Nursing care for Mr. N with severe head injury in the emergency room Dr.

Haulussy Ambon

By :

Name : Desy Rista Solly

Npm : 12114201180184

Class. :A

HEALTH FACULTY

THE STUDY OF NURSING

INDONESIAN CHRISTIAN UNIVERSITY MALUKU

2020
 The introduction

of Thanksgiving has always been mine to say to the Lord yme who gave me my abundance of blessings
able to finish this paper. It was designed to fulfill an English course that discussed "nursing care for
severe head injuries." I did it with everything I could and to the fullest possible. However, I learned that
writing was by no means perfect and there were many faults and deficiencies. Therefore I am the author
of this paper with the need for criticism, Suggestions and messages of all who read this paper especially
the English subject I hope will be a course of corrections for me.

Ambon 19 Juli 2020

DESY RISTA SOLLY

 PIG

PRELIMINARY

A. BACKGROUND

Head injuries are one of the major causes of death and disability in productive age groups and are
largely due to traffic accidents (mansjoer, 2007). It is estimated that 100,000 people die each year and
more than 700,000 injuries are severe in hospital care, two-thirds under 30 years of age with more men
than women, more than half of all head injuries had significant injuries to other body parts. (smeltzer
and bare, 2012). Among the types of head injuries are mild head injuries, moderate head injuries and
severe head injuries. Nursing and head injury both minor head injury, moderate head injury and severe
head injury should be treated seriously. An injury to the brain can cause a breakdown in the central
nervous system so that consciousness can drop. Tests will need to be performed to detect any trauma of
brain function caused by a head injury. In addition to the handling of the crash site and during the
transport of the victims to the hospital, early assessment and action in the emergency room determined
the policies and prognosis. Resuscitation, anamnesis and general physical and neurological examination
should be performed Simultaneously. A systematic approach can lessen the likelihood of passing vital
element evaluations. The severity of the injuries on the head, was immediately determined when the
patient arrived at the hospital. (sjahrir, 2014).

According to who each year in the United States nearly 1,500,000 cases of head injuries. Of these,
80,000 were maimed and 50,000 people died. Currently in America there are about 5,300,000 people
with disabilities from head injuries (Moore &argur, 2016). The most common causes of head injuries are
motor accidents (50%), crashes (21%), and sports injuries (10%). The number of head injuries treated at
hospitals in Indonesia is the second leading cause of death (4.37%) after stroke, and the fifth (2.18%) in
the 10 most common diseases treated at hospitals in Indonesia (nines, 2016).

B. Purpose

1. Common goal

Students are able to impose nursing care on Mr. "N" with neurologic system disorder: heavy head
injury in the hospital Haulusy ambon

2. Special purpose

a. conducted a study on Mr. "N" with a neurology system disorder: severe head injury at Dr Haulusy
hospital's hospital hospital.

b. formulates a diagnosis of nursing Mr. "N" with a neurology system disorder: severe head injury in
the hospital Dr Haulusy ambon.
 c. is planning an act of nursing care to Mr. "N" with a neurology system disorder: severe head injury in
the hospital Dr Haulusy ambon.

d. of nursing home with a neurology system disorder: severe head injury at the hospital hospital Dr
Haulusy ambon.

e. Examined the results of the treatment performed on Mr. "N" with neurology system disorder: severe
head injury in the hospital Dr Haulusy ambon.
 Chapter II

Theoretical review

A. definition

A head injury or capitis trauma is a traumatic disorder of the brain accompanied/without bleeding
intestinal ina brain substance, without followed a severed continuation of the brain. (nugroho, 2011)
head injury is a trauma that injury injury directly or indirectly (suriadi and yuliani, 2011). According to
brain injury association of America (2001), head injury is a damage to the head, not genital or
degenerative, but is caused by external physical attacks or impacts, which can reduce or alter
consciousness which results in impaired cognitive and physical function. A head injury is a normal brain
function disorder due to trauma both blunt and severe trauma. Neurological deficits are due to the
deterioration of subthansia alba, ischemia, and the hemorrhagic effects of the masses, as well as
cerebral edema around the brain tissue (batticaca, 2008).

Based on the definition of above - head injuries, the writer may draw the conclusion that a head
injury is an injury caused by both a sharp and a blunt force trauma that causes significant improvement
in the skin, skull, and brain tissue accompanied by or without bleeding.

