Nursing Care Process

The patient with: Poliomyelitis

TEACHER: M.E. Humberto Lucho Salazar.

Nombre del alumno: JAFET GUADALUPE REYES EVANGELISTA

Semestre: __Quinto_____. Grupo: ____503_____ Fecha de entrega: _____________ ______

 INTRODUCTION

Poliomyelitis ICD10 (A80)

Characteristics of the disease and epidemiology

Polio is an acute viral disease that can affect the central nervous system (CNS) causing flaccid paralysis. The site of
The entry of the virus is generally oral, it multiplies in the lymph nodes of the pharynx and the gastrointestinal tract. It enters the bloodstream.
and then invades nerve cells where it multiplies in the cytoplasm, damages them, and destroys them (when it replicates and destroys neurons
motor neurons of the previous spinal and/or bulbar roots). People may present with a mild illness indistinguishable from other causes. In
Most of the time, poliovirus infection is asymptomatic; sometimes it causes mild symptoms and only very rarely leads to paralysis.
symptoms include fever, general malaise, headache, nausea, and vomiting; if the disease progresses, intense myalgias and stiffness may appear
neck and back, with or without flaccid paralysis.

The site of paralysis depends on the location of the destruction of the cells, whether in the spinal cord or in the brainstem, but
characteristically it is asymmetric.
The last case in Mexico occurred in 1990 in Tomatlán, Jalisco.

In 1988, the 41st World Health Assembly adopted a resolution on the global eradication of polio that marked the creation of the
Global Polio Eradication Initiative, led by the World Health Organization (WHO), Rotary International
International, the Centers for Disease Control and Prevention of the U.S. (CDC), and the United Nations Fund for
Childhood (UNICEF); since then, the number of cases has decreased by more than 99%. The absence of poliomyelitis was certified in the
WHO's Americas region in 1994, in the Western Pacific Region in 2000, and in the European Region in July 2002. On the 27th of
March 2014 it was certified that the Southeast Asia region was free from poliomyelitis, which means that the transmission of wild poliovirus
has been interrupted in that group of 11 countries that extends from Indonesia to India. However, transmission continues to be
endemic in Pakistan and Afghanistan.
Due to the significant risk of having new annual cases, the WHO, in consultation with the countries affected by polio, stakeholders,
the donors, the partners, and the national and international advisory bodies have developed the 'Comprehensive Strategic Plan for Eradication
of Polio and the final phase 2013-2018" which was presented at the Global Vaccine Summit in April 2013; being the first plan
intended to simultaneously eradicate all types of poliomyelitis, both from wild poliovirus and from vaccine-derived poliovirus.

Etiological agent:
Polio viruses are riboviruses, with icosahedral symmetry, naked, in icosahedral or rounded shape, and small in size (30nm). The three
Polio virus serotypes are classified within the Picornaviridae family (picornavirus) in the Enterovirus genus and in the Enterovirus C species.
humans, in which other related viruses are also found. There are three antigenic types known: 1) Brunhilda, 2) Lansing, and 3) León.
the three strains of wild poliovirus, since 1999 it has been possible to stop the transmission of type 2 poliovirus and the number of cases caused by
Polio virus type 3 is at its lowest level.

Distribution:
Worldwide. In temperate regions, it appears during the summer and autumn with some seasonal variations from one year to another and from one region to another.
In countries with tropical climates, the disease occurs at any time of the year.
Reservoir:
The man. Chronic carriers have not been identified. It consists both of patients suffering from an active disease and of the
individuals with asymptomatic infections. Polioviruses are eliminated through feces and respiratory route, where they are found not only during the
active disease but is detected later. In children, fecal elimination is 3-4 weeks.

Mode of transmission:
Through the fecal-oral route, especially in areas where there are sanitation deficiencies: The contagion occurs particularly through a fecal mechanism.
oral through water, food, or hands, contaminated with infected feces.
Oral-to-oral transmission is likely to predominate in industrialized countries and also during outbreaks: There may be person-to-person transmission.
a person, oral-oral.
Respiratory transmission is surely important in high hygiene environments.

Incubation period:
From 7 to 14 days, with a minimum limit of 4 and a maximum of 40 days.

Period of transmissibility:
It is not known exactly. The polio virus is detectable in the pharyngeal secretion from 36 hours and in the feces 72 hours after the
exposure to infection. The virus persists in the throat for about a week, but continues to be isolated in that for 6 to 8 weeks. The
the maximum risk of contagion occurs two or three days before and six to seven days after the onset of clinical manifestations of the
disease.

