Diagnosis Keperawatan terkait Cardiovaskular Responses
Diagnosis Keperawatan terkait Cardiovaskular ResponsesSri
SetiyariniSubag. KGD
Tujuan Pembelajaran:Mampu memahami dan mampu merumuskan diagnosa
serta manajemen keperawatan terkait gangguan sistem
kardiovaskular.Pokok Bahasan:Diagnosa dan manajemen keperawatan
terkait gangguan sistem kardiovaskulerSubpokok Bahasan:Merumuskan
Diagnosa KeperawatanCardiovascular responsesCardiac Output
DeterminationEffect of various conditions on cardiac output
Merumuskan Diagnosa Kep. (NANDA 2007-2008, Hal 297)mulai dng
pengkajian & pengambilan data riwayat klien (pasien, keluarga,
komunitas)Data dikaji dan dikumpulkan untuk mengidentifikasi tanda
dan gejala atau mendefinisikan karakteristik-karakteristik
(defining characteristic) dari diagnosa tersebut.Faktor-faktor atau
variabel yang mempengaruhi diagnosa (related factors) terintegrasi
dengan riwayat, bukti-bukti lain atau chart dan KOMBINASI defining
characteristic & related factors akan diformulasi menjadi suatu
diagnosis.Bagan alurPengkajian: Pengumpulan dataIdentifikasi
defining characteristicRelated factorsTerintegrasi dng riwayat,
bukti-bukti lain atau chart Diagnosacek kesesuaiannya dng definisi
diagnosaCardiovaskular Responses(NANDA 2009 2011)Domain 4:
activity/restClass 4: cardiovaskular/respiratory responses
Diagnosa Keperawatan(NANDA 2009 - 2011Decrease cardiac Output
(00029)Ineffective Peripheral Tissue Perfusion (00204) Activity
Intolerance (00092)Risk for Activity Intolerance (00094)Risk For
Bleeding (00206)
Diagnosa keperawatanRisk for Decreased cardiac Tissue perfusion
(00200)Risk for Ineffective Cerebral Tissue Perfusion (00201)Risk
for Ineffective Gastrointestinal Perfusion (002002)Risk for
Ineffective Renal Perfusion (00203)Risk for Shock (00205)
8
Diagnosis Decrease Cardiac Output (CO) DefinitionInadequate
blood pumped by the heart to meet the metabolic demands of the
bodyCardiac Output Determination
Cardiac Output (C0) is the volume of blood that is pumped out of
the heart per minute. (Normal= 4-8 liters/minute)
CO = Heart Rate X Stroke Volume (CO=HR X SV)9EFFECT OF VARIOUS
CONDITIONS ON CARDIAC OUTPUT.
Interaksi antar komponen-komponen yang mengatur CO dan tekanan
atrial. Tanda panah tebal menandakan PENINGKATANTanda panah
putus-putus menandakan
PENURUNANCOAfterloadkontraktilitasPreloadPemendekan serat
miokardArterial PressureHeart RateSroke volumeUkuran ventrikel
kiriResistensi periferSTROKE VOLUME - volume of blood ejected as he
ventricles contract with each heart beat During systole = 70ml - 90
ml /PRELOAD - degree of tension on the muscle when it begins to
contractCARDIAC OUTPUT - the quantity of blood pumped into the
aorta each minute by the heartAFTERLOAD - load against which the
muscle exerts its contractile force - pressure in the artery
leading from the ventricleRelated FactorsAltered preloadAltered
afterloadAltered contractilityAltered heart rate, Altered
rhythmAltered Stroke Volume
Penyakit/kondisi yg menurunkan COUmumnya:myocardial
infarction,Hypertensionvalvular heart disease, congenital heart
disease, cardiomyopathy, pulmonary disease, arrhythmias, drug
effects, fluid overload, decreased fluid volume, electrolyte
imbalance.
