E N D
1. Grodon????????????
2. Grodon????????????
3. Gordon????????? 1.???????????:
????????????????????
2.????:
?????????
3.???????:
????????????????????????????
4. Gordon?????????<?> 4.???????:
????????????????
5.???????:
?????????????
6.???????:
??????????????
5. Gordon?????????<?> 7.????????????:
???????????????
8.??????????:
???????????????????
9.??????:
???????????????
6. Gordon?????????<?> 10. ??????????:
??????????????(?
???????,???????,
????????)?
11.???????:
?????????(????)?
?????????????
7. Gordon??????????? 1.???????????:
Health-perception- Health- management pattern
2.????:Elimination pattern
3.???????:Nutritional-metabolic pattern
4.???????:Activity-exercise pattern
5.???????:Sleep-rest pattern
6.???????:Cognitive-perception pattern
8. Gordon???????????<?> 7.????????????:
Self-perception-self-concept pattern
8.??????????:
Role-relationship pattern
9.??????:
Sexuality-reproductive pattern
10.??????????:
Coping-stress-tolerance pattern
11.???????:Value-belief pattern
9. Gordon??????????????? ?????????
????:
(1)?????????????????
(2)???????????????
(3)??????????????????
(4)?????????????????
(5)??????????????????
10. Gordon??????????????? ?????????<?>
????<?>:
(6)?????????????
(7)????????????
(8)???????????
(9)??????????????????????
?????
11. Gordon??????????????? ??:
(1)?????????????????????????????????
(2)?????????????????
????:?????
12. Gordon??????????????? 2.??—
????:
(?)urine:??,?,??,???????,??
?,??????,????,????
??,on Foley,?????????,
????
(?)stool:??,??,?,??????(???????)???????,??????,????
13. Gordon??????????????? 3.???????—
kcal???????:??????????
(???????????)
*??????:20-30yrs:?:62+(BH-170)×0.6 ?:52+(BH-158)×0.5 35-54yrs:?:62+(BH-166)×0.6
?:52+(BH-154)×0.5 55yrs??:?:62+(BH-164)×0.6 ?:52+(BH-152)×0.5
*???????=(????/????) ×100%
*????90%~110%
14. Gordon??????????????? ???? ???? ?? ????
?? 20 20-25 30
? 20-25 30 35
? 30 35 40
?? 35 40 45
??kcal??:???? ×?????????
(2)?????????
(3)???????????,???????
15. Gordon??????????????? ?????????:
(1)I/O????,????????
(2)??edema?????
(3)??loss?????
(4)??,??????
(5)????:??????,???
(6)??????,??,??,????,???
(7)???Deta
16. ??????—? Na+??—
?????????????????????????
?????????????????
Na+??—
????????????????????????????????
K +??—
??????????????????????????????????????????????EKG(T????U????ST????
K+??—
?????,??????EKG??(T????P????ST????
17. ??????—? Ca++??—
???????????????????????????????????????
Ca++??—
??????????????????????????????????(??????????????????)
18. Gordon??????????????? 4.?????—
????:
<?>?????:
(1)???????
(??????????????)
(2)???
(??????????????????
??ADL???)
19. ADL—Activity of daily living (??????) O:?????????????
?:?????????
?:??????????
?:?????????,????????
?:??????,??????,????
???
20. Gordon??????????????? (3)?????????????
????:
????????????????????????????????????????????????????????????????????????(Blood gas)?x-ray??
????:
?????????????????????
???????????????????????
???????????????????????
????????Hb?RBC?HCT?EKG??
21. Gordon??????????????? (4)????????????(???????
??P?R?????)?
(5)?????????????
<?>????????????:
(1)????????????????????
(2)??????????????????? ?????????
(3)??????????????????????
22. ??????(Manual Muscle Test> O:???,????????
?:Trace??,???????,???????
?:Poor??,????? ,?????????
?:Fair??,??????,????? ?
?:Good?,????????
?:Nomal??,???????
