A. Assessment
Failed porch left / right of the inability of the heart mengakibtkan provide enough output to meet the needs of the network and lead to pulmonary congestion and systemic. Therefore diagnostic and teraupetik berlnjut. GJK subsequent morbidity and mortality.
1. Activity / rest
a. Symptoms: Fatigue / tiredness throughout the day, insomnia, chest pain with activity, dyspnea at rest.
b. Signs: Restlessness, mental status changes eg lethargy, vital signs changing pad activity.
2. Circulation
a. Symptoms: History of HT, the new IM / acute, GJK previous episodes, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.
b. Signs:
1. TD; may be low (failed pumping).
2.Tekanan Nadi; may narrow.
3. Heart rhythm; dysrhythmias.
4. The frequency of heart; Tachycardia.
5. Apical pulse; PMI may spread and change
6. inferior position to the left.
7. Heart murmurs; S3 (gallop) is diagnostic, S4 can
8. occurs, S1 and S2 may be weakened.
9. Systolic and diastolic murmurs.
10. Color; bluish, pale gray, cyanotic.
11. Backs nails; pale or cyanotic with charging
12. slow capillary.
13. Liver; enlargement / can be palpated.
14. Breath sounds; krekels, ronkhi.
15. Edema; probably dependent, general or pitting
16. especially in the extremities.
3. Ego integrity
a. Symptoms: Anxiety, worry and fear. Stress-related illness / financial keperihatinan (work / cost of medical care)
b. Signs: Various manifestations of behavior, eg anxiety, anger, fear and irritability.
4. Elimination
Symptoms: Decreased urination, dark colored urine, night urination (nocturia), diarrhea / constipation.
5. Food / fluid
a. Symptoms: Loss of appetite, nausea / vomiting, penambhan significant weight loss, swelling of the lower extremities, clothes / shoes felt tight, high-salt diet / food that has been processed and the use of diuretics.
b. Signs: rapid weight gain and abdominal distension (ascites) and edema (general, dependent, pitting nd pressure).
6. Hygiene
a. Symptoms: Fatigue / weakness, fatigue during activities of self care.
b. Signs: Appearance indicate neglect personal care.
7. Neurosensori
a. Symptoms: Weakness, dizziness, fainting episodes.
b. Symptoms: Lethargy, tangled thought, oriented, behavioral changes and irritability.
8. Pain / Leisure
a. Symptoms: Chest pain, acute or chronic angina, upper right abdominal pain, and muscle pain.
b. Signs: Not calm, anxiety, focus narrows danperilaku protect themselves.
9. Breathing
a. Symptoms: dyspnea on exertion, sitting or sleeping with multiple pillows, cough with less / no formation of sputum, history of chronic diseases, use of rescue breathing.
b. Signs:
1) Breathing; tachypnea, shallow breathing, use of accessory muscles pernpasan.
2) Cough: Dry / loud / non productive or perhaps persistent cough with / without pemebentukan sputum.
3) Sputum; Perhaps the blood flushed, pink / frothy (pulmonary edema)
4) The sound of breath; may not sound.
5) mental function; may decline, anxiety, lethargy.
6) The skin color; Pallor and cyanosis.
10. Security
Symptoms: Changes in mental function, kehilangankekuatan / muscle tone, skin abrasions.
11. Social Interaction
Symptoms: Decreased participation in social activities are wont to do.
12. Learning / teaching
a. Symptoms: use / forget using cardiac drugs, eg calcium channel blockers.
b. Signs: Evidence of lack of success to improve.
B. Nursing Diagnosis
1. The decrease in cardiac output associated with; Amendment myocardial contractility / inotropic changes, change in frequency, rhythm and conduction of electrical, structural changes, characterized by;
a. Increased heart rate (tachycardia): dysrhythmias, changes in ECG patterns picture
b. Changes in blood pressure (hypotension / hypertension).
c. Extra sound (S3 & S4)
d. Decrease in urine output
e. No palpable peripheral pulses
f. Dull winter skin
g. Orthopnea, krakles, liver enlargement, edema and chest pain.
