LAPORAN PENDAHULUAN
Asuhan Keperawatan pada Penderita dengan Tumor Cerebri
1. Konsep dasar medikal
A. Definisi
Tumor cerebral atau tumor otak adalah pertumbuhan abnormal / reproduksi tak terkontrol sel – sel yang terdapat pada otak. (www.abta.com)
Tumor otak primer adalah tumor yang awalnya bermula pada jaringan otak, tumor ini dikategorikan sesuai dengan jenis sel otak yang pertama kali diserang. (www.medicinenet.com)
Tumor otak primer yang paling sering dijumpai adalah jenis Glioma yang menyerang sel glial, jenis ini memiliki tipe sebagai berikut (www.medicinenet.com) :
• Astrositoma
Tumor ini berawal dari sel glia jenis astrocytes yang pada orang dewasa sering berawal dari serebrum, sedangkan pada anak tumor ini didapatkan tumbuh dari batang otak, serebelum dan serebrum.
• Brain stem glioma
Tumor jenis ini sering didapati pada bagian bawah dari otak dan sering mengenai anak dan dewasa
• Ependyma
Tumor pertama kali tumbuh dari sel pada garis sentral dari spinal cord atau ventrikel. Tumor ini paling sering dijumpai pada anak dan remaja
• Oligodendroglioma
Tumor ini tumbuh dari substansi berlemak pada lapisan yang melindungi syaraf, biasanya timbul di serebrum. Tumor ini tumbuh lambat dan hampir tidak dijumpai adanya penyebaran ke sekitarnya. Biasanya menyerang pada usia dewasa.
Beberapa tipe tumor otak yang bukan berasal dari sel glia adalah :
• Medulloblastoma
• Meningioma
• Schwannoma.
• Craniopharyngioma
• Germ cell tumor
• Pineal region tumor
B. Etiologi
Penyebab secara pasti masih belum diketahui, namun banyak pakar dan riset (brain cancer research) yang menyebutkan beberapa faktor resiko terjadinya tumor otak yaitu (www.emedtv.com) :
• Laki laki
Umumnya tumor otak banyak menyerang pada kaum pria, kecuali meningioma yang banyak menyerang pada wanita
• Ras
Tumor ini banyak menyerang pada ras Caucasians dibandingkan pada ras yang lain
• Usia
Tumor otak banyak terdeteksi menyerang orang dengan usia 70 tahun atau lebih, namun ada juga tumor otak yang secara spesifik banyak terdapat pada anak kurang dari 8 tahun
• Riwayat keluarga
Penderita dengan riwayat kesehatan keluarga yang menderita tumor otak jenis glioma sering didapati menderita tumor jenis ini juga
• Dampak pemaparan rasiasi dan beberapa bahan kimia
Beberapa pemaparan radiasi dan bahan kimia meningkatkan resiko terjadinya tumor otak termasuk diantaranya :
a) Formaldehyde
b) Vinyl chloride
c) Acrylonitrile
• Pada saat ini sedang diselidiki adanya hubungan antara penggunaan telepon seluler dengan terjadinya tumor otak walaupun belum ada literatur pasti tentang hal itu, namun disarankan pada orang orang yang memiliki faktor faktor resiko diatas untuk lebih sering memeriksakan dirinya.
C. Tanda dan gejala
Di kalangan medis pada umumnya sudah dikenal trias gejala tumor otak yaitu nyeri kepala, muntah dan ditemukannya edema papil pada pemeriksaan fundus. Tetapi sebenarnya gejala klinis tumor otak sering tidak sejelas itu, apalagi pada fase dini. Tumor otak bisa memberikan gejala klinis beragam tergantung kepada lokasi dan ukurannya. Gejala itu bisa khas, tapi bisa pula kabur, sehingga bila kita tidak waspada bisa terkecoh dengan dugaan yang keliru.
Tumor otak bisa mengenai segala.usia, tapi umumnya pada usia dewasa muda atau pertengahan, jarang di bawah usia 10 tahun atau di atas 70 tahun. Sebagian ahli menyatakan insidens pada laki-laki lebih banyak dibanding wanita, tapi sebagian lagi
menyatakan tak ada perbedaan insidens antara pria dan wanita.
Gejala umum yang terjadi disebabkan karena gangguan fungsi serebral akibat edema otak dan tekanan intrakranial yang meningkat. Gejala spesifik terjadi akibat destruksi dan kompresi jaringan saraf, bisa berupa nyeri kepala, muntah, kejang, penurunan kesadaran, gangguan mental, gangguan visual dan sebagainya. Edema papil dan defisit neurologis lain biasanya ditemukan pada stadium yang lebih lanjut (cermin dunia kedokteran, 1992)
a) Nyeri Kepala (Headache)
Nyeri kepala biasanya terlokalisir, tapi bisa juga menyeluruh. Biasanya muncul pada pagi hari setelah bangun tidur dan berlangsung beberapa waktu, datang pergi (rekuren) dengan interval tak teratur beberapa menit sampai beberapa jam. Serangan semakin lama semakin sering dengan interval semakin pendek. Nyeri kepala ini bertambah hebat pada waktu penderita batuk, bersin atau mengejan (misalnya waktu buang air besar atau koitus). Nyeri kepaia juga bertambah berat waktu posisi berbaring, dan berkurang bila duduk. Penyebab nyeri kepala ini diduga akibat tarikan (traksi) pada pain sensitive structure seperti dura, pembuluh darah atau serabut saraf. Nyeri kepala merupakan gejala permulaan dari tumor otak yang berlokasi di daerah lobus oksipitalis.
b) Muntah
Lebih jarang dibanding dengan nyeri kepala. Muntah biasanya proyektil (menyemprot) tanpa didahului rasa mual, dan jarang terjadi tanpa disertai nyeri kepala.
c) Edema Papil
Keadaan ini bisa terlihat dengan pemeriksaan funduskopi menggunakan oftalmoskop. Gambarannya berupa kaburnya batas papil, warna papil berubah menjadi lebih kemerahan dan pucat, pembuluh darah melebar atau kadang-kadang tampak terputus putus. Untuk mengetahui gambaran edema papil seharusnya kita sudah mengetahui gambaran papil normal terlcbih dahulu. Penyebab edema papil ini masih diperdebatkan, tapi diduga akibat penekanan terhadap vena sentralis retinae. Biasanya terjadi bila tumor yang lokasi atau pembesarannya menekan jalan aliran likuor sehingga mengakibatkan bendungan dan terjadi hidrosefalus interim.
d) Kejang
Ini terjadi bila tumor berada di hemisfer serebri serta merangsang korteks motorik. Kejang yang sifatnya lokal sukar dibedakan dengan kejang akibat lesi otak lainnya, sedang kejang yang sifatnya umum/general sukar dibedakan dengan kejang karena epilepsi. Tapi bila kejang terjadi pertama kali pada usia dekade III dari kehidupan harus diwaspadai kemungkinan adanya tumor otak.
