30914789-PAE-Hipertension-Obesidad-Morbida-Diabetes-Mellitus-Coma-Vigil.pdf
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UNIVERSIDAD NACIONAL AUTÓNOMA DE MÉXICO FACULTAD DE ESTUDIOS SUPERIORES IZTACALA LICENCIATURA EN ENFERMERÍA ENFERMERÍA EN LA SALUD DEL ADULTO
PROCESO DE ATENCIÓN DE ENFERMERÍA APLICADO A PACIENTE CON DX. MÉDICO DE DIABETES MELLITUS + HIPERTENSIÓN ARTERIAL + OBESIDAD MÓRBIDA + COMA VIGIL.
ALUMNO: CAMACHO RODRÍGUEZ EMMANUEL ERNESTO PROFESOR: L.E. GARRIDO TENORIO JUAN CARLOS SEXTO SEMESTRE ABRIL DE 2010
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Tabla de contenido INTRODUCCIÓN/JUSTIFICACIÓN ..............................................................................................
3
OBJETIVOS ......................................................................................................................................
4
General...........................................................................................................................................
4
De Aprendizaje .............................................................................................................................
4
Del Proceso. ..................................................................................................................................
4
METODOLOGÍA ...............................................................................................................................
5
ETAPA I: VALORACIÓN .............................................................................................................
5
ETAPA II: DIAGNÓSTICO ..........................................................................................................
5
ETAPA III: PLANEACIÓN ...........................................................................................................
5
ETAPA IV: EJECUCIÓN..............................................................................................................
5
ETAPA V: EVALUACIÓN ............................................................................................................
5
CRONOGRAMA DE ACTIVIDADES .............................................................................................
6
LÍMITES .............................................................................................................................................
7
MARCO TEÓRICO. .........................................................................................................................
8
Hipertensión Hipertensión Arterial. ...................................................................................................................
9
Diabetes Mellitus tipo II .............................................................................................................
10
Obesidad ......................................................................................................................................
11
VALORACIÓN. ...............................................................................................................................
12
DIAGNÓSTICOS DE ENFERMERÍA ..........................................................................................
20
PLANES DE CUIDADOS. .............................................................................................................
21
EVALUACIÓN .................................................................................................................................
28
CONCLUSIÓN ................................................................................................................................
28
BARRERAS Y SUGERENCIAS ...................................................................................................
29
GLOSARIO. .....................................................................................................................................
30
REFERENCIAS BIBLIOGRÁFICAS ............................................................................................
32
ANEXOS ..........................................................................................................................................
32
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INTRODUCCIÓN/JUSTIFICACIÓN l Proceso de Enfermería constituye un instrumento que posibilita el diseño de las estrategias e intervenciones de enfermería necesarias para prevenir, reducir o eliminar problemas de salud en los individuos, éstos problemas son analizados y procesados gracias a una metodología que nos llevan a la identificación de la problemática presente en un paciente, en éste caso durante la edad adulta.
E
El siguiente Proceso Enfermero fue aplicado a una paciente captada en el servicio de Medicina Interna, en el Hospital General Regional 72 “Lic. Vicente Santos Guajardo”.
El Proceso fue diseñado a partir del modelo de atención de Marjory Gordon, siguiendo los 11 patrones funcionales, cuya importancia radica en que el estudiante aprenda cómo debe realizarse la valoración del paciente, pues le permite desarrollar la capacidad de ejercer un juicio crítico, poner en práctica el conocimiento adquirido en las aulas y familiarizarse con todas las actividades que implican el desarrollo del proceso. Posterior a las intervenciones se expondrá la evaluación para hacer público el cumplimiento o no los objetivos planteados al inicio del proceso, así como la conclusión a la que se llegó. Finalmente se evidenciarán las barreras que obstaculizaron la elaboración del desarrollo del Proceso Enfermero y se darán sugerencias para mejorar ésta elaboración.
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OBJETIVOS General
Integrar los conocimientos teórico-prácticos aprendidos en teoría y en módulos previos para proveer una atención integral al paciente y registrarlo en un proceso enfermero.
