NURSING CARE AT NY.

W WITH CHF IN THE LIVING CHRYSOLITE SETJONEGORO WONOSOBO GENERAL HOSPITAL

A. ASSESSMENT The assessment carried out on Day / date Hours : Monday, 6 June 2011 : 08.30 am - Family - Medical records 1. THE IDENTITY OF THE PATIENT Name Address Age Sex Religion Start dates 2. : Mrs. W : klowah 29 / 7, kalikajar, Wonosobo : 60 years : female : Islam : 2 June 2011 Number of RM: 495560

Source of data : - Patient

Medical Diagnosis : CHF

IDENTITY PERSON RESPONSIBILITY Name Address Relationships with patients : Mr. M : klowah 29 / 7, kalikajar, Wonosobo : younger brother

3. a.

HEALTH HISTORY The main complaint Patients say nausea

b.

Current medical history Patients come to a general hospital emergency department Setjonegoro area on 2 June 2011 with complaint shortness of breath since 5 days ago nausea (+), and heartburn radiating to waist. O2 therapy patients received 2 liters per minute, the injection of 2 x 50 mg ranitidine and attached infusion RL 15 drops per minute.

c.

Advance health history Patients say they have never suffered such pain now. Patients also said that had never been treated in hospital.

d.

Family health history Families of patients said in their family members has never been the same illness as the patient suffered. And in families of patients who have no infectious diseases such as hepatitis, diabetes mellitus, and congenital heart disease. 4. GORDON'S FUNCTIONAL PATTERNS a. Patterns of perception and health management The patient said she was not feeling well every patient always come to the village of poly clinic in her village to check her health. b. The pattern of activity and exercise Before ill patients can meet their own learning day actifity When sick patients assisted by his family to meet the total actifity day learning. Activity Eating and drinking Dressing Toileting mobilization 0 1 2 3 4 Description 0 1 2 3 4 : independent : assisted tool : assisted others : helped tools and others : total helped

c. Nutrition and metabolic patterns Before ill patients eat 3x a day denagn 1 portion of rice, vegetables and side dishes, the patient may spend a portion of it. For minimal patient to spend 6-8 glasses (200cc) per day. Patients often drink tea and to spend 3 cups per day

when sick patients eat 3x a day with soft rice menu, vegetables and side dishes. Patients only eat 3-4 tablespoons per meal. Patients said the nausea. Patients can spend weeks to drink 11-12 glasses per day. d. The pattern of elimination Before ill patients bowel movement 1x per day with soft consistency, stool characteristic odor. For patients to bladder 4-5 times per day with li helped tools and others quid consistency, color yellow, characteristic odor urea. after ill patients bowel movement 1x per day with soft consistency, stool characteristic odor. For patients with bladder catheter inserted Dower and produce 2000-3000 cc per day. e. Rest sleep patterns Before ill patients with a frequency of 6-7 hours sleep per harridan do not have a sleep disorder and patients rarely woke up during sleep. When sick patients to sleep with a frequency of 1-3 hours and patients are often awakened during the night. f. Patterns of perception and cognitive The patient said he did not know about the pain they experienced now, that he knew he was just sick nausea and unpleasant to eat. Patients have a good short-term memory it is proved by the patient to know now is where and know now what day. And also patients have good longterm memory it is proved by the patient knows how many children did and can tell if her husband had died 1 year ago g. Patterns of perception and self-concept The patient was a farmer, the patient wants to go home because they wanted to return to work paddy fields h. The pattern of relationships and roles Patient relationship with the family very well it is proved by ananknya always waiting for the patient during illness to meet patient needs. Patient relationship with the community is also very good it is proved by the number of visits for patients.

i. Sexual and reproductive patterns The patient was a widow, the patient had 3 children, 2 male, 1 female. The pattern of values and beliefs Patients religion of Islam, the patient said that he believes God will not give him healing. 5. PHYSICAL EXAMINATION General condition Consciousness Vital sign : Fair : Composmentis ( E4 M6 V5 = 15) : Blood pressure : 120/100 mmHg Pulse Temperature Head Eyes Nose Ears Mouth Neck Lung : 85x / min : 37,3 C

Respiration : 24x/ min : Hair Spread evenly, lesion (-), tenderness (-), clean enough. : Impaired vision (-), jaundice (-), anemis (-), a black circle on the eye (-) : nostril breathing (+), tenderness (-), lesion (-), O2 cannula inserted 3 liters / min : Hearing loss (-), clean enough, serumen (-) : mucosa moist, yellow teeth, stomatitis (-), lack of cleanliness : jugular venous distension (-), tenderness (-), lesion (-) enlargement of the thyroid (-) : I : Symmetrical P Per A : I P Per A : I A P : Pain press (-), tract vremitus balanced : Sonor : vesicular : : : : gallop : Symmetrical : Noisy gut: 34x / min : tender in all quadrants

Cardiovascular

Stomach

Per : Tymphani

Integument Genetalia Extremity

: dry skin, skin turgor enough, capillery reffill <2 seconds, jaundice (-) : Installed Dower catheter, enough hygiene : Top: mounted infusion RL 15 drops / minute, muscle strength 3, the lesion (-), black nails, dry skin, capillary refill <2 seconds Bottom: muscle strength 3, edema (+), dry skin, jaundice (-)

6.

THERAPY a. Injection Date 6/ 6/ 2011 Name of medication RL EAS Ondansentron Ranitidin Cefriaxon How to enter IV IV IV IV IV Dosage 15 drops / min 1 x 250 ml 2 x 4 gr 2 x 50 gr 1x 1 gr

7. 8.

DIET Patients receive heart diet EXAMINATION a. Laboratories No 1 2 3 4 5 6 7 8 9 10 Date 2/ 6/ 2011 Examination leokosit Eosinophils Netrofit lymphocyte blood glucose Ureum Creatinine triglycerides SGOT SGPT Results 14,9 x 103 /uL 0% 78,9 % 12,9 % 183 mg/ dL 263,7 mg/ dL 3,3 mg/ dL 153 mg/ dL 154 u/L 288 u/L Normal 3,6 11 24 50 70 25 40 70 150 < 50 0,4 0,9 > 0 140 0 33 0 35 Interpretation High Low High Low High High High High High High