护理临床实习案例分析

FarEasternUniversity-InstituteofNursingCASEPRESENTATIONFEUNRMFHOSPITALOBSTETRICSWARDGroupThreePengSijing(Stone),LiXiaojing(Cathy),MiaoChunmei(Mano),NieFengyan(Zara)第一页，共三十六页。ContentIntroduction1HistoryPhysicalAssessment3LaboratoryandDiagnosticExams.4MedicationsandIVfluid526NursingCarePlan2第二页，共三十六页。IntroductionPatientA,30yearsold,G1P0,pregnancyuterine39weeksand2days,cephalicinlabor,admittedatFEU-NRMFHOSPITALonFebruary8,2018.CHIEFCOMPLAINT:HypogastricPain3第三页，共三十六页。HistoryHISTORYOFPRESENTPREGNANCY: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.4第四页，共三十六页。HistoryHISTORYOFPRESENTPREGNANCY:SecondTrimester*Quickeningwasfeltonthe5thmonthofpregnancy(October2017).*ShehadregularintakeofMultivitamins1tabdaily,Ferroussulfate1tabletonceaday,andCalcium1tablettwiceaday.Onlyurinalysiswasdoneatthehealthcenterrevealingthatshehadurinarytractinfection.shewasprescribedCefuroxime500mgBIDfor1weektowhichshewascompliant.*Transabdominalultrasoundforgenderdeterminationwasdoneonthe7thmonthofpregnancyrevealingsingleintrauterinepregnancycompatibleto28weeksand4daysageofgestation(November2017).*Shedeniesanyhistoryofaccidents,trauma,illness,oranyexposuretoradiationandtoxicchemicals.5第五页，共三十六页。HistoryThirdTrimester*Subsequentprenatalcheck-upswereregularaswellasintakeofmultivitamins1tabletonceaday,Ferroussulfate1tabletonceaday,andcalcium1tablettwiceaday.*Capillarybloodglucosemonitoringand75gOGTTwasdonewhichrevealedincreasedresults.Exactvalueswereunrecalledbythepatient.ShewasprescribedwithNovoRapidinsulin,4unitstaken2hourspostmeals.Shewasalsoadvisedtodocapillarybloodglucosemonitoringathome.*Subjectivecomplaintsexperiencedincludedheadacheanddizziness.Nohypogastricpain,abnormalvaginaldischarge,vaginalspotting,dysuria,andfever.Shedeniesanyhistoryofaccidents,trauma,illness,oranyexposuretoradiationortoxicchemicalsThepresentconditionstarted5hoursprior(5:00pm)toadmissionwhenthepatientexperiencedcrampyintermittenthypogastricpainradiatingtothelowerbackwithapainscaleof8-9outof10.Thiswasassociatedwithscantybloodyvaginaldischarge.Shesoughtconsultatourinstitutionandwassubsequentlyadmitted.6第六页，共三十六页。HistoryPASTMEDICALHISTORY:Thepatienthadusualchildhooddiseasessuchasmumps,measles,andchickenpox.Shedeniesanyhistoryofmajorillnesses,trauma,accidents,ormajoroperations.ShewasadmittedlastJuneduetopersistentvomitinganddehydration.PatienthasallergicrhinitisandwasdiagnosedwithgestationaldiabeteslastJanuarymaintainedonNovoRapidinsulin4unitstaken2hourspostmeals.7第七页，共三十六页。HistoryFAMILYHISTORY:Father:hypertensionMother:kidneystones,diedduetocardiacarrestThepatientis3thamong5siblingswith4sistersand1brother.Hereldestis33yearsoldwhoisacontrolledhypertensivewithgestationaldiabetesmellitus.Hersecondsiblingis32yearsoldwithkidneystones.The4thsiblingis29yearsoldwhoisacontrolledhypertensive.The5thsiblingis20yearsoldwhoisapparentlywell.8第八页，共三十六页。