护理临床实习案例分析知识讲解课件.ppt

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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),Far Eastern University-Insti,Content,Introduction,1,History,Physical Assessment,3,Laboratory and Diagnostic Exams.,4,

2、2,Medications and IV fluid,5,2,6,Nursing Care Plan,ContentIntroduction 1History P,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,Introduction3 Patient A,History,4,HIST

3、ORY OF PRESENT PREGNANCY:LMP:May 9,2017 AOG by LMP:39 weeks 2 days EDC by LMP:February 12,2018PMP:April 8,2017 AOG by EUTZ:39 weeks 3 days EDC by EUTZ:February 12,2018First Trimester*On the 1 month of missed period(June 2017):cessation of menses,nausea and vomiting.Self-pregnancy test was done,which

4、 revealed a positive result.*She consulted a 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

5、 500mg BID for 1 week,and repeat urinalysis 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

6、regularly.*She denies any history 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.,History4HISTORY OF PRESENT PRE,History,5,HISTO

7、RY OF PRESENT PREGNANCY:Second Trimester*Quickening was 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 urin

8、ary tract infection.she was prescribed Cefuroxime 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

9、denies any history of accidents,trauma,illness,or any exposure to radiation and toxic chemicals.,History5HISTORY OF PRESENT PRE,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

10、1 tablet twice a day.*Capillary blood glucose monitoring and 75g 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 hom

11、e.*Subjective complaints experienced included headache and 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

12、)to admission when the patient experienced crampy 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.,History6Third TrimesterThe pre,

13、History,7,PAST MEDICAL HISTORY:The patient had usual childhood diseases such 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 diag

14、nosed with gestational diabetes last January maintained on Novo Rapid insulin 4 units taken 2 hours post meals.,History7PAST MEDICAL HISTORY:,History,8,FAMILY HISTORY:Father:hypertensionMother:kidney stones,died due to cardiac arrestThe patient is 3th among 5 siblings with 4 sisters and 1 brother.He

15、r eldest is 33 years old who is a controlled hypertensive with gestational diabetes mellitus.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.,History8FAMILY HISTORY:,History,

16、9,PERSONAL AND SOCIAL HISTORY:Patient is a high-school graduate and currently works as a machine operatorHabits: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

17、associated with dysmenorrhea.Subsequent menstruations were irregular,with an interval of approximately 1 to 3 months lasting 3 to 4 days,moderate flow,consuming 4-5 pads per day,and associated with dysmenorrhea.,History9PERSONAL AND SOCIAL HI,History,10,REPRODUCTIVE HISTORY:OBSTETRICAL HISTORYThe pa

18、tient is a primigravid METHOD OF CONTRACEPTION The method for contraception use is oral contraceptive pills from June 2016 to December 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 cu

19、rrently in a monogamous heterosexual relationship.,History10REPRODUCTIVE HISTORY:,Review of Systems:,11,Constitutional:No fever and chills,malaise,weight loss Hematology:No easy fatigability,no easy bruise ability,no pallor CNS:No headache;no seizure;no loss of consciousness HEENT:No blurring of vis

20、ion;no hearing loss;no tinnitus Respiratory:No dyspnea;no cough;no colds;no apnea CVS:No orthopnea;no palpitationGIT:No diarrhea;no constipation GUT:No dysuria,frequency,no urgencyNMS:No malaise;no arthralgia;no myalgia;no numbness,Review of Systems:11Constitut,Physical Examination,12,General Survey

21、: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:98%HEENT:Anicteric sclera,pink palpebral conjunctiva,no nasoaural discharge,notonsillopharyngeal congestion Neck:Supple neck,no neck vein engorgement,no lymph

22、adenopathies noted Chest:Symmetrical chest expansion,no retractions,no laggingLungs:Vesicular breath sounds,no crackles,no wheezes Heart:A dynamic precordium,normal rate,regular rhythm,no murmur Breast:Symmetrical contour,no dimpling,no palpable mass,no tenderness,no abnormal nipple discharge,Physic

