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신경계 간호과정 및 문제제출 보고서

성인간호학 신경계 파트 10문제 제작 밎 해설 작성 과제 입니다. 모두 창작한 문제이고, 문제마다 해설 꼼꼼히 작성했습니다.
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한컴오피스
최초등록일 2023.08.12 최종저작일 2023.04
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신경계 간호과정 및 문제제출 보고서
  • 본 문서(hwp)가 작성된 한글 프로그램 버전보다 낮은 한글 프로그램에서 열람할 경우 문서가 올바르게 표시되지 않을 수 있습니다. 이 경우에는 최신패치가 되어 있는 2010 이상 버전이나 한글뷰어에서 확인해 주시기 바랍니다.

    미리보기

    소개

    성인간호학 신경계 파트
    10문제 제작 밎 해설 작성 과제 입니다.
    모두 창작한 문제이고, 문제마다 해설 꼼꼼히 작성했습니다.

    목차

    I. 문제
    1. 개두술을 받은 환자의 의식 사정을 위해 이름을 불렀지만 반응이 없고, 통증자극을 가했을 때만 눈을 떴다. 자극을 주면 몸을 움츠리는 행동을 보이고, 대화 시 이해할 수 없는 소리만 내고 있다. 이 환자의 Glasgow coma scale(GCS) 평가 결과는?
    2. 두개내압 상승 환자의 간호로 옳은 것은?
    3. 아래 사례를 보고 의심할 수 있는 질병에 대한 설명으로 옳지 않은 것은?
    4. 외상성 뇌손상 중 뇌좌상에 대한 설명으로 옳은 것은?
    5. 30세 김씨는 요추천자 검사 시 혈성 뇌척수액이 검출되었다. 또한 의식저하, 두통, 구토, 경부경직, 눈부심 등의 증상을 호소하고 있다. 이 환자에게 예상되는 질환은?
    6. 뇌종양 수술 후 간호중재로 옳은 것은?
    7. 7세 김양은 초등학교에서 발표를 하던 중 갑자기 몇 초동안 멍하게 응시하는 모습을 보인다. 김양은 자신의 이러한 행동을 기억하지 못했으며, 곧바로 발표를 이어나갔다. 김양에게 나타나는 발작의 종류로 적절한 것은?
    8. 세균성 수막염의 임상증상으로 보기 어려운 것은?
    9. 파킨슨 환자에게 나타나는 임상증상으로 옳은 것은?
    10. 파킨슨 환자에게 일상생활에서의 주의점을 교육한 내용으로 옳지 않은 것은?

    본문내용

    1. 개두술을 받은 환자의 의식 사정을 위해 이름을 불렀지만 반응이 없고, 통증자극을 가했을 때만 눈을 떴다. 자극을 주면 몸을 움츠리는 행동을 보이고, 대화 시 이해할 수 없는 소리만 내고 있다. 이 환자의 Glasgow coma scale(GCS) 평가 결과는?
    ① E2 V1 M2
    ② E2 V2 M4
    ③ E2 V2 M5
    ④ E3 V2 M4
    ⑤ E3 V4 M2

    ▶ 정답 : ②
    ▶ 풀이
    통증 자극을 가했을 때 눈을 뜨는 반응(Eye Opening : E)은 2점에 해당한다. 대화 시 이해불가능한 소리를 하는 언어반응(Best Verbal Response : V)은 2점에 해당한다. 자극을 주면 몸을 움츠리는 운동반사반응(Best Motor Response : M)은 4점에 해당한다. 따라서 평가결과는 E2 V2 M4 이다.

    <중 략>

    1. 두개내압 상승 환자의 간호로 옳은 것은?
    ① 매일 2L 이상의 수분 섭취를 권장한다.
    ② 침상 머리 높이를 20~30° 정도로 유지한다.
    ③ Trendelenburg 체위를 2시간마다 취해준다.
    ④ 두개내압 상승의 증상인 빈맥, 혈압하강을 관찰한다.
    ⑤ 동맥혈탄산가스분압(PaCO2)을 45∼60mmHg로 높게 유지한다.

