seguimiento de enfermeria 5 semestre gineco
TRANSCRIPT
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SEGUIMIENTO DE ENFERMERA
DIANA NATALIA FONSECA ORTIZ
YESENIA DIAZ ROJASYINA PAOLA LUNA DIAZ
JESUS ALBERTO SANABRIA SANTOS
FERMIN PRADA BLANCO
FUNDACIN UNIVERSITARIA DE SAN GIL UNISANGIL
FACULTAD DE CIENCIAS DE LA EDUCACIN Y DE LA SALUD
PROGRAMA ENFERMERA
PROCESO DE ENFERMERA EN EL CUIDADO DE LA MUJER GESTANTE YRECIEN NACIDO
V SEMESTRE
2015-1
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SEGUIMIENTO DE ENFERMERA
DIANA NATALIA FONSECA ORTIZ
YESENIA DIAZ ROJAS
YINA PAOLA LUNA DIAZ
JESUS ALBERTO SANABRIA SANTOS
FERMIN PRADA BLANCO
DOCENTE ASESORA
MONICA MARCELA !UINTERO
ENFERMERA
FUNDACIN UNIVERSITARIA DE SAN GIL UNISANGIL
FACULTAD DE CIENCIAS DE LA EDUCACIN Y DE LA SALUD
PROGRAMA ENFERMERA
PROCESO DE ENFERMERA EN EL CUIDADO DE LA MUJER GESTANTE YRECIEN NACIDO
V SEMESTRE
2015-1
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INTRODUCCIN
L" #$"%" ' #()"*"+, %.#*%#*/, # . %#*/,&, /(%,*$"$# %"*" '" 3,#4/("&*#-6/7, #$# %*,3#, # #' 3/3', 8/$"' " 9.# *#%*##$" ." #*/# "()/, " /8#' :;/3, ,3/"' #(,3/,"' # #' 3."' )# ".(/**#%,")/'/&" "**,''"* 6")/'/&" %"*" #' 3./&"&, %*,%/, &.*"$# .#()"*"+, #' . 6/7, *#3/./(/#$, " '" #@,*" J?C?R? %#*(/$# ""'/+"* ', :"3$,*# 9.#":#3$" . "'.& #$" :,*(" #$")'#3#* %'"# 3./&"&, $"$, /&/8/&."'#3,(, :"(/'/"*# &"&, . (#7,*"(/#$, "**,'', %'#, " '" 3,&/3/,# '.#8, *,' #$" %.
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OBJETIVOS
OBJETIVO GENERAL
P*,%,*3/,"* 6#**"(/#$" :.&"(#$"'# %"*" #' (#7,*"(/#$, ' #$/', 8/&"$"$, '" ("&*# 3,(, ' 6/7, )*/&"&, #&.3"3/ $,("&, 3,(, %*/,*/&"&'" #3#/&" 9.# # %*##$" &.*"$# #' %*,3#, ("$#*/&"& # . %#*/,&,"%*,4/("&, 2 (## *#"'/+"&, %,* ', #$.&/"$# 9./$, #(#$*# #:#*(#*;" '" U/">/'?
OBJETIVOS ESPECFICOS
R#"'/+"* . #>./(/#$, " '" %"3/#$# JCR (#&/"$# 8//$" %#*/&/3" "'
'.>"* *#//" /$/:/3"&, '" #3#/&" %"*" $*"$"* # 3"&"/$#*8#3/ )"&,, # ', 3*/$#*/, '" NANDA NIC NOC?
B*/&"* /:,*("3/ $/' %"*" #' 3./&"&, '" ("&*# ' )#)# *#"'$"&, '"
/(%,*$"3/" ' 8;3.', ("&*#-6/7, ." ).#" "'/(#$"3/ )""&" # '"
'"3$"3/" ("$#*" #43'./8"?
I:,*("* ,)*# ', 3./&"&, 9.# # )# $##* # #' %,$,%#*"$,*/,
&/(/.#&, #' */#>, "'$#*"3/ , /:#33/ 9.# %.#&" %*##$"* '"6#*/&" %,* 3#*#" &"&, " 3,,3#* ', />, "'"*("?
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CRITERIOS DE SELECCIN
S# #'/>/ " '" %"3/#$# J?C?R? 9./# #$.8, 6,%/$"'/+"&" # #' #*8/3/, >/#3,-,)$#$*/3/" ' ,%/$"' R#>/,"' S" G/' '" 3."' 3.*")" . #>.&, &;" %,,%#*"$,*/, 3#*#"? U, ', "%#3$, %,* ', 3."'# #'#33/,"(, " '"%"3/#$# J?C?R? ,
A . &/#3/##*" "/#&"&? S/ "%,, #(,3/,"' %"*#7"? E8//" 3,,3/(/#$, #3", ,)*# '" /(%,*$"3/" '" '"3$"3/"
("$#*" '" /(%,*$"3/" ." "."&" .$*/3/? C,,3/(/#$, #3", ,)*# %'"/:/3"3/ :"(/'/"*?
P,* ,$*" %"*$# '" 7,8# . :"(/'/"*# "%*,)"*, :/*("* #' 3,#$/(/#$,/:,*("&, %#*(/$/#&, #$" ("#*" " ', #$.&/"$# ' >*.%, A %*3$/3""&9./*/* $,&, ', &"$, %#*$/#$# " . #$"&, "'.& "$#*/,* "3$."' ',
3."'# , 8/$"' /(%,*$"3/" %"*" '" *#"'/+"3/ 3"&" /$#*8#3/ " #7#3.$"*# #' %'" 3./&"&,?
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TEORA DE ENFERMERA
DOROTEA OREM
N"3/ # 11 # B"'$/(,*#,M"*'"& :"''#3/ . 22 J./, ' 200"'*#&,* ', "@, #&"&? S. %"&*# #*" . 3,$*.3$,* . ("&*# ."&.#@" 3""?
