Assessment, Physical Examination and Data Analysis - Nursing Care Plan for Heart Failure

Nursing Care Plan for Heart Failure


Assessment is the basic thinking and the nursing process which aims to collect data and information or data about the client in order to identify, recognize the problems of health and nursing needs of clients both physically, mentally, socially and environmentally. Systematic assessment in nursing in the four phases of activities which include: data collection, problem determination, problem analysis, evaluation. (Effendi Nasrul, 1995: 8).

1. Biodata
  • Name: to distinguish between patients with one another.
  • Age: heart failure usually occurs at the age above 50 years, with age, the body's organs function will decline. Including blood vessels, prone to atherosclerosis. But it could happen at the age of children due to congenital valvular abnormalities.
  • Gender: a greater risk of heart failure in men due and proportion of the heavier work, stress and smoking activities.
  • Tribe / nation: Africans (blacks) with hypertension have a 2-3 times higher risk of heart failure compared to whites. (Lestari Indah, 2002: 55).

2. The main complaint and history of present illness
  • Shortness of breath (dyspnea) due to fluid accumulation in the lungs because of left ventricular ineffective causing shortness.
  • Paroxysmal nocturnal dyspnea (or PND) (wake up at midnight the day because of difficulty breathing) caused by reabsorption of fluid in the lungs.
  • Fatigue: due to a decrease in cardiac output which causes depletion of ATP as an energy source for the contraction of the tool.
  • Ascites: due to accumulation of fluid in the abdominal cavity due to increased portal vera boosting serous fluid in and out and the portal circulation.

3. Past medical history
  • Congenital heart valve damage.
  • Hypertension (increase cardiac work and influence the process of atherosclerosis.
  • DM (Diabetes Mellitus).
  • Cardiac surgery.
  • Chronic myocardial infarction.

4. The family medical history
  • Children and parents with a history of heart disease or other persons are more susceptible to the same case.

5. Psychological and spiritual history

  • Experienced psychological history can continuously improve the work of the heart.
  • Spiritual clients can improve coping clients in overcoming anxiety.

6. The pattern of daily habits
  • Nutrition: Eat foods that contain a lot of cholesterol and fatty acid burn, causing atherosclerosis and increases blood pressure. Drinking coffee (caffeine) and alcohol which made the work of the heart.
  • Elimination: Nacturia: a decrease in urine output.
  • Activities and exercises: Fatigue (easily tired).
  • Rest and sleep: It's hard to sleep because of shortness of breath.

Assessment, Physical Examination and Data Analysis - Nursing Care Plan for Heart Failure
Physical Examination

1. General condition:
  • Awareness: (Compos Metis up to coma).
  • Weak.
  • Anxiety.
  • Cyanosis.
2. Vital signs
  • Tension: increased.
  • Pulse: increased.
  • Temperature: normal or increased.
  • Respiratory: increased and irregular.
3. Weight: may increase if edema.

4. Pemeriksaansaan cephalocaudal:
  • Head and neck:
  • Konjuctiva pale jugular vein enlargement,
  • There are signs of anemia,
  • Dry lips, cyanosis.

5.Thorax examination:
  • Dipsnea, tachipnea, orthopnea.
  • Breathing chyene - Stokes (irregular).
  • Intercostal retractions.
  • Ronkhi, whezzing.
  • Tachicardia.
  • Increased blood pressure.
6. Abdominal examination:
  • Ascites (fluid).
  • Tenderness.
  • Hepatomegaly.
7. Integumentary inspection and nails:
  • Peripheral cyanosis.
  • Pale.
  • Cold acral.
8. Examination extremities:
  • Ektrimitas peripheral cyanosis.
  • Limb edema.
9. Examination of genitalia, anus:
  • Edema of the genitalia and the sacrum.
10. Supporting investigation:
  • Laboratory examination or diognastik.
  • ECG examination.
  • Echocardiagrafi examination.

Data Analysis

Analysis of the data is the ability to associate data and linking these data with the concepts, theories and principles relevant, to make inferences in determining the client's health and nursing. Data analysis is a process that includes data validation. Grouping the data into two, namely the subjective data and objective data. Based on the needs of bio-psycho, social and spiritual, compared with the standard and make conclusions about the gap (nursing problems) were found (Nasrul Effendi, 1995: 23,24).

11 Symptoms of Schizophrenia You Need to Know

Schizophrenia. Disorders that we now know as schizophrenia is rampant discussed in public. However, many of us do not know what exactly schizophrenia. In some cases, people with this disorder considered to be possessed by demons, fear, tortured, exiled or even locked up forever.

Like most other mental disorders, the cause of schizophrenia is still not clearly presented. Most people imagine schizophrenic as a person vulnerable to violence or uncontrolled attitude.

One of the most obvious kind of damage caused by schizophrenia involves how a person thinks. Individuals may lose the capacity to think rationally in evaluating the environment and how to interact with others. They often believe things that are not true, and may have difficulty accepting what they see as reality "true".

Schizophrenia is often include hallucinations and / or delusions, which reflects the distortion in the perception and interpretation of reality. Nearly a third of those diagnosed with schizophrenia will attempt suicide. Approximately 10 percent of those diagnosed with this disorder will commit suicide within 20 years from the beginning of this disorder.

Patients with schizophrenia may not share their suicidal thoughts with others. The risk of depression would require special attention because of the high rate of suicide in patients with this disorder. They also often do things that are considered strange by others.

For example, people with schizophrenia, paranoid can act like buying a few key to their door, always look back every time walk in public, and refused to talk on the phone.

