血液透析个案护理
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A case of care for dialysis patients
人工透析患者的个案护理
LOGO
Hubei Medical University XX学校
XXX
XXX
Firstly：Patient data(患者资料）
XXX , XX years old , XXX admission, XXX dialysis, dialysis frequency: X times / week.
XXX，XX岁，XXX入院，XXX开始透析，透析频率：X次/周。
Ch来自百度文库ef Complaint: repeated fatigue, chest tightness, more than X months . Oliguria for X month , diarrhea X days.
主诉：反复乏力、胸闷X月有余，尿少X月，腹泻X天。
hheiasrttordyi.seLasOe, GnoOhistory of allergies, poisoning
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。
Laboratory tests（实验室检查）：
Secondly. Care issues and measures (护理问 题及措施)
1. Fluid overload Damage and acute renal failure due to glomerular filtration rate. 体液过多 与急性肾衰竭时所致的肾小球率过功能受 损有关。
B-Tip: kidneys shrink, sonographic abnormalities (in accordance with the ultrasound images of kidney disease),
LOGO prostatic calcification, abdominal effusion, I dialysis
shortness LofObGreOath. 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. 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。
LOGO
2.The risk of infection Restricted protein diet, dialysis, and the body lowered immunity.
有感染的危险 与限制蛋白质饮食、透析、机体 的抵抗力降低等有关。
3. Impaired skin integrity puncture site
Past medical history(既往史)：
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
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
diuretic, antihypertensive therapy. Ray: increased heart shadow.
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/L Urine: albumin 2.0g / L, WBC 16.2 / L
人工透析患者的个案护理
LOGO
Hubei Medical University XX学校
XXX
XXX
Firstly：Patient data(患者资料）
XXX , XX years old , XXX admission, XXX dialysis, dialysis frequency: X times / week.
XXX，XX岁，XXX入院，XXX开始透析，透析频率：X次/周。
Ch来自百度文库ef Complaint: repeated fatigue, chest tightness, more than X months . Oliguria for X month , diarrhea X days.
主诉：反复乏力、胸闷X月有余，尿少X月，腹泻X天。
hheiasrttordyi.seLasOe, GnoOhistory of allergies, poisoning
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。
Laboratory tests（实验室检查）：
Secondly. Care issues and measures (护理问 题及措施)
1. Fluid overload Damage and acute renal failure due to glomerular filtration rate. 体液过多 与急性肾衰竭时所致的肾小球率过功能受 损有关。
B-Tip: kidneys shrink, sonographic abnormalities (in accordance with the ultrasound images of kidney disease),
LOGO prostatic calcification, abdominal effusion, I dialysis
shortness LofObGreOath. 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. 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。
LOGO
2.The risk of infection Restricted protein diet, dialysis, and the body lowered immunity.
有感染的危险 与限制蛋白质饮食、透析、机体 的抵抗力降低等有关。
3. Impaired skin integrity puncture site
Past medical history(既往史)：
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
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
diuretic, antihypertensive therapy. Ray: increased heart shadow.
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/L Urine: albumin 2.0g / L, WBC 16.2 / L