Conclusion watched video :
1. Tells how the lives of some people who have heart failure, namely Steven,
Elisabeth and John. They have different lives and habits but experience the
same thing, namely heart failure. But they feel different complaints. The
video also explains what causes heart failure. As well as how to manage if
you have contracted heart failure, namely by changing a healthy lifestyle,
reducing salt, drinking at least 2 liters, and doing light exercise and don't
forget to always consult your doctor and don't forget to take medication.
Ethical SOAP Note
Nur Auliya
NIM 2010132p
03/4/2021 15:30
Mrs. K 56 year old, female, housewives
Referral: none
Source and Reliability : Self , husband , both reliable sources.
S (Subjective):
Chief complaint : “chest pain and shortness of breath.”
HPI: The patient said that chest pain and shortness of breath after doing the
activity, pain arises and increased shortness after doing the activity. Pain felt in the
left chest. Before entering the hospital, while sweeping the house, the client
suddenly feels short of breath and feels chest pain and fatigue and weakness.
Past medical history : The patient said that several years ago the patient had been
treated for diabetes mellitus, there was a wound on the leg and an operation was
performed.
Family history : The patient says that no family member has experienced illness
like her. Her husband has hypertension
Allergies: NKA
Current Mediation: Metformin 500 mg
Social History: The patient lives with her husband. They only live alone. their
children already have their own home. the patient does not smoke and does not
drink alcohol
Exercise & Diet: Do not eat nuts such as processed soybeans, long beans, and do
not eat foods that contain high sugar
O (Objective)/Physical Exam
VS – BP: 130/80 mg/dl , HR: 94, RR: 28, Temp 36,8 C, weight: 89 kg , height:
149 cm.
Mrs. K is appears short of breath, face looks grimace with pain scale 6, and is
weak. The patient just lies in bed. The results of high cholesterol blood tests, X-
rays found cardiomegaly and the ECG results looked abnormal.
A (Assessment)
Problem #1 – decreased cardiac output is associated with decreased left
ventricular contractility
Plan (P): after nursing action decreased cardiac output can be resolved and vital
signs within acceptable limits (controlled dysrhythmias or disappear), and
symptom free of heart failure (hemodynamic parameters within normal limits),
with the result criteria that the client's urine output is adequate will report a
decrease in episodes of dyspnoea, play a role in that activity can reduce the
workload of the heart, blood pressure within normal limits
Therapy/Treatment: assess and report signs of decreased bulk heart, check the
condition of the client by auscultating the apical pulse, assess frequency, heart
rhythm (documentation of dysrhythmias, if telemetry is available), record heart
sounds, palpate peripheral pulses, monitor urine output, record the amount and
concentration / concentration of urine, rest the client with rest optimal bed, set the
ideal bed rest position, avoid saline fluids, monitor the ECG series and Changes
in chest X-ray.
Evaluation : Subjective evaluation, namely the client said chest pain was reduced
with activity and not having trouble breathing. The objective evaluation of the
client's face is not visible grimace in pain, pain scale 3, the client does not seem
difficult to breathe, pressure blood: 120/80 mmHg, pulse 80x / minute.