the practice of indonesian nurses on...
TRANSCRIPT
THE PRACTICE OF INDONESIAN
NURSES ON EVIDENCE BASED
PRACTICE (EBP) TO IMPROVE
QUALITY OF CARE
By:
Professor Nursalam
FACULTY OF NURSING
UNIVERSITAS AIRLANGGA
CURRICULUM VITAE
Name : Prof. Dr. Nursalam, M.Nurs (Hons) 081339650000
Address : Jl. Keputih Tegal Timur 62 Surabaya 60111
E-mail : [email protected]
HIGHER, EDUCATION: 1. Doctor, Model of Nursing Care for HIV-AIDS, Postgraduate Programme,
Airlangga University, 2005
2. Honours Master of Nursing,, University of Wollongong, New South
Wales, Australia, 1997
3. Master of Nursing (Coursework), Univ. Wollongong, NSW, Australia,1996
4. Med. Surgical Nursing, Lambton College, Sarnia Ontario Canada, 1991
5. Diploma III in Nursing, Sutoma Surabaya 1988
ORGANISATION AND WORKING EXPERIENCES : 1. Lecturer and nurse in Diploma III in Nursing, Anesthesia, Ministry of Health, RI Surabaya (1988 – 1997)
2. Lecturer in School of Nursing, Faculty of Medicine / Faculty of Nursing, Airlangga University (since 1998)
3. Vice, Head, School of Nursing, Faculty of Medicine, UA (1999– 2008)
4. Vice Head, PPNI Educatin & Training, East Java Nursing Association (2000 – 2010)
5. Nursing Manager, Airlangga University Hospital (2011-2015)
6. Dean, Faculty of Nursing Airlangga University (2008 – 2010) & (2015 – 2020)
7. Head, AIPNI Regional JAWA TIMUR (2015-2020)
8. Head, PPNI Jawa Timur (2015-2020)
9. Head, Education and Training, DPP PPNI
PUBLICATION : 1. Books = 20
2. Acredited journal & (national & international)= 100
nursalam-2014
OUTLINES
1. INTRODUCTION
2. WHY
3. WHAT
4. HOW
5. CP
6. CONCLUSION
nursalam-2014
1 INTODUCTION?
World Class Healthcare Experience
1
2
3
4
5
7
8
9
6
TERCANTUM DALAM DESKRIPSI UMUM KKNI
SEBAGIAN DITETAPKAN DLM SNPT SEBAGIAN DIUSULKAN FORUM
PRODI
DITETAPKAN MENTERI ATAS USUL FORUM
PRODI SESUAI RUMPUN ILMU
KEMAMPUAN KERJA UMUM DITETAPKAN
DALAM SNPT
KEMAMPUAN KERJA KHUSUS
DITETAPKAN MENTERI ATAS USUL FORUM
PRODI
[email protected] Preceptorship_2014 5
Konsep rumusan capaian pembelajaran minimal lulusan program studi
1. Sikap dan Tata nilai
2. Kemampuan kerja umum
3. Kemampuan kerja khusus
4. Penguasaan pengetahuan
5. Hak, kewenangan dan tanggung jawab
Pelatihan Preceptorship_2014 6
LEVEL 5 KKNI
(lulusan D3)
• Mampu menyelesaikan pekerjaan berlingkup luas, memilih metode yang
sesuai dari beragam pilihan yang sudah maupun belum baku dengan
menganalisis data, serta mampu menunjukkan kinerja dengan mutu dan
kuantitas yang terukur.
• Menguasai konsep teoritis bidang pengetahuan tertentu secara umum, serta
mampu memformulasikan penyelesaian masalah prosedural.
• Mampu mengelola kelompok kerja dan menyusun laporan tertulis secara
komprehensif.
• Bertanggung jawab pada pekerjaan sendiri dan dapat diberi tanggung jawab
atas pencapaian hasil kerja kelompok.
LEVEL 6 KKNI (Sarjana S1 dan D4)
• Mampu memanfaatkan IPTEKS dalam bidang keahliannya, dan
mampu beradaptasi terhadap situasi yang dihadapi dalam
penyelesaian masalah.
• Menguasai konsep teoritis bidang pengetahuan tertentu secara umum
dan konsep teoritis bagian khusus dalam bidang pengetahuan tersebut
secara mendalam, serta mampu memformulasikan penyelesaian
masalah prosedural.
• Mampu mengambil keputusan strategis berdasarkan analisis
informasi dan data, dan memberikan petunjuk dalam memilih
berbagai alternatif solusi.