Susceptibility:
Universal. Children under five years old are usually more susceptible than adults, however the risk of paralytic disease
It increases with age. Any subject that is not vaccinated is susceptible.

Immunity:
Immunity is acquired through infection with the wild virus and through vaccination. The acquired responses are humoral and
cells (intestinal locales). This immunity has type specificity and is permanent. Vaccination with the anti-poliomyelitis vaccine.
Inactivated (VIP) confers humoral immunity and relatively less intestinal immunity, so vaccination with VIP does not provide resistance to
transport and spread of the wild virus in the community. Immune individuals have IgA antibodies against poliomyelitis present in
the tonsils and the gastrointestinal tract and can block the replication of the virus, while the IgG and IgM antibodies against PV
it can prevent the spread of the virus to the motor neurons of the central nervous system.

Pathogenesis:
Polioviruses enter through the oral route and replicate in the digestive tract at the oropharyngeal and intestinal levels, spreading to the regional lymphatics.
producing a first viremia. This seeding leads them to the reticuloendothelial system where they replicate again and produce a second
viremia through which they reach different organs, including the CNS. The virus penetrates it during this viremia and perhaps, also, through
axonal transport from the neuromuscular synapse.
Its ability to infect exclusively humans and some primates via the oral route is due to the cells of the epithelium associated with the
follicles, M cells, and Peyer's patches express their specific receptor, CD155, to which the capsid binds; this receptor is what explains
its ulterior tropism.
The replication of polioviruses follows these steps: they attach to their receptor CD155 and enter through endocytosis. They lose the capsid in the
interior of the cell they parasitize. The VPg protein is cleaved by a cellular phosphodiesterase and the translation of the ss (+) RNA is produced.
virus, which acts as mRNA, through a mechanism mediated by the Internal Ribosome Entry Site, not by the cap (contained in its 5' terminal end)
a methylated guanine or cap structure, which is the site where the ribosome initially binds, producing a polyprotein. From there,
Polypeptide and through a process of proteolysis, the structural and non-structural proteins of the virus are produced. The RNA chain of polarity
The positive strand of the virus serves as a template for the synthesis of a negative polarity complementary strand, resulting in a double-stranded RNA.
replication or RF). The RNA (-) is used at the same time for the replication of several ss RNA (+) chains, forming the replicative intermediate (RI). The
ss (+) RNAs can be used for new translation processes or join the capsid precursors, encapsulate themselves, and induce maturation
(precursor polypeptide P1>VP0, VP1 and VP3, Vp0> VP2 and VR4) and release the progeny of virions through cell lysis.

If replication occurs in the motoneurons of the anterior horns of the spinal cord or the bulb, they are destroyed and a
flaccid paralysis, whose persistence is related to the intensity and extent of the damage.

The three types of viruses show not only a different antigenicity but also a different pathogenicity; the one that caused the most paralysis was the
type 1 and the least type 2. The cVDPV strains and many of the iVDPV are capable of producing paralytic polio.

Clinical picture:

The infection is usually asymptomatic or inapparent in more than 90% of cases. In symptomatic forms, polio can be abortive or mild.
the least (4-8%), (febrile illness with pharyngeal and digestive manifestations, corresponding to the initial multiplication of the virus and is
hardly diagnosable), not paralytic or meningeal (1-2%), (like the previous one with meningeal manifestations) or paralytic (1% or less),
(after the manifestations of abortive polio, a flaccid and asymmetrical paralysis appears along with painful contractures of the unaffected muscles)
consequence of the injuries caused by the virus in the motor neurons.
Both spinal and bulbar functions can be affected; three clinical forms have been described: the spinal, the bulbar, and the bulbospinal.
the more common is the spinal one that affects the limbs, particularly the legs. The degree and extent of the injury determine that the
Whether paralysis is reversible or not, recovery generally occurs in the six months following the acute episode. Otherwise, complications occur.
the deformities, atrophies, and typical contractures in their phase of permanent sequelae. There are fatal cases, more in adolescents and adults (15-
30%) than in children (5-10%), which is particularly due to respiratory paralysis resulting from bulbar involvement. Neither is affected nor the
sensitivity or consciousness.

