Saturday, February 10, 2007

Jadi Perawat?... Ogah..ah!!!!



(Tulisan berseri dalam usaha membangun reputasi & persepsi positif bagi profesi)

Oleh :
Siswanto M. Muhammad
(Ketua Umum INNA-Kuwait)

Ada suatu fenomena yang menarik dalam “Ruang Keperawatan Indonesia”, Judul diatas adalah sebuah jawaban yang sering akan kita dapatkan ketika pertanyaan itu akan kita tanyakan kepada masyarakat secara umum.

Mereka akan dengan bangganya menyampaikan jawaban : “YA” ketika mereka di beri tawaran untuk melanjutkan study pada peminatan yang masih di anggap berada pada level yang tinggi di kalangan masayarakat Indonesia seperti : (ekonomi, tekhnik, hukum, kedokteran dsb). Tapi mereka akan mereka akan dengan cepat mengelengkan kepala dengan jawaban ÖGAH-AH”ketika mereka di Tanya tentang kesempatan untuk melanjutkan di peminatan “KEPERAWATAN".

Hal ini terjadi karena adanya suatu pemahaman yang salah dan keliru tentang “Perawat dan Keperawatan”di lingkup masyarakat Indonesia secara umum sehingga mengakibatkan perilaku tidak tertarik untuk menekuni apalagi memilih profesi perawat.

Yang lebih menarik lagi, ketika seorang mahasiswa keperawatan telah memulai suatu proses pembelajaran, ada perasaan penyesalan “Terbersit”dalam hati mereka karena persepsi yang salah tentang profesi “Perawat”itu sendiri. Persepsi keliru itu terjadi karena kesalan informasi yang mereka terima dan kenyataan di lapangan .

Menyesalkah mereka telah memilih Perawat sebagai profesi mereka??? Kalau pertanyaan itu ditanyakan kepada mereka maka dengan tersipu malu mereka akan memberikan jawab : “YA”saya menyesal……..

Mengapa??????

Tentu karena ada suatu kesenjangan antara harapan dan kenyataan awal yang mereka dapatkan, padahal itu semua terjadi karena misinterprestasi terhadap “Profesi perawat” yang akan mereka jalani.

Kondisi ini sangat berbanding terbalik dengan Negara-negara yang secara umum masyarakatnya sudah memahami benar dan tahu persis apa dan bagaimana serta kesempatan apa saja yang akan mereka dapatkan kalau menjadi “Perawat” seperti : Philipines, India, dsb.

Di Negara-negara tersebut bahkan seorang dokter spcialist, arsitek, pengacara, ahli komputer, mereka akan rela meninggalkan profesinya demi untuk jadi seorang perawat karena mereka yakin dengan menjadi perawat mereka akan dapat hidup dengan layak dan dapat bekerja di Negara manapun yang mereka inginkan.
Sekedar untuk berbagi informasi saya punya kawan Perawat yang berasal dari Philipines dan bekerja satu rumah sakit di Kuwait dia mantan seorang dokter specialis kebidanan di Phlipines dan yang bersangkutan rela meningggalkan profesinya dan Kuliah sebagai Perawat karena mereka menyadari benar dengan menjadi seorang Perawat yang bersangkutan dapat memiliki kesempatan untuk bekerja di Negara manapun dia inginkan. Dan itu hanya salah satu contoh, masih banyak cerita yang sama yang saya tidak bias utarakan satu persatu di tulisan saya ini.

Ada beberapa hal yang segera harus kita lakukan agar reputasi dan persepsi masyarakat terhadap perawat semakin positif antara lain :

1. Melakukan distribusi informasi kepada seluruh masyarakat
Sumber informasi seperti televisi, media massa, radio dan sarana sumber informasi lainya belum menjadi alat yang di optimalkan oleh seluruh Perawat Indonesia dalam semua sektor.

Masih sangat jarang kita temui Tulisan-tulisan tentang keperawatan masuk dalam Head line News Surat kabar nasional sebuah berita baik yang bersifat Berita, informasi dsb. Hal ini harusnya mulai disikapi dengan bijaksana terutama oleh para Ahli Keperawatan yang harusnya sudah mulai rajin menulis dan memberikan pembelajaran kepada masyarakat tentang profesi keperawatan dan peran sertanya. Bila semakin banyak para Pakar dan ahli keperawatan yang meluangkan waktu untuk membuat tulisan-tulisan dalam media seperti : Surat Kabar, internet, Televisi, radio, pasti ini akan sangat mendukung kampanye nasional penyebaran informasi positif tentang keperawatan sehingga pemahaman masayarakat tentang perawat dan keperawatan.

