护理临床实习案例分析

1、Far Eastern University - Institute of Nursing,CASE PRESENTATION,FEU NRMF HOSPITAL,OBSTETRICS WARD,Group Three,Peng Sijing (Stone ), Li Xiaojing (Cathy ), Miao Chunmei (Mano), Nie Fengyan (Zara),Content,Introduction,1,History,Physical Assessment,3,Laboratory and Diagnostic Exams.,4,2,Medications and

2、IV fluid,5,2,6,Nursing Care Plan,Introduction,3,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 Pain,History,4,HISTORY OF PRESENT PREGNANCY: LMP: May 9,2017 AOG by LMP: 39 weeks 2

3、days EDC by LMP: February 12, 2018 PMP: April 8, 2017 AOG by EUTZ: 39 weeks 3 days EDC by EUTZ: February 12, 2018 First 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

4、 private obstetrician 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 urinal

5、ysis afterwards was 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 histor

6、y of accidents, trauma, 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.,History,5,HISTORY OF PRESENT PREGNANCY: Second Trimester * Quickening wa

7、s felt on the 5th month 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 Cefuroxi

8、me 500mg BID for 1 week 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, i

9、llness, or any exposure to radiation and toxic chemicals.,History,6,Third 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

10、 OGTT was done which revealed 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

11、 dizziness. No hypogastric pain, abnormal vaginal discharge, vaginal spotting, dysuria, and fever. She denies any history of accidents, trauma, illness, or any exposure to radiation or toxic chemicals,The present condition started 5 hours prior (5:00pm) to admission when the patient experienced cram

12、py intermittent hypogastric 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.,History,7,PAST MEDICAL HISTORY: The patient had usual childhood diseases suc

13、h as mumps, measles, and chickenpox. 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 Rap

14、id insulin 4 units taken 2 hours post meals.,History,8,FAMILY HISTORY: Father: hypertension Mother: kidney stones, died due to cardiac arrest The 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 mellit

15、us. Her second sibling is 32 years 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.,History,9,PERSONAL AND SOCIAL HISTORY: Patient is a high-school graduate and currently works as a machine operator Habi

16、ts: Non-smoker, non-alcoholic beverage drinker REPRODUCTIVE HISTORY: GYNECOLOGIC HISTORY,The 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

17、 1 to 3 months lasting 3 to 4 days, moderate flow, consuming 4-5 pads per day, and associated with dysmenorrhea.,History,10,REPRODUCTIVE HISTORY: OBSTETRICAL HISTORY The patient is a primigravid METHOD OF CONTRACEPTION The method for contraception use is oral contraceptive pills from June 2016 to De

18、cember 2016. She took the pills everyday 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:,11,Constitutional: No fever and chills, malaise, weight

19、 loss Hematology: No easy fatigability, 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 palpitation GIT: No diarrhea; no con

20、stipation GUT: No dysuria, frequency, no urgency NMS: No malaise; no arthralgia; no myalgia; no numbness,Physical Examination,12,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 :

21、 98 % HEENT: Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge, notonsillopharyngeal congestion Neck: Supple neck, no neck vein engorgement, no lymphadenopathies noted Chest: Symmetrical chest expansion, no retractions, no lagging Lungs: Vesicular breath sounds, no crackles, no wh

22、eezes Heart: A dynamic precordium, normal rate, regular rhythm, no murmur Breast: Symmetrical contour, no dimpling, no palpable mass, no tenderness, no abnormal nipple discharge,Physical Examination,13,Abdomen: Globularly enlarged with a fundic height of 31cms, fundus occupied by breech, fetal back

23、on the right, fetal small parts on the left, cephalic, 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 smelling Internal Exam: Normal looking external genitalia, nu

24、lliparous introitus, vagina admits 2 fingers with ease , 4cms 50 % effaced , intact bag of waters , cephalic , station - 3,Extremities: No gross deformities, full and equal pulses no edema, no cyanosis, CRT 2 secs Skin : No active dermatoses,Laboratory and Diagnostic Exams.,14,URINALYSIS,Medications

25、 and IV fluid,15,Medications and IV fluid,16,Trade names: Zinacef, Ceftin,Cefuroxime,IV, IM: Adults, elderly, children 12 yrs and older: 750 mg1.5 g q8h. Chil-dren: 3 mos to older than 12 yrs: 75150 mg/kg/day divided q8h. Maximum: 6 g/day. Neonates: 50 mg/kg/dose q812h. Po: adults, elderly, children

