《uremia尿毒癥案例》演示PPT

1、L o g o Nursing Round uremia juri:mi 尿毒癥尿毒癥 Main content v Name: 吳吳* Gender: female Age: 48y v Start dialysis: 2009-8-3 v Dialysis frequency: 5 times/2 weeks v Vascular access for hemodialysis,hi:mdailisis, ,hem- : AVF 動(dòng)靜脈瘺管（動(dòng)靜脈瘺管（arteriovenous:,tiriuvi:ns fistulafistjul ,AVF) v Diagnosis: CGN ( 慢性腎

2、小球腎炎慢性腎小球腎炎Chronic glomerulonephritis l,merjulunifraitis ) v 動(dòng)靜脈瘺管動(dòng)靜脈瘺管是為了建造可供血液透析使用的管道，將動(dòng)脈與鄰近靜脈是為了建造可供血液透析使用的管道，將動(dòng)脈與鄰近靜脈 血管相連接的手術(shù)，通常選擇非慣用手的手臂或手腕血管，術(shù)后三到血管相連接的手術(shù)，通常選擇非慣用手的手臂或手腕血管，術(shù)后三到 四周，靜脈血流增多且膨脹就可使用。四周，靜脈血流增多且膨脹就可使用。 v hemodialysis,hi:mdailisis, ,hem- : AVF 動(dòng)靜脈瘺管動(dòng)靜脈瘺管 v 動(dòng)靜脈瘺管日常照護(hù)重點(diǎn)：動(dòng)靜脈瘺管日常照護(hù)重點(diǎn)： 1.避

3、免由瘺管處打針、抽血、量血壓，碰撞、用力壓迫、提重物等。避免由瘺管處打針、抽血、量血壓，碰撞、用力壓迫、提重物等。 2.隨時(shí)注意瘺管處有無(wú)博動(dòng)及可聽(tīng)見(jiàn)明顯水流聲，若發(fā)現(xiàn)以上現(xiàn)象減隨時(shí)注意瘺管處有無(wú)博動(dòng)及可聽(tīng)見(jiàn)明顯水流聲，若發(fā)現(xiàn)以上現(xiàn)象減 弱或消失，可能發(fā)生栓塞，應(yīng)及早治療。弱或消失，可能發(fā)生栓塞，應(yīng)及早治療。 3.若有紅、腫、熱、痛、化膿、麻木感、出血時(shí)應(yīng)趕快就醫(yī)若有紅、腫、熱、痛、化膿、麻木感、出血時(shí)應(yīng)趕快就醫(yī) 4.血管過(guò)度膨脹時(shí)，可以彈性護(hù)套保護(hù)，防止血流過(guò)強(qiáng)，造成心臟衰血管過(guò)度膨脹時(shí)，可以彈性護(hù)套保護(hù)，防止血流過(guò)強(qiáng)，造成心臟衰 竭。竭。 5.可利用遠(yuǎn)紅外線儀器提高瘺管血流并減少血栓形成。

4、可利用遠(yuǎn)紅外線儀器提高瘺管血流并減少血栓形成。 6.熱敷、按摩與握球運(yùn)動(dòng)可增加血管血流量，但透析后應(yīng)避免，并保熱敷、按摩與握球運(yùn)動(dòng)可增加血管血流量，但透析后應(yīng)避免，并保 持瘺管處干燥清潔。持瘺管處干燥清潔。 v 患者現(xiàn)呈灰暗面貌，自透析以來(lái)，尿量逐漸減少，至今年患者現(xiàn)呈灰暗面貌，自透析以來(lái)，尿量逐漸減少，至今年10 月份無(wú)尿?；颊呤湛s壓波動(dòng)在月份無(wú)尿?；颊呤湛s壓波動(dòng)在140-190mmg，舒張壓在，舒張壓在70- 100mmg，雙下肢凹陷性浮腫明顯，伴瘙癢。透析過(guò)程中常出，雙下肢凹陷性浮腫明顯，伴瘙癢。透析過(guò)程中常出 現(xiàn)惡心嘔吐，曾急發(fā)左心衰兩次。現(xiàn)口服降壓藥壓氏達(dá)，抗貧現(xiàn)惡心嘔吐，曾急發(fā)左心

5、衰兩次。現(xiàn)口服降壓藥壓氏達(dá)，抗貧 血藥力蜚能，糾酸藥小蘇打，每周一次血藥力蜚能，糾酸藥小蘇打，每周一次Epiao。家庭經(jīng)濟(jì)狀況不。家庭經(jīng)濟(jì)狀況不 好。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 縮壓(Systolicsistlik Blood Pressure) of the patient ranges from 140 to 190mmHg, the DB

6、P ,daistlik of the patient ranges from 70 to 100mmHg. The edemaidi:m of the legs is obvious, along with the prurituspruraits （瘙癢）.The v壓陷性水腫壓陷性水腫 Normal value 2010-122011-03 BUN before the dialysis21-2849.8742 BUN after the dialysis1/3(21-28)15.716.8 ALB(g/L)3535.130.3 HCT(l/L)0.37-0.480.130.11 K(mm