Destination
The client will: Demonstrate vital signs within acceptable limits (uncontrolled dysrhythmias or lost) and free of heart failure symptoms, decreased Report epiode dyspnea, angina, Participate in activities that reduce the heart's workload.
Intervention
a. Auscultation apical pulse; examine the frequency, heart iram
Rationale: The bias tachycardia (although at rest) to compensate for the decrease in ventricular contractility.
b. Record heart sounds
Rational: S1 and S2 may be weak due to reduced pumping work. Common Gallop rhythm (S3 and S4) generated as a disteni kesermbi bloodstream. Murmurs can indicate incompetence / stenosis.
c. Peripheral pulse palpation
Rationale: Decreased cardiac output may indicate decreased radial artery, popliteal, dorsalis, pedis and posttibial. Pulse may disappear fast or irregular to palpation and pulse alternan.
d. Monitor TD
Rationale: In the early GJK, sedng atu drah chronic stress may increase. In HCF-up body can no longer compensate danhipotensi NORML can not anymore.
e. Assess terhadp pale skin and cyanosis
Rational: Pale indicating reduced peripheral perfusion ekunder against dekutnya not curh heart; vasoconstriction and anemia. Cyanosis occurs as refrakstori GJK DAPT. Often ill areas or in striped blue because of increased venous congestion.
f. Give supplemental oxygen by nasal cannula / mask and drugs as indicated (collaboration)
Rational: raise higher dosage of oxygen to the need to counter the effects of myocardial hypoxia / ischemia. Many drugs can be used to improve the volume sekuncup, improve contractility and reduce congestion.
2. Activity intolerance related to: Imbalance between supply oxygenated. General weakness, Bed rest long / immobilization. Characterized by: weakness, fatigue, changes in vital signs, the disrirmia, dyspnea, pallor, sweating.
Goals / evaluation criteria:
The client will: Participate pad ktivitas desired, meet self-care, Achieve increased tolerance activity can be measured, proven herpetic decreased weakness and fatigue.
Intervention
a. Check vital signs before and immediately after the event, especially when clients are using vasodilator, diuretic and beta blockers.
Rational: Orthostatic hypotension can occur with activity due to the effects of the drug (vasodilation), displacement fluid (diuretics) or influence cardiac function.
b. Note the cardiopulmonary response to activity, noted tachycardia, diritmia, dyspnea sweaty and pale.
Rationale: Decrease / inability of the myocardium to increase the volume sekuncup for dpat activity causes an immediate increase heart rate and oxygen demand is also increasing fatigue and weakness.
c. Evaluation of increased activity intolerance.
Rationale: May indicate an increase in the activity of cardiac decompensation rather than excess.
d. Implementation of a cardiac rehabilitation program / activity (collaboration)
Rational: gradual increase in the activity of the heart avoiding / excessive oxygen consumption. Strengthening and improvement of cardiac function under stress, when the heart is unable to function better again,
3. Excess fluid volume related to: decreased glomerular filtration rate (cardiac output decrease) / increase in production of ADH and sodium retention / water. characterized by: orthopnea, S3 heart sound, oliguria, edema, weight gain, hypertension, respiratory distress, abnormal heart sounds.
Goals / evaluation criteria,
The client will: Demonstrate stable fluid volume balance danpengeluaran input, breath sounds clean / clear, vital signs within acceptable range, stable weight and no edema., Expressing understanding of individual fluid restriction.
Intervention:
a. Monitor expenditure urine, record the number and color of the time when diuresis occurs.
Rational: Spending a little and concentrated urine probably due to decreased renal perfusion. Supine position helps diuresis urine so spending can be increased during bed rest.
b. Monitor / pemaukan and spending balance count for 24 hours
Rational: diuretic therapy may be caused by fluid loss tiba-tiba/berlebihan (hypovolemia) although edema / ascites is still there.
c. Pertahakan sitting or bed rest with semifowler position during the acute phase.
