NURSING CARE OF PATIENTS MR.

NS
WITH ADHF PROFILE B + AF RVR + ALO + ACKD
IN ROYAL QUEEN C ROOM BALI ROYAL HOSPITAL
(BROS)
ON 11-14 OCTOBER 2019
 SUBJECT
CHAPTER I INTRODUCTION

CHAPTER II LITERATURE REVIEW

CHAPTER III NURSING CARE

CHAPTER IV DISCUSSION

CHAPTER V CONCLUSIONS AND SUGGESTIONS

 CHAPTER I
INTRODUCTION
BACKGROUND
Acute heart failure is the occurrence of rapid change of signs
and symptoms of heart failure. This condition is life-threatening
and must be treated immediately, and usually ends in
hospitalization (Price, 2012).
The Farmingham states that the incidence of heart failure
per year in people aged > 45 years is 7.2 cases for every 1000
men and 4.7 cases for every 1000 women. In America, nearly 5
million people suffer from heart failure (Sani, 2007). The
incidence of heart failure is expected to increase in the future
due to increasing life expectancy.
 CHAPTER I
INTRODUCTION
BACKGROUND
Overall, 50% of the total patients died within four years. As
many as 15.8% of patients died who come to the hospital with a
diagnosis of heart failure and 32% get hospitalization again
within the first year (Lapage, 2008).
Because the clinical course of heart failure is very frequent
and has a high mortality rate, the authors are interested in
making and discussing nursing care in cases of acute heart failure
(ADHF).
CHAPTER II
LITERATURE REVIEW
Acute Decompensated Heart Failure (ADHF) defined as a
rapid heart attack (rapid onset) of symptoms or signs due to
abnormal heart function. This dysfunction can be systolic or
diastolic dysfunction, abnormal heart rhythm or preload and
afterload imbalance (Hanafiah, 2006).
High-risk factors for ADHF disease include : People who
suffer from a history of hypertension, obesity. have experienced
a history of heart failure, smokers, very excessive activity, and
alcohol consumption (Hanafiah, 2006).
The clinical manifestations of acute decompensated heart
failure include : dyspnea during activities, orthopnea.
paroxysmal nocturnal dyspnea (PND), rhonchi, nausea and
vomiting, jugular venous distention, ascites, and peripheral
edema
CHAPTER II
LITERATURE REVIEW

Medical management in ADHF cases includes

pharmacological and non-pharmacological therapy.
Pharmacological therapy includes : the administration of
digitalis, diuretics, vasodilators, angiotensin converting enzyme
inhibitor (ACE inhibitor), and inotropic (dopamine adn
dobutamine). Nonpharmacological therapies include : low salt
diet, fluid restriction, reducing weight, avoiding alcohol, stress
management, and regulating physical activity
ADHF can cause several complications, that are : deep vein
thrombosis, cardiogenic shock, and digitalis toxicity.
 CHAPTER III
NURSING CARE
ASSESSMENT :
Mr. NS, male, 60 years old, came to the Emergency Room BROS
Hospital on 11/10/2019 at 11:58 am with complaints of shortness
of breath since 2 days ago, coughing since 3 days ago, swelling on
both legs since last night, nausea and feeling discomfort in the pit
of the stomach since yesterday. In the emergency room, the
patient received therapy such as oxygen therapy 3 liters per
minute by nasal cannula, IVFD NS 8 drops per minute, and
furosemide 40 mg by IV line. Furthermore, at 2:20 pm, the patient
moved to the Royal QUEEN C Room. The patient said that he had a
history of heart and kidney disease since 4 years ago and routinely
took medicines as recommended by the doctor.
 CHAPTER III
NURSING CARE
ASSESSMENT :
When the assessment was conducted on 11/10/2019 at 3:00
pm, the patient still complained of shortness of breath, the body
felt weak, and the heart was beating fast. History of allergies (-),
drinking coffee 3-4 times per week, smoking history (+), defecating
1 time per day, urinating 2-3 times per day.
Physical Examination : Awareness: compos mentis, GCS 15, BP:
110/60 mmHg, T: 36.6oC, pulse : 88 beats/min, RR: 28
breathes/min, pain scale: 0, body weight: 66 kg (increase 2 kg),
height : 168 cm, non-jaundice sclera, non-anemic conjunctiva, JVP:
4 cmH2O, weak and irregular palpable pulse, acites (-), elastic skin
turgor, CRT <3 seconds, edema of the lower extremities, nerves I -
XII : good
 CHAPTER III
NURSING CARE
ASSESSMENT :
Supporting data : WBC : 7,7 x 103 / µL (N), RBC : 4,13 x 106 / µL
(L), HGB : 13,3 g/dL (N), HCT : 39,3 % (L), PLT : 1,38 x 103 /µL (L),
BUN : 43 mg/dL (H),SC : 1,9 mg/dL (H), uric acid: 12.7 mg/dL (H),
ECG results: myocardial ischemia, X-ray impression: cardiomegaly
with congestive pulmonary signs.
Therapeutic Program : IVFD NS 0.9% 7 drops per minute,
oxygen therapy by using cannula nasal 2 liters per minute, roximid
3 x 40 mg per IV, digoxin 1 x 0.125 mg P.O, spironolactone 1 x 25
mg P.O, allopurinol 1 x 100 mg P.O candesartan 1 x 8 mg P.O, folic
acid 1 x 1 tablet P.O, and notisil 1 x 2 mg P.O
 CHAPTER III
NURSING CARE

