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Case Description

Patient named Mrs. Vanessa whose age is 50 years old with


medical diagnosis coronary heart disease. Her family brought her to
Emergency Department with complains of pain in her left chest and
hard to breath (dyspnea). Her face looks so pale and weak. Blood
Pressure 160/100 mmHg, pulse 96x/minute, RR 22x/minute.
ASSESSMENT FORM

Date of Hospital admission : 04-03-2018


Time of hospital admission : 07.00 WIB
Date of assessment : 04-03-2018
Time of assessment : 07.07 WIB
Number of MR : 000444
Medical Diagnosis : Coronary Heart Disease

PATIENT’S Name : Mrs. Vanessa


IDENTITY Age : 50th
Sex : Female
Occupation : Housewife
Address : Kediri
SUBJECTIVE DATA OBJECTIVE DATA
Patient complain of pain in her left chest - The patient looks grinning in pain
- Patient looks pale
- Blood Pressure : 160/100 mmHg
- Pain Scale : 5

Patient complain of weakness, shortness - Blood Pressure : 160/100 mmHg


of breath (dyspnea), difficulty in carrying - Pulse : 96x/minute
out excessive activity, and often wake up - cold skin
at night due to tightness and chest pain. - RR : 22x/minute

Patient complain of dyspnea if she wake - Cold sweats when changing the
up from a sleeping position position of sleep immediately seated
Diagnosis and Nursing Care Plans
Nursing Diagnosis Outcome Intervention
Acute pain related to After nursing Pain Management (1400)
tissue ischemia or interventions for 2x24 1. Monitor and assess the
blockage of the hours, the acute pain is characteristics and location of
coronary arteries resolved with the pain
outcomes criteria : 2. Monitor vital signs (blood
- Pain Control (1605) pressure, pulse)
- Pain Management 3. Create a calm and comfortable
(1843) environment
- patient relaxes 4. Teach and encourage patients
- pain scale : 0 to do relaxation techniques
- Blood Pressure : 120/80 5. Collaboration with doctors in
mmHg (normal) administering analgesics
- Pulse : 80x/minute
Nursing Diagnosis Outcome Intervention
Decreased cardiac After nursing interventions for Cardiac Risk Management
output related to 2x24 hours, the decreasing (4050)
decreased muscle cardiac output is resolved with 1. Take a blood pressure
contraction the outcomes criteria : measurement (compare your
Cardiac pump effectiveness arms in a standing position, sit
(0400) down and lie down if possible)
- patient looks enthusiastic 2. Assess the quality of the
- patient is not dyspnea pulse
- Blood Pressure : 120/80 3. auscultation of breath sounds
mmHg (normal) and heart sounds
- Pulse : 80x/minute 4. Collaboration with doctors in
- patient's temperature is examining serial EGC, chest
normal radiographs, administration of
- RR : 20x/minute anti-dysrhythmic drugs
Nursing Diagnosis Outcome Intervention
Activity intolerance After nursing Monitoring Vital Signs (6680)
(00092) is related to interventions for 2x24 Activity Theraphy (4310)
an imbalance hours, patients show 1. Record the heart rhythm,
between oxygen increased ability to carry blood pressure and pulse before
supply and demand out activities with and after carrying out the
outcome criteria : activity
- Rest (0003) 2. Encourage patients to rest
- Self Care : Daily more
Activity (0306) 3. Encourage the patient to avoid
- Blood Pressure : 120/80 an increase in abdominal
mmHg (normal) pressure for example pushing
- Pulse : 80x/minute during defecation
- RR : 20x/minute 4. Explain to the patient about
- Patient is comfortable in the stages of the activity that the
sleep patient can do

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