Nursing Rounduremia juri:mi 尿毒症尿毒症1Main content1. 1. General information on patientGeneral information on patient 2.History and 2.History and present illnesspresent illness 3 3. . Laboratory testsLaboratory tests 4 4. . Care issues and measuresCare issues and measures 5. 5. Health Health e e e educationducation 2General informationvName: 吴吴* Gender: female Age: 48yvStart dialysis: 2009-8-3vDialysis frequency: 5 times/2 weeksvVascular access for hemodialysis,hi:mdailisis, ,hem- : AVF 动静脉瘘管（动静脉瘘管（arteriovenous:,tiriuvi:ns fistulafistjul ,AVF)vDiagnosis: CGN ( 慢性肾小球肾炎慢性肾小球肾炎Chronic glomerulonephritis l,merjulunifraitis )3v动静脉瘘管动静脉瘘管是为了建造可供血液透析使用的管道，将动脉与邻近静脉是为了建造可供血液透析使用的管道，将动脉与邻近静脉血管相连接的手术，通常选择非惯用手的手臂或手腕血管，术后三到血管相连接的手术，通常选择非惯用手的手臂或手腕血管，术后三到四周，静脉血流增多且膨胀就可使用。四周，静脉血流增多且膨胀就可使用。vhemodialysis,hi:mdailisis, ,hem- : AVF 动静脉瘘管动静脉瘘管v动静脉瘘管日常照护重点：动静脉瘘管日常照护重点：1.避免由瘘管处打针、抽血、量血压，碰撞、用力压迫、提重物等。避免由瘘管处打针、抽血、量血压，碰撞、用力压迫、提重物等。2.随时注意瘘管处有无博动及可听见明显水流声，若发现以上现象减随时注意瘘管处有无博动及可听见明显水流声，若发现以上现象减弱或消失，可能发生栓塞，应及早治疗。弱或消失，可能发生栓塞，应及早治疗。3.若有红、肿、热、痛、化脓、麻木感、出血时应赶快就医若有红、肿、热、痛、化脓、麻木感、出血时应赶快就医4.血管过度膨胀时，可以弹性护套保护，防止血流过强，造成心脏衰血管过度膨胀时，可以弹性护套保护，防止血流过强，造成心脏衰竭。竭。5.可利用远红外线仪器提高瘘管血流并减少血栓形成。可利用远红外线仪器提高瘘管血流并减少血栓形成。6.热敷、按摩与握球运动可增加血管血流量，但透析后应避免，并保热敷、按摩与握球运动可增加血管血流量，但透析后应避免，并保持瘘管处干燥清洁。持瘘管处干燥清洁。4History History illnessillnessHistory andHistory and present illnesspresent illnessPresent illnessPresent illnessDeep venous Deep venous catheter catheter kitkit surgerysurgery（深静脉（深静脉（深静脉（深静脉置管手术史）；置管手术史）；置管手术史）；置管手术史）；Hepatitis BHepatitis B,heptaitis,heptaitis ；Repeated Repeated nausea nausea n:zin:zi vomitingvomiting，o o o oligurialiguria,lijuri,lijuri ( ( ( (少尿少尿少尿少尿) ) ) ). .5Present illness v患者现呈灰暗面貌，自透析以来，尿量逐渐减少，至今年患者现呈灰暗面貌，自透析以来，尿量逐渐减少，至今年10月份无尿。患者收缩压波动在月份无尿。患者收缩压波动在140-190mmg，舒张压在，舒张压在70-100mmg，双下肢凹陷性浮肿明显，伴瘙痒。透析过程中常出现，双下肢凹陷性浮肿明显，伴瘙痒。透析过程中常出现恶心呕吐，曾急发左心衰两次。现口服降压药压氏达，抗贫血恶心呕吐，曾急发左心衰两次。现口服降压药压氏达，抗贫血药力蜚能，纠酸药小苏打，每周一次药力蜚能，纠酸药小苏打，每周一次Epiao。家庭经济状况不好。家庭经济状况不好。v The patient has a gloomy outlook. Since the dialysis, the urine is on the decline, untill October this year the urine is zero. The SBP收缩压(Systolicsistlik Blood Pressure) of the patient ranges from 140 to 190mmHg, the DBP ,daistlik of the patient ranges from 70 to 100mmHg. The edemaidi:m of the legs is obvious, along with the prurituspruraits （瘙痒）.The nausea and vomitinausea and vomiting ng happens frequently, the left heart failure happened twice.happens frequently, the left heart failure happened twice.6v压陷性水肿压陷性水肿7Laboratory testsLaboratory testsNormal value2010-122011-03BUN before the dialysis21-2849.8742BUN after the