소개글

"성인2 만성신부전, 만성사구체신염 케이스 A+보장 원어+한글 고퀄 간호진단 3개"에 대한 내용입니다.

목차

1) 과거력

2) 진단명

3) 주관적 자료

4) 객관적 자료
1. 투약
2. Lab data
3. 특수검사

5) 간호과정 보고서
1. Excess fluid volume related to impared kidney function
2. Risk for electrolyte imbalance related to impaired kidney function resulting in hyperkalemia, especiallly and in hypocalcemia, hyperphosphatemia, and altered vitamin D
3. Imbalanced nutrition : less than body requirement related to restricted inke of nutrients, nausea, vomiting, anorexia and stomatitis

본문내용

1) 과거력

K.W. says he had an increase in urine production several months ago and was concerned about the possibility of diabetes.
History reveals grandmother and aunt have diabetes; no family history of renal disease.
He states that he has recently developed a severe decrease in urine output

2) 진단명 : chronic glomerulonephritis. > 만성 사구체신염

3) 주관적 자료

PLUS)
- “My heart has been beating fast lately”
- “Sometimes my hands and feet feel numb”
- “It's hard to breathe when I'm lying down”

Nutrition
: 고기를 못 먹고 싱겁게 먹어야 하니 밥맛이 없어요, nausea, vomiting, 입이 헐었어요. 빈혈이 있어서 어지러워요.

Elimination
: 소변이 잘 안 나와서 몸이 부었어요.

Activity
: 피곤하고 움직이기 힘들어요.

Sleep pattern
: 깊숙하게 잠이 들지 않아요.

4) 객관적 자료

PLUS)
- weight gain pattern
- edema on extremities

a) 투약 : PLUS) Regular Insuline, Kayexalate, Calcium gluconate
Darbepoetin alfa (Aranesp) weekly > 빈혈치료제
HCTZ 하이드로클로로치아지드 25 mg PO daily(HT) > 이뇨제(:고혈압, 부종)
Captopril (Capoten) 25 mg PO bid(HT) > 항고혈압약

참고 자료

황옥남 외, 성인간호학 제 6판 下, 현문사, 2017. 8.
성인간호학 2 수업 교재