护理临床实习案例分析

1、Far Eastern University - Institute of Nursing CASE PRESENTATIONFEU NRMF HOSPITALOBSTETRICS WARDGroup Three Peng Sijing (Stone ), Li Xiaojing (Cathy ), Miao Chunmei (Mano), Nie Fengyan (Zara)ContentIntroduction 1History Physical Assessment 3Laboratory and Diagnostic Exams.42Medications and IV fluid52

2、6Nursing Care Plan Introduction3 Patient A, 30 years old, G1P0, pregnancy uterine 39weeks and 2 days, cephalic in labor, admitted at FEU-NRMF HOSPITAL on February 8, 2018.CHIEF COMPLAINT: Hypogastric PainHistory4v HISTORY OF PRESENT PREGNANCY:LMP: May 9,2017 AOG by LMP: 39 weeks 2 days EDC by LMP: F

3、ebruary 12, 2018PMP: April 8, 2017 AOG by EUTZ: 39 weeks 3 days EDC by EUTZ: February 12, 2018First Trimester * On the 1 month of missed period (June 2017): cessation of menses, nausea and vomiting. Self-pregnancy test was done, which revealed a positive result. * She consulted a private obstetricia

4、n where diagnostic tests such as complete blood count, urinalysis, VDRL/RPR and hepatitis B antigen screening were done. All revealed normal results except for urinalysis which revealed urinary tract infection. She was prescribed Cefuroxime 500mg BID for 1 week, and repeat urinalysis afterwards was

5、normal. * Transvaginal ultrasound for pregnancy evaluation revealed a single intrauterine pregnancy compatible to 15 weeks and 2 days age of gestation (August 2017). * She was given multivitamins and Folic acid 1 tablet once a day which she took regularly. * She denies any history of accidents, trau

6、ma, or any exposure to radiation and toxic chemicals.* Patient had an episode of colds and took cefuroxime 500mg twice a day for 5 days.* She also took Loratadine 10mg once daily for her allergic rhinitis.History5v HISTORY OF PRESENT PREGNANCY:Second Trimester * Quickening was felt on the 5th month

7、of pregnancy (October 2017). * She had regular intake of Multivitamins 1 tab daily, Ferrous sulfate 1 tablet once a day, and Calcium 1 tablet twice a day. Only urinalysis was done at the health center revealing that she had urinary tract infection. she was prescribed Cefuroxime 500mg BID for 1 week

8、to which she was compliant. * Transabdominal ultrasound for gender determination was done on the 7th month of pregnancy revealing single intrauterine pregnancy compatible to 28 weeks and 4 days age of gestation (November 2017). * She denies any history of accidents, trauma, illness, or any exposure

9、to radiation and toxic chemicals. History6Third Trimester * Subsequent prenatal check-ups were regular as well as intake of multivitamins 1 tablet once a day, Ferrous sulfate 1 tablet once a day, and calcium 1 tablet twice a day. * Capillary blood glucose monitoring and 75g OGTT was done which revea

10、led increased results. Exact values were unrecalled by the patient. She was prescribed with Novo Rapid insulin, 4 units taken 2 hours post meals. She was also advised to do capillary blood glucose monitoring at home. * Subjective complaints experienced included headache and dizziness. No hypogastric

11、 pain, abnormal vaginal discharge, vaginal spotting, dysuria, and fever. She denies any history of accidents, trauma, illness, or any exposure to radiation or toxic chemicalsThe present condition started 5 hours prior (5:00pm) to admission when the patient experienced crampy intermittent hypogastric

12、 pain radiating to the lower back with a pain scale of 8-9 out of 10. This was associated with scanty bloody vaginal discharge. She sought consult at our institution and was subsequently admitted.History7v PAST MEDICAL HISTORY:The patient had usual childhood diseases such as mumps, measles, and chic

13、kenpox. She denies any history of major illnesses, trauma, accidents, or major operations. She was admitted last June due to persistent vomiting and dehydration. Patient has allergic rhinitis and was diagnosed with gestational diabetes last January maintained on Novo Rapid insulin 4 units taken 2 ho

14、urs post meals.History8v FAMILY HISTORY: Father: hypertensionMother: kidney stones, died due to cardiac arrestThe patient is 3th among 5 siblings with 4 sisters and 1 brother. Her eldest is 33 years old who is a controlled hypertensive with gestational diabetes mellitus. Her second sibling is 32 yea

15、rs old with kidney stones. The 4th sibling is 29 years old who is a controlled hypertensive. The 5th sibling is 20 years old who is apparently well.History9v PERSONAL AND SOCIAL HISTORY:Patient is a high-school graduate and currently works as a machine operatorHabits: Non-smoker, non-alcoholic bever

16、age drinker vREPRODUCTIVE HISTORY: GYNECOLOGIC HISTORYThe patient had menarche at 13 years old which lasted 4 days, light flow, consuming 3 pads per day and not associated with dysmenorrhea. Subsequent menstruations were irregular, with an interval of approximately 1 to 3 months lasting 3 to 4 days,

17、 moderate flow, consuming 4-5 pads per day, and associated with dysmenorrhea.History10vREPRODUCTIVE HISTORY: OBSTETRICAL HISTORYThe patient is a primigravid METHOD OF CONTRACEPTION The method for contraception use is oral contraceptive pills from June 2016 to December 2016. She took the pills everyd

