[성인간호학실습A+] 케이스스터디_Gastric cancer_위암_사례보고서

목차

Ⅰ. Admission Note
Ⅱ. 간호력
Ⅲ. 신체검진
Ⅳ. 검사소견
Ⅴ. Problem List
Ⅵ. 우선순위
Ⅶ. 간호진단 및 간호과정의 적용
Ⅷ. 참고문헌

본문내용

Ⅰ. Admission Note
∎입원일자 : 2023.02.27
∎입원과 : 혈액종양내과

[주호소]
abdominal pain, for CTx

[현병력]
# 2022.10 AGC
상기질환에 대하여 CTx 및 Supportive care 위해 입원

[과거력]
HTN / DM / Dyslipidemia / TB (+/-/-/-)
OP Hx : –
Family Hx : 아버지(Lung ca)
Alcohol : Former(Type: 소주, Quantity Unit: 1병, Frequency: 4회/주)
Smoking : Former(Type: Cigarettes, Quantity Unit: 1 pack, Frequency: 1 pack/일)

[계통문진]
General
General fatigue / general weakness (-/+)
febrile / chilly sense (-/-) myalgia (-)

GI Sx
Anorexia / nausea / vomiting / diarrhea / constipation (+/-/-/-/+)
abd pain / td / rtd (+/-/-)

URI Sx
c/s/r/sore throat (-/-/-/-)
tonsil enlargement / redness / injection / exuadate / white patch (-/-/-/-/-)

Neurologic
headache / dizziness / insomnia / unilateral limb weakness (-/-/-/-)

ENT
Sore throat / voice change (-/-)

Cardiovascular / Respiratory
dyspnea / chest pain / palpitation / cough / hemoptysis (-/-/-/-/-)

GU Sx
Genitourinary / frequency / residual urine sense (-/-/-)
gross hematuria (-)

출처 : 해피캠퍼스