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肿瘤系统疾患护理
癌症生物学
癌的定义
恶性肿瘤或恶性赘瘤可统称为癌(Cancer),它是一种由异常分化及繁殖的单一变异细胞逐步形成之组织,不受控制地任意生长.
癌的发展
癌的发生
起始阶段:细胞基因受到伤害之阶段.
促进阶段:含有突变基因之潜在性癌细胞开始异常分裂增殖的阶段.
进展恶化阶段:癌细胞已停止分化,但不断增生并侵袭邻近组织.
癌症生物学
致癌因子
癌症生物学
致癌因子
癌症生物学
正常细胞与癌细胞之间的差异
细胞生长,分裂之差异
癌细胞失去接触抑制作用
正常细胞生长及移动时,会呈现出接触抑制的现象.
癌细胞因细胞间的黏合力较弱使之较易移动,故会失去接触抑制作用.
癌细胞失去细胞周期中的限制点
正常细胞周期分为:G1期, S期, G2期, M期, G0期.
癌细胞具突变基因的细胞,能源源不绝的进行细胞分裂的工作.
癌症生物学
癌症生物学
癌细胞的有丝分裂指数增加
有丝分裂指数偏高表示有较高的细胞增殖活动.
正常细胞(如肠胃道黏膜细胞)不断进行汰换,故有较高的有丝分裂指数.
癌细胞组织中细胞增殖活动旺盛,其有丝分裂指数亦高.
癌症生物学
癌细胞无老化现象
大部分正常细胞可分裂50～60次,而后开始衰老死亡,称之为老化.
癌细胞分裂的次数却不在此限,亦即无老化现象.
癌细胞生长所需的生长因子减少
正常细胞需有适当的生长因子刺激才能增殖.
癌细胞可在低浓度生长因子的情况生长,或自行制造生长因子而刺激生长.
癌症生物学
癌症生物学
癌症生物学
癌症生物学
癌细胞有侵袭及转移的能力
侵袭指癌细胞藉蛋白酵素溶解邻近组织,而移行到邻近正常组织;转移则指癌细胞由原发部位扩散到远端的组织.
癌细胞的转移途径有三种
在体腔内播种
大肠癌
经淋巴系统散布
乳癌
经由血液循环散布
sarcoma
癌症生物学
结构型态之差异
因缺乏良好的骨架而呈现外形,大小各异.
细胞核变大且多形化.
细胞核染色质异常深染.
染色体数目异常.
异常的染色体重组.
异常的有丝分裂型态.
癌症生物学
生化代谢产物之差异
细胞膜表面酵素
癌细胞藉由制造细胞膜表面酵素,来侵袭其他的组织并转移到远处.
肿瘤相关抗原
α-胎儿蛋白(AFP):在肝癌,睾丸癌,肺癌,胰脏癌及卵巢癌会升高.
癌胚抗原(CEA):在直肠癌,胆道癌,乳癌,肺癌,胰脏癌及抽菸者会升高.
CA19-9 :在胃癌,胰脏癌及胆道癌者会升高.
异位性荷尔蒙:有些癌细胞会制造类似荷尔蒙物质,而引起生理效应,此种效应称为类肿瘤症候群.
癌症生物学
肿瘤的分类及命名
依生物行为
依据肿瘤的生物行为可分成良性肿瘤及恶性肿瘤.
依解剖部位
依肿瘤的解剖部位命名常以肿瘤发生的部位称之,可分原发性及转移性肿瘤.
依组织型态
依据肿瘤组织型态分类的方法是较常使用的,主要依据身体各种组织加以分类命名.
癌症生物学
预防及早期发现
癌症预防及早期发现是有效对抗癌症的方法之一.
癌症的预防可分为三层次
一级预防
藉由避免可能造成癌症的因素或移除可能好发癌症的部位,而减少罹患癌症的机会
二级预防
藉由早期发现早期治疗以改善癌症疾病过程
三级预防
藉由立即且有效的抗癌治疗,症状控制,复健,以减少癌症的死亡率
癌症生物学
护理评估
确认生活型态危险因子
饮食习惯
Smoking
Drinking
确认职业或环境危险因子
确认生物危险因子
确认医学引起的危险因子
评估采取预防行为的动机
癌症生物学
护理措施
鼓励可以减低癌症罹患危险的行为改变
饮食改变
避免过度饮食而造成肥胖
以低油饮食取代高油饮食
增加纤维摄取量
增加食物中维生素A及C之摄取量
减少摄食腌制食物,熏制食物及含硝酸盐之食品
癌症生物学
护理措施
生活型态改变
减少抽菸行为或戒菸
减少因阳光照射而暴露於紫外线中的机会
与病人互相订定目标及计画以减少致癌之危险因子
监测病人之状况并评估护理措施之成效
癌症生物学
二级预防(早期诊断,早期治疗)
个人癌症危险评估
护理评估
个人基本资料 :①年龄;②性别;③种族;④地理,生活型态;⑤社会经济环境;⑥癌症家族病史.
