英语护理查房

护理查房2014.9.4

17床，，男，岁，因“”于月日入院。目前诊断：。现予1级护理，饮食，保肝护胃，利尿抗感染等治疗。患者血常规结果显示：。

目前患者精神疲倦，面色晦暗，巩膜黄染。上腹部轻压痛，腹部稍膨隆，双下肢轻度水肿，轻微活动后即感气促。尿少，推注“呋塞米”之后尿量可至1200ml/天，大便正常。

主要护理问题：

1、疼痛

2、体液过多：与肝功能减退、门静脉高压引起水钠潴留有关

Too much body fluids: hypohepatia caused water sodium retention, portal hypertension 3、营养失调低于机体需要量：与肝功能减退、门静脉高压引起食欲减退、消化和吸收障碍有关。

Malnutrition less than body requirements: the liver function and portal hypertension caused disorder characterized by loss of appetite, digestion and absorption.

4、活动无耐力：与肝功能减退、大量腹水有关

Decrease of active tolerance : related to liver function impairment, a large amount of ascites

5、有皮肤完整性受损的危险：与营养不良、水肿、皮肤干燥、瘙痒及长期卧床有关。

A risk of impaired skin integrity: with malnutrition, edema, skin is dry, itching, and stay in bed for about for a long time.

6、有体液不足的危险：与腹泻和长期使用利尿剂有关

Danger of lack of body fluids: associated with diarrhea and long-term use of diuretics

7、焦虑：与对疾病知识的缺乏，长期住院担心预后有关

Anxiety: the disease and the lack of knowledge, long-term hospitalization worry about prognosis

8、潜在并发症：上消化道出血、感染、肝性脑病、低钾血症

Potential complications: upper gastrointestinal bleeding, infection, hepatic encephalopathy, hypokalemia

护理措施：

一、疼痛

1.观察并记录病人疼痛的部位、性质、程度，发作时间、频率，持续时间，以及相关疾病的其他临床表现，及时报告医生，采取疼痛的措施。

2. 非药物性止痛：a、松弛疗法：具体有呼吸松弛法、戒律按摩法。b、分散注意力止痛：如听音乐、看电视、与亲人聊天等，吸引病人注意力的内容都能拿来止痛。

3、药物性止痛：按医嘱使用止痛药，并观察药物的副作用。

1. To observe and record the position, nature, degree of pain patients, onset time, frequency, duration, and related other clinical manifestations of the disease, promptly report to the doctor, take measures of pain.

2. Non drug analgesia: a, relaxation therapy: concrete is breathing relaxation method, discipline massage method. B, distracting the pain, such as listening to music, watching TV, chatting with relatives and so on, drawing the attention of the patient content can be used to the pain.

Drug acetanilide:

3, the orders using painkillers, and observe the side effects of drugs.

二、体液过多

1、嘱病人多卧床休息取半卧位，抬高下肢，以减轻水肿

2、避免腹内压剧增：避免剧烈咳嗽，打喷嚏、用力排便等。

3、限制钠水摄入：无盐或低盐饮食，进水量控制在1000ml/d。

4、病情观察：监测病人的生病体征，测量病人的腹围和体重，准确记录出入量。

1, ask client to stay in bed for half supine position, raise the lower extremities and to alleviate the edema

2, avoid intra-abdominal pressure surge: avoid rough cough, sneeze, forcibly defecate, etc.

3, limit sodium intake of water: no salt or low salt diet, into the water control in 1000 ml/d. 4, illness observation: monitoring the patient's illness symptoms, measure the patient's 6 and the weight, accurate recording volume.

三、营养失调

1、饮食护理：给予高热量、高蛋白质、高维生素、易消化饮食，严禁烟酒。限制钠水摄入，食用含钠低的食物，例如粮谷类、瓜茄类、水果等，避免食用咸肉、酱菜、酱油等。

2、遵医嘱给予静脉补充营养

3、对病人的营养状况进行监测

1, diet nursing care: give high quantity of heat, high protein, high vitamin, easy to digest food, alcohol and tobacco are prohibited. Limiting sodium intake water, edible contains the