IABP護理查房課件ppt

一例心跳呼吸驟停使用IABP患者的護理查房主動脈內(nèi)球囊反搏泵Intra-AorticBalloonPump————簡稱IABP主動脈內(nèi)球囊反搏泵ACAT1PLUS

AUTOCAT2AUTOCAT2WAVE反搏的原理心臟收縮前一瞬間（主動脈開放時），球囊放氣，降低主動脈內(nèi)舒張末壓，減少左心室做功，降低后負荷，減少心肌耗氧心臟舒張前一瞬間（主動脈關(guān)閉時），球囊充氣，增加舒張期冠脈灌注壓力，增加心肌供氧冠脈分布示意圖使用科室應(yīng)用指征術(shù)前---國外：42-72%國內(nèi)：5%左右危重狀態(tài)或血液動力學不穩(wěn)，爭取時間手術(shù)---PTCA，旋切，支架等失敗，或難以控制心律失常---心梗后并發(fā)癥---MI合并左室功能低下，低心排---心衰狀態(tài)的術(shù)前病人

心臟外科（冠脈搭橋術(shù)、心臟瓣膜置換術(shù)）心臟內(nèi)科（急診PTCA）急診科（急性心梗合并心源性休克）適應(yīng)癥一、各種原因引起的心泵衰竭急性原因引起的心泵衰竭圍手術(shù)期發(fā)生的心肌梗塞體外循環(huán)后低心排綜合癥心臟挫傷中毒性休克病毒性心肌炎二、急性心肌梗塞后發(fā)生的機械性并發(fā)癥室間隔穿孔乳頭肌斷裂致二尖瓣關(guān)閉不全大室壁瘤三、內(nèi)科治療無效的不穩(wěn)定型心絞痛四、心肌缺血而致的室性心律失常五、進展性心肌梗塞六、圍手術(shù)期對重癥病人的支持和保護措施嚴重心肌缺血病人作冠脈造影、PTCA、溶栓術(shù)、麻醉誘導高危重癥病人作心導管檢查、心臟手術(shù)、普外手術(shù)七、心臟移植前后的輔助治療八、人工心臟的過渡治療九、手術(shù)中產(chǎn)生搏動性血流IABP使用禁忌癥主動脈瓣關(guān)閉不全主動脈瘤或主動脈血管性的疾病動脈粥樣硬化與嚴重的周圍血管疾病腦死亡患者疾病末期如癌癥轉(zhuǎn)移IABP并發(fā)癥下肢缺血：由于經(jīng)皮穿刺，損傷小，無鞘導管的應(yīng)用，這類并發(fā)癥已屬少見血栓形成：應(yīng)保持ACT(激活全血凝固時間)在150-180秒主動脈內(nèi)膜損傷，動脈破裂血小板減少氣栓感染，敗血癥IABP停用指征多巴酚丁胺＜5ug/kg/min心臟指數(shù)＞2.5L/min／m2平均動脈壓＞90mmHg尿量＞4ml/kg/小時手足暖，末稍循環(huán)好減慢反搏頻率時，上述指標穩(wěn)定一般不超過3天CompanyLogoIABP球囊的位置位置:左鎖骨動脈以下2-3cm（第二肋間）和腎動脈開口之間的降主動脈內(nèi).確定位置:

可通過胸部X光片觀察導管尖端是否位于第2-3肋間.接IABP機器IABP球囊的位置異?！穹胖梦恢眠^高

氣囊可能阻塞左鎖骨下動脈的開口左上肢灌注不足●放置位置過低氣囊可能阻塞腎動脈的開口腎動脈灌注不足尿量減少阻斷主動脈截面積：球囊充氣后的大小應(yīng)該是主動脈直徑的80-90%。如果球囊的太大，會損傷主動脈；而球囊的體積太小，反搏會無效。IABP導管阻塞面積DiastoleSystole<162cm<5’4”<182cm<6’0”>182cm>6’0”30cc40cc50ccIABP導管型號選擇IABP導管

BalloonMembraneProximalMarkerUniversalSheathSealSTAT-GARDSleeveY-fittingExtracorporealTubingDistalMarkerCatheterShaftSuturePadsInnerLumenPort遠端標記球囊膜近段標記延長管延伸管導管軸通用鞘STAT-GARD軸中心管內(nèi)腔Y型接口球囊導管耗材的組成

