A.

Concept Of Disease
1. Anatomy and Brain Physiology

The brain is divided into four parts, namely cerebrum, cerebellum,

brainstem, and limbic system (Muttaqin, 2008).
1) Cerebrum
The cerebrum is the largest part of the human brain, also called the
cerebral cortex, forebrain, or forebrain. Cerebrum makes people have the
ability to think, analyze, logic, language, awareness, planning, memory
and visual ability. The cerebrum is divided into 4 (four) parts called the
lobe of the frontal lobes, the parietal lobes, the occipital lobes and the
temporal lobes.
The frontal lobes are part of the lobe located at the front of the cerebrum.
This lobe deals with the ability to make excuses, motion abilities,
cognition, planning, problem solving, judgment, creativity, feeling
control, sexual behavior control and language skills in general. The
parietal lobe is associated with sensory sensor processes such as pressure,
touch and pain. The temporal lobes are related to the hearing ability, the
meaning of information and language in the form of sound. The occipital
lobes are at the very back, associated with visual stimuli that allow
humans to be able to interpret the objects captured by the retina of the
eye.

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 2) Cerebellum
Cerebellum or cerebellum is part of the central nervous system located at
the back of the skull (posterior cranial fossa). All activities in this section
are under conscious (involuntary). The main function of cerebellum is to
coordinate and smooth muscle movement and change the tone and
strength of contraction to maintain balance and posture. In the event of an
injury to the cerebellum, it can lead to disruption to the attitude and
coordination of muscle movement so that the movement becomes
uncoordinated.
3) Brainstem
The brainstem is inside the skull bone or the base cavity of the head and
extends to the spine or spinal cord. This part of the brain regulates basic
human functions including breathing, heart rate, regulating body
temperature, regulating the digestive process, and is the source of the
basic human instinct of fight or flight when danger comes. The brain
stem consists of three parts, namely:
a) Mesencephalon or midbrain (brain mid) is the top of the brain stem
connecting the cerebrum and cerebellum. Mesencephalon serves to
control vision response, eye movements, pupils enlargement, regulate
body movement, and hearing function.
b) Medulla oblongata is the starting point of the spinal cord from the left
side of the body to the right side of the body, and vice versa. Medulla
oblongata controls the involuntary function of the brain (unconscious
brain function) such as heart rate, blood circulation, respiration, and
digestion.
c) Pons also referred to as bridges or bridges are fibers that connect the
two cerebellar hemispheres and connect the upper midbrain with the
medulla oblongata. The lower part of the pons plays a role in the
breathing setting. The nuclei of the cranial nerve V (trigeminus), VI
(abdusen), and VII (facies) are present in this section.
4). Limbic system (limbic system)

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The limbic system is a functional grouping that includes the components
of the cerebrum, diensefalon, and mesensefalon. Functionally the limbic
system deals with the following matters.
a) An emotional stance or response that leads to the behavior of the
individual
b) A conscious response to the environment
c) Empower the intellectual function of the cerebral cortex
unconsciously and enable the brainstem automatically to respond to
circumstances
d) Facilitating the storage of a memory and retrieving the required
memory savings
e) Respond to an experience and mood expression, especially fear,
anger, and emotion-related reactions related to sexual behavior.
The brain is a very important part of the body that is protected by
hard skull bones, protective tissue, and cerebrospinal fluid. Two
main protective tissues are the meninges and ventricular system.
Meninges consists of three layers:
1) Durameter
Durameter is the outermost layer that is thick, hard, and flexible
but can not be stretched (unstrechable).
2) Arachnoid membrane
Arachnoid membrane is a middle layer that looks like a spider
web. The nature of this layer is soft, hollow-cavity, and is located
under a layer of durameter.
3) Piameter
Piameter is a protective layer located at the bottom layer (closest
to the brain, spinal cord, and protect other neural networks). This
layer contains blood vessels that flow in the brain and spinal cord.
Between the piameter and the arachnoid membrane there is a
section called the subarachnoid space (sub-arachnoid space) filled
with cerebrospinal fluid (CSS) (Puspitawati, 2009).

