About
Traumatic injury to the head/ brain causing potential disruption of blood flow to areas of the brain and increased intracranial pressure from edema and inflammation.
Assess
Airway and breathing assessment, complete neurological assessment, Vital signs, signs of increased intracranial pressure
Complications
- Increased intracranial pressure; death
- Neurological deficits
Diagnosis
- Risk for injury related to impaired cerebral function and altered level of consciousness
- Acute pain related to compression of bran tissue.
Goals
- The client will be free from injury.
- The client will maintain patent airway.
Interventions
- Priority is monitoring for airway, breathing and circulation.
- Monitor for s/s of increased intracranial pressure ( seizures, non-responsiveness, nausea, vomiting, hypertension, bradycardia, changes in neuro status).
- Have endotracheal equipment at the bedside in case of respiratory emergency.
- Monitor pain level, respiratory status, neuro status, electrolytes, fluid volume status, intakes/ outputs, vital signs, and pulse oximetry frequently.
- May need to be in an induced coma to prevent stress, agitation, pain, etc.
- Administer medications ( Mannitol, glucocorticoids, etc.) as indicated.
- Encourage coughing and deep breathing techniques or suction as needed.
- Maintain head of bed at 30 degrees.
- Initiate supportive care for bed-bound patient.
- Initiate plans for continued rehabilitation, physical therapy, occupational therapy, etc as indicated.
- Monitor for signs/ symptoms of complications.
ليست هناك تعليقات:
إرسال تعليق