Download - Critical Care Nursing
CRITICAL CARE NURSINGCRITICAL CARE NURSING
Ns. Reni Sulung Utami, S.Kep., M.Sc Adult Nursing Department PSIK-FK UNDIP
Tujuan Pembelajaran
Definisi pasien kritis
Indikasi dan prioritas masuk ICU
Tujuan pelayanan
Karakteristik ICU
Peran dan tanggung jawab perawat kritis
Pengkajian
Kebutuhan keluarga pasien kritis
Isu Etik dan Legal di area keperawatan kritis
DISKUSI
PASIEN??
TUJUAN PELAYANAN?
FASILITAS??
SUMBER DAYA MANUSIA??
DEFINISI (1)
Critical care nursing is the delivery of specialized care to critically ill patients—that is, ones who have life-threatening illnesses or injuries. Such patients may be unstable, have complex needs, and require intensive and vigilant nursing care (Manaci et al, 2012)
DEFINISI (2)
ICU adalah suatu bagian dari rumah sakit yang mandiri (instalasi di bawah direktur pelayanan), dengan staf dan perlengkapan yang khusus yang ditujukan untuk observasi, perawatan dan terapi pasien-pasien yang menderita penyakit, cedera atau penyulit-penyulit yang mengancam nyawa atau potensial mengancam nyawa dengan prognosis dubia (tidak tentu/ragu-ragu).
(KMK NO 1778 Th. 2010)
DEFINISI (3)
Area praktik keperawatan yang kompleks dan menantang yang bertujuan merawat pasien kritis yang mengancam nyawa, yang memerlukan pemantauan dan perawatan intensif, dengan melibatkan tenaga terlatih serta didukung dengan peralatan khusus.
GOALS
Menyelamatkan kehidupan
Mencegah terjadinya kondisi memburuk dan komplikasi
Meningkatkan kualitas hidup dan mempertahankan kehidupan
Mengoptimalkan kemampuan fungsi organ tubuh
Mempercepat proses penyembuhan pasien
Mengurangi angka kematian pasien kritis
RUANG LINGKUP PELAYANAN
1. Diagnosis dan penatalaksanaan spesifik penyakit2 akut yang mengancam nyawa dan dapat menimbulkan kematian dalam beberapa menit sampai beberapa hari
2. Memberi bantuan dan mengambil alih fungsi vital tubuh sekaligus melakukan pelaksanaan spesifik problema dasar
3. Pemantauan fungsi vital tubuh dan penatalaksanaan terhadap komplikasi yang ditimbulkan oleh penyakit atau iatrogenik (penyakit yg diakibatkan oleh kesalahan diagnosis/kealpaan dokter)
4. Memberikan bantuan psikologis pada pasien yang kehidupannya sangat tergantung pada alat dan orang lain
(KMK No. 1778 Tahun 2010)
KARAKTERISTIK PASIEN
1. Pasien yang memerlukan intervensi medis segera oleh tim intensive care
2. Pasien yang memerlukan pengelolaan fungsi sistem organ tubuh secara terkoordinasi dan berkelanjutan sehingga dapat dilakukan pengawasan yang konstan dan metode terapi titrasi
3. Pasien sakit kritis yang memerlukan pemantauan kontinue dan tindakan segera untuk mencegah timbulnya dekompensasi fisiologis
(KMK No. 1778 Tahun 2010)
DEFINISI PASIEN KRITIS
1. Pasien-pasien yang secara fisiologis tidak stabil dan memerlukan dokter, perawat, profesi lain yang terkait secara terkoordinasi dan berkelanjutan, serta memerlukan perhatian teliti, agar dapat dilakukan pengawasan yang ketat dan terus menerus serta terapi titrasi
2. Pasien-pasien yang dalam bahaya mengalami dekompensasi fisiologis sehingga memerlukan pemantauan ketat dan terus menerus serta dilakukan intervensi segera untuk mencegah timbulnya penyulit yang merugikan
INDIKASI MASUK…
Ancaman/ kegagalan sistem pernafasan (gagal nafas)
Ancaman/kegagalan sistem hemodinamik (syok)
Ancaman/kegagalan sistem neurologi
Overdosis obat
Intoksikasi
Infeksi berat (sepsis)
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PRIORITAS MASUK (KMK no 1778 th 2010)
PrioritasPrioritas 11 Pasien kritis, tidak stabil, perlu terapi intensif dan tertitrasi Do all/everything (terapi tidak memiliki batasan) Contoh: post bedah jantung, edema paru, septic shock, AMI, Disritmia
PrioritasPrioritas 22 Perlu pelayanan pemantauan canggih di ICU Do everything : post bedah mayor, post bedah jantung, pasca henti jantung,
penyakit dasar jantung-paru
PrioritasPrioritas 33 Kemungkinan sembuh/manfaat perawatan di ICU kecil Terapi diberikan untuk mengatasi kegawatan akutnya Do something : Metastase, penyakit jantung dan paru terminal dengan
komplikasi akut.
