Asuhan Keperawatan pada Tn. A dengan Acute Respiratory Failure Post Craniectomy Evakuasi ICH di Intensive Care Unit RSUD dr. Zainoel Abidin Banda Aceh
Main Article Content
Abstract
Intracerebral Hemorrhage (ICH) occurs due to rupture of blood vessels in the brain, which causes increased intracranial pressure (ICP). In this case study, it aimed to expound nursing care for patients with acute respiratory failure post craniectomy evacuation ICH in the intensive care unit (ICU) of the dr. Zainoel Abidin Regional General Hospital, Banda Aceh municipality. This research is a case study in implementing nursing care for patients. The main nursing planning and implementation that needs to be provided is, management of increased intracranial pressure, prevention of bleeding, prevention of shock, prevention of aspiration and weaning of mechanical ventilation. The results of the patient’s evaluation on the third day of treatment showed significant improvements in Mr. A’s condition, with an increase in the level of consciousness, hemodynamic stability, and a decrease in the risk of complications, patients with craniectomy, GCS E4M6V4, blood pressure 130/70 mmHg, MAP 90 mmHg, RR 18x/m, HR 88 x/m, SPO2 100%, nasal cannula therapy 2 l/m, have been extubated after 2 days of treatment. Acid-base balance status pH: 7.474, PCO2: 31.2 mmHg, PO2: 67 mmHg, HCO3: 22.9 mmol/L, BE: -1. It is also recommended for intensive care nurses continue to improve nursing care for patients with acute respiratory failure post craniectomy evacuation of ICH.
Article Details
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
How to Cite
References
Adcock, D.M. & Poirier, J., (2021). Coagulation testing in the core laboratory: Pathophysiology, clinical indications, and interpretation. Clinics in Laboratory Medicine, 41(3), pp.409-425. Available at: https://doi.org/10.1016/j.cll.2021.03.007.
Almar, J., Marna, A. & Bella, Y., (2023). Edukasi Penanganan Dan Pencegahan Syok Sepsis Di Rumah Sakit Elim Rantepao Tahun 2023. Lppm: Jurnal Pengabdian Kesehatan Promotif.
American Heart Association, (2020). Heart Disease and Stroke Statistical Update Fact Sheet At-aGlance Heart Disease, Stroke and other Cardiovascular Diseases. Circulation. American Heart Association.
Blackwood, B., Alderdice, F., Burns, K.E., Cardwell, C.R., Lavery, G. & O'Halloran, P., (2017). Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in critically ill paediatric patients. Cochrane Database of Systematic Reviews, (1), CD009082.
Branson, R.D., Gomaa, D. & Rodriguez, D., (2015). Role of the ventilator in the prevention of aspiration. Respiratory Care, 60(6), pp.855-870.
Burns, K.E., Rizvi, L., Cook, D.J. & Lebovic, G., (2021). Ventilator weaning and discontinuation practices for critically ill patients. In C. Seymour, ed. JAMA Network. Canada: JAMA Network. Available at: https://doi.org/10.1001/jama.2021.2384.
Cecep, M. & Faizal, M., (2023). Pengalaman perawat dalam proses penyapihan ventilator di ruang ICU. Jurnal Penelitian Perawat Profesional, 5(2), pp.559–570.
Chen, J., Liu, R., Wu, X., Zhu, Z., He, R., Yang, F. & Deng, S., (2021). Application of Nursing Risk Management in Nursing of Severe Peptic Ulcer Bleeding. Yangtze Medicine, 5(03), pp.226–234.
DeKrey, H., (2021). A 70 Year Old Male with Left-Sided Flaccidity Following Right Hemorrhagic Cerebrovascular Accident: A Case Study. Available at: https://commons.und.edu/pt-grad/728/.
Dewi, A.A., Fikriyanti, & Jufrizal, (2024). Asuhan Keperawatan Post Craniotomy Evakuasi Intracerebral Hemorrhage (Ich) Di Intensive Care Unit: Studi Kasus. Jurnal Gawat Darurat, 6(1), pp.9-17.
Dianti, T.N., (2022). Mengenal pendarahan intracerebral (ICH). Airlangga Nursing Journalist.
Farraj, Y., Buxboim, A., Cohen, J.E., Kan-Tor, Y., Hagege, S.G., Weiss, D., Goldman, V. & Beatus, T., (2021). Measuring Pupil Size And Light Response Through Closed Eyelids. Biomedical Optics Express, 12(10), pp.6486-6493.
Farsi, Z., Kamali, M., Butler, S. & Zareiyan, A., (2020). The effect of semirecumbent and right lateral positions on the gastric residual volume of mechanically ventilated, critically ill patients. Journal of Nursing Research, 28(4). Available at: https://doi.org/10.1097/jnr.0000000000000377.
Goldszmidt, A.J. & Caplan, L.R., (2013). Stroke Esensial (2nd ed.). Jakarta: Indeks.
