Coronary Artery Disease Case Study
-
Upload
endah-rahmawati -
Category
Documents
-
view
225 -
download
0
Transcript of Coronary Artery Disease Case Study
-
8/12/2019 Coronary Artery Disease Case Study
1/30
Askep Infark Miokard
-
8/12/2019 Coronary Artery Disease Case Study
2/30
Pendahuluan Infark miokard: rusaknya jaringanjantung akibat suplai darah yang tidak
adekuat.
Penyebab penurunan suplai darahakibat aterosklerosis atau penyumbatan
total arteri oleh emboli atau trombus.
-
8/12/2019 Coronary Artery Disease Case Study
3/30
Manifestasi klinis Nyeri dada yang tiba-tibadan berlangsung
terus-menerus, terletak di bagian bawah
sternum; Nyeri terasa berat sampai tidak tertahankan;
menyebar ke bahu dan lengan kiri
Nyeri tidak hilang dengan istirahat/
nitrogliserin Nyeri sering disertai nafas pendek, pucat,
berkeringat dingin, pusing, mual dan muntah
-
8/12/2019 Coronary Artery Disease Case Study
4/30
Evaluasi Diagnostik EKG
ST segment depression or T wave inversion
>1 mm in 2 or more related leads Biokimia :Troponin T
- More sensitive and specific than CKMB
- Rise in 3-4 hours persist up to 2 weeks- Mostly negative in early stage (repeat
in 6-12 hours)
-
8/12/2019 Coronary Artery Disease Case Study
5/30
ST Elevasi
CKMB
meningkat
Troponin Tmeningkat
http://bmj.com/content/vol324/issue7341/images/large/ecg08.f3.jpeg -
8/12/2019 Coronary Artery Disease Case Study
6/30
Non-ST Elevation Myocardial Infarction/
Unstable Angina
NSTEMI Unstable Angina
Troponin T (+) Troponin T (-)
CKMB meningkat
http://bmj.com/content/vol324/issue7341/images/large/ecg08.f9a.jpeg -
8/12/2019 Coronary Artery Disease Case Study
7/30
Penatalaksanaan Medis Terapi oksigen dan tirah baring
Vasodilator; Nitrogliserin
Antikoagulan; Heparin
Trombolitik; streptokinase
Analgetik; morphin sulfat IV 1-2mg
-
8/12/2019 Coronary Artery Disease Case Study
8/30
Pengkajian Nyeri dada
Sulit bernafas (dispnoe, palpitasi, diaporesis)
Tingkat kesadaran Frekuensi dan irama jantung
Bunyi jantung (S3 gallop ventrikel; setelahterjadi MI, tanda awal gagal ventrikel kiri
yang mengancam) Murmur perubahan fungsi otot miokardium
Tekanan darah ES vasodilator: hipotensi
-
8/12/2019 Coronary Artery Disease Case Study
9/30
Pengkajian Denyut nadi perifer perbedaan
frekuensi denyut nadi perifer dengan
denyut jantung: disritmia Sianosis kekurangan oksigen
Nafas pendek, bunyi krekel gagal
jantung Status volume cairan, edema
Oliguri tanda shock
-
8/12/2019 Coronary Artery Disease Case Study
10/30
Diagnosa Keperawatan Nyeri dada berhubungan dengan
berkurangnya aliran darah koroner
Potensial pola pernafasan tidak efektifberhubungan dengan cairan tubuh berlebih
Potensial gangguan perfusi jaringanberhubungan dengan curah jantung menurun
Cemas berhubungan dengan takut akankematian
-
8/12/2019 Coronary Artery Disease Case Study
11/30
Masalah kolaborasi Disritmia
Edema paru
Gagal jantung kongestif
Tromboembolisme
-
8/12/2019 Coronary Artery Disease Case Study
12/30
IntervensiMengurangi nyeri
Kolaborasi nitrogliserin, trombolitik,
morphin
Terapi oksigen 2-4 l/m nasal kanul
Istirahat fisik
-
8/12/2019 Coronary Artery Disease Case Study
13/30
Intervensi Memperbaiki fungsi respirasi
Kaji fungsi pernafasan mendeteksi
komplikasi paru
Catat status cairan mencegahkelebihan cairan di paru
Anjurkan nafas dalam
-
8/12/2019 Coronary Artery Disease Case Study
14/30
Intervensi Meningkatkan perfusi jaringan yang adekuat
Mengawasi suhu dan denyut nadi perifer
Memberikan oksigen
-
8/12/2019 Coronary Artery Disease Case Study
15/30
IntervensiMengurangi kecemasan
Membina hubungan saling percaya
Beri kesempatan pasien berbagi rasa
-
8/12/2019 Coronary Artery Disease Case Study
16/30
-
8/12/2019 Coronary Artery Disease Case Study
17/30
The emergency room staff start centraland peripheral intravenous lines and
begin to administer oxygen per nasalcannula at 2L/min. They obtain a lead12-lead ECG and the following labwork :cardiac enzymes and isoenzymes, ABGs,
CBC, and a chemistry panel. Morphinesulfate is successful at relieving Mrs.Williams's pain
-
8/12/2019 Coronary Artery Disease Case Study
18/30
Mrs. Williams's medical history includes adiagnosis of adult-onset diabetes, angina, and
hypertension. She has a 45-year history ofcigarette smoking, averaging 1 to 2 packsper day. Her family history reveals that Mrs.Williams's father died at age 42 of MI, and her
paternal grandfather died at age 65 of MI.
