护理临床实习案例分析.ppt

FarEasternUniversity-InstituteofNursing,CASEPRESENTATION,FEUNRMFHOSPITAL,OBSTETRICSWARD,GroupThree,PengSijing(Stone),LiXiaojing(Cathy),MiaoChunmei(Mano),NieFengyan(Zara),Content,Introduction,1,History,PhysicalAssessment,3,LaboratoryandDiagnosticExams.,4,2,MedicationsandIVfluid,5,2,6,NursingCarePlan,Introduction,3,PatientA,30yearsold,G1P0,pregnancyuterine39weeksand2days,cephalicinlabor,admittedatFEU-NRMFHOSPITALonFebruary8,2018.CHIEFCOMPLAINT:HypogastricPain,History,4,HISTORYOFPRESENTPREGNANCY:LMP:May9,2017AOGbyLMP:39weeks2daysEDCbyLMP:February12,2018PMP:April8,2017AOGbyEUTZ:39weeks3daysEDCbyEUTZ:February12,2018FirstTrimester*Onthe1monthofmissedperiod(June2017):cessationofmenses,nauseaandvomiting.Self-pregnancytestwasdone,whichrevealedapositiveresult.*Sheconsultedaprivateobstetricianwherediagnostictestssuchascompletebloodcount,urinalysis,VDRL/RPRandhepatitisBantigenscreeningweredone.Allrevealednormalresultsexceptforurinalysiswhichrevealedurinarytractinfection.ShewasprescribedCefuroxime500mgBIDfor1week,andrepeaturinalysisafterwardswasnormal.*Transvaginalultrasoundforpregnancyevaluationrevealedasingleintrauterinepregnancycompatibleto15weeksand2daysageofgestation(August2017).*ShewasgivenmultivitaminsandFolicacid1tabletonceadaywhichshetookregularly.*Shedeniesanyhistoryofaccidents,trauma,oranyexposuretoradiationandtoxicchemicals.*Patienthadanepisodeofcoldsandtookcefuroxime500mgtwiceadayfor5days.*ShealsotookLoratadine10mgoncedailyforherallergicrhinitis.,History,5,HISTORYOFPRESENTPREGNANCY:SecondTrimester*Quickeningwasfeltonthe5thmonthofpregnancy(October2017).*ShehadregularintakeofMultivitamins1tabdaily,Ferroussulfate1tabletonceaday,andCalcium1tablettwiceaday.Onlyurinalysiswasdoneatthehealthcenterrevealingthatshehadurinarytractinfection.shewasprescribedCefuroxime500mgBIDfor1weektowhichshewascompliant.*Transabdominalultrasoundforgenderdeterminationwasdoneonthe7thmonthofpregnancyrevealingsingleintrauterinepregnancycompatibleto28weeksand4daysageofgestation(November2017).*Shedeniesanyhistoryofaccidents,trauma,illness,oranyexposuretoradiationandtoxicchemicals.,History,6,ThirdTrimester*Subsequentprenatalcheck-upswereregularaswellasintakeofmultivitamins1tabletonceaday,Ferroussulfate1tabletonceaday,andcalcium1tablettwiceaday.*Capillarybloodglucosemonitoringand75gOGTTwasdonewhichrevealedincreasedresults.Exactvalueswereunrecalledbythepatient.ShewasprescribedwithNovoRapidinsulin,4unitstaken2hourspostmeals.Shewasalsoadvisedtodocapillarybloodglucosemonitoringathome.*Subjectivecomplaintsexperiencedincludedheadacheanddizziness.Nohypogastricpain,abnormalvaginaldischarge,vaginalspotting,dysuria,andfever.Shedeniesanyhistoryofaccidents,trauma,illness,oranyexposuretoradiationortoxicchemicals,Thepresentconditionstarted5hoursprior(5:00pm)toadmissionwhenthepatientexperiencedcrampyintermittenthypogastricpainradiatingtothelowerbackwithapainscaleof8-9outof10.Thiswasassociatedwithscantybloodyvaginaldischarge.Shesoughtconsultatourinstitutionandwassubsequentlyadmitted.,History,7,PASTMEDICALHISTORY:Thepatienthadusualchildhooddiseasessuchasmumps,measles,andchickenpox.Shedeniesanyhistoryofmajorillnesses,trauma,accidents,ormajoroperations.ShewasadmittedlastJuneduetopersistentvomitinganddehydration.PatienthasallergicrhinitisandwasdiagnosedwithgestationaldiabeteslastJanuarymaintainedonNovoRapidinsulin4unitstaken2hourspostmeals.,History,8,FAMILYHISTORY:Father:hypertensionMother:kidneystones,diedduetocardiacarrestThepatientis3thamong5siblingswith4sistersand1brother.Hereldestis33yearsoldwhoisacontrolledhypertensivewithgestationaldiabetesmellitus.Hersecondsiblingis32yearsoldwithkidneystones.The4thsiblingis29yearsoldwhoisacontrolledhypertensive.The5thsiblingis20yearsoldwhoisapparentlywell.,History,9,PERSONALANDSOCIALHISTORY:Patientisahigh-schoolgraduateandcurrentlyworksasamachineoperatorHabits:Non-smoker,non-alcoholicbeveragedrinkerREPRODUCTIVEHISTORY:GYNECOLOGICHISTORY,Thepatienthadmenarcheat13yearsoldwhichlasted4days,lightflow,consuming3padsperdayandnotassociatedwithdysmenorrhea.Subsequentmenstruationswereirregular,withanintervalofapproximately1to3monthslasting3to4days,moderateflow,consuming4-5padsperday,andassociatedwithdysmenorrhea.,History,10,REPRODUCTIVEHISTORY:OBSTETRICALHISTORYThepatientisaprimigravidMETHODOFCONTRACEPTIONThemethodforcontraceptionuseisoralcontraceptivepillsfromJune2016toDecember2016.ShetookthepillseverydaybeforegoingtobedSEXUALHISTORY,At27yearsoldwith2sexualpartners.Unknownnumberofsexualpartnersofherhusband.Sheiscurrentlyinamonogamousheterosexualrelationship.,ReviewofSystems:,11,Constitutional:Nofeverandchills,malaise,weightlossHematology:Noeasyfatigability,noeasybruiseability,nopallorCNS:Noheadache;noseizure;nolossofconsciousnessHEENT:Noblurringofvision;nohearingloss;notinnitusRespiratory:Nodyspnea;nocough;nocolds;noapneaCVS:Noorthopnea;nopalpitationGIT:Nodiarrhea;noconstipationGUT:Nodysuria,frequency,nourgencyNMS:Nomalaise;noarthralgia;nomyalgia;nonumbness,PhysicalExamination,12,GeneralSurvey:Thepatientisconscious,coherent,notincardiopulmonarydistresswiththefollowingvitalsigns:BP:110/80mmHgPR:81bpmRR:19Temp:36.2Sat:98%HEENT:Anictericsclera,pinkpalpebralconjunctiva,nonasoauraldischarge,notonsillopharyngealcongestionNeck:Suppleneck,noneckveinengorgement,nolymphadenopathiesnotedChest:Symmetricalchestexpansion,noretractions,nolaggingLungs:Vesicularbreathsounds,nocrackles,nowheezesHeart:Adynamicprecordium,normalrate,regularrhythm,nomurmurBreast:Symmetricalcontour,nodimpling,nopalpablemass,notenderness,noabnormalnippledischarge,PhysicalExamination,13,Abdomen:Globularlyenlargedwithafundicheightof31cms,fundusoccupiedbybreech,fetalbackontheright,fetalsmallpartsontheleft,cephalic,unengaged,FHT-140sbestheardontherightlowerquadrant,estimatedfetalweight2,945grams.SpeculumExam:Cleanlookingcervixwithscantypinkingtobrownishdischarge,non-foulsmellingInternalExam:Normallookingexternalgenitalia,nulliparousintroitus,vaginaadmits2fingerswithease,4cms50%effaced,intactbagofwaters,cephalic,station-3,Extremities:Nogrossdeformities,fullandequalpulsesnoedema,nocyanosis,CRT2secsSkin:Noactivedermatoses,LaboratoryandDiagnosticExams.,14,URINALYSIS,MedicationsandIVfluid,15,MedicationsandIVfluid,16,Tradenames:Zinacef,Ceftin,Cefuroxime,IV,IM:Adults,elderly,children12yrsandolder:750mg1.5gq8h.Chil-dren:3mostoolderthan12yrs:75150mg/kg/daydividedq8h.Maximum:6g/day.Neonates:50mg/kg/doseq812h.Po:adults,elderly,children12yrsandolder:250500mgtwiceaday.Chil-dren3mostoolderthan12yrs:2030mg/kg/dayin2divideddoses.Maxi-mum:1g/day.,UsualDosage,TreatmentofsusceptibleinfectionsduetogroupBstreptococci,pneumococci,staphylococci,H.influenzae,E.coli,Enterobacter,Klebsiellaincludingacute/chronicbronchitis,gonorrhea,impetigo,earlyLymedisease,otitismedia,pharyn-gitis/tonsillitis,sinusitis,skin/skinstruc-ture,UTI,perioperativeprophylaxis.,Use,Frequent:DiscomfortwithIMadministra-tion,oralcandidiasis(thrush),milddiar