1、人工透析患者的個(gè)案護(hù)理,XX學(xué)校,XXX XXX,A case of care for dialysis patients,Hubei Medical University,Firstly：Patient data(患者資料）,XXX，XX歲，XXX入院，XXX開(kāi)始透析，透析頻率：X次/周。,主訴：反復(fù)乏力、胸悶X月有余，尿少X月，腹瀉X天。,XXX , XX years old , XXX admission, XXX dialysis, dialysis frequency: X times / week.,Chief Complaint: repeated fatigue, chest

2、tightness, more than X months . Oliguria for X month , diarrhea X days.,X余前無(wú)明顯誘因出現(xiàn)乏力、胸悶，無(wú)氣促、心悸、胸痛，無(wú)發(fā)熱惡心嘔吐，無(wú)頭暈、頭痛。在當(dāng)?shù)蒯t(yī)院診斷為“尿毒癥”，予尿毒清服藥治療。癥狀無(wú)改善。X個(gè)月前上述癥狀加重伴尿量逐漸減少，雙下肢水腫及腹脹、尿量小于100ml/d，水腫逐漸加重伴氣促。10天前明顯誘引下出現(xiàn)腹瀉，每日解黃色水樣便X次，伴上腹隱痛，無(wú)惡心、嘔吐、無(wú)發(fā)熱、未治療。今年X來(lái)我院就診。,History of present illness(現(xiàn)病史): X more than a month

3、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 reduce

4、d, 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 stoolsX times, with abdominal pain, no nausea, vomiting, no fever, no treatment. X this year, o

5、ur hospital.,Past medical history(既往史)：,X余歲患急性腎炎，予青霉素治療后緩解，今年X日在我院急診行腹腔穿刺引流術(shù)。無(wú)高血壓、無(wú)糖尿病、無(wú)風(fēng)濕性心臟病史、無(wú)過(guò)敏史、無(wú)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,

6、 no history of rheumatic heart disease, no history of allergies, poisoning history.,Laboratory tests（實(shí)驗(yàn)室檢查）：,生化： 肌酐 2245umol/L,Bun 88.94mol/L ,co2-cp 15.4mmol/L,血k 7.09 mmol/L 。 血常規(guī)：WBC 9.19，HGB 56g/L 尿常規(guī)：白蛋白2.0g/L ,WBC 16.2/L B超提示：雙腎縮小、聲像圖異常（符合腎臟疾病聲像圖改變），前列腺鈣化，盆腹腔積液，予透析利尿，降壓治療。 胸片：心影增大。,Biochemical

7、 ：Creatinine 2245umol/L,Bun 88.94mol/L ,co2-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 effusio

8、n, I dialysis diuretic, antihypertensive therapy.Ray: increased heart shadow.,Secondly. Care issues and measures (護(hù)理問(wèn)題及措施),Fluid overload Damage and acute renal failure due to glomerular filtration rate. 體液過(guò)多 與急性腎衰竭時(shí)所致的腎小球率過(guò)功能受損有關(guān)。,2.The risk of infection Restricted protein diet, dialysis, and the b

9、ody lowered immunity. 有感染的危險(xiǎn) 與限制蛋白質(zhì)飲食、透析、機(jī)體的抵抗力降低等有關(guān)。,3. Impaired skin integrity Vascular changes and the puncture site 皮膚完整性受損 與穿刺部位血管變化有關(guān),4. Malnutrition Patients appetite is low, restricted diet, the primary disease and other factors 營(yíng)養(yǎng)失調(diào) 與病人食欲低下、 限制飲食、原發(fā)疾病等因素有關(guān),5.Anxiety Related to the patients

10、economic situation 焦慮 與患者家庭的經(jīng)濟(jì)狀況有關(guān),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

11、 pain 、Itchy skin 常見(jiàn)并發(fā)癥 ：失衡綜合征、低血壓、低氧血癥、心律失常、心包填塞、溶血、空氣栓塞、腦出血、硬膜下血腫、貧血、肌肉痙攣 、惡心嘔吐、血壓升高、穿刺部位血管痛 、皮膚瘙癢,Thirdly.Nursing interventions（護(hù)理措施）：,Fluid overload（體液過(guò)多的護(hù)理）: Control of intake, Demand for dialysis treatment .控制入量，按需透析。,Care of infection (感染的護(hù)理)： The ward ventilation, air disinfection, to avoid

