英语查房教学(病例实战)

WARD17南十七NursingTeachingRound护理教学查房CaseReport病例报告买买提·艾山，男，58岁，新疆籍新疆军区副政委。主因发现心脏杂音32年，发作性心悸5年于2007年3月7日入院。PatientMaiMaiTi,male,58year-old,wasborninxinjiang.HewasadmittedtothehospitalonMarch7th2007.Chiefcomplaint:Hehashadcardiacmurmursfor32years,Palpitationfor5years.现病史PresentHealthHistory缘于32年前查体发现心脏杂音，患者始终无症状。自5年前经常于劳累或饮酒后感心悸，伴轻度胸闷Thepatienthadcardiacmurmurs32yearsago,buthewasasymptomatic.Hefeltpalpitationafterfatigueoralcoholintake5yearsago,sometimesaccompaniedbychestdiscomfort.现病史PresentHealthHistory无头晕、恶心、呕吐及晕厥,无胸痛休息后可缓解Nonauseaandvomiting,chestpain,dizzy,faint.Thesesymptomscanberelievedbyrest.现病史PresentHealthHistory2005年6月动态心电图显示频发多型室性早搏和阵发性室速给予口服胺腆酮治疗超声心动图提示左室流出道压力阶差高,ΔPG＝113mmHgContinuousECGrevelsprematureventricularcontractionsandparoxysmalventriculartachycardiaonJune2006.OralAmiodaronewasgivenhimtocontrolthem.Echocardiographyshowsleftventriclehypertrophy,leftventricleoutflowwasnarrow.ΔPGis113mmHg.现病史PresentHealthHistory2005年7月明确诊断为肥厚型梗阻性心肌病会诊决定暂时应用β-受体阻滞剂和钙拮抗剂行药物治疗观察血流动力学，如左室流出道压差降低，则继续药物治疗，如左室流出道压力阶差降低不明显，考虑射频消融结合起搏治疗。HewasdiagnosedasHCM(HypertrophicCardiomyopathy)onJuly2005.Betablockersandcalciumchannelblockerswereused.Thehaemodynamymustbeobserved.既往史PastHealthHistory否认冠心病、糖尿病病史否认肝炎、结核等传染病史否认手术外伤及输血史无药物过敏史DenyhistoryofCAD,diabetesmellitus.DenyhistoryofheritagefamilydiseaseDenyhistoryofsurgicaloperations,injuriesandbloodtransfusion.Nomedicineallergy个人史PersonalHistory：生于原籍，长期居住新疆，到过全国各地否认疫区居住史，否认化学毒物及放射性物质接触史。有吸烟史数十年，已戒烟，偶尔饮酒，无明确规律。已婚，配偶子女均体健大学文化程度Hasneverbeentoepidemicarea,denyhistoryofpoisontouching.Hashistoryofsmokingformanyyears,hehasalreadyquitsmoking.Drinkingoccasionally.Hiswifeishealthy.Thetwodaughtersarealsohealthy.Bachelordegree.家族史FamilyHistory父母双亡，死因不详家族中无类似疾病患者否认家族遗传病病史Ithasnotbeenfoundsimilardiseaseinhisfamily.Denyhistoryoffamilyheritagedisease.Hisparentsweredied,thereasonhasnotbeenclear.入院查体physicalexaminationT36.5℃P69次/分，R18次/分BP120/80mmHg发育良好一般情况好，双肺呼吸音清，未闻及干、湿性罗音T:36.5℃,HR:69b/m,R:18t/m,Bp120/80mmHg,DevelopedwellGenerallyspeaking,heisingoodcondition.入院查体physicalexamination心前区无异常隆起，心尖搏动于左锁骨中线外0.5cm，无细震颤，心界增大，心率69次/分，律齐主动脉瓣听诊区可闻及3-4/6级收缩期吹风样杂音腹部未见阳性体征。双下肢无水肿。Systolicmurmurwasheardataorticarea.Therestwasnormal.心电图示：心电图不正常，窦性心动过缓，左心室肥厚伴劳损，偶发室性期前收缩。ECGTheECGrevealssinusbradycardia,prematureventricularcontractions,leftventriclehypertrophyandchangesinSTsegmentandTwave.