Repository Poltekkes Kemenkes Palangka Raya

Rizky, Haykal (2026) Studi kasus asuhan keperawatan pada pasien Tn. M dengan cedera kepala berat (CKB) di Ruang ICU RSUD Ulin Banjarmasin. Karya Tulis Ilmiah thesis, Poltekkes Kemenkes Palangka Raya.

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Abstract

Latar Belakang: Cedera Kepala Berat (CKB) merupakan kondisi kegawatdaruratan neurologis akibat trauma mekanik eksternal, ditandai dengan nilai Glasgow Coma Scale (GCS) ≤ 8. Kondisi ini berisiko tinggi menyebabkan peningkatan tekanan intrakranial (TIK), sehingga memerlukan asuhan keperawatan intensif yang komprehensif untuk mencegah komplikasi dan mempertahankan fungsi vital pasien. Tujuan Penelitian: Menggambarkan pelaksanaan asuhan keperawatan secara komprehensif pada pasien dengan Cedera Kepala Berat (CKB) di Ruang ICU RSUD Ulin Banjarmasin Kalimantan Selatan. Metode Penelitian: Penelitian menggunakan metode studi kasus deskriptif dengan pendekatan proses keperawatan yang meliputi pengkajian, diagnosis keperawatan, intervensi, implementasi, dan evaluasi keperawatan pada satu pasien dengan Cedera Kepala Berat (CKB) yang dirawat di Ruang ICU RSUD Ulin Banjarmasin pada bulan April 2026. Hasil Penelitian: Hasil pengkajian pada Tn. M (29 tahun) menunjukkan penurunan kesadaran dengan GCS 3T (koma), terpasang ETT dan ventilator mekanik, serta tidak adanya respons terhadap rangsang nyeri. Intervensi keperawatan yang diberikan pemberian posisi semi-Fowler, pemantauan status respirasi dan neurologis secara berkala. Setelah dilakukan tindakan keperawatan selama 3 hari tanda-tanda vital dan oksigenasi darah tetap terjaga baik dengan bantuan ventilator, penerapan posisi head up 30° berkontribusi pada perbaikan perfusi serebral secara bertahap. Kesimpulan : Asuhan keperawatan yang komprehensif, sistematis, dan berbasis bukti (evidence-based) pada pasien Cedera Kepala Berat di ruang ICU dapat membantu mempertahankan fungsi vital, serta mendukung optimalisasi perfusi serebral. Kata Kunci: Asuhan Keperawatan, Cedera Kepal a Berat, Bersihan Jalan Napas Tidak Efektif, Penurunan Kapasitas Adaptif Intrakranial. Background: Severe Head Injury (SHI) is a neurological emergency resulting from external mechanical, characterized by a Glasgow Coma Scale (GCS) ≤ 8. This condition carries a high risk of increasing intracranial pressure (ICP), failure, thereby requiring comprehensive intensive nursing care to prevent complications and maintain the patient's vital functions. Objective: To describe the implementation of comprehensive nursing care for a patient with Severe Head Injury (SHI) in the ICU of RSUD Ulin Banjarmasin, South Kalimantan. Methods: This study used a descriptive case study method with a nursing process approach encompassing assessment, nursing diagnosis, intervention, implementation, and nursing evaluation. The subject was one patient with Severe Head Injury (SHI) treated in the ICU of RSUD Ulin Banjarmasin in April 2026. Results: The assessment of Mr. M (29 years old) showed a decreased level of consciousness with a GCS of 3T (coma), placement of an endotracheal tube (ETT) and mechanical ventilator, and absence of response to painful stimuli. Nursing interventions provided included semi-Fowler positioning, and regular monitoring of respiratory and neurological status. After 3 days of nursing interventions, vital signs and blood oxygenation remained well-maintained with ventilator support. The application of the 30° head-up position contributed to the gradual improvement of cerebral perfusion. Conclusion: Comprehensive, systematic, and evidence-based nursing care for patients with Severe Head Injury in the ICU can help maintain vital functions, and support the optimization of cerebral perfusion. Keywords: Nursing Care, Severe Head Injury, Ineffective Airway Clearance, Decreased Intracranial Adaptive Capacity.

Item Type:	Laporan Tugas Akhir / Karya Tulis Ilmiah / Laporan Praktek Asuhan Kebidanan (stase 9) / Skripsi / Tesis / Disertasi (Karya Tulis Ilmiah)
Uncontrolled Keywords:	Asuhan Keperawatan, Cedera Kepala Berat, Bersihan Jalan Napas Tidak Efektif, Penurunan Kapasitas Adaptif Intrakranial.
Subjects:	11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing > 111003 Clinical Nursing - Secondary (Acute Care) 11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing > 111009 Nursing Research 11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing
Divisions:	Jurusan Keperawatan > Program Studi Diploma III Keperawatan
Depositing User:	Mahasiswa D3 Keperawatan
Date Deposited:	16 Jul 2026 07:34
Last Modified:	16 Jul 2026 07:34
URI:	http://repo.polkesraya.ac.id/id/eprint/3584

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