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Slide 2

Acute coronary syndrome is a collection of clinical symptoms of myocardial ischemia that
occurs due to lack of blood flow to the myocardium in the form of chest pain, ST segment
changes on the Electrocardiogram (ECG), and changes in cardiac biomarkers (Kumar &
Cannon, 2009). An acute state of ischemia can cause myocardial necrosis which can
progress to Acute Myocardial Infarction.
According to WHO in 2008, ischemic heart disease is the leading cause of death in the
world (12.8%) while in Indonesia ranks third.

Slide 3
•- Global
•WHO data shows that due to cardiovascular disease, there are 4 million deaths each
year in 49 countries in continental Europe and North Asia. Data released by the
American Heart Association (AHA) in 2016 stated that 15.5 million Americans have
cardiovascular disease.
•Basic Health Research (RISKESDAS) in 2013 states that nationally there is 0.5%
prevalence of coronary heart disease diagnosed by doctors. The prevalence is highest
in the provinces of North Sulawesi, Central Sulawesi, DKI Jakarta and Aceh.
•North Sulawesi
•According to the Basic Health Research (RISKESDAS) of coronary heart prevalence
based on doctor's diagnosis, North Sulawesi is 0.7% each.

Slide 4
In order that the discussion of the problem is more focused, the authors provide a limitation of
the problem in this paper.
The scope of the problem are:
1. In this paper only discusses issues related to acute coronary syndrome
2. This paper discusses the Definition, Classification, Etiology, Pathophysiology, Clinical
Manifestations, Diagnostic Examination, Medical Management, Complications and signs of
symptoms from acute coronary syndrome as well as matters related to nursing care.

Slide 5

Writing Objectives
Being able to apply theoretically the concept of nursing care to clients with acute
coronary syndrome.

Slide 6

Definition of
Acute Coronary Syndrome is a term for clinical signs and symptoms of myocardial
ischemia: unstable angina, non ST segment elevation of myocardial infarction, and ST
elevation myocardial infarction segment. Acute Coronary Syndrome is one of the three
coronary artery diseases, namely: STEMI, non-STEMI and unstable angina pectoris
(www. Nursing
Acute Coronary Syndrome is an emergency condition of the heart with clinical
manifestations in the form of chest discomfort or symptoms other symptoms resulting
from myocardial ischemia. (Woods, Susan L.2005 Cardiac Nursing).

Slide 7

classification of acute coronary syndrome is classified into three types, namely:

• ST elevasi MI (STEMI)
• Non ST elevasi MI (NSTEMI
• UAP (unstable angina pectoris

Slide 8

a. causative factors
1. Reduced oxygen supply to the myocardial is caused by 3 factors:
a.Factors for Arterial
b. Circulatory factors
aortic stenosis aortic
c. Blood Factors

Slide 9

2. Increased cardiac output

3. Myocardial oxygen demand increases in:

Predisposing factors
- Age> 40 years
- Gender
- Family history
Slide 10
Risk factors can be changed:
1. Major
- Risk factors that can be changed

Slide 11
2. Minor
- Physical activity / lifestyle
- Type A personality patterns (emotional, aggressive, ambitious,
- Psychological stress

Slide 12
The main causative factor in ACS is lack of blood flow to the myocardium
which is often caused by atherosclerosis. Atherosclerosis begins when fatty
cholesterol builds up in the large artery intima. This heap, called atheroma
or plaque will interfere with the absorption of nutrients by endothelial cells
that make up the inner lining of blood vessels and block blood flow because
the pile protrudes into the lumen of the arteries.

