Acceso usuarios
Zaragoza, España
La hemorragia subaracnoidea es un sangrado en la zona comprendida entre el cerebro y los tejidos que lo cubren. Esta zona se llama espacio subaracnoideo. Es una emergencia y necesita atención médica inmediata1.
Dentro de los cuidados de enfermería durante la estancia en UCI, se encuentra la observación, vigilancia y control neurológico. El control neurológico es muy importante en paciente con TCE, se le realiza horario, consiste en mirar tamaño de ambas pupilas, reflejo corneal, fotomotor, y Escala Glasgow. Las primeras horas de vigilancia y control son muy importantes en pacientes con TCE, para poder evitar complicaciones. Determinaremos el grado de dependencia-independencia en la satisfacción, según las Necesidades Básicas de Virginia Henderson. Se enunciarán los principales Diagnósticos de Enfermería basados en la Taxonomía II de NANDA-Internacional, resultados NOC e intervenciones durante su estancia en UCI.
Subarachnoid hemorrhage is bleeding in the area between the brain and the thin tissues that cover it. This area is called the subarachnoid space. It is an emergency and needs immediate medical attention. The cause in our patient was due to head trauma, caused by an accidental fall down the stairs at home; in other types of patients, it could be caused non-traumatically.
Within the Nursing Care during the stay in the ICU, there is observation, surveillance and neurological control. Neurological control is very important in patients with TBI, it is scheduled, it consists of looking at the size of both pupils, corneal reflex, photomotor, and Glasgow Scale. The first hours of monitoring and control are very important in patients with TBI, in order to avoid complications. We will determine the degree of dependence-independence in satisfaction, according to Virginia Henderson’s Basic Needs. The main Nursing Diagnoses based on the NANDA-International Taxonomy II, NOC results and interventions during their stay in the ICU will be enunciated.
