제1편 성인간호학

1장 성인간호 개론···························································································································· 2
01 성인간호 개론··············································································································· 2
1.1 간호의 핵심 개념 /2
02 성인의 시기별 이해····································································································· 5
03 간호과정에 대한 이해································································································· 6

2장 기본 병태생리···························································································································· 7
01 세포와 세포막··············································································································· 7
1.1 구조와 기능 / 7
02 염증······························································································································· 10
2.1 염증의 개념 및 증상 / 10 2.2 염증 반응 / 11
2.3 상처 회복 / 13 2.4 감염 / 14
03 면역반응······················································································································· 15
3.1 면역의 개요 / 15 3.2 특이적 면역의 종류 / 16
3.3 과민반응(알레르기 반응) / 20 3.4 면역결핍질환 / 22
04 수분과 전해질············································································································· 24
4.1 기본 개념 / 24 4.2 전해질 불균형 / 25
4.3 산·염기 / 28

3장 위장관계 건강문제와 간호······························································································· 32
01 구조와 기능················································································································· 32
1.1 위장관의 구조 / 32 1.2 위액 분비 / 33
02 건강사정······················································································································· 34
2.1 건강사정과 신체검진 / 34 2.2 복부사정 지침 / 34
03 위장관계 일반증상 간호··························································································· 35
3.1 오심과 구토 / 35 3.2 변비 / 36
3.3 설사 / 37 3.4 통증 / 38
3.5 출혈 / 38
04 위·식도 상부위장관 질환······················································································· 39
4.1 위·식도 역류성 질환 / 39 4.2 식도열공 탈장 / 41
4.3 식도이완불능증 / 42 4.4 식도 게실 / 42
4.5 식도암 / 43
05 위·십이지장 질환····································································································· 44
5.1 급성 위염 / 44 5.2 미란성 위염 / 45
5.3 만성 위염 / 45 5.4 소화성 궤양 / 47
5.5 위암 / 53
06 하부위장관 질환········································································································· 56
6.1 과민성 장증후군 / 56 6.2 급성 감염성 장질환 / 58
6.3 염증성 장질환 / 61 6.4 장 폐색 / 63
6.5 게실 질환 / 65 6.6 탈장 / 66
6.7 결장직장암 / 68 6.8 직장과 항문질환 / 70

4장 간담췌계 건강문제와 간호······························································································· 72
01 구조와 기능················································································································· 72
1.1 간과 담도 췌장의 구조와 기능 / 72
02 건강사정······················································································································· 74
2.1 신체검진 / 74 2.2 진단검사 / 75
03 간·담·췌계 일반증상 간호···················································································· 77
3.1 황달 / 77 3.2 그 외 일반적인 간호문제 / 79
04 간 질환························································································································· 80
4.1 간염 / 80 4.2 간경변증 / 86
4.3 지방간 / 89 4.4 간종양 / 90
4.5 간농양 / 91 4.6 기타 간 질환 / 91
05 담도 질환····················································································································· 92
5.1 담석증 / 92 5.2 담낭염 / 94
06 췌장 질환····················································································································· 95
6.1 급성 췌장염 / 95 6.2 만성 췌장염 / 97
6.3 췌장암 / 98 6.4 낭종성 섬유증 / 99
6.5 췌장 이식 / 100

5장 호흡기계 건강문제와 간호····························································································· 101
01 구조와 기능··············································································································· 101
02 건강사정····················································································································· 103
03 호흡 생리··················································································································· 106
04 호흡기계 일반증상 간호························································································· 108
05 상부 호흡기계 질환································································································· 109
5.1 인플루엔자 / 109 5.2 비염 / 110
5.3 비용종 / 111 5.4 부비동염 / 112
5.5 비출혈 / 113 5.6 급성 인두염 / 114
5.7 편도선염 / 115 5.8 수면 무호흡 / 116
5.9 후두 건강문제 / 117
06 환기장애····················································································································· 119
6.1 폐렴 / 119 6.2 폐결핵 / 121
6.3 폐농양 / 128 6.4 흉막 삼출 / 129
6.5 농흉·기흉·혈흉 / 130 6.6 폐암 / 132
07 가스교환 장애··········································································································· 133
7.1 천식 / 133 7.2 만성 폐쇄성 폐질환 / 136
7.3 기관지 확장증 / 138 7.4 낭종성 섬유증 / 139
7.5 폐색전증 / 140 7.6 기타 폐 질환 / 142
08 급성 호흡부전··········································································································· 144
8.1 급성 호흡부전 / 144 8.2 성인 호흡곤란증후군 / 146

