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APPENDIX – NURSING PROCESS FORMED

CREATED

1. ASSESSMENT

NURSING HISTORY Admission

Date: 12 July 2022 Time:No. Reg: 123-456-xxx
Medical Dx:
Penurunan curah jantung

Date of Assessment : 12 July 2022

I. Patient Identity:
1. Name : Mr. R
2. Age : 65 years old
3. Race : Male
4. Religion : islam
5. Education : SHS
6. Occupation : Retired Teacher
7. Address : Kesamben, Blitar

II. HISTORY OF PRESENT ILNESS

1. Chief Complain : excessive fatigue, coughing, constant restlessness
2. Present illness history : The patient's family said that Mr. R often complains of
restlessness, and excessive fatigue. In addition, the family said the patient often coughed. The
family provided treatment in the form of drugs purchased at the pharmacy, but Mr. R did not
recover. Finally, on July 12, the family took Mr. R to the hospital. After an EKG examination,
the patient was diagnosed with decreased cardiac output.
III. PAST NURSING HISTORY
1. History of Related Diseases :  None

2. History of contagious diseases : None

 Yes
Mentioned:
…………………………………………………………………………….
3. Hereditary Diseases :  None  Yes
Mentioned……………………………………………………………………
………………….
4. Allergic history : None medicine, food
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Mentioned……………………………………………………………………
…………………

IV. FAMILY HEALTH HISTORY (Genogram)

65 years old

OBSERVATION AND PHYSICAL EXAMINATION

VS: T: 36,5°C P: 50x/ minute R: 30x/minute BP: 80/60 mmHg

1. B1 : BREATHING (RESPIRATORY SYSTEM)

1) complain :  SOB  pain, breathing
√ Cough  others, mentioned :
…………………………
2) RR pattern: Frequency 30X/mnt
Rhythm:  regular 
Irregular Breathing : 
Vesicular 
BronchovesiculrSounds 
Ronchi  Wheezing
O2 adm :  Yes
 NoneOthers, mentioned
: Dispnea
……………………………………………………………………………………
……………………………………………………………………… …………… PROBLEM:
……………………………………………………………………… ……………
………………………………………………………

2. B2 : BLEEDING (CARDIOVASCULAR SYSTEM)

1) complain :  chest pain  dizziness

 headache  palpitation
2) Heart sounds
 Normal  Abnormal: S3  S4  Murmur
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3) Edema  None  YesOthers :

………………………………………………………………………… …………
PROBLEM
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…..................................................................................................................... ........
............................................................................................................................. ....
....................................................................................................................... ..........
.....................................................................................
3. B3: BRAIN (NERVOUS SYSTEM)
1) Orientation:  Person  Place  Time
2) Complain:
……………………………………………………………………………
…….
3) Awareness :  Composmentis  Apathies 
Somnolent
 Sopor  Coma
GCS: E 3 M 4 V 5, Total :3,
4, 5
4) Eye
Pupil:  Isochors  An isochors
Sclera:  Icterik  bleeding Others:
……………………………..
Conjungtiva:  Pale  light red
5) Nerves disturbance :
Trismus:  Yes, 
None Paralyze: 
Yes,  None
Sensory Perceptual  Yes,
 None
Mentioned:
……………………………………………………………………………..
Others:
………………………………………………………………………… ………… PROBLEM
………………………………………………………………………… …………
……………………………………………………………………………………
………………………………………
4. B4: BLADDER (GENITOURINARY
SYSTEM))
1) Complain:
……………………………………………… …………………………..

 Polyuria Oliguria  Anuria  Nocturia
2) Urine output: 400 ml/day. Color: Dark Yellow Smell:
Strong
3) Fluid Intake : Oral 500 cc/day, Parenteral : 1000
cc/dayOthers :
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
………………………………………
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5. B5: BOWEL (GASTROINTESTINAL SYSTEM – GI TRACT)

1) Mouth:  pain-swallowed  trachea wound

 Others;
2) Abdomen:  Press pain  wound operation
 Colostomy
3) Alvi elimination: ……. X/day  Normal 
Abnormal
Consistency:  hard  soft  fluid
 blood
4) Diet: ……  hard  fluid  softOthers :
…………………………………………………………………………… ………
…………………………………………………………………………… PROBLEM
………
…………………………………………………………………………… ………
………………………………………

6. B6: BONE (BONE-MUSCLE-INTEGUMENT

1) Joint Activity :  free  limited,
Reason;
2) Extremities complain:  Yes  None
3) Back Injury :  Yes  None
4) Integuments:  Icterik  cyanosis
 Redness  Hyper
pigmentation
Acral :  Warm  dry  redness Turgor:
 Excellent  Good  Poor
Others
………………………………………………………………………… ………… PROBLEM:
………………………………………………………………………… …………
………………………………………………………………………… …………
………………………………………
7. ENDOCRINE SYSTEM
Complain:  Yes  None
 Polydepsia  Polyphagia  Polyuria
Others :
PROBLEM
…………………………………………………………………………… ………
…………………………………………………………………………… ………
……………………………………
IV. PSYCHOOSOCIAL ASSEMENT
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1. Client perception about her disease.

