肺癌护理查房(完整版)

6月份科室护理查房

11床，董怀珠，男，左肺小细胞肺癌高血压病Contents病史汇报1护理体检2护理诊断3相关知识4病史汇报患者系确诊左肺小细胞癌8月余，按期治疗于6月12日入院患者既往有高血压病史8年，正规服药，血压控制一般入院时T：36.5度P：78次/分R：19次/分BP：150/110mmHgHotTip患者在住院期间出现经口进食呛咳、咳嗽咳痰明显，出现颅内肝脏多发转移，医嘱下病重，吸氧吸痰PRN6.20日予伊立替康及洛铂应用，5PM患者解稀水样便一次，予易蒙停口服，出现吞咽困难四评值ADL:25Braden：15Morse：85管道评分：4NRS：1ADL：45Braden：16Morse：85管道评分：4NRS：1ADL：85Braden：22Morse：65管道评分：2NRS：16.126.186.24治疗用药护胃：胃复安奥一麦瑞波特辅助抗肿瘤：鸦胆子油乳降颅压：甘露醇地塞米松保肝：天晴甘美门冬氨酸鸟氨酸降血压：兰迪化痰：必速平特步他林治疗用药辅助检查——血常规6.13中性粒细胞：86.5%淋巴细胞：3.5%6.20中性粒细胞：91.9%淋巴细胞：4.5红细胞：3、9HGB：1196.24中性粒细胞：94.5%淋巴细胞：3.1%辅助检查——生化6.13ALT：66尿素氮：15.5钾：3。076.20ALT：102尿素氮：10.7钾：4.316.24ALT：56尿素氮：12.07辅助检查——MRI辅助检查—胸部CT护理体检患者神志清楚，精神萎靡，言语不清，偶有流涎，仍有头晕及纳差不适四肢无力，颈软，双肺呼吸音粗。护理诊断焦虑有跌倒坠床的危险舒适的改变脑组织关注异常清理呼吸道低效自理能力下降有皮肤完整性受损的危险排便异常：便秘潜在并发症：脑疝猝死6.12焦虑与病情加重预后差有关护理目标：情绪稳定，能够积极配合治疗护理措施：1.积极与病人交流，讲解头晕等不适的原因，使其对疾病有所了解2.及时对症处理，减轻病人的痛苦，调动病人的积极情绪，更好的配合治疗3.加强对病人的关心和照顾，取得病人的信任4.密切和家属做好思想工作和保持联系，争取病人能够有更多机会与家属及亲友交流，消除孤独和绝望的不良情绪，以战胜疾病的信心护理评价：6.18患者情绪稳定，积极配合治疗6.24患者情绪稳定，积极配合治疗6.12有跌倒坠床的危险与患者头晕体弱有关护理目标：未出现跌倒坠床护理措施：1.根据患者的情况动态评估风险因素2.床头予警示标志3.穿防滑鞋及合适的衣裤4.使用双侧床栏5.讲解卫生间扶手及报警器的使用方法6.留陪护一人，24小时不间断陪护护理评价：6.18患者未出现跌倒坠床6.24患者未出现跌倒坠床6.12舒适的改变与患者体弱及病情重有关护理目标：患者感觉舒适护理措施：1.妥善安置卧位，定时翻身2.协助患者洗漱，温水擦洗，保持皮肤及床单位的清洁干燥3.遵医嘱用药，缓解患者头晕等不适4.指导患者进食高蛋白高维生素高纤维食物，增强体质护理评价：6.18患者感觉不舒适6.24患者感觉舒适6.13脑组织关注异常与肿瘤转移浸润有关护理目标：脑组织灌注正常，未造成脑组织进一步损害护理措施：1、抬高床头约15-30度，利于静脉回流，降低颅内压2.观察生命体征的变化及有无意识障碍的出现3.控制液体摄入量及输液速度4.遵医嘱予脱水利尿剂的应用，观察药物的疗效及副作用护理评价：6.15患者感觉头晕等不适未缓解6.18患者感觉头晕等不适6.22患者仍感觉头晕等不适6.24患者仍感觉头晕等不适6.16清理呼吸道低效与体弱及痰液粘稠有关护理目标：患者呼吸道通畅护理措施：1、观察患者痰液的颜色量及性状2.遵医嘱予化痰药物的应用3.指导患者定时翻身，进行拍背，促进痰液的排出4.嘱患者适量饮水护理评价：6.18患者痰液粘稠，不易咳出6.21患者可自主咳出白粘痰6.25患者可自主咳出白粘痰6.18自理能力下降与患者病情重及头晕有关护理目标：患者能够满足基本生活需要护理措施：1.根据患者的病情动态进行ADL评分2.留一人24小时不间断陪护3.予床头警示标志4.听取患者的主诉，及时满足患者的基本生活需求5.物品摆放有序，随手可及，鼓励患者自己做力所能及的事情护理评价：6.20患者的基本生活需求得到满足6.22患者的基本生活需求得到满足6.25患者的基本生活需求得到满足6.23排便异常：便秘与进食少及长期卧床有关护理目标：患者大便正常护理措施：1.嘱患者进食粗纤维食物2.适量饮水3.必要时遵医嘱用药4.指导患者进行腹部环形按摩护理评价：6.24患者大便未解6.25患者大便自解潜在并发症：脑疝猝死预防措施：1.密切观察患者的生命体征及瞳孔意识的变化2.急救药品及器械处于完好备用状态，出现病情变化时配合医生进行抢救思考问题晚期肺癌生活质量与治疗方案选择肺癌患者总的5年标化生存率为8%-14%。约65%的肺癌患者确诊时已属晚期。如何在延长患者生存期的同时，力争提高患者生活质量，已成为肺癌治疗方案设计中日益受到重视的问题。怎样有机地结合多学科的综合治疗，避免各自为主，简单的多学科相加治疗而对病人造成“过度”的损伤又是当前肺癌治疗研究的热点之一。相关知识：肺癌伴脑转移肺癌脑转移-出现在肺癌原发灶发现之前-肺癌原发灶同时发现-发现之后近来报道，约81%的肺癌脑转移发生在肺癌诊断后，其中位数为17个月非小细胞肺癌脑转移的发生率约20-40%，高到低：腺癌〉大细胞未分化癌〉鳞癌肺小细胞未分化癌首次就诊，脑转移发生率10%，诊疗过程中为40-50%，存活2年以上的患者脑转移达80%HotTip脑转移自然病程1-2个月；单纯化疗为2.5-3个月,全脑照射4-6月脑转移是原发瘤治疗失败的常见原因。脑转移途径和部位最常见途径-动脉循环的血源性转移。脑内灰白质交界以下区域血管管径变细，狭窄的血管内血流变慢，易形成瘤栓，该处是发生脑转移瘤的最常见部位。脑转移瘤的分布与其重量（及血流量）有关，约80%的脑转移位于大脑半球，15%在小脑，5%在脑干。影像表现：灰白质交界处病变，边界不规则，肿瘤较小伴大片水肿MRI:T1像显示低于正常脑组织信号

