血液透析个案的护理查房.ppt

谢 谢 * 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 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 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 reduced, 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, our 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, 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 ：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