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폐렴의 정의,원인,병태생리,치료에 대한 요약자료입니다.

Pneumonia■ difinitionAcute infection of the lung parenchyma, including alveolar spaces and interstitial tissue■ Etiology? causative agent: bacteria(community-acquired PN, nosocomical PN). viruses, fungi, parasites,mycoplasma? predisposing factors: age, smoking Hx, surgery, decresed level of consciousness, malnutritionchronic illness(COPD)? Immunocompromise: neutropenia, severely immunocompreomise pt? chronic immobility? nosocomical PN: concurrent antibiotics therapy, contaminated respiratory therapy equipment,endotracheal intubation, aspiration of oropharyngeal or gastric secretion■ Pathophysiologycausative agent predisposing factors Immunocompromiseinhalation microorganismcontaminated respiratory therapy equipmentendotracheal intubation aspiration oropharyngeal secretion immobilization↓lower respiratory tract infection↓activation defense mechanism↙ ↓ ↘multiful inflammatory mediatorimmune activationcellular infiltration↓↓infectious debrisalveoli become inflamed & edematous↘↓↘alveolar space fill exudation, consolidationbronchialmucous ↑↙↓↓pleural space abscesses ↑alveoli ventilation ↓airwayresistance ↑↓↓↓pneumothoraxorempyemaV/Q mismatch, shuntWOB ↑↓O2 diffusion ↓microorganismreleasetoxin↓hypoxemia, hypercapnia↓↓futhur lung damage→aucte respiratory failure■ Clinical presentation㉠ Subjective: infectious symptoms : chill, fever, tachycardia, HA, myalgia: chest pain, confusion㉡ Objective: tachycardia, fever, dehydration, diaphoresis, cyanosis: tachypnea, use of accessory muscles, breath sound(diminished, bronchial, crackle), productive cough(sputum mucoid, rusty, blood, purulent)■ Diagnostics㉠ Serum? WBC : bacterial - elevatedviral, immunocompromised pt - normal or decresed? ABGA : hypoxemia(PaO295%을 유지하도록 하며 chronic hypercapnia의 경우 SPO2>90%을 유지한다㉡ Intubation and mechanical ventilation: unable to maintain airway, much secretion, ineffective cough, fatigue: ABG values(PaO2>60mmHg) 유지시키기 위함.: high oxygen consentration, PEEP 필요함.㉢ Pharmacotherapy? Antibiotics: Erythromycin - most commonly use(CAP): nosocomical PN의 경우 antibiotics에 대한 resistant가 많음. sensitivity drug 사용? Antipyretics and analgesics: reduce temperature & significant pleuritic pain: opioid(codeine, morphine sulfate, meperidine) 계열의 경우 respiratory depression 발생할 수 있으므로 주의를 기울이고 반드시 RR, SPO2 monitoring을 해야한다.㉣ Hydration: IV fluid는 insensible loss(tachypnea, diaphoresis)를 보상하기 위해 필요.: 2-3L/24hr, 5% DS 권장㉤ Isolation : 필요한 경우㉥ Percussion and postural drainage■ complication: Acute Respiratory failure, pleural effusion, Empyema, Lung abscess, Septic shockIMMUNOLOGY, Ivan Roitt 외 2, 1993, MosbyCommon Variable Immunodeficiency, C Lucy Park, MD, 2004 May, e-Medicine

의/약학| 2010.10.27| 4페이지| 1,000원| 조회(240)

폐렴, 성인간호, 병태생리, pneumonia, 폐렴 문헌고찰

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급성 호흡곤란 증후군의 정의,원인,병태생리,치료에 대한 요약자료입니다.

