护理和查房中英对照

NursingwardroundinEnglish

September2012

Theconditionofthis

Patient

(wunanzhen)ThePatient,male,76yearsold,15daysagoafterthecoldhehadcough,sputum,sputumwithblood,Accompaniedbyshortnessofbreath,Shortnessofbreathafteractivityincreasedslightly,Withoutchills,fever,chestpain.病例概述

患者，男性，78岁，老年性肺炎患者诉15天前因受凉后出现咳嗽、咳痰，痰中带血丝，伴气促，稍活动后气促即加重，无畏寒、发热，无胸痛。Atthelocalhospitalfortreatmentwithantibiotics,specificagentsisunknown,TheSymptomsarenotcontrolled,andgraduallyincreased.在当地医院予以抗感染治疗，具体药物不详，症状未予控制，并逐渐加重。Withnocturnalparoxysmaldyspnea,butwithoutchestpain,Forfurthertreatment,andthentoourhospital.有夜间阵发性呼吸困难，无胸痛，为求进一步诊治，遂入我院就诊。InSeptember4,201215:30,thispatientontheflatcaradmittedtoemergencyform,Inourdepartment,Diagnosisof“TheSenilepneumonia”.于2012年9月4日15：30急诊平车入院，以“老年性肺炎收住我科。Inthistimewiththepatientsick,hisspiritandappetitearenormal,fecesandurinearenormal,poorsleep,weightdoesnothaveapparentchange.患者自起病以来，精神食欲可，大小便正常，睡眠欠佳，体重无明显改变。

Theadmissionexamination:temperature:37.2degreescentigrade,pulse:100timesperminute,breathing:20timesperminuteBp:160/90mmHg.Sane,lipsnocyanosis.Lungauscultation:breathingsoundrough,twolungmayhearandlittlemoistrales.thelegsnoedema.入院查体：T：37.2℃，P:100次/分，R:20次/分，Bp:160/90mmHg。神清，口唇无发绀。肺部听诊：双肺呼吸音粗，两肺可闻及少量湿性啰音。双下肢无浮肿。Pasthistory

Thispatienthad"hypertension,cerebralarteriosclerosis,coronaryheartdisease,chronicobstructivepulmonarydisease"formorethan10years,Hasalonghistoryofuseofantihypertensivedrugs.既往史既往有“高血压病3级极高危组、冠心病、脑动脉硬化、慢性阻塞性肺气肿疾病”10余年病史，有降压药长期服药史。

In52yearsago,hehavethetraumaoperationhistory,andmanyplaceofthewholebodyisthebombfragmentinjury.ThePatientwithasmokinghabit,smoking23years,daily60branch.Havingquitsmoking.Quitsmokingfor21years.52年前因外伤手术史，有52年前全身多处被炸弹碎片击伤外伤史，患者有吸烟嗜好，吸烟23年，每日60支。有戒烟。戒烟21年。Auxiliaryexamination

Routinebloodtestresults:anormalleukocytecount,neutrophilslightlyhigher.ChestX–rayshowed:twolungpatchyinfiltrationofshadow,andaccompaniedbypleuraleffusion.

辅助检查血常规结果示：白细胞计数正常，中性粒细胞稍增高。胸部X片结果示：两肺斑片状浸润性隐影，并伴有胸腔积液。LungComputerizedTomography(CT)indicated:pulmonaryinfection.Arterialbloodgasresultsshow:Partialpressureofoxygenis80mmHg,Partialpressureofcarbondioxideis40mmHg,Bloodoxygensaturationis90%.Electrocardiographicfindingsshow:atrialfibrillation,multipleventricularpremature.肺部CT示：肺部感染。ABG结果示：PO280mmHg,pco240mmHg,SaO2:90%。心电图结果示：房颤、多发室早。admittingdiagnosis：

(sumin)Pneumonia.Chronicobstructivepulmonarydisease.Coronaryheartdisease,HeartfunctionclassⅢ,Arrhythmia,Multipleroomsexprematurebeat,Rapidatriafibrillation.Hypertension,gradeⅢ,extremelyhighriskgroup.入院诊断1、肺炎；2、慢性阻塞性肺气肿；3、冠心病心功能3级心律失常多发室早快速房颤；4、高血压病3级极高危组。therapeuticprocess:

Afteradmission，withCefodizimefightinginfection、ambroxolresolvingthephlegmaerosolinhalation、vibrationsputumdiscarding.治疗经过患者入院后，医嘱予头孢地嗪抗感染治疗，予氨溴索祛痰治疗，同时辅助予雾化吸入及振动排痰。MeglumineadenosinecyclophosphateImprovingcardiacfunction、digoxinstrengtheningtheheart、mexiletinecontrolingarrhythmia,theeffectofallthesetreatingsarenotbeautifulaweeklater.予环磷腺苷葡胺改善心功能，地高辛强心，美西律控制心律失常。患者入院抗感染治疗一周后效果不佳。Thepatientisstillbeingcough、sputumandshortnessofbreath,aftercheckingbloodpicturehigh,wechangecefodizimetomeropenemfightinginfection.患者仍有咳嗽咳痰气促，复查血常规血象升高，医嘱予停用头孢地嗪，现改用美罗培南抗感染治疗。presentconditions

Atpresent，thepatientisconsciousandfeelfit.thetemperatureandthebloodpressurearenormal,butafterexerciseitwillcausesymptomssuchaspalpitationand

shortnessofbreaththesymptomshaveimproved.thereisnobloodinsputum.theneckveinisenlarged，Doublelungbreathsoundscoarse.目前情况

患者目前神清，精神可。体温、血压正常，诉活动后心悸气促症状略有减轻，痰中无血，颈静脉充盈，口唇无发绀，双肺呼吸音粗。Afewmoistandrhonchiraleshavebeenaudibleoverbothlung.heart

rateisninetypermin.thepulserateisuntidy.Pulsedeficit.Pulmonaryinfectionispoorlycontrolled.Thepatientstillhascoughandshortnessofbreath.双肺可闻及干湿性啰音，心率90次\分，律不齐，第一心音强弱不等，肺部感染仍控制不佳，仍有咳嗽气促。

Nursingdiagnosisandnursingmeasures

（suli)1、IneffectiveAirwayClearance:

Lunginfection,trachealandbronchialsecretionsincrease,stickyandfatigue

are

related①Observation

:

Closelyobservecough

and

coughphlegmsituation,

Includingsputumcolor,quantityandcharacter,

And

whether

expectorationissmooth

ornot.主要护理诊断及护理措施

1、清理呼吸道无效：与肺部感染，气管、支气管分泌物增多、黏稠及疲劳有关①病情观察：密切观察咳嗽咳痰的情况，包括痰液的颜色、量及性状，以及咳痰是否顺畅。②Medicationnursing:

Followthedoctor'sadvicetoanti-inflammatory,cough,expectorant,Noticethedrugcurativeeffectandadversereaction.③Tokeeprespiratorytractunobstructed:

Instruct

the

patient

to

have

morewater,inordertoachieveawetprocessairway

and

dilution

sputum

.②用药护理：遵医嘱予以抗炎，止咳，祛痰药，注意观察药物疗效和不良反应。③保持呼吸道通畅：指导病人多饮水，以达到湿化气道，稀释痰液的目的。2、Gas

exchangedamaged:

airwayobstruction,lackofventilationandrespiratorymusclefatigue,secretiontoomuchandalveolarbreathingareareduce

are

relevant(1)Restandactivity:

Thepatienttotakeacomfortableposition,dependingontheconditiontoarrangetheproperactivity,theactivitytonotfeelingfatigue,don'taggravatesymptomsadvisable.2、气体交换受损：与气道阻塞、通气不足、呼吸肌疲劳、分泌物过多和肺泡呼吸面积减少有关①休息与活动：病人采取舒适的体位，视病情安排适当的活动量，活动以不感疲劳、不加重症状为宜。

4、Havethe

dangerofbeinginjuried:relatedwithdizziness,faintcausedbyarrhythmia.（1）Assess

riskfactors:askthepatientwhetherhavesomeincentivefactorsandaurasymptomsbeforesyncopeandunderstandtheposition,durationandaccompanyingsymptomsetc.ifnecessary,usingECGmonitoringtoobservethetypeofarrhythmia.4、有受伤的危险：与心律失常引起的头晕、昏厥有关（1）评估危险因素：向病人及知情者询问病人晕厥发作前有无诱因及先兆症状，了解晕厥发作时的体位、晕厥持续时间、伴随症状等。必要时心电监护，动态观察心率失常的类型。（2）Stayinbedandstrengthenthecaretothelife，ifthepatienthavedizziness

