Komunikasi Terhadap Tindakan Keperawatan | Pengkajian sampai Evaluasi

Safa Aulia

13 Aug 202410:47

Summary

TLDRThe video script features a nursing team from Group 8, presenting a comprehensive approach to patient care, focusing on intervention, implementation, and case evaluation. The case revolves around a 20-year-old patient, Ms. A, who has been under care at MS U Tidar for three days due to a persistent cough and difficulty breathing. The nursing team conducts a thorough examination, identifies ineffective airway clearance due to retained secretions, and implements effective coughing exercises to clear the airways. The intervention includes positioning, chest percussion, and education on the procedure. The script concludes with an evaluation of the effectiveness of the coughing exercises and a recommendation for continued practice.

Takeaways

😷 The patient, a 20-year-old woman, is under care at MS U Tidar for the past three days with complaints of difficulty breathing due to phlegm.
🏥 The patient has been experiencing coughing with difficulty expectorating, leading to wheezing sounds and shortness of breath.
👩‍⚕️ Nurse Naura is on duty in the morning and conducts a preliminary assessment, including vital signs and auscultation.
🌡️ The patient's vital signs include a blood pressure of 120/90 mmHg, a temperature of 36.7 degrees Celsius, a pulse of 88 beats per minute, and a respiratory rate of 26 breaths per minute.
🔍 Auscultation reveals wheezing sounds during exhalation, and the patient's chest movement is asymmetrical with dry skin and no cyanosis.
🗣️ The patient reports difficulty in expectorating, worsening shortness of breath when lying down, and difficulty sleeping due to breathing discomfort.
💊 The patient has been using hot water and eucalyptus oil for relief, which are suggested to help loosen phlegm and ease breathing.
🛑 Nurse Safa, a student from Poltekes, is introduced and will be assisting the patient, explaining the nursing interventions and their purposes.
📝 The nursing diagnosis includes ineffective airway clearance due to retained secretions, and the goal is to improve cough effectiveness.
🔁 The planned interventions include teaching the patient effective cough techniques, positioning, and the use of nebulizers to facilitate expectoration.
📋 The effectiveness of the interventions is evaluated by the patient's ability to expectorate and improvements in respiratory symptoms.

Q & A

What is the patient's chief complaint in the script?
-The patient complains of difficulty expectorating phlegm, which leads to a feeling of heavy breathing and shortness of breath.
How old is the patient mentioned in the script?
-The patient is 20 years old.
What is the patient's condition that requires nursing intervention?
-The patient is experiencing ineffective airway clearance due to retained secretions, which causes difficulty in expectorating and shortness of breath.
What are the initial nursing assessments performed on the patient?
-The initial nursing assessments include checking blood pressure, temperature, pulse, and respiration rate, as well as auscultation and inspection of the chest.
What is the purpose of effective cough training for the patient?
-Effective cough training aims to clear the larynx, trachea, and bronchial tubes of secretions or foreign objects that obstruct the airway.
What is the expected outcome of the nursing intervention for the patient?
-The expected outcome is the effective expectoration of secretions, improved breathing, and a decrease in the frequency of coughing.
What therapeutic actions are planned for the patient's condition?
-The therapeutic actions include positioning the patient, using a flutter device to mobilize secretions, and possibly administering medications such as mucolytics or bronchodilators.
How does the script describe the patient's response to the initial cough training?
-The patient is able to perform the effective cough training but still experiences some discomfort and the sensation of a 'tickling' in the throat.
What additional advice is given to the patient for managing her condition?
-The patient is advised to consistently practice effective coughing exercises and to consider scheduling these practices after routine activities or work.
What is the final evaluation of the patient's condition after the intervention?
-The final evaluation shows some improvement in the patient's condition with the ability to expectorate secretions, but some secretions still remain, indicating the need for continued practice.
What collaborative approach is mentioned in the script for the patient's care?
-The script mentions collaboration with a doctor and a pharmacist for the administration of medications like Ventolin via a nebulizer to help clear blocked airways.

Outlines

00:00

🏥 Introduction to Patient's Respiratory Condition

The script introduces a nursing group presenting a case study involving a 20-year-old patient, Ms. A, who has been under care at MS Tidar for three days due to a persistent cough. The patient is experiencing difficulty in expectorating phlegm, leading to wheezing sounds and shortness of breath. The nursing staff, including Naura and Aisyah, discuss the patient's symptoms and perform initial assessments, such as blood pressure, temperature, pulse, and respiration rate. Auscultation reveals wheezing sounds during exhalation, and the patient's chest movement is asymmetrical with dry skin and no cyanosis. The patient reports increased difficulty in breathing when lying down and mentions the presence of wheezing sounds. The nursing staff plans to continue the examination and introduce interventions to improve the patient's respiratory condition.

05:01

📋 Effective Coughing Techniques and Patient Education

The script continues with a detailed explanation of the nursing interventions for Ms. A, who is diagnosed with ineffective airway clearance due to retained secretions. The nursing staff plans to educate the patient on effective coughing techniques to clear her airways. The interventions include observing the patient's ability to cough, monitoring secretions, positioning the patient, and providing education on the purpose and procedure of effective coughing. The script also mentions the collaboration with doctors and pharmacists for potential treatments like mucolytics or expectorants. The nursing staff demonstrates the coughing technique to the patient, emphasizing the importance of deep breathing and the use of hands to facilitate expectoration. The patient is encouraged to practice the technique consistently to improve her condition.

10:02

🔍 Evaluation of Effective Coughing Intervention

The final part of the script focuses on the evaluation of the effective coughing intervention. Despite the patient's efforts, some secretions remain unexpectorated, indicating the need for continued practice and possibly further interventions. The nursing staff suggests that the patient should consistently practice effective coughing techniques, potentially scheduling these sessions after her routine activities or work. The script concludes with the patient's agreement to continue the practice and the nursing staff's readiness to provide further assistance as needed.

