Nursing care in patients with Neurological System Disorders : Head InjuriesPosted by nurse87 on October 1, 2013Posted in : Uncategorized . Leave a Comment

    A. Basic Concept of Medical
    1 . definition
Head injury or brain injury is a traumatic disruption of brain function with or without bleeding within the brain substance interstiil without breaking the continuity of the brain followed . ( Arif Muttaqin 2008 , pp. 270-271 ) .
Trauma or head injury is known as a disorder of brain injury due to trauma to the brain's normal function both blunt trauma and sharp trauma . Neurological deficits occur due to rupture of the white matter , ischemic , and hemorrhagic effect of past due , as well as cerebral edema surrounding brain tissue ( Batticaca Fransisca , 2008, p 96 ) .
Head injury is a process where there is direct trauma or deceleration of the head that causes damage to the skull and brain . ( Pierce Agrace & Neil R. Borlei 2006 case 91 ) .
Based Glassgow Coma Scale ( GCS ) injury to the head or brain can be divided into three gradations :

    Mild head injury ( CKR ) = GCS 13-15
    Moderate head injury ( CKS ) = GCS 9-12
    Severe head injury ( CKB ) = GCS ≤ 8



    2 . anatomy Physiology

 The brain is wrapped by the lining of the brain ( meninges ) that consists of three layers , namely :

    Dura mater : The outer layer , derived from connective tissue that is thick and wiry strong , thick , inelastic , in the form of fibers and gray .
    Arachnoid : Membrane central part , is thin and soft . White because the blood is not flowing , there khoroid plexus that produces cerebrospinal fluid ( CSS ) CSS is contained villi that absorb the blood upon entry into the system ( due to trauma , aneurysm , stroke ) .
    Piamater : the innermost membrane , such as the walls are thin, transparent covering of the brain and extends to every layer of the brain .
Cerebrum , consists of 4 lobes , namely :

    Frontal Lobe : This area controls the behavior of individuals , make decisions , personality , and restraint . Largest lobe .
    Parietal lobe : sensory lobe , the area of ​​interpreting sensations , set the individual is able to determine the position and the location of the body .
    Temporal lobe : Sensation ketchup , smell , and hearing , short-term memory .
    Occipital lobe : interpreting the vision .
Diencephalon consists of the thalamus , hypothalamus , and pituitary gland .

    Thalamus : relays Center odor sensation and pain .
    The hypothalamus : Working closely with the pituitary gland to maintain fluid balance and maintain body temperature regulation . As the hunger center and BB control , regulating sleep , blood pressure , aggressive behavior , sexual , emotional response .
    The pituitary gland : Regarded as the master gland , because of a number of hormones and functions regulated by these glands . anterior lobe of the pituitary produces growth hormone, prolactin , TSH , ACTH , LH . The posterior lobe contains the hormone ADH .


Brainstem , consisting of the midbrain , pons , medulla oblongata .

    Midbrain / mesencephalon , the part that connects the diencephalon and pons . The main function of delivering impulses to the brain center associated with muscle movement , vision and hearing .
    Pons : Delivering impulses to the brain center .
    Medulla oblongata , a reflex center in order to control the involuntary functions such as breathing , sneezing , swallowing , coughing , spending saliva , vomit .
Cerebrum : stimulate and inhibit and responsibility for coordination of motion , balance , position .
Cerebral circulation
Receives approximately 20 % of the bulk jantung/750 ml per minute . This circulation is needed , because the brain does not store food , while having a high metabolic needs .
Mendarahi blood vessels of the brain tardiri :
1 ) A pair of carotid blood vessels : a large blood vessel pulsation can we touch the neck forward , left and right below the mandible , a pair of blood vessels after entry into the skull cavity will be three- pronged :
a) Most of the brain leading to the front ( anterior cerebral artery )
b ) Some headed to the back of the brain ( posterior cerebral artery )
c ) Most of the brain towards the inside ( interior cerebral artery )
All three will be interconnected through blood vessels called arteries posterior communicant .
2 ) A pair of vertebral veins : These veins pulse can not be felt because both the blood vessels infiltrate the bone to the side of the neck , the blood vessels and the brain stem memperdarahi two small brain , the blood vessels will both interconnected blood vessels on the brain surface called anastomosis .


