NURSING CARE FOR HEART FAILED CLIENTS WITH

NURING RISK PROBLEMS

MYOCARD PERFUSION IS INEFFECTIVE

Nama : DIMAS
PO7220119 1550
Kelas: 2A keperawatan

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 TABLE OF CONTENTS

Page Title Out......................................................................................................

Inner Title Page iii...............................................................................................
Letter Statement iii..............................................................................................
Approval Sheetiv.................................................................................................
Ratification Sheet v..............................................................................................
Life History vi......................................................................................................
Dan's motto of Offerings vii................................................................................
Pengantarix said..................................................................................................
Abstractx..............................................................................................................
List Fillxii.............................................................................................................
List Image xiv.......................................................................................................
List Tables xv.......................................................................................................
List Appendix xvi.................................................................................................
List of Symbols And Abbreviation xvii.............................................................

CHAPTER 1 INTRODUCTION
1.1 Background 1...................................................................................................
1.2 Limitation Problem 3.......................................................................................
1.3 Problem Formulas 3........................................................................................
1.4 Purpose3..........................................................................................................
1.4.1 Aim General3.........................................................................................
1.4.2 Aim Special4..........................................................................................
1.5 Benefits4..........................................................................................................
1.5.1 Benefits Theoretical 4..............................................................................
1.5.2 Practical Benefits4...................................................................................

CHAPTER 2 LITERATURE REVIEW

2.1 Concept Heart failure 5...................................................................................
2.1.1 Definition of Heart Failure 5.................................................................
2.1.2 Etiology 5..............................................................................................
2.1.3 Classification of Heart Failure7............................................................
2.1.4 Clinical Manifestation 8........................................................................
2.1.5 Pathophysiology 8.................................................................................
2.1.6 WOC9....................................................................................................
2.1.7 Complications Heart Failure 10............................................................
2.1.8 Management Heart Failure 10...............................................................
2.1.9 Examination Support 12........................................................................
2.2 The Concept of the Risk of Decreased Perfusion Heart Network 13..............
2.3 Concept Nursing Care 14................................................................................
2.3.1 Assessment 14.......................................................................................
2.3.2 Examination Physical 16.......................................................................
2.3.3 Nursing Diagnosis 21............................................................................
2.3.4 Nursing Interventions 22.......................................................................
2.3.5 Nursing Implementation 22...................................................................
2.3.6 Evaluation Nursing 24...........................................................................

CHAPTER 3 RESEARCH METHOD

3.1 Design Research 25.....................................................................................
xviii
3.2 Limitation Limitation of Terms 25..............................................................
3.3 Participants 26.............................................................................................
3.4 Time Research Location Research 26.........................................................
3.5 Data collection 27........................................................................................
3.6 Validity Test Data 29...................................................................................
3.7 Data Analysis 29..........................................................................................
3.8 Ethics Research 31......................................................................................
CHAPTER 4 RESULTS AND DISCUSSION
4.1 Result 32.....................................................................................................
4.1.1 General Description of Collection Location Data 33........................
4.1.2 Assessment 34..................................................................................
4.1.3 Therapy Medicine 37........................................................................
4.1.4 Data Analysis 38...............................................................................
4.1.5 Nursing Diagnosis 39.......................................................................
4.1.6 Intervention Nursing 39....................................................................
4.1.7 Implementation of Care Nursing 41.................................................
4.1.8 Evaluation of Care Nursing 45.........................................................
4.2 Discussion 47..............................................................................................
4.2.1 Assessment 47..................................................................................
4.2.2 Nursing Diagnosis 48.......................................................................
4.2.3 Intervention Nursing 49....................................................................
4.2.4 Implementation Nursing 50..............................................................
4.2.5 Evaluation Nursing 51......................................................................
CHAPTER 5 CONCLUSION AND SUGGESTION 52..................................
5.1 Conclusion 52.............................................................................................
5.2 Advice 53....................................................................................................
REFERENCES LIST 54................................................................................
Appendix 55.....................................................................................................

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 CHAPTER 1

INTRODUCTIO

1.1 Background

Cardiovascular disease has become one of the main causes of death in

adults (Sargowo, 2003). Failure of pump function is always associated with heart

failure, which often occurs due to inadequate oxygen circulating levels and

stagnation of blood in the tissues and results in decreased myocardial perfusion

(Tambayong, 2000). Thus, nursing intervention is needed in patients with heart

failure, namely by improving ineffective myocardial perfusion (Smeltzer & Bare,

2002). Decreased tissue perfusion in heart failure patients is a result of inadequate

circulating oxygen levels and stagnation of blood in peripheral tissues. And also

the result of the inability of the heart to pump blood in sufficient quantities to

meet the tissue's nutritional and oxygen needs will result in decreased myocardial

perfusion (Sani, A., 2007).

Data from the Word Health Organization (WHO) 2016 heart disease

occurs in 17.5 million people (31%) of the 58 million deaths in the world caused

by heart disease. In Indonesia, based on the records of the Indonesian Heart

Foundation, the prevalence of heart disease reaches 7-12% per year (YJI, 2013).

RISKESDAS data in 2013 showed that East Java had the second largest

prevalence after DI Yogyakarta at 0.19%.

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Estimated number of people with heart failure (0.19%) 54,826 people at the age of

more than 15 years and will increase every year.

The cause of heart failure is due to increased intravascular volume. The

right and left ventricles failed separately. Left ventricular failure most often

precedes right ventricular failure. Failure of one ventricle can result in decreased

tissue perfusion, but the manifestations of congestion can differ depending on the

ventricular failure that occurs (Kasron, 2012). Heart failure is also caused due to a

defect in myocardial contraction or an abnormality of the heart muscle, such as in

cases of cardiomyopathy or viral carditis (Kasper, 2004). Heart failure due to

myocardial dysfunction results in circulatory failure to supply tissue metabolic

needs. This is usually followed by myocardial damage when compensatory

mechanisms fail. Causes of damage to the myocardium include myocardial

infarction, cardiovascular stress (hypertension, valve disease), toxins (alcohol

consumption), infection or in some cases the cause is unknown (Crawford, 2002).

Other causes are coronary, congenital arteroskerosis, valve abnormalities,

hypertension or in normal heart conditions and there is an increase in load over

capacity, such as in hypertensive crises, rupture of aortic valve and in endocarditis

with massive embolic pulmonary. It can also occur with normal systolic function,

usually in chronic conditions, such as mitral stenosis without myocardial

abnormalities (Kasper, 2004). hypertension or in normal heart conditions and

there is an increase in the load over capacity, such as in hypertensive crises,

rupture of aortic valve and in endocarditis with massive embolic pulmonary. It can

also occur with normal systolic function, usually in chronic conditions, such as

mitral stenosis without myocardial abnormalities (Kasper, 2004). hypertension or

in normal heart conditions and there is an increase in the load over capacity, such

as in hypertensive crises, rupture of aortic valve and in endocarditis with massive

embolic pulmonary. It can also occur with normal systolic function, usually in
 3
chronic conditions, such as mitral stenosis without myocardial abnormalities

(Kasper, 2004).

The role of nurses is indispensable in handling heart failure patients,

namely (caring role) maintaining clients and creating a biological, psychological,

sociocultural environment that helps healing, (coordinating role)

 3

regulating the integration of nursing, diagnostic and therapeutic actions so that

effective and efficient services are established, (therapeutic role) as executing the

delegation of tasks from doctors for diagnostic and therapeutic measures

(Akatsuki, 2011). The role of nurses for the first time that can be carried out in

heart failure patients with decreased perfusion problems, namely by

recommending a lying position and limiting activities can reduce the workload of

the heart so that it can help the heart not work hard and oxygen supply can be

delivered to all cells, including cells. the heart itself (Muttaqin, 2012).

1.2 Scope of problem

Researchers only limit the case of clients with nursing care problems in

clients with heart failure with problems at the risk of ineffective myocardial

perfusion in Jombang General Hospital.

1.3 Formulation of the problem

How is the Nursing Care for Heart Failure Clients with the Risk of

Ineffective Myocardial Perfusion in Jombang General Hospital?