23. Gordon??????????????? 5.?????—
????:
(1)????:?????????(????? ??????????????? ???????????????????????)????????
(2)????:???????????????? ?????????
24. Gordon??????????????? 6.????—
??(??)??????:
(1)??:??????????,????
(2)??:???????????????? ????
(3)??:???????(??????) ????
?????
(4)??:??????????
(5)??:??????????????
?
????(?????):??????????????????????????????
25. Gordon??????????????? ????????:
(1) ???????????????????
??????
(2)?????
(3)????:??????????????
?????
(4)????:??????????????
???
26. Gordon??????????????? (5)??????:
1.???:???
2.???:???
3.????:???????,??????????
4.????:?????
5.????:??????????,??????
6.????:?????
7.????:????????????????(????2/3)??????
27. Gordon??????????????? (5)??????:
8.???:??????
9.????:??(????1/3)???????,????????????????????BP?R?
10.????:?????????????????,???
????????
11.????:???????,???????,?????
???
12.????:??????
28. Gordon??????????????? 7.?????????—
????:(????)
(1)????:
????:
????????????—????????? ????????????????
????:
????????????—??????????????????????? ?
29. Gordon??????????????? (2)????:
????:
????,????????????????
?????????(?????????,?
??? ???????)?
????:
?????????????,???????
?????????????(???????
?????????)?
30. Gordon??????????????? (2)????:
??,??,????:
?????????????????????,???????????,??????????(???????????????????………?)?
31. Gordon??????????????? ????:(????)
(1)???:
(2)???:
(3)???:
32. Gordon??????????????? 8.????--
?????????:
(1)???????:*????:???????????*????:????????*????:???
34. Gordon??????????????? (2)???????,??????????????
(3)???????????????????????
(4)??????:
*???
*???
*???
35. Gordon??????????????? ?????????:(1)????: ????:(2)?????????????????
(3)??????ADL??????
(?????????)
36. Gordon??????????????? 9.????—
????:
(1)??????:??????????????(???????????) ?
(2)??????:???????????,?????????,??????????
37. Gordon??????????????? 10.????????—
????:
-???????????:??????????????
-???????????????????????
-????????????????????????
????????????
38. Gordon??????????????? ?????????????
--???????????
--???????:???????????????????????????????????????
--???????:?????????????????????
39. Gordon??????????????? 11.?????—
?????????????
????????????????????
???????????????
???????????
??????? ?
???????????????
40. ??????? ????????? ??????(???)
(Health-perception-Health-management pattern)
????????
??????????
?????????????(???)
??????
??????
41. ??????? ???????(Nutritional-metabolic pattern) :
???????????;???????????
???????????????
??????????;??????;???????
????????;??????;????;????
??????? ?????????? ??????? ?????????? ??????????????; ??????? ?????? ???????
42. ??????? ???? (Elimination Pattern)
??
????
??
??????
??????
??????
43. ??????? ??????? (Activity Exercise Pattern)
?????
??
????????
??????????
????????:?????
44. ???????
???????(Sleep-Rest Pattern)
??????
45. ??????? ???????(Cognitive?Perceptual Pattern )
??
???????(???):?????????? ???????? ??
??????
??????
????
?????????
????????
46. ??????? ?????????
(Self-Perception?Self-Concept Pattern)
???
???:???
??????
?????????
???????
?????????
47. ??????? ?????????<?>
(Self-Perception?Self-Concept Pattern)
??
???
??
????
???
48. ??????? ???????(Role?Relationship Pattern)
?????
????
???????
??????
??????
49. ??????? ???????<?>(Role?Relationship Pattern)
??????
????????(??)
??????
50. ??????? ???????(Role?Relationship Pattern)
?????
????
???????
??????
??????
51. ??????? ???????<?>(Role?Relationship Pattern)
??????
????????(??)
??????
52. ??????? ???????(Role?Relationship Pattern)
???????????
???????—
??/????????
???????
????????????
???????????????:?
?????
53. ??????? ??????(Sexuality?Reproductive Pattern)
?????
