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VALUTAZIONE INIZIALE DEL PAZIENTE

CARATTERISTICHE DELLE SOLUZIONI DA INFONDERE

OSMOLARITA/mOsm/l pH Tossicit intimale

500 < 5 5 - 9 NO SI > 9

VIA DI SOMMINISTRAZIONE PERIFERICA

VIA DI SOMMINISTRAZIONE CENTRALE

DURATA DEL TRATTAMENTO

DURATA DEL TRATTAMENTO

4 settimane < 4 settimane > 4 settimane

Cannula periferica

Midline

PICC

CVC tunnellizzato

Port

PICC

CVC a breve termine

Cannula periferica

(sostituire ogni 72-96 ore )

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Score 0 Cute sana, integra, non segni di flogosi

Score 1 Iperemia < 1 cm Al punto di uscita del CVC; fibrina

Score 2 Iperemia > 1 < 2 cm al punto di uscita del CVC; fibrina

Score 3 Pus, iperemia, secrezione, fibrina

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###N.$/#& Firma del paziente (o del tutore*) Firma del Medico . Data .. Consenso ottenuto con l'ausilio di un interprete S NO Firma dellinterprete * se minore o incapacit legale Il sottoscritto Dott. ................ dichiara che il/la Sig. / Sig.ra ............................ non nelle condizioni psicofisiche di poter esprimere il proprio consenso

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SPAZIO PER ETICHETTA PAZIENTE

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RIMOZIONE CVC: Motivo: Fine trattamento Accidentale Malfunzionamento Infezione (locale sistemica) Altro_________________________ Data 20/12/2006 Firma [email protected]#.$.;;##/#&

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