23、al Examination12 General,Physical Examination,13,Abdomen:Globularly enlarged with a fundic height of 31cms,fundus occupied by breech,fetal back 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 Ex

24、am:Clean looking cervix with scanty pinking to brownish discharge,non-foul smellingInternal Exam:Normal looking external genitalia,nulliparous 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

25、 edema,no cyanosis,CRT 2 secsSkin:No active dermatoses,Physical Examination13Abdomen:,Laboratory and Diagnostic Exams.,14,URINALYSIS,Laboratory and Diagnostic Exam,Medications and IV fluid,15,Medications and IV fluid15Medi,Medications and IV fluid,16,Medications and IV fluid16IV f,Trade names:Zinace

26、f,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 12 yrs and older:250500 mg twice a day.Chil-dren 3 mos to older than 12 yrs:2030

27、 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 acute/chronic bronchitis,gonorrhea,impetigo,early Lyme disease,otitis media,pharyn-gitis/tonsil

28、litis,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 candidiasis.Occasional:Nausea,serum sicknesslike reaction(fever,joint pain;usually occurs after second course of

29、 therapy and resolves after drug is discon-tinued).Rare:Allergic reaction(rash,pruritus,urticaria),thrombophlebitis(pain,redness,swelling at injection site).,SIDE EFFECTS,BASELINE ASSESSMENTObtain CBC,renal function tests.Ques-tion for history of allergies,particularly cephalosporins,penicillins.INT

30、ERVENTION/EVALUATIONAssess oral cavity for white patches on mucous membranes,tongue(thrush).Monitor daily pattern of bowel activity,stool consistency.Mild GI effects may be tolerable(increasing severity may indi-cate onset of antibiotic-associated coli-tis).Monitor I&O,renal function tests for nephr

31、otoxicity.Be alert for superinfec-tion:fever,vomiting,diarrhea,anal/genital pruritus,oral mucosal changes(ulceration,pain,erythema).PATIENT/FAMILY TEACHINGDiscomfort may occur with IM injec-tion.Doses should be evenly spaced.Continue antibiotic therapy for full length of treatment.May cause GI up-se

32、t(may take with food,milk).,Nursing Responsibilities,头孢呋辛,Trade names:Zinacef,CeftinC,Feosol,Ferrous Sulfate,ADULTS,ELDERLY:65 mg 24 times a day.CHILDREN:36 mg/kg/day in 23 divided doses.,Usual Dosage,Prevention,treatment of iron deficiency anemia due to inadequate diet,malabsorption,pregnancy,blood

33、 loss.,Use,Occasional:Mild,transient nausea.Rare：Heartburn,anorexia,constipation,diarrhea.,SIDE EFFECTS,BASELINE ASSESSMENTAssess nutritional status,dietary history.To prevent mucous membrane and teeth staining with liquid preparation,use dropper or straw and allow solution to drop on back of tongue

34、.B。INTERVENTION/EVALUATIONMonitor serum iron,total iron-binding capacity,reticulocyte count,Hgb,ferritin.Monitor daily pattern of bowel activity,stool consistency.Assess for clinical improvement,record relief of iron deficiency symptoms(fatigue,irritability,pallor,paresthesia of extremities,headache

35、).C.PATIENT/FAMILY TEACHINGExpect stool color to darken.Oral liquid may stain teeth.If GI discomfort occurs,take after meals or with food.Do not take within 2 hrs of other medication or eggs,milk,tea,coffee,cereal.,Nursing Responsibilities,硫酸亚铁,FeosolFerrous SulfateADULTS,E,Zantac,Ranitidine,ORAL、IM

36、 or IV、Usual Adult Dose and16 years older：50 mg orally 2 times a day OR 300 mg orally once a day after the evening meal or at bedtimeLess than 1 month AND with Extracorporeal membrane oxygenation(ECMO):-2 mg/kg IV every 12 to 24 hours OR as a continuous infusionUsual Adult Dose and16 years older:50

