ASUHAN KEPERAWATAN PALIATIF

Summary

This video covers palliative nursing care, emphasizing the 5 key stages of the nursing process: assessment, diagnosis, intervention, implementation, and evaluation. It highlights common nursing problems in palliative patients, such as nutritional imbalances, mobility issues, and pain management, alongside strategies for addressing these issues. The video also emphasizes the importance of quality of life, supporting the patient and their family, and preventing complications. It discusses the need for continuous evaluation and adjustment of care based on the patient’s evolving needs and the success of interventions.

Takeaways

• 😀 Palliative nursing care follows a structured 5-step nursing process, starting with assessment, diagnosis, intervention, implementation, and evaluation.
• 😀 The first step in palliative care is nursing assessment, where patient data is gathered to understand their needs and condition.
• 😀 Nursing diagnosis identifies patient problems based on collected data, and can be found in resources like the S DKI book (Indonesia) or NANDA (international).
• 😀 After diagnosis, nursing interventions are planned with goals and actions outlined in resources such as the SLKI (Indonesia) and NIK (international).
• 😀 Nursing interventions aim to improve quality of life, focusing on symptoms such as pain management and respiratory care.
• 😀 The implementation stage involves carrying out the planned interventions and prioritizing based on the severity of the nursing problems.
• 😀 Nursing evaluation includes both process evaluation (daily review of interventions) and outcome evaluation (whether goals were achieved).
• 😀 Common nursing problems in palliative care include imbalanced nutrition, risk of infection, chronic pain, and impaired mobility.
• 😀 Family and caregiver education is an important part of nursing intervention, helping them recognize signs of a patient's decline and manage care appropriately.
• 😀 Palliative nursing involves managing both physical and psychological issues, addressing symptoms like fatigue, insomnia, and emotional distress.
• 😀 Evaluation helps determine whether nursing interventions are effective, and adjustments can be made if goals are not met.

Q & A

What is the general approach to nursing care for palliative patients?

Nursing care for palliative patients follows the same basic processes as general nursing care, involving five stages: nursing assessment, nursing diagnosis, nursing intervention, nursing implementation, and nursing evaluation.

What is the first stage in the nursing care process for palliative patients?

The first stage is the nursing assessment, which involves collecting data from the patient to understand their condition and needs.

How is the nursing diagnosis determined in palliative care?

The nursing diagnosis is based on the data collected during the nursing assessment. It identifies the nursing problems experienced by the patient and is formulated using the formula: nursing problem, etiology, and signs and symptoms.

What are the sources for nursing diagnosis references in Indonesia and internationally?

In Indonesia, nursing diagnoses can be referred to in the S DKI book (Indonesian Equipment Diagnostic Signs), while internationally, the NANDA book (North American Nursing Diagnosis Association) is used.

What are some common nursing problems for palliative patients related to nutrition and fluids?

Common nursing problems in this area include imbalanced nutrition, swallowing disorders, the risk of electrolyte imbalance, fluid imbalance, and the risk of impaired liver function in certain patients, such as those with liver cancer.

What nursing problems may arise in the elimination and exchange category?

Nursing problems in this category may include urine elimination disorders, constipation, diarrhea, and issues related to impaired mobility.

How are the nursing interventions planned in palliative care?

Nursing interventions are planned based on the nursing diagnosis and aim to alleviate symptoms, improve quality of life, educate the patient and their family, and prevent complications. Specific actions focus on pain management, improving endurance, and providing family support.

What is involved in the implementation stage of palliative nursing?

In the implementation stage, the planned nursing interventions are put into action. The approach follows the priority of nursing problems and focuses on improving patient comfort and quality of life.

What is the purpose of nursing evaluation in palliative care?

The nursing evaluation aims to assess whether the nursing interventions have resolved the identified nursing problems. It involves both process evaluation (daily assessment of actions taken) and outcome evaluation (whether the goals have been achieved).

How is the effectiveness of the nursing care evaluated?

Effectiveness is evaluated through process and outcome evaluations. Process evaluation looks at daily actions and their results, while outcome evaluation checks if the goals set during the planning stage have been achieved. If a problem persists, the plan may be adjusted or extended.