血液透析個(gè)案護(hù)理培訓(xùn)課件

血液透析個(gè)案護(hù)理Firstly：Patientdata(患者資料）

XXX，XX歲，XXX入院，XXX開始透析，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,XXyearsold,XXXadmission,XXXdialysis,dialysisfrequency:Xtimes/week.

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

2血液透析個(gè)案護(hù)理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。Historyofpresentillness(現(xiàn)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血液透析個(gè)案護(hù)理Pastmedicalhistory(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。MorethanXyear-oldsufferingfromacutenephritis,topenicillintreatment,mitigation,andonXthisyearinhospitalemergencyabdominalparacentesisdrainage.Nohypertension,nodiabetes,nohistoryofrheumaticheartdisease,nohistoryofallergies,poisoninghistory.4血液透析個(gè)案護(hù)理Laboratorytests（實(shí)驗(yàn)室檢查）：生化：肌酐2245umol/L,Bun88.94mol/L,co2-cp15.4mmol/L,血k7.09mmol/L。血常規(guī)：WBC9.19，HGB56g/L尿常規(guī)：白蛋白2.0g/L,WBC16.2/LB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：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血液透析個(gè)案護(hù)理Secondly.Careissuesandmeasures(護(hù)理問(wèn)題及措施)FluidoverloadDamageandacuterenalfailureduetoglomerularfiltrationrate.

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.TheriskofinfectionRestrictedproteindiet,dialysis,andthebodyloweredimmunity.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)。6血液透析個(gè)案護(hù)理

3.ImpairedskinintegrityVascularchangesandthepuncturesite

皮膚完整性受損與穿刺部位血管變化有關(guān)4.MalnutritionPatientsappetiteislow,restricteddiet,theprimarydiseaseandotherfactors

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)7血液透析個(gè)案護(hù)理5.AnxietyRelatedtothepatient‘seconomicsituation

焦慮與患者家庭的經(jīng)濟(jì)狀況有關(guān)6.Commoncomplication：Disequilibriumsyndrome、hypotension、hypoxemia,cardiacarrhythmias、cardiactamponade、hemolysis、airembolism、cerebralhemorrhage、subduralhematoma、anemia、Musclespasm、Nauseaandvomiting、Highbloodpressure、Thepuncturesite,vascularpain、Itchyskin常見并發(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

8血液透析個(gè)案護(hù)理Thirdly.Nursinginterventions（護(hù)理措施）：Fluidoverload（體液過(guò)多的護(hù)理）:Controlofintake,Demandfordialysistreatment.控制入量，按需透析。Careofinfection(感染的護(hù)理)：Thewardventilation,airdisinfection,toavoidtheflu.病室通風(fēng)，空氣消毒，避免上感(2)dialysisoperatingstrictlysteriletoavoidinfection.透析操作嚴(yán)格無(wú)菌，避免感染(3)infectionshouldbeprescribedbyadoctorrationaluseofthedrugontherenaltoxicity.感染時(shí)應(yīng)遵醫(yī)囑合理使用對(duì)腎臟毒性低的藥物9血液透析個(gè)案護(hù)理Skincare（皮膚的護(hù)理）：

Needleinjection,nearthepuncturesmearointment,anti-infectionandprotecttheskinintegrity.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。

Puncturewoundhealing,donotscratch,topreventskinscratches穿刺口愈合時(shí)，勿撓，防止皮膚抓傷.Careofmalnutrition(營(yíng)養(yǎng)失調(diào)的護(hù)理)：0.8g/(kg·d)Thehigh-qualityproteinintake,asappropriate,lowsodium,lowpotassium,lowchlorine,high-carbohydrate,high-fatdrink,relievesymptomssuchasnauseaandvomiting,increaseappetite.0.8g/(kg·d)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.10血液透析個(gè)案護(hù)理Anxietycare（焦慮的護(hù)理）：

(1)Bepatiencetounderstandtheeconomicsituationofthepatient‘sfamilyagreedwiththepatientsandtheirfamilieswithappropriatecareandtreatmentplan.

