英汉双语护理查房

.,脑梗死病人护理查房(Nursingroundaboutthepatientofcerebralinfarction),.,护理查房目的（Thepurposeofthisnursinground),1.掌握脑梗死的定义及临床表现Masterthedefinitionandclinicalmanifestationsofcerebralinfarction2.熟悉脑梗死的治疗及护理Befamiliarwiththetreatmentandthenursingcare3.进一步培养护理人员临床思维能力Furthertrainingtheclinicalthinkingabilityofnurse4.加强护患沟通能力，提供更好的服务Strengthenthecommunicationskills,toprovidebetterserviceforthepatients,.,临床资料Theintroductionofthepatientscondition,病情介绍(Casehistoryintroduction),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。Bed15，Dongjiatian,male,65yearsold.Hewasadmittedtoourhospitalbecauseofglossolalia,waterchokingcoughaggravatingfor4days.Pastmedicalhistoryhashypertension,diabetes,coronaryheartdiseaseandothermedicaldisease.Afterthat,hisrightupperlimbcantholdandneedhelptowalk.,.,临床资料Physicalexamination,查体(PE),T：36.6P：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：36.6degreecentigradeP：74timesminuteR:18timesminuteBP:170/106mmhg.Oldmale,conciousnes,dysarthria,hisrightupperlimbproximalmusclestrengthislowerthanlevel2,distallevel2,rightlowerlimbmusclestrengthislevel3.Themuscletentionisslightlyhigher.,.,肌力分级,0,没有肉眼可见的肌肉收缩,1,仅有肉眼可见的肌肉收缩,3,2,去除重力情况可看到关节活动,5,4,能对抗重力Activemovementagainstgravity能对抗重力和部分阻力Activemovementagainstgravityandsomeresistance,肌力正常Normalpower,Nocontractionofmusclevisible,Flickerortraceofcontractionvisible,Activemovementatjoint,withgravityeliminated,.,辅助检查(Auxiliaryexamination),.,影像学检查(Imagingexamination),.,诊断(Diagnosis),1.脑梗死(cerebralinfarction)2.糖尿病（Diabetes）3.冠心病（Coronaryheartdisease）4.颈动脉粥样硬化(Carotidarteryatherosclerosis)5.颅内动脉狭窄(Intracranialarterystenosis)6.高血压病(Hypertention),.,脑梗死的定义(Thedefinition),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(Astrokeisabraininjurycausedbyanabnormalityofthebloodvesselssupplyingthebrain.),.,2020/6/1,10,危险因素(Riskfactor),10,2020/6/1,.,脑梗死临床表现(Clinicalmanifestation),患者临床症状与脑内梗死部位密切相关VTS_01_1(000807755-000838760).vob,.,2020/6/1,12,一、出血性or缺血性？(Intracerebralhemorrhageorcerebralinfarction),出血？缺血？,12,2020/6/1,.,2020/6/1,13,二、静脉溶栓治疗(Intravenousthrombolysistreatment),4.5小时,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,13,2020/6/1,.,护理诊断,焦虑（anxiety）：与担心疾病的预后有关(Itisbecauseofworyyingabouttheprognosisofthedisease.)知识缺乏（Thelackofknowledge）:缺乏与疾病相关的治疗、康复、及护理方面的知识(ConcerningabouttheKnowledgeofthetreatment,reheblitation,andhowtolookafterthepatient),Nursing,Diagnosis,Nursingdiagnosis,.,护理诊断,自理能力缺陷(Defectofselfcareability)：与肢体肌力下降有关（Whichisassociatedwithdecreasedmusclestrenght）高血压（Hypertention）:与紧张及脑水肿导致颅内压增高有关（Whichiscausedbymentaltensionandincreasedintracranialpressure）,Nursing,Diagnosis,Nursingdiagnosis,.,营养失调（malnutrition）：与吞咽困难，流质饮食有关(Whichisrelatedtodysphagiaandneedtobegivenliquiddiet)潜在并发症：Potentialcomplication.有感染的危险（Theriskofinfection）：与饮水呛咳导致肺部感染有关(Whichisbecauseofdrinkingwaterchokingcoughcauselunginfection).有便秘的危险（Theriskofconstipation）：与活动和流质饮食有关(Whichisduetobegivenliquiddietanddecreasedactivity),.,护理措施,护理,措施,Nursinginterventions,1.做好入科宣教，为患者提供安全舒适的环境。（Weshouldcommunicatewithpatientsindetailwhentheyfirstcometooursection.）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。（Tellthepatienttheknowledgeandtheprognosisabouthisdisease，includingthetreatment，nursingcareandrehabilitation。）,.,护理措施,护理,措施,Nursinginterventions,3.与患者及家属共同制定康复计划，并督促其执行（Recoveryplanwiththepatientandhisfamilymemebers，andsuperviseitsimplementation.）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。（Followthedoctorsadvicetocontrolthebloodpressure，thenobservetheeffectandthesideeffectsofthemedicine,.,护理措施,护理,措施,Nursinginterventions,5.为患者提供低盐低脂高纤维素饮食。(Thepatientshouldacceptthehealthydiet,forexample,lowsalt,lowfatandhighfiberdiet.)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。(Turnoverthepatientandkn