心臟疾病患者的護(hù)理

1、心臟疾病患者的護(hù)理,邱愛(ài)富,心臟血管系統(tǒng)的解剖生理功能 邱愛(ài)富,,一、心臟的構(gòu)造與功能:,heart size: 拳頭，250-350 gmheart location: 2/3 胸骨中線(xiàn)左側(cè)；Base:2nd肋骨；Apex:5th肋間& L’t鎖骨中線(xiàn)heart function:deliver O2 and other es

2、sential substitute to tissue of bodyremove CO2 &代謝產(chǎn)物,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15-50 cc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

3、用心內(nèi)膜(endocardium),Coronary vasculature,Right coronary artery (RCA）、Left main--Left anterior descending artery (LAD)、Left circumflex (LCX)Ascending aorta (75% at diastolic) ?RCA (supply RA, RV, post LV, 90% AV node)?

4、Left main? LAD (supply Ant. LV, apex)、LCX (supply lateral LV, LA),The Cardiac Cycle,Blood Circulation CircuitsPulmonary Circuit – lungsSystemic Circuit - whole bodyCardiac CycleSystole – contractionDiastole – relax

5、ationAtria relax when Ventricles contract and vice versa,Steps in a contraction,When atria fill pressure opens AV valvesAtria contraction fills ventricles completelyVentricles begin to contract and AV valves snap shut

6、 (LUB)Increased contraction (inc. pressure) forces semilunar valves openBlood flows into vessels leading away. Pressure increases and forces SL valves shut (DUB)Process begins again,Cardiac Output,心輸出量(CO) = 心搏出量(SV)

7、x 心跳速率(HR)心搏出量(Stroke volume)：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 (heart rate & rhythm),前負(fù)荷(Preload),Frank-Starling 定律:

8、 舒張容積 (=前負(fù)荷) ? 心室收縮強(qiáng)度 ? 輸出容積 (myocardium fiber length↑? 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)）,Contractility收縮力,Vpk for the left ventricle is around 1.1 – 1.5 m/s in healthy patients. In patients wit

9、h cardiac failure or low contractility/inotropy this figure might well be only 0.6 or 0.7 m/s or even less. For the right ventricle the figure would be 0.7 to 1.2 in healthy patients.,後負(fù)荷(Afterload),Ohm’s law: R = ? P/

10、Q SVR = (MABP – CVP)/CO (systemic vascular resistance)PVR = (MPAP – LAP)/CO (pulmonary vascular resistance)臨床評(píng)估: SVR and PVR,A high BP meansthat the ventricle is pushing uphill,High viscosity and vasoconstriction me

11、an hard work for the ventricle,Cardiac Output,The amount of blood ejected by the left ventricle in one minuteCO = HR X SVHeart rate is 75 beats per minStroke volume is 70 ml per beatBlood volume?? do calculationCO=

12、SVxHR = 60-130 cc/beat X 75 beat/min = 4-8 L/min,Cardiac function index,Ejection Fraction心射出分率Is % of blood ejected with every beat=SV/LVEDV=2/3=60-75% (Normal>50%)Reflect LV performance Cardiac index(CI) 心臟指數(shù)Car

13、diac reserve 心臟儲(chǔ)備量,Cardiac index(CI) 心臟指數(shù),Is CO corrected for differences in body size=CO/body surface area= 2.5-4 L/min/m2,www.learnhemodynamics.com/hemo/contract.htm,Cardiac reserve 心臟儲(chǔ)備量,Cardiac reserve= ability to r

14、espond to the demand for increased CO (eg. Exercise,stress)Normal: 300-400%,Conduction System,Sinoatrial node (SA node) - RA, "fastest" autorhythmic tissue (pacemaker, 60-100 bpm)Atrioventricular node (AV nod

15、e) - last part of atria to depolarize signal hesitates then proceeds to ventricles (40-60 bpm)AV bundle (bundle of His) - connects atria to ventriclesRt and Lt bundle branches - send signal to apex of heartPurkinje fi

16、bers - action potential sent throughout ventricle tissue (20-40 bpm),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SA node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)--

