Historia Clínica Gineco 3ra Romda

8/19/2019 Historia Clínica Gineco 3ra Romda

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SECRETARIA DE EDUCACIONSUBSECRETARIA DE EDUCACION ESTATAL

DIRECCION DE EDUCACION SUPERIORINSTITUTO SUPERIOR DE ESTUDIOS DE ENFERMERIA DEL ESTADO DE

CHIAPAS

HISTORIA CLÍNICA

MATERIA: ENFERMERÍA EN LA REPRODUCCIÓN HUMANA

CATEDRÁTICA: LIC. MARÍA CANDELARIA HERNÁNDEZ ARAUJO

ALUMNOS:CABRERA TOLEDO GABRIEL

GÓMEZ DÍAZ KAREN DE LOS ÁNGELESHERNÁNDEZ ORTEGA KASSANDRA FABIOLAMARTÍNEZ UCO MONTSERRAT GUADALUPE

MAZARIEGOS DÍAZ CECILIA MAGDALENA

4° “B”

TUTLA GUTI!RREZ " CHIAPAS A #$ DE M%&'( DE )#*+


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DIAGNÓSTICO DE EMBARAZO


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C(, -% /,%-/0%0 012/231%3/'%& -(2 56/0%0(221 123%7-151, 5&/31&/(201:

SOSPECHA PROBABILIDAD CERTEZA


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S1 /,/5/% 01201 1- /,31&&(8%3(&/( 56%,0( 21 &1/1&1 %1,(&&1% 1, 6,% 691& 1, 10%0 &3/- 5(, ;/0%21?/3( %363/,( S/%-(&&1%. P1&;1&2/?, 01- 8623( @ 01- (-%3(. D/2/,6@1 1- 0/,%/2( S(,(-1,5/% M%&1(2 1 /&&/3%7/-/0%0 N/536&/% P(-%6/6&/% P(-/6&/% L%2 %%2 %61,3%,

SOSPECHA


5/41

S1 /,31,2//5%, -(2 2,3(%2 01 2(215%. A61,3( 01 12( 5(&(&%-

M(0//5%5/(,12 01 ?&8%,(2 -;/5(2:

C(-(&%5/?, &(2=51% 01 -% ;%8/,% 5%0/5P6-2( ;%8/,%- (22/%,01&C&;/< 1 /23( &17-%,015/0(2 18%&.

C61&( 631&/,( 8-(7(2( @ (,0(2 01 2%5((56%0(2 ,(7-1 @ 760/, I&&186-%&/0%0 01- (,0( 631&/,( /2%21

A61,3( 01- 3%%( 631&/,(

PROBABILIDAD


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S1 %6256-3%, -(2-%3/0(2 5%&0%5(213%-12

P1&515/?, 01%&312 13%-12 (&1- 1


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P%&% 61 -% %31,5/?, &1,%3%- 56-% 262(7913/;(2 0171 &16,/& -%2 2/86/1,312

5%&%531&23/5%2:BAJO RIESGO DE RIESGOD171 /,/5/%&21 %,312 01 -%21%,% *) 01 8123%5/?,

D171 %71& 6, ,/(01 5(,26-3%2: * 1, 1-&/1& 3&/123&1" -% ) @ 1, 1- 2186,0(3&/123&1" @ * 5(,26-3%1,26%- 1, 1- 31&51&3&/123&1

E- ,61&( 01 5(,26-3%221&=, 01 %561&0( % -(2FR 013153%0(2" %2 5((

-% &121,5/% 015(-/5%5/(,12 1, 5%0%5%2(.

D171 21& 5(-13%(&61 /,5-6/&= %55/(,12@ 123&%318/%2 01 (1,3(

@ &1%7/-/3%5/?, 01 -%2%-60.

Después de la semana 36, se debe valorar cada 7 días.


