Priority Interventions

adults
health
problems
nursing interventions guide
Guia dIntervencions dInfermeria a Problemes de Salut EAP Can Bou
Castelldefels Agents de Salut (CASAP)

Av. Ciutat de Mlaga, 18-20
08860 Castelldefels (Barcelona)
Translation by Clara Mart Aguasca
Nursing Interventions Guide to Health Problems - Can Bou EAP
index
Authors and contributors ............................................................................................................................................ 7
Presentation.................................................................................................................................................................. 9
11
Introduction ................................................................................................................................................................ 11
Commitment letter .................................................................................................................................................... 13
Circuit care demands............................................................................................................................................... 15
Acute health problems
Oral thrush ............................................................... 18
Emergency contraception ................................... 20
Burn ........................................................................... 22
Anxiety attack ........................................................ 24
Diarrhea ................................................................... 26
Blood pressure elevation....................................... 28
Epistaxis .................................................................... 30
Wound .................................................................... 32
Herpes ...................................................................... 34
Dermal lesion of skin folds ..................................... 36
Sore throat ............................................................... 38
Backache ............................................................... 40
Urgent health problems
Aggressions ............................................................. 66
Cardiac arrest......................................................... 68
Seizures..................................................................... 70
Heatstroke ............................................................... 72
Severe abdominal pain ........................................ 74
Chest pain ............................................................... 76
Fever > 39 ............................................................... 78
Intoxications ............................................................ 80
Serious eye injury .................................................... 82
Toothache ......................................................... 42
Distress when urinating .................................... 44
Animal bite ........................................................ 46
Stye ..................................................................... 48
Bite ...................................................................... 50
Mosquito bite .................................................... 52
Allergic reaction ............................................... 54
Respiratory symptoms in upper airways ....... 56
Sprained ankle .................................................. 58
Trauma .............................................................. 60
Whitlows ............................................................. 62
Intens headache .............................................. 84

Dizziness.............................................................. 86
Drowning ........................................................... 88
Loss of conscience ........................................... 90
Gastrointestinal bleeding ................................ 92
Traumatic brain injury ...................................... 94
Severe trauma .................................................. 96
Vomiting............................................................. 98
Anaphylactic shock ....................................... 100
Drugs guide
Analgesics and antipyretics .............................................................................................................................. 105
Antibiotics ............................................................................................................................................................ 107
Topical treatment ............................................................................................................................................... 109
Others .................................................................................................................................................................... 110
Annex
Pain scale ............................................................................................................................................................. 113
Radiographic projections .................................................................................................................................. 114
Nursing assessment ............................................................................................................................................. 115
Neurological assessment ................................................................................................................................... 116
Assessment of burn lesions ................................................................................................................................. 117
Bibliography ............................................................................................................................................................. 121
V 1.2 12/2012
Castelldefels Agents de Salut dAtenci Primria CASAP
authors
Direction
Brugus Brugus, Alba
Peris Grao, Antoni
Authors: working group of non scheduled demand management

Gascn Ferret, Jordi
Gmenez Jordan, Laura
Mateo Viladomat, Enric
Pavn Rodrguez, Francisca
Vilalta Garca, Susana
Coordination edition
Pavn Rodrguez, Francisca
Contributors
Nurses
Campoy Sanchez, Ana
Casado Montas, Isabel
Fernndez Delgado, Maite
Fernndez Molero, Snia
Hernndez Escriche, Carmen
Laserna Jimenez, Cristina
Malo Verde, Agustina
Moya Calaf, Griselda
Mulero Madrid, Ana
Noguera Argels, M Antnia
Osuna Gomera, Yolanda
Ravents Jurado, Paola
Rodrguez Hernndez, Yolanda
Sancho Domnec, Laura
Tpia Lpez, Montserrat
Torres Roca, Dolors
Doctors
Bernades Carulla, Carlos
Bosch Romero, Emilia
Chiriac, Ionut
Garcia Tristante, Daniel
Gomez Fernandez, Claudia
Gonzalez Azuara, Slvia
Jareo Sanz, M Jos
Manzotti, Carolina
Santamaria Martn, Maribel
Silvestre Puerto, Vctor
Dentistry
Prunera Badosa, Nria
Health administrative
Hurtado Colmenero, Natlia
Ibez Mancebo, Sandra
Madrid Ramn, Miguela
Muoz Roldan, Araceli
Osuna Muoz, Susana
Santana Cabrera, Maite
Sevillano Palma, Victria
Tello Prez, Alicia
Vilaseca Ortiz Urbina, Maite
Nursing assistant
Burgos Casado, Snia
Santana Cabrera, Imma
Reviewers
Amat Camats, Gemma. Associaci dInfermeria Familiar i Comunitria de Catalunya (AIFiCC)
Flores Mateo, Gemma. Institut dInvestigaci en Atenci Primria (IDIAP)
Morera Castell, Ramon. Societat Catalana de Medicina Familiar i Comunitria (CAMFiC)
Technical support and design

Cubells Asensio, Irene
Mateo Viladomat, Enric
V 1.2 12/2012
presentation
A few years ago we proposed that one of the priority objectives of the primary health care is to solve
maximum problems of population with better accessibility. The current economic situation makes it much
more necessary to move towards this goal. A few years ago, the Primary Care Team Can Bou and the
Consortium Castelldefels Health Agents (CASAP) developed this project which now we present in a new
version.
The document "Guide of nursing interventions to Health Problems" is the result of a teamwork. At first was
based on the scientific evidence for diagnostic and therapeutic procedures and the will to streamline the
care process of the known as spontaneous demands. It has served us to promote the integration of customer
care professionals as health care professionals in the care process and within the team itself, with nurses and
doctors.
These are Guidelines based on various documents of scientific rigor, and in turn, the tools to facilitate problem
solving by nurses, referred professionals to solve different acute health problems, both to expedite the
resolution and being professionals with demonstrated skills.
With the experience given us by years of working with this tool, with the review and improvement made
through the analysis and the recommendations made by the same professionals who use them daily, we
offer this update guideline that we trust you find illuminating, interesting and, over all, useful for the daily task
with population that requires our service.
Dr. Antoni Peris i Grao

Family physician - Director Manager
Health Center Can Bou
V 1.2 12/2012
introduction
Nurses here and abroad have initiated measures to enhance the role of nurses in the care of acute health
problems, with the goal of becoming the gateway to the health system and also in giving response to much
of the demands presented on the population. It is necessary to adapt activity and resolution capability of
the primary attention nurse to these demands for increasing systems efficiency and sustainability.
This project aims to provide all team members, the use of a methodology agreed on circuits, decision making
and interventions, based on available scientific evidence and methodological nursing tools.
By consensus of the working group and the rest of the team, have been chosen a number of health problems
that go straight to the consultation of spontaneous attention. The nurse, after making the assessment, can
give the user the right treatment (cure, tips, drug ...) or to quote the reference professional (doctor or nurse)
to do the monitoring.
To carry through demand management in a efficiently and operationally way, it is necessary to coordinate
the actions of the nurse who attends care consultation of spontaneous visits with the receiving of the user by
the health administrative team that prioritize and manage demands to the indicated professionals, and also
with the team of family physicians and pediatricians who provide support and assistance in cases that require
their intervention.
Other health problems, considered as emergencies, pass to the consultation of spontaneous attention
directly, where they are valued by the nurse who once made the history, contact the doctor on call and will
agree the action to follow.
How was the document elaborated
The first document was edited in September 2007. After 5 years, we have made a second edition, with a
complete overhaul of the protocols, circuits and treatments according to the latest scientific evidence.
Health problems, described according signs and symptoms, have been prioritized from a selection of the
most frequent problems, which most of the nurses working in primary care resolve in daily practice.
In this review we have identified 23 health problems solvable by nurses and 18 emergency possible
intervention.
Each health problem is divided into three sections: the first contains a brief definition of the problem, the
second describes an algorithm of actuation which includes the history, assessment, intervention, alert causes
and revisiting criteria and, finally, a third section includes most common nursing diagnoses NANDA (Norh
American nursing Diagnosis Association).for each common health problem and possible nursing interventionsNIC (nursing Interventions Classification).
NICs are divided into two blocks: the first block found those deemed essential or primary to be made to
make the situation of health, and in the second block, the secondary or optional, that can be performed
depending on the situation and nurse assessment.
In the Annex there is a guide of all those drugs which are indicated in the protocols, indicating the active
ingredient, presentation, route of administration, trademarks and properties of each, the pain scales most
commonly used, the radiological projections, nursing assessment according to V.Herderson pattern and
neurological assessment scales.
Parallel to the development of the guide, work meetings have been done monthly with administrative, in
order to identify weak points of the circuit. These sessions served to specific training on nomenclature,
identification of warning signs and correct processing and referral of patients.
V 1.2 12/2012
11
During the seven years we've been developing this project, the drive group, consisting of nurses, family
physicians and administrative, has maintained regular work meetings, and have made the agreed
modifications, both circuit and content according to a quality methodology.
After closing the guide by the authors and agreed with contributors, there has been a review by three
external professionals from three scientific entities: the Association of Family and Community Nursing of
Catalunya (Aificc), the Catalan Society of Family and Communitary Medicine (Camfic) and Jordi Gol
Foundation (Idiap)
Alba Brugus i Brugus

Nurse
Attached to Direction-Management
Health Center Can Bou
CASAP
V 1.2 12/2012
12
commitment letter
With the aim of giving the best service to the population served, the members of the Primary Care Team Can
Bou pledge to continue the nursing interventions guide to health problems developed with the consensus
of all team professionals. This Guide is based on current protocols and in the evidence recommended in our
country by scientific societies and public health services entities.
With the same intention and willingness to offer a solving and efficient service, we agree to follow the circuits
and procedures detailed in this compendium adapted for acute pathology attention and based on those
documents.
These circuits will be extended and procedures will be updated depending on the disposition of new
scientific evidence and the degree of resolution of our Primary Care Team deems necessary.
Healthcare team of EAP Can Bou

Castelldefels, december de 2012
V 1.2 12/2012
13
circuit care demands

DEMAND OF
NON SCHEDULED VISIT
ADMINISTRATIVE
REFERRAL
1
Nurse non scheduled
services portfolio
Programming
techniques on Diary
Box:
- Injection
Tracking cures
Control BP
Control OAT
(displaced)
Other acute health
problems non
protocolized on 3 & 4
groups
Pediatrician
emergency:
- Telephone call to
pediatry nurse
Family physician non

scheduled services
portfolio
Possible nursing solving

problems
Shared intervention
emergency problems
Clnic visit
Drop
Genital herpes & zoster
Eye injuries:
- Conjunctivitis
- Slight lesions
- Red eye
Otalgia
Varicella
Other acute health
problems non
protocolized on 1, 3 i 4
group
RX Interpretation
Administrative gestion
Hospital discharges
maternal IT
IT with hospital report
Recipes:
- hospital report
- > 72 h. delay
diary
- morphics
- antidepressants
- benzodiazepines
p
NURSE
APPOINTMENT
DOCTOR
APPOINTMENT
V 1.2 12/2012
Oral thrush
Emergency
contraception
Burn
Anxiety attack
Diarrhea
Blood presure elevation
Epistaxis
Wound
Herpes
Dermal lesion of skin
folds
Sore throat
Backache
Toothache
Discomfort when
urinating
Animal bite
Stye
Bite
Mosquito bite
Allergic reaction
Respiratory symptoms in
upper airways
Sprained ankle
Trauma
Whitlows
DIARY BOX
APPOINTMENT
Aggressions
Cardiac arrest
Seizures
Heatstroke
Severe abdominal pain
Chest pain
Fever >39C
Intoxications
Serious eye injury
Intens headache
Dizziness
Drowning
Loss of conscience
Gastrointestinal
bleeding
Traumatic brain injury
Severe trauma
Vomiting
Anaphylactic shock
TELEPHONE CALL &

DIARY BOX
APPOINTMENT
15
acute health
problems
oral thrush
Date:
09/2007
Revision:: 08/2012
Version:
1.2
There are many possible causes: superficial erosions, superinfections, nonspecific,

inflammatory bowel disease, sexually transmitted diseases, secondary lesions, odontodental pathology, immunosuppression, allergies, drug intolerance, herpes, etc.. Most of
the time the diagnosis is not confirmed and the lesions tend to disappear spontaneously.
Personal History
Drugs and allergies
Time of evolution
Clinical companion
Characteristics of pain
State vaccine (Td)
medical assessment
alert causes
anamnesis
Other cases outside the oral cavity

