【正文】 harges were found in external auditory tenderness in mastoid acuity was : No abnormal discharges were found in vetibulum nasi was in nares tenderness in nasal : Bilateral eyelids were not was not was were not projected or was pupils were round and equal in and indirect pupillary reactions to light were : Oral mucous membrane was smooth, and of no ulcer or was in was not were not : Symmetric and of no was not was in Chestwall: Veins could not be seen subcutaneous space was neither narrowed nor : Symmetric : Symmetric nipples nor skin were was : Respiratory movement was bilaterally symmetric with the frequency of 20/ expansion and tactile fremitus were symmetric pleural friction was heard during abnormal breath sound was : No bulge and no abnormal impulse or thrills in precordial point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not pericardial friction of the heart was sounds were strong and no 80/ rhythm was pathological : Flat and bulge or abdominal wall type or peristalses were not was not tenderness and rebound tenderness on abdomen or renal was not was not dullness 5/ vascular : No articular movements of all system: Physiological reflexes were existent without any pathological system: Not : not exanedInvestigation BloodRt: Hb 127g/l RBC : SG pH Bultrasound: myoma of uterus of loop is normal Hepatic function: Normal PT amp。（3）心理護(hù)理：針對患者不良心理予以相應(yīng)的心理護(hù)理，使患者自愿接受治療，消除不良心理，從而確保手術(shù)的療效及依從性。所以再次妊娠時(shí)，應(yīng)及時(shí)就診，不要輕易終止妊娠。七、出院指導(dǎo)：飲食指導(dǎo)：出院后給予患者高蛋白，高熱量，高維生素且易消化的飲食；少時(shí)生冷油膩的食物，多食用水果、蔬菜等高維生素食物，均衡營養(yǎng)，加速康復(fù)。：便秘，腹痛與手術(shù)有關(guān)。：疼痛與手術(shù)創(chuàng)口有關(guān)。（4）遵醫(yī)囑給予5%葡萄糖500ml靜點(diǎn)給藥。經(jīng)入院檢查，查體有腹膜刺激癥狀，下腹壓痛+，反跳痛+移濁177。：輸尿管行程無壓痛，右腎區(qū)叩痛（+），移動(dòng)性濁音（），腹部叩診腸鳴音正常，約5次/分。二、病史既往病史：患者有慢性婦科炎癥2年，無高血壓，糖尿病病史，無藥物過敏史，無毒物藥及疫區(qū)接觸史。第一篇：婦科方面 護(hù)理病歷婦科護(hù)理病歷一、病人基本情況科別：婦科 姓名：劉志玲 性別：女 年齡：45歲 婚姻：已婚 職業(yè)：干部 文化程度：大專 民族：漢 入院日期：20131110 收集資料日期：2013121 醫(yī)療診斷：異位妊娠 既往身體狀況：：生于原籍，久居成都市彭州，無放射性物質(zhì)及毒物接觸史，無煙酒等不良嗜好。：開放自然、獨(dú)立、依賴。：雙肺叩診是清音，雙呼吸音清，未聞及干濕羅音。五、病歷摘要患者停經(jīng)45天，下腹部 輕度疼痛，陰道有少量出血，尿HCG陽性，入院診斷。（3）陰道出血，劇烈腹痛，脈搏快而弱，應(yīng)警惕有內(nèi)出血或休克。（2）配合醫(yī)生進(jìn)行手術(shù)，予以相應(yīng)的體位護(hù)理、疼痛護(hù)理及并發(fā)癥的預(yù)防護(hù)理。（2）予以常規(guī)輸液護(hù)理，針對疼痛等并發(fā)癥進(jìn)行對癥處理。（3）予以出院指導(dǎo)，告知患者出院時(shí)間。：有異位妊娠病史的患者，再次異位妊娠的可能性增加，對于還有生育要求的患者予以指導(dǎo)，妊娠前需通過B超檢查對子宮的恢復(fù)程度進(jìn)行評估，恢復(fù)良好后方可進(jìn)行妊娠，防止子宮破裂的并發(fā)癥的發(fā)生；懷孕前對輸卵管通暢度進(jìn)行檢查，以減少再次異位妊娠的發(fā)生率；因輸卵管妊娠患者再次發(fā)生宮外孕的幾率為10%，不孕率高達(dá)5060%。以此術(shù)前及術(shù)后需就手術(shù)的操作、療效、注意事項(xiàng)及療效等相關(guān)內(nèi)容進(jìn)行健康宣教。由此，證實(shí)護(hù)理操作具有重要的價(jià)值。破宮產(chǎn)：于**時(shí)間送入手術(shù)室，產(chǎn)婦于**時(shí)間在手術(shù)室產(chǎn)一女嬰，哭聲響亮，皮膚色澤紅潤，外觀無缺陷，肢體活動(dòng)自如。危急值今接到XXX床危急值:，立即匯報(bào)醫(yī)生，遵醫(yī)囑給予50%GS 20ml靜脈注射。同時(shí)做好口腔護(hù)理，防止口腔內(nèi)感染。（藥物注射前回暖）糖尿病飲食：告知患者控制總量，建立合理飲食結(jié)構(gòu)，均衡營養(yǎng)，高纖維素飲食，飲食清淡，低脂少油，少鹽少糖，戒煙限酒?；颊弑景嘧襻t(yī)囑給予利尿劑，現(xiàn)跌倒評分為**分，已患者告知患者及家屬利尿劑使用后會(huì)出現(xiàn)頻繁排尿和四肢無力等現(xiàn)象，下床如廁時(shí)要有家屬攙扶并陪伴在旁，勿穿易滑倒的鞋，家屬輪換時(shí)做好交接，床尾懸掛防跌倒的警示標(biāo)志，患者及家屬表示理解。對壞死組織可用一些去腐生肌的藥物或水凝膠敷料清創(chuàng)，并結(jié)合外科清創(chuàng)，創(chuàng)面新鮮后處理同Ⅱ期壓力性損傷。家屬已知曉。卵巢腫瘤有囊性與實(shí)質(zhì)性、良性與惡性之分。不配合部分相關(guān)醫(yī)療檢查項(xiàng)目。焦慮相關(guān)因素個(gè)體健康受到威脅。提供安靜、舒適、整潔的環(huán)境，避免各種不良刺激。病人焦慮的程度以及所采取的措施是否得力，效果如何。告知病人化療后脫發(fā)是可逆的，指導(dǎo)脫發(fā)病人配戴假發(fā)，并教會(huì)病人保護(hù)假發(fā)的方法，即脫下假發(fā)用溫水清洗灰塵，梳子順梳、晾干備用?？诖礁闪?、疼痛，進(jìn)食困難。必要時(shí)可根據(jù)咽拭子培養(yǎng)結(jié)果，選擇適合病人的漱口液。傷口疼痛、呻吟不止。鼓勵(lì)病人術(shù)后盡早下床活動(dòng)，促進(jìn)腸蠕動(dòng)。病人能設(shè)法增加攝入營養(yǎng)物質(zhì)的品種和數(shù)量。指導(dǎo)家屬為病人合理搭配食物、并請營養(yǎng)護(hù)士為病人制定合理食譜。主要表現(xiàn)體溫、血白細(xì)胞