护理查房中英对照

Nursing ward round in English,September 2012,The condition of this Patient (wu nan zhen),The Patient,male,76 years old, 15 days ago after the cold he had cough, sputum, sputum with blood, Accompanied by shortness of breath, Shortness of breath after activity increased slightly, Without chills, fever, chest pain .,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。,At the local hospital for treatment with antibiotics, specific agents is unknown, The Symptoms are not controlled, and gradually increased.,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。,With nocturnal paroxysmal dyspnea, but without chest pain, For further treatment, and then to our hospital.,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。,In September 4, 2012 15:30,this patient on the flat car admitted to emergency form, In our department, Diagnosis of “The Senile pneumonia” .,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。,In this time with the patient sick, his spirit and appetite are normal, feces and urine are normal, poor sleep, weight does not have apparent change.,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。,The admission examination: temperature: 37.2 degrees centigrade, pulse: 100 times per minute, breathing: 20 times per minute Bp:160/90 mmHg. Sane, lips no cyanosis. Lung auscultation: breathing sound rough, two lung may hear and little moist rales . the legs no edema.,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。,Past history,This patient had hypertension, cerebral arteriosclerosis, coronary heart disease, chronic obstructive pulmonary disease for more than 10 years, Has a long history of use of antihypertensive drugs.,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。,In 52 years ago, he have the trauma operation history, and many place of the whole body is the bomb fragment injury. The Patient with a smoking habit, smoking 23 years, daily 60 branch. Having quit smoking. Quit smoking for 21 years.,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。,Auxiliary examination,Routine blood test results: a normal leukocyte count, neutrophil slightly higher. Chest X ray showed: two lung patchy infiltration of shadow, and accompanied by pleural effusion.,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。,Lung Computerized Tomography (CT) indicated: pulmonary infection. Arterial blood gas results show: Partial pressure of oxygen is 80mmHg, Partial pressure of carbon dioxide is 40mmHg, Blood oxygen saturation is 90%. Electrocardiographic findings show: atrial fibrillation, multiple ventricular premature.,肺部CT示：肺部感染。ABG结果示：PO2 80mmHg,pco2 40mmHg,SaO2:90%。心电图结果示：房颤、多发室早。,admitting diagnosis ： (su min),Pneumonia .Chronic obstructive pulmonary disease.Coronary heart disease, Heart function class ,Arrhythmia, Multiple room sex premature beat, Rapid atria fibrillation .Hypertension ,grade ,extremely high risk group.,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 。,therapeutic process :,After admission，with Cefodizime fighting infection、ambroxol resolving the phlegm aerosol inhalation 、vibration sputum discarding .,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。,Meglumine adenosine cyclophosphate Improving cardiac function、digoxin strengthening the heart、mexiletine controling arrhythmia,the effect of all these treatings are not beautiful a week later .,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。,The patient is still being cough 、sputum and shortness of breath, after checking blood picture high , we change cefodizime to meropenem fighting infection.,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。,present conditions,At present，the patient is conscious and feel fit .the temperature and the blood pressure are normal ,but after exercise it will cause symptoms such as palpitation and shortness of breath the symptoms have improved. there is no blood in sputum .the neck vein is enlarged ， Double lung breath sounds coarse .,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。,A few moist and rhonchi rales have been audible over both lung .heart rate is ninety per min .the pulse rate is untidy .Pulse deficit. Pulmonary infection is poorly controlled .The patient still has cough and shortness of breath.,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。,Nursing diagnosis and nursing measures （su li),1、Ineffective Airway Clearance:Lung infection, tracheal and bronchial secretions increase, sticky and fatiguearerelatedObservation:Closely observe coughandcough phlegm situation,Including sputum color, quantity and character,Andwhetherexpectoration is smoothor not.,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。,Medication nursing:Follow the doctors advice to anti-inflammatory, cough, expectorant,Notice the drug curative effect and adverse reaction.To keep respiratory tract unobstructed:Instructthepatienttohavemore water, in order to achieve a wet process airwayanddilutionsputum.,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。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、Gasexchange damaged:airway obstruction, lack of ventilation and respiratory muscle fatigue, secretion too much and alveolar breathing area reducearerelevant(1)Rest and activity:The patient to take a comfortable position, depending on the condition to arrange the proper activity, the activity to not feeling fatigue, dont aggravate symptoms advisable.,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。,(2)Observation:Observation cough, sputum, the degree of difficulty in breathing, monitoring artery blood gas analysis and water, electrolyte and acid-base balance situation.,病情观察：观察咳嗽、咳痰，呼吸困难的程度，监测动脉血气分析和水、电解质、酸碱平衡情况。