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心臟植入性電子儀器(CIED )護理照護指引 – 手術前及手術後_20130907北區

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心臟植入性電子儀器(CIED )護理照護指引 – 手術前及手術後_20130907北區

  1. 1. 心臟植入性電子儀器照護指引- 手術前及手術後 • 主講人:孫佩勤護理長
  2. 2. How many people implantation pacemaker every year in Taiwan ? Statistics 2010 Taiwan Device Implantation Units 4700 Pacemaker 4215 ICD 286 CRTD 64 CRTP 135
  3. 3. What Is a Pacemaker? A pacemaker is a small device that's placed in the chest or abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate. 三部份所組成 由節律器(pulse generator ) 電極(electrode)電極的前端安置在心臟裡面 導線(lead)導線連接節律器與電極間,節律器以一定的速度 將電刺激傳到心臟,使心臟維持規律的跳動。
  4. 4. Permanent Pacemakers組成 Pulse generator – 電池5-10years, Lead wire – Electrode(s) – Unipolar – Spike 大 Bipolar –Spike 小
  5. 5. Pacemaker function Most pacemakers perform four functions • Stimulate cardiac depolarisation. • Sense intrinsic cardiac function. • Respond to increased metabolic demand by providing rate-responsive pacing. • Provide diagnostic information stored by the pacemaker.
  6. 6. Indications for permanent cardiac pacing • Sinus node dysfunction • Atrioventricular (AV) block • Ventricular tachycardia • Carotid sinus hypersensitivity with recurrent syncope or ventricular asystole >3 seconds. • Neurocardiogenic syncope with • associated documented bradycardia. • Atrial fibrillation Symptomatic,drug-refractory atrial fibrillation with co-existing sinus node disease (tachy-brady syndrome). • Heart failure • Hypertrophic cardiomyopathy There is some evidence it reduces intra-left ventricular systolic pressure (Ritter 2005).
  7. 7. Single or dual-chamber pacing Toff et al (2005) found that dual-chamber pacemakers tended to prevent more subsequent heart problems than single-chamber ventricular pacemakers.
  8. 8. NASPE/BPEG generic code for antibradycardia pacing Chamber paced (電線刺激 處,pacing處) Chamber sensed (感知處) Response to sensing (感知有無跳 動會做的反 應) Program-ability (功能設定) Antitachyar rhymia function A= atrium V=ventricle D=dual O=none A= atrium V=ventricle D=dual O=none T=trigger I=inhibited D=dual O=none P=simple M=multiple C=communicative or telemetry ability R=rate responsive capabilities A= atrium V=ventricle D=dual O=none
  9. 9. Pre-implant preparation Depression and anxiety are reported to be more common in patients with permanent pacemakers than in the general population (Duru et al 2001, Tagney 2010). • Important sufficient information pre-operatively to prevent any misconceptions • suggested that pre-operative information should include an explanation of why the pacemaker is required, the different components of the pacemaker (generator and lead), and the pre-operative routine. • family should ideally be included in any discussions.
  10. 10. Pre-implant preparation • Surgical Consent 手術/醫療處置之適應症 手術效益手術風險 替代方案 醫師補充說明/病人提出之疑問及解釋: 說明醫師 手術同意書 心律調節器去顫器心臟再同步治療說明暨同 意書-20100208.doc
  11. 11. Pre-implant preparation • local skin preparation 需例行剃除毛髮(shaving),除非毛髮會影響手術部位。若需去 除毛髮應使用電動剪,並在手術前2小時內進行。 至少術前一日晚上或手術當天早上使用抗菌溶液,如 HIBISCRUB(2-4% chlorhexidine)淋浴或沐浴,特別是手術部位 。
  12. 12. Pre-implant preparation • Expense
