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Compiled by group 5:

Cantasyacitta Anggayasti /1614201013

Neng Mutamimah /1614201002
Rika Puspita Sari /1614201026
Siskta Ainun Nisa /1614201003
Siska Mariani /1614201034

Semester 4A
A. Definitions
• Acute myocardial infarction is a condition where
there is damage or death of the heart muscle
caused by the sudden reduction or delay of
coronary blood flow or suddenly oxygen demand
increases without adequate perfusion of the
coronary artery.
• IMA is the cause of death in America and
contributes to approximately 529,000 deaths each
B. Etiology
Some of the things that cause oxygenation disorders include:
1. Reduced oxygen supply to the myocardium
a. Blood vessel factors
b. Factor of circulation
c. Blood Factor
2. Increase the body's oxygen demand Modified IMA risk
factors that can be altered
a. Smoking
b. Consumption of alcohol
c. Infection
d. Systemic hypertension
e. Obesity
f. Lack of exercise
g. DM Disease
3. IMA risk factors that can be modified that can not
be changed
a. Age over 40 years
b. Gender
c. Family history
d. RAS
e. Geography
f. Social class
D. Complications
Infarction of infarction and post-infarction
Ischemia, arrhythmias (sinus brachikardi,
supraventricular, tachyarrhythmia, ventricular
arrhythmia, conduction disturbance) cardiac
muscle dysfunction (left heart failure,
hypotension) right ventricular infarction,
mechanical defects, myocardial rupture,
pericarditis, mural thrombus ).
E. Medical Management
• EKG (to menngetahui heart function)
• Cardiac enzymes (CPKMB isoenzymes found in
heart muscle), LDH, AST (aspartate
aminontransferase) troponin I, troponin T
• Electrolytes (imbalances can affect conduction and
contractility eg hypokalemia and hyperkalemia)
• Puh blood cells (leukocytes [10.000-20.000] usually
appear on the second day after IMA associated
with the process of imflamasi)
• Photo / Ro chest (possibly normal or enlarged
heart suspected GJK or ventricular aneurysm)

A. Assesment
1. Identity
a. Patient identity
Name : Tn. D
Age : 65 years
Gender : Male
Address : Kusumodilagan, Pasar Kliwon,
Tribe / nation : Java / Indonesia
Religion : Islam
b. Identity responsible
Name : Ny. N
Age : 36 years
Gender : female
Tribe / nation : Java / Indonesia
Religion :Islam
Education : High School
Job : Entrepreneur
Address : Kusumodilagan, RT 01/12
Joyosuran Market Kliwon,
Relationship with patient : Birth child
B. The main complaint
Patient shortness of breath.
C. History of nursing
• Nursing history now
± 3 days ago patient after waking up, stomach pain,
ampeg chest, lemes. Then take it to IGD RS. PKU
Muhammadiyah Surakarta, by the physician who
examined the patients treated in the ICU received
infusion of RL 16 tpm, and injection of 2 ml / 12 hour
rantin iv.
• Past medical history
Patients said they had had shortness of breath, had a
history of smoking, no history of anti-tuberculosis drugs.
• Family nursing history
Family patients say his family no one suffering from
infectious or hereditary diseases .
4. Functional patterns (bio psycho socio spiritual)
• Pattern of oxygenation perception
Before sick: the patient said breathing spontaneously,
without the tools.
During illness: shortness of breath, with RR 34 x / min, with
shallow and rapid breathing.
• Liquid and electrolyte patterns
Before illness: patients say at home drink ± 5-6 glasses /
day, drink tea and water.
During illness: patients drink out 3 glasses / day, drink tea
and water.
• Nutrition patterns
Before sick: the patient said to eat 3 times a day, with the
composition of rice, side dishes, vegetables.
Dillness: patients eat out 2 tablespoons / meal, diet:
team rice, patients nausea and vomiting 3 times
• Pattern of elimination
Before ill :
BAB: 11 x / day, consistency shaped
BAK: patients BAK 4-5 x / day, clear yellow color
During illness:
BAB: 11 x / day, shaped consistency
BAK: patient BAK 220 cc / day, installed DC color of thick
urine BAK.
• Security and comfort patterns
Before sick : the patient says feel safe and
During illness: the patient is uncomfortable with his
shortness of breath, the patient says pain at an incline,
the pain scale 5, the pain disappears, the patient
withhold pain Patient feels safe with the procedure of
action, the family gives attention.
• Personal hygiene patterns
Patients every day disibin by nurses, mouth no stomatitis,
CHAPTER assisted by nurses, nurses perform oral hygiene.
• Sleep rest pattern
Before getting sick: the patient says sleep at 21.00-05.00
(± 8 hours / day), sometimes nap ± 1 hour
During illness : the patient sleeps at 22.00-05.00 (± 7
hours / day) and naps.
• Patterns of activity and practice
Before illness : patients say ADL is self-contained.
During the illness : the patient's daily activities are
assisted by the nurse, still lying on the bed.
• Self concept
 Body image: the patient never complains with the
current situation
 Self ideal: the patient wants to get well soon.
 Self esteem: the patient is not ashamed of his current
 Identity: the patient realizes that he is a man and a
 Role: the patient as a father, husband and community
• Sexual patterns
Patient is male, has 3 children.
• Psychological
Patients when talked to the nurse would answer all
questions, politely and patiently.
• Social
The patient relationship with the nurse is good, with the
family also good.
• Spiritual
Patients during the 5 day prayer sessions on the bed
• Knowledge
The patient's family knows the current condition of the
patient by asking the nurse.
5. Physical examination
– General situation : Weak
– Level of consciousness : Composmentis, GCS: 15
– Vital signs : TD: 128/89 mmHg N: 154 x
/ min S: 36 ° C Rr: 34 x / min
– Head : Mesochepal
– Eyes : Conjunctival anemis, good
vision function
– Nose : No secretions, attached O2
3 lt /min
– Mouth : Clean, moist lips mucosa, no
– Ears : Clean, no serumen accumulation
– Neck : There is no enlargement of the
– Chest:
– Lung:
I : Development of right chest = left, fast and shallow
breathing frequency
P : Fremitus, right and left touch together
P : The sound of ronchi
A : Wheezing
– Heart:
I : Ictus cordis is not visible
P : Ictus cordis is not strong lift
P : Pekak
A : S I = S II, regular
– Abdomen:
I : No lesions, no bumps
A : Peristaltic bowel 12 x./min
P : Tympani
P : No massa
– Extremities:
Above: On the right and left hands attached infusion RL 16
drops / minute
Below: No oedem, can move freely
B. Data Analysis
1. DS :
Patient says shortness of breath
DO :
-TD: 128/89 mmHG
N : 154 x / min
RR: 34 x / min
S : 36 ° C
- Rapid and shallow breathing Oxygen
2. DS:
- P: Patients say pain at an angle
Q: Pain as stabbing
R: Patients say pain in the chest area
S: Pain scale 5
T: Pain disappears
- The patient appears to be holding back pain
c. Nursing Diagnosis

