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
Heart failure is a major health problem, where the prevalence of
heart failure in developing countries is quite high and is
increasing. Half of patients diagnosed with heart failure still
have hope to live for 5 years but approximately 250,000 patients
died because of heart failure either directly or indirectly every
year, 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 of
350 patients with heart failure diagnose, from total of 664
patients with heart disease.

BACKGROUND
DEFINITION
According 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 heart
muscle 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.
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, either
at rest or while experiencing physiological stress.
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


TREATMENT
According to Muttaqin (2009 : 103-104),
physiological responses in heart failure provide the
rationale for action. Target management of heart
failure are:
To reduce the hearts work
To increase cardiac output and myocardial
contractility
To reduce salt and water retention
Oxygen Therapy
Therapy of vasodilator and nitrate coronary
Diuretic Therapy
Digitalis Therapy
Positive Inotropic
Sedatives Therapy

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

NURSING CARE
ASSESSMENT
Clients identity
Name : Mr. A
Gender : Male
Age : 47 years old
Address : Kelayan B
Religion : Islam
Medical Diagnose : Heart failure
Date of entry : May 12
th
, 2014
Date of assessment : May 15
th
, 2014

Assessment
Main complaint of the client when assessment on May 15
th
, 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 12
th
, 2014
THE CLIENT
History of previous disease
The client said that he was ever hospitalized in
hospital in same ward with heart failure too. The client
said that he had heart failure since 6 months ago and
the client said that this is for 9 times when he took
medication in hospital in same ward. The client said
that he had no history of hypertension, diabetic and
contagious disease. The client said that he had no
history of allergic.

History of family disease
The client said that there were no family members
had the disease like the client had now, from the
families there were not having heart disease,
hypertension, and diabetic.

Assessment
Focus Data
The client said that
he had felt
breathless
The client said that
he had felt weak
doing 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 clients 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
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

Cont
Laboratory result of blood test on May 12
th
, 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 12
th
, 2014, fat and heart physiology,
LDH 580 U/I, CKMB 26 U/I
Laboratory result of blood test on May 12
th
, 2014, hepar, SGOT 47 U/I, SGPT
51 U/I
Laboratory result of blood test on May 12
th
, 2014, kidney, urea 52 mg/dl
Laboratory result of blood test on May 12
th
, 2014, electrolyte, potassium 3.3
mmol/I, chloride 100.6 mmol/I
Chest x-ray results on May 12
th
, 2014 shows cardiomegaly 60,37 %
enlargement of heart
ECG results on May 12
th
, 2014 : Regular heart rhythm, Heart rate 98 times a
minutes

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 mmHg
PERCUSSION
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

1. Impaired gas exchange related to inadequate
cardiac pump.
2. Imbalanced of nutrition: less than body
requirement related to inadequate intake of
nutrients.
3. Activity intolerance related to imbalance
between oxygen supply to tissues secondary
with cardiac output decrease (general
weakness).

Nursing Diagnosis
CONCLUSION
1. In the result of the assessment on May 15
th
to May 20
th
, 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
15
th
to May 20
th
, 2014. In the nursing evaluation, the problem
could only be half solved because of limited time and the client
went home.
By:
Muhammad Mustafa