ciroza hepatica licenta

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Cuprins

PARTEA TEORETICA..................................................................................................... 2INTRODUCERE..........................................................................................................2

ANATOMIA FICATULUI..............................................................................................5

FIZIOLOGIA FICATULUI.............................................................................................6

CIROZA HEPATICA.....................................................................................................9

ETIOLOGIE............................................................................................................ 9

PATOGENEZA.......................................................................................................10

SIMPTOMATOLOGIE............................................................................................. 10

EXAMEN OBIECTIV GENERAL...............................................................................15

EXPLORAREA FUNCTIONALA A FICATULUI............................................................15

DIAGNOTIC POZITIV............................................................................................ 19

DIAGNOSTIC DIFERENŢIAL..................................................................................20

COMPLICAŢIILE CIROZEI HEPATICE......................................................................21

TRATAMENTUL IN CIROZA HEPATICA....................................................................22

PARTEA PRACTICA.....................................................................................................25

ROLUL ASISTENTEI MEDICALE IN INGRIJIREA BOLNAVILOR CU CIROZĂ HEPATICĂ....26

STUDII DE CAZ........................................................................................................ 28

CAZUL I...............................................................................................................28

CAZUL II..............................................................................................................36



PARTEA

TEORETICA



Ingrijireapacientului cu ciroza hepatica

INTRODUCERE

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3




ANATOMIA FICATULUI

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FIZIOLOGIA FICATULUI

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%ca,u-u% %( cadru- a&ara,u-u% c%rcu-a,'r2

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5



Hematopoetică

Biligeră

ntito!ică

"ermogenetică

#egenerare

$egate %e meta&oli'mul interme%iar

(epozit

Homeo'tazie circulator

(eto!i)ere

*oagulare


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CIROZA HEPATICA

C%r'+a 1e&a,%c" 7CH8 re&re+%(," ),ad%u- %(a- a- 1e&a,'&a,%%-'r cr'(%ce0 carac,er%+a, &r%(

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ETIOLOGIE

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PATOGENEZA

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SIMPTOMATOLOGIE

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10




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11




? S%(dr'/u- 1e/'ra.%&ar

S%(dr'/u- (eur'e(d'cr%(

>2 S%(dr'/u- 1%&er,e()%u(%% &'r,a-e

Are ca e9&re)%e c-%(%c" ' ,r%ad" )%/&,'/a,%c" ce )e %(),a-ea+" ,re&,a,2

a D%)&e&)%a .a+'a)" $% /e,e'r%)/u- %reduc,%*%- da,'r%," ,u-*ur"r%% re)'r*!%e% .a+e-'r $%

1%&'9%e% &ere,e-u% %(,e),%(a-

* De+5'-,area c%rcu-a!%e% c'-a,era-e e9,er(e )% %(,er(e0 e9&re)%e a $1u(,"r%% )3(.e-u%

&'r,a-2

c E(cea-'&a,%a &'r,a-" e9&re)%e a %(,'9%ca!%e% )%),e/u-u% (er5') cu &r'du$% de

de.radare %(,e),%(a-" 7a/'(%ac0 a/%(e0 der%5a!% e('-%c%8 ce (u au /a% a6u() )a %e /e,a*'-%+a!%

#( %ca, da,'r%," )1u(,u-u% &'r,')%),e/%c2( &er%'ada %(%!%a-" a&ar: a-,er"r% #( c'/&'r,are $% 6udeca,a0 a-,er"r% a!" de

&er)'(a-%,a,ea )a0 ,u-*ur"r% de e/',%5%,a,e ce /er. &3(" -a a&a,%e=de&re)%e )au eu'r%e=a.%,a!%e

)'/('-e(!"0 %(5er)area r%,/u-u% )'/(=5e.1e2

A&'% )e adau." a),e(%a cu #(.reu(area ac,%5%,"!%% /e(,a-e0 ,u-*ur"r% de 'r%e(,are0

c'(u+%%0 a,%.a*%-%,a,e2 D%%cu-,a,ea de e9&r%/are $% deec,e de 5'r*%re &3(" -a de+'rd%(e0

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@2 S%(dr'/u- a)c%,'=ede/a,')E),e ce- care rea-%+ea+" a$a=(u/%,a Qdec'/&e()are 5a)cu-ar" a c%r'+e%<2 A)c%,a e),e

acu/u-area de -%c1%d ,ra())uda,%5 #( ca5%,a,ea &er%,'(ea-" care )e %(),a-ea+" -e(, $% (u e),e

dece-a*%-" c-%(%c c3(d -%c1%du- )e a-" )u* 0 > - c3(d acea),a e),e 5'-u/%('a)" duce -a

d%),e()%a $% 1e/%erea '/*%-%cu-u%2 Ede/e-e -'ca-%+a,e #(de')e*% -a (%5e-u- /e/*re-'r %(er%'are

)u(, a-*e0 /'%2

42 S%(dr'/u- %c,er%c

Ic,eru- &'a,e c'(),%,u% &r%/u- )%/&,'/ c-%(%c a- u(e% c%r'+e2 E),e u( %c,er de ,%& 1e&a,%c

carac,er%),%c &e(,ru dec'/&e()area c%r'+e%0 ade)ea %()'!%," de a)c%,"2

( c%r'+a *%-%ar" &r%/%,%5"0 %c,eru-0 )%/&,'/u- /a6'r0 e),e de ,%& re5er)%*%-0 )e #()'!e$,e

de ur%(% #(c1%)e $% )cau(e dec'-'ra,e2 Se adau." &rur%,u- &er)%),e(,0 .e(era-%+a,0 &r'du) de

re,e(!%a )"rur%-'r *%-%are2

?2 S%(dr'/u- 1e/'ra.%&ar

12




Se /a(%e)," &r%(: e&%),a9%)0 .%(.%5'ra.%%0 .a),r'ra.%e 1e/'ra.%% cu,a(a,e 7&ur&ur"0

1e/a,'a/e82 E),e u( )%(dr'/ /%9, &r%( c'a.u-'&a,%e0 ,r'/*'c%,'&e(%e $% 5a)cu-'&a,%e2

2 S%(dr'/u- (eur'-'.%c

Ma(%e),ar%-e (eur'-'.%ce )u(, c'()ec%(!a e(cea-'&a,%e% &'r,'ca5e0 a %()u%c%e(!e%

1e&a,'ce-u-are a5a()a,e $% a ,u-*urar%-'r 1%dr'e-ec,r'-%,%ce 71%&'(a,re/%e0 1%&'&',a)e/%e82