身体检查与评估
对於40岁以下没有症状的个人,应至少每3年接受一次全身健康检查.
对於40岁以上没有症状之个人,应每年接受一次全身健康检查.
癌症生物学
身体检查与评估
若个人出现「癌症七项危险徵兆」则应立即寻求医疗诊断
排便或排尿习惯改变
伤口长期无法愈合
不正常出血或分泌物
乳房或身体其他部分出现不正常肿块
吞咽困难
身上的痣发生明显的变化
长期咳嗽或声音沙哑
癌症生物学
癌症分期
TNM系统
"T"表原发性肿瘤的范围
"N"表区域性性的淋巴结被侵犯的程度和范围
"M"表是否有远处转移
癌症生物学
癌症分期
典型的分级群组
Stage 0
StageⅠ:T1N0M0
StageⅡ:T2N1M0
StageⅢ:T3N2M0
StageⅣ:T4N3M+
Lung Cancer
病因
吸菸
职业的暴露
遗传
酒精
营养状态
Vit. A不足可能会造成肺腺癌
已存在有肺脏疾病
居住环境
Lung Cancer
类型
良性肿瘤:少於10%.
原发性恶性肿瘤:主要包括二大类,即非小细胞癌及小细胞癌.
转移性恶性肿瘤:最常来自乳癌
Lung Cancer
临床表徵
与肺癌有关的警告讯号
呼吸型态改变
痰中带血丝
持续性咳嗽
铁锈色或化脓性的痰
明显的咳血
胸痛或胸闷
肩部,手臂或胸壁疼痛
反覆发作的肋膜积水,肺炎,或支气管炎
呼吸困难
声音沙哑
Lung Cancer
临床表徵
局部病变时的临床表徵
咳嗽,痰多不易咳出,呼吸困难,咳血,胸部不适及上腔静脉徵候群,也可能会有体重减轻
转移性的临床表徵
出现胸腔内转移
出现中枢神经系统转移
出现脊椎转移
出现肋膜积水
Lung Cancer
诊断检查
身体评估
触诊时会有压痛或肿块,但呼吸道有阻塞或肋膜有积水时则会减弱或消失,气管会有偏移
叩诊时患部出现浊音
听诊时呼吸音会减弱或消失,也可能会听到鼾音,喘鸣或肋膜摩擦音
在心脏评估时,可能会有心音减弱,杂音及节律障碍
Lung Cancer
诊断检查
细胞学检查 :由痰液中可能会发现癌细胞
胸部X光 :可看出有肿块,也可看出因肿瘤阻塞所造成的肺扩张不全及肺炎的现象
电脑断层扫描
核磁共振显像
支气管镜检
纵膈腔镜检
肺血管摄影术及肺脏扫描
胸腔放液穿刺术
肺切片检查
肺功能测试
Lung Cancer
肺癌的分期
Lung Cancer
医疗处置
手术切除
放射治疗
化学治疗
免疫治疗
镭射治疗
药物治疗
止痛剂,支气管扩张剂,抗生素,类固醇
Lung Cancer
护理措施
维持呼吸道通畅
促进气体交换
促进舒适
增加活动量
预防合并症发生
促进调适能力
出院前指导
Case study
张先生,58 years of age, was hospitalized because of an increasingly productive cough and complaints of fatigue and feelings of breathlessness when he climbs stairs or walks a distance. He had a continuous cold and cough. His wife explained that he was less and less active because of his breathing difficulties. Assessment revealed a barrel chest, weakness in his extremities, anorexia, nausea, vomiting, and fever. He had been smoking two to three packs of cigarettes a day for the last 30 years and was trying to reduce or stop the habit.
Case study
His chest x-ray showed an area of infiltration and pulmonary function tests showed restrictive and obstructive patterns. His hemoglobin was elevated. Cytological studies of sputum samples revealed malignant cells. Mr. Chang was diagnosed with non-samll-cell-lung carcinoma based on histologic and cytologic testing of tissue samples obtained from biopsies during fiberoptic bronchoscopy. A lesion was found in the parenchyma of his right lung. He was advised of the option for surgical removal of the tumor, and agreed to have a lobectomy.
