新生儿科：一例宫内感染性肺炎患儿的护理查房课件

1、（一例宫内感染性肺炎患儿的护理查房）speaker：何绮晴Physical examination：姚莲萍PPT production：石彩兰Advisor：陈松珠老师、陈丽英老师、何兆梅老师One case of intrauterine infection pneumonia of the newborn in nursing roundsOperation purpose1.Discussing and using 14 items about clinical nursing service quality in nursing rounds(探讨运用“14条”进行护理查房)2. Ma

2、ster(掌握) the nursing of intrauterine infection pneumonia with newborn 3. Improve the nurses understanding of intrauterine infection pneumoniaGeneral information（一般资料）：Name: Son of Geng yinghua （庾颖华之子）Age: 11 days Weight：3.55kg Sex: male Data of Birth：: 14:57 ,July 26th, 2016 Race: Han Nationality: C

3、hinaParents Name: father Chen haiyan，Mother Geng yinghuaDate of admission: July 27th, 2016Chief complaint（主诉）: short of breath for 2 hoursPresent illness（现病史）:GW: 38+weeks, G3P2, LMP: 2016-08-05; EDC: 2016-7-26 .Babys mother is a elderly pregnant woman with scarred uterus(疤痕子宫) .he birthed in 14:57

4、,July 26th, 2016 with cesarean(剖腹产) .The afflicted(受苦的) baby was delivered in 14:57 ,July 26th, 2016.His Birth weight was 3.55 kg and head circumference was 32 cm . There was no history of asphyxia rescue（无窒息抢救史） at birth with clear amniotic fluid（羊水清）. It was nine points with Apgar scoring in 1 min

5、ute , and 10 points with Apgar scoring in five minutes (1分钟阿氏评分为9分，五分钟阿氏评分为10分)，and had shortness of breath after 24 hours along with obtuse（迟钝的） response and Oral cyanosis (口唇发绀)and moaning（呻吟）.No restlessness（烦躁不安）or vomit or fever or pale complexion（面色苍白） or seizure（癫痫发作） or scream（尖叫） were obser

6、ved. Breast feed not very well and his crying is a bit poor .His stool(大便) and urine is normal .Family history（家族史）：The patients mother had an operation with laparoscopic myomectomy（子宫肌瘤剔除术） in 2005，and delivered a girl with cesarean(剖腹产) in 2009.The patients father suffered from hypertension（高血压） a

7、nd gout(痛风)Diagnosis(诊断)：intrauterine infection pneumonia of the newborn （宫内感染性肺炎）What s it ？Intrauterine infection pneumonia of the newborn（新生儿宫内感染性肺炎）:Caused by viruses（病毒）, bacteria（细菌）, protozoa（原虫）, or chlamydia（衣原体）Had infection before birth (出生前就感染)Always attacked（发病） within 24 hours after bi

8、rth with asphyxia（窒息史）Had shortness of breath（气促），moans（呻吟）, difficulty breathing（呼吸困难）, and had not stable temperature（体温不稳定）, and the response is poor（反应差)after recovery（复苏）.07-31 CPAP辅助通气间中呼吸稍促，停留胃管通畅，无潴留，持续心电监护显示：RR 35-45次/分，P 130-144次/分，BP 75/43 mmHg，SPO2 93-98%，反应稍差，哭声稍弱，轻度吸气三凹征阳性，双肺呼吸音粗，可闻及双肺

9、低湿性啰音，伴呻吟样呼吸，全身皮肤黏膜轻度黄染,，SB 7mg/dl，辅助检查：血培养至今：未见细菌、真菌生长，电解质：Na 142.3mmol/L，CA 2.08 mmol/L,K 3.28mmol/L ,CPR 2.1mg/L,目前继续监护、CPAP辅助通气、抗感染、营养心肌等治疗08-01试停CPAP辅助通气，呼吸尚顺，血氧饱和度可维持在90-98%之间，反应稍可，哭声响，停留胃管通畅，无潴留，持续心电监护显示：RR 40-48次/分，P 125-146次/分，BP 79/43 mmHg，SPO2 92-98%，全身皮肤轻度黄染，SB 7mg/dl，双肺呼吸音粗，未闻及双肺干湿啰音，目前

10、继续监护、抗感染、营养心肌等治疗08-02患儿呼吸顺，无发绀，血氧饱和度可维持在93-98%之间，持续心电监护显示：RR 40-45次/分，P125-148次/分，BP72/41mmHg，全身皮肤轻度黄染，SB 8mg/dl，双肺呼吸音粗，未闻及干湿啰音，G6PD 4.9U/L08-03患儿呼吸顺，无发绀，无三凹征，持续心电监护显示：RR 40-46次/分，P127-144次/分，BP 87/42 mmHg，SPO2 92-94%，全身皮肤轻度黄染，SB 7mg/dl，双肺呼吸音粗，辅助检查：血常规：WBC 11.68x109/L , HGB 117g/L,电解质：CA 2.14 mmol/L

11、,K 4.35 mmol/L ,CPR 0.2mg/L,患儿复查血红蛋白较前降低，必要时输注浓缩红细胞，目前继续监护、抗感染、营养心肌等治疗08-04患儿呼吸顺，无发绀，无三凹征，全身皮肤轻度黄染，SB 7mg/dl，双肺呼吸音稍粗，未闻及干湿啰音，血氧饱和度可维持在92-97%之间，持续心电监护显示：RR 40-48次/分，P120-142次/分，BP69/35mmHg，SPO2 92-97%，辅助检查：血培养：未见细菌、真菌生长，患儿呼吸顺，吃奶好，病情治愈，予出院Physical examination（体格检查）Nursing problem1、Ineffective Airway C

12、learance（清理呼吸道无效)：Associated with the respiratory secretions （呼吸道分泌物），and baby was unable to row of phlegm（痰液）weakly.2、Impaired gas exchange（气体交换受损）：Associated with lung inflammation（炎症）3、Malnutrition（营养失调）：Associated with inadequate（不足的）intake and the increase consumption(消耗)Maintain（保持）normal body

13、 temperatureMaintain normal body temperature： 36 to 37 Hypothermia（体温过低）：keeping warmHyperthermia（体温过高）： coolingIf necessary：Use the antipyretic （退热药）in accordance with the doctors adviceantibiotic therapy(抗生素治疗)According to the illness needs to choose the appropriate（合适的）antibiotics（抗生素）Observed the effect of drugs closely（密切观察药物的作用）Supply enough energy and moisture(水分)Eat smaller, more frequent meals（少量多餐）Prevent asphyxia during feeding（喂奶时防止窒息） severe patients（病重者）：Nasal feeding（鼻饲） &Intravenous supplement wi