Acute Respiratory Distress Syndrome■ difinitioncharacterized by noncardiac pulmonary edema & manifested by refractory hypoxemia caused by intrapulmonary shunt■ EtiologyDirect lung injuryIndirect lung injuryChest trauma : pulmonary contusionhypovolemiapul. edemaPneumonia : viral, bacterial, fungalAspiration pneumoniaInhalation injury: smoke, chemicals, oxygen toxicitypul. embolism : thrombotic, air, fatRadiationSepsis : most likely causeShock or prolonged hypotension: septic / hypovolemic / anaphylactic /cardiogenic / neurogenicMultiple traumaCardiopulmonary bypassDICDiabetic comaMultiple blood transfusion■ Pathophysiologyacute lung injury↓damage to pul. capillary membrane↓ ↓alveolar epithelium,capillary endothelium injurytype Ⅱ pneumocyte injury↓↓inactivation surfactant↙↓altered hydrostatic(push) & osmotic pressure(pull)↓permeability↑↓alveolar collapsepul. edema(fluid, blood, protein)↙↓↓ ↘stiffening lungairway resistance↑interference O2 diffusionphysical dead space↑↓↓gas exchange X→ atelectasisWOB↑↓↓↓V/Q mismatch, FRC & compliance ↓fatigue↓PaO2↓, hypoxia■ Clinical presentationphaseⅠphaseⅡphaseⅢphaseⅣHRtachycardiatachycardiatachycardiabradycardiacardiac indexNormalincresedincreseddecresedTV/MVeincresedincresedN or decreseddecresedPaCO2decreseddecresedN or incresedincresedacid-baserespiratoryalkaosisrespiratoryalkaosismetabolic(or res.)acidosismetabolic & res.acidosisPaO2 on room airNormalN or slightly decresed(~60mmHg)slightly decresed(~40mmHg)severely decresed(~25mmHg)shunt< 6%10%20%>30%complianceNormalslightly decresedmoderate decresedseverely decresedpul. clinical manifestationdyspnea+ fatigue, retraction+ cyanosisrespiratory arrest, rusty sputumbreath soundclearfine cracklescoarse cracklesor/and wheezecrackles, rhonchior/and wheezeChest X-rayNormalpatchy infiltratediffuse infiltrateconsolidationother signdysrhythmiasensorium ↓+ hypotension■ Diagnostics㉠ ABGA : refactory hypoxemia is key indicatorFiO2 증가에도 PaO2는 감소.hyperventilation으로 pH가 증가 가능(>7.45), CO2 정상 또는 증가ARDS 악화시 pH 감소하며 respiratory acidosisanaerobic metabolism 보상으로 metabolic acidosis㉡ Pulse oximetry : oxygenation 평가 위해 continuous monitoring㉢ Mixed venous oxygen saturation(SvO2) : noraml(60~80%)12mmHg) in cardiogenic pulmonoary edema* PAWP is more sensitive indicator of fluid balance CVP㉦ Tracheal-protein/plasma protein ratio? new diagnotic tool between cardiogenic & non-cardiogenic pul. edema(ARDS)? tracheal aspiration protein과 serum protein을 비교.? ratio 0.7 = generaly ARDS㉧ Lactic acid level : hypoxemia로 인한 anaerobic metabolism을 평가㉨ P(A-a) O2 : ARDS에서는 증가alveolar flooding으로 인한 intrapulmonary shunting을 반영㉩ QS/QT : normal physiologic shunt = 3-4%ARDS = 15-20%■ Medical management㉠ Oxygen therapy? goal : PaO2>60mmHg with FiO2≤0.50(필요시 FiO2 1.0)㉡ mechanical ventilation? FiO2≤0.50로 oxygenation이 안될 때? lung compliance가 감소하고 WOB, physiologic dead space가 증가할 경우 필요? goal : PaO2 유지? complication : airway pressure ↑, high oxygen concentration㉢ Positive end-expiratory pressure? low FiO2로 aterial oxygenation을 위해 positive airway pressure 유지? alveolar open으로 FRC 증가 및 collapse 방지? 5~20cmHO2㉣ corticosteroid : short-time, high-dose는 alveolar-capillary membrane 악화를 방지㉤ fluid therapy? goal : maintain minimal PAWP to provide adequate CO? crystalloid & colloid fluid leak across alveolar-capillary membranegenerally, crystalloid는 hypoalbuminemia pt에게 사용㉥ sedation : cooperate with mechanical ventilator? propofol, vecuronium로 heavy sedation(comatose state)alert or muscle control이 필요할 경우에는 lorazepam, morphine도 사용IMMUNOLOGY, Ivan Roitt 외 2, 1993, MosbyCommon Variable Immunodeficiency, C Lucy Park, MD, 2004 May, e-Medicine

의/약학| 2010.10.27| 4페이지| 1,000원| 조회(404)

병태생리, ARDS, 급성 호흡곤란 증후군

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case study, 급성호흡곤란증후군,폐렴,면역결핍

Assessment사정일: 2007. 12. 12(HD#6)General1. Diagnosis : Pneumonia with ARDScommon variable immnunodeficiency2. Age : 20세3. History내원 10여 일전부터 기침 가래, 발열, 오한 발생하여 OO내과 진료 후 경구약 복용하고 12월 4일 ‘폐렴’ 진단으로 입원 치료함. 발열 지속으로 12월 7일 △△병원 응급실 내원하고 흉부 방사선 검사상 우폐하엽 폐렴 진단되어 입원함.4. Past History어릴때부터 아토피 피부염과 중이염이 심하였음.사춘기 이후부터 재발성 폐렴 3회, 재발성 신우신염 10여회(last: 07년 7월)□□병원에서 CT, MRI 등 원인검사 시행하였으나 특이소견 발견하지 못함.5. 입원 후 경과HD#110여일전부터 발생한 발열, 기침, 가래 (흉통, 요통, 복통, 호흡곤란 : none)bronchial breath sound with crackle on RLLFceftriaxone, azythromycin 투여 시작HD#2발열, 운동시 호흡곤란, poor oral intakeSPO2: 94~95%(O2 5L/min via NP)CPA : lobar consolidation in RLLS. pneumoniae urinary Ag test - positiveLevofloxacin IV 추가HD#3CPA : slightly aggravated consolidationfever(BT: 39.2℃), SPO2: 85~88%(O2 5L/min via NP)HD#4CPA상 consolidation 증가하는 소견보여 Chest CT takenCT : massive pleural effusion, lobar consolidation with air-bronchogramRt. decubitus : shifting fluid(+)→ pleural tapping : serous fluid(non pus-like)Lympho-dominant exudateVancomycin IV 추가HD#5CXR 촬영도중 acute respiratory failure 발생하여ER에서 intubation 시행 후 ICU care 시작- mechanical ventilation : VC(TV500/RR20/PEEP8/FiO2 0.8)- sedation : Mida 3mg/hr, vecaron 2mg/hrRt. CTD(32Fr.)BP 감소 : dopamine 5mcg/kg/min투여 항생제 : Vancomycin, Imipeniem, Levofloxacin, AMKHD#6면역능 저하 의심되어 immunoglobulin 검사 시행(검사명:Immuno E.P)IVIG startV/S : 38.4-144-16-121/78-90%PIP 25~26CmH2O, MVe 7.8~8.6L/min, SpO2 89~92%HD#7Pneumonia with ARDS, Severe sepsis 진행소견 보임ABAGA : 7.280-42.6- 76.9-19.2-78.4%BP 저하 : dopamine doubling, Levophed, vasopressinUOP 감소 : lasixSpO2 68~70%면역글로불린 검사 확인IgG 104(549-1584), IgA

