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NURSING CARE REPORT OF MR.

M
WITH HEART FAILURE MEDICAL DIAGNOSIS IN ALAMANDA
WARD ULIN GENERAL HOSPITAL BANJARMASIN

FINAL PAPER

BY:
SITI RAHMAH
SRN. 1614401320209

UNIVERSITY OF MUHAMMADIYAH BANJARMASIN


FACULTY OF NURSING AND HEALTH SCIENCES
INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM
BANJARMASIN, 2017
NURSING CARE REPORT OF MR. M
WITH HEART FAILURE MEDICAL DIAGNOSIS IN ALAMANDA WARD
ULIN GENERAL HOSPITAL BANJARMASIN

Proposed to Fulfill One of the Requirements to Accomplish of


International Class of Nursing Diploma Program

By:
SITI RAHMAH
SRN. 1614401320209

UNIVERSITY OF MUHAMMADIYAH BANJARMASIN


FACULTY OF NURSING AND HEALTH SCIENCES
INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM
BANJARMASIN, 2017

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PREFACE

Thank to Allah, the most grateful the most merciful that always give rahmat,
taufiq, and hidayat. So the researcher can finish this scientific writing on time.
This final paper writing is one of the requirement to accomplish International
Class of Diploma Program for Nursing with title Nursing Care Report of Mr.M
with Heart Failure Medical Diagnosis in Alamanda Ward Ulin General Hospital
Banjarmasin. The researcher realizes that this scientific writing needs a help and
support from some parties sides.
Therefore, the researcher would like to say thanks to:
1. Prof. DR. H. Ahmad Khairuddin.,M.Ag, as the Rector of University of
Muhammadiyah Banjarmasin.
2. Mr. M. Syafwani, S.Kp., M.Kep.Sp.Jiwa, as the Dean of Faculty of
Nursing and Health Sciences.
3. Mr. Muhsinin, M.Kep.,Sp.Anak, as the Head of Nursing Diploma Program
4. Mr. Solikin, Ns., M.Kep., Sp.KMB, as the First Advisor and the First
Examiner.
5. Mrs. Tenny Murtiningsih, SH, M. Pd, as the Second Advisor and the
Second Examiner.
6. Mrs. Noorminawati, S.Kep, as the Clinical Instructure of Alamanda Ward
Ulin General Hospital Banjarmasin and the Third Examiner.
7. Patient and his family who were ready to give their time and opportunity
as a source of this scientific writing.
8. My beloved and blessed parents, H. Saharuddin and Hj. Sapariah, who
always pray and support with all the best ways until right now.
9. My beloved older sister Herna wati, the younger brother Sahrul Efendi,
my brother in law Hardiansyah & my little nephew Muhammad Dafa who
always support to finish this report.

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10. All my lovely friend from International Class of Nursing Diploma
Program the 7th batch who always stay together in happy and sorrow, and
help each other.
11. All lectures and all my senior at International Class of Nursing Diploma
Program who help me to finish this final paper.
12. My beloved friends Six Star who give me spirit and support.
13. Thank you for anyone else who help me to finish this final paper.
In this report, the researcher realized that there are some lackness because the
limitation of the researchers capabilities. So, the researcher needs comments and
suggestions from the other to make this final paper can be perfect. The last
sentence that I want to tell you, I hope this final paper can be useful for everyone.
Aamiin..

Banjarmasin, July 2017


Researcher

Siti Rahmah

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TABLE OF CONTENTS

TITLE PAGE ..................................................................................................... i


ADVISORS APROVAL ................................................................................. ii
ACKNOWLEDGEMENT ................................................................................. iii
PREFACE .......................................................................................................... iv
CONTENT ......................................................................................................... vi
LIST OF PICTURES ......................................................................................... x
LIST OF TABLES ............................................................................................. xi
LIST OF APPENDIXES .................................................................................... xii

CHAPTER 1 INTRODUCTION ....................................................................... 1


1.1 Background ............................................................................ 1
1.2 Purpose of Writing Report ...................................................... 3
1.2.1 General Purpose ............................................................ 3
1.2.2 Specific Purpose ........................................................... 3
1.3 Benefit of Writing Report ...................................................... 4
1.3.1 For the Patient ............................................................... 4
1.3.2 For the Family .............................................................. 4
1.3.3 For the Hospital ............................................................ 4
1.3.4 For the Institution ......................................................... 4
1.3.1 For the Nurse Profession .............................................. 5
1.4 Nursing Scientific Method...................................................... 5
1.5 Systematical Writing ............................................................. 5
1.5.1 Chapter 1 introduction .................................................. 5
1.5.2 Chapter 2 theoretical background ................................. 5
1.5.3 Chapter 3 nursing care report ....................................... 5
1.5.4 Chapter 4 conclusion and suggestion ........................... 5