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S18, -% NOM -%2 5(,26-3%2 0171, 21&: * 5(,26-3%: %,312 01 -% 21%,% )# ) 5(,26-3%: 1,3&1 -%2 )) @ )4 21%,%2 1& 5(,26-3%: 1,3&1 -%2 ) @ ) 21%,%2. 4 5(,26-3%: 1,3&1 -% @ 21%,%2. 5(,26-3%: 1,3&1 -%2 $ @ 4# 21%,%2.


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PRUEBAS DE VIGILANCIA

FETAL.De acuerdo a las condiciones maternas yfetales, las pruebas de bienestar fetalestán indicadas, según el criterio médico apartir del momento del balance riesgo-benecio de una intervención sobre elbinomio madre-hijo con base en elresultado obtenido de estas pruebas, es

favorable.


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!"#$%&' D# ()

&%*%()+%) #$)(.


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#$D' (%+%' D# &%*%)+%) #$)(.


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METODOS BIOFISICOS DE

VIGILANCIA FETAL.


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#sta prueba valora la reservafeto placentarias ante lascontracciones uterinas.

#$D(*%)/ 0resencia de 1contracciones uterinas en 23minutos, con una duración de

43 a 53 segundos y unaintensidad de 16 mm7g.

$%0'/ %nfusión de o8itocina o

liberación endógena por el

PRUEBA CONCONTRACCIÓN.


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0#:%D #+ ;6 de gestación.

D


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ULTRASONIDO DOPPLER

0ermite profundi9ar en elestudio hemodinámica de

la placenta y el feto.


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C%-56-( 01- 12( 13%-


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R18-% 01 J(,2(, @ T(2%5P&121,3%5/?, %&&/7% 01 -%2 12/,%2

5/=3/5%2:

P AFU 5Q *) < *

E91-(: ) 5 Q*) < * )) 8&%(2

P&121,3%5/?, % -% %-36&% ( (& 017%9( 01-%2 12/,%2 5/=3/5%2

P AFU 5 ** < *

E91-(: ) 5 Q** < * )*# 8&%(2


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19/41

CALCULO DE LA EDADGESTACIONAL


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POR INTERROGATORIO: %&% 5%-56-%& -%10%0 01 -% 8123%5/?, 0171 5(,3%&21 1,

21%,%2" % %&3/& 01- &/1& 0% 01 -%6-3/% 1,23&6%5/?," 21%-%,0( 2631&/,( F.P.P. %- /,%- 01 -% 56%0&%82/%

21%,%. )$# 0%2.


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POR EXAMEN FISICO: ALTURA DELFONDO UTERINO.-

Determinacin !e "a e!a! !e"em#ara$% &e'(n "a a"t)ra

)terina

E!a!Ge&taci%na"*&emana&+

A-36&% 631&/,%51,313&(2

, *)Q*/ *Q)*

0 *Q )41 ))Q)2 )Q#2 )$Q

0/ *Q


22/41

REGLA DE MC DONALD:C(, 1231 3(0( 21 6101 5%-56-%& -%2

21%,%2 01 10%0 8123%5/(,%-" 0131&/,%,0(1, 51,313&(2 1- 12%5/( 5(&1,0/0( 1,3&1

1- 7(&01 261&/(& 01 -% 2,/2/2 01- 67/2 @ 1-(,0( 631&/,(. E- ;%-(& 1, 51,313&(2 01-12%5/(" 21 6-3/-/5% (& $ @ 21 0/;/01 1,3&1 .

E91-(: )# 5 < $ *+# ..

)).$ 21%,%2


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F15% &(7%7-1 01 %&3( REGLA DE NAEGELE: T&%0/5/(,%-1,31 21

63/-/'% @ 5(,2/231 1, 26%& 0%2 %- &/1& 0%01 -% -3/% 1,23&6%5/?, @ &123%& 3&12 1212.S1 5(,2/01&% ,(&%- 6,% ;%&/%5/?, 01 Q *#0%2.

