心臟疾病患者的護(hù)理課件

心臟疾病患者的護(hù)理邱愛(ài)富心臟疾病患者的護(hù)理邱愛(ài)富1心臟血管系統(tǒng)的解剖

生理功能

邱愛(ài)富

心臟血管系統(tǒng)的解剖

生理功能

2一、心臟的構(gòu)造與功能:

heartsize:拳頭，250-350gmheartlocation:2/3胸骨中線左側(cè)；Base:2nd肋骨；Apex:5th肋間&L’t鎖骨中線heartfunction:deliverO2andotheressentialsubstitutetotissueofbodyremoveCO2&代謝產(chǎn)物一、心臟的構(gòu)造與功能:

heartsize:拳頭，2503心臟壁層:心包膜(pericardium)1)

外層(壁心包膜)：纖維性—防止heart過(guò)度擴(kuò)張、有保護(hù)、固定2)

內(nèi)層(臟心包膜)：漿膜性—兩層間為心包膜腔，含15-50cc心包膜液，可防止收縮時(shí)的磨擦

心外膜(epicardium);心肌(myocardium)--不隨意肌，具橫紋及分枝的纖維，有收縮作用心內(nèi)膜(endocardium)心臟壁層:心包膜(pericardium)4Coronaryvasculature Rightcoronaryartery(RCA）、Leftmain--Leftanteriordescendingartery(LAD)、Leftcircumflex(LCX)Ascendingaorta(75%atdiastolic)

RCA(supplyRA,RV,postLV,90%AVnode)

Leftmain

LAD(supplyAnt.LV,apex)、LCX(supplylateralLV,LA)

Coronaryvasculature Rightcor5TheCardiacCycleBloodCirculationCircuitsPulmonaryCircuit–lungsSystemicCircuit-wholebodyCardiacCycleSystole–contractionDiastole–relaxationAtriarelaxwhenVentriclescontractandviceversa

TheCardiacCycleBloodCircula6StepsinacontractionWhenatriafillpressureopensAVvalvesAtriacontractionfillsventriclescompletelyVentriclesbegintocontractandAVvalvessnapshut(LUB)Increasedcontraction(inc.pressure)forcessemilunarvalvesopenBloodflowsintovesselsleadingaway.PressureincreasesandforcesSLvalvesshut(DUB)Processbeginsagain

StepsinacontractionWhenatr7CardiacOutput心輸出量(CO)=心搏出量(SV)x心跳速率(HR)心搏出量(Strokevolume)：每一次心室收縮時(shí)所排出的血量，同時(shí)受到前負(fù)荷，後負(fù)荷及心臟收縮力的影響心輸出量的決定因素前負(fù)荷(preload):心室舒張末期,心肌所承受的張力後負(fù)荷(Afterload):心室收縮時(shí)所遭遇的阻力心臟收縮力(Contractility)心跳速率與節(jié)律(heartrate&rhythm)CardiacOutput心輸出量(CO)=心搏出量(8前負(fù)荷(Preload)Frank-Starling定律:舒張容積(=前負(fù)荷)

心室收縮強(qiáng)度

輸出容積(myocardiumfiberlength↑

preload↑

LVEDV↑

SV↑)

臨床上：以進(jìn)入心室的血量多寡為代表（一般用CVP及PAWP估計(jì)）前負(fù)荷(Preload)Frank-Starling定律:9Contractility收縮力Vpkfortheleftventricleisaround1.1–1.5m/sinhealthypatients.Inpatientswithcardiacfailureorlowcontractility/inotropythisfiguremightwellbeonly0.6or0.7m/sorevenless.Fortherightventriclethefigurewouldbe0.7to1.2inhealthypatients.

Contractility收縮力Vpkforthele10後負(fù)荷(Afterload)Ohm’slaw:R=

P/QSVR=(MABP–CVP)/CO(systemicvascularresistance)PVR=(MPAP–LAP)/CO(pulmonaryvascularresistance)臨床評(píng)估:SVRandPVRAhighBPmeansthattheventricleispushinguphillHighviscosityandvasoconstrictionmeanhardworkfortheventricle後負(fù)荷(Afterload)Ohm’slaw:Ahig11CardiacOutputTheamountofbloodejectedbytheleftventricleinoneminuteCO=HRXSVHeartrateis75beatsperminStrokevolumeis70mlperbeatBloodvolume??docalculation