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 Gambar 2. Lapisan meninges
The brain is very soft and supple so it is very easily damaged. In addition
to the meninges lining, the brain is also protected by cerebrospinal fluid
(CSS) in subarachnoid space. This fluid causes the brain to float,
reducing the pressure on the lower part of the brain that is affected by
gravity and also protect the brain from possible shocks. This CSS is
located in interconnected spaces with each other. These spaces are
called ventricles (ventricles). Ventricles are associated with
subarachnoid parts and are also associated with tubular forms in the
central canal (spinal canal) of the spine. The largest space filled with
fluid is mainly in the lateral ventricle pair (lateral ventricle). The lateral
ventricle is associated with the third ventricle located in the midbrain.
The third ventricle is connected to the fourth ventricle by the cerebral
aqueduct that connects the fourth ventricular caudal tip with the central
canal. The lateral ventricle also forms the first ventricle and the second
ventricle (Puspitawati, 2009).

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 Gambar 4. Saraf kranial
Autonomic nervous system The autonomic nervous system controls
activities independent of decisions. This system regulates the contraction
of muscles that are not under the control of consciousness such as heart
muscle, the secretion of all digestif or sweat glands, and the activity of
endocrine organs. Muscular nervous system has two divisions, namely
anatomically and functionally, the sympathetic nervous system and the
parasympathetic nervous system (Smeltzer & Bare, 2001).

2. Definitions

Head injury is a traumatic disorder of brain function accompanied or without

interstitial hemorrhage in brain substance without followed by discontinuity of
brain continuity (Muttaqin 2008).
Head injury or head trauma is a disorder of normal brain function due to
trauma both blunt trauma and sharp trauma. Neurologic deficits occur because
of the rupture of substansia alba, ischemia and mass influences due to
hemorrhag, and cereblal edema around the brain tissue. ([Link],
2008).According to Brain Injury Association of America, 2006. Head injury is

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 a damage to the head is not congenital or degenerative, but due to attacks /
physical impact from the outside that can reduce or alter the awareness which
cause damage to cognitive abilities and physical function

3. Pathway

Filcha Novirman,[Link]

Head trauma Self-care deficit

Disconnected continuity of bone

Risk of tissue, skin tissue, muscle, and Damage to brain cells
infection laceration of blood vessels Impaired
blood supply

Increase sympathetic stimulation

Changes in cerebrospinal fluid circulation
Ischemia
Acute
pain
Subdural hygroma Hypoxia
Increases systemic
vascular
Cerebrospinal fluid in the subdural layer
resistance and
Ineffective blood pressure
Cerebral edema perfusion of brain
Nauseous tissue

Increased ICT vomit Lowering

pulmonary
Risk of fluid vascular pressure
Mesensefalon volume deficiency
depressed
Increased
hydrostatic
Blurry vision
Disturbance of pressure
Decreased hearing
consciousness function
Headache Capillary fluid leak
Imobilisasi
Risk of injury

Stacking Pulmonary
secretions The risk of
edema
impaired skin
integrity Maintenance
deficit O2 diffusion
is inhibited
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Ineffective
Ineffective breath
clearance of airway
pattern
4. Supporting Investigation

1. CT-scan: attention to the presence of edema, hematoma.

2. Lumbar puncture: indicates a normal pressure and usually there is

thrombosis, cerebral embolism, and TIA (Transient Ischaemia Attack) or a

cinematic ischemic attack. Increased pressure and blood-borne fluid suggest
subarachnoid hemorrhage or intra-cranial haemorrhage. Total protein levels
are increased in cases of thrombosis due to the inflammatory process.

3. MRI (Magnetic Resonance Imaging): shows areas infarcted, hemorrhagic,

and arteriovenous malformations.

4. EEG (Electroencephalography): identifies the disease based on brain waves

and may exhibit specific lesion areas.

5. X-ray: describes changes in pineal plate gland area opposite from the
expanding mass, internal carotid calcification is present in cerebral
thrombosis.

