中英文護理病歷患者姓名：陳東林 性別：男 年齡：82歲主訴：因“反復發作，胸悶10余年，加重半月”入2003續約20-30分鐘，服用發放丹參滴丸有時效果不佳，服用速效救心丸癥狀可緩解，活動時可診以“冠心病、心絞痛”收入院。患者發病以來精神差，體力下降，睡眠可，飲食差，二便如常。既往史：高血壓病20年，冠心病10年，肝囊腫，左腎結石，前列腺增生，否認肝炎、結核或其它傳染病史，按國家計劃進行接種，喹諾酮類過敏史，否認外傷史，1988年腦脂肪手術。6218140/80mmHg，其它無特殊。專科檢查：血壓140/80mmHg，神志清楚，心率62個人史：無特殊婚姻史：已婚2233、前列腺增生護理評估：1、病史(1)患病及治療經過200020-30活動時可誘發，無夜間漸發性呼吸困難，輕咳嗽，少量白色泡沫痰。有時感到頭昏，無發熱盜汗。診治經過：在同濟醫院被診斷為“冠心病不穩定型心絞痛20-30用發放丹參滴丸有時效果不佳，服用速效救心丸癥狀可緩解。目前狀況：患者發病以來精神差，體力下降，睡眠可，飲食差，二便如常。20102、心理社會資料患者對疾病的性質、過程、預后及防治知識有一定程度的了解，但是了解不全面。患者住院期間無焦慮、恐懼、抑郁、悲觀等心理反應。其它無特殊。措施評價1、護理診斷：疼痛與心絞痛、心肌梗死有關護理計劃：患者疼痛減輕直至消失，生命體征平穩。疼、嘔吐、惡心等癥狀，同時指導患者保持大便通暢，不要用力解大便。2護理計劃：逐漸提高患者的機體耐力，生活自理能力基本恢復。護理措施：患者24小時內絕對臥床休息，待患者病情穩定后逐漸增加活動量，提高活動耐力，防止深靜脈血栓形成；為患者提供安靜舒適的環境，嚴格限制探視，保證充足的睡眠與休息；持續吸氧2-4L/min，增加心肌供養。護理評價：患者自理能力基本恢復3、護理診斷：有出血的危險與溶栓使用抗凝藥物有關護理計劃：患者住院使用溶栓藥物期間注意觀察各項指標，無出血，無不良反應發生。護理措施：注意觀察眼睛、牙齦、皮膚及粘膜有無出血情況以及嘔血、便血、黑便、血尿等癥狀的出現，出現時及時通知醫生。若出現出血情況，遵醫囑使用小分子肝素鈉皮下注射。評價:患者未出現出血、淤血情況的發生。4、護理診斷：潛在并發癥心律失常、心力衰竭、心源性休克、心臟驟停等5確的態度和樹立戰勝疾病額信心。顧之憂，樹立對待疾病的正確態度和樹立戰勝疾病的信心。護理評價：患者及家屬已經對疾病有了比較全面的了解，能正確看待疾病。Name:chendonglinSex:maleAge:82yearsoldChiefcomplaint:Becaufrepeateattacks,chghtness,mohan10monthsadmission.

halfHistorofpresenillness:Tatienfelrathetighandchespaina2003.Hewasdiagnosedwithcoronaryatheroscleroartdisease,unstabnginapectoriandremotemyocardialinfarctiyTongJihospital.Tymptomswererelieveaftestenimplantation.ecentmonths,thpatienfelrathetighandchespainfor20to30minutes.TakinDanshenpilissometimessymptoms.Thesymptomcanbeevokedavtivity.Nnightprogressivdyspnea,milcouugh,absencoffevernightwithcoronarydiseaseandanginapectoris.Tatieninpoormentalandphysicadecline,sinleep,poodietandtwothennormal.Historyofpastillness:Hypertensn20years,coronatheroscletrartdiseasin10years,livyst,tefkidneystones,hyperplaprostatgland.Deniehepatits,tuberoulosisandotheinfectioiseases.Accordiothenationaplanforvaccination,quinololergyhistortothenationaplanforvaccinatiouinoloneallerghistor.Deniedhistoroftrauma,Lipomasurgeryofbrainin1933.Body:Thebody36.462beatsperminute,18breathsperminute,normalheartsounds,rhythmoftheheartisregular,nootherspecial.Personalhistory:nospecialMatrialhistorymarriedPreliminaryatheroscleroticheartdisease,anginapectoris,stentingafterfailure2stage2、hypertension3grade,extremelyhigh-risk3hyperplasiaofprostateglandNursingassessment1、medical（1） PrevalenceandtreatmentPrevaleneThepatientfeltrathertightandchestpainat2003.Inrecentmonths,thepatientrathertightandchestpainfor20to30minutes.Thesymptomcanbeevokedavtivity..Nonightprogressivedyspnea,mildcouugh,absenceoffevernightsweats.diagnosedwithanginapectorisandremotemyocardialinfarctionbyTongJihospital.Thesymptomswererelievedaftestenimplantationrecenmonths,thpatienfelrathetighandchespainandtakingDanshenpillissometimesineffective.Buttakingsuxiaojiuxinpillscouldalleviatethesymptoms3)Thepresentsituation:Thepatientinpoormentalandphysicaldecline,sincesleep,poordietatwothennormal.4)Clinicalhitpertensionin202PsychosocialdataThepatieaveacertaidegreeofunderstandinforthenaturofdiseas,prognosiandpreventionknowledgeprocess.Butthepatientdidnotfullyunderstandforit.Patientwithouanxietyfeardepressioessimismandotherpsychologiceactioninhospital.Nursingdiagnosis/plan/measures/evaluation1Nursingwithanginapectorisandremotemyocardialinfarction.Nursingplan:Reductioninpainuntilitdisappearedinhospital.PatientswithstablevitalsigNursinNursingmeasuresAskthepatientobedrespainwhenhefeelpainFollowinthedoctor'sadvicegivepatientakenitratntimePayattentiowhethertheheadachevomitingnauseaandothesymptoms.Patientwereinstructomaintaismoothstool,donotforcestool.Nursingevaluation:Reductioninpainuntilitdisappearedinhospital.2Nursingdiagnosis:Activitywiththeheartfunctiondropsandoxygendependentdisorder.Nursingplan:Graduallyimprovepatientendurance,self-careskillIsthebasicrecoveryNursingmeasures:Thpatiengotobedrestabsolutlin24hoursForpatientwithstablediseaseaftergraduallyincreasetheamountofactivity,increaseactivitytolerance.Topreventvenousthrombo