Slide 13
- The main symptoms are chest pain that occurs suddenly and continuously
does not subside, usually felt above the lower sternal region and upper
abdominal region.
- The severity of pain can increase permanently until the pain is
- The pain is very painful, like a tingling which can spread to the shoulder
and continue down to the arm (usually the left arm).
- Pain begins spontaneously (does not occur after activities or emotional
disturbances), persists for several hours or days, and does not - disappear
with the help of rest or nitroglycerin.
- Pain can spread to the jaw and neck.
- Pain is often accompanied by shortness of breath, pale, cold, severe
diaphoresis, dizziness or head feels floating and nausea vomiting.
- Patients with diabetes mellitus will not experience great pain because the
neuropathy that accompanies diabetes can interfere with neuroreseptors.

Slide 14
Diagnostic Check
Laboratory Examination
- Chest X-ray
- Echocardiogram
- Nuclear imaging examination
- Coronary angiography
- Treatmill test
- Medical management

Slide 15
Medical Management
- The success of SKA therapy depends on the early recognition of
symptoms and the immediate transfer of patients to the emergency
department / unit. There are 3 things that must be done in patients
with myocardial infarction, namely:

1. Strengthening the opening of coronary arteries can be by

fibrinolytic, angioplasty, or CABG.
2. Keeping the coronary arteries open with anticoagulants or with anti
3. Prevent further spreading of myocardial damage by reducing
oxygen demand or meeting oxygen requirements.

Slide 16
1. Acute pulmonary edema
2. Heart failure
3. Cardiogenic shock
4. Papillary muscle dysfunction
5. Ventricular septal defect
6. Heart rupture
7. Ventricular aneurysm
8. Arrhythmia
9. Pericarditis
10. Thromboembolism

Slide 17
Signs and Symptoms
- Chest pain is a clinical syndrome that occurs due to reduced blood flow to
the coronary arteries. An imbalance that occurs between the supply and
demand of myocardium causes acute pain due to changes in aerobic
metabolism into anaerobes, an additional product of anaerobic metabolism
is lactic acid.
- In unstable angina pectoris, chest pain usually felt in the substernal and
retrosternal areas can spread to the neck, jaw, arms, back. Pain is felt as a
result of movement or activity, emotional disturbances, but can be reduced
with rest and nitroglycerin

Slide 18

complaint of chest pain:
Provocative / Paliaif:
chest pain onset of sudden (may or may not relate to the activity), not
relieved by rest or nitroglycerin (although most pain in and visceral)
"Crushing", narrow, heavy, sedentary, depressed, as can be seen.
Radiation :
Typical on the anterior, substernal, precordial chest, can spread to the
hands, jaws, face. Not specified location such as epigastric, elbow, jaw,
abdomen, back, neck.

Slide 19
Severity :
Usually 10 (on a scale of 1-10), perhaps the worst pain experience ever
Time :
The duration is less than 20 minutes for ischemia, in myocardial infarction,
the pain appears continuously, does not disappear with medication and
rest, and the duration is> 20 minutes.
Note: pain may not be present in postoperative patients, diabetes mellitus,
hypertension, elderly
Signs such as dyspnea, nausea, dizziness, weakness, and sleep
History of disease or previous treatment
Angina pectoris
Myocardial infarction
Diabetes mellitus
Risk factors for ACS

Slide 20

Diabetes mellitus
Personality type A

Physical examination
Vital signs (blood pressure, pulse, respiration)
Peripheral perfusion (skin, arterial pulsation)
Heart sounds (Normal, S3, S4, murmur)
Lung sounds (Ronchi, Wheezing)

Slide 21

Nursing Diagnosis
- Pain related to imbalance of supply and demand O 2

- Intolerance of activities related to an imbalance between myocardial

oxygen supply and needs, the presence of ischemic / necrotizing
myocardial tissue
- Impaired tissue perfusion associated with ischemic damage, heart
muscle damage, narrowing / blockage of coronary artery blood
vessels .
- Anxiety associated with the actual threat to biological integrity
- Risk of decreased cardiac output associated with changes in the
conductive system, decreased myocardial contractility.
- The risk of re-thrombosis is related to the release of thrombus after

