Nursing routine and hemodialysis related knowledge of hemodialysis patients.

1. Preparation of dialysis equipment: Dialyzer is a place for material exchange, and the most commonly used dialyzer is hollow fiber dialyzer. Hollow fiber is a synthetic semi-permeable membrane. Blood passes through the cavity and dialysate is outside. Hemodialysis machine can control the flow and temperature of dialysate, dehydration, blood flow and so on. , and has various monitoring systems for cardiopulmonary bypass. Nurses should be familiar with the operation of dialysis machine, and pay attention to the fact that dialysis can only be started after all indicators have reached stability after starting the machine. Dialysis equipment also includes dialysis water supply system, dialysis pipeline, puncture needle and preparation of dialysate. Dialysis fluid can be divided into acetate and bicarbonate. First, the dialysate with a concentration of 35 times is prepared, and then flows into the dialyzer after being diluted by the machine.

2. Preparation of dialysis drugs: including dialysis drugs (saline, heparin, 5% sodium bicarbonate), first aid drugs, hypertonic glucose injection, 10% calcium gluconate, dexamethasone and dialysate.

3. Patient preparation: mainly the preparation of vascular access. If arteriovenous fistula is used, you should be familiar with the puncture and protection methods of internal fistula; If arteriovenous fistula is used, you should be familiar with its use method, and pay attention to observe whether there is slippage, bleeding, embolism and infection, and keep the catheter clean and sterile. In addition, the nutritional problems of dialysis patients are also very important, and attention should be paid to supplementing protein (intake is 1.2 ~ 1.4g/(kg? 6? 1d), in addition, it is especially necessary to control the water intake, that is, the weight gain of patients during dialysis should not exceed 2.5kg.

4. Psychological nursing: Because uremia patients and their families are unfamiliar with hemodialysis treatment, they are prone to fear and psychological pressure, so they should be introduced and explained to make them understand the necessity, methods and precautions of hemodialysis, and try to eliminate the fear and tension of patients before dialysis.

Second, the nursing in the process of dialysis

1. Nursing of vascular access;

(1) Temporary vascular access: Temporary vascular access is a method used for emergency hemodialysis when the permanent vascular access is not established and immature. It includes internal jugular vein intubation, subclavian vein intubation, femoral vein intubation and direct arterial puncture.

1) Nursing care of intravenous intubation: keep the local area clean and dry, change the dressing every day to prevent infection; The fixation should be firm and the activity should be moderate to prevent falling off; Keep the pipeline unobstructed. After each HD, the pipeline was sealed with heparin saline (2mL containing heparin 500 ~ 1500IU) to prevent anticoagulation and pipeline blockage. Before each hemodialysis, heparin saline and possible blood clots are extracted with a syringe to ensure adequate blood flow.

2) Nursing care of arterial puncture: try to puncture successfully once and fix it firmly to prevent the needle from coming out. At the end of HD, the pressing time should be longer, about 20 ~ 30 min. But this method is gradually being eliminated.

(2) Permanent vascular access: The artery and vein adjacent to the patient's limb are anastomosed by surgery to become a blood flow channel, through which arterial blood flows to the vein. Nursing points are as follows:

1) Check whether it is unobstructed, and the vein side should feel tremor and hear murmur. It will take 4 ~ 6 weeks to use. Non-dialysis blood collection or injection, blood pressure measurement, hanging heavy objects, etc. It is forbidden to use it on the blood vessels on the side of internal fistula.

2) The puncture point should be more than 5cm away from the anastomosis. The needle gauge is more than 8 ~ 10 cm, so as to hit the nail on the head. If conditions permit, the blood vessels will be stressed evenly by rope ladder puncture, and no false aneurysm will occur.

3) When pulling out the puncture needle after 3)HD, the hemostasis method should be correct and effective, so as not to form hematoma and block the fistula.

4) Pay attention to keep the local area clean and dry to prevent infection. Apply hirudoid every day to diminish inflammation and soften blood vessels.

At the same time, the puncture of blood vessels should be strictly aseptic, and the movements should be skilled and light to minimize the pain of patients.

2. Monitoring of machines in hemodialysis

Hemodialysis machine can be divided into dialysate supply system, blood circulation control system and ultrafiltration control system according to its functions.

(1) dialysate supply system and ultrafiltration control system: the main monitoring contents are as follows:

1) The conductivity of dialysate is 13.5 ~ 14.5 ms/cm.

2) The temperature of dialysate is 36 ~ 37℃.

3) Blood leak detector function, once dialysis breaks the membrane and blood seeps into the dialysate side, the machine will automatically give an alarm.

4) dialysate flow, the setting range is 500+50ml/min.

5) The negative pressure of dialysate is set automatically by manual or machine according to dialysis time, dehydration amount and dialyzer used.

(2) Monitoring of blood circulation system: The monitoring contents include arterial pressure, venous pressure and air alarm.

1) Increased arterial pressure: venous puncture point blocked, venous tube blocked, and blood coagulation in dialyzer.

2) Decreased arterial pressure: hypotension, incomplete blockage of fistula or poor indwelling catheter, distorted arterial blood circuit, too fast blood pump or insufficient blood flow, needle slippage, etc.

3) Increased venous pressure: the puncture of venous needle outside the vein causes swelling, poor venous pipeline, venous spasm, venous needle close to the tube wall, vein stenosis near the heart, blood clot in the degassing cavity at the venous end, the lateral pressure of dialysate drops, and the posture changes.

