protocolo de atencion pediatrica

7/24/2019 Protocolo de Atencion Pediatrica

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HOSPITAL HORACIO HELLER

MANUAL DE

PROTOCOLOS DE

ENFERMERA

SECTOR 10

MAY0 2012

AUTORES:


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AGERO VALERIA

CALDERN MERCEDES

CASTILLO SUSANA

GARCA LORENA

GOMEZ RUTH

HUECHUCURA ROSA

MENDOZA SILVIA

NEIRA NATALIA

OSSES ROBERTO

PALACIOS ALFONSO

QUEZADA YANET SANDOVAL JUANA

VARGAS RAQUEL

VIDELA JUAN

ZAPATA VERNICA

COORDINADORA:Jefa e E!fe"#e"$a e% Se&'(" )*: L+&, CARI NORA,

COORDINADORES:

Jefe M-+&( e% Se&'(" )*: D", S('(#a.(" Ma"&e%(

C(("+!a(" e Pe+a'"$a: D", ROMERO C/SAR

AGRADECIMIENTO


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INTRODUCCIN

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&"+'e"+(4 e a'e!&+;! 4e1

E! e4'e (&0#e!'( 4e e4&"+9+"> %a f("#a +;!ea e %%e=a" a %a 2">&'+&a %a4+!'e"=e!&+(!e4 e e!fe"#e"$a3 4e '"a'( e 60e 4ea e87a04'+=( . &(#2%e'(3 e f("#a

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#0e" 0"a!'e e% 20e"2e"+(,

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e!fe"#e"$a3 Jefe e E!fe"#e"$a e% Se&'(",

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'((4 %(4 #+e#9"(4 +!'e"=+!+e!'e4 e! e% 2%a!'e% e e!fe"#e"$a e% Se&'(" )*,

E% Ma!0a% e P"('(&(%(4 &(!4'+'0.e e% ee f0!a#e!'a% 60e +!'e1"a %(4 4+4'e#a4 e

+!f("#a&+;! . &(#0!+&a&+;! e e!fe"#e"$a 60e e9e +" aa2'>!(4e a %(4 a=a!&e4

&+e!'$f+&(4 =a%+a(4 2(" %( 60e '+e!e e4'a" e! &(!4'a!'e "e=+4+;! . a&'0a%+5a&+;!,


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OBJETIVO:

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904&a e &a%+a . ef+&a&+a3 9a4>!(4e e! e% #>4 a%'( !+=e% e e=+e!&+a4

&+e!'$f+&a4 60e 20ea! a4e10"a" 60e %a a'e!&+;! e% 040a"+( 2e+>'"+&( . e

%a #0e" e! e% 2"(&e4( e% e#9a"a5( . 20e"2e"+( 4ea 2e"4(!a%+5aa .

70#a!+5aa,

OBJETIVOS ESPECFICOS:

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? P"(#(=e" %a 0!+f("#+a e &"+'e"+(4 &(! 0!a 9a4e 2a"a e% 2%a!ea#+e!'(

&"ea'+=(3 "a5(!a9%e . 4e10"( 2a"a %a '(#a e e&+4+(!e4 . %a ("1a!+5a&+;! e%

'"a9a(3 2a"a #e("a" e% a&&+(!a" 2"(fe4+(!a% e e!fe"#e"$a,

? L(1"a" %a 4a'+4fa&&+;! e% 040a"+( 2e+>'"+&(3 e %a e#9a"a5aa 20-"2e"a

&(! %a a'e!&+;! 9"+!aa : ( K,

? Te!e" e42a&+(4 e "e=+4+;!3 a&'0a%+5a&+;! . e0&a&+;! &(!'+!0a e %(4

&0+a(4 9"+!a(4,


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VALORACION INICIAL AL INGRESO DEL USUARIO PEDITRICO

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"+e41( e! f("#a (2("'0!a,

OBJETIVO:

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a'(43 e#2%ea!( &;+1(4 e &(#0!+&a&+;! 2e+>'"+&a3 #e+a!'e %a (94e"=a&+;!

+"e&'a e% !+@( e4&0&7a"%(3 (94e"=a" 2(4'0"a3 +90(43 e'& . e8a#e! f$4+&(,

De'e&'a" &a#9+(4 e! e% e4'a( e 4a%0 e% 040a"+( 2a"a e'e"#+!a" %a4

+!'e"=e!&+(!e4 e e!fe"#e"$a,

U!+f+&a" &"+'e"+(4 e a'e!&+;! e!'"e e!fe"#e"(4 . #-+&(4,

A9("ae +!+&+a%:

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OBSERVACIONES

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E!fe"#e"$a e% 4e&'(", Ta#9+-! e4 e% e!&a"1a( e '"ae" %a H+4'("+a &%$!+&a e%

040a"+(,

Fe&7a: , Se&'(" )*


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)? IDENTIFICACIN DEL PACIENTE

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,

? ANTECEDENTES DE SALUD

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T+2( e A%+#e!'a&+;!: V$a ("a%: P(" SNG:,Ga4'"(4'"(#$a:,

A9(#e!: B%a!(:,, G%(90%(4(: D+4'e!+(:,, R0+(4 H+"(a-"e(4: S+:

, N(:P"e4e!&+a e a!("#a%+ae4:,

Me+a4 A!'"(2(#-'"+&a4: Pe4(: Ta%%a: Pe"$#e'"( Cef>%+&(:,

P"e4e!&+a e N>04ea4: S+: N(: E#e4+4: S+:, N(:T+2(:

B+%+(4(:,,,,,,,,,,A%+#e!'+&+(:, Se&"e&+(!e4:, O'"(4:,

, Ne&e4+a e E%+#+!a&+;!

Ge!+'a%e4: N("#a%e4: S+:N(: P"e4e!&+a e %e4+(!e4: S+:,N(:,,

De"#a'+'+4: S+:,,N(:,,O'"(:,,


13/155

De2(4+&+(!e4: S+:,,N(: Ca"a&'e"$4'+&a4: L$60+a: Pa4'(4a:B%a!a:

E4'"e@+#+e!'(:, O'"a:,,

F"e&0e!&+a: U!a: D(4: T"e4: M>4 e '"e4:

D+0"e4+4: S+: N(: Ca"a&'e"$4'+&a4:

? Ne&e4+a e M(=+%+5a&+;!

M+e#9"(4 S02e"+("e4: I!'e1"+a e %a 2+e%:Def("#+ae4: S+:

,,N(: O'"(4:,,

M+e#9"(4 I!fe"+("e4: I!'e1"+a e %a 2+e%:

,, Def("#+ae4:,, T(!( #04&0%a":

Ma"&7a: C(("+!a&+;! e %a4 #a!(4 . %(4 2+e4: S+:N(:,

Ref%e(4: S+:,N(:,

M('("a4: Se 4+e!'a 4(%(: S+: N(: Dea#90%a: S+: N(:,, S(%(:,,

C(! a.0a:,

Se!4("+a%e4: C(!'"(% M04&0%(e460e%-'+&(: H+2e"'(!$a4:, H+2('(!$a4:

,A'"(f+a4:,

C(!'"(% !e0"(%;1+&(a%'e"a&+;! 4+&(#('"+&e4: S+:,N(:

? Ne&e4+a e Re2(4( . S0e@(

A%+#e!'a&+;! N(&'0"!a: S+: N(:Ca!'+a:, T+2(:

,

L%a!'( N(&'0"!(: S+: N(:M('+=(:

,

Re&7a5( a ("#+" e! 40 0!+a: S+N(: C(4'0#9"e e ("#+" &(! 404 2a"e4: S+:, N(:,

Ca#9+(4 e! e% 2a'";! e% S0e@(: S+: N(:, M('+=(:

,,

? Ne&e4+a e Te#2e"a'0"a ? H+1+e!e Ve4'+#e!'a P+e%

Te#2e"a'0"a A8+%a":CW N("#('e"#+a:, H+2('e"#+a:,, H+2e"'e"#+a:,,


14/155

E4'a( e %a P+e%: L+#2+a:,N("#(7+"a'aa:,De47+"a'aa:,, Se&a:

De4&a#aa:, Pe'e60+a4:E8a!'e#a:E60+#(4+4: O'"(:

C(%("a&+;!:N("#a%: E!"(e&+a:,P>%+a:,,I&'-"+&(,C+a!;'+&(:,

G"+4>&e(:,

H>9+'(4 H+1+-!+&(4: B0e!(:,, Re10%a": Ma%(:

,

Ca9e5a: C0e"( Ca9e%%0(: L+#2+(: S+:,N(:,Pe+&0%(4+4:,, E4&a9+(4+4:,,,,,

,,,, O(4: N("#a%:,, E!"(e&+(4:Se&"e&+(!e4: S+:, N(:, E4'"a9+4#(:

, O'"(4:

O+(4: I#2%a!'a&+;! e% 2a9e%%;! a0"+&0%a": N("#a%:,Baa:, A10e5a

a0+'+=a: N("#a%:H+2(a&04+a:,,Se&"e&+(!e4: S+:,N(:

Na"+5: Se&"e&+(!e4: S+:,,N(: Ca2a&+a 2a"a +!7a%a" . e87a%a" 2(" &aa

0!a e %a4 !a"+!a4: S+:, N(:,,

B(&a: H


15/155

VALORACIN DELOS SIGNOS VITALES

Def+!+&+;!:

La =a%("a&+;! e %(4 4+1!(4 =+'a%e4 !(4 2e"#+'e e'e&'a" a%'e"a&+(!e4

2('e!&+a%e4 ( "ea%e43 60e afe&'a! e% e60+%+9"+( 24+&(?f$4+&( e% +!+=+0(3 e4 e%

20!'( e 2a"'+a e! %a '(#a e e&+4+(!e4 (9e'+=a4 60e e'e"#+!a! 0! &0+a("ef%e8+=( e +!+=+0a%+5a( a% 2a&+e!'e,

L(4 4+1!(4 =+'a%e4: 'e#2e"a'0"a3 "e42+"a&+;!3 20%4( . 'e!4+;! a"'e"+a% 4(!

