Assessment

1) Anamnesis
In anamnesis, the part being studied is the chief complaint, history of present illness, and
past medical history

a) Main complaint
 Tachycardia
 Nausea/Vomiting
 Orthostatic hypotension
 Tachypnea
 Hypothermia
 Lethargy
 Dry mucous membranes
 Decreased skin turgor
 Decreased reflexes
b) History of present illness
 The cause of the physical weakness after mild to severe activity.
 As with any perceived weakness when performing activities, usually accompanied by
shortness of breath.
 Is physical weakness is local or overall skeletal muscle system and whether
accompanied by an inability to perform movements.
 How is the value range of capabilities in performing daily activities.
 When is the onset of complaints of weakness activities, how ever weaknesses activity,
whether at any time, at rest or during activity
c) Past medical history
 History of hypertension
 History of diabetes mellitus
 Historyhiperlipdemia
 History of typical chest pain myocardial infarction
 History of drug use diuretics, nitrates, beta blockers and antihypertensives
 d) Family history
The nurses asks about the disease ever experienced by the family, and if there is a family
member who died, the cause of death were also asked. Ischemic heart disease in the
elderly whose onset at a young age is a major risk factor for ischemic heart disease in
the offspring.
e) Job history and habits
The nurse asked a work situation and environment. Asks in lifestyle habits, such as
drinking alcohol, certain medications, and smoking habits.

2) Physical Examination
Physical examination consist of general situation and assessment of B1-B6.
a. Level of Conciousness
When examine the general situation of the heart failure clients are usually obtained a
good awareness or compos mentis and will change according to the level of perfusion
disorders involving the central nervous system.
b. Assessment of B1-B6
 B1 (Breathing)
The assessment obtained by signaling pulmonary vascular congestion is dyspnea,
orthopnea, paroksimal nocturnal dyspnea, cough, and acute pulmonary edema. Crackles
or smooth wet crackles generally heard posterior lung sounds on the base. It is
recognized as evidence of left ventricular failure. Before crackles regarded as a pump
failure, the client should be instructed to cough in order to open the basilar alveoli
which may be compressed from below the diaphragm.
 B2 (Bleeding)
a. Inspection
Inspection the scarring after heart surgery. See the impact of cardiac output
decrease. Check whether or not the appearance of the jugular venous distention.
Note the presence or absence of edema in the lower extremities.
b. Palpation
Palpation to determine whether or not the changes in pulse.
c. Percussion
 Percussion the limit of heart to know there is a shift that indicates the hypertrophy
of heart (cardiomegaly).
d. Auscultation
S3 or ventricular gallop is an important sign of left ventricular failure.
c. B3 (Brain)
Consciousness is usually compos mentis, peripheral cyanosis obtained when severe
tissue perfusion disturbances.
d. B4 (Bladder)
Measurement of urine output volume related to water intake. Monitor for oliguria for the
earliest signs of cardiogenic shock. The extremities edema indicates severe fluid
retention.
e. B5 (Bowel)
Clients are usually obtained nausea and vomiting, decreased appetite, and weight loss.
Assess whether there is hepatomegaly.
f. B6 (Bone)
Clients usually found cold skin and fatigue.