2.連接壓力傳感器中心腔血壓監(jiān)護的連接示意Y接頭加壓鹽水袋保持300mmHg壓力連續(xù)沖洗裝置測壓管路長度不超過8Ft或240cm連接至球囊反搏泵的魯爾接頭處導管連接顯示面板H-----HELIUM（氦氣）E-----ECG（心電圖）A-----AP（動脈血壓）R-----RESET（球囊氣量設(shè)置）

RATIO（反搏比率）T-----TRIGGER（觸發(fā)模式）TIMING（充放氣時機）

I.PowerOn打開電源

II.PatientConnect病人連接

III.PumpOn啟動泵IABP操作快速上路安裝氦氣瓶；打開減壓閥；如左圖屏幕右下方顯示氦氣余量。氦氣供應(yīng)在反搏中更換氦氣時無需中斷反搏，即可自動填充開機后，自動執(zhí)行排氣動作ECG導線ECG信號傳輸線ECG信號的輸入接口

連接心電圖導線心電圖是綠色波，以白色部分突出充放氣時間動脈壓是紅色波，以白色部分突出充放氣時間球囊壓是藍色波,以mmHg為單位波形顯示PSP、PDP、EDP、MAP壓力測量線（游標），可測量血壓和球囊壓力上的任一點的壓力值壓力信號自動校正，可分段顯示提供AP輸入、輸出接口觸發(fā)時機圖同步顯示在血壓圖上，以白色標識顯示血壓信號充氣量調(diào)節(jié)球囊充氣量球囊壓力波形123456789零基線球囊壓力基線快速充氣充氣機械波充氣后的穩(wěn)定壓力快速放氣放氣機械波回復基線球囊充/放氣周期時間CompanyLogo球囊壓力波形球囊充氣氣量的設(shè)置保證PDP與球囊的平臺壓力在25mmHg之間反搏比率1:1，1:2，1:4，1:8反搏頻率

1:1

1:2

1:3觸發(fā)模式ACTA1PLUS規(guī)范型（PATTERN）峰型（PEAK）自動房顫（AFIB）心室起搏觸發(fā)（VPACE）心房起搏觸發(fā)（APACE）血壓觸發(fā)（AP）最低3-5mmHg觸發(fā)內(nèi)觸發(fā)（INT）觸發(fā)模式AUTOCAT2觸發(fā)時機圖示充、放氣時間在R-R間期的標識R波-R波間期表示在R-R間期的35%充氣、90%放氣ECG和AP信號的自動識別，選擇，轉(zhuǎn)換觸發(fā)模式的自動選擇充放氣時間的自動選擇觸發(fā)模式AUTOCAT2ECG導聯(lián)間的轉(zhuǎn)換監(jiān)護儀和病人經(jīng)皮采集信號間的轉(zhuǎn)換在必要時在ECG和AP觸發(fā)間轉(zhuǎn)換持續(xù)ECG增益自動縮放AP波形比例自動選擇ECG/AP信號來源從6種觸發(fā)模式中自動選擇合適的觸發(fā)模式根據(jù)ECG信號情況自動在ECG和AP觸發(fā)間轉(zhuǎn)換自動觸發(fā)模式的選擇根據(jù)信號選擇模式自動選擇合適充放氣點在心律不規(guī)則時R波自動放氣早搏后長間歇自動補償充放氣時機的自動調(diào)整IABP的護理保證充足氦氣供應(yīng)

術(shù)前注意擰開氦氣瓶總開關(guān)和小開關(guān)，并檢查氦氣表。IABP使用期間，要隨時檢查壓力表，當指針指向紅線時要更換氦氣瓶。

CompanyLogoIABP的護理確保球囊位置正確

①術(shù)前預測量待置入球囊的長度。②術(shù)后立即拍床邊胸片，確保球囊位置正確。

CompanyLogoIABP的護理采取正確舒適的臥位，避免導管曲折

①嚴格臥床休息，適當限制術(shù)肢的活動，病情允許者床頭搖高不超過30°，側(cè)臥位是不超過40°，術(shù)肢伸直，避免屈曲。②下肢做被動功能鍛煉，即肢體按摩、拍打。加強皮膚護理，預防褥瘡。CompanyLogoIABP的護理密切觀察病情①注意病人心率、心律、有創(chuàng)動脈壓、反搏壓的變化，如出現(xiàn)心律失常而致反搏比例不當時，及時報告醫(yī)生。在醫(yī)生指導下，適當調(diào)整反搏比或球囊充氣放氣時間。②術(shù)后患者需要達到全身肝素化（ACT250～300秒，凝血酶原時間18±2秒），防止血栓形成。注意傷口出血情況及皮膚粘膜、尿液等有無出血。③注意觀察IABP并發(fā)癥的臨床表現(xiàn)。如每小時尿量、24小時出入量、雙側(cè)足背動脈搏動情況。CompanyLogoIABP的護理保證管道通暢及密閉性

