woocy的秘密基地

75歲女士有糖尿病及高血壓病史，因呼吸急促來急診，診斷肺炎併呼吸衰竭入住加護病房，尿量每小時20ml , TPR: 38, 115, 26   , BP: 90/55mmHg, CVP: 13 mmHg
 經醫師置放PICCO導管，經肺溫度稀釋法測得參數如下:

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對於所有準備跨出專科護理師的朋友們，對於繕寫入院病摘的病程紀錄時常很困擾，特別是書寫的順序與方法，尤其是要用英文繕打時不知從何下手，因此將下列原則把握，對於未來要走專師的人，會有幫助的。
HPI  (History of Present Illness)  書寫注意事項

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   有鑑於有些網友對於下載檔案有些困擾，所以特地將下載檔案步驟教學如下: (因為是免費的網路空間，請大家多包涵囉)~~~~  
    第一步驟:  將右邊英文字輸入下面小框框內 (HGNJ)，然後按確定~~~
         

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今年導論題目只能說是非常的生活化，題目出的範圍很廣，甚麼類型的題目都有，例如:病人安全相關問題，品質問題，法規問題，醫護倫理問題，當然也有疾病篩檢，身體評估基本題型。不過就以台灣醫策會方面的題目就出ㄉ不少囉~~除此之外基本的題型也不少，如果能小心仔細地作答，成績應該不會太差~~~第二十題的題目公告答案是 A，可是我查詢到的答案是C，這題應該有爭議ㄟ~~~~
1. 未取得專科護理師證書而於執業時使用專科護理師名稱，會受到何種懲處？
(A) 吊銷護理師執照 (B) 吊扣護理師執照半年 (C) 罰鍰並令限期改善 (D) 口頭警告並令限期改善

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 臨床上CKD是常見的疾病，腎臟疾病的嚴重度可由GFR及蛋白尿來做分級，但有關進展至腎衰竭風險的正確資訊是需要的，才能對於測試，治療及轉介做正確的臨床決定。JAMA 2011年發表了一篇發展及驗證一個可預測腎臟衰竭的模式，或許可以對於臨床上的治療可以及早處理。
研究設計/場所/研究對象: 為了發展及驗證一個可預測腎衰竭的模式，使用了來自兩群加拿大人的流行病學資料，臨床及實驗檢查值，兩組病患都是CKD第三至五級( (estimated GFR, 10-59 mL/min/1.73 m2)，被轉介至腎臟科醫師，時間介於2001-4-01至2008-12-31。預測模式使用Cox比例風險迴歸方式來發展及使用c統計量來評評值。第一群人用來發展預測模式，第二群人來驗證預測模式。
主要實驗終點: 需洗腎或應先腎臟移植

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當病人癲癇發作時，臨床上常常會開立 dilantin 使用，負荷劑量(loading dose):10~15 mg/kg(藥商建議)，但15~20mg/kg 一般也被建議使用， 最大輸住速度50mg/min。
維持劑量 (maintenance dose): 300 mg/day or 5-6 mg/kg/day in 3 divided doses or 1-2 divided doses using extended release (range: 200-1200 mg/day)。
治療範圍: Total phenytoin: 10-20 mcg/mL (children and adults), 8-15 mcg/mL (neonates)

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話說利尿劑用在心衰竭病患是滿常見的，常常都是從lasix bolus開始然後劑量在逐漸加大，如果尿還是出不來的話，再用連續滴注的方式給予，但是到底是間歇性給予還是連續輸注哪種方式較好呢??
Cochrane 資料庫在2009年發表了一篇綜合分析的文章--Continuous infusion versus bolus injection of loop diuretics in congestive heart failure--
Abstract
Background: Loop diuretics, when given as intermittent bolus injections in acutely decompensated heart failure, may cause fluctuations in intravascular volume, increased toxicity and development of tolerance. Continuous infusion has been proposed to avoid these complications and result in greater diuresis, hopefully leading to faster symptom resolution, decrease in morbidity and possibly, mortality.                                                        Objectives:To compare the effects and adverse effects of continuous intravenous infusion of loop diuretics with those of bolus intravenous administration among patients with congestive heart failure Class III-IV.
Search strategy: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2003), MEDLINE (1966 to 2003), EMBASE (1980 to 2003) and the HERDIN database. We also contacted pharmaceutical companies .
Selection criteria:Randomized controlled trials comparing the efficacy of continuous intravenous infusion versus bolus intravenous administration of loop diuretics in congestive heart failure were included Data collection and analysis:Two reviewers independently assessed study eligibility, methodological quality and did data extraction. Included studies were assessed for validity. Authors were contacted when feasible. Adverse effects information was collected from the trials.
Main results:Eight trials involving 254 patients were included. In seven studies which reported on urine output, the output (as measured in cc/24 hours) was noted to be greater in patients given continuous infusion with a weighted mean difference (WMD) of 271 cc/24 hour (95%CI 93.1 to 449; p<0.01). Electrolyte disturbances (hypokalemia, hypomagnesemia) were not significantly different in the two treatment groups with a relative risk (RR) of 1.47 (95%CI 0.52 to 4.15; p=0.5). Less adverse effects (tinnitus and hearing loss) were noted when continuous infusion was given, RR 0.06 (95%CI 0.01 to 0.44; p=0.005). Based on a single study, the duration of hospital stay was significantly shortened by 3.1days with continuous infusion WMD -3.1 (95%CI -4.06 to -2.20; p<0.0001) while cardiac mortality was significantly different in the two treatment groups, RR 0.47 (95% CI 0.33 to 0.69; p<0.0001). Based on two studies, all cause mortality was significantly different in the two treatment groups, RR 0.52 (95%CI 0.38 to 0.71; p<0.0001).(持續性輸注尿量較多，每日可較bolus組多271ml，電解質異常兩組無差異，較低的副作用-耳鳴/聽力喪失(危險比0.06); 根據一項單一研究，持續性輸注組可縮短住院天數3.1天，心臟死亡風險低(0.47);根據2篇研究結果，所有原因死亡風險低(0.52)。
Authors' conclusions: Currently available data are insufficient to confidently assess the merits of the two methods of giving intravenous diuretics. Based on small and relatively heterogenous studies, this review showed greater diuresis and a better safety profile when loop diuretics were given as continuous infusion. The existing data still does not allow definitive recommendations for clinical practice and larger studies should be done to more adequately settle this issue.(目前可獲得ㄉ資料仍不充分來評估兩種給藥途徑的價值，根據小規模及相對異質性的研究，結果顯示給予連續輸注利尿劑有較多的尿量及較好的安全性，目前的資料仍然無法明確推薦在臨床上，須大規模研究再釐清這些爭議)。    adapted from http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD003178/frame.html
 

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