ASUHAN KEPERAWATAN PADA TN.A DENGAN UNSTABLE ANGINA PECTORIS DIRUANG IGD RSUD dr. MOEWARDI
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PROGRAM STUDI PRO2ESI NERS STIKES KUSUMA HUSADA SURAKARTA ('%8
ASUHAN KEPERAWATAN PADA TN.A DENGAN UNSTABLE ANGINA PECTORIS DIRUANG IGD RSUD DR.MOEWARDI
A. PENGKAJIAN PENGKAJIAN 1. Iden Identi tita tass Pas Pasie ien n a. Nama Tn. A !. Usia "# Ta$%n Ta$%n &. Jenis Ke'amin La(i)'a(i d. A'amat Ka*an+an,a* e. Dia+n-sa Medis UAP . N-m-* Re+iste* /102333 +. P*i-*itas T*iase Me*a$ #. Pen+(a Pen+(a4ian 4ian P*ime* P*ime* 5P*i 5P*ima* ma*, , S%*6e S%*6e,7 ,7 a. Ai*8a, 5A7 Ja'an naas 9aten: !e*si$ dan tida( te*da9at 9en%m9%(an se(*et !. B*eat$in+ 5B7 Pasien Pasien te*'i$a te*'i$att sesa( sesa( naas: naas: RR #;3M" e. E39-s%* s%*e 5E 5E7 Tida( ada (e'ainan 9ada t%!%$ 9asien tida( ada 4e4as tida( ada (*e9itasi ma%9%n (e'ainan !ent%( t%!%$
0. Pen+(a Pen+(a4ian 4ian Se(% Se(%nde nde** 5Se&%nda 5Se&%nda*, *, S%*6e, S%*6e,77 a. ?%'' ?%'' Set Set - >ita' ita' Si+ Si+n n 5?7 5?7 ) TD 1#/<;/ mmH+ ) N 3
S 5'ima7 T Hi'an+ Tim!%' Tim!%' 5!e*tam!a$ n,e*i saat di+%na(an a(tiitas7 &. HistHist-*, *, and and Hea Head d tt- t-e t-e 5H7 5H7 17 Hist-*, S $Su9#e!+i5* K'ien men+ata(an n,e*i dada se!e'a$ (i*i men4a'a* (e 'en+n (i*i A $Alleries* Pasien dan (e'%a*+a men+ata(an tida( ada a'e*+i -!at: ma(anan ata% min%man M $Medi+i-n* Ke'%a*+a men+ata(an men+ata(an se!e'%m mas%( *%ma$ sa(it ('ien se$a*i)$a*i men+(-ns%msi -!at ,an+ di!e*i(an -'e$ d-(te* %m%m. P $Ps+ Medil His+-r#* Ke'% Ke'%a* a*+a +a men+ men+at ata( a(an an 9asie 9asien n 9e*n 9e*na$ a$ di*a8 di*a8at at di *%ma *%ma$ $ sa(i sa(itt d*. d*. M-e8a*d M-e8a*dii (a*ena (a*ena st*-(e. st*-(e. Ke'%a* Ke'%a*+a +a men+at men+ata(a a(an n 9asien 9asien memi'i( memi'i(ii *i8a,at 9en,a(it DM dan $i9e*tensi. L $Ls+ Orl In+!e* Pasien men+ata(an te*a($i* ma(an tadi 9a+i 4am /;.// WIB 5ma(an !%!%*7
E $E/en+* Pasien men+ata(an me*asa(an n,e*i dada se!e'a$ (i*i men4a'a* (e
'en+an (i*i dan n,e*i !e*tam!a$ !e*at 1 $a*i se!e'%m mas%( *%ma$ sa(it. N,e*i di*asa(an saat !e*a(tiitas !e*a(tiitas dan tida( !e*(%*an+ !e*(%*an+ den+an den+an isti*a$at: (em%dian (e'%a*+a mem!a8a 9asien (e IGD RSDM. Saat di'a(%(an di'a(%(an 9eme*i(saan 9eme*i(saan EKG di IGD dida9at(an dida9at(an sin%s !*adi(a*di: !