เสี่ยงต่อภาวะแทรกซ้อนเช่น แผลกดทับ

The risk of complications such as ulcers, constipation, atrophied muscles pressed because the movement itself. S: patients say "itchy skin, hip area."Patient: "taken from November 2 2557.": Patient complains of "a tight tummy feeling."O: with cuts, abrasions, 1st grade red buttocks, around the Reed.: There is no excretion of stool since November 2 2557.Rigid stomach: patients: Bowel sound 3-5 times/minDiscussion of diagnostic messagesเนื่องจากผู้ป่วยได้รับบาดเจ็บบริเวณสะโพกและกระดูกสันหลังทำให้ไม่สามารถเคลื่อนไหวได้และนอนติดเตียงเป็นเวลานานโดยไม่พลิกตะแคงตัวเป็นเวลามากกว่า 3-4 ชั่วโมง โดยถ้ามีแรงกดประมาณ 70 มม.ปรอท กดทับเป็นเวลา 1-2 ชั่วโมงติดต่อกันจะทำให้เกิดการขาดเลือด ทำให้เซลล์และเนื้อเยื่อบริเวณที่ขาดเลือดตาย เป็นสาเหตุที่ทำให้เกิดแผลกดทับ ซึ่งส่วนมากจะเกิดบริเวณปุ่มกระดูกและทำลายเนื้อเยื่อ ซึ่งผู้ป่วยรายนี้มีความเสี่ยงสูงในการเกิดภาวะแทรกซ้อนแผลกดทับและภาวะท้องผูกเป็นภาวะที่เกิดจากการเคลื่อนไหวของลำไส้น้อยกว่า 3 ครั้งต่อสัปดาห์โดยจะมีอุจจาระเป็นก้อนแข็งเล็ก ถ่ายอุจจาระลำบาก โดยปัจจัยส่งเสริมของผู้ป่วยรายนี้ได้แก่ การจำกัดการเคลื่อนไหว เนื่องจากผู้ป่วยได้รับบาดเจ็บบริเวณกระดูกบริเวณสะโพกและอุ้งเชิงกรานทำให้เคลื่อนไหวไม่ได้และแพทย์ให้ทำ Bed rest เป็นเวลา 7 วัน ทำให้ผู้ป่วยถูกจำกัดการเคลื่อนไหวให้นอนอยู่เฉพาะบนเตียง ทำให้กล้ามเนื้อหน้าท้องอ่อนแรง ขาดความตึงตัว ไม่มีแรงเบ่งอุจจาระ ต้องนั่งถ่ายบนหม้อนอนหรือถ่ายบนเตียง ทำให้รู้สึกไม่สบาย ถ่ายไม่สะดวก กล้ามเนื้อหูรูดทวารหนักชั้นในและชั้นนอกไม่คลายตัว ทำให้เกิดการกลั้นอุจจาระ เมื่อกลั้นอุจจาระนานๆทำให้อุจจาระที่ค้างในลำไส้แข็งและแห้ง ทำให้เกิดภาวะท้องผูกขึ้นThe objective, To prevent pressure sores, and the patient can excrete feces normally.Evaluation criteria. 1. no complications from the bedroom, a long, such as pressure sores constipation and weakness in the muscle or atrophied muscles.2. excretion of stool every day/2 day/time.3. patients don't complain of abdominal/stomach pressed tight soft.4.Bowel sound is 4-6 times/min.Nursing activities.1. assess patient's skin that pathological skin or not. How to plan your treatment, nursing2. assessment of patient's stools every day of shooting. Constipation assessment that occurs in patients with decreased Bowel sound like flatulence, etc.3.แนะนำการดูแลความสะอาดร่างกายทั่วไป ช่วยดูแลกรณีผู้ป่วยไม่สามารถทำความสะอาดร่างกายได้เพื่อให้ผิวหนังของผู้ป่วยสะอาดและลดอัตราเสี่ยงของการเกิดแผลกดทับ4.พลิกตะแคงตัวทุก2 ชม.โดยเฉพาะในรายที่ผู้ป่วยช่วยเหลือตัวเองไม่ได้ โดยจัดให้ตะแคงซ้าย ตะแคงขวา นอนหงาย นอนคว่ำกึ่งตะแคง สลับกันไปตามความเหมาะสม ควรใช้หมอนหรือผ้านุ่มๆรองบริเวณที่กดทับ หรือปุ่มกระดูกยื่นเพื่อป้องกันการเสียดสีและลดแรงกดทับ5.หลีกเลี่ยงการทำให้เกิดแรงเสียดทานกับผู้ป่วยเช่น ผ้าปูที่นอนไม่เรียบ เพื่อป้องกันการเสียดสีและลดแรงกดทับ6. skin care for the patient, clean, dry, not damp because if the skin wet or hot, can cause eczema, skin abrasions, easier later, especially the patient defecate or urinate and then. Must be clean and dry, and if observed that patients with dry, cracked skin is scaly? Should care cream or lotion skin irradiation.7. take care to receive the food that is high in protein and calories along with evaluation receive food, particularly protein, essential to patients whose wounds pressed because the patient. Lose too much toward the wound, protein In addition to care, vitamins, iron. 8. recommends eating foods such as fruit, vegetables, etc. are very residue food residue or fiber has a much greater amount of stool and moves inside the colon faster. 9. teaching patients and relatives. Do Active & Passive exercise to keep muscles, blood vessels, and skin and strong with good blood circulation.10. the urge to drink lots of water, 2000-3000 cc/day of lack of water and minerals make the water back to the colon, the stool is very hard lumps and take difficult. Drinking more water will make the stool soft, easy shooting. 11. listen to the Bowel sound 1-2 times a day, morning and evening) to evaluate the intestinal movement.12.