Sabtu, 01 September 2012


A. INTRODUCTION surgery done to treat a variety of heart problems. Procedures often include percutaneous coronary angioplasty, coronary artery revascularization, and repair of damaged heart valve replacement. At the present time, patients with heart disease and complications that accompany it can be helped to achieve a greater quality of life and the estimated ten-year sham. With advanced diagnostic procedure that allows the diagnostic begins earlier and more accurately, resulting in treatment can be done long before a significant weakness. Handling with the new technology and pharmacotherapy continues to be developed quickly and with increased security. Maybe no therapeutic interventions such as cardiac surgery meant to improve the quality of life of patients with heart disease.
The first successful heart surgery, right ventricular puncture wound closure, was performed in 1895 by the surgeon halls de Vechi. In the United States similar to the successful surgery, jugs puncture wound closure, made in 1902. Followed by valve surgery in 1923 and 1925, the closure of patent ductus in 1937 and 1938, and koarktasi aortic resection in 1944. A new era began tandur shortcuts coronary artery in 1954.
The most revolutionary developments in the development of cardiac surgery is a heart-lung shortcut technique. It was first used successfully in humans in 1951. At present more than 250,000 procedures performed using the heart lung shortcuts. Most (more than 200,000) conducted in North America. Most procedures are coronary artery bypass grafting (CABG = coronary artery bypass graft) and valve repair or replacement.
Advances in diagnostic, medical management, surgical and anesthetic techniques, and shortcuts pulmonary heart, and also the care given in a critical care unit and rehabilitation program has helped a lot of surgery to be a safe treatment option for patients with heart disease.

B. Shortcuts HEART LUNG
Many cardiac surgical procedures can be carried out because of the heart-lung shortcut (ekstrakorponeal circulation). This procedure is a mechanical device for the circulation and oxygenation of the blood to the entire body at the "bypass" the heart and lungs. Heart-panu engine enables the achievement of a free field openasi While blood perfusion can still be maintained for other tissues and organs in the body.
Shortcuts heart-lung performed by placing a cannula in the right atrium, vena cava, or femoral vein to drain blood from the body. Cannula is then connected to a tube containing a solution of isotonic crystalloid (usually dextrose 5% in lactated Ringer's solution). Venous blood drawn from the body and the cannula was filtered, dioksigenasi, cooled or heated. and then returned to the body. Cannula use uniuk magnified returns oxygenated blood is usually inserted into the ascending aorta, but it could be inserted into the femoral artery jugs.
Despite the heart-lung shortcut is a technique used in cardiac surgery, but sebenarna very complex. Patients requiring anticoagulation with rnencegah hatiin for thrombus formation and embolization possibilities that can happen when Danah associated with foreign surfaces shortcut circuit heart-lung and pumped to the body by a mechanical pump (not the normal heart and blood vessels) Upon release of the engine shortcut, the patient is given protamin sullal untiuk counteracting the effects of heparin.
During this procedure done, the body be kept in a state of hypothermia, typically 28 ° C to 32 ° C (82.4 ° F to 89.6 ° F). Cooled blood during cardiac pulmonary shortcuts and returned to the body. The cooled blood would lower basal metabolic rate, so that the need for oxygen is also reduced. Cold blood usually has a high viscosity, but the crystalloid solution used to fill the tube will thin the blood before surgery when the procedure has been completed, re-warm blood in the heart-lung circuit shortcut.
Output of urine, blood pressure, arterial blood gases, electrolytes, blood coagulation testing, and elektrokardiograrn (ECG) is used to monitor the status of all patients during heart-lung shortcuts.
There are still many things to be learned about pulmonary heart shortcuts. There are a variety of circuits and mechanisms pensompaan shortcuts are still in use today. Until now still being sought agan patients may take longer to be in the heart-lung machine shortcut more safely. Ongoing research to improve heart lung machine shortcut to prevent or minimize the following problems: hemolysis, increased capillary permeability and loss of electrolytes memhran, hypoxia and anoxia tissue, thrombus formation or embolism. Danah dissection of the heart and vessels, increasing ketekolamin and antidiuretic hormone (ADH), and systemic inflammatory response which is a complication of the procedure.

Installation of the artificial heart has attracted worldwide attention since the late 1950's. Since then, much progress was made so that the artificial heart can be used clinically humans. Cooley artificial heart used in Texas in 1969 to support the circulation before transpiantasi. Permanent implantation of a total artificial heart was first performed in 1982 to drg. Barney Clark at the University of Utah .. The development of the artificial heart continues to improve survival and reduce morbidity. National Heart, Lung, and Blood Institute (National Heart, Lung, and Blood Institute, NHLBI) and the National Institutes of Health (National Institutes of Health, NIH) has provided funding for permanent electromechanical jantungbuatan wirelessly. Texas heart Institute and 3-M and Penn Statet Abiomed participated in the experiment phase II. The overall objective is to provide installation of mi high quality of life for patients is free and percutaneous line installation. Tool mi run using transcutaneous electrical energy transmission system (transcutaneous electrical energy transmission systems, Teets) with a portable battery.

