室间隔缺损护理查房 - 副本

定义（definition）•室间隔缺损是指室间隔在胎儿时期因发育不全，在左右心室之间形成的异常通道。室间隔缺损引起血液自左向右分流，导致血流动力学异常。Theventricularseptuminthefetalperiodfordysplasia,abnormalpassageisformedintheleftandrightventricular.Ventricularseptaldefectcausedbybloodfromlefttorightshunt,resultinginabnormalhemodynamics.病因(Pathogeny)心血管畸形的发生主要由遗传和环境因素以及相互作用所致Thecongenitalmalformationrelatestogeneticfactor,environmentalfactorortheinteractionofbothfactors.1.早期宫内感染(earlyintrauterineinfection)2.孕母有放射线接触和服用药物(aradiationexposureandmedications)3.孕妇代谢紊乱性疾病(metabolicdisorderdisease)4.妊娠早期酗酒、吸食毒品等分类（classification）根据缺损的解剖位置不同，通长分为膜部缺损、漏斗部缺损和肌部缺损三大类。其中以膜部缺损最常见。绝大多数是单个缺损，偶见多个缺损。AccordingtothedifferentanatomicaldefectsusuallydividedintomembranedefectinfundibulardefectandmusculardefectthreecategoriesThemostcommonismembranedefect.Thevastmajorityaresingledefect,manydefectsarerare.病理生理（Pathophysiology）•室间隔缺损时，左心室血流向右分流，分流量取决于两侧心室间的压力阶差、缺损大小和肺血管阻力。肺动脉压力随右心负荷增大而逐渐增高。•Whentheventricularseptaldefects,theleftventricularflowshunt,flowdependsonthepressureorderdifferencebetweenthetwoventricles,defectsizeandpulmonaryvascularresistance.Thepulmonaryarterialpressuregraduallyincreaseswithrightheartload.临床表现（clinicalmanifestation）症状（symptom）呼吸道感染respiratory乏力、多汗Fatigue,sweating气促、心悸Shortness、palpitation•2、体征(signs)：（1）心前区轻度隆起Theareabeforetheheartslightlyelevated（2）胸骨左缘3-4肋间闻及3级以上粗糙响亮的全收缩期杂音。Leftparasternalintercostalcanheard3-4andmorethan3roughloudholosystolicmurmur.（3）发育迟缓和不良Growthretardationandpoor辅助检查(laboratoryexaminations)1、心电图(electrocardiogram)：小型VSD正常范围，大型VSD为左、右心室合并肥大。重度肺动脉高压时，显示双心室肥大、右心室肥大或伴劳损。2、X线检查(x-rayexamination)中度以上缺损时，心影轻到中度扩大，左心缘像左下延长，肺动脉段突出，重度梗阻性肺动脉高压时，肺门血管影明显增粗，甚至肺血管影呈残根征3、超声心动图(echocardiogram)示左心房、右心室内径增大。多普勒超声证实有左心室向右心室的分流。治疗(treatment)•1、缺损小、无血流动力学改变者，可暂观察，部分病例可自行闭合。patientwhodefectissmallorhemodynamicisnotchangeing,cantemporarilyobservation,somecasescancloseautomatically.治疗(treatment)•2、缺损大、分流量大于50%或伴肺动脉高压的婴幼儿，应早期在低温体外循环下行心内直视修补术。•Defectofinfantsandyoungchildren,dividedflowislargerthan50%orwithpulmonaryhypertensionwhoshouldbeearlyinthedownlinkhypothermiccardiopulmonarybypassandopenheartsurgery.•3、严重肺动脉高压、有右向左逆向分流者，禁忌手术。patientwhohaveaseverepulmonaryhypertension,righttoleftshuntoperationinreversecannotoperate.护理问题(Nursingproblems)术前(preoperative)：1、心输出量减少(decreasedcardiacoutput)2、活动无耐力(activityintolerance)3、恐惧(fear)4、有感染的危险(riskofinfection)5、知识缺乏(Lackofknowledge)术后(postoperative)：1、有心输出量减少的危险(riskofdecreasedcardiacoutput)2、清理呼吸道无效（cleartheairwaysinvalid）3、舒适度改变（thechangeofcomfort）4、有皮肤完整性受损的危险(impairedskinintegrityisinvalid)5、潜在并发症（thepotentialcomplications）：肺高压危象、心律失常护理措施nursingmeasures术前（Preoperative）1、根据患者心功能情况指导患者适量运动，避免激动，紧张，活动间隙给予充分休息，增加患者的营养。