维持血液透析患者护理查房

病区：血液净化科时间： 2013 年 1 月 17 日礼拜五主查人：杨阳职称：护士查房题目：血液透析患者护理查房病人姓名：乔振博记录：杨阳参加人员：查房过程记录：一、病案：患者青年男性， 25 岁，发育正常，营养中等，神志清楚，慢性病容，贫血貌。

检查：红细胞L血红蛋白：100g/L，钾：L.磷：L。

查体：体重T：℃P:101 次/ 分R:20 次/ 分BP:75/51mmHg。

患者行血液透析次 / 周。

患者因透析需要在颈内静脉留置长久导管。

二、依据患者病情，可给出以下护理诊疗：1、有感染的危险与颈内静脉长久导管有关。

2、水肿与水钠潴留有关。

三、依据护理诊疗可采纳以下护理举措：1、置管病人的护理（1）养成优秀的卫生习惯，保持局部干燥、洁净。

如需淋浴，患者必定要将留置导管及皮肤出口处用 3M 胶布密封，免得淋浴后感染。

若一旦有局部感染，应立刻就诊免得感染扩散：（2）血液透析患者的导管一般不宜另作他用，如输液、抽血等，如必定要用，用后一定按血液透析后导管的办理要求封管 ;（3）每次血液透析开始前，应拆掉包扎敷料，卸掉肝素帽，将其浸泡于消毒液中备用，再用毗咯酮液消毒导管口及四周皮肤。

透析结束后，应惯例消毒导管，用生理盐水、肝素封好管后用已消毒的肝素帽关闭管口，并将导管用无菌敷料包扎 ;（4）预防与导管有关的感染可用毗咯酮液洗导管帽，也实用万古霉素加肝素注人导管内防治感染 .2、增强壮康教育，控制水钠潴留（1）要严格控制水的摄取量，饮料也同样，要控制摄取。

两次血透之间体重增添不要超出 5%（体重增添应控制在 3 公斤之内）。

（2）要严格控制盐的摄取。

每日食盐控制在 3-4 克。

（3）要严格控制钾的摄取量，。

血透病人血钾易高升，高血钾可致使严重的心律失态，甚至心跳骤停，所以不要食用高钾食品，如橘类、苹果、葡萄、香蕉、榨菜、花生、胡桃、香菇等。

腌制品不要吃。

（4）要严格控制磷的摄取量。

含磷最低的食品有：米饭、面条、面包、牛奶、鱼类等。

血透护理查房范文护士长分析英文回答：Blood Dialysis Nursing Rounds Transcript.Nurse Manager's Analysis.Introduction.Blood dialysis is a life-sustaining treatment for patients with end-stage renal disease (ESRD). It involves the removal of waste products and excess fluid from the blood through a semi-permeable membrane. Nursing rounds are an essential part of blood dialysis care, providing an opportunity for nurses to assess patients, monitor their progress, and intervene as needed.Assessment.During nursing rounds, nurses assess patients' vitalsigns, weight, and fluid status. They also inspect the dialysis access site for signs of infection or complications. Nurses observe patients' general appearance, including their level of consciousness, skin color, and hydration status.Intervention.Based on their assessment findings, nurses may intervene to address any problems or concerns. This may include adjusting the dialysis prescription, administering medications, or providing education to patients. Nurses also monitor patients for complications, such as hypotension, cramping, or nausea, and intervene promptly to mitigate these symptoms.Education.Nursing rounds provide an opportunity for nurses to educate patients about their condition and treatment. They may explain the principles of hemodialysis, discuss the importance of fluid and dietary restrictions, and provideguidance on self-care measures.Collaboration.Nursing rounds are a collaborative process involving nurses, physicians, and other healthcare professionals. The nurse manager plays a vital role in coordinating care and ensuring that all members of the team are up-to-date on the patient's status and progress.Documentation.Nurses document their findings and interventions during nursing rounds in the patient's medical record. This documentation serves as a communication tool for other healthcare professionals and provides a record of the patient's care.Quality Improvement.Nursing rounds are an important part of quality improvement in blood dialysis care. By regularly assessingpatients and monitoring their progress, nurses can identify areas for improvement and implement strategies to enhance the quality of care.Conclusion.Nursing rounds are an essential component of blood dialysis care. They provide an opportunity for nurses to assess patients, intervene as needed, and educate them about their condition and treatment. By working collaboratively with other healthcare professionals, nurses can ensure that patients receive the highest quality of care.中文回答：血液透析护理查房记录。