2014, Number 2
Nursing care process applied to a patient with a pressure ulcer with suspected deep tissue damage
Full text
Language: Spanish
References: 27
Page: 60-69
PDF size: 312.27 Kb.
ABSTRACT
Introduction: A pressure ulcer is defined as an ischemic injury which is located in the skin and underlying tissues, over a bony prominence, caused by prolonged pressure, friction or shear forces. 95% of cases are preventable, and the remaining 5% occur due to patient conditions that do not allow modifying risk factors. Objective: To make interventions for a patient with suspected deep tissue injury, where the interventions made by the Wound Clinic are established. Methodology: Clinical case study in male aged 33, descriptive, prospective and longitudinal with monitoring for a month, based on the process of nursing care of Virginia Henderson conceptual approach addressing three altered needs. Diagnostic and plans are based on the taxonomic interrelationships NANDA-NIC-NOC. Results: 3 real diagnoses were identified in the need for security; the main diagnostic category was impaired skin integrity; secondaries were risk of infection and acute pain. A risk diagnosis was established: impaired skin integrity. Conclusion: Through established interventions by applying wet environment therapy full resolution and healing of pressure ulcers with suspected deep tissue damage where observed, without progression to more severe stages, allowing that the patient went home to continue treatment and outpatient follow-up.REFERENCES
1. Asociación Mexicana para el Cuidado Integral y Cicatrización de Heridas A.C. Úlceras por presión [Internet]. México: Asociación Mexicana para el Cuidado Integral y Cicatrización de Heridas A.C.; [citado 16 de marzo de 2014]. Disponible en: http://www.amcichac.com/index.php/component/content/article/10-heridas/65-úlcerasporpresion2.
European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel. Prevención de úlceras por presión: Guía de referencia rápida [Internet]. Washington DC: National Pressure Ulcer Advisory Panel; 2009 [citado 16 de marzo de 2014]. Disponible en: http://www.epuap.org/guidelines/QRG_Prevention_in_Spanish.pdf
García F, Montalvo M, García A, Pancorbo A, García F, González F et al. Guía de práctica clínica para la prevención y el tratamiento de las úlceras por presión [Internet]. Andaluz: Consejería de Salud. Junta de Andalucía; 2006 [citado 30 de marzo de 2014]. Disponible en: http://revistacuidandote.eu/fileadmin/VOLUMENES/2013/Volumen4/Recomendaciones/UPP.pdf
López C, Herrero S, De Diego S, López T, Rojas J, López T. Guía para la atención integral del paciente con heridas crónicas y úlceras por presión [Internet]. Segovia: Gerencia de atención primaria de Segovia; 2012 [citado 20 de marzo de 2014]. Disponible en: http://bazar.fundacionsigno.com/documentos/proceso-asistencial-del-paciente/guia-para-la-atencion-integral-del-paciente-con-heridas-cronicas-y-úlceras-por-presion.-gerencia-de-atencion-primaria-de-segovia
Lozano A. Úlceras por presión. Parte 1 [Internet]. México: Asociación Mexicana para el Cuidado Integral y Cicatrización de Heridas A.C. [citado 16 de marzo de 2014]. Disponible en: http://amcichac.com/index.php/noticias/pacientes/que-es-una-herida/que-es-una-herida/49-blog/blog-heridas/123-úlceras-por-presion
VanGilder C, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey 2006-2009. Adv Skin Wound Care [Internet]. 2010 [citado 24 de mayo de 2014]; 23(6): 254-261. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/20489387#
VanGilder C. Prevalence of suspected deep tissue injuries: analysis of the 2012 international pressure ulcer prevalence survey, 2012 NPUAP consensus panel, biennial meeting, oral presentation [Internet]. 2012 [Citado 24 de mayo de 2014]. Disponible en: http://www.npuap.org/wp-content/uploads/2012/01/VanGilder-sDTI-talk-NPUAP-2013-VanGilder-31.pdf
Muñoz A, Ballesteros M, Díaz C, González J, Aparicio A, Sánchez A et al. Manual de protocolos y procedimientos en el cuidado de las heridas [Internet]. Madrid: Hospital Universitario de Mostoles; 2011 [citado 25 de mayo de 2014]. Disponible en: http://www.gneaupp.es/app/adm/documentos-guias/archivos/104_pdf.pdf
Forteza M, Muñoz L, Alonso G, Machota P, Jiménez M, García D et al. TIME: eliminación del tejido no viable [Internet]. Smith & Nephew S.A.U. División Curación de Heridas: Sant Joan Despí; 2011 [citado 19 de marzo de 2014]. Disponible en: http://www.formacionpararesidencias.es/wp-content/uploads/2012/03/t-de-time_07-11.pdf
— Sari Y, Nagase T, Minematsu T, Akase T, Nakagami G, Sanada H et al. Hypoxia is involved in deep tissue injury formation in a rat model. Wounds [Internet]. 2010 [citado 9 de mayo de 2014]; 22(2): 44-51. Disponible en: http://www.google.com.mx/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&sqi=2&ved=0CC0QFjAA&url=http%3A%2F%2Fwww.researchgate.net%2Fpublication%2F236672923_Hypoxia_is_Involved_in_Deep_Tissue_Injury_Formation_in_a_Rat_Model._WOUNDS._201044-51%2Ffile%2F3deec518d8c28bc1b0.pdf&ei=mYl5U9WPM9aLqAaoq4CICA&usg=AFQjCNGdpT9u9sIlNGpYg1mlFEhdT6py2Q&bvm=bv.66917471,d.b2k
— Valdés M, Grondona F, Maya C. Úlceras por presión como complicación de la enfermedad cerebrovascular: estudio de nueve años [Internet]. [citado 25 de mayo de 2014]. Disponible en: http://www.sld.cu/galerias/pdf/sitios/urgencia/087_-_úlceras_por_presi%D3n_como_complicacion_de_la_enfermedad_cerebro_vascular.pdf