REPBLICA BOLIVARIANA DE VENEZUELA MINISTERIO DEL PODER POPULAR PARA LA EDUCACIN UNIVERSITARIA PLAN NACIONAL DE FORMACION UNERG PROGRAMA

MISIN SUCRE

ESTUDIO DE CASO COLECISTITIS AGUDA - LITIASIS VESICULAR

FACILITADOR: Lic. Yelitze Petre

BACHILLER: Yelitza Graterol C.I. 17.616.676

Marzo, 2013 INDICE Pg. INTRODUCCIN CAPITULO I: Objetivos de la Investigacin CAPITULO II: e!inicin "tiolog#a $isio%atolog#a (ignos ) (#nto*as ,edios de diagnostico -rata*iento Co*%licaciones -eor#a de "n!er*er#a CAPTULO III: 0ntecedentes Personales 0ntecedentes $a*iliares 12bitos Psicolgicos Lista de %roble*as 3es4*en del Caso Patrones de ,arjor)e Gordon (O0P" 5aloracin Objetiva "6a*en $#sico "62*enes Co*%le*entarios 3es4ltado de laboratorio Lista de *edica*entos C4adro anal#tico CONCLUSIONES 1'&1+ 1+ 1+ /. /1 // 15 15 15 15 16 16&17 17 5 6 7 7&' '&+ +&1. 1.&11 11 1/&14 4

ANEXOS: C4adro 0nat*ico C4adro $isio%atolgico Plan de C4idado I Plan de C4idado II Plan de C4idado III $ic8as $ar*acolgicas

/7 /4 /5 /6 /7 /' /+&71

INTRODUCCIN
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Para el %ro!esional de en!er*er#a se 8ace necesaria la a%licacin del %roceso de atencin de en!er*er#a9 el c4al es 4n *:todo de trabajo ;4e consiste en 4n siste*a con %asos ;4e se relacionan entre s# %er*itiendo identi!icar ) satis!acer necesidades del %aciente ) resolver los %roble*as de sal4d. La %resente investigacin se trata de 4n est4dio de caso cl#nico donde se %odr2 en %r2ctica el %roceso de atencin de en!er*er#a el c4al es 4n *:todo siste*2tico ) organizado en la atencin al %aciente< d4rante el desarrollo del %resente trabajo9 donde el objetivo %rinci%al es brindar 4na atencin de calidad al %aciente ;4ir=rgico.. La *etodolog#a 4tilizada !4e la recoleccin de datos obtenida del %aciente %or %arte del %ersonal de en!er*er#a s4*ado a la e6%loracin !#sica9 ne4rolgica ) la 8istoria cl#nica del %aciente. "l %resente est4dio de caso se trata de %aciente !e*enina de 4/ a>os de edad9 %resentando 4n diagnstico *:dico de colecistitis ag4da & litiasis vesic4lar.

CAPTULO I
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OBJETIVO GENERAL 0%licar las eta%as del Proceso de 0tencin de "n!er*er#a< a 4na %aciente con diagnstico *:dico de colecistitis ag4da9 litiasis vesic4lar9 ;4e se enc4entra en el 1os%ital 3an4arez ?alza. OBJETIVOS ESPECFICOS 1. (eleccionar %aciente de caso cl#nico a est4diar. /. 5aloracin del %aciente en todas las eta%as. 7. 3ealizar diagnsticos de en!er*er#a jerar;4izando %rioridades. 4. "laborar %lanes de c4idados ;4e se ada%te a las necesidades del %aciente. 5. "jec4tar acciones o atenciones ;4e %4edan eli*inar o *ini*izar los %roble*as encontrados. 6. "val4ar dic8as acciones con la !inalidad de *ejorarlas o *antenerlas. 7. 0%licar teor#a de en!er*er#a de orotea Ore*.

CAPITULO II MARCO TERICO Colecistitis Aguda La colecistitis ag4da es 4na in!la*acin ag4da de la ves#c4la biliar ;4e se aco*%a>a de dolor ) s#nto*as digestivos. "s 4na ca4sa *4) !rec4ente de cons4lta de 4rgencias ) de cir4g#a en %ersonas *a)ores. Las colecistitis est2n %rod4cidas en la *a)or#a de los casos %or %iedras en la ves#c4la @c2lc4losA9 ;4e %rovocan la obstr4ccin del cond4cto c#stico @cond4cto ;4e co*4nica la ves#c4la con el t4bo digestivoA9 reteniendo la bilis ) %rovocando la distensin de la ves#c4la. La obstr4ccin ) distensin ter*ina %rovocando la in!la*acin de la ves#c4la9 siendo !rec4ente la in!eccin %or g:r*enes %rocedentes del t4bo digestivo. 1asta los 5. a>os9 es tres veces *2s !rec4ente en *4jeres ;4e en varones. Por enci*a de esta edad9 casi se ig4alan los %orcentajes entre los dos se6os.

Litiasis Vesicular "s la %resencia de litos @%iedrasA dentro de la ves#c4la biliar. (eg=n %lantea el r. $ernando Goda)ol @/..5AB

Los c2lc4los en la ves#c4la son 4na ca4sa de cons4lta !rec4ente %ara 4n cir4jano9 %ero %ara el %aciente es 4na ca4sa de cir4g#a !rec4ente9 %redo*inan los c2lc4los @o %iedrasA en las *4jeres9 sobre todo si s4!ren de obesidad )Co 8an tenido *=lti%les %artos9 sin e*bargo ta*bi:n es 4na %atolog#a !rec4ente en el se6o *asc4lino9 las co*%licaciones son graves ) %4eden ser ca4sa de *4erte si no se tratan a tie*%o.