入院后复查超声心动图示：超声心动图结果：肥厚型梗阻性心肌病；左室肥厚：室间隔24mm，心尖部16mm，后壁19mm，侧壁16mm收缩期左室流出道可见五彩高速血流ΔPG＝168mmHg较前比较ΔPG有所升高EchocardiographyEchocardiographyshowsleftventriclehypertrophy,leftventricleoutflownarrowingatthesametime.Septalwallis24mm,theapexofleftventricleis16mm,posteriorleftventricleis19mm,inferiorsurfaceofleftventricleis16mmΔPGismorethanbefore.HighspeedbloodflowwerefoundinSystole.动态心电图动态心电图结果ContinuousECG频发多源室性期前收缩部分呈双型，部分形成加速的室性逸搏性心律及室性心动过速ContinuousECGrevealsmulti-focalPVCs,partlyventricularcoupletsandparoxysmalventriculartachycardia.治疗经过Treatmentprocess2007年3月27日植入5386DDDR型起搏器增加β-受体阻滞剂量超声心动图示主动脉跨瓣压缩小ΔPG=101mmHg于4月18日出院Dual-chamber,sequentialatrioventricularpacinghasbeeninsertedonMarch27th2007.ThedoseofBetablockerswasincreasedtoacquirebettereffect.ΔPGislessthanbefore.TheclientwasdischargedonApril18th.心理社会评估PsychosocialAssessment鉴于肥厚性心肌病无法根治以及无法预料的严重后果，患者有明显的不确定感，并导致恐惧和焦虑患者担心女儿患病Becauseoftheincurablenatureofthedisorderandtheunforeseeableoftheseriousconsequencesofthedisease,theclientisfacedwithuncertaintythatmaycreatefearandanxiety.Hewasworriedabouthisdaughter’conditionsNursingDiagnosis1PotentialComplicationsincludingarrhythmias,heartfailure,andsuddendeathNursingGoalsNooccurrenceoforearlydetectionofcomplicationsincludingarrhythmias,heartfailure,andsuddendeath护理诊断潜在并发症心律失常心衰猝死护理目标无心律失常无心衰无猝死等并发症NursinginterventionsAvoidimpairingventricularfilling,suchassuddenpositionchange,strenuousphysicalactivities,competitiveexercise.Observetheeffectsoftherapyapplied,thepossiblesideeffectsofmedications,complicationsObservevitalsigns,complaints.paymoreattentiontosuddendeath.护理措施避免可降低心室充盈的情况，如突然变换体位、体力活动、竞技运动药物治疗的护理：观察药物作用与付作用病情观察：生命体征、主诉，警惕猝死NursingDiagnosis2ActivityintolerancerelatedtotheimbalancebetweenoxygensupplyanddemandasaresultofcardiacinsufficiencyNursingGoalsIncreasedexercisetolerance护理诊断活动无耐力与心功能受损所致的氧供需失调有关护理目标足够的心排出量活动耐力增强NursinginterventionsInstructthepatientonpacingthedailyactivitiesandresttopromptcomfortCarefullymonitoringbeforeandafterpacemakerinsertion护理措施指导患者合理安排休息与活动，增进舒适安置起搏器前后的护理NursingDiagnosis3Fear/AnxietyrelatedtotheunknowingofandperceivedthreatofthediseaseNursingGoalsLessanxietyandapprehensionabouthisconditionandprognosis护理诊断恐惧或焦虑与对疾病缺乏了解和感知疾病威胁有关护理目标对疾病和预后的焦虑与恐惧感减轻NursinginterventionsEmotionalsupport:1.creatinganenvironmentinwhichhecanexpressconcernsandacknowledgefears2.showingacaringattitude3.offeringencouragement,acceptance.护理措施心理支持：接纳和理解患者创造有利于患者倾诉的环境给予关怀、鼓励、支持促进有效应对NursingDiagnosis4LackofHCMself-managementknowledgeandskillsNursingGoalsAdequateself-managementknowledgeandskills护理诊断知识缺乏缺乏肥厚性心肌病自我管理知识与技能护理目标有足够的自我管