英漢雙語護(hù)理查房

1、腦梗死病人護(hù)理查房(Nursing round about the patient of cerebral infarction),,護(hù)理查房目的（The purpose of this nursing round),1.掌握腦梗死的定義及臨床表現(xiàn) Master the definition and clinical manifestations of cerebral infarction2.熟悉腦梗死的治療及護(hù)理 B

2、e familiar with the treatment and the nursing care3.進(jìn)一步培養(yǎng)護(hù)理人員臨床思維能力 Further training the clinical thinking ability of nurse4.加強(qiáng)護(hù)患溝通能力，提供更好的服務(wù)Strengthen the communication skills, to provide better service for the pa

3、tients,臨床資料 The introduction of the patient’s 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 15，Dongjiatian , male ,65 year’s old .He w

4、as admitted to our hospital because of glossolalia ,water choking cough aggravating for 4 days. Past medical history has hypertension,diabetes, coronary heart disease and other medical disease. After that, his right uppe

5、r limb can’t hold and need help 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，遠(yuǎn)端肌力3級，右下肢肌力2級，右側(cè)肢肌張力略高。 T：36.6 degree centigrade P：74times／minute R: 18 time

6、s／minute BP: 170/106mmhg. Old male ,conciousnes, dysarthria,his right upper limb proximal muscle strength is lower than level 2,distal level 2,right lower limb muscle strength is level 3.The muscle tention is slightly h

7、igher.,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,3,2,去除重力情況可看到關(guān)節(jié)活動,5,4,能對抗重力 Active 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 power,No contraction of muscle visible,Fli

8、cker or trace of contraction visible,Active movement at joint, with gravity eliminated,輔助檢查(Auxiliary examination ),影像學(xué)檢查 (Imaging examination),,診斷(Diagnosis),1.腦梗死(cerebral infarction)2.糖尿?。―iabetes）3.冠心?。–oronar

9、y heart disease）4.頸動脈粥樣硬化(Carotid artery atherosclerosis)5.顱內(nèi)動脈狹窄(Intracranial artery stenosis)6.高血壓病(Hypertention),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)(A stroke is a brain

10、 injury caused by an abnormality of the blood vessels supplying the brain.),2024/3/12,10,危險因素(Risk factor),10,2024/3/12,腦梗死臨床表現(xiàn)(Clinical manifestation),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,2024/3/12,12,一、出

11、血性or缺血性？(Intracerebral hemorrhage or cerebral infarction),出血？缺血？,12,2024/3/12,2024/3/12,13,二、靜脈溶栓治療(Intravenous thrombolysis treatment),4.5小時,發(fā)病時間:是患者最后看起來正常狀態(tài)的時候為發(fā)病時間，而不是發(fā)現(xiàn)癥狀時間,13,2024/3/12,護(hù)理診斷,焦慮（anxiety）：與擔(dān)心疾病的預(yù)后有關(guān)

12、(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(guān)的治療、康復(fù)、及護(hù)理方面的知識(Concerning about the Knowledge of the treatment,reheblitation,and how to look after the patient),Nursing,

13、Diagnosis,Nursing diagnosis,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 caused by mental tension and increased in

14、tracranial pressure ）,Nursing,Diagnosis,Nursing diagnosis,營養(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 （

15、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 （The risk of constipation ）：與活動和流質(zhì)飲食有關(guān)(Which is due to be given liquid diet and decreased activity),護(hù)理

16、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。（Tell the patient the knowledge and the

17、 prognosis about his disease，including the treatment，nursing care and rehabilitation。）,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)計劃，并督促其執(zhí)行（Recovery plan with the patient and his family memebers，and supervise its

18、implementation.）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,Nursing interventions,,,5.為患者提供低鹽低脂高纖維素飲食。

19、(The patient should accept the healthy diet, for example, low salt ,low fat and high fiber diet.)6.加強(qiáng)翻身拍背，鼓勵病人有效咳嗽，必要時遵醫(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 cou

20、gh. Acorrding to the doctor’s advice and use antibiltic.),護(hù)理措施,,護(hù)理,措施,Nursing interventions,,,7.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)防便秘的發(fā)生。(Encourage the patient to do more functional exercise,give the patient’s abdomen circular mas