De Aprendizaje
Identificar los patrones funcionales afectados en la p aciente, y realizar las intervenciones adecuadas de acuerdo a la valoración elaborada.
Practicar técnicas adecuadas y fundamentadas en la atención del paciente adulto hospitalizado, ofreciendo una atención de calidad, eficiente y humana.
Del Proceso.
Identificar la problemática actual y de riesgo que propició a la paciente sus alteraciones al momento de la valoración.
Implementar acciones de enfermería que tengan como resultado la disminución de las alteraciones, alteraciones, la prevención de problemas potenciales y complicaciones propias de las patologías ya presentes.
Diseñar un plan de cuidados que satisfaga el déficit de salud en la paciente.
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METODOLOGÍA Para lograr el cumplimiento de los objetivos planteados, es necesario que como estudiantes de la Licenciatura en Enfermería perteneciente al grupo 2602 en el módulo de Enfermería en la Salud del Adulto, se realice un Proceso de Enfermería, con asesoría del L.E. Juan Carlos Garrido Tenorio, aplicado a una paciente en adulta hospitalizada en el Hospital de General Regional 72 “Lic. Vicente Santos Guajardo”.
Se presentan las cinco etapas que a continuación se describen:
ETAPA I: VALORACIÓN
Una vez seleccionado el paciente, se llevará a cabo la exploración física en dirección céfalo-podálica, posteriormente se empleará un cuestionario para obtener información de acuerdo a los 11 patrones funcionales del modelo de Marjory Gordon.
ETAPA II: DIAGNÓSTICO De acuerdo a los datos obtenidos en la valoración, se realizarán los diagnósticos de enfermería utilizando como herramienta los diagn ósticos de la NANDA.
ETAPA III: PLANEACIÓN En base a los diagnósticos, se planearán acciones de enfermería que contribuyan en la mejoría del estado de salud de la paciente, para lograrlo se utilizan las clasificaciones NIC y NOC.
ETAPA IV: EJECUCIÓN Se llevarán a cabo las técnicas y acciones de enfermería aplicadas en enfermería hospitalaria; planteadas en la etapa anterior.
ETAPA V: EVALUACIÓN
Se analizarán los resultados obtenidos de acuerdo a la ejecución para determinar si se cumplieron o no los objetivos planteados para cada diagnóstico, de no ser así, se hará una revaloración para identificar las barreras que no permitieron el logro de los mismos. Finalmente se hará una conclusión acerca del proceso elaborado y se darán sugerencias para mejorar la realización del Proceso de Enfermería.
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CRONOGRAMA DE ACTIVIDADES Marzo de 2010 ACTIVIDAD. Captación de paciente en servicio de hospitalización. Contactar paciente. - Obtención de datos generales. Valoración - Detección de factores de riesgo. - Anamnesis. - Exploración física. -Elaboración del marco teórico. Elaboración de Dx. De Enfermería - Análisis de datos. -Diagnósticos de enfermería NANDA. Planeación. - Objetivos. -Intervenciones. Ejecución. -Tecnicas y actividades de enfermería. Evaluación) - Comparación de resultados obtenidos y esperados. - Elaboración de la introducción del PE. Documentación y revisión. -Conclusión del informe y elaboración de conclusiones del mismo. Entrega de Proceso Enfermero.
18 19 22 J V L X X
23 M
Abril de 2010 9 13 V M
X
X X X
X
X X X X
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LÍMITES
El universo de trabajo es:
Hospital General Regional No. 72 Calle Filiberto Gómez, Esq. Dr. Gustavo Baz S/N, Col. Industrial, Tlalnepantla, Estado de México. C. P. 54000
Límites: Colinda al norte con Calle Filiberto Gómez; Al Sur con Av. Emilio Carranza; Al oeste
Localización aproximada: 19° 32’ 35.27” 35.27” N; 99° 12’17.63” 12’17.63” O
Vista de calle © Google maps. Mapa © 2010 INEGI
Fecha de la imagen aérea: 14 de Febrero de 2009 © Google Earth
con Vía Gustavo Baz; Y al Este con Roberto Fulton. Altitud: 2.259 2.259 m. SNM SNM
Indica localización aproximada del HRZ 72
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MARCO TEÓRICO.