*adi(a*di: HR 3R (em%dian ('ien menda9at(an te*a9i -(si+en 0 '9m: as9i'et 13;/m+: ISDN 13m+ dan in%s NaC' 9ada tan+an (i*i #/t9m. #/t9m. Pasien men+e'%$ men+e'%$ !adan te*asa 'emas dan m%da$ 'e'a$ 4i(a di+%na(an %mt%( !e*a(ti6itas. #7 Head Head t- t-e t-e a7 Keadaan %m%m Lema$ b) Kesada*an C-m9-smentis. GCS 1 E = > M " &7 Tanda)ta anda)tanda nda 6ita' 6ita' ) Te(an e(anan an da*a$ da*a$ 1#/ 1#/<; <;/ / mmH mmH+ + ) ?*e(%en ?*e(%ensi si nadi nadi 3
a7 Ke9a'a mes-&e9a': *am!%t $itam: tida( ada n,e*i te(an: 9asien
tam9a( me*in+is (esa(itan !7 Wa4a$ ) Mata !e*si$: da9at me'i$at den+an 4e'as: (-n4%n+ti6a tida( anemis: anemis: s&'e*a tida( i(te*i(: *e'e( &a$a,a ada: 9%9i' is-(-* is-(-* tida( men++%na(an a'at !ant% 9en+'i$atan ) Hid%n+ Hid%n+ tida( tida( ada se(*et: se(*et: tam9a( tam9a( na9as na9as &%9i &%9in+ n+ $id%n+ $id%n+ ) M%'%t !e*si$: tida( ada st-matitis: m%(-sa !i!i* 'em!a9 ) Gi+i Gi+i !e*si !e*si$ $ sedi(i sedi(itt (e(%ni (e(%nin+a n+an: n: tida tida( ( ada ada (a*ies (a*ies +i+i +i+i ) Te'in+a e'in+a simet*i simet*iss (a<(i: (a<(i: !e*si$ !e*si$:: %n+s %n+sii 9ende 9enden+ n+a*an a*an !ai( !ai( &7 Le$e* simet*is: tida( te*a!a 9em!esa*an t,*-id: J>P = &m: tida( n,e*i saat mene'an d7 Dada Dada 5T$5T$-*a *a37 37 Pa*%)9a*% ) Ins9e( Ins9e(si si !ent%( !ent%( simet*is: simet*is: 9en+em 9en+em!an !an+an +an (a<(i (a<(i sama: ) )
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te*da9at *et*a(si dindin+ dada. Pa'9asi tida( ada n,e*i te(an: 6-(a' 6-(a' *emit%s (a<(i sama. Pe*(%si Pe*(%si s-n-* s-n-* se'%*%$ se'%*%$ 'a9an+ 'a9an+ 9a*%: 9a*%: sisi sisi dada (i*i ICS ICS 2:
sisi dada (anan ICS ;: dindin+ 9-ste*i-* = 4a*i di 9%nda( ) A%s(%'tasi !*-n(-6esi(%'e*: tida( te*da9at s%a*a tam!a$an Jant%n+ ) Ins9e(si i&t%s &-*dis tam9a( 9ada i&s (e Pa'9asi i&t%s &-*dis &-*dis te*a!a tida( (%at ) Pa'9asi ) Pe*(%si 9e(a(: (esan me'e!a* (e (a%d-'ate*a' ) A%s(%'tasi BJ I)II *e+%'e*: tida( ada !%n,i tam!a$an A!d-men Ins9e(si tida( te*da9at asites: simet*is: tida( ada 4e4as: tida( te*'i$at 4-%ndis A%s(%'tasi asi !i !isin sin+ %s% %s%ss 1# 1#3
te*9asan+ in%s NaC' /:@ #/ t9m di tan+an (i*i Ba8a$ Ba8a$ (e(%at (e(%atan an -t-t (a<(i (a<(i : a(*a' a(*a' $an+at: $an+at: CRT CRT # deti(: deti(:
tida( te*da9at -edem i7 Inte+% Inte+%men men Tida Tida( ( tam9at tam9at (e'ainan (e'ainan 9ada 9ada (%'it: (%'it: (%'it (%'it tam9a( tam9a( !e*si !e*si$: $: dan tida( te*da9at da(i.