12、the flu.病室通風(fēng)，空氣消毒，避免上感 (2)dialysis operating strictly sterile to avoid infection.透析操作嚴(yán)格無(wú)菌，避免感染 (3) infection should be prescribed by a doctor rational use of the drug on the renal toxicity .感染時(shí)應(yīng)遵醫(yī)囑合理使用對(duì)腎臟毒性低的藥物,Skin care （皮膚的護(hù)理）：Needle injection, near the puncture smear ointment, anti-infection and

13、protect the skin integrity.拔針時(shí)，在穿刺口附近涂抹軟膏，抗感染、保護(hù)皮膚完整性。Puncture wound healing, do not scratch, to prevent skin scratches 穿刺口愈合時(shí)，勿撓，防止皮膚抓傷.,Care of malnutrition (營(yíng)養(yǎng)失調(diào)的護(hù)理)： 0.8g / (kg d) The high-quality protein intake, as appropriate, low sodium, low potassium, low chlorine, high-carbohydrate, high-fa

14、t drink, relieve symptoms such as nausea and vomiting, increase appetite. 0.8g/(kgd)優(yōu)質(zhì)蛋白攝入，酌情低鈉、低鉀、低氯、高碳水化合物、高脂飲、緩解惡心嘔吐等癥狀，增進(jìn)食欲.,Anxiety care（焦慮的護(hù)理）：(1)Be patience to understand the economic situation of the patients family agreed with the patients and their families with appropriate care and treatm

15、ent plan.耐心溝通，了解病人家庭經(jīng)濟(jì)狀況，與病人及其家屬議定合適的護(hù)理治療計(jì)劃(2) the observation of the patients psychological changes for the progress of information about the examination and treatment to relieve the patients fear觀察病人的心理變化，為其講述各項(xiàng)檢查及 治療的進(jìn)展信息，解除病人的恐懼(3) to give care and encourage patients to establish the confidence

16、to overcome the disease給予關(guān)懷和鼓勵(lì)，使病人樹(shù)立戰(zhàn)勝疾病的信心,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) During dialysis（透析過(guò)程中）,Low blood pressure （低血壓） 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 an

17、d 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 采取平臥，頭低腳高位，變慢血流量，變慢或暫停超濾。吸氧，必要時(shí)輸入生理鹽水100-200ml。癥狀重者加大補(bǔ)液量直至血壓上升，癥狀緩解。還可給予高滲鹽水、高滲蒲萄糖、白蛋白等，并應(yīng)聯(lián)合病因，對(duì)癥處理。,High blood pressu

18、re（血壓升高） 1.Between dialysis sessions to avoid too much water and salt intake.透析間期避免水鹽攝入過(guò)多 2.Sedation, give the ESTAZOLAM TABLETS 10mg.鎮(zhèn)靜,可予安定10mg。3.Given antihypertensive drug Nifedipine Tablets 10 to 15mg sublingual 15min does not alleviate can give the same dose.給予降壓藥心痛定1015mg 舌下含服 15min不緩解可以再給予同等

19、劑量。 4).The symptoms were significantly slower (high renin) in addition to water, reducing blood flow.癥狀顯著時(shí)( 高腎素型)減慢除水量,降低血流量。5.The end of the dialysis systolic blood pressure the 24kPa 180mmHg) above, after half an hour re-measured blood pressure, if still high given antihypertensive drugs.透析結(jié)束時(shí)收縮壓

20、24kPa 180mmHg) 以上時(shí),半小時(shí)后復(fù)測(cè)血壓,若仍高時(shí)給予降壓藥。,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) During dialysis（透析過(guò)程中）,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) During dialysis（透析過(guò)程中）,Imbalance syndrome（失衡綜合癥） Light does not have to deal with ，serious cases may be 50% glucose or 3% sodium chloride 40ml, can also lose albumin, w

21、hen necessary, to sedative drugs and other symptomatic treatment. 輕者不必處理，重者可予50蒲萄糖或3氯化鈉40ml，也可輸白蛋白，必要時(shí)予鎮(zhèn)靜藥及其他對(duì)癥治療。,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) During dialysis（透析過(guò)程中）,Muscle spasm(肌肉痙攣) With mild symptoms can be alleviated pause UF，symptoms of severe required infusion of hypertonic glucose sol

