NURSING PROCESS IN CRITICAL NURSING

AREA

Group 5
Preliminary
According to the American Association of
Critical-Care Nurses (AACN)

critical nursing is a special expertise in the

science of nurses which is obtained in detail
with humans or patients and is responsible for
life-threatening problems. Critical care is a
propesianal nurse who is officially responsible
for ensuring patients with illness critical and
patient families get optimal care (AACN, 2006)
 Discussion

According to Kurvilla in his book Essentials of

Critical Care,
the determination of the nursing plan in the critical
nursing area was formulated based on a combination of
two models, namely the model of Maslow's hierarchy
needs and Roy's Adaptation model. Abraham Maslow
divides human needs into physical and psychosocial
needs. Maslow divides 5 levels of psychological needs,
namely welfare, patient safety, affection, love and
friendship, self-esteem, and self-actualization.
The hierarchy is useful for assessing patient
strength, limitations and the need for nursing
interventions where all of these are applied to
the making of the nursing process.
The application of the nursing process in the area
of critical nursing still faces many obstacles both
in Indonesia and abroad. In Indonesia, nurses may
still focus a lot on meeting physical needs,
regardless of the psychological needs of critical
patients. This certainly contradicts the concept
promoted by Maslow and Roy as the basis for
establishing nursing interventions in the critical
nursing area.
STANDARD ASSESSMENT IN CRITICAL
AREAS
1. Critical nurses are able to collect data
continuously and conduct a comprehensive
assessment and data collection holistically.
2. Using the support of health technology devices.
3. Using non-invasive / invasive monitoring
techniques.
4. Critical care nurses collect laboratory specimens
5. Critical care nurses collect results obtained
from diagnostic / laboratory tests and integrate
findings with assessments according to
standards.
6. Critical care documents and communicating
with members of the health care team
concerned assessment findings within the
period according to the severity of the
patient's condition.
7. The critical care nurse sets priorities
according to the actual and potential needs of
the patient and reviews status changes
8. Critical care nurses collect
pathophysiological, psychosocial, cultural,
developmental and spiritual data based on
the patient's condition.
9.Critical care nurses obtain a medical history
using all available data and according to available
sources.
10. Critical care nurses collect data on family
needs and responses to health crises.
11. The critical care nurse collects data regarding
the risk of infection control for patients and staff.
ASSESSMENT IN CRITICAL AREAS
1. Prearrival Assessment It starts when the nurse
has received information from the health team in
another unit that there will be patients who will
be treated in an intensive room with conditions
that have declined or can be unstable.
2. Arrival quick check Assessment begins when
patients enter and are treated in intensive care.
The nurse observed in general and carried out
the ABCDE study quickly. ABCDE consists of
Airway, Breathing, Circulation and Cerebral
perfusion, Chief complaints, Drugs and
diagnostic tests, and Equipment and allergy.
3. Comprehensive initial assessment. These
assessments include past medical history, current
history of health status, psychosocial, spiritual, and
physical assessment.
4. Ongoing assessment The study becomes more
focused and more often done to determine the
condition of the patient's stability. Follow-up
monitoring is usually carried out 1-2 hours in
patients whose physiological status decreases and 2-
4 hours in patients who have started to stabilize their
condition.