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高危妊娠管理_2课件

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高危妊娠管理
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单击此处编辑母版标题样式 **1 高危妊娠管理 Nursing in High Risk Pregnancy 上海交通大学护理学院上海交通大学护理学院 黄文莉黄文莉 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 教学目标 Learning objectives 识记 写出下列定义 高危妊娠、NST、CST and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 教学目标 Learning objectives 理解 讲明高危妊娠的主要监护措施 识别胎心率监护的主要结果 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 内容 Content • 高危妊娠定义 • 高危妊娠监护方法 • 高危妊娠的处理原则 • 高危妊娠的护理 –护理评估和护理措施为重点 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 教学目标 Learning objectives 应用 运用护理程序护理高危妊娠的母儿 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 定义 Definition 高危妊娠是妊娠期有某种并发症或 致病因素可能危害孕妇、胎儿与新 生儿或导致难产者 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 范 畴 Category 个人、社会经济因素 –经济来源 –居住条件 –婚姻/营养/年龄/体重/身高 –教育、遗传因素 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 范 畴 Category 疾病因素 1、产科病史 2、各种妊娠合并症 3、目前产科情况 4、不良习惯:吸烟、饮酒 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 监护措施 Monitor Measures •人工监护 •妊娠图 •仪器监护 •实验室检查 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 人工监护 Artifical Monitor • 确定孕龄 • 测量宫高/腹围 • 高危妊娠评分 • 胎动记数 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 仪器监护 Instrument Monitor • B超 • 胎心听诊 • 胎儿心电图监测、 • 羊膜镜检查 • 电子胎心监护(内/外监护) and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 实验室检查 Experimental Examination •雌三醇:检查胎盘功能 •孕妇血清胎盘泌乳素:查胎盘功能 •孕妇血清催产素酶值:查胎盘功能 •阴道脱落细胞检查:查胎盘功能 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 实验室检查 Experimental examination •羊水分析:检查胎儿成熟度 •胎儿头皮血 PH:检查胎儿缺氧情况 •甲胎蛋白:检查胎儿有无开放性神经管 畸形 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 高危妊娠妇女的护理 Nursing in High Risk Pregnancy Women • 处理原则 • 护理评估 • 护理诊断 • 护理目标 • 护理措施 • 护理评价 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 处理原则 Treatment Principle 一般处理 • 增加营养 • 卧床休息 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 产科处理 • 产前:吸氧、提高胎儿对缺氧耐受力 ; 预防早产;选择合适的方式,及时 终止妊娠;防止发生新生儿呼吸窘迫 综合征 • 产时:严密监测;缩短第二产程;尽 量少用麻醉镇静药物 • 产后:加强监护 处理原则处理原则 Treatment PrincipleTreatment Principle and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 处理原则 Treatment Principle 病因处理 • 积极消除引起高危妊娠的因素 • 治疗妊娠合并症,病情严重者应及时终 止积极妊娠 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 护理评估 Nursing Assessment • 病史 • 生理状况 • 辅助检查 • 心理社会评估 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 病史 Medical History • 了解年龄 • 生育史 • 疾病史 • 有无病毒感染史,毒物接触史 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 生理评估 Physiological Assessment 症状:了解有无并发症的相应症状 体征: ①了解身高、步态、体重; ②测量宫底高度; ③了解胎位有无异常; ④测血压、评估心脏杂音及心功能; ⑤估计孕龄,描绘妊娠图; ⑥测胎心、胎动 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 胎儿成熟度检查 Fetal Maturity Examination • 胎儿头皮血PH –7.25-7.35正常, –7.20-7.24 轻度酸中毒 –2 肺成熟 • 肌酐176.8umol/L 肾成熟 • 胆红素类物质450U/L 唾液腺成熟 • 脂肪细胞出现率达20% 皮肤成熟 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 电子胎心监护 Electronic Fetal Heart Monitor • 采用超声多谱勒原理 • 通过电子监护仪描绘胎心率的变化 • 了解宫内胎儿中枢神经系统的机能状态 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 电子胎心监护 Electronic Fetal Heart Monitor • 方法: • 将超声传感器,宫缩传感器分别置于母 体腹壁外侧胎心音最响亮处及宫底下两 横指处 • 观察胎心率与胎动或宫缩之间的关系并 描绘其图形 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 电子胎心监护 Electronic Fetal Heart Monitor • 胎心率监测 –基线胎心率 –周期性胎心率 –无变化 –加速:15-20次/分 –减速:早期减速/变异减速/晚期减 速 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 电子胎心监护 Electronic Fetal Heart Monitor • 在无胎动、无宫缩间歇记录FHR • 评估胎心率基线 –每分钟心搏次数 –胎心FHR变异 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 电子胎心监护 Electronic Fetal Heart Monitor • 心动过速 • 心动过缓 • 基线摆动 –胎儿有一定的储备能力 • FHR基线变平(变异消失或静止型) –胎儿储备能力丧失 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies • 加 速(acceleration)-胎儿良好的表现 • 减 速(deceleration)分三种 –早期减速(early deceleration,FD) –宫缩时胎头受压 –变异减速(variable deceleration,VD) –脐带受压兴奋迷走神经 –晚期减速(late deceleration,LD) –胎儿缺氧的表现 胎心率变化胎心率变化 Variation of FHRVariation of FHR and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 早期减速 Early Deceleration,ED 宫缩时 胎头受压 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 晚期减速 Late Deceleration, LD 胎儿缺 氧表现 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 变异减速 Variable Deceleration, VD 脐带受 压兴奋 迷走神 经 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 开始时间时间持续时间续时间减速幅度原因 早期 减速 与宫缩同时 开始 宫缩后恢 复正常 50次/分 胎头受压,脑 血流量减少 变变异 减速 不定不定70次/分 脐带受压,迷 走神经兴奋 晚期 减速 宫缩开始后 一段时间 长50次/分 子宫胎盘功能 不良,胎儿缺 氧 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies NST (无负荷试验) 观察无宫缩时胎动与胎心率变化间关系 了解胎儿健康活动力情况。要求: (1)环境安静,孕妇取半卧位或侧卧位 (2)受试前12h一般不用镇静剂 (3)一般20min一次,无胎动则刺激胎儿 后再延长20min 胎心监护 Fetal Heart MonitorFetal Heart Monitor and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 无负荷/应激试验 Non-stress test, NST • 有反应 20min内至少3次胎动 + FHR加速15次/分 • 无反应 少于3次或FHR加速不足15次/分 应延长至40min • 仍无反应 胎儿胎盘储备功能差,应行催 产素激惹试验 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 无负荷/应激试验 Non-stress Test, NST • 反应型 胎儿宫内活动力健康良好,试 验后的一周内胎儿安全 • 可疑型 可以观察,如无胎心率改变, 第二天再监测一次NST • 无反应型 一般多表示胎儿在宫内有一 定损害,需行OCT试验,可以在24h内重 复试验 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 宫缩张力试验 Contraction Stress Test, CST • 阴 性: FHR无晚减,胎动后FHR • 阳 性: 连续出现3次以上晚减,胎动后 FHR不变,表明胎盘功能减退,胎儿宫内 窘迫 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 催产素激惹试验 Oxytocin Challenge Test, OCT • 观察10min无宫缩后,静滴催产素 • 自8滴/分开始渐,调至有效宫缩3次 /10min后监护 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 胎盘功能检査 Placental Function Examination • 间接判断胎儿状态 • 胎动 12h 10次 • 孕妇尿中E3值 >15mg/24h尿-正常值, 10~15mg/24h尿为警戒值, <10mg/24h尿-危险值 • 孕妇血清游离E3值 40nmol/L • 孕妇血清胎盘生乳素(HPL)值:411mg/L