Indonesian Nursing Blog

Hadirilah Seminar Online Keperawatan

2011-08-12T22:41:00.000-07:00

Teknologi Informasi untuk Perawat
Penggunaan Informasi Tekonologi Untuk Kemajuan Keperawatan Indonesia!

Perkembangan teknologi telah memudahkan layanan dari berbagai industri, termasuk dunia kesehatan. Dengan adanya teknologi informasi yang tidak mengenal jarak, melahirkan berbagai layanan baru dalam bidang keperawatan yang juga dikenal dengan sebutan telenursing.

Telenursing yang merupakan bagian dari telehealth adalah penggunaan telekomunikasi dan teknologi informasi untuk menyediakan pelayanan keperawatan dalam layanan kesehatan dimana terdapat jarak yang cukup jauh antara pasien dan perawat ataupun interaksi dengan berbagai perawat di belahan dunia. Telenursing juga memiliki hubungan dengan aplikasi baik medis atau non medis seperti telediagnosis, telekonsultasi, telemonitoring, dsb.
Di era sekarang ini, wajib bagi para perawat di Indonesia untuk mengenal lebih dekat lagi mengenai teknologi informasi agar tidak ketinggalan informasi dan kalah saing dengan perawat dari negara lain.
www.medicalbutler.com menghadirkan seminar online keperawatan yang akan menjelaskan mengenai teknologi informasi untuk perawat, apa dan bagaimana peran perawat dalam dunia teknologi informasi dan perkembangan telenursing pada:

Hari/tanggal : Kamis, 18 Agustus 2011
Pukul : 14.00-15.00 WIB
Bersama : Eri Yanuar Akhmad B. S., S.Kep, Ns, salah satu staf pengajar di Program Studi Ilmu Keperawatan Fakultas Kedokteran UGM, Yogyakarta.

Hanya dengan menyiapkan komputer/laptop, koneksi internet, headset atau speaker, maka anda telah siap mendengarkan seluruh presentasi dan dialog seminar online secara langsung, dari manapun. Anda pun dapat melayangkan pertanyaan kepada Eri Yanuar di akhir seminar online. Praktis, mudah dan yang terpenting, gratis! Tunggu apa lagi? Klik disini untuk mendaftarkan diri sekarang.

Cara menghadiri webinar/seminar online:

Klik link untuk mendaftar menjadi peserta webinar dan masukkan data diri pada formulir registrasi.
Setelah melengkapi formulir registrasi, link pribadi akan dikirimkan ke email Anda.
Persiapan, 30 menit sebelum webinar dimulai, klik link tersebut untuk memasuki ruang webinar dan ikuti instruksi untuk download software. Nomer ID webinar ini: 337-063-794.
Setelah download berhasil, Anda akan memasuki ruang virtual webinar.
Silakan ajak serta keluarga dan teman untuk menghadiri webinar!

Untuk info lebih lanjut kunjungi www.medicalbutler.com atau email ke info@medicalbutler.com

Perawatan Luka Modern

2009-01-21T03:58:00.000-08:00

I. Pendahuluan

Pada saat ini, perawatan luka telah mengalami perkembangan yang sangat pesat terutama dalam dua dekade terakhir ini. Teknologi dalam bidang kesehatan juga memberikan kontribusi yang sangat untuk menunjang praktek perawatan luka ini. Disamping itu pula, isu terkini yang berkait dengan manajemen perawatan luka ini berkaitan dengan perubahan profil pasien, dimana pasien dengan kondisi penyakit degeneratif dan kelainan metabolic semakin banyak ditemukan. Kondisi tersebut biasanya sering menyertai kekompleksan suatu luka dimana perawatan yang tepat diperlukan agar proses penyembuhan bisa tercapai dengan optimal.

Dengan demikian, perawat dituntut untuk mempunyai pengetahuan dan keterampilan yang adekuat terkait dengan proses perawatan luka yang dimulai dari pengkajian yang komprehensif, perencanaan intervensi yang tepat, implementasi tindakan, evaluasi hasil yang ditemukan selama perawatan serta dokumentasi hasil yang sistematis. Isu yang lain yang harus dipahami oleh perawat adalah berkaitan dengan cost effectiveness. Manajemen perawatan luka modern sangat mengedepankan isu tersebut. Hal ini ditunjang dengan semakin banyaknya inovasi terbaru dalam perkembangan produk-produk yang bisa dipakai dalam merawat luka. Dalam hal ini, perawat dituntut untuk memahami produk-produk tersebut dengan baik sebagai bagian dari proses pengambilan keputusan yang sesuai dengan kebutuhan pasien. Pada dasarnya, pemilihan produk yang tepat harus berdasarkan pertimbangan biaya (cost), kenyamanan (comfort), keamanan (safety). Secara umum, perawatan luka yang berkembang pada saat ini lebih ditekankan pada intervensi yang melihat sisi klien dari berbagai dimensi, yaitu dimensi fisik, psikis, ekonomi, dan sosial.

II. Definisi Luka, Klasifikasi dan Proses Penyembuhan Luka

Secara definisi suatu luka adalah terputusnya kontinuitas suatu jaringan oleh karena adanya cedera atau pembedahan. Luka ini bisa diklasifikasikan berdasarkan struktur anatomis, sifat, proses penyembuhan dan lama penyembuhan. Adapun berdasarkan sifat yaitu : abrasi, kontusio, insisi, laserasi, terbuka, penetrasi, puncture, sepsis, dll. Sedangkan klasifikasi berdasarkan struktur lapisan kulit meliputi: superfisial, yang melibatkan lapisan epidermis; partial thickness, yang melibatkan lapisan epidermis dan dermis; dan full thickness yang melibatkan epidermis, dermis, lapisan lemak, fascia dan bahkan sampai ke tulang. Berdasarkan proses penyembuhan, dapat dikategorikan menjadi tiga, yaitu:

A. Healing by primary intention

Tepi luka bisa menyatu kembali, permukan bersih, biasanya terjadi karena suatu insisi, tidak ada jaringan yang hilang. Penyembuhan luka berlangsung dari bagian internal ke ekseternal.

B. Healing by secondary intention

Terdapat sebagian jaringan yang hilang, proses penyembuhan akan berlangsung mulai dari pembentukan jaringan granulasi pada dasar luka dan sekitarnya.

C. Delayed primary healing (tertiary healing)

Penyembuhan luka berlangsung lambat, biasanya sering disertai dengan infeksi, diperlukan penutupan luka secara manual.

Berdasarkan klasifikasi berdasarkan lama penyembuhan bisa dibedakan menjadi dua yaitu: akut dan kronis. Luka dikatakan akut jika penyembuhan yang terjadi dalam jangka waktu 2-3 minggu. Sedangkan luka kronis adalah segala jenis luka yang tidak tanda-tanda untuk sembuh dalam jangka lebih dari 4-6 minggu. Luka insisi bisa dikategorikan luka akut jika proses penyembuhan berlangsung sesuai dengan kaidah penyembuhan normal tetapi bisa juga dikatakan luka kronis jika mengalami keterlambatan penyembuhan (delayed healing) atau jika menunjukkan tanda-tanda infeksi.

III. Proses Penyembuhan Luka

A. Luka akan sembuh sesuai dengan tahapan yang spesifik dimana bisa terjadi tumpang tindih (overlap)

B. Proses penyembuhan luka tergantung pada jenis jaringan yang rusak serta penyebab luka tersebut

C. Fase penyembuhan luka :

1. Fase inflamasi :

· Hari ke 0-5

· Respon segera setelah terjadi injuri à pembekuan darah à untuk mencegah kehilangan darah

· Karakteristik : tumor, rubor, dolor, color, functio laesa

· Fase awal terjadi haemostasis

· Fase akhir terjadi fagositosis

· Lama fase ini bisa singkat jika tidak terjadi infeksi

2. Fase proliferasi or epitelisasi

· Hari 3 – 14

· Disebut juga dengan fase granulasi o.k adanya pembentukan jaringan granulasi pada luka à luka nampak merah segar, mengkilat

· Jaringan granulasi terdiri dari kombinasi : Fibroblasts, sel inflamasi, pembuluh darah yang baru, fibronectin and hyularonic acid

· Epitelisasi terjadi pada 24 jam pertama ditandai dengan penebalan lapisan epidermis pada tepian luka

· Epitelisasi terjadi pada 48 jam pertama pada luka insisi

3. Fase maturasi atau remodelling

· Berlangsung dari beberapa minggu s.d 2 tahun

· Terbentuknya kolagen yang baru yang mengubah bentuk luka serta peningkatan kekuatan jaringan (tensile strength)

· Terbentuk jaringan parut (scar tissue) à 50-80% sama kuatnya dengan jaringan sebelumnya

· Terdapat pengurangan secara bertahap pada aktivitas selular and vaskularisasi jaringan yang mengalami perbaikan

IV. Faktor yang mempengaruhi proses penyembuhan luka

Status Imunologi
Kadar gula darah (impaired white cell function)
Hidrasi (slows metabolism)
Nutritisi
Kadar albumin darah (‘building blocks’ for repair, colloid osmotic pressure - oedema)
Suplai oksigen dan vaskularisasi
Nyeri (causes vasoconstriction)
Corticosteroids (depress immune function)

V. Pengkajian Luka

A. Kondisi luka

1. Warna dasar luka

· Slough (yellow)

· Necrotic tissue (black)

· Infected tissue (green)

· Granulating tissue (red)

· Epithelialising (pink)

2. Lokasi ukuran dan kedalaman luka

3. Eksudat dan bau

4. Tanda-tanda infeksi

5. Keadaan kulit sekitar luka : warna dan kelembaban

6. Hasil pemeriksaan laboratorium yang mendukung

B. Status nutrisi klien : BMI, kadar albumin

C. Status vascular : Hb, TcO2

D. Status imunitas: terapi kortikosteroid atau obat-obatan immunosupresan yang lain

E. Penyakit yang mendasari : diabetes atau kelainan vaskularisasi lainnya

VI. Perencanaan

A. Pemilihan Balutan Luka

Balutan luka (wound dressings) secara khusus telah mengalami perkembangan yang sangat pesat selama hampir dua dekade ini. Revolusi dalam perawatan luka ini dimulai dengan adanya hasil penelitian yang dilakukan oleh Professor G.D Winter pada tahun 1962 yang dipublikasikan dalam jurnal Nature tentang keadaan lingkungan yang optimal untuk penyembuhan luka. Menurut Gitarja (2002), adapun alasan dari teori perawatan luka dengan suasana lembab ini antara lain:

1. Mempercepat fibrinolisis

Fibrin yang terbentuk pada luka kronis dapat dihilangkan lebih cepat oleh netrofil dan sel endotel dalam suasana lembab.

