英汉双语护理查房-ppt

肌力分级
0 1 2 3 4 5
没有肉眼可见的肌肉收缩 No contraction of muscle visible 仅有肉眼可见的肌肉收缩 Flicker or trace of contraction visible Active movement at joint, with gravity eliminated 能对抗重力 Active movement against gravity 能对抗重力和部分阻力Active movement against gravity and some resistance 肌力正常 Normal power
临床资料 The introduction of the patient’s condition 病情介绍(Case
history introduction)
15床，董家田，男性，65岁，因言语不 清、饮水呛咳加重4天来诊，门诊以“脑梗 死收住院。既往有高血压、糖尿病，脑梗 死，冠心病病史。遗留有右上肢持物不能 ，需扶物行走。
出血？ 缺血？
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二、静脉溶栓治疗 (Intravenous thrombolysis treatment)
发病时间:是患者最后看起来正 常状态的时候为发病时间，而 不是发现症状时间
4.5小时
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护理诊断
Nursing diagnosis
临床资料 Physical examination
查体(PE)
T：36.6℃ P：74次/分 R : 18次/ 分 BP: 170/106mmhg,神志清，构音障 碍，伸舌居中，右上肢近端肌力2级 ，远端肌力3级，右下肢肌力2级， 右侧肢肌张力略高。
T：36.6 degree centigrade P：74times／ minute R: 18 times／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 higher.
Nursing
Diagnosis
• 营养失调 （malnutrition ）：与吞咽困难，流 质饮食有关(Which is related to dysphagia and need to be given liquid diet) • 潜在并发症： Potential complication .有感染的危险 （The risk of infection ）：与饮水 呛咳导致肺部感染有关(Which is because of drinking water choking cough cause lung infection) .有便秘的危险 （The risk of constipation ）：与活 动和流质饮食有关(Which is due to be given liquid diet and decreased activity)
辅助检查 (Auxiliary examination )
颅脑CT 颅脑MRI+MRA 未见出血。（No bleeding） DWI示桥脑高信号。MRA提示多发血管狭窄。（MRI showed that there are many intracranial vascular stenosis)
影像学检查 (Imaging examination)
护理
措施
• 对于接受溶栓治疗的病人，作为护理人应 采取哪些护理措施？(What measures should we
take if a patient received intravenous thrombolysis)
Nursing
• 焦虑（anxiety）：与担心疾病的预后有关(It is because of woryying about the prognosis of the disease.) • 知识缺乏（The lack of knowledge）:缺乏与疾病 相关的治疗、康复、及护理方面的知识 (Concerning about the Knowledge of the treatment,reheblitation,and how to look after the patient)
护理措施
Nursing interventions
• 1.做好入科宣教，为患者提供安全舒适的环境。 • （We should communicate with patients in detail when they first come to our section . ） • 2.加强与疾病相关知识宣教，如疾病的治疗，护理 及肢体语言康复等方面的宣教。 • （Tell the patient the knowledge and the prognosis about his disease，including the treatment，nursing care and rehabilitation。 措施 护理 ）
诊断(Diagnosis)
1.脑梗死(cerebral infarction) 2.糖尿病（Diabetes） 3.冠心病（Coronary heart disease） 4.颈动脉粥样硬化(Carotid artery atherosclerosis) 5.颅内动脉狭窄(Intracranial artery stenosis) 6.高血压病(Hypertention)
Diagnosis
护理诊断
Nursing diagnosis
• 自理能力缺陷 (Defect of selfcare ability) ： 与肢体肌力下降有关（Which is associated with decreased muscle strenght） • 高血压（Hypertention）:与紧张及脑水肿导致颅内 压增高有关 （Which is caused by mental tension and increased intracranial pressure ）
脑梗死的定义(The
definition )
定义：由于各种原因所致的局部脑组织区域 血液供应障碍，导致脑组织缺血缺氧性坏 死，进而产生的临床上对应神经功能缺失 表现(A stroke is a brain injury caused by an abnormality of the blood vessels supplying the brain.)
Be familiar with the treatment and the nursing care
3.进一步培养护理人员临床思维能力
Further training the clinical thinking ability of nurse
4.加强护患沟通能力，提供更好的服务
Strengthen the communication skills, to provide better service for the patients
护理措施
Nursing interventions
• 7.鼓励病人适当进行功能锻炼，给予腹部环形按摩 ，预防便秘的发生。 • (Encourage the patient to do more functional exercise,give the patient’s abdomen circular massage to prevent constipation.)
Bed 15，Dongjiatian , male ,65 year’s old .He was 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 upper limb can ’t hold and need help to walk.
危险因素(Risk factor)
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脑梗死临床表现 (Clinical manifestation)
患者临床症状与脑内梗死部位密切相关 VTS_01_1(000807755-000838760).vob
一、出血性or缺血性？(Intracerebral hemorrhage or cerebral infarction)
护理ቤተ መጻሕፍቲ ባይዱ施
Nursing interventions
• 5.为患者提供低盐低脂高纤维素饮食。 • (The patient should accept the healthy diet, for example, low salt ,low fat and high fiber diet.) • 6.加强翻身拍背，鼓励病人有效咳嗽，必要时遵医 嘱应用化痰药物及抗生素。 • (Turn over the patient and knock his back every 2 hours ,encourge the effectively cough. Acorrding to the doctor’s advice and 措施 use护理 antibiltic.)
脑梗死病人护理查房
(Nursing
round about the patient of cerebral infarction)
1.掌握脑梗死的定义及临床表现
2.熟悉脑梗死的治疗及护理
护理查房目的（The purpose of this nursing round)
Master the definition and clinical manifestations of cerebral infarction
护理措施
Nursing interventions
• 3.与患者及家属共同制定康复计划，并督促其执行 （Recovery plan with the patient and his family memebers，and supervise its implementation.） • 4.遵医嘱应用降压药及脱水药物，并观察药物的疗 效及副作用。 • （Follow the doctors advice to control the blood pressure，then observe the effect and 措施 the side effects of the medicine 护理