1、中英文护理病历患者姓名：陈东林 性别：男 年龄：82 岁主诉：因“反复发作，胸闷 10 余年，加重半月”入院现病史：患者于 2003 年出现胸痛、胸闷，在同济医院就诊断为“冠心病 不稳定型心绞痛 陈旧型心肌梗塞” ，并行支架植入术治疗，术后症状明显缓解。近半月来出现胸痛、胸闷，持续约 20-30 分钟，服用发放丹参滴丸有时效果不佳，服用速效救心丸症状可缓解，活动时可诱发，无夜间渐发性呼吸困难，轻咳嗽，少量白色泡沫痰。有时感到头昏，无发热盗汗。门诊以“冠心病、心绞痛”收入院。患者发病以来精神差，体力下降，睡眠可，饮食差，二便如常。既往史：高血压病 20 年，冠心病 10 年，肝囊肿，左肾结石，前
2、列腺增生，否认肝炎、结核或其它传染病史，按国家计划进行接种，喹诺酮类过敏史，否认外伤史，1988 年脑脂肪手术。查体：体温 36.4，心率 62 次/分，呼吸 18 次/ 分，血压 140/80mmHg，其它无特殊。专科检查：血压 140/80mmHg，神志清楚，心率 62 次/分，心音正常，心律齐，其他无特殊。个人史：无特殊婚姻史：已婚初步诊断：1、冠心病 心绞痛 支架术后心功能不全 2 级2、高血压病 3 级 极高危组3、前列腺增生护理评估：1、 病史(1) 患病及治疗经过1） 患病经过：患者于 2000 年出现胸痛、胸闷，近半月来出现胸痛胸闷，持续约 20-30 分钟，活动时可诱发，无夜
3、间渐发性呼吸困难，轻咳嗽，少量白色泡沫痰。有时感到头昏，无发热盗汗。2） 诊治经过：在同济医院被诊断为“冠心病 不稳定型心绞痛 陈旧型心肌梗塞” ，并行支架植入术治疗，术后症状明显缓解。近半月来出现胸痛、胸闷，持续约 20-30 分钟，服用发放丹参滴丸有时效果不佳，服用速效救心丸症状可缓解。3）目前状况：患者发病以来精神差，体力下降，睡眠可，饮食差，二便如常。4）相关病史：高血压病 20 年，冠心病 10 年2、心理社会资料患者对疾病的性质、过程、预后及防治知识有一定程度的了解，但是了解不全面。患者住院期间无焦虑、恐惧、抑郁、悲观等心理反应。其它无特殊。护理诊断/计划/措施/评价1、 护理诊断
4、：疼痛 与心绞痛、心肌梗死有关护理计划：患者疼痛减轻直至消失，生命体征平稳。护理措施：疼痛时嘱患者卧床休息，遵医嘱及时给予硝酸酯类药物，注意有无心动过速、头疼、呕吐、恶心等症状，同时指导患者保持大便通畅，不要用力解大便。护理评价：患者住院期间疼痛缓解直至消失，未使用止疼药物，未出现血压降低等不良症状。2、 护理诊断：活动无耐力 与心脏功能减退、氧的供养失调有关护理计划：逐渐提高患者的机体耐力，生活自理能力基本恢复。护理措施：患者 24 小时内绝对卧床休息，待患者病情稳定后逐渐增加活动量，提高活动耐力，防止深静脉血栓形成；为患者提供安静舒适的环境，严格限制探视，保证充足的睡眠与休息；持续吸氧 2
5、-4L/min，增加心肌供养。护理评价：患者自理能力基本恢复3、 护理诊断：有出血的危险 与溶栓使用抗凝药物有关护理计划：患者住院使用溶栓药物期间注意观察各项指标，无出血，无不良反应发生。护理措施：注意观察眼睛、牙龈、皮肤及粘膜有无出血情况以及呕血、便血、黑便、血尿等症状的出现，出现时及时通知医生。若出现出血情况，遵医嘱使用小分子肝素钠皮下注射。评价:患者未出现出血、淤血情况的发生。4、 护理诊断：潜在并发症 心律失常、心力衰竭、心源性休克、心脏骤停等护理计划：患者住院期间无心律失常、心力衰竭、心源性休克、心脏骤停等等并发症的发生。5、 知识缺乏 与缺乏冠心病的预防及康复知识有关护理计划：向患
6、者及家属讲解冠心病的预防及康复知识，帮助患者及家属建立对待冠心病正确的态度和树立战胜疾病额信心。护理措施：与病人及家属积极交流，讲解有关冠心病的预防及康复的知识，帮助他们介绍后顾之忧，树立对待疾病的正确态度和树立战胜疾病的信心。护理评价：患者及家属已经对疾病有了比较全面的了解，能正确看待疾病。Name:chen dong lin Sex:male Age:82 years oldChief complaint:Because of repeated attacks,chest tightness,more than 10 years,addingg a half months admissio
7、n.History of present illness:The patient felt rather tight and chest pain at 2003.He was diagnosed with coronary atherosclerotic heart disease,unstable angina pectoris and remote myocardial infarction by TongJi hospital.The symptoms were relieved after stent implantation.In recent months,the patient
8、 felt rather tight and chest pain for 20 to 30 minutes.Taking Danshen pill is sometimes ineffective.But taking suxiaojiuxin pills could alleviate the symptoms.The symptom can be evoked avtivity.No night progressive dyspnea,mild couugh,absence of fever night sweats.Outpatient clinic income with coron
9、ary atherosclerotic heart disease and angina pectoris.The patient in poor mental and physical decline,since sleep,poor diet and two then normal.History of past illness:Hypertension in 20 years,coronary atheroscletrtic heart disease in 10 years,liver cyst,the left kidney stones,hyperplasia of prostat
10、e gland.Denied hepatits,tuberoulosis and other infections diseases.According to the national plan for vaccination,quinolones allergy history to the national plan for vaccination, quinolones allergy history .Denied history of trauma,Lipoma surgery of brain in 1933.Body:The body temperature of 36.4 de