???????
???????
???????:?????
???????:?????
54. ??????? ??????<?>(Sexuality?Reproductive Pattern)
???????
????
??????:?????
55. ??????? ???????(Value?Belief Pattern)
????
????:?????
56. ??????? ?????????(Coping-Stress-Tolerance Pattern):
????????
?????? ?????
????????:???
????????:???
?????????
??????:?????
57.
58. ??? ???,72?,???,????,?????,?????,????????????????????,???????????38.6?,???????????????,???????????:many????:21~30/mm?????:3+???????????,??????10?5???39?,????????,?????10?6???????30~35?/?,SpO2 91%,??109?/?,????,???????,?????,??:120/42mmHg,??????,??????,?????????,???????????????????????FiO2:45%?ACMV??Rate10?/??????28~32?/??????650cc/?,?????????,???,?????????,??X-???????????
59. (?)??????????? 10/6????:??????????,?????????
10/9????:???????????,?????,????????,??????
10/9???:?????????????????
10/10???:?????????????,????????????
10/6????????,????????????????Valium 5mg?????,??????????
10/6????????,???????????????
10/7-10/8??????????,?????????
60. (?)??????????? ??:?????????????,????????,??????????,????????,???????,??????????????,??????????????????????,?????,??????????????
61. (?)????? ??:
10/3???????,???????? ???? WBC:many?RBC:21~30?OB:3+,?????????
10/6???????????
10/6~10/20 1000~1900cc/day,???????
10/7??:?????????,?????????,?????????????????
??:??????????????????,??????????????
62. (?)????? ??:
10/6????????
10/7~10/10??????????????,?????5?/?,???????????
10/8??:?????????????????????????
10/11??? 20ml 2#?????150gm???????
??:???????????,??????????,???????,??????????
63. (?) ??????? 10/5:Hb 15.1 gm/dl?
10/6:?????2000?/?,?????????10CC???????? ???????,????
10/7:??????????,?????,??????????
10/8??:?????,???????????????????165???
10/10:???62.8???
64. (?) ???????<?> 10/13:?????,???
10/14:Albumin:3.1gm%?Na124.2meq/L?
10/15:???????/?(???5.4?/?)?
10/7~10/20: I/O Postive620~1420cc/Day?
10/18: Na 131.9meq/L?
??:????:62+(165-164)×0.6=62.6kg????(+0.3%)??????,??Albumin??????,????????????(5?/?)???,???????????,????????
65. (?)??????? 10/6 :?????????30~35?/?,???,SPO2 90~91%,????,?????????,??????????????????,??????????
?????????????????????????????
?????????????? PH:7.492?PaCO2:30.2?PaO2:67.1?SaO2:94.9%?
??????????????PaO2???118.8???????ACMV ????10?/????? 25-30?/??HR:83-118?/??
66. (?)???????<?> 10/5 :???????:No growth?
10/6~10/22:????????????
10/6-10/20 :??:35.9-38.7????
10/6?10/17:??????????,??????
10/7:??X-????????
??:???????????????????????????
67. (?)??????? 10/7:??????8???????????????????,??????????????? ???ICU??????,?????????????????
10/10:????:??2?,??4?,??3??????????,?????10%???
10/12:???????????????????
10/15:??????????????
??:???????????,?????????,???????????
68. (?)??????? 10/6:????????????????,??????
10/8:????,???,??????????,?????
10/9:????:???87?5???,?????????????????????????8????????????????????????????,??????????????????????,???????ICU?????????,???????????
??:??????,??????????,????????????????????????????,???????????
69. (?) ??????????? 10/6:????????????,????????,?????????????????27-33?/??Bp:151/78mmhg,???98-108?/?????,
???????????????,??????,???????????????????,??????????????????????
????????????????:????????? ???????????,??????
10/17???:?????????????30???????:??????????,?!?????????
70. (?) ???????????<?> 10/18:???:???????,??????,???????????
10/19:???:???????,?????????????????,?????????????
??:??????????????????????????,??????????,????????????,???????????
