protocolo de atencion pediatrica
TRANSCRIPT
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HOSPITAL HORACIO HELLER
MANUAL DE
PROTOCOLOS DE
ENFERMERA
SECTOR 10
MAY0 2012
AUTORES:
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AGERO VALERIA
CALDERN MERCEDES
CASTILLO SUSANA
GARCA LORENA
GOMEZ RUTH
HUECHUCURA ROSA
MENDOZA SILVIA
NEIRA NATALIA
OSSES ROBERTO
PALACIOS ALFONSO
QUEZADA YANET SANDOVAL JUANA
VARGAS RAQUEL
VIDELA JUAN
ZAPATA VERNICA
COORDINADORA:Jefa e E!fe"#e"$a e% Se&'(" )*: L+&, CARI NORA,
COORDINADORES:
Jefe M-+&( e% Se&'(" )*: D", S('(#a.(" Ma"&e%(
C(("+!a(" e Pe+a'"$a: D", ROMERO C/SAR
AGRADECIMIENTO
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INTRODUCCIN
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OBJETIVO:
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%a #0e" e! e% 2"(&e4( e% e#9a"a5( . 20e"2e"+( 4ea 2e"4(!a%+5aa .
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OBJETIVOS ESPECFICOS:
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VALORACION INICIAL AL INGRESO DEL USUARIO PEDITRICO
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OBJETIVO:
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A9("ae +!+&+a%:
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OBSERVACIONES
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)? IDENTIFICACIN DEL PACIENTE
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Ref%e( e S0&&+;!?De1%0&+;!: S+: N(:
H>9+'(4 A%+#e!'a"+(4:L>&'ea:,, B%a!a: Pa2+%%a4:,, N("#a%:,,
Va"+aa:
La&'a!'e: T(#a &(! 9+9e";!: S+:,N(:, Le&7e e =a&a a% )*K:, A% )3K:
,, Le&7e e42e&+a%: S+: N(:,,La&'a!&+a Ma'e"!a: S+:,, N(:
,
T(%e"a!&+a: B0e!a:,, Re&7a5(:
T+2( e A%+#e!'a&+;!: V$a ("a%: P(" SNG:,Ga4'"(4'"(#$a:,
A9(#e!: B%a!(:,, G%(90%(4(: D+4'e!+(:,, R0+(4 H+"(a-"e(4: S+:
, N(:P"e4e!&+a e a!("#a%+ae4:,
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P"e4e!&+a e N>04ea4: S+: N(: E#e4+4: S+:, N(:T+2(:
B+%+(4(:,,,,,,,,,,A%+#e!'+&+(:, Se&"e&+(!e4:, O'"(4:,
, Ne&e4+a e E%+#+!a&+;!
Ge!+'a%e4: N("#a%e4: S+:N(: P"e4e!&+a e %e4+(!e4: S+:,N(:,,
De"#a'+'+4: S+:,,N(:,,O'"(:,,
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De2(4+&+(!e4: S+:,,N(: Ca"a&'e"$4'+&a4: L$60+a: Pa4'(4a:B%a!a:
E4'"e@+#+e!'(:, O'"a:,,
F"e&0e!&+a: U!a: D(4: T"e4: M>4 e '"e4:
D+0"e4+4: S+: N(: Ca"a&'e"$4'+&a4:
? Ne&e4+a e M(=+%+5a&+;!
M+e#9"(4 S02e"+("e4: I!'e1"+a e %a 2+e%:Def("#+ae4: S+:
,,N(: O'"(4:,,
M+e#9"(4 I!fe"+("e4: I!'e1"+a e %a 2+e%:
,, Def("#+ae4:,, T(!( #04&0%a":
Ma"&7a: C(("+!a&+;! e %a4 #a!(4 . %(4 2+e4: S+:N(:,
Ref%e(4: S+:,N(:,
M('("a4: Se 4+e!'a 4(%(: S+: N(: Dea#90%a: S+: N(:,, S(%(:,,
C(! a.0a:,
Se!4("+a%e4: C(!'"(% M04&0%(e460e%-'+&(: H+2e"'(!$a4:, H+2('(!$a4:
,A'"(f+a4:,
C(!'"(% !e0"(%;1+&(a%'e"a&+;! 4+&(#('"+&e4: S+:,N(:
? Ne&e4+a e Re2(4( . S0e@(
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,
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,,
? Ne&e4+a e Te#2e"a'0"a ? H+1+e!e Ve4'+#e!'a P+e%
Te#2e"a'0"a A8+%a":CW N("#('e"#+a:, H+2('e"#+a:,, H+2e"'e"#+a:,,
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E4'a( e %a P+e%: L+#2+a:,N("#(7+"a'aa:,De47+"a'aa:,, Se&a:
De4&a#aa:, Pe'e60+a4:E8a!'e#a:E60+#(4+4: O'"(:
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,
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,,,, O(4: N("#a%:,, E!"(e&+(4:Se&"e&+(!e4: S+:, N(:, E4'"a9+4#(:
, O'"(4:
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a0+'+=a: N("#a%:H+2(a&04+a:,,Se&"e&+(!e4: S+:,N(:
Na"+5: Se&"e&+(!e4: S+:,,N(: Ca2a&+a 2a"a +!7a%a" . e87a%a" 2(" &aa
0!a e %a4 !a"+!a4: S+:, N(:,,
B(&a: H
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VALORACIN DELOS SIGNOS VITALES
Def+!+&+;!:
La =a%("a&+;! e %(4 4+1!(4 =+'a%e4 !(4 2e"#+'e e'e&'a" a%'e"a&+(!e4
2('e!&+a%e4 ( "ea%e43 60e afe&'a! e% e60+%+9"+( 24+&(?f$4+&( e% +!+=+0(3 e4 e%
20!'( e 2a"'+a e! %a '(#a e e&+4+(!e4 (9e'+=a4 60e e'e"#+!a! 0! &0+a("ef%e8+=( e +!+=+0a%+5a( a% 2a&+e!'e,
L(4 4+1!(4 =+'a%e4: 'e#2e"a'0"a3 "e42+"a&+;!3 20%4( . 'e!4+;! a"'e"+a% 4(!
2a">#e'"(4 a '"a=-4 e %(4 &0a%e4 e4 2(4+9%e e=a%0a" %a 4a%0 e 0! +!+=+0(3
404 =a%("e4 4e #a!'+e!e! &(!4'a!'e4 e!'"( e &+e"'(4 %$#+'e43 e! e4'a( e
!("#a%+a,
O9e'+=(4$
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U'+%+5a" %a +!f("#a&+;! (9'e!+a3 2(" %a #e+&+;! e %(4 4+1!(4 =+'a%e43 &(#(
fa&'(" e'e"#+!a!'e 2a"a =a%("a" %a e=(%0&+;! e% 040a"+(3 %a "e420e4'a a%
'"a'a#+e!'( . a %a4 +!'e"=e!&+(!e4 e e!fe"#e"$a,
Re&(!(&e" %a "e%a&+;! 60e e8+4'e e!'"e %(4 4+1!(4 =+'a%e43 %a a&'+=+a f+4+(%;1+&a. %(4 &a#9+(4 f+4+(2a'(%;1+&(4,
C(!'"(%a" %(4 4+1!(4 =+'a%e4 &(! #a.(" f"e&0e!&+a 4+ e% e4'a( e% 040a"+( %(
"e60+e"e,
V'r"'"ones on &' e#'#
Edad Frecuencia Cardiaca
Normal
(latidos por
minuto)
Frecuencia Respiratoria
Normal
(respiraciones por minuto)
Neonato 110-160 30-500-5
meses
90-190 25-40
6-12
meses
80-140 20-30
1-3 aos 80-130 20-30
3-5 aos 80-120 20-306-10
aos
70-110 15-30
11-14
aos
60-105 12-20
14+ aos 60-100 12-20
CONTROL DE TEMPERATURA
Def+!+&+;!:
E4 e% 1"a( e &a%(" #a!'e!+( e! e% &0e"2( 2(" e% e60+%+9"+( e!'"e %a
'e"#(1-!e4+4 . %a 'e"#;%+4+4,La 'e"#(1-!e4+4 e4 e% &a%(" 2"(0&+( . %a
'e"#;%+4+4 e4 e% &a%(" 2e"+(,
E% 1"a( e &a%(" 20ee 4e" #e+( e! %a 9(&a3 +!1%e3 a8+%a ( "e&'( 2(" #e+( e
0! 'e"#;#e'"( +1+'a% ( e #e"&0"+(, La4 f("#a4 #e!(4 f"e&0e!'e4 4(!: O"a%3I!10+!a% . Re&'a%,
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O9e'+=(4:
? Va%("a" e% e4'a( e 4a%0 ( e!fe"#ea 4e1
1"a( e &a%(" &("2("a% . 404 a!("#a%+ae4,
C(!4+e"a&+(!e4:
? E% a0#e!'( e %a 'e#2e"a'0"a &("2("a% e4 0!a "e420e4'a a 0! 2"(&e4(
2a'(%;1+&(,? La 'e#2e"a'0"a &("2("a% 4e #(+f+&a &(! %a ea3 &%+#a3 ee"&+&+(3 e#9a"a5(3
&+&%( #e!4'"0a%3 e4'a( e#(&+(!a% . e!fe"#ea,? Fa&'("e4 60e afe&'a! e% a0#e!'( e %a 'e#2e"a'0"a: Ta4a #e'a9;%+&a 9a4a%3
A&'+=+a #04&0%a"3 A0#e!'( e %a 7("#(!a '+"(+ea3 e4'+#0%a&+;! 4+#2>'+&a
%+9e"a A"e!a%+!a3 N("a"e!a%+!a3Vasoconstriccin, Escalofrios,e#9(%+a
20%#(!a"3 2"e4e!&+a e '0#("e4 &(#( %a %e0&e#+a3 e47+"a'a&+;!3
A#9+e!'e3 '"a0#a'+4#(4 &"a!e(e!&ef>%+&(4 . %e4+(!e4 e %a #-0%a
e42+!a%3e'&,? Fa&'("e4 60e afe&'a! %a 2-"+a e %a 'e#2e"a'0"a$ C(!0&&+;!+
C(!=e!&+;!+ Va2("+5a&+;!3Vasodilatacin, Reposo y Sueo, ndiceMetablico Basal
? Va%("e4 !("#a%e4 e %a 'e#2e"a'0"a: R!: , & ? , & 3 La&'a!'e4 : ,
& ? & 3P"ee4&(%a" 3 e4&(%a" . A(%e4&e!'e4 : ? & 3Ea a0%'a :
, &3 Vee5 : & ,? A%'e"a&+(!e4: H+2e"e8+a ( 7+2e"'e"#+a : ) & 3 Fe9"+%: '+e!e f+e9"e &
3Afe9"+% : !( '+e!e f+e9"e &3 H+2('e"#+a : , &3 Fe9"$&0%a: , ,
INTERVENCIONES DE ENFERMERA
? E82%+&a" a% 040a"+(3 4e1'"+&(4
&aa 7("a43 . 4e1
? I!f("#a" a% 040a"+(3 a0%'( .( !+@(3 . a %(4 2a"e4 e% 2"(&e+#+e!'( a "ea%+5a",? P"e4e"=a" %a +!'+#+a e% 040a"+(,
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? C(%(&a"4e %a4 #a!(2%a4 e 2(%+e'+%e!( ( e %>'e8,? De4&(!'a#+!a" e% 'e"#;#e'"( &(! 0!a '("0!a &(! 4(%0&+;! a!'+4-2'+&a &(!
