Mardona, Sopi (2026) Asuhan Keperawatan pada An. W dengan cedera otak berat traumatik (COBT) pasca operasi kraniektomi di Ruang Flamboyan RSUD dr. Doris Sylvanus. Karya Tulis Ilmiah thesis, Potekkes Kemenkes Palangkaraya.
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Abstract
Latar Belakang: Cedera Otak Traumatik (COT) berat pasca kraniektomi dekompresi memicu risiko mortalitas tinggi dan komplikasi defisit neurologis akibat peningkatan tekanan intrakranial (TIK). Tujuan Penelitian: Memaparkan pelaksanaan asuhan keperawatan komprehensif pada An. W dengan COT pasca operasi kraniektomi di RSUD dr. Doris Sylvanus. Metode Penelitian: Studi kasus deskriptif pada pasien berusia 16 tahun selama tiga hari melalui wawancara keluarga, observasi klinis, pemeriksaan fisik, dan dokumentasi rekam medis. Hasil Penelitian: Pengkajian awal menunjukkan kesadaran apatis (GCS E4V3M6), hemiparesis sinistra, dan fraktur antebrachii sinistra. Hasil CT scan menunjukkan multiple ICH, EDH temporal bilateral, edema serebri, dan midline shift 1,4 cm. Masalah keperawatan utama adalah Penurunan Kapasitas Adaptif Intrakranial dan Gangguan Mobilitas Fisik. Intervensi meliputi pemantauan TTV/MAP, posisi head up 30°, kolaborasi terapi osmotik (manitol), dan latihan ROM pasif bertahap. Setelah 3 hari perawatan, kedua masalah belum teratasi karena pasien masih dalam fase akut. Kesimpulan: Asuhan keperawatan holistik sangat krusial untuk mengontrol TIK dan mencegah cedera sekunder. Diperlukan kolaborasi medis yang cepat serta pelibatan aktif keluarga guna mengoptimalkan pemulihan pasien. Kata Kunci: Asuhan keperawatan, Cedera Otak Traumatik, Gangguan Mobilitas Fisik, Kraniektomi, Penurunan Kapasitas Adaptif Intrakranial. Background: Traumatic Brain Injury (TBI) post-decompressive craniectomy carries a high mortality risk and severe neurological deficits due to increased intracranial pressure (ICP). Objective: To present comprehensive nursing care for Patient W with TBI post-craniectomy at Dr. Doris Sylvanus Regional General Hospital. Methods: A descriptive case study focused on a 16-year-old patient, with data collected over three consecutive days through interviews, observations, physical examinations, and medical records. Results: Assessment revealed an apathetic state (GCS E4V3M6), left hemiparesis, and a left forearm fracture. The CT scan showed multiple ICH, bilateral temporal EDH, cerebral edema, and a 1.4 cm midline shift. The primary nursing diagnoses were Decreased Intracranial Adaptive Capacity and Impaired Physical Mobility. Interventions included vital signs/MAP monitoring, maintaining a 30° head-up position, collaborative osmotic therapy, and gradual passive ROM exercises. After 3 days, both issues remained unresolved as the patient was in the acute recovery phase. Conclusions: Holistic nursing care is critical for controlling ICP and preventing secondary brain injury. Prompt medical collaboration and family engagement in passive stimulation are essential to optimize recovery. Keywords: Craniectomy, Decreased Intracranial Adaptive Capacity, Impaired Physical Mobility, Nursing care, Traumatic Brain Injury
| Item Type: | Laporan Tugas Akhir / Karya Tulis Ilmiah / Laporan Praktek Asuhan Kebidanan (stase 9) / Skripsi / Tesis / Disertasi (Karya Tulis Ilmiah) |
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| Uncontrolled Keywords: | Asuhan keperawatan, Cedera Otak Traumatik, Gangguan Mobilitas Fisik, Kraniektomi, Penurunan Kapasitas Adaptif Intrakranial. |
| Subjects: | 11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing > 111007 Nursing Theory 11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing > 111011 Nursing Specialties 11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing > 111011 Nursing Specialties > 11101113 Medical-Surgical Nursing 11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing |
| Divisions: | Jurusan Keperawatan > Program Studi Diploma III Keperawatan |
| Depositing User: | Mahasiswa D3 Keperawatan |
| Date Deposited: | 22 Jul 2026 05:29 |
| Last Modified: | 22 Jul 2026 05:29 |
| URI: | http://repo.polkesraya.ac.id/id/eprint/3615 |
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