The risk of complications such as pressure ulcers, constipation, muscle atrophy due to the movement itself is not
S: patients say "hip itch skin"
Patients tell. "Taken on November 2, 2557"
: The patient complained of "feeling distension"
O: A bruise Red Grade 1 occupies the bottom Reed
: no bowel movement on 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 lying next to the bed for a long time without a flip side for more than 3-4 hours, if the pressure is approximately 70 meters. m. of mercury pressure for 1-2 consecutive hours to cause ischemia. Causing cell death and ischemic tissue. The cause of ulcers. Most of it will come to the bones and tissue damage. Which patients are at high risk of developing complications, pressure ulcers and constipation is a condition caused by a bowel movement fewer than three times per week by a small stool is solid. Difficulty in defecation Other factors include the promotion of this patient. To limit movement Patients injured bone in the hips and pelvis, and doctors do not make moves Bed rest for 7 days, the patient was limited to a specific motion to lay on the bed. Weak abdominal muscles. The lack of tight Weakness strainFaeces Photos taken on the pot to sit on the bed or beds. Causing discomfort, inconvenience shot anal sphincter inner and outer layers are relaxed. Cause fecal incontinence When fecal incontinence long overdue in the gut, making the stool hard and dry. Constipation causes the
purpose
to prevent pressure ulcers, and patients can have a normal bowel movement
assessment criteria
1. complications of sleep, such as pressure ulcers, constipation and muscle atrophy, or muscle weakness. Strength
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 the 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 care. Take care when patients are unable to clean the body so that the patient's skin clean and reduce the risk of pressure ulcers
4. flip side, every second. Hour, especially in patients who do not help themselves. Aligning the left side, 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 reducing pressure
5. avoid causing friction with such patients. Sheets are not flat To prevent friction and reducing pressure
, skin care 6. Patients thoroughly. Dry If the skin is wet or hot, can cause ulcers. Simple skin abrasions Specifically, the patient defecate or urinate ago. To clean and dab it dry. If you notice that a patient has dry flaky skin. Skin care cream or lotion that radiation
7. Care to receive food with high protein and calories. The rate of getting food. In particular protein is important for patients with pressure ulcers because patients. Lose proteins to the wound for many. Also, take care to vitamins Iron
8. recommend eating foods containing fiber, such as vegetables, fruits, etc., or dietary fiber intake will cause more and feces inside the colon move faster
9. teach patients and families to make Active & Passive exercise. muscles, blood vessels and skin healthy. The flow of blood
to drink plenty of water stimulate 10. 2000 -3000 cc / day of dehydration and rehydration salt 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 assess the bowel movement
12. explain the recommendations, including encouraging patients and relatives. To realize the importance of the flip side
•. If the patient realizes The flip side has Try to rotate frequently, every 30 minutes, except during sleep
•. In the case of coma The flip side should change positions every two hours by alternates. From the left side, right side, lying prone (if possible) by relatives, nurses and physiotherapists
13. A soft pillow. Vice straight to the bones and crook foot braced with planks to prevent foot drop. Be careful not to hips are widened. This causes discomfort and went not provide restraint to the wrist. In the correct posture is slightly bent elbows, wrists and fingers stretched rubber soft grip. And raised a hand to prevent swelling. Exercise every 4-8 hours and allows
15. encourage patients to exercise the muscles of the still strong. And nurse help a weak every 2-4 hours to prevent the muscles weaken and shrink brace. And a growing movement To enhance the movement of the intestines and stimulates the excretion of
16 patients submitted to training and rehabilitation with physiotherapist. When symptoms are generally better The remaining disability
evaluation
November 5, 2557
the first grade red rash around the coccyx, the patient complained of stomach. With constipation do not excrete And muscle atrophy or muscle weakness Motor Power = 3
6 พฤศจิกายน 2557
the rash of red coccyx area Grade 1 patients complain distension. With constipation do not excrete And muscle atrophy or muscle weakness Motor Power = 3
7 พฤศจิกายน 2557
the rash of red coccyx area Grade 1 patients complain distension. With constipation do not excrete Muscle weakness and muscle atrophy or motor power = 4.
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