CHAPTER III

REVIEW OF CASE STUDY

ASSESSMENT FORM ADULT OF NURSING

Client Identity

Name : Mr. A No. RM : 234567

Age : 34 Years old Date of Entry : 23th March 2018
Gender : Male Date of Assessment : 23th March 2018
Adress : Silaberanti Information Source : Patient &family
Mobile : 083156750012 Closest family : Wife
phone
Marital : Farmers Address & Mobile : Silaberanti/
Status Phone 083156750012
Religion : Islam Medical diagnosis : Heart failure
Tribe : Java
Education : SHS
Occupation : Indonesia
Length of : 16 years old
work

Health History

Current Health

Main complaint : Complaints of shortness of breath and left chest pain

Predisposing : Patients who appear to be arising, coughing, easily feel tired
factors when doing activities so that only patients who are lying in
bed, patients also seem nervous and anxious about their
condition.
Precipitation : The client said he was admitted to the hospital on 23 March
factors 2018 at 23.00 WIB, Assessment on 23 March 2018 at 24:40
WIB, the client said 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. 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.

Current Health History (PQRST)

P : Pain when the patient is doing activities

Q : Pain like being pressed

R : Pain is felt in the left chest

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 :
Accident
Operations (type and time)
Disease (chronic and acute)
Last entered the hospital
Allergies (drugs, food, plaster, etc.) :
The client said he had no previous heart
history.
: The patient said he had never had an
accident
: The patient says he has never had
surgery
: The patient says he has no history of the
disease
: The patient said he had never been
hospitalized before
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

Sexuality (Can’t assesment)

Subjective Data : -
Objective Data : -
Nursing Problems:

Tolerance / Koping Stress

Subjective Data : The client when he is sick can only lie in bed and take a shower
wiped by Mr. family. A is married and has 2 children. Mr. A
had stress since he was sick because the client could not work
 while his child still needed fees for school
Objective Data : Patient looks limp
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

Assessment Review of System and Physical

Respiration system

Subjective data : The patient says shortness of breath while on the

move, and coughs with sputum.
Objective Data
Inspection : The shape of the spine is erect and normal chest shape
Palpation : No mass and tenderness
Percussion : Above the lung surface
Auscultation : Ronchi +/+, Wheezing +/+
Nursing Problems : Disruption of gas exchange

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 :

XII Cranial Nerves :

Physiological reflexes :
Pathological Reflexes :
Nursing Problems : There is no nursing problems

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 :

Inspection : Catheter urine production is 1000cc / day brownish yellow

Palpation : Good skin turgor
Percussion : There is no
Auscultation : There is no
Nursing Problems : There is no nursing problems

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

Inspection : symmetrical, good visual function, red conjunctiva, white sclera,

isocorous pupil
Palpation : Palpation is not done
Nursing problems: There is no nursing problem

Hearing
Subective data : The patient says his ears are normal
Objective data

Inspection : Good hearing function, clean, no abnormal lumps

Palpation : Palpation is not done
Nursing problems: There is no nursing problem

Snub
Subjective data : The patient says the smell is normal
Objective data

Inspection : Symmetrical, good olfactory function, presence of nasal lobes,

O₂nasal cannula 4 lpm
Palpation : Palpation is not done
Nursing problems: There is no nursing problem

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

Reaction during interaction

Cooperation………… Uncooperative………….

Explain :Patients receive assessment and follow orders during assessment

Nursing Problems: There is no nursing problem

Supporting Examination (Laboratory, Radiology, ECG, etc.)

Date of Examination: 23 March 2018

1. X-Ray examination with the result of enlargement of the heart and pulmonary
congestive
2. Blood gas analysis :pa O2 from-HR more than 100 x/minute
3. Result of ECG ST segment elevation and pathological Q
4. Increased cardiac enzymes, namely CK, AST, LDL/HDL.
Therapy

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

2. Arixtra 1x2,5 Injection Injectio Studies in Be careful if

mg Liquid n experimen you experience
tal impaired kidney
animals function, blood
not clotting
pregnancy disorders,
and endocarditis,
lactation angioedema,
show a gastric ulcers,
risk to the strokes, or just
fetus, but undergoing
there have brain, spinal and
been no eye surgery.
controlled
studies in
pregnant
women.
3. ASA 1X80 Oral Oral Treat mild Do not use this
mg medicatio to medication for
n moderate patients who
pain such have a history
as of allergies to
toothache aspirin
and after (acetosal),
tooth ibuprofen or
extraction, naproxen, or
headache, NSAIDs in
earache, general.
muscle
pain, joint
pain, as a
fever-
lowering,
and as an
anti-
inflammat
ory
(inflamma
tion).
 DATA ANALYSIS
DATA/PROBLEM ETIOLOGY NURSING PROBLEM
DS : Myocardial infraction Decreased cardiac output

1. Patient says he suffers

from rapid exhausation

2.Patient says it’s stuffy Diastolic filling

when there’s activity increase

DO :
Decrease the key
1. Cough content

2. Edema lower extremities

3. Result of ECG ST Ventricular load

segment elevation and increase
pathological Q

Decreased cardiac
output
DS : Myocardial infraction Disruption of gas exchange

1. The patient says

shortness of breath
Left Ventricular
dysfuntcion
DO : Contractility

1. Blood gas analysis : pa

O2 from-HR more than
100x/m Heart failure

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

1. The client said that

before he got sick he ate
well, ate 3 times a day with Valve malfunction
a menu of rice and side
dishes, drank water, coffee
and energy-enhancing
Heart failure
drinks, a total of ± 2000ml /
day

DO : Decrease Cardiac
output
1. Edema lower extremities

2. BP 180/90 mmHg
RAA Activation
3. RR 28 x/m

Increase in sodium and

water reabsorbsi in
urine

Excess fluid volume

LIST OF NURSING PROBLEM

1. Decreased cardiac output
2. Disruption of gas exchange
3. Excess fluid volume
PRIORITY OF NURSING PROBLEM
1. Decreased cardiac output
2. Disruption of gas exchange
3. Excess fluid volume

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.