- ASSESSMENT
Assessment Date: Wednesday, April 25, 2012 16:45 hours IST
Space: ICU
How assessment: interview, physical examination, observation
Date of admission: Wednesday, April 25, 2012 12:17 hours IST
Client Identity
Name: Mr.. A
Age: 73 years
No.. Register: C351746
Address: Pedurungan, Semarang
Occupation: Retired
Marital Status: Married
Medical Diagnosis: Acute Posterior Inferior MCI
Responsible Clients
Name: Mr.. M
Age: 45 years
Address: Pedurungan, Semarang
Occupation: PNS
Last Education: Bachelor
Relationships with clients: Children
- Primary Assessment
|
Clients were able to breathe spontaneously, no airway obstruction such as blood, secretions, or foreign bodies. No snoring or gurgling sound on the client's airway. There cough reflex.
|
|
RR 28x/menit, nasal oxygen cannula mounted 3 liter / min, breathing regular, symmetrical chest expansion, comparison of inspiration: expiration = 1:2, there is no retraction of the chest wall, no nostril breathing and no use of accessory muscles pernapasanterdengar ronkhi sound.
|
|
TD: 79/61 mm Hg, MAP: 57 mmHg, HR: 71 x / min, SpO2: 93%,Capilary refill less than 2 seconds, not bleeding appears, no cyanosis, akral on the upper and lower extremities cold, chest pain terapat very great until the cold sweat, JVP +3 cm.
|
|
Awareness composmentis with GCS: (E 4, M 6, V 5), pupil size 2/2 mm (isokor), there is light at the pupil reaction (right-left), upper extremity muscle strength right / left: 5/5, limb muscle strength bottom right / left: 5/5.
|
|
No injuries or injury to the whole body. Temperature: 36.8 ° C.The client lies with the position semifowler, akral the upper and lower extremities cold.
|
|
Installed Folley catheter, urine contained 100 ml of clear yellow.
|
|
Not attached NGT
|
|
Heart monitors shows heart rate 71 x / min, Sao 2 93%,respiratory rate 18 / min, blood pressure 79/51 mm Hg, MAP 57 mmHg.
|
- Secondary Assessment
- Medical history
- The main complaint
The client complained of chest pain is very great.
- History of present illness
Clients come to the ER Hospital Dr. Kariadi on April 25, 2012 at 12:17 pm with complaints of chest pain. Clients say less than 5 hours before hospital admission on chest yeri clients feel very great to the client in a cold sweat. Clients say the pain is felt after the client clean-room and bath. Client's family said earlier clients to check their health poly Hospital Dr. Kariadi and got drug (aspilet). The results of the data obtained in the ER assessment that the client is experiencing chest pain, nausea and vomiting are. TD: 97/47 mmHg, N: 56 times / min, RR: 12 times / min, temperature: 36.5 0 C and Atrial Fibrillation ECG. At IGD client is given intravenously intervention RL 12 TPM, O 2 cannula mounted 3 lpm, plavix 4 tablets, 2 SA injection ampoules, and dopamine 5 mg / kg / min (4 cc / hour) through Syring pump. The client was taken to the ICU around 16:45 pm. Composmentis client's level of consciousness with GCS E 4 M 6 V 5, the client uses a nasal cannula oxygen 3 liters / min, and mounted Dower catheter.
- Past medical history
Families say the client does not have a history of hypertension and cholesterol. Client's family said earlier client never admitted to the hospital.
- Family history of disease
Families said that no family members who have a history of diabetes, hypertension, kidney disease, asthma.
- KU and TTV
KU: Weak, level of consciousness: composmentis, GCS: E 4 M 5 V ET
16 April 2012
|
TD
(MmHg)
|
MAP
(MmHg)
|
HR
(Times / min)
|
SPO 2
(%)
|
RR
(Times / min)
|
Temperature
(O C)
|
17:00
|
116/85
|
92
|
115
|
92
|
28
|
36.8
|
18:00
|
106/71
|
79
|
82
|
90
|
28
|
36.7
|
19:00
|
108/69
|
79
|
80
|
90
|
28
|
36.8
|
20:00
|
100/70
|
78
|
88
|
90
|
29
|
36.9
|
21:00
|
106/71
|
79
|
82
|
90
|
28
|
36.7
|
- Physical examination
- Head and Neck
Studied
|
Information
|
Scalp
|
Clean, no injuries or lesions, no swelling.
|
The state of Hair
|
Black and straight, spread evenly, clean.