Etiologa "n el +.D de los casos9 la colecistitis ag4da es ca4sada %or la %resencia de c2lc4los biliares en la ves#c4la biliar. Otras ca4sas incl4)en 4na en!er*edad grave )9 en raras ocasiones9 t4*ores de la ves#c4la biliar. La colecistitis ag4da oc4rre c4ando la bilis ;4eda atra%ada en la ves#c4la. La ac4*4lacin de la bilis ocasiona irritacin ) %resin en la ves#c4la9 lo c4al %4ede cond4cir a in!eccin ) %er!oracin @ag4jeroA en el rgano. Los c2lc4los biliares oc4rren con *2s !rec4encia en *4jeres ;4e en 8o*bres ) se v4elven *2s co*4nes con la edad en a*bos se6os. La tasa de este ti%o de c2lc4los es *a)or en los abor#genes estado4nidenses ) en los 8is%anos ;4e en la *a)or#a de las otras %ersonas

Fisiopatologa "l t:r*ino de colecistitis ag4da es sinni*o de in!la*acin ag4da de la ves#c4la. "sta se *ani!iesta con dolor en la regin del 8i%ocondrio derec8o9 ocasional*ente este se irradia 8acia la es%alda %or *2s de /4 8oras9 en ocasiones se aco*%a>a con !iebre de *2s de 77.5 E C. ,4c8os de los %acientes ;4e %adecen colecistitis ag4da9 %resentan clicos 8e%2ticos %revios.

"n el +5D de los casos9 esta %atolog#a se enc4entra asociada con la obstr4ccin9 %or 4n c2lc4lo biliar9 del cond4cto c#stico. "sta obstr4ccin %rod4ce d:!icit del !l4jo venoso ) lin!2tico9 lo c4al %4ede ocasionar 4na in!la*acin ) ede*a de la %ared vesic4lar.

P4ede %rod4cirse 4na is;4e*ia @!alta de irrigacin sang4#neaA. "l origen del %ri*er e%isodio de colecistitis es de origen bio;4#*ico ) no bacteriano. Los *ediadores ;4#*icos res%onsables de la a%aricin de dic8a

%atolog#a sonB lisole4cina9 !os!oli%asa&09 %rostaglandinas9 etc. Signos y snto as Los s#nto*as general*ente co*ienzan des%4:s de ;4e 4n c2lc4lo grande blo;4ea el cond4cto c#stico o el cond4cto col:doco. "l cond4cto c#stico drena la ves#c4la ) el cond4cto col:doco es el cond4cto %rinci%al ;4e dese*boca en el d4odeno. F4ntos9 estos cond4ctos !or*an %arte del siste*a biliar. Gn c2lc4lo ;4e blo;4ea la abert4ra de la ves#c4la o el cond4cto c#stico general*ente %rod4ce s#nto*as de clico biliar9 ;4e es 4n dolor de ti%o clico desde la *itad 8asta la %arte s4%erior derec8a del abdo*en. (i el c2lc4lo no %asa 8acia el d4odeno9 %ero contin=a blo;4eando el cond4cto c#stico9 se %resenta 4na colecistitis ag4da. (i el cond4cto col:doco %er*anece blo;4eado %or 4n %er#odo considerable de tie*%o9 %4eden %roli!erar bacterias detr2s del c2lc4lo en la bilis estancada9 %rod4ciendo s#nto*as de colangitis9 4na a!eccin seria ;4e general*ente re;4iere 8os%italizacin. "l blo;4eo contin4o del !l4jo nor*al de la bilis %4ede %rod4cir ictericia @coloracin a*arillenta de la %iel ) los ojosA. Los c2lc4los ;4e blo;4ean el e6tre*o in!erior del cond4cto col:doco9 donde :ste entra en el d4odeno9 %4eden obstr4ir las secreciones del
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%2ncreas9 %rod4ciendo %ancreatitis. "sta a!eccin ta*bi:n %4ede ser seria ) re;4erir 8os%italizacin. "n t:r*inos generales9 se debe %restar atencin a los sig4ientes s#nto*asB

olor abdo*inal en el c4adrante s4%erior derec8o o en el centro del abdo*en s4%erior el c4alB %4ede ser rec4rrente %4ede ser ag4do9 ti%o cala*bre o sordo %4ede irradiarse a la es%alda o debajo del o*%lato derec8o %4ede e*%eorar con la ingestin de ali*entos grasos o grasosos se %resenta %ocos *in4tos des%4:s de las co*idas

Ictericia $iebre (#nto*as en!er*edadB 1eces color arcilla H24seas ) v*itos 0cidez esto*acal Gases o !lat4lencia e6cesiva Indigestin abdo*inal Llen4ra abdo*inal Medios !iagn"sticos# adicionales ;4e %4eden estar asociados con esta

Los e62*enes %ara detectar la %resencia de c2lc4los biliares o in!la*acin de la ves#c4la biliar abarcanB "cogra!#a abdo*inal -o*ogra!#a co*%4tarizada abdo*inal Colangio%ancreatogra!#a retrgrada endosc%ica @CP3"A Ga**agra!#a de la ves#c4la biliar con radion=clidos "cogra!#a endosc%ica Colangio%ancreatogra!#a %or resonancia *agn:tica @CP3,A Colangiogra!#a trans8e%2tica %erc4t2nea @C-1PA "l *:dico %4ede ordenar los sig4ientes e62*enes de sangreB ?ilirr4bina Pr4ebas de la !4ncin 8e%2tica "nzi*as %ancre2ticas $rata iento: CI3GGI0 0lg4nas %ersonas tienen c2lc4los biliares ) n4nca 8an tenido ning=n s#nto*a. "s %osible ;4e no se enc4entren c2lc4los biliares 8asta ;4e se 8aga 4na ecogra!#a %or otra razn. La cir4g#a %or lo reg4lar no es necesaria9 a *enos ;4e e*%iecen los s#nto*as. Gna e6ce%cin es en los %acientes ;4e se so*eten a cir4g#a %ara bajar de %eso. "n general9 los %acientes ;4e tengan s#nto*as necesitar2n cir4g#a )a sea in*ediata*ente o des%4:s de 4n corto %er#odo de tie*%o.

