Estudio de caso neumonia bacteriana

8/16/2019 Estudio de caso neumonia bacteriana

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Universidad Estatal del Sur de Manabí Creada mediante Ley Publicada en el registro Ofcial 261 del de !ebrero del 2""1

FACULTAD DE CIENCIAS DE LA SALUD

CARRERA DE ENFERMERÍA

UNIVERSIDAD ESTATAL DEL SUR DE MANABI

FACULTAD CIENCIAS DE LA SALUD

ESTUDIO DE CASO

NEUMONÍA BACTERIANA

HOSPITAL JIPIJAPA

INTERNO DE ENFERMERIA:

GARCIA CASTRO DANIEL

TUTORA ACADEMICA:

LCDA. MERCEDES LUCAS CHOEZ

PERIODO ACADEMICO

NOVIEMBRE 2015 – ABRIL 2016

INDICE

1. INTRODUCCIÓN____________________________________________________32. JUSTIFICACIÓN_____________________________________________________43. OBJETIVOS_________________________________________________________5

4. MARCO TEORICO___________________________________________________65. DATOS DE IDENTIFICACIÓN________________________________________126. ANAMNESIS________________________________________________________137. EXAMEN FÍSICO____________________________________________________158. PROBEMAS O FENÓMENOS OBSERVADOS__________________________2!". EXPICACIÓN CIENTÍFICA DE OS FENÓMENOS OBSERVADOS______2!1!. TRATAMIENTO TERAP#UTICO EMPEADO_________________________2!11. REPORTE DE ENFERMERÍAS TRANSCRITAS.________________________2412. PAN DE CUIDADOS._______________________________________________2513. VISITA DOMICIIARIAS____________________________________________2614. CONCUSIONES____________________________________________________28

15. RECOMENDACIONES______________________________________________2"16. BIBIO$RAFIA_____________________________________________________3!17. ANEXOS___________________________________________________________31

1. INTRODUCCIÓN

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3. OBJETIVOS

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4. MARCO TEORICO

EXPICACIÓN CIENTÍFICA SOBRE E DIA$NÓSTICO%

NEUMONÍA BACTERIANA

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5. DATOS DE IDENTIFICACIÓN

NOMBRES APELLIDOS: N"#,! E#"+-"*% C',-* P%! EDAD: K ',

SEO: (',+#%! RELIGIN: '-#% OCUPACIN: !%!8+!' ESTADO CIVIL: 7%+& LUGAR DE PROCEDENCIA: >%)%>')' LUGAR DE RESIDENCIA: >%)%>')' CON UIEN VIVE: ! $'(%#%'* @ %>' HOSPITAL: HOSPITAL BQSICO JIPIJAPA NUMERO DE HISTORIA CLÍNICA: 10602202 SERVICIO: ("&%%!' %!-"*!'

DIAGNOSTICO MEDICO: !"+(!4' '-"*%'!' FECHA DE INGRESO DEL PACIENTE: 0012016 FECHA DE EGRESO DEL PACIENTE: 16012016

6. ANAMNESIS

NOMBRE: NELSON ELEUTERIO CASTRO PIN

EDAD: K AOS

LUGAR FECHA DE NACIMIENTO: J%)%>')' 2 D" D%%"(*" D"# 1K20

ESCOLARIDAD: N%!8+!

PROCEDENCIA: J%)%>')'

RELIGION: C'-#%.

SEO: M',+#%!.

RESIDENCIA: J%)%>')'.

FECHA: 0012016

INFORMANTE: G'*4' C',-* D'!%"#

PROBEMAS ACTUAES

UE LE MOLESTA: +'&* *",)%*'-*%

CUANDO INICIARON LOS SINTOMAS: '" 1 (", 15 &%',

COMO APARECIERON LOS SINTOMAS: ! )*#"(', *",)%*'-*%, '#9' -?*(%'.

CON UE ALIVIA EL DOLOR: ! )'*'"-'(# ,%! (">*4'

ESTILO DE VIDA: !*('#

MEDIO AMBIENTE: '&"+'&

PROBLEMA DE SALUD ACTUAL: N"+(!4' B'-"*%'!'

PERFI DE PACIENTE

SU ALIMENTACION ES VARIABLE: SI NO

DESAUNO CARBOHIDRATOS: SI NO

ALMUERZO BAJO EN PROTEINAS: SI NO

MERIENDA BAJO EN CARBOHIDRATOS SI NO

ANTECEDENTES PATOO$ICOS

TUVO UNA ENFERMEDAD HACE AOS: SI NO

ES ALERGICO: SI NO

A UE ERES ALERGICO:

HA SIDO INTERVENIDO UIRURGICAMENTE: SI NO

ANTECEDENTES FAMIIARES

SU PADRE ESTA VIVO: NO

TIENE ALGUNA ENFERMEDAD UE UD. CONOZCA: !%!8+!'

UE ENFERMEDAD TIENE: !%!8+!'.

DE UE MURIO: )'* '*&%**",)%*'-*%

SU MADRE ESTA VIVA: NO

TIENE ALGUNA ENFERMEDAD UE UD. CONOZCA: !%!8+!'

UE ENFERMEDAD TIENE: !%!8+!'

7. VAORACION FISICA $ENERA

CFALOCAUDAL

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PANIFICACION DE A VISITA

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16.BIBIO$RAFÍA%YM"&#%!"P#+, @'*%# &" 200. [ N"+(!4'\ @"! ",)'#. Enciclopedia médica en

espa#ol . C!,+#-'& "# 1 &" ('3 &" 200. [L', !"+(!4', '-"*%'!', -%"!&"! ',"* #', (, 8*'7", 3 "! #, '&+#-, ,! #' '+,' (, (<! &" !"+(!4'. L' '-"*%' (, (<! +" '+,' !"+(!4' "! '&+#-, ", #' S-*")-+, )!"+(!%'"@!"+(.

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A("*%'! L+!8 A,,%'-%!] @200. [ N"+(!4'\ @"! ",)'#. C!,+#-'& "# 1 &"('3 &" 200.

A%&,M"&, 3 POZ ('8'9%!" @,")-%"(*" &" 2005. N"+(!4' B'-"*%'!' @"!

",)'#. ^#-%( '", 1 &" ('3 &" 200.FERRARI C A!' M'*4' PIREZ G M. C'-'#%!' MARTINEZ A A&*%'!' "- '#.E-%#84' &" #' !"+(!4' '-"*%'!' '&+%*%&' "! #' (+!%&'& "! !%,,)%-'#%9'&,: U*+8+'3 1KK200. R"7. %#. %!$"-#. Y!#%!". $". 200 7#.2!.1 Y%-'& 01 ('3 &" 200 ).0. D%,)!%#" "! #' _*#& _%&" _": Y1.ISSN 016101.

#"%! E S(%- DL L'=(%!'*'3'! R @200. [H,)%-'#%9'-%!, '!& D"'-, C'+,"& 3 M"-%%##%!R",%,-'!- S-')3#+, '+*"+, U!%-"& S-'-", 1KKK–2005\. Emerg

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