Pengenalan Perawatan Intensif: Muhamad Zulfatul A’la, M.kep

Pengenalan Perawatan intensif Muhamad Zulfatul A’la, M.Kep

Capaian pembelajaran 1. Mahasiswa mampu memahami ruang lingkup keperawatan kritis 2. Mahasiswa mampu memahami kompetensi perawat kritis 3. Falsafah ruang ICU 4. Mahasiswa mampu memahami kriteria ruang intensif 5. Mahasiswa mampu memahami tentang kriteria pasien kritis 6. Mahasiswa mampu memahami konsep etik di ruang kritis 7. Mahasiswa mampu memahami tentang brain death

Ruang lingkup kep. kritis • approximately 119,000 admissions to 141 general intensive care units (ICUs)

• in Australia per year; this includes 5500 patient readmissions during the same hospital episode • critical care treatment is a high expense component of hospital

care; one conservative estimate of cost exceeded $A2600 per day • Critical care as a specialty in nursing has developed over the last 30 years.

• Critical care nursing is defined by the World Federation of Critical Care Nurses as:

Specialised nursing care of critically ill patients who have manifest or potential disturbances of vital organ functions. Critical care nursing means assisting, supporting and restoring the patient

towards health, or to ease the patient’s pain and to prepare them for a dignified death. The aim of critical care nursing is to establish a therapeutic relationship with patients and their relatives and to

empower the individuals’ physical, psychological, sociological, cultural and spiritual capabilities by preventive, curative and rehabilitative interventions.

CCN Competencies According Canadian Association of critical care Nurses (2009) : 1.

Critical care nurses use advanced skills and specialized knowledge to

continuously assess, monitor and manage patients for the promotion of optimal physiological balance. 2.

Critical care nurses promote and facilitate optimal comfort and wellbeing in a highly technological environment that is often unfamiliar to patients and families.

3.

Critical care nurses foster mutually beneficial partnerships with patients and families based on trust, dignity, respect, communication and collaboration. Family is defined by the patient.

4. When providing care in a high risk environment, critical care nurses participate in safety initiatives and adhere to

best practice. 5. When life sustaining technologies are no longer beneficial, critical care nurses support patients and

families through the transition from active treatment to a peaceful death. 6. The critical care nurse promotes collaborative practice in

which the contribution of the patient, family and each health care provider is solicited, acknowledged and valued in a non-hierarchical manner.

7. Critical care nurses provide leadership by fostering a critical care culture conducive to collaboration, quality improvement, safety, professional growth and responsible resource utilization.

Pendidikan keperawatan kritis Ners generalis/perawat vokasi

Advanced practice nursing

Ners generalis

Spesialis keperawatan kritis

FALSAFAH PELAYANAN ICU 1.

Etika kedokteran

2.

Indikasi yang benar

3.

Kebutuhan pelayanan kesehatan pasien

4.

Kerjasama multidisipliner

5.

Asas prioritas

6.

Sistem manajemen peningkatan mutu terpadu

7.

Kemitraan profesi

8.

Efektifitas, keselamatan dan ekonomis

9.

Kontinuitas pelayanan

• (KMK 1778 tahun 2010)

Kriteria Ruang Intensif ICU PRIMER

ICU Sekunder

ICU tersier

Harus ada ruang isolasi

Harus ada ruang isolasi

Harus ada ruang tunggu keluarga

Harus ada ruang tunggu keluarga

Lab 24 jam

Lab 24 jam

ketenagaan Jenis tenaga

ICU Primer

ICU Sekunder

ICU tersier

Kepala ICU

dokter spesiaiis anestesiologi 2. dokter spesialis lain . yang teteh mengikuti Pelatihan)

1. Dokter ntensivis 2. dokterspesialis anestesiologi fiikabelum ada. dokter intensivis

Dokter intensivis

Tim Medis

dokter spesialis Sebagaikonsultan 2. dokteriaga24 jam dengan kemampuan Resusitasijantung paru

dokter spesialis2. dokter jaga 24 jam .dengan kemampuan ALS/ACLS, danFCCS

dokter spesialis2. dokter jaga 24 jam .dengan kemampuan ALS/ACLS, danFCCS

Jenis tenaga

ICU Primer

ICU Sekunder

ICU tersier

Perawat

Perawat terlatih yang Bersertifikat BTCLS

Minimal50% dari jumlah seluruh perawat di ICU merupakan perawat terlatih Dan, bersertifikat ICU

