UNIVERSITAS GADJAH MADA FAKULTAS KEDOKTERAN PROGRAM STUDI ILMU KEPERAWATAN
Jl. Farmako Sekip Utara Yogyakarta
Buku 2: RKPM Rencana Kegiatan Pembelajaran Mingguan Modul Pembelajaran Pertemuan ke-6
Modul Fungsi Kardiovaskuler Semester 5/2 sks oleh 1.Martina Sinta K., S.Kep., Ns., M.N 2. Eri Yanuar Akhmad B.S., S.Kep., Ns. 3. Anita Kustanti., S.Kep., Ns. 4. Sri Setiyarini., S.Kp., M.Kes.
Didanai dengan dana BOPTN P3-UGM Tahun Anggaran 2012 Desember 2012
Mata Kuliah
: Cardiac and Respiratory System
Tingkat / Blok
: 5 / 3.1
Pertemuan Ke
:6
Waktu pertemuan
: 1 x 2 jam
Tujuan Pembelajaran Setelah menyelesaikan pembelajaran ini mahasiswa diharapkan :
Mampu memahami dan mampu merumuskan diagnosa serta manajemen keperawatan terkait gangguan sistem kardiovaskular.
Diagnosis Keperawatan terkait Cardiovaskular Responses Merumuskan Diagnosa Kep. (NANDA 2007-2008, Hal 297) mulai dng pengkajian & pengambilan data riwayat klien (pasien, keluarga, komunitas) Data dikaji dan dikumpulkan untuk mengidentifikasi tanda dan gejala atau mendefinisikan karakteristik-karakteristik (defining characteristic) dari diagnosa tersebut. Faktor-faktor atau variabel yang mempengaruhi diagnosa (related factors) terintegrasi dengan riwayat, bukti-bukti lain atau chart dan KOMBINASI defining characteristic & related factors akan diformulasi menjadi suatu diagnosis.
Cardiovaskular Responses (NANDA 2009 – 2011) Domain 4: activity/rest Class 4: cardiovaskular/respiratory responses Diagnosa Keperawatan (NANDA 2009 - 2011 Decrease cardiac Output (00029) Ineffective Peripheral Tissue Perfusion (00204) Activity Intolerance (00092) Risk for Activity Intolerance (00094) Risk For Bleeding (00206) Diagnosa keperawatan Risk for Decreased cardiac Tissue perfusion (00200) Risk for Ineffective Cerebral Tissue Perfusion (00201) Risk for Ineffective Gastrointestinal Perfusion (002002)
Risk for Ineffective Renal Perfusion (00203) Risk for Shock (00205) *diagnosa keperawatan perfusi yang aktual hanya pada jaringan, lainya RESIKO(kaya contoh diatas) Cerebral Perfusion Pressure (CPP) = Mean Atrial Pressure (MAP) – Tekanan Intra Kranial (TIK) Cardiac Output (CO) menurun = MAP menurun penurunan perfusi ke organ vital seperti jantung, paru-paru, otak, ginjal, mesentrika (testis, usus, lambung) Jika CO menurun maka akan terjadi penurunan perfusi dan yang dikorbankan adalah ginjal (melihat urin output) dan gastro intestinal (melihat bising usus) Shock :tidak adekuatnya perkusi jaringan Diagnosa shock :orang yang Cardiac outputnya menurun beresiko shock Indikasi untuk mengetahui adanya shock atau tidak (harus gabungan ya nentuinya,jangan salah satu aja,ntar ga valid): Kadar asam laktat MAP <60 Sistolik <90 Oliguri Peningkatan WPK Cardiac Output Determination Cardiac Output (C0) is the volume of blood that is pumped out of the heart per minute. (Normal= 4-8 liters/minute) CO = Heart Rate X Stroke Volume CO=HR X SV) *Diagnosa keperawatan : decrease Cardiac Output Artinya :tidak adekuatnya pemompaan oleh jantung untuk kebutuhan metabolosme tubuh Untuk mengetahui heart rate bisa lewat pemeriksaan dada melalui palpasi pada apex cor di mid clavicula intercostalis 4 Hasil dari cardiac output (X) resistensi perifer = mean atrial pressure (MAP) EFFECT OF VARIOUS CONDITIONS ON CARDIAC OUTPUT. Condition or Factor Sleep No ChangeModerate changes in environmental temperature Anxiety and excitement 50 - 100% Eating 30% Exercise up to 700% High environmental temperature Pregnancy Epinephrine Increase Histamine Sitting or standing from lying position 20 - 30% Rapid arrhythmia Decrease Heart Disease
Interaksi antar komponen-komponen yang mengatur CO dan tekanan atrial. Tanda panah tebal menandakan PENINGKATAN Tanda panah putus-putus menandakan PENURUNAN
STROKE VOLUME - volume of blood ejected as he ventricles contract with each heart beat During systole = 70ml - 90 ml / PRELOAD - degree of tension on the muscle when it begins to contract CARDIAC OUTPUT - the quantity of blood pumped into the aorta each minute by the heart AFTERLOAD - load against which the muscle exerts its contractile force - pressure in the artery leading from the ventricle Related Factors Altered preload Altered heart rate, Altered afterload Altered rhythm Altered contractility Altered Stroke Volume Penyakit/kondisi yg menurunkan CO Umumnya: myocardial infarction, Hypertension valvular heart disease, congenital heart disease, cardiomyopathy, pulmonary disease, Diagnosis Lainnya (mendahului atau lanjutan) • Ineffective Peripheral Tissue Perfusion (00204) • Activity Intolerance (00092) • Risk for Activity Intolerance (00094) • Risk for Ineffective Cerebral Tissue Perfusion (00201) • Risk for Ineffective Gastrointestinal Perfusion (002002) • Risk for Ineffective Renal Perfusion (00203) • Risk for Shock (00205)
arrhythmias, drug effects, fluid overload, decreased fluid volume, electrolyte imbalance.
