脑出血英语护理查房

Nursing rounds of cerebral hemorrhage Xu guiying：Department of NeurologyCerebral hemorrhage Refers to the primary substance of non-traumatic brain hemorrhage，which accounts for 20% to 30% in acute cerebrovascular diseasecerebral vascular disease.脑出血是指原发性脑实质出血 占全部脑卒中的20%30%Etiological factor （1）Hypertension with atherosclerosis (most common)。 （2）Intracranial aneurysms (mainly congenital aneurysm)。 （3）Cerebral arteriovenous malformations （4）Other: moyamoya disease, blood disease. 病因（1）高血压并发细小动脉硬化（最常见）。（2）颅内动脉瘤（主要是先天性动脉瘤）。（3）脑动静脉畸形（4）其他：脑动脉炎，脑底异常血管网症、血液病。PathogenesisBasis of disease: hypertension and cerebrovascular diseaseAdditional factors: force and emotional changes发病机制基础疾病：高血压，脑血管疾病其他因素：用力，情绪改变Clinical manifestations1. it Often occurs in the hypertensive patients who are over 50 years old 2. Prodromal symptoms often do not have a feeling, a small number of dizziness, headache, numbness and slurred speech, and many more in the emotional stress, excitement, bowel movements, hard, and when the incidence of severe climate change.2. 临床表现1。常发生于50岁以上的高血压患者。2。发病前多无预感，少数有头晕、头痛，肢体麻木，言语不清等前驱症状，多在情绪紧张，兴奋，用力排便时发病。Clinical performance (continued)3. Onset form of sudden onset, reached a peak a few minutes to several hours.4. Clinical symptoms of acute symptoms were sudden headache, vomiting, hemiplegia, aphasia, disturbance of consciousness, incontinence, etc. Different site and amount of bleeding hasDifferent clinical manifestations3。起病突然，往往在数分钟至数小时内，病情发展至高峰。4。急性症状为突然头痛，呕吐，偏瘫，失语，意识障碍，大小便失禁等。脑出血的临床表现随着出血部位和量的不同而各异。Laboratory and other tests1. Leukocyte、blood urea nitrogen and blood glucose increase.2 Head CT, MRI examination can be the site、 scope and amount of early detection of cerebral hemorrhage。3. Cerebrospinal fluid pressure often increased,实验室和其他检查1。白细胞、血中尿素氮，血糖升高。2头颅CT，MRI检查可早期发现脑出血的部位，范围和出血量。3。脑脊液压力常增高。essentials of diagnosis1 patients who are over 50 years old ，with a history of hypertension。It often occurs in physical activity or emotional excitement。2 rapid emergence of different levels of consciousness and symptoms of increased intracranial pressure, associated with hemiplegia, aphasia and other signs3CT examination (high-density foci) can confirm the diagnosis诊断要点1有高血压病史的患者，年龄超过50岁。常发生于体力活动或情绪激动时。2迅速出现不同程度的意识障碍和颅内压增高的症状，伴有偏瘫，失语等体征3CT检查（高密度灶）可明确诊断Treatment PointsAcute phase treatment of major principles: to prevent further bleeding, cerebral edema control, and prevention of complications of life-sustaining functions.1.general treatment ：bed rest ，the patency of airway1 regulation of blood pressure 3 Control of cerebral edema： 20% mannitol ,furosemide治疗要点急性期治疗主要原则：防止再出血，控制脑水肿，预防并发症，维持生命功能。1一般治疗：卧床休息，保持呼吸道通畅 2调节血压3控制脑水肿：20甘露醇，呋塞米。Treatment elements (continued)4. Hemostasis and coagulation drugs 5.operation treatment 6. Early rehabilitation4。止血和凝血药物5。手术治疗6。早期康复。