1.4 Aim

1.4.1 General purpose

Able to perform Nursing Care for Heart Failure Clients with Ineffective

Myocardial Perfusion Risk Problems in Jombang General Hospital

1.4.2 Special purpose

The specific objectives of this case study are:

1. Conducting nursing assessments on clients with heart failure in the

HCU Kemuning room at RSUD Jombang

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2. Determine a nursing diagnosis to a client with heart failure in the HCU

Kemuning room at RSUD Jombang

3. Arranging nursing plans for clients with heart failure in the HCU

kemuning room at RSUD Jombang

4. Performing nursing actions on clients with heart failure in the HCU

Kemuning room at RSUD Jombang

5. Conducting nursing evaluations on clients with heart failure in the

HCU Kemuning room at RSUD Jombang

1.5 Benefits

1.5.1 Theoretical Benefits

So that the results of this study can be a reference for other researchers

similar to heart failure clients with problems with the risk of ineffective

myocardial perfusion

1.5.2 Practical Benefits

The results of this study can be an additional reference for students and

teachers in improving knowledge about the nursing process in cases of

heart failure, it can also improve the quality of service in cases of heart

failure and can pay attention to the conditions and needs of heart failure

patients with problems with the risk of ineffective myocardial perfusion,

can use as a basis for further research with the same nursing problems and

different themes, and can improve the quality of health care

 CHAPTER 2

LITERATURE

REVIEW

2.1. Heart Failure Concept

2.1.1. Definition of Heart Failure

Congestive heart failure (CHF) is a condition in which the function of the heart as

a pump to deliver oxygen-rich blood to the body is not sufficient to meet the

body's needs (Saferi, 2013). Heart failure is the inability of the heart to pump

blood in sufficient quantities to meet tissue oxygen and nutrient needs. The

mechanisms of heart failure include damage to the contractile properties of the

heart leading to less than normal cardiac output, atherosclerosis, atrial

hypertension, and inflammatory or degenerative diseases of the heart muscle.

Several systemic factors that can aggravate heart failure include an increase in the

metabolic rate (eg fever, coma, thyrotoxicosis), hypoxia, and anemia which

require an increase in cardiac output to meet oxygen requirements (Sani, A.,

2007).

2.1.2. Etiology

According to Wijaya & Putri (2013), in general heart failure can be caused by

various things which can be grouped into:

1. Myocardial Dysfunction

a. Cardiac muscle ischemia: is a condition in which there is progressive

blockage of blood flow so that the blood supply to the tissues is

inadequate.

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b. Myocardial infarction: is a condition of stopping blood flow from the

coronary arteries which causes a lack of oxygen and causes the death of

heart muscle cells.

c. Myocarditis: is a condition in which the heart muscle becomes inflamed

or inflamed.

d. Cardiomyopathy: is a heart disease that weakens and enlarges the heart

muscle.

2. Overload pressure on systolic (systolic overload)

a. Aortic stenosis: a condition in which there is narrowing of the aortic valve

b. Hypertension: is a condition in which the blood pressure in the artery

walls increases or is above the normal range.

c. Coartation of the aorta: is a narrowing of the aorta, which usually occurs

in the aorta that bends downward (decending aorta)

3. Diastolic overload volume (diastolic overload)

a. Mitral and tricuspid valve insufficiency: is a backflow leak through the

mitral and tricuspid valves when the ventricles contract as a result of not

closing the valve completely.

4. Increased metabolic requirements (demand overload)

a. Anemia: is a reduced number of red blood cells or hemoglobin in the

blood

5. Give - give

Beriberi is a disease caused by deficiency of vitamin B (thiamine)

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6. Impaired ventricular filling

a. Primary (failure of systolic distension)

1) Retrictive pericarditis

A form of heart defect in which the walls of the heart experience

stiffness, and the heart is restricted from expanding and filling blood

properly.

2) Cardiac tamponade

It is an acute type of pericardial effusion in which fluid accumulates

in the pericardium.

b. Secondary

Secondary ventricular filling disorders include heart valve stenosis, both

mitral and tricuspid valves, valve stenosis is a narrowing of the valve

orifice which results in increased resistance to blood flow from the atria to

the ventricles.

2.1.3 Classification of Heart Failure

New York Heart Association (NYHA) classifying heart failure in Manik

(2016), namely:

Table 2.1. Classification of heart failure based on the client's symptoms

Class Sympt
oms
There are no limitations to physical activity in sufferers. Physical
I activity usually does not cause complaints
fatique/ fatigue,
dyspnea/ fatigue, and palpitations / palpitations
A little limited physical activity, feel comfortable when resting, but
II strenuous physical activity can cause fatigue, dyspnea, or
palpitations.
Obvious limitations on physical activity, feeling comfortable at rest,
III but symptoms will appear when doing physical activity
lighter than usual.
Discomfort while doing any physical activity. Symptoms appear even
IV at rest and get worse when doing
physical activity.
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2.1.4 Clinical manifestations

1. Dyspnea

Dyspnea were characterized as rapid, shallow breathing, and a

condition that indicated the patient had difficulty getting enough air.

Sometimes patients complain of insomnia, restlessness, weakness due

to dyspnea.

2. Orthopnea

Orthopnea is the inability to lie flat due to dyspnea. The patient can

only lie down with the head much higher.

3. Paroximal nocturnal dyspnea (DNP)

This complaint is waking up in the middle of the night experiencing

severe shortness of breath.

4. Cough

This symptom is often not a concern of pulmonary vascular

congestion, but can be the dominant symptom. The cough in

pulmonary vascular congestion can be productive but is usually dry

and short.

2.1.5 Pathophysiology

Heart failure occurs due to a complex interaction between factors affecting

contractility, afterload, preload or relaxation function of the heart and the

neurohormonal and hemodynamic responses required to create circulatory

compensation. In systolic dysfunction there is a disturbance in the left

ventricle which causes a decrease in cardiac output.

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Several natural compensatory mechanisms will occur in patients with

heart failure in response to decreased cardiac output and help maintain

sufficient blood pressure to ensure adequate organ perfusion (Diah Y,

2009).

2.1.6 WOC (Web of Caution) Heart failure

Congestive Hypertrophic Restrictive

cardiomyopathy cardiomyopathy cardiomyopathy

Left ventricular ejection disorders

Blood stasis in the

ventricles and in the
atria

Improved preload and

afterload

Heart failure

Decreased
cardiac
output

Decreased oxygen
supply to tissues

Risk of ineffective
myocardial
perfusion

Figure 2.1 WOC Heart failure (Muttaqin, 2009)

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2.1.7 Complications

According to Kasron (2012) complications in heart failure patients are:

1. Cardiogenic shock

2. Thromboembolic episodes due to venous clot formation due to blood

stasis

3. Pericardium effusion and tamponade

4. Digitalis toxicity due to the use of digitalis drugs

2.1.8 According to Sani (2007) Management of patients with heart failure are:

1. Pharmacology

a. Diuretics: to reduce fluid buildup and swelling

b. Ace inhibitors: to lower blood pressure and reduce the

workload of the heart.

c. Beta blockers (beta blockers): to reduce heart rate and lower

blood pressure so that the burden on the heart is reduced

d. Digoxin: strengthens the heart rate and pumping power

e. Nitrate therapy and coronary vasodilators: cause peripheral

vasodilation and decreased myocardial oxygen consumption

f. Digitalis: slows down the ventricular frequency and increases

the force of contraction, increases the efficiency of the heart. as

cardiac output increases, a larger volume of fluid is delivered to

the kidneys for filtration and excretion and the intravascular

volume decreases.
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g. Positive inotropes: Dobutamine is a sympathomimetic drug

with beta 1 adrenergic action.

h. Sedative: Giving sedatives to reduce anxiety aims to rest and

provide relaxation to the client.

2. Non Pharmacology

Management of congestive heart failure with the aim of:

a. Reducing the work of the heart

b. Increases cardiac output and myocardial contractility

c. Lowering salt and water retention.

3. Rest in bed

Bed rest reduces the work of the heart, increases the reserve power

of the heart and lowers blood pressure

4. Oxygen

Oxygen fulfillment will reduce myocardial fever

and help meet the body's oxygen

needs.

5. Diet

Diet settings make the work and tension of the heart muscle at a

minimum. In addition, sodium restriction is aimed at preventing,

regulating, or reducing edema.

6. Coronary revascularization

7. Heart transplant

8. Cardiomyoplasty
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2.1.9 According to Sani (2007) Diagnostic Examination / Support for heart

failure, namely:

1. EKG (electrocardiogram): to measure the speed and regularity of the

heart rate.

2. Echocardiogram: uses sound waves to determine the size and shape

of the heart, and assesses the state of the heart chambers and the

function of the heart valves.

3. Chest X-ray: to check for an enlarged heart, fluid buildup in the

lungs or other lung diseases. BNP blood test: to measure the levels of

the hormone BNP (B-type natriuretic peptide) which in heart failure

will increase.

4. Sonogram: Can show the dimensions of the chamber enlargement,

change in valve function / structure or the area of decreased

ventricular contractility.

5. Cardiac scan: The act of injecting fractions and estimating wall

motion.

6. Cardiac catheterization: Abnormal pressure is indicative and helps

differentiate right-sided verus-left-sided heart failure, and valve

stenosis or insufficiency. Also assesses the potential for corornary

arteries.
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2.2 The Concept of Ineffective Myocardial Perfusion Risk

Definition of Ineffective Myocardial Perfusion Risk According to IDHS

(2016) there is a risk of experiencing decreased coronary artery circulation

which can interfere with myocardial metabolism.

