訪問看護で使えるフィジカルアセスメント③～循環～
訪問看護で使えるフィジカルアセスメント③～循環～
今回は訪問看護でも使えるフィジカルアセスメント、循環編です。
循環編は、血圧についてお伝えします。
目次
循環のアセスメントの鍵は血圧にあり
普段何気なく測定している血圧ですが、実はここに循環のアセスメントの鍵があります。
血圧は特殊な医療機器がなくても測定できます。血圧が高い、低いは誰が考えても分かりますが、その理由をアセスメントするのは意外と奥が深いです。
まずは血圧の式を覚えることからお勧めします。
血圧はこのように掛け算になっています。
血圧の式について
血圧＝心拍出量×血管抵抗です。理科の授業でオームの法則を習ったと思いますが、電圧＝電流×抵抗に似ています。
心拍出量とは、心臓が送り出す血液量のことです。血管抵抗とは、血液が流れる時に生じる全身の血管の抵抗のことです。つまり、血圧は心臓が送り出す血液の量が増える・減る、または血管抵抗が上がる・下がることで変化します。
例えば血圧が上がる場合でも、3通りあります。
①心臓から送り出す血液量が増える・血管抵抗が変わらない➝血圧は上がる
②心臓から送り出す血液量は変わらない・血管抵抗が上がる➝血圧は上がる
③心臓から送り出す血液量が増える・血管抵抗が上がる➝血圧は上がる
血圧の式を例える
心拍出量や血管抵抗といってもイメージしにくいので、別のものに例えます。
ポンプから出る水の量が心拍出量で、ホースをつまむ力加減が血管抵抗、水の勢いが血圧と例えます。
ポンプから出る水の量が変わらない場合でも、ホースをつまむ力を強めれば水の勢いは増します。これは寒い環境で血圧が上がる（血管が収縮する）場合です。
ポンプからの水の量が減るのは、脱水や失血、心不全でポンプ自体の力が弱い場合に起こります。通常このようなことが起きると、体は血圧を上げるために、ホースをつまむ力を増やそうとしますので、末梢血管が収縮して末梢が冷たくなります。
また、心不全の場合はポンプを押す力(心臓自体が収縮するパワー＝心収縮力）が弱いので、ポンプを押す回数を増やします。（心拍数が上がる）脱水の場合は、水自体が少ないのでポンプを押す回数を増やして心拍数が上がります。
末梢が暖かいのに血圧が下がっている場合
血圧が低いと、末梢血管も収縮して触ると冷たいイメージがあると思います。
しかし、末梢がぽかぽか暖かいのに、血圧が低い場合があります。これは、先程の例だとホースをつまむ力が弱すぎて水の勢いが落ちた場合です。
実際の体では、血管抵抗が下がりすぎてしまった場合（末梢血管が拡張する）にこのような事が起きます。血管抵抗が下がりすぎるものとして、アナフィラキシーショックや感染症によるショック（敗血症性ショック）があります。これらは大変危険な状態です。
他には、降圧剤（Ca拮抗薬など）や解熱剤で血管拡張が起こり、血圧が必要以上に下がってしまう場合もあります。
血圧が高い時、低い時に考えること
以上から、血圧が高い時、低い時には以下の原因がないのか考えます。
血圧が高い時（心拍出量が増えた時）➝苦痛（痛みなど）・運動・緊張・塩分過剰摂取など
血圧が高い時（血管抵抗が増えた時）➝いわゆる動脈硬化・寒冷刺激など
血圧が低い時（心拍出量が減った時）➝（血管内）脱水・失血・心不全・迷走神経反射・不整脈・全身状態の不良（なんらかの疾患の末期状態）など
血圧が低い時（血管抵抗が下がった時）➝アナフィラキシー・敗血症・薬剤性（降圧剤・解熱剤）など
血圧の式から観察・アセスメントにつなげる
繰り返しになりますが、血圧＝心拍出量×血管抵抗です。
心拍出量のアセスメントは、実際に心臓から送り出される血液量は分からないので関連することを観察してアセスメントしていきます。
例えば、皮膚、粘膜の乾燥・水分摂取不足・濃縮尿や尿量減少から脱水による心拍出量低下を疑います。他には、浮腫・栄養状態不良（低Alb血症）から、（血管内）脱水を疑います。他には、心不全の既往があれば、ポンプ機能低下による心拍出量低下があるのではないかと考えてアセスメントしていきます。
次に血管抵抗のアセスメントですが、血管抵抗を簡単に予測するのは末梢の温感・冷感の確認です。
例えば、感染症の診断がついていて、末梢がぽかぽか暖かく、血圧が低い場合は敗血症を疑います。感染症の診断がついていない場合でも、尿路感染や肺炎などが疑わしい場合は、同じように考えます。
血圧が低く、末梢が冷たい場合は、脱水や心不全で心拍出量が下がり、その結果として（血圧を下げないようにする体の反応として）末梢血管が収縮している可能性があります。また、このような場合は心拍数が上がっていることが多いです。
他には、交感神経が興奮すれば心拍出量も末梢血管抵抗も上がり、血圧が上がります。交感神経の興奮は運動、緊張、苦痛（痛みなど)などで起こります。
最後までお読みいただきありがとうございました。
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