Slide 22

1. Pain associated with an imbalance of O2 supply and demand,
characterized by:
Chest pain with / without spread, grimacing, restlessness, delirium,
changes in pulse, blood pressure.
Pain is reduced after treatment measures while in hospital
Results Criteria:
After taking nursing actions for 2x24 hours expected:
1. Chest pain is reduced for example from a scale of 3 to 2, or from 2
to 1
2. Facial expression relaxed / calm, no tension 3 Pulse 60 - 100 x / m
4. Not nervous 4. TD 120/80 mmhg
1. Observe the characteristics, location, time, and course of chest pain.
2. Encourage clients to stop activities during an attack and rest.
3. Help clients do relaxation techniques, such as deep breathing, distraction
behavior, visualization, or imagination guidance.
4. Maintain oxygenation with bikanul for example (4-6 L / min)
5. Monitor vital signs (pulse & blood pressure) every two hours.
6. Collaboration with the health team in providing analgesics.

Slide 23

2. Activity intolerance is related to an imbalance between myocardial

oxygen supply and needs, the presence of ischemic / necrotic
myocardial tissue.
There is an increase in tolerance for the client after nursing action is carried
out while in hospital.
Criteria Results:
After taking nursing action forexpected: The
client participates in activities according to the client's ability
Heart frequency 60-100 x / minute
2x24TD 120-80 mmHg
1. Record heart frequency, rhythm, and changes in BP during and after
2. Increase rest (in bed)
3. Limit activities to the base of pain and provide sensory activity that is not
4. Explain the pattern of a gradual increase in activity level, for example
from a chair if there is no pain, ambulation and rest for 1 hour after eating.
5. Review the signs of disturbance that show intolerance of activities or
require reporting to a doctor.

Slide 24

Impaired tissue perfusion associated with, ischemic, heart muscle

damage, narrowing / blockage of coronary arteries is characterized
Cold peripheral areas
ECG pathological ST & Q segment elevation in certain leads
RR more than 24 x / minute
Capillary refill more than 3 seconds
Peripheral saturation <95% with spontaneous breathing.
Chest pain Chest
picture picture of enlarged heart & lung congestion (not always)
HR more than 100 x / min, BP> 120/80
AGD with: pa O <80 mmHg, pa CO > 45 mmHg and Saturation <80 mmHg
2 2

pulse more than 100 x / minute

An increase in cardiac enzymes namely CK, CKMB, Troponin T, LDL / HDL
Impaired tissue perfusion is reduced / not widespread during the treatment
action at the hospital.
Outcome Criteria:
Afterof nursing care is expected:
Warm peripheral area
No cyanosis
ECG appearance does not show expansion of
RR 16-24 x / minute
No clubbing finger
capillary <3 seconds
2x24 hoursRefillPulse 60-100x / minute
TD 120/80 mmHg

Slide 25

1. Monitor heart rate and rhythm
2. Observe changes in mental status
3. Observe color and temperature of skin / mucous membranes
4. Measure urine output and record specific gravity
5. Collaboration: provide IV fluids as indicated
6. Monitor diagnostic and / eg laboratory ECG, electrolytes, AGD (Pa
O COPa and saturationO And giving oxygen.
2, 2 2).

Slide 26
Anxiety is related to the actual threat to the condition of the disease.

Worry is lost / reduced after nursing action during the hospital
Results Criteria:
After taking nursing action for 2x24 hours expected:
Clients appear relaxed
Clients can rest
TTV within normal limits
Assess verbal signs and responses and non verbal about anxiety
Create a calm and comfortable environment
Teach relaxation techniques
Minimize stressful stimuli
Discuss and orient clients with the environment and equipment
Give clients a touch and invite clients to talk in a calm atmosphere
Provide mental support
Collaborative provision of sedation as indicated

