노인간호학 보고서 A+, 간호진단 15개, 간호과정 13개(낙상의 위험, 상해의 위험, 만성통증, 기능적 독립성 감소, 신체 기동성 장애, 만성혼돈, 무력감, 만성적 자존감 저하, 우울감, 활동 지속성 장애, 비활동적 생활양식, 사회적 고립 위험, 의사소통 장애)

소개

"노인간호학 보고서 A+, 간호진단 15개, 간호과정 13개(낙상의 위험, 상해의 위험, 만성통증, 기능적 독립성 감소, 신체 기동성 장애, 만성혼돈, 무력감, 만성적 자존감 저하, 우울감, 활동 지속성 장애, 비활동적 생활양식, 사회적 고립 위험, 의사소통 장애)"에 대한 내용입니다.

목차

Ⅰ. 사정내용 ···················································································· 01
1. 노쇠정도 ······················································································ 01
2. 건강력 ·························································································· 02
3. 전반적 사정·················································································· 03
1) 요약
2) 신체사정
3) 인지기능
4) 정서평가
5) 낙상 및 이동능력
6) 영양상태
7) 대소변 조절
4. 일상생활활동 ·············································································· 07
1) 바텔의 일상생할도구 측정도구
2) 로톤의 도구적 일상생활 동작척도
5. 환경 ····························································································· 10
6. 사회적 지지 ················································································ 13
7. 재정 ····························································································· 13

Ⅱ. 생활 ··························································································· 14
1. 하루일과 ····················································································· 14
2. 일주일활동 ················································································· 14

Ⅲ. 간호진단 및 간호과정 ···························································· 15
1. 간호진단 ····················································································· 15
2. 간호계획 ····················································································· 15

Ⅳ. 팀활동 내용 ············································································ 28

Ⅴ. 참고문헌 ·················································································· 30

본문내용

Ⅰ. 사정내용
1. 노쇠 정도
∎ 노쇠선별검사

항목
질문
1점
0점
F
(fatigue, 피로)
지난 4주간 심한 피로감을 느낀 시간
항상/대부분
자주/가끔/없음
R
(resistance,저항)
혼자서 쉬지 않고 10계단 오르기 어려움
예
아니오
A
(ambulation,이동)
혼자서 100m 걷기 어려움
예
아니오
I
(illness, 지방)
고혈압, 당뇨병, 암, 폐질환, 심근경색, 심부전, 협심증, 천식, 관절염, 뇌졸중, 신질환 중 5개 이상의 만성 복합 질환
예
아니오
L
(loss of weight,
체중감소)
6개월 전과 비교하여 5% 이상 체중 감소
예
아니오
총점
1점:전노쇠

점수해석: 0점 정상, 1-2점 전노쇠, 3점 이상 노쇠

2. 건강력
1) 건강력

나이
만 87
성별
여
고혈압
O
당뇨
X
이상지질혈증
X
관상동맥질환
X
뇌졸중
X
부정맥
X
신부전
X
만성신장질환
X
치매
X
우울증
O
파킨슨병
X
COPD
X
관절염
O
골다공증
-
골절
O
Rt.
발가락
폐결핵
X
기타질환
-
결혼상태
사별
교육
무학: ⬛읽기가능 □쓰기가능
음주
X
흡연
X
운동
평소 일을 위하여 혹은 운동을 위하여 땀을 흘리는 경우가 있는가?
□전혀없다 ⬛별로없다 □때때로 있다 □자주 있다 □아주 많다
복용약물
오전약: 암모핀정, 코자플러스정, 씬지로이드정, 사포디필 SR정
뉴트리넥스트로엠비타민, 이모튼 캡슐
취침전:명인트리조돌염산염정, 드록틴캡슐, 뉴프람정, 지나탐정, 실버셉트장
11개/일 복용
∎ 항고혈압제, 갑상선호르몬 관련약, 항혈전제, 골관절염약
∎ 정신과: 항우울제 4개, 알츠하이머형 치매증상 치료제
예방접종
-

참고자료

· 권인순. (2014). 노인 포괄평가의 개념과 필요성. J Korean Med Assoc, 57(9), 749-755. https://doi.org/10.5124/jkma.2014.57.9.749
· 김수영, 원장원, & 노용균. (2004). 한국어판 바텔 일상활동 지표(Bathel ADL Index)의 개발. 가정의학회지, 25, 534-541.
· 김수영, 원장원, & 조경환. (2005). 한국어판 로톤 도구적 일상활동 지표(Lawton Instrumental Activities of Daily Living Index)의 개발. Journal of The Korean Geriatrics Society, 9(1), 23-29.
· 노용균. (2023). 노인 환자의 건강 상태 평가를 위한 포괄적 노인 평가. J Korean Med Assoc, 66(7), 439-447.
· 은영 외. (2020). 노인간호학 (제5판). 현문사.
· 양수. (2016). 정신건강간호학 (제5판). 현문사.
· 한지원 외. (2010). 치매 선별용 간이정신상태검사(Mini-Mental State Examination for Dementia Screening; MMSE-DS)와 단축형 MMSE-DS(SMMSE-DS)의 한국 노인 정상규준 연구. 노인정신의학, 14(1), 27-37.
· Kim, Y., & Others. (2024). Validating the Korean Version of the Duke Social Support Index. Journal of Social Service Research, 50(2), 206-214. https://doi.org/10.1080/01488376.2023.2277321