General InformationName: XU Guiying Sex: femaleAge: 74, culture: illiteracymarriage： married nation：hanHometown：yangzhou occupation: retirement Admission time : 2011 -3-01Admission diagnosis: cerebral hemorrhageChief Complaint: Theleftlimb weaknesswith Unsteady gait for two days病史摘要患者徐桂英，女，74岁，因“左侧肢体乏力伴行走不稳两天”入院，入院时间2012-03-01.住院号E89610.入院时查体：神志清楚，双侧瞳孔等大等圆，直径3mm，光反射灵敏，四肢肌张力增高，左侧肌力4级，右侧肌力5级。眼球活动自如，眼震阴性，颈软，克氏征、布氏征阴性。各生理反射存在，病理反射未引出。T：36.9、R:18次分、P80次分、BP11070mmhg。头颅CT示：右侧基底节区脑出血。遵医嘱予吸氧、心电监护，降颅压，止血，营养脑细胞等对症治疗。HistorysummaryPatientsXU Guiying, female, aged 74,she was admitted into ward because of left limbweaknesswith unsteady gaitfortwodaysin 2012 march first。 hospital numberE89610.physicalexamination: clear consciousness，bilateral and other large and round pupil diameter of 3.0mm. Lightreflexsensitivity，high muscle tension 、leftlimb muscle strength grade 4，rightlimb muscle strength grade 5.freely Eye movements，soft neck、Gsintrinsicnegative, Brandt negative, physiological reflex exists while Pathologicalreflex was not elicited。The temperature was36.9centigrade,breathing was18times per minute,Pulse was 80 times per minute,Blood pressure was 110/70mmhg.CT showed that: tthe right basal ganglia hemorrhage . Prescribed by a doctortooxygenECG monitoring, reduce cerebral edema, improvethemetabolism of brain cells .etc( AND SO FORTH) 四史现病史：患者于入院两天前出现左侧肢体乏力，伴明显行走不稳，家属为明确病因来我院，门诊查头颅CT示右侧基底节区脑出血，为进一步诊治，收住入院。病程中伴明显反应迟钝，记忆力下降。03-02患者不能自主排尿，遵医嘱予导尿。03-04患者出现发热，稍咳嗽咳痰，遵医嘱予抗感染、止咳化痰治疗。近来患者食纳及精神尚可，睡眠正常，留置导尿，大便正常。history of present illnesspatient was admitted to hospital because of left limbweaknesswith unsteady gaitfortwodays. The family members came to our hospital for a clear cause, out-patient check CT scan showed the right basal ganglia cerebral hemorrhage,。Thedoctoradvisedhospitalizationforher。.In The course of the disease ，with significant unresponsiveness, memory loss.03-02the patient had dysuriasymptoms，Prescribed by a doctorto catheterization.03-04she had a fever, and a little cough and expectoration, follow the doctors advice to the anti-infective treatment.Recently the patient is in good spirits, normal sleep, indwelling catheterization, normal Defecation.既往史：“高血压”病史数年，未服药。否认“肝炎”、“结核”等传染病病史。家族史：配偶和子女的身体健康，否认“糖尿病”，“心脏疾病”和其他遗传病史。过敏史：否认花粉，药品，食品和其他过敏史。Past medical history:hypertension, a history ofseveral years, without medication.Denythehistoryofhepatitis,tuberculosisand other infectious diseases.Family history:the healthofthespouses and children, denied THE “diabetes”,“heart disease”andothergenetic history. Allergy history: The patient denied pollen, drugs, food and other allergies.五方面饮食：一日三餐以米面为主，食欲正常，无吞咽困难。入院后予低盐低脂饮食。睡眠：正常，每天6-7小时。排泄：留置导尿。大便正常，1次/1-2天。爱好：无烟酒不良嗜好。自理能力缺陷，需他人协助。心理社会状态：退休老人，家庭和睦。焦虑，担心预后。