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UNIVERSIDAD NACIONAL DE TRUJILLO FACULTAD DE ENFERMERIA

PROCESO DE ENFERMERIA A. DATOS DATOS DE IDENTIFICACIÓN: IDENTIFI CACIÓN:          

Nombre y Apellidos: NRC NRC Edad: Edad: 40años Sexo: Sexo: FEMENINO Lugar Procedecia: Procedecia: PUCALLP PUCA LLPA A !rado de Is"rucci#: SECUNDARIA COMPLET C OMPLETA A Ocupaci#: OBRERA Ocupaci#: OBRERA Fec$a de Igreso: 22/ 10/ 14 Nom Nombre bre de la I Is" s"i" i"uc uci# i#: : POLI POLICL CLIN INIC ICO O DE FLORENCIA DE MORA Ser%icio: HOSPITALIZACIN Ser%icio: HOSPITALIZACIN Cama: 32

B. VALOR VALORACION ACION DE LOS PA PATRONES DE LA SALUD

I!" PATRON PERCEPCION/ MANTENIMIENTO DE LA SALUD Pa#$% #$%&'% &'% $&() &()%sa #a*$&a& $&a&+o +o a ,os,os-$$'a.$ 'a.$a#$& #$& -a)a -a)a s o-%)a#$& -)o()a*a+a! -)o()a*a+a! P)%s%&'a P)%s%&'a +o.o) a+o*$&a.! a+o*$&a.! R% R%3%)% 3%)% % ,a '%&$ '%&$+o +o $&'% $&'%)5 )5%& %&#$ #$o& o&%s %s $) $)6) 6)($ ($#a #ass a&'% a&'%)$ )$o) o)%s %s 7 s '8a '8a -)%s%&'o ,a#% años .a *$s*a %&9%)*%+a+! Pa+%#$ ,a#% & año +% as*a! Pa)a #$+a) s sa.+ s% a.$*%&'a #o& 5%)+)as 7 ,a#% %%)#$#$os! No #o&s*% 'aa#o &$ a.#o,o.! Es a.;)($#a a. -%s#a+o! C*-.% #o& %. );($*%& '%)a-;'$#o! II!" PATRON NUTRICIONAL/ NU TRICIONAL/ METABOLICO METABOLICO ENFERMERIA FUNDAMENTAL

1

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UNIVERSIDAD NACIONAL DE TRUJILLO FACULTAD DE ENFERMERIA

I&'o.%)a&'% a .a .a#'osa! I&(%s'a +% a.$*%&'os: < 5%#%s a. +8a! A#'a.*%&'% %. -a#$%&'% -)%s%&'a -$%. #=.$+a> -o#o ,$+)a'a+a! No -)%s%&'a +%&'a+)a -os'$a> -%)o .% 9a.'a& -$%as +%&'a)$as 7 &o -)%s%&'a -)%s%&'a %+%*as! S$ ? @( %& .os 6.'$*os < *%s%s! S +%(.#$& %s &o)*a.> s *#osa o)a. %s )osa+a % ,$+)a'a+a! III!" PATRON ELIMINACION EL IMINACION E.$*$&a#$& $&'%s'$&a. .$$+a +% +os a ')%s 5%#%s a. +8a! No s% %s9%)a -a)a +%9%#a)! P)%s%&'a +o.o) a+o*$&a. *7 9%)'%! D%*o)a -a)a *$##$o&a)! IV!"PATRON ACTIVIDAD/EJERCICIO S$(&os 5$'a.%s: PA: +% 10/0 **H(! P.so: ?  F)%#%&#$a )%s-$)a'o)$a: 1  T:  T: %s ')aaa+o)a 7 .#,a+o)a #7a #7a #a-a#$+a+ #a-a#$+a+ *=s &o'a.% &o'a.% %s .a )a-$+%! A+%*=s A+%*=s *a&$ *a &$3% 3%s' s'a a % % s% s$%& s$%&'% '% #a #a-a -a -a)a -a)a a9) a9)o&'a o&'a)) s$' s$'a# a#$o $o&% &%ss +$98#$.%s! ROL/RELACI ONES VIII!" PATRON ROL/RELACIONES Ma+)% +% 9a*$.$a +% 1 ,$o! B%&as )%.a#$o&%s so#$a.%s 'a&'o %& s ')aao #o*o s 5%#$&+a)$o! Pa# a#$% $%&' &'% % -)%s -)%s%& %&'% '% &a &a #o #o* *&$ &$#a #a#$ #$& & )%'$# %'$#%& %&'% '%>> '$%& '$%&% % .a #a-a #a -a#$ #$+a +a+ + -a)a -a)a ')a ')aa aa) a) ()()-a. a.*% *%&' &'%! %! A+%*= +%*=ss ')a ')aa aa a a)+a*%&'%! I!" PATRON SEUALIDAD/REPRODUCCION M%) a+.'a *a+)a +% 40 años +% %+a+> #o& & ,$o! Co& s$(&os +% o#,o)&o %& )%.a#$& a .a *%&o-as$a! !" PATRON AFRONTAMIENTO/ESTR AFRONTAMIENTO/ESTRS S S% s$%&'% &a -%)so&a % a. %s'a) a&'% & -)o.%*a +% sa.+ %s %s')%sa&'%> 7 a. s%) as8 %s 9=#$. %. #a*$o +% ,*o)! La -a#$%&'% )%3%)% % ,a %-%)$*%&'a+o )%#$%&'%*%&'% &a s$' s$'a# a#$ $& & %s %s') ')%s %sa& a&'% '% #a& #a&+o +o .a sa sa#a #a))o& +%. +%. $) $)9 9a& a&o o -o) -o) #o&'a*$&a#$&> -%)o -+$;&+os% a+a-'a) a +$#,o #a*$o! Pa)a )%.a %.aa) a)s% s% %s %s# ##, #,a a *6s$ *6s$#a #a 7 #%& #%&'a 'a #o #o& & %. a-o7o -o7o +% ss ss a*$(asK 7 %& ss )a'os .$)%s .%% .a $.$a!

