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Askep Infark Miokard

Pendahuluan
Infark miokard: rusaknya jaringan
jantung akibat suplai darah yang tidak
adekuat.
Penyebab penurunan suplai darah
akibat aterosklerosis atau penyumbatan
total arteri oleh emboli atau trombus.
Manifestasi klinis
Nyeri dada yang tiba-tiba dan 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
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)


ST Elevasi

CKMB
meningkat
Troponin T
meningkat

Non-ST Elevation Myocardial Infarction/
Unstable Angina
NSTEMI Unstable Angina
Troponin T (+) Troponin T (-)
CKMB meningkat

Penatalaksanaan Medis
Terapi oksigen dan tirah baring
Vasodilator; Nitrogliserin
Antikoagulan; Heparin
Trombolitik; streptokinase
Analgetik; morphin sulfat IV 1-2mg
Pengkajian
Nyeri dada
Sulit bernafas (dispnoe, palpitasi, diaporesis)
Tingkat kesadaran
Frekuensi dan irama jantung
Bunyi jantung (S3 gallop ventrikel; setelah
terjadi MI, tanda awal gagal ventrikel kiri
yang mengancam)
Murmur perubahan fungsi otot miokardium
Tekanan darah ES vasodilator: hipotensi
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
Diagnosa Keperawatan
Nyeri dada berhubungan dengan
berkurangnya aliran darah koroner
Potensial pola pernafasan tidak efektif
berhubungan dengan cairan tubuh berlebih
Potensial gangguan perfusi jaringan
berhubungan dengan curah jantung menurun
Cemas berhubungan dengan takut akan
kematian
Masalah kolaborasi
Disritmia
Edema paru
Gagal jantung kongestif
Tromboembolisme
Intervensi
Mengurangi nyeri
Kolaborasi nitrogliserin, trombolitik,
morphin
Terapi oksigen 2-4 l/m nasal kanul
Istirahat fisik

Intervensi
Memperbaiki fungsi respirasi
Kaji fungsi pernafasan mendeteksi
komplikasi paru
Catat status cairan mencegah
kelebihan cairan di paru
Anjurkan nafas dalam
Intervensi
Meningkatkan perfusi jaringan yang adekuat
Mengawasi suhu dan denyut nadi perifer
Memberikan oksigen

Intervensi
Mengurangi kecemasan
Membina hubungan saling percaya
Beri kesempatan pasien berbagi rasa
Case study of a client with acute
myocardial infarction : Betty Williams
Betty Williams, a 62 years old psychologist is
admitted to the emergency department with
complains of severe substernal chest pain. Mrs.
Williams states that she began feeling the pain
after eating lunch about 4 hours ago. She
described the pain , which radiates to her jaw
and left arm, as "like someone sitting on my
chest". It is accompanied severe shortness of
breath, and diaporesis. The pain is unrelieved by
rest, antacids, or three sublingual nitroglyserin
tablets .

The emergency room staff start central
and peripheral intravenous lines and
begin to administer oxygen per nasal
cannula at 2L/min. They obtain a lead
12-lead ECG and the following labwork :
cardiac enzymes and isoenzymes, ABGs,
CBC, and a chemistry panel. Morphine
sulfate is successful at relieving Mrs.
Williams's pain
Mrs. Williams's medical history includes a
diagnosis of adult-onset diabetes, angina, and
hypertension. She has a 45-year history of
cigarette smoking, averaging 1 to 2 packs
per 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.

The client history , initial assessment
data, and ECG results point toward an
acute anterior wall MI. Mrs Williams has
no contraindications to thrombolytic
therapy and is deemed a good
candidate
Assessment
Dan Morales, RN is assign as Mrs. Williams's
primary care nurse. He helps her get settled
into the room and then performs a head-to-
toe assessment. Mrs. Williams is alert and
oriented to person, place and time. Vital signs
are as follows : P, 118; BP, 172/92; R, 24;
with adequate depth; temperature 37.5 C.
Auscultation reveals an S4 and fine crackles
in the bases of both lungs.
The ECG shows sinus tachycardia and
evidence of an evolving anterior MI.
her skin is cool and slightly diaphoretic .
Capillary refill time is less than 3
seconds , and peripheral pulses are
strong and equal. Her nail beds are
pink.


Assessment
A triple lumen central line is in place .
Nitroglycerin is infusing at 200g/min in
the distal lumen; the alteplase infusion
is in the middle lumen, and a heparin is
in the proximal lumen. The peripheral
intravenous line is being maintained
with an infusion of 5% dextrose in
normal saline solution at 50mL/h.
Diagnosis
Pain (chest pain) related to imbalance between
oxygen supply and demand
Anxiety and Fear related to change in health status
Altered Protection related to the risk of bleeding
secondary to thrombolytic therapy
Risk for injury related to altered cardiac rate and
rhythm
Knowledge deficit regarding myocardial infarction
disease process and the use of thrombolytic therapy
Planning and Implementation
Instruct Mrs. Williams to alert the nurse for
any complaints of chest pain. Monitor and
evaluate Mrs. Williams complaint of chest
pain using a scale of 0 to 10. Administer
morphine intravenously in increaments of 2 to
4 mg for chest pain unrelieved by
nitroglyserin infusion.
Encourage Mrs. Williams to verbalize her
fears and concerns. Answer questions
honestly, and correct any misconceptions
regarding the disease process, therapeutic
interventions, or prognosis.
Encourage Mrs. Williams to verbalize her
fears and concerns. Answer questions
honestly, and correct any misconceptions
regarding the disease process, therapeutic
interventions, or prognosis.
Assess Mrs. Williams knowledge of how
atherosclerosis plaques develop and occlude
the coronary arteries.

Assess for manifestation of internal or
intracranial bleeding ; Note complaints
of back or abdominal pain, headache,
decreased level of consciousness ,
dizziness, bloody secretions or
excretions, or pallor. Perform guaiac
testing on all stools, urine, and vomitus.
Notify physician immediately of
abnormal findings.

Planning and Implementation
Monitor Mrs Williams for signs of
reperfusion : decresed chest pain,
return of ST segment to base line,
reperfusion dysrhytmias (bradycardia,
heart block)
Continuously monitor ECG for changes in
cardiac rate, rhythm, and conduction. Assess
vital signs and associated symptoms with
changes in ECG. Note hypotension, syncope
or palpitation.
Maintain a supply of emergency cardiac drugs
and equipment ( i.e., lidocaine, epinephrine,
atropine, the defibrillator, pacemaker,
intubation tray )

Evaluation
After the initial morphin dose, Mrs. Williams
notes a re duction in her chest pain from a
pain rating of 8 to 4. The nitroglyserin
infusion and thrombolytic therapy further
reduce her pain to 2. The nitroglyserin is
gradually discontinued after 24 hours.
She is able to describe a basic anderstanding
of plaque formation and the resulting
obstruction to blood flow.
No indication of bleeding problems are
noted.
Evidence of reperfusion is noted. Chest
pain has been relieved ; the ECG shows
that the ST segment is returning to
baseline
Mrs. Williams remains in CCU for 2 days
and is transferred to the floor.