《英漢雙語護(hù)理查房》

腦梗死病人護(hù)理查房

(Nursingroundaboutthepatientofcerebralinfarction)

精選ppt護(hù)理查房目的（Thepurposeofthisnursinground)1.掌握腦梗死的定義及臨床表現(xiàn)Masterthedefinitionandclinicalmanifestationsofcerebralinfarction2.熟悉腦梗死的治療及護(hù)理

Befamiliarwiththetreatmentandthenursingcare3.進(jìn)一步培養(yǎng)護(hù)理人員臨床思維能力Furthertrainingtheclinicalthinkingabilityofnurse4.加強(qiáng)護(hù)患溝通能力，提供更好的服務(wù)Strengthenthecommunicationskills,toprovidebetterserviceforthepatients

精選ppt臨床資料Theintroductionofthepatient’scondition

病情介紹(Casehistoryintroduction)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。

Bed15，Dongjiatian,male,65year’sold.Hewasadmittedtoourhospitalbecauseofglossolalia,waterchokingcoughaggravatingfor4days.Pastmedicalhistoryhashypertension,diabetes,coronaryheartdiseaseandothermedicaldisease.Afterthat,hisrightupperlimbcan’tholdandneedhelptowalk.精選ppt臨床資料Physicalexamination

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，遠(yuǎn)端肌力3級，右下肢肌力2級，右側(cè)肢肌張力略高。

T：36.6degreecentigrade

P：74times／minute

R:18times／minuteBP:170/106mmhg.Oldmale,conciousnes,dysarthria,hisrightupperlimbproximalmusclestrengthislowerthanlevel2,distallevel2,rightlowerlimbmusclestrengthislevel3.Themuscletentionisslightlyhigher.精選ppt肌力分級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(guān)節(jié)活動54能對抗重力Activemovementagainstgravity能對抗重力和部分阻力Activemovementagainstgravityandsomeresistance肌力正常NormalpowerNocontractionofmusclevisibleFlickerortraceofcontractionvisibleActivemovementatjoint,withgravityeliminated精選ppt顱腦CT未見出血。（Nobleeding）顱腦MRI+MRADWI示橋腦高信號。MRA提示多發(fā)血管狹窄。（MRIshowedthattherearemanyintracranialvascularstenosis)

輔助檢查(Auxiliaryexamination)精選ppt影像學(xué)檢查(Imagingexamination)精選ppt診斷(Diagnosis)1.腦梗死(cerebralinfarction)2.糖尿?。―iabetes）3.冠心病（Coronaryheartdisease）4.頸動脈粥樣硬化(Carotidarteryatherosclerosis)5.顱內(nèi)動脈狹窄(Intracranialarterystenosis)6.高血壓病(Hypertention)精選ppt腦梗死的定義(The

definition)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)生的臨床上對應(yīng)神經(jīng)功能缺失表現(xiàn)(Astrokeisabraininjurycausedbyanabnormalityofthebloodvesselssupplyingthebrain.)精選ppt2023/4/1210危險(xiǎn)因素(Riskfactor)102023/4/12精選ppt腦梗死臨床表現(xiàn)

(Clinicalmanifestation)

患者臨床癥狀與腦內(nèi)梗死部位密切相關(guān)VTS_01_1(000807755-000838760).vob精選ppt2023/4/1212一、出血性or缺血性？(Intracerebralhemorrhageorcerebralinfarction)

出血？缺血？122023/4/12精選ppt2023/4/1213二、靜脈溶栓治療(Intravenousthrombolysistreatment)4.5小時(shí)發(fā)病時(shí)間:是患者最后看起來正常狀態(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132023/4/12精選ppt護(hù)理診斷焦慮（anxiety）：與擔(dān)心疾病的預(yù)后有關(guān)(Itisbecauseofworyyingabouttheprognosisofthedisease.)知識缺乏（The

lackofknowledge）:缺乏與疾病相關(guān)的治療、康復(fù)、及護(hù)理方面的知識(ConcerningabouttheKnowledgeofthetreatment,reheblitation,andhowtolookafterthepatient)

NursingDiagnosisNursingdiagnosis精選ppt護(hù)理診斷自理能力缺陷(Defectofselfcareability)：與肢體肌力下降有關(guān)（Whichisassociatedwithdecreasedmusclestrenght）

高血壓（Hypertention）:與緊張及腦水腫導(dǎo)致顱內(nèi)壓增高有關(guān)（Whichiscausedbymentaltensionandincreasedintracranialpressure）NursingDiagnosisNursingdiagnosis精選ppt營養(yǎng)失調(diào)（malnutrition）：與吞咽困難，流質(zhì)飲食有關(guān)(Whichisrelatedtodysphagiaandneedtobegivenliquiddiet)潛在并發(fā)癥：

Potentialcomplication.有感染的危險(xiǎn)（Theriskofinfection）：與飲水嗆咳導(dǎo)致肺部感染有關(guān)(Whichisbecauseofdrinkingwaterchokingcoughcauselunginfection).有便秘的危險(xiǎn)（Theriskofconstipation）：與活動和流質(zhì)飲食有關(guān)(Whichisduetobegivenliquiddietanddecreasedactivity)精選ppt護(hù)理措施護(hù)理措施Nursinginterventions1.做好入科宣教，為患者提供安全舒適的環(huán)境。（Weshouldcommunicatewithpatientsindetailwhentheyfirstcometooursection.）2.加強(qiáng)與疾病相關(guān)知識宣教，如疾病的治療，護(hù)理及肢體語言康復(fù)等方面的宣教。（Tellthepatienttheknowledgeandtheprognosisabouthisdisease，includingthetreatment，nursingcareandrehabilitation。）精選ppt護(hù)理措施護(hù)理措施Nursinginterventions3.與患者及家屬共同制定康復(fù)計(jì)劃，并督促其執(zhí)行（Recoveryplanwiththepatientandhisfamilymemebers，andsuperviseitsimplementation.）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。（Followthedoctorsadvicetocontrolthebloodpressure，then

observetheeffectandthesideeffectsofthemedicine精選ppt護(hù)理措施護(hù)理措施Nursinginterventions5.為患者提供低鹽低脂高纖維素飲食。(Thepatientshouldacceptthehealthydiet,forexample,lowsalt,lowfatandhighfiberdiet.)6.加強(qiáng)翻身拍背，鼓勵病人有效咳嗽，必要時(shí)遵醫(yī)囑應(yīng)用化痰藥物及抗生素。(Turnoverthepatientandknockhisbackevery2hours,encourgetheeffectivelycough.Acorrdingtothedoctor’sadviceanduseantibiltic.)精選ppt護(hù)理措施護(hù)理措施Nursinginterventions7.鼓勵病人適當(dāng)進(jìn)行功能鍛煉，給予腹部環(huán)形按摩，預(yù)防便秘的