Ns. Reni Sulung Utami, S.Kep., M.

Sc
Adult Nursing Department
PSIK-FK UNDIP

CRITICAL CARE NURSING

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 patientsthat
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)
dll

PRIORITAS MASUK
(KMK no 1778 th 2010)

Prioritas 1

Prioritas 2

Perlu pelayanan pemantauan canggih di ICU

Do everything : post bedah mayor, post bedah jantung, pasca henti jantung,
penyakit dasar jantung-paru

Prioritas 3

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

Kemungkinan sembuh/manfaat perawatan di ICU kecil

Terapi diberikan untuk mengatasi kegawatan akutnya
Do something : Metastase, penyakit jantung dan paru terminal dengan
komplikasi akut.

Pengecualian

Pertimbangan luar biasa dan persetujuan kepala ICU

Sewaktu2
Sewaktu
2 pasien harus dapat dikeluarkan
Contoh:: menolak terapi agresif
Contoh
agresif,, vegetatif permanen
permanen,, mati batang otak

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

patients 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 patients 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 patients 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 lifethreatening 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, overthe-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 Leskes (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
Youll recognize a situation as an ethical

dilemma in the following circumstances:

More than one solution exists. That is, theres no

clear right or wrong way to handle a

situation.
Each solution carries equal weight.
Each solution is ethically defensible.

Thank You