2. Mempercepat angiogenesis

Dalam keadaan hipoksia pada perawatan luka tertutup akan merangsang lebih pembentukan pembuluh darah dengan lebih cepat.

3. Menurunkan resiko infeksi

Kejadian infeksi ternyata relatif lebih rendah jika dibandingkan dengan perawatan kering.

4. Mempercepat pembentukan Growth factor

Growth factor berperan pada proses penyembuhan luka untuk membentuk stratum corneum dan angiogenesis, dimana produksi komponen tersebut lebih cepat terbentuk dalam lingkungan yang lembab.

5. Mempercepat terjadinya pembentukan sel aktif.

Pada keadaan lembab, invasi netrofil yang diikuti oleh makrofag, monosit dan limfosit ke daerah luka berfungsi lebih dini.

Pada dasarnya prinsip pemilihan balutan yang akan digunakan untuk membalut luka harus memenuhi kaidah-kaidah berikut ini:

1. Kapasitas balutan untuk dapat menyerap cairan yang dikeluarkan oleh luka (absorbing)

2. Kemampuan balutan untuk mengangkat jaringan nekrotik dan mengurangi resiko terjadinya kontaminasi mikroorganisme (non viable tissue removal)

3. Meningkatkan kemampuan rehidrasi luka (wound rehydration)

4. Melindungi dari kehilangan panas tubuh akibat penguapan

5. Kemampuan atau potensi sebagai sarana pengangkut atau pendistribusian antibiotic ke seluruh bagian luka (Hartmann, 1999; Ovington, 1999)

Dasar pemilihan terapi harus berdasarkan pada :

· Apakah suplai telah tersedia?

· Bagaimana cara memilih terapi yang tepat?

· Bagaimana dengan keterlibatan pasien untuk memilih?

· Bagaimana dengan pertimbangan biaya?

· Apakah sesuai dengan SOP yang berlaku?

· Bagaimana cara mengevaluasi?

B. Jenis-jenis balutan dan terapi alternative lainnya

1. Film Dressing

· Semi-permeable primary atau secondary dressings

· Clear polyurethane yang disertai perekat adhesive

· Conformable, anti robek atau tergores

· Tidak menyerap eksudat

· Indikasi : luka dgn epitelisasi, low exudate, luka insisi

· Kontraindikasi : luka terinfeksi, eksudat banyak

· Contoh: Tegaderm, Op-site, Mefilm

2. Hydrocolloid

· Pectin, gelatin, carboxymethylcellulose dan elastomers

· Support autolysis untuk mengangkat jaringan nekrotik atau slough

· Occlusive –> hypoxic environment untuk mensupport angiogenesis

· Waterproof

· Indikasi : luka dengan epitelisasi, eksudat minimal

· Kontraindikasi : luka yang terinfeksi atau luka grade III-IV

· Contoh: Duoderm extra thin, Hydrocoll, Comfeel

3. Alginate

· Terbuat dari rumput laut

· Membentuk gel diatas permukaan luka

· Mudah diangkat dan dibersihkan

· Bisa menyebabkan nyeri

· Membantu untuk mengangkat jaringan mati

· Tersedia dalam bentuk lembaran dan pita

· Indikasi : luka dengan eksudat sedang s.d berat

· Kontraindikasi : luka dengan jaringan nekrotik dan kering

· Contoh : Kaltostat, Sorbalgon, Sorbsan

4. Foam Dressings

· Polyurethane

· Non-adherent wound contact layer

· Highly absorptive

· Semi-permeable

· Jenis bervariasi

· Adhesive dan non-adhesive

· Indikasi : eksudat sedang s.d berat

· Kontraindikasi : luka dengan eksudat minimal, jaringan nekrotik hitam

· Contoh : Cutinova, Lyofoam, Tielle, Allevyn, Versiva

5. Terapi alternatif

· Zinc Oxide (ZnO cream)

· Madu (Honey)

· Sugar paste (gula)

· Larvae therapy/Maggot Therapy

· Vacuum Assisted Closure

· Hyperbaric Oxygen

VII. Implementasi

A. Luka dengan eksudat & jaringan nekrotik (sloughy wound)

· Bertujuan untuk melunakkan dan mengangkat jaringan mati (slough tissue)

· Sel-sel mati terakumulasi dalam eksudat

· Untuk merangsang granulasi

· Mengkaji kedalaman luka dan jumlah eksudat

· Balutan yang dipakai antara lain: hydrogels, hydrocolloids, alginates dan hydrofibre dressings

B. Luka Nekrotik

· Bertujuan untuk melunakan dan mengangkat jaringan nekrotik (eschar)

· Berikan lingkungan yg kondusif u/autolisis

· Kaji kedalaman luka dan jumlah eksudat

· Hydrogels, hydrocolloid dressings

C. Luka terinfeksi

· Bertujuan untuk mengurangi eksudat, bau dan mempercepat penyembuhan luka

· Identifikasi tanda-tanda klinis dari infeksi pada luka

· Wound culture – systemic antibiotics

· Kontrol eksudat dan bau

· Ganti balutan tiap hari

· Hydrogel, hydrofibre, alginate, metronidazole gel (0,75%), carbon dressings, silver dressings

D. Luka Granulasi

· Bertujuan untuk meningkatkan proses granulasi, melindungi jaringan yang baru, jaga kelembaban luka

· Kaji kedalaman luka dan jumlah eksudat

· Moist wound surface – non-adherent dressing

· Treatment overgranulasi

· Hydrocolloids, foams, alginates

E. Luka epitelisasi

· Bertujuan untuk menciptakan lingkungan yang kondusif untuk “re-surfacing”

· Transparent films, hydrocolloids

· Balutan tidak terlalu sering diganti

F. Balutan kombinasi

Tujuan	Tindakan
Rehidrasi	Hydrogel + film atau hanya hydrocolloid
Debridement (deslough)	Hydrogel + film/foam Atau hanya hydrocolloid Atau alginate + film/foam Atau hydrofibre + film/foam
Manage eksudat sedang s.d berat	Extra absorbent foam Atau extra absorbent alginate + foam Atau hydrofibre + foam Atau cavity filler plus foam

VIII. Evaluasi dan Monitoring Luka

· Dimensi luka : size, depth, length, width

· Photography

· Wound assessment charts

· Frekuensi pengkajian

· Plan of care

IX. Dokumentasi Perawatan Luka

- Potential masalah

- Komunikasi yang adekuat

- Continuity of care

- Mengkaji perkembangan terapi atau masalah lain yang timbul

- Harus bersifat faktual, tidak subjektif

- Wound assessment charts

X. Kesimpulan

Penggunaan ilmu dan teknologi serta inovasi produk perawatan luka dapat memberikan nilai optimal jika digunakan secara tepat
Prinsip utama dalam manajemen perawatan luka adalah pengkajian luka yang komprehensif agar dapat menentukan keputusan klinis yang sesuai dengan kebutuhan pasien
Peningkatan pengetahuan dan keterampilan klinis diperlukan untuk menunjang perawatan luka yang berkualitas

Materi dari Hana Rizmadewi Agustina, SKp. MN

Referensi:

1. http://www.podiatrytoday.com/article/1894

2. Georgina Casey, Modern Wound Dressings. Nursing Standard, Oct 18-Oct 24, 2000:15,5: Proquest Nursing & Allied Health Search

3. Kathleen Osborn, Nursing Burn Injuries. Nursing Management; May 2003; 34,5: Proquest Nursing & Allied Health Search

4. Madelaine Flanagan, Managing Chronic Wound Pain in Primary Care. Practice Nursing; Jun 23, 2006; 31, 12; ABI/INFORM Trade & Industry

5. Maureen Benbow, Healing and Wound Classification. Journal of Community Nursing; Sep 2007; 21,9; Proquest Nursing & Allied Health Search

6. Ritin Fernandez, Rhonda Griffiths, Cheryl Ussia (2002). The Effectiveness of Solutions, Techniques and Pressure in Wound Cleansing. The Joanna Briggs Institute for Evidence Based Nursing & Midwifery. Australia. www.joannabriggs.org.au

7. Ruth Ropper. Principles of Wound Assessment and Management. Practice Nurse; Feb 24, 2006; 31,4; Proquest Nursing & Allied Health Search

I want to be a Nurse

2008-12-30T12:09:00.000-08:00

Saya ingin Jadi Perawat
Saya ingin jadi perawat, kamu harus jadi perawat sebab perawat membantu orang, kalau tidak ada cukup perawat, siapa yang akan merawat anda kalau sakit? Kalau anda terluka tidak ada orang yang mengobatin kamu, kamu akan menangis…..menangis…. dan kamu tahu ngga? Disini baru ada yang dua patah tangan.

Radiography: X-Ray Tests

2008-12-30T09:25:00.000-08:00

Dual-energy X-ray Absorptiometry

Dual-energy x-ray absorptiometry/DEXA bone densitometry is the standard test for measuring bone mineral density. The test is used to diagnose osteoporosis and assess an individuals risk for fractures.

DEXA calculates bone density by subtracting an x-ray measurement of soft tissue from a total measurement. The procedure is painless and radiation exposure is minimal. There are two types of DEXA equipment: central devices that measure hip and spine density and peripheral devices that measure

wrist, heel, or finger density. The central devices are found in hospitals and clinics and are more accurate than the peripheral devices. They consist of a padded table that contains the x-ray generator and an overhead arm with a detector. The peripheral devices are housed in boxes that are designed to accommodate the extremity to be tested.

DEXA is a safe procedure and requires no signed consent form. Contraindications for this test are:

Pregnancy (due to radiation).
Weight over 260 pounds.
Spinal deformity, osteoarthritis, or a history of spinal surgery. (The bone density of these patients can be evaluated with a CT scan instead.)
A barium study within the past ten days.

Preparation for DEXA

Prepare your patients for DEXA by advising them not to wear jewelry and to wear clothing without zippers. Inform them that the test takes 30 to 45 minutes and that the results will be given to them in a few days. They will receive a T score that compares their density to other adults of the same sex. They also receive a Z score, comparing them to people matched for sex, age, height, and weight. A diagnosis of osteoporosis is typically made if the vertebral bone density is more than 10% below expectation (Pagana & Pagana, 2003).

Ineligible Populations

Patients with extreme obesity (over 300 pounds) will not fit into the tunnel-type imaging equipment and may be too wide for DEXA equipment. Pregnancy risk advice for many of the diagnostic tests depends on what area of the body is being examined, the age of the fetus, the accumulation of radiation from multiple tests, and the individual risk of allergic reaction to contrast material.

Spiral/helical CT

Although this terminology was used in the past, virtually all CTs use this technology. You may still see an occasional order for “spiral CT” but it is no longer meaningful.

