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!-&'&"6>IDYL,&#B/8>,
The National
Early
Warning
Score
! National Early Warning Score adalah sistem penilaian kumulatif yang menstandarkan penilaian tingkat keparahan penyakit akut
! Alat sederhana
! Sistem Peringatan & Pemicu Warning Sistem
! Digunakan di semua rumah sakit di Irlandia
! Menunjukkan tanda-tanda awal pemburukan
! Skor dihitung dengan menggunakan tanda vital pasien
! Parameter penilaian didasarkan pada parameter ViEWS yang divalidasi untuk pasien medis dan bedah
NEWS Validation for Medical & Surgical Patientsusing ViEWS Parameters
1. Bleyer A.J. et al. (2011). Longitudinal analysis of one million vital signs in patients inacademic medical centre. Resuscitation doi:10.1016/j. Resuscitation, 2011.06.033
2. Kellett J & Kim A. (2011). Validation of an abbreviated VitalpacTM Early Warning Score(ViEWS) in 75,419 consecutive admissions to a Canadian Regional Hospital Resuscitation.doi:10.1016/j.resuscitation.2011.08.022
3. Prytherch D, Smith G, Schmidt P, Featherstone P. (2010). ViEWS – Towards a national earlywarning score for detecting adult inpatient deterioration. Resuscitation. 81(8), 932-7.
4. Mitchell I., McKay H., Van Leuvan C., Berry R., McCutcheon C., Avard B., Slater N., Neeman T.and Lamberth P. (2010). A prospective controlled trial of the effect of amulti-faceted intervention on early recognition and intervention in deteriorating hospital patients.Resuscitation. 81, 658–666.
5. National Institute for Health and Clinical Excellence (NICE), (2010). Acutely ill patients inhospital. Available at: http://www.nice.org.uk/guidance/index
Important Points
SkorDiniPeringatanDinitidakmenggantikanpenilaianklinisyang
kompeten
Ketikastafkhawatirtentangperawatanpasienharusditingkatkandapatditingkatkanterlepasdari
skor
NEWSdilanjutkanskrininguntukSepsissaatada
NEWSdari≥4(atau5jikapasienmenggunakanoksigentambahan)
Dalampersentasekecilpasien,NEWStidakmengidentifikasi
kemerosotandalamkondisipasien
@3&"'#'L_(C8>,36
! 03C3B&+ ,3'M3B36&#*&' [>"*6+>4$#'# 4363"C&+&"(6 -&4&CA! 73,&+&,# 43'C#'L'M& -&' "3B3P&'6#
43'L&,&C&' -&' N#6#>B>L# M&'L$,3'-&6&"#'M&
! 73'L3'&B# -&' ,3'L#'C3"4"3C&6#*&'43'L&,&C&' &^'>",&B
! .3"*>,('#*&6# 638&"& 3N3*C#N -3'L&'>"&'L$M&'L$C34&C -&' 4&-& 6&&C M&'L$C34&C
! 73'L3'&B# -&' ,3'L3B>B& 4&6#3' M&'L$,3,^("(*
! 73,N&6#B#C&6# *3"R& C#, -&B&, C#, ,(BC#$-#6#4B#' -&' ,3'L3,^&'L*&' "3'8&'&,&'&R3,3'
Overall COMPASS© / NEWS Education Programmeincorporates:
• Categorisation of patients’
SEVERITY of illness for EARLY detection of clinical deterioration
• A TRACKING system using the
NEWS based on the patient’s vital
signs
• A definitive plan to ESCALATEcare
• TRIGGERING a swift response i.e.
activation of an early response
appropriate to the level of the score
• The use of a structured
COMMUNICATION tool (ISBAR),
(more information on this later)
Jikaterjadiarrest jantungataupernafasan,aktifkansistemseranganjantung
Beberapapasienmungkinmemerlukanpemeriksaanmedis
segeranamuntidakakanmemicuskortinggi.
Protokolinidiaktifkandenganskor3dalamsatuparameteratau
totalskor3.
MengapakitamemerlukanNationalEarlyWarningScoredanProgramWorkshopini?
Cardiac Arrest Calls in aGeneral Hospital
Gallagher, J. Groarke, J.D. & Courtney, G. (2006) IMJ. 99(6),114-116.
