06 Nursing Care of CAD

8/16/2019 06 Nursing Care of CAD

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Emil Huriani 1

Asuhan keperawatan pada

Penyakit Arteri Koronaria


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Emil Huriani 2

Heart Anatomy

Figure 18.1


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Emil Huriani 3

Dinding Jantung

Epikardium – Lapisan terluar perikardium

Miokardium – Lapisan otot jantung yangmembentuk lapisan tebal pada jantung

Endokardium – lapisan endotelium di bagian

dalam miokardium


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Emil Huriani 5

Arteri – koronaria kiri dan kanan marginal!ir!um"le# dan arteri inter$entri!ular anterior

Vena – $ena besar anterior dan ke!il

Jantung bagian luar: Pembuluh darah yang

membawa darah ke dan dari dinding jantung

(Anterior


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Emil Huriani 6

External Heart: Po!terior View

Figure 18.4d


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Emil Huriani 7

Arteri – arteri koronaria kanan dan arteri

inter$entri!ular posterior

Vena – $ena besar $ena posterior $entrikel kirisinus !oroner dan $ena tengah

Jantung bagian luar: Pembuluh darah yang

membawa darah ke dan dari dinding jantung

(Po!terior


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Emil Huriani 8

"irkula!i #oroner

"irkula!i $oroner adalah suplay darah "ungsional ke

otot jantung

Jalur kolateral memastikan aliran darah ke jantung

walaupun pembuluh darah besar tersumbat


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Emil Huriani 9

%oronary %ir$ulation: Arterial "upply

Figure 18.%a


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Emil Huriani 10

%oronary %ir$ulation: Venou! "upply

Figure 18.%b


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Athero!klero!i!


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&eori Atero!klero!i!

/edera endothelium &ndothelial injury !aused byhyperlipidemia hypertension or other irritant agents

0e"ense "a!tors released into the endothelial lining and !auses

migration o" smooth mus!le !ells into the intima

he presen!e o" smooth mus!le !ells initiate the synthesis o"

!ollagen proteins and proteogly!ans

he a!!umulation o" intra!ellular and e#tra!ellular lipids and

platelets

Formation o" su!h lesions su!h as thrombus


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&ahapan Athero!klero!i!

Fatty 2treak

(ntermediate lesion

Atheroma

/ompli!ated lesion

rupture

Fibrosis pla3ue


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Athero!klero!i! &ahap '

&ndothelialdis"un!tion !aused

by L0L !holesterol

in"e!tion and "ree

radi!als

igration o"

monosite

lymphosites andma!rophages


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Athero!klero!i! &ahap

Prolipheration o"

smooth mus!le

!ell and platelet

aggregation


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Athero!klero!i! &ahap )

5e!rosis o" !orelesion


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Athero!klero!i! &ahap *

Fibrous !ap

thinning and

rupture due to thein"lu# and

a!ti$ation o"

ma!rophages


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Athero!klero!i! &ahap +

he release o"

proteolyti!

en6ymes

"ollowed byhemorrhage

thrombus

"ormation and

arterial o!!lusion


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,i!k -a$tor! ('

7nmodi"iable

Age' 9: years

;ender' men women

Family history


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,i!k .a$tor! () here are a number o" other less wellestablished risk "a!tors "or

atheros!lerosis in!luding'


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%lini$al Mani.e!tation!

Emil Huriani 23

he !lini!al mani"estations o" atheros!lerosis depend on the $essels in$ol$edand the e#tent o" $essel obstru!tion.

Atheros!leroti! lesions produ!e their e""e!ts through'

narrowing o" the $essel and produ!tion o" is!hemiaG

sudden $essel obstru!tion !aused by pla3ue hemorrhage or ruptureG

thrombosis and "ormation o" emboli resulting "rom damage to the $essel

endotheliumG

(n larger $essels su!h as the aorta the important !ompli!ations are those o"thrombus "ormation and weakening o" the $essel wall.

(n mediumsi6e arteries su!h as the !oronary and !erebral arteries is!hemiaand in"ar!tion !aused by $essel o!!lusion are more !ommon.

Although atheros!lerosis !an a""e!t any organ or tissue the arteries supplyingthe heart brain kidneys lower e#tremities and small intestine are most"re3uently in$ol$ed.


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%oronary heart di!ea!e

he term coronary heart disease */


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Angina Pe$tori!

0e"inition

;enerally des!ribed as retrosternal

hea$y or gripping sensation with

radiation to le"t arm or ne!k pro$oked

by e#ertion and eased with rest or

nitrates


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Angina $an be:

2table

7nstable !aused by

unstable pla3ue o!!urs at

rest unpredi!table pain !an

in!rease "or no ob$ious

reason

Prin6metalHs o!!urs

without pro$o!ation usually

at rest as a result o"

!oronary artery spasm


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"table angina pe$tori!

