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Gambar 1. Tumor Otak

Brain Tumor is the growth of abnormal cells in the brain. Many different
types of tumors. Some tumors may not be cancerous (benign) and some other brain
tumors are cancerous (malignant).Brain tumors can originate from the brain
(primary brain tumor) or cancer originating from other parts of the body and
propagating to the brain (secondary / metastatic brain tumors).
Brain tumors are the presence of lesions caused because there is pressure
from both benign and malignant spaces that grow in the brain, genes, and skulls. (
Sylvia .A , 1995: 1030). Brain tumor is an expansive lesion that is benign
(malignant) or malignant (malignant) to form a mass in the skull space (intra
cranial) or in the spinal cord (spinal cord). Neoplasms in brain tissue and
membranes can be either primary tumors or metastases. If tumor cells originating
from the brain tissue itself are called primary brain tumors and if they come from
other organs (metastases) such as lung, breast, prostate, kidney, and other cancers
are called secondary brain tumors. (Mayer. SA, 2002).
The Central Brain Tumor Registry for the United States (CBTRUS)
estimates that there will be 190,600 brain tumors that will be diagnosed in 2005.
Of these 43,800 are estimated to be primary brain tumors and the remainder are
secondary or metastatic. The general incidence for primary brain tumors and CNS
is 14 cases per 100,000 people / year. The incidence of brain tumors seems to be
increasing, but this may reflect a faster and more accurate diagnosis. CBTRUS
notes that, in 2000, around 359.00 people in the United States lived with primary
brain tumors with 75% having benign tumors and 23% having malignant tumors

There is no clear etiology fa c tors which have been found to be a primary brain
tumor. Although cell types that develop into tumors can often be identified, the
mechanism by which cells act abnormally remains unknown. Familial tendency,
immunosuppression, and fa c tor-sed a ng environmental factors studied. The peak
time for the incidence of brain tumors is the fifth and seventh decades.In addition,
men are affected more often than women.
The cause of the tumor is still unknown. The factors that need to be reviewed,

a. Hereditary
b. Embrional Cell Remnants ( Embryonic Cell Rest )
Embryonal buildings develop into buildings that have integrated morphology
and functions in the body. But there are times when a part of the embryonal
building remains in the body, becomes malignant and damages the surrounding
c. Radiation
The tissues in the central nervous system are sensitive to radiation and can
undergo degenerative changes, but there is no evidence that radiation can
trigger a glioma .
d. Virus
e. Carcinogenic substances
An investigation of the substance of the carcinogen has been long and
extensive. that there is a carcinogenic substance such as methylcholanthrone,
nitroso-ethyl-urea . This is based on experiments conducted on animals.
f. Head trauma
Head trauma that can cause a hematoma so that it urges the brain mass to
eventually occur a brain tumor.

Brain tumors me nyebabkan progressive neurological disorder that is
caused by two factors: focal interference by the tumor and increase in intracranial
pressure (ICT). Focal disorders occur when there is emphasis on brain tissue and
infiltration or direct invasion of the brain parenchyma with damage to neuronal

Changes in blood supply due to pressure caused by growing tumors cause
necrosis of brain tissue. The result is acute loss of function and can be confused
with primary cerebrovascular disorders.
Seizures as a manifestation of changes in neuron sensitivity due to
compression, invasion, and changes in blood supply into brain tissue.
Increased ICT can be caused by several factors such as increased mass in
the skull, edema around the tumor, and changes in circulating CSS. Malignant
tumors cause edema in brain tissue which is thought to be caused by differences in
osmotic pressure that causes absorption of tumor fluid. Venous obstruction and
edema caused by barrier damage in the brain, leading to increased intracranial
volume and increased ICP.
Increased ICTs endanger lives if they occur quickly. The compensation
mechanism takes days or months to be effective and is therefore not useful if the
intracranial pressure arises quickly. This compensation mechanism includes
intracranial blood volume, CSS volume, intracellular fluid content, and reduced
brain parenchymal cells. Increasing unresolved pressure will result in herniation
for the cerebellum.
Unusual herniation arises if the medial gyrus of the temporal lobe shifts
inferiorly through the tentorial incisor due to the presence of mass in the brain
hemisphere. Herniation suppresses the mesensefalon, causing loss of consciousness
and suppressing the 3rd brain nerve. In cerebellar herniation, the cerebellar tonsils
are displaced downward through the foramen magnum by a posterior mass.
Compression of the medulla oblongata and the cessation of breathing occur
quickly. Other physiological changes that occur due to rapid intracranial increase
are progressive bradycardia, systemic hypertension, and respiratory disorders