2a">#e'"(4 a '"a=-4 e %(4 &0a%e4 e4 2(4+9%e e=a%0a" %a 4a%0 e 0! +!+=+0(3

404 =a%("e4 4e #a!'+e!e! &(!4'a!'e4 e!'"( e &+e"'(4 %$#+'e43 e! e4'a( e

!("#a%+a,

O9e'+=(4$


16/155

U'+%+5a" %a +!f("#a&+;! (9'e!+a3 2(" %a #e+&+;! e %(4 4+1!(4 =+'a%e43 &(#(

fa&'(" e'e"#+!a!'e 2a"a =a%("a" %a e=(%0&+;! e% 040a"+(3 %a "e420e4'a a%

'"a'a#+e!'( . a %a4 +!'e"=e!&+(!e4 e e!fe"#e"$a,

Re&(!(&e" %a "e%a&+;! 60e e8+4'e e!'"e %(4 4+1!(4 =+'a%e43 %a a&'+=+a f+4+(%;1+&a. %(4 &a#9+(4 f+4+(2a'(%;1+&(4,

C(!'"(%a" %(4 4+1!(4 =+'a%e4 &(! #a.(" f"e&0e!&+a 4+ e% e4'a( e% 040a"+( %(

"e60+e"e,

V'r"'"ones on &' e#'#

Edad Frecuencia Cardiaca

Normal

(latidos por

minuto)

Frecuencia Respiratoria

Normal

(respiraciones por minuto)

Neonato 110-160 30-500-5

meses

90-190 25-40

6-12

meses

80-140 20-30

1-3 aos 80-130 20-30

3-5 aos 80-120 20-306-10

aos

70-110 15-30

11-14

aos

60-105 12-20

14+ aos 60-100 12-20

CONTROL DE TEMPERATURA

Def+!+&+;!:

E4 e% 1"a( e &a%(" #a!'e!+( e! e% &0e"2( 2(" e% e60+%+9"+( e!'"e %a

'e"#(1-!e4+4 . %a 'e"#;%+4+4,La 'e"#(1-!e4+4 e4 e% &a%(" 2"(0&+( . %a

'e"#;%+4+4 e4 e% &a%(" 2e"+(,

E% 1"a( e &a%(" 20ee 4e" #e+( e! %a 9(&a3 +!1%e3 a8+%a ( "e&'( 2(" #e+( e

0! 'e"#;#e'"( +1+'a% ( e #e"&0"+(, La4 f("#a4 #e!(4 f"e&0e!'e4 4(!: O"a%3I!10+!a% . Re&'a%,


17/155

O9e'+=(4:

? Va%("a" e% e4'a( e 4a%0 ( e!fe"#ea 4e1

1"a( e &a%(" &("2("a% . 404 a!("#a%+ae4,

C(!4+e"a&+(!e4:

? E% a0#e!'( e %a 'e#2e"a'0"a &("2("a% e4 0!a "e420e4'a a 0! 2"(&e4(

2a'(%;1+&(,? La 'e#2e"a'0"a &("2("a% 4e #(+f+&a &(! %a ea3 &%+#a3 ee"&+&+(3 e#9a"a5(3

&+&%( #e!4'"0a%3 e4'a( e#(&+(!a% . e!fe"#ea,? Fa&'("e4 60e afe&'a! e% a0#e!'( e %a 'e#2e"a'0"a: Ta4a #e'a9;%+&a 9a4a%3

A&'+=+a #04&0%a"3 A0#e!'( e %a 7("#(!a '+"(+ea3 e4'+#0%a&+;! 4+#2>'+&a

%+9e"a A"e!a%+!a3 N("a"e!a%+!a3Vasoconstriccin, Escalofrios,e#9(%+a

20%#(!a"3 2"e4e!&+a e '0#("e4 &(#( %a %e0&e#+a3 e47+"a'a&+;!3

A#9+e!'e3 '"a0#a'+4#(4 &"a!e(e!&ef>%+&(4 . %e4+(!e4 e %a #-0%a

e42+!a%3e'&,? Fa&'("e4 60e afe&'a! %a 2-"+a e %a 'e#2e"a'0"a$ C(!0&&+;!+

C(!=e!&+;!+ Va2("+5a&+;!3Vasodilatacin, Reposo y Sueo, ndiceMetablico Basal

? Va%("e4 !("#a%e4 e %a 'e#2e"a'0"a: R!: , & ? , & 3 La&'a!'e4 : ,

& ? & 3P"ee4&(%a" 3 e4&(%a" . A(%e4&e!'e4 : ? & 3Ea a0%'a :

, &3 Vee5 : & ,? A%'e"a&+(!e4: H+2e"e8+a ( 7+2e"'e"#+a : ) & 3 Fe9"+%: '+e!e f+e9"e &

3Afe9"+% : !( '+e!e f+e9"e &3 H+2('e"#+a : , &3 Fe9"$&0%a: , ,

INTERVENCIONES DE ENFERMERA

? E82%+&a" a% 040a"+(3 4e1'"+&(4

&aa 7("a43 . 4e1

? I!f("#a" a% 040a"+(3 a0%'( .( !+@(3 . a %(4 2a"e4 e% 2"(&e+#+e!'( a "ea%+5a",? P"e4e"=a" %a +!'+#+a e% 040a"+(,


18/155

? C(%(&a"4e %a4 #a!(2%a4 e 2(%+e'+%e!( ( e %>'e8,? De4&(!'a#+!a" e% 'e"#;#e'"( &(! 0!a '("0!a &(! 4(%0&+;! a!'+4-2'+&a &(!

#(=+#+e!'(4 "('a'("+(4 +!+&+a!( 2(" e% 90%9(,? S(4'e!e" e% 'e"#;#e'"( 2(" e% e8'"e#( (20e4'( a% e% 90%9( e #e"&0"+( .

4+'0a"%( a %a a%'0"a e %(4 ((43 4+ e% !+=e% e %a 9a""a e #e"&0"+( e4'> 2(" e!&+#ae %(4 C3 '(#a"%( f+"#e#e!'e .3 &(! #(=+#+e!'(4 4e&(4 e %a #0@e&a3

4a&0+" %+1e"a#e!'e,? Ve"+f+&a" 60e %a &(%0#!a e #e"&0"+( #a"60e C ,? C(#2"(9a" 60e %a a8+%a e% 2a&+e!'e e4'e 4e&a . %+9"e e "(2a,? Pe+"%e a% 040a"+( 60e 4e2a"e e% 9"a5( . &(%(&a" e% 'e"#;#e'"( e! e% &e!'"( e %a

a8+%a3 &(#2"(9a!( 60e e% 90%9( e #e"&0"+( e4'- e! &(!'a&'( &(! %a 2+e%3

4(%+&+'a" a% 040a"+( 60e (2"+#a e% 9"a5( &(!'"a %a 2a"e %a'e"a% e% ';"a8 (

&(%(60e 40 #a!( 4(9"e e% ';"a8,? Va%("a": el color de la piel: la"09+&0!e5 fa=("e&e %a e%+#+!a&+;! e &a%("3 %a

palidez +!+&a e% 2"+!&+2+( e% e4&a%(f"$( . e e%e=a&+;! e 'e#2e"a'0"a,La

presencia o ausencia de sudacin, cantidad y color de la orina, la conducta del

usuario (20ee e4'a" +""+'a9%e3 &a"a&'e"$4'+&a4 e %a 2+e%3 #0&(4a43 'a60+&a"+a3

4e3 a!("e8+a3 +!4(#!+(3 &(!=0%4+(!e43 e%+"+(3 a%0&+!a&+(!e4 . ('"(4 +!+&+(4 60e

!(4 +!+60e! 7+2('e"#+a e 7+2e"'e"#+a,? Ma!'e!e" e% 'e"#;#e'"( 2(" a #+!0'(4 . Re'+"a",? O94e"=a" e! %a &(%0#!a e% #e"&0"+( e% 1"a( 60e #a"&a,? Dea" a% 2a&+e!'e &;#((,? Re1+4'"a" %a =a%("a&+;! . %a &+f"a (9'e!+a3 e42e&+f+&a!( fe&7a3 7("a e! %a 60e

4e "ea%+5; e% &(!'"(% . f+"#a,? I!f("#a" a% #-+&( e f("#a +!#e+a'a 4+ 709+e"a a%10!a a%'e"a&+;!: 7+2e"'e"#+a

( 7+2('e"#+a,? La=a" e% 'e"#;#e'"( &(! a10a f"$a . e4&(!'a#+!a" &(! a!'+4-2'+&(3 9aa" %a

&(%0#!a e #e"&0"+( 7a4'a C . 10a"a",


19/155

CONTROL DE FRECUENCIA RESPIRATORIA

Def+!+&+;!:

E4 %a (94e"=a&+;! e %(4 #(=+#+e!'(4 '(">&+&(4 . a9(#+!a% e% 040a"+(

e! 0!a 0!+a e '+e#2( e4'a9%e&+(3 4e 2(!e! e #a!+f+e4'( 2(" e% 1"a( e

e42%a5a#+e!'( e% ';"a8 ( e% a9(#e!, La "e42+"a&+;! !("#a% +!&%0.e a#9(4

'+2(4 e #(=+#+e!'(43 2"e(#+!a!( e! Ia4 #0e"e4 e% &(#2(!e!'e '(">&+&( . e!