-rhea,mildabdominalcramping,vaginalcandidiasis.Occasional:Nausea,serumsicknesslikereaction(fever,jointpain;usuallyoccursaftersecondcourseoftherapyandresolvesafterdrugisdiscon-tinued).Rare:Allergicreaction(rash,pruritus,urticaria),thrombophlebitis(pain,redness,swellingatinjectionsite).,SIDEEFFECTS,BASELINEASSESSMENTObtainCBC,renalfunctiontests.Ques-tionforhistoryofallergies,particularlycephalosporins,penicillins.INTERVENTION/EVALUATIONAssessoralcavityforwhitepatchesonmucousmembranes,tongue(thrush).Monitordailypatternofbowelactivity,stoolconsistency.MildGIeffectsmaybetolerable(increasingseveritymayindi-cateonsetofantibiotic-associatedcoli-tis).MonitorIBeforeusingthismedication,tellyourdoctororpharmacistyourmedicalhistory,Getmedicalhelprightawayifyouhave:heartburnwithlightheadedness/sweating/dizziness,chest/jaw/arm/shoulderpain(especiallywithshortnessofbreath,unusualsweating),unexplainedweightloss.Donotusetotreatchildrenyoungerthan12unlessdirectedbythedoctor.Olderadultsmaybemoresensitivetothesideeffectsofthisdrug,especiallyconfusion.Ranitidinepassesintobreastmilk.Consultyourdoctorbeforebreast-feeding.,NursingResponsibilities,雷尼替丁,VitaminB9,FolicAcid,Orally,intramuscularly,IVAdultDose:400mcgdailyPregnancy:600mcgdailyLactation:500mcgdailyPediatricDose:1mgdaily,UsualDosage,Kidneydisease.HyperhomocysteinemiaReducingharmfuleffectsofamedicinecalledmethotrexate.Birthdefects,Use,FeverGeneralweaknessordiscomfortReddenedskinShortnessofbreathSkinrashoritchingTightnessinchestTroubledbreathingWheezing,SIDEEFFECTS,Assessallergytolactuloselowgalactosediet.UsecautionllywithdiabetespregnancyandlactationGivelaxativesyruporallywithfruitjuice,waterandilktoincreasepalatableMonitorserumammonialevCarefullymonitorbloodDonotuselaxativeformorethanlweekunlessprescribedbythedoctor,NursingResponsibilities,叶酸,Pitocin,Syntocinon,Oxytocin,10USPU/mL,UsualDosage,Usedforlaborinduction,augmentationoflabor,postpartumabbreviationofthirdstageoflabor,postpartumcontrolofuterinebleeding,terminationofpregnancyandfortheevaluationoffetalrespiratorycapability.Oxytocincannotbeusedforelectiveinductionoflabor,theremustbeaclearmedicalrequirement.,Use,AdverseEffectsCV:Hypertention,increaseheartrate,systemicvenousreturns,cardiacoutputGI:NauseaandVomitingRepiratory:Anoxia,AsphyxiaOthers:LowAPGARscoreat5mins.,SIDEEFFECTS,1)StartflowchartstorecordmaternalBPandothervitalsigns,Ievaluatetonusofmyometriumduringandbetweencontractionsandrecordonflowchart.Reportchangeinrateandrhythmimmediately.Stopinfusiontopreventfetalanoxia,turnpatientonherside,andnotifyphysicianifcontractionsareprolonged(occurringatlessthan2-minintervals)andifmonitorrecordscontractionsabout50mmHgorifcontractionslast90secondsorlonger.Stimulationwillwanerapidlywithin23min.Oxygenadministrationmaybenecessary.3)Iflocalorregional(caudal,spinal)anesthesiaisbeinggiventothepatientreceivingoxytocin,bealerttothepossibilityofhypertensivecrisis(suddenintenseoccipitalheadache,palpitation,markedhypertension,stiffneck,nausea,vomiting,sweating,fever,photophobia,dilatedpupils,bradycardiaortachycardia,constrictingchestpain).4)MonitorI&Oduringlabor.IfpatientisreceivingdrugbyprolongedIVinfusion,watchforsymptomsofwaterintoxication(drowsiness,listlessness,headache,confusion,anuria,weightgain).ReportchangesinalertnessandorientationandchangesinI&Oratio(i.e.,markeddecreaseinoutputwithexcessiveintake).5)Checkfundusfrequentlyduringthefirstfewpostpartumhoursandseveraltimesdailythereafter.6)Incidenceof