Trabajo Final Preeclampsia

UNITEC UNIVERSIDAD TECNOLÓGICA DE MÉXICO CAMPUS SUR PROCESO ATENCIÓN ENFERMERÍA APLICADO A PACIENTE CON PREECLAMPSIA

UNITEC UNIVERSIDAD TECNOLÓGICA DE MÉXICO CAMPUS SUR

PROCESO ATENCIÓN ENFERMERÍA APLICADO A PACIENTE CON PREECLAMPSIA

ELABORO: SANCHEZ DIAZ CARLOS ENRIQUE ENF. 7 * A

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ASESORO: ERIKA IMENEZ PEREZ

OCTUBRE! "#

%$INDICE INTRODUCCION.......................................................................................................& OBETIVOS GENERAL................. GENERAL.......................... .................. .................. ................. ......................... ........................................% .......................% OBETIVO ESPECIFICO............... ESPECIFICO........................ .................. .................. .................. ................. .......................................% ...............................% USTIFICACION........................................................................................................' MARCO TEORICO............. TEORICO...................... .................. .................. .................. ................. ................. .................. ..................................7 .........................7 FICHA DE IDENTIFICACION............. IDENTIFICACION...................... .................. .................. ................. ..........................................$$ ..................................$$ DIAGNOSTICO MEDICO............... MEDICO........................ .................. .................. .................. ................. .....................................$" .............................$" INDICACIONES MEDICAS............... MEDICAS........................ ................. ................. .................. ............................................$" ...................................$" CUESTIONARIO DE VALORACION........ VALORACION................. ................. ................. .................. .................. ............................$& ...................$& EXPLORACION FISICA................ FISICA......................... .................. ................. ................. .................. .......................................$% ..............................$% VALORACION DE ENFERMERIA...........................................................................$7 2


ASESORO: ERIKA IMENEZ PEREZ

OCTUBRE! "#

%$INDICE INTRODUCCION.......................................................................................................& OBETIVOS GENERAL................. GENERAL.......................... .................. .................. ................. ......................... ........................................% .......................% OBETIVO ESPECIFICO............... ESPECIFICO........................ .................. .................. .................. ................. .......................................% ...............................% USTIFICACION........................................................................................................' MARCO TEORICO............. TEORICO...................... .................. .................. .................. ................. ................. .................. ..................................7 .........................7 FICHA DE IDENTIFICACION............. IDENTIFICACION...................... .................. .................. ................. ..........................................$$ ..................................$$ DIAGNOSTICO MEDICO............... MEDICO........................ .................. .................. .................. ................. .....................................$" .............................$" INDICACIONES MEDICAS............... MEDICAS........................ ................. ................. .................. ............................................$" ...................................$" CUESTIONARIO DE VALORACION........ VALORACION................. ................. ................. .................. .................. ............................$& ...................$& EXPLORACION FISICA................ FISICA......................... .................. ................. ................. .................. .......................................$% ..............................$% VALORACION DE ENFERMERIA...........................................................................$7 2


NESECIDADES FUNCIONALES SOLO ALTERADOS......... ALTERADOS.................. .................. .................. ..............$7 .....$7 DIAGNOSTICOS DE ENFERMERIA................ ENFERMERIA......................... .................. .............................................$( ....................................$( PLAN DE ALTA........................................................................................................") CONCLUSIÓN........................................................................................................."%

GLOSARIO............... GLOSARIO........................ .................. .................. .................. ................. ................. .................. ...................... ................................."' ...................."' BIBLIOGRAFIAS......................................................................................................"7

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INTRODUCCION L +,-/012+ 34 +,-54,410/ 45 -/246 A0412+1 34 E184/,4/9 PAE; 46 5 <64 -/ 554=/  2< 0/46 34 4184/,4/9! >?3  ?0+5+@/ 45 -416,+410 2/90+2 > -514/ 45 2?+33. C, 4604 PAE ?0+5+@ 5 04/+ 34 =+/?+1+ 4/134/61 -5+23  ?1 -2+4104 4,</@3 ?4 -/46410 -/4425,-6+ 45 2?5 64 3462/+<+/ 218/,4  5 =5/2+1 34 E184/,4/9. E5 -/246 34 E184/,4/9 </2 5 /425422+1! 15+6+6 4 +104/-/402+1 34 306 -/42+66 -/ 3404/,+1/ 56 14246+3346 345 -2+4104. A-5+23 56 -/+12+-+6 345 ,03 2+41098+2: -/ 60 /@1 5 +18/,2+1 46 <40+= > -4/,+04 45 15+6+6 -4/,14104 > /@1,+410 1590+2! 2,-141046 8?13,410546 345 -/246 34 E184/,4/9. L -/4425,-6+ 46 ?1 34 56 2,-5+22+146 ,6 -/42?-1046 3?/104 45 4,</@! 60 -059 ?4 0+414 /+41 346212+3 > 460 62+3  ,50+-546 820/46 34 /+46! 2160+0?>4 ?1 34 56 -/+12+-546 -/<54,6 34 S5?3 P<5+2 41 1?460/ -96! ?4 24 ?1 ,-5+ 46-420/ 34 504/2+146 41 ,?26 6+604,6! ?4 -/3?241 21642?412+6 41 45 <+1,+ ,3/4840! > -/43+6-141  ?1 ,>/ ,/<+ ,/05+33 ,04/1! 8405 > 14105. L 8/42?412+ 34 ,?4/46 =4146 21 -/<54,6 34 -/4425,-6+ 23 =4@  +3 ?,41013  1+=45 ,?13+5. L +12+3412+ 34 -/4425,-6+ 62+5 410/4 "$# 34 56 4,</@6 > =/9 41 03 45 ,?13. L O/1+@2+1 M?13+5 34 5 S5?3 OMS; 460+, ?4 5 +12+3412+ 34 -/4425,-6+ 46 6+404 =4246 ,>/ 41 4


