Diagnosa Keperawatan AMI (Acute Myocardial Infarction)

Infark miokardium mengacu pada proses rusaknya jaringan jantung akibat suplai darah yang tidak adekuat sehingga aliran darah koroner berkurang.
(Brunner & Sudarth, 2002)

Infark miocard akut adalah nekrosis miocard akibat aliran darah ke otot jantung terganggu. (Suyono, 1999)

Sumber :
AMI (Acute Myocardial Infarction)

Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia. This usually results from an imbalance in oxygen supply and demand, which is most often caused by plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium.

Myocardial Infarction Nanda Nursing Diagnosis

Source :
http://nanda-list.blogspot.com

DIAGNOSA KEPERAWATAN DAN INTERVENSI AMI (Acute Myocardial Infarction)

1. Nyeri berhubungan dengan iskemia jaringan sekunder terhadap sumbatan arteri ditandai dengan :
  • nyeri dada dengan / tanpa penyebaran
  • wajah meringis
  • gelisah
  • delirium
  • perubahan nadi, tekanan darah.
Tujuan :
Nyeri berkurang setelah dilakukan tindakan perawatan selama di RS
Kriteria Hasil:
  • Nyeri dada berkurang misalnya dari skala 3 ke 2, atau dari 2 ke 1
  • ekpresi wajah rileks / tenang, tak tegang
  • tidak gelisah
  • nadi 60-100 x / menit,
  • TD 120/ 80 mmHg
Intervensi :
  • Observasi karakteristik, lokasi, waktu, dan perjalanan rasa nyeri dada tersebut.
  • Anjurkan pada klien menghentikan aktifitas selama ada serangan dan istirahat.
  • Bantu klien melakukan tehnik relaksasi, mis nafas dalam, perilaku distraksi, visualisasi, atau bimbingan imajinasi.
  • Pertahankan Olsigenasi dengan bikanul contohnya ( 2-4 L/ menit )
  • Monitor tanda-tanda vital ( Nadi & tekanan darah ) tiap dua jam.
  • Kolaborasi dengan tim kesehatan dalam pemberian analgetik.

2. Resiko penurunan curah jantung berhubungan dengan perubahan factor-faktor listrik, penurunan karakteristik miokard
Tujuan :
Curah jantung membaik / stabil setelah dilakukan tindakan keperawatan selama di RS
Kriteria Hasil :
  • Tidak ada edema
  • Tidak ada disritmia
  • Haluaran urin normal
  • TTV dalam batas normal
Intervensi :
  • Pertahankan tirah baring selama fase akut
  • Kaji dan laporkan adanya tanda – tanda penurunan COP, TD
  • Monitor haluaran urin
  • Kaji dan pantau TTV tiap jam
  • Kaji dan pantau EKG tiap hari
  • Berikan oksigen sesuai kebutuhan
  • Auskultasi pernafasan dan jantung tiap jam sesuai indikasi
  • Pertahankan cairan parenteral dan obat-obatan sesuai advis
  • Berikan makanan sesuai diitnya
  • Hindari valsava manuver, mengejan ( gunakan laxan )

3. Gangguan perfusi jaringan berhubungan dengan , iskemik, kerusakan otot jantung, penyempitan / penyumbatan pembuluh darah arteri koronaria ditandai dengan :
  • Daerah perifer dingin
  • EKG elevasi segmen ST & Q patologis pada lead tertentu
  • RR lebih dari 24 x/ menit
  • Kapiler refill Lebih dari 3 detik
  • Nyeri dada
  • Gambaran foto torak terdpat pembesaran jantung & kongestif paru ( tidak selalu )

Sumber :

Diagnosa Keperawatan AMI (Acute Myocardial Infarction)


Nursing Diagnosis for Myocardial Infarction
  1. Acute Pain related to ischemic tissue, secondary to clogged arteries.
  2. Decreased Cardiac Output related to changes in power factors, reduction miocard characteristics.
  3. Activity Intolerance related to the imbalance between oxygen supply and demand miocard, the ischemic / necrotic tissue miocard.
  4. Imbalanced Nutrition: Less than Body Requirements related to decreased renal perfusion, increased sodium / water retention, increased hydrostatic pressure, decreased plasma proteins.
  5. Ineffective Tissue Perfusion related to ischemic heart muscle damage, narrowing / blockage of coronary arteries.
  6. Anxiety related to actual threats to biological integrity.
  7. Ineffective Coping
  8. Ineffective Sexuality Patterns
Source :

Nursing Diagnosis for Myocardial Infarction

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