1. Classification is tadium ( Classification of primary lesions of the central
nervous system is based on grading ) :
a. WHO grade I: tumors with low proliferation potential, post-resection curability
is quite good.
b. WHO grade II: tumors are infiltrative, mitotic activity is low, but recurrence
often occurs. Certain types tend to be progressive towards higher degrees of
c. WHO grade III: description of clear mitotic activity, high infiltration ability,
and anaplasia.

d. WHO grade IV: active mitosis, tends to necrosis, generally associated with
rapid progression of the disease in pre / post surgery

2. Types of brain tumors based on WHO 2000, brain tumors are divided into:
a. Tumors of the Neuroepithelial tissue:
1) Astrocytic tumors consist of:
a) Pilocytic astrocytoma (grade I)
b) Diffuse Astrocytoma (grade II)
c) Anaplastic astrocytoma (grade III)
d) Glioblastoma multiforma (grade IV)
2) Oligodendroglioma tumors:
a) Oligodendroglioma (grade II)
b) Anaplastic oligodendroglioma (grade III)
3) Mixed Glioma:
a) Oligoastrocytoma (grade III)
b) Anaplastic oligoastrocytoma (grade III)
b. Ependymal tumors
c. Choroid plexus tumors
d. Pineal Parenchymal tumors
e. Embryonal tumors:
1) Medulloblastoma
2) Primitive neuroectodermal tumors (PNET)
f. Meningeal tumors: Meningioma
g. Primary CNS Lymphoma
h. Germs cell tumors
i. Tumors of the sellar region
j. Brain metastase of the systemic cancers.

Schematic table for classifying brain tumors

Tumor type Criteria
Astrocytoma Increased number of astrocytes; mature astrocytes ; normal
developing astrocytes.
Anaplastic Increased number of less mature astrocytes; there may be a
astrocytoma mitotic picture (the mitotic picture shows increased cell division
and malignant changes).
Glioblastoma The increase in cell number astrotis; astrotis immature; their
multiformis mitotic figures; bleeding; necrosis, swelling and bat a s tumor is

3. Based on the type of tumor
1) Benign
a. Acoustic Neuroma
b. Meningioma
c. Pitiutary Adenoma
d. Astrocytoma (Grade 1)

2) Malignan
Malignant tumors are often called cancer, grow quickly and tend to invade
the surrounding tissue so that the boundary is not firm and rarely capsules. In
general, malignant tumors are named according to the origin of tissue during
the embryo. Malignant tumors originating from ectoderm and endoderm are
called carcinomas, and those from the mesoderm are called sarcomas.
1) Astrocytoma (Grade 2,3,4)
2) Oligodendroglioma
3) Apendymoma
4) Metastases of Brain Tumors

4. Based on the location of the tumor

a. Supratentorial Tumor
1) Glioma:
a) Glioblastoma multiforme
These tumors can occur anywhere but are most common in the brain
hemispheres and often spread counter-lateral to the corpus
There are 2 subtypes of glioblastoma
1. De Novo (new or primary)
The de novo tumor grows very fast and immediately forms
cells that look dangerous.
2. Secondary
Secondary glioblastoma is characterized by the
commencement of moderate to moderate grade astrocytoma
grade originating from a gene abnormality that will turn into

Gambar 2. Glioblastoma – MR sagittal with contrast

2) Astroscytoma
Neoplasms in the central nervous system where predominant cells are
inherited in astrocytes (star-shaped neuroglia).
3) Oligodendroglioma
It is a slow-growing lesion resembling an astrocytoma but consists of
oligodendroglia cells.
4) Meningioma
Meningioma is the most important tumor originating from meninges,
mesothelial cells, and arachnoid connective tissue cells.\

Gambar 3. Meningioma
Gambar 4. Lokasi umum Meningioma
b. Infratentorial tumor

1) Schwanoma acousticus
2) Metastatic tumor
3) Meningioma
4) Hemangioblastoma

1. Clinical Manifestations
Clinical manifestations may not be specific which can be caused by edema and
enhancement of ICT or specific causes caused by certain anatomical locations.
a. Change in Mental Status
b. Headache
c. Nausea and Vomiting
d. Papiledema
e. Seizures

2. Local Manifestations
Local clinical manifestations are caused by damage, irritation, or compression
of part of the brain where the tumor is located.

