CRITICAL

CARE CONCEPT

SRI SETIYARINI
Departemen Keperawatan Dasar &
Emergensi FKKMK UGM
 Tujuan Pembelajaran

Mahasiswa mampu memahami:

1.  Konsep keperawatan kri:s
2.  Proses keperawatan pada area keperawatan
kri:s
3.  Efek kondisi kri:s terhadap pasien dan
keluarga
 HISTORY of ICU

•  ± 1970: first ICU in Indonesia

•  1980: Intensives – consultant in ICU
•  1985: undergraduate in nursing
•  1980: cri:cal care nursing training
•  ± 2000: Cri:cal care nursing associa:on
 DEFINISI ICU
PERMENKES RI NO. 37 Tahun 2014

Intensive Care Unit, yang selanjutya disingkat

ICU adalah suatu instalasi di rumah sakit dengan
staf yang khusus dan perlengkapan yang khusus
yang ditujukan untuk observasi, perawatan dan
terapi pasien-pasien yang menderita penyakit
akut, cedera atau penyulit- penyulit yang
mengancam nyawa atau potensial mengancam
nyawa dengan prognosis dubia yang diharapkan
masih reversibel.
 SCOPE of ICU

•  ICU SERVICES
•  ADMINISTRATION
•  EDUCATION
•  TRAINING
•  RESEARCH
 ASPEK LEGAL ICU
1.  KEPMENKES RI NO. 1778/MENKES/SK/XII/
2010
2.  KEPUTUSAN DIRJEN BINA UPAYA KESEHATAN
NO. HK.02.04/I/1966/11, Tentang
penyelenggaraan ICU di RS
3.  PERMENKES RI NO. 37 Tahun 2014
Penentuan Kema:an Dan Pemanfaatan
Organ Donor
 ICU STANDARD BUILDING

Pedoman Teknis Bangunan Rumah Sakit, Ruang Perawatan Intensif

Personal space = 12 – 16 m2/bed ISOLATED ROOMS:
Distance of bed to bed = 2 m Door: glass, high minimum 100 cm, nurses can
2 beds = 1 sink watch the pts.
AC, 23 – 250 C, Humidity = 50 – 70% Individual room,16 m2- 20 m2 / room
 ETIKA PELAYANAN PS ICU
•  Autonomy: hak ps unt menentukan apa yg
terbaik bg dirinya
•  Beneficience: kewajiban untuk memberikan
yg terbaik & bermanfaat bg ps
•  Non-Maleficience: TIDAK melakukan hal-hal
yg membahayakan ps
•  JusIce: kewajiban untuk memberikan
pelayanan yg sama bg ps
 RUANG LINGKUP PELAYANAN ICU DI
INDONESIA
1.  Diagnosis dan penatalaksanaan spesifik penyakit-
penyakit akut yang mengancam nyawa dan dapat
menimburkan kema:an.
2.  Memberi bantuan dan mengambil alih fungsi
sekaligus melakukan pelaksanaan spesifik problem
dasar
3.  Pemantauan fungsi vital tubuh dan penatalaksanaan
terhadap komplikasi yang di:mbulkan oleh penyakit
atau iatrigenik
4.  Memberikan bantuan psikologis pada pasien yang
kehidupannya sangat tergantung pada alat/mesin dan
orang lain.
 STANDAR ASUHAN KEPERAWATAN INTENSIF
(DEP KES RI 2006)

•  STANDAR ASUHAN KEPERAWATAN INTENSIF

adalah acuan minimal asuhan keperawatan yang
harus diberikan oleh perawat di Unit/Instalasi Rawat
Intensif

•  ASUHAN KEPERAWATAN INTENSIF
adalah kegiatan praktek keperawatan intensif yg
diberikan pada pasien/keluarga, menggunakan
pendekatan proses keperawatan yg merupakan
metode ilmiah dan panduan dalam memberikan
asuhan keperawatan yg berkualitas guna mengatasi
masalah pasien.
 CRITICAL CARE NURSES (CCN)
•  Specialty cerIficaIon /cer:fied in the
discipline of cri:cal care nursing
•  Cri:cal care nurses rouInely care for paIents
with complex, life-threatening condiIons
•  The overreaching professional goal for the
cri:cal care nurse is to promote opImal
outcomes for the paIents and families who
are being cared for in the complex sehng of
the cri:cal care unit.
 Characteristics of Patients, Clinical Units, and Systems of Concern to Nurses
THE CONCEPT OF HOLISM APPLIED TO CRITICAL
• Participation in decision making—extent to which patient/family engages in decision making
• Stability—the ability to maintain a steady-state equilibrium