%(4 !+@(4 . 7(#9"e4 e% a9(#+!a%,

La #e&>!+&a "e42+"a'("+a 4e 2"(0&e #e+a!'e %(4 #(=+#+e!'(4 e e82a!4+;!

+!42+"a&+;! . "e'"a&&+;! e42+"a&+;! e ';"a8 . 20%#;!,E% a&'( e "e42+"a" +!&%0.e %a e!'"aa e (8+1e!( . %a 4a%+a e +;8+( e &a"9(!(,

OBJETIVO:

? Va%("a" e% 2a'";! "e42+"a'("+( 2a"a e'e&'a" e% e4'a( e 4a%0 ( e!fe"#ea,

? Ie!'+f+&a" %a4 &a"a&'e"$4'+&a4 e %a "e42+"a&+;!,

CARACTERISTICAS DE LA RESPIRACION:


20/155

Fre!en"': 4e e!(#+!a f"e&0e!&+a a% !&+&a . e

%a 2a"e a9(#+!a% &(""e42(!+e!'e a &aa '+2( "e42+"a'("+(

R"t,o$ "e%a&+;! !("#a% e!'"e +!42+"a&+;! . e42+"a&+;!3 4+e#2"e %a +!42+"a&+;! e4

#e!(" 60e %a e42+"a&+;!, E8+4'e 0!a "e%a&+;! e!'"e a#9(4 #(=+#+e!'(4,

La "e42+"a&+;! !("#a% 4e e!(#+!a e02!ea,

TIPOS DE RESPIRACIN:

C(4'a% '(">8+&(: e4 %a 60e +!=(%0&"a %(4 #


21/155

-r'#"(ne': D+4#+!0&+;! e %a f"e&0e!&+a a&(#2a@aa 1e!e"a%#e!'e 2(" 0!

a0#e!'( e %a 2"(f0!+a,

T'.!"(ne': A0#e!'( e %a f"e&0e!&+a "e42+"a'("+a,

H"(er(ne'$A0#e!'( e %a f"e&0e!&+a . e %a 2"(f0!+a "e42+"a'("+a,

A%'e"a&+(!e4 e %a A#2%+'0 Re42+"a'("+a:

Respiracin s!(er/""'&: Ca"a&'e"+5aa 2(" +#+!0&+;! e %a a#2%+'03 4e (94e"=a

e! 2"(&e4(4 (%("(4(4 60e a%'e"a! %a +!>#+&a "e42+"a'("+a3 1e!e"a%#e!'e 4e

a&(#2a@a e 'a60+2!ea,

Res("r'"nprofunda: aracterizada 2(" a0#e!'( e %a a#2%+'0 "e42+"a'("+a, Se

a&(#2a@a 1e!e"a%#e!'e e 9"a+2!ea,

La "e42+"a&+;! 2"(f0!a #>4 '$2+&a e4 %a Re42+"a&+;! e [044#a0%3 &(!4+4'e e!

+!42+"a&+(!e4 2"(f0!a4 . "0+(4a4 4e10+a4 e 0!a 2a04a 60e 20ee a%&a!5a"

7a4'a 4e10!(4\ %0e1( %e 40&ee 0!a e42+"a&+;! 9"e=e . 60e0#9"(4a3 4e10+a

e 0!a !0e=a 2a04a3 #>4 %a"1a3 7a4'a e 4e10!(4, Se (94e"=a e! &a4(4 e

a&+(4+4, T+e!e &(#( (9e'( a0#e!'a" %a =e!'+%a&+;! 20%#(!a" 2a"a a4$ e%+#+!a" #>4

CO . +4#+!0+" %a a&+(4+4,

A%'e"a&+(!e4 e% R+'#( Re42+"a'("+(:

Res("r'"n #e Cene Sto3es$Se 2"(0&e! 2e"$((4 e 2a04a 4e1 e

0"a&+;! . a &(!'+!0a&+;! &(#+e!5a! %(4 #(=+#+e!'(4 "e42+"a'("+(43 2"+#e"( #>4

402e"f+&+a%e43 %0e1( #>4 a#2%+(43 7a4'a %%e1a" a 0! #>8+#(3 2a"a %0e1( +"

e&"e&+e!( 7a4'a %%e1a" !0e=a#e!'e a 0!a fa4e e a2!ea3 4e +!+&+a &(! 0! &+e"'(

1"a( e 7+2(8+a ,

Res("r'"n #e -"ot$&a"a&'e"+5aa 2(" 2e"$((4 e a2!ea e 0"a&+;! =a"+a9%e

a * 4e10!(4 4e10+a4 e "e42+"a&+(!e4 2"(f0!a43 !( 4(! 2"(1"e4+=a4, Se

(94e"=a e! %(4 2"(&e4(4 #e!+!1$'+&(4 . ('"(4 '"a4'("!(4 e% S+4'e#a Ne"=+(4(

Ce!'"aI,

ALTERACIONES DE LA EPANSION TORCICA

Retr'"ones tor4"'s "ns("r'tor"'s:

T"r'*e$e4 &0a!( e8+4'e 0! (94'>&0%( e! %a fa4e +!42+"a'("+a 60e +#2+e %a %+9"e

e82a!4+;! e% 20%#;!3 %a 2"e4+;! a'#(4f-"+&a e2"+#e %a4 2a"'e4 9%a!a4 e%

T;"a8 . 4e 2"(0&e e% 70!+#+e!'( e %(4 e42a&+(4 +!'e"&(4'a%e4, E8&e2&+(!a%#e!'e

4e (94e"=a 70!+#+e!'( e! %a "e1+;! +!f"aa8+%a" e! +!+=+0(4 #0. e%1a(4 0"a!'ee% &(#+e!5( e %a +!42+"a&+;!, P0ee 4e":


22/155

? B+%a'e"a%: &0a!( e% (94'>&0%( a4+e!'a a!'e4 e %a 9+f0"&a&+;! '"a60ea%,

? U!+%a'e"a%: 2(" (94'"0&&+;! ( e4'e!(4+4 e 0! 9"(!60+( 2"+!&+2a% e% 20%#;!

?L(&a%+5aa4: 2(" (9%+'e"a&+;! e 2e60e@(4 9"(!60+(4 ( &(!e!4a&+(!e4

20%#(!a"e4,

Abovedamientos torcicos espiratorios: E! e% e!f+4e#a . 0"a!'e e% a&'( e %a

'(4 4e 20ee (94e"=a" %+1e"( a9(=ea#+e!'( e %a4 f(4a4 402"a&%a=+&0%a"e4,

OTRAS ALTERACIONES DE LA RESPIRACION

Disnea: D+f+&0%'a 2a"a "e42+"a" 60e 4e a&(#2a@a 1e!e"a%#e!'e &(! 'a60+2!ea3

+""e10%a"+a e! e% "+'#(3 '+"ae3 '(43 &("!ae3 4+9+%a!&+a3 a%e'e( !a4a%3 &+a!(4+4 (

2a%+e53 60e+( e42+"a'("+(,

Ortopnea o disnea de decbito: D+f+&0%'a 2a"a "e42+"a" e! e% e&4

+!'e!4(4 e! %a e42+"a&+;!, L(4 roncus 4e ("+1+!a! e! 9"(!60+(4 1"a!e4 . 4(!4(!+(4 e '(!a%+a 1"a=e, La4 sibilancias 4(! 4(!+(4 e '(!a%+a a10a . 4e

("+1+!a! e! 9"(!60+(4 2e60e@(4, orna!e: S(!+( +!'e!4(3 2a"e&+( a% 4(2%+( e 0!

&0e"!(, I!+&a e4'"e&7a#+e!'( e %a %a"+!1e3 '">60ea . 9"(!60+(4 1"0e4(4,

Tos: E4 0! "ef%e( 60e &(!4+4'e e! 0!a e42+"a&+;! 9"04&a e4'+!aa a e820%4a"

e%e#e!'(4 +""+'a!'e4 e %a %a"+!1e3 %a '">60ea ( %(4 9"(!60+(43 a0!60e 'a#9+-!

