152

:'

:t3:iru cxallen ... 1 63

ILOR

--: .... ...170

dministrare. ...,...172

...t72 ...t] 5 or in spital ...116

...1 78 8... 1 80 ...180

hica injecliei... 1 83 lse... I 85 i--... I 88 , tehnica injec{iei .... 191

hica injec1iei ... I 95 fuica injecliei ... I 98 a.sei .15 8 111.6.3.

Instila1ia...

...".20.+ 1II.6.4. Aerosoloterapia,'

ncbuli2arca... .

... ...207

III.7. Administrarea medicamentelor pe suprafafa tegurnentelor gi

mucoaselor...

...210

I11.7.1.Administrareatledicar.nentelot'petequmente

...210

111.1 .2. Adilinistrarea rledicamentelor pe lrucoasa conjuctival6 ...212

III.8. Administrarea antibioticelor ^qi chimioterapicelor, dozarea medicamentului, verificarea sensibiliti(ii organismului. et'ifarea incompatibilitl{ilor qi a reacfiilor

adverse

...216

Ill.E.l. Aspccte

generale...

...216

i11.8.2. Chimioterapicele

...

...218

111.8.3.

Antibioticele

...220

III.9. Administrarea

insulinei...

....223

III.10. Administrarea medicamentelor pe cale

rectali

...226

III.lt.

Diagnostice nursing NANDA-I care pot fi asociate administrlrii

medicamentelor...

...228

CAPITOLUL IV ANEXE

I\l

¹ . Lista diagnosticelor NANDA-I. pe domenii gi clase, cu codurile specifice ^gi denumirile originale in linrba

en-ele2a...

...23 1 IY2. Lista,,de lucm" (scurtd) a diagnosticelor NANDA-I, pe domenii ;i ^clase. Ircntru utilizare eficienti in procesul didactic gi in

practica.

...215

IV.3. Lista cu diagnostice nursing NANDA-I care pot fi asociate unor diagnostice

clinice

...251

IV..i. Listd cu obiective nursing standard (NOC) fiecvent intalnitc in practicu ingrijirilor

nursing...

...253

1\'.5. Listd cu intcnentii nursing standard (NOC) freo,ent intahiitc in practice ingrijirilor

nursing...

... . ...266

I\.6. Foaie de ingrijiri nursing (nrodcl

orierrtatir,)....

...269 .201

.201 164

169

i

OI

YCNVN InlnrlolslS

i..uecr-reury quoN" trIYCNVN'lluo^ep

lEp 11

',.luuoIlelr1eluJ

E elss I-VONVNT

'Sutsrnu

rrrr

€eJd OleJolBp

-F0ine

ESIJCS ep Ernlerolll o elsp

rupe e

Suts.rnu tS

nB IJpJsnI A I01Se3€

orord ul rol

1VPZI1

ed P3ec ns

isfo'YiYlsUd

v8z' E8Z'

"' "' 9LC

"' (a;ulrues eluecrllsocl

erft.r8ur

ElullnsrroJ ogrrSorlqrg

rilnpe

!,rnl"-,roclurcl op

erlo4

Ai g

.ur 1r1or S

r,u1a n-rluccl,\ r

rtEtu-r r.to loporu

)

uuld cp

,8urs.rnu r.ull-riirr

iluoj

3p

,1I

'l

:.

.-..: -it iltscuqie ori de

- ,- -rlnclrirr.

irrclrr>ii

Yasile

BAGHIU

CAPITOLUL I

TEHNICI NURSING

t7

8I

pIEaH suDlllll\ T' surElTlI^A

rd ;ulslnN

s.llocuddI'Lr

i:,iu1ep

iuoum3op -

..rld

lueutedlqce - ap

alPSJJau JIBIJJlul/,t l.rcloqeloc nrlued ee]

]rjeoJ IcIu'gleleSexe

:

qle.1

utiuely

:

ri

atep ep tr.re8elnc

ea:ern8rsy ui

:':':.1:IEIU

CaJUlop - llJ

\ud

:-1

l.lJ

ealllulsul -

l:zeld

.;-

ue-tenlJaJJ -

:r.--,\LIoJ eo:ernStse

-

',lill1els ::1

I?3JenlEA3

-

-;.lruapl

eoJBJUIJ0A -

sra:t1eltds €o]€]run

ul

';ierrperu :

piueS.rn ec

'rEp iusJeJlpul aluraua8 alcadsY

EarBuralul'I'I'I UO]IAYI{TOfl Y

(I f

IfII{Hf,I'I'I

Inserap

1uu1urra1 15

nrpuls

rogfualcrd

ug

uarlfir8q .r.I.I

lnrngrurrj

.g.1.1

Baruuralxg

'z'I.I

uarBurolul

'I'I.I

uofr^VNfos

v _.I.r ^{rf,n{Hur s(I} yluual^g ^rs suyf,srr,{

,(

decesul

I.1. TEHNICI DE EVIDENTA $I MI$CARE

A BOLNAVILOR

I.1.1. Internarea

.\specte generale

Indiferent

daci

internarea se face conform unei programdri sau

ca urgen!6 medicali, procedurile

il

pregdtesc pe pacient pentru gederea

in unitatea spitaliceasci

qi

prestipun respectarea cAtorva paqi:

- verificarea identitdfii pacienrului de chtre cel pu{in doud persoane,

- evaluarea statusulLli pacientului din punct de vedere

clinic;

- asigurarea confortului minim;

- efecluarea

prezentirilor in

salon gi cu membrii stafului;

- instruirea cu

privire

la mediul spitaiicesc _Ai reguli;

- clotarea cu materiaiele necesare

ingrijilii

zilnice.

