血液透析个案护理培训课件

血液透析个案护理Firstly：Patientdata(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,XXyearsold,XXXadmission,XXXdialysis,dialysisfrequency:Xtimes/week.

ChiefComplaint:repeatedfatigue,chesttightness,morethanXmonths.OliguriaforXmonth,diarrheaXdays.

2血液透析个案护理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。Historyofpresentillness(现病史):Xmorethanamonthago,noobviousincentivetoappearweak,chesttightness,shortnessofbreath,palpitations,chestpain,nofever,nausea,vomiting,dizziness,headache.Diagnosedas"uremia"atalocalhospital,ForNiaoduqingmedication.Noimprovementofsymptoms.X,theabovesymptomswithurinegraduallyreduced,lowerextremityedemaandabdominaldistension,urineoutputlessthan100ml/d,theedemagraduallyincreasedwithshortnessofbreath.Diarrhea10daysbeforetheobviousluresolutionyellowwaterystoolsXtimes,withabdominalpain,nonausea,vomiting,nofever,notreatment.Xthisyear,ourhospital.3血液透析个案护理Pastmedicalhistory(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。MorethanXyear-oldsufferingfromacutenephritis,topenicillintreatment,mitigation,andonXthisyearinhospitalemergencyabdominalparacentesisdrainage.Nohypertension,nodiabetes,nohistoryofrheumaticheartdisease,nohistoryofallergies,poisoninghistory.4血液透析个案护理Laboratorytests（实验室检查）：生化：肌酐2245umol/L,Bun88.94mol/L,co2-cp15.4mmol/L,血k7.09mmol/L。血常规：WBC9.19，HGB56g/L尿常规：白蛋白2.0g/L,WBC16.2/LB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：Creatinine2245umol/L,Bun88.94mol/L,co2-cp15.4mmol/L,Potassium7.09mmol/L。Blood:WBC18.5,HGB56g/L

Urine:albumin2.0g/L,WBC16.2/LB-Tip:kidneysshrink,sonographicabnormalities(inaccordancewiththeultrasoundimagesofkidneydisease),prostaticcalcification,abdominaleffusion,Idialysisdiuretic,antihypertensivetherapy.

Ray:increasedheartshadow.5血液透析个案护理Secondly.Careissuesandmeasures(护理问题及措施)FluidoverloadDamageandacuterenalfailureduetoglomerularfiltrationrate.

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.TheriskofinfectionRestrictedproteindiet,dialysis,andthebodyloweredimmunity.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。6血液透析个案护理

3.ImpairedskinintegrityVascularchangesandthepuncturesite

皮肤完整性受损与穿刺部位血管变化有关4.MalnutritionPatientsappetiteislow,restricteddiet,theprimarydiseaseandotherfactors

营养失调与病人食欲低下、限制饮食、原发疾病等因素有关7血液透析个案护理5.AnxietyRelatedtothepatient‘seconomicsituation

焦虑与患者家庭的经济状况有关6.Commoncomplication：Disequilibriumsyndrome、hypotension、hypoxemia,cardiacarrhythmias、cardiactamponade、hemolysis、airembolism、cerebralhemorrhage、subduralhematoma、anemia、Musclespasm、Nauseaandvomiting、Highbloodpressure、Thepuncturesite,vascularpain、Itchyskin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

8血液透析个案护理Thirdly.Nursinginterventions（护理措施）：Fluidoverload（体液过多的护理）:Controlofintake,Demandfordialysistreatment.控制入量，按需透析。Careofinfection(感染的护理)：Thewardventilation,airdisinfection,toavoidtheflu.病室通风，空气消毒，避免上感(2)dialysisoperatingstrictlysteriletoavoidinfection.透析操作严格无菌，避免感染(3)infectionshouldbeprescribedbyadoctorrationaluseofthedrugontherenaltoxicity.感染时应遵医嘱合理使用对肾脏毒性低的药物9血液透析个案护理Skincare（皮肤的护理）：

Needleinjection,nearthepuncturesmearointment,anti-infectionandprotecttheskinintegrity.拔针时，在穿刺口附近涂抹软膏，抗感染、保护皮肤完整性。

Puncturewoundhealing,donotscratch,topreventskinscratches穿刺口愈合时，勿挠，防止皮肤抓伤.Careofmalnutrition(营养失调的护理)：0.8g/(kg·d)Thehigh-qualityproteinintake,asappropriate,lowsodium,lowpotassium,lowchlorine,high-carbohydrate,high-fatdrink,relievesymptomssuchasnauseaandvomiting,increaseappetite.0.8g/(kg·d)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.10血液透析个案护理Anxietycare（焦虑的护理）：

(1)Bepatiencetounderstandtheeconomicsituationofthepatient‘sfamilyagreedwiththepatientsandtheirfamilieswithappropriatecareandtreatmentplan.

