분만실 케이스 리포트 (간호진단 3개 )

목차

1. Date
2. General information
3. PHYSICAL ASSESSMENT DATA
4. Obstetric history
5. Antepartum Check
6. LABORATORY DATA
7. DIAGNOSTIC TESTS
8. MEDICATIONS
9. ALLERGIES/PAINS
10. TREATMENTS
11. Diet/Fluids
12. IV Fluids
13. Elimination
14. Activity
15. NEUROLOGICAL/MENTAL STATUS
16. MUSCULOSKELETAL STATUS
17. CARDIOVASCULAR SYSTEM
18. RESPIRATIRY SYSTEM
19. GASTROINTESTINAL SYSTEM
20. SKIN AND WOUNDS
21. EYES,EARS,NOSE,THROAT(EENT)
22. Psychosocial and Cultural Assessment
23. Delivery records
24. Doctor Progress Note Data.
25. 비정상 자료 목록(abnormal data list)
26. Data Clustering
27. Nursing Diagnosis list
28. Concept Care Maps
29. Nursing Plan, Practice, Evaluation

Reference

본문내용

Abnormal data list
* Subject Data
S1. "배가 뭉치는 것 같아요" “ I feel tight and hardening in lower abdomen.
S2. "아기가 저 때문에 잘못될까봐 걱정이에요.“ I’m afraid the baby is going to be wrong because of me.
S3. "새벽에 자꾸 깨서 피곤하네요" I had trouble sleeping at dawn.
S4. "아기가 건강해야 할텐데..." I hope the baby stays healthy..
S5. "몸에 힘이 없어요. 기운도 없고.." I don’t have any strength in my body. I feel weak.
S6. "소변기에 볼일 보는건 적응이 안되네요." I feel uncomfortable urinating on the urinal.
S7. "어렵게 가진 아기인데 저한테 문제가 많은가봐요" It was hard to get pregnant.. I guess I have a lot of problems with my body.
S8. "좀 더워요 답답하기도 하고" It’s kind of hot and stuffy.

* Objective data
O1. IUP 32/6wks preterm labor pain
O2. Dx: Placenta previa specified as without haemorrhage
O3. being pregnant at the age of 40. (pregnancy of advanced maternal age)
O4. G 4 Para 1 Premature 0 A(s.a 2 a.a 0) L 1
O5. s/p IUI #3(failed)
O6. s/p IVF&ET #4
O7. 2017.1.18. PH DR visit d/t vaginal bleeding (small pad #1)
2017.2.22. PH DR visit d/t vaginal bleeding (pad #1 full wet, fresh red)

참고자료

· Pillitteri, Adele (1992). Maternal and child health nursing : care of the childbearing and childrearing family. Philadelphia : Lippincott.
· 최연순 (2016). 여성건강간호학. 파주: 수문사.
· 하영수 외 (2016). 여성모성간호학 1, 2. 서울: 신광출판사.
· Lowdermilk, Deitra (2005). 여성건강간호학. 서울: 정담미디어.
· 강미정 외 (1994). 간호과정 실무지침. 서울 : 서울대학교출판문화원
· 공은숙, 윤진, 장효순, 정정숙, 차영남, 한혜실 (2012). 간호진단과 중재 가이드. 서울: 현문사
· 차영남, 장효순, 한혜실 외 (2013). NANDA 간호진단과 중재 가이드. 서울: 현문사.
· 김정애, 장은정 (2009). NANDA 간호진단별 간호중재 가이드북. 서울: 수문사.