Diagnosis Lainnya(mendahului atau lanjutan)Ineffective
Peripheral Tissue Perfusion (00204) Activity Intolerance
(00092)Risk for Activity Intolerance (00094) Risk for Ineffective
Cerebral Tissue Perfusion (00201)Risk for Ineffective
Gastrointestinal Perfusion (002002)Risk for Ineffective Renal
Perfusion (00203)Risk for Shock (00205)CO Arterial
PressureResistensi periferMAP= Tekanan Rata-rata Arterial(mean
arterial pressure)As blood is pumped out of the left ventricle into
the arteries, pressure is generatedMAP = (CO SVR) + CVP Karena CVP
umumnya dengan nilai /mendekati 0 mmHg, maka persamaan tersebut
dapat disederhanakan menjadi: MAP approx = CO SVR MAP = 1 sistolik
+ 2 Diastolik 3 atau
MAP
menggambarkan TEKANAN PERFUSI ke ORGAN-ORGAN tubuh
MAP normal = 70 105 mmHgMAPMAP > 60 mmhg, cukup untuk menjaga
perfusi organ.Jika MAP turun secara bermakna dan dalam waktu cukup
lama, aliran darah ke organ-organ akan berkurang dan dapat
berlanjut menjadi iskemiBlood Flow to the Organs Matches Body
Requirements
Active organs such as the liver, brain and kidney have high
blood flows at rest About 25% of the cardiac output goes to the
kidney Composition of the blood is continuously regulated by the
kidney Gastrointestinal tract & liver get another 25% Muscle
circulation at rest is about 20% of cardiac output Brain needs
about 15% of the cardiac output
Low blood pressure results in inadequate perfusionBrainHeart -
(70% coronary artery perfusion occurs during diastole) (Diastolic
pressure < 50 mmHg compromises perfusion of heart)KidneysBP = CO
PVR (peripheral vascular resistance )AtauBP CO/r4 (resistensi
pembuluh drh kecil)
111111Diagnosis :Ineffective Peripheral Tissue Perfusion
(00204)Definition: decrease in blood circulation to the periphery
that may compromise health Def Charac & related Fact; see NANDA
2009 2010Diagnosis: Activity Intolerance (00092)Definition:
insufficient physiological or psychological energy to endure or
complete required or desired daily avtivitiesDef Charac &
related Fact; see NANDA 2009 2010
Risk for Activity Intolerance (00094) Diagnosis: Risk for
Ineffective Renal Perfusion (00203)Definision: at risk for a
decrease in circulation to the kidney that may compromise
healthDiagnosis: Risk for Ineffective Cerebral Tissue Perfusion
(00201)Definition: risk for a decrease in cerebral tissue
circulationDiagnosis: Risk for Ineffective Gastrointestinal
Perfusion (002002)Definition: at risk for a decrease in
gastrointestinal circulationDiagnosis: Risk for Shock
(00205)Definition: at risk for an inadequate blood flow to the
bodys tissue wich may lead to lifr-threatening cellular
dysfunctionDiagnosis: Risk For Bleeding (00206)Definition: at risk
for a decrease in blood volume that may compromise healthDiagnosis:
Risk for Decreased cardiac Tissue perfusion (00200)Definition: risk
for a decrease in cardiac (coronary) circulation24Left
CHF/Pulmonary Congestion
Cardiac Pump Effectiveness Circulatory Status Tissue Perfusion:
Abdominal Organs Tissue Perfusion: Peripheral Vital Signs Status
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC LabelsDemonstrates adequate cardiac output as
evidenced byblood pressureand pulse rate and rhythm within normal
parameters for client; strong peripheral pulses; and an ability to
tolerate activity without symptoms of dyspnea, syncope, or chest
painRemains free of side effects from the medications used to
achieve adequate cardiac outputExplains actions and precautions to
take for cardiac diseaseClient OutcomesCardiac Care:
AcuteCirculatory Care NIC Interventions (Nursing Interventions
Classification)Suggested NIC Labels Monitor for symptoms of heart
failure and decreased cardiac output, Listen to heart sounds; note
rate, rhythm, presence of S3, S4, and lung sounds. Observe for
confusion, restlessness, agitation, dizziness. Central nervous
system disturbances may be noted with decreased cardiac
output.Observe for chest pain or discomfort; note location,
radiation, severity, quality, durationNursing InterventionsIf chest
pain is present, have client lie down, monitor cardiac rhythm, give
oxygen, run a strip, medicate for pain, and notify the physician.