56 -9646 41 346//55 ?4 41 56 346//5536 "!( > #!& 34 56 12+36 =+=6 /46-420+=,4104;.

OBJETIVOS GENERAL E5<// ?1 P/246 A0412+1 34 E184/,4/9  ?1 -2+4104 21 -/4425,-6+ -/ -34/ -5+2/ +104/=412+146 34 4184/,4/9 14246/+6 > -/-/2+1/56 34 ,14/ 5960+2 -/ ,4// 6? 65?3 > 210/+
OBETIVO ESPECIFICO J V5// 45 4603 34 65?3 34 5 -2+4104. J E5<// -5246 14246+3346 34 5 -2+4104; J E42?0/ 56 2?+336 34 4184/,4/9

JUSTIFICACION E5 PAE 46 ?1 4//,+410 ,4035+2! /1+@3 > 6+604,0+2 ?4 16 >?3  4104134/ 45 -342+,+410 34 1?460/ -2+4104! 69 ,+6, -/-/2+1/54 56 2?+336 414/546 > 46-4298+26 -/ 6? /42?-4/2+1 60+6820/+. A5 45<// 4604 -/246 34 4184/,4/9 64 2124/ 45 4603 34 65?3 34 5 -2+4104 21 -/4425,-6+ > 6? 4603 41 45 -4/+3 34 -6 246/4. E5 1,4/ 34 ,?4/46 ?4 -/464101 +-4/0416+1 41 45 2?/6 345 4,</@ -?434 460+,/64 5/4343/ 345 $#! 21 +12+3412+ 34 60 45 "# 6+ 5 -2+4104 46 1?59-/. L -/4425,-6+ 46 5 2,-5+22+1 ,3+2 ,6 8/42?4104 345 4,</@!  6+3 41210/3 41 %  $" 34 56 4,</@6. L -/44425,-6+ 210+1? 6+413 ?1 +,-/0104 2?6 34 ,/<+5+33 > ,/05+33 ,04/1 8405! -/ 56 484206 > 21642?412+6 ?4 26+1 41 /16 > 6+604,6 2, 93! 2/@1! /+1 > 41 5 2?52+1.

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MARCO TEORICO PREECLAMPSIA L -/4425,-6+ 46 ?1 346/341 ,?50+6+60,+2 +3+-0+2 46-4298+2 345 4,</@ > 345 -?4/-4/+ 41 ?,16. M6 -/42+6,4104! 46 ?1 4184/,433 2?63 -/ 5 -52410! -?46 64  3462/+0 41 4,</@6 3134 4+6041 04+3 0/8<560+2 -4/ 1 8405 4,</@6 ,5/46 2,-5406;. E6 5 +-4/0416+1 /04/+5 HTA; -/-+ 345 4,</@ > 64 2/204/+@ 34,6 -/ -/04+1?/+! 62+3  1  434,6. E60 4184/,433 8420 34 -/484/412+  56 1?59-/6! -/424 346-?6 34 56 "& 64,16 34 4602+1 > 46 09-+2,4104 /4=4/6+<54 41 45 -6-/0 +1,43+0. L -/4425,-6+ 46 ?1 4184/,433 34 /+41 346212+3 > ,?50+820/+5 2?> 0/0,+410 348+1+0+= 46 45 -/0! 34,6 34 64/ 2?65 34 /4-4/2?6+146 6 45 /42+1 12+3.

ETIOLOGIA 7


N 4+604 ?1 2?6 46-4298+2 34<+3  460! 64 5 341,+1 2, 4184/,433 34 56 04/96. E10/4 64 ,412+11 4601 5 -52410 1/,5! +1,?12,-546 41 5 -52410 546+1 345 413045+! 820/46 2+00+26 ?4 84201 56 25?56 413045+546! 1/,5 ,40<5+6, 34 -/60513+16! 410+2! 402..