E(%#+ . 3"**#*" #:#*(#*" 3, '" 6#*("" C"*/&"& # #' ,%/$"' #"6/>$, D?C? # *#3/)# 3,(, ." # #' "@, 1H0? L.#>, # C"$6,'/3U/8#*/$ ,: A(#*/3" *#3/)/ . B?S?N?E B"36#',* ,: S3/#3# / N.*/>E&.3"$/,? E 1H # 1K ,)$.8, . M?S?N?E? M$#* ,: S3/#3# / N.*/>E&.3"$/, L"#4%#*/#3/"%*,:#/,"'##'*#""/$#3/"''""**,'' ##' #*8/3/,%*/8"&, #'"./&"%#&/"$*;" "&.'$, /#&, "( .%#*8/,*" ,36## U*>#3/"?F.# &/*#3$,*" # '" #3.#'" E:#*(#*;" ' %"*$"(#$, E:#*(#*;" ' 6,%/$"' P*,8/3# ,%/$"' D#$*,/$?
E$*#115$*")"7#'"D/8//,:,%/$"'"&I$/$.$/,"'S#*8/3#' I&/""S$"$#B,"*&,:#"'$6? E"9.;&,"**,''"./3/'"%*3$/3" #:#*(#*"?
E 15 $*")"7, 3,(, "#,*" %*,>*"(" #$.&/,?D# 15-1K0 $*")"7 # . %*,#3$, %"*" (#7,*"* '" :,*("3/ %*3$/3" '"#:#*(#*"?E 15 $*")"7 3,(, %*,:#,*" 3,'"),*"&,*" #&.3"3/ #:#*(#*"# '" CUA 3,(, "" # :.3/,# '" #3.#'" #:#*(#*;" 3,(,%*,:#,*" ",3/"&" #&.3"3/ #:#*(#*"?E 10 #(%#+ " &/3"*# " . %*,%/" #(%*#" 3,.'$,*"?
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S# 7.)/' # 1 />./ $*")"7"&, # #' "**,'', '" $#,*;" #:#*(#*" '&/&" %,* '" %#*," ,)*# ; (/(" 6"3/" ', ( ,6"3/" #' #$,*, %"*" *#>.'"* ', :"3$,*# 9.# ":#3$" " . %*,%/, "**,'', :.3/,"(/#$, # )##:/3/, . 8/&" "'.& , )/##$"*?D#:/# "( $*# *#9.//$, ".$,3./&"&, #$#&/#&, %,* $"'# ', ,)7#$/8,, *#.'$"&, 9.# # 9./#*# "'3"+"* 3, #' ".$,3./&"&,/&/3" ." "3$/8/&"& 9.#. /&/8/&., )# *#"'/+"* %"*" 3./&"* ; (/(,
-R#9.//$, ".$,3./&"&, ./8#*"' , 3,(.# " $,&, ', /&/8/&., #/3'.# '" 3,#*8"3/ ' "/*# ">." #'/(/"3/ "3$/8/&"& ", ,'#&" /$#*"33/ ,3/"' %*#8#3/ */#>, # /$#*"33/ '" "3$/8/&"& 6.(""?-R#9.//$, ".$,3./&"&, ' "**,'', %*,(,8#* '" 3,&/3/,# #3#"*/"%"*" '" 8/&" '" ("&.*"3/ %*#8#/* '" "%"*/3/ 3,&/3/,# "&8#*" ,(/$/>"* ', #:#3$, &/36" /$."3/,# # ', &/$/$, (,(#$, ' %*,3#,#8,'.$/8, , ' "**,'', ' #* 6.(", /@#+ "&,'#3#3/" "&.'$, 8#7#+?- R#9.//$, ".$,3./&"&, /"3/ '" "'.& 9.# .*># , #$8/3.'"&, " ', #$"&, "'.&?
LA TEORA DEL DFICIT DE AUTOCUIDADO:
D#3*/)# #4%'/3" '" 3"." 9.# %.# %*,8,3"* &/36, &
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E '" 9.# # #4%'/3" ', (,&, # 9.# '" #:#*(#*", %.# "$#* " ',/&/8/&., /$/:/3"&, $*# $/%, /$#("
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Accin del paciente D##(%#@" "'>." (#&/&" ".$,3./&"&,= *#>.'" '""3$/8/&"& ".$,3./&"&,= "3#%$" #' 3./&"&, ".&" " '" #:#*(#*"? S/$#(" #:#*(#*;" "%,,-#&.3"3/ '" #:#*(#*" "3$" ".&"&,
" ', /&/8/&., %"*" 9.# #" 3"%"3# *#"'/+"* '" "3$/8/&" ".$,3./&"&, %#*, 9.# , %,&*;" 6"3#* / #$" ".&"
A33/ '" #:#*(#*" *#>.'" #' #7#*3/3/, "**,'', '" "3$/8/&"& ".$,3./&"&,? A33/ ' %"3/#$# C.(%'# 3, #' ".$,3./&"&,?
ANALISIS
L" $#,*;" D,*,$#" O*#( ,)*# #' ".$,3./&"&, # :/# 3,(, #' 3,7.$, "33/,# /$#3/,"&" 9.# *#"'/+" '" %#*," %"*" 3,$*,'"* ', :"3$,*# /$#*,, #4$#*, 9.# %.# 3,(%*,(#$#* . 8/&" "**,'', %,$#*/,*? E'".$,3./&"&, %,* $"$, # ." 3,&.3$" 9.# *#"'/+" , )#*;" *#"'/+"* '" %#*,"%"*" ; (/(" 3,/$# # '" %*3$/3" '" "3$/8/&" 9.# '" %#*,"("&.*" , 9.# #$ ("&.*"&, //3/" ''#8" " 3"), # $#*(/"&,%#*/,&, $/#(%, %,* . %*,%/" %"*$# 3, #' /$#*
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3,'"),*"3/ ' %"3/#$# 7.#>" . %"%#' .("(#$# /(%,*$"$# " '" 6,*" *#"'/+"* ." /$#*8#3/= " 9.# #' ".$,3./&"&, 8" '" (", 3, . 3,**#3$,
$*"$"(/#$, 9.# "' #* /(%'#(#$"&, ("#*" "."&" 3,$*/).# " '"#:/3"3/" '" /$#*8#3/,# 9.# # *#:'#7"* # #' )/##$"* $"$, '" ("&*#3,(, ' *#3/" 6#**"(/#$" :.&"(#$"'# %"*" #' (#7,*"(/#$, . #$/', 8/&"
'" . 6/7, %*/,*/+"&, '" #3#/&" 9.#
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VALORACIN DEL ESTADO DE SALUD:
INFORMACIN BASICA
FECHA DE LA VALORACIN ")*/' 2015
NOMBRE J? C? R?
