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

2、e leaflets adhesion, fusion,主動(dòng)脈瓣狹窄,aortic stenosis,主動(dòng)脈瓣 開口面積減少,肺靜脈高壓 右心衰竭,左心室射血負(fù)荷,左室向心性肥厚,左心室收縮功能,心排血量下降,室壁張力,順應(yīng)性下降,室壁張力,左心衰,病理生理pathophysiology,Pulmonary venous hypetension,心內(nèi)膜下心肌缺血和灌注不足,aortic stenosis,腦血流灌注下降,左心室做功,心肌耗氧量,順應(yīng)性下降,舒張末壓力,CO,冠狀動(dòng)脈平均灌注壓,心絞痛,暈厥,Angina pectoris,Syncope,急性Acute :,1.感染性心內(nèi)膜炎

3、Infective endocarditis 2.主A夾層 Aortic dissection 3.外傷 Trauma 4.人工瓣膜撕裂 Prosthetic valve tear,慢性Chronic:,主動(dòng)脈瓣疾病 Aortic valve disease,2/3為風(fēng)心病,主動(dòng)脈根部擴(kuò)張 Aortic root dilatation,主動(dòng)脈瓣關(guān)閉不全的病因 Causes of aortic incompetence,主動(dòng)脈瓣纖維化、增厚、縮短、變形,主動(dòng)脈瓣關(guān)閉不全,Aortic valves incompetence,主動(dòng)脈內(nèi)血液在舒張期返流入左室,偏心性肥厚、擴(kuò)大,左心衰,左心室容量負(fù)荷

4、,Sp、Dp,左心室舒張末期壓力,CO,室壁張力,心絞痛,pulmonary hypertension,右心衰,pathophysiology,反流面積的大小,心動(dòng)周期舒張期的長短,體循環(huán)血管阻力,AI reverse flow,Reverse flow aera of the size,Beckoning cycle diastolic length,Systemic vascular resistance,雙擊添加標(biāo)題文字,急性主動(dòng)脈瓣關(guān)閉不全,CO減少，低BP,急性左心衰竭,急性AI,What is valve replacemeng surgery,瓣膜置換術(shù)是用人工機(jī)械瓣或生物瓣進(jìn)行

5、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(dòng)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(dòng)后心悸、氣促、乏力伴呼吸困難，休息后無明

6、顯緩解一月余，于2011年2月10日以“非風(fēng)濕性主動(dòng)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 on December 10th,2014.because dizziness, chest pain have last three years, heart palpitation and shortness of breath with increased activities , and exertional dyspnea lasting o

7、ver a month.,Medical History,手術(shù)史Surgical operation history 2004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)” “neurogenic 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 w

8、idening of aortic diameter 2、Mild mitral incompetence, and mild tricuspid incompetence 3、The decreasing of left ventricular diastolic function , LVD：70mm,EF:55%,心臟彩超： 1、主動(dòng)脈瓣病變： 主動(dòng)脈瓣中度關(guān)閉不全并中度狹窄， 升主動(dòng)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(dòng)脈迂曲增寬 Aorta becomes widened and tortuous

9、 左室增大 left ventricle becomes bigger,診治經(jīng)過,2月16日前完善術(shù) 前準(zhǔn)備,2月17日-19日在ICU治療,2月20日患 者病情平穩(wěn) 搬回病房。,Preoperative preparation was completed before December 16th.,The patient was stablly moved back to the ward on December 20th,病 情,2月17日在全麻CPB下行主動(dòng)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

10、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 icu 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. T

11、he 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/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(lì)進(jìn)食。,The heart rate of the patient and 95-110times/min. BP by dopamine 4.9ug/kg/min, mai

12、ntained 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 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

13、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, 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 intervention,（一）低效性呼吸型態(tài) 1、加強(qiáng)呼吸道護(hù)理

14、，聽診雙肺呼吸音，定時(shí)拍背、霧化， 鼓勵(lì)患者咳嗽、咳痰。 Strengthen respiratory care, auscultation of lung breath sound, timed back patting ,and atomization ,and 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, a

15、nd oxygen saturation.,（一）低效性呼吸型態(tài),3、定時(shí)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 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 presc

16、ription 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)異常要及時(shí)報(bào)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.,nur

17、sing 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 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(shí)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

18、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 output) (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(lì)患者進(jìn)食 Encourage patients to eat,nursing i

19、ntervention,（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，生物瓣術(shù)后抗凝3-6個(gè)月。要定時(shí)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

20、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 monitoring 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 Education,Prevention

21、 of infection,Diet,Periodic review,Medication guide,Activity and rest,Self-test,用藥指導(dǎo) Medication guide,華法林只在體內(nèi)抗凝，通過拮抗維生素K而產(chǎn)生藥理作用。常用INR(國際標(biāo)準(zhǔn)化比值)評價(jià) Warfarin anticoagulation only in the body, vitamin K antagonism generated by pharmacological effects. Common INR (international normalized ratio) evaluatio

22、n,記住服藥時(shí)間要固定哦！,Diet,It is best for you to have more nourishing food and easily- digested 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. Avoid cigarettes, alcohol, coffee and spicy food. Patients with poor cardiac function should limit sodium intake . Patients should observe the changes in body weight.,保持飲食結(jié)構(gòu)的相對平衡,應(yīng)進(jìn)食富含營養(yǎng)，易于消化的食物，報(bào)告高蛋白、高維生素等，同時(shí)，應(yīng)少食多餐，養(yǎng)成良好飲食習(xí)慣。 禁忌煙酒、咖啡及刺激性食物。 心功能較差的病人要限制鈉鹽的攝入；應(yīng)用利尿劑的病人，注意觀察尿量及