护理临床实习案例分析.ppt

FarEasternUniversity InstituteofNursing CASEPRESENTATION FEUNRMFHOSPITAL OBSTETRICSWARD GroupThree PengSijing Stone LiXiaojing Cathy MiaoChunmei Mano NieFengyan Zara Content Introduction 1 History PhysicalAssessment 3 LaboratoryandDiagnosticExams 4 2 MedicationsandIVfluid 5 2 6 NursingCarePlan Introduction 3 PatientA 30yearsold G1P0 pregnancyuterine39weeksand2days cephalicinlabor admittedatFEU NRMFHOSPITALonFebruary8 2018 CHIEFCOMPLAINT HypogastricPain History 4 HISTORYOFPRESENTPREGNANCY 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 History 5 HISTORYOFPRESENTPREGNANCY SecondTrimester Quickeningwasfeltonthe5thmonthofpregnancy October2017 ShehadregularintakeofMultivitamins1tabdaily Ferroussulfate1tabletonceaday andCalcium1tablettwiceaday Onlyurinalysiswasdoneatthehealthcenterrevealingthatshehadurinarytractinfection shewasprescribedCefuroxime500mgBIDfor1weektowhichshewascompliant Transabdominalultrasoundforgenderdeterminationwasdoneonthe7thmonthofpregnancyrevealingsingleintrauterinepregnancycompatibleto28weeksand4daysageofgestation November2017 Shedeniesanyhistoryofaccidents trauma illness oranyexposuretoradiationandtoxicchemicals History 6 ThirdTrimester Subsequentprenatalcheck upswereregularaswellasintakeofmultivitamins1tabletonceaday Ferroussulfate1tabletonceaday andcalcium1tablettwiceaday Capillarybloodglucosemonitoringand75gOGTTwasdonewhichrevealedincreasedresults Exactvalueswereunrecalledbythepatient ShewasprescribedwithNovoRapidinsulin 4unitstaken2hourspostmeals Shewasalsoadvisedtodocapillarybloodglucosemonitoringathome Subjectivecomplaintsexperiencedincludedheadacheanddizziness Nohypogastricpain abnormalvaginaldischarge vaginalspotting dysuria andfever Shedeniesanyhistoryofaccidents trauma illness oranyexposuretoradiationortoxicchemicals Thepresentconditionstarted5hoursprior 5 00pm toadmissionwhenthepatientexperiencedcrampyintermittenthypogastricpainradiatingtothelowerbackwithapainscaleof8 9outof10 Thiswasassociatedwithscantybloodyvaginaldischarge Shesoughtconsultatourinstitutionandwassubsequentlyadmitted History 7 PASTMEDICALHISTORY Thepatienthadusualchildhooddiseasessuchasmumps measles andchickenpox Shedeniesanyhistoryofmajorillnesses trauma accidents ormajoroperations ShewasadmittedlastJuneduetopersistentvomitinganddehydration PatienthasallergicrhinitisandwasdiagnosedwithgestationaldiabeteslastJanuarymaintainedonNovoRapidinsulin4unitstaken2hourspostmeals History 8 FAMILYHISTORY Father hypertensionMother kidneystones diedduetocardiacarrestThepatientis3thamong5siblingswith4sistersand1brother Hereldestis33yearsoldwhoisacontrolledhypertensivewithgestationaldiabetesmellitus Hersecondsiblingis32yearsoldwithkidneystones The4thsiblingis29yearsoldwhoisacontrolledhypertensive The5thsiblingis20yearsoldwhoisapparentlywell History 9 PERSONALANDSOCIALHISTORY Patientisahigh schoolgraduateandcurrentlyworksasamachineoperatorHabits Non smoker non alcoholicbeveragedrinkerREPRODUCTIVEHISTORY GYNECOLOGICHISTORY Thepatienthadmenarcheat13yearsoldwhichlasted4days lightflow consuming3padsperdayandnotassociatedwithdysmenorrhea Subsequentmenstruationswereirregular withanintervalofapproximately1to3monthslasting3to4days moderateflow consuming4 5padsperday andassociatedwithdysmenorrhea History 10 REPRODUCTIVEHISTORY OBSTETRICALHISTORYThepatientisaprimigravidMETHODOFCONTRACEPTIONThemethodforcontraceptionuseisoralcontraceptivepillsfromJune2016toDecember2016 ShetookthepillseverydaybeforegoingtobedSEXUALHISTORY At27yearsoldwith2sexualpartners Unknownnumberofsexualpartnersofherhusband Sheiscurrentlyinamonogamousheterosexualrelationship ReviewofSystems 11 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 nonumbness PhysicalExamination 12 GeneralSurvey 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 noabnormalnippledischarge PhysicalExamination 13 Abdomen Globularlyenlargedwithafundicheightof31cms fundusoccupiedbybreech fetalbackontheright fetalsmallpartsontheleft cephalic unengaged FHT 140sbestheardontherightlowerquadrant estimatedfetalweight2 945grams SpeculumExam Cleanlookingcervixwithscantypinkingtobrownishdischarge non foulsmellingInternalExam Normallookingexternalgenitalia nulliparousintroitus vaginaadmits2fingerswithease 4cms50 effaced intactbagofwaters cephalic station 3 Extremities Nogrossdeformities fullandequalpulsesnoedema nocyanosis CRT 2secsSkin Noactivedermatoses LaboratoryandDiagnosticExams 14 URINALYSIS MedicationsandIVfluid 15 MedicationsandIVfluid 16 Tradenames Zinacef