34

5

-/4425,-6+! 5 56 ?4

FACTORES DE RIESGO Maternos:   

E33 ,04/1 ,41/ 34 "# > ,>/ 34 )% 6. R@ 14/.  H+60/+ -4/615 34 PE 41 4,</@6 104/+/46;. P/46412+ 34 5?16 4184/,43346 2/1+26: +-4/0416+1 /04/+5! <46+33! 3+<4046 ,455+0?6! /46+60412+  5 +16?5+1! 4184/,433 /415! 14?/8+ 0/6 4184/,43346 ?0+1,?146 6913/,4 10+ 86859-+3 642?13/+;! 0/,<8+5+6 > 3+65+-+34,+.

Relacionados con la gestación en curso:  



P/+,+/=+34@  4,</@ 34 1?4= 2,-4/ 64?5. S -5++3/,1+6;. E,</@ ,5/ 41 1?59-/.

Amientales:       

M51?0/+2+1 -/ 348420  -/ 4246. E626 +1460 34 252+ -/4=+ > 3?/104 5 4602+1. H+-,1464,+ > 348+2+412+6 34 @+12 > 64541+. A525+6, 3?/104 45 4,</@. B 1+=45 62+421,+2. C?+336 -/410546 348+2+41046. E60/6 2/1+2. 8

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DIAG!"STICO S4 14246+0 +60/+ 2591+2 340553! -0+,6 210/546 -/410546 -/ 340420/ -/0?1,4104 5 -059. E1 5 1,146+6 34<4/1 /424/64 306 34 56 10424341046 8,+5+/46! 345 2,-/0+,+410 34 5 -/46+1 /04/+5 41 56 4,</@6 104/+/46 6+ 56 ?<+4/! > 41 26 34 4+60+/ HTA 41 4556 -/42+6/ 5 -2 345 4,</@ 41 5 ?4 64 -/46410.

E1 45 4,41 896+2 64 =5// 45 2,-/,+6 34 212+412+! 5 -/46412+ 34 )  & /?+3 ?4 4-/4641 +16?8+2+412+ 2/392! 5 -/46412+ 34 434,6 41 2/! ,16 > /4+1 5?,<62/. T,<+1 46 +,-/462+13+<54 4,+1/ 45 813 34  3134 64 -?434 <64/=/ =62160/+22+1 /04/+5/ > 45 +12/4,410 34 2,-//5 21 56 454=2+146 41 56 26?506 6?<642?41046! 34 460 ,14/ 64 3+160+2/ -/0?1,4104 > 64 -5+2/ 45 0/0,+410 46-4298+2

TIPOS Preeclam#sia le$e. -/46+1 /04/+5 34 $&## ,,H  ,6! 346-?6 34 5 64,1 "# 60 )# 396 -6-/0! 21 -/04+1?/+ 34 ,6 34 )## , 41 "& /6. Preeclam#sia se$era. -/46+1 /04/+5 34 $'#$$# ,,H  ,6! 346-?6 34 5 64,1 "# 60 )# 396 -6-/0! 4+604 -/04+1?/+ ,>/ 34 % / 41 "& /6! -/46412+ 34 24854! 28416! 868416! 434, 414/5+@3. Eclam#sia. -/46+1 /04/+5 ,>/ 34 $(%$$% ,,H! -/04+1?/+ ,>/  $# / 41 "& /6! 460?-/! -/3+3 -/2+5  005 34 5 =+6+1! 35/ 4-+60/+2 41 <//! +-4//4854+ 414/5+@3 > 21=?56+146 > 4603 34 2,! 346-?6 34 5 64,1 "# 60 )# 396 -6-/0.

9


S%ndrome de &ell#. 46 5 -/46412+ 34 4,5+6+6! 454=2+1 34 41@+,6 4-0+26 > 0/,<2+0-41+ 41 -2+41046 21 4184/,433 +-4/0416+= +13?2+3 -/ 45 4,</@. TRATAMIE!TO

P/4425,-6+ 54=4. E5 ,3+2 345 -/+,4/ 1+=45 34 0412+1! /45+@/ 45 3+160+2 -/46?10+= 34 2?5?+4/ 0/60/1 +-4/0416+= 62+3 5 4,</@ 6+1 -/462/+-2+1 34 ,43+2,4106 10++-4/0416+=6 -/ 4=+0/ 218?6+146 5 ,,410 34 256+8+2/ 5 4184/,433 +-4/0416+=. S4 48420?/ 5 /484/412+ 34 5 -2+4104  ?1 64?13 1+=45 34 0412+1! 21 +60/+ 2591+2 2,-540 > 10 34 0/653 -/ 6? ,14 > 0/0,+410 348+1+0+= 60 5 /465?2+1 345 4,</@. P/4425,-6+ 64=4/. L /484/412+ > 0/653 34 ?1 -2+4104 21 -/4425,-6+ 64=4/  21 +1,+1412+ 34 425,-6+ 34<4 /45+@/64 21 ?/412+ > 5 /46-420 64 216+34/1 56 6+?+41046 ,43+36 04/-?0+26: • • • •

