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case conference 出院準備服務個案

case conference 出院準備服務個案. 萬芳醫院 邱郁婷 營養師 94.07.26. DPS 表單. 個案過去病史 -1. 93.01.17 Glioblastoma multiforme of brain tumor, s/p craniotomy & complete excision of tumor from L’t parietal area at 中山 hospital. 94.04.29~94.06.03 第一次住院 brain tumor GBM s/p, r/o local recurrence with IICP

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case conference 出院準備服務個案

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  1. case conference出院準備服務個案 萬芳醫院 邱郁婷 營養師 94.07.26

  2. DPS表單

  3. 個案過去病史-1 • 93.01.17 • Glioblastoma multiforme of brain tumor, s/p craniotomy & complete excision of tumor from L’t parietal area at 中山 hospital. • 94.04.29~94.06.03第一次住院 brain tumor GBM s/p, r/o local recurrence with IICP 94.05.03 OP: craniotomy + remove of tumor

  4. 個案過去病史-2 • 94.06.07 • 社區護理師詢問,病患出院後,於家訪時發現,病人灌食安麗奶昔. 當日早上立即電聯家屬,因無法詳述產品內容,故請其家人將產品帶到醫院,了解該產品內容(食品標示)及沖泡方式.家屬表示因家中較遠(土城),94.06.10才能到院. • 94.06.08 UTI

  5. 個案基本資料-1 • 入院日期:94/06/08 • 科別: 神外 • 主訴：fever • 入院診斷：UTI • 性別：男性 • 年齡：61歲 (33/08/29) • 身高：172 公分 • 入院體重：67公斤 • 通常體重：65公斤 • 理想體重：65  6.5公斤

  6. 94.06.13第一次訪視 * 家中配方:賀寶芙草莓奶昔2.5瓢內附匙+適美優質蛋白粉0.5瓢內附匙,沖250 c.c,一天灌食6次/天.有便秘習慣.餐次間未另給水. * Bedsore : 尾骶骨5*5*-,Ⅱ 右肩1.5*1.5*-, Ⅱ 左肩2*2*-, Ⅱ • BEE = 1414 kcal /day • TER = 1866~2036 kcal/day (AF=1.2 SF=1.1~1.2) • protein require : 79 g/ day

  7. Home diet 評估 Energy intake: 1335 kcal/day (under requirement) Protein intake: 99.5 g/day fiber: 11.2 g/day fluid: 1500 c.c/day

  8. 生化數據與飲食進展-1(第一次住院94.04.29~94.06.03)生化數據與飲食進展-1(第一次住院94.04.29~94.06.03) OP 94.05.03 OP: craniotomy + remove of tumor

  9. 生化數據與飲食進展-2(第一次住院94.04.29~94.06.03)生化數據與飲食進展-2(第一次住院94.04.29~94.06.03) 94.06.04,MBD

  10. 生化數據與飲食進展-3(第二次住院94.06.08~94.07.22)生化數據與飲食進展-3(第二次住院94.06.08~94.07.22) 2.7% loss 6/9.6/16~6/18 fever

  11. 生化數據與飲食進展-4(第二次住院94.06.08~94.07.22)生化數據與飲食進展-4(第二次住院94.06.08~94.07.22) 水腦症V-P shunt (腦室腹腔引流術)->V-T,予以CPR及電極

  12. 生化數據與飲食進展-5(第二次住院94.06.08~94.07.22)生化數據與飲食進展-5(第二次住院94.06.08~94.07.22) PRBC2u

  13. 出院管灌飲食 • 94.07.22 MBD • Bedsore: sacrum 約10元硬幣大小,表淺紅色 • TER=2000 kcal/day protein=78 g/day 補體素優纖9瓢內附匙(8.4g/瓢)+精鹽1g/沖330c.csupport 1946 kcal/d protein 78g/d Na=4360 mg/d

  14. 修正方向 未及時指導出院管灌食之個案,應以電話聯繫家屬,了解灌食配方之種類及內容.必要時請家屬到院,重新指導管灌食配方及注意事項. 若不便到院者,亦可請家屬傳真灌食配方內容,以便了解灌食情況並即時修正灌食配方.

  15. Thanks for your attention!

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