dialysis1/3(21-28)15.716.8ALB(g/L)3535.130.3HCT(l/L)0.37-0.480.130.11K(mmol/L)3.5-5.54.775.46Hb(g/L)1104036Fe(mmol/L)9.0-3048.53.81PTH(pg/mL)150-300632.61120P(mmol/L)0.96-1.782.412.10Cr(mmol/L)62-11511791101Blood 2micro blobulin0-2.244.2238.10blood urea nitrogen 血尿素氮8Nursing problem营养失调营养失调营养失调营养失调骨痛，瘙痒骨痛，瘙痒体液过多体液过多体液过多体液过多Related to excessive intake and dehydration(脱脱水水) shortage.Below the bodys requirements. .Related to i inadequate intake of FeFe、pprotein and EPO ,it,itlead to anemia（贫血）（贫血）Related to the high phosphorus and PTH ,it,itlead to the Renal bone disease. 1. 1. Fluid overloadFluid overload2.malnutrition2.malnutrition3. Bone pain,pruritus3. Bone pain,pruritus4. Psychological 4. Psychological carecare（心理护理）（心理护理）（心理护理）（心理护理）9Nursing problemHigh bloodPressure(高血压高血压)Muscle spasms（肌肉痉挛）（肌肉痉挛）nausea and vomiting(恶心呕吐恶心呕吐)High potassium hematic disease(高钾血症高钾血症) Acute left heartfailure（急性左心衰）（急性左心衰）Complications(并发症并发症) )101. Fluid overload严格限制水钠入量，透析间体重增长小于5%干体重。Strictly limit the amount of water Strictly limit the amount of water ，the the growth of the weight isgrowth of the weight is less less than than 5%ofdryweight.5%ofdryweight.5%ofdryweight.5%ofdryweight.增加透析次数，可改为每周两次HD，一次HDF。increasethetimesofdialysis,itmaybe2increasethetimesofdialysis,itmaybe2increasethetimesofdialysis,itmaybe2increasethetimesofdialysis,itmaybe2hemodialysisesand1hemodiafiltrationhemodialysisesand1hemodiafiltrationhemodialysisesand1hemodiafiltrationhemodialysisesand1hemodiafiltrationeveryweek.everyweek.everyweek.everyweek.11v血液透析滤过血液透析滤过是在血液透析基础上，利用透析滤过膜来清除中分子毒素，故尿毒症患者出现中分子毒素蓄积表现如严重心包炎、心包积液、周围神经病变时，均可考虑使该疗法。与血液透析相比，血液透析滤过不仅能清除中分子毒性物质，还能保证不影响小分子毒素清除效率，因此，特别适于需要血液滤过又不能增加透析次数患者；血液透析滤过具有心血管状态稳定特点，故适于普通血液透析时易发生低血压不耐受超滤患者。12TipsvUsethecupwhichhasscale;vEatsomethingsourwhenfeelsthirsty.vUsethecoldwatertogargle.vGuidethepatienttoweighseriouslybeforeandafterthedialysis.13malnutritionFeFeALBALBALBALBEPOEPOEPOEPO 2. 2.malnutrition14Managementv每日摄入充足热量的前提下，增加优质蛋白的摄入（每日摄入充足热量的前提下，增加优质蛋白的摄入（1.1-1.2g/kg）,50%以上的蛋白应来自奶类、蛋类、鱼类、肉。以上的蛋白应来自奶类、蛋类、鱼类、肉。 Besides the adequate heat,increase the input of high-quality protein,50% of the protein should be come from milk、eggs、fish and meat.v increase the input of food which not only contain much Fe but also has high absorption rate,for example,meat、liver、blood、kelp and black fungi.Besides,the food which has rich VitC can help Fe absorb.Milk、coffee and tea should be avioded.v Use EPO according to the doctors order,and supply the ferralia.153. Bone pain, pruritus1lower the temperture during the dialysis,and guide the patient to use the cold water to scrub（擦（擦洗）洗）,not to scratch the skin.2limit the food which contain much P,milk,animal entrails（内脏）（内脏）,nuts.Use the calcium during the meal.3Perfect the examination of the parathyroid,resecti-on （切除（切除术）术）is needed.164. 