• Bertanggung jawab pada pekerjaan sendiri dan dapat diberi tanggung
jawab atas pencapaian hasil kerja organisasi.
LEVEL 7 (PENDIDIKAN PROFESI )
• Mampu merencanakan dan mengelola sumberdaya di bawah
tanggung jawabnya, dan mengevaluasi secara komprehensif
kerjanya dengan memanfaatkan IPTEKS untuk menghasilkan
langkah-langkah pengembangan strategis organisasi.
• Mampu memecahkan permasalahan sains, teknologi, dan atau
seni di dalam bidang keilmuannya melalui pendekatan
monodisipliner.
• Mampu melakukan riset dan mengambil keputusan strategis
dengan akuntabilitas dan tanggung jawab penuh atas semua
aspek yang berada di bawah tanggung jawab bidang
keahliannya.
Aims of Health worker
•To promote health
•To prevent illness
•To restore health
•To facilitate coping with disability or death
10 Cs• CARING
• COMMUNICATION
• COLLABORATION
• CONSITENCE
• CAREFULNESS
• COMPASSION
• COURTESY
• COMPETENT
• CONFIDENCE
• COMMITMENT
(BILA PASIEN ITU SAYA / SAUDARA....)
PRINCIPLE OF CARING
PATIENT-CENTRED
CARE & PATIENT SAFETY
“BPIS”
How to achieve?
KARS, 2014
Nursing Responsibilities in Patient-Centered Approaches (Faye Abdellah)
Effective communication between patient and caregiver. Information is accurate, timely and appropriate.
Do everything possible to alleviate patients’ pain and make them feel comfortable.
We provide emotional support and alleviate fears and anxiety.
We involve family and friends in every phase of our patients’ care.
We ensure a smooth transition and continuity from one focus of care to another.
We guarantee every member of our community has access to our care (BPJS / poor / general)
nursalam-2014
PRINCIPLES ..... SHIFTING THE CULTURE OF CARING
nursalam-2014
Everyone’s
Responsibility
For EveryPatient
Everyday
2 WHY?
World Class Healthcare Experience
WHY?
•“It is not enough for students to be smart; we
must teach them to be good’ (Aristotle)
nursalam-2014
ISSUES …..PATIENT
SAFETY
The greatest difficulty in the world is
not for people to accept new ideas,
but to make them forget about old
ideas”
19/6/2013 KURIKULUM-NERS-NURSALAM
JOB
OPPORTUNITYEDUCATION
PROGRAM
EDUCATION
OUTCOME ?
(FACULTY) (FACTORY)
1. PROSPEK PEKERJAAN LULUSAN2. BEBAN TAMBAHAN PEMERINTAH3. KELEBIHAN PASOK LULUSAN4. PERSAINGAN PT5. PEMANNFAATAN SDM6. PERGESERAN INTERNAL
MARKET DEMANDS
Why should we worry
about using Evidence
Supported Treatments?
Why Evidence-Based Practice Now?
•A growing body of scientific knowledge
•Increased interest in consistent application of quality services
•Increased interest in outcomes and accountability by funders
•Because they work !!
Charles Wilson, MSSW, Executive Director of Chadwick CenterThe Sam and Rose Stein Chair on Child Protection
Rady Children’s Hospital-San Diego
Why Evidence-Based Practice
• Fueled by accrediting bodies, professional organizations, third party payers
• Potential to improve quality, reduce variations in care
• Focus on practices that result in best possible outcomes at possibly lower cost
• Provides a way to keep pace with advances
CONT’.. Why Evidence-Based Practice
• Potential to narrow the ‘research-practice gap’:
adoption of research findings into practice can
take as long as 17 years (Balas & Boren)
• Impacted by perception that published research is not relevant to practice
• Provides a means to answer problematic clinical
practice issues
• Potential to improve individual bedside practice; supports/improves clinical decision-making skills
• Bedside nurse as conduit!!
