Materi National Early Warning Score System HIPERCCI 2017

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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

6. Important Points
Skor Dini Peringatan Dini
tidak menggantikan
penilaian klinis yang
kompeten
Ketika staf khawatir
tentang perawatan pasien
harus ditingkatkan dapat
ditingkatkan terlepas dari
skor
NEWS dilanjutkan skrining
untuk Sepsis saat ada
NEWS dari ≥ 4 (atau 5 jika
pasien menggunakan
oksigen tambahan)
Dalam persentase kecil
pasien, NEWS tidak
mengidentifikasi
kemerosotan dalam
kondisi pasien

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8. Overall COMPASS© / NEWS Education Programme
incorporates:
• Categorisation of patients’
SEVERITY of illness for EARLY
detection of clinical deterioration
• A TRACKING system using the
NEWS based on the patient’s vital
signs
• A definitive plan to ESCALATE
care
• TRIGGERING a swift response i.e.
activation of an early response
appropriate to the level of the score
• The use of a structured
COMMUNICATION tool (ISBAR),
(more information on this later)

9. Jika terjadi arrest jantung atau pernafasan,
aktifkan sistem serangan jantung
Beberapa pasien
mungkin memerlukan
pemeriksaan medis
segera namun tidak akan
memicu skor tinggi.
Protokol ini diaktifkan
dengan skor 3 dalam
satu parameter atau
total skor 3.

10. Mengapa kita memerlukan National Early
Warning Score dan Program Workshop ini?

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

12. RASIONAL DARI
INDIKATOR NEWS

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15. Jalan napas yang memadai dan kemampuan
untuk melindungi jalan nafas
DO2 tergantung pada:

16. DO2 tergantung pada:
Effective lung mechanics – neurological and muscular

17. DO2 tergantung pada:
Berfungsinya jaringan paru-paru

18. Pasokan darah pulmonal yang cukup
DO2 tergantung pada:

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

24. Circulation

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• 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

36. Hypothermia (Temperature 350C)
Kemungkinan Penyebab
• Sepsis
• Hypoadrenalism,
hypopituatism, hypothyroidism
• Aggressive fluid resuscitation
• Exposure to low temperatures
(Intra-operatively)
• Neurological (stroke, trauma,
tumour)
• Skin disease (burns,
dermatitis)
• Drug induced (sedatives)
• Neuromuscular in-sufficiency
Signs and Symptoms
• HR, RR & metabolic rate
decreases
• Confusion
• Arrhythmias
• Cardiac Arrest

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

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40. Respiratory section

41. Version 6
Blood Pressure section

42. Version 6
Heart Rate section

43. Level of Consciousness section

44. Version 6
Temperature section

45. APA YANG HARUS
KITA LAKUKAN??

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56. LATIHAN DENGAN FORMULIR
NEWS VERSI ORIGINAL
EDIT BAHASA INDONESIA

57. Latihan dengan NEWS & Obs chart
• T - 370C,
• Nadi - 65,
• RR - 22,
• SaO2 - 96%
• BP 130/60
• patient is alert.

58. Latihan dengan NEWS & Observation
Chart
• T - 370C,
• Nadi - 65,
• RR - 22,
• SaO2 - 96%,
• BP 130/60
• patient is alert.
• T - 380C ,
• Nadi - 86,
• RR - 30,
• SaO2 - 92%,
• BP 110/60,
• patient is alert.

59. Latihan dengan NEWS & Observation Chart
• T – 370C,
• Nadi - 65,
• RR - 22,
• SaO2 – 96%,
• BP 130/60,
• patient is alert.
• T – 380C,
• Nadi - 86,
• RR - 30,
• SaO2 - 92%,
• BP 110/60,
• patient is alert.
• T – 380C,
• Nadi - 112,
• RR – 32,
• SaO2 – 92%
• BP 100/60,
• patient is alert.

60. Responsibilities
Beritahu Clinical Nurse
Manager/Nurse in Charge
dan/atau tenaga medis yang
sesuai.
Tingkatkan frekuensi
observasi sebagaimana
diidentifikasi dalam protokol
eskalasi.
Protokol Eskalasi dapat
diturunkan jika sesuai dan
didokumentasikan dalam
rencana pengelolaan.
Jika Anda khawatir,
perawatan pasien dapat
ditingkatkan tanpa
memperhatikanEarly
Warning Score.
Jika respon tidak sesuai
dengan protokol eskalasi,
Perawat yang Sedang
bertugas harus
menghubungi
Konsultan/Dokter.

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62. Communication, Management
Plans & Teamwork

63. KOMUNIKASI DENGANKOMUNIKASI DENGAN
(I)SBAR

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71. PERSIAPAN SEBELUM
MELAKUKAN KOMUNIKASI

72. Sebutkan nama dan bangsal anda
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Saya menelepon tentang pasien
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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
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79. ADA PERTANYAAN??

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.
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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.