1) Focal Weakness (eg, hemiparesis)

2) Sensory disorders, including not being able to feel (anesthesia), or
abnormal sensations (Paresthesia)
3) Language disorders
4) Impaired coordination (eg, staggering roads)
5) Impaired vision such as diplopia (double vision) or visual field disorder

Factor prognostic asmanagement consideration :
1. Age
2. General health
3. Tumor Size
4. Location of the tumor
5. Type of tumor

The first step in the treatment of brain tumors is the administration of corticostreoid
which aims to eradicate brain edema. The effect of corticostreoid can be seen
mainly in conditions such as severe headache, motor deficits, aphasia and
decreased consciousness. For brain tumors the main method used in the
management, namely :

1) Surgery
Benign tumors can often be treated with complete excision and surgery is
potentially curative, for primary malignant or secondary tumors it is
usually difficult to cure. Tumor surgery usually must go through a
histological diagnosis first.
2) Medical Therapy

a) Anticonvulsants for epilepsy

b) Corticosteroids (dextramethasone) for increased intracranial
pressure. Steroids can also improve transient focal neurological
deficits by treating brain edema
c) Chemotherapy is indicated in some cases of glioma, as an adjunctive
surgery and radiotherapy with the supervision of a neuro oncology
specialist unit.
3) Radiation Therapy
Conventional radiotherapy delivers radiation using a linear accelerator.

According to Muttaqin (2008) there are several diagnostic tests that are used to
indicate brain tumor disease, including the following:
1. Computed Tomography Scan (CT Scan)
2. Positron Emmision Tomography (PET)
3. Magnetic resonance imaging (MRI)
4. Electroencephalography
5. MR- Spectroscopy
6. Cerebral angiography
7. Lumbar puncture examination

According to some sources, one of them according to
Ginsberg ( 2008 ) k omplikasi that can occur in brain tumors, among others:
1. Increased Intrakraial Pressure
Increased intracranial pressure occurs when one or all of the factors
consisting of brain mass, blood flow to the brain and the amount of
cerebrospinal fluid increase.
An increase in one of the factors above will trigger:
a. Cerebral Edema
b. Hydrocephalus
c. Brain Herniation
2. Epilepsy
Epilepsy is caused by stimulation or disruption in the lining of the brain
(cerebral cortex) caused by tumor mass (Yustinus, 2006).
3. Reduced neurological function
Symptoms of reduced neurological function due to loss of brain tissue are
typical for a malignant tumor (Wim, 2002). This decrease in neurological
function depends on the part of the brain affected by the tumor.
4. Radiation encephalopathy
5. Metastase to another place
6. Dead

A. Assessment
Comprehensive and accurate nursing assessment is very important in treating
patients who have nerve problems. Nurses need to be alert to various
sometimes vague changes in a patient's condition that might indicate
worsening conditions.
1. Anamnesa
a) Demographic data
Identity to the client that must be known include: name, age, religion,
education, occupation, ethnicity / nation, address, gender, marital
status, and cost insurer.
b) Main complaint
Usually the client complains of headaches that are missing and the
duration is increasing
c) Current medical history
Clients complain of headache when changes in position and can
increase with activity, vertigo, projectile vomiting, mental changes
such as disorientation, lethargy, papiledema, decreased level of
consciousness, decreased vision or double vision, inability to sensation
(parathesia or anasthesia), loss of sharpness or diplopia.
d) Past medical history
The client has had head surgery or head trauma
e) Family history
Is there a disease suffered by a family member that might have
something to do with the client's current illness, namely a family
history with a head tumor.
f) Psycho-socio-spiritual study
Changes in personality and client behavior, mental changes,
difficulties in making decisions, anxiety and fear of hospitalization,
diagnostic tests and surgical procedures, changes in roles.

