Lucía Rodríguez Delgado, Marta Mateo Casanova, Victoria Emilia Souviron Dixon, Álvaro Moreno Gómez, Marta Ojeda Caparrós, Miguel López Lucena
Paciente que acude a urgencias con un cuadro de evolución de 3 días con sintomatología gastrointestinal e infecciosa. Es un paciente con antecedentes personales y quirúrgicos de neoplasia maligna de recto, portador de colostomía y con tratamiento ajustado a sus necesidades. Ingresa en urgencias donde se le extraen varias pruebas complementarias y en función de sus resultados se comienza con reposición de líquidos, analgesia y terapia antibiótica.
Tras una vigilancia estrecha, ingresa en la unidad de cirugía general para continuar con pruebas y ajuste de tratamiento, así como posible valoración quirúrgica.
Durante su ingreso en las urgencias, se le realiza un plan de cuidados acorde a su situación para poder optimizar sus cuidados en base a diagnósticos NANDA, objetivos NOC e intervenciones NIC.
A 71-year-old patient came to the emergency room with a 3-day history of gastrointestinal and infectious symptoms. He is a patient with a personal and surgical history of malignant neoplasia of the rectum, a colostomy patient, and treatment tailored to his needs. He is admitted to the emergency room where several complementary tests are performed and depending on their results, fluid replacement, analgesia and antibiotic therapy are started.
After close monitoring, he is admitted to the general surgery unit to continue testing and treatment adjustment, as well as possible surgical evaluation.
During his admission to the emergency room, a care plan is made according to his situation in order to optimize his care based on NANDA diagnoses, NOC objectives and NIC interventions.