    ▶ 정답 : ②
    ▶ 풀이
    ① 매일 2L 이상의 수분 섭취를 권장(→제한)한다.
    ② 침상 머리 높이를 20~30° 정도로 유지한다. →뇌로부터 정맥환류를 촉진하기 위함.
    ③ Trendelenburg 체위를 2시간마다 취해준다.(→금지한다)
    ④ 두개내압 상승의 증상인 빈맥, 혈압하강(→서맥, 혈압상승)을 관찰한다.
    ⑤ 동맥혈탄산가스분압(PaCO2)을 45∼60mmHg로 높게(→25∼30 mmHg로 낮게) 유지한다.

    ▶ 관련내용 (두개내압 상승 시 간호)
    ● 뇌관류 유지
    두개내압 상승 증상인 서맥, 혈압상승 관찰
    침상높이 20~30° 정도 유지, 경부의 과도한 신전/회전/굴곡 금지, Trendelenburg 체위 금지

    참고자료

    · 필통 성인간호학2(2020). 에듀팩토리(서울). p389. 02번 문제
    · 네이버 지식백과. Glasgow coma scale(인터넷). 서울: 정담편집부; 2013(2023.05.09.). https://terms.naver.com/entry.naver?docId=2842542&cid=56740&categoryId=56740
    · 성인간호학VI. 1. OT, 두개내압, 무의식, 두통(1주, 2주_2시간).pdf. 슬라이드 29-33.
    · 가톨릭 대학교 서울성모병원 평생건강증진센터. 뇌졸중 (인터넷). 서울: 2020(2023.05.08.). https://www.cmcseoul.or.kr/healthcare/bbs/view.do?idx=125
    · 네이버 지식백과. 뇌출혈(인터넷). 서울: 서울대학교병원 의학정보; 2019(2023.05.08.). https://terms.naver.com/entry.naver?docId=927318&cid=51007&categoryId=51007
    · 성인간호학VI. 3. 외상성뇌손상, 뇌종양(5주, 6주_2시간).pdf. 슬라이드 6-7.
    · 성인간호학VI. 3. 외상성뇌손상, 뇌종양(5주, 6주_2시간).pdf. 슬라이드 9-14.
    · 성인간호학VI. 3. 외상성뇌손상, 뇌종양(5주, 6주_2시간).pdf. 슬라이드 29-38.
    · 아산병원. 소발작(인터넷). 서울: 아산병원; 2023(2023.05.09.). https://www.amc.seoul.kr/asan/healthinfo/disease/diseaseDetail.do?contentId=31851
    · 성인간호학VI. 4. 발작 및 뇌전증, 감염성 질환, 파킨슨병(7주, 8주_2시간).pdf. 슬라이드 8-15.
    · 네이버 지식백과. 뇌수막염(인터넷). 서울: 서울대학교병원 의학정보; 2019(2023.05.08.).
    · https://terms.naver.com/entry.naver?docId=926867&cid=51007&categoryId=51007
    · 성인간호학VI. 4. 발작 및 뇌전증, 감염성 질환, 파킨슨병(7주, 8주_2시간).pdf. 슬라이드 24-25.
    · 성인간호학VI. 4. 발작 및 뇌전증, 감염성 질환, 파킨슨병(7주, 8주_2시간).pdf. 슬라이드 38-43.
    · 성인간호학VI. 4. 발작 및 뇌전증, 감염성 질환, 파킨슨병(7주, 8주_2시간).pdf. 슬라이드 45-50.
  • AI와 토픽 톺아보기

