血液透析个案护理

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,人工透析患者的个案护理,XX学校,XXX XXX,A case of care for dialysis patients,Hubei,Medical University,Firstly,：,Patient data(,患者资料）,XXX,，,XX,岁，,XXX,入院，,XXX,开始透析，透析频率：,X,次,/,周,。,主诉：反复乏力、胸闷,X,月有余，尿少,X,月，腹泻,X,天。,XXX,XX,years old ,XXX,admission,XXX,dialysis, dialysis frequency:,X,times / week.,Chief Complaint: repeated fatigue, chest tightness, more than,X,months .,Oliguria,for,X,month , diarrhea,X,days.,X,余前无明显诱因出现乏力、胸闷，无气促、心悸、胸痛，无发热恶心呕吐，无头晕、头痛。在当地医院诊断为,“,尿毒症,”,，予尿毒清服药治疗。症状无改善。,X,个月前上述症状加重伴尿量逐渐减少，双下肢水肿及腹胀、尿量小于,100ml/d,，水肿逐渐加重伴气促。,10,天前明显诱引下出现腹泻，每日解黄色水样便,X,次，伴上腹隐痛，无恶心、呕吐、无发热、未治疗。今年,X,来我院就诊。,History of present illness(,现病史,),:,X,more than a month ago, no obvious incentive to appear weak, chest tightness, shortness of breath, palpitations, chest pain, no fever, nausea, vomiting, dizziness, headache. Diagnosed as uremia at a local hospital, For,Niaoduqing,medication. No improvement of symptoms.,X, the above symptoms with urine gradually reduced, lower extremity edema and abdominal distension, urine output less than 100ml / d, the edema gradually increased with shortness of breath. Diarrhea 10 days before the obvious lure solution yellow watery stools,X,times, with abdominal pain, no nausea, vomiting, no fever, no treatment.,X,this year, our hospital.,Past medical history(,既往史,),：,X,余岁患急性肾炎，予青霉素治疗后缓解，今年,X,日在我院急诊行腹腔穿刺引流术。无高血压、无糖尿病、无风湿性心脏病史、无过敏史、无中毒史。,More than,X,year-old suffering from acute nephritis, to penicillin treatment, mitigation, and on,X,this year in hospital emergency abdominal,paracentesis,drainage. No hypertension, no diabetes, no history of rheumatic heart disease, no history of allergies, poisoning history.,Laboratory tests,（,实验室检查,）,：,生化： 肌酐,2245umol/L,Bun 88.94mol/L ,co2-cp 15.4mmol/L,血,k 7.09,mmol,/L,。,血常规：,WBC 9.19,，,HGB 56g/L,尿常规：白蛋白,2.0g/L ,WBC 16.2/L,B,超提示：双肾缩小、声像图异常（符合肾脏疾病声像图改变），前列腺钙化，盆腹腔积液，予透析利尿，降压治疗。,胸片：心影增大。,Biochemical,：,Creatinine,2245umol/L,Bun 88.94mol/L ,co,2,-cp 15.4mmol/L, Potassium 7.09,mmol,/L,。,Blood: WBC 18.5, HGB 56g/LUrine: albumin 2.0g / L, WBC 16.2 / L,B-Tip: kidneys shrink,sonographic,abnormalities (in accordance with the ultrasound images of kidney disease),prostatic,calcification, abdominal effusion, I dialysis diuretic, antihypertensive therapy.Ray: increased heart shadow.,Secondly. Care issues and measures (,护理问题及措施,),Fluid overload Damage and acute renal failure due to,glomerular,filtration rate,.,体液过多 与急性肾衰竭时所致的肾小球率过功能受损有关。,2.,The risk of infection Restricted protein diet, dialysis, and the body lowered immunity.,有感染的危险 与限制蛋白质饮食、透析、机体的抵抗力降低等有关。