護理病歷教學(xué)查房護理病歷臨床病案

教學(xué)查房病史匯報Historydebriefing1實驗室檢查Laboratorytests2病因病理、發(fā)病機制Etiology,pathology,andpathogenesis3臨床表現(xiàn)Clinicalpresentation4治療treat5目錄護理nursing6健康教育Healtheducation701病史匯報Historydebriefing

一般情況姓名:徐旭出生地:云南省昆明市性別:女

職業(yè):無業(yè)年齡:32歲民族:漢入院日期:2024-1-311病史匯報Name:XuXuPlaceofbirth:Kunming,YunnanProvinceGender:FemaleOccupation:UnemployedAge:32yearsoldEthnicity:HanDateofadmission:Jan31,2024BasicInformation：現(xiàn)病史患者就診時血壓160/120mmHg，休息后復(fù)測：170/120mmHg，自覺焦慮明顯，考慮為“妊娠合并慢性高血壓、焦慮狀態(tài)”，予收住我科。孕期精神、飲食可、睡眠可，大、小便正常，孕期體重無明顯變化2病史匯報Thepatient‘sbloodpressurewas160/120mmHgatthetimeofpresentation,andtheretestafterrestwas170/120mmHg,andtheanxietywasobvious.Duringpregnancy,thespirit,diet,andsleepwereOK,theurineandurinewerenormal,andtherewasnosignificantchangeinpregnancyweight.Historyofpresentillness：既往史患者4年前診斷為焦慮癥，自訴孕前曾規(guī)律服藥阿普唑侖1片，后期癥狀稍緩解后自行停藥，僅癥狀發(fā)作時用藥，懷孕后自行停藥。2年前發(fā)現(xiàn)血壓高，未予特殊處理。青霉素類抗生素過敏。3病史匯報Thepatientwasdiagnosedwithanxietydisorder4yearsago,andreportedthathehadregularlytakenalprazolam1tabletbeforepregnancy,andstoppedthedrugafterthesymptomswereslightlyrelievedinthelaterstage.Highbloodpressurewasdetected2yearsagoandnospecialtreatmentwasgiven.Allergytopenicillinantibiotics.Anamnesis：02實驗室檢查Laboratorytests

實驗室檢查

實驗室檢查03病因與發(fā)病機制Etiologyandpathogenesis

病因與發(fā)病機制1免疫機制：胎盤的免疫屏障作用

Immunemechanism:Immunebarrierroleofplacenta23血管內(nèi)皮細胞受損：血管進一步收縮導(dǎo)致高血壓的形成。Vascularendothelialcelldamage:Furtherconstrictionofbloodvesselsleadstotheformationofhypertension.胎盤淺著床：胎盤淺著床時，滋養(yǎng)細胞入侵淺，少數(shù)動脈不能擴張，進而引起血壓增高。Placentalshallowimplantation:Whenplacentalshallowimplantation,trophoblastinvasionshallow,afewarteriescannotdilate,resultinginincreasedbloodpressure.病因與發(fā)病機制4遺傳因素：父親有高血壓病史

Geneticfactors:Fatherhadahistoryofhighbloodpressure5營養(yǎng)缺乏：孕期營養(yǎng)攝入不足

Nutritionaldeficiency:insufficientintakeofnutrientsduringpregnancy6胰島素抵抗：胰島素不能發(fā)揮正常功能

Insulinresistance:Insulindoesnotfunctionproperly04臨床表現(xiàn)clinicalpicture.出現(xiàn)大量蛋白尿Proteinuriaisabundant血壓升高蛋白尿中樞系統(tǒng)消化系統(tǒng)水腫臨床表現(xiàn)收縮壓大于或者等于140mmHg。舒張壓大于或者等于90mmHg。Systolicbloodpressuregreaterthanorequalto140mmHg.Diastolicbloodpressuregreaterthanorequalto90mmHg.頭暈，頭痛，視力模糊Dizziness,headache,blurredvision.

惡心、嘔吐、上腹部伴疼痛感。Nausea,vomiting,painintheupperabdomen.

