内科护理学教学课件英语考试myocardial+infarction

1、Myocardial Infarction 心肌梗死 后逆需西韭棠遣妇膨嗜干赣侯馁马啃配狱般缠蹄侦郧戌凭监袁惋庶摸贡掠内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第1页，共44页。Myocardial infarction 心肌梗死Myocardial infarction (MI or AMI for acute myocardial infarction), also known as a heart attack心脏病发作, occurs when the blood supply to

2、part of the heart is interrupted, resulting ischemia and oxygen shortage, if left untreated for a sufficient period, can cause damage and/or myocardium infarction.Angina心绞痛as a result of ischemia causes reversible cellular injury, and infarction is the result of sustained ischemia, causing irreversi

3、ble cellular death.殖羊级活墟绦娜神伴杯你惹驻讥攻擞蛊雁气晾拔野蓝蕉桔姿悼肮鞘踊愿情内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第2页，共44页。Classification 分类 Acute myocardial infarction is a type of acute coronary syndrome急性冠脉综合征. The acute coronary syndromes include:unstable angina (UA)不稳定型心绞痛. ST segment

4、elevation myocardial infarction (STEMI) ST段抬高性心梗non-ST segment elevation myocardial infarction (NSTEMI) 非ST段抬高性心梗媚拣镭戍习幻篆反匙如均卓鹤盾阎塔菜脖延褪蜒停撵谆菊阂阂沼奎起沥创内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第3页，共44页。Myocardial infarction Infarctions are described by the area of occurrence

5、as anterior前壁, posterior后壁, inferior下壁 or lateral侧壁 wall infarctions.Inferior MI is also called a diaphragmatic MI (DMI)膈肌心梗Common combination of areas are the anterolateral前侧壁心肌梗塞 or anteroseptal (房室)隔前的MI. 陆挥常空爷燥伏型邱夯急陀难向拄半烙频奶噶枫湿全角丢褐项约畦弊寡屈内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardia

6、l+infarction第4页，共44页。Pathophysiology病理生理The most common triggering event is the disruption破损of an atherosclerotic plaque粥样硬化斑块in an epicardial coronary artery.Plaques can become unstable, rupture破裂, and additionally promote a thrombus血栓(blood clot) that occludes阻塞the artery. When a severe enough pla

7、que rupture occurs in the coronary vasculature, it leads to myocardial infarction. 涣甸兼咸眉槐除堂耳树芹铬考蜜呢前寅雕臆唁精礁萄完陕因毛冗炊竣拱拄内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第5页，共44页。Pathophysiology 病理生理Depending on the location of the obstruction in the coronary circulation, different

8、zones of the heart can become injured. An occlusion of the left anterior descending coronary artery(LAD)左冠状动脉前降支will result in an anterior wall myocardial infarct前壁心肌梗死.Infarcts of the lateral wall侧壁心肌梗死are caused by occlusion of the left circumflex coronary artery(LCx)冠状动脉左回旋支.Both inferior wall an

9、d posterior wall infarctions下壁和后壁心梗may be caused by occlusion of either the right coronary artery右冠状动脉or the left circumflex artery左冠状动脉回旋支, depending on which feeds the posterior descending artery. Right ventricular wall infarcts右心室壁梗死are also caused by right coronary artery右冠状动脉occlusion. 太棘佯囊代铺稽敷

10、其之体淑就洼喉虏妒瀑岗侦伊陀飘刊毙乱讽饵林蚊打唤内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第6页，共44页。摔班植灼漓堆澜荤帚智障胯喻麻畔颅敦绘烘咱砖咯预百腆咕铣讲矢违痰喻内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第7页，共44页。Pathophysiology病理生理The degree of preestablished collateral circulation侧支循环提前建立also

11、 determine the severity of infarction.In an individual with a history of heart disease, adequate collateral channels may have been established that provided the area surrounding the infarction site with a blood supply and oxygen. This is one explanation why the young person who has a severe MI is mo

12、re likely to have a more serious impairment than an older person with the same degree of occlusion.惮肋镭脂肾迟嫩耘杜舔墒柏晒淑凛脆粹中肃子淡镇途嚣衍里袖解愁悲盏恕内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第8页，共44页。Healing process愈合过程Within 24 hours:The bodys response to cell death is the inflammation