Rationale: The position is increasing kidney filtration and reduce the production of ADH thus increasing diuresis.
d. Monitor BP and CVP (if any)
Rationale: Hypertension and increased CVP showed excess fluid and may indicate an increase in lung congestion, heart failure.
e. Kaji bisisng intestine. Record complaints anorexia, nausea, abdominal distension and constipation.
Rational: visceral congestion (occurring in advanced GJK) can interfere with the function of gastric / intestinal.
f. Administration of drugs as indicated (collaboration)
g. Consult with a dietitian.
Rational: the need to provide an acceptable diet that meets the client's needs calories in sodium restriction.
4. High risk of impaired gas exchange related to: changes in capillary-alveolar menbran.
Goals / evaluation criteria,
The client will: Demonstrate ventilation and oxygenation dekuat on the network indicated by oximetry in the normal range and free of symptoms of respiratory distress., Participate in a treatment program in btas abilities / situations.
Intervention:
a. Monitor breath sounds, record krekles
Rational: declare adnya pulmonary congestion / secret collection demonstrates the need for further intervention.
b. Teach / encourage clients effective coughing, breathing deeply.
Rational: clearing the airway and facilitate the flow of oxygen.
c. Push the change of position.
Rationale: Helps prevent atelectasis and pneumonia.
d. Collaboration in the Monitor / draw series GDA, pulse oximetry.
Rational: Hypoxaemia may occur during severe pulmonary edema.
e. Give drug / supplemental oxygen as indicated
5. High risk of damage to skin integrity related to prolonged bed rest, edema and decreased tissue perfusion.
Goals / evaluation criteria
The client will: Maintain the integrity of the skin, Demonstrate behaviors / techniques to prevent skin damage.
Intervention
a. Monitor skin, bone protrusion noted, edema, impaired circulation area / pigmentation or overweight / underweight.
Rational: Skin disorders are at risk due to the peripheral circulation, physical immobilization and impaired nutritional status.
b. Massage the area red or white
Rationale: increased blood flow, minimizing tissue hypoxia.
c. Change position often in bed / chair, assistive range of motion exercises passive / active.
Rationale: Improve the circulation of an area that interferes with blood flow.
d. Give perawtan skin, minimize the moisture / excretion.
Rationale: Too dry or moist skin damage / speed up the damage.
e. Avoid drugs intramuscularly
Rational: interstitial edema and impaired circulation slows drug absorption and predisposition to skin damage / infection ..
6. Lack of knowledge (learning need) regarding condition and treatment programs related to lack of understanding / misperceptions about the relationship of cardiac function / disease / failure, characterized by: a Question of problems / errors of perception, GJK episode recurrence can be prevented.
Goals / evaluation criteria
The client will:
a. Identify the therapeutic relationship to reduce recurrent episodes and prevent complications.
b. Identify personal stress / risk factors and some techniques for handling.
c. Make changes to lifestyle / behavioral needs.
Intervention
a. Discuss normal cardiac function
Rationale: Knowledge of the disease process and hope to facilitate adherence to the treatment program.
b. Strengthen rational treatment.
Rationale: The client believes that the change is allowed when the post came home feeling good and free of symptoms or feel healthier which can increase the risk of exacerbation of symptoms.
c. Instruct food diet in the morning.
Rationale: To provide adequate time for the effects of the drug before bedtime to prevent / limit stop sleeping.
d. Refer to the sources in the community / support group an indication
Rational: can add their own help with monitoring / management of home.
REFERENCES
Barbara C. Long, Medical Surgical Nursing (Translation), Bandung Padjajaran IAPK Foundation, September 1996, p. 443-450
Marilynn E Doenges, Nursing care plan (Guidelines for Planning and Documenting Patient Care), Issue 3, EGC Kedikteran Book Publishers, 2002, p; 52-64 & 240-249.
Junadi P, hissing S, Husna A, Capita selekta Medicine (pleural effusion), Media Aesculapius, Faculty of Medicine, Universita Indonesia, 1982, Hal.206 - 208
Lorraine M Wilson, Pathophysiology (Concept Clinical Disease Processes), Book 2, Issue 4, 1995, It; 704-705 & 753-763.