• Retrospective study of cardiac arrest over 24month period (2002-2004)
• Subgroup of 20 patients progress in preceding 24 hours-
• Decline in patients condition evident in45- 75%
• Respiratory rate infrequently recorded
RASIONALDARIINDIKATORNEWS
!"#$%& %'( )#*%+,"'-
B"&#"$ F0'$I0*+(DJ+-0& 3FDK4! K3"6&,&&' #'# ,3'L+#C('L R(,B&+ >*6#L3' M&'L$-#*#"#, *3 R&"#'L&'43"$,3'#C
Jalan napas yang memadai dan kemampuan
untuk melindungi jalan nafas
DO2 tergantung pada:
DO2 tergantung pada:
Effective lung mechanics – neurological and muscular
DO2 tergantung pada:
Berfungsinya jaringan paru-paru
Pasokan darah pulmonal yang cukup
Version 6
DO2 tergantung pada:
Version 6
Chain of Oxygen Delivery
DO2 = (SVxHR) x (Hb) x SaO2 x 1.39)+PaO2 x 0.003
Haemoglobin-Normal Adult range / Concentration
(anaemia: causes)
Chain of Oxygen Delivery
DO2 = (SVxHR) x (HB) x SaO2 x 1.39)+PaO2 x 0.003
(SVxHR) = Cardiac output (CO)
Tergantung pada:
– Kontraktilitas otot jantung
– Pre-load (venous return ke
jantung)
– After-load (resistansi dari ejeksi
ventrikel)
– Heart rate
Airway & Breathing
Decreased oxygen delivery at the tissue level
Anaerobic metabolism
Lactate production
Acidosis
Stimulates respiratory drive
Increases the respiratory rate
C$*L"+ M(N*0"#@$&-
! Points to Note-• Some patients with Chronic Obstructive Pulmonary Disease
(COPD) are “CO2 retainers”, i.e. they do not respond to raised CO2
but do respond to low O2 - high concentrations of O2 may suppresstheir hypoxic drive.
• NB – these patients will also suffer end-organ damage or cardiac arrest if their blood O2 levels fall too low.
• In COPD if PCO2 " 8kPa but hypoxic (PO2 # 8kPa) – DO NOT TURNO2 DOWN
• Don’t rely on machines!
• Stay with the patient – aim to achieve a PaO2 of 8kPa, or SaO2 of90%.
Airway &Breathing
• Peningkatan laju pernafasan dapatterjadi dengan SaO2normal• Pasien meninggal karena hipoksialebih cepat dari pada CO2tinggi• Jika pasien memburuk janganmenghentikan oksigen tambahan saatmengambil AGD
Circulation
O$*/<'"#$%&
• Penurunan TD (Hipotensi) didefinisikan sebagaipenurunan lebih dari 20% dari tekanan darah biasaatau tekanan darah sistolik kurang dari 100 mmHg.
• Hipotensi dapat mencerminkan penurunan curahjantung yang dapat menyebabkan penurunanjumlah oksigen yang sampai ke jaringan
Circulation•Penurunan TDbisa jadi akibat dari:•Penurunan volumedarah intravaskular•Penurunan resistansi pembuluh darahperifer•Berkurangnya kontraktilitas jantung
CirculationPenurunan volume darah intravaskular
◦Curah jantung turun dari volume stroke rendah
◦Volume stroke jatuh menyebabkan takikardia
◦Untuk mempertahankan TD à resistensi perifermeningkat
Hipotensi, tangan dingin & tidak ada gagaljantung - cairan infus
Circulation
•Penurunan resistensi vaskular perifer•Vasodilatasi menyebabkan TDrendah•Vasodilatasi menyebabkan venousreturnrendah•Venousreturnrendah menyebabkan strokevolumerendah
•Hipotensi,tangan hangat:cairan IV
Circulation•Berkurangnya kontraktilitas jantung•Curahjantung turun dari volumestrokerendah•Volumestrokejatuh menyebabkan takikardia•Untuk mempertahankan BP,resistensi perifermeningkat
•Hipotensi,tangan dingin &tanda gagal jantung•Hentikan cairan•Konsultasi ICU/CCU
The Hypotensive Patient•Reduksi di preload (volume loss)
• (e.g. haemorrhage, sepsis, vomiting)
•Reduksi di cardiac contractility (pump failure)
• (e.g. MI, heart failure)
•Reduksi di afterload (vasodilation)
• (e.g. sepsis, overdose)
Hypotension &Organ Perfusion
Cerebralhypoxiaà agitation,confusion
Renalimpairmentà reducedurine
output
Myocardialischaemiaàangina,MI
Gutischaemiaàabdominalpain,
nausea
Peripheralischaemiaàakral
dingin
The Hypotensive Patient
Ø Heart rate and rhythm
Ø Peripheral pulses
Ø Capillary refill
Ø Limb temperature
Ø Central pulses
Ø TD
Ø Urine output
Ø Oxygen saturations
Ø Colour
Ø Chest Auscultation
Ø JVP
Bagaimana Anda menilai efek bolus cairan?
