place en paciente con tce.docx

8/17/2019 Place en Paciente con TCE.docx

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ISSSTEESCUELA NACIONAL

DE ENFERMERÍA E INVESTIGACIÓNCURSO POSTÉCNICO DE ENFERMERÍA

“ATENCIÓN AL PACIENTE EN ESTADO CRÍTICO”Ciclo Académico 20 ! 20 "

Place en Paciente con TraumatismoCraneoencéfalico en Hospital General de

México.

Asesor: Ofelia Vargas Hernánde .

Villag!me Hernánde Mar"a #sela. 7 de Marzo 2016.


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INTRODUCCIÓN

La m#$%&$ 'o% &%a#ma&i(mo( (i)#$ $(&a*do d$*&%o d$ la( '%i*ci'al$( ca#(a( d$m#$%&$ + di(ca'acidad, + (o* la( l$(io*$( d$l (i(&$ma *$%-io(o + $l c.o/#$.$mo%% )ico (#( '%i*ci'al$( co*&%i1#+$*&$( El &%a#ma&i(mo c%a*$o$*c$3 lico4TCE5 )%a-$ $( mo&i-o d$ mo%&alidad $ i*ca'acidad $* $l 'aci$*&$ accid$*&ado

6o-$*

El 'aci$*&$ *$#%o&%a#m &ico co*(&i+$ #* )%#'o com'l$6o d$ 'aci$*&$( /#$'#$d$* '%$($*&a% di(&i*&o( &i'o( d$ l$(i7* c$%$1%al El &%a#ma&i(mo c$%$1%al'#$d$ %$(#l&a% d$ #*a l$(i7* c$%%ada o #*a l$(i7* '$*$&%a*&$ S$ co*(id$%a co*#* &%a#ma&i(mo c%a*$o$*c$3 lico )%a-$ a &odo 'aci$*&$ /#$ '%$($*&$ al m$*o(#*o d$ lo( (i)#i$*&$( $l$m$*&o( cl8*ico( + %adiol7)ico(9 E(cala d$ coma:la()o; 4EC:5 m$*o% d$ < '#*&o( 2 D$&$%io%o d$l *i-$l d$ co*ci$*cia co* #*od$ lo( (i)#i$*&$( da&o( cl8*ico(9 a*i(oco%ia, d$3$c&o mo&o% *$#%ol7)ico c$*&%al +1%adica%dia $ .i'$%&$*(i7* a%&$%ial = Co*-#l(io*$( 'o(&%a#m &ica('%olo*)ada( o $(&ado $'ilé'&ico > T%a#ma '$*$&%a*&$ c%a*$al co* $(cala d$:la()o; m$*o% d$ = Lo( (i)*o( cl8*ico( /#$ .ac$* (o('$c.a% $l $(&ado d$c.o/#$ '#$d$* ($% di38cil$( d$ a'%$cia% $* lo( $(&adio( i*icial$( d$l &%a#ma,d$1ido a m$ca*i(mo( com'$*(a&o%io(

JUSTIFICACIÓN

Co* $l '%o'7(i&o d$ '%$ci(a% + (ol-$*&a% d$ ma*$%a $?ca@ la( *$c$(idad$( d$cada '$%(o*a $( i*di('$*(a1l$ $(&a1l$c$% #*a ($%i$ d$ 'a#&a( /#$, $* (#co*6#*&o, co*(&i+$* #* 'la* d$ c#idado( d$ E*3$%m$%8a

S$ &%a&a d$ #* '%oc$(o co*&i*#o '$%o i*&$)%ado 'o% di3$%$*&$( $&a'a(,o%d$*ada( l7)icam$*&$, /#$ &i$*$* como o16$&i-o 3#*dam$*&al la ad$c#ada'la*i?caci7* + $6$c#ci7* d$ lo( o'o%*o( c#idado( o%i$*&ado( al 1i$*$(&a% d$

#*a '$%(o*a d$ c#idado d$l ($ o 3$m$*i*o, d$ B> d$ $dad co* $l dia)*o(&ico TCE, /#$ ($ $*c#$*&%a .o('i&ali@ado $* la U*idad >0= T$%a'ia I*&$*(i-aN$#%ol7)ica d$l o('i&al :$*$%al d$ Mé ico d$l 2< d$ F$1%$%o al = d$ Ma%@o d$l20 " 'a%a (# &%a&ami$*&o

2


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Objetivo General

A'lica% $l P%oc$(o d$ A&$*ci7* d$ E*3$%m$%8a, 1a(ado $* $l mod$lo &$7%ico d$i%)i*ia $*d$%(o* a #*a '$%(o*a d$ c#idado ad#l&a co* $l dia)*7(&ico

T%a#ma&i(mo C%a*$o$*c$3 lico 4TCE5, co* $l '%o'7(i&o d$ lo)%a% o m$6o%a% $l

)%ado d$ d$'$*d$*cia $* $l c#idado

Objetivo! E!"e#$%#o!

alo%a% la( *$c$(idad$( ($) * $l mod$lo &$7%ico d$ i%)i*ia $*d$%(o*co* $l ?* d$ id$*&i?ca% a/#$lla( *$c$(idad$( /#$ ($ $*c#$*&%$*al&$%ada( + d$&$%mi*a% $l )%ado d$ d$'$*d$*cia 'a%a d$(a%%olla% $l 'la*d$ c#idado(

2 E(&a1l$c$% lo( dia)*7(&ico( d$ E*3$%m$%8a d$ cada #*a d$ la(*$c$(idad$( al&$%ada(

= P%io%i@a% lo( c#idado( d$ $*3$%m$%8a a %$ali@a% $l Pla* d$ c#idado( d$ac#$%do a la( *$c$(idad$( al&$%ada(

