主动脉瓣置换术后的护理课件

主动脉瓣置换术围手术期的护理Thenursingofaorticvalvereplacement1正常的主动脉瓣有三个瓣叶:左半月瓣、右半月瓣和后半月瓣2心室舒张期

Ventriculardiastole心室收缩期Ventricularsystole34主动脉瓣狭窄的病因

Causesofaorticstenosis先天性畸形Congenitalmalformations老年性主动脉瓣钙化Senileaorticvalvecalcification风湿性心脏病Rheumaticheartdisease主动脉瓣叶粘连、融合Aorticvalveleafletsadhesion,fusion5主动脉瓣狭窄aorticstenosis主动脉瓣开口面积减少肺静脉高压右心衰竭左心室射血负荷左室向心性肥厚左心室收缩功能心排血量下降室壁张力顺应性下降室壁张力

左心衰病理生理pathophysiologyPulmonaryvenoushypetension6

心内膜下心肌缺血和灌注不足aorticstenosis脑血流灌注下降左心室做功心肌耗氧量顺应性下降舒张末压力CO冠状动脉平均灌注压心绞痛晕厥AnginapectorisSyncope78急性Acute:1.感染性心内膜炎Infectiveendocarditis2.主A夹层

Aorticdissection3.外伤Trauma4.人工瓣膜撕裂Prostheticvalvetear慢性Chronic:主动脉瓣疾病Aorticvalvedisease2/3为风心病主动脉根部扩张Aorticrootdilatation主动脉瓣关闭不全的病因

Causesofaorticincompetence主动脉瓣纤维化、增厚、缩短、变形9主动脉瓣关闭不全Aorticvalvesincompetence主动脉内血液在舒张期返流入左室偏心性肥厚、扩大左心衰左心室容量负荷Sp

、Dp

左心室舒张末期压力CO室壁张力心绞痛pulmonaryhypertension右心衰pathophysiology10反流面积的大小

心动周期舒张期的长短

AI反流量体循环血管阻力AIreverseflowReverseflowaeraofthesizeBeckoningcyclediastoliclengthSystemicvascularresistance11双击添加标题文字急性主动脉瓣关闭不全左心室舒张期充盈量突然增加压力迅速增高左房压、肺静脉压迅速升高急性肺水肿心动过速以减少反流量增加CO二尖瓣舒张期提前关闭，缓解左房和肺静脉受左心室高舒张压的影响CO减少,低BP急性左心衰竭

急性AI

12Whatisvalvereplacemengsurgery瓣膜置换术是用人工机械瓣或生物瓣进行替换人心脏瓣膜进行置换Valvereplacementsurgeryistousemechanicalvalvesorbiologicalvalvestoreplaceoriginalhumanvalves.13主动脉瓣置换术14

病例介绍CaseIntroduction15病史medicalhistory罗菊梅,女,40岁,云南镇雄人PatientJumeiLuo,female,40yearsold,fromZhenxionginYunnanprovince.患者因头昏、胸痛3年,近一年来加重,活动后心悸、气促、乏力伴呼吸困难,休息后无明显缓解一月余,于2011年2月10日以“非风湿性主动脉瓣狭窄并关闭不全”收住ShewasadmittedtothehospitalforNon-rheumaticaorticstenosisandincompetenceonDecember10th,2014.becausedizziness,chestpainhavelastthreeyears,heartpalpitationandshortnessofbreathwithincreasedactivities,andexertionaldyspnealastingoveramonth.16MedicalHistory

手术史Surgicaloperationhistory2004年行“卵巢囊肿摘除术”"ovariancyst"in2004,2011年行“右上臂神经源性肿瘤切除术”“neurogenictumorresectionofrightarm”in2011

过敏史Allergichistory双黄连17Echocardiography:1、Aorticvalvedisease:moderateaorticincompetence,moderateaorticstenosis,andthewideningofaorticdiameter2、Mildmitralincompetence,andmildtricuspidincompetence3.Thedecreasingofleftventriculardiastolicfunction,LVD：70mm,EF:55%18心脏彩超：1、主动脉瓣病变：主动脉瓣中度关闭不全并中度狭窄，升主动脉内径增宽。2、二尖瓣轻度关闭不全三尖瓣轻度关闭不全3.左心舒张功能降低LV：70mm,EF:55%19DX检查:主动脉迂曲增宽Aortabecomeswidenedandtortuous左室增大leftventriclebecomesbigger20诊治经过2月16日前完善术前准备2月17日-19日在ICU治疗2月20日患者病情平稳搬回病房。Preoperative

preparationwascompletedbeforeDecember16th.ThepatientwasstabllymovedbacktothewardonDecember20th21病情2月17日在全麻CPB下行主动脉瓣置换术，术毕于12:50分带气管插管返ICU，呼吸机辅助呼吸，清醒后，查血气示正常，于22:30分拔出气管插管改面罩供氧。血氧饱和度99--100％，患者咳嗽咳痰力量稍差Ondecember17th,theaorticvalvereplacementwascompletedundergeneralanesthesiaCPB,andthepatientreturnedtheicuat12:50withventilatorbreathing.Afterwaking,herbloodcheckshowednormal,sopulledoutendotrachealintubationanditwasreplacebyoxygenmasks.Theoxygensaturationwasrespectively99%--100％.Patientswithcoughandexpectorationsomewhatlesspower.22病情HR95-110次/分,为窦性心律。BP由多巴胺4.9ug/kg/min,维持在88-122/65-84mmhg,CVP14-7,容量欠,引流液不多,总量为500ml,尿色、尿量正常,精神饮食稍差,鼓励进食。Theheartrateofthepatientand95-110times/min.BPbydopamine4.9ug/kg/min,maintainedat88-122/65-84mmhg.Centralvenouspressurewas9-10.Drainageoffluidwasnormal,Thetotalamountoffluiddrainageis500ml.Urinewasnormal,patient'sspiritanddietwasslightlypoor.Shewasencouragedtoeat.23护理问题NursingProblem