20ee e9e"4e a +""+'a&+(!e4, C0a!( !( 7a. 4e&"e&+(!e4 4e e!(#+!a '(4 4e&a .

4+ 4e a&(#2a@a e e%%a4 '(4 7


23/155

La4 4e&"e&+(!e4 ( e82e&'("a&+;! 4(! blan"uecinas 4+ 4e e9e! a +!f%a#a&+(!e4

a%-"1+&a43 a#arillo $erdosa 4+ &(""e42(!e! a +!fe&&+;! 9a&'e"+a!a . e% &(%(" e%

%erru#bre e! %a4 !e0#(!$a4, La e820%4+;! 9"04&a 2(" %a '(4 e 1"a! =(%0#e! e

4e&"e&+(!e4 4e e!(#+!a $#ica,

G">f+&( e %(4 T+2(4 e Re42+"a&+;!

EUPNEA

POLIPNEA

BRADIPNEA

APNEA


24/155

HIPERPNEA

RESPIRACIN DE [USSMAUL

RESPIRACIN DE CHEYNE STO[ES

RESPIRACIN DE BIOT


? N( 4e e9e +!f("#a" a% 040a"+( "e42e&'( a% 2"(&e+#+e!'( 60e 4e =a a

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a9(#e! e% 040a"+(3 4+#0%a( 60e a


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CONTROL DE PRESION ARTERIAL

Def+!+&+;!:

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&(!'+!0a#e!'e,

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#>8+#a, C0a!( e% &("a5;! 4e "e%aa 4e &+e""a! %a4 =>%=0%a43 &(#+e!5a %a +>4'(%e .

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1"a+e!'e 'e!4+(!a% 60e 4e e!(#+!a 2"e4+;! a"'e"+a% +a4';%+&a ( #$!+#a,

OBJETIVO$

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%a 2"e4+;! a"'e"+a%,

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26/155

VALORES NORMALES: "e&(#e!a&+(!e4 e% V C(#+'- Na&+(!a% e De'e&&+;!3

E=a%0a&+;! . T"a'a#+e!'( e %a 7+2e"'e!4+;! a"'e"+a%,

P"e4+;! N("#a%: P, S+4';%+&a: #e!(" )##H13 P, D+a4';%+&a: #e!(" ##H1

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H+2e"'e!4+;!:

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F'tores .!e "n/&!en en &' tens"n 'rter"'& #e !n "n#"5"#!o$

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27/155

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28/155

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29/155

CONTROL DE PULSO

Def+!+&+;!:

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Se e!(#+!a 20%4( a %a 4e!4a&+;! '>&'+% e e%e=a&+;! e %a 2a"e a"'e"+a%3 4+!&";!+&a

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0! 2%a!( e "e4+4'e!&+a,

OBJETIVO:

? De'e&'a" %a4 a%'e"a&+(!e4 60e +!f%0.e! e! %a 4a%0 e% 040a"+(,

? C(!'"+90+" a% +a1!;4'+&( e% 2a&+e!'e 2(" #e+( e a'(4 e8a&'(4,

CARACTERSTICAS DEL PULSO ARTERIAL:

? F"e&0e!&+a: e4 e% !


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e!'"( e %a4 a"'e"+a4 #>4 %a "e4+4'e!&+a 60e +&7a4 a"'e"+a4 (f"e&e! a e4a 2"e4+;!,

E% a0#e!'( e %a 'e!4+;! 4e e!(#+!a 20%4( 0"( . 4e 2"e4e!'a e! %a e4&%e"(4+4 e

%a 2a"e a"'e"+a% ( e! %a 7+2e"'e!4+;! a"'e"+a%, S0 +4#+!0&+;! 4e e!(#+!a 20%4(

9%a!( . 4e 2"e4e!'a e! %a 7+2('e!4+;! a"'e"+a%,

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#e+a!a3 4+ a0#e!'a e% 20%4( 4e e!(#+!a #a1!( . 4+ +4#+!0.e 2a"=( ( 2e60e@(,

6on's #e E7(&or'"n #e& P!&so$P!&so te,(or'&$2(" e%a!'e ( 2(" a""+9a e %a

("ea3 P!&so /'"'&$e! e% 9("e e% #a8+%a" +!fe"+("3 P!&so 'rot8#eo$a %( %a"1( e%

9("e +!'e"!( e% e4'e"!(&%e+(#a4'(+e(3 P!&so s!%&'5"o$4(9"e e% 'e"&+( #e+(

e %a &%a=$&0%a3 P!&so !,er'&$e! e% 'e"&+( #e+( e% 9"a5(3 P!&so %r'.!"'&$e! e%

2%+e10e e% &((3 P!&so r'#"'&$e! %a #0@e&a3 e! e% &a!a% "a+a%3 P!&so r!r'&$e!

%a +!1%e3 P!&so (o(&8teo$e! e% 70e&( 2(2%$'e(3 P!&so t"%"'& (oster"or$2(" e'">4

e% #a%-(%( +!'e"!(3 P!&so (e#"o$e! e% ("4( e% 2+e,

ALTERACIN EN SUS CARACTERSTICAS:

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&a"$a&a3 040a"+(4 #e+&a(4 &(! a!fe'a#+!a43 'e(f+%+!a3 e'&,

? B"a+4f+1#+a: +4#+!0&+;! e %a f"e&0e!&+a e% 20%4( 2(" e9a( e * 20%4a&+(!e4

2(" #+!0'(, Se 2"e4e!'a e!: 7+2('+"(++4#(3 e!fe"#ea e% !;0%( 4+!04a%3

e2"e4+;! #e!'a%3 2a&+e!'e4 #e+&a(4 &(! (2+>&e(43 9%(60e( a0"+&0%a"3e'&,

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31/155

a""+'#+a4,

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I!+&a 2"e4+;! +a4';%+&a e%e=aa,

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Reo,en#'"ones$

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32/155

? A04&0%'a" f"e&0e!&+a &a"$a&a &(! e4'e'(4&(2+( &(%(&>!(%( 4(9"e e%

+af"a1#a e!'"e e% III . IV e42a&+( +!'e"&(4'a% +560+e"(3 4+ e% 20%4( e4 -9+% e!

%a4 a"'e"+a4 e%e1+a4,? Va%("a" %a4 &a"a&'e"$4'+&a4 e% 20%4( 0"a!'e 0! #+!0'(,

? I!f("#a" a% #-+&( 4+ 709+e"a a%10!a a%'e"a&+;!,? Re1+4'"a" %a =a%("a&+;! "ea%+5aa . %a &+f"a (9'e!+a3 e42e&+f+&a!( fe&7a3

7("a e! %a 60e 4e "ea%+5; e% &(!'"(% . f+"#a,MEDIDAS ANTROPOM9TRICAS$ PESO+ TALLA Y PERMETRO

Def+!+&+;!:

E4 %a #e+&+;! e% 2e4(3 'a%%a . 2e"$#e'"( &ef>%+&( e% !e(!a'( .( !+@(,

OBJETIVOS:

? Te!e" 0! 2a'";! e "efe"e!&+a 2a"a e'e&'a" '"a4'("!(4 e% &"e&+#+e!'( e

+#2%e#e!'a" 2a0'a4 'e"a2-0'+&a4 ae&0aa4,? Va%("a" e% E4'a( N0'"+&+(!a%,? Va%("a" P-"+a e L$60+(4,? Ve"+f+&a" %a (4+f+&a&+;! e% #e+&a#e!'( +!+&a(,

CONTROL DE TALLA

Pe"$(( e &(!'"(%: E! e% "e&+-! Na&+( a %a4 ) 74 e =+a,

E! e% %a&'a!'e .( !+@( 4e1

? C(!'"(%a" e% 2e+;#e'"(3 2a"a &e"&+("a"4e e 40 90e! f0!&+(!a#+e!'(? E82%+&a" e% 2"(&e+#+e!'( a %(4 2a"e43 2a"a (9'e!e" %a &(%a9("a&+;! e e%%(4,? Rea%+5a" La=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? C(%(&a"4e %(4 10a!'e4 e %>'e8 ( 2(%+e'+%e!(,? S(%+&+'a" a %a #a"e 60e %e 60+'e %a "(2a . 2a@a%3 2("60e 20ee a%'e"a" %(4

a'(4 e #e+&+;!,? C(%(&a" e% 2e+;#e'"( e! 0! %01a" f+"#e3 0!a 4>9a!a 4(9"e e% #+4#(,? U9+&a"4e f"e!'e a% 2e+;#e'"(3 4+'0a" a% !e(!a'( e! 2(4+&+;! e&


