血液透析病人瘻管穿剌部位出血改善專案

Protocol to Alleviate Bleeding at Fistula Puncture Sites in Hemodialysis Patients

王麗珠(Li-Chu Wang) ； 蔡靜芬(Ching-Fen Tsai) ； 陳宥蓁(Yu-Chen Chen)

《澄清醫護管理雜誌》 14卷3期 (2018/07) Pp. 69-78

摘要

目的：血管通路是透析生命線，瘻管出血造成血液流失，影響透析品質。統計本單位2016年1月11日至1月16日瘻管穿刺部位出血達23.7％，因此引發專案小組改善動機。由現況分析發現導致透析瘻管穿刺部位出血原因為：穿刺前人員未確實評估穿刺部位，穿刺針、迴路管無統一固定方式，在穿刺針拔除後，加壓止血方式及加壓面積不一致，病人對於止血認知不足及徒手加壓力道不足所致，故本專案探討透析瘻管出血原因，早期介入處理，減少透析發生非預期血液流失及傷害，提升管路照護安全性。方法：藉由現況分析及文獻查證設計製作『洗腎中心瘻管穿刺部位出血查檢表』，實際查核動靜脈瘻管穿刺部位出血情形。以『護理人員穿刺前瘻管評估查核表』及『洗腎中心透析病人止血認知測驗卷』探討要因並介入製作血管評估口訣及瘻管穿刺記錄表、建立管路固定標準、修訂透析後止血加壓規範、舉辦管路固定及止血加壓體驗營、製作客制化萬用止血帶、止血照護衛教單及海報、舉辦血管照護講座及止血體驗營等改善措施。結果：瘻管穿刺部位出血由23.7％下降至4.1％，穿刺前評估由35.3％提升至88.2％，病人止血認知由62分提升至92分，達成專案目的。結論：希望藉由專案分享能降低臨床血液透析病人瘻管穿刺部位出血率，減少透析發生非預期血液流失及傷害，提升管路照護安全性。

關鍵字

血液透析 ； 瘻管穿剌 ； 出血

並列摘要

Purposes: Vascular access is the lifeline of dialysis. However, fistula bleeding causes blood loss and affects dialysis quality. Statistics from our department for January 11 to January 16, 2016 showed that 23.7% of patients experienced bleeding at the fistula puncture site. Therefore, an ad-hoc group was formed to improve the process. An analysis found that the causes of bleeding at the fistula puncture site included: staff failure to evaluate the site before puncture, lack of standardized puncture needles and tubing, inconsistent compression method for hemostasis after the puncture needle was removed, lack of patient knowledge about hemostasis, and insufficient compression. Therefore, this project aimed to examine the causes of fistula bleeding, to ensure early intervention and treatment and reduce unexpected blood loss and injury during dialysis, and to improve tubing care and safety. Methods: Based on an analysis of the current situation and literature review, we designed a ＂Checklist for bleeding at fistula puncture sites in dialysis centers＂ to assess the bleeding status at the arteriovenous fistula puncture site. The ＂Pre-puncture fistula evaluation checklist for nurses＂ and ＂Hemostasis knowledge survey for dialysis patients at the dialysis center＂ were used to examine relevant factors and to create a mnemonic for vascular evaluation and a fistula puncture record, establish fixed standards for tubing, revise postdialysis hemostatic compression standards, organize seminars to discuss tubing fixation and hemostatic compression, create customized universal tourniquets, print health education brochures and posters for hemostatic care, and organize vascular care seminars and hemostasis experience camps. Results: Bleeding at fistula puncture sites decreased from 23.7% to 4.1%, pre-puncture evaluation increased from 35.3% to 88.2%, and patient hemostatic knowledge increased from 62 to 92 points, thereby achieving the goals of this project. Conclusions: We hope that sharing this experience can decrease the incidence of bleeding at fistula puncture sites in hemodialysis patients, reduce unexpected blood loss and injury during dialysis, and improve tubing care and safety.

並列關鍵字

Hemodialysis ； Fistula puncture ； Bleeding