18、ay before going to bed SEXUAL HISTORY At 27 years old with 2 sexual partners. Unknown number of sexual partners of her husband. She is currently in a monogamous heterosexual relationship.Review of Systems: 11Constitutional: No fever and chills, malaise, weight loss Hematology: No easy fatigability,

19、no easy bruise ability, no pallor CNS: No headache; no seizure; no loss of consciousness HEENT: No blurring of vision; no hearing loss; no tinnitus Respiratory: No dyspnea; no cough; no colds; no apnea CVS: No orthopnea; no palpitationGIT: No diarrhea; no constipation GUT: No dysuria, frequency, no

20、urgencyNMS: No malaise; no arthralgia; no myalgia; no numbnessPhysical Examination12 General Survey: The patient is conscious, coherent, not in cardiopulmonary distress with the following vital signs: BP : 110 / 80mmHg PR : 81 bpm RR : 19 Temp : 36.2 Sat : 98 % HEENT: Anicteric sclera, pink palpebra

21、l conjunctiva, no nasoaural discharge, notonsillopharyngeal congestion Neck: Supple neck, no neck vein engorgement, no lymphadenopathies noted Chest: Symmetrical chest expansion, no retractions, no laggingLungs: Vesicular breath sounds, no crackles, no wheezes Heart: A dynamic precordium, normal rat

22、e, regular rhythm, no murmur Breast: Symmetrical contour, no dimpling, no palpable mass, no tenderness, no abnormal nipple discharge Physical Examination13Abdomen: Globularly enlarged with a fundic height of 31cms, fundus occupied by breech, fetal back on the right, fetal small parts on the left, ce

23、phalic, unengaged, FHT-140s best heard on the right lower quadrant, estimated fetal weight 2,945 grams. Speculum Exam: Clean looking cervix with scanty pinking to brownish discharge, non-foul smellingInternal Exam: Normal looking external genitalia, nulliparous introitus, vagina admits 2 fingers wit

24、h ease , 4cms 50 % effaced , intact bag of waters , cephalic , station - 3 Extremities: No gross deformities, full and equal pulses no edema, no cyanosis, CRT 38.5 in a single measurement, or three temperatures of 38 by discharge.Maintain a clean environment. Ensure the clients room and bathroom is

25、cleaned frequently and appropriately. A clean environment may discourage the growth of microorganisms.Goal Met: Linens separated r/t dirty and clean in restroom, personal care supplies kept off floor, bed linens changed per day open through to discharge.Nursing Care Plan27Nursing problem 2Risk for A

26、cute Pain: may be related to increased muscle contractions and psychological reactionsGoals: The patient verbalizes reduced discomfort or painNursing Care Plan28InterventionsRationaleEvaluation Assess location, nature(lithotomy position), and duration of pain, especially as it relates to the indicat

27、ion for cesarean birth.Indicates the suitable choice of treatment. The patient awaiting imminent cesarean birth may encounter varying degrees of discomfort, depending on the indication for the procedure, e.g., failed induction, dystocia.Goal Met: Patient verbalizes reduced discomfort or painDrop anx

28、iety-producing circumstance (e.g., loss of control), give accurate information, and encourage presence of partner.Levels of pain tolerance are individual and are affected by various factors. Extreme anxiety following an emergency situation may develop discomfort due to fear, tension, and pain affect

29、ing the patients ability to cope.Nursing Care Plan29InterventionsRationaleEvaluation Educate proper relaxation techniques; position for comfort as possible. Use Therapeutic Touch, as appropriate.May help in decreasing anxiety and tension, promote comfort and enhance sense of well-being.Goal Met: Pat

30、ient verbalizes reduced discomfort or painPatient participated in behaviors to diminish pain sensations and enhance comfort.If indicated, administer medications such as sedative, narcotics, or preoperative drugs.Promotes comfort by blocking pain impulses. Potentiates the action of anesthetic agents.

31、Nursing Care Plan30Nursing problem 3Anxiety: May be related to perceived/Actual threat of maternal and fetal well-being, situational crisis, threat to self-conceptGoals: *The patient discusses feelings about cesarean birth. *The patient appears relaxed and comfortable. *The patient verbalizes fears

32、for the safety of herself and infant.Nursing Care Plan31InterventionsRationaleEvaluation Assess psychological response to event and availability of support systems.The greater the patient perceives the threat, the greater the level of her anxiety.Goal Met: The patient discussed feelings about cesare

33、an birth. The patient appears relaxed and comfortable.The patient verbalizes fears for the safety of herself and infant.Remain with the patient, and stay calm. Speak in a slow manner. Convey empathy.Helps to reduce interpersonal transmission anxiety, and shows caring for the patient or couple.Reinfo

34、rce positive aspects of maternal and fetal condition.Focuses on likelihood of desirable outcome and helps to bring perceived or actual threat into perspective.Nursing Care Plan32InterventionsRationaleEvaluation Let the patient or couple verbalize or express inner thoughts and feelings.Helps to distinguish negative feelings and concerns as well as provides chance to cope with uncertain or unresolved feelings or grief. The patient may also feel an emotional intimidation to her self-esteem, owing to her feelings that she has fai