33/155

e% #+e#9"( +!fe"+(" &(! %a #a!( e"e&7a a04'a"> %a 2+e5a #;=+% e%

2e+;#e'"( 7a4'a %a 2%a!'a e %(4 2+e43 a4e10">!(4e e 60e %a &a9e5a

'(60e %a 2a"'e 402e"+(" e% 2e+;#e'"(,? Lee" %a #e+a e! e% >!10%( "e&'( 60e f("#a! %(4 2+e4 e% !e(!a'( &(! %a

e4&a%a #-'"+&a3 e% >!10%( "e&'( 2"(2("&+(!a 0!a #e+a e8a&'a,? Re1+4'"a" %a #e+a (9'e!+a e! %a 7(a e E!fe"#e"$a . efe&'0a" %a

=a%("a&+;! &(""e42(!+e!'e,

INTERVENCIONES DE ENFERMERA Ta%%a e! e% #a.(" e a@(4,

? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%

e!'("!( e 040a"+(,

? E82%+&a" e% 2"(&e+#+e!'( a% !+@( . a 404 2a"e4,? Rea%+5a" La=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? C(%(&a"4e 10a!'e4 e %>'e8 ( e 2(%+e'+%e!(,? De4&a%5a" a% !+@( . &(%(&a"%( 4+! "(2a e! 2(4+&+;! "e&'a 4(9"e %a 2%a'af("#a

e %a 9a%a!5a3 e 2+e . e e42a%a a% Ta%%$#e'"(3 0!'a" %(4 'a%(!e4

4e2a">!(%e %a 20!'a e %(4 2+e4 e! >!10%( e W, Cer"rese .!e e& n":o

.!e#e en (os""n ret' ,"r'n#o or";ont'&,entee%a 7a4'a '(&a" %a 2a"'e #>4

a%'a e %a &a9e5a3 fa&+%+'a %a +!#(=+%+a e% !+@( . e=+'a" e""("e4 e! %a %e&'0"a

e %a #e+&+;!,? A.0a" a% !+@( a e4&e!e" e %a 9a%a!5a . "e1"e4a" %a 9a""a #e+("a a 40

2(4+&+;! +!+&+a%3 2a"a e=+'a" a&&+e!'e4 e! e% !+@(,? Re1+4'"a" %a #e+a (9'e!+a e! %a 7(a e E!fe"#e"$a3 %( 60e !(4 2e"#+'+">

efe&'0a" %a =a%("a&+;! &(""e42(!+e!'e,

CONTROL DE PESO


34/155

Pe"+(( e &(!'"(%:

Pe4( e! U40a"+(4 Pe+>'"+&(4: a% +!1"e4( . &aa 743 4e1

&e4>"ea,

Pe4( e! Ne(!a'(4: a% +!1"e4( . 0!a =e5 2(" '0"!(,



e!'("!( e% 040a"+(,? I!f("#a" a %(4 2a"e4 e% 2"(&e+#+e!'(,? Rea%+5a" La=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? C(%(&a"4e %(4 10a!'e4 e %>'e8 ( 2(%+e'+%e!(,? C(%(&a" 0! 2a2e% %+#2+( 4(9"e %a 9a%a!5a . 4+'0a" %a4 2e4a4 e! &e"(,? S(%+&+'a" a %a #a"e 60e %e 60+'e '(a %a "(2a . e% 2a@a% a% !e(!a'(,? S+'0a" a&(4'a( ( 4e!'a( a% !e(!a'( .( !+@(3 e! #e+( e %a 9a!ea e %a

9a%a!5a,? M'ntener to#o e& t"e,(o &' ,'no s!s(en#"#' ' !nos (oos ent8,etros

so%re #e& neon'to =o n":o+ ('r' 't!'r on r'("#e; (re5en"r '8#'s


35/155

E! e% %a&'a!'e .( !+@( 4e1



e!'("!( e% 040a"+(,? I!f("#a" a %(4 2a"e4 e% 2"(&e+#+e!'(,? Rea%+5a" La=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? C(%(&a"4e 10a!'e4 e %>'e8 ( 2(%+e'+%e!(,? S+'0a" a% !+@( e! e&!(%a 2("

%a4 2"(#+!e!&+a4 ;4ea4 e %(4 2a"+e'a%e4 . 2(" e!&+#a e %a4 &ea43 2a"a(9'e!e" 0! a'( e8a&'( e %a #e+&+;!,

? J0!'a" %(4 e8'"e#(4 e %a &+!'a . %ee" %a #e+&+;!,? Re1+4'"a" %a #e+a (9'e!+a e! %a 7(a e E!fe"#e"$a . "ea%+5a" %a

=a%("a&+;! &(""e42(!+e!'e,

ADMINISTRACIN DE MEDICAMENTOS

OBJETIVO:

? E4'a9%e&e" 2a0'a4 2a"a %a a#+!+4'"a&+;! 4e10"a e #e+&a#e!'(4,

OBJETIVO ESPECIFICO:

? P"(2("&+(!a" 0!a 7e""a#+e!'a 2a"a (2'+#+5a" %a a#+!+4'"a&+;! e %(4

#e+&a#e!'(4,? U!+f+&a" &"+'e"+(4 e! %a 2"e2a"a&+;!3 a#+!+4'"a&+;! . &(!4e"=a&+;! e

#e+&a#e!'(4 e! e% 4e&'(" )* e% H(42+'a% H("a&+( He%%e",? P"e=e!+" e""("e4 e! %a fa"#a&('e"a2+a,


36/155

? P(4ee" 0! (&0#e!'( e &(!40%'a e! &0a!'( a a#+!+4'"a&+;!3 e4'a9+%+a3

"e&(!4'+'0&+;! . &(!4e"=a&+;! e #e+&a#e!'(4,

DEFINICIN:

Me+&a#e!'(: 4+!;!+#( e f>"#a&( ( "(1a3 404'a!&+a 60e a%

+!'"(0&+"4e a% ("1a!+4#( 70#a!( =+=(3 a%'e"a 404 f0!&+(!e4 #e+a!'e +!'e"a&&+;!

#(%e&0%a" . 4e 0'+%+5a &(! e% 2"(2;4+'( e &0"a"3 "e7a9+%+'a"3 2"e=e!+"3 +a1!(4'+&a",

METABOLISMO DE LOS FARMACOS:

? ABSORCION: T"a!4fe"e!&+a e% f>"#a&( e4e e% 20!'( e e!'"aa 7a4'a %a

&+"&0%a&+;! 1"a+e!'e e &(!&e!'"a&+;!3 PH3 >"ea e 402e"f+&+e +42(!+9%e3e'&,? DISTRIBUCION: 0!a =e5 %%e1a( a% '(""e!'e 4a!10$!e( 20ee 4e" +4'"+90+( a %(4

+4'+!'(4 &(#2a"'+#e!'(4 &("2("a%e4 %a 0!+;! a %a4 2"('e$!a4 2%a4#>'+&a43 f%0(4a!10$!e(3 &a2a&+a 2a"a a'"a=e4a" %a4 #e#9"a!a43 4(%09+%+a '+40%a",

? BIOTRANSFORMACION: C(!4+4'e e! %a &(!=e"4+;! e% f>"#a&( e! 404'a!&+a4

#a4 f>&+%e4 e e%+#+!a"3 . 2(" %( 1e!e"a% 4e %%e=a a &a9( e! e% 7$1a(3 60e e4 e%;"1a!( e4e!&+a% e! e% #e'a9(%+4#( e f>"#a&(4, L(4 20%#(!e43 "+@(!e43 #0&(4a

+!'e4'+!a% . %a 2%a&e!'a e4e#2e@a! &+e"'( 2a2e%,? ELIMINACION: E4 e% 2"(&e4( 2(" e% &0a% 4e e%+#+!a! %(4 #e+&a#e!'(4 e% &0e"2(,

L(4 "+@(!e4 4(! %a =$a 2"+!&+2a% e e%+#+!a&+;! e #e'a9(%+'(4 a '"a=-4 e %a ("+!a\

2e"( 7a. a%10!(4 60e 4e 20ee! e%+#+!a" 2(" %a4 7e&e43 a%+e!'(3 40("3 4a%+=a .

%e&7e #a'e"!a, La ef+&+e!&+a &(! 60e %(4 "+@(!e4 e8&"e'a! #e+&a#e!'(4 . 404

#e'a9(%+'(4 +4#+!0.e &(!f("#e a=a!5a %a ea,

L's /or,'s or'&es #e &os /4r,'os (!e#en ser$

L(4 &(#2"+#+(4 e9e! 4e" 2"e4e"=a(4 e %a 70#ea . %a %053 !( 2a"'+"%(4 4+ !(

'+e!e! %a "a!0"a 2(" %a +f+&0%'a e 2"e&+4+;! e! %a (4+4, E! &a4( e 'a9%e'a (

&>240%a3 e4%$&e%a e! %a 'a2a e% f"a4&( . 2;!1a%a e! e% "e&+2+e!'e 2"e2a"a( 4+!

'(&a" e% #e+&a#e!'(,

? Co,(r","#os nor,'&es>#e &"%er'"n "n,e#"'t'?$4e e9e! '"+'0"a" 7a4'a 60e

60ee 2(%=( f+!( ( e4%e+" e! a10a . a &(!'+!0a&+;! a#+!+4'"a",

? Co,(r","#os #e &"%er'"n ret'r#'#', N( e9e! '"+'0"a"4e3 %a '"+'0"a&+;!