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 "n la act4alidad9 se 4tiliza con *a)or !rec4encia 4na t:cnica lla*ada

colecistecto*#a la%arosc%ica. "n este %rocedi*iento9 se 8acen incisiones ;4ir=rgicas *2s %e;4e>as ;4e %er*iten 4na rec4%eracin *2s r2%ida. 0 los %acientes a *en4do se les da salida del 8os%ital el *is*o d#a de la cir4g#a o a la *a>ana sig4iente. "n el %asado9 la colecistecto*#a abierta @e6tir%acin de la ves#c4la biliarA era el %rocedi*iento 4s4al %ara los casos sin co*%licaciones. (in e*bargo9 a8ora se realiza con *enos !rec4encia. (e %4eden llevar a cabo 4na colangio%ancreatogra!#a retrgrada endosc%ica @CP3"A ) 4n %rocedi*iento lla*ado es!interoto*#a %ara encontrar o tratar c2lc4los biliares en el cond4cto col:doco. ," IC0,"H-O( (e %4eden ad*inistrar *edica*entos en %#ldoras lla*ados 2cidos ;4enodeso6iclicos @0J CA o 2cido 4rsodeso6iclico @0G C9 GrsodiolA %ara disolver los c2lc4los de colesterol. (in e*bargo9 %4eden tardar dos a>os o *2s en 8acer e!ecto ) los c2lc4los %4eden retornar des%4:s de ;4e el trata*iento ter*ine. "n raras ocasiones9 se introd4cen ;4#*icos dentro de la ves#c4la biliar a trav:s de 4n cat:ter. "l ;4#*ico dis4elve r2%ida*ente los c2lc4los de colesterol. "ste trata*iento no se 4tiliza con *4c8a !rec4encia9 debido a ;4e es di!#cil de llevar a cabo9 los ;4#*icos %4eden ser t6icos ) los c2lc4los biliares %4eden rea%arecer. Co plicaciones Pancreatitis

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 Peritonitis @in!la*acin del revesti*iento del abdo*enA 5es#c4la %er!orada Piocolecisto

$eora de En%er era !orot&ea 're # Ore* naci en ?alti*ore9 ) se ed4c con las 1ijas de la Caridad de (. 5icente de Pa=l (e grad4 en 1+7.. entro de s4 tra)ectoria co*o teorista no in!l4) ning4na en!er*era *2s ;4e otra9 sino ;4e !4e el conj4nto de todas con las ;4e 8ab#a tenido contacto9 ) la e6%eriencia de las *is*as lo ;4e le sirvi de !4ente terica. Ore* de!ine s4 *odelo co*o 4na teor#a general de en!er*er#a ;4e se co*%one de otras tres relacionadas entre s#B . T!"#$% &!' A()"*(+&%&": "n la ;4e e6%lica el conce%to de a4toc4idado co*o 4na contrib4cin constante del individ4o a s4 %ro%ia e6istenciaB K"l a4toc4idado es 4na actividad a%rendida %or los individ4os9 orientada 8acia 4n objetivo. "s 4na cond4cta ;4e e6iste en sit4aciones concretas de la vida9 dirigida %or las %ersonas sobre s# *is*as9 8acia los de*2s o 8acia el entorno9 %ara reg4lar los !actores ;4e a!ectan a s4 %ro%io desarrollo ) !4nciona*iento en bene!icio de s4 vida9 sal4d o bienestarK. e!ine ade*2s tres re;4isitos de a4toc4idado9 entendiendo %or tales los objetivos o res4ltados ;4e se ;4ieren alcanzar con el a4toc4idadoB

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3e;4isitos de a4toc4idado 4niversalB son co*4nes a todos los individ4os e incl4)en la conservacin del aire9 ag4a9 eli*inacin9 actividad ) descanso9 soledad e interaccin social9 %revencin de riesgos e interaccin de la actividad 84*ana. 3e;4isitos de a4toc4idado del desarrolloB %ro*over las condiciones necesarias %ara la vida ) la *ad4racin9 %revenir la a%aricin de condiciones adversas o *itigar los e!ectos de dic8as sit4aciones9 en los distintos *o*entos del %roceso evol4tivo o del desarrollo del ser 84*anoB ni>ez9 adolescencia9 ad4lto ) vejez. 3e;4isitos de a4toc4idado de desviacin de la sal4d9 ;4e s4rgen o est2n vinc4lados a los estados de sal4d. ,. T!"#$% &!' &-.+*+) &! %()"*(+&%&": "n la ;4e describe ) e6%lica las ca4sas ;4e %4eden %rovocar dic8o d:!icit. Los individ4os so*etidos a li*itaciones a ca4sa de s4 sal4d o relaciones con ella9 no %4eden as4*ir el a4toc4idado o el c4idado de%endiente. eter*ina c42ndo ) %or ;4: se necesita de la intervencin de la en!er*era. /. T!"#$% &! '"0 0+0)!1%0 &! !2.!#1!#$%: "n la ;4e se e6%lican los *odos en ;4e las en!er*erasCos %4eden atender a los individ4os9 identi!icando tres ti%os de siste*asB (iste*as de en!er*er#a total*ente co*%ensadoresB La en!er*era s4%le al individ4o. (iste*as de en!er*er#a %arcial*ente co*%ensadoresB "l %ersonal de en!er*er#a %ro%orciona a4toc4idado.

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(iste*as de en!er*er#a de a%o)o&ed4cacinB la en!er*era act=a a)4dando a los individ4os %ara ;4e sean ca%aces de realizar las actividades de a4toc4idado9 %ero ;4e no %odr#an 8acer sin esta a)4da. Ore* de!ine el objetivo de la en!er*er#a co*oB K 0)4dar al individ4o a llevar a cabo ) *antener %or s# *is*o acciones de a4toc4idado %ara conservar la sal4d ) la vida9 rec4%erarse de la en!er*edad )Co a!rontar las consec4encias de dic8a en!er*edadL. 0de*2s a!ir*a ;4e la en!er*era %4ede 4tilizar cinco *:todos de a)4daB act4ar co*%ensando d:!icits9 g4iar9 ense>ar9 a%o)ar ) %ro%orcionar 4n entrono %ara el desarrollo. "l conce%to de a4toc4idado re!4erza la %artici%acin activa de las %ersonas en el c4idado de s4 sal4d9 co*o res%onsables de decisiones ;4e condicionan s4 sit4acin9 coincidiendo de lleno con la !inalidad de la %ro*ocin de la sal4d. 1ace necesaria la individ4alizacin de los c4idados ) la i*%licacin de los 4s4arios en el %ro%io %lan de c4idados9 ) otorga %rotagonis*o al siste*a de %re!erencias del s4jeto.