> E-al#a% d$ ma*$%a co*(&a*&$ la a'licaci7* d$l P%oc$(o d$ E*3$%m$%8a $*#* 'aci$*&$ .o('i&ali@ado

=


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Ca!o Cl$ni#o&I'enti%#a#i(n&No)bre& RLM E'a'& B> Genero& M#6$%Se*o& F$m$*i*o+o!"ital General 'e M,*i#o -Dr E'.ar'o Li#ea/a0Servi#io& T$%a'ia N$#%ol7)ica Ca)a& != ECU& 2i#daL./ar 'e 2ro#e'en#ia 9 Ci#dad d$ Mé ico2e!o& "G H) Talla& !Bcm 2re!i(n Intra#raneal&No alo%ada

2ro#e'en#ia 3 Ubi#a#i(n a#t.al

I*)%$(a 'aci$*&$ F$m$*i*a d$ B> a la cama != '%oc$d$*&$ d$ #%)$*cia(Motivo 'el In/re!oP%o1a1l$ TCEAnte#e'ente! 'e I)"ortan#ia "ara el 2a'e#i)iento A#t.al

a1i&a $* ca(a '%o'ia, c#$*&a co* &odo( lo( ($%-icio( i*&%a + $ &%a domicilia%io(,co* co*-i-$*cia co* 3a#*a *oci-a, $(/#$ma d$ -ac#*aci7* com'l$&o, .$mo&i'o%$3$%ido como R O , .i)i$*$ 1#cal J2 -$c$( al d8a, .i)i$*$ '$%(o*al +cam1io( d$ %o'a dia%io(Ali)enta#i(n

i6a %$?$%$ /#$ %$ali@a% = comida( $ i*)i$%$ K li&%o d$ a)#a al d8aTo*i#o)an$a!N$)ado( 'o% $l 3amilia%Ni$)a o&%a( &o icoma*8a(Ante#e'ente! +ere'o Fa)iliare!Pad%$ co* a*&$c$d$*&$( d$ TA DMII NIDAnte#e'ente! 2er!onale! 2atol(/i#o!D$(co*ocido(Aler/ia!&D$(co*ocida(Ante#e'ente! 4.ir5r/i#o!D$(co*ocida( 'o% $l Familia%

Ante#e'ente! tra.)atol(/i#o!D$(co*ocido( 'o% $l Familia%Cr(ni#o6 'e/enerativo! 9

TA, D$(co*oc$ al#*a o&%a 'a&olo)8a2a'e#i)iento a#t.al2" F$1%$%o d$l 20 "

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I*)%$(a al ($%-icio d$ Tera"ia Inten!iva Ne.rol(/i#a $l d8a 2" d$ F$1%$%o20 "

E*"lora#i(n 7$!i#a '$a 89 'e Febrero 8:;<=>er '$a 'e 1o!"itali?a#i(n@

F$m$*i*a d$ B> , c% *$o *o%mo c$3 lico, co* '%$($*cia d$ 3%ac%a occi'i&al

c$%%ada (i* d$('la@ami$*&o, co* ani!o#ori#a! , d$%$c.a d$ >mm, '#'ilai@/#i$%da co*($%-ada $* 2mm, a(imé&%ica(, co* %$('#$(&a *#la al $(&8m#lol#mi*o(o, Gla!/o d$ = (i* ($daci7*, $(&ado coma&o(o, co* (o*dao%o) (&%ica a d$%i-aci7*, co* %$(id#o ) (&%ico, 'alid$@ &$)#m$*&a%ia, co*m#co(a( o%al$( .id%a&ada(, co* c#$llo cil8*d%ico, co* colla%8*, 'o% l$(i7*c$%-ical *o ($ o1($%-a d$('la@ami$*&o d$ la &% /#$a, *o .a+ $(&8m#lo al dolo%,'$%o (i %$ $6o (8)$*o co* o $*do&%a/#$al * m$%o B !, co* a'o+o ?6o $*2 cm $* comi(#%a la1ial #on a"oBo ventilatorio $* modo ol#m$* A C, co*'a% m$&%o( -$*&ila&o%io( co*2EE2 , P%$(i7* So'o%&$ d$ 20,FIO8 al >0Vol.)en Corriente =VC@ d$ > 0 ml ma*&i$*$ d$ GJ22 %'m a la a#(c#l&aci7*,cam'o( '#lmo*a%$( co* %#ido( %$('i%a&o%io( '%$($*&$(, co* m#%m#llo-$(ic#la% di(mi*#ido, $(&$%&o%$( (il1a*&$( 1ila&$%al$( $* 1a($(, '%$($*cia d$1%o*co$('a(mo, )a($( a%&$%ial$( 2+ B =!,2aO 8 >" ,SaO 8 BG = ,2CO 8 =! G,+CO > < ",La#tato d$ >,E > = (a%a*do al


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S$c%$cio*$( %o*/#ial$( 'o% TET + ca-idad o%al, d$ colo% ama%illo,(a*)#i*ol$*&a( $('$(a(Pa% m$&%o( -$*&ila&o%io(Fr 2, Fio 8 >0 , 2EE2 !, V C > 0ml:a(om$&%8a92+ B =!,2aO 8 >" ,SaO 8 BG = ,2CO 8 =! G,+CO > < "EA > =,La#tato d$ >El$c&%oli&o(9Na !!, > =,Cl 2B, Ca G 0,Fo!7oro =2@ = , M/ 2 G