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)theobservationofthepatient’spsychologicalchangesfortheprogressofinformationabouttheexaminationandtreatmenttorelievethepatient‘sfear

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)togivecareandencouragepatientstoestablishtheconfidencetoovercomethedisease

给予关怀和鼓励，使病人树立战胜疾病的信心11血液透析个案护理Commoncomplicationcare(常见并发症的护理)

Duringdialysis（透析过程中）

Lowbloodpressure（低血压）

Rapidadoptionofthesupine,Trendelenburgposition,slowbloodflow,slowdownorpausetheUF.Oxygen,ifnecessary,enterthephysiologicalsaline100-200ml.Symptomsandincreasethefluidvolumeuntiltheriseinbloodpressure,symptoms.Alsogivenhypertonicsaline,hypertonicglucose,albumin,andshouldjoinetiology,symptomatictreatment.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。

12血液透析个案护理Highbloodpressure（血压升高）1.Betweendialysissessionstoavoidtoomuchwaterandsaltintake.透析间期避免水盐摄入过多2.Sedation,givetheESTAZOLAMTABLETS

10mg.镇静,可予安定10mg。

3.GivenantihypertensivedrugNifedipineTablets

10to15mgsublingual15mindoesnotalleviatecangivethesamedose.给予降压药心痛定10~15mg舌下含服15min不缓解可以再给予同等剂量。4).Thesymptomsweresignificantlyslower(highrenin)inadditiontowater,reducingbloodflow.症状显著时(高肾素型)减慢除水量,降低血流量。

5.Theendofthedialysissystolicbloodpressurethe24kPa<180mmHg)above,afterhalfanhourre-measuredbloodpressure,ifstillhighgivenantihypertensivedrugs.透析结束时收缩压24kPa〈180mmHg)以上时,半小时后复测血压,若仍高时给予降压药。Commoncomplicationcare(常见并发症的护理)

Duringdialysis（透析过程中）13血液透析个案护理Commoncomplicationcare(常见并发症的护理)

Duringdialysis（透析过程中）

Imbalancesyndrome（失衡综合症）Lightdoesnothavetodealwith，seriouscasesmaybe50%glucoseor3%sodiumchloride40ml,canalsolosealbumin,whennecessary,tosedativedrugsandothersymptomatictreatment.轻者不必处理，重者可予50％蒲萄糖或3％氯化钠40ml，也可输白蛋白，必要时予镇静药及其他对症治疗。14血液透析个案护理Commoncomplicationcare(常见并发症的护理)

Duringdialysis（透析过程中）Musclespasm(肌肉痉挛)WithmildsymptomscanbealleviatedpauseUF，symptomsofsevererequiredinfusionofhypertonicglucosesolutionorhypertonicsaline，Ultrafiltrationvolumesettingstoasuitablenumberofcorrect，andthedialysatesodiumconcentrationisraisedto145mmol/Lorhigher.轻者暂停超滤即可缓解，重者需输注高渗蒲萄糖液或高渗盐水。超滤设置要数量适宜、正确，并将透析液钠浓度调至145mmol/L或更高。

15血液透析个案护理Commoncomplicationcare(常见并发症的护理)

Duringdialysis（透析过程中）Hypoxemia（低氧血症）Fortheelderly,cardiopulmonarydysfunction,observebreathing,facialorwithoutcyanosis,prepareoxygendevices.针对老年、心肺功能异常者，注意观察呼吸、面部有无发绀，预备吸氧装置16血液透析个案护理Commoncomplicationcare(常见并发症的护理)

Duringdialysis（透析过程中）Nauseaandvomiting(恶心呕吐)toavoidhypotension.避免低血压(2)slowdownthebloodflow.减慢血流量(3)accordingtohypotensioncare.按低血压护理(4)exceptforgastrointestinaldisorders除外消化道疾患17血液透析个案护理Commoncomplicationcare(常见并发症的护理)

Duringdialysis（透析过程中）Vascularpainofthepuncturesite(穿刺部位血管痛)1.re-adjusttheneedlefixed-wingposition.重新调整穿刺针翼固定位置.2Ifthetemperatureofthedialysateislow,re-setthetemperatureofthedialysate,asimpleUFandhemodialysisalternately;payattentiontobodyinsulation.若因透析液温度低,重新设定透析液温度,单纯超滤与血透交替进行;注意机体保温.3Dropinbloodpressure,addedwithnormalsaline.血压下降时,补充盐水.4Reusedialyzerandbloodcircuit,instrictaccordancewiththecleansinganddisinfectionproceduresoperation.复用透析器、血液回路时,严格按照清洗消毒程序操作.5Puncturesite,vascularpain,andthetimelyreplacementofthepuncturesite穿刺部位血管痛,及时更换穿刺部位.18血液透析个案护理Commoncomplicationcare(常见并发症的护理)

