英漢雙語護理查房

1、會計學1英漢雙語護理查房英漢雙語護理查房臨床資料 The introduction of the patients condition 病情介紹(Case history introduction) 15床，董家田，男性，65歲，因言語不清、飲水嗆咳加重4天來診，門診以“腦梗死收住院。既往有高血壓、糖尿病，腦梗死，冠心病病史。遺留有右上肢持物不能，需扶物行走。 Bed 15Bed 15，Dongjiatian , male ,65 years old .He Dongjiatian , male ,65 years old .He was admitted to our hospital be

2、cause of glossolalia was admitted to our hospital because of glossolalia ,water choking cough aggravating for 4 days. Past ,water choking cough aggravating for 4 days. Past medical history has hypertension,diabetes, coronary medical history has hypertension,diabetes, coronary heart disease and other

3、 medical diseaseheart disease and other medical disease. . After After that, his right upper limb canthat, his right upper limb cant hold and need help t hold and need help to walk.to walk.臨床資料 Physical examination 查體(PE) T：36.6 P：74次/分 R : 18次/分 BP: 170/106mmhg,神志清，構音障礙，伸舌居中，右上肢近端肌力2級，遠端肌力3級，右下肢肌力2

4、級，右側肢肌張力略高。 T：36.6 degree centigrade36.6 degree centigrade P：74times74timesminuteminute R: 18 times18 timesminute minute BP: 170/106mmhg. 170/106mmhg. Old male ,conciousnes, dysarthria,his right Old male ,conciousnes, dysarthria,his right upper limb proximal muscle strength is upper limb proximal mu

5、scle strength is lower than level 2,distal level 2,right lower than level 2,distal level 2,right lower limb muscle strength is level 3.The lower limb muscle strength is level 3.The muscle tention is slightly higher.muscle tention is slightly higher.0沒有肉眼可見的肌肉收縮1僅有肉眼可見的肌肉收縮32去除重力情況可看到關節(jié)活動54能對抗重力 Acti

6、ve movement against gravity能對抗重力和部分阻力Active movement against gravity and some resistance肌力正常 Normal powerNo contraction of muscle visibleFlicker or trace of contraction visibleActive movement at joint, with gravity eliminated 顱腦CT未見出血。（No bleeding） 顱腦MRI+MRADWI示橋腦高信號。MRA提示多發(fā)血管狹窄。（MRI showed that the

7、re are many intracranial vascular stenosis) 輔助檢查輔助檢查( (Auxiliary examination )Auxiliary examination ) 影像學檢查影像學檢查 ( (Imaging examination)Imaging examination)定義：由于各種原因所致的局部腦組織區(qū)域血液供應障礙，導致腦組織缺血缺氧性壞死，進而產生的臨床上對應神經功能缺失表現(A stroke is a brain injury caused by an abnormality of the blood vessels supplying the

8、 brain.)2021-12-1010102021-12-102021-12-1012出血？出血？缺血？缺血？122021-12-102021-12-10134.5小時小時發(fā)病時間發(fā)病時間: :是患者最后看起來正是患者最后看起來正常狀態(tài)的時候為發(fā)病時間，而常狀態(tài)的時候為發(fā)病時間，而不是發(fā)現癥狀時間不是發(fā)現癥狀時間132021-12-10護理診斷護理診斷 焦慮（anxiety）：與擔心疾病的預后有關(It is because of woryying about the prognosis of the disease.) 知識缺乏（The lack of knowledge）:缺乏與疾病相關

9、的治療、康復、及護理方面的知識(Concerning about the Knowledge of the treatment,reheblitation,and how to look after the patient) Nursing DiagnosisNursing diagnosis 護理診斷護理診斷 自理能力缺陷 (Defect of selfcare ability) ：與肢體肌力下降有關（Which is associated with decreased muscle strenght） 高血壓（Hypertention）:與緊張及腦水腫導致顱內壓增高有關 （Which is

10、 caused by mental tension and increased intracranial pressure ） Nursing DiagnosisNursing diagnosis 營養(yǎng)失調 （malnutrition ）：與吞咽困難，流 質飲食有關(Which is related to dysphagia and need to be given liquid diet) 潛在并發(fā)癥： Potential complication .有感染的危險 （The risk of infection ）：與飲水嗆咳導致肺部感染有關(Which is because of drink

11、ing water choking cough cause lung infection) .有便秘的危險 （The risk of constipation ）：與活動和流質飲食有關(Which is due to be given liquid diet and decreased activity)護理措施護理措施 護理措施Nursing interventions 1.做好入科宣教，為患者提供安全舒適的環(huán)境。 （We should communicate with patients in detail when they first come to our section .） 2.加

12、強與疾病相關知識宣教，如疾病的治療，護理及肢體語言康復等方面的宣教。 （Tell the patient the knowledge and the prognosis about his disease，including the treatment，nursing care and rehabilitation。）護理措施護理措施 護理措施Nursing interventions 3.與患者及家屬共同制定康復計劃，并督促其執(zhí)行（Recovery plan with the patient and his family memebers，and supervise its implemen

13、tation.） 4.遵醫(yī)囑應用降壓藥及脫水藥物，并觀察藥物的療效及副作用。 （Follow the doctors advice to control the blood pressure，then observe the effect and the side effects of the medicine護理措施護理措施 護理措施Nursing interventions 5.為患者提供低鹽低脂高纖維素飲食。 (The patient should accept the healthy diet, for example, low salt ,low fat and high fiber

14、 diet.) 6.加強翻身拍背，鼓勵病人有效咳嗽，必要時遵醫(yī)囑應用化痰藥物及抗生素。 (Turn over the patient and knock his back every 2 hours ,encourge the effectively cough. Acorrding to the doctors advice and use antibiltic.)護理措施護理措施 護理措施Nursing interventions 7.鼓勵病人適當進行功能鍛煉，給予腹部環(huán)形按摩，預防便秘的發(fā)生。 (Encourage the patient to do more functional ex

15、ercise,give the patients abdomen circular massage to prevent constipation.)臨床資料 Physical examination 查體(PE) T：36.6 P：74次/分 R : 18次/分 BP: 170/106mmhg,神志清，構音障礙，伸舌居中，右上肢近端肌力2級，遠端肌力3級，右下肢肌力2級，右側肢肌張力略高。 T：36.6 degree centigrade36.6 degree centigrade P：74times74timesminuteminute R: 18 times18 timesminute

16、minute BP: 170/106mmhg. 170/106mmhg. Old male ,conciousnes, dysarthria,his right Old male ,conciousnes, dysarthria,his right upper limb proximal muscle strength is upper limb proximal muscle strength is lower than level 2,distal level 2,right lower than level 2,distal level 2,right lower limb muscle

17、 strength is level 3.The lower limb muscle strength is level 3.The muscle tention is slightly higher.muscle tention is slightly higher.定義：由于各種原因所致的局部腦組織區(qū)域血液供應障礙，導致腦組織缺血缺氧性壞死，進而產生的臨床上對應神經功能缺失表現(A stroke is a brain injury caused by an abnormality of the blood vessels supplying the brain.) 營養(yǎng)失調 （malnut

18、rition ）：與吞咽困難，流 質飲食有關(Which is related to dysphagia and need to be given liquid diet) 潛在并發(fā)癥： Potential complication .有感染的危險 （The risk of infection ）：與飲水嗆咳導致肺部感染有關(Which is because of drinking water choking cough cause lung infection) .有便秘的危險 （The risk of constipation ）：與活動和流質飲食有關(Which is due to be given liquid diet and decreased activity)護理措施護理措施 護理措施Nursing