心内科一区中英文护理病历

护理病历首次护理记录单姓名：陈观连性别：男年龄：71岁科室：心内科一区床号：HNL01住院号/ID号：359101入院日期时间：2016-11-514:37职业：其他民族/宗教：汉族/无婚姻状态：已婚教育程度：中学资料来源：患者日常照顾者：自我照顾入院方式：步行入院类型：门诊过敏史：有（磺胺类）医疗费用支持方式：其他社会保险入院诊断：冠心病既往史：冠心病、PCI术、高血压病、肾功能不全、慢性胃炎、痛风、下肢动脉粥样硬化、下肢深静脉瓣膜技能不全、颈动脉硬化一、护理评估意识状态：呼之能应；对答：切题；饮食：自行进食咀嚼困难：无吞咽困难：无口腔黏膜：完整胃肠道症状：无睡眠：正常醒后疲劳感：无排尿：未发现异常排便：正常（1次/天）；四肢活动：自如自理能力：完全自理皮肤状况：完整语言沟通：最常用语言/语种：粤语，语言表达：清楚生活习惯：吸烟：无嗜酒：无伤口：无敷料：无造痿：无患者自我护理：能静脉置管：无留置引流管：无疼痛：无患者在最近1周内是否有膳食摄入减少：否；压疮风险：无；跌倒/坠床风险：有；走失风险：无最近3个月是否有体重减轻：否其他症状和体征：无二、住院告知住院须知物品管理作息探陪订餐介绍主管医生介绍护士长介绍主管护士三、护理重点1.基础护理：更衣护理、饮食护理2,专科护理：3.患者安全：身份识别、转运安全、上床栏、防跌倒四、其他五、护理交接班重点：注意患者血压情况记录时间：2016年11月05日14时56分责任护士签名：石彩兰审核时间：2016年11月05日16时52分审核人签名：黄清华

护理记录单姓名：姓名：陈观连性别：男年龄:71岁科室：心内科一区床号:HNL01住院号:359101入院日期:2016-11-5日期时间体温°C脉搏次/分呼吸次/分血压mmHg血氧饱和度吸氧/L入量ml尿量ml大便次数共/次特殊情况记录护士签名201611-514:5336.76820143/739621已行入院宣教，患者无诉不适石彩兰11-617:0037.07219142/72972共350共6000床边BNP结果：18.14pg/ml,PCT结果为：＜0.1ng/ml,CTNT结果为：＜50口蛔,已通知医生石彩兰11-79:1736.96718159/91982予硝酸甘油0.5mg舌下含服，异舒吉50mg以5ml/h静注石彩兰11-79:3037.27119142/89972共400共7001恶心呕吐一次，胃内容物量约80ml,予胃复安肌注。石彩兰11-810:2237.37517144/7998212016-11-08肌钙蛋白定量：高敏肌钙蛋白定量0.554ug/ml,结果已报告医生，患者现无诉不适，指导患者静卧休息，床边二便，避免用力排便。石彩兰11-816:0036.86920140/83992共350共9001患者准备明天行CAG术，已做好术前准备。遵医嘱予NS250ml慢滴。石彩兰11-99:1036.77421135/76982共200共8000在家属及医生的陪同下送患者至心导管室行CAG术。石彩兰11:0037.17216139/86100停共500共7501患者行PCI术后安返病房，术后情况详见术后护理介入记录单，遵医嘱予心电监护，示窦性心律。石彩兰11-1010:0037.06919135/8299共450共8000患者无诉不适，遵医嘱予停心电监护。石彩兰11-118:3036.57820145/9698共420共9501患者今早8am口服药全部掉落地面，遵医嘱予波立维75mg、拜阿司匹林100mg、螺内酯片20mg、丽倍乐20mg、倍他洛克95mg、万爽力20mg口服。石彩兰11-1414:0036.67918148/8199共350共10001患者诉仍间有胸闷不适，予异舒吉喷雾一只交患者备用，已指导使用方法。石彩兰11-1512:0036.77517133/7299共450共8501患者出院，指导患者低盐低脂饮食，定时监测血压，按时服药，勿情绪激动，勿用力排便，不适随诊。石彩兰病人出院指导一、休息和功能锻炼根据年龄及病情选择低强度的有氧运动，如步行、慢跑、打太极拳等。要采取循序渐进的方式来增加活动量，一般每周3~5次，每次30~60分钟。外出运动时请随身携带硝酸甘油，如出现胸闷、胸痛时应立即停止运动就地休息并含服硝酸甘油，如症状10分钟无缓解请立即至医院就诊或呼叫120。二、生活、工作中注意事项保持乐观情绪，避免紧张焦虑和情绪激动，多参加益于健康的娱乐活动，每天做些您感兴趣的事，保持身心轻松、愉快。避免过度劳累和用脑过度，生活有规律，保证充足睡眠。天气变化时，注意保暖，避免受凉。不宜用过热、过冷的水洗澡或蒸汽浴，洗澡时间不宜过长，门不应反锁。合并高血压，糖尿病，需严格控制好血压血糖，并注意监测血压及血糖。就诊其他疾病时应主动告知医生自己所患疾病、所行手术及服药情况。三、饮食1.控制能量的摄入，每日三餐最好定时定量，避免暴饮暴食。肥胖者应减轻体重，将体重指数（BMI）控制在25以下。（BMI=体重Kg：身高m2，正常范围18.5-24）限制脂肪的摄入，特别是肥肉、动物内脏、蛋黄。烹调时，尽量选用植物油。限制盐的摄入量，每日应控制在6克以下（普通啤酒盖去掉胶垫后，一平盖食盐约为6克）。适量摄入优质蛋白质，如淡水鱼类。多食新鲜的蔬菜、水果及纤维素类食物以预防便秘，少量多餐，避免暴饮暴食。便秘时，不可过度用力，以免增加心肌耗氧，甚至诱发心肌梗死。戒烟，吸烟是引起冠心病的一个重要因素，吸烟者需立即戒烟。限酒，有饮酒习惯者，每周4-5天，可适当饮用红酒30毫升/日。不饮咖啡、浓茶。四、自我监测和护理（药物治疗/伤口护理/病情观察等）：1.遵医嘱用药，每天坚持并按时、按量服药，不能擅自停药、改药，自我监测用药的不良反应，药物的增减与更换应咨询专科医生。PCI术后氯毗格雷片应至少服用1年，阿司匹林肠溶片、他汀类、B受体阻滞剂及ACEI（或ARB）等药物应终身服用。2..指导继续使用抗凝、抗血小板、降脂药、硝酸酯类、钙通道拮抗剂、ACE-I类药物，详细说明用药剂量，时间，方法及药物的毒副作用。服用抗凝，抗血小板药物（如阿司匹林，氯毗格雷）时，应注意观察是否有血尿、黑便、难以止住的牙龈及鼻腔出血；服用他汀类药物时，应注意观察是否有肌痛、恶心等症状，一旦有上述情况，请及时就诊，指导病人观察出血倾向。日常生活中，特别是外出时，要携带冠心病急救药物（硝酸甘油）以备急用。可在运动、涉及情绪激动情况前，先把硝酸甘油含于舌下，以预防心绞痛发作。另外，硝酸甘油见光易分解，故应放在棕色瓶中，最好6个月更换一次。