Duringdialysis（透析过程中）Hypokalemia低钾血症Dietcontrolpotassiumfoodstopreventpredialysishyperkalemia,andstrictlylimittheuseofdigitalisdrugsindialysispatients,andtheuseofpotassium>3.0mmol/Ldialysate.Arrhythmias,antiarrhythmicdrugs,butneedtoadjustthedoseaccordingtodrugmetabolism.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。

20血液透析个案护理Commoncomplicationcare(常见并发症的护理)

Afterdialysis（透析后）Hypertension（高血压）:Sodiumandwaterintakeshouldbelimitedtokeepthedryweight.Invalidmayincreasetheuseofantihypertensivedrugs,ACEIandcalciumchannelblockersispreferred3%to5%.Inpatientswithrefractoryhypertension,divertedtoperitonealdialysisorhemofiltrationmaybeeffective.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.21血液透析个案护理Commoncomplicationcare(常见并发症的护理)

Afterdialysis（透析后）Anemia贫血:Topromoteredbloodcellhormonedrugstodialysisafterinjection.予透析后注射促红细胞素类药物22血液透析个案护理HealthEducation（健康教育）

PsychologicalCare心理护理ReasonableDiet合理膳食FistulaCare内瘘的护理KnowledgeMissions知识宣教23血液透析个案护理Psychologicalcare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24血液透析个案护理Reasonablediet合理膳食1.Strictcontroloftheintakeandoutput,Expenditureandrevenues,andratherlessdomore.严格控制出入量，“量出为入，宁少勿多”2.Limittheintakeofproteinaccordingtothedisease:bloodureanitrogenistoohigh,giventhenon-proteindiet.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.Limittheintakeofpotassium,sodium,magnesium,phosphorus,suchasshouldnoteatbananas,peaches,spinach,rape,mushrooms,ediblefungus,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.Appropriateintakeofsodium,addition,accordingtothelossoftheamountofappropriatenutritionalsupplementsandvitamins.适当地摄取钠盐，另外根据丢失量适当补充营养和维生素。25血液透析个案护理Fistulacare内瘘的护理Thepre-dialysismaintainsfistulalimbskinclean.透析前保持内瘘侧肢体皮肤清洁。Avoidwithinthefistulasiteexposedtoreducethedamage,breakageshouldbeimmediatelydisinfected。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。Hemodialysistreatmentafter24hours。Donotcontaminateorwetfistulaskinpuncturesite,suchascontaminatedshallbeimmediatelyalcoholfortwotimes,andthensterilegauzebandageorBand-Aidcovering,soasnottoincreasethechancesofinfection。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。26血液透析个案护理Fistulacare内瘘的护理Fistulabloodvesselscannotcarryouttheoperationoftheinfusion,injection,bloodtoavoidpuncturedamage,liquidstimulationleadtophlebitis,thrombosisandothercomplications。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。Avoidfistulalimbvascularcompression,includingtoavoidwearingtightsleeveclothes,sleepinginsidethefistulasideside,donottakethefistulalimbswhenthepillowcausedbyprolongedpressureonthelimbofthefistulaunexpectedbloodpressure,noheavyliftingwithoutviolence。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。27血液透析个案护理Fistulacare内瘘的护理Reasonablehemostaticbandage.Preventionofthrombusformation,vascularocclusion.Theendofeachdialysistreatment,shouldbenotedthatthebloodvesselsofthefistulasitetremorandhemostasistime,ifthetremordisappearedtourniquetshouldimmediatelyreleasealittle,untilyoutouchthetremor,topreventhardpressedbythearteriovenousfistulaocclusion,suchashalfanhourReleasethetourniquetpunctureisstillbleeding,andshouldinformthedoctorinatimelymannertoadjustthedoseofanticoagulants.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。

28血液透析个案护理Fistulacare内瘘的护理Masterfistulableedingemergencytreatment掌握内瘘出血的紧急处理方法(1)hemostasis,theintensityofthebloodthrough,totouchthebloodvesselstremor,notbleedingasastandard,generallyaboutoppressionabout10minutes.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)oppressioncanraisethelimb.压迫时可以抬高肢体(3)Ifstillbleeding,pressureoppression,immediatelytothehospitaltore-dressing,fistula