10 Running Head: Modulo 2 Plan de Cuidado- (cuidado holístico) Situación Hipotética A 55-year-old woman admitted 2 days ago to the Intensive Care Unit. The admission diagnoses are: vomiting, seizures, and probable aspiration. She has a prior history of hypertension, COPD, and myocardial infarction with angioplasty performed six months ago. Family members report that the client uses the following routine medications: Toprol 50mg 1 tab. daily, Lipitor 20 mg 1 tab. daily, Aspirin 81 mg 1ab. Daily, Plavix 75 mg 1 tab. daily; He smokes a daily pack of cigarettes since he was 30 years old. They also report that the patient drinks alcohol continuously; "In the last 3 days I have found her drunk in the house" said the woman's nephew. The patient is 5'11'' and weighs approximately 180 pounds. Upon arrival at the emergency room she presents vital signs of: T-37°C, P-150/min., R-28/min. and B/P-193/124 mmHg. She is observed with recurrent vomiting and severe episodes of seizures, respiratory distress, and severe anxiety. Dr. Díaz orders ABG's which result in: pH-7.30, PaCO 2 -50 mmHg, PO 2 -81 mmHg and NaHCO 3 -23 mEq/L, Sat. 85%. The client is sedated with Propofol 5mL, for oroendotracheal intubation and transferred to the ICU area. Blood pressure after intubation medication decreased to 80/52 mmHg. She is restricted to patient per intubation protocol. Laboratory samples show elevated liver enzymes, elevated cholesterol and triglycerides, and normal CBC. Introduction: Aspiration pneumonia is caused by aspiration of oropharyngeal contents into the airways, leading to abscess lesions due to bacterial infection in the lower lung lobes. It generally occurs in patients with frequent seizures and loss of mental status, with impaired swallowing of food or loss of the gag reflex (Aspiration pneumonia, n.d.). In this work we will carry out the care plan and the nursing progress notes of a 55-year-old female patient admitted to the Intensive Care Unit with respiratory distress probably caused by pneumonia due to aspiration of her own vomit, leading her to a state of acute respiratory acidosis with adequate bicarbonate compensation by the kidney. Care Plan: Estimado Diagnóstico de Enfermería Expected results Nursing Interventions Evaluatión domains Needs maladaptive behaviors Focal Stimulus Interventions Scientific Rational subjective data Objective data Domain 3: Elimination Need 1: Breathe normally The patient reports shortness of breath and that he is anxious The patient is observed with labored breathing with RF at 28/min with abnormal arterial pH. respiratory distress (00030 Impaired gas exchange r/c ventilation-perfusion imbalance m/p shortness of breath, hypoxemia, and abnormal arterial pH. The patient will recover her adequate ventilation after treatment, in a period of approximately 48 hours. Domain 1: Security/ protection. Need 1: Have no aspiration risks Family me ...

1. 10
Running Head: Modulo 2 Plan de Cuidado- (cuidado
holístico)
Situación Hipotética
A 55-year-old woman admitted 2 days ago to the Intensive Care
Unit. The admission diagnoses are: vomiting, seizures, and
probable aspiration. She has a prior history of hypertension,
COPD, and myocardial infarction with angioplasty performed
six months ago.
Family members report that the client uses the following routine
medications: Toprol 50mg 1 tab. daily, Lipitor 20 mg 1 tab.
daily, Aspirin 81 mg 1ab. Daily, Plavix 75 mg 1 tab. daily; He
smokes a daily pack of cigarettes since he was 30 years old.
They also report that the patient drinks alcohol continuously;
"In the last 3 days I have found her drunk in the house" said the
woman's nephew.
The patient is 5'11'' and weighs approximately 180 pounds.
Upon arrival at the emergency room she presents vital signs of:
T-37°C, P-150/min., R-28/min. and B/P-193/124 mmHg. She is
observed with recurrent vomiting and severe episodes of
seizures, respiratory distress, and severe anxiety. Dr. Díaz
orders ABG's which result in: pH-7.30, PaCO 2 -50 mmHg, PO
2 -81 mmHg and NaHCO 3 -23 mEq/L, Sat. 85%. The client is
sedated with Propofol 5mL, for oroendotracheal intubation and
transferred to the ICU area. Blood pressure after intubation
medication decreased to 80/52 mmHg. She is restricted to
patient per intubation protocol. Laboratory samples show
elevated liver enzymes, elevated cholesterol and triglycerides,
and normal CBC.
Introduction:
Aspiration pneumonia is caused by aspiration of oropharyngeal
contents into the airways, leading to abscess lesions due to