|
Eye
|
= Left-right symmetric, conjunctival pallor, no jaundice sclera.
|
Nose
|
No lesions, no discharge, no septal deviation, nasal oxygen cannula mounted 3 liter / min.
|
Ear
|
Clean, symmetrical right = left, there was no discharge
|
Mouth
|
Lip and oral mucosa appears dry, clean, there is no candidiasis / stomatitis, dental complete, no false teeth, dental caries
|
Neck
|
Normal form, no palpable swelling of the thyroid gland, there is no deviation of the trachea, JVP +3 cm.
|
- Cardiovascular System
Studied
|
Information
|
Inspection
|
ICTUS Cordis does not appear, there are no lesions on the chest area
|
Palpation
|
No palpable masses, palpable pulse ICTUS cordis
|
Percussion
|
dullness, heart border is in ICS V.
|
Auscultation
|
I-II heart sound pure, no gallop, no murmurs
|
- Respiratory System
Studied
|
Information
|
Inspection
|
Symmetrical chest movement, no injury
|
Palpation
|
There is no mass, tactile fremitus at the right and left, there is no deformity
|
Percussion
|
Sonor entire lung field
|
Auscultation
|
Vesicular sounds throughout the lung fields, no wheezing sound and ronkhi.
|
- System persyarafan
- Cerebral Function
GCS: (E 4, M 6, V 5)
Level of Consciousness: Composmentis
- Nerves k ranial:
- Nerve I (olfactory)
Date / Time
|
25 April 2012 at 17:00
|
Right nasal sensation
|
Normal
|
The sensation of the left nasal
|
Normal
|
- Nerve II (optic)
Date / Time
|
25 April 2012 at 17:00
| |
Right eye
|
Visual acuity
|
Clear
|
Field of view
|
Being able to see the vast
| |
See color
|
Normal
| |
Eye
left
|
Visual acuity
|
Clear
|
Field of view
|
Being able to see the vast
| |
See color
|
Normal
| |
- Nerve III (oculomotor)
Date / Time
|
25 April 2012 at 17:00
| |
Right eye
|
Form
|
isokhor
|
Large pupils
|
2 mm
| |
Light reflex
|
normal
| |
Eye
left
|
Form
|
isokhor
|
Large pupils
|
2 mm
| |
Light reflex
|
normal
| |
- Nerve IV (trochlearis)
Date / Time
|
25 April 2012 at 17:00
| |
Right eye
|
Downward eye movement in
|
Normal
|
Eye
left
|
Downward eye movement in
|
Normal
|
- Nerve V (trigeminal)
Date / Time
|
25 April 2012 at 17:00
| |
Sensation on the face of the object rough, smooth, blunt, pointed.
|
Forehead
|
Normal
|
Chin
|
Normal
| |
Right cheek
|
Normal
| |
Left cheek
|
Normal
| |
Opening the mouth
|
Capable
| |
Chew
|
Capable
| |
Bite
|
Capable
| |
- Nerve VI (abducen)
Date / Time
|
25 April 2012 at 17:00
| |
Right eye
|
Lateral eye movement
|
Normal
|
See twins
|
There is no
| |
Eye
left
|
Lateral eye movement
|
Normal
|
See twins
|
There is no
| |
- Nerve VII (facial)
Date / Time
|
25 April 2012 at 17:00
|
Puckered forehead
|
Capable
|
Smile
|
Capable
|
Raised eyebrows
|
Capable
|
Blindfold
|
Capable
|
- Nerve VIII (vestibulochoclears)
Stairs / Time
|
25 April 2012 at 17:00
| |
Right ear
|
Voices whisper
|
Being able to hear
|
Seconds wristwatch
|
Being able to hear
| |
Ear
left
|
Voices whisper
|
Being able to hear
|
Seconds wristwatch
|
Being able to hear
| |
- Nerves IX (glossopharyngeal)
Date / Time
|
25 April 2012 at 17:00
|
Sensing acid
|
Capable
|
Feel the salty
|
Capable
|
- Nerve X (vagus)
Date / Time
|
25 April 2012 at 17:00
|
Swallow
|
Capable
|
Speak
|
Capable
|
- Nerve XI (accesorius)
Date / Time
|
25 April 2012 at 17:00
| |
Shrug
|
Right
|
Capable
|
Left
|
Capable
| |
Lifting the head
|
Capable
| |
- Nerve XII (hypoglossal)
Date / Time
|
25 April 2012 at 17:00
| |
Sticking her tongue out
|
Capable
| |
Move the tongue
|
To the right
|
Capable
|
To the left
|
Capable
| |
Tremor
|
There is no
| |
- Sensory function
Stimulus
|
25 April 2012
|
Visual
Auditory
Raba
Tasting
Smelling
Painful
|
+ / +
+ / +
+ / +
+
+
there is
|
Ket. : +: Good
- Motor function
Date
|
25 April 2012
| |
Muscle strength
|
Upper limb
|
5/5
|
Lower extremity
|
5/5
| |
Muscle tone
|
Upper limb
|
5
|
Lower extremity
|
5
| |
Trophic
|
Upper limb
|
Not undergo atrophy
|
Lower extremity
|
Not undergo atrophy
| |
- Reflex
Inferior extremity
Reflex
|
right
|
left
|
Babinski reflex
Reflex Chaddock
|
-
-
|
-
-
|
- Abdomen
Studied
|
Information
|
Inspection
|
Convex shape, no lesions, no discharge on the umbilical.
