Repository Poltekkes Kemenkes Palangka Raya

Ilmi, Alifah Rosihatul (2026) Studi kasus asuhan keperawatan pada Tn. H dengan stroke infark serebral di Ruang Seruni RSUD Ulin Banjarmasin. Karya Tulis Ilmiah thesis, Poltekkes Kemenkes Palangka Raya.

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Abstract

Latar Belakang: Stroke infark serebral merupakan gangguan neurologis akibat terhambatnya aliran darah ke otak yang menyebabkan kerusakan jaringan otak sehingga menimbulkan gangguan fungsi motorik, komunikasi, serta meningkatkan risiko jatuh dan ketergantungan dalam melakukan aktivitas sehari-hari. Kondisi tersebut memerlukan asuhan keperawatan yang komprehensif, sistematis, dan berkesinambungan untuk mendukung proses pemulihan serta mencegah komplikasi. Tujuan: Mendeskripsikan penerapan asuhan keperawatan pada pasien stroke infark serebral di Ruang Seruni RSUD Ulin Banjarmasin. Metode: Penelitian ini menggunakan desain studi kasus deskriptif dengan pendekatan proses keperawatan yang meliputi pengkajian, diagnosis keperawatan, perencanaan, implementasi, dan evaluasi. Subjek penelitian adalah satu pasien stroke infark serebral yang menjalani perawatan selama tiga hari. Pengumpulan data dilakukan melalui wawancara, observasi, pemeriksaan fisik, telaah rekam medis, dan studi dokumentasi. Hasil: Hasil pengkajian menunjukkan pasien mengalami hemiparesis sinistra, disartria, riwayat hipertensi yang tidak terkontrol, riwayat stroke berulang, serta memiliki risiko jatuh. Diagnosis keperawatan yang ditegakkan meliputi gangguan mobilitas fisik, risiko jatuh, gangguan komunikasi verbal, dan manajemen kesehatan tidak efektif. Implementasi keperawatan dilakukan selama tiga hari berdasarkan Standar Intervensi Keperawatan Indonesia (SIKI) dan disesuaikan dengan kondisi pasien. Hasil evaluasi menunjukkan bahwa gangguan mobilitas fisik belum teratasi karena kekuatan otot ekstremitas kiri masih menurun sehingga pasien masih memerlukan bantuan dalam mobilisasi. Risiko jatuh masih memerlukan upaya pencegahan secara berkelanjutan. Gangguan komunikasi verbal dan manajemen kesehatan tidak efektif teratasi sebagian, ditandai dengan peningkatan kemampuan komunikasi pasien serta meningkatnya pemahaman pasien dan keluarga mengenai penyakit, pengobatan, pengendalian faktor risiko, dan pencegahan stroke berulang. Kesimpulan: Penerapan asuhan keperawatan melalui pendekatan proses keperawatan memberikan perkembangan positif terhadap kondisi pasien, terutama pada kemampuan komunikasi verbal dan peningkatan pemahaman mengenai pengelolaan kesehatan. Namun, gangguan mobilitas fisik masih memerlukan intervensi dan rehabilitasi secara berkelanjutan untuk meningkatkan kemandirian pasien, sedangkan upaya pencegahan risiko jatuh perlu terus dipertahankan guna mencegah terjadinya cedera selama proses pemulihan. Kata Kunci: Asuhan Keperawatan; Gangguan Komunikasi Verbal; Gangguan Mobilitas Fisik; Risiko Jatuh; Stroke Infark Serebral. Background: Cerebral infarction stroke is a neurological disorder caused by impaired blood flow to the brain, resulting in brain tissue damage that leads to impaired motor function, communication difficulties, an increased risk of falls, and dependence in performing activities of daily living. This condition requires comprehensive, systematic, and continuous nursing care to support the recovery process and prevent complications. Objective: To describe the implementation of nursing care for a patient with cerebral infarction stroke in the Seruni Ward of Ulin Regional General Hospital, Banjarmasin. Methods: This study employed a descriptive case study design using the nursing process approach, which included assessment, nursing diagnosis, planning, implementation, and evaluation. The subject of this study was one patient with cerebral infarction stroke who received nursing care for three days. Data were collected through interviews, observations, physical examinations, medical record reviews, and documentation studies. Results: The assessment revealed that the patient experienced left-sided hemiparesis, dysarthria, uncontrolled hypertension, recurrent stroke, and was at risk of falls. The nursing diagnoses established were impaired physical mobility, risk for falls, impaired verbal communication, and ineffective health management. Nursing interventions were implemented for three days based on the Indonesian Nursing Intervention Standards (SIKI) and tailored to the patient’s condition. The evaluation showed that impaired physical mobility had not been resolved because the muscle strength of the left extremities remained decreased, requiring assistance with mobility. The risk for falls still required continuous preventive measures. Impaired verbal communication and ineffective health management were partially resolved, as indicated by improvements in the patient’s communication abilities and increased understanding of the disease, treatment, risk factor control, and prevention of recurrent stroke among the patient and family. Conclusion: The implementation of nursing care using the nursing process approach resulted in positive progress in the patient’s condition, particularly in verbal communication skills and understanding of health management. However, impaired physical mobility still requires ongoing interventions and rehabilitation to improve the patient’s independence, while continuous fall prevention efforts should be maintained to prevent injury during the recovery process. Keywords: Cerebral Infarction Stroke; Impaired Physical Mobility; Impaired Verbal Communication; Nursing Care; Risk for Falls.

Item Type:	Laporan Tugas Akhir / Karya Tulis Ilmiah / Laporan Praktek Asuhan Kebidanan (stase 9) / Skripsi / Tesis / Disertasi (Karya Tulis Ilmiah)
Uncontrolled Keywords:	Asuhan Keperawatan; Gangguan Komunikasi Verbal; Gangguan Mobilitas Fisik; Risiko Jatuh; Stroke Infark Serebral.
Subjects:	11 MEDICAL AND HEALTH SCIENCES > 1109 Neurosciences > 110904 Neurology and Neuromuscular Diseases 11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing > 111009 Nursing Research 11 MEDICAL AND HEALTH SCIENCES > 1109 Neurosciences 11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing
Divisions:	Jurusan Keperawatan > Program Studi Diploma III Keperawatan
Depositing User:	Mahasiswa D3 Keperawatan
Date Deposited:	27 Jul 2026 02:03
Last Modified:	27 Jul 2026 02:03
URI:	http://repo.polkesraya.ac.id/id/eprint/3679

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