Nursing Care for Patients with Vulnus Laceratum in the Emergency Unit: A Case Report
Abstract
Vulnus Laceratum is a disruption of the continuity of tissue so that there is a separation of tissue that was initially normal; torn wounds occur due to severe violence that severs the tissue. Vulnus Laceratum is the third most common type of injury in Indonesia, with a percentage of 23.2%. Nursing problems that often arise in patients with vulnus laceratum are acute pain, impaired skin and tissue integrity, and risk of infection. The knowledge and role of nurses are essential in the rapid treatment of vulnus laceratum patients at risk of bleeding, infection and even disability. This case study aims to analyze the application of nursing care to patients with vulnus laceratum. Nursing care methods using the SDKI, SLKI, and SIKI approaches. The results of the assessment obtained four male patients, the cause of vulnus laceratum 2 cases due to vehicle accidents, 1 case due to blunt objects, and 1 case due to sharp objects. The nursing diagnoses that appear are impaired skin and tissue integrity, acute pain, risk of ineffective cerebral perfusion, and risk of infection. Nursing interventions include wound care, wound suturing, pain management, vital sign monitoring, and infection prevention. During the implementation process, all interventions were carried out. Evaluation of nursing care with impaired skin and tissue integrity disorders resolved on the 10th and 30th days, acute pain resolved on the third day, risk of infection on the seventh day, and risk of ineffective cerebral perfusion 1 hour after implementation. The results of this case study are expected to increase knowledge and complement existing sources so that knowledge and management of vulnus laceratum are appropriate and fast.
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Wahyuni A, Sudrajat A, Pane JP, Trevie R, Ristandi H, Rahmawati EQ. Buku Ajar Keperawatan Gawat Darurat. Jakarta: PT Nuansa Fajar Cemerlang Jakarta; 2018. 1–159 p.
Wagiu YM. Asuhan Keperawatan Pada Tn. er dengan Vulnus Laceratum Parietal di Instalasi Gawat Darurat Rumah Sakit Gunung Muria Tomohon. Universitas Katolik De La Salle Manado; 2023.
Riskesdas K. Hasil Utama Riset Kesehata Dasar (RISKESDAS) [Internet]. 2018. Available from: http://arxiv.org/abs/1011.1669%0Ahttp://dx.doi.org/10.1088/1751-8113/44/8/085201%0Ahttp://stacks.iop.org/1751-8121/44/i=8/a=085201?key=crossref.abc74c979a75846b3de48a5587bf708f
Suwahyu R, Sahputra RE, Fatmadona R. Systematic Review: Penurunan Nyeri Pada Pasien Pasca Operasi Fraktur Melalui Penggunaan Teknik Napas Dalam. J Ilm Permas J Ilm STIKES Kendal. 2021;11(1):193–206.
Ovens L, Irving S. Advances in wound cleansing: An integrated approach. Wounds UK. 2018;14(1):58–63.
Soeno S, Hara K, Fujimori R, Hashimoto K, Shirakawa T, Sonoo T, et al. Initial assessment in emergency departments by chief complaint and respiratory rate. J Gen Fam Med. 2021;22(4):202–8.
Tim Pokja SDKI DPP PPNI. Standar Diagnosis Keperawatan Indonesia (SDKI). Jakarta: Persatuan Perawat Indonesia; 2018. 1–328 p.
Kaisma E. Asuhan Keperawatan Pada An. R Dengan Diagnosa Vulnus Laceratum di RSUD Daya Kota Makassar. Universitas Hasanuddin Makassar; 2022.
Tim Pokja SLKI DPP PPNI. Standar Luaran Keperawatan Indonesia (SLKI) Edisi 1. Jakarta: Persatuan Perawat Nasional Indonesia; 2018.
Tim Pokja SIKI DPP PPNI. Standar Intervensi Keperawatan Indonesia (SIKI) Edisi 1. Jakarta: Persatuan Perawat Nasional Indonesia; 2018.
Malorung A, Inayati A, Sari HS SA. Penerapan Kompres Dingin Unyuk Mengurangi Intensitas Nyeri Pada Pasien Post Operasi Di Rsud Jend. Ahmad Yani Metro. Cendikia Muda. 2022;2(2):162–7.
Prajayanti ED, Primaratri S, Putri AH, Fitri D, Utami E, Putri DA. Gudang Jurnal Multidisiplin Ilmu Peran Nutrisi Dalam Proses Penyembuhan Luka Di Bangsal Kultura RS Universitas Sebelas Maret. Gudang J Multidisiplin Ilmu. 2024;2(10):174–9.
Budiman LA, Sari AS, Safitri SJ, Prasetyo RD, Alyarizqina H, Sri I, et al. Analisis Status Gizi Menggunakan Pengukuran Indeks Massa Tubuh Dan Beban Kerja Pada Tenaga Kesehatan. Nutrizone. 2021;01(1):6–15.
Novitasari D, Pangestu RSA. Tatalaksana Keperawatan Nyeri Akut Pasien Fraktur Radius Ulna Sinistra dengan Terapi Relaksasi Nafas Dalam. J Penelit Perawat Prof. 2023;5(3):1067–76.
Fatriansari A. Pengaruh Kompres Dingin Terhadap Penurunan Skala Nyeri Pemasangan Infus Pada Anak Pra Sekolah. Babul Ilmi_Jurnal Ilm Multi Sci Kesehat. 2019;11(December 2018):44–52.
Putri SA, Izzah R, Putri S, Simanjorang C, Wasir R. Kesadaran Tenaga Kesehatan Dalam Pencegahan. Mot J Ilmu Kesehat. 2023;18(2):65–74.
Anggraini IPN. Asuhan Keperawatan Gawat Darurat Pada Tn.H Dengan Diagnosa Medis Cedera Otak Berat Di Instalasi Gawat Darurat RSPAL Dr. Ramelan Surabaya. Stikes Hangtuah Surabaya; 2021.
Febrianto BY, Putra EP, Zulkarnaini A, Hasni D. Ulkus kaki Diabetik: Sebuah Laporan Kasus. Heal Med J. 2022;5(1):75–9.
Potter P, Perry A. Buku Ajar Fundamental Keperawatan: Konsep, Proses, dan Praktik. Edisi 4. Asih Y, editor. Jakarta: EGC; 2005. 1–1152 p.
DOI: https://doi.org/10.70111/hg3201
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