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Nursing Care in ST-

Elevated Myocardial
Infarction
NS. AHMAD HASYIM W, M.KEP, MNG
Definisi
 INFARCT MYOCARD
Adalah suatu keadaan kematian jaringan otot jantung yang disebabkan
adanya sumbatan pada arteri coronaria oleh trombus, emboli atau
atherosclerosis yang mengakibatkan kurang/tidak adanya supplai darah
dan O2 pada myocard

 ACUTE CORONARY SYNDROME (ACS)


Merupakan kondisi kegawatan yang ditandai dengan onset akut drpd
iskemia myocardium yang dapat berakibat pada kematian myocardium jika
tidak ditangani dengan tepat.
Proses Penyakit Jantung
Koroner
Plak Stabil (stable plaque) Plak ruptur (ruptured plaque)

SUMBATAN
TOTAL
MECHANISMS OF CORONARY THROMBUS FORMATION
ATHEROSCLEROSIS
ATHEROSCLEROSIS

DYSFUNCTIONAL
DYSFUNCTIONAL
PLAQUE
PLAQUERUPTURE
RUPTURE ENDOTHELIUM
ENDOTHELIUM

Intraplaque Exposure
Exposureof Turbulent Vasodilator Anti
Intraplaque Release
Releaseof of
of subendothelial Turbulent Vasodilator Antithrombotic
thrombotic
hemorrhage
hemorrhage Tissue blood
bloodflow effect effect
TissueFactor
Factor subendothelial
collagen
flow effect effect
collagen

PLATELET
PLATELET
ACTIVATION
ACTIVATION&&
AGGREGATION
AGGREGATION
Vessel Activation
Vessel Activationof
of Vasoconstriction
Vasoconstriction
lumen
lumen the coagulation
the coagulation
diameter
diameter cascade
cascade

5
CORONARY
CORONARYTHROMBOSIS
THROMBOSIS
Oklusi
Oklusi Total
Total

Glikolisis
Glikolisisanaerob
anaerob
Metab.
Metab.aerobik
aerobikstop
stop
Depletio
DepletioCPCP ((88--10
10detik
detik))

Time Miosit
Miosit Rusak
(( 15
15 -- 20
Rusak
20 menit
menit ))
is Endokardium
Endokardium
Miokardium ((33--44jam
jam))
Muscle!! Miokardium
Epikardium
Epikardium

Nekrosis
Nekrosis Irreversible
Irreversible
(( 44 -- 66 jam
jam ))
Etiologi
 Coronary Arteri Disease : atherosclerosis, arteritis, trauma pd koroner, penyempitan arteri
koroner oleh krn spasme, dececting aorta & arteri koroner
 Coronary arteri emboli : infectife endokarditis, cardiac myxoma, cardio-pulmonal bypass
surgey, arteriography koroner
 Kelainan kongenital : anomali arteri coronaria
 Imbalance oxygen supply & demand myocard: thyrotoxicosis, hipotensi kronis, keracunan CO,
aorta stenosis/insuffisiensi
 Gangguan hematology: anemia, polycythemia vera, hypercoagulabity, thrombosis,
trombocytosis, DIC
Faktor Risiko:

1. Dapat Diubah
a. Merokok
b. Tekanan darah tinggi
c. Diabetes
d. Kadar kolesterol tinggi
e. Kegemukan
2. Tidak dapat diubah
a. Jenis kelamin
b. Usia
c. Faktor keturunan
Tanda dan Gejala
 Chest pain/nyeri dada seperti tertekan / berat / diremas
yg timbul scr mendadak / hilang timbul. Nyeri didaerah
anterior / precordial / sub sternal yg menjalar kelengan,
wajah, rahang, leher, punggung & epigastrium. Nyeri tdk
berkurang / hilang dg istirahat, merubah posisi/menarik
nafas dlm. Lama nyeri > 15 mnt.
 Sesak nafas (shortness of breath/dyspnea), diaphoresis,
PND
 Mual dan muntah
 Tachycardia
 Disritmia, hipotensi, shock
 Kulit pucat, cyanosis, dingin, lembab/berkeringat
 Anxiety
Spectrum of ACS

 Unstable angina pectoris (UAP)