4.ComplicationsMuscle Spasms 肌肉痉挛肌肉痉挛heart failure心衰心衰 Highpotassihematic diseae高钾血症高钾血症High blood pressure 血压过高血压过高提高钠浓度，肌肉痉提高钠浓度，肌肉痉挛时，停止血滤，挛时，停止血滤，使用高渗液。使用高渗液。improvetheconcenimprovetheconcentrationofsodium,iftrationofsodium,ifmuslemuslespasmshappen,usecalcihappen,usecalciumgluconate,stopumgluconate,stopUF.UF.呼吸困难气促呼吸困难气促, ,立即立即给予病人吸氧给予病人吸氧, ,抬高抬高床尾使用强心药物。床尾使用强心药物。IfthepatienthasIfthepatienthasshortnessofshortnessofbreath,wecangivebreath,wecangiveheroxygen,raiseheroxygen,raisetheendofbed,usetheendofbed,usethedrugtostrongthedrugtostrongheartheart避免食用高钾食物避免食用高钾食物，花生，核桃，瓜，花生，核桃，瓜子，水果，豆类，子，水果，豆类，瘦肉瘦肉Avoid eating high potassium food,such aspeanut, walnut, melon seeds, fruit, beans, meat.将钠浓度将钠浓度调低，体温略高，若调低，体温略高，若无缓解予心痛定舌无缓解予心痛定舌下含服。下含服。L Lower sodium concentration, ,make temperaturehigher.if not ease, ,usethedrug.usethedrug.17Na5modeNa5mode185.Psychological care 心理护理心理护理For patientFor patientWecanalways talk with thepatient and get the reason that we suit and to comfort, tell her the people around her dialysis for 20 years, still healthy and happy. Sets up her confidence of conqueringthedisease.Havingoptimistic attitudeto improve the quality of life.ForFor familiesfamiliesFamilies that dont cooperate with patient care, economic condition is poor, do not pay enough attention to the patient. We should tell the patients condition to family members, told the consequences of not insisting on hemodialysis, so as to obtain the economic support.19HealthEducationBasicguideBasicguideBasicguideBasicguideBalanceBalanceBalanceBalanceReasona-Reasona-Reasona-Reasona-bledietbledietbledietbledietPrevent Prevent infection infection 201.Basicknowldegeguide1.BasicknowldegeguidevExplain the basic knowledge of renal failure to patient and family .vEmphasize the importance of active therapy. Protect AVFcarefullly, dont press ,dont carry heavy loads. vLet the patient can speak of the commonly used medicine and takethemontime.vObservethebodywhetherhasthebleedingindailylife.212.Reasonablediet2.Reasonabledietvadequate heat and high-quality protein.vlimit the input of P、water and Na.vsupply the VitC and VitB and calcuim.223.Preventinfection3.Preventinfectionvkeep the AVF clean,wearing loose;vPut on more or less clothes according to the weather.vProper exercise to build up the resistance to disease。vNot to the place where crowded.234.Maintainthebalance4.MaintainthebalancevGuide the patient to record the input and output and weigh seriously everyday.vSelf management about the BP.24Thank You !25