英漢雙語護理查房-ppt

1、腦梗死病人護理查房腦梗死病人護理查房( (Nursing round about the patient of cerebral infarction) 護理查房目的（護理查房目的（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理 Be familiar with the treatment and the nursing care3.進一步培養(yǎng)護理人員臨床思維能力 Fu

2、rther training the clinical thinking ability of nurse4.加強護患溝通能力，提供更好的服務(wù)Strengthen the communication skills, to provide better service for the patients 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

3、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 because of was admitted to our hospital because of glossolaliaglossolalia ,water choking cough aggravating for 4 days. Past ,water choking cough aggravating for 4 days. Pa

4、st medical history has medical history has hypertension,diabeteshypertension,diabetes, coronary , coronary heart disease and other 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 he

5、lp 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，遠端肌力3級，右下肢肌力2級，右側(cè)肢肌張力略高。 T：36.6 degree centigrade36.6 degree centigrade P：74times74timesminuteminute R: 18 18 timestimesminuteminute BP: 170/106mmhg. 170/106mmhg. Old male ,Old male ,

6、conciousnesconciousnes, , dysarthria,hisdysarthria,his right 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 strength is level 3.The lower limb muscle strength is lev

7、el 3.The muscle muscle tentiontention is slightly higher. is slightly higher.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 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 powerNo contraction of muscle visibleFlicker or trace of contraction

8、 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 there 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)診斷診斷( (Diagn

9、osis)Diagnosis)1.腦梗死(cerebral infarction)2.糖尿病（Diabetes）3.冠心?。–oronary 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)腦梗死的定義腦梗死的定義( (TheThe definition )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，進而產(chǎn)生的臨床上對應(yīng)神經(jīng)功能缺失表現(xiàn)(A stroke is

10、a brain injury caused by an abnormality of the blood vessels supplying the brain.)2022-3-310危險因素危險因素( (Risk factor)Risk factor)102022-3-3腦梗死臨床表現(xiàn)腦梗死臨床表現(xiàn)( (Clinical manifestation)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).vob2022-3-312一、出血性一、出血性oror缺血性？缺血性？( (IntracerebralI

11、ntracerebral hemorrhage or cerebral infarction)hemorrhage or cerebral infarction) 出血？出血？缺血？缺血？122022-3-32022-3-313二、靜脈溶栓治療二、靜脈溶栓治療( (Intravenous Intravenous thrombolysisthrombolysis treatment) treatment)4.5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(xiàn)癥狀時間不是發(fā)現(xiàn)癥狀時間132022-3-3護理診斷護理診斷

12、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.) 知識缺乏（The lack of knowledge）:缺乏與疾病相關(guān)的治療、康復(fù)、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 self

13、care 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 intracranial pressure ） Nursing DiagnosisNursing 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

14、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(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)護理措施護理措施 護理措施Nursing inter

15、ventions 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.加強與疾病相關(guān)知識宣教，如疾病的治療，護理及肢體語言康復(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。）護理措施護理措施 護理措施Nursin

16、g 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 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護理措施護理措施 護理措施Nursing in

17、terventions 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 diet.) 6.加強翻身拍背，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 cough. Acorrding to the doctors advice and use antibiltic.)護理措施護理措施 護理措施Nursing inte