Coronary Artery Disease Case Study

8/12/2019 Coronary Artery Disease Case Study

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Askep Infark Miokard


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Pendahuluan Infark miokard: rusaknya jaringanjantung akibat suplai darah yang tidak

adekuat.

Penyebab penurunan suplai darahakibat aterosklerosis atau penyumbatan

total arteri oleh emboli atau trombus.


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Manifestasi klinis Nyeri dada yang tiba-tibadan 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


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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)


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ST Elevasi

CKMB

meningkat

Troponin Tmeningkat
http://bmj.com/content/vol324/issue7341/images/large/ecg08.f3.jpeg


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Non-ST Elevation Myocardial Infarction/

Unstable Angina

NSTEMI Unstable Angina

Troponin T (+) Troponin T (-)

CKMB meningkat
http://bmj.com/content/vol324/issue7341/images/large/ecg08.f9a.jpeg


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Penatalaksanaan Medis Terapi oksigen dan tirah baring

Vasodilator; Nitrogliserin

Antikoagulan; Heparin

Trombolitik; streptokinase

Analgetik; morphin sulfat IV 1-2mg


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Pengkajian Nyeri dada

Sulit bernafas (dispnoe, palpitasi, diaporesis)

Tingkat kesadaran Frekuensi dan irama jantung

Bunyi jantung (S3 gallop ventrikel; setelahterjadi MI, tanda awal gagal ventrikel kiri

yang mengancam) Murmur perubahan fungsi otot miokardium

Tekanan darah ES vasodilator: hipotensi


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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


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Diagnosa Keperawatan Nyeri dada berhubungan dengan

berkurangnya aliran darah koroner

Potensial pola pernafasan tidak efektifberhubungan dengan cairan tubuh berlebih

Potensial gangguan perfusi jaringanberhubungan dengan curah jantung menurun

Cemas berhubungan dengan takut akankematian


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Masalah kolaborasi Disritmia

Edema paru

Gagal jantung kongestif

Tromboembolisme


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IntervensiMengurangi nyeri

Kolaborasi nitrogliserin, trombolitik,

morphin

Terapi oksigen 2-4 l/m nasal kanul

Istirahat fisik


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Intervensi Memperbaiki fungsi respirasi

Kaji fungsi pernafasan mendeteksi

komplikasi paru

Catat status cairan mencegahkelebihan cairan di paru

Anjurkan nafas dalam


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Intervensi Meningkatkan perfusi jaringan yang adekuat

Mengawasi suhu dan denyut nadi perifer

Memberikan oksigen


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IntervensiMengurangi kecemasan

Membina hubungan saling percaya

Beri kesempatan pasien berbagi rasa


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The emergency room staff start centraland peripheral intravenous lines and

begin to administer oxygen per nasalcannula at 2L/min. They obtain a lead12-lead ECG and the following labwork :cardiac enzymes and isoenzymes, ABGs,

CBC, and a chemistry panel. Morphinesulfate is successful at relieving Mrs.Williams's pain


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Mrs. Williams's medical history includes adiagnosis of adult-onset diabetes, angina, and

hypertension. She has a 45-year history ofcigarette smoking, averaging 1 to 2 packsper 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.


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The client history , initial assessmentdata, and ECG results point toward an

acute anterior wall MI. Mrs Williams hasno contraindications to thrombolytictherapy and is deemed a good

candidate


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Assessment

Dan Morales, RN is assign as Mrs. Williams'sprimary care nurse. He helps her get settled

into the room and then performs a head-to-toe assessment. Mrs. Williams is alert andoriented to person, place and time. Vital signsare as follows : P, 118; BP, 172/92; R, 24;

with adequate depth; temperature 37.5 C.Auscultation reveals an S4 and fine cracklesin the bases of both lungs.


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The ECG shows sinus tachycardia andevidence of an evolving anterior MI.

her skin is cool and slightly diaphoretic .Capillary refill time is less than 3seconds , and peripheral pulses are

strong and equal. Her nail beds arepink.


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Assessment

A triple lumen central line is in place .Nitroglycerin is infusing at 200g/min in

the distal lumen; the alteplase infusionis in the middle lumen, and a heparin isin the proximal lumen. The peripheral

intravenous line is being maintainedwith an infusion of 5% dextrose in normal saline solution at 50mL/h.


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Diagnosis

Pain (chest pain) related to imbalance betweenoxygen supply and demand

Anxiety and Fear related to change in health status

Altered Protection related to the risk of bleedingsecondary to thrombolytic therapy

Risk for injury related to altered cardiac rate andrhythm

Knowledge deficit regarding myocardial infarctiondisease process and the use of thrombolytic therapy


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Planning and Implementation

Instruct Mrs. Williams to alert the nurse forany complaints of chest pain. Monitor andevaluate Mrs. Williams complaint of chest

pain using a scale of 0 to 10. Administermorphine intravenously in increaments of 2 to4 mg for chest pain unrelieved bynitroglyserin infusion.

Encourage Mrs. Williams to verbalize herfears and concerns. Answer questionshonestly, and correct any misconceptionsregarding the disease process, therapeuticinterventions, or prognosis.


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Encourage Mrs. Williams to verbalize herfears and concerns. Answer questions

honestly, and correct any misconceptionsregarding the disease process, therapeuticinterventions, or prognosis.

Assess Mrs. Williams knowledge of how

atherosclerosis plaques develop and occludethe coronary arteries.


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Assess for manifestation of internal orintracranial bleeding ; Note complaints

of back or abdominal pain, headache,decreased level of consciousness ,dizziness, bloody secretions orexcretions, or pallor. Perform guaiac

testing on all stools, urine, and vomitus.Notify physician immediately ofabnormal findings.


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Planning and Implementation

Monitor Mrs Williams for signs ofreperfusion : decresed chest pain,

return of ST segment to base line,reperfusion dysrhytmias (bradycardia,heart block)


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Continuously monitor ECG for changes incardiac rate, rhythm, and conduction. Assess

vital signs and associated symptoms withchanges in ECG. Note hypotension, syncopeor palpitation.

Maintain a supply of emergency cardiac drugs

and equipment ( i.e., lidocaine, epinephrine,atropine, the defibrillator, pacemaker,intubation tray )


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Evaluation

After the initial morphin dose, Mrs. Williamsnotes a re duction in her chest pain from a

pain rating of 8 to 4. The nitroglyserininfusion and thrombolytic therapy furtherreduce her pain to 2. The nitroglyserin isgradually discontinued after 24 hours.

She is able to describe a basic anderstandingof plaque formation and the resultingobstruction to blood flow.


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No indication of bleeding problems arenoted.

Evidence of reperfusion is noted. Chestpain has been relieved ; the ECG showsthat the ST segment is returning tobaseline

Mrs. Williams remains in CCU for 2 daysand is transferred to the floor.

Coronary Artery Disease Case Study

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