A.

Assessment
1. Anamnesis
a. Patients Identity
1) Name
: Mrs. T
2) Age
: 55
3) Gender
: Female
4) Religion
: Islam
5) Address
: Bogor
6) Education
: Graduated High School
7) Occupation
: Housewife
8) Medical Diagnosis
: CHD (Coronary Heart Disease)
9) Date of admission to hospital : June 20, 2015
10) Date of Assessment
: June 21, 2015
b. Main Complaint
Patient complaint of chest pain left side through back since three days ago. Pain
increases when made activity and decreases when made a break. Pain scale : 5
c. History of current illness
On June 20, 2015, the patient was administered to the hospital. 3 days ago patient
complained of chest pain left side through the back, nausea, dizziness, diaphoresis.
After a check by the doctor, the patient was diagnosed with CHD.
d. Previous history
Patient has a history of hypertension and diabetes Mellitus a year ago and the
patient has never been administered to the hospital.
e. Family disease history
Families of the patient do not have a CHD
f. Vital Signs
1) Body temperature : 37C
2) Pulse rate : 92 bpm
3) Blood pressure : 160/100 mmHg
4) Respiration rate : 22 tpm
2. Physical examination
a. Breathing : dyspnea, intercostal retraction
b. Blood : cyanosis, increase jugular vein pressure, capillary refill time more than 2
seconds, takikardi
c. Brain : NAA
d. Bladder : decrease urinary output
e. Bowel: constipate
f. Bone : decrease activity daily living, bed rest
B. Nursing Diagnosis
1. Decreased Cardiac Output related to Altered contractility
2. Acute Pain related to Biological injury agent (ischemia)
3. Activity intolerance related to imbalance between oxygen supply/demand
C. Intervention and rational
Nursing
Diagnosis

Outcomes to
measure Resolution

Outcome
overall rating

Intervention

rational

of Diagnosis
Domain 4 : Cardiac
Pump 1. (040001)
1. Cardiac Care 1. Limitation of
complications
(4040)
Activity / Rest
Effectiveness (0400)
Systolic
resulting from
2. Hemodynamic
blood
Class
4
:
an imbalance
Regulation
pressure :
between
Cardiovascular /
(4150)
4-5
myocardial
3. Vital Signs
pulmonary
2. (040019)
oxygen supply
Monitoring
responses
Diastolic
and demand for
(6680)
a patient with
blood
Code : 00029
symptoms of
pressure :
impaired
Decreased
4-5
cardiac
Cardiac Output
function.
3. (040023)
related
to
2.
Optimization of
Dyspnea at
Altered
heart rate,
rest : 4-5
contractility
preload,
afterload, and
contractility
3. Collection and
analysis of
cardiovascular,
respiratory, and
body
temperature
data to
determine and
prevent
complications
Domain 12 : Pain level (2102)
1 (210201)
1. analgesic
1. Use of
pharmacologic
administratio
Reported
Comfort
agents to reduce
n (2210)
pain : 4-5
or eliminate
Class
1
:
2. Pain
2 (210206)
pain
Physical
management
Facial
2. Alleviation of
(1400)
expressions
comfort
pain or a
of pain : 4-5 3. Sedation
reduction in
Code: 00132
management
3 (210227)
pain to a level
(2260)
Nausea : 4-5
of comfort that
Acute
pain
is acceptable to
releated
to
the patient
Biological
3. Administration
injury agent (
of sedatives,
ischemia)
monitoring of
the patients
response, and
provision of
necessary
physiological

Domain 4
Activity/Rest

: Activity
(0005)

Class
4
:
Cardiovascular/
pulmonary
responses
Code : 00092
Activity
intolerance
related to
imbalance
between oxygen
supply/demand

tolerance 1. (000501)
Oxygen
saturation
with
activity : 2-1
2. (000502)
Pulse rate
with
activity : 2-1
3. (000503)
Respiratory
rate with
activity : 2-1

support during a
diagnostic or
therapeutic
procedure
1. Activity
1. Prescription of
Therapy
and assistance
(4310)
with specific
physical,
2. Cardiac
cognitive,
Care:
social, and
Rehabilitativ
spiritual
e(4046)
activities to
increase the
3. Energy
range,
Management
frequency, or
(0180)
duration of an
individuals or
groups activity.
2. Promotion of
maximum
functional
activity level for
a patient who
has experienced
an episode of
impaired
cardiac function
that resulted
from an
imbalance
between
myocardial
oxygen supply
and demand
3. Regulating
energy use to
treat or prevent
fatigue and
optimize
function

D. Evaluation

1. Normally cardiac output

2. Pain level diminished or lost
3. Increase patients activity