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  • 5/28/2018 Plan de Nursing Neurologie PLAN de INGRIJIRE

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    NURSING in neurologie PLAN DE INGRIJIRE PE NEVOI

    (DUP MODELUL DE VIRGINIAHENDERSON)

    STUDENT : TOTEANU CRISTINA

    !"#"#$

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    EVALUARE

    (NURSING IN NEUROLOGIE)

    Data internrii :01.01.2010

    Data externrii:12.01.2010

    CULEGEREA INFORMAIILOR

    N!"e : MI#AI$ren!"e: ELENA

    D%"i&i'i!: $iteti !*. Ar+e%

    Sit!a,ia -a"i'ia': &t%rit 1 &%/i'

    A&tiit,i /r%-ei%na'e: /eni%nar

    Na,i%na'itate: r%"an

    M%ti!' internrii: A&&i*ent a&!'ar i&e"i&-iri'a,ie atria'

    Dia+n%ti& *e internare: #e"i/'e+ie &! a-a3ie. In-ar&t &erera'.

    Me*i& &!rant: Dr. Stan&i! Marian

    Ante&e*ente /er%na'e: -i3i%/at%'%+i&e4"enara 15ani

    Ante&e*ente ere*%6&%'atera'e:6-ar

    It%ri&!' %'ii:/a&ienta a -%t +it *i"inea,a &! !n *e-i&it /'e+i& a'

    "e"r!'!i !/eri%r i in-eri%r(*re/t)7 &! *ei*ratare +ra*8

    te+!"ente /a'i*e i !&atei/%t%nie(,r!t a*i/% 'are/re3entat)-iri'a,ie atria'.

    #A42209110 ""#+

    A" a&%r*at in+riiri &e tin *e ati-a&erea ne%ii *e a re/ira i a aea% &ir&!'a,ie n%r"a' ne%ia *e a ea %i a "an&a ne%ia *e a

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    e'i"inane%ia *e a e "i%&a %i a aea % /%t!r a*e&atne%ia *e ae %*inine%ia *e a e i"r&a %i *e3r&ane%ia *e a /trainte+ritatea te+!"ente'%rne%ia *e a eita /eri&%'e'ene%ia *e ain,a.

    In ti"/!' internrii a! -%t e-e&t!ate ineti+a,ii &'ini&e %i /ara&'ini&ein e*erea tai'irii !n!i *ia+n%ti& &%re&t i a&%r*area in+riiri'%r"e*i&a'e ne&eare.

    In-%r"a,ii -i3i&eVart: ani

    ;n',i"e:1

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    C%"/%rta"ent :/a&ienta /re3inta a-a3ie "%t%rie a%&iat &!e"ian%/ie/a&ienta n! e /%ate ex/ri"aex/reie %ra'ra&.

    In-%r"atii "e*i&a'e: inaintea /ita'i3rii /a&ienta &%ntr%'a #A&! &a/t%/ri'(&%n-%r" in-%r"a,ii'%r -!rni3ate *e a/ar,int%r).

    rata"ent :#e/arin Manit%'F!r%e"i*Di+%xin.

    Oie&tie: aitarea /a&ientei in e*erea "en,inerii i re*%an*irii

    %"e%ta3iei *e a % a!ta e a*a/te3e "%*i-i&ri'%r*i-!n&,ii'%r interne-i3i&e i /ii&e.

    a*"initrarea trata"ent!'!i &! e/arina /entr! *i3%'areatr%"!'!i '%&a'i3at in artera &%r%nar tan+.

    &a*erea #IC.

    re&!/erare /rin -i3i%tera/ie.

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    FIBRILAIE ATRIALACCIDENT VASCULAR ISCHEMIC

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    Analiza situatiei

    NR.

    CRT.