A&ar de),u- de &rec'ce ,u-*ur"r% de /e/'r%e -a care )e adau." ,u-*ur"r% &)%1%ce2

Ace),ea )u(,: de-%r0 de+'r%e(,are0 cr%+e de a.%,a!%e0 ,u-*ur"r% a-e ),"r%% de c'()%),e(!" de

)'/('-e(,a 7'*(u*%-are8 &3(" -a c'/a &r'u(d"2

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)cur,e0 de -e9%e0 e9,e()%e a-e /3%(%% d%( ar,%cu-a!%a /e,acar&'=a-a(.%a(" )u* 'r/" de )ecu)e0

a)e/"(",'are cu *",a%a ar%&%-'r &")"r%-'r2

M'd%%car% cu,a(a,e )u(, re&re+e(,a,e de ),e-u!e-e 5a)cu-are 7a(.%'a/e-e ),e-a,e8 d%)&u)e

&e ,er%,'r%u- 5a)cu-ar a- 5e(e% )u&er%'are er%,e/u- &a-/ar: c'-'ra!%a r'$u=a&r%() a e/%(e(!e-'r

,e(are $% 1%&',e(are $% a &u-&e% de.e,e-'r +'(e cu,a(a,e r',u(de /a% &a-%de dec3, re),u- &%e-%%0

c're)&u(d u(e% %)c1e/%% c'()ecu,%5e )cur,c%rcu%,e-'r 5a)cu-are /'d%%c"ar% a-e a(ere-'r: -a

a/*e-e )e9e )e &r'duce ' )c"dere a &"ru-u% a9%-ar $% &u*%a(2

13




F%. K2 A)&ec, /acr')c'&%c a- c%r'+e% 1e&a,%ce c'/&ara,%5e cu ),rc,ura 1e&a,%ca ('r/a-a

EXAMEN OBIECTIV GENERAL

F%ca,u- &'a,e % .")%, /"r%,0 ('r/a- )au a,r'%c #( u(c!%e de a+a e5'-u,%5" $% de ,%&u-

e,%'&a,'.e(%c a- c%r'+e%Ur/"r%rea d%/e()%u(%-'r 1e&a,%ce ara," ,e(d%(!a )&re /%c"'rare a

%ca,u-u%2C'()%),e(!a 'r.a(u-u% e),e ,',deau(a er/"20 u(e'r% dur"0 %ar /ar.%(ea %(er%'ara )%/,e

)u*!%a," #( a+e a5a()a,e = ,"%'a)"2U(e'r% -'*u- ),3(. e),e redu) -a ' )%/&-" -a/a )u*!%re0 u$'r

acr'$a*%-a2

Su&raa!a acce)%*%-" &a-&"r%% &'a,e % re.u-a," dar de)e'r% )e )%/, (ere.u-ar%,"! /acr'

)au /%cr'('du-are dure #( )&ec%a- #( a+a re)&%ra,'r%e2 S&re de')e*%re de %ca,u- )e()%*%- $%durer') d%( 1e&a,%,e-e cr'(%ce #( c%r'+e %ca,u- e),e %()e()%*%- $% (edurer')

( c%r'+e-e cu a)c%," a*u(de(,"0 %ca,u- e),e #/&%() )&re ,'race0 .reu &a-&a*%- )au (u/a%

#( &'+%,%e de decu*%, -a,era- ),3(.2

S&-%(a e),e ,',deau(a /"r%," #( c%r'+e2 S&-e('/e.a-%a &'a,e % /'dera,"0 &a-&a*%-" -a

(%5e-u- re*'rdu-u% c'),a- )au %/ed%a, )u* re*'rd0 de)e'r% de&a$e$,e cu @=? -a,ur% de de.e,

/ar.%(ea c'),a-"2 E),e er/"0 (edurer'a)" $% #( .e(era- &a),rea+a 'r/a 'r.a(u-u%2

S&-e('/e.a-%a )e &'a,e de+5'-,a de)ce(de, #( -a(c )au ,ra()5er)a- )&re e&%.a),ru

EXPLORAREA FUNCTIONALA A FICATULUI

M'd%%c"r%-e &ara/e,r%-'r u(c!%'(a-% *%'c1%/%c% &', % cu&r%()e #( ? )%(dr'a/e /a6're

$% a(u/e:

= S%(dr'/u- de 1e&a,'c%,'-%+"

= S%(dr'/u- de de%c%, u(c!%'(a- 1e&a,%c )au )%(dr'/u- 1e&a,'&r%5

= S%(dr'/u- de %(-a/a!%e )au de reac!%e /e+e(c1%/a-"

= S%(dr'/u- c'-e),a,%c 7e9cre,'*%-%ar8

a E9&-'rarea )%(dr'/u-u% de 1e&a,'c%,'-%+"

14




S%(dr'/u- de 1e&a,'c%,'-%+" re&re+%(,a a-,erarea %(,e.r%,"!%% 1e&a,'ce-u-are2

( ace), )c'& )e ac ur/",'are-e de,er/%("r%:

= Transaminazele: = TGP 7,ra()a/%(a+a .-u,a(%c'=&%ru5%c"8= are 5a-'r%

/u-, cre)cu,e #( c%r'+a a-c''-%c"

= TGO 7,ra()a/%(a+a .-u,a(%c'='9a-ace,%c"8

( c%r'+a 1e&a,%c" #()'!%," de u( )%(dr'/ 1e&a,'c%,'-%,%c /'dera,0 5a-'r%-e /ed%% a-e

ASATALAT )u(, de 4?44 U2I2

= Aldalozele şi alte enzime >=@ U2S2L2

= Sideremia (fierul seric) =>? .

Ace),ea (u )u(, )&ec%%ce (u/a% -e+%u(%-'r %ca,u-u%0 re+u-,a,e cre)cu,e &u,e/ .")% $% #(

)c-ecr'+a a-,'r 'r.a(e2

* E9&-'rarea )%(dr'/u-u% de de%c%, u(c!%'(a- 1e&a,%c )au )%(dr'/u-u% 1e&a,'&r%52

Pe(,ru e5a-uarea %()u%c%e(,e% 1e&a,%ce0 )e/(%%ca,%5e )u(, ur/",'are-e ,e),e:

1. Te),e care e5a-uea+" ac,%5%,a,ea /e,a*'-%c" $% de )%(,e+"

a8 Te),e care )e reer" -a /e,a*'-%)/u- &r',%d%c2

De,er/%(area &r',e%(e-'r: a-*u/%(e0 .-'*u-%(e2 Va-'r% )u* 4. a-e a-*u/%(e/%e%

)e/(%%c" %/%(e(!a %(),a-"r%% a)c%,e%2 Va-'r% )u* @. a-e a-*u/%(e/%e% %(d%c" u( &r'.('),%c