2. Physical Examination (ROS: Review of System)

Physical examination of clients with brain numbers includes general
physical examination per system from general observation, examinations
of vital signs, B1 (breathing), B2 (Blood), B3 (Brain), B4 (Bladder), B5
(Bowel), and B6 (Bone).
a) Breathing B1 (Breath)
The increase in respiratory rhythm (irregular breathing patterns) and
shortness of breath occur because the tumor urges the brain so that
hermiasi and compression of the medulla oblongata. The shape of the
chest and the sound of the client's breathing are normal, do not show

coughing, there is retention of the breathing muscles, and usually require
breathing apparatus with 2 LPM oxygen levels.

b) Cardiovascular B2 (Blood)
Urgent intracranial space will cause an increase in intracranial pressure
resulting in increased blood pressure. In addition, irregular heart
rhythms and bradycardia occur. Clients do not complain of chest pain,
normal heart sounds, warm akral, pulse bradycardia.

c) Nerve B3 (Brain)
a. Eyesight : Decreased vision, loss of sharpness or diplopia.
b. Hearing (ears): Interfered with the temporal lobe
c. Smell (nose) : Complains about an unusual odor, in the frontal
d. Tasting (tongue) : Inability to sensation (parathesia or
1) Aphasia: Damage or loss of language function, the possibility
of expressive or difficult speech, receptive or comprehensive
speech, or a combination of both.
2) Extremities: Weakness or unbalanced paraliysis of the hand,
reduced reflex tendon.
3) GCS: The scale used to assess the patient's level of awareness
(whether the patient is in a coma or not) by assessing the
patient's response to the stimulation given.
4) The results of the examination are expressed in degrees with a
range of numbers 1-6 depending on the response, namely:
a) Eye (eye opening response)
1. (4): Spontaneous
2. (3): With voice stimulation (telling patients to open
their eyes).
3. (2): With pain stimuli (give pain stimulation, for
example pressing finger nails)
4. (1): There is no response
b) Verbal (verbal response)
1. (5): Good orientation
2. (4): Confused, speaking of upsetting (frequently
asking questions) time and place disorientation.
3. (3): Words only (speaking is not clear, but the words
are still clear, but not in one sentence. For example
"ouch ..., sir ...")
4. (2): Sound without meaning (groaning)
5. (1): There is no response

c) Motor (motor response)
1. (6): Following orders
2. (5): Localizes pain (reaching out and keeping the
stimulus away when given pain relief)
3. (4): Withdraws (avoiding / pulling the extremities or
the body away from the stimulus when given pain
4. (3): Flexi is abnormal (one hand or both stiff position
above the chest & extended leg when given pain
5. (2): Abnormal extension (one hand or both extensions
on the side of the body, with fingers clenched &
extended legs when given pain relief).
6. (1): There is no response
d) Urination B4 (Bladder)
Disorders of urine intercourse control , clean cleanliness, normal genital
form, normal urethra, normal urine production
e) Digestion B5 (Bowel)
Nausea and vomiting occur due to an increase in intracranial pressure
which suppresses the vomiting center in the brain. Symptoms of nausea
and vomiting will usually be followed by a decrease in appetite in
patients . The condition of the mouth is clean and the mucosa is moist
f) Musculoskeletal / integument B6 (Bone)
Limitations of limb movements due to weakness and even
paralysis . The ability of free joint movement, fatigue.

B. Nursing diagnoses
1. Chronic pain (00133) is associated with tumor permeation: increased
intracranial pressure.
2. The ineffectiveness of the breath pattern (00032) is associated with
suppression of the medulla oblongata.
3. The risk of ineffective cerebral tissue perfusion (00200) is associated with
increased intracranial pressure, tumor surgery, cerebral edema.
4. The risk of injury (00035) is associated with vertigo secondary to
orthostatic hypotension.
5. Nutritional disorders: less than body requirements (00002) associated with
the effects of chemotherapy and radiotherapy.
6. Impaired physical mobility (00085) is associated with sensory and motor
7. Comfort feeling (00214) is associated with pain due to not being able to
move the neck.