雙下肢凹陷性水腫Pittededemaofbothlowerlimbs05治療treatment

治療目的：控制病情，延長孕周，確保母兒安全

Treatmentobjective:tocontrolthedisease,prolongthegestationalperiodandensurethesafetyofmotherandchild原則：解痙、休息與鎮(zhèn)靜、密切監(jiān)護母兒狀況、酌情降壓、有指針的利尿Principles:antispasmodic,restandsedation,closemonitoringofmotherandchildcondition,appropriatehypotension,diuresiswithPointers妊娠期高血壓治療要點（1）休息左側(cè)臥位，間斷吸氧；飲食充足蛋白質(zhì)和熱量（2）鎮(zhèn)靜（①地西泮②冬眠藥物③苯巴比妥）（3）密切監(jiān)護母兒狀態(tài)Keypointsoftreatmentofhypertensioninpregnancy(1)Restintheleftlateralposition,intermittentoxygeninhalation;Adequatedietofproteinandcalories(2)sedation(①diazepam②hibernationdrug③phenobarbital)(3)Closemonitoringofmaternalandinfantstatus妊娠期高血壓患者的藥物治療原則：Principlesofdrugtherapyforhypertensivepatientsduringpregnancy利尿藥物diuretic鎮(zhèn)靜藥物

