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## PROCESO DE ATENCION DE ENFERMERIA

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## cEtapas del proceso enfermero. c

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## ñc eva ación c  c

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## Requerimiento para aplicar proceso enfermero. c

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c   cc3cc c
+
{c
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c3
cc   cc
7 c  c
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 c2 c   6cc c
3,cc
4c c cc ,c
c c
c cc c2c7 6c
 c
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cc 3c  c c   c
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cc
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cc  +c
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
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 +c- c
+ 3 c
3cc- 8  {c c


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c  ccc 
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cc
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6c
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  +6c c  cc8 c
c2 c 
c7 c  c

c {c
ccc,
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c c c
76cc cc 5c3+ {c
; cc- c c
 c  c

c
 c cc+ cc
 
c c   +6c- cc3c 
cc c

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   6cc
32cc
c
 {c
c c+ c cc + cc c7 c
c c 6c- c
3
c c cc ccccc+ c6cc- c 2c
  cc c+ c
c cc53 cc c
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c  c  6c- c  c c  2c c  c  c c+c

cc  c+ 6c c  cc
 c
c c
- 3 c
      6cc cc  c<  c
=c
cc+3c
 c {c
ñc c- 8 c  5c

cc7 cc c c c+ 
cc
cc  c+{cc
;c c c7cc+ 8cc c c2c  6c
c
c
Ã
ñ {cc
HI JK
cc  c c
c c c
;c c c 
cc3 
4c 
cc c2c ccc ,c

c c
c c2c  c 
cc c7c3 6c  cc
c c
cÃ
 ñ c 6cc5c  6c c2c  c  {c c
c  cc c+  6cc3c cc c c c 3c,6cc
  cc5c   6c cc  c- c 
c{ c
;c c3 
4c+  cc c
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ñc 3c
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4c  cc+c
c3cc   6c c

  
ccc  c
cc c c
c c  c< c
c
 6c  c c+ 
6c c 3  c
c   ={ c
ñc2c
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4c7 c 8cc  c
c c  c c c
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6c
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> c
c cc
cc  2cc  6 c 
cc c cc
c c c c3c c c cc  c c
 5c
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 c
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c
cc 4
c   6cc
  c
cc 3c cc c cc+ c {cc
cc

c<
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3 
c< =c
Ãc<Ã=c

c JJJJJ{{  c

## c JJJJJ{{ c3 c cc1 

+
c

c JJJJJ{{ c3 c
c   c

;  c
 c

## c cÃc  c+cc 3   c

cÃc
 +  cc c 
c
cÃcÃ 2c    c
ÃcÃ 2c  cc c  c ccc  ccc

"cCOM L
CAC
ONc
c
; 
c ccc c + {cñc+cc  cccc+ c

c

ccc
c c {c

## Comp icacionesccranea esc c

c c c 6cc7c
c c+  6c c 3c c  5cc
   c
 c cc3  c+  cc cc
c  {c3,ccc
3c  c c
cc  c 
{ c
cc
c

c
LM NO
cc  c c
c c c
; 
c 3c

c  c
c-   c
c3 c7 c c 
c
{c3c

ñc+c
c c+  c 
c  c c
 6c
   
c  6c   cccc+ cc ,c
c{ c
c c  c 
c+ c c  3 +3 c  c
ccc

## c c+  c c 

cc c c  

{cc
 c c 6cc

c , c
3cc, cc3ccc 3  c
 
c
cc 26cc c 
c c  cc 6cc+c
c
cc
3 c3{c
cc
Comp icacionescorbitarias c
cC 9c
c c  c+  c
cc3 c c 
 cc
+

c
c c {cc c 
ccc 3c
cc c
 c
ccc 6c c  6c 5c+  cc c> 6c
3
cc- cc
 c c c 
c c c5c
 
ccc3 c  c  5c

c c c
 
cc6cc  c
  { c
 8c  cc 6c 
c c
 c 
c
c   c

## cc3 cc c  

 c

c
c+  c
cc5 c
c c<   ={c c
2 cc
c
cc c
c5
c  cccc
c+  c
c
 c  6ccc c c  c c 4  c c
cc {c