This behavior may be considered unreasonable and illogical. However, for those who suffer from schizophrenia, this behavior may reflect a natural reaction on their false beliefs about other people out there who want to do evil to them.

Incidence of schizophrenia in most emerging gradually that generally occurs in early adulthood stage - usually in the early 20s. Relatives and friends are able to see the early warning signs long before the major symptoms of schizophrenia occur in patients. During the initial phase, a person may appear not to have a purpose in life, became increasingly eccentric and unmotivated. They will isolate themselves and start to avoid family and their friends.

Here are the signs that indicate a person experiencing schizophrenia, as reported
  1. Self isolating or withdraw from social interaction.
  2. Irrational, say or believe anything strange or odd.
  3. Increased paranoid or questioning the motives of others.
  4. Easy emotion.
  5. Hostility or suspicion.
  6. Increased dependence on drugs or alcohol (in an attempt to self-medicate).
  7. Lack of motivation.
  8. Speaking in a strange way not like themselves.
  9. Often laugh at inappropriate times.
  10. Insomnia or sleeplessness.
  11. The decline in personal appearance and hygiene.
Although there is no guarantee that someone who experienced one or more symptoms suffered from schizophrenia, eleven sign above could be a reference to identify whether there is a disorder that affects a person.

9 Tips to Avoid Headaches

9 Tips to Avoid Headaches

Headache is a disease that must have been suffered by everyone. Ranging from mild headache, migraine, until a severe headache. Headaches are very disturbing daily activities if not treated immediately.

From now find out what the cause of the headache and begin seriously to stop the pain that is very annoying. Here are 10 steps that can be taken to reduce the risk of headaches:

1. Identify the trigger
You can record why you headaches on that day. Starting from what you eat, to what you are doing because some foods can trigger headaches. After knowing what triggers headaches, you can take steps to avoid it.

2. Reduce stress
You may not be able to avoid stress, but you can reduce it. Perform relaxation with slow rhythmic play cassettes, massage, or bath with aromatherapy.

3. Keep your eyes
Too long in front of computers and televisions can also cause eye fatigue and headache triggers.

4. Eat regularly
Eat regularly with nutrients that are rich in carbohydrates and vitamins, but low in fat. And do not forget to consume a lot of water to avoid dehydration.

5. Regular Sleeping
Sleep at least 8 hours a day so that the body gets a chance to replace cells that have been damaged or dead.

6. Familiarize upright body position
Incorrect posture when sitting or doing activities can cause muscle stiffness, neck and shoulders which then triggers the tension in the head.

7. Stop Smoking
Smoking is a risk factor for several types of headaches. Even cigarette smoke can trigger a headache for some people

8. Exercise regularly
With exercise, toxins and residual substances in the body can be released through sweat.

9. Avoid drug dependence
If you have been taking high doses of medication headaches 2-3 times a week but you still frequent headaches arise, better consult your doctor.

Pathophysiology of Diabetic Ulcers

Diabetes makes disorders / complications through damage to blood vessels throughout the body, called diabetic angiopathy. The disease runs a chronic and is two large vascular disorders (macrovascular) called macroangiopathy, and the small blood vessels (microvascular) called microangiopathy. If the affected blood vessels in the brain arise stroke, blindness occurs when the eye, the heart of coronary heart disease which can lead to heart attack / myocardial infarction, the kidneys become chronic kidney disease to end stage renal failure and should be dialysis or transplantation. When on foot injuries occur that are difficult to heal up into decay (gangrene). Moreover, if the affected nerve arises diabetic neuropathy, so there are parts that do not taste anything / numbness, though needles / spikes or exposed to hot objects.

Abnormalities of the lower limbs due to diabetes caused by vascular disorders, neurological disorders, and infection. In vascular disorders, feet can hurt, if tangible feel cold, if there are wounds are difficult to heal because blood flow to the parts have been reduced. Examination difficult palpable pulse in the legs, the skin appears pale or bluish, then eventually can become gangrenous / tissue decay, then infected and bacteria thrives, it will be dangerous for patients because the infection can spread throughout the body (sepsis). In the event of a nervous breakdown, called diabetic neuropathy may arise taste disorders (sensory) numbness, lack of taste to numbness. In addition, motor disturbances, muscle weakness arises, decreases muscle, muscle cramps, tiredness. Legs that do not taste would be dangerous because when stepping on sharp objects will not be felt when it had been incurred injuries, coupled with the ease of infection. If it's gangrene, legs should be cut in the upper part of the rot.

Diabetic gangrene is a long-term impact of arteriosclerosis and small thrombus embolism. Diabetic angiopathy almost always also lead to peripheral neuropathy. Diabetic neuropathy is a disruption of motor, sensory and autonomic, each of which plays a role in the occurrence of foot injuries. Paralysis of the leg muscles leads to changes in the balance of the foot joints, changes in gait, and will lead to new pressure points on the soles of the feet, causing a callus on the spot.

Sensory disturbance causes local numbness and loss of protection against trauma, so people were injured unnoticed. As a result, the callus can turn into ulcers which when coupled with the infection developed into cellulitis and ended up with gangrene.

Autonomic nerve disorder that results in loss of skin secretions dry skin and easy bruising are difficult to heal. And wound infections are difficult to heal and prone to necrosis resulting from three factors. The first factor is angiopathy arterioles causing poor tissue perfusion feet so that the mechanism of inflammation so ineffective. The second factor is the blood sugar environment fertile for the development of pathogenic bacteria. The third factor is the opening of the artery-vein bypass in subcutaneous, nutrient flow will bypass the site of infection in the skin.

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