sedative增加葉酸和甲鈷胺的攝入Increaseintakeoffolicacidandmecobalamine口服小劑量阿司匹林Orallow-doseaspirin補充多種維生素Multivitaminsupplement阿司匹林：改善孕婦凝血功能和血栓前狀態(tài)，抑制血小板凝集，防止血管內(nèi)皮受損，還可增加鈣的吸收，提高血清鈣水平，有效預(yù)防妊娠期高血壓疾病的發(fā)生。Aspirin:improvethecoagulationfunctionandpre-thromboticstateofpregnantwomen,inhibitplateletagglutination,preventvascularendothelialdamage,increasecalciumabsorption,improveserumcalciumlevel,andeffectivelypreventtheoccurrenceofhypertensivediseasesduringpregnancy.葉酸：降低血漿同型半胱氨酸的有效藥物。Folicacid:Effectivedrugforloweringplasmahomocysteine.維生素：維生素A、維生素C和維生素E都具有抗氧化作用，能減少血管內(nèi)皮細胞損傷，有效預(yù)防妊娠期高血壓疾病的發(fā)生。維生素C還能促進鈣、鐵吸收，維生素D可促進腸道對鈣的吸收。Vitamins:VitaminA,vitaminCandvitaminEallhaveantioxidanteffects,canreducethedamageofvascularendothelialcells,andeffectivelypreventtheoccurrenceofhypertensivediseasesduringpregnancy.VitaminCcanalsopromotecalcium,ironabsorption,vitaminDcanpromoteintestinalabsorptionofcalcium.鎮(zhèn)靜藥物：硫酸鎂可有效控制子癇，緩解孕婦精神緊張、焦慮癥狀，還可改善睡眠情況。Sedativedrugs:Magnesiumsulfatecaneffectivelycontroleclampsia,relievementaltension,anxietysymptomsofpregnantwomen,butalsoimprovesleep.利尿劑：不主張患者應(yīng)用利尿劑，盡在身體出現(xiàn)嚴重水腫、心腎衰竭時，可酌情應(yīng)用呋塞米等快速利尿劑。Diuretics:Donotadvocatetheuseofdiuretics,allinthebodyseriousedema,heartandkidneyfailure,canbeusedasappropriatefurosemideandotherrapiddiuretics.06妊娠高血壓護理護理診斷1.體液過多2.有受傷的危險4.潛在并發(fā)癥：胎盤早剝，腎功能衰竭，子癇等3.焦慮，恐懼與擔心母兒安全有關(guān);與下腔靜脈受增大子宮壓迫使血液回流受阻，蛋白丟失有關(guān);與高血壓引起的頭暈，眼花，視物模糊等有關(guān);與血壓升高，病情進一步發(fā)展有關(guān);1.ExcessivebodyfluidsItisrelatedtotheobstructionofbloodreturnandproteinlosscausedbytheincreaseduterinecompressionofinferiorvenacava.2.DangerofinjuryItisrelatedtodizziness,dizzinessandblurredvisioncausedbyhypertension.3.AnxietyandfearItisrelatedtoworryingaboutthesafetyofmotherandchild.4.Potentialcomplications:placentalabruption,renalfailure,eclampsia,etc.Itisrelatedtotheincreaseofbloodpressureandthefurtherdevelopmentofthedisease.護理措施1.體液過多：與下腔靜脈受增大子宮壓迫使血液回流受阻，蛋白丟失有關(guān);①密切觀察病情，評估水腫程度，記錄24小時出入量；②指導(dǎo)產(chǎn)婦進食高蛋白，高維生素飲食；③遵醫(yī)囑補充蛋白，給予消腫及利尿藥物；①Observetheconditionclosely,evaluatethedegreeofedema,andrecordthe24-hourinflowandoutflow.②Instructlying-inwomentoeatahighproteinandvitamindiet.③accordingtothedoctor'sadvicetosupplementprotein,givedetumescenceanddiureticdrugs.護理措施2.有受傷的危險：與高血壓引起的頭暈，眼花，視物模糊等有關(guān);①嚴密監(jiān)測生命體征；②保證充足的睡眠，加強安全防護；③解釋可能發(fā)生意外的危險因素及預(yù)防措施；①Closelymonitorvitalsigns;②Ensureadequatesleepandstrengthensafetyprotection;③Explainthepossibleriskfactorsofaccidentsandpreventivemeasures;護理措施3.焦慮，恐懼：與擔心母兒安全有關(guān);①理解病人的感受，耐心傾聽病人的述說，向其解釋疾病相關(guān)知識；②對病人極其家屬適當?shù)陌参?，治療過程中告知病人適當信息，減輕疑慮，增強戰(zhàn)勝疾病的信心；①Understandthepatient'sfeelings,patientlylistentothepatient'sstoryandexplainthedisease-relatedknowledgetoher;(2)giveappropriatecomforttothepatientandhisfamilymembers,informthepatientwithappropriateinformationduringthetreatment,reducedoubtsandenhanceconfidenceinovercomingthedisease;護理措施4.潛在并發(fā)癥：胎盤早剝，腎功能衰竭，子癇等:與血壓升高，病情進一步發(fā)展有關(guān);①積極治療原發(fā)病，遵醫(yī)囑正確使用解攣，降壓，鎮(zhèn)靜，利尿藥物；②保證環(huán)境安靜，空氣流通，減少刺激；③定期產(chǎn)前檢查，定期檢測尿蛋白變化；①Activelytreattheprimarydisease,andcorrectlyuseanti-clonic,antihypertensive,sedativeanddiureticdrugsaccordingtothedoctor'sadvice;②ensurethequietenvironment,aircirculation,reducestimulation;③Regularprenatalexamination,regulardetectionofurineproteinchanges;胎盤早剝子癇腎衰竭護理評價通過治療和護理，病人是否達到：①患者水腫減輕；②患者血壓得到控制，未出現(xiàn)頭暈等癥狀；③產(chǎn)婦訴生理及心理上舒適感增加；④產(chǎn)婦以了解疾病相關(guān)知識及注意事項。Throughtreatmentandnursing,doesthepatientachieve:①theedemaofthepatientisrelieved;②Thepatient'sbloodpressurewascontrolledwithoutdizzinessandothersymptoms;③Theparturientcomplainedofincreasedphysicalandpsychologicalcomfort;(4)pregnantwomentounderstandthediseaserelatedknowledgeandmattersneedingattention.07健康教育healtheducationⅠ.保持樂觀愉快的情緒。長期出現(xiàn)精神緊張、焦慮、煩燥、悲觀等情緒，會使大腦皮質(zhì)興奮和抑制過程的平衡失調(diào)，所以需要保持愉快的心情。Ⅰ.

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