,attackedbysyncopeorthehistoryoffallandinstructclienttoavoidgoingoutalonetopreventfromaccident.（2）有头晕、晕厥发作或曾有跌倒史者应卧床休息，加强生活护理。嘱病人避免单独外出、防止意外。（3）

avoidincentive:toldclienttoavoidstrenuousactivity,moodexcitedornervous,changeofpositionrapidandsoon.Inordertoavoidinjuries,oncethepatienthavetheauraofdizzinessamaurosiskeeprecumbent

immediatelly.（3）避免诱因：嘱病人避免剧烈活动、情绪激动或紧张、快速改变体位等，一旦有头晕、黑蒙等先兆时立即平卧，以免跌伤。（4）Givetreatmentfollowthedoctor'sadvice:givedigoxin,mexiletinetothepatientswhohaveatrialfibrillationandstartearlyofthemulti-pleventricular

tocontrolarrhythmiafollowthedoctor'sadvice,andlookatthereaction.(4)遵医嘱给予治疗：该病人有房颤和多发室早，应遵医嘱给予地高辛、美西律控制心律失常，并注意观察用药后反应。

(longlijuan)5、Potentialcomplications:infectiousshock,highbloodpressureemergency,respiratoryfailure,heartfailure,stroke5、潜在并发症：感染性休克、高血压急症、呼吸衰竭、心力衰竭、猝死

（1）Avoidincentive:toclarifythepatientundesirablemoodmayinducevariouscomplications,shouldavoidmoodexcited,keepmoodcalm,relaxed,stability.Accordingtothedoctor'sadvicetotaketheguidanceofanti-hypertensivedrugs,asfaraspossibleavoidoverfatigueandcoldstimulation.（1)避免诱因：向病人阐明不良情绪可诱发各种并发症的发生，应避免情绪激动，保持心绪平和、轻松、稳定。指导其按医嘱服用降压药物，尽量避免过劳和寒冷刺激。(2）Conditionmonitoring:monitoringpatient'slifesignsandsymptoms,oncefoundasharpraiseorlowerofthebloodpressure,heartrateincreasingfast,difficultybreathing,bodytemperaturedoesnotriseorhighfever,severeheadache,vomiting,bigsweat,blurringofvision,complexionandmindchange,bodymovementdisorders,andsoon,immediatelynotifythedoctor,andreadyforitems,andactivelycooperatewiththerescue.(2)病情监测：监测患者的生命体征，一旦发现血压急剧升高或降低、心率增快、呼吸困难、体温不升或高热、剧烈头痛、呕吐、大汗、视物模糊、面色及神志改变、肢体运动障碍等症状，立即通知医生，并备好物品，积极配合抢救。(3）therescueofSepticshock:1）Position:thepatienttakeonyourbackinthenotches,raisecephalothorax20degrees,driveuplowerlimbabout30degrees.Itwillbehelpfulforbreathingandvenousreturn.

(3)感染性休克抢救配合：1)体位：病人取仰卧中凹位，抬高头胸部20度、抬高下肢约30度，有利于呼吸和静脉血回流。2）Oxygen:givehighflowoxygen,maintainoxygenpartialpressure>60mmHg,improvetheanaerobiccondition.3）Addedbloodvolume:fastestablishtwovenouspath,followthedoctor'sadvicetogivedextranorbalancefluidtomaintaineffectivebloodvolume,reducebloodviscosity,preventdiffuseintravascularcoagulation;Haveobviousacidosiscanbeused5%NaHCO3staticdrop.2)吸氧：给予高流量吸氧，维持氧分压＞60mmHg，改善缺氧状况。3)补充血容量：快速建立两条静脉通路，遵医嘱给予右旋糖酐或平衡液以维持有效血容量，降低血液粘滞度，防止弥散性血管内凝血；有明显酸中毒可应用5%NaHCO3静滴。4）Medicationnursing:Followthedoctor'sadviceinputdopamine,betweenthehydroxylamine(alamine)andvasoactivedrugs.Combineduseofbroad-spectrumantibacterialdrugcontrolinfection,shouldpayattentiontodrugcurativeeffectandadversereaction.4)用药护理：遵医嘱输入多巴胺、间羟胺（阿拉明）等血管活性药物。联合使用广谱抗菌药物控制感染时，应注意药物疗效和不良反应。（4）Highbloodpressureemergencycare:Thepatientabsolutebedrest,raisetheheadofabed,avoidanybadstimulationandunnecessaryactivities,assistlifecare.Tokeeprespiratorytractunobstructed,oxygen.

