Ronde Keperawatan

Summary

The transcript describes a medical case review of a patient with respiratory issues, involving a team of nurses and doctors discussing the patient’s current condition. Despite five days of treatment, the patient, diagnosed with stage 3 lung disease, has shown minimal improvement. The team highlights various nursing interventions, including respiratory monitoring, oxygen therapy, and pain management. The discussion also covers the patient’s background, with potential risk factors like prolonged exposure to asbestos. Collaborative efforts are being made to refine the treatment plan and ensure the patient’s comfort, with a focus on improving breathing and alleviating discomfort.

Takeaways

• 😀 The script discusses a patient's case in the pulmonary ward with a focus on respiratory issues and ineffective breathing patterns.
• 😀 The patient has been receiving care for 5 days, but there has been no significant improvement in their condition.
• 😀 The patient's respiratory rate remains high, averaging 25 breaths per minute, despite efforts to manage the issue.
• 😀 The patient experiences persistent coughing, including some blood in the sputum, and ongoing chest pain.
• 😀 The patient has a history of exposure to asbestos in a construction environment, which may have worsened their condition.
• 😀 The medical team is collaborating and working to improve the patient's health by providing various interventions, including oxygen therapy and pain management.
• 😀 The team plans to conduct a care round and discusses actions to support the patient's recovery, involving both the patient and their family in decision-making.
• 😀 Nurses are continuously monitoring vital signs, administering oxygen, and providing comfort measures like semi-Fowler positioning and relaxation techniques.
• 😀 The medical team is considering adjustments to the patient's medication and treatment plan due to the lack of significant progress after 5 days of care.
• 😀 The patient's treatment may need to be adjusted, including potentially changing medications or incorporating additional measures like a humidifier to help with respiratory symptoms.

Q & A

What is the patient's primary medical condition discussed in the transcript?

The patient is suffering from a respiratory condition, likely tuberculosis (TB), which has been exacerbated by environmental factors such as asbestos exposure from working in a construction environment for 20 years.

What are the key symptoms the patient is experiencing?

The patient is experiencing persistent cough with blood-streaked sputum, chest pain, and ineffective breathing patterns (respiratory rate above 20 breaths per minute).

How long has the patient been receiving care, and what has been the result so far?

The patient has been receiving care for 5 days, but there has been minimal improvement in their condition despite the interventions.

What specific intervention methods have been employed so far?

Interventions include oxygen therapy, semi-Fowler positioning for comfort, pain management with analgesics, breathing exercises, and monitoring the patient’s respiratory rate and vital signs.

What issues have arisen regarding the patient’s pain management?

The analgesics provided have not been effective in alleviating the patient’s chest pain, which has remained unchanged despite treatment.

Why is the patient's breathing rate a concern, and what is being done to address it?

The patient's breathing rate remains above 20 breaths per minute, which is a sign of ineffective breathing patterns. The medical team is using oxygen therapy and adjusting the patient’s positioning to improve breathing, but there has been no significant change yet.

What environmental factors are considered to have contributed to the patient’s condition?

The patient worked in a building material store for 20 years, where they were exposed to asbestos, which likely contributed to the deterioration of their lung health.

How is the medical team planning to adjust the treatment plan moving forward?

The medical team plans to evaluate the effectiveness of the current medications and may consider changing the pain management and respiratory treatment methods. They are also focused on enhancing comfort measures and continuing collaboration with the patient’s family.

What collaborative efforts are being made by the healthcare team for the patient’s care?

The healthcare team, including doctors, nurses, and the patient’s family, are collaborating to develop and adjust the care plan. They discuss the patient's condition, make decisions about future interventions, and ensure the family’s involvement in the process.

What are the specific goals for the patient’s care in the upcoming days?

The goals include evaluating the effectiveness of the current interventions, making necessary adjustments to the medications, improving the patient’s comfort, and continuing to monitor and manage their respiratory condition.