《胆囊结石英语查房》由会员分享，可在线阅读，更多相关《胆囊结石英语查房（13页珍藏版）》请在金锄头文库上搜索。
1、Liu nurse: Welcome warmly the nursing department leadership nurses, nursing sisters to guide the work of our department. The contents is patients care of Gallbladder stones with diabetes. As limited, please give us help, thank you! here is the responsibility of nurse Xiang Yani to describe the condi
2、tion: 刘护士长：热烈欢迎护理部领导、各位护士长、护士姐妹们来我科指导工作， 我们查房的内容是胆囊结石合并糖尿病的护理，由于水平有限，准备时间不充 分，不足之处，请给以帮助指导。下面请护士项娅妮介绍病情:Xiang Yani: Good afternoon,Teachers, I am a level one nurse Xiang Yani,I was the day of the duty nurse, here I introduce the patients condition. 项娅妮：各位老师，大家下午好，我是 NI 级护士项娅妮，同时也是患者的责任 护士，下面我为大家介绍病人
3、情况。 Nursing round The Nursing of the Gallbladder stones with diabetes 护理查房护理查房 胆胆 囊囊 结结 石石 合合 并并 糖糖 尿尿 病病 的的 护护 理理Introduction: Patients with Sun Zhimings disease, male, 57 years old, the number of hospitalized patients: 601498 in March 30, 2015 11:20 entered the ward, with “epigastric fullness disc
4、omfort over January“. Patient with gallbladder stone and cholecystitis income my division. Go to already healthy patients. There are a total of more than 30 years history of smoking and drinking, no drug allergy and other allergic history. More than 40 years ago “measles“ caused by hypertension is b
5、lind in the left eye, more than three years, regularly taking metoprolol, ale, Feiluodiping Huanshi Pian, aspirin, aspirin has been disabled for eight days. More than one year for diabetes, insulin, acarbose, pre hospital outpatient B ultrasound tip of gallbladder stones. 病情简介：病情简介：患者孙志明，男，57 岁，住院号：
6、601498。患者于 2015 年 3 月 30 日 11:20 步入病房，主诉“上腹饱胀不适一月余”。门诊以胆囊结石并 胆囊炎收入我科,患者有吸烟饮酒史 30 余年，已戒烟酒一年。无药物过敏及其 他过敏史。40 余年前因“麻疹”致左眼失明，右眼视力正常。高血压病史三年 余，能遵医嘱按时服用倍他乐克、阿乐、非洛地平缓释片、阿司匹林等药物， 阿司匹林已停用八天。糖尿病一年余，曾在内分泌科治疗，能自行注射甘精胰 岛素，口服阿卡波糖，入院前门诊 B 超提示胆囊结石。T36.2, P72 times / min, BP110/70mmHg. The spirit of good, normal app
7、etite, physical strength is normal, normal sleep, urine normal, no significant changes in body weight, abdominal palpation: abdomen soft, no muscle tension, without apparent tenderness and rebound tenderness, did not touch bag piece, the lower bound of untouched liver, spleen was not palpable. Limb
8、muscle strength is normal, no sensory disability, ADL score of 85 points, scoring 30 points of skin. Fall / bed fall risk factor score of 10 points, For nutrition score 14 points.Were treated with anti infection, protecting stomach, blood glucose control therapy (0.9% sodium chloride 100ml+ ceftazid
9、ime intravenous infusion of 2G for two times a day,0.9% sodium chloride 100ml+pantoprazole 80mg intravenous drip once a day. Subcutaneous injection of insulin before breakfast and dinner 4U and 9U) .laboratory examination, fasting blood glucose 7.26 tendency for L, prescribed to detect blood sugar,
10、March 30, heart colour to exceed tip: left ventricular diastolic function to reduce, please heart medicine consultation Suggestions: blood pressure is normal, no special treatment; On March 31, CT tip: right lung bronchiectasis with infection, respiratory medicine consultation, please advice: after
11、anti-infection treatment; On April 4, please endocrinology consultation Suggestions: in diabetes diet, hypoglycemic therapy, monitoring of blood sugar.April 5 fingers on an empty stomach blood sugar control in tendency for 7.2 / L, two hours after meals tendency for 11.0 / L respectively, and the te
12、ndency for 8.7 / L, the tendency for 8.5 L. April 6, fasting blood sugar tendency for 6.7 / L finger, two hours after meals were 11.7 tendency L12.9 tendency L9.3 tendency/L. Is surgery on April 7, preoperative preparation, on April 7, finger blood sugar on an empty stomach tendency for 7.9 L. 查体：T3
13、6.2，P72 次/分，R19 次/分，BP110/70mmHg。精神食欲可，大 小便正常，体重 75KG，无明显增减，腹部触诊：腹软，无明显压痛、反跳痛、 肌紧张，莫非氏征阴性。四肢肌力正常，无感觉障碍，ADL 评分 100 分，皮肤 评分 30 分。跌倒/坠床危险因子评分 10 分，营养评分为 14 分。入院后给予抗 感染、护胃、控制血糖等治疗。完善术前相关检查，肺功能、胸片、心电图均 正常，实验室检查基本正常，空腹血糖为 7.26mmol/L,遵医嘱检测手指血糖。3 月 30 日心脏彩超提示：左室舒张功能减低，请心内科会诊建议：血压正常，暂 无特殊处理；于 3 月 31 日 CT 提示：
14、右肺支气管扩张伴感染，请呼吸内科会诊 后建议：行抗感染治疗；4 月 4 日请内分泌科会诊建议：进糖尿病饮食，降糖 治疗，监测血糖。4 月 5 日空腹手指血糖控制在 7.2mmol/L，三餐后两小时分别 为 11.0mmol/L，8.7mmol/L，8.5mmol/L。4 月 6 日空腹手指血糖 6.7mmol/L， 三餐后两小时分别为 11.7mmol/L，12.9mmol/L，9.3mmol/L。拟于 4 月 7 日手 术行术前准备，4 月 7 日空腹手指血糖为 7.9mmol/L.On April 7th 08:00 under general anesthesia downlink la
15、paroscopic gallbladder excision (LC), finish operation in, and get back to the room, postoperative ecg monitoring, oxygen inhalation, the diet, anti-infection, protecting stomach, protect liver, nutrition support treatment, such as for postoperative ADL score 20 points, catheter slippage risk factor
16、 score for 1 minute, fall/drop of bed risk factor score of 12 points, nutrition score of 12 points, pain score is 6 points, 28 points for skin pressure sores score. Stop on April 8, ecg monitoring and oxygen for ADL score 85 points, fall/drop bed risk factor score of 10 points, pain score of 3 points, catheter slippage risk factor score of 0. On April 9 semi-liquid diet is administered after the anus exhaust, for nutrition score 14 points, ADL scor
