ICH

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

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