17、 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,Neurologic Control of the Heart,Autonomic nervous system (自主神經(jīng)的控制)Sympathic ? NE ?β1 ?↑HR, contractility?↑CO,BPParasympathic? ACH ?↓HR, contractility,

18、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?trasfer massage to vasomotor center at medula ?stimulate parasymp. inhibit symp.? ↓HR, contractility化學(xué)接受器(Chemoreceptor)：位於頸動(dòng)脈體

19、、主動(dòng)脈體附近PO2, PH, PCO2↓? stimulate chemreceptor? vasomotor center?↑c(diǎn)ardiac activity ?↑PO2,??心臟血管疾病的評(píng)估及診斷檢查??,Nursing assessment: history, GoldenPhysical examinationDiagnostic testsLaboratoryHemodynamic monitoringNon-

20、invasive testsECG, Treadmill, Echo, Nuclear cardiology, CT, MRIInvasive testsCardiac catheterization, Coronary angiography, electrophysiologic study (EPS), endomyocardial biopsy(EMB), TEE, IVUS,Nursing assessment,Mai

21、n complaint:chest pain, dyspnea, fatigue, edema, palpitation, syncopeHistory of present illness:onset, signs & symptomsPast medical history:previous illness, injuries, surgery, medicationRisk factors: family hi

22、story, smoking, activity, diet, personalityGolden’s 11 functional health patterns,Chest Pain Assessment,Dyspnea,SOB (short of breath)呼吸短促DOE (Dyspnea on exercise/exertion)運(yùn)動(dòng)時(shí)呼吸困難, 最常見(jiàn)於walk, crimb stairOrthopnea端坐呼吸,無(wú)法

23、平躺，半坐臥緩解PND (paroxysmal nocturnal dyspnea)夜間陣發(fā)性呼吸困難,,Physical examination- Inspection,skin: central cyanosis (lip, mouth, conjundival)?poor arterial circulationperipheral cyanosis(lip, ear, nail)?peripheral vasoconstri

24、ctionEyes: arcus senitis老人弓, Xanthelasma黃斑瘤 ?atherosclerosis,Physical examination- Inspection,Fingers clubbing杵狀指? PO2↓or lung cancerCapillary refill (circulation): press nail to branches,color return<2 sec,Physical

25、 examination- Inspection,Skin tugor (elastrictry):捏起skin, return time>30 sec?dehydration, BW↓Edema: press 5 sec, remove(+<1/4”, ++ 1/4”-1/2”, +++1/2”-1”),Physical exam-Vital sign,BP: bilateral BP: L’t & R’t S

26、BP difference>15 mmHg?↓aorta blood flow in lower armPulse pressure:SBP-DBP=30~50,Orthostatic BP: lying-standing>20?dehydration, poor HTN, aorta disease,Physical exam-Vital sign,pulse: rate, rhythm, amplitude, bil

27、ateralpulsus paradoxus(奇脈): pulse change with呼吸, 吸氣? pulse weaken, BP↓pulsus alternanus(交替脈):pulse change with HR, pulsation:0=none, +=weak, ++=normal, +++=strong,Physical examination,Carotid artery: thrill, bruit(ves

28、sel murmur): arterial narrowingJugular vein pressure (JVP)<2 cm Hepatojugular reflux,Physical examination,Palpation & Auscultation of precordiumAreas: aortic, pulmonary, tricuspid, mitral, apex, PMIS1, S2, A

29、bnormal heart sounds: murmur, click, friction rub,Diagnostic studies,Laboratory：CBC, e-, Cholesterol, HDL, LDL, TG, cardiac enzymes ( CPK-MB, LDH, troponinT & I, myoglobin) PT(prothrombin time), (International norm

30、alized ratio; INR)、PTT, BUN, Cre, glucoseHemodynamic monitoringCVP=4~12 cmH2O; reflect RA pressureSwan-Ganz: PAWP,EKG,12 lead EKG,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,Nor

31、mal EKG,,Holter Monitoring,can record heart rate and rhythm when patients feel chest pain or symptoms of an arrhythmia over a 24-hour periodAmbulatory ECG; Dynamic ECGDeveloped in 1960s,Exercise Stress Tests (Treadmil