,3. Impaired skin integrity Vascular changes and the puncture site,皮肤完整性受损 与穿刺部位血管变化有关,4. Malnutrition Patients appetite is low, restricted diet, the primary disease and other factors,营养失调,与病人食欲低下、 限制饮食、原发疾病等因素有关,5.Anxiety Related to the patients economic situation,焦虑 与患者家庭的经济状况有关,6.Common complication,：,Disequilibrium syndrome,、,hypotension,、,hypoxemia, cardiac arrhythmias,、,cardiac,tamponade,、,hemolysis,、,air embolism,、,cerebral hemorrhage,、,subdural,hematoma,、,anemia,、,Muscle spasm,、,Nausea and vomiting,、,High blood pressure,、,The puncture site, vascular pain,、,Itchy skin,常见并发症 ：失衡综合征、低血压、低氧血症、心律失常、心包填塞、溶血、空气栓塞、脑出血、硬膜下血肿、贫血、肌肉痉挛,、,恶心呕吐、血压升高、穿刺部位血管痛,、皮肤瘙痒,Thirdly.Nursing,interventions,（护理措施）,：,Fluid overload,（体液过多的护理）,:,Control of intake, Demand for dialysis treatment .,控制入量，按需透析。,Care of infection (,感染的护理,),：,The ward ventilation, air disinfection, to avoid the flu.,病室通风，空气消毒，避免上感,(2)dialysis operating strictly sterile to avoid infection.,透析操作严格无菌，避免感染,(3) infection should be prescribed by a doctor rational use of the drug on the renal toxicity .,感染时应遵医嘱合理使用对肾脏毒性低的药物,Skin care,（皮肤的护理）,：,Needle injection, near the puncture smear ointment, anti-infection and protect the skin integrity.,拔针时，在穿刺口附近涂抹软膏，抗感染、保护皮肤完整性。,Puncture wound healing, do not scratch, to prevent skin scratches,穿刺口愈合时，勿挠，防止皮肤抓伤,.,Care of malnutrition (,营养失调的护理,),：,0.8g / (kg d) The high-quality protein intake, as appropriate, low sodium, low potassium, low chlorine, high-carbohydrate, high-fat drink, relieve symptoms such as nausea and vomiting, increase appetite.,0.8g/(kgd),优质蛋白摄入，酌情低钠、低钾、低氯、高碳水化合物、高脂饮、缓解恶心呕吐等症状，增进食欲,.,Anxiety care,（焦虑的护理）,：,(1)Be patience to understand the economic situation of the patients family agreed with the patients and their families with appropriate care and treatment plan.,耐心沟通，了解病人家庭经济状况，与病人及其家属议定合适的护理治疗计划,(2) the observation of the patients psychological changes for the progress of information about the examination and treatment to relieve the patients fear,观察病人的心理变化，为其讲述各项检查及 治疗的进展信息，解除病人的恐惧,(3) to give care and encourage patients to establish the confidence to overcome the disease,给予关怀和鼓励，使病人树立战胜疾病的信心,Common complication care(,常见并发症的护理,),During dialysis,（透析过程中,）,Low blood pressure,（低血压）,Rapid adoption of the supine,Trendelenburg,position, slow blood flow, slow down or pause the UF. Oxygen, if necessary, enter the physiological saline 100-200ml. Symptoms and increase the fluid volume until the rise in blood pressure, symptoms. Also given hypertonic saline, hypertonic glucose, albumin, and should join etiology, symptomatic treatment.,迅速,采取平卧，头低脚高位，变慢血流量，变慢或暂停超滤。吸氧，必要时输入生理盐水,100-200ml,。症状重者加大补液量直至血压上升，症状缓解。还可给予高渗盐水、高渗蒲萄糖、白蛋白等，并应联合病因，对症处理。,High blood pressure,（血压升高）,1.Between dialysis sessions to avoid too much water and salt intake.,透析间期避免水盐摄入过多,2.Sedation, give the ESTAZOLAM TABLETS,10mg.,镇静,可予安定,10mg,。,3.Given antihypertensive drug,Nifedipine,Tablets,10 to 15mg sublingual 15min does not alleviate can give the same dose.,给予降压药心痛定,1015mg,舌下含服,15min,不缓解可以再给予同等剂量。