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성인간호학 호흡기계 폐렴 흉막삼출 임상사례보고서

"성인간호학 호흡기계 폐렴 흉막삼출 임상사례보고서"에 대한 내용입니다.
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한컴오피스
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성인간호학 호흡기계 폐렴 흉막삼출
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성인간호학 호흡기계 폐렴 흉막삼출 임상사례보고서
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    • 🩺 전문적인 임상 사례 및 간호 프로토콜 상세 설명
    • 📋 흉막삼출 및 폐렴에 대한 체계적인 의학적 접근 제시
    • 🩸 실제 환자 사례를 통한 구체적인 간호 절차 학습

    미리보기

    목차

    1. pleural effusion에 대하여 정의하시오.
    2. transudate와 exudate의 차이는 무엇입니까?
    3. pleural effusion의 흔한 3가지 원인은 무엇입니까?
    4. thoracentesis에 대하여 정의하시오.
    5. pleural C&S 검사 결과 Klebsiella균이 검출되었다. Klebsiella pneumonia의 치료와 간호에 대하여 설명하시오.
    6. 흉관을 삽입 후에 밀봉흉곽배액관을 가지고 있는 환자의 관리 내용에 대하여 설명하시오.
    7. 대상자에게 적합한 간호진단을 PES양식으로 2가지 기술하시오.

    본문내용

    상황1 40세의 김씨는 pleural effusion으로 진단받고 내과 병동에 입원하였다. 김씨는 호흡곤란(shortness of breath), 흉통(chest pain), 허약감(weakness), 마르고 자극적인 기침(dry, irritating cough)을 호소하였다. 활력징후는 BP(142/82), P(118), RR(38, labored and shallow), BT(38.9°C) 이었고 흉부 X선 검진결과는 다음과 같았다(shows large pleural effusion and pulmonary infiltrates in the right lower lobe consistent with pneumonitis).
    (※ 폐 감염의 원인은 아직 알 수 없으며, 환자의 상태는 폐렴(pneumonitis)으로 추론하는 상황이다)

    1)pleural effusion에 대하여 정의하시오.
    흉막강은 흉벽, 횡격막, 종격동을 덮고 있는 벽측 흉막과 폐엽 간 틈새를 포함한 폐를 덮고 있는 장측 흉막으로 둘러싸인 공간을 뜻하며 정상적으로 흉막강에는 벽측 흉막과 장측 흉막이 마찰하지 않고 매끄럽게 움직이게 하는 윤활제 역할을 하는 소량의 액체(10-20ml)가 존재한다. 흉막 삼출이란 흉막강 내 액체가 정상 수준 이상으로 고이는 것을 말한다. 흉수는 양측 흉막에서 모두 생성될 수 있으나 주로 벽측 흉막에서 생성되며, 흡수는 벽측 흉막 림프관을 통해 이루어진다. 벽측 흉막 모세혈관은 대순환의 일부로 압력이 25mmHg이고, 장측 흉막의 모세혈관은 소순환의 일부로 압력이 10mmHg이므로 흉수는 두 압력 차이에 의해 벽측 흉막에서 장측 흉막으로 체액이 흐른다.

    참고자료

    · 흉막삼출(BruceBlaus, "pleural effusion",Wikimedia, 2015.11.5.)
    · 흉막삼출(Jon Johnson,“pleural effusion", Medical news today, 20176.21)
    · 장태원, “누출성 흉수 대 삼출성 흉수”,『대한내과 학회지』, 제81권 제2호(2011)
    · “흉관 삽입과 관리”,세브란스 병원, 2010.6.4. 수정, 2019.11.12. 접속,http://sev.iseverance.com/dept_clinic/treat_info/view.asp?con_no=43156
    · “호흡기 질환”, 병원간호 사회, 2019.11.12. 접속, http://khna.or.kr/homecare/disease/respiratory/respiratory_03.php
    · 폐렴”, 질병관리본부 국가건강정보포털, 2016.12.17. 수정, 2019.11.14 접속, http://health.cdc.go.kr/health/HealthInfoArea/HealthInfo/View.do?idx=4370
    · 윤은자 외, 성인간호학1(수문사,2019)
    · 강현숙 외, 기본간호학1(수문사,2006)
    · 성미혜외, 비판적 사고기반 간호과정의 적용(수문사,2018)
    · 부록, NANDA-1 간호진단 2018-2020(수문사,2018)