Asigurarea

intimitaliipacientului

gi a confldenJialita{ii in timpul

.-Lrlegelii de date gi zr

interviului

este obligatorie.

Atenlia

fa15 de pacient aritatd

intr-o

manierd profesionala

(nici

-'\aeeratd.

nici

foarte tehnicd) reduce anxietatea gi creqte disponibilita-

:.-r pentru colaborare. ^{I I}

\lateriale

necesare

- -':hipament ^de proteclie (halat,

minugi

etc.);

- .loCulrert de inregistrare a bunurilor personale;

Lippincott's Nursing Procedtres,

6

edition: Philadelphia

:

Wolrers Klurver/Lippincott

,'illiams & Wilkins Health, [2013]

t9

(tLra21

"'.rlr.5'

DA'tDl))fF: (.iirtt

-.,t^t))lb

'

al

):-t1!

..

-;,)i!it)

ap ?sd!7

:

:

.'::)lt(J

'(){100

'f .i1tD.rry

-

:1!)!JaL)

..)!ap

a.ILn-Jias

-,':i'l;.1

-

nalnl)al'f

,

,.:.ir.tQ) 1'

psCt7 a1t

, -

r .,

)t'))

AlDlatruf'

$L1a)D

il)

t!.Ultpaal

t t

\.r

t

tt 1

)llso ltgDtQ a

...

.,i\lEtls!J ..

u3J{u

'---

ir --

lLrlUOtCCd

r

-

:'-'

.:

rr-l1u3d 1et,-tacls

I

l!.,1 i,3 ilULIaIJed

- :I11l1131p3rli

-..

-s

ir -

\ Ilurlsll€d

-

:qJlLUeulporll

"-,',:r.td ad ut-id

arer

--:. '

r-.:al ESIELLIS]UI -

11iu

uasqg

AZ

'uorss,.unro, ]uro[

erlJ :-JI ,a3er-r3l Ioo.rq{uo?oo qpu,t1

lott{{,

ary1 .s1o1tdsot1

;t,r:r::rt,

-.kt'ozl pr€puels I..CSdN '10'I0 artsuauatdtuct3 uaTtoJtpa.D)D

.,io,..ior*o3

trurof

rrlJ.r .or€curruapr rriue,ualur ariecnpe ep n4uad acglceds ol'rErrps ^{11iog 1s} 'I'r9nre^o

I-voNYN

Suts-mu actlsou3elp^'rrfu8tlseaur rs

ezrluue 'aruoldurrs rs euruss

,e1u,os.,acl

eialep exeuylrl0lrdec,1,-, eleod g r,lrllsuol Ieporu un op ereoJ" ^{ap rrrr.rSur} rcr:qru nc,,3urs:nu ^n:1uad

:pip.+e Lrrp

alolrzr,t

ostLLrJad

luns eju3

Ltr lnlnlc.\.1-11

e

-ur

'eleJrpalu r.,drll3e .rololrzr,\'iolelUaurecrperu

rupjrsrrlrLupr? .lesaur

r11[11J8-rO

'rorices U

pJruIrz elrr]ru 1]

srr,rr:cl e1

rnllliuorCEd r13

e3.rrl.ljlsur

_

:]eutI.rInir

3p rnlnLucrsrs

e rs ,rlIrluoJale]

B 'JOZr^ole]

nlruod reloJ

.red e

ruJued riz

-usruoJelar

'efueSrn op u

,ienrrs

reun e s.iuleuiuos ep

rnlnuolnq

AisnlJ u

-Lrr 'uo[1]s Lrrp rrJnreJedu

earcztyln

e]Itr.rd e1

l]J

rl1lli]uerced

ea;rn-r1sur

_

irrrurilpui

,ig1,e-r8 1s

'ererr^ ore

rolricunl

ue:e:isr8e.rur rs eeJeJnspur -

ilateleot ue:eseldme

e.'r,tr.rd e1

nJ rnlnluor3ed eemr:1sur

-

:rrjp}tunlur eoJ€Jn8rse rs

raleruelid eeJeceJqurr

ui

rl1ll1luarced earulsrse

_

:eJBrtullluoc nrlued

lrqruodstpu r,se:1s

slels 3p

ur 0q nu

lnluercud es

BrirpuoJ EJ

r-rc

,,rolueluazercl ee,renlJoJo

_

:LrolES

.

