D.0066
Penurunan
Kapasitas Adaptif Intrakranial
Kategori : Fisiologis
Subkategori : Neurosensori
Definisi
Gangguan
mekanisme dinamika intrakranial dalam melakukan kompensasi terhadap stimulus
yang dapat menurunkan kapasitas intrakranial
Penyebab
1. 1. Lesi
menempati ruang (mis. space-occupaying lesion - akibat tumor,abses)
2. 2. Gangguan
metabolisme (mis. akibat hiponatremia, ensefalopatiuremikum, ensefalopati
hepatikum, ketoasidosis diabetik, septikemia)
3. 3. Edema
serebral (mis. akibat cedera képala [hematoma epidural, hematoma subdural,
hematoma subarachnoid, hematomaintraserebral), stroke iskemik, stroke
hemoragik, ensefalopati hipoksia, iskemik, pascaoperasi)
4. 4. Peningkatan
tekanan vena (mis. akibat trombosis sinus vena serebral,gagal jantung,
trombosis/obstruksi vena jugularis atau vena kavasuperior)
5. 5. Obstruksi
aliran cairan serebrospinalis (mis. Hidhidosefalus)
6. 6. Hipertensi intrakranial idiopatik
Gejala
dan Tanda Mayor Subjektif
Subjektif
1. 1. Sakit
kepala
Objektif
1. 1. Tekanan
darah meningkat dengan tekanan nadi (pulse pressure)melebar
2. 2. Bradikardia
3. 3. Pola
napas Ireguler
4. 4. Tingkat
kesadaran menurun
5. 5. Respon
pupil melambat atau tidak sama
6. 6. Refleks neurologis terganggu
Gejala
dan Tanda Minor
Subjektif
(tidak tersedia)
Objektif
1. 1. Gelisah
2. 2. Agitasi
3. 3. Muntah
(tanpa disertai mual)
4. 4. Tampak
lesu/lemah
5. 5. Fungsi
kognitif terganggu
6. 6. Tekanan
intrakranial (TIK) 220 mmHg
7. 7. Papiledema
8. 8. deserebrasi (ektensi)
9. 9. Postur
dekortikasi (fleksi)
Kondisi
Klinis Terkait
1. 1. Cedera
kepala
2. 2. Iskemik
serebral
3. 3. Tumor
serebral
4. 4. Hidrosefalus
5. 5. Hematoma
kranial
6. 6. Pembentukan
arteriovenous
7. 7. Edema
vasogenik atau sitotoksik serebral
8. 8. Hiperemia
9. 9. Obstruksi
aliran vena
Referensi
Ackley,
B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing Diagnosis
HandbookAn Evidence-Based Guide to Planning Care. 11 Ed. St. Louis: Elsevier
Almeida, M. d. A., da Silva, M. B., Panato, B. P., Siqueira, A. P. d. O., da Silva, M.P. Engelman, B.,. Nomura, A. T. G. (2015). Clinical Indicators to monito patients with risk for ineffective cerebral tissue perfusion. Investigación Educación En Enfermería, 33(1), 155-163.
Arbour,
R. (2004). Intracranial hypertension: Monitoring and nursing assessmentCritical
Care Nurse, 24(5), 19-20, 22-6, 28-32, quiz 33-4.
Carperito-Moyet,.L.
J. (2013). Nursing Diagnosis Application to Clinical Practice. 14"Ed.
Philadelphia: Lippincott Williams & Wilkins.
Herdman,
T. H., & Kamitsuru, S. (2014). Nursing Diagnosis Definitions and Classification
2015-2017/ 10th Ed. Oxford: Wiley Blackwell.
International
Council of Nurses (2015). Internasional Classification of NursingPractice,
Nursing Diagnosis and Outcomes Statement. GenevaSwitzerland: International
Council of Nurses.
Lee, Eva Lu T,M.S.N., A.N.P.-B.C., &
Armstrong. Terri S,PhD., A.N.P.-B.C.(2008)Increased intracranial pressure.
Clinical Journal of Oncology Nursing,12(1),37-41
Newfield,
S. A., Hinz, M. D., Tiley, D. S., Sridaromont, K. L., Maramba, P. J. (2012)
Cox's Clinical Applications of Nursing Diagnosis Adult, Child, Womer's Mental
Health, Gerontic, and Home Health Considerations. 6 Ed philadelphia:FA Davis
company
Suadoni,
M. T. (2009). Raised intracranial pressure: Nursing observations and interventions.
Nursing Standard (through 2013), 23(43), 35-40.
Wall,
B. M., Philips, J. P., & Howard, J. C. (1994). Validation of increased
intracranial pressure and high risk for increased intracranial pressure. Nursiy
Diagnosis: ND: The Official Journal Of The North American Nursing Diagnosis
Association, 5(2), 74-81