病情监测：教会患者心绞痛发作时的缓解方法，胸痛发作时应该立即停止活动，或者舌下含服硝酸甘油，连续使用三次若是没有缓解及时就医，应定期检查心电图，血压，血糖，血脂和肝功能等。不要听信任何可根治冠心病的广告或宣传，避免上当受骗。五、复查1、服药过程中应1-2周至门诊随诊。每月应行肝肾功、血糖、血脂、血常规、凝血功能、心肌酶及心电图等检查。于介入治疗术后6个月复查冠状动脉造影。2、本科专家出诊时间：我科室周一至周六设有主任门诊及普通门诊。六、其他清淡饮食低盐低脂控制体重适度运动忌烟限酒注意保暖避免受凉控制情绪心态平和愉悦生活睡眠充足遵嘱服药定期复查不适随诊七、护理小结（住院期间护理程序实施情况与存在问题）患者既往病史有很多，如慢性肾功能不全、下肢深静脉瓣膜不全、颈动脉硬化和痛风等，在患者住院期间中不仅要注重患者现存护理问题，也要注意患者潜在的护理问题，对患者的护理和宣教要做到认真和详细对待。NursingrecordsNursingrecordlistforthefirsttimeName:ChenGuanlianGender:maleAge:71yearsoldDepartment:No.1departmentofcardiologyBednumber:HNL01Hospital/IDnumber:359101Dateofadmission:14:37,Nov5th,2016Occupation:otherRace/Religions:Han/nomaritalstatus:MarriedProfession:otherEducationdegree:SecondaryschoolDateresource:Patientdailycaregivers:Self-careAdmissionform:WalkAdmissiontype:OutpatientClinicAllergy:SulfonamidesPaysupport:OthersocialinsuranceHospitaldiagnosis:coronaryheartdiseasePastmedicalhistory:Coronaryheartdisease,PCI,Hypertension,Renalinsufficiency,Chronicgastritis,Gout,Carotidarteryartherosclerosis,Deepvenousvalvulainsufficiencyoflowerextremities,CarotidatherosclerosisNursingassessmentStateofconsciousness:callcanbeanswerAnswers:relevant;Diet:eatingbyhimselfChewingdifficulties:noDysphagia:noOralmucosa:completeGastro-intestinalsymptoms:noSleep:normalTiredafterwakeup:noUrination:normalDefecation:normal(1time/day);Limb’activity:freelySelf-careability:fullySkincondition:completeLanguagecommunication:themostcommonlanguage:CantoneseLanguageexpression:clearHabits:nosmoking,nodrinkingWounds:noFistulizationoral:noVeintube:noIndwellingdrainagetube:noPain:noIntakereducedinlatestweek:no;Loseweightinthelast3months:noRiskofpressureulcers:no;Riskoffall/dropbed:yes;Riskoflost:noOthersignsandsymptoms:noAdmissionGuideMaterialmanagement,timetable,visitandaccompanyrules、rulesoforderfoods、introducechargedoctor,chargenurse、headnursenursingemphasisbasicnursing:clothes、dietsSpecializednursing:Security:identification,safetransport,bedsiderails、preventafallOtheremphasisofnursinghand-overprocess:bloodpressureRecordtime:14:56,Nov5th2016Nursesignature:ShiCailanAudittime:16:52,Nov5th,2016Reviewersignature:HuangQinghua

NursingrecordlistName::ChenGuanlianSex:maleAge:a71yearsoldDepartment:No.1departmentofcardiologyBednumber:HNL01Hospitalnumber:359101Dateofadmission：14:37,Nov5th,2016Date//TimeT°CPTime/minRTime/minBPmmHgSPO2%oxygenuptake(v/min)IntakeVolumeOutputvolumeMotions(time/minOthersSign2016-11-514:5336.76820143/739621ToinformthehospitalizingeducationandpatientswithoutfeelingunwellShiCailan11-617:0037.07219142/72972All350All6000HadinformtheresultstodoctorBNPresults:18.14pg/ml,PCTresultsasfollows:<0.1ng/ml,CTNTresults:<50ng/ml,ShiCailan11-79:1736.96718159/91982Tothesublingualnitroglycerin0.5mgadministering,intravenousisoketwith