Nursing Management

Acute Coronary
Syndromes (ACS)

Ns.Ns. Zahrah Maulidia S, S.Kep, M.Kep

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 Penyumbatan atau
penyempitan pada
pembuluh darah koroner
akibat kerusakan lapisan
dinding pembuluh yang
diikuti oleh penebalan
dan kekakuan pembuluh
tersebut (aterosklerosis)

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Nilai sirkulasi (C)

Nilai pernafasan
(A,B)

Nilai kesadaran

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KELUHAN
• NYERI DADA
• SESAK NAFAS
• PENURUNAN KESADARAN
• KERINGAT DINGN

GEJALA
• HIPOTENSI
• RENJATAN
• BENDUNGAN PARU
• GAGAL JANTUNG KONGESTI

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 Pembuluh Darah Koroner
Pembuluh Darah Koroner Berfungsi :
Memberi makan dan Oksigen ke otot- otot Jantung.

Terdiri Dari:
1. Pembuluh Darah Koroner Kiri , cabang :
kedepan : LAD ( Left Anterior Descendens Artery)
melingkar ke kiri : LCx ( Left Circumflex Artery)
2. Pembuluh Darah Koroner Kanan
( RCA = Right Coronary Artery)

Bercabang-cabang  ke dalam otot-otot jantung

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 Memory board
CAD risk factors
12 Just think the word RISKS:
1 Rising LDL, and triglyseride levels. LDLs should
be < 130 mg/dl, triglycerides < 200 mg/dl
2 Inadequate control of hypertension, diabetes,
3 and obesity - Diet and excersise life style
changes are the step to regaining control

4 Sex – CAD is more common in men until after

age 75
5 Kinfolk – Heredity is a nonmodifiable risk factor
6 Smoking – the soonner stopped the better
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 Onset of STEMI Hospital Management
- Prehospital issues - Medications
- Initial recognition and management
in the Emergency Department (ED)
- Reperfusion
- Arrhythmias
- Complications
- Preparation for discharge 1
Secondary Prevention/
Long-Term Management 1
Management
Before STEMI
2 2
1 2 3 4 5 6
3
4

Presentation Ischemic Discomfort

4
Working Dx
Acute Coronary Syndrome

5
ECG

Cardiac
No ST Elevation
UA NSTEMI
ST Elevation 6
Biomarker Modified from Libby. Circulation
2001;104:365, Hamm et al. The Lancet
Unstable 2001;358:1533 and Davies. Heart
Final Dx NQMI QwMI 2000;83:361.
Angina
Myocardial Infarction
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 Serangan Jantung

kematian sebagian otot jantung disebabkan

oleh terhentinya pasokan darah akibat
tersumbatnya satu / lebih pembuluh koroner
oleh gumpalan darah (trombus).

Akibat Serangan jantung

Fungsi pompa jantung (
memompakan darah
dgn segala nutrisi )  gagal

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 Mrpkketidakseimbangan sementara antara
kemampuan arteri koroner u/ mensuplai oksigen
dgn kebutuhan oksigen miokardium.

 Angina pectoris adalah rasa sakit dada akibat

adanya iskemia otot jantung. Sakit dada ini timbul
karena timbunan asam laktat, sifatnya sementara
dan reversible

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 Angina Tak
Plaque
Stabil

Normal
Fatty
streak
Fibrous
plaque
Athero-
sclerotic
plaque
rupture/
fissure &
thrombosis MI
}ACS
Ischemic
stroke/TIA

Critical leg
ischemia
Keluhan klinis (-)
Angina Stabil Kematian
Intermittent claudication Akibat Kardiovaskular

Bertambahnya Umur
ACS, acute coronary syndrome; TIA, transient ischemic attack
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 What to look for : Unstable angina and MI
Unstable angina Myocardial infarction
Character, location, Burning,squeezing,substernal or retrosternal pain Severe, persistent substernal pain or pain over
radiation spreading across chest; may radiate to inside of pericardium; may spread widely throughout chest
arm, neck, jaw or shoulder blade and be accompanied by pain in shoulders and
hands; may be described as crushing or
squeezing
Duration of pain 5 to 15 min > 15 min

Precipitating events Usually related to exertion, emotion, eating and Occurs spontaneously
cold May be sequela to ustable angina

Realiving measures Rest, nitroglycerin, oxygen Morphine sulfate, successful reperfusion of

blocked coronary artery

Associated Shortness of breath Feeling of impending doom

sympstoms Dizzeness Fatique
Nausea Nausea and vomiting
Palpitations Shortness of breath
Weakness Cool extremities
Cold sweat Perspiration
Anxiety
Associated signs Hypotension or hypertention Hypotention or hypertention
Tachycardia or bradycardia Palpable precordial pulses
Muffled heart sounds
Arrhytmias
Cardiac biomarkers Usually witjin normal range Elevated