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CAPITULO III MARCO METOLOGICO Ho*bre ) 0%ellidosB M., (ervicioB Cir4g#a. "dadB 4/ a>os. L4gar de naci*ientoB 0rag4a HN de 8istoriaB 6& .+&15&55

A2)!*!&!2)!0 P!#0"2%'!0: Hiega alergia a *edica*entos. 3e!iere ;4ir=rgicos %or ces2reas seg*entarias en / o%ort4nidades

A2)!*!&!2)!0 F%1+'+%#!0: Padre *4erto @8ace 47 a>osA %or tro*bosis. *adre *4erta9 no %recis.

H3+)"0 P0+*"'4g+*"0:

15

Hiega 82bitos tab2;4icos.

L+0)% &! P#"3'!1%0: olor Ha4seas (4e>o interr4*%ido

R!0(1!2 &!' C%0": Ingresa %aciente !e*enina de 4/ a>os de edad9 6. colecistitis ag4da &

litiasis vesic4lar9 consciente ) orientado @-ie*%o9 es%acio ) %ersonaA se %resent dolor abdo*inal de !4erte intensidad localizado en e%igastrio ;4e %osterior*ente se irradia al 8i%ocondrio derec8o con constante ce!alea ) alza t:r*ica c4anti!icada en 4. CN. D%)"0 0(35!)+6"0- P%)#"2!0 &! M%#5"#7! G"#&"2. (atrones Funcionales# 1. P%)#428 9!#*!9*+42 7 1%2!5" &!' E0)%&" &! S%'(&: Paciente *ani!iesta no tener conoci*iento sobre s4 en!er*edad ni de s4 estado de sal4d. /. P%)#42 2()#+*+"2%' 1!)%34'+*": Paciente *ani!iesta no co*er bien %or !alta de a%etito. 7. P%)#42 &! !'+1+2%*+42: Paciente *ani!iesta orinar con !rec4encia en el d#a9 ) evac=a 4na vez al d#a.

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4. P%)#42 &! A*)+6+&%&!0 7 E5!#*+*+"0: Paciente *ani!iesta ;4e antes de ser ingresada llevaba 4na vida activa caracterizada diaria*ente. 5. P%)#42 &! S(!:" 7 D!0*%20": Paciente *ani!iesta ;4e lleva *2s de tres d#as sin dor*ir bien debido a s4 co*%licacin de sal4d. 6. P%)#42 C"g2"0*+)+6"-P!#*!9)(%': Paciente *ani!iesta ;4e esc4c8a9 8abla ) *ira bien9 %or lo ;4e constante*ente est2 4bicado en el tie*%o ) es%acio. 7. P%)#42 &!' R"'-I2)!##!'%*+42: Paciente *ani!iesta tener b4ena relacin en s4 8ogar9 resto de !a*ilia ) a*igos. '. P%)#42 &! S!;(%'+&%& 7 #!9#"&(**+42: Paciente *ani!iesta tener 8ijos ) vivir !eliz. +. P%)#42 &! A()" 9!#*!9*+42 7 A()" *"2*!9)": Paciente *ani!iesta ser %ositivo ) ent4siasta. Con!#a en ;4e va a *ejorar ) todo saldr2 sin *enor co*%licacin. 1.. P%)#42 &! T"'!#%2*+% %' !0)#-0: Paciente *ani!iesta ser 4na %ersona tran;4ila9 de b4en 84*or ) %oco alterada9 evita acelerarse e*ocional*ente. 11. P%)#42 &! V%'"#!0 7 *#!!2*+%0: Paciente *ani!iesta ser cristiana ) !iel cre)ente en ios< asiste a la iglesia event4al*ente.

S.O.A.P.E. N"13#!: M.,. E&%&: 4/ a>os S!;": $e*enino

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I2g#!0"B /5C.1C/.17 D; M-&+*": Colecistitis ag4da9 Litiasis vesic4lar. Ingresa %aciente !e*enina de 4/ a>os de edad nat4ral del estado 0rag4a ) %rocedente de esta localidad9 con i*%resin 6 *:dicoB Colecistitis ag4da9 Litiasis vesic4lar. He4rolgica*ente consciente ) 4bicada en s4s tres %lanos %sicolgicos @-.".P.A %aciente *ani!iesta Otengo *4c8o dolorL9 Otengo ganas de vo*itarL. (e observa %aciente con !acies de dolor9 (C5 te*%. 77EC9 $.CB 6/PL9 $.3B16PL9 -.0B11.C7.**1g< abdo*en globoso %or e6%ensa de %an#c4lo adi%oso de%reciable doloroso a la %al%acin %ro!4nda en e%igastrio9 3s 1s Ps. Interrelacin est4diante&%aciente9 se ad*inistra --O indicado9 a%o)o e*ocional. Los res4ltados es%erados !4eron %ositivos.

VALORACION OBJETIVA

A09!*)"0 G!2!#%'!0: T!19!#%)(#%: 7797N P('0": '16L R!09+#%*+42: 1+6L T!20+42 %#)!#+%': 1/.C7. **8g. P!0": 7. Qg

E;%1!2 F$0+*":
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P+!': blanda9 nor*o8idratada9 l4gar ) elasticidad conservada. (in evidencia de lesiones a%arentes. C%3!<%: Hor*oce!ala9 centrada sin reblandeci*iento ni t4*ores. O5"0: (i*:tricos c4%tr!icos9 blan;4ea*iento conservado. O$&"0: si*:tricos9 c4%tr!icos9 sin %resencia de secreciones. N%#+<: -abi;4e nasal centrado9 !osas nasales %er*eables. B"*%: Labios si*:tricos c4%tr!icos ) leng4a centrada9 %resencia de %rtesis.

F%#+2g!: Ho e6%lorado. C(!''": Centrado *vil a *ovi*ientos9 activo ) %asivo conservado. G%2g'+"0 '+2.)+*"0: (in adeno%at#a %al%able. T4#%;: (i*:trico9 nor*oe6%ansible9 3s3s en a*bos 8e*itora6 sin agregados9 3sCsPs sin so%lo ni galo%e.

