妇产科病例讨论（Obstetrics and Gynecology case discussion）.doc

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妇产科病例讨论（Obstetrics and Gynecology case discussion）.doc

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妇产科病例讨论（Obstetrics and Gynecology case discussion）

妇产科病例讨论（Obstetrics and Gynecology case discussion） Case data 1 Ren Shanshan, female, 26 First visit: Chief complaint: G2P0 weeks of gestation, 26+2, first pregnancy examination. History: usuallymenstruationage rules, LMP:2006-05-02, DEC:2007-2-9, HCG (+), January postmenopausal pregnancy reaction significantly. Pregnant in April has not previously perceived fetal movement, prenatal examination. No palpitation, headache, malignancy, etc. Past history: past physical fitness, denial of hypertension history, no history of surgical trauma, no history of drug allergy. Childbearing history: 0-0-1-0, 3 years ago, more than 40 days pregnant, abortion once. Physical examination T:37 C; P:110 / min; R:20 / min; Bp:140/90mmHg. At the end of the heart lung and abnormal. Edema of the lower extremities (+). The abdomen is soft, not contraction, fetal heart 155 / min.. Waist 70cm, uterine height below the umbilicus in 2 fingers, fetal 600g estimation. Supplementary Examination Urine routine: protein + Routine blood test: RBC:3.4 * 1012/L, Hb:117g/L, WBC:13.7 * 109/L, N:87%, L10%, PLT:152 * 109/L B: BPD:56mm, FC:38mm, fetal heart 156 / min.. Clinical diagnosis: G2P0, 26+2 weeks, head position, mild pregnancy induced hypertension Handle： 1. pay attention to rest, daily blood pressure 1 times, 1 times a week pregnancy examination. 2. if you have headache, dizziness, nausea and other discomfort, visit immediately. The 3. day from the number of fetal movement. Ask: as an obstetrics and gynecology nursing staff, how should you care for this pregnant woman assessment, which nursing guidance should be carried out for pregnant women? Second visits: Complaints: G2P0, 29+1 weeks of pregnancy, elevated blood pressure, headache, dizziness, 3 days, nausea, 1 days, March. History: usuallymenstruationage rules, LMP:2006-05-02, DEC:2007-2-9, HCG (+), January postmenopausal pregnancy reaction significantly. Pregnant in April movement consciously so far, no prenatal examination. 3 weeks ago, the preg