1、Nursing Teaching RoundNursing Teaching Round护理教学查房Case Report病例报告买买提买买提艾山，男，艾山，男，5858岁，新疆籍新疆岁，新疆籍新疆军区副政委。军区副政委。主因发现心脏杂音主因发现心脏杂音3232年，发作性心悸年，发作性心悸5 5年于年于20072007年年3 3月月7 7日入院。日入院。o Patient Mai Mai Ti,male,58 year-old,was born in xinjiang.o He was admitted to the hospital on March 7th 2007.Chief compl
2、aint:o He has had cardiac murmurs for 32 years,Palpitation for 5 years.现现 病病 史史 Present Health Historyo缘于缘于3232年前查体发现心年前查体发现心脏杂音，患者始终无症脏杂音，患者始终无症状。状。o自自5 5年前经常于劳累或年前经常于劳累或饮酒后感心悸，伴轻度饮酒后感心悸，伴轻度胸闷胸闷o The patient had cardiac murmurs 32 years ago,but he was asymptomatic.o He felt palpitation after fatigu
3、e or alcohol intake 5 years ago,sometimes accompanied by chest discomfort.现现 病病 史史 Present Health Historyo无头晕、恶心、无头晕、恶心、呕吐及晕厥呕吐及晕厥,无胸痛无胸痛o休息后可缓解休息后可缓解 o No nausea and vomiting,chest pain,dizzy,faint.o These symptoms can be relieved by rest.现现 病病 史史 Present Health History20052005年年6 6月月o动态心电图动态心电图显示频
4、发显示频发多型室性早搏和阵发多型室性早搏和阵发性室速性室速o给予口服胺腆酮治疗给予口服胺腆酮治疗o超声心动图超声心动图提示左室提示左室流出道压力阶差高流出道压力阶差高,PGPG113mmHg 113mmHg o Continuous ECG revels premature ventricular contractions and paroxysmal ventricular tachycardia on June 2006.o Oral Amiodarone was given him to control them.o Echocardiography shows left ventric
5、le hypertrophy,left ventricle outflow was narrow.PG is 113mmHg.现现 病病 史史 Present Health Historyo20052005年年7 7月明确诊断为肥厚型月明确诊断为肥厚型梗阻性心肌病梗阻性心肌病o会诊决定暂时应用会诊决定暂时应用-受体阻受体阻滞剂和钙拮抗剂行药物治疗滞剂和钙拮抗剂行药物治疗o观察血流动力学，如左室流观察血流动力学，如左室流出道压差降低，则继续药物出道压差降低，则继续药物治疗，如左室流出道压力阶治疗，如左室流出道压力阶差降低不明显，考虑射频消差降低不明显，考虑射频消融结合起搏治疗。融结合起搏治疗。o
6、 He was diagnosed as HCM(Hypertrophic Cardiomyopathy)on July 2005.o Beta blockers and calcium channel blockers were used.o The haemodynamy must be observed.既既 往往 史史 Past Health Historyo 否认冠心病、糖尿否认冠心病、糖尿病病史病病史o 否认肝炎、结核等否认肝炎、结核等传染病史传染病史o 否认手术外伤及输否认手术外伤及输血史血史o 无药物过敏史无药物过敏史 o Deny history of CAD,diabete
7、s mellitus.o Deny history of heritage family diseaseo Deny history of surgical operations,injuries and blood transfusion.o No medicine allergy个人史个人史 Personal History：o 生于原籍，长期居住新生于原籍，长期居住新疆，到过全国各地疆，到过全国各地o 否认疫区居住史，否认否认疫区居住史，否认化学毒物及放射性物质化学毒物及放射性物质接触史。有吸烟史数十接触史。有吸烟史数十年，已戒烟，偶尔饮酒，年，已戒烟，偶尔饮酒，无明确规律。无明确规律。
8、o 已婚，配偶子女均体健已婚，配偶子女均体健o 大学文化程度大学文化程度 oHas never been to epidemic area,deny history of poison touching.oHas history of smoking for many years,he has already quit smoking.Drinking occasionally.oHis wife is healthy.The two daughters are also healthy.oBachelor degree.家家 族族 史史 Family Historyo 父母双亡，父母双亡，死
9、因不详死因不详o 家族中无类家族中无类似疾病患者似疾病患者o 否认家族遗否认家族遗传病病史传病病史 o It has not been found similar disease in his family.o Deny history of family heritage disease.o His parents were died,the reason has not been clear.入院查体入院查体 physical examinationo T36.5T36.5 P69 P69次次/分，分，R18R18次次/分分BP120/80mmHgBP120/80mmHgo 发育良好发育良
10、好o 一般情况好，双肺呼吸一般情况好，双肺呼吸音清，未闻及干、湿性音清，未闻及干、湿性罗音罗音o T:36.5,HR:69 b/m,R:18t/m,Bp 120/80mmHg,o Developed wello Generally speaking,he is in good condition.入院查体入院查体 physical examinationo 心前区无异常隆起，心尖心前区无异常隆起，心尖搏动于左锁骨中线外搏动于左锁骨中线外0.5cm0.5cm，无细震颤，心界增大，心无细震颤，心界增大，心率率6969次次/分，律齐分，律齐o 主动脉瓣听诊区可闻及主动脉瓣听诊区可闻及3-3-4/64
11、/6级收缩期吹风样杂音级收缩期吹风样杂音o 腹部未见阳性体征。双下腹部未见阳性体征。双下肢无水肿。肢无水肿。o Systolic murmur was heard at aortic area.o The rest was normal.心电图示：心电图不正常，窦性心动过缓，左心心电图示：心电图不正常，窦性心动过缓，左心室肥厚伴劳损，偶发室性期前收缩。室肥厚伴劳损，偶发室性期前收缩。E C GThe ECG reveals sinus bradycardia,premature ventricular contractions,left ventricle hypertrophy and ch