|
Auscultation
|
There bowel sounds 10 times / min.
|
Palpation
|
No palpable lump or mass. There is no enlargement of liver and spleen.
|
Percussion
|
Tympanic
|
- Extremity
Upper Extremity
Date / hour
|
Right
|
Left
| ||||||
Pins and needles
|
Edema
|
Baal
|
Painful
|
Pins and needles
|
Edema
|
Baal
|
Painful
| |
18/04/2012
19:00
|
There is no
|
There is no
|
There is no
|
There is no
|
There is no
|
There is no
|
There is no
|
There is no
|
Muscle strength = 5/5
Lower Extremity
Date / hour
|
Right
|
Left
| ||||||
Pins and needles
|
Edema
|
Baal
|
Painful
|
Pins and needles
|
Edema
|
Baal
|
Painful
| |
18/04/2012
19:00
|
There is no
|
There is
|
There is no
|
There is no
|
There is no
|
There is
|
There is no
|
There is no
|
Muscle strength = 5/5
- Integumentary System
Date / hour
|
Skin color
|
Turgor
|
Mucosal lip
|
Capillary refill
|
Abnormality
|
18/04/2012
19:00
|
Tanned, clean
|
Good
|
dry
|
Less than 2 seconds
|
There is no
|
- Genetalia
Installed DC, clean, no infection.
- Nutritional status
Anthropometric
BB: 60kg TB: 168cm
BMI: weight / height (m 2)
: 60/1, 68 2
: 22.78 (Normal)
- Food habits
Before the illness, the client usually eat 3 times a day with a menu of rice, vegetables, side dishes, and water. After the pain, the clients get the nutrients in the form of a low-salt diet from the hospital 3 times a day and snacks (snacks) 2 times a day.
The body is weak, the client is attached infusion, and Dower cathether.
- Diet
1700 kcal low-salt diet 3 times a day and snacks (snacks) 2 times a day.
- Fluid status
Date
|
Intake (mL)
|
Output (mL)
|
Balance of fluid (ml)
|
18/4/2012
|
And drug infusion: 201 ml
Drink: 0 ml
Eating: 0 ml
|
Urine: 75 ml
IWL: 87.5 ml
Stool: 0
|
+38.5 Ml
|
Total Input: 201 ml
|
Total output: 162.5 ml
|
- Status gie ne h y
During illness, Tn. I in a weakened state so that the client is not able to perform self-care independently. Personal hygiene is assisted by a nurse swabbed every morning and evening. Client's hair looks clean, clothes and pampers clients changed every day or when bathing
- Activity and exercise
Self-care ability
Bartel INDEX
|
Score
|
FEEDING
0 = Not capable
5 = With the help of cutting, spread jam, ask for diet
10 = Self
|
5
|
Bathing
0 = Depends
5 = Self (or the shower)
|
0
|
GROOMING
0 = Need help
5 = Self-grooming, combing hair, cut nails, etc.
|
0
|
DRESSING
0 = Depends
5 = Need help but can do most of their own
10 = Self (including the input buttons, rights, etc..)
