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  1. 1. BAB 1 Intensive care unit (ICU) is a managed special care unit to care for patients and critically ill, injured with life-threatening complications involving health workers trained, and supported by the completeness of specialized equipment (MOH, 2006). Judging from the criteria of ICU patients can be classified into three priorities, namely patients with a first priority of critically ill patients, unstable requiring intensive care with the help of ventilation equipment, monitoring and continuous vasoactive drugs and others. Patients with advanced second priority need of ICU care. This type of risk patients requiring intensive therapy soon. And the latter is the third priority, is critically ill and patients with unstable health status where previously, the underlying disease or acute disease, either individually or in combination greatly reduces the possibility of healing and or benefit from therapy in the ICU (MOH, 2006 ). Oral Hygiene and dental oral care is applied to patients who are unable to maintain oral hygiene and dental. This treatment is given by way of cleaning and brushing the teeth and oral cavity on a regular basis. Mouth and dental care aimed at maintaining oral hygiene and tooth, prevent infection due to damage to the mouth or teeth (Saputra, 2012). Clients who do not obey the Oral Hygiene sometimes have a bad gum tissue, inflamed gums, coated tongue, tooth discoloration (especially at the boundaries of the gums), dental caries, tooth loss, and halitosis (bad breath). And usually in patients who are not adequately perform Oral Hygiene themselves usually on the order of acute care clients who require a complete oral examination and treatment (Perry Potter, 2010). Dental hygiene and good oral is a state where the oral cavity free of an accumulation of debris, plaque, materia alba, and stain (Carranza's, 2002). As for the problems or disorders of the mouth and dental caries among other things, halitosis, plaque, periodontal disease, stomatotitis (thrush), glossitis and kilosis. In Indonesia, oral and dental care applied to patients who are unable to maintain oral hygiene and dental. This treatment is given by way of cleaning and brushing the teeth and oral cavity on a regular basis. Mouth and dental care aimed at maintaining oral hygiene and tooth, prevent infection due to damage to the mouth or teeth (Saputra, 2012).
  2. 2. As noted by the word of Allah in surah Al-Muddatsir paragraph 4 which means: "and wipe your clothes". Similarly, Islam against individual attention as stated in a hadith Rasullah Saw: Even if not incriminating my ummah, He enjoined them I brush my teeth every want to perform ablution. (HR-Al-Baikhaqi, Malik, Assyafii and Judge). According to (Potter & Perry, 2010) clients in order acute care requires a complete oral examination. Identification of the risk of infection will identify the type and frequency of oral care. Proper oral care reduces pneumonia because reduces the number of bacteria in the oral secretions aspirated and cause bacterial infections (Research Update, 2002). In ICU RSU PKU Muhammadiyah Bantul Oral Hygiene shall be done only 1 time in a day ie in the morning. However, patients with the aid of a ventilator can be done more than one time because the patient has respiratory problems and Oral Hygiene should be highly monitored by nurses. Patients with full awareness Oral Hygiene can do yourself with a toothbrush, but if patients with less Oral Hygiene awareness can be done by nurses. According to (Abidia, 2007) oral care for patients in the ICU is essential, but it must be done according to the procedures that have been implemented. Therefore, patients in ICU oral care is important, to prevent dental problems and the likelihood of complications. According to the head space in the ICU RSU PKU Muhammadiyah Bantul yet legally endorsed RS Oral Hygiene related SOP. However, be assured that soon passed. He told the investigators that the SOP Oral Hygiene in the ICU had only lived there passed away. Oral Hygiene current SOP is in use as a guide in Oral Hygiene care in the ICU. The interview with the Head of ICU mother said in the Oral Hygiene doing has not been done according to standard operating procedures for minimum nurse who was in the ICU. Not all the pieces SOP checklist could be done. We know the standard operating procedure is one of the guidelines in action. Given the role of nurses in ICU is essential, and interact directly with patients and play a role in the prevention of infection. Do with us as health workers or nurses, should receive more attention in carrying out their duties, especially knowledge about actions Oral Hygiene, as well as adherence to Oral Hygiene procedure implementation in accordance with the provisions set each hospital. Thus, researchers want to conduct research on the implementation of the
