1、主动动脉瓣置换术换术后的护护理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心室舒张期Ventricular diastole心室收缩期心室收缩期Ventricular systole主动脉瓣狭窄的病因Causes 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 lea
2、flets adhesion,fusion主动脉瓣狭窄aortic stenosis主动脉瓣主动脉瓣开口面积减少开口面积减少肺静脉高压肺静脉高压 右心衰竭右心衰竭左心室射血负荷左心室射血负荷左左室向室向心性肥厚心性肥厚 左心室收缩功能左心室收缩功能室壁张力室壁张力顺应性下降顺应性下降室壁张力室壁张力左心衰左心衰病理生理pathophysiologyPulmonary venous hypetensionaortic stenosis顺应性下降顺应性下降舒张末压力舒张末压力心绞痛心绞痛晕厥晕厥Angina pectorisSyncope急性Acute:1.感染性心内膜炎Infective end
3、ocarditis2.主A夹层 Aortic dissection3.外伤Trauma4.4.人工瓣膜撕裂Prosthetic valve tear慢性Chronic:1.主动脉瓣疾病Aortic valve disease2/32/3为风心病为风心病2.主动脉根部扩张Aortic root dilatation主动脉瓣关闭不全的病因Causes 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主动脉内血液主动脉内血液在舒张期返流入左室在舒张期返流入左室偏心性肥厚、扩大偏心性肥厚、扩大左心衰左心衰左
4、心室容量负荷左心室容量负荷Sp、Dp 左心室舒张末期压力左心室舒张末期压力CO室壁张力室壁张力心绞痛心绞痛pulmonary hypertension右心衰右心衰pathophysiology反流面积的大小反流面积的大小 心动周期舒张期的长短心动周期舒张期的长短体循环血管阻力体循环血管阻力AI reverse flowReverse flow aera of the sizeBeckoning cycle diastolic lengthSystemic vascular resistance急性主动脉瓣关闭不全左心室舒张期充盈量突然增加左心室舒张期充盈量突然增加 压力迅速增高压力迅速增高左房
5、压、肺静脉压迅速升高左房压、肺静脉压迅速升高急性肺水肿急性肺水肿心动过速以减少反流量心动过速以减少反流量 增加增加CO二尖瓣舒张期提前关闭，缓解左房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和肺静脉受左心室高舒张压的影响 CO减少，低减少，低BP急性左心衰竭急性左心衰竭 急性急性AI v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 valves or biological valves to replace original human valves.主动脉瓣置换术 病例
6、介绍Case Introduction病史medical history 罗菊梅，女，40岁,云南镇雄人 Patient Jumei Luo,female,40 years old,from Zhenxiong 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
7、 10th,2014.because dizziness,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Surgical operation history2004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 tumor resectio
8、n of right arm”in 2011过敏史Allergic 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 incompetence3、The decreasing of left ventricular diastolic function,LVD：70mm,E
9、F: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 Aorta becomes widened and tortuous左室增大left ventricle becomes bigger诊治经过诊治经过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。Preoperative preparation was completed before December 16th.The patient was
10、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 17th,the aortic valve replacement was completed under general anesthesia CPB,and the patient returned the icu at 12:50 with ventilator
11、breathing.After waking,her blood check showed 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,
12、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 88-122/65-84mmhg.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
13、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operation and postoperative wound 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 body fluid潜在并发症（potential complica
14、tion）抗凝不足或抗凝过度Inadequate or excessive anticoagulation、护理措施nursing interventionnursing 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 expectorate.2、持续心电监护，严密
15、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。Regularly monitor the result of blood gas analysis and adjust the way and the flow rate of oxygen offer based on the patien
