A+자료 성인간호학 Pleural effusion 흉막 삼출증(흉수) Case study(간호진단2개)(간호과정2개)

문서 내 토픽

1. Pleural effusion

흉수란 흉막강 내 정상 이상으로 고인 액체를 말한다. 흉막강은 흉벽, 횡격막, 종격동을 덮고 있는 벽측 흉막과, 폐엽 간 틈새를 포함한 폐를 덮고 있는 장측 흉막으로 둘러싸인 공간을 뜻한다. 여기에는 정상적으로 소량(5~10mL, 0.1~0.2mL/Kg)의 흉수가 존재하며, 생리적으로 호흡 운동 시 폐 확장을 촉진하는 한편, 폐와 흉벽을 연결함으로써 폐의 팽창을 유지하게끔 도와주는 역할을 한다. 정상적인 흉수는 벽측 흉막에서 만들어지며 모세혈관의 정수압과 삼투압의 차이 및 림프관으로의 배출 등을 통해 일정한 양이 유지된다. 이러한 생성-흡수의 기전에 변화가 초래되면 과도한 양의 흉수가 발생하게 되며 흉수는 그 발생 기전에 따라 크게 여출성(transudates)과 삼출성(exudates)으로 나눌 수 있다.
2. Nursing care for pleural effusion

간호사는 대상자의 호흡 양상(흡기/호기/깊이)을 세밀하게 관찰하고 호흡수를 매시간 마다 측정한다. 대상자에게 진해거담제 및 기관지 확장제를 투여하고 산소요법을 시행한다. 대상자의 향후 동맥혈가스분석(ABGA)의 결과를 확인하여 치료의 효과를 사정한다. 또한 대상자에게 균형 잡힌 음식섭취를 격려하고 보호자에게 대상자의 상태를 설명하여 지지를 받을 수 있도록 한다. 필수영양소 중 Na, K, 단백질을 공급하여 영양부족 상태를 완화한다.

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1. Pleural effusion

Pleural effusion is a medical condition characterized by the abnormal accumulation of fluid between the layers of the pleura, the thin membrane that lines the inside of the chest cavity and covers the lungs. This condition can be caused by a variety of underlying medical conditions, such as heart failure, cancer, infection, or autoimmune disorders. The symptoms of pleural effusion can include shortness of breath, chest pain, cough, and fever. Proper diagnosis and treatment of the underlying cause is essential to manage this condition effectively. Treatment options may include draining the excess fluid through a procedure called thoracentesis, administering medications to reduce fluid buildup, or addressing the underlying medical condition. Careful monitoring and management of pleural effusion is crucial to prevent complications and improve the patient's overall health and quality of life.
2. Nursing care for pleural effusion

Nursing care for patients with pleural effusion is crucial in ensuring the best possible outcomes. Nurses play a vital role in monitoring the patient's symptoms, administering medications, and coordinating with the healthcare team to provide comprehensive care. Key aspects of nursing care for pleural effusion include: 1. Respiratory assessment: Nurses should closely monitor the patient's respiratory status, including respiratory rate, oxygen saturation, and any signs of respiratory distress. They should be prepared to provide supplemental oxygen or assist with respiratory interventions as needed. 2. Symptom management: Nurses should be proactive in managing the patient's symptoms, such as chest pain, cough, and shortness of breath. This may involve administering pain medication, providing breathing exercises, and ensuring the patient is positioned comfortably. 3. Fluid management: Nurses should closely monitor the patient's fluid balance, including intake, output, and any changes in weight. They may assist with procedures such as thoracentesis to drain excess fluid from the pleural space. 4. Medication administration: Nurses are responsible for administering prescribed medications, such as diuretics, corticosteroids, or antibiotics, and monitoring the patient's response to treatment. 5. Patient education: Nurses should educate the patient and their family about the condition, the importance of treatment adherence, and any lifestyle modifications that may be necessary. 6. Coordination of care: Nurses should work closely with the healthcare team, including physicians, respiratory therapists, and other specialists, to ensure a comprehensive and coordinated approach to the patient's care. By providing high-quality nursing care, nurses can play a crucial role in improving the patient's outcomes and quality of life.