The blood supply to the spinal cord
Receiving nutrition through arterial branches vetebralis thoracic aorta and branches through the abdominal aorta . Spinal cord arterial and venous systems running in parallel to each other and have a relationship that is broad ramifications for insufficient blood supply to the tissues . Formed by the choroid plexus , and circulates in the ventricles and subarachnoid space . CSF is composed of water , electrolytes , oxygen , carbon dioxide , glucose and small amounts of protein , as well as potassium and chloride concentrations eminence . CSF production and reabsorption is constant and lasts a total volume of about 125 cc of CSF with CSF secretion rate per day 500-750 cc . CSF fluid pressure in about 5 to 12 cm H2O .



    3 . etiology
        Mostly caused by traffic accidents , fights , falls and injuries by sport .
        Open head injuries are often caused due to sharp objects and fire that can lead to bone fractures and laceration of the dura mater .
Various Bleeding in the Brain
a. Intracerebral hematoma ( ICH )
Intracerebral hemorrhage is bleeding that occurs in the brain tissue typically due to a tear of blood vessels present in the brain tissue . Is clinically characterized by loss of consciousness that is sometimes accompanied by lateralization , a CT scan is obtained which indicated the presence of local hiperdens surgery if single , diameter greater than 3 cm , peripheral , the movement of the center line , and clinically hematoma can cause neurological disorders / lateralization . The operation is usually performed with evacuation of hematoma decompression of the skull .
b . Subdural hematoma ( SDH )
Subdural hematoma is the accumulation of blood between the dura mater and brain tissue , may be acute chronic . Caused by fragments of vein / vein bridge that normally exists between the dura mater , a slow and a little bleeding . Another understanding of subdural hematoma is a hematoma which lies under layers of dura mater with the source of the bleeding can come from bridging vein ( most often ) , A / V cortical , dural venous sinuses . By the time the subdural hematoma bleeding divided into three subdural hematoma include acute occurred less than three days of events , subacute subdural hematoma occurs between 3 days - 3 weeks , and chronic subdural hematoma if bleeding occurs more than 3 weeks .
Acute subdural hematoma is clinically characterized by loss of consciousness , accompanied by the most frequent form of lateralization yanag hemiparese / hemiplegia and a CT scan is obtained in the form of a picture hiperdens crescent moon ( cresent ) .
Indication of operation , according to the Brain Injury Commition Europe ( EBIC ) , subdural hemorrhage if the bleeding is more than 1 cm . If there is a shift of the midline labih 5 mm . Operations performed are hematoma evacuation , stop the source of bleeding . If there is cerebral edema is usually not refundable bones ( decompression ) and stored sugalea . The prognosis of SDH client GCS determined from the initial time of surgery , duration of surgery clients coming up , dijaringan concomitant brain lesions , as well as the age of the client at the client with a GCS less than 8, the prognosis is 50 % , the lower GCS then the worse the prognosis . The older the client , the more bad prognosis . Another lesion will memperjelek prognosis .
Symptoms of subdural hematoma complaints include headache, confusion , drowsiness , withdrawal , changes in thought processes ( slow thinking ) , spasm , and edema of the pupil .
c . Epidural hematoma ( EDH )
Epidural hematoma is a hematoma which is located between the dura mater and the bone , usually the source of the bleeding is arterial tear meningica media ( most often ) , venous diploica ( because of the fracture calvaria ) , emmisaria vein , dural venous sinuses . Clinically characterized by loss of consciousness accompanied by lateralization ( no inequality between neurological signs left and right sides of the body ) that can be hemiparese / hemiplegia , pupils anisokor , pathological reflexes one hand , the existence of lateralization and lesion on the head shows the location of EDH . Pupils anisokor / dilatation and injury to the head lying to one side while the location EDH hemiparese / hemiplegia located contralateral to the location of EDH . Lucid interval is not a sure sign of the presence of EDH because it can occur in other intracranial hemorrhage , but lucid interval can be used as a benchmark of prognosis . The longer the lucid interval , the better the prognosis client EDH ( because the brain has a chance to make compensation ) . Severe headache that does not go away and settle analgetik . On CT scan obtained hiperdens picture area with biconvex shape between 2 suture , picture hemorrhage volume of more than 20 cc or more than 1 cm or with midline shift ( midline shift ) of more than 5 mm . Operations performed are hematoma evacuation , stop the source of bleeding while the skull can be developed . If the current operation is not obtained adanaya cerebral edema otherwise not be developed if the current bone surgery tense dura mater obtained and can be stored subgalea .



