Asuhan Keperawatan pada Pasien dengan Cedera Kepala Berat: Studi Kasus

Abstract

This case study aims to describe the nursing care management for a patient with a severe head injury who was admitted to the male neurology ward at Regional General Hospital dr. Zainoel Abidin Pemerintah Aceh. The patient presented with decreased consciousness, Glasgow Coma Scale score E4M5V2, restlessness, agitation, a hematoma in the right eye, and cerebral edema. CT scan findings indicated a subdural hematoma in the right temporoparietal region, a subarachnoid hemorrhage in the right frontotemporoparietal region, and a subgaleal hematoma in the left parietotemporal region. Additional symptoms included a laceration on the left shoulder, a sutured wound on the scalp, muscular rigidity in the upper and lower extremities, significant weight loss, and impaired ability to perform self-care. Identified nursing diagnoses included decreased intracranial adaptive capacity, impaired tissue integrity, impaired physical mobility, nutritional deficit, and self-care deficit. Interventions were implemented over five days, involving intracranial pressure monitoring, head elevation to 30°, administration of mannitol, cold compresses, Qur’anic recitation therapy, wound care, early mobilization (range of motion exercises), dietary education for high-calorie and high-protein intake, oral hygiene prior to meals, and support with personal care. The evaluation indicated resolution of two problems and partial improvement of the remaining three. Further education on passive range of motion exercises and home-based functional monitoring is recommended.