At the discretion of the nurse
assessment
Vital Signs (Temp)
properties injury
Oral thrush:
<7 days duration
One or few lesions smaller than 1cm. in
diameter, whitish background and red
outline
not have a high fever or malaise
intervention
revisiting criteria
If no improvement in 4-5 days
doctor
Analgesia if required as guideline:

1 gr/8h Paracetamol and /or Ibuprofen
600mg/8h
Topical Treatment:
Carbenoxolone 2% gel 1
aplicacin/8h. (6 days)
Explanatory notes
1
Check drugs guide
V 1.2 12/2012
18
oral thrush
NURSING DIAGNOSES NANDA
00132
Acute pain
00045
Impaired oral mucous membrane
NURSING INTERVENTIONS (NIC)

INDISPENSABLE
OPTIONAL
1400
Pain management
1710
2390
Medication prescribing
5616
Teaching: prescribed medication
5510
Health education
8100
Referral
7920
Documentation
V 1.2 12/2012
Oral Health maintenance
19
emergency contraception
Date:
09/2007
Revision: 08/2012
Version:
1.2
The
"morning after pill" is an emergency contraception and can be used in unprotected
Revisi
sexual intercourse or suspected that the contraceptive method used may have failed.
valoration
If time since intercourse> 72 h

If positive pregnancy test
referral ASSIR
Age
Personal history
Drugs and allergies
Time from intercourse (<72 h.)
Other unprotected intercourse in the
same cycle
Clinical companion
Last rule
Regular contraceptive method
Known hypersensitivity
Intestinal malabsorption syndrome
alert causes
If a history of hypersensitivity to the

drug
If intestinal malabsorption syndrome
Under 13 years old
If treatment with broad-spectrum
antibiotics, antiepileptics, antifungals,
antiretrovirals and/or tuberculostatic
General condition
Pregnancy test if I delayed
menstruation
Psychological and emotional maturity
in girls 13-16 years
Pediatrician valoration < 15 years

old
Family physician > 15 years old
anamnesis
intervention
V 1.2 12/2012
revisiting criteria
If vomits before 2 h, must return to
take another dose
If doesnt have rule in 21 d. need to
do a pregnancy test
nurse
1500 mcg Levonorgestrel

- Taken in front of us
Report:
- If vomits before 2 h, must return to
take another dose
- If doesnt have rule in 21 d. need to
do a pregnancy test
Recommend a visit with ASSIR
20
emergency contraception
00188
Risk-prone health behavior
00126
Deficient knowledge: contraception and safe sex
NURSING INTERVENTION (NIC)

INDISPENSABLE
OPTIONAL
2300
Medication administration
5248
Sexual counseling
5510
Health education
5616
7920
Documentation
8100
Referral
V 1.2 12/2012
21
burn
Date:
09/2007
Revision: 08/2012
Version:
1.2
It is the tissue injury caused by thermal, chemical, radioactive or physical contact that
causes cell destruction, edema and fluid loss.
alert causes
Age
Causal agent
Personal history
Drugs and allergies
Time evolution
Clinical companion
State vaccine (Td)
valoration
General condition
Vital Signs (temp and HR)
Grade, location, extension (see Annex
Shock
Circulars and mucous
Skull, car, neck and genitals
Locations with significant aesthetic /
functional compromise
2nd grade> 10% body surface
3rd grade> 2% body surface
power
inhalation
polytrauma
Suspected abuse or non-accidental
origin
medical valoration
anamnesis
5)
Pain (see Annex 1)

Signs of infection
Presence of other lesions
intervention
revisiting criteria
Signs of infection
Pain not controlled with scheduled
analgesia
Reappearance of flictenas
Paresthesias
Signs of vascular compression
Malaise
Fever appearance
An incident occured with dressing
nurse
In all cases:
- Assess the removal of clothing and
objects
- Wash and reduce local heat with
physiological saline
- Debride flictenas
- Cures in wet environment with
hydrocolloid with silver hydrofibre
dressing or hydrophilic polyurethane
gel or silver sulfadiazine
- No compression elastic bandage
- Tetanus prophylaxis if necessary
If pain:
- Paracetamol 500 mg - 1 gr/6-8h.
- Assess analgesia im d/p (if Metamizol
im, telephone consultation)1
If signs of infection:
- Amoxi/clavulanate 500/125 mg c/8h.
during 8 d.
- If allergic to penicillin: Erythromycin
500 mg every/6 h during 8-10 d.
To tar: Dissolve with olive oil
Electrical burn: do ECG
Sunburn:
- Moisturizer
- Hydrocortisone Lotion 1%
Explanatory notes
1
Check drugs guide

V 1.2 12/2012
22
burn
00046
Impaired skin integrity
00044
Impaired tissue integrity
00132
Acute pain
00004
Risk for infection

INDISPENSABLE
OPTIONAL
3660
Wound cure
2390
1400
Pain management
1380
Heat/Cold application
6530
Immunization/vaccines management
3584
Skin care: topical treatments
5510
Health education
2300
7920
Documentation
8100
Referral
V 1.2 12/2012
23
anxiety attack
Date:
04/2009
Revision: 08/2012
Version:
1.2
Episode of sudden and unexpected occurrence that manifests itself with fear of losing
Revisi
control or that something bad must happen, or even fear of dying. It is accompanied by
symptoms such as difficulty breathing, chest pain, palpitations, sweating, trembling,
dizziness and unsteadiness, tingling, nausea, and abdominal discomfort.
alert causes
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion
CVR factors
Mental health diagnoses
Psychological manifestations1
Physical manifestations2
medical valoration
anamnesis
ECG interpretation
Persistence of the clinic in 30'
If has already established a
psychiatric treatment: telephone
assessment
valoration
General condition
Vital signs (BP, HR, RR, SatO2)
Breathing type
intervention
revisiting criteria
doctor
If oppressive chest pain:

- Do ECG
If hyperventilation
- Breaths with bag or mask
- Tips and breathing exercises /
relaxation3
Diazepam 5 mg sbl./8h (give tt for
48h)
Report side effects
Preview / spontaneous appointment
with referring doctor
Exacerbation of symptoms
explanatory notes
1
2
3
Alert, fear, worry, fatigue, hypervigilance, distraction, lack of concentration, insomnia, stress ...
Tachycardia, palpitations, elevated BP, dyspnea, tachypnea, sweating, tremors, pain, muscle
tension, tingling, dizziness, gastrointestinal disorders...
Deep diaphragmatic breathing: inspire slowly and deeply for 5'', hold the air during 5-7' and
exhale slowly during 10''
Relaxed diaphragmatic breathing: nose inspiration by 2-3'', pause briefly, exhale slowly for 4-6''
and do another short break before returning to inspire.
V 1.2 12/2012
24
anxiety attack
00146
Anxiety
00148
Fear
00032
Ineffective breathing pattern

INDISPENSABLE
OPTIONAL
5820
Anxiety reduction
6160
Crisis intervention
6680
Vital signs monitoring
2300
3350
Respiratory monitoring
5230
Coping enhacement
5510
Health education
5880
Relaxation techniques
7920
Documentation
8100
Referral
V 1.2 12/2012
25
diarrhea
Date:
09/2007
Revision: 03/2012
Version:
1.2
Acute
gastroenteritis (AGE) is considered the increased number of stools, with or without
Revisi
abdominal discomfort and/or vomiting with or without fever, of less than 5 days duration
and no prior drug treatment. Keep in mind the possibility of food toxicoinfections.
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion
Presence of vomiting
Stool characteristics (blood, pus or
mucus)
Number and types of stools
Recent trips
Recent drugs
Others affected
valoration
General condition
Vital signs (temp, HR and BP)
Diabetic patient: capillary glycemia
Pain (see Annex 1)
Abdominal examination: soft belly and
increased peristalsis
Hydration, skin and mucous
alert causes
Important malaise
Fever> 38 C
immunosuppression
Fecal pathological products (blood,
pus, mucus)
Duration of more than 3 days
Frequent vomiting> 5/12h or bloody
oral intolerance
Suspected food toxoinfeccin
collective or pharmacological
DM with altered capillary glycemia
Signs of dehydration
Altered abdominal palpation
severe pain
Inflammatory bowel disease
Pain located at a point
medical valoration
anamnesis
intervention
V 1.2 12/2012
revisiting criteria
If fever> 38 C
Presence of blood, mucus and / or
pus in stool
Onset of frequent vomiting (> 5/12h)
Persistence of symptoms after 5 days
26
doctor
Diet:
- Oral Rehydration (water and
infusions)
- Dietary recommendations for the
gradual reinstatement of food
Relative rest
If fever or pain:
- Paracetamol 500 mg - 1gr/6-8h. o
If vomiting:
- Metoclopramide 10 mg im /o
Hygiene standards
If necessary, provide IT (Telephone
consultation. MF, N, print IT )
diarrhea
00013
Diarrhea
00134
Nausea
00028
Risk for deficient fluid volume

INDISPENSABLE
OPTIONAL
6680
2390
5602
Teaching: desease process
0460
Diarrhea management
5614
Teaching: prescribed diet
1450
Nausea management
5510
Health education
1570
Vomit management
7920
Documentation
2080
Liquids management
5616
8100
Referral
V 1.2 12/2012
27
blood pressure elevation

Date:
04/2009
Revision: 08/2012
Version:
1.2
When
a sudden increase in blood pressure takes place, in relation to normal pressure
Revisi
values of the person.
alert causes
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion
CVR factors
HTA known with therapeutic fulfillment
Reasons and conditions of its
encounter (how it was identified)
medical valoration
anamnesis
In case of presence of alert signs1

TAS 180 and TAS 110
valoration
General condition
Vital signs (temp, HR, RR, SatO2)
Confirm arm control:
- 2 mesures in a interval of 5'
Presence of alert signs1
intervention
revisiting criteria
Case of appearance of alert signs1
TAS 180 and TAS 110
doctor
If TAS 140-179 and TAD 90-109 without

warning signs
- Rest 30 '
- New control
Preview appointment with referring
nurse on 24/48 h.
explanatory notes
1 Sudden headache, syncope, blurred vision, chest pain or acute abdominal pain, palpitations,
dyspnea, tachypnea, tachycardia, and edema in lower limbs
V 1.2 12/2012
28
blood pressure elevation

00204
Ineffective peripherial tissue perfusion
00146
Anxiety
000079
Noncompliance

INDISPENSABLE
OPTIONAL
6680
2390
5510
Health education
5616
7920
Documentation
2300
V 1.2 12/2012
5820
Anxiety reduction
5040
Therapy of simple relaxation
4420
Patients contracting
5240
Counseling
8100
Referral
29
epistaxis
Date:
07/2012
Revision: 08/2012
Version:
1.1
It is bleeding originated in the nostrils. Anterior and posterior epistaxis: two clinical
variants we can differ.
Age
Personal history
Drugs and allergies (anticoagulants,
antiplatelet and antihypertensive)
Time evolution and prior history of
epistaxis
Clinical companion
Cause:
- Local (erosion, trauma, contusion,
mucosal dryness, rhinitis, cold)
- General (bleeding disorder, HBP
and use of anticoagulants)
alert causes
Case of presence of warning signs
TAS 150 and TAS 95
Suspected posterior epistaxis (nasal
bleeding non stop with compression)
Bleeding bilateral
Use of oral anticoagulant drugs or
patients with bleeding disorders.
medical valoration
anamnesis
valoration
General condition
Vital signs (BP, HR, Temp)
Warning signs and symptoms:
headache and systemic involvement
Amount of bleeding
INR if anticoagulation treatment
Nasal cavity exploration
Location of bleeding: anterior or
posterior
intervention
V 1.2 12/2012
revisiting criteria
Case of appearance of warning signs
Reappearance of bleeding
TAS 150 and TAS 95 + symptoms of
HBP added
30
doctor
Position: bring chin to chest (avoid

horizontal)
If contusion: local application of gel
Mechanical compression with 2 fingers
for 10 ' in the nostrils
If does not yield with compression,
value doing nasal anterior tamponade
with nasal gauze + vaseline or
tranexamic acid
Keep nasal tamponade up to 2 days
and re-evaluate
Recommended cure of tamponade
If not yield: valoration of a doctor
Preview appointment with referring
nurse on 48 h
epistaxis
00132
Acute pain
00146
Anxiety