6장 순환계 건강문제와 간호·································································································· 148
01 구조와 기능··············································································································· 145
1.1 순환계 주요 용어 / 148 1.2 순환계의 조절 / 150
02 순환계 증상··············································································································· 152
2.1 순환계 주요 증상 / 152 2.2 신체검진 / 153
2.3 심전도의 이해 / 155
03 울혈성 심부전··········································································································· 158
3.1 원인·병태생리 / 158 3.2 심부전의 분류 / 160
3.3 증상과 징후 / 161 3.4 간호중재 / 162
04 관상동맥 질환··········································································································· 164
4.1 개요 / 164 4.2 협심증 / 166
4.3 급성 심근경색 / 170
05 부정맥························································································································· 174
5.1 개요·병태생리 / 174 5.2 부정맥의 종류 / 175
5.3 진단·간호중재 / 183
06 염증성 심장질환······································································································· 185
6.1 류마티스성 심질환 / 185 6.2 감염성 심내막염 / 187
6.3 심근염 / 188 6.4 심장막염 / 189
6.5 심장압전 / 190
07 후천성 판막질환······································································································· 191
7.1 승모판 협착 / 191 7.2 승모판 폐쇄부전 / 192
7.3 대동맥판 협착 / 193 7.4 대동맥 폐쇄부전 / 194
7.5 삼첨판 질환 / 195 7.6 체외순환 심장수술 / 195

7장 혈관계 건강문제와 간호·································································································· 196
01 구조와 기능··············································································································· 196
1.1 혈관의 구조 / 196 1.2 기본 개념 / 196
1.3 혈관의 조절기전 / 197
02 건강사정····················································································································· 198
2.1 신체검진 주요내용 / 198
03 혈관계 일반증상 간호····························································································· 199
3.1 말초초직 관류의 증진 / 199 3.2 통증 예방 / 199
3.3 피부손상 및 합병증 예방 / 200
04 고혈압························································································································· 201
4.1 개요 / 201 4.2 원인·병태생리 / 201
4.3 증상·진단 / 203 4.4 간호중재 / 204
4.5 고혈압성 위기 / 207
05 대동맥 및 동맥질환································································································· 208
5.1 동맥경화증과 죽상경화증 / 208 5.2 급만성 동맥폐색 / 209
5.3 폐색성 혈전혈관염 / 210 5.4 레이노 증후군 / 211
5.5 동맥류 / 212 5.6 대동맥 박리 / 213
06 정맥질환····················································································································· 214
6.1 심부정맥혈전증 / 214 6.2 정맥류 / 217
6.3 정맥정체성 궤양 / 218 6.4 폐색전증 / 219
07 림프질환····················································································································· 220
7.1 림프부종 / 220 7.2 림프절염 / 221

8장 혈액계 건강문제와 간호·································································································· 222
01 구조와 기능··············································································································· 222
1.1 혈액의 구조와 기능 / 222 1.2 주요 개념 / 224
1.3 지혈과 혈액응고 / 225 1.4 혈액계 관련 기관 / 226
02 건강사정····················································································································· 227
2.1 신체검진 / 227 2.2 진단검사 / 228
03 적혈구 장애··············································································································· 230
3.1 빈혈 / 230 3.2 철분 결핍성 빈혈 / 231
3.3 악성 빈혈 / 233 3.4 용혈성 빈혈 / 235
3.5 기타 빈혈의 종류 / 237 3.6 적혈구증가증 / 238
04 백혈구 장애··············································································································· 239
4.1 호중구감소증 / 239 4.2 백혈병 / 240
05 조혈 장애··················································································································· 244
5.1 다발성 골수종 / 244 5.2 림프종 / 245
5.3 전염성 단핵구증 / 246
06 지혈 장애··················································································································· 247
6.1 자반증 / 247 6.2 응고장애 / 250
6.3 저프로트롬빈혈증 / 252 6.4 파종혈관내 응고 / 252

9장 근골격계 건강문제와 간호····························································································· 254
01 구조와 기능··············································································································· 254
1.1 뼈의 구조와 기능 / 254 1.2 관절과 인대 / 256
1.3 골격근의 구조와 기능 / 257
02 건강사정····················································································································· 258
03 근골격계 일반외상 간호························································································· 259
3.1 외상의 종류 / 259 3.2 골절 / 261
3.3 견인 장치 / 265 3.4 석고붕대 / 267
3.5 목발보행 / 268 3.6 절단 간호 / 271
04 염증성 장애··············································································································· 273
4.1 골수염 / 273 4.2 골결핵 / 274
4.3 기타 염증 / 275
05 류마티스 질환··········································································································· 276
5.1 류마티스 관절염 / 276 5.2 골관절염 / 282
5.3 통풍 / 284 5.4 전신 홍반루푸스 / 286
5.5 강직성 척추염 / 288 5.6 섬유근육통 / 289
06 골대사 장애··············································································································· 290
6.1 골다공증 / 290 6.2 골연화증 / 293
6.3 파제트병 / 294
07 골 종양······················································································································· 295
08 요통····························································································································· 297
8.1 구조와 기능 / 297 8.2 허리 근염좌 / 298
8.3 척추후만증 / 299 8.4 척추측만증 / 300
09 발의 장애··················································································································· 302
9.1 무지외반증 / 302 9.2 족저근막염 / 302

