Nursing process applied to patients with nutritional imbalance.

Abstract

Nursing process is applied to a male patient  of 51 years old who is surgically intervened for an  open cholecystectomy, which complicates due to the  migration of a gallstone to the pancreas initiating  with an acute process of pancreatitis. To asset we use the functional patterns of  the theoretical Marjorie Gordon having several  alterations in the activity-exercise pattern with signs  of dysnea, sialorrhea, the traqueostomy presents  thick and purulent secretions.  In the nutritional metabolic  pattern we found biliary drainage  spending in the orogastric tube and fetid serous  drainage proceeding from the Penrose, there's  also evisceration covered with a “Bolsa de Bogota”  we can observe the omentum and bowel loops as  well as the destruction of the skin layers due to the  surgical procedures. Also the cognitive perceptual  pattern is affected due to a score of 6 in scale of VAS  and whining in every procedure.  We manage to rank de diagnosis according to  the altered functional patterns. The applied labels  were:  Ineffective airway clearance, imbalanced  nutrition, acute pain and impaired skin integrity.  The main interventions were: Tracheostomy  Tube Care, Airway Management, Nutrition  Management, Pain Management and Wound Care.  The patient manages to have a hemodynamic  stability except for the temperature which keeps  throwing data of an insidious infection.  The care was given in a very efficient way and in time according to the human response having a  very significant achievements and it also allows  us to apply the acquired knowledge providing an holistic care and humanism.