Nursing Assessment - Nursing Care Plan for Congestive Heart Failure
Assessment is an early stage and the foundation of the nursing process. Required careful examination to know the patient's problem, in order to give direction to the nursing actions. The success of the nursing process is highly dependent on the precision and accuracy in the assessment phase (Lismidar, et al., 2005).
1. Identity
The client's identity consists of: name, age, gender, marital status, religion, ethnicity / race, education, occupation and address.
The identity of the person in charge consists of: name, relationship with clients, education, occupation and address.
2. Health history
a. Main complaint
The main complaint client with heart failure are shortness of breath, pain and weakness during the move.
b. Current medical history
Assessment that supports the main complaints made by asking a series of questions about physical weakness by using PQRST ways, namely:
P: Provoking incidents, physical weakness occurs after mild to severe activity, according to the disturbance of the heart.
Q: Quality of pain, such as what the complaints of weakness in an activity that is perceived by the client. Usually every move, clients feel shortness of breath.
R: Region, whether physical weakness localized or affect the entire musculoskeletal system and is accompanied by the inability to perform the movement.
S: Severity (scale) of pain, examine the range of the client's ability to perform daily activities. Usually the client's ability to move decreases the degree of interference experienced organ perfusion.
T: Time, nature of early onset, complaints of weakness activity usually occurs slowly. Old onset of weakness when the move is usually all times, both at rest and during activity.
c. Past medical history
Assessment of the support assessed by asking whether previously been suffering from chest pain, hypertension, myocardial ischemia, diabetes mellitus, and hyperlipidemia.
Ask about drugs commonly taken by the client in the past and are still relevant to current conditions. These drugs include drugs diuretics, nitrates, beta-blockers, and antihypertensives. Note the side effects that occurred in the past. Drug allergies and allergic reactions that arise. Often clients interpret an allergy as a side effect of medications.
d. Family history
The nurse asked about illnesses experienced by the family, the family members who died, especially in the productive age, and cause of death. Ischemic heart disease in the elderly who onset at a young age is a major risk factor for ischemic heart disease in the offspring.
3. Requirement: Biology - Psychology -Sosial -Spiritual, include:
a. Activity / rest
Clients usually complain of fatigue / tiredness constantly throughout the day, insomnia, chest pain on exertion and dyspnea at rest.
b. circulation
Usually the client has a history of hypertension, recent myocardial infarction / acute episodes prior CHF, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.
c. Ego Integrity
Clients say anxiety, worry and fear. Stress related illnesses / financial concerns (job / medical care costs).
d. Elimination
Clients say a decrease in urination, dark colored urine, like urination at night (nocturia), diarrhea / constipation.
e. Food / Fluid
Clients say has no appetite, always nausea / vomiting, weight gain significantly.
f. Hygiene
Client states feel tired / weak, ie the client perceived fatigue during self-care activities.
g. Neurosensory
Client states weakened, like the feel dizzy, and sometimes experience fainting.
h. Pain / comfort
Clients complain of chest pain, acute or chronic angina, upper right abdominal pain and muscle pain.
i. Breathing
Clients expressed dyspnea on exertion, sleep sitting up or with a few pillows, cough with / without the formation of sputum, history of chronic diseases, use of rescue breathing.
j. Security
Clients say experience changes in mental function, loss of strength, muscle tone, skin abrasions.
k. Social interaction
Client states rarely follow the usual social activities.
l. Learning / teaching
Client states use / forget to use heart medications, eg calcium channel blockers.
4. Physical Examination
a. General circumstances:
On examination of the general situation, the client's awareness of heart failure is usually good or composmentis and will change according to the level of perfusion disorders of the central nervous system.
b. Vital signs: blood pressure, pulse, respiration, temperature.
5. Examination Support
Investigations in congestive heart failure, namely:
Assessment is an early stage and the foundation of the nursing process. Required careful examination to know the patient's problem, in order to give direction to the nursing actions. The success of the nursing process is highly dependent on the precision and accuracy in the assessment phase (Lismidar, et al., 2005).
1. Identity
The client's identity consists of: name, age, gender, marital status, religion, ethnicity / race, education, occupation and address.
The identity of the person in charge consists of: name, relationship with clients, education, occupation and address.
2. Health history
a. Main complaint
The main complaint client with heart failure are shortness of breath, pain and weakness during the move.
b. Current medical history
Assessment that supports the main complaints made by asking a series of questions about physical weakness by using PQRST ways, namely:
P: Provoking incidents, physical weakness occurs after mild to severe activity, according to the disturbance of the heart.
Q: Quality of pain, such as what the complaints of weakness in an activity that is perceived by the client. Usually every move, clients feel shortness of breath.
R: Region, whether physical weakness localized or affect the entire musculoskeletal system and is accompanied by the inability to perform the movement.
S: Severity (scale) of pain, examine the range of the client's ability to perform daily activities. Usually the client's ability to move decreases the degree of interference experienced organ perfusion.
T: Time, nature of early onset, complaints of weakness activity usually occurs slowly. Old onset of weakness when the move is usually all times, both at rest and during activity.
c. Past medical history
Assessment of the support assessed by asking whether previously been suffering from chest pain, hypertension, myocardial ischemia, diabetes mellitus, and hyperlipidemia.
Ask about drugs commonly taken by the client in the past and are still relevant to current conditions. These drugs include drugs diuretics, nitrates, beta-blockers, and antihypertensives. Note the side effects that occurred in the past. Drug allergies and allergic reactions that arise. Often clients interpret an allergy as a side effect of medications.
d. Family history
The nurse asked about illnesses experienced by the family, the family members who died, especially in the productive age, and cause of death. Ischemic heart disease in the elderly who onset at a young age is a major risk factor for ischemic heart disease in the offspring.
3. Requirement: Biology - Psychology -Sosial -Spiritual, include:
a. Activity / rest
Clients usually complain of fatigue / tiredness constantly throughout the day, insomnia, chest pain on exertion and dyspnea at rest.
b. circulation
Usually the client has a history of hypertension, recent myocardial infarction / acute episodes prior CHF, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.
c. Ego Integrity
Clients say anxiety, worry and fear. Stress related illnesses / financial concerns (job / medical care costs).
d. Elimination
Clients say a decrease in urination, dark colored urine, like urination at night (nocturia), diarrhea / constipation.
e. Food / Fluid
Clients say has no appetite, always nausea / vomiting, weight gain significantly.
f. Hygiene
Client states feel tired / weak, ie the client perceived fatigue during self-care activities.
g. Neurosensory
Client states weakened, like the feel dizzy, and sometimes experience fainting.
h. Pain / comfort
Clients complain of chest pain, acute or chronic angina, upper right abdominal pain and muscle pain.
i. Breathing
Clients expressed dyspnea on exertion, sleep sitting up or with a few pillows, cough with / without the formation of sputum, history of chronic diseases, use of rescue breathing.
j. Security
Clients say experience changes in mental function, loss of strength, muscle tone, skin abrasions.
k. Social interaction
Client states rarely follow the usual social activities.
l. Learning / teaching
Client states use / forget to use heart medications, eg calcium channel blockers.
4. Physical Examination
a. General circumstances:
On examination of the general situation, the client's awareness of heart failure is usually good or composmentis and will change according to the level of perfusion disorders of the central nervous system.
b. Vital signs: blood pressure, pulse, respiration, temperature.
5. Examination Support
Investigations in congestive heart failure, namely:
- Echocardiography,
- Thoracic X-rays, and
- Electrocardiography.