2. bacterial infection in the lower lung lobes. It generally occurs
in patients with frequent seizures and loss of mental status, with
impaired swallowing of food or loss of the gag reflex
(Aspiration pneumonia, n.d.). In this work we will carry out the
care plan and the nursing progress notes of a 55-year-old female
patient admitted to the Intensive Care Unit with respiratory
distress probably caused by pneumonia due to aspiration of her
own vomit, leading her to a state of acute respiratory acidosis
with adequate bicarbonate compensation by the kidney.
Care Plan:
Estimado
Diagnóstico de Enfermería
Expected results
Nursing Interventions
Evaluatión
domains
Needs

3. maladaptive behaviors
Focal Stimulus
Interventions
Scientific Rational
subjective data
Objective data
Domain 3: Elimination
Need 1: Breathe normally
The patient reports shortness of breath and that he is anxious
The patient is observed with labored breathing with RF at
28/min with abnormal arterial pH.
respiratory distress
(00030 Impaired gas exchange r/c ventilation-perfusion
imbalance m/p shortness of breath, hypoxemia, and abnormal
arterial pH.
The patient will recover her adequate ventilation after
treatment, in a period of approximately 48 hours.
Domain 1: Security/ protection.

4. Need 1: Have no aspiration risks
Family members report that the patient drinks alcohol
continuously; “In the last 3 days I have found her drunk at
home”
Record
Previous smoking history, vomiting, alcohol ingestionprobable
aspiration
Female Age 55 years
History of hypertension, COPD, and myocardial infarction with
angioplasty.
Size
5'11''
Weight 180lbs
vital parameters.
FC-150/min., R-28/min. and B/P-193/124
mmHg. Hemogasometry:
pH-7.30,
PaCO2-50 mmHg, PO2-81 mmHg and NaHCO3-23 mEq/L, Sat.
85%.
seizures and vomiting
(00039) Risk of aspiration related to seizures and vomiting.
00004 Risk of infection related to invasive procedures
(endotracheal intubation).
The patient will remain free of aspiration risks from the
beginning of her hospitalization and within the next 2 hours
demonstrated by clear lung sounds, breathing without difficulty,
and oxygen saturation within normal limits for the patient.
Assess the level of consciousness.
Monitor respiratory rate, depth, and effort.
Keep suction machine available when feeding high-risk patients.
If aspiration occurs, suction immediately.
Keep the head of the bed elevated when feeding and for at least

5. half an hour afterwards.
Educate the patient and family about the need for proper
positioning.
The main risk factor for aspiration is a decreased level of
consciousness.
Note any signs of aspiration, such as dyspnea, cough, cyanosis,
wheezing, or fever. Signs of aspiration should be identified as
early as possible to prevent further aspiration and start
treatment that can aspire.
The patient remains free of risk of aspiration.
The interventions carried out to identify its usefulness are
valued and those that are necessary are changed..
Nota de Progreso (focus charting) Roxana):
Fecha
Hora
FOCO
D.A.R
Datos
Acción
Respuesta

6. 5/28/2022
05/28/2022
05/28/2022
05/28/2022
8:30 a.m

7. 10:30 a.m
2:00 p.m
9:00 p.m
Vómitos Convulsiones y Distress respiratorio

8. Resequedad de la piel
Paciente con Desequilibrio Electrolítico
Educacion importante sobre ingerir bebidas alcohólicas y fumar
Paciente adulta de 55 años, mide 5`11, pesa 180 lb (Aprox.)
llega a sala de emergencia, se observa al paciente con vómitos
recurrentes y severos episodios de convulsiones, muestra
ansiedad y distress respiratorio
Presenta signos vitales:
T = 37 °C
B/P = 193/124mm/Hg
P = 150 b.p.m. (Taquicardia)
R = 28/min. (Polipnea)
Se observa a la paciente sedada y bastante estable.

