9월 2일 강의 free

NGN 문제

Client History  Nurse's Notes   Vital Signs

84-year-old client diagnosed with stage 4 lung cancer with metastasis to the brain and liver. Client lives with his daughter and her family, who are his main caregivers at home. Client's advance directive states that he does not want CPR, intravenous fluids, antibiotics, a feeding tube, or hospitalization at the end of life. Daughter is his health care power of attorney.

1-5.The client's daughter is concerned about the fever and the fact the client is not eating or drinking. She requests IV fluids and antibiotics be given at once. Indicate which nursing interventions are most appropriate for the client. (Select all that apply.)

□Request an antibiotic from the HCP#

□Review the client's advance directive with the caregiver#.

□Instruct the caregiver to provide oral care every 4 hours.#

□Provide information to the family about music or massage therapy for the client.

□Provide oral suction at the bedside.

□Sponge the client with cold water.

□Monitor the client's urine output every 1 hour#.

□Begin a peripheral IV of NS at 100 mL/hr#

□Teach the daughter about signs and symptoms at end of life.#

□Ask the daughter if she would like to pra

1-6.At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show the client has declined.

Client Response	Improved   No Change     Declined

Respirations irregular with periods of apnea.	O          O         O #

client resting in recliner. RR 12, regular.       O	O         O

Oral mucous membranes dry.	O           O         O#

Axillary temp 102°F (38.9°C), client shivering.	O           O         O#

Client calm, not agitated. Grimaces with movement.O      O      O

Coarse rhonchi bilaterally. Crackles in bases       O      O      O

Productive cough                                   O      O      O

1.uterine atony시 뭐해줄래

oxytocin

MGSO4

Cytotec

steroid

2.N)태어난지 24시간된 애기 빌리루빈 12, 다음날 14, 첫출생당시 몸무게 3.0, 다음날 2.7kg인것. 소변 7시간째안봤음.광선치료시  OX 문제

안대착용,

래쉬생길수있,

옷 입힌다

diaper check

3.음날 몸무게 2.7kg.-> 잘못된거 아니다

u/o 2~5ml/kg/hr 목표이다?

#1-3 mL/kg/hour

4.N 첫 출생시 몸무게, 빌리루빈 수치 알려주다가 24시간뒤, 32시간뒤(?) 수치도 알려줌(24시간뒤 몸무게 조금 줄고 32시간뒤는 0.1 더 빠짐/빌리루빈 첫출생시 정상, 24시간뒤 14이상이었음,32시간뒤 다시 정상)

1) 현재 애기 해줘야할건? Phototherapy,

2) phototherapy 중재 .sata

안대착용

애기옷 다입히고 하셈,

3시간마다 체위변경,

저체온 혹은 고체온 확인하기

5.cardiomyopathy priority

① paroxysmal night dyspnea, fatigue

② jug. Vein distension

③ 다린지? Edema

④ murmur

•Fatigue

•Shortness of breath (dyspnea) when you're active or lying down

•Reduced ability to exercise

•Swelling (edema) in your legs, ankles and feet

•Swelling of your abdomen due to fluid buildup (ascites)

•Chest pain

•Extra or unusual sounds heard when your heart beats (heart murmurs)

Lt.CHF증상!!:weakness,activityintolerance,,부정맥.나아가서Rt.CHF까지..

6.myocaratiopathy 확진?

Muffle sounel

chest petechia

While cardiomyopathy can lead to a variety of cardiac issues, muffled heart sounds are primarily associated with conditions like pericardial effusion and cardiac tamponade, where fluid accumulation compresses the heart.

• Shortness of breath (dyspnea).Fatigue or feeling overly tired

• Swelling of the legs and feet (edema).Changes in urination

• Changes in urination. Chest pain .Abnormal weight gain .Palpitations

• Change in mental alertness can occur due to decreased circulation of oxygen to the brain. This can be described as lightheadedness, dizziness, fainting, decreased alertness, or difficulty concentrating

7. cardiomyophaty진단 받은 환자 care plan?

discuss home cardiac monitoring

activity제한

Na,K diet balance

fluid.laxatives discussion

8· preeclampsia 산모에게 DTR 검사 이유:

Mg 독성 or 발작 위험 확인

high bp check

ca level

In preeclampsia, deep tendon reflexes become overactive (hyperreflexia) because high blood pressure and other factors disrupt the brain's normal inhibitory control over the spinal cord reflexes. This central nervous system (CNS) hyperexcitability is a sign that the disease may be progressing to eclampsia (seizures), and a provider may prescribe magnesium sulfate to depress the CNS and prevent seizures

9. 단핵구증 .Mononucleosis 퇴원 설명. 다음중 맞는 것은?

면역이약하다.

6주간 안티인플라메이션 약 먹어야할수도 있어,

이틀 안에 다시 피곤하면 hcp 노티할게

antibiotic 치료할 것이다

정기적으로 cbc 검사받겠어요

A regular Complete Blood Count (CBC) check can be helpful in diagnosing mononucleosis, but it's not the primary test used. A CBC with a differential, along with a rapid heterophile antibody test, is typically performed. While a CBC can reveal a high white blood cell count, especially lymphocytes, and atypical lymphocytes, which are characteristic of mononucleosis, these findings are not specific to the condition

10. mononucleosis sx .sata

①Severe fatigue   ②Headache    ③Sore throat,

④Chills, followed by a feve

⑤Muscle aches  ⑥painless Lymphedema

11.severe diarrhea 후에 올 수 있는 증상? (SATA)

orthostatic hypotension

dizziness

wt loss

muscle weaknes

abd distention

12. severe diarrhea pt 중재 중 옳은 것(SATA)

필요시 Genital 부위에 moisturizing cream을 바른다.

이온음료를 마시도록 격려한다.

BWT을 qd로 check한다.

USG를 qd로 check한다.

고섬유 준다,

물 제한

bicarbonate 준다

13· 출산 후 산모 옳은 것은:

이제 엽산 그만 먹어도 돼요,

이제 철분 그만 먹어도 돼요

Drink mostly water, milk, and fruit juice. Eat foods that have protein such as milk, cheese, yogurt, meat, fish and beans. Protein rich foods are important to help you recover from childbirth and keep your body strong.

After delivery, continue to prioritize a balanced diet with foods rich in iron and folic acid to aid recovery and milk production, such as dark leafy greens, lean meats, beans, whole grains, and fruits high in Vitamin C

14.8세 cystoureterography 부모 설명, 더 교육할 내용은?

영상을 잘 보기 위해 하제 사용해서 장을 비우겠다

검사 후에 물을 많이 줄 거에요.

dye 를 사용할 것을 안다.

난 not indwelling cath~(indweling cath 가 필요 없다는 걸 안다.

15.cytometrogram 할거다. (성별 없었음) 옳은것. (sata)

I will report when i feel fullness of my bladder

allergy check for contrast dye

local anesthesia 할거다.

검사도중에 방광불편할 수 있어

검사 후 수분섭취를 격려할 것이다

검사를 위해 Foley 삽입 할 것이다