•

•

A>?1 R4-6 41 342<+0 504/5 +@?+4/3 V41 -4/,4<54 21 =4125+6+6: P6/ 2/ /-+3 )## 22 34 65?2+1 5?263 5 $# . C10+1?/ 21 65?2+1 5?263 $ ### 22 5 $#  -/ -6/ 41 ( /6. C522+1 34 613 34 F54>  -4/,1412+! 2?10+8+2/ =5?,41 > -/04+1?/+ ,43+104 0+/ /420+= M43+2+1 34 5 -/46+1 /04/+5 23 $# ,+1?06 > 8/42?412+ 2/3+2 8405

SI!TOMATOLOGIA

10


*&i#ertensión arterial: $&##  ,6 50. U1 +12/4,410 34 5 -/46+1 3+6054 34 $%  ,6  ?1 +12/4,410 34 5 -/46+1 6+605+2 34 )#  ,6. *Presencia de #rote%nas en su orina: )## ,+5+/,6 41 ?1 /425422+1 34 "& /6. *Edema de manos' #ies ( E6-42+5,4104 cara: 5/4343/ 34 56 6! ?4 64 <64/= ,43+104 5 8/,2+1 34 ?1 ?42 5 -/46+1/ 21 ?1 343. U1 -2 34 +12@1 46 1/,5 41 ?1 ,?4/ 4,</@3! -4/ ?1 434, 34 346//55 )Ce*alea

6<+0

46

6+4,-/4

66-426.

*!auseas o dolor en la #arte su#erior del adomen  Q?4 5?16 =4246 64 218?134 21 +13+460+1! 35/ 34 =4692?5  /+-4. S+1 4,</! 5 -/46412+ 34 1?646 41 56 50+,6 8646 345 4,</@ 1 46 1/,5. +S,ita ganancia de #eso: 34 $ +5  ,6 41 45 5-6 34 ?1 64,1 +Disnea

FICHA DE IDENTIFICACION D06 345 -2+4104

N, A-455+3: G1@546 L+1 F434/+2 S4/=+2+: O<6040/+2+ F42 34 +1/46: "$$#"#$% 11


N?,4/ 34 2,: $" E33: "$ 6 E603 C+=+5: 263 G/3 34 I160/?22+1: B2+554/0 P/846+1: A, 34 C6 D,+2+5+: E,+5+1 @-0 1 $# 25. B?41=+60 R45++1: 205+2 L?/ 34 12+,+410: M+2 D! F S4: F4,41+1 P46: (" K T55: $!'7 M06 M0+= 34 I1/46: $; P/4 425,-6+ "; E,<. "# 64,16 34 4602+1.

DIAGNOSTICO MEDICO S4 0/0 34 -2+4104 84,41+1 34 "$ 6 34 433! -/2434104 34 5 C+?33 34 M+2! I G460 21 842 34 50+, /45 FUR; "(%"#$%! 842 -/<<54 34 -/0 FPP; #&#""#$'! -/4641013 34634 24 2?0/ 396 24854 +10416! =+6+1 <//6! ,0+= -/ 45 2?5 -604/+/  5 =5/2+1 ,3+2 64 342+34 6? +1/46 21 3+160+2 ,43+2: 12


$; P/4425,-6+ G/=4 "; E,<. "& 64,16 34 4602+1.

INDICACIONES MEDICAS

13


CUESTIONARIO DE VALORACION.

14


E!LORACION FISICA E-AME! FISICO. C/*alo caudal

P2+4104 34 "$ 6 34 433! 64 <64/= 41 6?6 0/46 -516 -6+25+26  0+4,-! 46-2+ > -4/61;! 21 24/412+ 41 6?6 -416,+4106! 64 4-/46 25/! 25</3/! 21
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Cae0a: A 5 +16-422+1 1/, 2485+2 6+1 546+146 1+ 2+20/+246! 2<4556 5/6! -<536! 25/ 14/! 5+,-+! 2?4/ 2<455?3 6+1 64<//4 1+ -43+2?56+6. A 5 -5-2+1 1 -/46410 @16 35/66! 4,0,6 1+ ?13+,+4106! 2<455 <+41 +,-5103 > /?46.

Res#iratorio: !ari0: A 5 +16-422+1 -4/8+53! 6+,0/+2! 866 16546 -4/,4<546 6+1 -/46412+ 34 642/42+1 5?1. N 35/6  5 -5-2+1.

1oca: A 5 +16-422+1 -4?4! 5<+6 /?466 4 +3/036! 541? ,=+5! ,43! -+4@6 3410546 2,-5406 21 -/46412+ 34 2/+46 34105! 41296 1/,546.

Cuello: A 5 +16-422+1 2/0! ,=+,+4106 =5?10/+6! 6+1 -/46412+ 34 546+146 1+ 2+20/+246. A 5 -5-2+1 15+6 1 +185,36 1+ 35/66.