|
0
|
BOWELS
0 = Not able / incontinence (need giving enemas)
5 = Need help
10 = Can / continental / independent
|
0
|
Bladder
0 = incontinence, or dikateter and can not regulate their own
5 = Need help
10 = Can do yourself
|
0
|
TOILET USE
0 = Depends
5 = Need help, but sometimes can do themselves
10 = Self (wear and take off clothes)
|
0
|
Transfers (BED TO CHAIR AND BACK)
0 = Not capable of, there is no balance when sitting
5 = majority with the help of (1 or 2), can sit
10 = a little help (verbal and physical)
15 = independent
|
5
|
MOBILITY (ON LEVEL SURFACES)
0 = Not capable or <50 yards
5 = Depending wheelchair,> 50 yards
10 = Walking with assisted one person (verbal or physical)> 50 yards
15 = Self (but using a rock as a stick)> 50 yards
|
0
|
STAIRS (up stairs)
0 = Not capable
5 = Need help (verbal, physical, carrying a stick)
10 = Self
|
0
|
TOTAL SCORE
|
10
|
Classification of assessment:
0-20: Dependent total
21-40: dependent weight
41-60: being dependent
61-90: light dependent
91-100: independent / self-sufficient
Mr. Barthel index score total. A = 10 with a total dependent criteria.
All activities of clients assisted by nurses.
- Status of elimination
BAK
Date
|
Frequency
|
Number
|
Color
|
Painful
|
25/4/2012
|
DC
|
175 cc / 5 hours
|
Clear yellow
|
There is no
|
CHAPTER
CHAPTER 1 day smoothly client once, the last Chapter on April 25, 2012, at 05:30 pm.
- Medical Therapy
Date
|
Oral therapy
|
Injection therapy
|
IVFD
|
25/04/2012
|
|
Syring pump:
Injection:
|
|
- Investigations
- AP Photo Thorax X (25 April 2012)
- Cast: The apex of the heart displaced laterally.
- Pulmo: Corakan bronkovaskular normal left lung.
Invisible spots on both lung fields.
- Minor fissure was thickened.
- Hemithoraks right looks more bleak than the left.
- Right hemidiaphragm and costophrenic sinus closed gloom.
- Sinus Konto left-right phrenic taper.
Impression:
- Cardiomegaly (R V).
- Pleural effusion.
- ECG examination results (25 April 2012 at 17. 0 0 pm)
Rhythm: sinus rhythm
Axis: LAD
QRS rate: 62 x / min
P wave: P negative
Q wave: Q pathological
PR Interval: 0.19 seconds
QRS Duration: 0.08 seconds
ST segment: ST elevation in leads II, III, and AVF
Impression: Normal sinus rhythm, acute infarkinferior, right ventricular hypertrophy.
- Results of Laboratory Tests
Date 25/04/12 at 13:21 pm
Examination
|
Value
|
Unit
|
Normal Value
|
Ket
|
Hematology package
| ||||
Hemoglobin
|
11.19
|
g%
|
13.0 to 16.0
|
L
|
Hematocrit
|
33.6
|
%
|
40.0 to 54.0
|
L
|
Erythrocytes
|
3.70
|
Jt / mmk
|
4.50 to 6.50
|
L
|
MCH
|
30.26
|
Pg
|
27-32
| |
MCV
|
90.9
|
fL
|
76-96
| |
MCHC
|
33.28
|
g / dL
|
29-36
| |
Leukocyte
|
12.8
|
thousand / mmk
|
4-11
|
H
|
Platelets
|
171.3
|
thousand / mmk
|
150-400
| |
RDW
|
14.0
|
%
|
11.6 to 14.8
| |
MPV
|
7.64
|
fL
|
4-11
| |
Clinical Chemistry
| ||||
Glucose during
|
121
|
mg / dL
|
74-106
|
H
|
Urea
|
26
|
mg / dL
|
15-39
| |
Creatinine
|
1.48
|
mg / dL
|
0.6 to 1.3
|
H
|
CK-MB
|
48.0
|
U / l
|
7.0 to 25.0
|
H
|
Electrolyte
| ||||
Sodium
|
138
|
mmol / L
|
136-145
| |
Potassium
|
4.9
|
mmol / L
|
3.5 to 5.1
| |
Chloride
|
109
|
mmol / L
|
98-107
|
H
|
Calcium
|
2.32
|
mmol / L
|
2.12 to 2.52
| |
Magnesium
|
1.03
|
mmol / L
|
0.74 â € "0.99
|
H
|
Immunology
| ||||
Troponin I
|
0.12
|
Ug / l
|
<0.1
|
H
|
Blood Gas Analysis
| ||||
Temperature
|
36.8
|
C
| ||
Hb
|
11.19
|
g / dl
|
-
| |
FiO2
|
30.00
|
%
|
-
| |
pH (37 0 C)
|
7.31
|
-
| ||
PCO2 (37 0 C)
|
29.0
|
mmHg
|
-
| |
PO2 (37 0 C)
|
129.0
|
mmHg
|
-
| |
pH (Corrected)
|
7.31
|
7,350 â € "7,450
|
L
| |
PCO2 (Corrected)
|
29.0
|
mmHg
|
35.0 â € "45.0
|
L
|
PO2 (Corrected)
|
128
|
mmHg
|
83.0 â € "108.0
|
H
|
HCO3
|
14.6
|
mmol / l
|
18.0 â € "23.0
|
L
|
Base Excess
|
-10.0
|
mmol / l
|
-2.0 Â € "3.0
|
L
|
BE Effective
|
-11.10
| |||
SBC
|
16.5
|
mmol / l
| ||
O2 Saturation
|
99.0
|
%
|
95.0 â € "98.0
| |
A-ADO2
|
50.0
| |||
RI
|
0.40
| |||
AGD impression: partially compensated metabolic acidosis.