B. ETIOLGI

cause of head injury involves trauma from the head involving trauma from objects/bone fragments
that penetrate brain tissue, the effect of the force/energy that is forwarded to the brain and the
acceleration and deceleration (acceleration and deceleration) in the brain, which can also be caused by
accidents, fall, trauma from childbirth.
C. Anatomy of physiology

1. Anatomy of the head

a. When these vessels are torn, it is difficult to carry vasoconstrictions that could cause significant blood
loss. There are aspirational veins and diploxes that can bring in scalp infections to the skull (intracranial)
trauma that can cause abrasion, contusions, laceration, or avulation.

b. 's head is calvaria (skull roof) and an eranium base. A fracture of the skull is a malfunction of the ibis's
sustained cranial bone caused by trauma. Calvarea fractures are capable of lines that can decompress or
decompress. Skull fractures can be open (two broken) and covered (two undamaged). The head bone is
made up of two hollow bone - separated walls, outer walls (tabula externa) and inner walls (labula
interna) that contain the flow of artifacsia increases anterior, senses and prosterions. Bleeding in the
arteries can cause a hemorrhage of blood in the epidural chamber.

c. It contains three meningieles

of durameter, asachnoid and diameter.

(1). The durameter is a large, strong membran a semi translusen, with no elastic attached tight to the
skull. When the durameter is torn, it cannot be fixed perfectly. Durameter:

a. Protects the brain.

b. 's covering up vein sinuses (made up of just duramether and endothelial layers without vascular
tissue).

C. established periosteum tabula interna.

(2). The asachnoid is a fine membrane, vibrosa and elastic, not sticking to dura. Between the durameter
and the arachnoid is a subdural chamber that is a potential room. Subdural bleeding can spread freely.
And only limited to the size of the cerebral valks and the tentorium. Brain veins passing through the
subdural have small support tissues that can easily be injured and torn in the head trauma .

(3). The diameter isa tiny membrane very rich in fine blood vessels, moving into all the sulcus and
wrapping all the girus, the other two layers simply bridging the sulcus. In some fissure and sulkus on the
medial side the homissphere of the brain. Beehives form ventricles and sullens or vernia. This sawar is
the supporting structure of the pleksus foroideus on every ventricle. Between the arachnoid and the
perimeter is subarachnoid, this chamber widens and runs deep at a certain point. And allows for the
circulation of the cerebrospinal fluid. Into the vena system.

d. brain.

The brain is in the iquor cerebro spiraks. Brain damage seen in head trauma can occur through 2
combines:

1). A direct effect of trauma to brain function,

2). Further effects of brain cells that react to trauma.

If there is a direct link between the brain and the outside world (the open cranium fracture, the
cranium base fracture with the liquid from the nose/ear), it is a dangerous phenomenon because it can
result in brain inflammation.

The brain can develop swelling (edema cerebri) and because the skull is a tightly enclosed chamber, it
will result in pressure increases in the cranial cavity.
e. Cranial intra pressure.

The intracranial pressure is the result of a number of brain tissues, the volume of intracranial blood
and the cerebrospiral fluid inside the skull in a single unit of time. The normal circumstances of the tic
depend on the patient's position and range from approximately 15 MMHG. Cranial space that contains
brain tissue (1400 gr), blood (75 ml), cerebrospiral fluid (75 ml), to 2 pressures on these three
components is always connected with the balancing of the monro hypothesis - kellie states: because the
expansion of one of these components causes a change in the volume of cerebral blood without any
change, tic will rise. A high enough typewriter increase, causing the ptak stem to fall, resulting in death.

D. patopisiology

The absence of head injuries can cause structural damage, such as damage to brain-kim, damage
to blood vessels, bleeding, edema and brain biochemical impairment such as tripospat reduction,
changing permeability of vasculer. A head injury can be divided into two processes involving primary
head injuries and secondary head injuries, a primary head injury is a biomechanical process that occurs
directly upon the hit of the head and can cause brain tissue damage. Secondary head injuries are the
result of primary head injuries, such as the result of hypoxia, ischemia and bleeding.

Cerebral hemorrhage causes a hematoma, for example, at the epidural hematoma, the
concentration of the skull with the durameter, the subdura hematoma as a result of the blood in the
space between the durameter and the subaraknoid and intra cerebral, Death in a person with a head
injury results from hypotension due to autoregulation disorder, when autoregulation causes cerebral
tissue diffusion and ends in cerebral ischemia. (tarwoto, 2007).

