STRATEGI PELAKSANAAN PEMERIKSAAN ENDOSCOPY

Inisial pasien                : Ny. S

Umur                           : 52 tahun

Pertemuan                   : 1

A.    Proses Keperawatan

1.    Kondisi pasien                                  

Data Subjektif            : Klien mengeluh perut kembung, mual, nyeri ulu hati, dan sendawa berkali-kali.

Data Objektif             : Klien tampak pucat, lemas dan kadang meringis.

Riwayat Kesehatan    : Klien sudah dua kali dirawat dan pernah di USG sebelumnya dengan keluhan yang sama. Dokter penanggungjawab menganjurkan untuk Endoscopy.

2.    Diagnosa

ü Medis                     : Dyspepsia

ü        Keperawatan          : Kurangnya pengetahuan : tentang endoscopy b/d kurang informasi

3.    Tujuan           

ü  Untuk melihat kelainan-kelainan pada Saluran Cerna Atas (mulut, esofagus, lambung, usus halus / 12 jari).

ü  Untuk melakukan tindakan langsung seperti Pengambilan Jaringan / Biopsi pada bagian yang sakit (tumor, polip atau kelainan yang dicurigai) sehingga pengobatan dapat lebih cepat.

4.    Tindakan                               

Menjelaskan pemeriksaan endoscopy

B.     Strategi Pelaksanaan

1.      Fase Orientasi

a)      Salam Terapeutik

“Selamat pagi, Ibu Sim Kwi Lang. Perkenalkan bu, saya suster Ola. Saya perawat shift pagi yang dinas di ruangan ini. Ibu akan bertemu dengan saya dari pukul 07.00-14.00 WIB nanti. Sebelumnya maaf, Ibu senangnya dipanggil apa? Oh, Ibu lebih senang dipanggil oma. Baiklah, Oma..”

b)     Evaluasi / Validasi

“Bagaimana perasaan Oma saat ini? Apakah sudah merasa lebih baik dari sebelumnya?”

c)      Kontrak

Ø  Topik

“Tadi dokter sudah melihat keadaan Oma, Oma disarankan untuk endoscopy. Apakah Oma sudah pernah diendoscopy sebelumnya? Bagaimana kalau pagi ini kita mengobrol tentang apa itu endoscopy dan bagaimana prosedurnya?!”

Ø  Waktu

“Mungkin waktu yang kita butuhkan + 15 menit ya, Oma..”

Ø  Tempat

“Oma maunya kita berbincang-bincang dimana? Bagaimana kalau disini saja?Saya bantu memperbaiki posisi Oma ya..”

d)     Tujuan

Ø  “Oma, tujuan kita berbincang-bincang ini adalah supaya Oma mengerti tentang pemeriksaan endoscopy beserta prosedurnya, sehingga Oma tidak bingung nanti bila dilakukan tindakan endoscopy.”

Ø  “Apakah Oma bersedia? Baiklah Oma, saya akan menjelaskan tentang pemeriksaan endoscopy.”

2.      Fase Kerja

ü  Endoscopy yaitu suatu pemeriksaan dengan menggunakan alat seukuran tebal jari telunjuk dan sangat lentur untuk melihat kelainan-kelainan pada saluran cerna atas Oma secara langsung. Alat ini mempunyai kamera kecil, jadi nanti Oma bisa melihat langsung saluran cerna Oma melalui layar monitor.

ü  Dengan endoscopy, juga dapat dilakukan tindakan langsung seperti pengambilan jaringan pada bagian yang sakit, sehingga pengobatan dapat lebih cepat.

ü  Pemeriksaan endoscopy dilakukan bila ditemukan keluhan seperti :

·         Pucat (Anemia / kurang darah)

·         Rasa kembung, mual, nyeri ulu hati, sendawa (dyspepsia) yang berkepanjangan

·         Muntah-muntah tanpa sebab yang terus-menerus

·         Kesulitan menelan

·         Muntah darah atau buang air besar kehitaman

·         Tertelan benda asing

·         Dugaan adanya tumor di saluran cerna atas

·         Perdarahan, dilihat dari pemeriksaan X-Ray

“Nah, keluhan yang Oma rasakan juga ada disini, bukan? Inilah alasan mengapa dokter menganjurkan Oma untuk diendoscopy.”