P&/1& 0% 01 -% F.U.M. 0/%2 Q 1212

E91-(: *# 01 %8(23( 0%2 1212 * 01%@(


24/41

Hi&t%ria c"3nica'inec% 4 %#&t5trica

In&tr)ment% met%!%"'ic%


25/41

F/5% 01 /01,3//5%5/?,

S1 5(,23/36@1:

>%-(&%5/?, 01 ,1512/0%0126%,%2

>%-(&%5/?, 01

-%2 *4,1512/0%0127%9( 1- (01-(

01 >/&8/,/%H1,01&2(,


26/41

E>C: 1,1&10%0;%256-%& 51&17&%-

TBP: T671&56-(2/2 6-(,%&

HIE: /1&31,2/?, /,065/0%(& 1- 17%&%'(

NECESIDAD DEOIGENACION

C S


27/41

NL: ,(&%-

S1 5(-(5% 101%2: 3(7/--( @ %,(2

/1&,% %70(1,G1,1&%-/'%0% (%,%&5%2%

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E" !%66"er e& )na t5cnica 7)e mi!e "%8")9%& &an')3ne%& !e "a 6"acenta: e"

c%r!n )m#i"ica" ; "a& arteria&)terina&.S6 62( 12 1215/%-1,31 3&%251,01,31%&% 691&12 61 &121,3%, &(7-1%201:H/1&31,2/?,

I,26/5/1,5/% 01 -%51,3%

NECESIDAD DENUTRICIONHIDRATACION

PROBLEMAS URINARIOS :


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PROBLEMAS URINARIOS :DISURIA:D//56-3%0 ( 0(-(& 1, -% 1;%56%5/?,01 -% (&/,%.POLIURIA:

E


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FUR: 15% 01 6-3/% &18-% ANTECEDENTESOBST!TRICOS:G 8123%P %&3(

A %7(&3( C 512=&1%I>SA: /,/5/( 01 ;/0% 21


30/41

FCF: F&1561,5/% 5%&0/%5% 13%-TDP: 3&%7%9( 01 %&3(FPP: 15% &(7%7-1 01 %&3(P(& FU: (& (,0( 631&/,(SDG (& FUR: 21%,%2 01 8123%5/?, (& 6-3/% &18-%

FU: (,0( 631&/,(SDG LF: -%&8( 01- 6& DBP: 0/=13&( 7/%&13%-CONTRACCIONES DE BRATON HICKS5(,3&%55/(,12 01- 31&( 61 ,( 061-1," 2(, &1-%3/;%1,31 7&1;12 @ 616101, &121,3%&21 % %&3/& 01 -% 2186,0% /3%0 01- 17%&%'(

ANALISIS DE ORINA


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ANALISIS DE ORINAPH NORMAL EN ORINA: + &%,8(,(&%- 01 4" % $.DENSIDAD: *.### % *.##01,2/0%0 ,(&%-.

PROTEINURIA: P&121,5/% 1, -%(&/,% 01 &(31,%2 1, 6,% 5%,3/0%0261&/(& % -% ,(&%-.LEUCOCITURIA: P&121,5/% 01-165(5/3(2 1, -% (&/,%" C6%,0( 21%7-% 01 -165(5/3(2 5%2/ 2/1&1 21

%7-% 01 8&%,6-(5/3(2" @ 123(2/,0/5%, -% &121,5/% 01 &(512(2/,-%%3(&/(2 01- &/?, @ -% ;%6&/,%&/%.GLUCOSURIA: P&121,5/% 018-65(2% 1, -% (&/,%.

CETONURIA: T%2% 01 561&(2513?,/5(2 1, -% (&/,%.CILINDRURIA: P&121,5/% 01(&%5/(,12 /5&(25?/5%25/-,0&/5%2 1, 1- 210/1,3( 6&/,%&/(.S6 &121,5/% /,0/5% 6,% 1,1&10%0

&1,%- %860% ( 5&?,/5%.

