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MUHAMMAD MUSTAFA
SRN 011022 D3 KI
BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE
INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM
BANJARMASIN, 2014
•
NURSING CARE ON Mr. A
WITH MEDICAL DIAGNOSIS HEART FAILURE
IN ALAMANDA WARD OF ULIN GENERAL HOSPITAL BANJARMASIN
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• Heart failure is a major health problem, where the prevalence ofheart failure in developing countries is quite high and isincreasing. Half of patients diagnosed with heart failure stillhave hope to live for 5 years but approximately 250,000 patients
died because of heart failure either directly or indirectly everyyear, and that number has increased 6 times in the last 40 years.
• In Banjarmasin Ulin General Hospital, from the calculation beginning of 2013 until December 2013, it was found the total of350 patients with heart failure diagnose, from total of 664
patients with heart disease.
BACKGROUND
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DEFINITIONAccording to Muttaqin (2009), heart failure
is a condition when the heart is unable to maintain
adequate circulation to meet the body's needs,
although the normal venous filling.
ETIOLOGY
According to Kasron (2012), the etiology of heart
failure include :
• Abnormalities of the heart muscle.
• Coronary Atherosclerosis Myocardium resulting in
dysfunction due to disruption of blood flow to the heartmuscle to hypoxia and acidosis (due to lactic acid buildup).
• Myocardial infarction (death of heart cells).
• Systemic hypertension / pulmonary. Increase the workload
of the heart and in turn lead to hypertrophy of the heart
muscle fibers.
• Inflammation and myocardium disease.
• Heart disease.
• Systemic factors such as hypoxia and anemia who can
reduce oxygen supply to the heart.
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PATHOPHYSIOLOGY
According to Kasron (2012), the function of the
heart as a pump is indicated by its ability to meet
adequate blood supply to all parts of the body, eitherat rest or while experiencing physiological stress.
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SIGN AND SYMPTOM
According to Muttaqin (2009), signs and symptoms of heart
failure include:
• Increased intravascular volume (picture dominant)
• Ortopnuea is breathlessness on lying
• Dipsnea on effort (DOE) is Dipsnea when doing activities
• Paroxymal noctural dipsnea (PND) is a sudden shortness of
breath at night with a cough
• Palpitations, cold skin
•Hurry tired
• Cough
• Increased insistence on pulmonary venous (pulmonary edema)
is characterized by coughing and shortness of breath
• Increased insistence on systemic venous as seen in the general
peripheral edema and weight gain
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TREATMENT
According to Muttaqin (2009 : 103-104),
physiological responses in heart failure provide therationale for action. Target management of heart
failure are:
• To reduce the heart’s work
• To increase cardiac output and myocardialcontractility
• To reduce salt and water retention
• Oxygen Therapy
• Therapy of vasodilator and nitrate coronary• Diuretic Therapy
• Digitalis Therapy
• Positive Inotropic
• Sedatives Therapy
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DIAGNOSTIC
EXAMINATION
According to Muttaqin (2009 :
100-102), Diagnostic
Examination for heart failure :
• Echocardiography
• Chest X-ray
• Electrocardiography
COMPLICATION
• Kidney damage
• Heart valve problems
• Liver damage
• Heart attack and stroke
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NURSING CARE ASSESSMENT
Client’s identity Name : Mr. A
Gender : Male
Age : 47 years old
Address : Kelayan B
Religion : Islam
Medical Diagnose : Heart failure
Date of entry : May 12th, 2014
Date of assessment : May 15th, 2014
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Assessment Main complaint of the client when assessment on May 15th, 2014:
• the client said that he had felt breathless
• he had felt weak doing more activity
•he had no appetite during the hospitalized
Mr. A
1. Difficult to Breath
2. Weak
3. No appetite
treated in the Alamanda Ward
May 12th, 2014
THE CLIENT
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•History of previous diseaseThe client said that he was ever hospitalized inhospital in same ward with heart failure too. The clientsaid that he had heart failure since 6 months ago andthe client said that this is for 9 times when he took
medication in hospital in same ward. The client saidthat he had no history of hypertension, diabetic andcontagious disease. The client said that he had nohistory of allergic.
• History of family diseaseThe client said that there were no family members
had the disease like the client had now, from thefamilies there were not having heart disease,hypertension, and diabetic.
Assessment
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Focus Data
• The client said that
he had felt
breathless
• The client said that
he had felt weakdoing more activity
• The client said that
he had no appetite
during the
hospitalized
•
INSPECTION
• The client looked breathless
• The client looked weak
• The client looked just lied down on his bed
• The client looked using oxygen 3 liters
• The client’s consciousness level was
ompos mentis
• Body weight of the client is 46 kg
• Ideal body weight of the client is
56,7 kg – 69,3 kg
SUBJECTIVE DATA OBJECTIVE DATA
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Cont…
• Skin turgor was back less than 2 second
• Conjunctives were anemic
• Mocusa of the client looked dry
• The client looked had no appetite
• The client just ate 3 – 4 spoons
• Respiration 32 times a minutes
• There was no ictus cordis
• Activity scale was 2 (the client needs help)
• The client looked helped by family in activity• Muscle scale :
4444 4444
4444 4444
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Cont…
• Laboratory result of blood test on May 12th, 2014, hematology, hemoglobin
12.6 g/dl, erythrocyte 4.15 million/dl, hematocryte 38.7 vol%, RDW-CV 18.8
%
• Laboratory result of blood test on May 12th, 2014, fat and heart physiology,
LDH 580 U/I, CKMB 26 U/I• Laboratory result of blood test on May 12th, 2014, hepar, SGOT 47 U/I, SGPT
51 U/I
• Laboratory result of blood test on May 12th, 2014, kidney, urea 52 mg/dl
• Laboratory result of blood test on May 12th, 2014, electrolyte, potassium 3.3
mmol/I, chloride 100.6 mmol/I
• Chest x-ray results on May 12th, 2014 shows cardiomegaly 60,37 %
enlargement of heart
• ECG results on May 12th, 2014 : Regular heart rhythm, Heart rate 98 times a
minutes
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Cont…
AUSCULTATION
• Thorax : Breath sound was vesicular, there was no wheezing and ronchi sounds.
Heart Sound S1 S2 regular
• Abdominal : Bowel sound heard normal with frequency 12 times a minute
• Blood pressure 100/80 mmHgPERCUSSION
• Thorax : resonant sounds on all area of lungs
• Abdominal : thympani sounds, heard dull sound
PALPATION
• Pulse was 94 times a minute• CRT back less than 2 seconds
• Tactile premitus was symmetric between right and left chest
• It was not found mass in abdominal
• There was no pain pressure in abdominal
• Ictus cordis was not palpable
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1. Impaired gas exchange related to inadequatecardiac pump.
2. Imbalanced of nutrition: less than bodyrequirement related to inadequate intake ofnutrients.
3. Activity intolerance related to imbalance
between oxygen supply to tissues secondarywith cardiac output decrease (generalweakness).
Nursing Diagnosis
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CONCLUSION
1. In the result of the assessment on May 15th to May 20th , 2014 there are three
nursing diagnosis
– Impaired gas exchange related to inadequate cardiac pump.
– Imbalanced of nutrition: less than body requirement related to inadequate
intake of nutrients . – Activity intolerance related to imbalance between oxygen supply to tissue
secondary with cardiac output decrease (general weakness).
2. In the Nursing implementation based on the plan done in May
15th to May 20th, 2014. In the nursing evaluation, the problemcould only be half solved because of limited time and the client
went home.
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By:
Muhammad Mustafa