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 Gejala Serangan Jantung
 Nyeri dada khas
Lokasi :
Dibelakang tulang dada, Dada sebelah kiri
Kualitas:
seperti ditekan/ditindih benda berat,
dibakar, diremas, ditusuk, diiris, tercekik
Penjalaran:
Leher, Rahang bawah, Bahu,Punggung,
pergelangan s/d jari-jari, Ulu hati.
Gejala penyerta:
Rasa sukar hirup/ sesak napas
Keringat dingin, Pucat
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 Dibelakang Dibelakang tulang Dari dada menjalar
dada menjalar ke ke bahu dan lengan
tulang dada leher

Dari dada menjalar Didada bawah di ulu hati Didareah punnggung

ke rahang (sering ditafsirkan di antara kedua belikat
sebagai penyakit maag)

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 Diagnosis ditegakkan, bila:
( 2 dari 3 indikator )
kriteria WHO terpenuhi, yaitu

• Keluhan klinis
• Gambaran khas elektrokardiografi (EKG)
• Peningkatan kadar enzim jantung :
(CK, CKMB dan troponin)

Apa Yang Harus Dilakukan sebelum ke Dokter ?

Terpenting : Periksa Kesadaran Penderita !!!

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 Apa yang terjadi saat serangan jantung
Tergantung ringan beratnya serangan jantung
Arteri koroner mana & berapa arteri koroner
yang tersumbat
banyak pasien meninggal mendadak
dalam 1 jam setelah gejala timbul
Fibrilasi Ventrikel : jantung bergetar
berdenyut tidak efisien

penelitian terbaru terbukti jendalan :

trombosis koroner
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 Bila Terjadi Serangan Jantung?

• Pastikan keluhan  khas serangan jantung

• Merasa yakin  baringkan penderita
• Panggil dokter / langsung di bawa ke RS
• Aspirin dapat diberikan untuk dikunyah

penderita tidak sadarkan diri , segera

lakukan resusitasi jantung paru dg
melakukan bantuan hidup dasar

Kematian tertinggi  jam-jam pertama

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Ustable angina Myocardial Infarction

Burning
Squeezing
Crushing tightness

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Common chief complaints : chest pain
Memory board PQRST : What’s the story ?

P Q R S T
Provocative Quality or Region or Severity Timing
or palliative quantity radiation
How severe is When did the
What provokes What does the Where in the the chest pain? pain begin ?
or relieves the pain feel like chest the pain How would you
chest pain occur ? rate it on a Was the onset
Are you having
scale of 0 to sudden or
What makes the pain right Does the pain
10, with 10 gradual ?
the pain now? If so, is it appear in
being the most
worsen or more or less other regions
severe ? How often
subside severe than as well ? If so
does the pain
usual where ? Does the pain occur?
seem to be
To what degree
diminishing, How long does
does chest
intensifying, or it last ?
pain affect your
staying about
normal activities
the same ?
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Brief Physical Examination
in the Emergency Department
1. Airways, Breathing, Circulation (ABC)
2. Vital signs, general observation
3. Presence or absence of jugular venous
distention
4. Pulmonary auscultation for rales
5. Cardiac auscultation for murmurs and
gallops
6. Presence or absence of stroke
7. Presence or absence of pulses
8. Presence or absence of systemic
hypo-perfusion (cool, clammy, pale)
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NSTEMI STEMI

Locating myocardial damage

Wall affected Leads Artery involved
Anterior V2 , V3, V4 LCA, LAD

Anterolateral I,aVL, V3 to V6 LAD, LCx

Anteroseptal V1, V2, V3, V4 LAD

Inferior II, III, aVF RCA

Lateral I,aVL, V5, V6 LCx, Branch LAD

Poserior V8, V9 RCA, LCx

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CHARACTERISTICS OF SERUM CARDIAC MARKERS FOR THE DIAGNOSIS
OF ACUTE MYOCARDIAL INFARCTION

SERUM CARDIAC MARKERS TEST FIRST PEAK LEVEL

BECOMES ( Hours)
POSITIVE
(HOURS)

Cretinin Kinase
Single assay 3-8 12 - 24
Serial assay

Creatine Kinase- MB
Single assay 4-6 12 - 24
Serial assay
Troponin I and T
Measure 4 hours after onset of chest pain 4 - 10
Measure 10 hours after onset of chest pain 8 - 28

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 How it’s treated
For patients with angina reduce myocardial demand
or increase oxygen supply

