Nursing Interventions for a 35-Year-Old Man with Diffuse Axon Injury Caused by Fall: A Case Report

Abstract

Traumatic brain injuries are significant cause of disability and mortality worldwide, with Aceh having the highest incidence of head injuries at 14 percent, ranking 12th in Indonesia. This case report focuses on providing nursing care to patients with traumatic brain injuries at Dr Zainoel Abidin General Hospital in Banda Aceh. The patients had decreased consciousness, increased blood pressure, irregular breathing, pain due to increased intracranial pressure, decreased muscle strength, and grade II posterior ulcers. Common nursing issues included decreased intracranial adaptive capacity, pain, impaired physical mobility, impaired skin integrity, and self-care impairments. Interventions included monitoring vital signs, observing elevated intracranial pressure, elevating the head by 30 degrees, murottal therapy, muscle strength training, repositioning, wound care, and skin care. The nursing evaluation showed a significant increase in consciousness, reduced pain severity, improved muscle strength, and reduced skin layer damage. Nurses should follow recommendations for positioning patients with inadequate intracranial adaptive capacity and encouraging range of motion exercises. Keywords: Nursing care, diffuse axonal injury, severe head trauma, Traumatic brain injury