1、护理英语交班 Nursing English report,General conditions,Good morning, every one, March 21.2009 We are passing nursing report now. There are total 36 patients in the ward, including 3 patients discharged, 2 admitted ,2 transferred in ,2 transferred out ,1 died yesterday.,各位,早晨好 2009年3月21日护理交班 病人总数:36 出院病人数:
2、3 入院病人数:5 转入病人数:2 转出病人数:2 死亡病人数:1,3 patients were performed operation. The number of DIL case:1 the number of patient on grade one nursing care :10,手术病人数:3 病危病人总数:1 病重病人总数:2 一级护理病人总数:10,Discharged case,Bed 3,Wang Hong, coronary heart disease（CHD）, angina pectoris, was discharged at 9 oclock yesterda
3、y after treatment.,3床, 王红,冠心病、心绞痛于9：00出院,Death case,Bed 29, Zhao Liang, pulmonary infection, two type of respiratory failure, multiple organ failure , was died (passed on) at 10:00 yesterday after resuscitation failure.,29床, 赵良,肺部感染,二型呼衰,多功能脏器衰竭,经抢救无效于10：00死亡,New admission,Bed 18,Wei Haiming,male,47
4、 years old, was admitted at 10:00 oclock with complaining of a 15 days intermittent chest pain and palpitation. The diagnosis was uncertain chest pain, dysrhythmias, paroxysmal atrial fibrillation, bradycardia, hypertension on grade 3.,18床 魏海明 胸痛原因待查,心律失常、阵发性房颤、窦性心动过缓、高血病3级 患者，男性47岁，地方人员，于10：00入院。主因
5、为发作性胸痛伴心慌15天，为进一步治疗入院。,After admission, the doctor Li Xuehua was notified immediately and the admission interview was done. ECG at bedside showed sinus rhythm. BP was 130/88mmHg.The low salt and low fat diet was served. Dilated coronary artery, anticoagulation and anti-hypertension drugs were taken
6、and grade 2 nursing care was given as doctors orders.,入院后立即通知李学华医生,入院介绍已做.患者未诉胸痛、心慌，血压130/88mmHg.行床旁心电图示窦性心律.遵医嘱给予二级护理，低盐低脂普食，扩冠、抗凝、降压等药物治疗。,The patient slept well Last night and blood specimen were taken.The vital signs were normal in the morning.,病人睡眠好，晨起血标本已留，生命体征平稳.,DIL case,Bed 10，Wang Hua, cor
7、onary Heart disease, angina pectoris, acute extensive anterior myocardial infarction. The patient suddenly complained of chest pain at 22:30 Oxygen was given immediately and the flow rate was 3L/min.ECG monitoring was started and showed sinus rhythm.,10床,王华，冠心病，心绞痛，急性广泛前壁心肌梗死. 昨天22：30病人主诉心前区疼痛，立即给予吸
8、氧3升/分，心电监护仪监护，心电示波示窦性心律，,The heart rate was 63 beats/min. BP was 115/64mmHg. Meanwhile Dr.Zhang Xue was informed. After taking 3 tablets of nitroglycerin sublingually at 5 minute intervals as indicated, the pain was persistent. The ECG showed the 0.2-0.6 mv of elevated V1-V5 St segment. Dr. Zhao Yon
9、g saw the patient.,心率63次/分，血压115/64mmHg,通知张学医生看病人，遵医嘱给予硝酸甘油mg舌下含服，症状无缓解，行床旁心电图检查示V1-V5ST段抬高0.2-0.6mv.二线赵勇副主任医师到场看病人。,Heparin 100mg in normal saline 500ml and Dopamine 80mg in normal saline 500ml were give by IV infusion. The drop rate were 500u/h and 1.46ug/kg/min respectively. The patient was on DI
10、L.,遵医嘱给予静脉输入生理盐水500ml+肝素钠注射液100mg，滴速为500u/h,生理盐水250ml多巴胺注射液80mg，滴速1.46ug/kg/min，报病危。,Iv infusion were kept patent. The patient slept intermittently in the evening. The ECG showed sinus rhythm. The heat rate was at range of 63-74 beats/min and BP was 91-115/53-64mmHg. The patient was turned every 2 h