T2加权像显示水肿，表现高信号HotTiptumorT1WT2WHotTip治疗手术治疗

立体定向放疗全脑放射治疗化学治疗同步放化疗的应用HotTip降颅压甘露醇+激素-注意电解质平衡颅高压者–补液速度慢及少补液激素：减轻及防止组织炎症反应，↓毛细血管扩张及通透性，↓水肿形成。利尿剂：排泄体内过多纳和水，↓细胞外液容量，消除水肿。甘露醇：组织脱水药，↑血浆胶体渗透压，组织水份进入血管内，↓组织水肿。临床表现1头疼:患者会在清晨发作，性质多有强烈，有时会在睡觉中痛醒，但是起床后轻度活动后会得到缓解.2.视力障碍:颅内压增高时会使眼球静脉血回流不畅，导致淤血水肿，眼底视网膜上的视觉细胞受到伤害，导致视力下降。3.呕吐:颅内压力的增高，使远髓呼吸中枢受到刺激而引起呕吐，呕吐多大头痛后出现，呈喷射性的.HotTip4精神异常位于大脑前部额叶的脑瘤可破坏额叶的精神活动，造成兴奋，压抑，遗忘，虚构等精神异常表现。5幻嗅

额叶部的肿瘤可在其刺激下闻到一些不并存在的气味，如烧焦饭或烧焦塑料品等HotTip6单侧肢体感觉异常无力位于脑半球中部的顶叶，专管感觉，该部位的肿瘤经常会引起单侧部位肢体痛，温，震动，形体辨别觉减退或消失7偏瘫小脑部病变更有特异性，常表现为患者在头痛。呕吐，视物障碍之后出现的偏瘫或走路像酔酒时的样子。HotTip8耳鸣.耳聋此症状一般在患者打电话时发现，一边耳朵能听见，另外一边听不到，可能是颅内肿瘤压迫听神经所致。该表现多数是听神经瘤的先兆。护理病情观察心理护理呼吸道的护理饮食护理皮肤护理骨髓抑制的护理护理一。心理护理患者知道自己的病情时心理压力非常大，常会产生强烈的恐惧忧郁绝望等情绪反应，对治疗失去信心，甚至拒绝治疗，产生轻生的念头。所以在护理过程中态度应和蔼热情，以极大地同情心关心患者，以真诚的言语交流和娴熟的技术，取得患者的信任。同时鼓励家属陪同照顾，让其感受到家庭的温暖，建立良好的护患关系。认真向患者及家属解释治疗和护理的重要性。请一些治疗效果好的患者现身说法，鼓励患者积极配合治疗，使其相信经过治疗当前的症状是可以缓解的，树立战胜疾病的信心。HotTip二。病情观察认真听取患者有关头痛的诉说，评估头痛的性质程度持续时间，根据WHo疼痛三级阶梯指导原则，遵医嘱给予止痛药物，告诉患者疼痛不能忍受.密切观察患者的生命体征瞳孔意识及呕吐发生的时间性质量；准确记录24h出入量，防止电解质紊乱。肺癌脑转移患者出现体温升高与肺部感染有关。遵医嘱给予抗生素及退热药物以防加重脑缺氧。如患者出现抽搐时立即通知医生，同时给予开口器压舌板，防止发生舌咬伤。对于精神异常者，加强生活护理防止意外发生。

