정신간호학 vsim(브이심) andrew davis reflection document
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- 2021.02.10
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- 2020.09
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"정신간호학 vsim(브이심) andrew davis reflection document"에 대한 내용입니다.
목차
Ⅰ. 내용
1. Document your findings related to the focused assessment of Mr. Davis’s alcohol withdrawal symptoms. Include his responses to your assessment.
2. Document your findings related to the assessment of Mr. Davis using the Clinical Institute Withdrawal Assessment of Alcohol Scale. Include his responses to your assessment.
3. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care.
4. Document all patient teaching regarding assessments and safety issues provided to Mr. Davis, and his response to the teaching.
5. Document your handoff report in the SBAR format to communicate Mr. Davis’s future needs.
Ⅱ. 평가
1. Opening Questions
2. Scenario Analysis Questions*
3. Concluding Questions
본문내용
1. Document your findings related to the focused assessment of Mr. Davis’s alcohol withdrawal symptoms. Include his responses to your assessment.
두통, 진전, 불안, 외모 변화를 사정함. 사정하기 위한 질문을 계속하자 두통이 심해진다고 호소함.
2. Document your findings related to the assessment of Mr. Davis using the Clinical Institute Withdrawal Assessment of Alcohol Scale. Include his responses to your assessment.
Nausea/vomiting – 0
tactile disturbance – 0
Auditory disturbance – 0
visual disturbance – 2
headache / head fullness – 4
tremor –4
paroxysmal sweats – 4
anxiety – 4
agitation – 4
orientation / sensorium – 1 총 26점
3. Referring to your feedback log, document all nursing care provided and Mr. Davis’s response to this care.
병실이 안전한지 확인했다. 그 후, 손을 닦고 환자에게 간호사 자신을 소개했다. 환자 확인을 하고, 알러지 여부를 물었고 없다고 했다. 혈압, 체온, 호흡, 맥박, 산소포화도 등 활력징후를 확인했고 정상범위 안에 있는걸 확인했다. 통증 여부, 부위, 정도 등을 사정했을 때, 두통이 있으며 0부터 10까지 중 4정도에 속하며 사라지지 않는다고 말해서 알콜 금단 증상의 하나라고 말해주었다.
참고 자료
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