NURSING CARE PATIENT WITH Arrhythmias

Fauzziyah Febiannisa P1337420617064 Sheila Ratu Bagasandra H P13374206170 75

Dwi Ajeng Puspitaningrum P1337420617065 Aullen Anggita P1337420617077
Atikah Khairiyah P1337420617066 Athallah Muafanudin P1337420617078
Tania Setyo C ahyaningtyas P1337420617067 Istinganatul M P1337420617083
Devi Lailin Najah P1337420617068 Salma Eka P1337420617087
DEFINITION
Arrhythmias:
Change from impulse electricity normal cause abnormality
or disruption rhythm heart, Some expert mention as
dysrhythmias, arrhythmias could is disease primary and disease
secondary(disease heart/ischemia)
The normal conduction system
System conduction :
a. SA NODE (Normal maker Pace), mrpk generator naturally that
produce impulse electricity in continue constantly and will
delivered to lane conduction next, Implus that be produced 60-100
x /mnt
b. AV NODE, impulse that be produced 40-60 x /mnt
c. File his
d. fiber Purkinje
Implus generated
20-40 x / mnt
CARDIAC CYCLE
ETIOLOGY
arrhythmias could caused by many kinds of factor:
1. Disease heart coronary
2. Imbalance electrolyte
3. Imbalance acid alkali
4. Change muscle heart
5. poisoned drug
6. stress emotional
7. synchronized tool spur heart
Pathophysiology
MECHANISM CAUSED Arrhythmias
1. disruption automation
2. Excitatory activity (trigered activity)
3. disruption Conduction
CLASSIFICATION Arrhythmias

Arrhythmias TYPES BASED ON LOCATION AND BASICALLY Physiology:

1. arrhythmias because disruption formation impulseA. nodes SA: ST,
SB, SA, Sinus Arrest
b, Atrium: AES, PAT, AF, A Flutter
c, nodes AV: JR, JES, JT
d, supraventricular: SVT
e, ventricles: IVR, VES, VT, VF
2. arrhythmias because disruption hantaran impulse:
a. nodes SA: SA Block
b, nodes AV: AV Block
c, Intervenrikuler: RBBB, LBBB
CLASSIFICATION Arrhythmias
Arrhythmias TYPES BASED gravity:
1. Arrhythmias with hemodynamic stable: example: AES, AFNVR, SB,
JR, AV BLOCK I
2. arrhythmias with hemodynamic not stable:
a. level moderate: SR dg VES malignant, AVBlock II, AFSVR / RVR,
b. VT> 30 second, AVB III, SB, JR dg HR <40
3. arrhythmias without hemodynamic: VF, VT without pulse, AVB dg
asistole
Clinical manifestations
arrhythmias asymptomatic:
arrhythmias symptomatic:
 palpitations/flutter
 Dizzy
 fainting
 Crowded breath
 painful chest
 Weak, fast tired
DIAGNOSTIC
 ECG
 HOLTER MONITORING
 electrophysiology
MANAGEMENT
TREATMENT OF DEPENDENT Arrhythmias and the gravity:
1. OVERCOME CAUSES Arrhythmias (ischemia, HYPOXIA, electrolyte,
acidosis)
2. DO PREPARATION & APPROPRIATE PROCEDURES
3. THERAPY ANTI Arrhythmias
4. ELECTRICAL THERAPY: defibrillation, cardioversion
5. INSTALLATION OF PACE MAKER
6. INSTALLATION AICD
7. ablation
NURSING MANAGEMENT
assessment
1. anamnese presence complaint reply be perceived : palpitations, limp
, dizzy , fainting ,painful chest, crowded, cough, dizziness, gingung
,anxious
2. knowledge history treatment : intoxication drug (digitalis)
3. Sign vital: T / N / S / R, awareness, ECG
4. pulsation pulse peripheral, sound heart lung
5. Examination skin : cyanosis, Pale, sweat
6. knowledge result examination lab
Blood : hb, electrolyte , enzyme heart AGD
7. roentgen Thorax: normal or cardiomegaly, there is edema pulmo.
8. echocardiographic : There is a valve abnormalities, congenital
defects, myocardial tumors, and pericard effusion or decreased
cardiac pump function.
NURSING DIAGNOSES
 DECREASE IN BULK HEART
 ACTIVITY INTOLERANCE
 anxiety
 DEFICIT KNOWLEDGE OF THE PROCESS OF DISEASE, AND
MAINTENANCE OF HEALTH treatment regimen
 POTENTIAL COMPLICATIONS: malignant arrhythmias
PLANNING
SELF
1. monitor hemodynamic
2. Preparation procedure action and therapy
COLLABORATION
1. administration drug antiarrhythmic, correction electrolyte, acid
alkali, hypoxia
2. monitor responses therapy
3. Management examination laboratory
4. handling Emergency
CARE NURSING IN Tn. S With Arrhythmias in
Dr. Kariadi Hospital SEMARANG
A. ASSESSMENT
Biography Patient