EDAD 1K "@,
ESTADO CIVIL S,'$#*"
NIVEL EDUCATIVO 11Q CURSANDO ACTUALMENTE
PROCEDENCIA A*"$,3"
OCUPACION ACTUAL E$.&/"$#
RELIGIN C"$'/3"
AREA DE VIVIENDA U*)", B"**/, E' Z"9.#
DISPOSICIN P,3, /$#*
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CONFIABILIDAD R#>.'"*
DESCRIPCIN VIVIENDA, SERVICIOS PBLICOS Y RECURSOS DELBARRIO.
L" 8/8/#&" '" .."*/" J?C?R? # #3.#$*" .)/3"&" # #' B"**/, E' Z"9.# 'M./3/%/, A*"$,3"? A%"*#3# *#>/$*"&, # #' 3"3, .*)", %#*, &" #' "%#3$, *#" *.*"'? E' B"**/, #$ .)/3"&, " 20 (/.$, '" 8;" "3/,"' S" G/' B.3"*"(">"? S. "33#, # %,* 3"**#$#*" $"%"&" %,3" 3"" " ."'*#&,*? L" 3"" # '"&*/'', ". , $#*(/"&" # . $,$"'/&"& %/, #(#$, , $/## %.#*$" ,', %*##$" 3,*$/" # "'>." #%"*"3/,# $#36, #$#*/$? C.#$" 3, #*8/3/, '.+ #'." %,$")'# >" # %/%#$"
".9.# '" (",*;" "'/(#$, , %*,3#"&, # :,> '#@"? S# ,)#*8"$#'#8/,* #8#*" #9./%, ,/&, #$.:" %#9.#@"?
E' )"**/, 3.#$" 3, "%*,4/("&"(#$# 12 3"" '" 8;" "3/,"' 6"$" '"3"" &, 8/8# '" .."*/" J?C?R? N, $/## $/#&" 3#*3"" %"*" #' "33#, " ',"'/(#$, # %'"+" 6"$" #' 3#$*, ' (./3/%/, # $/#&" .)/3"&" ,)*#'" 8;" "3/,"'? S,', #4/$# ." ESE .)/3"&" # #' 3#$*, ' (./3/%/, I /8#' "$#3/?
QUEJA PRINCIPAL
P"3/#$# *#(/$/&" ' 6,%/$"' A*"$,3"
Am!"#$"%& '( !# )*(+# "&$"#!
P"3/#$# "&,'#3#$# %*/(/>#$"$# 1 #("" %,* FUR 3,:/")'# # *#(/$/&"' 6,%/$"' A*"$,3" %,* %*,',>"3/ ' #()"*"+, , //3/"* $*")"7, %"*$,%"3/#$# 3, :"3$,* */#>, %,* #&"& :.# 3,(#$"&" 3, >/#3',>, 9.# '""3#%$" %"*" *#"'/+"3/ %*.#)" )/##$"* :#$"' ://* 3,&.3$"? N/#>";$,(" .*/"*/, /#>" />, %*#(,/$,*/, /#>" %/"'#(,8/(/#$, :#$"'# "3$/8/&"& .$#*/" /**#>.'"*?
SIGNOS VITALES:
TA KH ((>FC H '"$/&, %,* (/.$, FR 1 *#%/*"3/,# %,* (/.$, THK?QC
ASPECTOS GENERALES
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PATRON MENSTRUAL CICLOS REGULARES 2 %,* K &;"
FUM 2 JUNIO DE 201G1 P0 C1 G#0 A0E0 O0 M,0 V1 M0
EDAD GESTACIONALPOR FUM 0 A)*/' 2015 2 K #(""
EDAD GESTACIONALPOR ECO DEL 20 FEBRERO DE 2015 H25 SEMANASH S#(""
FPP 12 ")*/' 2015 %,* #3,?
FPP 1 ")*/' 2015 %,* FUM?
ANTECEDENTES PERSONALES
GINECOLOGICOSM#"*9./" 1 "@,?S#4"*9./" 15 "@,N.(#*, 3,(%"@#*, #4."'# 1ETS N/#>"M;" N, # 6" $,("&,
OBSTTRICOS N/#>"PATOLOGICOS N/#>"HOSPITALARIOS A3$."' 6,%/$"'/+"3/QUIRURGICOS C#*#" &;" 1FARMACOLOGICOS N/#>"TO-ICOLOGICOS N/#>"TRAUMATICOS N/#>"ALERGICOS N/#>"PSIQUIATRICOS N/#>"
ANTECEDENTES FAMILIARES
CANCER A).#'" ("$#*" , #%#3/:/3"&,
EVOLUCIONES DE SU ESTADO DE SALUD HASTA EL MOMENTO ACTUAL.
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0015 0 G/#3,,)$#$*/3/"
ID/ P*/(/>#$"$#?0/ E()"*"+, 1 #(""?1/ F"3$,* */#>, %"*" '" #&"&?
PLAN
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8"*/")'# / "3#'#*"3/,#? C"$#>,*;" 1?
0015 121K G/#3,,)$#$*/3/"
S# $*"'"&" %"3/#$# " 9./*:", %*#8/" "#%/" "$/#%/" )"7, "#$#/"*"9.;" # %,# 3"(%, ,%#*"$,*/, # *#"'/+" /3// $/%, %:"#$/#' #&/#3" %,* %'", 6"$" ''#>"* " 3"8/&"& ")&,(/"' # *#"'/+" /3// $/%, #** #$#*, # #4$*"# '/9./&, "(/$/3, 3'"*, 12H0 *#3/
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P'"
L"3$"$, */>#* 500 33 10 UI ,4/$,3/" %""* " 150 336 6"$"3,(%'#$"* H0 UI 3,$/."* '"3$"$, " 150 336? D/#$" # #/ 6,*" C#:*"&/" 1 >* 3"&" K 6,*" D/3',:#"3, 5(> IM 3"&" 12 6,*" V/>/'"* $,, .$#*/, ',9./, CSV- AC
O*# ' R#3/
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H F"3$,* */#>, %,* '" #&"& POP 3#*#" &;" 2?