#(=+#+e!'(4 "('a'("+(4 +!+&+a!( 2(" e% 90%9(,? S(4'e!e" e% 'e"#;#e'"( 2(" e% e8'"e#( (20e4'( a% e% 90%9( e #e"&0"+( .
4+'0a"%( a %a a%'0"a e %(4 ((43 4+ e% !+=e% e %a 9a""a e #e"&0"+( e4'> 2(" e!&+#ae %(4 C3 '(#a"%( f+"#e#e!'e .3 &(! #(=+#+e!'(4 4e&(4 e %a #0@e&a3
4a&0+" %+1e"a#e!'e,? Ve"+f+&a" 60e %a &(%0#!a e #e"&0"+( #a"60e C ,? C(#2"(9a" 60e %a a8+%a e% 2a&+e!'e e4'e 4e&a . %+9"e e "(2a,? Pe+"%e a% 040a"+( 60e 4e2a"e e% 9"a5( . &(%(&a" e% 'e"#;#e'"( e! e% &e!'"( e %a
a8+%a3 &(#2"(9a!( 60e e% 90%9( e #e"&0"+( e4'- e! &(!'a&'( &(! %a 2+e%3
4(%+&+'a" a% 040a"+( 60e (2"+#a e% 9"a5( &(!'"a %a 2a"e %a'e"a% e% ';"a8 (
&(%(60e 40 #a!( 4(9"e e% ';"a8,? Va%("a": el color de la piel: la"09+&0!e5 fa=("e&e %a e%+#+!a&+;! e &a%("3 %a
palidez +!+&a e% 2"+!&+2+( e% e4&a%(f"$( . e e%e=a&+;! e 'e#2e"a'0"a,La
presencia o ausencia de sudacin, cantidad y color de la orina, la conducta del
usuario (20ee e4'a" +""+'a9%e3 &a"a&'e"$4'+&a4 e %a 2+e%3 #0&(4a43 'a60+&a"+a3
4e3 a!("e8+a3 +!4(#!+(3 &(!=0%4+(!e43 e%+"+(3 a%0&+!a&+(!e4 . ('"(4 +!+&+(4 60e
!(4 +!+60e! 7+2('e"#+a e 7+2e"'e"#+a,? Ma!'e!e" e% 'e"#;#e'"( 2(" a #+!0'(4 . Re'+"a",? O94e"=a" e! %a &(%0#!a e% #e"&0"+( e% 1"a( 60e #a"&a,? Dea" a% 2a&+e!'e &;#((,? Re1+4'"a" %a =a%("a&+;! . %a &+f"a (9'e!+a3 e42e&+f+&a!( fe&7a3 7("a e! %a 60e
4e "ea%+5; e% &(!'"(% . f+"#a,? I!f("#a" a% #-+&( e f("#a +!#e+a'a 4+ 709+e"a a%10!a a%'e"a&+;!: 7+2e"'e"#+a
( 7+2('e"#+a,? La=a" e% 'e"#;#e'"( &(! a10a f"$a . e4&(!'a#+!a" &(! a!'+4-2'+&(3 9aa" %a
&(%0#!a e #e"&0"+( 7a4'a C . 10a"a",
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CONTROL DE FRECUENCIA RESPIRATORIA
Def+!+&+;!:
E4 %a (94e"=a&+;! e %(4 #(=+#+e!'(4 '(">&+&(4 . a9(#+!a% e% 040a"+(
e! 0!a 0!+a e '+e#2( e4'a9%e&+(3 4e 2(!e! e #a!+f+e4'( 2(" e% 1"a( e
e42%a5a#+e!'( e% ';"a8 ( e% a9(#e!, La "e42+"a&+;! !("#a% +!&%0.e a#9(4
'+2(4 e #(=+#+e!'(43 2"e(#+!a!( e! Ia4 #0e"e4 e% &(#2(!e!'e '(">&+&( . e!
%(4 !+@(4 . 7(#9"e4 e% a9(#+!a%,
La #e&>!+&a "e42+"a'("+a 4e 2"(0&e #e+a!'e %(4 #(=+#+e!'(4 e e82a!4+;!
+!42+"a&+;! . "e'"a&&+;! e42+"a&+;! e ';"a8 . 20%#;!,E% a&'( e "e42+"a" +!&%0.e %a e!'"aa e (8+1e!( . %a 4a%+a e +;8+( e &a"9(!(,
OBJETIVO:
? Va%("a" e% 2a'";! "e42+"a'("+( 2a"a e'e&'a" e% e4'a( e 4a%0 ( e!fe"#ea,
? Ie!'+f+&a" %a4 &a"a&'e"$4'+&a4 e %a "e42+"a&+;!,
CARACTERISTICAS DE LA RESPIRACION:
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Fre!en"': 4e e!(#+!a f"e&0e!&+a a% !&+&a . e
%a 2a"e a9(#+!a% &(""e42(!+e!'e a &aa '+2( "e42+"a'("+(
R"t,o$ "e%a&+;! !("#a% e!'"e +!42+"a&+;! . e42+"a&+;!3 4+e#2"e %a +!42+"a&+;! e4
#e!(" 60e %a e42+"a&+;!, E8+4'e 0!a "e%a&+;! e!'"e a#9(4 #(=+#+e!'(4,
La "e42+"a&+;! !("#a% 4e e!(#+!a e02!ea,
TIPOS DE RESPIRACIN:
C(4'a% '(">8+&(: e4 %a 60e +!=(%0&"a %(4 #
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-r'#"(ne': D+4#+!0&+;! e %a f"e&0e!&+a a&(#2a@aa 1e!e"a%#e!'e 2(" 0!
a0#e!'( e %a 2"(f0!+a,
T'.!"(ne': A0#e!'( e %a f"e&0e!&+a "e42+"a'("+a,
H"(er(ne'$A0#e!'( e %a f"e&0e!&+a . e %a 2"(f0!+a "e42+"a'("+a,
A%'e"a&+(!e4 e %a A#2%+'0 Re42+"a'("+a:
Respiracin s!(er/""'&: Ca"a&'e"+5aa 2(" +#+!0&+;! e %a a#2%+'03 4e (94e"=a
e! 2"(&e4(4 (%("(4(4 60e a%'e"a! %a +!>#+&a "e42+"a'("+a3 1e!e"a%#e!'e 4e
a&(#2a@a e 'a60+2!ea,
Res("r'"nprofunda: aracterizada 2(" a0#e!'( e %a a#2%+'0 "e42+"a'("+a, Se
a&(#2a@a 1e!e"a%#e!'e e 9"a+2!ea,
La "e42+"a&+;! 2"(f0!a #>4 '$2+&a e4 %a Re42+"a&+;! e [044#a0%3 &(!4+4'e e!
+!42+"a&+(!e4 2"(f0!a4 . "0+(4a4 4e10+a4 e 0!a 2a04a 60e 20ee a%&a!5a"
7a4'a 4e10!(4\ %0e1( %e 40&ee 0!a e42+"a&+;! 9"e=e . 60e0#9"(4a3 4e10+a
e 0!a !0e=a 2a04a3 #>4 %a"1a3 7a4'a e 4e10!(4, Se (94e"=a e! &a4(4 e
a&+(4+4, T+e!e &(#( (9e'( a0#e!'a" %a =e!'+%a&+;! 20%#(!a" 2a"a a4$ e%+#+!a" #>4
CO . +4#+!0+" %a a&+(4+4,
A%'e"a&+(!e4 e% R+'#( Re42+"a'("+(:
Res("r'"n #e Cene Sto3es$Se 2"(0&e! 2e"$((4 e 2a04a 4e1 e
0"a&+;! . a &(!'+!0a&+;! &(#+e!5a! %(4 #(=+#+e!'(4 "e42+"a'("+(43 2"+#e"( #>4
402e"f+&+a%e43 %0e1( #>4 a#2%+(43 7a4'a %%e1a" a 0! #>8+#(3 2a"a %0e1( +"
e&"e&+e!( 7a4'a %%e1a" !0e=a#e!'e a 0!a fa4e e a2!ea3 4e +!+&+a &(! 0! &+e"'(
1"a( e 7+2(8+a ,
Res("r'"n #e -"ot$&a"a&'e"+5aa 2(" 2e"$((4 e a2!ea e 0"a&+;! =a"+a9%e
a * 4e10!(4 4e10+a4 e "e42+"a&+(!e4 2"(f0!a43 !( 4(! 2"(1"e4+=a4, Se
(94e"=a e! %(4 2"(&e4(4 #e!+!1$'+&(4 . ('"(4 '"a4'("!(4 e% S+4'e#a Ne"=+(4(
Ce!'"aI,
ALTERACIONES DE LA EPANSION TORCICA
Retr'"ones tor4"'s "ns("r'tor"'s:
T"r'*e$e4 &0a!( e8+4'e 0! (94'>&0%( e! %a fa4e +!42+"a'("+a 60e +#2+e %a %+9"e
e82a!4+;! e% 20%#;!3 %a 2"e4+;! a'#(4f-"+&a e2"+#e %a4 2a"'e4 9%a!a4 e%
T;"a8 . 4e 2"(0&e e% 70!+#+e!'( e %(4 e42a&+(4 +!'e"&(4'a%e4, E8&e2&+(!a%#e!'e
4e (94e"=a 70!+#+e!'( e! %a "e1+;! +!f"aa8+%a" e! +!+=+0(4 #0. e%1a(4 0"a!'ee% &(#+e!5( e %a +!42+"a&+;!, P0ee 4e":
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? B+%a'e"a%: &0a!( e% (94'>&0%( a4+e!'a a!'e4 e %a 9+f0"&a&+;! '"a60ea%,
? U!+%a'e"a%: 2(" (94'"0&&+;! ( e4'e!(4+4 e 0! 9"(!60+( 2"+!&+2a% e% 20%#;!