QUALITY PRINCIPLES- “S-T-E-E-E-P”• SAFE: avoiding injuries to patients from the care that is intended to help them
• TIMELY: reducing waits and sometimes harmful delays for both those who receive and those who give care
• EFFECTIVE: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse)
• EFFICIENT: avoiding waste, in particular waste of equipment, supplies, ideas, and energy
• EQUITABLE: FAIR, providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
• PATIENT-CENTERED: providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
“STEEEP” Framework outlined by the Institute of Medicine (“IOM”) 23
1.PATIENT SAFETY2. SATISFACTION (RATER)
3. SELF CARE
4. ANXIETY
5. COMFORT
6. KNOWLEDGE
Quality Indicators
25
I. Kelompok Standar Pelayanan Berfokus pada Pasien
Bab 1. Akses ke Pelayanan dan Kontinuitas Pelayanan (APK)
Bab 2. Hak Pasien dan Keluarga (HPK)
Bab 3. Asesmen Pasien (AP)
Bab 4. Pelayanan Pasien (PP)
Bab 5. Pelayanan Anestesi dan Bedah (PAB)
Bab 6. Manajemen dan Penggunaan Obat (MPO)
Bab 7. Pendidikan Pasien dan Keluarga (PPK)
II. Kelompok Standar Manajemen Rumah Sakit
Bab 1. Peningkatan Mutu dan Keselamatan Pasien (PMKP)
Bab 2. Pencegahan dan Pengendalian Infeksi (PPI)
Bab 3. Tata Kelola, Kepemimpinan, dan Pengarahan (TKP)
Bab 4. Manajemen Fasilitas dan Keselamatan (MFK)
Bab 5. Kualifikasi dan Pendidikan Staf (KPS)
Bab 6. Manajemen Komunikasi dan Informasi (MKI)
Standar Akreditasi Rumah Sakit
v.2012
PFP
PCC
26
III. Sasaran Keselamatan Pasien Rumah Sakit
Sasaran I : Ketepatan identifikasi pasien
Sasaran II : Peningkatan komunikasi yang efektif
Sasaran III : Peningkatan keamanan obat yang perlu diwaspadai (high-alert)
Sasaran lV : Kepastian tepat-lokasi, tepat-prosedur, tepat-pasien operasi
Sasaran V : Pengurangan risiko infeksi terkait pelayanan kesehatan
Sasaran VI : Pengurangan risiko pasien jatuh
IV. Sasaran Milenium Development Goals
Sasaran I : Penurunan Angka Kematian Bayi dan Peningkatan Kesehatan Ibu
Sasaran II : Penurunan Angka Kesakitan HIV/AIDS
Sasaran III : Penurunan Angka Kesakitan TB
EXAMPLEINDICATOR PERFORMANCE ON QUALITY OF CARE IN NURSING (SURVEILLANCE)•
NURSALAM-2004
ERINDICATOR PERFORMANCE
• Angka keterlambatan pelayanan pertama gawat darurat (>5 menit)= 5%
• Angka kegagalan pemasangan infus (>2x)= 5%
• Angka kesalahan transfer pasien= 7%
• Angka kesalahan pengambilan darah= 0%
• Angka kesalahan pemberian obat= 0%
NURSALAM-2004
INSTALASI RAWAT INAP
• Angka kejadian phlebitis = 5%
• Angka kejadian decubitus= 1,5%
• Angka kejadain pasien jatuh= 0%
• Angka kesalahan pemberian obat= 0%
• Tingkat kepuasan pasien terhadap pelayanan keperawatan = >75%
• Angka kesalahan pengambilan darah= 0%
NURSALAM-2004
ICU
• Angka kegagalan pengambilan sampling BGA (>3x)= 10%
• Angka kejadian phlebitis = 5%
• Angka kejadian decubitus = 1,5%
• Angka kejadian pasien jatuh= 0%
• Angka kesalahan pemberian obat= 0%
• Angka kejadian cedera akibat restrain= < 2%
• Angka kejadian terekstubasi = 2%
NURSALAM-2004
KAMAR OPERASI
Insiden kesalahan identifikasi pasien
• Insiden tertinggalnya kain kasa
• Angka terjadinya salah penjadwalan operasi
• Insiden tertinggalnya instrumen
• Angka kesalahan pemberian obat
• Angka kejadian pasien jatuh
• Respon time penyiapan ruangan operasi emergency (<60 menit)
NURSALAM-2004
INSTALASI RAWAT JALAN / POLI
• Angka kesalahan penjadwalan rencana kunjungan
• Angka kesalahan penjadwalan tindakan
• Tingka kepuasan pasien terhadap pelayanan perawat
NURSALAM-2004
3 WHAT?
World Class Healthcare Experience
WHAT?
nursalam-2014
Definition
“Process by which nurse, midwife, others health worker make clinical decisions using best available evidence, clinical expertise, & patient preferences in the context of available resources”(DiCenso, 1998)
What is Evidence-Based Practice
• Builds on process of research use, but more encompassing
•More specific than term ‘best practices’
•Does not foster rigid adherence to standardized guidelines
• Recognizes the role of clinical expertise
• EB practice is a state of mind!
Evidence-Based Practice
Evidence-based practice (EBP) is like a toolbox of methods available to the vocational / practitioner to aid clinical reasoning. The toolbox consists primarily of methods designed to integrate current and best evidence from research studies into the clinical reasoning process.
