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
출처 : 해피캠퍼스
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