추천자료
[성인간호학실습4] 간호사례연구보고서(회복실케이스스터디),Hepatectomy-Lobectomy,metastatic liver and intrahepatic bile duct malignancy
[성인간호학실습1[ 간호사례연구보고서, Urinary tract infection, UTI, 요로감염, Acute renal failure, ARF, 급성신부전, 케이스스터디, MED
[성인간호학실습2] 간호사례연구보고서, Heart failure, HF, Asthma, 심부전, 천식, 케이스스터디
[성인간호학실습3] 간호사례연구보고서, 케이스스터디, Thyroid nodule, 갑상선 결절, 일반외과, GS
[성인간호학실습4] 간호사례연구보고서, 케이스스터디, 수술실, OR, Closed fracture (Fx) of neck of femur, 폐쇄성골절, OSD
[성인간호학실습3] 일반외과 환자 간호, 약물요법과 간호, 학습과제, GS, 약물정리, 케이스스터디, 간호사례연구보고서, CASE STUDY
[성인간호학실습2] 내과계(심혈관계, 호흡기계, 혈액종양계), 약물요법과 간호, 학습과제, IM2, 약물정리, 케이스스터디, 간호사례연구보고서, CASE STUDY
지역사회간호학(방문간호) case study A+받음
간호사례 연구 보고서
[간호사례 연구] 식도암에 대한 원인과 예방법
소개글
간호사례 연구 보고서에 대한 자료입니다.
목차
목 차
1.일반적 정보(General Information)
2. 주호소(Chief Complaint)
3. 현병력(History of Present Illness)
4. 과거력(Past History)
1) Medical
2) Psychiatric
5. 가 족 력(Family History)
6. 사회력(Social History)
1) Personal / Developmental
2) Health related Habits
7. Mental Status Examination
Mental Status Examination
1) General Appearance
2) Behavior and acivity
3) Attitude to examiner
4) Speech
5) Mood and Affect
6) Perception
7) Thoughts
(1)Thought form & process
(2)Thought content
8) Sensorium / Cognition
9) Judgement
10) Insight
11) Reliability
8. 신체사정(Physical Examination)
1) Vital Sign
2) Sleep
3) Oral Intake
4) Elimination
5) Drug Side Effects
6) Other Physical Problems
9. 심리검사(Psychometry) 및 임상 검사(Clinical Lab) 결과
10. 의학적 진단
11. 의학적 치료
12. 간호 과정
본문내용
7. Mental Status Examination
Mental Status Examination
1) General Appearance
(1)입원시 상태: 묶여서 왔는지□, 도보□, wheel chair□, stretch car(ER)■
(2)자발적 입원여부: Yes□, No■
(3)외모: 체구, 신장, 옷차림새, 두발상태, 화장상태(여자)
보통키, 건장한 체격, 짧은 머리의 구릿빛 얼굴의 남환
(4)personal hygiene: good■, poor□ (so so)
(5)facial expression: blunted□, tense■, bright□, angry□, deperessive□
(6)posture; rigid□, slumped□, comfortable■, others:
(7)eye contact: Yes■, No□
2) Behavior and acivity
stereotypy□, mannerism□, rigid□, hyperactivity□, tremor□, retarded□, psychomotor agitation■, compulsive act□, others:
3) Attitude to examiner
cooperative□, submissive□, defensive□. apathetic□, hostile■,
others:
4) Speech
(1)spontaneity: +□, -■
(2)Verbal productivity: increased□, decreased□, normal■, talkative□,
others:
(3)Speed: rapid□, slow□, others: normal
(4)Pich(음의 고저): high □, low □, normal ■
(5)Tone: loud□, whispered□, monotonous□, normaly■
(6)Speech disturbance: dysarthria□, poverty of speech□, stammering(말더듬)□, mumbled, others: 없음