    EVOIEFU D ME T L

    PROBLEMA DIAGNOSTICUL DE

    NURSING

    OBIECTIVE

    1 Ne%ia *e a re/irai a aea %&ir&!'atie a*e&at

    6a'terareare/ira,iei %i&ir&!'a,iei

    6 a'terarea re/ira,iei %i&ir&!'a,iei &a!3ate #A

    6/a&ienta aia % re/ira,i%i % &ir&!'a,ien%r"a'

    2 Ne%ia *e a ea i a"an&a

    6*ei*ratare+ra* 6I6

    6 *ei*ratare /rin a/%rti*ri& in!-i&ient

    &antitatite+!"ente %i"!&%ae !&ate.

    6/a&ienta etei*ratat

    /arentera'

    Ne%ia *e a e'i"ina 6e'i"inareina*e&at

    6 e'i"inareina*e&at4%'i+!rie

    6"i&ti!nea e rea'i3ea3&! a!t%r!' %n*ei

    6/a&ienta ai % *i!re3n%r"a'

    !" Ne%ia *e a e"i&a i a "entine

    % /%t!ra a*e&at

    6*e-i&it t%ta' a'"%i'it,ii

    6*e-i&it t%ta' a' "%i'it,ii&! e"i/'e+ie

    *rea/t./a&ienta t in/er"anen, in /at

    6re&!/erare in-!n&,ie

    trata"ent

    # Ne%ia *e a *%r"i*e a e %*ini

    6in%"nie

    $ Ne%ia *e a eB"r&a i *e3ra&a

    6*e-i&it t%ta' *ea!t%in+riire

    6*e-i&it t%ta' *ea!t%in+riire *in &a!3ae"i/'e+iei

    6/a&ienta etei"r&ata *e&tre &a*re'e *in+riire/e&ia'i3ate

    % Ne%ia *e a /atrate"/erat!ra&%r/!'!i in 'i"iten%r"a'e

    6tare *e!-eri'itate

    6tare *e !-eri'itate in/e&ia' eara.

    6/trareate"/erat!rii&%r/!'!i in'i"ite n%r"a'e

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    & Ne%ia *e a -i &!rati a /r%teate+!"ente'e

    6te+!"enten%r"a'e

    te+!"ente n%r"a'e-re&are

    ' Ne%ia *e a eita

    /eri&%'e'e

    6 #IC 6#.I.C 6&*erea #.IC

    &! "anit%'.

    1( Ne%ia *e&%"!ni&are

    6a-a3ie 6a-a3ie "%t%ri3e/a&ientan! &%"!ni&

    11 Ne%ia *e a /ra&ti&are'i+ia i *e aa&ti%na &%n-%r"&re*inte'%r /r%/rii

    6*in &a!3a&%n*itiei -i3i&e/a&ienta n!/%ate a&ti%na&%n-%r"

    &re*inte'%r12 Ne%ia *e a -i !ti'*e

    a -i %&!/at6i"/%ii'itate*e a -i !ti'

    i"/%ii'itate *e a -i !ti'*in &a!3a i"%i'i3rii

    6/a&ienta arein 'a%i&ei!ri'e a'e&at "ai &!ran*

    1 Ne%ia *e re&reere 6i"%ii'itate *e&%"!ni&are

    6*e-i&it t%ta' *ei"%i'itate

    1" Ne%ia *e a inata 6a-a3ie 6i"/%ii'itatea&%'a%rrii &! &a*re'e"e*i&a'e

    PLAN DE INGRI)IRE

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    NR.

    CRT

    PROBLEMA DIADNOSTI

    C DE

    NURSING

    OBIECTIVE INTERVENTII DE

    NURSING

    EVALUAR

    1 ALTERAREA

    RESPIRATIEI SI

    CIRCULATIEI

    6a'terarea&ir&!'a,iei ire/ira,iei&! #A

    6/a&ienta ai %re/ira,ie i %&ir&!'a,ien%r"a' in 0"in.

    6/%3i,i%narea*e&atre+i" i+ien%6*ieteti&

    6"!rarea i n%tarea-!n&,ii'%r ita'e

    6ai+!rarea &%n*i,ii'%ri+ieni&%6anitare&%re/!n3t%are

    6/re+tirea "ateria'e'%ri intr!"ente'%r/entr! a*"initrarea"e*i&a"ente'%r.

