护理英语交班ppt课件.ppt

护理英语交班NursingEnglishreport Generalconditions Goodmorning everyone March21 2009Wearepassingnursingreportnow Therearetotal36patientsintheward including3patientsdischarged 2admitted 2transferredin 2transferredout 1diedyesterday 各位 早晨好2009年3月21日护理交班病人总数 36出院病人数 3入院病人数 5转入病人数 2转出病人数 2死亡病人数 1 3patientswereperformedoperation ThenumberofDILcase 1thenumberofpatientongradeonenursingcare 10 手术病人数 3病危病人总数 1病重病人总数 2一级护理病人总数 10 Dischargedcase Bed3 WangHong coronaryheartdisease CHD anginapectoris wasdischargedat9o clockyesterdayaftertreatment 3床 王红 冠心病 心绞痛于9 00出院 Deathcase Bed29 ZhaoLiang pulmonaryinfection twotypeofrespiratoryfailure multipleorganfailure wasdied passedon at10 00yesterdayafterresuscitationfailure 29床 赵良 肺部感染 二型呼衰 多功能脏器衰竭 经抢救无效于10 00死亡 Newadmission Bed18 WeiHaiming male 47yearsold wasadmittedat10 00o clockwithcomplainingofa15daysintermittentchestpainandpalpitation Thediagnosiswasuncertainchestpain dysrhythmias paroxysmalatrialfibrillation bradycardia hypertensionongrade3 18床魏海明胸痛原因待查 心律失常 阵发性房颤 窦性心动过缓 高血病3级患者 男性47岁 地方人员 于10 00入院 主因为发作性胸痛伴心慌15天 为进一步治疗入院 Afteradmission thedoctorLiXuehuawasnotifiedimmediatelyandtheadmissioninterviewwasdone ECGatbedsideshowedsinusrhythm BPwas130 88mmHg Thelowsaltandlowfatdietwasserved Dilatedcoronaryartery anticoagulationandanti hypertensiondrugsweretakenandgrade2nursingcarewasgivenasdoctor sorders 入院后立即通知李学华医生 入院介绍已做 患者未诉胸痛 心慌 血压130 88mmHg 行床旁心电图示窦性心律 遵医嘱给予二级护理 低盐低脂普食 扩冠 抗凝 降压等药物治疗 ThepatientsleptwellLastnightandbloodspecimenweretaken Thevitalsignswerenormalinthemorning 病人睡眠好 晨起血标本已留 生命体征平稳 DILcase Bed10 WangHua coronaryHeartdisease anginapectoris acuteextensiveanteriormyocardialinfarction Thepatientsuddenlycomplainedofchestpainat22 30Oxygenwasgivenimmediatelyandtheflowratewas3L min ECGmonitoringwasstartedandshowedsinusrhythm 10床 王华 冠心病 心绞痛 急性广泛前壁心肌梗死 昨天22 30病人主诉心前区疼痛 立即给予吸氧3升 分 心电监护仪监护 心电示波示窦性心律 Theheartratewas63beats min BPwas115 64mmHg MeanwhileDr ZhangXuewasinformed Aftertaking3tabletsofnitroglycerinsublinguallyat5minuteintervalsasindicated thepainwaspersistent TheECGshowedthe0 2 0 6mvofelevatedV1 V5Stsegment Dr ZhaoYongsawthepatient 心率63次 分 血压115 64mmHg 通知张学医生看病人 遵医嘱给予硝酸甘油mg舌下含服 症状无缓解 行床旁心电图检查示V1 V5ST段抬高0 2 0 6mv 二线赵勇副主任医师到场看病人 Heparin100mginnormalsaline500mlandDopamine80mginnormalsaline500mlweregivebyIVinfusion Thedropratewere500u hand1 46ug kg minrespectively ThepatientwasonDIL 遵医嘱给予静脉输入生理盐水500ml 肝素钠注射液100mg 滴速为500u h 生理盐水250ml多巴胺注射液80mg 滴速1 46ug kg min 报病危 