  3. 3. standard description of operating procedures (SOP) Oral Hygiene in ICU patients by nurses in RSU PKU Muhammadiyah Bantul. BAB 2 1. Definition of Standard Operating Procedures (SOP) Standard Operating Procedure is a performance standard or as the affairs of the desired values are able to be met in relation to the parameters that have been set (Donabedian, 1960). Standards that had understanding as a guide to improve the quality of being run effectively and efficiently and in the application of standards of medical care considered several aspects related to information, explanation of procedures, health care and medical ethics. 2. The purpose of Standard Operating Procedures (SOP) The purpose of the application of medical standards by the Ministry of Health in 1993 are: a. Protect the public from practices which are not in accordance with professional standards. b. Protect the profession of it, and sometimes people who are not fair and as guidance in the supervision and guidance as well as improving the quality of medical care. c. As a guideline for running health services effectively and efficiently. 3. Standard Operating Procedure (SOP) Oral Hygiene Standard Operating Procedure (SOP) Oral Hygiene in ICU RSU PKU Muhammadiyah Bantul: a. Standard Operating Procedure (SOP) with a toothbrush Oral Hygiene: 1) Checked the therapy program 2) Wash hands 3) Placing the device near the patient 4) Giving greetings and greeting the patient's name 5) Explain the purpose and implementation procedures 6) Ask the patient's consent and readiness 7) Maintain privacy 8) Install waterproof and base / towel under the patient's chin 9) Wear gloves 10) Helping patients gargle while preparing crooked 11) Helping prepare toothbrush and pasta 12) Helping patients brushing the front, side and in 13) Helping patients to rinse the mouth while preparing crooked
  4. 4. 14) Repeating help patients brushing the front, side and in 15) Helping patients gargle 16) Dry lips with a tissue 17) Tidy patient as comfortable as possible and give the position 18) Evaluate the results of the action 19) to Leave the patient 20) Clearing and return the device to its original place 21) Wash your hands 22) Record activities in the nursing record sheet Standard Operating Procedure (SOP) Oral Hygiene in unconscious patients: 1) Explain the procedure to the patient even though the patient is unconscious 2) Wash hands and wear gloves 3) Adjust the position of the client 4) Bring the tool kedekat patients 5) Open the patient's mouth with the tongue spatula 6) Take the tweezers and gauze rolls (depper) that has been moistened with a solution of chlorhexidin or Ekasari 7) Perform cleaning starts from the walls of the mouth, gums, teeth and tongue. If necessary use suctin for cleaning fluids / secretions when accumulated 8) Verify the condition of the oral cavity is clean 9) Clean equipment and return it to its original place 10) Remove the glove 11) Wash your hands 12) Documentation of procedures and evaluation of results 1. understanding Nurse According to the International Council of Nursing (1965 in Ali, 2002) nurse is someone who has completed a nursing education program, country authorities concerned to provide services, and are responsible for health promotion, disease prevention and patient services. Nurse is a person who plays a role in caring for and helping someone to protect them from pain, injury and aging process (Taylor in Ali, 2001). According to the Act - Act No. 23 of 1992 nurses are those who have the ability and authority to take action based on their knowledge of nursing, nursing education obtained through (Ali, 2002). Nurochmah (2002), states a nurse is one of the health professionals who
  5. 5. provide health services to people wherever they work. Form of service provided has always been a service provided to the client system who face health problems through the efforts of their basic needs. Nurse is a professional assessment of the soul, a form of honor to do the work of providing services to people in need and has the characteristics, autonomy, academic preparation time, commitment, and responsibility. 2. role of Nurses The role of nurses in CHS, 1989, is the behavior expected by others on a person in accordance with the position in the system, which can be influenced by both the social circumstances of the nursing profession and from outside the nursing profession which is constant. Role as provider of nursing care, client advocate, educator, coordinator, collaborator, consultant and innovator (Hidayat, 2008). According Sumijatun 2011 said that nurses have a major role in determining the standard of education and nursing services and apply nursing education activities and services. Nurses play an active role in the professional development of nursing activities. Then nurses actively participate in efforts to build and maintain professional working conditions conducive for the realization of high-quality nursing care. According to the National Workshop (1983) in (Ali, 2002) the role of the nurse: 1. As implementing nursing services. 2. Is nursing services and educational institutions. 3. Educators in nursing. 4. Researchers and developers of nursing. C. ICU 1. understanding ICU Intensive Care Unit (ICU) is a part of the independent hospitals, with specialized staff and equipment specifically intended for observation, care and treatment of patients suffering from an acute illness, injury or complicationsthreatening complications (MOH 2011). 2. ICU destination ICU destination according to (MOH, 2011) consists of general and special purpose. a. Main objectives: Improve the quality of care and patient safety in the ICU.
