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stoma
الثغير فتحة صغيرة في أحد الحيوانات
最終更新： 2022-11-16
使用頻度： 3
品質：
stoma ulcer
قَرْحَةُ الفُغْرَة,قَرْحَةٌ هامِشِيَّة
最終更新： 2022-10-19
使用頻度： 1
品質：
警告： このアラインメントは正しくない可能性があります。
間違っていると思う場合は削除してください。
i mean, this guy could've had surgery, leaving him without a voice box breathing through a stoma and i would never know because i've never actually heard his voice.
هذا الرجل كما لو انه قام بعملية جعلته لا يتحدث كمثل عملية ستوما (عملية ستوما هى عملية تجرى عن طريق فتحة فى الجسم من الداخل للخارج) ولن اعرف أبداً لاننى لم أسمع صوته
[1] patient's name (initials only) ________________ bed number __________ assessor: __________________________¬¬_____ interview date: _________ source of information (specify): ___________ reliability : good fair poor. birth date: __________ age: _____ gender: m. f. marital status: s m w d. if married, years married ______ number of children _______ highest level of education: _________ occupation: _______________ admission date: _________________ admitted from: _____________ medical diagnosis: _________________________________ address: _________________________ lives: alone with:_____________________ health insurance: yes no. past medical history:________________________________________________________________ past surgical history:________________________________________________________________ chief complaint(s):[2] ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ reason for admission:[2] ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ nursing diagnosis health perception and management [1] regular physical check ups: yes no. smoker: yes no. if yes, packs/day: _____ number of years _________ altered health maintenance narjileh use: yes no. if yes, frequency of use/week_______________ alcohol use: yes no. if yes, frequency/week_______ amount:______ other drugs: yes no. if yes, type, frequency, amount: _____________ safety and protection: [1] allergies (food, drug, dye, other) _____________ reaction: _______________ risk for suffocation impaired vision/hearing: yes no. mental disability ______________ risk for poisoning ambulatory devices _______ deformities ______ prosthesis _________ risk for injury blood transfusions: yes no. if yes, date: _______ reaction: _______ moving nursing diagnosis subjective [1] exercise habits (type, frequency) ________________________________ impaired physical mobility limitation(s) in mobility (specify): ______________________________ *(walking, bed mobility, fatigue weakness pain dyspnea ____________________________ * transferability) sleep: hours: ________ naps: ___________ aids: _______________ fatigue difficulty falling/remaining asleep: _____________________________ sleep pattern disturbance objective:[1] response to activity: at rest after activity (risk for) activity intolerance a- cardiovascular: hr ___________ ___________ b- respiratory: rr ___________ ___________ type of activity: ______________ other response:____________ muscle mass/tone/strength: emaciation flaccidity rigidity paralysis. posture: ______________ gait: ________________ range of motion: full other:______________________ fracture/dislocations: __________ joint problems: ___________ back problems:_______________ other: _________________ activities of daily living: subjective:[1] independent. dependent (check what applies to your client): mobility feeding hygiene dressing/grooming toileting impaired mobility other (specify): ______________________________________________ feeding self care deficit objective:[1] bathing/hygiene self care deficit body odor: ____________ presence of vermin: yes no dressing/grooming self care deficit toileting self care deficit systems i- cardiovascular subjective:[2] history of: hypertension: __________ heart disease: ________ altered tissue perfusion: rheumatic fever: _______ ankle/leg edema: ______ *cardiopulmonary phlebitis: ______________ *peripheral numbness/tingling (location):________________ chest pain (describe): _______________________________ altered comfort related to chest pain objective:[2] bp: rt: _______lt: ________ position: lying sitting standing. bp: r_________________l________________ position �lying �sitting �standing pulse pressure: _____________ nursing diagnosis pulses (palpation): carotid: ___temporal: ____ brachial: ____ radial: _____ femoral: ____ popliteal: ____ posttibial _____dorsalis pedis: ______ heart sounds: _______________________________________ heart rate: ______rhythm: regular irregular. quality: strong weak jugular vein distention: yes no. position: lying sitting. extremities: skin temperature: warm cold. capillary refill: ______ homan's sign: yes no. varicosities: ______________________ edema(specify): general dependent ascites (risk for) fluid volume excess skin: pallor: overall lips nailbeds conjunctiva skin: cyanosis: overall lips nailbeds conjunctiva ii- oxygenation: subjective:[2] dyspnea/orthopnea (describe): ________________________________ cough: productive nonproductive. hemoptysis: yes no history of: bronchitis: _________________ asthma: _________________ tuberculosis: _______________ emphysema: ______________ use of respiratory aids: _________________oxygen: _______________ objective:[2] respirations: rate:____ depth: _______ rhythm:_________ ineffective breathing pattern quality: labored unlabored. chest expansion: _____________________. accessory muscles use: yes no. pursed lip breathing: yes no breath sounds: rt upper lobe: normal decreased abnormal ___________________ lt upper lobe:normal decreased abnormal ____________________ rt lower lobe: normal decreased abnormal ___________________ lt lower lobe: normal decreased abnormal ___________________ sputum: color: _________ amount:________ consistency: thick thin ineffective airway clearance use of incentive spirometer: yes no. clubbing of fingers: yes no iii-nutrition subjective:[2] type of diet: at home: ____________ current ___________________ altered nutrition (risk for): food intolerance: yes no. if yes, describe______________________ *less than body requirement appetite changes: yes no. if yes, describe____________________ *more than body requirement nausea/vomiting: yes no. if yes, describe______________________ nursing diagnosis history of: ulcers heart burn indigestion: ____________________ altered oral mucous membranes dentures: upper lower. mastication problems: yes no. altered dentition swallowing problems: ___________________________ impaired swallowing usual weight: ________ changes in weight ( or ): _____________ risk for aspiration history of diabetes mellitus: ________________________________ objective:[2] current weight: _____ height: ______ body mass index:_________ hernia/masses: yes no. if yes, location/size:_________________ thyroid enlarged: yes no. halitosis: yes no condition of teeth/gums/tongue/mucous membranes: _____________ iv therapy: ______________________________________________ iv-elimination: - gastrointestinal/bowel subjective:[2] usual bowel patterns: frequency____ color/consistency: ________ constipation (risk for) diarrhea constipation incontinence. stoma/ostomy:yes no. diarrhea remedies used for bowel problems: _________________________ bowel incontinence history of bleeding: ________________ hemorrhoids: __________ altered comfort objective:[2] risk for fluid volume deficit bowel sounds (describe):___________________________________ abdomen tender: yes no. soft firm. liver enlarged: yes no palpable mass: yes no. if yes, describe______________________ hemorrhoids: (external): yes no - renal/urinary subjective:[2] (risk for): usual urinary patterns: times/day:_____ color_____ hematuria altered urinary elimination incontinence urgency frequency retention *incontinence pain burning difficulty voiding dribbling *retention use of aids to void:_______________________________________ history of kidney/ bladder disease: ____________________________ objective:[2] urine: color: _______ odor: _______ output/hr/shift:__________ fluid volume excess bladder palpable: yes no catheter/stoma/ostomy: yes no fluid volume deficit v- skin integrity nursing diagnosis subjective:[2] changes in moles: ________________ enlarged nodes: ____________ history of fever/infectious diseases: ____________________________ history of cancer: __________________________________________ objective:[2] temperature: ________ lymph nodes enlargement: ______________ hyperthermia skin: moist dry warm cool pale pink jaundiced hypothermia skin turgor: elastic firm fragile dehydrated impaired skin integrity skin integrity: intact. rashes: ____________ blisters: __________ impaired tissue integrity surgical incision/scar: ________________ ecchymosis: ______________ (risk for) lacerations: ________________________ ulcerations: _______________ risk for infection pressure sores: _________________________________________________ cognitive /perceptual subjective:[2] history of: fainting/ syncope:___________ dizziness:___________ headaches: location___________ frequency _________________ stroke _____________________ seizures ____________________ sensory/perceptual disturbance: vision: no problem deficit: right left. glasses lenses *visual hearing: no problem deficit: right left. hearing aid *auditory smell: no problem deficit:__________________________ *olfactory taste: no problem deficit:__________________________ *gustatory objective:[2] level of consciousness (check what applies to your patient): altered thought processes alert drowsy stuporous comatose restless/agitated orientation: time: yes no. place: yes no. person: yes no. loss of memory: recent: yes no. past: yes no. impaired memory pupils: equal size: yes no. if no, describe:_________________ pupil reaction: -direct: brisk: rt lt. sluggish: rt lt. non reactive: rt lt. -consensual: brisk: rt lt. sluggish: rt lt. non reactive: rt lt. facial droop: rt lt. gag reflex: present absent handgrasp: rt: __________________ lt: ___________________ deep tendon reflexes:___________________________________ nursing diagnosis verbal response: clear slurred unintelligible aphasic impaired verbal communication gait disturbance � yes � no paralysis (describe)_________________________ feeling a-pain subjective: [2] pain: yes no. pain onset: __________location: _________ radiation: __________ intensity (1-10): ______ quality: ________ frequency:_______ duration: _____ associated with: _________________________ aggravated by: ________________ alleviated by: ___________ objective:[2] facial grimacing: yes no. guarding affected area: yes no. emotional response to pain: crying withdrawn angry b-psycho-socio-cultural emotional integrity: subjective:[1] recent stressful life events other than illness: yes no. if yes, describe:____________________________________ how do you usually manage stress?____________________ objective:[1] emotional status (check those that apply): anxiety calm cooperative anxious angry withdrawn fear combative irritable euphoric other_____________________ grieving associated physical manifestations:__________________________ impaired social interaction role:[1] role within family: breadwinner caregiver other__________ altered role performance how does your illness affect your: family____________________________________________ job_______________________________________________ valuing:[1] does illness/hospitalization interfere with any of the following: 1. religious practices: yes no. _________________________ 2. cultural practices: yes no. __________________________ 3. family traditions: yes no. ___________________________ sexuality/reproduction nursing diagnosis female subjective:[1] age at menarche: ____ length of cycle: _____ duration: ________ last menstrual period: _______________ menopause: yes no. vaginal discharge: __________ bleeding between periods: : yes no. altered sexuality patterns practices breast self-examination: ______ last pap smear: _________ history of std: __________________________________________ sexual concerns/problems:___________________________________ objective:[1] breast examination: ______________________________________ vaginal warts/lesions: _____________________________________ male [2] penile discharge: _____________ prostate disorder: _____________ practices self-examination: breast: __________ testicles: ________ last prostate exam: _____________ history of std:________________________ sexual concerns/problems: _________________________________ knowing [1] familial history (specify which relative has the disease): anemia/blood dyscrasias ___________ peripheral vascular ____________ cancer _________________________ kidney disease _______________ diabetes ________________________ stroke ______________________ heart disease _____________________tuberculosis _________________ hypertension _____________________ other: ______________________ knowledge about current illness: ________________________________ knowledge deficit ___________________________________________________________ knowledge about current medications/treatments: ___________________ ___________________________________________________________ expectations of therapy: _______________________________________ requesting information concerning: _________________________________ list the nursing diagnoses identified to your client in priority order: 1. ______________________________________________ 2.______________________________________________ 3.______________________________________________
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