Asuhan Keperawatan Pasien dengan

Tindakan Diagnostik Invasif dan INB

Uup Harianto
Uup Harianto, S.Kep, Ners
uupharianto@yahoo.co.id
 OBJECTIVES
➢ Orientation to the Cathlab
➢ Three main roles for cath lab
nurses
➢ Nursing Care of Patients Undergoing
Cardiac Catheterization Procedures
 DEFINITION
Catheterization is an invasive
diagnostic examination in patients
suspected of having heart and / or
blood vessel abnormalities
(KATHERINE, 1989)
History of Cardiac Catheterization
Cardiac catheterizations in animals. 1840-
1900.
In 1844, first cardiac catheterization was performed
on a horse by Claude Bernard, a French
physiologist .

First human catheterization. In 1929, at age 25,

Werner Forssmann passed a 65 cm catheter through
one of his left antecubital veins until its tip entered
the right atrium, with the help of the nurse Ms.
Gerda Dizen. Then he walked to the radiology
department where a roentgenogram was taken.
 Cont…

Cournand was awarded the Nobel Prize in

Physiology or Medicine in 1956 along with Werner
Forssmann and Dickinson W. Richards for the
development of cardiac catheterization. Born in Paris,
Cournand emigrated to the United States in 1930
and, in 1941, became a naturalized citizen
 Cont…
Percutaneous arterial puncture.
In 1953, introduced a technique for
percutaneous arterial puncture and
catheter replacement of the needle over a
flexible wire
Sven-Ivar Seldinger

The birth of coronary

angioplasty. 16 September 1977
performed the first angioplasty
procedure in a 38-year-old
patient, in a single discrete lesion in
the proximal LAD artery
Andreas Gruentzig
History of Cardiovascular Intervention in Indonesia
Cathlab in Indonesia (2019)
 Jumlah tindakan
5000
4846 4808
4800

4600

4400 4347
Tahun 2018
4200 4137 tahun 2019
4000

3800

3600
Diagnostik invasif Intervensi Non Bedah

Sumber : RS Jantung dan Pembuluh Darah Harapan Kita

Indikasi Kateterisasi
➢ Seluruh Penyakit Jantung yang memerlukan
Operasi
➢ Penyakit Jantung Bawaan: Biru dan Tidak Biru
➢ Penyakit Jantung Koroner: UAP, AP, riwayat MCI.
➢ Disrythmia
➢ Kelainan pembuluh darah/vaskular
Contraindications
Absolute: Patient refuses
Relative : Need to consider risk-to-benefit ratio
❖ Severe uncontrolled HTN
❖ Ventricular dysrhythmias
❖ Acute stroke
❖ Unexplained febrile
illness &/or untreated
active infection
❖ Active gastrointestinal
bleed
❖ Acute renal failure
❖ Uncompensated HF
❖ Electrolyte imbalance
❖ Severe coagulopathy
❖ Severe anemia
❖ Allergy to radiographic
contrast
Complications and Risks
- Death
- Myocardial infarction
- CVA
- Arrhythmia
- Hemorrhage
- Contrast
- Hemodynamic
- Perforation
- CIN
- Haematom
 Tim yang melakukan prosedur

• Kardiolog Intervensi
• Perawat
• Tekhnisi KV
• Radiografer
Alat–alat dan perlengkapan Angiografy

➢ Kateter
➢ Contrast Media
➢ Pressure Injector
➢ Sistem X-Ray
Coronary Angiography