①注意導管各連接處有無松動、脫開及血液返流等情況出現(xiàn)。各接口緊密銜接。妥善固定有創(chuàng)動脈導管并保持其通暢。每小時用肝素鹽水（NS500ml+肝素5000u）沖管。②保證壓力換能器位置始終處于心臟水平。注意定時校正零位，確保測壓值正確反映患者情況及IABP使用效果。③注意保護導管。嚴禁經(jīng)導管抽血或進行其他治療，以免損傷球囊導管。

CompanyLogoIABP的護理確保反搏觸發(fā)信號清晰

確保心電圖信號清晰做到以下幾點：①固定好電極片。②心電圖導聯(lián)選用標準肢導聯(lián)中R波高尖，T波低平的導聯(lián)。③操作時要注意心電圖情況，防止心電導聯(lián)及電極脫落。必要時在操作時將心電圖觸發(fā)改為壓力觸發(fā)，同時注意反搏波形。IABP使用期間，密切觀察反搏波形及其振幅、球囊充氣、放棄時間是否正確。CompanyLogoIABP的護理正常的球囊壓力波形球囊壓力波形的變化CompanyLogo

正常的球囊壓力波形

心率慢時心率快時心率的影響球囊壓力波形的變化

血壓高時血壓低時血壓的影響球囊壓力波形的變化

正常波形充氣受限充氣受限球囊壓力波形的變化

正常波形排氣受限排氣受限球囊壓力波形的變化

導管扭曲球囊壓力波形的變化

漏氣球囊壓力波形的變化

持續(xù)充盈球囊壓力波形的變化舒張期切跡（DN）平均壓收縮壓PulsePressure舒張壓12010080收縮期舒張期mmHg如何確定正確的充放氣時機通過動脈壓力波形來判斷及調(diào)節(jié)動脈壓力波形圖WithoutIABPWithIABPassist1:2EKG動脈壓力波形圖充放氣時機的調(diào)整主要是觀察機器以1:2比率反搏時的血壓波形

1。PDP點是否高于PSP點10mmHg的壓力值以上。（虛線①）

2。PSP點是否略高于APSP點。（虛線②）

3。PAEDP點是否略高于BAEDP點。（虛線③）PSPAPSP反搏輔助后的收縮壓BAEDP球囊在主動脈內(nèi)的末期舒張壓PAEDP病患的主動脈末期舒張壓PDP①②③動脈壓力波形圖PDP應(yīng)大于PSP（PDP>PSP）除非: 1.病人每搏量遠遠大于球囊容量 2.導管位置太低 3.嚴重低血容量 4.球囊充氣量太小 5.體循環(huán)阻力太低

PSPPDP動脈壓力波形圖時相錯位-充氣過早有反搏收縮壓反搏壓有反搏舒張壓末尾沒反搏收縮壓

球囊于主瓣關(guān)閉前充氣波形特點:球囊在V型切口前充氣舒張壓侵占收縮期(可能難以分辨）生理效應(yīng):主動脈瓣提前關(guān)閉每搏量/心輸出量減少前負荷增加增加加心肌耗氧時相錯位-充氣過晚有反搏收縮壓反搏壓

V型切口有反搏舒張壓末尾

沒反搏收縮壓球囊于主瓣關(guān)閉后較晚充氣波形特點: ? 球囊在V型切口后充氣 ? 缺乏尖V ? 反搏壓不足生理效應(yīng): ? 冠脈灌注不足時相錯位-放氣過早有反搏收縮壓反搏壓有反搏舒張壓末尾沒反搏舒張壓末尾球囊于舒張期內(nèi)過早放期波形特點: ? 反搏壓出現(xiàn)后馬上看到其急降 ? 反搏壓不足 ? 有反搏舒張壓末尾可能等于或小于沒反搏舒張壓 ? 有反搏收縮壓可能提高生理效應(yīng): ? 反搏壓不足 ? 可能出現(xiàn)冠脈和頸動脈逆流 ? 由于冠脈血液逆流可引起心絞疼

? 沒足夠后負荷降低效果 ? 增加心肌耗氧時相錯位-放氣過晚反搏壓有反搏舒張壓末壓沒反搏收縮壓外觀加寬有反搏收縮壓上升時間延長當主瓣開始打開時球囊才放氣波形特點:

? 有反搏舒張壓末壓可能等于沒反搏舒張壓末壓

? 有反搏收縮壓上升時間延長

? 反搏壓外觀看來加寬生理效應(yīng):

? 完全沒有減低后負荷

? 由于是左心室射血的阻力增加和等容收縮期延長而增加心肌耗氧

? 球囊阻擋左室心排血而增加后負荷充放氣時機三部曲CompanyLogo

1. 在DN前充氣

如果在DN前>40ms–充氣過早

如果可見DN–充氣過晚

APSPPDPPSPPAEDPPAEDPBAEDPDN705580HypotheticalBP=90/70充放氣時機三部曲CompanyLogo2. BAEDP<PAEDP

如果BAEDP≥PAEDP–放氣過晚

3. APSP<PSP

如果APSP=PSP–放氣過早

CompanyLogoAPSPPDPPSPPAEDPPAEDPBAEDPDN705580CompanyLogo患者信息姓名苗XX性別女年齡21歲民族漢族職業(yè)學生入院日期2013-05-15主訴呼吸心跳驟停25分鐘，心肺復蘇術(shù)后6小時病史05-15凌晨1:40左右，同學發(fā)現(xiàn)其在床上翻動后，出現(xiàn)雙上肢抽搐，當時臉色、口唇蒼白，呼之不應(yīng)，訴觸頸動脈搏動減弱，立即送至我院急診。2:05到達我院急診室，當時患者處于昏迷狀態(tài)，呼之不應(yīng)，頸動脈搏動未捫及，立即行心肺復蘇術(shù)及氣管插管、“胺碘酮300mg”靜推、電除顫4次等搶救措施后患者于2:15恢復自主心率，心率167次/分，再次出現(xiàn)室顫，立即予電除顫、心肺復蘇術(shù)，于2:21恢復自主心率，當時心率123次/分，血氧飽和度91%。2:56查心電圖示竇性心率，頻發(fā)室早。9點復查電解質(zhì)示鉀3.43mmol/l，鈣1.85mmol/l，現(xiàn)為求進一步治療，轉(zhuǎn)入EICU治療。CompanyLogo病史既往史：2006年4月在當?shù)蒯t(yī)院診斷為“頻發(fā)室早”，入院治療后好轉(zhuǎn)。2009年2月因“頻發(fā)室早”在外院行“射頻消融術(shù)”，2012年11月先后有兩次暈厥病史，每次時間短，可自行恢復。2013年3月開始服用“普羅帕酮”，100mg，每天3次。近一月反復出現(xiàn)心悸。家族史：其父親有“二尖瓣關(guān)閉不全”。CompanyLogo入室評估T36.5℃P148次/分R18次/分Bp92/46mmHg神志處于鎮(zhèn)靜狀態(tài)，Ramsay評分5分。雙側(cè)瞳孔等大等圓，直徑約2.0mm，對光反射遲鈍。帶入氣管插管在位，兩肺呼吸音稍粗，未聞及明顯干、濕啰音。心律齊，未及明顯病理性雜音。脊柱、四肢無畸形。四肢肌張力不高。CompanyLogo實驗室及輔助檢查血氣分析（2013-5-1502:26本院）PH7.333，PCO237.0mmHg，PO2612mmHg，HCO319.6mmol/l，BE-6mmol/l，SpO2100%。

電解質(zhì)（2013-5-153:31本院）鉀3.43mmol/l，鈣1.85mmol/l。

心肌酶譜（2013-5-153:49本院）肌酸激酶同工酶48.80umol/l。

血氣分析（2013-5-1508:52本院）PH7.456，PCO231.5mmHg，PO2118mmHg，HCO322.1mmol/l，BE-2mmol/l，SpO299%，Lac2.48mmol/l。

CompanyLogo24小時動態(tài)心電圖（2013-3-26南京市第一醫(yī)院）1、竇性心率；2偶發(fā)房性早搏；3頻發(fā)室性早搏，短暫性室性心動過速；4、T波改變。

