Critical Care Nursing

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CRITICAL CARE NURSING CRITICAL CARE NURSING Ns. Reni Sulung Utami, S.Kep., M.Sc Adult Nursing Department PSIK-FK UNDIP

Transcript of Critical Care Nursing

Page 1: Critical Care Nursing

CRITICAL CARE NURSINGCRITICAL CARE NURSING

Ns. Reni Sulung Utami, S.Kep., M.Sc Adult Nursing Department PSIK-FK UNDIP

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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

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DISKUSI

PASIEN??

TUJUAN PELAYANAN?

FASILITAS??

SUMBER DAYA MANUSIA??

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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)

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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)

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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.

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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

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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)

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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)

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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

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INDIKASI MASUK…

Ancaman/ kegagalan sistem pernafasan (gagal nafas)

Ancaman/kegagalan sistem hemodinamik (syok)

Ancaman/kegagalan sistem neurologi

Overdosis obat

Intoksikasi

Infeksi berat (sepsis)

dll

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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

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INDIKASI KELUAR

Tidak memerlukan terapi intensif

Terapi intensif gagal

MBO

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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

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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.

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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)

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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

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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.

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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

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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

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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.

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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.

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BENEFITS MULTIDISCPLINARY CARE TEAMS (Barnato et al, 2010)

Reduced mortality

Improve communication

Facilitate implementation of best clinical practices

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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

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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.

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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.

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TYPE OF ASSESSMENT

Pre-arrival Assessment

Admission quick check ("just the basics“)

Comprehensive admission Assessment

Ongoing assessment

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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.

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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

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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.

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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

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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.

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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.

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HOLISTIC HEALTH CARE

Holistic care addresses all dimensions of a person, including:

Biological (Physical)

Psychological (Emotional)

Social

Spiritual

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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

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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)

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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

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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)

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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)

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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.

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Thank You