13、process. Leukocytes白细胞 infiltrate the area.Enzymes 酶are released from the death cardiac cells and are important diagnostic indicators.锨庙嗜讼慨拖寞揖勉噪够移竟荔绅慎流部腰蝗睁赁嘴幅咒识减窝浓缕绊颜内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第9页，共44页。Healing process愈合过程The second or third day: The prote

14、olytic enzymes蛋白水解酶of neutrophils and macrophages巨噬细胞remove all necrotic坏死 tissue and the necrotic muscle wall is thin.Development of collateral circulation improve the area of poor perfusion and may limit the zones of injury and infarction.Once infarction takes places, catecholamine-mediated儿茶酚胺介导

15、lipolysis脂解(作用) and glycogenolysis糖原分解 occur. For this reason, serum glucose levels are frequently elevated after MI and may be the reason for a pseudodiabetic state假性糖尿病.榨豪仓阿礁首呛曾好罢讳乐搐薛四秸瓣噶赛彪铅雍挚峭勋国藩叶肉福旺贱内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第10页，共44页。Healing process

16、愈合过程Within 4 to 10 days: The necrotic zone is identifiable by ECG changes, at this point, the phagocytes (neutriphils and monocytes 中性粒细胞和单核细胞) have clear the necrotic debirs坏死的碎片from the injury area and the collagen matrix 胶原基质that will eventually form the scar瘢痕is laid down.At 10 to 14 day:The beg

17、inning of scar tissue 疤痕组织 is weak. The myocardium is considered to be especially vulnerable to increased stress because of the unstable state of the healing heart wall.6 weeks after MI: Scar tissue has replaced necrotic tissue, at this time, the injured area is said to be healed. 捻操秤醚料铱训佬程曾镀扔嫡乡捏凯掺蛋

18、献胰汞享彼士竖颊喻楷秆掠五罢内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第11页，共44页。Clinical manifestation 临床表现Pain Severe, immobilizing chest pain not relieved by rest or nitrate administration is the hallmark of an MI. it is often described as a sensation of tightness, pressure压榨, or s

19、queezing紧缩. Common locations are substernal胸骨下and retrosternal胸骨后. Pain radiates most often to the left arm, but may also radiate to the lower jaw下颌， neck, right arm, back, and epigastrium腹上部, where it may mimic heartburn. Pain are commonly occurs in the early morning hours. It usually lasts for 20

20、minutes or more.卑邯萨花姐矗沂足霜腾驳丽局船帛篱萤锤侄惹锦等浮蜡颅庆琵祟瘟亭邪北内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第12页，共44页。Clinical manifestation Nausea and vomitingNausea and vomiting can result from reflex stimulation of the vomiting center by the sever pain and can also result from vasovag

21、al reflex血管迷走性反射from the area of the infarcted myocardium.Sympathetic stimulation Diaphoresis发汗, weakness, light-headedness, and palpitations心悸. These symptoms are likely induced by a massive surge of catecholamines儿茶酚氨from the sympathetic nervous system which occurs in response to pain and the hemo

22、dynamic abnormalities血流动力学的异常that result from cardiac dysfunction心功能不全. 充胡哺滔认挞入免铀痴棚汞模趾悼氏斗炭蜂呵诡制该那辩式墒肮毛楼簧净内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第13页，共44页。Clinical manifestation FeverThe temperature may increase within the first 24 hour up to 38 to 39. the temperature

23、elevation may lasts for as long as 1 week.Cardiovascular manifestationsThe BP and pulse rate may be elevated initially, later BP may drop because of decreased CO.Urine may be decreased.Crackles湿啰音may be noted in the lungs, persisting for several hours to daysHepatic engorgement 肝怒张and peripheral ede

24、ma外周水肿may indicate covert cardiac failure.Jugular veins 颈静脉 may distended and may have obvious pulsations搏动, indicating early right ventricular dysfunction and pulmonary congestion. 汛颐舶陌丰间语窄恼鼓拭毅固穴捍错锣啤漠津瓜殆祷哭犊佩俘忍警第饺誉内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第14页，共44页。Comp

25、lication Dysrhythmias 心律失常: are the most common complication, present in 80% of MI patient.The intrinsic rhythm of the heartburn is disrupted, causing either a fast HR (tachycardia心动过速 ), a slow HR (bradycardia心动过缓 ), or an irregular beat.Complete heart block心脏传导阻滞is seen in massive infarction.Ventr

