Nama : RIZKI YANI

Npm :17010500

PRODI : S1 KEPERAWATAN

DOSEN:

Px. Sy 69 years old , admitted to CM hospital with chest pain 1 day before . The pain was radiated to
his left arm . Pain score (5). He also expirienced dyspnea, anxiety . Her never expirienced chest pain
before as well as no heart disease history. From the assesment . It was found that :

RR : 30×/m

Bp : 80/50 mmHG

Hr : 48×/m

Temp : 36,1° C

SpO² : 85%

GCS : E4V5M6

Diagnostic

ECG : STEMI inferior

LAB : HB : 11.8

Leuko : 10.78

Eri : 3.70

SGOT : 838

SGPT : 704

UREUM :55.90

KREARININ :1.72

HDL Cholesterol :27

LDL Cholesterol :150

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NURSING CARE In Cardiovascular System Disorders With Chest Diagnosis Medical Diagnosis

A.Assessment

1.Client Identity

Name : SY

Age : 69 old

Gender : Male

Education :

Occupation :

Religion :

Address :

DateAssessment : Tuesday 8 june 2020

Diagnosis medical : Chest pain

No. MR :0812836

2. Person in charge

Name :RIZKI YANI

Age :25 old

Gender : female

Religious : islam

Education : high shcool

Address :

Relationship with client : child

3. Assesment primer

Airway : no airway obstruction , seemed to use muscles to breath additional

Breathing : dyspnea, rapid and shallow rhythm, spontaneous, P: 30 x / minute

Circulation :Radial pulse fast, lift strength, irregular, N: 120 x / minute

Disability a. GCS: E4V5M6

b. Awareness: Composmentist

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A.Current Disease History:

Clients enter with complaints of left chest pain, complaints weighing when lying down, tightness
when feeling pain, complaints are not influenced by activity. Pain assessment (PQRST)

The client says pain is felt suddenly and worsens when the client lies down, the quality of pain such
as pins and needles disappears, pain is felt from the left chest extending to the entire left hand, pain
scale is felt to 9, and pain felt by the client since 4 days ago.

B. Past illness history Client history of old HT, the father of the client also remains from the same
disease as the client.

C. Client's medical history often controls the clinic at Madani Hospital.

D.History of Allergy (medication and food): The client has no history of allergies and drugs 5.

Vital Signs

RR : 30×/m

Bp : 80/50 mmHG

Hr : 48×/m

Temp : 36,1° C

SpO² : 85%

GCS : E4V5M6

Head to Toe (Focus Assessment)

Head Sweating, :conjunctiva is not anemic, no palpable lumps.

Neck Increased : JVP R +1 H2O, no apparent abnormalities in the neck, no palpable hematoma

Thoracic Chest : Appears to use additional breathing muscles, rapid and shallow movements,
irregular, no visible injury. Additional brochovesicular breath sounds

Heart : Sound irregular and fast, no additional BJ is heard

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Abdomen :No palpable mass, no visible lesions, audible bowel sounds 16 x / minute

Akral extremities : are cold, palpable, radial pulses, fast, irregular and strong lift

Integumen :Cold sweat, S: 36.2 ⁰C

Psychosocial Assessment: Restless, the client says he is worried about his illness, tachycardia and
hyperventilation

Investigations

LAB : HB : 11.8

Leuko : 10.78

Eri : 3.70

SGOT : 838

SGPT : 704

UREUM :55.90

KREARININ :1.72

HDL Cholesterol :27

LDL Cholesterol :150

Therapy and medical instruction

IVFD RL 12 crossword /minute

02 nasal tubes 3-5 lpm

Ranitdine injection 1 ampoule /12 hours/iv

ISDN 3 x 5 mg (sl)

