06 Nursing Care of CAD
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Emil Huriani 1
Asuhan keperawatan pada
Penyakit Arteri Koronaria
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Emil Huriani 2
Heart Anatomy
Figure 18.1
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Emil Huriani 3
Dinding Jantung
Epikardium – Lapisan terluar perikardium
Miokardium – Lapisan otot jantung yangmembentuk lapisan tebal pada jantung
Endokardium – lapisan endotelium di bagian
dalam miokardium
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Emil Huriani 5
Arteri – koronaria kiri dan kanan marginal!ir!um"le# dan arteri inter$entri!ular anterior
Vena – $ena besar anterior dan ke!il
Jantung bagian luar: Pembuluh darah yang
membawa darah ke dan dari dinding jantung
(Anterior
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Emil Huriani 6
External Heart: Po!terior View
Figure 18.4d
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Emil Huriani 7
Arteri – arteri koronaria kanan dan arteri
inter$entri!ular posterior
Vena – $ena besar $ena posterior $entrikel kirisinus !oroner dan $ena tengah
Jantung bagian luar: Pembuluh darah yang
membawa darah ke dan dari dinding jantung
(Po!terior
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Emil Huriani 8
"irkula!i #oroner
"irkula!i $oroner adalah suplay darah "ungsional ke
otot jantung
Jalur kolateral memastikan aliran darah ke jantung
walaupun pembuluh darah besar tersumbat
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Emil Huriani 9
%oronary %ir$ulation: Arterial "upply
Figure 18.%a
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Emil Huriani 10
%oronary %ir$ulation: Venou! "upply
Figure 18.%b
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Athero!klero!i!
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&eori Atero!klero!i!
/edera endothelium &ndothelial injury !aused byhyperlipidemia hypertension or other irritant agents
0e"ense "a!tors released into the endothelial lining and !auses
migration o" smooth mus!le !ells into the intima
he presen!e o" smooth mus!le !ells initiate the synthesis o"
!ollagen proteins and proteogly!ans
he a!!umulation o" intra!ellular and e#tra!ellular lipids and
platelets
Formation o" su!h lesions su!h as thrombus
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&ahapan Athero!klero!i!
Fatty 2treak
(ntermediate lesion
Atheroma
/ompli!ated lesion
rupture
Fibrosis pla3ue
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Athero!klero!i! &ahap '
&ndothelialdis"un!tion !aused
by L0L !holesterol
in"e!tion and "ree
radi!als
igration o"
monosite
lymphosites andma!rophages
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Athero!klero!i! &ahap
Prolipheration o"
smooth mus!le
!ell and platelet
aggregation
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Athero!klero!i! &ahap )
5e!rosis o" !orelesion
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Athero!klero!i! &ahap *
Fibrous !ap
thinning and
rupture due to thein"lu# and
a!ti$ation o"
ma!rophages
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Athero!klero!i! &ahap +
he release o"
proteolyti!
en6ymes
"ollowed byhemorrhage
thrombus
"ormation and
arterial o!!lusion
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,i!k -a$tor! ('
7nmodi"iable
Age' 9: years
;ender' men women
Family history
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,i!k .a$tor! () here are a number o" other less wellestablished risk "a!tors "or
atheros!lerosis in!luding'
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%lini$al Mani.e!tation!
Emil Huriani 23
he !lini!al mani"estations o" atheros!lerosis depend on the $essels in$ol$edand the e#tent o" $essel obstru!tion.
Atheros!leroti! lesions produ!e their e""e!ts through'
narrowing o" the $essel and produ!tion o" is!hemiaG
sudden $essel obstru!tion !aused by pla3ue hemorrhage or ruptureG
thrombosis and "ormation o" emboli resulting "rom damage to the $essel
endotheliumG
(n larger $essels su!h as the aorta the important !ompli!ations are those o"thrombus "ormation and weakening o" the $essel wall.
(n mediumsi6e arteries su!h as the !oronary and !erebral arteries is!hemiaand in"ar!tion !aused by $essel o!!lusion are more !ommon.
Although atheros!lerosis !an a""e!t any organ or tissue the arteries supplyingthe heart brain kidneys lower e#tremities and small intestine are most"re3uently in$ol$ed.
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%oronary heart di!ea!e
he term coronary heart disease */
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Angina Pe$tori!
0e"inition
;enerally des!ribed as retrosternal
hea$y or gripping sensation with
radiation to le"t arm or ne!k pro$oked
by e#ertion and eased with rest or
nitrates
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Angina $an be:
2table
7nstable !aused by
unstable pla3ue o!!urs at
rest unpredi!table pain !an
in!rease "or no ob$ious
reason
Prin6metalHs o!!urs
without pro$o!ation usually
at rest as a result o"
!oronary artery spasm
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"table angina pe$tori!