อธิบาย ให้คำแนะนำ รวมทั้งให้กำลังใจแก่ผู้ป่วยและญาติ ให้ตระหนักถึงความสำคัญของการพลิกตะแคงตัว• ถ้าผู้ป่วยรู้ตัว และสามารถพลิกตะแคงตัวได้ ให้พยายามตะแคงตัวบ่อย ๆ ทุก 30 นาที ยกเว้นช่วงที่นอนหลับ• ในกรณีที่ไม่รู้สึกตัว ควรพลิกตะแคงตัวทุก 2 ชั่วโมง โดยเปลี่ยนท่าสลับกันไป ตั้งแต่ตะแคงซ้าย นอนหงาย ตะแคงขวา นอนคว่ำ (ถ้าทำได้) โดยญาติ พยาบาล และนักกายภาพบำบัด1. the soft pillows, Deputy direct button and fold the toe has a wood lathe, to prevent the foot from falling, being careful not to gluteal returns the message that it can no longer comfort walking provides pillows, wrist is in the correct posture is slightly bent, elbows, wrists, and fingers clawed soft rubber balls, and lifted a high end hand to prevent swelling and help exercise every 4-8 hours.3. encourage patients to exercise muscles that are also healthy and nursing assistant working out of every 2 – 4 hours of weakness, to prevent the muscles weaken and shrink, and there has been a growing movement to increase the movement of the bowels and stimulates the excretion.4. send the patient to practice rehabilitation with a physiotherapist. When typical symptoms and disabilities remain.The assessments.November 5 2557A red rash occurs, grade 1 The human coccyx area. Patients complained stomach tightly. Depression, constipation can not excrete and atrophied muscle, or muscle weakness in the motor power = 3.November 6 2557A red rash occurs, grade 1 The human coccyx area. Patients complained stomach tightly. Depression, constipation can not excrete and atrophied muscle, or muscle weakness in the motor power = 3.November 7 2557A red rash occurs, grade 1 The human coccyx area. Patients complained stomach tightly. Depression, constipation can not excrete and atrophied muscle, or muscle weakness in the motor power = 4.

The risk of complications such as pressure ulcers, constipation, muscle atrophy, because the movement itself is not
S: Patients tell "skin itching hip"
Patients tell. "Taken on November 2, 2557"
: Patients complain "feel distension"
O: A bruise Red Grade 1 occupies the bottom Reed
: no bowel movement since November 2, 2557
: The patient abdominal stiffness
: bowel sound 3. -5 / min
discuss their diagnosis
because patients wounded in the hip and spine, unable to move and lie next to the bed for a long time without a flip side for more than 3-4 hours a pressure of about 70 m. m. of mercury pressure for 1-2 consecutive hours to cause ischemia. Cells and tissues ischemic death. The cause of ulcers. Most of which will occur in the bones and tissue damage. Which patients are at high risk for complications of pressure ulcers and constipation, a condition caused by a bowel movement fewer than three times per week by a small hard lump of feces. difficulty in defecation Other factors include the promotion of this patient. To limit movement Because patients wounded in the hip and pelvic bone, and doctors do not make moves Bed rest for seven days, the patient was limited to a specific motion to lay on the bed. Abdominal muscle weakness. The lack of tight Weakness strainFaeces Take the pot to sit on the bed or a bed. Causes discomfort, inconvenience, taking anal sphincter inner and outer layers are relaxed. Cause fecal incontinence Fecal incontinence when the stool long overdue in the gut and freeze dried. Cause constipation was
intended
to prevent pressure ulcers, and patients can have a normal bowel movement
Evaluation Criteria
1. No complications of sleep, such as pressure ulcers, constipation and muscle atrophy, or muscle weakness. force
2. bowel movement every day / 2-3 days / times
3. patients do not complain distension / press soft stomach
4.Bowel sound 4-6 times / min
Nursing activities
1. assess the patient's skin with a skin pathology. or not Look like? To plan nursing
2. Assess the patient's bowel movement every day. Assessment constipation, bloating occur in such patients Bowel sound reduction, etc.
