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患儿,女,2岁,因晨起不能行走入院。入院前1天开始流清涕、低热,走路不稳,余无异常。既往身体健康。社区医院查体:T37℃,P150/min、R24/min、BP8.26/4.13kPa,嗜睡。瞳孔等大、同圆、对光反射正常,鼻流清涕,咽部未见异常。颈无力。皮肤温暖、干燥、色正常。淋巴结不肿大。心、肺、腹无异常。四肢肌力、肌张力无异常。双侧深腱反射减弱。扶持可站立,但不能走。双手试图持物时,出现痉挛。四肢运动功能丧失。实验室检查:血常规、血沉、血生化、尿常规、尿细菌学和毒理学检查无异常。X线胸片和头颅CT正常。 医疗中心进行神经系统和腰穿检查无异常。次日第2个小儿神经内科医生查体时发现在小儿耳后发际头皮上附一吸满血的森林壁虱。去除壁虱,24h后病人完全康复,次日出院,住院期间未用药物及其他支持疗法。 护理诊断 (1)高危损伤(由进行性麻痹引起,
Children, women, 2 years old, due to early morning can not walk to hospital. One day before hospitalization, runny nose, low fever, walking instability, no abnormalities. In the past, good health. Community Hospital examination: T37 ℃, P150 / min, R24 / min, BP8.26 / 4.13kPa, lethargy. Pupil and other large, with the circle, normal light reflex, nasal flow clear tears, throat no abnormalities. Neck weakness. The skin is warm, dry, normal color. Lymph nodes are not swollen. Heart, lung, abdomen without exception. Limb muscle strength, muscle tone without exception. Weak bilateral tendon reflex. Support can stand, but can not go. Spasms appear when trying to hold your hands. Extremities loss of motor function. Laboratory tests: blood, ESR, blood biochemistry, urine, urine bacteriological and toxicological examination no abnormalities. X-ray and skull CT normal. Medical center for nervous system and waist wear no abnormalities. The next day the second pediatric neurologist examination found in the pediatric hair on the back of the scalp attached to a full of blood filled forest ticks. The ticks were removed, the patient recovered fully after 24 hours, discharged the next day, and no medication and other supportive therapies were taken during hospitalization. Nursing diagnosis (1) high-risk injury (caused by progressive paralysis,