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  • 1. INFARK MIOKARDIUM (IMA) KELOMPOK II
  • 2. ANATOMI DAN FISIOLOGI
  • 3. DEFINISISuatu sindroma klinik yang menandakanadanya iskemia miokard akut, terdiri dari : Infark miokard akut Q wave (STEMI) Infark miokard akut non-Q (NSTEMI) Angina pektoris tidak stabil (UAP)Ketiga kondisi ini sangat berkaitan erat, berbeda hanya dalam derajat beratnya iskemi dan luasnya miokard yang mengalami nekrosis. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA 3 www.default.com
  • 4. PENYAKIT JANTUNG KORONER Pembunuh No. 1 di Dunia PJK 15 JUTA DIARE 5 JUTA KANKER 4,8 JUTA TBC 3 JUTA __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com Angka Kematian / Tahun
  • 5. PATOGENESIS• Umumnya disebabkan oleh aterosklerosis koroner• Plak aterosklerosis ruptur  terbentuk trombus diatas ateroma yang secara akut menyumbat lumen koroner• Apabila sumbatan terjadi secara total  hampir seluruh dinding ventrikel akan nekrosis __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA 5 www.default.com
  • 6. Risk Factors Uncontrollable Controllable •Sex •High blood pressure •Hereditary •High blood cholesterol •Race •Smoking •Age •Physical activity •Obesity •Diabetes •Stress and anger __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 7. The cardiovascular continuum of events Ischemia = oxygen supply and demand imbalance Myocardial Ischemia CAD plaque Atherosclerosis Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, __________ Default address Avenue, 4214, +55 32 3836 55 55 Fibrinogen, etc) Postal code 80.250-210 / Curitiba PR BR ___________________________________________ +55 32 9685 55 55LOGO AREA Adapted from www.default.com Dzau et al. Am Heart J. 1991;121:1244-1263
  • 8. The cardiovascular continuum of events Coronary Thrombosis Myocardial Ischemia CAD Atherosclerosis Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, __________ Default address Avenue, 4214, +55 32 3836 55 55 Fibrinogen, etc) Postal code 80.250-210 / Curitiba PR BR ___________________________________________ +55 32 9685 55 55LOGO AREA Adapted from www.default.com Dzau et al. Am Heart J. 1991;121:1244-1263
  • 9. The cardiovascular continuum of events ACS Coronary Thrombosis Myocardial Ischemia CAD Atherosclerosis Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, __________ Default address Avenue, 4214, +55 32 3836 55 55 Fibrinogen, etc) Postal code 80.250-210 / Curitiba PR BR ___________________________________________ +55 32 9685 55 55LOGO AREA Adapted from www.default.com Dzau et al. Am Heart J. 1991;121:1244-1263
  • 10. Coronary thrombosis Plaque rupture Stable angina UA/NSTEMI STEMI __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 11. Penyempitan Pembuluh darah __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 12. Clinical Spectrum of Acute Coronary Syndrome Acute Coronary Syndrome Non-ST Segment ST Segment Elevation Elevation STEMI NSTEMI Unstable Non-Q-wave Q-wave Angina Pectoris Acute Myocardial Infarction __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 13. Unstable NSTEMI STEMI Angina Occluding thrombus Complete thrombusNon occlusive occlusion sufficient to causethrombus tissue damage & mild myocardial necrosis ST elevations onNon specific ECG or new LBBBECG ST depression +/- T wave inversion on Elevated cardiacNormal enzymes ECGcardiacenzymes More severe Elevated cardiac enzymes symptoms __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 14. Diagnosis Anamnesis Pemeriksaan Fisik Pemeriksaan Penunjang : 1. Laboratorium 2. Elektrokardiografi 3. Thoraks Foto __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 15. HISTORYPRODROMAL SYMPTOMS History very valuable to establish D/. Prodoma : chest discomfort – unstable angina 1/3 symptoms for 1 – 4 wks 20% symptoms for < 24 hrs Malaise, exhaustionNATURE OF PAIN • Most patients severe prolonged,  30 minutes - hours • Constricting, crushing, oppressing, compressing heavy weight or squeezing in chest • Choking, vise-like, heavy pain or stabbing, knife-like, boring or burning discomfort • Location : retrosternal, spreading frequently to both sides of the chest with predilection to the left side • Often pain radiates down ulnar aspect of left arm, producing tingling sensation in left wrist, hand and fingers __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA 15 www.default.com