A. Intervensi Keperawatan
1. Chronic pain (00133) is associated with tumor permeation: increased
intracranial pressure.
Domain 12: Comfort
Class 1. Physical Comfort
Aim : after nursing action for 1 x 24 hours Pain Management (1400)
the perceived pain is reduced 1 or can be 1) Mengurangi/menghilangkan faktor-faktor
adapted by the client with the results yang memimbulkan / meningkatkan
criteria: pengalaman nyeri
a. Clients reveal pain that is felt to be 2) Memilih dan mengimplementasikan satu
reduced or can be adapted to be jenis tindakan (farmakologi, non-
shown to decrease the scale of farmakologi, interpersonal) untuk
pain.Scale = 2 memfasilitasi pertolongan nyeri
b. Clients do not feel pain. 3) Mempertimbangkan jenis dan sumber
c. The client is not nervous nyeri ketika memilih strategi pertolongan
Domain-Health Knowledge & Behavior nyeri
(IV) 4) Mendorong klien untuk menggunakan
Pain Control (1605) pengobatan nyeri yang adekuat
The client can recognize the onset i 5) Instruksikan pasien/keluarga untuk
Clients can describe the causal factors melaporkan nyeri dengan segera jika nyeri
Clients recognize symptoms related to timbul.
pain (160509) 6) Mengajarkan tehnik relaksasi dan metode
Report pain control (160511) distraksi
Pain: Disruptive Effects (2101) 7) Observasi adanya tanda-tanda nyeri non
Interpersonal relationships are not verbal seperti ekspresi wajah, gelisah,
interrupted menangis/meringis, perubahan tanda vital.
Can do daily activities Kolaborasi: Analgesic Administration (2210)
Physical activity is not disturbed 1) Menentukan lokasi, karakteristik, kualitas,
dan keparahan nyeri sebelum pengobatan
2) Mengecek permintaan medis untuk obat,
dosis, dan frekuensi dari analgesik yang
telah ditentukan (resep)

2. Ketidakefektifan pola nafas (00032) berhubungan dengan penekanan

medula oblongata.

Domain 4: Activity/Rest
Class 4. Cardiovascular/Pulmonary Responses
Tujuan : setelah dilakukan tindakan keperawatan Airway Management (3140)
selama 1x24 jam pola pernafasan kembali normal 1) Monitor status respirasi dan
dengan kriteria Hasil : oksigenasi, yang tepat
a. Pola nafas efekif Respiratory Management (3350)
b. GDA normal 1) Monitor kecepatan, irama,
c. Tidak terjadi sianosis kedalaman dan upaya pernafasan.
Domain-Physiologic Health (II) 2) Monitor pola pernapasan
Class-Cardiopulmonary (E) 3) Monitor tingkat saturasi oksigen
Respiratory Status (0415)
dalam klien yang tenang
Respiraroty Rate normal
Respiraory Rhytm normal 4) Auskultasi suara napas, mencatat
Kedalaman inspirasi normal area penurunan ketiadaan
Saturasi oksigen normal
ventilasi dan keberadaan suara
Tidak ada sianosis

3. Risiko ketidakefekifan perfusi jaringan serebral (00200) berhubungan

dengan peningkatan tekanan intrakranial, pembedahan tumor, edema
Domain 4: Activity/Rest
Class 4. Cardiovascular/Pulmonary Responses
Tujuan : setelah dilakukan Intracranial Pressure (ICP) Monitoring (2590)
tindakan keperawatan selama 1) Monitor kualitas dan karakteristik dari bentuk
1x24 jam perfusi jaringan gelombang TIK
klien membaik ditandai 2) Monitor tekanan perfusi cerebral
dengan tanda-tanda vital stabil 3) Monitor status neurologis
dengan kriteria hasil : 4) Monitor TIK klien dan respon neurologis untuk
a. Tekanan perfusi merawat aktivitas dan stimuli lingkungan
serebral >60mmHg, 5) Monitor jumlah, kecepatan, dan karakteristik dari
tekanan intrakranial aliran cairan serebrospinal (CSF)
<15mmHg, tekanan 6) Memberikan agen farmakologi untuk menjaga TIK
arteri rata-rata 80- pada batas tertentu
100mmHg 7) Memberi jarak waktu intervensi keperawatan untuk
b. Menunjukkan tingkat meminimalkan PTIK
kesadaran normal