CT Scan

Standard computerized axial tomography/CAT or CT scan produces computersynthesized images that are derived from x-rays. Images are taken at many different angles using x-rays that pass through digitally cross-sectioned body planes. During the test, patients are required to lie still within a large tunnel-like machine. CT scan images are over a hundred times clearer than those of normal x-rays. Graphics software turns them into enlarged 3-D images. When contrast material is used, the images further enhance differentiation between normal and diseased tissue.

You may be familiar with some specialized and advanced kinds of CT scans in addition to standard CT:

Dynamic CT: Contrast material is injected directly into an artery feeding the organ to be studied, as opposed to being injected into a peripheral vein. This allows for identification of very small tumors. CT portogram (study of the portal artery) is an example.
Helical/Spiral CT: A faster scanning produces continuous and more accurate images (most CT scans use this technology). Virtual colonoscopy is an example.
Ultrafast CT/EBCT/Electronbeam CT: This test specifically evaluates heart and chest structures and functions. This test is often used in the outpatient setting (Chernecky & Berger, 2004).
High resolution CT: A test used to evaluate pulmonary interstitial diseases
Dual modality imaging (Fusion Imaging): This test combines CT or MRI with nuclear medicine tools such as PET (Positron Emission Tomography) or SPECT is to study function as well as structure. Images from the different kinds of tests are fused together by the computer.
Xenon CT: This test evaluates cerebral blood flow by measuring a special gas inhaled by the patient while in the scanner.

CT scans are used to evaluate all parts of the body, especially the brain, liver, pancreas, adrenal glands, lungs, and bone. They are used to detect, stage, and monitor cancer. They are used to assess head injury from trauma and stroke. They are used in differential diagnoses, identifying tumors, cysts, abscesses, calculi, inflammation, hemorrhage, perforation, emboli, and aneurysms. They also guide biopsies and placement of catheters.

Contraindications for CT scans include:

Inability to cooperate and/or momentarily hold the breath.
Pregnancy, depending on the body part to be studied, the use of contrast medium and the age of the fetus.
Unstable vital signs (not an absolute contraindication if test is needed to gain information for treatment).
Obesity over 300 pounds (although some scanners can accommodate up to 450 pounds).
Previous or potential reaction to contrast material, if it is planned to be used.
Residual x-ray barium within the GI tract.

CT scans are considered generally safe, apart from the risks associated with the optional use of contrast material. Patients can be more comfortable and less apprehensive by medicating them as prescribed for claustrophobia and intolerance to lying on hard surfaces

Preparing for CT

Prepare your patients for a CT scan by:

Explaining the procedure including instructions about lying still and holding their breath as needed.
Removing metal accessories such as jewelry.
Informing them the test is painless and generally lasts only a few minutes.

If the scan will be done with contrast material

Explain the procedure including the common sensations of warmth when the dye is injected.
Tell your patient to inform the technician if they begin to feel itchy or have difficulty breathing (possible allergic reaction).
Confirm order to initiate IV access if none already exists and any orders for premedication.
Mark the peripheral pulses if an arterial catheter will be used.
Have the patient sign a consent form (if required).

If contrast material is used in the CT scan, images may be taken without it first. Then the contrast agent is injected and the scan repeated.

Tests Done with Contrast Agents

Contrast agents are used in x-rays, CT scans, and MRIs to make images clearer. They are commonly called ‘dyes’ but are not discoloring agents. Contrast agents temporarily alter the way images are picked up by a scanning tool. These agents are administered by mouth, enema, intravenously, or via arterial injection. Although there are a variety of contrast agents, those that contain iodine are commonly used. The associated risks with this type of contrast include:

Transitory side effects: feeling of warmth or flushing, a metallic or salty taste, light headedness, nausea, itching or hives, wheezing or SOB. About 5% of patients have some of these symptoms and they usually occur within the first half hour (Chernecky & Berger, 2004).
Anaphylactic reaction: acute bronchospasm, severe hypotension, severe urticaria. This occurs within minutes after the contrast agent is administered, requiring a readily available emergency cart.
Delayed reaction: flu-like syndrome including fever, chills, nausea, vomiting, diarrhea, abdominal pain, headache, fatigue, and congestion. This occurs in 10 to 30% of patients (Maddox, 2002).
Renal failure occurs in 0.1 to 13% of patients (Maddox, 2002).
Tissue damage caused by the direct toxic effect of the agent.

The patients most at risk for these complications are:

Pre-existing renal insufficiency or under treatment with nephrotoxic medications
History of asthma
Multiple food and medication allergies
Multiple medical problems, i.e. multiple myeloma, hyperuricemia
Diabetics, especially if taking metformin (Glucophage)
Advanced age

Techniques that can be used to reduce the risk for this group of patients include:

Use of the smallest amount of contrast material and or selection of an agent with lower osmolality or a nonionic agent that is less likely to cause an adverse reaction.
Pretreatment of the patient with a corticosteroid and an antihistamine such as diphenhydramine (Benadryl) to reduce the chance of an allergic reaction.
Use of a calcium channel blocker to prevent renal insufficiency.
Stopping metformin until 48 hours after the test.
Pre-testing for allergy with a small dose of contrast material prior to the test.
Discontinuation of nephrotoxic medications before the test.
Ensuring that at least 48 hours pass between procedures using contrast material.
Increasing hydration before and after the procedure.

You will need to monitor your patients’ renal function for at least three days after they receive contrast material. Monitor the intake and output record, electrolytes, and serum creatinine

Barium Studies

Barium swallow is a common x-ray test that uses a liquid mixture containing barium sulfate. A barium swallow is used to outline the structures of the pharynx and esophagus. The test is useful in diagnosing abnormalities such as ulcers, diverticula, fistulas, varices, and tumors. The test can indicate pyloric stenosis, hiatal hernia, and esophageal reflux. Patients swallow the contrast medium through a

straw. During a barium swallow the tilt table they are on is moved to a near-standing position and patients are asked to roll into various positions. A barium swallow is contraindicated during pregnancy, when there is dysphagia or intestinal obstruction, or when there is a risk of aspiration. In general the procedure is not considered risky and requires no consent form. The barium contrast material itself does not usually cause any adverse reactions. If possible leakage through a perforation is a concern, a water soluble contrast agent can be substituted for the barium (Pagana & Pagana, 2003). A vasovagal

reaction can occur during this procedure. Patients should be notified that there is a chance of the barium creating constipation or a fecal impaction.

Image : Barium swallow showing an obstruction in the patient’s esophagus (Courtesy of NASA’s Technical and Historical Perspectives of Remote Sensing, 2005)

Preparing for a Barium Swallow

Prepare your patients with a NPO status for eight hours and inform them that the test usually takes 15 to 30 minutes. After the test push fluids for 48 hours and take a mild cathartic as prescribed. Patients should be instructed that they should have a bowel movement within two days.

A barium enema is an x-ray exam of the large intestine following rectal installation of barium sulfate. Air is often pumped in through the rectum to enhance the image’s accuracy as well. This test is done to find tumors or structural abnormalities that interfere with normal intestinal activity.

A barium enema is not advisable during pregnancy or in patients with tachycardia. It is contraindicated in patients with severe active ulcerative colitis, intestinal perforations, and toxic megacolon. Although a consent form is not generally required there are certain risks:

Perforation
Constipation or fecal impaction
Dizziness
Vasovagal reaction

To be continued........

Cardiovascular Anatomy & Physiology

2008-12-30T07:10:00.001-08:00

INTRODUCTION

Cardiovascular anatomy and physiology is an example of both a mechanical and an electrical organ system. Although the heart is essentially a “pump”, the complex anatomy and physiology that make it able to successfully keep a person alive is truly amazing. Add to that the hormonal influences on the cardiovascular system and you have a truly complicated system of structures and events that need to operate correctly and efficiently to maintain homeostasis.

Cardiac Structures, Layers of the Heart

The human heart is protected by two layers that envelope it. The outer layer is called the pericardium. It covers the heart. The pericardium folds in on itself at the aorta forming the epicardium of the heart. Between these layers is a small amount of fluid (10-50 mL) that affords the layers a non-stick surface (American Association of Critical Care Nurses, 1998).

While the epicardium forms the outer layer of the heart, the myocardium forms the middle layer and the endocardium the innermost layer. The coronary arteries travel across the epicardium. The muscular myocardium is the thickest layer and the workhorse of the heart.

The endocardium has a smooth inner surface to allow blood to flow easily through the heart’s chambers. Within the endocardium of the atrium are pockets known as trabiculae. These pockets are sometimes the site of pathologic clot formation known as mural (wall) thrombi.

The heart’s valves are covered by the endocardium. The endocardium also has an endocrine function, releasing hormones such as endocardin - a substance that prolongs myocardial contraction.

Friction RUB

When infection occurs within the pericardial sac the inner surfaces of the layers begin to stick. This is known as pericarditis. This causes friction and pain. A friction rub may result.

Cardiac Tamponade

An accumulation of relatively small amounts of fluid in the pericardial sac is known as a pericardial effusion. If the fluid accumulates enough to affect the heart’s ability to contract, it is known as cardiac tamponade.

Mural Trombi

Mural thrombi typically form when blood is allowed to pool in these pockets. This usually happens due to an inability of the heart to effectively pump blood from the atria, such as in atrial fibrillation.

Cardiac Chambers & Blood Flow through the Heart

The human heart is a four-chambered pump made up of two receiving chambers called atria and two pumping chambers called ventricles.

Right Atrium

The right atrium receives oxygen-depleted blood returning from the body through the superior and inferior vena cava. It is a thin walled, low- pressure system. Normal pressures in the right atrium are typically 0–8 mm Hg. It is home to the sinoatrial, or SA node, the pacemaker of the heart (American Association of Critical Care Nurses, 1998)

Right Ventricle

The right ventricle is also a thin walled, low pressure chamber. It receives blood from the right atrium when the atrioventricular valve dividing the right atrium and ventricle (the tricuspid valve) is open. When this valve is open, and the chamber is resting, or filling with blood (diastole), typical right ventricular pressures are equal to pressures in the right atrium, 0-8 mm Hg. When the valve closes and contraction (systole) begins, pressures are 15-25 mmHg, enough to pump blood forward to the lungs via the right and left pulmonary arteries. The blood is then oxygenated in the lungs (American Association of Critical Care Nurses, 1998).

Cardiac Chambers & Blood Flow through the Heart

Left Atrium

The left atrium, another thin walled, low-pressure chamber, receives oxygen- rich, blood from the pulmonary circuit, via the right and left pulmonary veins. Normal resting pressures (diastolic pressures) in the left atrium are 4-12 mm Hg, less than that of the lungs. Because pressure is less in this chamber during diastole, blood is more easily returned from the higher pressure, pulmonary circuit (American Association of Critical Care Nurses, 1998).

