PRELIMINARY REPORT
A. Medical Concept
2. Etiology
1. Definition
3. Patofisiology
6. Medical 4. signs and
Treatment symptoms
5.Examination
Support
A. Medical Concept
1. Definition
Congestive heart failure (CHF) is an imbalance
in pump function in which the heart fails to
adequately maintain the circulation of blood.
A. Medical Concept
2. Etiology
According to Hudak Gallo (1997)
Dysritmias
Valve Malfunction
Abnormality of hearth muscle
Myocardial Rupture
A. Medical Concept
3. Patofisiology
Heart failure is not a clinical condition that involves only
one body system but rather a clinical syndrome due to
heart problems so that the heart no longer pumps meet
the needs of the body's metabolism. Heart failure is
characterized by a single hemodynamic response,
kidneys, nervous and hormonal real and a pathological
state of a decline in cardiac function.
A. Medical Concept
4. signs and symptoms
pulmunory symptoms : dyspnea, orthopnea, and
paroxymal noctural dyspnea
Systemic symptoms : weak, tired,oliguric,
nokturi, vomiting, ascites, hepatomegaly
Symptoms of central nervous system : insomnia,
headache, nightmares until delirium
A. Medical Concept
5. Examination Support
Chest X-ray
Examintaion echocardiography
ECG
Examination of blood gas analysis
Examination alaine amino transferase
Cardiac enzym
Examination creatinine
A. Medical Concept
6. Medical Treatment
3 important aspect of treatment ”: treatment of heart
failure, treatment of underlying, treatment of
trigger factors, included in the medical treatment.
The usual treatment is : rest, setting temperature
and humidity, oxygen, fluid and diet.
B. Nursing Concept
Impaired sense of comfort related to ischemia
heart tissue
Activity intolerance related to imbalance
between supply and demand of oxygen,
presence of necrotic tissue and ischemia on
myocardial
The risk of decreased cardiac output related to
changes in the rate, rhythm, cardiac
conduction, preload decreasing.
B. Nursing Concept
The risk of decreased tissue perfusion related
to decreased blood pressure
The risk of excess fluid imbalances related to
decreased organ perfusion, increased retansi
sodium, decreased protein plasm
NURSE PLAN REPORT
NURSE PLAN REPORT
A. Identity
Name : Mr. M
Gender : Male
Age : 52 years
Address : Jl. Veteran
Maritial Status : Married
Religion : Islam
Ethnic : Banjar
Date of admission : 1 November 2010
Date assessment : 1 november 2010
Medical Diagnosis : Congestif Heart Failure
NURSE PLAN REPORT
B. chest and circulation
Shape of client chest is symmetrical, there is not abnormalities
in the chest, there is not injury or inflammation of the chest,
the client looks difficult in breathing,
posterior anterior : lateral 1: 2
Tactile permitus,: movement in the right lung is harder,
vibration in the left lung is very weak.
Percussion: hear sonor sound
NURSE PLAN REPORT
C. Data Focus
Subjective Data :
Clients said that he no appetite
Clients said that he just just only oeat 3
tablespoons
Clients said that he often shortness of breath
Clients said that he feel difficult to sleep
The client said that he feel tightness when
lying down
NURSE PLAN REPORT
Objective Data :
examination
- The food always remain on the plate
- Client looks tired
- The client look has problems when breathing (inhalation)
palpation
- Permitus Textiles, movement in the right lung is harder
percussion
- Tap the resonant voice
auscultation
- There is another breath sounds (ronkhi wet)
NURSE PLAN REPORT
D. Nursing Diagnose
Ineffective airway clearance related to breathing
obstruction secondary with secretion on bronchial
Imbalance nutrition less than body requirements related to
reduction in nutrient input
sleep pattern disturbance related to shortness of breathing
NURSE PLAN REPORT
E. Implementation
Checking the respiratory function
Checking the ability of secretion of the
problem
Give the semi-Fowler position high
Teaching clients about deep breathing
Helping clients effective cough
Collaboration analgesic
Check the client's diet
Monitor intake and output
Giving preferred foods
Recommends eating little but often
Check the client's sleeping habits
Review of compliance with the sleeping client
Give the position of the sims / powler semi
Creating a peaceful environment
Collaboration: analgesic
F. Evaluation
Ineffective airway resolved with 3 days
treatment
Imbalance nutrition resolved with 4 days
treatment
Sleep pattern disturbance resolved withi three
days treatment
