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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16
 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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17
8

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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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28

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29

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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/
Stroke_Enny
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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42
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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44
Intervensi Keperawatan....pendekatan tim

 Pertemuan Tim minimal

1X/ mgg
 Ketua: DPJP
 Tujuan meeting :
- membahas pasien baru
- perkembangan pasien,
- discharge planning.

Askep Stoke/ Enny/ 2019 27/08/2021

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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46
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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47
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

Askep Stoke/ Enny/ 2019 27/08/2021

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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49

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)

Askep Stoke/ Enny/ 2019 27/08/2021

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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51
Nursing Innovation at Stroke Unit

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 Early Stimulation & Re-orientation
52

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Positioning & Mobilisasi dini

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53
54

Hoist

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55 Gangguan Menelan (Disfagia)

Rehabilitasi Stroke/ Enny/ 2019

56
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
57

Enny/ Stroke and Dysphagia 2017 8/27/2021

57
58
~ the effortful swallow
~ the mendelsohn maneuver
~ Latihan kekuatan otot lidah
~ Oral Hygiene
~ Permen Lolipop

Enny/ Stroke and Dysphagia 2017 8/27/2021

59
Bladder Training

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60
Personal Hygiene

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61

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62
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).

Rehabilitasi Stroke/ Enny/ 2019

64
Edukasi Care Givers

Rehabilitasi Stroke/ Enny/ 2019

65
Discharge Teaching

• Identifikasi kebutuhan Care Giver

• Buat prioritas.... Maslow
• Kategori kebutuhan:
- Must Know
- Good to know
- Nice to know

Rehabilitasi Stroke/ Enny/ 2019

66

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

69

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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