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1、Nursing Teaching Round护理教学查房,Case Report病例报告,买买提艾山，男，58岁，新疆籍新疆军区副政委。主因发现心脏杂音32年，发作性心悸5年于2007年3月7日入院。,Patient Mai Mai Ti,male,58 year-old,was born in xinjiang.He was admitted to the hospital on March 7th 2007.Chief complaint:He has had cardiac murmurs for 32 years,Palpitation for 5 years.,现 病 史 Prese
2、nt Health History,缘于32年前查体发现心脏杂音，患者始终无症状。自5年前经常于劳累或饮酒后感心悸，伴轻度胸闷,The patient had cardiac murmurs 32 years ago,but he was asymptomatic.He felt palpitation after fatigue or alcohol intake 5 years ago,sometimes accompanied by chest discomfort.,现 病 史 Present Health History,无头晕、恶心、呕吐及晕厥,无胸痛休息后可缓解,No nause
3、a and vomiting,chest pain,dizzy,faint.These symptoms can be relieved by rest.,现 病 史 Present Health History,2005年6月动态心电图显示频发多型室性早搏和阵发性室速给予口服胺腆酮治疗超声心动图提示左室流出道压力阶差高,PG113mmHg,Continuous ECG revels premature ventricular contractions and paroxysmal ventricular tachycardia on June 2006.Oral Amiodarone was
4、 given him to control them.Echocardiography shows left ventricle hypertrophy,left ventricle outflow was narrow.PG is 113mmHg.,现 病 史 Present Health History,2005年7月明确诊断为肥厚型梗阻性心肌病会诊决定暂时应用-受体阻滞剂和钙拮抗剂行药物治疗观察血流动力学，如左室流出道压差降低，则继续药物治疗，如左室流出道压力阶差降低不明显，考虑射频消融结合起搏治疗。,He was diagnosed as HCM(Hypertrophic Cardio
5、myopathy)on July 2005.Beta blockers and calcium channel blockers were used.The haemodynamy must be observed.,既 往 史 Past Health History,否认冠心病、糖尿病病史否认肝炎、结核等传染病史否认手术外伤及输血史无药物过敏史,Deny history of CAD,diabetes mellitus.Deny history of heritage family diseaseDeny history of surgical operations,injuries and
6、 blood transfusion.No medicine allergy,个人史 Personal History：,生于原籍，长期居住新疆，到过全国各地否认疫区居住史，否认化学毒物及放射性物质接触史。有吸烟史数十年，已戒烟，偶尔饮酒，无明确规律。已婚，配偶子女均体健大学文化程度,Has never been to epidemic area,deny history of poison touching.Has history of smoking for many years,he has already quit smoking.Drinking occasionally.His w
7、ife is healthy.The two daughters are also healthy.Bachelor degree.,家 族 史 Family History,父母双亡，死因不详家族中无类似疾病患者否认家族遗传病病史,It has not been found similar disease in his family.Deny history of family heritage disease.His parents were died,the reason has not been clear.,入院查体 physical examination,T36.5 P69次/分
8、，R18次/分BP120/80mmHg发育良好一般情况好，双肺呼吸音清，未闻及干、湿性罗音,T:36.5,HR:69 b/m,R:18t/m,Bp 120/80mmHg,Developed wellGenerally speaking,he is in good condition.,入院查体 physical examination,心前区无异常隆起，心尖搏动于左锁骨中线外0.5cm，无细震颤，心界增大，心率69次/分，律齐主动脉瓣听诊区可闻及3-4/6级收缩期吹风样杂音腹部未见阳性体征。双下肢无水肿。,Systolic murmur was heard at aortic area.The
9、 rest was normal.,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。,E C G,The ECG reveals sinus bradycardia,premature ventricular contractions,left ventricle hypertrophy and changes in ST segment and T wave.,入院后复查超声心动图示：,超声心动图结果：肥厚型梗阻性心肌病；,左室肥厚：室间隔24mm，心尖部16mm，后壁19mm，侧壁16mm收缩期左室流出道可见五彩高速血流PG168mmHg 较前比较PG有所升高,E
10、chocardiography,Echocardiography shows left ventricle hypertrophy,left ventricle outflow narrowing at the same time.Septal wall is 24mm,the apex of left ventricle is 16mm,posterior left ventricle is 19mm,inferior surface of left ventricle is 16mmPG is more than before.High speed blood flow were foun
11、d in Systole.,动态心电图,动态心电图结果 Continuous ECG,频发多源室性期前收缩部分呈双型，部分形成加速的室性逸搏性心律及室性心动过速,Continuous ECG reveals multi-focal PVCs,partly ventricular couplets and paroxysmal ventricular tachycardia.,治 疗 经 过 Treatment process,2007年3月27日植入5386DDDR型起搏器增加-受体阻滞剂量超 声 心 动 图示主动脉跨瓣压缩小 PG=101mmHg 于4 月18日出院,Dual-chamber
12、,sequential atrioventricular pacing has been inserted on March 27th 2007.The dose of Beta blockers was increased to acquire better effect.PG is less than before.The client was discharged on April 18th.,心理社会评估 Psychosocial Assessment,鉴于肥厚性心肌病无法根治以及无法预料的严重后果，患者有明显的不确定感，并导致恐惧和焦虑患者担心女儿患病,Because of the
