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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 gm heart location: 2/3 胸骨中線左側； Base:2nd肋骨；Apex:5th肋間 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) Ascendi
2、ng aorta (75% at diastolic) RCA (supply RA, RV, post LV, 90% AV node) Left main LAD (supply Ant. LV, apex)、LCX (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
3、when Ventricles contract and vice versa,Steps in a contraction,When atria fill pressure opens AV valves Atria contraction 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
4、 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 Dyn
5、amic ECG Developed in 1960s,Exercise Stress Tests (Treadmill;運動心電圖),Dx :CAD, functional capacityTarget HR=85%*max HRPositive: ST depression1mm Contraindications: Unstable angina with recent chest pain Critical aortic stenosis Severe hypertrophic obstructive cardiomyopathy Untreated life-threatening
6、cardiac arrhythmias Uncompensated congestive heart failure Advanced AV block Acute myocarditis or pericarditis Uncontrolled 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, short wave return示波鏡、描繪圖影像 show
7、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
8、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 through a c
9、atheter 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 system For
10、evaluation of cardiac chamber size and great vessels Chest X ray with enlarged heart size,Nuclear 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
11、 Patients with atrial fibrillation,Nuclear 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 viability,Nuclear Cardiology,Tc99鎝同位素 (hot spot)：與壞死心肌之Ca+
12、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 eff
13、usion, constrictive pericarditis, pericardial cyst Paracardiac, pericardial and cardiac masses Congenital heart disease Disease of the thoracic aorta Aortic dissection, aortic aneurysm Pulmonary embolism,Magnetic Resonance Imaging (MRI),Provide a 2-D view of the heart, including the chambers and val
14、ves, without having to inject a dye or insert a catheter. 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)
15、,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
16、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,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 study),understand arrhythmia mechanism (eg. Additional pathway) effects of drugs and ablation decide the need of