##  c7 c +   26c

 c
cc6cc ccc    c
 c
c 4 {c
c 
 c
6c c c 6c c c   c 
{c  c
 c c
 c
cc 
 c c c c
+   cc  c  { c
c cc
c c 
c
c 6c 
c 3c£c
 3  c  c5c 36c c c  c 
c cc
   cc6c c  cc
c
c {cccc 3 6c
. 9c
c c c+2c c  cc 9c- 
3c c { c
cc
 c  c c

.=cñc  c
cc+cc  
c 3  c c
cc  c 3 c
cc3 c 3 3  cc
0cc3 c 3  c
cc
=cc  c
cc+cc3  c+  c c
£=cc  cc c  { c

## c c 6cc

    c
3ccc3cc 
c  c
c
 6c c  c
c 7c ccc 6ccc6c
PQ RS
cc  c c
c c c
ccc c75c   c +2c 3 6c  +2c
  
6c c c , c c8 ccc
    c

+ccc 3cc 
c
c7 c
c  cc
cc
   6ccc 3{ c
cc

c c 2 cc  c
c 
 c  ccc  c c   c
cc
c

c
c c
c +   26c c   c
c  
c 3  c  ccc
    6cc
ccc
c cc c
c 
c
c c c  
{ c

c   c
3ccc3cc 3  c 5c
 
c6cc c
 36c  8cc   cc 3 c
cc c6c 3 c c
3 
c c {cc
ñc 2c c cc
c  cc c c
4c
 
c
c
  
c 
c cc2c 
cccc c
cc+ c
c c
3 6cc
4c
c cc ,c
c cccc5
c  cc
c8  c 3 {cc
c  c cc c  
6c c,7 6cc
c + { c
cc
Otrasccomp icaciones c

c    c
c c  c+6c cccc 

c
cÃ   c
c c   c6c  cc 2
c<    c
c
=cc+ c< cc  c
cc  ={cc c
cc
 c5c+  c
c+  c  +6c 
cc  c c c


c
c
+c c 
c7 c +  c   c
3{c
c    c7 c cc 

c c  ccc
c
c3 -  cc
cc3 - {c c c 5c+  c
cc cc  c  +{ c

## Res miendocComp icaciones: c

Ã

ñ c5c+  c  c c+   c

 ?  c
;
 ?  c

Ã c

7 
c
 
c
3c

 

c5c+  c c 
ccc> c

c c   c
cÃñ ñ  c  

c
c
Ã c   
 c
c  
 c
TU VW
cc  c c
c c c
  ñ  c1  c
Ã
ñ c
cc
 ;

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 ? ;

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  c
;

 c ; 
  c

## c3 -  c

cc3 - c
cc

c
XY Z[
cc  c c
c c c
M
MAc

Patología

c 
c
c+ 6c c 3 c
c   c  cc  c
  c +5c 3  c +  6c 3  c  6c 3  c +   6c
3  c  6c 3 c c 3  c  6c  c  c  c 3 c 6c
c
  c36c 5 cc
c   c3c<={c c
 3 cc c
c c+  c+  c    c

c 
c ñ3  c  c ::c c :96c 3 c  c c £ 9{ c
  c c ñ3  c +  { c
  c +
c ñ3  c  c c c { c
+c
 cñ3  c+  cc c+  c 3  c  c<6/={ c

c c
c   c c 5c +  c - c  c 3 c c
8 6c 
c 3,c c  c 5c  8c
c c 3c c c   c
36cc3  c  c
cc +6c 5 cc   c3c</={ c

## c ,+ c c   c  

c
c c +c  c c 3c
 +5c   6c  c 3  6c c c - c c +c c c
 3
6cc
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 
cc   { c

ñc  c
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c    c
  2  {c

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2c .c c £={c c 3c c + 
c
+  c 
c  c 3 c 3c c ?c c c 
c 
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2c/ccE={ccc  c
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cc+{ c

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c £c  c  c c <
2c . c c .£={c c   c   c
 cc
 c
c > cc  5 cc
 c c5 c

## c  5  c - c c  c   c c c 

c   c
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
c 3,c cc
 { c

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c /c  c  c 
2c <
2c ./c c    ={c ñc 5 c
  8c  5
c c c 5  c  c3 
 c c