PengecualianPengecualian PertimbanganPertimbangan luarluar biasabiasa dandan persetujuanpersetujuan kepalakepala ICUICU SewaktuSewaktu22 pasienpasien harusharus dapatdapat dikeluarkandikeluarkan ContohContoh:: menolakmenolak terapiterapi agresifagresif,, vegetatifvegetatif permanenpermanen,, matimati batangbatang otakotak
INDIKASI KELUAR
Tidak memerlukan terapi intensif
Terapi intensif gagal
MBO
FASILITAS DAN KETENAGAAN
KMK No 1778 Tahun 2010 Tentang Pedoman Penyelenggaraan Pelayanan Intensive Care Unit Di Rumah Sakit
Keputusan Direktur Jenderal Bina Upaya Kesehatan no HK.02.04/I tahun 1966 tentang Petunjuk Teknis Penyelenggaraan Pelayanan ICU di Rumah Sakit
What Nurse do?
Critical care nurses fill many roles in the critical care setting, such as staff nurses, nurse-educators, nurse-managers, case managers, clinical nurse specialists, nurse practitioners, and nurse researchers.
PERAN DAN TANGGUNG JAWAB NERS
Advocate
Menggunakan penilaian klinis (decision maker)
Menunjukkan perilaku caring (care giver)
Berkolaborasi dengan tim kesehatan lain
Mendemonstrasikan pemahaman ttg keragaman budaya
Memberikan pendidikan kepada pasien dan keluarga (Educator)
ADVOCATE Melindungi hak-hak pasien
Membantu pasien dan keluarganya dalam proses pengambilan keputusan dengan menyediakan pendidikan dan dukungan
Bernegosiasi dengan anggota tim kesehatan lain atas nama pasien dan keluarganya
Memberikan informasi kepada pasien dan keluarganya tentang rencana perawatan
Advokasi untuk fleksibilitas kunjungan di ICU
Menghormati dan mendukung keputusan pasien dan keluarganya
Melayani sebagai penghubung antara pasien dan keluarganya dgn anggota tim kesehatan lain
Menghormati nilai-nilai dan budaya pasien
Bertindak untuk kepentingan terbaik pasien
CLINICAL JUDGEMENT
A critical care nurse needs to exercise clinical judgment.
To develop sound clinical judgment, you need critical thinking skills.
Critical thinking is a complex mixture of knowledge, intuition, logic, common sense, and experience.
WHY BE CRITICAL?????
Mendorong pemahaman tentang masalah dan memungkinkan perawat untuk cepat menemukan jawaban atas pertanyaan-pertanyaan sulit
Meningkatkan kemampuan perawat untuk mengidentifikasi kebutuhan pasien
Memungkinkan perawat untuk menggunakan kemampuan dlm pengambilan keputusan klinis dan untuk menentukan tindakan keperawatan terbaik guna memenuhi kebutuhan pasien
Diperlukan ketika menerapkan proses keperawatan: pengkajian, perencanaan, intervensi
CARING PRACTICE
Caring practice is the use of a therapeutic and compassionate environment to focus on the patient’s needs.
Although care is based on standards and protocols, it must also be individualized to each patient.
Caring practice also involves: maintaining a safe environment
interacting with the patient and his family in a compassionate and respectful manner throughout the critical care stay
supporting the patient and his family in end-of-life issues and decisions
COLLABORATION
Collaboration allows a health care team to use all available resources for the patient.
The collaborative goal is to optimize patient outcomes and to provide effective and comprehensive (holistic) care.
Multidisciplinary Teams
Team Member:
Registered nurses
Doctors
Physician assistants
Advanced practice nurses (such as clinical nurse specialists and nurse practitioners)
Patient care technicians
Respiratory therapists and others.
BENEFITS MULTIDISCPLINARY CARE TEAMS (Barnato et al, 2010)
Reduced mortality
Improve communication
Facilitate implementation of best clinical practices
CULTURAL DIVERSITY
A critical care nurse is expected to demonstrate awareness and sensitivity toward a patient’s religion, lifestyle, family makeup, socioeconomic status, age, gender, and values.
Be sure to assess cultural factors and concerns and integrate them into the care plan
EDUCATOR
As an educator, a critical care nurse is the facilitator of patient, family, and staff education. Patient education involves teaching patients and their families about: The patient’s illness
The importance of managing comorbid disorders (such as diabetes, arthritis, and hypertension)
Diagnostic and laboratory testing
Planned surgical procedures, including preoperative and postoperative expectations
Instructions on specific patient care, such as wound care and range-of-motion exercises.
ASSESSMENT
The assessment can be individualized by adding more specific assessment requirements depending on the specific patient diagnosis
Assessments should focus first on the patient, then on the technology.
The patient needs to be the focal point of the critical care practitioner's attention, with technology augmenting the information obtained from the direct assessment.
TYPE OF ASSESSMENT
Pre-arrival Assessment
Admission quick check ("just the basics“)
Comprehensive admission Assessment
Ongoing assessment
PREARRIVAL ASSESSMENT
WHEN??
About the upcoming admission of the patient.
HOW??
The initial health care team contact paramedics in emergency department (ED), operating room (OR), or medical/surgical nursing unit.