D. Heart transplant
Transplantation of human-to-human, first performed in 1967. since the procedure, equipment and transplantation medicine continue to be developed. In 1983, sikosporin is available for general use. Cyclosporine is a potent immunosuppressant that suppresses the body's ability to resist foreign proteins such as, organ ditransplansikan. Unfortunately, cyclosporine also lowers the body's ability to fight infections, so it must be obtained excellent balance between suppression of rejection and infection prevention. Since the availability of cyclosporine in 1983, heart transplantation has become the treatment of choice for patients with end stage heart disease.
The most frequent transplant indication is cardiomyopathy, ischemic heart disease, congenital heart disease, valve disease and previous heart transplant rejection. Patients usually have severe symptoms that can not be controlled with medication, no other surgical options and prognosis of less than 12 months of his life. Patients were selected by a multidisciplinary team before it is declared as a candidate for a heart transplant. Age of patients, pulmonary status, other chronic health conditions, infections, transplant history, adjustment and health status of recently used to evaluate patients for transplantation.
Heart transplantation is considered as a last resort to overcome uaha to tackle the final stage heart disease refractory to pengobatankonvensional and surgery. Heart failure class III and IV have a life expectancy of less and one year. Two common causes deterioration of the myocardium is congestive cardiomyopathy and coronary disease further. These diseases are the 80% -90% of heart transplant dilakukarmya reasons.
Cardiomyopathy is a heart muscle disease of unknown cause. The key distinguishing cardiomyopathy and other heart abnormalities is the presence of underlying disease that only attacks the ventricular myocardium but do not attack other myocardial structures such as valve or coronary artery. Cardiomyopathies are classified according to three types of abnormalities of structure and function: (1) failure (dilatation), (2) restrictive or obliterative, or (3) hypertrophy.
Congestive cardiomyopathy characterized by ventricular dilation and hipodinamik real. Can teijadi hypertrophied myocardium lighter. Hipodinamik ventricles to contract bad, cause it to fail forward and backward as described previously. It should be noted that all four heart chambers dilated secondary to increased volume and pressure. Often formed thrombus in these spaces due to the blood that clump together and stasis; thus threatened embolism occurs. Usually the onset of the disease is not clear: but can progress to end-stage heart failure refractory. Refractory heart failure prognosis is very bad and can cause a heart transplant dipertimbangkarmya. The exact cause is still unknown congestive cardiomyopathy; however thought to be due faktorautoimun and viruses. The cause is probably multifactorial more satisfactory explanation.
Hypertrophic cardiomyopathy, congestive cardiomyopathy dengari opposite, characterized by cardiac hypertrophy and hyperdynamic. Increased muscle mass with significant dilation of the myocardium. Allegedly there is a genetic basis. Restrictive cardiomyopathy reflects impaired ventricular filling due to reduced tensile strength ventricle. Endocardial or myocardial fibrosis can lead to restriction of charging. Restriction reduces the size of the cavity; development of cardiomyopathy cavity to form a more severe restriction known as cardiomyopathy and hypertrophic cardiomyopathy obliterative Although restrictive can lead to heart failure, congestive cardiomyopathy is a common cause of heart transpiantasi done.

