主動脈瓣置換術(shù)后的護(hù)理

1、主動動脈瓣置換術(shù)換術(shù)后的護(hù)護(hù)理The nursing of aortic valve replacement正常的主動脈瓣有三個瓣葉：左半月瓣、右半月瓣和后半月瓣心室舒張期心室舒張期Ventricular diastole心室收縮期心室收縮期Ventricular systole主動脈瓣狹窄的病因Causes of aortic stenosis先天性畸形Congenital malformations老年性主動脈瓣鈣化Senile aortic valve calcification風(fēng)濕性心臟病Rheumatic heart disease主動脈瓣葉粘連、融合Aortic valve lea

2、flets adhesion, fusion主動脈瓣狹窄aortic stenosis主動脈瓣主動脈瓣開口面積減少開口面積減少肺靜脈高壓肺靜脈高壓 右心衰竭右心衰竭左心室射血負(fù)荷左心室射血負(fù)荷左左室向室向心性肥厚心性肥厚 左心室收縮功能左心室收縮功能室壁張力室壁張力順應(yīng)性下降順應(yīng)性下降室壁張力室壁張力左心衰左心衰病理生理pathophysiologyPulmonary venous hypetensionaortic stenosis順應(yīng)性下降順應(yīng)性下降舒張末壓力舒張末壓力心絞痛心絞痛暈厥暈厥Angina pectorisSyncope急性Acute : :1.感染性心內(nèi)膜炎Infective

3、 endocarditis2.主A夾層 Aortic dissection3.外傷Trauma4.4.人工瓣膜撕裂Prosthetic valve tear慢性Chronic:1. 主動脈瓣疾病Aortic valve disease2/32/3為風(fēng)心病為風(fēng)心病2. 主動脈根部擴(kuò)張Aortic root dilatation主動脈瓣關(guān)閉不全的病因Causes of aortic incompetence主動脈瓣纖維化、增厚、縮短、變形主動脈瓣關(guān)閉不全Aortic valves incompetence主動脈內(nèi)血液主動脈內(nèi)血液在舒張期返流入左室在舒張期返流入左室偏心性肥厚、擴(kuò)大偏心性肥厚、擴(kuò)大左

4、心衰左心衰左心室容量負(fù)荷左心室容量負(fù)荷Sp 、Dp 左心室舒張末期壓力左心室舒張末期壓力CO室壁張力室壁張力心絞痛心絞痛pulmonary hypertension右心衰右心衰pathophysiology反流面積的大小反流面積的大小 心動周期舒張期的長短心動周期舒張期的長短體循環(huán)血管阻力體循環(huán)血管阻力AI reverse flowReverse flow aera of the sizeBeckoning cycle diastolic lengthSystemic vascular resistance急性主動脈瓣關(guān)閉不全左心室舒張期充盈量突然增加左心室舒張期充盈量突然增加 壓力迅速增高壓

5、力迅速增高左房壓、肺靜脈壓迅速升高左房壓、肺靜脈壓迅速升高急性肺水腫急性肺水腫心動過速以減少反流量心動過速以減少反流量 增加增加CO二尖瓣舒張期提前關(guān)閉，緩解左房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和肺靜脈受左心室高舒張壓的影響 CO減少，低減少，低BP急性左心衰竭急性左心衰竭 急性急性AI v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Valve replacement surgery is to use mechanical valves or biological valves to replace original human valves. 主動

6、脈瓣置換術(shù) 病例介紹Case Introduction病史medical history 羅菊梅，女，40歲,云南鎮(zhèn)雄人 Patient Jumei Luo,female,40 years old, from Zhenxiong in Yunnan province. 患者因頭昏、胸痛3年，近一年來加重，活動后心悸、氣促、乏力伴呼吸困難，休息后無明顯緩解一月余，于2014年12月10日以“非風(fēng)濕性主動脈瓣狹窄并關(guān)閉不全”收住 She was admitted to the hospital for Non-rheumatic aortic stenosis and incompetence o

7、n 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.Medical History手術(shù)史Surgical operation history2004年行“ 卵巢囊腫摘除術(shù)” ovarian cyst in 2004,2011年行“右上臂神經(jīng)源性腫瘤切除術(shù)”“neurogeni

8、c tumor resection of right arm” in 2011過敏史Allergic history 雙黃連 Echocardiography:1、Aortic valve disease: moderate aortic incompetence, moderate aortic stenosis, and the widening of aortic diameter 2、Mild mitral incompetence, and mild tricuspid incompetence3、The decreasing of left ventricular diastoli

9、c function , LVD：70mm,EF:55%心臟彩超：1、主動脈瓣病變： 主動脈瓣中度關(guān)閉不全并中度狹窄， 升主動脈內(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%DX檢查：主動脈迂曲增寬 Aorta becomes widened and tortuous左室增大left ventricle becomes bigger診治經(jīng)過診治經(jīng)過12月16日前完善術(shù)前準(zhǔn)備12月17日-19日在ICU治療12月20日患者病情平穩(wěn)搬回病房。Preoperative preparation was completed before Decem

10、ber 16th.The patient was stablly moved back to the ward on December 20th病 情 12月17日在全麻CPB下行主動脈瓣置換術(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 On december 17th, the aortic valve replacement was completed under general anesthesia CPB ,and the patient returned the ic