Beberapa ahli mengemukakan gejala klinis berdasarkan lokasi timbulnya tumor yaitu
a) Brain Stem Tumors (Midbrain, Pons, Medulla Oblongata)
Gejala paling banyak adalah muntah biasanya pada saat bangun tidur, ataxia (uncoordinated walk), kelemahan otot wajah pada satu sisi, dysphagia dan dysarthria, penurunan penglihatan, serta perubahan kepribadian.
b) Cerebellopontine Angle Tumors (Usually Acoustic Nerve Tumors)
Tinnitus dan vertigo.
c) Cerebral Hemisphere Tumors
Frontal Lobe Tumors
One-sided paralysis (hemiplegia), penurunan daya ingat, ketidakmampuan penilaian, dan perubahan status mental. Jika tumor mengenai lobus frontal bagian bawah terdapat loss of sense of smell (anosmia), dan swollen optic nerve (papilledema)
Parietal Lobe Tumors
Gannguan bicara (biasanya hemisfer kiri), loss of ability to write (agraphia) adalah gejala yang sering timbul. Spatial disorders seperti kesulitan dalam orientasi anggota tubuh dengan ruang sekkitarnya serta gangguan dalam mengenali anggota tubuh bisa terjadi.
Occipital Lobe Tumors
Blindness in one direction (hemianopsia)
Temporal Lobe Tumors
Tumor pada daerah ini seringkali bersifat silent sehingga sulit dikenali namun kadang terjadi language disorders (dysphasia).
d) Subcortical Tumors
One-sided paralysis (hemiplegia), jika tumor mengenai thalamus seringkali terjadi penurunan sensasi raba
e) Meningeal Brain Tumors
f) Metastatic Brain Tumors
Nyeri kepala, mual dan muntah
g) Midline Tumors (Craniopharyngioma, Optic Nerve Glioma, Tumors of the Thalamus and Sellar areas)
Papilledema, abnormal eye movement (nystagmus)
h) Posterior Fossa Tumors (Tumors of the Fourth Ventricle, Cerebellar Tumors)
Tremors, gangguan koordinasi dan bicara
i) Spinal Cord Tumors
Gejalanya tergantung pada lokasi tumor seperti tumor pada thoracic area menyebabkan "girdle pain" pada dada yang semakin terasa berat pada saat batuk atau bersin. Tumors di daerah cervical atau lumbar menimbulkan nyeri pada leher, lengan, punggung, tungkai, dan seringkali timbul penurunan kontrol terhadap saluran cerna dan kemih
2. Pathological pathways
3. Penatalaksanaan
Penatalaksanaan pada tumor otak berbeda dengan tumor pada anggota tubuh yang lain, hal ini dikarenakan karakteristik organ otak yang unik serta mengingat prognosis yang buruk dari penyakit ini sehingga diperlukan terapi yang bertahap sehingga diperlukan multidisiplin profesional medis yang bekerja sama untuk memberikan penatalaksanaan yang paling manjur (first.national.and.evidence.based.guidelines.brain.cancer.released).
American Brain Tumor Asociation merumuskan tahapan penatalaksanaan tumor otak sebagai berikut :
a) SURGERY
Biopsy (Surgical removal of a sample of tumor)
Resection of a Tumor
Stereotactic localization
Laser microsurgery
Ultrasonic aspiration
b) RADIATION THERAPY
c) CHEMOTHERAPY
d) STEROIDS
e) IMMUNOTHERAPY
f) ONCOGENES
4. Fokus pengkajian
• Biodata pasien
Jenis kelamin
Usia
Ras
• Keluhan utama
Nyeri kepala / vertigo, mual muntah, kelemahan anggota gerak
• Riwayat kesehatan dahulu
Riwayat terpapar radiasi dan bahan kimia
• Riwayat kesehatan keluarga
Kemungkinan adanya anggota keluarga yang menderita tumor otak
• Pemeriksaan fisik
Kepala : kelemahan otot wajah pada satu sisi, dysphagia,
Mata : papiledema, nystagmus, penglihatan kabur, penurunan
lapang pandang, Blindness in one direction (hemianopsia)
Saraf : kejang, tingkah laku aneh, disorientasi, penurunan/
kehilangan memori, afek tidak sesuai, afasia sensoris
motoris,
Pendengaran : tinitus, penurunan pendengaran, halusinasi
Penciuman : anosmia
Jantung : bradikardi
Sistem pernafasan : irama nafas meningkat, dispnea
Motorik : hiperekstensi, kelemahan sendi, One-sided paralysis
(hemiplegia), gangguan keseimbangan, loss of ability
to write (agraphia), uncoordinated walk (ataxic gait)
Neuromuskuler : tremor, penurunan sensasi raba, kekuatan otot
Status mental : disorientasi, penurunan daya ingat
Sistem integumen : turgor turun,
• Pemeriksaan penunjang
CT or CAT
MRI
Skull x-ray
RN (Radionuclide)
LUMBAR PUNCTURE (Spinal Tap)
ELECTROENCEPHALOGRAM (EEG)
BIOPSY
ANGIOGRAM OR ARTERIOGRAM
5. Diagnosa keperawatan
Diagnosa Keperawatan :
1. Risiko gangguan keseimbangan cairan dan elektrolit s/d muntah proyektil
2. Nyeri s/d spasme otot dan trauma jaringan sekunder akibat peningkatan TIK
3. Risiko tinggi cidera s/d disfungsi muskuler, penurunan respon protektif
4. Kerusakan memori s/d perubahan sistem syaraf pusat sekunder tu. otak
5. Syndroma perawatan diri
6. Kerusakan mobilitas fisik ; berjalan
7. Kerusakan komunikasi verbal
8. PK : hypoxia cerebral
9. PK : herniasi cerebral
10. PK : hydrocephalus
6. Nursing care plan
1. Risiko gangguan keseimbangan cairan dan elektrolit s/s muntah proyektil
Tujuan : keseimbangan cairan dan elektrolit tetap normal
Rencana :
• Jelaskan kepada pasien atau keluarga pasien tentang pentingnya cairan
R/ tubuh manusia sebagian besar terdiri oleh air
• Berikan cairan / minum jika tidak ada kontraindikasi
R/ memberikan asupan saat muntah menyebabkan aspirasi bahkan obstruksi airway
• Kaji berat badan
Kehilangan berat badan 5% menandakan dehidrasi ringan, 8% menandakan dehidrasi sedang
• Kaji input dan output
R/ perubahan dalam kapasitas input / output menandakan adanya kekurangnan atau kelebihan
• Kolaburasi : infus
R/ profesionalisme lebih tepat
2. Nyeri s/d spasme otot dan trauma jaringan sekunder akibat peningkatan TIK
Tujuan : beradaptasi terhadap rasa nyeri
Tindakan :
• Jelaskan pada penderita atau keluarga penderita tentang penyebab nyeri dan sampai kapan nyeri akan dirasakan
