Acs Komite
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APA YANG BISA TERJADI
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NURSING CARE:ACUTE CORONARY SYNDROME
Ns. DEWA DEGE JULIAWAN, S.Kep
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Introduction
• CHD death > 500,000/year in US
• 200,000 – 300,000 die caused acute MI before hospitalization
• American has an acute MI every 29 seconds and die every minute
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7800
1457
8060
1499
8306
1678
6005
1253
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
2004 2005 2006 2007
total caseacs
Data pasien ACS di UGD PJNHK
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ADALAH SEKUMPULAN GEJALA YANG MENGGAMBARKAN ADANYA ISKEMI OTOT JANTUNG. ISKEMI OTOT JANTUNG SEBAGAI AKIBATTERGANGGUNYA ALIRAN DARAH ( OKSIGEN ) KE OTOT JANTUNG. SUPLY OKSIGEN KEDALAM OTOT JANTUNG TERHAMBAT OLEH KARENA ADANYA SUMBATAN ALIRAN ( TROMBUS ).
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Sequence of Events in IschemicHeart Disease
Risk Factor
Endothelial dysfunction
CAD
Ischemia
•Angina•Silent
MI
•Arrythmias•Lost of muscle
Remodeling
Progresif dilatation
Heart FailureDeath
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Topics
•Pathogenesis of ACSPathogenesis of ACS
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Typical Progression of Coronary Atherothrombosis
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Plaque Evolution
Intramural ThrombusIntramural ThrombusIntramural ThrombusIntramural ThrombusParietal ThrombusParietal ThrombusParietal ThrombusParietal ThrombusIntraluminal ThrombusIntraluminal ThrombusIntraluminal ThrombusIntraluminal Thrombus
Growing PlaqueGrowing PlaqueGrowing PlaqueGrowing PlaqueRuptured PlaqueRuptured PlaqueRuptured PlaqueRuptured Plaque
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Plaque Rupture Toward Plaque Rupture Toward OcclusionOcclusion
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Topics
• Risk FactorsRisk Factors
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Risk FactorsRisk Factors
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Topics
• AssessmentAssessment
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SAKIT DADAMasuk RS
DiagnosisKerja
ECG
Bio-chemistry
Stratifikasirisiko
Pengobatan
Pencegahan sekunder
Curiga Sindrom Koroner Akut
Elevasi STmenetap
Tanpa ElevasiST menetap
Normal atauTdk dpt ditentukan
Troponin CK/CKMB
Troponin ECGTroponin
2 X negative
Risiko tinggi Risiko rendah
Pemeriksaan awal pada Sindrom Koroner Akut
Esc/EHJ 2002
Mungkin bukan SKA
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1. Gejala Klinis SKA
Nyeri dada
PQRSTP : Placement dan Provokasi pencetus yang paling sering adalah aktifitas fisik,emosi yang berlebihan atau makan
Q : Quality sifat sakitnya apakah dirasakan seperti dipukul,terbakar, seperti tertimpa beban yang berat
R : Radiation apakah sakit dada menjalar ke punggung, tangan kiri, rahang, epigastrium.
S : Symptom apakah gejala sakit dada diserta mual muntah, keringat dingin, berdebar-debar, sesak
T : Time bila nyeri dada lebih dari 20 mnt kemungkinan terjadi nekrosis
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Pain patterns with myocardial ischemia
Usual distribution of pain withmyocardial ischemia
Less common sites of pain withmyocardial ischemia
Right side
Epigastrium
Jaw
Back
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TIMI Risk Score For UA/NSTEMITIMI Risk Score For UA/NSTEMI
• Age Age >> 65 y 65 y• >> 3 CAD Risk Factors 3 CAD Risk Factors• Prior Stenosis > 50 % Prior Stenosis > 50 % • ST deviationST deviation• >> 2 Anginal events 2 Anginal events << 24 h 24 h• ASA in last 7 daysASA in last 7 days• Elev Cardiac MarkersElev Cardiac Markers
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Topics
•ECGECG
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Evolusi Segmen ST
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Lokasi Infark Pada Gambaran EKG
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Anatomi Koroner dan EKG 12 sandapan
• Sandapan V1 dan V2 menghadap septal area ventrikel kiri
• Sandapan V3 dan V4 menghadap dinding anterior ventrikel kiri
• Sandapan V5 dan V6 ( ditambah I dan avL ) menghadap dinding lateral ventrikel kiri
• Sandapan II, III dan avF menghadap dinding inferior ventrikel kiri
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ECG demonstrates large anterior infarction
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A : Small inferior distal RCA occlusion
B : ECG changes in leads II, III, and aVF
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Topics
•Laboratory finding and Laboratory finding and CXRCXR
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Perubahan Biokimia Cedera Miokard
• Enzim jantung yang paling spesifik adalah troponin dan CK-MB. Kedua enzim ini mulai meningkat 4-8 jam setelah terjadinya infark.