INDISPENSABLE
OPTIONAL
6680
5880
Relaxation techniques
4160
Control of bleeding
2300
4024
Bleeding reduction: nasal
1400
Pain management
5510
Health education
8100
Referral
7920
Documentation
V 1.2 12/2012
31
wound
Date:
09/2007
Revision: 08/2012
Version:
1.2
The
most common injuries in primary care are bruises on the head or extremities, caused
Revisi
basically by domestic or sports accidents, followed by injuries with cutting objects, usually
on the hands.
anamnesis
alert causes
medical valoration
BP <100/60 or HR> 100

Affectation: face, joints, nerves or
tendons
If press injuries is necessary
Extensive hemorrhage
Age
Personal history
Drugs and allergies
Evolution time and date of injury
Causal agent of wound
Clinical companion
State vaccine (Td)
valoration
General condition
Vital signs (temp, BP)
Wound characteristics
Location, extension and depth
Signs of infection
Presence of foreign bodies
Presence of other injuries (fractures,
bruises, tendon affectation)
intervention
revisiting criteria
Appearance of infection signs
Pain not controlled with analgesia
scheduled
Active bleeding
Paresthesias
Malaise
Appearance of fever
If an incident occurs with the dressing
explanatory notes
1
Sutures
Face:
5-6/0
Head:
2-3/0 or staples
Chest and back: 3-4/0
V 1.2 12/2012
Extremities:
Lower extremities:
Subcutaneus tissue:
3-4-5/0
3-4/0
3-4/0 (vicryl)
32
nurse
In all cases:
- Haemostasis if necessary
- Cleaning and disinfection with
chlorhexidine
- Prophylaxis Td if necessary
- Occlusive dressing
- Quote nurse cures for later
If open <6 h. evolution:
- Anaesthesia mepivacaine and suture
if necessary1
If it is> 6 h. or no possibility of suture:
- Wet cure with semi-occlusive dressing
If pain:
- Paracetamol 500mg - 1gr/6-8h.
If signs of infection:
- Cure in humid environment. Assess
use of silver dressing or collagenase
- Amoxi/clavulanate 500/125mg
every/8h. during 8 d.
If allergic to penicillin: Erythromycin
500 mg every/6h during 8-10 d.
wound
00046
00044
00132
Acute pain
00004
Risk for infection

INDISPENSABLE
OPTIONAL
3660
Wound cure
2390
6530
1380
5510
Health education
3584
Skin care: topical treatments
7920
Documentation
2300
V 1.2 12/2012
1400
Pain management
3620
Suture
5618
Teaching: procedure/treatment
6550
Infection protection
8100
Referral
33
herpes
Date:
02/2010
Revision: 08/2012
Version:
1.2
Herpes
is characterized by causing painful or itchy vesicular lesions produced by the
Revisi
virus of the same name. If the lesion is located in the path of a nerve (dermatome), it is
caused by herpes zster. If the lesion is located in the perioral /oral or genital area, the
cause is herpes simple.
alert causes
Age
Personal history
Drugs and allergies
Evolution time
Clinical companion
State vaccine (Td)
If suspicion of:
- Herpes zoster
- Ocular Herpes
Case of:
- Extensive Herpes Simple
- Genitals
- Nose
- Recurrent episodes (> 6 episodes /
year)
valoration
medical valoration
anamnesis
General condition
Vital signs (temperature)
Lesion characteristics
Location and extension
intervention
revisiting criteria
If no improvement in 4-5 days
doctor
Treatment of herpes simplex:

- Analgesia if required by guideline:
Paracetamol 1gr/8h and / or
Ibuprofen 600mg/8h 1
- In active lesions (<48h) topical
acyclovir every/4h (under
development)
- In dry lesions: calcareous liniment oil
or 50% H2O
- If signs of infection: Mupirocin
- Prophylaxis (Td) if necessary
explanatory notes
1
Check drugs guide
V 1.2 12/2012
34
herpes
00132
Acute pain
00046

INDISPENSABLE
OPTIONAL
5510
Health education
2390
7920
Documentation
6530
8100
Referral
V 1.2 12/2012
35
dermal lesion of skin folds

Date:
04/2009
Revision: 08/2012
Version:
1.2
Erythematous lesion in the area of skin folds: groins, armpits, inframammary regions
and gluteal region.
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion
valoration
alert causes
Atypical features of the lesions
Systemic involvement
Pregnancy or breastfeeding
Immunosuppression or DM
Presence of other disseminated lesions
Presence of cellulite
Suspected allergic component
Injury to genital area or oropharyngeal
area
medical valoration
anamnesis
General condition
Location
Features: erythematous plaque, bright
red-edged
Presence of exudate and /or fissures
Presence of predisposing factors:
humidity, poor hygiene
Topical application of: Clotrimazole

1% every/12h during 2-3 weeks
Recommendations:
- Proper hygiene
- Keep the zone into the air and dry
- Correction of predisposing factors
V 1.2 12/2012
revisiting criteria
If no improvement in 1-2 weeks of
treatment
Systemic involvement
Exacerbation of symptoms
If there are other injuries
doctor
intervention
36
dermal lesion of skin folds

00004
Risk for infection
00046

INDISPENSABLE
OPTIONAL
6610
Risk identification
3590
Skin surveillance
5510
Health education
2390
7920
Documentation
5616
8100
Referral
V 1.2 12/2012
37
sore throat
Date:
09/2007
Revision: 08/2012
Version:
1.2
Odynophagia is painful swallowing, often accompanied by dysphagia (subjective

feeling of difficulty in passing the alimentary bolus during swallowing).
alert causes
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion
Clinic> 7 days duration

Immunosuppression
Fever> 40 C or> 38 C and> 72 h.
COPD or asthma
Shortness of breath and / or severe
aphonia
Heart disease and / or poorly
controlled DM
Intense earache
Asymmetry of the soft palate
Malaise
No improvement with previous
treatment
Pregnancy and lactation
Previous episodes the latest 15 days
valoration
General condition
Vital signs (temp, BP, HR)
Examination of the oral cavity and
pharynx (soft palate, tonsils, ...)
Exploration of submandibular and
laterocervical lymphadenopathy
medical valoration
anamnesis
intervention
revisiting criteria
If symptoms do not improve in 48 hours
explanatory notes
1
Check drugs guide
V 1.2 12/2012
38
doctor
Analgesia if required:
- Paracetamol 650 mg-1 g. every/6-8h
or Ibuprofen 600 every/6-8h1
If presents pharyngeal tonsillar
exudate and previous laterocervical
lymphadenopathy:
- Fever> 38 C:
Amoxicillin 500-750 mg every/8h.
(7 days). If allergy: Erythromycin
500 mg every/6 h. (8-10 days)
- Hygienic and dietary tips:
No smoking
Increased fluid intake
rinses with lemon juice, chamomile
or thyme
Avoid excess sugar
sore throat
00132
Acute pain
00007
Hyperthermia
00004
Risk for infection
00045
Impaired oral mucous membrane

INDISPENSABLE
OPTIONAL
6680
2300
1400
Pain management
2380
Medication management
2390
1710
5616
5602
5510
Health education
8100
Referral
7920
Documentation
V 1.2 12/2012
39
backache
Date:
09/2007
Revision: 08/2012
Version:
1.2
Revisiof pain localized at the dorso-lumbar spinal segment. Many of these pains are
Presence
part of a complete rachialgia, most of them have an unknown etiology, are self-limited
in time and have a benign prognosis.
alert causes
Age
Personal and work history
Previous episodes and treatments
Drugs and allergies
Time evolution
Clinical companion
- Constitutional symptoms
- Urinary discomfort
- Neurologic deficit
Pain features1
- Intensity of pain (see Annex 1)
- Mechanical
- Inflammatory
Age> 55. (only if its first episode)

Antecedent of trauma
History of previous backache with
treatment that has not improved
Immunosuppressed
Osteoporosis
corticosteroid prolonged Taken
Functional impotence
Constitutional symptoms:
- Fever, weight loss, malaise and / or
asthenia
Neurological deficit
- Incontinence of sphincter
Pain radiating to the lower extremities
Inflammatory characteristics pain
Pleuritic pain or pain in hemi-belt
Fever
Maneuver Lasgue positive
Positive lumbar fist percussion
valoration
General condition
Vital signs (temp, BP, HR)
Maneuver Lasgue2
Lumbar fist percussion
medical valoration
anamnesis
intervention
revisiting criteria
If symptoms do not improve in 72 h.
doctor
Staying active as far as pain allows

Local heat
Treatment: Paracetamol 650mg-1g
and / or Ibuprofen 400-600 mg
every/8h. and / or Tetrazepam 50 mg /
Diazepam 5 mg every / night. (3-4
days) 3
explanatory notes
1
Features of pain:
Inflammatory: not related to movement, no improvement or even worse over night rest and
is accompanied by morning stiffness.
Mechanical: increases with movement and does not improve with rest
Maneuver Lasgue: leg lifts with the knee in extension
Positive: radiating pain appears in the leg
Negative: there is pain in the lower back or in buttock
Check drugs guide
V 1.2 12/2012
40
backache
00132
Acute pain
00085
Impaired physical mobility

INDISPENSABLE
OPTIONAL
1400
Pain management
2210
2390
2380
5616
1380
5510
Health education
5612
Teaching: prescribed exercice
7920
Documentation
8100
Referral
V 1.2 12/2012
Analgesic administration
41
toothache
Date:
Revision:
Version:
09/2007
08/2012
1.2
Toothache is the cause of the most primary care practices related to the oral cavity and
accounts for up to 20% of acute pain treated in an emergency department.
anamnesis
alert causes
Immunosuppression
Fever> 38 C
Significant edema
Cellulitis or abscess
Systemic disturbance
Impaired swallowing
Pregnancy and lactation
medical valoration
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion
State vaccine (Td)
valoration
General condition
Constant (temp)
Recent oral manipulations
Exploration of the oral cavity
intervention
revisiting criteria
dentist
If no improvement in 48 h.
If intolerance to treatment
doctor
Prophylaxis if necessary
Analgesia, if necessary:
- Paracetamol 650 mg-1g. every/6-8
h., Ibuprofen 600 every / 8 h. or
Metamizol 575mg every / 8 h.1
Manage:
- IM Diclofenac or Metamizol vo
blisters. if necessary.
Antibiotic treatment:
- Amoxicillin / clavulanate 500/125
every / 8 h. (7 days)
- If allergic: Clindamycin 300 mg
every/ 6 h. (8-10 days)
Hygienic and dietary tips:
- No smoking
- Rinses with chlorhexidine 0.12%
every/24 h. (15 days)
- Avoid very hot or very cold drinks
Appointment with dentist
explanatory notes
1
Check drugs guide
V 1.2 12/2012
42
toothache
00132
Acute pain

INDISPENSABLE
OPTIONAL
1400
Pain management
1710
2390
2380
5510
Health education
2300
7920
Documentation
5602
8100
Referral
V 1.2 12/2012
43
distress when urinating

Date:
09/2007
Revision: 08/2012
Version:
1.2
An
uncomplicated urinary tract infection (UTI) is the lower urinary tract infection
Revisi
presenting exclusively local symptoms.
Man
Woman> 65.
Woman with DM
Temp> 37
Chills
More than 7 days evolution
Patients with recurrent UTI
- More than 2 episodes in 6 months
- More than 3 episodes in 1 year
Positive lumbar fist percussion
ITU relapse treated in the latest 15
days
History of pyelonephritis in the last year
Alteration of vaginal discharge
Carrier urinary catheter
Nephrology malformations or
abnormalities of the urinary tract
Frank hematuria
valoration
General condition
Vital signs: (temp)
Urine dipstick
Urine characteristics
Lumbar fist percussion
intervention
If presents 2 or more signs or 2 or more
symptoms:
Signs
Symptoms
Nitrites +
Dysuria
Leukocytes +
Pollakiuria
Hematuria +
Urinary urgency
Dark urine
suprapubic pain
Hygienic and dietary tips1
Fosfomycin 3 g (single dose). If allergy,
Amoxicillin-clavulanate 500-875 / 125
mg every/8h 5d
If pain: Paracetamol 500g - 1g
every/6-8h
revisiting criteria
Appearance of:
- Fever
- Frank hematuria
- Low back pain
- Nausea or vomiting
Anury
doctor
Age
Personal history
Other UTI
Drugs and allergies
Time evolution
Clinical companion
Persistence of symptoms after finishing

treatment 2
explanatory notes
1 Emptying the bladder c/2-3h, perianal hygiene, urination before / after intercourse, cotton
underwear
2 Reference nurse will request a urine culture after 5 days of treatment and will end giving
telephone appointment with their FP to pick the outcome / TT
V 1.2 12/2012
medical valoration
alert causes
44
nurse
anamnesis
distress when urinating

