4. 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
5. NEWS Validation for Medical & Surgical Patients
using ViEWS Parameters
1. Bleyer A.J. et al. (2011). Longitudinal analysis of one million vital signs in patients in
academic 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 early
warning 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 a
multi-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 in
hospital. Available at: http://www.nice.org.uk/guidance/index
11. Cardiac Arrest Calls in a
General Hospital
Gallagher, J. Groarke, J.D. & Courtney, G. (2006)
IMJ. 99(6),114-116.
• Retrospective study of cardiac arrest over 24
month period (2002-2004)
• Subgroup of 20 patients progress in
preceding 24 hours-
• Decline in patients condition evident in
45- 75%
• Respiratory rate infrequently recorded
19. Chain of Oxygen Delivery
DO2 = (SVxHR) x (Hb) x SaO2 x 1.39)+PaO2 x 0.003
Haemoglobin-
Normal Adult range / Concentration
(anaemia: causes)
20. 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
21. Airway & Breathing
Decreased oxygen delivery at the tissue level
Anaerobic metabolism
Lactate production
Acidosis
Stimulates respiratory drive
Increases the respiratory rate
22. 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 suppress
their 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 TURN
O2 DOWN
• Don’t rely on machines!
• Stay with the patient – aim to achieve a PaO2 of 8kPa, or SaO2 of
90%.
23. Airway & Breathing
• Peningkatan laju pernafasan dapat
terjadi dengan SaO2 normal
• Pasien meninggal karena hipoksia
lebih cepat dari pada CO2 tinggi
• Jika pasien memburuk jangan
menghentikan oksigen tambahan saat
mengambil AGD
25. O$*/<'"#$%&
• Penurunan TD (Hipotensi) didefinisikan sebagai
penurunan lebih dari 20% dari tekanan darah biasa
atau tekanan darah sistolik kurang dari 100 mmHg.
• Hipotensi dapat mencerminkan penurunan curah
jantung yang dapat menyebabkan penurunan
jumlah oksigen yang sampai ke jaringan
26. Circulation
•Penurunan TD bisa jadi akibat dari:
•Penurunan volume darah intravaskular
•Penurunan resistansi pembuluh darah
perifer
•Berkurangnya kontraktilitas jantung
27. Circulation
Penurunan volume darah intravaskular
◦Curah jantung turun dari volume stroke rendah
◦Volume stroke jatuh menyebabkan takikardia
◦Untuk mempertahankan TD à resistensi perifer
meningkat
Hipotensi, tangan dingin & tidak ada gagal
jantung - cairan infus
28. Circulation
•Penurunan resistensi vaskular perifer
•Vasodilatasi menyebabkan TD rendah
•Vasodilatasi menyebabkan venous return rendah
•Venous return rendah menyebabkan stroke volume
rendah
•Hipotensi, tangan hangat: cairan IV
29. Circulation
•Berkurangnya kontraktilitas jantung
•Curah jantung turun dari volume stroke rendah
•Volume stroke jatuh menyebabkan takikardia
•Untuk mempertahankan BP, resistensi perifer
meningkat
•Hipotensi, tangan dingin & tanda gagal jantung
•Hentikan cairan
•Konsultasi ICU / CCU
30. 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)
31. Hypotension & Organ Perfusion
Cerebral hypoxia
à agitation,
confusion
Renal impairment
à reduced urine
output
Myocardial
ischaemia à
angina, MI
Gut ischaemia à
abdominal pain,
nausea
Peripheral
ischaemia àakral
dingin
32. 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
33. Pasien dengan Gangguan Tingkat
Kesadaran
Airway, Breathing, Circulation
Don’t forget the Glucose
• AVPU
• Pupils
• Blood Glucose
34. Pasien dengan Gangguan Tingkat
Kesadaran
Glasgow 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
35. 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
37. Urine Output
• Keluaran urin harus lebih besar dari
0.5ml / kg / jam
• Pencegahan gagal ginjal akut penting
• Jangan berikan Forusemide untuk
keluaran urin rendah kecuali penyebab
lain sudah ditemukan dikesampingkan
& pasien kelebihan cairan secara klinis
72. 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,
73. Pasien tadi mengalami
! penurunan kesadaran
! Nafas cepat dan dangkal
! Saturasinya mulai menurun
! Tekanan darah mulai menurun
! Nilai NEWS ada yang 3
74. Saya rasa pasien saat ini
mengalami
5M3"#$-&-&$*&"3'&$R&'C('L
Masalah pasien saat ini adalah
Q&'LL(&'$4&-&$R&'C('L'M&
Saya tidak yakin namun pasien
sedang ke arah perburukan, kita
harus melakukan sesuatu
75. 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
80. REFERENSI
De Meester, K., Verspuy, M., Monsieurs, K. G., & Van Bogaert, P. (2013). SBAR
improves nurse–physician communication and reduces unexpected death: a pre and
post intervention study. Resuscitation, 84(9), 1192-1196.
Doyle, M. (2006). Promoting standardized nursing language using an electronic
medical record system. AORN journal, 83(6), 1335-1342.
Novak, K., & Fairchild, R. (2012). Bedside reporting and SBAR: Improving patient
communication 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 of
information transfer during medical handover in intensive care. Journal of the Intensive
Care Society, 1751143716660982.
Raymond, M., & Harrison, M. C. (2014). The structured communication tool SBAR
(Situation, Background, Assessment and Recommendation) improves communication
in neonatology. SAMJ: South African Medical Journal, 104(12), 850-852.
Woodhall, L. J., Vertacnik, L., & McLaughlin, M. (2008). Implementation of the SBAR
communication technique in a tertiary center. Journal of Emergency Nursing, 34(4),
314-317.
81. 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 cell
disease. Journal of Emergency 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 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). Toward
standard classification schemes for nursing language: recommendations of the American Nurses
Association Steering Committee on Databases to Support Clinical Nursing Practice. Journal of
the American Medical Informatics 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 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 of
graduate medical education, 4(3), 370-373.