Analysing Traumatic Brain Injury Care Through Indonesian Nursing Standards: A Case Report Approach
Abstract
Emergency nursing requires specialized skills and resources to address complex patient needs. However, the emergency nursing process is often underutilized, impacting care quality and patient safety. This case study evaluates nursing care for a 20-year-old male with head trauma following a traffic accident using the Indonesian Nursing Care Standards (SDKI, SIKI, SLKI). The patient, with a Glasgow Coma Scale of 7, presented with a head wound, gurgling airway, vomiting, and signs of increased intracranial pressure. Key nursing problems identified included ineffective airway clearance, ineffective breathing patterns, and the risk of ineffective cerebral perfusion. Interventions included suctioning, oxygen therapy, and positioning, but several gaps in the standards were noted, particularly in diagnosis, measurable outcomes, and intervention guidelines. This study highlights the need to refine the Indonesian Nursing Care Standards for emergencies, focusing on priority-based problem identification and evidence-based guidelines. These adjustments can improve decision-making, enhance care consistency, and reduce complications, ultimately improving patient outcomes and trust in emergency nursing services.References
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Meister, K.D., Pandian, V., Hillel, A.T., Walsh, B.K., Brodsky, M.B., Balakrishnan, K., Best, S.R., Chinn, S.B., Cramer, J.D., Graboyes, E.M., McGrath, B.A., Rassekh, C.H., Bedwell, J.R., Brenner, M.J., 2021. Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review. Otolaryngol Head Neck Surg 164, 984–1000. https://doi.org/10.1177/0194599820961990
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Oka, P., Nurhesti, Y., Ketut, N., Prapti, G., Oka, M., Kamayani, A., Suryawan, A., 2020. Analisis Penggunaan Diagnosis Keperawatan Berbasis SDKI dan NANDA. https://doi.org/https://doi.org/10.24843/coping.2020.v08.i02.p02
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Pokja, T., SDKI DPP PPNI, 2017. St Andar Intervensi.
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Rutto, A., Koech, P., Korir, A., Groom, R., White, R., 2022. Perfusion Practice in Kenya. J Extra Corpor Technol 54, 5–18. https://doi.org/10.1182/ject-5-18
Saavedra-Mitjans, M., David, P.-M., Frenette, A.-J., Arbour, C., Perreault, M., Williams, V., Bernard, F., Williamson, D., 2021. Experiences and attitudes towards Agitated behaviors in Traumatic brain injury in the Intensive Care Unit patients (ECSTATIC): a protocol for an interprofessional mixed-method study. BMJ Open 11, e045816. https://doi.org/10.1136/bmjopen-2020-045816
Talahatu, O., Korespondensi, P., Kesehatan, F., Kristen, U., Maluku, I., 2022. Diseminasi Penerapan SDKI, SLKI dan SIKI di Rumah Sakit Umum Daerah Kota Masohi. Karya Kesehatan Siwalima. https://doi.org/https://dx.doi.org/10.54639/kks.v1i2.788
Thayer, J.G., Ferro, D.F., Miller, J.M., Karavite, D., Grundmeier, R.W., Utidjian, L., Zorc, J.J., 2021. Human-centered development of an electronic health record-embedded, interactive information visualization in the emergency department using fast healthcare interoperability resources. Journal of the American Medical Informatics Association 28, 1401–1410. https://doi.org/10.1093/jamia/ocab016
Wahidin, Supraptini, N., 2020. Penerapan Teknik Head Up 30 derajat terhadap Peningkatan Perfusi Jaringan Otak Pada Pasien yang Mengalami Cedera Kepala Sedang. Nursing Science Journal (NSJ). https://doi.org/https://doi.org/10.53510/nsj.v1i1.14
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World Health Organization (WHO) [WWW Document], 2021. URL https://www.who.int/ (accessed 11.21.24).
Awaliyani, V.A., Pranatha, A., Wulan, N., 2021. Pengaruh Penggunaan Buku SDKI, SLKI Dan SIKI Terhadap Peningkatan Pengetahuan Perawat Dalam Membuat Dokumentasi Keperawatan Berbasi SDKI, SLKI dan SIKI di Rumah Sakit KMC Kuningan Tahun 2021. Journal of Nursing Practice and Education 2, 22–32. https://doi.org/10.34305/jnpe.v2i1.334
Bruijns, S.R., Guly, H.R., Bouamra, O., Lecky, F., Wallis, L.A., 2014. The value of the difference between ED and prehospital vital signs in predicting outcome in trauma. Emerg Med J 31, 579–582. https://doi.org/10.1136/emermed-2012-202271
Carney, N., Totten, A.M., O’Reilly, C., Ullman, J.S., Hawryluk, G.W.J., Bell, M.J., Bratton, S.L., Chesnut, R., Harris, O.A., Kissoon, N., Rubiano, A.M., Shutter, L., Tasker, R.C., Vavilala, M.S., Wilberger, J., Wright, D.W., Ghajar, J., 2017. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 80.