lt[

nrlnluarred ee-ujosul

_

llelc

.eurnu

,aia1rlod ad

nc luarced oJlp3 BoJesetp€

_

iii-rpcrlsor-r3'rp er,Sa,ou ejsa]

rrie8rtsa.rur rs

rulued:o[rierrpui

u

rs

Elorp nes e3r€rr,\rlce

pur,tud rolrrjculser

e 'rrJet're1ni

Jole^r]our s.,re]ou -

Irnlncrperu :ollriducsard

eprde: e

earprrlrJol

_

.,laueosred pnop uiind

Ieo eJlec ep rnllquoroecl

ea:ecgrluopt

_

:lolturglu euet8r

_

BJnpaJoJd

.doso;d ,Jeuun ,ro1un1esrp.t

e e,rplJaloJ

sel

op

:leluerurJdng :11jl0trlor[ta]

_

lruqeruorsuel

_

ldocsolals

_

,,1(lueruncop tsoJu lelueureldrur ne

a1e1u1rds

glep

's1r:tltttt ,tololup eale8elno rutued

lJuqnJ

uc) Buts:nu r-rrlu8ur ep

leoJ e _

:('c1e

erie,uasqo op eruoJ 'rr-rlsrBe;)

r,pruarur

e

elu,risr8a.i[,

op o]ueLullJop

-

:.-- .

--,lte de obsen,alie

::.::erea

_{dateior rni1iale,}

r:-.-r-l-. LrrOSOp.

,--, '-.,'LSOane;lr

....

rltir

itatea _{sau clieta}

,:

^:-'

tiii

gt-losticarii

; .-t--:

-:-. :i

^nu fie

in

stare de

-.

-Limrca intirnitagii:

. - .:, iIr'll

:-r.-:r:alii si

in5lfimii;

:t:t'.:tltiii

dirr saion. irr-

:

,-:s:nfa. a telecomen_

.-....r

;i

a sistemr:lui _de

: -,

"

secliei, a orarului

:-. ':'--i nredicllc. a

irr-

_.:.ri.rg" cu ntbrici pcutrL:

-

^.:.i.. r'u-rrsing NAir-if.\-l

. , -: i::li l.

..:,t,t,,.,,l..r.tti,tt

, r.... Joint Ci.lrtllission.

-

ob[inerea Llnui s]lmar al antecedentelori istoricului pacientului (inter-

ndri, alte afec{iuni. alergii.

restriclii

de dieta);

-

asigurarea

c[ lista cornpleti

a medicamentelor

(cu

doze 5i orar) ^pe

care pacientul le-a luat

pini

la inten-iare este scdsd

in

documentele de

internare

;i

cunoscr-rtii de medic 5i echipa ^de

ingrijire.

- evaluarea duredi;

- ieiena mdinilor;

- inregistrarea datelor rimase neinregistrate.

Observafii

- intemarea pacienftilui in situa{ie de

urgenl[

solicitd procedud speciale

care pun pe

primul

plan rnenlinerea

firnc{iilor

vitale qi stabilizarea he-

nrodinantici:

- pacientul va

fi

instruit sd nu mai ia niciun medicament

lIrd

consultarea

meclicului;

- pacientul cu dsc de transmitere ^a

infecliilor

va

fl

instalat intr-un salon

special pentru izolare;

- pacientr-rl va

fi instmit

sa aibd

in

vedere igiena mAinilor pentm preve-

nirea rispAndiri

i

infec{iiior.

Diugnostice nursing

hANDA-I

care

potJi

identificate in

timpul

sau in

legiiturd

cu oceustii procedurrt:

.*txietate

⁽⁰⁰ I 46. Anriery,)

Lipsa de cooperare (00079 ; ),loncontplitutce)';

Jfbc:ttrreu c'upac'ittiyii cle tuLto^ittgrijire:

sprilotul - 00108.

^Bathing

:el[-6rr,', cle;t'icit; imbrocatul/ clezbritccrtul

-

00109: Dressirtg self-g,,r'.

rlefic:it; ltt'cinireo

-

00102: F'eecling self-c:ure tle.fic:it:.fblosireu tocLletei -

i )t') I I ^{)

:

Tti letittg sclf-c'a re deficit)

Lipti

tle (Ltno.lrin{e ⁽⁰⁰ I 26." Deficient ltnov,ledge)