  6. 6. b. Specific Objectives: 1) Provide, improve and develop human resources. 2) Improve infrastructure and ICU equipment. 3) Improve efficiency and utilization of services efektitas ICU especially critical for stable patients who only require the supervisory ministry. 3. Scope of ICU The scope of services provided in the ICU are as follows: a. Diagnosis and management of acute specific diseases are life-threatening and can cause death. b. Provide assistance and take over the vital functions of the body and perform the necessary actions immediately useful and effective for survival. c. Monitoring of vital functions and management of the complications caused by the disease. d. Provide psychological support to patients and families whose lives depend on drugs, devices and machines (MOH, 2011). 4. ICU nurse According to (MOH, 2006) nurses in ICU aims to save lives, prevent worsening of the condition and its complications through observation and close monitoring with the ability of interpreting any data obtained, and conduct follow-up. Improve the patient's quality of life and sustain life as well as in reducing mortality and disability critically ill patients and accelerate the healing process of the patient. Characteristics of ICU nurses include: a. Manage patients based on standards consistent with intensive nursing b. Respect for fellow colleagues and other team c. Integrating scientific capabilities and special skills, and followed by the value of ethics and legal in providing nursing care d. Continually respond to the changing environment e. Apply effective communication skills f. Clinical skills that demonstrate the ability of high g. Interpret complex situation analysis h. Develop health education for patients and families i. critical thinking j. Able to face the challenges k. Develop knowledge and research
  7. 7. l. m. Innovative Thinking ahead D. oral Hygiene 1. Understanding Oral Hygiene Oral hygiene is an act done which seeks to clean and freshen the mouth, teeth and gums (Clark, the Shocker, 2008). According to Taylor, (the Shocker, 2008), the oral hygiene measures designed to maintain continuity of the lips, tongue and oral mucosa, prevent infection and moisten the membranes of the mouth and lips. Meanwhile, according to Hidayat and Uliyah (2005), oral hygiene is nursing actions performed on patients who are hospitalized. This can be done by a conscious patient independently or with the help of a nurse. For patients who are unable to maintain oral hygiene and tooth independently should be fully monitored by nurses. Then the provision of nursing care to clean the patient's mouth at least be done at least twice a day (Potter & Perry, 2005. 2. The purpose Oral Hygiene The importance of oral hygiene performed on patients. The multiple objectives of Oral Hygiene is to prevent oral disease, prevents disease transmission through the mouth, enhance immunity, improve the function of the mouth to enhance appetite by Clark (in Shocker, 2008). Pelakanaan Oral Hygiene by Hidayat and Uliyah (2005), the purpose of oral hygiene measures does aim to prevent gum and tooth infections. Maintain freshness and comfort of the mouth of the oral cavity. 3. Lack of Cleanliness danger Mouth Oral Hygiene main purpose of which is to improve oral health. Prevent the buildup of plaque and prevent stickiness of bacteria that forms on teeth. Accumulation of bacterial plaque on the teeth due to poor oral hygiene are the main causes of oral health issues, especially the tooth. Poor oral hygiene allows the accumulation of acid-producing bacteria to the tooth surface. Demineralizes acid enamel causing tooth decay (cavities). Dental plaque can also invade and infect the gums causing gum disease and periodontitis. Many oral health problems, such as thrush, mouth sores, bad breath and others considered the effects of poor oral health. Most of the teeth and mouth problems can be avoided simply by maintaining good oral hygiene (Forthnet, 2010). Clients who do not obey the Oral Hygiene sometimes have a bad gum tissue, inflamed gums, coated tongue, tooth discoloration (especially the gums), dental caries, tooth loss, and halitosis (bad breath). Pain and local infection is a common symptom of gum disease and tooth abnormalities (Potter & Ferry,
  8. 8. 2010). 4. How to Maintain Oral Hygiene a. do it Yourself According Denstisty (2010), in ways that can be done alone, and effective in keeping the Oral Hygiene, is as follows: 1) Brush your teeth Introduction of appropriate toothbrush, motivating to brush your teeth regularly with toothpaste and the selection of the right. Toothbrush technique is commonly performed horizontally and it is a mistake because in this way can eventually lead to tooth abrasion and gingival recession. In patients who are not aware, brush teeth replaced with wrapping cloth towel or gauze on the finger tip of the stem. Toothpaste helps but is not necessary. According to Potter & Perry (2005) perfectly done brushing teeth at least four times a day (after meals and at bedtime). Toothbrush should have a straight stem and a small brush to reach all areas. Brush the surface of a flat, round and soft nylon bristle brush is the best option. Antiseptic mouth rinse There are a variety of active ingredients that are often used as a mouth rinse, such as metal salicylate, chlorhexidine 0.20% H2O2 and 1.5% or 3.0%. Garglegargle cheaper and quite effective is with warm salt water. 