EVIDENCE BASED NURSING dgn PENDEKATAN PICOT SBG
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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 Address E-mail : Prof. Dr. Nursalam, M.Nurs (Hons) 081339650000 : Jl. Keputih Tegal Timur 62 Surabaya 60111 : [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 KEMAMPUAN KERJA UMUM DITETAPKAN DALAM SNPT TERCANTUM DALAM DESKRIPSI UMUM KKNI KEMAMPUAN KERJA KHUSUS DITETAPKAN MENTERI ATAS USUL FORUM PRODI 9 8 7 6 5 DITETAPKAN MENTERI ATAS USUL FORUM PRODI SESUAI RUMPUN ILMU SEBAGIAN DITETAPKAN DLM SNPT SEBAGIAN DIUSULKAN FORUM PRODI Pelatihan Preceptorship_2014 4 3 2 1 5 [email protected] Konsep rumusan capaian pembelajaran minimal lulusan program studi 1. 2. 3. 4. 5. Sikap dan Tata nilai Kemampuan kerja umum Kemampuan kerja khusus Penguasaan pengetahuan 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 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 How to achieve? “BPIS” PATIENT-CENTRED CARE & PATIENT SAFETY (BILA PASIEN ITU SAYA / SAUDARA....) PRINCIPLE OF CARING 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 Everyone’s Responsibility For Every Patient nursalam-2014 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” MARKET DEMANDS 1. 2. 3. 4. 5. 6. PROSPEK PEKERJAAN LULUSAN BEBAN TAMBAHAN PEMERINTAH KELEBIHAN PASOK LULUSAN PERSAINGAN PT PEMANNFAATAN SDM PERGESERAN INTERNAL 19/6/2013 EDUCATION OUTCOME ? EDUCATION PROGRAM JOB OPPORTUNITY (FACULTY) (FACTORY) KURIKULUM-NERS-NURSALAM 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 Center The 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-EE-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 Quality Indicators 1.PATIENT SAFETY 2. SATISFACTION (RATER) 3. SELF CARE 4. ANXIETY 5. COMFORT 6. KNOWLEDGE Standar Akreditasi Rumah Sakit v.2012 I. Kelompok Standar Pelayanan Berfokus pada Pasien Bab 1. Bab 2. Bab 3. Bab 4. Bab 5. Bab 6. Bab 7. Akses ke Pelayanan dan Kontinuitas Pelayanan (APK) Hak Pasien dan Keluarga (HPK) Asesmen Pasien (AP) PFP Pelayanan Pasien (PP) PCC Pelayanan Anestesi dan Bedah (PAB) Manajemen dan Penggunaan Obat (MPO) Pendidikan Pasien dan Keluarga (PPK) II. Kelompok Standar Manajemen Rumah Sakit Bab 1. Bab 2. Bab 3. Bab 4. Bab 5. Bab 6. Peningkatan Mutu dan Keselamatan Pasien (PMKP) Pencegahan dan Pengendalian Infeksi (PPI) Tata Kelola, Kepemimpinan, dan Pengarahan (TKP) Manajemen Fasilitas dan Keselamatan (MFK) Kualifikasi dan Pendidikan Staf (KPS) Manajemen Komunikasi dan Informasi (MKI) 25 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 26 EXAMPLE INDICATOR PERFORMANCE ON QUALITY OF CARE IN NURSING • (SURVEILLANCE) NURSALAM-2004 ER INDICATOR 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 Core Competencies (cont.) Search for evidence Read and understand research • Evaluate the evidence 4 HOW? World Class Healthcare Experience HOW TO? nursalam-2014 How do you expect to get from CURRENT PRACTICE • Where are you now? • Where do you want to be? • Potential Barriers to change? • Possible facilitators to Change? EBP =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 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 nursalam-MASALAH patients every 2 hours? P-I-C-O-T (Nancy M. Heddle, 2006) P Consider: • Gender • Age • Diagnostic category • In patient/outpa tient I Consider: • Dose (low or high) • How to define dose • Platelet type (apheresis, whole blood derived) • Prophylactic and/or therapeutic C O T 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 I - transfusion of a high platelet dose (equivalent to 12 whole blood derived platelet products) T – daily bleeding assessment during the period of thrombocytopenia O – days with bleeding (WHO Grade = 2) C – standard dose platelet transfusion (equivalent to 6 whole blood derived platelets) 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. 2. 3. 4. 5. 5. 6. Diagnosis Diagnosis Banding 7. Pemeriksa an Penunjang Keluhan klasik ditemukan dengan gula darah sewaktu > 200 mg/dl. Pemeriksaan glukosa plasma puasa ≥126 mg/dl dengan keluhan klasik. 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). Pemeriksaan HBA1c ≥ 6,5%, jika dilakukan pada sarana laboratorium yang terstandarisasi dengan baik. ……………………………………………………………………………......................... ………………………………………………………………………………………………. 1. 2. 3. 1. 2. 3. 4. 5. 6. 