  • 16. NATURE OF PAIN • SOME INSTANCES : pain begins in epigastrium, and simulates abdominal disorder • Sometimes pain radiates to shoulders, upper extremities, neck, jaw and interscapular region favoring the left side • Elderly : no chest pain but acute left ventricular failure and chest tightness or marked weakness or syncope • Pain arises from nerve endings in ischemic or injured, but not necrotic, myocardiumOTHER SYMPTOMS 50% nausea or vomiting in transmural infarcts Occasionally diarrhea, profound weakness, dizziness, palpitation, cold perspiration, sense of impending doom Occasionally : cerebral embolism or systemic arterial embolism __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA 16 www.default.com
  • 17. Pain Patterns with Myocardial Ischemia __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA 17www.default.com
  • 18. Anamnesis untuk UAP • 3 kategori presentasi klinik UAP:  Angina saat istirahat (resting angina)  Angina awitan baru (new onset angina)  Angina yang bertambah berat (increasing angina) • Riwayat penyakit dahulu :  Riwayat angina on effort, infark atau operasi pintas  Riwayat penggunaan nitrogliserin  Identifikasi faktor-faktor risiko __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA 18www.default.com
  • 19. PHYSICAL EXAMINATIONGENERAL APPEARANCEAnxious, considerable distress, restless, fist on chest (Levine sign)LV failure & symp. stimulation : cold perspiration, pallor, dyspnea, cough with frothy pink or blood-streaked sputum.Shock : cool, clammy skin, facial pallor, cyanosis, confusion or disorientationHEART RATEVariable depending on underlying rhythm and degree or ventr. failureMost commonly, HR 100 – 110/min; > 95% patients : VPB’s within first 4 hours __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA 19 www.default.com
  • 20. BLOOD PRESSUREMajority normotensive, but syst. BP may decline and diast. BP may rise Half of pts with inferior MI  parasympathetic stimulation : hypotension, bradycardia or both (Bezold – Jarisch reflex) half of pts with anterior MI,  sympathetic excess : hypertension, tachycardia or bothTEMPERATURE AND RESPIRATIONMost pts with extensive MI  fever within 24-48 hrs, fever resolves by 4th or 5th dayRespiration  due to anxiety and pain, in LV failure : resp. rate correlates with degree of heart failure __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA 20 www.default.com
  • 21. JUGULAR VENOUS PULSE JVP usually normal RV infarction : marked jug. venous distension CAROTID PULSE Small pulse  reduced stroke volume Pulse alternans : severe LV dysfunction __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA 21 www.default.com
  • 22. CHEST LV failure and/or LV compliance ↓ : moist rales Severe failure : diffuse wheezing, cough + hemopthysis 1967 : Killip & Kimball : prognostic classification Class I : patients free of rales or S3 II : rales < 50% lung fields +/- S3 III : rales > 50% lung fields, frequently pulm. edema IV : cardiogenic shock __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA 22 www.default.com