MAP = Sistole X 2(diastol) 3 Ket : MAP menggambarkan tekanan perfusi ke organ-organ tubuh Kalo tensi tiba-tiba naik dalam waktu dekat (dadakan) bisa menyebabkan mini stroke yang juga memungkinkan untuk stroke tingkat lanjut, karena kan partner2nya (organ tubuh lainya) kaget gitu, jadi sesuatu kan -___Arterial pressure terlalu tinggi bisa merusak serat miokard jantung lho. MAP > 60 mmhg, cukup untuk menjaga perfusi organ. (MAP < 60 ginjal dan mesentrika mulai terganggu) (ginjal urin normal : 0,5 – 1 ml/kg berat badan.) • Jika MAP turun secara bermakna dan dalam waktu cukup lama, aliran darah ke organ-organ akan berkurang dan dapat berlanjut menjadi iskemi • Blood Flow to the Organs Matches Body Requirements • Active organs such as the liver, brain and kidney have high blood flows at rest – About 25% of the cardiac output goes to the kidney • Composition of the blood is continuously regulated by the kidney – Gastrointestinal tract & liver get another 25% – Muscle circulation at rest is about 20% of cardiac output – Brain needs about 15% of the cardiac output
MAP > 50 otak diberi darah cukup Jika MAP 52 bisa ditegakkan diagnosa keperawatan : risk for ineffective cerebral perfusion Nafas normal : 12-28 x/menit 28-35 : compromisses(menuju kegagalan/kerusakan) Gagal nafas : >35 dan <12(tapi kata cerita ibunya ada yang kurang dari itu tetep normal,itu bisa dikarenakan riwayat profesinya,seperti angkatan,kuli,dll)
Low blood pressure results in inadequate perfusion • Brain • Heart - (70% coronary artery perfusion occurs during diastole) (Diastolic pressure < 50 mmHg compromises perfusion of heart) Kidneys
BP = CO × PVR (peripheral vascular resistance ) Atau (resistensi pembuluh drh kecil) 4 BP ∝ CO/r Diagnosis :Ineffective Peripheral Tissue Perfusion (00204) Definition: decrease in blood circulation to the periphery that may compromise health Def Charac & related Fact; see NANDA 2009 – 2010
Diagnosis: Activity Intolerance (00092) Definition: insufficient physiological or psychological energy to endure or complete required or desired daily avtivities Def Charac & related Fact; see NANDA 2009 – 2010 Diagnosis: Activity Intolerance (00092) Definition: insufficient physiological or psychological energy to endure or complete required or desired daily avtivities Def Charac & related Fact; see NANDA 2009 – 2010 Diagnosis: Activity Intolerance (00092) Definition: insufficient physiological or psychological energy to endure or complete required or desired daily avtivities Def Charac & related Fact; see NANDA 2009 – 2010 Diagnosis: Risk for Ineffective Renal Perfusion (00203) Definision: at risk for a decrease in circulation to the kidney that may compromise health Diagnosis: Risk for Shock (00205) Definition: at risk for an inadequate blood flow to the body’s tissue wich may lead to lifr-threatening cellular dysfunction Diagnosis: Risk For Bleeding (00206) Definition: at risk for a decrease in blood volume that may compromise health Diagnosis: Risk for Decreased cardiac Tissue perfusion (00200) Definition: risk for a decrease in cardiac (coronary) circulation
NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels • Cardiac Pump Effectiveness • Circulatory Status • Tissue Perfusion: Abdominal Organs • Tissue Perfusion: Peripheral • Vital Signs Status Client Outcomes • Demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for client; NIC Interventions (Nursing Interventions Classification)
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strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain Remains free of side effects from the medications used to achieve adequate cardiac output Explains actions and precautions to take for cardiac disease