Risk factors

1. Hypertension

2. Hyperlipidemia

3. Hyperglycemia

4. Hypoxemia

5. Hypoxia

6. Lack of fluid volume

7. Heart surgery

8. Substance abuse

9. Coronary artery spasm

10. Increased C-reactive protein

11. Cardiac tamponade

12. Pharmacological agent effects

13. Family history of cardiovascular disease

14. Lack of exposure to information about modifiable risk factors (eg

smoking, sedentary lifestyle, obesity)

2.2.1 Perfusion Myocardium

Decreased myocardial perfusion, which is a condition in which the

heart's blood pump is inadequate to achieve oxygen demand

(Wilkinson & Ahern, 2012)

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2.3 Concept of Nursing Care for Clients With Heart Failure

2.3.1 Assessment

1. Client Identity

a. Age: The age of people with heart failure is divided into 2, namely

46-65 years and ≥65 years with each portion of 50%. This shows that

no heart failure sufferer has heart failure in adulthood, because it

ranges from the elderly to the elderly. Age is indeed a risk factor for

heart failure. However, the role of age risk factors must be viewed

from the gender factor.

b. Gender: Gender susceptible to heart failure is influenced by the role

of the female hormone, namely estrogen, which protects women

from various cardiovascular diseases. Therefore, men are prone to

heart failure at the age of 50, while women are at the age of 65 or

after menopause (Soeharto, 2006).

c. Work: Hard work is known to be a burden and cause health problems,

especially in the cardiovascular system. The data shows that men who

are actively working are 10 percent less likely to develop heart failure.

Meanwhile, women are 20 percent less affected by the same disease.

(Lousiana, 2008). Physical activity in people with heart failure must

be adjusted to the level of symptoms.

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2. Medical History Now

a. Main complaint

Usually patients complain of shortness of breath and weakness during

activities, fatigue, chest pain, dyspnea during exertion.

b. Complaints when reviewed

The assessment was carried out by asking a series of questions about

the patient's physical weakness by PQRST. Usually the patient will

complain of shortness of breath and weakness during activities,

fatigue, heavy chest, and palpitations.

3. Past Medical History

Includes a history of the client's illness, especially those that support the

current disease. Patients with heart failure usually have previously had

chest pain, hypertension, myocardial ischemia, myocardial infarction,

diabetes mellitus, and hyperlipidemia. And also has a history of using

drugs in the past

4. Family medical history

The nurse asks about illnesses that have been experienced by the family,

family members who died, especially at productive age, and the cause of

death. Ischemic heart disease in offspring (Muttaqin, 2012)

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2.3.2 Physical examination

1. General circumstances

In mild or moderate heart failure the patient may appear to have no

complaints, except for feeling discomfort when lying flat for more than

a few minutes. In patients with more severe heart failure, the patient

may have heavy breathing efforts and may have difficulty completing

words due to shortness of breath (Williams & Wilkins, 2007).

2. Vital sign

Systolic blood pressure can be normal or high, but generally decreases.

Pulse pressure can be reduced, due to reduced stroke volume, and

arterial diastolic pressure may increase as a result of systemic

vasoconstriction (Williams & Wilkins, 2007).

3. Awareness

Compost mentis: The state of the patient is fully aware, both to the

environment and to himself.

b) Apathy: The condition of the patient in which he appears indifferent

and averse to his environment.

c. Delirium: The patient's condition has decreased consciousness

accompanied by motor disorders and disturbed sleep wake cycles.

d.Somnolence: The patient's drowsy state which can recover if

stimulated, but if the stimulation stops the patient will sleep again.

e.Sopor (stupor): The condition of the patient is deep drowsiness.

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f. Semi-coma (mild coma): the patient has decreased consciousness

that does not respond to verbal stimuli, and is unable to wake up at

all, but the response to pain is inadequate and reflexes (pupil &

cornea) are still good.

g. Coma: the patient's condition has a very deep decrease in consciousness,

there is no response to pain stimuli and there is no spontaneous

movement (Gordon, 2015)

4. The nervous system, including awareness, pupil size, movement of all

expressions and the ability to respond to verbal and non-verbal

responses (Aziza, 2010)

5. The visual system, in clients with heart failure, the eyes experience

blurred vision (Gordon, 2015)

6. The hearing system, in clients with heart failure, the ear hearing system

is not impaired (Gordon, 2015)

7. Abdominal system, clean, flat and no enlarged liver (Gordon, 2015)

8. Respiratory system, the assessment is carried out to determine in a

minimum the signs and symptoms of inadequate ventilation and

oxygenation. The assessment includes the percentage of oxygen

fraction, tidal volume, respiratory rate and mode used for breathing

(Aziza, 2010).
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9. Cardiovascular system

a. Inspection

The patient lies on a flat base. In the chest shape there is a wide local

protrusion in the precordium area, between the sternum and apex

codis. This lump can be confirmed by touch.

b. Palpation

Apical impulses can also sometimes be palpated. Normally felt as a

light pulsation, 1 to 2 cm in diameter. The palms were first used to

determine their size and quality.

c. Percussion

The use of percussion is to define the boundaries of the heart. In

normal circumstances between the left and right sternal lines in the

manubrium sterni there is a deaf which is the aortic area.

If this area is enlarged, it is likely the result of an aortic aneurysm.

To determine the left border of the heart perform percussion from the

lateral to the medial direction.

d. Auscultation

1) Heart Sounds

To hear heart sounds, pay attention to the localization and

origin of heart sounds.

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2) The rhythm and frequency of heart sounds

The rhythm and frequency of the heart sound must be compared

with the pulse rate. The normal rhythm of the heart is regular and

when it is irregular it is called an arrhythmia cordis. The

frequency of the heart sounds should be determined in minutes,

then compared with the pulse rate. If the pulse rate and heart

sound are more than 100 beats per minute each, it is called

tachycardia and if the frequency is less than 60 beats per minute

it is called bradycardia.

10. Gastrointestinal system, studies on gastrointestinal include auscultation

of bowel sounds, palpation of the abdomen (pain, distension) (Aziza,

2010).

11. Musculuskeletal system, in heart failure clients there is weakness and

muscle fatigue resulting in the inability to perform the expected

activities or activities that are usually carried out (Aziza, 2010).

12. Endocrine system, usually there is an increase in blood sugar levels

(Aziza, 2010).

13. Integumentary System, in clients of CHD (coronary heart disease), the

acral feels warm, the turgor is good (Gordon, 2015).

14. The urinary system, assess the presence or absence of swelling and

pain in the waist area, observe and palpate the lower abdominal area to

determine the presence of urinary retention and assess the type of

discharge (Aziza, 2010)

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15. Patterns of daily habits (Smeltzer & Bare, 2013)

a. Activity / rest

1) Symptoms: Fatigue / fatigue continuously throughout the day,

insomnia, chest pain with exertion, dyspnea at rest.

2) Signs: Restlessness, changes in mental status eg lethargy, changes

in vital signs on activity.

b. Elimination

Symptoms: Bowel sounds may be increased or they may be normal.

c. Food / liquid

1) Symptoms: Loss of appetite, nausea / vomiting, significant weight

gain, swelling of the lower extremities, tightness of clothing /

shoes, a diet high in salt / processed foods and use of diuretics.

2) Signs: Rapid weight gain and abdominal distension

(ascites) and edema (generalized, dependent, pressure and pitting).

d. Hygiene

1) Symptoms: Fatigue / weakness, fatigue during self-care

activities.

2) Sign: Appearance indicates neglect of personal care.

e. Neurosensory

1) Symptoms: Weakness, dizziness, episodes of fainting.

2) Signs: Letargi, changes in behavior and irritability.

f. Pain / Comfort
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1) Symptoms: Chest pain, acute or chronic angina, right upper

abdominal pain and muscle aches.

2) Signs: Uneasy, restless, narrowed focus and protective

behavior.

g. Security

Symptoms: Changes in mental function, loss of muscle strength /

tone.

h. Social interaction

Symptoms: Decreased participation in common social activities.

2.3.3 Nursing diagnoses

Nursing diagnoses are clinical decisions regarding individual, client or

community responses to actual or potential health problems as the basis for

selecting nursing interventions to achieve nursing care goals in accordance

with the nurse's authority (Herdman & Kamitsuru, 2015). Judging from the

client's health status, the diagnosis can be divided into actual, potential, risk

and possibility

1. Actual: Nursing diagnoses that represent clinical judgments that the nurse

must validate because there are major limitations. Examples of effective

airways due to accumulated secretions.

2. Potential: A nursing diagnosis that describes the client's condition in a

more positive direction (patient strength). An example of a potential

improvement in client health status relates to inadequate nutritional intake.

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3. Risks: Nursing diagnoses that reflect the clinical condition of an individual

more prone to problems. Examples of infection risk relate to the effects of

surgery.

4. Probability: Nursing diagnoses describing individual clinical conditions

that require additional data as a more adequate supporting factor. So what

is meant by nursing diagnoses is a clear statement relating to the problems

encountered by the patient, whether actual, potential, risk or possibility.