)e5er2- Te),e de c'a.u-are: ,%/& u%c0 ,%/& H'e--0 c'(ce(,ra!%a de

&r',r'/*%("2 Sc"derea %(d%ce-u% de &r',r'/*%(" )u*

(ec'rec,a," de ad/%(%),rarea &are(,era-" de 5%,a/%(a 0 )e

c're-ea+" cu /a)a 1e&a,'c%,ar" u(c!%'(a-" re),a(,"2 Va-'r% )u*

a-e %(d%ce-u% de &r',r'/*%(" au &r'.('),%c 'ar,e re+er5a,2

- Te),u- '--er: &rec%+ea+" dac" a-,erarea ,%/&u-u% u%c )e

da,'rea+" u(e% %()u%c%e(!e 1e&a,%ce 'r% u(e% cau+e

e9,ra1e&a,%ce0 cu/ ar %: de%c%,u- de a*)'r!%e a 5%,a/%(e% -a

(%5e-u- %(,e),%(u-u%0 ( ca+ de %c,er /eca(%c2 Te),u- '--er (e

a6u," -a d%er(!%erea u(u% %c,er /eca(%c de u(u- &are(c1%/a,')2

- D'+area %*r%('.e(u-u%: )c"derea %*r%('.e(u-u% )er%c a&are #(

),ad%%-e a5a()a,e de *'a-"2 Va-'r% )u* @ /. a-e

15




%*r%('.e(u-u% au )e/(%%ca!%e &r'.('),%c" .ra5"2

- A/'(%e/%a: (e 'er" da,e reer%,'are -a e(cea-'&a,%a &'r,a-"2

NW>? ? U. #( &-a)/a

*8 Te),e care )e reer" -a /e,a*'-%)/u- .-uc%d%c2

- Te),u- 1%&er.-%ce/%e% &r'5'ca,e 7,e),u- ,'-era(!e% -a .-uc'+"82

- Te),u- ,'-era(!e% -a .a-ac,'+" = ca&ac%,a,ea %ca,u-u% de a

/e,a*'-%+a .a-ac,'+a "r" %(,er5e(!%a %()u-%(e%2

c8 Te),e care )e reer" -a /e,a*'-%)/u- -%&%d%c

= De,er/%(area -%&%de/%e%2

2. Te),e care e9&-'rea+" e('/e(e-e /e,a*'-%ce e9cre,'r%% $% c%rcu-a,'r%%2

Ca&ac%,a,ea %ca,u-u% de a e&ura &-a)/a &'a,e % cerce,a," &r%(:

= Te),u- cu B2S2P2 7*r'/)u-'(,a-e%(a8 )au re,e(!%a de B2S2P= C-eare(ce=u- B2S2P 75'-u/u- de &-a)/" e&ura, de ce-u-e-e 1e&a,%ce #(,r=u( /%(u,

)cade #( aec!%u(% 1e&a,%ce82

a E9&-'rarea )%(dr'/u-u% de %(-a/a!%e )au de reac!%e /e+e(c1%/a-"2

Pe(,ru acea),a eec,u"/:

= VSH

= Te),e de d%)&r',e%(e/%e: Taa,a=Ara0 T1/'-0 Su-a, de Z(2

= E-ec,r''re+a = a-*u/%(e K= .-'*u-%(e ? d%( care Y>WK0 Y@W 0 4W>? 0 [W>=>

* E9&-'rarea )%(dr'/u-u% e9cre,'*%-%ar

De,er/%(area *%-%ru*%(e/%e% > /. d%rec," =0@ /. 0 %(d%rec," d%( cea ,',a-"2

( c%r'+a 1e&a,%c" *%-%ru*%(e/%a e),e #( .e(era- u$'r cre)cu," cu 5a-'r% /ed%%2

E9&-'r"r% u(c!%'(a-e cu )e/(%%ca!%e e,%'&a,'.e(%c"

Se ac ur/",'are-e de,er/%("r%:

= A. HB) 7a(,%.e( Au),ra-%a8 e),e &re+e(, #( )3(.e-e *'-(a5%-'r0 #(

1e&a,%,a 5%ra-" B

= Ac HB) 7a(,%c'r&u- a(,% HB)8 = a&ar%!%a a(,%c'r&%-'r are ' )e/(%%ca!%e

a5'ra*%-" &e(,ru e5'-u!%a &r'ce)u-u% 1e&a,%c2

= C'/&-e/e(,u- )er%c

16




= A-a e,'=&r',e%(a e),e &re+e(," -a d%(,re *'-(a5%% cu ca(cer

&r%/%,%5 1e&a,%c2

= IDR Ca)'(% &e(,ru c1%), 1%da,%c2

E9&-'rar% /'r'-'.%ce

a Pu(c!%a *%'&)%e 1e&a,%c" = ur(%+ea+" /a,er%a-u- &e(,ru e9a/e(u- 1%),'-'.%c0

caru%a #% re5%(e r'-u- &r%(c%&a- #( c'(%r/area d%a.('),%cu-u% de c%r'+"2

Gradu- de de+5'-,are a- c%r'+e% )e e),%/ea+" #( e9c-u)%5%,a,e -a e9a/e(u- 1%),'-'.%c

du&" &r'&'r!%a de &are(c1%/ ,ra()'r/a," #( ('du-%: &3(" -a > W ),ad%u- I W ),ad%u- II0

> W ),ad%u- III2

* La&ar')c'&%a = 5%+ua-%+area d%rec," a %ca,u-u% cu a6u,'ru- u(u% a&ara,

(u/%, -a&ar')c'&2 E),e %(d%ca," #( ),ad%%-e %(c%&%e(,e0 c'/&e()a,e0 dar (ue),e ' /e,'da rec5e(, u,%-%+a,"2

c Ec'.ra#a a*d'/%(a-" = &'a,e )" aduc" da,e #( )e()u- )u)!%(er%%

d%a.('),%cu-u% $% a(u/e: a)&ec,u- %ca,u-u%0 d%/e()%u(%-e )&-%(e%0 &re+e(!a

)e/(e-'r de 1%&er,e()%u(e &'r,a-"0 &re+e(!a -%c1%du-u% de a)c%,"0

d%/e()%u(%-e 5e(e% &'r,e0 &ere!%% du*-%% a% c'-ec%),u-u%2

d Sc%(,%.ra/a 1e&a,%c" = e),e ' /e,'d" &r%( care )e e5a-uea+" ),area

u(c!%'(a-" a %ca,u-u% $% #( )%,ua!%a #( care ace),a e),e d%%c%- de &a-&a,7'*e+%,a,e0 a)c%,a )u* &re)%u(e82 Se '-')e)c %+','&% rad%'ac,%5%: aur