S!2"0: no e6%lorado. P('1"2!0: ,4r*4llo vesic4lar 0sCs %4l*ones nor*o!on:tico sin agregado.

A3&"1!2: globoso %or e6%ensa de %an#c4lo adi%oso de%reciable doloroso a la %al%acin %ro!4nda en e%igastrio9 3s 1s Ps.

G!2+)%'!0: ,onte %4bis& tejido adi%oso ;4e c4bre el s#n!isis %4bis. Labios *a)ores& dobleces de tejido. Labios *enores& dobleces de tejido ;4e %rotegen la vagina ) la 4retra.
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R!*)": Hor*al. M+!13#"0 0(9!#+"#!0 ! +2.!#+"#!0: (i*:tricas c4%tr!icos9 sin ede*a9 se evidencia %resencia de varices.

N!(#"'4g+*" 7 90$=(+*": Consciente9 orientada -C"CP9 sin d:!icit *otor.

E;1!2!0 *"19'!1!2)%#+"0: Control de tensi"n# F!*>% /6&.1&/.17 /7&.1&/.17 /'&.1&/.17 )esultados de la*oratorio E;1!2!0 Glice*ia 1G? Grea Creatinina 5I1 5 3L E+, enes realizados# F!*>% /6&.1&/.17 /6&.1&/.17 /6&.1&/.17 /6&.1&/.17 /6&.1&/.17 /6&.1&/.17 R!0(')%&" 66 *gC L 1/.7 G30,(C L 17 *gC L ..6 *gC L Ho reactivo Ho reactivo R!0(')%&"0 1/.C7. **8g 11.C7. **8g 1/.C'. **8g

0n2lisisB se %4ede observar ;4e el %aciente %resenta ci!ras nor*ales en todos s4s valores. Lista de Medica entos Irto%anB 1 a*%. "5 cC'8ra. (O(. i%ironaB 1a*%. *g "5 cC' 8oras. (O( -e*%< R7'O( -e*%< R7'95SC.
20

C(%&#" A2%'$)+*" N"13#!: M.,. E&%&: 4/ a>os S!;": $e*enino H"09+)%': Israel 3an4arez ?alza S!#6+*+": Cir4g#a D+%g2"0)+*" 1!&+*" %*)(%': Colecistitis ag4da9 Litiasis vesic4lar. P%)#42 D+%g2"0)+*" &! D%)"0 0(35!)+6"0 D%)"0 "35!)+6"0 P#"3'!1% %')!#%&" !2.!#1!#$% Paciente re!iere Presenta !acies de olor $4erte Perce%cinC olor 3CC signos ) K*e d4ele *4c8o ) dolor Control sal4d s#nto*as de la *e c4esta %atolog#a9 "CP res%irarK. "6%resin verbal

21

del %aciente. Paciente re!iere Ono Presenta inso*nio. %4edo dor*ir bienL (4e>o ) descanso. (4e>o interr4*%ido (4e>o interr4*%ido 3CC dolor ) !alta de aire "CP "6%resin verbal del %aciente. H24seas ) 5*itos 3CC. "CP "6%resin verbal del %aciente.

Paciente re!iere Presenta na4seas. Otengo ganas de vo*itarL

H4tricional H24seas

CONCLUSIONES "s de in!erir ;4e los c2lc4los biliares es 4n trastorno de *a)or incidencia del tracto biliar ) se s4giere ;4e los %acientes ;4e %resentan tendencia a !or*arlas se le debe reco*endar 4na baja ingesta de grasas ) la ingesta de cantidades generosas de l#;4idos a *enos ;4e est: contraindicado co*o en el caso del %aciente seleccionado. Los c2lc4los biliares se co*%onen %rinci%al*ente de colesterol9 sales biliares9 calcio9 bilirr4bina ) %rote#nas9 ede*as de los !actores ;4e a4*entan
22

el riesgo de colelitiasis entre ellos los *etablicos debido a la sat4racin de colesterol biliar ) en!er*edades o reaccin del #leo -er*inal %or estasis e in!la*aciones. La alteracin del *etabolis*o de los ali*entos grasos %4ede estar ocasionada %or !latos9 diarreas9 distensin abdo*inal9 n24seas ) v*itos. "l dolor del c:lico biliar es irradiado a trav:s de la es%alda bajo el o*%lato ) 8acia el 8o*bro derec8o9 !iebre ) ta;4icardia. "l trata*iento *:dico es nada %or v#a oral9 sonda nasog2strica9 in!4siones %or v#a intravenosa9 es%as*ol#ticos9 anticolin:rgicos @condicin crnicaA9 antibiticos %or los e%isodios ag4dos9 cir4g#a. Con lo antes *encionado se !4nda*enta el %roceso de en!er*er#a obteni:ndose los diagnsticos de en!er*er#a ) con!ir*ando el diagnstico *:dico.

23

ANEXOS

24

C(%&#" A2%)41+*" A2%)"1$% E0)#(*)(#%

"l siste*a biliar consta de rganos ) cond4ctos @cond4ctos biliares9 ves#c4la biliar ) estr4ct4ras asociadasA ;4e %artici%an en la %rod4ccin ) trans%orte de la bilis. "l trans%orte de la bilis sig4e esta sec4enciaB 1. Las c:l4las del 8#gado segregan la bilis ;4e es recolectada %or 4n siste*a de cond4ctos9 los c4ales a s4 vez con!l4)en en los cond4ctos derec8o e iz;4ierdo del 8#gado. /. Por =lti*o9 estos cond4ctos drenan s4 contenido en el cond4cto 8e%2tico co*=n. 7. "l cond4cto 8e%2tico co*=n se 4ne des%4:s con el cond4cto c#stico de la ves#c4la biliar %ara !or*ar el cond4cto biliar co*=n ;4e va del 8#gado al d4odeno @%ri*era seccin del intestino delgadoA. 4. Ho obstante9 no toda la bilis %asa directa*ente al d4odeno. 0%ro6i*ada*ente 4n 5.D de la bilis %rod4cida %or el 8#gado se ac4*4la %ri*ero en la ves#c4la biliar9 4n rgano con !or*a de %era9 localizado directa*ente debajo del 8#gado. 5. C4ando se ingieren ali*entos9 la ves#c4la se contrae ) s4elta en el d4odeno la bilis ac4*4lada9 ;4e a)4da a degradar las grasas.