Currie, D., Snedden, T., Pierpoint, L., Comstock, R.D., Grubenhoff, J.A., 2019. Factors Influencing Primary Care Follow-Up After Pediatric Mild Traumatic Brain Injury. J Head Trauma Rehabil 34, E11–E19. https://doi.org/10.1097/HTR.0000000000000461
Dickinson, A., Joos, S., 2021. Barriers to integration of primary care into emergency care: Experiences in Germany. Int J Integr Care 21. https://doi.org/10.5334/ijic.5442
Dinallo, S., Waseem, M., 2024. Cushing Reflex. Treasure Island (FL).
Dwi Fibriansari, R., Astuti, A., Maisyaroh, A., Widyanto, E.P., 2022. Perceptions of Applications of Standard Nursing Language in Nursing Care Documentation. https://doi.org/https://doi.org/10.19184/jpsti.v1i1.73
ElGammal, M.E., 2014. Emergency department triage. Why and how? Saudi Med J 35.
Emergency Medicine Programme, 2021. A framework to support the delivery and recording of Nursing Care in Emergency Care Networks in Ireland. Ireland.
Ginting, L.R., Sitepu, K., Ginting, R.A., 2020. Pengaruh Pemberian Oksigen Dan Elevasi Kepala 30o Terhadap Tingkat Kesadaran Pada Pasien Cedera Kepala Sedang. Jurnal Keperawatan dan Fisioterapi (JKF) 2, 102–112. https://doi.org/10.35451/jkf.v2i2.319
Grasselli, G., Calfee, C.S., Camporota, L., Poole, D., Amato, M.B.P., Antonelli, M., Arabi, Y.M., Baroncelli, F., Beitler, J.R., Bellani, G., Bellingan, G., Blackwood, B., Bos, L.D.J., Brochard, L., Brodie, D., Burns, K.E.A., Combes, A., D’Arrigo, S.,
De Backer, D., Demoule, A., Einav, S., Fan, E., Ferguson, N.D., Frat, J.-P., Gattinoni, L., Guérin, C., Herridge, M.S., Hodgson, C., Hough, C.L., Jaber, S., Juffermans, N.P., Karagiannidis, C., Kesecioglu, J., Kwizera, A., Laffey, J.G., Mancebo, J., Matthay, M.A., McAuley, D.F., Mercat, A., Meyer, N.J., Moss, M., Munshi, L., Myatra, S.N., Ng Gong, M., Papazian, L., Patel, B.K., Pellegrini, M., Perner, A., Pesenti, A., Piquilloud, L., Qiu, H., Ranieri, M. V, Riviello, E., Slutsky, A.S., Stapleton, R.D., Summers, C., Thompson, T.B., Valente Barbas, C.S., Villar, J., Ware, L.B., Weiss, B., Zampieri, F.G., Azoulay, E., Cecconi, M., 2023. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 49, 727–759. https://doi.org/10.1007/s00134-023-07050-7
Grenier, G., Despatis, M.-A., Lebel, K., Hamel, M., Martin, C., Boissy, P., 2022. Removal of the cervical collar from alpine rescue protocols? A biomechanical non-inferiority trial in real-life mountain conditions. Scand J Trauma Resusc Emerg Med 30, 42. https://doi.org/10.1186/s13049-022-01031-3
Grover, E., Porter, J.E., Morphet, J., 2017. An exploration of emergency nurses' perceptions, attitudes and experience of teamwork in the emergency department. Australas Emerg Nurs J 20, 92–97. https://doi.org/10.1016/j.aenj.2017.01.003
Huda, N., 2017. Efektifitas Elevasi Kepala 30o Dalam Meningkatkan Perfusi Serebral Pada Pasien Post Trepanasi di Rumah Sakit Mitra Surabaya. Jurnal Ilmiah Keperawatan STIKES Hang Tuah Surabaya 12, 1137. https://doi.org/10.30643/jik.v12i1.20
Khan, Z., Karatas, Y., Hamid, S.M., 2023. Evaluation of health care professionals' knowledge, attitudes, practices and barriers to pharmacovigilance and adverse drug reaction reporting: A cross-sectional multicentral study. PLoS One 18, e0285811. https://doi.org/10.1371/journal.pone.0285811
Kinder, F., Mehmood, S., Hodgson, H., Giannoudis, P., Howard, A., 2022. Barriers to Trauma Care in South and Central America: a systematic review. European Journal of Orthopaedic Surgery and Traumatology 32, 1163–1177. https://doi.org/10.1007/s00590-021-03080-3
Kruk, M.E., Gage, A.D., Arsenault, C., Jordan, K., Leslie, H.H., Roder-DeWan, S., Adeyi, O., Barker, P., Daelmans, B., Doubova, S. V., English, M., Elorrio, E.G., Guanais, F., Gureje, O., Hirschhorn, L.R., Jiang, L., Kelley, E., Lemango, E.T., Liljestrand, J., Malata, A., Marchant, T., Matsoso, M.P., Meara, J.G., Mohanan, M., Ndiaye, Y., Norheim, O.F., Reddy, K.S., Rowe, A.K., Salomon, J.A., Thapa, G., Twum-Danso, N.A.Y., Pate, M., 2018. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. https://doi.org/10.1016/S2214-109X(18)30386-3
