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Nursing diagnosis: Ineffective cerebral Tissue Perfusion related to head injury

outcome: at the end of nursing intervention, patient will demonstrate improve level of consciousness, cognition, motor and sensory
function
Objectives
Unconscious
Weak in appearance
With O2 nasal cannula
Intervention
Monitor/document neurologic status
frequently and compare with baseline.

Rationale
Assesses trends in level of consciousness
(LOC) and potential for increased ICP and is
useful in determining location, extent, and
progression/resolution of CNS damage.

Monitor vital signs

To monitor condition of the patient

Monitor Glasgow Coma scale and SPERM

Monitor neurologic status of the patient

Position with head slightly elevated and in


neutral position.

Reduces arterial pressure by promoting


venous drainage and may improve cerebral
circulation/perfusion.

Maintain bed rest, provide quiet


environment, restrict visitors

Continual stimulation/activity can increase


ICP. Absolute rest and quiet may be needed
to prevent rebleeding in the case of
hemorrhage.

Administer supplemental oxygen as


indicated.

Reduces hypoxemia, which can cause


cerebral vasodilation and increase
pressure/edema formation.

Evaluation: at the end of 2 days intervention to the patient, patient did not demonstrate improvedin level of consciousness,
cognition, motor and sensory function.

Nursing Diagnosis: Impaired physical mobility related to lose consciousness ,head injury
Objectives: at the end of nursing intervention, patient will maintain skin integrity
Objective Cues
Unconscious
Weakness
Immobile
Intervention
Change positions at least every 2 hr

Rationale
Reduces risk of tissue ischemia/injury.

Position in prone position once or


twice a day.

Helps maintain functional hip


extension.

Inspect skin regularly, particularly


over bony prominences.

Pressure points over bony


prominences are most at risk for
decreased perfusion/ischemia.

Get client up in wheel chair as soon


as vital signs are stable.
Consult with physical therapist
regarding active, resistive exercises
and client ambulation.

promotes maintenance of extremities


in a functional position and emptying
of bladder
Individualized program can be
developed to meet particular
needs/deal with deficits in balance,
coordination, strength.

Evaluation: at the end 2 days, patient had maintained skin integrity

Ineffective airway clearance related to chest injury and increase secretion production.
objective:
-O2 inhalation attached to tracheostomy tube
-RR- 35-36
-increase accumulation of secretion
-restlessness
Intervention

Rationale

1. Checked for aspiration


and respiratory
insufficiency
2. Respiratory rate checked
every 15 minutes.
3. Elevate the head of the
bed as prescribed.
4. Provide oxygenation,
prescribed by the
physician
5. Suction patient PRN limit
5-10 second per suction

1. To assess patient states of


maintaining airway
2. To check vital signs, to assess
patient active airway, and for
documentation purposes
3. To allow secretions drain from
patient mouth.
4. To support patient maintenance of
air
5. To maintain patent airway

Eva:At the end of 15-30 mins.The


clients restlessness was alleviated
and remained calmed.

Nursing Diagnosis:
Disturbed in sensory perception related to brain trauma
Plan: At the end of 2 days intervention patient able to demonstrate the presence of residual involvement.

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Objective:
-motor incoordination
-alteration in posture
- altered communication pattern
- poor concentration-

Intervention
Continual monitor in changes

Rationale
1.Damage may may occur at time of

in orientation, ability to speak,

initial injury

2
3

mood, affect and sensorium.


Assess sensory awareness.
Eliminate extraneous stimuli

2.to determine the ability to perceive

met because patient was

and respond appropriately to stimuli

demonstrate of deterioration of

3. to reduce anxiety

neurologic status.

as necessary
Speak calm, quite voice,use
short, simple sentences,

and understanding, these measures

maintain eye contact


Reorient client to environment,

can help client attend

and procedure

4. Client have limited attention span,

communication.
5.to assist patient to differentiate
reality in the presence of altered

Allow adequate time for

perception

communication and

6. to progress toward independence,

performance.

enhancing, sense of control while


compensating for neurologic deficits.