71. (?)???????? 10/6-10/8:??????????
10/8:??????????
10/9:????GCS11?(E4VTM6)????3.0???????????,????????,?????,?????????,??????,??????????,??????????
10/10:????????????????
??:????????????????,????????????????????????????????
72. (?)????? 10/6-10/14:???????????,??????????,???????????????????:???72??????;???????????????????:??????
10/23:???????:??????,????,????
10/24:???:???????,?????,?????,???????????????,????????????,?????????????????????????????????????,???????????????????????,???????????,???????,?????????????????????????????
73. (?)?????? ????????30??,??????????????,?????,????????????????????????????,???????????????
74. (?)????????? 10/8-10/14:?????????,???????,??????,????,?????????????,????????,??????????,????????;???????????????????;????????
10/9:??????:??????????????,???????,??????????,?????????????????
????????????????????
75. (??)??????? ????????????????????????,???????,?????????
76. ???? ?????????????????????:
1.??/????????????????????(10/6?)
2.?????????/??????????????
???(10/7?)
3.??????/????????????(10/7?)
4.??????/?????????????????
?????(10/9?)
5.??/????,????????(10/10?)
6.?????/???????????????????
?????(10/10?)
77. ??? ???,50?,???????,????,?????????,??,??????,????????????,???????,???????
?????????,???????????????,???????????,????????????????,??????????????,????????????????????,??????????????????,?????????,???????
78. ???<?> ???6?11?????????????????????????,????????????,???????,?????????????2?3???,??????????????????,???????????????????;??????????????????????????,????????
79. (?)Gorden???????????? 1.????????????
???:??????????,??????????????????????,??????,????????????
???:???6/11???????????,?????????,??????????,???????????????,?????????????,???????????????,???????
80. (?)Gorden???????????? 2.????????
???:????????????,???????,???????????,????????????,??????2500?,??180???74??,????:62+(180-170)×0.6=68??????????
???:??????????????,????????,??????????????,????????????900kal\day,4\20??????????,???????,??????????1\3,????????6\24??????,?????,?????1000gm-1500gm,??????72??,?????25??????????,???????????????,????????????
81. (?)Gorden???????????? 3.????
???:??????????????????,????????,????????????
???:????????????,?????,????????????,????????????3000-4000?,????????????1-3?H2O,?????1500-2000????????????,??????????,????????????,???????????????????????????????,???????????????
82. (?)Gorden???????????? 4.????????
???:????????????????,??????????????????,????????????
???:???????????,??????????,???????,??????????????????,???????????????????,????????????
83. (?)Gorden???????????? 5.???????
???:??????,?????????????????????
???:???????,???????????,?????????????,?????????????????,????????,??????,??????????????????,???????:??????????????????????????????????????,??????????
84. (?)Gorden???????????? 6.???????
???:??????????????,???????????????,?????????,????????????,?????????
???:??????????,????????,??????,????????????,????:???????????????,????????????5-6??,??????????,????1-2???
85. (?)Gorden???????????? 7.????????????
???:???????????????????????????????,??????????
???:??????????,?????????????????,??????????????????,????????????,????????,??????????????,??????????
86. (?)Gorden???????????? 8.????????
???:?????????????????????,???????????????????
???:????????????????,???????????????,?????????????????????,???????,??????????????
87. (?)Gorden???????????? 9.???????
???:???????,????????????????,????????,?????????,??????????????????
???:??????????????,??????????????,?????????????
88. (?)Gorden???????????? 10.?????????
???:????????,??????,???????????,??????,??????
???:?????????????????,??????????????,????:?????,???????,???????????,??????????? ????????????????????,???????,????????
89. (?)Gorden???????????? 11.????????
???:????????,??????,???????,???????,???????????????????????
???:????????????,??????????????,??????????????????,?????????????
90. (?)Gorden???????????? ??????
1.?????????(6/11??)
2.??(6/11??)
3.??(6/12??)
4.?????(6/12??)
5.??????(6/12??)