R i'c tle slec'trn't' o

durutilit{ii

^{(00174: Rislt}

/br

contprontiset{ ltntrrut tiig-

,,il.t ₎

iit'L:tttt'e

o

sliutt'i cle .;inc; ,sitLtctyiottul (00120. Situcrtiottul

/otr

.-tg/7-g,;-

'- _{t'itl )}

2t

n{e

u1 1e1rds

un-4utp

ed 1rue;sue;1 a1u;aua8

alcadsy

lnraJsuuJl'g'I:I

ptunlon iI

Frzor

un

yynrrfta

t4

aruap n4aad

:ploN

(ttotqot

urrlutlwo) oatolta{y

atugsounc ap y

psdl7

vy:gf

t7il

arupffuY

qgsoaco f nc

pn4p&al

'talstnu

acpsoaSolq

ea

:(rjp}'lrqrsod luus

lnzuc rs

elsa pcep)oJrloJ

l1J LrneJS rl-lun EeJeJllirse

-

:(ll.LzcJ elsa pcep) rnlnpodsuu;1ee.re;n8rse

_

irolsiuauucrparil rnlnJu:o

is u

ose-ro^p€

lololcoJe ,-rolundocs uarecridxe

-

iereuralxe pdnp

,ip,,rrlJe

ore

ecrielerp rs

rola-rader ee-reJrurlLrroJ -

inrlrcrruop el ep-rri,Bur

err,trrcr u1

nc

rnJnJLicr3ecr es.,rn;1sur

-

:rz eJeoeg

ep eles rrier,t e;dns€

lJ etB

eJec ad

lnlcedur

nc rs es eluoq

no grn1g3e1

rerlrluul uJ

e rs rnlnluerced

ee_recnpe

-

:0p11[JUr 8A aJBUJO]XO

[nuBId ap

tOZ (S

'sernpero;4 Eursrn5l s,11ocurdct1)

.1e1rcls ur

eeJerlur el

Jerqc 0p

'nJurriolur lnsrnc.led

od 10i

sue^e BeJesurueld ur eund

-nse:d elseece

'purlru ep ptnpaco:d o

eise BeJeruolxo pJ€p J€rLIJ

Barauralxg.z.yl

iI

lnw,tlo^ _ul

_J

ltl,t

^tt.lourl

a$a)n aqulp

ac1\sottn\t7t n '8uts"Utu ^{as Dapa|}

l,,tnnp)ta

tS rufuad,taltn

(auparqo ,ptn-gE4

,n.to1rug[ap

aruawap nquad

.:ptoN ^(LtollDJ

-tutlLltluo)

lDqral

pa.tlnduJ

I9000

:

apqra^

trrDJttnlLuot oa.rnltalV

(ssautpuol tol:1s1y

.tg000

aytlntn7uts

)sly

ap

otut Q,r

t

o p a.n

duJ n

t

t

d

e 0

p

tu

a q t

rut)

; rt t

n 1

olu I.t

t

o

an4 t n

aly

(ttot1ca./irt

.to!t1sty

.t000il

allcaJul

ap rsly

(.ttD.t

lu0)

:gt

t),.t!.t!

(auo.tptris

ssa4s uottLDop.t,ro!-;1s1y

:6t

1017

ttrD)ola,t lD sarls ap

Luo.tllutt-

)stA ap

(dtqsuct

-ltDPr a,u1n{[aut

.ro.{t1s1y :6e

ay)t)os

e7o

.ro7rrin1a.r

,

a.tnlta{o

ap

rslu (sas

-sa:otd iQttuntlnuotl:;un{siq

:€g000

p111un/

11f12ttlouotl:tutt/.r.ta.rr4ta.fV

(8uluatod patruduJ

;gg00(,

a1ut.rod g!'o

4Jp111tqo oa.nt7ca.f1,, ap

(tu at a -.fi s,a

s a

ilo I

D I Lt

-otlDtuts to.{:1s7y

:tSI00)

psuot)uttlts;atns ap ratlilts u

a.u.4ca.[a

)s!A ap

.

.'-'

?.r,,./br sitttcttio-

-;.,'-- .; :. :; i'et ttittg)

' :,,. - ^{.. t, t t} t ^I _.f ctntily proces-

.:

-

:,,i' inef/bctit'e relctti-

)-.:

-

^ti-,,t' reloccttion slress

bed comfort)

').

uircd verbal

communi-

obiective,

intervenlii

_Si

fice

narsing,

a se veelea

l,e rutind, aceasta presu-

rilrii,

chiar de la intrarea

3)

. :,..rla sa gi cLr impacful

--,:lici1ir-i;

.: .:,rpir externale;

-, :--.. u i u'r ecli camentelor;

- ..rrr posibilirili

_r:

-

of-erirea unui

bilet

de iegire

;i

^{a aitor} docnrnente car.e

si

inclLrdi lista

cu medicamente gi recornandarile;

- o sacogi in care pacientul sa-gi

prml

lucnrrile personale.

Procedura

- r,erificarea dispoziliei scrise de externare gi a rnedica{iei prescrise;

- infomiarea pacientului

;i

^{a fanriliei}

^privind

data exactd a externdrii;

- igiena mAinilor;

- confirmarea identitSlii pacientului _de

c[tre

cel

pulin

doud persoane;

- instluirea pacientului gi a

lamiliei

cu

privire

la

ingrijirile,

medicafia qi

precaufiile _{care \,or}

Ii

avute in vedere la

domiciliu;

-

instruirea pacientului cu

privire la

viitoare programdri gi consultalii

de verificale;

- inapoierea bunurilor pacientului dupd ver-ificarea lor;

- sprijinirea pacientului in imbrdcarea hainelon

- _igiena mdinilor;

- inregistrarea

extemlrii.