HistoryPERSONALANDSOCIALHISTORY:Patientisahigh-schoolgraduateandcurrentlyworksasamachineoperatorHabits:Non-smoker,non-alcoholicbeveragedrinkerREPRODUCTIVEHISTORY:GYNECOLOGICHISTORYThepatienthadmenarcheat13yearsoldwhichlasted4days,lightflow,consuming3padsperdayandnotassociatedwithdysmenorrhea.Subsequentmenstruationswereirregular,withanintervalofapproximately1to3monthslasting3to4days,moderateflow,consuming4-5padsperday,andassociatedwithdysmenorrhea.9第九页，共三十六页。HistoryREPRODUCTIVEHISTORY:OBSTETRICALHISTORYThepatientisaprimigravidMETHODOFCONTRACEPTIONThemethodforcontraceptionuseisoralcontraceptivepillsfromJune2016toDecember2016.ShetookthepillseverydaybeforegoingtobedSEXUALHISTORYAt27yearsoldwith2sexualpartners.Unknownnumberofsexualpartnersofherhusband.Sheiscurrentlyinamonogamousheterosexualrelationship.10第十页，共三十六页。ReviewofSystems: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;nonumbness11第十一页，共三十六页。PhysicalExaminationGeneralSurvey:Thepatientisconscious,coherent,notincardiopulmonarydistresswiththefollowingvitalsigns:BP:110/80mmHgPR:81bpmRR:19Temp:36.2℃Sat:98%HEENT:Anictericsclera,pinkpalpebralconjunctiva,nonasoauraldischarge,notonsillopharyngealcongestionNeck:Suppleneck,noneckveinengorgement,nolymphadenopathiesnotedChest:Symmetricalchestexpansion,noretractions,nolaggingLungs:Vesicularbreathsounds,nocrackles,nowheezesHeart:Adynamicprecordium,normalrate,regularrhythm,nomurmurBreast:Symmetricalcontour,nodimpling,nopalpablemass,notenderness,noabnormalnippledischarge12第十二页，共三十六页。PhysicalExaminationAbdomen:Globularlyenlargedwithafundicheightof31cms,fundusoccupiedbybreech,fetalbackontheright,fetalsmallpartsontheleft,cephalic,unengaged,FHT-140sbestheardontherightlowerquadrant,estimatedfetalweight2,945grams.SpeculumExam:Cleanlookingcervixwithscantypinkingtobrownishdischarge,non-foulsmellingInternalExam:Normallookingexternalgenitalia,nulliparousintroitus,vaginaadmits2fingerswithease,4cms50%effaced,intactbagofwaters,cephalic,station-3Extremities:Nogrossdeformities,fullandequalpulsesnoedema,nocyanosis,CRT<2secsSkin:Noactivedermatoses13第十三页，共三十六页。LaboratoryandDiagnosticExams.URINALYSIS14第十四页，共三十六页。MedicationsandIVfluidMedications(postoperationorder)Cefuroxime750mg/TIVq8hStartedonFeb.9,completedonFeb.11Ranitidine50mg/TIVq8h,whileonNPOStartedonFeb.9,completedonFeb.11Cefuroxime500mg/tab,1tabletbidStartedonFeb.10FeSO4+FolicAcid1tabqdStartedonFeb.10Calcium+VitaminD1TABbidStartedonFeb.10multivitaminqdStartedonFeb.1015第十五页，共三十六页。MedicationsandIVfluidIVfluidDataNumberoffluidsTypesoffluidsFlowrateFeb.81D5NSS(NormalSalineSolutionin5%Dextrose),1L42gtts/minFeb.92D5NSS,1L10-12gtts/min3PNSS(0.9%SodiumChlorideSolution),1LFD4D5NSS+30unitsoxytocin42gtts/minSD#1PNSS,500ml+150Diclofenac250gtts/min#5D5NSS,1L+10unitsoxytocin42gtts/minFeb.106D5NSS,1L42gtts/min16第十六页，共三十六页。Tradenames:Zinacef,CeftinCefuroximeIV,IM:Adults,elderly,children12yrsandolder:750mg–1.5gq8h.Chil-dren:3mostoolderthan12yrs:75–150mg/kg/daydividedq8h.Maximum:6g/day.Neonates:50mg/kg/doseq8–12h.Po:adults,elderly,children12yrsandolder:250–500mgtwiceaday.Chil-dren3mostoolderthan12yrs:20–30mg/kg/dayin2divideddoses.Maxi-mum:1g/day.UsualDosageTreatmentofsusceptibleinfectionsduetogroupBstreptococci,pneumococci,staphylococci,H.influenzae,E.coli,Enterobacter,Klebsiellaincludingacute/chronicbronchitis,gonorrhea,impetigo,earlyLymedisease,otitismedia,pharyn-gitis/tonsillitis,sinusitis,skin/skinstruc-ture,UTI,perioperativeprophylaxis.UseFrequent:DiscomfortwithIMadministra-tion,oralcandidiasis(thrush),milddiar-rhea,mildabdominalcramping,vaginalcandidiasis.Occasional:Nausea,serumsickness–likereaction(fever,jointpain;usuallyoccursaftersecondcourseoftherapyandresolvesafterdrugisdiscon-tinued).Rare:Allergicreaction(rash,pruritus,urticaria),thrombophlebitis(pain,redness,swellingatinjectionsite).SIDEEFFECTSBASELINEASSESSMENTObtainCBC,renalfunctiontests.Ques-tionforhistoryofallergies,particularlycephalosporins,penicillins.INTERVENTION/EVALUATIONAssessoralcavityforwhitepatchesonmucousmembranes,tongue(thrush).Monitordailypatternofbowelactivity,stoolconsistency.MildGIeffectsmaybetolerable(increasingseveritymayindi-cateonsetofantibiotic-associatedcoli-tis).MonitorI&O,renalfunctiontestsfornephrotoxicity.Bealertforsuperinfec-tion:fever,vomiting,diarrhea,anal/genitalpruritus,oralmucosalchanges(ulceration,pain,erythema).PATIENT/FAMILYTEACHING•DiscomfortmayoccurwithIMinjec-tion.•Dosesshouldbeevenlyspaced.•Continueantibiotictherapyforfulllengthoftreatment.•MaycauseGIup-set(maytakewithfood,milk).NursingResponsibilities头(Tou)孢呋辛第十七页，共三十六页。FeosolFerrousSulfateADULTS,ELDERLY:65mg2–4timesaday.CHILDREN:

3–6mg/kg/dayin2–3divideddoses.UsualDosagePrevention,treatmentofirondeficiencyanemiaduetoinadequatediet,malabsorption,pregnancy,bloodloss.UseOccasional:Mild,transientnausea.Rare：Heartburn,anorexia,constipation,diarrhea.SIDEEFFECTSBASELINEASSESSMENTAssessnutritionalstatus,dietaryhistory.Topreventmucousmembraneandteethstainingwithliquidpreparation,usedropperorstrawandallowsolutiontodroponbackoftongue.B。INTERVENTION/EVALUATIONMonitorserumiron,totaliron-bindingcapacity,reticulocytecount,Hgb,ferritin.Monitordailypatternofbowelactivity,stoolconsistency.Assessforclinicalimprovement,recordreliefofirondeficiencysymptoms(fatigue,irritability,pallor,paresthesiaofextremities,headache).C.PATIENT/FAMILYTEACHINGExpectstoolcolortodarken.Oralliquidmaystainteeth.IfGIdiscomfortoccurs,takeaftermealsorwithfood.Donottakewithin2hrsofothermedicationoreggs,milk,tea,coffee,cereal.NursingResponsibilities硫(Liu)酸亚铁第十八页，共三十六页。ZantacRanitidineORAL、IMorIV、UsualAdultDoseand16yearsolder：50mgorally2timesadayOR300mgorallyonceadayaftertheeveningmealoratbedtimeLessthan1monthANDwithExtracorporealmembraneoxygenation(ECMO):-2mg/kgIVevery12to24hoursORasacontinuousinfusionUsualAdultDoseand16yearsolder:50mgIMorIVevery6to8hoursLessthan1monthANDwithExtracorporealmembraneoxygenation(ECMO):-2mg/kgIVevery12to24hoursORasacontinuousinfusionUsualDosage Duodenalulcers,GERD,Heartburn,Esophagitis,GIbleedUse1. MorecommonsideeffectsHeadache,constipation,diarrhea,nauseaandvomiting,stomachdiscomfortorpain2. Serioussideeffectsinflammationofyourliver,changesinyourbrainfunction,abnormalheartrateSIDEEFFECTS Beforetakingranitidine,tellyourdoctororpharmacistifyouareallergictoit; Beforeusingthismedication,tellyourdoctororpharmacistyourmedicalhistory, Getmedicalhelprightawayifyouhave:heartburnwithlightheadedness/sweating/dizziness,chest/jaw/arm/shoulderpain(especiallywithshortnessofbreath,unusualsweating),unexplainedweightloss. Donotusetotreatchildrenyoungerthan12unlessdirectedbythedoctor. Olderadultsmaybemoresensitivetothesideeffectsofthisdrug,especiallyconfusion. Ranitidinepassesintobreastmilk.Consultyourdoctorbeforebreast-feeding.NursingResponsibilities雷尼替(Ti)丁第十九页，共三十六页。