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)theobservationofthepatient’spsychologicalchangesfortheprogressofinformationabouttheexaminationandtreatmenttorelievethepatient‘sfear

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)togivecareandencouragepatientstoestablishtheconfidencetoovercomethedisease

給予關(guān)懷和鼓勵(lì)，使病人樹立戰(zhàn)勝疾病的信心11血液透析個(gè)案護(hù)理Commoncomplicationcare(常見并發(fā)癥的護(hù)理)

Duringdialysis（透析過(guò)程中）

Lowbloodpressure（低血壓）

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

12血液透析個(gè)案護(hù)理Highbloodpressure（血壓升高）1.Betweendialysissessionstoavoidtoomuchwaterandsaltintake.透析間期避免水鹽攝入過(guò)多2.Sedation,givetheESTAZOLAMTABLETS

10mg.鎮(zhèn)靜,可予安定10mg。

3.GivenantihypertensivedrugNifedipineTablets

10to15mgsublingual15mindoesnotalleviatecangivethesamedose.給予降壓藥心痛定10~15mg舌下含服15min不緩解可以再給予同等劑量。4).Thesymptomsweresignificantlyslower(highrenin)inadditiontowater,reducingbloodflow.癥狀顯著時(shí)(高腎素型)減慢除水量,降低血流量。

5.Theendofthedialysissystolicbloodpressurethe24kPa<180mmHg)above,afterhalfanhourre-measuredbloodpressure,ifstillhighgivenantihypertensivedrugs.透析結(jié)束時(shí)收縮壓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。Commoncomplicationcare(常見并發(fā)癥的護(hù)理)

Duringdialysis（透析過(guò)程中）13血液透析個(gè)案護(hù)理Commoncomplicationcare(常見并發(fā)癥的護(hù)理)

Duringdialysis（透析過(guò)程中）

Imbalancesyndrome（失衡綜合癥）Lightdoesnothavetodealwith，seriouscasesmaybe50%glucoseor3%sodiumchloride40ml,canalsolosealbumin,whennecessary,tosedativedrugsandothersymptomatictreatment.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。14血液透析個(gè)案護(hù)理Commoncomplicationcare(常見并發(fā)癥的護(hù)理)

Duringdialysis（透析過(guò)程中）Musclespasm(肌肉痙攣)WithmildsymptomscanbealleviatedpauseUF，symptomsofsevererequiredinfusionofhypertonicglucosesolutionorhypertonicsaline，Ultrafiltrationvolumesettingstoasuitablenumberofcorrect，andthedialysatesodiumconcentrationisraisedto145mmol/Lorhigher.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。

15血液透析個(gè)案護(hù)理Commoncomplicationcare(常見并發(fā)癥的護(hù)理)

Duringdialysis（透析過(guò)程中）Hypoxemia（低氧血癥）Fortheelderly,cardiopulmonarydysfunction,observebreathing,facialorwithoutcyanosis,prepareoxygendevices.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16血液透析個(gè)案護(hù)理Commoncomplicationcare(常見并發(fā)癥的護(hù)理)

Duringdialysis（透析過(guò)程中）Nauseaandvomiting(惡心嘔吐)toavoidhypotension.避免低血壓(2)slowdownthebloodflow.減慢血流量(3)accordingtohypotensioncare.按低血壓護(hù)理(4)exceptforgastrointestinaldisorders除外消化道疾患17血液透析個(gè)案護(hù)理Commoncomplicationcare(常見并發(fā)癥的護(hù)理)

Duringdialysis（透析過(guò)程中）Vascularpainofthepuncturesite(穿刺部位血管痛)1.re-adjusttheneedlefixed-wingposition.重新調(diào)整穿刺針翼固定位置.2Ifthetemperatureofthedialysateislow,re-setthetemperatureofthedialysate,asimpleUFandhemodialysisalternately;payattentiontobodyinsulation.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.3Dropinbloodpressure,addedwithnormalsaline.血壓下降時(shí),補(bǔ)充鹽水.4Reusedialyzerandbloodcircuit,instrictaccordancewiththecleansinganddisinfectionproceduresoperation.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.5Puncturesite,vascularpain,andthetimelyreplacementofthepuncturesite穿刺部位血管痛,及時(shí)更換穿刺部位.18血液透析個(gè)案護(hù)理Commoncomplicationcare(常見并發(fā)癥的護(hù)理)

Duringdialysis（透析過(guò)程中）Hypokalemia低鉀血癥Dietcontrolpotassiumfoodstopreventpredialysishyperkalemia,andstrictlylimittheuseofdigitalisdrugsindialysispatients,andtheuseofpotassium>3.0mmol/Ldialysate.Arrhythmias,antiarrhythmicdrugs,butneedtoadjustthedoseaccordingtodrugmetabolism.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。

