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"Pendahuluan: Program spesiais keperawatan medikal bedah merupakan salah satu pengingkatan kualitas pelayanan profesional. pengalaman belajar praktek klinik residensi bertujuan untuk menciptakan praktisi keperawatan yang memiliki kemampuan kognitif, afektif san psikomotor yang memadai dalam praktik residensi keperawatan medikal bedah (KMB). Sistem kardiovaskuler menjadi pilihan kepakaran penilis dalam mengikuti residensi KMB. Pelaksanaan : residensi kardiovaskuler ditempuh selama 25 minggu ( tanggal 29-09-2009 sampai 21-05-2010). selama praktik residensi melaksanakan peran care giver, educator dan counselor, dengan memberikan asuhan keperawatan lanjut pada kasus-kasus sistem kardiovaskuler yang kompleks. kasus utama dalam laporan akhir praktik residensi adalah kasus NSTEMI dengan pendekatan teori Ida Jean Orlando tentang hubungan perawat-pasien yang dinamis. peran researcher, mengaplikasikan evidence based nursing practice (EBN) mengenai penggunaan non humidifier pada oksigen transport. peran leader, membuat inovasi, yang dijadikan laporan adalah pembuatan draf kompetensi kardiovaskuler. Hasil : Analisis teori Orlando dirasakan lebih efektif karena dengan menjalin hubungan perawat-pasien, yang dinamis akan membuat proses keperawatan lebih jelas, ringkas dan mudah diaplikasikan. pelaksanaan EBN pada lima pasien yang memakai non humidifier oksigen transport, pemakaiannya sangat mudah dan simple, tidak memerlukan perawatan yang komplek, biayanya bisa lebih murah, dan aman. pelaksanaan inovasi yang dilakukan dengan penyususnan draf dapat diterima oleh ruang ICCU RSUP dt. Cipto Mangunkusumo. Kesimpulan : teori Orlando diterapkan pada reisdensi kardiovaskuler di ruang intensive care sangat efektif. EBN yang dilakukan sangat bermanfaat bagi pasien, ruang perawatan, dan diketahui tidak menimbulkan efek negatif. draf kompetensi kardiovaskuler dapat diterima ruangan sebagai salah satu peningkatan pelayanan keperawatan di ruangan. Saran : praktik reisdensi ini dapat digunakan sebagai peningkatan pelayanan keperawatan dan reevaluasi pelaksanaan residensi selanjutnya oleh pendidikan keperawatan.

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Introduction : program specialist medical surgical nursing is one of the increasing quality of professional service. experience learning residence clinical practice have purpose to create nursing practical that have adequate cognitive, afective, and psycomotor in residence practice of medical surgical nursing. cardovascular system being enthusiasm writer in following residence of medical surgical nursing.

Execution : cardiovascular residence has been done through 25 weeks (start at 25-09-2009 until 21-05-2010). during residence practice doing role of caregiver, educator, counsellor with giving continue nursing service in complex cases of cardiovascular system. Main case in final report residence practice is NSTEMI case with theory of Ida Jean Orlando approach about dynamic nurse - patient relationship. researcher role to applicate evidence based nursing practice (EBN) as for using of non humidifier oxygen transport. Leader role to make an innovation that to be a report is make draft of cardiovascular competence.

Result : Analyzing of Orlando theory more efective because of make dynamic relationship between nurse and atient will make nursing process more clearly, simple and easy to applicate. perform EBN to five patients using non humidifier oxygen transport using it very easier and simple, doesn't need complex care, more cheaper cost and safe. perform an innovation is doing with draft compilation can be acceptable by ICCU wards at RSUP dr Cipto Mangunkusumo.

Conclusion : Orlando theory that habe been done very usefull to patient, caringwards and knowed give positive effect. draft competences of cardiovascular can be acceptable in wards as one of the increasing quality of professional services.

Suggestion : this residence practice can be used increasing nursing services and re-evaluate next residence by nursing education. "

