英文肺癌护理病例学习PPT课件.ppt

CASESTUDY Eco601235802Paula601235815Vicky601235812 CONTENTS Basicinformationofthepatient Treatment Nursingcareplan Basicinformationofthepatient Name AunlamoolGender MaleAge 48Maritalstatus MarriedDateofhospitaladmission 15 6 2018Diagnosis lungcancerandhemoptysisPasthistoryillness IIIlungcancer NSCLCT3N0M1a SLPchemotherapy OnJune14 patienthadanintermittentlyhemoptysismorethan20timesandthevolumeofhemoptysisabout200ml Aftercontactingtheemergencydepartment thepatientwastakenfromthestretchertotheemergencydepartmentfortreatment ThedoctororderedIVdropsNSS1000ml vitalsigns T 36 9 P 116bpm R 20bpm BP 125 82mmHg O2saturation 94 Pasthistory CBC Hb12g Dl Hct37 3 WBC7780 cu mm Neutrophil88 4 Eosinophil1 7 Lympocyte7 8 Monocyte3 6 Basophil0 Platelet272000APTT27 80TT0 89MCV79 RDW14 8Totalprotein8 0gm dLAlbumin4 37gm dLGlobulin 8 7gm dLCholesterol 173mmol LTotalBil 0 33 mol LDirectBil 0 15 mol L Laboratoryresult EmergencyDepartment InJune15afternoon thepatientwastransferredtomaleward3fromtheemergencydepartmentwithgoodconsciousness Nochestpainbuthewasworriedabouthiscondition Patienthascoughduringnight sleepsnotverywell Givethepatientcontinuousoxygeninhalation Onadmission hisvitalsigns T 36 7 P 120bpm R 20bpm BP 123 80mmHg O2saturation 95 Pasthistory AboutNSCLC Thereare2maintypesoflungcancer non smallcelllungcancer NSCLC 80 85 smallcelllungcancer SCLC 80 85 Lungcancerisoneofthemostcommontypesofcancer duetocancer causingsubstances carcinogens intheairareinhaledandcausecelldamagethatlaterbecomescancer Themostcommoncauseoflungcancer byfar issmoking isadiseaseinwhichmalignant cancer cellsforminthetissuesofthelung SquamouscellcarcinomaLargecellcarcinomaAdenocarcinoma Complications Thecancerspreadingtootherareasofpatient sbodyAsideeffectoftreatmentplan likeChemotherapy Hemoptysis Hemoptysisistheexpectorationofbloodorblood tingedsputumfromthelungsortracheobronchialtree Duringtheclinicalcourseofnonsmallcelllungcancer NSCLC 20 60 ofpatientswilldevelophaemoptysis with5 10 ofcasesconsideredsevere Colorandamountofbleedingisusefulinthedifferentialdiagnosisofhemoptysis Emergencymanagementdependsuponlocalizationofthesiteofbleedingbyroentgenogram computerizedchesttompgraphyandbronchoscopy Thirddayafteronadmission heisingoodconsciousness asmallamountofhemoptysis intermittentcough nochestpain theconditionisstable thelaboratoryresultsarestable givethepatientthedischargeofthehospitalinaccordancewiththedoctor sorders Hisvitalsigns T 36 3 P 108bpm R 20bpm BP 120 70mmHg O2saturation 98 Currentcondition Homemedication Codepect1x3CpcFluimucil200mg1x3Cpc Laboratoryresult CBC Hb10 2g Dl Hct32 9 WBC5570 cu mm Neutrophil68 7 Eosinophil9 0 Lympocyte12 9 Monocyte8 3 Basophil1 Platelet260000MCV80 2RDW80 2 Laboratoryresult Treatment OnO2cannula3L minNPONSS1000mlintravenous80ml hTransamine500mgintravenousq6hrHomemedication Codepect1x3CpcFluimucil200mg1x3Cpc Treatment Treatment Transamin500mgintravenousq6hr Treatment Homemedication Nursingcareplan 1 Impairedgasexchange relatedtoretentionofrespiratorysecretions 15 6 2018 1 Impairedgasexchange relatedtoretentionofrespiratorysecretions 15 6 2018 2 Riskforhemorrhagicshock relatedtomassivehemoptysis 15 6 2018 2 Riskforhemorrhagicshock relatedtomassivehemoptysis 15 6 2018 3 Anxietyrelatedtochangeinhealthstatus 18 6 2018 3 Anxietyrelatedtochangeinhealthstatus 18 6 2018 4 sleeppatterndisturbancerelatedtohemoptysisduringnight 18 6 2018 conclusionMr Aunlamoolisa48yearsoldmalewithlungcancerforsixyears hewasadmittedtotheERsincehemoptysis morethan200ml onJune14 thebloodtestresultarenormal CBC Hb WBC Neutrophil Lympocyte PTT thedoctororderedIVdropsNSS1000ml June15hewastransferredtomaleward3tocontinuoustreatment ThedoctororderedO2cannula3L min NSS1000mlIVdrops80ml handTransamine500mgintravenousq6hr Aftertreatment thepatienthasgoodconsciousness hemoptysisdecreasedtoabout50ml andlaboratoryresultallstable Thenursegavethepat