1例肾病综合征病人的英语护理查房.docxVIP

1例肾病综合征病人的英语护理查房

Patient:ZhangXX,male,42yearsold,admittedon2024-03-18,bed12,room3B.

Primarydiagnosis:Primarynephroticsyndromewithbiopsy-provenminimalchangedisease,firstrelapseafter11monthsofremission.

Comorbidities:Stage-2essentialhypertension,dyslipidaemia,vitaminDdeficiency.

Currentmedications:Prednisolone60mgPOdaily,Tacrolimus3mgPObid,Losartan100mgPOdaily,Atorvastatin40mgPOnocte,Alfacalcidol0.25μgPOdaily,Furosemide40mgIVbid,Spironolactone25mgPOdaily,Rabeprazole20mgPOdaily,Calciumcarbonate1gPOtidwithmeals.

0800—Pre-shiftHandover

NightnurseZhengXXreported:

Urineoutput1850ml,darkamber,frothy,specificgravity1.035,noclots.

2-lbweightgainsinceyesterday(72.4→73.3kg).

Periorbitaloedemaunchanged;anklecircumference+1cmbilaterally.

BP148/92mmHgat0530afterLosartan;patientdeniesheadache.

Reports“tight”abdomen;girth96cm(↑2cm).

Deniesdyspnoea;lungscleartoauscultation.

Serumalbumin17g/L(yesterday),totalcholesterol9.8mmol/L,triglycerides4.7mmol/L.

24-hurineprotein8.4g(yesterday).

Tacrolimustrough6.2ng/ml(target5–8).

Bloodglucoseat04006.9mmol/L(nosteroid-inducedhyperglycaemiayet).

Patientslept5h,woketwicetovoid;states“Ifeelheavybutnotbreathless.”

0805—SafetyEnvironmentRound

Bedinlowposition,callbellwithinreach,non-slipsockson.

IVpumpalarmsset;500ml0.9%salinerunningat30ml/hascarrierforfurosemide.

Bathroomdoorunlocked;grabbarsdry;night-lightfunctional.

Noclutter;urinalplacedondominant-handside.

0810—PrimaryNurseAssessment(LiuXX,RN)

A.GeneralAppearance:Alert,oriented,mildmoonface,skinwithoutstriae,nobruises.

B.Vitals:Temp36.7°C,HR88regular,RR18,SpO?97%onroomair,BP144/90mmHg(sitting),132/84mmHg(lying);orthostaticdrop12/6mmHg—borderline.

C.Cardiovascular:JVP4cmabovesternalangleat45°;S1S2normal;noS3;2+pitting