N1512/0%0 0131&(&&186-%5/?,

N1512/0%0 01 (;1&21 @ %,31,1&6,% 761,% (236&%


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NECESIDAD DE DESCANSO W SUEXOH(&%&/( 01 0125%,2(I,2(,/(S/123% A@60%2E23%0( 1,3%-

NECESIDAD DE USAR PRENDAS DE>ESTIR ADECUADAS

E23%0( 01 %,/( 1, -% 1-155/?, 01&1,0%2 01 ;123/&

>/231 01 %561&0( % 26 10%0 @ % 26123%0( %536%-C%%5/0%0 2/5((3(&% %&% ;123/&21@ 012;123/&21


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NECESIDAD DE HIGIENE W PROTECCION A LA PIEL

F&1561,5/% 01- 7%(H/8/1,1 765%-C%7/( 01 &(%

A2153( 81,1&%-COLORACION:ERITEMA:E,&(915//1,3( 01 -% /1- 017/0( %- %61,3(01 -% 2%,8&1 5(,31,/0% 1, -(2 5%/-%&12.EVUIMOSIS:M%,5% 01 -% /1-" 01 5(-(& %'6- %(&%3%0("61 21 &(0651 (& -% %566-%5/?, 012%,8&1 6 (3&( -6/0( 5(&(&%-.PETEVUIAS:-12/(,12 161%2 01 5(-(& &(9(" (&%0%2(& 1


34/41

NECESITAD DE E>ITAR PELIGROS M/17&(2 61 5((,1, 26 %/-/%R1%55/?, %,31 2/36%5/(,12 01 6&81,5/%Y 01 %&19%2 21


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NECESIDAD DE >I>IR SEGNSUS CREENCIAS W >ALORES

C&11,5/% &1-/8/(2%

I,-61,5/% 01 26 &1-/8/?, 1, 1-17%&%'(P&/,5/%-12 ;%-(&12 %/-/%&12H=7/3(2 01 ;123/0(P1&/31 1- 5(,3%53( 2/5(


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NECESIDAD DE TRABAJAR WREALIZARSE

G&%0( 01 12360/(2

P&(12/?,T&%7%9% %536%-1,31S6 &16,1&%5/?, 15(,?/5% -11&/31 567&/& 262 ,1512/0%012E23%0( 1(5/(,%- " 135

NECESIDAD DE JUGAR WPARTICIPAR EN ACTI>IDADES

RECREATI>AS

A53/;/0%012 &15&1%3/;%2 61 &%53/5%1, 26 3/1( -/7&1R156&2(2 %&% -% &15&1%5/?,D/23&%55/?, &11&/0%I,318&/0%0 01- 2/231%,16&(6256-%&

E23%0( 01 %,/(

NECESIDAD DE APRENDIZAJE


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N/;1- 01 1065%5/?,P&(7-1%2 01 %&1,0/'%91S%71 5(( 63/-/'%& 61,312 01

%(@(C(,(51 %51&5% 01 26 17%&%'(@ 262 56/0%0(2C(,(51 -(2 56/0%0(2 01- RNE23%0( 01- 2/231% ,1&;/(2(M1(&/% &15/1,31

M1(&/% &1(3%

L-1,%0( 01 -% (9%


38/41

901 ;/8/-%,5/% @

%31,5/?, 01- %&3(

*° /3%0 01- 17%&%'(--1,%0% (& 1- 10/5(

)° /3%0 01- 17%&%'(

A-36&% 01- 31&( A-36&% 01&121,3%5/?, D/-%3%5/?,

D/%8,(23/5(


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S/8,(2 ;/3%-12

OTB

F%53(&12 01 &/128(01- 17%&%'(

C(,3&%55/(,12 (& /,63(

D/-%3%5/?,


40/41

E;(-65/(,12 01- %&3( (-18&%0(

N(3% &1(1&%3(&/%

N(3% (23 (5-62/?, 367%&/%(23 %&3(


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T1&/,%5/?, 01-17%&%'(

PARTO EUTOCICOFORCEPSCESAREA

ALUMBRAMIENTORECIEN NACIDO ANALGESIA EN T DEPARTO ANESTESIA ENPARTO LEGRADOQ

CESAREAPLACENTALEGRADO

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Historia Clínica Gineco 3ra Romda