"ABSTRAKDokumentasi catatan perkembangan pasien terintegrasi belum optimal karena kurangnya pemahaman perawat dalam melakukan penulisan, dan keseragaman dari isi kaidah penulisan, serta belum optimalnya dukungan dari kepala ruang. Tujuan penelitian mengidentifikasi pengaruh penguatan peran kepala ruang dengan pendekatan teori Orlando terhadap pelaksanaan pendokumentasian catatan perkembangan pasien terintegrasi. Metode pre eksperiment design dengan one group pre test and post test design without control, dengan sampel 115 dokumen catatan perkembangan pasien terintegrasi, teknik cluster sampling, melalui analisis Wilcoxon, Spearman dan Kruskal Wallis test. Hasil penguatan peran kepala ruang dengan pendekatan teori Orlando meningkatkan kualitas pelaksanaan pendokumentasian catatan perkembangan pasien terintegrasi secara bermakna p=0,0001; ?=0,025 . Kesimpulan kemampuan perawat pelaksana meningkat bermakna dalam pelaksanaan pendokumentasian catatan perkembangan pasien terintegrasi melalui penguatan peran kepala ruang dengan pendekatan teori Orlando. Rekomendasi adanya kebijakan, pendampingan, evaluasi, dan monitoring dari manajer keperawatan serta pengembangan melalui workshop penerapan peran kepala ruang dan pelaksanaan pendokumentasian catatan perkembangan pasien terintegrasi.

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ABSTRACTDocumentation of integrated patient development records has not been optimal due to lack of understanding of nurses in writing, and uniformity of the content of writing rules, and there has not yet optimal support from the head nurses. The purpose of this study was to identify the impact of strengthening the role of the head nurse using the Orlando rsquo s theoretical approach on the implementation in documented of integrated patient development records. The method used Pre experimental design with one group pre test and post test design without control, samples on this study are 115 documents of integrated patient development record, cluster sampling technique, analyzed used with Wilcoxon, Spearman and Kruskal Wallis test analysis. The result showed that the role strengthening of the head nurse with the Orlando rsquo s theoretical approach significantly improves the quality of implementation for documented of integrated patient development record p 0.0001 0,025 . The conclusion of nursing abilities of the implementers increased significantly in the implementation in documented of integrated patient development record. It is recommended can used as reference to make policies, assistance, evaluation and monitoring of nursing managers and development through workshops on the role of the head nurses and documentation of integrated patient development records."

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Consensus Statement of Standards for Interventional Cardiovascular Nursing Practice menetapkan  domain standar praktik interventional keperawatan kardiovaskular  meliputi mampu berfikir kritis dan menganalisis intervensi kardiovaskular dalam praktik keperawatan, terlibat dalam hubungan terapeutik dan hubungan profesional untuk meningkatkan pelayanan dan pengalaman dalam pemberian asuhan keperawatan.  The dynamic nurse-patient relationship model telah digunakan sebagai teori dasar dalam memberikan asuhan keperawatan pada praktik keperawatan, yang menekankan  prinsip-prinsip dasar pemikiran kritis, pendekatan yang berpusat pada klien intervensi serta berorientasi pada tujuan, dan penggunaan  rekomendasi intervensi keperawatan berbasis bukti. Penerapan The dynamic nurse-patient relationship model pada praktik residensi menetapkan penurunan curah jantung sebagai diagnosis keperawatan utama pada pasien kelolaan utama dan 30 pasien lainnya, dengan cardiac care sebagai pilihan intervensi keperawatan untuk mengoptimalkan fungsi jantung dan menurunkan beban kerja jantung. CAM-ICU sebagai instrumen diagnostik memiliki keandalan yang sempurna untuk menilai delirium pasca pembedahan jantung (sensitifitas 100% dan spesitifitas 100%), lain halnya BHIS sebagai istrumen untuk menilai risiko kejadian SSI pasca pembedahan jantung memiliki keandalan yang sedang ( sensitifitas 70% dan spesitifitas 67%), artinya BHIS perlu dikembangkan kembali dengan memperhatikan faktor-faktor yang berhubungan dengan kejadian SSI.

 

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The Consensus Statement of Standards for Interventional Cardiovascular Nursing Practice has established the standard domain of interventional cardiovascular nursing practices which includes the ability to think critically and to analyze cardiovascular interventions in nursing practice, engaging in therapeutic relationships and professional relationships to improve service and experience in providing nursing care. The dynamic nurse-patient relationship model has been used as a primary theory, providing nursing care approach into nursing practice which emphasizes the basic principles of critical thinking, client-centered and intervention-oriented approaches, and the use of evidence-based nursing intervention recommendations. The dynamic nurse-patient relationship model in residency practice establishes a decrease in cardiac output as the main nursing diagnosis in primary management patients and 30 other patients, with cardiac care as the choice of nursing intervention to optimize cardiac function and reduce cardiac workload. CAM-ICU as a diagnostic instrument has perfect reliability to assess delirium after cardiac surgery (100% sensitivity and 100% specificity). BHIS as an instrument to assess the risk of SSI events after cardiac surgery has moderate reliability (70% sensitivity and 67% specificity), meaning that BHIS needs to be developed by taking into account the factors related to SSI events.

 

Keywords: ida jean orlando, delirium, CAM-ICU, surgical site infection, cardiac surgery, low cardiac output, respiratory muscle training.

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