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5
Edición
Manual CTO de
Enfermería
Enfermería medicoquirúrgica 1:
Aparato respiratorio Equilibrio hidroelectrolítico
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No está permitida la reproducción total o parcial de este libro, su tratamiento informático, la transmisión de ningún otro formato o por cualquier medio, ya sea electrónico, mecánico, por fotocopia, por registro y otros medios, sin el permiso previo de los titulares del copyright . © CTO EDITORIAL, S.L. 2011 Diseño y maquetación: CTO Editorial C/ Núñez de Balboa, 115; 28006 - Madrid Tfno.: 91 782 43 30 - Fax: 91 782 43 43 E-mail:
[email protected] Página Web: www.grupocto.es
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5
Edición
Manual CTO de
Enfermería
Enfermería medicoquirúrgica 1:
Aparato respiratorio Autoras M.ª Lourdes Casillas Santana Susana Esquinas Serrano
Revisión técnica Saturnino Mezcua Navarro
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5
Edición
Manual CTO de
Enfermería
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ÍNDICE ENFER ENF ERMERÍA MERÍA M EDI EDICO CO QUIRÚ QUIRÚRGICA RGICA 1:
TEMA 1. INTRODUCCIÓN
521
TEMA 2. SINTOM SINTOMAT ATOLOGÍA OLOGÍA EN LAS PA PATOLOGÍAS TOLOGÍAS RESP RESPIRATORIAS IRATORIAS
521
APARATO RESPIRATORIO
2.1. 2.2. 2.3. 2.4. 2.5. 2.6.
Disnea Tos y expector expectoración ación Hemoptisis Dolor torácico Patrones respiratorios Ruidos respiratorios
TEMA 3. PA PATOLOGÍA TOLOGÍA INFE INFECCIOS CCIOSA A DEL APARAT APARATO O RESP RESPIRATORIO IRATORIO
3.1. 3.2. 3.3. 3.4. 3.5.
522 522 523 524 524 525
526
Tuberculosis pulmonar Tuberculosis Neumonía Bronquitis aguda Fibrosis quística Empiema
526 529 532 533 534
TEMA 4. FISIOLOGÍA RESPIRATORIA
535
4.1. 4.2. 4.3. 4.4.
Mecánica ventilatoria Control de la respiración Exploración funcional respiratoria Valores de las presiones de los gases de intercambi intercambio o
TEMA 5. INSUFICIEN INSUFICIENCIA CIA RESPIRATORIA
5.1. 5.2. 5.3.
Mecanismos de producción de insuficiencia respiratoria Clínica Detección, control y tratamiento
TEMA 6. ENFERMEDAD PULMONAR OBSTRUC TIVA CRÓNICA
6.1. 6.2. 6.3. 6.4.
Bronquitis crónica Enfisema pulmonar Diagnóstico de las EPOC Tratamiento Tratamien to de las EPOC
535 536 536 537
537 538 538 539
540 540 541 542 542
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ENFE NFER RM ERÍ RÍA A M EDIC DICO O Q UI UIR RÚR ÚRG G IC ICA A 1: E C
A PA PAR RA TO RESPIR PIRA A TO RIO TEMA 8. ASMA BRONQUIAL
8.1. 8.2. 8.3.
Clínica Diagnóstico Tratamiento
TEMA 9. ATELECTASIAS
9.1. 9.2. 9.3. 9.4.
Causas Clínica Tratamiento Cuidados de enfermería
TEMA 10. TROMBOEMBOLISM TROMBOEMBOLISMO O PULMONAR TEP
10.1. 10.2. 10.3. 10.4.
Concepto y factores de riesgo Clínica Tratamiento Cuidados de enfermería
TEMA 11. ENFERMEDADE ENFERMEDADESS PULMONARES PROFESIONAL PROFESIONALES ES
11.1. Enfermedades pulmonares profesionales por inhalación inhalación de polvo inorgánico 11.2. Enfermedades por inhalación inhalación de gases gases irritantes, irritantes, humos y sustancias tóxicas 11.3. Enfermedades por inhalación de polvo orgánico
TEMA 12. ENFERMEDADE ENFERMEDADESS DE LA PLEURA
12.1. Pleuritis seca 12.2. Derrame pleural 12.3. Neumotórax TEMA 13. NEOPLASIAS PULMONARES
13.1. Tumores malignos 13.2. Nódulo pulmonar solitario 13.3. Tumores benignos
545 546 546 546
547 547 547 548 548
548 548 549 549 550
550 550 551 551
551 551 551 553
554 554 555 556
I D N Í
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Aspectos esenciales 1
La disnea disnea es es la sensación subjetiva de falta de aire y la dificultad para respirar y es común a muchos procesos patológicos pulmonares. Las causas más comunes de disnea respiratoria son la EPOC, la neumonía y el neumotórax. La cantidad de esfuerzo para que se desencadene se cuantifica en grados.
2
La tuberculosis primaria suele restringir la afectación al pulmón. La tuberculosis posprimaria se puede manifestar en el aparato genitourinario, en el aparato locomotor, las meninges, los ganglios, el intestino, la piel, las serosas.
3
Los gérmenes causales de la neumonía neumonía pueden pueden llegar a los pulmones mediante: aspiración, inhalación, diseminación hematógena, por contigüidad o bien por inoculación directa. Los microorganismos causales varían con la edad. En la infancia suelen ser virus y en los adultos bacterias.
4
La bronquitis aguda es aguda es una enfermedad inflamatoria que afecta a la tráquea y los bronquios de origen viral habitualmente (virus de la gripe, adenovirus, rinovirus y virus sinticial respiratorio). Suele ser autolimitada y de duración breve (menor a dos semanas).
5
El empiema empiema es es la acumulación de líquido infectado en la pleura a consecuencia de una neumonía o un absceso pulmonar, o bien por diseminación hematógena o linfática desde cualquier lugar del organismo o por contigüidad desde el abdomen a través del diafragma.
6
El asma asma se produce por una hiperreactividad del árbol bronquial a diversos estímulos. La tríada clásica del asma es broncospasmo reversible con tos, disnea y sibilancias generalmente espiratorias. Otros síntomas son el uso de la musculatura accesoria al respirar, sensación de opresión, ansiedad creciente a medida que aumenta la disnea y presencia de pulso paradójico (a veces muy intenso).
TEMA 1
INTRODUCCIÓN Los cuidados del aparato respiratorio son de capital importancia dentro de la enfermería medicoquirúrgica.. En primer lugar, hay que tener en cuenta que la necesidad de respirar es la más básica quirúrgica de todas, y que a partir de ella es posible mantener la oxigenación normal de todas las células y de los tejidos. Existen múltiples factores que afectan al proceso respiratorio, y la mayoría son producto tanto de la sociedad industrializada y de su tecnología, como del estrés que provoca a sus habitantes: • Factores biológicos: ejercicio biológicos: ejercicio físico, tabaquismo, alimentación, edad. • Factores emocionales: ansiedad, emocionales: ansiedad, cólera, sueño, apatía y dep resión. • Factores socioculturales: profesión, socioculturales: profesión, contaminación atmosférica. • Pero, ¿qué se entiende por respiración? La respiración es un proceso que comprende la v entilación pulmonar (inspiración/espiración), la difusión pulmonar y el transporte de gases, de tal forma que entre el organismo y el ambiente se produce un intercambio de oxígeno (O 2 ) y de dióxido de carbono (CO ).
: o 1 i a r c o i g t r a r ú i r i p u s q e o r c i d o e t a r m a a í r p e A m r e f n E
Preguntas - No hay preguntas EIR representativas
E R 1 M
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Enfermería medicoquirúrgica 1:
Aparato respiratorio
2.1. DISNEA
Recuerda · La disnea es la sensación subjetiva de
·
·
·
·
falta de aire y dificultad para respirar y es común a muchos procesos patológicos pulmonares. Las causas más comunes comunes de disnea respiratoria son la EPOC, la neumonía y el neumotórax. La cantidad de esfuerzo para que se desencadene se cuantifica en grados. Puede tener tener su origen en patologías cardiacas y sus formas de presentación son: ortopnea y disnea paroxística nocturna (asma bronquial). Los cuidados enfermeros enfermeros deben ir encaminados a la detección de la disnea, la valoración de la respiración y el control de la misma, favoreciendo la correcta expansión del tórax. Los objetivos objetivos a conseguir son: favorefavorecer la ventilación y disminuir la ansiedad de los pacientes.
Es una sensación subjetiva de falta de aire y dificultad para respirar que depende en gran medida de la particularidad de cada paciente; es, en general, una situación común a muchos procesos patológicos pulmonares. La disnea de origen respiratorio es producto de la obstrucción al paso del aire por las vías aéreas. El paciente compensará este déficit con una respiración taquipneica, pero profunda. Las causas más comunes de disnea respiratoria son las EPOC, la neumonía y el neumotórax. Según la cantidad de esfuerzo físico que pueda hacer el sujeto antes de que aparezca la disnea, esta puede cuantificarse en varios grados (el primero es el más leve): • Grado I: disnea que aparece después de esfuerzos intensos. • Grado II: disnea II: disnea de esfuerzos moderados. • Grado III: disnea III: disnea de esfuerzos leves. • Grado IV: disnea IV: disnea de reposo. No obstante, existen formas de disnea que no son consecuencia directa del ejercicio físico, sino que su aparición es debida a una disfunción cardíaca en la cual el corazón no es capaz de bombear suficiente cantidad de sangre, de modo que esta queda estancada en los territorios pulmonares, congestionando el pulmón y reduciendo su distensibilidad, lo que interfiere en la función respiratoria. Las principales formas de manifestación de disnea de origen cardíaco son: • Ortopnea: Ortopnea: aparece aparece cuando el paciente está en decúbito supino y mejora al sentarse o incorporarse (por reducción de la congestión pulmonar y aumento de la capacidad vital por la expansión del pulmón). La respiración mejora si el paciente duerme con varias almohadas. • Disnea paroxística nocturna (también llamada asma cardíaca): de aparición brusca y que despierta al paciente. Al sentarse o levantarse de la cama, mejora la ventilación. A diferencia de la ortopnea, no siempre aparece nada más adoptar la posición de decúbito, sino en episodios esporádicos difíciles de predecir.
