[내분비계 특징]① secreted in minute amounts 소량분비② circulated in the blood③ regulated by negative feadback system 음성되먹임기전④ changes in the plasma concentration of specific substance 혈장농도 변화⑤ direct autonomic nervous system activity⑥ circadian rhythms 생물학적 주기(24시간 주기)- 같은 시간에 발생하는 현상<중 략>[Pituitary gland disorders] 뇌하수체 문제(증상/수술후 간호 중요)1. Hyperpituitarism 뇌하수체기능항진증1)Description- pituitary tumor같은 원인으로 호르몬이 과 분비됨. - acromegaly와 cushing’s disease 같은 질병이 일어남.2)Assessment: visual disturbances (뇌하수체 옆에 시신경이 있어서 영향을 받음)3)Interventions: Hypophysectomy 뇌하수체 절제술.2. Hypophysectomy1)Description- craniotomy개두술 or sublabial transsphenoidal입술밑 접형동(endoscopic transnasal, the latter approach)을 통해 pituitary tumor를 제거하는 것. - sublabial transsphenoidal이 합병증이 적어 더 선호됨- craniotomy의 합병증: IICP, bleeding, meningitis, hypopituitarism뇌하수체 기능저하증- transsphenoidal surgery의 합병증: ŒDI요붕증, visual disturbance, ŽCSF leakage hypopituitarism <4대 합병증>
[Nurse-Client Relationship]A. principles- Care for in holistic 총체적 manner, Consider Ct’s cultural & Beliefs 문화적/종교적 고려- Appropriate limits & boundaries define, Trust Relationship- ★Use therapeutic communication techniques-> 환자의 감정표현을 증가시켜서, 자연스럽게 Insight를 생기게 도와준다. B. Phases of Therapeutic nurse-Ct relationship★각단계 속하는 과업 알기①. Preinteraction phase- Begins before the First contact - nurse 자신의 preconseived ideas, stereotypes, biases, values를 identify 점검하고 배제한다.②. Orentation (1-2회) - identify purpose and the time frame of the relationship, client’s strengths and needs- collect date and forms basis for diagnosis and client-centered goals- 라포, 신뢰형성, Boundaries(횟수, 시간, 장소, 종료, “Goal을 정한다”) - ★ 이 관계는 내담 후에는 Termination되는 관계임을 분명히 알린다③. Working (3-6회) - Exploring, focus on problems → Improve support, Active listening- Insight (Identified problems) - Cope (문제해결)④. Termination or separation phase (7-8회) - Evaluate progress
2022엔클렉스기본 간호최신 기출[VAD 혈관접근]① Verify order(solution type, volume rate, dosage, route, medication, Transfusion)② Experience : 부작용, 혈관 잘 터지는지...③ OP, procedure 계획되어 있는가(수술 예정인 부위 접근 피하기 위함)④ Ask Dominant hand (non-dominant hand로 혈관 잡기 위함)⑤ Risk factor : heart failure, kidney failure, anticoagulant 복용⑥ condition of both arm(mastectomy..)⑦ Lab, allery 확인⑧ clinical condition(dehydration, weight)⑨ medication history, OTC medication(약국약)[VAD remove] ★순서① check the primary health care provider’s prescription ans explain the procedure to the client; ask the client to hold the extremity still during cannula or needle removal② turn off the IV tubing clamp and remove the dressing and tape covering site③ apply light pressure with sterile gauze with draw the catheter using slow, steady movement Keeping the hub parallel to the skin(=laterally) - No lift cathether line④ apply pressure for 2 to 3 min, use dry sterile gauze⑤ Inspect the site for redness drainage or swelling; check the catheter for intac주사 가능? ID시 바늘은 27G 1/2inch, bevel up 사면이 위로가게 15도 각도로[epinephrine pen]?옷 위로 injection?straight down?3sec(5-10sec) slowly inject[Iron dextran]?시행 전에 small test dose?19G -22G needle로 IM z-track dorsoglutear(DG) 부위?0.25ml air도 함께 inject?fever가 2일 이후에 3-4일 지속되면 노티?주기적 Hb f/u?epi-pen, ER 준비물을 환자 옆 준비[Z tract]?적응증 : medication의 SQ leakage 방지 (medication 을 muscle에 seal)--> irritation 감소?Z tract 순서1. select site2. cleanse3. retract the skin with your non dominant hand4. with your dominant hand insert the needle fast5. secure the syringe with your non dominant hand6. inject slowly with your dominant hand7. wait for 10seconds8. smoothy withdrawal needle release skin9. apply gentle pressure to the injection site (do not massage)[투약]? 약 주기전 minimum 3회 확인하기 : when remove약 꺼낼 때, before taking to client’s room, before giving? 6 right : client, medication, route, dose, time, document? one client ? at a time 한번에 한 환자 약 준비하기.? 적어도 두 개의 client’s identifier 확인하기? 용량 계산은 2명의 간호사와 double check 하기[기본간호]?약 병은+Donor AB-AB+, AB-Donor O+A+, B+, AB+, O+Donor O-A+, A-, B+, B-, O+, O-, AB+, AB-? Universal donor : O-? Universal recipient : AB+[Precaution and Nursing Responsibility]★?A large volume of refrigerated blood infused rapidly through a central venous catheter into the ventricle of the heart can cause cardiac dysrhythmias?normal saline 외 다른 solution 함께 투여 금지?Medication 함께 투여 금지?filetr 수혈 set는 each unit of blood 마다 change 하기?Check blood bag 의 expiration, leaks, abnormal color, clots, bubble?Blood bank에서 혈액 타오고 within 20 ?30min 이내에 수혈 시작하기 -> 20-30분 내로 못 줄 것 같으면 blood band 반환?