00132
Acute pain
00016
Impaired urinary elimination
00004
Risk for infection

INDISPENSABLE
OPTIONAL
7820
Specimen management
0590
Urinary elimination management
2390
1750
Perineal care
5510
Health education
5616
7920
Documentation
5602
8100
Referral
V 1.2 12/2012
45
animal bite
Date:
02/2010
Revision: 08/2012
Version:
1.2
Keep in mind that according to the origin of the bite, the vector can transmit various
infections. Cat bites and human are more likely to become infected than dog.
alert causes
Age
Personal history
Drugs and allergies
Time bite
Time evolution
State vaccine (Td)
Clinical companion
Causal animal
medical valoration
anamnesis
If is necessary a injuries press

Nausea and vomiting
Diarrhea and abdominal pain
Allergic reaction
Hypersensitivity to poison
valoration
General condition
Vital signs (BP and HR)
Lesion characteristics (location and
extension)
Pain (see Annex 1)
Signs of infection
intervention
revisiting criteria
Signs of infection
Pain not controlled with scheduled
analgesia
Active bleeding
Paresthesias
Malaise
Onset of fever
nurse
Wash with soap and water +

Chlorhexidine
Healing with silver dressing
Immobilization and / or occlusion of
the affected area
No suturing. If necessary, approach
points
Bacterial prophylactic treatment
according to guideline: AmoxicillinClavulanate 500-875/125mg every/8h
for 1 week. If allergies Erythromycin 500
mg. every/6h 8-10 days
Analgesia, if necessary1
Prophylaxis Td + IGT (in wound without
complete primary vaccination or
unknown primary vaccination)
Discard rabies infection if bat bite
Appointment with reference nurse. 1rst
cure in 24h
explanatory notes
1
Check drugs guide
Antirabies center: Hospital del Mar, Paseo Martimo, 25-29-08003 Barcelona - Tel: 93 221 10 10
Toxicology Institute in Barcelona: C. Merc, 1- 08002 Barcelona - Tel.93 317 44 00
Specialty Care: Hospital Vall d'Hebron, Paseo Vall d'Hebron, 119-129 08035 Barcelona Tel. 93 489 30 00
V 1.2 12/2012
46
animal bite
00046
00132
Acute pain
00004
Risk for infection

INDISPENSABLE
OPTIONAL
3660
Wound cure
1400
6530
2300
2390
3620
Suture
5510
Health education
6550
7920
Documentation
8100
Referral
V 1.2 12/2012
Pain management
47
stye
Date:
Revision:
Version:
03/2010
08/2012
1.2
Localized infection in the glands of the eyelids or in the hair follicles of the eyelashes. Usually
produced by Staphylococcus aureus.
anamnesis
Impaired vision
Red eye
Fever> 38 C
Presence of flictenas, eyelid cellulitis
or photophobia excess
medical valoration
Age
Personal history
Drugs and allergies
Date of injury
State vaccine (Td)
Clinical companion
alert causes
valoration
General condition
Vital signs (temp)
intervention
V 1.2 12/2012
revisiting criteria
If no improvement in 72 hours.
doctor
Chlortetracycline (Aureomycin
ointment) 1 applic/8h. 7 days.
Hot Rags 15 '3-4 times / day
Standards of hygiene (hand washing,
not sharing towels, not handle injuries
...)
48
stye
00044
00004
Risk for infection

INDISPENSABLE
OPTIONAL
1380
8100
2390
5510
Health education
7920
Documentation
V 1.2 12/2012
Referral
49
bite
Date:
08/2010
Revision: 08/2012
Version:
1.2
Wound mainly by insects, arthropods and marine animals through which inject toxic
substances that act locally and / or systemically depending on etiology, the amount of
toxin injected and the organic response of the person.
alert causes
Age
Personal history
Drugs and allergies
Time of contact
Clinical companion
medical valoration
anamnesis
Anaphylactic shock (see protocol)

Possible bone alteration
Paresthesia
valoration
General condition
Vital signs (BP and HR)
If dyspnea assess uvula and SatO2
Pain (see Annex 1)
Lesion characteristics:
- Dysesthesia (altered sensation)
- Edema, redness and heat
- Lymphatic route and regional
adenopathy
intervention
revisiting criteria
Persistence of symptoms after
treatment is finished
nurse
In all cases:
Remove rests of animal without
scrubbing
Wash with physiological saline
Apply local cold except weeverfish
(warm compresses gradually hot to
45C for 30-90 ')
Application:
- Chlorhexidine every/6-8h
- Hydrocortisone Lotion 1% every/812h 3d
Assess antibiotic treatment
Analgesia, if necessary 2
Prophylaxis (Td), if necessary
Immobilization of limb, if necessary
Treatment depending on etiologic
agent1
explanatory notes
1 Treatment depending on etiologic agent:
Paparra: Put Vaseline and after a minute remove it with tweezers by smooth and continuous
traction.
Bee: Remove the stinger carefully as it carries the venom (without pressure).
Scorpio: Inmersion of the affected part in cold water.
Spider: May require anesthesia and muscle relaxants sc, vo corticosteroids.
Medusa: Avoid friction and contact with fresh water
Weeverfish: Bathing the affected area with warm water or hot physiological saline
(thermolabile toxin).
Assess IM administration of corticosteroids (tel. Doctor on-call) in all cases if significant
reaction.
2 Check drugs guide
V 1.2 12/2012
50
bite
00132
Acute pain
00044
00004
Risk for infection

INDISPENSABLE
OPTIONAL
1400
Pain management
1380
2390
2380
3584
Skin care: topical treatment
2300
3680
Wound irrigation
6530
5510
Health education
8100
Referral
7920
Documentation
V 1.2 12/2012
51
mosquito bite
Data:
09/2007
Revisi: 08/2012
Versi:
1.2
Wound produced by the injection of toxic substances that act in a local and/or systemic
way depending on etiology, the quantity of toxins injected and the organic response.
alert causes
Age
Personal history
Drugs and allergies
Evolution time
Clinical companion
In case of shock anaphylactic (look

at protocol)
View nurse criterion
medical valoration
anamnesis
valoration
General condition
Vital signs (temp)
Mobility difficulties in case of limbs bite
If dyspnea assess uvula and SatO2
Characteristics of the lesions
(erythema, edema, induration,
warmth, pain, itching ...)
Lymphatic route and regional
adenopathy
Pain (see Annex 1)
intervention
revisiting criteria
View nurse criterion
Persistence of symptomatology when
the treatment finished
nurse
If presents edema, itching, induration,

erythema:
- Washed (physiological saline)
- Local desinfection Clorhexidina
- Lotion hidrocortisona 1% with
guiding home every/12h max. 7
days.
- Vacunal state valoration(Td)
- Local cold
If intense itching assess Antihistamine
im/orally1
If ampules:
- Open flictena, remove serous
content and the rests of skin
- Cure with silver dressing
- Treatment valoration in 24h
If infection signs:
- Valorate an Antibiotic orally2
If intense pain:
- Analgesia depending on
guideline(Paracetalmol/Ibuprofen)3
explanatory notes
1
2
3
Dexchlorpheniramine im puntual and/or by guideline orally every/8h making some variations

on the guideline depending on the sleepiness from 1 to 3 tablets/ day.
Antibiotic treatment: Amoxicilina- Clavulnic 500-875/125 mg. every/8h during 8 days. If
allergy to penicilin: Clindamycin 300mg every/6h during 8 days.
Check drugs guide.
V 1.2 12/2012
52
mosquito bite
00132
Acute pain
00044
00004
Risk for infection

INDISPENSABLE
OPTIONAL
1400
Pain management
1380
2390
2380
3584
Skin care: topical treatment
2300
5510
Health education
8100
Referral
7920
Documentation
V 1.2 12/2012
53
allergic reaction
Date:
02/2010
Revision: 08/2012
Version:
1.2
It is a response of the body when it comes into contact with certain substances
Revisi or allergens) from exterior.
(allergenic
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion
In case of severe urticaria *, prepare:

- Dexchlorpheniramine 5mg im
- Methylprednisolone 40-60 mg lm
- Actocortina 100 mg im
In case of anaphylactic shock:
- Check protocol
Edema of uvula
Alteration of the airway
valoration
medical valoration
alert causes
anamnesis
General condition
Vital signs (BP-HR-RR-Temp)
Lesion Characteristics
Intensity of pruritus
Oropharyngeal examination (edema)
Dyspnea (Sat O2)
intervention
revisiting criteria
Persistence of symptoms
doctor
For mild itching:

Remove jewelry
Antihistamine treatment by guideline:
- Loratadine 10 mg every/24h vo
- Dexchlorpheniramine 2mg
every/8h. orally or im for 7 days.
Appointment with referring physician
(24/72h.)
explanatory notes
* Etiologic agent of urticaria:
Immunologic IgE: food, drugs or pollen.
No immunological: antibiotics, aspirin, contrasts or nonsteroidal anti-inflammatory.
Idiopathic: unknown cause.
For the complement system: angioedema or urticaria-vasculitis.
V 1.2 12/2012
54
allergic reaction
00044
000204
Ineffective tissue perfusion: peripheral

INDISPENSABLE
OPTIONAL
6680
3590
Skin surveillance
2390
2380
6410
Allergy management
2300
3350
6412
Anaphylaxis management
5820
Anxiety reduction
3140
Airway management
6650
Surveillance
8100
Referral
5510
Health education
7920
Documentation
V 1.2 12/2012
55
respiratory symptoms in upper airways

Date:
09/2007
Revision: 08/2012
Version:
1.2
Set
of acute inflammatory processes affecting the respiratory mucosa of the upper
Revisi
airways. The most common symptom is dysthermic, nasal congestion, cough and malaise
among others.
alert causes
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion (cough,
expectoration, earache, pleuritic pain,
dyspnea, rhinorrhea, myalgia, sore
throat)
Severe headache, vomiting, and skin
lesions
valoration
General condition
Constants: (HR, RR, SatO2, Temp.)
Respiratory auscultation
Oropharyngeal exploration
Probing latero-cervical
lymphadenopathy and
submandibular
Patients with risk factors

- COPD
- Asthma
- Diabetes
- Immunosuppression
- Pregnancy
Fever> 38 maintained> 72h.
Fever> 40
Sat O2 <95
Altered respiratory auscultation
Pleuritic pain
Dyspnea
Stabbing pain in side
Presence of severe headache,
vomiting, and skin lesions
Earache or drainage
Recent hospitalization
Prostration
medical valoration
anamnesis
intervention
revisiting criteria
Persistence of fever> 39 C at 48 hours
and antipyretics resistance
Dyspnea
Progressive deterioration
Appearance of sharp pain in the side
explanatory notes
1
Dextromethorphan is contraindicated in cases of taking MAOI

V 1.2 12/2012
56
doctor
If fever, myalgia, malaise or

headache:
- Abundant water intake
- Sleep / hygienic measures
- Paracetamol 650 mg-1g. every/68h. or Ibuprofen 600 every/8h.
If dry cough:
- Dextrometorfano1 15 to 30 mg every
6-8h (max 120 mg / day)
If severe sore throat:
- Protocol sore throat
If nasal congestion:
- Nasal washes with hypertonic fluids
- Oxymetazoline every/12h (max 5
days)
- Loratadine every/24h
Anti-smoking Counseling
Facilitate Temporary Disability if
necessary
respiratory symptoms in upper airways

00132
Acute pain
00031
Ineffective cleansing of upper airways
00004
Risk for infection

INDISPENSABLE
OPTIONAL
6680
1800
Self-care assistance
2390
2380
5510
Health education
2300
7920
Documentation
1400
Pain management
5602
5616
8100
Referral
V 1.2 12/2012
57
sprained ankle
Date:
04/2009
Revision: 08/2012
Version:
1.2
Injury of parts of the ankle by a mechanism of transmitting forces and crushing.
alert causes
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion: pain and / or
functional impotence
Trigger mechanisms
medical valoration
anamnesis

Suspected grade III sprain
valoration
Pain (see Annex 1)
Degree of local edema and
hematoma
Rule Ottawa1
Define degree of esguince2
Suspected associated fracture and
need of Rx
If Rx advise not walking until the
assessment
intervention
In case onset of:

- Signs of vascular compression
- Paresthesias
- Pain not controlled with scheduled
analgesia
If an incident occurs with bandage
explanatory notes
1 Rule of Ottawa: Ability to maintain weight / Inability to take four steps / pain palpation.
2 Sprain degree:
Degree
I
II
III
inability
Minimum
Moderate
Severe
Pain
Punctual
Diffuse
Important
swelling
Minimum
slight
Important
inestability
No
slight
Yes
Recurrence
No
unfrequent
Frequent
3 Check drugs guide
V 1.2 12/2012
doctor
revisiting criteria
nurse
Local gel
Dressing according degree sprain
- Grade I or loosening: taping
- Grade II: compression bandage,
boot or plaster
- Grade III: plaster (acting as directed
by your doctor)
Recommend:
- Elevation of limb
- Rest
Antiinflammatory Ibuprofen 400600mg every/6-8 hours3
Review with nurse / physician referral
in a week
58
sprained ankle
00132
Acute pain
00046

INDISPENSABLE
OPTIONAL
1380
5820
Anxiety reduction
0910
Immobilization
8100
Referral
2390
5616
1400
Pain management
5510
Health education
7920
Documentation
V 1.2 12/2012
59
trauma
Date:
09/2007
Revision: 08/2012
Version:
1.2
Revisi
anamnesis
alert causes
Age
Personal history
Drugs and allergies
Evolution time and date of injury
Lesional mechanism1
Clinical companion
valoration
General condition
Vital signs (TA)
Pain (see Annex 1)
Lesion localization
- Rib cage: auscultation + SatO2
Hematuria (lumbar contusion)
Functional impotence
Deformity, swelling, edema
Ecchymosis, hematoma, paresthesia
If sprain: define degree2
BP <100/60 or HR> 100

Afectation to: skull / face, joints, or
abdomen
Trauma imp. abdominal / trunk
Extensive hemorrhage
Suspected grade III sprain
Assessment RX
Auscultation altered and / or
SatO2<96%
medical valoration
There are three types of injuries: bruise, sprain and fracture. The
treatment will be in function of the severity of the injury.
intervention
Annex 2)
revisiting criteria
Not controlled pain with scheduled
analgesia
Paresthesias
Malaise
Onset of fever> 38 C
doctor
If only bruise:
- Local Gel
- Analgesia, if necessary, according to
guideline (Ibuprofen 400-600mg/68h)3
- Immobilization:
Toes: Imbricated
Fingers: Finger splint
Sprain grade I-II: elastic adhesive
bandage
Sprain grade III: pressure dressing
(acting as directed by your doctor)
Suspected fracture: RX request (see
explanatory notes
1 Lesional mechanism:
Accident or assault: notify the physician on call for the release of injuries press.
Occupational accident: making the 1st cure initial assessment and refer the mutual labor.
If labor or traffic accident: Need notifying center management.
2 Sprain degree:
Degree
I
II
III
Inability
Minimum
Moderate
Severe
Pain
Punctual
Diffuse
Important
Swelling
Minimum
Slight
Important
Inestability
No
Slight
Yes
Recurrence
No
unfrequent
Frequent
3 Check drugs guide

V 1.2 12/2012
60
trauma
00132
Acute pain
00046
00085

INDISPENSABLE
OPTIONAL
2390
6680
1400
Pain management
2380
5510
Health education
2300
7920
Documentation
3680
Wound irrigation
3660
Wound cure
0910
Immobilization
V 1.2 12/2012
1380
8100
Referral
61
whitlows
Date:
09/2007
Revision: 08/2012
Version:
1.2
It is an acute infection in the nail area due to bacteria, fungi or herpes. The predisposing
factors are: local trauma, ingrown toenails, diabetic patients, immunosuppressed or bitten
nails. It is characterized by redness, swelling and pain, and in severe cases, cellulitis or
lymphangitis may reach occur.
anamnesis
Age
Personal history
Drugs and allergies
Date of injury
State vaccine (Td)
medical valoration
alert causes
If presents lymphangitis
Alteration of the nail bed
valoration
General condition
Vital signs (temp)
Lesion features 1
intervention
revisiting criteria
explanatory notes
1 Lesion features:
Greenish exudate (suspected pseudomonas: Ciprofloxacin 500mg/12h 10d orally)

Vesicles (suspected herpes: herpes see protocol)
If recurrent / chronic ingrown, fungal are suspected
Purulent / whitish exudate (suspects Staphylococcus: Cloxacillin 500mg every/6-8h orally 710d.)
V 1.2 12/2012
62
nurse
Wash with soap and water +

Chlorhexidine
Assess debridement, drainage and
cultivation takes
Cure with fusidic acid or silver dressing
Assess antibiotic treatment according
guideline1
Immobilization and / or occlusion of
the affected area
Prophylaxis (Td), if necessary
whitlows
00132
Acute pain
00046

INDISPENSABLE
OPTIONAL
3600
Wound cure
1380
2390
2380
5510
Health education
2300
7920
Documentation
6530
8100
Referral
V 1.2 12/2012
63
purgent health
problems
aggressions
Date:
09/2007
Revision: 08/2012
Version:
1.2
Revisi
Act
or violent attack that aims to cause injury to whom it is addressed.
anamnesis
referral
Call to doctor on call to release
injuries press2
Age
Personal history
Drugs and allergies
Time evolution
Injury mechanism1
Clinical companion
valoration
General condition
Vital signs (BP, RR, HR)
Emotional state
Presence of wounds and/or anxiety
Imminent proximity of the aggressor
Suspected fracture
intervention
If anxiety, act according to protocol
If injured, act according to the
protocol
If gender-based violence,
containment, information and referral
to social services and/or equipment.
If life-threatening, call the police(112)
explanatory notes
1 If sexual violence: Always refer to the hospital for assessment by gynecologist/forensic
Violence (GBV): its necessary to derive to social services and inform the team
If VG injury: physical examination always made by 2 professional
2 Press emited by GBV court: it is provided to the Customer Care and handled by fax and regular
mail (eCAP / patients / statement to the court)
V 1.2 12/2012
66
aggressions
00141
Post-trauma syndrome
00148
Fear

INDISPENSABLE
OPTIONAL
6680
5380
Security enhancement
4920
Active listening
6400
Abuse protection support
5240
Counseling
6403
Abuse protection support: spouse
5510
Health education
7920
Documentation
8100
Referral
V 1.2 12/2012
67
cardiac arrest
Date:
09/2007
Revision: 08/2012
Version:
1.2
It is stop breathing and heartbeat in an individual. The arrest of the heart implies
immediate (if it has not preceded it) stop breathing. This involves stopping the flow of
blood and therefore oxygen delivery to the brain.
anamnesis
referral
If possible:
- Causes giving rise to the SCA
- Personal history
- Drugs and allergies
Enable health scare

- Doctor
- Nurse
valoration
Consciousness
Airway
Breathing
basic intervention
advanced intervention
Prepare O2
- Connect O2 to 10 l. /min to reservoir
manual resuscitator
Peripheral venous via access
- Physiological Saline
Prepare medication:
- Adrenalin1
- Amiodarona2
- Serum glucose
Acting on medical Counselings or from
emergency medical service
Medical Emergency Service SEM
Enable health scare

If unconscious and not breathing
normally:
- Call 112
Airway:
- Liberate
-Place Guedel cannula
Chest compressions
- 30 chest compressions in middle
chest
Breaths of air
- 2 breaths with resuscitator manual
Place DEA
Alternate 30:2 following indications
DEA until help arrives
explanatory notes
1 Adrenalin will be administered in 9 cc physiological saline followed by 20 cc of physiological
saline, before the 3rd electric shock, subsequently will be administered every 3-5 minutes (each
two loops of CPR 30:2)
2 Amiodarone 300 mg diluted in 9 cc of SG before the 4th electric shock will be given (if
available)
V 1.2 12/2012
68
cardiac arrest
00204
Ineffective peripherial tissue perfusion (cardiopulmonary)
00035
Risck for injury

INDISPENSABLE
OPTIONAL
6680
6610
Risk identification
3320
Oxygen Therapy
6650
Surveillance
4200
Intravenous therapy
4150
Hemodynamic regulation
4254
Cardiac shock management
2380
2300
6320
Resuscitation
5510
Health education
7920
Documentation
8100
Referral
V 1.2 12/2012
69
seizures
Date:
09/2007
Revision: 08/2012
Version:
1.2
It is the clinical expression of cerebral excessive neuronal discharge that may cause
various symptoms and signs such as loss of consciousness, involuntary movements,
abnormal sensory phenomena or sensory, autonomic hyperactivity and / or
behavioral disturbances.
anamnesis
referral
Age
Personal and family history
- Toxic, neoplasms, CVA, DM, epilepsy,
TBI
- Ask if 1st episode
Drugs and allergies
Time duration of the crisis
Present signs 1
Clinical companion
Subsequent neurological deficit
Enable health scare

- Doctor
- Nurse
valoration
General condition
Vital signs (BP-HR-RR-Temp - SatO2)
Capillary glucose
ECG
State post-critical
Level of consciousness: test of
Glasgow (see Annex 4)
intervention (active convulsion)

Enable health scare
Security:
- Insert Guedel cannula
- Remove nearby objects to prevent
injury
Prepare suction and probes
Adm. O2 with ventimask 50%
Intravenous access
Prepare emergency medication:
- Diazepam 10mg iv or Midazolam 5
mg im/intranasal
Repeat the dose of drug if no cease
at 5 '
Lateral security post-seizure position
Notify the SEM (if necessary)
explanatory notes
1 Prior Aura, unconsciousness, automatisms, tongue bite, sphincter incontinence
V 1.2 12/2012
70
seizures
00035
Injury risk
00036
Risk for suffocation

INDISPENSABLE
OPTIONAL
6680
6610
Risk identification
2680
Seizure management
2690
Seizure precatiutions
6200
Emergency care
6490
Fall prevention
6654
Surveillance: safety
3390
Ventilation assistance
3350
0840
Positioning
3140
Airway management
3200
Aspitarion precautions
3320
Oxygen Therapy
5820
Anxiety reduction
5510
Health education
7920
Documentation
8100
Referral
V 1.2 12/2012
71
heatstroke
Date:
09/2007
Revision: 08/2012
Version:
1.2
Displayed when there are extreme temperatures or intense exercise. Body

temperature can reach 40.6 C and produces alterations on the CNS such as
headache, dizziness, lethargy, disorientation, delirium, convulsions or coma. Causing
frequently anhidrosis (hot red skin without sweating), shock, tachycardia and
hypertension. Mortality is up to15%.
anamnesis
referral
Age
Personal history
Drugs and allergies
Onset of symptoms
Identify if risk1 group belonging
Clinical companion
Call a doctor on call
valoration
General condition
Vital signs (BP-HR-Temp- RR - SatO2,
determine Temp every 5-10min)
Glasgow (see Appendix 4)
intervention
Lower temperature with physical
means (wet compresses / gel - no
alcohol because of absorption)
Do not give ASA
In conscious patients:
- Rehydration with isotonic drinks (Oral
Serum)
In patients with impaired
consciousness:
- Intravenous access
explanatory notes
1 Risk group:
Senior people, especially> 75 years
People with certain social circumstances: living alone, poverty ...
People with mental or physical disabilities with limited self-care
People with chronic diseases (DM, hypertension, heart disease)
People taking drugs that affect the CNS (Benzodiazepines, Neuroleptics, Antidepressants)
People with insufficient hydration and doing too much physical activity
V 1.2 12/2012
72
heatstroke
00028
00007
Hyperthermia

INDISPENSABLE
OPTIONAL
6680
0590
Urinary elimination management
3780
Heat exposure treatment
6650
Surveillance
3740
Fever treatment
2300
4140
Fluid resuscitation
1380
3900
Temperature regulation
5510
Health education
7920
Documentation
8100
Referral
V 1.2 12/2012
73
severe abdominal pain

Date:
09/2007
Revision: 08/2012
Version:
1.2
Abdominal pain with less than 72 h evolution, which can be very intense and present
obvious malaise.
The source can be very diverse: renal colic, intestinal occlusion - subocclusion,
appendicitis, cholecystitis, pelvic inflammatory disease, inflammatory bowel disease,
pancreatitis, vascular (intestinal ischemia, aortic dissection, vasculitis), ectopic
pregnancy, metabolic (diabetic ketoacidosis), neurogenic, referred (AMI,
pneumonia), fecaloma, psychogenic ...
anamnesis
Age
Personal history
Drugs and allergies
Day last menstrual
Time evolution
Clinical companion
- Diarrhea, vomiting and / or
constipation
- Acholia / coluria / jaundice
- Bleeding (hematemesis / melena /
metrorrhagia)
- Vegetatismo (sweating / nausea)
- Sd voiding and / or colic pain
radiating to F. renal
- How was it started to appear
- Circumstances that modifies it
referral
valoration
General condition
Vital signs (BP-Temp - HR - RR)
Depending on etiology of pain
- ECG (provided if: DM patient and /
or epigastric pain)
- Urine dipstick
- Pregnancy test
Abdominal exploration
- Inspection
- Auscultation
- Percussion
- Palpation
V 1.2 12/2012
74
severe abdominal pain