• Memungkinkan untuk
mengevaluasi tingkat
stenosis (penyempitan)
intracoronary
Coronary Angiography
ARTERI/VENOGRAPHY
Kateterisasi Jantung Kanan (Diagnostik)
Pengukuran tekanan dan Angiografy
digunakan untuk :
• Menentukan penyakit katup jantung
• Gagal jantung kongestif
• Hipertensi pulmonal
• Kardiomiopati
• Kelainan kongenital
Kateterisasi Jantung Kanan
(Diagnostik)
Biopsy
• Digunakan untuk memonitor
transplantasi jantung terhadap
penolakan jaringan
• Untuk membedakan antara
berbagai jenis kardiomiopati
Pemeriksaan Sistim Konduksi
Mulipolar catheters dimasukkan ke
dalam :
•High Right atrium dekat sinus
node
•Atrioventricular apex
•Coronary sinus
Pemeriksaan Sistim Konduksi
1. Kadang-kadang 3 selubung introducer ditempatkan
dalam satu vena :
• Femoral
• Vena jugularis interna
• Vena subklavia

2. Katoda melayani fungsi ganda :

• Mencatat signal listrik
• Pacu Jantung
KELAINAN VASKULAR
• ARTERIOGRAPHY
• VENOGRAPHY
Interventional Procedures
Percutaneous Coronary Intervention
(PCI)
• Balon angioplasty

• Stenting arteri
koroner

• Aterectomy
(rotablator)

• IVUS, FFR dan IFR

Percutaneous Translumina Angioplasty(PTA)
➢ Angioplasti
transluminal perkutan
(PTA) adalah prosedur
yang dapat melebarkan
pembuluh darah
tersumbat
menggunakan kateter,
guide wire, ballon,
serta stent jika
diperlukan

➢ Trombectomy
(angiojet, manual)
EVAR/TEVAR
Intervensi non bedah
pada kasus diseksi
atau aneurisma aorta
CATHETER DIRECT THROMBOLITIC
(CDT)

Tindakan trombolitik
pada kasus akut limb
iskemik atau deep vein
trombosis (DVT)
Permanent Pacemaker
Alat Antiarrhythmic :
❖ Pacemakers
❖Implantable cardioverter
defibrillators
CXR with Pacemaker
CARDIAC ABLATION
Ablasi pada jantung adalah suatu
tindakan yang digunakan untuk
menghancurkan atau
“membakar” satu atau beberapa
area kecil di jantung Anda yang
menjadi sumber timbulnya
masalah irama jantung (aritmia).
Pemasangan ASO, ADO, AVO
➢ Tahun 1995
➢ Radiologis - Austria : dr. Kurt Amplatz
➢ Menemukan alat penutup defek jantung yang diberi
nama “Amplatzer”
➢ pertama kali digunakan penutup defek sekat atrium
(ASD) : Amplatzer Septal Occluder (ASO).
➢ penutup sekat di ventrikel :Amplatzer Ventricular
Occluder (AVO)
➢ penutup saluran antara pembuluh besar aorta dan
pulmonal yaitu Amplatzer Ductal Occluder (ADO).
Transcatheter Closure of Septal Defects
1. Occlusion of ASD
Transcatheter Closure of Septal Defects
2. Occlusion of VSD
Occlusion of VSD
3. Occlusion of PDA
BALLOON MITRAL VALVULOPLASTY (BMV)

❖ BMV adalah prosedur yang

dilakukan untuk melebarkan
(dilatasi) katup mitral yang
sempit (stenosis).

❖Dilakukan dengan meletakkan

balon pada katup Mitral dan
kemudian balon
dikembangkan.
Interventional Procedures of the Vascular System: Children

• Balloon Septostomy untuk

melebarkan patent foramen ovale

• Ini memungkinkan mixing/

percampuran darah jantung kanan
dan kiri
– Menghasilkan perbaikan oksigenasi
arterial

• Balloon dimasukan ke atrium kiri

melalui lubang septal atrial,
Dikembangkan dengan cairan dan
kemudian ditarik melalui lubang
– Menyebabkan septum robek
Sistem MitraClip adalah pendekatan invasif minimal untuk
memperbaiki katup mitral dan mengobati regurgitasi mitral,
secara nonsurgical.
MitraClipp
 TAVI
Trans Aortic Valve Intervention
The Patient: Admission Strategy

