ASUHAN KEPERAWATAN GAWAT DARURAT PADA PASIEN PENDERITA STROKE HEMORAGIK DENGAN MASALAH KEPERAWATAN POLA NAPAS TIDAK EFEKTIF: NURSING CARE IN ADULT PATIENTS WITH HEMORRHAGIC STROKE WITH NURSING PROBLEMS INEFFECTIVE BREATHING PATTERNS - Piryanti, Asri; Nugroho, Christianto (Stikes Pamenang, 2025)
Introduksi : Stroke Hemoragik terjadi ketika adanya gangguan aliran darah ke otak yang diakibatkan pecahnya pembuluh intraserebral sehingga menyebabkan lemahnya otot – otot pernapasan dan dada yang akan mengalami kesulitan bernapas. Tindakan yang perlu dilakukan adalah manajemen jalan napas. Tujuan studi kasus ini untuk mendeskripsikan asuhan keperawatan gawat darurat pada pasien penderita stroke hemoragik dengan masalah keperawatan pola napas tidak efektif. Metode : Asuhan keperawatan gawat darurat di Ruang HCU Mahakam RSUD Dr. Saiful Anwar Provinsi Jawa Timur (Ny. S) selama 4 hari dan (Ny. J) selama 3 hari pada bulan November 2024. Metode yang dilakukan berupa pemecahan masalah dengan pendekatan proses keperawatan menggunakan metode deskriptif. Hasil : Hasil pengkajian didapatkan bahwa dua pasien Stroke Hemoragik, penurunan kesadaran, takipnea, terdapat otot bantu pernapasan, dan terdapat pernapsan cuping hidung. Masalah keperawatan prioritas yaitu pola napas tidak efektif. Tindakan yang dilakukan berupa memonitor pola napas, memposisikan semi fowler 30°, memberi minum hangat, dan mengkolaborasi pemberian bronkodilator. Evaluasi di hari terakhir menunjukkan (Ny. S) mengalami penurunan TTV, otot bantu napas menurun, pernapasan cuping hidung menurun, detak jantung melemah pasien meninggal dunia pola napas tidak efektif belum teratasi dan (Ny. J) otot bantu napas menurun, pernapasan cuping hidung menurun, takipnea menurun pola napas tidak efektif teratasi sebagian. Analisis : Manajemen jalan napas dengan pengaturan posisi semi fowler 30° dapat membuat oksigen didalam paru – paru meningkat, sehingga meringankan sesak napas. Aliran oksigen menuju otak menjadi tercukupi dan hipoksia serebral berkurang. Discuss : Rekomendasi untuk penulis selanjutnya dapat menyajikan data tentang tekanan ekspirasi dan inspirasi untuk memperkuat data pengkajian. Abstract Introduction: Hemorrhagic stroke occurs when there is an interruption of blood flow to the brain due to rupture of an intracerebral vessel, causing weakness of the respiratory and chest muscles that will have difficulty breathing. The action that needs to be taken is airway management. The purpose of this case study is to describe emergency nursing care in patients with hemorrhagic stroke with nursing problems of ineffective breathing patterns. Methods: Emergency nursing care in the Mahakam HCU Room at Dr. Saiful Anwar Hospital, East Java Province (Mrs. S) for 4 days and (Mrs. J) for 3 days in November 2024. The method used is problem solving with a nursing process approach using descriptive methods. Results: The results of the assessment found that two patients with hemorrhagic stroke, decreased consciousness, tachypnea, there are respiratory muscles, and there is nasal breathing. The priority nursing problem is ineffective breathing patterns. Actions taken in the form of monitoring breathing patterns, positioning semi-fowler 30 °, giving warm drinks, and collaborating on bronchodilator administration. Evaluation on the last day showed (Mrs. S) had a decrease in TTV, decreased breathing muscles, decreased nasal lobe breathing, weakened heart rate, the patient died, the ineffective breathing pattern had not been resolved and (Mrs. J) decreased breathing muscles, decreased nasal lobe breathing, decreased tachypnea, the ineffective breathing pattern was partially resolved. Analysis: Airway management with a 30° semi-Fowler position can increase oxygen in the lungs, thereby alleviating shortness of breath. The flow of oxygen to the brain is sufficient and cerebral hypoxia is reduced. Discuss: Recommendations for future authors could include presenting data on expiratory and inspiratory pressures to strengthen the review data.