MG Enny Mulyatsih, S.
Kep, Ners, Mkep, SpKMB
Magister Keperawatan Spesialis KMB (FIK UI, 2010)
Mahasiswa Program Doktor Keperawatan UNAIR
Courses: Organisasi:
Stroke Care (Perth, 1995) Ketua PP HIPENI
Multiple Schlerosis (Singp, Perth) Pengurus Kolegium KMB
Clinical Training ( Japan, 2015) Pengurus Kongres Perawat bedah Sarah asia
Epilepsy Manag (Thailand, 2019)
Kegiatan Lain: Pekerjaan:
-Nurse Consultant - Stroke Unit - RSCM (2002-2009)
-Lecturer , Clinical Teacher - Kepala Bidang Kep RS Otak (2013-2018)
-Surveyor of KARS - Ketua Komite Keperawatan RS Otak (2020-skg)
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Asuhan Keperawatan Pasien Stroke
Pre & Intra Hospital
Enny Mulyatsih, S.Kep, Ners, Mkep, Sp.KMB
National Brain Centre Hospital
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GLOBAL BURDEN OF STROKE
3rd leading cause of death in the USA and 2nd leading cause of
death worldwide.
More than 795.000 new cases and 200.000 recurrent cases of
stroke occur each year in the USA (AHA 2016)
Stroke kills about 140,000 Americans each year—that's 1 out of
every 20 deaths. Someone in the United States has a stroke every
40 seconds. Every 4 minutes, someone dies of stroke.
Major cause of long-term disability.
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Latar Belakang
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STROKE is
A BRAIN ATTACK!!!
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Sebaran RS yang telah menyediakan fasilitas Terapi Trombolisis
(Angels Indonesia, 2021)
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Data Pasien di Ruang Isolasi
RS Pusat Otak Nasional per 12 Mei 2020
MASA
PANDEMI
??
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Data Pasien di Ruang Isolasi
RS Pusat Otak Nasional per 12 Mei 2020
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Faktor risiko stroke
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KLASIFIKASI
Iskemik (Infak) Perdarahan
Patologi: perdarahan,
penyumbatan/ iskemik
Perjalanan penyakit: TIA, stroke
involusi, stroke komplit
Lokasi: hemisfer, batang otak • Both cause clinically very similar
symptoms but need opposing
Bamford: TACS, PACS, LACS,
treatment from the coagulation
POCS perspective
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MANIFESTASI KLINIS STROKE:
tergantung lokasi dan luas lesi
Penurunan tingkat kesadaran
Ggn penglihatan
Ggn memori Ggn sensori persepsiGangguan
Ggn lapang pandang bicara dan bahasa
Ggn menelan Ggn sensibilitas
Ggn fungsi kandung kemih
Ggn keseimbangan
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STROKE IS A BRAIN ATTACK
Kedaruratan medik
Intervensi dini dpt mengurangi “sequel”
Penanganan yg komprehensif dan terkoordinir dari tim stroke.
Starting with pre-hospital and emergency department care
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Stroke Care Management
❖ Hyperacute phase
❖ Acute Phase
❖ Subacute phase (recovery)
❖ Chronic phase/ adaptation/rehabilitation
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In hyper acute stroke care….
Time is of the utmost importance
“therapeutic window”
Perlu keterlibatan pasien, klg & tim kes
Stroke management protocols: well known,
rehearsed
(trained),easy to follow, should be in place.
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A stroke “Chain of survival”
Detection
Dispatch
Delivery
Door
Data
Decision
Drug
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Detection:
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25 Kampanye informasi publik
HUBUNGI TIM …DAN HAL
PENGENALA SETIAP DETIK EMERGENSI TERSEBUT
N GEJALA BERHARGA UNTUK DAPAT
BERTINDAK MEMBAWA
PERUBAHAN
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STROKE is
A BRAIN ATTACK!!!
60 min = life, Buat setiap detik berharga
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Dispatch & Delivery
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En route…EMS personal should
Covid 19 screening
Obtain time of onset
Time the pt was last seen to be a
normal.