Examples of emerging heart failure nursing diagnoses

a. Risk of ineffective myocardial perfusion

2.3.4 Nursing interventions

Table 2.2 Intervention Risk of Ineffective Myocardial Perfusion

DIAGNOSIS NOC NIC

Definition Risk Tissue Perfusion: 1. Monitor vital signs
are at risk of Cardiac Indicator a. Monitor blood pressure,
experiencing a. Apical heart rate pulse, temperature and
decreased coronary b. Radial pulse respiratory status
artery circulation c. Systolic blood pressure appropriately.
which can be disturb d. Diastolic pressure b. Monitor blood pressure
myocardial e. Average blood after the patient takes
metabolism. pressure values medication if possible
f. Fraction ejection c. Appropriately monitor
Risk factors g. Pulmonary wedge blood pressure, pulse
1. Hypertension pressure and respiration before,
2. Hyperlipidemia h. Cardiac enzymes during and after activity
3. Hyperglycemia i. Results of a coronary d. Heart rhythm and pressure
4. Hypoxemia angiogram monitor
5. Hypoxia j. Exercise stress test results 2. Oxygen therapy
6. Deficiency k. Thallium scan results a. Maintain patent airway
volume of fluid l. Angina b. Oxygen flow monitor
7. Surgery m. Arrhythmia c. Monitor the effectiveness
heart n. Tachycardia of oxygen therapy (eg
8. Abuse o. Bradycardia pressure oximetry, ABGs)
substance p. Sweating a lot appropriately
q. Nauseous vomit d. Watch for signs of
9. Spasms
oxygen-induced
artery coroner
hypovontilation
10. Enhancement
protein C-
reactive
 23

11. Cardiac Scale: e. Consult with other health

tamponade 1. Severe deviation from professionals regarding
12. Effect normal range the use of supplemental
agent 2. Considerable deviation oxygen during
pharmacologica from the normal range activities and / or sleep
l 3. Moderate deviation 3. Treatment management
13. History from normal range a. Determine what drugs are
cardiovascular 4. Mild deviation needed, and administer
disease in from normal range them according to
families 5. There is no deviation prescription and / or
14. Less from the normal protocol
are exposed to range b. Monitor the effectiveness
information of the appropriate drug
administration.
about risk
c. Monitor patient regarding
factors that therapeutic effects of drugs
could d. Monitor for signs and
symptoms of drug toxicity
changed (eg, e. Monitor drug side effects
smoking, style f. Monitor response to
life less medication changes in an
motion, appropriate manner
obesity) g. Specify impact
the use of drugs in the
patient's lifestyle
h. Give it
alternative regarding the
duration and method of
self-medication to
minimize lifestyle effects
i. Assist the patient and
family members in making
the necessary lifestyle
adjustments associated
with (taking) certain
medications in an
appropriate manner
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2.3.5 Nursing Implementation

Implementation is the execution of an intervention plan to achieve

specific goals. The implementation stage begins after the intervention

plan is drawn up and shown on nursing orders to help clients achieve the

expected goals.

Therefore a specific intervention plan is implemented to modify the

factors that affect the client's health problems (Nursalam, 2008).

2.3.6 Nursing Evaluation

Nursing evaluation is the stage that determines whether the goals that

have been set are achieved or not. Evaluation is based on how effective

the interventions are made by families, carers and others. There are

several evaluation methods used in treatment. The most important factor

is that the method must be tailored to the objectives and the intervention

being evaluated. (Friedman, 2016)

 25

CHAPTER 3

RESEARCH METHODS

3.1. Research design

The research design used is a case study. The case study which is the

subject of this research is used to explore the problem of Nursing Care for

Clients with Heart Failure and the Risk of Ineffective Myocardial Perfusion in

Jombang General Hospital.

3.2. Limitation of Terms

The term limits used to avoid mistakes in understanding the research title,

in this study are as follows:

1. Nursing care is a systematic and organized method of providing nursing

care, which focuses on the unique reactions and responses of individuals in

a group and individuals to health problems experienced, both actual and

potential.

2. Clients are individuals who seek or receive medical care.

The clients in this case study are 2 clients with the same medical diagnosis

and nursing problems.

3. According to J. Charles Reeves et al in Wijaya & Putri (2013) heart failure

is a condition in which the function of the heart as a pump to deliver

oxygen-rich blood throughout the body is not sufficient to meet the body's

needs.

25
 26

4. Ineffective myocardial perfusion in heart failure patients is the result of

inadequate circulating oxygen levels and stagnation of blood in

peripheral tissues (Myers, 2008).

3.3. Participants

Participants are a number of people who take part in an activity,

participation and participation. The subjects used in this study were clients

who were studied and met during the study as many as 2 clients and with a

medical diagnosis of heart failure with problems with the risk of ineffective

myocardial perfusion in Jombang General Hospital. The selected clients are

clients who are treated at the hospital who have gone through the 3 day

phase.

3.4. Location and Time of Research

1.4.1 Research sites

This research was conducted in the Kemuning room of the

Jombang Regional Hospital, which is located at JL. KH Wahid

Hasyim No.52, Jombang District, Jombang Regency.

1.4.2 Research time

The research was carried out starting from the preparation of

proposals in January 2018 to February 2018.

 27

1.5. Data collection

In order to obtain data that is in accordance with the problems in

this study, it is necessary to collect data techniques. The techniques are:

1. Submission of applications for permission to conduct research starts

from submitting a cover letter for permission from the Nursing D3 study

program and then processed to BAAK (Academic and Student

Administration Bureau), after the application for research permission

has been processed, the letter will be directly submitted to BAKORDIK

RSUD Jombang, where The researcher will get a reply letter that

includes the data and the division of the place or room according to the

respondent that the research will do.

2. Informed consent, where the subject must get complete information

about the purpose of the research being carried out, has the right to

freely participate or refuse to become a respondent.

3. Interviews are conversations that have a specific purpose, usually

between two people who exchange information and ideas through

question and answer. In this case study, the researcher used 2 types of

interviews, namely autoanamnesa and heteroanamnesa.

 28

4. Observation and Physical examination

Observation is the result of the soul's actions actively and attentively to

be aware of stimuli. The reason researchers make observations is to

present a realistic picture of behavior or events, answer questions, help

understand human behavior and evaluate. Physical examination in this

case uses the IPPA approach: inspection, palpation, percussion,

auscultation of the client's body systems.

5. Documentation Studies

Documentation study is the activity of finding data or variables from

sources in the form of notes, books, newspapers, magazines,

inscriptions, meeting minutes, agenda, and so on. What is observed in

the documentation study is inanimate objects (Suryono, 2013).

In this case study, a documentary study is used in the form of notes on

the results of medical record data, literature review and diagnostic tests

and other relevant data.

 29

3.6 Data validity test

The data validity test is intended to test the quality of data /

information obtained in the study so as to produce data with high validity.

Besides the integrity of the researcher (because the researcher is the main

instrument), the data validity test was carried out by:

1. Extend observation / action time

2. Additional sources of information use triangulation from three main

data sources, namely patients, nurses and client families related to the

problems studied.

3.7 Data analysis

According to Tri (2015), data analysis was carried out from the time the

researchers were in the field, during data collection until all data were

collected. Data analysis was carried out by stating facts, then comparing

with existing theories and then pouring it out in the discussion opinion.

The analysis technique is used by narrating the answers from the research

obtained from the interpretation of in-depth interviews conducted to answer

the formulation of research problems.

The analysis technique is used by means of observation by researchers and

documentary studies which produce data for further interpretation by the

researchers compared to existing theories as material to provide

recommendations for the intervention. The order of analysis is:

 30

1. Data collection.

Data were collected from the WOD results (interviews, observations,

documents). The results are written in the form of field notes, then

copied in the form of notes.

The data collected is related to assessment data, diagnosis, planning,

action / implementation, and evaluation

2. Data reduction.

Interview data collected in the form of field notes are put together in the

form of nursing care report studies. The objective data were analyzed

based on the results of diagnostic tests and then compared with normal

values

3. Presentation of data.

Presentation of data can be done with tables, pictures, charts and

narrative text. The confidentiality of the respondent is guaranteed by

obscuring the identity of the respondent.

4. Conclusion.

From the data presented, then the data is discussed and compared with

the results of previous studies and theoretically with health behavior.

The conclusion is drawn by the induction method.

 31

3.8 Research Ethics

Some ethical principles that need to be considered in research include:

1. Consent to be a respondent (Informed Consent), where the subject must

get complete information about the purpose of the research to be carried

out, have the right to freely participate or refuse to become a respondent.

Informed consent also needs to state that the data obtained will only be

used for scientific development.

2. Anonymous (anonymity), where the subject has the right to request that

the data provided must be kept confidential. The confidentiality of the

respondents is guaranteed by obscuring the identity of the respondent or

anonymity.

3. Confidentiality, the confidentiality given to respondents is guaranteed

by the researcher (Nursalam, 2014)

 CHAPTER 4
RESULTS AND DISCUSSION

4.1 Result
4.1.1 Overview of Data Collection Locations
Jombang District Hospital is a hospital owned by the Jombang

Regional Government. Based on the Decree of the Minister and Social

Welfare No. 238 / MenKes-Kesos / SK / 2001 RSUD Jombang became

RSUD Type B Non-Education and in 2015 RSUD Jombang was accredited

by 2012 version with the title of PARIPURNA Level 2015-2018. The

location of Jombang Regional Hospital is on Jalan KH. Wakhid Hasyim 52

Jombang. Jombang Regional Hospital is able to provide specialists and non-

specialist medical services. This hospital is able to accommodate referrals

from private hospitals and health centers around the Jombang area.

