腦梗死病人護理查房課件

腦梗死病人護理查房

(Nursingroundaboutthepatientofcerebralinfarction)

腦梗死病人護理查房1護理查房目的（Thepurposeofthisnursinground)1.掌握腦梗死的定義及臨床表現(xiàn)Masterthedefinitionandclinicalmanifestationsofcerebralinfarction2.熟悉腦梗死的治療及護理

Befamiliarwiththetreatmentandthenursingcare3.進一步培養(yǎng)護理人員臨床思維能力Furthertrainingtheclinicalthinkingabilityofnurse4.加強護患溝通能力，提供更好的服務Strengthenthecommunicationskills,toprovidebetterserviceforthepatients

腦梗死病人護理查房1臨床資料Theintroductionofthepatient’scondition

病情介紹(Casehistoryintroduction)15床，董家田，男性，65歲，因言語不清、飲水嗆咳加重4天來診，門診以“腦梗死收住院。既往有高血壓、糖尿病，腦梗死，冠心病病史。遺留有右上肢持物不能，需扶物行走。

Bed15，Dongjiatian,male,65year’sold.Hewasadmittedtoourhospitalbecauseofglossolalia,waterchokingcoughaggravatingfor4days.Pastmedicalhistoryhashypertension,diabetes,coronaryheartdiseaseandothermedicaldisease.Afterthat,hisrightupperlimbcan’tholdandneedhelptowalk.腦梗死病人護理查房1臨床資料Physicalexamination

查體(PE)T：36.6℃P：74次/分R:18次/分BP:170/106mmhg,神志清，構音障礙，伸舌居中，右上肢近端肌力2級，遠端肌力3級，右下肢肌力2級，右側肢肌張力略高。

T：36.6degreecentigrade

P：74times／minute

R:18times／minuteBP:170/106mmhg.Oldmale,conciousnes,dysarthria,hisrightupperlimbproximalmusclestrengthislowerthanlevel2,distallevel2,rightlowerlimbmusclestrengthislevel3.Themuscletentionisslightlyhigher.腦梗死病人護理查房1肌力分級0沒有肉眼可見的肌肉收縮1僅有肉眼可見的肌肉收縮32去除重力情況可看到關節(jié)活動54能對抗重力Activemovementagainstgravity能對抗重力和部分阻力Activemovementagainstgravityandsomeresistance肌力正常NormalpowerNocontractionofmusclevisibleFlickerortraceofcontractionvisibleActivemovementatjoint,withgravityeliminated腦梗死病人護理查房1顱腦CT未見出血。（Nobleeding）顱腦MRI+MRADWI示橋腦高信號。MRA提示多發(fā)血管狹窄。（MRIshowedthattherearemanyintracranialvascularstenosis)

輔助檢查(Auxiliaryexamination)腦梗死病人護理查房1影像學檢查(Imagingexamination)腦梗死病人護理查房1診斷(Diagnosis)1.腦梗死(cerebralinfarction)2.糖尿?。―iabetes）3.冠心?。–oronaryheartdisease）4.頸動脈粥樣硬化(Carotidarteryatherosclerosis)5.顱內動脈狹窄(Intracranialarterystenosis)6.高血壓病(Hypertention)腦梗死病人護理查房1腦梗死的定義(The

definition)定義：由于各種原因所致的局部腦組織區(qū)域血液供應障礙，導致腦組織缺血缺氧性壞死，進而產生的臨床上對應神經功能缺失表現(xiàn)(Astrokeisabraininjurycausedbyanabnormalityofthebloodvesselssupplyingthebrain.)腦梗死病人護理查房12024/6/1110危險因素(Riskfactor)102024/6/11腦梗死病人護理查房1腦梗死臨床表現(xiàn)

(Clinicalmanifestation)

患者臨床癥狀與腦內梗死部位密切相關VTS_01_1(0008060).vob腦梗死病人護理查房12024/6/1112一、出血性or缺血性？(Intracerebralhemorrhageorcerebralinfarction)

出血？缺血？122024/6/11腦梗死病人護理查房12024/6/1113二、靜脈溶栓治療(Intravenousthrombolysistreatment)4.5小時發(fā)病時間:是患者最后看起來正常狀態(tài)的時候為發(fā)病時間，而不是發(fā)現(xiàn)癥狀時間132024/6/11腦梗死病人護理查房1護理診斷焦慮（anxiety）：與擔心疾病的預后有關(Itisbecauseofworyyingabouttheprognosisofthedisease.)知識缺乏（The

lackofknowledge）:缺乏與疾病相關的治療、康復、及護理方面的知識(ConcerningabouttheKnowledgeofthetreatment,reheblitation,andhowtolookafterthepatient)

NursingDiagnosisNursingdiagnosis腦梗死病人護理查房1護理診斷自理能力缺陷(Defectofselfcareability)：與肢體肌力下降有關（Whichisassociatedwithdecreasedmusclestrenght）

高血壓（Hypertention）:與緊張及腦水腫導致顱內壓增高有關（Whichiscausedbymentaltensionandincreasedintracranialpressure）NursingDiagnosisNursingdiagnosis腦梗死病人護理查房1營養(yǎng)失調（malnutrition）：與吞咽困難，流質飲食有關(Whichisrelatedtodysphagiaandneedtobegivenliquiddiet)潛在并發(fā)癥：

Potentialcomplication.有感染的危險（Theriskofinfection）：與飲水嗆咳導致肺部感染有關(Whichisbecauseofdrinkingwaterchokingcoughcauselunginfection).有便秘的危險（Theriskofconstipation）：與活動和流質飲食有關(Whichisduetobegivenliquiddietanddecreasedactivity)腦梗死病人護理查房1護理措施護理措施Nursinginterventions1.做好入科宣教，為患者提供安全舒適的環(huán)境。（Weshouldcommunicatewithpatientsindetailwhentheyfirstcometooursection.）2.加強與疾病相關知識宣教，如疾病的治療，護理及肢體語言康復等方面的宣教。（Tellthepatienttheknowledgeandtheprognosisabouthisdisease，includingthetreatment，nursingcareandrehabilitation。）腦梗死病人護理查房1護理措施護理措施Nursinginterventions3.與患者及家屬共同制定康復計劃，并督促其執(zhí)行（Recoveryplanwiththepatientandhisfamilymemebers，andsuperviseitsimplementation.）4.遵醫(yī)囑應用降壓藥及脫水藥物，并觀察藥物的療效及副作用。（Followthedoctorsadvicetocontrolthebloodpressure，then

observetheeffectandthesideeffectsofthemedicine腦梗死病人護理查房1護理措施護理措施Nursinginterventions5.為患者提供低鹽低脂高纖維素飲食。(Thepatientshouldacceptthehealthydiet,forexample,lowsalt,lowfatandhighfiberdiet.)6.加強翻身拍背，鼓勵病人有效咳嗽，必要時遵醫(yī)囑應用化痰藥物及抗生素。(Turnoverthepatientandknockhisbackevery2hours,encourgetheeffectivelycough.Acorrdingtothedoctor’sadviceanduseantibiltic.)腦梗死病人護理查房1護理措施護理措施Nursinginterventions7.鼓勵病人適當進行功能鍛煉，給予腹部環(huán)形按摩，預防便秘的發(fā)生。(Encouragethepa