13、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.He was worried about his daughter conditions,Nursing Diagnosis 1,Potential Complications including arrhythmias,heart failure,and sud
14、den death,Nursing Goals,No occurrence of or early detection of complications including arrhythmias,heart failure,and sudden death,护理诊断,潜在并发症 心律失常 心衰 猝死,护理目标,无心律失常无心衰无猝死等并发症,Nursing interventions,Avoid impairing ventricular filling,such as sudden position change,strenuous physical activities,competit
15、ive exercise.Observe the effects of therapy applied,the possible side effects of medications,complicationsObserve vital signs,complaints.pay more attention to sudden death.,护理措施,避免可降低心室充盈的情况，如突然变换体位、体力活动、竞技运动药物治疗的护理：观察药物作用与付作用病情观察：生命体征、主诉，警惕猝死,Nursing Diagnosis 2,Activity intolerance related to the
16、imbalance between oxygen supply and demand as a result of cardiac insufficiency,Nursing Goals,Increased exercise tolerance,护理诊断,活动无耐力 与心功能受损所致的氧供需失调有关,护理目标,足够的心排出量活动耐力增强,Nursing interventions,Instruct the patient on pacing the daily activities and rest to prompt comfortCarefully monitoring before an
17、d after pacemaker insertion,护理措施,指导患者合理安排休息与活动，增进舒适安置起搏器前后的护理,Nursing Diagnosis 3,Fear/Anxiety related to the unknowing of and perceived threat of the disease,Nursing Goals,Less anxiety and apprehension about his condition and prognosis,护理诊断,恐惧或焦虑 与对疾病缺乏了解和感知疾病威胁有关,护理目标,对疾病和预后的焦虑与恐惧感减轻,Nursing inter
18、ventions,Emotional support:creating an environment in which he can express concerns and acknowledge fears showing a caring attitudeoffering encouragement,acceptance.,护理措施,心理支持：接纳和理解患者创造有利于患者倾诉的环境给予关怀、鼓励、支持促进有效应对,Nursing Diagnosis 4,Lack of HCM self-management knowledge and skills,Nursing Goals,Adequ
19、ate self-management knowledge and skills,护理诊断,知识缺乏 缺乏肥厚性心肌病自我管理知识与技能,护理目标,有足够的自我管理知识与技能,Nursing interventions,Knowledge of HCMExplain the effects and side effects of medicationCarry a medical condition card in case of emergencyFamily members be trained the basic life support techniquesKeep adherence
20、 to the therapeutical regimen and self-monitoringPrompt self-management by health teaching,护理措施,健康教育有关疾病知识有关用药知识家庭成员急救技能训练携带病历简卡遵从治疗方案，加强自我监测促进自我管理,Nursing Evaluation,Demonstrate an adequate cardiac outputIncreased exercise tolerance,improve the clients quality of life.Demonstrate proper management
21、of physical and emotional activities.Administer medications safely and recognize possible side effects.Obey the therapeutical regimen.,护理评价,足够的心输出量，无并发症发生患者活动耐力增加，生活质量提高患者显示对活动与情绪的恰当管理患者能安全用药和识别可能发生的副作用遵从治疗方案,Instructions,Avoid over exciting and be emotionally stable.Adjust lifestyles.Monitor the ef
22、fects and side effects of medications.Come back to the hospital for follow up checks regularly.Family member can master the basic life support techniques.,出 院 指 导,避免情绪激动，保持情绪稳定改变生活方式监测药物作用与付作用定时复查患者家庭成员掌握基本生命支持技术,讨 论,为什么该病人非常关心女儿的健康？,Discussion,Why was he worried about his daughters health?The exact
23、 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 论,患有HCM的病人常有明显的心理问题，为什么？,Discussion,The patients with HCM often have more emotional reactio
24、ns,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 论,起搏器治疗的目的是什么？,Discussion,What is the goal by pacemaker insertion?T
25、he beneficial effect is attributable to the modification of the ventricular activation sequence,therefore,preventing or lessening the left ventricular outflow obstruction.,讨 论,治疗该病，常用哪些药物？,Discussion,What kinds of medicines are most often used to treat the disease?Beta blockers and calcium channel b
26、lockers,讨 论,此病常见症状是什么？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.,Discussion,讨 论,本病中-受体阻滞剂的作用是什么？,Discussion,Whats the action of beta blockers?Beta blockers decrease outflow obstruction and heart rate,allowing greater time for filling of the chambers.,
