主动脉瓣置换术后的护理

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,主动脉瓣置换术后的护理,The nursing of aortic valve replacement,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,心室舒张期,Ventricular diastol,e,心室收缩期,Ventricular systol,e,主动脉瓣狭窄的病因Cause,s,of aortic stenosis,先天性,畸形,Congenital malformations,老年性,主动脉瓣,钙化,Senile aortic valve calcification,风湿性心脏病,Rheumatic heart disease,主动脉瓣叶粘连、融合,Aortic valve leaflets adhesion,fusion,主动脉瓣狭窄,aortic stenosis,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,pathophysiology,Pulmonary venous,hypetension,心内膜下心肌缺血和灌注不足,aortic,stenosis,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,Angina pectoris,Syncope,急性,A,cute,:,1.,感,染性心内,膜炎,Infective endocarditis,2.,主,A,夹层,Aortic dissection,3.,外伤,Trauma,4.,人,工瓣膜,撕裂,Prosthetic valve tear,慢性,Chronic,:,主动脉瓣疾病,Aortic valve disease,2/3,为风心病,主动脉根部扩张,Aortic root dilatation,主动脉瓣关闭不全的病因,Cause,s,of aortic,incompetence,主动脉瓣纤维化、增厚、缩短、变形,主动脉瓣关闭不全,Aortic valves incompetence,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,pulmonary hypertension,右心衰,pathophysiology,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,AI reverse flow,Reverse flow,aera,of the size,Beckoning cycle diastolic length,Systemic vascular resistance,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,What is valve,replacemeng,surgery,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,Valve replacement surgery is to,use,mechanical valve,s,or biological valve,s to re,place original human valves,.,主动脉瓣置换术,病例介绍,Case Introduc,tion,病史,medical history,罗菊梅，女，,40,岁,云南镇雄人,Patient,Ju,mei,L,uo,female,40 year,s,old,from Z,henxiong,in Yunnan province,.,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,2014,年,12,月,10,日以“非风湿性主动脉瓣狭窄并关闭不全”收住,She was admitted to the hospital,for,Non-rheumatic aortic,stenosis,and,incompetence,on December 10th,2014.,because,d,izziness,chest pain,have last three years,heart palpitation,and,shortness of breath,with,increased,activities,and,exertional dyspnea,lasting,over a month.,Medical,History,手术史S,urgical operation,history,2004,年行“卵巢囊肿摘除,术”,ovarian cyst,in 2004,2011,年行“右上臂神经源性肿瘤切除,术”,“neurogenic tu,mor resection,of,right arm”,in 2011,过敏史,Allerg,ic history,双,黄连,Echocardiography:,1、,Aortic valve disease:moderate aortic,incompetence,moderate,aortic,stenosis,and the widening of,aortic diameter,2、,Mild mitral,incompetence,and,mild tricuspid,incompetence,3、,The decreasing of l,eft ventricular diastolic function,LVD：70mm,EF:55%,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%,DX检查,：,主动脉迂曲增宽,A,orta,becomes widened and tortuous,左室增大,left ventricle,becomes bigger,诊治经过,12,月,16,日前完善术,前准备,12,月,17,日,-19,日在,ICU,治疗,12,月,20,日患,者病情平稳,搬回病房。,P,reoperative,preparation,was completed before December 16th,.,The,patient,was stablly,moved,back,to the ward,on December 20th,病 情,12,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,On december 17,th,the aortic valve replacement,was completed under,general anesthesia CPB,and,the patient,return,ed,the icu at 12:50,with,ventilator breathing,.,A,fter waking,her,blood,check,sho,wed,normal,so pulled out,endotracheal,intubation and it was replace by,oxygen masks,.The,oxygen,saturation,was respectively,99%-100,.Patients with cough and expectoration somewhat less power.,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。,The heart rate of the patient and,95-110times/min,.,BP by dopamine 4.9ug/kg/min,maintained at 88-1,22,/65-8,4,mmhg,.,Central venous pressure,was,9-10,.,Drainage of fluid,was,normal,The total amount of fluid drainage is,500ml,.,Urine was normal,patient,s spirit and diet,was slightly,poor,.She was,encouraged,to eat.,护理问题,Nursing Problem,低效性呼吸型态（Ineffective breathing pattern）,与手术及术后伤口疼痛,致咳痰,无力有关,operationand postoperativewound pain induced sputum weakness,心输出量减少,(decreased cardiac output),：,与心脏疾病、,体液,不足,有关,Associated with heart disease,insufficient,b,ody,fluid,潜在并发症（,potential complication,）,抗凝不足或抗凝过度,Inadequate or excessive anticoagulation、,护理措施,nursing intervention,（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。,Strengthen respiratory care,auscultation,of,lung breath sound,timed,back patting,and atomization,and,encourge,patients to cough,and,expectorat,e.,2、持续心电监护，严密观察心率、血压、呼吸、血氧饱和度,Continuous ECG monitoring,and,close observation of heart rate,blood pressure,respiration,and,oxygen saturation,.,（一）低效性呼吸型态,3,、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。,Regular,ly,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,、遵医嘱适当予以止痛剂，以减少病人呼吸肌做功,Provide,analgesics,appropriate,ly according to,prescri,ption,to reduce the,acting of,patient,s,breathing muscles,.,（一）低效性呼吸型态,(,二,),心输出量减少,(decreased cardiac output),（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,Keep close monitoring in the change of rhythm,HR,BP,CVP and Peripheral situation,and,report