lunes, 19 de enero de 2009

Protocolo de atención de enfermería en la atención del paciente quemado en la Unidad de Recuperación Post Anestésica ( URPA)

Lic. Gladis A. Méndez P. Dra. Dalia Granados
Unidad de Quemados Pearl F. Ort. Ciudad Sanitaria Dr. Luis E. Aybar
Santo Domingo, Republica Dominicana.

INTRODUCCIÓN

Las enfermeras que trabajan en las unidades de recuperación post anestésica asumen la responsabilidad de cuidar de un paciente que se encuentra en situación critica, por lo que los cuidados y vigilancia con este paciente deben ser extremos , sin embargo en nuestra practica hemos podido observar los inconvenientes a los que tienen que enfrentarse las enfermeras en la Unidad de Recuperación Post Anestésica (URPA), fundamentalmente por desconocimiento de la dinámica de trabajo y por estar poco familiarizados con problemas reales o potenciales del post-operatorio inmediato.
El monitoreo en la sala de recuperación es uno de los aspectos mas importantes en el manejo del paciente quemado, y en múltiples ocasiones la monitorización se dificulta.
Establecer un protocolo para manejo del paciente quemado en la URPA, tiene como objetivo general , ofrecer una guía para la atención del paciente en la recuperación post anestésica que permita un trabajo sistematizado , que envuelva la identificación y prevención de complicaciones , una gestión clínica por procesos, estandarizar la practica asistencial, basada en evidencia científica, ofreciendo un atención personalizada basada en los beneficios que éste protocolo tendrá para ofrecer una práctica asistencial dinámica hacia la mejora de la calidad asistencial al paciente y para la enfermera en la distribución y programación de los cuidados oportunos a los pacientes, colaborando en la fortalecimiento de su profesión.

OBJETIVO GENERAL:

Presentar conocimientos a los diferentes participantes sobre las atenciones de enfermería ofrecidas a los pacientes quemados de URPA en la Unidad de Quemados.

OBJETIVOS ESPECÍFICOS:

1. Analizar las diferentes técnicas de monitorización en la sala de recuperación post-anestésica de la Unidad de Quemados.
2. Relacionar la labor de enfermería con otras áreas.
3. Desarrollar un plan de cuidados estandarizados para actuar con efectividad ante situaciones que ponga en peligro la vida del paciente
4. Diferenciar las funciones independientes, interdependientes y dependientes de la enfermera
5. Establecer una comunicación eficaz entre los diferentes profesionales
6. Identificar factores de riesgos en la UPA
7. Actualizar protocolos de cuidados en conjunto con otros profesionales

MATERIAL Y MÉTODOS

Se establece un estudio retrospectivo y prospectivo basado en la recogida de datos sobre los pacientes recibidos en la URPA. La selección de pacientes es el universo de pacientes sometidos a procedimientos quirúrgicos. El estudio se lleva a cabo desde febrero de 1994 a febrero 2005. Para obtener los datos se revisaron las historias clínicas, hojas de anestesia, informe quirúrgico, hoja de recuperación anestésica, registro de enfermería.

RESULTADOS

Se revisaron un total de 2, 572 pacientes sometidos a cirugía de desbridamiento romo y/o tangencial, desbridamiento e injerto y amputaciones, y a cirugía ambulatoria para colocación de injerto

De los pacientes recibidos en la URPA 612 eran mujeres y 1960 hombres

La historia clínica del paciente estuvo completa lo que nos permitió orientarnos sobre sus datos generales, enfermedades concomitantes, medicación administrada , laboratorios

En el traslado del paciente de sala de cirugía a URPA, se realizo acompañado del anestesiólogo quien a su vez hizo entrega formal a la enfermera encargada, indicándole el tipo de procedimiento realizado, si hubo alguna anomalía durante el trans quirúrgico, el estado del paciente, si ha sido transfundido, su estado mental en el momento de llegar a la URPA y condición general. No se usaron monitores para su traslado

La camilla de transporte cubierta con sabanas dobles estériles cumpliendo con el protocolo del traslado

La vía aérea del paciente venia libre en el 100 % de los pacientes a los que se le coloco un catéter nasal o mascarilla según indicación médica.

Dentro de los cuidados de enfermería observar la permeabilidad de las vías aéreas, aspirando al paciente siempre que sea necesario utilizando técnicas aséptica, observar alteraciones en cuanto a la frecuencia respiratoria, cianosis de labios y extremidades, uso de los músculos accesorios y/o cualquier obstáculo que impida la ventilación sobre todo en pacientes con quemaduras de cara y cuello por presencia de edema.

La oximetría de pulso se utilizo en el 100 % de los pacientes, resulto útil pues nos brinda información continua de la saturación de O2, siendo un método no invasivo.

La vía intravenosa estaba permeable, con catéter de doble lumen en el gran quemado y con catéter periférico en los pacientes sometidos a cirugía ambulatoria. Las vías venosas deben ser cuidadas para que permitan grandes infusiones de soluciones y sangre y evitar al máximo la infección sobre las mismas ya que pueden ser fuentes para una septicemia

Los apósitos que cubren las heridas en ocasiones se encontraban húmedos, demostrando perdidas sanguíneas en sabanas por lo que fue necesario llamar al cirujano y colocar vendajes compresivos. Estos procedimientos quirúrgicos, tienen sangrados importantes, las perdidas sanguíneas a partir de escarotomias y las escisiones y desbridamiento tangencial, pueden provocar estado de choque por lo que cuando recibimos el paciente en la sala de recuperación debemos observar los vendajes, ya que en ocasiones se produce un sangrado en sabana, que debe ser detectado antes de que se produzcan cambios hemodinámicos.