Pro$oked by physi!al e#ertion
espe!ially in !old weather a"ter
meals and !ommonly aggra$ated by anger or e#!itement
he pain "ades 3ui!kly with rest
(n some patients pain o!!urs predi!tably at a !ertain le$el o"
e#ertion
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/0% %AD
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"ign! and !ymptom!
/hest pain
5ausea D $omitting
2timulation o" 2ympatheti! ner$ous system
Fe$er
/ardio$as!ular mani"estation
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Myo$ardial in.ar$tion
A!ute myo!ardial in"ar!tion *A(- also known as a heart atta!k is
!hara!teri6ed by the is!hemi! death o" myo!ardial tissue asso!iated withatheros!leroti! disease o" the !oronary arteries.
0iagnosis' 1. Pain
he pain typi!ally is se$ere and !rushing o"ten des!ribed as being
!onstri!ting su""o!ating. (t usually is substernal radiating to the
le"t arm ne!k or jaw although it may be e#perien!ed in other areas
o" the !hest. ;astrointestinal !omplaints are !ommon. here may be a sensation
o" epigastri! distressG nausea and $omiting may o!!ur. =. &/;
&le$ation o" the 2 segment usually indi!ates a!ute myo!ardialinjury.
Jhen the 2 segment is ele$ated without asso!iated wa$es it is
!alled a non"#$%ae in&arction. A non–wa$e in"ar!tion usually
represents a small in"ar!t that may e$ol$e into a larger in"ar!t.
. &n6ymes
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En1yme!
'yo!lo(in is an o#ygen!arrying protein similar to hemoglobin that isnormally present in !ardia! and skeletal mus!le. (t is a small mole!ule thatis released 3ui!kly "rom in"ar!ted myo!ardial tissue and be!omes ele$atedwithin 1 hour a"ter myo!ardial !ell death with peak le$els rea!hed within 4
to 8 hours. (t rapidly eliminates through urine *low mole!ular weight-.Be!ause myoglobin is present in both !ardia! and skeletal mus!le it is not!ardia! spe!i"i!.
Creatine )inase */K- "ormerly !alled creatinine phospho)inase, is anintra!ellular en6yme "ound in mus!le !ells. us!les in!luding !ardia!mus!le use AP as their energy sour!e. /reatine whi!h ser$es as a storage"orm o" energy in mus!le uses /K to !on$ert A0P to AP. /K e#!eedsnormal range within 4 to 8 hours o" myo!ardial injury and de!lines tonormal within = to days. here are three isoen6ymes o" /K with the B
isoen6yme */KB- being highly spe!i"i! "or injury to myo!ardial tissue.
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En1yme!
he troponin comple* !onsists o" three subunits *i+e+, troponin / troponin (and troponin - that regulate !al!iummediated !ontra!tile pro!ess in striatedmus!le. hese subunits are released during myo!ardial in"ar!tion. /ardia!
mus!le "orms o" both troponin and troponin ( are used in diagnosis o"myo!ardial in"ar!tion. roponin ( *and troponin G not shown- rises moreslowly than myoglobin and may be use"ul "or diagnosis o" in"ar!tion e$en upto to 4 days a"ter the e$ent. (t is thought that !ardia! troponin assays aremore !apable o" dete!ting episodes o" myo!ardial in"ar!tion in whi!h !elldamage is below that dete!ted by /KB le$el.
M di l i . ti
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Myo$ardial in.ar$tion
E.. . AM2
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E..e$t! o. AM2
he prin!ipal bio!hemi!al !onse3uen!e o" A( is the !on$ersion "rom aerobi!to anaerobi! metabolism with inade3uate produ!tion o" energy to sustain
normal myo!ardial "un!tion.
he is!hemi! area !eases to "un!tion within a matter o" minutes and
irre$ersible myo!ardial !ell damage o!!urs a"ter => to 4> minutes o" se$ere
is!hemia.
he term reper&usion re"ers to reestablishment o" blood "low through use o"
thrombolyti! therapy or re$as!ulari6ation pro!edures.
&arly reper"usion *within 1: to => minutes- a"ter onset o" is!hemia !an
pre$ent ne!rosis.
Ieper"usion a"ter a longer inter$al !an sal$age some o" the myo!ardial
!ells that would ha$e died be!ause o" longer periods o" is!hemia.
E%3
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E%3
2 segment ele$ations
typi!ally due to !omplete o!!lusion o" a !oronary
artery.
52&(s typi!ally a sudden narrowing o" a !oronary artery
with preser$ed *but diminished- "low to the distal
myo!ardium.
Anti!oagulation and antiplatelet agents
pre$ent the narrowed artery "rom o!!luding.