CO=SVxHR=60-130cc/beatX75beat/min=4-8L/minCardiacOutputTheamountofbl12CardiacfunctionindexEjectionFraction心射出分率Is%ofbloodejectedwitheverybeat=SV/LVEDV=2/3=60-75%(Normal>50%)ReflectLVperformanceCardiacindex(CI)心臟指數(shù)Cardiacreserve心臟儲(chǔ)備量CardiacfunctionindexEjection13Cardiacindex(CI)心臟指數(shù)IsCOcorrectedfordifferencesinbodysize=CO/bodysurfacearea=2.5-4L/min/m2

/hemo/contract.htm

Cardiacindex(CI)心臟指數(shù)IsCOco14Cardiacreserve心臟儲(chǔ)備量Cardiacreserve=abilitytorespondtothedemandforincreasedCO(eg.Exercise,stress)Normal:300-400%Cardiacreserve心臟儲(chǔ)備量Cardiacr15ConductionSystemSinoatrialnode(SAnode)-RA,"fastest"autorhythmictissue(pacemaker,60-100bpm)Atrioventricularnode(AVnode)-lastpartofatriatodepolarizesignalhesitatesthenproceedstoventricles(40-60bpm)AVbundle(bundleofHis)-connectsatriatoventriclesRtandLtbundlebranches-sendsignaltoapexofheartPurkinjefibers-actionpotentialsentthroughoutventricletissue(20-40bpm)

ConductionSystemSinoatrialno16

心臟電氣生理特性自律性(Automaticity)—心肌自動(dòng)去極化的能力，規(guī)則自動(dòng)的激發(fā)衝動(dòng)(Impulses)的能力，主要由SAnode擔(dān)任Pacemaker激搏點(diǎn)興奮性(Excitability)--心肌對(duì)於刺激產(chǎn)生去極化的能力(被衝動(dòng)激發(fā)產(chǎn)生興奮)傳導(dǎo)性(Conductivity)--心肌經(jīng)由細(xì)胞膜傳送刺激衝動(dòng)的能力不反應(yīng)期(Refractoriness)--心肌仍然處?kù)肚耙淮碳ぶ湛s，無(wú)法對(duì)於新刺激反應(yīng)的時(shí)期心臟電氣生理特性自律性(Automaticity)—心肌自17

NeurologicControloftheHeartAutonomicnervoussystem(自主神經(jīng)的控制)Sympathic

NE

β1

↑HR,contractility

↑CO,BPParasympathic

ACH

↓HR,contractility

NeurologicControloftheHe18壓力接受器(Baroreceptor)與化學(xué)接受(Chemoreceptor)壓力接受器(Baroreceptor：位於頸動(dòng)脈竇、主動(dòng)脈竇、心房BP↑

baroreceptor

trasfermassagetovasomotorcenteratmedula

stimulateparasymp.inhibitsymp.

↓HR,contractility化學(xué)接受器(Chemoreceptor)：位於頸動(dòng)脈體、主動(dòng)脈體附近PO2,PH,PCO2↓

stimulatechemreceptor

vasomotorcenter

↑c(diǎn)ardiacactivity

↑PO2壓力接受器(Baroreceptor)與化學(xué)接受(Chem19

心臟血管疾病的評(píng)估及診斷檢查

Nursingassessment:history,GoldenPhysicalexaminationDiagnostictestsLaboratoryHemodynamicmonitoringNon-invasivetestsECG,Treadmill,Echo,Nuclearcardiology,CT,MRIInvasivetestsCardiaccatheterization,Coronaryangiography,electrophysiologicstudy(EPS),endomyocardialbiopsy(EMB),TEE,IVUS心臟血管疾病的評(píng)估及診斷檢查Nursingasse20NursingassessmentMaincomplaint:chestpain,dyspnea,fatigue,edema,palpitation,syncopeHistoryofpresentillness:onset,signs&symptomsPastmedicalhistory:previousillness,injuries,surgery,medicationRiskfactors:familyhistory,smoking,activity,diet,personalityGolden’s11functionalhealthpatterns

NursingassessmentMaincompla21ChestPainAssessmentAssessment

AnginaPericarditisProvocation/PalliationExercise/restDeepbreath,平躺/前傾、坐起Quality/Quantity壓迫感、沉重、消化不良感尖銳如刀割Region/Radiation胸骨、頸、左手臂、肩↑Severity中度中至重度Time/onset,duration<10minSeveralhrstodaysChestPainAssessmentAssessmen22DyspneaSOB(shortofbreath)呼吸短促DOE(Dyspneaonexercise/exertion)運(yùn)動(dòng)時(shí)呼吸困難,最常見(jiàn)於walk,crimbstairOrthopnea端坐呼吸,無(wú)法平躺，半坐臥緩解PND(paroxysmalnocturnaldyspnea)夜間陣發(fā)性呼吸困難,