(4)高血压急症的护理：病人绝对卧床休息，抬高床头，避免一切不良刺激和不必要的活动，协助生活护理。保持呼吸道通畅，吸氧。

Emotionalstabilityandpatient,whennecessary,usedepressant.Connectionkindelectric,bloodpressure,breathingguardianship.Quicklyestablishingvenouspath,followthedoctor'sadviceasearlyaspossibleapplicationofanti-hypertensivedrugs,drugprocessnotemonitoringbloodpressurechange,avoidbloodpressuredip.安定病人情绪，必要时使用镇静剂。连接好心电、血压、呼吸监护。迅速建立静脉通路，遵医嘱尽早应用降压药物，用药过程注意监测血压变化，避免出现血压骤降。（5）Thenursingofrespiratoryfailure:1)Tokeeprespiratorytractunobstructed:a:removalofsecretionofrespiratorytractandforeignbodyb:alleviatebronchospasmc:establishingartificialairway(5)呼吸衰竭的护理：1)保持呼吸道通畅：a、清除呼吸道分泌物及异物，b、缓解支气管痉挛，c、建立人工气道2)Oxygentherapy3)Increasingventilation,reduceCO2retention:a:breathingstimulantb:mechanicalventilation4)Fightinfection5)Correctacid-basebalance2)氧疗3)增加通气量、减少CO2潴留：a、呼吸兴奋剂，b、机械通气4)抗感染5)纠正酸碱平衡(6)Heartfailurecare:Assistclienttoimmediatelytakeseat,doublelegprolapse,give6~8l/minhighflowoxygeninhalation.(6)心力衰竭的护理：立即协助病人取坐位，双腿下垂，给予6~8L/min的高流量氧气吸入。Quicklyestablishingtwovenouschannel,morphinecalmandfurosemidediuresis,sodiumnitroprusside,nitroglycerinorphentolamineexpandbloodvessel,digitalispreparationprotectingheartandaminophyllineremovebronchospasm.Rigorousmonitoringconditionchanges.迅速建立两条静脉通道，吗啡镇静，呋塞米利尿，硝普钠、硝酸甘油或酚妥拉明扩张血管，洋地黄制剂护心，氨茶碱解除支气管痉挛。严密监测病情变化。(7)suddendeathnursing:establishingvenouspath,readyforanti-arrhythmicdrugsandotherrescuedrugs,defibrillator,temporarypacemaker,etc.（7）猝死的护理：建立静脉通路，备好抗心律失常药物及其他抢救药品、除颤仪、临时起搏器等。Timelyfollowthedoctor'sadvicetogivedrugtherapy,whennecessary,cooperatewithtemporarycardiacpacemakerorcardioerter.Onceproducesuddendeathperformancesuchasconsciousnesssuddenlyloses,convulsions,aortabeatingdisappear,respiratoryarrest,immediatelytorescue.及时遵医嘱给予药物治疗，必要时配合临时心脏起搏或电复律。一旦发生猝死的表现如意识突然丧失、抽搐、大动脉搏动消失、呼吸停止，立即进行抢救。6、AnxietyworriedaboutthediseaseprognosisNursingstaffshouldbedetailedunderstandingofpatientsandtheirfamiliestodiseaseattitude,caringpatients,understandthepatientpsychologyandpersonality,lifestyle,etcforsickandchange,andpatientsandtheirrelativesonacommonformulationandimplementationrehabilitationplan.6、焦虑与担心疾病预后有关护理人员应详细了解病人及其家庭对疾病的态度，关心体贴病人，了解病人心理、性格、生活方式等方面因患病而发生的变化，与病人和家属共同制定和实施康复计划。Eliminateincentive,regularbreathingmachinefunctionexercise,reasonableuseofantibiotics,relievesymptoms,enhancetheconfidenceofconquerdisease.消除诱因、定期进行呼吸机功能锻炼、合理用药等，减轻症状，增强战胜疾病的信心。Totheperformanceanxietyofpatients,thechurchpatientsrelieveanxietymethods,suchaslisteningtolightmusic,playchess,suchasgameforrecreationalactivities,inordertodivertattentionfrom,reduceanxiety.对表现焦虑的病人，教会病人缓解焦虑的方法，如听轻音乐、下棋、作游戏等娱乐活动，以分散注意力，减轻焦虑。Healtheducation

(heshu)1、maintainthegoodlifehabit,payattentiontoadullboy,sufficientrest.2、inordinarylife,COPDpatientsshouldexercisebasedontheirownphysicalconditionsuchasimprovetheresistanceandlungfunction,etc.3、avoidcontactoreliminateinducedfactors,suchasdust,dietandhealth.respiratoryinfections,germs,etc.