Diagnostice nursing

NANDA-I

cure

potfi

identificate _tn timpul sau tn

legiturd

cu aceastd pr.ocedurd

.1rxietate ⁽⁰⁰ I 46 : Anxiet1,)

Lipsd de cunoStitlte rc7126; Deficient knoy,ledge)

1lbctarea

comunicdrii

v-erbale

(00051; Intpairecl verbal

conurturti-

.rtiorr)

\otd: Pentru

elemente

definitorii, PES-uri,

obiective,

intert,enlii

_$i

evolniiri tn

cazul unora clintre qceste tliagnostice nursing, a se tedea

volumul

I!

I.1.3. Transferul

\specte generale

Transfenrl pacientnhii dintr-o seclie in alta a aceluiagi spital sau

*rntr-un _spital in altul presupune minime pregdtiri qi o atenta verificare

/_J

lurl

' :

'eriE.ildsuc.ll

-

7Ues

-

eJlullulltllp

-

-

:

t'][]E.t; BeJJpEJS

-

:'.

..JrrrJl _..

r?alapEJs -

:,'\Jl{ :.

Ba.lJpE)s -

1.-ll'ncs :..

eolopEJs -

^.-.:

r'i.U

eejeJnPPJ -

j

,:

.!

alsulues

',\ISUeluI IEUo

::'-_'.r iltlLteIJBd

alE.IauaS JlJads\-

nsaJap Is

lBultural

\rrd

alradsY't'I'I

I

;

ltltttttlo

\

0tfit ltl:D)

ttt t'tpttlll

r'1

u -)

tttlla n4udd

:t)|0.\

/lr, -'

/ )r."- ..,

_--

-.' .

) 1').':'- r

-'

bZ

1r,ta1) (1

'Lrorssrutlro3 lurol 3rll.

'rcelal :1J

{oo.rqIEO Jooqpuntl 1nny'Jb

at1,1 :s1o7rt.lsoL1 .ro/

lDnuDtu uottDtlp).t))D

a,usuatlatdtuo,l'10

t0 Jd 10

plupu?ls '(71g;)

uorssrruLuoJ turof eqJ!r

lt

t 0Z 'ut1o'11 i sul{llA\

'T s..poturddrlr, Surs-rn1 9 'sa:npeco.16 :oourpr :erqd1epe1rq4 sretlo,\\ suurlllA\ ItorrnddrlT:a,u.n1y

(ttotlat

-tutTtttLtto) r)q.La,t

palndLuJ

:15000.) alDQrat

lLtD)tut'tltLo)

Da,LDDatb,

(a7pa1nou:1 tuaDll[ag

t00) a]u4lount

.ge

psdlT ap

(ftaxuV 9t11il

atDtaD{uy

:t)Jnpilo,td

D$Da)D

n)

DJnuSal

ut

lndwll

nDS

aru)Uiaary u!

{pd

atD I-yOAlvN

Stnstnu

a)USouSmO

'Jolrureur €uer8r -

l(elerp'inlueurele:]

purArJd rrineJald

'rnlnluerced

elelqups IB

InsUels 'ero ep

'e1ep) rn[[rajsueJ]

eaJe,rtsr8aJur -

:1nla1sue;1 cJeJ cs eJEc

rorices InJels rrr

31183

rnlnluorsBd eaJeluczcld -

iluruelur

qs oU

pzeouun Inluorred

epun BcsBeJrlelrds eal€lrun nes

erhes eJlgJ rniruaJSUEJ]

esJecrunruoc -

ilea,copu liodsueJ] ap

colftut

un

tuulru uneJs rS

rrn

e.rese33u ]ul]s Ecep oprJop

lullrsd e

rnlnlLior3Ed e oJVrJ

rr-rgls Be-ienle^a

-

( i

1r rer

ure3

rnlnluarced) rnln:agslrerl rS

role,\rlour Bo,rectldxc

-

isueos-ied gnop urind

e-r]gc Iec

ep rninluarJud rriglquepr BoJsurJguoJ

-

l.rolrureur euatAr -

BJnp0JoJd

'Jasac0u alsa Etep 'elrloJ

n3

LurBcs -

lrnlnluciced alr-rnJJnl

nJ

BlLrBoB nes eSoJus -

icrparu

p1€uruos ap

glepueruocer rS

eleie-r -

:rnlnluercud pugurj-rede,rolurlrcnl InJeluaAur

-

aJusaJau olErJJlBI{l

qr'JOIOLU-rOLr EeJelcadsaJ

nJ B-rnlqSal

ui

rnlnlBuoslad Bricolo-td

rs -roir.r

-rlr.r8Lri rriqynurluoJ

EJ;uJn8rsu nJluod

'o.rrlr't8ur cp Inuelcl

rnlnlucr:ud rS

Ee-rsls EI eJr,\rJd

llur]siJBd

nJ

1e:e.1suu,rl

qs ag

EZEOr.rrJn

epun rnlnlEtrds

rJriJes nBS

lnyurios;acl nc eiincsrp o

e.lusecou oJSe 'earreurasn oO

|

'ntllt.rajSLto_t |

l

J1a.\rloLrr acrlclxa

ti

as

3rnq3,r1 ES

retilrLrtsJ ts rnlnlnarcr?d

"rolelusLLrrltop

B

0t,' r,rt

-rlrgtdy

ap{lil

{gnwdot

Da-orte

,,

r se

erltlice

lll0tiYele

-.

r;r.>LtItillLr1 sec{ier sau

.... --. privire la

starca

r,.:

, -:trillLritaiii in_rrif

i-

- -..:. -ai nOrntelOr.r5

:

--:.:t

doui

persoane;

,-.-,::tiliei);

:.::

caca sunt necesare

:1.