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Expulsar sangre del corazón
Pericardio Endocardio
Hipertensión Arterial.
Miocardio Aurículas
Hipernatremia Aumentado en Obesidad Frecuencia Cardiaca
GastoCardiaco
Corazón (300 gr.)
Presión arterial
Anatomofisiología
Resistencia Periférica
Recibe sangre
Ventrículos
Toma de TA
HTA HT A
Dx
BH
Clasificación
ECG ColesterolHDL,LDL
Vasodilatadores.
Aorta
Sangre oxigenada
HTAEsencial
Sin causa identificable, es el 80% de los casos
HTA Secundaria
Hay causa identificable y es potencialmentecurable
HTASistólica Aislada
Cifras de TA sistolica > 140mmHg con cifras diastólicas normales
Pseudohipertensión
Cuando la pared arterial se encuentra calcificada. calcificada.
Diabetes
Tx
Etiología
Genética
IECA’s
Furosemida
Transportasangre carboxigenada
Sistólica > 140 mmHg Diastólica > 90 mmHg
Tono vascular de las arterias
EGO
Pulmonar
Arterias
Elevación persistente de la presión arte rial.
Fisiopatolog ía
Contracción
Valvas Auriculo Ventriculares
Valvas semilunares
Volumen circulante
Arterias coronarias
O2y nutrientes
Complicacion es
Diuréticos
Sexo
Betabloqueadores
Ejercicio
Hipertrofia ventricular
Cardiopatía Isquémica
Edad
Ca Antagonistas
Dieta
Arritmias
Insuf. Cardiaca Cardiaca Congestiva
Stress
Hemorragia Cerebral
EVCIsquémico
Encefalopatía Hipertensiva
Nefropatía Hipertensiva
Trae consigo
Aneurismas IRC
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Diabetes Mellitus tipo II
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Obesidad Obesidad significa tener un exceso de grasa en el cuerpo. Se diferencia del sobrepeso, que significa pesar demasiado. El peso puede ser resultado de la masa muscular, los huesos, la grasa y/o el agua en el cuerpo. Ambos términos significan que el peso de una persona es mayor de lo que se considera saludable según su estatura. La obesidad se presenta con el transcurso del tiempo, cuando se ingieren más calorías que aquellas que consume. El equilibrio entre la ingestión de calorías y las calorías que se pierden es diferente en cada persona. Entre los factores que pudieran inclinar el equilibrio se incluyen la constitución genética, el exceso de comer, el consumo de alimentos ricos en grasas y la falta de actividad física. Los adultos con un índice de masa corporal (IMC, calculado como peso en kilogramos, dividido por estatura en metros cuadrados) superior a 25 kg/m2 pero menor a 30 kg/m2 se consideran con sobrepeso. Los adultos con un IMC superior a 30 kg/m2 se consideran obesos. Se considera que cualquier persona con más de 45 Kg (100 libras) de sobrepeso o con un IMC superior a 40 kg/m2 padece obesidad mórbida.
Los problemas médicos que comúnmente resultan de la obesidad sin tratamiento y de la obesidad mórbida abarcan:
Diabetes tipo 2 y síndrome metabólico Hipertensión arterial , cardiopatía y accidente cerebrovascular
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VALORACIÓN
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UNIVERSIDAD NACIONAL AUTÓNOMA DE MÉXICO FACULTAD DE ESTUDIOS SUPERIORES IZTACALA LICENCIATURA EN ENFERMERÍA SEXTO SEMESTRE SALUD DEL ADULTO PRACTICA HOSPITALARIA VALORACIÓN DE ENFERMERÍA PARA EL ADULTO BASADO B ASADO EN LOS PATRONES FUNCIONALES DE GORDON DATOS GENERALES NOMBRE: F.C.V.S. GÉNERO: Femenino EDAD: 66 a. ETAPA DE LA VIDA: Adulto Mayor EDO. CIVIL: Viuda ESCOLARIDAD: Primaria Primaria OCUPACIÓN: Ama de Casa RELIGIÓN: Católica DOMICILIO: San Miguel Chalma , EDOMEX. SERVICIO DE SALUD: IMSS ( X ) DIAGNOSTICO MEDICO: DM tipo II, HTA, Obesidad Mórbida, coma vigil.. SERVICIO: Medicina Interna NO. DE CAMA: 224
PARENT PARENTESC ESCO O Hija
NOMBRE NOMBRE M. S. C.