DyspneaSOB(shortofbreath)呼23Physicalexamination-Inspection

skin:centralcyanosis(lip,mouth,conjundival)

poorarterialcirculationperipheralcyanosis(lip,ear,nail)

peripheralvasoconstrictionEyes:arcussenitis老人弓,Xanthelasma黃斑瘤

atherosclerosisPhysicalexamination-Inspecti24Physicalexamination-InspectionFingersclubbing杵狀指

PO2↓orlungcancerCapillaryrefill(circulation):pressnailtobranches,colorreturn<2secPhysicalexamination-Inspecti25Physicalexamination-InspectionSkintugor(elastrictry):捏起skin,returntime>30sec

dehydration,BW↓Edema:press5sec,remove(+<1/4”,++1/4”-1/2”,+++1/2”-1”)Physicalexamination-Inspecti26Physicalexam-VitalsignBP:bilateralBP:L’t&R’tSBPdifference>15mmHg

↓aortabloodflowinlowerarmPulsepressure:SBP-DBP=30~50,OrthostaticBP:lying-standing>20

dehydration,poorHTN,aortadiseasePhysicalexam-VitalsignBP:27Physicalexam-Vitalsignpulse:rate,rhythm,amplitude,bilateralpulsusparadoxus(奇脈):pulsechangewith呼吸,吸氣

pulseweaken,BP↓pulsusalternanus(交替脈):pulsechangewithHR,

pulsation:0=none,+=weak,++=normal,+++=strongPhysicalexam-Vitalsignpulse:28PhysicalexaminationCarotidartery:thrill,bruit(vesselmurmur):arterialnarrowing

Jugularveinpressure(JVP)<2cm

Hepatojugularreflux

PhysicalexaminationCarotid29PhysicalexaminationPalpation&AuscultationofprecordiumAreas:aortic,pulmonary,tricuspid,mitral,apex,PMIS1,S2,Abnormalheartsounds:murmur,click,frictionrubPhysicalexaminationPalpation30Diagnosticstudies

Laboratory：CBC,e-,Cholesterol,HDL,LDL,TG,cardiacenzymes(CPK-MB,LDH,troponinT&I,myoglobin)

PT(prothrombintime),(Internationalnormalizedratio;INR)、PTT,BUN,Cre,glucose

HemodynamicmonitoringCVP=4~12cmH2O;reflectRApressureSwan-Ganz:PAWP

Diagnosticstudies

Laboratory：31EKGEKG3212leadEKG雙極肢體導(dǎo)程(縱切面):I,II,III單極肢體導(dǎo)程(縱切面):aVR,aVL,aVF胸導(dǎo)程(橫切面):V1,V2,V3,V4,V5,V6

12leadEKG雙極肢體導(dǎo)程(縱切面):I,II,33NormalEKGNormalEKG34HolterMonitoring

canrecordheartrateandrhythmwhenpatientsfeelchestpainorsymptomsofanarrhythmiaovera24-hourperiodAmbulatoryECG;DynamicECGDevelopedin1960s

HolterMonitoringcanrecordh35

ExerciseStressTests

(Treadmill;運(yùn)動(dòng)心電圖)Dx:CAD,functionalcapacity

TargetHR=85%*maxHR

Positive:STdepression>1mmContraindications:UnstableanginawithrecentchestpainCriticalaorticstenosisSeverehypertrophicobstructivecardiomyopathyUntreatedlife-threateningcardiacarrhythmiasUncompensatedcongestiveheartfailureAdvancedAVblockAcutemyocarditisorpericarditisUncontrolledhypertension

ExerciseStressTests(Treadm36Echocardiography超音波usessoundwavestoproduceanimageoftheheartandtoseehowitisfunctioning.Transducer

highfrequency,shortwave

return

示波鏡、描繪圖

影像showthesize,shape,andmovementoftheheartmuscle,valvesdisease,bloodflow,arteries.TypesMotion-mode(收縮、活動(dòng)),2Dimensional-echo(縱、橫向結(jié)構(gòu)),Doppler(血流方向、流速)Echocardiography超音波usessound37TransesophagealEchocardiography

(TEE)Thetestislikestandardechocardiographyexceptthatthepicturesoftheheartcomefrominsidetheesophagusratherthanthroughthechestwall.NPO6-8hourssprayingthroatwithananestheticatube(probe)putdownthethroatGagreflexreturn,theneating

TransesophagealEchocardiograp38IntravascularUltrasound

(IVUS)isacombinationofechocardiographyandcardiaccatheterization.usessoundwaves,whicharesentthroughacathetertoarteryandheart,toproduceanimageofthecoronaryarteriesandtoseetheircondition.israrelydonealoneorasastrictlydiagnosticprocedure.Itisusuallydonewithatranscatheterinterventionlikeangioplasty.