HotTip颅内高压的护理肺癌脑转移者，不可避免的会发生颅内压升高脑水肿症状。一定要遵医嘱按时快速静滴甘露醇及地塞米松。为防止药物外渗保持药物的有效性，应用中心静脉导管输液，并做好管道的维护。抬高床头15-30度，利于颅内静脉回流。在治疗过程中密切观察患者有无头痛加剧意识改变意识模糊呕吐频繁肢体抽搐血压升高呼吸节律改变双侧瞳孔不等大烦躁不安等脑疝前期和脑疝的症状及体征，立即通知医生采取急救措施。HotTip由于患者处于应急状态，又加上应用激素和化疗药物，极易出现应激性溃疡，应注意观察大便的颜色形状，及早发现，及时处理。嘱患者保持安静，勿做屏气动作。便秘者给予缓泻剂或使用开塞露，禁用大量液体灌肠，避免加重脑水肿HotTip三、呼吸道的护理保持呼吸道的通畅，对于呕吐频繁特别是喷状呕吐者取侧卧位。呕吐后及时清洁口腔及鼻咽部，防止发生吸入性肺炎。昏迷患者因呼吸道分泌物增加，又不能自行排出，应及早气管切开改善通气，降低二氧化碳分压，改善低氧血症。定时吸痰，每次吸痰时间不超过15s，吸痰前用生理盐水3-5ml湿化气道，同事做好口腔护理及气管切开护理（定期消毒或更换气管套管）HotTip四、饮食护理因晚期肺癌脑转移患者常有食欲不振消瘦贫血免疫力低下等，足够的营养能增加机体的抵抗力和对治疗的耐受性，减少并发症的发生。除静脉补充营养外，鼓励患者多进食高蛋白高维生素高热量清淡易消化无刺激食物，少量多餐。对脑转移昏迷患者，给予鼻饲。进食时使患者的头部稍前倾，并偏向一侧，可防止呛咳舌后坠误吸等。为保证大便通畅患者要多食新鲜水果和蔬菜，必要时榨成果汁和蔬菜汁。对头痛恶心呕吐症状严重者，要限制水和盐的摄入。HotTip5.骨髓抑制的护理由于肺癌脑转移患者应用化疗药物，应查血常规1次/周。当白细胞小于3*109/L时，遵医嘱给予特尔津200ug皮下注射。保持房间整洁，定时通风。嘱患者勤洗手勤换衣物，并注意保暖防止感冒减少探视人员，严格执行无菌技术操作原则，避免交叉感染。嘱患者不要剧烈运动，避免磕碰。用软毛刷刷牙，不要挖鼻孔和使用牙签、HotTip6.皮肤的护理患者放化疗后出现皮肤色素沉着伴全身瘙痒干燥脱屑脱发。嘱患者不要用力搔抓头皮，常修剪指甲，睡前洗净双手。瘙痒较重者用菊花水薄荷水清洗皮肤。转移癌者一般全身状况差，长期卧床。经常换床单被褥，保持床铺整洁干燥舒适。有肢体功能障碍者，每天指导患者做好肢体功能锻炼，用温水擦洗肢体促进血液循环，使肢体处于功能状态。定时翻身，动作轻柔，避免推拉，防止压疮发生。HotTip7.做好基础护理病室的环境应保持整洁空气流通。为防止患者跌倒，保持地面干燥，嘱患者穿防滑鞋，专人陪护，禁止单独外出。对生活自理能力差得患者，要安置床栏。专人看护，避免坠床。ThankYou!晚期肺癌生活质量与治疗方案选择对于一般状况较差，以缓解症状为主要治疗目的的病人，短程，低剂量放疗具有费用低，就诊时间短和改善生活质量明显等优点，应作为作为首选。而对于一般状况好的局限晚期的患者，根治是治疗的目的，应选择标准剂量放疗，并考虑化放疗联合进行。晚期肺癌患者生活质量与放疗

晚期肺癌患者生活质量与化疗联合放疗化疗与姑息性放疗改善肺癌局部症状的有效率相似，即咳嗽40%-70%，咯血80%-90%，胸痛40%-47%和气急40%-75%，中位缓解期也相似达7—14周。4545赠送2套亮丽色表格可一键删除折线图/表格/数据关系Trending

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