Démarche de soins type

DEMARCHE DE SOINS    Promotion  Bloc Opératoire   


nom:  prénom: date de naissance:  Situation Familiale:  Nationalité:  Profession: Poids: Taille: Prothèse : Dentaire          Visuelle                 Autres :Groupe sanguin Prise en charge sociale: Allergie:











  Diagnostics infirmiers principaux à adapter à personnaliser  


Diagnostics infirmiers Objectifs Actions Evaluation


Risque d’Anxiété ou de Peur lié à l’anesthésieAux gestes opératoiresA l’environnement Assurer la sécurité psychologique de la personne soignée -La personne qui a fait la visite pré-op l’accueille, lui présente le personnel, est disponible-Expliquer les gestes prodigués-Parler ouvertement des craintes, répondre aux questions-Eviter les agressions sonores et visuelles-Respecter la pudeur   -En pré-op le patient s’endort tranquillement-En post-op il se réveille calmement


Risque d’erreur d’identité et/ou de coté à opérer Assurer la sécurité physique -Contrôle lors de l’accueille de l’identité du patient-Vérification du dossier, de la fiche de liaison, du tableau opératoire, demander de quel coté est opéré le patient Concordance des infos


Risque de chute lié aux transferts Assurer la sécurité physique -Clamper le lit et le brancard-Utilisation de roller-Personnel en nombre suffisant-Mettre les barrières pour les brancards ou -Rester près du patient jusqu’à l’installation Pas de chutes


Risque d’hypothermie lié à-La t°c de la salle-L’anesthésie-L’immobilité et la nudité Eviter le refroidissement du patient -Vérifier la t°c de la salle avant l’intervention-Laisser le patient le plus longtemps couvert-Vérifier et installer la couverture chauffante -Chauffer le sérum pour le pansement-En sspi lit chauffé pour le post-op
  • En post-op
il ne grelotte pas  lorsqu’il se réveille
  • Sa t°c est correcte 


Risque de syndrome  d’immobilité liée à la position sur la table  d’op Assurer sécurité physique, éviter altération intégrité de la peau (points d’appui) -Installation confortable-mettre les appuis avec les protections (géloses)-bras en abduction modéré-corps  bien aligné -rond de tête -En post-op immédiat :Absence de rougeur, d’escarre 


Risque de brûlure liée à l’utilisation du bistouri électrique et à la couverture chauffante Assurer la sécurité physique -Contrôle du bon fonctionnement du BE, du bon positionnement de la plaque et du cordon-Contrôle de la t°c sous la couverture chauffante -Per-op : bon fonctionnement du BE-Post_op : Présence de brûlure ou rougeur cutanée


    Risque infectieux lié à la mauvaise préparation locale et à l’utilisation de technique aseptique défectueuse, oubli de compresse     Assurer la sécurité physique     -Vérifier la préparation cutanée-Respecter les règles d’hygiène de base : Lavages des mains                Tenue réglementaire                                                       Entretien des locaux-Vérifier le matériel : Date de péremption                 Intégrité de l’emballage                  Témoin de sté-Badigeonnage en pré-op-Règles d’asepsie rigoureuse -Compte des compresses rigoureux     Post-op :-Absence de signes infectieux, t°c élevée-Pas de rougeurs au niveau de l’incision-Pas de retard de cicatrisation


Risque hémorragique lié à l’acte Assurer la sécurité physique -Bilan sanguin complet-BE allumé jusqu’à la fin de l’intervention-Evaluation des pertes sanguines Surveillance du pansement et des drainages en post-op


Risque thrombœmbolique lié à l’acte Assurer la sécurité physique Bas de contention Absence de signes de phlébites       



    Risque de syndrome inflammatoire lié à l’utilisation des gants poudrés     Eviter l’inflammation     Rincer  mes gants au départ et à chaque changement, proposer le rinçage à l’équipe chirurgicale  

  PREPARATION EN VUE DE L’INTERVENTION  Vérification du tableau opératoire, de la salle d’intervention, du matériel   












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