26、icular fibrillation室颤, a common cause of sudden death, is a lethal dysrhythmia that most often occurs within the first 4 hours after the onset of pain.Premature ventricular contractions室性早搏(PVCs) may precede ventricular tachycardia室性心动过速and fibrillation室颤. Ventricular dysrhythmia needs immediate tre

27、atment.窍捍壶陕鼓当忽迄潮赠誓赏勃事颁蓬谦据北糠瞬捻沂甘谴漠您匠译弹缓拘内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第15页，共44页。Complication Congestive heart failureCardiogenic shockPapillary muscle dysfunction乳头肌功能障碍Ventricular aneurysm室壁瘤Pericarditis心包炎Dressler syndrome德雷斯勒综合征，心肌梗死后综合征Pulmonary embolism肺

28、栓塞丫钱坯增相何宇融哟戊菲驾媳戏狈秩瑶衷咬赞悔攫损激队酣脑际傍久掂佑内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第16页，共44页。Diagnostic studies辅助检查 Three noninvasive diagnostic parameters are used to determine whether a person has sustained an acute MI:The patients history of pain, risk factors and health hi

29、story.12-lead ECG consistent with acute MI (inverted倒置T waves, ST-T waves elevations of greater than 1 mm or more in two contiguous leads, abnormal Q wave)Measurement of serial myocardial serum enzymesOther measures includes: Chest X-rayCBC, thyroid profileNuclear imaging studiesEndocardiogram劝瞄厢割衬切

30、蝗滤签茧擎识妈孟童绊瀑销颊蹿晚凶宋谍止者瑞则墓唬峰躇内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第17页，共44页。Diagnostic studies ECG findingsECG are approximately 80% specific for diagnosing an acute MI and represent a leading diagnostic criterion.鹃这尚担轴茶鸳琵妊盼咐镐索隶邯立汪个潘剿傣眺席帐叹类焚蹋频般勃悟内科护理学课件 英语 考试资料myocard

31、ial+infarction内科护理学课件 英语 考试资料myocardial+infarction第18页，共44页。剑卷坝玫辛琉臣疡则陛拱禁韩常烛澡肝昔顺炔浚乃挝陈厉雕陡拾唐契撂壶内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第19页，共44页。吝哨霹枫候苟鼠烽版趣庭曲胸泛摄往沃蔼盐刑蜕墙笆念鸽愉训概测嚣熙舱内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第20页，共44页。Diagnostic s

32、tudies辅助检查Cardiac enzymes: An important diagnostic criterion for acute MI is laboratory assessment of serial cardiac serum enzymes.Creatine kinase肌酸激酶(CK): CK levels begin to rise approximately 6 hours after an acute MI and return to normal within 2 to 3 days.Lactic dehydrogenase乳酸脱氢酶(LDH) Aspartate

33、 aminotransferase谷草转氨酶(AST) 氦堡臆帘订窘杉昭筑晋绥循恫究凛竣讹淑钓迁叶末谷抗幌挺戊缎隔疫滑鸵内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第21页，共44页。Therapeutic management治疗方案IV therapy Initial management of MI is best accomplished in a cardiac care unit (CCU), where constant monitoring is available.An IV

34、route is established to provide an accessible means for emergency drug therapy.Morphine 吗啡sulfate may be given IV 2-4 mg/hr as needed for relief of pain (or meperidine 度冷丁if patient is allergic to morphine) A continuous IV infusion of lidocaine 利多卡因may be given, prophylactically to prevent ventricul

35、ar fibrillation室颤. 搪惦刹喀栏程规枣溪兵钥孤石欧兵乡谬矿嘿全脆恃蹄和赚也稠饶措滴莎拔内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第22页，共44页。Therapeutic management治疗方案Oxygen therapyContinual ECG monitoring to deter dysrhythmiasVital signs are taken frequently during the first few hours after admission and a

36、re monitored 1-4 hr thereafter.Bed rest and limitation activity are usual initially, with a gradual increase in activity.Recording intake and outputA pulmonary artery (PA) catheter肺动脉导管and intraarterial line 动脉内置管may be used to accurately monitor intracardiac, pulmonary artery, and systolic arterial

37、 pressures in complicated MI so that the most effective mode of treatment in the acute phase can be determined.吕赘荆鲁明讯随生缨滚糙枢劲挝颅满时才威贷枢贪啄嗣侗侵元鲤式岳糊塘内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第23页，共44页。Therapeutic management Thrombolytic therapy溶栓疗法It is now known that 80% to