2.1.1. Cuidados de enfermería Los cuidados de enfermería son los siguientes:
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Manual CTO de Enfermería, 5.ª edición
• • • • • • • •
Respira Respi raci ción ón buca bucall de tipo tipo crón crónic ico. o. Gote Go teo o ret etrron onaasa sal.l. Infecc Inf eccion iones es de de las las vías vías aére aéreas as supe superio riores res.. EPOC. Tumor Tu moraci aciones ones y enfer enfermed medade adess neopl neoplási ásicas cas.. Neumonía. Sinusitis. Cuer Cu erpo poss ex extr traaño ñoss.
Si la tos es productiva viene acompañada de expectoración; en caso de tos seca irritativa, no habrá expectoración y se hablará de tos no productiva. Esta diferenciación entre tos productiva y no productiva lleva acompañado un detalle importante para recordar respecto a los antitusígenos. Si nos encontramos ante un paciente con tos de tipo productivo, no se le deberá administrar antitusígenos, ya que se evitaría la eliminación de secreciones, y en este caso, lo que se debe hacer es facilitarla. Sin embargo, si nos enfrentamos a un caso de tos no productiva, irritativa, sí es posible administrar antitusígenos para tratar de aliviar la irritación, sin riesgo de acúmulo de secreciones en el árbol bronquial. La expectoración expectoración es es la expulsión de secreciones, mediante la tos, del árbol bronquial. La cantidad normal de expectoración diaria es variable, pero se considera como normal unos 100 ml por día. Las expectoraciones (esputo) pueden clasificarse según su aspecto en: • Mucosas: Mucosas: son son transparentes y s e adhieren con facilidad. • Serosas: Serosas: muy muy fluidos y transparentes. • Purulentas: de color amarillo o verdoso y con pus. • Hemoptoicas: Hemoptoicas: oscuros oscuros o rojos, contienen sangre. TIPO DE TOS TOS IRRITATIVA SECA
TOS PRODUCTIVA
Tabla 1. Tipos 1. Tipos de tos
2.2.1. Cuidados de enfermería
Expectoración No produce expectoración · · · ·
Mucosa Serosa Purulenta Hemoptoica
E R 1 M
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Enfermería medicoquirúrgica 1:
Aparato respiratorio
2.3.1. Cuidados de enfermería En primer lugar, es preciso saber diferenciar entre hemoptisis y hematemesis (sangrado que procede del aparato digestivo en forma de vómito); después se debe valorar y comprobar el aspecto del esputo y si está relacionado con dolor o disnea; y por último, hay que cuantificar el volumen de la hemorragia y su rapidez de aparición, lo que ayudará a hacer un a valoración de gravedad. En general: • Mantene Mantenerr al paciente paciente acost acostado ado en decúbi decúbito to ipsilate ipsilateral ral al del pulmón pulmón afectado afectado.. • No practic practicar ar fisiote fisioterap rapia ia respi respirat ratori oriaa en ningún ningún caso. caso. • Tener dispon disponible ible todo el materia materiall necesario necesario para la intubac intubación. ión. • Con Contro trolar lar con con frecu frecuenc encia ia las las consta constante ntess vitales vitales.. • Adm Adminis inistra trarr oxig oxigeno enoter terapi apia, a, si si proce procede. de. • Di Dism smin inui uirr la la ans ansie ieda dad. d. • Lle Llevar var un regi registr stro o comp complet leto o y deta detalla llado. do.
2.4. DOLOR
TORÁCICO EIR 1011, 6
El primer paso ante un paciente que refiere dolor torácico consiste en averiguar el origen de éste: • Osteomuscular Osteomuscular (de (de la pared torácica). • Cardíaco Cardíaco (angina, (angina, infarto). • Esofágico Esofágico (espasmo (espasmo esofágico difuso, etc.). • Aparato respiratorio: respiratorio: - De las vías respiratorias: las respiratorias: las traqueítis derivadas de infecciones de vías aéreas altas presentan dolor retroesternal (de tipo quemazón) que se irradia a los flancos esternales y se incrementa con los accesos de tos. - Dolor pleurítico: suele pleurítico: suele deberse a la inflamación de la pleura parietal, que es la que tiene terminaciones nerviosas sensitivas; es característico que se acentúe con la tos y con la inspiración profunda.
2.4.1. Cuidados de enfermería
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Manual CTO de Enfermería, 5.ª edición
•
•
•
•
Hiperpnea: en este patrón respiratorio se mantiene el ritmo y la frecuencia de forma normal, pero las respiraciones son mucho más profundas. Cheyne-Stokes: se define como una suCheyne-Stokes: cesión de ciclos respiratorios intercalados por cortos periodos de apnea, siendo típico de estos ciclos que aumente gradualmente tanto la frecuencia como la profundidad de la respiración hasta que vuelven a descender, finalizando el ciclo y provocando apnea. Alguno de los procesos en los que típicamente puede aparecer son la insuficiencia renal (IR) y la insuficiencia cardíaca congestiva (ICC) (EIR 09-10, 51; EIR 07-08, 50). Biot: son Biot: son periodos mantenidos de taquipnea e hiperpnea que presentan pausas de forma brusca entre los periodos. Este tipo de respiración aparece de forma típica en lesiones encefálicas, más concretamente en lesiones de la protuberancia. Kussmaul: tiene como características el Kussmaul: aumento de la frecuencia y de la profundidad respiratorias de forma continuada, pero sin intervalos ni pausas. Este patrón respiratorio es típico de la acidosis metabólica (EIR 01-02, 47).
2.6. RUIDOS
RESPIRATORIOS RESPIRA TORIOS
E R 1 M
Figura 1. Patrones respiratorios
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Enfermería medicoquirúrgica 1:
Aparato respiratorio
•
Roce pleural: el pleural: el ruido surge al friccionar entre sí la pleura visceral y la parietal inflamadas, escuchándose tanto en inspiración como en espiración. El sonido es áspero y se asemeja bastante al crepitante, recordando al pisar de nieve o al frotar del dedo pulgar con el índice cerca del oído. Una característica que permite diferenciarlo de los estertores es que el roce pleural no se modifica con la tos (p. ej.: pleuritis seca). NOMBRE
LUGAR
SONIDO
EJEMPLO
Estridor
Vía aérea superior
Inspiración y/o espiración
Estenosis traqueal
Roncus
Vía aérea baja
Vibración tono bajo, modificación con tos
EPOC
Sibilancias
Vía aérea baja
Tono elevado más marcado en espiración
Asma bronquial agudo
Crep Cr epit itan ante tess es este terto rtore ress
Pare Pa renq nqui uima ma pul pulmon monar ar
Frot Fr otar ar de ca cabe bell llos os
Neum Ne umon onía ía
Pleura
· Sonido similar a crepitante, no se modifica con la tos · Pisar de nieve
Pleuritis seca
Roce pleural
Tabla 2. Ruidos 2. Ruidos respiratorios
Preguntas
- EIR 09-10, 58 - EIR 04-05, 48 - EIR 02-03, 59
TEMA 3
PATOLOGÍA INFECCIOSA I NFECCIOSA DEL AP APARAT ARATO O RESPIRATORIO R ESPIRATORIO La contaminación de las vías aéreas, en íntimo contacto con el medio ambien te, se produce generalmente por la inhalación de microorganismos. Los gérmenes también pueden llegar al aparato respiratorio por aspiración de secreciones orofaríngeas contaminadas o desde un foco séptico a distancia, ya sea por diseminación vía hematógena o por contigüidad. El organismo posee diferentes barreras naturales, que son la primera línea de defensa frente a los microorganismos:
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Manual CTO de Enfermería, 5.ª edición La curación de la lesión primaria se resuelve por fibrosis y calcificación. Los complejos de Ghon calcificados son visibles en la Rx de tórax.
El primer contagio con afectación pulmonar se conoce como tuberculosis pulmonar primaria o primoinfección tuberculosa, con signos y síntomas tan ligeros que la mayoría de las veces pasa inadvertida, descubriéndose de forma casual por un hallazgo radiológico o en la prueba de la tuberculina (Mantoux). Se denomina tuberculosis posprimaria o posprimaria osecundaria secundaria a a la reactivación endógena de una infección tuberculosa latente. A diferencia de la infección primaria, que suele localizarse en campos inferiores pulmonares, la tuberculosis posprimaria suele localizarse en los lóbulos superiores. Los bacilos vivos pero durmientes persisten durante años. La reactivación de la TB puede ocurrir si los mecanismos de defensa se alteran.
3.1.3. Manifestaciones clínicas En el caso de la primoinfección tuberculosa, tuberculosa, las manifestaciones clínicas son muy variables. Como ya se ha mencionado, con frecuencia pasa desapercibida y en otras ocasiones cursa con un discreto síndrome tóxico y febricular. Con menor frecuencia cursa con un estado tóxico importante y fiebre alta. En general, la afec-
E R 1 M
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Enfermería medicoquirúrgica 1:
Aparato respiratorio
3.1.3. Diagnóstico
Recuerda · La tuberculosis tuberculosis primaria suele restringir la afectación al pulmón. tuberculosis posprimaria se puede puede · La tuberculosis
· · · ·
· ·
manifestar en el aparato genitourinario, en el aparato locomotor, las meninges, los ganglios, el intestino, la piel, las serosas. Para comprobar la infección infección se utiliza la prueba de la tuberculina o intradermorreacción de Mantoux. La reacción a la prueba de Mantoux se valora a las 48-72 horas de la inyección intradérmica de tuberculina. En pacientes infectados por VIH se conconsidera positivo cualquier induración. Puede haber resultado falso negativo negativo en caso de alteraciones de la inmunidad, ancianos, o mala práctica en la inyección o medición. Para evitar la diseminación de la enfermedad las medidas a tomar son: aislamiento del paciente y quimioprofilaxis. El objetivo de los cuidados de enfer-
Para llevar a cabo el diagnóstico de la tuberculosis, son necesarias las siguientes acciones: • Ex Expl plor orac ació ión n físic física. a. • Exp Explor loraci ación ón radiol radiológi ógica: ca: radio radiogra grafía fíass de tórax. tórax. • Prueb Pruebaa de la tuberc tuberculina ulina (DPP): permit permitee comproba comprobarr la infec infección. ción. • Aislam Aislamiento iento del del bacilo: bacilo: cultivo cultivo de esputo esputo de tres tres muestras muestras de primera primera hora hora de la mañana mañana durante durante tres días consecutivos (tinción de Ziehl-Neelsen). Es importante distinguir los conceptos de infección y enfermedad. La infección sólo supone la entrada del bacilo al organismo y su diagnóstico se hace con la prueba de la tuberculina. Por otro lado, la enfermedad exige la confirmación de un cuadro clínico y/o radiológico compatibles. El principal sistema defensivo contra la micobacteria tuberculosa es la inmunidad celular, que se pone de manifiesto mediante la prueba de reactividad cutánea a la tuberculina. Dicha reactividad cutánea se estudia con la prueba de la tuberculina o intradermorreacción de Mantoux, consistente en la inoculación intradérmica en la cara anterior del antebrazo de la proteína purificada del bacilo tuberculoso. Se inyectan 5 U de tuberculina (0,1 ml) y se hace la lectura entre las 48-72 h. Para la valoración se mide el diámetro transversal de la induración, si ésta se produce (un eritema sin induración no es positivo). En España se consideran reactores positivos aquellos que presentan una induración mayor o igual a 5 mm. En el caso de que la persona haya sido previamente vacunada con BCG, será considerado positivo si mayor o igual a 15 mm de induración. Si la induración es menor de 5 mm, la prueba será considerada negativa. En el caso de que la prueba sea a un paciente infectado por el VIH, cualquier grado de induración será considerado positivo.
