간호) SBAR 12개

문서 내 토픽

1. Bleeding (출혈)

86세 남성 환자가 aspiration pneumonia 진단을 받고 dyspnea로 입원했습니다. L-tube irrigation 시 cbt 섞여 bloody한 배액양상이 관찰되었습니다. 현재 ECMO V-V mode 적용 중이며 Hb, RBC, PLT 수치가 감소한 상태입니다. 위 내시경 예약 및 추가 처방이 필요할 것으로 보입니다.
2. Hypotension (저혈압)

86세 남성 환자가 aspiration pneumonia 진단을 받고 dyspnea로 입원했습니다. 현재 ABP가 80대로 낮게 유지되고 있어 norpine 투여가 필요할 것으로 보입니다.
3. Hyperthermia (고체온)

54세 환자가 pneumonia로 입원 중이며 BT가 38.9℃로 측정되고 오한이 있습니다. 혈액검사 결과 WBC, neutrophil, CRP 수치가 증가하여 감염과 염증의 징후로 보입니다. paceta 추가 처방이 필요할 것으로 보입니다.
4. Dyspnea (호흡곤란)

54세 환자가 pneumonia로 입원 중이며 spo2가 83%로 측정되고 있습니다. 평소에도 DOE가 있었고, 현재 호흡 수가 30회/분이며 기침 시 가래 끓는 소리가 납니다. 산소 증량이 필요할 것으로 보입니다.
5. Hypotension (저혈압)

환자가 infective endocarditis 진단을 받고 vancomycin 치료 중이며 lasix도 사용 중입니다. 현재 BP가 90/60으로 측정되어 저혈압이 악화된 것으로 보입니다. Q-phrine 용량 증가가 필요할 것으로 보입니다.
6. Hyperthermia (고체온)

환자가 infective endocarditis 진단을 받고 vancomycin 투여 중입니다. 현재 BT가 38.7℃로 측정되고 오한이 있어 감염성 심내막염의 감염과 염증의 징후로 보입니다. paceta 추가 처방이 필요할 것으로 보입니다.
7. Anemia (빈혈)

환자가 만성적인 심장판막 질환이 있으며 현재 infecive carditis로 심장질환이 있습니다. EKG 상 VT, A-fib이 관찰되며 Hb 수치가 7.9로 빈혈 징후가 보입니다. RBC 수혈과 추가적인 Lab 검사가 필요할 것으로 보입니다.
8. Rejection reaction (거부반응)

90세 남성 환자가 pericardial effusion 진단을 받고 입원 중입니다. 현재 의식수준은 alert하나 장소, 시간 지남력이 없고 불안정한 모습을 보이고 있습니다. 치료적 중재가 필요할 것으로 보입니다.
9. Hypokalemia (저칼륨혈증)

환자가 infective endocarditis 진단을 받고 vancomycin 치료 중이며 lasix도 사용 중입니다. 현재 K 수치가 3.3으로 측정되어 저칼륨혈증이 있는 것으로 보입니다. 칼륨 제제 투약과 lasix 대신 aldactone 투여가 필요할 것으로 보입니다.
10. Sputum (가래)

환자가 pericardial effusion 진단을 받고 입원 중이며 지속적으로 기침과 가래 호소가 있습니다. 폐 경결과 삼출액이 원인으로 보이며 진해 거담제 투여를 고려해볼 수 있습니다.
11. Nausea (오심)

78세 여성 환자가 심실빈맥, 불안정 협심증, 식도역류 진단을 받고 입원 중입니다. 오전에 CAG 시술 예정이어서 어제 오후 10시부터 NPO 상태였고 오늘 오전 4시부터 DW 5% 500ml와 humulin-R 4unit을 mix하여 IV로 투약하였습니다. 투약 후 5분 만에 오심 호소가 있어 macperan(항구토제) IV 투여를 고려해볼 수 있습니다.
12. Hypoglycemia (저혈당)

78세 여성 환자가 심실빈맥, 불안정 협심증, 식도역류 진단을 받고 입원 중입니다. 오전에 CAG 시술 예정이어서 어제 오후 10시부터 NPO 상태였고 오늘 오전 4시부터 DW 5% 500ml와 humulin-R 4unit을 mix하여 IV로 투약하였습니다. 투약 후 BST 검사 결과 76mg/dL로 저혈당이 확인되어 Dextrose 20% 투여가 필요할 것으로 보입니다.