    • 1. Glasgow coma scale (GCS)
      The Glasgow Coma Scale (GCS) is a widely used clinical assessment tool to evaluate the level of consciousness in patients with neurological injuries or disorders. It provides a standardized way to measure a patient's responsiveness to external stimuli, which is crucial for determining the severity of the injury and guiding appropriate treatment. The GCS assesses three main components: eye opening, verbal response, and motor response, each scored on a scale from 3 to 15, with 15 indicating a fully alert and responsive patient. The GCS is an important tool for healthcare professionals, as it allows for consistent and objective monitoring of a patient's neurological status over time. It helps in the early detection of changes in consciousness, which can indicate the need for immediate intervention or further diagnostic testing. Accurate GCS scoring is essential for making informed clinical decisions, predicting outcomes, and providing appropriate care for patients with neurological conditions.
    • 2. 두개내압 상승 간호
      Nursing care for increased intracranial pressure (ICP) is a critical aspect of managing patients with neurological conditions. Elevated ICP can result from various causes, such as traumatic brain injury, stroke, or brain tumors, and can lead to serious complications if not properly addressed. The primary goal of nursing care in this context is to prevent further increases in ICP and to minimize the risk of secondary brain injury. Key nursing interventions include closely monitoring the patient's neurological status, maintaining a patent airway, ensuring adequate oxygenation and ventilation, and managing fluid balance. Nurses also play a crucial role in administering medications to reduce ICP, such as osmotic diuretics or corticosteroids, and in implementing non-pharmacological strategies, such as head positioning, temperature control, and seizure management. Additionally, nurses must be vigilant in identifying and promptly addressing any signs of increased ICP, such as changes in vital signs, pupillary changes, or altered level of consciousness. Effective nursing care for elevated ICP requires a deep understanding of the underlying pathophysiology, close collaboration with the interdisciplinary healthcare team, and a commitment to providing comprehensive, evidence-based care to optimize patient outcomes.
    • 3. 뇌졸중
      Nursing care for stroke patients is a critical component of the overall management of this devastating neurological condition. Nurses play a vital role in the early recognition of stroke symptoms, the prompt initiation of appropriate treatment, and the ongoing care and rehabilitation of stroke survivors. Key nursing interventions include closely monitoring the patient's neurological status, maintaining airway patency, ensuring adequate oxygenation and hemodynamic stability, and administering thrombolytic or anticoagulant medications as prescribed. Nurses also play a crucial role in educating patients and their families about the signs and symptoms of stroke, the importance of seeking immediate medical attention, and the long-term management of stroke-related complications, such as dysphagia, mobility impairments, and cognitive deficits. Effective nursing care for stroke patients requires a deep understanding of the pathophysiology of different stroke subtypes, the ability to recognize and respond to acute changes in the patient's condition, and a multidisciplinary approach to rehabilitation and long-term care. By providing comprehensive, evidence-based nursing interventions, nurses can significantly improve the outcomes and quality of life for individuals affected by stroke.
    • 4. 뇌좌상
      Nursing care for patients with traumatic brain injury (TBI), specifically brain contusions, is a critical component of the overall management of this complex and potentially life-threatening condition. Nurses play a vital role in the early recognition and stabilization of TBI, as well as the ongoing care and rehabilitation of these patients. Key nursing interventions include closely monitoring the patient's neurological status, maintaining airway patency, ensuring adequate oxygenation and hemodynamic stability, and administering appropriate medications to manage intracranial pressure, seizures, and other complications. Nurses also play a crucial role in educating patients and their families about the potential long-term consequences of TBI, such as cognitive, behavioral, and physical impairments, and in coordinating the multidisciplinary rehabilitation efforts to optimize the patient's functional recovery. Effective nursing care for TBI patients requires a deep understanding of the pathophysiology of brain injuries, the ability to recognize and respond to acute changes in the patient's condition, and a comprehensive, evidence-based approach to nursing interventions. By providing high-quality, patient-centered care, nurses can significantly improve the outcomes and quality of life for individuals affected by traumatic brain injuries.
    • 5. 외상성 거미막하 출혈
      Nursing care for patients with traumatic subarachnoid hemorrhage (tSAH) is a critical component of the overall management of this complex and potentially life-threatening condition. Nurses play a vital role in the early recognition and stabilization of tSAH, as well as the ongoing care and rehabilitation of these patients. Key nursing interventions include closely monitoring the patient's neurological status, maintaining airway patency, ensuring adequate oxygenation and hemodynamic stability, and administering appropriate medications to manage intracranial pressure, vasospasm, and other complications. Nurses also play a crucial role in educating patients and their families about the potential long-term consequences of tSAH, such as cognitive, behavioral, and physical impairments, and in coordinating the multidisciplinary rehabilitation efforts to optimize the patient's functional recovery. Effective nursing care for tSAH patients requires a deep understanding of the pathophysiology of traumatic brain injuries, the ability to recognize and respond to acute changes in the patient's condition, and a comprehensive, evidence-based approach to nursing interventions. By providing high-quality, patient-centered care, nurses can significantly improve the outcomes and quality of life for individuals affected by traumatic subarachnoid hemorrhage.