의/약학| 2010.10.27| 19페이지| 3,000원| 조회(229)

사례연구, 성인간호 case study, 폐렴 case study, case ..

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CVID의 정의,원인,병태생리,치료에 대한 요약자료입니다.

Common Variable Immunodificiency(CVID)■ difinition: common defects in B-cell function and acquired agammaglobulinaemia: heterogeneous group of immunologic disorders of unknown etiology, characterized by impaired antibody responses■ Etiology? not hereditarycommonly associated with MHC haplotype HLA-B8 & HLA-DR3- MCH : major histocompatibility complex, 주요조직적합유전자복합체- haplotypes : 한쪽 어버이에 의하여 기여- HLA : human lymphocyte antigen? pyogenic organism : pneumonia, otitis media, sinusitis■ Frequency? 1 case per 10,000-50,000 population(males and females equally)? age : peaks of onset = 1-5 years, 16-20 years■ Mortality? prognosis is good unless bronchiectasis, chronic lung damage, severe autoimmune disease? 진단 후 20년 이내 생존율 - 남성 94%, 여성 64~67%? 사망 질환lymphoma > chronic pulmonary infection > liver failure> inflammatory bowel disease > other viral infections■ Pathophysiologymany different immune system defectsinsult↙↙↘↘① specific② complement system③ cellular immunity(T-cell)④ humoral immunity(B-cell)defect →↓Ab formation X (IgG,IgM,IgA,IgE,IgD)↙↓cell membrane injuryvasodilation↓↓microvascular permeability↑SVR↓↓↙ ↓interstitial fluid↑maldysfunction ofcirculating vol.CO↑ butperfusion 유지 어려움↓↓↙↓edema, IVF↓organ & tissue hypoperfusion/damagelactic acidosis↓↓perfusion imbalanceMultiple organ dysfuction syndrom(MODS)■ Clinical presentation㉠ Temperature > 38.0℃, 90bpm㉢ RR > 20rpm or PaCO212,000cell/㎣, 500 mg/dL in adults: 400-600 mg/kg/month: f/u serum Ig level every 3monthAfter achieving normal serum IgG levels → stop & f/u every 3month? chronic lung disease: 600-800 mg/kg/month② Subcutaneous infusion of Ig(SCIG)- IV가 어려운 환자, home injection 가능- IVIG에 비해 감염률이 7배가 적다? 160 mg/kg per week ≒ IVIG 400-600 mg/kg per month③ 부작용? Nonanaphylactic reactions- first 30min. infusion: backache, nausea, chills, low-grade temperature, vomiting- end of infusion & continue for several hours: Headache, chills, fever, myalgia, fatigue⇒ trestememt : acetaminophen, diphenhydramine, hydrocortisone용량 조정 → 200-300 mg/kg? Anaphylactic reactions- IVIG are rareusually caused by fluid volume, salt, protein overload & high dose- close observation during and after infusions⇒ trestememt : 필요시 diuretics 사용? Transmission of infectious agents- 1993~1994 : hepatitis C virus 발견됨.㉡ Surgical Care? for treatment of complications : endoscopic sinus surgery, spleenectomy㉢ Diet : high-calorie diet(high-energy expenditure)㉣ Activity : Regular physical activity is encouraged.■ complication: ARDS, DIC, ARF, MODSIMMUNOLOGY, Ivan Roitt 외 2, 1993, MosbyCommon Variable Immunodeficiency, C Lucy Park, MD, 2004 May, e-Medicine

의/약학| 2010.10.27| 4페이지| 1,000원| 조회(148)

면역, 성인간호학, CVID, 면역결핍증후군, 면역결핍증

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