병동 refrigerated에 blood 넣지 말기. 무조건 blood band에 보관?수혈 전에 baseline V/S 확인하고 수혈 시작하고 15분 동안 V/S 잘 보기. 그 이후에는 30-60min 마다 V/S?수혈 시작 first 15분은 2ml/min 이하로 천천히 투여하기 ( 15분 동안 50ml 미만 들어가도록)[자가 수혈 Autologous]?Donations should begin within 5 weeks of the transfusion date and end at least 3days before the date of transfusion4-5주 전에 자가수혈 시작해서 수혈 받기 최소 3일 전에 끝내기?Donation can be made every 3days as long as the hemoglobin remains wi-10시간 후에 wash(suppress DNA synthesis, miotic activity, cell proliferation)┗ unpleasant odor, stinging, burning, irritation, stain skin/hair, sensitivity to sun 일어날 수 있다.Gently remove of scale with oil[Keloid 켈로이드]?Hyper-tropic scar tissue(excess collagen), Elevated/Red/Irregular?Disfigured cosmetic concern, African-American 호발?중재 : ①Surgical resection ②Internal corticosteroid (해당 부위에 steroid injection) ③Radiation[Tinea pedis 족부백선, 무좀]?Fungal infection 곰팡이 감염, Skin scale 증상, 여름에 호발, mild contagious[Acne 여드름]??중재 : - Skin cleansing (No scrub) twice a day gently(No vigorous)- Avoid chocolate, cola, milk, fried food- Acne을 not to squeeze, prick, or pick at lesions- use products labeled non-comedogenic and cosmetics that are water based and to avoid contact with product with an excessive oil base- Rest, exercise?Medication :① Topical Antibiotics : Benzoyl peroxide, Clindamycin and erythromycin, Clindamycin/Tretinoin combination gel② Topical Retinoids : Adapalene, Azelaic acid, Tazarotene, Tasily closed and dead space is eliminated (예: 수술)② Second intention : This type of healing occurs with injuries or wound that have tissue loss and require gradual filling in of the dead space with connective tissue③ Third(tertiary)intention : This type of healing involves delayed primary closure and occurs with wounds that are intentionally left open for several days for irrigation or removal of debris and exudates; once debris had been removed and inflammation resolves, the wound is closed by first intentionIntakeOutput? Oral fluids(water/milk/juice/soft drink/coffee/tea)? Ice chips 50%? Room temperature ? liquid 방에 두면 액체로 변하는 것gelatin, custard, sherbet, ice cream, pudding, popsicle(No pureed ? apple/sauce)? Tube feeding (flush 물도 포함)? Parenteral fluid 비경구투약: IV cathether irrigation, liquid medication? Hourly urine output? vomit & liquid feces(diarrhea) (NO 정상변)? Tube, wound 의 drainage? Wet diaper ? Dry diaper = ____ g(cc)* 1 cup = 8 Oz = 240 cc* 1 Oz = 230 cc? cc/min 분을 cc/hr 시간으로 바꾸아님.
2. Toddler (2-6세) 유아[physical] - reflecting growth spurts 빠름 and lags 정체(잘먹을 때, 안먹을 때 등 성장 속도 다름) - Lordosis(pot belly) 천추전만증 유아에서는 normal : concave하게 척추변형, wide based gait 뒤뚱뒤뚱- dental care 칫솔질 할 때 assistance 도움 필요- 불소fluoride 함유 치약은 2세 이상에서 recommend (불소는 치아를 rebuilding -> prevent cavities 치아우식 방지) - 불소 치약 크기는 2세에서 rice size, 3세 이상은 pea size 콩크기 - 우유나 주스 등sweet liquid 들어있는 젖병bottle 물고 자지 않도록 하기(물이 든 젖병으로 대체 or 우유 먹고 물로 헹구기) - 3세 이상은 낮잠 시간 필요없음- sameness/ritual/routine- temper tantrum 분노발작 :1-4세 에서는 가능- negativism(정상) : use “no” even when he means “yes” to assert independence -> 선택지를 주는 질문하기- undressing 옷벗기 18-24개월, dressing 옷입기 2세이상, 도움없이 self dressing 옷입기 5세이상 가능- V/S : 체온 axillary 36.4-37도 RR 20-30 breaths per min / HR 80-120 beats per min<중략>배변훈련을 위한 준비<physiological> - stay dry for 2 hours- wake up dry from a nap- able to sit, squat and walk<psychological or cognitive>- recognize the urge to defecate or urinate- expresses willingness tp please a parent - able to sit on the toilet for 5-10min withour fussing or getting off
The Eye and the Ear p799, 부p57눈의 진단검사*Corneal staining 각막 염색 : conjunctival sac에 dye 주입 -> 쉽게 볼 수 없는 각막 표면의 요철을 보여줌* Tonometry 안압측정검사. : 40세이후 매년 시행하며, 안압을 사정해서 녹내장을 진단함. 비접촉식과 접촉식 방법이 있는데 contact tonometry는 국소마취를 함. 국소마취 후 눈 문지르지 않기(각막반사 소실우려)[Disorders of the eye]위험요인: Aging process, Congenital, Diabetes mellitus, Hereditary, Medications, Trauma1. Refractive errors(굴절장애): Myopia(근시), Hyperopia(원시), Presbyoopia(노안), Astigmatism(난시)