11、u 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.病 情 HR95-110次/分，為竇性心律。BP由多巴胺4.9ug/kg/

12、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，鼓勵進(jìn)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

13、was normal, patients spirit and diet was slightly poor. She was encouraged to eat . 護(hù)理問題 Nursing Problem低效性呼吸型態(tài)（Ineffective breathing pattern） 與手術(shù)及術(shù)后傷口疼痛致咳痰無力有關(guān)operation and postoperative wound pain induced sputum weakness 心輸出量減少(decreased cardiac output)： 與心臟疾病、體液不足有關(guān)Associated with heart disease,

14、insufficient body fluid潛在并發(fā)癥（ potential complication ） 抗凝不足或抗凝過度Inadequate or excessive anticoagulation、護(hù)理措施nursing interventionnursing intervention（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，定時拍背、霧化， 鼓勵患者咳嗽、咳痰。 Strengthen respiratory care, auscultation of lung breath sound, timed back patting ,and atomization ,an

15、d encourge patients to cough and expectorate. 2、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 Continuous ECG monitoring, and close observation of heart rate, blood pressure, respiration, and oxygen saturation.（一）低效性呼吸型態(tài) 3、定時監(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。 Regularly monitor the result of blood gas analysis and adjust

16、 the way and the flow rate of oxygen offer based on the patients vital signs and blood gas. 4、遵醫(yī)囑適當(dāng)予以止痛劑，以減少病人呼吸肌做功 Provide analgesics appropriately according to prescription to reduce the acting of patients breathing muscles. （一）低效性呼吸型態(tài)(二)心輸出量減少(decreased cardiac output)（1）嚴(yán)密監(jiān)測心律、HR、BP、CVP及末梢情況，發(fā)現(xiàn)異

17、常要及時報告醫(yī)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(二)心輸出量減少(decreased cardiac output)（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 Use vasoactive drugs, and adjust according to the patients

18、 vital signs(二)心輸出量減少(decreased cardiac output) （3）引流管的監(jiān)測 The drainage tube monitoring： 定時擠壓引流管保持引流管的通暢 Squeeze drainage tube regularly to keep its patency. 觀察引流液量及性質(zhì)， Observe the drainage amount and nature. 觀察傷口有無滲血 Observe whether there is bleeding or not in wound.(二)心輸出量減少(decreased cardiac outpu

19、t) (4)準(zhǔn)確記錄出入量，注意水電解質(zhì)平衡 Record intake and output accurately, and pay attention to the balance of water electrolyte.（5）鼓勵患者進(jìn)食 Encourage patients to eatnursing interventionnursing intervention（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 Inadequate anticoagulation and excessive anticoagulation (1)、為避免血栓形成，機(jī)械瓣置換術(shù)后，需終身抗凝治療

20、，生物瓣術(shù)后抗凝3-6個月。要定時定量口服 Explain to patients the importance of taking warfarin orally, Take anticoagulant medicine regularly and quantitatively The dose is 2.5-5 milligram（2）、服藥期間監(jiān)測INR，使之維持在2.03.0. Monitor INR during the medication to maintain it at 2.0 to 3.0（3）加強(qiáng)患者的監(jiān)測，如有無皮膚青紫瘀斑、牙齦出血等Strengthen the mo

21、nitoring of patients, such as the skin bruising , and bleeding gums, etc.（4)、注意飲食對抗凝藥物的影響 Pay attention to the infuence of diet on anticoagulants. Health EducationPrevention of infectionDietPeriodic reviewMedication guideActivity and restSelf-test用藥指導(dǎo)Medication guide 華法林只在體內(nèi)抗凝，通過華法林只在體內(nèi)抗凝，通過拮抗維生素拮抗維

22、生素K K而產(chǎn)生藥理作用。而產(chǎn)生藥理作用。常用常用INR(INR(國際標(biāo)準(zhǔn)化比值國際標(biāo)準(zhǔn)化比值) )評價評價 Warfarin anticoagulation only in the body, vitamin K antagonism generated by pharmacological effects. Common INR (international normalized ratio) evaluation記住服藥時間要固定哦！記住服藥時間要固定哦！DietvIt is best for you to have more nourishing food and easily- di

23、gested 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.v Avoid cigarettes, alcohol, coffee and spicy food. vPatients with poor cardiac function should limit sodium intake . Patients should obser

24、ve the changes in body weight. 保持保持飲食結(jié)構(gòu)的相對平衡飲食結(jié)構(gòu)的相對平衡 應(yīng)應(yīng)進(jìn)食富含營養(yǎng)，易于消進(jìn)食富含營養(yǎng)，易于消化的食物化的食物，報告高蛋白、，報告高蛋白、高維生素等，同時，應(yīng)少高維生素等，同時，應(yīng)少食多餐，養(yǎng)成良好飲食習(xí)食多餐，養(yǎng)成良好飲食習(xí)慣。慣。 禁忌禁忌煙酒、咖啡及刺激性煙酒、咖啡及刺激性食物。食物。 心心功能較差的病人要限制鈉功能較差的病人要限制鈉鹽的攝入；應(yīng)用利尿劑的鹽的攝入；應(yīng)用利尿劑的病人，注意觀察尿量及體病人，注意觀察尿量及體重的變化。重的變化。 富含維生素富含維生素K的食物會降低華法林抗凝作用，的食物會降低華法林抗凝作用， 不易長期單調(diào)食用某種含