急性心肌梗死并发室间隔穿孔的护理及护理病案

目的探讨急性心肌梗死并发室间隔穿孔治疗的要点难点相应护理策略,以期对护理病案的规范化提供指导。方法收集、整理并总结2009年10月-2012年11月期间诊治的10例急性肌梗死并发室间隔穿孔患者的临床诊疗、护理相关资料。结果经积极的临床治疗和严谨科学的护理,最终5例存活,5例死亡,死因主要是迅速出现左心功能不全和心源性休克。结论护理病案的重点在于心功能状态观察与评估、主动脉球囊反搏的观察及护理、室间隔封堵术后护理,同时要加强基础护理、生命体征监测、健康指导等护理记录的规范和细化。规范化的心内科专业护理记录有助于严密地监测病情、精心的护理,为挽救患者生命增添机会。

Nursing Care and Records of the Patients with AMI and Ventricular Septal Rupture

Objective To investigate the treatment and nursing care strategies in patients with ventricular septal rupture（VSR） after acute myocardial infarction（AMI） in order to guide the standardization of nursing care records. Methods The clinical datum of 10 patients from October 2009 to November 2012 with VSR after AMI were collected and summarized. Results After positive treatment and scientific and scrupulous intensive care, 5 patients survived and 5 patients died of severe left ventricular insufficiency and cardiogenic shock. Conclusion The key points of nursing care records are the observation and evaluation of the cardiac function, observation and care of IABP, postoperative care of ventricular septal defect, in the same time strengthening the standardizations and refinements of the nursing care records of basic nursing, vital signs monitor, mental nursing and health guidance. The standardization of cardiac nursing care records is helpful for the accurately monitoring the condition of the disease, accurate nursing care and increasing the opportunity of the survival of the patients.