Admission Admission
Ambulatory
to ward to the CCU
The Patient: Ambulatory Procedures
Ambulatory Procedures Ambulatory

Diagnostic catheterization

Not complex” or one vessel PCI

Radial

Femoral with closure device

Cardiac day unit (2-4-6-12 hours)

The Patient: CCU Admission
Admission to CCU

Severe

Complications

risk NSTEMI

TAVI
 The Cath Lab Professional: Role

The staff members should hold certifications in advanced cardiac

life support and management of x-ray equipment
Role - The cath lab
professional is There are different accreditations being developed to certify the
responsible for assisting knowledge of the professionals working in cardiac cath lab units
the physician when
performing procedures in All the different cath lab professionals must understand the role
the cardiac of their colleagues
catheterization unit
The three main roles for cath lab nurses worldwide are: Scrub,
Circulate, Monitor
 The Cath Lab Professional: Scrubbing
The scrub nurse must show
good knowledge of the
sterile surgical technique to
reduce infections
Assists with materials to
perform PCI: Performing
contrast injections, Setting
fluoroscopic projections,
Using the inflation device to
inflate balloons and stents
Checks for PCI
complications and prepares
the adequate materials and
devices to resolve them,
such as: Pericardiocentesis
kit, IABP, stent graft
Prepares the sterile table/field
and assist beside the Prepares the contrast injector
physician, participating in the and the pressure system
procedure
Prepares all the support Injects medications such as
devices for PCI, including NTG, IIB-IIIA inhibitors and
IVUS, OCT, FFR or rotational other medication through the
atherectomy catheters
Prepares complex devices for
implantation in structural and
congenital interventions, such
as: THV, devices for ASD,
VSD, PFO, PDA and LAA
occlusion
 The Cath Lab Professional: Circulating

Person Transfers Gives Check the

Manages
responsible the patient materials to Administers patient Detect
non sterile medications complications
for room to table and the scrub state at all
equipment
preparation monitors nurse times
The Cath Lab Professional: Circulating
In case of
haemodynamic
instability, must
prepare/administer
medications and
prepare devices

• Dopamine
• Dobutamine
Drugs commonly • Epinephrine
used in the lab: • Norepinephrine
• Analgesia /
antiarrhythmics

• Defibrillator
• Temporary
Devices commonly pacemaker
used in the lab • IABP
• Mechanical
ventilation
 The Cath Lab Professional: Monitoring
Adjust
Assess and antithrombotic
Avoid crossover
document therapy doses
between UFH
bleeding risk in based on
and LMWH
every patient weight and renal
function

Check
Adopt selective
Stop Clopidogrel
Add UFH when downstream use of
anticoagulation loading dose
Fondaparinux GPIIb–IIIa inhibitors,
after PCI unless given when
was as required in the
a specific using
administered catheterization
indication exists Bivalirudin
laboratory
monotherapy
 The Cath Lab Professional: Monitoring

Valvular stenosis

Diastolic dysfunction
Responsible for
identifying ,
recording and
measuring Intracardiac shunt
correctly
haemodynamic
data necessary
to evaluate: Other diseases, such as
pulmonary hypertension

The monitoring cath lab professional assists in the evaluation

process by providing accurate haemodynamic data
The Cath Lab Professional: Staffing Models
Cath lab nurses circulating,
scrubbing and monitoring

Radiological technicians or radiographers

Division of roles managing X-ray equipment
with cath lab
nurses and
technicians
Cardiovascular technicians in some places use IVUS,
pressure wire and other devices

Professionals can not rotate roles and always perform

the same job. It is not a good model if your lab is short
on staff
 The Cath Lab Professional: Training
The number of professionals and roles working in each lab may vary

It can be 2, 3 or even 4 professionals in each lab doing the same role all the time or switching
roles

Sometimes one professional is doing more than one role in the same case, like circulating and
monitoring – this is not recommended

