수술실 급성통증, 감염의 위험 간호과정

목차

Ⅰ. 간호사정 [수술실]
Ⅱ. 간호진단
Ⅲ. 간호계획
Ⅳ. 간호수행
Ⅴ. 간호평가

본문내용

 환자명: 김00
 추정진단: Thyroid nodule NOS
 past history: (-)
 Allergy: (-)
 Family history: 여동생 (PTC)
 Social hostory: occupation>사무직

 Review of System
① Head and neck
– HA (-)
– cough (-)
– sputum (-)
② Chest
– pain (-)
– wheezing (-)
③ Abdomen
– pain (-)
– diarrhea (-)
– constipation (-)

 Physical Examination
① G/A
– not so ill looking appeerance
② M/S : alert
③ HEENT
– isocoric pupul with L/R (+/+)
– nonanemic conjuctiva
– anicteric sclera
– not palpable neck mass
④ CHEST
– BSE, CBS without rale/wheezing
– RHB without murmur
⑤ ABD
– soft
– T/RT (-/-)
– mass (-)
– organomegaly (-)
⑥ B&E
– CVAT (-/-)
– PTPE (-/-)

 CarePlan
– 수술계획 : Robotic right lobectomy
활력징후
– SBP:125 DBP:83 PR:70 RR:18 BT:36.5

출처 : 해피캠퍼스