CARE NURSING PRACTICE (AACN)

• Resiliency—the capacity to return to a restorative level of functioning using compensatory/coping mechanisms; the
ability to bounce back quickly after an insult
6 P A R T O N E The• Concept of Holism Applied to Critical Care Nursing Practice
Complexity—the intricate entanglement of two or more systems (e.g., body, family, therapies)
• Participation in care—extent to which patient/family engages in aspects of care
• Resource availability— extent of resources (e.g., technical, fiscal, personal, psychological, and social) the
patient/family/community bring to the situation
RACTERIS or course of illness
R E CHA of events
• Predictability—the ability to expect a certainScourse TIC
U S
• Vulnerability—susceptibility to actual or Npotential stressors that may adversely
Cl affect patient outcomes
g ini
in ca
arn l
Nurse Competencies of Concern to Patients, Clinical Units, and Systems
Participation

Ju
Le
• Clinical judgment—clinical reasoning which includes in

dg
clinical decision making, critical thinking, and a global grasp of

of

me
Decision

tor
the situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential

nt
Vulnerability Making Stability
ilita
knowledge and evidence-based guidelines
Fac
• Advocacy and moral agency—working on another’s behalf and representing the concerns of the patient/family and

Adv
nursing staff; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within and

ocacy/
outside the clinical setting.
Clinical Inquiry

• Caring practices—nursing activities that create CRITICALLY

a compassionate, supportive, and therapeutic environment for patien
ILL and preventing unnecessary suffering; includes, but is not

Moral Agenc
and staff, with the aim of promoting comfort
Predictability and healing Resiliency
PATIENT/
limited to, vigilance, engagement, and responsiveness of caregivers, including family and healthcare personnel.
FAMILY
• Collaboration—working with others (e.g., patients, families, healthcare providers) in a way that promotes/encourages
each person’s contributions toward achieving optimal/realistic patient/family goals; involves intradisciplinary and
interdisciplinary work with colleagues and community

y
ity

• Systems thinking— body of knowledge Resource

and tools that allow theComplexity
nurse to manage whatever environmental and system
ers

Ca
Availability
resources exist for the patient/family and staff, within or across healthcare and non-healthcare systems
v

rin
i

Participation
D

• Response to diversity—the sensitivity to recognize, appreciate, and incorporate differences into the provision of care

g
to

in

P
differences may include, but are not limited to, cultural differences, spiritual beliefs, gender, race, ethnicity, lifestyle,
e

ra
ns

Care

c
tic
socioeconomic status, age, and values sp
o es
e
• Clinical inquiry (innovator/evaluator)—the ongoing process of questioning and evaluating practice and providing
R Co
llab
informed practice; creating practice changes through research utilization and experiential learning
inki
ng orat
Systems Th ion
• Facilitator of learning—the ability to facilitate learning for patients/families, nursing staff, other members of the health
team, and community; includes both formal and informal facilitation of learning

F I Characteristics
G U R E 1 - 1 Theofsynergy
Patients,model.
ClinicalSynergy
Units, andresults
Systems of Concern
when to Nurses
the needs and characteristics of a patient, clinical
• Participation
unit, or systemin (blue)
decisionare
making—extent to which
matched with patient/family
a nurse’s engages in(green)
competencies decision making
• Stability—the ability to maintain a steady-state equilibrium
 NURSE CONCERN :
Characteris:c of Pt.'s Clinical Unit & System