    4 . pathophysiology
Some of the variables that influence the extent of a head injury are :
a) The location and direction of the cause of the collision
b ) The speed of the power that comes
c ) The surface of the override force
d ) The condition causes the head when it gets clash
The brain damage found in head injuries can occur in two ways

    The immediate effect ; trauma on brain function
        Indirect effects ; neurologic damage directly caused by an object or bone fragments penetrating and tearing of brain tissue . All of this results in acceleration - deselarasi .
The degree of damage is influenced by the strength of that hit . There are two kinds of power generated :

        Local injury caused by a sharp object , neurologic damage occurs in a confined area at the site of the attack .
        Injury is more prevalent overall in blunt trauma and after the accident .
Damage occurs when the energy or force transmitted to the brain . Many of the energy absorbed by the protective coating that is : the hair , scalp and skull . But the injury is not severe enough absorption to protect the brain .
If the head moves and stops abruptly and rudely , the damage caused not only by locals but also by injuries and deselarasi acceleration . Acceleration and deceleration strength causes the contents of the skull are hard to move , thus forcing the brain within the skull surface membantur on the opposite side impact collision and what happens is the brain tissue injury .
Whenever tissue is injured , there will be changes in intracellular and extracellular fluid content . Penigkatan blood supply to the place where the injury occurred causing intracranial pressure as a result of injuries suffered penigkatan circulation of the brain to regulate the volume of blood to the brain is experiencing its ability to cause ischemia in the brain .



    5 . Signs and Symptoms

 Signs and symptoms may include disturbances of consciousness , confusion , pupillary abnormalities , attack ( onset ) form suddenly neuorologis deficit , changes in vital signs , visual disturbances , sensory dysfunction , muscle spasms , headache , vertigo ( dizziness ) , movement disorders , seizures , and shock due to multiple system injuries .
Classification of head injury based on the mechanism and severity of injury :

    The mechanism is based on the presence of penetration of the dura mater :
        Blunt trauma ; speeds ( collision )
        Sharp trauma ; penetrating bullet wounds and other penetrating injuries .
        Severity of injury :
            Mild head injury ( low risk group )
1 ) Glasgow coma scale score 13-15 ( full conscious and orientatif )
2 ) There is no loss of consciousness
3 ) No alcohol or drug intoxication
4 ) The patient may complain of headache and dizziness
5 ) The patient may suffer from hematoma on the scalp
6 ) There is no moderate injury criteria - severe

    Moderate head injury ( moderate risk group )
1 ) Glasgow coma scale score 9-12 ( lethargy )
2 ) post- traumatic amnesia
3 ) Vomiting
4 ) Signs skull fracture probability ( myopic eyes , hemotimpanum , otorea , cerebrospinal fluid rhinorrhea )
5 ) Seizures

    Severe head injury ( severe risk group )
1 ) Glasgow coma scale score ≤ 8 ( coma )
2 ) Decreased level of consciousness progressively
3 ) neurological signs vocals
4 ) penetrating head injury or palpable skull fracture .









    6 . Diagnostic Test
Investigations are needed on the client with a head injury include :

    CT Scan ( with / without contrast )
Identify the extent of the lesion , hemorrhage , determinants , ventricular , and changes in brain tissue

    MRI ( Magnetic Resonance Imaging )
Used together with CT Scan with / without contrast radioactive

    cerebral angiography
Shows such as changes in cerebral circulation anomalies secondary brain tissue becomes edema, hemorrhage , and trauma .