Head injury patopisiology can be explained as follows:

1. Primary injury

Direct trauma damage, including skull bone fractures, laceration of blood vessels (hematoms),
damaged brain tissue (including duramater, laseration, kontusio).

2. Secondary injury

Further damage from existing primary injuries continues beyond the compensation limit of the skull
room. Monroe kellie's law says the skull chamber is closed and the volume stays fixed. The volume is
affected by three compartments which are blood, liquor, and cerebro. Exceeded compensation results in
a progressive tick.

And there's a decline in cerebral diffusion pressure that can be fatal at cellular levels. Secondary injury
and diffusion pressure:

CPP = map - icp

CPP: cerebral pressure pressure

Map: mean arterial pressure

Icp: intra cranial pressure

A CPP drop of less than 70 causes brain ischemia. Brain ischemia leads to cytoxic edema -
irreversible cellular damage. Increased by extracial hypotency/shock, hycause bi, hypoxia, hypertermi,
seizures, etc.

3. Topical edema.

Tissue damage causes the release of a neurotransmitter that causes ectocyation (exitatory amino
acid a.l. glutamate, aspartate). Eaa through ampa receptors (n-methyl d-aspartate) and nmda (amino
methyl propionat acid) cause the overinfluks that produce edema and activate hereditary enzymes and
causes fast depolarization (clinical convulsions).

4. Membrane damage to cells

Effects of cacces influks moism degradable will lead to DNA, protein, and cellular phosplipid (BBB
breakdown) through a low CDP cholin (which serves as a much needed prekusor on the phospholipid
synthesis to maintain integrity and repair the membrane). Through destruction the phosplipid will lead
to the development of arachic acid, which produces excess free radicals.

5. Apoptotic

cell linkage signals are transmitted to the nucleus membrane bound apoptotic bodies occur with
condensation of chromatin and plenotic nuclei, DNA fragmentation and eventually cells will shrink
(shrinkage).

PATHWAY
E. clinical manifestation

1. Blackouts of consciousness less than 30 minutes or so

2. Confusion

3. Iritabel

4. Pallor

5. Nausea and vomiting

6. Dizzy head

7. There's a hematoma

8. Anxiety

9. It's hard to wake up

10. If it frayed, it might have cerebrospinal fluid coming out of the nose (rhinorrohea) and ear
(authorization) when the temporal bone fracture.

11. Increase in td, decrease in pulse frequency, increased respiration.

F. complications

1. Cranial intra bleeding

2. Spasms

3. Cranial nerve parese

4. Meningitis or brain abscesses

5. An infection in a wound or sepsis

6. Cerebri edema

7. The rise of pulmonary edema neurogenic, a consumer product

8. Spinal fluid leak

9. Headache after waking

G. classification

When viewed from light to weight, then we can see it as follows:

1. A mild head injury (CKR) if the GCS between 13-15, there can be less than 30 minutes of
consciousness, but some call less than 2 hours, if there are, like a cranial fracture, a kontusio ora
temotom (about 55%).

2. Moderate head injury (CKS) if GCS is between 9-12, loss of consciousness or amnesia between 30
minutes -24 hours, it can fracture the skull, mild disorientation.

3. Heavy head injury (CKB) if GCS 3-8, loss of consciousness more than 24 hours, also includes cerebral
contusio, laceration or the presence of hematina or edema.

In addition, there are other terms for this type of head injury:

1. Open head injury the skin has lacerated to the point of damaging the skull bone.

2. The injury of a closed head can be likened to a slight concussion with an edema cerebra. Glasgow
coma seale (GCS) presents three fields of neurological function, providing an overview of patients'
responsive levels and can be used in extensive search when evaluating the status of neurologic patients
with head injuries. This evaluation is only limited to the evaluation of the patient's motor, verbal and
eye-opening responses.

GCS scale:

open-eye. :4

with command :3

with pain :2

don't respond. :1

Motor : with command :6

localized pain :5

attracts area of pain :4

abnormal flexion :3

extensions :2
not resonating :1

Verbal : orientated :5

puzzling speech :4

inappropriate words :3

incomprehensible voices :2

no response :1

H. Diagnostic check

1. Lab exam: full blood, urine, blood chemistry, blood gas analysis.

2. Ct scans (with or without contrast: identify the size of lesions, bleeding, ventruler's determination,
and changes in brain tissue.

3. Mri: used as ct scans with or without radioactive contrast.

4. Cerebral angiography: indicates cerebral circulation anomalies, such as secondary brain tissue
changes into udema, bleeding and trauma.