4) Decreased venous pressure: low blood pressure, improper position of arterial needle, twisted arterial duct, slippage of puncture needle, insufficient blood flow, membrane rupture of dialyzer, etc.

5) Air alarm: poor blood flow, loose connection, air leakage in blood pipeline, accidental air entry during infusion, etc.

3. Observation during dialysis: changes of blood pressure, pulse, respiration and body temperature; Observe blood flow, blood pressure, dialysate flow, temperature and concentration; Accurately record the dialysis time, dehydration amount and heparin dosage, and pay attention to the alarm and troubleshooting of the machine.

4. Observation and prevention of acute complications:

（ 1）

1) Cause: ○ 1 Decreased effective blood volume; ○2 Decreased vasoconstriction; ○3 Decreased cardiac output; ○4 The dialysis membrane has poor biocompatibility.

2) Clinical manifestations: A small number of patients have asymptomatic hypotension, and most patients may show pallor, chest tightness, cold sweat, nausea and vomiting, and even transient loss of consciousness. Patients with coronary heart disease may induce arrhythmia and angina pectoris.

3) Treatment: Lie flat, head down, feet raised quickly, slow down blood flow and slow down or suspend ultrafiltration. Inhale oxygen, and supplement physiological saline100-200ml if necessary. For those with severe symptoms, increase fluid replacement until blood pressure rises and symptoms are relieved. Hypertonic saline, hypertonic glucose, albumin, etc. Can also be given, and should be combined with the cause of symptomatic treatment.

(2) Imbalance syndrome: refers to the syndrome with nervous and mental system as the main symptoms that appears 65±0h hours or several hours after the start of dialysis, and often disappears after several hours to 24 hours.

1) Cause: After HD, the toxin in blood drops rapidly, and the osmotic pressure of plasma drops, while the blood-brain barrier makes solutes such as urea in cerebrospinal fluid slowly drop, making the osmotic pressure of cerebrospinal fluid greater than that of blood, and water enters cerebrospinal fluid from blood to form brain edema. It is also related to the increase of PH gradient between cerebrospinal fluid and blood after dialysis, that is, the PH value in cerebrospinal fluid is relatively low.

2) Clinical manifestations: mild headache, nausea, vomiting, lethargy, restlessness, muscle spasm, blurred vision and elevated blood pressure. In severe cases, it is characterized by seizures, convulsions, numbness and even coma.

3) Treatment: Mild patients do not need treatment, and severe patients can be given 40ml of 50% glucose or 3% sodium chloride or albumin, and sedatives and other symptomatic treatments if necessary.

(3) Muscle spasm: The main parts are gastrocnemius, feet or upper limbs and abdominal muscles.

1) reasons: low blood pressure, too much ultrafiltration and too fast, so that the weight after dialysis is lower than the dry weight; Low sodium dialysate.

2) Treatment and prevention: mild cases can be relieved by suspending ultrafiltration, and severe cases need to be infused with hypertonic glucose solution or hypertonic saline. Ultrafiltration settings should be appropriate and correct, and the sodium concentration of dialysate should be adjusted to145mol/l or higher.

(4) Arrhythmia: Ventricular premature beats are more common.

1) reason: The main reason is the change of serum potassium and calcium concentration, followed by the decrease of blood pressure during dialysis, the decrease of coronary circulation blood volume and myocardial ischemia and hypoxia.

2) Treatment and prevention: monitor the changes of serum potassium and calcium concentrations before and after HD, correct electrolyte disorder in time, and stop HD if severe arrhythmia occurs.

⑤ Heart failure:

1) reason: people with hypertension, water and sodium retention or cardiac insufficiency are prone to heart failure during HD. Therefore, simple ultrafiltration should be performed before HD, and the osmotic pressure of dialysate should be close to that of plasma.

2) Causal treatment.

[6] air embolism:

1) Cause: During HD, transfusion before blood pump, blood pipeline rupture, loose connection of each pipeline, dialysis membrane rupture, air in dialysate inadvertently diffused into blood, blood inadvertently reinfusion, air trap damage or air leakage caused air to escape into vein and cause embolism.

2) Clinical manifestations: a small amount of air is a tiny foam, which slowly enters the blood without any symptoms; If the bubble is large and the air leakage rate is fast, when it enters more than 5ml at a time, obvious air embolism symptoms may occur, such as dyspnea, cough, cyanosis, chest tightness, irritability, spasm, loss of consciousness and even death.

3) Treatment: immediately stop the pump and clamp the venous line, and put the patient in the left lateral position with his head low and his feet high to prevent cerebral embolism and take oxygen; In severe cases, percutaneous puncture can be used to extract ventricular air, and hyperbaric oxygen chamber treatment is feasible when conditions permit.

4) Others: allergic reaction, blood loss, hemolysis, fever, etc.

Third, nursing after dialysis

1. At the end of dialysis, blood should be slowly reinfusion. After measuring blood pressure, if the blood pressure is normal, ask the patient to lie down for a few minutes and get up slowly after sitting for a few minutes to prevent postural hypotension.

2. Pay attention to the bleeding situation: after the arteriovenous puncture needle is pulled out, immediately apply moderate pressure to stop bleeding 10 ~ 15 min, and the compression point should be the blood vessel puncture point. If the artery is punctured, the compression time exceeds 30 minutes. If there is bleeding tendency, protamine can be used for neutralization, and the ratio of heparin to protamine is 1 mg: 1 mg.

3. Pay attention to the nursing of puncture and internal fistula after dialysis to prevent blockage and infection.

4. Weigh yourself and make an appointment with the patient for the next dialysis.