  • 23. Kelas Definisi Proporsi pasien Mortalitas(%) Tidak ada tanda gagal jantung I 40-50% 6 kongestif + S3 dan/atau ronki basah di basal II 30-40% 17 paru III Edema paru akut 10-15% 30-40 IV Syok kardiogenik 5-10% 60-80 __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 24. Patofisiologi __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 25. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 26. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 27. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 28. TRIAS DIAGNOSTIK IMA GEJALA GEJALA KHAS 1. Riwayat a. Nyeri dada bag dada depan ( bawah nyeri sternum) dg/ tnp penjalaran, kdg berupa dada yg nyeri dagu,leher/spt sakit gigi, pend tdk khas bs menunjukan rasa nyeri dg satu jari tetapi dg tangan. b. Kualitas nyeri spt ditekan,rasa berat/panas terbakar. c. Durasi . 15 “ smp 30 ‘ d. Kdg disertai mual, keringat dingin, berdebar/sesak e. Nyeri tak hlg dg istirahat/ nitrogliserin sublingual __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 29. 2. Adanya a. Gelombang Q (signifikan infark) / Q perubahan patologis EKG b. Segmen ST elevansi c. Gel T meninggi/menurun 3. Kenaikan a. CKMB mrp enzim yg spesifik sbg penanda enzim otot tjdnya kerusakan otot jtg , enzim ini jantung meningkat 6 – 10 jam stl nyeri dada & kembali normal dlm 48 – 72 jam b. Px. Aspartate Amino Transferase (AST) ps. Dtg sth hr ke 3 nyeri dada/ LDH (laktat dehydrogenase meningkat address Avenue,hr ke 4 & ssdh 4214, __________ DefaultLOGO AREA normal pd hr ke 10 Postal code 80.250-210www.default.com +55 32 3836 55 55 / Curitiba PR BR ___________________________________________ +55 32 9685 55 55
  • 30. The cardiovascular continuum of events ACS Coronary Thrombosis Arrhythmia and Loss of Muscle Myocardial Ischemia Remodeling Ventricular CAD Dilatation Atherosclerosis Congestive Heart Failure Risk Factors End-stage Heart ( DYSLIPIDEMIA , BP, DM, Disease Insulin Resistance, Platelets, __________ Default address Avenue, 4214, +55 32 3836 55 55 Fibrinogen, etc) Postal code 80.250-210 / Curitiba PR BR ___________________________________________ +55 32 9685 55 55LOGO AREA Adapted from www.default.com Dzau et al. Am Heart J. 1991;121:1244-1263
  • 31. •Get regular medical checkups. •Control your blood pressure. •Check your cholesterol. •Don’t smoke. •Exercise regularly. •Maintain a healthy weight. •Eat a heart-healthy diet. •Manage stress. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 32. Evidence base CMS AMI Quality Measures Inpatient Measures* • Aspirin at Arrival** • Fibrinolytic medication within 30 minutes of arrival • Aspirin at Discharge • Angiotensin Converting Enzyme (ACE) Inhibitor or Angio tensin Receptor Blocker (ARB) for • Left Ventricular Systolic Dysfunction (LVSD)** • Beta blocker at discharge** • Percutaneous Coronary Intervention (PCI) within 90 min utes of hospital arrival __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 33. Outpatient/Emergency Department Measures • Aspirin at arrival • Fibrinolytic medication within 30 minutes of arriv al • Median Time to Fibrinolysis • Median time to transfer to another facility for acu te coronary intervention • Median Time to Electrocardiogram (ECG) __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 34. IDENTITAS • Nama : Tn. D • Usia : 77 tahun • Pekerjaan : Pensiunan • Agama : Islam • Status : Menikah • Alamat : Lebak Wangi RT 04 RW 02 Arjasari • No. RM : 272400 Tanggal masuk RSUD Al Ihsan 02 Oktober 2012. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 35. ANAMNESIS Keluhan Utama • Nyeri dada sejak Sejak 3 hari sebelum masuk rumah sakit (SMRS). Riwayat Penyakit Sekarang • Sejak Sejak 3 hari SMRS, pasien merasakan nyeri dada yang mulai dirasakan saat hendak tidur. Nyari dada sebelah kiri menjalar ke leher dan punggung. Nyeri dada terasa seperti ditimpa beban berat. Nyeri dada seperti ini sering hilang timbul sejak 1 tahun SMRS dan mereda bila beristirahat. Nyeri saat ini dirasa memberat sejak 4 jam SMRS. Pasien merasa sesak nafas. Terdapat keringat dingin. Terdapat mual. Dada dirasakan berdebar-debar. Pasien pingsan saat dibawa ke RS. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 36. Riwayat Penyakit Dahulu • Sejak 2 tahun SMRS, pasien dikatakan mempunyai hipertensi dan tidak teratur minum obat. Pada bulan Maret 2012 klien dirawat di ruang ICU RSUD Al IHsan dengan CAD AMI VES multivokal, saat itu pasien sedang tidak teratur minum obat, dirawat karena muka bengkak dan sesak napas, diberikan obat Captopril 3x25 mg, Simart 2 1x1, Aldecto 1x25 mg, Lasix 1x1, Ascardia 1x1. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 37. Riwayat Penyakit Dahulu • Riwayat asma, alergi, gastritis, stroke, dan Diabetes mellitus disangkal Riwayat Penyakit Keluarga • Riwayat darah tinggi, Diabetes mellitus, penyakit jantung, asma disangkal Riwayat Pekerjaan,Sosial Ekonomi, Kejiwaan dan Kebiasaan • Pembiayaan RS secara pribadi __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 38. PEMERIKSAAN FISIK (02 Oktober 2012) Keadaan umum : Pasien tampak sakit sedang, Kesadaran : Compos mentis Nadi : 102x/menit, reguler, isi kurang, equal Nafas : 22x/menit, reguler, kedalaman cukup Suhu : 37.1 oC (aksila) Tekanan Darah : 106 / 61 mm hg Kesan gizi baik Kepala : deformitas (-). Rambut hitam, tidak mudah dicabut, dan tersebar merata. Nyeri tekan sinus (-) Mata : deformitas (-), ptosis (-), eksoftalmus (-), enoftalmus (-), xanthelasma -/-, pupil isokor, refleks pupil langsung (+ /+ ), refleks pupil tidak langsung (+/+), konjungtiva anemis (-/-). sklera ikterik (-/-). Hidung : deformitas (-), sekret (-), deviasi septum nasal (-), pernafasan cuping hidung (-) Mulut : lidah basah, tidak hiperemis. Stomatitis (-). T1-T1. caries dentis (-) Telinga : deformitas (-), serumen (-/-) Leher : Trakea di tengah. JVP 5-2 cmH2O, KGB leher tidak teraba KGB : KGB supraklavikula tidak teraba KGB intraklavikula tidak teraba KGB axila tidak teraba KGB inguinal tidak diperiksa __________ Default address Avenue, 4214, +55 32 3836 55 55 Kulit : kecoklatan Postal code 80.250-210 / Curitiba PR BR ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 39. Toraks Paru: simetris statis-dinamis, spider nevi (-), retraksi iga (-), sikatriks (-), massa (-). Bunyi napas vesikuler, rhonki basah halus basal paru (+/+), wheezing (-/-) Jantung: iktus kordis tidak terlihat. Iktus kordis teraba pada sela iga 5 linea midklavikula kiri, batas jantung kanan pada sela iga 4 pada linea sternalis kanan, batas jantung kiri pada sela iga 5 pada 2 jari lateral linea mid klavikula kiri. Bunyi jantung I/II normal, murmur (-), gallop (-) Abdomen : simetris, datar, lemas. Tidak ada nyeri tekan, massa (-), hati tidak teraba, limpa tidak teraba, ballottement (-/-), shifting dullness (-), bising usus (+) normal Alat Genitalia : tidak diperiksa Anus : tidak diperiksa Ekstremitas : Edema (-/-), akral hangat, sianosis -/-, clubbing finger -/-, atrofi otot (-/-), turgor baik. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 40. TIMI 02 Oktober 2012 :0 • Usia >65 tahun • Tekanan darah sistolik <100 mmHg :0 • Frekuensi nadi >100x/menit :2 • Killip kelas II-IV :2 • ST elevasi anterior atau LBBB :1 • Riwayat diabetes, hipertensi, atau angina :1 • Berat badan <67 kg :1 • Waktu sampai mendapat pengobatan >4 jam :1 • TOTAL : 8/14 __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 41. PEMERIKSAAN PENUNJANGLab 02 Oktober 2012HematologiHb : 13,2 g/dL (N: 12-14)Ht : 39.4 % (N: 40-48)Leukosit : 5400/ul (N:5000-10.000)Cardiac EnzymesCKMB : 50 U/l (N: 0-24)Troponin T : 0,1 ng/ml (MCI: 0,1-2)Renal ProstatUreum : 40 mg/dl (N: 13-43)Kreatinin : 1.20 mg/dl (N: 0-1,4)BUN : 20,09 mg/dl (N: 6-20)GlukosaGDS : 87 mg/dl (N:<180 mg/dl)ElektrolitNa : 142 mmol/l (N: 135-147)K : 3,6 mmol/l (N: 3,5-5,5)Cl : 110 mmol/l (N: 95-111) __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 42. EKG 02 Oktober 2012QRS rate 103x/menit, Aksis LAD, Gelombang P morfologi normal, durasi 0,08detik, PR interval 0,16’’, Kompleks QRS durasi 0,06’’, ST elevasi V2-V5, Qpatologis V3-V4 __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55 LOGO AREA www.default.com