9. Paciente se muestra menos ansiosa presentando un lenguaje
incoherente. Presenta un pequeño vómito bilioso, se mantiene
estable a pesar de lo difícil que le cuesta respirar por sí misma
Paciente recibió charlas, folletos, y números telefónicos para
que pueda contactarse a grupos de ayuda que ayudará a
beneficiar al paciente
Se administró medicamentos según prescripción médica, la
paciente recibió terapia de rehidratación, se le administró
propofol 5ml, vía intravenosa, para la intubación endotraqueal y
así ser transferida a ICU.
-Se le colocó una cánula nasal de Oxigenoterapia, según
prescripción médica
Se encuentra en posición semi fowler, la paciente continúa
encamada con todas las precauciones de protección para evitar
riesgos de caídas.
El récord de signos vitales muestran parámetros normales
propios de un paciente en ICU.
Cada 2 horas chequeamos el aparato mecánico o respirador.
Paciente se le cambió de posición a decúbito lateral.
Se desajusto la ropa para la comodidad del paciente
Se dirige los movimientos para evitar lesiones en el paciente
Paciente en estado consciente y estable acepta su primera cita
para ir al grupo de apoyo de alcoholismo y tabaquismo
Paciente después de recibir el medicamento propofol disminuye
su presión arterial a 80/52 mmHg. Mejora su frecuencia
cardiaca, debido a su sedación la paciente no muestra ansiedad.

10. La saturación de oxígeno de la paciente se logró estabilizar a 97
%, el IV ha sido chequeado constantemente para evitar una
posible infección, logrando salir la paciente de cuidados
intensivos a hospitalización.
La paciente logró superar su crisis convulsiva sin ningún
traumatismo, recuperando su desequilibrio electrolítico,
presenta un nivel de confort, y la paciente refiere “me siento
mejor”
Paciente muestra un gran interés para mejorar su nivel de vida y
se compromete a asistir a todas sus terapias que sean necesarias,
además se refirió a las enfermeras “gracias a todos por su
ayuda”
Evaluación (Marisol) :
Reflexión (Nicole):
Conclusiones (Otilia):
Logramos diseñar un plan de cuidados de enfermería que nos

11. resultó un poco difícil, pero hemos aprendido. Realmente
demostró ser de mucha utilidad para nuestro futuro como
profesionales de enfermería. Basado en la mejor evidencia
científica. Se valoró la pacienteestableciendoprioridades en su
estado crítico. Logramos determinar los diagnósticos de
enfermería en una paciente con deterioro del intercambio de
gases y riesgo de aspiración. En las Unidad de Cuidados
Intensivos se ingresan pacientes con compromiso de órganos
vitales. Por lo general requieren de un método de soporte con
seguridad de la permeabilidad y el mantenimiento de la vía
aérea con intubación. Evitando la broncoaspiración y
complicaciones de mayor envergadura (Ramírez, 2020).
Se valoró al paciente con síndrome de distrés respiratorio agudo
que es una insuficiencia del aparato respiratorio de instalaci ón
aguda. La causa es por edema del pulmón por inflamación de
causa no cardiogénica. Además de cuadro de convulsiones,
vómitos y mucha ansiedad. La enfermería en los cuidados
intensivos juega un rol protagónico en el proceso de lograr
mejoría del cliente. Con la monitorización de parámetros
vitales, control de la hemodinamia, de la estabilidad de la
mecánica. Además de lograr de forma precoz detectar signos de
empeoramiento (Hernandis, 2021).
Aplicamos diferentes intervenciones adecuadas según la
evidencia científica. Evaluamos la calidad y la eficacia de las
diferentes intervenciones de acuerdo a los indicadores de los
resultados esperados. Resultando que enestos pacientes se
requiere de un elevado nivel de cuidados por el enfermero a pie
de cama. Es necesario el entrenamiento del personal de
enfermería en el manejo de estos pacientes. Por lo que
exhortamos a los enfermeros a colaborar con nuevos y mejores
procesos de enfermería, con la mejor evidencia científica.
Hemos demostrado que siempre que ponemos empeño y
ofrecemos un mejor cuidado obtenemos éxitos en los pacientes
críticos (Arias et al., 2020).