Suggested NIC Labels • Cardiac Care: Acute • Circulatory Care – Monitor for symptoms of heart failure and decreased cardiac output, – Listen to heart sounds; note rate, rhythm, presence of S3, S4, and lung sounds. – Observe for confusion , restlessness, agitation, dizziness. Central nervous system disturbances may be noted with decreased cardiac output. – Observe for chest pain or discomfort; note location, radiation, severity, quality, duration – If chest pain is present, have client lie down, monitor cardiac rhythm, give oxygen, run a strip, medicate for pain, and notify the physician. – Place on cardiac monitor; monitor for dysrhythmias, especially atrial fibrillation. Atrial fibrillation is common in heart failure. – Monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in cardiac output and index. – Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician's order. – If chest pain is present, have client lie down, monitor cardiac rhythm, give oxygen, run a strip, medicate for pain, and notify the physician. – Place on cardiac monitor; monitor for dysrhythmias, especially atrial fibrillation. Atrial fibrillation is common in heart failure. – Monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in cardiac output and index. – Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician's order. – oxygen as needed per physician's order. – semi-Fowler's position or position of comfort.
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Check blood pressure, pulse, and condition before administering cardiac medications :(ACE) inhibitors, digoxin, and beta-blockers such. the nurse evaluate how well the client is tolerating current medications before administering cardiac medications; During acute events, ensure client remains on bed rest or maintains activity level that does not compromise cardiac output. In severe heart failure, restriction of activity often facilitates temporary recompensation. Gradually increase activity when client's condition is stabilized by encouraging slower paced activities or shorter periods of activity with frequent rest periods following exercise prescription; observe for symptoms of intolerance. Serve small sodium-restricted, low-cholesterol meals. Monitor bowel function. Provide stool softeners as ordered. Caution client not to strain when defecating. Straining when defecating that results in the Valsalva maneuver can lead to dysrhythmia, decreased cardiac function, and sometimes death. Have clients use a commode or urinal for toileting and avoid use of a bedpan. Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. Schedule rest periods after meals and activities. Rest periods decrease oxygen consumption. Weigh client at same time daily. Assess for presence of anxiety; music will decrease anxiety & improve cardiac function. Closely monitor fluid intake including IV lines. Maintain fluid restriction if ordered. Refer to heart failure program or cardiac rehabilitation program: education, evaluation, guided support to increase activity and rebuild life.
MATERI PENGAYAAN http://www.homesteadschools.com/nursing/courses/cardiovascular%20nursing/Chapter12.html http://www.rnceus.com/ekg/ekgnd.html MATERI UNTUK LATIHAN 1. Jelaskan beberapa efek dari kondisi curah jantung yang berubah? 2. Sebutkan beberapa diagnosa terkait dengan sistem kardiovaskular beserta outcomenya? JAWABAN 1.
Condition or Factor Sleep No ChangeModerate changes in environmental temperature Anxiety and excitement 50 - 100% Eating 30% Exercise up to 700% High environmental temperature Pregnancy Epinephrine Increase Histamine Sitting or standing from lying position 20 - 30% Rapid arrhythmia Decrease Heart Disease
2.
Diagnosa Activity Intolerance Risk for Ineffective Renal Perfusion Risk for Shock Risk For Bleeding Risk for Decreased cardiac Tissue perfusion NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels • Cardiac Pump Effectiveness • Circulatory Status • Tissue Perfusion: Abdominal Organs • Tissue Perfusion: Peripheral • Vital Signs Status
REFERENSI Herdman, T. H., & North American Nursing Diagnosis Association. (2008). NANDA-I nursing diagnoses: Definitions & classification, 2009-2011. Oxford: Wiley-Blackwell. Moorhead, S. (2008). Nursing outcomes classification (NOC). St. Louis, Mo: Mosby/Elsevier. Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. C. (2008). Nursing Interventions Classification (NIC). St. Louis, Mo: Mosby/Elsevier. Potter, P. A., & Perry, A. G. (2005). Fundamentals of nursing. St. Louis, Mo: Mosby.