20血液透析個(gè)案護(hù)理Commoncomplicationcare(常見并發(fā)癥的護(hù)理)

Afterdialysis（透析后）Hypertension（高血壓）:Sodiumandwaterintakeshouldbelimitedtokeepthedryweight.Invalidmayincreasetheuseofantihypertensivedrugs,ACEIandcalciumchannelblockersispreferred3%to5%.Inpatientswithrefractoryhypertension,divertedtoperitonealdialysisorhemofiltrationmaybeeffective.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.21血液透析個(gè)案護(hù)理Commoncomplicationcare(常見并發(fā)癥的護(hù)理)

Afterdialysis（透析后）Anemia貧血:Topromoteredbloodcellhormonedrugstodialysisafterinjection.予透析后注射促紅細(xì)胞素類藥物22血液透析個(gè)案護(hù)理HealthEducation（健康教育）

PsychologicalCare心理護(hù)理ReasonableDiet合理膳食FistulaCare內(nèi)瘺的護(hù)理KnowledgeMissions知識(shí)宣教23血液透析個(gè)案護(hù)理Psychologicalcare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24血液透析個(gè)案護(hù)理Reasonablediet合理膳食1.Strictcontroloftheintakeandoutput,Expenditureandrevenues,andratherlessdomore.嚴(yán)格控制出入量，“量出為入，寧少勿多”2.Limittheintakeofproteinaccordingtothedisease:bloodureanitrogenistoohigh,giventhenon-proteindiet.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.Limittheintakeofpotassium,sodium,magnesium,phosphorus,suchasshouldnoteatbananas,peaches,spinach,rape,mushrooms,ediblefungus,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.Appropriateintakeofsodium,addition,accordingtothelossoftheamountofappropriatenutritionalsupplementsandvitamins.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)和維生素。25血液透析個(gè)案護(hù)理Fistulacare內(nèi)瘺的護(hù)理Thepre-dialysismaintainsfistulalimbskinclean.透析前保持內(nèi)瘺側(cè)肢體皮膚清潔。Avoidwithinthefistulasiteexposedtoreducethedamage,breakageshouldbeimmediatelydisinfected。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。Hemodialysistreatmentafter24hours。Donotcontaminateorwetfistulaskinpuncturesite,suchascontaminatedshallbeimmediatelyalcoholfortwotimes,andthensterilegauzebandageorBand-Aidcovering,soasnottoincreasethechancesofinfection。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)。26血液透析個(gè)案護(hù)理Fistulacare內(nèi)瘺的護(hù)理Fistulabloodvesselscannotcarryouttheoperationoftheinfusion,injection,bloodtoavoidpuncturedamage,liquidstimulationleadtophlebitis,thrombosisandothercomplications。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。Avoidfistulalimbvascularcompression,includingtoavoidwearingtightsleeveclothes,sleepinginsidethefistulasideside,donottakethefistulalimbswhenthepillowcausedbyprolongedpressureonthelimbofthefistulaunexpectedbloodpressure,noheavyliftingwithoutviolence。避免內(nèi)瘺側(cè)肢體血管受壓,包括避免穿緊袖衣服,睡覺時(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。27血液透析個(gè)案護(hù)理Fistulacare內(nèi)瘺的護(hù)理Reasonablehemostaticbandage.Preventionofthrombusformation,vascularocclusion.Theendofeachdialysistreatment,shouldbenotedthatthebloodvesselsofthefistulasitetremorandhemostasistime,ifthetremordisappearedtourniquetshouldimmediatelyreleasealittle,untilyoutouchthetremor,topreventhardpressedbythearteriovenousfistulaocclusion,suchashalfanhourReleasethetourniquetpunctureisstillbleeding,andshouldinformthedoctorinatimelymannertoadjustthedoseofanticoagulants.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。

28血液透析個(gè)案護(hù)理Fistulacare內(nèi)瘺的護(hù)理Masterfistulableedingemergencytreatment掌握內(nèi)瘺出血的緊急處理方法(1)hemostasis,theintensityofthebloodthrough,totouchthebloodvesselstremor,notbleedingasastandard,generallyaboutoppressionabout10minutes.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)oppressioncanraisethelimb.壓迫時(shí)可以抬高肢體(3)Ifstillbleeding,pressureoppression,immediatelytothehospitaltore-dressing,fistula