PROJECT BASED LEARNING

NURSING MANAGEMENT IN CARDIOVASCULAR SYSTEM

Presented byGroup 1:
1. ZakiyahDarajat S

131423001

2. MatildisAsry S

131423003

3. MaulanaArif M

131423005

4. HartantiUtami

131423007

5. Fristhina M

131423009

6. M. Hayat Sadan

131423011

7. YuniHidayati

131423014

NURSING FACULTY
AIRLANGGAUNIVERSITY
SURABAYA
2014

PREFACE

First at all, give thanks for Gods love and grace for us. Thanks to God for
helping and give uschance to finish this project based learning timely. And we
would like to say thank you to Mrs.Yulis Setiya Dewi, Skep,Ns M.Ng.as the
lecturer and facillitator that always teaches us and give much knowledge about
how to make this project.
This assignment is the one of Project Based Learning that especially of
Nursing Management in CardiovascularSystem. We realized this assignment is
not perfect but we hope it can be useful for us. Critics and suggestion are needed
here to make this project be better. Hopefully we as a student in Nursing Faculty
Airlangga University can work more professional by using English as the second
language whatever we done. Thank you.

Surabaya, October 24 2014

NURSING PROCESS OF CLIENT WITH

CONGESTIVE HEART FAILURE
A. ASSESSMENT
NURSING HISTORY
Admission Date
: Oct 30th, 2014
No. Reg
: 628822
Hospital
: RSUA
Time
:10.00 am
Medical Dx
:Angina Pectoris with STEMI
Date of Assessment : Nov 2nd, 2014
I.
Patient identity
:
a. Name
: Mr. Alan
b. Age
: 30 years old
c. Sex
: Male
d. Race
: Java
e. Religion : Moslem
f. Education : Magister of accounting
g. Occupation : Accountant at Delloitte
h. Address
: Surabaya
II.

History of present Illness

1. Chief Complain: Chest pain and difficult to breath.
2. Present Illness Story: Patient had been often feeling
uncomfortable with his chest. When at work, with many things
to do, especially on hectic schedule, its getting more painful.
Patient had difficulty in breathing suddenly, and his chest is
really pain. He hadnt been taken medicine from hospital. He is
a smoker, consume soda water everyday, and fast food.

III.

Past nursing history

1. History of Contagious Disease: Yes, with the same symptom
like now.
2. Hereditary Disease:Yes. Hypertension, stroke.
3. Allergic History: None.

IV.

Family health history (Genogram )

65

35

30

Advert:
: Male
: Female
: Living together
: Patient
: Passed away
Patients mother has passed away four years ago due to stroke, and
his father was also a heavy smoker.

V.

Observation and physical examination

Vital Signs: T: 36,6oC; HR: 86 x/min weak pulsation; RR: 25x/m;
BP: 150/90 mmHg.

VI.

Environment of home
House is good condition. Hygiene of the environment around the
house is good.

VII.

Physical assessment
1. B1: Breathing (Respiratory System)
a. Complain
:difficult to breath
b. RR patern
: abnormal; frequency: 25 x/min, rhytm:
regular, breathing: vesicular, sounds: -, O2 adm: yes.
c. Others
: using the asessory muscle.
PROBLEM

:-

2. B2: Blood (Cardiovascular System)

a. Complain
: chest pain; His pain radiate to the his
shoulder, it feels like burning. His level pain is 6. Duration
of pain about 15 minutes.
b. Heart Sound :normal
c. Edema
:none

d. Others

: looks pale, grimace, no conjunctival pallor,

no cyanosis on the lips, there is no sign JVP in the neck,

normal character in carotid pulse and billaterally,
PROBLEM
: Acute Chest Pain
3. B3: Brain (Nervous System)
a. Orientation : Person: good; Time: good; Place: good.
b. Complain
: None
c. Awareness
: Compos mentis (GCS: E=4, M=5, V=6)
d. Eye
: Pupil: isochors; sclera: normal; conjuctiva:
normal light red.
e. Nerve disturbance: Trismus: none; paralyze: none.
PROBLEM
:4. B4: Bladder (Genitourinary System )
a. Complain
: none
b. Urine Output : 350 ml/ day; color: light yellow; smell:
none.
c. Fluid Intake
PROBLEM

: oral: water: 600 cc/ day; parenteral: none.

:-

5. B5: Bowel (Gastrointestinal system- GI Tract)

a. Mouth
: normal
b. Abdomen
: soepel; peristaltic: 10 x/min
c. Alvi elimination: not yet.
Consistency : d. Diet
:DJ
e. Weight
: 94 kg (before ill: 95 kg)
PROBLEM
:6. B6: Bone (Bone Muscle Integument)
a. Joint Activity
: limited
b. Extremitas complain : none
c. Back injury
: none
d. Integuments
: normal (brown); acral: warm, no
clubbing finger; turgor: good; no midline sternotomy.
PROBLEM
: Activity Intolerance
7. Endocrine System
a. Complain
: none
PROBLEM
:VIII. Psychosocial assessment
1. Client perception about her disease (parents perception ): God
Struggle.
2. Client expression toward his disease: look sad.