38、90% of all acute MI are secondary to thrombus formation. Thrombolytic therapy is the standard of practice in the treatment of acute MI. Myocardial cells do no die instantly. It takes approximately 4 to 6 hours for entire thickness of the muscle to become necrosed and this is known as transmural infa

39、rction 跨壁梗死.Treatment of acute MI is geared to quickly dissolving thrombus in the coronary artery and reperfusing the myocardium before cellular death occurs.To be of most benefit, thrombolytics must be given as soon as possible, perferably within the first 6 hours after the onset of pain.麦菩烁铬旨号孕他记浇

40、鹏痹偷躺酬踢彰太胁缩轴融绚瞻萨榜嗜兄校瓮抨邪内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第24页，共44页。Therapeutic management Thrombolytic therapy溶栓疗法Thrombolytic agents used to treat myocardial infarction are: streptokinase (链激酶 ), urokinase (尿激酶 ), tissue plasminogen activator (t-PA) (组织纤维蛋白溶酶原激活

41、剂).Indications of thrombolytic therapy:Chest pain typical of acute MI less than or equal to 6 hr in duration (some centers extend the time limit to 12 hr).12-lead ECG findings consistent with acute MI. 秦劣现淡躺今菏啼徽携勿耙骗混恋景铀肮瞧兢萧刀锄慌讥伏洲梨泅综涣讼内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infa

42、rction第25页，共44页。Thrombolytic therapy溶栓疗法Contraindications of thrombolytic therapy:Absolute contraindications禁忌:History of hemorrhagic strokeUncontrolled hypertension (SBP200, DBP120)Recent surgery or trauma (within 2 wk)Active internal bleedingKnown bleeding disorderSuspected aortic dissention主动脉剥离R

43、elative contraindications:History of stroke Acute, poor Uncontrolled hypertension (BP180/110)Malignancy妊娠Acute pericarditis急性心包炎Pregnancy妊娠Active peptic ulcer活动性消化性溃疡Diabetic hemorrhagic retinopathy 糖尿病性视网膜病变Artial fibrillation房颤脖猪朗大逢倔剃邻氧门逼付被酸楞问奋鄂治煮跃尾谎彪旅雅揖逻宙萎问孪内科护理学课件 英语 考试资料myocardial+infarction内科护

44、理学课件 英语 考试资料myocardial+infarction第26页，共44页。nursing care for thrombolytic therapyECG, vital signs, heart and lung assessments are completed as often as every 5 minutes to evaluate the patients response to therapy.When reperfusion occurs, several clinical markers may occurs, nurses should monitor them

45、, those signs of reperfusion includes chest pain resolution, return of ST segment to baseline on the ECG, the presence of reperfusion dysrhythmias再灌注性心律失常 (premature ventricular contractions室性早搏, ventricular tachycardia室性心动过速, ventricular fibrillation心室颤动), rapid rise of the CK enzymes within 3 hrs

46、of therapy, peaking within 12 hrs.傍栓仍陕召裸桑忠贵弗用求缎斩田次鸦堵喧拂掏鹿谚柄戏芋盖绒巾垣惹瑟内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第27页，共44页。nursing care for thrombolytic therapyAnother major concern with therapy is reocclusion动脉重新堵塞of the artery, because of this possibility, an IV bolus is g

47、iven, followed by heparin drip to maintain the patients Partial Thromboplasm Time (PPT)部分凝血酶原时间at one to two times normal, this prevent another clot form forming in the coronary artery.The major complication with thrombolytic therapy is bleeding. The nurses must pay particular attention to signs and

48、 symptoms of bleeding such as gingival bleeding牙龈, drop in BP, an increasing in HR, hematuria 血尿, a sudden change in patients level of consciousness and oozing渗出of blood from IV or catheter site. 命伊屹碳探角跃逼慢镣辗荷市啊抱痪蚜向俞吵咆拂炒停涎奢装陡躺寺氢很内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction

49、第28页，共44页。Therapeutic management 9.Percutaneous Coronary Intervention (PCI)冠状动脉介入治疗BalloonStentLaserRotablator阿侵虐年痈樟擦咎吸秆赁睫酚锻板秋皆鸳劝蜜榜湾鬼仿车芹苗噶锁傀祝委内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第29页，共44页。Percutaneous transluminal coronary angioplasty (PTCA) 经皮腔内冠状动脉成形术.稻篓药找援患录帜裁拆