    Serial EEG ( Electroencephalography )
Can see the development of pathological wave

    X-ray
Detecting changes in bone structure ( fracture ) , changes in the structure of the line ( hemorrhage / edema ) of bone fragments

    BAER ( Brainstem Auditory Evoked Response )
Correcting limit cortex and cerebellum function

    PET ( Positron Emission Tomography )
Detecting changes in brain metabolism aktifititas

    CSS ( cerebrospinal fluid )
Lumbar functions can be performed if the suspected subarachnoid hemorrhage

    electrolyte levels
To correct electrolyte balance as an increase in intracranial

    toxicology screen
To detect the influence of drugs that can cause loss of consciousness

    2 -way thoracic radiograph ( PA / AP and lateral )
Thoracic radiograph declared accumulation of air / fluid in the pleural area .

    Toraksentesis expressed blood / fluid
    Analysis of blood gases ( ABG / Astrup )
Analysis of blood gases ( ABG / Astrup ) is one of the diagnostic tests to determine the status of respiratory status . Respiratory status can be illustrated through examination of the AGD is the status of oxygenation and acid-base status

    Laboratory tests ; hematocrit , platelets , whole blood , protombin period .



    7 . Medical management
Management is currently in the initial trauma head injury factors other than maintaining the function of ABC ( airway, breathing , circulation ) and assess the neurological status (disability , exposure) , the factors to be taken into account is reducing cerebral ischemia occurs . This situation can be helped with the administration of oxygen and glucose to the brain even traumatized requires oxygen and glucose is relatively lower .
Besides the possibility needs to be controlled due to elevated intracranial cerebral edema . Although not uncommon to require surgery , but the effort to lower the intracranial pressure can be done by lowering the PaCO2 by hyperventilation which reduces acidosis and increased intracerebral intracerebral metabolism . The effort to reduce the PaCO2 this with endotracheal intubation . Intubation is done as early as possible to clients who coma to prevent elevated PaCO2 . ABC principle and regular ventilation can prevent the increase in cranial pressure .


Conservative management includes :

    total bedrest
    Observation of vital signs ( GCS and level of consciousness )
    The provision of medicines
1 ) Dexamethason / kalmethason as anti - cerebral edema treatment , dosage according to the severity of the trauma
2 ) hyperventilation therapy ( severe head trauma ) , to reduce the weight of vasodilation .
3 ) anti - edema treatment with hypertonic solution , which is 20 % mannitol , or glucose 40 % , or 10 % glycerol .
4 ) Antibiotics containing the blood brain barrier ( panisillin ) or given metronidazole for anaerobic infections .

    Food or liquids . In minor trauma if vomiting can not be given anything , only 5 % dextrose intravenous fluids , aminofusin , aminopel ( the first 18 hours of the occurrence of the accident ) , 2-3 days later given soft food .
    In severe trauma . The first days of the client obtained decreased consciousness and tend to occur retention of sodium and electrolytes the first few days ( 2-3 days ) does not need a lot of fluid . Dextrose 5 % during the first 8 hours , 8 hours both Ringer dextrose , and dextrose 5 % 8 third hour . On the next day when the low awareness of the food given through a nasogastric tube (25000-3000 TKTP ) . Giving a protein depends on the value urenitrogennya .



    8 . complication

            Complications arising is increased ICP , sensory and motor loss , brain damage , and cranial nerve dysfunction .
Operative action that can be given is kraniotomy or trepanation and debridement .









    B. Basic Concepts of Nursing
        1 . assessment
        Patterns and perceptions of health care
1 ) Use a safety / protective at work .
2 ) History of trauma .
3 ) Headache , stiff neck

    The pattern of metabolic nutrition
1 ) Nausea , vomiting , anorexia
2 ) swallowing disorders
3 ) Loss of absorption
4 ) Hipertermi

    The pattern of elimination
1 ) Changes in the pattern of urination and bowel movements ( incontinence )
2 ) negative bowel
3 ) Disorders Chapter ( obstipation )

    Patterns of activity and exercise
1 ) Physical Weakness
2 ) the occurrence of disorders of muscle tone muscle weakness , impaired level of consciousness

    The pattern of sleep and rest
1 ) Restless
2 ) It's hard to sleep , often waking
3 ) Tend to sleep .

