PEMANTAUAN SUHU

& HEMODINAMIK
Ganis Indriati
 SUHU

04/11/21 g.indri 2
■ Suhu à rutin di monitor pd semua pasien yg dirawat di RS
■ Ps dg kondisi kritis sering melaporkan à abnormalitas, ketidakteraturan
& suhu tubuh yg ekstrim à poor outcomes.
■ Normalnya suhu tubuh dipertahankan dlm suatu rentang oleh
thermostat tubuh à hypothalamus
■ Suhu tubuh diluar rentang ini akan menyebabkan hilangnya fungsi
biochemical and cellular.
■ Biochemical abnormalities: hypokalemia, hypomagnesemia à ggn QT
intervals.

05/11/21 g.indri 3
■ Suhu tubuh yg tinggi pd penyakit kritis à berkaitan dg dampak negative
thdp fisiologis & biochemical penyakit à disarankan utk memonitor,
memanipulasi & mengatur suhu tubuh scr akurat à maintenance of
optimal body temperature in the ICU setting à meminimalkan dampak.
■ Core temperature à temperature of the deep tissues à dimonitor
melalui suhu urinary, nasopharyngeal, atau esophageal.

06/11/21 g.indri 4
Faktor – Faktor yg Mempengaruhi Suhu
Tubuh
Perubahan suhu tubuh dlm rentang yg dpt diterima, tjd bila mekanisme
fisiologis & perilaku mengganggu proses produksi atau kehilangan panas
tubuh. Faktor yg dpt dikaji antara lain:
■ Usia, pd newborn temperature-control mechanism msh immature hingga
mencapai pubertas & newborn, dgn rentang suhu 35,5 0C – 37,5 0C.
kehilangan 30% panas tubuh dr kepala à pakai topi utk mencegah
kehilangan panas tubuh. Pd lansia tjd ggn control vasomotor
(vasokonstriksi & vasodilatasi), ↓ jar sub cutan, ↓ aktivitas kal keringat &
↓ metabolisme, shg rentang suhu 35 0C – 36, 1 OC.
■ Olahraga, jenis apapun akan meningkatkan metabolism, memproduksi
panas & meningkatkan suhu tubuh.

06/11/21 g.indri 5
■ Kadar hormone, fluktuasi suhu tubuh tjd lebih banyak tjd pd wanita
dibandingkan laki –laki. Kadar progesterone akan ↑↓ selama siklus
menstruasi, progesterone ↓, suhu tubuh ↓ 1/10 derajat di bawah suhu
dasar tubuh. Wanita menopause mengalami ↑ suhu tubuh 40C akibat
ketidakstabilan control vasomotor à hot flashes
■ Irama sirkadian tubuh, suhu tubuh akan rendah pd jam 1.00 – 4.00 AM,
siang stabil, maksimal pd 4.00 PM & turun pd pagi hari. Butuh waktu 1 –
3 mgg utk mengubah siklus suhu tubuh.
■ Stress, stress fisik dan emosi meningkatkan suhu tubuh melalui stimulasi
hormonal & neural.
■ Lingkungan, tubuh tdk mengatur suhu tubuh dg mengaktifkan mekanisme
heat-loss pd ruangan yg hangat à suhu ↑, di linngkungan yg dingin
kehilangan panas akibat radiasi & konduksi.
■ Gangguan suhu tubuh, dpt tjd akibat excessive heat production, excessive
heat loss, minimal heat production, minimal heat loss, atau kombinasinya.

06/11/21 g.indri 6
Efek Fisiologis dr Suhu
■ Fever atau pyrexia à tjd krn mekanisme heat-loss tdk dpt mengimbangi
produksi panas yg berlebih shg menyebabkan peningkatan suhu tubuh yg
abnormal.
■ Fever, biasanya tdk berbahaya jika < 390C (dewasa) atau < 40 0C (anak - anak)
à a true fever results from an alteration in the hypothalamic set point.
■ Fever is an important defense mechanism.
– Mild temperature elevations as high as 39° C enhance the immune system
of the body.
– A febrile episode, white blood cell production is stimulated.
– Increased temperature reduces the concentration of iron in the blood
plasma, suppressing the growth of bacteria.
– Fever also fights viral infections by stimulating interferon, the natural virus-
fighting substance of the body.