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CHAPTER 2 THEORETICAL BACKGROUND ............................................. 6
2.1 Anatomy Physiology of Heart ............................................... 6
2.2 Definition of Heart Failure .................................................... 10
2.3 Etiology of Heart Failure ....................................................... 11
2.4 Clinical Manifestation of Heart Failure ................................. 13
2.4.1 Left-Sided Heart Failure ............................................... 13
2.4.2 Right-Sided Heart Failure ............................................. 13
2.4.3 The Classic Sign and Symptom of Heart Failure ......... 14
2.5 Pathophysiology of Heart Failure .......................................... 14
2.6 Pathway of Heart Failure ....................................................... 18
2.7 Classification of Heart Failure ............................................... 19
2.7.1 The heart disease classification according to NYHA
(New York Heart Association) .................................... 19
2.7.2 The heart disease classification according to American
College of cardiology or AHA (American Heart
Association) .................................................................. 19
2.8 Diagnostic Examination of Heart Failure .............................. 20
2.8.1 Echocardiogram ............................................................ 20
2.8.2 ECG .............................................................................. 20
2.8.3 Chest X-ray ................................................................... 20
2.8.4 Radionuclide Ventriculography .................................... 20
2.8.5 Brain Natriuretic Peptide Measurement ....................... 20
2.8.6 Treadmill Stress Test and Cardiac Catherization ......... 21
2.9 Treatment of Heart Failure .................................................... 21
2.9.1 Pharmacologic Therapy ................................................ 21
2.9.2 Non Pharmacologic Therapy ........................................ 21
2.9.3 Surgical Management ................................................... 22
2.10 Prognosis of Heart Failure ................................................... 22
2.11 Complications of Heart Failure ........................................... 23
2.11.1 Plueral Effusion ....................................................... 23
2.11.2 Dysrhythmias ........................................................... 23

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2.11.3 Left Ventricular Thrombus ...................................... 23
2.11.4 Hepatomegaly .......................................................... 23
2.11.5 Renal Failure ............................................................ 23
2.12 Nursing Care Plan of Heart Failure ..................................... 23
2.12.1 Nursing Assessment ................................................ 23
2.12.2 Nursing Diagnosis and Intervention ........................ 26

CHAPTER 3 NURSING CARE ........................................................................ 40


3.1 Case Overview ....................................................................... 40
3.1.1 Health History of Current Disease ................................ 40
3.1.2 History of Previous Disease ......................................... 40
3.1.3 History of Family Disease ............................................ 41
3.1.4 General Condition and Consciousness ......................... 41
3.1.5 Skin ............................................................................... 41
3.1.6 Head and Neck .............................................................. 42
3.1.7 Sight and Eye ................................................................ 42
3.1.8 Olfactory and Nose ....................................................... 42
3.1.9 Auditory and Ear .......................................................... 42
3.1.10 Mouth and Teeth ......................................................... 43
3.1.11 Respiration and Circulation ........................................ 43
3.1.12 Abdomen .................................................................... 44
3.1.13 Genitalia ...................................................................... 44
3.1.14 Upper and Lower Extremities ..................................... 44
3.1.15 Activity and Rest ........................................................ 44
3.1.16 Personal Hygiene ........................................................ 45
3.1.17 Nutrition ...................................................................... 45
3.1.18 Elimination ................................................................. 45
3.1.19 Reproduction .............................................................. 46
3.1.20 Psychosocial ............................................................... 46
3.1.21 Spiritual ...................................................................... 46
3.2 Diagnostic Examinations ....................................................... 46

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3.2.1 X-Ray ............................................................................ 46
3.2.2 Electrocardiography ...................................................... 47
3.2.3 Hematology Laboratory Examination .......................... 48
3.3 Pharmacologic Therapy ......................................................... 49
3.4 Data Focus ............................................................................. 50
3.4.1 Subjective Data ............................................................. 50
3.4.2 Objective Data .............................................................. 50
3.5 Data Analysis ......................................................................... 52
3.6 Problem Priority .................................................................... 54
3.7 Intervention, Implementation & Evaluation .......................... 55
3.8 Progress Note ......................................................................... 63

CHAPTER 4 CONCLUSION AND SUGGESTION ....................................... 80


4.1 Conclusion ............................................................................. 80
4.2 Suggestion ............................................................................. 81
4.2.1 Patient ........................................................................... 81
4.2.2 Family ........................................................................... 81
4.2.3 Hospital ......................................................................... 81
4.2.4 Institution ...................................................................... 81
4.2.5 Nurse ............................................................................. 82
4.2.6 Public ............................................................................ 82

REFERENCES ................................................................................................... 83
LIST OF PICTURES
LIST OF TABLES
LIST OF APPENDIXES

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LIST OF PICTURES

Picture 1.1 Anatomy of Heart ...................................................................... 7


Picture 2.1 Pathway of Heart Failure ........................................................... 18

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LIST OF TABLES

Table 3.1 Hematology Laboratory Examination ......................................... 48


Table 3.2 Pharmacologic Therapy .............................................................. 49
Table 3.3 Data Analysis .............................................................................. 52
Table 3.4 Intervention, Implementation & Evaluation ............................... 55
Table 3.5 Progress Note .............................................................................. 63
Table 3.6 Progress Note .............................................................................. 66
Table 3.7 Progress Note .............................................................................. 69
Table 3.8 Progress Note .............................................................................. 72
Table 3.9 Progress Note .............................................................................. 75
Table 3.10 Progress Note ............................................................................. 78

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LIST OF APPENDIXES

Appendix 1. Consciousness Level


Appendix 2. Glasgow Coma Scale
Appendix 3. Muscle Strength Scale
Appendix 4. Activity Scale
Appendix 5. Pitting Edema
Appendix 6. Consultation Sheet
Appendix 7. Students Presence List
Appendix 8. Letter of Consent
Appendix 9. Surat Pengantar Pengambilan Data
Appendix 10. Data 10 Penyakit Terbanyak
Appendix 11. Curriculum Vitae

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