ABSTRACT
Se presenta el caso de una recién nacida prematura de 27 semanas de gestación y 420g de peso, que nació como consecuencia de una preeclampsia materna y un crecimiento intrauterino retardado. Durante los 125 días de ingreso se desarrolló y aplicó un plan de cuidados individualizado basado en el modelo de Virginia Henderson, tanto a la niña como a sus padres, utilizando los diagnósticos NANDA, las intervenciones según la clasificación de intervenciones de enfermería y los resultados esperados según la clasificación de resultados de enfermería. Para la valoración inicial utilizamos los patrones funcionales de Marjory Gordon. Gracias al plan aplicado, la recién nacida prematura vio suplidas todas sus necesidades, que fueron modificándose a lo largo del tiempo de ingreso con nuevas necesidades que se unían a las que planteaba de base y que requerían una valoración continua con la consiguiente adaptación del plan de cuidados. Asimismo, la atención que requerían los padres fue variando desde el duelo inicial por la posible pérdida de su hija hasta el aprendizaje de los signos de alarma y cuidados a domicilio que requería su hija. Finalmente, la niña fue dada de alta con 2.900 g y un desarrollo neurológico y psicomotor normales, aunque por debajo del peso adecuado a su edad. Asimismo, el vínculo entre los padres y la niña es adecuado. Actualmente, con 2 años de vida, la niña tiene un desarrollo neurológico y psicomotor normal, aunque con percentil en peso y talla inferior al percentil 3. Precisa de tratamiento con logopeda y foniatra por parálisis de la cuerda vocal derecha (AU)
A case is presented of a premature newborn of 27 weeks gestation and weighing 420 grams who was delivered as a result of a maternal pre-eclampsia and retarded intra-uterine growth. During the 125 days of hospitalisation, an individual care plan based on the Virginia Henderson model was devised and applied to both the child and her parents using NANDA diagnostics, interventions according to the NIC classification, and the expected results according to the NOC classification. The Marjory Gordon functional patterns were used for the initial assessment. By applying the pre-term newborn (PTNB) plan, all their needs were provided and were modified throughout the hospital stay, with new needs that were added to the established ones. These required a continuous assessment with the subsequent adapting of the care plan. Likewise, the care required by the parents varied from the initial grief due to the possible loss of their child to learning the alarm signs and the home care that their child would need. The child was finally discharged weighing 2900 grams and with normal neurological and psychomotor development, although with a lower weight appropriate to her age. Currently, at 2 years old, the child has a normal neurological and psychomotor development, but with weight and size lower than the P3 percentile. She requires speech therapy treatment due to paralysis of the right vocal cord (AU)
Subject(s)
Humans , Female , Infant, Newborn , Infant, Premature , Neonatal Nursing , Nursing DiagnosisABSTRACT
A case is presented of a premature newborn of 27 weeks gestation and weighing 420 grams who was delivered as a result of a maternal pre-eclampsia and retarded intra-uterine growth. During the 125 days of hospitalisation, an individual care plan based on the Virginia Henderson model was devised and applied to both the child and her parents using NANDA diagnostics, interventions according to the NIC classification, and the expected results according to the NOC classification. The Marjory Gordon functional patterns were used for the initial assessment. By applying the pre-term newborn (PTNB) plan, all their needs were provided and were modified throughout the hospital stay, with new needs that were added to the established ones. These required a continuous assessment with the subsequent adapting of the care plan. Likewise, the care required by the parents varied from the initial grief due to the possible loss of their child to learning the alarm signs and the home care that their child would need. The child was finally discharged weighing 2900 grams and with normal neurological and psychomotor development, although with a lower weight appropriate to her age. Currently, at 2 years old, the child has a normal neurological and psychomotor development, but with weight and size lower than the P(3) percentile. She requires speech therapy treatment due to paralysis of the right vocal cord.