,::.

sltitaliceasci _unde

: - ^-.'luce

trartslcrul:

: r: --,:.rlu- al pacientuiui.

i.fitilte in timpul sau

in

"..,'

^.,

et'bol

conununi-

. ', ..

r:i

Lrppincott\\'illiams

"

- .;.irlissicn. (Levcl I)

llec'tat'eo capat'ita{ii

cle

otio-ittgrijire:

spdlatLtl

-

0A108: Bathing

se/f-care

t{cficit; itnbrdcatuli

dezbrdcatul

-

^00109; Dr.essirtg sel.f'-corc

defir:it; ltrdttirea

-

00102: Feacling self-ca'e cle/icit; fblo.tir-eu touletei -

00 I 1 0

:

^Toi Ieting selJ-6'r,r" detrcir)

Risc tle ulbctctre a dertutitirlii

Oal7l:

Risk.fbr" c'otrtpt'orttisecl htunun dig-

triS:1

.l.fec:ltu'ea stintei

tle

sine: situayionul (00120: Situcrtional

lov,

self-es-

teettt )

Ri,sc de ofectare a stimei de,sine: sitttct{ionctl (00153; RiskJbr.situatio-

rt o I loty,se(-estee rn)

Rirc de stndrom de stre,s

al relocirrii

^(00119. Risli.for relocatiort s/zzss

s.,,'ttdront e)

1lbctarea conJbrtului: ambiental rc12 I 4 lrultaired cotnfort)

lfbctarea cotntuticdrii verbale

⁽⁰⁰⁰⁵ I

: Intpaired t,erbal

conrrtruni-

- ^, tt iott)

\otii: Pentru

elemente

definitorii, PES-nri,

obiective,

intervenlii

_Si

evuludri

tn

cuzul

unora

dintre aceste diagnostice

nursing,

a se vedeu

volunrul

I!

1.1.4.

Aspecte privind ingrijirea pacienfitor in stadiu

terminal gi decesul

\specte generale

Pacientul aflat

in

stadiu terminal

neccsiti sprijin fizic ;i

^cl.)ro!i-

,.nal intensiv.

Semnele qi simptorlele

rno(ii

imineute sunt:

- r'educerea fren,enlei gi

amplitudinii

respira!iei:

- scdderea sau absenla tensiunii arteriale:

- sciderea frecven{ei pulsului;

- iciderea temperaturii corpului:

- scaderea gradului de congtienli;

- .lirninuarea

senzorialiti(ii

_$i a controlului neuro-muscular:

- lranspira{ie, paloare, cianozd, rigiditate.

25

tssu

lDraqdtad avpag

4lolncttc o

t2fualc{aul

F)rqarar

attltffiut rcl

\JttJ

arap0)s ap D

csl[

(uot1o1\uat sno

ptlrt pua td

t'

oa"tolc

afi

gtuatc{aut ;)

