33 hours ago What should be immediately reported by the nurse for a 90 year old patient with a closed head injury? Blood pressure change from 147/72 to 176/70 mm Hg. A patient with generalized convulsive disorder has a nursing diagnosis of Deficient knowledge, related to lack of information about the side effects of phenytoin. >> 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.
The nurse is assessing an acutely ill patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock when: 1- Fluid circulating in the blood vessels decreases.
The nurse evaluates the following as a complication of the therapy: 1- The balloon deflates prior to systole. 2- The right foot is cooler than the left foot. 3- Vesicular breath sounds are audible in the lung periphery. 4- Bilateral pedal pulses are 1+. You are the nurse caring for a client in septic shock. You know to closely monitor your client.
A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
1. A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to.
The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute , and his skin is warm and dry.
2- "The client is in shock because the heart is unable to circulate the body fluids.". 3- "The client is in shock because your loved one is not responding and brain dead.".
1. A nurse educator is teaching a group of nurses about assessing critically ill clients for multiple organ dysfunction syndrome (MODS). The nurse educator evaluates understanding by asking the nurses to identify which client would be at highest risk for MODS. It would be the client who is experiencing septic shock and is.
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient's increased risk for what complication?
Ans: Preparing to assist with intubating the patient. Feedback: A patient who has ARDS usually requires intubation and mechanical ventilation. The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer.
If the patient has undergone surgical embolectomy, the nurse measures the patient's pulmonary arterial pressure and urinary output. Pressure is not monitored in a patient's vena cava. White cell levels and pupillary responses would be monitored, but not to the extent of the patient's pulmonary arterial pressure.
Feedback: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. The nurse is caring for a 46-year-old patient recently diagnosed with the early stages of lung cancer.
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.
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.
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.
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.
Grade-2:in grade-2 also there is no loss of consciousness. A little confusion, symptoms remain more than 15 minutes. Persistent symptoms after 1 week of injury need immediate imaging of the brain and doctor consultation. Grade-3:If there is loss of consciousness, it is considered as severe form of concussion.