“Apakah Oma sudah mengerti apa itu endoscopy? Kenapa Oma harus diendoscopy? Bagus sekali ya Oma, Oma sudah mengerti tentang endoscopy, berarti nanti tidak bingung lagi apabila diendoscopy”

ü  Sebelum Oma diendoscopy, kita akan melakukan persiapan terlebih dahulu, diantaranya :

·         Oma puasa, tidak boleh makan dan minum selama 6-8 jam sebelum tindakan dilakukan. Nanti perawat ruangan akan meletakkan plang PUASA di atas meja yang ada disamping tempat tidur Oma ini sebagai pengingat.

·         Bila Oma mempunyai penyakit kencing manis, tekanan darah tinggi, atau sedang menggunakan obat-obatan tertentu atau mempunyai alergi; diharapkan dapat memberitahukan dokter atau perawat.

·         Oma harus melepaskan gigi palsu, kaca mata, perhiasan dan benda-benda berlogam lainnya.

·         Sebaiknya Oma ditemani oleh keluarga apabila tindakan menggunakan obat penenang.

·         Oma (boleh diwakili keluarga) menyetujui dan menandatangani lembaran persetujuan yang sebelumnya sudah ditandatangani oleh dokter dan petugas administrasi.

ü  Setelah persiapan dilakukan, perawat ruangan akan mengantar Oma ke ruangan endoscopy. Disana sudah ada dokter dan perawat yang menunggu Oma, lengkap dengan persiapan alat endoscopynya.

ü  Sewaktu dilakukan endoscopy :

·         Tenggorokan Oma akan disemprot dengan suatu bius setempat dan menerima obat melalui urat darah halus / vena untuk membantu Oma supaya lebih santai selama dilakukan pemeriksaan.

·         Oma dibaringkan kearah samping dengan posisi yang nyaman, lalu endoscope dimasukkan dengan hati-hati melalui mulut Oma.

ü  Setelah endoscopy dilakukan :

·         Oma harus istirahat sekurang-kurangnya 15-30 menit dan boleh makan seperti biasa setelah 1 jam.

·         Jika Oma diberi obat penenang, sebaiknya ada keluarga yang menunggui Oma selama 24 jam.

·         Tenggorokan Oma akan terasa tidak nyaman selama 1 atau 2 hari.

ü  Dokter akan memberitahukan hasil pemeriksaan kepada Oma setelah tindakan dilakukan tentang apa yang terlihat di bagian saluaran cerna atas Oma. Bila dibutuhkan pengambilan jaringan, hasil akan selesai selama 3-5 hari kerja. Hasil tersebut akan dikirim ke dokter yang merujuk/ mengirimkan.

ü  “Apakah Oma sudah mengerti dengan penjelasan saya tentang pemeriksaan endoscopy?”

  

3.      Fase Terminasi

a)      Evaluasi Subjektif

“Bagaimana perasaan Oma setelah kita berbincang-bincang mengenai pemeriksaan endoscopy tadi?”

b)     Evaluasi Objektif

“Bisakah Oma mengulangi penjelasan saya tentang pemeriksaan endoscopy tersebut? Wah, bagus sekali Oma. Sekarang Oma sudah mengerti apa itu pemeriksaan endoscopy dan bagaimana prosedurnya.”

c)      Rencana tindak lanjut

Ø  Saya sudah mempersiapkan lembaran persetujuan pemeriksaan endoscopy yang akan saya tinggalkan disini. Oma boleh mendiskusikan dengan keluarga untuk persetujuan tindakan. Bila sudah ada keputusan, silahkan menekan Nurse bell. Nanti perawat ruangan akan datang ke kamar Oma. Atau bila ada keluarga, boleh diserahkan langsung ke Nurse Station.

d)     Kontrak selanjutnya

Ø  Baiklah Oma, berhubung waktu kita telah habis, kita cukupkan sampai disini. Besok saya masih shift pagi, bagaimana kalau kita lanjutkan lagi besok dengan Diit Lambung, Oma?

Ø   “Oma bisanya pukul berapa kita lanjutkan besok? Bagaimana kalau pukul 09.00 WIB? Oma maunya dimana? Apakah disini saja?”

