1、护理临床实习案例分析Introduction2 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护理临床实习案例分析History3v HISTORY OF PRESENT PREGNANCY:LMP:May 9,2017 AOG by LMP:39 weeks 2 days EDC by LMP:February 1
2、2,2018PMP:April 8,2017 AOG by EUTZ:39 weeks 3 days EDC by EUTZ:February 12,2018First Trimester 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 private obstetrician where
3、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 urinary tract infectiontract infection.She was prescribed Cefuroxime 500mg BID for 1 weekCefuroxime 500mg BID for 1 w
4、eek,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 regularly.*She den
5、ies 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 dayshad an episode of colds and took cefuroxime 500mg twice a day for 5 days.*She also took Loratadine 10mg once daily for her allergic rh
6、initis.Loratadine 10mg once daily for her allergic rhinitis.护理临床实习案例分析History4v HISTORY OF PRESENT PREGNANCY:Second Trimester 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
7、Calcium 1 tablet twice a day.Only urinalysis was done at the health center revealing that she had urinary urinary tract infectiontract infection.she was prescribed Cefuroxime 500mg BID for 1 week Cefuroxime 500mg BID for 1 week to which she was compliant.*Transabdominal ultrasound for gender determi
8、nation 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,illness,or any exposure to radiation and toxic chemicals.护理临床实习案例分析History5Third TrimesterThird Trimeste
9、r*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 OGTT was done which revealed increased results.Exact values were unrecalled by the pati
10、ent.She was prescribed with Novo Rapid insulin,4 units Novo Rapid insulin,4 units taken 2 hours post mealstaken 2 hours post meals.She was also advised to do capillary blood glucose monitoring at home.*Subjective complaints experienced included headache and dizzinessheadache and dizziness.No hypogas
11、tric pain,abnormal vaginal discharge,vaginal spotting,dysuria,and fever.She denies any history of accidents,trauma,illness,or any exposure to radiation or toxic chemicalsThe present condition started 5 hours prior(5:00pm)to admission when the patient experienced crampy intermittent hypogastric pain
12、radiating to the crampy intermittent hypogastric pain radiating to the lower back with a pain scale of 8-9 out of 10lower 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.护理临床实习案例分析His
13、tory6v PAST MEDICAL HISTORY:The patient had usual childhood diseases such as mumps,measles,and chickenpoxmumps,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 dehydrationpersistent vomitin
14、g and dehydration.Patient has allergic rhinitis allergic rhinitis and was diagnosed with gestational diabeteswith gestational diabetes last January maintained on Novo Rapid insulin 4 units taken 2 hours post meals.on Novo Rapid insulin 4 units taken 2 hours post meals.护理临床实习案例分析History7v FAMILY HIST
15、ORY:Father:hypertensionMother:kidney stones,died due to cardiac arrestThe 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 mellitus.Her second sibling is 32 years old with kidney stones.The 4th sibling
16、is 29 years old who is a controlled hypertensive.The 5th sibling is 20 years old who is apparently well.护理临床实习案例分析History8v PERSONAL AND SOCIAL HISTORY:Patient is a high-school graduate and currently works as a machine operatorHabits:Non-smoker,non-alcoholic beverage drinker v REPRODUCTIVE HISTORY:G
17、YNECOLOGIC HISTORYGYNECOLOGIC HISTORYThe 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 irregularmenstruations were irregular,with an interval of approximately 1 to 3 months lasting 3 to
18、4 days,moderate flow,consuming 4-5 pads per day,and associated with dysmenorrhea.护理临床实习案例分析History9vREPRODUCTIVE HISTORY:OBSTETRICAL HISTORYOBSTETRICAL HISTORYThe patient is a primigravid METHOD OF CONTRACEPTION METHOD OF CONTRACEPTION The method for contraception use is oral contraceptive pills fro
19、m June 2016 to December 2016.She took the pills everyday before going to bed SEXUAL HISTORY 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.护理临床实习案例分析Review of Systems:10Constitutional:C
20、onstitutional:No fever and chills,malaise,weight loss Hematology:Hematology:No easy fatigability,no easy bruise ability,no pallor CNS:CNS:No headache;no seizure;no loss of consciousness HEENT:HEENT:No blurring of vision;no hearing loss;no tinnitus Respiratory:Respiratory:No dyspnea;no cough;no colds
21、;no apnea CVS:CVS:No orthopnea;no palpitationGIT:GIT:No diarrhea;no constipation GUT:GUT:No dysuria,frequency,no urgencyNMS:NMS:No malaise;no arthralgia;no myalgia;no numbness护理临床实习案例分析Physical Examination11 General Survey:The patient is conscious,coherent,not in cardiopulmonary distress with the fo
22、llowing 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 lymphadenopathies noted Chest:Symmetrical chest expansion,no retractions,no lagging
23、Lungs: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 护理临床实习案例分析Physical Examination12Abdomen:Globularly enlarged with a fundic height of