There are cases of paralytic polio caused, in addition to wild viruses, by those used in the oral vaccine (VDPV) and by derivatives of these.
The incubation period in immunocompromised patients with infection from vaccine-derived virus can be very long.
a case of 12 years having been reported.
In patients who suffered from polio in childhood, a condition may appear after many years, fifteen or more, characterized by
weakness, atrophy, and muscular fatigue of unknown cause that has been termed post-polio syndrome. It is estimated that it may affect between 20-
85% of this population lacks specific treatment.

There are two forms of illness. Minor and major illness, differentiated and specific to young children, and that in adolescents and
adults do not differ. The symptoms of the mild disease coincide with the first viremia. They are nonspecific: fever, vomiting, diarrhea,
headache and discomfort. In most cases, the disease stops at this point. It is called 'abortive poliomyelitis.'
In some cases, the disease progresses and symptoms of 'paralytic poliomyelitis' appear: high fever, severe headache, vomiting, and pain in
the lumbar region and neck affecting muscle groups preventing walking. If this situation does not progress and returns, it is called 'poliomyelitis'
no paralytic." If, on the contrary, they persist and progress, spinal poliomyelitis or bulbar poliomyelitis can occur. The former is more common.
and is characterized by asymmetric flaccid paralysis of the trunk and limbs, with a variable degree of affectation ranging from mild paralysis to a
tetraplegia and respiratory paralysis. Generally, it progresses until the fever disappears.
In the affected limbs, there is a decrease or abolition of the osteotendinous reflexes, along with severe muscle atrophy.
Diagnosis and prognosis:
Polio is one of the causes to consider in the differential diagnosis of acute flaccid paralysis that may have other etiologies.
infectious or other types. The WHO has published successive editions of a Laboratory Manual for polio that includes the entire process
diagnosis, from the collection and transport of samples to the characterization of viruses. It recommends the cultivation of feces and the
serological characterization (neutralization) of the type and to differentiate whether it is wild or VDPV an ELISA, a hybridization or a PCR. This
the procedure has been surpassed as most laboratories in the health network use a PCR-TR and for the characterization of the VDPV
a PCR-TR of the genes that encode VP1. Given the genetic plasticity of polioviruses, studies of molecular epidemiology are
essentials. PCR-TR has been developed which allows for the detection of vaccine viruses directly in feces and wastewater.

Viruses can also be searched for in:

Lumbar puncture
Respiratory secretions
Viral culture (stool, throat, and cerebrospinal fluid)
Polymerase chain reaction with reverse transcriptase in blood or cerebrospinal fluid
Serological tests for the search of poliovirus, enterovirus, and West Nile virus serotypes.

Since the identification of poliovirus or another enterovirus as a cause of acute flaccid paralysis is important for public health, in all
Viral cultures should be requested in samples from throat swabs, feces, and cerebrospinal fluid, as well as polymerase chain reaction.
with reverse transcriptase in the cerebrospinal fluid and blood.
In the absence of manifestations of the central nervous system, symptomatic poliomyelitis (abortive poliomyelitis) resembles other infections.
systemic viruses are not taken into account or diagnosed, except in epidemics.
Non-paralytic poliomyelitis resembles other meningitis. In these patients, lumbar puncture is commonly used and the characteristic findings in the
Cerebrospinal fluid consists of normal glucose levels, a slight increase in protein levels, and a cell count between 10 and 500/microL.
predominance of lymphocytes). The detection of the virus in a throat swab, feces, or cerebrospinal fluid or the demonstration of an increase
the title of specific antibodies confirms infection by poliovirus, but it is not usually necessary in patients with aseptic meningitis
complicated.
Paralytic poliomyelitis can be suspected in unimmunized children or young adults who have asymmetric flaccid paralysis of the limbs or
bulbar paralysis without sensory loss during an acute febrile illness.

In non-paralytic poliomyelitis, recovery is complete.

In paralytic poliomyelitis, about two-thirds of patients present with permanent residual weakness. Bulbar paralysis
it is more likely to resolve than peripheral paralysis. The mortality rate ranges from 4 to 6%, but increases to 10 to 20% in the
adults and in patients with bulbar disease.

Support treatment:
Polio has no specific treatment. During the acute phase, necessary supportive measures must be implemented that can reach
include assisted breathing. Physiotherapy should be done to minimize consequences and facilitate recovery as much as possible. For deformities
and paralysis can be addressed through corrective surgery, the use of orthoses and other orthopedic devices. The conventional therapy for poliomyelitis is
It is based on supportive measures, such as rest, analgesics, and antipyretics as needed. There is no specific antiviral therapy available.