Mindmap

Keywords

💡Auscultation

Auscultation is a medical examination technique used to listen to the internal sounds of the body, typically using a stethoscope. It is a crucial part of physical examination, especially in assessing the respiratory and cardiovascular systems. In the video, auscultation is used to detect wheezing sounds in the patient, indicating possible respiratory issues. The script mentions 'auskultasi wzing, terdengar pada saat pasien menghembuskan nafas,' which translates to 'auscultation wheezing, heard when the patient exhales,' showcasing its use in diagnosing the patient's condition.

💡Dyspnea

Dyspnea refers to the sensation of difficulty in breathing or shortness of breath. It is a common symptom in various respiratory conditions and can significantly impact a patient's quality of life. In the script, the patient complains of 'sesak nafas yang semakin memburuk saat bergaring' which translates to 'increasingly worsening shortness of breath when lying down,' highlighting dyspnea as a key symptom that the healthcare providers are addressing.

💡Expectoration

Expectoration is the act of coughing up and spitting out mucus or phlegm from the respiratory tract. It is an important process in clearing the airways of secretions that can obstruct breathing. The video discusses ineffective expectoration as a problem, with the patient having difficulty expelling sputum, as indicated by 'merasa kesulitan, mengeluarkan dahak meskipun batuknya kuat,' which means 'feeling difficulty in expelling sputum even though the cough is strong.'

💡Effective Cough

An effective cough is a technique used to clear the airways of mucus and other secretions. It involves a forceful exhalation to expel the material from the lungs. In the video, 'latihan batuk efektif' or 'effective cough exercise' is introduced as an intervention to help the patient clear her airways more efficiently. The script describes a step-by-step process for the patient to practice this technique, aiming to improve her respiratory condition.

💡Secretions

Secretions in the context of the video refer to the mucus or fluid produced by the respiratory system. Accumulation of secretions can lead to respiratory distress and the need for clearance. The script mentions 'sekresi yang tertahan' which translates to 'retained secretions,' indicating a buildup of mucus that is causing the patient's difficulty in breathing and the necessity for therapeutic intervention.

💡Respiration

Respiration is the process by which the body takes in oxygen and releases carbon dioxide, primarily through the act of breathing. In the video, the term is central to the patient's condition, as indicated by the patient's complaints of 'tidak bisa bernafas dengan lega' or 'unable to breathe comfortably.' The healthcare providers assess and monitor the patient's respiratory rate and sounds to evaluate her condition and provide appropriate care.

💡Ventolin

Ventolin is a brand name for salbutamol, a medication used to treat asthma and other respiratory conditions by relaxing the muscles in the airways. It is mentioned in the script as 'pemberian ventolin melalui nebulis' or 'administration of Ventolin through a nebulizer,' which is a method of delivering the medication directly to the lungs to help open up the airways and alleviate symptoms like wheezing and shortness of breath.

💡Mucus

Mucus is a slimy substance produced by the mucous membranes and glands in the body, particularly in the respiratory tract, to trap and remove foreign particles and pathogens. In the video, the patient's difficulty in expectoration is related to the presence of excessive mucus, as indicated by 'penumpukan mukus yang banyak di jalan nafas,' which translates to 'a large accumulation of mucus in the airway,' leading to her respiratory distress.

💡Ineffective Airway Clearance

Ineffective airway clearance refers to the body's inability to clear mucus and other secretions from the airways, which can lead to respiratory problems. The script describes the patient's condition as 'bersih jala nafas yang tidak efektif,' which translates to 'ineffective airway clearance,' due to the retention of secretions causing difficulty in breathing and the need for therapeutic interventions.

💡Nebulisers

A nebuliser is a device that turns liquid medication into a fine mist that can be inhaled directly into the lungs. It is used to deliver medication for respiratory conditions. In the video, 'nebulis' is mentioned as part of the treatment plan to help the patient with her breathing difficulties, specifically to administer 'ventolin melalui nebulis' or 'Ventolin through a nebuliser' to clear her airways.

💡Pursed-Lip Breathing

Pursed-Lip Breathing is a technique where a person breathes in through the nose and exhales slowly through pursed lips, similar to blowing out a candle. It is used to help control rapid or shallow breathing and can be part of respiratory therapy. The script refers to this technique when the healthcare provider instructs the patient to 'bernafas dalam dan' or 'breathe in deeply and,' suggesting the use of this method to improve her respiratory condition.

Highlights

Introduction of the healthcare team and their roles in patient care.

Patient's complaint of persistent coughing and difficulty breathing.

Description of the patient's symptoms, including difficulty expectorating and shortness of breath.

Introduction of Nurse Naura, who is on duty in the morning.

Nurse Naura's approach to handling the patient's symptoms with warm water and eucalyptus oil.

Explanation of the patient's vital signs and physical examination findings.

Identification of ineffective airway clearance as the nursing diagnosis.

Description of the nursing intervention plan, including effective coughing exercises.

Demonstration of effective coughing techniques by the healthcare provider.

Explanation of the purpose and procedure of effective coughing exercises to the patient.

Collaboration with doctors and pharmacists for medication administration.

Use of Ventolin through a nebulizer to clear blocked airways.

Assessment of the patient's understanding and willingness to perform the coughing exercises.

Observation of the patient's ability to perform effective coughing after the intervention.

Evaluation of the patient's condition post-intervention and the effectiveness of the coughing exercises.

Recommendation for the patient to practice effective coughing consistently to improve condition.

Encouragement for the patient to rest and call for assistance if needed.