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iu dng Ni
KHOA NI
H CAO NG IU DNG (LU HNH NI B)
MC LC
TRIU CHNG HC H TUN HON ......................................................................... 3 VIM NI TM MC BN CP NHIM KHUN..................................................... 12 VIM MNG NGOI TIM ............................................................................................. 18 SUY TIM........................................................................................................................... 25 CN AU THT NGC ................................................................................................ 33 NHI MU C TIM........................................................................................................ 37 TNG HUYT P ........................................................................................................... 43 TM PH MN ............................................................................................................... 47 TRIU CHNG HC H HP ...................................................................................... 52 VIM PHI ...................................................................................................................... 59 P XE PHI ..................................................................................................................... 65 UNG TH PHI .............................................................................................................. 70 HEN PH QUN ............................................................................................................. 75 HO RA MU .................................................................................................................... 80 TRIU CHNG HC TIU HA .................................................................................. 85 P XE GAN ...................................................................................................................... 89 X GAN ........................................................................................................................... 94 UNG TH GAN ............................................................................................................... 99 LOT D DY - T TRNG ....................................................................................... 105 UNG TH D DY ...................................................................................................... 109 CHY MU TIU HA ............................................................................................... 112 TRIU CHNG H TIT NIU ................................................................................... 119 SUY THN MN .......................................................................................................... 122 NHIM KHUN TIT NIU ........................................................................................ 127 VIM BNG QUANG ................................................................................................... 127 TRIU CHNG HC V MU ................................................................................... 130 THIU MU .................................................................................................................. 134 BNH BCH CU CP................................................................................................ 137 BASEDOW ..................................................................................................................... 141 I THO NG ...................................................................................................... 144 VIM A KHP DNG THP .................................................................................... 148 TI LIU THAM KHO ............................................................................................... 151
Xut hin da, nim mc, u ngn tay, ngn chn. Do tnh trng hemoglobin kh (hemoglobin khng c kt hp vi O2) tng ln. Tm thng gp trong: - Suy tim - Tim bm sinh c lung mu thng t phi qua tri 1.4. Ph C ch: - Do mu ngoi vi l ch yu. Ngoi ra cn do: - p lc keo gim - Do ri lon tnh thm mao mch - Do mui trong c th Tnh cht ph: - Ph vng thp trc nh bn, chn v sau khi suy tim nng hn ph cao hn, ph ngc bng, ph ton thn, hoc ph mng bng, mng phi. - Thng ph v chiu, trng hp nng th ph c ngy c m. 1. 5. au vng trc tim
V tr v hng lan ca cn au tht ngc C th do: - Thiu mu c tim: chng au tht ngc v nhi mu c tim do x va ng mch vnh; bnh thiu mu; hp van dng mch ch - au ngoi tim: au thn kinh lin sn, vim mng phi, vim phi tri 1.6. Ngt Ngt l do thiu O2 no trong thi gian ngn. Ngi bnh bt tnh, da ti nht, mt tri gic. Tim ngng p hoc p chm, ngng th. C th gp trong bnh tim hoc khng do bnh tim. Ngt do tim, gp trong cc trng hp:
- Blc nh tht hon ton: tim p < 40 nhp/ ph - Bnh mch vnh v c tim lm tim co bp yu nn no thiu O2 - Hp van ng mch ch - H huyt p 2. Phng php khm tim T th ngi bnh: ngi bnh nm, u v lng gi hi cao, hai chn co, bc l ngc. Y sinh ngi bn tri hoc bn phi ngi bnh. 2.1. Nhn - Mu sc da v nim mc: tnh trng tm da, nim mc, ngn tay chn di trng trong tim bm sinh, vim ni tm mc bn cp Osler - Tnh trng kh th: nhp th, co ko lng ngc, khong gian sn, - Hnh dng lng ngc: bin dng lng ngc - Mm tim: v tr, tn s, cng p. ngi bnh thng mm tim p gian sn 4 trn ng trung n. Mm tim p mnh trong tim to, p yu trong trn dch mng tim, thnh ngc dy - Tnh mch c: ni trong suy tim phi 2.2. S 2.2.1. Mm tim
S mm tim - V tr: trong trng hp tim to, mm tim thp di hoc ra ngoi ng trung n. Trng hp dy dnh mng phi v mng tim, tim b co ko v pha dy dnh - Cng : mm tim p yu trong trn dch mng tim, ngi c thnh ngc dy. Mm tim p mnh trong tim to, h van ng mch ch, 2.2.2. Ting rung miu: do ting thi hay rung qu ln. t tay ln vng ngc c cm gic rung ging nh t ln lng mo. Tu theo rung th tm thu hay tm trng m gi l rung miu tm thu hay rung miu tm trng
2.3. G G tim nh gi v tr mm tim, kch thc tim. - Tm mm tim: g cho t di ln, t tri sang ch bt u c l mm tim - Din c ca tim: din tim gii hn bi cc ng sau y + B trn gan: g t trn xng n xung, n khi n vng c l vng c ca b trn gan, ngang mc gian sn 5 + B phi tim: g t dng nch trc vo n khi thy vng c ca b phi tim. Bnh thng b phi tim khng vt qu b phi xng c + B di tim: ni mm tim v im giao nhau ca b phi tim v b trn gai, ta c b di tim + B tri tim: g chch t hm nch tri v pha mi c, t ngoi v trong, t trn xung cho n khi tm c mt ng gii hn b tri tim. Bnh thng b ny i t st b xng c tri xng sn 2 i xung v phnh ra thnh ng cong ti gian sn 4 trong ng trung n 1- 2cm 2.4. Nghe
Cc t th nghe tim Trong khm tim, nghe tim l quan trng nht, nh gi c nhiu triu chng c gi tr chn on 2.4.1. V tr nghe tim: nghe 5 van tim
- van 2 l: mm tim - van 3 l: sn sn 6 bn phi xng c - van ng mch ch: khong gian sn 2 bn phi xng c v van ng mch ch ph khong gian 3 cch b tri xng c 3cm gi l Eck Botkin - van ng mch phi: gian sn 2 bn tri xng c 2.4.2. Ting tim - Ting tim bnh thng: Ting th nht: Ting T1: nghe trm v di; do ng van nh tht Ting th hai: Ting T2: nghe cao v ngn: do ng van ng mch Ting th 1 cch ting th 2 mt khong thi gian ngn, ting th 2 cch ting ting th 1 mt khong ngh di. - Ting tim bnh l: + Thay i v cng : Cng tng trong xc ng, th thao, lao ng nng, st, cng gip Cng gim trong trn dch mng tim, vim c tim, nhi mu c timTing T1 anh trong hp van 2 l: do van 2 l dy, x cng do vim, khi ng cc van p vo nhau gy ra ting anh. Ting th 2 mnh trong tng huyt p. + Thay i v nhp iu: bnh thng nhp tim u do h thng thn kinh t ng chi phi. Khi tn thng h thn kinh ny s gy nhp nhanh, nhp chm hoc lon nhp + Thay i v s lng ting: ting nga phi: nhp 3 ting ny do mt ting nh thm vo trong k tm trng. ting nga phi do tm tht suy nhiu, thi k tm trng tim d gin ra khi mu xung y mm tim chm vo lng ngc ta nghe c thm mt ting trong k tm trng. Ngi ta gi l ting nga phi phi hay tri tu theo tm tht phi hay tri b suy. Nga phi phi nghe r cnh mm c, nga phi tri nghe r mm tim. 2.4.3. Cc ting thi:
- Trn lm sng ta nghe c ting thi tm thu, ting thi tm trng v ting thi lin tc. Ting thi tm thu l ting nghe ng thi vi mch ny, ting thi tm trng l ting nghe ng thi vi mch chm, ting thi lin tc nghe c 2 th ca tim. - C ch pht sinh ting thi: Cc ting thi tim l do dng mu i t ch rng qua ch hp ri i vo ch rng. + Trong h van 2 l, ting thi tm thu do dng mu pht t tht tri ln nh tri qua l van 2 l khng ng kn. + Trong hp van 2 l ting rung tm trng do mu t nh tri qua ch hp ca van v va vo dy chng ct c. + Trong h van ng mch ch c ting thi tm trng do dng mu t ng mch ch v tm tht tri qua van ng mch ch ng khng kn. - Ting thi c nng v ting thi thc th: ting thi thc th do c tn thng van tim, ting thi c nng khng do tn thng van tim m do mt l do no cc van tim khng ng kn, khi tim co bp gy ra ting thi. + Ting thi thc th: V tr: tu theo tn thng van no nghe r ting thi van . V d ting thi tm thu mm tim trong bnh h van 2 l, ting thi tm trng gian sn 2 phi v 3 tri trong bnh h van ng mch ch. Thi gian: Ting thi c th chim ht hay mt phn th tm thu hoc tm trng Lan truyn: Ting thi lan truyn theo hng i ca dng mu, ni nghe r nht l v tr tn thng, cc ni khc t r hn l ni ting thi lan n. V d ting thi tm thu lan nch trong h van 2 l Cc ting thi thc th: Ting thi a im Ting thi - Mm tim tm thu Tnh cht Hng lan Bnh - Chim ht th tm thu, - Ra nch v H van 2 l nh ting pht hi nc, sau lng c th c rung miu - Lin sn 3, - C rung miu, chim ht - Lan theo hnh Thng 4 tri vng th tm thu nan hoa tht trc tim Ting thi Lin sn 2 Nh, m du tm trng phi hoc 3 tri cnh xng c Rung trng tm Mm tim trng trn mt trng, c Dc xng c H van hoc xung ng mch mm tim Nh ting v nh di t lan ch Hp van 2 l lin
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rung miu tm trng + Ting thi c nng: Cc van tim khng tn thng nhng do cc bung tim gin to cc van khng ng kn to ra ting thi. Ting thi c nng thng m nh, t lan v thay i m sc khi thay i t th. Ting thi c nng gp trong suy tim. * Phn bit ting thi thc th v ting thi c nng Ting thi thc th Thi gian Cng m sc Rung miu Tm thu, tm trng, lin tc Thng mnh, r Lan xa theo dng mu Thng c Ting thi c nng Ch yu l ting thi tm thu; t khi chim ht th tm thu Thng nh, m du, t khi mnh t lan Khng
Lan truyn
Tnh thng C thng xuyn, khng thay i C th thay i, mt hn khi ngi xuyn m sc khi thay i khi thay i t bnh thay i t th th 3. Cc phng php cn lm sng tim mch 3.1. X quang: chiu, chp, chp ct lp, chp bung tim (vi cht cn quang) Hnh nh chiu chp tim t th thng bnh thng Bn phi: Cung trn: tnh mch ch trn Cung di: cung nh phi Bn tri: Cung trn: quai ng mch ch Cung gia: thn ng mch phi Cung di: tm tht tri Phn tim tip xc c honh: tht phi.
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3. 2. in tm : nh gi c cc ri lon nhp tim, bnh mch vnh tim, dy gin tht, dy gin nh... 3.3. Siu m: nh gi c tnh trng hot ng ca tim, cc van tim, dch mng ngoi tim 3.4. Thng tim Mc ch: nh lng kh. o p lc mu. Pht hin d tt bt thng Dng ng thng nh, di, do, cn quang. Nu thng tim phi th lun ng thng theo tnh mch tay hoc tnh mch i vo nh phi, xung tht phi ri ln ng mch phi, dng X quang theo di u ng thng. Nu thng tim tri th theo ng mch ln bung tim tri, hoc t tm nh phi chc thng vch lin nh. 3.5. Cc xt nghim sinh ho - nh lng in gii Na, K, Cl - Phn ng min dch trong bnh thp - nh lng cholesterol, lipit mu - nh lng men tim trong nhi mu c tim
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Tn thng ni tm mc thng l cc van, nhiu nht l van 2 l ri n van ng mch ch, him khi gp van 3 l, ng mch ch. Nhng nt si trn ni tm mc l tn thng ch yu nht. Nhng nt si ni trn rt d b tch ri ra theo dng mu i ti cc c quan gy nn nhng hin tng tc mch, ng thi li cc vt lot van. Nhng vt lot ny thng l nng, nhng cng c khi su n mc c th lm thng van hoc thm ch lm t c dy chng, ct c hoc lm thng c vch lin tht. 4. Triu chng 4.1. Lm sng 4.1.1. St: - L mt triu chng lun lun gp, nhng hnh thi st v mc st rt thay i. Thng thng nht l kiu st va, nhng st c tnh cht dao ng v nht l st ko di mt cch dai dng. - Vic cp nhit ba gi mt ln l cn thit pht hin cn st v tip s cy mu trong lc st th t l cy mu dng tnh thng cao hn. 4.1.2. Biu hin tim: - Xut hin triu chng h ng mch ch hoc h van 2 l, bnh thng xy ra trn bnh tim c trc (hoc cng c th khng) do quan trng nht l s thay i ting tim: + Xut hin nhanh chng v t ngt. + Thay i nhanh chng v cng v m sc. - Suy tim l bin chng hay gp v l nguyn nhn t vong 4.1.3. Nhng biu hin da, nim mc v ngn tay: - C th c xut huyt di da v nim mc di dng nhng m xut huyt. - Ngn tay di trng: u ngn tay to ra, cc mng trn v cong l mt triu chng c nhiu gi tr gi chn on, nhng thng l du hiu mun.
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Lch to l mt triu chng c nhiu gi tr gi cho chn on trn c s mt bnh nhn tim c st. 4.1.5. Cc tai bin tc nghn mch: V hay xy ra nn c th c sp xp vo triu chng ca bnh. - Nhi mu ni tng c th xy ra gan, rut, lch, thn v nht l no: tn thng no c th gy ra lit na ngi. - C th gp m t ngt do tc ng mch trung tm vng mc. 4.2. Cn lm sng 4.2.1. Cy mu - L xt nghim ch yu c tnh cht quyt nh chn on v nh khng sinh s gip cho vic iu tr khng sinh - Cn phi cy mu nhiu ln trc khi cho khng sinh. - C gng cy mu khi bnh nhn ang st v lc kh nng dng tnh thng cao hn bnh thng. 4.2.2. Siu m tim Siu m tim ngy cng c coi l mt xt nghim rt hu ch trong chn on xc nh cng nh theo di din bin cc tn thng tim trong bnh vim ni tm mc bn cp nhim khun. Vi k thut siu m kiu TM v nht l siu m hai chiu (2D), ngi ta c th xc nh s c mt ca cc tn thng si trn b mt cc van tim, pht hin c nhng hin tng t cc dy chng, ct c hoc thng cc vch tim. 5. Chn on 5.1. Chn on xc nh: da vo 5.1.1. Triu chng nhim trng: St dai dng 5.1.2. Xy ra trn bnh nhn: - c bnh tim mc phi - Hoc va xut hin h van ng mch ch hay van 2 l - Hoc c d dng bm sinh tim S nghi ng tr nn chc chn nu trong tin trin xut hin: - Lch to - Ngn tay di trng... - Triu chng vim thn - Bin chng thn kinh: lit na ngi, xut huyt mng no Cy mu c vi khun s gip iu tr, nhng cy mu m tnh khng loi tr vim ni tm mc bn cp.
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Tuy nhin, trn thc t, c th chn on v iu tr sm, ta nn ngh n vim ni tm mc bn cp nhim khun trc mt bnh nhn tim c st dai dng trong 2 tun m khng c l do. 5.2. Chn on phn bit: Ch cn t ra trong trng hp cy mu m tnh, lc cn phn bit vi: 5.2.1. Thp tim tin trin: Thp tim tin trin, cc mng tim cng vim, nht l c tim nn bnh biu hin ca bnh tim suy c st. 5.2.2. Tc mch ngi suy tim 5.2.3. Nhng bnh khc ngi bnh tim - St rt - Vim i b thn - Lao phi - Ung th ni tng, bnh mu c tnh 6. Cc th bnh: C nhiu th 6.1. Th thiu mu, nhim trng ko di 6.2. Th i mu: d nhm lao thn, si thn. 6.3. Th vim thn cp: bnh nhn cng c ph, i mu, ur mu cao, nc tiu c tr hnh v albumin. 6.4. Th suy tim: suy tim cng ngy cng kh hi phc, hoc suy tim cp gy ph phi cp 6.5. Th thn kinh: vi lit na ngi 6.6. Th cy mu khng vi khun. Th ny c c im: + Chim t l cao + Rt kh iu tr, t l t vong cao. 7. iu tr Trc thi i khng sinh, y l mt bnh chc chn gy t vong. Ngy nay, tuy t l t vong c gim bt nhng vn cn l mt bnh nng. 7.1. Khng sinh - Nguyn tc l phi iu tr sm, liu cao, ko di. - Ngay sau khi cy mu nhiu ln, khng cn ch kt qu cy mu, ta nn iu tr phi hp ngay Penicillin v Streptomycin , v y l nhng thuc khi phi hp c nhiu tc dng dit khun m li t c v d kim. - Thng dng Pennicillin (10 triu n v/ ngy) phi hp vi Streptomycin 1g/ ngy). - Sau , ty theo kt qu cy mu v khng sinh m ta iu chnh - iu tr khng sinh t nht 6 tun v ko di 20 ngy sau khi ht st * Trng hp cy mu m tnh: Thng phi hp Penicillin hoc Ampicilin vi Gentamicin.
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7.2. iu tr cc biu hin suy tim, ri lon nhp tim... nu c, bng nhng phng php thng thng. 8. Chm sc 8.1. nh gi nh gi chm sc bnh nhn VNTMNK, gm: - nh gi triu chng st ca bnh nhn. Triu chng st khng nhng rt c gi tr trong chn on m cn rt quan trng trong tin lng bnh nhn. - nh gi cc bin chng ca VNTMNK. 8. 2. K hoch chm sc Chm sc v tinh thn - v sinh thn th cho bnh nhn. Chm sc v dinh dng Thc hin y lnh thuc Gio dc sc khe cho bnh nhn VNTMNK 8.3. Thc hin chm sc 8.3.1. Chm sc tinh thn - v sinh thn th: - VNTMNK l mt bnh rt nng, t l t vong rt cao, nht l trong nhng thng u, nn bnh nhn phi nm vin rt lu, hng thng, c khi nhiu thng do vy cn an i, ng vin bnh nhn, khuyn khch tinh thn h yn tm iu tr. - Hng ngy ch v sinh thn th cho bnh nhn v h phi nm lu trong bnh vin. Cng vic tm gi, thay qun o, chn, mn, m gi, cn tin hnh theo lch thng xuyn trnh lm cho bnh nhn mc thm cc bnh nhim khun khc. 8.3.2. Chm sc v dinh dng: VNTMNK l mt bnh rt nng, bnh nhn st ko di dai dng nn rt chn n. Hn na, hng ngy ngi bnh li phi dng rt nhiu khng sinh cng lm bnh nhn km n hn. Cn c bit quan tm n ch dinh dng ca bnh nhn. - Gii thch, ng vin hng ngy bnh nhn n ht khu phn. - Thc n phi ch bin tt, m bo y thnh phn, tng protid v rau qu. Bnh nhn suy tim phi thc hin n gim mui. 8.3.3. Thc hin y lnh thuc: Bnh nhn VNTMNK phi tim khng sinh thi gian rt di, thng phi 4 - 6 tun l, cho nn thuc tim bp gy au n nhiu. iu dng nn: - Tm mi bin php lm gim au n cho bnh nhn do tim khng sinh. - Hng ngy thay i v tr tim, v tr tim nn chn l tim mng bnh nhn au, tip nhn thuc tt. 8.3.4. Gio dc sc khe cho bnh nhn:
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Mc ch chnh ca vic gio dc sc khe cho bnh nhn VNTMNK l trang b cho h nhng kin thc c bn v cc bin php phng nga VNTMNK ti pht. Mun phng VNTMNK ti pht bnh nhn phi thc hin trit cc bin php sau: - iu tr bng khng sinh tht tch cc cc nhim khun d l nh theo n thy thuc. - Tun theo ch nh iu tr phu thut sm nu c ch nh phng nga VNTMNK. - n thy thuc khm bnh ngay khi c xut hin mt trong cc triu chng: st, chn n, gim cn nng, mt mi. 9. D phng Cho n nay, mc d c nhng loi khng sinh mi rt tt, nhng vim ni tm mc bn cp do vi khun vn l mt bnh nng, lun e da tnh mng ca bnh nhn. V vy chng ta phi rt ch n vic iu tr d phng cho tt c nhng bnh nhn c bnh tim. C th l: - iu tr mi nhim khun nh thong qua: vim hng, vim xoang, vim li, vim bng quang... - iu tr khng sinh cho tt c cc bnh nhn tim trc, trong v sau khi tin hnh cc th thut d l nh nht (v d nh nh rng) hoc sau khi sinh . - Tin hnh phu thut sm cho nhng bnh nhn tim bm sinh c th m c v d b e da nhim khun.
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2.3. Phn ng d ng v min dch: Phn ng d ng v min dch bao gm c hi chng sau m tch van hai l hay hi chng sau nhi mu c tim (hi chng Dressler). 2.4. Ung th: c bit l di cn ung th phi. 2.5. Ri lon chuyn ha: nhiu trng hp ur mu cao thng c phn ng vim mng ngoi tim. 2.6. Cc p xe ln cn v vo mng tim (p xe gan, p xe thc qun,...) 2.7. Nhi mu c tim 2.8. Chn thng do vt thng lng ngc hay tai bin ca qu trnh thng tim, m tim. 2.9. V cn 3. Triu chng - Chn on Trong phm vi bi ny chng ta cp ti chn on th vim mng ngoi tim c trn dch. 3.1. Chn on xc nh 3.1.1. Triu chng ton thn: thng khng hng nh v khng c g c hiu, n thng ph thuc vo nguyn nhn gy bnh. C th gp cc triu chng sau: st, chn n, mt mi, c th gy st. 3.1.2. Triu chng c nng: - au ngc: l mt triu chng thng gp nhng khng phi l lun lun c. + V tr au thng vng trc tim, i khi l vng sau xng c. au c th lan ln c, ln vai hoc lan ra sau lng. + C th au nhiu hoc au t. au thng tng ln khi bnh nhn ht su hoc ho. Nhn chung bnh nhn thng c cm gic b p ngc tri. - Kh th: lc u kh th khi gng sc, v sau nm yn cng kh th. + Thng l kh th kiu nhanh, nng. + Mc kh th thng va phi, nhng trong trng hp c p tim th bnh nhn kh th rt d di. - Mt s triu chng khc t gp hn: kh nut (do tim to ra p vo thc qun pha sau), ho khan, nc. 3.1.3. Triu chng thc th: - Nhn v s: khng thy mm tim p hoc p rt yu. - G: din c ca tim thng to ra. - Nghe: nhp tim thng nhanh, ting tim m t hoc nhiu. C th nghe thy ting c mng ngoi tim. Ting c mng ngoi tim l mt du hiu c trng, chng t mng ngoi tim b vim (c th vim kh hay vim c trn dch nhng s lng dch thng t). - Cc du hiu ca tr tun hon ngoi bin: c th thy c cc triu chng sau, nht l khi dch mng tim nhiu: + Tnh mch c ni, gan to, ph hai chi di.
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+ p lc tnh mch ngoi bin tng, thng trn 25cm nc. - Mch thng nhanh nh. Huyt p ng mch thng h hoc tr nn kp. 3.2. Cn lm sng 3.2.1. X.quang - Chiu X quang tim phi l mt xt nghim gip ch rt nhiu cho ngi thy thuc, trong vic chn on trn dch mng ngoi tim. Trong nhng trng hp ny, ta thng thy tim to, p yu hoc gn nh khng p. - Chp X quang tim phi thng cho thy r hnh nh c trng : tim to b sang hai bn, cung tim ngn to ra hnh ging qu bu. B tim thng rt r nt v tim p yu. C th thy hnh hai b tim; b trong l bng tim, b ngoi l mng ngoi tim cha dch. i khi cng c th thy c hnh nh mt vi ch vi ha mng ngoi tim.
X quang tim phi trong trn dch mng ngoi tim 3.2.2. in tm : ST thng chnh ln ng hng cc chuyn o trc tim t V1 n V6.
3.2.3. Siu m tim: - Trong trng hp trn dch mng ngoi tim, lm siu m tim s cho ta thy r c mt khong trng siu m pha sau ca thnh sau tht tri. Nu dch mng ngoi tim nhiu th ta cn thy c c khong trng siu m pha trc ca tht phi. Cc khong trng siu m th hin lp dch ngoi mng tim.
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- Ngoi ra, ta cn thy bin di ng ca thnh sau tht tri v ca vch lin tht u tng. 3.2.4. Xt nghim mu: thng cho thy cc biu hin ca mt hi chng vim: tc lng mu tng. 3.2.5. Chc d mng ngoi tim - Chc d mng ngoi tim l th thut dng kim a vo trong khoang mng tim ht dch. Nu ht c dch th y l tiu chun quan trng nht chn on xc nh c trn dch mng tim. - Ngoi ra, chc d mng ngoi tim cn gip cho vic chn on nguyn nhn gy bnh (qua xem xt, phn tch cc tnh cht ca dch mng ngoi tim c ly ra). - Trong mt s trng hp dch mng ngoi tim nhiu gy chn p tim th chc tho dch mng tim l ng tc cp cu kp thi v hu hiu nht cho bnh nhn. 3. 3. Chn on nguyn nhn Cc din bin lm sng v tnh cht ca dch mng ngoi tim phn no c th gip cho chng ta xc nh c nguyn nhn gy bnh. 3.3.1. Dch vng chanh: dch mng ngoi tim mu vng chanh c th gp trong nhiu bnh nh: lao, bnh virus, ung th, mt s bnh h thng, bnh d ng. Ni chung, cn phi xt nghim k v mt t bo v vi khun c th pht hin ra nguyn nhn gy bnh. 3.3.2. Dch m: m thng c mu trng vng, hoc nu, tc nhn gy bnh chc chn l vi khun sinh m m thng gp l t cu vng. 3.3.3. Dch mu khng ng: - Trc mt trng hp dch mu khng ng, ngi ta hay ngh ti kh nng ung th, m thng l ung th phi di cn hoc ung th mng ngoi tim, nht l khi xy ra mt bnh nhn ln tui v dch ti pht nhanh sau khi chc. - Dch mu cn gp c trong trng hp lao, trong trn dch sau m tim, sau chn thng lng ngc, sau khi dng qu nhiu liu thuc chng ng ngi nhi mu c tim v mt s trng hp ur huyt cao, chy thn nhn to c s dng heparin. - Trng hp khng rt c dch mng ngoi tim mc d thm d nhiu v tr, nht l khng r hi chng tr tun hon ngoi bin v ch nghe thy ting c mng ngoi tim th c th gi l vim mng ngoi tim kh. Thp tim, ur huyt cao, mt s trng hp phn ng mng ngai tim do vim nhim d ng, thng gy ra vim mng ngoi tim kh. 4. Tin trin, bin chng Din bin ca vim mng ngoi tim ty thuc vo nguyn nhn gy bnh v cch iu tr. C th gp mt s kh nng sau: - p tim, do khi lng dch mng ngoi tim tng nhanh mt cch t ngt. - Mng ngoi tim b vim co tht. 4.1. p tim
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- p tim l tnh trng thiu nng tm trng cp do trn dch mng ngoi tim xut hin nhanh, gy gim nhanh cung lng tim ng thi p lc tnh mch ngoi bin tng cao. - Bnh thng bt u mt cch t ngt. Bnh nhn kh th d di, th nhanh, nng v thng c cm gic au tc nh c g chn ngang ngc. Bnh nhn thng vt v, ht hong, mt ti nht, v m hi. - Khm thc th thy din c ca tim to ra, ting tim m, xa xm. Huyt p kp hoc khng o c. Cc du hiu tr tun hon ngoi bin c th hin mt cch r rt: gan to nhiu, tnh mch c ni r, p lc tnh mch tng cao (thng trn 30cm nc). - p tim l mt tnh trng bnh l nng n, i hi phi chn on tht nhanh x tr cp cu ngay. - Trong trng hp p tim th chc tho dch mng tim l ch nh tuyt i v l cch duy nht cu c bnh nhn. 4.2. Vim co tht mng ngoi tim Vim co tht mng ngoi tim l tnh trng mng ngoi tim b vim dy, c khi nhim vi, bp cht tim, lm gim kh nng tm trng ca tim. 5. iu tr 5.1. iu tr triu chng Nu bnh nhn au ngc, ta c th dng mt s thuc hoc bin php chng au nh: Aspirin, cc loi thuc an thn, chm nng ni au. 5. 2. iu tr tr tun hon - Cn chc tho dch mng ngoi tim v dn lu nu cn bnh nhn d th hn v phng p tim. i vi vim m mng ngoi tim th rt cn dn lu sm qua ng thng to. - Thuc li tiu cng c th c s dng nu khng phi l cp cu. - Ni chung khng nn dng thuc tr tim. 5.3. iu tr nguyn nhn Ty theo nguyn nhn gy bnh m ta c nhng bin php iu tr khc nhau. - Trong VMNT do lao th bt buc phi dng cc thuc chng lao. - Trong VMNT do thp tim, th Corticoid kt hp vi Penicillin l nhng thuc ch yu, nhng trong vim m mng ngoi tim th dn lu m kt hp vi khng sinh c hiu l bin php chnh. 5. 4. Phu thut i vi vim mng ngoi tim co tht, th phu thut bc tch mng ngoi tim l bin php ch yu nht c th ci thin tnh trng huyt ng ca bnh nhn. 6. Chm sc 6.1. nh gi
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nh gi chm sc gm nh gi cc triu chng ca VMNT v nht l cc triu chng ca hi chng p tim cp. 6.1.1. nh gi cc triu chng ca VMNT: - au ngc: nh gi v tr, mc , hng lan - Kh th: nh gi mc , kiu kh th - nh gi cng p ca mm tim, nghe ting tim m, ting c mng tim - Bt mch. o huyt p. - Cc du hiu tr tun hon ngoi bin: tnh mch c, gan ln 6.1.2. nh gi hi chng p tim cp: Kh th d di v c triu chng sc: mt nht nht, v m hi, chn tay lnh, mch nhanh nh thm ch khng bt c, huyt p kp v thm ch khng o c phi ngh n ngay n hi chng p tim kp thi bo co thy thuc. 6.1.3. Cc xt nghim: - X quang tim phi: nh gi bng tim ln - Siu m: dch mng tim - Dch mng tim (nu chc ht c): mu sc, xt nghim vi khun, t bo, sinh ho 6.2. K hoch chm sc Vi mc tiu nhm lm gim v mt cc triu chng v trnh bin chng, k hoch chm sc gm cc im sau: - Gim v mt triu chng au - Gim kh th - Ch dinh dng - Chm sc tinh thn 6.3. Thc hin chm sc 6.3.1. Gim v mt triu chng au: - Bnh VMNT l mt bnh nng, bnh nhn cn c chm sc trong phng cp cu tin vic chm sc theo di. - Cho bnh nhn nm u cao, hoc na nm na ngi, c th cho bnh nhn ngi trong gh ta thoi mi, t th nh vy bnh nhn s d dng thay i t th, d chu v bt au. - An i, ng vin tinh thn cho bnh nhn cng gp phn lm gim au - Thc hin thuc gim au theo y lnh ca thy thuc, thuc an thn cng phn no c tc dng gim au vi bnh nhn VMNT 6.3.2. Gim kh th: - Nm u cao, hoc na ngi na nm, phi khng b p, c honh khng b y ln cao s gip cho bnh nhn kh th.
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- Thuc li tiu lm gim bt gnh nng tun hon cng lm cho bnh nhn kh th. (Ch nn cho bnh nhn ung bui sng v theo di khi lng nc tiu /24 gi). - Nu bnh nhn kh th d di cho hi chng p tim cp th bin php hiu qu nht m iu dng vin c th gip bnh nhn kh th l chun b dng c v ph gip thy thuc chc tho dch mng tim cho bnh nhn. 6.3.3. Ch dinh dng - v sinh: - m bo ch dinh dng y cho bnh nhn. Thc n d tiu, cht, nn n nht. - Nn khuyn bnh nhn hn ch nc ung, da vo khi lng nc tiu b nc cho bnh nhn. - VMNT l mt bnh thng phi nm lu hng thng, ch hng ngy v sinh thn th, thay qun o, chn mn, gi m, 6.3.4. Chm sc v tinh thn: - VMNT l mt bnh nng, bnh nhn thng phi nm lu trong bnh vin, iu dng vin nn quan tm chm sc an i tinh thn cho bnh nhn. - Khi bnh nhn c hi chng p tim, bnh nhn thng trong trng thi ht hong do thiu oxy no, iu dng vin nn bn bnh nhn bnh nhn yn tm.
