妊娠高血压个案护理范文

妊娠高血压个案护理范文
英文回答：
Nursing Care Plan for Preeclampsia.
Assessment:
History: Assess for risk factors (e.g., nulliparity, pre-existing hypertension, obesity, multiple gestation), symptoms (e.g., headache, visual disturbances, epigastric pain, nausea/vomiting), and past medical history.
Physical Exam: Monitor blood pressure (BP), assess for proteinuria, edema, and fetal growth.
Laboratory Studies: Perform renal function tests (creatinine, BUN), liver function tests (AST, ALT),
platelet count, and coagulation studies.
Nursing Diagnosis:
Risk for hypertensive crisis.
Impaired physical mobility related to edema.
Risk for impaired fetal growth.
Risk for placental abruption.
Risk for HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets)。

Interventions:
Hypertension Management: Monitor BP every 15-30 minutes; administer antihypertensive medications as prescribed; rest in bed with head elevated.
Fluid Restriction: Limit fluid intake to 1,500-2,000 mL/day.
Protein Intake Maintenance: Encourage adequate protein
intake (80-100 g/day) to reduce edema.
Fetal Monitoring: Monitor fetal heart rate and movement regularly; perform biophysical profiles or non-stress tests as indicated.
Prevention of Placental Abruption: Avoid trauma to the abdomen and sudden movements.
HELLP Syndrome Management: Monitor for signs and symptoms (e.g., nausea/vomiting, jaundice, abdominal pain); administer blood transfusions and coagulation factors as needed.
Evaluation:
Hypertension Management: BP remains within normal range (120/80 mmHg).
Fluid Restriction: Edema is reduced or absent; fluid intake is within limits.
Fetal Monitoring: Fetal well-being is maintained; no signs of fetal growth restriction or distress.
Placental Abruption: No abdominal trauma or sudden movements occur; placenta remains intact.
HELLP Syndrome Management: Signs and symptoms are absent or controlled; blood transfusions and coagulation factors are administered as needed.
中文回答：
妊娠高血压个案护理计划。

评估：
病史，评估危险因素（如初产妇、已有高血压病史、肥胖、多胎妊娠）、症状（如头痛、视力障碍、上腹部疼痛、恶心/呕吐）和既往病史。

体格检查，监测血压（BP）、评估蛋白尿、水肿和胎儿生长情况。

实验室检查，进行肾功能检查（肌酐、BUN）、肝功能检查（AST、ALT）、血小板计数和凝血检查。

护理诊断：
高血压危象风险。

与水肿相关的活动能力受损。

胎儿生长受损风险。

胎盘早剥风险。

HELLP 综合征（溶血、肝酶升高和血小板减少）风险。

干预措施：
高血压管理，每 15-30 分钟监测血压；按医嘱服用降压药；卧床休息，头部垫高。

限制液体摄入，限制液体摄入量至 1500-2000 毫升/天。

维持蛋白质摄入，鼓励摄入足够的蛋白质（80-100 克/天）以减少水肿。

胎儿监测，定期监测胎心率和胎动；根据需要进行生物物理特征评估或无应激试验。

预防胎盘早剥，避免腹部外伤和突然动作。

HELLP 综合征管理，监测体征和症状（如恶心/呕吐、黄疸、腹痛）；根据需要进行输血和凝血因子治疗。

评估：
高血压管理，血压保持在正常范围（120/80 mmHg）。

限制液体摄入，水肿减少或消失；液体摄入量在限制范围内。

胎儿监测，胎儿健康状况良好；无胎儿生长受限或窘迫迹象。

胎盘早剥，无腹部外伤或突然动作发生；胎盘保持完整。

HELLP 综合征管理，体征和症状不存在或得到控制；根据需要进行输血和凝血因子治疗。