Ø  “Baiklah Oma, saya permisi dulu..Oma silahkan istirahat, sampai jumpa besok Oma, selamat pagi…”

NURSING ASSESSMENT AND PROCEDURE

Miss. Fenny Firdaus, 22 years old, Indonesian, female, was administered to Padang Hospital in female internist ward at 08:30 a.m. with complained of dizziness and headache. She said that she has been insomnia for 3 days. The nurse who received her will make a nursing process for her and check her vital sign.

Nurse       : Good morning, Miss. Are you Miss. Feni Firdaus?

Patient      : Yes, I am. Just call me Fe, please.

Nurse       : All right Fe, I’m nurse Nola Asril. You can call me Ola, it’s sound more friendly. I’m the nurse who responsible to care you during your hospital stay. It pleasure to meet you.

Patient      : Nice to meet you too, Ola.

Nurse       : Bye the way, how are you today, Fe? It’s better than before?

Patient      : Well, I’ve got a little bit dizzy.

Nurse       :  I see. Your doctor give you a reffere letter and send you here because you got high blood pressure. So, I want to check your vital sign, Fe. It’s used to notice your health status, beside it’s my routine job.

If  there any changes or abnormal record, I’ll inform the doctor during ward round.

Do you agree and understand, Fe?

Patient      : Yes, I agree with it. What time the doctor  will come?

Nurse       : At 10:00 a.m. Lie down over here and could you please place this termometer on your armpit for 5 minutes, Fe. Now, give me your right hand and roll your sleeve up, I’ll take your blood pressure.

Patient      :  Is everything OK, Ola?

Nurse       :  I haven’t finish yet. Now, give me your right hand, I’ll take your pulse and respiration. Well, it’s done.

Patient      :  How is my vital sign, Ola?

Nurse       :  Well, your blood pressure and pulse is slightly higher than normal, it’s 140/100 mmHg. Did you take or consume anything this morning?

Patient      : As far as I remember there is nothing, Ola.

Nurse       :  Fine, there is nothing to worry about. I’ll inform them to your doctor immediately. He will be here in 1 hour.

                   Do you mind if I ask you few question to complete your registration form?

Patient      : No. I don’t mind. Please go a head.

Nurse       :  Your name is written here Miss. Feni Firdaus. Let me  check the list. How do you spell your complete name, Fe?

Patient      : Sure. My name is Fenny  Firdaus.                                                         F-E-N-N-Y F-I-R-D-A-U-S

Nurse       : OK, Fe. What’s your religion?

Patient      : My religion is Moslem

Nurse       : Where do you live?

Patient      : I live at Jl. Irigasi No. 11c

Nurse       : Tell me your civil state, are you married?

Patient      : No, I’m single

Nurse       : How old are you?

Patient      : I’m 22^nd years old

Nurse       : What is your occupation?

Patient      : I’m a student at Andalas University

Nurse       : When were you born?

Patient      : I was born on 17^th of August 1989

Nurse       : Your place of birth, please?

Patient      : I was born in Sawahlunto

Nurse       : Do you have health insurance, Fe?

Patient      : Yes, I have. ASKES

Nurse       : What is your phone number?

Patient      : 085365665665

Nurse       : Who is your next of kin’s name?

Patient      : Firdaus, my father

Nurse       : Where does he live?

Patient      : He live in Sawahlunto

Nurse       : Have you ever been hospitalized before?

Patient      : Yes, 3 years ago with fever and 5 years ago with tonsil operation.

Nurse       : Do you have any allergic?

Patient      : No, I don’t.

Nurse       : What is your current height and weight?

Patient      : My height is 150cm and my weight is 45kg.

Nurse       : Tell me about your typical day’s menu, please.

Patient      : Dendeng, cornet, pindang fish, sardenes, cheese, butter, bread

Nurse       : Do you have any problems with hearing? Vision?

Patient      : No, I don’t

Nurse       : Do you feel well rested after sleep?

Patient      : Yes, I do. But I’ve got insomnia for 3 days.

Nurse       : What do you do when you are under stress?

Patient      : I’ll meals.

Nurse       : Well, for this time, it’s done.

                   If you have any complain or need something, please press the bell.

Patient      : OK, Ola. I’ll call you latter.

Nurse       : Thank you for your good cooperation Fe.

                   Have a nice day.