Left Ventricle

The left ventricle is a thick walled chamber that receives blood from the right atrium, and is approximately three times thicker than the right ventricle. When the atrioventricular valve dividing the left atrium and ventricle (the mitral valve) is open and the chamber is resting, or filling with blood (diastole) typical left ventricular pressures are equal to that in the left atrium, 4-12 mm Hg. However, when the valve closes and contraction (systole) begins, pressures must be generated to overcome the body’s systemic vascular resistance (SVR). These pressures are typically 110-130 mm Hg (American Association of Critical Care Nurses, 1998). When the ventricle generates enough pressure to overcome SVR, blood moves forward, out the semilunar valve (known as the aortic valve) and into the aorta. There it is transported throughout the body via a network of arteries, capillaries and veins. Eventually the blood will return to the right atrium where the oxygenation process starts all over again. The right and left atria and ventricular chambers are separated by a septal wall or septum.

Cardiac Output

About two-thirds of the atrial blood flows passively from the atria into the ventricles. When atrial contraction occurs, the atrial blood is pushed down into the ventricles. This atrial contribution is called atrial kick and accounts for approximately thirty percent of the cardiac output (American Association of Critical Care Nurses, 1998).

Cardiac output (C.O.) is the amount of blood ejected by the left ventricle every minute. Cardiac output equals the stroke volume times the heart rate.

The heart rate is defined as the number of times per minute that the heart beats. Heart rate increases or decreases based upon the metabolic and oxygen demands of the body. The stroke volume is the amount of blood pumped by the heart per cardiac cycle. It is measured in ml/beat. A decreased stroke volume may indicate impaired cardiac contractility or valve dysfunction and may result in heart failure. An increased stroke volume may be caused by an increase in circulating volume or an increase in inotropy, or contractile force of the ventricle.

When the heart rate or the stroke volume (amount of blood ejected with each contraction) increases, cardiac output increases. When the heart rate or the stroke volume decreases, cardiac output decreases. Cardiac output varies according to body mass, but is typically between 4-8 liters per minute.

Cardiac index (C.I.) is cardiac output normalized for body surface area. There are several methods for measuring cardiac output. Typical cardiac indices are between 2.5-4.0 liters of blood per minute per meter2 (American Association of Critical Care Nurses, 1998).

Atrial Kick

When atrial contraction occurs atrial blood is pushed down into the ventricles.

Cardiac Output

Cardiac output = Stroke Volume x heart rate

C.O. = S.V. x H.R.

Cardiac Valves

When blood flows through the heart, it follows a unidirectional pattern. There are four different valves within the myocardium and their functions are to assure that blood flows from the right side to the left side of the heart and always in a “forward” direction. When blood does not flow in a forward direction regurgitation or shunting may occur.

The two valves found between the atria and ventricles are appropriately called atrioventricular (A-V) valves. The tricuspid valve separates the right atrium from the right ventricle. Similarly, the mitral valve separates the left atrium from the left ventricle. The tricuspid valve is named so because of its three (tri) leaflets (cusps). Mitral valve regurgitation when blood flows backward from the left ventricle into the left atrium.

The two remaining valves are called semilunar valves (because they look like half moons). The valve located where the pulmonary artery meets the right ventricle is called the pulmonic valve. The aortic valve is located at the juncture of the left ventricle and aorta. Both semilunar valves prevent backflow of blood into the ventricles

Valve Type

Valve Name

Location

Atrioventricular (AV)

Tricuspid Mitral

Separates right atrium and right ventricle

Separates left atrium and left ventricle

Semilunar

Pulmonic

Aortic

Between right ventricle and pulmonary artery

Between left ventricle and aorta

Correlation with Heart Sounds

The first heart sound is called S1 (AKA: the “Lub” of the “Lub-Dub” sound). It is the result of closure of the tricuspid and mitral valves during ventricular contraction. The second heart sound is called S2 (AKA: the “Dub” of the “Lub-Dub” sound). It occurs at the end of ventricular contraction due to the closure of the aortic and pulmonic valves.

If your computer has sound, you can visit this site to hear heart sounds

http://www.med.ucla.edu/wilkes/intro.html

The Conduction System

Depolarization and Repolarization

In a cardiac cell, two primary chemicals provide the electrical charges: sodium (Na+) and potassium (K+). In the resting cell, the potassium is mostly on the inside, while the sodium is mostly on the outside. This results in a negatively charged cell at rest (the interior of the cardiac cell is mostly negative or polarized at rest). When depolarized, the interior cell becomes positively charged and the cardiac cell will contract.

In summary, the polarized or resting cell will carry a negative charge on the inside. When depolarized, the opposite will occur. This is due to the movement of sodium and potassium across the cell membrane.

Depolarization moves an electrical wave through the myocardium. As the wave of depolarization stimulates the heart’s cells, they become positive and begin to contract. This cell-to-cell conduction of depolarization through the myocardium is carried by the fast moving sodium ions.

Repolarization is the return of electrical charges to their original state. This process must happen before the cells can be ready conduct again.

Note the depolarization and repolarization phases as they are represented on the ECG.

Electrical Impulse

The electrical impulse signals the heart to beat. This property is called automaticity. Automaticity means that specialized cells within the heart can discharge an electrical current without an external pacemaker, or stimulus from the brain via the spinal cord

The mechanical beating or contraction of the heart occurs after the electrical stimulation. When the mechanical contraction occurs, the person will have both a heart rate and a blood pressure.

Mechanical Impulse

The mechanical beating or contraction of the heart occurs after the electrical stimulation. When the mechanical contraction occurs, the person will have both a heart rate and a blood pressure.

The heart also has two distinct types of cells. There are electrical (conductive) cells, which initiate electrical activity and conduct it through the heart. There are also mechanical (contracting) cells, which respond to the electrical stimulus and contract to pump blood.

The contracting or myocardial “working cells” contain contractile filaments. When these cells are electrically stimulated, filaments slide together and the myocardial cell contracts and the atria or ventricular chambers contract. This is how we get our pulse and blood pressure.

The electrical cells are responsible for conducting impulses through the myocardial tissue and electrical pathways of the heart. They are responsible for the heart rate and rhythm. An ECG tracing is designed to give a graphic display of the electrical activity in the heart.

Sinoatrial (SA) Node

The Sinoatrial node (also called the SA node or sinus node) is a group of specialized cells located in the posterior wall of the right atrium. The SA node normally depolarizes or paces more rapidly than any other part of the conduction system. It sets off impulses that trigger atrial depolarization and contraction. Because the SA node discharges impulses quicker than any other part of the heart, it is commonly known as the natural pacemaker of the heart. The SA node normally fires at a rate of 60-100 beats per minute.

After the SA node fires, a wave of cardiac cells begin to depolarize. Depolarization occurs throughout both the right and left atria (similar to the ripple effect when a rock is thrown into a pond). This impulse travels through the atria by way of inter-nodal pathways down to the next structure, which is called the AV node.

The SA node is not only the primary pacemaker of the heart but it also triggers atrial depolarization and the contribution of the atrial kick. The heart has one dominant pacemaker (the SA node) and two back up pacemakers. One back- up pacer is located in the area of near the Bundle of His, the other back-up pacer is located in the ventricles along the Purkinje fibers.

Atrioventricular (AV) Node and AV Junction

The next area of conductive tissue along the conduction pathway is at the site of the atrioventricular (AV) node. This node is a cluster of specialized cells located in the lower portion of the right atrium, above the base of the tricuspid valve. The AV node itself possesses no pacemaker cells.

The AV node has two functions. The first function is to DELAY the electrical impulse in order to allow the atria time to contract and complete filling of the ventricles. The second function is to receive an electrical impulse and conduct it down to the ventricles via the AV junction and Bundle of His.

Bundle of His

After passing through the AV node, the electrical impulse enters the Bundle of His (also referred to as the common bundle). The bundle of His is located in the upper portion of the interventricular septum and connects the AV node with the two bundle branches. If the SA node should become diseased or fail to function properly, the Bundle of His has pacemaker cells, which are capable of discharging at an intrinsic rate of 40-60 beats per minute.

The AV node and the bundle of His are referred to collectively as the AV junction. The Bundle of His conducts the electrical impulse down to the right and left bundle branches.

The right bundle branch spreads the wave of depolarization to the right ventricle. Likewise, the left bundle branch spreads the wave of depolarization to both the interventricular septum and the left ventricle. The left bundle further divides into 3 branches or fasicles. The bundle branches further divide into Purkinje fibers.

Purkinje Fibers

At the terminal ends of the bundle branches, smaller fibers distribute the electrical impulses to the muscle cells, which stimulate contraction. This web of fibers is called the Purkinje fibers. The Purkinje fibers penetrate about 1/4 to 1/3 of the way into the ventricular muscle mass and then become continuous with the cardiac muscle fibers. Electrical impulses spread rapidly through the right and left bundle branches and Purkinje fibers to reach the ventricular muscle, causing ventricular contraction, or systole.

Purkinje fibers within the ventricles also have intrinsic pacemaker ability however this area of the myocardium can only pace at a rate of 20-40 beats per minute. The further you travel away from the SA node, the slower the backup pacemakers become. For example, if you only have a heart rate of 30 (generated from the ventricular back-up pacemaker), your blood pressure is likely to be low and you might be quite symptomatic.

Summary of Pacemaker Functions

The heart is designed with a system of one dominant and two back-up pacing systems.

Summary of Pacemaker Function
Level 1 (normal)	SA Node	60-100 beats/minute
Level II (back-up system)	Bundle of His/ AV Node/ Junction	40-60 beats/minute
Level III (lowest back-up system)	Purkinje Fibers within Ventricles (typically called the Ventricular Pacemaker)	20-40 beats/minute

Coronary Arteries

The coronary arteries receive their name for the “crown” they form over the heart. These arteries are the Right Coronary Artery (RCA) and Left Coronary Artery (LCA) and they arise off the aorta at the Sinus of Valsalva.

When the aortic valve closes at the beginning of diastole, the Sinus of Valsalva distends and blood flows into the RCA and LCA.

RCA (Right Coronary Artery)

The RCA arises from the right side of the aorta and follows the atrioventricular groove between the right ventricle and the left ventricle. It extends to the back of the heart, forming the posterior descending artery. The RCA has two branches, the posterior descending artery and the right marginal artery. The main portion of the RCA provides blood to the right side of the heart. This includes the right atrium and the right ventricle, much of conduction system and the inferior and posterior left ventricle. The RCA supplies blood to the SA Node (in fifty-five percent of the population) and the AV node (in ninety percent of the population). Occlusion of the right coronary artery can lead to inferior and posterior MIs. Bradycardia and Arrhythmias are commonly seen in these MIs.

LCA (Left Coronary Artery)

The LCA arises off of the left side of the aorta. Know as the left main coronary artery, it divides into two separate arteries, the left anterior descending (LAD) and the circumflex.

