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1、脑梗死病人护理查房 (Nursing round about the patient of cerebral infarction),护理查房目的（The purpose of this nursing round),1.掌握脑梗死的定义及临床表现Master the definition and clinical manifestations of cerebral infarction 2.熟悉脑梗死的治疗及护理Be familiar with the treatment and the nursing care 3.进一步培养护理人员临床思维能力Further training the
2、clinical thinking ability of nurse 4.加强护患沟通能力，提供更好的服务 Strengthen the communication skills, to provide better service for the patients,临床资料 The introduction of the patients condition,病情介绍(Case history introduction),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。Bed 1
3、5，Dongjiatian , male ,65 years old .He was admitted to our hospital because of glossolalia ,water choking cough aggravating for 4 days. Past medical history has hypertension,diabetes, coronary heart disease and other medical disease. After that, his right upper limb cant hold and need help to walk.,
4、临床资料 Physical examination,查体(PE),T：36.6 P：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：36.6 degree centigrade P：74timesminute R: 18 timesminute BP: 170/106mmhg. Old male ,conciousnes, dysarthria,his right upper limb proximal muscle strength is lower than level 2,
5、distal level 2,right lower limb muscle strength is level 3.The muscle tention is slightly higher.,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 Active movement against gravity能对抗重力和部分阻力Active movement against gravity and some resistance,肌力正常 Normal power,No contraction of muscle visib
6、le,Flicker or trace of contraction visible,Active movement at joint, with gravity eliminated,辅助检查 (Auxiliary examination ),影像学检查 (Imaging examination),诊断(Diagnosis),1.脑梗死(cerebral infarction) 2.糖尿病（Diabetes） 3.冠心病（Coronary heart disease） 4.颈动脉粥样硬化(Carotid artery atherosclerosis) 5.颅内动脉狭窄(Intracrania
7、l artery stenosis) 6.高血压病(Hypertention),脑梗死的定义(The definition ),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(A stroke is a brain injury caused by an abnormality of the blood vessels supplying the brain.),2018/9/25,10,危险因素(Risk factor),10,2018/9/25,脑梗死临床表现 (Clinical manifestation),患者临床症状
8、与脑内梗死部位密切相关VTS_01_1(000807755-000838760).vob,2018/9/25,12,一、出血性or缺血性？(Intracerebral hemorrhage or cerebral infarction),出血？ 缺血？,12,2018/9/25,2018/9/25,13,二、静脉溶栓治疗 (Intravenous thrombolysis treatment),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,13,2018/9/25,护理诊断,焦虑（anxiety）：与担心疾病的预后有关(It is because of w
9、oryying about the prognosis of the disease.) 知识缺乏（The lack of knowledge）:缺乏与疾病相关的治疗、康复、及护理方面的知识(Concerning about the Knowledge of the treatment,reheblitation,and how to look after the patient),Nursing,Diagnosis,Nursing diagnosis,护理诊断,自理能力缺陷 (Defect of selfcare ability) ：与肢体肌力下降有关（Which is associated
10、 with decreased muscle strenght）高血压（Hypertention）:与紧张及脑水肿导致颅内压增高有关 （Which is caused by mental tension and increased intracranial pressure ）,Nursing,Diagnosis,Nursing diagnosis,营养失调 （malnutrition ）：与吞咽困难，流 质饮食有关(Which is related to dysphagia and need to be given liquid diet) 潜在并发症： Potential complica
11、tion.有感染的危险 （The risk of infection ）：与饮水呛咳导致肺部感染有关(Which is because of drinking water choking cough cause lung infection).有便秘的危险 （The risk of constipation ）：与活动和流质饮食有关(Which is due to be given liquid diet and decreased activity),护理措施,护理,措施,Nursing interventions,1.做好入科宣教，为患者提供安全舒适的环境。 （We should comm
12、unicate with patients in detail when they first come to our section .） 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。 （Tell the patient the knowledge and the prognosis about his disease，including the treatment，nursing care and rehabilitation。）,护理措施,护理,措施,Nursing interventions,3.与患者及家属共同制定康复计划，并督促其执行（Recovery
13、 plan with the patient and his family memebers，and supervise its implementation.） 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。 （Follow the doctors advice to control the blood pressure，then observe the effect and the side effects of the medicine,护理措施,护理,措施,Nursing interventions,5.为患者提供低盐低脂高纤维素饮食。 (The patient shoul
14、d accept the healthy diet, for example, low salt ,low fat and high fiber diet.) 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。 (Turn over the patient and knock his back every 2 hours ,encourge the effectively cough. Acorrding to the doctors advice and use antibiltic.),护理措施,护理,措施,Nursing interventions,7.鼓励病人适当进行功能锻炼，给予腹部环形按摩，预防便秘的发生。 (Encourage the patient to do more functional exercise,give the patients abdomen circular massage to prevent constipation.),对于接受溶栓治疗的病人，作为护理人应采取哪些护理措施？(What measures should we take if a patient received intravenous thrombolysis),
