英汉双语护理查房-ppt.ppt

Intracerebral hemorrhage or cerebral infarction?题目 判断发病时间，询问病史很关键 结合本病人 * 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 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 patient’s 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 15，Dongjiatian , male ,65 year’s 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 can’t hold and need help to walk. 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：74times／minute R: 18 times／minute BP: 170/106mmhg. Old male ,conciousnes, dysarthria,his right upper limb proximal muscle strength is lower than level 2,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 visible Flicker or trace of contraction visible Active movement at joint, with gravity eliminated 颅脑CT 未见出血。（No bleeding） 颅脑MRI+MRA DWI示桥脑高信号。MRA提示多发血管狭窄。（MRI showed that there are many intracranial vascular stenosis) 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 h