A 34-year-old man was admitted to the Muhamadiyah hospital in Palembang on 23 March 2018

at 23.00 WIB, Assessment on 23 March 2018 at 24:40 WIB in an emergency room with
complaints of shortness of breath and left chest pain. From the assessment of patients who appear
to arise, cough, easily feel tired when doing activities so that only patients who are lying in bed,
patients also appear nervous and anxious about his condition. patient diagnosed with heart
failure. From the results of physical examination, lower extremity edema, hepatomegaly,
anorexia, and nocturia appear. BP: 180/90 mmhg, RR: 28x / m, T: 36 C, P: 88x / m. The patient
underwent X-ray examination with the result of enlarged heart and pulmonary congestive, blood
gas analysis: PA O2 from HR more than 100X / minute, results of ST ECG and Q pathological
segment increase and increase in cardiac enzymes, namely CK, AST, LDL / HDL . Patients now
only lie in the treatment room to minimize fatigue when doing activities and just wait for the
next intervention.

1. Nursing diagnoses
a. Excess fluid volume
b. Decreased cardiac output
2. Nursing Interventions
Diagnosis NOC NIC
Excess fluid volume 1. Electrolytes and Liquid Management :
Definition : alkaline balance 1. Weigh diapers
Increase in isotonic 2. Balance of fluid 2. Maintain record of
fluid retention 3. Hydration intake and output
3. Install catheter if
Limitation of Criteria for results : necessary
characteristics : 1. Free from edema,
1. Edema effusion and anasark Liquid Monitor :
2. Anxiety 2. Clean breath, no 1. Determine history of
3. Dispnea more dipsnea or number and type of
oropnea fluid intake and
3. Free from distention elimination
of the jugular vein 2. Determine possible
 risk factors for fluid
imbalance
(hpertermia, diuretic
therapy, renal
abnormalities, heart
failure, daporsesis,
liver dysfunction)
3. Monitor weight

Decreased cardiac 1. The effectiveness of Heart care :

output a heart pump 1. Routinely checking
Definition : 2. Agitation Level patients both
The inability of blood 3. Knowledge: Heart physically and
pumped by the heart to Disease psychologically in
meet the body's Management accordance with the
metabolic needs. policies of each
Criteria for results : agent
Limitation of 1. Vital signs within 2. Ensure the level of
characteristics : normal limits that activity of patients
1. Bradycardia can be accepted that does not
2. Heart palpitations according to the age endanger cardiac
3. Electrocardiogram limit output
changes 2. Heart frequency and 3. Encourage a gradual
cardiac output increase in activity
within acceptable when the condition
limits has stabilized
3. Urine output Heart care: acute :
increases 1. Evaluate chest pain
2. Instruct patients on
the importance of
reporting
 immediately if they
feel chest discomfort
3. Provide a device that
can immediately and
continuously call the
nurse and can tell the
patient and family
that the call will be
answered
immediately