Seguimiento de Enfermeria 5 Semestre Gineco

7/23/2019 Seguimiento de Enfermeria 5 Semestre Gineco

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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

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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"?

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CRITERIOS DE SELECCIN

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TEORA DE ENFERMERA

DOROTEA OREM

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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./&"* ; (/(,

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LA TEORA DEL DFICIT DE AUTOCUIDADO:

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ANALISIS

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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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VALORACIN POR DOMINIOS

DOMINIO : PROMOCION DE LA SALUD

ENTREVISTA:

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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,

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TSH NEONATAL RESULTADO: 6.0 m!U4m!

VALOR DE REFERENCIA: SANGRE DE CORDON UMBILICAL15('U ('SANGRE DE TALON 20 ('U('

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TRATAMIENTO FARMACOLOGICO

MEDICAMENTO DOSIS

MEDICAS

INDICACIONES

METROCLOPRAMIDA

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N.#" 8(/$, /3'.# ', %*,&.3/&,&.*"$# #' %,$,%#*"$,*/, ', /&.3/&,%,* (#&/3"(#$,?

TRAMADOL Am9!!#

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DICLOFENACO Am9!!# 4

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E-AMEN FSICO:

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DOMINIO 0: NUTRICION:

ENTREVISTA:

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E-AMEN FSICO:

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NDICE MASA CORPORAL CLASIFICACIN.22.22 .77.22 3.573.62 05.7706.22 07.7712.22 15.77

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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"*,$/, %"'%")'#

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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/"

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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'"*/&"& " $,&, ', 9.# #'# &/3# , ("/:/#$"?

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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/."' &.*"$# '"

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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"

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25/67

JCR ("/:/#$" $##* #3", 3,,3/(/#$, %,* ', 9.# (.#$*" /$#*


26/67


27/67

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$# #' )/##$"* %*,%/, ' )#)


28/67

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:

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29/67

%/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"(" #

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DOMINIO 1. CRECIMIENTO Y DESARROLLO

ENTRAVISTA

L" .."*/" , $/## (.36" #4%#3$"$/8" ' *,' 3,(, ("&*# $/## (/#&, *#"'/+"* ', 3./&"&, " '" *#3/


30/67

L#36# ("$#*" /.:/3/#$# *3 .33/ /#:/3"+ " *#:'#7, .33/

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31/67

S(, /:#33/ :* %*,3#&/(/#$, /8"/8, " 3#*#"

C9&?9

D/3,:,*$ *3 /:,*(# :"'$" "$/:"33/ 3, '" /$."3/ " #()"*"+,, #"&,?

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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

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DEFINICIN:G*"&, '" 3,(%*#/ $*"(/$/&" ,)*# '" "/$#3/" ' /@, #' "3/(/#$, 6"$" 1 "@, #&"&?


33/67

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37/67

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40/67

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LACTANCIA MATERNA

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43/67

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DIAGNOSTICO

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