EDAD EDAD
ANTECEDENTES HISTORIA FAMILIAR DE ENFERMEDADES
45 a.
OCUPAC OCUPACII N Ama de Casa
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PATRONES FUNCIONALES 1.- PATRÓN PERCEPCIÓN DE SALUD/MANEJO DE LA SALUD S ALUD El estado de salud de la paciente es considerado malo debido al coma vigil que le ha sido diagnosticado, padece DM II e Hipertensión Arterial desde hace 15 años, siendo cardiópata desde hace 5. Hace 43 días sufrió para respiratorio durante una exploración laparoscópica. El primer contacto fue llevado a cabo en el área de urgencias debido a shock hipovolemico, hace 45 días. Actualmente Actualmente se lleva lleva el siguiente siguiente tratamiento tratamiento médico: médico:
Omeprazol 40 mg IV cada 12 hrs Digoxina ½ Tab, por SNG Cada 24 hrs. Paracetamol 500 mg por SNG PRN Enalapril 10 mg por SNG cada 12 hrs Insulina NPH 20 UI a las 8 hrs Furosemide 10 mg IV cada 24 hrs Metformina 425 mg (1/2 Tab.) por SNG, antes del desayuno Levofloxaciona 500 mg cada 24 hrs IV Metamizol Sódico 500 mg IV PRN Cloramfenicol Cloramfenic ol Fotalmico 2 gotas en cada ojo cada 4 hrs. Salbutamol 2 disparos cada 8 hrs PRN
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VALORACIÓN DE: PESO S/D1
TALLA
S/D2
GLUCEMIA
180 mg/dL
INDICIOS PIEL Morena, deshidratada, gruesa, con presencia de anasarca y ulcera por decúbito en área sacra y en nalga izquierda.. CABELLO Teniño, con pocas canas, opaco, desaliñado, enredado, sin pediculosis. pediculosis. UÑAS Curvatura convexa, textura lisa, color normal, llenado capilar de 3 segundos MUCOSA ORAL Deshidratada, ENCÍAS Sin gingivitis, rosadas, en buen estado. LENGUA De mapa, tamaño normal, blanquecina. DENTADURA Ausencia de 14 y 24. INDICIOS ANOREXIA N/A NÁUSEAS N/A VÓMITO N/A DOLOR ABDOMINAL N/A HERIDAS Úlceras por decúbito en área sacra y nalga derecha izquierda ( 5x10;2x2). PIROSIS N/A POLIFAGIA N/A REGURGITACIÓN N/A DISFAGIA N/A OBSERVACIONES
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4.- PATRÓN ACTIVIDAD/EJERCICIO. 75 x’ 20 x’ FRECUENCIA CARDIACA FRECUENCIA RESPIRATORIA TENSIÓN ARTERIAL (18/03/10) (18/03 /10) 150/70 mmHg (23/03/10) 150/80 150/8 0 mmHg CARACTERÍSTICAS DE: PULSO Presente, rítmico RESPIRACIÓN Asistida por ventilador mecánico. CAPACIDAD O DIFICULTAD PARA REALIZAR SU AUTO CUIDADO: SI TIENE ALGUNA INCAPACIDAD O LIMITACIÓN PARA EL MOVIMIENTO: SI
UTILIZA ALGÚN DISPOSITIVO O AUXILIAR PARA LA DE AMBULACIÓN: No puede moverse. ACTIVIDADES ACTIVIDADES RECREATIVAS RECREATIVAS HABITUALES HABITUALES:: NO (DATO OBTENIDO OBTENIDO DE FAMILIAR) FAMILIAR) PRACTICA ALGUNA ACTIVIDAD DEPORTIVA: NO (DATO OBTENIDO DE FAMILIAR) INDICIOS CONTRACTURA MUSCULAR DISTENCIÓN VENOSA YUGULAR PIEL MARMÓREA SUDORACIÓN FRÍA PALPITACIONES DESMAYOS VÉRTIGO ACUFENOS FOSFENOS
NO NO NO NO NO N/A N/A N/A N/A
