건강사정 완벽정리 (A+ 자료/자세함)

목차

Ⅰ. 사정의 기초 단계
1. 건강력 ···································································································································································· 3

Ⅱ. 건강사정
1. 건강사정의 종류와 범위 ·································································································································· 4
2. 대상자와 환경의 준비 ······································································································································· 5

Ⅲ. 신체검진
1. 신체검진 기구 ······················································································································································ 5
2. 체위 ··········································································································································································· 5
3. 신체검진 방법 ······················································································································································· 5

Ⅳ. 체계적 건강사정 방법
1. 전반적 조사 ··························································································································································· 6
2. 피부와 부속기 사정 ··········································································································································· 6
3. 두경부 사정 ··························································································································································· 8
4. 흉부와 폐 사정 ·················································································································································· 11
5. 심혈관계 사정 ···················································································································································· 13
6. 유방과 액와 사정 ············································································································································· 13
7. 복부사정 ······························································································································································· 14
8. 여성과 남성의 생식기 사정 ························································································································· 15
9. 직장과 항문 사정 ············································································································································· 15
10. 근골격계 사정 ················································································································································· 16
11. 신경계 사정 ······················································································································································ 16

Ⅴ. 진단적 처치 검사
1. 임상병리 검사 ···················································································································································· 19
2. 진단적 처치 검사 ············································································································································· 19
3. 진단적 검사에서 간호사의 역할 ················································································································ 20

Ⅵ. 요약 ······································································································································································· 20

Ⅶ. 참고문헌

본문내용

건강사정(health assessment)은 전문직 간호를 수행하는 데 필수적인 부분이며, 간호과정의 기초가 된다. 건강사정은 질병예방, 건강회복과 불구나 죽음을 극복하는 중재를 통하여 최적의 건강수준을 증진시키기 위한 교육과 간호를 계획, 수행, 평가하기 위해 사용된다.

Ⅰ. 사정의 기초 단계
1. 건강력
: 대상자에 대한 주관적인 자료를 모으고 과거와 현재의 문제를 조사하는 것
1) 건강력 수집
- 건강력을 구하는 것에서 신체검진을 시행하기까지의 정확한 사정방법을 알면 의미있는 문제를 밝혀내고 적절한 간호계획을 수립하는데 도움이 된다.
- 객관적 자료는 관찰을 토해 얻어지며 검증될 수 있는 것이다. 예를 들면 팔 통증을 호소하는 대상자에게서 빨갛게 부어오른 팔은 대상자보다 다른 사람에 의해 더 쉽게 발견되고 확인 될 수 있는 자료이다.
- 주관적 자료는 대상자 이외의 다른 사람에 의해서는 확인될 수 없는 자료이다. 이 자료는 대상자 스스로의 설명을 통해서만 얻어질 수 있다. 예를 들면, "머리가 아프다"라든가 “밤에 잠자기 힘들다” 등이다.
가. 과거와 현재 조사
- 대상자의 전체적인 신체적 그리고 정서적인 건강에 대해 질문한다. 그 후 구체적인 신체 계통 구조에 대하여 질문한다.
- 대상자의 답변이 얼마나 정확하고 완벽한지는 면담자의 기술에 달려있다.
2) 대상자 면담하기
가. 면담
가) 준비 단계
- 조용하고 프라이버시가 유지되며 빛이 잘 드는 환경을 선택한다.
- 대상자가 편안한가 확인한다. 1M정도 떨어져 대상자를 향하여 마주보고 앉는다.
- 자신을 소개하고 건강력과 사정의 목적은 대상자의 문제를 확인하고 간호를 계획하기위하여 정보를 수집하는 것임을 설명한다.
- 대상자가 말하는 모든 것은 비밀이 보장될 것이라고 안심시킨다.
- 면담이 어느 정도 계속될 것인지를 대상자에게 알려주고 면담에 대해 무억을 기대하고 있는지를 질문한다.
- 신체적 접촉은 삼간다.
나) 말하는 것에 신중하기
- 언어장벽이 존재하는지 여부를 조사하기 위해 대상자를 사정한다.
- 이해하기 쉬운 언어를 사용하고 천천히 명확하게 말한다.

참고 자료

홍금표, 권연숙 외 41명 . (2018년 2월) . 기본간호학Ⅰ . 수문사 . KOREA
임난영 외 5명 . (2002년 4월 2일) . ACE 건강사정 . 군자출판사 . KOREA