It is recognised worldwide that the best patient care is given when professionals cross-train

They are prepared to work It is easier to cover staff needs Overuse and repetitive injuries can
in each area of the lab in busy laboratories be prevented exchanging roles
rather than doing always the same
work
Scrubbing Role
• Prepare a sterile trolley with appropriate equipment
• Maintain a sterile field to prevent cross-infection
• Ensure all catheters are flushed with heparinised saline to prevent
clots and air embolism
• Assist the operator ensuring hospital protocol are adhered to
procedure
• Safe disposal of sharps and
blood contaminated
equipment
• Monitor patient’s vitals
 ScrubbingRole Contd …

• The scrub stands at the table alongside the physician and prepares
the sterile field
• He / She will assist with the materials needed to perform the PCI:
• Injector, wires, catheters, stent and indeflator
• Maintains sterile technique at all times
• Check for PCI complications
• Inject medications such as NTG, GP IIB/IIIA inhibitors and other
medication
through the catheters
ScrubbingRole Contd …

• Know your anatomy

• Especially aorta size and shapes
• Coronary take of
• Know your kit
• Wires and catheters
 Diagnostic Procedure: Scrub Role
• During the diagnostic procedure, the scrub may:
➢ Assist the physician by performing adequate injections of the
arteries (non-culprit vessel first in STEMI)
➢ Assist is getting the necessary projections, allowing good
visualization of the culprits vessel or segment stenosis
➢ Help to identify:
❑ Culprit vessel or coronary stenosis
❑ Location of the occlusion/ lesion
❑ Morphology of the lesion
PCI Procedure: ScrubRole
• During the intervention, the scrub may need to:
• Prepare the necessary devices to the perform PCI
• Assist in performing contrast test injections
• Set the adequate projections to treat the stenosis
• Asses the flow (TIMI 0, I, II, III)
• Identify complications associated with PCI and the
nursing interventions needed should they arise
(dissections or perforations)
• Prevent thrombus or air embolization at all times
PCI Procedure : PreventingThrombus/Air

• To prevent thrombus/ bleeding balance

• Maintain a good knowledge of any anti platelets and
anticoagulant given prior to the PCI
• Bases on that information, administer additional
anticoagulation as needed
• To prevent air
• Ensure correct preparation of the injection/pressure
system, avoiding air at all times
• Ensure adequate blood backflow in the catheter, prior to
injecting
Monitoring Room
 Hemodynamic Monitoring
• The hemodynamic component of the cardiac
catheterization procedure focuses on pressure
measurement, the measurement of flow and the
determination of vascular resistance
• Accurate recording of pressure waveforms and
correct interpretation of physiological data
derived from these waveforms are major goals
of cardiac catheterization
• Hemodynamic pressure measurements are to
evaluate heart function
• A pressure wave is the cyclical force generated by cardiac
muscle contraction
Persiapan pasien Pre Tindakan
➢ Administrasi: Kelengkapan data
administrasi maupun status → informed
consent

➢ Riwayat sebelumnya :
• Perdarahan
• Alergi terhadap obat-obatan
• Reaksi terhadap kontras
➢ Mental: penjelasan dan pendidikan
kesehatan bagi pasien dan keluarga
Cont’ Persiapan pasien pre tindakan

➢ Puasa makan 3 - 4 jam,

minum & Obat-obatan tetap
diberikan
➢ Hydrasi
➢ Berat badan, tinggi badan, tanda2
vital
➢ Lab:Elektrolit, Fungsi Renal,
HbSAg, Hematology
➢ Cukur lipatan paha
➢ Cek Pulse :Pedal, Radial
➢ IV Line, terutama intervensi &
anak
➢ EKG, Foto Thorax
Cont’ Persiapan pasien pre tindakan

Kaji tentang Obat-obatan :