06/11/21 g.indri 7
Hyperthermia
■ An elevated body temperature related to the inability of the body to
promote heat loss or reduce heat production.
■ Demam à peningkatan set point, hyperthemia à tjd akibat
mekanisme tubuh yg berlebihan.
■ Penyakit atau trauma pd hypothalamus dpt merusak mekanisme heat
– loss.

12/11/21 g.indri 8
Hypothermia
■ Heat loss during prolonged exposure to cold overwhelms the ability of
the body to produce heat.
■ Hipotermia bukan hanya sebagai konsekuensi negative penyakit tp
dpt juga sebagai terapi modalitas.
■ As a treatment modality, therapeutic hypothermia à neurobeneficial
effect à reducing ischemic reperfusion injury, decreasing
excitotoxicity, free-radical production.

06/11/21 g.indri 9
 PRIORITAS
PEMANTAUAN
PASIEN KRITIS
YG MENGALAMI
MASALAH SUHU

11/11/21 g.indri 10
 HEMODINAMIK

04/11/21 g.indri 11
■ Hemodinamik à perubahan dinamis pd system cardiovascular.
■ Monitoring hemodynamik dilakukan utk menyiapkan pemahaman praktisi
terkait kondisi patofisiologi dari masalah kesehatan pasien yg sedang
ditindaklanjuti.
■ Alasan dilakukan monitoring hemodinamik scr umum adalah:
– Menegakkan diagnose keperawatan yg tepat.
– Menentukan terapi yg tepat
– Memonitor respon terhadap terapi.
■ Monitoring hemodinamik dpt dilaksanakan scr non - invasive atau invasive,
dpt berkelanjutan atau intermiten (berselang) tergantung kebutuhan
pasien.

04/11/21 g.indri 12
Monitoring Non – Invasive
■ Non – invasive : tdk membutuhkan alat apapun yg dimasukkan ke dlm
tubuh dan tdk melukai kulit.
– Monitoring hemodinamik langsung mis: suhu tubuh, nadi, tekanan
darah, frekuensi nafas & output urine.
– Lainnya: EKG, doppler arteri / vena, transcutaneous pulse oximetry,
expired carbon monoxide.

04/11/21 g.indri 13
Monitoring Invasive
■ Invasive : membutuhkan alat yg dimasukkan ke dlm siskulasi system
vascular agar tekanan / alirannya dapat diinterpretasikan dan dpt
memfasilitasi Analisa komponen darah yg lebih luas lagi spt gas darah
arteri dan vena.
■ The invasive nature of this monitoring allows the pressures that are
sensed at the distal ends of the catheters to be transduced, and to
continuously display and monitor the corresponding waveforms.
■ Invasive haemodynamic monitoring technology includes:
– systemic arterial pressure monitoring
– central venous pressure (CVP)
– pulmonary artery pressure (PAP)
– cardiac output /thermodilution

06/11/21 g.indri 14
Prinsip Monitoring Hemodinamik
■ Akurat, data hemodinamik yg diperoleh harus akurat krn data
menggambarkan secara langsung kondisi pasien.
■ Tren Data, kemampuan membuat tren data via monitor atau system
informasi klinis, sangat penting utk praktik keperawatan klinis. Tren data dpt
digunakan utk menilai perkembangan kondisi klinis pasien & memantau
respon pasien thdp pengobatan.
■ Standar Pemantauan, mencakup pemantauan terhadap sirkulasi,
pernafasan dan oksigenasi dg peralatan penting yg tersedia utk setiap
pasien spt:
– EKG : pemantaun jantung
– Ventilator mekanik:
– Pulse Oximeter : oxygen delivery & consumption
– Peralatan lain utk mengukur tekanan intra arterial & pulmonal, cardiac
output, tekanan inspirasi, aliran udara tekanan intracranial, CO2
ekspirasi.
04/11/21 g.indri 15
Faktor yg Mempengaruhi Hemodinamik
■ Preload
– Preload à tekanan pengisian di ventrikel pd akhir diastole.
– Preload di ventrikel kanan à Central Venous Pressure (CVP),
dipengaruhi oleh tekanan intra thoraks, tonus vascular & obstruksi.
– Preload di ventrikel kiri à tekanan baji kapiler paru / Pulmonary
Capillary Wedge Pressure (PCWP).
■ Afterload
– Tekanan yg dihasilkan ventrikel utk mengatasi resistensi thdp ejeksi
yg dihasilkan dlm sirkulasi sistematik atau pulmonal oleh arteri atau
arteriol.
– Afterload jtg kiri: tercermin sbg Resistensi Vascular Sistemik (RVS)
– Afterload jtg kanan: tercermin sbg Resistensi Pembuluh Darah Paru
(PVR)