    The pattern of sensory perception and cognitive
1 ) Changes in mental status ( orientation , attention , emotion , behavior , memory ) .
2 ) Impaired vision
3 ) Loss of tendon reflexes .
4 ) Weakness
5 ) Loss of sensory stimuli
6 ) Impaired sense of taste and smell
7 ) Impairment of consciousness up to coma
8 ) Decrease in memory , problem solving
9 ) Loss of the ability of the influx of stimulus fisual

    Patterns of perception and self-concept
1 ) Feelings of helplessness and despair .
2 ) Emotional instability and difficulty expressing

    The pattern of role relationships with fellow
1 ) Inability to communicate ( loss of verbal communication / speech pelo )

    The pattern of reproductive sexuality
1 ) Not to have sexual intercourse
2 ) Deviation sexuality

    The pattern of coping mechanisms and tolerance to stress
1 ) Feelings of helplessness , hopelessness
2 ) Emotional instability
3 ) Easily offended

    The pattern of belief system
1 ) religious activities interrupted



    2 . Nursing Diagnosis
Nursing diagnoses that often arise in moderate head injury patients according Doengoes Marilyn E (2000 : 273 )

    Changes in cerebral tissue perfusion associated with the presence of edema or hematoma and brain hemorrhage .
    High risk for ineffective breathing pattern related to the neurovascular damage .
    Sensory perception changes associated with changes in sensory perception , transmission , and or integration ( trauma / neurologic deficit ) .
    Damage to physical mobility related to perception or cognitive damage , decreased endurance , therapy restrictions / security guard ( bed rest ) .
    The risk of infection associated with tissue trauma , broken skin , invasive procedures .
    Changes in nutrition less than body requirements related to inadequate intake .



    3 . Nursing plan
        Changes in cerebral tissue perfusion associated with the presence of edema or hematoma and brain hemorrhage .
Objective : optimal cerebral tissue perfusion is done gradually after nursing action within 7 x 24 hours
target :
- Awareness of patients compos mentis
- Vital signs within normal limits ( TD : 100-130/60-90mmHg , P :12 - 20x / min , N : 60-100x/mnt , S : 36 º C - 37 º C ) .
- The patient seemed to relax .
intervention :
1 ) Assess the complaint , vital signs every 2-4 hours of observation and awareness of the client
Rationale : To determine the patient's general condition as a standard

                    in determining the appropriate intervention
2 ) Assess characteristics of pain ( intensity , location , frequency and factors
influence ) .
Rationale : Decreased signs and symptoms of neurological or failure in

                    recovery is a recovery beginning in monitoring ICT .
3 ) Assess capillary refill , GCS , the color of the skin moist .
Rationale : To determine the level of awareness and the potential increase in ICT
4 ) Assess for signs of increased ICP ( stiff neck , vomiting and projectile
loss of consciousness .
Rationale : To determine the potential of increased ICP .
5 ) Give the client semifowler position , the head elevated 30 degrees .
Rationale : Giving a sense of comfort for clients
6 ) Instruct the nearest person ( family ) to talk with clients , although only by touch .
Rationale : The expression of family fun giving effect

                    lowering effects of ICT and relaxation for the client .
7 ) Collaboration with the doctor in medicine therapy
neurological .
Rationale : As a therapy against the loss of consciousness due to

                 brain damage , traffic accidents and brain surgery .



     High risk for ineffective breathing pattern related to the neurovascular damage ( injury to the respiratory center )

                   Objective : Airway clearance back effectively after the act of nursing in the 3 x 24 hours .

                   Target : breathing patterns in normal and regular rhythm .

                   intervention :
1 ) Assess complaints TTV

            Rational : to know the general condition and the standard for determining

                                interventions.
2 ) Auskutasi breath sounds , frequency , rhythm and depth of breathing .

