新生儿科一例宫内感染性肺炎患儿护理查房

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2016/8/13 Saturday,#,（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 rounds,Operation purpose,1.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.,Master(,掌握,),the,nursing of intrauterine,infection pneumonia,with newborn,3,.,Improve,the nurses,understanding of intrauterine infection pneumonia,General 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: China,Parents Name: father Chen haiyan,，,Mother Geng yinghua,Date of admission: July 27th, 2016,Chief,complaint,（主诉）,:,short,of breath for 2 hours,Present 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 ,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 minute , 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 observed. 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）,and 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,birth 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）,.,clinical manifestation,（,临床表现）,Serum,（血清）,IgM,and IgA is higher than normal newborns,and,Ig M, 200 mg/L,in umbilical,cord blood(,脐带血,),or the specificity Ig M is higher,for prenatal,diagnosis,（产前诊断）,.,X-ray,chest radiography is often shown as interstitial,pneumonia,（间,质性肺,炎,), and the bacterial pneumonia(,细,菌性肺,炎,)is bronchopneumonia(,支,气管肺,炎,).,Checked the,gastric,juice(,胃液,),1 2 hours,after birth, which could see,pus,cells,脓细胞, and find bacteria sometimes.,Concha,pharyngeal swab bacteria,culture(,外,耳道咽拭子细菌培,养,)can,be,positive(,阳性,).,Progress note,（病程记录）,2016-07-27,SPO2 80-85%,，,呼吸急促,，约,80,次,/,分，,伴呻吟样呼吸,，,口周发绀,，,吸气三凹征阳性,，给予,CPAP,辅助通气,（,PEEP 5cmH2O,，,FiO2 30-35%,），患儿气促较前好转，,SPO2,上升至,93-95%,，,禁食,，停留胃管无潴留，予告病重，给予抗感染、营养心肌及补液等治疗，续观,07-28,CPAP,辅助通气,（,PEEP 5cmH2O,，,FiO2 30-35%,），,禁食,停留胃管无潴留，,呼吸稍促,，三凹征阳性，双肺呼吸音粗，,闻及双肺低湿性啰音,，,全身皮肤黏膜无黄染,，辅助检查：血气分析：,PH 7.279,PC O2 47.1mmol/L,HCO3 -21.6mmol/L,BE -6.1mmol,血常规：,WBC 19.63x109/L , HGB 142g/L,血型“,B,”，电解质：,Na142.5mmol/L,，,CA 1.94 mmol/L,K 4.40mmol/L , CL108.1mmol/L,，,CK-MB,床边,胸片,X,片显示斑片状阴影,，目前诊断明确：,宫内感染性肺炎,，继续、监护、,CPAP,辅助通气、抗感染、营养心肌等治疗,07-28,PO2,氧分压,37.2 mmHg,，继续给予,CPAP,辅助通气，持续血氧饱和度维持在,90-95%,07-29,CPAP,辅助通气（,PEEP 5cmH2O,，,FiO2 30-35%,），,呼吸稍促,，反应稍差，哭声稍弱，,试喂,5ml/,次，停留胃管通畅,，无潴留，,轻度吸气三凹征阳性,，,双肺呼吸音粗,，可闻及,双肺低湿性啰音，伴呻吟样呼吸,，查,CPR,升高，,胸片提示可见斑片状阴影,，查,HGB 137 g/L,，全身皮肤黏膜轻度黄染，,SB 5mg/dl,07-30,CPAP,辅助通气，,间中呼吸稍促，,反应稍差，哭声稍弱，,轻度吸气性三凹征,，全身皮肤黏膜轻度黄染，,SB 5mg/dl,，双,肺呼吸音粗，可闻及双肺低湿性啰音，伴呻吟样呼吸,，开塞露塞肛后排出,16g,胎便，血钾较低，已静脉补钾，低钾血症,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.,3,mmol/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/L,08-03,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 11.68x10,9,/L , HGB 117g/L,电解质：,CA 2.14 mmol/L,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 problem,1,、,Ineffective,Airway Clearance,（清理呼吸道无,效,),：,A,ssociated,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,),4,、,Ineffective Thermoregulation,（体温调节无效）：,associated with the lung,infection,5,、,Potential Complication,（潜在并发症,),：,(,1,),heart failure,（心力衰竭,）：,Associated with pulmonary,hypertension,（,肺动脉高压,）,and the toxic myocarditis,（,中毒性心肌,炎）,.,(,2),toxic,encephalopathy,（,中毒性脑病,）：,Related to the lack of oxygen and carbon dioxide retention,.,（,二氧化碳储,留）,(,3),toxic,enteroparalysis,（,中毒性肠麻痹,）：,Related to,toxemia,毒,血症,and the severe cyanosis,（,严重缺氧,）,.,Nursing measures,Keep from obstruction,（保持呼吸道通畅）：,（,1,）,slapping back to excretory,sputum,（拍背排痰）,（,2,）,ultrasonic aerosol inhalation,（超声雾化吸入）,If,necessary,：,（,3,）,expectorant,（,祛痰,药）,（,4,）,Mouth,sputum suction with negative pressure,（口腔吸痰负压）：,Premature,（早产儿）：,Term infant,（足月儿）：,Rational,(,合理,),usage of oxygen,Control the time and oxygen concentration,（浓度）,吸氧指征：,PaO2,50-60mmHg,(1)nasal,catheter oxygen inhalation(,鼻,导,管给氧,),：,0.5-1 L/min,(2)mask,oxygen,inhalation(,面罩给氧,),:2-4 L/min,(3)Hood,oxygen,inhalation(,头,罩吸,氧,):5-8 L/min,(4)CPAP,：,continuous,positive airway,pressure (,持续气道正压通,气）,Maintain,（保持）,normal body temperature,Maintain normal body,temperature,：,36,to 37,Hypothermia,（体温过低）：,keeping warm,Hyperthermia,（体温过高）：,cooling,If,necessary,：,Use the antipyretic,（,退热,药）,in,accordance with the doctors,advice,antibiotic,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,with,nutrient,ion,and liquid,由静脉补充营养物质及液体,Closely observe the illness,（,1,）,Heart,rate,：,120-140 times/min on average,（,2,）,breathing,：,40,times/min on,average,（,3,）,Blood pressure monitoring: 70/50 mmHg on average,（,4,）,conscious,responses:,discharge,(,出,院,),guidance,Explain the relevant,knowledge of the,disease to parents,Give,the living,guidance of feeding and growing.,Pay,attention to prevent infection,Inform,parents,to attend,the,clinic,（复诊）,when baby,is feeling,unwell,Medical,staff,should have follow-up survey(,随访,) for neonates in times,，,and know,the recovery,situation,of neonates,.,Thank you,！,