    6/a&ienta % &ir&!'a,ii %re/ira,ien%r"a' in "in!te.

    2 DEFICIT DE

    VOLUM

    LIC*IDIAN

    6*ei*ratare /rin a/%rtin!--i&ient*e 'i&i*e

    6/a&ienta -iee&i'irati*r%e'e&tr%'iti&

    6"!rarea -!n&,ii'%rita'e6re/ira,ia/!'!'*i!re3a

    te"/erat!ra.A.

    6 ai+!rarea &%n*i,ii'%ri+ieni&%6anitare&%re/!n3t%are

    6/re+tirea "ateria'e'%ri intr!"ente'%r/entr! a*"initrarea"e*i&a"ente'%r

    6/a&ienta !n a/%rti*ri&ati-&t

    *i!re3a tin

    en%r"a'i3ee

    &%ntin!in+riiri'e.

    DEFICIT DEAUTOINGRI)IR

    E

    6*e-i&it t%ta'*ea!t%in+riire

    6/a&ienta ii/%at e-e&t!at%a'eta &!a!t%r

    6/%3i,i%narea*e&atre+i" i+ien%6*ieteti&

    6"!rarea i n%tarea-!n&,ii'%r ita'e

    6ai+!rarea &%n*i,ii'%r

    6/a&ientan!6i /%ate-e&t!at%a'eta.*ea&et a/e%&!/an*!e

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    i+ieni&%6anitare&%re/!n3t%are

    6/re+tirea "ateria'e'%ri intr!"ente'%r

    /entr! a*"initrarea"e*i&a"ente'%r

    /er%na'!/e&ia'i3a

    " DIMINUAREA

    MOBILITA+II

    6*i"in!area"%i'it,ii*in &a!3a"e"re'%ra-e&tate

    6/a&ienta e/%at "%i'i3e&! a!t%r

    6"!rarea i n%tarea-!n&,ii'%r ita'e &iar i/e ti"/!' n%/tii

    6ai+!rarea &%n*i,ii'%ri+ieni&%6anitare&%re/!n3t%are

    6/re+tirea "ateria'e'%ri intr!"ente'%r/entr! a*"initrarea"e*i&a"ente'%r

    6/a&ienta e ri*i&

    6e &%ntinin+riiri'e

    # AN,IETATE 6anxietate*in &a!3ane&!n%aterii e%'!,iei%'ii

    6/a&ienta n!"ai -ieanxi%a in 25*e %re.

    6/i%tera/ie

    6 ai+!rarea &%n*i,ii'%ri+ieni&%6anitare&%re/!n3t%are

    6/a&ienta "ai eteanxi%a

    6e!r"rete

    e%'!,iatrii/a&ientei.

    Ni-el e e/enen0

    NR"

    NEVOIA

    FUNDAMENTALA

    NIVEL 1 NIVEL 2 NIVEL NIVEL "

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    CRT.

    1 Ne%ia *e a re/ira i aaea % &ir&!'atie

    a*e&at

    2 Ne%ia *e a ea i a"an&a

    Ne%ia *e a e'i"ina

    !" Ne%ia *e a e "i&a i a

    "entine % /%t!raa*e&at

    # Ne%ia *e a *%r"i *e ae %*ini

    $ Ne%ia *e a e B"r&ai *e3ra&a

    % Ne%ia *e a /atrate"/erat!re &%r/!'!i in'i"ite n%r"a'e

    & Ne%ia *e a -i &!rat i a/r%tea te+!"ente'e

    ' Ne%ia *e a eita/eri&%'e'e

    1( Ne%ia *e &%"!ni&are

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    11 Ne%ia *e a /ra&ti&are'i+ia i *e a a&ti%na&%n-%r" &re*inte'%r/r%/rii

    12 Ne%ia *e a -i !ti'*e a -i%&!/at

    1 Ne%ia *e re&reere

    1" Ne%ia *e a inata

    TOTAL&'

    P*ien+ *u ,e-en,en./ +o+l/"

    RECUPERARE *EMIPLEGIE FLASC

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