【正文】 刺激性食物，以免加重刺激，損傷口腔粘膜。主要表現(xiàn)腹脹、腹痛。保持病人床單位整潔、舒適。護(hù)理目標(biāo)病人及家屬認(rèn)識(shí)到營(yíng)養(yǎng)不足的原因及應(yīng)對(duì)措施。必要時(shí)靜脈補(bǔ)充營(yíng)養(yǎng)品，如輸血、白蛋白、氨基酸等?；熀罂谇徽衬€。下腹部疼痛，呈漸進(jìn)性。定期監(jiān)測(cè)血清球蛋白、白蛋白、總蛋白值，以觀察病人治療效果。病人的水、電觖質(zhì)、血清白蛋白、球蛋白、血紅蛋白等指標(biāo)恢復(fù)正常。重點(diǎn)評(píng)價(jià)病人的休養(yǎng)環(huán)境是否令人滿意。護(hù)理目標(biāo)病人自覺舒適感增加。如：①輕度口腔感染 者，選用朵貝氏液；②口腔感染、口臭者，選用1%3%過氧化氫液；③霉菌感染者，選選用1%4%碳酸氫鈉液；④綠膿桿菌感染者，%醋酸液。護(hù)理目標(biāo)病人主訴口腔疼痛感減輕或消除。對(duì)情緒不穩(wěn)定的尚未生育的病人不當(dāng)面談孩子的問題，以免傷害病人。自我形象紊亂相關(guān)因素手術(shù)切除生殖器官導(dǎo)致影響生育或夫妻生活。安慰體貼病人，與病人多交談，及時(shí)了解病人的心理狀況。擔(dān)心個(gè)人婚姻、生育有所影響。護(hù)理目標(biāo)病人了解疾病一般衛(wèi)生常識(shí)。囊性多屬良性，實(shí)質(zhì)性多屬惡性。）導(dǎo)管描述：導(dǎo)管在位，通暢，外露**cm,引流出**ml**液體，周圍皮膚**。（4）4期壓力性損傷：應(yīng)清潔瘡面，去除壞死組織，保持引流通暢，促進(jìn)愈合。（預(yù)防跌倒措施可參照：預(yù)防跌倒、墜床警示標(biāo)識(shí)使用）壓瘡：（預(yù)防壓瘡措施參照：預(yù)防壓瘡警示標(biāo)識(shí)使用）預(yù)防壓瘡，對(duì)高齡、低蛋白血癥、水腫、消瘦、剛手術(shù)病人、病情危重、Braden 評(píng)分≤12分、有壓力性損傷者需每天動(dòng)態(tài)評(píng)估，Braden評(píng)分1314分，每周評(píng)估2次，Braden評(píng)分1518分，每周評(píng)估1次壓力性損傷處理： 對(duì)處于危險(xiǎn)的患者采取有效的預(yù)防策略，包括：分析危險(xiǎn)因素、降低壓力、防止再次受壓、評(píng)估營(yíng)養(yǎng)狀況、糾正皮膚不良狀態(tài)、控制疼痛、避免過度的臥床休息和長(zhǎng)期的坐位，保持皮膚的完整性。飲食應(yīng)定時(shí)，定量，固定。冰敷（于各大動(dòng)脈搏動(dòng)處）時(shí)間不超過30min，30min后復(fù)測(cè)體溫（不能在冰敷處立即測(cè)體溫），當(dāng)體溫降至38℃以下，則取下冰袋。**時(shí)間復(fù)查血糖**mmol/L，患者現(xiàn)無特殊不適。**時(shí)間產(chǎn)婦由手術(shù)轉(zhuǎn)入病房，立即給去枕平臥位，觀產(chǎn)婦神志清，精神一般，腹部切口敷料干燥無滲血滲液，按壓腹部，陰道約有**ml血液流出，子宮收縮好，導(dǎo)尿管在位通暢，幫助母嬰接觸、指導(dǎo)早吸吮、早開奶，囑其暫禁飲禁食、24小時(shí)母嬰同室、母乳喂養(yǎng)等，治療遵醫(yī)囑用藥。第二篇：婦科英文病歷CASEMedical Number: 756943 General information Name: Yue Junrong Age: Fortytwo years old Sex: Female Race: Han Occupation: Unemployment Nationality: China Marital status: Married Address: Xiaochang countyofXiaogan city in : 4835963Date of admission: , 2003 Date of record: 3pm, , 2003 Complainer of history: the patient herselfReliability: Reliable Chief plaint: The patient was found “myoma of uterus” over two years ago and menometrorrhagia for 5 illness: In 1999, the patient was found “myoma of uterus” in a physical she had nothing unfortable and her catamenia was used some Chinese traditional 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period lasted from 2 days to 4 felt no pain and the quantity was was accepted in our hospital and her diagnosis was “subserous myoma of uterus”.Since onset, her appetite was good, and both her spiritedness and physical energy are and urination are normal, history Operative history: Never undergoing any history: No history of severe infectious history: She was not allergic to penicillin or system: No history of respiratory system: No history of precordial system: No history of system: No history of genitourinary system: No history of anemia and mucocutaneous system: No excessive system: No history of confinement of system: No history of headache or history She was born in Hubei on July 16th, 1956 and almost always lived in graduated from senior high living conditions were bad personal habits and history: The first time when she was 2 days every times and its cycle is about 30 history: Pregnacy 3 times, once nature production, induced abortion history: Not history: His parents are both examinationT ℃, P 80/min, R 20/min, BP 120/ is well developed and moderately skin was not stained skin angioma was not pitting lymph nodes were not Cranium: Hair was black and well : Bilateral auricles were symmetric and of no disc