Case study of a user with diagnosis: post-operated decompresive craniotomy, probable subdural empyema

Introduction: The case study focuses on a user with post operative medical diagnosis of decompressive craniotomy, probable subdural empyema, hospitalized in the Internal Medicine service in a public hospital institution in the state of Sonora. Methodology: A focused nursing assessment was carried ou...

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Bibliografische gegevens
Hoofdauteurs: Sandoval-Gutierrez, Karla Abigail, Rojas-Vega, María Emma
Formaat: Online
Taal:spa
Gepubliceerd in: Universidad de Sonora 2019
Online toegang:https://sanus.unison.mx/index.php/Sanus/article/view/80
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Samenvatting:Introduction: The case study focuses on a user with post operative medical diagnosis of decompressive craniotomy, probable subdural empyema, hospitalized in the Internal Medicine service in a public hospital institution in the state of Sonora. Methodology: A focused nursing assessment was carried out, implementing the nursing assessment guide according to the functional health pattern of Marjory Gordon. Nursing diagnoses were identified based on the unique responses of the user, using the NANDA I taxonomy II; later the interventions were planned, implementing individualized care plans with the NOC NIC taxonomies, focused on the persons needs. Results: Eight nursing diagnoses were identified from the focused assessment carried out, of which four are real diagnoses and four are risk diagnoses. Conclusions: the nursing assessment allows us to identify the unique users needs and it is the nursing staff responsibility to have the necessary knowledge to be able to offer a warmth and quality human care to the users with different pathoolgies.