50、孝吃聚悲梭甜兢垛兹肢衣锈憎贞腿夷讯瞳个谈碴绚内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第30页，共44页。Percutaneous transluminal coronary angioplasy (PTCA) 经皮腔内冠状动脉成形术 .了涨垂寇历资概伤斯拦拙碍讥莽豌波蔫禾紫饰狈煮购宇还旗咀豹另揣峡糟内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第31页，共44页。Percutaneous tra

51、nsluminal coronary angioplasy (PTCA) 经皮腔内冠状动脉成形术 .遇痔窗炉萨圭经婴遁咸蹈贴瘫鞍雷算礁拙际态锨甘交涂鸳原派戚发往督廷内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第32页，共44页。PCI Complication 冠状动脉介入治疗的并发症Acute abrupt closure of coronary vesselsserious arrhythmias : VT室速，VF室颤。Cardiac tamponade心包填塞Vascular compl

52、icationLow blood pressureStrokeHemorrhageRenal failureHeart attackDeath瑟靶粱掩觅弥再烂届侩饵矩秸库舷升池超嗅噪奎刁管哩蘑食牲斑腿扼援腰内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第33页，共44页。Coronary artery bypass surgery (CABG)冠状动脉搭桥手术挂垃嫡啼辙叔埠巧菱沽收饿死到惕治瞬割亿堵敬隔勿区澜奶才具拘另狼氨内科护理学课件 英语 考试资料myocardial+infarction内科

53、护理学课件 英语 考试资料myocardial+infarction第34页，共44页。Coronary artery bypass surgery (CABG)冠状动脉搭桥手术瞬彬查骑聂资竞殿痛悠貉良言旅睹争罚缸绣虞袜瞻旷缉沮驳内员顽毕疾石内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第35页，共44页。Pharmacologic management药物管理 IV nitroglycerin硝酸甘油IV Morphine 吗啡Morphine can reduce anxiety, decre

54、ase cardiac work load, reduce contractility, lower BP and slow the HR. Antidysrhythmic drugs抗心律失常药物Dystrhythmia are the most common complications after MI.-BlockersCalcium channel blockersAngiotensin-converting enzyme inhibitorsStool softeners 中镁募七迂啦淹姐唇疯焉将侨磕膜佣蛋枣冬拼漫讥祁押乘乌吱涤睹酮圆叼内科护理学课件 英语 考试资料myocardia

55、l+infarction内科护理学课件 英语 考试资料myocardial+infarction第36页，共44页。Nutrition management Diet is restricted in saturated fats饱和脂肪和 and cholesterol胆固醇and is sometimes low in sodium to prevent fluid retention.The patient may have a clear liquid diet the first day when there may still be nausea. 滩策瀑掐忘捡到畦谦沪换互泵顷刻缓

56、烟矫伟讼澡尹位莉悬撵莹迫轧纱伴群内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第37页，共44页。Nursing diagnosis and intervention Acute pain related to lactic acid production from myocardial ischemia and altered myocardial oxygen supply.Administer oxygen through nasal cannula to increase oxygenat

57、ion of myocardial tissue and prevent further tissue ischemia.Administer morphine sulfate IV as needed to decrease anxiety, elevated pain and decrease cardiac work load.Monitor vital signs q1-2hr to provide on-going assessment of patients response to treatment.田鼠学皖极淖碧助溢残煮院擞霹逃炮皖瘩飞藩鲜闻卞烙啄哪饶起阅肪澎撮内科护理学课件

58、英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第38页，共44页。Nursing diagnosis and intervention Altered cardiac tissue perfusion related to myocardial damage, ineffective CO and potential pulmonary congestionProvide long, uninterrupted rest period to promote cardiac rest and healing. Mi

59、nimize cardiac workload during healing.Explain necessity of bed rest and decreased activity to promote patient cooperation.Allow rest periods between concentrated nursing care time to reduce fatigue and oxygen requirements of myocardium.Asses urine output to determine adequacy of renal blood flow.酋殉

60、僵稳汽桃囱果逮志碑懊夯枕贵驱浸协拥隔嫂修胜推刀芬央褪游乍儿粪内科护理学课件 英语 考试资料myocardial+infarction内科护理学课件 英语 考试资料myocardial+infarction第39页，共44页。Nursing diagnosis and intervention Impaired gas exchange related to ineffective breathing pattern and decreased systemic tissue perfusion secondary to decreased CO.Elevated head of bed to