c'-'%da-0 r'+ *e(.a-0 a-*u/%(a u/a("2

e Rad%'.ra%a *ar%,a," a e)'a.u-u% = &u(e #( e5%de(!" 5ar%ce-e e)'a.%e(e2

E)'a.'du'de(')c'&%a = e),e ' /e,'d" d%rec," &e(,ru 5%+ua-%+area

5ar%ce-'r e)'a.%e(e c3, $% &e(,ru ),a*%-%rea /"r%/%% ace),'ra2

V%+ua-%+area 5ar%ce-'r &e ca-e e(d')c'&%c" (e &er/%,e ' /a% *u("

a&rec%ere a (u/"ru-u%0 5'-u/u-u% $% a -'ca-%+"r%% ace),'ra2

. E9&-'r"r% a(.%'.ra%ce )u(, %(d%ca,e (u/a% -a c%r',%c%% care r%d%c"

&r'*-e/e de d%a.('),%c $% ,ra,a/e(, a- 1%&er,e()%u(%% &'r,a-e0 /a% a-e)

du&" )3(.erare2

1 Me,'da )&-e('&'r,'.ra%c" (e 'er" &')%*%-%,a,ea /")ur"r%% &re)%u(%%

)&-e(%ce0 care #( .e(ere0 c're)&u(de &re)%u(%% &'r,a-e2

1+




% Parace(,e+a )e &rac,%c" de re.u-" #( /'d e9&-'ra,'r &e(,ru de,ec,area

a)c%,e% $% &e(,ru e9a/%(area -%c1%du-u% de a)c%,"2 C3(d 5'-u/u- a)c%,e%

e),e a&rec%a*%- -a e9a/e(u- c-%(%c0 eec,uarea &arace(,e+e% e),e ac%-" $% )e

e9ecu," du&" ,e1(%ca '*%$(u%,a #( ')a %-%ac" ),3(."0 -a u(%rea ,re%/%%

/ed%% cu cea e9,er(" a -%(%e% '/*%-%c'=%-%ace2

L%c1%du- de a)c%," '*!%(u, e),e )u&u) e9a/e(u-u% /acr')c'&%c0 *%'c1%/%c 7d'+area

&r',e%(e-'r80 c%,'-'.%c $% *ac,er%'-'.%c2 ( c%r'+e ace),a e),e c-ar0 .a-*e(=c%,r%(2 I(,e()%,a,ea

cu-'r%% .a-*e(e de&%(de de .radu- *%-%ru*%(e% $% de c'(ce(,rarea -%c1%du-u% #( &r',e%(e2

U(e'r% &'a,e a5ea u( a)&ec, )er'=)a(.u%('-e(,0 a)&ec, care0 dac" e),e &a)a.er )e

da,'rea+" u(u% 5a) #(!e&a,0 dac" e),e &er)%),e(, )e/(%%c" %e u( )%(dr'/ 1e/'ra.%&ar #( cadru-

c%r'+e%0 %e e9%),e("a u(u% &r'ce) (e'&-a+%c2

L%c1%du- ,u-*ure )u.erea+" %(ec!%a2Reac!%a R%5'-,a e),e #( .e(ere- (e.a,%5"0 %ar c'(ce(,ra!%a #( &r',e%(e )u* @2

C'(ce(,ra!%% /a% /ar% #( &r',e%(e )e #(,3-(e)c #( a)c%,e-e %(-a/a,'r%% $% (e'&-a+%ce2

DIAGNOTIC POZITIV

D%a.('),%cu- &'+%,%5 a- c%r'+e% re+u-," d%( #()u/area da,e-'r c-%(%ce cu ce-e u(c!%'(a-=

*%'c1%/%ce $% /a% a-e) /'r'-'.%ce2

D%a.('),%cu- de )u)&%c%u(e 5%+ea+" /a% a-e) &e &',a,'r%% cr'(%c% cu 1e&a,'/e.a-%e $% &e

ce% cu 1e&a,%," cr'(%c" &'),5%r',%c" cu ,e),e 1e&a,%ce c'(),a(, &'+%,%5e2

Su(, cu(')cu,e 4 ),a.%% de recu('a$,ere a c%r'+e% 1e&a,%ce:

> Su)&%c%'(area ace),e%a #( *a+a da,e-'r c-%(%ce0 a(a/(e+e%0 a e9a/e(u-u% '*%ec,%5 $%

a e9a/e(e-'r de -a*'ra,'r2

D%a.('),%cu- de c%r'+" de5%(e e5%de(, -a u( *'-(a5 cu 1e&a,%," 5%r',%c" #( a(,ecede(,e0

/a% a-e) cu 5%ru) ('( A ('( B $% cu &er)%),e(,a A. HB) #( )3(.e )au cu ' %),'r%e #(de-u(.a," de

c'()u/ a*u+%5 de a-c''-0 care #( &re+e(, )e &-3(.e de a),e(%e0 ,u-*ur"r% d%)&e&,%ce0 /a(%e),"r%

1e/'ra.%&are0 )c"dere &'(dera-" $% %c,er2 E),e (ece)ar ca *'a-a cr'(%c" de %ca, )" %e

18




recu(')cu," #( ),ad%u- de 1e&a,%," cr'(%c" )au de c%r'+" %(c%&%e(," c3(d &'a,e % c'(,r'-a," )u*

,ra,a/e(,2

Pr'*e-e de -a*'ra,'r de cer,%,ud%(e )u(,: a-*u/%(e/%a )u* 40 .0 C- BSF )u* K cu

T%@ &re-u(.%, &e),e > /%(u,e2

@ C'(%r/area /'r'-'.%c" a d%a.('),%cu-u% de c%r'+" &r%( PBH $% -a&ar')c'&%e2 PBH

e),e 'ar,e )u.e),%5" /a% a-e) #( c%r'+a /%cr'('du-ar" #( care -e+%u(%-e au

d%),r%*u!%e ac%('a)" dec3, #( c%r'+a /acr'('du-ar" #( care d%),r%*u!%a -e+%u(%-'r e),e

(ere.u-a,"2

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19




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20




@ E(cea-'&a,%a &'r,'1e&a,%c"

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TRATAMENTUL IN CIROZA HEPATICA