 Pasien mengalami S/S iskemia miokard, tapi ECG dan enzim jantung
normal
 ST elevated myocardial infarction (STEMI)
 Pasien mengalami S/S iskemia miokard, didukung dengna
abnormalitas ECG pada minimal 2 lead  kerusakan signifikan pada
myocardium
 Non ST elevated myocardial infarction (NSTEMI)
 Pasien mengalami S/S iskemia miokard , akan tetapi ECG tidak
menunjukkan kelainan  peningkatan enzim jantung
How ECG works
STEMI MYOCARDIAL INFARCTION
SKA dengan ST Elevasi

Infark Miokard Akut (Acute MCI)


Troponin T
CKMB Memerlukan terapi trombolitik (strepto
Kinase) atau Percutaneous Coronary
Manajemen ACS Prehospital

 Masalah keterlambatan pasien


 Time is Muscle , penyelamatan miokard bergantung pd waktu faktor pasien &
EMS
 Lambatnya penanganan SKA diakibatkan : pengenalan keluhan SKA,
Transportasi & evaluasi di RS
 Kelambatan di RS akibat (4 D) : door  data (EKG)  decisien  drug
 Pentingnya Defibrilasi dini

Pasien meninggal karena IMA 50% terjadi dini sebagian besar akibat
Ventricular Fibrilasi (VF), resiko terjadi VF 4 jam awal pd fase hiperakut
Angioplasti : pemulihan pembuluh darah yg tersebumbat dgn menggunakan “balon”
yg bisa dipompa untuk membuka penyumbat / pembuluh darah koroner yg menyempit.

Kawat bantu yg dimasukkan


ke dalam pembuluh yg tersumbat

Pipa balon dimasukkan


ke dalam sepanjang kawat bantu

Balon ditiup untuk


membuka penyumbat

Setelah prosedur tersebut,


pembuluh tidak tersumbuat

Untuk mencegah terjadinya pemyumbatan ulang, dipasang


stent yaitu semacam cincin yang dipasang secara
permanen sebagai penyangga.
19
Stent bisa dilapisi obat untuk menghambat pertumbuhan
sel-sel sehingga tidak terjadi penyempitan
20
Nursing Care in
Patients With
STEMI
STEMI: actual damage to cardiac
muscle
 Priority of care:
1. Menghilangkan/mengurangi nyeri
2. Mempertahankan perfusi jaringan  mencegah infark meluas 
memulihkan area iskemi
3. Mencegah/mendeteksi & membantu dlm pengobatan disritmia yg
mengancam jiwa
4. Memberikan suport psikologis
List of nursing diagnosis

 Decreased cardiac output


 Acute pain
 Anxiety
 Noncompliance
Decreased cardiac output

 Definition
 Inadequate blood pumped by the heart to meet the metabolic
demands of the body.
 NOC
 Cardiac Pump Effectivenes
 Circulation Status
 Energy Conservation
 NIC
 Cardiac care
 Cardiac care: rehabilitative
Cardiac care activities

 Independent
 Monitoring: vital sign, cardio-respiratory status, drug effect, ecg
 Encourage rest and supportive environment, psychological calming
 Avoid valsava maneuver
 Education: stop smoking, healthy diet, physical activity pattern

 Collaborative
 Medications: antiarrythmia, thrombolytics, beta blockers, vasodilators
 Nutrition: hypertension diet
 Medical procedures: fluid balance,
Cardiac care: rehabilitative
activities
 Independent
 Evaluate activity tolerance  Adjust exercise accordingly
 Risk factor modification, lifestyle adjustment
 Exercise with proper sequence
 Evaluation and decision making
 Collaborative
 Ongoing laboratory tests
 Medications
Acute pain

 Definition
 Unpleasant sensory and emotional experience arising from actual or potential tissue damage or
described in terms of such damage (International Association for the Study of Pain); sudden or slow
onset of any
intensity, from mild to severe, with an anticipated or predictable end and a duration of less than 6
months
 NOC
 Pain Level
 Pain Control

 NIC
 Pain Management
 Analgesic Administration
Noncompliance

 Behavior of person and/or caregiver that fails to coincide with a health-


promoting or therapeutic plan agreed on by the person (and/or family, and/or
community) and healthcare professional. In the presence of an agreed-upon
health-promoting or therapeutic plan, person’s or caregiver’s behavior is fully or
partially nonadherent and may lead to clinically ineffective or partially
ineffective outcomes
[Author Note: When the plan of care is reviewed with client/SO, use of the term
noncompliance may create
a negative response and sense of conflict between healthcare providers and
client.
 NOC: Compliance behavour
 NIC: Teachings