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SUY TIM
MC TIU 1. Trnh by c nguyn nhn gy bnh, triu chng bnh. 2. Phn c suy tim theo NYHA. 3. Trnh by c cch iu tr, cch chm sc bnh. 1. i cng Suy tim l mt hi chng thng gp trong nhiu bnh v tim mch nh bnh van tim, bnh c tim, bnh tim bm sinh v mt s bnh ngoi tim. Suy tim l trng thi bnh l trong cung lng tim khng p ng vi nhu cu oxy cho c th trong mi tnh hung sinh hot ca bnh nhn. 2. Nguyn nhn 2.1. Suy tim tri 2.1.1. Tng huyt p ng mch: l nguyn nhn thng gp nht trong vic gy ra suy tim tri. Tng huyt p lm cho cn tr s tng mu ca tht tri tc l lm tng hu gnh. 2.1.2. Mt s bnh van tim - H hay hp van ng mch ch n thun hoc phi hp vi nhau. - H van hai l. 2.1.3. Cc tn thng c tim - Nhi mu c tim. - Vim c tim do thp tim, nhim c, hay nhim khun. - Cc bnh c tim. 2.1.3. Mt s ri lon nhp tim 2.1.4. Mt s bnh tim bm sinh: hp eo ng mch ch, cn ng ng mch... 2.2. Suy tim phi 2.2.1. Cc nguyn nhn v phi v d dng lng ngc, ct sng - Cc bnh phi mn tnh: hen ph qun, vim ph qun mn, gin ph nang, gin ph qun, x phi, bnh bi phi. - G vo ct sng v cc d dng lng ngc khc. 2.2.2. Cc nguyn nhn v tim mch - Hp van hai l l nguyn nhn thng gp nht. - Mt s bnh tim bm sinh: hp ng mch phi, tam chng Fallot. 2.3. Suy tim ton b - Cc trng hp suy tim tri tin trin thnh suy tim ton b.
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- Bnh c tim gin, vim c tim. - Cc nguyn nhn ngoi tim: cng gip trng, thiu vitamin B1, thiu mu nng. 3. Triu chng 3.1. Suy tim tri 3.1.1. Lm sng - Triu chng c nng: + Kh th: l triu chng thng gp nht. Lc u kh th khi gng sc, v sau kh th s xy ra thng xuyn, bnh nhn nm cng kh th, nn phi ngi dy th. Din bin v mc kh th cng rt khc nhau: c khi kh th n mt cch dn dn, nhng nhiu khi kh th li p n mt cch t ngt, kh th d di nh trong cn hen tim hay cn ph phi cp. + Ho: Hay xy vo ban m hoc khi bnh nhn gng sc. Thng l ho khan, nhng cng c khi ho ra m ln vi mt t mu ti. - Triu chng thc th: + Nhn v s thy mm tim p hi lch sang tri. + Nghe tim: ngoi triu chng ca bnh van tim gy nn suy tim tri, ta thng thy ba du hiu. + Nhp tim nhanh. + C th nghe thy ting nga phi. + Cng thng thy c mt ting thi tm thu nh mm, du hiu ca h hai l c nng v bung tht tri b gin to. 3.1.2. Cn lm sng - X quang: + Tim to ra, nht l cc bung tim bn tri. Trn phim thng: tm tht tri gin, biu hin bng cung di bn tri hi phng v b ko di ra. + C hai phi u m, nht l vng rn phi. - in tm : trc tri, dy nh tri v dy tht tri. - Siu m tim: thng thy kch thc cc bung tim tri (nh tri v nht l tht tri) gin to. Ngoi ra siu m tim cn gip cho ta bit c s co bp ca cc vch tim cng nh nh gi c chnh xc chc nng ca tm tht tri. 3.2. Suy tim phi 3.2.1. Lm sng - Triu chng c nng: + Kh th: t hoc nhiu nhng kh th thng xuyn, ngy mt nng dn v khng c cc cn kch pht nh trong suy tim tri.
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+ Ngoi ra, bnh nhn hay c cm gic au tc vng h sn phi (do gan to v au). - Triu chng thc th: + Ch yu l nhng du hiu ca mu ngoi bin: Gan to u, mt nhn, b t, au mt cch t pht hoc au khi s vo. Lc u, gan nh i khi c iu tr v gan to li trong t suy tim sau, nn cn gi l gan "n xp", v sau, do mu lu, nn gan khng thu nh c na v tr nn x cng. Tnh mch c ni to v du hiu phn hi gan - tnh mch c dng tnh. p lc tnh mch trung ng v p lc tnh mch ngoi bin u tng cao. Tm da v nim mc: ty theo mc nhiu hay t. Nu suy tim nh th ch thy tm t mi v u chi, suy tim nng th c th thy r ton thn. Ph: ph mm, lc u ch khu tr hai chi di, v sau nu suy tim nng th c th ph ton thn, thm ch c th c trn dch cc mng (trn dch mng phi, c trng ...) + Bnh nhn thng i t (khong 200 - 500ml/ngy). Nc tiu sm mu. + Khm tim: S: c th thy du hiu Hartzer: tm tht phi p vng mi c Nghe: ngoi cc triu chng ca bnh gy suy tim phi, ta c th nghe thy: Nhp tim thng nhanh, i khi c th nghe c ting nga phi phi. Cng c khi nghe thy mt ting thi tm thu nh trong mm hoc vng mi c do h van ba l c nng. Huyt p ng mch ti a bnh thng, nhng huyt p ng mch ti thiu thng tng ln. 3.2.2. Cn lm sng - X quang: Trn phim tim phi thng: + Cung di phi (tm nh phi) gin. + Mm tim nng cao hn pha trn ca vm honh tri, do tm tht phi gin. + ng mch phi cng gin to. + Phi m nhiu do mu phi. - in tm : trc phi, dy nh phi, dy tht phi. - Siu m tim: + Ch yu thy kch thc tht phi gin to. + Trong nhiu trng hp thy cc du hiu ca tng p lc ng mch phi. 3.3. Suy tim ton b Thng l bnh cnh ca suy tim phi mc nng - Bnh nhn kh th thng xuyn, ph ton thn... - Tnh mch c ni to. - Gan to nhiu.
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- Thng c thm trn dch mng phi, mng tim hay c trng. Huyt p ti a h, huyt p ti thiu tng, lm cho huyt p tr nn b kp. - X quang: tim to ton b. - in tm : c th c biu hin dy ca hai tht. 4. Phn suy tim Hi Tim mch Hoa k (New York Heart Asociation) vit tc l NYHA, ngh chia suy tim thnh 4 giai on nh sau: - Giai on 1: bnh nhn c bnh tim nhng khng c triu chng c nng no c, vn sinh hot v hot ng v th lc gn nh bnh thng. - Giai on 2: cc triu chng c nng ch xut hin khi gng sc nhiu. Bnh nhn c b gim nh cc hot ng v th lc. - Giai on 3: cc triu chng c nng xut hin k c khi gng sc t lm hn ch nhiu cc hot ng v th lc. - Giai on 4: cc triu chng c nng tn ti mt cch thng xuyn, k c khi bnh nhn ngh ngi. 5. iu tr - iu tr suy tim nhm gim tr tun hon v tng cng kh nng co bp ca c tim - iu tr nguyn nhn ca suy tim. 5.1. Cc thuc iu tr 5.1.1. Thuc li tiu Cc thuc li tiu s tng cng o thi mui v nc, do s lm gim bt tin gnh, gim gnh nng cho tim. Ngi ta thng dng mt trong ba loi li tiu sau: - Hypothiazid (Hydrochlorothiazide). + L thuc c tc dng li tiu va phi v ko di, nn hay c dng trong cc trng hp suy tim mn tnh. + Thuc gy o thi nhiu kali ra nc tiu, nn khi dng thuc ny phi cho ung thm kali clorua. - Lasix (Furosemid) + L mt loi li tiu mnh, tc dng nhanh, nn thng c dng trong trng hp suy tim tri cp v trong cc th suy tim khng hi phc khng li thuc li tiu khc. + Thuc cng gy o thi nhiu kali, nn cn phi cho thm kali clorua, trnh b h kali mu. - Aldactone (Spironolactone) + L loi thuc li tiu trung bnh, c c im l khng lm mt kali nh nhiu thuc li tiu khc.
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+ Thng dng loi ny khi c ph ko di hoc iu tr bng cc loi thuc li tiu khc khng thy c kt qu. 5.1.2. Thuc tr tim - Ngi ta thng s dng cc glucozid tr tim thuc nhm Digitalis v Strophantus - Cc loi tr tim thuc nhm Digitalis c c tnh lm tng sc co bp ca c tim, lm chm nhp tim, lm gim dn truyn cc xung ng tim v lm tng tnh kch thch ca c tim. - Trng hp suy tim cp tnh ngi ta dng thuc tc dng nhanh, tim tnh mch nh Uabain, Lanatosid C 5.1.3. Cc thuc gin mch - Cc thuc gin mch lm gim trng lc tnh mch hay tiu ng mch, do lm gim tin gnh, bt ng mu trong tm tht hay gim hu gnh hot ng ca tim nh nhng hn, tng th tch tm thu, gip cho tim b suy yu hot ng thun li hn. - Ni chung, khng c dng cc thuc gin mch khi huyt p ng mch ti a di 90 mmHg. - Ngi ta thng chia ra lm 3 loi thuc gin mch: + Loi tc dng ch yu ln tnh mch, lm gim tin gnh: Thng dng nht l cc dn xut ca nhm Nitr: Risordan (Isosorbide dinitrate), Lenitral: trinitrin. + Loi tc dng ch yu ln ng mch, lm gim hu gnh: Nepressol (Dihydralazin): lm gin c trn thnh ng mch, c bit l cc tiu ng mch. Cc thuc c ch calci (tuyt i khng dng Isoptin (Verapamil) trong trng hp suy tim, v thuc lm gim nhiu sc co bp ca c tim, nn rt nguy him). + Loi tc dng ch yu ln c ng mch v tnh mch: Cc thuc c ch men chuyn dng angiotensin: chng c tc dng c ch s tng hp angiotensin II l mt cht gy co mch, do lm gin cc mch ngoi vi nhiu. Cc thuc thng c dng l: Lopril, Captolan (Captopril), Renitec (Enalapril), Coversyl (Perindopril) 5.1.4. Cc Amin ging giao cm Thng dng loi Dopamine hay tt hn l Dobutamine (Dobutrex). 5.1.5. Thuc chng ng Trong suy tim, mu thng li cc c quan ngoi bin nn rt d to thnh nhng cc mu ng trong h thng tun hon v t d gy ra nhng tai bin tc nghn mch, cn iu tr d phng to thnh cc mu ng trong cc trng hp suy tim, nht l trong trng hp lon nhp hon ton do rung nh. 5.2. u tr nguyn nhn Ty theo tng loi nguyn nhn gy ra suy tim.
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- Trng hp suy tim do cng tuyn gip: phi iu tr bng khng gip trng tng hp hoc nu cn phi phu thut ct b tuyn gip. - Trong trng hp suy tim do thiu vitamin B1 th cn phi dng vitamin B 1 liu cao. - Trng hp suy tim do ri lon nhp tim ko di th cn iu tr nhng lon nhp tim bng thuc, bng sc in hoc bng my to nhp tim. - i vi mt s bnh van tim hoc mt s bnh d tt bm sinh ca tim gy ra suy tim th ngi ta s t vn phu thut (nong van bng bng, thay van hay sa cha cc d tt). 6. Chm sc 6. 1. nh gi nh gi triu chng suy tim: - Tnh trng kh th: Nghe tim: m tn s tim; nhp tim u hay lon nhp; ting nga phi. Nghe phi: m tn s th, kiu th; ran ng ... - nh gi ph. - nh gi gan to, du hiu phn hi gan tnh mch c. - Lng nc tiu: hng ngy o v ghi li lng nc tiu trong 24 gi. 6.2. K hoch chm sc - Ch ngh ngi v chm sc v tinh thn - Ch dinh dng - Thc hin y lnh thuc - Gio dc sc khe 6.3. Thc hin k hoch chm sc 6.3.1. Ch ngh ngi v chm sc v tinh thn: - t bnh nhn nm u cao so vi mt ging t 20 - 23cm, hoc na nm na ngi. t th ny s tr v tim ca dng mu tnh mch gim i, lm gim s tr phi bnh nhn, phi khng b p li, c honh khng b y ln cao to iu kin cho bnh nhn kh th. - Khi suy tim gim cho bnh nhn vn ng va phi. Ch thng xuyn thay i t th, tp th su, luyn tp v xoa bp hai chn lm cho mu tnh mch tr v tim tt hn, trnh tai bin nghn mch phi do cc mu ng hnh thnh t tnh mch chi di . - Chm sc v tinh thn l gip bnh nhn gim bt lo u s hi trong trng thi thiu oxy no do suy tim, nh: + bn ging bnh nhn cng nhiu cng tt + Nu bnh nhn s hi, vt v do thiu oxy no cho bnh nhn th oxy. + Nu cn thit cho bnh nhn dng n thn nh 6.3.2. Ch dinh dng: - Quan trng nht l phi n nht tu tnh trng suy tim - Thc n phi d tiu, chia thnh nhiu ba nh
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- cht dinh dng, n nhiu loi qu c nhiu kali - Trnh dng thuc l, ru, bia, c ph s lm tng nhp tim, tng cng tim 6.2.3. Thc hin y lnh thuc: Khi thc hin y lnh thuc cn lu nhng im sau y: - Thuc Digital lm gim tn s tim, trc khi cho bnh nhn dng phi m nhp tim nu thy < 60 ln/ pht cn gi thuc li, bo bc s. - Cn theo di bnh nhn hng ngy pht hin cc du hiu sm ca ng c Digital l chn n, bun nn, nn, c th c ri lon nhp: nhp chm, ngoi tm thu tht, cn nhp nhanh nh kch pht... - Khi cho bnh nhn ung thuc li tiu phi cho ung vo bui sng tc dng li tiu khng nh hng ti gic ng m ca bnh nhn - Ghi vo h s bnh nhn lu lng nc tiu hng ngy v cn nng bnh nhn hng ngy nh gi tc dng thuc li tiu. 6.3.4. Gio dc sc kho: Bnh nhn suy tim cn thc hin tt nhng vn sau: - Trnh gng sc - Trnh cc sang chn v tinh thn - Chp thun ch n gim mui, king ru, thuc l, c ph - Ti khm, dng thuc theo ng ch nh - Khi c mt trong cc du hiu sau nn n thy thuc ngay: tng trng lng, kh th tng, ph chn, au ngc, ho ko di
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CN AU THT NGC
MC TIU 1. Trnh by c nguyn nhn gy bnh, sinh l bnh, gii phu bnh 2. Nu c cc triu chng bnh 3. Trnh by c cch iu tr bnh, cch chm sc bnh 1. i cng L hi chng au, c Heberden m t nm 1772, vi c tnh "co tht, lo u, cm gic kh chu trong ngc", biu hin gim thiu cung cp oxy cho c tim trong chc lt, tuyt i hay tng i. 1.1. Nguyn nhn 1.1.1. Bnh ng mch vnh - Va x gy bt tc ng mch vnh. - Khng do va x ng mch vnh (co tht ng mch, vim ng mch trong mt s bch to keo, d dng bm sinh). 1.1.2. Bnh van tim - Bnh van ng mch: hp van ng mch ch, h van ng mch ch, giang mai gy bt tc l vo ca ng mch vnh. - Bnh van hai l: sa van hai l. Hp van hai l (t gp hn). - Hp van ng mch phi. 1.1.3. Bnh c tim ph i 1.1.4. Cc yu t thun li Thiu mu (gim lng oxy trong mu), nhp nhanh, sc (gim lu lng tim v lu lng vnh), cng gip trng (tng nhu cu oxy c tim). Nhng yu t ny ch gy cn au tht ngc khi ng mch vnh t nhiu b tn thng. 1.2 Sinh l bnh Cn au tht ngc xut hin khi vic cung cp oxy cho c tim khng so vi nhu cu oxy c tim trong lc 1.2.1. Nhng yu t lm tng nhu cu oxy c tim Nhp nhanh, tng co bp c tim. Tng trng lc c tim, dy c tim. 1.2.2. Nhng yu t lm gim cung cp oxy cho c tim - Hp lng ng mch. - Gim hm lng oxy - hemoglobin, gim hm lng hemoglobin trong mu. - Gim p lc ng mch ch tm trng lm gim lu lng vnh.
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1.3. Gii phu bnh Mt hay nhiu ng mch vnh b hp do qu trnh va x. ng mch hay b nht l nhnh lin tht trc v nhnh m, xut pht t ng mch vnh tri ngay on u. C tim c nhng vng hoi t hoc x, khu tr lp di ni tm mc. Tm tht tri thng b ph i. 2. Triu chng 2.1. Lm sng 2.1.1. Cn au tht ngc khi gng sc Cn au thng xy ra khi i. Xut hin sau khi i c mt on nht nh, on ny thng c nh mt cch kh chnh xc. Cng thng xy ra sau ba cm thnh son, khi xc ng mnh, khi giao hp... 2.1.2. Tnh cht ca au Thng au vng sau xng c, au ngang ngc, lan ln vai tri, ra pha mt trong ca tay v bn tay tri. l hng lan kinh in nhng khng phi bao gi cng nh vy. C khi lan ln c, ln hm, thm ch au c rng. 2.1.3. Thi gian ca cn au Thng thng ch ko di vi giy n vi pht. Mt cn au qu 15 - 20 pht phi nghi ng nhi mu c tim. S ln xut hin cc cn rt thay i ty theo tng trng hp. C khi rt tha, mi nm 1-2 cn, nhng cng c khi rt mau, trng hp nng cn au lin tip, khng ngng. 2.1.3. Tc dng ca nitroglycerin t di li, thuc c tc dng ct cn au trong vng vi pht. y l mt test c gi tr trong chn on cn au tht ngc. 2.2. in tm Trong lc ang c cn au nu lm in tm s thy on ST chnh xung 2 - 3mm cc chuyn o ngoi bin v cc chuyn o trc tim tri. Nu l cn au kiu Prinzmetal th ST li chnh ln. Ngoi cn, in tm c th bnh thng hoc c hnh nh nhi mu c tim c, ph i tm tht tri hoc ri lon nhp tim cc kiu. 3. Tin trin v tin lng L thuc vo s ng mch vnh b tn thng v s lan rng ca cc tn thng . 4. Chn on Chn on xc nh da vo:
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- Cn au in hnh: cn au vng sau xng c, ngang ngc km theo hi hp lo u, xut hin khi gng sc, gim khi ngh ngi hoc khi dng nitrit, ko di vi pht. au lan ln vai, tay tri, c v hm. - ECG: on ST chnh xung trong lc c cn au hoc gng sc. - Hnh nh chp ng mch vnh bt thng. 5. iu tr 5.1. Trong cn au 5.1.1. Nitrit Nitroglycerin t di li 0,15 - 0,6mg. Kt qu ht au trong vng 1 - 2pht. Isosorbid dinitrat vin 2,5 - 5mg dng di li, cng c tc dng tng t. Nu dng di ngy nn thn trng trnh ngng t ngt v c th gy cn au tht ngc. 5.1.2. Thuc khng calci Nefedipin vi liu 10mg c tc dng cha cn au tht do co mch (loi Prinzmetal). 5.2. Ngoi cn au 5.2.1. Loi b nhng yu t lm khi pht cn au: 5.2.2. iu tr cc cn nguyn gy bnh nu bit c, gim cn nng i vi ngi bo, iu tr tng huyt p ng mch, tng m mu. 5.2.3. Ch sinh hot Cn c ch luyn tp vn ng theo mt chng trnh c cn nhc k v quy nh c th. Khng c ht thuc l. King ru mnh, ch c th ung t ru nh, ru vang, bia. 5.2.4. Thuc - Nitrit: Nitroglycerin tc dng chm, ung 6,5mg ngy 3 - 4 ln. Hoc dng loi Nitroglycerin thm qua da, hoc dng Isosorbid dinitrat ung 10 - 40mg, mi ngy 3 - 4 ln. - Thuc chn bta: loi thuc ny lm gim tiu th oxy c tim. Propranolol dng ung mi ngy 80 - 320mg chia lm 2 ln. - Thuc khng calci: Nifedipin v cc cht tng t c th lm gim tn sut cn au. Dng ch yu do cn au tht ngc kiu Prinzmetal hoc cc trng hp c chng ch nh dng cc thuc chn bta. Khng calci c th dng theo ng ung 10 - 20mg mi ngy 3-4 ln. 5.2.5. Phu thut bc cu ni ch vnh, nong p lng mch vnh 6. Chm sc 6.1. nh gi - nh gi cn au tht ngc: hon cnh xut hin cn au, cn au ko di bao lu, tnh cht au, hng lan; ngm nitroglycerin c au khng, xut hin dy hay tha - nh gi cc triu chng km theo nh: lo u, bun nn, kh th, - nh gi tnh trng bnh va x ng mch. Tin s c nhi mu c tim.
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6.2. K hoch chm sc - Chm sc bnh nhn trong cn au - Gio dc sc khe bnh nhn t chm sc 6.3. Thc hin chm sc 6.3.1. Chm sc bnh nhn trong cn au: - bn cnh bnh nhn c n khi ht cn au, bnh nhn thng tm trng lo s, i khi s cht, li vi bnh nhn lm gim cm gic s ny. - Cho bnh nhn ngm di li 1 vin Nitroglycerin, Adalat hay Izosorbit dinitrat theo y lnh. Sau khi cho bnh nhn ngm thuc iu dng vin theo di din bin cn au. 6.3.2. Gio dc bnh nhn au tht ngc: Mc tiu ca vic gio dc bnh nhn au tht ngc l: Bnh nhn bit cch ngn nga xut hin ca cn au. Bnh nhn i ph c vi cn au. - Bnh nhn c th ngn nga c cn au bng: + Khng c lm vic qu sc, khng luyn tp v hot ng th thao qu sc. + Trnh mi xc ng thi qu +Trnh n qu no, qu thnh son, trnh thc n c nhiu cholesterol. Khng lm vic ngay sau ba n. + Khng ht thuc, khng ung ru, khng ung qu nhiu c ph. + Trnh lnh t ngt, khng i b xa, khng i xe p ngc chiu gi. + Ung thuc theo ch dn ca thy thuc. - Bnh nhn bit cch i ph vi cn au: + Lun lun mang theo thuc ct cn au bn mnh + Hng dn bnh nhn bit theo di cn au. Nu cn au khng mt sau ngm thuc 3 - 5 pht hoc li ti pht ngay phi n thy thuc khm. + Nu bnh nhn c bnh tng huyt p phi theo di huyt p v ung thuc h p thng xuyn theo ch dn ca thy thuc.
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NHI MU C TIM
MC TIU 1. Trnh by c nguyn nhn gy bnh, gii phu bnh, sinh l bnh 2. Nu c cc triu chng ca bnh, bin chng ca bnh 3. Trnh by c cch iu tr bnh, cch chm sc bnh Nhi mu c tim l hoi t mt phn ca c tim do thiu mu cc b, xy ra sau khi tc nghn mch vnh nui dng vng . 1. Nguyn nhn 1.1. Huyt khi: Huyt khi ti mt vng ca ng mch vnh b hp do va x ng mch. 1.2. Co tht ng mch C trng hp nhi mu c tim khng c tc nghn ng mch vnh r rt trn phim chp cn quang. Ngi ta gii thch bng hin tng co tht ko di ng mch vnh, hoc mt cc huyt khi c thng dng nhanh, hoc mt bnh ca vi tun hon vnh. Cng c khi do chp ng mch vnh khng ng quy cch hoc nhn nh trn phim chp khng chnh xc. 1.3. Nhng nguyn nhn t gp Nghn mch vnh do cc nghn t xa a ti (nh trong vim ni tm mc, hp van hai l). Hp l vo ng mch vnh do mt tn thng ng mch ch ( nguyn nhn giang mai hoc va x).Vim mch trong cc bnh t min, d dng ng mch vnh, chn thng tim. 2. Gii phu v sinh l bnh 2.1. Gii phu bnh - Tc ng mch lin tht trc (mt nhnh ca ng mch vnh tri) gy nhi mu c tim pha trc. Tc ng mch vnh phi, gy nhi mu c tim pha sau v i khi hoi t tm tht phi v cc nh. - Nhi mu c tim c th di dng ni tm mc hoc xuyn thnh (t ni tm mc n thng tm mc), hoc di thng tm mc, cng c khi c nhng nh ri rc. - Din tch vng nhi mu c tim ph thuc vo ln ca ng mch b tn thng v mng li mch ni hnh thnh gia ba ng mch vnh ln (ng mch vnh phi, ng mch lin tht trc v ng mch m). 2.2. Sinh l bnh Nhi mu c tim no cng lm gim hot ng ca c tim tri tng ng vi khi c tim b hai t. Lu lng tim v kh nng mu gim, huyt p ng mch tt, p lc cui tm
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trng tng, cng nh p lc trong nh tri, p lc mao mch phi bt (10 - 15 mmHg trong nhng trng hp nhi mu c tim nh, trn 20 - 25 mm Hg trong nhi mu c tim ln). 3. Triu chng 3.1. Th in hnh 3.1.1. au vng trc tim - au vng trc tim c th xut hin trn mt ngi trc cha h b bnh tim mch, nhng cng c th xy ra trn ngi b nhiu ln cn au tht ngc. - au trong nhi mu c tim cng ging nh trong cn tht ngc nhng d di hn v dng nitroglycerin khng . C th xut hin lc ngh ngi, hoc sau mt gng sc, sau ba n thnh son ban ngy hay ban m. au thng km theo cm gic hi hp, bn chn, v m hi, lnh, nn... 3.1.2. Khm bnh Tay chn lnh, huyt p ng mch bnh thng hoc thp. C trng hp huyt p tng trong cn au. Nhng gi u thng khng st, nhng sau nhit tng ln khong 38 3805C. Sau 2 - 3 ngy c th nghe thy ting c mng ngoi tim. 3.2. Cc th khng in hnh 3.2.1.Th khng au: trong 10 n 15 % trng hp nhi mu c tim khng au hoc ch au nh khng in hnh, bnh nhn ch thy tc vng tim. 3.2.2. Tai bin mch mu no: trn mt s bnh nhn rt gi, c khi nhi mu c tim ch biu hin di dng tai bin mch mu no. 3.2.3. Ph phi cp: c bnh nhn t ngt b ph phi cp. Lm in tm v cc xt nghim men mi pht hin ra nhi mu c tim cp. 3.2.4. Cht t ngt: 80% trng hp cht t ngt ngi ln tui l do bnh ng mch vnh. Cng c trng hp bnh c bit n t trc, nhng cng c nhiu trng hp khng c tin s suy mch vnh v ch khi khm nghim t thi bnh nhn cht t ngt mi pht hin ra bnh. 3.3. Cn lm sng 3.3.1. X Quang: X quang lng ngc c th pht hin cc du hu sung huyt phi, hnh nh cc tnh mch phi gin rng i khi pht hin c hnh nh m ca ph phi. 3.3.2. in tm : nu thy hnh nh in tm bnh thng cng cha c th loi tr c nhi mu c tim cp, c khi rt rng. Chn on nhi mu c tim cp phi da vo nhng bin i ca phc b QRS (sng Q bnh l) v ca pha cui (ST chnh ln). in tm c th gip xc nh v tr ca nhi mu c tim. 3.3.3. Siu m: trn hnh nh siu m hai bnh din, thy nhng chuyn ng bt thng ca thnh tim v ca vch. Bng siu m c th pht hin c l thng vch lin tht, hot ng bt thng ca van hai l. Cng c th pht hin c huyt khi thnh tim.
