Penatalaksanaan Perawatan Pasien Sindroma Koroner Akut (SKA) Di Rumah Sakit

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Penatalaksanaan Perawatan Pasien

Sindroma Koroner Akut (SKA)

Di Rumah Sakit

Ns. Rita Sekarsari, Sp.KV., MHSM

Disampaikan pada Seminar STIKES KUDUS

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No Pendidikan

1 AKPER DEPKES RI 1985 2 S1 PSIK UI 1993

3 S2 Monas Uni Melbourne 2001 4 Pengakuan Ns Sp KV 2011

5 S3 FIK UI 2010 , candidate doctor

Rita Sekarsari

No Pekerjaan

1 Kepala Diklat Internal-Eksternal RSJPDHK 2012

-2 Ketua Sub Komite Keperawatan RSJPDHK 2005 - 2012

3 Manajer Instalasi Rawat Inap RSJPDHK 2001- 2007

4 Ka Ru ICU RSJPDHK 1993 - 2001 5 Supervisor Keperawatan RSJPDHK

1993 - 2009

6 Koordinator DIKLAT POST BASIC 1993 - 2001

NO Organisasi saat ini

1 Ketua II PP PPNI 2010-2016 2 President INKAVIN 2012-2017

3 Ketua Kolegium Keperawatan Spesialis Kardiovaskula 2010 - 2016

4 Surveyor KARS

5 Pengurus MTKI 2011- 2016

6 Pengurus ARSPI

Kontak :

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Objektif



Proses Penyakit Jantung Koroner (PJK)



Faktor Risiko Penyakit Jantung Koroner



Patofisilogi Sindroma Koroner Akut (SKA)



Mengenal Keluhan Utama SKA



Perbedaan UAP , NSTEMI dan STEMI



Pencapaian Asuhan Keperawatan SKA

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12

Just think the word RISKS:



R

ising LDL, and triglyseride

levels-LDLs should be < 130 mg/dl, triglycerides < 200

I

nadequate control of hypertension, diabetes, and obesity - Diet and excersise life style changes are the step to regaining control



S

ex – CAD is more common in men until after age 75



K

infolk – Heredity is a nonmodifiable risk factor



S

moking – the soonner stopped the better

CAD risk factors

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12

How it happens (ACS)

Patient with ACS have some degree of coronary artery occlusion. Developement begins with rupture or errosion of plaque-an ustable and lipid-rich subtance

The rupture results in platelet adhesions, fibrin clot formation, activation of trombin

A thrombus progresses and ocludes blood flow (an early thrombus

doesn’nt neceessarily block blood flow).The effect is an imbalance in myocardial oxygen supply and demand. Depending on the dgree of occlusion. ACS is defined as three types

If the patient has unstable angina, a thrombus partially

occludes a coronary vessel. This thrombus is full of platelets. The partially occluded vessell may have distal microthrombi that cause necrosis in some myocytes

If smaller vessels infarct, the patient is a higher risk for MI, which may progress to a non ST-segment elevation MI. Usually, only the inner most layer of the hearts is damaged

ST-segment elevation MI results when reduced blood flow through one of the coronary arteries causes myocardial ischemia, injury, and

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Coronary artery close-up

Atherosclerosis

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PENURUNAN PASOKAN

OKSIGEN

ATEROSKLEROSIS PLAK

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Mekanisme SKA

Robekan/ruptur plak ateroskelerosis

Aktivasi inflamasi dan kaskade koagulasi

Terbentuk Thrombus: --Adhesi

--Aktivasi --Agregasi

Sumbatan Koroner

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Plak Stabil (stable plaque) Plak ruptur (ruptured plaque)

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Sidroma Koroner Akut (SKA)

Klasifikasi SKA meliputi:

Angina Pektoris Tak Stabil

(15)



_{Nyeri dada iskemik (angina) pd saat istirahat atau}

dgn aktivitas fisik minimal atau emosi (lama 2 x 5

menit atau >10 mnt)



Adanya bukti Penyakit Jantung Koroner (PJK):

-EKG: ST depresi, T inversi, ST elevasi sesaat

-Peningkatan enzim CK-MB atau Trop T

-Bukti PJK dari angiografi koroner/ perfusion

scanning

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1.

Angina saat istirahat

Timbul saat istirahat dan berkepanjangan,

biasanya > 20 menit

2.

New-onset angina - Baru pertama muncul

3.

Angina yang bertambah (progressif)

Sudah ada angina tetapi bertambah sering,

lebih lama, dgn pencetus yg lebih ringan

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Troponin T CKMB

Infark Miokard Akut (Acute MCI)

Memerlukan terapi trombolitik (strepto

(18)



Nyeri dada khas infark: nyeri dada atau

leher atau rahang (seperti ditekan atau

dihimpit) berlangsung lebih dari 30 menit



Disertai gejala sistemik : berkeringat seluruh

tubuh, mual dan muntah, sesak



Pemeriksaan fisik : Hipotensi, ronkhi basah

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KELUHAN UTAMA: NYERI DADA

Memory board PQRST : What’s the story ?

P

Provocative or palliative

What provokes or relives the chest pain

What makes pain feel like

Are you having the pain right now? If so, is it more or less severe than usual

To what degree does chest pain affect your normal activities

When did the pain begin ?

Was the onset sudden or

gradual ?

How often does the pain occur?

How long does it last ?

Where in the chest the pain occur ? the chest pain? How would you rate it on a scale of 0 to 10, with 10 being the most severe ?