a$o"ndsaY

tP !7

p

qu.Lll.lc

s

a,nc\caty o

plonl

gg1 pluauquocuy

(acuau

t{

p.to

ut,trt

lua P

u!|uo

uI

J

(arun1ort

pm{ruaP{aP

wqtltllrazap P

ap r'slu

p\soaca nc atd

ptn7P3o7

yN Surs,ttttt

acgs

ou8nlq

eareiunue

re{eldser

tS

e

Flueurotu eererlsrEerul -

plr-u e

urncerd';oluqu

rS

rJqqulqcs eere4sr8erul -

gnpacord

uarurlsl8erul

'ecqrceds

IelielsFel

eIIrueJ nJ e

eoJelnsslp -

mlruuetced ecgrceds r

enl

gd nc telllrueJ eeJlru]sul

-

rnlruuerced eruo; uad

u1t}

ffial ezeq eQ r{ot,r ePV\x

IStrurss e

pluetced

gcep

-

alulrads

gfuraPlsuo3

rcpigrrmlce eere4sr8erul -

I.lopurgru euetEt -

roa:d Inun ry

eeJ€]celuoo -

9Z luepo,t I-e

op mlnluarced

eiurrop e:dsep 't\uazetd

luns

pcep 'rarpiueJ

nu

JolrJquieut

ealriunue

-

isles a1eluettrr]uas

erdsep rqJoA e

lndurrl ap

erzeco rS

r-tUo eA

r rnlnlucrcud'o1ey1rqe es

Elseaoe

pcpp - 3Je

ippne

pcur qs

ealnd;e

e1

-seJE

ruluod pc

rol:rfi:3ri1

:oieluetrieleJl rS

luercud n4uad e

eareerldxs -

iaprdu.r ieur atteJe rulued soua,reltur

Irq

-epuetrloco.t'rerfdr:csard uuo3uoc ecrSlerlue reriecrpaui

eoJeJlsrurupe -

ie1e1r.r

:olnlcnrg

eoJeJnspur -

ipiuetlSuoc ep rnlnla^ru rueppcs

rarjerdsue:1 rS

'ruoled

eaJe,\-resqo -

i.roirSnugur ealaund

:olrureu

rS

euor8r - lle1s urp

aueos:ad gnop

urind

eJtpc IeJ

rnlnluorced rriglrluopr op

BeJerruguoc -

irnlnluelced

1n1

ep -ed

edeo;de 'gtrguaprig JoielrroLLredrqca BI

roleler"le1eru rS ee-rr1q8e;d -

IJnp?JOJd

'erfe-irdse ep ]ueuredrqca

';eur:n Jalol€c :J€sacau alsa

gcup -

iericeto-rd ap eureSnru

- ladeoso:d -

iundgs

pde 15

nc luardrca:

-

iericalo-rd

luauredtlca ep

-

ielernc ungeS;eao

-

aJus0cau aIBIJaIBIAI

(sroz

'se:npeco.r6 3ursln51 s,11ocurcldr1)

'alh;8ug

ap lodrqce rS:opcrpcur gluc

-runuroo

glulcedser ernqaJl rS

rnlryuarced uiui-rop 'zec lsecu

'prlro)

uI

op

tr:pts eduede pdnp lriai,r

alaurjuaru u

"roloceolftu eo:ezrplnau ep

plitArrd

triu:u1cep ezecuures riuercecl

'rugi uun

erielsr8al ep oricr-m1

u1

'rnlnsecop ll oJeoleznec altcleJnoul

IIIocl

elnaicftcur a1e

eiozp.+

urp qJUr JBSaJeu

else urfi.rds op

]soJV dr1

'a1u1p,iniurs

Inluelrrrllres ep

ecrr3 enurlLup rS

e

nrluacl

p)tzly

p,lLLeze.rc1 rS e.rapo,rJLn llosape

gr.rLue3s

-Lrr

ioi

olriJlLUeJ rS riual.rL:d

r1S:rr rt:ruad

leuorioun

lnLrrli-rdg

.-. .-..:iirile ior

in-

'.'-.. .,

..rnrirrtra

frica

yi

-:::

r.Iecesar incd _din

:.:;ceSului.

..

^.,'

nncazi

declaraiii

....- dupi

aparitia starii

,

r'->i.c-tlta gi cornuni-

'-

\,..r':irrg Procedurcs,

emdir5., aproape de pa-

I

pulin

dou6 persoane

*.-':

de conqtienfa;

: s ; :t;rtigl, recomanda*

-'::"ritrr pentru Ci aceS-

-r

^{ociZis gi}

timpul

de

:z::tti.

despre dorinla

- contactarea unni preot dacd acest 1ucru este solicitat;

- igiena mAinilor;

- inregistrarea activitdlilor.

Considera{ii

speciale

- dacd pacientul a semxat un document cle renun{are la sus{inerea ar-tifi-

cial5 a

viclii

^(pe baza legisla{iei specificc), mcdicul va consemna aceas-

ta in foaia pacientului pentrll a fi in atenlia stafului din turele urmdtoaler

- instruirea

familiei

cu privire la nevoile, tratamentele

;i

^{planul de}

^ingri-

,iire specifice pacicntr"rh,ri qi oferirea suportuiui emolional;

-

discutarea

cu

l'amilia a op{iunii

privind

donarea de organe, pe baza

legislajiei specifice.

inregistrarea procedurilor

- inregistrarea

schimbirii valorilol

semnelor vitale, a ingestiei _Ei

elimi-

nirilor,

precum gi a

nivelului

de conqtienld;

- ir-rregistrarea momentuiui

in

care se constatd oprirea firnc{iei

inimii

qi

.r respiraliei qi anunlarea medicuhii

in

legdturd cu acestea;

Diugnostice nursing

NANDA-I

cure pot.fi identificate tn timpul sau in

Iegriturd _cu uceustei proceclut

ii:

Risc cle clezec:hilibru

ul

vohmtului.fluiclelor:

in

deficit (00028: _Risk.for

. i' e fi c i e nt .flu ⁱ cl vo ltmt e)

i;tcctntirtenlii Lu'inard.firnc{ionalii (00020: Frntctionctl Lt'incut. irtcorrti-

':t'tlC€)

i;icontinenla

fecaki

^{(000 I 4 : BotreI} incontinence)

-it,ctctreo scltimbului de gaze (00030: Intpairecl gas exchange)

:,.

;pirolie

ineJtc:ientti (0003 2 :

Inffictive

: breuthing pattern)

,iecturecL v"entiluliei pulntr_tnure spontune (00033: [mpoired spotttone-

.