?L(&a%+5aa4: 2(" (9%+'e"a&+;! e 2e60e@(4 9"(!60+(4 ( &(!e!4a&+(!e4
20%#(!a"e4,
Abovedamientos torcicos espiratorios: E! e% e!f+4e#a . 0"a!'e e% a&'( e %a
'(4 4e 20ee (94e"=a" %+1e"( a9(=ea#+e!'( e %a4 f(4a4 402"a&%a=+&0%a"e4,
OTRAS ALTERACIONES DE LA RESPIRACION
Disnea: D+f+&0%'a 2a"a "e42+"a" 60e 4e a&(#2a@a 1e!e"a%#e!'e &(! 'a60+2!ea3
+""e10%a"+a e! e% "+'#(3 '+"ae3 '(43 &("!ae3 4+9+%a!&+a3 a%e'e( !a4a%3 &+a!(4+4 (
2a%+e53 60e+( e42+"a'("+(,
Ortopnea o disnea de decbito: D+f+&0%'a 2a"a "e42+"a" e! e% e&4
+!'e!4(4 e! %a e42+"a&+;!, L(4 roncus 4e ("+1+!a! e! 9"(!60+(4 1"a!e4 . 4(!4(!+(4 e '(!a%+a 1"a=e, La4 sibilancias 4(! 4(!+(4 e '(!a%+a a10a . 4e
("+1+!a! e! 9"(!60+(4 2e60e@(4, orna!e: S(!+( +!'e!4(3 2a"e&+( a% 4(2%+( e 0!
&0e"!(, I!+&a e4'"e&7a#+e!'( e %a %a"+!1e3 '">60ea . 9"(!60+(4 1"0e4(4,
Tos: E4 0! "ef%e( 60e &(!4+4'e e! 0!a e42+"a&+;! 9"04&a e4'+!aa a e820%4a"
e%e#e!'(4 +""+'a!'e4 e %a %a"+!1e3 %a '">60ea ( %(4 9"(!60+(43 a0!60e 'a#9+-!
20ee e9e"4e a +""+'a&+(!e4, C0a!( !( 7a. 4e&"e&+(!e4 4e e!(#+!a '(4 4e&a .
4+ 4e a&(#2a@a e e%%a4 '(4 7
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La4 4e&"e&+(!e4 ( e82e&'("a&+;! 4(! blan"uecinas 4+ 4e e9e! a +!f%a#a&+(!e4
a%-"1+&a43 a#arillo $erdosa 4+ &(""e42(!e! a +!fe&&+;! 9a&'e"+a!a . e% &(%(" e%
%erru#bre e! %a4 !e0#(!$a4, La e820%4+;! 9"04&a 2(" %a '(4 e 1"a! =(%0#e! e
4e&"e&+(!e4 4e e!(#+!a $#ica,
G">f+&( e %(4 T+2(4 e Re42+"a&+;!
EUPNEA
POLIPNEA
BRADIPNEA
APNEA
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HIPERPNEA
RESPIRACIN DE [USSMAUL
RESPIRACIN DE CHEYNE STO[ES
RESPIRACIN DE BIOT
INTERVENCIONES DE ENFERMERA
? N( 4e e9e +!f("#a" a% 040a"+( "e42e&'( a% 2"(&e+#+e!'( 60e 4e =a a
"ea%+5a" 2a"a e=+'a" a%'e"a&+(!e4 e! %a "e42+"a&+;!,? Rea%+5a" &(!'"(% e f"e&0e!&+a "e42+"a'("+a 0!a =e5 2(" '0"!(3 e! %(4 040a"+(4
2e+>'"+&(4 &aa 7("a43 . 4e1
e4'0=+e"a =a%("a!( 20%4(,? O94e"=a" %(4 #(=+#+e!'(4 a4&e!e!'e4 . e4&e!e!'e4 e% ';"a8 (
a9(#e! e% 040a"+(3 4+#0%a( 60e a
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? S+'0a" %a #a!( 4(9"e e% 2e&7( e% 040a"+(3 4+ !( 4e 20e( (94e"=a" %(4
#(=+#+e!'(4 '(">&+&(4 ( a04&0%'a" . &(!'a9+%+5a" %a +!42+"a&+;! ( %a
e42+"a&+;! e! 0! #+!0'(,? Va%("a" %a "e10%a"+a3 '+2( . &a"a&'e"$4'+&a4 e %a4 "e42+"a&+(!e43 'e!e" e!
&0e!'a 60e 20ee 7a9e" =a"+a&+(!e4 4+ 2"e4e!'a 7+2e"'e"#+a3 (%("3 e'&,? I!f("#a" a% #-+&( 4+ 709+e"a a%10!a a%'e"a&+;!: Ta60+2!ea3 B"a+2!ea3
A2!ea3 C7e.!e S'(]e43 D+4!ea3 H+2e"!ea3 [044#a0%3 O"'(2!ea3 P(%+2!ea3
e'&,? Re1+4'"a" %a =a%("a&+;! "ea%+5aa . %a &+f"a (9'e!+a3 e42e&+f+&a!( fe&7a3
7("a3 . f+"#a,? Dea" a% 040a"+( &;#((,
CONTROL DE PRESION ARTERIAL
Def+!+&+;!:
E4 %a "e4+4'e!&+a 60e (f"e&e! %a4 2a"ee4 a"'e"+a%e4 &(!'"a %a 4a!1"e&+"&0%a!'e e! e%%a43 e82"e4a %a e%a4'+&+a =a4&0%a"3 !( e4 e4'a9%e 4+!( 60e &a#9+a
&(!'+!0a#e!'e,
E% &("a5;! +!.e&'a 0!a e'e"#+!aa &a!'+a e 4a!1"e =(%0#e! 4+4';%+&(3 %( &0a%
+4'+e!e %a4 2a"ee4 a"'e"+a%e4 e%>4'+&a43 4e %%a#a 2"e4+;! a"'e"+a% 4+4';%+&a (
#>8+#a, C0a!( e% &("a5;! 4e "e%aa 4e &+e""a! %a4 =>%=0%a43 &(#+e!5a %a +>4'(%e .
%a e%a4'+&+a e %a4 a"'e"+a4 . e% 2"(2+( =(%0#e! &+"&0!a!'e %(1"a! #a!'e!e" 0!
1"a+e!'e 'e!4+(!a% 60e 4e e!(#+!a 2"e4+;! a"'e"+a% +a4';%+&a ( #$!+#a,
OBJETIVO$
?C(!(&e" . =a%("a" %(4 fa&'("e4 e "+e1(4 60e +!f%0.e! e! %a a%'e"a&+;! e
%a 2"e4+;! a"'e"+a%,
? De'e&'a" 2"e&(5#e!'e a%'e"a&+(!e4 &a"+(=a4&0%a"e4,
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VALORES NORMALES: "e&(#e!a&+(!e4 e% V C(#+'- Na&+(!a% e De'e&&+;!3
E=a%0a&+;! . T"a'a#+e!'( e %a 7+2e"'e!4+;! a"'e"+a%,
P"e4+;! N("#a%: P, S+4';%+&a: #e!(" )##H13 P, D+a4';%+&a: #e!(" ##H1
P"e4+;! N("#a% A%'a: P, S+4';%+&a: )* ) ##H13 P, D+a4';%+&a: ? ##H1
H+2e"'e!4+;!:
E4'a+( I %e=e P, S+4';%+&a: ) * ? ) ##H13 P, D+a4';%+&a: * ? ##H1
E4'a+( II #(e"a( P, S+4';%+&a: )* ) ##H13 P, D+a4';%+&a: )** ? )* ##H1
E4'a+( III 1"a=e P, S+4';%+&a: )* ? * ##H13 P, D+a4';%+&a: ))* ? )) ##H1
E4'a+( IV #0. 1"a=e P, S+4';%+&a: #a.(" )*##H13P,D+a4';%+&a: #a.(" )*
##H1,
F'tores .!e "n/&!en en &' tens"n 'rter"'& #e !n "n#"5"#!o$
a Ea: %a T,A, a0#e!'a &(! %a ea,
9 Se8(: #e!(" T,A, e! %a #0e" 60e e! e% 7(#9"e e +10a% ea,
& C(!4'+'0&+;! &("2("a%: %a4 2e"4(!a4 e &(!4'+'0&+;! f0e"'e 1e!e"a%#e!'e '+e!e! %a
'e!4+;! #>4 a%'a 60e %a4 e &(!4'+'0&+;! %+=+a!a,
A%+#e!'a&+;!: e420-4 e %a a%+#e!'a&+;! %a T,A, a0#e!'a,
e Ee"&+&+(4: 0"a!'e e% ee"&+&+( %a T,A, a0#e!'a,
f De2"e4+;!3 A.0!(3 Re2(4( . 40e@(: +4#+!0.e! %a T,A,
1 E4'"-4: %a a!4+ea3 e% #+e( . e% (%(" 20ee! +!&"e#e!'a" %a T,A, e9+( a%
a0#e!'( e %a f"e&0e!&+a &a"+a&a . e %a "e4+4'e!&+a =a4&0%a" 2e"+f-"+&a,
7 Ra5a : %a e%e=a&+;! 'e!4+;! a% e! %a "a5a !e1"a 60e e! %a 9%a!&a ,
I He"e!&+a : %a 2"e=a%e&$a e 7+2e"'e!4+;! e4 402e"+(" e!'"e %(4 fa#+%+a"e4 e
7+2e"'e!4(4 ,
J E% 7a&+!a#+e!'( 3 %a (&02a&+;! 3 a#9+e!'e4 24+&(4(&+a%e4 a=e"4(4 e#+1"a?