PO2/FiO2 = 129/0, 30 = 430 (Normal, the client did not have ALI or ARDS)
- DATA ANALYSIS
No.
|
Analysis of data
|
Problem
|
Etiology
|
1.
|
DS:
DO:
pH: 7.31 (L)
PCO2: 29.0 mmHg (L)
HCO3: 14.6 mmol / l (L)
Impression: metabolil acidosis partially compensated
Impression: pleural effusion
|
Impaired gas exchange
|
Changes in the membrane of the alveoli
|
2.
|
DS:
DO:
Impression: cardiomegaly (LV)
Rhythm: sinus rhythm
Axis: LAD
QRS rate: 62 x / min
P wave: P negative
Q wave: Q pathological
PR Interval: 0.19 seconds
QRS Duration: 0.08 seconds
ST segment: ST elevation in leads II, III, and AVF
Impression: Normal sinus rhythm, acute infarkinferior, right ventricular hypertrophy.
|
Decreased cardiac output
|
Changes in myocardial contractility
|
- PRIORITY ISSUE
- The decrease in cardiac output associated with changes in myocardial contractility.
- Impaired gas exchange related to changes in the membrane of the alveoli.
- Nursing Plan
DATE / HOUR
|
NO DX
|
OBJECTIVES AND CRITERIA RESULTS
|
ACTION PLAN
|
TTD
|
04/25/12
17:00
|
1
|
After nursing actions for 3x24 hours, the client does not experience a decrease in cardiac output with the expected outcomes:
TD: 110-130/70-90 mmHg
HR: 60-100 x / min
RR: 16-24 x / min
S: 36.5 to 37.5 0 C
|
Vital Sign Monitoring (6680)
Electrolyte Monitoring (2020)
Oxygen Therapy (3320)
Fluid Monitoring (4130)
Medication Management (2380)
|
Dinny
|
04/25/12
17:00
|
2
|
After nursing actions for 3 x 24 hours adequate gas exchange with the expected outcomes:
PH: 7:35 to 7:45
PCO 2: 35-45 mmHg
HCO 3: 18-23 mmol / L
BE: -2 - (+2) mmol / L
|
Respiratory Monitoring (3350)
Positioning (0840)
Oxygen Therapy (3320)
Acid Base Monitoring (1920)
|
Dinny
|
- NOTE DEVELOPMENT
Date / Time
|
No..Dx
|
Implementation
|
Response
|
Signed
|
04/25/12
17:05
17:08
17:40
18:00
18:10
18:15
19:00
19:10
19:15
20:00
20:15
20:25
20:30
20:35
20:40
|
2
2
1
1
2
2
1
2
2
1
1
2
2
1
1
|
Providing a comfortable position on the patient (semi-Fowler)
Giving oxygen mask nonrebreathing 6 liters / minute
Do an EKG
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Provide pharmacological therapy: aspilet 160 mg, plavix 75 mg, simvastatin 10 mg, and 25 mg via oral spironolacton.
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor the input and output of fluids
Monitor fluid balance client
|
S: Clients say more comfortable with a half-sitting position according regulated nurses.
O: The client appears to be more relaxed with the semi-Fowler position.
S: The client said it was still crowded, but it's better than ever.
O: RR: 22 x / minute, regular with a ratio of i: e = 1:2.