P"3/#$# # POP C#*#" #>(#$"*/" / 3,(%'/3"3/,# 3, ).#"#8,'.3/ # . %.#*%#*/, 3, %"*"3';/3, 3,$*,' 9.# #8//" '#8#'#.3,3/$,/ 3, #.$*,:/'/" "#(/" / #()"*>, %"3/#$# / SIRS 3';/3, %,* ',3."' # 3,/*" &"* "'/&" 3, ("#7, ""'>/#3,',>;" # 15 &;"?
P'" S"'/&" A3#$"(/,:# 500 (> V?O? 3"&" K %,* 6,*" %,* &;"
C#:*"&/" 500(> 3"&" K 6,*" %,* &;" S.':"$, :#**,, H00(> "' &;" %,* H0 &;" C"*),"$, 3"'3/, K00 (> V?O? &;" %,* H0 &;" A3#$"$, (#&*,4/%*,>#$#*," "(%,''" %,* 150(3>? A%'/3"* 1 "(%,''" #
1 (# '.#>, 1 "(%,''" 3"&" H (## 6"$" 3,(%'#$"* . "@,? C/$" 3,$*,' %,* 3,.'$" #4$#*" >/#3,',>;" # 15 &;" R#$/*, %.$, # &;" L"3$"3/" ("$#*" " '/)*# ("&" S# &" *#3,(#&"3/,# />, "'"*("?
VALORACIN POR DOMINIOS
DOMINIO : PROMOCION DE LA SALUD
ENTREVISTA:
P"3/#$# JCR *#:/#*# >,+"* ).#" "'.& , $/## "$#3#$# %"$,'>/3,$/## %,3, 3,,3/(/#$, ,)*# ("$#*/&"& 3./&"&, '" )#)# , # 6"*#"'/+"&, #4"(# #, / 3/$,',>;" //3/, . 8/&" #4."' " ', 15 "@, ,', 6"
$#/&, . 3,(%"@#*, #4."' . /$."3/ "3$."' # ,'$#*" ":/*(" 9.# :.# .#()"*"+, , #"&, %,* ', 9.# ', ,3.'$, 6"$" ', (## >#$"3/&.*"$# '" >#$"3/ ,', "/$/ " &, 3,$*,'# # '" #("" H2?5 # '"#("" H?
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LABORATORIOSFECHA: 234254026
FECHA: 274254026
FECHA: 34254026
L#89#9"9; R(;*!#'9H(m9'!H(m9$!#;"?"$#$"%& O G!"$(m"# (& #@* KS(9!9"$/8,
L#89#9"9; R(;*!#'9H(m9'!L(*$9$"9; 1?H00 ((?HN(*%?"!9; WL"&?9$"9; 15 W
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TSH NEONATAL RESULTADO: 6.0 m!U4m!
VALOR DE REFERENCIA: SANGRE DE CORDON UMBILICAL15('U ('SANGRE DE TALON 20 ('U('
E$9
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E9.#(" 8"3."3/ 3,(%'#$, # *#"'/+ . *#:.#*+, $,4,/ $#$/3,&.*"$# #' #()"*"+,?
TRATAMIENTO FARMACOLOGICO
MEDICAMENTO DOSIS
MEDICAS
INDICACIONES
METROCLOPRAMIDA
Am9!!#2 M"$*/$/ >"$*,%"*#/"?
N.#" 8(/$, /3'.# ', %*,&.3/&,&.*"$# #' %,$,%#*"$,*/, ', /&.3/&,%,* (#&/3"(#$,?
TRAMADOL Am9!!#
62 M
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DICLOFENACO Am9!!# 4
2 m< $#'#
0 9#;
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A$//:'"("$,*/, 9.# %,## "3$/8/&"""'>#/$,.*/"*/,/3'.#&, #%/&/&/(/$/ %*,$"$/$/?X O$/$/ (#&/"?X F"*/>/$/ )"3$#*/"" , "(/>&"'/$/?X N#.(,;" )"3$#*/""?X S#%$/3#(/" )"3$#*/""?X I:#33/ %/#' $#7/&, )'"&,?
E-AMEN FSICO:
A' #4"(# :;/3, . 3,$/$.3/ # ,*("' '" #&"& "%"*#$# # "3,* 3, '"#&"& 3*,,'>/3" "' (,(#$, '" 8"',*"3/ , %*##$" #(" #/)/'/&"& ,("" / #()"*>, *#:/#*# 9.# &.*"$# #' #()"*"+, %*##$, #(" #(/#()*, /:#*/,*#? E' #4"(# :;/3, # *#"'/+ #' #>.&, &;" %,% 3#*#"%,* ', 9.# %*##$")" &,',* '#8# "' (,8/'/+"*# # *#>/ 6#*/&" 9./**>/3"?
DOMINIO 0: NUTRICION:
ENTREVISTA:
A3$."'(#$# '" .."*/" JCR 3,(# 8#3# "' &;" #@"'" 9.# . &/#$" # ,*("'".9.# , $/## ).# "%#$/$, $,'#*" $,&, $/%, "'/(#$, ":/*(" #$/*#"$/:#36" *#:/#*# #3", "%,*$# ';9./&, " 9.# , '# >.$" #' ">." *"*" 8#+
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$/## #&? L, "'/(#$, , %*#%"*"&, # 3"" 3, #$.:" # ,3"/,# 3,'#@"?