Kalangan intelektual keperawatan( seperti : Mahassiwa, dose, parktisi) juga harus mampu bersaing dan tidak terkesan “GAPTEK (gagap tekhnologi)” sehingga kita akan semakin bias berkiprah dalam segala aspek kehidupan bermasayarakat baik secara Politik, Ekonomi, Sosial ataupun dimensi kehidupan bermasayarakat lainnya.

Pepatah “Tak Kenal maka Tak Sayang” tentu masih sangat relevan dengan kondisi ini.

2. Memotivasi secara Psikologis kepada Mahasiswa Keperawatan\
Ada pekerjaan rumah yang besar bagi para perawat yang bekerja di sektor pendidikan (sebagai dosen) bahwa kewajiban mereka bukan hanya menyampaikan materi sesuai capain kurikulum tapi juga memiliki tugas berat dalam rangak membangun keyakinan hidup dan optimisme profesi bagi calon Perawat bahwa mereka dapat hidup lebih mapan secara ekonomi bahkan di banding dengan profesi lain kalau mereka benar-benar menjadi perawat yang professional.

Perlu di tumbuhkan keyakinan pada seluruh mahasiswa di semua program keperawatan bahwa dengan menjadi seorang Perawat kita akan mampu menjelajah dan bekerja diseluruh dunia yang mungkin akan sangat sulit diperoleh oleh profesi lain seperti : Dokter, Arsitek, pengacara, dsb.

3. Menghentikan segala kegiatan Malpraktek
Seluruh Perawat harus secepatnya menyadari bahwa Cakupan dan kewenagan pekerjaan seorang Perawat sangat berbeda dengan dokter, sehingga tidak ada lagi Perawat yang melakukan Praktek Pelayanan Kedokteran. Dalam hal ini organisasi profesi seperti PPNI tentu harus memiliki kontribusi yang lebih konkrit dalam menciptakan aturan dan perundang-undangan dalam rangka menciptakan situasi yang kondusif. Hal ini sangat penting dalam rangka pembelajaran kepada masyarakat bahwa Perawat adalah profesi yang terpisah dan berbeda dari seorang dokter dan memiliki batasan kewenangan yang berbeda. Perawat juga bukan pembantu (asisten) dokter tapi Mitra dalam arti kesetaraan dalam segala aspek.

4. Menciptakan iklim Persaingan dan Penyampain Peluang Pekerjaan
Pearawat tidak seharusnya berkecil hati dengan takut tidak mendapatkan pekerjaan yang layak dan hanya menggantungkan bahwa kesempatan dan peluang kerja pada satu kesempatan (banyak perawat kita yang hanya berharap untuk bias jadi pegawai negero sipil).

Padahal kalau kita menyadari sebenarnya banyak sekali kesempatan dan tawaran kerja di luar negeri seperti :
a. USA
b. Canada
c. United Kingdom (Inggris)
d. Kuwait
e. Saudi Arabia
f. Australia
g. New Zaeland
h. Malaysia
i. Qatar
j. Oman
k. UEA
l. Jepang
m. German
n. Belanda
o. Swiss


Di Negara-negara tersebut gaji perawat bias 5-30 kali lipat gaji pegawai Negeri di Negara Indonesia, tentu tidak mudah untuk bias mencapai itu semuanya tapi bukan sesuatu yang sulit untuk dicapai kalu kita telah mempersiapkan sejak kita masih di bangku kuliah. Untuk bisa bekerja di negara-negara tersebut kita harus melalui beberapa test seperti : NCLEX-RN, IELTS, CGFNS (akan saya bahas dalam tulisan saya selanjutnya)

Apa persiapan-persiapan yang harus kita lakukan untuk dapat mencapai itu semuanya (akan saya bahas dalam tulisan saya berikutnya).

Ketika kwalitas SDM keperawatan sudah meningkat dan berada dalam standarisasi kualitas internasional (Cakap secara teori dan praktek) dan mampu berbahasa internasional seperti (English dan atau Arabic) maka bukan lagi Perawat yang akan mencari pekerjaan tapi Ruimah sakit yang akan mencari mereka. Saat itulah saatnya bicara “Selamat Tingga dan Good Bye” pada rumah sakit atau pemilik lapangan pekerjaan yang menggaji perawat dengan stnadar gaji yang rendah. Bila ditinjau dari hokum Ekonomi kalau kondisi itu sudah tercipta dengan sendirinya tidak akan ada Rumah sakita atau lapangan pekerjaan yang akan menggaji perawat dengan semau-maunya, tidak akan adalagi profesi yang memandang rendah perawat.

