UNIVERSIDAD PRIVADA SAN JUAN BAUTISTA

FACULTAD CIENCIAS DE LA SALUD

ESCUELA DE ENFERMERIA

NURSING CARE PROCESS

CURSO:

INGLES TECNICO I

PRESENTADO POR:
PACHAS MACHA YULEIKA ZULEMA

DOCENTE:
DEL PINO ASCONA DENNIS YVONNE

AÑO:
2023-I

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 PNEUMONIA

It is an infection that inflames the air sacs of one or both lungs. The air sacs may fill with
fluid or pus (purulent material), leading to coughing up phlegm or pus, fever, chills, and
shortness of breath. Various microorganisms, such as bacteria, viruses, and fungi, can cause
pneumonia.
SIGNS AND SYMPTOMS:
 Chest pain when breathing or coughing
 Disorientation or changes in mental perception (in adults age 65 and older)
 Cough that can produce phlegm
 Fatigue
 Fever, sweating, and chills with shaking
 Lower-than-normal body temperature (in adults older than 65 and people with a
weak immune system)
 Nausea, vomiting, or diarrhea
 Shortness of breath
WHAT ORGANS DOES PNEUMONIA AFFECT?
Pneumonia is a type of acute respiratory infection that affects the lungs. These are made up of tiny
sacs, called alveoli, which—in healthy people—fill with air when you breathe.

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 MELLITUS DIABETES

A disease in which the body does not control the amount of glucose (a type of sugar) in the blood
and the kidneys make a large amount of urine. The disease occurs when the body does not produce
enough insulin or does not consume it the way it should.
SIGNS AND SYMPTOMS
 Increased thirst
 Frequent urination
 Fatigue
 Increased appetite
 Numbness or tingling in the hands or feet
 Ulcers that do not heal
 Weight loss for no apparent reason
 Blurry vision

WHAT ORGANS DOES DIABETES MELLITUS AFFECT?

Damage to the autonomic nerves affects the heart, bladder, stomach, intestines, sexual organs, or
eyes. Symptoms may include: Bladder or bowel problems that may cause urine loss, constipation, or
diarrhea. Nausea, loss of appetite and vomiting.

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 CLINICAL CASE
Mrs. Blanca Palomino, 68 years old with a history of diabetes mellitus, awake, feverish; she was admitted to
medicine due to pneumonia, she was dyspnea, exhausted, with hyperthermia, profuse sweating, diaphoretic. She
refers to having chest pain; both lung fields are auscultated, which are heard crackling and hoarse, with a
productive cough.
Intravenous metamizol is administered every 8 hours, intravenous ceftriaxone every 24 hours, salbutamol 3puffs
every 2 hours, and X-rays are processed.
DATA ORGANIZATION

RELEVANT DATA DOMAIN/ CLASS/ CODE NURSING DIAGNOSIS

SUBJECTIVE DATA:
Does not apply SELF-CARE DEFICIT IN
DOMAIN: 4 Activity / Rest
OBJECTIVE DATA: BATHROOM R/C
CLASS: 5 Self-care: bath
It is observed thin DISCOMFORT E/P BAD
CODE: 00108
With bad conditions HYGIENIC CONDITIONS
Of hygiene.

NURSING
OBJECTIVE INTERVENTIONS FUNDAMENTALS ASSESSMENT
DIAGNOSIS
SELF-CARE Patient upgrade to 1. Make awareness to the 1. Explain the procedure will help the Patient improves your
DEFICIT IN your hygiene staff patient of procedure that patient feel more secure and calm. hygiene staff with
BATHROOM R/C with help of the will be performed. help of the care of
DISCOMFORT care of nursing. 2. Foster in the patient 2. This will improve your adequate nursing.
E/P BAD practice of self-care nutrition at needs, measures hygiene,
HYGIENIC stress management, etc.
CONDITIONS 3. Maintain a routine 3. It will help the patient practice
activity diary of hygiene. daily grooming preventing the risk of
diseases.
4. Perform cleaning of 4. Helps remove dirt visible and also
nails. unseen microorganisms.
5. Check level of 5. Improves digestion and prevents
hydration. constipation, increases the energy and
improves capacity physics helps
maintain skin without imperfections.
6. Carry out washing 6. It will help prevent infections on
hair. the scalp and lice appearances.
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 DATA ORGANIZATION

RELEVANT DATA DOMAIN/ CLASS/ CODE NURSING DIAGNOSIS

SUBJECTIVE DATA:
 Refers to drowning with
DOMAIN: 11 Security/protection INEFFECTIVE TRACK
the phlegm
ineffective track cleaning CLEANING AERIAL R/C
 Communicates with signs.
aerial OBSTRUCTION AIRWAY M/P
OBJECTIVE DATA:
CLASS: 2 Physical injury ARE OBSERVED HEMOPTOIC
It is observed thin
CODE: 00031 SECRETION
With bad conditions
Of hygiene.

NURSING
OBJECTIVE INTERVENTIONS FUNDAMENTALS ASSESSMENT
DIAGNOSIS
INEFFECTIVE Patient will achieve 1. Prepare materials to do 1. Have materials ready will help to Patient achieves
TRACK remove the aspiration of secretions. optimize the time in that we will remove the
CLEANING accumulation carry out the procedure. accumulation
AERIAL R/C abundant of 2. Do the washing hand 2. Performing clinical lavage will abundant of
OBSTRUCTION secretions with the clinician help achieve a high level of asepsis. secretions.
AIRWAY M/P help of the staff of 3. Put on PPE 3. To create a barrier between you PA: 118/60
ARE OBSERVED Nursing during his and the microbes. FR: 23
HEMOPTOIC stay hospitable. 4. Approach the patient 4. Explaining the procedure will help HR: 83
SECRETION and explain the procedure make the patient feel more safe and SapO: 95%
calm. Patient will be note
5. Verify that the patient 5. Place the patient in recumbent calmer and can
is found in position of position supine reduces mortality in breathe with ease.
supine position with head clinical situations, in addition to
at 30 degrees. improves the patient's oxygenation.
6. Increase their 2 6. Increasing fio2 helps to decrease
concentration 13-17 g/dL the confinement of oxygen in the tree
in males. respiratory.
7. Review constantly the 7. Checking vital signs will help see
vital signs o patient. if the body is working correctly
8. Perform the correct 8. Carry out the correct aspiration
assisted aspiration of the with help from the collaborator will
collaborator. help in the improvement of the
patient