主動(dòng)脈瓣置換術(shù)后的護(hù)理課件

主動(dòng)脈瓣置換術(shù)圍手術(shù)期的護(hù)理Thenursingofaorticvalvereplacement1正常的主動(dòng)脈瓣有三個(gè)瓣葉:左半月瓣、右半月瓣和后半月瓣2心室舒張期

Ventriculardiastole心室收縮期Ventricularsystole34主動(dòng)脈瓣狹窄的病因

Causesofaorticstenosis先天性畸形Congenitalmalformations老年性主動(dòng)脈瓣鈣化Senileaorticvalvecalcification風(fēng)濕性心臟病Rheumaticheartdisease主動(dòng)脈瓣葉粘連、融合Aorticvalveleafletsadhesion,fusion5主動(dòng)脈瓣狹窄aorticstenosis主動(dòng)脈瓣開口面積減少肺靜脈高壓右心衰竭左心室射血負(fù)荷左室向心性肥厚左心室收縮功能心排血量下降室壁張力順應(yīng)性下降室壁張力

左心衰病理生理pathophysiologyPulmonaryvenoushypetension6

心內(nèi)膜下心肌缺血和灌注不足aorticstenosis腦血流灌注下降左心室做功心肌耗氧量順應(yīng)性下降舒張末壓力CO冠狀動(dòng)脈平均灌注壓心絞痛暈厥AnginapectorisSyncope78急性Acute:1.感染性心內(nèi)膜炎Infectiveendocarditis2.主A夾層

Aorticdissection3.外傷Trauma4.人工瓣膜撕裂Prostheticvalvetear慢性Chronic:主動(dòng)脈瓣疾病Aorticvalvedisease2/3為風(fēng)心病主動(dòng)脈根部擴(kuò)張Aorticrootdilatation主動(dòng)脈瓣關(guān)閉不全的病因

Causesofaorticincompetence主動(dòng)脈瓣纖維化、增厚、縮短、變形9主動(dòng)脈瓣關(guān)閉不全Aorticvalvesincompetence主動(dòng)脈內(nèi)血液在舒張期返流入左室偏心性肥厚、擴(kuò)大左心衰左心室容量負(fù)荷Sp

、Dp

左心室舒張末期壓力CO室壁張力心絞痛pulmonaryhypertension右心衰pathophysiology10反流面積的大小

心動(dòng)周期舒張期的長短

AI反流量體循環(huán)血管阻力AIreverseflowReverseflowaeraofthesizeBeckoningcyclediastoliclengthSystemicvascularresistance11雙擊添加標(biāo)題文字急性主動(dòng)脈瓣關(guān)閉不全左心室舒張期充盈量突然增加壓力迅速增高左房壓、肺靜脈壓迅速升高急性肺水腫心動(dòng)過速以減少反流量增加CO二尖瓣舒張期提前關(guān)閉，緩解左房和肺靜脈受左心室高舒張壓的影響CO減少,低BP急性左心衰竭

急性AI

12Whatisvalvereplacemengsurgery瓣膜置換術(shù)是用人工機(jī)械瓣或生物瓣進(jìn)行替換人心臟瓣膜進(jìn)行置換Valvereplacementsurgeryistousemechanicalvalvesorbiologicalvalvestoreplaceoriginalhumanvalves.13主動(dòng)脈瓣置換術(shù)14

病例介紹CaseIntroduction15病史medicalhistory羅菊梅,女,40歲,云南鎮(zhèn)雄人PatientJumeiLuo,female,40yearsold,fromZhenxionginYunnanprovince.患者因頭昏、胸痛3年,近一年來加重,活動(dòng)后心悸、氣促、乏力伴呼吸困難,休息后無明顯緩解一月余,于2011年2月10日以“非風(fēng)濕性主動(dòng)脈瓣狹窄并關(guān)閉不全”收住ShewasadmittedtothehospitalforNon-rheumaticaorticstenosisandincompetenceonDecember10th,2014.becausedizziness,chestpainhavelastthreeyears,heartpalpitationandshortnessofbreathwithincreasedactivities,andexertionaldyspnealastingoveramonth.16MedicalHistory

