Más allá de una herida. A propósito de una caso clínico

Abstract

1.- Objective(s): Explain the necessity to carry out integral asessment to our patients and to establish an adequate coordination with other professionals. 2.- Material and methods / description of the experience: It is described a clinical case related to a traumatic wound in a patient with Rheumatoid Arthritis (RA) through the use of nurse methodology with NANDA-NOC-NIC language, completed by the revision of related bibliography. 3.- Developement or results: Woman of 48 years of age with severe RA not well controlled, who goes to Primary Care nurse because of a traumatic wound in left inferior limb. It is carried out an asessment by health functional patterns from M. Gordon finding out diagnoses of skin integrity deterioration , risk of infection, pain, deficient knowledge, fear and capability to improve to treatment; treatment is initiated following the recommendations of guides to ulcer treatment base don the evidence and objectives and appropiate interventions are established. Because of the unwell evolution of the wound, she was derived to two hospital services with a previous nurse form and she was treated in a multidisciplinary way. 4.- Conclusions: It is important to carry out integral approaches and work with nurse methodology to bear in mind those data that can be transcendent for a better attention and evolution of the processes. In many ocassions it is necessary to work together with other services, being fundamental to do this in a coordinated way and elaborating nurse forms bi-directional with nurse language, in order to favor the process of recovery and to generate a climate of reliability among patients.