5. X-rays: detecting changes in bone structure (fracture), changes in line structure (bleeding, edema),
bone fragments. X-ray of both skull and thorak.

6. CSF, animal blockage: can be performed if suspected of subarachnoid bleeding.

7. Abgs: detecting ventilation or oxygenation problems if intracranial pressure increases.

8. Electrolyte level: to correct electrolyte balance as a result of increasing intracranial pressure.

(musliha, 2010).

I. observe

The medical examination of a major head injury is to prevent secondary brain injury. Secondary
brain injury is caused by systemic factors such as hypotension or hypoxia or because of compression of
the brain tissue. (tunner, 2000) an adequal supervisor of pain is also recommended on head injury
(Turner, 2000).

 General management is:

1. Value of respiratory and respiratory function.

2. Stabilization of cervical vertebrates in all cases of trauma.

3. Give oxygenation

4. Monitor blood pressure

5. Recognize signs of shock due to hypovelemic or neurogenic.

6. Overcome shock

7. Monitor for possible seizures.

 Other treatments:
1. Dexamethasone / Kalmethasone as an anti-cerebral edema treatment, dosage according to severity of
trauma.

2. Hyperventilation therapy (severe head trauma). To reduce vasodilation.

3. Provision of analgesics

4. Anti treatment. edema with hypertonic solution that is 20% mannitol or 40% glucose or 10% glycerol.

5. Antibiotics that contain blood brain barrier (penicillin).

6. Food or liquid. In mild trauma if there is vomiting can not be given anything, only 5% dextrose infusion
fluid, aminofusin, aminofel (first 18 hours and the occurrence of accidents), 2-3 days later given soft
food, In severe trauma, days first (2-3 days), not too much fluid. Dextrosa 5% for the first 8 hours, ringer
dextrose for the second 8 hours and dextrose 5% for the third 8 hours. On the next day if awareness is
low, food is given through ngt (2500-3000 tktp). Giving protein depends on the value of urea.

 Measures to increase ICT are:

1. ICT Monitoring strictly.

2. Adequate oxygenation.

3. Provision of mannitol

4. Steroid use

5. Increased head bed.

6. Neuro surgery.

 Other supporting actions are:

1. Ventilation support

2. Prevention of seizures

3. Maintenance of fluids, electrolytes and nutritional balance

4. Anti-convulsant therapy

5. Chlorpromazine to calm the client.

6. Installation of nasogastric tube. (Mansjoer, et al, 2000).

 Case in point

Mr. Nando at 26 year old PNS 'work, ma 'am's mountain address, at 19/07 2020 at 12:00, ona
motorcycle at 12:00, when he was at the intersection, Mr. Nando was able to bounce around
two meters away from the scene and pass out, so the local people carried him directly to the
hospital's hospital hauling usy ambon. The delivery said the patient could faint at least 20
minutes and puke twice. Physical examinations have resulted in multiple trauma: with apathy
awareness of td, 110/80mmhg, pulse 88 degrees per minute, rr 30 minutes and acral cold CRT>
2 minutes, spo2 88% of gurus breath, lesions and bruising of the right side of the face, left head
swelling, right leg looks swollen and bruised There was also the active bleeding of the right
thigh from the laceration after the examination of the doctor's instructions for the installation
of a rl 28 TPM iv; Pairs of fracture areas; Put collar collar by size; Give oxygen 15 liters a minute
using the non-rebreathing mask. The therapy ranitidin gave 2 doses 1 iv, the photo of the femur
X-ray shows a femur receipt of 1/3 bone and a ct scan of the head, and a nearby epidural
hemorrhage in frontoparietal right. Doctors diagnosed patients with severe head and frak
injuries.
 EMERGENCY NURSING FORMAT

PEDIATRIC NURSE IN Mr. N WITH A NEUROLOGI SYSTEM DISORDER: A SEVERE HEAD + OPEN
FEMUR FRACTURE DEXTRA 1/3 DISTAL IN HOSPITAL HOSPITAL IGD Dr. Haulusy ambon.

A. nursing study

Student review : DESY RISTA SOLLY

NPM : 12114201180184

ROOM. : igd/resuscitation

OF ENTRY : July 19, 2020

OF REVIEW. : July 19, 2020

TIME : 13.00 WIT

B. PATIENT ID

Name's : Mr. N

Age : 26

Place/date of birth : ambon March 23, 1994

Gender : male.