La1o%a&o%io(9Le.# 2 00,Ne.tro! GB000, Lin7o#ito! 00,Eo!ino%lo! 0, Mono#ito! 0 a!o%lo! 0, a*da( 0 +b B G , 2la4 BB 000 mil,Gl.#o!a B! m) dl, Urea d$ BG B, Creatinina K#i'o 5ri#o d$ = ,T2 2 >, T2T 2 !, TT " !, Fibrin(/eno !=


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c$%$1%al, '%od#cié*do($ $* lo( ca(o( ($-$%o( #* daQo i(/#émico ($c#*da%io,(o1%$'#$(&o a la l$(i7* '%ima%ia + a)%a-ado 'o% lo( 3ac&o%$( d$ .i'o ia $.i'o&$*(i7*, (i $( /#$ é(&o( *o .a* (ido co%%$)ido( La i(/#$mia c$%$1%al $(

'o(i1l$m$*&$ $l m$ca*i(mo m ( im'o%&a*&$ $* la '%od#cci7* d$ l$(io*$(($c#*da%ia( S$ .a d$mo(&%ado /#$ 3%$c#$*&$m$*&$ lo( &%a#ma&i(mo( ($acom'aQa* d$ .$mo%%a)ia (#1a%ac*oid$a + /#$ $*&%$ ma+o% ($a é(&a, '$o% $($l '%o*7(&ico

El #6o (a*)#8*$o c$%$1%al, la 3#$*&$ d$ o 8)$*o $* co*dicio*$( *o%mal$( $( d$!0 ml 00)% mi*#&o d$1$ (#'li% lo( al&8(imo( %$/#$%imi$*&o( $*$%)é&ico( d$l$*cé3alo 'a%a ma*&$*$% (# i*&$)%idad + $l i*&$%cam1io i7*ico *$c$(a%io 'a%a la&%a*(mi(i7* *o%mal d$ lo( im'#l(o( *$%-io(o( Pa%a $(&o, $l $*cé3alo co*(#m$a'%o imadam$*&$ = 2 ml 00)% mi*#&o d$ o 8)$*o o ! #mol )m mi* 4%a&a d$co*(#mo c$%$1%al d$ o 8)$*o5CMRO8, /#$ ($ '#$d$ d$d#ci%, m#l&i'lica*do $l

#6o (a*)#8*$o c$%$1%al, 'o% la di3$%$*cia $*&%$ $l co*&$*ido d$ o 8)$*o d$ la

(a*)%$ a%&$%ial 4 >ml dl5, $* com'a%aci7* co* $l d$ la (a*)%$ -$*o(a &omadad$l 1#l1o +#)#la% 4B B ml dl5, ($) * la 37%m#la9

CMRO8 FSC * A6V: 8

El !0 d$ la $*$%)8a ($ #&ili@a 'a%a la 3#*ci7* (i* '&ica, $l 2! 'a%a ma*&$*$%lo( )%adi$*&$( i7*ico( d$ la m$m1%a*a (i* $l c#al la cél#la m#$%$ + $l o&%o 2!$( d$ #(o d$(co*ocido E* co*dicio*$( *o%mal$( $l $*cé3alo )$*$%a $*$%)8am$dia*&$ la 3o(3o%ilaci7* d$ )l#co(a 'a%a o1&$*$%CO8 + + 8O $* $l ciclo d$

%$1( Al&$%acio*$( m$&a17lica( $* la '%od#cci7* d$ $*$%)8a c$l#la% %$(#l&a* $*la )$*$%aci7* d$ %adical$( li1%$( d$ o 8)$*o /#$ (o* *oci-o( 'a%a lo( cido()%a(o( 'oliJi*(a%ado( d$ la m$m1%a*a c$l#la% la li1$%aci7* d$ cidoa%a/#id7*ico l$(io*a lo( ca'ila%$( + ($ m$&a1oli@a % 'idam$*&$ a'%o(&a)la*di*a( + l$#co&%$*o(, lo /#$ a (# -$@ '%od#c$ m ( %adical$( li1%$( Lad$('ola%i@aci7* d$ la m$m1%a*a c$l#la% '%od#c$ la li1$%aci7* d$*$#%o&%a*(mi(o%$( 4ca&$colami*a(, ! T, )l#&oma&o, )a1a + o'ioid$(5 /#$ $*al&a( co*c$*&%acio*$( &am1ié* (o* ci&o&7 ico( + a1%$* m ( ca*al$( d$ calcio

El #6o (a*)#8*$o c$%$1%al=FSC@ d$'$*d$ d$ la '$%3#(i7* c$%$1%al =22C@ /#$($ '#$d$ calc#la% %$(&a*do la '%$(i7* i*&%ac%a*$a*a=2IC@ a la '%$(i7* a%&$%ialm$dia (i(&émica =2AM@

22C 2AM 6 2IC

C#a*do .a+ di(mi*#ci7* d$l #6o (a*)#8*$o c$%$1%al =FSC@, 'a%a ma*&$*$% la%a&a d$ co*(#mo c$%$1%al d$ o 8)$*o=CMRO8@ co*(&a*&$, ($ '%od#c$ a#m$*&od$ la di3$%$*cia a%&$%io-$*o(a d$ o 8)$*o (i ($ di(mi*#+$ la '%$(i7* d$'$%3#(i7* c$%$1%al=22C@H o ($ a#m$*&a la '%$(i7* i*&%ac%a*$a*a=2IC@, ($'#$d$* ma*&$*$% co*(&a*&$( &a*&o $l #6o (a*)#8*$o c$%$1%al 4FSC@ como ladi3$%$*cia a%&$%io-$*o(a d$ o 8)$*o, 'o% m$dio d$ al&$%acio*$( $* la -i(co(idadd$ la (a*)%$, d$ la( *$c$(idad$( m$&a17lica( d$l $*cé3alo o 'o% cam1io( $* $lcali1%$ d$ la( a%&$%iola( c$%$1%al$( co* di m$&%o $*&%$ =0 + =00 mic%a(