Selection Criteria
Heart transplant recipients who meet the selection criteria underwent clinical examination and psychological detail. With the increasingly wide application of this procedure, the decision to determine who is eligible to undergo heart ttansplantasi become increasingly controversial. The availability of donor remains a limiting factor. As a result, so it was decided to perform transpiantasi, then the problem arises in determining priorities between one another. Determining what's even harder is to set priorities among patients on VADs and artificial heart as a bridge to transplantation does.
Generally, factors that can cause complications after surgery or affect long-term survival must be removed. These factors include active systemic infection or disease, pulmonary hypertension with pulmonary vascular resistance were settled (more and 4 Wood units), pulmonary embolism or infarction, active peptic ulcer disease, insulin dependent diabetes mellitus with secondary disease in other organs, kidney failure or irreversible liver, alcohol or drug addict. The things that are not real, such as the motivation for rehabilitation, family support, and psychological state, should also be considered. With the increasing extent of reimbursement by insurance, personal financial problems are becoming less significant for the selection process. If there are no contraindications are identified, we can begin the process of finding a donor.
Potential donors are usually young accident victims who do not have heart failure or heart disease and no obvious systemic infection. Matching donor tissue to the recipient include matching ABO system. Matching the appropriate body weight is also important to do; 20% difference in body weight masth considered acceptable. Procedure
Surgical techniques for heart transpiantasi relatively easy to understand, as illustrated in Fig. 33-17. Part two atria and left in place to anastomose the donor heart. Parts of the right atrium near the superior vena cava is left intact to maintain sinus node function. The donor heart then sutured to the recipient two atria and the aorta and pulmonary artery. Procedures mi (ie when replacing the heart transplant recipient) known as transpiantasi ortotopik, unlike transpiantasi heterotopik or "piggyback", performed by some of the health centers if pulmonary vascular resistance is high and when the load is high at the end of the pulmonary artery may cause it to fail refractory right ventricle of the heart transplant. The reason is that the right ventricle of the original has been adapted to high-end load that should be left in place. As an alternative, some medical centers performing transplants kardiopulmonar primary pulmonary hypertension or pulmonary vascular disease due to congenital heart disease.
Rejection and Infection
The biggest challenge in transplantation is the treatment of rejection reactions. The body to reject foreign tissue is a fundamental biological process. Sikiosporin invention and monoclonal antibodies have much improved survival after transpiantasi. Immunosuppressive therapy with sikiosporin be started before surgery. Three-drug immunosuppressive therapy with azathioprine, cyclosporine, and steroids given continuously after surgery. Immunological monitoring will be done strictly tandatanda rejection. A biopsy is the determinant definitely endomiokardium tramsvenosa (gold standard) for the detection and diagnosis of rejection. Biopsy was performed in a certain time interval as indicated. (Non-invasive method to detect rejection reactions, such as MRI and echocardiography, are still being studied) endomiokardium biopsy techniques include biopsy catheter (or bioptome) through the jugular vein subclavian artery or vein into the right ventricle endocardium to pick up some parts for analysis. Furthermore, immunosuppressive therapy can be adjusted based on the results of the biopsy. Antithymocyte globulin (ATG), antilimfosit globulin (ALG) or OKT3 monoclonal antibodies can be added to handle the rejection reaction. In addition to adverse reactions, is also a serious problem due to immunosuppressive therapy. Infection is the leading cause of death in the first year after transplantation. For that performed preventive and therapeutic measures are appropriate.
Postoperative trip. Heart transplant patients must be kept in balance between the risk of rejection and the risk of infection. They have complex rules about diit mcmaluhi, medications, activity, laboratory examinations. biopsy (to diagnose rejection) and a visit to the clinic. Patients are often given cyclosporine and corticosteroids for meminirnalkan rejection. In addition to rejection and infection, complications can include the acceleration of coronary artery arteriosclerosis; hypertension and hypotension; sistern disorders of the central nervous, respiratory, and gastrointestinal (UI), kidney failure, and response to psychosocial stress due tran.splantasi organ.
Heart transplant patients with 1-year survival rate of about 80% to 90% and 5-year survival rate of about 60% sarnpai 70%.

E. Excision of the tumor
Cardiac tumors are rare. Primary tumors happen less and 1% in the population; metastatic tumors reported in 1.5% to 35% in oncology patients. Tumors can be a risk of thrombus formation, creating emboli. Dysrhythmias may occur when the myocardium or delivery system. Most cardiac tumors are benign.
Surgical excision is done only to prevent obstruction of the heart's chambers or valves. Heart-lung shortcuts used. except epikardial tumor, which can be excised without entering the heart and without stopping the heart beat. Due to its location, tumor excision followed valve replacement may be necessary. filling the heart, or the implantation of a pacemaker. Nursing care similar to that given to other cardiac surgery.

Patients who require surgery due to trauma caused by a blow Antung be blunt, gunshot wounds or stab wounds. Repair course at the valve and septum when the cause blunt trauma, and the wall of the atrium or the ventricle when the cause puncture wounds. Do debridement and closed surgical wounds when possible, but valve repair and penggantlan or patches tandur the septum and ventricular atrial wall AAU may be required. Surgery here is usually an emergency procedure, so the risk of complications due to injury or surgery is very high.

The use of heart-lung shortcuts cardiac surgery and the possibility of a transplant torch in end-stage heart disease have rneningkatkan need for cardiac assist devices. Patients who are unable to be removed and the patient's lungs or heart shortcuts browsing dalarn cardiogenic shock may benefit from a period of mechanical cardiac assistance. The most commonly used tool is the ultra aortic balloon pump (IABP - Intra-aortic baloon pump). Nsengurangi IABP during contraction of the heart, but it does not resemble the actual performance of the heart.
Performance tool that resembles a partially or scmua for cardiac pumping function is also being developed. Ventricular assistive devices more sophisticated by the minute to circulate the blood as that of the heart. Each ventricular assist devices are used for each mnasilig ventricle. Currently, the most commonly used is the centrifugal pump. Many tools used pneumatic thrust and basil clinical menianjikan enough. Some ventricular assist devices can be combined with oxvgenalor-ex! Racorporeal membrane oxygenation (ECMO). Combination tool of ventricular-oxygenators used in patients whose heart can not adequately pump blood to the lungs or the body.
Total artificial heart is designed to replace both ventricles. Heart patients should be appointed for a total artificial heart nmemasang earlier. All of these instruments are still in early stages of ekspenimental. Janvik-7 has experienced short-term success, but long-term result is quite disappointing. Most of the total artificial heart researchers hope to develop a tool that can be permanently installed and will be able to replace the need for human donor heart transplantation for treatment of end-stage heart disease.
Tools of the total artificial heart ventricle is now being used as a temporary treatment. while patients wait for their own heart recovers or until a suitable donor heart is available for transplant. Abnormalities of blood coagulation, hemorrhage, thrombus, embolism, hemolysis, infection, and mechanical failure are some of the complications of a total artificial heart and ventricular assist devices. Nursing care for the patient is directed not only to the study and minimize complications. but also involves emotional support and counseling about mechanical aids itself.