- Perhatian untuk pasien dengan disangka / terdiagnosis
penyakit jantung
Pasien dengan Gangguan Tingkat
Kesadaran
Airway, Breathing, Circulation
Don’t forget the Glucose
• AVPU
• Pupils
• Blood Glucose
Pasien dengan Gangguan Tingkat
KesadaranGlasgow Coma Scale
Patients best response to stimuli out of 15
3 components
• Eye opening
• Best motor response
• Best verbal response
Range 1-4
Range 1-6
Range 1-5
Pasien dengan Gangguan Tingkat
Kesadaran
Glasgow Coma Scale
ü Kaji setelah resusitasi selesai
ü Pantau GCS secara teratur
ü Jika GCS turun> 2 poin, hubungi staf medis
ü Jika GCS berada di bawah 9, hubungi ICU atau
staf anestesi karena intubasi mungkin diperlukan
Hypothermia (Temperature 350C)
Kemungkinan Penyebab
• Sepsis
• Hypoadrenalism, hypopituatism, hypothyroidism
• Aggressive fluid resuscitation
• Exposure to low temperatures (Intra-operatively)
• Neurological (stroke, trauma, tumour)
• Skin disease (burns, dermatitis)
• Drug induced (sedatives)
• Neuromuscular in-sufficiency
Signs and Symptoms
• HR, RR & metabolic rate decreases
• Confusion
• Arrhythmias
• Cardiac Arrest
Urine Output
• Keluaran urin harus lebih besar dari0.5ml/kg/jam• Pencegahan gagal ginjal akut penting• Jangan berikan Forusemide untukkeluaran urin rendah kecuali penyebablainsudah ditemukan dikesampingkan&pasien kelebihan cairan secara klinis
!"#$%&'(#$ )*'&+#*,-.*/,0-1*/#&#$-23+/"-4"#$*#5"#$$(#*6*# 7&*$/*5-
89:"/;*:&<(#'(6 =*:&"# 4">*:* 0*#$-'&4*6 %*5&,?
@%"-)*'&+#*,-A*'&"#'-89:"/;*'&+#-B%*/'-(:":-'%"-C&/>*0D-E/"*'%&#$D-B&/3(,*'&+#D-7&:*9&,&'0D-.F=+:(/"-<CEB7.?-*::"::5"#'-*==/+*3%
Version 6
Respiratory section
Version 6
Blood Pressure section
Version 6
Heart Rate section
Level of Consciousness section
Version 6
Version 6
Temperature section
APAYANGHARUSKITALAKUKAN??
K">C>*>B!6*&B&6#
T)B.5(RC!S(CFC(F5(5!FD!).5C
LATIHANDENGANFORMULIRNEWSVERSIORIGINAL
EDITBAHASAINDONESIA
Latihan dengan NEWS & Obs chart• T - 370C,
• Nadi - 65,
• RR - 22,
• SaO2 - 96%
• BP 130/60
• patient is alert.
Latihan dengan NEWS & ObservationChart
• T- 370C,• Nadi - 65,• RR- 22,• SaO2- 96%,• BP130/60• patientisalert.
• T - 380C ,
• Nadi - 86,
• RR - 30,
• SaO2 - 92%,
• BP 110/60,
• patient is alert.
Latihan dengan NEWS &Observation Chart
• T – 370C,
• Nadi - 65,
• RR - 22,
• SaO2 – 96%,
• BP 130/60,
• patient is alert.