During active myelitis, it may be necessary to implement precautions to prevent the complications of bed rest (e.g.,
deep vein thrombosis, atelectasis, urinary infections) and prolonged immobility (contractures). Respiratory failure may
require mechanical respiratory assistance. Mechanical respiratory assistance or bulbar paralysis demand intensive cleaning measures.
pulmonary.

Prevention:
The vaccine is very effective and has made polio an eradicable disease as humans are the only known reservoir. Prevention
is based on the systematic vaccination of the population which is allowing its global eradication. Furthermore, it is necessary to emphasize
general measures, such as chlorination of drinking water and swimming pools, which is effective in preventing the transmission of the virus. It is not
quarantine indicated.
Two types of vaccines have been developed, inactivated and attenuated. From the former, the one obtained by Salk and his team is used, and from the
according to Sabin and his group.
Although they are rare, cases of vaccine-derived poliovirus paralysis (VAPP) can occur after oral vaccination in both recipients and
contacts, especially after the first dose.
In 2014, the WHO updated its position regarding polio vaccination. It emphasizes the recommendation to add, in countries where
use the oral vaccine, at least one dose of inactivated vaccine in order to reduce the risk of PV2 reappearing after withdrawal from the vaccine
oral Sabin type 2. It recognizes, regardless of cost-effectiveness, that the change from the oral vaccine to inactivated or the start with this and
continuing with oral reduces or avoids the risk of VAPP.
 VALUATION
Nursing Assessment Based on Marjory Gordon's Functional Health Patterns
Select a patient from your daily practice and perform the assessment by noting their signs and symptoms in the corresponding functional pattern..
Think about the assessment and nursing process of a day of care, a shift or a consultation, explore and interrogate your patient, you don't need to copy data from a file, although it is necessary.
you can check laboratory results, reports, etc.
Medical Unit: Social Security number or file:
Nombre del paciente (Iniciales): F.P.G. Date of the appraisal:
HGSZ No. 33-IMSS 8619042656-8 08/12/2020
Hour:

Date of Admission: Blood Group:

Edad: 5 años Sexo: Masculino Days of stay: 3 Bed: C-6
05-12-2020 B+
Functional Patron of INITIAL PATIENT ASSESSMENT Domains
health of M. Gordon Subjective and objective data and information (Describe signs and symptoms, Use Assessment Guide)NANDA:
1, 11, 12
Patron 1 Management - Reason for admission (Medical diagnosis): General malaise, headache, nausea and vomiting, odynophagia.
perception of mild to moderate myalgias (its intensity has been increasing), stiffness in the neck and back.
health
Diseases: Medical or medical-surgical problems (Underlying pathologies): Non-paralytic poliomyelitis
with aseptic meningeal manifestations.
(Allergies, Medical history, APP background, AHF, Procedures, Pharmacological treatments and
medidas terapéutcas, estlo de vida, riesgos, habitos saludables, ¿Como se siente?, Estado de salud):

Pediatric patient enters without allergic conditions, their guardians express the presence of discomfort.
general, headache, nausea and vomiting (upon admission, currently not), odynophagia for the past few days and
recent mild to moderate myalgias, neck and back stiffness, and febrile episodes, reason for
who was admitted to the emergency service (3 days prior). Only child, full-term product of birth
eutocic, with an Apgar score of 7-8, Silverman score of 1. Parents apparently healthy, paternal grandparents
diabetics and hypertensives in control, maternal grandparents passed away due to complications from DM2. Has
presented diseases typical of childhood such as acute respiratory infections, acute diarrheal diseases, dehydration, dental caries,
 chickenpox, common cold. Incomplete vaccination schedule and poor follow-up (only 2 are highlighted
doses of acellular pentavalent after time). Exclusive breastfeeding up to 6 months of
age, weaning at 8-9 months of age, does not have good growth and development control. Lives with
his parents, good hygiene habits, housing with all services. Currently presents a risk
(from falls).
Procedures carried out:
Lumbar puncture (the findings of: specific antibodies positive for poliovirus,
normal glucorrhachia [60mg/dl], mild increase in proteinorrhachia, cell count of 300/microL at
predominance of lymphocytes). Reverse transcriptase polymerase chain reaction positive to
poliovirus in CSF and blood.
Pharyngeal exudate and coproparasitic examination (positive for specific antibodies to poliovirus).
Pharmacological therapy:
Physiological saline of 1000 for 24 hours, analgesic and antipyretic medications: ibuprofen
(suspension) VO 135 mg (7.5 ml) every 8 hours;