S: -
O: Rhythm: sinus tachycardia, axis: LAD, QRS rate:114x/menit, P wave: the negative P, Q wave: Q pathological, PR interval: 0.12 sec, QRS duration: 0.08 seconds, the ST segment: ST elevation in V1, V2, V3
S: -
O: BP: 116/85 mm Hg, MAP: 92 mmHg, HR: 115 x / min, Sao2: 97%, temperature: 36.1 0 C, JVP: +4 cm, ECG: sinus tachycardia, GCS E 4 M 6 V 5.
S: The client said it was still a bit claustrophobic.
O: RR: 18 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: BP: 106/71 mm Hg, MAP: 101 mmHg, HR: 79 x / min, Sao2: 97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus rhythm, GCS E 4 M 6 V 5.
S: The client said it was still a bit claustrophobic.
O: RR: 28 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: The client is able to take medication without vomiting. No allergic reactions.
S: The client complained of disturbed sleep due to chest pain.
O: BP: 105/70 mm Hg, MAP: 78 mmHg, HR: 88 x / min, Sao 2:96%, temperature: 36.3 0 C, JVP: +3 cm, ECG: atrial fibrillation, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 29 x / minute, regular, rapid, shallow with a ratio of i: e = 1:1, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: Clients say already drank 1 small glass while taking the medication.
O: Intake: drink 200 ml, 204 ml infusion and drugs; output: 250 ml urine, IWL 175.5 ml.
S: -
O: Intake: 404 ml, output: 425.5, BC: -21.5 ml.
|
Dinny
|
04/26/12
14:05
14:10
15:00
15:05
15:10
15:15
16:00
16.5
16:10
17:05
17:08
17:40
18:00
18:10
18:15
19:00
19:10
19:15
20:00
20:15
20:25
20:30
20:35
20:40
|
2
2
1
2
2
1
1
2
2
1
2
2
1
2
2
1
2
2
1
1
2
2
1
1
|
Providing a comfortable position on the patient (semi-Fowler)
Giving oxygen mask nonrebreathing 6 liters / minute
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor the provision of dopamine 5 g / kg / min
and heparin 1.2 cc / hour
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Provide pharmacological therapy: aspilet 160 mg, plavix 75 mg, simvastatin 10 mg, and 25 mg via oral spironolacton.
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor the input and output of fluids
Monitor fluid balance client
|
S: Clients say more comfortable with a half-sitting position according regulated nurses.
O: The client appears to be more relaxed with the semi-Fowler position.
S: The client said it was still crowded, but it's better than ever.
O: RR: 22 x / minute, regular with a ratio of i: e = 1:2.
S: Clients say chest pain.
O: TD: 96/60 mm Hg, MAP: 67 mmHg, HR: 93 x / min, Sao 2:97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus rhythm, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 18 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: No signs of phlebitis and allergies.
S: Clients say chest pain.
O: TD: 79/52 mm Hg, MAP: 58 mmHg, HR: 88 x / min, Sao 2:97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus rhythm, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 24 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: TD: 96/56 mm Hg, MAP: 65 mmHg, HR: 108 x / min, Sao 2:97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus tachycardia, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 28 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: BP: 101/68 mm Hg, MAP: 74 mmHg, HR: 103 x / min, Sao2: 97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus tachycardia, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 22 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: The client complained of disturbed sleep due to chest pain.
O: BP: 105/70 mm Hg, MAP: 78 mmHg, HR: 88 x / min, Sao 2:96%, temperature: 36.3 0 C, JVP: +3 cm, ECG: atrial fibrillation, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 29 x / minute, regular, rapid, shallow with a ratio of i: e = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: The client is able to take medication without vomiting. No allergic reactions.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: BP: 101/68 mm Hg, MAP: 74 mmHg, HR: 103 x / min, Sao2: 97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus tachycardia, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 22 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: Clients say already drank 1 small glass while taking the medication.
O: Intake: drink 200 ml, 308 ml infusion and drugs; output: urine 350 ml, 198 ml IWL.
S: -
O: Intake: 404 ml, output: 425.5, BC: -21.5 ml.
|
Dinny
|
27/04/12
14:05
14:10
15:00
15:05
15:10
15:15
16:00
16.5
16:10
17:05
17:08
17:40
18:00
18:10
18:15
19:00
19:10
19:15
20:00
20:15
20:25
20:30
20:35
20:40
|
2
2
1
2
2
1
1
2
2
1
2
2
1
2
2
1
2
2
1
1
2
2
1
1
|
Providing a comfortable position on the patient (semi-Fowler)
Giving oxygen mask nonrebreathing 6 liters / minute
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor the provision of dopamine 5 g / kg / min
and heparin 1.2 cc / hour
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Provide pharmacological therapy: aspilet 160 mg, plavix 75 mg, simvastatin 10 mg, and 25 mg via oral spironolacton.