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Manual CTO de Enfermería, 5.ª edición
•
Vacuna antituberculosa (BCG): está (BCG): está desa consejada en la actualidad ya que la eficacia de la vacuna no está clara. Puede dar reacción DPP positiva; el tamaño medio de la induración es de 10 mm.
El tratamiento farmacológico es el aspecto más importante para conseguir la curación de la enfermedad. La monoterapia no es efectiva, por lo que se utilizan combinaciones de fármacos para conseguir la eliminación de todos los bacilos y evitar la creación de formas resistentes que provocan recaídas. La medicación se suele tomar por la mañana, en ayunas y de manera conjunta todos los fármacos. Generalmente se aplica la siguiente pauta: • Pauta de tratamiento de seis meses: isomeses: isoniazida, rifampicina y pirazinamida durante dos meses, prosiguiendo después con isoniazida y rifampicina cuatro meses más hasta completar seis meses. En ocasiones se añade etambutol en la primera fase del tratamiento. • En el paciente VIH: se seguirá el mismo
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Enfermería medicoquirúrgica 1:
Aparato respiratorio
Figura 4. Clasificación de las neumonías
Recuerda
Si fracasan los mecanismos de defensa tendrá lugar la colonización bronquial, la infección del parénquima pulmonar o ambos procesos. La llegada de los microorganismos hasta el parénquima pulmonar puede producirse de diferentes formas: • Aspiración: Aspiración: la la vía más frecuente de contaminación de las vías respiratorias inferiores es la aspiración de secreciones orofaríngeas, ya que los individuos normales son portadores de una flora polimicrobiana en dicho lugar. La aspiración es más frecuente y grave en personas con alteración del nivel de conciencia, disfunción neurológica de la orofaringe y trastornos de la deglución (EIR 09-10, 58). La 58). La intubación para ventilación mecánica es el factor de riesgo más importante para el desarrollo de neumonía nosocomial. • Inhalación: Inhalación: las las partículas menores de 5 micras pueden permanecer suspendidas en el aire durante mucho tiempo y, si son inhaladas, pueden depositarse en los bronquiolos y alveolos, produciendo por tanto infección, ya que transportan los microorganismos. Se podría hablar en este caso de inhalación de aerosoles infecciosos. Dado que los lóbulos inferiores del pulmón están mejor ventilados, la concentración y el depósito alveolares de los aerosoles son mayores en las bases pulmonares. • Diseminación hematógena: hematógena: a partir de un foco séptico distante. Algunos ejemplos de este tipo de producción serían los casos de endocarditis bacteriana o la infección de catéteres intravenosos.
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Manual CTO de Enfermería, 5.ª edición
3.2.2. Clínica Neumonías adquiridas en la comunidad •
Síndrome típico: la típico: la neumonía se caracteriza por la aparición brusca de fiebre, escalofríos, afectación del estado general con m alestar, artromialgias y cefalea, acompañado de tos productiva con expectoración purulenta, dolor torácico de tipo pleurítico y disnea. - El cuadro cuadro clínic clínico o suele inici iniciarse arse de de manera manera brusca brusca con un un escalofrí escalofrío o intenso. intenso. - Importan Importante te afectaci afectación ón del del estado estado general general.. Puede Puede aparec aparecer er herpes herpes labial labial.. - La tos tos suele suele ser ser produc productiv tivaa y el esput esputo o es purul purulent ento. o. - La inflamación inflamación de de la pleura pleura adyacente adyacente prov provoca oca dolor dolor en punta de costado costado (aumenta (aumenta con con la tos y con la inspiración profunda). - En la exploraci exploración ón física física se auscultan auscultan crepitan crepitantes tes y disminució disminución n del murmullo murmullo vesicular vesicular,, la percusión es mate y la resonancia de las cuerdas vocales, aumentada. - Re Respi spira raci ción ón ráp rápid idaa y supe superfic rficia ial.l. - Hipox Hipoxia ia por la la dificultad dificultad respira respiratoria toria y por por la mala mala ventilaci ventilación ón de los alveol alveolos. os. - La taquip taquipnea nea y la fiebre fiebre puede pueden n provoca provocarr deshidr deshidrata atació ción. n. - Su Suel elee pres presen enta tarr leuc leucoc ocit itos osis is..
•
Síndrome atípico: se atípico: se caracteriza por una clínica más subaguda. La neumonía atípica por M. pneumoniae se caracteriza por una disociación clínico-radiológica (en contraste con la escasez de sintomatología, las alteraciones en la radiología son evidentes y graves). Las manifestaciones no son tan bruscas. El inicio es progresivo, la fiebre no es tan alta y no se suele acompañar de escalofríos, la tos suele ser intensa, pero raramente es productiva y la semiología respiratoria es escasa. Las
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Enfermería medicoquirúrgica 1:
Aparato respiratorio
• • •
Sepsis. Síndrom Sínd romee de dist distrés rés res respir pirato atorio rio del del adul adulto to.. Fal allo lo org orgán ánic ico o múlt múltip iple le..
3.2.6. Cuidados de enfermería Los cuidados de enfermería serán los siguientes: • Co Contr ntrol olar ar las las const constan ante tess vital vitales es.. • Vi Vigi gila larr el est estad ado o neur neurol ológ ógic ico. o. • Intenta Intentarr mejorar mejorar el el estado estado general general ofrec ofreciendo iendo conf confort ort y bienest bienestar. ar. Adminis Adm inistra trarr l fár ito
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Manual CTO de Enfermería, 5.ª edición
3.3.3. Cuidados de enfermería • • • • • • •
Enseñar a toser toser de forma forma eficaz eficaz para para moviliza movilizarr y expulsar expulsar las secrec secreciones. iones. Mante Man tene nerr perme permeab able less las vía víass aérea aéreas. s. Aumentar Aument ar la ingesta ingesta de líquidos líquidos,, con el fin de favor favorecer ecer que que las secrecio secreciones nes sean menos menos espesas. espesas. Efec Ef ectu tuar ar inha inhala laci cion ones es de de vapo vaporr. Fav avor orec ecer er el re repo poso so.. Cont Co ntro rola larr la med medic icac ació ión. n. Insisti Insi stirr en el aband abandono ono del háb hábito ito tab tabáqu áquico ico..
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Enfermería medicoquirúrgica 1:
Aparato respiratorio
• •
afectación puede variar desde alteraciones mínimas por obstrucción de los conductos hasta la degeneración y sustitución de los acinos por fibrosis y grasa, lo que provoca una insuficiencia pancreática, con aparición de malabsorción de lípidos que produce esteatorrea y signos de malnutrición debida a malabsorción de grasas, proteínas y vitaminas liposolubles. La insuficiencia pancreática avanzada puede afectar a la función endocrina (diabetes mellitus). Íleo meconial en recién nacidos: en nacidos: en pacientes de mayor edad puede haber obstrucción ileal por materia fecal. Prolapso rectal: es rectal: es relativamente frecuente.
Aparato genitourinario
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Manual CTO de Enfermería, 5.ª edición
del germen desde cualquier lugar del organismo o bien por contigüidad desde un absceso en el abdomen a través del diafragma. Los gérmenes más frecuentes que lo provocan son: Streptococcus pneumoniae, Staphilococcus Staphilococcus aureus y Klebsiella pneumoniae, aunque también puede ser provocado por microorganismos anaerobios (EIR 04-05, 48). 3.4.1. Clínica • • •
Disnea progre progresiva siva y disminuci disminución ón de los movimi movimientos entos de de la pared pared torácica torácica del del lado afect afectado. ado. Dolorr pleurí Dolo pleurític tico o (depen (depende de de la la enferm enfermeda edad d de base) base).. Fiebre Fie bre,, sudora sudoració ción n nocturn nocturna, a, tos tos y pérdid pérdidaa de peso. peso.
Recuerda · El empiema es la acumulación de líquido infectado en la pleura a consecuencia de una neumonía o un absceso pulmonar, o bien por diseminación hematógena o linfática desde cualquier lugar del organismo o por contigüidad desde el abdomen a través del diafragma. · Suele estar estar provocado provocado por por gérmenes aerobios aunque también lo pueden provocar anaerobios anaerobios · La clínica clínica es progresiva: disnea y dis-
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Enfermería medicoquirúrgica 1:
Aparato respiratorio
3. La perfusión (): el (): el sistema vascular pulmonar está formado por vasos diferentes a la circulación sistémica, con paredes mucho más finas que ofrecen menor resistencia, por lo que las presiones son mucho más bajas. Las arterias bronquiales, ramas de la arteria aorta, irrigan las estructuras de sostén y drenan en las venas pulmonares que llegan a la aurícula izquierda. La perfusión sanguínea del pulmón no es igual en todas las partes, ya que las bases están mejor perfundidas. Una adecuada relación entre la ventilación/perfusión determinará las presiones parciales de O2 y CO2 que abandonan cada unidad alveolocapilar. Mecanismo que se podrá comprobar mediante una gasometría arterial y la pulsioximetría (grado de saturación de la hemoglobina por el O2).