5. Nursing Management

In scalp injuries, subcutaneous injection through subcutaneous lesions makes it

easy to clean and treat. The wound area is irrigated to remove the foreign body
and minimize the entry of the infection before the area is closed.
[Link] the airway: clear the airway from debris and vomit, remove the

dentures, keep the cervical bone in line with the body with a cervical collar,
pairs of guedel / mayo if intolerable. Orofacial jikacedera interfere with the
airway, then the patient should be intubated.

2. Assess breathing: determine whether the patient breathes spontaneously /not.

Do not give O2 via O2 mask. If the patient breathes spontaneously

investigate and overcomes severe chest injuries such as tension
pneumothorax, hemopneumothorax. Install a pulse oximeter to maintain a
95% O2minimum saturation. If the patient's airway is unprotected and even

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 O2> 45% and Pa CO2 <40% mmHg and O2> 95% saturation) or vomiting
then the patient should be intubated and vented by anesthesia.

3. Assess the circulation: the damaged brain does not tolerate [Link]
all bleeding by pressing the artery. Note the presence of intra-abdominal /
breast injury. Measure and record the frequency of heartbeat and EKG set
blood pressure. Install a large intravenous line. Providing colloid solutions
where crystalloid solutions cause exacerbations of edema.

4. Seizures convulsions: Convulsive seizures may occur after a head injury and
should be treated initially given 10mg intravenous diazepam slowly and twice
repeat 2x if still seizure. If not successfully given fenitoin15mg / kgBB.

5. Assess the severity: CKR, CKS, CKB6. In all patients with head and / or
neck injury, do cervical rear photographs (AP projections, lateral and
odontoid), new cervical colic removed after ensuring that all cervical C1-
[Link] all patients with moderate and severe head injury: -
Intravenous fluids with normal saline solution (Nacl 0.9%) or RL
fluidisotonis more effectively replace intravascular volume than
fluorescotonis and this solution does not increase cerebral edema- Perform
examination: Ht, complete peripheral blood check , thrombocyte, blood
chemistry. Perform CT scan Patients with CKR, CKS, CKB should be
evaluated for the following: 1. Epidural Hematoma2. Blood in sub arachnoid
and intraventrikel3. Contusion and brain tissue hemorrhage 4. Cerebral
edema 5. Middle [Link] [Link] comatose patients (GCS
score < 8) or patients with herniated signs: Head Elevation 30,
Hyperventilation, Give mannitol 20% 1gr / kgBB intravenously in 20-30
minutes. Repeat dose can be given 4-6 hours later at ¼ dose semulasetiap 6
hours to a maximum of 48 hours I- Install foley catheter- Consul
neurosurgery when there are indications of opoerasi (large epidural
hematoma, sub dural hematoma, open head injury, impression fracture> 1
diplo).

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 According to Corwin (2009) mentions management for Intra Cerebral
Hematom is as follows:

a. Observation and bed rest for too long.

b. Ligation of broken vessels and surgical evacuation of the hematoma.
c. Mechanical ventilation may be required.
d. For open injuries antibiotics are required.
e. Methods for lowering intra-cranial pressure include the administration of
diuretics and anti-inflammatory drugs.
f. Laboratory examination such as: CT-Scan, Thorax photo, and other
supporting laboratory.

B. Nursing Care Plan

[Link]
Data to be reviewed Brain Tumor Filcha Novirman,[Link]
a. Client ID: to assess client status (name, age, gender, religion, education,
address, occupation, marital status)
b. Medical history: medical diagnosis, major complaint, current medical
history, previous medical history consisting of any disease ever
experienced, allergy, immunization, habit / lifestyle, medication used,
family disease history
c. Genogram
d. Nursing Assessment (11 patterns of Gordon)
e. Physical examination
1) General state, vital signs
2) Physical Assessment (inspection, palpation, percussion, auscultation):
head, eyes, ears, nose, mouth, neck, chest, abdomen, urogenital,
extremities, skin and nails, and local circumstances.
A more thorough and in-depth review of the various aspects of the client's
problems with severe brain injuries and trauma to the abdomen may result
in a client's problems. General principles that can be done to examine the
problems in patients with B6:

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a. Breathing: Compression in the brain stem will result in heart rhythm
disturbance, resulting in changes in the breath pattern, depth, frequency
and rhythm, can be Cheyne Stokes or Ataxia breathing. Breath sounds,
stridor, ronkhi, wheezing (possibly due to aspiration), tend to increase
sputum production on the airway. Blunt trauma in the abdomen can
lead to the emergence of swelling of the intraabdominal organs
resulting in diaphragm compression which may cause increased
respiratory frequency.
b. Blood: The effect of increased intracranial pressure on blood pressure
varies. Pressure at the vasomotor center will increase the transmission
of parasympathetic stimulation to the heart which will cause the pulse
to slow, a sign of increased intracranial pressure. Changes in heart
frequency (bradycardia, tachycardia interspersed with bradycardia,
dysrhythmias). Damage to the vascular tissue of the abdomen can lead
to massive bleeding resulting in the potential for intra-abdominal
bleeding complications.
c. Brain: Impaired consciousness is one form of manifestation of brain
disorders caused by head injury. Loss of temporary consciousness,
amnesia around events, vertigo, syncope, tinnitus, hearing loss,
numbness in extremities.
If bleeding is severe and concerns the brainstem there will be a
disturbance in the cranial nerve, then it may occur:
1. Changes in mental status (orientation, alertness, attention,
concentration, problem solving, emotional / behavioral and memory
influences)
2. Changes in vision, such as sharpness, diplopia, loss of some field of
view, photo phobia
3. Change of pupil (response to light, symmetry), deviation on the eyes.
4. There is a decrease in hearing power, body balance.
5. Often arises hiccup / hiccups because compression in the vagus nerve
causes spasmodic compression of the diaphragm.

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 6. Disturbance of the hypoglossal nerve. Disorders that appear to be
falling on one side of the tongue, dysphagia, disatria, so difficulty
swallowing.
7. GCS examination
8. Assessment of cranial nerves
a. Bladder: In head and abdominal injuries there is often a retention
disorder, urinary incontinence, inability to withstand micturition.
b. Bowel: Decreased digestive function: weak bowel sounds, nausea,
vomiting (possibly projectile), bloating and taste changes.
Disorders of swallowing (dysphagia) and disruption of alvi
elimination process.
c. Bone: Patients with head injuries often come in parese, paraplegi.
In the old conditions can occur contractures due to
immobilization and can also occur spasticity or imbalance
between the antagonist muscles that occur due to damage or
breakage of the relationship between the nerve center in the brain
with reflexes in the spinal addition can also decrease muscle tone.
e. Therapy, investigation & laboratory tests

2. Nursing Diagnosis

a) the risk of perfusion of cerebral tissue inefficiency is associated with

decreased blood flow to the brain

b) Ineffective breathing pattern associated with neuromuscular damage,

diaphragm compression, maximal lung expansion

c) The ineffectiveness of airway clearance is related to the accumulation

of secretions
d) Imbalances in the fulfillment of nutritional needs less than body needs

associated with decreased awareness and nausea vomiting

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 e) Acute pain associated with tissue continuity loss, suppression of pain

receptors
f) The risk of infection is related to discontinuation of continuity of bone

tissue, skin tissue, muscle, and laceration of blood vessels

g) Lack of fluid volume associated with persistent nausea and vomiting
h) Sensory perception disorders are associated with decreased awareness
i) The risk of injury is associated with decreased awareness
j) The ineffectiveness of airway clearance is associated with the

accumulation of secretions in the airway

k) The risk of damage to skin integrity is linked to immobilization for a

long time
l) Nausea is associated with distress in the stomach

3. Intervention Of Nursing

No Diagnosis Aim Intervention Rational

1 Risk The ineffectiveness of NOC: NIC: 1. Know the status of
cerebral tissue perfusion is circulation Circulatory peripheral circulation
associated with decreased blood status Precaution and the existence of
flow to the brain Tissue NANDA NIC- abnormal conditions in
Perfusion: NOC 2012 the body
Cerebral
Results criteria: 1. Assess 2. Knowing any changes
Demonstrate comprehensive due to peripheral
the circulation peripheral circulatory disturbances
status indicated circulation 3. Avoid injury to
by: (peripheral minimize injuries
1. pressure of pulse, edema, 4. Trendelenberg