Case study
Facts
He had been smoking two to three packs of cigarettes a day for the last 30 years smoking again
Cough
fatigue
feelings of breathlessness
he was less and less active because of his breathing difficulties
barrel chest
weakness in his extremities, anorexia, nausea, vomiting, and fever
chest x-ray showed an area of infiltration
pulmonary function tests showed restrictive and obstructive patterns
fever
Case study
Clinical data
Lab values
CEA :<5ng/ml
Medications
止痛剂
类固醇
Antibiotics
支气管扩张剂
Case study
Nursing diagnoses/Etiology
焦虑/与缺乏手术讯息有关
Expected outcome
能说出手术过程及手术注意事项
Nursing interventions
说明术前各项准备工作及代表意义
告知肺叶切除手术的过程及术中工作流程
解释手术中,后存放气管内管,胸管及尿管的目的
Case study
Nursing diagnoses/Etiology
潜在皮肤完整性受损/长期卧床不动有关
Expected outcome
除手术切口及胸管伤口外无其他伤口
Nursing interventions
胸腹背腰部用脂肪垫减压
骨突出处衬脂肪垫
转动手术床动作宜慢
Case study
Nursing diagnoses/Etiology
呼吸道清除功能失效/ 呼吸道分泌物多稠及无效性咳嗽有关
Nursing interventions
教导深呼吸咳嗽的方法
教导背部扣击运动
咳嗽时用胸口固定法以减轻伤口疼痛
协助诱导性肺活量侧定器的使用
鼓励一天摄取1500c.c.水份
Case study
Level of Priority
Healthcare professionals and medical care needed
Colon cancer
以腺癌占95%为最多,好发於直肠
病因
环境因素:饮食中含高脂肪与动物蛋白,或缺乏蔬菜,纤维及抑制因子(维生素A,C)
遗传基因
发炎性肠病变
息肉因素
胆囊切除术后
放射线治疗后
Colon cancer
高危险因子
年龄大於40岁者
有结肠癌,息肉的家族史者
有过结肠息肉的病患
有慢性发炎性结肠疾病的病患
排便习惯不正常,有习惯性便秘的人
Colon cancer
临床表徵
解便习惯改变
解血便或柏油便的现象
腹痛,腹胀的现象
体重减轻,食欲不振的症状
右结肠癌较少引起肠道阻塞,因右结肠的肠腔大,粪便为液状,但易造成贫血
Colon cancer
诊断检查
收集病史
理学检查
粪便是否有潜血反应
内视镜检查
血液检查
Hb. ,CEA
大肠钡剂灌肠摄影
肾盂泌尿摄影
超音波或电脑断层摄影
Colon cancer
医疗处置
手术治疗
升结肠癌:右半结肠切除术
横结肠癌:横结肠切除术
降结肠癌:左半结肠切除术
乙状结肠癌:乙状结肠切除术
直肠癌:发生於直肠上1/3及中1/3段,低位切除术;直肠癌病灶在直肠下1/3段,采腹部会阴切除术
齿状线以下5公分的病灶,做结肠肛门吻合术
Colon cancer
并发症
肠阻塞
肠穿孔
出血
吻合处渗漏
辅佐治疗
最主要是化学治疗及放射线治疗,化学治疗包括5-Fluorouracil,Mitomycin-C及Levamisole等
术后追踪
术后最初两年每2个月追踪一次,后三年每4个月追踪一次
Colon cancer
护理措施
适应疾病及身体心像之改变
增加对造口排便控制的能力
协助度过哀伤过程
居家照顾的卫教
Case study
Mr. Wu, 55 years of age, wanted to practice illness prevention and health promotion activities. He had no family history of colon cancer, but when he learned of the high incidence of colon cancer in adults over 55 years of age, he underwent a routine colonscopy. He believed that he had no symptoms of disease, so he was stunned when the colonscopy showed a lesion in his ascending colon. The physician removed tissue for a biopsy and reported that the tumor was an adenocarcinoma, originating in the epithelial lining of the intestine.
Case study
In retrospect, Mr. McKinsey was able to identify symptoms that he had mistaken for normal patterns. He recalled complaining of dull abdominal pain and occasional black tarry stools. Because of the location of the lesion, he was prepared for abdominoperineal resection with a permanent sigmoid colostomy. His surgery was scheduled immediately.
As you plan his nursing care, limit your preparation for class to his preoperative care and the first 48 hours of his postoperative care.
Case study
Facts
abdominoperineal resection with a permanent sigmoid colostomy
Clinical data
Lab values
OB (+)
CEA↑(＜2ng/ml)
Medications
Antibiotics
Kanamycin,erythomycin and neomycin
Case study
Nursing diagnoses/Etiology
焦虑/OP,造瘻护理
Expected outcome
增加对疾病认识,以减轻焦虑
Nursing interventions
评估个案焦虑程度
采轻松及同理心的态度接触个案,接受个案的行为
教导放松技巧,缓解压力
说明诊断检查,治疗计划,手术过程
回答问题要诚实,态度要诚恳
Case study
Nursing diagnoses/Etiology
急性疼痛/与手术后伤口有关
Expected outcome
病患疼痛情形能获得缓解
Nursing interventions
安排轻松,安静,舒适的环境
经常协助更换姿势,按摩背部,以促进舒适
教导放松技巧,分散注意力
By order给止痛药并评估效果
Case study
Nursing diagnoses/Etiology
营养不均衡:少於身体需要/与疾病及治疗过程有关
Expected outcome
能摄取适当的营养及维持体液电解质的平衡
Nursing interventions
能由口进食时,鼓励摄入高热量,高蛋白,高醣类及低渣食物,若无法进食,则采TPN
每日测量体重
Case study
Nursing diagnoses/Etiology
潜在危险性体液容积缺失/与伤口引流及造瘻口有关
Expected outcome
能维持水分及电解质的平衡
Nursing interventions
Monitor I/O
若每小时尿量<30c.c. ,应立即通知医师
监测由IV补充的液体与电解质的量
Monitor V.S.
