Dieu Duong Noi Cao Dang

BI GING

iu dng NiKHOA NIH CAO NG IU DNG (LU HNH NI B)

TRNG CAO NG Y T QUNG NAM

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MC LCTRIU 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

iu dng Ni Cao ng Khoa Ni CYT Qung Nam

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TRIU CHNG HC H TUN HONMC TIU 1. Trnh by c cc triu chng c nng khi mc bnh h tun hon 2. M t c phng php khm h tun hon (khm tim) 3. Trnh by c cc phng php cn lm sng thng dng trong bnh l h tun hon H tun hon gm tim v cc mch mu (ng mch, tnh mch v mao mch). Nhim v quan trng ca h tun hon l vn chuyn mu i khp c th, v vy khi tn thng th hu qu nng n, thm ch nh hng nhanh n tnh mng ngi bnh. Tim ngng p trong 10 pht th t bo no cht khng hi phc. 1. Triu chng c nng 1.1. Kh th Kh th trong bnh tim l mt triu chng thng gp v c gi tr chn on, tin lng bnh. Kh th trong bnh tim, c chia lm 3 loi: - Kh th gng sc - Kh th thng xuyn - Kh th tng cn Kh th gng sc: l kh th xut hin khi lm vic, ngh ngi th khng kh th. Kh th thng xuyn: xy ra sau mt thi gian kh th gng sc. Ngi bnh kh th c khi khng lm vic, nm cng kh th. Kh th tng cn gp trong cc trng hp ph phi cp, hen tim, nhi mu phi Kh th trong cc bnh tim l do: - O2 mu gim, CO2 mu tng. - Xung huyt phi cn tr h hp, tr mu phi. 1.2 . Ho ra mu Trong bnh tim, ho ra mu gp trong: - Hp van 2 l: thng gp nht - Tc ng mch phi - Ph phi cp Trong hp van 2 l, do cn tr mu t nh xung tht tri, mu phi lm tng p lc mao mch phi, v mao mch ngi bnh ho ra mu 1.3. Tm


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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:


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- 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


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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


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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


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- 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:


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- 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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VIM NI TM MC BN CP NHIM KHUNMC TIU 1. Trnh by c nguyn nhn gy bnh, gii phu bnh ca bnh vim ni tm mc bn cp nhim khun. 2. Nu c cc triu chng ca bnh, tiu chun chn on bnh, chn on phn bit ca bnh. 3. Trnh by c cch iu tr bnh, cch chm sc bnh v nu c cch phng bnh. 1. i cng Vim ni tm mc bn cp nhim khun l tnh trng vim ni tm mc c lot v si, thng xy ra trn mt ni tm mc c tn thng bm sinh hoc mc phi t trc. Nhng c tnh ca bnh c xc nh nh cc cng trnh nghin cu ca Jaccoud (1882), Osler (1885) v Schottmuller (1905). V vy bnh c khi cn c gi l bnh Jaccoud - Osler. 2. Nguyn nhn 2.1. Vi khun gy bnh 2.2.1. Vi khun: trong a s trng hp, vi khun gy bnh l lin cu khun. Nhng loi vi khun v tc nhn gy bnh khc: - T cu khun, no m cu, ph cu, lu cu, trc khun Friedlander, Salmonella, Brucella, Corynebacterium, Vibrio foetus. - Cc loi nm Actinomycs, Candida albicans 2.2.2. ng vo ca vi khun: - Nhim khun rng ming - Nhim khun ngoi da, nhim khun do no ph thai, mt s th thut khng c v khun cn thn (t catheter, truyn mu, chy thn nhn to...) - Nhim khun tiu ha, nhim khun tit niu do phu thut h tit niu, si bng quang... - Tuy nhin, trong nhiu trng hp ngi ta khng tm thy r ng vo ca vi khun (Theo Cates v Christic, c ti 62% cc trng hp khng pht hin c r ng vo ca vi khun). 2.2. Vai tr ca bnh tim c trc Vim ni tm mc nhim khun nguyn pht rt t gp. Ni chung bnh thng xy ra trn mt bnh nhn c tn thng tim t trc: mc phi hay bm sinh. 3. Gii phu bnh


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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.

Ngn tay di trng 4.1.4. Lch to v au


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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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VIM MNG NGOI TIMMC TIU 1. K c nguyn nhn gy bnh, trnh by c triu chng bnh. 2. Trnh by c chn on dng tnh bnh, chn on nguyn nhn, bin chng ca bnh. 3. Trnh by c cch iu tr, cch chm sc bnh. 1. i cng Vim mng ngoi tim (VMNT) l bnh ca mng ngoi tim (MNT). Cn phi x tr cp cu. Nu chm s t vong nhanh (trn dch mng ngoi tim p tim cp). Hoc phi x tr ngoi khoa nu chm s dn n tin lng xu (VMNT co tht). Ngy nay nh c siu m gip cho chn on chnh xc, v sm. iu tr kp thi gim t l bin chng xu cho bnh nhn. 1.1. Nhc li v gii phu v sinh l mng ngoi tim Mng ngoi tim gm c hai lp: - Lp trong: gm hai l, l tng dnh lin vi c tim v l thnh dnh lin vi lp ngoi. Hai l ny bao bc tim nh mt ci ti sut t cc bung tm tht, tm nh, ln n gc cc mch mu ln tim. Bnh thng gia hai l ny c mt t dch nhn hai l trt ln nhau mt cch d dng. - Lp ngoi : l mt ci ti x, dy cng hn, dnh lin vi cc c quan khc ca trung tht nh c cc dy chng, c bit l dy chng honh - tim. 1.2. Sinh l bnh Khi mng ngoi tim b vim nhim, c th gy nn trn dch mng ngoi tim hoc dy dnh mng ngoi tim. Kt qu l hn ch kh nng gin ra ca cc bung tim, gy nn mt tnh trng thiu nng tm trng. Khi cc bung tim phi b p li th lng mu tnh mch ngoi vi tr v tim s tr nn kh khn. V vy v mt huyt ng, s c hai ri lon: tng p lc tnh mch ngoi vi v gim lu lng tim. 2. Nguyn nhn Vim mng ngoi tim c th gp trong nhng trng hp sau: 2.1. Nhim khun - Trc khun lao. - Cc loi vi khun khc. - Virus. 2.2. Vim nhim: Thp tim - Vim a khp dng thp - Lupus ban - Vim nt quanh ng mch.


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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 TIMMC 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 NGCMC 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 TIMMC 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 PMC 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 MNMC 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 HPMC 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 PHIMC 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.

Vim phi thy di phi

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 PHIMC 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

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