Slide 27
Data that the group found in the assessment conducted at the Emergency
Room of the Harapan Kita Heart and Blood Vessels on January 9, 2013
1. BasicData
Patient Identity
Name: M
Age: 65 years
Sex: Male
Ethnic group: Batak
Religion: Christian
Status: Married
Education: Bachelor
Occupation: Entrepreneur
Date of Entry: 9 January 2013 At 11:45 WIB
No.Med. Rec. : 2013-34-25-53

Slide 28

Medical History
- Main Complaints: The patient complained that the head was still dizzy,
the body was limp, and the stomach felt uncomfortable.
History of Disease Now
- Patients say that when BAK is suddenly dizzy, a lot of sweat comes out,
and fainting for about 1 minute, then vomiting filled with fluid and food
debris. Patients brought by friends were taken to Pondok Kopi Hospital,
patients were diagnosed with acute STEMI Inferior onset 5 hours Killip IV
Timi 11/14 ec cardiogenic shock with BP entered 70/45 mmHg, given 0.9%
NaCl loading, dobutamine therapy up to 10 micrograms / kg / min, aspilet
160 mg, plavix 300 mg and diazepam. Pondok Kopi Hospital refers patients
to PJNHK for Percutaneous Coronary Intervention (PCI).

Slide 29

Past Disease History

- Asthma, strokes, gastritis are absent. Risk factors: DM (-), smoking
from 1990 to 1996, Hypertension (+) but not with treatment.
Family Disease History
- Patients say in the family no one has ever experienced this pain or
heart disease.
Psychosocial History
- At the time the patient was seen looking anxious and anxious about
the current state, the patient did not experience communication
problems. The person closest to the patient is the family, especially
the wife. The patient's job is as an employee and the patient feels
happy with his work.
Spiritual History
- The patient is Christian and is quite devout in worship and the
patient hopes to recover quickly

Slide 30

Physical Examination
General Conditions: Weak
Awareness: Composmentis
Weight: 65 Kg
Height: 165 cm
Vital signs: TD = 98/78 mmHg, RR = 20 x / min, HR = 132 x / min, oxygen
saturation = 100% by administering oxygen NRM 10 L / min.

Slide 31

Eyes: Eyes tend to close because they are still dizzy, non-anemic
conjunctiva, pupil isochorism, non-jaundice sclera
Hair: Hair and scalp look clean, black in color and look gray.
Nose: Symmetrical shape, clean, no nose lobe movement, attached
oxygen NRM 10 L / min.
Ears: Hearing is within normal limits. Paien does not use hearing aids.
Face: Expression looks nervous and looks agitated.
Neck: JVP pressure within normal limits

Slide 32

Inspection: Cordic ectus is not visible
Palpation: Ictus cordis is palpated in intercostal V, 2 cm from the left
midklavicula, capillary refill 2 seconds, acral cold.
Percussion: Dim sound in the heart area
Auscultation: BJ I and BJ II normal, murmur (-), gallop (-)
Inspection: Symmetrical chest wall movement. Patient attached with
NRM oxygen 10 L / min
Palpation: Right and left focal fremitus equal, RR 20 x / min
Percussion: Resonant throughout the lung fieldVesicular lung
Auscultation:sounds, ronchi - / -, wheezing - / -

Slide 33

Inspection: No visible abdominal vein, ascites (-)
Palpation: Tenderness (-), liver not palpated
Percussion: Timpani
Auscultation: Intestinal peristalsis 8 x / min
Genitalia: Clean
Extremities: Akral cold, edema - / -, pulsation Weak peripheral arteries
+/ +, attached IV Line in the right hand.
Skin: Moist, good skin turgor, no lesions.
4. Nutrition Pattern: Patients are fasted while in the Emergency Room
in preparation for PCI.
5. Elimination Pattern: The patient is attached to a dower catheter, the
amount of urine is 700 cc in 4 hours.