Gultom, A.F.E., Nadeak, R.F., Hamdi, T. & Yunanda, Y., (2024). Perbandingan Vasopressin dan Norephinephrine sebagai Vasopressor pada Pasien Syok Sepsis. Jurnal Anestesi Perioperatif (JAP), 12(2), pp.97–108.
Hart, D., Dupaix, R., Rusa, J., Kane, T. & Volpi, E., (2016). Interventions for aspiration risk reduction in critically ill patients: A review of the literature. Journal of Critical Care Nursing, 36(4), pp.189-197.
Ishariani, L. & Rachmania, D., (2021). Hubungan Respon Time Keluarga dalam Membawa Pasien Stroke ke Pelayanan Kesehatan dengan Tingkat Keparahan Pasien Stroke. The Indonesian Journal of Health Science, 13(1).
Karwiti, W., Lestari, W.S., Rezekiyah, S., Fitriana, E., Nasrazuhdy & Rezky, M.D., (2022). Kadar Hemoglobin Pada Pasien Yang Mendapatkan Tindakan Operasi di Rumah Sakit St Theresia Kota Jambi. Nursing Care and Health Technology Journal (NCHAT), 2(1), pp.31-36.
Mustikarani, A. & Mustofa, A., (2020). Peningkatan Saturasi Oksigen Pada Pasien Stroke melalui Pemberian Posisi Head Up. Ners Muda, 1(2), pp.115-117.
Nitta, K., Okamoto, K. & Satou, T., (2019). A comprehensive protocol for ventilator weaning and extubation: a prospective observational study. Journal of Intensive Care, 7(50), pp.2-9.
Nurzahri, E., Ahyana, Amalia, R., (2022). Asuhan Keperawatan Pada Pasien Intracranial Haemorhage (ICH): Suatu Studi Kasus. JIM Fkep, I(4).
Pamungkas, S.M.W., Budi, A.W.S. & Nurfaizah, (2024). Penerapan Posisi Head Up 30° Pada Pasien Post Craniotomy Meningioma Terhadap Penurunan Tekanan Intrakranial: Studi Kasus. Jurnal Penelitian Perawat Profesional, 6(6), pp.2437-2443.
PPNI, (2017). Standar Diagnosis Keperawatan Indonesia. Definisi dan Indikator Diagnostik (Edisi 1). Jakarta: DPP PPNI.
PPNI, (2018). Standar Intervensi Keperawatan Indonesia. Definisi dan Tindakan Keperawatan (Edisi 1). Jakarta: DPP PPNI.
PPNI, (2019). Standar Luaran Keperawatan Indonesia. Definisi dan Kriteria Hasil Keperawatan (Edisi 1). Jakarta: DPP PPNI.
Rahmadiena, Q. & Saroh, S.A., (2022). Cerebral Palsy Dengan Syok Septik Dan Gizi Buruk: Laporan Kasus. Continuing Medical Education.
Rajashekar, D. & Liang, J., (2023). Intracerebral Hemorrhage. StatPearls. Available at: https://www.ncbi.nlm.nih.gov/books/NBK553103/#article-23683.
Rhodes, A., Evans, L.E., Alhazzani, W., et al., (2016). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock. Critical Care Medicine.
Riset Kesehatan Dasar (Riskesdas), (2018). Badan Penelitian dan Pengembangan Kesehatan Kementerian RI tahun 2018.
Sari, W. & Susanti, I.H., (2023). Asuhan Keperawatan Penurunan Kapasitas Adaptif Intracranial Pada Ny. T Dengan Diagnosa Medis Tumor Otak Di Instalasi Gawat Darurat (Igd) Rsud Prof Dr. Margono Soekarjo. Journal of Nursing & Health, 8(3), pp.325–330.
Sekiguchi, H. & Schenck, L.A., (2021). Mechanical ventilation liberation. In StatPearls [Internet]. StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK560543/.
Setiawan, P.A., (2021). Diagnosis Dan Tatalaksana Stroke Hemoragik. Jurnal Medika Hutama, 3(1), pp.1660-1664.
Silva, L.C.R., Tonelis, I.S., Oliveira, R.C.C., Lemos, P.L., Matos, S.S. & Chianca, T.C.M., (2020). Clinical study of dysfunctional ventilatory weaning response in critically ill patients. Revista Latino-Americana de Enfermagem, 28, pp.1-13. doi:10.1590/15188345.3522.3334.
Sudadi, S., Rahardjo, S. & Suharso, P.H., (2022). Weaning Ventilator Pada Pasien Tetraparesis Neglected Cervical Spondyloptosis Dengan Dislokasi Fase Bilateral Cervical 5-6 Dan Spinal Cord Injury Inkomplet Level Cervical 6. Jurnal Komplikasia Anestesi, 9(2).