대동맥판막역류 케이스 스터디 aortic valve regurgitation(AVR) care study report 보고서 간호대학원

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"대동맥판막역류 케이스 스터디 aortic valve regurgitation(AVR) care study report 보고서 간호대학원"에 대한 내용입니다.

목차

1. Patient Profile
2. 주호소
3. 주호소 분석틀
4. 과거력
5. Social history
6. Review of System(ROS)

Ⅱ. Objective Data
1. Physical exam
2. Lab data
3. Radiologic finding 등 diagnostic test data

Ⅲ. Assessment
1. 주 ․ 객관적 자료의 해석과 통합
2. 감별진단
3. 예상되는 문제 포함(합병증, 결과 등등)

Ⅳ. Plan
1. 합리적인 치료/간호계획

Ⅴ. Implementation

Ⅵ. Evaluation
1. 환자 문제 해결 여부
2. 새로운 문제 발생 여부

Ⅶ. 건강증진과 질병예방 전략

Reference

본문내용

2. 주호소
“일주일 전부터 미열의 감기 기운이 있어서 종합감기약 복용했는데 낫지를 않고 며칠 전부터 점점 숨이 차고 다리 부기가 심해져서 왔어요.”

3. 주호소 분석틀
1) oneset(suddenly or gradually)
2017년 8~9월 경 부터 양하지 부종 있었으며, 최근 공연연습 하느라 몸에 무리가 있었고 일주일 전 열감, 기침 발생함. 4-5일 전부터 호흡곤란, 하지부종 더욱 악화됨.

2) location / radiation
하지부종은 발목부위부터 생겼으며 점차 발등, 종아리까지 커지며 심해지는 양상임.

3) duration / frequency
호흡곤란은 주로 움직이거나 계단을 오를 때 심하며, 하지부종은 2~3개월 동안 점차 악화됨.

4) characteristics
호흡이 빨라지고 과호흡을 하게 됨. 하지부종은 손으로 누르면 꾹 들어갔다가 살이 바로 차지 않고 한참 기다려야 차오름.

5) aggravating / relieving factors
50m 이상 평지를 걷거나 계단 3개 이상을 오르면 호흡곤란이 심해지고, 특히 똑바로 누운 자세에서 숨 쉬기 힘든 양상임. 앉은 자세에서 휴식을 취할 때 숨쉬기가 가장 편함.

6) associated factors
호흡곤란과 함께 미열, 경미한 기침 동반됨.

<중 략>

6. Review of System (ROS)
1) 일반적 상태
최근 6개월 이내 체중변화(+): 최근 2~3개월 동안 3kg 정도의 체중증가 있음, 식욕저하(-), 피로(+), 발진(-), 외상(-), 전신쇠약(-), 수면장애(+): 최근 호흡곤란으로 숙면 이루지 못하고 아침에 일어나면 피로감 있음.

2) 호흡
기침(+): 간헐적으로 마른기침 양상, 객담(-), 객혈(-), 결핵(-), 호흡곤란(+): 계단 3칸, 평지 50m만 걸어도 숨이 차며 휴식 시 완화되는 양상임, 호흡 시 통증(-), 기침 시 통증(-).

3) 피부
발진(-), 덩어리(-), 소양감(-), 건조감(+): 겨울에 손 발 건조감 있음, 색깔 변화(-), 피부조직 변화(-), 탈모증(-), 두피변화(-).

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