12、anges in ST segment and T wave.入院后复查超声心动图示：超声心动图结果：超声心动图结果：肥厚型梗阻性心肌病；肥厚型梗阻性心肌病；o左室肥厚：左室肥厚：室间隔室间隔24mm，心尖部，心尖部16mm，后壁，后壁19mm，侧壁侧壁16mmo收缩期左室流出道可见五收缩期左室流出道可见五彩高速血流彩高速血流oPG168mmHg 较前较前比较比较PG有所升高有所升高Echocardiographyo Echocardiography shows left ventricle hypertrophy,left ventricle outflow narrowing at the
13、 same time.o Septal wall is 24mm,the apex of left ventricle is 16mm,posterior left ventricle is 19mm,inferior surface of left ventricle is 16mmo PG is more than before.o High speed blood flow were found in Systole.动态心电图动态心电图动态心电图结果动态心电图结果 Continuous ECGo频发多源室性期频发多源室性期前收缩前收缩o部分呈双型，部部分呈双型，部分形成加速的室分形成加
14、速的室性逸搏性心律及性逸搏性心律及室性心动过速室性心动过速o Continuous ECG reveals multi-focal PVCs,o partly ventricular couplets and paroxysmal ventricular tachycardia.治治 疗疗 经经 过过 Treatment processo 20072007年年3 3月月2727日植入日植入5386DDDR5386DDDR型起搏器型起搏器o 增加增加-受体阻滞剂量受体阻滞剂量o 超超 声声 心心 动动 图示主图示主动脉跨瓣压缩小动脉跨瓣压缩小 PG=101mmHg PG=101mmHg o 于于
15、4 4 月月1818日出院日出院o Dual-chamber,sequential atrioventricular pacing has been inserted on March 27th 2007.o The dose of Beta blockers was increased to acquire better effect.o PG is less than before.o The client was discharged on April 18th.心理社会评估心理社会评估 Psychosocial Assessmento鉴于肥厚性鉴于肥厚性心肌病无法心肌病无法根治以及无根
16、治以及无法预料的严法预料的严重后果，患重后果，患者有明显的者有明显的不确定感，不确定感，并导致恐惧并导致恐惧和焦虑和焦虑o患者担心女患者担心女儿患病儿患病o Because of the incurable nature of the disorder and the unforeseeable of the serious consequences of the disease,the client is faced with uncertainty that may create fear and anxiety.o He was worried about his daughter co
17、nditions Nursing Diagnosis 1o Potential Complications including arrhythmias,heart failure,and sudden deathNursing Goals oNo occurrence of or early detection of complications including arrhythmias,heart failure,and sudden death护理诊断潜在并发症潜在并发症o 心律失常心律失常o 心衰心衰o 猝死猝死 护理目标o无心律失常无心律失常o无心衰无心衰o无猝死等无猝死等并发症并发症
18、Nursing interventionso Avoid impairing ventricular filling,such as sudden position change,strenuous physical activities,competitive exercise.o Observe the effects of therapy applied,the possible side effects of medications,complicationso Observe vital signs,complaints.pay more attention to sudden de
19、ath.护理措施o 避免可降低心室充盈的情况，如突然变换体位、避免可降低心室充盈的情况，如突然变换体位、体力活动、竞技运动体力活动、竞技运动o 药物治疗的护理：观察药物作用与付作用药物治疗的护理：观察药物作用与付作用o 病情观察：生命体征、主诉，警惕猝死病情观察：生命体征、主诉，警惕猝死Nursing Diagnosis 2o Activity intolerance related to the imbalance between oxygen supply and demand as a result of cardiac insufficiencyNursing Goals o Incr
20、eased exercise tolerance护理诊断活动无耐力活动无耐力 与心功能受损与心功能受损所致的氧供所致的氧供需失调有关需失调有关 护理目标o 足够的心足够的心排出量排出量o 活动耐力活动耐力增强增强Nursing interventionso Instruct the patient on pacing the daily activities and rest to prompt comforto Carefully monitoring before and after pacemaker insertion护理措施o 指导患者合理安排休息与活动，增进舒适指导患者合理安排休息
21、与活动，增进舒适o 安置起搏器前后的护理安置起搏器前后的护理Nursing Diagnosis 3o Fear/Anxiety related to the unknowing of and perceived threat of the diseaseNursing Goals o Less anxiety and apprehension about his condition and prognosis护理诊断o 恐惧或焦虑恐惧或焦虑 与对疾病缺与对疾病缺乏了解和感乏了解和感知疾病威胁知疾病威胁有关有关 护理目标对疾病和预后对疾病和预后的焦虑与恐惧的焦虑与恐惧感减轻感减轻Nursing
