Zuständige Pflegekraft: HZ |
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PPR-Pflegekategorien: |
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A2 |
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S2 |
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A2 |
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S1 |
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A1 |
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S2 |
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A1 |
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S1 |
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A1 |
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S1 |
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A1 |
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S1 |
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Maßnahmen: |
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Pflegearbeitszeit (Minuten): |
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6 |
2 |
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1 |
0 |
8 |
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9 |
8 |
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6 |
2 |
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6 |
2 |
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5 |
2 |
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5 |
2 |
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Pflegebedarf: |
AufnTag |
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OP-Tag |
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1.-Tag |
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2.-Tag |
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3.-Tag |
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4.-Tag |
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5.-7. Tag |
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Lfd.Nr. |
Probleme-
Ressourcen |
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T |
V |
Z |
S |
T |
V |
Z |
S |
T |
V |
Z |
S |
T |
V |
Z |
S |
T |
V |
Z |
S |
T |
V |
Z |
S |
T |
V |
Z |
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WB |
OP-Tag: Abends wenn möglich Hilfe am WB. |
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1. |
Körperpflege:
allgemein |
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x |
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x |
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x |
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x |
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x |
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x |
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Intimpflege |
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x |
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x |
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x |
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x |
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x |
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x |
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WB |
1.Tag: Morgens Hilfe am WB, dann selbständig. |
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Mundpflege |
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x |
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x |
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x |
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x |
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x |
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x |
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sonstige |
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2. |
Ernährung:
enteral |
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x |
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x |
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x |
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x |
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x |
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Tag vor OP: Vollkost. |
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parenteral |
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x |
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INF |
OP-Tag: Nüchtern, Tee nach 6-8 Std., Inf. lt.
Narkoseprot. |
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sonstige:
Infusion |
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x |
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1.Tag und folgende: Vollkost. |
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3. |
Ausscheidung:
Urin |
x |
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x |
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x |
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x |
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x |
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x |
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x |
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Tag vor OP: Dulcolax Supp. abends |
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Stuhl |
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x |
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x |
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x |
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x |
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x |
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x |
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x |
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BU |
OP-Tag: Urinflasche,
Bettschüssel. Auf Miktion achten. |
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Drainagen:
Redon |
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x |
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x |
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x |
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BT |
Redon! |
- 1.Tag: evtl. Begleitung zur Toilette |
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sonstige |
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2. Tag: Abends 2 Dr. Dulcolax b. Bed. |
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4. |
Mobilität: |
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x |
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x |
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x |
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x |
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x |
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x |
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MOBH |
OP-Tag: Abends wenn möglich mobilisieren. |
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mit
Hilfsmitteln |
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MOBH |
1.Tag: Morgens mobilisieren; dann selbständig. |
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im
Bett |
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x |
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x |
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Prophylaxen: |
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strenge
Bettruhe |
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PRT |
Thrombose: TED-Strümpfe bis zur Entlassung |
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sonstige |
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Pneumonie: OP-Tag und 1.Tag morgens: Franzbranntwein |
5. |
Kommunikation: |
x |
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x |
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x |
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x |
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x |
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x |
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x |
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bes.
psych. Belastung |
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sonstige |
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6. |
Atmung:
eingeschränkt |
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x |
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VZ |
OP-Tag: RR, P, Temp., entspr. Narkoseprotokoll |
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Kreislauf:
eingeschr. |
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x |
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1.Tag: Temp. 1x tgl. rektal, P, RR 1x tgl. |
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Körpertemp.:
aus Norm |
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Dann 1x tgl. RR, P, Temp. (oder nach Bedarf) |
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7. |
Ruhe/Schlaf:
gestört |
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durch
Schmerz |
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OP-Vorbereitung: |
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äußere
Bedingungen |
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OPVR |
Rasur: ab Nabel bis einschl. Schambehaarung. |
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pers.
Gewohnheiten |
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Abführen: 1 Supp. Dulcolax am Vorabend |
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8. |
Sonstiges: |
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VW |
Verband: 1. VW am 2.Tag; Redon am 2.Tag ziehen. |
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OP-Wunde |
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x |
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x |
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x |
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x |
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x |
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x |
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Danach Pflasterwechsel jeden 2. Tag |
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Pflegeplan: |
OPVR |
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WB / MOBH |
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WB |
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PRT |
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PRT |
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PRT |
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PRT |
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Fäden am 7./8.Tag entfernen (b. Bed. poststationär). |
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Handzeichen |
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BU |
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MOBH |
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VW |
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Sandsack: Am OP-Tag auf Wund (Leiste) |
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hier
eintragen: |
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PRT |
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BU |
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Verba bis Redons gezogen werden |
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VZ |
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BT |
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INF |
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PRT |
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