護理英語交班ppt課件

1、1;.2General conditionsGood morning, every one, March 21.2009 We are passing nursing report now.There are total 36 patients in the ward, including 3 patients discharged, 2 admitted ,2 transferred in ,2 transferred out ,1 died yesterday.各位各位,早晨好早晨好2009年年3月月21日護理交班日護理交班病人總數(shù)病人總數(shù):36 出院病人數(shù)出院病人數(shù):3 入院病人數(shù)入院病

2、人數(shù):5轉(zhuǎn)入病人數(shù)轉(zhuǎn)入病人數(shù):2 轉(zhuǎn)出病人數(shù)轉(zhuǎn)出病人數(shù):2 死亡病人數(shù)死亡病人數(shù):133 patients were performed operation.The number of DIL case:1the number of patient on grade one nursing care :10手術(shù)病人數(shù)手術(shù)病人數(shù):3 病危病人總數(shù)病危病人總數(shù):1 病重病人總數(shù)病重病人總數(shù):2一級護理病人總數(shù)一級護理病人總數(shù):104Discharged caseBed 3,Wang Hong, coronary heart disease（CHD）, angina pectoris, was di

3、scharged at 9 oclock yesterday after treatment.3床床, 王紅王紅,冠心病、心絞痛于冠心病、心絞痛于9：00出院出院 5Death caseBed 29, Zhao Liang, pulmonary infection, two type of respiratory failure, multiple organ failure , was died (passed on) at 10:00 yesterday after resuscitation failure.29床床, 趙良趙良,肺部感染肺部感染,二型呼衰二型呼衰,多功能臟器衰竭多功能臟

4、器衰竭,經(jīng)搶救無效經(jīng)搶救無效于于10：00死亡死亡6New admissionBed 18,Wei Haiming,male,47 years old, was admitted at 10:00 oclock with complaining of a 15 days intermittent chest pain and palpitation. The diagnosis was uncertain chest pain, dysrhythmias, paroxysmal atrial fibrillation, bradycardia, hypertension on grade 3.

5、 18床床 魏海明魏海明 胸痛原因待查胸痛原因待查,心律失常、陣發(fā)性房顫、竇性心律失常、陣發(fā)性房顫、竇性心動過緩、高血病心動過緩、高血病3級級患者，男性患者，男性47歲，地方人員，于歲，地方人員，于10：00入院。主因為發(fā)作性入院。主因為發(fā)作性胸痛伴心慌胸痛伴心慌15天，為進(jìn)一步治療入院。天，為進(jìn)一步治療入院。7After admission, the doctor Li Xuehua was notified immediately and the admission interview was done. ECG at bedside showed sinus rhythm. BP was

6、 130/88mmHg.The low salt and low fat diet was served. Dilated coronary artery, anticoagulation and anti-hypertension drugs were taken and grade 2 nursing care was given as doctors orders.入院后立即通知李學(xué)華醫(yī)生入院后立即通知李學(xué)華醫(yī)生,入院介紹已做入院介紹已做.患者未訴胸痛、心患者未訴胸痛、心慌，血壓慌，血壓130/88mmHg.行床旁心電圖示竇性心律行床旁心電圖示竇性心律.遵醫(yī)囑給予遵醫(yī)囑給予二級護理，低鹽

7、低脂普食，擴冠、抗凝、降壓等藥物治療。二級護理，低鹽低脂普食，擴冠、抗凝、降壓等藥物治療。8The patient slept well Last night and blood specimen were taken.The vital signs were normal in the morning.病人睡眠好，晨起血標(biāo)本已留，生命體征平穩(wěn)病人睡眠好，晨起血標(biāo)本已留，生命體征平穩(wěn).9DIL caseBed 10，Wang Hua, coronary Heart disease, angina pectoris, acute extensive anterior myocardial inf

8、arction. The patient suddenly complained of chest pain at 22:30Oxygen was given immediately and the flow rate was 3L/min.ECG monitoring was started and showed sinus rhythm.10床床,王華，冠心病，心絞痛，急性廣泛前壁心肌梗死王華，冠心病，心絞痛，急性廣泛前壁心肌梗死. 昨天昨天22：30病人主訴心前區(qū)疼痛，立即給予吸氧病人主訴心前區(qū)疼痛，立即給予吸氧3升升/分，心電監(jiān)分，心電監(jiān)護儀監(jiān)護，心電示波示竇性心律，護儀監(jiān)護，心電示波

9、示竇性心律，10The heart rate was 63 beats/min. BP was 115/64mmHg. Meanwhile Dr.Zhang Xue was informed.After taking 3 tablets of nitroglycerin sublingually at 5 minute intervals as indicated, the pain was persistent. The ECG showed the 0.2-0.6 mv of elevated V1-V5 St segment. Dr. Zhao Yong saw the patient.

