护理查房(肺气肿)-2

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1、thrift of excellent traditional and style lack deep of understanding, one-sided think in now of good situation Xia, economic smooth more fast development, and reform made major progress, and people living significantly improve, and social the career made new progress, no necessary always hard has, n

2、o awareness to China also has many poverty area, and also has many poverty population of exists, more living improve has, more need keep hard of style. Three is not strictly honest. Total thought units is a water sector, clean self-discipline away from himself too far, no real processing good living

3、 of improve and hard, and thrift excellent traditional of relationship, no effective do comply with Constitution and party of regulations must from I do up, no right mercy good bitter Le, and wealth of relationship, no right awareness to in comply with Constitution and party of regulations aspects e

4、veryone has accountability. Four, future direction and improvement measures 1, belief and faith, strengthen party spirit. One is to firmly establish the noble ideals of struggle for the ideals of communism, communist struggle for life, ready to sacrifice everything for the party and the people. Seco

5、nd is to continuously improve the quality and standard of political, conscientiously study Deng Xiaoping theory and three represents important thought and the scientific Outlook on development, implement the partys basic program for the primary stage of socialism, adhere to the correct political ori

6、entation, maintain highly consistent with the CPC Central Committee, is good at theories of socialism with Chinese characteristics to analyze and solve problems. Third, strengthening the party spirit and the world transformation, perseverance of the party Constitution, relive Party vows to establish

7、 correct world Outlook, Outlook on life and the world, practically embodies ideals and beliefs into action, combine lofty ideals and practical activities, transforming the objective world, actively participate in the great practice of building socialism with Chinese characteristics. 2, keep the purp

8、ose in concept, changing the style of work. First, keep in mind that the purpose of serving, adhere to assuming power for the people, keep in mind the people and care about people, and the joys and sorrows of the masses, .According to city discipline, and municipal organization Department requiremen

9、ts, today we held implement implementation independent Commission against corruption guidelines effective strengthening led cadres style construction topic democratic life, main task is close contact thought, and work actual, control check district Standing Committee team and the personal in impleme

10、ntation independent Commission against corruption guidelines Shang exists of problem, in-depth carried out criticism and self-critical, further clear rectification direction and measures, effective enhanced clean politics of consciousness and initiative, firm set good of ruling image. Before the mee

11、ting, the way we take surveys solicited a views, combed, related to team building护理查房肺气肿 护理评估基本资料医院 华东医院 科别 呼吸内科 病室 新12楼 姓名 葛维宝 性别 男 年龄 58岁 住院号 床号 71208民族 汉 婚姻史 已婚 文化程度 大专 职业 职工 宗教信仰 无家庭地址 江苏省江都市 联系人 马高荣 联系电话 入院诊断 左肺社区获得性肺炎 过敏史 青霉素过敏入院日期 2012-08-12 09:00 入院方式 门诊步行一般资料生命体征:T37 P86次/分 R20次/分 BP13070mm

12、Hg 身高178cm 体重75kg神智:清楚 淡漠 嗜睡 烦躁 昏迷体型:一般 肥胖 消瘦 恶病质皮肤:正常 异常 压疮:有 无语言:正常 语言障碍 不能评论心理状态:开朗 欣快 恐惧 焦虑 痛苦 压抑 紧张吸烟:不吸 吸烟 戒烟呼吸状态:平稳 不规则 气促 困难 端坐呼吸呼吸道症状:无咳嗽 咳痰 咯血口腔黏膜:正常 破损 溃疡 发疹 排尿形态:正常 尿频 尿急 尿痛 少尿 夜尿增多尿液潴留 失禁 留置导尿排便形态:正常 便秘 失禁 腹泻 造口睡眠形态:正常 失眠 辅助睡眠饮食形态:普食 半流质 流质 禁食 特殊饮食对疾病的认识:认识 不理解 隐瞒安全评估及应对措施活动障碍:无 全瘫 截瘫 偏

13、瘫自理能力:自理 协助 完全依赖认知感觉(视觉):正常 近视 远视 弱视 (听觉):正常 弱视 失聪舒适程度:无不适 稍不适疼痛 思维:正常 混乱 注意力分散 记忆力下降 不能评估顺应性:配合 一般 差 不听从 过去一年曾经跌倒:无 1次 2次 3次 防范意外伤:宣教 环境(床位 地面 照明) 陪护 床栏 约束带 警示牌简要病史主诉:反复咳嗽、咳痰、气促三十余年、发热一天现病史:患者20余岁起有反复发作性气喘,当时诊断为“支气管哮喘”,发作时氨茶碱治疗科好转。后症状逐渐加重,近两年来每年均有气急急性发作。曾与2013-6-26日因“反复咳嗽加重伴发热三天”入院,给予止咳、消炎、化痰治疗后于07

14、-06日出院。此次入院前两周出现咳嗽、咳痰加重,入院前一天出现发热、体温38.3摄氏度,无明显气促、胸闷、心悸、呼吸困难等不适。血常规检查显示白细胞、中性粒细胞,CRP上升,为进一步诊治收治入院。患者发病以来,精神可,胃纳睡眠可,大便尚正常,体重无明显下降,既往史:传染病史:否认结核、肝炎病史过敏史:对青霉素过敏输血史:否认输血史手术外伤史:患者2010年因车祸右下肢骨折,行切开复位内固定术。预防接种史:不详系统回顾:呼吸系统:详见现病史。2013年我科住院期间行睡眠呼吸检测,诊断为轻度阻塞性睡眠呼吸暂停综合征循环系统:有高血压病史十余年,最高150/110mmHg,服用非洛地平治疗消化系统:

15、否认恶心、呕吐、腹泻、腹痛史血液系统:否认皮肤瘀点、瘀斑等内分泌系统:否认糖尿病史泌尿系统:否认尿频、尿急、尿痛等,否认腰酸、血尿史等神经系统:否认头昏史,否认反复头痛,晕厥,四肢震颤,抽搐史运动系统:否认四肢关节红、肿、热、痛史个人史:出生于河南,否认疫水疫地接触史。吸烟三四十年,每天20支,未戒烟。否认饮酒史。否认夜游史。生育史:已婚已育,家人体健体格检查:T:37. P:86次/分 R:20次/分 BP:130/70mmHg患者神志清晰,发育可,营养可,步入病房,检体合作,对答切题。皮肤黏膜无黄染,浅表淋巴结未及肿大。双侧巩膜无黄染,结膜无充血,双瞳孔等大等圆,对光反射存在。鼻中隔居中,副鼻窦无压痛。口唇无紫绀,伸舌居中,双侧扁桃体无肿大。颈软,气管居中,双侧甲状腺未及肿大和结节。胸部无局限性隆起或凹陷,双侧呼吸运动度正常,双侧肋间隙无增宽。叩诊心界无明显增宽。双肺呼吸音清,未及干湿啰音。心率86次/分,律齐,各瓣膜区未及病理性杂音。腹部未见蠕动波和肠型;肝、脾下未触及,无压痛、腹部未及明显包块,移动性浊音(-),肠鸣音不亢。脊柱无偏曲,四肢运动自如。生理反

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