  • AI와 토픽 톺아보기

    • 1. pleural effusion
      Pleural effusion is the abnormal accumulation of fluid in the pleural space, which is the area between the visceral and parietal pleura. This condition can be caused by a variety of underlying medical conditions, such as congestive heart failure, pneumonia, cancer, or autoimmune disorders. Proper diagnosis and management of pleural effusion is crucial, as it can lead to respiratory distress and other complications if left untreated. Thorough clinical assessment, imaging studies, and analysis of the pleural fluid are essential for determining the underlying cause and guiding appropriate treatment. Prompt intervention, which may include diuretics, antibiotics, or pleural fluid drainage, is often necessary to alleviate symptoms and address the underlying condition.
    • 2. transudate와 exudate
      Transudate and exudate are two distinct types of pleural effusions, which are differentiated based on the composition and characteristics of the fluid. Transudate is a type of pleural effusion that is caused by an imbalance in the hydrostatic and oncotic pressures within the pleural space, often due to conditions like congestive heart failure or liver cirrhosis. Transudate is typically a clear, light-colored fluid with a low protein content. In contrast, exudate is a pleural effusion that is caused by increased permeability of the pleural membranes, often due to inflammation or infection. Exudate is typically a cloudy, protein-rich fluid that may contain cellular elements like white blood cells or bacteria. Distinguishing between transudate and exudate is crucial for identifying the underlying cause of the pleural effusion and guiding appropriate treatment. Diagnostic tests, such as the Light's criteria, can help differentiate between these two types of pleural effusions.
    • 3. pleural effusion의 원인
      Pleural effusions can have a wide range of underlying causes, which can be broadly categorized into transudative and exudative etiologies. Transudative pleural effusions are typically caused by systemic conditions that lead to an imbalance in hydrostatic and oncotic pressures, such as congestive heart failure, liver cirrhosis, or kidney disease. Exudative pleural effusions, on the other hand, are often associated with local or systemic inflammatory processes, such as pneumonia, malignancy, or autoimmune disorders. Other potential causes of pleural effusions include pulmonary embolism, pancreatitis, and trauma. Identifying the underlying cause of a pleural effusion is crucial for guiding appropriate diagnostic workup and treatment. A thorough medical history, physical examination, and various diagnostic tests, such as imaging studies, pleural fluid analysis, and sometimes pleural biopsy, may be necessary to determine the etiology of the pleural effusion. Prompt recognition and management of the underlying condition is essential to prevent complications and improve patient outcomes.
    • 4. thoracentesis
      Thoracentesis is a medical procedure in which a needle or small catheter is inserted into the pleural space to remove excess fluid or air. This procedure is commonly performed to diagnose the cause of a pleural effusion or to provide symptomatic relief for patients experiencing respiratory distress due to fluid accumulation. During the procedure, the healthcare provider uses imaging guidance, such as ultrasound, to identify the optimal site for needle insertion and to ensure the safe removal of the fluid. Thoracentesis is generally considered a safe procedure, but it does carry some risks, such as bleeding, infection, or lung puncture. Careful patient selection, proper technique, and close monitoring are essential to minimize these potential complications. The analysis of the aspirated pleural fluid, including its appearance, cell count, and chemical composition, can provide valuable information about the underlying cause of the effusion and guide further diagnostic and treatment decisions. Thoracentesis is an important tool in the management of pleural effusions, allowing for both diagnostic and therapeutic interventions.
    • 5. Klebsiella pneumonia의 치료와 간호
      Klebsiella pneumonia is a serious bacterial infection that can cause severe pneumonia, particularly in individuals with underlying medical conditions or weakened immune systems. The treatment of Klebsiella pneumonia typically involves the administration of appropriate antibiotics, which may include cephalosporins, carbapenems, or fluoroquinolones, depending on the antibiotic susceptibility of the specific strain. In addition to antibiotic therapy, supportive care is crucial, which may include supplemental oxygen, fluid management, and respiratory support as needed. Nursing care plays a vital role in the management of Klebsiella pneumonia, as nurses are responsible for closely monitoring the patient's respiratory status, administering medications, and providing comfort measures. Nurses must also be vigilant in implementing infection control measures, such as hand hygiene and the use of personal protective equipment, to prevent the spread of the infection to other patients or healthcare workers. Additionally, nurses should educate patients and their families about the importance of completing the full course of antibiotic therapy and the potential complications associated with Klebsiella pneumonia. Effective collaboration between healthcare providers, including physicians and nurses, is essential for the successful management of this serious respiratory infection.