I. Pathophysiology of heart surgery
Krdiomiopati, congenital heart disease Atherosclerosis, aa spasm. Coronaria
Network iskemic
Changes in metabolism
Ventrike function decline
The heart of the movement disorder
Decreased myocardial contraction
Hemodynamic changes
Decreased cardiac output
Ischemic widespread
Myocardial infarction
Cardiac surgery
Heart failure
Heart transplantation
Pain Changes in tissue perfusion Hyperthermia Risk lack of fluid volume

H. Perioperative Nursing MANAGEMENT
1. MANAGEMENT preoperative
Health Assessment. Preoperative history and health assessment must be complete and documented balk because it is the basis for comparison postoperative. Systematic assessment should be performed on all systems, with an emphasis on cardiovascular function.
Functional status of the cardiovascular system is determined by observing the patient's symptomatology. including current and past experiences of the chest pain, hypertension. pounding. cyanosis, difficulty breathing (dispnu). leg pain that occurs after walking, ortopnu. paroxysmal nocturnal dispnu, peripheral edema, and intermittent claudication. Because of changes in cardiac output can affect kidney function, respiratory. gastrointestinal, skin, hematology and nerves. the systems must be studied in detail. History of major disease, previous surgery, drug therapy, and the use of drugs, alcohol and tobacco should also be explored.
Do a complete physical examination, with particular emphasis on the following parameters:
a. General condition and behavior
b. Vital signs
c. Nutritional and fluid status, weight and height
d. Inspection and palpation of the heart, to determine the point of impulse maxima! (PMI = point of maximal impulse), abnomsal pulsation, thrill
e. Auskukasi heart, pulse rate notes, mama and quality. S, S4, snap, click, murmur, friction rub
f. Jugular venous pressure
g. Peripheral pulses
h. Peripheral edema
Psychosocial Assessment. Psychosocial assessment and assessment of teaching and learning needs of patients and their families is as important as checking Stitch. Preparation of cardiac surgery is a source of severe stress for patients and their families. They will be anxious and frightened, and often have a lot of unanswered questions. Their anxiety increased when the patient is usually hospitalized and immediately performed surgery. Assessment of severity of anxiety is very important. If mild, may be a rejection. When severe, it should be taught the use of coping mechanisms. Effectively through preoperative counseling. Questions need to be asked for the following information about the patient and his family:
- Meaning of surgery for patients and their families
- Coping mechanism used
- The method used in the past to cope with stress
- Lifestyle changes are anticipated
- An effective support system
- Fears about the present and future
- Knowledge and understanding of the surgical procedure, postoperative trips, and long-term rehabilitation

Nursing Diagnosis
Nursing diagnoses for patients undergoing cardiac surgery varies between one patient with another patient, depending on their heart disease and simptomatologinya - Kebanyakari mernpunyai patient nursing diagnosis decreased cardiac output. In addition, kepenawatan preoperative diagnosis for most patients include the following:
a. Fear in connection with surgical procedures. the results of surgery are not clear, and the fear of losing health
b. Lack of knowledge about the procedure and the run of postoperative pcmbedahan

Collaboration Issues / Potential Complications
The stress of the surgery to be performed can trigger complications that require collaborative management dcngan doctors. Based on assessment data, the potential complications that may occur include:
a. Angina (or in accordance with angina)
b. Severe anxiety drug mcmerlukan antiolitik (reduction-anxiety)
c. Cardiac arrest

Nursing Intervention
a. Reduce Fear. Patients and their families should be given ample opportunity to express their fears and. If there is fear of the unknown, the experience of others who have endured surgery patients can dihandingkan with surgery to be performed. Sometimes very mcnibantu explain kepacla patients feelings will arise (Anderson and Masur 1989). If the patient had undergone cardiac catheterization, the similarities and differences with the surgical procedure to be run can be compared. Patients are also encouraged to express any concerns about dealing with previous experience.
b. Patient Counseling and Home Care Considerations. Patient and family education based on learning needs that have been assessed. Outreach usually includes information about the hospitalization, the surgery (preoperative and postoperative care, latnanya surgery, pain and discomfort that may occur, visiting hours and procedures in critical units), and information on the recovery phase (duration of hospitalization, when normal activities such as housework, helanja and work can be resumed). Any changes made pads drug therapy and preoperative preparation should be explained and emphasized.
c. Monitoring and Management of Potential Complications. Patients who experience angina typically responds with the usual angina therapy, the most common is nitroglycerin placed under the tongue Some patients require oxygen and intravenous nitroglycerin drip.