                        Rationale: The change may indicate the extent of brain involvement .
3 ) Give the client a comfortable position ; semi-Fowler position .
Rationale : provide clients ease in breathing and

                                Provide a sense of comfort .
4 ) Encourage the client to cough effectively in doing deep breathing if

            conscious clients

                        Rationale : prevent / decrease atelectasis .
5 ) Suction Slym carefully .

            Rationale : Slym at tracheostomy suctioning deeper to

                                causing hypoxia .
6 ) Perform clapping and vibration on the client , especially in the area of

            backs .

                        Rational : that clients are more relaxed and comfortable .
7 ) Collaboration with physicians in the delivery of bronchodilator therapy and
oxygen .
Rationale : bronchodilators as thinning sputum and oxygen to give the client the ease in breathing .



    Same perception changes associated with changes in sensory perception

                 sensory , transmission ( trauma / neurologic deficit ) is characterized by : disorientation

                 time , the place , the changes repon to stimuli .

                   Objective : Sensory Perception can be re- optimized in stages

                                     after the act of 3 x 24 hour nursing .

 target :
- Orientation to time , place , person .
- Maintaining the level of awareness and perceptual functioning normally
intervention :
1 ) Evaluate / monitor regularly orientation , ability to speak and
sensory .

            Rationale : Cerebral function is usually the top of the first affected by the presence of impaired circulation , oxygenation , damage may occur

     when the initial trauma or occasionally .
2 ) Remove the noise / excessive stimulation as needed .

            Rationale : lowering anxiety , excessive emotional response / confused related to sensory overload.
3 ) Speak softly and slowly , use short and simple sentences , maintain eye contact .

            Rationale : Patients may have limited attention / understanding and healing during the acute phase and this action helps the patient to bring up the communication .
4 ) Create a schedule adequate rest / sleep periods without interruption .

                        Rationale : reduce fatigue , prevent saturation , giving the opportunity to sleep .
5 ) Collaboration with experts fisiotherapy ..

            Rationale : The approach between disciplines can create integrated management plan based on a combination of ability / inability of a unique individual with a focus on the evaluation and improvement of physical function , cognitive , and actual skills .



     Damage to physical mobility related to perception or cognitive damage , a decrease in the strength of the defense , but the restriction / vigilance ( bed rest ) .
Objective : Activity fulfilled after doing the actions in nursing 3 × 24 hours .
Goal : The client is able to perform light activities such as bathing himself in the bathroom , head pain less .

                 intervention :
1 ) Check back capability and functional state of the

              damage occurs .

       Rationale : Identify possible functional damage

                       and the influence of intervention to be performed .
2 ) Place the client in a particular position to avoid damage

              because of the pressure .

       Rationale : change position regularly increase the circulation in

                       whole body .
3 ) Help to perform range of motion .

              Rationale : mobilization and maintaining joint function
4 ) Increase the activity and participation in taking care of themselves in accordance

              capabilities .

       Rational : slow healing process often accompanies

                       head trauma , client involvement in planning and

                       success
5 ) Give careful skin care , massage with moisturizer

              Rationale : improve circulation and skin elasticity .
6 ) Collaboration with experts Fisiotherapi to appropriate rehabilitation programs

   indication .

            Rational : help with a good teaching method for

                            compensation on the ability of movement disorders .



    Sekuder high risk of infection associated with invasive procedures .

                 Objective : Infection does not occur after the act of nursing 3 × 24
hours .

                 target :

    There were no signs of infection ( tumor , dolor , calor , rubor and fungsileisa ) .
    Vital signs within normal limits .
    The wound looked clean

                   intervention :
1 ) Assess vital signs , note the increase in temperature .

              Rationale : increased temperature part of the signs of infection .
2 ) Assess for signs of infection ( rubor heat tumor , dolor , fungsileisa )

              Rational : to determine the next action is more appropriate .
3 ) Perform a sterile wound care techniques 1x/day

              Rational : to prevent further infection .
4 ) Wash your hands before and after wound care .

              Rationale : reducing cross-contamination .
5 ) Give an inclined position left or right as needed .