LAD (Left Anterior Descending) Artery

The LAD travels down the heart between the right ventricle and left ventricle to the apex and turns back up the heart. It is the main blood supply to left ventricle, septum, and anterior wall. Diagonal arteries arise off of the LAD.

Circumflex Artery

The circumflex artery curves around left side of the heart between the left atrium and the left ventricle. It supplies blood to the posterior surface of the heart. It supplies blood to the SA node (in forty-five percent of the population) and the AV node (in ten percent of the population). Its marginal branches provide the left lateral ventricle and the posterior left ventricle with its blood supply.

Location of MI

Location of Myocardial Infarction	Coronary Artery
Inferior	Right Coronary Artery
Anterior or Anteroseptal	Left Anterior Descending Artery
Lateral MI	Left Circumflex
Posterior	Left Circumflex or Right Coronary Artery

Two-thirds of coronary blood flow occurs during diastole, or when the heart is at rest. Five percent of cardiac output goes to the coronary arteries. Seventy percent of oxygen is extracted by the myocardial tissues of the heart, in comparison to the rest of the body at twenty-five percent. During times of extreme demand, the coronary arteries can dilate up to four times greater than normal to increase the supply of oxygen to the myocardial tissues.

The de-oxygenated blood from the myocardium is collected in the coronary sinus. This large vein then returns the de-oxygenated blood to the right atrium.

Bradycardias	Coronary Artery Disease
Bradycardias increase diastolic filling time. This is why cardiac patients can tolerate bradycardias better than tachycardias.	Patients with Coronary Artery Disease have fixed lesions that cannot dilate to meet increased demand. This leads to angina and coronary dysfunction, which may eventually lead to myocardial infarction.

Arteries

The arterial system carries about thirteen percent of the body’s blood volume at any given time. The heart pumps blood out through one major artery – the aorta. The aorta branches and these branches further divide into smaller arteries known as arterioles. Arterioles contain smooth muscle, are innervated by autonomic nervous system and can constrict and dilate to regulate blood supply to tissues. Arterioles are largely responsible for our systemic vascular resistance (SVR). Eventually, the arterioles divide enough that they become capillaries – where the exchange of oxygen, carbon dioxide, and nutrients occurs.

Arteries are composed of three layers: the intima (the inner layer of epithelial cells), the media the muscular middle layer), and the adventitia (the tough outer layer). The media layer helps the heart pump the blood. When the heart beats, the artery expands as it fills with blood. When the heart relaxes, the artery contracts, exerting a force that is strong enough to push the blood along. This rhythm between the heart and the artery results in successful circulation of the blood to the body.

Capillaries

Blood spends only approximately 0.5 seconds in capillaries. Our capillaries are only about one cell thick. The exchange of oxygen, carbon dioxide, and nutrients takes place through this very thin wall. At this cellular level, the red blood cells inside the capillaries release their oxygen. This oxygen then passes through the wall and into the surrounding tissue. Simultaneously, the tissues release their waste products, such as carbon dioxide. These wastes pass through the wall and into the red blood cells. The red blood cell transports the wastes to the lungs, liver and other organs to be processed for their excretion. Additionally, capillaries have both pre and post capillary sphincters that have a high degree of intrinsic tone that are independent of neurohormonal controls. Capillaries also auto-regulate to meet metabolic needs of surrounding tissues.

Pre-capillary Sphincters

In shock, pre- capillary sphincters dilate and post-capillary sphincters contract in an attempt to supply cells with more needed nutrients due to decreased blood supply.

Venous System

Blood leaving the capillaries returns to the heart through the venous system, beginning with venules and progressing to larger and larger veins. The larger veins lead to the superior and inferior vena cavae which enters the right atrium. Veins are highly distensible, thin walled vessels. They act as a volume reservoir for circulatory systems. At any given time, the veins carry about fifty percent of the body’s blood volume. Veins are very much like arteries however they transport blood at a much lower pressure than arteries. The veins transport blood back to the lungs and heart. Veins have valves that help to keep blood moving back to the heart. The vein valves provide footholds for the blood as it travels against gravity towards the heart. For example, blood returning to the heart from the foot has to travel against gravity. The venous valves and muscle contractions of the leg prevent backflow of blood (American Association of Critical Care Nurses, 1998).

Venous Capacity

Drugs that increase venous capacity (diuretics, morphine, and nitroglycerin) will decrease preload, thus decreasing the amount of blood returning to the right side of the heart. High fowlers also increases venous capacity & decreases preload. The supine position decreases venous capacity and increases preload, or the amount of blood returning to the right side of the heart.

Neurohormonal Control of the Heart and Blood Vessels Overview

The brain and central nervous system control the body through two pathways - the somatic & autonomic nervous systems. The somatic nervous system is typically under voluntary control. The autonomic nervous system is not voluntary and regulates the activities of the internal organs including the heart.

The autonomic nervous system has two main parts, the sympathetic and the parasympathetic systems. These two “opposite” systems often operate in opposition to each other. Many internal organs are stimulated by both systems. When one stimulates an organ, the other tends to depress the organ. The sympathetic nervous system is responsible for the “fight-or-flight" response. This response prepares us for emergency situations. The parasympathetic nervous system, oppositely, tends to inhibit these reactions. The response of our body depends on the proportionate strength of stimulation supplied by each system at any given instance. The heart is also stimulated by sympathetic and parasympathetic systems.

Sympathetic Nervous System of the Heart

Activation of the sympathetic nervous system, increases heart rate (positive chronotropy), increases contractility (positive inotropy), and increases conduction velocity (positive dromotropy). Additionally, in blood vessels, sympathetic activation constricts arteries and arterioles. This increases systemic vascular resistance (SVR, increases central blood flow and decreases distal blood flow). Sympathetic activation causes blood to be shunted away from the periphery to the heart, brain and skeletal muscles. Sympathetic activation also produces an effect on the body’s venous system causing a decrease in venous blood volume and an increases venous pressure (Tortora, 1989).

The overall effect of sympathetic activation is to increase cardiac output, systemic vascular resistance (both arteries and veins), and arterial blood pressure. Enhanced sympathetic activity is particularly important during exercise, emotional stress, and during hemorrhagic shock.

Parasympathetic Nervous System of the Heart

When the parasympathetic system of the heart is activated, it works to decrease heart rate (negative chronotropy), decrease contractility (negative inotropy), and decrease conduction velocity (negative dromotropy) via the vagus nerve. Most blood vessels in the body do not have parasympathetic innervation. Parasympathetic nerves do innervate salivary glands, gastrointestinal glands, and genital erectile tissue where they cause vasodilation (Tortora, 1987).

The overall effect of activation of the sympathetic nervous system is to increase:

• Heart rate

• Cardiac output

• Sympathetic vascular resistance

Receptor Control

Baroreceptors

Baroreceptors are located in the aortic arch, the carotid bodies of the external carotid arteries, the pulmonary artery and the atria. They respond to changes in blood pressure. The baroreceptors of the aortic arch have a high threshold pressure and are less sensitive than the carotid sinus receptors.

The baroreceptors of the carotid sinus typically respond to pressures ranging from 60-180 mmHg. These receptors are the dominant receptors and work by sensing the “mean” arterial blood pressure. This "set point" changes during hypertension, heart failure, and other chronic disease states. When there is an acute increase or decrease in mean arterial pressure, the baroreceptors alter their firing rate.

Hypotension for example decreases the firing rate of the carotid baroreceptors, and results in the brain’s normal inhibition of sympathetic response to be not as intense. This action increases sympathetic activity which leads to increased blood pressure by increasing vasoconstriction (increased SVR), increasing heart rate and increasing the force of contraction of the heart. These changes will result in increase in arterial pressure. Alternatively, an acute increase in arterial pressure increases the firing rate of the baroreceptors which increases the inhibition of sympathetic activity in the brain (medulla). If sympathetic stimulation is inhibited – bradycardia, decreased conductivity and decreased contractility of the myocardium results.

Chemoreceptors

Chemoreceptors are located both peripherally and centrally. Their role n the body is to detect abnormal changes in oxygen, carbon dioxide and hydrogen ion concentration in the blood stream.

The body’s major chemoreceptors are located in the carotid bodies of the external carotid arteries near the bifurcation of the internal carotid arteries. These carotid bodies continually sense oxygen, carbon dioxide and hydrogen ion concentration in the blood. When these receptors are stimulated, respiratory activity in incited to change to correct the “sensed” disturbance.

Respiratory arrest and circulatory shock dramatically increase chemoreceptor activity leading to increased sympathetic stimulation to the heart and vasculature via activation of the vasomotor center.

Vasomotor Center

The vasomotor center in the medulla of the brain is responsible for the overall control of blood distribution and pressure throughout the body. Impulses from the vasomotor center are mostly in typically cause vasoconstriction everywhere except for the coronary and skeletal arteries, where they cause vasodilation.

Hormonal Influences on the Heart and Blood Vessels

Certain hormones and substances help the body auto-regulate its blood pressure.

Vasopressin or Anti Diuretic Hormone (ADH) is released from the pituitary gland in the brain when the baroreceptors sense a fall in blood pressure. Its effect on vessels is to cause vasoconstriction – which usually results in an increased blood pressure.

Endothelin is released from the endothelial cells of the vasculature after vascular damage. It produces vasoconstriction of the underlying vascular smooth muscle and prevents blood loss

Atrial natriuretic peptide (ANP) is released from the atria of the heart and endothelium due to an increase in pressure or venous return to the atria and excess stretching of the vessels. Its net effect is to relax vascular smooth muscle and decrease blood pressure.

Nitric oxide is also released from the endothelium of the vasculature when stretching increases, producing a net effect of vasodilation

Nitric Oxide

Nitric Oxide is the basis of the therapeutic action of nitroglycerine. It vasodilates coronary arteries.

It also acts as the basis of action for the drug Viagra. It blocks the destruction of the chemical messenger that is produced when nitric oxide dilates the vascular smooth muscles of the penis – net effect vasoconstriction of the vessels of the penis and subsequently an erection.

Renin-Angiotensin System

When the kidneys sense a decrease in blood pressure, the renin-angiotensin system is activated. This system has the net effect of increasing organ perfusion and arterial blood pressure. This system can be very effective when there is a blood loss. When the system is activated due to a pathologic condition such as heart failure, the system itself is pathologic to the body, resulting in an increase in blood pressure that may be detrimental.

Ace Inhibitors

The mechanisms of actions of many drugs used to control hypertension work by interfering with specific pathways within this system, such as ACE Inhibitors and Beta Blockers.

Conclusion

Knowledge of the anatomy and physiology of the complex structures and mechanisms of the cardiovascular system involves not only the physical structures but the electrical and hormonal influences that make them work. As a caregiver, an awareness of the multiple factors that have the potential to influence and alter the regulation of the heart is an extremely important factor to consider.