Five aspectsThediet: Three meals a dayinrice-based,normal appetite.nodifficulty in swallowing.Low-saltlow-fat diet after admission, Sleep:normal,6-7 hoursaday.Excretion:keep catheterization after admission, normalDefecation ,1/1-2 days.Hobbies:no alcohol and other bad habitsDefectsofself-care ability ,needassistance.Psychological and social status: the patient was aretired elderly,andfamily harmony,worry abouttheprognosis.体格检查：T：36.9、R:18次分、P80次分、BP11070mmhg。神志清楚，双侧瞳孔等大等圆，直径3mm，光反射灵敏，左侧肌力4级，右侧肌力5级。颈软，克氏征、布氏征阴性。physicalexamination showed thatThe temperature was 36.9centigrade,breathing was18times per minute,Pulse was 80 times per minute,Blood pressure was 110/70mmhg.clear consciousness，bilateral and other large and round pupil diameter of 3.0mm. leftlimb muscle strength grade 4，rightlimb muscle strength grade 5. soft neck、Gsintrinsicnegative, Brandt negative.辅助检查：03-01 CT示右侧基底节区脑出血03-02 心电图示 窦性心律、心肌缺血。Supplementary examination:03-01CT showedtherightbasal gangliacerebral hemorrhage03-02electrocardiogramshowed sinus rhythm,myocardial ischemia.护理诊断2012-3-01 潜在并发症：脑疝2012-3-01 自理能力缺陷 与肌力下降、医源性限制有关2012-3-01 有皮肤完整性受损的危险 与长期卧床有关2012-3-01 焦虑 与担心疾病预后有关2012-3-01 知识缺乏 缺乏与疾病相关知识2012-3-02 排尿型态改变 与脑功能受损、留置导尿有关2012-3-04 清理呼吸道低效 与咳嗽咳痰无力有关2012-3-04 体温过高 与感染和脑出血的吸收有关Nursing diagnosis 2012-3-01potentialcomplications:cerebral hernia2012-3-01Defectsofself-care ability related withdecreased muscle strength,iatrogenic limit。2012-3-01 the risk of impaired skin integrity and long-term bed rest, 2012-3-01anxietyandfearofdisease prognosis2012-3-01lack ofdisease-related knowledge2012-3-02voidingpatternschanged related with impairedbrain function and keeping catheterization2012-3-04clean airwayrespiratoryinefficient because of the inability to cough2012-3-04 hyperthermia and infection and the absorption of the cerebral hemorrhage.2012-3-01潜在并发症：脑疝护理目标:患者住院期间未发生脑疝、或脑疝发生时能得到及时发现和处理。护理措施：1密切观察生命体征变化，特别意识、瞳孔的变化。2嘱患者卧床休息，抬高床头1530，以减少脑水肿3遵医嘱使用脱水剂，期间应监测水电解质的变化。4向患者解释颅内压增高的诱因，如：用力、情绪激动等。5保护患者安全，保持安静，避免刺激。治疗和护理时动作应轻柔。评价：患者目前病情好转，未发生脑疝。potentialcomplications:cerebral herniaGoal:do not occurin cerebral hernia oronce hernia occurrence，it can be detected andtreated timely.Measures: a close observation of the patients awareness of changes in vital signs and observation of pupil particularly.2 bed rest。Raising the bed 15 degree 30 to reduce cerebral edema3 Use the dehydration 。during this time， renal function and water-electrolyte should be monitored.4explainthe incentiveofincreased intracranial pressure, such as:force and emotional changes.5toprotectpatient safety, keep quiet,to avoid irritation.to do the treatment and care when the action should be gentle Evaluation do not occurin cerebral hernia 2012-3-01 自理能力缺陷 与肌力下降、医源性限制有关目标：患者住院期间基本需要得到满足措施：1做好晨晚间护理，增加患者舒适。2.及时更换衣物，保持皮肤清洁3保持床单元清洁干燥5 协助患者进食更衣等生活护理评价：患者基本需要能得到满足2012-3-01Defectsofself-care ability related withdecreased muscle strength,iatrogenic limit。Goal:basic needs can be satisfied during patients hospitalizationMeasures:to dothemorning andeveningcare,increasepatient comfort.