R/ kesiapan menghadapi nyeri menimbulkan self opiat
• Beri posisi yang nyaman
R/ relaksasi menghambat respon nyeri ascendens
• Monitor tanda vital dan skala nyeri jika memungkinkan
R/ nyeri memicu aktifasi sistem simpatis dan parasimpatis
• Berikan kompres dimana pada area yang sakit
R/ vaskularisasi yang baik menghambat aktivasi reseptor akibat trauma
• Kolaborasi pemberian obat : analgetik, relaksan, prednison
R/profesionalisme lebih tepat
3. Risiko tinggi cidera s/d disfungsi muskuler, penurunan respon protektif
Tujuan : cidera tidak terjadi
Tindakan :
• Jelaskan akibat cidera dan penyebabnya
R/ cidera pada kepala memperparah peningkatan tekanan intra kranial
• Diskusikan dengan pasien atau keluarga tentang penggunaan pengaman tempat tidur, tali, alat bantu jalan, dll
R/ alat bantu merupakan benda asing dan mungkin bertentangan dengan value yang diharapkan pasien dan keluarganya
• Orientasikan penderita pada keadaan sekitarnya
R/ pengenalan lingkungan memungkinkan penderita mengingat kondisi di sekitarnya
• Anjurkan keluarga membantu memecahkan masalah pasien
R/ manusia adalah mahluk sosial
4. Kerusakan memori s/d perubahan sistem syaraf pusat sekunder tu. Otak
Tujuan : terjadi peningkatan memori
Tindakan :
• Bina hubungan yang baik dengan klien
R/ perbaikan status memori harus didasari oleh keinginan dari penderita sendiri
• Berikan selalu informasi yang akurat dan berulang
R/ stimulus terhadap sel neuron harus benar benar - kuat agar bisa diingat
• Ajarkan metode peningkatan ketrampilan memori mis : menulis, asosiasi kata
R/ pencapaian status memori dibantu dengan pelaksanaan metode mengingat
• Anjurkan menggunakan alat bantu
R/ stimulus terhadap sel neuron harus benar benar - kuat agar bisa diingat
Syndroma perawatan diri
Tujuan : perawatan diri terpenuhi
Tindakan :
• Jelaskan pentingnya perawatan diri
R/ infeksi nosokomial dapat berasal dari tubuh penderita sendiri
• Kaji kemampuan untuk berpartisipasi
R/ memberikan bantuan dapat total, partial, atau penderita mandiri
• Berikan bantuan perawatan diri
R/ kelemahan dalam koordinasi anggota gerak memerlukan waktu yang lama untuk pulih
• Anjurkan keluarga berparisipasi
R/ harga diri penderita berperan penting dalam peningkatan motivasi untuk memenuhi kebutuhannya sendiri
5. Daftar pustaka
www.abta.com
www.medicinenet.com
www.pubmed.com
Cermin Dunia Kedokteran PDF search, 1992
Carpenito, lynda juall. Hanbook of nursing diagnosis edisi 8. 2001
Senin, 24 Januari 2011
Evidence Base On Operating Room
An evaluation of five protocols for surgical handwashing in relation to skin condition and microbial counts.
Pereira LJ, Lee GM, Wade KJ.
Department of Biological Sciences, Faculty of Health Sciences, University of Sydney, Australia.
Five protocols for surgical handwashing (scrubbing) were evaluated for their efficiency of removal of micro-organisms and their drying effect on the skin. The scrubbing protocols tested were: (1) an initial scrub of 5 min and consecutive scrubs of 3.5 min with chlorhexidine gluconate 4% (CHG-5); (2) an initial scrub of 3 min and consecutive scrubs of 2.5 min with chlorhexidine gluconate 4% (CHG-3); (3) an initial scrub of 3 min and consecutive scrubs of 2.5 min with povidone iodine 5% and triclosan 1% (PI-3); (4) an initial scrub of 2 min with chlorhexidine gluconate 4% followed by a 30 s application of isopropanol 70% and chlorhexidine gluconate 0.5%, and a 30 s application of isopropanol 70% and chlorhexidine gluconate 0.5% for consecutive scrubs (IPA); and (5) an initial scrub of 2 min with chlorhexidine gluconate 4% followed by a 30 s application of ethanol 70% and chlorhexidine gluconate 0.5%, and a 30 s application of ethanol 70% and chlorhexidine gluconate 0.5% for consecutive scrubs (EA). A convenience sample of 23 operating theatre nurses completed each scrub protocol for one week in a randomized order. A week of normal work activities intervened between each protocol. Subjects were assessed before commencing and after completing the week of each protocol to determine changes in the microbial counts and skin condition of the hands. Specimens for microbial analysis were collected before, immediately after and 2 h after an initial scrub, and 2 h after a consecutive scrub. The CHG-5, CHG-3 and PI-3 protocols, which used detergent-based antiseptics only, were compared with protocols incorporating an alcohol-based antiseptic (IPA and EA). The protocols incorporating alcohol-based antiseptics and the CHG-5 protocol were generally associated with the lowest post-scrub numbers of colony forming units (cfu). No difference between the CHG-5 protocol and the alcohol-based antiseptics was found at the beginning of the test week, but after exclusive use of the respective protocols for a week, the alcohol-based antiseptics were associated with significantly lower cfu numbers in two out of the three post-scrub samples (P = 0.003, P = 0.035). Although virtually no statistically significant differences in skin condition were found, many subjects reported the alcohol-based antiseptic protocols to be less drying on the skin. The findings of this study support the proposition that a scrub protocol using alcohol-based antiseptics is as effective and no more damaging to skin than more time-consuming, conventional methods using detergent-based antiseptics.
PMID: 9172045 [PubMed - indexed for MEDLINE]
Dermatology. 2006;212 Suppl 1:21-5.
Comparison of the antimicrobial efficacy of povidone-iodine, povidone-iodine-ethanol and chlorhexidine gluconate-ethanol surgical scrubs.
Nishimura C.