Bagaimana…? Masih meyesal menjadi Perawat…Jawabanya tentu sangat tergantung pada posisi mana anda sekarang, Tapi kalau pertanyaan itu di tanyakan kapada saya saya akan menjawab dengan lantang dan tegas : TIDAK, Saya sangat bangga dan bersyukur telah dilahirkan untuk menjadi seorang Perawat, Idealnya seluruh Perawat Indonesia juga akan memberikan jawaban yang sama.

Ada sebuah realita yang menarik yang mungkin akan bias membangkitkan semangat kita semua : bahwa seorang perawat akan bias memiliki keahlian apapun tanpa ada batas pengahalang dan bias berkecimpung dalam keahlian lain .\

Perawat bias jadi ahli Komputer, Entrepreneur, Penulis, Politikus sekalipun tanpa hambatan apapun. Tapi coba kondisi ini di balik : bisakah ahli computer, penulis, politikus, Ekonom, melakuakn praktek keperawatan, Jeals tidak bias karena keahlian keperawatan harus dengan keahlian yang spesifik.

Bagaimana…Banggakah anda menjadi Perawat???

Sampai ketemu dalam Seri tulisan selanjutnya….moga bias membangkitkan semangat.
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Sunday, August 20, 2006

"Cerebral Vascular Accident/Disease (STROKE)"


Definition

Hemorrhagic stroke involves bleeding within the brain, damaging nearby brain tissue.

Causes, incidence, and risk factors
Hemorrhagic stroke occurs when a blood vessel bursts inside the brain. The brain is very sensitive to bleeding and damage can occur very rapidly, either because of the presence of the blood itself, or because the fluid increases pressure on the brain and harms it by pressing it against the skull.Bleeding irritates the brain tissue, causing swelling. The surrounding tissues of the brain resist the expansion of the bleeding, which is finally contained by forming a mass (hematoma). Both swelling and hematomawill compress and displace normal brain tissue.Most often, hemorrhagic stroke is associated with high blood pressure, which stresses the artery walls until they break.

Another cause of hemorrhagic stroke is an aneurysm. This is a weak spot in an artery wall, which balloons out because of the pressure of the blood circulating inside the affected artery. Eventually, it can burst and cause serious harm. The larger the aneurysm is, the more likely it is to burst. It is unclear why people develop aneurysms, but genes may play a role, since aneurysms run in families.Stroke can also be caused by the accumulation of a protein called amyloid within the artery walls, particularly in the elderly. This makes the arteries more prone to bleeding.

Amyloid protein is also implicated in the brain damage related to Alzheimer's disease, but the difference is that people with Alzheimer´s disease have amyloid accumulation in the brain tissue instead of in the arteries. Therefore people with Alzheimer´s usually do not develop brain bleeding.Some people with brain hemorrhage have abnormal connections between arteries and veins. Under normal circumstances, circulating blood travels through the arteries into the capillaries, where it provides nutrients and oxygen to the tissues. Once the blood has deposited the nutrients and oxygen, it is carried back to the heart from the capillaries via the veins.

In some people, however, a brain artery may connect directly to a vein, instead of going through the capillaries first. This is called an arterial-venous malformation (AVM). Since blood pressure in the arteries is much greater than in the veins, the veins may rupture, causing bleeding into the brain.Another important brain disease that can cause bleeding is cancer. This is especially true for cancers that spread to the brain from distant organs, such as the breast, skin, and thyroid.

About 20% of strokes are hemorrhagic -- but the other 80% are caused by the opposite problem: too little blood reaching an area of the brain, which is usually due to a clot that has blocked a blood vessel. This is called "ischemic stroke." This type of stroke can sometimes lead to a brain hemorrhage because the affected brain tissue softens and this can lead to breaking down of small blood vessels.


In addition, brain hemorrhage can occur when people have problems forming blood clots. Clots, which are the body's way of stopping any bleeding, are formed by proteins called coagulation factors and by sticky blood cells called platelets. Whenever the coagulation factors or platelets do not work well or are insufficient in quantity, people may develop a tendency to bleed excessively.


Some medications (often used, ironically, to prevent ischemic stroke) prevent clot formation. These work by blocking the production of clotting factors (such as the blood thinner warfarin) or interfering with the function of platelets (such as aspirin). The most common side effects of such medications is bleeding, which may occasionally affect the brain. Controlling bleeding to avoid stroke is a very fine balancing act.