DISNEA N/A TOS NO CIANOSIS NO ESTERTORES NO EPISTAXIS NO DISFONÍA N/A TIROS INTERCOSTALES SIBILANCIAS SIBILANCIAS
NO SI
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6.- PATRÓN COGNITIVO/PERCEPTUAL
ESTADO FÍSICO Y MENTAL ACTUAL
La paciente se encuentra en coma vigil, de forma que no está orienta en ninguna de las tres esferas, teniendo un puntaje de 6 en escala de Glasgow, no presenta crisis convulsivas, las pupilas son isocoricas, normoreflexicas, con reflejo corneal positivo. INDICIOS CRISIS CONVULSIVAS NO DOLOR NO MIDRIASIS NO AFASIA NO MIOSIS NO HIPERESTESIA N/A ANISOCORIA ANISOCORIA NO HIPOESTESIA HIPOESTESIA N/A IRRITABILIDAD NO PARESTESIA N/A ATAXIA NO PARÁLISIS PARÁLISIS N/A MIOCLANIAS NO SIGNOS MENINGEOS OTROS: ( ) Especificar:
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7.- PATRÓN AUTO PERCEPCIÓN/AUTO-CONCEPTO El familiar refiere que la imagen que tenía la paciente de sí misma era adecuada, debido a que quería mejorar su salud llevando una dieta adecuada. La imagen corporal puede haber estado deteriorada debido a la obesidad mórbida que tiene. INDICIOS NERVIOSISMO ( ) ESPECIFICAR: SUSPIRO ( ) ESPECIFICAR: TEMBLORES ( ) ESPECIFICAR: SENTIMIENTO DE CULPA ( ) CONDUCTA VIOLENTA () APATÍA () OTROS ()
ESPECIFICAR: ESPECIFICAR: ESPECIFICAR: ESPECIFICAR: ESPECIFICAR:
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10.- PATRÓN ADAPTACIÓN/TOLERANCIA AL STRESS El primer contacto en el hospital, se dio hace aproximadamente 47 días previos a esta valoración, en la sala de urgencias derivado de shock hipovolemico causado por diarrea y vomito intenso. INDICIOS INQUIETUD N/A NEGACIÓN DEL PROBLEMA TENSIÓN MUSCULAR N/A HIPERSENSIBILIDAD A LA CRÍTICA POSTURA RÍGIDA NO CONDUCTA MANIPULADORA MANOS HÚMEDAS N/A AUTOCOMPASIÓN BOCA SECA SI CONDUCTA AUTODESTRUCTIVA: N/A CAMBIOS EN EL ESTILO DE VIDA SI ( X ) NO ( ) Especificar: El pronóstico médico es malo para la vida y la función.
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DIAGNÓSTICOS DE ENFERMERÍA Patrón Nutricional/Metabólico: Nutricional/Metabólico:
Hiperglucemia secundaria a disminución en la producción de insulina. Desequilibrio nutricional por exceso relacionado con desequilibrio entre el consumo de alimentos y gasto de energía, manifestado por peso corporal superior al 20% al ideal según la talla y constitución física. Déficit de alimentación relacionado con deterioro cognitivo manifestado por incapacidad para llevar los alimentos a la boca. Riesgo de aspiración relacionado con sonda naso gástrica y presencia de tubo de traqueotomía Deterioro de la integridad cutánea relacionado con inmovilización física y presión
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UNIVERSIDAD NACIONAL AUTÓNOMA DE MÉXICO. FACULTAD DE ESTUDIOS SUPERIORES IZTACALA. MODULO DE ENFERMERÍA EN LA SALUD DEL ADULTO. PLAN DE CUIDADOS
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