护理临床实习案例分析.pptxVIP

护理临床实习案例分析第1页/共35页 ContentIntroduction 1History Physical Assessment 3Laboratory and Diagnostic Exams.42Medications and IV fluid526Nursing Care Plan 第2页/共35页 Introduction3 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第3页/共35页 History4HISTORY OF PRESENT PREGNANCY:LMP: May 9,2017 AOG by LMP: 39 weeks 2 days EDC by LMP: February 12, 2018PMP: April 8, 2017 AOG by EUTZ: 39 weeks 3 days EDC by EUTZ: February 12, 2018First 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 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 tract infection. She was prescribed Cefuroxime 500mg BID for 1 week, 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 denies 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 days.* She also took Loratadine 10mg once daily for her allergic rhinitis.第4页/共35页 History5HISTORY OF PRESENT PREGNANCY: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 Calcium 1 tablet twice a day. Only urinalysis was done at the health center revealing that she had urinary tract infection. she was prescribed Cefuroxime 500mg BID for 1 week to which she was com