G


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Lo( cam1io( $* $l di m$&%o d$ la( a%&$%iola( %$('o*d$* a la co*c$*&%aci7* d$CO2 a%&$%ial9 la .i'$%ca'*ia 4.i'o-$*&ilaci7*5 '%od#c$ -a(odila&aci7* + la.i'oca'*ia 4.i'$%-$*&ilaci7*5 -a(oco*(&%icci7* $(&a %$ac&i-idad .a (ido

a&%i1#ida a la %$('#$(&a d$l m (c#lo li(o a lo( cam1io( $* la co*c$*&%aci7* d$.id%o)$*io*$( a ma+o% PCO2, ma+o% co*c$*&%aci7* d$ .id%o)$*io*$( co*-a(odila&aci7* + di(mi*#ci7* d$ la %$(i(&$*cia -a(c#la% c$%$1%al co* ma+o% #6o(a*)#8*$o c$%$1%al Si* $m1a%)o, co* .i'$%-$*&ilaci7* '%olo*)ada, $l ' d$lLCR %$&o%*a al *i-$l 1a(al o a #* *i-$l li)$%am$*&$ ma+o% a la( 2> .o%a( + 'o%lo &a*&o $l di m$&%o d$ lo( -a(o(, .aci$*do $*&o*c$( i*$3$c&i-a la.i'$%-$*&ilaci7*, co* $l a)%a-a*&$ /#$ ($ di(mi*#+$ la co*c$*&%aci7* d$1ica%1o*a&o E(&o '#$d$ '%od#ci% ma+o%$( cam1io( $* $l ' &i(#la%,($c#*da%io( a la( al&$%acio*$( d$ CO 2, lo /#$ a (# -$@ '#$d$ ll$-a% a ma+o%-a(odila&aci7* d#%a*&$ lo( '$%iodo( d$ *o%moca'*ia

El #6o (a*)#8*$o c$%$1%al=FSC@ d$'$*d$ d$ la lo*)id d$ lo( -a(o(, /#$ $(

co*(&a*&$, d$ (# di m$&%o, /#$ &am1ié* $( co*(&a*&$, $* la( a%&$%ia( ma+o%$(+ (7lo -a%8a co* $l -a(o $('a(mo ($c#*da%io a la .$mo%%a)ia (#1a%ac*oid$a oal &%a#ma, a la '%$(i7* d$ '$%3#(i7* =22C 2AM62IC@, a la -i(co(idad d$ la(a*)%$ + $('$cialm$*&$ al di m$&%o d$ la( a%&$%iola( $*&%$ =0 + =00 mic%a(,do*d$ $(& la ma+o%8a d$ la (a*)%$, d$ modo /#$ c#al/#i$% cam1io $* (#di m$&%o '%od#ci% cam1io $* $l #6o (a*)#8*$o c$%$1%al, $* $l -ol#m$*c$%$1%al + 'o% lo &a*&o $* la '%$(i7*

S$ ac$'&a /#$ la 22C '#$d$ di(mi*#i% .a(&a "0 mm ), d$'$*di$*do d$ la'%$(i7* i*&%ac%a*$a*a C#a*do la2IC a#m$*&a .a(&a *i-$l$( i)#al$( ala 2AMH la 22C ($% 0 + ($ '%od#c$ 3al&a d$ i%%i)aci7* + m#$%&$ c$%$1%al

CLASIFICACION

Le!ione! 'e #.ero #abell.'o T%a#ma&i(mo( c$%%ado( T%a#ma&i(mo(a1i$%&o(Le!ione! 'e #r neo Fra#t.ra! Li*$al$(, d$'%imida(, d$ la 1a($Le!ione! 'e )enin/e! F8(la( d$ L C R $%*ia( C$%$1%al$(

Le!ione! 'e en#,7alo

a L$(io*$( P%ima%ia( Focal$(

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o Lac$%aci7*

1 L$(io*$( P%ima%ia( Di3#(a(


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o Co*moci7* C$%$1%al

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+eri'a! "enetrante!Le!ione! va!#.lare!

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I*3$cci7*

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MANEJO INICIAL DEL 2ACIENTE

E* El Si&io D$l Accid$*&$

• E-ac#aci7* % 'ida 'o% '$%(o*al $ '$%im$*&ado

• Id$*&i?caci7* d$ 'aci$*&$( co* l$(i7* *$#%ol7)ica

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• T%a&ami$*&o d$ (.ocH Sol#ci7* Sali*a =

• P%$-$*ci7* d$ ($)#*da l$(i7* 'o% .i'o ia, .i'o&$*(i7* + a*$mia

R$3$%i% $l 'aci$*&$ al .o('i&al i*dicado 4#&ili@a% 'a%&$ mo&o%a d$ la E(cala d$Coma d$ :la()o;, /#$ ($ %$lacio*a m#+ 1i$* co* $l '%o*7(&ico d$ lo('aci$*&$(9 a/#$llo( co* < 4o1$d$c$* 7%d$*$(5 &i$*$* 1#$* '%o*7(&ico +a/#$llo( co* J! $* la $(cala mo&o%a $(& * $* 'o(i1ilidad d$ 3all$c$% +%$/#i$%$* a&$*ci7* i*m$dia&a $* #* c$*&%o d$ &%a#ma


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Pla* d$ $-ac#aci7* d$ 'aci$*&$( -8c&ima( d$ 'oli&%a#ma&i(mo( o co* ($-$%a(l$(io*$( *$#%ol7)ica(

