儿科 护理 查房

儿科 护理 查房 迟发性维生素K1缺乏致颅内出血的护理 一、概 述 迟发性维生素K缺乏性出血是严重危害我国小儿健康的营养性疾病，是当前我国婴儿死亡和致残的主要原因之一 。迟发性维生素K缺乏症指出生2周,1岁因缺乏维生素K而引起的出血性疾病，以1,3个月母乳喂养儿多见，因母乳中维生素K含量低，使凝血因子?、?、?、?合成障碍。正常时颅内容物与颅腔之间存在着精细平衡，以保持颅内压稳定，3个月内小儿脑发育迅速，其血管周围组织改变较快，此即为维生素K缺乏症并颅内出血发生的生理解剖学基础。 二、病因和影响因素 1 新生儿肝脏对凝血酶原的合成尚未成熟，凝血因子在新生儿期仅为正常人的30%—60% 2 由于维生素K经过胎盘的通透性差，母体内的维生素很少进入胎儿体内。婴儿(尤其是早产儿，小于胎龄儿)肝内维生素储存量低。 3 母乳维生素的质量浓度低，仅为1-15ug/L(牛乳为60ug/L) 4 新生儿肠道菌群尚未充分建立，致使维生素合成不足。 5 出生前孕母接受抗癫痫药、抗凝剂、抗结核药等。 6 婴儿肝胆系统疾病或代谢性疾病。 7 胃肠道感染 8 长期使用抗生素，特别是头孢菌素类。 三、分 类 国际出血与血栓协会儿科委员会定义维生素K1缺乏性出血是指由于vitK1缺乏导致维生素依赖，凝血因子活性低下，并能被维生素K所纠正的出血。根据发病年龄段不同分3型 (1)早发型在出生后24小时内发病 (2)经典型在出生后1—7天发病 integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, (3)迟发型在出生8天以后发病。早发型较罕见，经典型预后好，迟发型以突发性颅内出血为主要临床表现，颅内出血发生率为92%病死率22%该病致残率较高。 四、临床表现 一般情况: 发病的男女比率为2.62:1 ，发病高峰年龄4-8周，农村多于城市，母乳喂养儿常合并感染。 神经系统表现: 突发起病，进行性面色苍白，发热或体温不升，四肢冷，呕吐，烦躁不安或尖叫，意识障碍乃至昏迷，呼吸不规则，抽搐，前囟饱满或颅蜂裂开，严重者瞳孔不等大，对光反射减弱或消失，患儿可出现脑疝表现。部分伴有黄疸，眼底检查可见视乳头水肿或动脉痉挛，视网膜出血。 其他部位出血: 消化道，皮肤或注射，损伤部位出血不止。 诊断主要依据:3个月母乳喂养儿，突发严重贫血且有颅内压增高症状及体征，如伴有针眼出血不止、PT延长、出血时间正常，血小板正常，头颅CT检查证实有颅内出血者均可确诊。 五、护理诊断、护理措施 P1 脑疝—— 与颅内出血有关 1 置患儿头背部抬高30?仰卧位，头偏向一侧 2 保持患儿安静，治疗操作集中进行，减少搬动和刺激 3 遵医嘱使用镇静剂 4 遵医嘱使用脱水降颅内压的药物 5 予止血剂维生素K1使用 6 吸氧1升,分 7 观察神志心率呼吸瞳孔的变化 P2 清理呼吸道无效——与昏迷有关 1 抬高头肩部，头偏向一侧 2保持呼吸道通畅，备吸痰器在床旁 integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, 3 必要时禁食禁水 P3 有抽搐的可能——与颅内出血有关 1 保持患儿安静，治疗护理集中进行 2 遵医嘱使用镇静剂 3 脱水剂使用并且要防止液体外渗 P4 营养失调 低于机体需要量——与禁食有关 1 准确记录24小时出入量 2 遵医嘱予鼻饲牛奶q3h 3 根据医嘱给予静脉补液及静脉营养应用 P5 有皮肤粘膜完整性受损的危险——与昏迷有关 1 保持床铺清洁平整干燥 2 定时改变体位 3 便后及时更换尿布，清洁臀部 4 保持输液通畅，使用脱水剂时要防止液体外渗 P6 体温调节失常——与颅内积血有关 1 解包散热，降温贴头部外敷 2 病情许可时多喂水 3 必要时予退热剂应用 4 观察体温的变化，测体温q4h P7 家长焦虑——与患儿病情危重及担心预后有关 1 向家长介绍相关疾病的知识及转归并介绍同类病例的预后情况 2 介绍主管医生护士和病区环境及规章 制度 关于办公室下班关闭电源制度矿山事故隐患举报和奖励制度制度下载人事管理制度doc盘点制度下载 integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, 3 与家长多交流，鼓励家长说出内心感受及困惑，并做解答 4 指导家长早期康复训练 补充资料 今年7月21日因“右侧肢体活动偏少”来我院，门诊拟“脑出血后遗症”收住小儿神经科行康复治疗。入院时，四肢屈肌张力高，右侧重，双上肢主动运动少，中线运动不能，俯卧位抬头不能，肘支撑不能，屈髋屈膝位，内收肌紧张，双眼可追视物体180?，听力可。拥抱反射(+)，ATNR(非对称性紧张性颈反射)(-)，侧弯反射(+)双踝阵挛(+)，滴水症(+)。入院后予营养脑细胞药物及康复训练，现患儿四肢肌张力明显下降，头控制能力可，手支撑较充分，可自主翻身，欠灵活，坐位全前倾。右侧肢体主动运动明显增多，对外界刺激反应较前灵敏 补充诊断 P8 躯体功能障碍—— 与颅内出血有关 1 遵医嘱给予康复训练，被动运动，降低四肢肌张力。 2 加强头控制能力，肘支撑能力和翻身训练。 3 训练中控制训练强度，并注意观察患儿，以防呕吐，窒息，骨折的发生。 4 指导家长家庭康复训练方法，并积极配合。 P9智力言语摄食吞咽障碍的可能—— 与颅内出血有关 1 遵医嘱给予营养脑细胞药物应用 2 教会家长给患儿做舌操，促进舌的协调性及灵活性 3 督促家长多与患儿交流，多予患儿视听觉刺激，以促进其智力及语言发育 六、维生素K1缺乏为什么多发生于母乳喂养儿 一是孕期母体供给维生素K不足;二是新生婴儿的肠道在出生几天之内是处于无菌状态，故不能由微生物合成维生素K;三是初生儿血浆中的凝血酶原水平很低，在正常条件下，出生数周以后才升高到成人的水平。因此，对于胎儿或新生儿来说，母亲的维生素K营养水平直接与孩子的维生素K水平有关。但是，母乳中维生素K的含量低，仅为1-15ug/L(牛乳为60ug/L) ，因而新生婴儿在出生头几天，维生素K营养水平不足。 在农村地区，由于风俗习惯的影响，产后妇女不允许吃蔬菜，使乳母维生素K的供给不足，因而在这些地区更易发生维生素K缺乏。 