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:heartsize:拳頭，250-350gmheartlocation:2/3胸骨中線左側；Base:2nd肋骨；Apex:5th肋間&Lt鎖骨中線heartfunction:deliverO2andotheressentialsubstitutetotissueofbodyremoveCO2&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15-50cc心包膜液，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)CoronaryvasculatureRightcoronaryartery(RCA）、Leftmain-Leftanteriordescendingartery(LAD)、Leftcircumflex(LCX)Ascendingaorta(75%atdiastolic)RCA(supplyRA,RV,postLV,90%AVnode)LeftmainLAD(supplyAnt.LV,apex)、LCX(supplylateralLV,LA)The Cardiac CycleBloodCirculationCircuitsPulmonaryCircuitlungsSystemicCircuit-wholebodyCardiac CycleSystolecontractionDiastolerelaxationAtriarelaxwhenVentriclescontractandviceversaSteps in a contractionWhenatriafillpressureopensAVvalvesAtriacontractionfillsventriclescompletelyVentriclesbegintocontractandAVvalvessnapshut(LUB)Increasedcontraction(inc.pressure)forcessemilunarvalvesopenBloodflowsintovesselsleadingaway.PressureincreasesandforcesSLvalvesshut(DUB)ProcessbeginsagainCardiac 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 & 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）Contractility收縮力Vpkfortheleftventricleisaround1.11.5m/sinhealthypatients.Inpatientswithcardiacfailureorlowcontractility/inotropythisfiguremightwellbeonly0.6or0.7m/sorevenless.Fortherightventriclethefigurewouldbe0.7to1.2inhealthypatients.後負荷(Afterload)Ohms law: R = P/Q SVR = (MABP CVP)/CO (systemicvascularresistance)PVR = (MPAP LAP)/CO (pulmonary vascular resistance)臨床評估: SVR and PVRAhighBPmeansthattheventricleispushinguphillHighviscosityandvasoconstrictionmeanhardworkfortheventricleCardiac OutputThe amount of blood ejected by the left ventricle in one minuteCO=HRXSVHeartrateis75beatsperminStrokevolumeis70mlperbeatBloodvolume?docalculationCO=SVxHR=60-130cc/beatX75beat/min=4-8L/minCardiacfunctionindexEjectionFraction心射出分率Is%ofbloodejectedwitheverybeat=SV/LVEDV=2/3=60-75%(Normal50%)ReflectLVperformanceCardiacindex(CI)心臟指數Cardiacreserve心臟儲備量Cardiacindex(CI)心臟指數IsCOcorrectedfordifferencesinbodysize=CO/bodysurfacearea=2.5-4L/min/m2www.learnhemodynamics.com/hemo/contract.htmCardiacreserve心臟儲備量Cardiacreserve=abilitytorespondtothedemandforincreasedCO(eg.Exercise,stress)Normal:300-400%Conduction SystemSinoatrialnode(SAnode)-RA,fastestautorhythmictissue(pacemaker,60-100bpm)Atrioventricularnode(AVnode)-lastpartofatriatodepolarizesignalhesitatesthenproceedstoventricles(40-60bpm)AVbundle(bundleofHis)-connectsatriatoventriclesRtandLtbundlebranches-sendsignaltoapexofheartPurkinjefibers-actionpotentialsentthroughoutventricletissue(20-40bpm)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SAnode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NeurologicControloftheHeartAutonomicnervoussystem(自主神經的控制)SympathicNE1HR, contractilityCO,BPParasympathicACHHR, 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(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Nursingassessment:history,GoldenPhysicalexaminationDiagnostictestsLaboratoryHemodynamicmonitoringNon-invasivetestsECG,Treadmill,Echo,Nuclearcardiology,CT,MRIInvasivetestsCardiaccatheterization,Coronaryangiography,electrophysiologicstudy(EPS),endomyocardialbiopsy(EMB),TEE,IVUSNursingassessmentMaincomplaint:chestpain,dyspnea,fatigue,edema,palpitation,syncopeHistoryofpresentillness:onset,signs&symptomsPastmedicalhistory:previousillness,injuries,surgery,medicationRiskfactors:familyhistory,smoking,activity,diet,personalityGoldens11functionalhealthpatternsChestPainAssessmentAssessmentAnginaPericarditisProvocation/PalliationExercise/restDeepbreath,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/onset,duration10minSeveralhrstodaysDyspneaSOB(shortofbreath)呼吸短促DOE(Dyspneaonexercise/exertion)運動時呼吸困難,最常見於walk,crimbstairOrthopnea端坐呼吸,無法平躺，半坐臥緩解PND(paroxysmalnocturnaldyspnea)夜間陣發性呼吸困難,Physicalexamination-Inspectionskin:centralcyanosis(lip,mouth,conjundival)poorarterialcirculationperipheralcyanosis(lip,ear,nail)peripheralvasoconstrictionEyes:arcussenitis老人弓,Xanthelasma黃斑瘤atherosclerosisPhysicalexamination-InspectionFingersclubbing杵狀指PO2or lung