Slide 34

6.Support Examinations on
Laboratory9 January 2013 at 10.30 at the Pondok Kopi Hospital


14,9 12-14
Ht g/dl g/dl
Leukosit 45% 37-45
a.Liver Pankreas 13.40
SGOT 0 /uL 5000-
a.Fungsi Ginjal 435,2
Ureum 0 U/L
Creatinin 181,8 U/L
0 U/L
a.Elektrolit 10-45
Na U/L
K 20
Cl L 10-50
a.Enzim jantung mg/dL
CK mg/d 0.67-
CKMB L 1,17
Troponin T
mmo 135-
l/L 145
3,47 L
l/L 3,5-5,5
Kolesterol total
98 L
HDL Kolesterol
LDL Kolesterol l/L 98-110
Trigliseride L
a.GDS 337
< 171
42 U/L
1831 U/L
< 50
132 in AMI
mg/d 100-
L 2000
36 ng/L
mg/d diduga

85 >2000
mg/d ng/L
L pasti
L 120-
187 200
mg/d mg/dL
l 40-60

SLIDE 36 :
- AGD examination results on January 9, 2013 at the Harapan
Kita Heart and Blood Vessel Hospital:
PH: 7.45
PaO2: 94 mmHg
PaCO2: 27 mmHg
BE: -2.9 mmol / L
HCO3: 19.1 mmol / L
SaO2: 98.9 %
ECG (9 January 2013)
- ECG recording results at Pondok Kopi Hospital = sinus rythm,
rate 76 x / min, normal axis, normal P wave, PR interval 0.14
seconds, QRS duration 0.06 seconds, ST elevation lead II, III,
AVF, V5-V6, ST depression AVL, V1-V2.
ECG recording results in PJNHK = Sinus takichardi, rate 132x /
m, normal axis, normal P wave, PR interval 0.14 seconds, QRS
duration 0.10 seconds, Q in leads II, III, aVF, ST elevation in
lead II, III, AVF, V7-V9.

- X-ray Thorax
CTR 52%, Aortic segment: normal, pulmonary segment: normal,
horizontal heart waist, apex downward, infiltrate (-), congestion (-
- Catheterization
The results of the catheterization on 9 January 2013 were LM:
normal, LAD: stenosis 50-60% in mid, LCx: small did not
develop, RCA: diffusely diseased from proximal to mix part and
total occlusion in mid part.

- Therapy obtained at IGD

Loading aspirin 320 mg (at Pondok Kopi Hospital 160 mg)
tomorrow 1x80 mg
Loading plavix 600 mg (at Pondok Kopi Hospital 300 mg)
tomorrow 1x75 mg
Simvastatin 1 x 20 mg
ISDN 3 X 5 mg, extra k / p
Diazepam 1x5 mg
Laxadin syrup 1 x CI
KSR 3 x 2 tab
Captopril 3 x 6.25 mg
Bisoprolol 1 x 1.25
mg Dobu 10 micrograms / kg / min

Slide 48

SKA is an emergency situation characterized by the onset of

myocardial ischaemia and results in myocardial tissue death, if
there is no immediate treatment. SKA includes unstable angina,
non-ST segment elevation (NSTEMI), and ST segment
elevation. The diagnosis of SKA is not only based on patient
complaints but is supported by investigations, such as changes
in ECG waves that support either ST segment changes,
pathological Q waves, or with the presence of hyper T, or new
LBBB waves, accompanied by the presence / absence of
changes in heart enzyme values . Handling quickly starts with
administration of oxygen, nitroglycerin, morphine, aspirin, beta-
bolcker, ACE inhibitors within 24 hours, anti-coagulation with
heparin and platelet inhibitors. Followed with therapy for
indications of reperfusion, such as PCI and thrombolytic therapy,
then continued with therapy, such as intravenous heparin,
clopidogrel (plavix), glycoprotein IIb / IIIa inhibitors, and a
minimum bed rest of 12-24 hours (Atman, et al., 2007 ).