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UNIVERSIDAD NACIONAL DE TRUJILLO FACULTAD DE ENFERMERIA

R%.$($&: #a'.$#a> %s +%5o'a +%. #)$s'$a&$s*o! T%*% a .a 5%% 7 so.%+a+> -%)o .% *o'$5a 5$5$) s ,$o!  % %. s9)$*$%&'o .% %s $*-os$.% +% %-.$#a)! Co.ao)a %& ss #$+a+os -a)a *%o)a) s sa.+> -%s $%)% %s'a) sa&a 7 %s #a-a +% )%#o&o#%) ss #.-as!

C. EXAMEN FISICO 1. APA APARIENCIA RIENCIA GENERA GENERAL: L:

A+.'a *a+)a +% #o&'%')a +%.(a+a> a-a)%&'a .a %+a+ % '$%&%> +% %s'a')a aa> #a%..o #o)'o> -%)*a&%#% %& -os$#$& +% #$'o +o)sa.> 5$s'% &a a'a #o.o) ')%sa> a .a os%)5a#$& a-a)%&'a '%&%) +o.o) a+o*$&a.> -%s'o % a6& &o .a o-%)a&! Ho)a: 10:00a* PA: 10/0 **H(! P.so: ?  F)%#%&#$a )%s-$)a'o)$a: 1  T:  T: 2 )a&(o %&')% 1>1"2 PESO NORMAL

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UNIVERSIDAD NACIONAL DE TRUJILLO FACULTAD DE ENFERMERIA

T%*-%)a')a %*-%)a')a ,o*o'%)*$a> ,o*o'%)*$a> s% os%)5a -$%. +%s,$+)a'a+a> +%s,$+)a'a+a> #a%..o #a%..o .$*-$o .$*-$o #o& %&a %&a $*-.a&'a $*-.a&'a#$&> #$&> ñas ñas #o& %& ..%&a+o #a-$.a) 3. CABE CABEZA ZA::

Ca% Ca%a a s$*;') s$*;')$#a $#a>> 9o)*a 9o)*a a.a a.a)( )(a+a a+a -)o-o -)o-o)# )#$o& $o&a. a. a. #%)-o #%)-o>> $*-. $*-.a& a&'a 'a#$ #$& & s$*; s$*;') ')$# $#a a +%. +%. -%.o -%.o>> as% as%&# &#$a $a +% s% s%o o)) ))%a %a 7 -a)=s$'os! Ca%..o ()%so> s%#oK as%&#$a +% o&as +o.o)osas> *asas o +%-)%s$o&%s

4. CARA:

 Ca)a a.a)(a+a> 5o.*%& -)o-o)#$o&a. a. #%)-o> s$*%')8a> '%*-%) '%*-%)a' a')a )a ,o*o'% ,o*o'%)* )*$a $a>> 9as#$ 9as#$%s %s +% +o.o)> +o.o)> -$%. -$%. $&'%( $&'%()a> )a> as%&#$a +% *asas 7 &o -)%s%&'a o&as +o.o)osas 5. OJOS:

S% os% os%)5 )5a a -=)-=)-a+ a+os os #o #o& & %& %&a a o# o#. .s$ s$& & % $&'% $&'%() ()$+ $+a+ a+>> %&a %&a $*-.a& $*-.a&'a# 'a#$& $& +% -%s'a -%s'añas ñas>> $&'%() $&'%()$+ $+a+ a+ +%. a-a)a' a-a)a'o o .a#)$*a.> $)$s $)$s +% #o.o) &%()o &%()o $&'%()o> $&'%()o> --$.as $(a.%s> $(a.%s> .os +os oos oos )%a# )%a##$ #$o& o&a& a& a .a . 7 a .a -a.-a.-a# a#$ $& & o# o#. .a) a) &o ,a7 *asas &$ +o.o)! . O!DOS

Pa%..o&% a%..o&%ss a)$#. a)$#.a) a)%s %s $%& $*-.a&'a $*-.a&'a+os> +os> '%*-%)a' '%*-%)a')a )a %& )%.a#$& a. )%s'o +%. #%)-o> a .a -a.-a#$& &o +%.%> %s *5$ *5$.K .K -)%s -)%s%& %&'a 'a #% #%) )*% *%& & %& -o#a -o#a #a #a&' &'$+ $+a+ a+ %& a* a*o oss o8+os!

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 S% os%)5a &a)$ -)o-o)#$o&a. a .a #a)a> -%)*%a$.$+a+ %& a*as 9osas &asa.%s> a .a -a.-a#$& as%&#$a +% *asas> *#osa &asa. )os=#%a! #. OROF OROFA ARI RING NGE E:

S% os% os%)5 )5a a .a$ .a$os os s$*; s$*;') ')$# $#os os )%s %s%# %#os os>> *#o *#osa sa -o#o -o#o ,$+)a'a+a> as%&#$a +% -$%as +%&'a)$as> .%&(a s$*;')$#a )%s%#aK -a.a+a) $&'%()o )osa+o! $. CUELLO

A .a $&s-%##$& s% os%)5a #%..o s$*;')$#o> -$%. +% #o.o) ')$(%ño s$*;')$#o &o ,a7 -)%s%&#$a +% *asas %. %a*$&a+o )%a.$ )% a.$a a *o5$*$ *o5$*$%& %&'os 'os s$& .$*$'a .$*$'a#$ #$&> &> &o -)%s% -)%s%&'a &'a &+.o &+.os> s> )%a.$a )%a.$a *o5$*$%&'os *o5$*$%&'os s$& +o.o)> +o.o)> '%*-%)a')a '%*-%)a')a ,o*o'%)*$a! ,o*o'%)*$a! S % -a.-a -.so #a)o'$+%o +% 1  1%.

TORAX

 T)a  T)a s$*;')$#o> )%s-$)a#$& )%s-$)a#$& +$a9)a(*='$#a +$a9)a(*='$#a>> 1 -o) *$&'o> #o.*&a s$& +%s5$a#$o&%s

11.

SISTEMA CIRCULATORIO

F)%#%&#$a #a)+$a#a> ? -o) *$&'o> as%&#$a +% )$+os so)% a()%(a+os 12.

EXAMEN FISICO DE MAMAS

No )%a.$a+o! 13.

. EXAMEN FISICO DE ABDOMEN

A+o*%& s$*;')$#o> +o.o)oso a .a -a.-a#$& %& .a o&a +%.

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No )%a.$a+o! 15.

EXAMEN RECTAL

No )%a.$a+o! 1.

EXAMEN MUSCULOES&UELETICO:

A+. A+.'a 'a *a+ *a+)a )a>> o) o)$% $%&' &'a+ a+a a %& '$%* '$%*-o -o>> -%)s -%)so& o&a a 7 %s %s-a -a#$ #$o o OTEP $#$o #o&s%)5a+o!