Name patient : Mr. S

Age : 78 year
Gender :Man
Address : Semarang
Religion : Christian
Education :graduate SMP
Work : Retired
Diagnosis medical : arrhythmias

COMPLAINT MAIN
Patient say out of breath
HISTORY NURSING
1. HISTORY NURSING NOW
Client saystart feel crowded breath around 1 Sunday that then when client do activity light
as climbing stairs, walking more than 100 meters, moving goods.

2. HISTORY NURSING FIRST

Client say ever have history disease as hypertension, client get drug for hypertension when
client treatment to puskesmas but client rarely drink drug mentioned, Client only drink
drug when client feel dizzy,

3. HISTORY FAMILY HEALTH

Client say that father have disease attack heart but family client not have disease spread as
stroke, hypertension and DM.
PHYSICAL EXAMINATION

Awareness : composmentis
Signs vital:
Pressure blood : 160/100 mmHg
Pulse : 21x /mnt
breathing : 29x /mnt
Temperature : 36.3oC
Examination Head to Toe:
1. Head and hair : Head mesocepal, growth hair equally, hair short colored white, not
dandruff, not there bump or lesions on head,
2. Nose : There breathing lobe nose, installed simple mask, clean not there is
cumulation secret.
3. Ear : Symmetrical, clean not there is cumulation cerumen, not there is lesions and
not wear tool help hear,
4. Eye : conjunctiva not anemis, sclera not jaundice, reflex to light positive, movement
eye symmetrical, and not there is disruption vision
5. Mouth :Not there cyanosis, mucous lip dry,
6. Neck : Form symmetrical, not there distention jugular, not there is painful pressure
on tracheal, not there is enlargement gland thyroid and not there is enlargement
tonsil.
7. Skin :Skin dry, capillaries refill time less from 3 second, wrinkles
Chest
lung - lung
I : Form symmetrical, expansion not maximum, breath fast and shallow
Pa : fremitus right = left
Pe : sonor second roomy lung
Au : Sound basic vesicular
Heart
I : Ictus cordis not appear
Pa : Ictus cordis palpable in SIC V, 2 cm mid LMCS
Pe : Deaf
Au : BJ 1 and BJ 2 regular
abdomen Inspection : Not there is bump
auscultation : noisy gut normal
palpation : Not there is painful pressure
percussion : audible sound timpani

extremity
- On : Hand left installed infusion RL 20 TPM, not happen edema around installation
infusion, not there is wound on hand patient, not there is painful pressure, hand right left
patient could be moved, capille refill less from 2 second
- Under : Second leg patient not there wound, there edema and not there is painful pressure,
skin leg dry, turgor skin back in less from 3 second, akral warm,
A Antropometri)
Before sick BB : 43 kg
TB : 145 cm
IMT : BB / TB²
: 43 / (1,45) ²
: 20:47 kg / m2
B (Bhiochemical )
hb : 9.9 g / dl
Ht : 27.8%
Hemoglobin levels and hematocrit that be below limit normal signify client experience anemia, if body
experience anemia heart should work more hard for supply blood that rich will oxygen to Other organs, case
this if allowed continue constantly could result hypertrophy on heart, arrhythmias and failed heart,
C (Clinical sign)
turgor skin : Elastic, back in time less from 3 second, skin dry
conjunctiva : not anemis
Mouth : mucous lip dry
Face : pale
D (Dietary intake) : food soft TKTP.
Supporting investigation
ECG
date : May 7, 2019

Conclusion ECG: atrial Fibrillation 100x /minutes, normoaksis, LVH

NO Date and Time Data Focus PROBLEM TTD
1. 6 May 2019 DS: Inneffectuive breathing Team 3
4.30 pm Clients complain of shortness of breath. patterns associated with
DO: decreased inspiration or
Looks short of breath expiratory pressure
Looks heavy on inspiration
RR: 29x / min