NURSING DIAGNOSIS :
1. Ineffective breathing pattern related to energy decreased as evidenced
by patients complaining of shortness of breath, RR: 28 breaths/minute,
shallow breath quality.
2. Decreased cardiac output related to contractility changes as evidenced
by patients complaining of feeling tired and shortness of breath,
peripheral edema, JVP 4 cmH 2 O, weak peripheral pulse, ECG results:
myocardial ischemia, X-ray impression: cardiomegaly with congestive
pulmonary signs.
3. Hypervolemia related to venous return disorder as evidenced by
patients complaining of shortness of breath, peripheral edema, JVP 4
cmH 2 O, HCT: 39.3%, fluid balance +100 cc.
4. Activity intolerance related to an imbalance between oxygen supply and
demand as evidenced by patients complaining of fatigue easily when
during activities, ECG results: myocardial ischemia.
 CHAPTER III
NURSING CARE

NURSING INTERVENTIONS :
1st diagnosis : Ineffective breathing pattern related to energy
decreased
Outcomes : After given nursing care for 3 x 24 hours, it is expected
tha the patient's breathing pattern is effective
Results Criteria :
• There is no dyspnea
• There is no pursed-lip breathing
• Normal breathing frequency (16-20 breaths/min)
• Normal breath depth
 CHAPTER III
NURSING CARE
INTERVENTIONS & IMPLEMENTATIONS :
1st diagnosis
NO INTERVENTIONS IMPLEMENTATIONS

1 Monitor breathing pattern (frequency, depth, breathing effort) Yes

2 Monitor for additional breath sounds Yes

3 Monitor the production of sputum Yes

4 Monitor oxygen saturation Yes

5 Monitor the blood gas analysis or arterial blood gas (ABG) value No

6 Monitor the thorax X-ray result Yes

7 Give the semi-fowler or fowler position Yes

8 Give oxygen, if necessary Yes

 CHAPTER III
NURSING CARE
NURSING INTERVENTIONS :
2nd diagnosis : Decreased cardiac output related to contractility
changes
Outcomes : After given nursing care for 3 x 24 hours, it is expected
that there will be no decrease in cardiac output
Results Criteria :
• Normal peripheral pulse • There is no edema
strength • There is no jugular venous
• Cardiac index is within distension
normal limits • There is no dyspnea
• No palpitations • Does not occur Paroxysmal
• There is no tachycardia nocturnal dyspnea (PND)
• There is no description of • No orthopnea
ECG arrhythmia • There is no cough
• Do not feel fatigued • Normal body weight
• CRT <3 seconds
 CHAPTER III
NURSING CARE
INTERVENTIONS & IMPLEMENTATIONS :
2nd diagnosis
NO INTERVENTIONS IMPLEMENTATIONS

1 Identification of primary signs/symptoms of decreased cardiac Yes

output
2 Identification of secondary signs/symptoms to decreased Yes
cardiac output
3 Monitor blood pressure Yes