-
8/12/2019 Coronary Artery Disease Case Study
19/30
The client history , initial assessmentdata, and ECG results point toward an
acute anterior wall MI. Mrs Williams hasno contraindications to thrombolytictherapy and is deemed a good
candidate
-
8/12/2019 Coronary Artery Disease Case Study
20/30
Assessment
Dan Morales, RN is assign as Mrs. Williams'sprimary care nurse. He helps her get settled
into the room and then performs a head-to-toe assessment. Mrs. Williams is alert andoriented to person, place and time. Vital signsare as follows : P, 118; BP, 172/92; R, 24;
with adequate depth; temperature 37.5 C.Auscultation reveals an S4 and fine cracklesin the bases of both lungs.
-
8/12/2019 Coronary Artery Disease Case Study
21/30
The ECG shows sinus tachycardia andevidence of an evolving anterior MI.
her skin is cool and slightly diaphoretic .Capillary refill time is less than 3seconds , and peripheral pulses are
strong and equal. Her nail beds arepink.
-
8/12/2019 Coronary Artery Disease Case Study
22/30
Assessment
A triple lumen central line is in place .Nitroglycerin is infusing at 200g/min in
the distal lumen; the alteplase infusionis in the middle lumen, and a heparin isin the proximal lumen. The peripheral
intravenous line is being maintainedwith an infusion of 5% dextrose in normal saline solution at 50mL/h.
-
8/12/2019 Coronary Artery Disease Case Study
23/30
Diagnosis
Pain (chest pain) related to imbalance betweenoxygen supply and demand
Anxiety and Fear related to change in health status
Altered Protection related to the risk of bleedingsecondary to thrombolytic therapy
Risk for injury related to altered cardiac rate andrhythm
Knowledge deficit regarding myocardial infarctiondisease process and the use of thrombolytic therapy
-
8/12/2019 Coronary Artery Disease Case Study
24/30
Planning and Implementation
Instruct Mrs. Williams to alert the nurse forany complaints of chest pain. Monitor andevaluate Mrs. Williams complaint of chest
pain using a scale of 0 to 10. Administermorphine intravenously in increaments of 2 to4 mg for chest pain unrelieved bynitroglyserin infusion.
Encourage Mrs. Williams to verbalize herfears and concerns. Answer questionshonestly, and correct any misconceptionsregarding the disease process, therapeuticinterventions, or prognosis.
-
8/12/2019 Coronary Artery Disease Case Study
25/30
Encourage Mrs. Williams to verbalize herfears and concerns. Answer questions
honestly, and correct any misconceptionsregarding the disease process, therapeuticinterventions, or prognosis.
Assess Mrs. Williams knowledge of how
atherosclerosis plaques develop and occludethe coronary arteries.
-
8/12/2019 Coronary Artery Disease Case Study
26/30
Assess for manifestation of internal orintracranial bleeding ; Note complaints
of back or abdominal pain, headache,decreased level of consciousness ,dizziness, bloody secretions orexcretions, or pallor. Perform guaiac
testing on all stools, urine, and vomitus.Notify physician immediately ofabnormal findings.
-
8/12/2019 Coronary Artery Disease Case Study
27/30
Planning and Implementation
Monitor Mrs Williams for signs ofreperfusion : decresed chest pain,
return of ST segment to base line,reperfusion dysrhytmias (bradycardia,heart block)
-
8/12/2019 Coronary Artery Disease Case Study
28/30
Continuously monitor ECG for changes incardiac rate, rhythm, and conduction. Assess
vital signs and associated symptoms withchanges in ECG. Note hypotension, syncopeor palpitation.
Maintain a supply of emergency cardiac drugs
and equipment ( i.e., lidocaine, epinephrine,atropine, the defibrillator, pacemaker,intubation tray )
-
8/12/2019 Coronary Artery Disease Case Study
29/30
Evaluation
After the initial morphin dose, Mrs. Williamsnotes a re duction in her chest pain from a
pain rating of 8 to 4. The nitroglyserininfusion and thrombolytic therapy furtherreduce her pain to 2. The nitroglyserin isgradually discontinued after 24 hours.
She is able to describe a basic anderstandingof plaque formation and the resultingobstruction to blood flow.
-
8/12/2019 Coronary Artery Disease Case Study
30/30
No indication of bleeding problems arenoted.
Evidence of reperfusion is noted. Chestpain has been relieved ; the ECG showsthat the ST segment is returning tobaseline
Mrs. Williams remains in CCU for 2 daysand is transferred to the floor.