(A+) CASE study_ 알콜성 간질환 MICU케이스 (간호진단 5개, 간호과정 2개)

소개

간호진단을 상세히 간호과정으로 작성하였습니다.

질병에 대한 설명, 약물기전, 간호계획 근거, 간호수행, 평가 및 재조정까지 매우 자세하게 적었습니다!!
꼭 이 케이스 아니더라도 약물 정리 등의 내용과 같이 도움 될만한 내용이 있을거에요

목차

1. 집담회 후 피드백 받은 부분 추가 사항·······················1
2. 일반적 사항········································································ 3
3. 간호력·················································································· 4
4. 질병에 대한 설명···························································· 10
5. 활력징후 등······································································ 11
6. I/O ······················································································ 12
7. 경구, 비경구 투약 및 수분전해질공급···························· 15
8. 진단의학검사···································································· 16
8. 영상의학검사······································································ 16
9. 각종 처치(각종 튜브 포함)··············································· 16
10. 간호진단 LIST·································································· 17
11. 간호과정 1 : 의식수준저하와 관련된 낙상 위험성··18
12. 간호과정 2 : 간 기능 저하와 관련된 출혈 위험성··23
13. 참고문헌·········································································· 28

본문내용

현재 질환과 관련된 입원 전 치료과정, 입원 후 치료과정
4/9 입원: 입원 당일 술 먹다가 일어나면서 seizure하며 낙상하여 이마 타박상 및 열상 발생 함.(2cm) 의식 없고 GTC type seizure activity 있어 119 통해 ER로 내원함.

<중 략>

10. 간호 과정
▪ 간호진단 LIST

우선순위 진단명 및 근거
#1
의식수준저하와 관련된 낙상 위험성
#2
간 기능 저하와 관련된 출혈 위험성

참고자료

· 서울대학교병원, 알코올성 간질환. 서울대학교병원 의학정보 외 본문기재