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21




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22




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23




PARTEA

PRACTICA

ROLUL ASISTENTEI MEDICALE IN INGRI5IREA BOLNAVILOR CU CIROZ6

HEPATIC6

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24




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STUDII DE CAZ

CAZUL I

CULEGEREA DATELOR

NUME SI PRENUME : I'(e)cu Ge'r.e,a

25




V]RSTA: K a(%

SEX: e/%(%(

DOMICILIUL: Ga-a,%

STAREA CIVILĂ: ca)a,'r%,"

OCUPAŢIA: &e()%'(ar"

NAŢIONALITATEA: r'/a("

RELIGIA: 'r,'d'9a

ANTECEDENTE PERSONALE: c%r'+" 1e&a,%c" cu a)c%," d%a.('),%ca," cu @ a(% %( ur/"2

ANTECEDENTE HEREDOCOLATERALE: -%&)%,e de %/&'r,a(!"2

GRUPA DE S]NGE: BIII (e.a,%52

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• C%r'+a 1e&a,%ca dec'/&e()a,a 5a)cu-ar2

• E(cea-'&a,%e

• Her(%e '/*%-%ca-a

MOTIVELE INTERNARII:

• D%)&(ee /arca,a de e'r, )% re&a')0 a),e(%e e9,er(a

• Cre),erea %( 5'-u/ a a*d'/e(u-u%

• Ede/e a-e /e/*re-'r %(er%'are

• S,are de d%)c'('r, a*d'/%(a-2

ISTORICUL BOLII: =&ac%e(,a %( 5ar),a de K a(%0 a '), %(,er(a," da,'r%," d%)&(ee% /arca(,e0

cre),er%% %( 5'-u/ a a*d'/e(u-u%0 e(de/e a-e /e/*re-'r %(er%'are )% 1er(%e '/*%-%ca-a2 S=a

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c-%(%c%% &e(,ru ,ra,a/e(, de )&ec%a-%,a,e2

PROBLEMELE PACIENTEI

=d%)&(ee

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=ede/e -a /e/*re-e %(er%'are

NEVOI:

>2 Ne5'%a de a re)&%ra )% a a5ea ' *u(a c%rcu-a,%e

26




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a-e

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28




Ne5'%a de

a

c'/u(%ca

('r/a-

=re-a,%% a(e5'%'a)e

cu a/%-%a

u(u% c-%/a,

care )a

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)% e9&r%/e

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e>>2Ne5'%a

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ac,%'(ac'('r/

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)% 5a-'r%0

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a %

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29




de a %(5a,a

cu/ )a=,%

&a),re+%

)a(a,a,ea

e),e ('u &ac%e(,e% cu

&r%5%re -a

*'a-a )%

&re5e(%rea

e%

30



Ingrijirea pacientului cu ciroza hepatica

Ta*e- @2 P-a(d de %(.r%6%re &ac%e(, I

D%a#)!&%' ,e

I)#(%7%(e

O0%e'%e I)e(e)%% Ea$+a(e

>2DISPNEE Pac%e(,a 5a a5ea ' re)&%ra,%e

cu ' rec5e(,a %( -%/%,e

%+%'-'.%ce %( decur) de ?=

+%-e2

A/ a)e+a, &ac%e(,a %( &'+%,%e'r,'&(e%ca &e(,ru a a5'r%+a

re)&%ra,%a0 a)e+a(d %( )&a,e-e

&ac%e(,e% d'ua &er(e2

A/ aer%)%, )a-'(u-2

A/ %(5a,a, &ac%e(,a )a

re)&%re c'rec, 7)a %()&%re

&r'u(d &e (a) )% )a e9&%re &e

.ura8

Pac%e(,e% I )=a ad/%(%),ra,

'9%.e( &e /a)ca K-1 cu

%(,er/%,e(,a > /%( de d'ua

'r% &e 'ra2 A/ )u&ra5e.1ea,

cu /are a,e(,%e /'du- de

ad/%(%),rare a O@ de*%,u- -u%

)% rec5e(,a ad/%(%),rar%%

'9%.e(u-u%2S=a eec,ua,

Du&a /a)ur%-e a&-%care -a ' 'ra ),area

&ac%e(,e% e),e u)'r a/e-%'ra,a rec5e(,a

re&%ra,%e% %%(d de @/%(=-a >@ 're de -a

%(,er5e(,%% ),area &ac%e(,e% )=a /a%

%/*u(a,a,%,0 rec5e(,a re)&%ra,%e% %%(d

de >/%( &u-)u- e),e de /%( %ar

TAW>?K//H.

31




&arace(,e+a

@2 ALIMENTATIE

INADECVATA PRIN

DEFICIT

Pac%e(,a )a %e ec1%-%*ra,a

(u,r%,%'(a- )% 1%dr'e-ec,'-%,%c

%( 4 +%-e

A/ &re+e(,a, &ac%e(,e%

(ece)%,a,ea u(e% d%e,e

1%&')'da,e2

A/ %(,'c/%, ' -%),a cu

a-%/e(,e-e &er/%)e )%

%(,er)%)e0 educa(d a/%-%a )%

a/ ceru, de -a *uca,ar%a

)&%,a-u-u% re)&ec,area

re.%/u-u%2

Au '), e9&-'ra,e .u),ur%-e

&ac%e(,e%2

A-%/e(,e-e au '), )er5%,e -a

're re.u-a,e2

A&'r,u- de &r',e%(e )=a

I( &r%/e-e @ +%-e &ac%e(,a )=a

a-%/e(,a, )% 1%dra,a, &er= %()u%c%e(,

I( ur/a,'are-e +%-e &ac%e(,a a reu)%,

)a /a(a(ce )a,%)aca=,'r )% )a )e

1%dra=,e+e cu >/- -%c1%de2

32




)ca+u, de'arece &ac%e(,a

&re+e(,a e(cea-'&a,%e2

A-%/e(,a,%a era *'.a,a %(

.-uc%de )% -%c1%de 7)uc

(a,ura-0 a&a &-a,a0

cea%%(du-c%, cu/%ere8

Pe &arcur)u- re+'-5ar%%

e(cea-'&a,%e% )e 5'r

)u&-%/e(,a care(,e-e %(

&r',e%(e2

La %(d%ca,%%-e /ed%cu-u%

&ac%e(,e% % )=a ad/%(%),ra,

P'-%5%,a/%(e 49>+%

Pe(,ru reacerea

&are(c1%/u-u% 1e&a=,%c % )=a

ad/%(%),ra, A)&a,''r, @9>%( /- .-uc'+a +%

Du&a re+'-5area

e(cea-'&a,%e% % )=a

ad/%(%),ra, 1%dr'-%=

+a(,e de &r',e%(e

7A/(%'&-a/a- 8 /-+%

33




42 ELIMINARE

INADECVATA

CANTITATIV

Pac%e(,a )a %e ec1%-%*ra,a

1%de'e-ec,r'-%,%c )% )a (u

&re+%(,e r%)c a- %(ec,%%-'r

ur%(are

Z%-(%c )=a eec,ua, *%-a(,u-

1%dr'=e-ec,r'-%,%c2

I(.e),%a

=.-uc'+a > /-9S

_>U2I2 %()u-%(a

=de9,ra( ?=/-

=)uc >/-

=a-%/e(,e @.

