1. การบันทึกรายงานแบบแก้ปัญหา
Rangsima Poomsawat
Public Health Nursing ,Faculty of Nursing, Chiang Mai University
E mail : rangsima@chiangmai.ac.th
to_rangsima@hotmail.com
http://www.facebook.com/RangsimaPoomsawat
http://www.slideshare.net/rpoom
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http://www.facebook.com/pages/Nursing-Room-By-Rangsima/109937325743807?v=wall
NP 5_ 2005 rangsima@chiangmai.ac.th 1
2. Outline of POMR
1. Data base
2. Problem list
…. Temporary of problem list
…. Sequence of events diagram
…. Permanent of problem list
…. Analysis of problem : SOA
3. Initial plan P
1. Plan for Diagnosis
2. Plan for Treatment
3. Plan for Nursing Care
4. Plan for Health Education
4. Progress note
5. Discharge summary
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3. PRIMARY MEDICAL CARE
NURSE PRACTITIONER 5/2005
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10. 2005.5.16 08:10
• GA : Good orientation
• Skin: Yellow-brown color
• Eye : Icteric sclera
• Lung: Clear
• Heart sound: Regular, no murmur
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11. • Abdomen: Distention of Abdomen,
no visible peristalsis on dilated veins,
no pulsations, umbilicus located slightly
below the center of the abdomen,
no hernia, surgical scar 4 cm at midline,
normal bowel sound q ten seconds,
normal abdominal tympany ,
no shifting dullness, no fluid thrill,
spleen and liver not palpable ,
Murphy’s sign positive, marked tenderness
at right costal margin , no rebound
tenderness ,no tenderness at Mc Burney’s
NP 5_ 2005 point, mild guarding, no rigidity, no mass
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12. • What do you think was the cause of this
man’s problem?
• What would be your initial plan?
NP 5_ 2005
QUESTIONS
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17. Hi fat diet,DM
Hypercholesterolemia Bile ที่มีsupersaturated
Normal level of Bile Cholesterol
salt, Lecithin
Gallstone: Cholesterol stone
Cystic duct obstruction
Impaired excretion of Gallbladder distention
bilirubin to bile canaliculi
Colicky pain
Hematolymphatic system Cholecystitis:
Fever
Tenderness at RUQ
Conjugated bilirubinemia สูง
Murphy’s sign +ve
NP 5_ 2005 Bilirubin deposit in skin and sclera
rangsima@chiangmai.ac.th 17
Dark urine (bilirubinuria)
18. Contaminated food with Recipients of blood
Hepatitis A transfusions
Contact with career
+Immune Liver cell Virus
Alcohol
drinking Liver cell damage เข้าสู่กระแสเลือด
Fibrosis Liver function loss
Hepatomegally Impaired hepatic
Tenderness at conjugation of bilirubin
RUQ
Jaundice:Bilirubin deposit
in skin and sclera
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19. Alcohol +gastrin +parietal cell of stomach Gastric acid Duodenum หลัง H.secretin
่
Gallstone Bile reflux to pancreatic duct Pancreatic enzyme
cell damage
Fever
Hyperlipidemia Impaired function Autodigestion: proteolytic enzye
of pancreas
Vascular damage,Edema
Parenchyma necrosis
Head of pancrease กด Serosanginous exudate
bile duct เข้ าไปใน retroperitoneal tissue
Jaundice Peritonitis Hypotension
Rigidity
Bowel sound absent
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20. gastric acid secretion
Hx. PU, PU Perforate
Hx.Smoking
Alcohol drinking gastric mucosal Irritation
Edema in gastric outlet region Gastric secretion
leak to abd. cavity
gastric outlet obstruction Peritoneal irritation
Infection
Gastric distention Fever
Chill
Board like rigidity
Nausea/vomiting
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34. Problem List
• Cholecystitis
– Abdominal Pain
– High Fever
• DM
– Hyperglycemia
• Sepsis shock
– Hypotension
– Dyspnea
– Anuria
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35. •NPO
•Record V/S
•Record I/O
•Retained Foley cath
•Oxygen 3 L/min via nasal pronge
•DTX q 6 hrs hr if > 250 ให้ RI 5 unit ,
if < 70% ให้ glucose 50 cc IV
•0.9% NSS 1000 ml IV load 500 cc and then 100 cc/hr
•dopa 1:1 IV 15µd/min
•Paracet 1 amp IM prn for fever > 38 c q 6 hr
•Cef-3 1 gram IV q 12 hrs
•Genta 240 mg in 5% D/W 100 cc IV drip ½ hr OD
•Ranidine 50 mg IV q 8 hrs
•Lasix40 mg IV Loadrangsima@chiangmai.ac.th ml then 100 ml/hr (20.00)
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IV fluid 200 35