Illicit drugs, such as cocaine, can also cause hemorrhagic stroke.

Symptoms
  • Stroke symptoms are typically of sudden onset and may quickly become worse. The following is a list of possible problems:

  • Weakness or inability to move a body part

  • Numbness or loss of sensation

  • Decreased or lost vision (may be partial)

  • Speech difficulties

  • Inability to recognize or identify familiar things

  • Sudden headache

  • Vertigo (sensation of the world spinning around)

  • Dizziness

  • Loss of coordination

  • Swallowing difficulties

  • Sleepy, stuporous, lethargic, comatose, or unconscious



Signs and tests
A neurologic exam is almost always abnormal. The patient may look drowsy and confused. An eye examination may show abnormal eye movements, and changes may be seen upon retinal examination (examination of the back of the eye with an instrument called ophthalmoscope). The patient may have abnormal reflexes. However, these findings are not specific to brain hemorrhage.

The most important test to confirm the presence of a brain hemorrhage is a CT scan, which provides pictures of the brain. A CT scan should be obtained without delay. A brain magnetic resonance imaging (MRI) scan can also be obtained later to better understand what caused the bleeding. A conventional angiography (x-ray of the arteries using dye) may be required to identify aneurysms or AVM.

Other tests may include:
  • CBC

  • Bleeding time

  • Prothrombin/partial thromboplastin time (PT/PTT)

  • CSF (cerebrospinal fluid) examination (rarely needed)


Treatment
Treatment includes life-saving measures, relieving symptoms, repairing the cause of the bleeding, preventing complications, and starting rehabilitation as soon as possible. Recovery may occur over time as other areas of the brain take over functioning for the damaged areas.

IMMEDIATE TREATMENT
Treatment is ideally administered in an intensive care unit, where complications can immediately be detected. Medical personnel pay careful attention to breathing because sometimes persons with brain hemorrhage develop very irregular breathing patterns or even stop breathing entirely.

A person having a hemorrhagic stroke may be unable to protect the airway during coughing or sneezing because of impaired consciousness. Saliva or other secretions may go "down the wrong pipe," which is potentially serious and may cause lung problems such as aspiration pneumonia. To treat or prevent these breathing problems, a tube may need to be placed through the mouth into the trachea to start mechanical ventilation.

The blood pressure may be too high or too low in patients with brain hemorrhage. These problems need to be addressed immediately by doctors. In addition, brain bleeding may cause swelling of surrounding brain tissue, and this may require therapy with some drugs called hyperosmotic agents (mannitol, glycerol, and hypertonic saline solutions).

Bedrest may be advised to avoid increasing the pressure in the head (intracranial pressure). This may include avoiding activities such as bending over, lying flat, sudden position changes or similar activities. Stool softeners or laxatives may prevent straining during bowel movements (straining also causes increased intracranial pressure).

Medications may relieve headache but should be used with caution because they may reduce consciousness. This may produce the wrong impression that the patient is getting worse. Antihypertensive medications may be prescribed to moderately reduce high blood pressure. Medications such as phenytoin may be needed to prevent or treat seizures.

Nutrients and fluids may need to be supplemented if swallowing difficulties are present. This can be intravenous or through a feeding tube into the stomach (gastrostomy tube). Swallowing difficulties may be temporary or permanent.

Positioning, range-of-motion exercises, speech therapy, occupational therapy, physical therapy, and other interventions may be advised to prevent complications and promote maximum recovery of function.


SURGERY
Sometimes, surgery is needed to save the patient's life or to improve the chances of recovery. The type of surgery depends upon the specific cause of brain bleeding. For example, a hemorrhage due to an aneurysm requires special treatement (see aneurysm).

For other types of bleeding, removal of the hematoma may occasionally be needed, especially when bleeding occurs in the back of the brain. Some physicians are currently investigating whether the injection of a "clot buster" inside the hematoma can facilitate the removal of brain hemorrhages through needles or catheters, allowing less invasive surgery.

One common problem related to brain bleeding is hydrocephalus, which is the accumulation of a water-like fluid within the brain cavities called ventricles. To solve this problem, the fluid may need to be drained with a special procedurecalled ventriculostomy.

For AVM, different treatments are available, including surgical removal of the AVM network, radiosurgery (using ionizing radiation to reduce the size of the AVM), and intra-arterial embolization (a procedure in which glue is injected into the AVM to close the connection between arteries and veins).

