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Hoja de enfermería IMSS
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INSTITUTO MEXICANO DEL SEGURO SOCIALDIRECCIÓN DE PRESTACIONES MÉDICAS
REGISTROS CLÍNICOS, ESQUEMA TERAPÉUTICO E INTERVENCIONES DE ENFERMERÍA
NOMBRE : Castillo Reyes Julio Cesar NÚMERO DE SEGURIDAD SOCIAL: 0174 56 9989 1M 1976OR
FECHA DE NACIMIENTO
SEXO: Hombre EDAD: 46 años DX. MÉDICO: Crisis Hipertensiva/ Edema Pulmonar
/ 1976
SERVICIO O ÁREA: (Observación regular) Medicina
UNIDAD MÉDICA: Hospital General de Zona N° 8 CAMA/CAMILLA/CUNA/INCUBADORA: (5) 425
Interna
Fecha 19/10/22 20
Dias de Hosp. Ingreso: 08:00 0 01
FC TI T EVD 8 12 16 20 24 4 8 12 16 20 24 4
170 36 C
41 12
160 35 11
150 34 40 10
140 33 9
130 32 39 8
120 31 7
110 30 38 6
100 29 5
90 28 37 4
80 27 3
70 26 36 2
60 25 1
50 24 35 0
Tensión Arterial 150/ 90 140/80 160/90 150/85 140/90 130/80 135/85 130/80 150/85 140/85 150/95 130/80
P.V.C. SPO2 78% 95% 90% 96% 90% 95% 90% 96% 98% 96% 90% 94%
Frecuencia Respiratoria 19 x' 22x' 22x' 22 x' 22 x' 22 x' 18 x' 20 x' 20 x' 18x' 22 x' 18x'
Código de Temperatura A A A A A A A A A A A A
Peso
Talla 1.56 cm 125kg
Perímetro
Fórmula
Dieta Normal
19h: Porción: 1/2 pan, 1
13h: Porción: 1/2 pan, 1 Ayuno I:22:30:00h
Dieta (Ayuno I: 08:00h) manzana, 1 pieza de pollo, vaso
manzana, 1 pieza de pollo, vaso T:08:00h
de agua 250ml
de agua 200ml
Total 200ml 250ml
SF 500 ml P/ 24h R= 375.2 ml R=229.6ml R=21ml R= 255ml R= 425ml
I: 08:00 h RP=50ml RP= 80ml RP=80ml RP=10ml RP= 50ml
T: 08:00 h RB=80ml RB= 52ml RB=12ml RB=80ml RB= 52ml
Propofol 1gr 10ml/h Propofol 1gr 10ml/h Propofol 1gr 10ml/h SF 500ml + 20 mEq KCL P/12h Propofol 1gr 10ml/h Propofol 1gr 10ml/h
Líquidos parenterales y I: 09:00 h I: 19:00 h I: 05:00 h I:08:00h I: 15:00 h I: 01:00 h
electrólitos Buprenorfina 900 mcg + SF SH 500 ml CR SH 50 ml CR T:20:00h SF 500ml + 20 mEq KCL P/12h SF 500ml + 20 mEq KCL P/12h
100 ml P/24h I: 17:00 h I: 03.00 h Buprenorfina 900 mcg + SF I:18:00h I:06:00h
I: 09:00 h 100 ml P/24h T:06:00h T:18:00h
SH 500ml CR I: 09:00 h
I: 11.00h
Plasma O+, 200 ml P/2 h Paq.Globular O+250ml P/3h R= 83 ml
Sangre y Hemoderivados I: 15:00 h I:13:00h
T 17:00 h T:15:00h
Total 695ml 943.6ml 850ml 607ml 426ml 575ml
CONTROL DE LÍQUIDOS
INGRESOS
Vía Oral - - - 200ml 250ml -
Sonda - - - - - -
Sol. Parenterales y elect. 194,8ml 233.6ml 348ml 357ml 343ml 575ml
Sangre y Hemoderivados - 200ml - 167ml - -
Nutrición Parenteral - - - - - -
Medicamentos 70ml 10ml 10ml 40ml 10ml 10ml
Otros 500ml 500ml 500ml
Total Ingresos 764.8ml 943.6ml 858ml 764ml 603ml 585ml
EGRESOS
Uresis 900ml 850ml 500ml 850ml 600ml 700ml
Evacuaciones - ✓L 80 ml ✓L/V 50ML ✓✓SL 100ML - ✓P 70gr
Sangrado - - - - 80ml -
Vómito - - - - - 100 ml
Aspiración 50ml Secrec. Bronquial 65ml Secrec. Bronquial 50ml Secrec. Bronquial 70ml Secrec. Bronquial 80ml Secrec. Bronquial 65ml Secrec. Bronquial
Drenajes - - Penrose 30ml Penrose 35ml Penrose 20ml Penrose 25ml
Pérdidas Insensibles 400ml 612.5ml 687.5ml 550ml 525ml 737.5ml
Total de egresos 1350ml 1697.5ml 1317.5ml 1605ml 1305ml 1697.5
Balance de líquidos -585.2ml -753.9ml -459.5ml -841ml -702ml -1112.5
Balance de 24 Horas - 1798.6ml Balance de 24 Horas -2655.5ml
ESTUDIOS, CIRUGÍAS Y OTROS
Estudios de Laboratorio Bh ,TP, TPT,QS,EGO,ES ✓ GASA✓ GASA✓ - Bh, QS, GASA✓ -
Estudios de Gabinete TAC Craneo y Torax ✓ USG abdominal Pend. Rx. Abdomen✓ - - -
Cirugía Programada - Apendicectomia✓ - - -
Cirugía Realizada - - Apendicectomia ✓ - - -
Productos Biológicos - - - Toxoide Tetanico✓ -
16 h Glicemia capilar 200 24 h Glicemia capilar 240
mg/dl mg/dl
Reactivos Glicemia capilar 180 mg/dl Glicemia capilar 140 mg/dl Glicemia capilar 140 mg/dl Glicemia capilar 140 mg/dl
20 h Glicemia capilar 100 04 h Glicemia capilar 140
mg/dl mg/dl
Clave:2660-009-144
M.A.I.S Gertrudis Cervantes Martínez
Jefatura de Enfermería HGZ 8
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