The capacity of Jombang Hospital consists of 486 inpatient beds, 2

bedroom suites, 52 beds in VIP / VVIP class, 50 beds in class I, 65 beds in

class II, 184 beds in class III, 28 beds in ICU and 105 beds in HCU . RSUD

Jombang has 22 outpatient polyclinics consisting of 18 specialist and 4 non-

specialist polyclinics and 8 inpatient installations, which are currently in the

form of SMF.

Services are also equipped with an Emergency Room (IGD), Clinical

Laboratory Installation, Anatomical Pathology Laboratory Installation,

Radiology Installation, Central ICU Installation, Central Surgical

Installation, Central Sterilization Installation, pharmacy, nutrition services

and medicinal rehabilitation.

 33

The assessment was carried out by the Kemuning HCU Room, with a

capacity of 1 room with 6 beds and 6 inpatient clients accompanied by

ventilation and a clean room

4.1.2 Assessment
1. Client Identity
Table 4.1 Identity of Clients with Heart Failure with Problems The Risk of
Ineffective Myocardial Perfusion in the HCU Kemuning Room,
Jombang Hospital, 2018
Client Identity Client Client
1 2
Name Mr. MS Mr. S
Age 60 Years 45Years
Religion Islam Islam
Education MI Junior High School
Profession Farm workers General employees
Marital status Married Widower

Address Diwek, Jombang Together, Jombang

Tribes Javanese / Indonesian Javanese / Indonesian
MRS date April 24, 2018 April 24, 2018

Entry Hours 17.44 WIB 22.41 WIB

Assessment Date April 25, 2018 April 25, 2018
Study hours 08.00 WIB 10.00 WIB
No. RM 390XXX 401XXX
Diagnostic Entry HF (Heart failure) with HF (Heart failure)
Dyspnea + AF
Source: Primary Data (2018)
 34

2. History of Disease

Table 4.2 History of client with heart failure with problems, the risk of
ineffective myocardial perfusion in the HCU Kemuning Room,
Jombang Hospital, 2018
History of Disease Client
1 2
Main complaint The client said
crowded, breath
rubbing
Current Disease History The client said he came to
Jombang Hospital with
complaints of shortness of
breath, coughing, rubbing
suddenly without any
activity. Then the client was
brought to the IGD Jombang
and MRS Hospital at the hour
17.44 WIB in the HCU
Kemuning room
Past medical history The client said he did not
history
hypertension and DM. But
the client said that he had
MRS in the Kemuning room
of Jombang Hospital in
February with illness
coronary heart and treated for
4 days.
Family History The client said there was a
family who had a history of
heart disease, namely
client's father
Allergy History The client said no
have a history of allergies
Source: Primary Data (2018)
Client
Client says access,
breath rub left chest pain
The client's family said that
the client was taken to the
Jombang Regional Hospital
with a state of shortness of
breath, rubbing and the right
leg was swollen for 2 weeks,
then the client was taken to
the ER and MRS.
at 22.41 WIB in the
Kemuning HCU room
The client's family said they
did not have a history of
hypertension and DM. The
client's family said the client
had never been hospitalized
The client's family said there
was no family history of
heart disease
The client said no
have a history of allergies

3. Change in Health Patterns (Gordon Approach)

Table 4.3 Changes in the Health Pattern of Clients with Heart Failure with
Problems The Risk of Ineffective Myocardial Perfusion in the HCU
Kemuning Room, Jombang Hospital, 2018
No Activity Pattern At home In the hospital
.
Client 1 Client 2 Client 1 Client 2
1 Nutrition and Eat 2x / day Eat 3- Eat Eat
Fluids
(rice, 4x / day 3x / day (diit 3x / day (diit
vegetables, servings
side dishes large (rice, low low
with a portion side dishes), salt), salt),
a little, drink ± 500 with a portion eat a little
drink ± 700 cc per day great drink but often,
cc per day). limited to 600 drink
cc per day limited to 600
cc
 36

2 Rest / sleep Irregular nap Difficulty Sleep at Difficulty

(± 4 hours) sleeping night at sleeping
from during the 22.00-02.00. during the
10:00 - day. At Difficulty day and at
14.00 WIB. night, sleep sleeping night sleep
Sleep at is ± 9 hours during the often
night from 200.00- day awakens
± 8 hours 05.00
from 21.00 -
05.00 WIB
3 Elimination BAB (-)
CHAPTER CHAPTER BAK ± 1000 BAB (-)
1x / day. 1x / day. BAK cc in 24 BAK ± 2000
BAK often often. hours in 24 hours
but slightly
4 Personal Hygiene (± 400 cc). Wiped in the
morning and Wiped in the
Shower 2x / Shower 2x / evening, morning and
day, brush day, brush change evening,
your teeth 2x / your teeth 1x clothes 1x / change
day, shampoo / day, day. clothes 1x /
3x / week, shampoo 2x / day.
change clothes week, change
5 Activity 2x / day. clothes 2x /
day. Client only
Clients work bedrest. Client only
as farm Client works bedrest.
laborers as
employees
private
Source: Primary Data (2018)

4. Physical Examination (Systems approach)

Table 4.4 Physical Examination of Clients with Heart Failure with Problems
Risk of Ineffective Myocardial Perfusion in the HCU Kemuning Room,
Jombang Hospital, 2018
Observation Client 1 Client
2
Temperat 36.70 C 36.60 C
ure Pulse 94x / minute 109x / minute
Blood Pressure 100/70 mmHg 170/120 mmHg
Respiration Rate 28x / minute 37x / minute
Awareness General 4-5-6 4-5-6
Conditions weak weak
Examination
Physical B1 Inspection: the client looks Inspection: the client looks
Breathing short, the shape of the chest is tight, the chest is symmetrical,
symmetrical, the rhythm of the rhythm of breathing is fast
breathing is fast and regular, and regular, there is nasal
there is nostril breathing, 4 breathing. Inserted O2 nasal 4
lpm of nasal oxygen is lpm Palpation: vocal fremitus
attached vibrates.
Palpation: vocal fremitus Auscultation: vesicular
trembles. breath sounds.
Ausculation: normal breath Percussion: faint sound.
sounds
Percussion: faint sound.
Inspection: asymmetrical chest
B2 Blood Inspection: no distension of the shape, no jugular vein distension,
jugular veins, conjunctiva no conjunctiva
not anemic, not customary
 37
cyanosis. anemic, no sign of cyanosis.
Asymmetric chest Palpation: There is tenderness in
shape the left chest, CRT <2 seconds,
Palpation: CRT <2 seconds, the pulse is vulnerable to
pulse tachycardia normal
Auscultation: apical heart rate, Auscultation: apical heart
low diastolic systolic blood rate, high diastolic blood
pressure pressure in systole, there is a
murmur on ICS 2 3

B3 Brain Inspection: composmentis

Inspection: composmentis awareness, GCS 4-5-6, pupil
awareness, GCS 4-5-6, isochor, + / + light reflex.
pupil isochor, light reflex
B4 Bladder + / +. Inspection: attached folley
Inspection: attached folley cateter with urine production
cateter with urine production ± 2000 cc in 24 hours
± 1000 cc in 24 hours Palpation: no tenderness.
Palpation: no
tenderness.
B5 Bowel Inspection: not installed NGT.
Inspection: not installed Palpation: no tenderness.
NGT. Auscultation: bowel sounds
Palpation: no (+).
tenderness.
Auscultation: bowel sounds
B6 Bone (+).
Inspection: free joint movement,
Inspection: free joint no fractures, no injuries, edema
movement, no fractures, on both legs.
no injuries. Palpation: warm acral, skin
Palpation: warm acral, skin turgor <2 seconds. .5 5
turgor <2 sec. 5 5 Strength Strength muscle
muscle 55
55

Source: Primary Data (2018)

5. Diagnostic Checks

Table 4.5 Diagnostic Examination of Clients with Heart Failure with Problems
The Risk of Ineffective Myocardial Perfusion in the HCU Kemuning
Room, Jombang Hospital, 2018
Diagnostic Checks on Mr. MS Diagnostic Checks on Mr. S
12 lead EKG examination on April 25 2018 12 lead EKG examination on April 25
Conclusion: RBBB, VF 2018
12 lead EKG examination on 26 April 2018 Conclusion: Anteroceptal OMI, LH 12
Conclusion: AF, RBBB lead ECG examination on April 26 2018
12 lead EKG examination on 27 April 2018 Conclusion: Anteroceptal OMI 12 lead
Conclusion: AF, RBBB ECG examination on 27 April 2018
Photo of AP thorax dated April 25 2018 Conclusion: Anteroceptal OMI, LH
Conclusion: cardiomegaly with lung edema, Photo of AP thorax April 25 2018
good tug fug Conclusion: cardiomegaly with lung edema,
left pleural effusion, good tug fug
 37

