• Efris Kartika Sari School of Nursing Universitas Brawijaya
  • Nisofa Nisofa Saiful Anwar General Hospital
  • Rendi Yoga Saputra School of Nursing Universitas Brawijaya
  • Masriami Masriami School of Nursing Universitas Brawijaya
  • Muhammad Khoirudin
  • Richardus MGP Lahamukang
  • Klara Yunita Inuq Thomas



blast injury, sepsis, nursing care


Blast injury is an injury due to the mechanism of barotrauma (involving excessive pressure) which results in organ trauma. Trauma and extensive injury can progress to sepsis condition to the patient. A man is hospitalized due to blast injury. The patient suffered a third-degree burn involving 18% total body surface area locate in the abdomen and right thigh, and right femoral trauma. The patient has right hip disarticulation and abdominal wound debridement surgery. After surgery, the patient has decreased consciousness and respiratory failure so that he was treated in the intensive care unit. The nursing assessment identified that patient has sepsis conditions. Nursing problems of the patient are ineffective airway clearance, impaired spontaneous ventilation, the risk for shock, and impaired tissue integrity. The nurse performs nursing care to maintain airway patency, provide adequate ventilation, maintain hemodynamic stability, and optimize the wound healing process of the patient.

Author Biographies

Efris Kartika Sari, School of Nursing Universitas Brawijaya

Department of Medical Surgical Nursing

Nisofa Nisofa, Saiful Anwar General Hospital

Intensive Care Unit Nurse


  • Bennett, J. E., Dolin, R., & Blaser, M. J. (2015). Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (8th ed.). Philadelphia: Saunders.
  • BPKN (2010). [Pelabelan Tabung Gas Rumah Tangga Gas 3 kg dan 12 kg].
  • Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. (2013). Nursing Interventions Classification (NIC) (6th ed.). Missouri: Elsevier.
  • Camm, C. F., Hayward, G., Elias, T. C. N., Bowen, o. S. T., Hassanzadeh, R., Fanshawe, T., . . . Lasserson, D. S. (2018). Sepsis recognition tools in acute ambulatory care: associations with process of care and clinical outcomes in a service evaluation of an emergency multidisciplinary unit in Oxfordshire. BMJ Open, 8, e020497.
  • Fatmadona, R., & Oktarina, E. (2016). Aplikasi modern wound care pada perawatan luka infeksi di RS Pemerintah Kota Padang. Ners Jurnal Keperawatan, 12(2), 159-165.
  • Finkelsztein, E. J., Jones, D. S., Ma, K. C., Pabón, M. A., Delgado, T., Nakahira, K., . . . Siempos, I. I. (2017). Comparison of qSOFA and SIRS for predicting adverse outcomes of patients with suspicion of sepsis outside the intensive care unit. Critical Care, 21(73), 1-10.
  • Gnatta, J. R., Silveira, I. R. d., Lacerda, R. A., & Padoveze, M. C. (2013). Evidence on the best chlorhexidine concentration to perform oral hygiene: meta-analysis. O Mundo da Saude, 37(4), 464-471.
  • Gyawali, B., Ramakrishna, K., & Dhamoon, A. S. (2019). Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Medicine, 7, 1-13.
  • Jorolemon, M. R., & Krywko, D. M. (2019). Blast Injuries.
  • Keenan, A.-V., & Ferraiolo, D. M. (2017). Oral care with chlorhexidine seems effective for reducing the incidence of ventilator-associated pneumonia. Evidence-Based Dentistry, 18, 113-114.
  • Levy, i. M., Evans, L. E., & Rhodes, A. (2018). The surviving sepsis campaign bundle: 2018 update. Critical Care Medicine, 46(6), 997-1000.
  • Liu, X.-W., Jin, Y., Ma, T., Qu, B., & Liu, Z. (2015). Differential effects of endotracheal suctioning on gas exchanges in patients with acute respiratory failure under pressure-controlled and volume-controlled ventilation. Biomed Res Int, 2015, 941081. doi: 10.1155/2015/941081
  • Marx, J. A., Hockberger, R. S., & Walls, R. M. (2014). Rosen's Emergency Medicine (8 th ed.). Philadelphia: Saunders.
  • Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2013). Nursing Outcomes Classification (NOC) (5th ed.). Missouri: Elsevier.
  • NANDA-I. (2018). Diagnosis Keperawatan Definisi dan Klasifikasinya 2018-2020 (11 ed.). Jakarta: EGC.
  • Oematan, Y., Manoppo, J. I. C., & Runtunuwu, A. L. (2009). Peran inflamasi dalam patofisiologi sepsis dan syok septik pada anak. Jurnal Biomedik, 1(3), 166-173.
  • Oro, N. D., Gauthreaux, M. E., Lamoureux, J., & Scott, J. (2019). The use of procalcitonin as a sepsis marker in a community hospital. J Appl Lab Med, 3(4), 545-552.
  • Samra, T., Pawar, M., & Kaur, J. (2014). Challenges in management of blast injuries in Intensive Care Unit: Case series and review. Indian J Crit Care Med, 18(12), 814-818.
  • Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., . . . Chiche, J.-D. (2016). The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA, 315(8), 801-810.
  • Syafii, A. (2017). Upaya pencegahan dan penanggulangan tindak pidana terorisme di Indonesia. Maleo Law Journal, 1(2), 168-186.
  • Zuckerman, L. M. (2016). Oral chlorhexidine use to prevent ventilator-associated pneumonia in adults. Dimens Crit Care Nurs, 35(1), 25-36.