Ladny, M., Gawel, W., 2022. Neck Stabilization In Trauma Patient: An Emergency Medicine Perspective. Disaster and Emergency Medicine Journal. https://doi.org/10.5603/DEMJ.a2022.0007
Meister, K.D., Pandian, V., Hillel, A.T., Walsh, B.K., Brodsky, M.B., Balakrishnan, K., Best, S.R., Chinn, S.B., Cramer, J.D., Graboyes, E.M., McGrath, B.A., Rassekh, C.H., Bedwell, J.R., Brenner, M.J., 2021. Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review. Otolaryngol Head Neck Surg 164, 984–1000. https://doi.org/10.1177/0194599820961990
Miller, M.R., Hankinson, Bursasco, V., Casaburi, R., Coates, A., Crapo, Enright, 2005. Standardisation of spirometry. ersjournals. https://doi.org/10.1183/09031936.05.00034805
Nibbelink, C.W., Brewer, B.B., 2018. Decision-making in nursing practice: an integrative literature review. J Clin Nurs 27. https://doi.org/10.1111/jocn.14151
Oka, P., Nurhesti, Y., Ketut, N., Prapti, G., Oka, M., Kamayani, A., Suryawan, A., 2020. Analisis Penggunaan Diagnosis Keperawatan Berbasis SDKI dan NANDA. https://doi.org/https://doi.org/10.24843/coping.2020.v08.i02.p02
Olson, A., Rencic, J., Cosby, K., Rusz, D., Papa, F., Croskerry, P., Zierler, B., Harkless, G., Giuliano, M.A., Schoenbaum, S., Colford, C., Cahill, M., Gerstner, L., Grice, G.R., Graber, M.L., 2019. Competencies for improving diagnosis: an interprofessional framework for education and training in health care. Diagnosis (Berl) 6, 335–341. https://doi.org/10.1515/dx-2018-0107
Pinto, A., Berritto, D., Russo, A., Riccitiello, F., Caruso, M., Belfiore, M., 2018. Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department. Acta Biomed 89.
Pokja, T., SDKI DPP PPNI, 2017. St Andar Intervensi.
Rison, R.A., 2013. A guide to writing case reports for the Journal of Medical Case Reports and BioMed Central Research Notes. J Med Case Rep 7, 239. https://doi.org/10.1186/1752-1947-7-239
Ristanto, R., Indra, M.R.I., Poeranto, S., Setyorini, I., 2016. Akurasi revised trauma score sebagai prediktor mortality pasien cedera kepala. Jurnal Kesehatan Hesti Wira Sakti 4, 76–90.
Rutto, A., Koech, P., Korir, A., Groom, R., White, R., 2022. Perfusion Practice in Kenya. J Extra Corpor Technol 54, 5–18. https://doi.org/10.1182/ject-5-18
Saavedra-Mitjans, M., David, P.-M., Frenette, A.-J., Arbour, C., Perreault, M., Williams, V., Bernard, F., Williamson, D., 2021. Experiences and attitudes towards Agitated behaviors in Traumatic brain injury in the Intensive Care Unit patients (ECSTATIC): a protocol for an interprofessional mixed-method study. BMJ Open 11, e045816. https://doi.org/10.1136/bmjopen-2020-045816
Talahatu, O., Korespondensi, P., Kesehatan, F., Kristen, U., Maluku, I., 2022. Diseminasi Penerapan SDKI, SLKI dan SIKI di Rumah Sakit Umum Daerah Kota Masohi. Karya Kesehatan Siwalima. https://doi.org/https://dx.doi.org/10.54639/kks.v1i2.788
Thayer, J.G., Ferro, D.F., Miller, J.M., Karavite, D., Grundmeier, R.W., Utidjian, L., Zorc, J.J., 2021. Human-centered development of an electronic health record-embedded, interactive information visualization in the emergency department using fast healthcare interoperability resources. Journal of the American Medical Informatics Association 28, 1401–1410. https://doi.org/10.1093/jamia/ocab016
Wahidin, Supraptini, N., 2020. Penerapan Teknik Head Up 30 derajat terhadap Peningkatan Perfusi Jaringan Otak Pada Pasien yang Mengalami Cedera Kepala Sedang. Nursing Science Journal (NSJ). https://doi.org/https://doi.org/10.53510/nsj.v1i1.14
Wilson, E., 2012. Emergency management of severe burns, Journal of Paramedic Practice. https://doi.org/10.12968/jpar.2012.4.2.114
World Health Organization (WHO) [WWW Document], 2021. URL https://www.who.int/ (accessed 11.21.24).
Published
2024-11-29
How to Cite
ASMARA, A Danang et al.
Analysing Traumatic Brain Injury Care Through Indonesian Nursing Standards: A Case Report Approach.
NurseLine Journal, [S.l.], v. 9, n. 2, p. 132-143, nov. 2024.
ISSN 2541-464X.
Available at: <https://jurnal.unej.ac.id/index.php/NLJ/article/view/52143>. Date accessed: 22 dec. 2024.
doi: https://doi.org/10.19184/nlj.v9i2.52143.
Section
Case Study
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
