섬망 케이스 스터디 피피티 delirium case study PPT 대학원

소개글

"섬망 케이스 스터디 피피티 delirium case study PPT 대학원"에 대한 내용입니다.

목차

Ⅰ. Subject Data
Ⅱ. Objective Data
Ⅲ. Assessment
Ⅳ. Plan
Ⅴ. Implementation
Ⅵ. Evaluation
Ⅶ. 건강증진과 질병예방 전략
Ⅷ. Reference

본문내용

2. 과거력

1) 병력, 입원력, 수술력 등

① Immunizations
- Tdap(2017/2/17)
- 폐렴 및 독감백신 접종함(2017)
② Illness Systemic sclerosis, Pulmonary fibrosis
③ Mental illness 불안감, 수면장애
④ Accidents 무
⑤ Allergies 무
⑥ Hospitalization or ER visit
- Systemic sclerosis with lung involvement로 인한 dyspnea로 수 차례 응급실 치료 및 입원치료 받음.
- 가장 최근 2017/5/17-29 dyspnea 악화로 입원치료 받음
⑦ Surgery 무

<중 략>

1. Onset : 2017/11/12

간밤에 거의 자지 않고 불안해함. 반복적으로 병실바닥을 가리키며 불 난다고 말함.

밤 중에 slight agitation / confusion 있음. 자신이 살아있는지 질문하는 모습 보임.

2017/11/13

자연배뇨 하지 못해 담당 간호사가 CIC 하러 갔는데, SPO2 sensor 손가락에서 제거하며 간호사 손을 때리며 다들 이상하다고 소리침. 자신은 죽어야 한다고 말하며 눈에 눈물 맺힌 모습 보임.

CIC 필요함을 설명하니 웃으면서 알았다고 하다가, 준비하려고 하면 “너가 언제부터 나를 그렇게 챙겼냐”며 소리지르며 멱살 잡으려 함.

참고 자료

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