评估有无脱水症状
Case study
Nursing diagnoses/Etiology
潜在危险性感染/与手术及造瘻口有关
Expected outcome
没有感染症状
Nursing interventions
Monitor blood tests
Monitor infection s/s
注意伤口护理的无菌技术
Monitor V.S.
评估有无脱水症状
Case study
Postoperatively, Mr. Wu progressed as expected. His abdominal wound was clean and intact and his perineal wound had a drain in place that was to be removed gradually. The slight swelling of his stoma was receding and the small amount of normal oozing after surgery had resolved.
Case study
Questions
When planning care for Mr. Wu identify the problems that focus attention on the following physical aspects: respiratory, circulatory, nutritional, and integumentary
墬积性肺炎
血栓性静脉炎
肺栓塞
营养不足
伤口感染
伤口破裂
瘻管
Case study
Questions
Write expected outcomes for the emotional/psychological issues in Mr. Wu's care
病患能适应疾病及身体心像之改变
病患能顺利度过哀伤的过程
Plan a patient education program that will have as its goal to enhance Mr. Wu's self-care abilities
结肠造瘻灌洗
造瘻口护理
饮食卫教
Ovarian cancer
病因病理
原发性常发生於卵巢囊肿转变而来.续发性则由其他部位的癌症转移而来
临床表徵
卵巢癌都是直到已确定是恶性时,才有症状出现.身体评估时通常经由触诊可摸到骨盆肿块,进一步藉由超音波等来确定诊断
医疗处置
第Ⅰ期至第Ⅳ期卵巢癌皆是用腹式全子宫切除术及两侧输卵管卵巢切除术治疗.第Ⅱ期至第Ⅳ期手术后常合并使用全身性化学治疗
Case study
Mrs. Lee and her husband celebrated her 50th birthday by taking a cruise to several islands near the Equator. Their happiness was marred only by her vague complaints of pelvic pressure, abdominal discomfort, and urinary frequency. She attributed her symptoms either to having indulged in the buffet tables at all hours of the day and night during the cruise or to a urinary tract infection. When they returned home, Mrs. Lee immediately made an appointment with her physician. The physician in the office thoroughly assessed Mrs. Lee.
Case study
The assessment revealed that Mrs. Lee had had irregular periods for some time, with menorrhagia and tenderness of her breasts. During the assessment, Mrs. Lee admitted that her gastrointestinal symptoms were vague but persistent, and that abnormal menses had been long-standing symptoms. In discussing her options with her doctor, she expressed concern about having a hysterectomy. She wanted to know whether she would be able to maintain her intimate relationship with her husband after the operation and whether he would still find her attractive.
Case study
Questions
How is cancer of the ovary staged
Case study
Questions
What assumptions can be made about the stage of Mrs. Lee's cancer at diagnosis
She is in at least stage II because she has symptoms: pelvic pressure, abdominal discomfort, and urinary frequency, irregular periods for some time, with menorrhagia and tenderness of her breasts. Her treatment is hysterectomy with radiation treatment which is for stage II and III.
Case study
Questions
What are the treatment choices for women with ovarian cancer and what criteria are used to make decisions about treatment Why
第Ⅰ期至第Ⅳ期卵巢癌皆是用腹式全子宫切除术及两侧输卵管卵巢切除术治疗.
经腹部全子宫切除术:适用於曾接受腹部手术
经阴道全子宫切除术
第Ⅱ期至第Ⅳ期手术后常合并使用全身性化学治疗
Case study
Questions
What testing is indicated in the assessment of ovarian cancer
骨盆腔检查
阴道超音波检查
CA125↑
Case study
Questions
What are the priorities of pre- and postoperative care
Pre-
肠道准备
手术前一晚以优碘行阴道冲洗
皮肤准备
手术前一天午夜后开始禁食
手术前给予麻醉前驱剂
鼓励病人表达内心感触及担心害怕的事情
Case study
Questions
What are the priorities of pre- and postoperative care
Post
先进食开水,清淡饮食,而后恢复正常饮食
可教导病人采取坐浴或使用烤灯
手术后一个月内避免举重物,做粗重的家事或剧烈
经医师检查伤口确定已愈合后,才可开始性生活
避免久坐或双腿长时间交叉坐的姿势
适当的运动及充足的水分
鼓励病人适当地表达其情绪
促进性生活的调适
Case study
Questions
What are the priorities of patient education for Mrs. Lee during radiation therapy
口腔护理
头发护理
皮肤护理
照射部位护理
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癌症生物学
癌的定义
恶性肿瘤或恶性赘瘤可统称为癌(Cancer),它是一种由异常分化及繁殖的单一变异细胞逐步形成之组织,不受控制地任意生长.