Drugs
Name of Drug: Phenytoin
Classification: Anticonvulsant
Dosage/ Frequency: 100mg 1cap QID

At the end of nursing


intervention my goal was not

Mechanism of Action:
It works by slowing down impulses in the brain that cause seizures.
Indications:
Treating certain types of seizures (eg, status epilepticus). It is also used to prevent and treat seizures that may occur during or after
brain or nervous system surgery. It may also be used for other conditions as determined by your doctor.
Contraindications:

you are allergic to any ingredient in Phenytoin or to another hydantoin (eg, fosphenytoin)

you have certain types of heart problems (eg, very slow heart beat, certain types of heart block, Adams-Stokes syndrome)

Adverse Reactions:
Constipation; dizziness; headache; mild nervousness; nausea; trouble sleeping; vomiting.
Nursing Considerations:
Phenytoin may cause dizziness. This effect may be worse if you take it with alcohol or certain medicines. Use Phenytoin with
caution. Do not drive or perform other possibly unsafe tasks until you know how you react to it.
Check with your doctor before you drink alcohol while you are taking Phenytoin . Alcohol may increase or decrease the amount of
medicine in your blood.
Do not change brands or dose forms (eg, tablets, suspension, injection) of Phenytoin without talking with your doctor.
Do NOT take more than the recommended dose without checking with your doctor.
Proper dental care is important while you are taking Phenytoin . Brush and floss your teeth and visit the dentist regularly.
Phenytoin may raise your blood sugar. High blood sugar may make you feel confused, drowsy, or thirsty. It can also make you
flush, breathe faster, or have a fruit-like breath odor. If these symptoms occur, tell your doctor right awa

Atrovent
Drug Classification: autonomic nervous system agent; anticholinergic
Dose:250mg
Mechanism of Action: Atrovent (ipratropium) is a bronchodilator that relaxes muscles in the airways and increases air flow to the
lungs.
Indications:
Atrovent is used to prevent bronchospasm, or narrowing airways in the lungs, in people with bronchitis, emphysema, or COPD
(chronic obstructive pulmonary disease).
Adverse Reactions
blurred vision, eye pain, or seeing halos around lights;
pain or burning when you urinate;
urinating less than usual or not at all; or
worsening of your symptoms.
Nursing Considerations

Monitor respiratory status; auscultate lungs before and after inhalation.

Report treatment failure (exacerbation of respiratory symptoms) to physician.

Name of Drug: Ranitidine


Brand: Zantac

Classification: Histamine-receptor antagonist


Dose and Frequency: 150 mg PO BID or 300 mg at bedtime
Mechanism of Action: Competitively inhibits action of histamine2 receptor sites of parietal cells, decreasing gastric acid secretion.
Indications: Acute duodenal or gastric ulcer and gastroesophageal reflux
Contraindications: Contraindicated to patients hypersensitive to the drugs and use cautiously in patients with impaired renal and
hepatic function.
Adverse Reactions:
Hepatic: jaundice
Skin: rash
CNS: malaise
GI: abdominal discomfort
EENT: blurred vision
Nursing Considerations:
Monitor patient for adverse reactions, especially hypotension and arrhythmias.
Peridically monitor lab tests, such as cbc and renal and hepatic studies.

Clexane
Classification: Anticoagulant
Dose:40mg
Mechanism of Action: Inhibits thrombus and clot formation by blocking factor Xa and factor IIa.

Indications:
Patients at risk for thromboembolic complications due to severely restricted mobility during acute illness
Prevention of pulmonary embolism and deep-vein thrombosis (DVT) after abdominal surgery
Prevention of ischemic complications of unstable angina or non-Q-wave myocardial infarction
Contraindications:
Hypersensitivity to drug, heparin, sulfites, benzyl alcohol, or pork products
Thrombocytopenia
Active major bleeding Adverse Reactions
Adverse Reactions:
CNS: dizziness, headache, insomnia, confusion,cerebrovascular accident
CV: edema, chest pain,atrial fibrillation, heart failure
GI: nausea, vomiting, constipation
GU: urinary retention
Nursing Considerations:
Monitor CBC and platelet counts. Watch for signs and symptoms of bleeding or bruising.
Monitor fluid intake and output. Watch for fluid retention and edema.

Pantoprazole

Classification: proton pump inhibitors


Dose:40mg
Mechanism of Action: blocks the enzyme in the wall of the stomach that produces acid.
Indications:
conditions such as ulcers, gastro esophageal reflux disease
Contraindications:
Hypersensitivity to drug, heparin, sulfites, benzyl alcohol, or pork products
Thrombocytopenia
Active major bleeding Adverse Reactions
Adverse Reactions:

headache

nausea

vomiting

gas

joint pain

constipation

Nursing Considerations:
Monitor CBC and platelet counts. Watch for signs and symptoms of bleeding or bruising.
Monitor fluid intake and output. Watch for fluid retention and edema.