VitaminB9FolicAcidOrally,intramuscularly,IVAdultDose:400mcgdailyPregnancy:600mcgdailyLactation:500mcgdailyPediatricDose:1mgdailyUsualDosage Kidneydisease. Hyperhomocysteinemia Reducingharmfuleffectsofamedicinecalledmethotrexate. BirthdefectsUse Fever Generalweaknessordiscomfort Reddenedskin Shortnessofbreath Skinrashoritching Tightnessinchest Troubledbreathing WheezingSIDEEFFECTS Assessallergytolactuloselowgalactosediet. Usecautionllywithdiabetespregnancyandlactation Givelaxativesyruporallywithfruitjuice,waterandilktoincreasepalatable Monitorserumammonialev Carefullymonitorblood DonotuselaxativeformorethanlweekunlessprescribedbythedoctorNursingResponsibilities叶(Ye)酸第二十页，共三十六页。Pitocin,SyntocinonOxytocin10[USP'U]/mLUsualDosageUsedforlaborinduction,augmentationoflabor,postpartumabbreviationofthirdstageoflabor,postpartumcontrolofuterinebleeding,terminationofpregnancyandfortheevaluationoffetalrespiratorycapability.Oxytocincannotbeusedforelectiveinductionoflabor,theremustbeaclearmedicalrequirement.UseAdverseEffectsCV:Hypertention,increaseheartrate,systemicvenousreturns,cardiacoutputGI:NauseaandVomitingRepiratory:Anoxia,AsphyxiaOthers:LowAPGARscoreat5mins.SIDEEFFECTS1) StartflowchartstorecordmaternalBPandothervitalsigns,I&Oratio,weight,strength,duration,andfrequencyofcontractions,aswellasfetalhearttoneandrate,beforeinstitutingtreatment.2) MonitorfetalheartrateandmaternalBPandpulseatleastq15minduringinfusionperiod;evaluatetonusofmyometriumduringandbetweencontractionsandrecordonflowchart.Reportchangeinrateandrhythmimmediately.Stopinfusiontopreventfetalanoxia,turnpatientonherside,andnotifyphysicianifcontractionsareprolonged(occurringatlessthan2-minintervals)andifmonitorrecordscontractionsabout50mmHgorifcontractionslast90secondsorlonger.Stimulationwillwanerapidlywithin2–3min.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) IncidenceofhypersensitivityorallergicreactionsishigherwhenoxytocinisgivenbyIMorIVinjectionratherthanbyIVinfusion(dilutedsolution).7) Patient&FamilyEducation.NursingResponsibilities催产(Chan)素第二十一页，共三十六页。AllthemedicinesinformationcomefromNCLEX-RN(NURSINGDRUGHANDBOOK,2016)第二十二页，共三十六页。What’stheNursingproblems?Question第二十三页，共三十六页。NursingCarePlanNursingproblem1RiskforInfection:Atincreasedriskforbeinginvadedbypathogenicorganisms.MayberelatedtoCSandgestationaldiabetes.Goals:*Thepatientwillnotexperiencesignsofinfectionbydischarge.*Thepatientachievestimelywoundhealingwithoutcomplications24第二十四页，共三十六页。