護理英語交班

護理英語交班第1頁/共25頁GeneralconditionsGoodmorning,everyone,March21.2009Wearepassingnursingreportnow.Therearetotal36patientsintheward,including3patientsdischarged,2admitted,2transferredin,2transferredout,1diedyesterday.各位,早晨好2009年3月21日護理交班病人總數(shù):36出院病人數(shù):3入院病人數(shù):5轉(zhuǎn)入病人數(shù):2轉(zhuǎn)出病人數(shù):2死亡病人數(shù):1第2頁/共25頁3patientswereperformedoperation.ThenumberofDILcase:1thenumberofpatientongradeonenursingcare:10手術(shù)病人數(shù):3病危病人總數(shù):1病重病人總數(shù):2一級護理病人總數(shù):10第3頁/共25頁DischargedcaseBed3,WangHong,coronaryheartdisease（CHD）,anginapectoris,wasdischargedat9o’clockyesterdayaftertreatment.3床,王紅,冠心病、心絞痛于9：00出院第4頁/共25頁DeathcaseBed29,ZhaoLiang,pulmonaryinfection,twotypeofrespiratoryfailure,multipleorganfailure,wasdied(passedon)at10:00yesterdayafterresuscitationfailure.29床,趙良,肺部感染,二型呼衰,多功能臟器衰竭,經(jīng)搶救無效于10：00死亡第5頁/共25頁NewadmissionBed18,WeiHaiming,male,47yearsold,wasadmittedat10:00o’clockwithcomplainingofa15daysintermittentchestpainandpalpitation.Thediagnosiswasuncertainchestpain,dysrhythmias,paroxysmalatrialfibrillation,bradycardia,hypertensionongrade3.18床魏海明胸痛原因待查,心律失常、陣發(fā)性房顫、竇性心動過緩、高血病3級患者，男性47歲，地方人員，于10：00入院。主因為發(fā)作性胸痛伴心慌15天，為進一步治療入院。第6頁/共25頁Afteradmission,thedoctorLiXuehuawasnotifiedimmediatelyandtheadmissioninterviewwasdone.ECGatbedsideshowedsinusrhythm.BPwas130/88mmHg.Thelowsaltandlowfatdietwasserved.Dilatedcoronaryartery,anticoagulationandanti-hypertensiondrugsweretakenandgrade2nursingcarewasgivenasdoctor’sorders.入院后立即通知李學華醫(yī)生,入院介紹已做.患者未訴胸痛、心慌，血壓130/88mmHg.行床旁心電圖示竇性心律.遵醫(yī)囑給予二級護理，低鹽低脂普食，擴冠、抗凝、降壓等藥物治療。第7頁/共25頁ThepatientsleptwellLastnightandbloodspecimenweretaken.Thevitalsignswerenormalinthemorning.病人睡眠好，晨起血標本已留，生命體征平穩(wěn).第8頁/共25頁DILcaseBed10，WangHua,coronaryHeartdisease,anginapectoris,acuteextensiveanteriormyocardialinfarction.Thepatientsuddenlycomplainedofchestpainat22:30Oxygenwasgivenimmediatelyandtheflowratewas3L/min.ECGmonitoringwasstartedandshowedsinusrhythm.10床,王華，冠心病，心絞痛，急性廣泛前壁心肌梗死.昨天22：30病人主訴心前區(qū)疼痛，立即給予吸氧3升/分，心電監(jiān)護儀監(jiān)護，心電示波示竇性心律，第9頁/共25頁Theheartratewas63beats/min.BPwas115/64mmHg.MeanwhileDr.ZhangXuewasinformed.Aftertaking3tabletsofnitroglycerinsublinguallyat5minuteintervalsasindicated,thepainwaspersistent.TheECGshowedthe0.2-0.6mvofelevatedV1-V5Stsegment.Dr.ZhaoYongsawthepatient.心率63次/分，血壓115/64mmHg,通知張學醫(yī)生看病人，遵醫(yī)囑給予硝酸甘油mg舌下含服，癥狀無緩解，行床旁心電圖檢查示V1-V5ST段抬高0.2-0.6mv.二線趙勇副主任醫(yī)師到場看病人。第10頁/共25頁Heparin100mginnormalsaline500mlandDopamine80mginnormalsaline500mlweregivebyIVinfusion.Thedropratewere500u/hand1.46ug/kg/min