癌的发展
癌的发生
起始阶段:细胞基因受到伤害之阶段.
促进阶段:含有突变基因之潜在性癌细胞开始异常分裂增殖的阶段.
进展恶化阶段:癌细胞已停止分化,但不断增生并侵袭邻近组织.
癌症生物学
致癌因子
癌症生物学
致癌因子
癌症生物学
正常细胞与癌细胞之间的差异
细胞生长,分裂之差异
癌细胞失去接触抑制作用
正常细胞生长及移动时,会呈现出接触抑制的现象.
癌细胞因细胞间的黏合力较弱使之较易移动,故会失去接触抑制作用.
癌细胞失去细胞周期中的限制点
正常细胞周期分为:G1期, S期, G2期, M期, G0期.
癌细胞具突变基因的细胞,能源源不绝的进行细胞分裂的工作.
癌症生物学
癌症生物学
癌细胞的有丝分裂指数增加
有丝分裂指数偏高表示有较高的细胞增殖活动.
正常细胞(如肠胃道黏膜细胞)不断进行汰换,故有较高的有丝分裂指数.
癌细胞组织中细胞增殖活动旺盛,其有丝分裂指数亦高.
癌症生物学
癌细胞无老化现象
大部分正常细胞可分裂50～60次,而后开始衰老死亡,称之为老化.
癌细胞分裂的次数却不在此限,亦即无老化现象.
癌细胞生长所需的生长因子减少
正常细胞需有适当的生长因子刺激才能增殖.
癌细胞可在低浓度生长因子的情况生长,或自行制造生长因子而刺激生长.
癌症生物学
癌症生物学
癌症生物学
癌症生物学
癌细胞有侵袭及转移的能力
侵袭指癌细胞藉蛋白酵素溶解邻近组织,而移行到邻近正常组织;转移则指癌细胞由原发部位扩散到远端的组织.
癌细胞的转移途径有三种
在体腔内播种
大肠癌
经淋巴系统散布
乳癌
经由血液循环散布
sarcoma
癌症生物学
结构型态之差异
因缺乏良好的骨架而呈现外形,大小各异.
细胞核变大且多形化.
细胞核染色质异常深染.
染色体数目异常.
异常的染色体重组.
异常的有丝分裂型态.
癌症生物学
生化代谢产物之差异
细胞膜表面酵素
癌细胞藉由制造细胞膜表面酵素,来侵袭其他的组织并转移到远处.
肿瘤相关抗原
α-胎儿蛋白(AFP):在肝癌,睾丸癌,肺癌,胰脏癌及卵巢癌会升高.
癌胚抗原(CEA):在直肠癌,胆道癌,乳癌,肺癌,胰脏癌及抽菸者会升高.
CA19-9 :在胃癌,胰脏癌及胆道癌者会升高.
异位性荷尔蒙:有些癌细胞会制造类似荷尔蒙物质,而引起生理效应,此种效应称为类肿瘤症候群.
癌症生物学
肿瘤的分类及命名
依生物行为
依据肿瘤的生物行为可分成良性肿瘤及恶性肿瘤.
依解剖部位
依肿瘤的解剖部位命名常以肿瘤发生的部位称之,可分原发性及转移性肿瘤.
依组织型态
依据肿瘤组织型态分类的方法是较常使用的,主要依据身体各种组织加以分类命名.
癌症生物学
预防及早期发现
癌症预防及早期发现是有效对抗癌症的方法之一.
癌症的预防可分为三层次
一级预防
藉由避免可能造成癌症的因素或移除可能好发癌症的部位,而减少罹患癌症的机会
二级预防
藉由早期发现早期治疗以改善癌症疾病过程
三级预防
藉由立即且有效的抗癌治疗,症状控制,复健,以减少癌症的死亡率
癌症生物学
护理评估
确认生活型态危险因子
饮食习惯
Smoking
Drinking
确认职业或环境危险因子
确认生物危险因子
确认医学引起的危险因子
评估采取预防行为的动机
癌症生物学
护理措施
鼓励可以减低癌症罹患危险的行为改变
饮食改变
避免过度饮食而造成肥胖
以低油饮食取代高油饮食
增加纤维摄取量
增加食物中维生素A及C之摄取量
减少摄食腌制食物,熏制食物及含硝酸盐之食品
癌症生物学
护理措施
生活型态改变
减少抽菸行为或戒菸
减少因阳光照射而暴露於紫外线中的机会
与病人互相订定目标及计画以减少致癌之危险因子
监测病人之状况并评估护理措施之成效
癌症生物学
二级预防(早期诊断,早期治疗)
个人癌症危险评估
护理评估
个人基本资料 :①年龄;②性别;③种族;④地理,生活型态;⑤社会经济环境;⑥癌症家族病史.