Place on cardiac monitor; monitor for dysrhythmias, especially
atrial fibrillation. Atrial fibrillation is common in heart
failure.Monitor hemodynamic parameters for an increase in pulmonary
wedge pressure, an increase in systemic vascular resistance, or a
decrease in cardiac output and index. Titrate inotropic and
vasoactive medications within defined parameters to maintain
contractility, preload, and afterload per physician's order.
Monitor intake and output. ( measure hourly urine output acute
cond)Note results of EKG and chest Xray. Results of diagnostic
imaging studies such as echocardiogram, radionuclide imaging or
dobutamine stress echocardiography.. An ejection fraction in a
healthy heart is approximately 50%. Most patients experiencing
heart failure have an ejection fraction of less than 40%.Watch
laboratory data closely, especially arterial blood gases and
electrolytes, including potassium. Client may be receiving cardiac
glycosides and the potential for toxicity is greater with
hypokalemia; hypokalemia is common in heart clients because of
diuretic use.Monitor lab work such as complete blood count, sodium
level, and serum creatinine. Routine blood work can provide insight
into the etiology of heart failure and extent of decompensation. A
low serum sodium level often is observed with advanced heart
failure and can bea poor prognostic sign. Serum creatinine levels
will elevate in clients with severe heart failure because of
decreased perfusion to the kidneys.Creatinine may also elevate
because of ACE inhibitors.oxygen as needed per physician's
order.semi-Fowler's position or position of comfort. Check blood
pressure, pulse, and condition before administering cardiac
medications :(ACE) inhibitors, digoxin, and beta-blockers such. the
nurse evaluate how well the client is tolerating current
medications before administering cardiac medications; During acute
events, ensure client remains on bed rest or maintains activity
level that does not compromise cardiac output. In severe heart
failure, restriction of activity often facilitates temporary
recompensation.Gradually increase activity when client's condition
is stabilized by encouraging slower paced activities or shorter
periods of activity with frequent rest periods following exercise
prescription; observe for symptoms of intolerance. Serve small
sodium-restricted, low-cholesterol meals. Monitor bowel function.
Provide stool softeners as ordered. Caution client not to strain
when defecating. Straining when defecating that results in the
Valsalva maneuver can lead to dysrhythmia, decreased cardiac
function, and sometimes death.Have clients use a commode or urinal
for toileting and avoid use of a bedpan.Provide a restful
environment by minimizing controllable stressors and unnecessary
disturbances. Schedule rest periods after meals and activities.
Rest periods decrease oxygen consumption.Weigh client at same time
daily. Assess for presence of anxiety; music will decrease anxiety
& improve cardiac function. Closely monitor fluid intake
including IV lines. Maintain fluid restriction if ordered. Refer to
heart failure program or cardiac rehabilitation program: education,
evaluation, guided support to increase activity and rebuild life.
Referensi Herdman, T. H., & North American Nursing Diagnosis
Association. (2008). NANDA-I nursing diagnoses: Definitions &
classification, 2009-2011. Oxford: Wiley-Blackwell.Moorhead, S.
(2008). Nursing outcomes classification (NOC). St. Louis, Mo:
Mosby/Elsevier.Bulechek, G. M., Butcher, H. K., & Dochterman,
J. M. C. (2008). Nursing Interventions Classification (NIC). St.
Louis, Mo: Mosby/Elsevier.Potter, P. A., & Perry, A. G. (2005).
Fundamentals of nursing. St. Louis, Mo: Mosby.
Any questions?Sheet1Condition or FactorNo ChangeSleepModerate
changes in environmental temperatureIncreaseAnxiety and excitement
50 - 100%Eating 30%Exercise up to 700%High environmental
temperaturePregnancyEpinephrineHistamineDecreaseSitting or standing
from lying position 20 - 30%Rapid arrhythmiaHeart Disease