DIANOSTICO DE LOS PATRONES FUNCIONALES DE LA SALUD 1! PATRON CONOCITIVO"PERCEPTIVO CONOCITIVO "PERCEPTIVO

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)&ANALISIS )& ANALISIS E IN'ERPRE' IN'E RPRE'ACION ACION DE DA'OS S%(6& o)+o&> o&> +%s#)$% %s'% -a')& #o*o o*o: s%&so)$o" -%)#%-'a. 7 #o(&$'$5o +%. $&+$5$+o! Es +%#$) s% )%3%)% a % .as .as 9&# 9&#$o $o&% &%ss +% .os .os s% s%&' &'$+ $+os os s% s%a& a& a+%# a+%#a a+a +ass 7 o-'$ o-'$*a *as> s> a+%*=s %s'% 8'%* %s'+$a +%'%)*$&a s$ %$s'% +o.o) a. $(a. % % #o #o**-) )% %a a .as .as #a #a-a -a#$ #$+a +a+% +%ss #o #o(& (&$' $'$5 $5as as )%.a' %.a'$5 $5as as a .a *%*o)$a 7 %. .%&(a%! E. +o.o) %s &a %-%)$%&#$a s%&so)$a. 7 %*o#$o&a. s%'$5a> (%&%)a.*%&'% +%sa()a+a.%> % -%+%& %-%)$*%&'a) 'o+os a%..os s%)%s 5$5os % +$s-o&%& +% & s$s'%*a &%)5$oso #%&')a.! E. +o.o) -%+% a7+a) a +$a(&os'$#a) & -)o.%*a! S$& +o.o)> s'%+ -o+)8a .as'$*a)s% ()a5%*%&'% s$& sa%).o o &o +a)s% #%&'a +% % '$%&% & -)o.%*a *;+$#o % )%$%)% ')a'a*$%&'o! U&a 5% % %. -)o.%*a s% ')a'a> %. +o.o) s%.% +%sa-a)%#%)! Po) #o #o&s &s$( $($ $%& %&'% '%>> %. +o.o +o.o)) s% os% os%)5 )5a> a> #a& #a&+o +o .a -a#$ -a#$%& %&'% '% -)%s%&'a %s'os *$o*as o 3)o*as> % so& '*o)%s %&$(&os +%. 6'%)o % s% #.as$3#a&> s%(6& .a .o#a.$a#$& 7 %. #)%#$*$%&'o % a+o-'%&> %& s*#osos> $&')a*s#.a)%s o s% s%))os osas as!! Lo Loss *$o* *$o*as as s* s*# #os osos os '$%& '$%&%& %& s as% as% %& %. *$o*%')$o 7 #)%#%& ,a#$a .a #a5$+a+ '%)$&a %&+o*%')$o> .os $&')a*s $&')a*s#.a #.a)%s )%s s% .o#a.$a& .o#a.$a& 'o'a.*%& 'o'a.*%&'% '% %& %. %s-%so) +% .a -a)%+ '%)$&a *$o*%')$o> 7 .os s%)osos #)%#%& ,a#$a 9%)a +%. 6'%)o> ,a#$a .a #a5$+a+ a+o*$&a.! S$ $%& &o %s'=& #.a)as .as #asas %a#'as +%. o)$(%& +% %s'as

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UNIVERSIDAD NACIONAL DE TRUJILLO FACULTAD DE ENFERMERIA

Po) 'a. 'a. *o'$ *o'$5o 5o>> .a -a#$ -a#$%& %&'% '% *a *a&$ &$3% 3%s' s'a a % % a .a -a.-a.-a# a#$ $& & -)o9&+a ,a7 +o.o)! CONC CONCL L*SIO *SION N RA+O RA+ONA NADA: DA: #o(&$'$5o -%)#%-'$5o -%)#%-'$5o

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-o) %-)%s$& 9a#$a.! 2! PATRON MANTENIMIENTO"PERCEPCION DE LA SALUD A&DA'OS SI!NIFICA'I(OS  A&'%#%+%&'%s 9a*$.$a)%s  Es'a+o #o&s$%&'% #o& ()a+o +% o)$%&'a#$&  D: L%$o*$o*a '%)$&o )&ANALISIS )& ANALISIS E IN'ERPRE' I N'ERPRE'ACION ACION DE DA'OS S%(6& o)+o&> %. *a&'%&$*$%&'o"-%)#%-#$& +% .a sa.+ ,a#% )%9%)%&#$a +% #*o -%)#$% %. $&+$5$+o s sa.+ 7 $%&%s'a)> a+%*=s %5a.6a .as -)a#'$#as -)%5%&'$5as % )%a.$a %. -a#$%&'%> %s +%#$) %s'% -a')& a&a.$a =s$#a*%&'% .a -%)#%-#$& +% sa.+ +%. -a#$%&'% 7 .as -)a#'$#as % -%+%& -)%5%&$) %&9%)*%+a+%s! 

