Asuhan Keperawatan: penerapan SDKI, SLKI, SIKI

Summary

This educational video introduces the nursing care process based on Indonesian standards, focusing on a post-appendectomy patient case. It covers essential nursing stages, including assessment, diagnosis, planning, implementation, and evaluation. The patient, a 35-year-old male, experiences post-surgical pain, which is managed through interventions like pain relief, breathing exercises, and Quranic recitations. The video highlights the use of Indonesian nursing standards to create effective care plans, monitor patient progress, and adjust interventions for optimal outcomes. It's a practical guide for nursing students and professionals seeking to apply these standards in real-world scenarios.

Takeaways

• 😀 The nursing care process is divided into five stages: assessment, diagnosis, planning, intervention, and evaluation.
• 😀 The first stage, assessment, involves collecting patient data, such as pain levels and vital signs, to identify issues.
• 😀 Diagnosis is made by analyzing collected data, categorizing it, and formulating nursing diagnoses, such as acute pain from surgery.
• 😀 Setting goals and expected outcomes based on the nursing diagnosis helps define the criteria for success.
• 😀 Nursing interventions are selected from Indonesian nursing standards, addressing the patient's needs such as pain management, breathing techniques, and Murottal therapy.
• 😀 The implementation stage involves carrying out the planned interventions, such as administering pain medication or teaching deep breathing exercises.
• 😀 Patient responses to interventions are documented, helping to assess the effectiveness of the care provided.
• 😀 Evaluation compares subjective and objective data to see if the goals are met, with adjustments made if needed.
• 😀 If the patient shows improvement but has not fully met the goals, the issue is considered partially resolved.
• 😀 If there is no improvement or the patient's condition worsens, a reassessment of the interventions is required to adjust the care plan.
• 😀 The process is aligned with Indonesian nursing care standards, ensuring a structured approach to patient management.

Q & A

What is the first stage of nursing care in the process outlined in the video?

The first stage of nursing care is the assessment, where the nurse collects subjective and objective data to understand the patient's condition.

How is the nursing diagnosis formulated in the script?

The nursing diagnosis is formulated by analyzing both subjective and objective data, categorizing the findings, and identifying the main problem. In this case, the diagnosis is acute pain due to the appendectomy operation.

What is the primary nursing diagnosis in the case study provided?

The primary nursing diagnosis is acute pain related to physical injury from the appendectomy surgery, evidenced by sharp, stabbing pain and limited mobility.

What are the key goals set in the planning stage of nursing care?

The key goals are to reduce the patient's pain level to less than 3 on the pain scale and ensure that the patient can move without wincing or experiencing pain.

What are some of the interventions chosen for the patient in the video?

The interventions chosen include pain management through analgesics, educating the patient on breathing techniques, and providing Murottal therapy (listening to or reading Quran recitations).

How does the nurse assess the patient's pain according to the script?

The nurse assesses the patient's pain by identifying the location, characteristics, duration, frequency, and intensity of the pain, as well as checking for non-verbal signs of discomfort like wincing.

What specific breathing technique is taught to the patient?

The breathing technique involves instructing the patient to inhale for four seconds, hold the breath for two seconds, and then exhale slowly for eight seconds.

What is the purpose of Murottal therapy in the nursing intervention?

Murottal therapy, which involves listening to or reading Quran recitations, is used to soothe the patient and help manage pain by promoting relaxation and emotional comfort.

What are the expected outcomes after the interventions are implemented?

The expected outcomes are a decrease in pain level (below a 3 on the pain scale), the patient being able to move without pain, and the absence of issues such as difficulty sleeping or breathing problems.

How is the effectiveness of the interventions evaluated?

The effectiveness of the interventions is evaluated by comparing subjective and objective data to the set goals. If the pain is reduced but not fully resolved, it indicates partial achievement of the goals.