Instrucciones generales: Estudie cuidadosamente el contenido del módulo 6.1 sobre

Instrucciones generales:

  1. Estudie cuidadosamente el contenido del módulo 6.1 sobre el Proceso de Enfermería Aplicado a las Necesidades del Cliente-Familia. Luego lleve a cabo el  Taller de Plan de Cuidados con Nota de Progreso de Enfermería III  .

Instrucciones específicas para esta tarea:

Utilizando los datos del  caso clínico hipotético   que te presentamos en esta tarea, realiza el Plan de Cuidados de Enfermería  para este cliente. Encontrarás los materiales necesarios y la tabla para elaborar el plan de cuidado y la nota de progreso en la sección de  Materiales Suplementarios Módulo 6.1   :

  1. Identifica en orden de prioridad dos (2)   necesidades de salud   de este cliente hipotético, uno (1)   real   y uno (1)   a riesgo  , que sean las mayores prioridades al ofrecer cuidado de enfermería en esta situación hipotética.
  2. Enumera los datos   objetivos y subjetivos   que evidencian la existencia de la necesidad de salud.
  3. Identifica los   estímulos focales   relacionados en ambas necesidades seleccionadas.
  4. Usando las etiquetas de   NANDA 2018-20   y el formato   PES  , redacta cada uno de los dos diagnósticos de enfermería de prioridad, real ya riesgo.
  5. Redacta un (1)   resultado esperado   para cada diagnóstico de enfermería identificado en esta situación. (Utiliza el formato: sujeto, verbo de acción, indicador / res de modificación de conducta inadaptada y tiempo para conseguirlo) según aprendido en el módulo2.
  6. Colocando en orden de prioridad, escriba al menos cinco (5)   intervención de enfermería   que llevaría a cabo para lograr cada uno de los   resultados esperados  . Es importante que incluya en las intervenciones, al menos una para prevención y promoción de la salud del cliente-familia.
  7. Menciona el   científico racional   que valide el llevar a cabo cada uno por   intervención  .
  8. Redacta una   evaluación   para cada diagnóstico de enfermería a la luz del resultado esperado que desarrollaste.

Situación Clínica Hipotética:

Varón de 50 años que llega a la Sala de Emergencias (ER) por disnea, palidez, palpitaciones, con periodos de confusión y disminución de la atención. Cliente fumador que fue diagnosticado con EPOC (Enfermedad Pulmonar Crónica Obstructiva) hace cuatro (4) años. Los familiares se refieren a que el cliente ha estado presentado un cuadro de refriado común desde hace seis (6) días el cual está tratando con medicamentos antigripales comprados sin receta. Presenta síntomas de escalofríos, dolor de cabeza y dolores musculares con falta de energía, a menudo, congestión nasal, estornudos, rinorrea con moco de color verde. Signos vitales: pulso 110/minuto, Presión Arterial 80/40 mm Hg, Temperatura 38°C, Respiraciones en 28/minuto con sibilancias y Saturación de Oxígeno en 89%.  

El médico prescribe admitir al cliente a cuarto en la unidad de medicina con descanso absoluto, oxigeno por cánula nasal a 4 litros/minuto, pruebas de función pulmonar, prueba de gases arteriales y hematologías, placa de pecho y CT SCAN de tórax, terapia terapéutica con 0.9 de salina normal, antibióticos intravenosos, corticosteroides orales y broncodilatadores inhalados.

Libro de Texto y Referencias:

Craven, R., Hirnle, C. & Henshaw, C. (2017) Fundamentos de enfermería: salud y función humana. 8ª  ed  . Wolters Kluwer: Filadelfia. 

NANDA diagnosticos enfermeros: definicion y clasificacion 2018-2020. 11a ed. Barcelona: Elsevier España SLU; 2019.

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