Professional Documents
Culture Documents
Nursing Interventions
2. Decreased cardiac After nursing actions for 2 x 24 hours are 1) TTV Monitor 1) To see the patient's
output is related to expected to have normal cardiac output with 2) Monitor blood pressure is high
changes in heart the following criteria: The effectiveness of a cardiovascular status or low because it will
frequency heart pump 3) Monitor fluid affect the heart's
Indikator Early Purpose balance working system
Blood pressure within 2 4 4) Monitor client 2) Poor cardiovascular
the expected limit activity tolerance status can be caused by
5) Monitor signs and pulmonary edema and
Weaknesses in 2 4
symptoms of edema this is closely related to
extensibility don't exist
6) Monitor the amount heart failure
The heart index is 2 4
and rhythm of the 3) Increased loss of fluid
within the expected
heart in response to changes
limit
in speed and depth of
E. Nursing Implementation
Day, date,
No. Nursing Diagnose Implementation Response
time
1. Ineffectiveness of Saturday, 1) observe vital signs The client responds well to the
breath patterns May 11, 2019 2) to treat breath sounds, note the actions taken
associated with pain 02.00 am presence of additional breaths
(chest) 3) maintain semi fowler position
4) recommend to clients to drink warm
water
5) guide and practice regular deep
breathing and effective coughing
techniques
Saturday, 1) give the nebulizer as indicated The client responds well to the
May 11, 2019 2) continue the administration of O2 actions taken
02.15 am according to the doctor's instructions
2. Decreased cardiac Saturday, 1) Monitoring TTV The client responds well to the
output is related to May 11, 2019 2) Monitoring cardiovascular status actions taken
changes in heart 02.30 am 3) Monitoring fluid balance
frequency 4) Monitoring tolerance of client
activity
5) Monitoring signs and symptoms of
edema
6) Monitoring the amount and rhythm of
the heart
3. Pain associated with Saturday, 1) comprehensive pain assessment P: Pain is felt suddenly when
biological injury May 11, 2019 including location, characteristics, coughing and holding cough
agents 02.45 am duration, frequency, quality and Q: Pain is felt like being slashed
precipitation factors R :: pain in the left chest radiates
2) observe nonverbal reactions from behind the back
discomfort T: sudden pain
3) evaluating past pain experiences S: Pain scale 5
Saturday, 1) do pain management with deep The client responds well to the
May 11, 2019 breath actions taken
02.50 am 2) provide analgesics to reduce pain
4. Activity intolerance is Saturday, 1) observe the level of client activity The client responds well and
related to immobility May 11, 2019 2) help clients carry out activities that understands what is being
03.00 am cannot be done instructed on the actions taken
3) involving the family in fulfilling the
client's ADL
4) encourage clients to carry out
activities according to their abilities
5) over the period of activity with rest
F. Evaluation
1. Sunday, May 12, Ineffectiveness of breath S: patients say they are still short of breath
2019 patterns associated with pain O:
06.00 pm (chest) installed binasal kanul 5 liters / minute
RR: 28 x / minute
use O2 therapy with binasal kanul 5 liters /
minute
the client is more relaxed after getting O2
therapy
sweat a lot
semi fowler position
A: The problem has not been resolved
P: Continue intervention
Auscultation of breath sounds, note the
presence of additional breaths
Monitor inspiration from O2 status
2. Sunday, May 12, Decreased cardiac output is S: patients say the heart is still pounding frequently
2019 related to changes in heart O:
06.15 pm frequency BP : 180/90 mmHg, P : 88 x / min, RR: 28x
/ min, T: 36 ° C
Irregular heart rhythms and ECG results
obtained irregular rhythm, HR 100x / m
A: The problem has not been resolved
P: continue the intervention
Monitor the amount and rhythm of the heart
Monitor TTV and cardiovascular status
monitors
3. Sunday, May 12, Pain associated with S: the patient still says chest pain when coughing
2019 biological injury agents and holding cough
06.30 pm O: looks holding on to his chest
A: the problem has not been resolved
P: continue the intervention
Give analgesics to reduce pain
Perform a comprehensive pain assessment
including location, characteristics, duration,
frequency, quality and precipitation factors
Observation of nonverbal reactions from
discomfort
4. Sunday, May 12, Activity intolerance is S: the client said he was still tight and felt tired
2019 related to immobility when doing activities a little overcame
06.45 pm O:
general weakness, composmentist
awareness,
BP : 180/90 mmHg
P : 88 x / minute
T : 36 ° C
RR : 28 x / minute
fatigue, anxiety, anxiety.
A: the problem has not been resolved
P: Continue intervention
Observing the level of client activity
Complete the period of activity with rest
G. Discharged Planning
1. Eat soft, low-salt foods as needed
2. Activity and rest, where the abnormal heart work must be reduced by several activities such as total bedres, with rest
can reduce symptoms of heart failure
3. Provide education about specific conditions
4. Provide specific instructions about the drug and its side effects
5. Teaches feeding techniques and nutritional needs