Marital status : single.

Religion : protestant Christian.

Citizen of : Indonesia.

The language used : Indonesian.

Education : bachelor.

Job : civil servant

Address : miss mountain

 examination
PRIMARY SURVEY

Airway : Nose/mouth

- Free

- Sputum

- Spasm

- The root of the tongue falls

- Clogged

- The presence of blood

- Alien object

SOUNDS BREATHING

- Normal

- Gurgllng

- Ronchi

- Stridor

- Wheezhing

- Miscellaneous

NURSING PROBLEMS

Imeffectiveness of breath net net

BREATHING :

 Respiration 30 centimeter per minute

- Orderly.
 - Apneas.

- Bradinea.

- Chest retraction.

- Chest/stomach breathing.

- Not irregular.

- Dispnea.

- A takipnea.

- Nasal lobe.

- Kusmaul/chyne stokes

 Sounds breathing
- Normal
- Gurgling
- Ronchi
- Stridor
- Wheezing
- Miscellaneous
NURSING PROBLEMS
Imeffectiveness of breath net net
CIRCULATION

- Pale

- Bleeding

- sum : CC

- cyanosis

- scald

- location

- grade

PULSE
 - The tats.

- It's intangible.

- Steady rhythm.

- Frequency: 88 meters.

- Irregular rhythm

TD : 110/80mmHg T : 37, 5°c

Capillary Refill Time

✓<2 detik - > 2 detik

Akral

- Warm ✓Chilly - edema

Turgor

✓normal - sedang - kurang

NURSING PROBLEMS

There's no nursing problem

Disabillity : Level of consciousness:

GCS : 3

Pupil

- isokor

✓ Anisokor

- muntah proyektil

- miosis

- midriasis

- riwayat kejang
 Speech function

- normal

- afasia

- pelo

- mulut mencong

Muscle power

0 0

0 0

Ket :

0 : Unable to contro

1 : Can only contract

2 : There's movement that won't fight the force of gravity

3 : No movement can only overcome the force of gravity

4 : Able to resist the force of gravity and resist the few prisoners

5. Capable of resisting gravity and resisting the maximum inmates

Sensabilitas

- Normal ✓ Disorder swallows water

✓ Disorder swallows water and food

Nursing problems

The ineffective fusion of cerebral tissue

Exposure Trauma :

Jejas. : there are lesions in the right eye and cheek area, 3 cm woun on
the right rear head
Large :-

depth : -

SECONDARY SURVEY

a. Interview

main complaint : decreased KLL post awareness

history of disease now : the community who helped the client said, the client was
unconscious ± 2o minutes before being admitted to the hospital because of a traffic accident
that hit a car that was parked on the edge of the road, the client threw up 2 times. Then the
client is immediately taken to RSH to get help. Arriving at the RSH the client with decreased
awareness of GCS 3 (E1M1V1) immediately entered the Priority 1 treatment room (Red Triage)
and carried out the action of cleaning the airway and installing ETT on Juli 19, 2020 at 13.00
WIT. On Juli 19, 2020 at 14:30 a nursing case review was conducted and the client experienced
a decrease in consciousness with GCS 2t (E1VtM1), splint splint area, neck collar attached, IVFD
RL gtt 28x / min, oxygen 15ltr / minute attached using a non-rebreathing mask, TD = 110/80
mmHg, RR = 30x / min, T = 37.50C, N = 88x / min, there are lesions in the eye area, cheeks, on
the back of the left head on the left side looks swollen, right thigh looks swollen.

Past medical history : The family said that the client had never had a serious accident like this
now and also there was no history of chronic and acute diseases before such as hypertension
and DM.

Family histori : not reviewed

History of allergies : there ia no

Smoking history : the client's family saya the smoker client ia active

b. Physical examination :