3. Year reaction: cooperative.

4. Self concept disturbance: Not.
PROBLEM: Diagnosis Test and Medical Treatment
1. Laboratory: Oct 30th ,2014: Hb: 12,7 g/dl (14-18 g/dl);
leucocyte: 7.500 /UL (4,8-10,8/UL); Ht: 36,4% (42-52%); Tr:
216.000/UL (150.000-450.000); LED: 20 (0-15).
2. Ro Thoraks: cardiomegali (-).
3. ECG: ST segmen elevation.
4. Therapy: O2 3L/mnt; RL 500cc/ 24 hours; Aspilet 2x 80 mg;
Ranitidine 2x 150 mg; Captopril 3x 12,5mg; ISDN 3x1 tab.
DATA ANALYSIS
Data
Subjective Data:

Etiology
Atherosclerosis

He said that:

and/or coronary

-chest pain

Problems
Acute chest pain

spasm

-his pain radiate to the

his shoulder, it feels
like burning.
-his level pain is 6.
-duration of pain about
15 minutes.
Objective Data:
- T: 36,6C; HR: 86
x/min, weak pulsation;
RR: 25x/m; BP: 150/90
mmHg.
-grimace
-looks pale
Subjective Data:
-

Ineffective

teaching Deficit knowledge

He hadnt been or learning in past

taken medicine
from

hospital.

He is a smoker,
consume

soda

water everyday,
and fast food.
Objective Data: -

B. NURSING DIAGNOSIS
1. Acute chest pain related to atherosclerosis and/or coronary spasm.
2. Deficit knowledge related to ineffective teaching or learning in past.
C. PLANNING
Nursing Diagnosis

Goal and Objective

Nursing Orders
(NOC)
(NIC)
Acute
chest
pain Within 48-72 hours:
a. Asses
patients
a.Patient
verbalized
related
to
description of pain.
relief
of
chest b. Monitor vital sign.
atherosclerosis and/or
c. Assess
for
discomfort.
coronary spasm.
b. Patient
appears
performing of ECG.
d. Instruct patient to
relaxed
and
relax or rest.
comfortable.
e. Give
breathing
exercise.
f. Administer oxygen
as ordered.
g. Instruct patient to

Deficit

knowledge Within 48-72 hours:

Patient or significant
related to ineffective
others understand and
teaching or learning in
verbalize
causes,
past
treatment, and followup

care

related

to

take

sublingual

NTG.
a. Asses

knowledge

of

causes,

treatment,
follow-

and
up

care

related to Angina

Angina Pectoris.

Pectoris.
b. Dietary
modification.

D. IMPLEMENTATION
Problem
Acute pain

Implementation
a. Asses patients
description
pain.
b. Monitor

of

for

performing

of

patient

exercise.
f. Administer

feels

like

burning;

his

duration of pain
about

15

minutes.

and

looks grimace.
b. T: 36,6C; HR:
as

ordered.
g. Instruct patient
to

his shoulder, it

level pain is 6;

to relax or rest.
e. Give breathing

oxygen

pain, his pain

radiate to the

vital

sign.
c. Assess
ECG.
d. Instruct

Evaluation
a. He feel chest

take

sublingual NTG.

86 x/min, weak
pulsation;

RR:

25x/m;

BP:

150/90 mmHg.
c. ST
segmen
elevation.
d. Patient follow
the instruction.
e. O2 3 l/m nasal

Deficit knowledge

a.

Asses knowledge of
causes,

treatment,

canule.
f. He feel better.
g. He feel better.
a. He hadnt been
taken medicine

and follow- up care

from

hospital.

related to angina

He is a smoker,

pectoris.
b. Dietary
modification
limit

consume

soda

water everyday,
to
sodium

ingestion.

and fast food.

b. He
looks
understand.

E. EVALUATION
1. Acute chest pain related to atherosclerosis and/or coronary spasm.
S:He said that he feel chest pain, his pain radiate to the his shoulder, it
feels like burning; his level pain is 6; duration of pain about 15
minutes. and looks grimace
O: T: 36,6C; HR: 86 x/min, weak pulsation; RR: 25x/m; BP: 150/90
mmHg; He looks grimace; looks pale.
A: Decreased pain but still possible to happen.
P: Management in relaxation/ breathing exercise if pain might be
increase.
2. Deficit knowledge related to ineffective teaching or learning in past.
S: He hadnt been taken medicine from hospital. He is a smoker,
consume soda water everyday, and fast food.
O: He looks understand.
A: Problem not solved.
P: Monitor the dietary.

Reference:
Gulanick, et all. 2007. Nursing Care Plans: Nursing Diagnosis and Intervention.
Philadelphia: Mosby Elsevier.
Nursalam. 2010. English for Nursing-Midwifery Science and Technology. Jakarta:
Salemba Medika