Tóra2 Res#iratorio: A 5 +16-422+1 6+,0/+2! 6416 <+41 346//5536! 6+1 546+146. A 5 -5-2+1 1/,4-16+<54! 1 64 -5-1 ,66  1+=45 +5/ 1+ 34 6416! 6416+<+5+33 1/,5. A 5 ?62?502+1 8/,+0 =25 1/,5! 8/42?412+ /46-+/0/+ 525+@<54 "$ /46-+/2+146 -/ ,+1?0! 15


,?/,?556 =46+2?5/46 -/4641046 41 ,<6 4,+0/ -?5,1/46 6+1 /436.

•

Tóra2 Cardio$ascular: A 5 ?62?502+1 /?+36 2/3+26 /90,+26 6+1 6-56 1+ 5-46! 8/42?412+ 2/3+2 525+@<54 34 # -?562+146 -/ ,+1?0.

Metaólico 3 tegumentario •

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-5+34@ 2?014 2410?3! -+45 ,/41! Piel: 1/,0/,+2! 04,-4/0?/ )7!% C.

+3/03!

Cara: A 5 +16-422+1 21 434, 54=4. A 5 -5-2+1 1 -/46410 8=4 1+ @16 35/66! 6416+<+5+33 6+1 504/2+1 5?1! 6416 -/16546! 8/10546 > ,+5/46 6+1 504/2+1 -/4104.

Adomen: A 5 +16-422+1 /=+3! 3+60413+3 21  3+6,+1?+36. A 5 -4/2?6+1 61+36 0+,-1+26 -/4641046.

Genitales: A 5 +16-422+1 -/4104,4104 34 6-420 > 218+?/2+1 1/,5.

Miemros su#eriores: A 5 +16-422+1 6+,0/+2! ,=+,+4106 =5?10/+6 6+1 1,596!  1+=45 34 ,16 -/46410 434, 54=4! 3436 34 56 ,16 2,-5406! ?6 2/06 > 5+,-+6! =9 -4/+8/+2 20404/+@3 41 ,1 +@?+4/3 > /42+<4 +3/02+1 -/4104/5. A 5 -5-2+1 6+1 -/46412+ 34 @16 35/66! ?6 <+41 +,-51036.

16

UNITEC UNIVERSIDAD TECNOLÓGICA DE MÉXICO CAMPUS SUR PROCESO ATENCIÓN ENFERMERÍA APLICADO A PACIENTE CON PREECLAMPSIA •

Miemros in*eriores: A 5 +16-422+1 6+,0/+2! ,=+,+4106 =5?10/+6 1/,546! 6+1 -/46412+ 34 =/+246!  1+=45 -/40+<+5 -/46412+ 34 434, 54=4! 3436 34 56 -+46 2,-5406! ?6 2/06 > 5+,-+6. A 5 -5-2+1 1 -/46410 8=4 1+ @16 35/66! ?6 <+41 +,-51036.

VALORACION DE ENFERMERIA NESECIDADES FUNCIONALES SOLO ALTERADOS $. R46-+/2+12+/2?52+1: /48+4/4 1 041 -/<54,6 34 93! 1/+@ > =+60 65 2?13 ,4 6?<4 5 0416+1 ?4 =4 460/455+06 > <//6. 17


". P4/24-2+1 > ,14 345 4603 34 65?3: -2+4104 /48+4/4 > 6+4,-/4 4 6+3 61! 34 5 ?4 4 6?8/+3 46 34 /+-46 > 2?13 ,4 3 8?4/04 => 5 ,3+2 >  =4246 64 ,4 6?<4 5 0416+1 2?13 ,4 ,5460! > 1?12 ,4 4184/,4 41 5 1+4@.

). C,4/ > <4<4 34 8/, 342?3: /48+4/4 2,4/ 2?0/ =4246 5 39! > 2, 34 03.

&. E5+,+12+1: R48+4/4 ?4 24 -?-? ?1 65 =4@ 5 39 -4/ 6+ /+1 <60104.

%. M=4/64 > ,10414/ ?1 -60?/ 342?3 /48+4/4 ?4  =4246 ,4 6+410 2163 2?13 65  2,+1/ 21 ,+ 46-6.

'. D/,+/ > 346216/: R48+4/4 2?13 460> 41 ,+ 26 ,4 54=10 0/34! 3?4/, 5 ,43+ 39 > 41 5 124 ,4 2?460 ,?2 -/?4 6+410 ,5460+

7. R5  R452+146: R48+4/4 =+= 21 ,+ 46-6 > 21 ,+ ,,! 1 6 ? /9 6+ 1 0?=+4/  ,+ ,, 21,+! ,4 5 554= <+41 21 ,+ 8,+5+

(. S4?5+33 > /4-/3?22+1: R48+4/4 ?4 ,4 346//554  56 0/424 6!  56 "# 659 4,</@3! > 1 041 ,?2 /452+1 64?5 21 ,+ 46-6 -/ 2?+3/ 34 ,+ 4,</@.