3. The introduction of a common body cleanliness. If the patient can not take care of cleaning the body so that the patient's skin clean and reduce the risk of pressure ulcers
4. The flip side of every second. Hour, particularly in patients who do not help themselves. On the left side to the right side, lying prone, semi side. Alternates as appropriate Use a pillow or soft pad in the press. Or submit the bones to prevent friction and reduce pressure
5. avoid causing friction with such patients. Bedding uneven To avoid friction and reduce pressure
6. Skin care patients thoroughly. Dry damp If the skin is wet or moist heat can cause eczema. Skin abrasions easy Specifically, the patient defecate or urinate then. To clean and wipe dry. If you notice that a patient has dry flaky skin. Skin care cream or lotion that radiation
7. Ensuring get protein and high in calories. The rate of getting food. In particular protein is important for patients with pressure ulcers because patients. Lose to the wound with lots of protein. In addition, the need for vitamins Iron
8. recommend eating foods containing fiber, such as vegetables, fruits, etc., or dietary fiber or more to make up the stool and moves inside the large intestine faster
9. teach patients and families to make Active & Passive exercise. muscles, blood vessels and skin healthy. The flow of blood
to drink lots of water, prompting 10. 2000 -3000 cc / day of dehydration and rehydration salt makes the colon making stools more solid and trouble shooting. Drinking more water will make stools soft and easy shot
11. Listen Bowel sound 1-2 times a day - morning and evening) to evaluate the movement in the intestines
12. Notes provide guidance and support to patients and their relatives. The flip side is aware of the importance of a
•. If the patient is conscious The flip side has Try to rotate frequently, every 30 minutes, except during sleep
•. In the case of comatose The flip side should change positions every hour or two alternates. From the left side, right side, lying prone (if possible) by relatives, nurses and physiotherapists
13. A soft pillow. Secondary bone meets the crook and toe boards are braced to prevent foot drop. Be careful not to splay out the rump. This causes discomfort and walking is not provided to wrist restraints. The correct posture is slightly bent elbows, wrists and fingers stretched rubber soft grip. And raised a hand to prevent swelling. And help exercise every 4-8 hours
15. encourage patients to exercise the muscles of the still strong. Ambulance and rescue exercise at all, beaten 2-4 hours to prevent the muscles weaken and shrink brace. And is moving up To increase bowel movements and stimulates the excretion
16. Sending patients to exercise rehabilitation with physiotherapist. When symptoms are generally better The remaining disability
evaluation
November 5, 2557
the first grade red rash around the coccyx patients complain distension. Constipation is not yet toilet Muscle weakness and muscle atrophy or Motor Power 3 =
6 พฤศจิกายน 2557
grade 1 rash, red itchy areas coccyx patients complain distension. Constipation is not yet toilet Muscle weakness and muscle atrophy or Motor Power 3 =
7 พฤศจิกายน 2557
grade 1 rash, red itchy areas coccyx patients complain distension. Constipation is not yet toilet Muscle weakness and muscle atrophy or motor power = 4.

The risk of complications such as pressure ulcers, muscle atrophy, constipation, because the movement itself.S: patient said, "itchy skin around the hips.": the patients tell "taken since the day 2 November 2557."The patient complained: "feel distension."O: bruises Red 1 grade straight at the bottom of a reed.: no bowel movement since the day 2 November 2557.: the patients gagging friendships.: bowel sound 3-5 / minute.Discussion of diagnosis.Because patients injured at hip and spine cannot move, and sleep on the bed for a long time without celebration on for more than 3-4 hours. If there is pressure about 70 mm Hg pressure for 1-2 consecutive hours, will cause the loss of blood. Cell and tissue area infarction died. The cause that causes sores. Most of which will be born the tuberosity and destroy tissue. That this patient has a high risk of complications and bedsore constipation is a condition caused by bowel movement less than 3 times per week the feces solidification is small. Defecation hard by the promoting factors of this patient were the limited movement. Because the patient injured bone area at hip and pelvis deactivated and doctors to do Bed rest for 7 days. The patient is restricted movement, sleep is only on the bed. The abdominal muscle weakness, lack of tight, no push stool to sit on or taken หม้อนอน taking on the bed feel sick. Taking is convenient. The inner and outer anal sphincter muscles not loose, causing a bearing feces. When hold feces feces intestinal long to hold hard and dry, causing constipation.Objective.To prevent pressure ulcers and patients can excrete feces as usual.The evaluation criteria.1. No complications from sleep for a long time, such as pressure ulcers, constipation, and muscle atrophy, or muscle weakness.2. Bowel movements every day / 2-3 days / times.3 patients complaining of distension / press the stomach soft.4.Bowel sound 4-6 / minute.Activity photos.