cancerCapillaryrefill(circulation):pressnailtobranches,colorreturn30secdehydration,BWEdema:press5sec,remove(+15mmHgaortabloodflowinlowerarmPulsepressure:SBP-DBP=3050,OrthostaticBP:lying-standing20dehydration,poorHTN,aortadiseasePhysicalexam-Vitalsignpulse:rate,rhythm,amplitude,bilateralpulsusparadoxus(奇脈):pulsechangewith呼吸,吸氣pulseweaken,BPpulsusalternanus(交替脈):pulsechangewithHR,pulsation:0=none,+=weak,+=normal,+=strongPhysicalexaminationCarotidartery:thrill,bruit(vesselmurmur):arterialnarrowingJugularveinpressure(JVP)1mmContraindications:UnstableanginawithrecentchestpainCriticalaorticstenosisSeverehypertrophicobstructivecardiomyopathyUntreatedlife-threateningcardiacarrhythmiasUncompensatedcongestiveheartfailureAdvancedAVblockAcutemyocarditisorpericarditisUncontrolledhypertensionEchocardiography超音波usessoundwavestoproduceanimageoftheheartandtoseehowitisfunctioning.Transducerhighfrequency,shortwavereturn示波鏡、描繪圖影像showthesize,shape,andmovementoftheheartmuscle,valvesdisease,bloodflow,arteries.TypesMotion-mode(收縮、活動),2Dimensional-echo(縱、橫向結構),Doppler(血流方向、流速)Transesophageal Echocardiography (TEE)Thetestislikestandardechocardiographyexceptthatthepicturesoftheheartcomefrominsidetheesophagusratherthanthroughthechestwall.NPO6-8hourssprayingthroatwithananestheticatube(probe)putdownthethroatGagreflexreturn,theneatingIntravascular Ultrasound(IVUS)isacombinationofechocardiographyandcardiaccatheterization.usessoundwaves,whicharesentthroughacathetertoarteryandheart,toproduceanimageofthecoronaryarteriesandtoseetheircondition.israrelydonealoneorasastrictlydiagnosticprocedure.Itisusuallydonewithatranscatheterinterventionlikeangioplasty.Chest X rayMostcommonlyperformedimagingtestforCVsystemForevaluationofcardiacchambersizeandgreatvesselsChest X ray with enlarged heart sizeNuclear cardiology (心臟核子醫學檢查)Ejectionfraction+wallmotionEvaluationofcardiacperformanceandregionalwallmotionLeftventriculardiastolicphaseindex(MUGA)UsefulforevaluationofdiastolicfunctionPatientswithatrialfibrillationNuclear cardiologyTl-201Singlephotonemissioncomputedtomography(SPECT)MyocardialperfusionimagingTETTl-201,PersantinTl-201Positronemissiontomography(PET)MyocardialbloodflowandmyocardialviabilityNuclearCardiologyTc99鎝同位素(hotspot)：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lMI4hours可發現，24-72hrs最靈敏Thallium201myocardialimaging鉈(coldspot):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(coldspot)Computed tomography (CT scan)Cardiacdimensions,calcificationsandfunctionIschemicheartdisease,LVaneurysm,etc.PericardialdiseasePericardialeffusion,constrictivepericarditis,pericardialcystParacardiac,pericardialandcardiacmassesCongenitalheartdiseaseDiseaseofthethoracicaortaAorticdissection,aorticaneurysmPulmonaryembolismMagnetic 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 catheter.Interfere with pacemaker functionCant use with prosthetic metallic devices (valves, prosthetic joints, pacemaker etc.Invasive testsCardiaccatheterizationCoronaryangiography(CAG)Electrophyiologicstudy(EPS)Endomyocardialbiopsy(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Cardiaccatheterizationpost-cath：vitalsign:q15min*4q30min*2(or4)q1h股動脈:bedrest6-8hours,compress4-6hrs橈動脈:bedrest1-2hours,compress2hrscheckwound:bleeding？infection？checkP+P(pulsation&perfusion)？complications：bleeding,hemotoma,dyeallergy,arrhythmia,thrombusEPS(Electrophysiologicstudy)understandarrhythmiamechanism(eg.Additionalpathway)effectsofdrugsandablationdecidetheneedofpacemakerEndomyocardial Biopsy(EMB)GradeFindingRejection Severity0NoinfiltratesNone1AFocal(perivascularofinterstisialinfiltrateswithoutnecrosisMild1BDiffusebutnotsparseinfiltratewithoutnecrosisMild2Onefocusonlywithaggressiveinfiltrateand/ormyocytedamageFocalModerate3AMultifocaaddressiveinfiltratesand/ormyocytedamageModerate3BDiffuseinflammatoryinfiltrateswithnecrosisBorderlinesevere4DDiffuseaggressivepolymorphousinfiltratewithedema,hemorhageandvasculitis,withnecrosisSevereInternational Society for Heart & Lung Transplantation Endomyocardial Biopsy Grading SchemeReviewAnatomyandphysiologyoftheheartPhysicalexaminationofcardiovascularsystemNursingassessmentNon-invasivetests:Lab.,chestX-ray,EKG,echo,Nuclearcardiology,CT,MRIInvasivetests:Cath,EPS,EMB,TEE,IVUS