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3.3.4. Xt nghim - Xt nghim thng thng: Bch cu tng 10.000 n 20.000. Tc lng mu tng. ng huyt i khi tng nht thi. - Xt nghim men + Creatin - phosphokinase (CPK) v isoenzym c hiu ca c tim (CKMB). Men tng 3 n 4 gi sau khi bt u b nhi mu c tim v t nh cao vo gia gi th 12 v 18 (i khi n gi th 36). Tr v gi tr bnh thng sau 2 n 4 ngy. + Lactic dehydrogenase (LDH) gm 5 isoenzym (LDH- 1 -2- 3- 4- 5) tng 2, 3 ngy sau khi bt u b nhi mu c tim v nh cao nht gia ngy th 7. + Transaminase gluarmino - axalo acetic (SGOT, GOT hoc ASAT), tng 12 n 48 gi sau khi bt u b nhi mu c tim. Mau chng tr li bnh thng, men ny t c hiu. + Men Tropnin I, T: (+) 4. Bin chng 41. Ri lon nhp tim - Xut hin vo nhng gi u v nhng ngy u ca nhi mu c tim. L mt nguyn nhn ch yu gy t vong. - Lon nhp tim hay gp nht l nhp nhanh xoang, nhp chm xoang, ngoi tm thu tht thng bo hiu cn au nhp nhanh tht hoc rung tht 4.2. Suy tim C th l suy tim cp hay bn cp xy ra trong bt c giai on no ca nhi mu c tim, biu hin di dng nh hoc nng, thm ch rt nng nh ph phi ti cp. 4.3. Sc tim - Xut hin khi 40% c tim b ph hy. - T l t vong cao (80%). Mch nh yu, huyt p ng mch tt. 4.4. V tim Him gp v xut hin gia ngy th 7 v ngy th 10. Thng l thng vch gy thng lin tht C khi l thng thnh tm tht gy nn trn mu mng ngoi tim v hi chng p tim. C th hnh thnh ti phng ca thnh tim. 4.5. H van 2 l Nghe thy mt ting thi cui th tm thu mm, do h hng b van hai l, t ct van t gp. 4.6. Vim mng ngoi tim Thng nghe thy mt ting c mng ngoi tim, 2-3 ngy sau khi xut hin nhi mu c tim, ng thi c du hiu au vng trc tim, on ST chnh ln trn in tm . 4.7. Huyt khi tc mch
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Do nhng huyt khi chi di gy nn, nht l i vi bnh nhn phi nm lu ngy, c ri lon tun hon. Cng c khi do mt huyt khi hnh thnh trn ni tm mc ca vng va b hoi t. 5. Chn on Chn on dng tnh. Da vo: - au vng trc tim kiu cn au tht ngc nhng ko di, cho cc dn xut Nitrit khng hoc ch rt t. - Bin i sng Q v on ST trn in tm . - Tng cc men tim trong huyt thanh. 6. Tin lng C khong 30% trng hp nhi mu c tim cht trc khi vo bnh vin. T l t vong ti bnh vin l t 3 n 30%. T l sng st sau mt thng khong 45%. Nu nhi mu c tim nh v khng bin chng th t l t vong ni chung thp, di 5%. Nhi mu c tim pha sau v xuyn thnh c tin lng tt hn nhi mu c tim di ni tm mc hoc pha trc. T l t vong rt cao (80 - 90%) trong cc trng hp c sc tim hoc suy tim nng. Bnh tr nn nng nu c nhi mu c tim ti pht, i tho ng, ri lon nhp tim, ri lon dn truyn nh tht hay trong tht, bin chng huyt khi tc mch. Tin lng xa ph thuc vo khi lng tim hoi t. 7. iu tr 7.1. Nhi mu c tim khng bin chng 7.1.1. Giai on trc khi vo bnh vin - An thn: bnh nhn nhi mu c tim thng lo u , bn chn, kch ng. V vy, cn cho thuc an thn nh Diazepam 5 - 10 mg ung. - Chng au: 2- 5 mg Morphin tim tnh mch, 10 - 15 pht sau tim li nu khng c kt qu, - Oxy: tc dng lm gim au v lm gim kh th. Cho th bng t ng thng qua mi. - iu tr lon nhp tim - Ngng tim phi: h hi thi ngc, bp tim ngoi lng ngc, ni kh qun, m kh qun nu cn. Chng rung - Adrenalin tnh mch 7.1.2. Giai on bnh vin - Bin php chung: Cho nm yn ti ging, cho n ng nh. - Cho thuc an thn v thuc chng au: Diazepam, Morphin, Pethidin. - Cho oxy nu bnh nhn cn au v kh th. - Cc thuc khc:
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+ Nitroglycerin t di li c 15 - 20 pht mt ln hoc tim tnh mch khi cn (theo di tt huyt p). + Propranolol: khi cho Nitroglycerin khng lm ht c au vi iu kin khng c sc hoc suy tim. Cho ung 20 mg, mt ngy 2 4 ln. Cng c th tim tnh mch chm, 1mg c 4 - 6 gi tim 1 ln (nguy him nu c suy tim, hen ph qun). + Thuc c ch calci. Phi hp vi Nitroglycerin v Propranolol: Nifedipin ung, liu 10 20mg, 3 ln/ngy (thn trng v c nguy c tt huyt p). - Thuc chng ng - Ch sinh hot: Trong nhng trng hp nhi mu c tim n gin, thi gian nm vin vo khong 10 - 15 ngy. + Ngy u: c ng nh, tr mnh trn ging bnh. + Ngy th hai, ba tr i: tp i b tng dn, cho n khi ra vin c th i li trong phng. + Vi tun sau c th i ln gc 2. + Hai thng sau c th tr li cng tc bnh thng v c th chi th thao nh ph hp vi tnh trng sc khe. 7.2. iu tr tiu si huyt trong nhi mu c tim Truyn qua mt ng thng vo ng mch vnh pha trn ch c huyt khi 250.000 n 500.000 n v quc t. Streptokinase trong 20 pht. Cho trong 3 gi u ca nhi mu c tim. 7.3. iu tr ngoi khoa - i vi nhi mu c tim cp dng k thut bc cu ni ng mch ch vi ng mch vnh cp cu trong mt s trng hp sc, khng p ng vi mi thuc tr tim, gin mch... t l t vong rt cao. - i vi nhi mu c tim qua giai on cp cu: ch yu l bc cu ni ch vnh. - Nhng ch nh khc ca phu thut trong nhi mu c tim: ti phng thnh tim, thng vch lin tht, t c nh ca van tim. - Nong ng mch vnh. 8. Chm sc 8.1. nh gi 8.1.1. nh gi triu chng cn au ngc, kh th... thi gian, tnh cht, din bin, nhng yu t lm gim i v nng ln ca cc triu chng trn, (nh trong bi au tht ngc). 8.1.2. nh gi cc bin chng ca NMCT: - Sc: mt ti, v m hi, kh th, mch nhanh nh, huyt p tt - Suy tim: kh th, gan to, ph, tnh mch c ni r - Ri lon nhp tim - Ph phi cp: kh th d di, ho m bt hng, phi nhiu ran m
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8.1.3. Cc xt nghim: ECG, men tim, 8.2. K hoch chm sc - Lm gim v mt cn au ngc cho bnh nhn. - Gim kh th. - Gim lo u. - Gio dc sc khe cho bnh nhn. 8.3. Thc hin chm sc 8.3.1. Nhanh chng lm gim hoc m t cn au ngc cho bnh nhn bng: - Cho bnh nhn nm bt ng trn ging. - Thc hin khn trng y lnh tim morphin tnh mch, morphin c th lm mt cn au nhanh chng nhng nu tim nhiu c th gy nghin, gy to bn. Nu c to bn nhiu phi tht tho phn cho bnh nhn. Nu nhp th qu chm < 12 ln/pht phi bo co thy thuc. - An thn: Diazepam hay Seduxen 10mg tim tnh mch hay tim bp c tc dng an thn ng thi cng c tc dng lm gim cn au. 8.3.2. Lm gim kh th cho bnh nhn bng: Cho th Oxy qua mi theo ch nh ca thy thuc, th Oxy cn c tc dng lm gim cn au ngc. 8.3.3. Gim lo u Bnh nhn NMCT lun lun lo lng s hi v cm gic s cht, ngi iu dng nn bn cnh bnh nhn cng nhiu cng tt. Ginh cho bnh nhn mt thi gian khuyn khch h by t ni lo lng, s hi ca mnh, trn c s ng vin, an i gii thch bnh nhn yn tm. Khi cn thit c th cho bnh nhn dng thuc an thn. 8.3.4. Gio dc sc khe cho bnh nhn NMCT, : Bnh nhn bit cch luyn tp v hot ng trong giai on phc hi bnh. Bit thay i li sng cho ph hp vi tnh trnh bnh tt v ngn nga NMCT ti pht. - Luyn tp v hot ng trong giai on phc hi bnh. + Tp i b hng ngy, tng dn v thi gian v khong cch. + Lp chng trnh cho ngy lm vic v luyn tp v khng ph v chng trnh y. - Thay i li sng cho ph hp vi tnh trng bnh tt v phng nga NMCT ti pht: + Trc ht cn trnh mi hot ng gy nn au ngc, gy kh th, mt. + Trnh nhit mi trng qu nng hoc qu lnh. Trnh i b ngc chiu gi. + B hn thuc l v ru. + Trnh n qu no, khng n qu thnh son. Nn n ba nh 3 - 4 ln/ngy, lng thc n nn hng nh cho mi ba. Trnh n trong trng thi vi vng, hn ch cc thc n c nhiu cholesterol, hn ch cc loi nc ung c cafein, n gim mui.
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+ Gim trng lng nu thy thuc khuyn iu . + Trnh trnh thi qu xc ng v ng y . + Tun th trit ch ung thuc theo n ca thy thuc. + Lun lun mang theo ngi nitroglycerin nhanh chng ct ngay cn au ngc khi n xy ra. + n thy thuc khm ngay khi c mt trong cc du hiu sau: Cm gic nng n ngc hoc au ngc khng mt i 15 pht ngm nitroglycerin; kh th; hoc bt c du hiu g khc thng xut hin.
TNG HUYT P
MC TIU 1. Trnh by c nh ngha, nguyn nhn bnh 2. Nu c triu chng, bin chng bnh 3. Trnh by c cch iu tr bnh, cch chm sc bnh 1. i cng 1.1. nh ngha Theo t chc Y t th gii v Hip hi tng huyt p quc t th mt bnh nhn c gi l b tng huyt p nu huyt p ng mch ti a 140mmHg v/hoc huyt p ng mch ti thiu 90mmHg. 1.2. Tnh trng mc bnh tng huyt p cc nc cng nghip pht trin t l t 15 - 20% ngi ln c tng huyt p. Vit Nam t l vo khong 6 - 12% 1.3. Phn loi tng huyt p Trong tng huyt p c th chia ra: + Tng huyt p lnh tnh. + Tng huyt p c tnh. + Tng huyt p th pht cn gi l tng huyt p triu chng nu tm thy nguyn nhn. + Tng huyt p nguyn pht, cn gi l tng huyt p bnh nu khng tm thy nguyn nhn. 2. Nguyn nhn Nhng nguyn nhn chnh ca tng huyt p l:
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2.1. Nguyn nhn thn. - Vim thn cp, vim thn mn, mc phi hoc bm sinh (cu thn, k thn). - Thn a nang. - nc b thn. - U tng tit rnin. - Bnh mch thn (hp ng mch thn). 2.2. Nguyn nhn ni tit - Cng aldosteron tin pht (hi chng Conn). - Ph i thng thn bm sinh. - Hi chng Cushing. 2.3. Nguyn nhn khc - Hp eo ng mch ch. - Nhim c thai nghn. - Bnh tng hng cu. * Khi khng tm thy nguyn nhn no ngi ta gi l tng huyt p nguyn pht, chim > 90% trng hp tng huyt p. Phn ln trng hp tng huyt p ca ngi trung nin v tui gi thuc loi nguyn pht. 3. Triu chng v bin chng Triu chng ca tng huyt p ph thuc vo cc giai on ca bnh. Theo T chc Y t th gii tng huyt p c 3 giai on: - Giai on I: bnh nhn khng c du hiu khch quan v tn thng thc th no - Giai on II: bnh nhn c t nht mt trong cc du hiu thc tn sau y: + Dy tht tri, pht hin c trn lm sng, X quang, in tm , siu m. + Hp ng mch vng mc lan rng hay khu tr. + Protein niu v/ hoc creatinin huyt tng tng nh. - Giai on III: bnh tng huyt p gy ra nhng tn thng cc c quan khc, th hin bng cc triu chng c nng v du hiu thc th sau y: + tim: suy tim, au tht ngc, nhi mu c tim + no: xut huyt no, bnh no do tng huyt p. + y mt: xut huyt vng mc v xut tit c th c hay khng ph gai th. Cc du hiu ny c trng cho giai on nng, tin trin nhanh. + Suy thn * Tng huyt p c tnh: chim 2 - 5% cc trng hp tng huyt p. Phn ln xy ra trn mt ngi c tng huyt p t trc. Tt c cc loi tng huyt p do nguyn nhn khc nhau u c th chuyn bin thnh c tnh.
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Triu chng ni bt l hi chng no, nhc u d di, bin i y mt III, IV. S huyt p thng rt cao, c ti a ln ti thiu. Kht nc nhiu, st cn, ri lon tiu ha. Mt s t c biu hin ng mu ni mch ri rc. Tin trin nhanh v nng, hay c bin chng no, tim. Trong tt c cc trng hp tng huyt p c tnh ngi u c tng renin, aldosteron. 4. iu tr Nguyn tc l trn bnh nhn tng huyt p phi c gng tm nguyn nhn. Khi bng mi cch khng tm thy nguyn nhn mi coi nh l tng huyt p nguyn pht. 4.1. Trng hp tng huyt p dao ng Nu tng huyt p ch va phi, khng cn cho cc thuc chng tng huyt p, ch cn dng an thn hoc thc hin ch n hn ch mui, ngh ngi, gim mi cng thng th lc v tinh thn, thc hnh th gin. 4.2. Trng hp tng huyt p thng xuyn Thc hin phc iu tr theo bc thang ca T chc y t th gii. Bc I: - i vi ngi tng huyt p di 45 tui, thuc u tin cn dng l loi chn bta, hoc thuc c ch men chuyn angiotensin (Captopril - Enalapril). - i vi ngi tng huyt p trn 45 tui, thuc u tin cn dng l thuc li tiu. - iu tr nh vy m huyt p xung th gi liu tc dng. Nu huyt p khng xung hoc xung qu t th tng dn liu (ba tun tng ln mt ln). Nu huyt p vn khng xung th chuyn sang bc II. Bc II: phi hp hai th thuc li niu + chn bta hoc c ch men chuyn i angiotensin. Nu huyt p xung th gi liu tc dng. Nu khng xung hoc xung t qu, c th tng dn liu. Nu huyt p vn khng xung phi chuyn sang bc III. Bc III: phi hp thuc li niu + chn bta vi mt trong 4 loi sau y. Hydralazin, Alpha methyldopa, Clonidin v Guanethidin. Nu khng th phi hp li niu - chn bta vi 2, 3 trong cc thuc ni trn, ng thi kim tra li xem bnh nhn c thc hin ng y lnh khng, ch n v sinh hot c ng khng. 4.3. Trng hp tng huyt p c tnh - Cn c iu tr ni tr ti cc bnh vin hoc cc trung tm cp cu v c th c bin chng nguy him. - Vi nhng cn tng huyt p cao vt phi dng thuc mnh loi gin mch nh Diazoxit, Nitroprussiat natri tnh mch. 5. Chm sc 5.1. nh gi nh gi chm sc bnh nhn THA ch yu l ch s huyt p v cc bin chng ca THA.
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- Ch s huyt p: phi o HA mt cch chnh xc v ng nguyn tc - Thu thp cc du hiu biu hin bin chng ca THA: + Pht hin cn au ngc + Pht hin triu chng kh th do suy tim tri. + Pht hin cc biu hin ca thiu mu no: nhc u, chng mt, tai, gim tr nh... hay tai bin mch no: l m, hn m, lit na thn. + Pht hin triu chng gim th lc. + Thc hin y cc xt nghim cho bnh nhn: prtin niu; creatinin mu, ur mu; x quang tim phi; in tm ; soi y mt 5.2 K hoch chm sc - Ch ngh ngi v chm sc tinh thn - Ch dinh dng - Ch dng thuc - Gio dc sc khe cho bnh nhn 5.3. Thc hin chm sc 5.3.1.Ch dinh dng, sinh hot Vi bnh nhn THA, ch dinh dng ng ng vai tr rt quan trng trong iu tr. - Gim mui. - Gim m, thay bng du thc vt, trnh thc n c nhiu cholesterol: m ng vt, lng trng, cc ph tng ng vt - Gim calo nu bnh nhn qu bo, cn hng dn cho bnh nhn cch thc hin. - King thuc l, ru bia, c ph. - Nn n nhiu rau qu. - Vn ng chn tay nh nhng, th dc liu php, tp th, kh cng, i b... - Trnh xc ng mnh. 5.3.2. Ch thuc: Khi dng thuc cho bnh nhn lu : - o huyt p trc v sau khi dng thuc h p - Cho bnh nhn ung thuc li tiu vo bui sng trnh nh hng ti gic ng m. - Vi mt s thuc gy h p mnh, hoc gy h huyt p khi ng cn khuyn bnh nhn nm ngh 30 pht trn ging sau khi ung nh: Adalat, Minipress, Guanethidin. 5.3.3. Gio dc sc khe cho bnh nhn: Gio dc sc khe cho bnh nhn THA l gii thch v bnh THA nhm bnh nhn thay i li sng v chp thun iu tr sut i.
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- Gii thch bnh l mt bnh nguy him, gy rt nhiu bin chng, l k git ngi thm lng; tuy vy bnh iu tr ng, s lm gim nguy c gy bin chng, gim t l t vong, ko di tui th. - Hng dn ch n ung, sinh hot, mt s thuc diu tr cn c thng xuyn x dng ngay khi HA tng cao. - Cn khm bnh nh k, bnh tng HA l bnh phi iu tr sut i. * Kt lun Tng huyt p l mt bnh c nhng nh hng xu n sc khe v sn xut. C loi c nguyn nhn r nhng cng c loi khng r nguyn nhn. Hin nay phng bnh cn c ch n ung sinh hot hp l. Cha bnh hin nay theo tng bc thang t thp n cao, t mt thuc n nhiu thuc phi hp. Tng huyt p l mt bnh x hi do phi c s quan tm ca ton x hi v tch cc phng chng ca chnh bn thn ngi bnh.
TM PH MN
MC TIU 1. Trnh by c nh ngha, nguyn nhn ca tm ph mn. 2. Nu c triu chng lm sng v cn lm sng ca cc giai on tm ph mn v tin trin. 3. Bit cch chn on bnh v giai on bnh 4. Trnh by c phc iu tr v d phng tm ph mn 5. Trnh by c cch chm sc bnh nhn tm ph mn 1. nh ngha Tm ph mn l mt s ph i v hay l gin th pht ca tht phi sau nhng ri lon hay bnh ca h h hp. Tng p phi lun lun i trc tm ph mn trong c suy tim phi. T sau 50 tui, tm ph mn l bnh tim mch ng hng th ba thng gp nht sau bnh tim thiu mu v tng huyt p. Bnh thng th pht sau bnh ph qun mn tc nghn. Hin nay n ng b nhiu hn n b, c l l do thuc l. 2. Nguyn nhn 1. Bnh phi tc nghn mn tnh Bnh phi tc nghn mn tnh l nguyn nhn chnh gy nn tng p phi v tm ph mn. 2. Nhng bnh phi k
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Bnh l phi k c th th pht sau bnh sarcoidose, bnh bi amian, bnh cht to keo, nhng cng c th khng r nguyn nhn. 3. Gim thng kh ph bo vi phi bnh thng Bnh nhc c, lon dng c; g vo ct sng v qu mp ph. 4. Nhng bnh cht to keo Trong nhng bnh cht to keo nh lupt ban h thng thng c tn thng mch mu phi. 5. Bnh huyt khi - thuyn tc ng mch phi 3. Triu chng 3.1. Giai on u 3.1.1. Triu chng lm sng ca bnh phi tc nghn mn tnh: vim ph qun mn, kh ph thng do thuc l, hen ph qun ko di trong s phc hi ph qun km, gin ph qun, thng xy ra nhng t bc pht cp. Sau mi t bc pht, bnh li nng thm. 3.1.2. Triu chng ca nhng bnh phi hn ch: nh lao x phi, gin ph nang, mp ph, g vo ct sng, d dng lng ngc, bnh x phi lan to, dy dnh mng phi, bnh mch phi. 3.1.3. C th phi hp nhng triu chng ca hai nhm bnh trn. Giai on bnh phi mn tnh ny tin trin c th nhiu nm, thay i t 3 nm n 20 nm. 3.2. Giai on tng p lc ng mch phi 3.2.1. Triu chng lm sng - Triu chng chc nng + Kh th gng sc: lun lun c + Hi chng vim ph qun: ho v khc m. + au gan do gng sc: thng m h. - Triu chng thc th Ngoi triu chng bnh gc, nhng triu chng v tim sm nht l ting tim th hai mnh van ng mch phi, du Harzer t gp hn, nhp tim nhanh khng c gi tr lm, mng tay khum mt knh ng h, c th c au gan khi mnh vo vng h sn phi. 3.2.2. Triu chng cn lm sng - X quang phi Ngoi nhng du chng ca bnh ph qun - phi gc, thng gp nht l cung ng mch phi phng. 3.3. Giai on suy tim phi 3.3.1. Triu chng lm sng - Triu chng chc nng
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Kh th cng ngy cng tng dn t kh th khi gng sc, n kh th khi leo ln dc hay khi ln cu thang, n kh th khi i nhanh trn ng phng, n kh th khi i chm trn ng phng, cui cng kh th khi lm vic nh nh v sinh, ci qun o, v sau kh th c khi ngh ngi. - Triu chng thc th + Triu chng ngoi bin Gan ln v au,tnh mch c ni ln v p, ph, tm, mt li v xung huyt, o p lc tnh mch trung ng trn 25 cm nc, ngn tay hnh di trng. + Triu chng tim mch Nhp tim nhanh, c khi lon nhp hon ton, du hiu Harzer, T2 mnh v tch i van ng mch phi.Ting nga phi phi thi k tin tm thu, ting thi tm thu van 3 l. 3.3.2. Triu chng cn lm sng - X quang phi Thn ng mch phi phng to, ph i tht phi r rng lm tim c hnh hia v trong phim chp nghing trc tri thy mt khong sng sau xng c. Trn dch mng phi c th xut hin. - Tm in : c dy nh phi (P ph) v dy tht phi - Huyt hc: a hng cu, tng hematocrite. 4. Tin trin - Tm ph mn tin trin t t, gy tn thng chc nng v cu trc ca phi dn n suy h hp tng phn ri suy h hp ton b ri suy tim phi v cui cng l suy tim ton b. Ngy nay d c nhiu phng php iu tr hin i, nhng suy tim phi vn chim mt t l t vong rt cao: 60 - 70% t suy tim phi ln u hay ln th hai. - S tin trin ca bnh ph thuc vo nguyn nhn gy bnh, v nht l ph thuc vo vic ngi bnh c pht hin bnh ca mnh sm hay khng, khi c pht hin bnh ri c c iu tr v theo di thng xuyn hay khng. - Nu bnh nhn c theo di v iu tr tt th bnh c th n nh, c th t 10 - 20 nm hoc lu hn na mi c bin chng suy tim, c trng hp c th chung sng vi bnh nhn sut i. 5. iu tr 5.1. Ch n ung v ngh ngi + Ngh ngi rt cn thit, nn lm vic nh, khi c du hiu suy tim cn gim hoc b cc cng vic phi gng sc. Ch n nht, t mui, c th n 1 - 2 g mui / ngy. Trong trng hp suy tim nng, ph nhiu, ch n nht kht khe hn; mi ngy ch dng 0,5 g mui, nhng khng ko di. 5.2. Liu php oxy
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Ngi ta c th cho th oxy bng xng mi, oxy nn c dn qua mt bnh nc lm m, khng nn cho th oxy 100% vi liu lng thp 1,5 - 2 lt / pht, mun c hiu qu phi dng t nht 12 gi / 24 gi, nhng tt nht l 15 - 20 gi / 24 gi. 5.3. iu tr suy tim Trong tm ph mn c th c suy tim ton b, nhng ch yu vn l suy tim phi, do thuc iu tr chnh l li tiu, sau l digitale, c th phi hp vi cc thuc dn xut nitr. 5.3.1. Li tiu + Furosemide (LASIX): 2 - 4 vin loi 40 mg / ngy, chia u; hoc loi tim 2 - 3 ng loi 20 mg / ngy, chia u. Khi dng li tiu furosemide phi thn trng v s gy kim chuyn ho, nh vy c th c nguy c lm nng thm suy h hp do hiu qu kch thch h hp ca kh carbonic b gim i. + Spironolactone (ALDACTONE): 50 mg - 100 mg (1 - 2 vin) / ngy, trong nhng th nng c th tng ln 6 vin / ngy, chia u. thng dng Aldactazine (Aldactone 50mg+Alizide 15mg) x 2 vin/ngy 5.3.2. Digitale: thng hay dng digoxine, ch s dng trong suy tim cn b, cho liu nh 0,25 mg - 0,50 mg (1 - 2 vin) / ngy, khng dng khi suy tim mt b. 5.3.3. Dn xut nitr: nh Isosorbide mononitrate (Imdur) 60mg x 1/2 vin/ngy 5.3.4. c ch men chuyn: nh captopril 6,25mg/ngy hay Lisinopril 2,5mg/ngy Thuc li tiu v digitale, dn xut nitr hay c ch men chuyn trong trng hp ny khng quan trng bng cc phng php ci thin thng kh ph nang nh liu php oxy. 5.4. Corticoides Rt c hiu nghim trong iu tr t cp, Prednisone ung 5 mg, 4 vin / ngy hay kh dung dipropionate de beclomethasone, hay Depersolone 30 mg tim tnh mch va c tc dng chng vim va c tc dng chng d ng va lm gim tit dch. 5.5. Khng sinh Khng sinh ch dng khi c bi nhim ph qun - phi. 5.6. Liu php vn ng Tp th rt quan trng, lm tng gin n ca phi v lng ngc, tng thng kh ph nang, nht l th bng c honh. 5.7. Loi b nhng yu t gy kch thch Phi b thuc l, trnh tip xc vi bi bm, cc kh c... 6. Chm sc - Chm sc bnh nhn tm ph mn bao gm chm sc tnh trng suy tim v chm sc bnh phi gy ra tm ph mn (ch yu l cc bnh phi tc nghn mn tnh).
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- Gio dc bnh nhn chm sc sc khe ti nh, v bnh tim phi lin quan n iu tr nguyn nhn chnh, thng l mt qu trnh ko di, cho nn hu nh mi trng hp u c theo di nh. Hng dn cch trnh nhng yu t kch thch ng th (thuc l, bi,). Bnh nhn cn thay i thi quen n ung, cn n nht, hn ch ung nc (nu c suy tim). Hng dn bnh nhn dng thuc li tiu khi cn. Cc bin php lm sch ng th, dn lu t th, tp th rt cn cho bnh nhn t chm sc nh.
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TRIU CHNG HC H HP
MC TIU - Trnh by c cc triu chng c nng v h hp, k c cc nguyn nhn gy ra cc triu chng . - Trnh by triu chng thc th v h hp - cch khm lm sng cc triu chng . 1. Triu chng c nng L triu chng m bnh nhn cm thy, nhn bit ri khai li vi thy thuc v l nguyn nhn a bnh nhn i khm. 1.1. Ho 1.1.1 nh ngha: Ho l phn x c iu kin, mc ch l tng m hay cht l ra khi ng h hp. - V phng din sinh l hc: giai on ht vo tht su, thanh mn ng li, p lc trong lng ngc tng ln, sau thanh mn m ra t ngt v vi s tr gip ca cc c h hp nn cc cht trong ng h hp c tng ra ngoi. - Phn x ho c vng th cm l nim mc hu hng, kh ph qun mng phi, trung tht theo ng trung tm l dy thn kinh ph v n trung tm ho hnh ty sau no tht IV, ri theo ng ly tm n cc c h hp trong c c honh. - Thng l mt phn x c li bo v ng h hp nhng ho nhiu c th gy nn mt s iu bt li nh mt, xut huyt, suy tim, nhim trng, au ngc, xung huyt no, mu, gim cung lng tim... 1.1.2 Nguyn nhn - Tn thng ng h hp: tn thng ng h hp trn; hu, hng, thanh qun, kh ph qun cp hay mn, u phi, hen ph qun.. - Cc bnh v tim mch: cc bnh v tim mch lm tng p lc tun hon phi nh: hp van hai l, suy tim, nhi mu phi. 1.3 Cc dng ho - Ho khan (khng c m). - Ho c m: trong m c nhiu cht m, m, mu... - Ho g: l ho tng chui k tip nhau, cng lc cng nhanh ri yu dn, sau c giai on ht vo tht su nghe nh ting g gy. Sau cn ho th mt , mi tm, hai m mt sng, tnh mch c ni... - Ho lng thanh: m trm v m cao xen ln nhau do tn thng dy thn kinh quc ngc. - Ho tc ting, khn ting: do vim yt hu hay thanh qun. 1.2. Khc m
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1.2.1 nh ngha: m l cht tit ng h hp gm cc cht nhy, hng cu, bch cu, m...c tng ra ngoi ng h hp sau khi ho. 1.2.2 Nguyn nhn - p xe phi: m c m ln mu, s lng c th nhiu hay nh, c mi tanh hay rt thi. - Nhi mu phi: m c mu bm, khng bt... - Ph phi cp m thng lng, c bt hng . - Vim phi m c mu r st, lng t v kh khc. - Hen ph qun: m dnh c ln cn nhng ht gi l m ngc, sau khi khc m th kh th gim v bnh nhn thy d chu hn. - Gin ph qun: m s lng nhiu mi tanh, khc nhiu vo bui sng khi vo ng nghim c bn lp t di ln trn: m c, nc nhy, m nhy, bt. 1.2.3 Cc loi m - m thanh dch: l m lng trong c t bt, tit ra t cc ph huyt qun, gp trong ph phi cp. - m nhy - m m: cht nhy, bch cu, t bo hoi t, vi trng, c khi ln mu... - m mu: mu ti, sm hay bm en. - m b u: c mu trng ng, nhuyn v dch nhy trong trng hp u lao v. 1.3. Kh th 1.3.1 nh ngha: l cm gic b cn tr khi th nn phi vn dng n c h hp. y cng l triu chng ch quan cng l triu chng khch quan m ngi thy thuc nhn bit qua s thay i cc yu t h hp bnh thng. 1.3.2 Phn loi kh th - Kh th vo: thng gp do tn thng hay hp ng h hp nh: vim yt hu, thanh kh qun, bnh bch hu, chn p thanh kh ph qun.. - Kh th ra: do co tht cc tiu ph qun trong hen ph qun, vim ph qun cp thng kh th chm. - Kh th cp tnh: l kh th c hai thy, kh th nhanh, gp trong cc bnh lm gim th tch h hp nh: vim phi, trn dch, trn kh mng phi... - Kh th dng Kussmaul: l kh th su chm th vo ngh- th ra ngh gp trong trng hp mu nhim toan. - Kh th dng cheynes- Stokes: nhp th nhanh su v chm li dn- ngh v tip tc nh th gp trong tn thng trung tm h hp nh nhim c nng, chn thng s no. - Kh th tng cn gp trong hen ph qun. - Kh th khi gng sc: trong suy h hp mn v bnh tim mch. - Kh th thng xuyn: trong suy tim nng, suy h hp nng.
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1.4. au ngc 1.4.1 nh ngha: l mt triu chng hon ton ch quan, nn phi hi k tnh cht ca triu chng ny nh hon cnh xut hin, v tr, cng , hng lan v cc triu chng km theo. 1.4.2 Cc kiu au ngc - au xc ngc: thng au nng, au y ngc, xy ra t ngt v nhiu, km theo kh th cp gp trong vim phi, trn dch mng phi. - au nh dao m: l au su mt bn ngc, au d di nh c mt vt nhn m vo ngc, km theo kh th v v m hi, mch nhanh gp trong trn kh mng phi. - au ran trc ngc: thng au m , lin tc, au nng thng gp trong cc bnh phi mn tnh. 2. Triu chng thc th Khi khm phi bnh nhn ngi hoc nm t th thoi mi, cn i, cc c ngc trong trng thi ngh ngi, m ht o ti tht lng, bo bnh nhn th u, th bng mi. Phi khm k ng h hp trn v ton thn gip chn on nguyn nhn, chn on xc nh v chn on phn bit cc bnh khng phi h hp... 2.1. Nhn Phi nhn ton th t th ngi bnh, cch th, v mt, mu da, nhng bt thng trn da, mng tay, mng chn... 2.1.1. Da - Mu sc ca da: xem da c tm hay khng (tm l mt trng thi thiu oxy t chc, nu nh th tm mi v u chi, nng th tm ton thn), v m hi, da xanh ti l do thiu mu gy ra... - Cc bt thng trn da nh: vt so c, ph ngc, tun hon bng h, cc khi u, cc bt thng da vng ngc, hch bch huyt - Mng tay, mng chn c khum mt ng h khng (trong suy h hp mn), ngn tay di trng (nung m ko di).
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Ngn tay di trng v mng tay khum mt knh ng h 2.1.2. Hnh th lng ngc Bnh thng lng ngc cn xng hai bn, di ng u theo nhp th. - Lng ngc hnh thng: l lng ngc gin to v mi pha, ng knh trc sau gn bng ng knh ngang. Cc gian sn gin rng, xng sn nm ngang gp trong hi chng kh ph thng.
Lng ngc hnh thng - Lng ngc hnh c g: do xng c b y nh pha trc nn lng ngc nh ra trc nh c g gp trong hen ph qun ngi b hen t nh.
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Ngc hnh c g - Lng ngc gin ln mt bn: gp trong trn kh, trn dch mng phi, u phi qu ln...
Lng ngc gin ln bn tri do trn dch mng phi - Lng ngc b xp mt bn: gp trong xp phi hay dy dnh mng phi. - Lng ngc b vo mt bn: do vo ct sng bm sinh hay mc phi.
Lng ngc b vo do vo ct sng - Lng ngc ci xng: c hai chui ht hai bn dc theo cc sn sn. 2.2. S Gip ta pht hin nhng bt thng ca cc c h hp, cc xng sn, cc khong gian sn, tm cc im au, ph v khm rung thanh. - Khm rung thanh: rung thanh l m ni ca bnh nhn truyn qua thnh ngc v di vo lng bn tay ca thy thuc t trn ngc bnh nhn. Bnh thng rung thanh tng i u hai bn, ngi gy thng r hn ngi mp.
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- Cch khm: bnh nhn ngi ngay ngn, thy thuc t hai bn tay ln 2 bn lng ngc ca bnh nhn, cc ngn tay nm ngang, dc theo cc khong gian sn. lng bn tay p st lng ngc. Bo bnh nhn m 1, 2, 3 s c cm gic rung lng bn tay, khm t trn xung di, pha trc v pha sau v so snh rung thnh 2 bn lng ngc. Bnh l: nu rung thanh tng hn bnh thng th vng l ng c phi, nu rung thanh gim hoc mt do trn kh, trn dch mng phi, dy dnh mng phi, xp phi. 2.3. G 2.3.1 G trc tip: dng cc ngn tay ca ngi thy thuc g ln thnh ngc ca bnh nhn tm vng c v vng trong, phng php ny t dng v gy au cho bnh nhn v t chnh xc. 2.3.2 G gin tip: thy thuc dng ngn tay ca bn tay ny g ln mu cc ngn tay ca bn tay kia t sn trn lng ngc bnh nhn, cc ngn tay nm ngang theo cc khong gian sn, g t trn xung t phi sang tri, pha trc v pha sau.
