急性肾衰竭cgmhorgtw.doc

目 錄 腎臟科工作規範 2 問題與解答Q A in Nephrology Ward 8 腎臟科常見症狀 血尿Hematuria 13 尿液分析Urinalysis 17 腎臟科常見疾病 急性腎衰竭 Acute Renal Failure 21 慢性腎衰竭及其併發症 Chronic Renal Failure 31 酸鹼異常Acid-Base Disorders 38 糖尿病腎病變Diabetic Nephropathy 45 腎病症侯群 Nephrotic syndrone___________ 49 電解質的問題--鈉離子篇 Electrolytes: Sodium 53 泌尿道感染Urinary Tract Infections 61 腹膜透析之腹膜炎CAPD-associated Peritonitis 70 巴拉刈中毒 (Paraquat Poisoning) 76 腎臟科工作規範 Fresh Uremic Patient 1)Check I/O, body weight QD 2)Diet restriction: low salt (3-5gm/day), low K (40meq/day), low protein (40gm/day) (視臨床情況調整,若已開始接受透析,限鹽4gm即可)Fresh Uremic Patient 3)Check CBC, VDRL, i-PTH, HBsAg, Anti-HCV, CCr and 24 hours urine total protein 4)Arrange renal echo (先查閱舊病歷, 若近六個月已做，先問主治醫師後再排) 5)病況穩定病人,不必on IV; 必需parenteral medications時,儘量on IV lock,如果病人NPO,需基本IVF,則約40 ml/hr即可. (大量點滴極易造成肺水腫) 6)每天check病人有無crackles, wheezes, S3 gallop, tachycardia, orthopnea, Kussmaul respiration, hypotension, paradoxical pulse, edema, 或者severe uremic symptoms,並記載於病歷. 7)Follow up BUN, Cr, Na, K Ca, P, and CO2 prn Maintenance Hemodialysis 1)開立新住院病人血液透析醫囑時,請聯絡血液透析室(TEL: 2302或2332),若欲在透析時輸血,或需用特殊Dialysate或Dialyzer時,請在Order上記載並事先聯絡洗腎室; 血液透析醫囑格式如後附 2)出院以前Consult dietitian 3)出院病人,請詳細填寫血液透析醫囑單、血液透析基本資料表(含背面洗腎原因), 並準備一份出院病歷摘要(綠單) , 交由家屬至復健大樓三樓, 門診洗腎室排程, 並且要Complete HBsAg, anti-HCV Ab, VDRL data 4)住院中血液透析醫囑至少每週Renew一次 5)Fresh uremia之Dialyzer一律用FB170G, Heparin Free; 如果病人的BUN 150mg/d或是有任何的Bleeding Signs時,未避免加重Uremic Bleeding請使用 FB 170G, Non-heparin once then heparin free. 6)血液透析前FFP priming或血液透析中輸血,請先備妥血並開立於醫囑單上,病人在血液透析中經dialyzer輸血,原則上PRBC或FFP皆以2u為限 (經由周邊輸血不在此限) 7)若病人需要在洗腎中接受輸血請先事先知會洗腎室Fellow. 針對住院病人Underlying disease的多樣性以及各種潛在出血危險,血液透析室乃採用低劑量Heparin甚至是Non-heparin 之透析器為病患實行hemodi