## 1 c      c c c 

c 3
c c 
 c
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c c


c
c  
c  c c 
2 c  - c 7 c c   c c c  c
 
cc
 c   c c

c
c

\] ^_
cc  c c
c c c
Microbiología

ñ c+ c
  c
c c
c c c  c    c5c
 33cc

c
c 
c c   cccc
c 
c    cc
 
c
cccc 
   c 
 cc

 cÔacteroides c
Prevotellac c 
 
 c
c 
cc 
   cÔacteroidesc c
c 
 
 cStaphylococcus
aureuscHaemophilusc c
 cc FusobacteriumcPrevotellac
Ôacteroides  cc 
   c

c 
cc 
 
cS. aureusc 
   , Clostridiumc
 c 
 
 c
 c 
c cc Fusobacterium, Actinomyces,
ÔacteroidesccPrevotellac cc

 c 
   , Nocardiac c
 
c 
c S. aureusc 
   c

 c  c 
   cHaemophilusc c
!
 c " c
 c#
c \$cc

 c 
 
 cNocardia spp.c
%&'c Nocardia  cMycobacterium  
Listeria monocytogenesc

ñ c     c <3 6c 3 c c  + =c  c c 3 c
5c   c < 3c 9={c 13  c c   c c + c
7 6c  c - c  c c c £ c c C 9c
c
c  c  {c ñ c 5c   c
 c c   c c <S. anginosus6c S.c constellatus, S. intermedius=c - c

ccc

c 6c,
6c  c  c+  cc  c cc
+ c
{ccS. pneumoniaecc+  c<cc£9=cc

## cStaphylococcus aureusc 5c ccc. cc.:9c

c c
6c   c
c c c c  c c c

c+ {c13  c
 c
c  c8c3 c
c
c<6£6/6:={ c

ñc3 c36c
3
ccc4 ccc ,c
c   6c c c
 
c  c  c

c  c
c </ c c . 9={c ñc c 5c
+  c  c Ôacteroides {c y Prevotellac {c c  c c / 9c
c  c
 c  c    c 7 c <6/={c c Fusobacteriumc c 
c 
c
 8 cc  c  { c

`a bc
cc  c c
c c c
ñ c 3 c  , c ?c    c <Proteusc {6c E. coli6c Klebsiellac {c c
Pseudomonasc {=c 
c
c  8 c 8 c c    c <C={c
c 
c c + c 7 c c c £c c £ 9c
c  c  6c  c
+ c  c
c c +  c   c c c  c c   c
   
cc

c   c
c Haemophilusc{c c
cc:cc. 9c
c c 6
cc
5c+   ccH. aphrophilus{ccH. influenzaecc+  cc

c Actinomycesc
c Ãc c  c c c C 9c
c  c  c   c
c
 
 cc
c   c
c c+cc
c c c
 c +{cÃ 
c c c+  c
 c
3c  c c  c

 cc

## c  c  c  c 

c Salmonella, Streptobacillus, Ôrucella,
Propionibacterium, Nocardia, ñisteria, Citrobacter, Mycobacterium y Eikenella cc

Presentación clínica

## ñc +  c 2c

c  c
c  
c c
c + c    c

3
cc8 c+ c- c c c
c   6c 
c
    c
c ,
6c  6c 8 c
c  c c c c c
 c
c   c c   c c  2  {c

## 56c  c 2 c

c   c
 c
c+c 
c
{ c

ñc  c
c c2 c 
cc

c
 c  c+  {ccc
:9c
c c  cc
c
c c2 cc
ccc< c
c£cc
. c
2=c</={c

cc 2c
c c cc+  c2c c
3
cc  c
7 c+5 c5c- ccc+6c
cc+cc2 c5c
 8c<

cccc 5c c 
 ={c

c
c 
c
+cc c2cc
c
,+ c     c 8c
 c 3{c

~
 c cc ccc
~
 ccc  c
c ()*c
cccc +()*c
,  c
 c c -.)*c

cc /0\$0)*c

c1c c
cc  c c +0)*c
2c 30\$40*c
!5cc2c 30\$40*c
67cc c 30*c
8 cc 30*c
de fg
cc  c c
c c c
c

iagnóstico

cxámenescgenera es c
ccc
c
ccc
   c
c
{c c 3c c   c


c<Kc { c,F=6c c 

c
c
 c  c
c</:c
c::cF {=6c c 2cÃc cc     c+   c
   {c; 
c c7 c c
c c  c  {c

## c nciónc mbarc c

 5c  

c 
cc  c cc+ c c+ c
c{c
c  
c c  c  c2+ c    - cc c
:9c
c c 6c  - ccC ccD.9cc  ccC cc 9c
c
 c c<Kc: c,Fc
c
 c    ={cñ c   c c
 c   {c