Cch g ngc Vng g pha trc Vng g pha sau - Bnh thng hai phi trong, vng tim v vng gan g c. - G vang c hai phi gp trong kh ph thng ton th. - G vang mt phi hay mt vng: gp trong trn kh mng phi. - G c trong dch mng phi, xp phi, c phi hay dy dnh mng phi. 2.4. Nghe phi bnh ngi hay nm, t th thoi mi cn i v th bng mi. 2.4.1 m th: do m hu mn v m ph bo, nghe m du c hai th nhng th th vo r hn, thay i tuy v tr nh vng nh phi, rn phi , nch nghe r hn, ngi gy, tr em nghe r hn ngi mp. * Thay cng - m ph bo gim trong xp phi, hp ph qun, kh ph thng, c phi, trn kh, trn dch mng phi.. - m ph bo tng: vng phi th b (trn mc dch trong trn dch mng phi). 2.4.2. Cc m thi
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- m thi ng: l m hu mn truyn qua ph qun gp vng phi b ng c nn tng ln, nghe c c hai th nhng th th vo r hn (gp trong vim phi thy) - m thi hang: l m hu mn truyn qua ph qun vo trong mt hang rng ln, c v dy v nm st lng ngc, nghe trm hn v r th th ra (gp trong lao hang, p xe phi giai on khc m) 2.4.3. Cc ting ran - Ran n hay ran mt th nghe c cui th th vo, nghe nh ting rang mui trong ni, gp trong hi chng ng c phi gy tit dch c trong lng ph nang. - Ran m: c ran m to va v nh ht do tit dch lng trong lng cc ph qun, nghe c hai th. - Cc ran ph qun: ran rt v ran ngy, nghe c th th ra hoc c 2 th do hp cc tiu ph qun v co tht hay do chn p ca khi u hoc do hp lng ph qun v cht tit. - Ting c mng phi: do hai l mng phi b vim dy nn khi th th c vo nhau nh ting l kh chm vo nhau, nghe c hai th gp trong vim mng phi kh, giai on u v cui ca trn dch mng phi. 3. Cn lm sng 3.1. X quang - Chp phim phi thng, nghing. - Chp ct lp - Chp ph qun c cn quang. 3.2. Kho st m: phi ly m t trong lng ph qun mi chnh xc. - Kho st vi trng bng soi, nhum hay cy mi trng thch hp. - Kho st sinh hc tm t bo l, bch cu v cc cht khc trong m. 3.3. Kho st dch mng phi Qua lm sng, x. quang, siu m ngi ta chc ly dch mng phi xt nghim. 4. Ni soi ph qun. 5. Kho st v kh mu: ly mu ng mch xt nghim kh mu trong cc trng hp suy h hp cp 6. Thm d chc nng h hp 7. Phn ng mantoux nh gi tnh trng nhim lao.
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VIM PHI
MC TIU 1. Trnh by c nguyn nhn, triu chng, bin chng ca vim phi. 2. Trnh by c phng php iu tr ca vim phi. 3. Trnh by c cch chm sc bnh nhn vim phi. 1. i cng - Vim phi l hin tng vim nhim nhu m phi bao gm ph nang, ti ph nang, ng ph nang, t chc lin kt khe, k v vim tiu ph qun tn cng. - Vim phi l mt bnh cp tnh v h hp hay gp c bnh cnh rt in hnh, bt u v kt thc mt cch t ngt. Mc d hin nay c nhiu phng php iu tr rt hu hiu nhng t vong vn cn cao, nht l tr em v ngi gi. 2. Nguyn nhn 2.1. Do vi khun: lin cu, ph cu, t cu 2.2. Do vi rt 2.3. Do k sinh trng 2.4. Ha cht 2.5. Cc nhn tt thun li khc nh: mi trng nhim, nhim lnh t ngt 3. Triu chng 3.1. Triu chng lm sng 3.1.1 Triu chng ton thn v c nng - Xy ra t ngt vi rt cao, rt run 390C - 400C, st dng cao nguyn. - Sau vi gi th thy kh th v v m hi. - C th c Herpes mi, mi. - au ngc l triu chng lun lun c, ni bt l au bn tn thng. - Ho, lc u ho khan v sau ho c m mu r st. 3.1.2 Triu chng thc th - Trong nhng gi u, ch c r ro ph nang gim, g v rung thanh bnh thng, c th c ting c mng phi v ran n kh. - Thi k ton pht c hi chng ng c phi in hnh: khm vng phi tn thng thy: + G c. + Rung thanh tng. + R ro ph nang gim hoc mt. + m thi ng.
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+ Ran n kh, v sau c th nghe ran m. 3.2. Cn lm sng - Cng thc mu: bch cu tng 15000 25000/mm3 ch yu l bch cu a nhn trung tnh. - Vss (tc lng mu) tng. - Xt nghim: cn ly m trc khi cho khng sinh, ly m soi ti v cy lm khng sinh . - Cy mu - X. quang phi: thy mt m m ng u mt thy hay mt phn thy c hnh tam gic y quay ra ngoi, nh vo trong.
3.3. Tin trin - St vn duy tr trong nhng tun u, khc m c m vng. - Sau triu chng c nng c th tng ln, nhng st gim. - Khm phi vn cn c hi chng ng c. - Hnh nh x. quang cn tn ti trong vi tun. 4. Bin chng 4.1. Bin chng ti phi - Vim phi lan ta: bnh lan rng ra hai hay nhiu thy phi, kh th nhiu, tm mi, mch nhanh, bnh nhn c th cht trong tnh trng sc. - Xp mt thy phi: do cc m qunh lm tc ph qun mt thy phi. - p xe phi: bnh nhn st dai dng, khc nhiu m c m. X quang c mt hay nhiu hnh hang c mc nc, mc hi. - Vim phi mn tnh: bnh tin trin ko di, thy phi b tn thng tr nn x ha. 4.2. Bin chng ngoi phi - Trn dch mng phi: vim phi di mng gy trn dch mng phi, nc vng chanh, nh, chng khi, thng do ph cu khun gy ra.
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- Trn m mng phi: bnh nhn st dai dng, chc d mng phi c m, thng xy ra trong trng hp vim phi - mng phi, hoc do chc d mng phi gy bi nhim. - Vim mng ngoi tim: triu chng au vng trc tim, nghe c ting c mng tim, thng l vim mng tim c m. 4.3. Bin chng nhim khun th pht xa hn -Vim ni tm mc cp do ph cu: him gp, bnh nhn st cao, rt run, lch to, c th c triu chng van tim. - Vim khp do ph cu: gp ngi tr tui, thng ch b mt khp, sng, , nng, au. - Vim mng no do ph cu: him gp, nc no ty cha nhiu ph cu, glucose gim, c t bch cu a nhn. - Vim phc mc: thng gp tr em. - Vim tai xng chm: thy tr em. - Vim thn t xy ra nhim khun ngoi da v vim tuyn mang tai. - p xe no him gp. 4.4. Bin chng tim mch - Suy tim: xy ra tnh trng sc, gan to mu ngoi bin, c ting nga phi. - Nhp tim nhanh, nhp xoang, lon nhp ngoi tm thu, i khi c rung nh. - Sc: h huyt p, h thn nhit, tm mi, tin lng d dt. 4.5. Bin chng tiu ha - Biu hin vng da, vng mt do suy gan - C khi biu hin lit hi trng: a chy nht l tr em. 4.6. Bin chng thn kinh -Vt v, m sng xy ra ngi gi, ngi nghin ru. 5. iu tr 5.1. Ch tit thc ngh ngi - Cho bnh nhn ngh ngi ti ging, n nh, d tiu, nhiu protid v vitamin. - Cn bng nc in gii cn ch , c bit l khi c st cao hoc khi bnh nng, e da sc nhim khun. 5.2. iu tr triu chng - Chng au ngc v h st: bng paracetamol, thuc gim au chng vim khng steroide, codein, nu au qu th cho morphin. - Gim ho long m: acemuc, terpine codein... 5.3. iu tr nguyn nhn Cn phi s dng khng sinh sm, tt nht l dng theo khng sinh : - Vim phi nh dng khng sinh ng ung: + Ampicillin: 2- 3g/ 24h.
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+ Amoxicillin + clavulanic acid: 2- 3g/24h. + Cefuroxim: 2-3g/24h. + Ciprofloxacin 1g/ 24h. - Vim phi va: + Penicillin 3 triu n v / 24h. + Gentamicin 3mg/kg/24h. - Vim phi nng: dng khng sinh theo ng tnh mch phi hp 2-3 loi khng sinh: + Penicillin 5-10 triu n v / 24h. + Ampicillin 4-6g/ 24h. + Cephalosporin th h 2, 3 liu 3-6g/ 24h. + Cc khng sinh thuc nhm aminoglycosid thng phi hp vi nhm khm sinh lactam. + Quinolon : ciprofloxacin liu 1g/24h. + Metronidazole: 1g/24h. 6. Phng bnh - iu tr tt nhim khun vng tai mi hng: nht l vim xoang c m, vim amidan c m, vim hng bng khng sinh ton thn hoc kh dung. - iu tr tt nhng t vim ph qun mn tnh: bng khng sinh ung hoc tim tnh mch. - Loi b nhng yu t kch thch c hi: thuc l, thuc lo. - Gi m c, ngc trong ma lnh. - Tim phng vc xin. 7. Chm sc bnh nhn vim phi 7.1. Nhn nh tnh trng ngi bnh Hi bnh - Khi bnh t lc no? - Mc ca st?, C cn rt run hoc n lnh khng? - Kh th khng, c ho khng? Tnh cht ca cn ho : ho khan hay ho c m ? S lng, mu sc, tnh cht m ? au ngc t khi no ? au ngc c tng ln khi ho hay khi th khng ? Tin s c mc bnh v ng h hp khng ? c nghin thuc l khng ? iu tr thuc g cha ?
Quan st - Mu da, sc mt, mi, li - Hnh th ca lng ngc, tnh trng h hp. Mc kh th. S lng, mu sc ca m.
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Thm khm - Ly mch, nhit, huyt p, nhp th. - Nghe phi, nghe tim. Thu thp cc d kin - Thu thp cc d kin qua h s, bnh n, cc kt qu xt nghim, x quang..... 7.2. Lp k hoch chm sc Da vo cc thng tin thu thp phn nhn nh, iu dng xc nh cc nhu cu cn chm sc cho ngi bnh lp mt k hoch nh: - Lm h nhit c th ngi bnh. Thc hin y lnh. Theo di cc du hiu sinh tn. m bo dinh dng cho ngi bnh. Thc hin cc hnh ng chm sc c bn. Gio dc sc khe.
7.3. Thc hin k hoch chm sc Lm h nhit c th ngi bnh Chm mt bng khn bng nh lm gim bt nhit c th. Theo di st thn nhit khi s dng thuc h nhit. Thc hin y lnh - ngi bnh nm t th thch hp d th, cho ngi bnh th oxy (nu c ch nh). - Thc hin thuc: thc hin kp thi, chnh xc cc y lnh v thuc tim, thuc ung. - Thc hin cc xt nghim cn lm sng: Cc xt nghim mu, nc tiu, xt nghim m, chp X quang Theo di cc du hiu sinh tn v cc du hiu bt thng - o mch, nhit, huyt p, nhp th. - Tnh trng h hp. - Tnh cht ca cn ho - S lng, mu sc m. - Cc du hiu tm ti, kh th, vt v kch thch, ri lon thc (c th l du hiu ca thiu oxy no). - Theo di h huyt p v sc, c bit trong trng hp vim phi do vi khun Gram m v vim phi ngi gi. - Theo di cc bin chng khc c th xy ra. Dinh dng m bo ch n ung y , ch n cn tng m nh: tht, c trng, sagiu vitamin nh cc loi rau qu ti, trnh king khem. n thc n lng, m, d tiu.
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Tng cng lng dch vo c th trong gii hn cho php. Lng dch s c tc dng lm long m v dch xut tit, ng vai tr nh thuc lm long m thay th cho lng dch b mt khi c th do st, ra m hi v mt nc do th nhanh. Cc hnh ng chm sc - Khuyn khch ngi bnh ho v khc m, trnh ng m di Thc hin v, rung lm long m, dch xut tit d ra ngoi. Gip ngi bnh cc t th dn lu phi khng cn b ng nhiu m. Tng cng s thng thong kh cc bung bnh, gi v sinh bung bnh sch s. X l cht thi, dng c nh ng nh, b vt..theo quy nh.
Gio dc sc khe - Gii thch cho ngi bnh bit v bnh tt ca h h yn tm iu tr. Khuyn khch ngi bnh tp vn ng, luyn tp theo mc tng dn. - Khuyn khch ngi bnh tp th su, tp ho, tp lm gin n phi, lm sch phi gip chc nng h hp hot ng tt. Gii thch cho ngi bnh bit tc hi ca thuc l, khuyn ngi bnh b thuc. - C ch n ung y , ngh ngi hp l v sau khi b vim phi ngi bnh rt d b nhim khun ng h hp tr li. - Khuyn ngi bnh nn trnh b nhim lnh. Khuyn ngi bnh nn ti khm theo hng dn ca thy thuc. 7.4. nh gi - Ngi bnh vim phi c chm sc tt khi c th p ng tt vi iu tr v chm sc, yn tm iu tr, ngi bnh cm gic d chu thoi mi. - Cc du hiu sinh tn v triu chng ca bnh thuyn gim v dn n nh, khng b cc bin chng trong qu trnh iu tr. - Ngi bnh c kin thc phng trnh c bnh v phng trnh s ti pht ca bnh, thc hin tt nhng li khuyn ca cn b y t.
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P XE PHI
MC TIU 1. K c nguyn nhn chnh gy p xe phi. 2. Trnh by c cc triu chng, bin chng ca p xe phi. 3. Trnh by c cch iu tr ca p xe phi. 4. Trnh by c cch chm sc bnh nhn b p xe phi. 1. i cng - p xe phi l m trong nhu m phi, sau khi c ra ngoi th to thnh hang, l qu trnh hoi t do vim nhim cp tnh phi (do vi khun, k sinh vt, nm). - C th c mt hay nhiu m, khi hoi t nng v lan rng th gi l hoi th phi. - p xe phi: l mt bnh c tnh cht ni ngoi khoa, ngha l iu tr ni khoa khng th phi m. 2. Nguyn nhn 2.1.Vim nhim hoi t - Cc vi khun lm m nh: t cu vng, Klebsiella, lin cu khun nhm A, ph cu, trc khun m xanh. - Nm: Aspergillus, Candida Albidan, Mucor. - K sinh vt: amp, sn l phi.. 2.2. nhi mu phi - Tc mch. - Tc mch nhim khun (do cc vi khun ym kh khc nhau, t cu, nm candida.) - Vim mch mu (vim nt quanh ng mch, bnh u ht). 2.3. Ung th nguyn pht ph qun 2.4. Nhng nguyn nhn khc - Kn hi nhim khun. - Tn thng hoi t trong bnh bi phi. * Vit Nam nguyn nhn thng hay gp l: t cu vng, lin cu, ph cu, trc khun m xanh, amp, nht l p xe gan v ln phi mng phi. 2.5. Yu t thun li - Chn thng lng ngc c mnh n nm trong phi. - Sau gy m t ni kh qun, m kh qun, th my. - Sau phu thut vng tai mi hng, rng hm mt. - B mt s bnh khc nh: i ng, suy kit.. - C bnh phi mn tnh, vim ph qun mn tnh, gin ph qun..
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- Nghin ru, thuc l.. - t catheter tnh mch di ngy 2.6. ng xm nhp - Do nhim trng cao: nh nhim trng rng, xoang... - Do phu thut: nh rng ct amidan hay b sc cht nn - Do nhim trng huyt hay gp trong t cu vng thng c p xe nh. - Ung th phi p xe ha: him gp thng gp bnh nhn cht trc khi c p xe. - p xe phi do ng k cn nh: p xe di c honh, p xe gan do amp v ln, vim m trung tht. 3. Triu chng 3.1. Triu chng lm sng: thng din bin qua ba giai on 3.1.1 Giai on vim 3.1.1.1. Hi chng nhim trng - a s trng hp bt u nh mt vim phi nng, st cao 39- 400C, mi kh, li bn, i t, nc tiu sm mu. - Mt s trng hp bt u t t nh mt trng thi cm. 3.1.1.2. Triu chng phi - Ho khc m c, c khi c mu - au ngc: thng au bn tn thng, c khi au ngc l triu chng ni bt. - Kh th: tn s th ln hn 25 chu k / pht. - Khm phi c hi chng ng c mt vng, c ran n mt vng, c khi c hi chng ba gim (rt thng gp). 3.1.2 Giai on khc m Thng sau giai on vim t 5 - 7 ngy, c ba dng: - Khc m lng ln: t gp hn, trc bnh s ho, c th bnh nhn ho ra mu hi th hi, sau bnh s ho tng trng v khc m. y l giai on nguy him, bnh nhn c th cht (do phn x ph giao cm co tht ph qun ). - Khc m t: Khc ra t m thng khng c du hiu chc nng g, khng kh th, khng au ngc, - Khc m hnh ng xu 3.1.3 Giai on nung m h - Sau khi khc m, kh th s gim. -Thc th c hi chng hang: g c, rung thanh tng, ran m to ht v m thi hang. C th c hi chng trn dch mng phi. 3.2.Cn lm sng - Cng thc mu: bch cu tng ch yu l bch cu a nhn trung tnh.
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- Tc lng mu tng. - Xt nghim m: soi ti, cy v lm khng sinh . - X quang: hnh nh mc nc, mc hi bu dc hay trn bao quanh ch m phi.
4. Tin trin v bin chng 4.1. Tin trin - Trc kia p xe phi l mt bnh nng: bnh nhn c th cht trc khi khc m hay sau khi khc m, li c nhng trng hp bnh nhn ko di hng nm. - Hin nay p xe phi c coi l mt bnh lnh tnh v c nhiu khng sinh c hiu, nu iu tr ng th bnh s khi hon ton, khng li di chng. 4.2. Bin chng - p xe di mng phi thng vi mng phi gy trn m mng phi - Ho ra mu do v mch mu ln, nht l nhng p xe gn rn phi - Nhim trng huyt - Gin ph qun v x ha - Trn dch, trn m mng phi c th gy dy dnh mng phi 5. iu tr v phng bnh 5.1. iu tr ni khoa - Nguyn tc iu tr phi da vo khng sinh chn khng sinh. Nu khng lm khng sinh hoc cha c kt qu ca khng sinh th chn: + Penicillin liu lng t 10- 20 triu n v / ngy truyn tnh mch. + Ampicillin 10-20g/ngy, truyn tnh mch. + Cephalosporin th h 1 hoc 2, 3 liu lng 4- 8g /ngy tim hoc truyn tnh mch. + Aminoglycosid thuc thng c dng phi hp vi cc nhm beta- lactam. + Metronidazole 1g/ngy thng dng khi ho c khc m thi.
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- Thng dng phi hp hai hay ba loi khng sinh, ko di t 6-8 tun. C tc gi cho rng phi dng khng sinh cho n khi hnh nh X quang b xa ch cn li nhng nt m nh. - Dn lu t th bnh nhn nm t th thch hp. - Cho thuc long m. - Soi ht ph qun: ch khi c tc ph qun do d vt hoc m khng th thot ra c. - a khng sinh vo tn p xe. - Chc ht m qua thnh ngc nu p xe gn thnh ngc. - iu tr triu chng: h st, gim ho bng thuc hoc phng php ng y. 5.2. iu tr ngoi khoa Hin nay t c ch nh iu tr ngoi khoa v c nhiu loi khng sinh rt tt v c hiu lc. S can thip iu tr ngoi khoa khi c nhng du hiu sau y: - Ho ra mu lin tip - p xe phi mn tnh ko di trn 3 thng sau iu tr ni khoa. C th ct thy phi b p xe. 5.3. Phng bnh - V sinh rng ming tt. - iu tr nhim khun vng mi hng, rng hm mt cn phi phng p xe phi do sc phi m, mu, cht tit. - Nhng bnh nhn hn m, ng kinh, nhc c, vic nui dng bng ng thng phi cn thn trnh sc. - C thc phng nga tc d vt tr em, sc xng du. 6. Chm sc bnh nhn b p xe phi 6.1.Nhn nh Hi bnh - Tin s bnh: + Ngi bnh c ht phi vt l trong thi gian gn y khng? + C mc bnh v ng h hp trong thi gian gn y khng? - C st khng? (thng st cao, rt run). - Tnh cht ca ho? Khc m: s lng nhiu hay t, mu sc, mi? (thng c mi hi thi) au ngc? au c tng ln khi ht vo v ho khng?
Quan st theo di - Tnh trng ton thn: mt mi, st cn - Cc du hiu nhim khun: st. Tnh trng h hp: hnh th lng ngc, tn s th, tnh cht th Ho v khc m: s lng, tnh cht,
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Tnh trng tun hon: tn s, tnh cht mch. Xem kt qu cc xt nghim, h s bnh n.
6.2. Lp k hoch chm sc - Lm gim s lo lng cho ngi bnh. - Thc hin th thut dn lu m. Theo di. Thc hin y lnh. Ch n ung. Ch v sinh. Gio dc sc kho.
6.3. Thc hin k hoch chm sc Lm gim s lo lng cho ngi bnh - Gii thch cho ngi bnh hiu, yn tm iu tr, nng h tr khi ngi bnh ho, khc m, kh th. Bung bnh yn tnh, thoi mi, tng cng thong kh. Thc hin th thut dn lu m - Dn lu t th: t ngi bnh t th no tu thuc vo phn thu hay vng b p xe. Dn lu t th cn tin hnh 2 - 4 ln trong mt ngy trc khi n ( ngn nga nn, bun nn v ht phi thc n). mi t th dn lu t 10 - 15 pht. Sau khi kt thc mt t th dn lu, bo ngi bnh ho mt cch c hiu qu tng m ra ngoi. Nu khng dn lu t th c th phi thay i t th 2 gi/ln. - Lm cc ng tc h tr: V, rung lng ngc, hng dn ngi bnh tp th su, tp ho, rn luyn lm gin n phi. - Chun b ngi bnh tin hnh lm cc th thut soi, ht ph qun hoc chc ht p xe. - Theo di st tnh trng h hp v gim st s luyn tp ca ngi bnh. Khi hng dn phi gii thch, khuyn khch v ngi bnh s au khng dm th su. Theo di - Cc du hiu sinh tn: thc, nhp th, mch, nhit , huyt p. - Ch cc du hiu bt thng: kh th, tm, v m hi, mch nhanh ln t ngt, c th tt huyt p. - Theo di du hiu au ngc, ho. Ch ngi bnh c th c m nhiu gy tc ng th dn n t vong. - Theo di s lng, mu sc, tnh cht ca m (nu m c ln mu ti phi bo ngay cho bc s bit phng v cc mch mu trong phi). Theo di s lng m khc ra hng ngy. Khc vo ca c np y.
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Thc hin y lnh Thc hin y cc y lnh v thuc v cc xt nghim theo y lnh . Ch n ung - Ngi bnh b p xe phi nn suy kit nhanh, cho ngi bnh ch n giu m, vitamin, m bo calo: 3000 calo/ngy. Cn ngi bnh 2 ln/tun. - Cho ngi bnh ung nhiu nc, duy tr nc tiu khong 1,5 lt/ngy. Lp bng cn bng dch vo, ra hng ngy. Ch v sinh Thc hin v sinh c nhn sch s, lu v sinh rng ming, thng xuyn cho ngi bnh sc ming v ngi bnh p xe phi hi th rt hi do m cn ng li trong phi. Gio dc sc kho - Gii thch cho ngi bnh bit s cn thit phi ko di thi gian iu tr ngi bnh yn tm, kin tr, tun th ch iu tr v luyn tp. Hng dn ngi bnh tp th chm ht vo su, th ra bng ming nh tp kh cng. Tp th dc, th thao u n. B thuc l, trnh khi bi. Gi m trong ma lnh.
UNG TH PHI
MC TIU 1. Trnh by c nguyn nhn v yu t thun li gy ung th phi. 2. Trnh by c triu chng lm sng v cn lm sng ca ung th phi. 3. Trnh by c di cn ca phi v hng iu tr ca ung th phi. 1. i cng Ung th phi l mt bnh rt hay gp ng hng th ba trong cc bnh ung th mn tnh v hng th nm trong cc bnh ung th ph tng khc. Ung th ph qun phi nguyn pht hin nay c tn sut ang tng ln mt cch ng s. L nguyn nhn gy t vong do ung th hng u nam v hng th 4 n. Bnh nguyn ch yu l thuc l. Pht hin thng mun nn iu tr kh v vy tin lng lun lun nng. 2. Nguyn nhn: cha r nhng c mt s yu t thun li sau y:
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2.1. Thuc l: l yu t chnh gy ra ung th phi. - Khi thuc l c xc nh mt cch chc chn l nguyn nhn gy ung th phi. T l ung th phi tng theo s iu thuc l tng trong ngy v s nm nghin. - Trong khi thuc l c khong 5000 cht ha hc. Trong s cht ha hc ny c nhng cht gy ung th... 2.2. nhim mi trng: T l ung th phi nhng thnh ph tc l vng k ngh cao hn vng nng thn. 2.3. Mt s yu t khc So phi c th lm ung th dng tuyn hn cc th khc, nhi mu phi, mt s bnh phi khc nh lao phi v ung th phi. 3. Triu chng lm sng 3.1. Giai on tim tng - Lc u biu hin ho khan hoc c khc m t, ho ko di dng cc thuc iu tr triu chng khng . - Ho ra mu: gp triu chng ny khong 50% cc trng hp, ho ra mu rt t ln vi m thng ho v bui sng v trong nhiu ngy, c th nghe ran rt ph qun chng t khi u lm tc ph qun khng hon ton. - Hi chng vim ph qun cp hoc bn cp: thng gp trong ung th ph qun ln, c biu hin nh mt vim phi hoc ph qun ph vim. 3.2. Nhng du hiu ung th lan ta: - au ngc: thng au bn tn thng au ku thn kinh lin sn. C khi au quanh b vai mt, trong cnh tay trong ung th nh phi. - Kh th: kh th t gp thng do tc ph qun hay xp phi hon ton, nu kh th kiu thanh qun v ting c c th do khi u ng ba kh ph qun, cng c khi kh th do lit c honh. - Kh ni: ging khn, ging i do thn kinh qut ngc b chn p. - Kh nut o thc qun b chn p. - Hi chng chn p tnh mch ch trn: ph o khoc, tun hon bng h ngc, mt mi, tm. - Hi chng trn dch mng phi: ung th di cn vo trong mng phi. 3.3. Du hiu ngoi phi - St nh, tc lng mu tng nhanh, c khi bch cu tng. - Xm ln hch trc c thang, ly hch thng n lm sinh thit hch. 3.4. Du hiu ni tit v thn kinh - C th c v to mt bn hoc hai bn nam gii. - Hi chng Cushing, tin trin nhanh.
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4. Cn lm sng 4.1. Du hiu X quang - C th thy hnh nh xp phi mt phn hay ton b. - Chp ph qun sau khi bm thuc cn quang thy ph qun b xp, ct. 4.2. Chp ct lp vi tnh 4.3. Ni soi ph qun. 4.4. Siu m ngc: Xem c trn dch mng phi hay khng? 5. Bin chng v di cn 5.1. Bin chng - p xe phi th pht. - Bi nhim phi. - Xp phi. - Trn kh mng phi. - Khi huyt nng do ung th gm v ng mch ln. 5.2. Di cn - ng ng mch phi. - Bch mch. - Ph qun. - Cn ph qun. 6. iu tr - Phu thut: ct khi u l bin php hu hiu, c th ct thy phi hay ton b phi. Chng ch nh phu thut khi c di cn. - Phng x - Ha tr liu - iu tr triu chng: Dng thuc gim au, khng sinh chng bi nhim. 7. Chm sc 7.1. Nhn nh tnh trng ngi bnh Hi bnh - Ngi bnh ho khan hay ho c m? Mu sc, tnh cht ca m? C st khng? au ngc khng? C khn ting, mt ting khng? Ngi bnh chn n? Hi v tin s, ngh nghip?
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Quan st, theo di - Ngi bnh gy, mt mi, st cn. - C kh th khng? Mu sc, tnh cht m: (m c, vng, m ln mu). 7.2. Lp k hoch chm sc - Chm sc v tinh thn. Gim au. Gim kh th. Phng nhim khun. Gio dc sc kho.
7.3. Thc hin chm sc Chm sc v tinh thn - Thng xuyn thm hi, ng vin, an i ngi bnh an tm iu tr. - Quan tm n din bin tm l ngi bnh pht hin nhng bt thng. Gii thch nhng thc mc ca ngi bnh h khng lo lng. Gim au - C th gim au cho ngi bnh bng cc cch sau: + Hng dn ngi bnh la chn t th thoi mi nm gim au. + Hng dn ngi bnh t tay m ngc khi ho gim au. - Tng cng gic ng. Cc tr gii tr tiu khin. Lm gim lo lng cho ngi bnh. Thc hin thuc gim au theo y lnh (ch s dng khi cc phng php khng dng
thuc tht bi) Gim kh th - t ngi bnh t th thoi mi, ngi bnh cm gic d chu nht. - Th oxy theo ch nh. - Dng thuc theo y lnh. Phng nhim khun Nhim khun vn l nguyn nhn cht ch yu ngi bnh ung th. Bo v chng nhim khun bng nhiu cch khc nhau. - Lm sch ng th: ngi bnh ung th phi c nguy c nhim bn ng th do tit dch ph qun v b tc ph qun do khi u, cn tin hnh vt l tr liu lng ngc nh: dn lu t th, v, rung lng ngc, ho c hiu qu. Nu m c c th kh dung hi nc, ung nhiu nc lm lng m. Khng c ht thuc v n lm gim sc bo v ca ng h hp.
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Tng cng dinh dng: ngi bnh ung th thng dinh dng km do chn n.
+ m bo ch n giu m, tng calo, nhiu vitamin. + Cho ngi bnh n nhiu ba, thc n lng, d tiu nh: cho tht, sp, sa, rau, hoa qu Theo di pht hin sm cc du hiu nhim khun: st l du hiu quan trng nht. V sinh rng ming lm gim nguy c nhim khun ng h hp trn. Gip ngi bnh
v sinh c nhn. Gio dc sc kho cho ngi bnh v gia nh - Gii thch cho ngi bnh yn tm iu tr. - Khng c ht thuc l, khng c ung ru, khng tip xc khi bi - Dng thuc theo ch dn ca bc s, chp hnh ch iu tr, ch iu tr c th ko di. Ch n ung, v sinh c nhn. Vn ng, xoa bp thn th, th dc hp l.
