目的 探索慢性肾脏病维持性血液透析患者的有效管理模式.方法 采取自身前后对照研究,筛选血磷≥1.78 mmol/L的规律透析患者入组,组建医护患质量改善团队,采取责任护士分组管理,运用五"E"模式通过鼓励、教育、运动、工作、评价5项措施干预18个月,并评价患者自我管理能力和血磷水平改善情况.结果 五"E"模式干预18个月后,患者自我管理各维度及总分较干预前明显提高,血磷平均值由(2.15±0.32)mmol/L下降至(1.78±0.42)mmol/L(t=6.249,P<0.01),血磷<1.78 mmol/L的比例提升60.32％;NT-proBNP平均值下降幅度43.24％.结论 运用五"E"模式对透析患者进行全程管理,形成以护士为主导的医护患多团队协作一体化闭环管理架构,可以提高患者自我管理能力,有利于患者的预后及提高生活质量.

目的:调查北京市血液透析中心自体动静脉内瘘(AVF)功能不良监测的实施情况.方法:通过自行设计的问卷,对北京市各级医疗机构的123家血液透析中心的基本情况和AVF功能不良监测的实施情况进行调查,并分析结果.结果:北京市123家血液透析中心对AVF功能不良监测的实施情况中,除了患者宣教的实施率为92.68％外,其余有关流程和制度、人员和监测方法及内容的各项条目实施率均低于70.00％.此外,三级医院与非三级医院的血液透析中心在有无由多学科团队组成的血管通路小组(χ2=10.593,P=0.001)、是否每次穿刺前进行物理检查(χ2=5.752,P=0.016)及是否对患者宣教(χ2=7.102,P=0.008)方面的差异有统计学意义.结论:北京市123家血液透析中心在AVF功能不良监测的流程和制度、人员、监测方法及内容层面仍有较大的改进空间,未来需要基于最佳证据建立起相关规范,并优化和均衡医疗资源,以提高对血管通路的整体管理水平.

目的 探索适合血液透析患者的系统饮食教育,改善透析患者的钙磷水平,提高患者的营养状况.方法 组建健康饮食教育团队,筛选40例高磷血症维持性血液透析患者,采取责任护士分组管理,通过集体教育、个体化教育的系统饮食教育,干预3个月后,采取自身前后对照研究的方法评估患者营养状况及钙磷代谢变化.结果 3个月后,患者血磷由(2.12±0.31) mmol/L下降到(1.68 ±0.49) mmol/L(P＜0.01),全段甲状旁腺激素由(824.52±588.07) ng/ml下降到(567.61±526.59) ng/ml(P＜0.05).结论 通过集体教育、个体化教育的系统饮食教育,可以提高患者健康饮食知识水平和依从性,改善饮食习惯,减少磷的摄入,血磷水平下降,改善患者的钙磷代谢.

Objective To investigate the effect of shortening the hemodialysis patients′waiting time for treatment on improving the medical condition. Methods A total of 294 hemodialysis patients in our dialysis center were randomly enrolled in the study from January to June, 2013. The patients, enrolled from January to March, received traditional method ( n=150 ) , and the patients, enrolled from April to June received quality control circle method (n=144), using of the method of slip the peak waiting time for treatment. The application of quality control circle was applied in patients′ waiting, pre-diagnosis, on-line and other medical aspect of continuous quality. The time and satisfaction were compared. Results Three months after the intervention, the waiting time of patients shortened 11 minutes compared with before. The satisfaction of patients improved from 80. 00% to 94. 40% in the pre-diagnosis in order, and the difference was statistically significant (χ2 =13. 792, P<0. 05). Conclusions The implementation of slip the peak waiting time for treatment shortened patients′waiting time and make the pre-diagnosis in order. It can not only reduces the incidence of cross infection, but enhance the concept of nursing care-fair and reasonable. Patients satisfaction on nursing work is also significantly improved, so it effectively avoid the accidental events.

