Nursing Care Plan for Heart Failure
Assessment
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
2. The main complaint and history of present illness
3. Past medical history
4. The family medical history
5. Psychological and spiritual history
6. The pattern of daily habits
Physical Examination
1. General condition:
4. Pemeriksaansaan cephalocaudal:
5.Thorax 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).
Assessment
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.
1. General condition:
- Awareness: (Compos Metis up to coma).
- Weak.
- Anxiety.
- Cyanosis.
- Tension: increased.
- Pulse: increased.
- Temperature: normal or increased.
- Respiratory: increased and irregular.
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.
- Ascites (fluid).
- Tenderness.
- Hepatomegaly.
- Peripheral cyanosis.
- Pale.
- Cold acral.
- Ektrimitas peripheral cyanosis.
- Limb edema.
- Edema of the genitalia and the sacrum.
- 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).