2"(0&e 2-"+a e &a"a&'e"$4'+&a4 e %+9e"a&+;!3 e8+4'e "+e41( e '(8+&+a e

+!ae&0a( #a!'e!+#+e!'( e %(4 !+=e%e4 e f>"#a&( 0"a!'e e% '"a'a#+e!'(,

? Co,(r","#os on !%"ert' ent@r"', N( e9e! '"+'0"a"4e3 %a 2-"+a e %a

&09+e"'a 20ee 2"(=(&a" %a +!a&'+=a&+;! e% 2"+!&+2+( a&'+=( ( fa=("e&e" %a +""+'a&+;!

e %a #0&(4a 1>4'"+&a,


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Co,(r","#os e/er5esentes$ De9e! +4(%=e"4e e! a10a a!'e4 e a#+!+4'"a"240%a +4(%=e" 40

&(!'e!+( e! a10a . a &(!'+!0a&+;! a#+!+4'"a", E! &a4( e +!e4'a9+%+a .

2"+!&+2+(4 a&'+=(4 #0. +""+'a!'e4 !( e4 ae&0a(,

C4(s!&'s #e Be&'t"n' #!r' >onten"#o #e ,"roBr4n!&os #e &"%er'"n

ret'r#'#' o on !%"ert' ent@r"'?$ La4 &>240%a4 20ee! a9"+"4e3 2e"( %(4

#+&"(1">!0%(4 !( e9e! '"+'0"a"4e2("60e 2e"e"$a! 404 &a"a&'e"$4'+&a4, La

+42(!+9+%+a e %a a#+!+4'"a&+;! 2(" 4(!a e2e!e e! 1"a! #e+a e% +>#e'"(

e %(4 #+&"(1">!0%(4 . e% e %a 4(!a,

C4(s!&'s #e Be&'t"n' %&'n#' >onten"#o &8.!"#o?$ S+ e% 2"+!&+2+( e4 e4'a9%e . !(

+""+'a!'e3 20ee (2'a"4e 2(" e8'"ae" e%&(!'e!+( &(! 0!a e"+!1a3 2e"( !( 4e

"e&(#+e!a %a (4+f+&a&+;! 20ee 4e" +!&(#2%e'a3 . 20ee 60ea" a7e"+( a %a4

2a"ee4 e %a 4(!a,

? 'r'%es+ so&!"ones: a1+'a" e% f"a4&( . =e"+f+&a" 60e !( 60ee! "e4'(4 e 2(%=(

e! e% f(!( e% #+4#(, E! 1e!e"a% e4 %a #e(" f("#a e a#+!+4'"a&+;! 2(" 4(!a

Na4(1>4'"+&a3 4e 20ee! a#+!+4'"a" 4+! +%0+"3 4+ e4 #0. =+4&(4( +%0+" e! a10a3 !(

a#+!+4'"a" e! 9(%04 e! e% +!'e4'+!( .a 60e 20ee 2"(=(&a" +a""ea (4#;'+&a3 e9e!

4e" a#+!+4'"a(4 4+e#2"e e! 2+( a%

+!'e4'+!(3 !( a#+!+4'"a" &(! %e&7e !+ a%&a%+!(4 .a 60e e4'(4 e4+!'e1"a!

2"e#a'0"a#e!'e %a &(9e"'0"a 2"('e&'("a,Los (o&5os e9e! 4e" a#+!+4'"a(4 +!#e+a'a#e!'e e420-4 e %a +4(%0&+;!,

FACTORES QUE MODIFICAN LA ACCION DE LOS FARMACOS:Ea3 Pe4(

C("2("a%+ Se8(3 P"e4e!&+a e E!fe"#ea3 Fa&'("e4 Ge!-'+&(4+ T(%e"a!&+a3

Ta60+f+%a8+43 H+2e"4e!4+9+%a3 P"e4e!&+a e D"(1a43 e'&,

ACCION DE LOS MEDICAMENTOS: D(4+f+&a&+;! e %(4 #e+&a#e!'(43I!+&a&+(!e43 C(!'"a+!+&a&+(!e4 =;#+'(43 +!&(!4&+e!&+a3 +f+&0%'ae4 e


38/155

De1%0&+;!3 Rea&&+(!e4 4e&0!a"+a43 Va"+a9%e4 60e #(+f+&a! %a a&&+;! e%

f>"#a&(3 =e!'aa4 4+#2%e . &;#((3 %( 20ee "ea%+5a" e% #+4#(3e4=e!'aa4:

a94("&+;! "e%a'+=a#e!'e %e!'a3 ef+&a&+a +#2"ee&+9%e3 +""+'a&+;! 1>4'"+&a 3 4a9("

e4a1"aa9%e3 e'&,

TARETA DE MEDICACIN$ #e%e ontener$

`USUARIO CORRECTO

` MEDICAMENTO CORRECTO

` DOSIS CORRECTA

` HORA CORRECTA

` VIA CORRECTA,

` FIRMA DEL ENFERMERO QUE LA REALIZA

VIAS DE ADMINISTRACION

` Me+&a&+;! a#+!+4'"aa 2(" =$a ("a%

` Me+&a&+;! a#+!+4'"aa 2(" 4(!a !a4(1>4'"+&a

` Me+&a&+;! a#+!+4'"aa 2(" =$a "e&'a%

` Me+&a&+;! a#+!+4'"aa 2(" =$a 2a"e!'e"a%

` Me+&a&+;! a#+!+4'"aa 2(" =$a "e42+"a'("+a

` Me+&a&+;! a#+!+4'"aa 2(" =$a ';2+&a

` O'"a4,

REGLAS PARA LA ADMINISTRACION SEGURA DE MEDICAMENTOS

1< A#,"n"str'r e& ,e#"',ento orreto$Ie!'+f+&a" e% #e+&a#e!'( a%10!(4

#e+&a#e!'(4 '+e!e! !(#9"e . a42e&'( 4+#+%a", C(!f+"#a" 60e 4ea e%

#e+&a#e!'( &(""e&'( a!'e4 e a#+!+4'"a"%(, E! &a4( e 0a3 !( a#+!+4'"a" .&(!40%'a", O94e"=a" e% a42e&'( e% #e+&a#e!'( a!'e4 e a#+!+4'"a"%( 3 2(4+9%e4

2"e&+2+'a&+(!e43 &a#9+(4 e &(%(" 3e'&,2< A#,"n"str'r e& ,e#"',ento '& ('"ente "n#"'#o$C(#2"(9a" 4+e#2"e %a

+e!'+f+&a&+;! e% 2a&+e!'e, N( 0'+%+5a" e% !&+% e60+=(&a"4e,< A#,"n"str'r &' #os"s orret'$La4 #(+f+&a&+(!e4 #$!+#a4 e! %a (4+4 f("#0%aa

20ee! 4e" +#2("'a!'e4 . 2e%+1"(4a4, E! a%10!(4 #e+&a#e!'(4 e% #a"1e! e!'"e

0!a (4+4 'e"a2-0'+&a . ('"a 2('e!&+a%#e!'e %e'a% e4 #0. e4'"e&7(, C(#2"(9a" (4


39/155

=e&e4 %a (4+4 f("#0%aa &(! %a 60e e4'> a 20!'( e a#+!+4'"a", E! &a4( e 60e %a

(4+4 4ea +!040a%#e!'e e%e=aa ( 9aa &(!f+"#e +"e&'a#e!'e &(! e% #-+&( 60e %a

2"e4&"+9+;, C(#2"(9a" (4 =e&e4 %a (4+4 2"e4&"+'a,< A#,"n"str'r e& ,e#"',ento (or &' 58' orret'$La a#+!+4'"a&+;! e

#e+&a#e!'(4 4e 20ee "ea%+5a" 2(" =$a ("a% . e!'e"a% 0'+%+5a!( e% '"a&'( +1e4'+=( .