√ God-struggle  Penalty  Other
2. Client expression toward his/her disease
 Quit  restlessness  Anxiety  Angry / crying
3. Year reaction
√ Cooperatif Not Cooperatif  prejudice
4. Self concept disturbane
 Yes; self ideal, identity, role, self -esteem, and body image
√ Not,
 Ot
hers,
Explain,
Others: ... :
…………………………………………………………………………… ………
PROBLEM
…………………………………………………………………………… ………
…………………………………………………………………………… ………
………………………………………
DIAGNOSTIC TEST AND MEDICAL TREATMENT
1. Laboratory:

2. Radiology: X Ray, STScans

3. ECG

4. USG, etc

5. Therapy:
………………………………………………………………………………
………………………………………………………………………………
…………………………………………………………………………… …
………………………………………………………
6. Others :
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………
Additional Data
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………
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DATA ANALYSIS

DATA ETIOLOGY PROBLEMS

Jantung tidak
Subjective dapat Decreased cardiac output
exces berkontraksi
sive secara
fatigu normal
e,
cough
ing,
consta
nt
restles
sness Daya pompa jantung

Objective menurun
1. EKG
aritmia
2. Edema ↓
3. Oliguri
a
4. Skin
color Penurunan curah
sianosis
5. Sound
of heart jantung
S3
T:
36,5°
C P:
50x/
minut
e R:
30x/m
inute
BP:
80/60
mmH
g

Subjective
Data:

Objective
Data:
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Subjective
Data:

Objective
Data:

B. Nursing Diagnosis
1.

2.
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3.

4.

Blitar, 12 july 2022

………………………
………….
Nurses,
Yuda aji pw
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C. INTERVENTION (POR – PROBLEM ORIENTED RECORDS)

NURSING NOC NIC

DIAGNOS (Nursing (Nursing
IS Outcome Intervention
Criteria) Classification)

GOAL D – Diagnostic
type (assess,
check, observe,
monitor, identify,
NOC etc)
(SMART –
Specific, E – Education
Measurable, Type (educate,
Achievable, explain, tell,
Rationale, teach, ask, etc)
Time)

T – Treatment
Type
(Independent,
interdependent,
dependency)
Position, postural
drainage,
administer,
exercise, feed,
etc.

R – Refferal
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B. INTERVENTION (PIE APPROACHES)

PROBLEM IMPLEMENTATION EVALUATION

(SDKI) (SIKI)

MORNING NOON
Decreased cardiac Observasi
output 1. Identify the main -09.00
signs/symptoms of
decreased cardiac output
(including dyspnea,
fatigue, edema,
orthopnea, paroxysmal
nocturnal dyspnea,
increased CVP)
2. Identify secondary -09.10
signs/symptoms of
decreased cardiac output
(including weight gain,
hepatomegaly, jugular
venous distention,
palpitations, wet crackles,
oliguria, cough, pale skin)
3. Monitor blood pressure -09.20
(including orthostatic
blood pressure, if
necessary)
4. Monitor fluid intake and
output
5. 12 lead ECG monitor -09.45
6. Monitor arrhythmias
(rhythm and frequency
abnormalities) -09.50
 PROBLEM IMPLEMENTATION EVALUATION
(SDKI) (SIKI)
156
MORNING NOON
Decreased cardiac 7.Check blood pressure and -10.00
output pulse before administering
medications (eg, beta blockers)
ACE inhibitors, calelum channel
blockers, digoxin)
Terapiutik :
1. Position the patient in a
semi-Fowler's or Fowler's -11.00
position with the feet
down or in a comfortable
position
2. Provide a heart-friendly
diet (e.g. limiting intake
of caffeine, sodium, -11.05
cholesterol, and high-fat
foods)
3. Use intermittent
-11.10
pneumatic or elastic
stockings, as indicated
Edukasi
1. Encourage physical -11.15
activity gradually
2. Teach patient and family
to measure daily fluid -11.20
intake and output
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5. EVALUATION

NURSING EVALUATION
DIAGNOS
IS
1. S: Patients say anxiety is reduced, cough is
reduced, fatigue is reduced
O: normal blood pressure, normal palpable
tone, normal urine intensity, normal skin color,
normal heart sound.
A: the problem is resolved
P: stop intervention

2. S
O
A
P