and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 辅助检查 Assistant Examinations • 实验室检查 • B超检查 • 电子胎心监护 • 羊膜镜检查等 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 心理社会评估 Psychosocial Assessment • 高危孕妇的应对机制 • 心理承受能力 –妊娠的早期--担心流产及胎儿畸形 –妊娠28周后--担心早产、医疗指征需 要终止妊娠及胎死宫内或死产 • 社会支持系统 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 心理社会评估 Psychosocial Assessment • 孕妇前次妊娠失败--对此次妊娠产生恐惧 • 由于需要休息停止工作--烦躁不安 • 自己的健康与维持妊娠相矛盾--焦急、无 助感 • 不可避免的流产、死产、死胎、胎儿畸形 等--悲哀和失落 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 护理诊断 Nursing Diagnosis 恐惧 与现实或设想的对胎儿及自身健康的威胁 有关 自尊紊乱 与分娩的愿望及对孩子的期望得不到满足 有关 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 护理目标 Nursing Objectives • 孕妇安全、胎儿健康 • 孕妇恐惧感减轻或消失 • 孕妇维持良好的自尊 • 孕妇正确面对自己及孩子的危险 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 护理措施 Nursing Implementation • 心理护理 • 一般护理 • 健康护理 • 病情观察 • 检查及治疗配合 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 护理措施 Nursing Measures • 一般护理:环境,个人卫生,营养,卧 床休息 • 病情观察:孕期;产时 • 检查及治疗配合 • 健康指导 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 护理措施 Nursing Measures • 左侧卧位,吸氧,监测FHR • 宫口开全、胎先露已达坐骨棘平面以下 3厘米,行阴道助产 • 术前准备 • 新生儿抢救准备 • 心理护理 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 小结 Summary • 高危妊娠定义 • 高危妊娠监护方法 • 高危妊娠的处理原则 • 高危妊娠的护理 –护理评估和护理措施为重点 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 预习内容 Preview Contents 第七章 妊娠期并发症妇女的护理 一、高危妊娠定义 二、高危妊娠的处理原则 三、高危妊娠的护理 重点:高危妊娠的护理评估和护理措施 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 复习思考题 Exercises 1、当前检查胎盘功能最常用的方法是: A 测孕妇尿中二醇值 B 测孕妇尿中雌三醇值 C 测孕妇血中胎盘生乳素值 D 羊水雌三醇测定 E 测孕妇尿中绒毛膜促性腺激素值 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 复习思考题 Exercises 2、羊水成分属于胎儿肺成熟度指标是: A 肌酐 B 雌三醇 C 碱性磷酸酶 D 卵磷脂/鞘磷脂比值 E 胆红素 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 3、初孕妇,孕36周检查,胎头较小, 怀疑无脑儿,对确诊最有价值的检查是 A 羊水染色体检查 B 测定雌三醇 C B超 D A超 E 监测胎心音 复习思考题复习思考题 ExercisesExercises and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 复习思考题 Exercises 4、一孕妇妊娠超过42周,拟终止妊娠, 而孕妇及家属担心引产对胎儿不利, 相信“瓜熟蒂落”,你不应该采取的措施: A 同意孕妇及家属的意见 B 讲解终止妊娠的方法 C 解释过期妊娠对胎儿危害 D 检查胎盘功能 E 监测胎心音 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 复习思考题 Exercises 请简述: 1、常见的胎儿监护方法 2、电子胎心监护中三种减速的特点及 其原因 and Hyperthermia Associated with Poisoning or and Neonatal Respiratory Care Embryologic Development Births Obstetric Emergencies 单击此处编辑母版标题样式 **56 Pp4KyngV0Zms9qM5Xu#YTOPA&$16mDpIlEIq17vS(IGo&MH1$7Q2j$YLhjqd#d$xPZtkxlLkHPQQf3%v4Bgztst9YAdzZvUOfnFayn+VgI(+!%76&-VU4TCaWSZ&6og7&P+3Y*utc1JTU-RimI5+l7ipeyNhJw*3Ioml70e$adoZgdmNoutKGUVp&P)COkT5Sw0E&B136U2VixVx#&R2ZaR$b+Z05lhvSM#GgFSY+CrJaOc-py!PIU*C!Q2Us(STm5Qtjy2t5P!42BJ3!2s%He!XDZIyU(bHFBXjpPigugf7hb9Y*yIhduj-+sHcvfPFzFlpTdL+75kJYlFDa*#s+(pQyXSV5jb+xdRQ&hHUyvBnnSrN3RXbLMo8j*Y8r1&&y8+CR-Iwy-oJcXzxOCw5bMg- 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