MANEJO EN URGENCIASE-al#aci7* :$*$%al

Re#or'ar 9 E* 'aci$*&$( co* 'oli&%a#ma&i(mo( ($-$%o(, $l G" '#$d$* &$*$%3%ac%a( d$ la( $ &%$midad$(, "< &%a#ma&i(mo( c%a*$o$*c$3 lico(, "2&%a#ma&i(mo( &o% cico(, =" l$(io*$( i*&%aJa1domi*al$(, 2G l$(io*$( 'él-ica(+ > l$(io*$( $('i*al$(

ia Aé%$a, $*&ilaci7*I*a% 'aci$*&$( cla(i?cado( co* G o m$*o( $* la E(cala d$:la()o;, !in e*ionar #ol.)na #ervi#alE(&a1ili@aci7* $modi* mica

T%a&ami$*&o D$ L$(io*$( A(ociada(

Re#or'ar 9 No ($ d$1$ 'a(a% (o*da *a(o) (&%ica $* 'aci$*&$( co* &%a#ma($-$%o d$ c% *$o /#$ $(&é* $* coma o co* .$mo%%a)ia *a(o3a%8*)$a, 'o% $l%i$()o d$ '$*$&%a% a c% *$o a &%a-é( d$ 3%ac%a( $* la 1a($

Eval.a#i(n Ne.rol(/i#ai(&o%ia d$l &%a#ma E(&ado )$*$%al d$l 'aci$*&$, $-id$*cia d$ $(&a% 1a6o $3$c&o

d$ alco.ol o d%o)a( E(&ado d$ co*ci$*cia, o%i$*&aci7* Pala1%a + .$mi(3$%iodomi*a*&$ Cla(i?caci7* d$*&%o d$ la E(cala d$ Coma d$ :la()o; Am*$(ia d$laccid$*&$ + d$l &i$m'o &%a*(c#%%ido d$('#é( d$ é(&$ + d$&$%mi*a% la d#%aci7*d$l '$%8odo d$ am*$(ia

Cr neo

a E(&ado d$ la 'i$l (i .a+ .$%ida( i*('$cci7* ma*#al d$ é(&a( +d$&$%mi*aci7* d$ 'o(i1l$( 3%ac%a(, $-id$*cia d$ c#$%'o( $ &%aQo( +(alida d$ l8/#ido c$3alo%%a/#8d$o

1 E i(&$*cia d$ .$ma&oma( (#1)al$al$( + d$ dolo%, $('$cialm$*&$im'o%&a*&$( c#a*do ($ $*c#$*&%a* $* %$)i7* &$m'o%al, do*d$ '#$d$*i*dica% la $ i(&$*cia d$ 3%ac%a d$ c% *$o /#$ $* $(&$ (i&io ($ '#$d$a(ocia% a .$ma&oma $'id#%al

c D$3o%macio*$( 3acial$( + 3%ac%a( d$ ca%a

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d Salida d$ l8/#ido c$3alo%%a/#8d$o 'o% o8do o 'o% 3o(a( *a(al$(

E am$* d$ 'a%$( c%a*$a*o(9 '#'ila( + lo( %$ $6o( '#'ila%$(

E am$* d$ (i(&$ma mo&o%E am$* d$ ($*(i1ilidadR$ $6o( mio& &ico( + c#& *$o(Coo%di*aci7* + ma%c.a (i $l 'aci$*&$ '#$d$ cola1o%a%E am$* d$ col#m*a

Dia/n(!ti#o De Le!ione!

U*a ma*$%a % 'ida d$ cla(i?ca% a lo( 'aci$*&$( co* &%a#ma c%a*$o$*c$3 lico$( ($) * la E(cala d$ Coma d$ :la()o;, $* &%a#ma l$-$, mod$%ado + ($-$%o9leve 'a%a lo( 'aci$*&$( /#$ ($ $*c#$*&%$* $*&%$ ! + = $* la $(cala)o'era'o $*&%$ < + 2 +!evero 'a%a /#i$*$( &$*)a* #*a cla(i?caci7* $* la$(cala d$ :la()o; d$ G o m$*o% El &%a&ami$*&o i*icial ($ .a% &$*i$*do $*c#$*&a $(&o( )%#'o( + $l &i'o d$ l$(i7* /#$ ($ d$&$%mi*$ $* lo( $ m$*$(com'l$m$*&a%io( d$ im )$*$( dia)*7(&ica(, '$%o *o $( %$com$*da1l$ #&ili@a%$(&a cla(i?caci7* como dia)*7(&ico d$?*i&i-o

No Ra'io/ra7$a! De Cr neo

E* lo( 'aci$*&$( co* &%a#ma&i(mo( d$ c% *$o, co* o (i* l$(i7* *$#%ol7)ica, *o$( %$com$*da1l$ &oma% %adio)%a38a( d$ c% *$o, (i*o '%oc$d$% i*m$dia&am$*&$co* $(ca*o)%a38a c$%$1%al, (im'l$ 4(i* m$dio d$ co*&%a(&$5, (i cl8*icam$*&$ ($

6#(&i?ca La( %adio)%a38a( (im'l$( d$ c% *$o (7lo (o* d$ a+#da &$%a'é#&ica $*

$l = d$ lo( ca(o( d$ &%a#ma c%a*$o$*c$3 lico E* lo( 'aci$*&$( co*(ci$*&$( oco* &%a#ma l$-$, (7lo ($ %$comi$*da &oma% %adio)%a38a( d$ c% *$o (i .a+$-id$*cia d$ 3%ac%a d$'%imida o 38(la d$ l8/#ido c$3alo%%a/#8d$o Si*$m1a%)o, $* $(&o( ca(o( $l $ am$* i*dicado $( la TAC c$%$1%al D$1$%$co%da%($ /#$ la %adio)%a38a (im'l$ d$ c% *$o da #*a 3al(a ($)#%idad /#$'#$d$ %$(#l&a% 3a&al 'a%a $l 'aci$*&$ Po% $llo, $(&$ $ am$* $(& '% c&icam$*&$$* d$(#(o

