脑出血英语护理查房.docx
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脑出血英语护理查房.docx
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脑出血英语护理查房
Nursingroundsofcerebralhemorrhage
Xuguiying:
DepartmentofNeurology
Cerebralhemorrhage
Referstotheprimarysubstanceofnon-traumaticbrainhemorrhage,whichaccountsfor20%to30%inacutecerebrovasculardisease
cerebralvasculardisease.
脑出血 是指原发性脑实质出血占全部脑卒中的20%~30%
Etiologicalfactor
(1)Hypertensionwithatherosclerosis(mostcommon)。
(2)Intracranialaneurysms(mainlycongenitalaneurysm)。
(3)Cerebralarteriovenousmalformations
(4)Other:
moyamoyadisease,blooddisease.
病因
(1)高血压并发细小动脉硬化(最常见)。
(2)颅内动脉瘤(主要是先天性动脉瘤)。
(3)脑动静脉畸形(4)其他:
脑动脉炎,脑底异常血管网症、血液病。
Pathogenesis
Basisofdisease:
hypertensionandcerebrovasculardiseaseAdditionalfactors:
forceandemotionalchanges
发病机制
基础疾病:
高血压,脑血管疾病
其他因素:
用力,情绪改变
Clinicalmanifestations
1.itOftenoccursinthehypertensivepatientswhoareover50yearsold2.Prodromalsymptomsoftendonothaveafeeling,asmallnumberofdizziness,headache,numbnessandslurredspeech,andmanymoreintheemotionalstress,excitement,bowelmovements,hard,andwhentheincidenceofsevereclimatechange.
2.临床表现
1。
常发生于50岁以上的高血压患者。
2。
发病前多无预感,少数有头晕、头痛,肢体麻木,言语不清等前驱症状,多在情绪紧张,兴奋,用力排便时发病。
Clinicalperformance(continued)
3.Onsetformofsuddenonset,reachedapeakafewminutestoseveralhours.
4.Clinicalsymptomsofacutesymptomsweresuddenheadache,vomiting,hemiplegia,aphasia,disturbanceofconsciousness,incontinence,etc.Differentsiteandamountofbleedinghas
Differentclinicalmanifestations
3。
起病突然,往往在数分钟至数小时内,病情发展至高峰。
4。
急性症状为突然头痛,呕吐,偏瘫,失语,意识障碍,大小便失禁等。
脑出血的临床表现随着出血部位和量的不同而各异。
Laboratoryandothertests
1.Leukocyte、bloodureanitrogenandbloodglucoseincrease.
2HeadCT,MRIexaminationcanbethesite、scopeandamountofearlydetectionofcerebralhemorrhage。
3.Cerebrospinalfluidpressureoftenincreased,
实验室和其他检查1。
白细胞、血中尿素氮,血糖升高。
2头颅CT,MRI检查可早期发现脑出血的部位,范围和出血量。
3。
脑脊液压力常增高。
essentialsofdiagnosis
1patientswhoareover50yearsold,withahistoryofhypertension。
Itoftenoccursinphysicalactivityoremotionalexcitement。
2rapidemergenceofdifferentlevelsofconsciousnessandsymptomsofincreasedintracranialpressure,associatedwithhemiplegia,aphasiaandothersigns
3CTexamination(high-densityfoci)canconfirmthediagnosis
诊断要点1有高血压病史的患者,年龄超过50岁。
常发生于体力活动或情绪激动时。
2迅速出现不同程度的意识障碍和颅内压增高的症状,伴有偏瘫,失语等体征
3 CT检查(高密度灶)可明确诊断
TreatmentPoints
Acutephasetreatmentofmajorprinciples:
topreventfurtherbleeding,cerebraledemacontrol,andpreventionofcomplicationsoflife-sustainingfunctions.