(Temperatura, peso, talla, IMC, dieta, metabolismo, glucemia, Estado de hidratacion, funcion renal, piel,
Injuries) What is your nutritional status? Metabolic changes?
Patron 2
nutritional Febricula (37.8°C), peso: 18.7 kg, talla: 111 cm, IMC: 15.17, su dieta es blanda (por la odinofagia), 2, 11
metabolic oral and conjunctival mucosae hydrated, skin pallor, stable renal function, consumption of
abundant fluids.

(Diarrhea, constipation, incontinence, retention, dysuria, elimination pattern, etc.) What is your
elimination?
Patron 3
Evacuates 2 times a day with pasty consistency, urination (5-6 times a day) affected by discomfort. 3
elimination
general (needs help from his/her mother for both things).

Pattern 4 activity (Vital Signs BP HR, RR, Hemodynamic state, Respiratory pattern, SpO2, Tissue perfusion, 4
and exercise Self-care: bath-dress-feed, uses toilet by himself/herself - dependent or independent / Mobility -
immobility, weakness, strength, rest, musculoskeletal
With a heart rate of 84 bpm, respiratory rate of 23 bpm (good pattern of respiratory mechanics, lung fields are fine
ventilated), blood pressure of 90/60 mmHg, needs the support of her mother to walk, go to the bathroom, mobility
moderate in bed, presents musculoskeletal weakness, and slight alteration of reflexes
 Osteotendinous. High risk of falls (he already fell once while trying to do it alone).

(insomnia, excessive sleep or fatigue, physiological sleep or sedation, sleep hours, etc) How
Are you sleeping?
Patron 5 dream andSleeps about 10 hours a day (approximately 10:00 PM - 8:00 AM) (his pattern is disrupted by pain)
4
rest and musculoskeletal stiffness), reports fatigue, and difficulty falling asleep due to the
hospital routine environment.

(Dolor, Disconfort, Estado conciencia, Valoracion Neurologica, Sentdos, ¿tene algun malestar?
Sufficient knowledge about something?) :
Patron 6 cognitive
5
perceptual
Recent mild to moderate myalgias (VAS of 5, using the visual scale), neck and back stiffness.
discomfort (with his mother and the staff) and unease, Glasgow Scale at 14, general malaise.
(Sadness, depression, body image, etc) How does one feel about themselves?
Patron 7
He feels sad because he does not understand the situation, he misses his classmates and kindergarten teacher.
self-perception 6
bored at the hospital.
self-concept

(Roles of the caregiver, personal, family relationships) Family, work, or school problems that
do they affect your health?
Patron 8 role
He has a very good relationship with his parents (to a greater degree with his mother), his mother expresses that she 7
relationships
feels anxious because the hospital causes him stress.

Patron 9 (Gynecology obstetrics, pregnancy, childbirth, postpartum, sexual organs = reproductive system, sexual pattern,
sexuality family planning 8
reproduction Due to their age, it does not apply (external sexual organs intact according to age and sex without anomalies).
(Nervousness, fear, mourning, coping, distress, resilience, neurobehavioral stress)
Patron 10 Neonates: adaptation to extrauterine life) How do they cope with their problems?
Adaptation He is afraid of the hospital (especially the nurses and injections, which worsens after the 9
tolerance to He gets very nervous every time a member of the interdisciplinary team enters his cubicle.
stress distress manifested by a state of anguish and overwhelm.
 (Suffering in general, moral suffering, spiritual suffering, religion, conflict of decisions)
The pediatric patient is suffering from the lack of understanding of what is happening around him.
Patron 11 values
very frequent mother so that everything goes well. 10
and beliefs

Changes in the most relevant signs and symptoms of the patient (Evolution). FINAL ASSESSMENT OF THE PATIENT:

Pediatric patient who cooperates with the interdisciplinary team in the procedures, establishing a relationship of trust.
safety, the pain, now from moderate to mild, has evolved in intensity and frequency causing general discomfort
especially at the skeletal muscle level) is more tolerable, effective communication with family members when carrying out the
support measures and rest, strength and muscle function recovered thanks to physical therapy and pain management. A prognosis
doctor (non-paralytic poliomyelitis) of complete recovery.