  13. 13. Pre-implant preparation • 12-lead electrocardiogram. • Chest X-ray. • CBC BCS and electrolytes. • Vital sign • Methicillin-resistant Staphylococcus aureus screen,ideally at pre- operative assessment. • NPO for 4-6 hours depending on sedation or anaesthesia. • Anticoagulants to be reviewed pre-procedure to minimise risk of bleeding. • Temporary alteration of diabetic medication. • Antibiotic prophylaxis.於手術劃刀前30~60分鐘內給予,以維持 組織有效濃度。預防性抗生素使用原則上不超過24小時;手術 時間若超過3小時,應依據術式及抗微生物製劑之藥物動力學性 質追加給藥。 • Mild pre-procedural sedation.
  14. 14. Post-procedure considerations • Analysing pacemaker rhythms
  15. 15. Ventricular Pacing-VVI  容易固定,atrial功能喪失導致  pacemaker syndrome:病人常會出現疲倦、頭昏、甚至昏厥,而 在心室彈性差且舒張期灌注壓較高的病人則可能出現低血壓及肺 鬱血的症狀。此併發症可以用DDD型節律器重建正常的心房心室 收縮次序來改善。
  16. 16. 雙腔型心臟節律調節器 (Dual chamber pacemaker) • 二條導線分別置於心房與心室 • 可感應及去極化
  17. 17. Troubleshooting • Failure to sensing:spike pace 在不正確的位置
  18. 18. Undersensing : Pacemaker does not "see" the intrinsic beat, and therefore does not respond appropriately From http://www.pacemakerproject.com/treatments/tr_pacemaker_how.htm 2008/10/31
  19. 19. Oversensing : An electrical signal other than the intended P- or R-wave is detected From http://www.pacemakerproject.com/treatments/tr_pacemaker_how.htm 2008/10/31
  20. 20. Troubleshooting Failure to pacing: 該pacing, 卻沒有pacing
  21. 21. Post-procedure complications
  22. 22. Post-procedure complications
  23. 23. PPM 術後護理 1. 密切監測心電圖波形、生命徵象變化。 2. 維持靜脈給藥路徑管路通暢。 3. 檢視導管插入處啟動器放置傷口的情況,滿48小時後或 必要時予以換藥。 4. 在裝置PPM後可不須絕對臥床,只須限制 24-48小時內 勿過度伸展患側手臂 5. 勿過度活動或使患側手臂過度外展,用三角巾固 定患側三天? 6. 依醫囑給予止痛劑止痛。 7. 依醫囑使用抗生素預防感染。 8. 記錄心搏啟動器的型式,植入日期及設定情形。 9. 裝置滿一週後拆線。
  24. 24. Post-operative education Wound care advice • NICE (2008) recommends covering the wound transparent dressing post-operatively for 48 hours • Patients should be advised to look for wound complications such as haematoma or infection sign • Wearing sterile gloves dressing • Do not touch wound and pacemaker
  25. 25. Post-operative education Driving • The Driver and Vehicle Licensing Agency (2010)states that a car or motorbike cannot be driven for at least one week post-pacemaker insertion. • ICD patient Recommendation 3-6 months driving
  26. 26. Post-operative education • Work • when patients return to work as long as they feel well enough to do so. • activity in the first few weeks to prevent lead dislodgement.
  27. 27. Post-operative education • Electronic Article Surveillance System/EAS • 進出大賣場、書店 – 正常走 (10~15秒)  – 賴著不走 (15公分,2分鐘)
  28. 28. 病人衛教事項-1 1. 教導測量脈搏的技巧,並告知每日自我測量的重要 性。 2. 告知若脈搏高於或低於預定速率時,需告知醫師。 3. 注意失效或功能異常可能出現的徵象。 4. 心勿重擊,避免穿緊身衣,以免壓迫心搏啟動器。 5. 心臟節律器植入後預防冰凍肩,一星期內手可平行 活動,一個星後手可以慢慢舉高,一個月後可以可 恢復日常活動。
  29. 29. 病人衛教事項-2 7. 活動無限制但在一個月內,避免急速或劇 烈肩關節活動例如游泳及高爾夫,或提重 物超過5公斤(患側)。 8. 避免及防止電干擾,如遠離高電量(大型 發電機或馬達)、強磁場(工業用磁鐵、 手機基地台),勿靠近高壓電(Kusumoto& Goldschlager,1998)。 9. 定期返院追蹤檢查。 10.隨時攜帶識別卡。
  30. 30. 醫療檢查及治療-1 1. 拔牙:不影響,但應評估是否給予預防性抗生 素。 2. 核磁共振:依機型而定,請call廠商來協助。 3. 放射線檢查:若腫瘤生於心搏啟動器置放處, 需考慮更換部位。若PPM直接暴露於離子放射線, 應先使用防護罩,並監測累積輻射量。 4. 體外去顫整流器:應先關閉其速率 調整功能,必要時調整為VOO。 最好離15公分以上的位置,並備有TCP
  31. 31. 醫療檢查及治療-2 5. 體外震波碎石術:最好離15公分以上的位置。 DDD調為VVI。 6. 經皮神經電流刺激術:此項程序會將電流傳入 人體,因此可能影響體內的植入裝置。考慮進 行這項程序者最好先諮詢其心臟科醫師。
  32. 32. Permanent pacemaker remove when body care • 因容易發生嚴重影響焚化爐產生高電熔且有引 爆焚化爐之顧慮 • 告知家屬須於屍體護理時取出 • 醫令碼:62009C00-肌肉或深部組織異物取出 • 皮下剪斷lead ‚取出電池即可
  33. 33. Thanks for your attention 歡迎指教 台大心臟內科護理長孫佩勤 suen@ntuh.gov.tw

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