Estudio de caso acerca de paciente con diagnostico de derrame pleural cirrótico y aplicación del proceso de atención en enfermería

Abstract

Cirrhotic pleural effusion or hepatic hydrothorax is a rare complication of cirrhosis with the presence of ascites. It develops when the ascitic fluid advances from the abdomen, accumulating in the pleural cavity through small defects of the diaphragm favored by negative pleural pressure. The symptoms present in patients with this pathology are those characteristic of cirrhosis and ascites, adding to it respiratory symptoms such as: dyspnea, cough without expectoration, pleuritic chest pain and fatigue; The intensity and severity of these symptoms will depend on the amount of fluid accumulated in the pleural cavity. The general objective of the present study is to analyze the clinical case of a patient diagnosed with cirrhotic pleural effusion by collecting data through the clinical history for the elaboration of care plans based on the functional patterns of Marjory Gordon. This is a qualitative and descriptive study since a real case is analyzed through the review of the clinical history and also the most relevant characteristics of the study categories are described. The information was collected by directly observing the clinical history data and the corresponding filling of the observational record in which the most relevant categories were listed. As a result, it was obtained that the patient in question entered with a clinical picture characterized by asthenia, dyspnea of medium efforts, presence of ascites with removal of pleural fluid and edema of lower limbs; Chest ultrasound revealed the presence of a right pleural effusion with 639ml fluid accumulation, while in the laboratory tests performed evidence altered results such as albumin <3.50 g / dl and total bilirubin> 1.10 mg / dl. As a pharmacological treatment, furosemide is administered for the management of ascites, increasing the administration of antibiotics such as ceftriazone, ciprofloxacin and the administration of electrolyte fluid therapy. During his stay in the hospital he presents a radical decompensation showing hemodynamically unstable and adding to his symptomatology anasarca, jaundice and pleuritic pain. After 33 days of hospitalization, the patient died after suffering a cardiorespiratory arrest. After analyzing the results obtained, it is concluded that with an adequate treatment of cirrhosis it is possible to maintain a compensated phase in which there are no risk symptoms and its prognosis of life is favorable, but if this disease advances to a decompensation phase Multiple complications develop such as the cirrhotic pleural effusion considered as a risk to the patient's life. From the assessment of the patient and through the application of Marjory Gordon's theory, it is determined that the altered patterns are: perception / health management, nutritional / metabolic, activity / exercise and perceptive / cognitive; In order to improve the quality of life in patients suffering from cirrhotic pleural effusion, care plans are elaborated based on altered functional patterns, through the NANDA, NIC, NOC taxonomy.