3) Dental floss or dental floss This method was introduced and started being powerful enough to clean in between teeth. 4) Wash the tongue Piles of debris on the dorsum of the tongue is full of germs and candida opportunists who live as normal flora and transient. b. Performed in patients with decreased level of consciousness According to Potter & Perry (2005) equipment 1) Fresh Air 2) spatel tongue with pads or sponges 3) face towels, paper towels 4) small Kom 5) Crooked 6) glass with cold water 7) Spuit small air-bulb 8) suction catheter connected to a vacuum 9) Disposable gloves
  9. 9. 10) 11) Depper Tweezers BAB 3 CHAPTER III METHODS A. Research Design This study uses a non-experimental research design was descriptive crosssectional approach is the design of the study by taking measurements or observations at the same time (all the time). B. population Research 1. population Is the subject of the study population overall. If one wants to examine all the elements that exist in the area of research, the research is the study population (Arikunto, 2006). The population in this study were all nurses in the ICU RSU PKU Muhammadiyah Bantul which in total amounted to 12 people. 2. samples Sampling technique in this study used purposive sampling. Purposive sampling is a technique of determination among the sample population according to the researchers desired so that the samples can represent the characteristics of the population that has been known previously (Nursalam, 2003). Samples taken as many as 12 people. C. Location and Time Research 1. Research Sites The research was conducted in the ICU RSU PKU Muhammadiyah Bantul. 2. Research time This study was conducted on May 10, 2013 until the date of June 10, 2013. D. Research Variables
  10. 10. Variables used in this study is a variable that is the implementation of standard operating procedures Oral Hygiene. E. Operational definition Standard Operating Procedure (SOP) Oral Hygiene conducted by nurses on patients in the ICU RSU PKU Muhammadiyah Bantul. Consists of several stages: pre-interaction, orientation, employment and termination. Ordinal scale used is said to be good if all the points of procedure Oral Hygiene persetase is achieving 76-100%, enough if the percentage of 56-75%, said to be less if the percentage of 40-55%, and no good if the percentage ˂40%. F. Research instrument Instrument used in this study is the observation sheet by SOP Oral Hygiene ICU consisting of several checklist. SOP Oral Hygiene in the unconscious patient and Oral Hygiene with a toothbrush and modified by the researcher. G. Data Collection Method Implementation of observations carried out on schedule Oral Hygiene in ICU patients in RSU PKU Muhammadiyah Bantul. Data retrieval is taken once a day for a full month. Before conducting the study researchers write biographical data of each ICU nurse and given full informed consent. H. Data analysis In this study, a descriptive analysis of the data revealed that the frequency distribution both in absolute and percentage. Then use the formula Average (mean) as follows: Description: x: fx: n: number of data the frequency average of mean data I. Research Ethics Researchers must protect the rights of the respondents during the research process, ethical issues that must be considered is memnerikan researchers informed consent (consent form) that the respondent understands the intent and purpose of the research, ethics, and the other is anonymous confidetiality
  11. 11. (confidentiality), in this study did not use names of the respondents, but only in the form of code, so that the confidentiality of respondents maintained (Azis, 2007). J. Test Validity and Reliability Validity is a measure that indicates the level of validity or authenticity of something instrumental in collecting the data (Nursalam, 2003). Test the validity of the instrument in this study using the formula Pearson product moment correlation formula, as follows: Pearson product moment formula Description: rxy: the correlation coefficient between variables X and Y NΣXY: number multiplication X and Y Σx: sum score of items (X) Σy: item total score (Y) N: the number of respondents Valid instrument if the correlation index (r) 0.800 to 1.000 = very high .600 To .799 = high 0.400 to 0.599 = high 0.200 to 0.399 = low 0.000 to 0.199 = very low (not valid) Reliability was calculated using Cronbach Alpha coefficient formula as follows: Description: Σ: Mean : k: Mean squared inter-subject squared Variance error total K. The course of study 1. Preparation Phase Includes study of the literature to capture the data, preliminary study, the research permit administration, preparation of proposals, consult a tutor, test proposal. 2. Implementation phase Conduct primary research data collection using valid and reliable instruments are held every day from May 10 2013 until June 10, 2013.