16、ts 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 appropriately according to prescription to reduce the acting of patients 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
17、 and Peripheral situation,and report to the doctor promptly when abnormal situation is found.nursing intervention(二)心输出量减少(decreased cardiac output)（2）运用血管活性药物，根据患者的生命体征进行调整 Use vasoactive drugs,and adjust according to the patients vital signs(二)心输出量减少(decreased cardiac output)（3）引流管的监测 The drainage
18、 tube monitoring：定时挤压引流管保持引流管的通畅 Squeeze drainage tube regularly to keep its patency.观察引流液量及性质，Observe the drainage amount and nature.观察伤口有无渗血 Observe whether there is bleeding or not in wound.(二)心输出量减少(decreased cardiac output)(4)准确记录出入量，注意水电解质平衡 Record intake and output accurately,and pay attentio
19、n to the balance of water electrolyte.（5）鼓励患者进食 Encourage patients to eatnursing interventionnursing intervention（三）潜在并发症的预防和护理 1、抗凝不足与抗凝过度 Inadequate anticoagulation and excessive anticoagulation (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 Explain to patients the importance of taking warfarin
20、orally,Take anticoagulant medicine regularly and quantitatively The dose is 2.5-5 milligram（2）、服药期间监测INR，使之维持在2.03.0.Monitor INR during the medication to maintain it at 2.0 to 3.0（3）加强患者的监测，如有无皮肤青紫瘀斑、牙龈出血等Strengthen the monitoring of patients,such as the skin bruising,and bleeding gums,etc.（4)、注意饮食对
21、抗凝药物的影响 Pay attention to the infuence of diet on anticoagulants.Health EducationPrevention of infectionDietPeriodic reviewMedication guideActivity and restSelf-test用药指导Medication guide 华法林只在体内抗凝，通过华法林只在体内抗凝，通过拮抗维生素拮抗维生素K K而产生药理作用。而产生药理作用。常用常用INR(INR(国际标准化比值国际标准化比值)评价评价 Warfarin anticoagulation only
22、in the body,vitamin K antagonism generated by pharmacological effects.Common INR(international normalized ratio)evaluation记住服药时间要固定哦！记住服药时间要固定哦！DietvIt 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 hav
23、e more meals with less food for each meal,develop good living habits.v Avoid cigarettes,alcohol,coffee and spicy food.vPatients with poor cardiac function should limit sodium intake.Patients should observe the changes in body weight.保持保持饮食结构的相对平衡饮食结构的相对平衡 应应进食富含营养，易于消进食富含营养，易于消化的食物化的食物，报告高蛋白、，报告高蛋白、
24、高维生素等，同时，应少高维生素等，同时，应少食多餐，养成良好饮食习食多餐，养成良好饮食习惯。惯。禁忌禁忌烟酒、咖啡及刺激性烟酒、咖啡及刺激性食物。食物。心心功能较差的病人要限制钠功能较差的病人要限制钠盐的摄入；应用利尿剂的盐的摄入；应用利尿剂的病人，注意观察尿量及体病人，注意观察尿量及体重的变化。重的变化。富含维生素富含维生素K的食物会降低华法林抗凝作用，的食物会降低华法林抗凝作用，不易长期单调食用某种含维生素不易长期单调食用某种含维生素K多的绿色青菜多的绿色青菜活动与休息Activity and rest 术后术后1 1个月内避免剧烈体育活动，个月内避免剧烈体育活动，3 3个月内应限量活个月
25、内应限量活动，以后可逐渐增大活动量，动，以后可逐渐增大活动量，6 6个月后可恢复正常个月后可恢复正常学习和工作学习和工作,但但所有锻炼和运动均不应过度所有锻炼和运动均不应过度。Within a month after surgery,patients should avoid strenuous physical activity;within three months,patients should be limited in activity;after six months,patients can gradually come back to normal study and work
26、,but all exercise and sport should not be excessive.Prevention of infection 尤其注意呼吸道炎症、牙周炎、泌尿系统感染等症状。对于不明原因的发热应及时就诊。Particular attention should be paid to airway inflammation,periodontitis,urinary tract infection,and other symptoms.Unexplained fever should be timely treated.定期复查Periodic review 定期复查，有什么不适症状时及时就诊 Check regularly,and go to see the doctor promptly when there is any symptom.