E-AMEN FSICO:
A' *#"'/+"* #' #4"(# :;/3, # ,)#*8" %"3/#$# 3,$#4$.*" ,*("' #$"$.*"(#&/" 1?5 3, . %#, > "' //3/, '" >#$"3/ &.*"$# #$#%#*/,&,.)/ " 52>? L")/, /(." *,"&" 6(#&"8.'" 3#$*"&" "(;>&"'" %*##$# 3,',* *,"&, $"("@, ,*("' /%*##3/" "'$#*"3/,#?
P(;9 #$*#!:5 >
T#!!#:1 5
IMC:21?H %#, ,*("'
T#8!# '( &'"$( '( m#;# $99#!
T")'" /3*#(#$, %#, # >#$"$#?
NDICE MASA CORPORAL CLASIFICACIN.22.22 .77.22 3.573.62 05.7706.22 07.7712.22 15.77
16.22 52.2252.22
I:*"%#, D#'>"+ S#8#*"I:*"%#, D#'>"+ (,*"&"I:*"%#, D#'>"+ "3#%$")'#P#, N,*("'S,)*#%#,O)#, T/%, I
O)#, T/%, IIO)#, T/%, III
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R(!#$"%& (;9 ## !# #!!# G#&$"# 9#! ($9m(&'#'# K." "'$#*"3/ %"*" 3,3/'/"* #' .#@, / $"(%,3, 3,.(# (#&/3"(#$,%"*" %,* &,*(/* , %*##$" .#@, '/8/", $"(%,3, %#"&/''" 9.# ":#3$# .6,*"*/, .#@,?
E4%*#" 9.# " '" 1200 "( '" )#)# # %/#*$" " %#&/* 9.# '" "("("$# "6; # "'"$# &.#*(# "$/:"3$,*/"(#$#= " '" K 00 "( //3/" . 7,*"&"#$.&/"$/' # #' 3,'#>/, S" L./ '" 3."' 3.'(/" " '" 12 H0 %(?
ACTIVIDAD 4 EJERCICIO
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ENTREVISTA:
L" .."*/" J?C?R #4%*#" 9.# &.*"$# . #()"*"+, , *#"'/+ />."%*#%"*"3/ :;/3" # 3."$, " '" >/("/" %*#"$"'= # . >#$"3/ ,', *#"'/+")". '"),*# 3,$/&/"" 3"(/")" $,&, ', &;" %"*" ''#>"* " '" /$/$.3/#$.&/"$/' &, 3.*" 11 >*"&,?
E-AMEN FISICO:
S# #8//" 3.#'', /('&.'" $/*,/" ".(#$"&" >'&.'".)'/>."'# # #$"&, ,*("'= (.3.', $*"%#3/, #$#*,3'#/&,("$,/, 3,:.#*+" "."&" :.3/,"&, 3,**#3$"(#$# , %*##$" ("" >">'/,'/:$/3, # #$"&, ,*("' / />, /:'"("3/ %.', 3"*,$/, %"'%")'#
$#(%#*"$.*" "3,* # $,&, . 3.#*%, ("*36" "."&" / %*##3/" ",*("'/&" 3,'.(" "*$/3.'"3/ 3,4,:#(,*"' # ).# #$"&, , %*##$"&/"$"/ # ', *#3$, ")&,(/"'#?
EQUILIBRIO DE LA ENERGIA:
R#:/#*# >,+"* ).#" ##*>;" # . 8/&" &/"*/" , .:*/* :"$/>"?
RESPUESTAS CARDIOVASCULARES 4 PULMONARES:
E-AMEN FISICO:
VALORACION RESPIRACION:
R#%/*"3/ $/%, $,*3/3" "."&" %*,:.&" 3, :*#3.#3/" 1 %,*(/.$, "*/+ :,*(" "'"*>"&" $"("@, %*,%,*3/,"' " . 3"*" / /> $/%, /"3/ %/#' / %*##3/" ("36" , #8. (.3," ""' /$#>*" 3,#3*#3/ (.3," (#"$, ,*("'# "'#$" ""'# /$#>*"?
VALORACION TRA-:
S# ,)#*8" $*"4 #';%$/3, /(
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N, # ,)#*8" %#$#9./" *#>.*>/$"3/ .>.'"* %.'"3/,# 0 %,* (/.$, #".3.'$" /3"(#$# R1 R2 "*$/3, %.'(,"* $*/3%/ (/$*"' :*#3.#3/"
*/$(, 3"*&/"3, $*, ', ';(/$# ,*("'# / %*##3/" ,%',$#'">/#3$"/"? S/ %*##3/" 8"*/3# #(" # (/#()*, /:#*/,*# #%"'%" %.', 3"*,$/, "4/'"* )*"9./"' *"&/"' :#(,*"' %,%';$#, %#&/, '"$/&,#%/>$*/3, %*##$# / "'$#*"3/,# %*#/ "*$#*/"' 1200 ((>?
DOMINIO 6: PERCEPCION Y COGNICION:
ENTREVISTA:
J?C?R %*##$" #$"&, 3,3/#3/" ,*("' # #3.#$*" "',%/9./3" ".$,%;9./3" # . $*# #:#*" $/#(%, #%"3/, '.>"* (#(,*/" "."&" ,*$, '"*>, %'"+, #$"&, /(, #$")'# '#>."7# ,*("' "."&, "3.#*&, " . /8#' #&.3"$/8, #3.36" "$#$"(#$# 3, 3'"*/&"& " $,&, ', 9.# #'# &/3# , ("/:/#$"?
M"/:/#$" , $##* 3,,3/(/#$, 3./&"&, %"*" #' %.#*%#*/, />, "'"*(" 9.# # %.#&" %*##$"* , 3,,3# '" $."7# 3,*%,*"' # %'", " 9.# , (.#$*" /$#*
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ESCALA DE GLASGO PUNTAJE. APERTURA OCULAR ESPONTANEA OJOS ABIERTOS
MANTENIDOS
0. RESPUESTA VERBAL ORIENTADA 51. RESPUESTA MOTORAS OBEDECE ORDENES K
5. TOTAL 1515
DOMINIO : AUTOPERCEPCION
ENTREVISTA
L" .."*/" J?C?R? *#:/#*# #$/*# " >.$, 3,/>, (/(" , #$.8, " >.$, 3, .#()"*"+, %,* ', 3."' ', ("$.8, ,3.'$, #' (",* $/#(%, %,/)'# " . :"(/'/"? N,#$ 3(,&" %,* #' %*,3#, %,* #' 9.# %"" # #8"'" " / (/(" 3,(, ."%#*," ,*("' 9./#*# "'/* "'"$# 7.$, " . 6/7, . :"(/'/"?