Tickle-Degnen, 2000
Steps in Evidence Based Practice Process
• Identify a practice issue
• Formulate an answerable question
• Search for best evidence
• Critically evaluate the evidence and clinical relevance
• Make recommendations
• Apply to clinical practice
• Evaluate impact/effectiveness/ outcomes
Levels of Evidence Hierarchy(Stetler et al.)*
• Level I: Meta-analysis of multiple RCTs
(‘gold standard’)
• Level II: Individual RCTs
• Level III: Quasi-experimental
• Level IV: Non-experimental; qualitative
• Level V: Program evaluation; QI; RU; case reports
• Level VI: Opinion of respected authorities
*modified slightly by Padula
What to look for in Practice?• Treatment or intervention protocol that has at least some
scientific, empirical research evidence for its efficacy with its intended target problems and populations.
• Evidence may be based on a variety of research designs.
• Randomized Clinical Trial (RCT)• Controlled studies without randomization• Open trials, pre- post-, or uncontrolled studies• Multiple baseline, single case designs
• The degree to which we are persuaded that the treatment is effective will vary by the quality of empirical support.• Number of RCT’s• Replication by researchers other than the treatment developers• Sampling, sample size used, comparison treatment, effect size
• Various methods have been developed for classifying the level of empirical support enjoyed by treatment approaches.• Should be useful for front-line practitioners
What are Core Competencies?
• Ask: why are we doing this.. what is the evidence?
• Think critically!
• Think out of the box!
• Prioritize and clearly articulate answerable
clinical questions with a focus on outcomes
• Appreciate role of quality improvement activities
• Evaluate practice outcomes
• *Work effectively with others
Search for evidence
• Evaluate the evidence
Core Competencies (cont.)
Read and understand
research
4 HOW?
World Class Healthcare Experience
HOW TO?
nursalam-2014
How do you expect to get fromCURRENT EBP
PRACTICE
• Where are you now?
• Where do you want to be?
• Potential Barriers to change?
• Possible facilitators to Change?
=HOW to get to desired outcomes, EBP
nursalam-MASALAH
Forming A Good Questions: EVIDENCE BASED - PICOT• P = Patient population or disease of interest (age, gender, ethnicity,
with a certain disorder hepatitis)
• I = Intervention or range of interventions of interest (exposure to disease, prognostic factor A, risk behavior)
• C = Comparison, you want to compare the intervention against (no disease, placebo or no intervention, prognostic factor B, absence of risk factor)
• O = Outcome of interest (accuracy of diagnosis, rate of occurrence of adverse outcome)
• T= THOERY / TIMES
nursalam-MASALAH
In (P) immobile acute care patients, what is the effect of (I) turning every 2 hours on (O) prevention of pressure ulcers compared with (C) not turning
patients every 2 hours?
P-I-C-O-T (Nancy M. Heddle, 2006)
P I C O T
Consider:
• Gender
• Age
• Diagnostic
category
• In
patient/outpa
tient
Consider:
• Dose (low or
high)
• How to define
dose
• Platelet type
(apheresis,
whole blood
derived)
• Prophylactic
and/or
therapeutic
Consider:
• Standard
dose or no
platelets
• Platelet type
(apheresis or
therapeutic)
• Prophylactic
and/or
therapeutic
Consider:
• Morbidity or
mortality
• Bleeding (what
severity)
• Post transfusion
platelet count
• Corrected count
increment
• Blood product
use
Consider:
• How frequently to
assess and
document bleeding
• Platelet count
increment at 1 hour
versus 24 hours
• Duration of followup
(i.e., for a
specified period
after each
transfusion or for
total duration of
platelet
dependency
Example Question
Question: In adults with a diagnosis of acute myeloblastic leukemia who are receiving
prophylactic platelet transfusions, does the transfusion of a high platelet dose (equivalent to 12
whole blood derived platelet products), result in fewer days with bleeding during the period of
thrombocytopenia (WHO Grade = 2), compared to a standard dose platelet transfusion(equivalent to 6
whole blood derived platelets) ?
Question: In adults with a diagnosis of acute myeloblastic leukemia who are receiving
prophylactic platelet transfusions, does the transfusion of a high platelet dose (equivalent to 12 whole
blood derived platelet products), result in fewer days with bleeding during the period of
thrombocytopenia (WHO Grade = 2), compared to a standard dose platelet transfusion (equivalent to 6
whole blood derived platelets) ?