Nitrates reduce myocardial oxygen compsumption

Beta-adrenergic blockers reduce the workload and
oxygen demand of the heart
Angina cause by coronary artery spasm , calsium
channel blockers
Antiplatelet drugs minimize platelet aggregation and
the danger of coronary occlusion
Antilipemic drugs reduce elevated serum cholesterol
or triglyceride
Obtructive lession may nessessitate : CABG or PTCA
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 Manajemen ACS :
Penatalaksanaan Medis

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 Terapi Fibrinolisis atau PCI (Percutaneous
Coronary Intervention )
 teknik reperfusi dengan memberikan obat
“penghancur bekuan darah”. Obat ini
menguraikan trombus dengan mengkonversi
plasminogen menjadi plasmin dan
mendegradasi bekuan bekuan fibrin
 Obat harus segera diberikan dalam 30 menit
sejak pasien masuk RS. Terapi ini sangat efektif
diberikan 3 jam dari onset gejala ACS. Walaupun
begitu, pemberian setelah 12 jam onset masih
memberikan keuntungan untuk reperfusi
koroner. Sedangkan pemberian setelah 24 jam
dari onset dapat berbahaya.

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 PCI adalah tindakan invasif dengan memasukan kateter
melalui pembuluh darah arteri femoral (atau radial)
menuju arteri koroner yang mengalami sumbatan untuk
membuka sumbatan tersebut dan mengembalikan perfus
ke miokard.
 Indikasi PCI meliputi; onset < 3jam; pasien dengan
kontraindikasi terapi fibrinolisis; pasien dengan risiko
terjadinya gagal jantung; atau pasien dengan diagnosis
tersangka (susp) STEMI. PCI harus dilakukan 90 menit sejak
pasien masuk RS. Komplikasi yang dapat terjadi pada
pasien meliputi perdarahan, hematoma di area insersi
kateter, penurunan perfusi perifer, retroperitoneal
bleeding, cardiac arrhythmias, coronary spasm, acute
renal failure, stroke, dan cardiac arrest.
 Perawatan pasca tindakan meliputi monitoring tanda tanda
vital, irama jantung pulsasi perifer, area insersi kateter,
keluhan nyeri dan intake output secara rutin.

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 TYPICAL HOSPITAL ADMISSION ORDER
FOR PATIENTS WITH ST SEGMENT ELEVATION MI

Maintain Iv line at a keep open rate using NaCl 0.9% or D5W %

Continous ECG monitoring for the presence ST segment elevation & dysrythmia

Performance of vital sigs every 30 mnt until stable and then every 4 hours

Bed rest until stable and then progress to bedside commode (usually within 12 to 24 hours) and activity

Oxygen at 2 ltr by nasal cannula with continous oximetry for 6 hours if patient is stable and SaO2 exceedd 90%, discontinue
oxygen

Nothing by mouth with until stable: NCEP ATP III Therapeutic Lifestyle Change diet: low cholesterol ( less than 200 mg/d),
low saturated fat ( less than 7 % of total daily callories from saturated fats), and increased omega-3 fatty acids

2-g sodium diet, in addition, for patients with hypertansion or heart failure

Medications

Nitroglycerin sublingual 0.4 mg every 5 mnt for chest pain/disconfort

Aspirin daily 75 to 162 mg

Oral beta blockes beginning immediately only for tachydysrhythmia or hypertansion

Oral ACE inhibitor ( or angiotension II receptor blocke if patient is tolerant of ACE inhibitor for ptients with anterior
infarction,Or left ventricular ejection fraction less than 40 %, as long as patient is not hypotensive

IV morphine sulfate 2 to 4 mg every 5 to 15 mnt as needed for chest pain/disconfort

Stool softerner daily

Anxiolytic as needed
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 NYERIAKUT
 PENURUNAN CURAH JANTUNG
 INTOLERANSI AKTIFITAS
 POLA NAPAS TIDAK EFEKTIF
 HIPERVOLEMIA

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 SLKI : setelah dilakukan intervensi keperawatan
selama 60 menit maka curah jantung meningkat
dengan kriteria hasil :
 1. Gambaran EKG Aritmia menurun
 2. dyspnea menurun

 3. edema menurun
 4. CTR < 50%

(SLKI, 2019, P. 20)

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 Diagnosis keperawatan : penurunan curah
jantung
 SIKI :
 Perawatan jantung
 O : Monitor dan identifikasi EKG, lab,
tekanan darah
 T : berikan posisi semi fowler
 E : anjurkan dan ajarka n pasien aktifitas
fisik secara toleransi
 K : kolaborasi pemberian antiaritmia

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 Perawatan jantung
 Perawatan jantung akut
 Manajemen nyeri
 Terapi oksigen
 Manajemen energy
 Pemantauan cairan

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 Thanks for your attention …
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