Komunikasi Terhadap Tindakan Keperawatan | Pengkajian sampai Evaluasi

Summary

The 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.