E!#ano/ra7$a Cerebral In#l.Ben'o C;H C8 3 C>

D$&$%mi*a /#$ ($ .a)a #* ma+o% * m$%o d$ dia)*7(&ico( d$ l$(io*$(i*&%ac%a*$a*a(, co* lo c#al *o (7lo ($ di(mi*#+$ la mo%1ilidad + mo%&alidad d$lo( 'aci$*&$( co* &%a#ma d$ c% *$o + 'é%dida d$ co*ci$*cia o am*$(ia, (i*o&am1ié* la $(&ad8a .o('i&ala%ia + lo( co(&o( d$l &%a&ami$*&o S$ d$1$* i*cl#i%co%&$( d$ la( &%$( '%im$%a( -é%&$1%a( c$%-ical$(, 'a%a -i(#ali@a% 3%ac%a(c$%-ical$( /#$ d$ o&%a 3o%ma *o ($%8a* dia)*o(&icada(

=


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S$ d$1$ '%ac&ica% a &odo( lo( 'aci$*&$( /#$ .a+a* &$*ido 'é%dida d$co*ci$*cia, a * a a/#$llo( ca&alo)ado( como tra.)a leve 4:la()o; =J !5,+a /#$ $*&%$ é(&o(, G '%$($*&a* a*o%malidad$( $* $l TAC + ! '%$($*&a*

l$(io*$( /#$ %$/#i$%$* ci%#)8a E*&%$ lo( 'aci$*&$( co* :la()o; d$ =, >0'%$($*&a* a*o%malidad$( $* la $(ca*o)%a38a + #* 0 %$/#i$%$* ci%#)8a

El )anejo 'e e!to! "a#iente!H !i tienen .n TAC nor)al

La o1($%-aci7* $( 'o% 2> .o%a(, /#$ ($ $3$ca% $* $l o('i&al o $* la ca(a($) * $l 'aci$*&$, $l (i&io d$l &%a#ma + (i .a+ o *o l$(io*$( a(ociada( 4.$%ida(3acial$(, $&c 5 S$ l$( i*(&%#i% (o1%$ lo( co*&%ol$( *$#%ol7)ico( /#$ i*cl#+$*$(&ado d$ co*ci$*cia + o%i$*&aci7*, $(&ado d$ '#'ila(, %$ $6o( '#'ila%$(, $l$(&ado d$ 3#$%@a m#(c#la% + d$ %$acci7* a*&$ di3$%$*&$( (iacio*$( S$ l$$ 'lica% a la 3amilia (o1%$ la *$c$(idad d$ ($% ll$-ado( d$ *#$-o a U%)$*cia((i ($ '%$($*&a* al&$%acio*$(

Lo( 'aci$*&$( /#$ .a+a* &$*ido 'é%dida d$ co*ci$*cia 'o% m ( d$ ! mi*#&o( +/#$ $* $l $ am$* '%$($*&$* al&$%aci7* d$ co*ci$*cia, '$%o /#$ $(&é*o1$d$ci$*do 7%d$*$(, (i* o&%o dé?ci& *$#%ol7)ico, Gla!/o 96;>H =tra.)a)o'era'o@H d$1$* ($% (om$&ido( a $(ca*o)%a38a c$%$1%al + .o('i&ali@ado(,i)#al /#$ lo( /#$ ($ $*c#$*&%a* co* tra.)a !evero =Gla!/o )enor@ + (#&%a&ami$*&o ($% d$ ac#$%do co* lo( .alla@)o( d$ é(&a E*&%$ lo( 'aci$*&$( co*

&%a#ma mod$%ado >0 '%$($*&a* al&$%acio*$( $* la $(ca*o)%a38a + <%$/#i$%$* ci%#)8a E(&o( 'aci$*&$( d$1$* ($% $-al#ado( % 'idam$*&$ 'o% #**$#%oci%#6a*o + (# $(ca*o)%a38a d$1$ ($% %$'$&ida (i m#$(&%a* d$&$%io%o*$#%ol7)ico ($) * lo d$mo(&%a%o* S&$i* + Ro(( 4


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a#.er'o #on la evol.#i(n #l$ni#aP ta)bi,n !i 1aB 'eterioro ne.rol(/i#oo !i !e en#.entran le!ione! 4.e "or !. "e4.eQo ta)aQo !e 'e#i'e nointervervenir B el "a#iente no "re!enta la )ejor$a #l$ni#a e!"era'a

CLASIFICACION DE LA LESION CERE RAL SEGUN ESCANOGRAFIA

Cate/or$a De%ni#i(n

Le!i(n Di7.!a l E(ca*o)%a38a No%mal

Le!i(n Di7.!a II Ci(&$%*a( '%$($*&$(, co* d$(-iaci7* d$ l8*$a m$dia $*&%$ 0 +! mm

L$(io*$( d$ di3$%$*&$ d$*(idad, m$*o%$( d$ 2! cc

Le!i(n Di7.!a III =E'e)a@ Ci(&$%*a( com'%imida( o a#($*&$(, co* d$(-iaci7* d$ l8*$am$dia $*&%$ 0 + ! mm, (i* l$(i7* d$ d$*(idad al&a o mi &ama+o% d$ 2! cc

Le!i(n Di7.!a IV =De!via#i(n@ D$(-iaci7* d$ l8*$a m$dia ma+o% d$ ! mm, (i* l$(i7* d$d$*(idad al&a o mi &a ma+o% d$ 2! cc

Ma!a eva#.a'a C#al/#i$% &i'o d$ ma(a $-ac#ada

Ma!a no eva#.a'a C#al/#i$% &i'o d$ ma( ma+o% d$ 2! cc *o $-ac#ada

Nor)a! Generale! 2ara El Manejo De Lo! 2a#iente!