11、grees velsius,the heart rate of 62 beats per minute,18 breaths per minute,normal heart sounds,rhythm of the heart is regular,no other special.Personal history:no specialMatrial historymarriedPreliminary diagnoes:1、coronary atherosclerotic heart disease,angina pectoris,stenting after heart failure 2
12、stage 2、 hypertension 3 grade,extremely high-risk groups3、 hyperplasia of prostate glandNursing assessment1、 medical history（1） Prevalence and treatment1）Prevalence：The patient felt rather tight and chest pain at 2003. In recent months,the patient felt rather tight and chest pain for 20 to 30 minute
13、s. The symptom can be evoked avtivity. .No night progressive dyspnea,mild couugh,absence of fever night sweats.2）Treatment: The patient was diagnosed with coronary atherosclerotic heart disease,unstable angina pectoris and remote myocardial infarction by TongJi hospital.The symptoms were relieved af
14、ter stent implantation. In recent months,the patient felt rather tight and chest pain and taking Danshen pill is sometimes ineffective.But taking suxiaojiuxin pills could alleviate the symptoms.3)The present situation: The patient in poor mental and physical decline,since sleep,poor diet and two the
15、n normal.4) Clinical history：Hypertension in 20 years.2、Psychosocial dataThe patient have a certain degree of understanding for the nature of disease , prognosis and prevention knowledge process. But the patient did not fully understand for it.Patients without anxiety, fear, depression, pessimism an
16、d other psychological reactions in the hospital.Nursing diagnosis / plan / measures / evaluation1、Nursing diagnosis:pain associated with angina pectoris and remote myocardial infarction.Nursing plan: Reduction in pain until it disappeared in hospital. Patients with stable vital signs.Nursing measure
17、s: Ask the patient to bed rest pain when he feels pain. Following the doctors advice give patient take nitrates in time. Pay attention to whether the Heartbeat tachycardia headache, vomiting, nausea and other symptoms. Patients were instructed to maintain smooth stool, do not force stool.Nursing eva
18、luation: Reduction in pain until it disappeared in hospital.2、Nursing diagnosis :Activity intolerance associated with the heart function drops and oxygen dependent disorder.Nursing plan: Gradually improve patient endurance, self - care skill Is the basic recoveryNursing measures:The patient go to be
19、d rest absolutly in 24 hours. For patients with stable disease after gradually increase the amount of activity, increase activity tolerance. To prevent deep venous thrombosis. Provide a quiet and comfortable environment for patients. Strictly limited visitation. To ensure adequate sleep and rest. Continuous oxygen inhalation of 2-4L/min. Increased myocardial support.Nursing evaluation :The patients self-care ability basic recovery