DATA ORGANIZATION
OBJECTIVE DATA SUBJECTIVE DATA DATA CURRENT DATA
HISTORICAL
Fever (37.8°C) My head hurts Chickenpox Fever (37.8°C)
Mild to moderate myalgias My neck hurts when I move it IRAS Mild to moderate myalgias (with visual scale of)
(with a visual scale of EVA of 5) It's hard for them to move like EDAS EVA of 5)
Stiffness of neck and back before your back Dehydration Stiffness of neck and back
High fall risk It hurts when swallowing Dental caries High risk of falls
Cell count of 300/microL to Walk with my help Common cold Cell count of 300/microL with predominance of
predominance of lymphocytes needs to go to the bathroom Lymphocyte vaccination schedule
Positive specific antibodies feel sad, distressed, incomplete Specific antibodies positive for poliovirus
the poliovirus present in PCR worried, scared present in PCR through reverse transcriptase, in
through reverse transcriptase, special a procedures lumbar puncture, blood, pharyngeal exudate and
in lumbar puncture, blood, invasive) coproparasitoscope.
exudate pharyngeal y It feels calmer if I take it. Slight alteration of the osteotendinous reflexes
coproparasitoscope. hand in hand My head hurts
Slight alteration of the reflexes It is difficult for him/her to reconcile the My neck hurts when I move it.
osteotendinous dream, have unease He finds it hard to move his back like before.
It hurts when swallowing.
Walk with my help, you need me to do
of the bathroom
Feels sad, anxious, worried, afraid
(especially invasive procedures).
 It feels calmer if I take it by the hand
He has trouble falling asleep.
unease.

DIAGNOSTIC PHASE

NURSE DIAGNOSIS PATTERN

ALTERED
Sharp pain related to injury by biological agent as evidenced by self-report of intensity 6. Cognitive-perceptual
with standardized pain scales, facial expression of pain, report from an authorized person about
attitudes of pain/activity changes and expressive behavior.
Deterioration of physical mobility related to pain, intolerance to activity, and reduction of activity and exercise.
muscle strength manifested by alterations in gait, difficulty turning, decrease in
gross motor skills, limitation of the range of efforts and slow movements.
Associated condition: neuromuscular deterioration.
Deterioration of ambulation related to pain, insufficient muscle strength, and decreased activity and exercise.
resistance as evidenced by the deterioration of the ability to walk the required distances.
Associated condition: musculoskeletal deterioration. 230
Discomfort related to insufficient environmental control, insufficient control of the situation as it
demonstrates anxiety, unease, fear, symptoms of distress, and a sensation of discomfort. Cognitive-perceptual
Associated condition: symptoms related to the disease.
466
Fall risk according to evidence of decreased strength in lower extremities, deterioration 4: Activity and exercise
of mobility and difficulty walking.
Population at risk: history of falls.
Associated condition: proprioceptive deficit 408
5: Dream and rest
Altered sleep pattern related to environmental barriers as evidenced by difficulty in
initiate sleep, difficulty staying asleep and dissatisfaction with sleep.
Associated condition: immobilization 234
PLANNING, EXECUTION AND EVALUATION.
Nursing care plan for the patient with POLIO

Bifocal (X) From the nursing diagnosis ( )

DIAGNÓSTICO DE ENFERMERÍA NANDA RESULTADO ESPERADO INDICADOR DEL RESULTADO
Likert scale PUNCTUATION
DIANA
Functional pattern 6: Cognitive perceptual LABEL OF MA AA EVA
Domain 12: Comfort RESULTADO:
Class 1: Confortfsico
Referred pain
Page NANDA: 468 Pain level Facial expressions Grave 2 4 3
(ED, FR, CD) of pain Substantial 2 4 4
Muscle tension 3. Moderate 1 3 3
Unease 4. Light 1 4 4
Acute pain related to injury due to CLASS ( V ): Irritability None 2 4 4
biological agent as demonstrated Symptomatology
self-report of intensity with scales
standardized pain, facial expression
of pain, report of a person
authorized about attitudes of DOMINION ( V ): Serious deviation of
pain/activity and behavior changes Perceived health normal range 2 4 4
expressive. Sweating Substantial deviation
Code: 2102 within the normal range
Associated conditions: not applicable 3. Deviation
moderate range
normal
At-risk population: not applicable Page NOC: 466 4. Mild deviation of
normal range
5. Without deviation from
normal range
 Global score of the 2 4 4
result.