NursingCarePlanInterventions(干预措施)Rationale(基本原理)EvaluationWashhandsbeforeandaftercaringforpatient,usinggloveswhenindicated;nosharingofequipmentwithotherunits.InterventionshelppreventthespreadofpathogensbetweenstaffandpatientsGoalMet:Patientremainsfreefromsymptomsofinfectionbydischarge.Assesslowerabdominalincision（腹腔切开术；腹部切口，剖腹术）notingifareaunderandaroundsteric-stripsisclean,dryandintact,ifincisionsexhibitredness,edema,ecchymosis,drainage,andapproximation.Assessmentprovidesinformationaboutdevelopinginfection:Localinflammatoryeffectscauserednessandedema.Thismaybefollowedbypurulentdrainageandwoulddehiscence.GoalMet:Incisionisdryandintact,edgeswell-approximated,withoutrednessoredemathroughtodischarge.25第二十五页，共三十六页。NursingCarePlanInterventionsRationaleEvaluationAssesstemperatureq4horally.Fevermaybethefirstsignofinfectionintheobstetricspatient,andtemperaturevaluescanhaveimportantconsequencesfortreatmentdecisions.GoalMet:Patientwithouttemperature>38.5℃inasinglemeasurement,orthreetemperaturesof>38℃bydischarge.Maintainacleanenvironment.Ensuretheclient’sroomandbathroomiscleanedfrequentlyandappropriately.Acleanenvironmentmaydiscouragethegrowthofmicroorganisms.GoalMet:Linensseparatedr/tdirtyandcleaninrestroom,personalcaresupplieskeptofffloor,bedlinenschangedperdayopenthroughtodischarge.26第二十六页，共三十六页。NursingCarePlanNursingproblem2RiskforAcutePain:mayberelatedtoincreasedmusclecontractionsandpsychologicalreactionsGoals:Thepatientverbalizesreduceddiscomfortorpain27第二十七页，共三十六页。NursingCarePlanInterventionsRationaleEvaluationAssesslocation,nature(lithotomyposition),anddurationofpain,especiallyasitrelatestotheindicationforcesareanbirth. Indicatesthesuitablechoiceoftreatment.Thepatientawaitingimminentcesareanbirthmayencountervaryingdegreesofdiscomfort,dependingontheindicationfortheprocedure,e.g.,failedinduction,dystocia.GoalMet:PatientverbalizesreduceddiscomfortorpainDropanxiety-producingcircumstance(e.g.,lossofcontrol),giveaccurateinformation,andencouragepresenceofpartner. Levelsofpaintoleranceareindividualandareaffectedbyvariousfactors.Extremeanxietyfollowinganemergencysituationmaydevelopdiscomfortduetofear,tension,andpainaffectingthepatient’sabilitytocope.28第二十八页，共三十六页。NursingCarePlanInterventionsRationaleEvaluationEducateproperrelaxationtechniques;positionforcomfortaspossible.UseTherapeuticTouch,asappropriate. Mayhelpindecreasinganxietyandtension,promotecomfortandenhancesenseofwell-being. GoalMet:PatientverbalizesreduceddiscomfortorpainPatientparticipatedinbehaviorstodiminishpainsensationsandenhancecomfort.Ifindicated,administermedicationssuchassedative,narcotics,orpreoperativedrugs.Promotescomfortbyblockingpainimpulses.Potentiatestheactionofanestheticagents.29第二十九页，共三十六页。NursingCarePlanNursingproblem3Anxiety:Mayberelatedtoperceived/Actualthreatofmaternalandfetalwell-being,situationalcrisis,threattoself-conceptGoals:*Thepatientdiscussesfeelingsaboutcesareanbirth.*Thepatientappearsrelaxedandcomfortable.*Thepatientverbalizesfearsforthesafetyofherselfandinfant.30第三十页，共三十六页。NursingCarePlanInterventionsRationaleEvaluationAssesspsychologicalresponsetoeventandavailabilityofsupportsystems. Thegreaterthepatientperceivesthethreat,thegreaterthelevelofheranxiety.GoalMet:Thepatientdiscussedfeelingsaboutcesareanbirth.Thepatientappearsrelaxedandcomforta