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- 2017-05-18 发布于浙江
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新生儿科:一例宫内感染性肺炎患儿的护理查房
(一例宫内感染性肺炎患儿的护理查房);Operation purpose;General information;Present illness(现病史):
GW: 38+weeks, G3P2, LMP: 2016-08-05; EDC: 2016-7-26 .
Baby′s mother is a elderly pregnant woman with scarred uterus(疤痕子宫) .he birthed in 14:57 ,July 26th, 2016 with cesarean(剖腹产) .
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(无窒息抢救史) at birth with clear amniotic fluid(羊水清).
;It was nine points with Apgar scoring in 1 minute , and 10 points with Apgar scoring in five minutes (1分钟阿氏评分为9分,五分钟阿氏评分为10分),and had shortness of breath after 24 hours along with obtuse(迟钝的) response and Oral cyanosis (口唇发绀)and moaning(呻吟).
No restlessness(烦躁不安)or vomit or fever or pale complexion(面色苍白) or seizure(癫痫发作) or scream(尖叫) were observed. 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 patient’s mother had an operation with laparoscopic myomectomy(子宫肌瘤剔除术) in 2005,and delivered a girl with cesarean(剖腹产) in 2009.
The patient’s father suffered from hypertension(高血压) and gout(痛风)
Diagnosis(诊断):
intrauterine infection pneumonia of the newborn (宫内感染性肺炎)
;What ′s it ???;clinical manifestation(临床表现);Progress note(病程记录);07-31
;Physical examination(体格检查);Nursing problem;4、Ineffective Thermoregulation(体温调节无效):associated with the lung infection
5、Potential Complication(潜在并发症):
(1) heart failure(心力衰竭):Associated with pulmonary hypertension(肺动脉高压)and the toxic myocarditis(中毒性心肌炎).
(2) toxic encephalopathy(中毒性脑病):Related to the lack of oxygen and carbon dioxide retention.(二氧化碳储留)
(3) toxic enteroparalysis(中毒性肠麻痹):Related to toxemia毒血症and the severe cyanosis(严重缺氧). ;Nursing measures ;Rational(合理) usage of oxygen;Maintain(保持)normal body temperature;antibiotic therapy(抗生素治疗);Supply enough energy and moisture(水分);Closely observe the illness;discharge(出院)guidance;
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