Easy AI와 토픽 톺아보기

1. Bleeding (출혈)

Bleeding is a serious medical condition that requires prompt attention and treatment. It can be caused by a variety of factors, including trauma, underlying medical conditions, or side effects of certain medications. Proper management of bleeding is crucial to prevent further complications and potential life-threatening situations. Healthcare professionals should carefully assess the cause and severity of the bleeding, and implement appropriate interventions such as applying pressure, controlling the bleeding source, and providing fluid resuscitation if necessary. In some cases, specialized treatments like blood transfusions or surgical interventions may be required. Patients should be closely monitored, and any underlying conditions should be addressed to prevent recurrent bleeding episodes. Effective communication and coordination between healthcare providers are essential to ensure the best possible outcomes for patients experiencing bleeding.
2. Hypotension (저혈압)

Hypotension, or low blood pressure, is a medical condition that can have various underlying causes, ranging from dehydration and medication side effects to more serious underlying conditions like heart or endocrine disorders. Proper management of hypotension is crucial to prevent complications such as organ damage, shock, and even death. Healthcare professionals should carefully assess the patient's symptoms, medical history, and potential contributing factors to determine the appropriate course of treatment. This may involve fluid resuscitation, adjusting medication dosages, or addressing the underlying cause. Patients with chronic or recurrent hypotension may require ongoing monitoring and management to maintain stable blood pressure levels and prevent adverse outcomes. Effective communication between healthcare providers and patients is essential to ensure timely and appropriate interventions, as well as to educate patients on lifestyle modifications and self-care strategies to manage their condition.
3. Hyperthermia (고체온)

Hyperthermia, or elevated body temperature, can be a serious medical condition that requires prompt recognition and treatment. It can be caused by a variety of factors, including environmental exposure, underlying medical conditions, or adverse reactions to certain medications. Healthcare professionals should carefully assess the patient's symptoms, medical history, and potential contributing factors to determine the appropriate course of treatment. This may involve cooling measures, fluid resuscitation, and addressing the underlying cause. In severe cases, hospitalization and intensive medical interventions may be necessary to prevent complications such as organ damage, neurological impairment, and even death. Effective communication between healthcare providers and patients is crucial to ensure timely and appropriate interventions, as well as to educate patients on prevention strategies and self-care measures to manage their condition. Ongoing monitoring and follow-up care are essential to ensure the patient's well-being and prevent recurrent episodes of hyperthermia.
4. Dyspnea (호흡곤란)

Dyspnea, or difficulty breathing, is a medical condition that can have various underlying causes, ranging from respiratory disorders to cardiovascular or neurological conditions. Proper management of dyspnea is crucial to ensure the patient's well-being and prevent complications. Healthcare professionals should carefully assess the patient's symptoms, medical history, and potential contributing factors to determine the appropriate course of treatment. This may involve oxygen therapy, medication adjustments, or addressing the underlying cause through specialized interventions. In severe cases, hospitalization and intensive medical care may be necessary to stabilize the patient's condition and prevent life-threatening complications. Effective communication between healthcare providers and patients is essential to ensure timely and appropriate interventions, as well as to educate patients on self-care strategies and lifestyle modifications to manage their condition. Ongoing monitoring and follow-up care are crucial to ensure the patient's long-term well-being and prevent recurrent episodes of dyspnea.
5. Hypotension (저혈압)

Hypotension, or low blood pressure, is a medical condition that can have various underlying causes, ranging from dehydration and medication side effects to more serious underlying conditions like heart or endocrine disorders. Proper management of hypotension is crucial to prevent complications such as organ damage, shock, and even death. Healthcare professionals should carefully assess the patient's symptoms, medical history, and potential contributing factors to determine the appropriate course of treatment. This may involve fluid resuscitation, adjusting medication dosages, or addressing the underlying cause. Patients with chronic or recurrent hypotension may require ongoing monitoring and management to maintain stable blood pressure levels and prevent adverse outcomes. Effective communication between healthcare providers and patients is essential to ensure timely and appropriate interventions, as well as to educate patients on lifestyle modifications and self-care strategies to manage their condition.
6. Hyperthermia (고체온)

Hyperthermia, or elevated body temperature, can be a serious medical condition that requires prompt recognition and treatment. It can be caused by a variety of factors, including environmental exposure, underlying medical conditions, or adverse reactions to certain medications. Healthcare professionals should carefully assess the patient's symptoms, medical history, and potential contributing factors to determine the appropriate course of treatment. This may involve cooling measures, fluid resuscitation, and addressing the underlying cause. In severe cases, hospitalization and intensive medical interventions may be necessary to prevent complications such as organ damage, neurological impairment, and even death. Effective communication between healthcare providers and patients is crucial to ensure timely and appropriate interventions, as well as to educate patients on prevention strategies and self-care measures to manage their condition. Ongoing monitoring and follow-up care are essential to ensure the patient's well-being and prevent recurrent episodes of hyperthermia.
7. Anemia (빈혈)

Anemia, a condition characterized by a decrease in the number or function of red blood cells, can have various underlying causes, including nutritional deficiencies, chronic diseases, or blood loss. Proper management of anemia is crucial to prevent complications and ensure the patient's overall health and well-being. Healthcare professionals should carefully assess the patient's symptoms, medical history, and laboratory findings to determine the underlying cause and implement appropriate interventions. This may involve dietary modifications, supplementation, medication adjustments, or addressing the underlying condition. In severe or persistent cases, more specialized treatments, such as blood transfusions or iron infusions, may be necessary. Effective communication between healthcare providers and patients is essential to ensure timely and appropriate interventions, as well as to educate patients on self-care strategies and lifestyle modifications to manage their condition. Ongoing monitoring and follow-up care are crucial to monitor the patient's progress and prevent recurrent episodes of anemia.
8. Rejection reaction (거부반응)