4 Monitor fluide intake and output Yes

5 Monitor weight every day at the same time Yes

6 Monitor oxygen saturation Yes

7 Monitor for chest pain complaints Yes

8 Monitor 12 lead of ECG No

 CHAPTER III
NURSING CARE
INTERVENTIONS & IMPLEMENTATIONS :
2nd diagnosis
NO INTERVENTIONS IMPLEMENTAIONS

9 Give the semi-fowler or fowler position Yes

10 Give oxygen to maintain oxygen saturation> 94% Yes

11 Collaborative management of antiarrhythmics, if necessary Yes

 CHAPTER III
NURSING CARE

NURSING INTERVENTIONS :
3rd diagnosis : Hypervolemia related to venous return disorder
Outcomes : After 3 x 24 hours of nursing care, it is expected that
there will be no hypervolemia
Results Criteria :
• Normal urine output
• There is no edema
• Without ascites
• Blood pressure within normal limits
• Radial pulses within normal limits
• Weight loss
 CHAPTER III
NURSING CARE
INTERVENTIONS & IMPLEMENTATIONS :
3rd diagnosis
NO INTERVENTIONS IMPLEMENTATIONS

1 Check for signs and symptoms of hypervolemia Yes

2 Monitor fluide intake and output Yes

3 Monitor of patient's weight regularly Yes

4 Limit salt fluid intake Yes

5 Head up position around 30-40 degrees Yes

6 Collaborative management of diuretics Yes

7 Collaborative replacement of potassium loss due to diuretic No

8 Monitor vital signs Yes

 CHAPTER III
NURSING CARE
INTERVENTIONS & IMPLEMENTATIONS :
3rd diagnosis
NO INTERVENTIONS IMPLEMENTATIONS

9 Monitor CRT Yes

10 Monitor elasticity or skin turgor Yes

11 Monitor albumin and total protein levels No

12 Monitor the results of the serum test No
 CHAPTER III
NURSING CARE
NURSING INTERVENTIONS :
4th diagnosis : Activity intolerance related to an imbalance between
oxygen supply and demand
Outcomes : After given nursing care for 3 x 24 hours, it is expected that
the patient to be able to move normally
Results Criteria :
• The pulse rate is normal
• Normal oxygen saturation
• Normal breathing frequency
• There is no tired
• There is no dyspnea during and after activities
• There is no arrhythmia during and after activities
• There is no cyanosis
• There is no weakness
 CHAPTER III
NURSING CARE
INTERVENTIONS & IMPLEMENTATIONS :
4th diagnosis
NO INTERVENTIONS IMPLEMENTATIONS