11、ours and now is on supine (prone, lateral, Fowlers, semi-Fowlers) position.,夜班输液通畅，患者间断睡眠，心电监护仪显示窦性心律，心率波动在63-74次/分，血压波动在91-115/53-64mmHg.每2小时翻身一次,现病人平卧位(伏卧位、侧位、半卧位、较低半卧位）。,The skin was integrity. The total input was 400ml and the output was 300ml.,皮肤无破损，全天入量400ml，尿量300ml.,Operation case,Bed 11,Duan
12、 Rong, colon cancer. Ater being performed the colectomy with general anesthesia ,the patient was conscious when he came to the ward at 15:30. The dressing kept integrity and the outer dressing layer hadt been wet or soiled. The Abdominal drainage tube was secured well and drained 50ml bloody exudate
13、s.,11床,段荣,直肠癌,今日在全麻下直肠癌切除术,术后于15:30返回病房,清醒,血压154/96mmHg,切口敷料包扎好,外层敷料未见明显渗出. 腹腔引流管固定通畅，引流液为血性。,The nasogastric tube was attached to low suction for decompression and drained 100ml of dark -green color of exudates. The catheterization was maintained patent and its drained 1200ml of clear urine.,持续胃肠减压
14、通畅，引流墨绿色液体100ml. 尿管通畅，尿色清亮，皮肤好。,The central venous catheter was kept patent and there were no redness and swelling in the skin. The saturation of oxygen was continuously monitored by pulse oximetry and the values were 95% to 99%. The grade 1 nursing care and fasting food were given as doctors orders
15、.,中心静脉输液通畅，穿刺部位无红、肿.持续血氧饱和度监测，SPO2维持在95-99%之间，术后遵医嘱给予一线护理，禁食.,The patient was changed the position every 2 hours and the skin was integrity. The patient slept intermittently Last night. The total intake was 2500ml and the output was 1350ml.,定时翻身，皮肤好。夜间间断入睡,全天入量2500ml,出量1350ml，其中尿量1200ml,腹腔引流50ml,胃肠引
16、流液100ml.,Preoperation cases,Ded 3, Sun Yi, cholecystitis, cholelithiasis, will be performed the laparoscopic cholecystectomy with general anesthesia. The skin at and around the operative site was shaved. Preoperative patient education was done.,3床,孙义,胆囊炎,胆石症.患者常规准备于明日在全麻下行腹腔镜胆囊切除术.皮已备,术前指导已做,青霉素皮试(一
17、).晚上给予清洁灌肠一次,大便3次，夜间睡眠好，晨起已禁食水。,Penicillin allergy test was negative. The patient was given a cleaning enema (laxative) and passed watery (loose)stool 3 times. He slept well at night and took nothing by mouth (NPO) in the morning. The vital signs were normal.,青霉素皮试(一).晚上给予清洁灌肠一次,解水样大便3次，夜间睡眠好，晨起已禁食水
18、，生命体征平稳。,Other notes,The patients who had fever:Bed 8, Su Haokai, the temperature at 14:00 was 39.0. After cold compress and tepid (cool water) sponging giving to the patient, the body temperature fell to 37.8 at 14:30 .,发热患者: 8床,苏浩凯,14点测体温为39.0,给予冰袋物理降温,温水擦浴.14:30体温降为37.8.,Clinic tests will be done
19、 today: Bed 15 ,Wang Yonglin is on nothing-by-mouth regimen for abdominal ultrasound. Bed 32, Xue Hua,24-hour urine collection was started today,the specimen should be sent at 8:00 tomorrow morning.,今日拟检查 15床 王永林,今晨禁食水,行腹部B超检查. 32床 薛华,今日起留24小时尿,明天早8点标本送检.,Thats all Nurse on duty: Wang Yan,交班完毕. 值班护士;王艳,常用医学单位英文表达方式,ml=milliliter mg=milligram mm=millimeter mv=millivolt mmHg=millimeter of mercury U=unit IU=International Unit=micron Mol=micromole Kg=kilogram,Thanks!,