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systole and CRT, color, position will increase
diastole in and extremity ICT so that aggravate
expected range temperature) the condition of the
2. no 2. Assess limb client
orthostatic conditions 5. Reduces the pressure
hypertension include to avoid undisturbed
3. no signs of redness, pain, perfusion
increased or swelling 6. Drugs to improve the
intracarnial 3. Avoid injury sodus perfusion
pressure (no to areas with 7. Reduce family
more than 15 minimal anxiety
mmHg) perfusion 8. Help speed up client
4. 4. Avoid recovery
demonstrating clients from
cognitive trendy
abilities positions that
characterized increase ICT
by: 5. Avoid any
5. communicate emphasis on
clearly and in the area of
accordance injury
with ability 6. Maintain
6. show fluids and
attention, medicines
concentration according to
and orientation the program
7. process 7. Health
information education
8. make about patient's
decisions condition and
correctly condition to

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9. attributes the family
sensory 8.
function of Collaboration
complete of medical
cranial motion: therapy
the level of Peripheral
awareness sensation
improves, there management
is no (Management
movement of of peripheral
involent sensations)
movements NANDA NIC-
NOC 2015
[Link]
existence of
certain dearah
which only
sensitive to hot
/ cold / sharp /
blunt
2. monitor the
presence of
paretase
3. instruct the
family to
observe the
skin if there is
any contents or
laceration
4. Use gloves
for protection

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 5. motion
movement on
the head, neck,
and back
6. Absorbment
ability monitor
[Link] of
thromboplebitis
8. discuss
mangenai
causes of
sensation
change
[Link]
of analgesic
administration
2. Ineffective breathing patterns are Respiratory Respiratory 1. Knowing the patient's
associated with neuromuscular status: monitoring respiratory condition
damage Ventilation 1. Monitor the 2. Knowing the
Respiratory speed, condition of the lungs
status: frequency, and heart of the patient
Ventilation depth and 3. Knowing the patient's
Vital sign power as the breathing sound
status patient breathes 4. Knowing the
Results criteria: 2. Monitor the condition of the patient
1. results of chest to determine the next
demonstrating x-rays intervention as indicated
effective cough 3. Monitor the 5. To monitor the
and breath patient's patient's condition
sounds clean. breathing (patient's breathing
No cyanosis sound sound) to determine

15
and dyspnea 4. Kaji and interventions as
(able to remove monitor indicated
sputum, mapu changes in 6. Reduce family
breathing breathing anxiety
easily, no 5. Monitor the 7. Assist client healing
pursed lips) secretions
2. show the issued by the
patent airway patient
(client does not 6. Health
feel choked, education
breath rhythm, about patient's
breathing condition and
frequency in condition to
normal range, family
no abnormal 7.
breath sound) Collaboration
Vital signs in of medical
the normal therapy
range (blood Vital sign
pressure, pulse, monitoring
respiration. (NANDA NIC-
NOC 2015)
1. monitor
blood pressure,
temperature,
and RR
2. monitor lung
sound
3. monitor
cyanosis prifer
4. monitor

