OUTLINE OF NURSING CARE PLAN

2020
Group 1
Member :
Afita Sety Aji (180103002)
Alfiyani Khoiriyah (180103005)
Alisa Fikhul Fitriyah (180103006)
Andika Parnomo Putra (180103007)
Anggi Nurin Kamarina (180103008)

Class : English For Nursing 3 A-A

Case Mr. B
Mr. B was bought to emergency department with several complaints. He had of
shortness of breath since a week before admission and doing activities made it
worse . Two days before he was admitted to the hospital, his shortness of breath
was getting worse. He also had swollen legs and loss appetite. He was
hospitalized . After the assessment, it was found that : vital sign : BP :110/70
mmHg, P: 92 bpm, RR : 32 breath /minut, T : 360 C , Cyanosed lips, Pale face,
Neck : JVP : 5=4 cm, Lower extremity edema +/+, capillary refill: 5 seconds, Ro
Thorax : Cardiomegaly, Echocardiography :EF :52%
 CASE REVIEW
Chief Complaint
Mr. B was brought to
emergency department with
several complaints. He had a
shortness of breath.
History of Present Past Medical
Illness
History
Patients said had a shortness of breath since a week
before admission and doing activities made it worse. Two -
days before he was admitted to the hospital, his shortness
of breath was getting worse. He also had swollen legs
and loss of appetite.

Physical Family Additional

Examination History Data
After the assessment ,it was found that: Vital
Signs: BP: 110/70 mmHg, P:92 bpm, RR: - Ro Thorax: Cardiomegaly,
32breath/minute, T: 3600C, Cyanosed Lips, Pale Echocardiography: EF: 52%
Face, Neck: JVP: 5+4cm, Lower extremity
edema+/+, Capillary refill: 5seconds,
 DATA ANALYSIS Data Clustering
No. Date Focus Data Problem Etiology
 
1. SD: Decreased Cardiac Changes in cardiac contractility
 The patient said that he had Output (00029) characterized by changes in the
experienced shortness of  EKG, fatigue, dyspnea
breath since a week before
being admitted to the hospital.
 The patient said that after
doing the activity it made him
worse.
 The patient said Two days
before being admitted to the
hospital, his shortness of
breath was getting worse.
 The patient also reported
experiencing swelling of the
legs and loss of appetite.
 
OD:
VitalSigns:

BP: 110/70mmHg,
P:92bpm,
RR: 32breath/minute,
T: 3600C,
Cyanosed Lips,
Pale Face,
Neck: JVP:5+4cm,
Lower extremity
edema+/+,
Capillary refill:
5seconds,
RoThorax:Cardiomegal
y
Echocardiography:
EF:52%
Nursing Diagnosis
Decreased Cardiac Output
(00029)
 NURSING OUT
No.
COME
Nursing Expected Outcome Rationale
Diagnosis
 
Decreased Cardiac After doing intervension for 2x 24 hours  Vital Signs within normal
Output (00029) of status cardiovascular patient within range (Blood pressure,
normal ranges with the results criteria: Pulse, respiration)
NOC Label:  Can tolerate activity, no
Cardiac Pump Effectiveness fatigue
 Blood pressure systolic will No pulmonary, peripheral
increase from level 2 to 4 edema and no ascites
 Blood pressure The diastolic will
increase from level 3 to 4
 Abnormal heart sound from level 3
to 4
 The fatigue will increase from level
3 to 4
 The distension of the neck veins
will increase from level 3 to 4
 Dypsnea with light activity will
increase from level 1 to 4
 Cyanosis will increase from level 2
to 4
 NURSING
INTERVENTION
No. Expected Outcome Nursing Intervention Rationale
  1 After doing intervension for Heart care: acute(4044) NIC Label: Cardiac Care
2x 24 hours of status 1. Performa comprehensive1. To know the state of the heart status
cardiovascular patient assessment of cardiac and also the peripheral circulation
within normal ranges with status including peripheral2. To determine the supply of oxygen
the results criteria: circulation. for myocardial needs to counter the
NOC Label: 2. Monitor determinants of effects of hypoxia / ischemia.
Cardiac Pump oxygen delivery (PaO2, Hb 3. By being given relaxation, it is
Effectiveness levels, and cardiac output), hoped that the client's chest
 Blood pressure as appropriate. expansion will be more optimal and
systolic will increase3. Provide a heart-proper diet shortness of breath is reduced
from level 2 to 4 (limit intake of caffeine, 4. The client may experience sudden
 Blood pressure The sodium, cholesterol and shortness of breath due to the
diastolic will increase fattyf oods). activities undertaken, this activity
from level 3 to 4 4. Perform relaxation therapy can make the client's
 Abnormal heart sound appropriately breathlessness add to the activity
from level 3 to 4 when nursing actions are performed
 The fatigue will 5. Meet the needs of clients for
increase from level 3 treatment.
to 4  
 
THANK YOU