50mgto5ml/h.ShiCailan11-79:3037.27119142/89972All400All7001Patientfeelnauseaandvomitingonce,andgastriccontentsisabout80ml,andgivemetoclopramideintramuscularinjection.ShiCailan11-810:2237.37517144/799821HavebeenreportedtheresultofquantitativetroponintodoctoronNov.8:quantitativehigh-sensitivitytroponinis0.554ug/ml.Patientfeelnodiscomfort,andguidepatientstorest,andbedsidethebed,andavoiddefecatingfiercely.ShiCailan11-816:0036.86920140/83992All350共All9001PatientsisreadytotheCAGtomorrow..andfollowthedoctor'sadvicetoNS250mlinaslowdrip.ShiCailan11-99:1036.77421135/76982All200All8000SendpatientstocardiaccatheterizationroomtoShiCailan

CAGwithdoctorsandfamilies.11:0037.17216139/86100停All500All7501PatientsbacktowardsafelyafterPCI,andpostoperativeconditionscanbefoundintherecordofinterventionalnursingcareaftersurgery,andgiveECGmonitoringwiththedoctor'sadvice.andshowinsinusrhythm.ShiCailan11-1010:0037.06919135/8299All450All8000Patientswithnodiscomfort,stoptoECGmonitoringwiththedoctor'sadvice.ShiCailan11-118:3036.57820145/9698All420All9501Thepatient'soralmedicationsallfellonthegroundat8amthismorning.Then,giveoralmedicationstopatientwithPlavixwith75mg,Aspirinwith100mg,Spironolactonewith20mg,Spironolactonetabletswith20mg,Betalocwith95mg,RabeprazoleSodiumEnteric-coatedCapsuleswith20mg,andvasorelwith20mg.ShiCailan11-1414:0036.67918148/8199All350All10001patientstillhavechestdiscomfort,andgiveisoketspraytopatientswhenneeded,andhasbeenguidingthemethodofusage.ShiCailan11-1512:0036.77517133/7299All450All8501Togivethepatientsdischargeguidancewithalowsalt,lowfatdiet,regularmonitoringofbloodpressure,andtakemedicineontime,Donotemotional,notdefecateforcibly,andreviewwhenfeeldiscomfort.ShiCailanThepatientdischargeguidanceRestandfunctionalexerciseAccordingthepatient'sageandconditiontochoosethelow-intensityaerobics,suchaswalking,jogging,taichi,etc.Thepatientshouldexercise3~5timesaweekgenerally,andeverytimeis30to60minutesduringtheincreasingactivitystep-by-step.Pleasecarrynitroglycerinwhenyougoouttoexercise.Iffeelchesttightness,chestpain,youshouldstopexercisingandtakingnitroglycerinimmediatelyontherest.Besides,pleasegotothehospitalorcall120immediatelyifthesymptomscan'treliefin10minutes.AttentioninlifeandworkTrytokeepoptimisticmood,andavoidanxiousandexcited.Itisbeneficialtoyoutoparticipateinmorehealthyentertainmentactivities.Trytokeeprelaxedandhappyinphysicalandmentalateveryday,anddosomethingwhatyouareinterestedin.Avoidoverworkandoverstrainnerves.Besides,trytoassureenoughsleepandkeeparegularlife.Besuretokeepwarmandavoidcatchacoldwhentheweatherchanges.Itisinappropriatetouseoverheatingandovercoolingwatertobathorsauna.Shower'stimeshouldnotbetoolong,andtheshower'sdoorshouldnotbelocked.Thepatientwithhypertensionanddiabeteswhoneedtocontrolthebloodsugar,bloodpressurestrictlyandpayattentiontothemonitorbloodpressureandbloodsugar.Youshouldinformthedoctoraboutthesituationofdisease,surgeryandmedicationwhenyougotohospitaltoseeotherdiseases.Self-psychologicaladjustment,adjuststateofmind,alleviatepsychologicalpressure,avoidexcessiveoverworked,emotional,forciblydefecate.DietTrytocontroltheintakeofenergy:avoidovereatingandthreemealsatregulardietsperday.Obeseshouldreduceweight,andbodymassindex(BMI)undercontrol25.(BMI=weightKgpresentheightm2,normalrange18.5-to24)Limittheintakeoffatmeat,especiallyfat,liver,eggyolk.Itisbettertousevegetableoilduringcooking.Besides,trytolimittheintakeofsalt,anditshouldbecontrolledbelow6gramsdaily(afterremovingthecommonbeer'scoverrubbergasket,aflatcoversaltisabout6g).Itisbettertointakehigh-qualityproteininproperquantity,suchasfreshwaterfish,etc.Youshouldeatenoughfreshvegetables,fruit,andfiberfoodsinordertopreventconstipation.Avoidovereatingandeatingmorefrequentlyinsmallermeals.Youshouldn'tuseexcessiveforcewhenyouhaveconstipation,inordertoavoidincreasemyocardialoxygenconsumption,eveninducemyocardialinfarction.Toquitsmoking,becausesmokingisamajorcauseofcoronaryheartdisease.Smokershouldbekickedthehabitofsmokeimmediately.Drinkersshouldlimittheintakeofalcohol,butdrinkercandrink30ml/daywithredwine4to5daysaweekappropriately.Don'tdrinkcoffee,tea,too.Self-monitorandcareYoushouldfollowthedoctor'sadvicetotakemedicationontimeeveryday,andcannotchangeorstopwithoutdoctor'sagreement.Also,Youshouldself-monitortheadversereactionsofdrug,andincreasingordecreasingandchangingthedrugshouldconsultaspecialist.Theclopidogrelshouldbetakenatleast1yearafterPCI,andaspirinenteric-coatedmetforminhydrochloride,statins,betablockersandACEIorARBdrugsshouldbetakenforthewholelife.Guidingthedrug'sdosage,time,methodandthesideeffectsofdrugstothepatientwithnticoagulationandantiplatelet,lipid-lowering,nitrates,calciumchannelblockers,ACE-Idrugs.Takinganticoagulantsandantiplateletdrugs(suchasaspirinandclopidogrel),shouldpayattentiontoobservewhetherthereisbloodintheurine,andblackindefecation,andifthereadifficultytostopbleedinginthenasalandgums.Thepatientshouldobservewhetherthereisamusclepain,nauseawhentakingstatins.Oncetheabovesituationappear,pleasedonothesitatetoseeadoctor,andinstructclienttoobservethebleedingtendency.Youshouldcarrytheemergencydrugs(nitroglycerin)ofcoronaryheartdiseaseespeciallygooutindailylifeincaseofurgentneed.Butinordertopreventheartattacks,youshouldsublingualnitroglycerinifinvolveemotionalsituationinmotionatfirst.Inaddition,nitroglyceriniseasydecomposesinthelight,soitshouldbeplacedinbrownbottle,anditisbettertoreplaceevery6months.Teachthemethodstorelieveanginapectorisattack,andshouldstoptheactivityorsublingualnitroglycerinimmediatelywhenchestpainocc