Darandoi Teodor Sebastian Anul II - 2015Fisa de evaluare a grevidei pre si post-operator

Ora si data prezentari pe sectie a gravidei la internare:..........................Initiale:............;Vrsta:...........................;Sexul: F, M.Naionalitatea:.....................................Lb. vorbit:.........................................Religia:..............................................Ocupaia:...................................................................................................;Mediul din care provine:.............................................................................;Dommiciliul:.............................................................................................;Dg. de trmitere:.......................................................................................;Dg.la internare:......................................................................................;Dg la 72 de ore:......................................................................................;Exemane clinic general:Greutatea:...................;nlimea:....................;Talia (circumferina abdominal)................................;Tensiunea Arterial (T.A.)..........................................;Alura ventricular (Pulsu)..........................................;Temperatura:..............................................................;Tegumente si mucoase:..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................;

Motivele internri:....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................; HPF:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................; HPP:.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................;HHC:.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................;

Istoricul bolii:.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................;Analize de laborator:DenumireValorii obinuteValorii normale

Nr. Eritrocite3.800.000-5.100.000 mm3

Nr. Leucocite 4.500 - 11.000/1mm3 sg.

Neutrofile60-70%

Eozinofile1-4%

Limfocite4-8%

Monocitele25-30%

Nr. Trombocite150.0000-450.000/1mm3

Fibrinogeniul200-400 mg/100 ml

INR0,8-1,2

TS3-4 minute

TC12-15 minute

Hematocrit36-42%

Hemoglobina11-15 g/100 ml sg.

Glicemia0,80-115 mg/dl

Creatina

Acidul uric2-5 mg/100ml

Uree seric30-45 mg%

Trigliceride100 mg/100 ml ser

Ionograma: Na K Ca Cl Na = 135-145mEq/l sg.K = 3,5 -4,5 mEq/l sg.Ca = 8,5 -10,5 mg/100 mlCl = 354-395 mg/100 ml

Colesterolul 120-290 mg/100m ml ser

VSH6-13 mm/1h, 1-20 mm/2h

Bilirubina0,2-1,5 mg/dl

TGP (transaminaza glutamat pivuric)7-56 U/L

TGO (transaminaza glutamica oxaloacetic)5-40 U/L

Ag HBsNegativ

Ac HCVNegativ

VDRLNegativ

UroculturaNegativ

Sumar urina1000-1600 ml/24 h

Densitatea urinara1,015-1,025

Ph urinar4,8-7,8

Leucocite (urina)0

Celule (epiteliale)0

Saruri (urai, oxacilai, epitelii, microbi)

Negativ

Gr. Sg

Rh+ sau -

Dieta zilnic de pe data de pn la data de

Data/ZiuMic dejun Ora 8:00Supliment Ora 10:00Dejun Ora 13:00Supliment Ora 14:00Cina Ora 16:00Toleran Digestiv.

Ziua I

Ziua II

Ziua III

Ziua IV

Ziua V

Ziua VI

Ziua VII

Monitorizarea F.V zilnic

F.VZiua IZiua IIZiua IIIZiua IVZiua VZiua VIZiua VII

Respiraie

T.A.

Puls

Temperatur

Diurez

Tranzit intestinal

Alte eliminri

Sonde, Drenuri

Alimentaie

Diet

Micare

Igen

Tegumnte, Mucoase

Edeme

Greutate

Somn

Durere

Comunicare

Cunotine

Altele

Prima zi post-operatoriu:Exemane clinic general:Greutatea:...................;nlimea:....................;Talia (circumferina abdominal)................................;Tensiunea Arterial (T.A.)..........................................;Alura ventricular (Pulsu)..........................................;Temperatura:..............................................................;Tegumente si mucoase:...............................................................................................................................................................................................................................................................;Somn/Odihn ore:..........................................................................................................................................................................................................................................................;Mers i postur:........................................................................................;Orientare temporo-spaial:.......................................................................;Diureza:......................................................................................................;Scaune:.....................................................................................................;

Tratament instituit:MeicamentulDoza de administrareModul de administrareI.M, I.V, S.C.

Interventii autonome:..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................;

Intervenii delegate:..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................;

A doua zi post-operatoriu:Exemane clinic general:Greutatea:...................;nlimea:....................;Talia (circumferina abdominal)................................;Tensiunea Arterial (T.A.)..........................................;Alura ventricular (Pulsu)..........................................;Temperatura:..............................................................;Tegumente si mucoase:...............................................................................................................................................................................................................................................................;Somn/Odihn ore:..........................................................................................................................................................................................................................................................;Mers i postur:........................................................................................;Orientare temporo-spaial:.......................................................................;Diureza:......................................................................................................;Scaune:.....................................................................................................;Tratament instituit:MeicamentulDoza de administrareModul de administrareI.M, I.V, S.C.

Intervenii autonome:...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................;

Intervenii delegate:...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................;

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