c. Orientasi pasien baik 8) Monitor secara berkala tanda dan gejala peningkatan
d. RR 16-20x/menit TIK
e. Nyeri kepala berkurang a. Kaji perubahan tingkat kesadaran, orientasi,
atau tidak terjadi memori, periksa nilai GCS
Domain-Physiologic Health b. Kaji tanda vital dan bandingkan dengan keadaan
(II) sebelumnya
Class-Cardiopulmonary (E) c. Kaji fungsi autonom: jumlah dan pola pernapasan,
Perfusi Jaringan: Serebral ukuran dan reaksi pupil, pergerakan otot
(0406) d. Kaji adanya nyeri kepala, mual, muntah, papila
Tekanan intracranial normal edema, diplopia, kejang
Tekanan darah sistolik normal e. Ukur, cegah, dan turunkan TIK
Tekanan darah diastolic 1. Pertahankan posisi dengan meninggikan bagian
normal kepala 15-300, hindari posisi telungkup atau
Mean Blood Pressure normal fleksi tungkai secara berlebihan
Sakit kepala hilang 2. Monitor analisa gas darah, pertahankan PaCO2
Tidak mengalami penurunan 35-45 mmHg, PaO2 >80mmHg
tingkat kesadaran 3. Kolaborasi dalam pemberian oksigen
Tidak ada gangguan reflek 4. Hindari faktor yang dapat meningkatkan TIK
neurologik 9) Istirahatkan pasien, hindari tindakan keperawatan yang
dapat mengganggu tidur pasien
10) Berikan sedative atau analgetik dengan kolaboratif.
4. Resiko cedera (00035) berhubungan dengan vertigo sekunder terhadap
hipotensi ortostatik.
Domain 11: Safety/Protection
Class 2. Physical Injury
Tujuan : setelah dilakukan tindakan Fall Prevention (6490)
keperawatan selama 1x24 jam diagnosa tidak 1) Identifikasi tingkah laku dan faktor
menjadi masalah actual dengan kriteria hasil : yang berpengaruh pada risiko jatuh
a. Pasien dapat mengidentifikasikan kondisi- 2) Memberikan tanda untuk
kondisi yang menyebabkan vertigo mengingatkan klien untuk meminta
b. Pasien dapat menjelaskan metode tolong ketika pergi dari tempat tidur,
pencegahan penurunan aliran darah di otak yang tepat
tiba-tiba yang berhubungan dengan 3) Menggunakan teknik yang sesuai
ortostatik. untuk mengantar klien ked an dari

c. Pasien dapat melaksanakan gerakan kursi roda, tempat tidur, toilet dan
mengubah posisi dan mencegah drop lainnya
tekanan di otak yang tiba-tiba. 4) Kaji tekanan darah pasien saat pasien
d. Menjelaskan beberapa episode vertigo mengadakan perubahan posisi tubuh.
atau pusing. 5) Diskusikan dengan klien tentang
Domain-Health Knowledge & Behaviour fisiologi hipotensi ortostatik.
(IV) 6) Ajarkan teknik-teknik untuk
Class-Risk Control & Safety (T) mengurangi hipotensi ortostatik
Falls Occurrence (1912) a. Untuk mengetahui pasien
Tidak terjadi jatuh ketika posisi berdiri, berjalan, mengakami hipotensi ortostatik
duduk dan ketika tidur ataukah tidak.
Domain-Health Knowledge & Behaviour b. Untuk menambah pengetahuan
(IV) klien tentang hipotensi ortostatik.
Class-Risk Control & Safety (T) c. Melatih kemampuan klien dan
Physical Injury Severity (1913) memberikan rasa nyaman ketika
Cedera bedah kepala tidak ada mengalami hipotensi ortostatik.
Gangguan mobilitas tidak ada
Penurunan tingkat kesadaran tidak terjadi
Perdarahan tidak terjadi
5. Gangguan nutrisi: kurang dari kebutuhan tubuh (00002) berhubungan
dengan efek kemoterapi dan radioterapi.
Domain 2: Nutrition
Class 1. Ingestion
Tujuan : setelah dilakukan tindakan keperawatan Nutrition Monitoring (1160)
selama 1x24 jam kebutuhan nutrisi klien dapat 1) Kaji tanda dan gejala
terpenuhi dengan adekuat dengan kriteria hasil: kekurangan nutrisi:
a. Antropometri: berat badan tidak turun (stabil) penurunan berat badan,
b. Biokimia: albumin normal dewasa (3,5-5,0) g/dl tanda-tanda anemia, tanda
c. Hb normal (laki-laki 13,5-18 g/dl, perempuan 12- vital
16 g/dl) 2) Monitor intake nutrisi pasien
1) Clinis: tidak tampak kurus, terdapat lipatan 3) Berikan makanan dalam
lemak, rambut tidak jarang dan merah porsi kecil tapi sering.
2) Diet: klien menghabiskan porsi makannya dan 4) Timbang berat badan 3 hari
nafsu makan bertambah sekali
Nutritional Status (1004)