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#la!i.ika!i #2442P
7sed in indi$iduals with an a!ute myo!ardial in"ar!tion
to risk strati"y
(ndi$iduals with a low Killip !lass are less likely to die withinthe "irst >
K(LL(P ( 2esak tanda gagal jantung *- Mortality rate 5 67
K(LL(P (( 2esak Ihonkhi *?- Mortality rate 5 '87
K(LL(P ((( 2esak Ihonkhi luas *&dema Pulmonal- Mortalityrate 5 )97
K(LL(P (M 2yok Kardiogenik. Mortality rate 5 9'7
http://en.wikipedia.org/wiki/Myocardial_infarctionhttp://en.wikipedia.org/wiki/Myocardial_infarction
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&AIL) A5A;&&5
he patientHs history and 1=lead &/; are the primary methods
used to determine initially the diagnosis o" (.
he &/; is e#amined "or the presen!e o" 2 segmentele$ations o" 1 mM or greater in !ontiguous leads.
1. Administer aspirin 19> to =: mg !hewed.
=. A"ter re!ording the initial 1=lead &/; pla!e the patient ona !ardia! monitor and obtain serial &/;s.
. ;i$e o#ygen by nasal !annula.
Management
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4. Administer sublingual nitrogly!erin *unless thesystoli! blood pressure is less than C> mm or greater than 1>>
beats?minute-.
:. Pro$ide ade3uate analgesia with morphine sul"ate.
Pro$ide ade3uate analgesia with morphine sul"ate.
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% li ti
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%ompli$ation!
Arrhythmias
/ongesti$e
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Treatment (continued)
1) Stenting
N a stent is introdu!ed into a blood $essel on a balloon!atheter and ad$an!ed into the blo!ked area o" the artery
N the balloon is then in"lated and !auses the stent to e#pand
until it "its the inner wall o" the $essel !on"orming to
!ontours as needed
N the balloon is then de"lated and drawn ba!k
Nhe stent stays in pla!e permanently holding the $esselopen and impro$ing the "low o" blood.
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Treatment
(continued)
2) AngioplastyN a balloon !atheter is passed through the guiding !atheter to thearea near the narrowing. A guide wire inside the balloon !atheter is
then ad$an!ed through the artery until the tip is beyond the
narrowing.
N the angioplasty !atheter is mo$ed o$er the guide wire until the
balloon is within the narrowed segment.
N balloon is in"lated !ompressing the pla3ue against the artery wall
N on!e pla3ue has been !ompressed and the artery has been
su""i!iently opened the balloon !atheter will be de"lated and
remo$ed.
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Treatment (continued)
- Bypass surgery
N healthy blood $essel is remo$ed "rom leg arm or !hest
N blood $essel is used to !reate new blood "low path in your heart
N the +bypass gra"t, enables blood to rea!h your heart by "lowingaround *bypassing-
the blo!ked portion
o" the diseased
artery. he in!reased
blood "low redu!esangina and the risk
o" heart atta!k.
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N3et regular medi$al $he$kup!
N%ontrol your blood pre!!ure
N%he$k your $hole!terol
NDon;t !moke
NExer$i!e regularly
NMaintain a healthy weight
NEat a heart
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Myo$ardial in.ar$tion
=ur!ing pro$e!!
ssessment A $are.ul hi!tory
De!$ription o. !ymptom! ( $he!t pain> palpitation>dy!pnea> !yn$ope or !weating Ea$h !ymptom!
mu!t be e?aluated with regard to time> duration>
pre$ipitating @ relie?ing .a$tor! 2n addition
$omplete phy!i$al a!!e!!ment .or:
le?el o. $on!$iou!ne!!
=ur!ing pro$e!! ($ont
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Heart !ound!
Peripheral pul!e!
4ung !ound
=ur!ing pro$e!! ($ont…
=ur!ing Diagno!e!
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• A!ute Pain related to o#ygen supply and demand
imbalan!e
• Iisk "or ine""e!ti$ely o" !ardia! tissue per"usion
• An#iety related to !hest pain "ear o" death threatening
en$ironment
• 0e!reased /ardia! Eutput related to impaired
!ontra!tility
• A!ti$ity (ntoleran!e related to insu""i!ient o#ygenation
to per"orm a!ti$ities o" daily li$ing de!onditioning
e""e!ts o" bed rest
• Iisk "or (njury *bleeding- related to dissolution o"
prote!ti$e !lots
=ur!ing Diagno!e!
=ur!ing pro$e!! ($ont
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=ur!ing pro$e!! ($ont…
Patient's goals
, eport that pain i! de$rea!ed
Breath e..e$ti?ely
Experien$e le!! anxiety le?el
Ha?e impro?ed ti!!ue per.u!ion
Adhere to the !el. $are program
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=ur!ing pro$e!! ($ont…
Nursing intervention
Ielie" or !ontrol o" !hest pain
Alle$iate respiratory di""i!ulties
Iedu!e the an#iety le$el
aintain ade3uate tissue per"usion
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