Patient      : Welcome, Ola. Have a nice day too.

MANAGEMENT OF MULTIDRUG RESISTANCE TB

Hadiarto Mangunnegoro

Dept of Respiratory Medicine

Faculty of Medicine UI

MDR-TB will become a serious problem to maintain the sustainable success of National TB Program (NTP) in declining TB prevalence in Indonesia. Since the main cause of MDR due to inappropriate medication or treatment failure, obviously the most important strategy for controlling MDR-TB only by curing each TB patients on the first place, because to treat MDR TB patients will be extremely expensive far beyond the patient affordability as well as government capability.

WHO (2003) declared the increasing incidence of MDR TB gradually by 2% per year.

MDR-TB prevalence in developing countries are predicted between 4.6% to 22.2% .

Preliminary data from the first drug-resistance survey in Java suggests low rates of MDR-TB in new cases (1-2%), but elevated rates of MDR-TB in NTP patients reporting previous treatment (15%). Limited and unrepresentative hospital data (2006) show the reality of MDR-TB and XDR-TB, with one third of MDR-TB cases resistant to Ofloxacin and one documented XDR-TB case (among 24 MDR-TB cases). MDR-TB cases in Indonesia do not yet have access to adequate treatment of MDR-TB, as not all relevant drugs are available in the country.

From 2005 to 2007, 3727 total number TB patients in Persahabatan Hospital 554 (15%) patients confirmed as MDR-TB by culture.

The biggest problems lies in private sectors that is private practicing physicians  and most hospitals which are not covered NTP.

Past and current use of second line drugs.

Currently there only two categories of second line drugs avalailable in Indonesia: Kanamycin (KM) and Fluoroquinolones (FQ). Kanamycin is almost exclusively used for TB and short treatment of STI.

The other four categories of second line drugs: Capreomycin, Ethionamide Prothionamid and PAS are not registered in Indonesia. Cycloserine is registered but not avalailable in the market.

Kanamycin and streptomycin were widely used exclusively for treating TB patients before the era of short course therapy Rifampicin containing regiment.

FQs are regarded as the most cost effective drugs for the treatment of MDR-TB, unfortunately the FQs are already being widely used for almost all kind infectious diseases mainly respiratory infections regardless of true or false infections, bringing this class of drugs to rapid resistance including to M tuberculosis in the near future, furthermore it also known to be highly cross resistance with other FQs.

Our previous study (1997) with FQ namely Ofloxacin for the treatment of MDR-TB (58 pts) showed promising even with lower than recommended dosage(400 mg/day) in combination with Pyrazinamide, Ethambutol and Streptomycin for 9-12 months plus 12 months follow up period  with smear conversion up to 72% at the end of therapy, relapse rate 11.2% on 12 months follow up. Those who were resistance with only two drugs (RH) and duration of resistance less than 3 years showed better cure rate (90%) and lower relapse rate than those who were more than two drug resistance (8%) and more than 3 years duration of resistance. The resistance pattern of Oflo for Mtb in that study showed 20% (MIC>2mcg), clearly it should be higher rate by now.

Yew WW et al in retrospective comparison study  effectiveness of Ofloxacin versus Levofloxacin in patients wih  MDR-TB showed that Levo was more effective than oflo by 90 to 79% respectively

Limitation towards successful treatment of MDR-TB patients includes: substandard diagnostics and drug therapy, high cost of therapy, no government support, long duration (24 months), adverse reactions.

Current management of MDR-TB patients will be following WHO Guidelines os DOTS Plus Program.

Conclusions.

The top priority is not how to manage  MDR-TB, but how to prevent MDR-TB.

Controversies in the Management of Acute Severe Asthma

Hadiarto Mangunnegoro

Dept of Respiratory Medicine

Faculty of Medicine University of Indonesia

Acute asthma or acute asthma exacerbation is a very common condition that can be found in emergency department (ED) in most hospitals world wide ranging from mild attacks to nearly fatal, even death can be occurred. In many countries, asthma mortality increased from the 1960s to the second half of the 1980s, due to better management of acute asthma in primary health care and hospitals, a recent downward trend was observed, overall asthma has a low mortality rate compared to other lung diseases. In Persahabatan Hospital only 2.0 % death occurred in hospital admitted patients.