Intake nutrisi adekuat 5) Monitor hasil laboratorium:
Intake makanan adekuat Hb, albumin
Intake cairan adekuat 6) Kolaborasi dalam pemberian
Hidrasi obat antiemetic
6. Gangguan mobilitas fisik (00085) berhubungan dengan gangguan sensorik
dan motorik
Domain 4: Activity/Rest
Class 2. Activity/Exercise
Tujuan : setelah dilakukan tindakan
keperawatan selama 1x24 jam, gangguan 1) Kaji fungsi motorik secara berkala
mobilitas dapat diminimalkan dengan 2) Menjaga pergelangan kaki 90 derajat
kriteria Hasil : dengan papan kaki. Gunakan trochanter
1. Mempertahankan posisi fungsi yang rolls sepanjang paha saat di ranjang
dibuktikan dengan tidak adanya 3) Ukur dan pantau tekanan darah pada fase
kontraktur. Foodtrop akut atau hingga stabil. Ubah posisi
2. Meningkatkan kekuatan tidak secara perlahan
terpengaruh/ kompenssi bagian tubuh 4) Inspeksi kulit setiap hari. Kaji terhadap
3. Menunjukan teknik eprilaku yang area yang tertekan dan memberikan
meingkinkan dimulainya kembali perawatan kulit secara teliti
kegiatan 5) Membantu mendorong pulmonary
Mobility (0208) hygiene seperti napas dalam, batuk,
Keseimbangan terjaga suction
Koordinasi terjaga 6) Kaji dari kemerahan,
Bergerak dengan mudah bengkak/ketegangan otot jaringan betis
7. Gangguan rasa nyaman (00214) berhubungan dengan nyeri akibat tidak
mampu menggerakan leher.
Domain 12: Comfort
Class 1. Physical Comfort
Tujuan : setelah dilakukan tindakan
keperawatan selama 1x24 jam 1) Kaji rentang gerak leher klien
memberikan kenyamanan gerak leher 2) Memberi helth education kepada pasien
pada klien dengan kriteria Hasil : mengenai penurunan fungsi gerak leher
a. Klien dapat menggerakan leher 3) Kolaburasi dengan fisioterapi
secara normal 4) Mengetahui kemampuan gerak leher klien

b. Klien dapat beraktifitas secara 5) Membantu pasien untuk dapat menerima
normal kondisi yang dialami
6) Terapi dapat membantu mengembalikan
gerak leher klien secara normal

Herediter Trauma Virus Onkogenik (Rotavirus) Radiasi

Mengenai lobus oksipitalis Pertumbuhan Sel yang Abnormal Obstruksi cairan Peregangan Epidural
serebrospinal dari ventrikel
lateral ke sub arachnoid
Gangguan visual TUMOR OTAK Nyeri Kepala

Penambahan Massa Otak dan atau Cairan Otak

Kerusakan pembuluh darah otak Kompresi jaringan otak Mengenai lobus frontalis Mengenai batang otak Bergesernya ginus
medialis lobus temporal
terhadap sirkulasi darah & O2
ke inferior melalui
Perpindahan cairan intravaskuler Kompresi daerah motorik Iritasi pusat vagal di insisura tentorial
ke jaringan serebral Penurunan suplai O2 ke medula oblongata
jaringan otak akibat obstruksi
Herniasi medula
Volume intrakranial naik (PTIK) Mual & Muntah oblongata
Iskemik MK. Gangguan
Menggangu fungsi spesifik Mobilitas Fisik MK. Nutrisi Menekan pusat saraf napas
bagian otak tempat tumor MK. Gangguan Perfusi Kurang dari
Jaringan Cerebral Kebutuhan Tubuh
Mengenai lobus parietalis
MK. Ketidakefektifan
MK. Nyeri Kronis
MK. Risiko Pola Napas
Kejang fokal
Tinggi Cedera


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