Patient Mr. M with acute medical diagnosis of STEMI Inferior 5-
hour onset Killip IV Timi 11/14 ec cardiogenic shock. Data
obtained at the time of the assessment on 9 January 2013 were
patients complaining that the head was still dizzy, the body was
limp, and the stomach felt uncomfortable. ECG examination is
sinus takichardi, rate 132x / m, normal axis, normal P wave, PR
interval 0.14 seconds, QRS duration 0.10 seconds, Q in leads II,
III, aVF, ST elevation in leads II, III, AVF , V7-V9. The laboratory
results obtained CKMB results: 33 u / l, Troponin T: 1980 ng / L,
while the results of catheterization showed LM: normal, LAD:
stenosis 50-60% in mid, LCx: small did not develop, RCA:
diffusely diseased from proximal to mix part and total occlusion
in mid part.
2. Impaired myocardial perfusion associated with
narrowing / blockage in the coronary arteries
S: -
100% oxygen saturation with NRM 10 L / min.
The results of ECG recording on 9 January 2013 are
Sinus takichardi, rate 132x / m, normal axis, normal P
wave, PR interval 0.14 seconds, QRS duration 0.10
seconds, Q in leads II, III, aVF, ST elevation in leads II,
III, AVF, V7-V9.
Catheterization results on 9 January 2013: LM: normal,
LAD: stenosis 50-60% in mid, LCx: small does not
develop, RCA: diffusely diseased from proximal to mix
part and total occlusion in mid part.
Laboratory examination results on January 9, 2013
CKMB: 33 u / l, Troponin T: 1980 ng / L.
A: The problem has not been resolved
P: Continue nursing intervention


1. Decreased cardiac output associated with myocardial

S: -
Warm acral.
100% oxygen saturation with NRM 10 L / min.
Capillary refill 2 seconds.
The patient is attached IV Line with support dobu 10 micrograms
/ kgBW / minute.
Vital signs: TD 100/74 mmHg, HR 110 x / min, RR 20 x / min.
A: The problem has not been resolved
P: Continue nursing intervention

Menerima pasien baru rujukan dari RS Pondok Kopi. Mengukur
tanda–tanda vital. Respon: TD 98/78 mmHg, RR 20 x/menit, HR
132 x/menit, Sat. O2 100 % dengan O2 NRM 10 L/mnt
Melakukan EKG. Respon: Sinus takichardi, rate 132x/m, axis
normal, P wave normal, PR interval 0,14 detik, QRS durasi 0,10
detik, Q di lead II, III, aVF, ST elevasi di lead II, III, AVF, V7-V9.
Memberikan posisi semifowler dan menganjurkan klien untuk
istirahat (tirah baring). Respon: pasien mengatakan lebih
nyaman dengan posisi ini dibandingkan tidur telentang.
Mengambil sampel darah untuk pemeriksaan AGD, enzim
jantung, dan darah rutin. Respon: PH: 7.45, PaO2: 94 mmHg,
PaCO2: 27 mmHg, BE: -2,9 mmol/L, HCO3 : 19,1 mmol/L, SaO:
98,9 %. Hb: 14,9 g/dl, Leu: 11.840/UL, Ht: 44%, CKMB: 33 u/l,
GDS: 167 mg/dl, Troponin T: 1980 ng/L, Na: 137 mmol/L, K: 3,8
mmol/L, Ca: 2,03 mmol/L, Mg: 1,9 mmol/L, Cl: 105 mmol/L.
Menginformasikan pasien untuk puasa dan mencukur area
pubis. Respon: pasien dan keluarga mengerti tujuan puasa dan
pencukuran area pubis untuk persiapan tindakan.
Mengukur tanda-tanda vital. Respon: TD 100/74 mmHg, HR 110
x/ menit, RR 20 x/menit, Sat 100 % O2 dengan O2 NRM 10 L/mnt.
Mengantar klien ke ruang kateterisasi untuk PCI