健康教育1、保持良好的生活习惯，注意劳逸结合,充足休息。

2、在平时生活中,慢阻肺患者应根据自身的体质及病情选择合适的项目进行锻炼，提高抵抗力及改善肺功能等。

3、尽量避免接触或消除诱发因素，如粉尘、饮食卫生、呼吸道感染、病菌等。

4、SmokingisthemaincauseofCOPD,sogiveupsmokingassoonaspossibleisthekeyofpreventionCOPDdisease.5、Keepgooddietarycollocationinlifeisnecessary,ofseasonablecompensatorybodyneedednutrientsandenergy,trytoavoideatingcrude,coldandasweet,spicy.6、Staycalmandavoidemotionalandexcessivetension,anxiety,whenanythingcropsuptocalm.4、吸烟是造成及促发慢阻肺疾病的主要原因，所以及早戒烟也是预防慢阻肺疾病的关键。

5、在生活中还应保持良好的膳食搭配，及时补充身体所需的营养及能量，尽量避免食用生冷、过甜、过辣等的刺激性食物。

6、保持平静的心境，避免情绪激动及过度紧张、焦虑，遇事要沉着冷静。7、Mustadheretothelong-termuseofantihypertensivedrugs,andunderstandtheeffectandsideeffectsofmedicines,monitoringthebloodpressureregularly.8、Applicationantihypertensiveprocess,actionshouldtrytoslowiy,especiallythenightupurinatemoreattentionshouldbepaidto,inordertoavoidbloodpressuredropssuddenlycausesyncope.7、必须坚持长期服用降压药，并了解药物的作用和副作用，定期监测血压。

8、应用降压药过程中，从坐位起立或从平卧位起立时，动作应尽量缓慢，特别是夜间起床小便时更要注意，以免血压突然降低引起晕厥而发生意外。9、Completesthecoronaryheartdisease“secondaryprevention”:primarypreventionisfocusedonbloodlipid,bloodglucose,bloodpressure;Secondarypreventionarticle5lines:A:takingaspirinandangiotensinconvertingenzymeinhibitor9、做好冠心病的二级预防：一级预防重点是干预血脂、干预血糖、干预血压；二级预防的5条防线是：A、服用阿司匹林及血管紧张素转换酶抑制剂。B:takingβ-receptorblockersandcontrolofbloodpressureC:lowercholesterolandquitsmokingD:controllingdiabetesandreasonabledietE:movementandhealtheducation

B、服用β受体阻滞剂和控制血压

C、降低胆固醇和戒烟

D、控制糖尿病及合理饮食

E、适量运动和健康教育。Nursingnewprogress(liyuanyuan)

OralcareAspirationoforal,pharyngealsecretioninelderlypatientswithbacterialpneumoniaistheimportantfactor,andpoororalhygienecaninducethesenilepatientswithpneumonia.Prospectivestudyofelderlypatientswithgoodoralcarecanreducetheincidenceofpneumoniariskinelderly.口腔护理

误吸口腔、咽部分泌物中的细菌是高龄老患者感染性肺炎的重要因素，而口腔卫生较差可促使高龄老年患者并发肺炎。前瞻性研究高龄老年人做好口腔护理可降低老年人发生肺炎的危险性。InawakepatientscaughttheattentionoftheomissionofFuracilinSolution,3-4timesaday,withhighheat,lookforwardto,comapatientsdailyoralcare2times,accordingtooralpHvaluechoicegargle,PH<72%boricacidsolution,PH>7andoralmucosaulcerorpustulewithhydrogenperoxide,oralmucosahaveherpes,coatedwith2%gentianviolet.清醒患者瞩其用呋喃西林溶液疏漏，3-4次每天，对高热、瞻望、昏迷患者每天进行口腔护理2次，根据口腔PH值选择漱口液，PH＜7时用2%硼酸溶液，PH＞7且口腔黏膜有溃疡或脓包选用双氧水，口腔黏膜有疱疹者，涂以2%的龙胆紫。Strengthennutritionanddietnursing:Accordingtotheelderlypatientswiththedietarycharacteristics,selectionofacceptablefood,encouragingeatinghighcalorie