;

t'entilcttion)

' 't

de.scdtlere tt circ'uloliei,sttttguine

in

_{esuttil cerebrttl

(00201;

Ri.sk

'

ⁱ ite/|bc'tive c'erebrol tis.tue perfitsiotr)

,'tc'iettsit

tt

c:it'atlnsiei scltgtLine i'n les'rLturile trterifbric'c (00204. _Ine-

- -

iile

pe,ripherul tis.strc petfit,siott)

21 ':Sl.:la1re.

il

lnwnpn

lnzrrJ u! ntn

upnpLa

vruap n4aad :ploN

gllil

orluon

atarnQ

:ztI00

pln)D a'D"mQ

oogfaut

a,ru1aa"toruna1 (otru.taqt

od anusalodlq ap cslY

antlrarcdlq

n)

cslY aP

v. OU

(nrwtary1od,(U

qOOCil :

aruualodtll

(a"ut1o.r

-adtLrat ,ipoq patttnlDqLut

"to/:1s1y .50000)

)nurrt tuqtlnpa:ap

)sllJ ap

-ttl

rt*ls pa.nocltut

"rrl:1s1y

;1t000)

!!layl7lr2t1fiatu1

atopta!,':;'::i;

o

(NrBatut

urqs'

patrudtul

:9t000)

nlad

ulpl1t8alut

oa"rn1cafi,

Qacyt a"mssatd

",rotysly

:6rc0d

a.tzrsa

rsly

ap

(actrotoalc

io,ruru

at4ca.{{au1

:t€00d

tr"rolo.udsat

roltD) o

r2tuatcghur Daroraqllg

(lltsor8tlat

panodut

"rolt1s7y

:01t00 llftltlzotSlpt

alolcaln ap n

csty

(ssaussa1nilod

Z g

00) I

octzgf atarnd ap psdt.1

(tnlrtsatap

flzo)

'aptdo.tdo apunos"tad uJ

o1

;8um.

-ar"t8 palocudruoc

n{t1s1y

Zll0D

ntpp

lupts

ap

atocr1druoc ap D

rs!tr

(Smaar8

paloctldtuo)

Sg00

lnt

-t*a)ap fED) ut

'aprdotdn

alaunos"tad ol -

tlllop

tuDls na.,ntctldtuo3 ap

(3uta.ar"rg

gtI00)

u'tltxsa)ap f'LzDr

ul'aptdo.tdo

alauoos.tad

-

Dl

rnlop

ap

arDg

(toa7 :ght0U

ryU!

a"to8a11 o1uang[aut

I0g0

^{Z :} adtpa.[au1 ^(1nruap

({launo tlqaq :b100

ttf,rotu Daapt ap ?toztlD)

atDptxuv

(8utdoc aaqca.{au1

69000) prualrg[au! :

ato1dopV (t11u31p

uDLwlq pastruotdtuot .rol

)tslv

:hlt0d

ttlpltutuap

a"tnltalo D

ap )s!A

(uo4oc

-runLuao)

pq.ta^

pa.ttodtul :19000 alDqnt

ttrz)lunLuoc oatnleatV

(uotsttluot

aynv

17il

:ge

ottnD

atn{uo3

1tp{ap a'utc-fias 8uryayo1

:0It00

- DplDot

aatrsolol

l1p{ap

a"toc-l1as Sutpaag :20100

- Darruutq

:ry{ap

a"tnt-t1as Surssatq :60109

lntD)D.tqzap

-

/Uto)DrqLq

;tp{ap

a"nt-t1as

Suttltog '90100

-

lnloytds

:a.rtfr.t8urottlD

ap lllp4cndoc

oatnltaJp,

su (a

odsa.t 8tu

a,tt uo

it

1 o7o

ryuat

lnLrotlcut{si67'lrt000) npuorl:tunfslp

ptDts!sD o.rouourrtd

agn1trya1

o (tr

s r

tt /-r

d a

a n s

4 s'

p

t

a

dt.t t1

d a

t4 a

a$a c

r u

o.f' -r

:1

ty

s'

e :ge

acr.tqfuad alr.utlrtsaf

00

auut8uos tagolnc.uc ut

o r2luarcg[aut ap

JSrA

te periferice (00228:

034:

Dysfi,tnctional

- 0AlA8:

Bathing

: Dressing self-care

: folosirea toaletei -

;;,'.

,,

^]

erbal

comntuni-

." _-, /)t;!)i'otni.secl human

.;'-, i..n ^t

.;:,i.

Llece.sulti (00 1 36

.:j-."rit,, itt c:ct:ul decesu-

l'

,,;;' contplicatecl

grie-

' .,.: ::.;i re d religiosity)

'-:

-'.

Iite-ffbctive airw-ay

:,: :)tiegt'ity)

'" '

,i' inrpairecl skin in-

: ".,',; iicetl _bodl, ternpe-

Risc de hipoterntie (00253: Risk./br h1'potherntia)

Ri,:;c de hipoterntie perioperatorie (00254: Risk for periopercfiive hypo-

thermict)

Tenno reglare ine.ficienta (0000I : Ine//bctive thennoregtt\ation)

Dttrere acutd (00132: Arute

pain)

Durere

cronicii

(00133. Chronic pain)

Notd: Pentru

elemente

deJinitorii, PES-uri,

obiective,

intervenlii

qi

evaludri

tn

cazul

unoril

dintre aceste diagnostice

nursing,

a se veclea

volumul

I!

29