Failed porch left / right of the inability of the heart mengakibtkan provide enough output to meet the needs of the network and lead to pulmonary congestion and systemic. Therefore diagnostic and teraupetik berlnjut. GJK subsequent morbidity and mortality.
1. Activity / rest
a. Symptoms: Fatigue / tiredness throughout the day, insomnia, chest pain with activity, dyspnea at rest.
b. Signs: Restlessness, mental status changes eg lethargy, vital signs changing pad activity.
2. Circulation
a. Symptoms: History of HT, the new IM / acute, GJK previous episodes, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.
b. Signs:
1. TD; may be low (failed pumping).
2.Tekanan Nadi; may narrow.
3. Heart rhythm; dysrhythmias.
4. The frequency of heart; Tachycardia.
5. Apical pulse; PMI may spread and change
6. inferior position to the left.
7. Heart murmurs; S3 (gallop) is diagnostic, S4 can
8. occurs, S1 and S2 may be weakened.
9. Systolic and diastolic murmurs.
10. Color; bluish, pale gray, cyanotic.
11. Backs nails; pale or cyanotic with charging
12. slow capillary.
13. Liver; enlargement / can be palpated.
14. Breath sounds; krekels, ronkhi.
15. Edema; probably dependent, general or pitting
16. especially in the extremities.
3. Ego integrity
a. Symptoms: Anxiety, worry and fear. Stress-related illness / financial keperihatinan (work / cost of medical care)
b. Signs: Various manifestations of behavior, eg anxiety, anger, fear and irritability.
4. Elimination
Symptoms: Decreased urination, dark colored urine, night urination (nocturia), diarrhea / constipation.
5. Food / fluid
a. Symptoms: Loss of appetite, nausea / vomiting, penambhan significant weight loss, swelling of the lower extremities, clothes / shoes felt tight, high-salt diet / food that has been processed and the use of diuretics.
b. Signs: rapid weight gain and abdominal distension (ascites) and edema (general, dependent, pitting nd pressure).
6. Hygiene
a. Symptoms: Fatigue / weakness, fatigue during activities of self care.
b. Signs: Appearance indicate neglect personal care.
7. Neurosensori
a. Symptoms: Weakness, dizziness, fainting episodes.
b. Symptoms: Lethargy, tangled thought, oriented, behavioral changes and irritability.
8. Pain / Leisure
a. Symptoms: Chest pain, acute or chronic angina, upper right abdominal pain, and muscle pain.
b. Signs: Not calm, anxiety, focus narrows danperilaku protect themselves.
9. Breathing
a. Symptoms: dyspnea on exertion, sitting or sleeping with multiple pillows, cough with less / no formation of sputum, history of chronic diseases, use of rescue breathing.
b. Signs:
1) Breathing; tachypnea, shallow breathing, use of accessory muscles pernpasan.
2) Cough: Dry / loud / non productive or perhaps persistent cough with / without pemebentukan sputum.
3) Sputum; Perhaps the blood flushed, pink / frothy (pulmonary edema)
4) The sound of breath; may not sound.
5) mental function; may decline, anxiety, lethargy.
6) The skin color; Pallor and cyanosis.
10. Security
Symptoms: Changes in mental function, kehilangankekuatan / muscle tone, skin abrasions.
11. Social Interaction
Symptoms: Decreased participation in social activities are wont to do.
12. Learning / teaching
a. Symptoms: use / forget using cardiac drugs, eg calcium channel blockers.
b. Signs: Evidence of lack of success to improve.
B. Nursing Diagnosis
1. The decrease in cardiac output associated with; Amendment myocardial contractility / inotropic changes, change in frequency, rhythm and conduction of electrical, structural changes, characterized by;
a. Increased heart rate (tachycardia): dysrhythmias, changes in ECG patterns picture
b. Changes in blood pressure (hypotension / hypertension).
c. Extra sound (S3 & S4)
d. Decrease in urine output
e. No palpable peripheral pulses
f. Dull winter skin
g. Orthopnea, krakles, liver enlargement, edema and chest pain.
