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ScribdTranslationsJUÁREZ AUTONOMOUS UNIVERSITY OF TABASCO
“STUDY IN DOUBT. “ACTION IN FAITH”
Multidisciplinary Academic Division of Jalpa de Méndez
NURSING CARE PROCESS APPLIED TO A PATIENT WITH A DIAGNOSIS OF
ISCHEMIC HEART DISEASE/TEMPORARY PACEMAKER.
CENTER OF MEDICAL SPECIALTIES “DR. “JULIAN MANZUR OCAÑA”
STUDENT:
PERLA PIEDAD VALENCIA GARCÍA
CLINICAL FUNDAMENTAL NURSING
TEACHER'S NAME:
RIGOBERTO JIMENEZ HERNANDEZ
VILLAHERMOSA, TABASCO, OCTOBER, 2015
INDEX
INTRODUCTION…………………………………………………………………………………………...2
OBJECTIVES……………………………………………………………………………………………………
..3
GENERAL OBJECTIVE………………………………………………………………………………3
IDENTIFICATION SHEET………………………………………………………………………………4
ASSESSMENT GUIDE ACCORDING TO MARJORY GORDON'S FUNCTIONAL
PATTERNS………………………………………………………………………………………………………
………. 5
1-HEALTH PERCEPTION/MAINTENANCE PATTERN…………………………………….5
2-NUTRITIONAL/METABOLIC PATTERN…………………………………………………………..5
3-ELIMINATION
PATTERN……………………………………………………………………………….6
4-ACTIVITY-EXERCISE
PATTERN……………………………………………………………………..6
5-SLEEP-REST PATTERN……………………………………………………………………6
6-COGNITIVE-PERCEPTUAL PATTERN…………………………………………………………..6
7-SELF-PERCEPTION-SELF-CONCEPT PATTERN………………………………………………7
8- ROLE-RELATIONSHIP
PATTERN……………………………………………………………………..7
9-SEXUALITY-REPRODUCTION
PATTERN………………………………………………………….7
10-ADAPTATION PATTERN-STRESS TOLERANCE……………………………………8
11-VALUES-BELIEF PATTERN…………………………………………………………………….8
PHYSICAL
EXAMINATION………………………………………………………………………………………….9
TAKING ANTHROPOMETRIC MEASUREMENTS……………………………………………………
10
CONCLUSION…………………………………………………………………………………………11
BIBLIOGRAPHY………………………………………………………………………………………….12
INTRODUCTION
The nursing process is the application of the scientific method to healthcare
practice. This method allows nurses to provide care in a rational, logical and
technical way, it is essential to record data and actions in such a way that they can
be discussed, analyzed, and thus evaluate the conditions of the patients who need
care for their health. speedy recovery.
In nursing assessment, different methods and techniques are used, such as
interviews and exploratory exams, which allow functional and dysfunctional health
patterns to be detected, thus detecting in which situation users or patients require
professional help.
Thus, nursing staff can create a problem identification with health data, identify the
main problems, establish priorities, plan and organize the care that the patient
requires.
This work shows the implementation of the nursing care process applied to a user
in the medical specialty center “Dr. Julián Manzur Ocaña”, in the hospitalization
area, with a diagnosis of ischemic heart disease/temporary pacemaker. Where the
nursing assessment will be carried out, using Marjori Gordon's 11 functional
patterns, which allows us to identify the signs and symptoms of the patient's altered
pattern, using the already known assessment instruments.
2
GENERAL OBJECTIVE
Apply knowledge, principles and skills in nursing practice, identifying the
health needs of individuals, families and groups with a holistic vision, using
critical thinking for the assessment and diagnosis of real and potential health
problems in the environment. hospital setting.
SPECIFIC OBJECTIVES
Provide nursing care to the hospitalized patient with Dx, ischemic heart
disease/temporary pacemaker carrier, previously considering the
assessment to identify needs and carry out the execution of techniques and
procedures specific to the service.