&+;! 3 &a#9+(4 +e'-'+&a4 3 24+&(%;1+&(43 +!&"e#e!'a! %a T,A,[ La 2"e=a%e&$a e 7+2e"'e!4(4 e4 #a.(" &0a!'( #e!(" e4 e% !+=e% e&(!;#+&(
. e0&a'+=(,
Re&(#e!a&+(!e4:
? T(( e% 2"(&e+#+e!'( !( e9e 4(9"e2a4a" %(4 #+!0'(4,
? Pa"a "ea%+5a" 0! !0e=( &(!'"(% 4e e9e ea" '"a4&0""+" #+!0'(4 e!'"e &aa
#e+&+;! &(! e% #a!10+'( '('a%#e!'e e4+!f%a( a f+! e 2e"#+'+" e% "e!ae e %a
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4a!1"e =e!(4a, De %( &(!'"a"+( %(4 =a%("e4 2(4'e"+("e4 e4&+e!e! 2(" %a
+!'e"=e!&+;! e fe!;#e!(4 =a4(#('("e4 2"(0&+(4 2(" %a &(#2"e4+;!,
? E=+'a" &(!'"(%a" %a T,A, 4(9"e %a "(2a e% 040a"+( 2("60e 2"(0&e e% efe&'( e 0!a
(9%e &>#a"a !e0#>'+&a3 a0#e!'a %a 2(4+9+%+a e "0+(4 4(9"ea1"e1a(4 . a
=a%("e4 fa%4(4,
? E=+'a" %a I!40f%a&+;! %e!'a 2("60e +4#+!0.e %a +!'e!4+a e %(4 "0+(4,
? E=+'a" I!40f%a&+;! e8&e4+=a 2("60e 2"(0&e (%(" . e4e!&ae!a "ef%e(4
4+#2>'+&(4 60e 20ee a0#e!'a" '"a!4+'("+a#e!'e e %a 2"e4+;! 4a!10$!ea,
? E=+'a" %a e4+!f%a&+;! ">2+a e %a &>#a"a !e0#>'+&a 2("60e 4e 20ee!
4e%e&&+(!a" e60+=(&aa#e!'e e% =a%(" e 2"e4+;! 4+4';%+&a . +a4';%+&a,
? La a2%+&a&+;! e"";!ea e %a #e#9"a!a e% e4'e'(4&(2+( 2(" e9a( e %a &>#a"a
!e0#>'+&a 2"(0&e "0+(4 4(9"ea1"e1a(4,
? La !( &(%(&a&+;! e %a &>#a"a !e0#>'+&a 4(9"e e% ee %(!1+'0+!a% e %a a"'e"+a3
2"(0&e fa%4a4 2"e4+(!e4 a%'a4,
INTERVENCIONES DE ENFERMERA
? Rea%+5a" &(!'"(% e 2"e4+;! a"'e"+a% 0!a =e5 2(" '0"!( . 4e1
&(#( %a (9e4+a3 +e'a3 7>9+'(4 !(&+=(4 a%&(7(%3 'a9a&(3 e4'"-4 .
4ee!'a"+4#(,? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? P"e4e"=a" %a +!'+#+a e% 040a"+(,? C(!'"(%a" 2"e4+;! a"'e"+a% &0a!( e% 040a"+( 4e e!&0e!'"a e! e4'a( e
"e2(4(3 e! 0! a#9+e!'e ;2'+#( e '"a!60+%+a . 'e#2e"a'0"a,? C(#2"(9a" f0!&+(!a#+e!'( e% 'e!4+;#e'"(3 e! e42e&+a% %a =>%=0%a e
e820%4+;! e a+"e3 . e4'e'(4&(2+(,? C(!'"(%a" 60e e% #e!+4&( e% #e"&0"+( ( a10a e% #a!;#e'"( a!e"(+e
e4'-! e! &e"( . e% #a!10+'( e4+!f%a(,? U'+%+5a" 9"a5a%e'e a&("e a %a ea . &(!'e8'0"a e% 040a"+(,? C(%(&a" a% 040a"+( a&(4'a( e! 2(4+&+;! 402+!a &(! e% 9"a5( a2(.a( a %a
a%'0"a e% &("a5;!3 e! %a 2(4+&+;! e 2+e ( 4e!'a( &(! e% 9"a5(
2e"2e!+&0%a" a !+=e% e% &0a"'( e42a&+( +!'e"&(4'a%, La e'e"#+!a&+;! e %a
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2"e4+;! 4a!10$!ea &(! e% 9"a5( =e"'+&a% a =a%("e4 e%e=a(4 e9+( a%
a0#e!'( e %a 2"e4+;! 7+"(4'>'+&a e %a &(%0#!a 4a!10$!ea,? Ve"+f+&a" 60e e% 9"a5( e% 040a"+( e4'- %+9"e e "(2a3 a2(.a( e! 0!a
402e"f+&+e %+4a . &(! %a f(4a a!'e"( &09+'a% a !+=e% e% &("a5;!,
? C(%(&a" e% #a!10+'( e% 'e!4+;#e'"( , 2(" e!&+#a e %a f(4a a!'e"(&09+'a% . "(ea" e% 9"a5(,
? Pa%2a" %a a"'e"+a 9"a60+a% ( "a+a% . &(%(&a" e% e4'e'(4&(2+( e!&+#a 4+!
2"e4+(!a"3 +!40f%a" e% #a!10+'( 0!(4 *?* ##H13 2(" e!&+#a e% 20!'( e!
60e ee e 2a%2a" e% 20%4( 9"a60+a% ( "a+a%,? A9"+" %a =>%=0%a e 4a%+a e a+"e %e!'a#e!'e a 0!a =e%(&+a a2"(8+#aa e
( ##H13 2(" 4e10!(3 e% 2"+#e" "0+( a"'e"+a%)^ fa4e e [("('](_ 60e
4e e4&0&7a +!+&a %a 2"e4+;! 4+4';%+&a ( #>8+#a . e%
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CONTROL DE PULSO
Def+!+&+;!:
E4 %a #e+&+;! e %a4 =+9"a&+(!e4 60e ee"&e e% 2a4( e %a 4a!1"e
9(#9eaa 2(" %a &(!'"a&&+;! =e!'"+&0%a"3 a% 2a%2a" %a4 2a"ee4 e 0!a a"'e"+a,
Se e!(#+!a 20%4( a %a 4e!4a&+;! '>&'+% e e%e=a&+;! e %a 2a"e a"'e"+a%3 4+!&";!+&a
&(! %(4 %a'+(4 &a"$a&(4 . 60e 4e 2e"&+9e &aa =e5 60e 4e 2a%2e 0!a a"'e"+a &(!'"a
0! 2%a!( e "e4+4'e!&+a,
OBJETIVO:
? De'e&'a" %a4 a%'e"a&+(!e4 60e +!f%0.e! e! %a 4a%0 e% 040a"+(,
? C(!'"+90+" a% +a1!;4'+&( e% 2a&+e!'e 2(" #e+( e a'(4 e8a&'(4,
CARACTERSTICAS DEL PULSO ARTERIAL:
? F"e&0e!&+a: e4 e% !
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? Te!4+;! ( 0"e5a: 4e #+e a '"a=-4 e %a 2"e4+;! 60e e9e efe&'0a" %a #a!(
e% (2e"a(", La 0"e5a e% 20%4( e4'> aa 2(" %a 2"e4+;! 60e ee"&e %a 4a!1"e
e!'"( e %a4 a"'e"+a4 #>4 %a "e4+4'e!&+a 60e +&7a4 a"'e"+a4 (f"e&e! a e4a 2"e4+;!,
E% a0#e!'( e %a 'e!4+;! 4e e!(#+!a 20%4( 0"( . 4e 2"e4e!'a e! %a e4&%e"(4+4 e
%a 2a"e a"'e"+a% ( e! %a 7+2e"'e!4+;! a"'e"+a%, S0 +4#+!0&+;! 4e e!(#+!a 20%4(
9%a!( . 4e 2"e4e!'a e! %a 7+2('e!4+;! a"'e"+a%,
? A#2%+'0: e4 %a a%'0"a e %a (!a e% 20%4(,E% 20%4( !("#a% '+e!e 0!a a#2%+'0
#e+a!a3 4+ a0#e!'a e% 20%4( 4e e!(#+!a #a1!( . 4+ +4#+!0.e 2a"=( ( 2e60e@(,
6on's #e E7(&or'"n #e& P!&so$P!&so te,(or'&$2(" e%a!'e ( 2(" a""+9a e %a
("ea3 P!&so /'"'&$e! e% 9("e e% #a8+%a" +!fe"+("3 P!&so 'rot8#eo$a %( %a"1( e%
9("e +!'e"!( e% e4'e"!(&%e+(#a4'(+e(3 P!&so s!%&'5"o$4(9"e e% 'e"&+( #e+(
e %a &%a=$&0%a3 P!&so !,er'&$e! e% 'e"&+( #e+( e% 9"a5(3 P!&so %r'.!"'&$e! e%
2%+e10e e% &((3 P!&so r'#"'&$e! %a #0@e&a3 e! e% &a!a% "a+a%3 P!&so r!r'&$e!
%a +!1%e3 P!&so (o(&8teo$e! e% 70e&( 2(2%$'e(3 P!&so t"%"'& (oster"or$2(" e'">4
e% #a%-(%( +!'e"!(3 P!&so (e#"o$e! e% ("4( e% 2+e,
ALTERACIN EN SUS CARACTERSTICAS:
? Ta60+4f+1#+a: a0#e!'( e %a f"e&0e!&+a e% 20%4( 2(" e!&+#a e * 20%4a&+(!e4
2(" #+!0'(, Se 2"e4e!'a e! f+e9"e3 7+2e"'+"(++4#(3 7e#(""a1+a a10a3 +!40f+&+e!&+a
&a"$a&a3 040a"+(4 #e+&a(4 &(! a!fe'a#+!a43 'e(f+%+!a3 e'&,
? B"a+4f+1#+a: +4#+!0&+;! e %a f"e&0e!&+a e% 20%4( 2(" e9a( e * 20%4a&+(!e4
2(" #+!0'(, Se 2"e4e!'a e!: 7+2('+"(++4#(3 e!fe"#ea e% !;0%( 4+!04a%3
e2"e4+;! #e!'a%3 2a&+e!'e4 #e+&a(4 &(! (2+>&e(43 9%(60e( a0"+&0%a"3e'&,
? P0%4( #a1!(: %a a#2%+'0 e %a (!a 20%4>'+% a%'0"a e %a (!a e4'> a0#e!'aa,
Se 2"e4e!'a &0a!( %a 2"e4+;! +fe"e!&+a% a0#e!'a, E,: +!40f+&+e!&+a a;"'+&a,
? P0%4( 2a"=(: +4#+!0&+;! e %a a#2%+'0 e %a (!a 20%4>'+%, D+4#+!0&+;! e %a2"e4+;! +fe"e!&+a%, E,: e4'e!(4+4 a;"'+&a,
? P0%4( f+%+f("#e: a0#e!'( e %a f"e&0e!&+a . +4#+!0&+;! e %a a#2%+'0, E,: 47(&],
? P0%4( &e%e" : ">2+( a4&e!4( e %a (!a 20%4>'+%, E,: +!40f+&+e!&+a a;"'+&a,
? P0%4( +&";'+&(: e% e4&e!4( e %a (!a 20%4>'+% (&0""e e! (4 '+e#2(4, E,: f+e9"e
e%e=aa ? 7+2e"'+"(++4#(,
? P0%4( a""$'#+&(: %(4 '+e#2(4 ( e42a&+(4 60e 4e2a"a! %a4 20%4a&+(!e4 4(!
e4+10a%e4, Se 2"e4e!'a e! a""+'#+a4,? P0%4( e4+10a%: %a4 20%4a&+(!e4 '+e!e! +fe"e!'e4 a#2%+'0e4, Se 2"e4e!'a e!