10장 신경계 건강문제와 간호······························································································· 303
01 구조와 기능··············································································································· 303
1.1 중추신경계 / 303 1.2 말초신경계 / 307
02 건강사정····················································································································· 310
2.1 건강상태 검사 / 310 2.2 뇌신경 검사 / 311
2.3 운동과 감각능력검사 / 312 2.4 반사검사·뇌 특수검사 / 314
03 신경계 일반증상 간호····························································································· 315
3.1 무의식 환자 간호 / 315 3.2 두개내압 상승 / 317
3.3 두통 / 319
04 감염성 질환··············································································································· 321
4.1 뇌수막염 / 321 4.2 뇌염 / 324
4.3 뇌농양 / 325
05 뇌혈관성 질환··········································································································· 326
5.1 뇌졸중 / 326
06 신경계 종양··············································································································· 330
6.1 뇌종양 / 330 6.2 척수종양 / 332
07 신경계 외상··············································································································· 333
7.1 두부 외상 / 333 7.2 척수 손상 / 335
7.3 추간판탈출증 / 338 7.4 말초신경 손상 / 339
08 퇴행성 질환··············································································································· 340
8.1 파킨슨병 / 340 8.2 근위축성 측상경화증 / 343
8.3 중증 근무력증 / 344 8.4 만성 진행성 무도병 / 346
8.5 다발성 경화증 / 347 8.6 알츠하이머병 / 349
8.7 치매 / 350
09 경련성 질환··············································································································· 351
10 말초신경 질환··········································································································· 353
10.1 삼차신경통 / 353 10.2 안면 신경마비 / 355
10.3 길랭-바래 증후군 / 357

11장 내분비계 건강문제와 간호·························································································· 358
01 구조와 기능··············································································································· 358
1.1 구조와 기능 / 358 1.2 호르몬의 조절 / 359
02 뇌하수체 장애··········································································································· 360
2.1 뇌하수체 기능항진증 / 360 2.2 뇌하수체 기능저하증 / 362
2.3 요붕증 / 363 2.4 항이뇨호르몬 분비 부적절증후군 / 365
03 갑상샘 장애··············································································································· 366
3.1 갑상샘 증대 / 367 3.2 갑상샘 기능항진증 / 370
3.3 갑상샘 기능저하증 / 374
04 부갑상샘 장애··········································································································· 375
4.1 부갑상샘 기능항진증 / 375 4.2 부갑상샘 기능저하증 / 377
05 부신 장애··················································································································· 378
5.1 쿠싱 증후군 / 379 5.2 알도스테론증 / 380
5.3 부신피질 기능저하증 / 381 5.4 급성 부신기능 상실증 / 382
5.5 갈색세포종 / 383
06 당뇨병························································································································· 384
6.1 개요 / 384 6.2 원인과 병태생리 / 382
6.3 증상과 징후 / 385 6.4 간호사정·진단 / 386
6.5 간호중재 / 387 6.6 합병증 / 391

12장 요로계 건강문제와 간호······························································································· 395
01 구조와 기능··············································································································· 395
1.1 콩팥의 구조와 기능 / 395 1.2 요관·방광·요도의 구조와 기능 / 397
02 건강사정····················································································································· 398
2.1 일반 소변검사 / 398 2.2 혈액검사 / 399
03 배뇨 장애··················································································································· 400
3.1 요정체 / 400 3.2 요실금 / 401
3.3 신경성 방광 / 403 3.4 요역류 / 404
3.5 물콩팥증 / 405
04 염증성 질환··············································································································· 406
4.1 신우신염 / 406 4.2 방광염 / 407
4.3 요관 및 요도염 / 407 4.4 급성 사구체신염 / 408
4.5 만성 사구체신염 / 410 4.6 콩팥 증후군 / 412
4.7 신농양 / 413 4.8 신결핵 / 413
05 결석····························································································································· 414
5.1 신결석 / 414 5.2 방광결석 / 415
06 요로계 외상··············································································································· 416
07 신생물························································································································· 417
7.1 콩팥암 / 417 7.2 방광암 / 418
08 기타 콩팥 질환········································································································· 419
09 콩팥기능상실············································································································· 420
9.1 급성 콩팥기능상실 / 420 9.2 만성 콩팥기능상실 / 423
10 투석····························································································································· 427
10.1 개요 / 427 10.2 투석의 종류 / 428
11 신장 이식··················································································································· 431
11.1 신장 이식 간호 / 431