• double antiplatelet (Plavix & aspirin)
pada tindakan PCI
• Lasix : konfirmasi dengan dokter
• Betablockers dan Antihypertensives
tidak apa – apa diberikan.
• Anticoagulants : konfirmasi dengan
dokter
• Obat Insulin dan Diabetic :
konfirmasi dengan dokter
Cont’ Persiapan pasien pre tindakan

➢ Periode Menstruasi terakhir atau

kemungkinan hamil
➢ Kateterisasi sebelumnya yang
mempunyai efek terhadap akses
vaskuler → Jaringan parut yang luas
(Extensive scar tissue), membuat
sheaths & dilators sulit lewat & seringkali
memerlukan dilation.
Selama Tindakan
➢ Lakukan Sign in, Time out dan Sign out
➢ Hemodinamik dan EKG dipantau secara ketat.
Perawat berada di sekitar pasien
sampai prosedur ini selesai.
Pasien disarankan untuk tidak bergerak selama
angiogram.

➢ Jika Angioplasti Koroner ....

▪ Pastikan pasien dengan antiplatlet ganda
▪ Heparin 100 ui/KgBB
▪ Memantau ACT optimal pada 300sec - 350sec → setiap 1 jam
▪ Memantau jumlah kontras digunakan (300 - 350 ml / prosedur)
▪ Periksa EF%
➢ Pada akses radial, sheath akan dicabut di ruang cathlab (diagnostik & PCI)
Post Catheterization Care

Hemostasis pada area penusukan:

- Radial → dengan alat
- Brachial → Penekanan manual
dengan tangan
- Femoralis → Penekanan manual
dengan penekanan tangan atau
alat selama 15 – 30 menit
Cont’

➢ Hidrasi
➢ Pemantauan terhadap tanda –
tanda vital perdarahan, hematome
setiap 15 menit dalam 1 jam
pertama, setiap 30 menit dalam jam
ke 2, setiap 1 jam selama 2 jam ,
setiap 4 jam sampai pasien stabil.
➢ Untuk pasien ODC (One Day Care)
Pasien akan diamati di ruang
pemulihan selama 4 jam
 Perawatan di ruang rawat
➢ Pasien diperbolehkan untuk makan dan minum
➢ Anjurkan untuk banyak minum jika tidak ada
kontraindikasi
➢ Tanda vital dipantau setiap 4 jam
➢ Amati reaksi alergi; urtikaria, sakit kepala, muntah
➢ Amati area tusukan terhadap perdarahan dan
hematoma
➢ Amati nyeri dada terutama pada pasien
pasca PCI, Untuk segera diinformasikan ke dokter
Perawatan lokasi pungsi
Hemostasis pada area penusukan:
❖ Radial & brakialis:
- mencabut segera sheath arteri
❖ Femoralis:
- pencabutan sheath Segera jika tidak
diberikan heparin selama prosedur, jika selama
prosedur mendapat Heparin, sheath akan dicabut
jika ACT di bawah < atau =100 secs.
Cont’ Perawatan Luka Pungsi

➢ Penilaian pulsasi distal:

Dorsalis pedis & radial / ulna arteri harus
dirasakan
➢ Untuk tusukan arteri femoralis & brakialis
Menilai perfusi - warna, temp, sensasi
➢ Observasi perdarahan pada tempat tusukan
➢ Istirahat: area tusukan arteri femoralis - minimal
6 jam
Hal2 yg harus dihindari pada area tusukan
A. Femoralis:
❖ Jangan mengoperasikan mesin berbahaya selama 24 jam.
❖ Jangan mengemudi selama 24 jam
❖ Jangan naik tangga atau mengangkat benda berat lebih
dari 5 kg selama 48 jam
❖ Batasi membungkuk di pinggang selama 48 jam
❖ Tekan dengan lembut area tusukan dengan tangan
pasien sendiri setiap kali batuk atau bersin
Hal2 yg harus dihindari pada area tusukan
B. Radial / brakialis:
❖ Jangan mengemudi selama 24 jam
❖ Hindari manipulasi pergelangan tangan selama 24 jam.
❖ Istirahatkan lengan selama 2-3 hari
❖ Untuk mencegah pembengkakan :
- Jangan mengangkat lebih dari 5 kg selama 1 minggu
- Tidak ada aktivitas berat selama 1 minggu.
Nursing Care of Patients Undergoing Cardiac
Catheterization Procedures