1.generaltreatment:
bedrest,thepatencyofairway
1regulationofbloodpressure3Controlofcerebraledema:
20%mannitol,furosemide
治疗要点
急性期治疗主要原则:
防止再出血,控制脑水肿,预防并发症,维持生命功能。
1一般治疗:
卧床休息,保持呼吸道通畅2调节血压3控制脑水肿:
20%甘露醇,呋塞米。
Treatmentelements(continued)
4.Hemostasisandcoagulationdrugs5.operationtreatment
6.Earlyrehabilitation
4。
止血和凝血药物5。
手术治疗
6。
早期康复。
GeneralInformation
Name:
XUGuiyingSex:
female
Age:
74,culture:
illiteracy
marriage:
marriednation:
han
Hometown:
yangzhouoccupation:
retirement
Admissiontime:
2011-3-01
Admissiondiagnosis:
cerebralhemorrhage
ChiefComplaint:
The left limbweakness withUnsteadygaitfortwodays
病史摘要
患者徐桂英,女,74岁,因“左侧肢体乏力伴行走不稳两天”入院,入院时间2012-03-01.住院号E89610.入院时查体:
神志清楚,双侧瞳孔等大等圆,直径3mm,光反射灵敏,四肢肌张力增高,左侧肌力4级,右侧肌力5级。
眼球活动自如,眼震阴性,颈软,克氏征、布氏征阴性。
各生理反射存在,病理反射未引出。
T:
36.9℃、R:
18次/分、P80次/分、BP110/70mmhg。
头颅CT示:
右侧基底节区脑出血。
遵医嘱予吸氧、心电监护,降颅压,止血,营养脑细胞等对症治疗。
History summary
Patients XUGuiying,female,aged74, shewasadmittedintowardbecauseofleftlimb weakness withunsteadygait for two days in2012marchfirst。
hospitalnumber E89610. physical examination:
clearconsciousness,bilateralandotherlargeandroundpupildiameterof3.0mm.Light reflex sensitivity,highmuscletension、left limbmusclestrengthgrade4,right limbmusclestrengthgrade5.freelyEyemovements,softneck、G's intrinsic negative,Brandtnegative,physiologicalreflexexistswhilePathological reflexwasnotelicited。
Thetemperaturewas
36.9centigrade, breathingwas 18 timesperminute, Pulsewas80times perminute, Bloodpressurewas110/70mmhg. CTshowedthat:
t therightbasalgangliahemorrhage.Prescribedbyadoctor to oxygen
ECGmonitoring,reducecerebraledema,improve the metabolismofbraincells.etc(ANDSOFORTH)
四史
现病史:
患者于入院两天前出现左侧肢体乏力,伴明显行走不稳,家属为明确病因来我院,门诊查头颅CT示右侧基底节区脑出血,为进一步诊治,收住入院。
病程中伴明显反应迟钝,记忆力下降。
03-02患者不能自主排尿,遵医嘱予导尿。
03-04患者出现发热,稍咳嗽咳痰,遵医嘱予抗感染、止咳化痰治疗。
近来患者食纳及精神尚可,睡眠正常,留置导尿,大便正常。
historyofpresentillness
patientwasadmittedtohospitalbecauseofleftlimb weakness withunsteadygait for two days .Thefamilymemberscametoourhospitalforaclearcause,out-patientcheckCTscanshowedtherightbasalgangliacerebralhemorrhage,。
The doctor advised hospitalization for her。
. InThecourseofthedisease,withsignificantunresponsiveness,memoryloss. 03-02thepatienthaddysuria symptoms,Prescribedbyadoctor tocatheterization. 03-04shehadafever,andalittlecoughandexpectoration,followthedoctor'sadvicetotheanti-infectivetreatment. Recentlythepatientisingoodspirits,normalsleep,indwellingcatheterization,normalDefecation.
既往史:
“高血压”病史数年,未服药。
否认“肝炎”、“结核”等传染病病史。
家族史:
配偶和子女的身体健康,否认“糖尿病”,“心脏疾病”和其他遗传病史。
过敏史:
否认花粉,药品,食品和其他过敏史。
Pastmedicalhistory:
hypertension,ahistoryof severalyears,withoutmedication. Deny the history of hepatitis, tuberculosis andotherinfectiousdiseases.
Familyhistory:
thehealth of the spousesandchildren,deniedTHE“diabetes”, “heartdisease” and other genetichistory.
Allergyhistory:
Thepatientdeniedpollen,drugs,foodandotherallergies.
五方面
饮食:
一日三餐以米面为主,食欲正常,无吞咽困难。
入院后予低盐低脂饮食。
睡眠:
正常,每天6-7小时。
排泄:
留置导尿。
大便正常,1次/1-2天。
爱好:
无烟酒不良嗜好。
自理能力缺陷,需他人协助。
心理社会状态:
退休老人,家庭和睦。
焦虑,担心预后。
Fiveaspects
The diet:
Threemealsaday in rice-based, normalappetite. no difficultyinswallowing. Low-salt low-fatdietafteradmission,
Sleep:
normal, 6-7hours a day.
Excretion:
keepcatheterizationafteradmission,normal
Defecation, 1 / 1-2days.
Hobbies:
noalcoholandotherbadhabits
Defects of self-careability, need assistance.
Psychologicalandsocialstatus:
thepatientwas a retiredelderly, and familyharmony, worryabout the prognosis.
体格检查:
T:
36.9℃、R:
18次/分、P80次/分、BP110/70mmhg。
神志清楚,双侧瞳孔等大等圆,直径3mm,光反射灵敏,左侧肌力4级,右侧肌力5级。
颈软,克氏征、布氏征阴性。
physical examinationshowedthat Thetemperaturewas36.9centigrade, breathingwas 18 timesperminute, Pulsewas80times perminute, Bloodpressurewas110/70mmhg.clearconsciousness,bilateralandotherlargeandroundpupildiameterof3.0mm.left limbmusclestrengthgrade4,right limbmusclestrengthgrade5.softneck、G's intrinsic negative,Brandtnegative.