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What to look for : Unstable angina and MI

Unstable angina Myocardial infarction

Character, location, radiation

Burning,squeezing,substernal or retrosternal pain spreading across chest; may radiate to inside of arm, neck, jaw or shoulder blade

Severe, persistent substernal pain or pain over pericardium; may spread widely throughout chest and be accompanied by pain in shoulders and hands; may be described as crushing or squeezing

Duration of pain 5 to 15 min > 15 min

Precipitating events Usually related to exertion, emotion, eating and cold

Occurs spontaneously

May be sequela to ustable angina

Realiving measures Rest, nitroglycerin, oxygen Morphine sulfate, successful reperfusion of blocked coronary artery

Associated sympstoms

Shortness of breath Dizzeness

Nausea Palpitations Weakness Cold sweat

Feeling of impending doom Fatique

Nausea and vomiting Shortness of breath Cool extremities Perspiration Anxiety

Associated signs Hypotension or hypertention Tachycardia or bradycardia

Hypotention or hypertention Palpable precordial pulses Mufled heart sounds Arrhytmias

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Ustable angina

Myocardial Infarction

Burning

Squeezing

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Management Before STEMI

4

1 2 3 4 5 6

Onset of STEMI - Prehospital issues

- Initial recognition and management in the Emergency Department (ED) - Reperfusion

Hospital Management - Medications

- Arrhythmias - Complications

- Preparation for discharge

Secondary Prevention/ No ST Elevation

NSTEMI

Ischemic Discomfort Acute Coronary Syndrome

Unstable Angina

Myocardial Infarction

ST Elevation

Modified from Libby. Circulation

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Electrocardiography

Harus direkam dan dibaca

dalam waktu 10 menit

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Pasien harus dimonitor

dengan defibrilator

karena aritmia letal dapat

terjadi sewaktu waktu

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Locating myocardial damage

Wall affected Leads Artery involved

Anterior V2 , V3, V4 LCA, LAD Anterolateral I,aVL, V3 to V6 LAD, LCx Anteroseptal V1, V2, V3, V4 LAD

Inferior II, III, aVF RCA

Lateral I,aVL, V5, V6 LCx, Branch LAD Poserior V8, V9 RCA, LCx

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CHARACTERISTICS OF SERUM CARDIAC MARKERS FOR THE DIAGNOSIS OF ACUTE MYOCARDIAL INFARCTION

SERUM CARDIAC MARKERS TEST FIRST BECOMES POSITIVE (HOURS)

PEAK LEVEL ( Hours)

Cretinin Kinase

Single assay Serial assay

Creatine Kinase- MB

Single assay Serial assay

Troponin I and T

Measure 4 hours after onset of chest pain Measure 10 hours after onset of chest pain

3 - 8

SKA harus ditegakan tanpa menunggu hasil enzym WHO: D/STEMI ( 2 hal ): Nyeri dada tipikal,

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Pencapaian Asuhan Keperawatan

Lakukan Perawatan dan Kolaborasi

Lakukan triage secara optimal

Lakukan Reperfusi berdasarkan protokol

Berikan terapi oksigen ( selama 6 jam setelah on set , gunakan pulse oximeter) , terapi nyeri dada

Berikan rasa nyaman , dukungan , edukasi dan kepercayaan kepada pasien dan keluarga

Monitor secara terus menerus irama, ST elevasi

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Deteksi dan cegah komplikasi :

Monitor perubahan gambaran EKG dan aritmia Gunakan penempatan sadapan yang tepat

Monitor status hemodinamik secara ketat spt penurunan curah jantung . Kaji denyut jantung, suara paru , pulsasi perifer , status cairan, status neurologik, nyeri dada, dan lainnya spt cemas, depresi pemahaman pasien terhadap kondisi nya , koping .

Perhatikan tanda tanda ronchi, batuk, tachypmea, edema

 LHF . Monitor BB, Pemasukan dan Pengeluaran cairan, RR, Gambaran EKG. Enzym, TD, bunyi jantung S3 & S4 gallops

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Penatalaksanaan Nyeri Dada:

Gunakan skala penilaian nyeri dada yang terstandarisasi

Ajarkan pasien dan keluarga pentingnya pelaporan nyeri dada , buat mereka menyadari manfaat dari pelaporan tersebut dan berikan terapi iskemi berulang

Batasi aktivitas pada 12 jam pertama

Berikan nitrates dan morphine sulfate intra vena sesuai kebutuhan . Morphin HR , Vasocontriction.

Nitrates menurunkan afterload & preload

Pada iskemia berulang / nyeri dada . Kaji (ECG 12 lead dan obati dengan nitrates & morphine jika diperlukan

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Mendukung Pemulihan yang optimal

Memberkan penjelasan terkini tentang kondisi pasien kepada keluarga

Melmulai lebih awal memberikan pendidikan dan konseling kepada pasien dan keluarga

Memberkan penjelasan tentang perilaku hidup sehat dan memodifikasi faktor risiko kepada psien dan

keluarga

Mengkaji dan mengelola kecemasan dan depresi serta penghambat terhadap kepatuhan

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Memberikan pendidikan dan dukungan kepada

pasien dan keluarga

Menilai pasien & kesiapan keluarga untuk perubahan, menentukan hambatan perubahan

Menilai koping

Jelaskan tujuan dan apa yang diharapkan dari pemeriksaan atau tes yang dilakukan .

Sebelum pulang, pastikan hal berikut ini meliputi: Faktor risiko & tujuan rencana, rekomendasi gaya hidup, resep obat, pentingnya kepatuhan, mengenali gejala iskemia dan apa yang harus dilakukan, rekomendasi mengikuti pelatihan BHD untuk keluarga, mengikuti program rehabilitasi, dan memastikan tindak lanjut program konsultasi/kunjungan .