,4).The symptoms were significantly slower (high,renin,) in addition to water, reducing blood flow.,症状显著时,(,高肾素型,),减慢除水量,降低血流量。,5.The end of the dialysis systolic blood pressure the 24kPa 3.0mmol / L,dialysate,. Arrhythmias,antiarrhythmic,drugs, but need to adjust the dose according to drug metabolism.,饮食控制含钾食物以防透前,高血钾,，严格限制透析患者洋地黄类药物的使用，以及使用含钾,3.0mmol/L,的透析液。发生心律失常时可使用抗心律失常药物，但需根据药物代谢情况调整剂量。,Common complication care(,常见并发症的护理,),After dialysis,（透析后）,Hypertension,（高血压）,:,Sodium and water intake should be limited to keep the dry weight. Invalid may increase the use of antihypertensive drugs, ACEI and calcium channel blockers is preferred 3% to 5% .In patients with refractory hypertension, diverted to peritoneal dialysis or,hemofiltration,may be effective.,应限制水钠摄入，注意保持干体重。无效者可加用降压药物，,ACEI,类及钙通道阻滞剂为首选,3%5%,患者为难治性高血压，改行,腹透,或,血液滤过,可能有效,.,Common complication care(,常见并发症的护理,),After dialysis,（透析后）,Anemia,贫血,:,To promote red blood cell hormone drugs to dialysis after injection.,予透析后注射促,红细胞,素类药物,Health Education,（健康教育）,Psychological Care,心理护理,Reasonable Diet,合理膳食,Fistula Care,内瘘的护理,Knowledge Missions,知识宣教,Psychological care,心理护理,心理护理保持良好情绪，因精神因素能影响维持性血透（慢性肾衰竭需作长期血透）患者的存活时间；因此，血透病人特别是维持性血透者要学会自我心理疏导，克服消极心情，正确认识疾病，增强战胜疾病的信心,Reasonable diet,合理膳食,1.,Strict control of the intake and output, Expenditure and revenues, and rather less do more.,严格控制出入量，,“,量出为入，宁少勿多,”,2.,Limit the intake of protein according to the disease: blood urea nitrogen is too high, given the non-protein diet.,根据病情限制蛋白质的摄取：血尿素氮过高，给予无蛋白质饮食。,3.,Limit the intake of potassium, sodium, magnesium, phosphorus, such as should not eat bananas, peaches, spinach, rape, mushrooms, edible fungus, peanuts, etc.,限制钾、钠、镁、磷的摄入，如不宜吃香蕉、桃子、菠菜、油菜、蘑菇、木耳、花生等。,4.,Appropriate intake of sodium, addition, according to the loss of the amount of appropriate nutritional supplements and vitamins.,适当地摄取钠盐，另外根据丢失量适当补充营养和维生素。,Fistula care,内瘘的护理,The pre - dialysis maintains fistula limb skin clean.,透析前保持内瘘侧肢体皮肤清洁。,Avoid within the fistula site exposed to reduce the damage, breakage should be immediately disinfected,。避免内瘘部位暴露在外,减少损伤,有破损处应即刻进行消毒处理。,Hemodialysis,treatment after 24 hours,。,Do not contaminate or wet fistula skin puncture site, such as contaminated shall be immediately alcohol for two times, and then sterile gauze bandage or Band-Aid covering, so as not to increase the chances of infection,。血液透析治疗后,24,小时切勿污染或浸湿内瘘皮肤穿刺点,如被污染应立即酒精消毒,2,次,再用无菌纱布包扎或用创可贴覆盖,以免增加感染机会。,Fistula care,内瘘的护理,Fistula blood vessels can not carry out the operation of the infusion, injection, blood to avoid puncture damage, liquid stimulation lead to phlebitis, thrombosis and other complications,。内瘘血管不可以进行输液、注射、采血等操作,以免因穿刺损伤、药液刺激等导致静脉炎、血栓形成等并发症。