• T – 380C,
• Nadi - 86,
• RR - 30,
• SaO2 - 92%,
• BP 110/60,
• patient is alert.
• T – 380C,
• Nadi - 112,
• RR – 32,
• SaO2 – 92%
• BP 100/60,
• patient is alert.
Responsibilities
BeritahuClinicalNurseManager/NurseinCharge
dan/atautenagamedisyangsesuai.
Tingkatkanfrekuensiobservasisebagaimana
diidentifikasidalamprotokoleskalasi.
ProtokolEskalasidapatditurunkanjikasesuaidandidokumentasikandalamrencanapengelolaan.
JikaAndakhawatir,perawatanpasiendapat
ditingkatkantanpamemperhatikanEarly
WarningScore.
Jikarespontidaksesuaidenganprotokoleskalasi,PerawatyangSedang
bertugasharusmenghubungi
Konsultan/Dokter.
J364>'6#^#B#C#36! K3"C#,^&'L*&' *3^(C(+&' ('C(* *3B(&" -&"#^&'L6&B! K3"C#,^&'L*&' *3&+B#&' 43"6>'#B b$43"&B&C&'M&'L$-#^(C(+*&' ('C(* C"&'64>"C&6# M&'L$&,&'
Communication, ManagementPlans&Teamwork
KOMUNIKASI DENGAN KOMUNIKASI DENGAN
(I)SBAR
2!5)K)$S)JO0$9:<0.)J
2!5)K)$S)JO0$9:<0.)J
2!5)K)$S)JO0$9:<0.)J
2!5)K)$S)JO0$9:<0.)J
!NN38C#P3$8>,,('#8&C#>'1$8>e>43"&C#>'$&'-$C3&,[>"*$+&P3$^33'$#-3'C#N#3-$&6$*3M$-3C3",#'&'C6$>N$4&C#3'C$
6&N3CM/$
.3"*>'C"#^(6#$('C(*$36*&B&6#$,&'&R3,3'$M&'L$3N3*C#N$-&'$,3'#'L*&C*&'$4&6#3'$6&N3CM$-&'$-#"3*>,3'-&6#*&'$>B3+$\>"B-$S3&BC+$_"L&'#h&C#>'$9\S_<$-&'$C+3$O2$5&C#>'&B$S3&BC+$03"P#83
0.)J$90#C(&C#>'1$.&8*L">('-1$)66366,3'C$&'-$J38>,,3'-&C#>'<$&-&B&+ ,3C>-3 C3"6C"(*C(" ('C(*,3'L*>,('#*&6#*&' #'N>",&6# M&'L$,3,3"B(*&' 43"+&C#&' -&' C#'-&*&'63L3"&/
PERSIAPAN SEBELUM
MELAKUKAN KOMUNIKASI
Sebutkan nama dan bangsal anda
0&M& 43"&[&C !"# %&'(&" -&"#.&'L6&B i
Saya menelepon tentang pasien
5&,&$4&6#3' 9.3R><$-3'L&'-#&L'>6& 4>6C$43"-&"&+&' &^->,3'0&&C #'# 4&6#3' ,3'L&C&*&' 'M3"#-&-&$^3"&C -#$-&-&$*#"# -&' 63,&*#'^3"&C
Pasien saat ini:
(R-A-B-C-D-E)R = Kesadaran Somnolen,
A = Airway spontan,
B =Nafas spontan, RR 24x/menit, SpO2 92%,
C = Nadi 110 x/menit, TD 100/65 mmHg, RR 24 x/menit, Suhu 36.5 C,
D = GCS 10 Nyeri skala 8,
Pasien tadi mengalami
! penurunan kesadaran
! Nafas cepat dan dangkal
! Saturasinya mulai menurun
! Tekanan darah mulai menurun
! Nilai NEWS ada yang 3
Saya rasa pasien saat ini
mengalami
5M3"#$-&-&$*&"3'&$R&'C('LMasalah pasien saat ini adalah
Q&'LL(&'$4&-&$R&'C('L'M&Saya tidak yakin namun pasien
sedang ke arah perburukan, kita
harus melakukan sesuatu
Saya rasa kita harus
J3*&,$!2Q$EV$@3&-2>'6(B$:;;O;3*$@&^$('C(*$43'#'L*&C&'$3'h#,$R&'C('L
Apakah ada pengobatan yang akan
diberikan?