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Enfermería medicoquirúrgica 1:
Aparato respiratorio
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
De esta forma, dado que la grasa apenas contiene agua, cuanto más obeso es un individuo, menor es la proporción de agua en su peso corporal total (una persona muy obesa puede tener un 25-30% menos de agua que otra persona sin sobrepeso). El menor porcentaje de agua en la mujer se debe a que su tejido celular subcutáneo es más abundante que en el hombre y su masa corporal algo menor. La mayor parte del agua corporal es intracelular (40% del peso). El agua extracelular, que representa alrededor del 20% del peso corporal (Figura 1), se halla distribuida en dos compartimentos: el intersticial, con un 16% del peso corporal, y el intravascular o plasmático, que supone entre un 4-5% del p eso corporal. Un tercer compartimento es el líquido transcelular (1 l) que incluye los líquidos del espacio cefalorraquídeo, gastrointestinal, sinovial, pleural y peritoneal (Figura 2).
Figura 1. Distribución del agua corporal
CARGA NEGATIVA ANIONES
CARGA POSITIVA CATIONES
· · · ·
Sodio Potasio Calcio Magnesio
· · · · ·
Cloro Bicarbonato Fosfato Sulfato Ácidos orgánicos · Proteínas
Tabla 2. Iones corporales (electrolitos)
Figura 2. Porcentajes y volúmenes del agua corporal
La composición de los solutos es diferente en el agua intracelular y extracelular (Tabla 2). Estas diferencias se deben a que la mayoría de membranas celulares poseen sistemas de transporte que activamente acumulan o expelen solutos específicos ( Tabla 3). • Sodio , calcio, bicarbonato y cloro: abundan en los líquidos extracelulares. • Potasio, magnesio, y fosfatos: son intracelulares. • Glucosa: penetra en la célula mediante transporte activo por la insulina, y una vez en su interior, es convertida en glucógeno u otros metabolitos, por lo que sólo se encuentra en cantidades significativas en el espacio extracelular. • Urea: atraviesa libremente la mayoría de las membranas celulares, por lo que su concentración es similar en todos los espacios corporales. • Proteínas intravasculares: no atraviesan la pared vascular, creando así una presión oncótica que retiene el agua en el espacio intravascular. La libre permeabilidad de las paredes capilares al agua y a pequeños solutos (sodio, potasio, cloro, calcio, etc.) hace que las determinaciones de las concentraciones en plasma se consideren equivalentes a las del medio intersticial o extracelular en conjunto. Cada electrolito puede tener una función específica en el organismo, pero, en general, sus funciones principales son las siguientes: • Sodio: es imprescindible para el mantenimiento de la osmolalidad de los líquidos corporales. • Potasio, calcio y magnesio: tienen una importancia vital en la fisiología neuromuscular y hormonal. • Hidrogeniones: su concentración determina diversas reacciones químicas del organismo. INO NES INTRACELULARES
I ONES EXTRACELUL ARES
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Manual CTO de Enfermería, 5.ª edición TEMA 2
MOVILIZACIÓN Y TRASTORNOS DE LOS LÍQUIDOS CORPORALES Y SU VOLUMEN 2.1. INTRODUCCIÓN
Las membranas celulares son estructuras laminares constituidas sobre todo por proteínas y lípidos. Los lípidos formadores de membranas son fosfolípidos, glucolípidos y colesterol. Las membranas plasmáticas desempeñan funciones esenciales para la super vivencia: • Con Confier fieren en a las las célu células las ind indivi ividua dualid lidad. ad. • Con Consti stituy tuyen en barrer barreras as de permeab permeabili ilidad dad muy muy selectiv selectivas. as. • Posib Posibilitan ilitan la comun comunicaci icación ón media mediante nte sus rece receptore ptores. s. Para una mejor comprensión del movimiento de los líquidos corporales, se repasan a continuación unas nociones sobre la osmolalidad (presión osmótica) y presión oncótica.
2.1.1. Osmolalidad
La diferencia de composición iónica entre el líquido intracelular y el extracelular se mantiene gracias a la pared celular, que ejerce de membrana semipermeable. Por ejemplo, sodio y glucosa no atraviesan libremente la membrana celular entre estos dos compartimentos. Cada compartimento difiere en la concentración de solutos debido a que se dan transpor tes activos específicos. La presión osmótica definida como la suma de presiones parciales ejercidas por cada proporcional onal al número de partíuno de los solutos que aloja, generada en cada compartimento es proporci culas de soluto por unidad de volumen. Esta presión osmótica determina la distribución de agua en el espacio intracelular y el extracelular, de manera que en cada uno de ellos un soluto actuará como determinante principal de la presión osmótica, reteniendo agua. Así, el sodio es el principal osmol extracelular y el potasio, intracelular. Las proteínas plasmáticas lo son del espacio intravascular intravascular.. La osmolalidad plasmática se define pues como el número total de partículas osmóticamente activas por litro de solución, tomando la osmolalidad normal del líquido extracelular humano valores entre 280-294 mOsm/kg. La variación de la presión osmótica en un compartamiento llevará a una nueva distribución de agua. Un valor superior a 295 mOsm/kg indica que la concentración de partículas es muy elevada o que hay un contenido escaso de agua. Esta situación se llama déficit de agua. Un valor inferior a 279 mOsm/kg revela que hay muy pocos solutos para la cantidad de agua o mucha agua para la cantidad de soluto, dando lugar a una situación de exceso de agua. Se denomina presión osmótica de una solución a la suma de presiones parciales ejercidas por cada uno de los solutos que aloja, entendiendo por presión osmótica eficaz la que depende de las sustancias que no pueden atravesar los poros de la membrana semipermeable. En condiciones de normalidad, para mantener la homeostasis del organismo, las presiones osmóticas de dos compartimentos se equilibran gracias al paso libre del agua a través de la membrana semipermeable. Por esta razón, se considera que las presiones osmóticas eficaces de uno y otro compartimento son iguales. Debido a esto, la variación de la presión osmótica en alguno de los compartimentos llevará a una nueva distribución del agua entre ambos. Se exponen dos ejemplos:
1. Si aumenta la concentración concentración de sodio en el espacio extracelular, extracelular, esto conlleva un incremento incremento de
Preguntas
- EIR 10-11, 5-MQEM; 45-MQDI - EIR 09-10, 6; 44; 61 - EIR 08-09, 56 - EIR 07-08, 27 - EIR 05-06, 23 Q E 1 M
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
2.1.2. Presión oncótica
Entre los compartimentos intravascular e intersticial, es la pared del lecho vascular la que ejerce las funciones de membrana semipermeable y son las proteínas disueltas en el plasma, en este caso, las que generan la diferencia de presión entre ambos compartimentos. A la presión osmótica ejercida por las proteínas proteínas séricas séricas y, en particular, por la albúmina albúmina se denomina presión oncótica (EIR 09-10, 6). Las proteínas séricas permanecen confinadas en el interior de los capilares y son los únicos solutos que ejercen la fuerza osmótica efectiva que se opone a la salida de agua fuera de los del árbol vascular. El aumento de la presión hidrostática y/o la disminución de la presión oncótica de las proteínas séricas suponen la causa más frecuente de acumulación de líquido en el espacio intersticial (edema). Considérese el siguiente ejemplo de equilibrio de presión oncótica. Supóngase que, debido a una patología (síndrome nefrótico), los niveles de proteínas plasmáticas de una persona son más bajos de lo habitual. Esto hará que la presión oncótica del lecho vascular sea menor que la del espacio intersticial y, por tanto, será menor la “succión” de líquido que se estará realizando. Como consecuencia, se producirá un escape de líquido desde el espacio intravascular hacia el intersticial. Esto explicaría el edema que aparece en los p acientes con síndrome nefrótico. La presión oncótica es la presión osmótica ejercida por las proteínas séricas, en particular por la albúmina. El aumento de la presión hidrostática y/o la disminución de la presión oncótica de las p roteínas séricas suponen la acumulación de líquido en el espacio intersticial, es decir, edema.
2.2. EQUILIBRIO
HOMEOSTÁTICO
Para una correcta función celular es preciso que su medio interno y su medio ambiente que la rodea (medio extracelular) se mantengan con una determinada concentración constante de electrolitos. Pero esto no quiere decir en ningún caso que se trate de compartimentos estancos, sino que tal como se acaba de ver, cada uno de ellos está en continuo intercambio, siendo el resultado de ello una composición constante. Para mantener el equilibrio homeostático se deben tener en cuenta diferentes aspectos: • Desplazamiento del agua entre compartimentos: - Paso del agua entre el compartimento intracelular y el extracelular: está determinado por la concentración de las sustancias osmóticamente activas a ambos lados de la membrana celular, es decir, decir, como se ha visto ya, la osmolalidad que existe entre los compartimentos. - Paso del agua entre los compartimentos intravascular e intersticial: está determinado, entre otras, por la presión oncótica del espacio intravascular ejercida por las proteínas (recordar el ejemplo del apartado anterior). Sin embargo, a nivel de la membrana capilar son cuatro las presiones que regulan el equilibrio del líquido: ĺ Presión capilar (hidrostática): es la que ejerce el líquido del interior del capilar, en dirección hacia el exterior y en contra de la membrana. ĺ Presión del líquido intersticial (hidrostática): ejerce una fuerza similar hacia dentro, contra la membrana capilar. ĺ Presión oncótica del plasma: una atracción de las proteínas semejante a la de un imán, mantiene el líquido del espacio intravascular en el interior de los capilares. ĺ Presión oncótica del líquido intersticial: es otro imán proteico que actúa en sentido contrario, manteniendo el líquido del espacio intersticial fuera de los capilares (en un tercer espacio). •
Desplazamiento de solutos entre compartimentos: la existencia de sistemas de transporte en
las membranas celulares permite mantener las concentraciones de solutos necesarias para una correcta función celular. Algunos de estos mecanismos son los siguientes: Difusión simple: movimiento de moléculas de un área de alta concentración a otra de baja
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Manual CTO de Enfermería, 5.ª edición
son posibles mediante una combinación con proteínas transportadoras y un aporte de energía procedente del ATP. •
La regulación hormonal: - Hormona antidiurética (ADH) o vasopresina: regula la retención de agua por los riñones.