22、ution or hypertonic saline，Ultrafiltration volume settings to a suitable number of correct，and the dialysate sodium concentration is raised to 145 mmol / L or higher. 輕者暫停超濾即可緩解，重者需輸注高滲蒲萄糖液或高滲鹽水。超濾設(shè)置要數(shù)量適宜、正確，并將透析液鈉濃度調(diào)至145mmol/L或更高。,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) During dialysis（透析過(guò)程中）,Hypoxemia（

23、低氧血癥） For the elderly, cardiopulmonary dysfunction, observe breathing, facial or without cyanosis, prepare oxygen devices. 針對(duì)老年、心肺功能異常者，注意觀察呼吸、面部有無(wú)發(fā)紺，預(yù)備吸氧裝置,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) During dialysis（透析過(guò)程中）,Nausea and vomiting (惡心嘔吐) to avoid hypotension.避免低血壓 (2) slow down the blood flow.減慢

24、血流量 (3) according to hypotension care.按低血壓護(hù)理 (4) except for gastrointestinal disorders除外消化道疾患,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) During dialysis（透析過(guò)程中）,Vascular pain of the puncture site(穿刺部位血管痛) 1.re-adjust the needle fixed-wing position.重新調(diào)整穿刺針翼固定位置. 2 If the temperature of the dialysate is low, r

25、e-set the temperature of the dialysate, a simple UF and hemodialysis alternately; pay attention to body insulation.若因透析液溫度低,重新設(shè)定透析液溫度, 單純超濾與血透交替進(jìn)行;注意機(jī)體保溫. 3 Drop in blood pressure, added with normal saline.血壓下降時(shí),補(bǔ)充鹽水. 4 Reuse dialyzer and blood circuit, in strict accordance with the cleansing and di

26、sinfection procedures operation.復(fù)用透析器、血液回路時(shí),嚴(yán)格按照清洗消毒程序操作. 5 Puncture site, vascular pain, and the timely replacement of the puncture site 穿刺部位血管痛,及時(shí)更換穿刺部位 .,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) During dialysis（透析過(guò)程中）,Itchy skin（皮膚瘙癢） 1. Symptomatic treatment and taking allergy medication.對(duì)癥治療服用抗過(guò)敏藥 2.

27、 Selection can be cleared in the molecules, macromolecules dialyzer.選擇可以清除中分子、大分子物質(zhì)的透析器。 3. The use of bicarbonate dialysate.使用碳酸氫鹽透析液。 4. Replacement of anticoagulant drugs, use of small molecular weight heparin or other anticoagulation methods.更換抗凝藥 , 使用小分子肝素 , 或其他抗凝方法。 5. Local skin cold water, t

28、o avoid the use of harsh soaps.局部皮膚冷水清洗 , 避免使用刺激性香皂等。 6. The use of low-temperature dialysate, to help ease the itching of skin cancer in the dialysis.使用低溫透析液 , 有助于緩解透析中皮膚癌癢。 7. Local skin coated with lubricant.局部皮膚外涂潤(rùn)滑劑,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) During dialysis（透析過(guò)程中）,Hypokalemia低鉀血癥 Diet

29、control potassium foods to prevent predialysis hyperkalemia, and strictly limit the use of digitalis drugs in dialysis patients, and the use of potassium 3.0mmol / L dialysate. Arrhythmias, antiarrhythmic drugs, but need to adjust the dose according to drug metabolism.飲食控制含鉀食物以防透前高血鉀，嚴(yán)格限制透析患者洋地黃類藥物的

30、使用，以及使用含鉀3.0mmol/L的透析液。發(fā)生心律失常時(shí)可使用抗心律失常藥物，但需根據(jù)藥物代謝情況調(diào)整劑量。,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) After dialysis（透析后）,Hypertension（高血壓）: 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

31、3% to 5% .In patients with refractory hypertension, diverted to peritoneal dialysis or hemofiltration may be effective.應(yīng)限制水鈉攝入，注意保持干體重。無(wú)效者可加用降壓藥物，ACEI類及鈣通道阻滯劑為首選3%5%患者為難治性高血壓，改行腹透或血液濾過(guò)可能有效.,Common complication care(常見(jiàn)并發(fā)癥的護(hù)理) After dialysis（透析后）,Anemia貧血: To promote red blood cell hormone drugs to di