Operating Suite, Shinshu University Hospital, Nagano 390-8621, Japan. cnishim@hsp.me.shinshu-u.ac.jp
BACKGROUND: Scrubbing of the hands and forearms with a brush and antiseptic agents has been the standard for surgical practice. However, it has been increasingly recognized that brush scrubbing may provoke side effects and that an alcohol-based hand antiseptic used in conjunction with a scrub agent enhances the effectiveness. In this study, two types of alcohol-based agents were used after a povidone-iodine (PVP-I) scrub and compared for their effectiveness. MATERIALS AND METHODS: The study was conducted as a crossover trial with 20 volunteers. After hand rubbing with PVP-I, either PVP-I-ethanol rubbing or chlorhexidine gluconate-ethanol (CHG-ethanol) rubbing was used for surgical hand cleansing. Samples were collected by the modified glove juice method to count bacteria on hands. RESULTS: In both groups, the bacterial count was significantly reduced after handwashing (p < 0.001), and the reduction was still significant after 2 h (p < 0.001 for PVP-I-ethanol and p < 0.002 for CHG-ethanol). The log(10) reduction factor (RF) in the PVP-I-ethanol group was significantly higher than that in the CHG-ethanol group immediately after handwashing (p < 0.001) but significantly lowered after 2 h (p < 0.01) to the level similar to that of CHG-ethanol. Although RF was lower in the CHG-ethanol group immediately after and 2 h after handwashing compared to the PVP-I-ethanol group, it did not decrease with time. CONCLUSION: Brushless surgical scrubbing with PVP-I-ethanol or CHG-ethanol in conjunction with PVP-I showed antiseptic effects immediately after and 2 h after handwashing. RF immediately after handwashing was significantly higher with PVP-I-ethanol compared to CHG-ethanol, but it was similar in both groups after 2 h. These results suggest that when used in combination with a PVP-I scrub, an alcohol-based hand antiseptic containing the same active agent (PVP-I in this study) has a powerful antiseptic effect; however, when it contains different antiseptic agents (i.e. CHG in this study), it should be selected carefully based on its antiseptic property.
Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004288.
Surgical hand antisepsis to reduce surgical site infection.
Tanner J, Swarbrook S, Stuart J. De Montfort University and University Hospitals Leicester, Charles Frears Campus, 266 London Road, Leicester, UK, LE2 1RQ. jtanner@dmu.ac.uk
BACKGROUND: Surgical hand antisepsis, to destroy transient micro-organisms and inhibit the growth of resident micro-organisms, is routinely carried out before undertaking invasive procedures. Antisepsis may reduce the risk of surgical site infections in patients. OBJECTIVES: To determine the effects of surgical hand antisepsis on the number of surgical site infections (SSIs) in patients. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony forming units (CFUs) of bacteria on the hands of the surgical team. SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (Issue 2, 2007), MEDLINE (Week 5, 2007), CINAHL (June 2007), EMBASE (Week 23, 2007) and ZETOC (2005). SELECTION CRITERIA: Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions. DATA COLLECTION AND ANALYSIS: Three authors independently assessed studies for selection, trial quality and extracted data. MAIN RESULTS: Ten trials were included in this review. Only one trial reported the primary outcome, rates of SSIs, and nine trials measured numbers of CFUs. One trial involving 4387 patients found alcohol rubs with additional active ingredients were as effective as aqueous scrubs in reducing SSIs. Four trials compared different alcohol rubs containing additional active ingredients with aqueous scrubs for numbers of CFUs on hands. One trial found N-duopropenide more effective than chlorhexidine and povidone iodine aqueous scrubs. One trial found 45% propanol-2, 30% propanol-1 with 0.2% ethylhexadecyldimethyl ammonium ethylsulfate more effective than chlorhexidine scrubs. One trial found no difference between 1% chlorhexidine gluconate in 61% ethyl alcohol or zinc pyrithione in 70% ethyl alcohol against aqueous povidone iodine. A fourth trial found 4% chlorhexidine gluconate scrubs more effective than chlorhexidine in 70% alcohol rubs. Four trials compared the relative effects of different aqueous scrubs in reducing CFUs on hands. Three trials found chlorhexidine gluconate scrubs were significantly more effective than povidone iodine scrubs. One trial found no difference between chlorhexidine gluconate scrubs and povidone iodine plus triclosan scrubs. Two trials found no evidence of a difference between alternative alcohol rubs in terms of the number of CFUs. Four trials compared the effect of different durations of scrubs and rubs on the numbers of CFUs on hands. One trial found no difference after the initial scrub but found subsequent three minute scrubs using chlorhexidine significantly more effective than subsequent scrubs lasting 30 seconds. One trial found that following a one minute hand wash, a three minute rub appears to be more effective than the five minute rub using alcohol disinfectant. The other comparisons demonstrated no difference. AUTHORS' CONCLUSIONS: Alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs however this evidence comes from only one, equivalence, cluster trial which did not appear to adjust for clustering. Four comparisons suggest that alcohol rubs are at least as, if not more, effective than aqueous scrubs though the quality of these is mixed and each study presents a different comparison, precluding meta analysis. There is no evidence to suggest that any particular alcohol rub is better than another. Evidence from 4 studies suggests that chlorhexidine gluconate based aqueous scrubs are more effective than povidone iodine based aqueous scrubs in terms of the numbers of CFUs on the hands. There is limited evidence regarding the effects on CFUs numbers of different scrub durations. There is no evidence regarding the effect of equipment such as brushes and sponges.
PMID: 18254046 [PubMed - indexed for MEDLINE]
JAMA. 2002 Aug 14;288(6):722-7.
Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study.
Parienti JJ, Thibon P, Heller R, Le Roux Y, von Theobald P, Bensadoun H, Bouvet A, Lemarchand F, Le Coutour X; Antisepsie Chirurgicale des mains Study Group.
Departments of Infectious Diseases and Intensive Care Unit, Côte de Nacre University Hospital Centre, 14 033 Caen Cedex, France. parienti@u444.jussieu.fr
Erratum in:
• JAMA 2002 Dec 4;288(21):2689. Bensadoun, Hervé [corrected to Bensadoun, Henri].
Comment in:
• JAMA. 2002 Dec 4;288(21):2688; author reply 2688-9.
• Evid Based Nurs. 2003 Apr;6(2):54-5.
