D.

Nursing Interventions

Nursing Care Planning

No. Nursing Diagnose
Purpose And Criteria Intervention Rational
1. Ineffectiveness of After nursing actions for 2 x 24 hours, the 1) Observation of vital 1) To determine the next
breath patterns client is expected to show effective signs intervention
associated with pain breathing with the results criteria: 2) Auscultation of breath 2) Abnormal breath
(chest) Respitratory status: ventilation sounds, note the sounds indicate a
indicator early purpose presence of additional problem
Respiratory frequency 2 4 breaths 3) Semi fowler position
as expected 3) Maintain a semi can reduce tightness
fowler position 4) Dilute phlegm to get it
Inspiration depth 2 4
4) Encourage clients to out easily
Use of respiratory 2 4
drink warm water 5) Uncontrolled coughing
muscle muscles
5) Guide and practice is tiring and ineffective
Sound adequately 2 4
regular breathing and causing frustration
effective coughing 6) Giving a nebulizer can
Information : techniques help thin the phlegm
1. Inadequate
6) Provision of nebulizer 7) O2 can reduce
2. A little adequate as indicated tightness and help meet
3. Medium
oxygen needs
4. Adequate
 5. Very adequate 7) Continue giving O2
according to the
doctor's instructions

2. Decreased cardiac After nursing actions for 2 x 24 hours are 1) TTV Monitor 1) To see the patient's
output is related to expected to have normal cardiac output with 2) Monitor blood pressure is high
changes in heart the following criteria: The effectiveness of a cardiovascular status or low because it will
frequency heart pump 3) Monitor fluid affect the heart's
Indikator Early Purpose balance working system
Blood pressure within 2 4 4) Monitor client 2) Poor cardiovascular
the expected limit activity tolerance status can be caused by
5) Monitor signs and pulmonary edema and
Weaknesses in 2 4
symptoms of edema this is closely related to
extensibility don't exist
6) Monitor the amount heart failure
The heart index is 2 4
and rhythm of the 3) Increased loss of fluid
within the expected
heart in response to changes
limit
in speed and depth of

Information : breath due to

1. Heavy movement in the lungs

2. quite heavy will affect the heart

3. medium 4) To see the client's

4. Mild complaints limitations that are

caused by a client's
 5. No complaints illness, and the grade
can be established
from a client's disorder
5) Because pulmonary
edema is closely
related to heart failure
6) disorders of the heart
come from where the
heart rate is very fast
and irregular.
3. Pain associated with After nursing actions for 2 x 24 hours, the 1) Perform a 1) To determine the
biological injury pain is expected to be resolved by the comprehensive pain client's comfort level
agents results criteria: Pain level assessment including and to determine the
Indicator Early Purpose location, appropriate treatment
Report pain 2 4 characteristics, 2) Complaints of pain can
duration, frequency, also be observed
Frequency of pain 2 4 quality and through vital signs and
Length of pain 3 4 precipitation factors non-verbal reactions
episodes
2) Observation of 3) Evaluation is carried
Facial pain expression 2 4 nonverbal reactions out to measure the
from discomfort success of the
Information : treatment performed
 1. Inadequate 3) Evaluate past pain on the client and to
2. A little adequate experiences determine the next plan
3. Medium 4) Practice handling pain 4) Monitor patient
4. Adequate with deep breath response and provide
5. Very adequate 5) Give analgesics to physiological support
reduce pain that is done during
diagnostic or
teraupetik procedures
5) Use pharmacological
agent agents to reduce
or eliminate pain
4. Activity intolerance After nursing measures for 2 x 24 hours, it is 1) Observation of the 1) Overcoming the
is related to expected that activity intolerance will be level of client activity limitations that clients
immobility resolved by the results criteria: Durability 2) Help clients do can do
Indicator Early Purpose activities that cannot 2) With the help of others,
Carry out routine 3 5 be done the client's ADL needs
activities 3) Involve the family in are met
Physical activity 3 5 fulfilling the client's 3) Reducing family
Blood oxygen when 3 5 ADL dependence on officers
on the move 4) Encourage clients to 4) Appropriate activities
carry out activities can prevent muscle
Information : stiffness
 1. Very disturbed according to their 5) Reducing muscle work
2. Many are disturbed abilities and minimizing
3. Pretty disturbed 5) Complete periods of excessive energy use
4. A little disturbed activity with breaks
5. Not disturbed

