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 well-
being 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
Advanced practice nursing
vokasi

Spesialis keperawatan
Ners generalis
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 Harus ada ruang tunggu
keluarga keluarga
Lab 24 jam Lab 24 jam
 ketenagaan
Jenis ICU Primer ICU Sekunder ICU tersier
tenaga
Kepala ICU dokter spesiaiis 1. Dokter ntensivis Dokter intensivis
anestesiologi 2. dokterspesialis
2. dokter spesialis anestesiologi
lain . yang teteh fiikabelum ada.
mengikuti dokter
Pelatihan) intensivis

Tim Medis dokter spesialis dokter dokter

Sebagaikonsultan spesialis2. dokter spesialis2. dokter
2. dokteriaga24 jam jaga 24 jaga 24
dengan jam .dengan jam .dengan
kemampuan kemampuan kemampuan
Resusitasijantung paru ALS/ACLS, ALS/ACLS,
danFCCS danFCCS
Jenis ICU Primer ICU Sekunder ICU tersier
tenaga
Perawat Perawat terlatih yang Minimal50% dari Minimal 75% dari
Bersertifikat BTCLS jumlah seluruh jumlah seluruh
perawat di ICU perawat di ICU
merupakan merupakan
perawat terlatih perawat
Dan, bersertifikat terlatih dan
ICU bersertifikat ICU

Tenaga non Tenaga administrasi, Tenaga Tenaga

medis pekarya dan kebersihan administrasi, administrasi,
pekarya dan pekarya dan
kebersihan kebersihan

Tenaga rekam
medik, lab, farmasi,
ilmiah
 Kemampuan
ICU Primer pelayanan
ICU Sekunder ICU tersier

RJP, airway management, RJP, airway management, Prosedur isolasi,

terapi O2, pemasangan
CVC, EKG, titrasi, nutrisi
enteral dan parenteral, lab
khusus, penggunaan alat
portabel, fisioterapi dada
terapi O2, pemasangan hemodialisis
CVC, EKG, titrasi, nutrisi intermitten dan
enteral dan parenteral, lab kontinyu
khusus, penggunaan alat
portabel, fisioterapi dada

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)

• Gerakan bola mata /gerakan okular:

a. 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