25

C(%&#" F+0+"9%)"'4g+*"

D!.+2+*+42

E)+"'"g$%

S+g2"0 7 S$2)"1%0 olor

M!*%2+01" F+0+"9%)"'4g+*" & Obstr4ccin del drenaje vesic4lar sec4ndario a la incr4stacin 1art*ann clico biliar. & 04*ento dentro de de %resin la l4z9 o de en 4n el c2lc4lo en la !osa de cond4cto c#stico. Inicia

C"19'+*%*+"2!0

T!#%9!()% &! T#%)%1+!2)" "n general el debe ser tratado en a*biente 8os%italario9 cal*ar el dolor es el %ri*er objetivo9 estabilizar al %aciente9 sobre todo si est2 con C"G

"s 4na in!la*acin de la %ared de de la la ves#c4la ade*2s en la *is*a. biliar9

1& I*%actacin de 4n c2lc4lo en

& In!eccin & Per!oracin de %aciente la ves#c4la & $#st4las intestinales & Pancreatitis & Col:doco litiasis & C2ncer ves#c4la.

alg=n $iebre H24seas de

sitio del siste*a de Indigestin drenaje de bilis. /& C2lc4los !or*ados %or a4*ento colesterol. 7& C2lc4los !or*ados %or 4& a4*ento ricas de en bilirr4bina. ietas grasas ) az=cares9 %obres en !ibra.

!or*acin de c2lc4los

de @!iebre9 etc.A.

na4seas9

desencadenado %or el incre*ento del vol4*en de bilis ) secreciones.

v*itos9 8i%otensin9

-rata*iento de!initivo & Contraccin9 obstr4ccin9 ves#c4la llena9 e in!eccin. Cir4g#a electiva C Colecistecto*#a la%arosc%ica.

26

P'%2 &! C(+&%&" I N"13#! 7 %9!''+&": M.,. E&%&: 4/ a>os S!;": $e*enino D; M-&+*": Colecistitis9 litiasis vesic4lar. D; E2.!#1!#": olor 3CC %atolog#a. "CP "6%resin verbal del %aciente. T!"#$% &! C#+)!#+" &! A**+"2!0 &! P#"3'!1% E6%'(%*+42 E2.!#1!#$% R!0(')%&" E2.!#1!#$% Dorotea Orem: (iste*a en!er*er#a a%o)o ed4cacionalB "n este siste*a la en!er*era a)4da %aciente trav:s de orientacin9 ense>anzas consejos9 ) %ara al a la de de olor
0l cabo de 7. Interact4ar el 0l cabo de 7. *in4tos

con el el %aciente %aciente9 %aciente *ani!estar2 8aber ,edir signos *ani!estar2 8aber dis*in4ido el dolor vitales.
*in4tos dis*in4ido el dolor

;4e sea ca%az de realizar s4 a4toc4idado.

l4ego de 8aber Pro%orcionarle l4ego de 8aber *edidas de a%licado las acciones relajacin %ara de en!er*er#a. a%licado las a)4darlo a acciones de dis*in4ir en!er*er#a. dolorB ejercicios9 dib4jos9 esc4c8ar *=sicas. "d4car acerca de la %osicin adec4ada %ara *ini*izar el dolor.

0d*inistrar trata*iento seg=n orden *:dica.

27

P'%2 &! C(+&%&" II N"13#! 7 %9!''+&": M.,. E&%&: 4/ a>os S!;": $e*enino D; M-&+*": Colecistitis9 litiasis vesic4lar. D; E2.!#1!#": (4e>o interr4*%ido relacionado con dolor. "CP "6%resin verbal del %aciente. T!"#$% &! E2.!#1!#$% Dorotea Orem: (iste*a a%o)o ed4cacionalB "n siste*a en!er*era a)4da %aciente orientacin9 ense>anzas ) consejos9 %ara ;4e sea ca%az de realizar s4 a4toc4idado. al a este la de C#+)!#+" &! R!0(')%&" 0l cabo de 4na sesin ed4cativa ) de s4*inistrar trata*iento %ara el dolor c*oda9 %ro%orcion2ndol e 4n estado de relajacin9 a4*entando as# las 8oras de s4e>o noct4rno. red4cir a el la A**+"2!0 &! E2.!#1!#$% Interact4ar con %aciente9 ,edir

P#"3'!1%

E6%'(%*+42

(4e>o interr4*%ido .

0l cabo de 4na el sesin ed4cativa ) de s4*inistrar

en!er*er#a de

signos trata*iento %ara el red4cir el vitales. a la ?rindar 4n dolor a*biente %ro%icio9 c*odo %aciente9 se deja c*oda9

%aciente9 se deja

) %ro%orcion2ndole 4n estado de con!ortante9 %ara *ejorar relajacin9 estado s4e>o. 0d*inistrar trata*iento seg=n *:dica. orden de a4*entando as# las 8oras de s4e>o noct4rno.

trav:s de la

28

P'%2 &! C(+&%&" III N"13#! 7 %9!''+&": M.,. E&%&: 4/ a>os S!;": $e*enino D; M-&+*": Colecistitis9 A**+"2!0 &! E2.!#1!#$% Interact4ar con el %aciente. ,edicin

litiasis vesic4lar. D; E2.!#1!#": Ha4seas T!"#$% &! C#+)!#+" &! P#"3'!1% E2.!#1!#$% R!0(')%&" Dorotea Orem: (iste*a en!er*er#a %arcial*ente co*%ensadora. de Ha4seas. 0l cabo de 4n d#a9 del *edica*ento9 el %aciente las dis*in4) n24seas. con la ad*inistracin

E6%'(%*+42

0l cabo de 4n d#a9 con la

de ad*inistracin del signos vitales. *edica*ento9 0d*inistrar el %aciente trata*iento seg=n *:dica. orden dis*in4) las n24seas.