Accordingtothecardiacfunctionofthepatients,weshouldinstructthemexercise,avoidexcitedandtension,makesuresufficientrestandincreasetheirnutritions.2、护士应该热情接待患者，做好入院宣教，消除患者的陌生感。Thenurseshouldreceptwarmly,doagoodadmissioneducationsothattheyeliminatethestrangeness.•3、病房开窗通风，患者注意保暖,减少人员探视，避免呼吸道感染。•weshouldventilatwindowsintheward，patientspayattentiontokeepwarm,reducepersonnelvisittopreventrespiratoryinfection.4、向患者及家属讲述术前的注意事项置管情况，并介绍手术室及监护室的一些情况。Tellpatientandtheirfamiliesabouttheattentiontothewoundandcatheterorsomeconditionaboutoperationroomandintensivecareunit术后(postoperative)：1、循环及意识的监测,密切观察患者生命体征Monitoringofcirculationandconsciousness,observethevitalsignscloselyHeartratesBloodpressureOxygensaturationRespiration2保持呼吸道通畅,术后应用呼吸机辅助呼吸,保持患儿四肢温暖，促进末梢血液循环.Keepairwayclear,applyventilatorassistedbreathingandkeepwarmtopromotethebloodcirculation3、采用体位引流，采取体疗促进痰液排出，遵医嘱用药，必要时进行吸痰。takeposturaldrainageandphysicaltherapytopromotesputumdischarge,sputumsuctionifnecessary.ultrasonicnebulizationbackslap4、观察疼痛的性质，持续时间，给予患儿舒适的体位，必要时遵医嘱给予药物止痛。Observethenatureofpain,duration,andgivepatientacomfortableposture,whenisnecessarygivedrugatthedoctor'sadvice.5、预防发生肺高压危象preventpulmonaryhypertensioncrisisHOW?（1）适当延长呼吸机辅助时间，防止发生肺部并发症Prolongingventilationtimeappropriatelypreventtheoccurrenceofpulmonarycomplications（2）维持适当的过度通气。Maintainhyperventilationappropriately（3）应用降低肺动脉压的血管活性药物Applythevasoactivedrugstoreducethepulmonaryarterypressure（4）充分镇静，减少刺激。keepcalm,reducethestimulus5、饮食与活动(dietandactivity)•患者拔除气管4小时可饮水，进食流质饮食，若无呛咳，可改为普食。Patientcantrydrinkwaterandfluidfoodwhentrachealintubationwerepulledoutwithinfourhours,ifthereisnocough,Insteadofcommonfood.6、术后注意观察引流液的颜色、量、有无凝血块等。Observecolor,volumeofthedrainagefluid7、护患之间采取有效沟通，做好阶段性健康指导，指导家属正确认识疾病及正确照护患者，提高患者及家属的合作和依从性。Effectivecommunicationbetweennurseandpatient,makestagehealthguidance,givethemacorrectunderstandingofthediseaseandthecorrectfamilycareofpatients,improvethemcooperationandcompliance.健康指导（HealthGuidance）术前(Preoperative)：1、减少剧烈活动，活动量以不引起疲乏、呼吸困难、胸闷等不适为宜Reduceviolentactivity,stopactivitywhenpatientfeelfatigue,difficultybreathing,chestpainandsoon2、帮助患者及家属尽快认识和熟悉周围环境，寻找有效的支持系统.Helpthepatientsandtheirfamiliesarefamiliarwiththesurroundingenvironment.3、指导患者及家属开窗通风，防寒保暖，预防感染。Guidepatientsandtheirfamiliesopenthewindowventilation,preventofinfection.4、指导患者及家属合理饮食，增强体质,讲解疾病知识，给予患者及家属心理支持Guidepatientsandtheirfamiliesh