-
-
Es sintetizada como prehormona en un núcleo hipotalámico. Desde aquí emigra por los axones neuronales y se almacena en forma de gránulos secretores dentro de las terminaciones nerviosas de la hipófisis posterior o neurohipófisis. Cuando algún estímulo apropiado libera la hormona, ésta se une a receptores renales presentes en el túbulo contorneado distal y en los tubos colectores, logrando que dichos túbulos se hagan permeables al agua, potenciando de esta forma su reabsorción desde la luz tubular hacia el intersticio medular, que tendrá como consecuencia la eliminación de poca cantidad de orina (oliguria) a través del riñón. Dado que la ADH moviliza sobre todo agua libre, y no solutos, la orina eliminada bajo su influencia estará más concentrada que la que se elimina con niveles bajos de vasopresina (Figura 4). Aldosterona: es el principal mineralocorticoide de la corteza suprarrenal y, tras el estímulo oportuno, se va a liberar desde la capa glomerular de la glándula suprarrenal. Al igual que la ADH, llegará hasta receptores de los túbulos renales, pero a diferencia de ésta, que recuérdese moviliza fundamentalmente agua, la aldosterona moviliza sobre todo iones, de forma que retiene sodio y elimina potasio y protones. Los estímulos que promueven la liberación de aldosterona son varios: ĺ Hiponatremia: al liberarse la aldosterona se origina la reabsorción de sodio en los túbulos renales. ĺ Hiperpotasemia: por acción de la aldosterona se logrará la eliminación del exceso de potasio. ĺ Hipovolemia: en este caso se estimula la secreción de renina, lo que permite a su vez que mediante eje renina-angiotensina-aldosterona, se impulsa la secreción de aldosterona. Paratohormona: es una hormona hi-
percalcemiante que actúa en el organismo a diferentes niveles (Figura 5): ĺ Intestino: a través de la vitamina D favorece la absorción de calcio y fósforo. ĺ Hueso: ayuda a la reabsorción ósea, es decir, disminuye el calcio del hueso para aumentar su con-
Q E 1 M
Figura 4. Influencia hormonal en el movimiento de líquidos
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
•
Los órganos que participan en el equilibrio homeostático son los siguientes: - Riñón: es el principal regulador. - Pulmones: a través de la respiración hay una pérdida insensible de agua. - Corazón y vasos sanguíneos: incluye al sistema linfático que, dada su importante participa-
-
ción en la formación del edema, merece mención aparte. El factor natriurético atrial es una hormona liberada por la aurícula en respuesta a la elevación de la presión auricular (aumento de volumen), su acción es la vasodilatación y la eliminación urinaria de sodio y agua para disminuir el volumen sanguíneo. Gastrointestinal: el tubo digestivo representa la mayor parte de los ingresos hídricos. Una mínima parte de agua se elimina con las heces.
El equilibrio homeostático se mantiene por varios mecanismos: 1, desplazamiento del agua entre compartimentos; 2, desplazamiento de solutos entre compartimentos; 3, participación de riñón, pulmón, corazón y vasos.
2.3. EL
TERCER ESP E SPACIO ACIO Y EL EDEMA
2.3.1. El sistema linfático
Recuerda Linfa: líquido compuesto de glóbulos blancos y líquido proveniente del intestino. El sistema linfático recoge líquido del espacio intersticial y lo realoja en el extremo capilar para ser llevado al corazón.
El sistema linfático está integrado por una red de órganos, ganglios linfáticos, conductos y vasos linfáticos que producen y transportan linfa desde los tejidos hasta el torrente sanguíneo. La linfa es un líquido entre transparente y blanquecino compuesto de: • Líquido proveniente de los intestinos (quilo) que contiene proteínas y grasa. • Glóbulos blancos, en especial linfocitos. En condiciones de normalidad, la presión en el extremo ar terial del capilar es casi tres veces superior a la que existe en el extremo venoso. El mantenimiento de esta diferencia de presión es la clave fundamental para el movimiento de los líquidos a través de la pared capilar (Figura 6). El líquido que llega hasta el extremo capilar abandona el lecho vascular por el extremo arterial y vuelve a entrar en él a nivel del extremo venoso por su reabsorción. Dado que la fuerza neta de salida es superior a la de entrada, un 10% del líquido filtrado en el extremo arterial no se reabsorbe en el extremo venoso. Si esto se mantuviese indefinidamente sin corrección, con el tiempo, el espacio intersticial quedaría sobrecargado de líquido. Para solucionar este problema, el sistema linfático es capaz de recoger este 10% restante, además de realojar otras otras moléculas demasiado grandes y ciertas proteínas. Una vez recogido en el sistema linfático, éste lo devolverá al extremo capilar y de aquí hasta el corazón. Cuando por alguna razón este juego de presiones se altera y el 10% habitualmente rescatado deja de serlo, se va acumulando líquido en el espacio intersticial que no se logra evacuar. El resultado final es la aparición del edema. Las situaciones que pueden dar lugar a una presión anormalmente alta del líquido intersticial son: • Presión capilar elevada: la fuerza hidrostática elevada del capilar empuja en el extremo capilar más líquido hacia el exterior del que es capaz de recoger el el extremo venoso. El líquido sobrante aumentará la presión del líquido intersticial que, con el tiempo, dará lugar al edema. Este fenómeno ocurre en la trombosis, la fl ebitis, las varices y en la insuficiencia cardíaca. • Disminución de proteínas plasmáticas: que hace que baje la presión oncótica que realizan las proteínas, de manera que va a ser superada por la presión capilar. El resultado es que el líquido fluye fuera del capilar, pero no pu ede ser reabsorbido. Este fenómeno sucede en la desnutrición, en la cirrosis o en el síndrome nefrótico. • Alteración del sistema linfático: en este caso, la linfa se acumulará en tejidos localizados, provocando un edema también localizado. Este fenómeno tiene lugar en procesos infecciosos, inflamatorios y tras la linfadenectomía de u na zona concreta. • Aumento de la permeabilidad capilar: si los capilares son demasiado permeables, permitirán que las proteínas se escapen a través de sus poros, lo que llevará a una disminución de la presión
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Manual CTO de Enfermería, 5.ª edición
Q E 1 M
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
Recuerda
•
El edema es un exceso de líquido en los tejidos del organismo. Puede ser intracelular o extracelular extracelular..
•
Fase de pérdida: aparece de forma inmediata tras un traumatismo o una intervención quirúrgi-
ca, pudiendo oscilar su duración entre 48-72 h. Durante esta fase se producirá un aumento de la permeabilidad capilar, que, como se ha dicho antes, permitirá la fuga de proteínas, que a su vez llevará al desplazamiento del líquido desde el espacio vascular al intersticial. En esos momentos se está produciendo una fuga masiva del líquido hacia espacios hísticos (tercer espacio), donde queda atrapado, motivo por el cual, a pesar de intentar una reposición de la volemia con líquidos intravenosos, éstos tampoco permanecen en el lecho vascular. A causa del aumento del líquido en los tejidos, el paciente presentará un transitorio aumento de peso. En esta fase, lo más importante es la reposición adecuada de proteínas plasmáticas (líquidos coloides) y los dos objetivos principales son prevenir la hipovolemia y la insuficiencia renal. Fase de reabsorción: comienza cuando ceden el traumatismo y la inflamación. Al ir cicatrizando los tejidos que habían sido lesionados, los capilares se reparan y se normaliza entonces su permeabilidad. Además vuelve a retomar su correcto funcionamiento el sistema linfático y, finalmente, la concentración de proteínas plasmáticas también se regulariza. Esto permite restablecer las presiones capilares y retomar una filtración y reabsorción del líquido capilar normal. Todos estos cambios logran que el líquido que antes se encontraba en los tejidos ( tercer espacio) vuelva al compartimento vascular y sea excretado por el riñón. El paso al tercer espacio es el desplazamiento de líquido desde el espacio vascular al intersticial.