    • 6. 흉관 삽입 및 관리
      Chest tube insertion and management is a critical component of the care for patients with various thoracic conditions, such as pleural effusions, pneumothorax, or hemothorax. The placement of a chest tube, also known as a thoracostomy tube, involves the insertion of a hollow, flexible tube into the pleural space to facilitate the drainage of fluid or air. Proper insertion technique, using appropriate imaging guidance and sterile precautions, is essential to minimize the risk of complications, such as bleeding, infection, or organ injury. Once the chest tube is in place, ongoing management is crucial, including monitoring the drainage, maintaining the integrity of the drainage system, and managing any complications that may arise. Nurses play a pivotal role in the care of patients with chest tubes, as they are responsible for closely monitoring the patient's clinical status, adjusting the drainage system as needed, and providing patient education and support. Effective communication between the healthcare team, including physicians and nurses, is crucial for ensuring the safe and effective management of chest tubes and the underlying thoracic condition.
    • 7. 간호진단 1
      Nursing diagnoses are essential components of the nursing process, as they provide a framework for identifying and addressing the unique healthcare needs of individual patients. In the context of caring for patients with thoracic conditions, such as pleural effusions or pneumonia, potential nursing diagnoses may include: 1. Impaired Gas Exchange related to fluid or air accumulation in the pleural space, as evidenced by changes in respiratory rate, oxygen saturation, and arterial blood gas values. 2. Ineffective Breathing Pattern related to pain, discomfort, or mechanical limitations caused by the underlying condition, as evidenced by the use of accessory muscles, pursed-lip breathing, or altered respiratory depth and rate. 3. Anxiety related to the fear and uncertainty associated with the diagnosis and treatment of the thoracic condition, as evidenced by verbalized concerns, restlessness, or physiological signs of anxiety. 4. Impaired Skin Integrity related to the presence of a chest tube or other invasive devices, as evidenced by skin breakdown, infection, or discomfort at the insertion site. 5. Deficient Knowledge related to the patient's understanding of the condition, treatment plan, and self-care requirements, as evidenced by verbalized questions or concerns. The accurate identification of nursing diagnoses, along with the development of evidence-based nursing interventions and evaluation of patient outcomes, is crucial for providing comprehensive, patient-centered care for individuals with thoracic conditions.
    • 8. 간호진단 2
      In addition to the nursing diagnoses mentioned in the previous response, other potential nursing diagnoses for patients with thoracic conditions may include: 1. Fluid Volume Imbalance related to the accumulation of fluid in the pleural space, as evidenced by changes in vital signs, edema, or laboratory values. 2. Risk for Infection related to the presence of invasive devices, such as chest tubes or catheters, as evidenced by the potential for microbial colonization or entry points for pathogens. 3. Impaired Mobility related to pain, discomfort, or mechanical limitations caused by the underlying condition or the presence of medical devices, as evidenced by decreased range of motion or activity tolerance. 4. Acute Pain related to the underlying condition, the presence of invasive devices, or the associated medical interventions, as evidenced by verbalized pain, guarding behaviors, or changes in vital signs. 5. Ineffective Airway Clearance related to the accumulation of secretions or the inability to effectively cough and clear the airways, as evidenced by changes in respiratory rate, breath sounds, or oxygen saturation. The identification of these nursing diagnoses, along with the development of appropriate nursing interventions and the evaluation of patient outcomes, is crucial for providing comprehensive, patient-centered care for individuals with thoracic conditions. Nurses must work collaboratively with the healthcare team to address the multifaceted needs of these patients and promote optimal health outcomes.

  • 자료후기

      Ai 리뷰
      이 문서는 호흡기계 임상 사례보고서로, pleural effusion의 정의와 특성, 감염성 폐렴의 치료와 간호 방안, 그리고 간호진단을 상세히 다루고 있습니다.

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