Presentación de un caso clínico en el que un varón de 91 años acude al servicio de Urgencias de su Hospital de referencia por disnea o dificultad respiratoria sin especificar de mínimos esfuerzos, dolor torácico y taquicardia. Tras valoración y realización de pruebas, se decide ingreso en la planta de Neumología.
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 paciente con drenaje pleural acorde a sus necesidades, además de conocer y estar alerta sobre las posibles complicaciones que puedan aparecer, como son la hemorragia, infección, lesiones orgánicas, neumotórax, hematoma y disnea.
Presentation of a clinical case in which a 91-year-old man goes to the Emergency Department of his referral hospital due to dyspnea or unspecified respiratory difficulty with minimal effort, chest pain and tachycardia. After evaluation and tests, it was decided to admit him to the Pulmonology 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 the patient with pleural drainage according to their needs, in addition to knowing and being alert about the possible complications that may appear, such as hemorrhage, infection, organic lesions, pneumothorax, hematoma and dyspnea.