1、1簡淑慧簡淑慧 _Symptom Management II單元名稱單元名稱 : 末期病患常見不適末期病患常見不適症狀之評估及醫護處置症狀之評估及醫護處置 (II) 整理者整理者 : 簡淑慧簡淑慧 老師老師(N棟棟 1樓樓 ; 分機分機 : 3136)單元時數: 2 小時*簡淑慧簡淑慧 _Symptom Management II 2Dyspnea-Physiology-1呼吸調節機轉 神經性*呼吸道伸展接受體 (Airway stretch receptors) *肺間質接受體 (Lung parenchymal receptors): 肺間質.肺泡與微血管之 J-receptors, 此被
2、認為與呼吸困難產生有關 .*呼吸肌 : 肋間肌與橫膈膜有接受體 .對呼吸肌之伸展及無力敏感 .當呼吸肌無力 呼吸效能下降 呼吸困難 .*簡淑慧簡淑慧 _Symptom Management II 3Dyspnea-Physiology-2 化學性 : PaCO2 & PaO2*周邊化學接受體 (Peripheral chemo-receptors): 位於主動脈弓及頸動脈體 , 對於 PaO2 較敏感 , 但長時間後就不敏感 .*中樞化學接受體 (Central chemoreceptors):位於延腦呼吸中樞對血中 PaCO2 及 酸鹼度 (PH) 較敏感 .*簡淑慧簡淑慧 _Symptom
3、 Management II 4Dyspnea-Physiology-1高度大腦中樞腦下垂體 大腦皮質呼吸中樞延腦 橋腦脊髓(C3-5; T11-12)呼吸肌肉橫膈 肋間肌 輔助肌機械接受器伸展接受體化學接受器上呼吸道運動神經呼吸道肌肉之控制Ref: Jantarakept, P., & Porock, D. (2005). Dyspnea management in Lung cancer. ONF, 32(4), 785-795.*簡淑慧簡淑慧 _Symptom Management II 5Prevalence of Dyspnea by Disease DiseaseChronic O
4、bstructive Pulmonary Disease (COPD)Congestive Heart DiseaseStrokeAmyotropic Lateral SclerosisDementiaOutpatient CancerTerminal CancerLung CancerPrevalence of Dyspnea95%61%37%47% to 50% (漸凍人 )70% (失智症 )50%45% to 70%90% (Dudgeon, 2001) Cancer*簡淑慧簡淑慧 _Symptom Management II 6Dyspnea-causeDyspneaTreatmen
5、t (化療 /電療 )Psychological Symptoms(焦慮 )肺泡失去結構呼吸肌無力氣道阻塞氧氣流量減少肺膜轉移 -肋膜積水現存疾病COPD CHF漸凍人 末期失智症腎衰竭 肝疾病 -腹水營養缺乏腫瘤壓迫Ref: Jantarakept, P., & Porock, D. (2005). Dyspnea management in Lung cancer. ONF, 32(4), 785-795.*簡淑慧簡淑慧 _Symptom Management II 7Dyspnea-Etiology-2 肋膜液之生成Mesothelial cells of pleural (肋膜間皮細胞
6、 ): 5-10L/day80-90% is reabsorbed by capillary of visceral pleural 10-20% is reabsorbed by lymphatic channels of visceral pleural 5-20ml remains in the pleural space Regulated by: Capillary permeability, hydrostatic pressure, Colloidal osmotic pressure, negative intralpleural pressure, lymphatic dra
7、ining *簡淑慧簡淑慧 _Symptom Management II 8Dyspnea-Etiology-3 惡性肋膜積水*Malignant cell irritation & inflammation- Capillary permeability (微細血管通透性增加 )- Obstruction of the pleural lymphatic systems (淋巴細統阻塞 )-Capillary endothelial cell change the hydrostatic pressure (微細血管改變其靜體滲透壓 ) protein and fluid leak to p
8、leural space (蛋白質及水外流 )-Colloid osmotic pressure (膠體滲透壓增加 ) absorption (再吸收能力 ) *簡淑慧簡淑慧 _Symptom Management II 9Dyspnea-Etiology-2 Treatment-related factors R/T or C/T : fibrosis (肺纖維化 ) (Bleomycin, MTX, Busulfex)相關治療 : CVP or Port-A insertion Pneumothorax*簡淑慧簡淑慧 _Symptom Management II 10Dyspnea-Assessment-11. 主觀性 -主訴-呼吸短促 (SOB), 吸不到氣 (Air hunger) ,malaise (不安 ),乾咳或 無痰性咳嗽 ,胸部壓迫感或疼痛感 ,焦慮或害怕 . 2. 客觀徵象 -身體評估 PQRST呼吸次數及深度 ,呼吸肌或輔助肌使用 ,臉色及周邊膚色 ( 發绀或蒼白 )胸腔括張情形 ,呼吸音 (是否減少 ,磨擦音 ) ,局部扣診 (濁音 ) 精神及意識程度 : 清醒 ,專注度 ,記憶能力 .*