Participate in the promotion and protection of health through patient and
family education, with didactic techniques, maintaining a professional and
ethical attitude at all times of their practical development.
3
IDENTIFICATION FILE :
Entry date: 11-10-15
Name: MERH
Female gender
Age: 56 years
Weight: 70kg.
Size : 1.59 cm.
BMI: 27.6
Date of birth: 07/25/59
Place of birth : R/A San Simón. Nacajuca, Tabasco.
Religion: Jehovah
Service: hospitalization
Bed: 211
Education: none
Occupation: housewife
Marital status Married
Monthly income: $2,000
4
ASSESSMENT GUIDE ACCORDING TO MARJORY GORDON'S
FUNCTIONAL PATTERNS
1.- HEALTH PERCEPTION/MAINTENANCE PATTERN
A 56-year-old female patient is brought by her family member (daughter-in-law) to
the “DR. JULIAN MANZUR OCAÑA” stating that his mother-in-law has been
feeling listless for two days. The services your home has are: drinking water
system, electricity, septic tank and garbage collection service that runs periodically
three times a week. Her daughter-in-law indicates that the hygienic characteristics
of her home are: daily cleaning at home, hygienic preparation of food. And that
before entering the hospital his self-care was bathing 2 times a day, brushing his
teeth 3 times a day. He mentions that he has never consumed intoxicating drinks,
and indicates that he washes his hands before eating and after going to the
bathroom. She has a history of surgery, hysterectomy and a cesarean section.
2.- NUTRITIONAL/METABOLIC PATTERN
The patient has a weight of 70kg, a height of 1.59 cm, the result is BMI: 27.6, so it
is considered that she is in a state of grade 1 obesity, with changes in her weight
o
since the hospital stay, her body temperature is 36.3 C, hair is long, black,
capillary refill of 03 seconds, with a trace of dandruff, thin, clean appearance, nails
with a smooth texture, short and clean, dry and pale lips, dry skin, dehydrated
mucosa , average dental hygiene, no prosthesis, with cavities, missing tooth
(incisor one). No edema, no vomiting, currently no gastrointestinal pain, no
wounds, with central venous catheter infusion.
In his diet, he states that he eats three times a day, the foods he consumes each
week are a varied diet, consumption of chicken, red meat, fruits and vegetables,
and dairy products (low in salt). During his stay in the hospital, he had dietary
restrictions. The diet prescribed to him was an astringent diet without irritants and
without salt with plenty of fluids.
5 3.-ELIMINATION PATTERN
The patient reports that the characteristics of urination are light yellow 1 to 2 times
a day of approximately 300 ml, normal brown stools once a day of 200 to 300 mg.
He does not have problems with colic, flatulence or any type of intestinal problem.
4.-EXERCISE ACTIVITY PATTERN
She comments that she has little activation, since she feels a lack of energy, feels
tired and needs help to carry out an activity.
The following data are found in the assessment of vital signs. HR: 80x, T/A: 120/80
mm Hg AND RR: 23x, capillary refill 03 seconds
It is observed that he has all his upper and lower limbs and needs help to carry out
his activities.
5.-SLEEP-REST PATTERN
When evaluating this pattern, the patient reports having sleep disturbances due to
the noise of the hospital. She sleeps at least 10 hours a day but has difficulty falling
asleep due to the noise of the hospital.
6.-COGNITIVE-PERCEPTUAL PATTERN
The patient is conscious and located in his 3 neurological spheres (time, place and
space), he mentions that he lives with his relatives (husband and daughter), he
does not have visual or taste problems, he only has hearing problems, he hears
little with the right ear.
The patient states that she has little knowledge of her illness and the complications
for which she is hospitalized, and she does everything she can to ensure her care
and improvement. She mentions that 14 years ago she was diagnosed with T2
diabetes mellitus and she needs to do everything she can. for your care and
improvement.