CONTEXT: Surgical site infections prolong hospital stays, are among the leading nosocomial causes of morbidity, and a source of excess medical costs. Clinical studies comparing the risk of nosocomial infection after different hand antisepsis protocols are scarce. OBJECTIVE: To compare the effectiveness of hand-cleansing protocols in preventing surgical site infections during routine surgical practice. DESIGN: Randomized equivalence trial. SETTING: Six surgical services from teaching and nonteaching hospitals in France. PATIENTS: A total of 4387 consecutive patients who underwent clean and clean-contaminated surgery between January 1, 2000, and May 1, 2001. INTERVENTIONS: Surgical services used 2 hand-cleansing methods alternately every other month: a hand-rubbing protocol with 75% aqueous alcoholic solution containing propanol-1, propanol-2, and mecetronium etilsulfate; and a hand-scrubbing protocol with antiseptic preparation containing 4% povidone iodine or 4% chlorhexidine gluconate. MAIN OUTCOME MEASURES: Thirty-day surgical site infection rates were the primary end point; operating department teams' tolerance of and compliance with hand antisepsis were secondary end points. RESULTS: The 2 protocols were comparable in regard to surgical site infection risk factors. Surgical site infection rates were 55 of 2252 (2.44%) in the hand-rubbing protocol and 53 of 2135 (2.48%) in the hand-scrubbing protocol, for a difference of 0.04% (95% confidence interval, -0.88% to 0.96%). Based on subsets of personnel, compliance with the recommended duration of hand antisepsis was better in the hand-rubbing protocol of the study compared with the hand-scrubbing protocol (44% vs 28%, respectively; P =.008), as was tolerance, with less skin dryness and less skin irritation after aqueous solution use. CONCLUSIONS: Hand-rubbing with aqueous alcoholic solution, preceded by a 1-minute nonantiseptic hand wash before each surgeon's first procedure of the day and before any other procedure if the hands were soiled, was as effective as traditional hand-scrubbing with antiseptic soap in preventing surgical site infections. The hand-rubbing protocol was better tolerated by the surgical teams and improved compliance with hygiene guidelines. Hand-rubbing with liquid aqueous alcoholic solution can thus be safely used as an alternative to traditional surgical hand-scrubbing.
PMID: 12169076 [PubMed - indexed for MEDLINE]
Pereira LJ, Lee GM, Wade KJ.
Department of Biological Sciences, Faculty of Health Sciences, University of Sydney, Australia.
Five protocols for surgical handwashing (scrubbing) were evaluated for their efficiency of removal of micro-organisms and their drying effect on the skin. The scrubbing protocols tested were: (1) an initial scrub of 5 min and consecutive scrubs of 3.5 min with chlorhexidine gluconate 4% (CHG-5); (2) an initial scrub of 3 min and consecutive scrubs of 2.5 min with chlorhexidine gluconate 4% (CHG-3); (3) an initial scrub of 3 min and consecutive scrubs of 2.5 min with povidone iodine 5% and triclosan 1% (PI-3); (4) an initial scrub of 2 min with chlorhexidine gluconate 4% followed by a 30 s application of isopropanol 70% and chlorhexidine gluconate 0.5%, and a 30 s application of isopropanol 70% and chlorhexidine gluconate 0.5% for consecutive scrubs (IPA); and (5) an initial scrub of 2 min with chlorhexidine gluconate 4% followed by a 30 s application of ethanol 70% and chlorhexidine gluconate 0.5%, and a 30 s application of ethanol 70% and chlorhexidine gluconate 0.5% for consecutive scrubs (EA). A convenience sample of 23 operating theatre nurses completed each scrub protocol for one week in a randomized order. A week of normal work activities intervened between each protocol. Subjects were assessed before commencing and after completing the week of each protocol to determine changes in the microbial counts and skin condition of the hands. Specimens for microbial analysis were collected before, immediately after and 2 h after an initial scrub, and 2 h after a consecutive scrub. The CHG-5, CHG-3 and PI-3 protocols, which used detergent-based antiseptics only, were compared with protocols incorporating an alcohol-based antiseptic (IPA and EA). The protocols incorporating alcohol-based antiseptics and the CHG-5 protocol were generally associated with the lowest post-scrub numbers of colony forming units (cfu). No difference between the CHG-5 protocol and the alcohol-based antiseptics was found at the beginning of the test week, but after exclusive use of the respective protocols for a week, the alcohol-based antiseptics were associated with significantly lower cfu numbers in two out of the three post-scrub samples (P = 0.003, P = 0.035). Although virtually no statistically significant differences in skin condition were found, many subjects reported the alcohol-based antiseptic protocols to be less drying on the skin. The findings of this study support the proposition that a scrub protocol using alcohol-based antiseptics is as effective and no more damaging to skin than more time-consuming, conventional methods using detergent-based antiseptics.
PMID: 9172045 [PubMed - indexed for MEDLINE]
Dermatology. 2006;212 Suppl 1:21-5.
Comparison of the antimicrobial efficacy of povidone-iodine, povidone-iodine-ethanol and chlorhexidine gluconate-ethanol surgical scrubs.
Nishimura C.
Operating Suite, Shinshu University Hospital, Nagano 390-8621, Japan. cnishim@hsp.me.shinshu-u.ac.jp
BACKGROUND: Scrubbing of the hands and forearms with a brush and antiseptic agents has been the standard for surgical practice. However, it has been increasingly recognized that brush scrubbing may provoke side effects and that an alcohol-based hand antiseptic used in conjunction with a scrub agent enhances the effectiveness. In this study, two types of alcohol-based agents were used after a povidone-iodine (PVP-I) scrub and compared for their effectiveness. MATERIALS AND METHODS: The study was conducted as a crossover trial with 20 volunteers. After hand rubbing with PVP-I, either PVP-I-ethanol rubbing or chlorhexidine gluconate-ethanol (CHG-ethanol) rubbing was used for surgical hand cleansing. Samples were collected by the modified glove juice method to count bacteria on hands. RESULTS: In both groups, the bacterial count was significantly reduced after handwashing (p < 0.001), and the reduction was still significant after 2 h (p < 0.001 for PVP-I-ethanol and p < 0.002 for CHG-ethanol). The log(10) reduction factor (RF) in the PVP-I-ethanol group was significantly higher than that in the CHG-ethanol group immediately after handwashing (p < 0.001) but significantly lowered after 2 h (p < 0.01) to the level similar to that of CHG-ethanol. Although RF was lower in the CHG-ethanol group immediately after and 2 h after handwashing compared to the PVP-I-ethanol group, it did not decrease with time. CONCLUSION: Brushless surgical scrubbing with PVP-I-ethanol or CHG-ethanol in conjunction with PVP-I showed antiseptic effects immediately after and 2 h after handwashing. RF immediately after handwashing was significantly higher with PVP-I-ethanol compared to CHG-ethanol, but it was similar in both groups after 2 h. These results suggest that when used in combination with a PVP-I scrub, an alcohol-based hand antiseptic containing the same active agent (PVP-I in this study) has a powerful antiseptic effect; however, when it contains different antiseptic agents (i.e. CHG in this study), it should be selected carefully based on its antiseptic property.
Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004288.
Surgical hand antisepsis to reduce surgical site infection.
Tanner J, Swarbrook S, Stuart J. De Montfort University and University Hospitals Leicester, Charles Frears Campus, 266 London Road, Leicester, UK, LE2 1RQ. jtanner@dmu.ac.uk
BACKGROUND: Surgical hand antisepsis, to destroy transient micro-organisms and inhibit the growth of resident micro-organisms, is routinely carried out before undertaking invasive procedures. Antisepsis may reduce the risk of surgical site infections in patients. OBJECTIVES: To determine the effects of surgical hand antisepsis on the number of surgical site infections (SSIs) in patients. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony forming units (CFUs) of bacteria on the hands of the surgical team. SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (Issue 2, 2007), MEDLINE (Week 5, 2007), CINAHL (June 2007), EMBASE (Week 23, 2007) and ZETOC (2005). SELECTION CRITERIA: Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions. DATA COLLECTION AND ANALYSIS: Three authors independently assessed studies for selection, trial quality and extracted data. MAIN RESULTS: Ten trials were included in this review. Only one trial reported the primary outcome, rates of SSIs, and nine trials measured numbers of CFUs. One trial involving 4387 patients found alcohol rubs with additional active ingredients were as effective as aqueous scrubs in reducing SSIs. Four trials compared different alcohol rubs containing additional active ingredients with aqueous scrubs for numbers of CFUs on hands. One trial found N-duopropenide more effective than chlorhexidine and povidone iodine aqueous scrubs. One trial found 45% propanol-2, 30% propanol-1 with 0.2% ethylhexadecyldimethyl ammonium ethylsulfate more effective than chlorhexidine scrubs. One trial found no difference between 1% chlorhexidine gluconate in 61% ethyl alcohol or zinc pyrithione in 70% ethyl alcohol against aqueous povidone iodine. A fourth trial found 4% chlorhexidine gluconate scrubs more effective than chlorhexidine in 70% alcohol rubs. Four trials compared the relative effects of different aqueous scrubs in reducing CFUs on hands. Three trials found chlorhexidine gluconate scrubs were significantly more effective than povidone iodine scrubs. One trial found no difference between chlorhexidine gluconate scrubs and povidone iodine plus triclosan scrubs. Two trials found no evidence of a difference between alternative alcohol rubs in terms of the number of CFUs. Four trials compared the effect of different durations of scrubs and rubs on the numbers of CFUs on hands. One trial found no difference after the initial scrub but found subsequent three minute scrubs using chlorhexidine significantly more effective than subsequent scrubs lasting 30 seconds. One trial found that following a one minute hand wash, a three minute rub appears to be more effective than the five minute rub using alcohol disinfectant. The other comparisons demonstrated no difference. AUTHORS' CONCLUSIONS: Alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs however this evidence comes from only one, equivalence, cluster trial which did not appear to adjust for clustering. Four comparisons suggest that alcohol rubs are at least as, if not more, effective than aqueous scrubs though the quality of these is mixed and each study presents a different comparison, precluding meta analysis. There is no evidence to suggest that any particular alcohol rub is better than another. Evidence from 4 studies suggests that chlorhexidine gluconate based aqueous scrubs are more effective than povidone iodine based aqueous scrubs in terms of the numbers of CFUs on the hands. There is limited evidence regarding the effects on CFUs numbers of different scrub durations. There is no evidence regarding the effect of equipment such as brushes and sponges.
PMID: 18254046 [PubMed - indexed for MEDLINE]
JAMA. 2002 Aug 14;288(6):722-7.
Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study.
Parienti JJ, Thibon P, Heller R, Le Roux Y, von Theobald P, Bensadoun H, Bouvet A, Lemarchand F, Le Coutour X; Antisepsie Chirurgicale des mains Study Group.
Departments of Infectious Diseases and Intensive Care Unit, Côte de Nacre University Hospital Centre, 14 033 Caen Cedex, France. parienti@u444.jussieu.fr
Erratum in:
• JAMA 2002 Dec 4;288(21):2689. Bensadoun, Hervé [corrected to Bensadoun, Henri].
Comment in:
• JAMA. 2002 Dec 4;288(21):2688; author reply 2688-9.
• Evid Based Nurs. 2003 Apr;6(2):54-5.
CONTEXT: Surgical site infections prolong hospital stays, are among the leading nosocomial causes of morbidity, and a source of excess medical costs. Clinical studies comparing the risk of nosocomial infection after different hand antisepsis protocols are scarce. OBJECTIVE: To compare the effectiveness of hand-cleansing protocols in preventing surgical site infections during routine surgical practice. DESIGN: Randomized equivalence trial. SETTING: Six surgical services from teaching and nonteaching hospitals in France. PATIENTS: A total of 4387 consecutive patients who underwent clean and clean-contaminated surgery between January 1, 2000, and May 1, 2001. INTERVENTIONS: Surgical services used 2 hand-cleansing methods alternately every other month: a hand-rubbing protocol with 75% aqueous alcoholic solution containing propanol-1, propanol-2, and mecetronium etilsulfate; and a hand-scrubbing protocol with antiseptic preparation containing 4% povidone iodine or 4% chlorhexidine gluconate. MAIN OUTCOME MEASURES: Thirty-day surgical site infection rates were the primary end point; operating department teams' tolerance of and compliance with hand antisepsis were secondary end points. RESULTS: The 2 protocols were comparable in regard to surgical site infection risk factors. Surgical site infection rates were 55 of 2252 (2.44%) in the hand-rubbing protocol and 53 of 2135 (2.48%) in the hand-scrubbing protocol, for a difference of 0.04% (95% confidence interval, -0.88% to 0.96%). Based on subsets of personnel, compliance with the recommended duration of hand antisepsis was better in the hand-rubbing protocol of the study compared with the hand-scrubbing protocol (44% vs 28%, respectively; P =.008), as was tolerance, with less skin dryness and less skin irritation after aqueous solution use. CONCLUSIONS: Hand-rubbing with aqueous alcoholic solution, preceded by a 1-minute nonantiseptic hand wash before each surgeon's first procedure of the day and before any other procedure if the hands were soiled, was as effective as traditional hand-scrubbing with antiseptic soap in preventing surgical site infections. The hand-rubbing protocol was better tolerated by the surgical teams and improved compliance with hygiene guidelines. Hand-rubbing with liquid aqueous alcoholic solution can thus be safely used as an alternative to traditional surgical hand-scrubbing.
