主动脉瓣置换术后的护理（888）.ppt

主动脉瓣置换术后的护理,The nursing of aortic valve replacement,1,医学培训,正常的主动脉瓣有三个瓣叶：左半月瓣、右半月瓣和后半月瓣,2,医学培训,心室舒张期 Ventricular diastole,心室收缩期 Ventricular systole,3,医学培训,4,医学培训,主动脉瓣狭窄的病因 Causes of aortic stenosis,先天性畸形 Congenital malformations 老年性主动脉瓣钙化 Senile aortic valve calcification 风湿性心脏病 Rheumatic heart disease 主动脉瓣叶粘连、融合 Aortic valve leaflets adhesion, fusion,5,医学培训,主动脉瓣狭窄,aortic stenosis,主动脉瓣 开口面积减少,肺静脉高压 右心衰竭,左心室射血负荷,左室向心性肥厚,左心室收缩功能,心排血量下降,室壁张力,顺应性下降,室壁张力,左心衰,病理生理pathophysiology,Pulmonary venous hypetension,6,医学培训,心内膜下心肌缺血和灌注不足,aortic stenosis,脑血流灌注下降,左心室做功,心肌耗氧量,顺应性下降,舒张末压力,CO,冠状动脉平均灌注压,心绞痛,晕厥,Angina pectoris,Syncope,7,医学培训,8,医学培训,急性Acute :,1.感染性心内膜炎 Infective endocarditis 2.主A夹层 Aortic dissection 3.外伤 Trauma 4.人工瓣膜撕裂 Prosthetic valve tear,慢性Chronic:,主动脉瓣疾病 Aortic valve disease,2/3为风心病,主动脉根部扩张 Aortic root dilatation,主动脉瓣关闭不全的病因 Causes of aortic incompetence,主动脉瓣纤维化、增厚、缩短、变形,9,医学培训,主动脉瓣关闭不全,Aortic valves incompetence,主动脉内血液在舒张期返流入左室,偏心性肥厚、扩大,左心衰,左心室容量负荷,Sp、Dp,左心室舒张末期压力,CO,室壁张力,心绞痛,pulmonary hypertension,右心衰,pathophysiology,10,医学培训,反流面积的大小,心动周期舒张期的长短,体循环血管阻力,AI reverse flow,Reverse flow aera of the size,Beckoning cycle diastolic length,Systemic vascular resistance,11,医学培训,双击添加标题文字,急性主动脉瓣关闭不全,CO减少，低BP,急性左心衰竭,急性AI,12,医学培训,What is valve replacemeng surgery,瓣膜置换术是用人工机械瓣或生物瓣进行替换人心脏瓣膜进行置换,Valve replacement surgery is to use mechanical valves or biological valves to replace original human valves.,13,医学培训,主动脉瓣置换术,14,医学培训,病例介绍 Case Introduction,15,医学培训,病史medical history,罗菊梅，女，40岁,云南镇雄人 Patient Jumei Luo,female,40 years old, from Zhenxiong in Yunnan province. 患者因头昏、胸痛3年，近一年来加重，活动后心悸、气促、乏力伴呼吸困难，休息后无明显缓解一月余，于2014年12月10日以“非风湿性主动脉瓣狭窄并关闭不全”收住 She was admitted to the hospital for Non-rheumatic aortic stenosis and incompetence on December 10th,2014.because dizziness, chest pain have last three years, heart palpitation and shortness of breath with increased activities , and exertional dyspnea lasting over a month.,16,医学培训,Medical History,手术史Surgical operation history 2004年行“ 卵巢囊肿摘除术” “ovarian cyst“ in 2004, 2011年行“右上臂神经源性肿瘤切除术” “neurogenic tumor resection of right arm” in 2011 过敏史Allergic history 双黄连,17,医学培训,Echocardiography: 1、Aortic valve disease: moderate aortic incompetence, moderate aortic stenosis, and the widening of aortic diameter 2、Mild mitral incompetence, and mild tricuspid incompetence 3、The decreasing of left ventricular diastolic function , LVD：70mm,EF:55%,18,医学培训,心脏彩超： 1、主动脉瓣病变： 主动脉瓣中度关闭不全并中度狭窄， 升主动脉内径增宽。 2、二尖瓣轻度关闭不全 三尖瓣轻度关闭不全 3、左心舒张功能降低 LV：70mm,EF:55%,19,医学培训,DX检查： 主动脉迂曲增宽 Aorta becomes widened and tortuous 左室增大 left ventricle becomes bigger,20,医学培训,诊治经过,12月16日前完善术 前准备,12月17日-19日在ICU治疗,12月20日患 者病情平稳 搬回病房。,Preoperative preparation was completed before December 16th.,The patient was stablly moved back to the ward on December 20th,21,医学培训,病 情,12月17日在全麻CPB下行主动脉瓣置换术，术毕于12：50分带气管插管返ICU，呼吸机辅助呼吸，清醒后，查血气示正常，于22：30分拔出气管插管改面罩供氧。血氧饱和度99-100，患者咳嗽咳痰力量稍差 On december 17th, the aortic valve replacement was completed under general anesthesia CPB ,and the patient returned the icu at 12:50 with ventilator breathing. After waking, her blood check showed normal, so pulled out endotracheal intubation and it was replace by oxygen masks. The oxygen saturation was respectively 99%-100. Patients with cough and expectoration somewhat less power.,22,医学培训,病 情,HR95-110次/分，为窦性心律。BP由多巴胺4.9ug/kg/min, 维持在88-122/65-84mmhg,CVP14-7,容量欠，引流液不多, 总量为500ml,尿色、尿量正常,精神饮食稍差，鼓励进食。