=. Peme Peme*i( *i(saa saan n 9en 9en%n %n4a 4an+ n+ 17 Peme Peme*i *i(s (saan aan *-nt *-nt+e +en n Tan++a' #2 Mei #/12 4am 12.#/ WIB Kesan Ca*di-me+a'i #7 Peme Peme*i *i(s (saa aan n EKG EKG Tan++a' #2 Mei #/12 4am 1".# WIB Dida9at(an +am!a*an EKG sin%s !*adi(a*di: HR 3R 07 Peme Peme*i *i(s (saa aan n La! La! Tan++a' #2 Mei #/12 4am 1".0/ WIB Peme*i(saan He"+-l-i Ru+in Hem-+'-!in Hemat*-(it Le%(-sit T*-m!-sit E*it*-sit Inde; Eri+r-si+ MC> MCH MCHC RDW MP> PWD Hi+un 7enis Nit*-i' Lim-sit M-n-: e-s: !as He"-s+sis A'!%min C*eatinin U*e%m AP APTT INR Ki"i Klini! GDS SGOT SGPT Asam %*at C$-'este*-' T-ta' C$-'este*-' LDL C$-'este*-' HDL T*i+'ise*ida SEROLOGI He6+i+is H9sA R5id
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2unsi Pen&e+a$an 9*ime* dan 9en,a(it t*-m!-em!-'i( dan (a*di-6as(%'e* Men+atasi an an+ina 5n 5n,e*i dada dada77 ,an+ ,an+ dise! dise!a! a!(a (an n -'e$ 9en,a(it 4ant%n+ Men+em!a'i(an (eseim (eseim!an !an+an +an e'e(t*e'e(t*-'it 'it dan &ai*an t%!%$ Mem9e*!ai(i stat%s -(si+enasi dan memen%$i (e!%t%$an -(si+en Unt%( mensta!i'(an te(anan da*a$: men+%*an+i ata% men&e+a$ &ai*an !e*'e!i$ da'am t%!%$ dan men+%*an+i !e!an 4ant%n+
B. ANALISA DAT DATA N-. 1
Hri<+l<7" Kamis: #2<#/12 1. WIB
D+ 2-!us Pr-9le" DS 9asien Resi(men+ata(an sesa( 9en%*%nan na9as dan &e9at 'e'a$ &%*a$ saat di+%na(an %nt%( 4ant%n+ !e*a(ti6itas DO ) Te(anan da*a$ 1#/<;/ mmH+ ) ?*e(%ensi nad nadi 3R. ) Peme*i(saan *-nt+en Dida9at(an adan,a &a*di-me+a'i ) Hasi' 'a! C KM KMB ":22 ) T*-9-nim /:#/
E+i-l-i Pe*%!a$an I*ama 4ant%n+
#
1".//WIB
DS Pasien N,e*i a(%t men+ata(an n,e*i dada dada 1 $a*i $a*i se!e'% se!e'%m m mas%( *%ma$ sa(it. P 9asien men+ata(an n,e* n,e*ii saat saat di+% di+%na na(a (an n !e*a(tiitas N,e*i se9e*ti te*tim9a !enda !e*at R Ba+i Ba+ian an dada dada (i*i (i*i men4 men4a' a'a* a* (e 'en+ 'en+an an (i*i S 5'ima7 T Hi'an+ Tim!% m!%' 5!e*tam!a$ n,e*i saat di+%na(an a(tiitas7
Is(emia
T+d
0
1. WIB
DO ) Pasien tam9a( me*in+is (esa(itan ) 9asien tam9a( meme+an+i dada ) Saat di 'a(%a(an 9eme*i(saan di IGD dida9at(an +am!a*an EKG sin%s !*adi(a*di: HR 3R A>R DS Pasien men+ata(an sesa( naas dan &e9at 'e'a$ saat !e*a(ti6itas: !adan te*asa 'emas DO ) Te*da9a a9at *e *et*a t*a(si dindin+ dada ) Te(anan da*a$ 1#/<;/ mmH+ ) Den,%t n ad adi 3
Int-'ensi a(ti6itas
5Ka*di- ,+ !*masa'a$7 (etida(seim!an+an anta*a s%9'ai O # den+an (e!%t%$an t%!%$
C. Pri-ri+ Pri-ri+ss Din-s Din-s 1. Resi(- 9en%*%nan &%*a$ 4ant%n+ !.d 9e*%!a$an i*ama 4ant%n+ 2. N,e*i a(%t !.d Is(emia 3. Int-'e*an a(ti6itas !.d 5Ka*di- ,+ !*msa'a$7 (etida(seim!an+an anta*a s%9'ai O # den+an (e!%t%$an t%!%$
D. In+er/ensi Ke6er4+n Ke6er4+n Nama Tn.A N-.RM /10333 Um%* "# ta$%n D3. Medis UAP N- Ha*i: tan++a' T%4%an dan K*ite*ia $asi' Inte*6ensi NOC Jam NIC
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1
Kamis #2<<#/12 1.