7. Hiperglikemia reaktif Toleransi glukosa terganggu Toleransi glukosa puasa terganggu Gula darah puasa dan 2 jam post prandial HbA1C Profile lipid pada keadaan puasa (kolesterol total, HDL, LDL, dan trigliserida) Kreatinin serum Urinalisa : proteinuria, keton, sedimen Elektrokardiogram Foto sinar –X dada 1. Terapi 1. 2. 5. Terapi nutrisi medis (diet DM sesuai anjuran ahli gizi) Latihan jasmani aerobic (jalan kaki, bersepeda, jogging, dan renang) secara teratur (3-4 kali seminggu selama kurang lebih 30 menit) 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 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) Kombinasi obat antidiabetik oral dan insulin 1. 2. 3. 4. 5. 6. Promosi Edukasi Edukasi Edukasi Edukasi Edukasi 3. 4. 2. Edukasi 3. Prognosis 4. Tingkat Evidens Tingkat Rekomend asi Penelaah Kritis Indikator Medis Kepustaka an 5. 6. 7. 8. perilaku sehat pola diet DM sesuai anjuran ahli gizi kontrol rutin dan penggunaan obat diabetic secara teratur penyulit akut dan kronik DM deteksi dini kelainan kaki risiko tinggi penyakit penyerta DM Ad vitam : dubia ad bonam/malam Ad sanationam : dubia ad bonam/malam Ad fumgsionam : dubia ad bonam/malam IV C 1. 2. Evaluasi gula darah plasma dan komplikasi 1. Konsensus Pengelolaan dan pencegahan diabetes mellitus di Indonesia, PERKENI, 2011 Panduan pelayanan medik, Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia, 2006 2. Surabaya ………………………………….2015 Ketua Komite Medik .................................... Ketua SMF............................................... ...................................... Direktur RS Universitas Airlangga Surabaya, ....................................................... Contoh: CLINICAL PATHWAYS DIABETES MELITUS Nama Pasien: …………………………………………………… Diagnosis Awal: ………………………………. R. Rawat Aktivitas Pelayanan Diagnosis: Penyakit Utama Penyakit Penyerta Hipertensi Dislipidemia Congective heart failure ……………. Hari Rawat 1 Hari Sakit: … Umur: Berat Badan: Tinggi Badan: Nomor Rekam Medis: ……………… ……………..kg …………..cm ……………………………. Kode ICD 10 : …………………… Rencana rawat : …… hari Tgl/Jam masuk: Tgl/Jam keluar: Lama Rwt Kelas: Tarif/hr (Rp): Biaya (Rp) ………………. ………………. ……... hari …….. …………. …………… 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: … Diabetes Melitus (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) 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 Asessmen Klinis: Pemeriksaan dokter ………….. ………….. Konsultasi Interna Cardio Bedah Syaraf Anestesi Gizi (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) Pemeriksaan Penunjang: Darah rutin GDS (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) GDP/GD2JPP HbA1C Profile lipid, Ureum/Creatinin SGOT/SGPT Serum ekeltrolit Blood gas analysis EKG Ro Thorax ………….. (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) Tindakan: Oksigenasi Pasang IV line Hidrasi cairan Pasang kateter ………….. (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) 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 ………………………….. Nutrisi: (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) Rencana pulang : ………………. Obat oral ……………… ………………. Diet sesuai anjuran gizi ………….. Diet DM 25-30 kcal/kgBB/hari + factor penyesuaian (usia > 40 tahun, status gizi, stress metabolic, hamil) Mobilisasi: Semi fowler Duduk Aktif (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) Hasil (Outcome): Klinis : Penurunan kesadaran Hipertensi Sesak Nyeri dada Hipoglikemia Kaki diabetic (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) (+)/(-) ………….. Pendidikan/Rencana Pemulangan: Perjalanan penyakit dan rencana terapi Penjelasan diet makanan Penjelasan untuk kontrol rutin Varians: (+)/(-) (+)/(-) Diagnosis Akhir: Perawat (PPJP) (+)/(-) (+)/(-) (+)/(-) Kode ICD 10 Jenis Tindakan: Jumlah Biaya ………….. Kode ICD 9 – CM ……………… PPDU: …………… Utama Diabetes Melitus ……….. Pasang infus ………………. PPDS: …………… Penyerta Hipertensi ……….. Oksigenasi ………………. Dislipidemia CHF Ketoasidosis metabolik ……….. ……….. ……….. Pemasangan kateter ……………………………………… ……………………………………… ………………. ………………. ………………. ……………………………………… ………………. ……….. ……….. ……………………………………… ……………………………………… ………………. ………………. ……….. ……………………………………… ………………. ……….. ……………………………………… ………………. ……….. ……….. ……….. ……….. ……………………………………… ……………………………………… ……………………………………… ……………………………………… ………………. ………………. ………………. ………………. Dokter Penanggung Jawab Pasien (DPJP): ............................. Verifikator: ……………… …… Komplikasi Status hiperglikemia hyperosmolar Hipoglikemia Makroangiopati pembuluh darah koroner Makroangiopati pembuluh darah otak Makroangiopati pembuluh darah tepi Nefropati Diabetik Retinopati diabetik Neuropati Kaki diabetik APPLICATION “INFECTION PREVENTION” EXAMPLE – DATA TN. X, 65 THN DX MEDIS Tumor Paru dekstra NY. Y, 58 THN DM tipe 2 TN. A, 50 THN 2. Selulitis + Ulkus cruris + 1. Abses brachialis dextra + DM 2. Pasien TN B, 68 THN TNY C, 38 THN 1. 