Basic Nursing Assessment data by Doenges (1999) :
- Activity / Rest
- Symptoms: weakness, fatigue, shortness of breath, monotonous lifestyle.
- Signs: The frequency of the heart increases, changes in heart rhythm, tachypnoea.
- Circulation
- Symptoms: History of hypertension, atherosclerosis, coronary heart disease / valve and cebrocaskuler disease, episodes of palpitations.
- Signs: The increase in BP, pulse throbbing clear from the carotid, jugular, radial, tachycardia, valvular stenosis murmur, jugular venous distension, pale skin, cyanosis, cold temperature (peripheral vasoconstriction) filling the capillary may be slow / delayed.
- Ego Integrity
- Symptoms: History personality changes, anxiety, multiple stress factors (relationship, financial, work related).
- Signs: Explosion mood, anxiety, continue narrowing of attention, tears burst, face muscles tense, breathing heaved, increased speech patterns.
- Elimination
- Symptoms: Impaired renal current or (such as obstruction or a history of kidney disease in the past).
- Food / fluid
- Symptoms: The preferred food that includes foods high in salt, fat and cholesterol, nausea, vomiting and changes in body weight lately (up / down) Historical use of diuretics.
- Signs: normal weight or obese, the presence of edema, glikosuria.
- Neuro Sensory
- Genjala: Complaints of dizziness / headache, throbbing, headache, suboksipital (happens when you wake up and eliminate spontaneously after a few hours) Impaired vision (diplobia, blurred vision, epistaxis).
- Signs: mental status, changes in waking, orientation, pattern / content of speech, effects, think the process, decreased hand grip strength.
- Pain / discomfort
- Symptoms: Angina (coronary artery disease / heart involvement), headache.
- Respiratory
- Symptoms: dyspnea related to the activities / work Tachypnoea, orthopnea, dyspnea, cough with or without the formation of sputum, history of smoking.
- Signs: respiratory distress / respiratory accessory muscle use additional breath sounds (krakties / wheezing), cyanosis.
- Security
- Symptoms: Impaired coordination / gait, postural hypotension.
- Risk for Decreased Cardiac Output related to increased afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy
- Acute Pain: headache related to increased cerebral vascular pressure
- Ineffective Tissue perfusion : cerebral, renal, cardiac related to circulatory disorder
- Knowledge Deficit related to lack of information about the disease process and self-care.