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CONCL*SION RA+ON CONCL*SION RA+ONADA: ADA: A.'%)a#$& +%. -a')& *a&'%&$*$%&'o +% .a sa.+! C&FORM*LACI,N DEL DIA!N,S'ICO D: Ma&'%&$*$%&'o Ma&'%&$*$%&'o $&%3#a +% .a sa.+ )%.a#$o&a+o )%.a#$o&a+o #o& .a $&#a-a#$ $&#a-a#$+a+ +a+ -a)a -a)a as*$) .a )%s-o& )%s-o&sa$ sa$.$+a .$+a+ + +% ..%5a) a #ao .as -)a#'$#as =s$#as +% sa.+ *a&$9%s'a+a -o) .a 5%)a.$a#$& +% .a -a#$%&'%! > %s %s'% '% -a') -a')& & +%s# +%s#)$ )$% % .a 9&# 9&#$ $& & %#) %#)%' %'o) o)a a $&'%s'$&a.> )$&a)$a 7 +% .a -$%.> a. $(a. % 'o+os .os as-%#'os % '$%&%& % 5%) #o& %..aK %s +%#$) % 'a*$;& +%s#)$% )'$&as -%)so&a.%s 7 #a)a#'%)8s'$#as +% .as %#)%#$o&%s! La %.$*$&a# %.$*$&a#$& $& +% .os -)o+#' -)o+#'os os +% +%s%#,o +%s%#,o +% .a +$(%s' +$(%s'$& $& +%. o)(a&$s*o %s %s%&#$a. -a)a .a Sa.+! S #%)-o +$($%)% .os a.$*%&'os *$%&')as %s'os ')a&s$'a& -o) %. ')a#'o (as')o$&'%s'$&a.! (as')o$&'%s'$&a.! Los +%s%#,os so)a&'%s +%. a.$*%&'o +$(%)$+o $&()%sa& a. $&'%s'$&o ()%so %& 9o)*a +% .8$+o! E. $&'%s'$&o

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Po) .o 'a&'o .a -a#$%&'% %& %s'+$o '$%&% a.'%)a+o %. 9&# 9&#$o $o&a &a*$ *$%& %&'o 'o 3s$o 3s$o. .($ ($#o #o +% .a %5a# %5a#a a#$ #$& & +%$ +%$+o +o a .a #o*-) #o*-)%s$ %s$& & +%. $&'%s' $&'%s'$&o $&o .%$o*$ .%$o*$o*a o*a '%)$&o '%)$&o -)o5o# -)o5o#a& a&+o +o #o&s'$-a#$& o a.'%)a#$o&%s +%. ,=$'o $&'%s'$&a.! CONCL CONC L*S *SIO ION N %.$*$&a#$&!

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a*%&'o +% .a -)%s$& a+o*$&a. 7 +o.o) a. +%9%#a)! -. PA'R 'R,N ,N : AFR FRON ON' 'AMI MIEN EN'O 'O / 'O 'OLE LERA RANC NCIA IA AL ES'R0S A&DA'OS SI!NIFICA'I(OS: SI!NIFICA'I(OS:  F% o-%)a+a ,a#%  años +% -.$-o )%#'a.  A&s$%+a+ ,a#$a .a %s-%)a +% .a o-%)a#$& )%-)o()a*a+a )&ANALISIS )& ANALISIS E IN'ERPRE' I N'ERPRE'ACION ACION DE DA'OS S%(6& S%(6 & o o))+o +o& & &o &oss +$ +$#% #%>> %s %s'% '% -a -a') ')& & %s .a Fo)*a +% ,a#%) 9)%&'% a .os a#o&'%#$*$%&'os 7 -)o#%sos 5$'a.%s! E5a.6a .os &$5%.%s +% a+a-'a#$& 7 'o.%)a&#$a +% .a -%)so&a a #$+a) a. %s');s> .o #a. $&#.7% .a #a-a#$+a+ +% )%s$s'$)s% a a*%&aas ,a#$ ,a#$ .a $a $&'% $&'% $+a+ $+a+ 9o +% o +%. +%. ');s ');s

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PRIORI+ACION DE DIA!NOS'ICO 1.

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UNIVERSIDAD NACIONAL DE TRUJILLO FACULTAD DE ENFERMERIA

DIAG DIAGNÓ NÓSTI STICO CO

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OBJE OBJETI TIVO VOS S

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FUNDAMENTOS FUNDAMENTOS EVA E VALUA LUACIÓN CIÓN

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UNIVERSIDAD NACIONAL DE TRUJILLO FACULTAD DE ENFERMERIA

2! PATRON MANTENIMIENTO"PERCEPCION DE LA SALUD INTERVENCI DIAGNÓSTICO

OBJET JETIVOS

ÓN ENFERMERA

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MANTENIMIENTO INEFICA DE LA SAL/D RELACIONADO CON LA

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