Presentación de un caso clínico en el que un varón de 75 años acude al servicio de Urgencias de su Hospital de referencia por presentar un empeoramiento progresivo de su disnea habitual de 3-4 días de evolución, hasta hacerse de reposo, asociando ortopnea e hinchazón de las extremidades inferiores. Tras valoración y realización de pruebas, se decide ingreso en la planta de Medicina Interna.
Con respecto a la valoración del paciente se ha empleado el modelo de 14 necesidades de Virginia Henderson. Además, se ha utilizado la taxonomía NANDA (North American Nursing Diagnosis Association) (2021-2023), NIC (Nursing Interventions Classification) y NOC (Nursing Outcomes Classification). El plan de cuidados va dirigido al control de síntomas, vigilar la aparición de signos de alarma indicativos de descompensación de la enfermedad y al mantenimiento de un estilo de vida saludable.
Presentation of a clinical case in which a 75-year-old man went to the Emergency Department of his referral hospital due to a progressive worsening of his usual dyspnea lasting 3-4 days, until he began resting, associating orthopnea and swelling of the joints. lower extremities. After evaluation and tests, it was decided to admit him to the Internal Medicine ward.
Regarding the assessment of the patient, the model of 14 needs of Virginia Henderson has been used. In addition, the NANDA (North American Nursing Diagnosis Association) (2021-2023), NIC (Nursing interventions classification) and NOC (Nursing outcomes classification) taxonomy have been used.
The care plan is aimed at controlling symptoms, monitoring the appearance of warning signs indicative of decompensation of the disease and maintaining a healthy lifestyle.