Prevention or detection
Education of the Obtaining vital signs
of vascular access
patient in the lab and blood test results complications

Hydration & Anxiety

Pain management
diuresis management

Patient safety
Education of the Patient in the CathLab
The Any chest pain or discomfort they may be feeling
patient
Pain or bleeding at the access site
should
report to Shortness of breath
his/her
nurse Doubts
 Diagnosa Keperawatan
➢ Defisit Pengetahuan tentang prosedur
kateterisasi.
Obtaining Vital Signs & Blood Tests
ECG monitoring is done to detect ST abnormalities and
arrhythmias

Blood pressure and O2 saturation levels are observed

ACT should be <180 seconds before sheath removal Blood

glucose should be monitored

Hematology and electrolytes should be repeated

ancompared with previous valuesd
Diagnosa Keperawatan
➢ Penurunan curah jantung
➢ Gangguan sirkulasi spontan
➢ Resiko perdarahan
➢ Resiko perfusi miokard tidak efektif
➢ Resiko perfusi serebral tidak efektif
Preventing Vascular Access Site Complications

Femoral approach Radial approach

The amount of time the

patient should remain at Keep the affected hand, wrist,
complete bed rest without and arm still for 2-4 hours and,
bending the knee is again, follow local practice
dependent on the local
practice and whether a
percutaneous closure device
was used
Preventing Vascular Access Site Complications
Record French size and location of punctures

Check access site periodically to detect signs of complications, such as

bleeding, hematoma or swelling

Groin and circulation observations include pedal pulses, color, warmth,

movement and sensation of the affected leg and foot

Be aware and check for retroperitoneal bleed

Patient stability, heart Pain at the site, back, Diagnosis: abdominal

rate, blood pressure or rectum CT Scan
Diagnosa Keperawatan
➢ Perfusi perifer tidak efektif
➢ Resiko perdarahan
➢ Nyeri akut
➢ Gangguan integritas kulit/ jaringan
 Hydration & Diuresis
Patients may have oral fluids and normal medication,
but should not eat until after the sheath is removed

Urinary retention may occur while the sheath is in place

• Monitor urine output and signs of bladder distention or Discomfort
• A urinary catheter may need to be inserted

Oral hydration may be helpful in preventing contrast

induced nephropathy
Diagnosa Keperawatan
➢Resiko perfusi renal tidak efektif
➢Resiko alergi
➢Retensi urin
 Pain Management
If the patient
It is important has been
Patients should Monitor the
to keep the prescribed
not be suffering patient’s pain
patient medication,
from pain level
comfortable administer it as
instructed
Diagnosa Keperawatan
➢ Gangguan rasa nyaman
➢ Nyeri
 Anxiety Management
Potential causes of patient’s anxiety
• Pain
• Future CABG
• Lack of information/education
• Worried about their family

Try to uncover and address the patient’s needs, thereby

reducing anxiety
Diagnosa Keperawatan
➢ Ansietas
➢ Koping tidak efektif
 Patient Safety
Surgical/ Sign in
Non Surgical
Intervention Time out
Safety
Checklist Sign out
 CONCLUSION
1. Ensure patient comfort and safety
2. Prevent and detect vascular complications
3. Monitor the patients hemodynamics and vital signs
4. Give the patient adequate information and education
5. Educate the patient on how to recognise the signs and
symptoms of angina and how to administer adequate
treatment
6. Detect and treat any pain or anxiety