辅助检查:
03-01CT示右侧基底节区脑出血
03-02心电图示窦性心律、心肌缺血。
Supplementaryexamination:
03-01 CTshowed the right basalganglia cerebralhemorrhage
03-02 electrocardiogram showedsinusrhythm, myocardialischemia.
护理诊断
2012-3-01潜在并发症:
脑疝
2012-3-01自理能力缺陷与肌力下降、医源性限制有关
2012-3-01有皮肤完整性受损的危险与长期卧床有关
2012-3-01焦虑与担心疾病预后有关
2012-3-01知识缺乏缺乏与疾病相关知识
2012-3-02排尿型态改变与脑功能受损、留置导尿有关
2012-3-04清理呼吸道低效与咳嗽咳痰无力有关
2012-3-04体温过高与感染和脑出血的吸收有关
Nursingdiagnosis
2012-3-01 potential complications:
cerebralhernia
2012-3-01 Defects of self-careabilityrelatedwith decreasedmusclestrength, iatrogeniclimit。
2012-3-01theriskofimpairedskinintegrityandlong-termbedrest,2012-3-01 anxiety and fear of diseaseprognosis
2012-3-01 lackof disease-relatedknowledge
2012-3-02 voiding patterns changedrelatedwith impaired brainfunctionandkeepingcatheterization
2012-3-04 cleanairway respiratory inefficientbecauseoftheinabilitytocough
2012-3-04hyperthermiaandinfectionandtheabsorptionofthecerebralhemorrhage.
2012-3-01潜在并发症:
脑疝
护理目标:
患者住院期间未发生脑疝、或脑疝发生时能得到及时发现和处理。
。
护理措施:
1密切观察生命体征变化,特别意识、瞳孔的变化。
2嘱患者卧床休息,抬高床头15°〜30°,以减少脑水肿
3遵医嘱使用脱水剂,期间应监测水电解质的变化。
4向患者解释颅内压增高的诱因,如:
用力、情绪激动等。
5保护患者安全,保持安静,避免刺激。
治疗和护理时动作应轻柔。
评价:
患者目前病情好转,未发生脑疝。
potential complications:
cerebralhernia
Goal:
donotoccur incerebralherniaor onceherniaoccurrence,itcanbedetectedand treatedtimely.
Measures:
acloseobservationofthepatient'sawarenessofchangesinvitalsignsandobservationofpupilparticularly.
2bedrest。
Raisingthebed15degree~30°toreducecerebraledema
3Usethedehydration。
duringthistime,renalfunctionandwater-electrolyteshouldbemonitored.
4 explain theincentive of increasedintracranialpressure,suchas:
forceandemotionalchanges.
5 to protect patientsafety,keepquiet, toavoidirritation. todothetreatmentandcarewhentheactionshouldbegentle
Evaluationdonotoccur incerebralhernia
2012-3-01自理能力缺陷与肌力下降、医源性限制有关
目标:
患者住院期间基本需要得到满足
措施:
1做好晨晚间护理,增加患者舒适。
2.及时更换衣物,保持皮肤清洁
3保持床单元清洁干燥
5协助患者进食更衣等生活护理
评价:
患者基本需要能得到满足
2012-3-01 Defects of self-careabilityrelatedwith decreasedmusclestrength, iatrogeniclimit。
Goal:
basicneedscanbesatisfiedduringpatient′shospitalization
Measures:
todo the morningand evening care, increase patientcomfort.
(2) thetimelyreplacementof clothing, keeptheskinclean
3 tomaintain aclean,dry sheets
5 toassist patientswith eating, dressing andother life care
Evaluation:
patients basicneedscanbesatisfied。
2012-3-01有皮肤完整性受损的危险与长期卧床有关
目标:
患者住院期间皮肤完整,未发生压疮
措施:
1保持床单元清洁干燥,及时更换潮湿的衣物及被褥,避免局部长期受压。
2置肢体于功能位,软枕垫起骨隆突部位。
3使用气垫床及体位垫。
评价:
目前患者皮肤完整,未发生损伤。
2012-3-01theriskofimpairedskinintegrityandlong-termbedrest,
Goals:
completeskinofpatientswithnooccurrenceofpressuresores.
Measures:
1tokeepcleansheets,and thetimelyreplacementofwet clothingand bedding, toavoid long-term compression.
2 positiontomaintainlimbfunction,boneprotuberanceatthesoftpillowpad
3providesairbed,turningthepatientevery2hoursonce.
Evaluation:
skin integrity, not injury.
2012-3-01焦虑与担心疾病预后有关
目标:
患者入院一周内
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- 脑出血 英语 护理 查房