aplikasi snl pada pasien kritis - fikes.ummgl.ac.idfikes.ummgl.ac.id/downlot.php?file=1. aplikasi...
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APLIKASISTANDARDIZEDNURSINGLANGUAGE(SNL)PADAPASIENKRITIS
Eri Yanuar Akhmad B.S.,S.Kep.,Ns.,M.N.Sc.(I.C)
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BeberapaPemahaman
Diagnosasebagaiformalitasaskep
Menentukandiagnosa pada klienberdasarkan terapiyangdiberikan
Bahasadiagnosis:sesukahati
Mengangkatmasalahmedismenjadimasalahkeperawatan
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BEBERAPADIAGNOSATERKAITDENGANAIRWAYDANBREATHING
BersihanJalanNafasTidak
Efektif
GangguanVentilasiSpontan
PolaNafasTidakEfektif
DisfungsionalResponWeaning
Ventilator
GangguanPertukaranGas
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BEBERAPADIAGNOSATERKAITDENGANDISABILITY
AcuteConfusion RiskforAcuteConfusion
ChronicConfusion
DecreasedIntracranial
adaptivecapacityNyeri Akut
BEBERAPADIAGNOSATERKAITDENGANEXPOSUREdanEQUIPMENT
• RisikoInfeksi
• RisikoPressureUlcer
• Impairedskinintegrity
• Riskforimpairedskinintegrity
• Impairedtissueintegrity
• Riskforimpairedtissueintegrity
DOKUMENTASI
• S:-----• O:• A:Sputumproduktif,ETT21cmdibibir• B:OnVentilatorSIMVPS15,AGDAsidosis Respiratorik
• C:TD100– 120/70– 80mmHg,WPK<2detik,EKGSR,terpasangIVline• D:GCS10• E:Dekubitus disakrum
• A:• Bersihan jalan nafas tidak efektif• Kerusakan ventilasi spontan• Resiko jatuh• Resiko infeksi• Krusakan integritas kulit
• P:• Suctionberkala• Monitorventilatordan humidifier• Restraintdan monitorsedasi• Kontrol infeksi
KESIMPULAN
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ADAPERTANYAAN??
REFERENSI• De Meester, K., Verspuy, M., Monsieurs, K. G., & Van Bogaert, P. (2013). SBAR improvesnurse–physician communication and reduces unexpected death: a pre and postintervention study. Resuscitation, 84(9), 1192-1196.
• Doyle, M. (2006). Promoting standardized nursing language using an electronic medicalrecord 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 communication inneonatology. 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) maybenefit individuals who frequent emergency departments: Adults with sickle cell disease. Journal ofEmergency Nursing, 37(6), 559-561.
• Lisbeth Blom MSc, R., Pia Petersson PhD, R. N., Peter Hagell PhD, R. N., & Albert Westergren PhD, R. N.(2015). The Situation, Background, Assessment and Recommendation (SBAR) Model for Communicationbetween Health Care Professionals: A Clinical Intervention Pilot Study. International Journal of CaringSciences, 8(3), 530.
• McCormick, K. A., Lang, N., Zielstorff, R., Milholland, D. K., Saba, V., & Jacox, A. (1994). Toward standardclassification schemes for nursing language: recommendations of the American Nurses AssociationSteering Committee on Databases to Support Clinical Nursing Practice. Journal of the American MedicalInformatics Association, 1(6), 421-427.
• Martin, H. A., & Ciurzynski, S. M. (2015). Situation, Background, Assessment, and Recommendation–Guided Huddles Improve Communication and Teamwork in the Emergency Department. Journal ofEmergency Nursing, 41(6), 484-488.
• Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice. OJIN: TheOnline Journal of Issues in Nursing, 13(1), 243-50.
• Tews, M. C., Liu, J. M., & Treat, R. (2012). Situation-background-assessment-recommendation (SBAR) andemergency medicine residents' learning of case presentation skills. Journal of graduate medical education,4(3), 370-373.