,The heart rate of the patient and 95-110times/min. BP by dopamine 4.9ug/kg/min, maintained at 88-122/65-84mmhg. Central venous pressure was 9-10. Drainage of fluid was normal, The total amount of fluid drainage is 500ml. Urine was normal, patients spirit and diet was slightly poor. She was encouraged to eat .,23,医学培训,护理问题 Nursing Problem,低效性呼吸型态（Ineffective breathing pattern） 与手术及术后伤口疼痛致咳痰无力有关 operation and postoperative wound pain induced sputum weakness 心输出量减少(decreased cardiac output)： 与心脏疾病、体液不足有关 Associated with heart disease, insufficient body fluid 潜在并发症（ potential complication ） 抗凝不足或抗凝过度 Inadequate or excessive anticoagulation、,24,医学培训,护理措施 nursing intervention,（一）低效性呼吸型态 1、加强呼吸道护理，听诊双肺呼吸音，定时拍背、雾化， 鼓励患者咳嗽、咳痰。 Strengthen respiratory care, auscultation of lung breath sound, timed back patting ,and atomization ,and encourge patients to cough and expectorate.,25,医学培训,2、持续心电监护，严密观察心率、血压、呼吸、血氧饱和度 Continuous ECG monitoring, and close observation of heart rate, blood pressure, respiration, and oxygen saturation.,（一）低效性呼吸型态,26,医学培训,3、定时监测血气分析结果，根据病人的生命体征和血气情况，调整供氧方式及流量。 Regularly monitor the result of blood gas analysis and adjust the way and the flow rate of oxygen offer based on the patients vital signs and blood gas. 4、遵医嘱适当予以止痛剂，以减少病人呼吸肌做功 Provide analgesics appropriately according to prescription to reduce the acting of patients breathing muscles.,（一）低效性呼吸型态,27,医学培训,(二)心输出量减少(decreased cardiac output) （1）严密监测心律、HR、BP、CVP及末梢情况，发现异常要及时报告医生 Keep close monitoring in the change of rhythm, HR, BP, CVP and Peripheral situation, and report to the doctor promptly when abnormal situation is found.,nursing intervention,28,医学培训,(二)心输出量减少(decreased cardiac output) （2）运用血管活性药物，根据患者的生命体征进行调整 Use vasoactive drugs, and adjust according to the patients vital signs,29,医学培训,(二)心输出量减少(decreased cardiac output) （3）引流管的监测 The drainage tube monitoring： 定时挤压引流管保持引流管的通畅 Squeeze drainage tube regularly to keep its patency. 观察引流液量及性质， Observe the drainage amount and nature. 观察伤口有无渗血 Observe whether there is bleeding or not in wound.,30,医学培训,(二)心输出量减少(decreased cardiac output) (4)准确记录出入量，注意水电解质平衡 Record intake and output accurately, and pay attention to the balance of water electrolyte. （5）鼓励患者进食 Encourage patients to eat,31,医学培训,nursing intervention,（三）潜在并发症的预防和护理 1、抗凝不足与抗凝过度 Inadequate anticoagulation and excessive anticoagulation (1)、为避免血栓形成，机械瓣置换术后，需终身抗凝治疗，生物瓣术后抗凝3-6个月。要定时定量口服 Explain to patients the importance of taking warfarin orally, Take anticoagulant medicine regularly and quantitatively The dose is 2.5-5 milligram （2）、服药期间监测INR，使之维持在2.03.0. Monitor INR during the medication to maintain it at 2.0 to 3.0,32,医学培训,（3）加强患者的监测，如有无皮肤青紫瘀斑、牙龈出血等Strengthen the monitoring of patients, such as the skin bruising , and bleeding gums, etc. （4)、注意饮食对抗凝药物的影响 Pay attention to the infuence of diet on anticoagulants.,33,医学培训,Health Education,Prevention of infection,Diet,Periodic review,Medication guide,Activity and rest,Self-test,34,医学培训,用药指导 Medication guide,华法林只在体内抗凝，通过拮抗维生素K而产生药理作用。常用INR(国际标准化比值)评价 Warfarin anticoagulation only in the body, vitamin K antagonism generated by pharmacological effects. Common INR (international normalized ratio) evaluation,记住服药时间要固定哦！,35,医学培训,Diet,It is best for you to have more nourishing food and easily- digested food, including high-protein,high-vitamins, and so on.At the same time,you should have more meals with less food for each meal,develop good living habits. Avoid cigarettes, alcohol, coffee and spicy food. Patients with poor cardiac function should limit sodium intake . Patients should observe the changes in body weight.,保持饮食结构的相对平衡,应进食富含营养，易于消化的食物，报告高蛋白、高维生素等，同时，应少食多餐，养成良好饮食习惯。 禁忌烟酒、咖啡及刺激性食物。 心功能较差的病人要限制钠盐的摄入；应用利尿剂的病人，注意观察尿量及体重的变化。,36,医学培训,富