04/11/21 g.indri 16
 PEMANTAUAN CENTRAL
VENOUS PRESSURE (CVP) &
KATETER ARTERI PULMONALIS

04/11/21 g.indri 17
Prinsip Pemantauan CVP
■ Central venous catheters are inserted to facilitate the monitoring of central venous
pressure; facilitating the administration of large amounts of IV fluid or blood; providing
long-term access for fluids, drugs, specimen collection; and/or parenteral feeding.
■ CVP monitoring can produce erroneous results: a low CVP does not always mean low
volume and it may reflect other pathology, including peripheral dilation due to sepsis.
Hypovolae- mic patients may have normal CVP due to sympathetic nervous system
activity increasing vascular tone. An increase in CVP can also be seen in patients on
mechani- cal ventilation with application of PEEP
■ Central venous catheters used for haemodynamic moni- toring are classed as short-term
percutaneous (non- tunnelled) devices. Short-term percutaneous catheters are inserted
through the skin, directly into a central vein, and usually remain in situ for only a few
days or for a maximum of 2–3 weeks.37 They are easily removed and changed, and are
manufactured as single- or multi-lumen types. However, they can be easily dislodged, are
throm- bogenic due to their material, and are associated with a high risk of infection

04/11/21 g.indri 18
■ A number of locations can be used for central venous access. The two commonly used sites in
critically ill patients are the subclavian and the internal jugular veins. Other less common sites
are the antecubital fossa (gener- ally avoided but may be used when the patient cannot be
positioned supine), the femoral vein (associated with high infection risk), and the external jugular
vein (although the high incidence of anomalous anatomy and the severe angle with the
subclavian vein make this an unpopular choice)
■ Internal jugular cannulation has a high success rate for insertion; however, complications related
to insertion via this route include carotid artery puncture and laceration of local neck structures
arising from needle probing.44,45 There are a number of key structures adjacent to the vein,
including the vagus nerve (located posteriorly to the internal jugular vein); the sympathetic trunk
(located behind the vagus nerve); and the phrenic nerve (located laterally to the internal
jugular).46 Damage can also occur to the sympathetic chain, which leads to Horner’s syn- drome
(constricted pupil, ptosis, and absence of sweat gland activity on that side of the face). Central
venous catheters inserted in the internal jugular vein pose a number of nursing challenges which
can cause fixation problems and the need for repeated dressing changes. These include beard
growth, diaphoresis and poor control of oral secretions.
■ The subclavian approach is used often, perhaps because of a reported lower risk of catheter-
related bloodstream infection.46,47 Coagulopathy is a significant contraindica- tion for this
approach, as puncture of the subclavian artery is a known complication. There is also a risk of
pneumothorax, which rises if the patient is receiving intermittent positive pressure ventilation
(IPPV).47 Complications of any central venous access catheters include air embolism,
pneumothorax, hydrothorax and haemorrhage.

04/11/21 g.indri 19
Pemantauan Kateter Arteri Pulmonalis
/ Pulmonary Artery Pressure (PAP)
■ Pulmonary artery catherisation facilitates assessment of filling pres- sure of the left ventricle
through the pulmonary artery wedge (occlusion) pressure
■ By using a thermodilution pulmonary artery catheter (PAC), cardiac output and other
haemodynamic measurements can also be calculated. PAP monitoring is a diagnostic tool that
can assist in determination of the nature of a haemodynamic problem and improve diagnostic
accu- racy. In addition to measuring PA pressures, PAC may also be used for accessing blood for
assessment of mixed- venous oxygenation levels
■ PAP monitoring may be indicated for adults in severe hypovolaemic or cardiogenic shock, where
there may be diagnostic uncertainty, or where the patient is unresponsive to initial therapy. The
PAP is used to guide administration of fluids, inotropes and vasopressors. PAP monitoring may
also be utilised in other cases of haemo- dynamic instability when diagnosis is unclear. It may
be helpful when clinicians want to differentiate hypovolae- mia from cardiogenic shock or, in
cases of pulmonary oedema, to differentiate cardiogenic from non-cardiogenic origins.56 It has
been used to guide haemodynamic support in a number of disease states such as shock, and
to assist in assessing the effects of fluid management therapy.

04/11/21 g.indri 20