P - adults with a diagnosis
of acute myeloblastic
leukemia who are
receiving prophylactic
platelet transfusions
O – days with bleeding
(WHO Grade = 2)
C – standard dose platelet
transfusion (equivalent
to 6 whole blood
derived platelets)
I - transfusion of a high
platelet dose (equivalent to
12 whole blood derived
platelet products)
T – daily bleeding
assessment during the
period of
thrombocytopenia
5 CLINICAL PATHWAY
(CP)?
World Class Healthcare Experience
CLINICAL PATHWAY : - contoh (word)
Sama dengan care pathway, care map, critical pathway,
integrated care pathways, multi disciplinary pathways of care,
pathways of care, collaborative care pathways.
Merupakan langkah secara details apa yg harus dilakukan dlm
kondisi klinis yang terjadi pada pasien, merupakan rencana
kegiatan day to day dari manajemen pasien
Menggunakan pendekatan multidisiplin karena itu dapat
digunakan format yang sama untuk setiap pemberi asuhan/
pelayanan.
LUWI 21 April 2014
dr Luwi - PMKP 4 maret 13 54
Panduan Praktik Klinis
SMF : Penyakit Dalam
RS Universitas Airlangga Surabaya
DIABETES MELITUS
1. Pengertian
(Definisi)
Penyakit metabolik yang ditandai oleh hiperglikemia akibat defek pada :
1. Kerja insulin (resistensi insulin) di hati (peningkatan produksi gula
hepatic) dan di jaringan perifer (otot dan lemak).
2. Sekresi insulin oleh sel beta pancreas
3. Atau keduanya.
Klasifikasi Diabetes Melitus (DM) :
1. DM tipe 1 (destruksi sel beta, umumnya diikuti defisiensi insulin
absolut)
2. DM tipe 2 (umumnya mulai dari resistensi insulin)
3. DM tipe lain (defek genetic pada fungsi sel beta, defek genetic pada
kerja insulin, penyakit eksokrin pancreas, endokrinopati, diindusi obat,
infeksi, bentuk lain immune mediated DM, sindrom genetic lain)
4. DM gestasional
2. Anamnesis Keluhan klasik : poliuria, polidipsia, polifagia, dan penurunan berat badan yang
tidak dapat dijelaskan sebabnya.
Keluhan lain berupa : lemah badan, kesemutan, gatal, mata kabur, dan
disfungsi ereksi pada pria, serta pruritus vulvae pada wanita.
3. Pemeriksa
an Fisik
Tinggi badan, berat badan, tekanan darah, lingkar pinggang
Tanda neuropati.
Mata (visus, lensa mata dan retina).
Gigi mulut.
Keadaan kaki (termasuk rabaan nadi kaki), kulit dan kuku.
4. Kriteria
Diagnosis
1. Keluhan klasik ditemukan dengan gula darah sewaktu > 200 mg/dl.
2. Pemeriksaan glukosa plasma puasa ≥126 mg/dl dengan keluhan klasik.
3. Kadar gula plasma 2 jam pada tes toleransi glukosa oral (TTGO) ≥ 200
mg/dl (TTGO dilakukan dengan standar WHO, menggunakan beban
glukosa yang setara dengan 75 gram glukosa anhidrus yang dilarutkan
dalam air).
4. Pemeriksaan HBA1c ≥ 6,5%, jika dilakukan pada sarana laboratorium
yang terstandarisasi dengan baik.
5. …………………………………………………………………………….........................
5. Diagnosis ……………………………………………………………………………………………….
6. Diagnosis
Banding
1. Hiperglikemia reaktif
2. Toleransi glukosa terganggu
3. Toleransi glukosa puasa terganggu
7. Pemeriksa
an
Penunjang
1. Gula darah puasa dan 2 jam post prandial
2. HbA1C
3. Profile lipid pada keadaan puasa (kolesterol total, HDL, LDL, dan
trigliserida)
4. Kreatinin serum
5. Urinalisa : proteinuria, keton, sedimen
6. Elektrokardiogram
7. Foto sinar –X dada
1. Terapi 1. Terapi nutrisi medis (diet DM sesuai anjuran ahli gizi)
2. Latihan jasmani aerobic (jalan kaki, bersepeda, jogging, dan renang)
secara teratur (3-4 kali seminggu selama kurang lebih 30 menit)
3. Obat hipoglikemik oral
Pemicu sekresi insulin : sulfonylurea dan glinid
Peningkatan sensitivitas terhadap insulin : metformin dan
tiazolidindion.
Penghambat gluconeogenesis (metformin)
Penghambat absorpsi glukosa : penghambat glukosidase alfa.