=&-a)/a >/-

E9cre,%a

= d%ure+a @/-

=)cau( 4/-

=-%c1%d a)c%,%c ?/-

&ac%e(,e% % )=a %(d%ca, )a (u

c'()u/e /a% /u-, de > - de

-%c1%de +% /a% a-e) d%( ce-e *'.a,e %( Na2

A/ rec'-,a, ur%(a &e(,ru

e9a/e(u- ru/ar de ur%(a )%

*ac,er%'-'.%c La a&-%carea

)'(de% 5e+%ca-e a/ re)&ec,a,

re.u-%-e de a)e&)%e0 )'(da

Pac%e(,a e ec1%-%*ra,a 1%dr'=

e-ec,r'-%,%c ede/e-e )% a)c%,a )=au

/%c)'ra, %ar ,e.u/e(,e-e )u(, )u&-e2

I( ur/a ,ra,a/e(,u-u% ad/%(%),ra, 0

&ac%e(,a (u /a% &re+%(,a %(ec,%e

ur%(ara2

I( ur/a eec,uar%% &arace(,e+e% )=au

e-%/%(a, ?- de -%c1%d a)c%,%c

I( ace), /'d ac%e(,a re)&%ra /a%

u)'r 0 rec5e(,a re)&%ra,%%-'r %%(d de

>/%(

34




%%(d )c1%/*a,a -a @ de 're2

I( ur/a e9a/%(ar%-'r

eec,ua,e )=a dece-a, &re+e(,a

%( e9a/e(u- de ur%(a a

&ur'%u-u% )% -euc'c%,e-'r2

Da,'r%,a ace),u% -ucru )=a

%(,r'du) ad/%(%)=,rarea

A/&%c%-%(e% K.@?1

A/ &ar,%c%&a, -a eec,uarea

&arace(,e+e% &r%( &re.a,%rea

/a,er%a-e-'r )% %(),ru/e(,e-'r

(ece)are )er5%(d /ed%cu- )%

a&-%ca(d u( &a()a/e(,

c'/&re)%5 du&a ,er/%(area

&u(c,%e%2

35




?2 INCAPACITATEA DE

A=SI REALIZA

SINGURA INGRIJIRI

MEDICALE

Pac%e(,a )a=)% &'a,a

eec,ua )%(.ura %(.r%6%r%-e

&er)'(a-e %( decur) de

+%-e Sa=)% e9&r%/e

acce&,u- de a %(de&-%(%

%(.r%6%r% de %.%e(a %(

,er/e( de > +%-e2

A/ a6u,a, &ac%e(,a )a )e

/'*%-%+e+e2

La )'-%c%,ar%-e &ac%e(,e% a/

ra)&u() cu &r'/,%,ud%(e2

Pac%e(,a a '), a6u,a,a %(

eec,uarea ,'a-e,e%0

a)%.ura(du=% -a &a, ,'a,e ce-e

(ece)are2

I( ur/a /a)ur%-'r -ua,e -a +%-e0

&ac%e(,a e cura,a )% %(.r%6%,a0 dar

reu+a )a e9ecu,e )%(.ura )%

ac,%5%,a,%%-e ce ' )'-%c%,a &u,%(2 La >

+%-e &ac%e(,a e),e /a% c''&era(,a )%

%(cearca )a )e %/*race )% )a=)%

eec,ue+e ,'a-e,a )%(.ura2

36




CAZUL II

CULEGEREA DATELOR

NUME SI PRENUME : R"d'% I'a(a

V]RSTA: K@ a(%

SEX: e/%(%(

DOMICILIUL: Ga-a,%

STAREA CIVILA: c")",'r%,"

OCUPAŢIA: &e()%'(ar" NAŢIONALITATEA: r'/3("

RELIGIA: 'r,'d'9"

ANTECEDENTE PERSONALE: = cu(')cu," de c%rca 4 a(% cu d%a.('),%cu- de c%r'+" 1e&a,%c"

dec'/&e()a," 5a)cu-ar0 cu re&e,a,e %(,er("r%0 cu a/e-%'rarea ),"r%% .e(era-e2

= c'()u/a,'are cr'(%ca de e,a('-

= (u re)&ec,a re.%/u- a-%/e(,ar 7%(.ur.%,ea+a +%-(%c @ - -%c1%d8

= (eu/a,'areANTECEDENTE HEREDOCOLATERALE:

= /a/a= d%a*e, +a1ara,

= ,a,a= (e)e/(%%ca,%5

GRUPA DE SANGE DIAGNOSTIC MEDICAL LA INTERNARE:

• C%r'+a 1e&a,%ca e,a('-%ca dec'/&e()a,a 5a)cu-ar

MOTIVELE INTERNARII:

: AII &'+%,%52

• a),e(%e %+%c" /arca(,"0

• ,u)e cu e9&ec,'ra!%%

• #(a&e,e(!"0

• .re!ur%0

3+




• 5"r)",ur%

ISTORICUL BOLII: =&ac%e(,a %( 5ar),a de K@ a(% %( e5%de(,a cu c%r'+a 1e&a,%ca dec'/&e()a,a

5a)cu-ar de 4 a(% 0 a '), %(,er(a,a &e(,ru a),e(%e %+%ca /arca(,a0 %(a&e,e(,a0 .re,ur%0 5ar)a,ur%0

a)c%,a 5'-u/%'a)a0 ede/e /arca,e a-e /e/*re-'r %(er%'are2 La d'/%c%-%u (u a re)&ec,a,

%(d%ca,%%-e de ,ra,a/e(, a-e /ed%cu-u% )% (u a re)&ec,a, %(d%ca,%%-e de a re(u(,a -a a-c''-2 Se

adre)ea+a c-%(%c%% &e(,ru ,ra,a/e(, de )&ec%a-%,a,e2

PROBLEMELE PACIENTEI

= a-%/e(,a,%a care(,%a-a da,'r%,a %(a&e,e(,e%0 a-c''-%)/u-u%

= a(9%e,a,e /'dera,a

= d%)&(ee

= cre),erea %( 5'-u/ a a*d'/e(u-u% da,'r%,a a)c%,e%

=ede/e -a /e/*re-e %(er%'are

= d%%cu-,a,ea de a )e 'd%1(%

= r%)cu- u('r c'/&-%ca,%% %(ec,%'a)e

NEVOI:

>2 Ne5'%a de a )e a-%/e(,a )% 1%dra,a

@2 Ne5'%a de a re)&%ra

42 Ne5'%a de a e-%/%(a?2 Ne5'%a de a d'r/% )% )e 'd%1(%

2 Ne5'%a de a=)% /e(,%(e ,e.u/e(,e-e cura,e )% %(,e.re

K2 Ne5'%a de a e5%,a &er%c'-e-e

Ta*e- 42 P-a( de (e5'% &ac%e(, II

NEVOIA MANIFESTARILE PROBLEME SURSE DE

DIFICULTAT

E

OBIECTIV

EDE

INDEPENDENT

A

DE

DEPENDEN

TA>2Ne5'%a

de a

re)&%ra )%

a a5ea '

T2A2W >>K //

H.

=a*d'/e(

5'-u/%(')

=,a1%&(ee

=),are &'),

=&re)%u(e

a*d'/%(a-

cre)cu,a cu

%/&')%*%-%,a,

=a)c%,a =e5acuarea

a)c%,e%

38




*u(a

c%rcu-a,%e

c'()u/

a-c''-

ea

e9&a()%'(ar%%

d%ara./a,%c

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=d%%cu-,a,e %(

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de(,are

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care(,%a-

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c'()u/u- de

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re a de(,%,%e%

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42 Ne5'%a

de a

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e-%/%(a,e:^>/

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a5ea '

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39




de a

d'r/% )% a

)e 'd%1(%

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40




a

c'/u(%ca

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cu a/%-%a

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a %

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e),e ('u

= =(e&a)are =de&e(de(,a

a-c''-%ca

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&ac%e(,e% cu

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&re5e(%rea e%

41




D%a#)!&%' ,e %)#(%7%(e O0%e'%e I)e(e)%%

>2DISPNEE Pac%e(,a 5a a5ea '

re)&%ra,%e cu '

rec5e(,a %( -%/%,e

%+%'-'.%ce %( decur)

de ?= +%-e2

A/ a)e+a, &ac%e(,a %( &'+%,%e 'r,'&(e%ca

&e(,ru a a5'r%+a re)&%ra,%a 0a)e+a(d %(

)&a,e-e &ac%e(,e% d'ua &er(e2A/ aer%)%,

)a-'(u-2A/ %(5a,a, &ac%e(,a )a re)&%re

c'rec, 7)a %()&%re &r'u(d &e (a) )% )a

e9&%re &e .ura82 Pac%e(,e% % )=a ad/%(%),ra,

'9%.e( &e /a)ca K-1 cu %(,er/%,e(,a >

/%( de d'ua 'r% &e 'ra2 A/ )u&ra5e.1ea,

cu /are a,e(,%e /'du- de ad/%(%),rare a

O@ de*%,u- -u% )% rec5e(,a ad/%(%),rar%%

'9%.e(u-u%2S=a eec,ua, &arace(,e+a &e(,ru

a u)ura re)&%ra,%a

Du&a

),area

rec5e

-a >@

&ac%e(

rec5e

&u-)u-

TAW>

@2 ALIMENTATIE

CARENTIALA

DATORITA

INAPETENTEI

Pac%e(,a )a %e

ec1%-%*ra,a (u,r%=

,%'(a- )% 1%dr'e-ec=

,'-%,%c %( 4 +%-e2

A/ &re+e(,a, &ac%e(,e% (ece)%,a,ea u(e%

d%e,e 1%&')'da,e2A/ %(,'c/%, ' -%),a cu

a-%/e(,e-e &er/%)e )% %(,er)%)e0 educa(d

a/%-%a )% a/ ceru, de -a *uca,ar%a

)&%,a-u-u% re)&ec,area re.%/u-u%2 Au '),

e9&-'ra,e .u),ur%-e &ac%e(,e%2A-%/e(,e-e

au '), )er5%,e -a 're re.u-a,e2A&'r,u- de

&r',e%(e )=a )ca+u, de'arece &ac%e(,a

&re+e(,a e(cea-'&a,%e2

A-%/e(,a,%a era *'.a,a %( .-uc%de )%

-%c1%de 7)uc (a,ura-0 a&a &-a,a0 cea%%(du-c%,

cu/%ere82Pe &arcur)u- re+'-5ar%%

e(cea-'&a,%e% )e 5'r )u&-%/e(,a care(,e-e%( &r',e%(e2La %(d%ca,%%-e /ed%cu-u%

&ac%e(,e% % )=a ad/%(%),ra, P'-%5%,a/%(e

49>+%2Pe(,ru reacerea &are(c1%/u-u%

1e&a=,%c % )=a ad/%(%),ra, A)&a,''r, @9>

I( &r

a-%/

ur/a

)a /

1%dra

42




%( /- .-uc'+a +% Du&a re+'-5area

e(cea-'&a,%e% % )=a ad/%(%),ra, 1%dr'-%=

+a(,e de &r',e%(e 7A/(%'&-a/a- 8

/-+%

42 ELIMINARE

INADECVATA

CANTITATIV

Pac%e(,a )a %e

ec1%-%*ra,a 1%dr'=

e-ec,r'-%,%c )% )a (u

&re+%(,e r%)c a-

%(ec,%%-'r ur%(are

Z%-(%c )=a eec,ua, *%-a(,u- 1%dr'ec,r'-%,%c2

I(.e),%a =.-uc'+a > /-9S _>U2I2

%()u-%( =de9,ra( ?=/- =)uc

>/- =a-%/e(,e @. =&-a)/a >/-

E9cre,%a= d%ure+a >?/-=)cau( 4/-

=-%c1%d a)c%,%c ?/-

&ac%e(,e% % )=a %(d%ca, )a (u c'()u/e /a%

/u-, de > - de -%c1%de +% /a% a-e) d%( ce-e *'.a,e %( Na2 A/ rec'-,a, ur%(a &e(,ru

e9a/e(u- ru/ar de ur%(a )% *ac,er%'-'.%c

La a&-%carea )'(de% 5e+%ca-e a/ re)&ec,a,

re.u-%-e de a)e&)%e0 )'(da %%(d )c1%/*a,a

-a @ de 're2 A/ &ar,%c%&a, -a eec,uarea

&arace(,e+e% &r%( &re.a,%rea /a,er%a-e-'r )%

%(),ru/e(,e-'r (ece)are )er5%(d /ed%cu- )%

a&-%ca(d u( &a()a/e(, c'/&re)%5 du&a

,er/%(area &u(c,%e%2

Pac%e

e-ec,

/%c)