2(" =$a 2a"e!'e"a% 0'+%+5a!( 2"+!&+2a%#e!'e e% 4+4'e#a =a4&0%a"3 e% 'e+( &e%0%a"

409&0'>!e(3 %a e"#+4 . #0&(4a3 %a #a4a #04&0%a" . e% &a!a% #e0%a", L(4

#e+&a#e!'(4 2a"e!'e"a%e4 a&'"#a&( !+ #>4 e #e+a 7("a a!'e4 !+

e420-4 e %a 7("a +!+&aa, P"e4'a" e42e&+a% a'e!&+;! e! %a a#+!+4'"a&+;! e

a!'+9+;'+&(4 .( #e+&a#e!'(4 60e e8+a! 0! +!'e"=a%( e (4+f+&a&+;! e4'"+&'(,< ReB"str'r to#os &os ,e#"',entos '#,"n"str'#os$E% "e1+4'"( e% #e+&a#e!'(

e9e +!&%0+" e% !(#9"e e% f>"#a&(3 %a fe&7a . 7("a e a#+!+4'"a&+;!\ %a (4+4 . %a

=$a e a#+!+4'"a&+;!, Re1+4'"a" e% #e+&a#e!'( +!#e+a'a#e!'e e420-4 e 40

a#+!+4'"a&+;!, Re1+4'"a" 404 (94e"=a&+(!e4 4(9"e %a "e420e4'a e% 2a&+e!'e a%

#e+&a#e!'(3 e42e&+a%#e!'e 4+ 2"e4e!'a a%1

(%=+a" !0!&a %a "e42(!4a9+%+a %e1a% 60e !( +!=(%0&"a,< In/or,'r e "nstr!"r '& ('"ente so%re &os ,e#"',entos .!e est4 re"%"en#o!ea#e!'e e! %a #+4#a

e"+!1a,? R('0%a"3 0!a =e5 2"e2a"a(3 &(! e% !(#9"e e% #e+&a#e!'(3

&(!&e!'"a&+;!3 fe&7a3 7("a e 2"e2a"a&+;!3 #e+a4 e42e&+a%e4 e 04( .

a%#a&e!a#+e!'(,? C(%(&a"4e 10a!'e4 %>'e8 ( 2(%+e'+%e!( 4+ e4 60e e% 040a"+( e4'a e!

a+4%a#+e!'( e &(!'a&'(,? S+'0a" a% 040a"+( e! 0!a 2(4+&+;! 60e fa&+%+'e %a e1%0&+;! 2(4+&+;! e

F(_%e",? A#+!+4'"a" %a #e+&a&+;! 2(" =$a ("a% . a4e10"a"4e e %a +!1e4'a e%

#+4#(,? I!4'"0+" a %(4 2a"e4 "e42e&'( a %a &(""e&'a a#+!+4'"a&+;! e %a #e+&a&+;!,

? Sa&a"4e 10a!'e4 . "ea%+5a" %a=a( e #a!(4,? Va%("a" %a '(%e"a!&+a . %(4 2(4+9%e4 efe&'(4 a=e"4(4 e% #e+&a#e!'(

a#+!+4'"a(3 'e!e" e! &0e!'a 60e &0a%60+e" #e+&a#e!'( 20ee 2"(0&+"

0!a "ea&&+;! +#2"ee&+9%e . ("+1+!a" efe&'(4 a=e"4(4 #0. +fe"e!'e43

a%10!(4 e a2a"+&+;! +!#e+a'a . ('"(4 e a2a"+&+;! 'a"$a, Re1+4'"a" e

+!f("#a" a% #-+&(,? Re1+4'"a" e! %a 7(a e e!fe"#e"$a e% !(#9"e e% #e+&a#e!'(3 (4+43 =$a3

7("a e a#+!+4'"a&+;! . f+"#a,? E0&a" a% 040a"+( .( 2a"e4 "e42e&'( a %(4 a42e&'(4 a =a%("a" 0"a!'e %a

a#+!+4'"a&+;! e% #e+&a#e!'( . 2"e=+( a% a%'a #-+&a,


42/155

ADMINISTRACIN DE MEDICACIN POR VA SU-LINGUAL

Def+!+&+;!:

E4 %a a#+!+4'"a&+;! e% #e+&a#e!'( 2(" e9a( e %a %e!10a3 %a

a94("&+;! 4e 2"(0&e e! %(4 &a2+%a"e4 e %a &a"a +!fe"+(" e %a %e!10a3 2a4a e%

f>"#a&( a 4a!1"e 4e +!&("2("a =$a =e!a &a";'+a+"e&'a#e!'e a %a &+"&0%a&+;!

1e!e"a%, La4 &(!+&+(!e4 e% 2H e %a 9(&a fa&+%+'a %a +f04+;! 2a4+=a e !0#e"(4(4

f>"#a&(4 . e=+'a %a e4'"0&&+;! e a%10!(4 f>"#a&(4 e9+( a% 2H 1>4'"+&(, U!( e

%(4 2"+!&+2a%e4 +!&(!=e!+e!'e4 e4 e% 104'( e4a1"aa9%e e #0&7(4 f>"#a&(4,

OBJETIVO:

? A#+!+4'"a" f>"#a&(4 &(! e% f+! e (9'e!e" 0! efe&'( #>4 ">2+(,


? Rea%+5a" %a 'a"e'a e #e+&a&+;! 2a"a &aa 040a"+(3 a&'0a%+5a"%a &aa =e5

60e 4e #(+f+60e 0!a 2"e4&"+2&+;! #-+&a,? Re&("a" . a2%+&a" %a4 REGLAS PARA LA ADMINISTRACION SEGURA DE

MEDICAMENTOS,? Va%("a" e% !+=e% e &(!&+e!&+a e% 040a"+(,

? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%040a"+(,
http://es.wikipedia.org/w/index.php?title=Vena_car%C3%B3tida&action=edit&redlink=1http://es.wikipedia.org/w/index.php?title=Vena_car%C3%B3tida&action=edit&redlink=1


43/155

? E82%+&a" a% 040a"+( e% 2"(&e+#+e!'( a "ea%+5a" . 4(%+&+'a" 40 &(%a9("a&+;!,? C(!(&e" . (94e"=a" %a e4'a9+%+a . &(!+&+(!e4 e &(!4e"=a&+;! e%

#e+&a#e!'( a a#+!+4'"a",? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e 2"(&e+#+e!'(,? A#+!+4'"a" e% f>"#a&(3 4+ e8+4'e %a 2(4+9+%+a3 2(" e4'a =$a e420-4 e %a4

&(#+a4 .a 60e %a =a4&0%a"+5a&+;! e %a 5(!a e4 #>8+#a,? S(%+&+'a" a% 040a"+( 60e %e=a!'e %a %e!10a e +!'"(0&+" e% f>"#a&( e9a( e

-4'a3 4(%+&+'a"%e 60e &+e""e %a 9(&a . 60e +!'e!'e !( '"a1a" 4a%+=a 0"a!'e 0!(4

#+!0'(4,? C(#2"(9a" 40 &(""e&'a a94("&+;! . (94e"=a" e4'"+&'a#e!'e a% 040a"+( e9+(

a %a ">2+a a94("&+;! e e4'a =$a,? Va%("a" %a '(%e"a!&+a . %(4 2(4+9%e4 efe&'(4 a=e"4(4 e% #e+&a#e!'(

a#+!+4'"a(3 "e1+4'"a" e +!f("#a" a% #-+&(,

? Re1+4'"a" e! %a 7(a e e!fe"#e"$a e% !(#9"e e% #e+&a#e!'(3 (4+43 =$a37("a e a#+!+4'"a&+;! . f+"#a,

? E0&a" a% 040a"+( .( 2a"e4 "e42e&'( a %(4 a42e&'(4 a =a%("a" 0"a!'e %a

a#+!+4'"a&+;! e% #e+&a#e!'( . 2"e=+( a% a%'a #-+&a,


44/155

ADMINISTRACION DE MEDICAMENTOS POR SONDA NASOGSTRICA

Def+!+&+;!:

E4 e% #e+( e %a a#+!+4'"a&+;! e %a #e+&a&+;! e! e% '"a&'(

1a4'"(+!'e4'+!a%,

OBJETIVO:

A#+!+4'"a" f>"#a&(4 &(! f+!e4 +a1!;4'+&(43 'e"a2-0'+&(4 .(

2"e=e!'+=(4 2a"a 60e 4ea! a94("9+(4 2(" %a #0&(4a 1a4'"(+!'e4'+!a%,



60e 4e #(+f+60e 0!a 2"e4&"+2&+;! #-+&a,? Re&("a" . a2%+&a" %a4 REGLAS PARA LA ADMINISTRACION SEGURA DE

MEDICAMENTOS,? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%

040a"+(,? E82%+&a" a% 040a"+( .( 2a"e4 e% 2"(&e+#+e!'(,? C(!(&e" . (94e"=a" %a e4'a9+%+a . &(!+&+(!e4 e &(!4e"=a&+;! e%

#e+&a#e!'( a a#+!+4'"a",? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e% 2"(&e+#+e!'(,? P"e2a"a" %a #e+&a&+;! 4e1

O De4%e+" . +4(%=e" e% &(#2"+#+(3 +!'"(0&+" +"e&'a#e!'e e! %a e"+!1a e


45/155

#%3 #%3)*#%3 2"e=+a "e'+"aa e% -#9(%( e2e!+e!( e %a (4+43 a@a+"

*3 ? #% e a10a 'e#2%aa . a1+'a"3 0!a =e5 +%0+(3 ea" (4+4 a

a#+!+4'"a",? A1"e1a" ? #%, e a10a3 0!a =e5 +%0+(3 a %(4 #e+&a#e!'(4 60e 4(!