DPP-IV (enzim dipeptidyl peptidase-IV) inhibitor
4. Insulin
Insulin kerja cepat (rapid acting insulin)
Insulin kerja pendek (short acting insulin)
Insulin kerja menengah (intermediate acting insulin)
Insulin kerja panjang (long acting insulin)
Insulin campuran (premixed insulin)
5. Kombinasi obat antidiabetik oral dan insulin
2. Edukasi 1. Promosi perilaku sehat
2. Edukasi pola diet DM sesuai anjuran ahli gizi
3. Edukasi kontrol rutin dan penggunaan obat diabetic secara teratur
4. Edukasi penyulit akut dan kronik DM
5. Edukasi deteksi dini kelainan kaki risiko tinggi
6. Edukasi penyakit penyerta DM
3. Prognosis Ad vitam : dubia ad bonam/malam Ad sanationam : dubia ad bonam/malam Ad fumgsionam : dubia ad bonam/malam
4. Tingkat
Evidens
IV
5. Tingkat
Rekomend
asi
C
6. Penelaah
Kritis
1.
2.
7. Indikator
Medis
Evaluasi gula darah plasma dan komplikasi
8. Kepustaka
an
1. Konsensus Pengelolaan dan pencegahan diabetes mellitus di Indonesia,
PERKENI, 2011
2. Panduan pelayanan medik, Perhimpunan Dokter Spesialis Penyakit
Dalam Indonesia, 2006
Surabaya ………………………………….2015
Ketua Komite Medik Ketua SMF...............................................
.................................... ......................................
Direktur RS Universitas Airlangga Surabaya,
.......................................................
Contoh: CLINICAL PATHWAYS
DIABETES MELITUS
Nama Pasien: ……………………………………………………
Umur: ………………
Berat Badan: ……………..kg
Tinggi Badan: …………..cm
Nomor Rekam Medis: …………………………….
Diagnosis Awal: ………………………………. Kode ICD 10 : …………………… Rencana rawat : …… hari
Aktivitas Pelayanan R. Rawat
……………. Tgl/Jam masuk: ……………….
Tgl/Jam keluar: ……………….
Lama Rwt ……... hari
Kelas: ……..
Tarif/hr (Rp): ………….
Biaya (Rp) ……………
Hari Rawat 1 Hari Rawat 2 Hari Rawat 3 Hari Rawat 4 Hari Rawat 5 Hari Rawat 6 Hari Sakit: … Hari Sakit: … Hari Sakit: … Hari Sakit: … Hari Sakit: … Hari Sakit: …
Diagnosis:
Penyakit Utama Diabetes Melitus
Penyakit Penyerta Hipertensi Dislipidemia Congective heart failure
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Komplikasi Ketoasidosis metabolik
Status hipergliemia hyperosmolar
Hipoglikemia
Makroangiopati pembuluh darah koroner
Makroangiopati pembuluh darah tepi
Makroangiopati pembuluh darah otak
Retinopati diabetik
Nefropati diabetik
Neuropati
Kaki diabetik
Disfungsi ereksi
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Asessmen Klinis: Pemeriksaan dokter (+)/(-)
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Konsultasi Interna
Cardio
Bedah
Syaraf
Anestesi
Gizi
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…………..
Pemeriksaan Penunjang: Darah rutin
GDS GDP/GD2JPP HbA1C
Profile lipid,
Ureum/Creatinin
SGOT/SGPT
Serum ekeltrolit
Blood gas analysis
EKG
Ro Thorax
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…………..
Tindakan: Oksigenasi
Pasang IV line
Hidrasi cairan
Pasang kateter
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Aff iv line
Aff kateter
…………..
Obat obatan: Drip insulin sesuai algoritme ……. Unit/jam Drip bicnat …..meq dalam NaCl 0,9%500 cc Drip kalium …..meq dalam NaCl 0,9% 500 cc Insulin short acting 3 x … unit sub cutan Insulin long acting 0 – 0 – 0 - … unit subcutan Antihipertensi Statin 1 x …. mg Obat antidiabetik oral D40% bolus …………………………..
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Rencana pulang : Obat oral
………………. ……………… ……………….
Nutrisi: Diet DM 25-30 kcal/kgBB/hari + factor penyesuaian (usia > 40 tahun, status gizi, stress metabolic, hamil)
Diet sesuai anjuran gizi …………..