2.3.2. El edema
El edema se puede definir como un exceso de líquido en los tejidos del organismo. En general, hace referencia, sobre todo, a líquido aumentado en el espacio extracelular, pero el líquido en exceso también puede acumularse en el interior de las células. Etiología Se diferencias dos tipos de edema: • Edema intracelular ocasionado por: - Nutrición celular insuficiente y/o disminución de la actividad de los sistemas metabólicos tisulares: cuando un tejido está poco perfundido, la cantidad de nutrientes y de oxígeno que le llega es insuficiente para mantener su metabolismo correcto, se alteran los sistemas de transportes iónicos de membrana, entre ellos la bomba de sodio, que no puede expulsar con normalidad el sodio filtrado al interior. Esto conlleva un aumento del sodio intracelular, que por fenómeno osmótico arrastrará agua al interior celular, ocasionando edema celular. El volumen celular normal puede incrementarse hasta dos o tres veces, siendo este aumento frecuentemente el preludio de muerte tisular. - Inflamación tisular: la inflamación altera la permeabilidad de la membrana celular, aumentándola y permitiendo que el sodio y otros iones difundan al interior de las células. Una vez que el sodio ha difundido al esp acio intracelular, intracelular, por fenómenos osmóticos el agua no tardará en difundir igualmente al interior de la célula. •
Edema tisular o extracelular: es el exceso de acumulación de líquidos en los espacios extrace-
lulares (Tabla 4). - Edema causado por la retención de sodio: entre las posibles causas están las siguientes: ĺ Reabsorción excesiva: tal es el caso de la insuficiencia cardíaca o la cirrosis. En la insuficiencia cardíaca el corazón no bombea bien la sangre, lo que acrecienta la presión venosa y capilar, aumentándose la filtración capilar. En la cirrosis se desarrollan grandes cantida-
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Manual CTO de Enfermería, 5.ª edición
ĺ
Efecto secundario de algunos fármacos: varios tipos de corticoides, algunos antiinfla-
matorios, etc. ĺ ĺ
Desnutrición: en aquellos casos en los que la dieta no cubre las necesidades proteicas
del individuo (hipoproteinemia), disminuye la presión oncótica del lecho vascular, provocándose el desplazamiento del líquido desde el lecho vascular hacia los tejidos. Obstrucción linfática: cuando se produce el edema puede ser especialmente intenso porque no hay otra forma de extraer las proteínas plasmáticas que salen al intersticio. El aumento de concentración de proteínas hace que se evacúe más líquido al exterior de los capilares. El bloqueo de vasos linfáticos puede producirse en ciertos tipos de cáncer o después de una cirugía en la que se eliminen u obstruyan vasos linfáticos. Retención renal excesiva de sal y agua: · Insuficiencia renal renal aguda o crónica · Exceso de mineralcortic mineralcorticoides oides
Aumento de la presión capilar
Presión venosa alta y constricció constricción n venosa: · Insuficiencia cardíaca · Obstrucción venosa · Fallos de las bombas venosas Reducción de la resistencia alveolar: · Calor corporal excesivo · Insuficiencia del sistema sistema nervioso simpático simpático · Fármacos Fárma cos vasodilat vasodilatadores adores Pérdida de proteínas en la orina (síndrome nefrótico)
Reducción de las proteínas plasmáticas
Pérdida de proteínas en zonas desprovistas de piel: · Quemaduras · Heridas Síntesis insuficiente de proteín proteínas: as: · Hepatopatías · Malnutrici Malnutrición ón proteica o calórica grave Reacciones inmunitarias que provocan la liberación de histamina Toxinas
Aumento de la permeabilidad capilar
Infecciones bacterianas Deficiencias de vitaminas en especial vitamina C Isquemia prologada Quemaduras Cáncer
Bloqueo del drenaje linfático
Cirugía Infecciones Falta o anomalía congénita de vasos linfáticos
Tabla 4. Resumen de las causas del edema extracelular
Patogenia Los edemas alteran el balance de presiones del equilibrio homeostático (presiones hidrostáticas y
Recuerda Los edemas alteran el balance de presiones, aumentando el agua en el lecho vascular por aumento de sodio en el mismo, esto hace que la presión capilar sea mayor lo que hará salir el líquido al exterior acumulándose en los tejidos.
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
Recuerda Principios de enfermería en edemas: re poso en cama con elevación de miembros inferiores, restricción de líquidos, dieta hiposódica y diuréticos.
No obstante, hay algunos principios fundamentales que pueden aplicarse en los casos de edemas generalizados: • Reposo en cama con elevación de los miembros inferiores: se deben además utilizar medias elásticas para favorecer el retorno venoso. Estas medidas que sirven para favorecer el retorno venoso logran inhibir al SRAA, facilitando así una mayor excreción de sodio. • Restricción de líquidos. • Dieta hiposódica: para favorecer el balance negativo de sodio. • Diuréticos: facilitan la eliminación de sodio por la orina y además, al aumentar la diuresis, disminuye el volumen intravascular y con ello la presión hidrostática capilar, lo que permite el paso del líquido intersticial hacia el compartimento vascular.
2.4. ALTERACIONES
DEL VOLUMEN EXTRACELULAR
Las alteraciones de volumen en los compartimentos corporales pueden tener lugar tanto por defecto (deshidratación) como por exceso (hiperhidratación). Cuando no se realiza ninguna aclaración adicional, la deshidratación y la hiperhidratación se refieren a los cambios del volumen extracelular.
extracelular.. Deshidratación 2.4.1. Depleción de volumen extracelular La deshidratación es la pérdida de agua y electrolitos. Según la concentración de sodio en el agua perdida por el organismo respecto a la concentración plasmática normal (140 mEq/l), la deshidratación puede ser: • Deshidratación isotónica: se pierde igual cantidad de agua que de iones, por lo que la osmolalidad final se mantiene igual: - Con Concen centra tració ción n sodio sodio séric sérico o de 130 130 a 150 150 mEq/l mEq/l.. - Bal Balanc ancee hid hidroe roelec lectro trolít lítico ico neu neutro tro.. - En la deshidra deshidratación tación isotón isotónica ica hay hay disminución disminución de de líquido líquido y, por tanto, tanto, hipov hipovolemia olemia..
Recuerda La deshidratación es la pérdida de agua y electrolitos. Tipos: pérdida de agua que que · Isotónica: igual pérdida de iones. · Hipotónica: más pérdida de iones iones que de líquido. · Hipotónica: más pérdida de líquido que de iones.
•
Deshidratación hipotónica: se pierde menos agua que de iones, de modo que la concentración
plasmática disminuye: - Con Concen centra tració ción n de sodio sodio séri sérico co menor menor de de 130 mEq/ mEq/l.l. - Edemas. •
Deshidratación hipertónica: se pierde más cantidad de líquidos que de iones, por lo que la con-
centración plasmática sube. - Con Concen centra tració ción n de sodio sodio séri sérico co mayor mayor de de 150 mEq/ mEq/l.l. - Dé Défic ficit it de ag agua ua lilibr bre. e. Causas Se citan tres causas posibles de la deshidratación (Figura 7) (EIR 10-11, 45-MQDI): • Deshidratación isotónica: su principal causa son las hemorragias de cualquier origen. Este tipo de deshidratación no se acompaña de cambios en la osmolalidad plasmática ni en el volumen
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Manual CTO de Enfermería, 5.ª edición
-
Causas extrarrenales: ĺ Hiperhidrosis (sudoración excesiva): el sudor es hipotónico. ĺ Pérdidas pulmonares: pérdida importante de agua, sobre todo en situaciones de hiper-
ventilación y traqueostomía. Ante una pérdida relativamente rica en agua, aparece una situación de hipertonicidad plasmática. La mayor tonicidad extracelular provocará una salida de agua del interior de la célula con deshidratación celular. celular. Debido a la salida s alida de agua intracelular existirá una mitigación de la deple ción de volumen extracelular.
Figura 7. Efecto de los diferentes tipos de deshidratación sobre las células EIR 10-11, 5-MQEM
Clínica (EIR 07-08, 27) La clínica de la deshidratación está caracterizada por: • Seq Sequed uedad ad de mucosa mucosass y signo signo del pliegu plieguee (turgen (turgencia cia de la la piel) piel) (EIR 05-06, 23). • Se Sed d más más o men menos os in inte tens nsa. a. • Hipote Hipotensión nsión,, consecuenc consecuencia ia de la hipovol hipovolemia emia que se se produce, produce, será más más marcada marcada en las deshideshidrataciones isotónicas y las hipotónicas. En las des hidrataciones hipertónicas, la entrada de agua procedente del espacio intracelular hace que la repercusión hemodinámica sea menor. • Manif Manifestac estaciones iones del sistema sistema nervioso nervioso central central (SNC): la deshidrat deshidratación ación intrac intracelular elular se manifest manifestará ará en forma de sed intensa, letargia e incluso coma; y en la hiperhidratación celular aparecerá cefalea, convulsiones y coma.
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
Recuerda Hiperhidratación: retención extracelular de agua y sodio. Puede llevar al aumento de la volemia y a edema.
Ante pérdidas hidrosalinas moderadas puede ser suficiente una ingesta oral adecuada. Si las pérdidas son más graves, será necesaria la administración parenteral de sueroterapia. Los sueros más utilizados son el Ringer con lactato o el suero fisiológico al 0,9%. Cuidados de enfermería La primera actuación del profesional enfermero será la prevención. Las intervenciones necesarias son los siguientes: • Ident Identificar ificar al pacient pacientee con riesgo riesgo potencia potenciall de padecer padecer una deshidra deshidratació tación n o déficit déficit de volumen. volumen. • Adopta Adoptarr las medidas medidas oportunas oportunas para para evitar evitar que ese problema problema potenc potencial ial se convie convierta rta en real, real, minimizando las pérdidas de líquidos (diarreas, vómitos, aspirados gástricos, etc.). • Corr Corregir egir ese déficit déficit reponien reponiendo do líquidos líquidos y solutos, solutos, cuando cuando el problema problema ya esté esté instaurado instaurado,, a ser posible vía oral, aportando pequeños volúmenes de líquidos a intervalos frecuentes, en lugar de grandes volúmenes de una sola vez. • Conv Convenir enir con con el facultativ facultativo o responsable responsable (en caso caso de deshidrat deshidratación ación grav gravee y cuando el pacien paciente te no pueda ingerir líquidos v.o.) la restauración vía enteral o parenteral, eligiendo las soluciones más adecuadas, dependiendo del tipo de pérdidas (isotónicas, hipotónicas o hipertónicas). 2.4.2. Aumento del volumen extracelular. Hiperhidratación
La hiperhidratación se debe a una retención de agua y sodio en el medio extracelular, lo que produce una gran expansión del Volumen Extracelular (VEC). Puede conducir a hipervolemia (aumento del volumen sanguíneo), y a edema (exceso de líquido en el espacio intersticial). Esta expansión del VEC puede ser de dos tipos: • Co Con n ed edem emas as ge gene nera raliliza zado dos. s. • Sin edemas. Expansión del VEC con edemas generalizados Los edemas generalizados son una acumulación excesiva de agua en el espacio intersticial asociada a una retención renal de sodio. Existe una presión osmótica extracelular incrementada que hace que
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Manual CTO de Enfermería, 5.ª edición
Expansión del VEC sin edemas Existen situaciones con expansión del VEC y del volumen circulante eficaz que cursan característicamente sin edemas. 1. Etiología • Hiperaldosteronismo primario acompañado: de hipertensión arterial, tendencia a la hiperna-
•
tremia e hipopotasemia y ausencia de edemas. Síndrome de secreción inadecuada de ADH (SIADH): no hay hipertensión y es característica la hiponatremia.
Cuidados de enfermería
Los cuidados de enfermería deberán contemplar los siguientes aspectos: • Identi Identificar ficar y preveni prevenirr a los pacientes pacientes susceptibl susceptibles es de padecer padecer exceso exceso de volumen, volumen, instaur instaurando ando dieta hiposódica o asódica (eliminando sal de mesa). • Pauta Pautarr restricc restricción ión de de líquidos, líquidos, ya sea vía oral oral o vía endov endovenosa enosa.. • Acon Aconsejar sejar repos reposo, o, ya que favore favorece ce la diure diuresis sis del del líquido líquido del edema. • Det Determ ermina inarr el uso de diur diuréti éticos cos seg según ún inindicación, para favorecer la disminución del edema sistémico.
