英漢雙語(yǔ)護(hù)理查房

1、會(huì)計(jì)學(xué)1英漢雙語(yǔ)護(hù)理查房英漢雙語(yǔ)護(hù)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(yǔ)不清、飲水嗆咳加重4天來(lái)診，門(mén)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(gòu)音障礙，伸舌居中，右上肢近端肌力2級(jí)，遠(yuǎn)端肌力3級(jí)，右下肢肌力2

4、級(jí)，右側(cè)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(méi)有肉眼可見(jiàn)的肌肉收縮1僅有肉眼可見(jiàn)的肌肉收縮32去除重力情況可看到關(guān)節(jié)活動(dòng)54能對(duì)抗重力 Acti

6、ve movement against gravity能對(duì)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(jiàn)出血。（No bleeding） 顱腦MRI+MRADWI示橋腦高信號(hào)。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(xué)檢查影像學(xué)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(yīng)障礙，導(dǎo)致腦組織缺血缺氧性壞死，進(jìn)而產(chǎn)生的臨床上對(duì)應(yīng)神經(jīng)功能缺失表現(xiàn)(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(shí)小時(shí)發(fā)病時(shí)間發(fā)病時(shí)間: :是患者最后看起來(lái)正是患者最后看起來(lái)正常狀態(tài)的時(shí)候?yàn)榘l(fā)病時(shí)間，而常狀態(tài)的時(shí)候?yàn)榘l(fā)病時(shí)間，而不是發(fā)現(xiàn)癥狀時(shí)間不是發(fā)現(xiàn)癥狀時(shí)間132021-12-10護(hù)理診斷護(hù)理診斷 焦慮（anxiety）：與擔(dān)心疾病的預(yù)后有關(guān)(It is because of woryying about the prognosis of the disease.) 知識(shí)缺乏（The lack of knowledge）:缺乏與疾病相關(guān)

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

10、 caused by mental tension and increased intracranial pressure ） Nursing DiagnosisNursing diagnosis 營(yíng)養(yǎng)失調(diào) （malnutrition ）：與吞咽困難，流 質(zhì)飲食有關(guān)(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(xiǎn) （The risk of infection ）：與飲水嗆咳導(dǎo)致肺部感染有關(guān)(Which is because of drink

11、ing water choking cough cause lung infection) .有便秘的危險(xiǎn) （The risk of constipation ）：與活動(dòng)和流質(zhì)飲食有關(guān)(Which is due to be given liquid diet and decreased activity)護(hù)理措施護(hù)理措施 護(hù)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(qiáng)與疾病相關(guān)知識(shí)宣教，如疾病的治療，護(hù)理及肢體語(yǔ)言康復(fù)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(hù)理措施護(hù)理措施 護(hù)理措施Nursing interventions 3.與患者及家屬共同制定康復(fù)計(jì)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(yīng)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(hù)理措施護(hù)理措施 護(hù)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(qiáng)翻身拍背，鼓勵(lì)病人有效咳嗽，必要時(shí)遵醫(yī)囑應(yīng)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(hù)理措施護(hù)理措施 護(hù)理措施Nursing interventions 7.鼓勵(lì)病人適當(dāng)進(jìn)行功能鍛煉，給予腹部環(huán)形按摩，預(yù)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(gòu)音障礙，伸舌居中，右上肢近端肌力2級(jí)，遠(yuǎn)端肌力3級(jí)，右下肢肌力2級(jí)，右側(cè)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(yīng)障礙，導(dǎo)致腦組織缺血缺氧性壞死，進(jìn)而產(chǎn)生的臨床上對(duì)應(yīng)神經(jīng)功能缺失表現(xiàn)(A stroke is a brain injury caused by an abnormality of the blood vessels supplying the brain.) 營(yíng)養(yǎng)失調(diào) （malnut

18、rition ）：與吞咽困難，流 質(zhì)飲食有關(guān)(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(xiǎn) （The risk of infection ）：與飲水嗆咳導(dǎo)致肺部感染有關(guān)(Which is because of drinking water choking cough cause lung infection) .有便秘的危險(xiǎn) （The risk of constipation ）：與活動(dòng)和流質(zhì)飲食有關(guān)(Which is due to be given liquid diet and decreased activity)護(hù)理措施護(hù)理措施 護(hù)理措施Nursing