Pro$oked by physi!al e#ertion

espe!ially in !old weather a"ter

meals and !ommonly aggra$ated by anger or e#!itement

he pain "ades 3ui!kly with rest

(n some patients pain o!!urs predi!tably at a !ertain le$el o"

e#ertion


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/0% %AD


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"ign! and !ymptom!

/hest pain

5ausea D $omitting

2timulation o" 2ympatheti! ner$ous system

Fe$er

/ardio$as!ular mani"estation


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Myo$ardial in.ar$tion

A!ute myo!ardial in"ar!tion *A(- also known as a heart atta!k is

!hara!teri6ed by the is!hemi! death o" myo!ardial tissue asso!iated withatheros!leroti! disease o" the !oronary arteries.

0iagnosis' 1. Pain

he pain typi!ally is se$ere and !rushing o"ten des!ribed as being

!onstri!ting su""o!ating. (t usually is substernal radiating to the

le"t arm ne!k or jaw although it may be e#perien!ed in other areas

o" the !hest. ;astrointestinal !omplaints are !ommon. here may be a sensation

o" epigastri! distressG nausea and $omiting may o!!ur. =. &/;

&le$ation o" the 2 segment usually indi!ates a!ute myo!ardialinjury.

Jhen the 2 segment is ele$ated without asso!iated wa$es it is

!alled a non"#$%ae in&arction. A non–wa$e in"ar!tion usually

represents a small in"ar!t that may e$ol$e into a larger in"ar!t.

. &n6ymes


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En1yme!

'yo!lo(in is an o#ygen!arrying protein similar to hemoglobin that isnormally present in !ardia! and skeletal mus!le. (t is a small mole!ule thatis released 3ui!kly "rom in"ar!ted myo!ardial tissue and be!omes ele$atedwithin 1 hour a"ter myo!ardial !ell death with peak le$els rea!hed within 4

to 8 hours. (t rapidly eliminates through urine *low mole!ular weight-.Be!ause myoglobin is present in both !ardia! and skeletal mus!le it is not!ardia! spe!i"i!.

Creatine )inase */K- "ormerly !alled creatinine phospho)inase, is anintra!ellular en6yme "ound in mus!le !ells. us!les in!luding !ardia!mus!le use AP as their energy sour!e. /reatine whi!h ser$es as a storage"orm o" energy in mus!le uses /K to !on$ert A0P to AP. /K e#!eedsnormal range within 4 to 8 hours o" myo!ardial injury and de!lines tonormal within = to days. here are three isoen6ymes o" /K with the B

isoen6yme */KB- being highly spe!i"i! "or injury to myo!ardial tissue.


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En1yme!

he troponin comple* !onsists o" three subunits *i+e+, troponin / troponin (and troponin - that regulate !al!iummediated !ontra!tile pro!ess in striatedmus!le. hese subunits are released during myo!ardial in"ar!tion. /ardia!

mus!le "orms o" both troponin and troponin ( are used in diagnosis o"myo!ardial in"ar!tion. roponin ( *and troponin G not shown- rises moreslowly than myoglobin and may be use"ul "or diagnosis o" in"ar!tion e$en upto to 4 days a"ter the e$ent. (t is thought that !ardia! troponin assays aremore !apable o" dete!ting episodes o" myo!ardial in"ar!tion in whi!h !elldamage is below that dete!ted by /KB le$el.

M di l i . ti


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E.. . AM2


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E..e$t! o. AM2

he prin!ipal bio!hemi!al !onse3uen!e o" A( is the !on$ersion "rom aerobi!to anaerobi! metabolism with inade3uate produ!tion o" energy to sustain

normal myo!ardial "un!tion.

he is!hemi! area !eases to "un!tion within a matter o" minutes and

irre$ersible myo!ardial !ell damage o!!urs a"ter => to 4> minutes o" se$ere

is!hemia.

he term reper&usion re"ers to reestablishment o" blood "low through use o"

thrombolyti! therapy or re$as!ulari6ation pro!edures.

&arly reper"usion *within 1: to => minutes- a"ter onset o" is!hemia !an

pre$ent ne!rosis.

Ieper"usion a"ter a longer inter$al !an sal$age some o" the myo!ardial

!ells that would ha$e died be!ause o" longer periods o" is!hemia.

E%3


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E%3

2 segment ele$ations

typi!ally due to !omplete o!!lusion o" a !oronary

artery.

52&(s typi!ally a sudden narrowing o" a !oronary artery

with preser$ed *but diminished- "low to the distal

myo!ardium.

Anti!oagulation and antiplatelet agents

pre$ent the narrowed artery "rom o!!luding.