Monitor hemodynamic status and level of consciousness
Monitor the client's breathing pattern (frequency, depth, breathing effort)
Breath sounds Mengauskultasi client
Monitor the input and output of fluids
Monitor fluid balance client
|
S: Clients say more comfortable with a half-sitting position according regulated nurses.
O: The client appears to be more relaxed with the semi-Fowler position.
S: The client said it was still crowded, but it's better than ever.
O: RR: 22 x / minute, regular with a ratio of i: e = 1:2.
S: Clients say chest pain.
O: TD: 96/60 mm Hg, MAP: 67 mmHg, HR: 93 x / min, Sao 2:97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus rhythm, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 18 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: No signs of phlebitis and allergies.
S: Clients say chest pain.
O: TD: 79/52 mm Hg, MAP: 58 mmHg, HR: 88 x / min, Sao 2:97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus rhythm, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 24 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: TD: 96/56 mm Hg, MAP: 65 mmHg, HR: 108 x / min, Sao 2:97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus tachycardia, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 28 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: BP: 101/68 mm Hg, MAP: 74 mmHg, HR: 103 x / min, Sao2: 97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus tachycardia, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 22 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: The client complained of disturbed sleep due to chest pain.
O: BP: 105/70 mm Hg, MAP: 78 mmHg, HR: 88 x / min, Sao 2:96%, temperature: 36.3 0 C, JVP: +3 cm, ECG: atrial fibrillation, GCS E 4 M 6 V 5.
S: The client says rather claustrophobic.
O: RR: 29 x / minute, regular, rapid, shallow with a ratio of i: e = 1:2, no intercostal retractions and use of accessory muscles.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: -
O: The client is able to take medication without vomiting. No allergic reactions.
S: -
O: TD: 124.74 mmHg, MAP: 85 mmHg, HR: 114 x / min, Sao 2:97%, temperature: 36.1 0 C, JVP: +3 cm, ECG: sinus tachycardia, GCS E 4 M 6 V 5.
S: -
O: No snoring and gurgling sounds in the airway. There is no sound of wheezing in both lungs. Vesicular sounds in the left lung. Ronkhi sound right at the lung bases.
S: The client says rather claustrophobic.
O: RR: 22 x / minute, regular, the ratio I: E = 1:2, no intercostal retractions and use of accessory muscles.
S: Clients say already drank 1 small glass while taking the medication.
O: Intake: drink 200 ml, 308 ml infusion and drugs; output: urine 350 ml, 198 ml IWL.
S: -
O: Intake: 404 ml, output: 425.5, BC: -21.5 ml.
|
Dinny
|
- EVALUATION
Date / Time
|
Nursing Diagnosis
|
Evaluation
|
Signed
|
04/25/12
21:00
|
The decrease in cardiac output associatedwith changes in myocardial contractility.
|
S: The client complained of difficulty sleeping due to shortness of breath.
O:
A: The problem is not resolved.
Q: Continue intervention:
|
Dinny
|
04/25/12
21:00
|
Impaired gas exchange related to changes in the membrane of the alveoli.
|
S: The client said it was still a bit claustrophobic.
O:
A: The problem is not resolved.
Q: Continue intervention:
|
Dinny
|
04/26/12
21:00
|
The decrease in cardiac output associatedwith changes in myocardial contractility.
|
S: The client complained of disturbed sleep due to chest pain.
O:
A: The problem is not resolved.
Q: Continue intervention:
|
Dinny
|
04/26/12
21:00
|
Impaired gas exchange related to changes in the membrane of the alveoli.
|
S: The client said it was still a bit claustrophobic.
O:
pH: 7.42 (H)
PCO2: 23.0 mmHg (L)
HCO3: 19.4 mmol / l
Impression: pH and HCO3 in the normal range, but still low PCO2
PO2: 130.0 mmHg (H)
FiO2: 52.0%
PO2/FiO2 = 130/52 = 250
Impression: Client suffered ARDS
A: The problem is not resolved.
Q: Continue intervention:
|
Dinny
|
27/04/12
21:00
|
The decrease in cardiac output associatedwith changes in myocardial contractility.
|
S: The client complained of disturbed sleep due to chest pain.
O:
A: The problem is not resolved.