低效性呼吸型态（Ineffectivebreathingpattern）与手术及术后伤口疼痛致咳痰无力有关operation

andpostoperative

woundpaininduced

sputumweakness

心输出量减少(decreasedcardiacoutput):与心脏疾病、体液不足有关Associatedwithheartdisease,insufficientbodyfluid

潜在并发症（potentialcomplication）抗凝不足或抗凝过度Inadequateorexcessiveanticoagulation、24护理措施

nursingintervention（一）低效性呼吸型态1.加强呼吸道护理，听诊双肺呼吸音，定时拍背、雾化，鼓励患者咳嗽、咳痰。Strengthenrespiratorycare,auscultationoflungbreathsound,timedbackpatting,andatomization,andencourgepatientstocoughandexpectorate.252.持续心电监护，严密观察心率、血压、呼吸、血氧饱和度ContinuousECGmonitoring,andcloseobservationofheartrate,bloodpressure,respiration,andoxygensaturation.（一）低效性呼吸型态263、定时监测血气分析结果，根据病人的生命体征和血气情况，调整供氧方式及流量。Regularlymonitortheresultofbloodgasanalysisandadjustthewayandtheflowrateofoxygenofferbasedonthepatient‘svitalsignsandbloodgas.4.遵医嘱适当予以止痛剂，以减少病人呼吸肌做功Provideanalgesicsappropriatelyaccordingtoprescriptiontoreducetheactingofpatients'breathingmuscles.（一）低效性呼吸型态27(二)心输出量减少(decreasedcardiacoutput)（1）严密监测心律、HR、BP、CVP及末梢情况,发现异常要及时报告医生Keepclosemonitoringinthechangeofrhythm,HR,BP,CVPandPeripheralsituation,andreporttothedoctorpromptlywhenabnormalsituationisfound.nursingintervention28(二)心输出量减少(decreasedcardiacoutput)（2）运用血管活性药物,根据患者的生命体征进行调整Usevasoactivedrugs,andadjustaccordingtothepatient'svitalsigns29(二)心输出量减少(decreasedcardiacoutput)（3）引流管的监测Thedrainagetubemonitoring:定时挤压引流管保持引流管的通畅Squeezedrainagetuberegularlytokeepits'patency.观察引流液量及性质，Observethedrainageamountandnature.观察伤口有无渗血Observewhetherthereisbleedingornotinwound.30(二)心输出量减少(decreasedcardiacoutput)(4)准确记录出入量,注意水电解质平衡Recordintakeandoutputaccurately,andpayattentiontothebalanceofwaterelectrolyte.（5）鼓励患者进食Encouragepatientstoeat31nursingintervention（三）潜在并发症的预防和护理

1.抗凝不足与抗凝过度Inadequateanticoagulationandexcessiveanticoagulation

(1)、为避免血栓形成，机械瓣置换术后，需终身抗凝治疗，生物瓣术后抗凝3-6个月。要定时定量口服Explaintopatientstheimportanceoftakingwarfarinorally,TakeanticoagulantmedicineregularlyandquantitativelyThedoseis2.5-5milligram（2）、服药期间监测INR，使之维持在2.0～3.0.MonitorINRduringthemedicationtomaintainitat2.0to3.032（3）加强患者的监测,如有无皮肤青紫瘀斑、牙龈出血等Strengthenthemonitoringofpatients,suchastheskinbruising,andbleedinggums,etc.（4)、注意饮食对抗凝药物的影响Payattentiontotheinfuenceofdietonanticoagulants.33

HealthEducationPreventionofinfectionDietPeriodicreviewMedicationguideActivityandrestSelf-test34用药指导

Medicationguide华法林只在体内抗凝,通过拮抗维生素K而产生药理作用。常用INR(国际标准化比值)评价Warfarinanticoagulationonlyinthebody,vitaminKantagonismgeneratedbypharmacologicaleffects.CommonINR(internationalnormalizedratio)evaluation记住服药时间要固定哦！35DietItisbestforyoutohavemorenourishingfoodandeasily-digestedfood,includinghigh-protein,high-vitamins,andsoon.Atthesametime,youshouldhavemoremealswithlessfoodforeachmeal,developgoodlivinghabits.Avoidcigarettes,alcohol,coffeeandspicyfood.Patientswithpoorcardiacfunctionshouldlimitsodiumintake.Patientsshouldobservethechangesinbodyweight.保持饮食结构的相对平衡

应进食富含营养,易于消化的食物,报告高蛋白、高维生素等,同时,应少食多餐,养成良好饮食习惯。

禁忌烟酒、咖啡及刺激性食物。心功能