1、心臟疾病患者的護理邱愛富心臟血管系統的解剖生理功能 邱愛富 一、心臟的構造與功能:heart size:拳頭，250-350 gm heart location:2/3 胸骨中線左側；Base:2nd肋骨；Apex:5th肋間&Lt鎖骨中線 heart function:deliver O2 and other essential substitute to tissue of body remove CO2&代謝產物心臟壁層:心包膜(pericardium)1)外層(壁心包膜)：纖維性防止heart過度擴張、有保護、固定 2)內層(臟心包膜)：漿膜性兩層間為心包膜腔，含15-50 cc心包膜
2、液，可防止收縮時的磨擦 心外膜(epicardium);心肌(myocardium)-不隨意肌，具橫紋及分枝的纖維，有收縮作用 心內膜(endocardium)Coronary vasculature Right coronary artery(RCA）、Left main-Left anterior descending artery(LAD)、Left circumflex(LCX)Ascending aorta(75%at diastolic)RCA(supply RA,RV,post LV,90%AV node)Left main LAD(supply Ant.LV,apex)、LCX
3、 (supply lateral LV,LA)The Cardiac Cycle Blood Circulation Circuits Pulmonary Circuit lungs Systemic Circuit-whole body Cardiac Cycle Systole contraction Diastole relaxation Atria relax when Ventricles contract and vice versa Steps in a contraction When atria fill pressure opens AV valves Atria cont
4、raction fills ventricles completely Ventricles begin to contract and AV valves snap shut(LUB)Increased contraction(inc.pressure)forces semilunar valves open Blood flows into vessels leading away.Pressure increases and forces SL valves shut(DUB)Process begins again Cardiac Output心輸出量(CO)=心搏出量(SV)x 心跳
5、速率(HR)心搏出量(Stroke volume)：每一次心室收縮時所排出的血量，同時受到前負荷，後負荷及心臟收縮力的影響心輸出量的決定因素前負荷(preload):心室舒張末期,心肌所承受的張力後負荷(Afterload):心室收縮時所遭遇的阻力心臟收縮力(Contractility)心跳速率與節律(heart rate&rhythm)前負荷(Preload)Frank-Starling 定律:舒張容積(=前負荷)心室收縮強度 輸出容積 (myocardium fiber length preload LVEDVSV)臨床上：以進入心室的血量多寡為代表（一般用CVP及PAWP估計）Contr
6、actility收縮力 Vpk for the left ventricle is around 1.1 1.5 m/s in healthy patients.In patients with cardiac failure or low contractility/inotropy this figure might well be only 0.6 or 0.7 m/s or even less.For the right ventricle the figure would be 0.7 to 1.2 in healthy patients.後負荷(Afterload)Ohms law
7、:R=P/Q SVR=(MABP CVP)/CO (systemic vascular resistance)PVR=(MPAP LAP)/CO (pulmonary vascular resistance)臨床評估:SVR and PVRA high BP meansthat the ventricle is pushing uphill High viscosity and vasoconstriction mean hard work for the ventricle Cardiac Output The amount of blood ejected by the left vent
8、ricle in one minute CO=HR X SV Heart rate is 75 beats per min Stroke volume is 70 ml per beat Blood volume?do calculation CO=SVxHR=60-130 cc/beat X 75 beat/min=4-8 L/min Cardiac function index Ejection Fraction心射出分率 Is%of blood ejected with every beat=SV/LVEDV=2/3=60-75%(Normal50%)Reflect LV perform
9、ance Cardiac index(CI)心臟指數 Cardiac reserve 心臟儲備量Cardiac index(CI)心臟指數 Is CO corrected for differences in body size=CO/body surface area=2.5-4 L/min/m2 Cardiac reserve 心臟儲備量 Cardiac reserve=ability to respond to the demand for increased CO(eg.Exercise,stress)Normal:300-400%Conduction System Sinoatria
10、l node(SA node)-RA,fastest autorhythmic tissue(pacemaker,60-100 bpm)Atrioventricular node(AV node)-last part of atria to depolarize signal hesitates then proceeds to ventricles(40-60 bpm)AV bundle(bundle of His)-connects atria to ventricles Rt and Lt bundle branches-send signal to apex of heart Purk
11、inje fibers-action potential sent throughout ventricle tissue(20-40 bpm)心臟電氣生理特性自律性(Automaticity)心肌自動去極化的能力，規則自動的激發衝動(Impulses)的能力，主要由SA node擔任Pacemaker激搏點興奮性(Excitability)-心肌對於刺激產生去極化的能力(被衝動激發產生興奮)傳導性(Conductivity)-心肌經由細胞膜傳送刺激衝動的能力不反應期(Refractoriness)-心肌仍然處於前一刺激之收縮，無法對於新刺激反應的時期 Neurologic Control o