•  Par:cipan In Decision
Making
•  Stability
•  Resiliency
•  Complexity
•  Par:cipa:on in Care
•  Resources Availability
•  Predictability
•  Vulnerability
 NURSE CONCERNS:NURSE
COMPETENSY
•  Advocacy & Moral Agency
•  Clinical Judgment
•  Caring prac:ce
•  Collabora:on
•  System Thinking
•  Response to diversity
•  Facilitator of Learning
•  Clinical Inquiry (innova:on)
ASSESSMENT
 CCN INTERVENTIONS
•  Based on EBN
•  Working to cul:vate core nursing competencies (eg,
clinical judgment, advocacy, collabora:on)
•  Standard for working to create and promote a healthy
work environment (HWE)
1.  Skilled Communica:on
2.  True Collabora:on
3.  Effec:ve Decision Making
4.  Appropriate Staffing
5.  Meaningful Recogni:on
6.  Authen:c Leadership

 MINIMUM SKILLS: NURSE
1.  CPR
2.  AIRWAY MANAGEMENT
3.  Terapi Oksigen
4.  Pemantauan EKG
5.  Pacemaker: kegawatan
6.  Penatalaksanaan PN, EN
7.  Peralatan khusus: perfusor, dll
8.  Melakukan tehnik khusus ICU
9.  Pemeriksaan & pembacaan Lab
10.  Bantuan fungsi vital saat
transportasi
 KOLABORASI DI ICU

•  Interdisciplinary
•  Working with others (pts., Fam, health care provider) to promote/
encourage each person contribu:on toward achieving op:mal/
realis:c/pts. ,family Goal
•  Interdisciplinary Work w colleagues & community
these operations, the nurse can start implementing these decisions and evalu-

NURSING PROCES:
ating their outcomes (Bachion, 2009).

THEORICAL FRAMEWORK
Theoretical framework

Assessing

Diagnosing

Planning

Implementing

Evaluating

Fig. 5.2 The nursing process.

3S atau SNL
 SNL: NANDA-I; NOC; NIC
/ . ..
18
,
Camila Takáo Lopes
Shigemi Kamitsuru
T. Heather Herdman

o a
b
Lis
de
e m
g
Definitions and Classification
NURSING DIAGNOSES

m a
f er
E n
de

NURSING
DIAGNOSES
Twelfth Edition
2021–2023

Definitions and Classification

2021–2023
Twelfth Edition

14.12.2020 12:08:24
SNL
 NANDA-I: Taxonomy Ii, Domains &
Classes

Elimi- Percep- Role Coping / Growth /

Health Activity Self- Life Safety /
Nutrition nation / tion / relation- Sexuality Stress Comfort Develop-
promotion / Rest perception principles Protection
Exchange Cognition ship tolerance ment

Health Urinary Post-

Self- Caregiving Sexual Physical
awareness Ingestion function Sleep / Rest Attention trauma Values Infection Growth
concept roles identity comfort
responses

Health Gastroin- Family Environ-

manage- Activity / Self- Sexual Coping Physical Develop-
Digestion testinal Orientation relation- Beliefs mental
ment Exercise esteem function responses injury ment
function ships comfort

Value /
Integu- Energy Role Neuro-
Sensation / Body Re- Belief / Social
Absorption mentary balance perform- behavioral Violence
Perception image production Action con- comfort
function ance stress
gruence

Cardio-
Metabo- Respiratory vascular / Environ-
lism Cognition mental
function Pulmonary
responses hazards

Communi- Defensive
Hydration Self-care cation processes

Thermore-
gulation
 NURSING PROCESS
Contribu:ons:
•  Decrease in the incidence and LOS
•  Diagnosis and treatment become faster
•  Crea:on of a cost effec:veness plan
•  Communica:on Improvement
•  Preven:ng mistakes and unnecessary repe::ons
•  Care for the individual and not only for the
disease
•  Contributes a qualified and individualized care

 NURSING PROCESS
Limita:ons/barriers:
•  Nurse’s lack of knowledge (major problem)
•  Lack of knowledge on compu:ng
•  Originated in the teaching related to the tool
itself

DOCUMENTATION

•  Problem based
documenta:on: Flow
chart, assessment,
progress note,
educa:onal note, etc
•  Mostly paper
documenta:on
•  Partly E-documenta:on
 ROUTINE QUALITY ASSESSMENT &
MONITORING in ICU