6. Laboratory examination
Table 4.6 Laboratory Examination of Clients with Heart Failure with Problems
The Risk of Ineffective Myocardial Perfusion in the HCU Kemuning
Room, Jombang Hospital, 2018
Examination Client 1 Client 2 Normal Value
April 25 2018 April 25 2018
HEMATOLOGY
Complete Blood
Leukocyte 9,500 7,300 L 3,800 - 10,600 / ul
Hemoglobin (HGB) 16.2 11.9 L 13.2 - 17.3 g / dl
Hematocrit (HCT) 47.4 34.1 L 40 - 52%
Erythrocytes 5,680,000 3,960,000 4.5 - 5.5 jt / ul
Platelet Count 234,000 207,000 150000 - 350000 / cmm
type
Eosinophils - - 1 - 3%
Basophyll - -
Stem - - 3 - 5%
Segment 75 72 50 - 65%
Lymphocyte 15 18 25 - 35%
Monocytes 10 10 4 - 10%
CLINIC CHEMISTRY
Glucose as Urea 189 132 <200 mg / dl
serum creatinine 1.07 2.88 <1.5 mg / dl
SGOT 46.8 103.8 10 - 50 mg / dl
SGPT 272 191 <38 u / l
Potassiu 220 157 <40 u / l
m - 131 136 - 144 meq / l
Chlorid - 101 96 - 107 meq / l
e - 3.39 3.80 - 5.50 meq / l
Sodium

7. Drug Therapy
Table 4.7 Providing Therapy for Clients with Heart Failure with Problems at the
Risk of Ineffective Myocardial Perfusion in the HCU Kemuning
Room, Jombang Hospital, 2018.
Client 1 Client 2
April 25, 2018 April 25, 2018
RL 500cc / 24 RL 500cc / 24 hours
hours Injection: Drip kcl 25mEq / 24
Lasix 1x20 mg hours Injection:
Syringe Pump: Lasix 1x20 mg
Dobutamine 5 mcg / (bb) kg / Per Oral:
minute Per Oral: ISDN 3x5mg
ISDN 3x5mg Spironolactone 1x25 mg
Bisoprolol 1x½mg Aspilet 1X80 mg
ASA 0-0-80mg KSR 2x600 mg
Nasal Kanul 4 lpm ASA 0-0-80mg
Nasal Kanul 4 lpm
Source: Primary Data (2018)
 38

4.1.3 Data analysis

Table 4.8 Data Analysis of Client 1 Client with Heart Failure with Problems
Risk of Ineffective Myocardial Perfusion in the Kemuning HCU
Room, Jombang Hospital, 2018
Data Etiology Nursing Problems
Client 1 Risk of ineffective
Subjective data: The client said myocardial Risk of ineffective myocardial
shortness of breath, rubbing breath. perfusion perfusion
Objective data: Awareness:
composmentis
General condition:
weak Temperature:
36.7 ° C
Pulse: 94x / minute
Blood Pressure: 100/70 mmHg
Respiration Rate: 28x / minute
CRT <2 seconds, heart rate,
tachycardia, pulse rate
12 lead ECG examination on 25
April 2018 Conclusion: RBBB,
VF

Table 4.9 Data Analysis of Clients 2 with Heart Failure with Problems Risk of
Ineffective Myocardial Perfusion in the Kemuning HCU Room,
Jombang Hospital.
Data Etiolog Nursing Problems
y
Client 2
Subjective Data :The client said Risk of ineffective Risk of ineffective myocardial
shortness of breath, rubbing his myocardial perfusion
breath. Objective data: Awareness: perfusion
composmentis
General condition:
weak Temperature:
36.7 ° C
Pulse: 94x / minute
Blood Pressure: 170/120 mmHg
Respiration Rate: 28x / minute
CRT <2 seconds, pulse 109x /
minute
heart rate tachycardia 12 lead ECG
examination on 25 April 2018
Conclusion: Anteroceptal OMI, LH
Source: Primary Data (2018)
 39

4.1.4 Nursing diagnoses

Client 1: Risk of Ineffective Myocardial Perfusion Related to Decreased

blood supply to the heart muscle

Client 2: Ineffective Myocardial Perfusion Risk Associated With

Decreased blood supply to the heart muscle

4.1.5 Nursing Interventions

Table 4.10 Nursing Interventions for Clients with Heart Failure with Problems
Risk of Ineffective Myocardial Perfusion in the Kemuning HCU
Room, Jombang Hospital.
DIAGNOSIS NOC NIC
Client 1
Definition The risk of having Tissue Perfusion: Cardiac Monitor vital signs
impaired coronary artery Indicators: a. Monitor blood pressure,
circulation metabolism a. Apical heart pulse, temperature and
myocardial. rate respiratory status
b. Radial pulse appropriately.
Risk factor c. Systolic blood
1. Hypertension
b. Monitor blood pressure
pressure after patient takes
2. Hyperlipidemia
d. Diastolic medication if possible
3. Hyperglycemia
pressure c. Appropriately monitor
4. Hypoxemia
e. Average blood pressure, pulse
5. Hypoxia
blood and respiration before,
6. Lack of fluid volume
pressure during and after activity
7. Heart surgery
values d. Monitor heart rhythm and
8. Substance abuse f. Fraction ejection pressure
9. Coronary artery spasm g. Pulmonary Oxygen therapy
10. Increased C-reactive wedge e. Maintain patent airway
protein pressure f. Monitor oxygen flow
11. Cardiac tamponade 12. h. Cardiac enzymes g. Watch for signs of
Effects of pharmacological i. Results of a oxygen-induced
agents coronary hypovontilation
13. History disease angiogram h. Consult with other health
cardiovascular disease in j. Exercise stress professionals regarding
families 14. Lack of exposure test results the use of supplemental
to information about k. Thallium scan oxygen during activities
changeable stress factors (e.g., results and / or sleep. Treatment
smoking, lifestyle, movement, l. Angina management
obesity) m. Arrhythmia a. Determine what drugs are
n. Tachycardia needed, and administer
o. Bradycardia them according to
p. Sweating a lot prescription and / or
q. Nauseous vomit protocol
b. Monitor the effectiveness
Scale: of the appropriate drug
1. Severe deviation administration.
from normal
range
2. Considerable
deviation from the
normal range
3. Moderate deviation
from normal range
 40

4. Mild deviation c. Monitor patient regarding

from normal range therapeutic effects of drugs
5. There is no d. Monitor for signs and
deviation from the symptoms of drug toxicity
normal range e. Monitor drug side effects
f. Monitor response to
change treatment
in the right way

Client 2:

Definition of risk to Tissue Perfusion: Monitor vital signs

experience drop Cardiac Indicator a. Monitor blood pressure,
coronary artery circulation a. Apical heart pulse, temperature and
which can disturb rate
myocardial metabolism. respiratory status
b. Radial pulse appropriately.
c. Systolic blood b. Monitor blood pressure
Risk factor
pressure after patient takes
1. Hypertension
d. Diastolic medication if possible
2. Hyperlipidemia
pressure c. Appropriately monitor
3. Hyperglycemia
e. Average blood pressure, pulse and
4. Hypoxemia
blood respiration before, during
5. Hypoxia
pressure and after activity
6. Deficiency volume values d. Monitor heart rhythm and
fluid
f. Fraction ejection pressure
7. Heart surgery
g. Pulmonary
8. Substance abuse
wedge Oxygen therapy
9. Coronary artery spasm
pressure a. Maintain patent airway
10. Increased C- h. Cardiac enzymes
reactive protein b. Monitor oxygen flow
i.Results c. Watch for signs of
11. Cardiac tamponade
angiogram oxygen-induced
12. Effect
coroner hypovontilation
agent j. d. Consult with other health
pharmacological
k. Exercise stress professionals regarding
13. Family history of
test results the use of supplemental
cardiovascular
l. Thallium scan oxygen during activities
disease
results and / or sleep. Treatment
14. Less exposed
m. Angina management
information about n. Arrhythmia
modifiable risk a. Determine what drugs
o. Tachycardia are needed, and
factors (eg, smoking, p. Bradycardia
lack of lifestyle administer them
q. Lots according to
sweating prescription and / or
motion, obesity) r. Nauseous vomit protocol
Monitor the effectiveness of
Scale:
the appropriate drug
1. Severe deviation
administration.
from normal
range
b. Monitor the patient
2. Considerable
about therapeutic effect of
deviation from
the drug
the normal
c. Monitor for signs and
range
symptoms of drug toxicity
3. Moderate
d. Monitor drug side effects
deviation from
normal range
4. Mild deviation
from normal range
5. There is no
 41
deviation
 41

from the e. Monitor response to change

normal treatment in the right way
range f. Specify impact
the use of drugs on the style
patient's life

Source: Bullechek (2013)

4.1.6 Nursing Implementation

Table 4:11 Nursing Implementation in Clients with Heart Failure with Nursing
Problems The Risk of Ineffective Myocardial Perfusion in the Hcu
Kemuning Room, Jombang Hospital
Date and time Time Implementation Initia
ls
Wednesday, 13:00 Observe vital signs with
25
April 2018 TD 100/70 mmHg, N 94x / min, S 36.7 ° C, RR
28x / minute
13:05 Observe heart rhythm by auscultating the chest
and there is a sound
CLIENT 1 fast heart or tachycardia
Monitoring the client's oxygen flow while still
13:15 giving 4 lpm of nasal oxygen
13:20 Determine what drugs are needed
according to the doctor's prescription
13:30 Provide an explanation to the client about the effect
side of drugs like the drug bisoprolol can
resulting in the client having trouble sleeping.
13:35 Provide explanations to clients and families
about adjustments to the life style
required according to the use of the drug
right
Collaborating with internal doctors
13:45 administration of lasix 1x20 mg injection, oral medication
ISDN 3x5 mg, bisoprolol 1x½, and ASA 0-0-1
13:55 Collaborating with internal doctors
giving Ringer's Lactate fluid 500 cc in
24 hours.
14:05 Observing the client's excess fluid
while still giving a drinking limit of 600 cc
in 24 hours
Observing the client's input output by counting
14:15
the urine that comes out with fluids
who entered.