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HEN PH QUN
MC TIU 1. Trnh by c phn loi hen ph qun. 2. Trnh by c triu chng hen ph qun. 3. Trnh by c hng iu tr hen ph qun. 4. Trnh by c phng bnh v cch chm sc bnh nhn hen ph qun. 1. i cng Hen ph qun biu hin bng nhng cn kh th ch yu th th ra km theo nhng ri lon v mch mu, tit dch v co tht ph qun. 2. Nguyn nhn 2.1. D ng: vai tr d ng trong hen ph qun c xc nh. Nhng cht gy d ng rt nhiu nh: ht phi nhng cht v nhng mi kch thch nh phn hoa, bi, xng du, khi thuc l. Cc thc n l nh tm, cua, trng... 2.2. Nhim khun: c vai tr quan trng, cc nhim khun mn tnh nh; vim xoang, vim ph qun ... 2.3. Nguyn nhn vt l: s thay i thi tit, gi ma, p sut, m.. 2.4. Do gng sc: hay gp tr em v ngi tr. C th gng sc lm thay i nhit v p sut ca kh th kch thch vo nim mc ca kh qun lm khi pht cn hen. 2.5. Stress: Yu t thn kinh rt quan trng, c l do ri lon thng bng thn kinh th dch, stress c th lm khi pht cn hen. 3. Phn loi 3.1.Hen ngoi sinh cn gi l hen d ng c nhng c im sau: - Bnh xy ra tr em v ngi tr. - C tin s bn thn v gia nh c d ng: chm, my ay, vim mi d ng v hen. - Cn hen xy ra c lin quan n d nguyn c bit, tin lng tt, t l t vong t. 3.2. Hen ni sinh cn gi l hen nhim khun c nhng c im sau: - Bnh xy ra nhng ngi ln tui > 35tui - Cn hen xy ra c lin quan n nhim khun ng h hp. - Cn hen thng ko di v nng, tin lng khng tt, c th t vong v c nhiu bin chng. 3.3. Hen hn hp: l s phi hp gia hen nhim khun v hen d ng. 4. Triu chng 4.1. Triu chng lm sng Cn hen ph qun in hnh thng din ra ba giai on:
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4.1.1. Khi u - Cn hen ph qun thng xy ra bui chiu v m. -Yu t lm xut hin cn hen l s thay i thi tit hay tip xc vi cc d nguyn. - Triu chng bo trc: nhc u, ht hi, chy mi, ri lon tiu ha nh ... 4.1.2. Ton pht Bnh nhn kh th, phi ngi dy th, kh th ch yu th th ra. - Tm nh v v m hi. - Lng ngc hai bn gin, khong gian sn nm ngang. - C du hiu co ko hm trn ca xng c v cc khoang sn. - Rung thanh bnh thng hay gim nh. - G trong hn bnh thng. - Nghe phi c rales rt, rales ngy hai ph trng. - Tim mch: nhp tim thng nhanh, c khi ln ti 120 ln- 140 ln/ pht 4.1.3. Tin trin Trong vi chc pht, cn hen gim dn, bnh nhn khc ra nhiu m nhy do. 4.1.4. Cn hen c tnh L cn hen ko di t 24- 48 gi sau khi dng cc thuc gin ph qun thng thng vn khng gim, gy tnh trng suy h hp cp, c nguy c t vong. * Triu chng lm sng: biu hin qua cc triu chng sau y - Kh th c tnh cht kch pht, lin tc, kh th ch yu th th ra. - Du hiu thiu oxy nh xanh tm, kch thch.. - Du hiu tng kh CO2 mu nh; v m hi, mch nhanh. - Huyt p lc u tng sau try mch giai on cui. - Ri lon thc lc u l l m, sau hn m. - Du hiu suy tim phi. 4.2. Cn lm sng - Cng thc mu: bch cu bnh thng, bch cu a acid tng nh - Chp X quang phi: Chiu phi thy hai trng phi sng hn bnh thng. C honh h thp v t di ng, gian sn nm ngang, khong gian sn gin rng km di ng. - Lm kh mu: thng lm trong cn hen nng c ri lon kh mu. - Xt nghim m - in tim. Trong cn hen th thy nhp nhanh xoang. 5. Tin trin, bin chng v tin lng 5.1.Tin trin: bnh tin trin kh m bit trc c, c ngi b mt thi gian ri khi, c ngi ko di hng chc nm, c nhng bnh nhn ln cn lin tc hng nm.
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5.2. Tin lng: hen ngoi sinh c tin lng tt t bin chng, hen ni sinh tin lng xu hn v c nhiu bin chng. 5.3. Bin chng: * Cp: + Nhim trng: bnh nhn c st, khc m trng, khm phi c rales m, xt nghim mu c bch cu tng. + Trn kh mng phi do v bng kh ph thng. + Tm ph mn cp, bn cp: suy tim phi bn cp: gan to tnh mch c ni, phn hi gan tnh mch c dng tnh. * Mn: + Kh ph thng: lng ngc bin dng hnh thng, gan sa. Khong gian sn gin rng. + Suy h hp mn: mng tay khum mt ng h, ngn tay hnh di trng. + Tm ph mn: suy tim phi v x gan. + Gin ph qun: ho khc ra m c bn lp 5. iu tr 5.1. iu tr cn hen thng - Cn khuyn bnh nhn trnh nhng yu t gy d ng( i vi ring tng bnh nhn). - Dng thuc: + Cc loi thuc gin ph qun nh: salbutamol, Diaphyline... + i vi hen ni sinh dng thm corticoide. + Khi b bi nhim th dng thm khng sinh ph rng. 5.2. iu tr hen ph qun c tnh Hen ph qun c tnh l mt cp cu ni khoa, bt buc phi nhp vin gp hi sc khn trng v tch cc. - Liu php oxy: phi thc hin lin, khng cn ch kt qu kh trong mu, cho bnh nhn nm u cao, th oxy 4-6 lit/ pht. -Thuc gin ph qun: salbutamol, adrenaline, diaphyline. - Corticoide. - Khng sinh: dng khng sinh ph rng. - Cho th my h tr - iu ha nc in gii 6. Phng bnh: Gi m khi tri lnh v trnh cc yu t tng gy ra cn hen. 7. Chm sc bnh nhn hen ph qun 7.1. Nhn nh tnh trng ngi bnh Hi bnh - C nhng triu chng kh th v ho khng?
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Kh th c thnh cn khng? Cn kh th thng xut hin vo khi no? Ko di bao lu? C thng xuyn khng? Khi kh th c m sc g bt thng khng? Kh th khi nm hay ngi. Ngi bnh c ho khng? Ho khan hay ho c m? S lng mu sc, tnh cht ca C tin s bnh v chm, d ng thc n khng? Tin s gn y v nhim khun? Tin s gia nh v d ng? iu kin hon cnh sng v lm vic.
m?
Quan st theo di - Tnh trng ton thn, tnh trng tinh thn (mt mi, lo lng, bn chn) Tnh trng h hp: tn s th, tnh cht th, s co ko cc c h hp T th ngi bnh khi th. Ho v khc m. Tnh trng tun hon: tn s tnh cht ca mch, tnh trng da v nim mc Cc du hiu khc (thn nhit, nc tiu) Xem xt kt qu cc xt nghim cn lm sng.
7.2. Lp k hoch chm sc Qua thng tin thu thp c, iu dng cn c k hoch chm sc c th cho ngi bnh. Theo di cc du hiu sinh tn v cc du hiu bt thng ca ngi bnh trong cn hen. Chm sc tinh thn Thc hin cc y lnh ca thy thuc. Thc hin cc hnh ng chm sc ngi bnh. Gio dc sc kho.
7.3. Thc hin k hoch chm sc Theo di cc du hiu sinh tn v cc du hiu bt thng ca ngi bnh trong cn hen - Theo di s thay i ca c quan h hp: m nhp th ch tn s, bin th. - o nhit , m mch, nu thy kt qu bt thng phi bo bc s can thip sm, phng bin chng xy ra. Chm sc tinh thn - Thit lp mi quan h tin tng vi ngi bnh. - ng vin, an i ngi bnh, lun c mt bn cnh ngi bnh trong cn hen h yn tm.
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Theo di st sao i vi ngi bnh hen c bi nhim, ngi gi xut hin cn hen,
phng nhng cn ngng th x tr kp thi. Thc hin cc y lnh ca thy thuc - Chun b phng tin, dng c, kh dung thuc gin ph qun. - Thc hin cc xt nghim: xt nghim mu, kh mu Thc hin y lnh thuc kp thi, chnh xc, theo di s p ng ca thuc cng nh phn ng ca thuc i vi ngi bnh. Thc hin cc hnh ng chm sc - Khi ang c cn hen: c kh th d di, ngi bnh t th thch hp, to thun li cho s th v loi b dch xut tit. iu dng n cn ng vin, t s thng cm ngi bnh vt qua cn kh th. Hn ch ngi nh, bn b n thm khi ang c cn kh th. - Theo di, nh gi tnh trng mt nc, tng cng lng dch vo c th lm long dch xut tit (khuyn kch ngi bnh ung nhiu nc, c bit l nc hoa qu). Lp bng cn bng dch hng ngy, ghi chp chnh xc. - Khi ht cn hoc ngi bnh c cn hen ko di nhng phi cho ngi bnh n ung m bo lng calo/ngy, thc n giu cht dinh dng, vitamin (sa, cho tht, sp, hoa qu ti) Theo di sc mt, mi, du hiu khc nc, thi ca ngi bnh, s lng nc tiu. Theo di s thay i v tnh tnh, thi .
- Theo di s thay i ca tnh trng h hp: tn s, bin th (th su), pht hin du hiu thiu oxy mu v suy h hp. Lu : Khi cho ngi bnh th oxy nht l ngi bnh hen ph qun mn phi rt cnh gic vi s ngng th. - Khi cn kh th gim dn v ht, ngi bnh rt mt nhc, iu dng gip v rung ngi bnh d khc nh m, lm thng thong ng h hp. - Chm sc s ng v ngh ca ngi bnh. Cn ch bung bnh phi yn tnh, hn ch ting ng, s gy n o do khch n thm, do nhn vin y t. - Thc hin nhng ng tc chm sc nh nhng ngi bnh d chu, an i ng vin, loai tr nhng yu t gy cng thng (stress) cho ngi bnh. - Theo di gic ng ca ngi bnh, thi gian ng trong ngy. Gio dc sc kho - Kim sot cht ch mi trng gy d ng. c bit trong phng ng, trong nh, trnh tip xc vi d nguyn gy hen ph qun nh: bi nh, phn hoa, lng ch, mo. Hn ch yu t gy stress lm ngi bnh cng thng, lo lng, cu gin.
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Hng dn ngi bnh tp th su: tp th bng (th c honh), th chm mi, luyn tp
lm gin n phi, tp ho - Tng cng rn luyn nng cao sc kho, duy tr dinh dng, ung nc, ch ng, ngh ngi, vn ng hp l. - Trnh mi trng nhim, ni m cao. Khng ht thuc. Khng lm dng thuc gin ph qun v thuc co mch. Khng dng cc loi thuc hay gy d ng: penicillin.
Lng gi Ngi bnh hen ph qun c chm sc tt khi: - Ngi bnh yn tm, tin tng vo cng tc cha bnh v chm sc ca cn b y t. t. Khng b nhim khun, khng c cc bin chng xy ra. Ngi bnh c chm sc chu o c th cht v tinh thn. Chc nng h hp n nh. Ngi bnh c kin thc v y hc, hiu v thc hin c nhng hng dn ca cn b y
HO RA MU
MC TIU 1. Trnh by c nh ngha v nguyn nhn ca ho ra mu. 2. Trnh by c triu chng lm sng 3. Trnh by c cch iu tr ca ho ra mu. 4. Cch chm sc bnh nhn ho ra mu. 1. nh ngha: ho ra mu l khc ra mu khi ho, mu chy t thanh qun, ph qun v do nhiu nguyn nhn khc nhau. Mu ho ra l mu ti ln m v bt sau vi ngy, nu mu tip tc theo m gi l ui khi huyt. Mu lc ny thng mu en. 2. Nguyn nhn 2.1. Nguyn nhn ng h hp - Cc bnh nhim khun phi: giai on u ca vim phi, p xe phi, lao phi... - Cc bnh khc ca ng h hp nh gin ph qun, ung th phi v ph qun, sn l phi, nm phi, kn phi, gin ng mch ph qun. 2.2. Ngoi ng h hp
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- Tng p lc tun hon phi: hp van hai l, suy tim tri, cao huyt p, h van ng mch ch, nhi mu phi. - Bnh v mu: bch cu kinh, suy ty... 3. Triu chng lm sng C th xy ra trong lc khe mnh, sau mt lao ng gng sc, hoc sau khi n nhiu, ni nhiu, xc ng mnh, thay i thi tit hoc trong giai on hnh kinh. 3.1. Tin triu - C cm gic nng ngc, kh th nh, nga c hng, ho trong trng hp ho ra mu do gin ng mch, bnh nhn c cm gic si s s c hng. 3.2. Triu chng ho: - Gia cn ho c khc ra mu ti v m, s lng mi ln ty tng loi. + Nh: s lng di 100ml mch nhanh, huyt p gim nh. + Trung bnh: 100ml - 200ml mch nhanh, huyt p gim nh. + Nng: 300 - 1000ml mch nhanh nh, huyt p gim, p lc tnh mch trung ng gim, suy h hp do ho sc v do mt mu nhiu. + Ti cp: Trn 1000ml bnh nhn suy sp nhanh, suy h hp, sc do gim th tch mu tun hon. 4. iu tr 4.1. Chng suy h hp - Th oxy, ht ph qun bng my ht trnh tc ph qun. - Nu ho ra mu nng, t sonde hai nng ngn cho mu t bn phi tn thng trn sang phi bn kia ng thi thng kh tt cho bn phi lnh. 4.2.B lng mu mt Truyn dch phn t lng ln, c th truyn mu. Thc t b lng mu mt cha phi l iu quan trng nht m vn chnh l m bo thng kh phi. 4. Cm mu - u tin l iu tr ni khoa, bng cch ny c th cm mu c phn ln cc trng hp ho ra mu. C th dng cc thuc: + Adrenoxyl + Transamin + Sandostatin + Hn hp ng min: Dolargan + Aminazin + Pipolphen 5. Ngoi ra ta c th dng thuc: an thn, morphin nhng phi rt cn thn v c th lm cho suy h hp nng thm 6. Chm sc
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6.1. Nhn nh tnh trng ngi bnh Hi bnh - Cn au ngc khng? Khc ho ra mu nhiu ln cha? C st khng? C au vng thng v, hi, chua khng? C tin s bnh phi hoc tim mch khng?
Quan st - Mu da, sc mt, nim mc. Tnh trng th. S lng, mu sc mu ( ti hay c ln m v bt) Hnh th lng ngc: c d dng hoc bin dng khng?
Thm khm - Ly ngay mch, nhit , nhp th. iu dng cn phi nhn nh ngi bnh ho ra mu hay nn ra mu. Khi chc chn ngi bnh ho ra mu th phi xc nh xem ho ra mu th nh, th va hay ho ra mu th nng. 6.2. Lp k hoch chm sc - T th ngh ngi. - Thc hin y lnh. Theo di v chm sc. Gio dc sc kho.
6.3. Thc hin k hoch chm sc T th ngh ngi - Ngi bnh nm ngh ngi yn tnh ti ging theo t th Fowler, u nghing v mt bn khi ho ra mu, ( phng mu trn vo phi gy suy h hp) + Ho ra mu th nh: hn ch vn ng + Ho ra mu th va: ngh ngi tuyt i ti ging + Ho ra mu th nng: Ngh ngi tuyt i ti ging, ch chm sc cp I. Thc hin y lnh - X tr thuc cm mu, dch truyn theo y lnh ca bc s - Ht mu cc, m di bng my ht nu c hin tng bt tc lm thng thong ng h hp. - Cho th oxy theo y lnh nu ngi bnh kh th. Xt nghim: + Cng thc mu, hematocrit, mu chy mu ng.
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+ Xt nghim m tm BK. + X quang ch chp khi ngi bnh n nh. Theo di v chm sc - Theo di mu da, sc mt, nim mc. - Theo di mch, nhit , nhp th, huyt p 15 pht/ln, 1h/ln, 3h/ln tu theo mc nng, nh. Nu kh th cho ngi bnh th oxy qua ng thng mi ngt qung. - Theo di lng mu ho ra hng ngy, mu sc v tnh cht. Nu mu ho ra mu ti tc l mu cn ang chy, cn phi x tr thuc cm mu. Nu mu ho ra mu nu en th hng dn ngi bnh khc ht ra ngoi trnh bi nhim ng h hp. - Nu st cao cho ngi bnh thuc h nhit v p khn lnh vng trn, thng xuyn thay khn. Theo di nc tiu 24 gi (trng hp nng v va) Chun b ng nh c chia ngi bnh nh v o khi lng mu. Cho ngi bnh n ch lng, d tiu, thc n ngui, giu dinh dng nhiu calo, chia
nhiu ba trong ngy. - V sinh c nhn: hng ngy v sinh thn th, lau ra bng nc m. - ng vin, an i ngi bnh yn tm, tin tng vo s iu tr v chm sc ca chuyn mn. Gii thch cho ngi bnh hiu v ho ra mu cng phi hp iu tr. Gio dc sc kho cho ngi bnh v gia nh - Gii thch cho ngi bnh ho ra mu thng hay ti pht v vy phi bnh tnh, nu ngi bnh ht hong, lo lng, s hi th nhng yu t s kch thch gy ho ra mu tip. - Hng dn ngi bnh cch ung thuc, sinh hot, ng, ngh ng gi, hn ch vn ng mnh gng sc v thc hin theo hng dn ca thy thuc. - Hng dn cch x l m, mu phng ly nhim cho ngi xung quanh. - Phng chng ly nhim nu ho ra mu do lao. nh gi kt qu chm sc Tnh trng ngi bnh tt ln nu: - Cm ho ra mu hoc ho ra mu t sm mu. Cc du hiu sinh tn n nh. Cc triu chng tn thng phi n nh. Kt qu xt nghim dn dn tr v bnh thng. n ung tt, gi hoc tng cn.
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1.6. Ri lon i tin: tiu chy hoc to bn... 2. Khm lm sng v h tiu ha Qu trnh khm chia ra lm hai phn: khm tiu ha trn - di, khm tiu ha gia. 2.1. Khm tiu ha trn v tiu ha di 2.1.1. Khm mi - Bnh thng: mi mu hng m t, cn xng. - Bnh l: tm trong suy tim, tim bm sinh c tm, suy h hp mn thiu oxy mu, nht nht trong thiu mu, mi kh trong st cao nhim trng. 2.1.2. Khm ming - Bnh thng: nim mc ming hng m t. - Bnh l: lot trong bch cu cp, nhim trng, thiu Vitamin E 2.1.3. Khm li - Bnh thng: hng t gai li u r. - Bnh l: trng bn kh gp trong nhim khun, c bit l trong thng hn, li mt gai trong thiu mu mn. 2.1.4. Li rng - Bnh thng: li hng, bng t. - Bnh l: lot li gp trong nhim c; nh ch thy ngn, thiu VitaminE. 2.1.5. Khm hng (hc chuyn khoa khm sau) 2.1.6. Khm thc qun: da vo c nng v triu chng cn lm sng l chnh . - au kiu nng rt y c, sau xng c, tng khi nut gp trong vim lot thc qun. - Nut nghn do co tht, hp thc qun. 1.7 Khm hu mn v trc trng - T th bnh nhn khm hu mn: bnh nhn nm ph phc, hai chn qu hi ging, mng cao, u thp, ngi khm ng i din v quan st, dng tay banh hu mn ca bnh nhn, bo bnh nhn rn nh gin c vng hu mn, quan st nim mc bn trong. - Bnh thng: da hu mn nhn, np nhn mn mi, nim mc hng t. - Bnh l: hu mn hm, lot gp tr sau l, v sinh km, d hu mn, nt hu mn, tr ngoi, sa trc trng, p xe quanh hu mn. * Khm trc trng - T th bnh nhn nh khm hu mn hoc nn nga, hai chn co ging rng hoc nm nghing, chn trn co, chn di dui. - Thy thuc dng ngn tay mang gng a nh nhng, t t vo hu mn su khong 10 12cm. - Bnh thng: lng trc trng rng, nim mc trn mm, nam gii pha trc c tuyn tin lit.
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- Bnh l: tr ni. 2.2. Khm tiu ha gia - Da vo bn ng sau y ngi ta chia vng bng thnh 9 phn khu.
+ Hai ng ngang: ng ni t hai im thp nht hai bn b sn v ng thng ni hai gai chu trc trn. + Hai ng thng dc qua im gia hai cung i. + Thng v: gm c thy tri ca gan, mt trc ca d dy, tm v, mn v, mc ni gan d dy, t trng ty, on u ca ng mch, tnh mch ch bng. + H sn phi: thy gan phi, ti mt, gc i trng phi, tuyn thng thn v cc trn thn phi. + H sn tri: lch, d dy, gc i trng tri, ui ty, tuyn thng thn tri v cc trn thn tri. + Rn: mc ni ln, i trng ngang, rut non, mc treo rut, hch mc treo rut, hai niu qun, ng mch, tnh mch ch bng. + Mng m phi: i trng ln, rut non, thn phi. + Mnh m tri: i trng xung, rut non, thn tri. + H v: mc ni ln, rut non, bng quang, on cui niu qun, hai vi trng dy chng rng ... + H chu phi: manh trng, rut non, rut tha, bung trng phi. + H chu tri: rut non, bung trng tri. i trng Sigma. 2.2.1 T th bnh nhn Bnh nhn nm nga hai chn co, th u bng mi. 2.2.2. Cch khm bng
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2.2.2.1. Nguyn tc khm: - Khm nh nhng, t nng n su, t ch lnh n ch au. - t st lng bn tay vo thnh bng khng nn ch dng ngn tay khm. - Ni khm phi nh sng, m, gii thch cho bnh nhn an tm. - bnh nhn nm nga, hai tay dui, hai chn co, ming h th u v su c thnh bng mm, thy thuc ngi bn thun d khm. 2.2.2.2. Cch khm: theo tun t sau *Nhn: - Bnh thng: bng thon u, c ng nhp nhng theo nhp th, ph n sinh nhiu s c vt rn da. - Bnh l: vng da, c mng sc t, tun hon bng h, nt gin tnh mch hnh sao, t ban, vt m c...thng gp trong cc bnh l v gan mt... * S: - Dng hai bn tay p st thnh bng, day theo mt vng theo chiu ngc kim ng h, bo bnh nhn ht su v th u. - S cc c quan trong bng nh gan, lch, cc khi u, m t v tr, hnh dng, kch thc, mt , di ng hay khng, au hay khng au. - n cc im au: + im au thng v di mi xng c thng 2cm. + im cnh c phi cch im mi c 2cm v pha bn phi, thng gp au trong giun chui ng mt. + im ti mt, im Murphy. + im rut tha ( Mac - Burney ) 1/3 ngoi ca ng ni rn vi gai chu trc trn phi. * G : bnh nhn nm nga, nghing phi hoc nghing tri. + Mt s bnh l thng gp: g trong ton bng, bng chng hi mt vng c trc gan gp trong thng trng rng. * Nghe: t c gi tr thng nghe m rut c tng hay gim... 2.3 Khm gan: (hc k trong bi cch khm gan mt)
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P XE GAN
MC TIU 1. Trnh by c nguyn nhn, ng xm nhp, triu chng ca p xe gan do amp v p xe gan mt qun. 2. Trnh by c phng php iu tr p xe gan v cch chm sc bnh nhn p xe gan. 1. i cng p xe gan l mt tnh trng nung m xy ra gan bao gm nhu m gan v h thng ng dn mt trong gan. 2. Nguyn nhn - Do amp: ch yu l th hot ng ca Entamoeba histolytica. Lc u amp ch sng v gy bnh i trng, trong mt s iu kin thun li khi c tn thng mch mu v hch bch huyt chng c th n gan gy ra p xe gan do amp. Cn khai thc k bnh nhn c hi chng l. - Do vi trng sinh m: si v giun chui ng mt l hai nguyn nhn v yu t hay gp nht. Bnh thng khi c vng Oddi hot ng tt, trong ng mt khng c vi trng hay c rt t khng gy bnh. Khi c si hay tc nghn, tr hoc tng p lc dch mt to iu kin cho vi trng i ngc dng gy nhim trng ng mt v cui cng l p xe mt qun. 3. ng xm nhp: ng xm nhp ca tc nhn gy bnh thng thng qua 1 trong 5 c ch sau: - Qua ng tnh mch ca v ng bch mch, t mt vim nhim tin pht trong bng thng l t rut, rut tha, vim ti tha, thng i trng. - Qua ng nhim trng huyt ca mt nhim trng t xa trong c th vi trng n gan qua ng mch gan. - Nhim trng ng mt ngc dng c lm d do s tc nghn ng mt, do si, giun chui ng mt, ung th ng mt... - ng tip cn t p xe di c honh, ung th d dy, ung th i trng, gy vim p xe ha v lan vo gan. - Do chn thng: trc tip do vt thng h hay mu t bi nhim th pht. 4. Triu chng 4.1. p xe gan do amp 4.1.1 Triu chng lm sng Bi cnh lm sng rt phong ph, c th va gp p xe gan va gp p xe rut hay bnh nhn c tin s l t rt lu hay tin s ch c l thong qua.
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4.1.1.1.Thi k khi pht Khi pht t t vi st, sau au h sn phi 3-4 ngy, 5- 7 ngy sau th triu chng mi r hn. Mt s bnh nhn xut hin t ngt st cao au h sn phi, gan to v c m ngay. 4.1.1.2. Thi k ton pht: biu hin lm sng r vi hai hi chng. * Hi chng nhim trng - St cao gp trn 90% trng hp, st xut hin u tin trc au h sn phi c th mt gi hay vi ngy. - Mt mi chn n mi kh, li bn, v mt nhim trng. * Hi chng tn thng vng gan - au vng gan c 100% trng hp, tuy nhin c ngi au t, c ngi au nhiu. au t pht tri ln khi x dch, khi ho v khi ht su. - Gan to: gp trn 90% trng hp, c th to di h sn phi hay to ln di c honh phi. Vng gan rt au, vng h sn phi khng, rung gan au, cn n im lin sn mt cch k lng tm im au khu tr. 4.1.2. Cn lm sng - Cng thc mu: bch cu tng, ch yu l bch cu a nhn trung tnh. - Vss tng cao. - Xt nghim phn tm amp (t l dng tnh khng cao). - Siu m gan mt: l xt nghim tt nht chn on xc nh, theo di tin trin v hng dn iu tr. Rt c gi tr khi ng knh p xe ln hn 2cm. 4.2. p xe mt qun Cn khai thc k tin s c si mt hay cn au qun gan do giun chui ng mt hay si mt. 4.2.1 Triu chng lm sng 4.2.1.1. Khi pht: thng t ngt, t nhin hay c nhng yu t lm d nh giun chui ng mt hay n nhiu thc n c du m vi tam chng Charcot (au h sn phi, st, vng da vng mt). Ton thn c hi chng nhim trng v hi chng tc mt. Gan ln au ton gan nht l gan tri, c km theo du tn thng ti mt vi ti mt ln. 4.2.1.2. Ton pht: Nu khng c iu tr hay iu tr khng p ng s chuyn qua giai on p xe mt qun vo tun l th hai vi: - Hi chng nhim trng rm r hn vi nhng cn vng trng huyt. - Hi chng tc mt ngy cng nhiu. - Hi chng tn thng vng gan rt r vi gan ln, rt au c im au khu tr nhiu ch in hnh l cc im g ln trn mt gan. 4.2.2 Cn lm sng - Cng thc mu: bch cu tng ch yu l bch cu a nhn trung tnh. - Vss tng cao.
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- Bilirubin tng cao nht l bilirubin trc tip - Phosphatase kim tng. - Cy mu c th pht hin c vi trng gy bnh. - Siu m c gi tr pht hin p xe ng thi pht hin nguyn nhn l si hay giun thng tn ng mt hay ti mt. - CT scanner cng c gi tr tng t. - Chp v soi ng mt ngc dng trong trng hp siu m c kt qu m tnh, y cng l phng tin chn on hu hnh. 5. Bin chng 5.1. Ni khoa - Nhim trng huyt vi chong nhim trng gram m. - Trn dch mng phi, mng tim - Vim ty cp - X gan mt 5.2. Ngoi khoa - V p xe vo bng gy vim phc mc. - Thm mt vo bng gy vim phc mc mt. - Chy mu ng mt: nn ra mu in hnh c hnh thi bt ch, bnh cnh xut huyt ni gy ra bnh cnh chong phi hp xut huyt v nhim trng. 6. iu tr 6.1. iu tr ni khoa: bin php chung bao gm ngh ngi, n ung y nng lng, gim au v h st nu cn. 6.1.1 i vi p xe gan do amp - Emetine liu 1mg/kg/ ngy x 7-10 ngy, liu trnh th hai sau 4 tun. - Metronidazole: dit amp t chc v dit amp trong rut liu 25- 30mg/kg/ ngy x 10- 14 ngy. 6.1.2. i vi p xe gan mt qun - Cn hng ti vi khun gram m ng rut v vi khun k kh nn cn dng khng sinh ph rng, nng cao trong ng mt, thng dng ng tim v ko di trn hai tun. Tt nht cn dng khng sinh theo khng sinh v phi hp khng sinh. - Ngoi ra cn chng chong nhim trng gram m nu c. - Gim au v chng co tht ng mt. 6.2. iu tr ngoi khoa 6.2.1 i vi p xe gan do amp - Chc ht p xe di s hng dn ca siu m, c th pht hin p xe cn nh, xc nh v tr ca p xe chc ht, ra hay c th a trc tip thuc dit amp vo tn p xe.
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- phu thut ch p dng cho nhng trng hp p xe qu ln, hoc v tr nm khng th chc ht c. 6.2.2 i vi p xe mt qun: Phu thut nhm loi b nhng tc nghn c hc nh giun, si. Nhng rt kh thc hin v bnh nhn trng thi nhim trng, nhim c nng. 7. Chm sc bnh nhn b p xe gan 7.1. Nhn nh tnh trng ngi bnh Hi bnh - Ngi bnh au v tr no? mc au? au c lin tc khng, c au m vng h sn phi khng? au c tng ln khi ho v c ng mnh khng? - C st khng? st thnh cn?, khi st c rt run?, (st cao 39 - 400C, cng c trng hp ch st nh). Ngi bnh mt mi, chn n, n khng thy ngon ming. C hay n gi c khng? T trc n nay b mc nhng bnh g? Gia nh ngi bnh c ai b bnh gan khng?
Khm v quan st - Ngi bnh gy st, nt mt lo u. Mi c kh, li trng v bn khng? i tiu nhiu hay t, mu sc nc tiu?
- Da c vng hay khng? - Gan to v au, giai on nng b bin chng s c cc biu hin nh trn dch, c trng, ph Quan st phn: phn biu hin ca ri lon tiu ho. 7.2. Lp k hoch chm sc - Lm gim s lo lng v bnh tt Lm gim au, ngh ngi. Theo di cc du hiu sinh tn v cc bin chng ca bnh. Thc hin y lnh. Thc hin hnh ng chm sc. Gio dc sc kho.
7.3. Thc hin k hoch chm sc Chm sc v tinh thn - iu dng lun n cn, ng vin ngi bnh gip h gim bt lo lng v bnh tt, yn tm iu tr.
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nhng trnh gy au n cho ngi bnh. Theo di cc du hiu sinh tn v cc bin chng ca bnh - o mch, nhit , nhp th, huyt p ngy 2 ln, trong trong trng hp cn thit ly theo ch nh ca thy thuc. Theo di phn: nt hoc ly nhy do b ri lon tiu ho Theo di ph: cn ngi bnh nh gi ph. Theo di st pht hin sm, x tr kp thi cc bin chng: + p xe v vo bng: au d di khp bng, tru tim mch, s thnh bng thy + V vo mng phi: gy trn dch mng phi, ngi bnh ho nhiu, ho khan hoc m ln m, kh th, tm ti. + Chy mu trong p xe: mch nhanh, nh, huyt p h, chn tay lnh, v m hi, au vng gan d di. Khi iu dng pht hin thy cc triu chng trn phi bo ngay cho bc s x tr kp thi. Thc hin y lnh - Thc hin y lnh thuc: Tt c cc y lnh thuc dng cho ngi bnh u phi c thc hin nghim tc v liu lng, thi gian dng thuc. Thc hin cc xt nghim: mu, nc tiu. a ngi bnh i siu m, X quang
cng
- Ph gip bc s thc hin th thut: Chun b phng tin, dng c, thuc men ph gip thy thuc chc ht m. Thc hin cc hnh ng chm sc - Ngi bnh mt mi nhiu, chn n do vy iu dng cn c nhng hnh ng chm sc tn tu nh nng h khi thay i t th - Cho ngi bnh n calo 2400 - 3000 calo/ngy. n hoa qu ti, thc n khng phi king khem, ng vin ngi bnh n nhiu, n thc n nh d tiu, n theo s thch ca h. - Cho ngi bnh ung nc y 1,5 lt - 2 lt/ngy, cho ung lm nhiu ln - Chm sc v sinh hng ngy: v sinh rng ming, da hng ngy, dng nc m khi tri lnh. Gio dc sc kho Hng dn ngi bnh v ngi nh cch phng bnh nh: n ung hp v sinh, trnh n gi c, rau sng. Ty giun nh k. Tuyt i khng c ung ru.
