Resumen de Plan de cuidados de enfermería en paciente con hemorragia digestiva alta

Marcela Estefanía Núñez Martínez, Daniel Sánchez Moyano, Edna Rocío Salazar Sánchez, Sara Zurbano Serena, María Rosario Taguas Rodríguez, Elena Laura Badescu Pirvulescu

• español

  Varón de 40 años que acude por hematemesis hace dos días (3 vómitos al día con coágulos) y deposiciones melaninas sin dolor abdominal. Ayer tras ir al baño realizó una deposición normal y posteriormente caída al suelo con contusión y pérdida de conciencia. Durante la entrevista refiere debilidad generalizada, no focalidad neurológica. También nos comenta que aumentó el consumo de tabaco en contexto de baja laboral.

  Paciente trasladado en ambulancia desde su domicilio, no quiere avisar a nadie, sus padres que viven en Málaga. Nos comenta que lleva cuatro meses de baja, reconoce que debido al dolor se ha sobremedicado, lleva varios meses aislado sin salir de casa, apenas se relaciona con sus amigos y familiares. Debido al dolor no dormía y sus hábitos alimenticios no eran adecuados.

• English

  A 40-year-old man presented with hematemesis two days ago (3 vomitings a day with clots) and melanin stools without abdominal pain. Yesterday after going to the bathroom he had a normal bowel movement and subsequently fell to the floor with bruises and loss of consciousness. During the interview, he reported generalized weakness, not neurological focality. He also tells us that tobacco consumption increased in the context of sick leave.

  Patient transported by ambulance from his home, he does not want to notify anyone, his parents who live in Malaga. He tells us that he has been out for four months, he recognizes that due to the pain he has overmedicated, he has been isolated for several months without leaving the house, he barely interacts with his friends and family. Due to the pain, he did not sleep and his eating habits were not adequate.