护理病历教学查房护理病历临床病案

教学查房病史汇报Historydebriefing1实验室检查Laboratorytests2病因病理、发病机制Etiology,pathology,andpathogenesis3临床表现Clinicalpresentation4治疗treat5目录护理nursing6健康教育Healtheducation701病史汇报Historydebriefing

一般情况姓名:徐旭出生地:云南省昆明市性别:女

职业:无业年龄:32岁民族:汉入院日期:2024-1-311病史汇报Name:XuXuPlaceofbirth:Kunming,YunnanProvinceGender:FemaleOccupation:UnemployedAge:32yearsoldEthnicity:HanDateofadmission:Jan31,2024BasicInformation：现病史患者就诊时血压160/120mmHg，休息后复测：170/120mmHg，自觉焦虑明显，考虑为“妊娠合并慢性高血压、焦虑状态”，予收住我科。孕期精神、饮食可、睡眠可，大、小便正常，孕期体重无明显变化2病史汇报Thepatient‘sbloodpressurewas160/120mmHgatthetimeofpresentation,andtheretestafterrestwas170/120mmHg,andtheanxietywasobvious.Duringpregnancy,thespirit,diet,andsleepwereOK,theurineandurinewerenormal,andtherewasnosignificantchangeinpregnancyweight.Historyofpresentillness：既往史患者4年前诊断为焦虑症，自诉孕前曾规律服药阿普唑仑1片，后期症状稍缓解后自行停药，仅症状发作时用药，怀孕后自行停药。2年前发现血压高，未予特殊处理。青霉素类抗生素过敏。3病史汇报Thepatientwasdiagnosedwithanxietydisorder4yearsago,andreportedthathehadregularlytakenalprazolam1tabletbeforepregnancy,andstoppedthedrugafterthesymptomswereslightlyrelievedinthelaterstage.Highbloodpressurewasdetected2yearsagoandnospecialtreatmentwasgiven.Allergytopenicillinantibiotics.Anamnesis：02实验室检查Laboratorytests

实验室检查

实验室检查03病因与发病机制Etiologyandpathogenesis

病因与发病机制1免疫机制：胎盘的免疫屏障作用

Immunemechanism:Immunebarrierroleofplacenta23血管内皮细胞受损：血管进一步收缩导致高血压的形成。Vascularendothelialcelldamage:Furtherconstrictionofbloodvesselsleadstotheformationofhypertension.胎盘浅着床：胎盘浅着床时，滋养细胞入侵浅，少数动脉不能扩张，进而引起血压增高。Placentalshallowimplantation:Whenplacentalshallowimplantation,trophoblastinvasionshallow,afewarteriescannotdilate,resultinginincreasedbloodpressure.病因与发病机制4遗传因素：父亲有高血压病史

Geneticfactors:Fatherhadahistoryofhighbloodpressure5营养缺乏：孕期营养摄入不足

Nutritionaldeficiency:insufficientintakeofnutrientsduringpregnancy6胰岛素抵抗：胰岛素不能发挥正常功能

Insulinresistance:Insulindoesnotfunctionproperly04临床表现clinicalpicture.出现大量蛋白尿Proteinuriaisabundant血压升高蛋白尿中枢系统消化系统水肿临床表现收缩压大于或者等于140mmHg。舒张压大于或者等于90mmHg。Systolicbloodpressuregreaterthanorequalto140mmHg.Diastolicbloodpressuregreaterthanorequalto90mmHg.头晕，头痛，视力模糊Dizziness,headache,blurredvision.

恶心、呕吐、上腹部伴疼痛感。Nausea,vomiting,painintheupperabdomen.

双下肢凹陷性水肿Pittededemaofbothlowerlimbs05治疗treatment

治疗目的：控制病情，延长孕周，确保母儿安全

Treatmentobjective:tocontrolthedisease,prolongthegestationalperiodandensurethesafetyofmotherandchild原则：解痉、休息与镇静、密切监护母儿状况、酌情降压、有指针的利尿Principles:antispasmodic,restandsedation,closemonitoringofmotherandchildcondition,appropriatehypotension,diuresiswithPointers妊娠期高血压治疗要点（1）休息左侧卧位，间断吸氧；饮食充足蛋白质和热量（2）镇静（①地西泮②冬眠药物③苯巴比妥）（3）密切监护母儿状态Keypointsoftreatmentofhypertensioninpregnancy(1)Restintheleftlateralposition,intermittentoxygeninhalation;Adequatedietofproteinandcalories(2)sedation(①diazepam②hibernationdrug③phenobarbital)(3)Closemonitoringofmaternalandinfantstatus妊娠期高血压患者的药物治疗原则：Principlesofdrugtherapyforhypertensivepatientsduringpregnancy利尿药物diuretic镇静药物