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php iu tr kp thi. - Thc hin ch thuc men theo s ch dn ca thy thuc. nh gi Ngi bnh b p xe gan c chm sc tt khi: Cc du hiu sinh tn n nh, ngi bnh ht st. Gim au vng h sn phi v dn dn ht au. n thy ngon ming, n m bo lng calo/ngy Khng ung ru v ngi bnh hiu c tc hi ca ru. Khng n gi c. Khng b xy ra cc bin chng trong qu trnh iu tr v chm sc. Ngi bnh yn tm iu tr v c kin thc v y hc phng bnh.
X GAN
MC TIU 1. Trnh by nguyn nhn, triu chng, tin lng ca x gan. 2. Trnh by c phng php iu tr x gan v cch chm sc bnh nhn b x gan 1. i cng - X gan l mt bnh hay gp Vit Nam cng nh trn th gii, chim hng u trong cc bnh v gan mt. 2. Nguyn nhn - Do vim gan siu vi, nht l vim gan siu vi B v mt s nhm khc. - X gan do vim gan mn tnh: vim gan t min. - Do mt ko di: + Nguyn pht: hi chng Hanot, hay cn gi l x gan mt tin pht. + Th pht: do si, giun chui, vim ng mt. - Do ru hay gp Chu u hn. - Do ng mu ko di: gp trong suy tim, vim tc tnh mch trn gan... - Do k sinh trng: sn l gan, sn mng. - Do nhim c ha cht: Aldomet, Paracetamol... - Do di truyn: x gan lch to nh trong hi chng Banti. - X gan do suy dinh dng. - X gan do ri lon chuyn ha.
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3. Triu chng 3.1. Triu chng lm sng 3.1.1. Giai on sm Triu chng lm sng rt ngho nn: - Ngi mt mi, chn n, kh tiu. - Ri lon tiu ha, chng hi bng, phn lc lng, lc to bn nhng lng l ch yu. - au nh vng h sn phi. - C th c gan to, mt chc, nhn. - C cc sao mch da mt c, ngc, bn tay son. - C th c lch to. - Chy mu cam, chy mu chn rng. * giai on ny chn on ch yu da vo cc xt nghim cn lm sng: xt nghim chc nng gan b ri lon, soi bng, sinh thit gan xt nghim m bnh hc. 3.1.2. Giai on mun (giai on mt b): Thng biu hin bng hai hi chng: 3.1.2.1. Hi chng suy chc nng gan - Sc khe gim st, n km, kh nng lm vic gim. - Da xm en, c th c du xut huyt di da di hnh thc mng xut huyt hay chm xut huyt. - C th c chy mu chn rng. - Hng ban m hay lng bn tay. - Gan c th to nhng thng teo nh. 3.1.2.2. Hi chng tng p lc tnh mch ca - Nn ra mu do v tnh mch trng thc qun hoc i cu ra mu ti do tr ni. - Lch ln - Tun hon bng h - Ph hai chi di - Bng bng, thng l do hi chng tng p lc tnh mch ca - Ngoi ra bnh nhn c th c st nhim khun, hoi t hay ung th ha. C th c vng da. 3.2. Cn lm sng - T Prothrombin gim - Cholesterol ester ha gim - NH3 mu tng - Siu m bng - Chp X quang tm gin tnh mch thc qun - Nu c hoi t t bo gan km theo th c men transminase tng
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4. Tin lng v bin chng 4.1. Tin lng: tin lng ph thuc vo - X gan to tt hn x gan teo. - Dai dng, iu tr li tiu t tc dng, ti pht nhanh th tin lng xu. - Vng da ko di l biu hin nng ca bnh. 4.2. Bin chng - Xut huyt tiu ha do gin tnh mch thc qun l tnh trng nng - Hn m gan: thng xy ra sau nhng yu t thun li nh: nhim khun, nhim c, xut huyt tiu ha hoc giai on cui ca x gan. - Nhim trng: bnh nhn d b nhim trng nh lao phi, vim phi, nhim trng ng tiu ha. Khi b nhim trng li lm cho bnh nng thm. - Ung th ha: t l cao t 70% - 90%, thng th gan s to, b sc, mt chc, b mt ln nhn, c th suy kit, cn lm thm xt nghim alpha- foetoprotein, dch mng bng thng l dch tit. 5. iu tr 5.1. Ch ngh ngi v n ung Giai on c trng: bnh nhn ngh ngi tuyt i ti gng. n m 100g/ngy. Glucid, lipid, hoa qu ti. Ch nn hn ch cht m khi c du hiu no gan, nn hn ch n m khi c du hiu phn m. Nu c du hiu c trng th n nht tuyt i. 5.2. Thuc 5.2.1. Nhm thuc lm ci thin chuyn ha t bo gan - Vitamine nhm B v C, acide folic... - Dng glucose bng ng ung hoc ng tim truyn. - Cc thuc lm tng chuyn ha mt: cc dng vin cao, nc sc artiso. - Glucocorticoid hay s dng trong vim gan siu vi hoc x gan do mt tin pht: prednisolon 20-25 mg/ ngy x 1-2 tun, sau duy tr 5-10 mg/ ngy. Khng nn dng prednisolon khi c bng, ph, vim lot ng tiu ha. - Testosteron tng cng ng ha m. - Truyn mu khi bnh nhn c t Prothrombine gim, xut huyt di da, xut huyt tiu ha v c th truyn plasma. 5.2.2. iu tr c trng - Ch nh chc ht dch khi bng qu cng to, mi ln chc ly 1- 3 lt, khng nn chc khi c xut huyt tiu ha, nhim trng nng, hn m gan. - Thuc li tiu: + Thuc li tiu chng o thi kali: nh Aldacton vin 25mg c th cho 150- 200mg/ 24 gi. Spironolacton 50mg/ 24gi c th cho 200- 300mg/ 24gi.
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+ Nu dng nhm thuc trn c trng gim t, c th chuyn sang dng li tiu mnh nhng o thi kali nh furosemide. - C th dng thuc gim transaminase nh: legalon, fortec... Nhn lm tng kh nng chuyn ha t bo gan khi phc li cc chc nng gan ca t bo gan lnh. 6. Chm sc bnh nhn x gan 6.1.Nhn nh ng trc ngi bnh x gan ngi iu dng cn nhn nh ngi bnh giai on x gan cn b hay giai on x gan mt b c k hoch chm sc thch hp. Hi bnh Giai on x gan cn b - C au tc h sn phi khng ? C nhng ri lon v tiu ho nh : chn n, s m, kh tiu ...... C tiu chy khng ? Ph hai chi di ? Hi k tin s c lin quan n bnh x gan ( trc y c b vim gan do vi rt hay
nghin ru khng ?) Quan st - Da mt c vng khng ? Bng c bng khng ? Hai chi di c ph khng ?
Giai on x gan mt b Cn quan st theo di hai hi chng sau - Hi chng tng p lc tnh mch ca: ngi bnh c y hi, bng chng, sau c c chng, xut hin tun hon bng h trn da, lch ln.. - Hi chng suy gan: biu hin suy nhc, chn n, chm tiu, s m, ph hai chi di, da vng, thiu mu, nt gin mch hnh sao ngc v lng, ngi bnh c chy mu cam v chy mu chn rng. 6.2. Lp k hoch chm sc - Nhng bin php chung i vi 2 giai on ca x gan. Chm sc i vi hi chng suy t bo gan. Chm sc ngi bnh ph v c trng. Chm sc khi c bin chng chy mu tiu ho. Theo di phng hn m gan. Gio dc sc kho
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6.3. Thc hin k hoch chm sc Nhng bin php chung - Ngi bnh phi c ngh ngi khi bnh ang tin trin, ng vin an i ngi bnh. Ch n m bo m, ng, vitamin v hn ch m. Hn ch mui v n nht khi c ph v c chng. Hn ch m khi x gan mt b. Tuyt i khng c ung ru.
Chm sc hi chng suy t bo gan - Cn ngi bnh hng tun. Pht hin nhng bin php chn n chm tiu c bin php nui dng ph hp. Theo di lng nc tiu 24 gi. V sinh mi ming khi c chy mu cam, chy mu chn rng.
Thc hin y lnh - Thc hin y lnh thuc v cc xt nghim chnh xc, kp thi. Chm sc hi chng ph v c chng - ngi bnh nm ngh tng i. - n nht tng i, hn ch m, n tng ng v m, khng nn n nhiu cht x v d gy v tnh mch. Theo di lng nc vo ra. Cn ngi bnh 2 ngy/ ln hoc tu theo tnh trng ngi bnh.
- o vng bng. - Khi c y lnh chc ht dch mng bng, iu dng chun b dng c y v ph gip bc s chc ht dch mng bng, ng thi quan st mu sc dch, o lng dch ht ra v theo di trong v sau khi chc. Chm sc bin chng xut huyt tiu ho - Cho ngi bnh nm ngh tuyt i ti gng, u thp, gi mng di vai, k chn cao Tm ngng cho ngi bnh n bng ng ming m cho ngi bnh Ph gip thy thuc t catheter theo di p lc tnh mch trung tm Truyn dch, truyn mu khn trng theo y lnh. t sonde d dy theo di s chy mu. Tht tho phn loi tr nhanh chng mu xung rut.
Theo di phng hn m gan - Theo di s thay i tnh tnh : ngi bnh c th ang vui ri li bun, th C nhng biu hin ri lon v tr nh Mt phng hng v thi gian v khng gian, mt kh nng tp trung t tng
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Bn tay run do ri lon trng lc c. Khi pht hin cc du hiu ny, ngi iu dng
phi bo ngay vi thy thuc c bin php x l kp thi Gio dc sc kho - Hng dn ngi bnh nhng kin thc c bn v bnh x gan h c ch n ung v ngh ngi hp l cng nh t chm sc v theo di bnh Ngh ngi hon ton khi bnh tin trin Trnh lao ng nng Tuyt i khng c ung ru, n gi c. Ch n nn hn ch m, tng ng, m v cc loi vitamin. Hn ch mui hoc n
nht khi c ph. - Khm bnh nh k, theo di bnh ti cc c s y t hoc n ngay c s y t khi pht hin bin chng. nh gi X gan l mt loi bnh khc ph bin. Biu hin bng 2 hi chng rt r rt, hi chng suy gan v hi chng tng p lc tnh mch ca. Do vic chm sc ngi bnh c coi l c hiu qu khi : - Cc triu chng ca bnh x gan gim hoc ht hn. - Ngi bnh khng ung ru, nu nghin th phi b c ru. Khng xy ra cc bin chng. Ngi bnh yn tm, thoi mi khi nm vin v c s hiu bit nht nh v bnh.
UNG TH GAN
MC TIU 1. Trnh by nguyn nhn, cc yu t thun li gy ung th gan. 2. Trnh by c triu chng v chn on ung th gan. 2. Nu c hng iu tr x gan v cch chm sc bnh nhn b x gan. 1. i cng - Ung th gan c th nguyn pht hoc th pht. Trong bi ny ch ni n ung th gan tin pht. - Ung th gan tin pht l mt trong nhng ung th ph bin nht nc ta cng nh nhiu nc trn th gii. y l mt loi ung th pht trin nhanh, rt kh chn on sm, tin lng rt nng.
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2. Bnh nguyn v cc yu t thun li - Bt k nguyn nhn g, bnh gan mn tnh u c th l tin cho pht trin ung th gan, c bit l x gan sau vim gan siu vi B v C. - Yu t vi trng: c bit nht l sau vim gan siu vi. - Cht c: ru, c t nm, cht dioxine... - Yu t ni tit: thng gp nam gii v nhng ngi iu tr bng thuc kch t nam. 3.Triu chng 3.1. Triu chng lm sng 3.1.1 Thi k khi pht Rt t c triu chng in hnh, do rt kh bit. - Mt mi - Km n, y bng, kh tiu - Cm gic au m h sn phi, gy st. - C th c st nh. - au khp xng nhng khng sng. * Cc triu chng trn thng ri rc, khng y v khng in hnh. 3.1.2. Thi k ton pht 3.1.2.1. Triu chng c nng Bnh nhn thng c cc triu chng sau y: - Km n, y bng, mt mi lm cho bnh nhn khng mun hot ng. - Ri lon tiu ha: i cu nhiu ln, phn nt hoc st, c nhy. - Gy st: trong mt thng c th gim 4-5 kg - au h sn phi: lc u au t nhng cng ngy cng au nhiu, giai on cui bnh nhn rt au. 3.1.2.2. Triu chng thc th Triu chng giai on ny ngy cng y hn. Ty theo ung th gan trn gan lnh hay trn x gan m triu chng thc th c khc nhau: * Ung th gan trn gan lnh: triu chng quan trng nht v gn nh duy nht l gan to vi cc c im sau: - Cng nh , to khng u, ln nhn, ch to gan phi hoc gan tri hoc b gan li ra mt khi u. - Gan ln nhanh. - au t nhin, tng ln khi n vo vng gan. - Nghe vng gan c th c ting thi tm thu. - Vng da, vng mt do khi u chn p ng mt. - Ph do suy tim.
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- Tun hon bng h vng tng ng vi khi u hoc trn ton b vng gan. - Cc triu chng ca di cn: trn dch mng phi, mng tim, hch di n... * Ung th gan trn gan x: Ngoi cc triu chng nh nu trn cn c thm cc triu chng sau: - Thay i da rt hay gp: da sm en, mi tm, lng bn tay , sao mch, gin mch. - C trng: nc vng chanh hoc c mu, phn ng Rivalta c th dng tnh - Lch to - Tun hon bng h 3.2. Cn lm sng - Sinh hc: cc xt nghim v chc nng gan thng b ri lon, kh phn bit x gan hoc ung th gan. + Phosphatase kim tng. + Alpha foetoprotein l cht ch im ung th (+) + Siu m: cho php pht hin 80-90% ung th gan. + Chp ct lp t trng: c nhy tng ng vi siu m + Chp cng hng t + Sinh thit gan 4. iu tr 4.1. Ngoi khoa - Ct gan: ch nh khi khi ung th nh < 5cm cn khu tr cha c di cn xa- gan khng x. - Tht ng mch gan, gy tc ng mch gan: phng php n gin nhanh gn nhng kt qu hn ch. - Ghp gan: rt phc tp v kh thc hin nhng l phng php t kt qu tt hin nay. 4.2. Ni khoa iu tr triu chng l ch yu - Chng au: dolargan, morphine hoc cc thuc ng. - Dinh dng: nu bnh nhn khng n c th phi truyn dch thay th. - Ha tr liu - Gy tc mch bng lipiodol. - Bm thuc chng ung th vo ng mch nui khi u. - Tim cn tuyt i vo khi u. - t nhit khi u bng sng cao tn (radio frequence ablation:RFA). 5. Chm sc 5.1. Nhn nh Hi bnh - Hi ngi bnh xem c cm gic nng tc vng h sn phi khng?
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C chn n, y bng khng ? (thng ngi bnh khng thch n tht hoc mt thc n
no , lun c cm gic m ch, kh chu trong bng) Quan st v thm khm - Ngi bnh c gy v mt mi khng ? * Thi k ton pht : Quan st th trng ngi bnh ( thng gy st nhiu v nhanh) o nhit ca ngi bnh : c th st dao ng v ko di
- Khm: gan to nhanh, rt cng, ln nhn * Thi k cui : Ngi iu dng cn quan st: - Du hiu c trng Tun hon bng h bng ? Ngi bnh au bng nhiu hay t ? Da v mt c vng khng ? Quan st mu sc ca phn v nc tiu
- Theo di st pht hin sm cc nguyn nhn dn n t vong nh : + Suy kit nng ton thn + Hn m gan + V ung th trong bng 5.2. Lp k hoch chm sc * Thi k u v thi k ton pht : - Ch ngh ngi - Ch v sinh m bo dinh dng Theo di mch, nhit , huyt p, nhp th Thc hin thuc theo y lnh
* Thi k cui : - Gim au - Ch ngh ngi, v sinh, m bo dinh dng Theo di mch, nhit, huyt p, nhp th Theo di du hiu mt Chm sc khi c c chng Pht hin sm v x tr khi c bin chng
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5.3.Thc hin k hoch chm sc Thi k u v thi k ton pht Ch ngh ngi Ngi bnh cn c ngh ngi, i li nh nhng. Trnh suy ngh lo lng. iu dng vin lun n cn, thng cm, ng vin ngi bnh gip h vi bt ni lo lng v bnh tt. Ch v sinh V sinh rng ming, ton thn v thay qun o cho ngi bnh hng ngy m bo dinh dng Ngi bnh b ung th gan thng chn n, n vo kh tiu, do vy iu dng cn hng dn gia nh ngi bnh cch ch bin thc n m bo c t nht 2000 calo/ ngy hoc cho ngi bnh n thc n ch bin sn. Thnh phn thc n cn hn ch m, tng m v ng (hn ch m khi gan mt b) hn ch mui nu c ph, cho n thc n nh d tiu, ng vin ngi bnh n nhiu, n theo s thch ph hp.Tuyt i khng c ung ru. Theo di Mch, nhit , huyt p, nhp th hng ngy, nu c du hiu bt thng phi bo ngay vi thy thuc. Thc hin y lnh Thc hin y lnh chnh xc, kp thi (dng cc thuc gim au t nh n nng ) Thi k cui Gim au Trong thi k ny ngi bnh rt au, nn vn gim au l quan trng nht. Ngi iu dng cn ng vin nng tinh thn cho ngi bnh, ng thi nhanh chng thc hin thuc gim au theo y lnh. Ch ngh ngi, v sinh, dinh dng Ch ngh ngi, v sinh, dinh dng vn c duy tr nh thi k ton pht. Nu ngi bnh khng n c phi nui dng bng ng tnh mch, ngi bnh n c th cho n theo mun ca h. - Theo di - Theo di mch, nhit , huyt p, nhp th 30 pht /ln, 1 gi/ln.. .hoc tu tnh trng ngi bnh. Theo di du hiu mt - Quan st mu sc ca nc tiu v o s lng nc tiu 24 gi. Mu sc ca phn (thng phn bc mu ) Vng da, vng mt.
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ngi bnh n km v gy st nhanh - Theo di ph v theo di lng nc tiu 24 gi ( thng i t di 500 ml/24 gi) Chun b ngi bnh, phng tin, thuc men ph gip bc s chc ht dch mng bng. o s lng v quan st mu sc dch (nc c trng thng c mu ) Pht hin sm v x tr khi c bin chng:
+ V ung th trong bng + Hn m gan. + Xut huyt tiu ho do v tnh mch thc qun + Suy kit dn dn n t vong. Gio dc sc khe - Hng dn ngi bnh v gia nh cch phng trnh bnh nh: Hn ch cc yu t gy bnh Khng ung ru Trnh tip xc vi ho cht, phng x, nu ngh nghip cn phi tip cn th phi c bin php bo h. Khi chm sc ngi bnh vim gan phi c bo h trnh ly nhim. Nhng ngi vim gan, x gan phi c theo di khm bnh nh k. Nhng ngi lnh mang HBsAg th 6 thng siu m 1/ln theo di s tin trin ca bnh. nh gi Bnh ung th gan hin nay y hc pht trin nhng vn cha c thuc c tr cu sng ngi bnh. Do trong qu trnh chm sc ngi iu dng cn c thi nh nhng, ng vin an i, chm sc tn tnh cng gip h ko di thm thi gian sng, o lng s chm sc da vo cc vn sau: - Ngi bnh c p dng cc bin php gim au mc ti a v kp thi - Ngi bnh lc quan, khng lo lng suy ngh v bnh tt. - p ng c nhu cu dinh dng cho ngi bnh. - Cc y lnh c thc hin sm, chnh xc. - Ngi bnh c theo di sm v x tr kp thi khi c cc bt thng xy ra.
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LOT D DY - T TRNG
MC TIU 1. Trnh by c nguyn nhn gy ra lot d dy - t trng. 2. Trnh by c cc triu chng v bin chng ca lot d dy - t trng. 3. Trnh by c nguyn tc iu tr bnh nhn b lot d dy - t trng. 1. i cng - Lot d dy- t trng l mt bnh ph bin nc ta cng nh cc nc trn th gii. - L mt bnh mn tnh, din bin c tnh cht chu k. - Bnh tin trin l do ri lon thn kinh th dch v ni tit ca qu trnh bi tit, vn ng v chc nng bo v nim mc d dy. - Nam mc bnh nhiu hn n t l chim khong 4/5 tng s bnh nhn khi nhp vin. - Tui thng hay gp 20- 40 tui, c bit c trng hp gp ngi gi >70 tui v tr em <1 tui. 2. Nguyn nhn Cho n nay cha tm ra mt nguyn nhn chung nht cho lot d dy - t trng nhng ngi ta thy c mt s yu t nguyn nhn tham d vo, i khi phi hp vi nhau. Cc yu t ny c s tham gia ca di truyn, yu t v thn kinh v mi trng. 2.1. Yu t v di truyn Tn sut cao mt s gia nh, lot ng thi xy ra hai anh em sinh i cng non nhiu hn khc non. 2.2. Tm l: Do qu cng thng v thn kinh, do stress. 2.3. Do ri lon nhp iu v tnh cht ca thc n. - n khng ng ba, n qu nhanh, thc n nhiu gia v v cht cay. - Ung ru, bia, ht thuc l... 2.4. Cc thuc khng vim steroid hoc non steroid. 2.5. Vi khun Helicobacter pylori (H.P) 2.6. Bnh l ca mt s c quan khc km theo lot d dy t trng nh: U ty, cng v thng thn, Basedow... 3. Triu chng 3.1. Triu chng lm sng 3.1.1. Triu chng c nng * au bng - V tr au: vng thng v.
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- Tnh cht au: nng rt, bt rt, co rt... - Tnh chu k: lin quan ti ba n. - Tnh nh k: bnh thng xut hin vo mt ma nht nh trong nm. - Hng lan: ra sau lng, lan bn sn tri. * Nn v bun nn * hi, chua 3.1.2. Khm thc th - n im thng v au. - Trong cn au c th thy co cng c bng vng thng v. 3.2. Cn lm sng - Chp X quang d dy - t trng c thuc cn quang thy hnh nh thuc ng li lot. - Ni soi d dy - t trng. - Xt nghim clotest H.P. - Ht dch v lc i nh gi tnh trng bi tit ca dch v, nh lng HCl t do hoc ton phn. 4. Bin chng - Xut huyt tiu ha: Nn ra mu, i cu phn en. - Thng lot: au bng d di, au nh dao m, bng cng nh g, mt vng c trc gan, X quang bng thng ng c lim hi di c honh. - K ha: Gy st, suy kit, cn au ko di. - Hp mn v: au lin tc, nn ra thc n, c nhng thc n ca ngy hm trc. 5. Nguyn tc iu tr v chm sc 5.1. Nguyn tc iu tr Phi iu tr ni khoa ng cch v y , nu khng c kt qu mi phu thut, khi phu thut th ct dy thn kinh ph v trc, nu khng th mi t vn ct d dy. Khi iu tr ni khoa cn phi tun th theo: + iu tr tn cng khi let ang tin trin. + iu tr duy tr sau khi iu tr tn cng. + Phi nh gi bng kt qu ni soi. 5.2. Cc thuc thng dng 5.2.1. Thuc tc ng ln v no: nh Diazepan, Prinperan... 5.2.2 Thuc c ch bi tit HCl - Thuc c ch ln dy thn kinh X: + Khng Cholinergic, atropine. + Khng c quan cm th M1 nh Gastrozepine... - Thuc khng H2: Nh Cimetidine, Ranitidine....
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- Thuc c ch bm Proton: nh Lanzoprazol, Omeprazol... - Prostaglandine: c hai tc dng; chng bi tit v bo v nim mc d dy.
5.2.3 Thuc khng acide: trung ha ion H+ ca HCl nh Maalox, Gelox cn phi ung nhiu
ln trong ngy.
Quan st Quan st tnh trng ca ngi bnh: da v nim mc, t th chng au, tnh trng tm thn, tnh cht ca cht nn v phn. Thm khm - Ly du hiu sinh tn. - Khm bng xc nh v tr v mc au. Xem xt cc kt qu cn lm sng. Thu thp thng tin - Qua h s bnh n, qua gia nh ngi bnh. 6.2.Lp k hoch chm sc - Gim lo lng. Ch ngh ngi.
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6.3.Thc hin k hoch chm sc Gim lo lng - Ngi bnh cn c ngh ngi, trnh suy ngh cng thng. - iu dng cn quan tm, ng vin an i ngi bnh yn tm iu tr, gip cho ngi bnh trnh cng thng v thn kinh, gim c cn au. Ch ngh ngi - C ch ngh ngi v lm vic ph hp. Trnh lm vic gng sc, lm vic cng thng, thc khuya Nu ngi bnh mt ng c th dng thuc ng. Khi au phi ngh ngi c th cht ln tinh thn.
Thc hin y lnh - Gim au cho ngi bnh: chm nng vng thng v khi au - Dng thuc iu tr vim lot d dy- t trng, thuc gim au, thuc an thn, Vitamin + Khi cho ngi bnh ung thuc bo v nim mc d dy, phi cho ung trc khi n. + Thuc chng bi tit dch v phi cho ung sau ba n. + Thuc dit khun khng sinh phi cho ung trc khi n. Thuc tim theo y lnh Thc hin cc xt nghim cn lm sng theo ch nh ca bc s.
Ch n ung Mc ch ch n ung trong bnh lot d dy t trng l trnh tng tit v tng vn ng trong ng tiu ho. - Trong t au nn cho n nhng thc n mm, nh, lng, khng nng qu v cng khng lnh qu, hn ch cht x si d tiu ho v d hp thu. Khng n thc n chua, cay, kch thch, thc n sinh hi ( hp) - Ba n cn ng gi. Nn n nh, tng t mt v nhai k, khng nn n qu nhiu v qu nhanh. King ru, c ph, ch c, thuc l. C th thc hin mt ch n c bit theo yu cu ca bc s trung ho acid d dy. Khuyn ngi bnh ung nhiu nc (chng acid tt).
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+ Tnh trng n ung. + Tnh trng s dng thuc. Pht hin cc bin chng Gio dc sc kho - Cung cp cho ngi bnh mt s kin thc c bn v bnh, gip h trnh c nhng yu t lm bnh nng thm. King cc cht kch thch nh : ru, c ph, ch m, ht tiu..... Nn n nhng thc n mm, d tiu ,n chm, nhai k. Khi dng thuc phi theo ch dn ca bc s. C ch ngh ngi, lm vic ph hp vi bnh. Thay i li sng hn ch bnh ti pht. phng cc bin chng c th xy ra.
4. nh gi Ngi bnh lot d dy t trng c chm sc tt khi: Ngi bnh c ngh ngi yn tnh, trnh suy ngh, lo lng. Cc triu chng ca bnh gim. Cc y lnh v thuc men, chm sc c thc hin y , chnh xc. Thc hin n ung theo s hng dn ca cn b y t. Ngi bnh c kin thc v bnh, bit theo di, pht hin sm cc bin chng.
UNG TH D DY
MC TIU 1. Trnh by c bnh sinh ca ung th d dy. 2. Trnh by c triu chng lm sng v cn lm sng ca ung th d dy. 3. Trnh by c cch iu tr ca ung th d dy. 4. Trnh by c cch chm sc bnh nhn b ung th d dy. 1. i cng L loi ung th thng gp trong cc loi ung th ca ng tiu ha. nam gii n ng hng th t sau ung th ph qun, i trng v ung th da. 2. Bnh nguyn - Yu t di truyn c gi ra da trn t l mc bnh cao nhng ngi c nhm mu A, cng nh thy trong gia nh v anh em sinh i. Nhng kh gii thch v n tng tc vi cc yu t mi trng.
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- Dng nh ung th lan ta, yu t di truyn quan trng hn loi ung th loi rut non. - Yu t mi trng cng ng vi tr rt quan trng . - Nc ung c nhiu Nitrate cng d gy ung th hn. 3. Triu chng 3.1. Triu chng lm sng Cc du hiu lm sng hai giai on sm v tin trin th hin khc nhau. Nu bnh nhn n sm s cha c biu hin r rt. Nu bnh nhn n mun, cc du hiu rt in hnh. Do vy cn ch nhng du hiu m bnh nhn phi n khm. 3.1.1 Giai on u - au tc trn rn: au nh khng c tnh cht chu k, khng lin quan ti ba n, i khi au thy m ch. - Chn n - Gy st. - Bun nn, , n vo c cm gic au nhiu hn. 3.1.2 Giai on tin trin Khi tn thng pht trin thnh khi u, nhng lot lan rng hay nhng tn thng ang xm nhim cng trn mt vng hay ton b d dy th cc biu hin lm sng hon ton c th xc nh c mt cch d dng. Tuy nhin ty theo tng mc tin trin m cc du hiu s th hin nh sau: 3.1.2.1. Triu chng c nng - au tc trn rn, ko di, ngy cng tng, au khng c tng cn d di, nhng au khng c tnh cht chu k, au sut ngy, au tng ln khi n. - Bun nn hoc nn: do cm gic y bng, n khng tiu nn c du hiu bun nn hoc nn e. - Chn n y bng, kh tiu l du hiu ngy cng in hnh. Bnh nhn hon ton khng thm n, i khi cn s n. 3.1.2.2. Du hiu ton thn Ty theo giai on tin trin m c nhng du hiu sau y: - Gy st: cm gic gy st nhiu trong mt thi gian ngn. - Thiu mu - Vng da, mt mi, km n, n khng tiu dn ti suy kit. 3.1.2.3. Du hiu thc th - U bng: th hin di dng mt khi u c ranh gii rt r rng hay nh mt mng cng khng c ranh gii. - Mng cng: thng tn thng dng thm nhim cng hoc khi u thm nhim sang cc tng xung quanh, thng khng di ng, n au tc hoc khng au.
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- Nhng trng hp n mun s c nhng triu chng in hnh nh: ton thn suy kit nng, thiu mu nng, ph, gan to.. 3.2. Cn lm sng - X quang - Ni soi - Siu m - Chp ct lp - Xt nghim t bo hc - Xt nghim sinh ha 4. iu tr: 4.1. Phu thut iu tr: l ct b ton b ung th c th thy c, tuy nhin cho thy rng ch thc hin c trong khong 1/2 bnh nhn khi m. 4.2. iu tr x tr liu v ha tr liu:Ch l b sung can thip phu thut iu tr chm lm ti pht t hch hoc di cn khng bit, trong ung th khng m c. 5. Chm sc 5.1.Nhn nh Hi bnh - au vng no? (thng au vng thng v), lc u au t, m , sau au tng dn. Chn n, y bng, chm tiu, n vo au tng ln? C nn khng? Nut c nghn khng? Hi v tin s: c b vim, lot d dy t trng khng? Tin s gia nh?
Quan st - Ngi bnh gy, mt mi, st cn? - Da v nim mc? - T th chng au, tnh trng tm thn? Tnh cht ca cht nn? 5.2. Lp k hoch chm sc - Gim lo lng.. Gim au. Gim nn. Ch dinh dng. Gio dc sc kho. Chm sc ngi bnh trc m v sau m
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5.3.Thc hin chm sc Chm sc v tinh thn - Thng xuyn thm hi, ng vin, an i ngi bnh an tm iu tr. Quan tm n din bin tm l ngi bnh pht hin nhng bt thng. Gii thch nhng thc mc ca ngi bnh h khng lo lng.
Gim au - Gim au cho ngi bnh bng cch xoa nn nh nhng, chm nng. - Thc hin y lnh thuc gim au theo y lnh, giai on cui cc thuc khc khng kt qu mi dng morphin hoc dolargan Gim nn - Thc hin thuc gim nn theo y lnh. Ch n - Thc n lng hoc thc n nghin tht nt nh: sa, cho lc ly nc, sp nghin k. Gio dc sc kho cho ngi bnh v ngi nh - ng vin ngi bnh ng bi quan, gii thch cho h hiu khng phi ung th th v phng cu cha. Phu thut l bin php iu tr tch cc v c hiu qu, sau m ngi bnh s n ung c v s ln cn ly li sc. - ng vin ngi bnh chp nhn phu thut. M cng sm cng tt.