•  Assessment ac:vi:es of pa:ents entering the

ICU (Pa:ent scoring)
•  Staff mee:ng (monthly report)
•  Mortality discussion – 3 month
•  Rou:ne report: monthly & every year
•  NURSING CARE EVALUATION - monthly
 PATIENT SAFETY GOALS

The Joint Commission National Patient Safety

Goals

Examples relative to critical care nursing

•  Communication
•  Medication safety
•  Reduce infections
•  Reconcile medications

28
 Harms Targeted for Reduction
•  Adverse drug events
•  Infections
–  Catheter-associated urinary tract infections (CAUTI)
–  Central line–associated bloodstream infections
(CLABSI)
–  Surgical site infections
–  Ventilator-associated pneumonia (VAP)
•  Injuries from falls and immobility
•  Obstetric adverse events
•  Pressure ulcers
•  Venous thromboembolism (VTE)
29
 The Patient’s and Family’s
Experience With Critical Illness

S
content in this chapter, the reader should be able to:
effects of prolonged stress and anxiety and describe measures
an take to minimize the amount of stress and anxiety patients and
bers experience.
e critical care nurse’s role in assisting the family through the crisis.
ategies to promote sleep in critically ill patients.
 PT’S EXPERIENCE IN ICU:
EARLY INITIAL STAGE
PT’S: restrained, suc:oning, chest physiotherapy, NGT,
the inability to communicate and ET

§  Terror
§  Dread C
§  Uncertainty And Facing Imminent Death O
§  Confusing,
M
§  Shaqering And A Feeling Of Emp:ness
§  Death Anxiety F
§  Feelings Of Loss Of Control O
§  Powerless- Ness R
§  Panic And Abandonment T
§  STRESS
§  Fear And Anxiety
 stressors
(neural stimuli) possible behaviors/responses

anxiety, fear
increased mental activity
cognitive appraisal dyspnea
of the stressor hyperventilation
CRF gastric irritation
tremors
pituitary
muscle tension
diaphoresis
restlessness
activates agitation
sympathetic
nervous system
F I G U R E 2 - 1 The stress response. Prolonged stress has
far-reaching physiological effects that hinder the body’s
norepinephrine
ability to heal. CRF, corticotropin releasing factor; ACTH,
adrenocorticotropic hormone.
direct effects
on target
organs

ACTH

H plasma costisol
ACT
adrenal gland and aldosterone

effects contribute to:

no

kidney elevated blood pressure

re
p

decreased urinary output

hi

ep
RED FLAG! It is important to assess patien
n

h ri increased serum glucose

ne
and family members for anxiety. The top five
plasma norepinephrine
and epinephrine
physiological and behavioral indicators of a
effects contributeare
to: agitated behavior, increased blood pres
increased heart rate
increased heart rate, verbalization of anxiet
elevated blood pressure
dilated pupils restlessness.2
angina, palpitations
 KEBUTUHAN PS ICU

Tindakan resusitasi-dukungan hidup untuk

fungsi-fungsi vital : A-B-C-BRAIN-Fungsi ORGAN
LAIN, DIAGNOSIS & TERAPI DEFINITIF
 HUMAN NEEDS IN ICU: BISCITS

•  Biological Rhythm
•  Iden:ty
•  Self-esteem
•  Control And Interdependence
•  Informa:on And
Communica:on
•  Territoriality
•  Spiritual Health, Hope, Meaning
 FAMILY EXPERIENCE
SITUASI ICU à SAKIT YANG TERJADI TIBA-TIBA DAN
PENGALAMAN TRAUMATIC

•  anxiety and depression (69% - 35%)

•  post-trauma:c stress symptoms (± 30%)
•  ke:dakpas:an
•  bergejolaknya emosi
•  keseimbangan antara harapan dan realitas
•  keinginan untuk melindungi dan menjaga pasien sebagai
keluarganya
•  bercampurnya peran pengasuh dan dukungan
•  ke:dakseimbangan antara dukungan dan jaringan sosial
 KEBUTUHAN PSIKOSOSIAL
KELUARGA
•  Mendapat jaminan (harapan terhadap hasil
perawatan)
•  Mendapat informasi perkembangan pasien
•  Mendapat informasi yang jujur dan bisa menerima
keadaan dan hasil perawatan pasien
•  Memiliki akses & dekat dengan pasien
•  Berada dekat pasien saat kondisi kri:s
•  Rasa nyaman
•  Mendapat dukungan sosial (Dukungan: emosional,
penghargaan, instrumental, informasi)