The presence of seizure/ trauma
The pt’s health history
the pt’s medication therapy
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En route…EMS personal should
Elevate HOB 15-30 degree
Check Oxygen saturation
ABCDE
Provide Oxygen 2 L/ mnt
FAST IV line…. Isotonic fluids
Neurological deficit Check blood sugar level
Special intervention Correction if hyperg/
hypoglicemic
NPO/ NBM
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DOOR – Emergency Room
Covid 19 screening
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ACUTE STROKE FAST TRACK
Onset > 24 jam Onset <4,5 jam Onset 4,5 – 24 jam Suspect Sirkulasi Posterior/ Arteri Vertebrobasiler
✓ Lapor dr Jaga Neuro Onsite ✓ Lapor dr Jaga Neuro Onsite
✓Pasang infus 2 lines ✓ Pasang infus 2 lines
✓Ambil sampling darah ✓ Ambil sampling darah
MRI/ MRA Kepala
✓EKG ✓ EKG
✓Timbang BB ✓ Timbang BB
✓ Hubungi Tim Stroke ✓ Hubungi Tim Stroke
CT Scan Otak non kontras - CT Scan Otak non kontras + CTA Stenosis arteri basiler Oklusi arteri
- CTP atau MRI & MRA basiler
Perdarahan Iskemik
Ada stenosis arteri berat Tdak ada stenosis arteri atau
Berikan r-TPA oklusi arteri besar
CTA + CTP
Lihat PPK Stroke Lihat PPK Stroke
Ada stenosis arteri berat
Tidak ada stenosis arteri/
oklusi arteri besar
Hubungi dr Neurointervensi & dr Pertimbangkan tindakan endovasculer/
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Lihat PPK StrokeMulyatsih_2021 Anestesi Mechanical Thrombectomy
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Emergency Dept Evaluation
Time is of the essence of stroke care Neurological
Receive the highest triage priority examination
Rapid assessment & treatment Vital sign
Stroke CP or protocol should be in place GCS
A collaborative team approach
Motor function
Pupil
Other neurological
dysfunction
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Stroke / Brain Attack Team
Nursing
Neurology Glucose & electrolytes
Complete blood cell • CT Scan
Neurosurgery
count • MRI
Radiology
PT/ aPTT • MRA
Pharmacy
Cardiac enzyme • CTA
Clinical laboratory ABG • DSA
Hemostasis
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Phycical examination
Be strategic & directed Level of
toward: consciousness
ABC’s Visual function
Vital signs: especially BP Motor function
Tanda SAH: kaku kuduk, Sensation &
nyeri kepala neglect
Neurologic examination Cerebellar function
language
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Decision
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DRUG……General Management
Goal: speed and efficiency
Supplement O2 if indicated
Monitor blood pressure
Continuous monitoring for cardiac ischemic or AF
Identify & treat hypoglycemia/ hyperglycemia
Avoiding hypotonic and excessive fluids
NBM in the first few hours
Avoid hyperthermia
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Hyperakut phase…..Thrombolitic
The administration of recombinant tissue
plasminogen activator (t-PA) improves
the outcome after stroke when given
very early, and within 4,5 hours of onset
of stroke in carefully selected persons.
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Blood pressure management
Tekanan darah sebaiknya jangan diturunkan kecuali:
Bila sistolik >220 mmHg, Diastolik > 120mmHg (2x
pengukuran) atau MABP >130mmHg – 140mmHg.
Terdapat AMI, gagal jantung/ ginjal akut
Stroke berdarah, tensi dapat diturunkan sedikit (maks. 20%)
Hipotensi harus dilakukan koreksi.
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Neurological Intervention
• DSA
• Mechanical Thrombectomy
• Coiling
• Ballooning
• Stanting
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Acute Phase.. Stroke Unit
Acute intensive care/ Stroke Care Unit
Comprehensive care
Rehabilitation Unit
Askep Stoke/ Enny/ 2019 27/08/2021
43 INTEGRATED COOPERATION MODEL IN STROKE UNIT
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Intervensi Keperawatan....pendekatan tim
Pertemuan Tim minimal
1X/ mgg
Ketua: DPJP
Tujuan meeting :
- membahas pasien baru
- perkembangan pasien,
- discharge planning.