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 temperature,
color, and
humidity
3 The ineffectiveness of airway NOC: NIC: 1. Maintain oral hygiene
clearance is related to the 1. Respiratory Airway suction prevents sputum buildup
accumulation of secretions status: 1. Ensure the 2. Knowing the presence
Ventilation need for oral / or absence of sputum
2. Respiratory tracheal 3. Informed consent
status: Airway suctioning action
patency 2. Auscultation 4. Accommodates O2 as
3. Aspiration of breath sound a backup
Control before and after 5. O2 is still there for
Results suctioning. breathing
Criteria: 3. Inform 6. Prevent infection
1. Demonstrate clients and 7. Give patient time to
effective cough family about rest
and breath suctioning 8. Knowing the patient's
sounds clean, 4. Ask the oxygen status
no cyanosis client to 9. Preventing excessive
and dyspneu breathe in hypoxia
(able to remove before suction
sputum, able to is done.
breathe easily, 5. Give O2 by
no pursed lips) using nasal to
2. Shows the facilitate
airway of the nasotracheal
patent (client suksion
does not feel 6. Use a sterile
choked, breath tool every
rhythm, action
breathing 7. Instruct the

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frequency in patient to rest
normal range, and deep breath
no abnormal after the
breath sound) catheter is
3. Able to removed from
identify and the
prevent factors nasotracheal
that can inhibit 8. Monitor
the airway patient oxygen
status
9. Stop suction
and give
oxygen if the
patient shows
bradycardia,
increased O2
saturation, etc.
Airway
Management
1. Open the
airway,
guanakan chin
lift technique
or jaw thrust if
necessary
2. Position the
patient to
maximize
ventilation
3.
Identification

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of the patient
for the
installation of
artificial
airway
4. Install the
mayo if
necessary
5. Do chest
physiotherapy
if necessary
6. Remove the
secretion by
coughing or
suction
7. Auscultation
of breath
sound, note the
presence of
additional
sound
8. Do suction
on mayo
9. Give the
bronchodilator
if necessary
10. Give moist
air humidifier
moisturizer
NaCl moist
11. Set the

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 intake to
optimize the
balance liquid.
12. Monitor
respiration and
O2 status
4 The imbalance in the fulfillment NOC: NIC: 1. Meet the patient's
of nutritional needs is less than 1. Nutritional Nutrition nutritional needs
the needs of the body associated Status: Food Management 2. To prevent
with decreased awareness and Fluid 1. Install the regurgitation and
Intake stomach pipe aspiration
Results as indicated, 3. Knowing the amount
Criteria: check the of patient's daily intake
1. The position of the 4. Knowing the presence
existence of pipe each will or absence of
weight gain in provide food gastrointestinal bleeding
accordance 2. Elevate the 5. Increase family
with the head of the bed knowledge
purpose as high as 30 6. Meet the daily
2. Ideal weight degrees nutritional needs of
according to 3. Record the patients
height incoming food
3. Be able to 4. Assess the
identify gastric fluid,
nutritional vomit
needs 5. Health
4. No sign of education
malnutrition about diet with
5. No family
significant 6.
Collaboration

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 weight loss with
occurs nutritionists in
the provision of
appropriate diet
to the patient's
condition
5 Acute pain associated with NOC: NIC: a. Assist in determining
tissue discontinuity - Pain level Pain patient pain status and
- Pain control Management become baseline data for
- Comfort level a. Assess intervention and
Results criteria: patient monitoring of
a. Able to characteristics intervention success
control pain on PQRST b. Enhance the feeling
(know the b. Perform pain of comfort by reducing
cause of pain, management the compressive
able to use according to sensation in the affected
nonfarmakologi the scale of area
technique to pain such as c. Localized hypoxemia
reduce pain) physiological can cause pain and
b. Reported position increased oxygen supply
that pain is settings in the pain area can help
reduced by c. Teach reduce pain
using pain relaxation d. Improves the blood
management techniques flow response in the
c. Be able to such as deep pain area and is one of
recognize pain breath and the distraction methods
(scale, distraction e. Maintain drug levels
intensity, when the pain and avoid peak period
frequency and comes (if the pain
pain sign) patient is
d. Express the conscious and

21
feeling of cooperative)
comfort after d. Give touch
the pain is management in
reduced the form of
ringat massage
on the area
around the pain
e.
Collaboration
with periodic
administration
of analgesics

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