12. Referencias:
Arias, M., Henríquez, k., Ponzon, D. (2020).Cuidados de
enfermería a pacientes con enfermedades respiratorias en una
unidad de cuidados intensivos
https://repository.ucc.edu.co/bitstream/20.500.12494/20207/2/2
020_cuidado_enfermeria_respiratorias.pdf
Hernandis, R. (2021). Tratamiento del paciente crítico con
síndrome de distrés respiratorio agudo.
https://revistasanitariadeinvestigacion.com/tratamiento-del-
paciente-critico-con-sindrome-de-distres-respiratorio-agudo/
Ramírez, F. (2020). Proceso de Enfermería a un Paciente con
Ventilación Mecánica Invasiva.
https://repositorioinstitucional.buap.mx/bitstream/handle/20.500
.12371/11303/20200917132324-3444-
T.pdf?sequence=2&isAllowed=y
Referencia:
Neumonía por aspiración (s.f). Neumonía por aspiración -
Síntomas, diagnóstico y tratamiento | Mejores prácticas de BMJ.
Recuperado de: https://bestpractice.bmj.com/topics/es-es/21

13. Topic: Cell Proliferation: Cancer
1. Illustrate the process of carcinogenesis in a concept map.
Example:
2. Explain the difference between invasion and metastasis?
3. Describe the clinical manifestations of cancer?
4. Mention and describe the different cancer treatments?
5. Discuss how environmental changes can cause cancer?
6. Relate lifestyles and carcinogénesis?
For the construction of nursing diagnoses, you must use the
NANDA 2018-2020 labels in PDF format.
Hypothetical situation
A 55-year-old woman admitted 2 days ago to the Intensive Care
Unit. The
Admitting diagnoses are: vomiting, seizures, and probable
aspiration. she has a history
prior hypertension, COPD, and myocardial infarction with
angioplasty performed six months ago.
Family members report that the client uses the following routine

14. medications: Toprol 50mg
1 tab. daily, Lipitor 20 mg 1 tab. daily, Aspirin 81 mg 1ab.
Daily, Plavix 75 mg 1 tab. daily;
He smokes a daily pack of cigarettes since he was 30 years old.
They also report that the
patient drinks alcohol continuously; “In the last 3 days I have
found her drunk in the
home" said the woman's nephew.
The patient is 5'11'' and weighs approximately 180 pounds.
Arriving at the room
emergencies she presents vital signs of: T-37 ° C, P-150 / min.,
R-28 / min. and B/P-193/124
mmHg. She is observed with recurrent vomiting and severe
episodes of seizures, distress
breathing and severe anxiety. Dr. Diaz orders ABG's which
result in: pH-7.30,
PaCO2-50 mmHg, PO2-81 mmHg and NaHCO3-23 mEq/L, Sat.
85%. Client is sedated with
Propofol 5mL, for oroendotracheal intubation and transfer to the
ICU area. The pressure
blood pressure after medication for intubation decreased to
80/52 mmHg. She restricts herself to
patient per intubation protocol. Laboratory samples liver
enzymes are observed
elevated, elevated cholesterol and triglycerides and normal
CBC.
2. Write, in order of priority, at least five nursing interventions
that you would carry out to achieve each of the two expected
results. It is important that you include in the interventions at
least one for prevention and promotion of the health of the
client-family?.
3. Mention the scientific rationale that validates carrying out
each intervention?
4. Write an evaluation (a hypothetical review) for each nursing
diagnosis in light of the expected outcome you developed.?