1 Facilitate independence, help if the patient unable to take care Yes

of themself
2 Encourage self-care consistently according to ability Yes

3 Encourage bed rest Yes

4 Encourage to doing the activity by step Yes

5 Collaboration with nutritionists on how to increase food intake No

 CHAPTER III
NURSING CARE
NURSING EVALUATIONS
Performed on 10/14/2019 at 14.30 pm
1st diagnosis
S : The patient said that he was not shortness of breath
O : RR : 20 x/menit, no pursed-lip breathing, normal breathing
depth
A : The problem is resolved, the goal is reached
P : Stop the intervention
 CHAPTER III
NURSING CARE
NURSING EVALUATIONS
Performed on 10/14/2019 at 14.30 pm
2nd diagnosis
S : The patient said the feeling of beating fast in the heart is gone,
shortness of breath at night is gone, shortness of breath when
sleeping on your back (+), cough is reduced, the feeling tired is
still
O : Pulse 85 beats/min, strong of peripheral pulse strength, no
edema, CRT <3 seconds, body weight decreased 1 kg (65 kg)
A : The problem is resolved, the goal is reached
P : Stop the intervention
 CHAPTER III
NURSING CARE
NURSING EVALUATIONS
Performed on 10/14/2019 at 14.30 pm
3rd diagnosis
S :–
O : No edema, no ascites, BP: 121/64 mmHg, pulse 85 beats/min,
body weight decreased by 1 kg (65 kg), fluid balance +50 cc
A : The problem is resolved, the goal is reached
P : Stop the intervention
 CHAPTER III
NURSING CARE
NURSING EVALUATIONS
Performed on 10/14/2019 at 14.30 pm
4th diagnosis
S : The patient said shortness of breath after activity is still, feeling
easily tired is still, feeling weak is still
O : Pulse 85 beats/minute, RR: 20 breathes/minute, SaO2 : 99%,
no cyanosis
A : The problem is not resolved, the goal is reached
P : Continue the intervention
 CHAPTER IV
DISCUSSION
ASSESSMENT :
• Age : . As a person ages, the risk of heart failure is increased due
to increasing age, so there is a decrease in heart function. In the
case of Mr. NS is 60 years old. So the case of Mr. NS is following
the existing theory and cases.
• Education : In this case of Mr. NS, last education is an elementary
school, so in providing education nurses must use language that
is more common so it's easy to understand Mr. NS. In this case,
nurses have been communicating in ways and languages ​that are
easy to understand, and involve families in communication. This
is following existing theories.
 CHAPTER IV
DISCUSSION
ASSESSMENT :
• The main complaint : Mr. NS came with the main complaint of
shortness of breath. According to Udjianti (2010), in the case of
ADHF shortness of breath can occur due to dysfunction of the
mitral and aortic or ventricular valves in heart failure which causes
the pulmonary veins will stretch and the bronchial wall is pinched
and experiencing edema and arising of shortness of breath. So that,
there is no gap between Mr. NS's case and the theory.
• History of disease : Mr. NS complained of shortness of breath,
coughing, swelling in both legs, nausea, and feeling discomfort in
the pit of the stomach. According to the theory, other symptoms
that appear in cases of ADHF are nausea, vomiting, and peripheral
edema. So that, there is no gap between Mr. NS's case and the
theory.
 CHAPTER IV
DISCUSSION
ASSESSMENT :
• Vital signs : According to the theory, in the case of ADHF, there
will be changes in vital signs such as hypotension, increased
respiration, and an increase or decrease in pulse frequency. In
the case of Mr. NS, blood pressure 110/60 mmHg, pulse 88
beats/min, respiration 28 beats/min and temperature 36.60 C.
There is an increase in respiration in Mr. NS so there is no gap
between theory and case.
• Neck : Increased JVP indicates right heart failure. In the case of
Mr. NS, JVP examination has been performed and the value is 4
cmH 2 O. It means that there is jugular venous distention in the
case of Mr. NS. There is no difference between theory and
practice.
 CHAPTER IV
DISCUSSION
ASSESSMENT :
• Thorax : According to Hanafiah (2006), in ADHF cases occur
abnormal cardiac dysfunction occurs. The dysfunction such as
systolic and diastolic dysfunction, heart rhythm abnormalities or
imbalance of preload and afterload. In the case of Mr. NS, heart
rhythm is irregular and weak. This shows that there is no gap
between theory and case.
• Extremities : In the case of ADHF, there is a decrease in
contractility which affects the decreased strength of the heart
muscle contractions. This situation causes a person to experience
a decrease in cardiac output which affects the congestion of the
viscera and peripheral tissue so that peripheral blood fluid is not
transported (Weinstock, 2010). In the case of Mr. NS, lower
extremities Mr. NS got edema so there is no gap between theory
and case.
 CHAPTER IV
DISCUSSION
Nursing Diagnosis :
Nursing diagnoses that appear on Mr. NS as follows: 1)
ineffective breathing pattern, 2) decreased cardiac output, 3)
hypervolemia, and 4) activity intolerance.
All diagnoses that appear on Mr. NS following existing theories.
This is supported by data such as patients complaining of shortness
of breath, RR: 28 beats/min, shallow breath quality, patients
complaining of feeling tired, peripheral edema, JVP 4 cmH2O, weak
peripheral pulse, ECG results: myocardial ischemia, X-ray
impression: cardiomegaly with congestive pulmonary signs, HCT:
39.3%, fluid balance +100 cc, patients feel fatigued easily during
activities.
 CHAPTER IV
DISCUSSION
Nursing Interventions :
All of nursing interventions are compile according to existing
theories, which are based on Standar Intervensi Keperawatan
Indonesia (SIKI) and Standar Luaran Keperawatan Indonesia (SLKI).
 CHAPTER IV
DISCUSSION
Nursing Implementations :
All of nursing implementations are implemented according to
nursing interventions.
 CHAPTER IV
DISCUSSION
Nursing Evaluation :
The results of the nursing evaluation to Mr. NS following
specified results criteria. Nursing problems at the first, second and
third diagnoses have been resolved. But on the fourth diagnosis, the
problem has not been resolved and the patient still complains of
shortness of breath after a mild activity, feeling tired, and still
feeling weak.
 CHAPTER V
CONCLUSIONS AND SUGGESTIONS

Heart failure is the final form and most severe manifestation

of almost all forms of heart disease such as coronary
atherosclerosis, myocardial infarction, valve abnormalities,
hypertension, congenital heart disease, and cardiomyopathy.
In the implementation of the process of nursing care to Mr.
NS there is no gap between theory and practice, so things that
happen to patient, as well as the implementation given to
patient are following existing theories.
It is expected with this case report about ADHF the provision
of nursing care to patients with ADHF can be done as maximal
and as possible as to reduce the risk or other complications.