WHAT?? Paints the initial picture of the patient and allows the critical care
nurse to begin anticipating the patient's physiologic and psychological needs.
Allows the critical care nurse to determine the appropriate resources that are needed to care for the patient.
PREARRIVAL ASSESSMENT
Abbreviated report on patient (age, sex, chief complaint, diagnosis, pertinent history, physiologic status, invasive devices, equipment and status of laboratory/diagnostic tests)
Room setup complete, including verification of proper equipment functioning
ADMISSION QUICK CHECK
Obtained immediately upon arrival and is based on assessing the parameters represented by the ABCDE acronym
A quick overview of the adequacy of ventilation and perfusion to ensure early intervention for any life-threatening situations.
Also focused on exploring the chief complaint and obtaining essential diagnostic tests to supplement physical assessment findings.
A high-level view of the patient, but is essential because it validates that basic cardiac and respiratory function is sufficient.
ADMISSION QUICK ASSESSMENT
General appearance (consciousness)
Airway Patency; Position of artificial airway (if present)
Breathing Quantity and quality of respirations (rate, depth, pattern, symmetry, effort, use of accessory muscles); Breath sounds; Presence of spontaneous breathing
Circulation and Cerebral Perfusion Blood pressure; Peripheral pulses and capillary refill; Skin, color, temperature, moisture; Presence of bleeding; Level of consciousness, responsiveness
Chief Complaint Primary body system; Associated symptoms
Drugs and Diagnostic Tests Drugs prior to admission (prescribed, over-the-counter, illegal); Current medications; Review diagnostic test results
Equipment Patency of vascular and drainage systems; Appropriate functioning and labeling of all equipment connected to patient
Allergies
COMPREHENSIVE ADMISSION ASSESSMENT
Performed as soon as possible, with the timing dictated by the degree of physiologic stability and emergent treatment needs of the patient.
An in-depth assessment of the past medical and social history and a complete physical examination of each body system.
Is vital to successful outcomes because it provides the nurse invaluable insight into proactive interventions that may be needed.
ONGOING ASSESSMENT
After the baseline comprehensive assessment is completed, ongoing assessments, an abbreviated version of the comprehensive admission assessment, are performed at varying intervals.
The assessment parameters outlined in this section are usually completed for all patients, in addition to other ongoing assessment requirements related to the patient's specific condition, treatments, and response to therapy.
HOLISTIC HEALTH CARE
Holistic care addresses all dimensions of a person, including:
Biological (Physical)
Psychological (Emotional)
Social
Spiritual
PENGALAMAN PASIEN KRITIS
Difficulty communicating
Pain
Thirst
Difficulty swallowing
Anxiety
Lack of control
Depression
Fear
Lack of family or friends
Physical restraint
Feeling of dread
Inability to get comfortable
Difficulty sleeping
Loneliness
Thoughts of death & dying
FAMILY NEEDS
Molter and Leske’s (1983) Critical Care Family Needs Inventory (CCFNI): Information
Proximity (Kedekatan dg pasien)
Assurance (Jaminan pelayanan)
Comfort (Kenyamanan)
Support (Dukungan mental)
FAMILY NEEDS
Kebutuhan keluarga pasien ICU di RSDK (Saputra &
Utami, 2013)
Kebutuhan jaminan pelayanan (96,3%)
Kebutuhan dekat dengan pasien (86,4%)
Kebutuhan rasa nyaman (85,5%)
Kebutuhan informasi (79,8%)
Kebutuhan dukungan mental (72,3%)
Prioritas C:\Users\VAIO\Downloads\kebutuhan keluarga pasien ICU.pdf
ETHICAL & LEGAL ISSUES
Informed consent
Do not resuscitation order
Withholding or withdrawal of life support
End of life issues advance directives, promoting a good death
PRINSIP ETIK
Beauchamp and Childress (2001) identify four primary ethical principles:
■ autonomy : An individual's right of self-determination and freedom of decision making (hak membuat keputusan)
■ non-maleficence: do no harm to clients (Tidak membahayakan/ mencederai pasien baik fisik maupun psikologis)
■ beneficence: do or promote good to client (melakukan tindakan yang baik/bermanfaat buat pasien)
■ justice: Being fair to all and giving equal treatment, including distributing benefits, risks, and costs equally (Bersikap adil)
Derivative ethical principles: Fidelity: Being loyal and faithful to commitments and
accountable for responsibilities. (menghargai janji dan setia pada komitmen)
Veracity: Telling the truth and not intentionally deceiving or misleading clients (kejujuran)
Privacy: A right of limited physical or informational inaccessibility (melindungi kebebasan pribadi)
Confidentiality: The prohibition of some disclosures of information gained in certain relationships without the consent of the original source of the information. (menjaga rahasia)
Beauchamp and Childress (2001)
DILEMA ETIK
You’ll recognize a situation as an ethical dilemma in the following circumstances:
More than one solution exists. That is, there’s no clear “right” or “wrong” way to handle a situation.
Each solution carries equal weight.
Each solution is ethically defensible.
Thank You