2 6 May 2019 DS: Activity intolerance is Team 3

4.30 pm The client said he needed help to move associated with an
The client said that he should not move much because he would feel chest pain if there imbalance between
was too much physical activity oxygen supply to the
DO: tissue
General condition is weak
Patients rarely move
DIAGNOSIS KEPARAWATAN
 ineffectiveness pattern breath related with pemurunan inspiration or expiratory
pressure
 Intoleransi activity related with imbalance between suplaioksigen to network
 NURSING PLAN
Date and DX TUJUAN DAN KRITERIA HASIL INTERVENSI
time
06/05/1 1 NOC: NIC:
9 Respiratory status: ventilation 1. Position the patient to maximize
07.00 pm Respiratory status: Airway ventilation ventilation
Vital sign status 2. Give Oxygen Therapy
After nursing action is carried out for ... minutes 3. Monitor the flow of oxygen
Result Criteria: 4. Maintain the patient's position
The patient feels less breathless 5. Monitor blood pressure, pulse,
Vital signs in the normal range (blood pressure, pulse, respiration) temperature, and respiratory rate
6. Auscultation of lung sounds
6/5/19 2 NOC: NIC;
7.15 pm Self Care 1. Monitor the client's ability in
Activity tolerance self-care dependence
Energy conservation 2. Create limits on activities that
After nursing care for 3x24 hours with the results criteria: make clients become tired quickly
Know and understand the importance of activities gradually 3. Help get an activity aid tool such
as a wheelchair
4. the patient's monitor for
excessive physical and emotional
fatigue
 IMPLEMENTATION
Date and DX IMPLEMENTATION CLIENT RESPONSE TTD
Time
07/05/19 1 Give the patient semi fowler position S: Clients say they feel more comfortable Team 3
09. 15 p O: The client is seen sitting in a semi fowler position
10.45 1 Collaboration on installing O2 10L with a simple S: the client says the tightness decreases from 4 to 3 Team 3
mask O: installed O2 10L
11.30 1 Measuring Vital Signs O: Team 3
TD 160/120 mmHg,
HR 88 x / min,
RR 29 x / min,
S 36.3 ° C
2 Record emotional responses to mobilization

2 Providing activities according to the circumstances

of the client
2 Provides active passive motion training

2 Helping clients in carrying out burdensome

activities
08/05/19 1 Give the patient semi fowler position S: The client says it's more comfortable sitting position Team 3
O: The client is seen sitting in a semi fowler position
09. 00 am
1 Measuring Vital Signs O: Installed O2 10L / min simple mask
TD 160/110 mmHg, HR 84x / min, RR 22 x / min, S 36.3
°C

10.30 1 Collaboration on installing O2 10L with a simple mask S: The client says the tightness is reduced if using O2 Team 3
O: installed O2 10L
2 Record emotional responses to mobilization
Providing activities according to the circumstances of the client
Provides active passive motion training
Helping clients in carrying out burdensome activities
09/05/19 1 Give the patient semi fowler position S: The client says it's more comfortable sitting position Team 3
08. 15 O: The client is seen sitting in a semi fowler position
10.45 1 Collaboration on installing O2 3lt nasal cannula S: the client said that he rarely felt tight Team 3
Clients only use nasal cannula if they feel tight
O: installed O2 3L
11.50 1 Measuring vital signs O: Team 3
TD 150/100 mmHg,
HR 82 x / min,
RR 20 x / min,
S 36.3 ° C
2 Record emotional responses to mobilization
Providing activities according to the circumstances of the client
Provides active passive motion training
Helping clients in carrying out burdensome activities
EVALUATION

Date
and DX EVALUATION TTD
Time
07/05/1 1 S: The patient says shortness of breath Team 3
9 O: Installed O2 10L / min simple mask
02.00pm TD 160/120 mmHg,
HR 88 x / min,
RR 29 x / min,
S 36.3 ° C
A: The problem has not been resolved
P: Continue Intervention with:
Monitor oxygen flow
Maintain the patient's position
Monitor BP, pulse, temperature, and RR
8/05/19 1 S: Patients say shortness of breath decreases slightly Team 3
02.10 O: Installed O2 10L / min simple mask
TD 160/110 mmHg, HR 84x / min, RR 22 x / min, S 36.3 ° C
A: The problem has not been resolved
P: Continue Intervention with:
Monitor oxygen flow
Maintain the patient's position
Monitor BP, pulse, temperature, and RR
9/05/19 1 S: Patients say shortness of breath decreases Team 3
13.30 O: Attached O2 3L / min nasal cannula
BP 150/100 mmHg,
HR 82 x / min,
RR 20 x / min,
S 36.3 ° C
A: The problem has not been resolved
P: Continue Interventions with: 1. Monitor oxygen flow
2. Maintain the patient's position
3. Monitor TD, pulse, temperature, and RR