Captopril 2 by 25 milligrams

Amlopidin 1 by 10 milligrams

Trombo aspilet 1 × 1

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Data analysis

Data clasification Etiologi Nursing problem

Ds:
-Client complains amply the client myocardial iskemic
says he's worried about the disease
-Clients say it pays more when they Heart workload increasing
lie down
D0: Vol. The ventricle residue
-dyspnea increases
-Apparent use of muscle
-muscles in the respiratory Hydrostatic juice capillaries
-rhythm is fast and shallow Lungs
-hyperventilating
-The client seems agitated Fluid laceration to the lungs
RR : 30×/m A lungs
Bp : 80/50 mmHG
Hr : 48×/m Respiratory function
Temp : 36,1° C declining
SpO² : 85%
GCS : E4V5M6 dyspnea

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Ds: - myocardial iskemic
-Client said the pain was immediate
-The client said the pain was severe -Supply Myocardial acute pain
when he lay down and felt like he decrease
was stabbed and said the pain felt
from his left breast spread over his - Lactic acid increasing
left hand
-Client says the scale of pain is felt to -The release of a chemical
the extent of the 5 stances mediator
Do:
-sweating -Stimulating nosiceptors
-Akral teraba's cold
-Upgrading of JVP r +1 h20 -Transmission, transduction,
-Rhythm of iregularity takardi heart modulation
RR : 30×/m
Bp : 80/50 mmHG -Pain perception in
Hr : 48×/m hypothalamus
Temp : 36,1° C
SpO² : 85%
GCS : E4V5M6

Date Diagnosa Goals and Intervention Impelemetion Evaluation

criteria result
diagnosis Destination: 1. 30 minutes I'm at 18. 45 At 8:30pm
Inefficiency of After the two- of observation
breath patterns hour nursing and document 1. Observing S: The client said it
is linked to the performed, the TTV TTV every 30 doesn't feel
pulmonary client displayed 2. Monitor and minutes: claustrophobic anymo
evice. an effective document RR : 30×/m O:the rhythm of the
breathing speed, rhythm. Bp : 80/50 asars
pattern. Deeper and mmHG Tcratur the client
respiration Hr : 48×/m seemed calm
Results criteria: businesses Temp : 36,1° C A: Destination achieve
3. Set up your SpO² : 85% The client is ready to b
1. The client client position GCS : E4V5M6 transferred to the
will say it as comfortable infirmary
doesn't feel as possible 2. Monitor and
claustrophobic 4. Create a Documenting
anymore quiet speed, rhythm,
2. Rr in a span environment depth and
Sixteen-twenty for the client respiration
a minute 5. Engage in a efforts:

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 8. Regular medical P: 30 times
breath rhythm collaboration Irregular
4. The client with therapy: rhythm is fast
seems calm If vd rl 12 and shallow
crossword hyperventilas
crosswords, 02 3. Configure
nasal 2-5, ipm client positions
Real comfort:
Fowler's
position, heads
over
450 feet high
Creating a calm
environment
for clients by
reducing the
guards who
assist clients in
providing a
medical
collaboration
for treatment:
Installed 02
nasal spray 5
ipm
Infusing iv
Liquid rl 12
TTSMT

Acute pain Destination: I got 18.50 20 to 30

associated with 1. Assess client -clients said the pain
ischemic in After treatment complaints It diminishes the scale
myocaranother for 1 x 2 hours, By using porst: the nyerii felt on the
the pain P: client said scale 4
lessened. nycri was
perceived 0:Clients can do the
Result criteria suddenly o: technique
client said his Client relaxation appea
1. The client yerself was to be calmer
would say that stabbed.
was perceived Stab and sheath A: goals achieved
by the least R: client says
2. Clients can yeri perceived
do independent start dani's left
relaxation breast expand
techniques all over s left
3. Scale of pain hand: client
6 says the scale of
4. The client the pain was on
seems calm a 5 (range i-i0)
Q: client said

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 the pain was
felt four days
ago.

2. Teaches
clients deep
relaxation
techniques to
cope with pain
The client
understands
and can do all
alone

ASKEP