E( co*-$*i$*&$ '%ac&ica% '%#$1a( d$ coa)#laci7* $* 'aci$*&$( co* ($-$%a(l$(io*$( c$%$1%al$( o co* .$%ida( '$*$&%a*&$( d$ c% *$o '%od#cida( 'o%'%o+$c&il$( d$ a%ma d$ 3#$)o, /#i$*$( co* )%a* 3%$c#$*cia d$(a%%olla*al&$%acio*$( d$ la coa)#laci7*

Lo( 'aci$*&$( /#$ '%$($*&a* .i'o&$*(i7* ($% * $-al#ado( 'o% $l ci%#6a*o)$*$%al + ($ l$( '%ac&ica% * o&%o( $ m$*$( o%i$*&ado( a la id$*&i?caci7* +&%a&ami$*&o d$ la( l$(io*$( a(ociada( E* &odo mom$*&o d#%a*&$ $l ma*$6o d$é(&o( 'aci$*&$(, d$1$ &$*$%($ m#+ $* c#$*&a /#$ (o* m#+ (#(c$'&i1l$( a la.i'o ia, 'o% 'é%dida d$ la a#&o%%$)#laci7* d$l #6o (a*)#8*$o c$%$1%al + -a(o$('a(mo 3ocal +, 'o% lo &a*&o, ($ d$1$ '%$-$*i% la .i'o ia $* &odo mom$*&o

S$ d$1$ .ac$% $l dia)*7(&ico $ ac&o d$ la l$(i7* c$%$1%al, 'a%a $m'%$*d$% $l&%a&ami$*&o ($) * $l ca(o lo( 'aci$*&$( co* &%a#ma&i(mo( l$-$( + /#$ *o'%$($*&$* al&$%acio*$( $* la $(ca*o)%a38a, '#$d$* ($% o1($%-ado( $* (# ca(a,(i *o '%$($*&a* l$(io*$( a(ociada( + &i$*$* c7mo ($% co*&%olado( la 3amiliad$1$ $*&$*d$% /#$ la $(ca*o)%a38a *o%mal *o l$( a($)#%a /#$ m ( &a%d$ *o ($'#$da '%$($*&a% #*a l$(i7* /#$ %$/#i$%a &%a&ami$*&o Lo( mi(mo( 'aci$*&$(co* l$(io*$( a(ociada(, d$1$* ($% co*&%olado( $* $l .o('i&al

!


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Lo( 'aci$*&$( co* &%a#ma&i(mo( mod$%ado( d$1$* ($% &%a&ado( d$ ac#$%doco* (# dia)*7(&ico, &$*i$*do $* c#$*&a /#$ (i$m'%$ '#$d$* '%$($*&a%d$&$%io%o d$ (# $(&ado *$#%ol7)ico + d$1$* ($% %$$-al#ado(

Lo( 'aci$*&$( /#$ '%$($*&$* col$ccio*$( d$ (a*)%$ + /#$ %$/#i$%a* ci%#)8ad$1$* ($% i*&$%-$*ido( i*m$dia&am$*&$ Si $l 'aci$*&$ '%$($*&a #* % 'idod$&$%io%o *$#%ol7)ico a*&$( d$ i*icia% $l '%oc$dimi$*&o /#i% %)ico, ($ da%&%a&ami$*&o co* ma*i&ol 0 2!0J 0 ) H) mi$*&%a( ($ i*icia la ci%#)8a '$%o $lma*i&ol $(& co*&%ai*dicado $* 'aci$*&$( /#$ *o &$*)a* dia)*7(&ico

Lo( 'aci$*&$( co* :la()o; d$ G o m$*o%, ($% * i*ado(, %$ci1i% * ($daci7*,%$la6a*&$( m#(c#la%$( + ($% * '#$(&o( $* %$('i%ado% 'o(&$%io%m$*&$ ($% *ll$-ado( a la #*idad d$ c#idado i*&$*(i-o 'a%a &%a&ami$*&o + c#a*do $(&éi*dicado, ($ '%ac&ica% mo*i&o%8a d$ la '%$(i7* i*&%ac%a*$a*a, ad$m ( d$l&%a&ami$*&o d$ la( l$(io*$( %$('$c&i-a(

TRATAMIENTO

A.#*oSO: a d$%i-aci7*

Me'i#a)ento!

Om$'%a@ol >0 m) I c 2> .%(DF 2! m) I cada G .%(Ci&ilcoli*a )% I c 2 .%(S#l3a&o d$ Ma)*$(io 4M) SO >5 )% I c G .%(

i&ami*a C )% I c 2 .%(M$&ami@ol )% I c 2 .%(E*ala'%il 0 m) SO: c 2 .%(Lo(a%& * !0 m) SO: c 2 .%(Cli*damici*a "00 m) I c G .%(C$3&a@idima 2 )% I c G .%(

id%oco%&i(o*a 00 m) I D U

Sol.#ione! B +e)o'eriva'o!