NOC C%*a$ 4ant%n+ NIC Pe*a8atan Stat%s si*(%'asi Ka*di-6as(%'e* Sete'a$ di'a(%(an as%$an 1. E6a' E6a'%a %asi si adan adan,a ,a n,e* n,e*ii (e9e*a (e9e*a8ata 8atan n se'ama se'ama 132 dada dada 59en 59en&e &et% t%s: s: (%a' (%a'it itas as:: 4am *esi(- 9en%*%nan '-(asi: s(-*: 8a(t%7 &%*a$ &%*a$ 4ant%n 4ant%n+ + !e*(%* !e*(%*an+ an+ #. Cata Catatt adan adan,a ,a tand tandaa dan dan den+an (*ite*ia $asi' +e4a +e4a'a 'a 9en% 9en%*% *%na nan n &%*a &%*a$ $ a. TT> da'am !atas 4ant%n+ n-*ma' 5TD S 1//)1#/ D 0. M-nit-* stat%s "/)@/ mmH+: N"/) (a*di-6as(%'a* 1//3
#
Kamis #2<<#/12 1.
0
Kamis #2<<#/12 1.
NIC Pain &-nt*-' Sete'a$ di'a(%(an tind tinda( a(an an (e9e (e9e*a *a8a 8ata tan n se'a se'ama ma 132 132 4am n,e*i ,e*i !e*(%*an+ den+an (e*ite*ia $asi' 5n-*ma'n,a7 a. Mam9% men+ena'i n,e* n,e*ii 5s(a' 5s(a'a: a: inte intens nsit itas as:: *e(%ensi dan tanda n,e*i7 b. Tanda)tanda 6ita' da'am !atas n-*ma' 5TD S 1//)1#/ D "/)@/ mmH+ mmH+:: N"/ N"/)1 )1// //3< 3
NOC Pain Mana+emen 1.Ka 1.Ka4i 4i (a*a (a*a(t (te* e*ist isti( i( n,e* n,e*ii 5PRST7 #. Ka4i Ka4i 9en+ en+a'am a'aman an *asa asa n,e*i masa 'am9a% 0.Ka4i !e*sama 9asien a&t-* ,an+ mem9e*!e*at dan mem9e*in+an n,e*i =. K-nt*-' K-nt*-' 'in+(%n+an 'in+(%n+an ,an+ da9at da9at mem9en mem9en+a* +a*%$i %$i n,e*i n,e*i se9e*ti s%$% *%an+an: 9en&a$a,aan: dan (e!isin+an . A4a*(an te$ni( n-n a*ma a*ma( (a'a'-+i 5*e 5*e'a( 'a(sasi sasi:: dist dist*a *a(s (si: i: masa masass sse: e: te*a te*a9i 9i m%si(7 ". K-'a K-'a!!-*a *asi si 9em! 9em!e* e*ia ian n -!at)-!atan ana'+esi& ses%ai d+n *e(-mendasi
NIC Te*a9i Te*a9i a(ti6itas 1. Bant% ('ien %nt%( men+identi men+identii(asi i(asi a(ti6itas a(ti6itas ,an+ mam9% di'a(%(an #. Bant% 9asien %nt%( memi'i$ a(ti6itas (-n (-nsist sisten en ,an ,an+ ses% ses%ai ai den+an (emam9%an isi(: 9si(-'-+i dan s-&ia' 0. Ban Bant% 9asi 9asien en < (e'% (e'%a* a*+ +a
N: RR %ntt%( %ntt%( men+id men+ident entii( ii(asi asi !. TT> da'am !atas (e(%*an+an da'am n-*ma' 5TD S 1//)1#/ D !e*a(ti6itas "/)@/ mmH+: N"/) =. Bant% 9asien 1//3
E. I"6le"en+si Ke6er4+n Ke6er4+n
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Men+(a4i (a*a(te*isti( n,e*i 9asien
S Pasien men+ata(an men+ata(an me*asa( me*asa(an an n,e*i n,e*i dada dada se!e'a$ (i*i men4a'a* (e 'en+ 'en+an an (i*i (i*i da*i da*i 9a+i 9a+i $a*i dan n,e*i !e*tam!a$ !e*at 1 $a*i se!e'% se!e'%m m mas%( mas%( *%ma$ *%ma$ sa(it. P 9asien 9asien men+at men+ata(a a(an n n,e* n,e*ii saat saat di+% i+%na(a na(an n !e*a(tiitas N,e*i se9e*ti te*tim9a !enda !e*at R Ba+ian dada (i*i men4a'a* (e 'en+an (i*i S 5'ima7 T: Hi'an+ Tim!%' 5!e*tam!a$ n,e*i saat di+%na(an a(tiitas7 O
