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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
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
Diagnosa keperawatan
Diagnosis
Decrease Cardiac Output (CO)
Definition
Inadequate blood
pumped by the heart to
meet the metabolic
demands of the body
8
Cardiac Output (C0) is the volume of blood that is pumped out of the heart per
minute.
(CO=HR X SV)
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
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)
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
menggambarkan
TEKANAN PERFUSI ke
ORGAN-ORGAN tubuh
MAP normal = 70 105 mmHg
MAP
Brain
Heart - (70% coronary artery perfusion
occurs during diastole) (Diastolic pressure <
50 mmHg compromises perfusion of heart)
Kidneys
BP CO/r4
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)
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
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
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.
Referensi
Any questions?