. A?0 -4/24-2+1  A?0 C124-0: > ,4 216+34/ ?1 ,?4/ <+41 20+= -4/ 34634 ?4 460> 4,</@3 1 -?43 24/ ,?26 266 > -/48+4/ 460/ 2603. 18


$#.O2+! 20+=+3346 /42/40+=6.: R48+4/4 ?4 2?13 ,4 6+410 ,5 ,4 -1 0416 > 65  3/ ?16 =?4506 -/ 0/1?+5+@/,4.

$$. V5/46 > C/4412+6: R48+4/4 ?4  =4246 =>  ,+6 56 3,+1 -/ 3/ /2+6  D+6 -/ 03 5 ?4 041

DIAGNOSTICOS DE ENFERMERIA

DOLOR AGUDO RELACIO!ADO CO! AGENTES LESIVOS MA!IFESTADO POR CAMBIOS EN LA PRESION ARTERIAL O<40+=6  /46?5036 ?4 64 46-4/1 <0414/ NOC;

I104/=412+146 NIC;

F?10,4102+1

$'#%; MANEO DEL DOLOR ##$)"; CONTROL DEL DOLOR

""$#; ADMINISTRACION DE ANALGESICOS ")#(; APOO EMOCIONAL ")(#; MENEO DE LA MEDICACION

19

E=5?2+1

R42124/ 5 -/46412+ 4 +10412+33 345 35/ 34 1?460/ -2+4104! 5+=+/ > 3+6,+1?+/ 45 P?10?2+1 A20?5: " 35/  ?1 1+=45 34 054/12+ ?4 64 P?10?2+1 D+1: % 24-0<5 -/ 45 -2+4104 > ?,410/ 45 218/0 > <+41460/ 3410/ > 8?4/ 345 /4 6-+05/+


RIESGO DE INFECCION RELACIO!ADO CO! ALTERACION DE LA DEFENSAS PRIMARIAS RUPTURA DE LA PIEL CESAREA 4 MA!IFESTADO POR PROCESO DE CICATRIZACION O<40+=6  /46?5036 ?4 64 46-4/1 <0414/ NOC;

I104/=412+146 NIC;

F?10,4102+1

'%%#; PROTECCION CONTRA LAS INFECCIONES #7#"; ESTADO INMUNE

")##; ADMINISTRACION DE MEDICACION

20

E=5?2+1

L=/64 56 ,16 1046 > 346-?6 34 23 20+=+33 34 2?+336 5 -2+4104. U6/ ?1046 641 P?10?2+1 A20?5: ) 5 4+41 56 1/,6 34 P?10?2+1 D+1: % -/42?2+1 ?1+=4/65. M+1+,+@/ 45 210+ 34 0/16,+6+1 34 41046 +18422+66


LACTANCIA MATERNA INEFICAZ RELACIO!ADO CO! INTERRUPCION DE LA LACTANCIA MA!IFESTADO POR INSUFICIENCIA DEL LACTACTANTE PARA SUPCIONAR EL PECHO O<40+=6  /46?5036 ?4 64 46-4/1 <0414/ NOC;

5 $(##; CONOCIMIENTO: LACTANCIA MATERNA

I104/=412+146 NIC;

$#%&; AUDA EN LA LACTANCIA MATERNA

21

F?10,4102+1

L 5424 ,04/1 46 45 5+,410 +345 -/ ?1 /42+1 12+3! -4/ 5 52012+ 1 460 4410 34 3+8+2?50346

E=5?2+1

P?10?2+1 A20?5: ) P?10?2+1 D+1: %


RIESGO DE NIVEL DE GLUCEMIA INESTABLE RALACIO!ADO CO! EMBARAZO O<40+=6  /46?5036 ?4 64 46-4/1 <0414/ NOC; •

ESTADO NUTRICIONA L: INGESTA ALIMENTARIA  DE LIQUIDOS

I104/=412+146 NIC;

F?10,4102+1

"$"#;

L6 <+06 5+,410/+6 61 ?1 820/ 3404/,+1104 345 4603 34 65?3 6+60+/! +18/,/! 8/,/! 43?2/! 646// > 3+460//! 34634 45 6-420 <+ -6+262+5

MANEO DE LA HIPERGLUCEMIA %'$&; ENSEWANZA: DIETA PRESCRITA

22

E=5?2+1

P?10?2+1 A20?5: ) P?10?2+1 D+1: %


DETERIORO DE LA ELIMINACION RELACIO!ADO CO! EL TIPO DE INTERVENCION QUIRURGICA

O<40+=6  /46?5036 ?4 64 46-4/1 <0414/ NOC; #%#); ELIMINACION URINARIA

I104/=412+146 NIC;

F?10,4102+1

$(7'; CUIDADOS DEL CATETER URINARIO #&(#; CUIDADOS DE LA OSTOMIA

23

L ,1+0/+@2+1 34 56 21601046 =+0546 46 ?1 820/ 25=4 41 45 64?+,+410 460/+20 345 4603 2591+2 345 -2+4104

E=5?2+1

P?10?2+1 A20?5: ) P?10?2+1 D+1: %


!LAN DE ALTA $. •

•

RECOMENDACIONES

A1046 34 3/ 34 50 ,3+2 64 34<4 3/ /+4102+1 5 -2+4104 > 8,+5+/46. M10414/64 25,3 -/ ?4 45 4603 34 16+433 3+6,+1?>! /452+1 41643.