7、ol/L)3.5-5.54.775.46 Hb(g/L)1104036 Fe(mmol/L)9.0-3048.53.81 PTH(pg/mL)150-300632.61120 P(mmol/L)0.96-1.782.412.10 Cr(mmol/L)62-11511791101 Blood 2micro blobulin 0-2.244.2238.10 blood urea nitrogen 血尿素氮 Nursing problem 骨痛，瘙癢骨痛，瘙癢 Related to excessive intake and dehydration(脫脫 水水) shortage. Below the

8、 bodys requirements. Related to inadequate intake of Fe 、 protein and EPO , it lead to anemia（貧血）（貧血） Related to the high phosphorus and PTH ,it lead to the Renal bone disease. Nursing problem High blood Pressure (高血壓高血壓) Muscle spasms （肌肉痙攣）（肌肉痙攣） nausea and vomiting (惡心嘔吐惡心嘔吐) High potassium hemat

9、ic disease (高鉀血癥高鉀血癥) Acute left heart failure（急性左心衰）（急性左心衰） Complications (并發(fā)癥并發(fā)癥 1. 嚴(yán)格限制水鈉入量，透析間體重增長(zhǎng) 小于5%干體重。 增加透析次數(shù)，可改為每周兩次HD， 一次HDF。 v 血液透析濾過(guò)血液透析濾過(guò)是在血液透析基礎(chǔ)上，利用透析濾過(guò)膜來(lái) 清除中分子毒素，故尿毒癥患者出現(xiàn)中分子毒素蓄積表現(xiàn) 如嚴(yán)重心包炎、心包積液、周圍神經(jīng)病變時(shí)，均可考慮使 該療法。與血液透析相比，血液透析濾過(guò)不僅能清除中分 子毒性物質(zhì)，還能保證不影響小分子毒素清除效率，因此， 特別適于需要血液濾過(guò)又不能增加透析次數(shù)患者；血液透

10、 析濾過(guò)具有心血管狀態(tài)穩(wěn)定特點(diǎn)，故適于普通血液透析時(shí) 易發(fā)生低血壓不耐受超濾患者。 Tips vUse the cup which has scale; vEat something sour when feels thirsty. vUse the cold water to gargle. vGuide the patient to weigh seriously before and after the dialysis. Management v 每日攝入充足熱量的前提下，增加優(yōu)質(zhì)蛋白的攝入（每日攝入充足熱量的前提下，增加優(yōu)質(zhì)蛋白的攝入（1.1- 1.2g/kg）,50%以上的蛋白應(yīng)來(lái)

11、自奶類、蛋類、魚(yú)類、肉。以上的蛋白應(yīng)來(lái)自奶類、蛋類、魚(yú)類、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 b

12、lack 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. 3. 1 lower the temperture during the dialysis,and guide the patient to use the cold water to scrub（擦（擦 洗）洗）,not to scratch the s

13、kin. 2 limit the food which contain much P,milk,animal entrails（內(nèi)（內(nèi) 臟）臟）,nuts.Use the calcium during the meal. 3 Perfect the examination of the parathyroid,res ecti-on （切除（切除 術(shù)）術(shù)）is needed. 4.Complications Muscle Spasms 肌肉痙攣肌肉痙攣 heart failure 心衰心衰 High potassi hematic diseae 高鉀血癥高鉀血癥 High blood pres

14、sure 血壓過(guò)高血壓過(guò)高 提高鈉濃度，肌肉痙提高鈉濃度，肌肉痙 攣時(shí)，停止血濾，攣時(shí)，停止血濾， 使用高滲液。使用高滲液。 improve the concen tration of sodium, if musle spasm s happen,use calci um gluconate,stop UF. 呼吸困難氣促呼吸困難氣促 ,立即立即 給予病人吸氧給予病人吸氧 ,抬高抬高 床尾使用強(qiáng)心藥物。床尾使用強(qiáng)心藥物。 If the patient has shortness of breath,we can give her oxygen, raise the end of bed,us

15、e the drug to strong heart 避免食用高鉀食物避免食用高鉀食物 ，花生，核桃，瓜，花生，核桃，瓜 子，水果，豆類，子，水果，豆類， 瘦肉瘦肉 Avoid eating high potassium food, such as peanut, walnut, melon se eds, fruit, beans, meat. 將鈉濃度將鈉濃度 調(diào)低，體溫略高，若調(diào)低，體溫略高，若 無(wú)緩解予心痛定舌無(wú)緩解予心痛定舌 下含服。下含服。 Lower sodium concentration, make temperature higher.if not ease, use th

16、e drug. We can always talk with the patient 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 conquering the disease.Having optimistic attitude to improve the quality of life. Families that dont co

17、operate 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. Health Education v Explain the basic knowledge of

18、renal failure to patient and family . v Emphasize the importance of active therapy. Protect AVF carefullly, dont press ,dont carry heavy loads. v Let the patient can speak of the commonly used medicine and take them on time. v Observe the body whether has the bleeding in daily life. vadequate heat and high-quality protein. vlimit the input of P、water and Na. vsupply the VitC and VitB and calcuim. vkeep th