E-AMEN FISICO
S. %*##$"3/ %#*,"' # ).#" , ("$/## #' 3,$"3$, 8/."' &.*"$# '"
#$*#8/$" . $,, 8,+ # )"7, %*##$" &/$*"33/,# %"*" $*"$"* #8"&/*?S. /$."3/ ":#3$" ("#*" #>"$/8" . #$/(" " 9.# " %#"* ' "%,,:"(/'/"* # /#$# /#>.*" , " >.$, 3,/>, (/("?
DOMINIO : ROL 4 RELACIONES
ENTREVISTA:L" %"3/#$# J?C?R? *#:/#*# %#* . :"(/'/" ("/:/#$" $##* ).#"*#'"3/,# 3, . ("(" . 6#*("" / #()"*>, ("$/## ." *#'"3/&/$"$# 3, . %"&*# 9./# 8/8# # B.3"*"(">" *#%, %,* #''"#3,(/3"(#$#? L" *#'"3/ "(/>, # ).#" " %#"* 9.# # /#(%*# 6"
/&, ." %#*," 3"''"&"? A3$."'(#$# , %*##$" *#'"3/ 3, #' %"&*# .6/7" " 9.# , $,(, '" ,$/3/" ' #()"*"+, '" (#7,* ("#*" $#*(/"*,&/3.$/#&, 6"$" :/"'/+"* 8;3.', ":#3$/8,? S. /$."3/ "3$."' # #$.&/"$##$ 3.*"&, .&*"&, # #' 3,'#>/, S" L./ ' (./3/%/, A*"$,3"%,* #$# (,$/8, , %.# '"),*"* " 9.# (#&/, $/#(%, #$.&/" #' *#$, ' &;" #', &/3" "' 3./&"&, . 6/7"? D.*"$# '" #$"3/" 6,%/$"'"*/" # &/:/3.'$, '""'/(#$"3/ '" )#)# %,* 9.# %*##$")" &
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JCR ("/:/#$" $##* #3", 3,,3/(/#$, %,* ', 9.# (.#$*" /$#*
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E-AMEN FSICO
A '" 8"',*"3/ # ,)#*8 9.# '" %"3/#$# $/## %,3" /$#*"33/ 3, '" (%#*," , '# >.$" 6")'"* (.36, ,', *#%, 3, (,,;'"), " '"%*#>.$" 9.# # '# *#"'/+"? S# #8//" ("(" #3*#$"$# ).# ">"**# (#7,*" # '" "'/(#$"3/ '" )#)#?
D9m"&"9 3. SE-UALIDAD
ENTREVISTA:
L" %"3/#$# J?C?R? 1K "@, ":/*(" , $##* ).#" *#'"3/,# 3, #' #4,,%.#$, ("/:/#$" # #' (,(#$, , $##* 8/&" #4."' "3$/8" *#:/#*# 9.# ,%'"/:/3")" 3, (.*/&"& " 9.# , 3.#$" 3, #'"%,, #(,3/,"' . %"*#7" %.#$, 9.# "' #$#*"*# . #()"*"+, /&,? N, 3,.(# />." 3'"# .$"3/" %/3,"3$/8" / ,$*,$/%, .$"3/" 9.# ":#3$# #' )/##$"* %*,%/, ' )#)
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E-AMEN FISICO
L" .."*/" J?C?R # #8//" 9.# , # (. "'#>*# 3, . #$"&, #(,3/,"'#$")'# / '")/'/&"& #(,3/,"' / ,3/'"3/,# 6.(,* , ("$/## #'3,$"3$, 8/."' 3."&, # '# 6")'"? N, %*##$" #$/(/#$, #4%*#/,# $#(,* ,)*# '" #8,'.3/ . #$"&, "'.& '" %,/)'# 3,(%'/3"3/,#9.# # '# %.#&" %*##$"*? N, ("$/## ." ).#" 3,&.3$" &/%,/3/%,* #' (#7,*"(/#$, . "'.& , $/## 3,&.3$" :#/8" # /#>.*"?
DOMINIO 2: PRINCIPIOS VITALES
ENTREVISTA
L" .."*/" J?C?R M"/:/#$" 9.# #''" # 3"$'/3" , "/$# 3, %#*/,&/3/&"& "'" />'#/" %#*, *#:/#*# 9.# D/, # #' #7# . 8/&"? S# 8# 3,(, ." %#*,"3,(%"@#*/$" "(")'# $,'#*"$#? E #$# (,(#$, ', 8"',*# (/(%,*$"$# '" 8/&" , #' "(,* #' *#%#$, '" 6,#$/&"& $*"$" 6"3#*'" 3," "."&"(#$# 3"&" &;" "3$."* "3.#*&, " ', %*/3/%/, 8"',*# 9.# %#9.#@" . ("&*# '# ##@, *#:/#*# , 3,,3#* ,)*# ',(/$, , 3*##3/" %#*, . ("&*# '# /3.'3" ,)*# ', 3./&"&, ' %.#*%#*/, ' *#3/" %*,)'#(" # '" 3/3"$*/+"3/?
E-AMEN FISICO
P"3/#$# 3, '#8# %"'/+ 3.$#" 3, #$*;" # #, ")&,(# 3,6#*/&" 9./**>/3" .$.*"&" '/(%/" / />, /:#33/ 3, ),*":*,$"&, #8,'.3/,"&, "$/:"3$,*/"(#$#
DOMINIO 0: CONFORT
ENTREVISTA:
L" .."*/" J?C?R ("/:/#$" , %*##$"* .#" *#:/#*# , $##*6/%#**"8;&/3" # /#$# :;/3"(#$# )/# " 9.# %.# *#"'/+"* '"(",*;" ', ,:/3/, '" 3"" ".9.# "'>." "3$/8/&" , '" %.#*#"'/+"* ("/:/#$" , #$/*# $,$"'(#$# /3,(,&" 3, . #$"&, :;/3,
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%/3,'>/3"(#$# # #3.#$*" )/# " /8#' ,3/"' */)# 9.# .*#'"3/,# , ).#" 3, ', "(/>, ".9.# , %,3, # /#$# 3(,&"
3, '" %#*," 9.# '" *," 3, *#%#3$, "' "()/#$# # #' 9.# ##3.#$*" # /#$# " >.$,?
