新生兒科：一例宮內(nèi)感染性肺炎患兒的護(hù)理查房課件

1、（一例宮內(nèi)感染性肺炎患兒的護(hù)理查房）speaker：何綺晴Physical examination：姚蓮萍PPT production：石彩蘭Advisor：陳松珠老師、陳麗英老師、何兆梅老師One case of intrauterine infection pneumonia of the newborn in nursing roundsOperation purpose1.Discussing and using 14 items about clinical nursing service quality in nursing rounds(探討運(yùn)用“14條”進(jìn)行護(hù)理查房)2. Ma

2、ster(掌握) the nursing of intrauterine infection pneumonia with newborn 3. Improve the nurses understanding of intrauterine infection pneumoniaGeneral information（一般資料）：Name: Son of Geng yinghua （庾穎華之子）Age: 11 days Weight：3.55kg Sex: male Data of Birth：: 14:57 ,July 26th, 2016 Race: Han Nationality: C

3、hinaParents Name: father Chen haiyan，Mother Geng yinghuaDate of admission: July 27th, 2016Chief complaint（主訴）: short of breath for 2 hoursPresent illness（現(xiàn)病史）:GW: 38+weeks, G3P2, LMP: 2016-08-05; EDC: 2016-7-26 .Babys mother is a elderly pregnant woman with scarred uterus(疤痕子宮) .he birthed in 14:57

4、,July 26th, 2016 with cesarean(剖腹產(chǎn)) .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（無窒息搶救史） at birth with clear amniotic fluid（羊水清）. It was nine points with Apgar scoring in 1 min

5、ute , and 10 points with Apgar scoring in five minutes (1分鐘阿氏評分為9分，五分鐘阿氏評分為10分)，and had shortness of breath after 24 hours along with obtuse（遲鈍的） response and Oral cyanosis (口唇發(fā)紺)and moaning（呻吟）.No restlessness（煩躁不安）or vomit or fever or pale complexion（面色蒼白） or seizure（癲癇發(fā)作） or scream（尖叫） were obser

6、ved. 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（子宮肌瘤剔除術(shù)） in 2005，and delivered a girl with cesarean(剖腹產(chǎn)) in 2009.The patients father suffered from hypertension（高血壓） a

7、nd gout(痛風(fēng))Diagnosis(診斷)：intrauterine infection pneumonia of the newborn （宮內(nèi)感染性肺炎）What s it ？Intrauterine infection pneumonia of the newborn（新生兒宮內(nèi)感染性肺炎）:Caused by viruses（病毒）, bacteria（細(xì)菌）, protozoa（原蟲）, or chlamydia（衣原體）Had infection before birth (出生前就感染)Always attacked（發(fā)?。?within 24 hours after bi

8、rth with asphyxia（窒息史）Had shortness of breath（氣促），moans（呻吟）, difficulty breathing（呼吸困難）, and had not stable temperature（體溫不穩(wěn)定）, and the response is poor（反應(yīng)差)after recovery（復(fù)蘇）.07-31 CPAP輔助通氣間中呼吸稍促，停留胃管通暢，無潴留，持續(xù)心電監(jiān)護(hù)顯示：RR 35-45次/分，P 130-144次/分，BP 75/43 mmHg，SPO2 93-98%，反應(yīng)稍差，哭聲稍弱，輕度吸氣三凹征陽性，雙肺呼吸音粗，可聞及雙肺

9、低濕性啰音，伴呻吟樣呼吸，全身皮膚黏膜輕度黃染,，SB 7mg/dl，輔助檢查：血培養(yǎng)至今：未見細(xì)菌、真菌生長，電解質(zhì)：Na 142.3mmol/L，CA 2.08 mmol/L,K 3.28mmol/L ,CPR 2.1mg/L,目前繼續(xù)監(jiān)護(hù)、CPAP輔助通氣、抗感染、營養(yǎng)心肌等治療08-01試停CPAP輔助通氣，呼吸尚順，血氧飽和度可維持在90-98%之間，反應(yīng)稍可，哭聲響，停留胃管通暢，無潴留，持續(xù)心電監(jiān)護(hù)顯示：RR 40-48次/分，P 125-146次/分，BP 79/43 mmHg，SPO2 92-98%，全身皮膚輕度黃染，SB 7mg/dl，雙肺呼吸音粗，未聞及雙肺干濕啰音，目前

10、繼續(xù)監(jiān)護(hù)、抗感染、營養(yǎng)心肌等治療08-02患兒呼吸順，無發(fā)紺，血氧飽和度可維持在93-98%之間，持續(xù)心電監(jiān)護(hù)顯示：RR 40-45次/分，P125-148次/分，BP72/41mmHg，全身皮膚輕度黃染，SB 8mg/dl，雙肺呼吸音粗，未聞及干濕啰音，G6PD 4.9U/L08-03患兒呼吸順，無發(fā)紺，無三凹征，持續(xù)心電監(jiān)護(hù)顯示：RR 40-46次/分，P127-144次/分，BP 87/42 mmHg，SPO2 92-94%，全身皮膚輕度黃染，SB 7mg/dl，雙肺呼吸音粗，輔助檢查：血常規(guī)：WBC 11.68x109/L , HGB 117g/L,電解質(zhì)：CA 2.14 mmol/L

11、,K 4.35 mmol/L ,CPR 0.2mg/L,患兒復(fù)查血紅蛋白較前降低，必要時(shí)輸注濃縮紅細(xì)胞，目前繼續(xù)監(jiān)護(hù)、抗感染、營養(yǎng)心肌等治療08-04患兒呼吸順，無發(fā)紺，無三凹征，全身皮膚輕度黃染，SB 7mg/dl，雙肺呼吸音稍粗，未聞及干濕啰音，血氧飽和度可維持在92-97%之間，持續(xù)心電監(jiān)護(hù)顯示：RR 40-48次/分，P120-142次/分，BP69/35mmHg，SPO2 92-97%，輔助檢查：血培養(yǎng)：未見細(xì)菌、真菌生長，患兒呼吸順，吃奶好，病情治愈，予出院Physical examination（體格檢查）Nursing problem1、Ineffective Airway C

12、learance（清理呼吸道無效)：Associated 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（氣體交換受損）：Associated with lung inflammation（炎癥）3、Malnutrition（營養(yǎng)失調(diào)）：Associated with inadequate（不足的）intake and the increase consumption(消耗)Maintain（保持）normal body

13、 temperatureMaintain normal body temperature： 36 to 37 Hypothermia（體溫過低）：keeping warmHyperthermia（體溫過高）： coolingIf necessary：Use the antipyretic （退熱藥）in accordance with the doctors adviceantibiotic therapy(抗生素治療)According to the illness needs to choose the appropriate（合適的）antibiotics（抗生素）Observed the effect of drugs closely（密切觀察藥物的作用）Supply enough energy and moisture(水分)Eat smaller, more frequent meals（少量多餐）Prevent asphyxia during feeding（喂奶時(shí)防止窒息） severe patients（病重者）：Nasal feeding（鼻飼） &Intravenous supplement wi