Proceso de Enfermería aplicado a paciente con desequilibrio nutricional.
Authors: Quezada Urban Rosalía , Aguilar Hernández Paulina , Sánchez Cruz Beatríz 
Published: May 2019

<div>Resumen:</div><div><br /></div><div>Se aplica un proceso enfermero a un</div><div>paciente masculino de 51 a&ntilde;os que es intervenido</div><div>quir&uacute;rgicamente realizando colecistectom&iacute;a abierta,</div><div>la cual se complica debido a migraci&oacute;n de un lito</div><div>vesicular a p&aacute;ncreas iniciando con Diagn&oacute;stico de</div><div>Pancreatitis aguda.</div><div><br /></div><div>La valoraci&oacute;n se realizo con la teor&iacute;a de los</div><div>patrones funcionales de Marjory Gordon teniendo</div><div>alteraciones en el patr&oacute;n de actividad- ejercicio</div><div>con datos de disnea, sialorrea, traqueostom&iacute;a con</div><div>secreciones espesas y purulentas verdosas.</div><div>En el&nbsp;patr&oacute;n nutricional metab&oacute;lico se encuentran datos&nbsp;</div><div>como drenaje con gasto biliar en la sonda orog&aacute;strica&nbsp;</div><div>y drenaje serohem&aacute;tico f&eacute;tido del penrose, tambi&eacute;n&nbsp;</div><div>presenta evisceraci&oacute;n cubierta con bolsa de &nbsp;&nbsp;</div><div>Bogot&aacute; visualizando epipl&oacute;n y asas intestinales, &nbsp;&nbsp;</div><div>as&iacute; como destrucci&oacute;n de las capas de la piel &nbsp;&nbsp;</div><div>debido a procedimientos quir&uacute;rgicos. &nbsp;</div><div>Otro patr&oacute;n&nbsp;alterado es el cognitivo perceptual debido a &nbsp; que el&nbsp;paciente refiere un EVA de 6 y quejidos al &nbsp;realizar&nbsp;procedimientos.</div><div>Se jerarquizaron los diagn&oacute;sticos&nbsp;de acuerdo a los &nbsp;patrones funcionales con mayor&nbsp;alteraci&oacute;n.&nbsp;</div><div>&nbsp;Las etiquetas utilizadas fueron, Limpieza&nbsp;</div><div>ineficaz de las v&iacute;as a&eacute;reas, Desequilibrio nutricional,&nbsp;</div><div>Dolor agudo y Deterioro de la integridad cut&aacute;nea.&nbsp;</div><div><br /></div><div>Las intervenciones principales fueron:</div><div><br /></div><div>Cuidados de la de traqueostom&iacute;a, Aspiraci&oacute;n de &nbsp;</div><div>secreciones, Nutrici&oacute;n parenteral, Manejo del dolor &nbsp;</div><div>y Cuidados de la herida quir&uacute;rgica.</div><div><br /></div><div>El paciente logra una estabilidad&nbsp;</div><div>hemodin&aacute;mica a excepci&oacute;n de la temperatura &nbsp;</div><div>manteniendo datos insidiosos de infecci&oacute;n.&nbsp;</div><div><br /></div><div>Se aplicaron cuidados de enfermer&iacute;a de &nbsp;</div><div>manera oportuna y eficaz de acuerdo a la respuesta &nbsp;</div><div>de la persona con logros significativos involucrando &nbsp;</div><div>nuestros conocimientos adquiridos proporcionando &nbsp;</div><div>siempre un cuidado hol&iacute;stico y con alto humanismo. &nbsp;</div><div><br /></div><div><br /></div><div>Abstract:</div><div><br /></div><div>Nursing process is applied to a male patient&nbsp;</div><div>of 51 years old who is surgically intervened for an&nbsp;</div><div>open cholecystectomy, which complicates due to the&nbsp;</div><div>migration of a gallstone to the pancreas initiating&nbsp;</div><div>with an acute process of pancreatitis.</div><div><br /></div><div>To asset we use the functional patterns of&nbsp;</div><div>the theoretical Marjorie Gordon having several&nbsp;</div><div>alterations in the activity-exercise pattern with signs&nbsp;</div><div>of dysnea, sialorrhea, the traqueostomy presents&nbsp;</div><div>thick and purulent secretions.&nbsp;</div><div><br /></div><div>In the nutritional metabolic&nbsp;</div><div>pattern we found biliary drainage&nbsp;</div><div>spending in the orogastric tube and fetid serous&nbsp;</div><div>drainage proceeding from the Penrose, there's &nbsp;</div><div>also evisceration covered with a &ldquo;Bolsa de Bogota&rdquo;&nbsp;</div><div>we can observe the omentum and bowel loops as&nbsp;</div><div>well as the destruction of the skin layers due to the&nbsp;</div><div>surgical procedures. Also the cognitive perceptual&nbsp;</div><div>pattern is affected due to a score of 6 in scale of VAS&nbsp;</div><div>and whining in every procedure.&nbsp;</div><div><br /></div><div>We manage to rank de diagnosis according to&nbsp;</div><div>the altered functional patterns.</div><div><br /></div><div>The&nbsp;applied&nbsp;labels &nbsp;were:&nbsp;</div><div>Ineffective airway clearance, imbalanced&nbsp;</div><div>nutrition, acute pain and impaired skin integrity.&nbsp;</div><div><br /></div><div>The main interventions were: Tracheostomy&nbsp;</div><div>Tube Care, Airway Management, Nutrition&nbsp;</div><div>Management, Pain Management and Wound Care.&nbsp;</div><div><br /></div><div>The patient manages to have a hemodynamic&nbsp;</div><div>stability except for the temperature which keeps&nbsp;</div><div>throwing data of an insidious infection.&nbsp;</div><div><br /></div><div>The care was given in a very efficient way and&nbsp;</div><div>in time according to the human response having a&nbsp;</div><div>very significant achievements and it also allows&nbsp;</div><div>us to apply the acquired knowledge providing an&nbsp;</div><div>holistic care and humanism.</div>