ENGLISH

NURSING CARE

OLEH:
KELOMPOK 5
ASTI WINDA WATI
ERIKA ALMIRA
KHOIROMI PUTRI SARI
KURNIA SAPITRI KHAZ

PROGRAM STUDI ILMU KEPERAWATAN

STIKES PAYUNG NEGERI
PEKANBARU
2018
 NURSING DIAGNOSES
1. Diagnoses : Decreased cardiac output associated with changes in
afterload

Subjective data
1. The patient says tightness in the chest
2. The patient says it is easy to get tired
3. The patient says there is a history of hypertension in the family
Objective data
1. The patient's skin is moist
2. Blood pressure 140/90 mmHg
3. Respiration of 28x / minute
4. The patient looks pale
5. Bad skin turgor

2. Diagnoses : Imbalance of nutrients less than the body’s needs associated

lack of food intake.

Subjective data
1. the patient said there was a history of ulcer
2. patients say less interest in eating
3. patients say they prefer to drink tea water than eat
4. The patient says sometimes it is a bit nauseous when eating
objective data
1. BMI: 15.6
2. Unstable gait
3. Skin looks pale
4. Bad skin turgor
5. Flatulence and cramps

2
 NURSING INTERVENTION
1. Diagnosis: Decreased cardiac output associated with changes in afterload
The perpose: After 3x24 hours nursing action is expected, the patient's
circulation status is improved
Result criteria:
1. Blood pressure returns to normal
2. Shortness of breath is lost / reduced
3. Breathing returns to normal in the range (16-24 x / minute)
4. The patient doesn't look pale anymore
Intervention: heart care
Observation:
1. Monitor ttv
2. ECG monitor
3. Monitor cardiac dystrhythmias
4. Monitor breathing and fatigue
Nursing:
1. do a commrehenship assessment
2. note the signs and symptoms of decreased peripheral pulse
3. evaluation of episodes of chest pain (location, scale, duration, intensity)
4. do relaxation therapy
Education:
1. teach the patient and family the techniques of deep breathing relaxation
2. teach patients who are prohibited food and good food consumed
Collaboration:
1. collaboration with antihypertensive drugs

2. Diagnosis : Imbalance of nutrients less than the body’s needs associated

lack of food intake.

The perpose: After nursing action 3x 24 hours, nutritional status is expected:

nutrition and energy intake improves

3
Result criteria:
1. Nutritional intake is balanced and fulfilled
2. BB increases and imt returns in the normal range (17-23)
3. The patient's skin color returns to normal
4. Patients become interested in food
Intervention: nutritional management
Observation :
1. Determine nutritional status and ability ( patients to meet nutritional
needs)
2. Monitor calories and food intake
Nursing

1. Instruct patients about nutrional needs

2. Encourage patients to be related to specific food needs based on
development or age ( calcium and protein )

Education :

1. Give medicine before eating ( painkillers, antiemetics ) if needed.

2. Provide food choices while offering guidance on healthy food choice, if
needed.

Collaboration

1. Colaboration with nutrionsists