       Rationale : Excessive emphasis on the wound area can irritate

                       skin .
6 ) Collaboration with physicians in the delivery of antibiotics

              Rational : antibiotics to prevent infection



    Changes in nutrition less than body requirements related to
inadequate intake .

        Objective : Nutritional needs are met after the action

                         nursing within 3 × 24 hours .

               target :

    Clients can spend 1 serving of food .
    Complaints of nausea , vomiting and anorexia is reduced until it disappears .
    Clients eat spontaneously.
    Increased weight .

              intervention :
1 ) Observation of TTV and the general state of the client .

              Rational : to determine the actual health of the client
2 ) Assess tugor skin , oral mucosa clients .

              Rational : to know the signs of nutritional deficiencies .
3 ) Assess complaints of nausea , vomiting and appetite client .

       Rational : to determine the severity of the complaint , as standard

                       in determining the appropriate intervention .
4 ) Weigh the client body weight if possible .

              Rational : to assess the nutritional state of the client .
5 ) Liquid Feed via NGT .

              Rational : to meet the nutritional needs .
6 ) Record the number / client spent portions of food .

              Rational : to find out how much nutrients that enter .
7 ) Give an easy to swallow liquid food like porridge .

       Rationale : easy to swallow foods can reduce labor

                       stomach .
8 ) Collaboration with physicians in the delivery of parenteral therapy , anti-

   emetic .

       Rational : to insufficient intake of less and reduce nausea

                       and vomiting .



    4 . implementation of Nursing
The implementation is significantly nursing care in a series of activities based on systematic planning to achieve optimal results . Before performing nursing plan of action , let the nurse explains nursing actions performed on the patient . In the implementation , maintenance perform its function as an independent , interdependent and dependent . In the independent functions of nurses act on their own initiative . For example, give abdominal breathing exercises in sitting and lying positions . In interdependent functions , nurses perform the functions of collaboration with other health care team . And independent functions of nurses perform additional functions to run the program from other health team such treatment .
In addition, the nurse must observe the patient's general condition and response during execution . And to train patients to become independent, preferably in the implementation phase are as follows : preparation , execution and documentation . In the preparation phase , nurses are required to have knowledge and skills . In addition nurses should also be able to analyze the situation and kondiri patients both physically and mentally so as to plan , validate plans and in the implementation of nurses will avoid mistakes .

    5 . evaluation of Nursing
Evaluation is the final step of the nursing process that can be used as a measure of success of a plan of nursing that have been made ​​. Although evaluation is considered as the final stage of the nursing process does not stop this process , which has been solved and the problems that need to be re-examined , re- planned , implemented and evaluated again .



    6 . discharge Planning
    Explain to the family , that the changes that occur in patients is not a form of mental disorder , but it is a complication of collisions experienced by the patient .
    Instruct the family , so when talking to the patient using the " back to reality "
    Instruct the family so as not to change the position / location of the items that exist in the patient's home , especially room .
    Encourage the family to assist patients in self-care and fulfillment of basic needs .


REFERENCES


Arif Muttaqin , ( 2008) , Textbook of Nursing Clients With Nerves of System Disorders , New York: Salemba Medika


Batticaca Fransisca B , ( 2008) , Nursing Care Clients With Nerves of System Disorders , New York: Salemba Medika


Brunner and Suddarth ( 2000) . Textbook of Medical Surgical Nursing . Jakarta : EGC .


Doengoes , Marilyn , E ( 2000) Nursing care plan 3rd edition , EGC , Jakarta



 Hardjasaputra , S.L.P. et al (2002 ) . DOI Indonesian Drug Data . Edition 10 London: Grafidian Mediapress


M. Arif Mansjoer ( 2000) . Capita Selecta Medicine . Issue 3 . Jakarta : Media Aeusculapius .


Evelyn Pearse C , ( 2002) , Anatomy Physiology for Paramedics . PT Gramedia Jakarta .



            Pierce A. Grace and Neil R. Borley , ( 2006) . Surgical Sciences , New York: McGraw


Price, Sylvia A. ( 1994) . Pathophysiology Clinical Concepts disease processes . Issue 4 . Jakarta : EGC .