DUKUNGAN
PSIKOSOSIAL DI ICU
 Definisi –Definisi Psikososial

•  PERAWATAN PSIKOSOSIAL: Pendekatan psikologis yang

memberi perha:an pada pasien dan orang dekat
pasien untuk mengekspresikan pikiran, perasaan dan
kekhawa:ran yang berkaitan dengan penyakit mereka,
menilai kebutuhan dan sumber daya individu, dan
memas:kan tersedianya dukungan psikologis dan
emosional
•  DUKUNGAN PSIKOSOSIAL : dukungan yang :dak
menggunakan metode psikososial formal yang
diberikan oleh profesional namun dapat meingkatkan
kesejahteraan, rasa percaya diri dan fungsi sosiaL
 PRINSIP UTAMA MEMBERIKAN
DUKUNGAN PSIKOSOSIAL
1.  PENDENGAR YANG BAIK
2.  Mendukung ungkapan verbal yg dirasakan Ps
3.  Hindari memberikan kata-kata (misal
“semuanya akan baik-baik saja”)
4.  Ha:-ha: dan hindari: merubah pasien, kri:kan
nega:f, sikap menghakimi, ekspresi wajah yang
menunjukan penolakan.
 PRINSIP UTAMA MEMBERIKAN
DUKUNGAN PSIKOSOSIAL

1.  Mengenali dan menghorma: individu,

keinginan personal dan kebutuhan manusia
2.  Memahami sakitnya dan menger: efek-efek
psikologis
3.  gunakan kesempatan untuk mendengarkan
masalah pasien dan Berikan Kasih sayang ,
4.  konseling yang realis
 PENGKAJIAN PSIKOSOSIAL
ASPEK ISI
S - SELF-ESTEEM: melipu: informasi tentang kebersihan, perawatan, kontak mata,
pernyataan tentang diri sendiri dan karakteris:k lain tentang harga diri pasien.
E - (ENERGY) : perubahan :ngkat ak:vitas.
L – (LIFESTYLE) pengaturan hidup, hubungan yang bermakna, pekerjaan, hobi,
pendidikan, dan data lain akan situasi pribadi pasien.
F – (FAMILY): kontak pasien dan dukungan anggota keluarga atau orang pen:ng
lainnya, sumber stress keluarga, peris:wa krisis, coping
P – (PHYSIOLOGIS) berhubungan dengan hasil penilaian fisik.
A – (AFFECT) informasi tentang suasana ha: atau perasaan emosional (bahagia,
gembira, datar, :dak pantas, dan is:lah deskrip:f lainnya).
C – (CULTURE): semua variabel budaya, ras, atau antropologi yang mempengaruhi
gaya hidup, kesehatan mental, agama/spiritual .
I – (INTEREST)
N – (NEEDS)
G – (GOALS)
MANAGING PT’S STRESS & ANXIETY IN
ICU
•  supportive care
–  nutrition
–  oxygenation
–  pain management
–  sedatives
–  Anxiolytics
•  Fostering trust.
•  Providing information
•  Ensuring privacy.
•  Allowing control
PATIENT SOCIAL SUPPRT NEEDS
 INTERVENTION: FAMILY
•  SUPPORT PROGRAM
•  Open Visita:on (more :me to visit)
•  Communica:on
•  Medical Informa:on of pts.
•  Par:cipant in decision making
•  Support for psychosocial
•  CONSULTATION TEAM
ASSISTING THE FAMILY THROUGH THE
CRISIS
Nurse seeks to:
•  Provide A Human, Caring Presence
•  Acknowledge Mul:ple Percep:ons
•  Respect Diversity
•  Value Each Person Within The Context Of The
Family.
Evolu:on in ICU
Terimakasih