Injury

brain injury
Treatment
Drug therapy
No therapeutic name Dose Way of giving
Damage to brain
1 cells Ceftriaxon 2 x 1 gr I.V
2 Ranitidin 2 x 1 gr I.V

3 increased Ondansetron 2 x 1 gr I.V

4stimulation Tranexamic Acid 3 x 1 gr I.V
5 Ringerlaknat 28 tpm continuous I.V

Data analysis
No Data
Increase in cytematik Etiology Problem
vascular Resistance
DS : Cannot be The ineffectiveness of the airway
assessed clearance
DO :
1. Ku: Loss of
Pulmonary bloodconsciousnes
pressure
s
2. Awareness:
Coma
hydrostatic pressure
3. RR: 30x/m,
N: 88x/m
T: 37,5'C
TD: 110/80
mmHg
4. Additional
breath
sounds:
Stridor
 Fluid
head Leaks
injury

pulmonary edema
primary brain injury

Buildup

increased brain cell damage

O2 diffusion

autorelugation disorder
The ineffectiveness
of the airway
clearance

decreased blood flow to the brain

2. DS : Cannot be ineffectiveness of injured perfusion

assessed tissue
DO :
1. Ku: Loss of
consciousnes
s
2. Awareness:
coma
3. GCS: 2t
(E1VtM1)
4. RR: 30x/m
N: 88x/m
T: 37,5'C
TD: 110/ 80
mmHg
5. Anisochoric
pupils
6. Bluish around
the eyes
(lesions)
7. Swollen and
asymmetrical
head
 O2 decreases

metabolic disorders
head injury

lactic acid
Increased brain

Lactic acid

Ineffectiveness of injured
perfusion tissue

traffic accident

3 DS : Cannot be Ineffective breathing pattern

assessed
DO :
1. Ku: Cannot
be assessed
2. Awareness:
coma
3. Mounted
ventilator
4. RR: 30x/m
N: 65x/m
T: 37,5'C
TD: 100/70
mmHg
5. additional
breath sound
stridor
Ineffective breathing pattern

Implementation

Nursing Actions (Nursing Implementation)

N Nursing diagnoses Date /time Nursing actions Evaluation

o
1 The ineffectiveness of the Friday, 24-4- 1. Monitor respiratory Friday, April 24,
airway clearance b / d airway and oxygenation 2020 at 2:30 p.m.
obstruction is indicated by 2020 status S: Not reviewed
DS: cannot be assessed R /: Respiration: 28x / O:
DO:
13:00 Wit minute Spo2: 80% 1. Ku:
1. Ku: loss of 13:05 wit 2. Position the client to Decreasing
consciousness maximize ventilation Awareness
2. Awareness: Coma R /: Semi-fowler client 2. Awareness:
3. GCS: E1VtM1 position coma
4. RR: 30x/m 3. Do suctioning 3. GCS:
N: 88x/m 13:10 Wit (suction) through E1VtM1
T: 37,5'C endotracheal 4. Ventilator
TD: 110/80 mmHg R /: Secret buildup in Installed
5. There is a secret in the client's airway is 5. RR: 30x /
the throat and reduced after suction m,
mouth 4. Position to ease N: 88x / M
6. Gargling breath shortness of breath T: 37, 50C
sounds R /: The client's bed TD: 110 /
13: 15 Wit position is high (semi 80mmHg
fowler) A: The
5. Consult breath ineffectiveness of
sounds, note areas the airway clearance
where ventilation is has not been
13:17 Wit decreased or absent resolved
and additional sounds P: Intervention is
are present continued
R /: additional breath
sound stridor
 6. Educate the client's
family about the
client's condition.
R /: client's family
accepts whatever
happens to the client
because the client is
already critical

7. Collaborate with a
team of doctors in
drug administration
 Ceftriaxone
 Ondansentron
 Ranitidin
 RingerLactate
 Tranexamic Acid
2 The ineffectiveness of Friday, 24-4- 1. Monitor respiratory Friday, April 24,
breathing patterns b / d and oxygenation 2020 at 2:30 p.m.
neurological disorders are 2020 status S: -
characterized by R /: Respiration: 28x / O:
DS: cannot be assessed
13:00 Wit minute Spo2: 80% 1. Ku: Died
DO: 13:05 Wit 2. Position the client to 2. Awareness:
1. Ku: Decreased maximize ventilation -
awareness 13:10 Wit R /: Semi-fowler client 3. GCS: -
2. Awareness: coma position 4. Mounted
3. GCS: E1VtM1, 3. Consult breath Ventilator
4. Attached Ventilator, 13: 15 sounds, note areas 5. RR: -x / m,
5. RR: 30x / m, where ventilation is N: -x / M
N: 88x / M decreased or absent Q: - 0C
Q: 37.50C and additional sounds TD: - mmhg
TD: 110/80 mmHg are present A: The
6. There is a secret in R /: additional breath ineffectiveness of
the ETT tube and sound stridor breathing patterns
mouth 4. Educate the client's has not been
7. Stridor breath soun family about the resolved
client's condition. P: Intervention
13:17
R /: client's family terminated (client
accepts whatever dies)
happens to the client
because the client is
already critical
5. Collaborate with a
team of doctors in
drug administration
 Ceftriaxone
 Ondansentron
 Ranitidin
 RingerLactate
 Tranexamic Acid
3 Ineffective cerebral tissue Friday, 24-24-2020 1. Monitor neorological Friday, April 24,
perfusion b / d trauma 1:00 p.m. status 2020 at 2:30 p.m.
Marked by Wit R /: GCS: 2T, E: 1 V: T S: -
DS: cannot be assessed M: 1 O:
DO: 13:05 2. Adjusting the head of 1. Ku: Plus
Ineffective cerebral tissue Wit the bed to optimize 2. Awareness:
perfusion b / d trauma cerebral tissue -
Marked by perfusion 3. GCS: -
DS: cannot be assessed 1:10 R /: supine client 4. Attached
DO: Wit position Ventlator,
1. Ku: decreased 5. RR: -x / m,
consciousness 13:15 3. Provide information N: -x / M
2. Awareness: coma Wit to family / other Q: - 0C
3. GCS: E1VtM1, important people the TD: - mmHg
4. Attached Ventlator, client's circumstances A: The
5. RR: 30x / m, 13:17 Wit R /: The client's family ineffectiveness of
N: 88x / M accepts and resigns to cerebral tissue
Q: 37.50C the client's perfusion has not
TD: 110/80 mmHg 2PM increasingly critical been resolved
6. Anisochoric pupils Wit situation P: Intervention
7. Bluish around the terminated (client
eyes (lesions) 4. Collaboration with a dies)
8. Swollen and team of doctors in
asymmetrical head drug administration
 Ceftriaxone
 Ondansentron
 Ranitidin
 RingerLactate
 Tranexamic Acid