1. General condition : loss of consciousness

2. Vital sign : TD : 110/80 mmHg

N : 88×/menit
3. Head : - symmetrical ✓ Asymmetric ✓ Bleeding

✓ Swollen - Skull Bone depression

✓ Echymosis - Tenderness

- Bone deformity

✓ Wound, size 3 cm, location : back left head

- Other : none

4. Eye : ✓ Bluish ( eye circle)

- Eye bleeding, Rupture : - Location : -

- Anemia : - Ananemia : - ikterik : -

- Pupillary response : - Isokor : - Anisokor : -

- RC : - Midriasis : - Miosisis : -

- Other : none

5. Ear : ✓ fluid : - color : - Total : -

- Blisters/redness/laceration

- foreign objects, forms : -

- Ects

6. Nose : - fluid - color - Amount

- Blisters/redness/laceration

- foreign objects, forms : -

- Ects
7. Neck : - foreign body penetration - Tendernes

- Tracheal deviation - jugular venous distension

- Swollen - Bluish around the neck

- crepitation - Etc

8. Chets/lung : ✓ simetris - Asimetris - Swollen

: chets wall expansion increases/decreases

- stab Wound : - size : - the location : -

- RR 30×/menit Irregular

- use of chest wall muscles

- chest pain

- pain scale : 1 2 3 4 5 6 7 8 9 10

9. Abdomen : - Abdominal wall : - ✓ Symmetrical : - - Not symmetrical : -

- bleeding/Swelling ✓ lacerations/lesions/blisters

- stab Wound : - ✓ cut : - size : -

- abdominal distension : - ✓ felt hard and tense: -

- Tenderness, pain scale : 1 2 3 4 5 6 7 8 9 10

- BU : not reviewed

- Ects

10. Genetalia : ✓sintetis : - - Asimetris : -

- Bump : - - size :- - location : -

- rectum blood - BAB : not reviewed

 - Tenderness, pain scale : 1 2 3 4 5 6 7 8 9 10

- BAK : Catheter attached

- Ects : -

11. Ekstermitas : - deformity ✓ Bleeding ✓ Swollen

- injury/laceration ✓ location : right hand extermity

- the fingers are gone. ✓ Limitation of motion

- Fracture, location : -

- pain, scale : 9

- Ects

12. Skin : ✓ there ia a Wound ✓ Location : right extermity

✓ Echymosis - ptechie

✓ itching/ prurititus

✓ operating incision: - - size : - ✓ location : -

✓ pain, scale : 9

3. PSYCHOSOCIAl, CULTURAL, SPIRITUAL ASSESSMENT

 PSYCHOSOCIAL : Not reviewed

 SOCIAL : Not reviewed
 CULTURAL. : Not reviewed
 SPIRITUAL. : Not reviewed
4. SUPPORTING INVESTIGATION

a. Blood chemistry laboratory

Inspection date July 19 2020

BLOOD CHEMISTRY EXAMINATION RESULT

INVESTIGATION THE RESULTS UNIT NORMAL VALUE

Glucose moment 150 Mg/dl 70-140

Urea 32 Mg/dl 10-50

Creatinine 1,00 Mg/dl 0,5-1,2

SGOT 23 u/L 0-31

SGPT 14 u/L 0-32

K 41 Mmol/L 3,4-5,4

Na 145 Mmol/L 135-155

Cl 99 Mmol/L 95-108

NURSING PROBLEM
a). Ineffectiveness of cerebral tissue perfusion

b). Ineffectiveness of airway clearance

c). Ineffectiveness breathing pattern

PRIORITY PROBLEM

a). Ineffectiveness of airway clearance

b). Ineffectiveness breathing pattern

c). Ineffectiveness of cerebral tissue perfusion

NURSING DIAGNOSES

a). ineffectiveness of the airway clearance associated with airway obstruction is characterized
by:

DS : cannot be rated

DO :

1. Ku : loss of consciousness

2. awareness : coma

3. GCS : E1VtM1

4. RR : 30×/menit

N : 88×/menit

T : 37, 5°C

TD : 110/80 mmHg

5. there is a secret in the ETT tube and mouth

6. sound of breath stridor

b). ineffective breathing patterns associated with neurological disorders are characterized by:

DS : cannot be Rated
 DO :

1. Ku : loss of consciousness

2. Awareness : Coma

3. GCS : E1VtM1

4. RR : 30×/menit

N : 88×/menit

T : 37,5°C

TD : 110/80mmHg

5. there is a secret in the ETT tube and mouth

6. sound of breath stridor

c). ineffectiveness of cerebral tissue perfusion associated with trauma is characterized by:

DS : cannot be Rated

DO :

1. Ku : loss of consciousness

2. Awareness : Coma

3. GCS : E1VtM1

4. mounted ventilator

5. RR : 30×/menit

N : 88×/menit

T : 37,5°C

TD : 110/80 mmHg

6. Anisochoric pupils

7. bluish around the eyes (lesions)

 8. swollen and asymmetrical head

 INTERVENTION

Nursing Action Plan