•

I14/+/ 5 3+40 +- 63+2 +13+23

•

M10414/ 5 ++414 2/-/5 3+/+,4104.

•

•

C?,-5+/ 21 56 ,43+2,4106! 45 210/5 ,3+2! 5 3+40 +13+23! 5 /4/46/ 5 / A5 -/46410/ 24854! =/0+6  =+6+1 <//6! 2?3+/ +1,43+0,4104 5 ,3+2.

2. CUIDADOS PERSONALES

•

R4-6 41 2, > 2?+336 -4/61546 41 45 /

•

V++5/5  ?6043 >  6? <4< 24


3. RECOMENDACIONES SOBRE LA DIETA.

L /42,413<54 46 ?455 5+,4102+1 ?4 2?,-54 21 56 -/+12+-+6 ?4 5 1?0/+2+1 460<5424 > ?4 /4?52+1 34 56 04+36! 69 2, -/ 5 /4-6+2+1 34 5 414/9 -4/3+3. P/ 5// 45 21?10 34 -50+556 ?4 218/,1 5 5+,4102+1 3+/+! 34<4 /4?1+/ 56 6+?+41046 C/204/960+26: 









Com#leta6 E1 5 3+40 ?4 <+0?5,4104 210+4141 036 56 1?0/+,4106! 56 ?4 -/01 414/9! 56 ?4 -/01 -/04916 > 56 ?4 -/01 =+0,+16 > ,+14/546. E7uilirada6 E6 5 3+40 41 5 2?5 56 1?0/+,4106 ?/31 -/-/2+146 -/-+36 410/4 4556! ?4 34,6 64 < 41 65! 1 4246+= 41 254604/5 > 50 41 8+ 210,+11046.

Su*iciente6 46 ?455 3+40 ?4 0+414 5 210+33 34 5+,4106 ?4 ?1 +13+=+3? 34<4 216?,+/ -/ 2? 346//55/64 41 0+4,- /@1<54. 8ariada6 E6 ?455 3+40 ?4 +125?>4 3+84/41046 5+,4106 > -50+556 41 5 2,+3. E60 =/+2+1 64 -?434 5// ?0+5+@13 ?1 ,+6, 5+,410 41 3+84/41046 8/,6 > 2,460+<546 -/-+6 34 5 4602+1.

4. RECOMENDACIONES SOBRE LOS MEDICAMENTOS.

T3 -/243+,+410 34 5 6?,+1+60/2+1 > ?0 6?,+1+60/2+1 34 ,43+2,4106 ?4 64 1 -/462/+0 34<4 64?+/ 4606 2+12 -66: $. M43+2,410 2//420 ". D6+6 2//420 ). V9 34 3,+1+60/2+1 2//420 &. H/ 34 3,+1+60/2+1 2//420 25


%. P2+4104 2//420 

A1046 34 3,+1+60// 2?5?+4/ ,43+2,410 460/ 64?/ 34 56 10424341046 34 54/+6  8/,26.



E-5+2/ 5 4184/, 45  56 ,43+2,4106 ?4 64 5 =1  3/ > 34 56 /46?5036 ?4 64 46-4/1.

 

E-5+2/ 0,<+1 2?5?+4/ 48420 3=4/6 46-4/3. A1046 34 3,+1+60// 45 ,43+2,410 -/ 5 <2! > ?4 24/2+//64 ?4 45 -2+4104 0+414  3+6-6+2+1 ?.



A5 64/ 45 ,43+2,410 ,?> 346/3<54 5 -53/! 8/4@2 ?  120/! 6+ 1 4+604 210/+13+22+1 -/ 5 3+40  5?1 +12,-0+<+5+33.



S+ 45 ,43+2,410 0+414 48420 643104! /45104  0/1?+5+@104! 64 54 -+34 5 -2+4104 ?4 /+14! 62?/424/ 5 <+02+1 > 3+6,+1?+/ 56 4609,?56 404/16! 1046 34 3/54 2+4/0 ,43+2,410.



H> ?4 5=/64 56 ,16 41 2?5?+4/ ,+1+60/2+1 34 ,43+2,410 -/ 2?5?+4/ =9 -/ 4=+0/ 5 -/-2+1 34 +18422+146 34 ?1 -4/61  0/.