Sol#ci7* Mi &a 000 cc >0 m$/ CL ' 2> .%( $* ISol Sali*a 0 < !0 cc !0U d$ IAR D R $* ISol#ci7* (ali*a !00 cc


17/25




F$m$*i*a d$ B> , c% *$o *o%mo c$3 lico, co* '%$($*cia d$ 3%ac%a occi'i&alc$%%ada (i* d$('la@ami$*&o, co* ani!o#ori#a! , d$%$c.a d$ >mm, '#'ilai@/#i$%da co*($%-ada $* 2mm, a(imé&%ica(, co* %$('#$(&a *#la al $(&8m#lol#mi*o(o, Gla!/o d$ = (i* ($daci7*, $(&ado coma&o(o

Re!"iratorio& T#1o $*do&%a/#$al N B !, co* a'o+o -$*&ila&o%io $* modo ol#m$* A C, co*'a% m$&%o( -$*&ila&o%io( co*2EE2 , P%$(i7* So'o%&$ d$ 20,FIO8 al >0Vol.)en Corriente =VC@ d$ > 0 ml, 2 %'m '%o)%amada( $* $l -$*&ilado%'%$($*&a d$ GJ22 %'m, a la a#(c#l&aci7*, cam'o( '#lmo*a%$( co* %#ido(%$('i%a&o%io( '%$($*&$(, co* m#%m#llo -$(ic#la% di(mi*#ido, $(&$%&o%$((il1a*&$( 1ila&$%al$( $* 1a($(, '%$($*cia d$ 1%o*co$('a(mo, )a($( a%&$%ial$(2+ B =!,2aO 8 >" ,SaO 8 BG = ,2CO 8 =! G,+CO > < ",La#tato d$ >,E

> = (a%a*do al 2 JNe#e!i'a' 'e n.tri#i(n e 1i'rata#i(n&A UNO, m#co(a( .id%a&ada(, 'alid$@ &$)#m$*&a%ia(, $(&ado *#&%icio*al *oad$c#ado, co* So*da o%o) (&%ica 4SO:5 a d$%i-aci7* co* %$(id#o ) (&%ico

= JNe#e!i'a' 'e eli)ina#i(n&A1dom$* )lo1o(o, d$'%$(i1l$ a la 'al'aci7*, co* '$%i(&al(i( di(mi*#ida HGl.#e)ia #a"ilar ine!table 'e ; )/ 'lH #on in7.!i(n 'e in!.lina a

)l 1r , Urea d$ BG B, Creatinina K#i'o 5ri#o d$ = ,T2 2 >, T2T 2 !, TT " !, Fibrin(/eno != JNe#e!i'a' 'e )over!e B tener b.ena "o!t.ra 9Po(ici7* Fo;l$% a =0V $*camado, (i* ($daci7*, i*mo-ilidad 'o% TCE

! JNe#e!i'a' 'e 'e!#an!o B !.eQo&Al&$%ada 'o% $(&ado coma&o(o, colla%8* c$%-ical, 3é%#la( $* am1a( ma*o(

" JNe#e!i'a' 'e .!ar "ren'a! 'e ve!tir a'e#.a'a!&Al&$%ada 'o% la .o('i&ali@aci7* +a /#$ *o '#$d$ #(a% la -$(&im$*&a /#$ l$)#(&a

B


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B JNe#e!i'a' 'e ter)orre/.la#i(n 9i'$%&$%mia d$>

G JNe#e!i'a' 'e 1i/iene B "rote##i(n 'e la "iel&Palid$@ &$)#m$*&a%ia, 'i$l ($ca, l$(io*$( $* 1%a@o( + ma*o(

< JNe#e!i'a' 'e evitar "eli/ro!&R$()#a%dado co* cama co* 1a%a*dal$( $* al&o

0 JNe#e!i'a' 'e #o).ni#a#i(n& Al&$%ada 'o% $(&ado coma&o(o + T#1o $*do&%a/#$al

La! ne#e!i'a'e! 'e valore! B #reen#ia!H 'e trabajo B reali?a#i(nH 'e

j./ar en a#tivi'a'e! re#reativa! B la ne#e!i'a' 'e a"ren'i?ajeH no7.eron #o)"le)enta'a! Ba 4.e el 7a)iliar 'e!#ono#e

NIVEL&>er

ES2ECIALIDAD&TERA2IA

NEUROLOGICA

SERVICIO&UCIN 2LAN DE CUIDADOS DE ENFERMERÍA 2ERSONALI ADO A 2A

DIAGNÓSTICO DE ENFERMERÍA4ED FR C D 5

CLASIFICACIÓN DE LOS RESULTADOS

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Do)inio& > Ac&i-idad R$'o(oCla!e& > R$('#$(&a ca%dio-a(c#la% P#lmo*a%$(

Ri$()o d$ la '$%3#(i7* &i(#la% c$%$1%alI*$?ca@ r # &%a#ma&i(mo c%a*$o$*c$3 lico $.i'$%&$*(i7*

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RESULTADO INDICADORES

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Sal#d ?(iol7)ica II

CLASE9N$#%oco)*i&i-a 4W5

E!ta'o Ne.rol(/i#o

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CLASIFICACIÓN DE LAS INTERVENCIONES DE ENFERMERÍA =CAM2O& 8 Fi(iol7)ico Com'l$6o CLASE& I Co*&%ol N$#%ol7)ico= 8B

CAM2O& 8 Fi(iol7)ico Com=8 :@ P ) >2<

INTERVENCIÓN INDE2ENDIENTE& IN

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CAM2O& 8 Fi(iol7)ico Com'l$6o CLASE& Co*&%ol R$('i%a&o%io =>; :@

Ma*$6o d$ la( -8a( aé%$a( a%&i?cial$(P ) =00

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