Mobilisasi: Semi fowler Duduk Aktif
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Hasil (Outcome): Klinis : Penurunan kesadaran Hipertensi Sesak Nyeri dada Hipoglikemia Kaki diabetic
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Pendidikan/Rencana Pemulangan: Perjalanan penyakit dan rencana terapi Penjelasan diet makanan Penjelasan untuk kontrol rutin
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Varians:
Jumlah Biaya ………….. Perawat (PPJP)
………………
Diagnosis Akhir: Kode ICD 10 Jenis Tindakan: Kode ICD 9 – CM
PPDU: ……………
Utama Diabetes Melitus ……….. Pasang infus ……………….
PPDS:
…………… Penyerta Hipertensi ……….. Oksigenasi ……………….
Dokter
Penanggung
Jawab Pasien
(DPJP):
.............................
Dislipidemia ……….. Pemasangan kateter ………………. CHF ……….. ……………………………………… ……………….
Komplikasi Ketoasidosis
metabolik ……….. ……………………………………… ……………….
Status hiperglikemia
hyperosmolar ……………………………………… ……………….
Hipoglikemia ……….. ……………………………………… ………………. Makroangiopati
pembuluh darah
koroner
……….. ……………………………………… ……………….
Verifikator: ……………………
Makroangiopati
pembuluh darah otak ……….. ……………………………………… ……………….
Makroangiopati
pembuluh darah tepi ……….. ……………………………………… ……………….
Nefropati Diabetik ……….. ……………………………………… ………………. Retinopati diabetik ……….. ……………………………………… ………………. Neuropati ……….. ……………………………………… ………………. Kaki diabetik ……….. ……………………………………… ……………….
APPLICATION“INFECTION PREVENTION”
EXAMPLE – DATA
Pasien DX MEDIS DX KEPERAWATAN
TN. X, 65 THN Tumor Paru dekstra 1. Intergritas kulit
2. Nyeri akut
3. Resiko ketidakefektifan pola nafas
NY. Y, 58 THN DM tipe 2 1. Ketidakseimbangan nutrisi: kurang dari
kebutuhan tubuh
2. Kerusakan integritas kulit
TN. A, 50 THN Selulitis + Ulkus cruris +
Abses brachialis dextra + DM
1. PK: Hiperglikemia
2. Kerusakan integritas kulit
TN B, 68 THN OMI anteroseptal + DMND III +
DCFC IV + ISK
1. Penurunan curah jantung
2. Kelebihan volume cairan & integritas
kulit
3. PK: Hiperglikemia
4. PK: HiponatremiaTNY C, 38 THN TB Paru + DILI + Dermatitis
Atopik
1. Nyeri akut
2. Mual
3. Kerusakan integritas kulit
EXAMPLE – 1) RESEARH EVIDENCE & BASED THEORY
Pasien IntervensiCompara
sionOutcome Teori
317 pasien yang terpasang
infus dan dirawat di
bangsal rumah sakit pusat
di Portugal
Menggunakan 139
instrumen VIP
35 orang dari
317 pasien
mengalami
plebitis
Data dikumpulkan
selama 6 minggu (30
Januari – 12 Maret
2010)
427 pasien yang terpasang
infus dan dirawat di
rumah sakit Italia
Menggunakan
instrumen VIP
276 dari 317
pasien
mengalami
plebitis
Data dikumpulkan tahun
2007. Masing-masing
diteliti selama 12-96 jam
12 pasien dengan aritmia di
ICU yang menerima
aminoderon melalui IV
Infusion nursing standards
of practise / INS
0 : tanpa sign and syptomp
4 : ada sign and symptomp
12 x kejadian
plebitis dari
24x
pemasangan
infus
Penelitian
dilakukan selama 6
bulan (2009)
Incidence and severity of
phlebitis in patients
receiving peripherally
infused amiodaron
Pasien Intervensi Comparasion Outcome Teori
Ny. K (P/ 57
tahun)
DMND + DCFC
IV
Penggantian balutan insersi
intravena dengan transparan
dressing
Mobilisasi: bebas
Nutrisi: cukup
Personal Hygiene: baik
IV cath taka no 22
NaCl 0,9 % 500 cc/24 jam
Dopamin 3 mikro/24 jam
stand by
Furosemid 3 x 40 mg
Pemasangan tanggal
01/01/2015 jam
19.30 WIB
penggantian pada
hari ke 4, dan
kemudian tiap 3
hari
Tidak ada tanda
plebitis
The Centers for Disease
Control and Prevention
menganjurkan
penggantian katheter stiap
72-96 jam untuk
membatasi potensi infeksi
(Darmawan, 2008)
Ny. F (P/ 40 tahun)
Gastritis akut DM
(40thn)
Mobilisasi: bebas