• Ineffective breathing patterns are associated

with decreased oxygen supply.
• Pain (acute) associated with lack of oxygen in
the coronary arteries
• Changes in nutrients less than body needs
associated with inadequate intake.
D. Intervention
Dx. I.
Purpose: After nursing action for 3 x 24 hours shortness of
breath is reduced or lost.
Results criteria:
Respiratory rate 16-20 x / min
Not feeling breathless
Assess the pattern of vital signs
Observe the general state of the patient
Position semi-fowler patient
Keep O 2 3 l / min
Give medicine according to the program
Advanced. . .
Dx. II
Objective: After nursing action for 3 x 24 hours of chest pain is reduced
or lost.

Results criteria:
Pain scale 2-3
The patient's face looks relaxed
Does not seem to hold back pain
Assess vital signs
Assess the characteristics of pain
Help do relaxation techniques, deep breath
Provide a quiet environment, slow activity and comfortable action
Collaboration of the drug as indicated
Advanced. . .
Purpose: After nursing care for 3 x 24 hours of
nutrition fulfilled
Results criteria:
No BB decrease
Eat 1 serving
Assess nutritional status
Feed the patient well in tolerance
Teach less but often
Give an attention-grabbing feed
Collaboration with physicians with drug function.
E. Implementation
Advanced. . .
F. Evaluation
S: Patients say shortness of breath is reduced
O: Terpaang O2 3 l / min
TD: 126/87 mmHg
N; 94 x / min
R: 24 x / min
S: 36.2 ° C

A: Partially resolved problem

P: Continue intervention
- Keep O 2
- Keep the semi-fowler position
Advanced. . .
S: Patients say chest pain is reduced
O: The face looks relaxed
P: Pain is felt when the patient is tilted
Q: Pain as stabbing
R: Pain is felt on the chest
S: Pain scale 3
Q: Pain disappears

A: Partially resolved problem

P: Intervention resumed
- Continue relaxation techniques
- Fx injection analgesic
Advanced. . .

S: -
O: - The patient eats ½ servings
- Nausea vomiting missing
- KU: medium
A: Partially resolved problem
P: Intervention resumed
- Give a warm meal