Expected Results
a. Showed reduced kecetnasan
- Identify the fear
- Discuss with family fear
- Use your first experience as a focus of comparison
- Expressing a positive view of the results of surgery
- Mengeksprcsikan confidence about the means used to reduce pain
b. Receive pcngetahuan about surgical procedures and postoperative trip
- Identify the mean preoperative preparation procedures
- Reviewing the intensive care unit if desired
- Mengidentitikasi limitations of results after surgery
- Discuss with the immediate postoperative environment, eg, pipes. machine. nurse examination.
- Demonstrate activities that should be performed after surgery (eg, deep breathing, coughing effectively, leg exercises)
Most cardiac surgical procedures performed through a median incision sternotomi. Patients were prepared for monitoring bcrkcsinambungan: electrodes, indwelling catheters and probes installed prior to the procedure and the patient's status assessment rnemudahkan penubahan therapy when needed. Pipes must be installed when required intravenous fluids, medications and blood components. In addition, patients will be intubated and connected to mechanical ventilation.
Before the chest incision was closed, placed a chest tube for air and expenditure and the mediastinum and thoracic drainage. Epikardial pacemaker electrodes implanted on the surface of the right atrium and right ventricle. Epikardial electrode can be used to stimulate the heart or postoperative monitoring through the heart if there is lead atrial dysrhythmias.
In addition to helping a surgical procedure, a surgical nurse is also responsible for the comfort and safety of patients. The scope of intervention include positioning, skin care, and emotional support to patients and their families.
Intraoperative complications that may occur include dysrhythmias, bleeding, myocardial infarction, cerebrovascular injury, emboli, and organ failure due to shock, embolus or drug reactions. Imraoperatif careful patient assessment is essential in preventing complications in addition to detect symptoms and initiate immediate action.
3. MANAGEMENT postoperative
The parameters studied were as follows;
Ø neurological status-level of responsiveness, pupil size and reaction to light, reflex, limb movements, and hand grip strength.
Ø Status-frequency heart and heart rhythm, heart sounds, arterial blood pressure, central venous pressure (CVP), pulmonary artery pressure, pulmonary artery wedge pressure (PAWP = pulmonary artery wedge pressure). left atrial pressure (LAP), waveforms and noninvasive blood pressure pipes, cardiac output or index. systemic vascular resistance and pulmonary, pulmonary arterial oxygen saturation (SVO,) if any, drainage of the chest cavity, and the status and functions of pacemaker.
Ø Status respiration-chest movement, breath suana, determination ventilator (fnekuensi, tidal volume, oxygen concentration, mode [eg, SIMV], positive end-expiratory pressure [PEEPfl, breathing rate, pressure ventilators, anteri oxygen saturation (Sao,), CO2 end tidal, drainage pipe chest, arterial blood gases.
Ø Status of peripheral-vascular peripheral pulses, color of skin, nail, mucous. lip and ear lobe, skin temperature, edema, invasive conditions and pipe wrapping.
Ø kidney function output of urine, urine specific gravity and osmolarity
Ø Status-fluid and electrolyte intake; output of all plumbing and drainage. and cardiac output parameters and electrolytes ketidakseinibangan following indications:
Hypokalemia: digitalis intoxication, dysrhythmias (U waves, AV block, T wave flat or inverted)
Hyperkalemia. - Mental confusion, not calm, nausea, weakness, paresthesias eksremitas, disrirmia (high T wave peaks, increased amplitude, widening of the QRS complex; QT interval prolongation)
Hyponatremia: weakness, fatigue, confusion, seizures, coma
Hypocalcaemia paresthesias, spasm of the hands and feet, muscle cramps, tetany
Hypercalcemia digitalis intoxication, asistole
Ø Pain-nature, type, location, duration, (a painful incision should be distinguished from angina pain): aprehensi, response to analgesics.
Ø Note: Some of the patients who had undergone CABG with arterial mamaria interns will mengalaini parestesis ulnanis nerve on the same side with the graft is taken. Paresthesia can be temporary or permanent. Patients who underwent CABG with arieni gasiroepiploika will also experience postoperative ileus for some time and will experience abdominal pain at the site of incision than chest pain.
The assessment also includes observation of all equipment and piping to determine whether its function well: endotracheal tube, ventilator, end tidal CO2 monitor, monitor Sa02, pulmonary artery catheter, monitor SO2, arteries and veins pipes, and hoses slat intravenous infusion, cardiac monitor, pacemaker, chest tube, and urinary drainage systems.
Once the patient is conscious and progress during the postoperative period, the nurse must develop assessments to include parameters that indicate psychological and emotional status. Patients can irternperlihatkan iingkah behavior reflecting rejection and depression or psychosis may also experience post kardiotomi. Typical signs of psychosis include (1) the illusion of temporary perception, (2) hearing and visual hallucinations (3) disorientation and paranoid delusions.

