Nursing
Anoxic Brain Injury impaired physical mobility r/t muscle weakness and disease process
self care deficit: dressing and grooming r/t cognitive impairment
chronic confusion r/t impaired decision making
ineffective coping r/t impaired information processing
noncompliance with nursing staff r/t behavior problem due to mental decline
impaired verbal communication r/t aphasia-speech deficit
risk for falls r/t muscle weakness
risk for impaired skin integrity r/t bedridden/chairbound
- History of Trauma - Time, cause, direction and force of the blow - Loss of consciousness, duration Assess LOC - Glasgow Coma Scale - Response to verbal commands or tactile stimuli - Pupillary response to light - Motor Function Vital Signs - Monitor for signs of increased ICP Motor Function - Move extremities, hand grasp, pedal push, speech
Ineffective airway clearance related to accumulation of secretions and decreased LOC Maintain patient airway - Suction carefully - Discourage coughing (causes increase in ICP) - Elevate HOB 30 degrees - Guard against aspiration - Monitor ABGs to assess ventilation
Ineffective breathing pattern related to neurological dysfunction Monitor constantly for respiratory irregularities - Cheyne Stokes, hyperventilation, Effective suctioning HOB 30 degrees Position patient lateral or semi prone
Altered cerebral tissue perfusion related to increased intracranial pressure Position patient to reduce ICP : - head in midline position to promote venous drainage - Elevate HOB 30 degrees - Avoid extreme rotation or flexion of neck - Avoid extreme hip flexion Prevent straining - Stool Softeners - High Fibre diet Space Nursing activities Maintain calm atmosphere, reduce stimuli
Risk for fluid volume deficit related to dehydration procedures and decreased LOC Monitor
self care deficit: dressing and grooming r/t cognitive impairment
chronic confusion r/t impaired decision making
ineffective coping r/t impaired information processing
noncompliance with nursing staff r/t behavior problem due to mental decline
impaired verbal communication r/t aphasia-speech deficit
risk for falls r/t muscle weakness
risk for impaired skin integrity r/t bedridden/chairbound
- History of Trauma - Time, cause, direction and force of the blow - Loss of consciousness, duration Assess LOC - Glasgow Coma Scale - Response to verbal commands or tactile stimuli - Pupillary response to light - Motor Function Vital Signs - Monitor for signs of increased ICP Motor Function - Move extremities, hand grasp, pedal push, speech
Ineffective airway clearance related to accumulation of secretions and decreased LOC Maintain patient airway - Suction carefully - Discourage coughing (causes increase in ICP) - Elevate HOB 30 degrees - Guard against aspiration - Monitor ABGs to assess ventilation
Ineffective breathing pattern related to neurological dysfunction Monitor constantly for respiratory irregularities - Cheyne Stokes, hyperventilation, Effective suctioning HOB 30 degrees Position patient lateral or semi prone
Altered cerebral tissue perfusion related to increased intracranial pressure Position patient to reduce ICP : - head in midline position to promote venous drainage - Elevate HOB 30 degrees - Avoid extreme rotation or flexion of neck - Avoid extreme hip flexion Prevent straining - Stool Softeners - High Fibre diet Space Nursing activities Maintain calm atmosphere, reduce stimuli
Risk for fluid volume deficit related to dehydration procedures and decreased LOC Monitor