본문내용
:
pain 주었을 때 아주 미세하게 움직임
Extrmity (temperature, edema, sensation)
사지 모두 cool하고 전체적으로 edema
Motor: ROM x 4 extremities NA
Ted hose/plexi pulses/compression devices: type
casts, splint, collar, brace : 양팔 edema로 압박붕대
25) CARDIOVASCULAR SYSTEM
Pulses(radial, pedal) (to touch or with Doppler):
93회, 요골/대퇴 정확하게 잡힘
Capillary refill(<3s)
■ Yes □ No
Neck vein(distention)
정확하게 잡힘
Sounds: S1, S2, regular, irregular:
Apical rate:
Any chest pain:
NA
26) RESPIRATIRY SYSTEM
Depth, rate, rhythm:
26회, normal
Use of accessory muscles:
NA
Cyanosis:
NA
Sputum color, amount:
yellowish
Cough: productive, nonproductive
Breath sounds: clear, rales, wheezes
clear하나 약간 가래 낀 소리
Use of oxygen: nasal cannula, mask, trachollar : Endotracheal tube로 O2 공
Flow rate of oxygen:
4L/min
Oxygen humidification:
■ Yes □ No
Pulse oximeter:
100 % oxygen saturation
Smoking
□ Yes ■ No
27) GASTROINTESTINAL SYSTEM
Abdominal pain, tenderness, guarding: distention, soft, firm:
soft
Bowel sounds x4 quadrants:
소실
NG tube: describe drainage
NA
Ostomy: describe stoma site and stools:
NA
Other:
28)SKIN AND WOUNDS
color,turgor:
op site 약간 민감한 상태
rash,bruises:
iv로 양팔 국소적으로 멍든 상태
Describe wounds
(size, locations):
head, 약 20cm
Edges approximated:
Type of wound drains:
NA
characteristics of drainage:
NA
Dressings(clan,dry,intact):
Dry but little yello drainage
Sutures,staples,setri-strips,other: op site staples
Risk for pressure ulc
er assessment rating :
고위험
other:
29)EYES,EARS,NOSE,THROAT(EENT)
Eyes:redness,drainage,edema,ptosis
NA
Ears:drainage
NA
Nose:redness,drainage,edema NA
Throat:sore
NA
Psychosocial and Cultural Assessment
30)Religious preference(face sheet)
불교
31)Marital status (face sheet)
기혼
32)Heealth care benefits and insurancee(face sheet)
NA
33)Occupation(face sheet)
무직
34)Emotional state(nurse's notes)
NA
pain 주었을 때 아주 미세하게 움직임
Extrmity (temperature, edema, sensation)
사지 모두 cool하고 전체적으로 edema
Motor: ROM x 4 extremities NA
Ted hose/plexi pulses/compression devices: type
casts, splint, collar, brace : 양팔 edema로 압박붕대
25) CARDIOVASCULAR SYSTEM
Pulses(radial, pedal) (to touch or with Doppler):
93회, 요골/대퇴 정확하게 잡힘
Capillary refill(<3s)
■ Yes □ No
Neck vein(distention)
정확하게 잡힘
Sounds: S1, S2, regular, irregular:
Apical rate:
Any chest pain:
NA
26) RESPIRATIRY SYSTEM
Depth, rate, rhythm:
26회, normal
Use of accessory muscles:
NA
Cyanosis:
NA
Sputum color, amount:
yellowish
Cough: productive, nonproductive
Breath sounds: clear, rales, wheezes
clear하나 약간 가래 낀 소리
Use of oxygen: nasal cannula, mask, trachollar : Endotracheal tube로 O2 공
Flow rate of oxygen:
4L/min
Oxygen humidification:
■ Yes □ No
Pulse oximeter:
100 % oxygen saturation
Smoking
□ Yes ■ No
27) GASTROINTESTINAL SYSTEM
Abdominal pain, tenderness, guarding: distention, soft, firm:
soft
Bowel sounds x4 quadrants:
소실
NG tube: describe drainage
NA
Ostomy: describe stoma site and stools:
NA
Other:
28)SKIN AND WOUNDS
color,turgor:
op site 약간 민감한 상태
rash,bruises:
iv로 양팔 국소적으로 멍든 상태
Describe wounds
(size, locations):
head, 약 20cm
Edges approximated:
Type of wound drains:
NA
characteristics of drainage:
NA
Dressings(clan,dry,intact):
Dry but little yello drainage
Sutures,staples,setri-strips,other: op site staples
Risk for pressure ulc
er assessment rating :
고위험
other:
29)EYES,EARS,NOSE,THROAT(EENT)
Eyes:redness,drainage,edema,ptosis
NA
Ears:drainage
NA
Nose:redness,drainage,edema NA
Throat:sore
NA
Psychosocial and Cultural Assessment
30)Religious preference(face sheet)
불교
31)Marital status (face sheet)
기혼
32)Heealth care benefits and insurancee(face sheet)
NA
33)Occupation(face sheet)
무직
34)Emotional state(nurse's notes)
NA
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