32、l;運(yùn)動(dòng)心電圖),Dx :CAD, functional capacityTarget HR=85%*max HRPositive: ST depression>1mmContraindications:Unstable angina with recent chest painCritical aortic stenosisSevere hypertrophic obstructive cardiomyopathy

33、Untreated life-threatening cardiac arrhythmiasUncompensated congestive heart failureAdvanced AV blockAcute myocarditis or pericarditisUncontrolled hypertension,Echocardiography超音波,uses sound waves to produce an image

34、 of the heart and to see how it is functioning.Transducer? high frequency, short wave? return?示波鏡、描繪圖?影像show the size, shape, and movement of the heart muscle, valves disease,blood flow, arteries.TypesMotion-mode(收縮、

35、活動(dòng)), 2 Dimensional-echo(縱、橫向結(jié)構(gòu)),Doppler(血流方向、流速),Transesophageal Echocardiography (TEE),The test is like standard echocardiography except that the pictures of the heart come from inside the esophagus rather than throug

36、h the chest wall. NPO 6-8 hours?spraying throat with an anesthetic?a tube (probe) put down the throat Gag reflex return,then eating,Intravascular Ultrasound (IVUS),is a combination of echocardiography and cardiac cat

37、heterization. uses sound waves, which are sent through a catheter to artery and heart, to produce an image of the coronary arteries and to see their condition. is rarely done alone or as a strictly diagnostic procedure

38、. It is usually done with a transcatheter intervention like angioplasty.,Chest X ray,Most commonly performed imaging test for CV system For evaluation of cardiac chamber size and great vesselsChest X ray with enlarge

39、d heart size,Nuclear cardiology (心臟核子醫(yī)學(xué)檢查),Ejection fraction + wall motionEvaluation of cardiac performance and regional wall motionLeft ventricular diastolic phase index (MUGA)Useful for evaluation of diastolic funct

40、ionPatients with atrial fibrillation,Nuclear cardiology,Tl-201 Single photon emission computed tomography (SPECT) Myocardial perfusion imagingTET Tl-201, Persantin Tl-201Positron emission tomography (PET)Myocardial

41、 blood flow and myocardial viability,Nuclear Cardiology,Tc99鎝同位素 (hot spot)：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     MI 4 hours可發(fā)現(xiàn)，24-72hrs最靈敏Thallium 201 myocardial imaging 鉈(cold spot):測(cè)心肌灌注情形

42、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)(cold spot),Computed tomography (CT scan),Cardiac dimensions, calcifications and functionIschemic heart disease, LV aneurysm, etc.Pericardial diseasePericardial effusion, constrictive pe

43、ricarditis, pericardial cystParacardiac, pericardial and cardiac massesCongenital heart diseaseDisease of the thoracic aortaAortic dissection, aortic aneurysmPulmonary embolism,Magnetic Resonance Imaging (MRI),Provi

44、de a 2-D view of the heart, including the chambers and valves, without having to inject a dye or insert a catheter.Interfere with pacemaker functionCan’t use with prosthetic metallic devices (valves, prosthetic joints,

45、 pacemaker etc.,Invasive tests,Cardiac catheterizationCoronary angiography (CAG)Electrophyiologic study (EPS)Endomyocardial biopsy (EMB),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

46、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。,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)

47、月以?xún)?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,Cardiac catheterization,post-cath：vital sign: q15min *4 → q30 min *2 (or 4) → q1h股動(dòng)脈:bed rest 6-8 hours, compress 4-6 hrs橈動(dòng)脈: bed rest 1-2 hours, compress 2 hrsch

48、eck wound: bleeding？infection？check P+P (pulsation&perfusion)？complications：bleeding, hemotoma, dye allergy, arrhythmia, thrombus,EPS (Electrophysiologic study),understand arrhythmia mechanism (eg. Additional pathw

49、ay)effects of drugs and ablationdecide the need of pacemaker,Endomyocardial Biopsy(EMB),International Society for Heart & Lung Transplantation Endomyocardial Biopsy Grading Scheme,Review,Anatomy and physiology of t