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#la!i.ika!i #2442P

7sed in indi$iduals with an a!ute myo!ardial in"ar!tion

to risk strati"y

(ndi$iduals with a low Killip !lass are less likely to die withinthe "irst >

K(LL(P ( 2esak tanda gagal jantung *- Mortality rate 5 67

K(LL(P (( 2esak Ihonkhi *?- Mortality rate 5 '87

K(LL(P ((( 2esak Ihonkhi luas *&dema Pulmonal- Mortalityrate 5 )97

K(LL(P (M 2yok Kardiogenik. Mortality rate 5 9'7

http://en.wikipedia.org/wiki/Myocardial_infarctionhttp://en.wikipedia.org/wiki/Myocardial_infarction


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&AIL) A5A;&&5

he patientHs history and 1=lead &/; are the primary methods

used to determine initially the diagnosis o" (.

he &/; is e#amined "or the presen!e o" 2 segmentele$ations o" 1 mM or greater in !ontiguous leads.

1. Administer aspirin 19> to =: mg !hewed.

=. A"ter re!ording the initial 1=lead &/; pla!e the patient ona !ardia! monitor and obtain serial &/;s.

. ;i$e o#ygen by nasal !annula.

Management


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4. Administer sublingual nitrogly!erin *unless thesystoli! blood pressure is less than C> mm or greater than 1>>

beats?minute-.

:. Pro$ide ade3uate analgesia with morphine sul"ate.

Pro$ide ade3uate analgesia with morphine sul"ate.


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% li ti


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%ompli$ation!

Arrhythmias

/ongesti$e


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Treatment (continued)

1) Stenting

N a stent is introdu!ed into a blood $essel on a balloon!atheter and ad$an!ed into the blo!ked area o" the artery

N the balloon is then in"lated and !auses the stent to e#pand

until it "its the inner wall o" the $essel !on"orming to

!ontours as needed

N the balloon is then de"lated and drawn ba!k

Nhe stent stays in pla!e permanently holding the $esselopen and impro$ing the "low o" blood.


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Treatment

(continued)

2) AngioplastyN a balloon !atheter is passed through the guiding !atheter to thearea near the narrowing. A guide wire inside the balloon !atheter is

then ad$an!ed through the artery until the tip is beyond the

narrowing.

N the angioplasty !atheter is mo$ed o$er the guide wire until the

balloon is within the narrowed segment.

N balloon is in"lated !ompressing the pla3ue against the artery wall

N on!e pla3ue has been !ompressed and the artery has been

su""i!iently opened the balloon !atheter will be de"lated and

remo$ed.


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Treatment (continued)

- Bypass surgery

N healthy blood $essel is remo$ed "rom leg arm or !hest

N blood $essel is used to !reate new blood "low path in your heart

N the +bypass gra"t, enables blood to rea!h your heart by "lowingaround *bypassing-

the blo!ked portion

o" the diseased

artery. he in!reased

blood "low redu!esangina and the risk

o" heart atta!k.


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N3et regular medi$al $he$kup!

N%ontrol your blood pre!!ure

N%he$k your $hole!terol

NDon;t !moke

NExer$i!e regularly

NMaintain a healthy weight

NEat a heart


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=ur!ing pro$e!!

ssessment A $are.ul hi!tory

De!$ription o. !ymptom! ( $he!t pain> palpitation>dy!pnea> !yn$ope or !weating Ea$h !ymptom!

mu!t be e?aluated with regard to time> duration>

pre$ipitating @ relie?ing .a$tor! 2n addition

$omplete phy!i$al a!!e!!ment .or:

le?el o. $on!$iou!ne!!

=ur!ing pro$e!! ($ont


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Heart !ound!

Peripheral pul!e!

4ung !ound

=ur!ing pro$e!! ($ont…

=ur!ing Diagno!e!


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• A!ute Pain related to o#ygen supply and demand

imbalan!e

• Iisk "or ine""e!ti$ely o" !ardia! tissue per"usion

• An#iety related to !hest pain "ear o" death threatening

en$ironment

• 0e!reased /ardia! Eutput related to impaired

!ontra!tility

• A!ti$ity (ntoleran!e related to insu""i!ient o#ygenation

to per"orm a!ti$ities o" daily li$ing de!onditioning

e""e!ts o" bed rest

• Iisk "or (njury *bleeding- related to dissolution o"

prote!ti$e !lots

=ur!ing Diagno!e!

=ur!ing pro$e!! ($ont


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Patient's goals

, eport that pain i! de$rea!ed

Breath e..e$ti?ely

Experien$e le!! anxiety le?el

Ha?e impro?ed ti!!ue per.u!ion

Adhere to the !el. $are program


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Nursing intervention

Ielie" or !ontrol o" !hest pain

Alle$iate respiratory di""i!ulties

Iedu!e the an#iety le$el

aintain ade3uate tissue per"usion


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Documents

06 Nursing Care of CAD