【精选】直肠癌护理病例讨论共34页

直肠癌病例讨论一般资料•姓名：高洁•性别：女•年龄：70•婚姻状况：已婚•职业：退休人员•民族：汉族•籍贯：山东省主诉•大便带血、里急后重8月余，加重三天。

现病史患者于2012年10月出现大便带血，出血呈鲜红的，曾在当地医院就诊，初步诊断混合痔，给与对症治疗，症状缓解不明显，此后患者出现间断大便带血，有时呈鲜红色，有时呈深红色或浅红的，并出现里急后重，再次到医院就诊，建议做结肠镜检查，排除结肠肿瘤，患者拒绝检查，给与云南白药对症治疗，症状时好时坏，近三天来，患者出现大便带血，呈深红色，并出现里急后重，故来我院就诊，门诊以“直肠占位”收住院，患者自发病以来，精神可，饮食睡眠好，小便正常，体重无明显变化。

既往史患“回盲部结核切除术”54年，恢复良好，于2013.2.6患急性心肌梗死于齐鲁医院抢救治疗，后间断服用倍他乐克治疗，症状缓解，无高血压病史，无糖尿病病史，无重大外伤手术史，无输血史，无药物过敏史。

•个人史：生于原籍，无疫区久居史。

生活规律，无冶游史，无烟酒习惯，无工业毒物、粉尘、放射性物质接触史。

•婚育史：25岁结婚，育有两子，配偶及孩子身体健康。

•月经史：13/5-7/25-39/50，月经规律，经量正常，无痛经史。

•家族史：父母已故，否认家族中有遗传性疾病可记载。

体格检查(2013,6,13)•体温36.6℃，脉搏88次/分，呼吸22次/分，血压140/70mmHg。

患者女性，发育良好，营养中等，自主体位，查体合作，全身皮肤黏膜颜色正常，无水肿，无皮疹，毛发分布正常，无压疮。

全身浅表淋巴结未触及肿大，周围血管阴性。

头颅大小正常，无畸形，眼睑无水肿，结膜无充血，巩膜无黄染，耳鼻无异常，口唇无紫绀，咽部无充血，扁桃体无肿大。

颈软，气管居中，甲状腺无肿大。

胸廓无畸形，双侧乳房对称，未触及明显包块。

双肺呼吸音清晰，未闻及干湿性啰音，心率88次/分，节律规整，各瓣膜听诊区无闻及病理杂音。

腹部平坦，无压痛，无反跳痛。

直肠癌癌疑难病例讨论护理记录范文英文回答：Patient Name: Mr. Smith.Diagnosis: Rectal Cancer.Date: 10/15/2021。

Discussion of Difficult Case:Mr. Smith is a 58-year-old male diagnosed with rectal cancer. He has undergone surgery and is currently receiving chemotherapy. However, he has been experiencing severe pain and discomfort, which has been difficult to manage.Nursing Care:1. Pain Management: Mr. Smith's pain is being managed with a combination of medications, including opioids andnon-opioids. We are closely monitoring his pain levels and adjusting the medication as needed to ensure his comfort.2. Wound Care: Mr. Smith has a surgical wound that requires regular dressing changes and monitoring for signs of infection. We are also providing education on proper wound care to prevent complications.3. Nutritional Support: Due to the side effects of chemotherapy, Mr. Smith has been experiencing loss of appetite and weight loss. We are working with the dietitian to provide him with a nutritionally balanced diet and offering small, frequent meals to help maintain his strength.4. Emotional Support: Dealing with a cancer diagnosis and undergoing treatment can be emotionally challenging. We are providing Mr. Smith with emotional support and counseling to help him cope with the stress and anxiety associated with his condition.5. Symptom Management: In addition to pain, Mr. Smithis experiencing other symptoms such as fatigue, nausea, and diarrhea. We are addressing these symptoms with appropriate medications and interventions to improve his quality of life.Overall, Mr. Smith's care involves a multidisciplinary approach, including collaboration with the medical team, physical therapists, dietitians, and social workers to provide comprehensive care and support.中文回答：患者姓名，史密斯先生。

直肠癌癌疑难病例讨论护理记录范文英文回答：Patient Name: Mr. Smith.Age: 55。

Diagnosis: Rectal cancer.Discussion of the case:Mr. Smith is a 55-year-old male with a diagnosis of rectal cancer. He has been undergoing treatment for the past few months, including chemotherapy and radiation therapy. However, his condition has not improved as expected, and he is experiencing persistent pain and discomfort.Nursing Care Plan:1. Pain management: Mr. Smith is experiencing significant pain, which is impacting his quality of life. We will closely monitor his pain levels and administer pain medication as prescribed. Additionally, we will explorenon-pharmacological pain management techniques such as relaxation techniques and massage therapy.2. Nutritional support: Due to the nature of hisillness and the side effects of treatment, Mr. Smith has been struggling with poor appetite and weight loss. We will work with a dietitian to develop a personalized nutrition plan to ensure he is receiving adequate nourishment.3. Emotional support: Coping with a cancer diagnosis can be emotionally challenging. We will provide Mr. Smith with emotional support and counseling to help him navigate through the psychological impact of his illness.4. Wound care: If Mr. Smith has undergone surgery or is experiencing any wounds related to his treatment, we will provide meticulous wound care to prevent infection and promote healing.5. Education and support for family members: We will also provide education and support for Mr. Smith's family members, as they play a crucial role in his care and support system.Overall, our goal is to provide holistic care for Mr. Smith, addressing not only his physical symptoms but also his emotional and psychological well-being.中文回答：患者姓名，史密斯先生。