帮我中译英一篇医护文章

消化道穿孔病人的护理查房
一、简要病史
2317床，陈娟，女，22岁，江苏太仓人，汉族，已婚，初中文化。因“突发右侧腹痛2小时伴进行性加剧”于2010-06-14 03：10急诊入院。入院时神志清楚，精神可，急性痛苦貌。查体：右下腹明显压痛、反跳痛、轻度肌卫，未及明显肿块，移动性浊音阴性，肠鸣音不亢进，腹部立位片显示右膈下游离气体，血常规示：白细胞14.0×109/L，NEU79.2%，怀疑消化道穿孔收住我科。

二、术前准备
入住我科后，查体：T36.5℃，P74次/分，R20次/分，Bp99/65mmHg。既往体健，无过敏史及手术史，立即遵医嘱给与禁食、胃肠减压等护理，并抽血送检免疫常规和肝肾功能电解质，检查结果均正常。其Hb92g/L，凝血酶原时间11.2秒，故遵医嘱常规备皮，给予术前常规用药，即阿托品和鲁米那肌肉注射。于2010-06-14 03：40开始手术，05：10手术顺利完成，安全返回病房。

三、手术后护理
患者于2010-06-14 05：10手术完成后安返病房，遵医嘱给予一级护理、禁食、胃肠减压、去枕平卧和吸氧6小时等护理，术后留有腹腔引流管一根，妥善固定，并告知家属各管道的作用及注意事项，表示理解。由于特殊情况，下达病重通知单，各种记录均转记于危重症护理记录单。同时给予保胃、消炎、止血、补钾、营养、补液等支持治疗。至夜班交班，胃肠减压及腹腔引流量均为0mL。

四、护理治疗经过
2010-06-14 08：00，患者主诉切口疼痛，但能耐受，无恶心、呕吐，无发热，无胸闷气促感，无咳嗽咳痰，未排气排便。检查伤口敷料，显示包扎完好，清洁干燥。观察胃肠减压引流出黄色胃液10mL，腹腔引流出淡血性液体5mL。王益主任认为患者病情稳定，故停病重，继续给予抗炎、抑酸、止血、补液等支持治疗。

2010-06-15 08：00，患者无不适主诉，切口疼痛较前好转，伤口敷料清洁干燥，术后24小时引流量分别：胃肠减压100mL，腹腔引流淡血性液体30mL。考虑其长时间禁食，营养丢失较多，故增加补液量，长期给予平衡液500mL、氯化钾10mL及羟乙基淀粉500mL静脉滴入，临时给予5%葡萄糖500mL和氯化钾10mL静脉滴入。

五、手术前存在的护理问题
1.护理问题：2010-06-14疼痛：腹痛
相关因素：与消化道穿孔、消化液漏出刺激腹膜有关
诊断依据：患者急性痛苦貌
护理目标：一天内患者能说出疼痛的原因及减轻疼痛的措施
护理措施：
评价：2010-06-14患者主诉疼痛减轻，疼痛控制在二级 护理措施
1）评估患者腹痛的部位、性质、持续时间、间隔时间及疼痛的等级；
2）遵医嘱立即给予禁食，并持续胃肠减压，以减少消化液的漏出，从而减轻腹膜刺激；
3）指导病人取半卧位或屈膝侧卧位，减轻腹壁张力，从而间接减轻疼痛；
4）心理安慰

Gastrointestinal perforation patient care rounds First, a brief history of 2317, Chen, the female, 22 years old, Jiangsu Taicang people, Han nationality, married, middle school culture. Due to "sudden right abdominal pain 2 hours with progressive increase" in hospital emergency 2010-06-14 03:10. Conscious on admission, the spirit, appearance of acute pain. Examination: right lower quadrant tenderness, rebound tenderness, mild muscle health and less obvious mass, mobility, voiced negative, not hyperactive bowel sounds, abdominal films showed subphrenic orthostatic free gas, blood showed: WBC 14.0 × 109 / L, NEU79.2%, suspected gastrointestinal perforation admitted to our department. Second, preoperative preparation Check our department, the investigation body: T36.5 ℃, P74 / min, R20 / min, Bp99/65mmHg. Past physical health, no allergies and surgical history, and immediately was prescribed to give fasting, gastrointestinal decompression and other care, and routine blood and liver and kidney function immune censorship electrolyte test results were normal. The Hb92g / L, prothrombin time 11.2 seconds, it was prescribed routine skin preparation, preoperative conventional medicine, that is, intramuscular injection of atropine and luminal. Began operation on 2010-06-14 03:40, 5:10 surgery successfully completed, the safe return of wards. Third, post-operative care of patients after surgery at 2010-06-14 05:10 security back to the wards, as directed to give a care, fasting, gastrointestinal decompression, to pillow 6 hours so supine and oxygen care, surgery left shunt after a properly fixed, and inform the families of the role of various channels and notes that they understand. Due to exceptional circumstances, handed down ill notice, all records are recorded in critically ill patients transferred care sheets. At the same time to protect the stomach, inflammation, bleeding, potassium, nutrition, fluid replacement and other supportive treatment. To the night shift, decompression and drainage volume are 0mL. Fourth, care treatment after 2010-06-14 08:00, the patient complained of incisional pain, but can tolerate, no nausea, vomiting, no fever, no chest tightness, shortness of breath feeling, no cough, expectoration, defecation did not exhaust. Check wound dressing, dressing well shows, clean and dry. Drainage out of observation of gastrointestinal decompression yellow juice 10mL, a short bloody peritoneal fluid drainage 5mL. Wang Yi, director that patients in stable condition, so stop ill continue to be given anti-inflammatory, inhibiting gastric acid secretion, bleeding, fluid replacement and other supportive treatment. 2010-06-15 08:00, the patient complained of no discomfort, incision pain, better than before, wound dressings clean and dry, 24 hours after drainage were: gastrointestinal decompression 100mL, light bloody peritoneal drainage fluid 30mL. Consider their long fasting, nutrition, lose more, so to increase fluid volume, long-term solution to balance 500mL, potassium chloride, and hydroxyethyl starch 10mL 500mL infusion on temporary given 5% glucose and potassium chloride 10mL 500mL intravenous drip income. Fifth, there is nursing problems before surgery 1. Care issues :2010-06-14 pain: pain-related factors: and gastrointestinal perforation, digestive fluid leakage diagnosis based on the stimulation of peritoneal: appearance in patients with acute pain care goals: patients in one day can say the causes of pain and pain relief measures for nursing care: evaluation :2010-06-14 in patients complained of pain relief, pain control measures in the secondary care 1) to assess the site of patients with abdominal pain, nature, duration, interval time and the level of pain ; 2) was prescribed immediately for fast and continuous gastrointestinal decompression in order to reduce leakage of digestive fluid, thus reducing peritoneal irritation; 3) to direct patients to take semi-supine or lateral position knees to reduce abdominal wall tension, thereby indirectly reducing the pain; 4) psychological comfort

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