22.37 Anexa2 Fisa Sintetica Monitorizare Dializat Peritoneal
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Anexa 2 FIŞĂ SINTETICĂ DE MONITORIZARE A BOLNAVULUI DIALIZAT PERITONEAL ANUL ..........
______________________________________________________________________________ | Numele ........................... Prenumele ............................... | | _ _ _ _ _ _ _ _ _ _ _ _ _ | | CNP |_||_||_||_||_||_||_||_||_||_||_||_||_| Nr. carnet (pentru bolnavii | | _ _ _ _ _ _ _ _ | | incluşi în programele de sănătate) |_||_||_||_||_||_||_||_| | | _ _ _ _ | | Număr înregistrare a Fişei de spitalizare de zi SZ |_||_||_||_| | | Întocmit de ................................................................ | | (parafa medicului) | |______________________________________________________________________________| ______________________________________________________________________________ | |Ianuarie | Februarie | Martie | Aprilie | Mai | Iunie | |_______________________|_________|___________|________|_________|_____|_______| | Data | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Apetit | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Greutate (kg) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Presiune arterială | | | | | | | | (cmHg) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | - clinostatism | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | - ortostatism | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Semne de | | | | | | | | hiperhidratare | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Diureză medie (l/zi) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Ultrafiltrare medie | | | | | | | | netă (ml/zi) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Test echilibrare | | | | | | | | peritoneală*2) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | DPCA/DPCC | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Sistem | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Nr. schimburi | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Orar schimburi | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Tip soluţie | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Volum | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Starea orificiului de | | | | | | | | ieşire*1) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Recomandări | | | | | | | | - Dietă | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | - Tratament | | | | | | | | medicamentos | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Probleme | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| *1) După clasificarea Tdwardowky 22.37;A4;t2
_____________________________________________________________________________ | |Iulie|August |Septembrie|Octombrie|Noiembrie|Decembrie| |_______________________|_____|_______|__________|_________|_________|_________| | Data | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Apetit | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Greutate (kg) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Presiune arterială | | | | | | | | (cmHg) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | - clinostatism | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | - ortostatism | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Semne de | | | | | | | | hiperhidratare | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Diureză medie (l/zi) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Ultrafiltrare medie | | | | | | | | netă (ml/zi) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Test echilibrare | | | | | | | | peritoneală*2) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | DPCA/DPCC | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Sistem | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Nr. schimburi | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Orar schimburi | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Tip soluţie | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Volum | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Starea orificiului de | | | | | | | | ieşire*1) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Recomandări | | | | | | | | - Dietă | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | - Tratament | | | | | | | | medicamentos | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Probleme | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| *1) După clasificarea Tdwardowky Observaţii ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ...............................................................................
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______________________________________________________________________________ | Numele ........................... Prenumele ............................... | | _ _ _ _ _ _ _ _ _ _ _ _ _ | | CNP |_||_||_||_||_||_||_||_||_||_||_||_||_| Nr. carnet (pentru bolnavii | | _ _ _ _ _ _ _ _ | | incluşi în programele de sănătate) |_||_||_||_||_||_||_||_| | | _ _ _ _ | | Număr înregistrare a Fişei de spitalizare de zi SZ |_||_||_||_| | | Întocmit de ................................................................ | | (parafa medicului) | |______________________________________________________________________________| ______________________________________________________________________________ | |Ianuarie | Februarie | Martie | Aprilie | Mai | Iunie | |_______________________|_________|___________|________|_________|_____|_______| | Data | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Apetit | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Greutate (kg) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Presiune arterială | | | | | | | | (cmHg) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | - clinostatism | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | - ortostatism | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Semne de | | | | | | | | hiperhidratare | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Diureză medie (l/zi) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Ultrafiltrare medie | | | | | | | | netă (ml/zi) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Test echilibrare | | | | | | | | peritoneală*2) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | DPCA/DPCC | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Sistem | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Nr. schimburi | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Orar schimburi | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Tip soluţie | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Volum | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Starea orificiului de | | | | | | | | ieşire*1) | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Recomandări | | | | | | | | - Dietă | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | - Tratament | | | | | | | | medicamentos | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| | Probleme | | | | | | | |_______________________|_________|___________|________|_________|_____|_______| *1) După clasificarea Tdwardowky 22.37;A4;t2
_____________________________________________________________________________ | |Iulie|August |Septembrie|Octombrie|Noiembrie|Decembrie| |_______________________|_____|_______|__________|_________|_________|_________| | Data | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Apetit | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Greutate (kg) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Presiune arterială | | | | | | | | (cmHg) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | - clinostatism | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | - ortostatism | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Semne de | | | | | | | | hiperhidratare | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Diureză medie (l/zi) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Ultrafiltrare medie | | | | | | | | netă (ml/zi) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Test echilibrare | | | | | | | | peritoneală*2) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | DPCA/DPCC | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Sistem | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Nr. schimburi | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Orar schimburi | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Tip soluţie | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Volum | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Starea orificiului de | | | | | | | | ieşire*1) | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Recomandări | | | | | | | | - Dietă | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | - Tratament | | | | | | | | medicamentos | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| | Probleme | | | | | | | |_______________________|_____|_______|__________|_________|_________|_________| *1) După clasificarea Tdwardowky Observaţii ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... ...............................................................................
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