Minimal 75% dari jumlah seluruh perawat di ICU merupakan perawat terlatih dan bersertifikat ICU

Tenaga non medis

Tenaga administrasi, pekarya dan kebersihan

Tenaga administrasi, pekarya dan kebersihan

Tenaga administrasi, pekarya dan kebersihan Tenaga rekam medik, lab, farmasi, ilmiah

ICU Primer

Kemampuan pelayanan ICU Sekunder

RJP, airway management, terapi O2, pemasangan CVC, EKG, titrasi, nutrisi enteral dan parenteral, lab khusus, penggunaan alat portabel, fisioterapi dada

RJP, airway management, terapi O2, pemasangan CVC, EKG, titrasi, nutrisi enteral dan parenteral, lab khusus, penggunaan alat portabel, fisioterapi dada

Prosedur isolasi, hemodialisis intermitten dan kontinyu

ICU tersier Prosedur isolasi, hemodialisis intermitten dan kontinyu

Kriteria pasien masuk 1. Gol pasien prioritas 1  kritis, tidak stabil, perlu terapi intensif (ventilasi, obat-obatan vasoaktif, antiaritmia dll)

2. Gol pasien prioritas 2  perlu pemantauan canggih peralatan ICU, contoh pasien dengan pulmonary arterail chateter 3. Gol pasien prioritas 3  kritis, tidak stabil, perlu terapi intensif

akibat penyakit yang mendasarinya • Pengecualian : pasien dengan keadaan vegetatif permanen, pasien yang menolak terapi tunjangan hidup, karena adanya donor organ.

Kriteria pasien keluar 1. keadaan pasien telah membaik dan cukup stabil

2. Ketika pemantauan intensif pada pasien sudah tidak bermanfaat

Alur pelayanan ICU

Konsep etik diruang intensif 1. Ethics deal with all aspects of human behavior and are often complex and contentious

2. Ethics involve principles and rules that guide and justify conduct

3. Key ethical (moral) principles include autonomy, beneficence, non-maleficence, justice and paternalism

AUTONOMY 1.

Individuals should be treated as autonomous agents

2.

To respect autonomy is to give weight to autonomous persons’ considered opinions and choices, while refraining from obstructing their actions unless these are clearly detrimental to others or themselves. According to the principle of autonomy, critical care

3.

patients are entitled to be treated as self-determining. Where the

patient is incompetent, healthcare professionals ought to act so as to respect the autonomy of the individual as much as possible, for example by attempting to discover what the patient’s preference would have been in the current circumstances

BENEFICIENCE

1. The principle of beneficence requires that nurses act inways that promote the

wellbeing of another person 2. doing no harm, and maximising possible

benefits while minimising possible harms (non-maleficence)

JUSTICE • Justice may be defined as fair, equitable and appropriate treatment in light of what is due or owed to an individual • In health care, egalitarian theories generally propose that people be provided with an equal distribution of particular goods or services

Consent to treatment 1.

A competent individual has the right to decline or accept healthcare treatment

2.

Consent is considered valid when the following criteria are fulfilled; consent must:

• be informed (the patient must understand the broad nature and effects of the proposed intervention and the material risks it entails)

• be voluntarily given • encompass the act to be performed • be given by a person legally competent to do so.

End of life decision making • A common ethical dilemma found in critical care is related to the opposing positions of ‘maintaining life at all costs’ and ‘relieving suffering

associated with prolonging life ineffectively’. • The withholding or withdrawal of life support is considered ethically acceptable and clinically desirable if it reduces unnecessary patient suffering in patients whose prognosis is considered hopeless.

• Lack of communication creates a potential for patients to undergo burdensome and expensive treatments that they may not desire • End-of-life decision making is usually very difficult and traumatic

BRAIN DEATH 1.

Brain death occurs in the setting of a severe brain injury associated with marked elevation of intracranial pressure.

2.

Determination of brain death requires that there is unresponsive coma, the absence of brainstem reflexes and the absence of respiratory centre function, in the clinical setting in which these findings are irreversible.

3.

death isdetermined using the brain death criteria, it is certified by two

medical practitioners as defined by local legislation 4.