  • 43. Foto Rontgen 02 Oktober 2012 • CTR 60% • Segmen aorta elongasi • Segmen pulmonal normal • cardiomegali (LV,LA) dengan bendungan paru • Apex lateral downward • Kongesti (-), infiltrat (-) __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 44. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 45. ECHOCARDIOGRAFI •  Dilatasi LV dan LA •  Akinetik anterior hipokinetik berat anteroseptal dan lateral •  EF 19% •  Disfungsi diastolic gr III •  MR moderat, PH mild •  PE minimal •  Kontraktilitas RV normal •  SPEC (+) di LV __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 46. DIAGNOSA KEPERAWATAN 1. Nyeri b.d ketidakseimbangan suplai drh & o2 dg kebutuhan miokardium akibat sekunder dari penurunan suplai drh ke miokardium, ↑ produksi asam laktat. 2. Aktual/ resiko tinggi ↓ curah jtg yg b.d perubahan, irama, konduksi elektrikal 3. Intoleransi aktifitasyg b. d. ↓ perfusi perifer akibat sekunder dr ketidakmampuan antara suplai dan kebutuhan 02 4. Cemas b.d. rasa takut akan kematian / perubahan kesehatan __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 47. Intervensi Nyeri b.d ketidakseimbangan suplai drh & o2 dg kebutuhan miokardium akibat sekunder dari penurunan suplai drh ke miokardium, ↑ produksi asam laktat • Tujuan : Dlm waktu 1 X 24 jam terdapat penurunan respon nyeri dada. • Kriteria hasil : 1. Secara subjektif klien menyatakan penurunan rasa nyeri dada. 2. Secara objektif didapatkan tanda vital dlm batas normal, wajah rileks, tdk terjadi penurunan perfusi perifer, produksi urine > 600 ml. __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 48. INTERVENSI RASIONAL Catat karakteristik nyeri, lokasi, Variasi penampilan & perilaku intensitas, lamanya dan klien krn nyeri yg terjadi dianggap penyebarannya sebagai temuan pengkajian Anjurkan klien u/ melaporkan nyeri Nyeri berat dpt mengakibatkan dg segera syok kardiogenik yg dampak pd kematian mendadak Lakukan managemen nyeri keperawatan 1. Atur posisi fisiologis ↑ asupan 02 kejarinag yg mengalami iskemik __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 49. 2. Istirahatkan klien ↓ kebutuhan 02 jar perifer shg akan ↓ keb miokardium & ↑ suplai drh dan 02 ke miokardium yg membthkan 02 utk ↓ iskemia 3. Beri 02 dg canul/ masker ↑ jml 02 yg ada utk sesuai indikasi pemakaian miokardium sekaligus ↓ ketidaknyamanan sekunder thd iskemia 4. Manajemen lingkungan , ↓ stimulus nyeri eksternal dan tenang & batasi ↑ kondisi 02 ruangan pengunjung 5. Ajarkan tehnik relaksasi ↑ asupan 02 shg a/ ↓ nyeri pernapasan dalam pd saat nyeri 6. Ajarkan tehnik distrasi pada Pengalihan code 80.250-210 / Curitiba PRdpt+55↓ 3836 55 55 perhatian4214, __________ Default address Avenue, Postal BR 32 stimulus internal www.default.com mll produksi ___________________________________________ +55 32 9685 55 55 saat nyeriLOGO AREA endorfin & enkefalin yg dpt
  • 50. 7. Lakukan manajemen Berupa sentuhan yg sentuhan merupakan dukungan psikologis dpt membantu ↓nyeri , masase ringan dpt ↑ aliran drh dg otomatis membantu suplai drh & 02 ke area nyeri Kolaborasi Antiangina ( nitrogliserin) Berguna u/ kontrol nyeri dg efek vasodilatasi koroner Analgesik ( morfin ) ↓ nyeri hebat, memberikan sedasi dan ↓ beban kerja __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA miokardium www.default.com