24、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 Exam:Clean looking cervix with scanty pinking to brownish discharge,non-foul smellingInternal Exam:Norm
25、al looking external genitalia,nulliparous introitus,vagina admits 2 fingers with ease,4cms 50%effaced,intact bag of waters,cephalic,station-3 Extremities:Extremities:No gross deformities,full and equal pulses no edema,no cyanosis,CRT 38.5 in a single measurement,or three temperatures of 38 by discha
26、rge.Maintain a clean environment.Ensure the clients room and bathroom is cleaned frequently and appropriately.A clean environment may discourage the growth of microorganisms.Goal Met:Linens separated r/t dirty and clean in restroom,personal care supplies kept off floor,bed linens changed per day ope
27、n through to discharge.护理临床实习案例分析Nursing Care Plan26Nursing problem 2Risk for Acute Pain:may be related to increased muscle contractions and psychological reactionsGoals:The patient verbalizes reduced discomfort or pain护理临床实习案例分析Nursing Care Plan27InterventionsRationaleEvaluation Assess location,nat
28、ure(lithotomy position),and duration of pain,especially as it relates to the indication for cesarean birth.Indicates the suitable choice of treatment.The patient awaiting imminent cesarean birth may encounter varying degrees of discomfort,depending on the indication for the procedure,e.g.,failed ind
29、uction,dystocia.Goal Met:Patient verbalizes reduced discomfort or painDrop anxiety-producing circumstance(e.g.,loss of control),give accurate information,and encourage presence of partner.Levels of pain tolerance are individual and are affected by various factors.Extreme anxiety following an emergen
30、cy situation may develop discomfort due to fear,tension,and pain affecting the patients ability to cope.护理临床实习案例分析Nursing Care Plan28InterventionsRationaleEvaluation Educate proper relaxation techniques;position for comfort as possible.Use Therapeutic Touch,as appropriate.May help in decreasing anxi
31、ety and tension,promote comfort and enhance sense of well-being.Goal Met:Patient verbalizes reduced discomfort or painPatient participated in behaviors to diminish pain sensations and enhance comfort.If indicated,administer medications such as sedative,narcotics,or preoperative drugs.Promotes comfor
32、t by blocking pain impulses.Potentiates the action of anesthetic agents.护理临床实习案例分析Nursing Care Plan29Nursing problem 3Anxiety:May be related to perceived/Actual threat of maternal and fetal well-being,situational crisis,threat to self-conceptGoals:*The patient discusses feelings about cesarean birth
33、.*The patient appears relaxed and comfortable.*The patient verbalizes fears for the safety of herself and infant.护理临床实习案例分析Nursing Care Plan30InterventionsRationaleEvaluation Assess psychological response to event and availability of support systems.The greater the patient perceives the threat,the g
34、reater the level of her anxiety.Goal Met:The patient discussed feelings about cesarean birth.The patient appears relaxed and comfortable.The patient verbalizes fears for the safety of herself and infant.Remain with the patient,and stay calm.Speak in a slow manner.Convey empathy.Helps to reduce inter
35、personal transmission anxiety,and shows caring for the patient or couple.Reinforce positive aspects of maternal and fetal condition.Focuses on likelihood of desirable outcome and helps to bring perceived or actual threat into perspective.护理临床实习案例分析Nursing Care Plan31InterventionsRationaleEvaluation
36、Let the patient or couple verbalize or express inner thoughts and feelings.Helps to distinguish negative feelings and concerns as well as provides chance to cope with uncertain or unresolved feelings or grief.The patient may also feel an emotional intimidation to her self-esteem,owing to her feeling
37、s that she has failed,that she is weak as a woman,and that her expectations have not been met.Goal Met:The patient discussed feelings about cesarean birth.The patient appears relaxed and comfortable.The patient verbalizes fears for the safety of herself and infant.Allow patient to discuss and elabor
38、ate past childbirth experience or expectations,as appropriate.Patient may have twisted thoughts of past delivery or unrealistic perceptions of abnormality of cesarean birth that will increase anxiety.护理临床实习案例分析Nursing Care Plan32InterventionsRationaleEvaluation Support/redirect expressed coping mech
39、anisms.Improves fundamental and automatic coping mechanisms,increases self-confidence and acceptance,and reduces anxiety.Note:Some actions by the patient may be viewed as ineffective(e.g.,screaming and throwing things)and need to be redirected to enhance patients sense of control.Goal Met:The patient discussed feelings about cesarean birth.The patient appears relaxed and comfortable.The patient verbalizes fears for the safety of herself and infant.Allot time for privacy.Allows patient or couple to internalize information,organize resources,and cope effectively.护理临床实习案例分析33护理临床实习案例分析
