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Client Identity
Health History
Current Health
T : Pain scale 4
Subjective : The client says complaints of shortness of breath and left chest
data pain.
Objective : The client looks coughing, easily feels tired when doing activities
Data so that only patients who are lying in bed, the patient also seems
nervous and anxious about his condition. BP: 180/90 mmhg, RR:
28x / m, T: 36 C, P: 88x / m.
Nursing problems : There are no nursing problems
Previous Health History
Disease that has been experienced : The client said he had no previous heart
history.
Accident : The patient said he had never had an
accident
Operations (type and time) : The patient says he has never had
surgery
Disease (chronic and acute) : The patient says he has no history of the
disease
Last entered the hospital : The patient said he had never been
hospitalized before
Allergies (drugs, food, plaster, etc.) : Patients say he do not have drug
allergies, food, plaster.
Habit
Type Frequency Total Duration
Smoke : 1 Pcs x 1 16 Bar 1,5 h/d
Coffee : 1 Cup x 1 1 Cup 1 x/d
Alcohol : - - -
Medicines Used
Type Duration Dose
Medicine Shop 3 x/d 1 Tablet
- -
Family History : The client's family says, the family does not
have the same illness as the client
Genogram
Case Handling Notes (Begins when the patient is treated in the care room until the
case is managed) :
A 34-year-old man was admitted to the Muhamadiyah hospital in Palembang on 23
March 2018 at 23.00 WIB, Assessment on 23 March 2018 at 24:40 WIB in an
emergency room with complaints of shortness of breath and left chest pain. From the
assessment of patients who appear to arise, cough, easily feel tired when doing
activities so that only patients who are lying in bed, patients also appear nervous and
anxious about his condition. patient diagnosed with heart failure. From the results of
physical examination, lower extremity edema, hepatomegaly, anorexia, and nocturia
appear. BP: 180/90 mmhg, RR: 28x / m, T: 36 C, P: 88x / m. The patient underwent
X-ray examination with the result of enlarged heart and pulmonary congestive, blood
gas analysis: PA O2 from HR more than 100X / minute, results of ST ECG and Q
pathological segment increase and increase in cardiac enzymes, namely CK, AST,
LDL / HDL . Patients now only lie in the treatment room to minimize fatigue when
doing activities and just wait for the next intervention.
Nursing Assessment (12 Domains NANDA)
Health Improvement
Subjective Data : The client said that when he was sick he went to the doctor who
was not far from the client's house, when the client's condition
became severe, he finally went to RSMP
Objective Data : Checked his illness to the general practitioner
Nursing problem: There is no nursing problems
Nutrition
Subjective Data : The client said that before he got sick he ate well, ate 3 times a
day with a menu of rice and side dishes, drank water, coffee and
energy-enhancing drinks, a total of ± 2000ml / day
Objective Data : Edema lower extremities
BP 180/90 mmHg
RR 28 x/m
Nursing Problem: Excess fluid volume
Elimination
Subjective Data : The patient says shortness of breath
Objective Data : Blood gas analysis : pa O2 from-HR more than 100x/m
Abnormalities of frequency and respiratory depth
Nervous
Nursing Problems: Disruption of gas exchange
Activity / Rest
Subjective Data : Patient says he suffers from rapid exhausation
Patient says it’s stuffy when there’s activity
Objective Data : Cough
Edema lower extremities
Result of ECG ST segment elevation and pathological Q
Nursing Problems: Decreased cardiac output
Perception / Cognitive
Subjective Data : There are no signs and symptoms that appear
Objective Data : There are no signs and symptoms that appear
Nursing Problems: There is no nursing problems
Self Perception
Subjective Data : There are no signs and symptoms that appear
Objective Data : There are no signs and symptoms that appear
Nursing Problems: There is no nursing problems
Role of Relationship
Subjective Data : There are no signs and symptoms that appear
Objective Data : There are no signs and symptoms that appear
Nursing Problems: There is no nursing problems
Principles of life
Subjective Data : Patient's response to the disease: Mr. A considers this disease a
trial from God
Objective Data : Mr. A can only lie in bed and can't do anything. Patients cannot
gather with all their families and communities
Nursing Problems: There is no nursing problems
Safety / Protection
Subjective Data : The patient says his body feels weak
Objective Data : Pale skin color, dry lips mucosa, BP: 180/90 mmHg
Nursing Problems: There is no nursing problems
Convenience
Subjective Data : The patient says coughing up phlegm
Objective Data : The patient looks limp
Nursing Problems: There is no nursing problems
Respiration system
Cardiovascular system
Subjective data : The patient says shortness of breath while on the
move
Objective Data
Inspection : Symmetrical left and right
Palpation : Sensitive voice
Percussion : Right and left sonor
Auscultation : Wheezing +/+
Nursing Problems : Decreased cardiac output
Nerve System
Subjective data: The patient says he can move his arms and legs, can
feel stimulation like pinching
Objective data :
Urination System
Subjective data : The client said that the habit of urinating at home is ±
7x / day brownish yellow a distinctive smell of urine, 2
x / day defecation is yellow, a typical odor of faeces
Objective data :
Digestive system
Subjective data : The client said that before he got sick he ate well, ate 3
times a day with a menu of rice and side dishes, drank
water, coffee and energy-enhancing drinks, a total of ±
2000ml / day
Objective Data
Inspection : Flat
Palpation : No tenderness
Percussion : Not bloated
Auscultation : Normal bowel sounds
Nursing Problems : There is no nursing problems
Musculoskeletal System
Subjective data :
Objective data
Inspection : The upper limb has no edema, right hand is attached to 7 pm
sodium chloride infusion, and Lower extremities have edema of the
right foot
Palpation :
Nursing Problems : There is no nursing problems
Integumen System
Subjective data :
Objective data
Inspection : Scalp clean, no lumps, no scars and there is edema on the right foot
Palpation : Warm acral lower extremities
Nursing Problems: Excess fluid volume
Endocrine System
Subjective data :
Objective data
Inspection :
Palpation :
Nursing problems: There is no nursing problems
Sensing System
Vision
Subjective data : The patient says his eyes are normal
Objective data
Hearing
Subective data : The patient says his ears are normal
Objective data
Snub
Subjective data : The patient says the smell is normal
Objective data
Psychosocial Assessment
Client's perception of the disease : Patient's response to the disease: Mr. A considers
this disease a trial from God
Nursing problems : There is no nursing problem
Cooperation………… Uncooperative………….
Type of
No Medicine Dose Rute Indication Contraindicatedi
medicine
1. Ns 500 Infusion IV Low Sodium
cc/24 liquid magnesiu retention and
hours m levels, edema,
low congestive heart
sodium failure, severe
levels, kidney
low disorders, liver
potassium cirrhosis
levels,
low
calcium
levels,
fluid and
blood loss
DO :
Decrease the key
1. Cough content
Decreased cardiac
output
DS : Myocardial infraction Disruption of gas exchange
2. Abnormalities of
frequency and respiratory
depth Pulmonary Congestion
3. Nervous
Enlargement of Alveoli
fluid
Disruption of gas
exchange
DS : Myocardial infraction Excess fluid volume
DO : Decrease Cardiac
output
1. Edema lower extremities
2. BP 180/90 mmHg
RAA Activation
3. RR 28 x/m
NURSING DIAGNOSE
1. Decreasing cardiac output is associated with changes in afterload
2. Disruption of gas exchange is associated with an imbalance of perfusion
ventilation
3. Excess fluid volume is associated with increased hydrostatic pressure.