26、 12 yrs and older: 250500 mg twice a day. Chil-dren 3 mos to older than 12 yrs: 2030 mg/kg/day in 2 divided doses. Maxi-mum: 1 g/day.,Usual Dosage,Treatment of susceptible infections due to group B streptococci, pneumococci, staphylococci, H. influenzae, E. coli, Enterobacter, Klebsiella including a

27、cute/chronic bronchitis, gonorrhea, impetigo, early Lyme disease, otitis media, pharyn-gitis/tonsillitis, sinusitis, skin/skin struc-ture, UTI, perioperative prophylaxis.,Use,Frequent: Discomfort with IM administra-tion, oral candidiasis (thrush), mild diar-rhea, mild abdominal cramping, vaginal can

28、didiasis. Occasional: Nausea, serum sicknesslike reaction (fever, joint pain;usually occurs after second course of therapy and resolves after drug is discon-tinued). Rare: Allergic reaction (rash, pruritus, urticaria), thrombophlebitis (pain, redness, swelling at injection site).,SIDE EFFECTS,BASELI

29、NE ASSESSMENT Obtain CBC, renal function tests. Ques-tion for history of allergies, particularly cephalosporins, penicillins. INTERVENTION/EVALUATION Assess oral cavity for white patches on mucous membranes, tongue (thrush). Monitor daily pattern of bowel activity, stool consistency. Mild GI effects

30、 may be tolerable (increasing severity may indi-cate onset of antibiotic-associated coli-tis). Monitor I Before using this medication, tell your doctor or pharmacist your medical history, Get medical help right away if you have: heartburn with lightheadedness/sweating/dizziness, chest/jaw/arm/should

31、er pain (especially with shortness of breath, unusual sweating), unexplained weight loss. Do not use to treat children younger than 12 unless directed by the doctor. Older adults may be more sensitive to the side effects of this drug, especially confusion. Ranitidine passes into breast milk. Consult

32、 your doctor before breast-feeding.,Nursing Responsibilities,雷尼替丁,Vitamin B9,Folic Acid,Orally, intramuscularly, IV Adult Dose: 400 mcg daily Pregnancy: 600 mcg daily Lactation: 500 mcg daily Pediatric Dose: 1 mg daily,Usual Dosage,Kidney disease. Hyperhomocysteinemia Reducing harmful effects of a m

33、edicine called methotrexate. Birth defects,Use,Fever General weakness or discomfort Reddened skin Shortness of breath Skin rash or itching Tightness in chest Troubled breathing Wheezing,SIDE EFFECTS,Assess allergy to lactulose lowgalactose diet. Use cautionlly with diabetes pregnancy and lactation G

34、ive laxative syrup orally with fruit juice, water and ilk to increase palatable Monitor serum ammonia lev Carefully monitor blood Do not use laxative for more than l week unless prescribed by the doctor,Nursing Responsibilities,叶酸,Pitocin, Syntocinon,Oxytocin,10 USPU/mL,Usual Dosage,Used for labor i

35、nduction, augmentation of labor, postpartum abbreviation of third stage of labor, postpartum control of uterine bleeding, termination of pregnancy and for the evaluation of fetal respiratory capability. Oxytocin cannot be used for elective induction of labor, there must be a clear medical requiremen

36、t.,Use,Adverse Effects CV: Hypertention, increase heart rate, systemic venous returns, cardiac output GI: Nausea and Vomiting Repiratory: Anoxia, Asphyxia Others: Low APGAR score at 5 mins.,SIDE EFFECTS,1)Start flow charts to record maternal BP and other vital signs, I evaluate tonus of myometrium d

37、uring and between contractions and record on flow chart. Report change in rate and rhythm immediately.Stop infusion to prevent fetal anoxia, turn patient on her side, and notify physician if contractions are prolonged (occurring at less than 2-min intervals) and if monitor records contractions about

38、 50 mm Hg or if contractions last 90 seconds or longer. Stimulation will wane rapidly within 23 min. Oxygen administration may be necessary. 3)If local or regional (caudal, spinal) anesthesia is being given to the patient receiving oxytocin, be alert to the possibility of hypertensive crisis (sudden

39、 intense occipital headache, palpitation, marked hypertension, stiff neck, nausea, vomiting, sweating, fever, photophobia, dilated pupils, bradycardia or tachycardia, constricting chest pain). 4)Monitor I&O during labor. If patient is receiving drug by prolonged IV infusion, watch for symptoms of wa

40、ter intoxication (drowsiness, listlessness, headache, confusion, anuria, weight gain). Report changes in alertness and orientation and changes in I&O ratio (i.e., marked decrease in output with excessive intake). 5)Check fundus frequently during the first few postpartum hours and several times daily therea