References:

American Association of Critical Care Nurses (1998). The Cardiovascular System. In J. Alspach (Ed.), Core curriculum for critical care nursing (5th ed., Rev., pp. 137-338). Philadelphia: Saunders.

Cable, Christopher, (1997). Auscultation Assistant. Retrieved September 21, 2006 from www.med.ucla.edu/wikes/intro.html

Sherwood, L. (Ed.). (1997). Human physiology: From cells to systems (3rd ed.). Belmont, California: Wadsworth.

Tortora, G. (1989). The autonomic nervous system. In E. Dollinger (Ed.), Principals of human anatomy (5th ed., pp. 533-547). New York: Harper & Row.

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IS NURSING AS A PROFESSION?

2008-12-24T05:58:00.000-08:00

NURSING AS A PROFESSION

Occupation a job or a career profession is learned vocation or that has status of superiority and procedure in a division work.

CHARACTERISTIC OF A PROFESSION;

1) A defined knowledge base

2) Power and authority over training and education

3) Registration

4) Altruistic service

5) Code of ethics

6) Lengthy Socialitazation

7) Autonomy

8) In addition professionals are responsible and accountable

Criteria to Identify Profession

- Involve intellectual operations

- Derived from science and learning

- Possess educationally communicable technique

- Work up to a practical and definitive end

- They tend to self organization

- Becomingly altruistic in motivation

Criteria of a Profession

• Intellectual level of higher learning

• Enlarges body of knowledge

• Entrusts to institution of higher education

• Service vital to human and social welfare

• Functions autonomously

• Exalt service above personal gains

• Provides freedom of action and growth

Professional Characteristics of Nursing

• Expertise

• Accountability

• Autonomy

• Authority

• Unity

EXPERTISE

>Having a high level of specialized skills and knowledge

Benner Stages of Expertise

Expert

Highly proficient

Highly skilled intuitive and analytical ability

Proficient

Has 3 – 5 years experience

Holistic perspective of situation

Competent

Has 2 – 3 years experience

Has organizational and planning abilities

Advanced Beginner

Demonstrate acceptable performance

Recognizes meaningful aspects of real situation

Novice

No Experience

Performance is limited, and inflexible

ACCOUNTABILITY

>Being answerable to someone for something one has done!

AUTONOMY

>Having the power and authority to control various aspects of work

AUTHORITY

>Having legitimate power and sovereignty granted by stature, based on contract with society

UNITY

>Moral uniformity and class ideology among practitioners

The NATURE of a PERSON

Has inherent DIGNITY

An END and NOT a MEANS to an END

Are EQUAL

SHOULD DECIDE on what is BEST

3 Determinants of the Morality of Human Act

The OBJECT

The END

The CIRCUMSTANCES

Inviolability of LIFE

All human life, from the moment of conception and through all subsequent stages, is SACRED!

No one can violate or destroy life!

TOTALITY

Parts are integral, destined to be part of and subordinate to a whole!

SOLIDARITY

One to be with others; to have a unity of interest, responsibility or goal

Solidarity is based on the common good, love of neighbour, preferential for the most proximate and most need

4 Basic Elements of Autonomy

Respect for Autonomous Person
Ability to determine personal goals
Capacity to decide
Has Freedom to Act

AS A PROFESSION

What is nursing?

- is an art , a science, client centered, holistic, adaptive, concerned w/ health promotion, health maintenance, and health restoration.

-is a profession focused in assisting individual, families & communities in attaining & maintaining & recovering optimal health and functioning.

- the modern definition of nursing is “ a science and an art that focuses in promoting quality of life”

NURSING is:

Caring

An art

A science

Client centered

Holistic

Adaptive

Concerned with health promotion, health maintenance, and health restoration

A helping profession

PERSONAL CHARACTERISTIC OF A NURSE

1) PROBLEM SOLVING AND CRITICAL THINKING ABILITIES

2) EFFECTIVE WRITTEN AND VERBAL COMMUNICATION SKILLS

3) ORGANIZATIONAL SKILLS

4) GOOD JUDGMENT & THE ABILITY TOMAKE DECISIONS QUICKLY, ESP IN STRESSFUL SITUATION

5) PATIENCE, UNDERSTANDING & A CARING ATTITUDE

6) FLEXIBILITY, HUMOUR AND ENTHUSIASM

7) THE ABILITY TO LEAD AND WORK COOPERATIVELY W/ OTHERS

8) GENERAL GOOD HEALTH

What personal qualities are appropriate for being a professional nurse?

- Empathy, being able to identify with others

- Caring, being compassionate and committed.

- Professional in every aspect of your job

- Ethical and non- judgmental

- Honesty and integrity

- Emotional stability to deal with a range of outcomes -which may not be good.

- Confidential and trustworthy

- Physically fit as the job is very demanding.

- Open to learning and have an enquiring mind.

- Be an advocate for your patients, have their best interests at heart.

- Be a good listener and a good communicator.

NURSING HISTORY

History provides current nurses with the same intellectual and political tools that determined nursing pioneers applied to shape nursing values and beliefs to the social context of their times. Nursing history is not an ornament to be displayed on anniversary days, nor does it consist of only happy stories to be recalled and retold on special occasions. Nursing history is a vivid testimony, meant to incite, instruct and inspire today's nurses as they bravely trod the winding path of a reinvented health care system

HISTORICAL OVERVIEW OF NURSING HISTORY

Issues nurse is better understand

1) Autonomy (being self directed)

unity w/in the profession, supply and demand, salary, education and current practices.

2) History- study of the past that includes events, individual events and situations

3) Empowerment

the process of enabling others to do for themselves

EVOLUTION OF NURSING

1) EARLY CIVILIZATION

* 4000 BC to primitive societies in which mother-nurses worked w/ priest.

* 2000BC –the use of wet nurses is recorded in babylonia and Assyria

2) Ancient Greece

The Ancient Greece built temples to honor Hygica ( the goddess of Health)- these temples were more like spas rather then hospital in that they were religious institutions governed by priests ( who were not nurses) attended to those in the temples. The nursing that was done by women was performed in the home

3) Roman Empire

* Hospital was first established in the Eastern Roman Empire( Byzantine Empire) St. Jerome was responsible through one of his disciples (FABIOLA) for introducing hospital in the west.

* Western hospitals were primarily religious and charitable institution housed in monasteries and convents.

* The caregiver had no formal training in Therapeutic modalities & and volunteered their time nursing the sick.

4) Middle ages

Hospitals in Byzantine cities were staffed primarily by paid male assistants and male nurses. During the medieval. These hospitals were established primarily as almhouse w/ care of the sick being secondary.

* These remain basically during the 11th – 12th centuries… when formal medical educ. for physician was required in a university setting.

Since there were not enough physician to care for the sick…other caregiver were not required to receive formal training.

Middle ages…..

The dominant caregiver in Byzantine were men, however this was not true in the rural areas of the eastern roman empire and in the west. In these societies nursing was viewed as a natural nurturing for women.

5) Renaissance

* During the Renaissance (AD 1400-1550)- interest in the arts and science emerge.

* Bec. of the renewed interest, universities were established, but no formal school of nursing were founded, bec. of social status and customs- women were not enc to leave their homes, they continued to fulfill the traditional role of nurture, caregiver in the home.

* Enlightenment and industrial revolution

o the industrial revolution introduced technology that led to proliferation of factories. Condition of factory workers were deplorable, long hours, grueling work and unsafe condition prevailed in the work place. The health status of the receive little attention.

* Medical schools were founded inc. the Royal College of Surgeon in London in 1800.

* In France men who were barber also function as surgeons by performing procedures such as leeching, giving enemas & extracting teeth.

* In the 18th century- thwere were no standard for nurses who worked in the hospital.

* In the early to mid 1800 nursing was unseemingly for women, even though some hosp. (almhouse)relied on women to make beds, scrub floors & bathe the poor. Most n/c were done at home by relative of the ill.

Religious Influences

* the strong influence of religious on the dev. of nursing started in India (800-600 bc) and flourished in Greece & Ireland w/ male nurse-priest.

* in 1836- Theodur Fleidner revived the church order of deaconesses to care for those in a hospital he had founded.

RELIGIOUS INFLUENCE

Fabiola, Marcela & Paula

* converts to christianity during the 3rd & 4rth century, used their wealth to provide houses of care and healing for the poor, the sick, and the homeless

* knights of St John, Teutonic Knights, Knight of St. Lazarus provided nursing care to the sick and injured, built hospital throughout Europe.

HISTORICAL……..

DATE EVENTS

1522---------------------- Military nursing orders

1600-1752-------------- Deterioration of hospital and nursing

1633---------------------- Founded daughter of charity

1820---------------------- Florence nightingale born

1826---------------------- Kaisewerth deaconesses reestablished

1837--------------------- First American College for Women

1841--------------------- Founded nursing sister of the Holy cross

1848--------------------- Womens right convention, Seneca falls- New York

1854-1856-------------- Crimean war

FLORENCENIGHTINGALE

- (also known as lady w/ a lamp) famous of her work in the military hospitals of the crimean war. She established nursing as a respectable profession for women.

1851- she went to kaissewerth in Germany for 3 mos nursing training

1853- became a superintendent of a hospital for gentle women in Harley st.

1854- crimean war

- seen reports on the newspaper were describing the desperate lack of proper medical facilities for wounded british soldiers of the front

- Sydney Herbert (war minister) asked her to oversee a team of nurses in the military hosp. in turkey.

1856- RETURNED TO ENGLAND, ESTABLISHED THE Nightingale training school for nurses at St Thomas Hospital in London.

The first theories to clearly articulate a role of nurses distinct fr medical profession was “Florence Nightingale”, her theories were developd during the crimean war & published in “Notes of Nursing WHAT IT IS AND WHAT IT IS NOT” in 1859. nightingale ideas is based on the idea that the nurse manipulates environment (cleanliness, sanitation, fresh air comfort and socialization were necessary to healings) to promote the patient’s well being.

VIRGINIA HENDERSON (1966)

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible.

AMERICAN NURSES ASSOCIATION
(ANA)

Nursing is the diagnosis and treatment of human responses to actual or potential health problems”

Describes nursing practice as:

“direct, goal oriented, and adaptable to the needs of the individual, the family, and community during health and illness”

CANADIAN NURSES ASSOCIATION (CNA)

“Nursing” or “the practice of nursing” means the identification and treatment of human responses to actual or potential health problems and includes the practice of and supervision of functions and services that, directly or indirectly, in collaboration with a client or providers of health care other than nurses, have as their objectives the promotion of health, prevention of illness, alleviation of suffering, restoration of health and optimum development of health potential and includes all aspects of the nursing process.