Setelah terapi diberikan/tindakan
dilakukan
)4&*&+$6&M&$B&4>"$B&L#$*3$&'-&j.3"&4&$R&,$B&L#$6&M&$+&"(6$B&4>"j
0.)J$*#'# C3B&+ -#&-&4C&6# >B3+ ^&'M&* >"L&'#6&6# 63^&L&# *3"&'L*& *3"R&('C(* 83*B#6C *343"&[&C&' ('C(* ,3,(-&+*&' 43'L&B#+&' C&'LL('L R&[&^
4&6#3' -&"# 43"&[&C M&'L$*3B(&" 6+#NC$*3 M&'L$,&6(* 6+#NC/
@&4>"&' -&' 43'LL('&&' *>,('#*&6# 6C&'-&" 6343"C# 0.)J$,3,3'(+# ^&'M&*?(R(&' 2363B&,&C&' K&6#3'1$^3",&'N&&C ^&L# 4&6#3' -&' *3B(&"L&1$-&'
,3'LL('&*&' 6(,^3" -&M& ,#'#,&B$('C(* ,3'3"&4*&' 43"(^&+&' C3"63^(C/
ADAPERTANYAAN??
REFERENSI
De Meester, K., Verspuy, M., Monsieurs, K. G., & Van Bogaert, P. (2013). SBARimproves nurse–physician communication and reduces unexpected death: a pre andpost intervention study. Resuscitation, 84(9), 1192-1196.Doyle, M. (2006). Promoting standardized nursing language using an electronicmedical record system. AORN journal, 83(6), 1335-1342.Novak, K., & Fairchild, R. (2012). Bedside reporting and SBAR: Improving patientcommunication and satisfaction. Journal of pediatric nursing, 27(6), 760-762.Ramasubbu, B., Stewart, E., & Spiritoso, R. (2016). Introduction of the identification,situation, background, assessment, recommendations tool to improve the quality ofinformation transfer during medical handover in intensive care. Journal of the IntensiveCare Society, 1751143716660982.Raymond, M., & Harrison, M. C. (2014). The structured communication tool SBAR(Situation, Background, Assessment and Recommendation) improves communicationin neonatology. SAMJ: South African Medical Journal, 104(12), 850-852.Woodhall, L. J., Vertacnik, L., & McLaughlin, M. (2008). Implementation of the SBARcommunication technique in a tertiary center. Journal of Emergency Nursing, 34(4),314-317.
REFERENSI
Beyea, S. C. (1999). Standardized language—Making nursing practice count. AORN journal,70(5), 831-838.Jenerette, C., & Brewer, C. (2011). Situation, background, assessment, and recommendation(SBAR) may benefit individuals who frequent emergency departments: Adults with sickle celldisease. Journal of Emergency Nursing, 37(6), 559-561.Lisbeth Blom MSc, R., Pia Petersson PhD, R. N., Peter Hagell PhD, R. N., & Albert WestergrenPhD, R. N. (2015). The Situation, Background, Assessment and Recommendation (SBAR) Modelfor Communication between Health Care Professionals: A Clinical Intervention Pilot Study.International Journal of Caring Sciences, 8(3), 530.McCormick, K. A., Lang, N., Zielstorff, R., Milholland, D. K., Saba, V., & Jacox, A. (1994). Towardstandard classification schemes for nursing language: recommendations of the American NursesAssociation Steering Committee on Databases to Support Clinical Nursing Practice. Journal ofthe American Medical Informatics Association, 1(6), 421-427.Martin, H. A., & Ciurzynski, S. M. (2015). Situation, Background, Assessment, andRecommendation–Guided Huddles Improve Communication and Teamwork in the EmergencyDepartment. Journal of Emergency Nursing, 41(6), 484-488.Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice.OJIN: The Online Journal of Issues in Nursing, 13(1), 243-50.Tews, M. C., Liu, J. M., & Treat, R. (2012). Situation-background-assessment-recommendation(SBAR) and emergency medicine residents' learning of case presentation skills. Journal ofgraduate medical education, 4(3), 370-373.