身体检查与评估
对於40岁以下没有症状的个人,应至少每3年接受一次全身健康检查.
对於40岁以上没有症状之个人,应每年接受一次全身健康检查.
癌症生物学
身体检查与评估
若个人出现「癌症七项危险徵兆」则应立即寻求医疗诊断
排便或排尿习惯改变
伤口长期无法愈合
不正常出血或分泌物
乳房或身体其他部分出现不正常肿块
吞咽困难
身上的痣发生明显的变化
长期咳嗽或声音沙哑
癌症生物学
癌症分期
TNM系统
"T"表原发性肿瘤的范围
"N"表区域性性的淋巴结被侵犯的程度和范围
"M"表是否有远处转移
癌症生物学
癌症分期
典型的分级群组
Stage 0
StageⅠ:T1N0M0
StageⅡ:T2N1M0
StageⅢ:T3N2M0
StageⅣ:T4N3M+
Lung Cancer
病因
吸菸
职业的暴露
遗传
酒精
营养状态
Vit. A不足可能会造成肺腺癌
已存在有肺脏疾病
居住环境
Lung Cancer
类型
良性肿瘤:少於10%.
原发性恶性肿瘤:主要包括二大类,即非小细胞癌及小细胞癌.
转移性恶性肿瘤:最常来自乳癌
Lung Cancer
临床表徵
与肺癌有关的警告讯号
呼吸型态改变
痰中带血丝
持续性咳嗽
铁锈色或化脓性的痰
明显的咳血
胸痛或胸闷
肩部,手臂或胸壁疼痛
反覆发作的肋膜积水,肺炎,或支气管炎
呼吸困难
声音沙哑
Lung Cancer
临床表徵
局部病变时的临床表徵
咳嗽,痰多不易咳出,呼吸困难,咳血,胸部不适及上腔静脉徵候群,也可能会有体重减轻
转移性的临床表徵
出现胸腔内转移
出现中枢神经系统转移
出现脊椎转移
出现肋膜积水
Lung Cancer
诊断检查
身体评估
触诊时会有压痛或肿块,但呼吸道有阻塞或肋膜有积水时则会减弱或消失,气管会有偏移
叩诊时患部出现浊音
听诊时呼吸音会减弱或消失,也可能会听到鼾音,喘鸣或肋膜摩擦音
在心脏评估时,可能会有心音减弱,杂音及节律障碍
Lung Cancer
诊断检查
细胞学检查 :由痰液中可能会发现癌细胞
胸部X光 :可看出有肿块,也可看出因肿瘤阻塞所造成的肺扩张不全及肺炎的现象
电脑断层扫描
核磁共振显像
支气管镜检
纵膈腔镜检
肺血管摄影术及肺脏扫描
胸腔放液穿刺术
肺切片检查
肺功能测试
Lung Cancer
肺癌的分期
Lung Cancer
医疗处置
手术切除
放射治疗
化学治疗
免疫治疗
镭射治疗
药物治疗
止痛剂,支气管扩张剂,抗生素,类固醇
Lung Cancer
护理措施
维持呼吸道通畅
促进气体交换
促进舒适
增加活动量
预防合并症发生
促进调适能力
出院前指导
Case study
张先生,58 years of age, was hospitalized because of an increasingly productive cough and complaints of fatigue and feelings of breathlessness when he climbs stairs or walks a distance. He had a continuous cold and cough. His wife explained that he was less and less active because of his breathing difficulties. Assessment revealed a barrel chest, weakness in his extremities, anorexia, nausea, vomiting, and fever. He had been smoking two to three packs of cigarettes a day for the last 30 years and was trying to reduce or stop the habit.
Case study
His chest x-ray showed an area of infiltration and pulmonary function tests showed restrictive and obstructive patterns. His hemoglobin was elevated. Cytological studies of sputum samples revealed malignant cells. Mr. Chang was diagnosed with non-samll-cell-lung carcinoma based on histologic and cytologic testing of tissue samples obtained from biopsies during fiberoptic bronchoscopy. A lesion was found in the parenchyma of his right lung. He was advised of the option for surgical removal of the tumor, and agreed to have a lobectomy.
