성인간호학실습 위장관 출혈 환자 사례 보고서 A+, 간호과정 3개(흡인의 위험, 피부 통합성 장애, 낙상의 위험)

소개

"성인간호학실습 위장관 출혈 환자 사례 보고서 A+, 간호과정 3개(흡인의 위험, 피부 통합성 장애, 낙상의 위험)"에 대한 내용입니다.

목차

1. 질환연구 ······································································································································ 1~7쪽
1) 병태생리
2) 임상소견
3) 치료
4) 간호, 예후

2. 간호력 ············································································································································· 8쪽

3. 간호력사정도구 ·················································································································· 9~17쪽

4. 수술노트 ····························································································································· 18~22쪽

5. 진단검사 ································································································································ 23-24쪽

6. 특수검사 ···························································································································· 24~25쪽

7. 치료 및 경과 ················································································································ 25~41쪽

8. 간호진단 ················································································································ 41~62쪽
1) 복합적 요인(노령, 의식 장애, 기관내관 튜브 삽입)과 관련된 흡인의 위험
2) 신체적 부동과 관련된 피부 통합성 장애(욕창)
3) 복합적 요인(고령, 전신 쇠약, 의식 장애)과 관련된 낙상의 위험

9. 참고문헌 ···························································································································· 63쪽

본문내용

1. 병태생리
위장관 출혈은 식도와 위, 소장, 대장 등의 점막이 손상되어 혈관이 노출되어 발생하는 출혈을 의미한다. 위장관 출혈은 식도, 위, 십이지장에서 발생하는 상부 위장관 출혈과, 소장과 대장에서 발생하는 하부 위장관 출혈로 구분할 수 있다.
(출처: 서울아산병원)
출혈을 일으키는 원인은 다양하며 상부 위장관 출혈의 원인 중에는 소화성 궤양이 50% 정도로 가장 많다. 그 밖에 식도 정맥류, 출혈성 위염 등에 의해 발생한다. 최근 조사 결과에 따르면, 상부 위장관 출혈의 원인 중에서 소화성 궤양은 점차 줄고, 식도 정맥류 출혈은 점차 늘어나는 추세이다. 음주 후에 처음에는 음식물만 토하다가 나중에 피를 토하는 경우에는 위점막 열상에 의한 출혈을 생각할 수 있다. 또한 식도 정맥류에 의한 출혈이 나타날 수 있는데, 이는 다른 출혈에 비해 위험할 수 있다.
하부 위장관 출혈의 원인은 연령에 따라 다르다. 대장의 혈관 이형성증, 대장 게실, 장티푸스, 장 결핵, 궤양성 대장염, 대장암, 대장 용종, 치질 등이 원인이 된다.

상부 위장관 출혈
(식도, 위, 십이지장 출혈) 하부 위장관 출혈
(공장, 회장, 결장 및 직장 출혈)
• 소화 궤양 질환(35~50%): 위산, 펩신 등 소화액이 소화기관을 자가소화함

• 정맥류: 만성간질환에서 문맥압 항진으로 식도, 위 정맥에 혈액 고임
• Mallory-Weiss syndrome: 반복적인 구토 등 식도의 압력상승으로 인한 식도점막의 열상
• 식도염
• 출혈성 위염
• 스트레스 궤양
• 위암 • 결장직장암
• 용종
• 감염성 설사
• 크론병
• 궤양성 대장염
• 허혈성 대장염(ischemic colitis)
• 게실질환
• 치핵
• 치열
• 항문직장 누공
• 결장 혈관 형성장애(colonic angiodysplasia)

참고자료

· 김보환 외, 『병태생리학 2판』, 한문사, 2022.
· 박근혜, 『프셉마음: 소화기 간호편』, 드림널스, 2022.
· 윤은자 외, 『성인간호학1 9판』, 수문사, 2019.
· https://www.amc.seoul.kr/asan/healthinfo/disease/diseaseDetail.do?contentId=31517, 서울아산병원(위장관 출혈)
· http://www.snuh.org/intro.do, 서울대학교병원 의학정보(장출혈)