,(3)Medication nursing:Follow the doctors advice application antibiotics, bronchial diastolic medicine and eliminating phlegm drugs, attention to the observation of curative effect and adverse reaction.,用药护理：遵医嘱应用抗生素、支气管舒张药和祛痰药物，注意观察疗效及不良反应。,(4)Respiratoryfunction exercise:Instructthe patientto exhale to shrink lip, abdominal breathing, diaphragmatic muscle pacemaker, suction resistance device breathing exercises to strengthen the chest, respiratory muscle strength and endurance, improve the respiratory.,呼吸功能锻炼：指导病人进行缩唇呼气、腹式呼吸、膈肌起搏、吸气阻力器呼吸锻炼以加强胸、膈呼吸肌肌力和耐力，改善呼吸功能。,(PENG YU),3、Without enduring activitives:related with fatigue,or difficulty in breathing, the imbalanced between oxygen supply and consumption and the change of cardiac output due to arrhythmia .,3、活动无耐力：与疲劳、呼吸困难、氧供与氧耗失衡，心律失常导致心排血量有关,(1)Arrange it reasonablely and adjust the way of daily activities, for example,if permits, you can increase the amount of exercise and change the way in a planed way, such as walking in the house ,taking part in outdoor activities, walking around, going quickly, jogging, taiji, gymnastics, etc,to raise vital capacity and activity endurance gradually.,（1）、合理安排休息和活动量，调整日常活动方式，如病情许可，有计划的增加运动量和改变方式，如室内走动、室外活动、散步、快走、慢跑、太极拳、体操等，逐步提高肺活量和活动耐力。,(2)Keep in a Comfortable position: patients should keep the body forward when sitting or semirecumbent, use some support such as pillow, back frame or table with the principle of the comfortable feeling of the patient. Avoid to exacerbate chest constriction by tight clothes or too thick cover.,（2）、舒适体位：病人采取身体前倾坐位或半卧位，可使用枕头、靠背架或桌边等支撑物，以病人自觉舒适为原则。避免紧身衣服或过厚盖被而加重胸部压迫感。,(3)Observation: observe the vital signs and the condition of his consciousness; Pay attention to cyanosis and breathing difficulties, and its degree.,（3）、病情观察：观察病人的生命体征及意识状态；注意有无发绀和呼吸困难，及其严重程度。,If the patient ,in the process of activities, have difficulty in breathing, chest pain, heart palpitations, dizziness, fatigue, sweating, pale,or hypotension etc , then he should stop the activities at once. If the symptoms continue to exist after relax , then you should notify the doctor in time .,若病人活动过程中有呼吸困难、胸痛、心悸、头晕、疲劳、大汗、面色苍白、低血压等情况时应停止活动。如病人经休息后症状仍持续不缓解，应及时通知医生。,4、Have thedanger of being injuried : related with dizziness, faint caused by arrhythmia .（1）Assessrisk factors: ask the patient whether have some incentive factors and aura symptoms before syncope and understand the position ,duration and accompanying symptoms etc. if necessary, using ECG monitoring to observe the type of arrhythmia.,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）Stay in bed and strengthen the care to the life ，if the patient have dizziness,attacked by syncope or the history of fall and instruct client to avoid going out alone to prevent from accident.,（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）avoid incentive: told client to avoid strenuous activity, mood excited or nervous, change of position rapid and so on .In order to avoid injuries ,once the patient have the aura of dizziness amaurosis keep recumbent 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）Give treatment follow the doctors advice: give digoxin , mexiletine to the patients who have atrial fibrillation and start early of the multi- pleventricularto control arrhythmia follow the doctors advice, and look at the reaction.,(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。,(long li juan),5、 Potential complications: infectious shock, high blood pressure emergency, respiratory failure, heart failure, stroke,5、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）Avoid incentive: to clarify the patient undesirable mood may induce various complications, should avoid mood excited, keep mood calm, relaxed, stability. According to the doctors advice to take the guidance of anti-hypertensive drugs, as far as possible avoid over fatigue and cold stimulation.,（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）Condition monitoring: monitoring patients life signs and symptoms, once found a sharp raise or lower of the blood pressure, heart rate increasing fast, difficulty breathing, body temperature does not rise or high fever, severe headache, vomiting, big sweat, blurring of vision, complexion and mind change, body movement disorders, and so on, immediately notify the doctor, and ready for items, and actively cooperate with the rescue.,(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）the rescue of Septic shock :1） Position: the patient take on your back in the notches, raise cephalothorax 20 degrees, drive up lower limb about 30 degrees.It will be helpful for breathing and venous return.,(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: give high flow oxygen, maintain oxygen partial pressure 60 mmHg, improve the anaerobic condition.3） Added blood volume: fast establish two venous path, follow the doctors advice to give dextran or balance fluid to maintain effective blood volume, reduce blood viscosity, prevent diffuse intravascular coagulation; Have obvious acidosis can be used 5% NaHCO3 static drop.,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） Medication nursing :Follow the doctors advice input dopamine, between the hydroxylamine (alamine) and vasoactive drugs.Combined use of broad-spectrum antibacterial drug control infection, should pay attention to drug curative effect and adverse reaction.,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）High blood pressure emergency care:The patient absolute bed rest, raise the head of a bed, avoid any bad stimulation and unnecessary activities, assist life care. To keep respiratory tract unobstructed, 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。