However death still occur typically in patients with poorly controlled disease whose condition gradually deteriorates over a period of days or even weeks before the fatal attack. Infrequently, death occurs suddenly. Accordingly, most deaths are preventable, and a useful practice is to assume that every exacerbation is potentially fatal

The majority of deaths occur at home, work, or during transport to the hospital as also shown by data from Persahabatan Hospital in which 2.7% ( 6/2209) death on arrival occurred in ED.

There are two different pathogenic scenarios involved in the asthma attack progression, type 1 or slow-onset acute asthma and type 2 or asphyxic or hyperacute asthma. Type 1 characterized predominantly by airway inflammation ^.patients show a progressive (over many hours, days, or even weeks) clinical and functional deterioration prevalence of this type of asthma progression is between 80% and 90% of adults with acute asthma in ED. In the less common asthma progression scenario, bronchospasm is predominant and patients presenting with a sudden-onset asthma attack characterized by rapid development of airway obstruction (< 3 to 6 h after the onset of the attack).

Acute asthma is a medical emergency that must be diagnosed and treated urgently. The assessment of an asthma exacerbation constitutes a process with two different dimensions: (1) a static assessment to determine the severity of attack, and (2) a dynamic assessment to evaluate the response to treatment. Overall, it requires an analysis of several factors.

The severity of asthma exacerbations determines the treatment. The goals of treatment may be summarized as maintenance of adequate arterial oxygen saturation with supplemental oxygen, relieve airflow obstruction with repetitive administration of rapid-acting inhaled bronchodilators (β-agonists and anticholinergics), and reduce airway inflammation and to prevent future relapses with early administration of systemic corticosteroids. Controversies exist among different delivery on drug administration, combination therapy, inhaled versus oral or systemic drugs administration, including the benefit of i.v Mg.³

The patient should be hospitalized if, despite 2 to 3 hours of intensive treatment in the ED he or she still has significant wheezing, accessory muscle use, permanent requirement for oxygen to maintain SpO₂ ≥ 92%, and a persistent reduction in lung function (FEV₁ or PEF ≤ 40% of predicted), in much the same way that the presence of factors indicating high risk of asthma-related would lead to a decision to hospitalize the patient.

Patients with findings of severe airflow obstruction who improve minimally or deteriorate despite therapy should be admitted to an ICU. Clinical markers for this include respiratory distress, high pulse pressure or a falling pulsus in a patient with fatigue, or the patient’s subjective sense of impending respiratory failure. Other indications for ICU admission include respiratory arrest, altered mental status, SpO₂ < 90% despite supplemental oxygen, and a rising PaCO₂ coupled to clinical evidence of non resolution

Many patients admitted to the ICU with acute asthma simply require additional time for the therapies instituted in the ED to be continued and for respiratory function to improve. These patients often require a relatively brief period of time in the ICU; when improvement is clear, they can be discharged to the regular ward.

A few patients will require positive pressure ventilatory support because of progression to respiratory failure in advance of response to treatment or prior to treatment, and these challenging patients require specific ventilator strategies to be employed to optimize outcome.

Among patients sent home from the ED following acute asthma therapy, 17% will have a relapse and PEFR does not predict who will develop this outcome.The rate was slightly higher (21.7% ) in  Persahabatan Hospital .^2,4

Another study from Persahabatan Hospital demonstrated a significant advantage in overall maximal bronchodilator response when repeated high doses nebulized steroid or intravenous steroid combined with b₂ agonist in treatment of acute severe asthma⁵

References

1.        Rodrigo and Rodrigo. Acute Asthma in Adults. A review. Chest 2004;3:s

2.        Emerman CL et al. Prospective Multicenter Study of Relapse Following Treatment for Acute Asthma Among Adult Presenting to the Emergency Department. Chest. 1999; 115:919-927

3.        Fitzgerald M. Clinical Review Extracts from “Clinical Evidence” Acute Asthma”. BMJ 2001;323:841-845

4.        Husain B, Yunus Fet al. Relapse rate post asthma exacerbation treated with oral methyl prednisolon and other related factors. J Respir Indo 2004; 24:52-64

5.        Febrina S, Yunus F. The efficacy of nebulized versus systemic steroid in acute severe asthma. Paper presented at the Asia Pacific Society of Respirology. Kyoto Japan 2007