Transcript Diagnosis Keperawatan terkait Cardiovaskular Responses

Diagnosis Keperawatan
terkait
Cardiovaskular Responses
Sri Setiyarini
Subag. KGD
Tujuan Pembelajaran:
 Mampu memahami dan mampu merumuskan diagnosa serta manajemen
keperawatan terkait gangguan sistem kardiovaskular.
Pokok Bahasan:
 Diagnosa dan manajemen keperawatan terkait gangguan sistem
kardiovaskuler
Subpokok Bahasan:
 Merumuskan Diagnosa Keperawatan
 Cardiovascular responses
 Cardiac Output Determination
 Effect of various conditions on cardiac output
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.
Bagan alur
Pengkajian: Pengumpulan data
Identifikasi
defining
characteristic
Related
factors
Diagnosa
cek kesesuaiannya dng
definisi diagnosa
Terintegrasi
dng riwayat,
bukti-bukti
lain atau
chart
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)
Diagnosis
Decrease Cardiac Output (CO)
Definition
Inadequate blood
pumped by the heart to
meet the metabolic
demands of the body
8
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)
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
Afterload
kontraktilitas
Preload
Pemendekan serat
miokard
Sroke
volume
Heart
Rate
CO
Ukuran
ventrikel kiri
Resistensi
perifer
Arterial Pressure
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 afterload
Altered contractility
Altered heart rate,
Altered rhythm
Altered Stroke Volume
Penyakit/kondisi yg menurunkan CO
Umumnya:
 myocardial
infarction,
 Hypertension
 valvular heart
disease,
 congenital heart
disease,
 cardiomyopathy,






pulmonary
disease,
arrhythmias,
drug effects,
fluid overload,
decreased fluid
volume,
electrolyte
imbalance.
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)
As blood is
pumped out of the
left ventricle into
the arteries,
pressure is
generated
Resistensi
perifer
CO
Arterial Pressure
MAP= Tekanan Rata-rata Arterial
(mean arterial pressure)
MAP approx = CO × SVR
atau
MAP = (CO × SVR) + CVP
Karena CVP umumnya dengan nilai
/mendekati 0 mmHg, maka persamaan
tersebut dapat disederhanakan menjadi:
MAP = 1 sistolik + 2 Diastolik
3
MAP
menggambarkan
TEKANAN PERFUSI ke
ORGAN-ORGAN tubuh
MAP normal = 70 – 105 mmHg
MAP



MAP > 60 mmhg, cukup untuk menjaga perfusi organ.
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
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
BP ∝ CO/r4
(resistensi pembuluh drh kecil)
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
Risk for Activity Intolerance (00094)
Diagnosis: Risk for Ineffective Cerebral Tissue Perfusion
(00201)
Definition: risk for a decrease in cerebral tissue circulation
Diagnosis: Risk for Ineffective Gastrointestinal Perfusion
(002002)
Definition: at risk for a decrease in gastrointestinal circulation
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
Left CHF/Pulmonary Congestion
24
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; 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
NIC Interventions
(Nursing Interventions Classification)
Suggested NIC Labels
• Cardiac Care: Acute
• Circulatory Care
Nursing Interventions
• 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.
• Monitor intake and output. ( measure hourly urine output –acute cond)
• Note results of EKG and chest Xray.
• Results of diagnostic imaging studies such as echocardiogram,
radionuclide imaging or dobutamine stress echocardiography.. An ejection
fraction in a healthy heart is approximately 50%. Most patients
experiencing heart failure have an ejection fraction of less than 40%.
• Watch laboratory data closely, especially arterial blood gases and
electrolytes, including potassium. Client may be receiving cardiac
glycosides and the potential for toxicity is greater with hypokalemia;
hypokalemia is common in heart clients because of diuretic use.
• Monitor lab work such as complete blood count, sodium level, and serum
creatinine. Routine blood work can provide insight into the etiology of
heart failure and extent of decompensation. A low serum sodium level
often is observed with advanced heart failure and can bea poor prognostic
sign. Serum creatinine levels will elevate in clients with severe heart
failure because of decreased perfusion to the kidneys.Creatinine may also
elevate because of ACE inhibitors.
• oxygen as needed per physician's order.
• semi-Fowler's position or position of comfort.
• 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.
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.
Any questions?