心電圖（2013-5-152:56本院）竇性心率，頻發(fā)室早。

床旁胸片（2013-5-154:06本院）右肺胸腔少量積液，兩肺紋理增多。CompanyLogo實驗室及輔助檢查護理問題心輸出量減少與心泵功能降低有關(guān)（05-15）組織灌注量改變與有效循環(huán)血量減少有關(guān)（05-15）不能維持自主呼吸與鎮(zhèn)靜藥，肌松藥使用有關(guān)（05-15）有感染的危險與低溫治療及各種導管留置有關(guān)（05-15）有皮膚完整性受損的危險與臥床，IABP治療移動減少有關(guān)（05-15）CompanyLogo護理問題營養(yǎng)失調(diào)低于機體需要量與不能進食，疾病消耗有關(guān)（05-15）潛在并發(fā)癥心跳呼吸驟停﹑出血﹑墜積性肺炎﹑心律失常﹑血栓﹑動脈破裂（05-15）CompanyLogo護理目標患者能維持足夠的心輸出量，生命體征平穩(wěn)及尿量正?；颊呓M織灌注量能得到改善患者能漸漸恢復自主呼吸直至完全脫機患者導管留置及低溫治療階段無感染發(fā)生患者住院期間皮膚能維持完整，無壓瘡發(fā)生患者能得到機體所需的能量供應(yīng)住院期間防治各種并發(fā)癥的發(fā)生CompanyLogo護理措施24h心電監(jiān)護，密切觀察患者神志，瞳孔，意識，皮膚溫度，有無出血傾向。記錄24h生命體征及出入量。做好IABP的護理遵醫(yī)囑按時準確使用各種藥物，并注意觀察療效及不良反應(yīng)。遵醫(yī)囑控制輸液速度。做好各項基礎(chǔ)護理。保持皮膚的完整性，防止凍傷。定時翻身。做好各種導管的護理，標示清晰，嚴格無菌操作。保持呼吸道通暢，按需吸痰。CompanyLogo備好搶救車除顫儀，隨時準備配合醫(yī)生搶救。定時檢測血糖。遵醫(yī)囑留取血標本，及時查看結(jié)果。做好床邊交接班。班班調(diào)節(jié)心電監(jiān)護呼吸機等的報警線。肺部聽診。做好患者家屬的解釋溝通工作。CompanyLogo護理措施05-1612點開始復溫。偶見室早，05-1701:29至01:30可見頻發(fā)室早。呼吸機模式改為A/C新護理問題復溫并發(fā)癥（心律失常）與亞低溫復溫治療有關(guān)目標患者復溫階段未發(fā)生休克，心律失常次數(shù)減少措施做好復溫階段的護理。遵醫(yī)囑用藥，密切監(jiān)測體溫變化，生命體征，記錄24出入量，CVP；監(jiān)測血糖防止體溫上升過快，由于血管擴張，回心血量減少，血壓下降而發(fā)生低血容量休克；如體溫不升，可增加蓋被等。CompanyLogo05-1709點停萬可松，10:30球囊反搏調(diào)為1:2。15:45拔出球囊反搏置管。停亞低溫治療。停靜安？停去甲腎？患者可睜眼，能明白言語，神志清。痰液呈黃白色。停亞低溫治療。右下肢腫脹，皮溫高。新護理問題有發(fā)生血栓的危險與IABP治療有關(guān)目標患者住院期間溶栓成功或血栓未脫落措施定時測量雙側(cè)下肢大腿圍，觀察下肢皮溫，足背動脈搏動情況。防止右下肢肢體動作過大。CompanyLogo05-1808:20試停呼吸機，08:30遵醫(yī)囑拔出氣管導管，給予雙腔鼻導管吸氧5L/分。18點T38.7x℃。17日血常規(guī)示白細胞計數(shù)14.44×10^9/L，中性粒細胞91.20%，中性粒細胞計數(shù)13.17×10^9/L，淋巴細胞4.60%。新護理問題體溫過高與感染有關(guān)目標患者3天內(nèi)體溫下降至正常措施遵醫(yī)囑使用物理降溫，1小時后復測體溫。做好降溫護理CompanyLogo05-1909點停多巴胺。發(fā)生肛周失禁性皮炎。新護理問題肛周失禁性皮炎目標患者一周內(nèi)皮炎恢復措施使用液體敷料噴涂。增加翻身次數(shù)。保持局部清潔干燥。CompanyLogo05-20右下肢腫脹好轉(zhuǎn)05-21肛周失禁性皮炎好轉(zhuǎn),右下肢腫脹消退。CompanyLogo護理評價（05-23）患者生命體征平穩(wěn)，尿量正常，但仍有心衰的可能患者完全恢復自主呼吸患者有感染發(fā)生，體溫暫正?；颊咦≡浩陂g無壓瘡發(fā)生患者能得到機體所需的能量供應(yīng)患者有室早的發(fā)生患者皮炎好轉(zhuǎn)，右下肢腫脹消退CompanyLogoYourcompanysloganThankYou!8686贈送2套亮麗色表格可一鍵刪除折線圖/表格/數(shù)據(jù)關(guān)系Trending

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