37、mg IM or IV every 6 to 8 hoursLess than 1 month AND with Extracorporeal membrane oxygenation(ECMO):-2 mg/kg IV every 12 to 24 hours OR as a continuous infusion,Usual Dosage,Duodenal ulcers,GERD,Heartburn,Esophagitis,GI bleed,Use,1.More common side effects Headache,constipation,diarrhea,nausea and vo

38、miting,stomach discomfort or pain2.Serious side effects inflammation of your liver,changes in your brain function,abnormal heart rate,SIDE EFFECTS,Before taking ranitidine,tell your doctor or pharmacist if you are allergic to it;Before using this medication,tell your doctor or pharmacist your medica

39、l history,Get medical help right away if you have:heartburn with lightheadedness/sweating/dizziness,chest/jaw/arm/shoulder 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

40、 more sensitive to the side effects of this drug,especially confusion.Ranitidine passes into breast milk.Consult your doctor before breast-feeding.,Nursing Responsibilities,雷尼替丁,ZantacRanitidine ORAL、IM or IV,Vitamin B9,Folic Acid,Orally,intramuscularly,IVAdult Dose:400 mcg dailyPregnancy:600 mcg da

41、ilyLactation:500 mcg dailyPediatric Dose:1 mg daily,Usual Dosage,Kidney disease.HyperhomocysteinemiaReducing harmful effects of a medicine called methotrexate.Birth defects,Use,FeverGeneral weakness or discomfortReddened skinShortness of breathSkin rash or itchingTightness in chestTroubled breathing

42、Wheezing,SIDE EFFECTS,Assess allergy to lactulose lowgalactose diet.Use cautionlly with diabetes pregnancy and lactationGive laxative syrup orally with fruit juice,water and ilk to increase palatableMonitor serum ammonia levCarefully monitor bloodDo not use laxative for more than l week unless presc

43、ribed by the doctor,Nursing Responsibilities,叶酸,Vitamin B9Folic AcidOrally,in,Pitocin,Syntocinon,Oxytocin,10 USPU/mL,Usual Dosage,Used for labor induction,augmentation of labor,postpartum abbreviation of third stage of labor,postpartum control of uterine bleeding,termination of pregnancy and for the

44、 evaluation of fetal respiratory capability.Oxytocin cannot be used for elective induction of labor,there must be a clear medical requirement.,Use,Adverse EffectsCV:Hypertention,increase heart rate,systemic venous returns,cardiac outputGI:Nausea and VomitingRepiratory:Anoxia,AsphyxiaOthers:Low APGAR

45、 score at 5 mins.,SIDE EFFECTS,1)Start flow charts to record maternal BP and other vital signs,I evaluate tonus of myometrium during 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 notif

46、y physician if contractions are prolonged(occurring at less than 2-min intervals)and if monitor records contractions about 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)ane

47、sthesia is being given to the patient receiving oxytocin,be alert to the possibility of hypertensive crisis(sudden intense occipital headache,palpitation,marked hypertension,stiff neck,nausea,vomiting,sweating,fever,photophobia,dilated pupils,bradycardia or tachycardia,constricting chest pain).4)Mon

48、itor I&O during labor.If patient is receiving drug by prolonged IV infusion,watch for symptoms of water 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 intak

49、e).5)Check fundus frequently during the first few postpartum hours and several times daily thereafter.6)Incidence of hypersensitivity or allergic reactions is higher when oxytocin is given by IM or IV injection rather than by IV infusion(diluted solution).7)Patient&Family Education.,Nursing Responsi

50、bilities,催产素,Pitocin,SyntocinonOxytocin10,All the medicinesinformation come from NCLEX-RN(NURSING DRUG HANDBOOK,2016),All the medicines,Whats the Nursing problems?,Question,Whats the Nursing problems?Q,Nursing Care Plan,24,Nursing problem 1Risk for Infection:At increased risk for being invaded by pa