7.-SELF-PERCEPTION-SELF-CONCEPT PATTERN
The patient has a perception of herself and is interested in her health and mentions
that she is a very happy person and that despite being hospitalized she does not
lose her good humor. He also comments that during his stay in the hospital he has
received good treatment from the nurses and the doctors in charge and that they
have the necessary hygienic measures and care for his speedy recovery.
8.-ROLE-RELATIONSHIP PATTERN
The people who live with her are her husband and one of her daughters. Currently,
he says that he lives very happily with his entire family without any problems, he
does not have small children to support. He presents feelings of loss (father and
mother deceased), he does not present anxiety and sadness during his stay in the
hospital, his family supports him for his speedy improvement and encourages him
to move forward. There are some difficulties for self-care, he needs help with his
needs, no abandonment, no isolation, no difficulty in communication.
9.-SEXUALITY-REPRODUCTION PATTERN
She currently lives with her husband, she has very good communication with the
whole family, she says she is satisfied with having 6 children, she does not feel
alone, she feels happy with how she lives, she comments on the beginning of an
active sexual life at 18 years old and she does not plan. She is unaware of most of
the methods, menarche at age eleven, last menstrual period at age 23, never had
menstrual problems, no sexually transmitted diseases, zero abortions, one
cesarean section, vaginal cytology, breast examination is done.
10.-ADAPTATION PATTERN-STRESS TOLERANCE
The patient reports that when she presents personal or family problems, she faces
them through dialogue in order to find a solution for it. He hardly gets angry or yells
at home, he mentions that respect for the family is the best for promoting values.
Currently he has managed to face his illness problem and does not worry since he
has the support of his entire family and complies with all the doctor's instructions,
takes all his medications, because he wants to recover.
11.-VALUE PATTERN- BELIEFS
The patient professes the Jehovah religion and is a very believer. He comments
that when he has any worries he entrusts himself to God since he is a faithful
believer. He belongs to a religious group in his church in which he likes to
participate.
PHYSICAL EXAM
Name: MERH
Age: 56 years
Vital signs constants:
Temperature: 36.3 o C
Pulse: 80x
Blood pressure: 120/80 mm Hg
Breathing: 23x
TAKING ANTHROPOMETRIC MEASUREMENTS
Weight: 70kg
Size: 1.59 cm
BMI: 27.6
HEAD: Normocephalic, black hair, well established dry, brittle, long,
thin, with traces of dandruff.
FACE: Broad symmetrical forehead, evaluation shows thin,
symmetrically aligned eyebrows.
EARS: Symmetrical, well-placed pinnae at the level of the external
angle of the eye, flexible, uniform in color to the skin of the face, the
ear canals are well marked, they are intact, firm and pain-free.
EYES: Symmetrical, normoreflexic, dehydrated conjunctive pupils,
auricular movements, good palpable opening, transparent cornea,
eyelashes with good implantation, with dark circles.
NOSE: median, central, patent nostril and nasal septum without
deviation.
ORAL CAVITY: The mouth is small, symmetrical, thin, pale lips,
incomplete teeth, one incisor missing,
NECK: Symmetrical, short, without presence of edema or lymph
nodes
THORAX: Symmetrical chest movements, ventilated lung fields on
auscultation, normal respiratory sounds. Normal and symmetrical
breasts and nipples
ABDOMEN: Soft to palpation, without pain, with scarring from a
cesarean section, and from a womb operation.
UPPER LIMBS: Both limbs present symmetrical, with presence of
integral and thin nails
LOWER LIMBS: Both limbs present, symmetrical, with hair,
hydrated skin, symmetrical, thermal norm without edema, with
presence of intact nails.
CONCLUSION
What I did in this work helped me to reaffirm theoretical knowledge by developing
skills in nursing practice. Writing the work was a little difficult for me due to the
collection of data, but with the help of the teacher and my effort I managed to reach
the goal. indicated objective and also thanks to the patient who was willing to
collaborate with the requested information.
BIBLIOGRAPHY