Case study
Facts
He had been smoking two to three packs of cigarettes a day for the last 30 years smoking again
Cough
fatigue
feelings of breathlessness
he was less and less active because of his breathing difficulties
barrel chest
weakness in his extremities, anorexia, nausea, vomiting, and fever
chest x-ray showed an area of infiltration
pulmonary function tests showed restrictive and obstructive patterns
fever
Case study
Clinical data
Lab values
CEA :<5ng/ml
Medications
止痛剂
类固醇
Antibiotics
支气管扩张剂
Case study
Nursing diagnoses/Etiology
焦虑/与缺乏手术讯息有关
Expected outcome
能说出手术过程及手术注意事项
Nursing interventions
说明术前各项准备工作及代表意义
告知肺叶切除手术的过程及术中工作流程
解释手术中,后存放气管内管,胸管及尿管的目的
Case study
Nursing diagnoses/Etiology
潜在皮肤完整性受损/长期卧床不动有关
Expected outcome
除手术切口及胸管伤口外无其他伤口
Nursing interventions
胸腹背腰部用脂肪垫减压
骨突出处衬脂肪垫
转动手术床动作宜慢
Case study
Nursing diagnoses/Etiology
呼吸道清除功能失效/ 呼吸道分泌物多稠及无效性咳嗽有关
Nursing interventions
教导深呼吸咳嗽的方法
教导背部扣击运动
咳嗽时用胸口固定法以减轻伤口疼痛
协助诱导性肺活量侧定器的使用
鼓励一天摄取1500c.c.水份
Case study
Level of Priority
Healthcare professionals and medical care needed
Colon cancer
以腺癌占95%为最多,好发於直肠
病因
环境因素:饮食中含高脂肪与动物蛋白,或缺乏蔬菜,纤维及抑制因子(维生素A,C)
遗传基因
发炎性肠病变
息肉因素
胆囊切除术后
放射线治疗后
Colon cancer
高危险因子
年龄大於40岁者
有结肠癌,息肉的家族史者
有过结肠息肉的病患
有慢性发炎性结肠疾病的病患
排便习惯不正常,有习惯性便秘的人
Colon cancer
临床表徵
解便习惯改变
解血便或柏油便的现象
腹痛,腹胀的现象
体重减轻,食欲不振的症状
右结肠癌较少引起肠道阻塞,因右结肠的肠腔大,粪便为液状,但易造成贫血
Colon cancer
诊断检查
收集病史
理学检查
粪便是否有潜血反应
内视镜检查
血液检查
Hb. ,CEA
大肠钡剂灌肠摄影
肾盂泌尿摄影
超音波或电脑断层摄影
Colon cancer
医疗处置
手术治疗
升结肠癌:右半结肠切除术
横结肠癌:横结肠切除术
降结肠癌:左半结肠切除术
乙状结肠癌:乙状结肠切除术
直肠癌:发生於直肠上1/3及中1/3段,低位切除术;直肠癌病灶在直肠下1/3段,采腹部会阴切除术
齿状线以下5公分的病灶,做结肠肛门吻合术
Colon cancer
并发症
肠阻塞
肠穿孔
出血
吻合处渗漏
辅佐治疗
最主要是化学治疗及放射线治疗,化学治疗包括5-Fluorouracil,Mitomycin-C及Levamisole等
术后追踪
术后最初两年每2个月追踪一次,后三年每4个月追踪一次
Colon cancer
护理措施
适应疾病及身体心像之改变
增加对造口排便控制的能力
协助度过哀伤过程
居家照顾的卫教
Case study
Mr. Wu, 55 years of age, wanted to practice illness prevention and health promotion activities. He had no family history of colon cancer, but when he learned of the high incidence of colon cancer in adults over 55 years of age, he underwent a routine colonscopy. He believed that he had no symptoms of disease, so he was stunned when the colonscopy showed a lesion in his ascending colon. The physician removed tissue for a biopsy and reported that the tumor was an adenocarcinoma, originating in the epithelial lining of the intestine.
Case study
In retrospect, Mr. McKinsey was able to identify symptoms that he had mistaken for normal patterns. He recalled complaining of dull abdominal pain and occasional black tarry stools. Because of the location of the lesion, he was prepared for abdominoperineal resection with a permanent sigmoid colostomy. His surgery was scheduled immediately.
As you plan his nursing care, limit your preparation for class to his preoperative care and the first 48 hours of his postoperative care.
Case study
Facts
abdominoperineal resection with a permanent sigmoid colostomy
Clinical data
Lab values
OB (+)
CEA↑(＜2ng/ml)
Medications
Antibiotics
Kanamycin,erythomycin and neomycin
Case study
Nursing diagnoses/Etiology
焦虑/OP,造瘻护理
Expected outcome
增加对疾病认识,以减轻焦虑
Nursing interventions
评估个案焦虑程度
采轻松及同理心的态度接触个案,接受个案的行为
教导放松技巧,缓解压力
说明诊断检查,治疗计划,手术过程
回答问题要诚实,态度要诚恳
Case study
Nursing diagnoses/Etiology
急性疼痛/与手术后伤口有关
Expected outcome
病患疼痛情形能获得缓解
Nursing interventions
安排轻松,安静,舒适的环境
经常协助更换姿势,按摩背部,以促进舒适
教导放松技巧,分散注意力
By order给止痛药并评估效果
Case study
Nursing diagnoses/Etiology
营养不均衡:少於身体需要/与疾病及治疗过程有关
Expected outcome
能摄取适当的营养及维持体液电解质的平衡
Nursing interventions
能由口进食时,鼓励摄入高热量,高蛋白,高醣类及低渣食物,若无法进食,则采TPN
每日测量体重
Case study
Nursing diagnoses/Etiology
潜在危险性体液容积缺失/与伤口引流及造瘻口有关
Expected outcome
能维持水分及电解质的平衡
Nursing interventions
Monitor I/O
若每小时尿量<30c.c. ,应立即通知医师
监测由IV补充的液体与电解质的量
Monitor V.S.
