主动脉夹层护理教学-.pptx

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,主动脉夹层动脉瘤患者的护理,主动脉夹层动脉瘤,疾病简介,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,在主动脉壁存在或不存在自身病变的基础上，并在一系列可能外因的作用下导致主动脉内膜撕裂，血液由内膜撕裂口进入主动脉壁中层，造成主动脉中层沿长轴分离，从而使主动脉管腔呈现真假两腔的一种病理状态。,定义,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,名 词 解 释,真腔,：主动脉原有的管腔称为真腔；,假腔,：主动脉壁分离形成的管腔称为假腔；,夹层隔膜,：位于真假腔之间，被撕裂的内 膜和中膜的内,1/3,层称为夹层隔膜；,动脉瘤,：病变动脉的直径大于正常动脉,1.5,倍者称动脉瘤。夹层动脉瘤属于假性动脉瘤的范畴,夹层裂口,：内膜的破口称为夹层裂口。,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,特点,发病急,发展快,死亡率高,心血管外科最凶险的疾病,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,stanford,分型,DeBakey,分型,I,型,:,夹层分离遍及升主动脉、主动脉弓降主动脉及腹主动脉；,型,:,夹层分离限于升主动脉；,型,:,夹层分离限于胸主动脉,(a),或延及 腹主动脉,(b),Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,DeBakey,分型,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,临 床 表 现,1.,疼痛：多为撕裂样或刀割样疼痛；,2.,高血压：难以控制的高血压；,3.,脏器缺血表现：,神经系统：偏瘫、截瘫 一过性脑缺血；,四肢缺血：肢体发凉、紫绀、脉搏消失；,肾脏缺血：尿少、肾衰；,肠缺血：肠绞痛、肠梗阻，肠坏死等。,4.,破裂表现：,破入心包腔、胸膜腔引起心包填塞或胸腔积液；,破入腹腔、食道、气管内出现休克、胸痛、呼吸,困难、心悸及呕血、咯血等。,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,诊 断 要 点,有高血压病史，继发于胸骨后或腰背部疼痛或伴有药物难以控制高血压的应考虑。,辅助检查,：,X,线、经食道,B,超；,CTA,、,MRA,、,DSA,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,治 疗,内科治疗：降压、止痛、镇静、制动。,手术治疗,：主动脉夹层并不会自愈，手术是,唯一有效的治疗方法。,手术治疗方法：传统手术,和,腔内治疗,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,主动脉夹层动脉瘤,护 理,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,一般 护 理,监护,：重症患者入住监护病房，心电监护血压心率、呼吸、血氧饱和度、尿量的变化，持续低流量吸氧,23L/min,；,卧床休息,：要求患者绝对卧床休息，一切生活护理均由护理人员协助完成，翻身动作轻柔，避免情绪波动；,建立最佳静脉通路,：接诊后即刻建立静脉通路，以利于快速输液，泵入药物及抢救；,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,一般 护理,保持大小便通畅,：指导病人多吃水果、蔬菜及粗纤维，清淡易消化饮食，少食多餐，不过饱，保持大便通畅，禁止用力排便，可给予通便药物；,心理护理,：根据不同层次的患者，掌握其心理状态给予不同的心理护理。精神紧张可导致血压升高，保持良好的心理状态,，正确对待疾病，有利于血压控制。,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,血压和心率的护理,控制血压：早期降压治疗，使用硝普钠静脉持续泵入以 降低血压，根据病人的耐受能力控制血压在最低范围，一般,90-110/60-70mmHg,，并密切观察血压变化及硝普钠的副作用；,控制心率：给予,受体阻滞剂以控制心率，使心室率控制在,55-70,次,/,分,，以减低左室收缩力，要按时按量服用药物，不可错服、漏服，并观察心率反应。,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,血压护理,掌握血压的特殊性：,1,.,在急性期，有面色苍白、冷汗、周围性紫绀等表现，仍表现为高血压。