Wednesday, 15:00 Observing vital signs with a BP of 170/120

25 mmHg, N 109x / minute, S 37 ° C, RR 33x /
April 2018 minute
15:05 Observe heart rhythm by auscultating the chest
KLEN 2 and there is a sound
 42

fast heart or tachycardia

15:15 Monitor the client's oxygen flow while still giving
15:20 4 lpm of nasal oxygen. Determine what drugs are
needed according to the doctor's prescription
Provide an explanation to clients about the side
15:30
effects of drugs such as ISDN drugs that cause
chest palpitations and ASA which cause the
client to have difficulty breathing.
Provide an explanation to clients and families
15:35 about the necessary lifestyle adjustments in
accordance with the proper use of drugs
Collaborating with doctors in administering 1x20
mg of lasix injection, 3x5 mg of ISDN, 1x 25 mg
15:45 of spironolactone and 0-0-1 ASA.
Collaborating with doctors in administering
Lactate Ringer's fluid 500 cc in 24 hours
Observe the client's excess fluid while still giving
a limit of drinking 600 cc in 24 hours
15:05 Observing client input output with
count the urine that comes out with the fluids that
15:15 enter.

15:30

Thursday, 26 8:00 Observing vital signs with BP 90 / p mmHg, N

am 130x / minute, S 36.4 ° C, RR 28x / minute
April 2018 Perform heart rhythm observation by auscultating the
chest and displaying rapid heart sounds or
CLIENT 1 8:05 tachycardia
Monitoring the client's oxygen flow while still giving
am
4 lpm of nasal oxygen
Determine what drugs are needed according to a
8:15 doctor's prescription
am Providing an explanation to clients about the side
effects of drugs such as bisoprolol can cause
8:20 insomnia and spironolactone which causes the client
am to be congested.
Provide an explanation to clients and families about
8:30 the necessary lifestyle adjustments in accordance
am with the proper use of drugs
Collaborating with doctors in administering 1x20 mg
of lasix injection, 3x5 mg of ISDN oral medication,
1x½ bisoprolol, and 0-0-1 ASA, 1x25 mg
spironolactone and 1x1 digoxin.
8:35 Collaborating with doctors in administering Lactate
am Ringer's fluid 500 cc in 24 hours.
Observing the client's excess fluid while still giving a
drinking limit of 600 cc in 24 hours. Observing client
8:45 input and output with
am count the urine that comes out with that fluid
come in.

8:55
am

9:05
am

9:15
 43
am
 44

Thursday, 26 10:00 Observe vital signs with BP 160/100 mmHg, N 94x /

minute, S 37.3 ° C, RR 30x / minute
April 2018 Perform heart rhythm observation by auscultating the
10:05 chest and displaying rapid heart sounds or tachycardia
10:15 Monitoring the client's oxygen flow while still giving 4
CLIENT 2
lpm of nasal oxygen
Determine what drugs are needed according to a
10:20 doctor's prescription
10:30 Provide an explanation to clients about the side effects
of drugs such as ISDN drugs that cause chest
10:35 palpitations and ASA which cause the client to have
difficulty breathing.
Provide an explanation to clients and families about the
necessary lifestyle adjustments in accordance with the
10:45 proper use of drugs
Collaborating with doctors in administering lasix
injection 1x20 mg, oral drug ISDN 3x5 mg,
spironolactone 1x25 mg and ASA 0-0-1
10:55 Collaborating with doctors in administering 500 cc of
Ringer's Lactate in 24 hours and 25 mEq of KCL drip
11:05 in 24 hours
am Observing the client's excess fluid while still giving a
limit of drinking 600 cc in 24 hours. Observing the
client's input output by counting
11:15 urine that comes out with the incoming fluid.

11.30

Friday, 27 8:00 am Observe vital signs with BP 100/70 mmHg, N 88x /

minute, S 36.3 ° C, RR 24x / minute
April 2018 Perform heart rhythm observation by auscultating the
8:05 am chest and displaying rapid heart sounds or
CLIENT 1 tachycardia
Monitoring the client's oxygen flow while still giving
8:15 am
4 lpm of nasal oxygen
Determine what drugs are needed according to a
8:20 am doctor's prescription
Provide an explanation to clients about the side
8:30 am effects of drugs such as ISDN drugs that cause chest
8:35 am palpitations and ASA which cause the client to have
difficulty breathing.
Provide an explanation to clients and families about
8:45 am the necessary lifestyle adjustments in accordance
with the proper use of drugs
Collaborating with doctors in providing 1x20 mg of
8:55 am
lasix injection, 3x5 mg ISDN oral medication, 1x25
mg spironolactone, 0-0-1 ASA, 1x1 digoxin and 1x ½
bisoprolol.
Doing collaborations with doctors
9:05 am in giving Ringer's Lactate fluid 500 cc
in 24 hours Observing the client's excess fluid while
still giving a limit to drinking 600 cc in 24 hours
9:15 am Observing client input with
count the urine that comes out with the fluids that
09.30 enter.

Friday, 27 11:05 Observing vital signs with a BP of 170/110 mmHg,

April 2018 am N 100x / minute, S 37 ° C, RR 30x / minute
Perform heart rhythm observation by auscultating
CLIENT 2 the chest and displaying rapid heart sounds or
 45
11:15 tachycardia
Monitoring the client's oxygen flow while still
11:20 giving 4 lpm of nasal oxygen
Determine what drugs are needed according to a
doctor's prescription
11:30
am Provide an explanation to clients about the side
effects of drugs such as ISDN drugs that cause
chest palpitations and ASA which cause the client
11:35 to have difficulty breathing.
Provide an explanation to clients and families
about the necessary lifestyle adjustments in
accordance with the use of the right medication.
11:45 Collaboration with doctors
in administration of lasix injection
1x20 mg, oral drugs such as ISDN 3x5 mg, 1x25
11:55
mg spironolactone and ASA 0-0-1
am Doing collaborations with doctors
in giving Ringer's Lactate fluid 500
cc in 24 hours and KCL drip 25 mEq in 24 hours
Observing the client's excess fluid while still
12:05 limiting drinking 600 cc in 24 hours
Observing the client's input output by counting the
urine that comes out with the incoming fluid.
12:15

12.30
 45

4.1.7 Nursing Evaluation

Table 4:17 Evaluation of Nursing Care for Client 1 Heart Failure with
Ineffective Myocardial Perfusion Risk Problems
Diagnosis Day 1 Day 2 Day 3
Client 1 S: the client said S: The client said he S: The client
Risk of shortness of breath, was still feeling said the
Ineffective rubbing breath tight. O: k / u was tightness had
Myocardial O: k / u weak, enough, awareness decreased
Perfusion composmentis of composmentis. O: k / u
awareness. BP: 90 / p mmHg enough,
TD: 100/70 mmHg N: 130x / minute composmentis
N: 130x / min S: 36.40 C awareness.
S: 36.80 C RR: 28x / minute TD: 100/70
RR: 28x / minute CRT <2 seconds mmHg
CRT <2 seconds, there with inhalation N: 88x /
is nostril breathing, nostrils, pulse minute S:
pulse tachycardia tachycardia, apical 36.30 C
clients use oxygen heart rate RR: 24x / minute
nasal cannula 4 lpm. clients use oxygen CRT <2 seconds
A: the problem is nasal cannula 4 lpm. normal pulse rate,
not resolved A: the problem is client's normal
P: Continue the not resolved heart rate using 4
intervention lpm nasal oxygen.
1. Monitor vital P: Continue A: The problem
signs the is partially
2. Monitor intervention resolved
exhalation 1. Monitor vital
3. Give 4 lpm signs P: Intervention
of nasal 2. Monitor is stopped. The
oxygen exhalation client moves to
4. Monitor input 3. Give 4 lpm yellow care
output of nasal room
5. Collaboration oxygen
with doctors in 4. Monitor input
drug output
administration 5. Collaboration
with doctors
in giving
drug
Table 4:18 Evaluation of Nursing Care for Client 2 Heart Failure with
Ineffective Myocardial Perfusion Risk Problems
Diagnosis Day 1 Day 2 Day 3
Client 2 S: the client said it was S: the client said it S: the client said that
Risk of ngongsrong and tight was still uneasy and he was still hanging out
Ineffective congested and short of breath
Myocardial O: k / u weak, O: k / u weak,
Perfusion composmentis composmentis O: k / u weak,
awareness, awareness, composmentis
TD: 170/120 mmHg TD: 160/100 mmHg awareness,
N: 109x / N: 94x / TD: 170/90 mmHg
minute S: 370 minute S: N: 96x / min
C 37.30 C S: 360 C.
RR: 33x / minute RR: 30x / minute RR: 28x / minute
CRT <2 seconds CRT <2 seconds CRT <2 seconds
There is nostril Nasal lobe There is pain in
breathing exhalation left chest. The odema
Heart rate Heart rate of the legs is reduced,
tachycardia.There is pain tachycardia the heart rate is still
in the left chest, there is a There is pain in the left tachycardic
murmur on ICS 2 3 chest, there is a murmur The client uses O2
Odema on both feet The on ICS 2 3 nasal 4 lpm.
client uses 4 lpm of Odema on both feet The
nasal oxygen. client uses 4 lpm of
nasal oxygen. A: the problem is not
A: the problem is not resolved