sedative增加叶酸和甲钴胺的摄入Increaseintakeoffolicacidandmecobalamine口服小剂量阿司匹林Orallow-doseaspirin补充多种维生素Multivitaminsupplement阿司匹林：改善孕妇凝血功能和血栓前状态，抑制血小板凝集，防止血管内皮受损，还可增加钙的吸收，提高血清钙水平，有效预防妊娠期高血压疾病的发生。Aspirin:improvethecoagulationfunctionandpre-thromboticstateofpregnantwomen,inhibitplateletagglutination,preventvascularendothelialdamage,increasecalciumabsorption,improveserumcalciumlevel,andeffectivelypreventtheoccurrenceofhypertensivediseasesduringpregnancy.叶酸：降低血浆同型半胱氨酸的有效药物。Folicacid:Effectivedrugforloweringplasmahomocysteine.维生素：维生素A、维生素C和维生素E都具有抗氧化作用，能减少血管内皮细胞损伤，有效预防妊娠期高血压疾病的发生。维生素C还能促进钙、铁吸收，维生素D可促进肠道对钙的吸收。Vitamins:VitaminA,vitaminCandvitaminEallhaveantioxidanteffects,canreducethedamageofvascularendothelialcells,andeffectivelypreventtheoccurrenceofhypertensivediseasesduringpregnancy.VitaminCcanalsopromotecalcium,ironabsorption,vitaminDcanpromoteintestinalabsorptionofcalcium.镇静药物：硫酸镁可有效控制子痫，缓解孕妇精神紧张、焦虑症状，还可改善睡眠情况。Sedativedrugs:Magnesiumsulfatecaneffectivelycontroleclampsia,relievementaltension,anxietysymptomsofpregnantwomen,butalsoimprovesleep.利尿剂：不主张患者应用利尿剂，尽在身体出现严重水肿、心肾衰竭时，可酌情应用呋塞米等快速利尿剂。Diuretics:Donotadvocatetheuseofdiuretics,allinthebodyseriousedema,heartandkidneyfailure,canbeusedasappropriatefurosemideandotherrapiddiuretics.06妊娠高血压护理护理诊断1.体液过多2.有受伤的危险4.潜在并发症：胎盘早剥，肾功能衰竭，子痫等3.焦虑，恐惧与担心母儿安全有关;与下腔静脉受增大子宫压迫使血液回流受阻，蛋白丢失有关;与高血压引起的头晕，眼花，视物模糊等有关;与血压升高，病情进一步发展有关;1.ExcessivebodyfluidsItisrelatedtotheobstructionofbloodreturnandproteinlosscausedbytheincreaseduterinecompressionofinferiorvenacava.2.DangerofinjuryItisrelatedtodizziness,dizzinessandblurredvisioncausedbyhypertension.3.AnxietyandfearItisrelatedtoworryingaboutthesafetyofmotherandchild.4.Potentialcomplications:placentalabruption,renalfailure,eclampsia,etc.Itisrelatedtotheincreaseofbloodpressureandthefurtherdevelopmentofthedisease.护理措施1.体液过多：与下腔静脉受增大子宫压迫使血液回流受阻，蛋白丢失有关;①密切观察病情，评估水肿程度，记录24小时出入量；②指导产妇进食高蛋白，高维生素饮食；③遵医嘱补充蛋白，给予消肿及利尿药物；①Observetheconditionclosely,evaluatethedegreeofedema,andrecordthe24-hourinflowandoutflow.②Instructlying-inwomentoeatahighproteinandvitamindiet.③accordingtothedoctor'sadvicetosupplementprotein,givedetumescenceanddiureticdrugs.护理措施2.有受伤的危险：与高血压引起的头晕，眼花，视物模糊等有关;①严密监测生命体征；②保证充足的睡眠，加强安全防护；③解释可能发生意外的危险因素及预防措施；①Closelymonitorvitalsigns;②Ensureadequatesleepandstrengthensafetyprotection;③Explainthepossibleriskfactorsofaccidentsandpreventivemeasures;护理措施3.焦虑，恐惧：与担心母儿安全有关;①理解病人的感受，耐心倾听病人的述说，向其解释疾病相关知识；②对病人极其家属适当的安慰，治疗过程中告知病人适当信息，减轻疑虑，增强战胜疾病的信心；①Understandthepatient'sfeelings,patientlylistentothepatient'sstoryandexplainthedisease-relatedknowledgetoher;(2)giveappropriatecomforttothepatientandhisfamilymembers,informthepatientwithappropriateinformationduringthetreatment,reducedoubtsandenhanceconfidenceinovercomingthedisease;护理措施4.潜在并发症：胎盘早剥，肾功能衰竭，子痫等:与血压升高，病情进一步发展有关;①积极治疗原发病，遵医嘱正确使用解挛，降压，镇静，利尿药物；②保证环境安静，空气流通，减少刺激；③定期产前检查，定期检测尿蛋白变化；①Activelytreattheprimarydisease,andcorrectlyuseanti-clonic,antihypertensive,sedativeanddiureticdrugsaccordingtothedoctor'sadvice;②ensurethequietenvironment,aircirculation,reducestimulation;③Regularprenatalexamination,regulardetectionofurineproteinchanges;胎盘早剥子痫肾衰竭护理评价通过治疗和护理，病人是否达到：①患者水肿减轻；②患者血压得到控制，未出现头晕等症状；③产妇诉生理及心理上舒适感增加；④产妇以了解疾病相关知识及注意事项。Throughtreatmentandnursing,doesthepatientachieve:①theedemaofthepatientisrelieved;②Thepatient'sbloodpressurewascontrolledwithoutdizzinessandothersymptoms;③Theparturientcomplainedofincreasedphysicalandpsychologicalcomfort;(4)pregnantwomentounderstandthediseaserelatedknowledgeandmattersneedingattention.07健康教育healtheducationⅠ.保持乐观愉快的情绪。长期出现精神紧张、焦虑、烦燥、悲观等情绪，会使大脑皮质兴奋和抑制过程的平衡失调，所以需要保持愉快的心情。Ⅰ.

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