七、婴儿颅内出血时怎样观察病情, integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, 成人在颅内压增高时常表现头痛呕吐症状，小儿由于颅骨及囟门尚未闭合，颅内压力能得到缓冲。故此头痛呕吐症状常不如成人显著。这就要求我们在观察病情时更为细心。早期为兴奋症状，如烦躁、脑性尖叫、惊厥等。随着病情发展，则出现抑制状态，如精神及反应差、嗜睡、昏迷、肌张力低下、拥抱反射减弱或消失等。严重者有面色苍白、青紫，前囟饱满或隆起，双眼凝视，双瞳孔大小不等或固定，对光反射消失，呼吸不规则或暂停等表现。 八、颅内出血患儿康复训练的最佳时间 颅内出血患儿急性期后即可进行康复训练。早期康复训练，可激活有残存功能的神经细胞。死亡的神经细胞虽然不能再生，但脑的可塑性可再构成，即神经元与神经元之间可通过轴突和树突建立新的联络，恢复兴奋传递，发挥代偿作用，并且干预越早，再构成代偿能力越强，预后就会越好。 九、 总结 初级经济法重点总结下载党员个人总结TXt高中句型全总结.doc高中句型全总结.doc理论力学知识点总结pdf 由于母乳中维生素K含量(<15ug/L)比牛乳中低(60 ug/L)，且主要存在于绿叶蔬菜、蛋黄、鱼类等辅食中的维生素K，此年龄往往极少食用，另外母乳喂养儿肠道内的主要细菌为乳酸杆菌，该菌不能合成维生素K，故内源性维生素K也不足。维生素K缺乏时，维生素K依赖因子活性降低导致出血。目前对母乳喂养是本病发生的主要原因看法颇为一致。发病前服用抗生素，长期消化功能紊乱，也影响维生素K的合成和吸收，故维生素K的缺乏，系由维生素K的摄取、吸收、生成、利用等复杂的综合因素所引起。治疗上应立即补充维生素K1，同时尽早输血。此外，还应行给氧、降颅压等对症处理 integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed, integrated energy, chemicals and textile Yibin city, are the three core pillars of the industry. In 2014, the wuliangye brand value to 73.58 billion yuan, the city's liquor industry slip to stabilise. Promoting deep development of integrated energy, advanced equipment manufacturing industry, changning district, shale gas production capacity reached 277 million cubic metres, built the country's first independent high-yield wells and pipelines in the first section, the lead in factory production and supply to the population. 2.1-3 GDP growth figure 2.1-4 Yibin, Yibin city, Yibin city, fiscal revenue growth 2.1.4 topography terrain overall is Southwest, North-Eastern State. Low mountains and hills in the city landscape as the main ridge-and-Valley, pingba small fragmented nature picture for "water and the second land of the seven hills". 236 meters to 2000 meters above sea level in the city, low mountain, 46.6% hills 45.3%, pingba only 8.1%. 2.1.5 development of Yibin landscapes and distinctive feature in the center of the city, with limitations, and spatial structure of typical zonal group, 2012-cities in building with an area of about 76.2km2. From city-building situation, "old town-the South Bank" Center construction is lagging behind, disintegration of the old city is slow, optimization and upgrading, quality public service resources are still heavily concentrated in the old town together. Southbank Centre has not been formed, functions of the service area space is missing. Meanwhile, peripheral group centres service was weak and inadequate accounting for city development, "suspicious" pattern could not be formed. As regards transport, with the outward expansion of cities, cities have been expanding, centripetal city traffic organization has not changed,