resolved P: Continue the A: the problem is P: Intervention is

not resolved stopped. The client
intervention moves to yellow
1. Sign-monitor P: Continue the care room
vital signs intervention
2. Monitor 1. Monitor vital
exhalation signs
3. Give 4 lpm 2. Monitor
of nasal exhalation
oxygen 3. Give 4 lpm
4. Monitor input of nasal
output oxygen
5. Collaboration 4. Monitor input
with doctors in output
drug 5. Collaboration
administration with doctors
in giving
drug
 48

4.2 Discussion
Based on the results of research that has been carried out at Mr. M. Sdan

Tn. S in the HCU Kemuning room at RSUD Jombang in cases of heart failure

with problems with the risk of ineffective myocardial perfusion, an assessment

was found on:

4.2.1 Assessment
1. Subjective Data / Objective Data

a. Client 1

The client said he came to Jombang Hospital with complaints of shortness

of breath, coughing, rubbing suddenly without any activity. Then the

client was brought to the IGD Jombang and MRS Hospital at the hour

17.44 WIB in the HCU Kemuning room.

b. Client 2

The client's family said the client was taken to the Jombang Regional

Hospital with a state of shortness of breath, rubbing and the right leg was

swollen for 2 weeks, then the client was taken to the ER and MRS at the

hour.

22.41 WIB in the Kemuning HCU room.

Congestive heart failure (CHF) is a condition in which the function

of the heart as a pump to deliver oxygen-rich blood to the body is not

sufficient to meet the body's needs (Saferi, 2013).

According to researchers in a case study study of heart failure,

clients experience shortness of breath due to an enlarged heart, which

causes the cavity between the heart and lungs to become full so that the

lungs are pressed by the heart. So that it causes the lungs not to expand

completely. This is what causes the client to experience shortness of breath

and needs to be treated using oxygen therapy to reduce tightness in clients.

 49
4.2.2 Nursing diagnoses

In the case of clients 1 and 2, the researcher established the main

diagnosis, namely the risk of ineffective myocardial perfusion associated

with decreased blood supply to the heart muscle supported by subjective

data that client 1 was short of breath with a respiratory rate of 28 times per

minute and O2nasal 4 was attached. lpm, in client 2 shortness of breath

with respiration rate 31 times per minute and 4 lpm O2nasal attached.

Nursing diagnoses in both clients from the results of the

assessment, physical examination, and diagnostic tests obtained, showed

that the problem experienced was the risk of ineffective myocardial

perfusion related to decreased blood supply to the heart muscle. According

to IDHS (2017) the risk of ineffective myocardial perfusion is at risk of

experiencing a decrease in coronary artery circulation which can interfere

with myocardial metabolism.

According to researchers, the risk of myocardial perfusion is

ineffective with problems with decreased blood supply to the heart muscle

because the blood flow to the heart is not fulfilled so that the oxygen

supply in the heart decreases and causes tightness in heart failure clients.
 49

4.2.3 Nursing Interventions

Interventions given to Client 1 and Client 2 with problems Risk of

Ineffective Myocardial Perfusion. The intervention given to the client was

mainly a way to reduce the tightness that both clients complained about.

Based on research on the third day of the client there is a significant

change in the client's very comprehensive process of healing because the

client wants to immediately carry out daily activities.

Nursing interventions that are given with the problem of

Ineffective Myocardial Perfusion Risk, namely by monitoring vital signs

to determine blood pressure, pulse, temperature, and respiratory status

precisely. Perform oxygen therapy by maintaining patency of the airway,

monitor oxygen flow, observe for signs of oxygen-induced

hypovontilation. Carry out treatment management by determining what

drugs are needed. According to (Bullechek, 2013).

According to the researchers, based on the NIC research, which is

in accordance with the client with heart failure, vital signs can be

monitored, oxygen therapy, and medication management.

4.2.4 Nursing Implementation

The nursing implementation carried out on client 1 and client 2 is

in accordance with that in nursing interventions, namely: Observing blood

pressure, pulse, temperature, and respiratory status, observing blood

pressure after the client takes medication, observing heart rhythm,

maintaining the patency of the client's airway ,

 50

monitor the client's oxygen flow, observe for signs of oxygen-induced

hypovontilation, determine what drugs are needed according to the doctor's

prescription, explain to the client about the side effects of the drug, explain

to the client and family about the necessary lifestyle adjustments according

to usage appropriate medication, collaborate with doctors in administering

crystalloid fluids (for example, normal saline and Ringer's lactate), observe

the presence of excess fluid, observe client input output

Implementation is the implementation of the nursing action plan to

achieve the specified goals or results. Activities in implementation are in

the form of direct action to clients and observing client responses after

actions (Nursalam, 2014).

In clients with the risk of ineffective myocardial perfusion,

implementation is in accordance with the intervention, but in

implementation there are still differences in actions that are tailored to the

client's condition at the time of the study.

4.2.5 Nursing Evaluation

The nursing evaluation on both clients was carried out for three

consecutive days. The data obtained on the first day of client 1 is short of

breath with rr: 28x / minute, client 2 is short of breath with rr: 31x /

minute, on the second day client 1 feels short of breath with rr: 28x /

minute, as well as client 2 with rr : 30x / minute, on the third day of

congestion of both clients

 51

it has decreased, in client 1 with rr: 22x / minute and in client 2 with rr:

31x / minute.

Evaluation is something that is planned and a systematic

comparison of the client's health status. Nurses can determine the

effectiveness of nursing care in achieving a goal by seeing and measuring

the client's development (Nursalam, 2014).

Evaluation on client 1 and client 2 changes that are influenced by

the client's condition, besides changes in the client's condition as well

because the intervention given is in accordance with the client's condition.

 CHAPTER 5
CONCLUSIONS &
SUGGESTIONS

5.1 Conclusion

After performing nursing care for clients with heart failure with problems

with the risk of ineffective myocardial perfusion in the HCU Kemuning room at

RSUD Jombang, the authors can draw conclusions and suggestions based on the

case study reports, as follows:

1. The results of the study conducted by the author on April 25 2018 obtained

subjective data from Mr. MS complaining of shortness of breath, coughing,

rubbing suddenly without any activity. The objective data arose in the

presence of nasal lobe breathing while Mr. S subjective data with

complaining of shortness of breath, rubbing, and chest pain on the left.

Objective data arise in the presence of nasal lobe breathing.

2. The main diagnosis in Mr. MS and Tn.S, namely the risk of ineffective

myocardial perfusion associated with shortness of breath supported by

subjective data on Mr. MS and Mr. S. who complained of shortness of

breath on April 25, 2018.

3. Nursing interventions given to clients are in accordance with the 2015 NIC

regarding oxygen therapy.

4. Implementation in clients with heart failure with problems at the risk of

myocardial perfusion is not effective in accordance with the intervention

and is carried out thorough52

 53

5. Evaluation of both clients with heart failure with problems with the risk of

myocardial perfusion was ineffective, showing that both clients still had to

continue the intervention to the next treatment room.

5.2 Suggestion

1. For Students

The results of this study can be an additional reference for students

and teachers in improving their knowledge of the nursing process in

cases of heart failure.

2. For Nurses

Can improve the quality of service in cases of heart failure and be able

to pay attention to the conditions and needs of heart failure patients

with problems at the risk of ineffective myocardial perfusion. For

further researchers, it can be used as a basis for further research with

the same nursing problems and different themes.

3. For the Hospital

It is hoped that it will be able to improve the quality of health services

in cases of heart failure by increasing the knowledge and training of

health personnel training in nursing care as a whole, especially if it

fails. heart.
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