+""+'a!'e4 2a"a %a #0&(4a 1>4'"+&a,? R('0%a"3 0!a =e5 2"e2a"a(3 &(! e% !(#9"e e% #e+&a#e!'(3 &(!&e!'"a&+;!3

fe&7a3 7("a e 2"e2a"a&+;!3 #e+a4 e42e&+a%e4 e 04( . a%#a&e!a#+e!'(,? C(%(&a"4e 10a!'e4 %>'e8 ( 2(%+e'+%e!( 4+ e4 60e e% 040a"+( e4'a e! a+4%a#+e!'(

e &(!'a&'(,? S+'0a" a% 040a"+( e! 2(4+&+;! e 4e#+?F(_%e"3 2a"a e=+'a" "ef%0(4 .

a42+"a&+;! 9"(!&(20%#(!a",? Ve"+f+&a" 60e %a 4(!a e4'e e! e4';#a1(3 a42+"a" %e!'a#e!'e &(! 0!a

e"+!1a ? #% 4+ !( =+e!e 0!a 2e60e@a &a!'+a e "e4+0( 1>4'"+&(3 &(%(&a"e% e4'e'(4&(2+( e! e% e4';#a1( . a#+!+4'"a" %a #+4#a &a!'+a e a+"e .

a04&0%'a", A!'e %a 0a "e&(%(&a" %a 4(!a,? A#+!+4'"a" %a #e+&a&+;!3 2"+#e"( %a4 f("#a4 %$60+a4 . ea" %a4

2"e4e!'a&+(!e4 #>4 e!4a4 2a"a e% f+!a%,? La=a" %a 4(!a &(! ? #% e a10a3 a!'e4 e %a a#+!+4'"a&+;! %a

#e+&a&+;!3 2a"a e%+#+!a" "e4+0(4 a%+#e!'+&+(4 e! 040a"+(4 &(! !0'"+&+;!

e!'e"a%3 !( a@a+" e% #e+&a#e!'( a %a f;"#0%a 2a"a e=+'a" +!'e"a&&+(!e4

? E=+'a" #e5&%a"3 e! &a4( e 'e!e" 60e a#+!+4'"a" =a"+(4 #e+&a#e!'(43 e! %a#+4#a e"+!1a,

? La=a" %a 4(!a &(! ? #% e a10a e!'"e 0!( . ('"( #e+&a#e!'( . a%

f+!a%+5a" %a a#+!+4'"a&+;! e %a #e+&a&+;!3 2a"a a4e10"a"4e 60e !( 60ee!

"e4'(4 e #e+&a#e!'(4 e! %a 4(!a,? P"(&ee"3 0!a =e5 a#+!+4'"aa %a #e+&a&+;!3 a &(!e&'a" e !0e=(

a%+#e!'a&+;! e!'e"a% 34+ e% 040a"+( e4'a9a "e&+9+-!(%a,? P+!5a" %a 4(!a !a4(1>4'"+&a 0"a!'e * #+!0'(4 e420-4 e %a

a#+!+4'"a&+;! e %a #e+&a&+;!3 4+ e4 60e -4'a e4'a9a &(!e&'aa a 0!4+4'e#a a42+"a'+=(,

? Sa&a"4e 10a!'e4 . "ea%+5a" %a=a( e #a!(4,? Va%("a" %a '(%e"a!&+a . %(4 2(4+9%e4 efe&'(4 a=e"4(4 e% #e+&a#e!'(

a#+!+4'"a( =;#+'(43 +4'e!4+;! a9(#+!a%3 1a4'"(e!'e"+'+43 e'&3 "e1+4'"a" e

+!f("#a" a% #-+&(,? Re1+4'"a" e! %a 7(a e e!fe"#e"$a e% !(#9"e e% #e+&a#e!'(3 (4+43 7("a

e a#+!+4'"a&+;! . f+"#a,? E0&a" a% 040a"+( .( 2a"e4 "e42e&'( a %(4 a42e&'(4 a =a%("a" 0"a!'e %a

a#+!+4'"a&+;! e% #e+&a#e!'( . 2"e=+( a% a%'a #-+&a,


46/155

ADMINISTRACION DE MEDICAMENTOS POR VIA RECTAL

Def+!+&+;!:

E4 %a +!'"(0&&+;! e 0! f>"#a&( e! e% ("1a!+4#( +"e&'a#e!'e

402(4+'("+(4 ( &(! %a a.0a e a%1

S0 2"+!&+2a% +!&(!=e!+e!'e e4 60e %a a94("&+;! e4 #0. e"">'+&a3 e9+( a %a

2"e4e!&+a e #a'e"+a fe&a% 60e +f+&0%'a e% &(!'a&'( e% f>"#a&( &(! %a #0&(4a, La4

f("#a4 e a#+!+4'"a&+;! "e&'a% 4e 0'+%+5a! 2a"a &(!4e10+" efe&'(4 %(&a%e4 . &0a!(

e8+4'e! +f+&0%'ae4 2a"a %a a#+!+4'"a&+;! 2(" ('"a4 =$a4,

Fa&'("e4 60e +!f%0.e! e! %a a94("&+;! "e&'a% 4(!: V(%0#e! e %$60+( e! %a #0&(4a

"e&'a%3 V+4&(4+a3 S02e"f+&+e e %a #0&(4a "e&'a% . T+e#2( e "e'e!&+;!,

OBJETIVO:

? A#+!+4'"a" 404'a!&+a4 #e+&a#e!'(4a4 e! e% +!'e"+(" e% "e&'(3 a '"a=-4 e%

a!(3 &(! f+!e4 'e"a2-0'+&(43 2"e=e!'+=(4 ( +a1!;4'+&(4,



60e 4e #(+f+60e 0!a 2"e4&"+2&+;! #-+&a,

? Re&("a" . a2%+&a" %a4 REGLAS PARA LA ADMINISTRACION SEGURA DEMEDICAMENTOS,


040a"+(,? C(!(&e" . (94e"=a" %a e4'a9+%+a . &(!+&+(!e4 e &(!4e"=a&+;! e%

#e+&a#e!'( a a#+!+4'"a",? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e "ea%+5a" e% 2"(&e+#+e!'(,? I!f("#a" a% 040a"+(3 a0%'( . !+@(43 . a %(4 2a"e4 e% 2"(&e+#+e!'( a

"ea%+5a",
http://es.wikipedia.org/wiki/Supositoriohttp://es.wikipedia.org/wiki/Supositorio


47/155

? P"e2a"a" %a #e+&a&+;! a a#+!+4'"a": 4+ e% 402(4+'("+( e4'> e#a4+a(

9%a!(3 4e 20ee a0#e!'a" 40 &(!4+4'e!&+a #a!'e!+-!(%( e! a10a f"$a

0"a!'e 0!(4 #+!0'(43 4+ e4 e!e#a &(#2"(9a" 60e %a 'e#2e"a'0"a e %a

4(%0&+;! e4 %a &(""e&'a !( 2a4a" e C,? A#+!+4'"a" * #+!0'(4 a!'e4 e %a4 &(#+a43 4+ e4 e efe&'( %a8a!'e,? A#+!+4'"a" e!'"e %a4 &(#+a43 4+ !( e4 e efe&'( %a8a!'e,? C(%(&a"4e 10a!'e4 e %>'e8 e4&a"'a9%e4,? Of"e&e" a% 040a"+( %a 2(4+9+%+a e +" a% 9a@( ( &(%(&a"%e %a &7a'a,? S+'0a" a% 040a"+( e! 2(4+&+;! e S+#4 e&


48/155

CONSIDERACIONES GENERALES

` Se%e&&+(!a" e% 20!'( e P0!&+;!

` N( e%e1+" 5(!a4 &(! %e4+(!e43 +!f%a#a&+;! ( =e%%(

` A4e10"a"4e 60e %a a10a 4e%e&&+(!aa e4 %a ae&0aa a% '+2( e +!.e&&+;!

` E4'a9%e&e" 0! 2%a! e "('a&+;! e %(4 20!'(4 e 20!&+;! e! '"a'a#+e!'(4

2"(%(!1a(4,

ADMINISTRACIN DE MEDICACIN POR VIA INTRAD9RMICA

Def+!+&+;!:

E4 %a +!'"(0&&+;! e 0!a 2e60e@a &a!'+a e %$60+( e! %a &a2a

-"#+&a e %a 2+e% 2a"a 2"0e9a4 +a1!;4'+&a4 . e 7+2e"4e!4+9+%+a e %(4

040a"+(43 60e 20ee! 40f"+" 0! 47(&] a!af+%>&'+&( 4e=e"(,

OBJETIVO:

? De'e&'a" e! f("#a (2("'0!a %(4 efe&'(4 a%e"1-!+&(43 . 4e!4+9+%+a a

a%10!(4 f>"#a&(4,


? Re&("a" . a2%+&a" %a4 REGLAS PARA LA ADMINISTRACION SEGURA DE

MEDICAMENTOS,? Rea%+5a" %a=a( e #a!(4 a!'e4 . e420-4 e e4'a" e! &(!'a&'( &(! e%

040a"+(,? I!f("#a" a% 040a"+( e% 2"(&e+#+e!'( a "ea%+5a" . 4(%+&+'a" 40 &(%a9("a&+;!,

? C(!(&e" . (94e"=a" %a e4'a9+%+a . &(!+&+(!e4 e &(!4e"=a&+;! e%#e+&a#e!'( . a!'$1e!( a a#+!+4'"a",

? A4e10"a"4e 60e e% 040a"+( !(es '&@rB"o '& /4r,'o (resr"(to

protocolo de atencion pediatrica

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