22、interventionso Emotional support:1.creating an environment in which he can express concerns and acknowledge fears 2.showing a caring attitude3.offering encouragement,acceptance.护理措施心理支持：心理支持：o 接纳和理解患者接纳和理解患者o 创造有利于患者倾诉的环境创造有利于患者倾诉的环境o 给予关怀、鼓励、支持给予关怀、鼓励、支持o 促进有效应对促进有效应对Nursing Diagnosis 4o Lack of HC
23、M self-management knowledge and skillsNursing Goals o Adequate self-management knowledge and skills护理诊断知识缺乏知识缺乏 缺乏肥厚性心缺乏肥厚性心肌病自我管理肌病自我管理知识与技能知识与技能 护理目标有足够的自我管有足够的自我管理知识与技能理知识与技能Nursing interventions1.Knowledge of HCM2.Explain the effects and side effects of medication3.Carry a medical condition card
24、 in case of emergency4.Family members be trained the basic life support techniques5.Keep adherence to the therapeutical regimen and self-monitoringPrompt self-management by health teaching 护理措施健康教育健康教育o 有关疾病知识有关疾病知识o 有关用药知识有关用药知识o 家庭成员急救技能训练家庭成员急救技能训练o 携带病历简卡携带病历简卡o 遵从治疗方案，加强自我监测遵从治疗方案，加强自我监测o 促进自我管
25、理促进自我管理Nursing Evaluationo Demonstrate an adequate cardiac outputo Increased exercise tolerance,improve the clients quality of life.o Demonstrate proper management of physical and emotional activities.o Administer medications safely and recognize possible side effects.o Obey the therapeutical regime
26、n.护理评价o 足够的心输出量，无并发症发生足够的心输出量，无并发症发生o 患者活动耐力增加，生活质量提高患者活动耐力增加，生活质量提高o 患者显示对活动与情绪的恰当管理患者显示对活动与情绪的恰当管理o 患者能安全用药和识别可能发生的副作用患者能安全用药和识别可能发生的副作用o 遵从治疗方案遵从治疗方案Instructionso Avoid over exciting and be emotionally stable.o Adjust lifestyles.o Monitor the effects and side effects of medications.o Come back to
27、 the hospital for follow up checks regularly.o Family member can master the basic life support techniques.出出 院院 指指 导导o 避免情绪激动，保持情绪稳定避免情绪激动，保持情绪稳定o 改变生活方式改变生活方式o 监测药物作用与付作用监测药物作用与付作用o 定时复查定时复查o 患者家庭成员掌握基本生命支持技术患者家庭成员掌握基本生命支持技术讨讨 论论为什么该病人为什么该病人非常关心女儿非常关心女儿的健康？的健康？Discussion DiscussionWhy was he worrie
28、d about his daughters health?The exact etiology of HCM is yet unclear.About one third of the affected clients have family history.It is currently recognized as a genetically transmitted disease that is associated with multiple gene alterations.讨讨 论论患有患有HCMHCM的病人常有明的病人常有明显的心理问题，为什显的心理问题，为什么？么？Discuss
29、ionDiscussionThe patients with HCM often have more emotional reactions,why?To many people,heart is the symbol of their life.A client with HCM perceives it as a major life crisis.They may confront not only the possibility of death,but also fears,forced changes of daily life,family and social roles.讨讨
30、 论论起搏器治疗的目的起搏器治疗的目的是什么？是什么？DiscussionDiscussionWhat is the goal by pacemaker insertion?The beneficial effect is attributable to the modification of the ventricular activation sequence,therefore,preventing or lessening the left ventricular outflow obstruction.讨讨 论论治疗该病，常用哪治疗该病，常用哪些药物？些药物？DiscussionDi
31、scussionWhat kinds of medicines are most often used to treat the disease?Beta blockers and calcium channel blockers 讨讨 论论此病常见症状是什么？此病常见症状是什么？它是怎样引起的？它是怎样引起的？Whats the most common symptom of HCM?Whats the reason?It is dyspnea after physical activity,which is due to high pulmonary pressure caused by the elevated left ventricular diastolic pressure.DiscussionDiscussion 讨讨 论论本病中本病中-受体阻滞受体阻滞剂的作用是什么？剂的作用是什么？Discussion Discussion Whats the action of beta blockers?Beta blockers decrease outflow obstruction and heart rate,allowing greater time for filling of the chambers.