32、alysis after injection.予透析后注射促紅細(xì)胞素類藥物,Health Education（健康教育）,Psychological Care 心理護(hù)理 Reasonable Diet 合理膳食 Fistula Care 內(nèi)瘺的護(hù)理 Knowledge Missions 知識(shí)宣教,Psychological care 心理護(hù)理,心理護(hù)理保持良好情緒，因精神因素能影響維持性血透（慢性腎衰竭需作長(zhǎng)期血透）患者的存活時(shí)間；因此，血透病人特別是維持性血透者要學(xué)會(huì)自我心理疏導(dǎo)，克服消極心情，正確認(rèn)識(shí)疾病，增強(qiáng)戰(zhàn)勝疾病的信心,Reasonable diet 合理膳食,1.Strict co

33、ntrol of the intake and output, Expenditure and revenues, and rather less do more.嚴(yán)格控制出入量，“量出為入，寧少勿多” 2.Limit the intake of protein according to the disease: blood urea nitrogen is too high, given the non-protein diet.根據(jù)病情限制蛋白質(zhì)的攝?。貉蛩氐^(guò)高，給予無(wú)蛋白質(zhì)飲食。 3. Limit the intake of potassium, sodium, magnesium,

34、 phosphorus, such as should not eat bananas, peaches, spinach, rape, mushrooms, edible fungus, peanuts, etc.限制鉀、鈉、鎂、磷的攝入，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.適當(dāng)?shù)財(cái)z取鈉鹽，另外根據(jù)丟失量適當(dāng)補(bǔ)充營(yíng)養(yǎng)

35、和維生素。,Fistula care 內(nèi)瘺的護(hù)理,The pre - dialysis maintains fistula limb skin clean.透析前保持內(nèi)瘺側(cè)肢體皮膚清潔。 Avoid within the fistula site exposed to reduce the damage, breakage should be immediately disinfected。避免內(nèi)瘺部位暴露在外,減少損傷,有破損處應(yīng)即刻進(jìn)行消毒處理。 Hemodialysis treatment after 24 hours 。Do not contaminate or wet fistula

36、 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。血液透析治療后24小時(shí)切勿污染或浸濕內(nèi)瘺皮膚穿刺點(diǎn),如被污染應(yīng)立即酒精消毒2次,再用無(wú)菌紗布包扎或用創(chuàng)可貼覆蓋,以免增加感染機(jī)會(huì)。,Fistula care 內(nèi)瘺的護(hù)理,Fistula blood vessels can not

37、 carry out the operation of the infusion, injection, blood to avoid puncture damage, liquid stimulation lead to phlebitis, thrombosis and other complications。內(nèi)瘺血管不可以進(jìn)行輸液、注射、采血等操作,以免因穿刺損傷、藥液刺激等導(dǎo)致靜脈炎、血栓形成等并發(fā)癥。 Avoid fistula limb vascular compression, including to avoid wearing tight sleeve clothes, sl

38、eeping 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。避免內(nèi)瘺側(cè)肢體血管受壓,包括避免穿緊袖衣服,睡覺(jué)時(shí)不向內(nèi)瘺側(cè)側(cè)臥,不拿內(nèi)瘺側(cè)肢體當(dāng)枕頭造成長(zhǎng)期受壓,內(nèi)瘺側(cè)肢體不測(cè)血壓,不提重物、不用暴力等。,Fistula care 內(nèi)瘺的護(hù)理,Reasonable

39、 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,

40、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。預(yù)防血栓的形成、血管閉塞。每次透析治療結(jié)束, 應(yīng)注意內(nèi)瘺部位的血管震顫情況和止血時(shí)間,若震顫消失應(yīng)立即稍微松解止血帶,直到觸及震顫為止,以預(yù)防

41、壓迫過(guò)緊導(dǎo)致動(dòng)靜脈內(nèi)瘺閉塞，如半小時(shí)后松開(kāi)止血帶穿刺處仍有出血，應(yīng)告知醫(yī)生，及時(shí)調(diào)整抗凝劑的劑量。,Fistula care 內(nèi)瘺的護(hù)理,Master fistula bleeding emergency treatment掌握內(nèi)瘺出血的緊急處理方法 (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.壓迫止血，力度為血液能通過(guò),能摸到血管震顫,又不出血為標(biāo)準(zhǔn),一般大約壓迫10分鐘左右即可。 (2) oppression can raise the limb.壓迫時(shí)可以抬高肢體 (3) If still bleeding, pressure oppression, immediat