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Pasien te*'i$at me*isin+is (esa(itan Pasien te*'i$at meme+an+i dada se!e'a$ (i*i
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Men+a4a*(an Men+a4a*(an te$ni( &-nt*-' &-nt*-' S Pasien men+ata(an n,e* n,e*ii den+ den+an an te(n te(ni( i( n-n n-n !e*sedia dia4a*(an a*ma(-'-+i 5naas da'am7 naas da'am O Pasien te*'i$at men+i(%ti te$ni( naas da'am ,an+ dia4a*(an 9e*a8at
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1
Me'a Me'a(% (%(a (an n EKG
9eme 9eme*i *i(s (saa aan n
S ) O Dida9at(an +am!a*an EKG sin%s !*adi(a*di: HR 3R
1".0
0
Men+id Men+ident entii ii(as (asii a(ti6i a(ti6itas tas ,an+ da9at di'a(%(an 9asien
S Pasien men+ata(an $an,a !isa tid%*an O Pasien te*'i$at $an,a !e*!a*in+ ditem9at tid%*
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Mem!e*i(an -!at -*a' As9i'et 13;/ m+ dan ISDN 13m+
S ) O 9asien te*'i$at min%m -!at: 9asien te*'i$at 'e!i$ n,aman
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me'a(%(an PRST
S Pasien Pasien men+at men+ata(a a(an n me*asa( me*asa(an an n,e*i n,e*i dada dada se!e'a$ (i*i men4a'a* (e 'en+ 'en+an an (i*i (i*i da*i da*i 9a+i 9a+i $a*i dan n,e*i !e*tam!a$ !e*at 1 $a*i se!e'% se!e'%m m mas%( mas%( *%ma$ *%ma$ sa(it. P 9asien 9asien men+at men+ata(a a(an n n,e* n,e*ii saat saat di+% i+%na(a na(an n !e*a(tiitas N,e*i se9e*ti te*tim9a !enda !e*at R Ba+ian dada (i*i men4a'a* (e 'en+an (i*i S = 5Em9at7 T Hi'an+ Tim!%' 5!e*tam!a$ n,e*i saat di+%na(an a(tiitas7
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S(a'a n,e*i !e*(%*an+ da*i men4adi 0 Pasien te*'i$at me*isin+is (esa(itan Pasien te*'i$at meme+an+i dada se!e'a$ (i*i
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Men+an4%*(an 9asien %nt%( S 9asien 9asien men+at men+ata(a a(an n !ed*est ma% men+i(%ti 9e*inta$ ,an+ dian4%*(an O 9asien te*'i$at !e*!a*in+ dite9at tid%*
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O ) Te(an e(anan an da*a da*a$ $ 1#< 1#<;0 ;0 mmH+ mmH+ ) Den, Den,%t %t nad nadii "; 3R. A Masa'a$ !e'%m te*atasi P Lan4%t(an inte*6ensi ) Catat adan,a tanda dan +e4a'a 9en%*%nan &%*a$ 4ant%n+ ) M-nit-* stat%s (a*di-6as(%'e* ) M-nit-* 6ita' si+n ) K-'a!-*asi 9em!e*ian -!at)-!atan Kamis S Pasien men+ata(an n,e*i !e*(%*an+ sete'a$ me'a(%(an #2<<#/12 naas da'am dan min%m -!at s(a'a n,e*i da*i men4adi 0: 12.// n,e*i di*asa di*asa se9e*ti se9e*ti te*tim9a te*tim9a !enda !e*at !e*at da*i dada dada (i*i men4a'a* (e 'en+an (i*i O Te(anan da*a$ 1#<;0 mmH+ Den,%t nadi "; 3