Resumen de Caso clínico: Continuidad asistencial en un paciente con insuficiencia cardiaca avanzada en tratamiento con Dobutamina

Ana María Muñoz Bautista, Raquel Cruz Díaz, Y. Vélez Pérez, Marta Puig Calvet,, Carlos Luís Durán Escuadra, María Vilà Mir,, Hospital Universitari Doctor Josep Trueta (Girona)

• español

  Describimos el caso clínico de un varón de 68 años con múltiples factores de riesgo cardiovascular. Se utilizó el modelo de Henderson y las taxonomías NANDA, NIC y NOC. Los principales problemas fueron los derivados de los diagnósticos enfermeros: �intolerancia a la actividad� y �gestión ineficaz de la propia salud�. También surgieron problemas de colaboración como: �infección del reservorio venoso� e �hiperglicemia�. En los NOC, el resultado ini de la causa de la fatiga, la suplencia en las actividades de autocuidado y la enseñanza respecto al autocontrol de la enfermedad.

• English

  We describe a clinical case report of a 68 year old male patient, with multiple cardiovascular risk factors. We used Henderson model and NANDA, NIC and NOC taxonomies in our evaluation. Main problems were raised with nurse diagnosis concerning �activity intolerance� and �non competent self-health management�. There were also problems concerning considerations related to �central venous subcutaneous system infection (CVSS)� and �hyperglycaemia�. In NOC, initial results (IR) about support in daily life activities were low; with infections of CVSS happened in two occasions. Finally, eighteen months later, the patient accepted home social care support and was then when the best final results (RF5) were achieved. To assure continuing assistance some activities were carried out such as optimizing energy management and working out to define weakness cause, as well as encouraging patient in self-care and enhancing his knowledge in illness self-management.