CONCLUSI"N L -/4425,-6+ 6?454 -/46410/64 41 -/+,+4606  41 ,?4/46 21 4184/,43346 2/3+=62?5/46! E6 ?1 0/60/1 345 4,</@ ,43+104 5 +-4/0416+1 /04/+5.

L -/4 425,-6+ 46 ?1 0/60/1 ?4 -?434 2,-5+2/64 > 554/ 60 5 ,?4/04 34 5 ,3/4 > 45 840! 21 5 -5+22+1 345 -/246 34 0412+1 34 4184/,4/9! 16 -4/,+0+ =5//  5 -2+4104 21 306 <40+=6 > 6?<40+=6!  0/=6 34 5 26


410/4=+60 /45+@3 > 45 4,41 896+2 414/5! -/ 5 +3410+8+22+1 34 6?6 14246+3346!

GLOSARIO

$. Des#rendimiento #rematuro de la #lacenta: S4-/2+1 -/4,0?/ 34 5 -52410 8405 345 04/ 21 +,-5102+1 1/,5.

". Eclam#sia: T/,+1 414/5 ?4 346+1 56 21=?56+146 251+201+26 34 2/204/ -/960+2! 64?+36 414/5,4104 34 -/3+3 34 212+,+410 > 34<+36  2?66 3+=4/66. 27


). Eclam#sia gra$%dica: L <64/=3 41 4,</@36 ?4 -/464101 ?1 2?3/ 34 04,+ /=93+2 > ?4 64 2/204/+@ -/ +-4/0416+1 /04/+5! 5 2,.

&. Edema: A2?,?52+1 4246+= 34 59?+3 64/5/ -4/,4<+5+33 34 56 -/4346 2-+5/46 ? <60/?22+1 34 56 =96 5+180+26. L +12@1 -/3?2+3 64 2/204/+@ -/ 2164/=/ 5 ?455 34 5 -/46+1 345 343.

%. &i#ertensión: A?,410 345 01  0416+1 41 414/5 46-42+5,4104 ?,410 34 5 -/46+1 =62?5/  61?914.

'. Oliguria: S42/42+1 348+2+4104 34 /+1.

7. Placenta: Ó/1 /431343 -51! <513 > 46-16! 34 /6/ > 0, =/+<54 6+0?3 41 45 +104/+/ 345 04/ 3?/104 5 4602+1 > -/ 45 ?4 64 460<5424 45 +104/2,<+ 1?0/+0+= 410/4 5 ,3/4 > 45 840. S4 346//55  56 0/46 ,4646 34 5 4602+1! 345 2/+1 345 4, 34 5 342+3? <65 345 04/. C160 34 ?1 -/2+1 +104/1  8405! 0-+@3 -/ 45 2/+1 > -/ 45 ,1+6! 41 5 ?4 64 /,+8+21 56 =66 345 2/31 > ?1 -/2+1 404/1  ,04/1! 2?> 2/ 34/4104 5 04/ 46 / > 460 3+=+3+3 -/ 6?/26 -/8?136 41 5
(. Primigr9$ida: M?4/ 4,</@3 -/ -/+,4/ =4@.

. Proteinuria: P/46412+ 34 -/04916 41 5 /+1 5

$#. Segmentación: C16+604 41 ?1 64/+4 6?246+= > /-+3 34 ,+06+6! ?4 213?24  5 -/3?22+1 34 25?56 23 =4@ ,6 -4?46! 341,+136 <560,4/6.

BIBLIOGRAFIAS $. 00-6:-/4@+.2,1@=2%@/#3--/246340412+1344184/,4/+3+/++3 ?1-2+41042 ". 00-:65?3.43,4+2.<.,0,53206?4+243?22+1-/4425,-6+.-38 ). 00-:.62+45./.,-38-/="71&="71&.-38 &. 00-:/4-6+0/+.?.43?.42<+060/4,/43?"#)7$TESIS "#COMPLETA.-38 %. 00-:46.65+346/4.140-5?0+4//4@,43+13+<40464602+15 3+-6+0+=6Y/45043$ '. 00-:.2414042.65?3.<.,3462/6-2C05M460/%('[GP C[E184/,4/+41-/4425,-6+%('GRR.-38 7. 00-:.,1/8+6.2,0/<6(#-/425,-6+/=426 25+1+2-/425,-6+/=42625+1+2".60,5 (. 00-:.113.46-51-?<5+2.--Y ?/5+37$4)234&#&&&8((&&'32)#(<<7783<'7323$ . 00-6:.25+1+23,.2,65?3%###((.0,5 $#. 00-:.2414042.65?3.<.,3462/6-2C05M460/%('[GP C[E184/,4/+41-/4425,-6+%('GER.-38 $$. 00-:.65?3,410540/4,3?/.2,8+543,+132?,4106D2?,410 6[T421+26[SESPLANES[DE[CUIDADOS[ENFERMEROS[EN[SM.-38 29

Trabajo Final Preeclampsia

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