,Emotional stability and patient, when necessary, use depressant. Connection kind electric, blood pressure, breathing guardianship. Quickly establishing venous path, follow the doctors advice as early as possible application of anti-hypertensive drugs, drug process note monitoring blood pressure change, avoid blood pressure dip.,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）The nursing of respiratory failure: 1) To keep respiratory tract unobstructed: a: removal of secretion of respiratory tract and foreign body b: alleviate bronchospasm c: establishing artificial airway,(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) Oxygen therapy3) Increasing ventilation, reduce CO2 retention: a: breathing stimulant b: mechanical ventilation4) Fight infection5) Correct acid-base balance,2) 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) Heart failure care: Assist client to immediately take seat, double leg prolapse, give 6 8 l/min high flow oxygen inhalation.,(6)心力衰竭的护理：立即协助病人取坐位，双腿下垂，给予68L/min的高流量氧气吸入。,Quickly establishing two venous channel, morphine calm and furosemide diuresis , sodium nitroprusside, nitroglycerin or phentolamine expand blood vessel, digitalis preparation protecting heart and aminophylline remove bronchospasm. Rigorous monitoring condition changes.,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) sudden death nursing: establishing venous path, ready for anti-arrhythmic drugs and other rescue drugs, defibrillator, temporary pacemaker, 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。,Timely follow the doctors advice to give drug therapy, when necessary, cooperate with temporary cardiac pacemaker or cardioerter. Once produce sudden death performance such as consciousness suddenly loses, convulsions, aorta beating disappear, respiratory arrest, immediately to rescue.,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、 Anxiety worried about the disease prognosis Nursing staff should be detailed understanding of patients and their families to disease attitude, caring patients, understand the patient psychology and personality, life style, etc for sick and change, and patients and their relatives on a common formulation and implementation rehabilitation plan.,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。,Eliminate incentive, regular breathing machine function exercise, reasonable use of antibiotics, relieve symptoms, enhance the confidence of conquer disease.,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。,To the performance anxiety of patients, the church patients relieve anxiety methods, such as listening to light music, play chess, such as game for recreational activities, in order to divert attention from, reduce anxiety.,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。,Health education (he shu),1、 maintain the good life habit, pay attention to a dull boy, sufficient rest.2、 in ordinary life, COPD patients should exercise based on their own physical condition such as improve the resistance and lung function, etc.3、 avoid contact or eliminate induced factors, such as dust, diet and health .respiratory infections, 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、Smoking is the main cause of COPD, so give up smoking as soon as possible is the key of prevention COPD disease.5、 Keep good dietary collocationin life is necessary , of seasonable compensatory body needed nutrients and energy, try to avoid eating crude, cold and a sweet, spicy.6、Stay calm and avoid emotional and excessive tension, anxiety, when anything crops up to calm.,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、 Must adhere to the long-term use of antihypertensive drugs, and understand the effect and side effects of medicines , monitoring the blood pressure regularly.8、 Application antihypertensive process, action should try to slowiy, especially the night up urinate more attention should be paid to, in order to avoid blood pressure drops suddenly cause syncope .,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、 Completes the coronary heart disease “secondary prevention” : primary prevention is focused on blood lipid, blood glucose, blood pressure; Secondary prevention article 5 lines :A :taking aspirin and angiotensin converting enzyme inhibitor,9、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: taking -receptor blockers and control of blood pressure C: lower cholesterol and quit smoking D :controlling diabetes and reasonable diet E: movement and health education,B、服用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。,Nursing new progress (li yuan yuan),Oral care Aspiration of oral, pharyngeal secretion in elderly patients with bacterial pneumonia is the important factor, and poor oral hygiene can induce the senile patients with pneumonia. Prospective study of elderly patients with good oral care can reduce the incidence of pneumonia risk in elderly.,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。,In awake patients caught the attention of the omission of Furacilin Solution, 3-4 times a day, with high heat, look forward to, coma patients daily oral care 2 times, according to oral pH value choice gargle, PH 7 and oral mucosa ulcer or pustule with hydrogen peroxide, oral mucosa have herpes, coated with 2% gentian violet.,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，PH7时用2%硼酸溶液，PH7且口腔黏膜有溃疡或脓包选用双氧水，口腔黏膜有