NURSING ASSESSMENT IN

CONGESTIVE HEART FAILURE

ROLEPLAY
For fulfilling the study assignments
English Language
That are guided by Mr. Yulius Irham, S.Pd., MM

By :
Riska Fitriani
P17220194052

POLITEKNIK KESEHATAN KEMENKES MALANG

NURSING PROGRAM
D-III KEPERAWATAN LAWANG
3 APRIL 2020
 NURSING ASSESSMENT IN
CONGESTIVE HEART FAILURE

In a RSUD Malang on the Lotus Room, to be precise, was a male patient named
Mr.A, a 58 years old, who complained of dispnea since the night before he went
to the hospital, who said he had a cough that wasn’t bleeding and swollen on
his right leg and left so that the family was takin the patient to the emergency
room RSUD Malang for first aid. For that the nurse was assigned to assess in
depth Mr.A’s condition.

Nurse : Good Morning Sir? Is it really Mr.A

Patient : Yes, sure.

Nurse : Ok Sir, Let me introduce myself my name is Nurse Riska,

how are you today?

Patient : I felt breathless and my legs would swell up.

Nurse : Ok, I’ll assess and ask a little about your healt.
Would you like to do that?

Patient : Very well. Gladly.

Nurse : Let me first ask you about your history of illness. Do you and
your family have a previous heart history?

Patient : My family had no heart history, but i had a history of

hypertension.

Nurse : I get it. What do you think of this disease? And how is support for
you?

Patient : I think this illness was iven by God as a test for me and my
family. My family and the people around me were very supportive
no to ive up on my current situation.
Nurse : Good. What changes did you feel when sick and before sick? Like
your diet or your activity everyday?

Patient : I think that i have change in diet, when the pain of my appetite
declined because of not being used to hospital food and everyday
activities that i could shower on my own when sick i needed help.

Nurse : Allright, Sorry i’m a little rude. How about your sex activity and
your rest time? Is there a problem with the pee and poop?

Patient : Haha it’s okay. I decrease my sexual activity because of sickness

and for my rest, unlike when i’m well, i often wake up at night
feeling breathless and i have only 5 – 6 hours of sleep. I haven’t
had a poop since the hospital, and when i came in the emergency
room i plugged a catheter.

Nurse : Well, next step I’ll check your vital’s sign. I expect you to stay
calm and relaxed during the check up.

Patient : Allright please.

Nurse : First, I’ll check your temperature, excuse me i’ll open your
clothes, can you raise your arm? And flank the thermometer in
your armpit.

Patient : Just do it.

Nurse : Next, I’ll take your blood preasure, your pulse and breathing. Just
relax Mr.A

While keeping score in the heart of the nurse tries to ask about the daily
routine of the patient to feel relax and comfort.

Nurse : Do you have grandchildren? How does it feel to have

grandchildren can you tell it to me?

Patient : Yes, of course. I have 3 grandchildren, two boys and a girl. They
were so cute and every weekend they would come visit us in the
village and sometimes we would o fishing together.
 Nurse : Woah, it’s fun. Oke Sir, I’ll read you the examination results
your temperature is 36,5°C, your blood preasure is 140/90 mmHg,
your pulse is 93 and your breath is 24 in one minute.

Nurse : Okay, next i’ll check your physical and i’ll report your condition
to the doctor.

Patient : Okay.

During a physical examination from head to toe, we found abnormal

conditions in the thoracic region, which was that patients high frequency
breathing sounds at the end, and then to lower extremities, there was oedema
on the right and left leg with oedema 3 mm depth.

Nurse : Okey Sir, today’s check up has concluded I’ll report on your
doctor’s condition in order to obtain further treatment.

Patient : Oke Nurse, what should i do now?

Nurse : I suggest to you, to minimize strenuous activity and to keep up

with the doctor’s wishes.

Patient : Well I’ll follow orders of encouragement well.

Nurse : Of course, if you need anything please press an emergency button

or one of your family to call me in Nurse Station. Have a nice day
and Get well soon.

Patient’s Family : Oke thank you very much.

Nurse : Your are wellcome, see you.

The nurse, coming out of the patient’s room, immediately calls the doctor to
explain the condition of the patient’s heart failure, because the patient is
excessively gaining weiht because of a build up of fluids in his legs, and gives
direction to an ADH medication that stimulates patient’s urination ang
regulates his diet by consulting with a nutritionist. And for the breathless the
nurse is directed, providing oxygen to the patient.
Nurse : Excuse me doctor, I’ll give the patient’s book about heart failure.
Please read this patient’s book.

Doctor : Okay, Let me read it.

Doctor : For now give him an intravenous Furosemide 2 x 40 mg, to

breathless, give it oxygen at rate of 4 liters a minute and monitor
the patient’s intake and output. Don’t forget to rate the amount of
urine on a catheter before being eliminated.

Nurse : Thank you, Doctor, for your advice. After this i’m going to go
back to the patient for the medicines. See you, Have a nice day.

Doctor : See you and have a nice day.

The nurse return to the patient’s room to administer intravenous medicine

and teaches the patient’s family to register urine in a catheter bag before
dumping.

Nurse : Good afternoon, Mr and Mrs.A

Patient’s Wife: Good afternoon, nurse. What action will be given to my

husband?

Nurse : Okay, Let me tell you first, I’ll give to Mr. A intravenous
medicine it’s Furosemide 2 x 40 mg and I want to teach you
register urine in a catheter bag before you dump it. Your attention,
please.

Patient’s Wife : Of course, I’ll take a good attention.

Nurse : First, you have to look at the amount of urine attached to a

chateter bag, then register that urine to the book. Also, endeavor to
keep a record of how the patient eats and drinks. The purpose of
this action is to let the nurse know what condition the patient is
developing to reduce swelling in the patient’s legs. Is that
undestood?

Patient’s Wife: Yes, I’m understand.

Nurse : Okay, next i’ll give to Mr. A intravenous medicine, May i give
you it?

Patient : Yes, please.

Nurse : Okay, excuse me. I’ll find the vein in your arm then I’ll clear out
of it so the injection site is sterile from microorganisms.

Patient : I’m ready.

Nurse : Yes I’ve found it, Sir. Breathe as i inject it. The act is finished.

Patient : Wow you injected it quickly.

Nurse : Yes, of course. How are you feeling after your injection?

Patient : When the injection i feel no pain i hope after this my condition
gets better.

Nurse : Okay, Let me take my left. If you need anything please press an
emergency button or one of your family to call me in Nurse
Station. Have a nice day and Get well soon.

Patient : Okay, thank you very much Nurse.

Nurse : You are wellcome, Sir.