Analysing Traumatic Brain Injury Care Through Indonesian Nursing Standards: A Case Report Approach

Emergency nursing requires specialized skills and resources to address complex patient needs. However, the emergency nursing process is often underutilized, impacting care quality and patient safety. This case study evaluates nursing care for a 20-year-old male with head trauma following a traffic accident using the Indonesian Nursing Care Standards (SDKI, SIKI, SLKI). The patient, with a Glasgow Coma Scale of 7, presented with a head wound, gurgling airway, vomiting, and signs of increased intracranial pressure. Key nursing problems identified included ineffective airway clearance, ineffective breathing patterns, and the risk of ineffective cerebral perfusion. Interventions included suctioning, oxygen therapy, and positioning, but several gaps in the standards were noted, particularly in diagnosis, measurable outcomes, and intervention guidelines. This study highlights the need to refine the Indonesian Nursing Care Standards for emergencies, focusing on priority-based problem identification and evidence-based guidelines. These adjustments can improve decision-making, enhance care consistency, and reduce complications, ultimately improving patient outcomes and trust in emergency nursing services.