TOTAL PARENTERAL NUTRITION

2008-12-07T05:48:00.001-08:00

PENDAHULUAN
Nutrisi adalah proses dimana tubuh manusi menggunakan makanan untukmembentuk energi, mempertahankan kesehatan, pertumbuhan dan untuk berlangsungnya fungsi normal setiap organ dan jaringan tubuh (Rock CL, 2004).Status nutrisi normal menggambarkan keseimbangan yang baik antara asupan nutrisi dengan kebutuhan nutrisi (Denke, 1998; Klein S, 2004). Kekurangan nutrisi memberikan efek yang tidak diinginkan terhadap struktur dan fungsi hampir semua organ dan sistem tubuh (Suastika, 1992).

Terdapat 3 pilihan dalam pemberian nutrisi yaitu diet oral, nutrisi enteral dan nutrisi parenteral. Diet oral diberikan kepada penderita yang masih bisa menelan cukup makanan dan keberhasilannya memerlukan kerjasama yang baik antara dokter, ahli gizi,penderita dan keluarga. Nutrisi enteral bila penderita tidak bisa menelan dalam jumlah cukup, sedangkan fungsi pencernaan dan absorbsi usus masih cukup baik. Selama sistem pencernaan masih berfungsi atau berfungsi sebagian dan tidak ada kontraindikasi maka diet enteral (EN) harus dipertimbangkan, karena diet enteral lebih fisiologis karena meningkatkan aliran darah mukosa intestinal, mempertahankan aktivitas metabolik serta keseimbangan hormonal dan enzimatik antara traktus gastrointestinal dan liver.
Diet enteral mempunyai efek enterotropik indirek dengan menstimulasi hormon usus seperti gastrin, neurotensin, bombesin, enteroglucagon. Gastrin mempunyai efek tropik pada lambung, duodenum dan colon sehingga dapat mempertahankan integritas usus,mencegah atrofi mukosa usus dan translokasi bakteri, memelihara gut-associated lymphoid tissue (GALT) yang berperan dalam imunitas mukosa usus (Shike, 1996;Bruera, 2003; Rombeau, 2004; Trujillo, 2005; Boediwarsono, 2006).
Nutrisi Parenteral adalah suatu bentuk pemberian nutrisi yang diberikan langsung melalui pembuluh darah tanpa melalui saluran pencernaan.Para peneliti sebelumnya menggunakan istilah hiperalimentasi sebagai pengganti pemberian makanan melalui intravena, dan akhirnya diganti dengan istilah yang lebih tepat yaitu Nutrisi Parenteral Total, namun demikian secara umum dipakai istilah Nutrisi Parenteral untuk menggambarkan suatu pemberian makanan melalui pembuluh darah.Nutrisi parenteral total (TPN) diberikan pada penderita dengan gangguan proses menelan, gangguan pencernaan dan absorbsi (Bozzetti, 1989; Baron, 2005; Shike 1996;Mahon, 2004; Trujillo, 2005).
Pemberian nutrisi parenteral hanya efektif untuk pengobatan gangguan nutrisi bukan untuk penyebab penyakitnya.Status nutrisi basal dan berat ringannya penyakit memegang peranan penting dalam menentukan kapan dimulainya pemberian nutrisi parenteral. Sebagai contoh pada orang-orang dengan malnutrisi yang nyata lebih membutuhkan penanganan dini dibandingkan dengan orang-orang yang menderita kelaparan tanpa komplikasi.
Pasien-pasien dengan kehilangan zat nutrisi yang jelas seperti pada luka dan fistula juga sangat rentan terhadap defisit zat nutrisi sehingga membutuhkan nutrisi parenteral lebih awal dibandingkan dengan pasien-pasien yang kebutuhan nutrisinya normal.Secara umum, pasien-pasien dewasa yang stabil harus mendapatkan dukungan nutrisi 7 sampai dengan 14 hari setelah tidak mendapatkan nutrisi yang adekuat sedangkan pada pasien-pasien kritis, pemberian dukungan nutrisi harus dilakukan dalam kurun waktu 5 sampai dengan 10 hari (ASPEN, 2002).
Berdasarkan cara pemberian Nutrisi Parenteral dibagi atas (ASPEN, 1995):
1.Nutrisi Parenteral Sentral.
2.Nutrisi Parenteral Perifer.

TUJUAN
1. Menyediakan nutrisi bagi tubuh melalui intravena,karena tidak memungkinkannya saluran cerna untuk melakukan proses pencernaan makanan.
2. TPN digunakan pada pasien dengan luka bakar yang berat,pancreatitis,inflammatory bowel syndrome,inflammatory bowel disease,ulcerative colitis,acute renal failure,hepatic failure,cardiac disease,pembedahan dan cancer.
3. Mencegah lemak subcutan dan otot digunakan oleh tubuh untuk melakukan katabolisme energy.

DASAR FISIOLOGI
1.Apabila di dalam aliran darah tidak tercukupi kebutuhan nutrisinya,kekurangan kalori dan nitrogen dapat terjadi.
2.Apabila terjadi defisiensi nutrisi,proses glukoneogenesis akan berlangsung dalam tubuh untuk mengubah protein menjadi karbohidrat.
3.Kebutuhan kalori Kurang lebih 1500 kalori/hari,diperlukan oleh rata-rata dewasa untuk mencegah protein dalam tubuh untuk digunakan.
4.Kebutuhan kalori menigkat terjadi pada pasien dengan penyakit hipermetabolisme,fever,injury,membutuhkan kalori sampai dengan 10.000 kalori/hari.
5.Proses ini menyediakan kalori yang dibutuhkan dalam konsentrasi yang langsung ke dalam system intravena yang secara cepat terdilusi menjadi nutrisi yang tepat sesuai toleransi tubuh.

Indikasi Nutrisi Parenteral :
1. Sebagai pengganti untuk oral nasogastrik,bila ini tidak efektif,tidak memungkinkan dan berbahaya.TPN digunakan dalam kondisi sebagai berikut:
Kronik vomiting
Cancer,radiotherapy atau chemoteraphy
Stroke
Anorexia nervosa
2. Sebagai supplemen untuk pasien yang kehilangan banyak nitrogen ( pasien dengan luka bakar,kanker metastatic,radiasi dan chemoteraphy.
- Mengistirahatkan gastrointestinal :
Gastrointestinal fistula,
Extensive inflammatory bowel disease
Intestinal resection
Intestinal obstruction
Multiple gastro intestinal surgery,gastro intestinal trauma,intolerance enteral feeding yang berat.
Pemberian nutrisi parenteral secara rutin tidak direkomendasikan pada kondisi-kondisi klinis sebagai berikut :
Pasien-pasien kanker yang sedang menjalankan terapi radiasi dan kemoterapi.
Pasien-pasien preoperatif yang bukan malnutrisi berat.
Pankreatitis akut ringan.
Kolitis akut.
AIDS.
Penyakit paru yang mengalami eksaserbasi.
Luka bakar.
Penyakit-penyakit berat stadium akhir (end-stage illness).

INTRAVENOUS SITES
A. Central Parenteral Nutrition
1. Diberikan melalui central venous,bila konsentrasi > 10% glukosa.
2. Subclavian atau internal vena jugularis digunakan dalam waktu singkat sampai < 4minggu.
3. jika > 4 minggu,diperlukan permanent cateter seperti implanted vascular access device.
B. Periferal Parenteral Nutrition (PPN)
1. PPN diberikan melalui peripheral vena.
2. PPN digunakan untuk jangka waktu singkat 5 -7 hari dan ketika pasien perlu konsentrasi kecil dari karbohidrat dan protein.
3. PPN digunakan untuk mengalirkan isotonic atau mild hypertonic solution.High hypertonic solution dapat menyebabkan sclerosis,phlebitis dan bengkak.

JENIS NUTRISI PARENTERAL
LIPIDS (FAT EMULSION)
Lipid diberikan sebagai larutan isotonis yang dapat diberikan melalui vena perifer .
Lipid diberikan untuk mencegah dan mengoreksi defisiensi asam lemak.
Sebagian besar berasal dari minyak kacang kedelai,yang komponen utamanya adalah linoleic,oleic,palmitic,linolenic,dan stearic acids.
Jangan menambah sesuatu ke dalam larutan emulsi lemak.
Periksa botol terhadap emulsi yang terpisah menjadi lapisan lapisan atau berbuih,jika ditemukan,jangan digunakan,dan kembalikan ke farmasi.
Jangan menggunakan IV filter karena partikel di emulsi lemak terlalu besar untuk mampu melewati filter.
Filter 1.2 μm atau lebih besar digunakan untuk memungkinkan emulsi lemak lewat melalui filter.
Gunakan lubang angin karena larutan ini tersedia dalam kemasan botol kaca.
Berikan TPN ini pada awalnya 1 ml/menit,monitor vital sign setiap 10 menit dan observasi efek samping pada 30 menit pertama pemberian.
Jika ada reaksi yang tidak diharapkan ,segera hentikan pemberian dan beritahu dokter.
Jika tidak ada reaksi yang tidak diharapkan,lanjutkan kecepatan pemberian sesuai resep.
Monitor serum lipid 4 jam setelah penghentian pemberian.
Monitor terhadap tes fungsi hati, untuk mengetahui kegagalan fungsi hati dan ketidakmampuan hati melakukan metabolism lemak.
Karbohidrat
Yang terutama dalam bentuk glukosa dari 5% (peripheral)sampai dengan 50% -70% (Central venous parenteral).
Vitamin
Mineral
Elektrolit

JENIS NUTRISI PARENTERAL YANG TERSEDIA ANTARA LAIN :
1. Clinimix N9G15E adalah larutan steril, non pirogenik untuk infus intravena. Dikemas dalam satu kantong dengan dua bagian: satu berisi larutan asam amino dengan elektrolit, bagian yang lain berisi glukosa dengan kalsium.
Tersedia dalam ukuran 1 liter
Composition
Nitrogen (g) 4.6 Asam Amino (g) 28 Glukosa 75 (g) 75 Total kalori (kkal) 410 Kalori glukosa (kkal) 300 Natrium (mmol) 35 Kalium (mmol) 30 Magnesium (mmol) 2.5 Kalsium (mmol) 2.3 Asetat (mmol) 50 Klorida (mmol) 40 Fosfat dalam HPO4-- (mmol) 15 pH 6 Osmolaritas (mOsm/l) 845
2. Cernevit adalah preparat multivitamin yang larut dalam air maupun lemak (kecuali vitamin K) dikombinasi dengan mixed micelles (glycocholic acid dan lecithin). Mengingat kebutuhan vitamin tubuh yang mungkin berkurang karena berbagai situasi stress (trauma, bedah, luka bakar, infeksi) yang dapat memperlambat proses penyembuhan.