)u&-e

ad/%

&re+%

I( ur

au e-I( ac

u)'r

de >

43




?2 DIFICULTATEA DE

A SE ODIHNI

2 RISC AL

COMPLICATIILOR

INFECTIOASE

Pac%e(,u- )a

*e(e%c%e+e de

)'/( ca(,%,a%5 )%

ca-%,a,%5

)a,%)aca,'r

Pac%e(,a )a (u

&re+%(,e r%)cu-

c'/&-%ca,%%-'r

Pac%e(,e% % )e ad/%(%),rea+a -%c1%de ca-de

7-a&,e0 cea% de /u)e,e-0 de ,e% 8 %(a%(,e de

cu-care2 Se %(,'c/e),e u( &r'.ra/ de

'd%1(a %( c'/u( de ac'rd cu &ac%e(,u-

Se rea-%+ea+a u( c-%/a, de -%(%),e )% c'('r,

care )a (u )u&ra)'-%c%,e a(a-%+a,'r%% aud%,%5%

)% 5%+ua-%2Nu )e &', ad/%(%),ra /ed%ca=

/e(,e cu eec, )eda,%52 I( ace), )c'& )e

ad/%(%),rea+a /ed%ca/e(,e cu eec, u)'r

)eda,%5 de ,%&u-: C%&r'1e&,ad%(a >,* -a

cu-care )au Fe(%ra/%(a >,* )eara -a cu-care

&e(,ru a e5%,a eec,u- ,'9%c 1e&a,%c a- *ar*%,ur%c%-'r2 A/ e9&-%ca, &ac%e(,e%

(ece)%,a,ea re)&ec,ar%% re&a')u-u% %+%c )% a-

,ra,a/e(,u-u%2 Pe(,ru a (u=% &er%c-%,a

re)&%ra,%a )% u(c,%a card%'5a)cu-are

&ac%e(,u-u% % )=a eec,ua, &arace(,e+a

e-%/%(a(d ?- -%c1%d a)c%,%c2

Du&a eec,uarea ,e1(%c%% a/ de+%(ec,a,-'cu- &u(,%% )% a/ a&-%ca, ' c'/&re)%e

),er%-a &e(,u &re5e(%rea %(ec,%e%2

A/ )a,u%, &ac%e(,u- )a (u )e /%),e &rea

/u-, %( &a, )% )a (u )e r%d%ce du&a

eec,uarea &u(,%%2

A/ a)%.ura, ca &ac%e(,a )a %e ec1%-%*ra,

(u,r%,%'(a- ad/%(%),ra(du=% ' d%e,a *'.a,a

%( .-uc%de0 %,a/%(e )% &r',e%(e2

Se a)%.ura cura,e(%a -e(6er%e% de &a, )% de

c'r& a- &ac%e(,u-u% &e(,ru a &re5e(%%

a-,erarea %(,e.r%,a,%% ,e.u/e(,are2

A/ )u&ra5e.1ea, ca,e,ere-e 5e('a)e

I( ur

d'ar

d%/%

Pac%e

re)&%

Re)&TAW

Pu-)W

Pac%e

%(ec

c'r&u

I( ur

&ac%e

,e.u/

44




a&-%ca,e &e(,ru rea-%+area &eru+%%-'r )% /=

a/ a)%.ura, )a %e )c1%/*a,a -a @ de 're2

Ta*e- ?. P-a( de %(.r%6%r% &ace%(, II

45




C!)'$+3%%

A/ a-e) acea),a -ucrare &e(,ru a e5%de(,%a .ra5%,a,ea e('/e(e-'r ce a&ar %( c%r'+a 1e&a,%ca

)% &e(,ur a ,ra.e u( )e/(a- de a-ar/a a)u&ra eec,e-'r ('c%5e a-e c'()u/u-u% de ac''-2

F%ca,u- are r'- de de,'9%%ere a 'r.a(%)/u-u%0 %%(d 'ar,e %/&'r,a(, %( ,'a,e &r'ce)e-e

/e,a*'-%ce2 U( e('/e( %(-a/a,'r0 ,u/'ra-0 5%ra-0 e,c care &er,ur*a 1'/e'),a+%a ace),u%a are

re&ercur)%u(% a)u&ra %(,re.u-u% 'r.a(%)/2 De&%),area &rec'ce a u('r *'-%0 &recu/ )% a u('r

,a*%e,ur% a-%/e(,are .re)%,e &'a,e de,er/%(a %(ce,%(%rea &r'ce)e-'r de de.radare2 O da,a a6u()

&ac%e(,u- %( )&%,a-0 a)%),e(,a /ed%ca-a are r'- %/&',a(, %(ca de -a %(,rarea ace),u%a &e &'ar,a

)&%,a-u-u%0 'cu&a(du=)e de %(,e.rarea0 5%(decarea )% reacerea &ac%e(,u-u%2

A/ %(cerca, &r%( acea),a -ucrare )a re5%+u%e)c ,e1(%c%-e de (ur)%(. (ece)are %(.r%6%r%% u(u%

a),e- de &ac%e(,0 %()a ,e/a,%ca ra/a(a(d %(ca de)c1%)a2

46




B%0$%!#(a%e

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@2 Tra,a, de /ed%c%(a %(,er(a0 Oc,a5%a( F'd'r0 ed%,ura Med%ca-a0 >

42 C1%ra O-%/&%a ; B'-%-e cr'(%ce a-e %ca,u-u% ;0 Ed%,ura Med%ca-a 0>@ 0 Bucure),%

?2 Ga-ea G1e'r.1e ;C%r'+a He&a,%ca ; 0 Ed%,ura Med%ca-a 0>4 0 Bucure),%

F%. >: 1,,&:2/ed%c%(e(e,2c'/)cr%&,/a%(ar,2a)&ar,%c-eeW@K4K

F%. @: 1,,&:2r'/ed%c2r'c%r'+a=1e&a,%ca

F%. 4: 1,,&:2*e(d'2r'a)c%,a=d%(=c%r'+a=1e&a,%ca

F%. ?: 1,,&:2.a),r'/ed2r'C%r'+a=1e&a,%ca21,/-

F%. : 1,,&):2.''.-e2r')earc1`W1e&a,%cb*%W>@b*%1WKb)'urceW-(/)b,*/W%)c1

b)aWXb5edWa1UE6.u,XNA1MDR'HZ1CAUIB%.B,*/W%)c1b`

Wc%r'+ab%/.rcWG/A-&GG`R.M4A

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