    • 6. 뇌종양 수술 후 간호
      Nursing care for patients undergoing brain tumor surgery is a critical component of the overall management of this complex and potentially life-threatening condition. Nurses play a vital role in the pre-operative preparation, intraoperative monitoring, and post-operative care of these patients. Key nursing interventions include assessing the patient's neurological status, maintaining airway patency, ensuring adequate oxygenation and hemodynamic stability, and administering appropriate medications to manage pain, seizures, and other post-operative complications. Nurses also play a crucial role in educating patients and their families about the surgical procedure, the potential risks and complications, and the expected course of recovery. In the post-operative period, nurses must be vigilant in monitoring for signs of increased intracranial pressure, cerebral edema, or other neurological changes, and promptly reporting any concerns to the healthcare team. Effective nursing care for brain tumor patients requires a deep understanding of the pathophysiology of brain tumors, the surgical techniques used, and the potential complications that may arise. By providing comprehensive, evidence-based nursing interventions, nurses can significantly improve the outcomes and quality of life for individuals undergoing brain tumor surgery.
    • 7. 소발작
      Nursing care for patients with absence seizures, also known as petit mal seizures, is an important aspect of managing this type of epileptic disorder. Absence seizures are characterized by brief, sudden lapses of consciousness, often lasting only a few seconds, and can be challenging to recognize and manage effectively. Nurses play a crucial role in the care of these patients, as they are often the first to observe and respond to these seizure episodes. Key nursing interventions include closely monitoring the patient's behavior and level of consciousness, ensuring the patient's safety during seizure episodes, and providing appropriate first aid and support. Nurses also play a vital role in educating patients and their families about the nature of absence seizures, the importance of medication adherence, and strategies for managing seizure triggers and minimizing the impact on daily life. Effective nursing care for patients with absence seizures requires a deep understanding of the underlying pathophysiology, the ability to recognize and respond to seizure episodes, and a comprehensive, patient-centered approach to managing this chronic neurological condition. By providing high-quality, evidence-based nursing care, nurses can significantly improve the quality of life and overall well-being of individuals living with absence seizures.
    • 8. 세균성 수막염
      Nursing care for patients with bacterial meningitis is a critical component of the overall management of this life-threatening infectious disease. Nurses play a vital role in the early recognition of symptoms, the prompt initiation of appropriate treatment, and the ongoing care and support of these patients. Key nursing interventions include closely monitoring the patient's neurological status, maintaining airway patency, ensuring adequate oxygenation and hemodynamic stability, and administering intravenous antibiotics and other medications as prescribed. Nurses also play a crucial role in educating patients and their families about the nature of the disease, the importance of early treatment, and the potential long-term complications, such as hearing loss, cognitive impairments, and neurological sequelae. Effective nursing care for bacterial meningitis patients requires a deep understanding of the pathophysiology of the disease, the ability to recognize and respond to acute changes in the patient's condition, and a comprehensive, evidence-based approach to nursing interventions. By providing high-quality, patient-centered care, nurses can significantly improve the outcomes and quality of life for individuals affected by this serious and potentially devastating neurological infection.
    • 9. 파킨슨병 증상 및 간호
      Nursing care for patients with Parkinson's disease is a critical component of the overall management of this chronic and progressive neurological disorder. Nurses play a vital role in the recognition and management of the diverse range of symptoms associated with Parkinson's disease, as well as the coordination of the multidisciplinary care required to optimize the patient's quality of life. Key nursing interventions include closely monitoring the patient's motor and non-motor symptoms, such as tremors, rigidity, bradykinesia, cognitive impairments, and autonomic dysfunction, and adjusting medication regimens accordingly. Nurses also play a crucial role in educating patients and their families about the disease, the importance of medication adherence, and the various strategies for managing symptoms and maintaining independence. Effective nursing care for Parkinson's disease patients requires a deep understanding of the pathophysiology of the disease, the ability to recognize and respond to changes in the patient's condition, and a comprehensive, patient-centered approach to nursing interventions. By providing high-quality, evidence-based care, nurses can significantly improve the quality of life and overall well-being of individuals living with Parkinson's disease.
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