00132
Acute pain

INDISPENSABLE
OPTIONAL
6680
2400
1400
Pain management
6482
Environmental management: comfort
6650
Surveillance
2380
5510
Health education
2300
7920
Documentation
5616
8100
Referral
V 1.2 12/2012
Patient-controlled analgesia assistance
75
chest pain
Date:
09/2007
Revision: 08/2012
Version:
1.2
Chest pain is the reflection of chest or extra-thoracic disease of varying gravity, which
can cause anything from trivial to life threatening emergencies.
anamnesis
Age
Personal history (cardiovascular risk
factors)
Drugs and allergies
Ask if 1st Episode
Time evolution
Clinical companion
- Vegetatismo (sweating / nausea)
- Dyspnea
- Oppressive
- Mechanical
- Start time
- Location
- Irradiation
- Intensity
- How worsens
- Starting when rest or when exercise
referral
valoration
General condition
Vital Signs: (BP-HR-RR- SatO2)
ECG
Monitorize
- ECG
- Pulse oximetry
V 1.2 12/2012
76
chest pain
00132
Acute pain

INDISPENSABLE
OPTIONAL
6680
6610
Risk identification
1400
Pain management
6140
Code management interventions
4010
Bleeding precautions
6482
4044
Cardiac care: acute
5820
Anxiety reduction
6650
Surveillance
5510
Health education
7920
Documentation
8100
Referral
V 1.2 12/2012
77
fever > 39C

Date:
09/2007
Revision: 08/2012
Version:
1.2
Increase in body temperature above 39 C, which shows the reaction of the organism
to a pathological process.
anamnesis
referral
Age
Personal history
Drugs and allergies
Time evolution
Presence chills
Cocaine consumption
Precipitating causes and recovery
Immune status and immunizations
performed
Epidemiological history (interview for
detection of focus) 1
Clinical companion
valoration
General condition
Constants: (BP-HR-RR-Temp - SatO2)
Skin condition
- Macules
- Papules
- Vesicles
- Blisters
- Petechiae
Signs of dehydration
ECG (if cocaine consumption or
suspected cardiac origin)
Urine Strip
Basic exploration (Respiratory,
ear&nose...)
Maneuver exploration neck stiffness
intervention
Paracetamol 500 - 1g orally.
No excess shelter
Tell adequate fluid intake
Give treatment depending on the
cause
explanatory notes
1 If founded focus: act as appropriate protocol (discomfort when urinating, sore throat, flu,
diarrhea, insect bites, respiratory symptoms in upper airways)
V 1.2 12/2012
78
fever > 39C

00007
Hyperthermia

INDISPENSABLE
OPTIONAL
6680
4260
3900
Temperature regulation
2300
3740
Fever treatment
2380
6650
Surveillance
5510
Health education
7920
Documentation
8100
Referral
V 1.2 12/2012
Shock prevention
79
intoxications
Date:
09/2007
Revision: 08/2012
Version:
1.2
The entry into the body of any living substance capable of causing pathological
changes in the vital functions of the person. 70% of poisonings are voluntary and
about 60% are because of drugs, followed by overdose drug abuse, domestic
accidents, and working accidents finally.
anamnesis
Age
Personal history
Drugs and allergies
Toxic type
Time evolution and exposure time
Way of exposure to toxic (orally,
inhalation, intravenous,
percutaneous ...)
Clinical companion
- Pain
- Dizziness
- Dyspnea - Headache
referral
valoration
General condition
Constants: (BP-HR-RR-Temp - SatO2)
Unconscious and not breathing
normally: act as Cardiac arrest
guideline
Unconscious and breathing normally:
act as loss of consciousness guideline
intervention
Treatment of alterations as specific
protocols
Acting on doctor's orders
V 1.2 12/2012
80
intoxications
00044
00134
Nausea
00013
Diarrhea
00028
00035
Risck for injury

INDISPENSABLE
OPTIONAL
6680
5820
Anxiety reduction
1450
Nausea management
6482
5510
Health education
5246
Nutritional counseling
7920
Documentation
4140
Fluid resuscitation
8100
Referral
2080
Fluid/Electrolyte management
4200
Entravenous therapy
V 1.2 12/2012
4060
Shock prevention
2380
5616
2300
4120
Fluid management
81
serious eye injury

Date:
09/2007
Revision: 08/2012
Version:
1.2
Need to assess the origin of the pathology. If it is a trauma, it may be periorbital

(hematoma or wound around the orbit with possible eye edema, blurred vision or loss
of vision and painful eye) or ocular either with or without foreign body. There may be
eye pain, redness, blurred vision, loss of vision and tearing.
anamnesis
referral
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion
Injury mechanism
State vaccine (Td)
valoration
General condition
Vital Signs: (BP)
Pain (see Annex 1)
Causal agent:
- Organic foreign body
- Non-organic foreign body
- Substance
Hemorrhage and/or hematoma
Eyelid edema
Tearing
Blurred vision
intervention
Ocular trauma and/or foreign body:
- Washing with saline
- Application of Fluorescein (if MF is
down to box)
explanatory notes
If labor or traffic accident: Need to notify to center administration
If labor accident: do initial assessment on the 1st cure and refer to the work insurance
V 1.2 12/2012
82
serious eye injury

00044
00132
Acute pain

INDISPENSABLE
OPTIONAL
3680
Wound irrigation
3590
Skin surveillance
2310
Medication administration: eye
6550
6680
1400
Pain management
1650
Eye care
6530
5510
Health education
8100
Referral
7920
Documentation
V 1.2 12/2012
83
intens headache
Date:
09/2007
Revision: 08/2012
Version:
1.2
It is the intense painful sensation localized between orbital and sub-occipital region.
Tension headache and migraine account for over 80% of primary headaches.
Secondary headache may be accompanied of any febrile and/or infectious process
(GEA, flu, sinusitis, toothache, trauma, vascular disorders, metabolic ...)
anamnesis
Age
Personal history (if usually suffers, from
what age)
Drugs and allergies
Time evolution of the episode
Establishment (sudden or gradual)
Location (hemicranial, holocraneal,
front)
Quality (pulsating, oppressive)
Clinical companion
- Nausea, vomiting, photophobia,
intolerance to noise
- Hemiparesis, diplopia, unsteadiness
- Vertigo, aphasia, confusion
referral
Neurological examination, if
necessary
valoration
General condition
Vital Signs: (BP-Temp - HR-RR)
V 1.2 12/2012
84
intens headache
00132
Acute pain

INDISPENSABLE
OPTIONAL
6680
6482
1400
Pain management
2400
6650
Surveillance
5270
Emotional support
5510
Health education
2380
7920
Documentation
2300
8100
Referral
5616
V 1.2 12/2012
85
dizziness
Date:
09/2007
Revision: 08/2012
Version:
1.2
Unpleasant
sensation of weakness, having an empty head, to be floating in the air,
Revisi
insecurity when lying or walking, but no sense of displacement.
anamnesis
referral
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion (nausea,
sweating, palpitations, rotation of
subjects, dizziness, cephalic mov ...)
Track start and exacerbation of
symptoms
Discard neurological pathology or TBI
valoration
General condition
Constants: (BP-HR-RR Temp.)
Capillary glucose
ECG
intervention
If BP>= 210/120 mmHg symptomatic:
act according to physician orders
If BP>= 210/120 mmHg asymptomatic:
rest and check BP
If glucose <60 mg/dl:
- Urine dipstick (ketonuria)
- Glucose orally (conscious patient)
If glucemia > 300 mg/dl:
- Urine dipstick (ketonuria)
If other etiologies1:
- Psychogenic
- Pre-syncope or syncope
- Vertigo
- Mixed
- Hypovolemic
explanatory notes
1
Etiology:
Psychogenic: anxiety, agoraphobia ...

Pre-syncope or syncope: vasovagal, orthostatic. Valvular and arrhythmias
Vertigo: central or peripheral (rotation of objects, nausea ...)
Mixed: gait disorders and multiple sensory deficits in the elderly
Hypovolemic: severe liquid loss (hematemesis, melena ...)
V 1.2 12/2012
86
dizziness
00134
Nausea
00035
Risck for injury

INDISPENSABLE
OPTIONAL
6680
5616
6490
Fall prevention
6610
Risk identification
6654
Surveillance: safety
5820
Anxiety reduction
5510
Health education
6482
7920
Documentation
1450
Nausea management
8100
Referral
1570
Vomit management
2380
V 1.2 12/2012
87
drowning
Date:
09/2007
Revision: 08/2012
Version:
1.2
Subjective sensation of difficulty in breathing associated with increased effort to

breathe.
anamnesis
Age
Personal history
Drugs and allergies
Time evolution
Clinical companion
Causes of diyspnea1 (COPD, heart
disease)
Features of dyspnea
referral
valoration
General condition
Constants (BP-HR-RR Temp.)
Pulse Oximetry
Auscultation
ECG
intervention
Prepare O2
Prepare bronchodilators
Act depending on SatO2:
SatO2 (%) Acting
> 95 No immediate action
90-95 treatment if necessary and
monitoring
80-90 severe hypoxia. O2 +
bronchodilator
<80 Emergency situation
explanatory notes
1
Causes of dyspnea:
Acute: Blockage of the airway (foreign body, edema of the glottis, asthma attack,
tumors ...); chest causes (pneumothorax, pleural effusion and traumatism); cardiogenic
edema (arrhythmias, AMI and CHF) and secondary hyperventilation in panic attacks.
Chronic: Chronic obstructive pulmonary disease; pulmonary fibrosis; cardiovascular
causes (pulmonary hypertension and decreased cardiac volume) and metabolic causes
(acidosis, hypo-hyperthyroidism)
V 1.2 12/2012
88
drowning
00033
Impaired spontaneous ventilation
00032
Ineffective breathing pattern

INDISPENSABLE
OPTIONAL
6680
3200
3350
3230
Chest physiotherapy
3140
Air way management
3180
Artificial airway management
6200
Emergency care
3160
Airway suctioning
3390
Ventilation assistance
2300
3320
Oxygen Therapy
2380
6650
Surveillance
5510
Health education
7920
Documentation
8100
Referral
V 1.2 12/2012
89
loss of conscience
Data:
09/2007
Revisi: 08/2012
Versi:
1.2
Occurs when the person, for a time, no longer alert and respond to environmental
stimuli. It may occur transiently and spontaneously recovery (syncope) or in a
sustained time without spontaneous recovery (coma).
anamnesis
referral
Age
Personal history (Heart Failure, syncope
or sudden death)
Number of episodes
Drugs and allergies
Time evolution
Witnessed loss of consciousness or not
Prdromes: inestability sensation, visual
disturbances, nausea, sweating, ...
Precipitating causes and recovery
Clinical companion:
- Chest pain
- Fever
- Dyspnea
- Headache
- Palpitations
valoration
General condition
Constants: (BP-HR-RR - Temp.)
Skin (petechiae and venipuncture)
Capillary glucose
ECG (discard cardiogenic syncope)
intervention
If NOT breathing normally: see
protocol of cardiac arrest.
If breathing normally:
- Lateral safety position
- Guedel cannula
- Prepare O2 (intravenous access)
- Prepare emergency medication 1
If no recovery, warn 061
explanatory notes
1 Emergency medication prepared according to etiology:
Hypoglycemia: Glucose 50% ev (Glucosmon R50)
Benzodiazepine Overdose: Flumazenil 0.2 mg ev in 30'' and repeat up to 2 mg
Opiate overdose: Naloxone 0.4 - 0.8 mg ev
V 1.2 12/2012
90
loss of conscience
00035
Risck for injury
00204
Ineffective peripherial tissue perfusion (cerebral)
00039
Risk for aspiration