2. 3. 1. DX KEPERAWATAN Intergritas kulit Nyeri akut Resiko ketidakefektifan pola nafas Ketidakseimbangan nutrisi: kurang dari kebutuhan tubuh Kerusakan integritas kulit PK: Hiperglikemia Kerusakan integritas kulit OMI anteroseptal + DMND III + 1. Penurunan curah jantung DCFC IV + ISK 2. Kelebihan volume cairan & integritas 3. 4. TB Paru + DILI + Dermatitis 1. Atopik 2. 3. kulit PK: Hiperglikemia PK: Hiponatremia Nyeri akut Mual Kerusakan integritas kulit EXAMPLE – 1) RESEARH EVIDENCE & BASED THEORY Pasien Compara sion Intervensi 317 pasien yang terpasang Menggunakan infus dan dirawat di instrumen VIP bangsal rumah sakit pusat di Portugal 139 427 pasien yang terpasang Menggunakan infus dan dirawat di instrumen VIP rumah sakit Italia 12 pasien dengan aritmia di Infusion nursing standards ICU yang menerima of practise / INS aminoderon melalui IV 0 : tanpa sign and syptomp 4 : ada sign and symptomp Outcome Teori 35 orang dari 317 pasien mengalami plebitis Data dikumpulkan selama 6 minggu (30 Januari – 12 Maret 2010) 276 dari pasien mengalami plebitis 317 Data dikumpulkan tahun 2007. Masing-masing diteliti selama 12-96 jam 12 x kejadian Penelitian Incidence and severity of plebitis dari dilakukan selama 6 phlebitis in patients 24x bulan (2009) receiving peripherally pemasangan infused amiodaron infus EXAMPLE – 2) EVIDENCED FROM ASSESSMENT PATIENT & PATIENT VALUES Pasien Ny. K (P/ 57 tahun) DMND + DCFC IV Ny. F (P/ 40 tahun) Gastritis akut DM (40thn) Mobilisasi: bebas Intervensi Comparasion Outcome Teori 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 Tidak ada tanda 01/01/2015 jam plebitis 19.30 WIB penggantian pada hari ke 4, dan kemudian tiap 3 hari The Centers for Disease Control and Prevention menganjurkan penggantian katheter stiap 72-96 jam untuk membatasi potensi infeksi (Darmawan, 2008) 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 Tidak ada tanda 01/01/2015 jam plebitis 12.15 WIB penggantian pada hari ke 3 The Centers for Disease Control and Prevention menganjurkan penggantian katheter stiap 72-96 jam untuk membatasi potensi infeksi (Darmawan, 2008) INTEGRATED NOTES SOR-Source Oriented Record SOURCES / PROFESSI ON TIME dr. A 07.00 Ns. X 08.00 Ns. X 09.00 : : 14.00 Pharmacy Ns. Y 14.30 INTEGRATED NOTES 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= -… nursalam-2014 INTEGRATED NOTES 3) PROFESSIONAL EXPERTISE in Client-Centred Evidence-Based Practice Professional Expertise Clinical Practice Guidelines Clinical Client Decision Evidence Making Research Evidence Re-thinking Professional Expertise in Client-Centred Evidence-Based Practice The Role of Professional Expertise in CCEP Stage 1 Client Evidence C L I E N T 1. Gather and appraise client evidence 2. Identify occupational performance issues Stage 3 Integration of Evidence Stage 4 DecisionMaking 1. Identify problem and research question 1. Establish applicability and appropriateness 1. Discuss evidence with client 2. Gather relevant evidence 2. Determine method 2. Develop collaborative plans for intervention Stage 2 Research Evidence 3. Appraise quality of evidence Collaborative Role Professional Role Professional & Client Research Expertise 3. Identify evaluation criteria Stage 5 Enablement and Evaluation 1. Further assessments as needed 2. Undertake processes for enablement 3. Evaluate outcomes 4. Anticipate outcomes Professional Role Clinical Expertise Collaborative Role Professional & Client Collaborative Role Professional & Client SPECIFIC CONTEXT OF PRACTICE O U T C O M E 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 Meeting client’s needs now and in the future Making good contributions to Patient safety SUSTAIN QUALITY AND PRODUCTIVITY (REMEMBER A-P-I) Building skills and competency of nurses 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.