Case study of a person with autoimmune encephalitis based on the theory of self-care deficit of Dorothea Orem

Estudio de caso de una persona con encefalitis autoinmune basado en la teoría déficit de autocuidado de Dorothea Orem

Abstract

Introduction: This case study describes a nursing intervention plan in a 49 years old female with autoimmune encephalitis, aiming to identify altered universal requirements in the evolution of her disease to restore them.

Methodology: PICO question was used to consult articles in the database, application of the neurological assessment instrument, electronic medical record, interviews with the primary caregiver with prior informed consent, respecting the ethical principles that govern our actions, transferring nursing care to the home through a discharge plan.

Description of the clinical case: Her condition began on April 27, 2021, 48 hours previously with stabbing headache in occipital region VAS 6/10 paroxysmal episodes four times a day, language alteration, periods of agitation, inattention and emotional lability, puncture lumbar showed a discrete inflammatory process, for which therapeutic management was provided.

Relevance: Knowing the course of the disease and the impact it has on the person improves nursing care.

Results and conclusions: During their hospital stay, nursing neurological identification assessments were carried out and, according to the clinical judgment obtained with the valued information, they were real, possible and well-being problems, managing to carry out the nursing care process.