Ceftin Cefuroxime IV 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 UsualDosage TreatmentofsusceptibleinfectionsduetogroupBstreptococci pneumococci staphylococci H influenzae E coli Enterobacter Klebsiellaincludingacute chronicbronchitis gonorrhea impetigo earlyLymedisease otitismedia pharyn gitis tonsillitis sinusitis skin skinstruc ture UTI perioperativeprophylaxis Use Frequent 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 SIDEEFFECTS BASELINEASSESSMENTObtainCBC 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 头孢呋辛 Feosol FerrousSulfate ADULTS ELDERLY 65mg2 4timesaday CHILDREN 3 6mg kg dayin2 3divideddoses UsualDosage Prevention treatmentofirondeficiencyanemiaduetoinadequatediet malabsorption pregnancy bloodloss Use Occasional Mild transientnausea Rare Heartburn anorexia constipation diarrhea SIDEEFFECTS BASELINEASSESSMENTAssessnutritionalstatus 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 硫酸亚铁 Zantac Ranitidine ORAL IMorIV UsualAdultDoseand16yearsolder 50mgorally2timesadayOR300mgorallyonceadayaftertheeveningmealoratbedtimeLessthan1monthANDwithExtracorporealmembraneoxygenation ECMO 2mg kgIVevery12to24hoursORasacontinuousinfusionUsualAdultDoseand16yearsolder 50mgIMorIVevery6to8hoursLessthan1monthANDwithExtracorporealmembraneoxygenation ECMO 2mg kgIVevery12to24hoursORasacontinuousinfusion UsualDosage Duodenalulcers GERD Heartburn Esophagitis GIbleed Use 1 MorecommonsideeffectsHeadache constipation diarrhea nauseaandvomiting stomachdiscomfortorpain2 Serioussideeffectsinflammationofyourliver changesinyourbrainfunction abnormalheartrate SIDEEFFECTS Beforetakingranitidine tellyourdoctororpharmacistifyouareallergictoit Beforeusingthismedication tellyourdoctororpharmacistyourmedicalhistory Getmedicalhelprightawayifyouhave heartburnwithlightheadedness sweating dizziness chest jaw arm shoulderpain especiallywithshortnessofbreath unusualsweating unexplainedweightloss Donotusetotreatchildrenyoungerthan12unlessdirectedbythedoctor Olderadultsmaybemoresensitivetothesideeffectsofthisdrug especiallyconfusion Ranitidinepassesintobreastmilk Consultyourdoctorbeforebreast feeding NursingResponsibilities 雷尼替丁 VitaminB9 FolicAcid Orally intramuscularly IVAdultDose 400mcgdailyPregnancy 600mcgdailyLactation 500mcgdailyPediatricDose 1mgdaily UsualDosage Kidneydisease Hyperhomocysteinemia Reducingharmfuleffectsofamedicinecalledmethotrexate Birthdefects Use Fever Generalweaknessordiscomfort Reddenedskin Shortnessofbreath Skinrashoritching Tightnessinchest Troubledbreathing Wheezing SIDEEFFECTS Assessallergytolactuloselowgalactosediet Usecautionllywithdiabetespregnancyandlactation Givelaxativesyruporallywithfruitjuice waterandilktoincreasepalatable Monitorserumammonialev Carefullymonitorblood Donotuselaxativeformorethanlweekunlessprescribedbythedoctor NursingResponsibilities 叶酸 Pitocin Syntocinon Oxytocin 10 USP U mL UsualDosage Usedforlaborinduction augmentationoflabor postpartumabbreviationofthirdstageoflabor postpartumcontrolofuterinebleeding terminationofpregnancyandfortheevaluationoffetalrespiratorycapability Oxytocincannotbeusedforelectiveinductionoflabor theremustbeaclearmedicalrequirement Use AdverseEffectsCV Hypertention increaseheartrate systemicvenousreturns cardiacoutputGI NauseaandVomitingRepiratory Anoxia AsphyxiaOthers LowAPGARscoreat5mins SIDEEFFECTS 1 StartflowchartstorecordmaternalBPandothervitalsigns Ievaluatetonusofmyometriumduringandbetweencontractionsandrecordonflowchart 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 催产素 AllthemedicinesinformationcomefromNCLEX RN NURSINGDRUGHANDBOOK 2016 What stheNursingproblems Question NursingCarePlan 24 Nursingproblem1RiskforInfection Atincreasedriskforbeinginvadedbypathogenicorganisms MayberelatedtoCSandgestationaldiabetes Goals Thepatientwillnotexperiencesignsofinfectionbydischarge Thepatientachievestimelywoundhealingwithoutcomplications NursingCarePlan 25 NursingCarePlan 26 NursingCarePlan 27 Nursingproblem2RiskforAcutePain mayberelatedtoincreasedmusclecontractionsandpsychologicalreactionsGoals Thepatientverbalizesreduceddiscomfortorpain NursingCarePlan 28 NursingCarePlan 29 NursingCarePlan 30 Nursingproblem3Anxiety Mayberelatedtoperceived Actualthreatofmaternalandfetalwell being situationalcrisis threattoself conceptGoals Thepatientdiscussesfeelingsaboutcesareanbirth Thepatientappearsrelaxedandcomfortable Thepatientverbalizesfearsforthesafetyofherselfandinfant NursingCarePlan 31 NursingCarePlan 32 NursingCarePlan 33 34 THANKS