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a""+'#+a4,
? P0%4( +""e10%a" . e4+10a%: e4 &a"a&'e"$4'+&( e %a f+9"+%a&+;! a0"+&0%a",
? P0%4( 9+1e#+!a(: 1e!e"a%#e!'e 4e e9e a e8'"a4$4'(%e4 e! 40&e4+;! "e10%a"
e420-4 e &aa %a'+( !("#a%, Se 2"e4e!'a! 1"02(4 e (4 %a'+(4 4e2a"a(4 e%
4+10+e!'e 2(" 0! +!'e"=a%( #>4 %a"1(, E4 &a"a&'e"$4'+&( e %a +!'(8+&a&+;! +1+'>%+&a,
? P0%4( a%'e"!a!'e: 4e 40&ee "e10%a"#e!'e %a'+(4 e #a.(" . #e!(" a#2%+'03 e%
'+e#2( e!'"e &aa 20%4a&+;! e4 +10a%, E,: +!40f+&+e!&+a &a"$a&a,
? P0%4( 0"(: 4e !e&e4+'a #>4 2"e4+;! 2a"a 7a&e" e4a2a"e&e" %a (!a 20%4>'+%,
I!+&a 2"e4+;! +a4';%+&a e%e=aa,
? P0%4( 9%a!(: 4e !e&e4+'a #e!(" 2"e4+;! 2a"a 7a&e" e4a2a"e&e" %a (!a
20%4>'+%, I!+&a 2"e4+;! +a4';%+&a 9aa,
Reo,en#'"ones$
a Rea%+&e %a 2a%2a&+;! 4(9"e 2%a!( "e4+4'e!'e,
9 N0!&a 0'+%+&e 40 e( 20%1a" 2("60e -4'e '+e!e 40 2"(2+a 20%4a&+;!,
& N( '(#e e% 20%4( a% 040a"+( e420-4 60e -4'e 7a.a "ea%+5a( a%1
"e4+4'e!'e a2(.a!( e% 9("e +!'e"!( e 'a% f("#a 60e e% 9("e e8'e"!( #+"e
7a&+a a""+9a . ae!'"(,? Pa%2a" &(! %(4 e(4 $!+&e3 #e+( . a!0%a" %a a"'e"+a
e%e1+a 2"efe"e!'e#e!'e a"'e"+a %a "a+a%3 7a&+e!( 0!a %+1e"a 2"e4+;!3
e4%+5a" %(4 e(4 e! 4e!'+( %(!1+'0+!a% . '"a!4=e"4a% a f+! e e=+e!&+a" %a
2"e4e!&+a e a!(#a%$a4 e %a 2a"e a"'e"+a%3 !("#a%#e!'e 4e 2"e4e!'a %+4(3
9%a!( . &(! "e&(""+( "e&'+%$!e(,
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? A04&0%'a" f"e&0e!&+a &a"$a&a &(! e4'e'(4&(2+( &(%(&>!(%( 4(9"e e%
+af"a1#a e!'"e e% III . IV e42a&+( +!'e"&(4'a% +560+e"(3 4+ e% 20%4( e4 -9+% e!
%a4 a"'e"+a4 e%e1+a4,? Va%("a" %a4 &a"a&'e"$4'+&a4 e% 20%4( 0"a!'e 0! #+!0'(,
? I!f("#a" a% #-+&( 4+ 709+e"a a%10!a a%'e"a&+;!,? Re1+4'"a" %a =a%("a&+;! "ea%+5aa . %a &+f"a (9'e!+a3 e42e&+f+&a!( fe&7a3
7("a e! %a 60e 4e "ea%+5; e% &(!'"(% . f+"#a,MEDIDAS ANTROPOM9TRICAS$ PESO+ TALLA Y PERMETRO
Def+!+&+;!:
E4 %a #e+&+;! e% 2e4(3 'a%%a . 2e"$#e'"( &ef>%+&( e% !e(!a'( .( !+@(,
OBJETIVOS:
? Te!e" 0! 2a'";! e "efe"e!&+a 2a"a e'e&'a" '"a4'("!(4 e% &"e&+#+e!'( e
+#2%e#e!'a" 2a0'a4 'e"a2-0'+&a4 ae&0aa4,? Va%("a" e% E4'a( N0'"+&+(!a%,? Va%("a" P-"+a e L$60+(4,? Ve"+f+&a" %a (4+f+&a&+;! e% #e+&a#e!'( +!+&a(,
CONTROL DE TALLA
Pe"$(( e &(!'"(%: E! e% "e&+-! Na&+( a %a4 ) 74 e =+a,
E! e% %a&'a!'e .( !+@( 4e1
? C(!'"(%a" e% 2e+;#e'"(3 2a"a &e"&+("a"4e e 40 90e! f0!&+(!a#+e!'(? E82%+&a" e% 2"(&e+#+e!'( a %(4 2a"e43 2a"a (9'e!e" %a &(%a9("a&+;! e e%%(4,? Rea%+5a" La=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? C(%(&a"4e %(4 10a!'e4 e %>'e8 ( 2(%+e'+%e!(,? S(%+&+'a" a %a #a"e 60e %e 60+'e %a "(2a . 2a@a%3 2("60e 20ee a%'e"a" %(4
a'(4 e #e+&+;!,? C(%(&a" e% 2e+;#e'"( e! 0! %01a" f+"#e3 0!a 4>9a!a 4(9"e e% #+4#(,? U9+&a"4e f"e!'e a% 2e+;#e'"(3 4+'0a" a% !e(!a'( e! 2(4+&+;! e&
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e% #+e#9"( +!fe"+(" &(! %a #a!( e"e&7a a04'a"> %a 2+e5a #;=+% e%
2e+;#e'"( 7a4'a %a 2%a!'a e %(4 2+e43 a4e10">!(4e e 60e %a &a9e5a
'(60e %a 2a"'e 402e"+(" e% 2e+;#e'"(,? Lee" %a #e+a e! e% >!10%( "e&'( 60e f("#a! %(4 2+e4 e% !e(!a'( &(! %a
e4&a%a #-'"+&a3 e% >!10%( "e&'( 2"(2("&+(!a 0!a #e+a e8a&'a,? Re1+4'"a" %a #e+a (9'e!+a e! %a 7(a e E!fe"#e"$a . efe&'0a" %a
=a%("a&+;! &(""e42(!+e!'e,
INTERVENCIONES DE ENFERMERA Ta%%a e! e% #a.(" e a@(4,
? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%
e!'("!( e 040a"+(,
? E82%+&a" e% 2"(&e+#+e!'( a% !+@( . a 404 2a"e4,? Rea%+5a" La=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? C(%(&a"4e 10a!'e4 e %>'e8 ( e 2(%+e'+%e!(,? De4&a%5a" a% !+@( . &(%(&a"%( 4+! "(2a e! 2(4+&+;! "e&'a 4(9"e %a 2%a'af("#a
e %a 9a%a!5a3 e 2+e . e e42a%a a% Ta%%$#e'"(3 0!'a" %(4 'a%(!e4
4e2a">!(%e %a 20!'a e %(4 2+e4 e! >!10%( e W, Cer"rese .!e e& n":o
.!e#e en (os""n ret' ,"r'n#o or";ont'&,entee%a 7a4'a '(&a" %a 2a"'e #>4
a%'a e %a &a9e5a3 fa&+%+'a %a +!#(=+%+a e% !+@( . e=+'a" e""("e4 e! %a %e&'0"a
e %a #e+&+;!,? A.0a" a% !+@( a e4&e!e" e %a 9a%a!5a . "e1"e4a" %a 9a""a #e+("a a 40
2(4+&+;! +!+&+a%3 2a"a e=+'a" a&&+e!'e4 e! e% !+@(,? Re1+4'"a" %a #e+a (9'e!+a e! %a 7(a e E!fe"#e"$a3 %( 60e !(4 2e"#+'+">
efe&'0a" %a =a%("a&+;! &(""e42(!+e!'e,
CONTROL DE PESO
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Pe"+(( e &(!'"(%:
Pe4( e! U40a"+(4 Pe+>'"+&(4: a% +!1"e4( . &aa 743 4e1
&e4>"ea,
Pe4( e! Ne(!a'(4: a% +!1"e4( . 0!a =e5 2(" '0"!(,
INTERVENCIONES DE ENFERMERA
? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%
e!'("!( e% 040a"+(,? I!f("#a" a %(4 2a"e4 e% 2"(&e+#+e!'(,? Rea%+5a" La=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? C(%(&a"4e %(4 10a!'e4 e %>'e8 ( 2(%+e'+%e!(,? C(%(&a" 0! 2a2e% %+#2+( 4(9"e %a 9a%a!5a . 4+'0a" %a4 2e4a4 e! &e"(,? S(%+&+'a" a %a #a"e 60e %e 60+'e '(a %a "(2a . e% 2a@a% a% !e(!a'(,? S+'0a" a&(4'a( ( 4e!'a( a% !e(!a'( .( !+@(3 e! #e+( e %a 9a!ea e %a
9a%a!5a,? M'ntener to#o e& t"e,(o &' ,'no s!s(en#"#' ' !nos (oos ent8,etros
so%re #e& neon'to =o n":o+ ('r' 't!'r on r'("#e; (re5en"r '8#'s
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E! e% %a&'a!'e .( !+@( 4e1
INTERVENCIONES DE ENFERMERA
? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%
e!'("!( e% 040a"+(,? I!f("#a" a %(4 2a"e4 e% 2"(&e+#+e!'(,? Rea%+5a" La=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? C(%(&a"4e 10a!'e4 e %>'e8 ( 2(%+e'+%e!(,? S+'0a" a% !+@( e! e&!(%a 2("
%a4 2"(#+!e!&+a4 ;4ea4 e %(4 2a"+e'a%e4 . 2(" e!&+#a e %a4 &ea43 2a"a(9'e!e" 0! a'( e8a&'( e %a #e+&+;!,
? J0!'a" %(4 e8'"e#(4 e %a &+!'a . %ee" %a #e+&+;!,? Re1+4'"a" %a #e+a (9'e!+a e! %a 7(a e E!fe"#e"$a . "ea%+5a" %a
=a%("a&+;! &(""e42(!+e!'e,
ADMINISTRACIN DE MEDICAMENTOS
OBJETIVO:
? E4'a9%e&e" 2a0'a4 2a"a %a a#+!+4'"a&+;! 4e10"a e #e+&a#e!'(4,
OBJETIVO ESPECIFICO:
? P"(2("&+(!a" 0!a 7e""a#+e!'a 2a"a (2'+#+5a" %a a#+!+4'"a&+;! e %(4
#e+&a#e!'(4,? U!+f+&a" &"+'e"+(4 e! %a 2"e2a"a&+;!3 a#+!+4'"a&+;! . &(!4e"=a&+;! e
#e+&a#e!'(4 e! e% 4e&'(" )* e% H(42+'a% H("a&+( He%%e",? P"e=e!+" e""("e4 e! %a fa"#a&('e"a2+a,
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? P(4ee" 0! (&0#e!'( e &(!40%'a e! &0a!'( a a#+!+4'"a&+;!3 e4'a9+%+a3
"e&(!4'+'0&+;! . &(!4e"=a&+;! e #e+&a#e!'(4,
DEFINICIN:
Me+&a#e!'(: 4+!;!+#( e f>"#a&( ( "(1a3 404'a!&+a 60e a%
+!'"(0&+"4e a% ("1a!+4#( 70#a!( =+=(3 a%'e"a 404 f0!&+(!e4 #e+a!'e +!'e"a&&+;!
