
EMR인수인계 보고서(게실질환 입원대상자)/간호관리사례보고서
본 내용은
"
EMR인수인계 보고서(게실질환 입원대상자)/간호관리사례보고서
"
의 원문 자료에서 일부 인용된 것입니다.
2024.03.16
문서 내 토픽
-
1. Diverticular disease환자는 8월 20일부터 우측 옆구리 통증이 발생하여 응급실을 통해 입원하였습니다. 환자의 과거력으로는 심실중격결손(완치, 22년전), 장염(본원), 디스크(19년, 본원), 좌측 슬개골 골절 수술(작년 10월)이 있습니다. 입원 당시 검사 결과 상행결장 및 맹장 게실증이 확인되었으며, 심한 지방간 소견이 관찰되었습니다. 그 외 특이 소견은 없었습니다.
-
2. Nursing care간호사는 환자의 활력징후, 통증 관리, 수액 및 약물 투여, 검사 결과 확인 등의 간호 중재를 수행하였습니다. 특히 통증 관리를 위해 진통제를 투여하고 환자의 통증 수준을 모니터링하였습니다. 또한 환자의 상태 변화를 주치의에게 보고하고 필요한 처치를 시행하였습니다.
-
1. Diverticular diseaseDiverticular disease is a common gastrointestinal condition that affects the large intestine, particularly the colon. It occurs when small pouches, called diverticula, form in the lining of the intestine and bulge outward through weak spots in the intestinal wall. While diverticular disease is often asymptomatic, it can lead to various complications such as diverticulitis, bleeding, and intestinal obstruction. The exact cause of diverticular disease is not fully understood, but it is believed to be influenced by a combination of factors, including diet, lifestyle, and genetic predisposition. Effective management of diverticular disease often involves a multifaceted approach, including dietary modifications, medication, and in some cases, surgical intervention. Dietary changes, such as increasing fiber intake and limiting consumption of certain foods, can help prevent the formation of diverticula and reduce the risk of complications. Medications, such as antibiotics and anti-inflammatory drugs, may be prescribed to manage acute episodes of diverticulitis. In severe or recurrent cases, surgical procedures, such as colectomy or bowel resection, may be necessary to remove the affected portion of the intestine. Nursing care plays a crucial role in the management of diverticular disease. Nurses are responsible for assessing the patient's symptoms, monitoring their condition, and providing education and support to help patients manage their disease effectively. Nurses may also coordinate with other healthcare professionals, such as gastroenterologists and dietitians, to ensure a comprehensive and personalized treatment plan. By working closely with patients and their families, nurses can help improve the quality of life for those living with diverticular disease.
-
2. Nursing careNursing care is a fundamental aspect of the healthcare system, as nurses are responsible for providing comprehensive and compassionate care to patients throughout their healthcare journey. Nurses play a vital role in assessing patients' physical, emotional, and social needs, and they work collaboratively with other healthcare professionals to develop and implement personalized care plans. One of the key responsibilities of nurses is to provide direct patient care, which includes administering medications, monitoring vital signs, and assisting with activities of daily living. Nurses also play a crucial role in patient education, helping patients and their families understand their medical conditions, treatment options, and self-care strategies. This education can empower patients to take an active role in their own healthcare, leading to better outcomes and improved quality of life. In addition to direct patient care, nurses are also responsible for coordinating and communicating with other members of the healthcare team, such as physicians, therapists, and social workers. This collaboration ensures that patients receive comprehensive and coordinated care, which is essential for achieving optimal health outcomes. Nursing care also extends beyond the hospital setting, as nurses work in a variety of healthcare settings, including outpatient clinics, long-term care facilities, and community-based programs. In these settings, nurses play a vital role in promoting health, preventing illness, and managing chronic conditions, helping to improve the overall health and well-being of the communities they serve. Overall, nursing care is a critical component of the healthcare system, and nurses are essential in providing high-quality, patient-centered care that addresses the physical, emotional, and social needs of patients. By continuously striving to improve their knowledge, skills, and compassion, nurses can make a profound impact on the lives of the individuals and communities they serve.