Se recibieron paciente con signos de cambios de temperatura, se procedió a cubrirlo, calentar líquidos infundidos cubrir toda la zona expuesta con manta que proporcionaran calor, para evitar los temblores. La monitorización de la temperatura es muy importante, ya que el paciente quemado es muy propenso a la hipotermia. La disminución de la temperatura conduce a inestabilidad hemodinámica y a trastorno de la perfusión. Debemos establecer mecanismos que impidan grandes pérdidas, cubriendo las áreas intervenidas calentando las soluciones intravenosas y las de lavado, etc. Preparar la URPA, para brindarle al paciente, un área confortable con temperatura adecuada de 26˚ a 28˚, no permitir que puertas queden abiertas al mismo tiempo, pues causan corrientes de aire.

El monitoreo en la sala de recuperación es uno de los aspectos más importantes en el manejo del paciente quemado, la necesidad de la mayor cantidad de información posible dadas las condiciones de limitada estabilidad del paciente se dificulta mucho ya que muchas veces no se tiene siquiera una extremidad para tomar la tensión arterial, colocar un estetoscopio o fijar electrodos del ECG. Esto nos constriñe, que en ocasiones se tenga que conceder una gran importancia a la información directa, supervisando la excursión ventilatoria, las perdidas sanguíneas a través de vendajes, la perfusión, a través del llenado capilar, diuresis horaria, y los resultados de laboratorios.

La técnica de monitoreo en el paciente quemado deben ser lo más estéril posible así como la manipulación. La invasión no es recomendable, sin embargo es muy importante contar cuando menos con un catéter central o una sonda urinaria en los pacientes con quemaduras graves.

La tensión arterial por el aumento de tono simpático en este tipo de paciente, la hace poco sensible del estado de la volemia. Sin embargo continua siendo una herramienta útil, que en mucha ocasiones se dificulto su registro por los vendajes que cubren las extremidades, y por no tener los recursos para el registro invasivo. La presencia de taquicardia como signo clínico de alerta ante la posibilidad de hipovolemia después de descartar la presencia de dolor fue de utilidad. Poder diferenciar si estos signos clínicos son debido a disminución de la volemia o al estado de hipermetabolismo, exige el conocimiento de la fisiopatología del paciente quemado
El diagnostico diferencial abordando otros signos y síntomas, nos permitirá la instauración de la terapéutica de lugar.

La monitorización del ECG es útil para detectar arritmias y vigilar el segmento ST, en muchos casos se dificulto la colocación de los electrodos y el sostén de ellos en el lugar correcto, pudiendo observar ante estas dificultades que no fueron colocados en la posición correcta en varios casos , por lo que se altero el registro ECG
La medición del balance hídrico rigurosamente a través de los ingresos y egresos que acontecen durante su estadía en la URPA, no se completaron rigurosamente anotándolos en el record, para llevar un seguimiento de las necesidades hídricas.

El paciente quemado exhibe mucho dolor, desde su ingreso a la URPA se instaura su tratamiento según protocolo por el servicio de anestesiología, y se da seguimiento, al observar dolor, o cuando el paciente lo refiere, se contacta al anestesiólogo para que indique la terapéutica adecuada según el caso , y observar la respuesta a los medicamentos administrados y comunicar cualquier cambio en el estado respiratorio y cardiovascular al médico inmediatamente. Debemos recordar NO DESPRECIAR LAS QUEJAS DEL PACIENTE, procurar alivio del dolor pues este causa ansiedad, estado hipermetabólico, disminución de volumen respiratorio, inmovilidad, mayor inmunodepresión.

El uso estricto de guantes, mascarilla y sobre todo el lavado de mano al manipular cada paciente para evitar contaminaciones cruzadas. Así como mantener las normas de bioseguridad estricta.

La enfermera debe tener en cuenta antes de trasladar al paciente de sala de recuperación que este cumpla al máximo con la puntuación óptima de la Escala de Aldrete , solo debe realizarse cuando el paciente este recuperado de la anestesia, debe estar sedado y sin dolor, con una temperatura adecuada y estabilidad hemodinámica. Es responsabilidad de la enfermera de URPA participar en el traslado del paciente en coordinación del médico anestesiólogo responsable del caso y entregarlo formalmente a la enfermera de UCI.

El área de recuperación postanestésica debe ser de circulación restringida y dedicada exclusivamente al cuidado de la recuperación del paciente, la enfermera es la responsable de mantener el control y el orden del área.


RECOMENDACIONES:

- Mantener en el área de URPA un personal altamente capacitado. Solo la experiencia, los conocimientos junto con la identificación de los posibles problemas nos da la habilidad para el manejo y resolución de problemas de forma rápida y segura.
- Mantenimiento de la calidad en las actuaciones de enfermería , evaluación continua y comunicación fluida entre todos los profesionales que participan en el proceso perioperatorio
- Este protocolo debe ser actualizado por lo menos cada dos años

Bibliografía

D. Herdón. Total Burn Care. Editorial Saunders. 2002

J. I. Ruiz. Anestesia y Reanimación del paciente quemado. Curso III FEEA. 2004. 169-184

B. Forero. Intervención de enfermería en el manejo del dolor del paciente quemado. www.encolombia.com/medicina/enfermeria.

R. Rocha. Relato de una experiencia de construcción de protocolo de cuidados de enfermería. Revista Electrónica Semestral de Enfermería. www.um.es/eglobal. 2003

D. Granados. Anestesia en el paciente quemado. Curso III FEEA. 2005. 130-147

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