#(%e&0%a" . 4e 0'+%+5a &(! e% 2"(2;4+'( e &0"a"3 "e7a9+%+'a"3 2"e=e!+"3 +a1!(4'+&a",
METABOLISMO DE LOS FARMACOS:
? ABSORCION: T"a!4fe"e!&+a e% f>"#a&( e4e e% 20!'( e e!'"aa 7a4'a %a
&+"&0%a&+;! 1"a+e!'e e &(!&e!'"a&+;!3 PH3 >"ea e 402e"f+&+e +42(!+9%e3e'&,? DISTRIBUCION: 0!a =e5 %%e1a( a% '(""e!'e 4a!10$!e( 20ee 4e" +4'"+90+( a %(4
+4'+!'(4 &(#2a"'+#e!'(4 &("2("a%e4 %a 0!+;! a %a4 2"('e$!a4 2%a4#>'+&a43 f%0(4a!10$!e(3 &a2a&+a 2a"a a'"a=e4a" %a4 #e#9"a!a43 4(%09+%+a '+40%a",
? BIOTRANSFORMACION: C(!4+4'e e! %a &(!=e"4+;! e% f>"#a&( e! 404'a!&+a4
#a4 f>&+%e4 e e%+#+!a"3 . 2(" %( 1e!e"a% 4e %%e=a a &a9( e! e% 7$1a(3 60e e4 e%;"1a!( e4e!&+a% e! e% #e'a9(%+4#( e f>"#a&(4, L(4 20%#(!e43 "+@(!e43 #0&(4a
+!'e4'+!a% . %a 2%a&e!'a e4e#2e@a! &+e"'( 2a2e%,? ELIMINACION: E4 e% 2"(&e4( 2(" e% &0a% 4e e%+#+!a! %(4 #e+&a#e!'(4 e% &0e"2(,
L(4 "+@(!e4 4(! %a =$a 2"+!&+2a% e e%+#+!a&+;! e #e'a9(%+'(4 a '"a=-4 e %a ("+!a\
2e"( 7a. a%10!(4 60e 4e 20ee! e%+#+!a" 2(" %a4 7e&e43 a%+e!'(3 40("3 4a%+=a .
%e&7e #a'e"!a, La ef+&+e!&+a &(! 60e %(4 "+@(!e4 e8&"e'a! #e+&a#e!'(4 . 404
#e'a9(%+'(4 +4#+!0.e &(!f("#e a=a!5a %a ea,
L's /or,'s or'&es #e &os /4r,'os (!e#en ser$
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'+e!e! %a "a!0"a 2(" %a +f+&0%'a e 2"e&+4+;! e! %a (4+4, E! &a4( e 'a9%e'a (
&>240%a3 e4%$&e%a e! %a 'a2a e% f"a4&( . 2;!1a%a e! e% "e&+2+e!'e 2"e2a"a( 4+!
'(&a" e% #e+&a#e!'(,
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60ee 2(%=( f+!( ( e4%e+" e! a10a . a &(!'+!0a&+;! a#+!+4'"a",
? Co,(r","#os #e &"%er'"n ret'r#'#', N( e9e! '"+'0"a"4e3 %a '"+'0"a&+;!
2"(0&e 2-"+a e &a"a&'e"$4'+&a4 e %+9e"a&+;!3 e8+4'e "+e41( e '(8+&+a e
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&09+e"'a 20ee 2"(=(&a" %a +!a&'+=a&+;! e% 2"+!&+2+( a&'+=( ( fa=("e&e" %a +""+'a&+;!
e %a #0&(4a 1>4'"+&a,
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Co,(r","#os e/er5esentes$ De9e! +4(%=e"4e e! a10a a!'e4 e a#+!+4'"a"240%a +4(%=e" 40
&(!'e!+( e! a10a . a &(!'+!0a&+;! a#+!+4'"a", E! &a4( e +!e4'a9+%+a .
2"+!&+2+(4 a&'+=(4 #0. +""+'a!'e4 !( e4 ae&0a(,
C4(s!&'s #e Be&'t"n' #!r' >onten"#o #e ,"roBr4n!&os #e &"%er'"n
ret'r#'#' o on !%"ert' ent@r"'?$ La4 &>240%a4 20ee! a9"+"4e3 2e"( %(4
#+&"(1">!0%(4 !( e9e! '"+'0"a"4e2("60e 2e"e"$a! 404 &a"a&'e"$4'+&a4, La
+42(!+9+%+a e %a a#+!+4'"a&+;! 2(" 4(!a e2e!e e! 1"a! #e+a e% +>#e'"(
e %(4 #+&"(1">!0%(4 . e% e %a 4(!a,
C4(s!&'s #e Be&'t"n' %&'n#' >onten"#o &8.!"#o?$ S+ e% 2"+!&+2+( e4 e4'a9%e . !(
+""+'a!'e3 20ee (2'a"4e 2(" e8'"ae" e%&(!'e!+( &(! 0!a e"+!1a3 2e"( !( 4e
"e&(#+e!a %a (4+f+&a&+;! 20ee 4e" +!&(#2%e'a3 . 20ee 60ea" a7e"+( a %a4
2a"ee4 e %a 4(!a,
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e! e% f(!( e% #+4#(, E! 1e!e"a% e4 %a #e(" f("#a e a#+!+4'"a&+;! 2(" 4(!a
Na4(1>4'"+&a3 4e 20ee! a#+!+4'"a" 4+! +%0+"3 4+ e4 #0. =+4&(4( +%0+" e! a10a3 !(
a#+!+4'"a" e! 9(%04 e! e% +!'e4'+!( .a 60e 20ee 2"(=(&a" +a""ea (4#;'+&a3 e9e!
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+!'e4'+!(3 !( a#+!+4'"a" &(! %e&7e !+ a%&a%+!(4 .a 60e e4'(4 e4+!'e1"a!
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FACTORES QUE MODIFICAN LA ACCION DE LOS FARMACOS:Ea3 Pe4(
C("2("a%+ Se8(3 P"e4e!&+a e E!fe"#ea3 Fa&'("e4 Ge!-'+&(4+ T(%e"a!&+a3
Ta60+f+%a8+43 H+2e"4e!4+9+%a3 P"e4e!&+a e D"(1a43 e'&,
ACCION DE LOS MEDICAMENTOS: D(4+f+&a&+;! e %(4 #e+&a#e!'(43I!+&a&+(!e43 C(!'"a+!+&a&+(!e4 =;#+'(43 +!&(!4&+e!&+a3 +f+&0%'ae4 e
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De1%0&+;!3 Rea&&+(!e4 4e&0!a"+a43 Va"+a9%e4 60e #(+f+&a! %a a&&+;! e%
f>"#a&(3 =e!'aa4 4+#2%e . &;#((3 %( 20ee "ea%+5a" e% #+4#(3e4=e!'aa4:
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e4a1"aa9%e3 e'&,
TARETA DE MEDICACIN$ #e%e ontener$
`USUARIO CORRECTO
` MEDICAMENTO CORRECTO
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` FIRMA DEL ENFERMERO QUE LA REALIZA
VIAS DE ADMINISTRACION
` Me+&a&+;! a#+!+4'"aa 2(" =$a ("a%
` Me+&a&+;! a#+!+4'"aa 2(" 4(!a !a4(1>4'"+&a
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REGLAS PARA LA ADMINISTRACION SEGURA DE MEDICAMENTOS
1< A#,"n"str'r e& ,e#"',ento orreto$Ie!'+f+&a" e% #e+&a#e!'( a%10!(4
#e+&a#e!'(4 '+e!e! !(#9"e . a42e&'( 4+#+%a", C(!f+"#a" 60e 4ea e%
#e+&a#e!'( &(""e&'( a!'e4 e a#+!+4'"a"%(, E! &a4( e 0a3 !( a#+!+4'"a" .&(!40%'a", O94e"=a" e% a42e&'( e% #e+&a#e!'( a!'e4 e a#+!+4'"a"%( 3 2(4+9%e4
2"e&+2+'a&+(!e43 &a#9+(4 e &(%(" 3e'&,2< A#,"n"str'r e& ,e#"',ento '& ('"ente "n#"'#o$C(#2"(9a" 4+e#2"e %a
+e!'+f+&a&+;! e% 2a&+e!'e, N( 0'+%+5a" e% !&+% e60+=(&a"4e,< A#,"n"str'r &' #os"s orret'$La4 #(+f+&a&+(!e4 #$!+#a4 e! %a (4+4 f("#0%aa
20ee! 4e" +#2("'a!'e4 . 2e%+1"(4a4, E! a%10!(4 #e+&a#e!'(4 e% #a"1e! e!'"e
0!a (4+4 'e"a2-0'+&a . ('"a 2('e!&+a%#e!'e %e'a% e4 #0. e4'"e&7(, C(#2"(9a" (4
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=e&e4 %a (4+4 f("#0%aa &(! %a 60e e4'> a 20!'( e a#+!+4'"a", E! &a4( e 60e %a
(4+4 4ea +!040a%#e!'e e%e=aa ( 9aa &(!f+"#e +"e&'a#e!'e &(! e% #-+&( 60e %a
2"e4&"+9+;, C(#2"(9a" (4 =e&e4 %a (4+4 2"e4&"+'a,< A#,"n"str'r e& ,e#"',ento (or &' 58' orret'$La a#+!+4'"a&+;! e
#e+&a#e!'(4 4e 20ee "ea%+5a" 2(" =$a ("a% . e!'e"a% 0'+%+5a!( e% '"a&'( +1e4'+=( .