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45 Nursing Assessment
General assessment:
1. Alergic
2. Reason of admission
Neurology assessment
3. Health history
4. Physical examination GCS
5. psycho social Vital Sign
6. Fall risk Pupil
7. Functional Status Motorik function
8. Pain Neurology deficit
9. Screening nutrition psychological& Emosi
10. Edukation need
11. Discharge planning
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Diagnosis Keperawatan
Tidak efektifnya jalan napas Kerusakan mobilisasi fisik
Risiko perubahan perfusi serebral Defisit perawatan diri
Gangguan keseimbangan cairan dan Gangguan psikologis:
elektrolit cemas, takut, marah,
depresi
Perubahan pemasukan nutrisi
Gangguan sensori persepsi
Perubahan eliminasi urin
Gangguan komunikasi
Perubahan eliminasi bowel verbal
Gangguan memori
Hambatan sosial
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The Objectives of nursing care:
1. Maintain cerebral perfusion
2. identification of early signs of increased
intra-cranial pressure
3. Prevent and treat any complication
4. Family support
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48 Maintain cerebral perfusion
Stroke patient with GCS < 8:
must be intubated and • Increased of HOB 30⁰
ventilated • Avoid flexion, extention, or extreme
for airway protection rotation of neck
• Monitor Cervical collars and
Maintain adequate
thracheostomy …. Don’t be tight
oxygenation
• Avoid an extreme hip flexion >90⁰
- PO₂>90mmHg
- SPO₂>95%
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Seizure Prophylaxis
Compression of brain tissue impairs function, which might
result in seizures
Seizure activity ↑ cerebral metabolic rate and tissue
hypoxia leading to cellular death.
Phenytoin Sodium 100 mg (3 times a day)
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50 Maintain normal blood sugar
• Hyperglycaemia ↑ cerebral ischemia (by ↑
osmotic pressure)
• Hypoglycaemia starves neurones of fuel
needed to produce energy.
• Maintain level at 80–120 mg/dl; use continuous
glucose infusion or insulin drip as needed
• Avoid Dextrose 5%
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Nursing Innovation at Stroke Unit
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Early Stimulation & Re-orientation
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Positioning & Mobilisasi dini
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Hoist
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55 Gangguan Menelan (Disfagia)
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Latihan Menelan
Non- Oral Feding
Oral Feeding • NGT
• PEG
• TPN
Enny/ Stroke and Dysphagia 2017 8/27/2021
1. Metode Tidak Langsung (Indirect Methods)
Modifikasi Diet
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~ the effortful swallow
~ the mendelsohn maneuver
~ Latihan kekuatan otot lidah
~ Oral Hygiene
~ Permen Lolipop
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Bladder Training
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Personal Hygiene
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Discharge Planning
Team Meeting
• Waktu: 1X/ mgg
• Ketua: dr Rehabilitasi
• Tujuan meeting :
pasien baru
perkembangan pasien,
dan discharge planning.
Rehabilitasi Stroke/ Enny/ 2019
Discharge planning:
63
• Promoting partnerships
between the cared-for
person, the family and
staff has been
recognised as a
strategy for improving
nursing quality (Brown
et al. 2011).
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Edukasi Care Givers
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Discharge Teaching
• Identifikasi kebutuhan Care Giver
• Buat prioritas.... Maslow
• Kategori kebutuhan:
- Must Know
- Good to know
- Nice to know
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Metode????
• Pertimbangkan:
❖ I hear and I forget
❖ I see and I remember
❖ I do and I understand
Rehabilitasi Stroke/ Enny/ 2019
67 Unit Neurorestorasi sbg Unit Rehabilitasi Pasca Stroke
RS Pusat Otak Nasional Jakarta
Patient and Care Giver Education/ Enny/ 2018
68
Ruang Ketrampilan & Ruang
Makan
Patient and Care Giver Education/ Enny/ 2018
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Gymnasium
Laporan Proper Enny Mulyatsih Diklat PIM III/ 2017 27/08/2021
70 “Taman Mandiri”@Unit
Neurorestorasi
@Hospital @Home
Patient and Care Giver Education/ Enny/ 2018
71
Sistem Transportasi
Rehabilitasi Stroke/ Enny/ 2019
72 RS Pusat Otak Nasional Jakarta
Patient and Care Giver Education/ Enny/ 2018
73
I dedicated to my cousin, the
Ilustrator of my book
Patient and Care Giver Education/ Enny/ 2018
Remember: Time is Brain
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Terima Kasih
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