간호학과) A+ 기본간호학 욕창 예방과 관리 보고서

소개

간호학과 재학생입니다
기본간호학 욕창 보고서로 교수님께서 excellent를 주신 보고서이며, 욕창에 관련된 것들을 최대한 담으려고 노력한 자료입니다.
복붙으로 쓰시지 마시고 참고용으로 사용하시길 바랍니다.( 복붙은 교수님이 아십니다)

목차

Ⅰ. 서론 ······················································································· 3
1. 욕창의 정의················································································································ 3
2. 욕창의 단계················································································································ 3
2. 욕창 발생 위험요인·································································································· 4
4. 욕창의 발생기전········································································································ 4

Ⅱ. 본론························································································· 5
1. 욕창예방······················································································································ 5
2. 욕창관리······················································································································ 8

Ⅲ. 결론·························································································10

Ⅳ. 참고문헌················································································· 11

본문내용

1. 욕창의 정의
욕창이란 신체의 일정한 부위(주로 뼈 돌출부)에 압력 혹은 마찰과 응전력이 결합한 압력이 지속적 또는 반복적으로 가해짐으로써 모세혈관의 순환장애로 인한 허혈성 조직괴사로 생기는 피부나 하부 조직의 손상상태를 말한다. 욕창은 환자에게 통증을 일으키거나 회복을 더디게 할 뿐 아니라 입원치료나 수술 등으로 입원기간이 길어지게 하고 치료비가 늘어나는 등의 심각한 문제를 일으킬 수 있다. 하지만 대부분의 욕창은 사전에 예방할 수 있으며 조기에 발견하여 적절한 조치를 취할 경우에는 충분히 호전시킬 수 있다. 그러므로 욕창이 이미 발생하였거나 욕창의 위험이 있는 환자들을 잘 확인하여 욕창을 예방하고 관리해야 한다.

2. 욕창의 단계
욕창은 조직손상의 상태와 심한 정도에 따라 여러 단계로 구분되며 욕창관리는 이에 따라 구별하여 적용한다. 본 지침은 미국 NPUAP(National Pressure Ulcer Advisory Panel; 국립욕창 자문위원회, 2007)에서 제시한 여섯 개 분류를 따른다.

1) 심부조직 손상이 의심되는 단계: 피부손상이 없는 보라색 또는 적갈색의 부분적 피부변색 혹은 혈액이 찬 수포를 말한다. 주위조직에 비하여 단단하거나 물렁거리고 통증을 유발할 수 있으며 따뜻하거나 차갑게 느껴질 수 있다. 증상이 심해지면 조직손상으로 진행될 수 있다.

2) 1단계: 눌렀을 때 하얗게 되지 않는 발적(non-blanching redness)이 나타나며 발적 부위는 압력제거 후에도 정상 피부색으로 회복되지 않는다. 피부가 손상되지 않은 상태이며 침습부위는 표피에 제한된다.

3) 2단계: 표피와 진피의 일부분까지 침범된 부분층 피부손상을 말한다. 피부는 붉고 습하며 통증이 심한 얕은 상처로 피부색이 변화되고 부분적인 피부상실과 표재성궤양이 있다. 괴사조직은 없으며 손상이 없는 수포 혹은 손상된 수포가 나타날 수 있다.

4) 3단계: 전층 피부손상상태로 피하층이 노출되나 근막, 근육, 뼈의 노출은 없다. 괴사조직이 있을 수 있으며 동로(sinus tract)와 잠식(undermining)의 형성이 가능하다.

참고자료

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