12、f the Heart Autonomic nervous system(自主神經的控制)Sympathic NE 1 HR,contractilityCO,BP Parasympathic ACH HR,contractility壓力接受器(Baroreceptor)與化學接受(Chemoreceptor)壓力接受器(Baroreceptor：位於頸動脈竇、主動脈竇、心房 BPbaroreceptortrasfer massage to vasomotor center at medula stimulate parasymp.inhibit symp.HR,contractility 化學
13、接受器(Chemoreceptor)：位於頸動脈體、主動脈體附近 PO2,PH,PCO2 stimulate chemreceptor vasomotor centercardiac activity PO2心臟血管疾病的評估及診斷檢查 Nursing assessment:history,Golden Physical examination Diagnostic tests Laboratory Hemodynamic monitoring Non-invasive tests ECG,Treadmill,Echo,Nuclear cardiology,CT,MRI Invasive te
14、sts Cardiac catheterization,Coronary angiography,electrophysiologic study(EPS),endomyocardial biopsy(EMB),TEE,IVUSNursing assessment Main complaint:chest pain,dyspnea,fatigue,edema,palpitation,syncope History of present illness:onset,signs&symptoms Past medical history:previous illness,injuries,surg
15、ery,medication Risk factors:family history,smoking,activity,diet,personality Goldens 11 functional health patternsChest Pain AssessmentAssessment AnginaPericarditisProvocation/PalliationExercise/restDeep breath,平躺/前傾、坐起Quality/Quantity壓迫感、沉重、消化不良感尖銳如刀割Region/Radiation胸骨、頸、左手臂、肩Severity中度中至重度Time/ons
16、et,duration10 minSeveral hrs to daysDyspnea SOB(short of breath)呼吸短促 DOE(Dyspnea on exercise/exertion)運動時呼吸困難,最常見於walk,crimb stair Orthopnea端坐呼吸,無法平躺，半坐臥緩解 PND(paroxysmal nocturnal dyspnea)夜間陣發性呼吸困難,Physical examination-Inspection skin:central cyanosis(lip,mouth,conjundival)poor arterial circulation
17、 peripheral cyanosis(lip,ear,nail)peripheral vasoconstriction Eyes:arcus senitis老人弓,Xanthelasma黃斑瘤 atherosclerosisPhysical examination-Inspection Fingers clubbing杵狀指 PO2or lung cancer Capillary refill(circulation):press nail to branches,color return30 secdehydration,BW Edema:press 5 sec,remove(+15 m
18、mHgaorta blood flow in lower arm Pulse pressure:SBP-DBP=3050,Orthostatic BP:lying-standing20dehydration,poor HTN,aorta diseasePhysical exam-Vital sign pulse:rate,rhythm,amplitude,bilateral pulsus paradoxus(奇脈):pulse change with呼吸,吸氣 pulse weaken,BP pulsus alternanus(交替脈):pulse change with HR,pulsati
19、on:0=none,+=weak,+=normal,+=strongPhysical examination Carotid artery:thrill,bruit(vessel murmur):arterial narrowing Jugular vein pressure(JVP)1mm Contraindications:Unstable angina with recent chest pain Critical aortic stenosis Severe hypertrophic obstructive cardiomyopathy Untreated life-threateni
20、ng cardiac arrhythmias Uncompensated congestive heart failure Advanced AV block Acute myocarditis or pericarditis Uncontrolled hypertensionEchocardiography超音波 uses sound waves to produce an image of the heart and to see how it is functioning.Transducer high frequency,short wave return示波鏡、描繪圖影像 show
21、the size,shape,and movement of the heart muscle,valves disease,blood flow,arteries.Types Motion-mode(收縮、活動),2 Dimensional-echo(縱、橫向結構),Doppler(血流方向、流速)Transesophageal Echocardiography(TEE)The test is like standard echocardiography except that the pictures of the heart come from inside the esophagus
22、rather than through the chest wall.NPO 6-8 hoursspraying throat with an anesthetica tube(probe)put down the throat Gag reflex return,then eating Intravascular Ultrasound(IVUS)is a combination of echocardiography and cardiac catheterization.uses sound waves,which are sent through a catheter to artery