  • 51. PTCA (Angioplasti Koroner Usaha u/ memperbaiki aliran Transluminal Perkutan ) drh arteri koroner dg menhancurkan plak/ateroma yg tlah tertimbun& mengganggu aliran drh ke jtg CABG ( Coronary Arteri Tandur pintas arteri koroner Bypass Graft ) bertujuan ↑asupan suplai darah ke miokardium dg mengganti alur pintas __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 52. 2. Aktual/ resiko tinggi ↓ curah jtg yg b.d perubahan, irama, konduksi elektrikal Aktual/ resiko tinggi ketidak efektifan pola • Tujuan : dlm waktu 2 X 24 jam tdk tjd ↓ curah jantung • Kriteria hasil : stabilitas hemodinamik T : dbn, Curah jantung ↑,int & out sesuai, urine > 600 ml, tanda disritmia __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 53. Intervensi Rasional Auskultasi TD Hipotensi dpt tjd pd ,bandingkan ke 2 disfungsi ventrikel, lengan hipertensi  dg nyeri cemas pengeluaran katekolamin Evaluasi kualitas dan ↓ curah jantung kesamaan nadi mengakibatkan ↓ kekuatan nadi __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 54. Pantau frekuensi jtg & Perub frekuensi & irama irama jtg menunjukan komplikasi disritmia Beri makan kecil/ mdh Mkn besar dpt ↑kerja dikunyah, batasi asupan miokardium. Kafein dpdt kafein merangsang lgs ke jtg shg ↑frekuensi jtg Kolaborasi Jalur paten pemberian Pertahankan cara msk obat darurat heparin (IV) sesuai indikasi Memantau perluasan Pantau lab enzim jtg, infark,elektrolit GDA & elektrolit berpengaruh thd irama __________ Default address Avenue, 4214, +55 32 3836 55 55 jantung Postal code 80.250-210 / Curitiba PR BR ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 55. 5.Intoleransi aktifitasyg b. d. ↓ perfusi perifer akibat sekunder dr ketidakmampuan antara suplai dan kebutuhan 02 • Tujuan : 3 x 24 J aktifitas klien mengalami peningkatan • Kriteria hasil : * tdk mengeluh pusing, ttv dbn, CRT <3“ __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 56. Intervensi Rasional Catat frekuensi jtg, Respon klien thd aktifitas irama perub TD selama & dpt mengidentifikasi ↓O2 sesudah aktifitas miokardium Tingkatkan istirahat, ↓ kerja miokardium/ batasi aktifitas & beri konsumsi O2 aktifitas yg tdk berat Anjurkan u/ menghindari Mengakibatkan ↑tekanan abdomen  bradikardi, ↓ curah jtg, mengejan ↑TD __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 57. Jelaskan pola ↑ bertahap Aktifitas yg maju memberikan kontrol jtg, ↑ regangan & mencegah aktifitas berlebih Rujuk ke program ↑ O2 yg ada u/ rehabilitasi jatung pemakaian miokardium sekaligus > ketidak nyamanan karena iskemik __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 58. Evaluasi • Hasil yg diharapkan pd proses perawatan klien tanpa komplikasi __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 59. EVIDENCE PERLU PENELITIAN LEBIH LANJUT • Efektifitas Echocardiografi berulang dengan kondisi klien yang sudah dirawat sebelumnya sehingga perlunya penelitian lebih lanjut. • Sesuai kasus Tn, I bahwa pasien kurang mendapat informasi tentang kondisi sakitnya, sehingga dapat mempengaruhi tingkat kooperatif pasien maka berdasarkan evidence tersebut penting digali lebih dalam bagaimana pengaruh pengetahuan penyakit jantung terhadap tingkat ketaatan pasien saat dirawat, karena kerjasama dengan perawat pasien sangat penting diperlukan dan juga perlu digali pengalaman pasien yang mengalami serangan jantung yang pertama kali dan yang lebih dari dua kali sehingga didapat gambaran tentang kondisi-kondisi pasien yang mengalami serangan jantung __________ Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ +55 32 9685 55 55LOGO AREA www.default.com
  • 60. Thank You __________ __________ Default address Avenue, 4214, Default address Avenue, 4214, Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 Postal code 80.250-210 / Curitiba PR BR +55 32 3836 55 55 ___________________________________________ ___________________________________________ +55 32 9685 55 55 +55 32 9685 55 55LOGO AREA www.default.com www.default.com