手術(shù)史Surgicaloperationhistory2004年行“卵巢囊腫摘除術(shù)”"ovariancyst"in2004,2011年行“右上臂神經(jīng)源性腫瘤切除術(shù)”“neurogenictumorresectionofrightarm”in2011

過敏史Allergichistory雙黃連17Echocardiography:1、Aorticvalvedisease:moderateaorticincompetence,moderateaorticstenosis,andthewideningofaorticdiameter2、Mildmitralincompetence,andmildtricuspidincompetence3.Thedecreasingofleftventriculardiastolicfunction,LVD：70mm,EF:55%18心臟彩超：1、主動(dòng)脈瓣病變：主動(dòng)脈瓣中度關(guān)閉不全并中度狹窄，升主動(dòng)脈內(nèi)徑增寬。2、二尖瓣輕度關(guān)閉不全三尖瓣輕度關(guān)閉不全3.左心舒張功能降低LV：70mm,EF:55%19DX檢查:主動(dòng)脈迂曲增寬Aortabecomeswidenedandtortuous左室增大leftventriclebecomesbigger20診治經(jīng)過2月16日前完善術(shù)前準(zhǔn)備2月17日-19日在ICU治療2月20日患者病情平穩(wěn)搬回病房。Preoperative

preparationwascompletedbeforeDecember16th.ThepatientwasstabllymovedbacktothewardonDecember20th21病情2月17日在全麻CPB下行主動(dòng)脈瓣置換術(shù)，術(shù)畢于12:50分帶氣管插管返ICU，呼吸機(jī)輔助呼吸，清醒后，查血?dú)馐菊＃?2:30分拔出氣管插管改面罩供氧。血氧飽和度99--100％，患者咳嗽咳痰力量稍差Ondecember17th,theaorticvalvereplacementwascompletedundergeneralanesthesiaCPB,andthepatientreturnedtheicuat12:50withventilatorbreathing.Afterwaking,herbloodcheckshowednormal,sopulledoutendotrachealintubationanditwasreplacebyoxygenmasks.Theoxygensaturationwasrespectively99%--100％.Patientswithcoughandexpectorationsomewhatlesspower.22病情HR95-110次/分,為竇性心律。BP由多巴胺4.9ug/kg/min,維持在88-122/65-84mmhg,CVP14-7,容量欠,引流液不多,總量為500ml,尿色、尿量正常,精神飲食稍差,鼓勵(lì)進(jìn)食。Theheartrateofthepatientand95-110times/min.BPbydopamine4.9ug/kg/min,maintainedat88-122/65-84mmhg.Centralvenouspressurewas9-10.Drainageoffluidwasnormal,Thetotalamountoffluiddrainageis500ml.Urinewasnormal,patient'sspiritanddietwasslightlypoor.Shewasencouragedtoeat.23護(hù)理問題NursingProblem

低效性呼吸型態(tài)（Ineffectivebreathingpattern）與手術(shù)及術(shù)后傷口疼痛致咳痰無力有關(guān)operation

andpostoperative

woundpaininduced

sputumweakness

心輸出量減少(decreasedcardiacoutput):與心臟疾病、體液不足有關(guān)Associatedwithheartdisease,insufficientbodyfluid

潛在并發(fā)癥（potentialcomplication）抗凝不足或抗凝過度Inadequateorexcessiveanticoagulation、24護(hù)理措施