29

FICHAS FARMACOLGICAS DIPIRONA Mecanis o de Acci"n# ejerce s4 e!ecto analg:sico %or *edio de la in8ibicin de las %rostaglandinas en el tejido nerviosos9 es decir9 tiene accin analg:sica %redo*inante a nivel del siste*a nervioso central. (4 e!ecto co*o anti%ir:tico se debe a ;4e s4s *etabolitos activos %enetran en el siste*a nervioso central ) gracias a la in8ibicin de la s#ntesis 8i%otal2*ica de %rostaglandinas9 %rod4ce anti%ire6ia. (4 e!ecto co*o anties%as*dico se debe a la dis*in4cin de la e6citabilidad de los *=sc4los lisos %eri!:ricos. -ndicaciones# es analg:sico ) anti%ir:tico. "st2 indicado %ara el trata*iento del dolor intenso ag4do o crnico co*o el dolor de la en!er*edad re4*2tica9 ce!alea9 odontalgias o dolor t4*oral9 ) %osterior a tra4*atis*os o cir4g#a. olores intensos debidos a es%as*os de la *4sc4lat4ra lisa9 ag4da ) crnica en la regin gastrointestinal9 tracto biliar9 ri>ones ) v#as 4rinarias in!eriores. Para bajar la !iebre c4ando otras *edidas no res4lten e!icaces. Ad.ertencias# Ho ad*inistrar d4rante el e*barazo o c4ando se sos%ec8e s4 e6istencia9 ni d4rante la lactancia9 a *enos ;4e a criterio *:dico el balance riesgoCbene!icio sea !avorable. "n caso de ser i*%rescindible s4 4so9 s4s%:ndase te*%oral*ente la lactancia *aterna *ientras d4re el trata*iento. )eacciones Ad.ersas# 1e*atolgicasB ane*ia 8e*ol#tica9 ane*ia a%l2sica9 agran4locitosis. Cardiovasc4larB 8i%otensin. He4rolgicasB *areo9 v:rtigo9 ce!alea. GastrointestinalesB n24seas9 v*itos9 irritacin g2strica9 6erosto*#a.

30

Contraindicaci"n#

1i%ersensibilidad

la

i%irona9

al

Tcido

0cetilsalic#lico o a otros 0IH"(.

iscrasia sang4#nea o s4%resin de la

*:d4la sea. Glcera gastrod4odenal activa. (resentaci"n# "st4c8e con /. ) 1.. tabletas de 7.. *g. "st4c8e con /. ) 1.. tabletas de 5.. *g. $rasco con 1/. *l @/5. *gC 5 *lA. $rasco gotero con 15 *l @5.. *gC*lA. "st4c8e con 4 ) 1.. a*%ollas de / *l @1 gC/*lA. IRTOPAN Co posici"n# ,etoclo%ra*ida. -ndicaciones# 0ntie*:tico. (osologa# 0d4ltosB 1. U 15 *g tres veces al d#a. Hi>osB .95 *gC QgCd#a divididos en tres dosis. Ad.ertencias# Ho e6ceder de .95 *gCQgCd#a @dosis totalA9 es%ecial*ente en ni>os *enores %ara evitar %osibles e!ectos e6tra%ira*idales. Ho debe asociarse con anticolin:rgicos9 )a ;4e :stos an4lan s4 e!ecto en el tracto gastrointestinal. Ho se ad*inistre d4rante el e*barazo o c4ando se sos%ec8e s4 e6istencia9 ni d4rante la lactancia9 a *enos ;4e a criterio *:dico el balance riesgoCbene!icio sea !avorable. e ser i*%rescindible s4 4so %or no e6istir otra alternativa tera%:4tica s4s%enda la lactancia *aterna *ientras d4re el trata*iento. "ste %rod4cto tiene 4n e!ecto esti*4lante de la secrecin de la Prolactina9 s4stancia ;4e 8a sido relacionada con a4*ento del riesgo de carcino*a *a*ario.
31

)eacciones Ad.ersas# He4rolgicasB In;4iet4d9 debilidad9 reacciones e6tra%ira*idales9 inso*nio9 ce!alea9 conv4lsiones. GastrointestinalesB iarrea. 1or*onalesB Galactorrea9 a*enorrea reversible9 gineco*astia. OtrosB 1i%ertensin transitoria. Contraindicaci"n# 1i%ersensibilidad a la ,etoclo%ra*ida. "%ile%sia9

%acientes con trastornos dis;4in:ticos9 %acientes ;4e reciben *edica*entos ;4e ca4sen trastornos e6tra%ira*idales9 !enotiazinas9 !eocro*ocito*as )Co 8e*orragias gastrointestinales. -nteracciones# Potencia los e!ectos e6tra%ira*idales de la $enotiazina9 ?4tiro!enona ) -iro6antinas. Potenciacin de s4 e!ecto c4ando se asocia con otros de%resores del siste*a nervioso centralB O%i2ceos9 barbit=ricos9 anest:sicos9 de%endientes. alco8ol9 otros analg:sicos9 sedantes9 8i%nticos ) tran;4ilizantes. P4ede alterar los re;4eri*ientos de Ins4lina en Ins4lino& is*in4)e la absorcin de igo6ina. Incre*enta la absorcin de 0ceta*ino!:n9 0s%irina9 iaze%an9 "tanol9 Levodo%a ) Litio. (resentaci"n# "st4c8e con /. tabletas de 1. *g "st4c8e con / ) 6 a*%ollas de 1. *g @1. *gC / *lA $rasco con 1/. *l @5 *gC 5 *lA $rasco gotero con 7. *l @/96 *gC*lA

32

HISTORIA DE ENFERMERA

DATOS DE IDENTIFICACIN: Ho*bres ) a%ellidosB L4gar de naci*iento< $ec8aB VVVVVVVVVVVVV "dadB VVVVVVVV "stado CivilB VVVVVVVVVVVV -el:!onoB VVVVVVVVVVVV Grado de instr4ccinB VVVVVVVVVVVVVVVVVVVVVV Pro!esin 4 o!icioB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV $ec8a de ingresoB VVVVVVVVVVVVVV (ervicioB VVVVVVVVVVVVVVVVVVVVVVVV Ca*aB VVVVVVVVVVV ,otivo de IngresoB VVVVVVVVVVVVVVVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV

A2)!*!&!2)!0 P!#0"2%'!0 P%)"'4g+*"0: 5aricelaB VVVVVVVVVVVVVVVVVV (ara*%inB VVVVVVVVVVVVVVVV -os!erinaB VVVVVVVVVVVVVVVVV ParotiditisB VVVVVVVVVVVVVVVV i!teriaB VVVVVVVVVVVVVVVVVVV Pal4dis*oB VVVVVVVVVVVVVVVV -.?.CB VVVVVVVVVVVVVVVVVVVV 0lergiaB VVVVVVVVVVVVVVVVVVV J4ir=rgicaB VVVVVVVVVVVVVVVV "s%eci!i;4eB VVVVVVVVVVVVV "s%eci!i;4eB VVVVVVVVVVVVV

EXAMEN FUNCIONAL DATOS SUBJETIVOS C"2"*+1+!2)" 7 M%2!5" &! '% S%'(& (e considera Gd. Gna %ersona sana o en!er*aB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV

33

Gd. 0lg4na vez 8a estado en!er*oB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Gd. C4*%le las indicaciones o %rescri%ciones del *:dico )Co en!er*era@oAB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV WJ4: sabe 4sted de s4 en!er*edadXB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVV N()#+*+42 7 M!)%3"'+01": 0li*entacin diariaB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV L#;4idos ingeridosB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV ,:todos de cocina de %re!erenciaB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Gso de salB VVVVVVVVVVVVVVVVV Cons4*e ca!: o t:B VVVVVVVVVVVVVVVVVV Ingiere s4%le*entos vita*#nicosB VVVVVVVVVVVV c4alesB VVVVVVVVVVVVVVVV C42l es s4 %esoB VVVVV tallaB VVVVVVVVV est2 en el %eso idealB VVVVVVVVVVV 1a %erdido %esoB VVVVVVVV =lti*a*enteB VVVVVV c4antoBVVVVVVV co*oBVVVVVVVVVVVVVVVVV Perdida o ganancia de a%etitoB VVVVVVVVVVVVVV Ha4seasB VVVVVVVVVVVVVVVVVVVVVVV dentad4raB VVVVVVVVVVVVVVVVVVVV ObservacionesB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV E'+1+2%*+42 IntestinalB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Proble*a %ara evac4arB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV $rec4encia de evac4acinB VVVVVVVVVVVVVVV a)4daB VVVVVVVVVVVVVVVVVV 5esicalB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Proble*a %ara orinarB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV $rec4encia de *iccinB VVVVVVVVVVVVVVVVV Por %ielB VVVVVVVVVVVVVVVVV A*)+6+&%& 7 E5!#*+*+" 0ctividades diarias ) nor*alesB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV "jerciciosB VVVVVVVVVVV ti%oB VVVVVVVVVVVVVVVVVVVVV tie*%oB VVVVVVVVV 3ealiza %or s# *is*o s4s %ro%ios c4idadosB VVVVVVVVVVVVVVVVVVVVVVVVVV 1obbieB VVVVVVVVVVVVVVVVVVV tie*%o ;4e le dedicaB VVVVVVVVVVVVVVVVV
34

S(!:" 7 &!0*%20": Proble*as %ara dor*irB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV C4antas 8oras ) c4ales d4er*eB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV (e des%ierta !rec4ente*ente ) %or ;4:B VVVVVVVVVVVVVVVVVVVVVVVVVVVVV -iene !rec4entes %esadillasB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV 12bitos %ara dor*irB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV P!#*!9*+42 0!20"#+%'8 *"2"*+1+!2)" 7 *"1(2+*%*+42: Conoce le %roceso de s4 en!er*edadB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Conoce la tera%:4tica %ara s4 en!er*edadB VVVVVVVVVVVVVVVVVVVVVVVVVV -iene %roble*as en a4dicinB VVVVVVVVVVVVVV visinB VVVVVVVVVVVVVVVVV Gsa lentesB VVVVVVVVVVVVVVV a)4da a4ditivasB VVVVVVVVVVVVVVVVVVVVVVV ObservacionesB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV R"' ! +2)!##!'%*+42: HN de %ersonas en s4 casaB VVVVVV interrelacin con ellosB VVVVVVVVVVVVVV "stado civilB VVVVVVVVVVVVVVV so%orte de !a*iliaB VVVVVVVVVVVVVVVVVVVVV "stado de sal4d de los otros *ie*bros de la !a*iliaB VVVVVVVVVVVVVVVVVVV Co*o se 8a a!ectado la !a*ilia con s4 en!er*edadB VVVVVVVVVVVVVVVVVVV Co*o se res4elven los %roble*as en s4 8ogarB VVVVVVVVVVVVVVVVVVVVVVV J4ien c4ida d4rante s4 en!er*edadB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV C42l es s4 trabajoB VVVVVVVVVVVVV -iene *4c8os ene*igosB VVVVVVVV Co*o se lleva con s4s co*%a>eros de trabajoB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV S!;(%'+&%& - R!9#"&(**+42: HN de 8ijosB VVVVVVVVVVVV Planes %ara s4s 8ijosB VVVVVVVVVVVVVVVVVVVVV Plani!ica s4 !a*iliaB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Proble*as con s4s relaciones se64alesB VVVVVVVVVVVVVVVVVVVVVVVVVVVV
35

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ObservacionesB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV E6%'(%*+42 2!(#"'4g+*% E&". M!2)%': Hivel de concienciaB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV OrientacinB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Leng4ajeB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV ,e*oriaB 3etrgradaB VVVVVVVVVVVVVVVVVVVV 0ntergradaB VVVVVVVVVVVVVVVVVVV C2lc4loB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV F4icioB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV P%#!0 *#%2!%'!0: Ol!atorioB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Z%ticoB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV ,otor Oc4lar Co*=n @,.O.C.AB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV @,.O.$.".AB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV $acialB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV 0c=sticoB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Gloso!ar#ngeoB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV 5ago o He4*og2stricoB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV "s%inalB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV 1i%oglosoB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV C""#&+2%*+42 7 1%#*>%: VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV R!.'!5"0: Pro!4ndos @OsteontedinososA ?ici%italB VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
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PROBLEMAS IDENTIFICADOS VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV

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