评估有无脱水症状
Case study
Nursing diagnoses/Etiology
潜在危险性感染/与手术及造瘻口有关
Expected outcome
没有感染症状
Nursing interventions
Monitor blood tests
Monitor infection s/s
注意伤口护理的无菌技术
Monitor V.S.
评估有无脱水症状
Case study
Postoperatively, Mr. Wu progressed as expected. His abdominal wound was clean and intact and his perineal wound had a drain in place that was to be removed gradually. The slight swelling of his stoma was receding and the small amount of normal oozing after surgery had resolved.
Case study
Questions
When planning care for Mr. Wu identify the problems that focus attention on the following physical aspects: respiratory, circulatory, nutritional, and integumentary
墬积性肺炎
血栓性静脉炎
肺栓塞
营养不足
伤口感染
伤口破裂
瘻管
Case study
Questions
Write expected outcomes for the emotional/psychological issues in Mr. Wu's care
病患能适应疾病及身体心像之改变
病患能顺利度过哀伤的过程
Plan a patient education program that will have as its goal to enhance Mr. Wu's self-care abilities
结肠造瘻灌洗
造瘻口护理
饮食卫教
Ovarian cancer
病因病理
原发性常发生於卵巢囊肿转变而来.续发性则由其他部位的癌症转移而来
临床表徵
卵巢癌都是直到已确定是恶性时,才有症状出现.身体评估时通常经由触诊可摸到骨盆肿块,进一步藉由超音波等来确定诊断
医疗处置
第Ⅰ期至第Ⅳ期卵巢癌皆是用腹式全子宫切除术及两侧输卵管卵巢切除术治疗.第Ⅱ期至第Ⅳ期手术后常合并使用全身性化学治疗
Case study
Mrs. Lee and her husband celebrated her 50th birthday by taking a cruise to several islands near the Equator. Their happiness was marred only by her vague complaints of pelvic pressure, abdominal discomfort, and urinary frequency. She attributed her symptoms either to having indulged in the buffet tables at all hours of the day and night during the cruise or to a urinary tract infection. When they returned home, Mrs. Lee immediately made an appointment with her physician. The physician in the office thoroughly assessed Mrs. Lee.
Case study
The assessment revealed that Mrs. Lee had had irregular periods for some time, with menorrhagia and tenderness of her breasts. During the assessment, Mrs. Lee admitted that her gastrointestinal symptoms were vague but persistent, and that abnormal menses had been long-standing symptoms. In discussing her options with her doctor, she expressed concern about having a hysterectomy. She wanted to know whether she would be able to maintain her intimate relationship with her husband after the operation and whether he would still find her attractive.
Case study
Questions
How is cancer of the ovary staged
Case study
Questions
What assumptions can be made about the stage of Mrs. Lee's cancer at diagnosis
She is in at least stage II because she has symptoms: pelvic pressure, abdominal discomfort, and urinary frequency, irregular periods for some time, with menorrhagia and tenderness of her breasts. Her treatment is hysterectomy with radiation treatment which is for stage II and III.
Case study
Questions
What are the treatment choices for women with ovarian cancer and what criteria are used to make decisions about treatment Why
第Ⅰ期至第Ⅳ期卵巢癌皆是用腹式全子宫切除术及两侧输卵管卵巢切除术治疗.
经腹部全子宫切除术:适用於曾接受腹部手术
经阴道全子宫切除术
第Ⅱ期至第Ⅳ期手术后常合并使用全身性化学治疗
Case study
Questions
What testing is indicated in the assessment of ovarian cancer
骨盆腔检查
阴道超音波检查
CA125↑
Case study
Questions
What are the priorities of pre- and postoperative care
Pre-
肠道准备
手术前一晚以优碘行阴道冲洗
皮肤准备
手术前一天午夜后开始禁食
手术前给予麻醉前驱剂
鼓励病人表达内心感触及担心害怕的事情
Case study
Questions
What are the priorities of pre- and postoperative care
Post
先进食开水,清淡饮食,而后恢复正常饮食
可教导病人采取坐浴或使用烤灯
手术后一个月内避免举重物,做粗重的家事或剧烈
经医师检查伤口确定已愈合后,才可开始性生活
避免久坐或双腿长时间交叉坐的姿势
适当的运动及充足的水分
鼓励病人适当地表达其情绪
促进性生活的调适
Case study
Questions
What are the priorities of patient education for Mrs. Lee during radiation therapy
口腔护理
头发护理
皮肤护理
照射部位护理
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