## c ectroencea ograma c

c   c cc c c
6c
cc cccc
 c
c: 9c
c c c</={ c

 c cc7 cc cc,- c+5 6c c- c 3,c
c  c- c c 
 c
5+ c 5
ccc c

cc 2
c
{c

## ñc3 c cc 

c c c5c  c
c34c


c
- c 
c c c   c cc
c
c   { c

ñc3 c 
2c cccc
c   c  c c5c
c34c



c c c c+, c + c- cc
c c c5c 
c
3c
c
c3{cñcc
c
c
c   c 2 c
cc c+, c<6/6:={ c

ñcÃc 3,cc 
cc cc  c
c
 c
 ,c
cc{c

"cResonanciacmagnéticac'RM( c
cc 
 c
cccc
   c
c
{cc5c3c- c
cÃcc +c + c 4ccc
 c
cc3 c 6c

cc4 c
+c c+6c 2  cc c
 3 2
 cc
 c
c c , {c3,cc 
cc
   cc  c
cc {c

## cc c.cc5 cc  c c c

 c- cc
   c c c    6cc   c c 
 c c cc

c c
c3 { c

## cc ccc c

c
c- c
cc3 cc 3c c
 c+
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1. Manejo inicial

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. Cirugía

## - c  c c 

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
FECHA DE VAñORACION:  -10-09 a 13-11-09


Ficha de Identificación

Paciente: V.G.D

Sexo: Masculino

## Fecha de Ingreso: 1-10-09

Fecha de cirugía : -10-09

Servicio: Neurocirugía

Cama: 0

Signos vitales:

## ëc  c cc7Lc c

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3
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c
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 c 
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c c    2c c  , 6c
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tu vw
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RFRNC
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Ne troi osc D{Cc £{ D { c
Linocitosc . {£c . { : { c
Monocitosc C{:c { .{ c
osinoi osc {/Cc { {{ c
asoi osc {//c { £{ c
c c c
FORMULAcROAc c c
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RDWc .:{Dc ..{C./{Dc
M c c ..{C./{Dc
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 -10-09

RFRNC
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Le cocitosc ./{Cc /{C . {c
Ne troi osc C{.c £{ D { c
Linocitosc ..{.£c . { : { c
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13. segundos 11.·-13 segundos

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Ac

Oxigenación:

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Nutrición

alimentación

Hidratación

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c
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Eliminación

## ëc Riesgo de déficit de volumen de líquidos r/c drenaje bifrontal

Movimiento y Postura

Descanso y Sueño

## ëc Deterioro del patrón del sueño r/c ambiente hospitalario

Vestido y Desvestido

Termorregulación

infeccioso

## ëc Riesgo de infección r/c procedimiento invasivo

ëc Riesgo de infección r/c herida quirúrgica (drene por craneotomía
bifrontal)
ëc Alteración de la falta de continuidad de la piel r/c destrucción mecánica
del tejido m/p procedimiento invasivo (drenaje por craneotomía bifrontal)

 
cc  c c
c c c

## ëc Disposición para mejorar la prevención, de los procesos infecciosos

ëc Ôaja autoestima situacional r/c larga estancia intrahosp italaria 30 días)
m/p tristeza e informes verbales de la situación actual.

Comunicación

## ëc Disposición para la mejora de la comunicación

Creencias y valores

## ëc Disposición para mejorar la religiosidad m/p reforzar las costumbres y

creencias

Trabajo y realización

## ëc Interrupción de los procesos familiares r/c cambio en el estado de salud

de un miembro m/p expresión de conflictos

Recreación

tratamiento largo m/p los pasatiempos habituales no puedes realizarse
en el hospital.

Aprendizaje

## Alto riesgo de manejo inefectivo del régimen terapéutico r/c falta de

conocimiento sobre la enfermedad, tratamiento y prevención m/p dudas sobre

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## ëc CEFAñEA: Dolor de cabeza

ëc DEPRESION:  
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