LONG-TERM TREATMENT
Recovery time and the need for long-term treatment are highly variable in each case. Physical therapy may benefit some patients. Activity should be encouraged within the person's physical limitations. Alternative forms of communication such as pictures, verbal cues, demonstration or others may be needed depending on the type and extent of language deficit. Speech therapy, occupational therapy, or other interventions may increase the ability to function.

Urinary catheterization or bladder or bowel control programs may be required to control incontinence.A safe environment must be considered. Some people with stroke appear to have no awareness of their surroundings on the affected side. Others show a marked indifference or lack of judgment, which increases the need for safety precautions.

In-home care, boarding homes, adult day care, or convalescent homes may be required to provide a safe environment, control aggressive or agitated behavior, and meet physiologic needs. Behavior modification may be helpful for some patients in controlling unacceptable or dangerous behaviors. This consists of rewarding appropriate or positive behaviors and ignoring inappropriate behaviors (within the bounds of safety). Reality orientation, with repeated reinforcement of environmental and other cues, may help reduce disorientation.

Family counseling may help in coping with the changes required for home care. Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful. Legal advice may also be appropriate early in the course of the disorder. Advance directives, power of attorney, and other legal actions may make it easier to make ethical decisions regarding the care of the person with hemorrhagic stroke.

Expectations (prognosis)
Stroke is the third leading cause of death in developed countries. About one-forth of people who have a stroke die as a result of the stroke or its complications, about one-half have long-term disabilities, and about one-forth recover most or all function.

Hemorrhagic stroke is less common but more frequently fatal than ischemic stroke.

Complications
  • Pressure sores

  • Permanent loss of movement or sensation of a part of the body

  • Joint contractures

  • Muscle spasticity

  • Permanent loss of cognitive or other brain functions (dementia)

  • Disruption of communication, decreased social interaction

  • Decreased ability to function or care for self

  • Decreased life span

  • Urinary and respiratory tract infections


Prevention
Most cases of hemorrhagic stroke are associated with specific risk factors, such as high blood pressure, smoking, or cocaine use. Controlling blood pressure and avoiding smoking and cocaine can reduce the chances of brain bleeding. Surgery to correct blood vessel abnormalities like aneurysms or AVMs is sometimes advisable to prevent bleeding.

Assesssment
1. Subjective Data
  • Weakness, sudden or gradual loss of mevement of extremities on one side

  • Difficulty forming words

  • difficulty swallowing (dysphagia)

  • Nausea, Vomiting

  • History of TIAs


2. Objective Data
a. Vital Signs :
  • BP: elevated;widened pulse prssure.

  • Temperatue: elevated

  • Pulse : normal, slow

  • Respirations : Tachypnea, altered pattern ; deep; sonorous.


b. Neurologic :
  • Altered level of consciousness

  • Pupils : unequal ; vision : hormonymous hemianopia.

  • Ptosis of eyelid, drooping mouth.

  • Paresis or paralysis (hemiplagia)

  • Loss of sensation and reflexes

  • Incontinence of urine oe feces

  • Aphasia


Analysis/ Nursing Diagnosis :
1. Impaired physical mobility related to hemiplagia
2. Impaired swallowing related to paralysis
3. Impaired verbal communication related to aphasia
4. Risk for aspiration related to uncosciousness
5. sensory/perceptual alteration related to altered cerebral blood flow, visual field blindness
6. Altered thought processes related to cerebral edema
7. Self-care defisit related to paresis or paralysis
8. Body image disturbance related to hemiplegia
9. Total incontinence related to interruption of normal nerve transmission
10. Impaired social interaction related to aphasia or neurologic defisit.
11. Risk for impaired skin integrity related to immobility
12. Unilateral neglect related to cerebral damage.

Nursing Care Plan/Implementation
1. Reduce cerebral anoxia (Patent airway, Activity, Position)
2. Promote cardiovascular function and maintain cerebral perfusion.
3. Provide for emotion relaxation
4. Patient safety
5. Health Teaching (Exercise, Diet)

Evaluation/Outcome Criteria :
1. No complication (pneumonia)
2. Regains functional independence
3. Return of control over body functions.

#References :
  • Sally L. Lagerquist, NCLEX-RN Examination Review, 1998

  • Dolores F. Saxton, Comprehensive Review Of Nursing For NCLEK-RN, Sixteenth Edition, Mosby, St. louis, Missouri, 1999.

  • The lippincott Manual of Nursing Practice, 7th Edition, 2005.

  • Nursing Procedures, Springhouse Publishing Co, 3rd, ed, Mosby, 2000
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