动脉壁撕裂引起疼痛，刺激主动脉弓压力感受器释放儿茶酚胺使血压升高，血流搏动增加对动脉血管壁的冲击，促进夹层的发展，因此有效的降压止痛是治疗休克的关键；,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,血压护理,掌握血压的特殊性：,2,.,由于主动脉内膜撕裂可引起外周动脉阻塞现象，因而不仅要观察桡动脉压，还必须常规观察颈、股动脉搏动变化，若动脉搏动消失或两侧强弱不等则提示阻塞可能。,此外还要观察病人意识及有无头痛、头昏征象，因主动脉内膜撕裂到主动脉弓时有时会阻塞主动脉弓三分支，引起大脑缺血缺氧；,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,血压护理,掌握血压的特殊性：,3,.,急性期,(,两周内,),一般先采用保守治疗，两周后再手术，因为急性期主动脉壁充血、水肿，支架植入容易致夹层破裂。,(,急性期有胸腔积液者或夹层进一步发展、加重者随时手术,),因此，术前有效地控制血压和降低心率是治疗成功的关键。,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,使用硝普钠的注意事项,1.,特点：降压迅速、但持续时间短,；,2.,浓度：硝普钠,50-100mg,加入,5%GS 500ml,；,3.,药物现配现用、避光使用，每,4-6,小时更换；,4.,必须在心电监护下，静脉输液泵控制滴速使,用，根据血压调整硝普钠浓度、滴速；,5.,根据病人的耐受能力控制血压在最低范围，,一般,90-110/60-70mmHg,，心率,55-70,次,/,分；,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,使用硝普钠的注意事项,6.,药物有局部刺激性，谨防外渗；,7.,长时期、高浓度使用，易引起氰化物中毒，,(,肾脏排泄前在肝脏代谢成硫氰酸盐）肝肾,功能障碍者慎用；,8.,氰化物中毒时患者可出现运动失调、视物模,糊、谵妄、头痛、烦躁等药物性精神症状；,9.,能口服降压药物控制血压的，尽量采用口服,降压。,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,疼痛的护理,解除疼痛：疼痛是所有患者的首发症状，因此解除疼痛应该是首要问题，在积极控制血压、心率的同时，若患者仍有疼痛，应使用镇痛剂，可使用吗啡,3mg,静推，对于疼痛较重者可间断,46h,重复使用。,尽可能早期使用有效止痛、镇静药物,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,疼痛的护理,疼痛的观察：,由于夹层撕裂的部位、走向不同，可放射至头颈、腹部背部,:,累及肾动脉时可引起腰痛,;,胸部疼痛需与心肌梗死鉴别；,在腹部需与急腹症鉴别；,在股部需与急性髂股动脉栓塞鉴别；,无痛性胸主动脉夹层动脉瘤,(,马凡氏综合征,),;,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,疼痛的护理,疼痛的观察：,疼痛减轻后反复出现，提示夹层分离继续扩展；,疼痛突然加重提示主动脉夹层动脉瘤有破裂趋势；,疼痛骤然减轻提示主动脉夹层动脉瘤远端重新破入血管腔（再破口）,。,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,出 院 健 康 指 导,1.,注意休息，合理安排生活，劳逸结合,2.,教会患者自测心率、脉搏、血压，坚持按医嘱 服降压药，不擅自调整药量，有效控制血压，防止加重病情；,3.,不做剧烈活动，控制活动量，不搬抬重物，保持良好心态，避免情绪激动；,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,出 院 健 康 指 导,4.,饮食清淡、易消化、富含营养，少食多餐，不吃动物内脏，控制体重，禁烟 酒；,5.,做好疾病健康教育，若出现胸、腹、腰痛症状及时就诊；,6.,定期复查。,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,Thank you,Department of Cardiology,Cardiac Care Unit,Cardiovascular Medical Center of Jiangsu,The First Affiliated Hospital of Nanjing Medical University,Jiangsu Province Hospital,