Composition
Setiap vial mengandung:
Retinol Palmitat Amount corresponding to retinol 3.500 IU, Cholecalciferol 220 IU, DL alphatocopherol 10.200 mg ,Amount corresponding to alphatocopherol 11.200 IU,Asam Askorbat 125.000 mg, Cocarboxylase tetrahydrate 5.800 mg ,Amount corresponding to thiamine 3.510 mg ,Riboflavine sodium phosphate dihydrate 5.670 mg ,Amount corresponding to riboflavine 4.140 mg, Pyridoxine Hydrochloride 5.500 mg ,Amount corresponding to Pyridoxine 4.530 mg, Cyanocobalamine 0.006 mg, Asam Folat 0.414 mg ,Dexpanthenol 16.150 mg, Amount corresponding to Pantothenic Acid 17.250 mg ,Biotin 0.069 mg, Nicotinamide 46.000 mg, Glisin 250.000 mg ,Glycoholic Acid 140.000 mg Soya Lecithin 112.500 mg, Sodium hydroxide q.s. pH=5.9.

TINDAKAN KEPERAWATAN
1. Keluarkan Cairan TPN dari dalam lemari es 30 menit sebelum prosedur.
Rasional : cairan yang dingin dapat menyebabkan nyeri, hypothermia,spasme vena dan konstriksi.
2. Bandingkan isi botol dengan resep dokter.
Rasional: ingat 7 rights(right patient, dose,route,medicine,time,purpose ,documentation)
3. Observasi larutan terhadap kejernihan, adanya partikel dan keburaman.
Rasional: larutan yang buram kemungkinan sudah terkontaminasi
4. Mulai pemberian TPN dengan pelan-pelan .
Rasional :larutan TPN berisi kadar glukosa yang tinggi.Aliran yang pelan memungkinkan sel beta pancreas untuk beradaptasi dengan meningkatkan sekresi insulin nya.
5. Ambil urine specimen setiap 6 jam untuk tes glukosa dan acetone
Rasional:laporkan ke dokter jika glukosa lebih dari 2+
6. Catat intake dan output
Rasional:untuk mengetahui keseimbangan cairan tubuh.

TINDAKAN KEPERAWATAN DALAM PENCEGAHAN KOMPLIKASI
1. Untuk mengurangi dan mencegah terjadinya infeksi:
Larutan disiapkan setiap hari dan dalam keadaan segar,simpan dalam lemari es sampai dengan digunakan.
Jaga kesterilan selama procedure untuk mencegah sepsis
Monitor vital sign dan tanda –tanda infeksi yaitu menggigil,leukosit meningkat, erytema dan keluar cairan dari tempat insersi,demam.
Gunakan teknik aseptic karena larutan TPN mempunyai glukosa konsentrasi tinggi yang merupakan media bacteria untuk tumbuh.
Monitor temperature,jika ada fever,curigai adanya sepsis.
Kaji tempat insersi vena,terhadap kemerahan,bengkak, lunak,dan drainage .
Ganti larutan TPN setiap 12 -24 jam atau sesuai dengan protokol
Lakukan dressing di tempat insersi setiap 48 jam atau sesuai protokol.
Cabut IV cateter,dan lakukan pemasangan kembali ditempat lain.
Jika tanda infeksi terjadi di tempat insersi,lakukan hal- hal sebagai berikut;
 Ambil ujung IV cateter dan kirim ke laboratorium untuk pemeriksaan cultur.
 Siapkan pasien untuk pengambilan cultur darah.

2. Fever
jika pasien terdapat fever setelah pemberian TPN,hentikan pemberian TPN dan ganti dengan 10%dextrose in water sesuai dengan resep dokter.
jika fever kemudian turun,dalam 4-6 jam,kemungkinan demam berhubungan dengan larutan yang diberikan.
jika fever tetap ada,kemungkinan cateter-related-sepsis.
sampel darah dan urine diperlukan untuk mengetahui penyebab infeksi

3. Emboli udara dan pneumothorax
Tanda –tanda emboli udara:
dyspnea,chest pain,tachycardia,hypotension,cyanosis,seizure,coma,cardiac arrest.
jika diduga terjadi emboli udara,posisikan pasien kearah kiri dalam trendelenberg,berikan oksigen sesuai protocol.
Perintahkan pasien untuk melakukan valsava maneuver ketika penggantian tube dan cap.
Ketika melakukan penggantian tube dan cap,posisikan pasien dengan kepala di bawah (jika tidak kontra indikasi) dengan kepala menoleh ke arah yang berlawanan dengan tempat insersi (untuk meningkatkan tekanan vena intra torakal).
Pneumothorax
Monitor tanda-tanda pneumothorax.
Setelah pemasangan cateter lakukan x-ray untuk memastikan ketepatan lokasi insersi cateter dan untuk mendeteksi adanya pneumothorax.
Pemberian TPN tidak akan dilaksanakan sampai verifikasi ketepatan letak cateter dan tidak adanya pneumothorax.
Setelah pasti tidak ada pneumothorax dan posisi tepat,barulah dimulai pemberian TPN.
Tanda – tanda pneumothorax
Tidak ada suara nafas ditempat yang terkena.
Nyeri dada dan atau pundak
Pernafasan yang tiba-tiba pendek
Tachycardia
Jika diduga terjadi emboli udara , lakukan hal -hal berikut :
Klem,cateter intra vena
Posisikan pasien terlentang miring kekiri,dengan kepala lebih rendah dari posisi kaki.
Beritahu dokter
Berikan oksigen sesuai resep.

4. Fluid Overload
 Terjadi jika pasien mendapatkan pemberian dengan tetesan terlalu cepat
 TPN selalu diberikan melalui infusion pump
 Monitor intake dan output
 Ukur berat badan pasien tiap hari.
5. Hyperglikemia
 Kaji riwayat pasien tentang glucose intolerance
 Kaji riwayat terapi pasien (corticosteroid kemungkinan dapat meningkatkan kadar gula darah)
 Mulai pemberian TPN dengan slow rate (biasanya 40 – 60 ml/jam).
 Monitor kadar glukosa darah tiap 4 – 6 jam.
 Berikan insulin secara teratur sesuai resep.
6. Hypoglikemia
 Lanjutkan monitor glukosa darah.
 Penghentian pemberian TPN secara bertahap.
 Ketika pemberian glukosa tinggi dihentikan,infuse dextrose 10% diberikan selama 1 -2 jam untuk mencegah hypoglikemia.
 Cek gula darah 1 jam setelah penghentian TPN.
 Siapkan pemberian glukosa jika hypoglikemia terjadi.

NURSING CONSIDERATION
Selalu cek larutan TPN dengan resep dokter.
Untuk mencegah infeksi dan solution incompability,jangan memberikan terapi obat-obatan IV,melalui jalur TPN.
Monitor partial thromboplastin time dan prothrombin time untuk pasien yang mendapat anticoagulant.
Monitor elektrolit,albumin,dan fungsi hati serta ginjal.
Pada pasien dengan dehidrasi yang berat,kemungkinan serum albumin akan turun sebagai kompensasi tubuh untuk rehidrasi cairan.
Larutan TPN harus di simpan di lemari es dan diberikan dalam 24 jam dari waktu awal persiapan,keluarkan 30 menit sampai 1 jam sebelumnya.

Prosedure pemasangan
Nursing Action
Keluarkan cairan TPN 30 menit sebelum prosedure dilakukan
Sambungkan pump tube,filter dan extension tube
Gunakan teknik aseptik saat insert pump tubing ke TPN container
Jelaskan prosedure kepada pasien,dan jangan menyentuh tempat insersi cateter
Atur posisi pasien dengan kepala lebih rendah
Perintahkan pasien untuk memalingkan wajah dari tempat insersi yang telah dipilih

Rational
Pemberian cairan yang dingin dapat menyebabkan nyeri,,hypothermia,spasme vena dan konstriksi
Mencegah tercabut
Mencegah accidental separation dan potensial emboli udara
TPN adalah media bagi tumbuh bakteri
Mencegah cateter terkontaminasi
Posisi ini memungkinkan dilatasi pembuluh darah leher dan bahu yang membuat pemasangan lebih mudah dan mencegah emboli udara
Untuk mencegah kontaminasi di tempat TPN

Nursing Action
Gunakan masker dan gown
Support posisi pasien dengan ekstensi bahu
Jika perlu cukur rambut
Desinfeksi area yang dipilih dengan cara memutar dari arah dalam ke luar selama 2 menit
Lakukan injeksi lokal anestesia (oleh dokter)
Needle ditusukkan dibawah klavikula ke vena subklavikula
Perintahkan pasien untuk melakukan valsava manuever

Rasional
Memungkinkan area TPN tetap steril
Dapat menggunakan handuk,atau rolled sheet secara vertikal sepanjang vertebra spinal
Mengurangi kemungkinan kontaminasi
Mencegah infeksi
Membuat pasien nyaman dan mencegah gerakan pasien
Vena subclavia dipilih karena akan tersambung dengan vena cava superior yang mempunyai bloodflow yang besar dan memungkinkan dilusi larutan yang cepat
Memberikan tekanan positif,mencegah emboli udara saat cateter dimasukkan

Nursing action
Masukkan cateter dan cabut needle,sambungkan cateter dengan tubing
Cateter di jahit dengan jaringan kulit sekitar
Bersihkan tempat insersi dengan povidone iodine,oleskan povidone iodine ointment dan tutup dengan kasa steril pada tempat insersi
Dokumentasikan ukuran cateter,tanggal,waktu pemasangan dan jenis solution nya
Observasi tanda-tanda tromboplebitis,edema,erytema ditempat insersi cateter,juga swelling di leher,lengan,wajah sepanjang vena
Ganti dressing tiap 72 jam atau sesuai kebutuhan.

Rational
Memungkinkan cateter yang flexible tetap berada di tempatnya.
Mencegah tercabutnya cateter
dapat membuat efek antimikrobial lebih lama
Memudahkan observasi dan orientasi waktu pemasangan
Jika ini terjadi,beritahu dokter
Mencegah terjadinya infeksi

Referensi :
Practical Aspects of Nutritional Supports: an Advanced Practice Guide. Saunders, 2004.
Modern Nutrition in Health and Disease, 9th edition. Lippincott Williams & Wilkins, 1999.
The Lippincott Manual of Nursing Practice,5th Edition,1991
Linda Anne Silvestari,Comprehensive Review for the NCLEX-RN examination,Saunders,2005

LINK:
http://www.palliative-surabaya.com/gambar/pdf/buku_pkb_vi-bagian_1308082008.pdf
http://www.kalbefarma.com/index.php?mn=product&tipe=detail&jenis=adv&detail=60
http://en.wikipedia.org/wiki/Image:Triple-Lumen.jpg