目的 探讨使用血管通路记录表指导护士有计划变换穿刺点对透析患者动静脉内瘘维护的影响,为延长透析患者动静脉内瘘使用时间提供依据.方法 选取2009年1月至2011年12月162例患者为对照组,采用常规阶梯式法;2012年1月至2014年12月176例患者为观察组,采取阶梯法设计穿刺位点,为每位患者建立血管通路记录表,绘制内瘘血管穿刺示意图,护士穿刺前结合血管通路记录表评估血管情况,严格按位点顺序变换穿刺点.观察干预前后两组患者发生血栓、动脉瘤、狭窄等不良事件的发生情况.结果 观察组患者发生动脉瘤、内瘘血栓、狭窄等不良事件发生率为13.64％,较对照组低(P＜0.01).结论 使用血管通路记录表指导护士进行内瘘维护,能够明显减少血栓、动脉瘤、狭窄等不良事件的发生,促进内瘘血管均匀扩张,延长内瘘使用时间.

Objective The quality of maintenance hemodialysis was continuously improved based on the KDOQI guideline and analyze its effect on outcome. Methods Seventy-five patients with maintenance hemodialysis in total were enrolled in 2005. The average age was 63.43±13.16 yd and men accounted for 61.3%. 109 patients were with maintenance hemodialysis in 2008. The average age of this group was 62.75±13.44 yd,in which men accounted for 57.8%. The average URR in 2008 was much better than that of 2005(69.15±7.18)% and (65.23±6.46)% respectively,P 0.001. The hemoglobulin level of patients in 2008 was significantly higher than that of 2005(111.9±16.02)g/L vs. (98±17.39)g/L respectively,P 0.001. Although the serum phosphorus level,calcium multiply phosphorus and serum calcium was decrease slightly in 2008 when compared to those in 2005(serum phosphorus level were (1.56±0.49)mmol/L vs. (1.77±0.61)mmol/L,respectively,P = 0.013; serum calcium multiply phosphorus were (43.39±13.39) mg2/dl2 vs. (52.23±19.22) mg2/dl2 respectively,P = 0.001; serum calcium level were (2.34±0.2)mmol/L vs. (2.4±0.3)mmol/L respectively,P = 0.081,the difference was not statistically significant. The proportion of patients who met the iPTH Level criteria of KDOQI guideline was higher than that of 2005(31.3% vs. 22%,P = 0.028). The absolute level of iPTH was decreased slightly(393.61±443.91) pg/ml vs. (427.75±380.99)pg/ml,respectively P = 0.615. The CRP level,which was an indicator for inflammation,decreased in 2008 compared to that in 2005[(5.1±4.4mg/L vs. (9.6±14.7)mg/L,respectively,P = 0.014]. Serum albumin level was better in 2008 than that in 2008[(39.1±2.81)g/L vs. (37.86±4.31)g/L respectively,P = 0.034]. The duration of hemodialysis in 2008 was (51.19±50.22)month,much longer than that in 2005(32.11±32.37)month. Eleven patients died in 2004(14.7%) and 5 patients(4.6%) died in 2008. The difference was significant(P = 0.017). Conclusions According to KDOQI guideline,continuous quality improvememt can improve anemia,serum phosphorus level,secondary hyper-parathyroidism,nutrition,chronic inflammation status and hemodialysis patients' outcomes. The duration of hemodialysis is prolonged and the mortality is decreased.

Objective To evaluate the risk of falls in patients with hemodialysis,explore the preventive measures of falls and decrease the harmful outcomes due to falls.Method The Morse Falls Scale was used in 111 patients with hemodialysis to evaluate the risk degree of falls.Results Based on the risk factors of blood pressure medicine,muscle and skeleton pathological changes,advanced age,gait and balance problems,and poor vision,one patient(0.90%) was rated as zero risk level,93 patients (83.78%) were rated as low risk level and 17 patients (15.32%) were rated as high risk level.Conclusion The patients with hemodialysis were the high risk group of falls.It is necessary to take preventive measures to prevent the falls.

终末期肾病患者的心脑血管疾病发生率是肾功能正常人群的10～30倍,并居尿毒症、血液透析患者的死亡原因之首,约占总死亡率的50%[1].心肌肌钙蛋白T是近年发现的诊断急性心肌梗死的高度特异和敏感的血清生化标记物[2].

目的探讨中央静脉置管术并发症的预防及其护理.方法分析血肿、动静脉瘘、气胸、血胸、栓塞和感染等并发症的原因及其预防方法,提出护理要点.结果股静脉置管术成功率高(98.3%),中位颈内静脉置管术和锁骨下静脉置管术被认为是值得应用和推荐的方法.结论各种方法均有利弊,应根据术者技术和病人情况选择不同的置管术.