Assessment of Complications
Patients are constantly assessed the threat indications of complications. Nurses and physicians working collaboratively unruk know the signs and symptoms of early complications and provide measures to prevent perkemhangannya.
Rainfall decrease heart. The decrease in cardiac output is always a threat to patients who have recently undergone heart surgery. This can occur due to various causes:
a. Disorders preload-too little or too much blood volume returning to the heart caused by hypovolemia. bleeding continued. cardiac tamponade, or fluid overload.
b. Disorders afterload-arterial and capillary dilation too constricting or too due to changes in body temperature or hypertension.
c. Impaired heart rate-too fast, too slow. or dysrhythmias
d. -Impaired contractility of heart failure. myocardial infarction. ketidakseiinbangan electrolyte, hypoxia

Disorders of fluid and electrolyte balance.
Disorders of fluid and electrolyte balance may occur after cardiac surgery. Nursing assessment for these complications include the monitoring of intake and output, weight PAWP, left atrial pressure measurements and CVP, hematocrit levels, distended neck veins, edema, liver size, breath sounds (eg krekels smooth, wheezing) and electrolyte levels.
Changes in serum electrolytes should be reported immediately so that treatment can be promptly provided. The important levels of potassium, sodium and calcium is high or low.

Impaired gas exchange.
Impaired gas exchange is another complication that may occur after cardiac surgery. All body tissues require oxygen supply and adequate nutrition to survive. To achieve this, the post-surgery, the endotracheal tube should be installed with the help of a ventilator for 4 to 48 hours or more. Ventilatory support was continued until the patient's normal blood gas values ​​and the patient's ability to breathe on his own show. Stable patients can be extubated immediately after surgery after 4 hours post-surgery, thus reducing anxiety in connection with the limited ability to communicate.
Patients were assessed continuously for indications of impaired gas exchange; restlessness, anxiety, cyanosis of the mucous membranes and peripheral tissues, tachycardia and trying to remove the ventilator. Breath sounds assessed as often as possible to detect the presence of fluid in the lung and to monitor the development of pulmonary arterial blood gas was monitored.

Brain Circulatory Disorders.
The function of the brain depends on a continuous supply of blood oxygen. The brain does not have the capacity to store oxygen and highly dependent on adequate and continuous perfusion of the heart. So it is important to observe the patient about the presence of hypoxia symptoms: anxiety, headache, confusion. dispnu, hypotension. and cyanosis. Arterial blood gases, SAO, SO and end tidal CO should be reviewed when there is decreased oxygen and increased carbon dioxide. Assessment of patient's neurologic status include levels of consciousness. response to verbal commands and painful stimuli, pupil size and reaction to light. limb movements. menggenggarn hand strength. the popliteal pulse and legs, as well as color temperature and extremities. Any signs that indicate a change in status must be recorded and any abnormal findings should be reported to the surgeon immediately because it could be an early sign of complications in the postoperative period. Hypoperfusion and mikroemboli rnenyebahkan can damage the central nervous system after cardiac surgery.

Nursing Diagnosis
Based on assessment data and the type of surgical procedure performed. The main nursing diagnosis include the following:
a. Decreased cardiac output associated with blood loss and impaired cardiac function.
b. Impaired gas exchange risk associated with extensive chest trauma due to surgery
c. The risk of lack of fluid volume and electrolyte keseirnbangan berkurangan associated with circulating blood volume
d. Risk perception-sensing disorder associated with excessive sensing (ambience critical care, surgical experience)
e. Pain associated with trauma surgery and irritation caused by chest tube
f. Risk of changes in tissue perfusion related to venous stasis, embolization. underlying atherosclerotic disease. vasopresor effects, or blood clots rnasalah.
g. Risk of changes in renal perfusion associated with decreased cardiac output, hemolysis, or drug therapy vasopresor
h. The risk of hyperthermia associated with infection or post-perikardiotomi sindrorn
i. Lack of knowledge about self-care activities

Collaborative Problems / Potential Complications
Based on assessment data, the potential complications that can occur include:
a. Cardiac complications: congestive heart failure, myocardial infarction, cardiac arrest. dysrhythmia.
b. Pulmonary complications: pulmonary edema, pulmonary embolism. pleural effusion, pneumo or hematotoraks, respiratory failure. adult respiratory distress syndrome
c. Bleeding
d. Neurological complications: cerebrovascular injury, air embolism
e. Painful
f. Renal failure, acute or chronic
g. Electrolyte imbalance
h. Liver failure
i. Coagulopathy
j. Infection, sepsis

Planning and Implementation
Purpose. Primary goal of restoration curali include heart, adequate gas exchange, maintenance of fluid and electrolyte balance. reduced symptoms of excessive sensing. pain relief, attempt to rest, maintenance of adequate tissue perfusion, maintenance of adequate renal perfusion, maintenance of normal body temperature, learning self-care activities. and the absence of complications.