E. Nursing Implementation

Day, date,
No. Nursing Diagnose Implementation Response
time
1. Ineffectiveness of Saturday, 1) observe vital signs The client responds well to the
breath patterns May 11, 2019 2) to treat breath sounds, note the actions taken
associated with pain 02.00 am presence of additional breaths
(chest) 3) maintain semi fowler position
4) recommend to clients to drink warm
water
5) guide and practice regular deep
breathing and effective coughing
techniques
 Saturday, 1) give the nebulizer as indicated The client responds well to the
May 11, 2019 2) continue the administration of O2 actions taken
02.15 am according to the doctor's instructions

2. Decreased cardiac Saturday, 1) Monitoring TTV The client responds well to the
output is related to May 11, 2019 2) Monitoring cardiovascular status actions taken
changes in heart 02.30 am 3) Monitoring fluid balance
frequency 4) Monitoring tolerance of client
activity
5) Monitoring signs and symptoms of
edema
6) Monitoring the amount and rhythm of
the heart
3. Pain associated with Saturday, 1) comprehensive pain assessment P: Pain is felt suddenly when
biological injury May 11, 2019 including location, characteristics, coughing and holding cough
agents 02.45 am duration, frequency, quality and Q: Pain is felt like being slashed
precipitation factors R :: pain in the left chest radiates
2) observe nonverbal reactions from behind the back
discomfort T: sudden pain
3) evaluating past pain experiences S: Pain scale 5
 Saturday, 1) do pain management with deep The client responds well to the
May 11, 2019 breath actions taken
02.50 am 2) provide analgesics to reduce pain

4. Activity intolerance is Saturday, 1) observe the level of client activity The client responds well and
related to immobility May 11, 2019 2) help clients carry out activities that understands what is being
03.00 am cannot be done instructed on the actions taken
3) involving the family in fulfilling the
client's ADL
4) encourage clients to carry out
activities according to their abilities
5) over the period of activity with rest
 F. Evaluation

No Day, date, time Nursing Diagnose Implementation Initials

1. Sunday, May 12, Ineffectiveness of breath S: patients say they are still short of breath
2019 patterns associated with pain O:
06.00 pm (chest)  installed binasal kanul 5 liters / minute
 RR: 28 x / minute
 use O2 therapy with binasal kanul 5 liters /
minute
 the client is more relaxed after getting O2
therapy
 sweat a lot
 semi fowler position
A: The problem has not been resolved
P: Continue intervention
 Auscultation of breath sounds, note the
presence of additional breaths
 Monitor inspiration from O2 status
2. Sunday, May 12, Decreased cardiac output is S: patients say the heart is still pounding frequently
2019 related to changes in heart O:
06.15 pm frequency  BP : 180/90 mmHg, P : 88 x / min, RR: 28x
/ min, T: 36 ° C
 Irregular heart rhythms and ECG results
obtained irregular rhythm, HR 100x / m
A: The problem has not been resolved
P: continue the intervention
 Monitor the amount and rhythm of the heart
 Monitor TTV and cardiovascular status
monitors
3. Sunday, May 12, Pain associated with S: the patient still says chest pain when coughing
2019 biological injury agents and holding cough
06.30 pm O: looks holding on to his chest
A: the problem has not been resolved
P: continue the intervention
 Give analgesics to reduce pain
 Perform a comprehensive pain assessment
including location, characteristics, duration,
frequency, quality and precipitation factors
 Observation of nonverbal reactions from
discomfort
4. Sunday, May 12, Activity intolerance is S: the client said he was still tight and felt tired
2019 related to immobility when doing activities a little overcame
06.45 pm O:
 general weakness, composmentist
awareness,
 BP : 180/90 mmHg
 P : 88 x / minute
 T : 36 ° C
 RR : 28 x / minute
 fatigue, anxiety, anxiety.
A: the problem has not been resolved
P: Continue intervention
 Observing the level of client activity
 Complete the period of activity with rest

G. Discharged Planning
1. Eat soft, low-salt foods as needed
2. Activity and rest, where the abnormal heart work must be reduced by several activities such as total bedres, with rest
can reduce symptoms of heart failure
3. Provide education about specific conditions
4. Provide specific instructions about the drug and its side effects
5. Teaches feeding techniques and nutritional needs