CHY MU TIU HA MC TIU 1.Trnh by c nguyn nhn, triu chng ca chy mu tiu ha. 2. nh gi c mc chy mu tiu ha. 3. Trnh by c phng php iu tr chy mu tiu ha. CHY MU TIU HA CAO 1. i cng Chy mu tiu ha cao l chy mu tiu ha trn gc Treitz khng k chy mu t rng li. Chy mu tiu ha cao thng biu hin hoc l di hnh thc nn ra mu hoc i cu ra mu hoc c hai. Bt lun nhiu hay t, chy mu c th t cM hoc ngc li c th nng thm v dn n t vong.
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2. Nguyn nhn 2.1. T thc qun - Chy mu t tnh mch trng thc qun: gp trong x gan, trong tng p tnh mch ca tng phn, trong gin tnh mch ca bm sinh. - K thc qun: gy vim lot hoi t gy chy mu t cc mch mu tn sinh trong u. - Hi chng Mallory - Weiss: thng xy ra nhng ngi ung ru, thot v honh, tng p ca. tng p lc trong bng, trong nn v tro ngc thc qun v d dy. Chy mu y l do cc vt nt, lot t ch ni d dy thc qun c di ngn, nng su rt thay i. - Vim lot thc qun cp: do nhim trng hay do cc cht lm bng nh acide, base mnh. - Polype thc qun 2.2. T d dy t trng: thng gp nht - Lot d dy t trng - K d dy - Vim d dy cp - Tnh mch trng d dy trong tng p ca - Polype d dy t trng - Thot v honh 2.3. Chy mu t mt v ty - Chy mu ng mt: ch yu l do si ng mt hoc do giun chui ng mt. - Chy mu t ty: do cc nang ty lot vo mch mu. 2.4. Chy mu do cc bnh v mu - St xut huyt: do gim tiu cu v tn thng thnh mch - Xut huyt gim tiu cu - Leucmie: do gim tiu cu v gia tng h thng khng ng - Suy ty: do gim tiu cu - Suy gan nng 3. Triu chng lm sng 3.1. C nng - Tin triu: + Cm gic lm ging, kh chu cao co vng thng v v bun nn. + au vng thng v thng gp trong vim lot d dy t trng. + Cm thy hoa mt chng mt hoc ngt xu nht l chy mu cp v nng. + au bng qun v mun di cu. - Nn ra mu: mu thng ln vi thc n v dch v, s lng v mu sc rt thay i ty theo s lng mu chy, tnh cht chy mu v thi gian lu li trong d dy. + Nu chy mu t v nn ngay, thng c mu hng.
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+ Chy mu t v nn chm thng c mu en v long. + Nu chy mu nhiu v cp th thng nn ra ngay, do c mu ton ca mu. + Nu chy mu t tnh mch trng thc qun th c ra mu ti c th c cc mu ng. - i cu ra mu: thng trong chy mu cao nht l t d dy tr ln v s lng nhiu v u c nn sau i cu ra mu. Phn thng c mu en, nu, phn nt bng, c mi rt thi. 3.2 Thc th - Mch nhanh l triu chng nhy v thng t l vi lng mu mt. Nu chy mu cp nng nht l khi c chong th mch nhanh nh, nhiu khi khng bt c. - Huyt p h: nht l huyt p thp v kp l mt triu chng phn nh xut huyt nng. - Mu sc da: ch xut hin khi chy mu nng, da nht nht. - V mi hi v chn tay lnh cng l mt triu chng mt mu cp nng do co mch ngoi bin v ri lon vn mch. - Du hiu thiu mu no: thng chm tnh trng ngt hoc m. - Lng nc tiu: kh theo di v vy cn phi t sonde tiu theo di v cng phn nh gin tip s ti mu qua thn nn ch xy ra khi mt mu nng. 4. Cn lm sng - Hng cu v HCt: thng phn nh trung thc lng mu mt nhng c iu bt tin l cn phi c thi gian 3-4 gi sau mi phn nh trung thc lng mu mt. - Hb cng c ngha tong t. - Hng cu li tng nhng khng nhy. - Ngoi ra cn c nhiu s thay i cn lm sng khc ty nguyn nhn gy chy mu. 5. Chn on mc xut huyt tiu ha Du hiu S lng mt Mch Huyt p Hng cu Hct Hb Nh mu < 100ml Va Khong 500ml Nng > 1000ml > 120 l/pht Thp kp 80mmHg < 2 triu/ mm3 < 20% < 6g/l <
Tng nh khong Khong 100 l/pht 10 l/pht Cha hoc gim Khong 90- 100mmHg 10mmHg > 3 triu/mm3 > 30% > 9g/l Khong 3 triu/ mm3 < 30% 6g/l <Hb <9g/l
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6. iu tr 6.1. Nguyn tc - Phc hi th tch mu v hi sc tch cc - Cm mu - X tr nguyn nhn trnh xut huyt ti pht 6.2. iu tr thc th 6.2.1 i vi xut huyt tiu ha mc nh - Ngh ngi trn ging n nh. - Theo di lm sng v huyt hc hng ngy. - Tin hnh cc bin php chn on nguyn nhn. 6.2.2 i vi xut huyt mc va v nng - Nm u thp bt ng - t sonde d dy theo di tnh trng chy mu - Xt nghim huyt hc - Truyn dch v truyn mu: truyn mu vn tt nht, nu cha c mu th thay bng dung dch huyt tng, dung dch Ringer lactate, dung dch NaCl 0,9% khi lng dung dch ph thuc vo khi lng mu mt cng nh tnh trng mch, huyt p, cc xt nghim ca bnh nhn. - Ni soi d dy- t trng nu c iu kin th cm mu qua ni soi. - Nu xut huyt do lot d dy t trng th iu tr theo hng lot ngay. - Nu xut huyt do v tnh mch trng thc qun th iu tr ni khoa bng cch t onde Blakemore vo thc qun cm mu, ht dch d dy lin tc. 6.2.3 Ch n: Trong nhng ngy u cn chy mu nn cho bnh nhn n lng cho n nhiu ba, khng bnh nhn i, khi chy mu n nn cho bnh nhn n c dn tr li. 6.2.4 Ch nh iu tr ngoi khoa Mt s trng hp cn can thip phu thut nh chy mu lot pht thnh tia nhn c qua ni soi hay chy mu ti pht nhiu ln, do ung th hay khi u lnh tnh. CHY MU TIU HA THP 1. Nguyn nhn 1.1. Chy mu t rut non - Vim rut xut huyt - Thng hn - Vim rut xut huyt hoi t
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- Bnh Crohn: thng gp tn thng vng hi manh trng vi au bng i cu phn lng tng t. Bin chng chy mu thng hay gp giai on 2- 3 ca bnh. - Lng rut 1.2. Chy mu t i trng - L trc trng - L amip - K i trng - Vim lot i trng chy mu 1.3. Tr ni 2. Triu chng lm sng - a ra mu ti, mu cc ln theo phn hoc ra theo phn, c khi chy thnh tia khi i tin thng gp trong cc bnh tr. - a ra mu ti ln cht nhy theo phn hoc ln m. - Tnh trng ton thn ph thuc vo khi lng mu mt nhiu hay t. - Chy mu tiu ha phn di thng chy t, mn tnh, him khi chy mu o t a n tnh trng mt mu cp rt nng. 3. Chm sc 3.1. Nhn nh Hi bnh ng trc ngi bnh xut huyt tiu ho ngi iu dng cn hi : Xut huyt t bao gi ? Nn ra mu hay i cu ra mu ? Mu en hay mu ti ? S lng nn v i cu ra mu ? Trc khi nn ra mu c ung thuc g khng ? C au bng khi nn hoc i tin khng ? C st khng ?
Quan st - Trng thi tinh thn ca ngi bnh. Tnh trng da v nim mc. Tnh cht v s lng mu mt cng nh cc cht km theo. Th trng chung ca ngi bnh.
Thm khm v thu thp thng tin - Ly du hiu sinh tn, c bit ch mch v huyt p. Nu c bt thng phi bo ngay cho bc s bit c bin php x l kp thi. o s lng nc tiu trong ngy.
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o lng mu mt qua cc ng khc nhau. Xem xt cc kt qu xt nghim (nu c). Xem h s bnh n v cc giy t khc c lin quan n bnh.
3.2. Lp k hoch chm sc - Chm sc c bn Thc hin cc y lnh Theo di Gio dc sc kho
3.3. Thc hin k hoch chm sc c im ca bnh xut huyt tiu ho l mt bnh cp tnh v l mt cp cu ni khoa, cn c xc nh sm, theo di v x l kp thi trnh t vong cho ngi bnh. i vi ngi bnh chy mu ng tiu ho mc nh - Trn an ngi bnh, ng vin gim bt lo lng. - ngi bnh nm u thp khng gi, bung bnh yn tnh. Theo di st mch, huyt p, nhp th v cc du hiu ton thn trong vng 48 gi u, khng c g bt thng xy ra chng t ngi bnh mc nh v cm chy mu. Ngi bnh b mt mu va v nng - Vic u tin cn chm sc tinh thn l trn an ngi bnh h yn tm khng hong s. - ngi bnh nm bt ng ti ging, u thp nghing an ton, t khay ht u cnh ging phng khi b nn. - Thc hin cc y lnh: + iu dng khn trng t ngay ng truyn tnh mch khi mt khi lng mu nhiu. Khi ton trng qu nng cn phi thng bo ngay cho bc s bit ng thi nhanh chng chun bi dng c ph bc s t ng thng tnh mch trung tm b nhanh khi lng tun hon (dch hoc mu), phng chy mu t, tt huyt p, tru mch. + Thc hin y lnh thuc: cm mu, khng sinh, nng huyt p + Thc hin cc xt nghim: nhm mu, cng thc mu.. - Theo di: + Vic theo di ngi bnh l rt quan trng, gp phn nh gi mc chy mu hay cm mu. + Nu ngi bnh truyn mu m khng duy tr c huyt p, chy mu ko di qu 24 gi th cn chuyn ngay n khoa ngoi can thip cm mu sm. + Theo di mch, huyt p, nhp th, nhit 15 pht/ln, 30 pht/ln, hoc 1gi /ln, tu thuc vo tnh trng ngi bnh (ch tnh trng mch v huyt p) + Theo di cht nn v phn: s lng, tnh cht, mu sc.
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+ Theo di nc tiu pht hin triu chng thiu niu hay v niu + Theo di tnh trng ton thn pht hin tnh trng mt mu nhiu do nn v i cu ra mu (da nim mc nht nht, mch nhanh, huyt p tt, chng mt.) + Theo di lng nc vo ra. + Cho ngi bnh nhn n khi ang chy mu. Khi ngng chy mu: cho n thc n ngui v lng nh cho, sa, spch n tng protid, d tiu, trnh nhng thc n c cht kch thch (nh: cay, chua, ht tiu ) - V sinh: hng ngy v sinh rng ming v da trnh cc nhim khun, vi tri ging v cc vt dng khc phi lun c sch s. Gio dc sc kho - Gii thch cho ngi bnh v gia dnh bit v bnh c thi iu tr v phng bnh tt nhm trnh ti pht, c th : Phng phi thong mt, sch s Gi m v ma ng Ch n ung v ngh ngi iu Khng nn ung ru, c ph, thuc l. S dng cc thuc khng vim, gim au phi theo hng dn ca thy thuc iu tr tt cc bnh d dy t trng cng nh cc bnh v i trng nu c
- Khi ra vin hng dn ngi bnh cch pht hin sm tnh trng xut huyt tiu ho v khuyn iu tr sm. nh gi - Ngi bnh b chy mu ng tiu ho c chm sc tt khi: - Tnh trng chy mu gim hoc mt. Cc du hiu sng n nh. Lng nc tiu tng ln. Ngi bnh c n ung theo ch hp l. Ngi bnh c ngh ngi yn tnh, an tm iu tr v c kin thc v bnh.
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Nguyn nhn thng gp l do si thn, si niu qun di chuyn gy au. i khi do lao thn hoc ung th thn. 2. Triu chng ton thn 2.1. Ph c tnh ca ph do thn l ph mt ri n chn, cui cng l ph ton thn. Ph trng, mm, n lm. Mun theo di ph phi cn bnh nhn hng ngy. 2.2. Tng huyt p Bnh thn v tng huyt p c mi lin h khng kht vi nhau. Tng huyt p l mt trong nhng triu chng ca suy thn mn v tnh trng suy thn mn lm cho vic iu tr tng huyt p rt kh khn. 2.3. Thiu mu Trong suy thn thng c thiu mu, bnh nhn da xanh, s lng hng cu v Hb gim.
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3. Triu chng thc th Khm lm sng tit niu tin hnh theo trnh t sau: Thn Niu qun Bng quang Niu o Trc trng ( m o hoc tuyn tin lit). 3.1. Khm thn 3.1.1. Nhn Bnh nhn ngi hoc nm nga. Nhn vng h tht lng xem c sng khng, c thy khi u ni ln khng. Nhn vng h v trn xng mu pht hin cu bng quang. 3.1.2. S L phng php quan trng nht khm thn to. C hai t th khm:
3.1.2.1. Ngi bnh nm nga: chn chng, i gp vo bng, th u. Thy thuc ngi bn phi hoc tri ty theo khm thn phi hoc tri. S bng khi ngi bnh th ra v khi cc c bng mm, d s. Dng hai tay, mt tay lun xung pha di vng h tht lng, mt tay t trn bng pha i din, hai tay p dn st vo nhau. Du chm thn: Nu thn to, khi hai bn tay thy thuc p dn st vo nhau s c cm gic chc chc bn tay. Du bp bnh thn: Tay trn ca thy thuc yn, tay di dng u cc ngn tay n v ht mnh ln ri lm ngc li. Nu thn to, bn tay gi nguyn s c cm gic nh mt cc chm vo ri mt i. 3.1.2.2. Ngi bnh nm nghing: mt chn dui, mt chn co. Mun khm thn bn no th nm nghing bn i din, thy thuc ngi pha sau lng. Mt tay t h tht lng, mt tay t bng. Khi ngi bnh ht vo su, thn c y xung v ta s thy thn nu thn to. 3.1.3. G thn: Trong trng hp thn to, g thy c. G xc nh ranh gii vng c ca thn v phn bit vi gan to hoc lch to. 3.1.4. Tm cc im au: Bnh thng thn khng au. Trong trng hp bnh l, n vo cc im sau y bnh nhn s au: ( sau lng) - im sn sng: Ti gc xng sn th 12 v ct sng.
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3.2. Khm niu qun: Bnh thng cc im niu qun khng au. Trong cc trng hp bnh l, tm cc im au sau: - im niu qun trn: Ch gp nhau gia ng ngang qua rn v b ngoi c thng bng. - im niu qun gia: Ch gp nhau gia ng ngang ni hai gai chu trc trn vi b ngoi c thng bng. - im niu qun di: Thm trc trng hoc m o v tr 10 gi v 2 gi xc nh im au niu qun di. 3.3. Khm bng quang - Bnh thng: Khng c cu bng quang nn khng khm thy bng quang. - Bnh l: Khi nc tiu bng quang s nhn thy h v, trn xng mu c khi u cng trn, khng di ng. Nu thng tiu ly ra nhiu nc tiu, khi u s xp ngay. Nu c si to bng quang, kt hp vi thm trc trng, c th s thy c. 3.4. Thm trc trng: pht hin im niu qun di au v khm tuyn tin lit nam gii. Bnh thng tuyn tin lit l mt khi nh, khng s thy hoc ch hi ni ln, mm, c hai thy, gia c mt rnh. Tuyn nm vng c bng quang, m ly niu o mng, ngay di khp v. ngi gi, tuyn ny b x nn c th hi cng v to hn mt cht so vi ngi tr. Trng hp bnh l tuyn to ln gp trong u x, ung th hoc vim tuyn tin lit. 3.5. Khm niu o: Nng qui u ln, ly tay nn t pha trong ra, bnh thng khng thy g chy ra c. ph n, vch hai mi ln v b, s thy l niu o nm trn, di m vt. nam ln n c th thy cc tn thng: vim ty l niu o, lot ming so hoc c m chy ra.
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SUY THN MN
MC TIU 1. Trnh by c nh ngha ca suy thn mn. 2. Nu c cc nguyn nhn thng gp, triu chng ca suy thn mn. 3. Trnh by c phn suy thn mn v thi x tr cho tng . 4. Trnh by c 2 bin php c bn trong x tr suy thn mn. 5. Nu cch chm sc bnh nhn suy thn mn. 1. nh ngha Suy thn mn l hu qu ca cc bnh mn tnh ca thn gy gim st t t s lng nephron chc nng lm gim dn mc lc cu thn. Khi mc lc cu thn gim xung di 50% (60m /pht) so vi mc bnh thng (120ml/pht) th c coi l c suy thn mn. Qu trnh ny c th ko di t nhiu thng n nhiu nm. 2. Nguyn nhn 2.1. Bnh vim cu thn mn: Thng gp nht ( 40%). - Vim cu thn cp - Vim cu thn bnh nhn Lupus ban h thng, i ng - Hi chng thn h 2.2. Bnh vim thn b thn mn: Chim t l khong 30%. 2.3. Bnh vim thn k: Thng do dng thuc gim au ko di nh Phenylbutazon, tng Canxi mu 2.4. Bnh mch thn - X mch thn - Huyt khi mch thn - Tc tnh mch thn 2.5. Bnh thn bm sinh - Thn a nang - Lon sn thn 3. Triu chng lm sng 3.1. Ph: Thng c ph giai on cui km tng huyt p, suy tim. 3.2. Thiu mu: Thng gp. Suy thn cng nng, thiu mu cng tng v kh hi phc 3.3. Tng huyt p: Gp trong 80% trng hp suy thn mn. Tng huyt p nng v ko di lm chc nng thn suy sp nhanh chng gy t vong nhanh. 3.4. Suy tim: Do tng huyt p trong giai on cui ca suy thn mn.
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3.5. Vim mng ngoi tim: Thng nghe c ting c mng ngoi tim, y l mt triu chng tin lng nng ca suy thn mn, bo hiu t vong gn. 3.6. Nn, a chy: Thng gp suy thn III tr ln. C khi km xut huyt tiu ha. 3.7. Xut huyt: Chy mu mi, chy mu chn rng, chy mu di da. Xut huyt tiu ha nu c th rt nng, ur mu s tng ln nhanh. 3.8. Nga: L mt biu hin ngoi da thng gp do lng ng canxi trong da. 3.9. Chut rt: Thng xut hin ban m, c th do gim Natri v Canxi mu. 3.10. Vim thn kinh ngoi vi: Bnh nhn c cm gic rt bng, kin b chn. 3.11. Hn m: Hn m do ur mu cao l biu hin cui cng ca suy thn mn. Bnh nhn c th co git, ri lon tm thn giai on tin hn m. 4. Cn lm sng - Ur, Creatinin mu tng. - in gii: Natri mu gim, Kali mu bnh thng hoc gim. Khi kali mu tng l biu hin ca t cp c km thiu niu hoc v niu. - Canxi mu gim, toan mu d tr kim gim. - Protein niu: suy thn mn III IV bao gi cng c nhng khng nhiu. Thng khong 1 3 gam / 24h. - C hng cu, bch cu, tr niu trong nc tiu. - Th tch nc tiu: C khi tiu 2 3 lt / ngy, nht l do vim thn b thn. i nhiu v m l mt trong nhng triu chng gi suy thn mn. 5. Phn suy thn mn Gi tr chun lm c s cho phn loi l mc lc cu thn, gi tr c on l creatinine mu. Mc suy thn Thn bnh thng I II IIIa IIIb IV Mc lc cu thn Creatinin mu ( ml / pht) ( mol / lt) 120 70 110 60 41 40 21 20 11 10 05 <5 < 130 130 299 300 499 500 900 > 900 Ch nh iu tr
6. Chn on 6.1. Chn on xc nh - C tin s ph do bnh thn, nhim khun tit niu, si tit niu.
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- Ph + tng huyt p + thiu mu. - Ur, creatinin mu tng. - Protein niu (+). 6.2. Chn on giai on (PHN ): Da theo bng phn loi trn. 6.3. Cc yu t lm bnh nng thm - Tng huyt p - Nhim khun - Xut huyt tiu ha - Dng thuc c cho thn - n qu nhiu protid 7. iu tr 7.1. Chng cc yu t lm bnh nng thm - iu tr tng huyt p. - Chng nhim khun. - iu chnh nc, in gii. 7.2. Trnh nhng sai st thng mc phi - Dng li tiu khng ng: Lasix gy mt nc khi dng liu cao ko di, Hypothiazide gy gim mc lc cu thn. - n nht qu mc v ko di khng cn thit, gy gim Natri mu. - Dng thuc c cho thn: Streptomycin, Gentamicin. 7.3. Hai bin php c bn trong iu tr suy thn mn l: iu tr bo tn. iu tr thay th thn suy: chy thn nhn to, ghp thn. 7.3.1. iu tr bo tn 7.3.1.1. Khng ch tng huyt p - n nht. - Li tiu: Lasix vin 40mg; ng 20mg. Liu trung bnh 80 120 mg/24h. - Aldomet, Dopegyt thuc h huyt p c tc dng trung ng, khng nh hng n chc nng thn vin 250mg 2 4. - Nu huyt p vn cao th kt hp thm thuc c ch Canxi hoc cc thuc c ch men chuyn nh: + Nifedipin chm ( Adalat retard) vin 20mg 1 2 vin / 24h. + Captopril vin 25mg 1 2 vin / 24h. Trong iu tr tng huyt p bnh nhn suy thn cn ch : - phng mt kali do dng Lasix ko di.
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- phng tt huyt p th ng do Aldomet hoc tt huyt p qu mc khi dng Adalat. - Cn cho thuc duy tr khng huyt p tng tr li (gim liu hoc cho thuc cch nht. 7.3.1.2. Ch n t protid: Ch n cho bnh nhn suy thn phi m bo cc nguyn tc sau: - Hn ch m. - Giu nng lng. - vitamin. - m bo cn bng nc, mui khong. - Ch bin hp khu v. 7.3.1.3. Chng nhim khun v gii quyt cc hoi t, xut huyt: S dng khng sinh trong suy thn mn cn ch dng cc khng sinh t c cho thn nh: ampicillin, amoxicillin, erythromycin 7.3.1.4. Chng thiu mu do suy thn mn - B st, acid folic, vitamin B12: Tothema, siderfol - Tim Erythropoietin (Eprex, Epogen) trong suy thn III, IV. Liu trung bnh 2000UI 2 3 ln / tun tim di da hoc tnh mch. Khi Hb ln n 120g / lt th gim liu duy tr khong 1000UI 2 ln / tun. 7.3.2. iu tr thay th thn suy Ch nh cho suy thn mn IIIb v IV, bao gm: - Lc mu bng thn nhn to. - Ghp thn. 8. Chm sc Mc tiu ca chm sc l gip bnh nhn duy tr chc nng thn cng lu cng tt, hn ch cc yu t lm bnh nng thm v hn ch bin chng. 8.1. Chn on chm sc - Ri lon nc, in gii - Ri lon dinh dng do chn n, ri lon d dy rut, n king - Nhng thiu ht v kin thc bnh suy thn mn - Cc thay i tm l do mc bnh nng 8.2. Thc hin chm sc 8.2.1. Duy tr cn bng nc in gii nh gi ri lon ny bng cch: - Cn bnh nhn hng ngy - Xt nghim in gii - nh gi lng dch vo ra hng ngy bnh nhn qua thc n, nc ung, truyn dch 8.2.2. Duy tr dinh dng
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nh gi ri lon dinh dng bng cch: - Cn nng bnh nhn hng ngy - nh lng calo trong ba n hng ngy ca bnh nhn - Pht hin tnh trng thiu protein: gim protein mu, vt thng lu lnh - Pht hin nhng du hiu lm nng ri lon dinh dng nh: chn n, nn, ri lon tiu ha - Gii thch cho bnh nhn v ngi nh hiu ti sao cn p dng ch n hn ch protein, hn ch mui, Kali v nc, mi quan h ca ch n king ny vi chc nng thn v hi chng tng ur mu. Cung cp nhng thc n cn hn ch cho bnh nhn. 8.2.3. Tng thm s hiu bit ca bnh nhn v bnh v ch iu tr Cung cp nhng thng tin ti thiu v suy thn mn: th no l suy thn? Nguyn nhn suy thn l g? Ti sao phi iu tr thay th cho chc nng thn?... 8.2.4. Ci thin trng thi tm l cho bnh nhn bng cch quan tm chm sc, ng vin, chia s ni au ca bnh nhn. Khuyn khch v nui dng nhng hy vng cho bnh nhn h c th dng cm chp nhn mt cuc sng tuy b ph thuc nhng cha phi l ht mi hy vng.
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1. Nguyn nhn 1.1. ph n - Hu ht l do nhim khun ngc dng t niu o. S nhim bn phn l ngoi ca niu o, cc vim nhim m o gy vim bng quang theo c ch ngc dng. - Do th thut khng trit v khun. 1.2. nam gii - Phn ln th pht sau vim tin lit tuyn, vim mo tinh hon. - Vim niu o bng quang do lu cu. - Do th thut khng trit v khun. 2. Triu chng 2.1. Triu chng lm sng - Tiu but. - Tiu rt. - Cm gic bng rt vng bng quang. - C th i ra mu vi git cui bi nc tiu. 2.2. Triu chng nc tiu - Nc tiu c th c do c m, c th hng do c mu. - Xt nghim: c nhiu vi khun trong nc tiu nhiu trong nc tiu. 3. iu tr 3.1. Loi b cc yu t thun li gy vim bng quang - Hng ngy ung nc m bo lng nc tiu khong 1,5 2 lt / ngy. - V sinh sinh dc, tit niu hng ngy. - Hn ch s dng cc th thut, t bit thng tiu, soi bng quang phi m bo tuyt i v trng. 3.2. Khng sinh - Trc khi iu tr, cn ly mu nc tiu xt nghim vi khun ( nhum soi, cy khng sinh ) iu tr thch hp. - Khi cha c kt qu khng sinh , c th cho: * Nibiol 100mg 2 vin / ngy / 7 ngy ung sau ba n. 2 vin / ngy / 7 ngy. lactam nhm A (Amoxicillin), * Ofloxacin 200mg 100.000 / 1 ml. C hng cu v bch cu
nhm Aminosides (Gentamicin, Amikacin,), nhm Sulfamides chm (cotrimoxazol) - Liu khng sinh trong ngy nn cho bnh nhn ung v m trc khi ng khng sinh c lu gi lu bng quang tng cng tc dng trn vi khun.
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- Sau liu trnh khng sinh, nn xt nghim li nc tiu xem ht vi khun cha. 4. Chm sc bnh nhn vim bng quang 4.1. nh gi chm sc - Hi bnh nhn c: i rt, but, cm gic nng rt khi tiu, thi quen v v sinh thn th, v sinh ph n, sinh hot tnh dc v mi lin h gia cc yu t vi nguyn nhn gy bnh. - Quan st nc tiu bnh nhn nh gi v mu sc, s lng, trong c, - Thc hin cc xt nghim nc tiu theo y lnh thy thuc. - Hi bnh nhn kin thc v bnh vim bng quang, kin thc v iu tr v phng bnh. 4.2. Chn on chm sc - Nhng bt thng ca bnh nhn trong khi tiu do vim bng quang. - S thiu kin thc ca bnh nhn v bnh vim bng quang. 4.3. Thc hin chm sc 4.3.1. Gim au v kh chu cho bnh nhn: thc hin y lnh dng khng sinh, thuc chng co tht c trn, ngi vo chu nc m, ung nhiu nc tng lu lng mu qua thn, trnh nhng thc ung gy kch thch bng quang nh c ph, ch, coca 4.3.2. Gio dc bnh nhn t chm sc nh: nht l i vi bnh nhn n - Tng cng v sinh c nhn: tm hng ngy, tt nht l tm di vi nc sch. - Ra tht sch xung quanh vng tng sinh mn, l niu o (ra t trc ra sau) sau mi ln i tiu tin. - Ung nhiu nc hng ngy lm sch vi khun ng tit niu. - C 2-3 gi i tiu mt ln ngn nga s qu gin ca bng quang lm ngn cn s cung cp mu ti thnh bng quang mt yu t c th thc y nhim khun bng quang.
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TRIU CHNG HC V MU MC TIU 1. Trnh by c phng php khm lm sng bnh mu 2. Trnh by c cc xt nghim cn lm sng v bnh mu: xt nghim mu, xt nghim tu, cc xt nghim v cm mu, ng mu. Trn lm sng cng ngy bnh mu cng nhiu, thng cc bnh ny c tin lng xu. Triu chng lm sng ca bnh mu rt thay i nh: st, mt, xanh xao, au hng, xut huyt, nga, ri lon tiu ho, au xng, khp Triu chng thc th thng l c hch to, lch to. V cc bnh mu, triu chng lm sng t c gi tr chn on, nht l giai on bt u ca bnh, v vy xt nghim cn lm sng l cn thit trong chn on cc bnh v mu. PHNG PHP THM KHM BNH NHN BNH MU A. PHNG PHP LM SNG 1. Bnh s - Tin s Cng ging nh cc bnh l khc, y cn ch mt s im sau 1.1. Ngh nghip Ngh nghip tip xc nhiu vi ho cht nh: ch, benzen, cht phng x, quang tuyn... Cc cht ny l mt trong nhng nguyn nhn gy bnh mu c tnh nh: bnh bch cu, suy tu Ngh nghip tip xc vi phn ti d mc bnh giun mc, l mt trong nhng nguyn nhn gy thiu mu rt thng gp 1.2. Cc loi thuc dng: Mt s thuc nh Cloroxit, Quinin, thuc chng ung th, hocmon,c th gy cc bnh v mu nh chy mu di da hay ni tng, suy tu,... 1.3. Tin s Bn thn: Ch tin s chy mu nh chy mu cam, chy mu lu cm mi khi va chm nh hay tim, chch, nh rng; hi v kinh nguyt nh rong kinh, rong huyt, tin s cha (sy thai lin tip ngh n khng ho hp yu t Rh ) Gia nh: Hi tnh trng bnh tt ca nhng ngi thn nh anh ch em rut, b m, ch bc, c d 2. Khm thc th Ging nh cc bnh l ni khoa khc, y cn lu : 2.1. Mu sc da v nim mc
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2.2. Xut huyt di da: chm, mng, nt xut huyt 2.3. Cc biu hin khc ngoi da nh nga, ban , u ht di da 2.4. Cc t chc vng ni m: hch, gan, lch... B. CN LM SNG 1. Xt nghim mu 1.1. Hng cu 1.1.1. S lng hng cu - Bnh thng ngi ln: 3,8 - 4,2 triu/mm3 - Bnh l: < 3,5 triu/mm3: thiu mu > 5 triu/mm3: tng hng cu. Gp trong bnh a hng cu, tim bm sinh, thiu oxy kinh din, trn cao 1.1.2. Huyt cu t: - Bnh thng huyt cu t (Hb): 14 - 15g/ 100ml; theo qui c tng ng 100%. ngi c Hb 80 % c ngha l lng huyt cu t ca ngi bng 80% ngi bnh thng - Bnh l: < 14g/ 100ml: Gp trong thiu mu 1.2. Bch cu 1.2.1. S lng bch cu - Bnh thng: 4000 - 8000bc/ mm3. tr em c th ln n 10.000/mm3, tr s sinh c th n 15.000/mm3 - Bnh l: < 4000/mm3. Gp trong cc bnh nhim virus, thng hn, suy tu, cng lch > 9000/mm3. Gp trong a s cc bnh nhim khun, bnh bch cu,... 1.2.2. Cng thc bch cu: - Bnh thng ngi ln Bch cu a nhn trung tnh: Bch cu a nhn a axit: Bch cu a nhn baz: Bch cu lympho: Bch cu mono: 55 - 70 % 2-4% 0-1% 12 - 33 % 4-8%
- Bnh l T l bch cu a nhn trung tnh Tng: thng km theo tng s lng bch cu. Gp trong a s cc bnh nhim khun, sau chy mu, khi u c tnh Gim: km theo gim s lng bch cu trong bnh suy tu. T l bch cu lympho: thng tng trong cc bnh nhim virut quai b, si; vim mn nh lao phi, giang mai, vim gan
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1.3. Tiu cu 1.3.1. Bnh thng: c t 150.000 - 300.000 tc/mm3. Tr em c khong 400.000/mm3 1.3.2. Bnh l: Gim: < 80.000/ mm3. Gp trong hi chng chy mu tin pht hoc th pht. Gim tiu cu km theo gim hng, bch cu trong bnh suy tu Tng: khng c gi tr lm sng 2. Xt nghim tu Trong nhiu trng hp, xt nghim cng thc mu ngoi bin khng nh gi c tnh trng tn thng ca cc t bo mu, lc phi ly mu trong tu xng. Thng chc tu xng chu hay xng c, cng c th chc xng chy hoc ni khc. Bnh l - Qu sn (cn gi l phn ng tu xng): gp trong cc bnh thiu mu do mt mu cp - Qu sn t bo c tnh dng bch cu: bnh bch cu - Qu sn t bo c tnh dng hng cu: bnh Vaquez (bnh a hng cu) - Thiu sn tu: c th thiu sn mt trong ba dng hoc c ba dng: bnh suy tu 3. Xt nghim cm mu, ng mu 3.1. Cc giai on cm mu 3.1.1. Giai on 1: Co mch: lm hp lng mch. 3.1.2. Giai on 2: Giai on tiu cu: tiu cu tp trung vt thng, to thnh nt cm mu. Nt ny khng bn vng, d v, gy chy mu li. 3.1.3 Giai on 3: Giai on huyt tng: to cc mu ng. Fibrin to thnh mng li lm cho cc tiu cu tp trung c vng chc. - Th u: Di tc dng ca Thromboplastin (mt cht c to ra do t chc tn thng cng vi tiu cu) bin Prothrombin thnh Thrombin - Th hai: Thrombin bin Fibrinogen thnh Fibrin Prothrombin Fibrinogen
Thromboplastin
Thrombin Fibrin
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3.2. Cc xt nghim cm mu, ng mu 3.2.1. o sc bn thnh mch Lm nghim php dy tht: dng dy cao su hoc my o huyt p qun vo on chi ri bm ln n gn s huyt p ti a, trong 10 pht ri tho hi ra tht nhanh, du hiu dng tnh khi di ch qun xut hin nhiu chm chy mu (> 20 chm ) 3.2.2. o thi gian mu chy: nh gi thnh mch v tiu cu - Bnh thng: 2 - 5 pht - Bnh l: > 15 pht 3.2.3. Xt nghim s lng tiu cu, tp trung tiu cu 3.2.4. o thi gian co cc mu: Bnh thng: cc huyt co sau 2 - 4gi. Trong bnh thiu tiu cu cc huyt khng co li c 3.2.5. o thi gian ng mu: nh gi cc yu t ng mu - Bnh thng: 8 - 15 pht - Bnh l: 15 - 25 pht: nghi ng > 25 pht: thi gian ng mu ko di 3.2.6. nh lng Fibrinogen - Bnh thng: 3 - 5 g/ l huyt tng - Bnh l: < 3 g/l nh hng n ng mu. Gp trong cc bnh l tn thng t bo gan, cc chng tiu si huyt.