Nursing Intervention
Maintain Bulk heart.
Nursing management includes continuous observation of the patient's cardiac status and the surgeon immediately notify any changes that indicate a decrease in cardiac output. Nurses and surgeons then work collaboratively sarna to fix the problem.
Dysrhythmias, which can occur when the heart perfusion is reduced, is also an important indicator of the function of the heart. The most sening dysrhythmias during postoperative peniode are bradycardia, tachycardia and ectopic beats. Observation of continuous monitoring of the heart to the various dysrhythmias an important part in the management and care of patients.
Any indication of a decrease in cardiac output should be immediately reported to the doctor. Data and test results of the assessment will then be used by doctors to determine the cause of the problem. Once the diagnosis has been established, a doctor with a nurse works collaboratively to maintain cardiac output and prevent further complications. If necessary, the doctor can membenikan blood components, fluids, digitalis, diuretics, vasodilators, or vasopresor. If you need surgery again, and then the patient should keluanganya dibenitahu on that procedure.

Adequate Gas Exchange Promotion.
To assure the adequate gas exchange, the nurse must assess and maintain the endotracheal tube patency. hose must be exploited if there is wheezing or krekel (ronkhi). Aspiration may be done through existing catheter; nurses and respiratory therapists should increase the fraction of inspired oxygen ventilator (Fi02) for three or more breaths, sebelurn started sucking. It could also, 100% oxygen to patients with resusitator diherikan manual (Ambu) before and after inhalation to prevent hypoxia that can result from inhalation procedure. Arterial blood gas measurements should be compared with the initial data and any changes should be reported to a doctor immediately.

Maintaining Fluid and Electrolyte Balance.
For the promotion of fluid and electrolyte balance, peravat should review carefully any income and expenditure. Use the special sheet to record positive or negative fluid balance. All fluid intake should be recorded, including intravenous fluids, rinse solution used to rinse the arterial and venous catheters and nasogastric tube and fluids orally. Similarly, all outputs should also be noted, include urine, nasogastric drainage, and chest drainage.
Hemodynamic parameters (blood pressure, pulmonary wedge pressure and the left atrium, and CVP) must comply with the intake, output of and weight to determine the adequacy of hydration and cardiac output. Serum electrolytes should be monitored and patients should be observed for signs of the imbalance of potassium, sodium and calcium (hypokalemia, hyperkalemia, hyponatremia and hypocalcemia).

Symptoms Lowering Sensing Overload.
Excessive sensing mempakan common effects, which are associated with the experience of surgery and environmental factors in the critical care unit. Post kardiotomi psychosis can occur after cardiac pembedahari. The term refers to a group mi abnormal behavior occurring in varying intensity and duration in most patients. In the early years pembedahn heart, this phenomenon is more common than it is now. At that time due to lack of cerebral perfusion during surgery, mikroemboli, and duration of the patient is in the heart lung machine shortcut. Advances in surgical techniques have significantly lowered these factors. Now, if there is, it may be caused by anxiety, lack of sleep, excessive sensory input, and disorientation of the night and the day when patients lose time. There are important findings that suggest that patients who are unable to express his anxiety before surgery would be more prone to psychosis in the postoperative period.

Pain reduction.
Pain in the possibility can not be felt just above the area of ​​injury but to a more widely and evenly. Patients who have recently undergone heart surgery will experience pain due terpotongnya intercostal nerve irritation along the incision and pleura by chest catheter. (Similarly, CABG patients with internal mamaria artery may experience paresthesia ulnar nerve on the same side by side grafnya.)
Observation and listening to the signs of pain are spoken or not spoken by the patient need to be considered. Nurses must accurately record the nature, type, location, and duration of pain. (Pain slices should be distinguished from angina pain.) Patients should be advised taking medication as prescribed to reduce pain. Then the patient must be able to participate in benlatih took a deep breath and cough. and progressively memngkatkan self care.
Pain causes tension. that will stimulate the central nervous system to release adrenaline, which cause constriction of the arteries. This will lead to increased cardiac output and decreased afrerload. Morphine sulfate can reduce pain and anxiety and inducing sleep, which in turn lowers metabolic rate and oxygen keburuhan. After administration of opioids (narcotics), any signs of a decline aprehensi and pain should be recorded in the patient's status. Patients should also be monitored for signs of respiratory depression due to the effects of analgesics. In case of respiratory depression. should be given opioid antagonists (eg, naloxone [Narcan]) to counteract the effects rersebut.