(2)the timely replacement ofclothing,keep the skin clean3to maintaina clean, drysheets5to assistpatients witheating,dressingand otherlifecareEvaluation:patients basic needs can be satisfied。2012-3-01 有皮肤完整性受损的危险 与长期卧床有关目标：患者住院期间皮肤完整，未发生压疮措施：1保持床单元清洁干燥，及时更换潮湿的衣物及被褥，避免局部长期受压。2置肢体于功能位，软枕垫起骨隆突部位。3使用气垫床及体位垫。评价:目前患者皮肤完整，未发生损伤。2012-3-01 the risk of impaired skin integrity and long-term bed rest,Goals:complete skin of patients with no occurrence of pressure sores.Measures:1 to keep clean sheets，andthe timely replacement of wetclothing andbedding,to avoidlong-termcompression.2position to maintain limb function, bone protuberance at the soft pillow pad3 provides air bed, turning the patient every 2 hours once.Evaluation: skinintegrity,notinjury.2012-3-01 焦虑 与担心疾病预后有关目标：患者入院一周内焦虑症状减轻或消失措施：1 主动向患者介绍环境，解释病情，消除患者陌生和紧张感2经常巡视病房，鼓励患者说出内心感受，了解患者的需要，及时帮助患者解决问题。3 保持环境安静，避免与其他焦虑患者接触4指导患者使用放松技术，如深呼吸，听音乐等。争取家属支持。评价：2011-3-05 患者焦虑减轻2012-3-01anxietyandfearofdisease prognosisAnxietysymptoms were relieved ordisappearedin a weekMeasures: 1to explainthe environment、condition to the patient actively。2 inspecttheward frequentlytoencouragethe patienttoexpress her needs, to help hersolve the problem in time.3Keep quiet,avoidcontactwith otherpatientswithanxiety4Instruct the patientto userelaxation techniquessuch as deep breathing, listening to music.Strive forfamily support.Evaluation:2011-3-05 Anxietysymptoms were relieved 2012-3-01 知识缺乏 缺乏与疾病相关知识目标：患者或家属入院一周内能简述疾病相关知识措施 1 运用通俗易懂的语言向患者及家属介绍疾病的病因、诱因、治疗及预后等。2 定时发放健康处方 ，提供适合病人学习的学习材料3 鼓励患者提出问题，耐心给予解答评价：2012-3-06 家属能简述疾病相关知识2012-3-01 lack ofdisease-related knowledgeBriefdisease-relatedknowledgegoals:the patient orfamily members could know part of disease-relatedknowledge in a weekMeasures：1touseplain languagetointroducethe cause、incentives and treatment ofthe disease2to provide ahealthprescription3 Encourage the patient toask questions,andto answer questions patiently。Evaluation:2012-3-06family memberscanknow part of disease-related knowledge2012-3-02 排尿型态改变 与脑功能受损、留置导尿有关目标：患者住院期间未发生尿路感染，排尿型态恢复正常措施：1保持会阴部清洁干燥2鼓励患者多饮水。3观察尿液的颜色，性质和量，做好记录。4定时夹放导尿管，锻炼膀胱反射功能。5定时更换尿管及尿袋，注意无菌操作。评价：目前患者未发生尿路感染，排尿型态未恢复正常。2012-3-02 voiding patternschanged related with impairedbrain function and keeping catheterizationGoal:Avoid urinarytractinfectionduring the hospitalization,voidingpatternsreturn to normalMeasures:1 to keep the perineumclean and dry2 Encourage the patient todrink more water. 3observeurinecolor, natureand quantity, make a record.4 The proper use of thecatheter , exercisethefunctionofthe bladderreflex.5regular replacement ofthecatheterand urine bag,Evaluation:The patient did not have urinary tract infection,voidingpatterns did notreturn to normal.2012-3-04 清理呼吸道低效 与咳嗽咳痰无力有关目标：患者三日内咳嗽咳痰减少，保持呼吸道通畅。1保持环境安静，整洁，空气清新，适宜温湿度。 2观察痰的颜色，性质，数量，气味和咳嗽的频率等。3留取新鲜的痰标本进行培养和药敏试验，并根据药敏使用抗生素，止咳化痰药。4予翻身叩背，以促进痰液排出。评价：2012-3-07患者咳嗽咳痰减少，呼吸道通畅。 clean airwayrespiratoryinefficient beca