IntravascularUltrasound

(IVU39ChestXrayMostcommonlyperformedimagingtestforCVsystemForevaluationofcardiacchambersizeandgreatvesselsChestXraywithenlargedheartsizeChestXrayMostcommonlyperfo40Nuclearcardiology(心臟核子醫(yī)學(xué)檢查)Ejectionfraction+wallmotionEvaluationofcardiacperformanceandregionalwallmotionLeftventriculardiastolicphaseindex(MUGA)UsefulforevaluationofdiastolicfunctionPatientswithatrialfibrillationNuclearcardiology(心臟核子醫(yī)學(xué)檢查)E41NuclearcardiologyTl-201Singlephotonemissioncomputedtomography(SPECT)

MyocardialperfusionimagingTETTl-201,PersantinTl-201Positronemissiontomography(PET)MyocardialbloodflowandmyocardialviabilityNuclearcardiologyTl-201Singl42NuclearCardiologyTc99鎝同位素(hotspot)：與壞死心肌之Ca++結(jié)合

聚集於受損或梗塞之心肌部位

凸顯梗塞之心肌部位

l

MI4hours可發(fā)現(xiàn)，24-72hrs最靈敏

Thallium201myocardialimaging鉈(coldspot):測(cè)心肌灌注情形

聚集於心肌供血處，灌注好

分佈均勻，缺血處

無(wú)法進(jìn)入

空白冷點(diǎn)(coldspot)NuclearCardiologyTc99鎝同位素(ho43Computedtomography(CTscan)Cardiacdimensions,calcificationsandfunctionIschemicheartdisease,LVaneurysm,etc.PericardialdiseasePericardialeffusion,constrictivepericarditis,pericardialcystParacardiac,pericardialandcardiacmassesCongenitalheartdiseaseDiseaseofthethoracicaortaAorticdissection,aorticaneurysmPulmonaryembolismComputedtomography(CTscan)C44MagneticResonanceImaging(MRI)

Providea2-Dviewoftheheart,includingthechambersandvalves,withouthavingtoinjectadyeorinsertacatheter.InterferewithpacemakerfunctionCan’tusewithprostheticmetallicdevices(valves,prostheticjoints,pacemakeretc.MagneticResonanceImaging(MR45InvasivetestsCardiaccatheterizationCoronaryangiography(CAG)Electrophyiologicstudy(EPS)Endomyocardialbiopsy(EMB)InvasivetestsCardiaccatheter46心導(dǎo)管術(shù)的功能有哪些？

在檢查方面可以達(dá)到顯影評(píng)估心臟功能、血流的情況或是血管阻塞的情形、記錄心臟氧氣變化、測(cè)量心臟電位、測(cè)量心臟血管各部位的壓力等。在治療方面可以利用氣球擴(kuò)張術(shù)或置入支架撐開(kāi)阻塞的血管段、將心律不整的原因給予電燒灼，以及放置心律調(diào)整器等。心導(dǎo)管術(shù)的功能有哪些？在檢查方面可以達(dá)到顯影評(píng)估心臟功能、47心導(dǎo)管檢查前需注意之事項(xiàng)

由醫(yī)師解釋心導(dǎo)管檢查的利弊，並簽寫(xiě)同意書(shū)。禁食4-6小時(shí)。檢查部位（穿刺部位）毛髮剔除。檢查四肢末梢動(dòng)脈循環(huán)及做上記號(hào)。須換上手術(shù)衣，並取下假牙、義眼、眼鏡、及所有飾物等。檢查前先排空膀胱。心導(dǎo)管檢查前需注意之事項(xiàng)由醫(yī)師解釋心導(dǎo)管檢查的利弊，並簽寫(xiě)48施行心導(dǎo)管之禁忌癥

絕對(duì)禁忌病患拒絕設(shè)備或儀器不足相對(duì)禁忌控制不良之心臟衰竭,高血壓,心律不整一個(gè)月以內(nèi)之腦中風(fēng)發(fā)燒/感染電解質(zhì)不平衡急性消化道出血懷孕易出血之體質(zhì)或情形無(wú)法合作之病人腎衰竭施行心導(dǎo)管之禁忌癥絕對(duì)禁忌49Cardiaccatheterization

post-cath：vitalsign:q15min*4→q30min*2(or4)→q1h股動(dòng)脈:bedrest