Ivinfusionwerekeptpatent Thepatientsleptintermittentlyintheevening TheECGshowedsinusrhythm Theheatratewasatrangeof63 74beats minandBPwas91 115 53 64mmHg Thepatientwasturnedevery2hoursandnowisonsupine prone lateral Fowler s semi Fowler s position 夜班输液通畅 患者间断睡眠 心电监护仪显示窦性心律 心率波动在63 74次 分 血压波动在91 115 53 64mmHg 每2小时翻身一次 现病人平卧位 伏卧位 侧位 半卧位 较低半卧位 Theskinwasintegrity Thetotalinputwas400mlandtheoutputwas300ml 皮肤无破损 全天入量400ml 尿量300ml Operationcase Bed11 DuanRong coloncancer Aterbeingperformedthecolectomywithgeneralanesthesia thepatientwasconsciouswhenhecametothewardat15 30 Thedressingkeptintegrityandtheouterdressinglayerhad tbeenwetorsoiled TheAbdominaldrainagetubewassecuredwellanddrained50mlbloodyexudates 11床 段荣 直肠癌 今日在全麻下直肠癌切除术 术后于15 30返回病房 清醒 血压154 96mmHg 切口敷料包扎好 外层敷料未见明显渗出 腹腔引流管固定通畅 引流液为血性 Thenasogastrictubewasattachedtolowsuctionfordecompressionanddrained100mlofdark greencolorofexudates Thecatheterizationwasmaintainedpatentanditsdrained1200mlofclearurine 持续胃肠减压通畅 引流墨绿色液体100ml 尿管通畅 尿色清亮 皮肤好 Thecentralvenouscatheterwaskeptpatentandtherewerenorednessandswellingintheskin Thesaturationofoxygenwascontinuouslymonitoredbypulseoximetryandthevalueswere95 to99 Thegrade1nursingcareandfastingfoodweregivenasdoctor sorders 中心静脉输液通畅 穿刺部位无红 肿 持续血氧饱和度监测 SPO2维持在95 99 之间 术后遵医嘱给予一线护理 禁食 Thepatientwaschangedthepositionevery2hoursandtheskinwasintegrity ThepatientsleptintermittentlyLastnight Thetotalintakewas2500mlandtheoutputwas1350ml 定时翻身 皮肤好 夜间间断入睡 全天入量2500ml 出量1350ml 其中尿量1200ml 腹腔引流50ml 胃肠引流液100ml Preoperationcases Ded3 SunYi cholecystitis cholelithiasis willbeperformedthelaparoscopiccholecystectomywithgeneralanesthesia Theskinatandaroundtheoperativesitewasshaved Preoperativepatienteducationwasdone 3床 孙义 胆囊炎 胆石症 患者常规准备于明日在全麻下行腹腔镜胆囊切除术 皮已备 术前指导已做 青霉素皮试 一 晚上给予清洁灌肠一次 大便3次 夜间睡眠好 晨起已禁食水 Penicillinallergytestwasnegative Thepatientwasgivenacleaningenema laxative andpassedwatery loose stool3times Hesleptwellatnightandtooknothingbymouth NPO inthemorning Thevitalsignswerenormal 青霉素皮试 一 晚上给予清洁灌肠一次 解水样大便3次 夜间睡眠好 晨起已禁食水 生命体征平稳 Othernotes Thepatientswhohadfever Bed8 SuHaokai thetemperatureat14 00was39 0 Aftercoldcompressandtepid coolwater sponginggivingtothepatient thebodytemperaturefellto37 8 at14 30 发热患者 8床 苏浩凯 14点测体温为39 0 给予冰袋物理降温 温水擦浴 14 30体温降为37 8 Clinictestswillbedonetoday Bed15 WangYonglinisonnothing by mouthregimenforabdominalultrasound Bed32 XueHua 24 hoururinecollectionwasstartedtoday thespecimenshouldbesentat8 00tomorrowmorning 今日拟检查15床王永林 今晨禁食水 行腹部B超检查 3