E-AMEN FSICO:
L" .."*/" J?C?R *#:/#*# %*##$"* &,',* ',3"'/+"&, # /$/, 6#*/&"9./**>/3" &.*"3/ (;/(" / />, /**/$"3/ /$#/&"& *#>.'"* ', :"3$,*#9.# 6"3# 9.# /3*#(#$# #' &,',* # '" (,8/'/&"& # 3"(" , #' 3"(/"* %"*"'" (#&/&" "'/8/, # '# "&(//$*" $*"("&,' 50(> 3&" 6,*" # ',#:#3$, 3,&.3$."'# #''" #8/$" , (,8/'/+"*# ("$##*# # 3"(" #
%,/3/ .%/" #' ">#$# 3"."' ' &,',* #$ *#'"3/,"&, 3, '" 6#*/&"9./**>/3"?
DOMINIO 1. CRECIMIENTO Y DESARROLLO
ENTRAVISTA
L" .."*/" , $/## (.36" #4%#3$"$/8" ' *,' 3,(, ("&*# $/## (/#&, *#"'/+"* ', 3./&"&, " '" *#3/
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L#36# ("$#*" /.:/3/#$# *3 .33/ /#:/3"+ " *#:'#7, .33/
&/(/./&,?
A$""'#' @ (9;9
D#$#*/,*, '" "().'"3/ *3 &,',* " %,$,%#*"$,*/, 3#*#"?D#$#*/,*, '" (,8/'/&"& :;/3" *3 &/3,:,*$
P($($"%&4 $9/&"& 6.("" :* %"*$/3/%"3/ /"."&" #'" $,(" //,#?
R9!4(!#$"9&(;
R/#>, 3""3/, ' *,' 3./&"&,* :* :"'$" #4%#*/#3/" %"*" 3./&"*?L"3$"3/" ("$#*" /#:/3"+ *3 &/:/3"$/8" "3,:'/3$, 3, '" %"*#7"
S(*#!"'#'
P*,3#, ("$#*/&"& /#:/3"+ *3 3,,3/(/#$, :/3/#$#%"*$,"'.()*"(/#$, 3./&"&, ' *#3/
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S(, /:#33/ :* %*,3#&/(/#$, /8"/8, " 3#*#"
C9&?9
D/3,:,*$ *3 /:,*(# :"'$" "$/:"33/ 3, '" /$."3/ " #()"*"+,, #"&,?
P"9"#$"%& '( '"#
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DEFINICION:C"*#3/" , :/3/#3/" /:,*("3/ 3,>/$/8" *#'"3/,"&" 3, . $#("#%#3;:/3,?
CARACTERISTICAS DEFINITORIAS:1? S#>./(/#$, /#4"3$, '" /$*.33/,#2? C,(%,*$"(/#$, /"%*,%/"&, "%"$;" 6,$/'/&"&H? V#*)"'/+"3/ ' %*,)'#("
EL EMBARAO A TEMPRANA EDAD
L" "&,'#3#3/" #> '" OMS # ://&" 3,(, #' %#*/,&, # '" 8/&" # #' 3."' #'/&/8/&., "&9./#*# '" 3"%"3/&"& *#%*,&.3$/8" &, ,3.**# 3"()/, :;/3, %/3,'>/3, = '" .."*/" J?C?R " . 1K "@, #&"& # #3.#$*" # '""&,'#3#3/" (#&/" '" 3."' $*"/$" ', 1-1K "@,= E' #()"*"+, #"&,'#3#$# # . %*,)'#(" "'.& %)'/3" " /8#' (.&/"' " 9.# # '"(",*;" ', 3", #$# ":#3$" #>"$/8"(#$# '" "'.& '" ("&*# ' /@, "&/3/,"'(#$# %.# ,3"/,"* "'$#*"3/,# # '" 3"'/&"& 8/&" , ,', #'',/, $"()/ 3,,3/(/#$, )/&, " '"/("&.*#+ " '" :"'$" #4%,/3/ = #$, /:'.# ("#*" &/*#3$" # '""&,%3/ ' *,' ("$#*"' # #8//" %,* '" :"'$" #4%#*/#3/" 9.# $/## %"*".%'/* '" 3,$"$# 8/$"'# ' *#3/*"' ' )#)# .
RESULTADO: CONOCIMIENTO: CUIDADOS DEL LACTANTE
DOMINIO:C,,3/(/#$, 3,&.3$" "'.&CLASE:C,,3/(/#$, ,)*# "'.&ESCALA:N/> 3,,3/(/#$, 6"$" C,,3/(/#$, #4$#,
DEFINICIN:G*"&, '" 3,(%*#/ $*"(/$/&" ,)*# '" "/$#3/" ' /@, #' "3/(/#$, 6"$" 1 "@, #&"&?
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I&'"$#'9(; N"&."$/)/"?C,(/#+"" )"@"* "')#)"&"
">." $/)/"?C,(/#+" ")"@"* "')#)"&" ">." $/)/"?P,# "' )#)"" 8"*/"8#3# %,* #'(/(, '.>"*
R#"'/+"'/(%/#+" '3,*&.()/'/3"' 3,>"" "'3,6,' )'"3,%""&, '">"" ." ,'"8#+ *#%/$/#&, #'%*,3#&/(/#$,
R#"'/+'/(%/#
>"""%'/3""'3,6,# .()/'/%"">"" # #' '/(%/"
),*,"%'/3"/(%*#"'3,6,
JCRE%#*
C9m*&"$#$"%&'(! ($"&
$"'9
N,(.#$*"
/$#*
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3,(./3"3/ "'
(,(#$, '"3$"*?
