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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 gmheart 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 bodyremove 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
2、膜液，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)、LC
3、X(supply lateral LV,LA),The Cardiac Cycle,Blood Circulation CircuitsPulmonary Circuit lungsSystemic Circuit-whole bodyCardiac CycleSystole contractionDiastole relaxationAtria relax when Ventricles contract and vice versa,Steps in a contraction,When atria fill pressure opens AV valvesAtria contractio
4、n fills ventricles completelyVentricles begin to contract and AV valves snap shut(LUB)Increased contraction(inc.pressure)forces semilunar valves openBlood 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 心跳速率(HR)心
5、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）,Contractil
6、ity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:R=
7、P/Q SVR=(MABP CVP)/CO(systemic vascular resistance)PVR=(MPAP LAP)/CO(pulmonary vascular resistance)臨床評估:SVR and PVR,A 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 ventricl
8、e in one minuteCO=HR X SVHeart rate is 75 beats per minStroke volume is 70 ml per beatBlood volume?do calculationCO=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 performance Cardi
9、ac 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,Sinoatrial node(SA
10、 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 ventriclesRt and Lt bundle branches-send signal to apex of heartPurkinje fibers
11、-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 of the Hea
12、rt,Autonomic nervous system(自主神經的控制)Sympathic NE 1 HR,contractilityCO,BPParasympathic 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化學接受器(Chemor
13、eceptor)：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,GoldenPhysical examinationDiagnostic testsLaboratoryHemodynamic monitoringNon-invasive testsECG,Treadmill,Echo,Nuclear cardiology,CT,MRIInvasive testsCardiac cathet
14、erization,Coronary angiography,electrophysiologic study(EPS),endomyocardial biopsy(EMB),TEE,IVUS,Nursing assessment,Main complaint:chest pain,dyspnea,fatigue,edema,palpitation,syncopeHistory of present illness:onset,signs&symptomsPast medical history:previous illness,injuries,surgery,medicationRisk
15、factors:family history,smoking,activity,diet,personalityGoldens 11 functional health patterns,Chest Pain Assessment,Dyspnea,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 stairOrthopnea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-Ins
16、pection,skin:central cyanosis(lip,mouth,conjundival)poor arterial circulationperipheral cyanosis(lip,ear,nail)peripheral vasoconstrictionEyes:arcus senitis老人弓,Xanthelasma黃斑瘤 atherosclerosis,Physical examination-Inspection,Fingers clubbing杵狀指 PO2or lung cancerCapillary refill(circulation):press nail
17、to branches,color return2 sec,Physical examination-Inspection,Skin tugor(elastrictry):捏起skin,return time30 secdehydration,BWEdema:press 5 sec,remove(+1/4”,+1/4”-1/2”,+1/2”-1”),Physical exam-Vital sign,BP:bilateral BP:Lt&Rt SBP difference15 mmHgaorta blood flow in lower armPulse pressure:SBP-DBP=3050
18、,Orthostatic BP:lying-standing20dehydration,poor HTN,aorta disease,Physical exam-Vital sign,pulse:rate,rhythm,amplitude,bilateralpulsus paradoxus(奇脈):pulse change with呼吸,吸氣 pulse weaken,BPpulsus alternanus(交替脈):pulse change with HR,pulsation:0=none,+=weak,+=normal,+=strong,Physical examination,Carot
19、id artery:thrill,bruit(vessel murmur):arterial narrowingJugular vein pressure(JVP)2 cm Hepatojugular reflux,Physical examination,Palpation&Auscultation of precordiumAreas:aortic,pulmonary,tricuspid,mitral,apex,PMIS1,S2,Abnormal heart sounds:murmur,click,friction rub,Diagnostic studies,Laboratory：CBC
20、,e-,Cholesterol,HDL,LDL,TG,cardiac enzymes(CPK-MB,LDH,troponinT reflect RA pressureSwan-Ganz:PAWP,EKG,12 lead EKG,雙極肢體導程(縱切面):I,II,III單極肢體導程(縱切面):aVR,aVL,aVF胸導程(橫切面):V1,V2,V3,V4,V5,V6,Normal EKG,Holter Monitoring,can record heart rate and rhythm when patients feel chest pain or symptoms of an arrhyt
21、hmia over a 24-hour periodAmbulatory ECG;Dynamic ECGDeveloped in 1960s,Exercise Stress Tests(Treadmill;運動心電圖),Dx:CAD,functional capacityTarget HR=85%*max HRPositive:ST depression1mmContraindications:Unstable angina with recent chest painCritical aortic stenosisSevere hypertrophic obstructive cardiom
22、yopathyUntreated life-threatening cardiac arrhythmiasUncompensated congestive heart failureAdvanced AV blockAcute myocarditis or pericarditisUncontrolled hypertension,Echocardiography超音波,uses sound waves to produce an image of the heart and to see how it is functioning.Transducer high frequency,shor
23、t wave return示波鏡、描繪圖影像show the size,shape,and movement of the heart muscle,valves disease,blood flow,arteries.TypesMotion-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 com
24、e from inside the esophagus 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
25、 through a catheter to artery 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 sy
26、stem For evaluation of cardiac chamber size and great vesselsChest X ray with enlarged heart size,Nuclear cardiology(心臟核子醫學檢查),Ejection fraction+wall motionEvaluation of cardiac performance and regional wall motionLeft ventricular diastolic phase index(MUGA)Useful for evaluation of diastolic functio
27、nPatients with atrial fibrillation,Nuclear cardiology,Tl-201 Single photon emission computed tomography(SPECT)Myocardial perfusion imagingTET Tl-201,Persantin Tl-201Positron emission tomography(PET)Myocardial blood flow and myocardial viability,Nuclear Cardiology,Tc99鎝同位素(hot spot)：與壞死心肌之Ca+結合聚集於受損或
28、梗塞之心肌部位凸顯梗塞之心肌部位l MI 4 hours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 functionIschemic heart disease,LV aneurysm,etc.Pericardial diseasePericardial effusion,constricti
29、ve pericarditis,pericardial cystParacardiac,pericardial and cardiac massesCongenital heart diseaseDisease of the thoracic aortaAortic dissection,aortic aneurysmPulmonary embolism,Magnetic Resonance Imaging(MRI),Provide a 2-D view of the heart,including the chambers and valves,without having to injec
30、t a dye or insert a catheter.Interfere with pacemaker functionCant use with prosthetic metallic devices(valves,prosthetic joints,pacemaker etc.,Invasive tests,Cardiac catheterizationCoronary angiography(CAG)Electrophyiologic study(EPS)Endomyocardial biopsy(EMB),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
31、管阻塞的情形、記錄心臟氧氣變化、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,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,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,Card
32、iac 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 hrscheck wound:bleeding？infection？check P+P(pulsation&perfusion)？complications：bleeding,hemotoma,dye allergy,arrhythmia,thrombus,EPS(Electrophysiologic study),
33、understand arrhythmia mechanism(eg.Additional pathway)effects of drugs and ablationdecide the need of pacemaker,Endomyocardial Biopsy(EMB),International Society for Heart&Lung Transplantation Endomyocardial Biopsy Grading Scheme,Review,Anatomy and physiology of the heartPhysical examination of cardiovascular systemNursing assessmentNon-invasive tests:Lab.,chest X-ray,EKG,echo,Nuclear cardiology,CT,MRIInvasive tests:Cath,EPS,EMB,TEE,IVUS,