NIC interventions and/or GPCE recommendations

RECOMMENDATIONS OF THE GPC. CODE: Nursing Interventions (NIC)

DOMAIN 1: Physiological: Basic CLASS (E): Promotion of physical comfort
NIC Intervention Label: Pain Management: Acute
Código NIC: _1410____________ Pág. NIC:306
Activities:
I conducted a thorough assessment of the pain that included location, onset,
duration, frequency and intensity, as well as the factors that relieved it and
they were acting as guides.
I monitored the pain using a valid and reliable measurement tool.
appropriate to age and communication ability.
I observed if there were signs of nonverbal discomfort, especially in this.
pediatric patient who cannot be effectively communicated with.
I asked the patient about the level of pain that allows for their comfort and I tried
NOT APPLICABLE, THERE IS NO GPC FOR THIS appropriately, trying to keep it at the same or lower level.
Suffering I ensured that the patient received immediate pain relief before
that the pain worsens or before the activities that induced it.
According to the center's protocols for the selection of analgesics and doses
according to the medical indication and prevented the side effects of the
medications.
I selected and implemented interventions adapted to the risks, benefits and
patient preferences to facilitate pain relief, as appropriate.
I administered analgesics by the least invasive route possible, avoiding the IM route.
I incorporated non-pharmacological interventions into the etiology of pain and the
patient preferences, as appropriate.
I modified the pain control measures based on the patient's response.
 to the treatment.
Notify the doctor if the pain control measures were unsuccessful.

Clinical records:

Nursing note/Objectives and subjective data/Signs and symptoms/Assessment

Preschool pediatric patient who reports substantial referred pain at the time of assessment, reason for which...
reflect substantial facial expressions of pain, severe muscle tension and serious restlessness, and therefore expresses
both irritability and substantial sweating.

NURSING DIAGNOSIS EXPECTED RESULT Interventions and/or recommendations GPCE

Acute pain related to injury by agent Improve the pain level of Utilization Management intervention
biological as demonstrated by self-report of a substantial deviation from pain: sharp.
intensity with standardized pain scales,
range normal a a
facial expression of pain, report of a person
authorized on pain attitudes/changes of slight deviation from the range
activity and expressive behavior. normal.
Associated conditions: not applicable
At-risk population: not applicable

Key of the GPCE and consulted documents NANDA 2018-2020, NOC 6th Ed., NIC 7th Ed.

Evaluation/Responses and Evolution

I leave the patient with considerable improvement, as indicated by moderate referred pain, as shown by the mild
In general, the level of pain is now with a slight deviation from the normal range according to the Likert scale.

BIBLIOGRAPHIC SOURCES

[Link] OSTIC 2018-2020. Eleventh edition. Elsevier Publishing, Barcelona Spain.

2. Moorhead Sue, Swanson E., Johnson M., Mass M. 2018. Nursing Outcomes Classification (NOC). 6th Ed. Elsevier Publishing.
Barcelona Spain.
[Link] Howard k., Bulechek G., Dochterman J., Wager C. 2018. Clasificacion Nursing Interventions (NIC). 7th Ed.
Elsevier Editorial, Barcelona Spain.
C
4. Vaccination manual 2017, Censia. D.R. Secretary of Health. National Vaccination Council.
5. Garcia Sanchez, J. Garcia Sanchez, E. Fresnadillo Martinez, M. Infectious diseases. Clinical microbiology. SEIMC Editorial. The
polio, el largo camino hacia el final de la partda. Vol. 33. Num. 10. Paginas e69-e78 Paginas 639-702 (Diciembre 2015). ISSN: 0213-
005X. Available in htps://[Link]/en-journal-infectious-diseases-microbiology-clinical-28-arThe long run for polio
path-S0213005X14003437 consulted on 09/12/2020.
6.L. Tesini, B. 2019. Poliomyelitis (Infantile paralysis, acute anterior poliomyelitis, polio). MD, University of Rochester School of
Medicine and Dentistry. MSD Manuals. Article consulted on 09/12/2020 available at htps://[Link]/es-
mx/professional/infectious-diseases/enterovirus/poliomyelitis.