.,腦梗死病人護理查房(Nursingroundaboutthepatientofcerebralinfarction),.,護理查房目的（Thepurposeofthisnursinground),1.掌握腦梗死的定義及臨床表現Masterthedefinitionandclinicalmanifestationsofcerebralinfarction2.熟悉腦梗死的治療及護理Befamiliarwiththetreatmentandthenursingcare3.進一步培養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,.,臨床資料Theintroductionofthepatientscondition,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,65yearsold.Hewasadmittedtoourhospitalbecauseofglossolalia,waterchokingcoughaggravatingfor4days.Pastmedicalhistoryhashypertension,diabetes,coronaryheartdiseaseandothermedicaldisease.Afterthat,hisrightupperlimbcantholdandneedhelptowalk.,.,臨床資料Physicalexamination,查體(PE),T：36.6P：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：36.6degreecentigradeP：74timesminuteR:18timesminuteBP:170/106mmhg.Oldmale,conciousnes,dysarthria,hisrightupperlimbproximalmusclestrengthislowerthanlevel2,distallevel2,rightlowerlimbmusclestrengthislevel3.Themuscletentionisslightlyhigher.,.,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,3,2,去除重力情況可看到關節活動,5,4,能對抗重力Activemovementagainstgravity能對抗重力和部分阻力Activemovementagainstgravityandsomeresistance,肌力正常Normalpower,Nocontractionofmusclevisible,Flickerortraceofcontractionvisible,Activemovementatjoint,withgravityeliminated,.,輔助檢查(Auxiliaryexamination),.,影像學檢查(Imagingexamination),.,診斷(Diagnosis),1.腦梗死(cerebralinfarction)2.糖尿病（Diabetes）3.冠心病（Coronaryheartdisease）4.頸動脈粥樣硬化(Carotidarteryatherosclerosis)5.顱內動脈狹窄(Intracranialarterystenosis)6.高血壓病(Hypertention),.,腦梗死的定義(Thedefinition),定義：由于各種原因所致的局部腦組織區域血液供應障礙，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(Astrokeisabraininjurycausedbyanabnormalityofthebloodvesselssupplyingthebrain.),.,2020/6/1,10,危險因素(Riskfactor),10,2020/6/1,.,腦梗死臨床表現(Clinicalmanifestation),患者臨床癥狀與腦內梗死部位密切相關VTS_01_1(000807755-000838760).vob,.,2020/6/1,12,一、出血性or缺血性？(Intracerebralhemorrhageorcerebralinfarction),出血？缺血？,12,2020/6/1,.,2020/6/1,13,二、靜脈溶栓治療(Intravenousthrombolysistreatment),4.5小時,發病時間:是患者最后看起來正常狀態的時候為發病時間，而不是發現癥狀時間,13,2020/6/1,.,護理診斷,焦慮（anxiety）：與擔心疾病的預后有關(Itisbecauseofworyyingabouttheprognosisofthedisease.)知識缺乏（Thelackofknowledge）:缺乏與疾病相關的治療、康復、及護理方面的知識(ConcerningabouttheKnowledgeofthetreatment,reheblitation,andhowtolookafterthepatient),Nursing,Diagnosis,Nursingdiagnosis,.,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）,Nursing,Diagnosis,Nursingdiagnosis,.,營養失調（malnutrition）：與吞咽困難，流質飲食有關(Whichisrelatedtodysphagiaandneedtobegivenliquiddiet)潛在并發癥：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),.,護理措施,護理,措施,Nursinginterventions,1.做好入科宣教，為患者提供安全舒適的環境。（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。）,.,護理措施,護理,措施,Nursinginterventions,3.與患者及家屬共同制定康復計劃，并督促其執行（Recoveryplanwiththepatientandhisfamilymemebers，andsuperviseitsimplementation.）4.遵醫囑應用降壓藥及脫水藥物，并觀察藥物的療效及副作用。（Followthedoctorsadvicetocontrolthebloodpressure，thenobservetheeffectandthesideeffectsofthemedicine,.,護理措施,護理,措施,Nursinginterventions,5.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，必要時遵醫囑應用化痰藥物及抗生素。(Turnoverthepatientandkn