,Avoid fistula limb vascular compression, including to avoid wearing tight sleeve clothes, sleeping inside the fistula side,side, do not take the fistula limbs when the pillow caused by prolonged pressure on the limb of the fistula unexpected blood pressure, no heavy,liftingwithout,violence,。避免内瘘侧肢体血管受压,包括避免穿紧袖衣服,睡觉时不向内瘘侧侧卧,不拿内瘘侧肢体当枕头造成长期受压,内瘘侧肢体不测血压,不提重物、不用暴力等。,Fistula care,内瘘的护理,Reasonable,hemostatic,bandage. Prevention of thrombus formation, vascular occlusion. The end of each dialysis treatment, should be noted that the blood vessels of the fistula site tremor and,hemostasis,time, if the tremor disappeared tourniquet should immediately release a little, until you touch the tremor, to prevent hard pressed by the,arteriovenous,fistula occlusion, such as half an hour Release the tourniquet puncture is still bleeding, and should inform the doctor in a timely manner to adjust the dose of anticoagulants.,合理的止血包扎。预防血栓的形成、血管闭塞。每次透析治疗结束,应注意内瘘部位的血管震颤情况和止血时间,若震颤消失应立即稍微松解止血带,直到触及震颤为止,以预防压迫过紧导致动静脉内瘘闭塞，如半小时后松开止血带穿刺处仍有出血，应告知医生，及时调整抗凝剂的剂量。,Fistula care,内瘘的护理,Master fistula bleeding emergency treatment,掌握内瘘出血的紧急处理方法,(1),hemostasis, the intensity of the blood through, to touch the blood vessels tremor, not bleeding as a standard, generally about oppression about 10 minutes.,压迫止血，力度为血液能通过,能摸到血管震颤,又不出血为标准,一般大约压迫,10,分钟左右即可。,(2) oppression can raise the limb.,压迫时可以抬高肢体,(3) If still bleeding, pressure oppression, immediately to the hospital to re-dressing, fistula compression time should not be too long to avoid fistula thrombosis.,如果仍然出血，加压压迫的同时,立即到医院重新包扎,瘘口压迫时间不宜过长,以免内瘘血栓形成。,Fistula care,内瘘的护理,Move,arteriovenous,fistula blood flow is too large causing increased cardiac load, a long time will lead to heart failure, enlarged heart and other complications, therefore, the elastic bandage control fistula expansion even if the decompression.,动静脉内瘘血流量太大会引起心脏负荷增加,久之会导致心衰,心脏扩大等并发症,因此,使用弹力绷带控制内瘘的扩张即使减压。,Usually you and your families should observe more attention to the,arteriovenous,fistula encountered, such as fistula exception, must be promptly to the hospital, even if the hours of delay may cause irreparable damage,arteriovenous,fistula.,平时您和家属都应多观察多注意动静脉内瘘的情况,遇到如内瘘异常时,必须及时到医院就诊,因为即使数小时的延误都可能造成动静脉内瘘不可修复的损伤。,Knowledge Missions,知识宣教,Explain in detail the principle of,hemodialysis, methods, roles,and new technological advances allowed to understand that,adequate dialysis, and can achieve high quality of life, and,encourage patients return to society, work within their,capabilities, increase income, reduce family,anda,burden on,society, to enrich themselves at the same time, reflecting the,self-worth and increased self-confidence, maintain a healthy,state of mind.,详细讲解血液透析的原理、方法、作用及新的技术进展让,其明白如果做到充分透析，能达到很高的生活质量，并鼓励患者回归社,会，从事力所能及的工作，增加经济收入，减轻家庭及社会的负担，同时,充实自己，体现自我价值，增加自信心，保持健康的心态 。,谢 谢,