2.5. BALANCE
HÍDRICO
Tanto el agua como los solutos están en contiTanto nuo intercambio con el medio ambiente. En condiciones de normalidad existe un equilibrio constante (o balance) entre las ingestas y las pérdidas hidroelectrolíticas (Tabla 5). Las entradas de agua diarias en un individuo normal proceden de: • Ing Ingest estaa libre libre de agua agua:: entre entre 1.0 1.00000-1.3 1.300 00 ml.
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
Se pueden presentar situaciones que aumenten la cantidad de agua perdida: • Hiperventilación: se pierde 1 ml/h por cada respiración. • Fiebre: se pierde 6 ml/h por cada grado de temperatura por encima de los 37 ºC. • Sudoración: que puede ser: - Abu bun nda dan nte te:: 20 20 ml/ ml/h. h. - Pro roffus usa: a: 20 ml ml/h /h.. Otras pérdidas variables deben contabilizarse en: vómitos, eliminación gástrica, diarrea, drenajes, fístulas y quemaduras. Las pérdidas ocurridas en el acto quirúrgico son las siguientes: • Evaporación de líquido: al exponer la cavidad peritoneal o resección de segmentos del tubo gastrointestinal. • Intervenciones menores: 400-600 ml/h. • Intervenciones mayores: 800-900 ml/h. Los pacientes de riesgo se identifican con: • Posoperados. • Qu Quem emad ados os y po polilitr trau auma mati tiza zado dos. s. • En Enffer ermo moss crón crónic icos os.. • Co Con n infu infusi sion ones es int intra rave veno nosa sas. s. • Co Con n son sonda dass o dr dren enaj ajes es.. • Con fár fármac macos os diu diurét rético icoss o est estero eroide ides. s. • Ancianos. • Pac acie ient ntees en en com coma. a.
Preguntas
- EIR 10-11, 5 - EIR 09-10, 28; 45 - EIR 07-08, 107 - EIR 01-02, 31
TEMA 3
IONES CORPORALES Y SUS DESEQUILIBRIOS En la Tabla Tabla 6 se muestran los valores normales de las concentraciones de iones en el organismo.
Na+
PLASMA (mOsm/l H2O)
INTERSTICIAL (mOsm/l H2O)
INTRACELULAR (mOsm/l H2O)
142
139
14
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Manual CTO de Enfermería, 5.ª edición
3.1. SODIO
Na+
El sodio es el catión más abundante del compartimento extracelular, es más, constituye casi el 90% del total de cationes, oscilando su concentración plasmática normal entre 135-145 mEq/l. Es el encargado de la distribución del agua corporal y del volumen extracelular. También participa en la transmisión de impulsos nerviosos, en la contracción muscular y en el equilibrio ácido-base. 3.1.1. Hiponatremia plasmática de sodio menor de 135 mEq/l. La hipoLa hiponatremia se define como una concentración plasmática natremia causa hipoosmolalidad con movimiento de agua hacia las células. Las manifestaciones a las que da lugar van a depender del modo en que s e produzca. Así, si se presenta de forma aguda, la clínica será manifiesta, mientras que si ocurre de forma crónica, los mecanismos adaptativos tienden a minimizar las manifestaciones.
Se observa hiponatremia en el 4,5% de los pacientes de edad avanzada hospitalizados y en el 1% de los pacientes posoperados. Es particularmente frecuente en el SIDA. La mortalidad de los pacientes hiponatrémicos es más del doble que la de los enfermos que tienen concentraciones normales de sodio en el plasma. Etiología y clasificación •
Hiponatremia con volumen extracelular disminuido: en este tipo de hiponatremia existe un
déficit mixto de sodio y de agua, pero predomina la pérdida de sodio. Sus causas pueden ser: - Extrarrenales: concentración de Na + menor de 10-20 mEq/l. Pueden ser pérdidas por causas: ĺ Gastrointestinales: vómitos, diarreas, fístulas, obstrucción. ĺ Cutáneas: quemaduras, hipersudoración. ĺ A un tercer espacio: peritonitis, pancreatitis. -
Renales: concentración de Na + mayor de 20-40 mEq/l. Se diferencian entre sus causas las
siguientes: ĺ Abuso de diuréticos: es la situación más frecuente de hiponatremia asociada a hipovolemia. ĺ Nefropatía perdedora de sal: en esta situación, hay una incapacidad renal para ahorrar
Recuerda El sodio es el catión extracelular más abundante. Concentración plasmática: 135-145 mEq/l.
Q E 1 M
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
•
•
Hiponatremia hipotónica: en la hiponatremia verdadera o hipotónica hay un aumento del agua
libre respecto al sodio en los líquidos extracelulares, pero esto no representa necesariamente un aumento de volumen de los líquidos extracelulares. El volumen extracelular puede ser bajo, normal o elevado en los pacientes con hiponatremia. Hiponatremia sintomática: la principal complicación de la hiponatremia es la encefalopatía metabólica, que se debe a edema cerebral con aumento de la presión intracraneal. Puede acompañarse de síndrome de distrés respiratorio agudo. Existe otra encefalopatía asociada con el tratamiento de la hiponatremia, en especial cuando se corrige ésta con demasiada rapidez. Se caracteriza por lesiones desmielinizantes difusas y puede acompañarse de lesiones hipofisarias y parálisis de los nervios oculomotores.
Clínica Las manifestaciones dependen del grado de hiponatremia y de la rapidez de instauración. Cuando la natremia se sitúa por debajo de 120 mEq/l, aparecen sobre todo manifestaciones neurológicas como expresión del edema cerebral: cefalea, letargia, convulsiones y coma. Las m anifestaciones gastrointestinales de anorexia y náuseas son más precoces, pero inespecíficas. Debido a su par ticipación en la transmisión de impulsos nerviosos y en la contracción muscular, su déficit puede dar calambres musculares y agotamiento. Tratamiento El paso fundamental previo al tratamiento es un adecuado diagnóstico etiológico. Ante situaciones neurológicas graves por hiponatremias intensas, deberá aumentarse con rapidez (dentro de unos límites) la osmolalidad plasmática con soluciones hiper tónicas. • En las hiponatr hiponatremias emias con con volumen volumen extracelula extracelularr disminuido disminuido se deben deben administrar administrar solucio soluciones nes salinas isotónicas. • Las hiponatr hiponatremias emias con con volumen volumen extracelu extracelular lar normal normal o mínimamen mínimamente te aumentado aumentado se tratan tratan con con restricción hídrica. • Las hiponatr hiponatremias emias con con volumen volumen extracelu extracelular lar aumentad aumentado o y edemas se tratan tratan con restric restricción ción de líquidos y de sal, así como con administración de diuréticos. Para limitar el riesgo de encefalopatía desmielinizante, la tasa de ascenso del sodio plasmático no debe ser superior a 0,5 mEq/l/h y su concentración final no ha de exceder los 130 mEq/l.
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Manual CTO de Enfermería, 5.ª edición
3.1.2. Hipernatremia La hipernatremia consiste en un incremento de la concentración de sodio por encima de 150 mEq/l. • Hipernatremia por pérdida de agua superior a la de sodio: existe una pérdida mixta de agua
y sodio, pero con predominio de la pérdida de agua. Estos pacientes presentan signos propios de hipovolemia con hipotensión, taquicardia y sequedad de piel y mucosas. Puede deberse a: - Pér Pérdidas didas hipotón hipotónicas icas extrarr extrarrenale enaless a través través de la piel, durant durantee una sudación sudación copiosa copiosa en amambiente húmedo y caliente y por diarreas acuosas, especialmente diarreas infantiles. - Pér Pérdidas didas hipotó hipotónicas nicas a través través del del riñón riñón durante durante una una diuresis diuresis osmótic osmótica. a. - La pérdida pérdida de cualquiera cualquiera de de los líquidos líquidos corporales corporales (orina, (orina, diarrea diarrea,, secreciones secreciones gástrica gástricas, s, sudor, diuresis por durosemida) provoca hipernatremia. •
Hipernatremia por pérdida exclusiva de agua: la pérdida de agua sin sal raramente conduce a
situaciones de hipovolemia clínica. La hipernatremia progresiva crea un gradiente osmótico que induce el paso de agua desde el espacio intracelular al extracelular, con lo que la hipovolemia queda minimizada. Esta situación puede deberse a: - Pér Pérdidas didas extrarre extrarrenales nales a través través de la piel y la respira respiración ción durante durante estados estados hipercat hipercatabóli abólicos cos o febriles que coincidan con un aporte insuficiente de agua. - Pér Pérdidas didas renales renales de agua agua que se dan dan en la diabetes diabetes insípida insípida centra centrall y en la nefrogéni nefrogénica. ca. •
Hipernatremia con balance positivo de sodio: se da un exceso de sodio. Excepto la moderada
hipernatremia que producen los síndromes con exceso de aldosterona (hiperaldosteronismo primario), la mayoría de los casos son yatrogénicos. En este último grupo se encuentran la administración de cantidades excesivas de bicarbonato de sodio, las dietas y la sueroterapia
Recuerda Causas de hipernatremia: mayor pérdida de agua que de sodio, pérdida exclusiva de agua y balance positivo de sodio. Q E 1 M
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
influye en la distribución transcelular del potasio: en la acidosis, el potasio pasa al medio extracelular, y en la alcalosis, el potasio entra en la célula. La regulación del balance externo del potasio se efectúa principalmente por eliminación renal. El potasio se filtra por el glomérulo y alrededor del 30-50% se reabsorbe en el túbulo proximal, pero son los segmentos terminales los que regulan la cantidad de potasio que aparecerá en la orina. La secreción distal de potasio estará regulada por la ingesta del potasio en la dieta, el aporte de sodio al túbulo distal con el cual se intercambia y la acción de la aldosterona. En cuanto a las funciones del potasio, su efecto fisiológico más importante es la influencia sobre los mecanismos de activación de los tejidos excitables, como son el corazón, el músculo es quelético y el músculo liso (EIR 09-10, 28). 3.2.1. Hipopotasemia
Recuerda
El potasio es el electrolito elec trolito intracelular principal. La concentración sérica normal es de 3,5 a 5 mEq/l.