2(" =$a 2a"e!'e"a% 0'+%+5a!( 2"+!&+2a%#e!'e e% 4+4'e#a =a4&0%a"3 e% 'e+( &e%0%a"
409&0'>!e(3 %a e"#+4 . #0&(4a3 %a #a4a #04&0%a" . e% &a!a% #e0%a", L(4
#e+&a#e!'(4 2a"e!'e"a%e4 a&'"#a&( !+ #>4 e #e+a 7("a a!'e4 !+
e420-4 e %a 7("a +!+&aa, P"e4'a" e42e&+a% a'e!&+;! e! %a a#+!+4'"a&+;! e
a!'+9+;'+&(4 .( #e+&a#e!'(4 60e e8+a! 0! +!'e"=a%( e (4+f+&a&+;! e4'"+&'(,< ReB"str'r to#os &os ,e#"',entos '#,"n"str'#os$E% "e1+4'"( e% #e+&a#e!'(
e9e +!&%0+" e% !(#9"e e% f>"#a&(3 %a fe&7a . 7("a e a#+!+4'"a&+;!\ %a (4+4 . %a
=$a e a#+!+4'"a&+;!, Re1+4'"a" e% #e+&a#e!'( +!#e+a'a#e!'e e420-4 e 40
a#+!+4'"a&+;!, Re1+4'"a" 404 (94e"=a&+(!e4 4(9"e %a "e420e4'a e% 2a&+e!'e a%
#e+&a#e!'(3 e42e&+a%#e!'e 4+ 2"e4e!'a a%1
(%=+a" !0!&a %a "e42(!4a9+%+a %e1a% 60e !( +!=(%0&"a,< In/or,'r e "nstr!"r '& ('"ente so%re &os ,e#"',entos .!e est4 re"%"en#o!ea#e!'e e! %a #+4#a
e"+!1a,? R('0%a"3 0!a =e5 2"e2a"a(3 &(! e% !(#9"e e% #e+&a#e!'(3
&(!&e!'"a&+;!3 fe&7a3 7("a e 2"e2a"a&+;!3 #e+a4 e42e&+a%e4 e 04( .
a%#a&e!a#+e!'(,? C(%(&a"4e 10a!'e4 %>'e8 ( 2(%+e'+%e!( 4+ e4 60e e% 040a"+( e4'a e!
a+4%a#+e!'( e &(!'a&'(,? S+'0a" a% 040a"+( e! 0!a 2(4+&+;! 60e fa&+%+'e %a e1%0&+;! 2(4+&+;! e
F(_%e",? A#+!+4'"a" %a #e+&a&+;! 2(" =$a ("a% . a4e10"a"4e e %a +!1e4'a e%
#+4#(,? I!4'"0+" a %(4 2a"e4 "e42e&'( a %a &(""e&'a a#+!+4'"a&+;! e %a #e+&a&+;!,
? Sa&a"4e 10a!'e4 . "ea%+5a" %a=a( e #a!(4,? Va%("a" %a '(%e"a!&+a . %(4 2(4+9%e4 efe&'(4 a=e"4(4 e% #e+&a#e!'(
a#+!+4'"a(3 'e!e" e! &0e!'a 60e &0a%60+e" #e+&a#e!'( 20ee 2"(0&+"
0!a "ea&&+;! +#2"ee&+9%e . ("+1+!a" efe&'(4 a=e"4(4 #0. +fe"e!'e43
a%10!(4 e a2a"+&+;! +!#e+a'a . ('"(4 e a2a"+&+;! 'a"$a, Re1+4'"a" e
+!f("#a" a% #-+&(,? Re1+4'"a" e! %a 7(a e e!fe"#e"$a e% !(#9"e e% #e+&a#e!'(3 (4+43 =$a3
7("a e a#+!+4'"a&+;! . f+"#a,? E0&a" a% 040a"+( .( 2a"e4 "e42e&'( a %(4 a42e&'(4 a =a%("a" 0"a!'e %a
a#+!+4'"a&+;! e% #e+&a#e!'( . 2"e=+( a% a%'a #-+&a,
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ADMINISTRACIN DE MEDICACIN POR VA SU-LINGUAL
Def+!+&+;!:
E4 %a a#+!+4'"a&+;! e% #e+&a#e!'( 2(" e9a( e %a %e!10a3 %a
a94("&+;! 4e 2"(0&e e! %(4 &a2+%a"e4 e %a &a"a +!fe"+(" e %a %e!10a3 2a4a e%
f>"#a&( a 4a!1"e 4e +!&("2("a =$a =e!a &a";'+a+"e&'a#e!'e a %a &+"&0%a&+;!
1e!e"a%, La4 &(!+&+(!e4 e% 2H e %a 9(&a fa&+%+'a %a +f04+;! 2a4+=a e !0#e"(4(4
f>"#a&(4 . e=+'a %a e4'"0&&+;! e a%10!(4 f>"#a&(4 e9+( a% 2H 1>4'"+&(, U!( e
%(4 2"+!&+2a%e4 +!&(!=e!+e!'e4 e4 e% 104'( e4a1"aa9%e e #0&7(4 f>"#a&(4,
OBJETIVO:
? A#+!+4'"a" f>"#a&(4 &(! e% f+! e (9'e!e" 0! efe&'( #>4 ">2+(,
INTERVENCIONES DE ENFERMERA
? Rea%+5a" %a 'a"e'a e #e+&a&+;! 2a"a &aa 040a"+(3 a&'0a%+5a"%a &aa =e5
60e 4e #(+f+60e 0!a 2"e4&"+2&+;! #-+&a,? Re&("a" . a2%+&a" %a4 REGLAS PARA LA ADMINISTRACION SEGURA DE
MEDICAMENTOS,? Va%("a" e% !+=e% e &(!&+e!&+a e% 040a"+(,
? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%040a"+(,
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? E82%+&a" a% 040a"+( e% 2"(&e+#+e!'( a "ea%+5a" . 4(%+&+'a" 40 &(%a9("a&+;!,? C(!(&e" . (94e"=a" %a e4'a9+%+a . &(!+&+(!e4 e &(!4e"=a&+;! e%
#e+&a#e!'( a a#+!+4'"a",? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e 2"(&e+#+e!'(,? A#+!+4'"a" e% f>"#a&(3 4+ e8+4'e %a 2(4+9+%+a3 2(" e4'a =$a e420-4 e %a4
&(#+a4 .a 60e %a =a4&0%a"+5a&+;! e %a 5(!a e4 #>8+#a,? S(%+&+'a" a% 040a"+( 60e %e=a!'e %a %e!10a e +!'"(0&+" e% f>"#a&( e9a( e
-4'a3 4(%+&+'a"%e 60e &+e""e %a 9(&a . 60e +!'e!'e !( '"a1a" 4a%+=a 0"a!'e 0!(4
#+!0'(4,? C(#2"(9a" 40 &(""e&'a a94("&+;! . (94e"=a" e4'"+&'a#e!'e a% 040a"+( e9+(
a %a ">2+a a94("&+;! e e4'a =$a,? Va%("a" %a '(%e"a!&+a . %(4 2(4+9%e4 efe&'(4 a=e"4(4 e% #e+&a#e!'(
a#+!+4'"a(3 "e1+4'"a" e +!f("#a" a% #-+&(,
? Re1+4'"a" e! %a 7(a e e!fe"#e"$a e% !(#9"e e% #e+&a#e!'(3 (4+43 =$a37("a e a#+!+4'"a&+;! . f+"#a,
? E0&a" a% 040a"+( .( 2a"e4 "e42e&'( a %(4 a42e&'(4 a =a%("a" 0"a!'e %a
a#+!+4'"a&+;! e% #e+&a#e!'( . 2"e=+( a% a%'a #-+&a,
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ADMINISTRACION DE MEDICAMENTOS POR SONDA NASOGSTRICA
Def+!+&+;!:
E4 e% #e+( e %a a#+!+4'"a&+;! e %a #e+&a&+;! e! e% '"a&'(
1a4'"(+!'e4'+!a%,
OBJETIVO:
A#+!+4'"a" f>"#a&(4 &(! f+!e4 +a1!;4'+&(43 'e"a2-0'+&(4 .(
2"e=e!'+=(4 2a"a 60e 4ea! a94("9+(4 2(" %a #0&(4a 1a4'"(+!'e4'+!a%,
INTERVENCIONES DE ENFERMERA
? Rea%+5a" %a 'a"e'a e #e+&a&+;! 2a"a &aa 040a"+(3 a&'0a%+5a"%a &aa =e5
60e 4e #(+f+60e 0!a 2"e4&"+2&+;! #-+&a,? Re&("a" . a2%+&a" %a4 REGLAS PARA LA ADMINISTRACION SEGURA DE
MEDICAMENTOS,? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%
040a"+(,? E82%+&a" a% 040a"+( .( 2a"e4 e% 2"(&e+#+e!'(,? C(!(&e" . (94e"=a" %a e4'a9+%+a . &(!+&+(!e4 e &(!4e"=a&+;! e%
#e+&a#e!'( a a#+!+4'"a",? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? P"e2a"a" %a #e+&a&+;! 4e1
O De4%e+" . +4(%=e" e% &(#2"+#+(3 +!'"(0&+" +"e&'a#e!'e e! %a e"+!1a e
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#%3 #%3)*#%3 2"e=+a "e'+"aa e% -#9(%( e2e!+e!( e %a (4+43 a@a+"
*3 ? #% e a10a 'e#2%aa . a1+'a"3 0!a =e5 +%0+(3 ea" (4+4 a
a#+!+4'"a",? A1"e1a" ? #%, e a10a3 0!a =e5 +%0+(3 a %(4 #e+&a#e!'(4 60e 4(!