Improve break.
Efforts basis to provide comfort to the patient along with pembehan will amplify the effects of analgesics analgesia and improve resting. Patients should be helped to change position every 1 to 2 hours and is positioned in such a way so as to avoid tension on the wound area and chest tube. Emphasis on local incision during coughing and breathing nenarik clalam can reduce pain. Aktivita scheduled nursing uniuk reduce interference as much as possible at the break. If the condition has stabilized and therapeutic procedures and monitoring has begun to decrease, the patient can rest longer.

Maintain Adequate Perfusion Network.
Peripheral pulses (pedis, popliteal. Tibial, femoral, radial, brachial) palpated regularly to assess the presence of arterial obstruction. If no palpable pulses in the extremities, the cause may be due to the catheterization sebelurnnya the extremities. If there is a pulse that has just disappeared should be immediately reported to the doctor.
After the surgery should be pursued to prevent venous stasis can lead to thrombus formation and subsequent embolism: (1) wear elastic stockings or elastic halutan, (2 avoid crossing legs. (3) avoiding the use of step-up knee on the bed, (4) take all the pillows on popliteal cavity., and (5) provide passive exercises followed by active exercise umuk meningkaikan circulation and prevent the loss of muscle tone.
Symptoms embolization, which differ according to place, can be characterized by (1) abdominal pain or middle back (2) pain, loss of pulses, pallor, numbness, or cold in the extremities (3) chest pain or respiratory distress in pulmonary embolism and myocardial infarction : and (4) one-sided weakness and pupillary changes, as occurs in cerebral vascular injury. All symptoms should be reported immediately.

Keeping Kidney Perfusion Adequacy.
Inadequate renal perfusion as a result of surgery can tenjadi janrung open. One possible cause is rendahnva cardiac output. Besides trauma to blood cells during pulmonary heart shortcuts cause hernolisis red blood cells. This incident resulted in the formation of toxic compounds because glomerular debris clogged by red blood cells that had been damaged. Vasopresor to increase the use of blood pressure can also cause a decrease in renal blood alinan.
Nursing management includes accurate measurement of output of urine. Urine output of less than 20 ml clock indicates hypovolemia. Density should also be measured to determine the ability of the kidneys mengkonsentrasilcan urine in the renal tubules. Diuretics work faster or inotropika drugs (digitalis, isopnoterenol) may be given to increase cunah heart and renal blood flow. Nurses should pay attention to the blood urea nitrogen (BUN) and serum creatinine, and serum electrolyte levels. If abnormalities are found immediately report to the doctor because it may be necessary restrictions and limitations on the use of liquid-ohat drugs normally excreted through the kidneys.

Keeping Permanent Normal Body Temperature.
Patients biasanva hipotermik when inserted into the intensive care unit and cardiac surgical procedures. Patients should be gradually warmed up to normal temperature, which partly can be obtained from the patient's own basal metabolism plus help the warmed air ventilator, a warm blanket, or a heating lamp. Besides patients still hipotermik, the freezing process becomes less efficient. vulnerable to cardiac dysrhythmias, and oxygen is not immediately ready to move and hemoglobin to the network. Because anesthetics suppress basal metabolism. oxygen supply that is usually sufficient for the cell.
After cardiac surgery, patients at risk of an increase in body temperature due to infection sindrorn pascaperikardiotomi atan. The increase in metabolic rate that occurs will increase tissue oxygen demand thus increasing the workload of the heart. Efforts should be made to prevent or stop the sequence of events is well known.

Expected Results
a. Achieving adequate cardiac output
b. Maintenance of adequate gas exchange
c. Terpeliharanva fluid balance and elekirolit
d. Loss of sensing excessive symptoms, re-oriented towards people. place and time
e. Loss of pain
f. Maintenance of adequate tissue perfusion
g. Achieving adequate rest
h. Maintenance of adequate renal perfusion
i. The maintenance of normal body temperature
j. Able to perform self-care activities

Sylvia A. Price et. Al (1994). Pathophysiology Clinical Concepts Disease Processes, 4th Edition Book Medical Publishers EGC, Jakarta.
S.C Smeltzer and Brenda G Bare (2002). Textbook of Medical Surgical Nursing Brunner & Suddarth (Ed. 8 Vol 2), EGC, Jakarta.
Juall Lynda Carpenito (1999). Nursing Care Plans and Documentation Nursing (Ed. 2), New York: Publishers of medical books. EGC.
Barbara C Long, (1996). Medical Surgical Nursing, Volume II, Foundation alumni associations of nursing education Padjadjaran Bandung: Bandung.
Engram (1999). Rencanan Medical Surgical Nursing, Volume 2, Translation of Medical Surgical Nursing Planning, (1993), Interpreting the language Suharyati, EGC: Jakarta.
Marlynn E Doenges (1999) Nursing Care Plans Guidelines for Planning and Documenting Patient Care (3rd Edition) Publisher medical books. EGC

I hope this information may be useful ...

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