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.