Destination
The client will: Demonstrate vital signs within acceptable limits (uncontrolled dysrhythmias or lost) and free of heart failure symptoms, decreased Report epiode dyspnea, angina, Participate in activities that reduce the heart's workload.
Intervention
a. Auscultation apical pulse; examine the frequency, heart iram
Rationale: The bias tachycardia (although at rest) to compensate for the decrease in ventricular contractility.
b. Record heart sounds
Rational: S1 and S2 may be weak due to reduced pumping work. Common Gallop rhythm (S3 and S4) generated as a disteni kesermbi bloodstream. Murmurs can indicate incompetence / stenosis.
c. Peripheral pulse palpation
Rationale: Decreased cardiac output may indicate decreased radial artery, popliteal, dorsalis, pedis and posttibial. Pulse may disappear fast or irregular to palpation and pulse alternan.
d. Monitor TD
Rationale: In the early GJK, sedng atu drah chronic stress may increase. In HCF-up body can no longer compensate danhipotensi NORML can not anymore.
e. Assess terhadp pale skin and cyanosis
Rational: Pale indicating reduced peripheral perfusion ekunder against dekutnya not curh heart; vasoconstriction and anemia. Cyanosis occurs as refrakstori GJK DAPT. Often ill areas or in striped blue because of increased venous congestion.
f. Give supplemental oxygen by nasal cannula / mask and drugs as indicated (collaboration)
Rational: raise higher dosage of oxygen to the need to counter the effects of myocardial hypoxia / ischemia. Many drugs can be used to improve the volume sekuncup, improve contractility and reduce congestion.
2. Activity intolerance related to: Imbalance between supply oxygenated. General weakness, Bed rest long / immobilization. Characterized by: weakness, fatigue, changes in vital signs, the disrirmia, dyspnea, pallor, sweating.
Goals / evaluation criteria:
The client will: Participate pad ktivitas desired, meet self-care, Achieve increased tolerance activity can be measured, proven herpetic decreased weakness and fatigue.
Intervention
a. Check vital signs before and immediately after the event, especially when clients are using vasodilator, diuretic and beta blockers.
Rational: Orthostatic hypotension can occur with activity due to the effects of the drug (vasodilation), displacement fluid (diuretics) or influence cardiac function.
b. Note the cardiopulmonary response to activity, noted tachycardia, diritmia, dyspnea sweaty and pale.
Rationale: Decrease / inability of the myocardium to increase the volume sekuncup for dpat activity causes an immediate increase heart rate and oxygen demand is also increasing fatigue and weakness.
c. Evaluation of increased activity intolerance.
Rationale: May indicate an increase in the activity of cardiac decompensation rather than excess.
d. Implementation of a cardiac rehabilitation program / activity (collaboration)
Rational: gradual increase in the activity of the heart avoiding / excessive oxygen consumption. Strengthening and improvement of cardiac function under stress, when the heart is unable to function better again,
3. Excess fluid volume related to: decreased glomerular filtration rate (cardiac output decrease) / increase in production of ADH and sodium retention / water. characterized by: orthopnea, S3 heart sound, oliguria, edema, weight gain, hypertension, respiratory distress, abnormal heart sounds.
Goals / evaluation criteria,
The client will: Demonstrate stable fluid volume balance danpengeluaran input, breath sounds clean / clear, vital signs within acceptable range, stable weight and no edema., Expressing understanding of individual fluid restriction.
Intervention:
a. Monitor expenditure urine, record the number and color of the time when diuresis occurs.
Rational: Spending a little and concentrated urine probably due to decreased renal perfusion. Supine position helps diuresis urine so spending can be increased during bed rest.
b. Monitor / pemaukan and spending balance count for 24 hours
Rational: diuretic therapy may be caused by fluid loss tiba-tiba/berlebihan (hypovolemia) although edema / ascites is still there.
c. Pertahakan sitting or bed rest with semifowler position during the acute phase.