Rejection reaction is a serious medical condition that can occur in patients who have undergone organ transplantation or other medical procedures involving the introduction of foreign materials into the body. It is a complex immune response where the body recognizes the transplanted organ or material as foreign and attempts to attack and destroy it. Proper management of rejection reactions is crucial to prevent graft failure, organ damage, and potentially life-threatening complications. Healthcare professionals should closely monitor transplant recipients for signs of rejection, such as changes in organ function, and promptly implement appropriate interventions, which may include adjustments to immunosuppressive medications, additional treatments to suppress the immune response, or even the need for a new transplant. Effective communication and coordination between the healthcare team, the patient, and their family are essential to ensure timely recognition and management of rejection reactions, as well as to educate the patient on the importance of adherence to their treatment regimen and regular follow-up care. Ongoing monitoring and proactive management are key to maintaining the health and function of the transplanted organ and preventing long-term complications.
9. Hypokalemia (저칼륨혈증)

Hypokalemia, or low potassium levels in the blood, can be a serious medical condition that requires prompt recognition and treatment. It can be caused by a variety of factors, including dietary deficiencies, medication side effects, or underlying medical conditions. Healthcare professionals should carefully assess the patient's symptoms, medical history, and laboratory findings to determine the underlying cause and implement appropriate interventions. This may involve potassium supplementation, adjustments to medication regimens, or addressing the underlying condition. In severe cases, hospitalization and intensive medical care may be necessary to stabilize the patient's condition and prevent life-threatening complications, such as cardiac arrhythmias or muscle weakness. Effective communication between healthcare providers and patients is essential to ensure timely and appropriate interventions, as well as to educate patients on the importance of maintaining a balanced diet, monitoring their potassium levels, and reporting any concerning symptoms. Ongoing monitoring and follow-up care are crucial to ensure the patient's well-being and prevent recurrent episodes of hypokalemia.
10. Sputum (가래)

Sputum, or phlegm, is a common medical symptom that can be associated with a variety of respiratory conditions, such as respiratory infections, chronic lung diseases, or lung cancer. Proper evaluation and management of sputum production are important to identify the underlying cause and provide appropriate treatment. Healthcare professionals should carefully assess the patient's symptoms, medical history, and any associated factors, such as color, consistency, or volume of the sputum, to determine the appropriate course of action. This may involve diagnostic tests, such as sputum cultures or imaging studies, to identify any underlying infections or other conditions. Treatment may include medications to thin or suppress sputum production, as well as addressing the underlying cause through targeted therapies. Effective communication between healthcare providers and patients is crucial to ensure timely and appropriate interventions, as well as to educate patients on self-care strategies, such as proper hydration and techniques for effective cough and sputum clearance. Ongoing monitoring and follow-up care are essential to ensure the patient's respiratory health and prevent any complications associated with persistent or excessive sputum production.
11. Nausea (오심)

Nausea is a common medical symptom that can have a wide range of underlying causes, including gastrointestinal disorders, medication side effects, or even psychological factors. Proper management of nausea is important to alleviate the patient's discomfort and prevent any associated complications, such as dehydration or electrolyte imbalances. Healthcare professionals should carefully assess the patient's symptoms, medical history, and any potential contributing factors to determine the appropriate course of treatment. This may involve the use of anti-nausea medications, dietary modifications, or addressing the underlying cause through targeted therapies. In some cases, more specialized interventions, such as intravenous fluids or alternative therapies, may be necessary. Effective communication between healthcare providers and patients is crucial to ensure timely and appropriate interventions, as well as to educate patients on self-care strategies, such as maintaining proper hydration, avoiding trigger foods, and practicing relaxation techniques. Ongoing monitoring and follow-up care are essential to ensure the patient's well-being and prevent recurrent episodes of nausea.
12. Hypoglycemia (저혈당)

Hypoglycemia, or low blood sugar levels, is a medical condition that can be particularly concerning for individuals with diabetes or other conditions that affect glucose regulation. Proper management of hypoglycemia is crucial to prevent serious complications, such as seizures, coma, or even death. Healthcare professionals should carefully assess the patient's symptoms, medical history, and any potential contributing factors, such as medication use or dietary intake, to determine the appropriate course of treatment. This may involve the administration of glucose or other fast-acting carbohydrates, adjustments to medication regimens, or addressing the underlying cause through dietary modifications or other interventions. Effective communication between healthcare providers and patients is essential to ensure timely and appropriate interventions, as well as to educate patients on recognizing the signs and symptoms of hypoglycemia, and implementing self-care strategies to prevent and manage these episodes. Ongoing monitoring and follow-up care are crucial to maintain stable blood sugar levels, prevent recurrent hypoglycemic events, and ensure the patient's overall health and well-being.

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기본간호학 요약정리<인간, 환경, 건강, 간호, 간호과정, 기록과 보고, 안위, 체위, 통증, 활동과 운동, 감염관리, 체온유지>

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2025.05.06 · 의학/약학

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