Las manifestaciones clínicas de la hi popotasemia están relacionadas con el sistema neuromuscular.
Etiología En la hipopotasemia, la concentración sérica de potasio es inferior a 3,5 mEq/l. Los motivos de la hipopotasemia pueden ser los siguientes: Desplazamiento transcelular: por tratamiento con β-agonistas broncodilatadores inhalados
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Manual CTO de Enfermería, 5.ª edición
Cuidados de enfermería Se procederá de la siguiente manera: • Prevenir la aparición del déficit de potasio e identificarlo con prontitud, como principal tratamiento. • Colabo Colaborar rar en la correc corrección ción sin peligr peligro o ni riesgos, riesgos, si ya está instaura instaurado do el déficit, déficit, en prevenció prevención n de problemas graves en la función cardíaca y respiratoria. • Aume Aumentar ntar la ingesta ingesta de potasio potasio adiciona adicionall (sales de potasio), potasio), a ser posible posible versión versión origina original.l. Si la administración es endovenosa, prestar mucha atención a la concentración de la dilución y la velocidad de administración. administración. NUNCA administrar potasio sin diluir y de forma rápida debido al peligro de paro cardíaco.
Q E 1 M
3.2.2. Hiperpotasemia
En primer lugar, ante una hiperpotasemia, hay que descartar que no se trate de una pseudohiperpotasemia. La pseudohiperpotasemia se define como la liberación de potasio por hemólisis traumática durante la punción venosa que que puede producir producir una falsa falsa elevación de de sus niveles séricos. séricos.
La liberación de potasio a partir de los músculos distales a un torniquete puede ser también causa de falsas hiperpotasemias.
Recuerda La clínica de la hipopotasemia se caracteriza por alteraciones musculares y cardíacas.
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
• • • •
Eliminar Elimi nar de la dieta dieta alimento alimentoss con alto alto contenido contenido en en potasio potasio (café, (café, cacao, cacao, frutos frutos secos, secos, plátanos, etc.), así como los medicamentos que contienen potasio (diuréticos ahorradores de potasio). Constatar Const atar que los los valores valores obtenidos obtenidos son correct correctos os y no producto producto de una extrac extracción ción inadecu inadecuada: ada: torniquete demasiado apretado y durante largo tiempo, extracción de vía venosa por la que se esté infundiendo K +. Administrar Admin istrar el tratamien tratamiento to de colaboraci colaboración, ón, resinas resinas intercambia intercambiadoras doras,, insulina, insulina, gluconato gluconato de calcio, diálisis, etc. Efectuar monitoriza monitorización ción cardíaca cardíaca para detectar posibles arritmias y efectos efectos del tratamiento.
3.3. CALCIO
Recuerda El calcio es el catión extracelular presente en tres formas diferentes: unidos a proteínas, formando parte del comple jos y en forma de forma de iones libres que es la forma activa del mismo.
Ca2+
El calcio existe en el plasma en tres formas diferentes, una gran parte se haya unido a proteínas, fundamentalmente albúmina, otra está formando parte de complejos (citrato, fosfato o carbonato) y el resto se encuentra en forma de iones libres (calcio iónico). Este último es el único biológicamente activo. Un dato importante es el hecho de que el calcio iónico puede variar de forma independiente al calcio total. Así, en la alcalosis, que aumenta la fijación del calcio iónico a las proteínas, disminuye la proporción de calcio libre circulante, pudiendo aparecer en esta circunstancia clínica tetania, a pesar de una medición de calcio total normal.
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Manual CTO de Enfermería, 5.ª edición
Clínica Hiperreflexia, calambres musculares: la tetania por irritabilidad neuromuscular es el signo clínico fundamental. La tetania latente se puede poner de manifiesto mediante dos maniobras: • Signo de Chvostek: se estimula ligeramente la zona del nervio facial, con lo que se produce una contracción de los músculos faciales (Figura 12). • Signo de Trousseau: se infla el manguito de presión por encima de la tensión arterial sistólica y se produce un espasmo carpal (Figura 13) (EIR 07-08, 107). Otros síntomas: • Ado Adorme rmecim cimien iento to alr alrede ededor dor de la boc boca. a. Hormigueo. • Es Espa pasm smo o lar larín ínge geo o. • En sit situac uación ión de hip hipoca ocalce lcemia mia sev severa era se pueden dar convulsiones, psicosis o demencia. • En el sist sistema ema car cardio diovas vascul cular ar pued puedee apaaparecer una disminución de la contractilidad miocárdica, que es posible que
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
Clínica
Recuerda Síndrome de Trousseau: se realiza hinchando el manguito de presión por encima de la tensión arterial sistólica y se produce un espasmo carpal. carpal.
El exceso de calcio bloquea el efecto del sodio en el músculo esquelético, con lo que se reduce la excitabilidad de ambos, músculos y nervios. Las manifestaciones de la hipercalcemia dependen del nivel de calcio sérico y de la enfermedad de base. Es posible encontrar un paciente totalmente asintomático y que el hallazgo sea casual. Letargia, debilidad, disminución de los reflejos, confusión, anorexia, náuseas, vómitos, dolor óseo, fracturas, poliuria, deshidratación. Por otro lado, hay crisis hipercalcémica, caracterizada por una hipercalcemia severa, insuficiencia renal y obnubilación progresiva, y si no se trata, puede complicarse con insuficiencia renal aguda oligúrica, estupor, coma y arritmias ventriculares. En los estados hipercalcémicos crónicos se producen calcificaciones en diferentes tejidos.
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Manual CTO de Enfermería, 5.ª edición
Clínica • • • •
En alguno algunoss enfermo enfermoss no se dan dan manif manifestaci estaciones ones clíni clínicas. cas. Cuando Cuand o aparecen aparecen síntomas síntomas,, éstos se localiza localizan n principalme principalmente nte en el sistema sistema neuromus neuromuscular cular con con astenia, hiperexcitabilidad muscular con fasciculaciones, mioclonías o tetania. También Tambi én puede puede existir existir encefalopat encefalopatía ía metabólica metabólica con desorientac desorientación, ión, convulsion convulsiones es y obnubilación obnubilación.. A nivel nivel cardíaco cardíaco se se puede manife manifestar star como como arritmias arritmias ventri ventricular culares es graves. graves.
Tratamiento El tratamiento consiste en administrar una sal magnésica por vía parenteral. La más usada es el sulfato de magnesio.
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
3.5. FÓSFORO
P
El fósforo del organismo se encuentra fijado al oxígeno, por lo que normalmente se suele hablar de fosfato (PO43-). El fosfato intracelular es el sustrato para la formación de los enlaces energéticos del ATP, ATP, es un componente importante de los fosfolípidos de las membranas celulares e interviene en la regulación del calcio intracelular. Actúa como intermediario en el metabolismo de los hidratos de carbono, proteínas y grasas. La concentración de fosfato sérico se regula a nivel renal. 3.5.1. Hipofosfatemia
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Manual CTO de Enfermería, 5.ª edición
Cuando los depósitos se crean en el corazón, puede aparecer paro cardíaco. Tratamiento En situaciones agudas, cuando el paciente tiene una función renal normal, se realiza una hidratación forzada y diuréticos de acción a nivel de túbulo proximal (acetazolamida) para favorecer la eliminación urinaria de fosfato. Si existe insuficiencia renal, se tendrá que recurrir a la diálisis.
La hiperfosfatemia crónica se trata con dieta pobre en fosfatos y quelantes intestinales, como el hidróxido de aluminio.
Recuerda El pH refleja la concentración de hidrogeniones de una solución. El aumento de H + produce acidez y la disminución alcalinidad.
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Enfermería medicoquirúrgica 1:
PARÁMETRO
Piel
Equilibrio hidroelectrolítico
VARIACIÓN
· · · ·
Fría Seca y sin elasticidad > 5 s relleno capilar Ruborizadas
· Caliente y húmeda, pálida y con edema · Brillante, hinchada y tirante Mucosas
Sed
· Oral seca · Lengua seca y pergaminosa
Presente
PROBL EMA
Disminución del volumen de líquidos y deshidratació deshidratación n
Exceso de líquido extracelular · Disminución Disminución del volumen de líquidos · Hipercalcemia · Hipermagnesemia · Exceso o déficit de volumen de líquidos · Hipercalcemia
POSIB LES DIAGNÓSTICO S
· Riesgo de déficit déficit en el volumen volumen de líquidos · Déficit de volumen volumen de líquidos líquidos · Deterioro potencial de la integridad cutánea · Exceso del volumen de líquidos · Deterioro potencial de la integridad cutánea · Déficit del volumen de líquidos · Riesgo de alteración de la mucosa oral · Alteración de la mucosa oral · Exceso de volumen de líquidos · Déficit de volumen volumen de líquidos líquidos
POSIBLES INTERVENCI ONES
· · · ·
Control de líquidos/electr líquidos/electrolitos olitos Punción intravenosa Actuación ante la hipovolemia Terapia intravenosa
· Vigilancia de la piel · Cambio de posición · Precauciones circulatorias · Mantenimiento Mantenimiento de la la salud salud bucal bucal · Restablecimi Restablecimiento ento de la salud bucal · Vigilancia periódica de los signos vitales · Actuación ante la hipovolemia
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Manual CTO de Enfermería, 5.ª edición
3.7. SUEROTERAPIA
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
Una de las principales tareas homeostáticas del organismo va dirigida al mantenimiento de valores esta-
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Manual CTO de Enfermería, 5.ª edición
La extracción de la gasometría arterial s e practica de la siguiente manera:
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Enfermería medicoquirúrgica 1:
Equilibrio hidroelectrolítico
cloro. La compensación no es total, ya que el pH no recupera valores normales excepto en trastor-
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Manual CTO de Enfermería, 5.ª edición
Suministrar Sumin istrar una una dieta dieta baja en en carbohidra carbohidratos tos y alta alta en grasas grasas (alimenta (alimentación ción de cuidado cuidadoss pulmonapulmona-
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