36 hours ago Nursing and Clinical. Print New Topic : The nurse caring for a 90-year-old patient with a closed head injury would immed. nurse2mrow. wrote... Go to Answer: Posts: 7336 Rep: 8 … >> Go To The Portal
Nursing care plan of head injury includes nursing diagnosis, intervention, and rationale. Let us discuss nursing diagnoses one by one. increased cerebral blood flow. increase in intracranial pressure more than 10 mm Hg Expected outcomes: Patient maintains optimal cerebral tissue perfusion, ICP less than 10 mm Hg.
In circumstances where a patient with a head injury requires hospital admission, admit the patient only under the care of a team led by a consultant who has been trained in the management of this condition during their higher specialist training.
In-hospital observation of patients with a head injury should only be conducted by professionals competent in the assessment of head injury. [2003] 1.8.6.
A clinician with training in safeguarding should be involved in the initial assessment of any patient with a head injury presenting to the emergency department. If there are any concerns identified, document these and follow local safeguarding procedures appropriate to the patient’s age. [2003, amended 2014]
Nursing Interventions Interventions to lower or stabilize ICP include elevating the head of the bed to thirty degrees, keeping the neck in a neutral position, maintaining a normal body temperature, and preventing volume overload.
Dependent PatientSit the patient fully upright or in an elevated side-lying position to prevent aspiration during mouth cleaning.Inspect the patient's mouth: ... Remove loose material or debris (especially important if patient is NPO/Nothing by Mouth): ... Brush the teeth with toothpaste.More items...•
The most important nursing action following cardiac catheterization is assessing the groin for bleeding and the leg for color, warmth (circulation) and pulse. Postcatheterization care involves monitoring vital signs every 15 minutes for an hour, then every 30 minutes for an hour or until stable.
Audit. A record means to examine and review a group of patient records for completeness and accuracy.
Procedure for oral assessmentGain consent.Wash hands.Wear gloves and apron.Maintain privacy as required. Assess the oral cavity using an appropriate assessment tool. You may need a tongue depressor and a torch to carry out the assessment efficiently.
Daily assessment It is the responsibility of the nurse managing the patient's care to assess the oral mucosa and decide on subsequent methods of oral hygiene in consultation with the medical team. The Oral Assessment Guide (OAG) can assist in determining the patient's oral health and function.
General patient care after the procedure A nurse will monitor vital signs, the insertion site, and circulation/sensation in the affected leg or arm. The plastic sheath which was inserted in the patient's groin, neck, or arm will be removed soon after unless the patient requires specialised blood thinning medication.
Before a cardiac catheterization, you will likely have your blood pressure and pulse checked. You may be asked to use the toilet to empty your bladder. You may be asked to remove dentures and any jewelry, especially necklaces that could interfere with pictures of the heart.
Cardiac auscultation should be conducted with the patient in three positions. These are sitting up, lying on the left side, and lying on the back with the head of the bed raised 30 to 45 degrees. Murmurs and pericardial friction rubs are best heard with the patient sitting up and leaning forward.
Similar to the levels of history, there are four levels of physical exam documentation: Problem Focused. Expanded Problem Focused. Detailed. Comprehensive.
Client's Words, Clarity, Completeness, Conciseness, Chronological Order and Confidentiality.
Information on a patient such as, demographics, progress notes, problems, medication, vital signs, past medical history, immunizations, laboratory data, radiology pictures, and other personal data (height, weight, and billing information).
It is tearing or injury to the cortical surface of the brain resulting in mechanical disruption of neural function. It forms hepatoma and edema. It mostly occurs due to penetrating injury or rotational shearing injury inside the brain.
In the assessment we will discuss how to assess the patient in each type of injury. Concussion. It is mild most common brain injury. It takes few days to get back to normal condition. Brain imaging such as CT scan and MRI shows no changes in structure of brain. Concussion has three grades based on severity of injury.
Secondary problems are hematoma, rupture of blood vessels, ischemia to brain tissue, infection, and increased intracranial pressure. Before planning any carenurses first assess the condition of the patient.
GCS assesses the conscious level of the patient. GCS 13-15 is considered as mild, 9-12 is moderate and 3-8 level indicates a decrease in the severe level of consciousness. It is considered the most sensitive indicator of the brain. In the assessment we will discuss how to assess the patient in each type of injury. Concussion.
Symptoms of concussion areheadache, dizziness, nausea, lethargy, difficulty in focusing, irritability to bright light, and loud noises, sleep disturbances, difficulty in concentration and attention. Diffuse Axonal Injury.
Sometimes amnesia may occur for which the patient forgets not an only traumatic events but also past events. Contusion symptoms like loss of consciousness, agitation , and confusion may last for long hours. General symptoms in contusion are nausea, vomiting, headache, lethargy, motor paralysis may occur.
Concussion has three grades based on severity of injury. Grades with symptoms given below: Grade-I: There is no loss of consciousness. There may be little confusion. Symptoms disappear and it becomes normal within 15 minutes of injury. Grade-2:in grade-2 also there is no loss of consciousness.