+""+'a!'e4 2a"a %a #0&(4a 1>4'"+&a,? R('0%a"3 0!a =e5 2"e2a"a(3 &(! e% !(#9"e e% #e+&a#e!'(3 &(!&e!'"a&+;!3
fe&7a3 7("a e 2"e2a"a&+;!3 #e+a4 e42e&+a%e4 e 04( . a%#a&e!a#+e!'(,? C(%(&a"4e 10a!'e4 %>'e8 ( 2(%+e'+%e!( 4+ e4 60e e% 040a"+( e4'a e! a+4%a#+e!'(
e &(!'a&'(,? S+'0a" a% 040a"+( e! 2(4+&+;! e 4e#+?F(_%e"3 2a"a e=+'a" "ef%0(4 .
a42+"a&+;! 9"(!&(20%#(!a",? Ve"+f+&a" 60e %a 4(!a e4'e e! e4';#a1(3 a42+"a" %e!'a#e!'e &(! 0!a
e"+!1a ? #% 4+ !( =+e!e 0!a 2e60e@a &a!'+a e "e4+0( 1>4'"+&(3 &(%(&a"e% e4'e'(4&(2+( e! e% e4';#a1( . a#+!+4'"a" %a #+4#a &a!'+a e a+"e .
a04&0%'a", A!'e %a 0a "e&(%(&a" %a 4(!a,? A#+!+4'"a" %a #e+&a&+;!3 2"+#e"( %a4 f("#a4 %$60+a4 . ea" %a4
2"e4e!'a&+(!e4 #>4 e!4a4 2a"a e% f+!a%,? La=a" %a 4(!a &(! ? #% e a10a3 a!'e4 e %a a#+!+4'"a&+;! %a
#e+&a&+;!3 2a"a e%+#+!a" "e4+0(4 a%+#e!'+&+(4 e! 040a"+(4 &(! !0'"+&+;!
e!'e"a%3 !( a@a+" e% #e+&a#e!'( a %a f;"#0%a 2a"a e=+'a" +!'e"a&&+(!e4
? E=+'a" #e5&%a"3 e! &a4( e 'e!e" 60e a#+!+4'"a" =a"+(4 #e+&a#e!'(43 e! %a#+4#a e"+!1a,
? La=a" %a 4(!a &(! ? #% e a10a e!'"e 0!( . ('"( #e+&a#e!'( . a%
f+!a%+5a" %a a#+!+4'"a&+;! e %a #e+&a&+;!3 2a"a a4e10"a"4e 60e !( 60ee!
"e4'(4 e #e+&a#e!'(4 e! %a 4(!a,? P"(&ee"3 0!a =e5 a#+!+4'"aa %a #e+&a&+;!3 a &(!e&'a" e !0e=(
a%+#e!'a&+;! e!'e"a% 34+ e% 040a"+( e4'a9a "e&+9+-!(%a,? P+!5a" %a 4(!a !a4(1>4'"+&a 0"a!'e * #+!0'(4 e420-4 e %a
a#+!+4'"a&+;! e %a #e+&a&+;!3 4+ e4 60e -4'a e4'a9a &(!e&'aa a 0!4+4'e#a a42+"a'+=(,
? Sa&a"4e 10a!'e4 . "ea%+5a" %a=a( e #a!(4,? Va%("a" %a '(%e"a!&+a . %(4 2(4+9%e4 efe&'(4 a=e"4(4 e% #e+&a#e!'(
a#+!+4'"a( =;#+'(43 +4'e!4+;! a9(#+!a%3 1a4'"(e!'e"+'+43 e'&3 "e1+4'"a" e
+!f("#a" a% #-+&(,? Re1+4'"a" e! %a 7(a e e!fe"#e"$a e% !(#9"e e% #e+&a#e!'(3 (4+43 7("a
e a#+!+4'"a&+;! . f+"#a,? E0&a" a% 040a"+( .( 2a"e4 "e42e&'( a %(4 a42e&'(4 a =a%("a" 0"a!'e %a
a#+!+4'"a&+;! e% #e+&a#e!'( . 2"e=+( a% a%'a #-+&a,
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ADMINISTRACION DE MEDICAMENTOS POR VIA RECTAL
Def+!+&+;!:
E4 %a +!'"(0&&+;! e 0! f>"#a&( e! e% ("1a!+4#( +"e&'a#e!'e
402(4+'("+(4 ( &(! %a a.0a e a%1
S0 2"+!&+2a% +!&(!=e!+e!'e e4 60e %a a94("&+;! e4 #0. e"">'+&a3 e9+( a %a
2"e4e!&+a e #a'e"+a fe&a% 60e +f+&0%'a e% &(!'a&'( e% f>"#a&( &(! %a #0&(4a, La4
f("#a4 e a#+!+4'"a&+;! "e&'a% 4e 0'+%+5a! 2a"a &(!4e10+" efe&'(4 %(&a%e4 . &0a!(
e8+4'e! +f+&0%'ae4 2a"a %a a#+!+4'"a&+;! 2(" ('"a4 =$a4,
Fa&'("e4 60e +!f%0.e! e! %a a94("&+;! "e&'a% 4(!: V(%0#e! e %$60+( e! %a #0&(4a
"e&'a%3 V+4&(4+a3 S02e"f+&+e e %a #0&(4a "e&'a% . T+e#2( e "e'e!&+;!,
OBJETIVO:
? A#+!+4'"a" 404'a!&+a4 #e+&a#e!'(4a4 e! e% +!'e"+(" e% "e&'(3 a '"a=-4 e%
a!(3 &(! f+!e4 'e"a2-0'+&(43 2"e=e!'+=(4 ( +a1!;4'+&(4,
INTERVENCIONES DE ENFERMERA
? Rea%+5a" %a 'a"e'a e #e+&a&+;! 2a"a &aa 040a"+(3 a&'0a%+5a"%a &aa =e5
60e 4e #(+f+60e 0!a 2"e4&"+2&+;! #-+&a,
? Re&("a" . a2%+&a" %a4 REGLAS PARA LA ADMINISTRACION SEGURA DEMEDICAMENTOS,
? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%
040a"+(,? C(!(&e" . (94e"=a" %a e4'a9+%+a . &(!+&+(!e4 e &(!4e"=a&+;! e%
#e+&a#e!'( a a#+!+4'"a",? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e "ea%+5a" e% 2"(&e+#+e!'(,? I!f("#a" a% 040a"+(3 a0%'( . !+@(43 . a %(4 2a"e4 e% 2"(&e+#+e!'( a
"ea%+5a",
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? P"e2a"a" %a #e+&a&+;! a a#+!+4'"a": 4+ e% 402(4+'("+( e4'> e#a4+a(
9%a!(3 4e 20ee a0#e!'a" 40 &(!4+4'e!&+a #a!'e!+-!(%( e! a10a f"$a
0"a!'e 0!(4 #+!0'(43 4+ e4 e!e#a &(#2"(9a" 60e %a 'e#2e"a'0"a e %a
4(%0&+;! e4 %a &(""e&'a !( 2a4a" e C,? A#+!+4'"a" * #+!0'(4 a!'e4 e %a4 &(#+a43 4+ e4 e efe&'( %a8a!'e,? A#+!+4'"a" e!'"e %a4 &(#+a43 4+ !( e4 e efe&'( %a8a!'e,? C(%(&a"4e 10a!'e4 e %>'e8 e4&a"'a9%e4,? Of"e&e" a% 040a"+( %a 2(4+9+%+a e +" a% 9a@( ( &(%(&a"%e %a &7a'a,? S+'0a" a% 040a"+( e! 2(4+&+;! e S+#4 e&
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CONSIDERACIONES GENERALES
` Se%e&&+(!a" e% 20!'( e P0!&+;!
` N( e%e1+" 5(!a4 &(! %e4+(!e43 +!f%a#a&+;! ( =e%%(
` A4e10"a"4e 60e %a a10a 4e%e&&+(!aa e4 %a ae&0aa a% '+2( e +!.e&&+;!
` E4'a9%e&e" 0! 2%a! e "('a&+;! e %(4 20!'(4 e 20!&+;! e! '"a'a#+e!'(4
2"(%(!1a(4,
ADMINISTRACIN DE MEDICACIN POR VIA INTRAD9RMICA
Def+!+&+;!:
E4 %a +!'"(0&&+;! e 0!a 2e60e@a &a!'+a e %$60+( e! %a &a2a
-"#+&a e %a 2+e% 2a"a 2"0e9a4 +a1!;4'+&a4 . e 7+2e"4e!4+9+%+a e %(4
040a"+(43 60e 20ee! 40f"+" 0! 47(&] a!af+%>&'+&( 4e=e"(,
OBJETIVO:
? De'e&'a" e! f("#a (2("'0!a %(4 efe&'(4 a%e"1-!+&(43 . 4e!4+9+%+a a
a%10!(4 f>"#a&(4,
INTERVENCIONES DE ENFERMERA
? Re&("a" . a2%+&a" %a4 REGLAS PARA LA ADMINISTRACION SEGURA DE
MEDICAMENTOS,? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%
040a"+(,? I!f("#a" a% 040a"+( e% 2"(&e+#+e!'( a "ea%+5a" . 4(%+&+'a" 40 &(%a9("a&+;!,
? C(!(&e" . (94e"=a" %a e4'a9+%+a . &(!+&+(!e4 e &(!4e"=a&+;! e%#e+&a#e!'( . a!'$1e!( a a#+!+4'"a",
? A4e10"a"4e 60e e% 040a"+( !(es '&@rB"o '& /4r,'o (resr"(to