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THIU MU
MC TIU 1. Trnh by c nh ngha, nguyn nhn thiu mu 2. Phn loi c thiu mu, nu c cc triu chng bnh 3. Trnh by c iu tr thiu mu 4. Trnh by c cch chm sc bnh nhn thiu mu 1. nh ngha Thiu mu l tnh trng gim s lng hng cu hoc gim s lng huyt sc t trong mu ngoi bin. 2. Triu chng 2.1. Ton thn Da xanh xao, nim mc nht nht, lng bn tay bn chn trng nht, mi mt hi ph, mt c chn ph nh, mng tay kh d gy. 2.2. Triu chng c nng - Mt mi c th, kh th khi gng sc, nhp th nhanh, tai, hoa mt, chng mt, thong ngt v ngt. - Chn n, bun nn, t lng hoc to bn. - N: Ri lon kinh nguyt: b kinh hoc kinh ko di. - Nam: Gim tnh dc, lit dng. 2.3. Triu chng thc th - Tim nhanh, c ting thi tm thu chc nng. - Trng hp thiu mu ko di gy tim suy, din c tim to ra. 2.4. Cn lm sng - S lng hng cu gim: < 3,8 triu/1ml mu hoc - Huyt sc t Hemoglobin (Hb) gim: < 14g%. 3. Nguyn nhn v phn loi C rt nhiu nguyn nhn v nhiu cch phn loi thiu mu 3.1. Theo c ch sinh bnh : 3.1.1. Thiu mu do thiu nguyn liu sinh hng cu: Nguyn liu sinh hng cu gm protein, Fe, axit folic, Vitamin B 12, Vitamin C, Vitamin B2, Vitamin B6 ... - Do ch n khng cht dinh dng. - Do bnh l ng tiu ho: bnh nhn khng n c hoc km hp thu: hp mn v, lot d dy, ct on rut...
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- Do giun sn. 3.1.2. Thiu mu do c quan to mu: - Do bnh l tu xng, bnh bch cu, u c tnh... - Do thiu hocmon erythropoietin sinh hng cu ca thn. 3.1.3. Thiu mu do mt mu: - Thiu mu do chy mu: + Mt mu cp tnh: do chn thng, chy mu tiu ho (nn ra mu, i cu ra mu nhiu), ho ra mu, chy mu sau sinh, st xut huyt nng... + Mt mu mn tnh: Mt mi ngy mt t nhng ko di. Gp trong u x t cung, tr, K d dy, K trc trng, giun sn... - Thiu mu do huyt tn: + Do nhim khun, nhim c ho cht, kim loi nng. + Do nhim k sinh trng st rt. + Do tia phng x. + Thiu mu tan huyt bm sinh. - Cng lch 3.2. Phn loi theo mu sc, kch thc hng cu 3.2.1. Thiu mu u sc: - Hng cu to, huyt cu t nhiu - Thiu Vitamin B 12 hay axit folic. - Do ri lon tiu ho km hp thu, ct on d dy lm gim yu t ni hp thu Vitamin B12. 3.2.2. Thiu mu nhc sc: - Hng cu nh, huyt cu t t. - Do thiu st; gp trong tr, u x t cung, lot d dy t trng, giun mc, vim rut, K trc trng... 3.2.3. Thiu mu ng sc: - Hng cu bnh thng, huyt cu t bnh thng. - Gp trong bnh mu c tnh, sau chn thng mt mu nhiu... 4. iu tr 4.1. iu tr nguyn nhn Tm v iu tr nguyn nhn thiu mu l quan trng. 4.2. iu tr tnh trng thiu mu - Chuyn mu: Nu thiu mu nng, hng cu > 2triu/1ml mu. - Chuyn m, vin amin. - Vin st oxalat: 0,05g x 10 vin/ngy.
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- Vitamin B12 200 - 500 microgam/ ngy. 4.3. Tng cng ch dinh dng: y m, vitamin... 5. Phng bnh - n y cht dinh dng. - Pht hin bnh sm, iu tr kp thi. - Ph n c thai, cho con b cn b sung cc cht, c bit l Fe. - Khng dng phn ti bn rau... 6. Chm sc bnh nhn thiu mu 6.1. nh gi chm sc: cn nh gi cc biu hin sau: - Thay i mu sc da, nim mc: da xanh, vng da c th c thiu mu do tan mu hoc do bnh mu c tnh, kh da thiu mu nhc st, - Tnh trng tim mch: hi hp, tim nhanh, kh th, chng mt, triu chng ca suy tim do thiu mu ko di - Hi tin s v dinh dng, gia nh c mc cc bnh mu di truyn, kinh nguyt (rong kinh, a kinh,), dng thuc nh hng n to mu (chloramphenicol). 6.2. Chn on chm sc Da trn cc s liu nh gi, c th thit lp cc chn on chm sc sau: - Gim kh nng hot ng do yu mt - Gim lu lng tim do tng gnh nng ca tim - Dinh dng khng y 6.3. Thc hin chm sc 6.3.1. Tng kh nng hot ng: Ngh ngi y , luyn tp nh tng cng sc chu ng 6.3.2. Duy tr lu lng tim bnh thng - iu tr tt thiu mu theo y lnh thy thuc - Trnh gng sc khng cn thit trong khi ang iu tr - C th th oxy khi cn, trnh truyn nhiu dch khi c ph, gim lu lng nc tiu, tnh mch c ni 6.3.3. Duy tr dinh dng y - Ch n giu protein, nng lng, hoa qu, rau ti, giu st, vitamin, c bit l vitamin B12. - Cc mn n ch bin hp khu v gip bnh nhn n ngon, tiu ha tt.
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BNH BCH CU CP
MC TIU 1. Trnh by c nh ngha, nguyn nhn gy bnh 2. Trnh by c triu chng, chn on v tin trin ca bnh bch cu cp 3. Trnh by c cch iu tr bnh bch cu cp 4. Trnh by c cch chm sc bnh nhn b bnh bch cu cp 1. i cng 1.1. nh ngha Bch cu cp l bnh mu c tnh, trong cc t bo mu nguyn thu tu xng ngng bit ho nhng khng ngng sinh sn, pht trin rt nhiu trong tu xng v ra c mu ngoi vi. 1.2. c im ca bnh - L bnh mu c tnh, bao gi cng tin trin n t vong - Thng gp tr em, ngi tr tui. - Bnh d chn on v xt nghim mu c rt nhiu nguyn bo mu, nhng c khi nguyn bo ch c nhiu trong tu m khng c trong mu ngoi vi khi phi chc d tu xem tu . 1.3. Sinh l bnh Trong bnh bch cu cp cc nguyn bo tu xng pht trin rt nhiu s ln t cc dng hng cu, tiu cu, ng thi bch cu trng thnh cng ch c mt s t. Hu qu: - Gim hng cu: bnh nhn xanh xao thiu mu - Gim tiu cu: Bnh nhn c biu hin chy mu - Gim bch cu trng thnh: d nhim trng - Nguyn bo tng nhiu ngm vo bt c b phn no, thng l cc t chc vng mc lm cho cc b phn to ra nh lch to, hch to, 2. Nguyn nhn gy bnh Cho n nay ngi ta cha khng nh. C nhiu gi thuyt cho rng: - Do virus - Do phng x, ho cht
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- Yu t di truyn: cha c kt lun chc chn, nhng c nhn xt rng: trong gia nh c ngi ung th khc th ngi trong gia nh c nguy c Lucemie cao hn gp 4 ln ngi trong gia nh khng c ngi mc 3. Triu chng 3.1. Th in hnh 3.1.1. Hi chng nhim trng: Bnh nhn st, c th st nh 37,5 380C hoc st nhiu 39 400C Bnh nhn mt mi, km n, li trng bn 3.1.2. Hi chng thiu mu: - Da xanh, nim mc, lng bn tay chn nht nht - Nghe c ting thi tm thu mm tim 3.1.3. Hi chng xut huyt: Xut huyt da; nim mc nh chy mu rng mi hay xut huyt ni tng: chy mu mng no, mng phi... 3.1.4. Hi chng lot: Hng v li rng thng b lot; li rng khng lot th cng sng v chy mu. 3.1.5. T chc vng mc: Hch to hu ht cc v tr c hch: nch, bn, c, di hm. Hch to va, cng, di ng v khng au. Lch to va. Gan to, mp m b sn 3.1.6. Cn lm sng: - Cng thc mu + S lng hng cu gim: 1.000.000- 1.500.000/mm3 c th t hn + S lng tiu cu gim + S lng bch cu tng ln rt nhiu: 200.000, 300.000, 400.000/ mm3 mu + Cng thc bch cu Phn ln l nguyn bo: 95 - 99 % Bch cu trung gian: khng c Bch cu trng thnh: rt him C khong trng bch cu do bch cu non (nguyn bo) tng rt nhiu trong khi bch cu trng thnh rt t. - Tu ging nh cng thc mu: + Rt nhiu nguyn bo: 80 - 90% + Rt t bch cu trng thnh: 1 -2 - 5% + Khng c bch cu trung gian 3.2. Th khng in hnh 3.2.1. Th bt u t ngt: bnh nhn t vong trong vi gi. 3.2.2. Th ch c thiu mu v st 3.2.3. Th st v chy mu
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3.2.4. Th hch to, lch to 3.2.5. Th bt u bng u xng: au nhc cc khp xng. 4. Chn on Da vo huyt , tu - S lng bch cu tng rt nhiu - Nguyn bo chim a s trong cng thc bch cu - Khng c bch cu trung gian (khong trng bch cu) 5. Tin trin Trc y bnh t vong trong vng tun l hay vi thng, hin nay nh c iu tr (Corticoit, 6MP, Vinblastin, truyn mu) i sng ca bnh nhn ko di hng nm hay nhiu nm. Bnh tin trin tng t, gia 2 t cc triu chng lm sng v cn lm sng u gim. Tuy nhin tin lng bnh cui cng cng xu. Bnh nhn cht v: - Xut huyt nng - Tc ng, tnh mch - Suy mn dn 6. iu tr 6.1. Cc thuc iu tr - Vinblastin - 6MP (6 Mercaptopurin) - Methotrexat - Prednisolon 6.2. Quang tuyn liu php 6.3. iu tr triu chng - iu tr nhim khun - iu tr thiu mu bng dinh dng, nng cao th trng l ch yu. Truyn mu ch t ra khi hng cu < 2 triu/mm3, c triu chng suy tim, thiu mu no. 7. Chm sc 7.1. Chn on chm sc - Nguy c chy mu do gim tiu cu - Nguy c nhim khun do gim bch cu - Gim kh nng hot ng do thiu mu - Cm gic kh chu (nh au) do thm nhim bch cu vo t chc - Dinh dng gim do tiu ha km v tc dng c ca ha tr liu - Bin i ngoi hnh do rng tc 7.2. Thc hin chm sc
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7.2.1. An i, ng vin bnh nhn chu ng c ni au bnh nng. Gii thch cc th thut cn cho chn on, cc tc dng ph ca thuc iu tr v c v bnh nhn tham gia v chp thun ch iu tr. 7.2.2. Ngn nga chy mu do gim tiu cu - Bnh nhn c th chy mu nng nu tiu cu gim < 20.000/mm3. St, nhim khun u lm tng kh nng chy mu nn cn ch . - Theo di st cc tnh trng xut hin: trn da, phn en, tiu mu - Trnh tim bp v chn thng phn mm, trnh dng cc thuc c ch kt tp tiu cu nh aspirin. - Truyn khi tiu cu, khi hng cu khi c ch nh 7.2.3. phng v pht hin sm nhim khun - Bnh c nguy c nhim khun rt ln do mt chc nng bo v ca bch cu, do dng thuc c ch min dch trong iu tr. V vy, cn pht hin nhim khun iu tr sm, c bit l triu chng st v du hiu ch im tn thng c quan nh ho, tiu chy, tiu rt, tiu c, - m bo thc hin th thut v khun - V sinh thn th, rng ming tt 7.2.4. Bnh nhn cn c nng khi cn thit, ngh ngi ci thin kh nng hot ng hng ngy 7.2.5. Gim cm gic kh chu do bnh c tnh: to mi trng thoi mi, dng thuc gim au khi cn, trnh di chuyn khi khng cn thit, thc hin th thut nh nhng, ung nhiu nc trnh si uric do tiu hy t bo gii phng ra trong khi ha tr liu. 7.2.6. Tng cng dinh dng - Do iu tr, bnh nhn thng c chn n, bun nn, nn, tiu chy, nim mc ming cng d b tn thng nn trnh cho n thc n c cc cht kch thch. - Cn cho n nhiu ln, s lng nh, thc phm c nhiu protein, vitamin. 7.2.7. Ci thin ngoi hnh Rng tc l mt chn thng tinh thn thng gp. Bnh nhn cn c bo trc chun b tinh thn i ph vi vn ny. C th dng tc gi, s dng m, khn trm u thch hp vi bnh nhn.
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BASEDOW
MC TIU 1. Nu c khi nim v bnh, nguyn nhn gy bnh 2. Trnh by c triu chng bnh, tin trin, bin chng bnh 3. Trnh by c cch iu tr bnh 4. Trnh by c cch chm sc bnh nhn Basedow 1. i cng Bnh Basedow l mt hi chng cng tuyn gip trng, hocmon tuyn gip tng trong mu. y l bnh ni tit ph bin, thng gp cc nc, cng nh nc ta. Bnh thng gp n, gp mi la tui nht l 20 - 40. 2. Nguyn nhn - V nguyn nhn, ngi ta cho l mt bnh ca h thng thn kinh - tuyn gip trng, sinh ra do s mt iu chnh gia v no, tuyn yn v tuyn gip trng - Cc yu t lm d nh: + Chn thng mnh v th cht, tinh thn nh chin tranh, tai nn, nhim trng + C a: n mc bnh nhiu hn nam gii, n chim 80% + C yu t gia nh, di truyn. 3. Triu chng 3.1. Triu chng lm sng 3.1.1. Triu chng chnh: - Tim mch: l triu chng thng nht, bao gio cng c. Nhp nhanh xoang, u, 120-160 ln/pht. Huyt p tm thu tng - Gy nhanh: Bnh nhn n nhiu, ngon ming nhng vn gy nhanh (mt 4-5 cn/tun) - Chuyn ho c bn tng: > 20%. Thng chuyn ho c bn tng n 60%, 80%. - Tuyn gip ln, lan to, c th c nhn; phn ln l bu mch: nghe c ting thi tm thu hay thi lin tc hay s c rung miu bu. - Run tay: run u ngn tay, bn tay; c th chn, tng ln khi xc ng; run tay bin nh - Li mt, mt sng: li c 2 bn; th li nng c th khng khp c mi 3.1.2. Triu chng ph: - St nh - Thay i tnh tnh, d nng gin, cu gt, ng ngi khng yn, khng tp trung t tng c...
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- Kh ng, khng chu c nng, d chu lnh, hay ku mt, mt d hay hot ng. - Mi c, c du hiu gh u: bnh nhn ngi trn gh u thp, khng th ngi dy nu khng chng tay. 3.2. Cc xt nghim cn lm sng - tp trung Iot: tng - Chuyn ho c bn: tng > 20% - T3, T4: tng - TSH gim - Cholesterol gim, ng huyt tng 4. Tin trin Basedow l bnh nng v tin trin bt ng, kh tin on. Cng c th nh, khng nng ln, bnh nhn sinh hot gn nh bnh thng, mc d khng c iu tr tch cc. Bnh tin trin qua 4 giai on: + Giai on 1: triu chng thn kinh l ch yu, bu c nh + Giai on 2: triu chng thn kinh, cng gip r + Giai on 3: c tn thng ni tng + Giai on 4: suy kit khng hi phc 5. Bin chng 1. Suy tim, ri lon nhp tim 2. Cn tin trin cp tnh 3. Suy mn 4. Nhim trng: vim phi, lao phi... 6. iu tr Basedow l bnh l cng gip trng, do vic iu tr nhm hn ch sn xut v phng thch hocmon thyroxin 6.1. iu tr ni khoa 6.1.1. Lugol 5%: dng trong giai on tn cng; X - XX git/ngy 6.1.2. Thuc khng gip tng hp (lm c ch sn xut thyroxin): - PTU 50mg x 6-8 vin/ngy - Carbimazol 5mg x 6-8 vin/ngy. Tn cng 4-6 tun, t c bnh gip chuyn sang liu cng c. Liu cng c bng na liu tn cng trong 2 thng. Liu duy tr 1 vin/ngy x 12 thng. 6.2. Phu thut: ct b mt phn tuyn gip 6.3. Iot phng x: c tc dng tiu dit t bo; y c coi l phu thut khng cn dao. 7. Chm sc 7.1. Chn on chm sc
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- Tnh trng tng kch thch, hay hong ht, d xc ng, cu bn. - Tng mc cm do thay i ngoi hnh - Cm gic kh chu do khng chu c nng - Thay i dinh dng do tng chuyn ha 7.2. Thc hin chm sc 7.2.1. Lm gim s kch thch - Gii thch cho bnh nhn cc triu chng ch tm thi, s mt i sau iu tr. - Gip bnh nhn trnh stress: gi yn tnh, tham gia hot ng th gin nghe nhc nh, tp th dc nh 7.2.2. Lm gim s mc cm: chia s, an i, ng vin. Trnh bn tn ca nhng ngi xung quanh v bnh nhn. 7.2.3. Lm gim cm gic kh chu do nng: b tr nm phng thong mt, sch s, c qut, nc mt tm. Mc qun o mt, nh d thot nhit. 7.2.4. Tng cng dinh dng v iu chnh ch n sao cho ph hp vi khu v v lng thc n hng ngy ca bnh nhn m bo calo trong ngy, khng qu tha nhng cng khng thiu. m bo cn i dinh dng.
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I THO NG
MC TIU 1. Trnh by c khi nim v bnh, nguyn nhn gy bnh 2. Trnh by c triu chng ca 2 loi i ng tp1 v tp 2. 3. Nu c cc bin chng, tiu chun chn on i ng 4. Trnh by c cch iu tr bnh. 5. Trnh by c cch chm sc bnh nhn i tho ng 1. i cng i tho ng l mt chng bnh mn tnh, do ri lon chuyn ho Glucid lm cho Glucose trong mu tng cao; ng mu tng qu cao vt qu ngng hp thu li ca ng thn v xut hin ng ra ngoi nc tiu. ng mu tng cao gy ra ri lon chuyn ho v gy ra nhiu bin chng. 2. Nguyn nhn, phn loi, triu chng i tho ng tp 1 i tho ng tp 2 - Do bnh l tu nh: si tu, vim tu, K - Do u tuyn ni tit, x gan, lo ho, cso tu ... - Insulin mu gim - Thng xy ra ngi tr tui, gy - Hi chng 4 nhiu r, rm r + n nhiu + Ung nhiu + Tiu nhiu + Gy nhiu - Bnh nng nhiu bin chng - Triu chng cn lm sng + ng mu tng cao + ng niu (+) + C th c xeton niu thai, dng cortizol ... - Insulin mu bnh thng hoc tng - Thng gp ngi gi, mp - Hi chng 4 nhiu khng r.
- Bnh nh hn, t bin chng - Triu chng cn lm sng + ng mu tng cao nh + ng niu (+) + Khng bao gi c th xeton
(Th xeton c sinh ra do s ri lon chuyn ho glucid trong khi t bo khi t bo khng s dng c glucose)
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3. Bin chng - Bnh i tho ng l bnh ton th, c quan no cng c th b bin chng. - Bnh i tho ng gy ri lon chuyn ho, sinh ra nhng sn phm c cho c th v dn dn thoi ho cc c quan, tng ph. - Cc bin chng i tho ng l do: + Nhim trng + Thoi ho do tn thng cc vi ng mch + Ri lon chuyn ho 3.1. Bin chng mn tnh - Ngoi da: nhim trng da dai dng, ko di, l nga, mun nht, inh ru - Mt: c thu tinh, vim vng mc, vim thn kinh th, lit dy thn kinh ngoi bin, ri lon mi trng chit quang... - Rng: d rng, vim m chn rng - Phi: vim phi, lao phi - Thn: vim ng tit niu, hi chng thn h, suy thn - Tim mch: + X m ng mch vnh dn ti thiu mu c tim, nhi mu c tim, suy tim (bnh nhn i ng d x m ng mch v lipid mu tng cao) + Vim ng mch chi di lm hoi th chi + Cao huyt p, tai bin mch mu no - Thn kinh: + Vim a dy thn kinh + X m ng mch no gy tai bin mch mu no - Gan to nhim m - i cu lng ko di d gy suy dinh dng, t vong - C teo, thoi ho khp 3.2. Bin chng cp tnh: Hn m i ng do: - Tng p lc thm thu - Tng axit lactic - Nhim toan x-ton 4. Chn on xc nh Da vo: - ng mu lc i - ng mu bt k 7 mmol/1 ( 126mg %) 11,1 mmol/1 ( 200mg %)
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- Nghim php dung np Glucose (cho bnh nhn ung nc ng, xt nghim ng mu sau 2 gi) 11,1 mmol/1 5. Tin trin L bnh mn tnh, lun e do bi cc bin chng. Hn m i ng l bin chng nng d gy t vong. Tin lng ph thuc vo chm sc theo di, s dng thuc v ch n. 6. iu tr 6.1. i tho ng tp 2 6.1.1. Ch n: - Ch n thch hp lm n nh ng huyt cng c kh nng iu tr tt i ng th 2. - Lng calo cung cp khong 1500 kcalo, trong glucid: 55 - 60%, lipid: 30 35%, protid: 10 - 15% 6.1.2. Vn ng th lc: luyn tp th dc, th thao thch hp. 6.1.3. Thuc h ng mu: - Thuc h ng mu c ch nh khi ch n v vn ng tht bi. - Sunfamit h ng huyt c ch nh bnh nhn trong lng trung bnh hay nh cn. Biguanid u tin trn bnh nhn bo ph. - Nu tnh trng khng ci thin c th phi hp nhiu loi thuc, phi hp Insulin. 6.2. i tho ng tp 1 6.2.1. Ch n: - Hn ch glucid nhng m bo th trng bnh thng - Lng calo mi ngy: 1800 kcalo 6.2.2. Insulin: - C loi Insulin tc dng nhanh: thi gian tc dng 4-6 gi, loi tc dng bn chm: thi gian tc dng 12 gi, loi Insulin tc dng chm: thi gian tc dng 24 gi - Liu lng Insulin tu theo tnh trng thiu Insulin, mc khng Insulin ... Thng khi u 0,3 - 0,4 UI/kg 7. Chm sc 7.1. Chn on chm sc - Thiu kin thc v cc phng php iu tr nhm duy tr glucose mu bnh thng. - Khng tn trng ch iu tr - Nguy c gim glucose mu do iu tr: qu liu thuc - Nguy c nhim toan chuyn ha - Nguy c xut hin v pht trin cc bin chng 7.2. Thc hin chm sc
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7.2.1. Gio dc bnh nhn: cn thc hin ngay khi bnh nhn vo vin v tip tc sut i, bao gm: - Cc khi nim c bn trong iu tr bng ch n - Ch luyn tp, dng thuc - Cc xt nghim nc tiu v mu cn lm - Cc triu chng ca gim glucose mu 7.2.2. Duy tr nng glucose mu bnh thng - Hng dn bnh nhn t theo di glucose mu ca mnh c th iu chnh ch n, luyn tp v dng thuc nh t i xt nghim sau mt thi gian. - C th t vn cho bnh nhn v thc phm, s ba n trong ngy ph hp vi tng bnh nhn. - Cn nhc nh bnh nhn khng c b iu tr cng nh khng t dng thuc ngoi ch nh ca thy thuc. 7.2.3. phng gim glucose mu - Hng dn triu chng ca gim glucose mu cho bnh nhn. - Khuyn bnh nhn lun mang theo ng, bnh ko khi luyn tp 7.2.4. Phng chng bin chng - Duy tr nng glucose mu n nh l gip cho cc bin chng chm xy ra - Bo v da, trnh chn thng bng cch tng cng v sinh da bng nc m, trnh x phng kch thch da. - B thuc l v trnh ung ru bia v lm tng kh nng xut hin bin chng mun.
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2.2. Triu chng cn lm sng 2.2.1 Xt nghim mu: - VSS (tc lng mu): tng. Fibrin mu tng - Albumin gim, Globulin tng - Phn ng Waaler - Rose, hay Latex: (+) (phn ng tm yu t dng thp trong mu) 2.2.2. Xquang: Khe khp hp, dnh khp, bin dng khp, lch trc. 3. Tin trin - tin lng Bnh mn tnh, ko di nhiu nm 5 - 10 nm, thnh thong nhng t vim cp tnh lm cho khp tn thng nng hn gy cng khp, bin dng, teo c; cui cng bnh nhn mt kh nng lao ng, sinh hot tr thnh tn ph. 4. Chn on 4.1. Chn on dng tnh: Theo hi khp hc M, chn on xc nh khi c 4 trong 7 tiu chun sau: 1. Cng khp bui sng 2. Sng au 3 trong 14 khp nh (ngn tay gn, bn ngn, c tay, khuu, gi, c chn, ngn chn) 3. Sng au 1 trong 3 v tr khp ngn tay gn, bn ngn tay, c tay 4. Sng au i xng 5. Nt di da 6. Hnh nh Xquang r 7. Phn ng Waaler-Rose (+) Thi gian biu hin triu chng lm sng t nht l 6 tun 4.2. Chn on phn bit: vi thp khp cp. Trong VKDT: - Khp nh thng b hn khp ln - Mi khp b vim lu hn trong thp khp cp. - Vim khp ko di hn 3 thng - Khng au nhi khp bng thp khp cp. - Tc dng ca Aspirin, Corticoid khng r rt bng thp khp cp. - C th c vim mng ngoi tim, khng khi no c vim ni tm mc - VS gi mc cao lu hn trong thp khp cp c iu tr 5. iu tr 5.1. Thuc khng vim, gim au - Aspirin vin 0.05mg x 4 - 6 vin/ ngy - Indomethacin 25mg x 4 - 6 vin/ ngy - Diclofenac 50 mg x 4 6 vin/ ngy
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Trong trng hp nng dng kt hp Corticoid - Prednisolon vin 5mg x 8 - 12 vin/ ngy - Dexamethason 0.5mg x 8 - 12 vin/ ngy Khi bnh nhn n nh, iu tr cng c bng cc thuc khng vim khng Corticoid vi liu thp. 5.2. Vt l tr liu: chm cu, phc hi chc nng...ngoi t cp trnh dnh cng khp, teo c. C th kt hp ngoi khoa khi c di chng khp, teo c, bin dng. 6. Chm sc 6.1. Chn on chm sc - Bnh nhn au v kh chu do cc khp b vim. - Gim kh nng vn ng do hn ch vn ng khp. - Nhng thay i v dinh dng. 6.2. Thc hin chm sc 6.2.1. Lm gim au v kh chu - Chm nng c tc dng tt lm gim au, gim co cng, gim vim v co c. - Chm lnh bng ti nc : vi bnh nhn, nhit c th lm tng au, gy co c, kch thch tng bi tit dch. Nu khp b vim cp, chm lnh c th c tc dng tt. - Bt ng v ngh ngi lm gim au khp ang vim: bnh nhn nm nga, chn dui thng, tt c cc khp u c t v t th tt nht. - Thc hin y lnh dng thuc gip gim au khp. 6.2.2. Tng cng kh nng vn ng ca khp: c v, ng vin bnh nhn luyn tp khp, gip bnh nhn thc hin nhng ng tc tinh vi m bnh nhn khng thc hin c. - Nu bnh nhn i li kh khn, c th khuyn dng gy chng lm gim sc nng c th m cc khp chi di phi chu ng. ng giy thch hp vi chn bnh nhn tp i b, bo v khp, trnh ng v lm gim bin dng khp thm. 6.2.3. Tng cng v iu chnh dinh dng - Bnh nhn thng mt mi, chn n v thiu mu. Cn hng dn la chn thc n cung cp nng lng t bn nhm thc phm chnh. n lm nhiu ba, thc phm dinh dng cao nh tht, trng, sa v cc sn phm sa i vi nhng bnh nhn chn n. - Vi nhng bnh nhn qu bo, hng dn bnh nhn ch n gim cn v trng lng qu nng lm tn thng thm cc khp.
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TING ANH 1. Current Medical Diagnosis and treatment (2002), Lange. 2. Endocrinology (2001), 4th Edition, W.B. Saunders Company. 3. Global Initative for Chronic Obstructive Lung Disease (GOLD) (2001), National Heart, Lung, Blood Institute. 4. Hurst' s THE HEART (2002), Robert C. Schlant, R. Wayne Alexander. 5. HARRISON'S- Principles of Internal Medicine (2005) 6. Harrison (2002). Principle of internal medicine, 15th edition. 7. J.M.H.Moll, V Minh c (2000), Cc bnh v khp, NXB Y hc. 8. John Muray (1995), Respiratory failure, Cecil textbook of medicine 17th edition, W.B Sauders company. 9. Shubhada N. Ahya, Kellie Flood et al (2001), Renal diseases, The Washington manual of medical therapeutics, Lippincott Williams & Wilkins, 256-274. 10. Thomas E. Andreoli et al (1988), Renal diseases, Textbook of medicine. WB Saunders Company 502-655.