23、 and heart,to produce an image of the coronary arteries and to see their condition.is rarely done alone or as a strictly diagnostic procedure.It is usually done with a transcatheter intervention like angioplasty.Chest X ray Most commonly performed imaging test for CV system For evaluation of cardiac
24、 chamber size and great vesselsChest X ray with enlarged heart sizeNuclear cardiology(心臟核子醫學檢查)Ejection fraction+wall motion Evaluation of cardiac performance and regional wall motion Left ventricular diastolic phase index(MUGA)Useful for evaluation of diastolic function Patients with atrial fibrill
25、ationNuclear cardiology Tl-201 Single photon emission computed tomography (SPECT)Myocardial perfusion imaging TET Tl-201,Persantin Tl-201 Positron emission tomography(PET)Myocardial blood flow and myocardial viabilityNuclear Cardiology Tc99鎝同位素(hot spot)：與壞死心肌之Ca+結合聚集於受損或梗塞之心肌部位凸顯梗塞之心肌部位l MI 4 hours
26、可發現，24-72hrs最靈敏 Thallium 201 myocardial imaging 鉈(cold spot):測心肌灌注情形 聚集於心肌供血處，灌注好分佈均勻，缺血處無法進入空白冷點(cold spot)Computed tomography(CT scan)Cardiac dimensions,calcifications and function Ischemic heart disease,LV aneurysm,etc.Pericardial disease Pericardial effusion,constrictive pericarditis,pericardial
27、 cyst Paracardiac,pericardial and cardiac masses Congenital heart disease Disease of the thoracic aorta Aortic dissection,aortic aneurysm Pulmonary embolismMagnetic Resonance Imaging(MRI)Provide a 2-D view of the heart,including the chambers and valves,without having to inject a dye or insert a cath
28、eter.Interfere with pacemaker function Cant use with prosthetic metallic devices(valves,prosthetic joints,pacemaker etc.Invasive tests Cardiac catheterization Coronary angiography(CAG)Electrophyiologic study(EPS)Endomyocardial biopsy(EMB)心導管術的功能有哪些？心導管術的功能有哪些？在檢查方面可以達到顯影評估心臟功能、血流的情況或是血管阻塞的情形、記錄心臟氧氣變
29、化、測量心臟電位、測量心臟血管各部位的壓力等。在治療方面可以利用氣球擴張術或置入支架撐開阻塞的血管段、將心律不整的原因給予電燒灼，以及放置心律調整器等。心導管檢查前需注意之事項心導管檢查前需注意之事項 由醫師解釋心導管檢查的利弊，並簽寫同意書。禁食4-6小時。檢查部位（穿刺部位）毛髮剔除。檢查四肢末梢動脈循環及做上記號。須換上手術衣，並取下假牙、義眼、眼鏡、及所有飾物等。檢查前先排空膀胱。施行心導管之禁忌症施行心導管之禁忌症 絕對禁忌病患拒絕設備或儀器不足相對禁忌控制不良之心臟衰竭,高血壓,心律不整一個月以內之腦中風發燒/感染電解質不平衡急性消化道出血懷孕易出血之體質或情形無法合作之病人腎衰竭
30、Cardiac catheterization post-cath：vital sign:q15min*4 q30 min*2(or 4)q1h 股動脈:bed rest 6-8 hours,compress 4-6 hrs 橈動脈:bed rest 1-2 hours,compress 2 hrs check wound:bleeding？infection？check P+P(pulsation&perfusion)？complications：bleeding,hemotoma,dye allergy,arrhythmia,thrombus EPS(Electrophysiologic
31、study)understand arrhythmia mechanism(eg.Additional pathway)effects of drugs and ablation decide the need of pacemaker Endomyocardial Biopsy(EMB)GradeFindingRejection Severity0No infiltratesNone1AFocal(perivascular of interstisial infiltrates without necrosisMild1BDiffuse but not sparse infiltrate w
32、ithout necrosisMild2One focus only with aggressive infiltrate and/or myocyte damage Focal Moderate3AMultifoca addressive infiltrates and/or myocyte damageModerate3BDiffuse inflammatory infiltrates with necrosisBorderline severe4DDiffuse aggressive polymorphous infiltrate with edema,hemorhage and vas
33、culitis,with necrosisSevereInternational Society for Heart&Lung Transplantation Endomyocardial Biopsy Grading Scheme Review Anatomy and physiology of the heart Physical examination of cardiovascular system Nursing assessment Non-invasive tests:Lab.,chest X-ray,EKG,echo,Nuclear cardiology,CT,MRI Invasive tests:Cath,EPS,EMB,TEE,IVUS
