성인간호학-심장계질환

목차

1. 고혈압의 분류
2. 고혈압환자의 교육내용
3. CAD
4. CAD 위험원
5. Angina pectoris 분류 3가지
6. Angina pectoris 사정
7. MI환자의 병리적 변화
8. MI risk factor
9. MI환자의 진단적 검사
10. MI환자의 사정
11. MI 간호중재
12. Inflammatory disease of the Heart - Infective bacterial endocarditis

본문내용

P (투약 후 세심하게 관찰,, SBP가 100이하이거나,
이전보다 25 mmHg 이하로 낮아지면, 침대 머리쪽을 낮추어주고, 의상에게 연락한다.)
21. provide reassurance to the client & family
12. Inflammatory disease of the Heart
- Infective bacterial endocarditis
-sign & symptoms : fever, anorexia, Wt. loss, fatigue, cardiac murmurs,
heart failure, embolic complication (traveling through the circulation)
petechiae, splinter hemorrhages in the nailbeds
Osler's nodes(reddish tender lesions) in the pads of the fingers, hands, toes
Janeway's lesions(nontender hemorrhagic lesions) on the fingers, toes, nose or ear lobes
splenomegaly, clubbing of the fingers
-간호중재
1. provide adequate rest balanced with activity to prevent thrombus formation
2. maintain antiembolism stockings
3. monitor for signs of heart failure
4. monitor for signs of emboli
5. monitor for splenic emboli
(sudden abd. pain radiating to the lt. shoulder, the presence of rebound abd. tenderness on palpation)
6. monitor for renal emboli(flank pain radiating to the groin, hematuria, pyuria
7. monitor for CNS emboli (confusion, aphasia, dysphagia)
8. monitor for pulmonary emboli(pleuritic chest pain, dyspnea, cough)
9. assess skin, mucous membranes, conjuctiva for petechiae
10. assess nailbeds for splinter hemorrhages(손톱선상 출혈)
11. assess for Osler's nodes (붉고 자줏빛 손발바닥의 node, 1-2일 지속)
12. assess for Janeway's lesions (손, 발바닥의 작은 점상출혈반점)
13. assess for clubbing of the fingers
14. evaluate blood culture results
15. administer antibiotics IV
16. plan and arrange for discharge

키워드

심장질환,   고혈압,   Heart Disease,   CAD,   MI,   Angina pectoris,   간호중재,   간호