13장 남성생식기계 건강문제와 간호················································································ 432
01 구조와 기능··············································································································· 432
1.1 내부 생식기 / 432 1.2 외부 생식기 / 433
02 건강사정····················································································································· 434
2.1 신체검진 / 434 2.2 진단검사 / 434
2.3 고환 자가검진 / 434
03 전립샘 기능장애······································································································· 435
3.1 양성 전립샘비대증 / 435 3.2 전립샘암 / 437
3.3 전립샘염 / 438
04 음경 기능장애··········································································································· 439
4.1 여러 음경 질환 / 439 4.2 매독과 임질 / 441
05 음낭 기능장애··········································································································· 442
5.1 고환염과 부고환염 / 442 5.2 여러 음낭 질환 / 443

14장 유방 건강문제와 간호···································································································· 444
01 구조와 기능··············································································································· 444
1.1 유방의 구조 / 444 1.2 유방의 기능과 영향요인 / 445
02 건강사정····················································································································· 446
2.1 유방 자가검진 / 446 2.2 진단검사 / 447
03 양성 질환··················································································································· 448
04 유방암························································································································· 449

15장 감각계 건강문제와 간호······························································································· 451
눈 건강문제와 간호 ··········································································································· 451
01 구조와 기능··············································································································· 451
1.1 눈의 구조와 기능 / 451
02 건강사정····················································································································· 453
2.1 시력 검사 / 453 2.2 시야 검사 / 453
2.3 기타 진단검사 / 454
03 눈의 일방증상 간호································································································· 455
3.1 공통 간호문제 / 455 3.2 눈 질환자 간호중재 / 456
04 눈 질환별 간호········································································································· 457
4.1 눈꺼풀·외안근 질환 / 457 4.2 결막·각막·포도막 감염질환 / 458
4.3 외상성 질환 / 460 4.4 백내장 / 461
4.5 녹내장 / 462 4.6 망막 질환 / 464
귀 건강문제와 간호 ··········································································································· 465
01 구조와 기능··············································································································· 465
1.1 귀의 구조와 기능 / 465 1.2 소리 전도과정 / 466
1.3 평형 / 466
02 건강사정····················································································································· 467
2.1 청력 검사 / 467 2.2 평형 사정 / 467
03 질환별 간호··············································································································· 468
3.1 외이염 / 468 3.2 중이염 / 469
3.3 기타 중이 질환 / 470 3.4 메니에르병 / 471
3.5 난청 / 472
피부 건강문제와 간호 ······································································································· 473
01 구조와 기능··············································································································· 473
1.1 피부의 구조 / 473 1.2 피부의 기능 / 474
02 진단검사····················································································································· 475
03 공통 피부병변 간호································································································· 476
3.1 공통 피부병변 / 476 3.2 양성 피부병변 / 477
3.3 건선 / 478
04 피부 질환별 간호····································································································· 479
4.1 세균 감염 / 479 4.2 바이러스 감염 / 480
4.3 진균 감염 / 481 4.4 기생충 감염 / 482
4.5 여드름 / 483 4.6 습진 피부질환 / 485
4.7 두드러기 / 487 4.8 피부암 / 488
05 화상····························································································································· 489
5.1 개요 / 489 5.2 화상의 단계 / 492

16장 응급 간호······························································································································· 498
01 응급의 개념··············································································································· 498
02 응급처치의 일반적 원칙························································································· 498
03 응급환자의 중증도 분류························································································· 499
3.1 4단계 중증도 분류표 / 499 3.2 응급환자 사정 / 499
04 심폐소생술················································································································· 501
4.1 의료제공자에 의한 기본 소생술 / 501 4.2 기본 심폐소생술 / 502
05 상황별 응급 간호····································································································· 505
5.1 기도폐쇄 응급처치 / 505 5.2 외상환자 응급 간호 / 507
5.3 중독 응급 간호 / 509 5.4 열·냉 응급 간호 / 510
5.5 교상 응급 간호 / 512
06 쇼크····························································································································· 514
6.1 개요 / 514 6.2 쇼크의 유형 / 515
6.3 쇼크 병태생리 / 517 6.4 쇼크의 일반 증상·간호중재 / 518