A+ 성인 CASE STUDY(담석증, Cholelithiasis)

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"A+ 성인 CASE STUDY(담석증, Cholelithiasis)"에 대한 내용입니다.

목차

Ⅰ. 일반적 정보 ············································································· 1

Ⅱ. 입원 관련 정보 ······································································· 1

Ⅲ. 진단 검사 ················································································· 1
1. 임상병리 검사 ··································································································· 1
2. 영상의학 검사 및 기타 특수검사 ······························································ 5
3. 환자에게 적용된 검사 전/후 간호 및 주의사항 ·································· 6
Ⅳ. 약물요법 ···················································································· 7

Ⅴ. 수술 간호 ··············································································· 10
1. 수술명 ················································································································ 10
2. 수술 전 준비사항 및 간호 ········································································· 11
3. 수술 후 간호 ··································································································· 13

Ⅵ. 참고문헌 ················································································· 14

본문내용

Ⅰ. 일반적 정보. 이름 이OO 나이/성별 51 / F
입원 날짜 0000-00-00 입원 경로 OPD
키/몸무게 163.8cm / 65.3kg 직업 주부
결혼유무/자녀 기혼 / 아들 내원수단 도보
정보 제공자 본인 작성자 박OO

Ⅱ. 입원 관련 정보.
진단명 other cholelithiasis, without mention of obstruction
C.C Dyspepsia, Abdominal pain
onset 0000-00-00
입원동기 및
현병력
0000년 00월 00일 외부병원 CT 소견상 여러 개의 작은 담낭 결석 소견이 보여
f/u 중 00월 00일 화요일부터 Dyspepsia가 있었고, 내원 하루 전 Abdominal pain으로 본원 외래 내원 후 진료. OP위해 Admission.
최근투약상태 None
과거력 0000년 lapa-myomectomy(경북대병원) / 0000년 C/SEC / 0000년 치질 수술
가족력
부
HTN, DM,
후두암 모
HTN, DM
본인
남동생
HTN

Ⅲ. 진단검사.
1. 임상병리 검사.
검사항목 정상 수치 00월 00일 00월 00일
임상적 의의
증가 감소
WBC 4.0-10.0 K/ul 8.43 10.97 ▲
Ÿ 세균감염, 염증
Ÿ 백혈병
Ÿ 재생불량 빈혈
Ÿ 악성 빈혈
RBC 4.2-5.4 M/ul 4.77 3.99 ▼
Ÿ 선천성 심질환
Ÿ 탈수, shock
Ÿ 빈혈
Ÿ 골수기능부전
Hgb 12.0-16.0 g/dl 11.2 ▼ 9.9 ▼
Ÿ 심장질환
Ÿ 화상, 탈수
Ÿ 빈혈, 백혈병
Ÿ 만성질환, 출혈
Hct 36.0-46.0 % 36.3 32.5 ▼ Ÿ 탈수 Ÿ 빈혈
Platelet 140-400 K/ul 350 259 Ÿ 적혈구수증가 Ÿ 골수 억제
Ÿ 재생불량성빈혈

참고 자료

아홉 번째 판 성인간호학 Ⅰ 2019, 저자 윤은자, 김숙영 외, 수문사
OO대학병원 OOW EMR.
https://www.health.kr/ / 약학정보원
https://www.druginfo.co.kr/index.aspx / 드러그인포
https://cafe.naver.com/kumcguroor/182?art=ZXh0ZXJuYWwtc2VydmljZS1uYXZlci1zZWFyY2gtY2FmZS1wc
g.eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJjYWZlVHlwZSI6IkNBRkVfVVJMIiwiY2FmZVVybCI6Imt1bWNnd
XJvb3IiLCJhcnRpY2xlSWQiOjE4MiwiaXNzdWVkQXQiOjE2ODU2MzQ4Njg3MjN9.U2BWA6lcTFe4v2yLKc0L0
WOakRl5g3u-SQpvLPhdPsI / Robot Operation
https://www.gclabs.co.kr/pr/live/view/30?divcode1=02 / 신장기능검사(검사결과수치)
https://terms.naver.com/entry.naver?docId=926876&cid=51007&categoryId=51007 / 담석증(Naver)
https://terms.naver.com/entry.naver?docId=6225945&cid=51007&categoryId=51007#TABLE_OF_CONTENT6 /
담낭절제술(Naver)