nursingintervention（一）低效性呼吸型態(tài)1.加強(qiáng)呼吸道護(hù)理，聽診雙肺呼吸音，定時(shí)拍背、霧化，鼓勵(lì)患者咳嗽、咳痰。Strengthenrespiratorycare,auscultationoflungbreathsound,timedbackpatting,andatomization,andencourgepatientstocoughandexpectorate.252.持續(xù)心電監(jiān)護(hù)，嚴(yán)密觀察心率、血壓、呼吸、血氧飽和度ContinuousECGmonitoring,andcloseobservationofheartrate,bloodpressure,respiration,andoxygensaturation.（一）低效性呼吸型態(tài)263、定時(shí)監(jiān)測血?dú)夥治鼋Y(jié)果，根據(jù)病人的生命體征和血?dú)馇闆r，調(diào)整供氧方式及流量。Regularlymonitortheresultofbloodgasanalysisandadjustthewayandtheflowrateofoxygenofferbasedonthepatient‘svitalsignsandbloodgas.4.遵醫(yī)囑適當(dāng)予以止痛劑，以減少病人呼吸肌做功Provideanalgesicsappropriatelyaccordingtoprescriptiontoreducetheactingofpatients'breathingmuscles.（一）低效性呼吸型態(tài)27(二)心輸出量減少(decreasedcardiacoutput)（1）嚴(yán)密監(jiān)測心律、HR、BP、CVP及末梢情況,發(fā)現(xiàn)異常要及時(shí)報(bào)告醫(yī)生Keepclosemonitoringinthechangeofrhythm,HR,BP,CVPandPeripheralsituation,andreporttothedoctorpromptlywhenabnormalsituationisfound.nursingintervention28(二)心輸出量減少(decreasedcardiacoutput)（2）運(yùn)用血管活性藥物,根據(jù)患者的生命體征進(jìn)行調(diào)整Usevasoactivedrugs,andadjustaccordingtothepatient'svitalsigns29(二)心輸出量減少(decreasedcardiacoutput)（3）引流管的監(jiān)測Thedrainagetubemonitoring:定時(shí)擠壓引流管保持引流管的通暢Squeezedrainagetuberegularlytokeepits'patency.觀察引流液量及性質(zhì)，Observethedrainageamountandnature.觀察傷口有無滲血Observewhetherthereisbleedingornotinwound.30(二)心輸出量減少(decreasedcardiacoutput)(4)準(zhǔn)確記錄出入量,注意水電解質(zhì)平衡Recordintakeandoutputaccurately,andpayattentiontothebalanceofwaterelectrolyte.（5）鼓勵(lì)患者進(jìn)食Encouragepatientstoeat31nursingintervention（三）潛在并發(fā)癥的預(yù)防和護(hù)理

1.抗凝不足與抗凝過度Inadequateanticoagulationandexcessiveanticoagulation

(1)、為避免血栓形成，機(jī)械瓣置換術(shù)后，需終身抗凝治療，生物瓣術(shù)后抗凝3-6個(gè)月。要定時(shí)定量口服Explaintopatientstheimportanceoftakingwarfarinorally,TakeanticoagulantmedicineregularlyandquantitativelyThedoseis2.5-5milligram（2）、服藥期間監(jiān)測INR，使之維持在2.0～3.0.MonitorINRduringthemedicationtomaintainitat2.0to3.032（3）加強(qiáng)患者的監(jiān)測,如有無皮膚青紫瘀斑、牙齦出血等Strengthenthemonitoringofpatients,suchastheskinbruising,andbleedinggums,etc.（4)、注意飲食對抗凝藥物的影響Payattentiontotheinfuenceofdietonanticoagulants.33

HealthEducationPreventionofinfectionDietPeriodicreviewMedicationguideActivityandrestSelf-test34用藥指導(dǎo)

Medicationguide華法林只在體內(nèi)抗凝,通過拮抗維生素K而產(chǎn)生藥理作用。常用INR(國際標(biāo)準(zhǔn)化比值)評價(jià)Warfarinanticoagulationonlyinthebody,vitaminKantagonismgeneratedbypharmacologicaleffects.CommonINR(internationalnormalizedratio)evaluation記住服藥時(shí)間要固定哦！35DietItisbestforyoutohavemorenourishingfoodandeasily-digestedfood,includinghigh-protein,high-vitamins,andsoon.Atthesametime,youshouldhavemoremealswithlessfoodforeachmeal,developgoodlivinghabits.Avoidcigarettes,alcohol,coffeeandspicyfood.Patientswithpoorcardiacfunctionshouldlimitsodiumintake.Patientsshouldobservethechangesinbodyweight.保持飲食結(jié)構(gòu)的相對平衡

應(yīng)進(jìn)食富含營養(yǎng),易于消化的食物,報(bào)告高蛋白、高維生素等,同時(shí),應(yīng)少食多餐,養(yǎng)成良好飲食習(xí)慣。

禁忌煙酒、咖啡及刺激性食物。心功能