JCR I&"$"#!
(.#$*"/$#*
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'/(%/"&, #' ),* /:#*/,* 3, . "%'/3"&,* /(%*#>"&, "'3,6,' 3,,3# *#"'/+" '" "33/,# #3#"*/" %"*" #8/$"* #' ''"$, . )#)
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L/(%/"* #' 3,*& .()/'/3"' 3, . %*#%"*"&,%*#3*/$,?
S# #&.3, ,)*# '"("#*" "."&"
*#"'/+"* '" %*,:/'"4/.()/'/3"'?
M"$##* #' 3,*& .()/'/3"' #3, "' "/*# %,/#&,#' %"@"' %,* )"7, ' 3,*&?
C,(%*,)"* #' ).# #$"&, ' )#)< "$# "&(//$*"* ', 3./&"&,?
S# #4%'/3, '" /(%,*$"3/" %*,%,*3/,"* ."()/#$# $*"9./', .).# #$,*, .3,$"3$, 8/."' %"*"(#7,*"* '" 3,(./3"3/?
D/%,#* . "()/#$# $*"9./',?M"$##* 3,$"3$, 8/."' 6")'"* "' )#)< (/#$*"# '# "&(//$*" ', 3./&"&,?
INTERVENCIN: E#@"+" #>.*/&"& /:"$/'?
C#m9:F"(/'/" 3./&"&, 9.# "%," '" ./&"& :"(/'/"*?C!#;(:Z C./&"&, 3*/"+" . .#8, )#)
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"."&, " '" #3#/&" 3,,3/(/#$,/$/:/3"&"
:,''#$, #&.3"$/8, " '".."*/" JCR %"*"
*#:,*+"* ',3,,3/(/#$,?C,(%*,)"* '" $#(%#*"$.*" ' ">." ' )"@, S# *#"'/+, #&.3"3/
,)*# #' )"@, # 6/>/##"' )#)"*',?
D/"',>"(, 3, '" .."*/" JCR ,)*# .*#'"3/ 3, #' %"&*# '" RN '" &.&" ,)*#. %"%#' ("$#*,?
C,$*,'"* #' #$"&, "'.&%"*#$"' '" "3$/8/&" '("$#/(/#$, "'.&
S# &/, #&.3"3/ ,)*# ', 3./&"&, ' *#3/* . 3,,3/(/#$,.$"3/"' ,)*# 3./&"&, ' '"3$"$#? N/8#' 120 #8//"&, %,*9.#*#3,,3# %"$* ,*("' .#@, ' *#3/"" ." ,'" 8#+ *#%/$/#&, #' %*,3#&/(/#$,? C,,3# *#"'/+" '""33/,# #3#"*/" %"*" #8/$"* #' ''"$, . )#)
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"%*#*?
JCRI&"$"#!
3,*$,?
JCR F"!
3"$/&"& #3#
"("("$"&,?JCR E;(#'9
3"*"3$#*;$/,*("'#
'" #&"&?
C9m98## #!!#$#&(.
N, 3,,3#/>%", %"*")"@"* #''"3$"$#?
JCR I&"$"#!
L'#" '"$/" 3,."3."$"%.'>"&" ">."$/)/"?C,(/#+"
" )"@"* "')#)"&" ">." $/)/"?C,(/#+" ")"@"* "' )#)." $/)/"?P,# "' )#)< #
'" $/" 3, ',%/# %,* '"$#?C,(/#+" ")"@"* "' )#)." $/)/"?P,# "' )#'" $/" 3,
%/# %,* C,(/#+" )"@"* "' *%/&"(#$#8/$"&,%#*&/&" 3"',*S"3" #)#)"" 8"*/"8#3# %,* #'
R#"'/+" '/(%/#+"' 3,*&.()/'/3"' 3,
>"" "'3,6,')'"3, %""&,'" >"" ." ,'"8#+ *#%/$/#&,#'%*,3#&/(/#$,?
R#"'/+" '/(3, >"%'/3"&,*#"'3,6,' )# 3.()/'/3"'%""&, '"." 8#+ 3,*&
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JCR I&"$"#!
(/(, '.>"*JCR- F/"' '/(%/"&,
),* /3, . "%'//(%*#>"&,"'3,6,'?
JCR E%#C9m*&"$#$"%& '(!($"&$"'9
N,(.#$*"/$#*
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L" /$#*8#3/,# *#"'/+"&" #3"(/"&" "' 3,,3/(/#$, ', 3./&"&, ''"3$"$# :.#*, #:/3"3# # . 1W
LACTANCIA MATERNA INEFICA R4C REFLEJO DEBIL DE SUCCION DELLACTANTE.
DEFINICIN: '" ("&*# #' '"3$"$# , #' /@, #4%#*/(#$" /"$/:"33/ ,&/:/3.'$"& 3, #' %*,3#, '"3$"3/" ("$#*"?
CARACTERSTICAS DEFINITORIAS:
L'"$, ' '"3$"$# "' %,#*', " ("("*? F"'$" 3,$/./&"& # '" .33/ ' %#36,? R#/$#3/" " 3,>#* #' %#36,? I"$/:"33/ 3, #' %*,3#, "("("$"(/#$,?
LACTANCIA MATERNA
L" '"3$"3/" ("$#*" # '" (#7,* :.#$# "'/(#$"3/ %"*" $. )#)< *#3/
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DEFINICIN:./ .33/ ' '"3$"$# ' %#36, '" ("&*# %"*" ."'/(#$"3/ &.*"$# '" %*/(#*" H #("" '"3$"3/"?
I&'"$#'9 I'($*#'9
L"
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JCRE;(#'9
D(%#36,?
JCRI&"$"#!
">'.3/%,* 2(/.$,# 3"&"%#36,?
? ">'.3/%,* H(/.$, #3"&" %#36,?
">'.3/ %,* (/.$, #3"&" %#36,?
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DIAGNOSTICO
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CONCLUSIONES
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BIBLIOGRAFA