Asuhan Keperawatan Post Op Trakeostomi dengan Masalah Bersihan Jalan Napas Tidak Efektif dengan Tindakan Manajemen Jalan Napas pada Pasien Tn. S di Ruang ICU RSUD Haji Provinsi Jawa Timur

Pendahuluan: Trakeostomi berisiko menimbulkan bersihan jalan napas tidak efektif akibat akumulasi sekret. RSUD Haji Provinsi Jawa Timur mencatat 27 kasus trakeostomi (Juli 2025–Januari 2026). Studi ini bertujuan mendeskripsikan asuhan keperawatan pada pasien post op trakeostomi dengan bersihan jalan napas tidak efektif melalui manajemen jalan napas di ICU. Metode: Desain deskriptif kualitatif dengan pendekatan studi kasus pada satu pasien (Tn. S, 63 tahun), dirawat di ICU sejak 8 Februari 2026 dengan DM post hipoglikemia, pneumonia, sepsis, MODS, AKI, ARDS, dan ensefalopati metabolik. Data dikumpulkan melalui wawancara, observasi fisik (B1–B6), dan studi dokumentasi. Analisa: Data dianalisis secara naratif dengan membandingkan teori dan fakta di lapangan mengikuti tahapan proses keperawatan hingga evaluasi SOAP. Hasil: Ditemukan sekret purulen banyak, ronki, gurgling, dan ketidakmampuan batuk efektif, sehingga ditegakkan diagnosis bersihan jalan napas tidak efektif, risiko perfusi serebral tidak efektif, dan risiko infeksi. Intervensi EBP meliputi suction selektif, humidifikasi, posisi head-up 30°, dan log roll. Setelah 3×24 jam, kedua masalah teratasi sebagian tanpa perburukan neurologis. Kesimpulan: Tidak ditemukan kesenjangan berarti antara teori dan praktik. Disarankan perawat konsisten menerapkan prinsip aseptik dan rumah sakit memperkuat SOP trakeostomi berbasis bukti.

====================================================================================

Introduction: Tracheostomy carries the risk of ineffective airway clearance due to secretions. Haji Regional General Hospital, East Java Province recorded 27 tracheostomy
cases from July 2025 to January 2026. This study aims to describe nursing care for post operation tracheostomy patients with ineffective airway clearance through airway
management in the ICU. Methods: Descriptive qualitative design with a case study approach on one patient (Mr. S, 63 years old), treated in the ICU since February 8, 2026,
with post-hypoglycemic DM, pneumonia, sepsis, MODS, AKI, ARDS, and metabolic encephalopathy. Data were collected through interviews, physical observations (B1–B6), and documentation studies. Analyzed: The data were analyzed narratively by comparing theory and field observations, following the nursing process through the SOAP evaluation. Result: Many purulent secretions, crackles, gurgling, and inability to cough effectively were found, leading to the diagnosis of ineffective airway clearance, risk of ineffective cerebral perfusion, and risk of infection. EBP interventions include selective suction, humidification, a 30° head-up position, and log-roll. After 3×24 hours, both issues were partially resolved without neurological deterioration. Discussion No significant gap was found between theory and practice. It is recommended that nurses consistently apply aseptic principles and that the hospital reinforce evidence-based tracheostomy SOPs.