10、心率心率63次次/分，血壓分，血壓115/64mmHg,通知張學(xué)醫(yī)生看病人，遵通知張學(xué)醫(yī)生看病人，遵醫(yī)囑給予硝酸甘油醫(yī)囑給予硝酸甘油mg舌下含服，癥狀無緩解，行床旁心電圖檢舌下含服，癥狀無緩解，行床旁心電圖檢查示查示V1-V5ST段抬高段抬高0.2-0.6mv.二線趙勇副主任醫(yī)師到場看二線趙勇副主任醫(yī)師到場看病人。病人。11Heparin 100mg in normal saline 500ml and Dopamine 80mg in normal saline 500ml were give by IV infusion. The drop rate were 500u/h and 1.4

11、6ug/kg/min respectively. The patient was on DIL.遵醫(yī)囑給予靜脈輸入生理鹽水遵醫(yī)囑給予靜脈輸入生理鹽水500ml+肝素鈉注射液肝素鈉注射液100mg，滴速為滴速為500u/h,生理鹽水生理鹽水250ml多巴胺注射液多巴胺注射液80mg，滴速，滴速1.46ug/kg/min，報病危。，報病危。12Iv infusion were kept patent. The patient slept intermittently in the evening. The ECG showed sinus rhythm. The heat rate was at

12、range of 63-74 beats/min and BP was 91-115/53-64mmHg. The patient was turned every 2 hours and now is on supine (prone, lateral, Fowlers, semi-Fowlers) position.夜班輸液通暢，患者間斷睡眠，心電監(jiān)護儀顯示竇性心律，心夜班輸液通暢，患者間斷睡眠，心電監(jiān)護儀顯示竇性心律，心率波動在率波動在63-74次次/分，血壓波動在分，血壓波動在91-115/53-64mmHg.每每2小時翻身一次小時翻身一次,現(xiàn)病人平臥位現(xiàn)病人平臥位(伏臥位、側(cè)位、半臥

13、位、較低伏臥位、側(cè)位、半臥位、較低半臥位）。半臥位）。13The skin was integrity. The total input was 400ml and the output was 300ml.皮膚無破損，全天入量皮膚無破損，全天入量400ml，尿量，尿量300ml.14Operation caseBed 11,Duan Rong, colon cancer. Ater being performed the colectomy with general anesthesia ,the patient was conscious when he came to the ward

14、at 15:30. The dressing kept integrity and the outer dressing layer hadt been wet or soiled. The Abdominal drainage tube was secured well and drained 50ml bloody exudates. 11床床,段榮段榮,直腸癌直腸癌,今日在全麻下直腸癌切除術(shù)今日在全麻下直腸癌切除術(shù),術(shù)后于術(shù)后于15:30返回病房返回病房,清醒清醒,血壓血壓154/96mmHg,切口敷料包扎好切口敷料包扎好,外層敷料外層敷料未見明顯滲出未見明顯滲出. 腹腔引流管固定通暢，

15、引流液為血性。腹腔引流管固定通暢，引流液為血性。15The nasogastric tube was attached to low suction for decompression and drained 100ml of dark -green color of exudates.The catheterization was maintained patent and its drained 1200ml of clear urine.持續(xù)胃腸減壓通暢，引流墨綠色液體持續(xù)胃腸減壓通暢，引流墨綠色液體100ml. 尿管通暢，尿色尿管通暢，尿色清亮，皮膚好。清亮，皮膚好。16The cen

16、tral venous catheter was kept patent and there were no redness and swelling in the skin. The saturation of oxygen was continuously monitored by pulse oximetry and the values were 95% to 99%.The grade 1 nursing care and fasting food were given as doctors orders.中心靜脈輸液通暢，穿刺部位無紅、腫中心靜脈輸液通暢，穿刺部位無紅、腫.持續(xù)血氧

17、飽和度監(jiān)測，持續(xù)血氧飽和度監(jiān)測，SPO2維持在維持在95-99%之間，術(shù)后遵醫(yī)囑給予一線護理，禁食之間，術(shù)后遵醫(yī)囑給予一線護理，禁食.17The patient was changed the position every 2 hours and the skin was integrity. The patient slept intermittently Last night. The total intake was 2500ml and the output was 1350ml.定時翻身，皮膚好。夜間間斷入睡定時翻身，皮膚好。夜間間斷入睡,全天入量全天入量2500ml,出量出量135

18、0ml，其中尿量，其中尿量1200ml,腹腔引流腹腔引流50ml,胃腸引流液胃腸引流液100ml.18Preoperation casesDed 3, Sun Yi, cholecystitis, cholelithiasis, will be performed the laparoscopic cholecystectomy with general anesthesia. The skin at and around the operative site was shaved. Preoperative patient education was done.3床床,孫義孫義,膽囊炎膽囊炎

19、,膽石癥膽石癥.患者常規(guī)準(zhǔn)備于明日在全麻下行腹患者常規(guī)準(zhǔn)備于明日在全麻下行腹腔鏡膽囊切除術(shù)腔鏡膽囊切除術(shù).皮已備皮已備,術(shù)前指導(dǎo)已做術(shù)前指導(dǎo)已做,青霉素皮試青霉素皮試(一一).晚上晚上給予清潔灌腸一次給予清潔灌腸一次,大便大便3次，夜間睡眠好，晨起已禁食水。次，夜間睡眠好，晨起已禁食水。19Penicillin allergy test was negative. The patient was given a cleaning enema (laxative) and passed watery (loose)stool 3 times.He slept well at night and

20、took nothing by mouth (NPO) in the morning. The vital signs were normal.青霉素皮試青霉素皮試(一一).晚上給予清潔灌腸一次晚上給予清潔灌腸一次,解水樣大便解水樣大便3次，夜間次，夜間睡眠好，晨起已禁食水，生命體征平穩(wěn)。睡眠好，晨起已禁食水，生命體征平穩(wěn)。20Other notesThe patients who had fever: Bed 8, Su Haokai, the temperature at 14:00 was 39.0. After cold compress and tepid (cool water) sponging giving to the patien