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未知题型

男性,28岁,2小时前,餐后突然出现上腹部刀割样疼痛,迅速波及全腹,伴出冷汗、恶心、呕吐,呕吐为胃内容物。体检:T 36.9°C,P 104次/分钟,R 24次/分钟,BP80/50mmHg,急性面容,面色苍白,全腹肌紧张,压痛、反跳痛,肝浊音界消失,移动性浊音（）目前的护理措施有哪些？

【参考答案】

: （1）可能原因:胃十二指肠穿孔引起继发性腹膜炎。（2分） （2）主要护理诊断1体液不足:主要与胃十二指肠穿孔致腹腔内......

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