Penggantian balutan insersi
intravena dengan transparan
dressing
1.Nutrisi: cukup
2.Personal Hygiene: baik
3.IV taki no 22
4.Antrain 2x 1000 mg
Asering 500 cc /24 jam
Primperan 3 x 10 mg
Pemasangan tanggal
01/01/2015 jam
12.15 WIB
penggantian pada
hari ke 3
Tidak ada tanda
plebitis
The Centers for Disease
Control and Prevention
menganjurkan
penggantian katheter stiap
72-96 jam untuk
membatasi potensi infeksi
(Darmawan, 2008)
EXAMPLE – 2) EVIDENCED FROM ASSESSMENT
PATIENT & PATIENT VALUES
INTEGRATED NOTESSOR-Source Oriented Record
SOURCES /
PROFESSI
ON
TIME INTEGRATED NOTES
dr. A
Ns. X
Ns. X
Pharmacy
07.00
08.00
09.00
:
:
14.00
SOAP
-Chek DL
-IV RL
-…
-Blood sampling
-IV Line on the left hend
- VS= TD: 110/70mmHg, N: 80x/mnt, S: 38,2oC, RR:20x/mnt
-Administering antibiotic IV
S=
B=
A=
R=
Ns. Y 14.30 -… nursalam-2014
INTEGRATED NOTES
Professional Expertise
Clinical Decision Making
Client Evidence
Research Evidence
3) PROFESSIONAL EXPERTISE
in Client-Centred Evidence-Based Practice
Clinical Practice Guidelines
The Role of Professional Expertise in CCEP
C
L
I
E
N
T
Stage 1
Client
Evidence
1. Gather and
appraise client
evidence
2. Identify
occupational
performance
issues
Collaborative
Role
Professional
& Client
Re-thinking Professional Expertise
in Client-Centred Evidence-Based Practice
O
U
T
C
O
M
E
Stage 2
Research
Evidence
1. Identify
problem and
research
question
2. Gather
relevant
evidence
3. Appraise
quality of
evidence
Professional
Role
Research
Expertise
Stage 3
Integration of
Evidence
1. Establish
applicability and
appropriateness
2. Determine
method
3. Identify
evaluation criteria
4. Anticipate outcomes
Professional
Role
Clinical Expertise
Stage 4
Decision-
Making
1. Discuss
evidence with
client
2. Develop
collaborative
plans for
intervention
Collaborative Role
Professional
& Client
Stage 5
Enablement and
Evaluation
1. Further
assessments as
needed
2. Undertake
processes for
enablement
3. Evaluate
outcomes
Collaborative
Role
Professional &
Client
SPECIFIC CONTEXT OF PRACTICE
6. CONCLUSION? 1. EBP IN NURSING PRACTICE IS THE BEST WAY TO MEET
PATIENT NEEDS
2. EBP IS CLINICAL GUIDELINES FOR PROFESSIONAL NURSES AND HEALTH WORKER
3. CONTEXT OF CARING IN EBP: CLINICAL EVIDENCE & PATIENT VALUES; RESEARCH EVIDENCE & THEORY; AND PROFESSIONAL EXPERTISE DECISION MAKING
nursalam-2014
Making good contributions
to Patient safety
SUSTAIN QUALITY
AND PRODUCTIVITY
(REMEMBER
A-P-I)
Building skills and
competency
of nurses
Meeting client’s needs now
and in the future
mtrla/13072010 71
THANK YOU & GOOD LUCK
References
• Baras, E., & Boren, S. (2000). Managing clinical knowledge for
• healthcare improvement (pp. 65-70). Germany: Schattauer Publishing.
• Dee, C., & Stanley, e. (2005). Nurses’ information needs: nurses’ and
• hospital librarians’ perspective. J Hosp Librar, 5(2), 1-13.
• Hallyburton, A., & St. John, B. (2009). Partnering with your library to
• strengthen nursing research. J Nsg Educ, 49(3), 164-167.
• McClure, M., & Hinshaw, A. (2002). Magnet hospital revisited.
• Washington DC: ANA.
• Pravikoff, D., Tanner, A., & Pierce, S. (2005). Readiness of US nurses
• for evidence-based practice. AJN, 105(9), 40-51.
• Rourke, D. (2007). The hospital library as a “Magnet Force”…Med Ref Svcs Quar, 26(3), 47-54.
Sherwill-Navarro, P., & Roth, K. (2007). Magnet hospital/magnetic
• libraries. J Hosp Librar, 7(3), 21-31
• Stetler C. et al. (1998). Evidence-based practice and the role of nursing leadership. JONA, 28(7/8), 45-53.
• Stetler, C. et al. (1998). Utilization-focused integrative reviews. Appl