PORTOFOLIO MATA KULIAH
BAHASA INGGRIS DALAM
KEPERAWATAN II
KODE MATA KULIAH: BAE 112
PENULIS:
NAMA : SAGITA WULAN SARI
NIM: 131511133021
FAKULTAS KEPERAWATAN UNIVERSITAS
AIRLANGGA SURABAYA
2016
Nama
: SAGITA WULAN SARI
NIM
: 131511133021
Mata Kuliah
: ENGLISH NURSING II
Judul Tugas
: RESUME NURSING PLAN CORONARY HEART DISEASE
Pertemuan Ke
:8
Tanggal
mengumpulkan
: 11 November 2016
Dengan ini saya menyatakan bahwa tugas berikut adalah hasil karya saya
sendiri. Apabila dengan sengaja terdapat kesamaan (plagiarisme) dalam
pengerjaannya. Saya bersedia untuk mengulang pengerjaan portofolio
sebagaimana ditetapkan bersama dengan PJMK BAE 112.
Surabaya, 10 NOVEMBER 2016
(SAGITA WULAN SARI)
NIM:131511133021
Tugas terlampir telah direview dan ditelaah
Nama Dosen
Pengampu
NIP/NIK
Hasil Review
Nilai Tugas (0100) :
Tanda Tangan Dosen
Nursing Plan Coronary Heart Disease
Coronary heart disease (CHD) also called coronary artery disease, CHD one of problem
heart disease because of there plaque builds up inside the coronary arteries. Coronary
heart disease is a narrowing of the small blood vessels which supplies blood rich oxygen to
the your heart.
Pathophysiology coronary heart disease => coronary heart disease is usually caused by a
build up cholesterol rich deposits or plaques on the lining inside the artery. That plaque
also called atheromatous plaques or simply atheromas, overtime plaque hardens and
narrows the arteries, reducing blood flow heart muscle.
Etiology coronary heart disease => coronary heart disease there many factors is not only
caused by a single factor like as atherosclerosis, but weighed down also many other factors
such as hypertension, lipid levels, smoking, blood sugar levels are abnormal.
Sign and Symptoms :
Chest pain (angina)
Shortness of breath
Heart attack
Risk factors :
Age (age get older, risk for CHD increases)
Sex ( Female or Male, domain risk factor get CHD is male and female after
menopause)
Family history of early heart disease because of almost their history all activity or
eating, it is same menu that them consumption.
Smoking
High blood pressure
High blood cholesterol levels
High amounts of sugar in the blood due to insulin resistence (Diabetes)
Management of Coronary Heart Disease
Lifestyle changes (being active person, regullary sporty or movement your body)
Drugs ( discipline of consumption drugs by doctor given, the reason is some drugs were
given have many function for treatment be better)
Procedures to restore and improve blood flow
Complications
Stroke
Heart failure
Abnormal heart rhythm (arrhythmia)
Heart Attack
Nursing Plan Coronary Heart Disease
Nursing Process :
Assessment => Diagnosis => Intervention=>Out Come Identification and Planning =>
Implementation => Evalution
A. Types of Assessment
a) Intial / first assessment : Identity patient like as common identity, main complaint,
history of current illness, previous history, family disease history.
b) Reassement / evaluation : after looking for condition and interview make planning
what must to do for patient like as injuction, give medical or another for example : vital
signs, physical examination.
B. Nursing Diagnosis => may be part of the nursing process and is a clinical judgment about
individual, family or community experiences/responses to actual or potential health
problems / life processes.
Nursing diagnosis CHD :
1. Decreased Cardiac Output related to Altered contractility
2. Acute Pain related to Biological injury agent (ischemia)
3. Activity intolerance related to imbalance between oxygen supply/demand
C. Intervention and rational
Nursing
Diagnosis
Outcomes to
Outcome
Intervention
rational
measure Resolution overall rating
of Diagnosis
Domain 4 : Cardiac
Pump 1. (040001)
1. Cardiac Care 1. Limitation of
Activity / Rest
Effectiveness (0400)
complications
(4040)
Systolic
Class
4
:
resulting from
2. Hemodynamic
blood
Cardiovascular /
an imbalance
Regulation
pressure :
pulmonary
between
(4150)
4-5
responses
myocardial
3. Vital Signs
2. (040019)
Code : 00029
oxygen supply
Monitoring
Diastolic
Decreased
and demand for
(6680)
Cardiac Output
a patient with
blood
related
to
symptoms of
pressure :
Altered
impaired
4-5
contractility
cardiac
function.
3. (040023)
2. Optimization of
Dyspnea at
heart rate,
rest : 4-5
preload,
afterload, and
contractility
3. Collection and
Domain 12 : Pain level (2102)
Comfort
Class
1
:
Physical
comfort
Code: 00132
Acute
pain
releated
to
Biological
injury agent (
ischemia)
1 (210201)
Reported
pain : 4-5
2 (210206)
Facial
expressions
of pain : 4-5
3 (210227)
Nausea : 4-5
1. analgesic
1.
administratio
n (2210)
2. Pain
management
2.
(1400)
3. Sedation
management
(2260)
3.
Domain 4 : Activity
Activity/Rest
(0005)
Class
4
:
Cardiovascular/
pulmonary
responses
Code : 00092
Activity
intolerance
related to
imbalance
between oxygen
supply/demand
tolerance 1. (000501)
Oxygen
saturation
with
activity : 2-1
2. (000502)
Pulse rate
with
activity : 2-1
3. (000503)
Respiratory
rate with
activity : 2-1
1. Activity
Therapy
(4310)
2. Cardiac
Care:
Rehabilitativ
e(4046)
3. Energy
Management
(0180)
1.
analysis of
cardiovascular,
respiratory, and
body
temperature
data to
determine and
prevent
complications
Use of
pharmacologic
agents to reduce
or eliminate
pain
Alleviation of
pain or a
reduction in
pain to a level
of comfort that
is acceptable to
the patient
Administration
of sedatives,
monitoring of
the patients
response, and
provision of
necessary
physiological
support during a
diagnostic or
therapeutic
procedure
Prescription of
and assistance
with specific
physical,
cognitive,
social, and
spiritual
activities to
increase the
range,
frequency, or
duration of an
individuals or
groups activity.
2. Promotion of
maximum
functional
activity level for
a patient who
has experienced
an episode of
impaired
cardiac function
that resulted
from an
imbalance
between
myocardial
oxygen supply
and demand
3. Regulating
energy use to
treat or prevent
fatigue and
optimize
function
D. Evaluation => The result nursing want/hope from intervention their do before.
1. Normally cardiac output
2. Pain level diminished or lost
3. Increase patients activity
