血液透析个案_护理.ppt

1、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

2、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

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,

6、 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

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 (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 b

9、ody 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

10、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

11、 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

12、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

13、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-fa

14、t 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 treatm

15、ent 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

16、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 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 pressu

18、re（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

19、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 180mmHg) above, after half an hour re-measured blood pressure, if still high given antihypertensive drugs.透析结束时收缩压

20、24kPa 180mmHg) 以上时,半小时后复测血压,若仍高时给予降压药。,Common complication care(常见并发症的护理) During dialysis（透析过程中）,Common complication care(常见并发症的护理) During dialysis（透析过程中）,Imbalance syndrome（失衡综合症） 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. 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。,Common complication care(常见并发症的护理) During dialysis（透析过程中）,Muscle spasm(肌肉痉挛) 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. 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。,Common complication care(常见并发症的护理) During dialysis（透析过程中）,Hypoxemia（

23、低氧血症） For the elderly, cardiopulmonary dysfunction, observe breathing, facial or without cyanosis, prepare oxygen devices. 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,Common complication care(常见并发症的护理) During dialysis（透析过程中）,Nausea and vomiting (恶心呕吐) to avoid hypotension.避免低血压 (2) slow down the blood flow.减慢

24、血流量 (3) according to hypotension care.按低血压护理 (4) except for gastrointestinal disorders除外消化道疾患,Common complication care(常见并发症的护理) During dialysis（透析过程中）,Vascular pain of the puncture site(穿刺部位血管痛) 1.re-adjust the needle fixed-wing position.重新调整穿刺针翼固定位置. 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. 3 Drop in blood pressure, added with normal saline.血压下降时,补充盐水. 4 Reuse dialyzer and blood circuit, in strict accordance with the cleansing and di

26、sinfection procedures operation.复用透析器、血液回路时,严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,及时更换穿刺部位 .,Common complication care(常见并发症的护理) During dialysis（透析过程中）,Itchy skin（皮肤瘙痒） 1. Symptomatic treatment and taking allergy medication.对症治疗服用抗过敏药 2.

27、 Selection can be cleared in the molecules, macromolecules dialyzer.选择可以清除中分子、大分子物质的透析器。 3. The use of bicarbonate dialysate.使用碳酸氢盐透析液。 4. Replacement of anticoagulant drugs, use of small molecular weight heparin or other anticoagulation methods.更换抗凝药 , 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.局部皮肤冷水清洗 , 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.使用低温透析液 , 有助于缓解透析中皮肤癌痒。 7. Local skin coated with lubricant.局部皮肤外涂润滑剂,Common complication care(常见并发症的护理) During dialysis（透析过程中）,Hypokalemia低钾血症 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.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

30、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

31、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 di

32、alysis 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 co

33、ntrol 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,

34、 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

35、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

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

37、 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, 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

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。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

41、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 c