PMID: 12169076 [PubMed - indexed for MEDLINE]
SAFE POSITIONING FOR NEUROSURGICAL PATIENTS
AORN Journal, June, 2008 by Danielle St-Arnaud, Marie-Josee Paquin
Positioning the patient for surgery is an important part of perioperative nursing care. Although it can become routine, its importance should not be underemphasized because the combined factors of time, mechanical pressure, and immobility increase the patient's risk of tissue damage. (1) The neurosurgical perioperative team faces additional challenges related to positioning because of the potential for complications during prolonged and complex procedures. Perioperative neurosurgical nurses are responsible for the safety of their patients, and safe positioning ranks high on their list of priorities. As do all perioperative nurses, the neurosurgical nurses at Montreal Neurological Hospital, Quebec, Canada, apply principles of anatomy and physiology to the process of positioning surgical patients. In many circumstances, the OR team must use creative methods to protect their patients from mechanical injury and maintain cardiovascular, pulmonary, and other physiological functions. Technological advances in specialty positioning devices also have contributed to improved patient outcomes. (1,2) This article discusses general principles of positioning as well as the most frequently used positions for neurosurgery: supine, knee-chest, prone, lateral, park-bench, and sitting.
GENERAL PRINCIPLES OF POSITIONING
Safely positioning the patient must be a team effort; each member of the surgical team plays a significant role and shares the responsibility for establishing and maintaining the correct patient position. Each member of the team brings his or her knowledge of anatomy and physiology, as well as experience in using various positioning aids and accessories, to the safe positioning of patients.
The primary objective of these activities is to balance optimal surgical exposure with the prevention of any injury related to positioning. At Montreal Neurological Hospital, the perioperative team involved with positioning consists of the circulating nurse, neurosurgeon, anesthesia care provider, and patient attendant. Throughout the intraoperative period, it is the circulating nurse's responsibility to preserve the patient's dignity, safety, and physical well-being. One of the circulating nurse's most important responsibilities is performing the preoperative assessment of each patient in regard to positioning risk factors and documenting any preexisting conditions.
POSITIONING ACTIVITIES.
The circulating nurse is responsible for coordinating positioning activities and is an active participant in safely positioning the patient. Furthermore, the circulating nurse ensures that a sufficient number of personnel are available to position the patient safely and effectively. The neurosurgeon determines optimal exposure of the surgical site, the anesthesia care provider ensures physiological stability, and the patient attendant prepares and installs positioning devices and equipment.
After the neurosurgeon determines appropriate exposure of the surgical site but before the patient is transferred to the OR bed, the circulating nurse ensures that all positioning devices and equipment are readily available, in proper working order, and clean. Positioning devices should be able to perform the following functions effectively:
* absorb compressive forces,
* prevent uneven and potentially excessive pressure distribution,
* prevent excessive stretching or compression, and
* allow chest expansion for proper ventilation and gas exchanges.
Normal body alignment must be maintained without excess flexion, extension, or rotation. For example, extreme rotation of the head can cause pressure on the carotid sinus and induce hypotension and arrhythmias or restrict venous outflow leading to congestion. (3) The nurse and anesthesia care provider work cooperatively to ensure that direct pressure on the patient's eyes is avoided to minimize the risk of central retinal artery occlusion and other ocular damage (eg, corneal abrasion). If possible, the patient is positioned so that his or her head is level with or higher than the heart and is maintained in a neutral forward position without significant neck flexion, extension, lateral flexion, or rotation. (4)
The anesthesia care provider requires access to IV lines and monitoring devices throughout the procedure to monitor and control the patient's physiological functions. The anesthesia care provider ensures that there is adequate room for chest and abdominal expansion to protect the patient's respiratory functions. The circulating nurse applies thromboembolic disease (TED) stockings or intermittent pneumatic sequential compression devices (SCDs) to reduce blood pooling in the legs; the nurse also applies SCDs if the patient is undergoing a surgical procedure with general anesthesia that will last longer than 30 minutes. (5)
MAINTAINING NORMOTHERMIA. Maintaining normothermia in relation to positioning is important." (6) The fall in core temperature that occurs after induction of anesthesia leads to a peripheral vasoconstriction, which can result in peripheral hypo-perfusion and cell hypoxia. (6) The tissue-damaging effects of pressure are more likely to occur after a decrease in oxygen delivery.
To be continued……………
Positioning the patient for surgery is an important part of perioperative nursing care. Although it can become routine, its importance should not be underemphasized because the combined factors of time, mechanical pressure, and immobility increase the patient's risk of tissue damage. (1) The neurosurgical perioperative team faces additional challenges related to positioning because of the potential for complications during prolonged and complex procedures. Perioperative neurosurgical nurses are responsible for the safety of their patients, and safe positioning ranks high on their list of priorities. As do all perioperative nurses, the neurosurgical nurses at Montreal Neurological Hospital, Quebec, Canada, apply principles of anatomy and physiology to the process of positioning surgical patients. In many circumstances, the OR team must use creative methods to protect their patients from mechanical injury and maintain cardiovascular, pulmonary, and other physiological functions. Technological advances in specialty positioning devices also have contributed to improved patient outcomes. (1,2) This article discusses general principles of positioning as well as the most frequently used positions for neurosurgery: supine, knee-chest, prone, lateral, park-bench, and sitting.
GENERAL PRINCIPLES OF POSITIONING
Safely positioning the patient must be a team effort; each member of the surgical team plays a significant role and shares the responsibility for establishing and maintaining the correct patient position. Each member of the team brings his or her knowledge of anatomy and physiology, as well as experience in using various positioning aids and accessories, to the safe positioning of patients.
The primary objective of these activities is to balance optimal surgical exposure with the prevention of any injury related to positioning. At Montreal Neurological Hospital, the perioperative team involved with positioning consists of the circulating nurse, neurosurgeon, anesthesia care provider, and patient attendant. Throughout the intraoperative period, it is the circulating nurse's responsibility to preserve the patient's dignity, safety, and physical well-being. One of the circulating nurse's most important responsibilities is performing the preoperative assessment of each patient in regard to positioning risk factors and documenting any preexisting conditions.
POSITIONING ACTIVITIES.
The circulating nurse is responsible for coordinating positioning activities and is an active participant in safely positioning the patient. Furthermore, the circulating nurse ensures that a sufficient number of personnel are available to position the patient safely and effectively. The neurosurgeon determines optimal exposure of the surgical site, the anesthesia care provider ensures physiological stability, and the patient attendant prepares and installs positioning devices and equipment.