• Peningkatan tekanan enzim tersebut dikatakan bermakna bila terjadi peningkatan paling sedikit 1 ½ kali nilai batas normal.
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Topics
• TreatmentTreatment
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PENDEKATAN STRATEGIS PENANGANAN SKA
Pendekatan strategis penanganan SKA bertujuan untuk menegakkan diagnosa dini untuk mengantisipasi terjadinya IMA maka menurut kriteria WHO diagnosa IMA dapat ditegakkan berdasarkan terpenuhinya minimal 2 dari 3 kriteria
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MASALAH
• PENGERTIAN/PENGETAHUAN MASYARAKAT
• BUDAYA• SISTEM PELAYANAN : EMS, SDM,
SIKAP• FASILITAS
KEBERHASILAN PENGOBATAN
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PENEGAKKAN DIAGNOSA
PENEGAKKAN DIAGNOSA
PEMERIKSAAN FISIK
LABORATORIUM
ANAMNESA
EKG
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Onset of symptoms of STEMI
9-1-1 EMS
Dispatch
EMS on-scene• Encourage 12-lead ECGs• Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min
EMS Triage Plan
Hospital fibrinolysis :Door-to-Needle within 30
min
Not PCI capable
PCI capableGoals†
Call 9-1
-1
Call fas
t
Inter-Hospital
Transfer
Total ischemic time: Within 120 min*
EMS transportEMS on scenePatient Dispatch
5 min after symptom onset
1 min Within 8 min
Prehospital fibrinolysis : EMS-to-Handle within 30 min
*Golden Hour = First 60 minutes
EMS transport:EMS-to-Balloon within 90 min
Patient self-transport:Hospital Door-to-Balloon within 90 min
PELAYANAN KEGAWATAN JANTUNG KORONER
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Penatalaksanaan Medik
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Treatment of UAP/NSTEMI
• O2• Bed rest• Pain killer• Nitrate and anti-ischemia• Antiplatelet : Aspirin, Clopidogrel• Heparin• Hyperglicemia • Treat the complication etc
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Treatment of STEMI
• O2• Bed rest• Pain killer• Nitrate and anti-ischemia• Antiplatelet : Aspirin, Clopidogrel• Fibrinolytic/PCI• Hyperglicemia • Treat the complication etc
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Pemasangan Stent Koroner
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Topics
•ComplicationComplication
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Extension / IschemiaExtension / Ischemia
Complications of Acute MI
Acute MIAcute MI
ArrhythmiaArrhythmia
Heart FailureHeart Failure
Expansion / AneurysmExpansion / Aneurysm RV InfarctRV Infarct
PericarditisPericarditis
MechanicalMechanical Mural ThrombusMural Thrombus
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Topics
•Nursing CareNursing Care
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Manajemen Keperawatan SKAPengkajian : 1. Anamnesa• Keluhan sakit dada, faktor pencetus adalah
kegiatan fisik,emosi kualitas sakit dada dirasakan di daerah mid
sternal, rasa sakit tidak jelas, seperti ditusuk, dibakar atau ditimpa beban berat
• Penjalaran ke rahang, leher dan ke bahu/lengan kiri
• Gejala yang menyertai mual,muntah,keringat dingin,berdebar, sesak napas
• Lama sakit dada tidak melebihi 30 mnt
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Diagnosa Keperawatan• Nyeri dada b.d peningkatan asam laktat dari
iskemi miokard, penurunan oksigen supply ke miokard
• Gangguan perfusi ke jaringan b.d kerusakan otot jantung,inadekuat curah jantung
• Cemas b.d nyeri dada, perubahan pola hidup• Intoleransi aktifitas b.d fatique,perubahan
pola hidup• Gangguan pola tidur b.d nyeri,cemas,sressfull• Manajemen pengobatan yang tidak adekuat
b.d pengetahuan pasien terhadap pengobatan, rehabilitasi, aktifitas di rumah, diet, tanda dan gejala penyakit
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Collaborative theraphy• Rawat CCu• Bedrest• IV theraphy• EKG monitoring• Pemberian terapi medik• Catat intake dan output• Persiapan tindakan referfusi koroner
(trombolitik terapi,PTCA, CABG )• Pendidikan kesehatan• Rehabilitasi• Pengelolaan diet
Pengelolaan faktor resiko
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Program Rehabilitasi Pada MI
• Adalah rangkaian usaha dalam membantu penyembuhan pasien PJK agar dapat kembali dengan cepat pada kehidupan normalnya atau mendekati kondisi sebelum sakit.
• Tujuan memulihkan kondisi fisik, mental, sosial serta vokasional seoptimal mungkin setelah serangan jantung.
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Akibat Tirah Baring Lama
Kapasitas kerja 20-25% sesudah tirah baring lama
Kemungkinan terjadi hipovolemia yang mengakibatkan viskositas emboli
Refleks vasomotor < hipotensi ortostatik
Ventilasi paru akan berkurangKekuatan kontraktilitas otot ber<
kebutuhan oksigen me pada aktifitas fisik
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