respectively.ThepatientwasonDIL.遵醫(yī)囑給予靜脈輸入生理鹽水500ml+肝素鈉注射液100mg，滴速為500u/h,生理鹽水250ml多巴胺注射液80mg，滴速1.46ug/kg/min，報病危。第11頁/共25頁Ivinfusionwerekeptpatent.Thepatientsleptintermittentlyintheevening.TheECGshowedsinusrhythm.Theheatratewasatrangeof63-74beats/minandBPwas91-115/53-64mmHg.Thepatientwasturnedevery2hoursandnowisonsupine(prone,lateral,Fowler’s,semi-Fowler’s)position.夜班輸液通暢，患者間斷睡眠，心電監(jiān)護儀顯示竇性心律，心率波動在63-74次/分，血壓波動在91-115/53-64mmHg.每2小時翻身一次,現(xiàn)病人平臥位(伏臥位、側(cè)位、半臥位、較低半臥位）。第12頁/共25頁Theskinwasintegrity.Thetotalinputwas400mlandtheoutputwas300ml.皮膚無破損，全天入量400ml，尿量300ml.第13頁/共25頁OperationcaseBed11,DuanRong,coloncancer.Aterbeingperformedthecolectomywithgeneralanesthesia,thepatientwasconsciouswhenhecametothewardat15:30.Thedressingkeptintegrityandtheouterdressinglayerhad’tbeenwetorsoiled.TheAbdominaldrainagetubewassecuredwellanddrained50mlbloodyexudates.11床,段榮,直腸癌,今日在全麻下直腸癌切除術(shù),術(shù)后于15:30返回病房,清醒,血壓154/96mmHg,切口敷料包扎好,外層敷料未見明顯滲出.腹腔引流管固定通暢，引流液為血性。第14頁/共25頁Thenasogastrictubewasattachedtolowsuctionfordecompressionanddrained100mlofdark-greencolorofexudates.Thecatheterizationwasmaintainedpatentanditsdrained1200mlofclearurine.持續(xù)胃腸減壓通暢，引流墨綠色液體100ml.尿管通暢，尿色清亮，皮膚好。第15頁/共25頁Thecentralvenouscatheterwaskeptpatentandtherewerenorednessandswellingintheskin.Thesaturationofoxygenwascontinuouslymonitoredbypulseoximetryandthevalueswere95%to99%.Thegrade1nursingcareandfastingfoodweregivenasdoctor’sorders.中心靜脈輸液通暢，穿刺部位無紅、腫.持續(xù)血氧飽和度監(jiān)測，SPO2維持在95-99%之間，術(shù)后遵醫(yī)囑給予一線護理，禁食.第16頁/共25頁Thepatientwaschangedthepositionevery2hoursandtheskinwasintegrity.ThepatientsleptintermittentlyLastnight.Thetotalintakewas2500mlandtheoutputwas1350ml.定時翻身，皮膚好。夜間間斷入睡,全天入量2500ml,出量1350ml，其中尿量1200ml,腹腔引流50ml,胃腸引流液100ml.第17頁/共25頁PreoperationcasesDed3,SunYi,cholecystitis,cholelithiasis,willbeperformedthelaparoscopiccholecystectomywithgeneralanesthesia.Theskinatandaroundtheoperativesitewasshaved.Preoperativepatienteducationwasdone.3床,孫義,膽囊炎,膽石癥.患者常規(guī)準備于明日在全麻下行腹腔鏡膽囊切除術(shù).皮已備,術(shù)前指導已做,青霉素皮試(一).晚上給予清潔灌腸一次,大便3次，夜間睡眠好，晨起已禁食水。第18頁/共25頁Penicillinallergytestwasnegative.Thepatientwasgivenacleaningenema(laxative)andpassedwatery(loose)stool3times.Hesleptwellatnightandtooknothingbymouth(NPO)inthemorning.Thevitalsignswerenormal.青霉素皮試(一).晚上給予清潔灌腸一次,解水樣大便3次，夜間睡眠好，晨起已禁食水，生命體征平穩(wěn)。第19頁/共25頁OthernotesThepatientswhohadfever:Bed8,SuHaokai,thetemperatureat14:00was39.0℃.Aftercoldcompressandtepid(coolwater)sponginggivingtothepatient,thebodytemperaturefellto37.8℃at14:30.發(fā)熱患者:8床,蘇浩凱,14點測體溫為39.0℃,給予冰袋物理降溫,溫水擦浴.14:30