After the neurosurgeon determines appropriate exposure of the surgical site but before the patient is transferred to the OR bed, the circulating nurse ensures that all positioning devices and equipment are readily available, in proper working order, and clean. Positioning devices should be able to perform the following functions effectively:
* absorb compressive forces,
* prevent uneven and potentially excessive pressure distribution,
* prevent excessive stretching or compression, and
* allow chest expansion for proper ventilation and gas exchanges.
Normal body alignment must be maintained without excess flexion, extension, or rotation. For example, extreme rotation of the head can cause pressure on the carotid sinus and induce hypotension and arrhythmias or restrict venous outflow leading to congestion. (3) The nurse and anesthesia care provider work cooperatively to ensure that direct pressure on the patient's eyes is avoided to minimize the risk of central retinal artery occlusion and other ocular damage (eg, corneal abrasion). If possible, the patient is positioned so that his or her head is level with or higher than the heart and is maintained in a neutral forward position without significant neck flexion, extension, lateral flexion, or rotation. (4)
The anesthesia care provider requires access to IV lines and monitoring devices throughout the procedure to monitor and control the patient's physiological functions. The anesthesia care provider ensures that there is adequate room for chest and abdominal expansion to protect the patient's respiratory functions. The circulating nurse applies thromboembolic disease (TED) stockings or intermittent pneumatic sequential compression devices (SCDs) to reduce blood pooling in the legs; the nurse also applies SCDs if the patient is undergoing a surgical procedure with general anesthesia that will last longer than 30 minutes. (5)
MAINTAINING NORMOTHERMIA. Maintaining normothermia in relation to positioning is important." (6) The fall in core temperature that occurs after induction of anesthesia leads to a peripheral vasoconstriction, which can result in peripheral hypo-perfusion and cell hypoxia. (6) The tissue-damaging effects of pressure are more likely to occur after a decrease in oxygen delivery.
To be continued……………
SEMINAR SEHARI "KNEE PAIN MANAGEMENT"
STAF MEDIS FUNGSIONAL
ORTHOPAEDI DAN TRAUMATOLOGI
RUMAH SAKIT DAERAH Dr. SOEBANDI JEMBER
A. Pendahuluan
Masalah pada sendi lutut merupakan masalah yang sering dijumpai dan mengenai kalangan dari berbagai rentang usia. Sendi lutut merupakan pertemuan antara tungkai bawah dan tungkai atas yang mampu memberikan kekuatan dan stabilitas untuk menopang beban tubuh selain itu kelenturan, kekuatan, dan stabilitas sendi lutut sangat dibutuhkan oleh manusia dalam bergerak
Sendi lutut terdiri dari berbagai elemen penting antara lain tulang, ligament, otot, tulangrawan, dan tendon.Setiap unsure tersebut memiliki kecenderungan mengalami penyakit atau trauma, hal inilah yang mendasari adanya berbagai permasalahan pada sendi lutut yang bisa berimbas pada kehidupan.Dari hasil penelitian didapatkan 46 % permasalahan sendi lutut bersifat kronis sedangkan 54 % bersifat non kronis.
RSD dr. Soebandi sebagai RumahSakit rujukan dan pendidikan merasa harus ikut berandil dalam proses penanganan penyakit sendi lutut, maka Staf Medis Fungsional Bedah Orthopaedi bekerjasama dengan Bidang Pendidikan dan Pelatihan RSD dr. Soebandi berinisiatif menyelenggarakan seminar tentang berbagai permasalahan sendi lutut meliputi diagnosis, terapi, dan follow up dengan tema“ Knee Pain Management “.
Panitia berharap kesediaan para praktisi kesehatan khususnya tenaga Medis berpartisipasi dalam seminar ini agar kemampuan penanganan permasalahan sendi lutut semakin meningkat demi tercapainya Indonesia yang sehat dan produktif.
A. Waktu dan tempat
Acara ini diselenggarakan pada hari Sabtu, tanggal 16 April 2011mulai jam : 08.00 WIB sampai selesai. Tempat di Hotel Panorama Jember Jl. KH Agus Salim No 28, Telp (0331) 333666
B. Peserta
Peserta acara ini adalah para Dokter Umum/Spesialis, Perawat, Mahasiswa dengan jumlah peserta maksimal 200 orang.
C. Registrasi
1. Biaya seminar sebesar Rp.300.000,00 ( seratus ribu rupiah ) per peserta
2. Peserta bisa mendaftar sendiri ke sekretariat IBS RSUD Dr Soebandi Jember atau transfer ke Bank Jatim Cab. Jember a/n HIPKABI PC PENTAGON No Rek 0032996744
D. Susunan Acara
| Waktu | Acara | Pembicara |
| 08.00 – 09.00 | Registrasi | |
| 09.00 – 09.10 | Pembukaan | |
| 09.10 – 09.20 | Sambutan ketua panitia | |
| 09.20 – 09.30 | Sambutan Direktur RSD Dr. Soebandi Jember sekaligus membuka acara | |
| 09.30 – 10.00 | COFFE BREAK | |
| 10.00 – 10.15 | Fraktur intercondyllar femur and Tibial plateau | Dr. I Nyoman Semita, Sp.OT, Spine, (K) |
| 10.15 – 10.30 | Osteo sarcoma and Giant cell tumor | Dr. Tito Sumarwoto, Sp.OT |
| 10.30 – 10.45 | Trauma Olah raga | Dr. Suparimbo S, Sp.OT |
| 10.45 – 11.15 | DISKUSI | |
| 11.15 – 11.45 | ISHOMA | |
| 11.45 – 12.00 | Chondro malacia patella (patellofemoral syndrome) | Dr. Choirul Yahya, Sp.OT |
| 12.00 – 12.15 | Osteoarthritis tibiofemoral | Dr. I Nyoman Semita, Sp.OT, Spine, (K) |
| 12.15 – 12.30 | Osgood schlater disease | Dr. Moch. Hasan, Sp.OT |
| 12.30 – 13.00 | DISKUSI | |
| 13.00 – 13.15 | Gonitis TB | Dr. Suparimbo Supadi, Sp.OT |
| 13.15 – 13.30 | Arthritis | Dr. Antonio Inoki, Sp.OT |
| 13.30 – 13.45 | Osteomyelitis | Dr. Novi Hamzah, Sp.OT |
| 13.45 – 14.00 | DISKUSI | |
| 14.00 – 14.15 | Penutup dan Do’a | |
E. Contact Person
Jumanto HP : 08123483469
M. Agus Malik HP : 081336715401 / 0331 3419651
Tacuk Kurniawan HP : 087757631125
Sekretariat IBS : 0331 - 423313
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