6680
4250
Shock management
3320
Oxygen Therapy
2550
Cerebral perfusion promotion
6610
Risk identification
0840
Positioning
6650
Surveillance
3200
5510
Health education
3160
Airway aspiration
7920
Documentation
1570
Vomit management
8100
Referral
4200
Intravenous therapy
2380
2300
V 1.2 12/2012
91
gastrointestinal bleeding
Date:
09/2007
Revision: 08/2012
Version:
1.2
Blood from the digestive apparatus which, according to their location, will have one
aspect or another and with varying degrees of severity. We need to stress the fact
differential of hemoptysis that although out of the mouth, is blood from the respiratory
tract.
anamnesis
referral
Age
Personal history (gastric ulcer)
Drugs and allergies
Time evolution
Clinical companion
valoration
General condition
Constants: (BP-HR-Temp - RR)
Color and condition of the skin and
mucous
Location of the bleeding1
intervention
If rectal bleeding with no gravity signs2:
- Analgesia, if necessary, according
guideline3
- Hygienic tips
- Hygiene and dietary Counseling for
constipation
- Appointment with physician referral
Rest of bleeding (hematemesis, rectal
bleeding imp, melena, hemoptysis):
- Intravenous Access
- Acting on doctor's orders
If there is no recovery, Warn 112
explanatory notes
1 Location of bleeding:
Rectal: Red Blood coming from the anus alone or accompanied by stool
Melena: black stools, bright, colored and fetid sticky (tarry stools)
Hematemesis: Red blood without gastric contents from the digestive system. Also vomiting
have blackish appearance
Hemoptysis: Red Blood coming from the mouth, usually accompanied by cough, from the
respiratory tract.
2 Rectal bleeding without signs of severity:
Hemorrhoids
Fissures
Red blood at the end of stool
3 Check drugs guide
V 1.2 12/2012
92
gastrointestinal bleeding
00204
Ineffective peripherial tissue perfusion (gastrointestinal)
00028
00132
Acute pain

INDISPENSABLE
OPTIONAL
6680
4022
Bleeding reduction: gastrointestinal
4180
Hypovolemia management
4260
Shock prevention
6650
Surveillance
4258
Shock management: volume
4160
Control of bleeding
6482
5510
Health education
5270
Emotional support
7920
Documentation
4200
Intravenous therapy
8100
Referral
2380
2300
4190
Intravenous insertion
4140
Fluid resuscitation
5616
V 1.2 12/2012
93
traumatic brain injury

Date:
09/2007
Revision: 08/2012
Version:
1.2
A traumatic brain injury is any injury caused by external mechanical action on the
head regardless of possible neurological repercussions. Should this occur would speak
about traumatic encephalic brain injury.
anamnesis
referral
Age
Personal history
Drugs and allergies
Time evolution
Lesional mechanism1
Clinical companion
- Pain
- Dizziness
- Dyspnea - Headache
valoration
General condition
Vital Signs: (BP-Temp- RR-HR-SatO2)
Unconscious and not breathing
normally: act as cardiac arrest
guideline
Unconscious and breathing normally:
act as loss of consciousness guideline
Skin condition
intervention
Recovery position
Prepare material for cures
explanatory notes
1
Lesional mechanism:
Accident or aggression: notify the physician on call for the release of injuries press
Labor accident: Make initial assessment and first cure, and refer to labor insurance
Case of labor or traffic accidents: need to communicate at administration of the center
V 1.2 12/2012
94
traumatic brain injury

00132
Acute pain
00046

INDISPENSABLE
OPTIONAL
6680
5616
1400
Pain management
2400
6650
Surveillance
6482
3660
Wound cure
3620
Suture
5510
Health education
3590
Skin surveillance
7920
Documentation
6530
8100
Referral
2380
2300
V 1.2 12/2012
95
severe trauma
Date:
09/2007
Revision: 08/2012
Version:
1.2
Any person with a traumatic injury involving significantly or potentially compromise to

the respiratory function and/or cardiocirculatory, and therefore with high lifethreatening
anamnesis
referral
Age
Personal history
Drugs and allergies
Time evolution
Lesional mechanism 1
Clinical companion
- Pain
- Dizziness
- Dyspnea
- Headache
valoration
General condition
Vital signs: (BP-HR - RR-Temp - SatO2)
Hemorrhage (open wounds / signs of
shock)
Permeable airway
intervenci
explanatory notes
1
Lesional mechanism:
Accident or aggression: notify the physician on call to release injuries press
Labor accident: Make initial assessment and 1st cure, refer to laboral insurance
Case labor or traffic accidents: need to communicate to the administration of the center
We must imagine the potential injuries not apparent (hidden). Considering the apparently
healthy patient as a serious injuried patient until the contrary is proved. 5-10% of patients
who do not have anatomical lesions or alterations in vital signs in the first review, and have
suffered an accident at high energy, subsequently suffer serious injuries.
V 1.2 12/2012
96
severe trauma
00132
Acute pain
00046

INDISPENSABLE
OPTIONAL
3660
Wound cure
1380
1400
Pain management
3680
Wound irrigation
6680
2300
6650
Surveillance
6530
5510
Health education
6482
7920
Documentation
3620
Suture
8100
Referral
0910
Immobilization
2380
5616
V 1.2 12/2012
97
vomiting
Date:
09/2007
Revision: 08/2012
Version:
1.2
It is the oral violent expulsion of gastric contents.
anamnesis
referral
Age
Personal history
Drugs and allergies
Time evolution
Vomiting features
- A fetid odor
- Hematemesis
- Gastric Contents (food)
Associated diarrhea stools: GEA
protocol
valoration
General condition
Vital signs: (BP-HR-Temp - RR)
Capillary glucose
Urine strip (if DM / if lumbar pain)
Signs of dehydration (mucosal, fold...)
intervention
Safety position to prevent aspiration
V 1.2 12/2012
98
vomiting
00134
Nausea

INDISPENSABLE
OPTIONAL
6680
5820
Anxiety reduction
1450
Nausea management
6482
5510
Health education
2380
7920
Documentation
5616
8100
Referral
2300
V 1.2 12/2012
99
anaphylactic shock
Date:
09/2007
Revision: 08/2012
Version:
1.2
Syndrome Initiated by acute systemic hypoperfusion, which leads to tissue hypoxia

and dysfunction of vital organs.
anamnesis
Age
Personal history
Drugs and allergies
Time evolution of the initial
Etiology by hypersensitivity
Clinical companion
- Tachycardia
- Hypotension
- Seizures
- Oliguria
- Erythema
- Urticaria
- Nausea
- Diarrhea
- Hypo-perfusion tissue
referral
valoration
General condition
Vital Signs: (BP-HR - RR - Temp - SatO2)
Skin and mucous membranes:
ictericia, pale mucous membranes,
hives, petechiae
Edema of glottis
Hyperthermia, chills
Hypoventilation
intervention
Supine position with 20 elevation of
lower limbs
Venous access placement
Prepare medication:
- Methylprednisolone 40-60 mg im
- Adrenalina amp sc
Insert Guedel cannula if necessary
V 1.2 12/2012
100
anaphylactic shock
00132
Acute pain
00046

INDISPENSABLE
OPCIONALS
6680
1380
6650
Surveillance
2380
5510
Health education
2390
7920
Documentation
2300
8100
Referral
V 1.2 12/2012
101
drugs guide
analgesics and antipyretics

Date:
09/2007
Revision: 08/2012
Analgesics are drugs used to relieve pain relatively independently of its cause or origin.
DRUGS
Anamnesis:
Allergies
Other drugs
Features of pain
Personal history
Assess intensity of pain (growing):

Paracetamol orally
Ibuprofen orally
Diclofenac orally im
Metamizol orally im
In case of:
Allergies
Gastrointestinal problems
Gestation and lactation
Anticoagulant treatment
Paracetamol orally
If needs more
Consult a doctor on call
V 1.2 12/2012
105
analgesics and antipyretics

ACTIVE PRINCIPLE
DOSE
PARACETAMOL
500 mg-1 g/4-6 h.

(max. 4 g/day)
IBUPROFEN
DICLOFENAC
ADMINISTRATION WAY
TRADEMARKS
Oral
Paracetamol EFG
Termalgin
Efferalgan
Xumadol
Gelocatil
400-600 mg/4-6 h.p

(mx. 2400 mg/day)
Oral
Ibuprofen EFG
Espidifen
Neobrufen
50 mg/8 h.
(max. 150 mg/day)
Oral
Diclofenac EFG
Voltaren
75 mg
Intramuscular
575 mg/6-8 h.
Oral
2g
Intramuscular
Metamizol EFG
Nolotil
Lasain
METAMIZOL
In case of intolerance to AINES, renal insuficiency, ulcer background, asthma, hiatal hernia, 65 and older, IC or HTA, Paracetamol only.
We can alternate paracetamol with AINE (Ibuprofen or Diclofenac) every 3 or 4 hours.
If contraindications, Metamizol can replace AINE, or being used as a rescue (alternated with paracetamol/AINE).
In case of oral anticoagulant teraphy (OAT), AINE and Metamizol can alter its action.
V 1.2 12/2012
106
antibiotics
Date:
Revision:
09/2007
08/2012
When antibiotic treatment for a presumptive diagnosis is given, the choice will be made
according to the most probable organisms, choosing antibiotic regimens that adequately
cover the narrowest possible spectrum. It must be considered the location of the infection,
the age of the patient, the severity of symptoms and possible allergies or intolerances.
DRUGS
Anamnesis:
Allergies
Other drugs
Features of the infection
Personal history
Penicilines:
Amoxiciline clavulanic
Cloxaciline
In case of:
Other antibiotics:
Claritromicine
Clindamicine
Eritromicine
Fosfomicine
V 1.2 12/2012
Allergies
Gastrointestinal problems
Gestation - Lactation
Anticoagulant treatment
Consult a doctor on call
107
antibiotics
ACTIVE PRINCIPLE
DOSE
ADM.
WAY
AMOXICILINE
AC. CLAVULANIC
500-875/125 mg c/8 h.
(8-10 days)
CLINDAMICINE
150-300 mg
c/6 h.
(8-10 days)
CIPROFLOXACINE
CLOXACILINE
ERITROMICINE
Amoxiciline - clavulanic acid

EFG
Augmentine
Clavumox
Infections of skin and soft tissues:

Dental abscess
Celulitis
Animal bites
Dalacin 150 mg
Dalacin 300 mg
Antibiotic choice in case of

allergie to peniciline
500 mg
c/12 h.
(8-10 days)
Ciprofloxacino EFG
Pseudomones Infection
500 mg/ 6-8 h.

(8-10 days)
Orbenin 500 mg
Infections of skin and soft tissues:

Furunculosis,
Wound and infected burn
Celulitis
Piomiositis
Bronsema 500 mgr sobres env

12
Eritorgobens 500 mgr comprim
env 12
Eritromicina estedi EFG 250 mgr
env 12 i 24 caps
Antibiotic
Monurol 3 g
Urinary infections
3g
(single dose)
V 1.2 12/2012
INDICATIONS
250-500 mgr every/6h 810d
FOSFOMICINE
TRADEMARKS
108
topical treatments
Date:
09/2007
Revision: 08/2012
ACTIVE PRINCIPLE
TRADEMARK
PROPERTIES
ACICLOVIR
Aciclovir EFG
Zovirax
Antiviric
FUSIDIC ACID
Fucidine
Antibacterian
TRANEXAMIC ACID
Amchafibrin
Antihemorrhagic
CARBENOXOLONE
Afta juventus
Sanodyn gel
Oral antiulcer
CLORHEXIDINE
Cristalmina
Antiseptic
CLOTRIMAZOL 1%
Canesten
Clotrimazol byfarma EFG
Fungistatic
FLUORESCENE
Fluorescena oculos
Eye contrast
HIDROCORTISONE
Dermosa Hidrocortisona
Lactisona
Antiinflammatory
HIDROFIVER
Aquacel
Aquacel Ag
Hydrosorb
Antibacterian and epithelium
Calcareous oil liniment + oxid of zinc 250

cc
Topical antiseptic
ARGENTIC SULFADIAZINE
Silvederma
Antibacterian
VASELINE
Vaseline
Emollient and dermoprotector
CALCAREOUS OIL LINIMENT
V 1.2 12/2012
109
others
Date:
09/2007
Revision: 08/2012
ACTIVE PRINCIPLE
PRESENTATIONS
ADM.
VIA
ACICLOVIR
Tablets 200 mg
Aciclovir 200 EFG

