ASUHAN KEPERAWATAN DENGAN MASALAH PERFUSI JARINGAN SEREBRAL TIDAK EFEKTIF PADA PASIEN CEDERA OTAK DI RSU ANWAR MEDIKA KRIAN - SIDOARJO

Abstract

A brain injury is the highest cause of death for a productive age, a male and female comparison is 2:1 which is about 70% caused by a traffic accident. Based on the classification according to Glascow Coma Scale (GCS), brain injury is distinguished into 3 namely mild, moderate, and severe brain injuries. The problem of nursing often occurs in cases of brain injury is a disorder in the neurology system, i.e., the perfusion of ineffective cerebral tissue is because the injury can lead to tissue, skin, muscle, and vascular continuity that can interfere with blood supply and cause hypoxia or lack of oxygen in the brain. In the hypoxia cerebral, will be held anaerobic metabolism resulting in less energy and residual lactic acid that can alter PH, PC2, and PO2 resulting in lactic acidosis and vasodilation of blood vessels that are capable of causing edema in the brain and disrupt perfusion in cerebral tissues. Aim of the study is to explore nursing care with the problem of ineffective cerebral tissue perfusion in brain injury patients at the Anwar Medika General Hospital Krian Sidoarjo. The method used in the preparation of this final task is a case study method. The standards of nursing care on both clients start from assessment, diagnosis, intervention, implementation, and evaluation. The data collection is obtained from interviews, observations, physical examinations, and documentation. The nursing intervention is done by giving head up 30 º position, maintain neutral head, and neck position, and collaboration for giving diuretic. The result that the researcher obtained is on client 1 client’s GCS increased to E:4 V:4 M:6, while on client 2 occurs a slight increase in GCS to E:2 V:X M:5. From the result of the study, it is expected to be used by further researchers to further develop and modify nursing actions so that it can achieve optimal results.