Rationale: The position is increasing kidney filtration and reduce the production of ADH thus increasing diuresis.
d. Monitor BP and CVP (if any)
Rationale: Hypertension and increased CVP showed excess fluid and may indicate an increase in lung congestion, heart failure.
e. Kaji bisisng intestine. Record complaints anorexia, nausea, abdominal distension and constipation.
Rational: visceral congestion (occurring in advanced GJK) can interfere with the function of gastric / intestinal.
f. Administration of drugs as indicated (collaboration)
g. Consult with a dietitian.
Rational: the need to provide an acceptable diet that meets the client's needs calories in sodium restriction.
4. High risk of impaired gas exchange related to: changes in capillary-alveolar menbran.
Goals / evaluation criteria,
The client will: Demonstrate ventilation and oxygenation dekuat on the network indicated by oximetry in the normal range and free of symptoms of respiratory distress., Participate in a treatment program in btas abilities / situations.
Intervention:
a. Monitor breath sounds, record krekles
Rational: declare adnya pulmonary congestion / secret collection demonstrates the need for further intervention.
b. Teach / encourage clients effective coughing, breathing deeply.
Rational: clearing the airway and facilitate the flow of oxygen.
c. Push the change of position.
Rationale: Helps prevent atelectasis and pneumonia.
d. Collaboration in the Monitor / draw series GDA, pulse oximetry.
Rational: Hypoxaemia may occur during severe pulmonary edema.
e. Give drug / supplemental oxygen as indicated
5. High risk of damage to skin integrity related to prolonged bed rest, edema and decreased tissue perfusion.
Goals / evaluation criteria
The client will: Maintain the integrity of the skin, Demonstrate behaviors / techniques to prevent skin damage.
Intervention
a. Monitor skin, bone protrusion noted, edema, impaired circulation area / pigmentation or overweight / underweight.
Rational: Skin disorders are at risk due to the peripheral circulation, physical immobilization and impaired nutritional status.
b. Massage the area red or white
Rationale: increased blood flow, minimizing tissue hypoxia.
c. Change position often in bed / chair, assistive range of motion exercises passive / active.
Rationale: Improve the circulation of an area that interferes with blood flow.
d. Give perawtan skin, minimize the moisture / excretion.
Rationale: Too dry or moist skin damage / speed up the damage.
e. Avoid drugs intramuscularly
Rational: interstitial edema and impaired circulation slows drug absorption and predisposition to skin damage / infection ..
6. Lack of knowledge (learning need) regarding condition and treatment programs related to lack of understanding / misperceptions about the relationship of cardiac function / disease / failure, characterized by: a Question of problems / errors of perception, GJK episode recurrence can be prevented.
Goals / evaluation criteria
The client will:
a. Identify the therapeutic relationship to reduce recurrent episodes and prevent complications.
b. Identify personal stress / risk factors and some techniques for handling.
c. Make changes to lifestyle / behavioral needs.
Intervention
a. Discuss normal cardiac function
Rationale: Knowledge of the disease process and hope to facilitate adherence to the treatment program.
b. Strengthen rational treatment.
Rationale: The client believes that the change is allowed when the post came home feeling good and free of symptoms or feel healthier which can increase the risk of exacerbation of symptoms.
c. Instruct food diet in the morning.
Rationale: To provide adequate time for the effects of the drug before bedtime to prevent / limit stop sleeping.
d. Refer to the sources in the community / support group an indication
Rational: can add their own help with monitoring / management of home.
REFERENCES
Barbara C. Long, Medical Surgical Nursing (Translation), Bandung Padjajaran IAPK Foundation, September 1996, p. 443-450
Marilynn E Doenges, Nursing care plan (Guidelines for Planning and Documenting Patient Care), Issue 3, EGC Kedikteran Book Publishers, 2002, p; 52-64 & 240-249.
Junadi P, hissing S, Husna A, Capita selekta Medicine (pleural effusion), Media Aesculapius, Faculty of Medicine, Universita Indonesia, 1982, Hal.206 - 208
Lorraine M Wilson, Pathophysiology (Concept Clinical Disease Processes), Book 2, Issue 4, 1995, It; 704-705 & 753-763.