Brain death cannot be determined without evidence of sufficient intracranial pathology

1.

Kematian batang otak didefinisikan sebagai hilangnya seluruh fungsi otak,

2.

termasuk fungsi batang otak, secara ireversibel. Tiga tanda utama manifestasi

kematian batang otak adalah koma dalam, hilangnya seluruh refleks batang otak, dan apnea(3,4). 3.

Seorang pasien yang telah ditetapkan mengalami kematian batang otak berarti secara klinis dan legal-formal telah meninggal dunia. Hal ini dituangkan dalam pernyataan IDI tentang Mati dalam SK PB IDI No.336/PB IDI/a.4 tertanggal 15 Maret 1988 yang disusul dengan SK PB IDI No.231/PB.A.4/07/90. Dalam fatwa tersebut dinyatakan bahwa seorang dikatakan mati, bila fungsi pernafasan dan jantung telah berhenti secara pasti atau irreversible, atau terbukti telah terjadi kematian batang otak(5,6)

Koma dalam • Tidak adanya respon motorik serebral terhadap rangsang • nyeri di seluruh ekstremitas (nail-bed pressure) dan penekanan di supraorbital • faktor perancu, seperti intoksikasi obat, blokade neuromuskular, hipotermia, • atau kelainan metabolik lain yang dapat menyebabkan koma namun masih berpotensi reversible.

HILANGNYA REFLEKS BATANG OTAK •

Pupil:

a.

Tidak terdapat respon terhadap cahaya / refleks cahaya negatif

b.

Ukuran: midposisi (4 mm) sampai dilatasi (9 mm)

• a.

Gerakan bola mata /gerakan okular: Refleks okulosefalik negatif (pengujian dilakukan hanya apabila secara nyata tidak terdapat retak atau ketidakstabilan vertebrae cervical atau basis kranii)

b.

Tidak terdapat penyimpangan /deviasi gerakan bola mata terhadap irigasi 50 ml air dingin di setiap telinga (membrana timpani harus tetap utuh; pengamatan 1 menit setelah suntikan, dengan interval tiap telinga minimal 5 menit)

• Respon motorik facial dan sensorik facial: a.

Refleks kornea negatif

b.

Jaw reflex negatif (optional)

c.

Tidak terdapat respon menyeringai terhadap rangsang tekanan dalam pada kuku, supraorbita, atau temporomandibular joint

• Refleks trakea dan faring: a.

Tidak terdapat respon terhadap rangsangan di faring bagian

posterior b.

Tidak terdapat respon terhadap pengisapan trakeobronkial / tracheobronchial suctioning

APNEA Prasyarat :

• Suhu tubuh ≥ 36,5 °C atau 97,7 °F • Euvolemia (balans cairan positif dalam 6 jam sebelumnya) • PaCO2 normal (PaCO2 arterial ≥ 40 mmHg) • d. PaO2 normal (pre-oksigenasi arterial PaO 2 arterial

≥ 200 mmHg)

•

Pasang pulse-oxymeter dan putuskan hubungan ventilator

•

Berikan oksigen 100%, 6 L/menit ke dalam trakea (tempatkan kanul setinggi carina)

•

Amati dengan seksama adanya gerakan pernafasan (gerakan dinding dada atau abdomen yang

menghasilkan volume tidal adekuat) •

Ukur PaO2, PaCO2, dan pH setelah kira-kira 8 menit, kemudian ventilator disambungkan kembali

•

Apabila tidak terdapat gerakan pernafasan, dan PaCO2 ≥ 60 mmHg (atau peningkatan PaCO2 lebih atau sama dengan nilai dasar normal), hasil tes apnea dinyatakan positif (mendukung kemungkinan klinis kematian batang otak)

•

Apabila terdapat gerakan pernafasan, tes apnea dinyatakan negatif (tidak mendukung kemungkinan klinis kematian batang otak)

•

Hubungkan ventilator selama tes apnea apabila tekanan darah sistolik turun sampai < 90 mmHg (atau lebih rendah dari batas nilai normal sesuai usia pada pasien < 18 tahun), atau pulse-oxymeter mengindikasikan adanya desaturasi oksigen yang bermakna, atau terjadi aritmia kardial.

TERIMAKASIH