Zovirax 200
Antiviric
ADRENALINE
Blister 1 mg
sc
Adrenaline Braun
Adrenaline Level
Vasoconstrictor
AMIODARONE
Blisters 150 mg
ev
Trangorex
Antiaritmic
DEXCLORFENIRAMINE
Tablets 2 mg
Blisters 5 mg
o
im
Polaramine
Antihistaminic
DEXTROMETORFANE
Syrup
Tablets
Romilar jarabe
Romilar tablets 15 mgr
Antitussive
DIAZEPAM
Tablets 5 mg
Blisters 10 mg
o
im
Diazepam EFG
Valium
Anxiolytic
FLUMACENIL
Blisters 0,5mg
Blisters 1 mg
im
Anexate
Flumacenilo EFG
Antidot of benzodiazepines
GLUCOSE 33%
Blisters 10 ml
im
Glucosmon
For hipoglucemia
HIDROCORTISONE
FOSFAT SODIC
Blisters 100 mg
im
Actocortina
Antiinflamatori
Antiallergic
LEVONORGESTREL
Tablet 15mgr
1 x container
Norlevo
Postinor
Progestagen
Day after pill
LORATADINE
Tablets 10 mg
Loratadine EFG
Antihistamnic
MEPIVACAINE
Blisters 2%
sc
Scandinibsa
Local anesthetic
MIDAZOLAM
Blisters 5 mg
Im
intranas
Dormicum
Midazolam EFG
Hipnothic
METILPREDNISOLONE
Blisters of:
8 mg
20 mg
40 mg
im
Urbason
Solu Moderin
Antiinflammatory
Antiallergic
METOCLOPRAMIDE
Tablets 10 mg
Blisters 10 mg
o
im
Primperan
Antiemethic
NALOXONE
Blisters 0,4 mg
ev
im
Naloxona
Antdot opioide
OXIMETAZOLINE
Drops
Spray
topical
nasal
Respir
Utabon
Nasal decongestant
GLUCOSE SERUM
Blisters 250 ml
Blisters 500ml
ev
Glucosed serum
Way maintenance
ORAL SERUM
Envelopes
Oral serum Casen

Oral serum Hiposdico
Oral rehydration
TETRAZEPAM
Tablets 50 mg
Myolastan
Myorelaxant
V 1.2 12/2012
TRADEMARK
PROPERTIES
110
annex
1. pain scales
Pain scales are a resource that is used to describe the amount of pain a person is feeling.
These scales include numerical rating scale, visual analogy, categories and faces pain
scale:
NUMERICAL RATING SCALE

0
(0) No pain
10
The worst pain imaginable (10)
It has to be asked the person to choose a number between 0 and 10, depending on the intensity of pain he/she has.
VISUAL ANALOGY
No pain
The worst pain imaginable
It has to be asked the person to choose a point in the line that corresponds to the pain he/she feels.
CATEGORIES SCALE
None (0)
Mild (13)
Moderated (46)
Severe (710)
It is asked the person to select the categorie reflexing much better the pain he/she feels.
FACES PAIN SCALE
0
Happy
No pain
2
Just feels a little
pain
4
feeling a little more
pain
6
Feels even more
pain
8
Feels a lot of pain
10
Pain is the worst
imaginable (no
need to mourn for
feeling this strong
pain)
It is asked the person to select the face that best describes how he/she feels. This scale can be used with patients older than 3 years.
V 1.2 12/2012
113
2. radiographic projections
The following table shows the most common projections when simple radiography is
requested for possible fractures assessment. In case of children, they are always
bilateral.
RADIOGRAPHIC PROJECTIONS
ZONE TO EXPLORE
REQUESTED PROJECTIONS
Skull and face
Frontal and profile
Column
Frontal and profile
Pelvis
Frontal
Fmur
Frontal and profile
Knee
Frontal and profile ( axial of patella)
Tibia and fibula
Frontal and profile
Foot and toes
Frontal and oblique ( axial of patella)
Thorax
Rib cage
Clavicle
Frontal, axial and AP acromioclavicular
Back
Frontal and axial
Humerus, elbow and forearm
Frontal and profile
Wrists
Frontal and profile
Scaphoid
Sneck
Hand
Frontal and oblique
Fingers and thumb
Frontal and profile
V 1.2 12/2012
114
3. nursing assessment
We base nursing assessment on the Virginia Henderson model, where we identify the
manifestations of dependence in every need.
To simplify the evaluation we have considered using the Likert scale where 1 is
dependence and 5 is independence.
14 NEEDS OF VIRGINIA HENDERSON

NEED
LIKERT SCALE
1
1 Breathe
2 Nourish and hydrate
3 - Remove
4 Move and mantain good posture
5 Rest and sleep
6 Using adequate clothes
7 - Thermoregulation
8 - Hygiene and skin protection
9 Avoid risks
10 - Communicate
11 - Live according to their values and beliefs
12 Work and perform
13 - Play / participate in recreational activities
14 - Learn
V 1.2 12/2012
115
4. neurological assessment
Consciousness is the state in which the person becomes aware of itself and the
environment. This means that the subject is alert and sufficient intellectual and emotional
mental attitude that allows the integration and response to internal and external stimuli.
The elaborated scales and responses to various stimuli, are usefull for us to get a measure
of the level of consciousness reproducible in subsequent checks.
TEST OF GLASGOW
Ocular response
Motor response
Spontaneous
Strong voice
To pain
Null
4
3
2
1
Obeys orders
Localizes pain
Removes the pain
Flex the pain
Abnormal extension to pain
Null
CONSCIOUSNESS STATE
Conscious
Unconscious
Clouded
Oriented
Disoriented
6
5
4
3
2
1
Oriented
Confusing conversation
Inappropriate words
Incomprehensible sounds
Null
5
4
3
2
1
PUPIL ASSESSMENT (mm)
V 1.2 12/2012
Verbal response
116
4. burn lesions assessment

Depending on depth
Affected layer
Degree I
Degree II superficial
or dermal
Epidermis
Capilar dermis
Image
Features
Redness
Lack of ampules
Hiperestesia or
acute pain
Depending on extension
Wallace Rule (use only with adults)
Flictenas
Redness
Hiperestesia
Degree II deep
Capilar dermis +
reticular dermis
No flictenas
Whitish colored
Hiposensibility
Degree III or
thick
Hypodermis
No flictenas
Pale colour or yellow
to black
Thrombossed vessels
Anesthesia
Rule of 1: as reference of the palm of the hand

of the patient (can be used in adults and
children)
Land & Browder rule (used with children until 14-16 years): on this rule, proportions of children in relation to
age are specified.
V 1.2 12/2012
117
bibliography
articles, books & webs

Brugus Brugus A, Peris Grao A. Cmo organizar la consulta del centro de salud? En: Guia de Actuacin en
Atencin Primaria. (4a edic). semFYC, Barcelona, 2011. 15.3: 1369-1373
Brugus Brugus A et al. Abordaje de la demanda de visitas espontneas de un equipo de atencin primaria
mediante una gua de intervenciones de enfermera. Aten Primaria. 2008;40(8):387-91
Camfic. Guia dactuaci en urgncies per a lAtenci Primria. Semfyc Ediciones. 2009
Casajuana Brunet J. En busca de la eficiencia: dejar de hacer para poder hacer. FMC. 2005;12(9):579-81
Generalitat de Catalunya Departament de Salut. Llibre Blanc: consens sobre les activitats preventives a ledat
adulta a lAtenci Primria. 1a edici. Barcelona: Generalitat de Catalunya; 2005
Garca I. Conoce la poblacin los servicios que ofrece la enfermera comunitaria? Enfermera Comunitaria 2006,
2 (1): 17-23
Hernndez-Faba E,Sanfeliu-Julia C. Atencin de la patologia aguda de enfermera en atencin primaria: caso
clnico en la odinofagia. EnfermClin. 2010;20:197-200. vol.20 nm 03
Institut Catal de la Salut. Gesti de la demanda espontnia.[Internet] Disponible en:
http://www.gencat.cat/ics/professionals/pdf/gestio_demanda_espontania_2011.pdf
Johnson M. & col. Diagnsticos enfermeros, resultados e intervenciones. Interrelaciones NANDA, NOC y NIC. 2a
edici. Madrid: Elsevier Mosby; 2007
Johnson M. et al. Vnculos de NOC y NIC a NANDA-I y diagnsticos mdicos. 3a edici. Elsevier: 2012
Kilpatrick K. Nurs Inq. Praxis and the role development of the acute care nurse practitioner.2008 Jun;15(2):116-26.
Lalanda, M. De Okupas, Efer-mesas y Nurse Practitioners. ENE. Revista de Enfermera. 5(3):69-72 [Internet]
Disponible en: http://enfermeros.org
Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Sustitucin de mdicos por enfermeras en la
atencin primaria. Reproduccin de una revisin Cochrane, traducida y publicada en La Biblioteca Cochrane
Plus, 2008, Nmero 2
Llus MT. Los diagnsticos enfermeros. Revisin crtica y gua prctica. 8a edici. Barcelona: Elsevier Masson; 2008
Martin Santos FJ, Morilla Herrera JC, Morales Asencio JM, Gonzalo Jimenez E. Gestin compartida de la demanda
asistencial entre mdicos y enfermeras en Atencin Primaria. Enfermeria Comunitaria. 2005; 1 (1): 35-42
McCloskey Dochterman J, Bulechek GM. Clasificacin de NURSING INTERVENTION (NIC). 5a edici. Madrid: Elsevier
Mosby; 2009
Millas Ros J, et al. Consulta de atencin primaria: todo es del mdico? Atencin Primaria. 2011.
Morales Asencio JM, Martin Santos FJ, Morilla Herrera JC, Contreras Fernndez E. Prescripcin de medicamentos y
productos sanitarios por enfermeras comunitarias. Enfermera Comunitaria. 2006; 2 (1)
Morilla Herrera JC, Morales Asencio JM, Martin Santos FJ, Cuevas Ferndez-Gallego M. El juicio clnico enfermero:
conjugacin de modelo, lenguaje y efectividad de las intervenciones enfermeras. Metas de enfermeria. 2005; 9
(2): 6-12
Moorhead S, Johnson M, Maas M. Clasificacin de resultados de enfermera (NOC). 4a edici. Madrid: Elsevier Mosby;
2009
NANDA International. Diagnsticos enfermeros: definiciones y clasificacin 2009-2011. Barcelona: Elsevier; 2010
Ruiz Tllez A. La organizacin de un equipo de Atencin Primaria. Centro de Salud 1999; 7: 592-606.
semFYC. Gua de Actuacin en Atencin Primaria. (4a edic). semFYC, Barcelona, 2011
Villa LF. Medimecum. Gua de terapia farmacolgica. 17a edici. Adis Internacional; 2012
WY Chin, Cindy LK Lam, SV Lo. Quality of care of nurse-led and allied Health personnelled primary care clinics.
Hong Kong Med J 2011;17:217-30
V 1.2 12/2012
121

Priority Interventions

Diunggah oleh

Informasi Dokumen

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Priority Interventions

Diunggah oleh

Hak Cipta:

Format Tersedia

adults

Guia dIntervencions dInfermeria a Problemes de Salut EAP Can Bou

Castelldefels Agents de Salut (CASAP)

Translation by Clara Mart Aguasca

Nursing Interventions Guide to Health Problems - Can Bou EAP

Intens headache .............................................. 84

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP

Authors: working group of non scheduled demand management

Technical support and design

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP

Dr. Antoni Peris i Grao

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP

Alba Brugus i Brugus

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP

Healthcare team of EAP Can Bou

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP

circuit care demands

Family physician non

Possible nursing solving

Castelldefels Agents de Salut dAtenci Primria CASAP

TELEPHONE CALL &

Nursing Interventions Guide to Health Problems - Can Bou EAP

There are many possible causes: superficial erosions, superinfections, nonspecific,

Other cases outside the oral cavity

Analgesia if required as guideline:

Check drugs guide

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP

Impaired oral mucous membrane

NURSING INTERVENTIONS (NIC)

Teaching: prescribed medication

Oral Health maintenance

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP

If time since intercourse> 72 h

If a history of hypersensitivity to the

Pediatrician valoration < 15 years

Castelldefels Agents de Salut dAtenci Primria CASAP

1500 mcg Levonorgestrel

Nursing Interventions Guide to Health Problems - Can Bou EAP

Risk-prone health behavior

Deficient knowledge: contraception and safe sex

NURSING INTERVENTION (NIC)

Teaching: prescribed medication

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP

Pain (see Annex 1)

Check drugs guide

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP

Impaired skin integrity

Impaired tissue integrity

Risk for infection

NURSING INTERVENTION (NIC)

Skin care: topical treatments

Castelldefels Agents de Salut dAtenci Primria CASAP

Nursing Interventions Guide to Health Problems - Can Bou EAP