Nursing Diagnosis : Ineffective Tissue Perfusion
Syncope is one of the causes of loss of consciousness that are found in the emergency room (ER). Syncope is a transient loss of consciousness with acute onset followed by a fall, and with spontaneous recovery and perfect without any intervention. Syncope is a symptom of a disease that must be sought etiology.
Definition of syncope (according to the European Society of Cardiology: ESC), is a characteristic clinical symptoms with loss of consciousness sudden and temporary, and usually lead to falls. Relatively rapid onset and recovery occurs spontaneously. The loss of consciousness caused by cerebral hypoperfusion.
Activities before syncope can provide clues about the cause of the symptoms. Syncope can occur at rest, with changes in posture, the power, after a workout, or with certain situations such as coughing, or standing for long. Syncope occurs within 2 minutes of standing shows orthostatic hypotension.
The cause of syncope is divided into two. Due to cardiac disorders (cardiac syncope) and causes no heart abnormalities. This division is very important, because it deals with the level of risk of death. The cause of syncope can be classified into five groups: vascular-cardiac, neurology, reflex syncope, metabolic syncope, and others syncope.
Before syncope, dizziness, or lightheadedness occurs in 70% of patients experiencing syncope. Other symptoms, such as vertigo, weakness, diaphoresis, epigastric discomfort, nausea, blurred vision or faded, pale, or paresthesias, may also occur in the period presyncope.
An attack of syncope (fainting), the following characteristics:
- No time shouts during attacks.
- Time attack lasts a few seconds.
- No bedwetting.
- After the attack usually fully conscious, although there is a feeling limp and weak.
- Not occur bite the tongue.
- Pallor.
- Syncope rarely arise when the patient is lying.
Nursing Diagnosis : Ineffective Tissue Perfusion related to decrease in peripheral blood circulation; cessation of arterial-venous flow.
Nursing Interventions :
- Monitor changes suddenly or continuous mental disorders (anxiety, confusion, lethargy, pinsan).
- Observation of pallor, cyanosis, striped, skin cold / humid, record peripheral pulse strength.
- Assess Homan's sign (pain in the calf with dorsiflexion), erythema, edema.
- Encourage leg exercises active / passive.
- Monitor breathing.
- Assess GI function, note; anorexia, decreased bowel sounds, nausea / vomiting, abdominal distension, constipation.
- Monitor input and changes in urine output.
Rationale :
- Cerebral perfusion is directly related to cardiac output, influenced by the electrolyte / acid-base variations, hypoxia or systemic embolism.
- Systemic vasoconstriction caused by a decrease in cardiac output may be evidenced by a decrease in skin perfusion and decreased pulse.
- Indicator of the presence of deep venous thrombosis.
- Lowering venous stasis, increasing venous return and lower risk of thrombophlebitis.
- Failing heart pump can trigger respiratory distress. But the sudden dyspnea / continue showing pulmonary thromboembolic complications.
- Decreased blood flow to the mesenteric artery can result in GI dysfunction, eg loss of peristalsis.
- Decrease input / persistent nausea may result in a decrease in circulating volume, which have a negative impact on perfusion and organ.