Q: Continue intervention:
|
Dinny
|
27/04/12
21:00
|
Impaired gas exchange related to changes in the membrane of the alveoli.
|
S: The client said it was still a bit claustrophobic.
O:
pH: 7.40
PCO2: 24.0 mmHg (L)
HCO3: 20.1 mmol / l
Impression: pH and HCO3 in the normal range, but still low PCO2
PO2: 130.0 mmHg (H)
FiO2: 52.0%
PO2/FiO2 = 130/52 = 250
Impression: Client suffered ARDS
A: The problem is not resolved.
Q: Continue intervention:
|
Dinny
|
- DISCUSSION
Acute myocardial infarction is myocardial necrosis due to blood flow to the heart muscle is interrupted. This can be caused by coronary artery thrombus, plaque rupture is facilitated by the occurrence of factors such as hypertension, smoking and hypercholesterolemia. The occurrence of acute myocardial infarction is usually due aterosklerosi coronary arteries. Acute myocardial necrosis caused by a total blockage of the coronary arteries by a thrombus formed in unstable atherosclerotic plaque. Also often follow the rupture of plaque in a coronary artery with mild stenosis. Factors that facilitate the IMA include: smoking, hypertension, obesity, hypercholesterolemia, diabetes mellitus, and neurotic personality (Sylvana and Gabriela, 2005). It also happens on the client. The client has a history of heavy smoking and hypertension. Both of these lead to the emergence of plaque and thrombus-thrombus in the coronary arteries. Because hypertension is not handled properly, plaque and thrombus-thrombus increasingly enumpuk and block blood flow, causing necrosis of the coronary.
The assessment was conducted on 25 April 2012 at which time a physical examination is auscultation sound Ronchi in basal lung due to pulmonary edema. This is due to the increasing pressure of arterial and venous resulting decline in cardiac output. An increase in pulmonary venous pressure resulting in fluid flow from the pulmonary capillaries into the alveoli resulting in pulmonary edema. This is reinforced by the presence of pulmonary edema picture. This edema is a result of a buildup of secretions in the basal part of the right lung. So it can be lifted nursing diagnoses associated with impaired gas exchange with the alveoli membrane change interventions: monitor the general state of the client, the client monitors changes in respiratory status, provide a comfortable position on the client (semi-Fowler) and supplemental oxygen as indicated and collaboration with the monitoring of blood gas analysis.
At the time of the assessment also found that the data clients in a weakened state, GCS 15 komposmentis consciousness accompanied cyanosis, cold akral, capillary refill> 2 seconds and the client is experiencing dyspnoea. Weak conditions are the result of a decrease in cardiac output, circulation disorders and metabolic processes are not adequate (Smelter, Bare, 2001). So it can be lifted a second diagnosis is a decrease in cardiac output associated with changes in myocardial contractility with intervention: provide supplemental oxygen, monitor the level of consciousness and GCS, vital signs monitors and MAP, pupil evaluation and capillary refill , monitor fluid balance, maintain bed rest; elevate the head of the bed as well as collaboration with the monitor measures BGA laboratory tests, creatinine, electrolytes, hemoglobin, and hematocrit and give diuretic and vasodilator drugs as indicated. After nursing actions and collaboration client state of 25-27 April 2012 in which hemodynamically stable clients improved although conditions are still weak and still feel shortness of breath.
REFERENCES
Hudak, Gallo. , 1997. Nursing Critical Edition VI . Editor Esther Monica. Jakarta: EGC.
McCloskey, Joanne C & Gloria M. Bulechek. , 2000. Intervensions Nursing Classification (NIC) Third Edition. Mosby, Inc.: United State of America.
Nanda International.2010. Nursing Diagnoses Definitions and Classification 2009-2011 . Editor T. Heather Herdman. Jakarta: EGC.
Rokhaeni, Heni, et al. , 2001. Cardiovascular Nursing Textbook Medical Center Cardiovascular Harapan Kita National First Edition . Jakarta: Education and Training Center Cardiovascular Health National Harapan Kita.
Smelzer, C. Susanne. , 2002. Textbook of Medical Surgical Nursing 8th Edition. Jakarta: EGC.
Sudoyo, Aru W. 2006. Textbook of Internal Medicine 4th Edition . York: Publishing Center of Medicine FK UI.
Sylvana, Fransisca and Gabriela. , 2005. AMI (Acute Myocardial Infarction). Scientific Articles . Faculty of Medicine, University Wijaya Kusuma Surabaya.
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