지역사회간호학 A+ 치매 케이스 + 신체사정 k-mmse 노인 우울척도 k-adl braden scale 수면측정도구 낙상위험측정도구 낙상사정 도구 등

소개

지역사회간호학 A+ 실습 케이스이며, 지도 교수님과 컨퍼시 수정할것이 아무것도 없다며 칭찬 받았지만, 마지막 제출날짜까지 최대한 수정해서 제출했고, 실습점수 당연히 100점 받았습니다. 수간호사 선생님께도 컨퍼 받은 결과 칭찬받았습니다. 그대로 사용하셔도 충분히 A+받으실 수 있습니다.
지역사회간호학 A+ 실습케이스 100점 받았음.
간호진단 8개, 간호과정 2개

1.부적절한 이동 보조장치 사용과 관련된 낙상의 위험성
2.신체적 부동과 관련된 피부통합성 장애
3.약화된 건강상태와 관련된 활동 지속성 장애
4.신체활동 감소와 관련된 변비
5.인지장애와 관련된 건강유지장애
6.신경근육계 장애와 관련된 신체 기동성 장애
7.신체활동 감소와 관련된 과체중
8.신체적 제한과 관련된 비활동적 생활양식

간호과정2개
1. 부적절한 이동 보조장치 사용과 관련된 낙상의 위험성
2. 신체적 부동과 관련된 피부통합성 장애

목차

Ⅰ. 서론 및 문헌고찰(필요성) ················································3P

Ⅱ. 간호력 ·······························································································8P
(1) 대상자의 일반적 특성···············································································8P
(2) 대상자의 간호사정 ····················································································8P
①입소 상태······························································································································8P
②사회적 상태·····························································································································8P
③입소경로 및 현재 상태······································································································8P
④vital check 및 BST ·············································································································9P
⑤과거병력 ··································································································································9P
⑥최근투약상태··························································································································9P
⑦신체적 상태···························································································································11P
⑧··의식 및 정서상태·············································································································11P
⑨습관 ·········································································································································11P
⑩보철기 OR 부착물 ···········································································································11P
⑪대상자 사정···························································································································12P
->1.신체사정······························································································································12P
->2.K-MMSE······························································································································20P
->3.노인 우울척도···················································································································22P
->4.K-ADL 측정도구···············································································································23P
->5.K-IADL 측정도구·············································································································25P.
->6.Braden Scale·····················································································································28P
->7.수면측정도구·····················································································································30P
->8.낙상위험측정도구············································································································31P
->9.낙상사정도구·····················································································································32P
->대상자 사정 요약정리 및 결과····················································································33P

Ⅲ. 대상자 간호문제 도출 및 우선순위 ··················34P

Ⅳ. 간호진단 및 간호과정의 적용 ······························39P

Ⅴ. 회상요법···········································································53P

Ⅵ. 결론 (실습 소감) ························································54P

Ⅶ. 참고문헌 ········································································54P

본문내용

: 치매의 유병률은 65세 이상 노인 인구에서 약 5~10%의 유병률을 보이고 있다. 현재 한국 노인의 치매 유병률은 65세를 기준으로 5세가 증가할 때 마다 거의 2배씩 증가하여, 65세~69세 나이는 1.3%이었지만, 85세 이상에서는 33.9%로 급격히 증가하고 있음을 볼 수 있다. 또한 2020년 기준 약 84만명의 환자가 관찰되고, 2030년엔 약 127만명의 환자수 관측될것임을 예측하고 있다.
치료가 주인 기타 의료기관과 다르게 요양원은 요양시설로 입소한 대상자들이 적절한 일상생활을 통해 삶의 질을 향상 시키고, 개인위생 또는 질병을 관리하는 곳이다. 장기요양등급을 받은 대상자들로 입소 할 수 있고, 재가급여 or 시설급여로 나뉘기도 한다. 일상생활을 목표로 하는 요양원엔 대부분의 어르신들이 치매를 앓고 있다. 치매는 아직 치료약이 개발되지 않고 질병의 속도를 늦추는 약만 개발되었다. 따라서 내가 지금 할 수 있는 간호가 어떤것들이 있고, 어르신들의 더 나은 일상생활을 위해서 어떻게 행동하고 간호해야하는지를 파악하고 학습하기 위해, 치매 어르신을 케이스 대상자로 선정하였다.

(1) 정의
치매는 그 자체가 하나의 질환을 의미하는 것이 아닌, 여러 가지 원인에 의한 뇌손상에 의해 기억력을 위시한 여러 인지기능의 장애가 생겨 예전 수준의 일상생활을 유지할 수 없는 상태.

(2) 병태생리 및 원인
치매의 원인질환은 약 60여 가지 이상으로, 크게 퇴행성 뇌질환에 의한 치매, 뇌혈관질환에 의한 치매, 이차적 치매 등으로 나눌 수 있다. 이차적 치매는 뇌염, 뇌막염, 뇌매독, 비타민결핍증, 호르몬장애, 약물중독, 뇌종양, 일산화탄소중독, 경막하출혈 등과 같이 어떤 알려진 원인에 의해 대뇌가 광범위하게 파괴되고 이로 인해 치매의 증상이 나타나는 경우로, 조기에 발견해 치료하면 치매 증상의 진행을 막을 수도 있고 일부의 경우 완치도 가능하다. 뇌혈관질환에 의한 치매는 각종 뇌혈관질환에 의해 대뇌에 손상이 생기고 이로 인해 치매증상이 나타나는 것을 말한다.

참고자료

· 지역사회간호학1/2.성기월 외, 수문사. 2022.
· 노인간호학 제2판 유선영 외 고문사 2023
· N 의학정보 | 서울대학교병원 (snuh.org) - 치매
· 약학정보원 (health.kr)
· 10th edition 난다 간호진단, 중재 및 결과 가이드 현문사