B. Nursing Management 1.

Nursing Care Plan Problem # 1: Hyperthermia

ASSESSMENT

PROBLEM

BACKGROUND KNOWLEDGE Fever is the most common sign of systemic response to injury & it is most likely caused by indigenous pyrogens released from neutrophils & macrophages. These substance reset the hypothalamic thermoset, w/c controls body temp. & produce fecer. Leukocyosis, an increase in the synthesis & release of neutrophils from born marrow may occur to provide the body w/ greater ability to fight infection. During the process general non-specific symptoms develop, including malaise, loss of appetite, aching & weakness

OBJECTIVE

INTERVENTION

EVALUATION

S> O> Pt may manifest the following: >flushed skin >skin warm to touch >restlessness >weakness >Increased body temp of 38C >body malaise >seizures or convulsion >tachycardia >loss of appetite

Hyperthermi a

Short term: 1.Monitor & Short term: After 4 of NI, recorded VS The pt shall have the pt will for baseline maintained core maintain core temp will data temp will 2.Perform TSB decrease from decrease from heatloss by 39C to 37.5C. 39C to evaporation & 37.5C. conduction 3.Use blanket & wrap extremities w/ bath towel Long term: to minimize After 3 days of Long- term shivering NI, the pt will 4. monitor intake & be free of output complication to know if such as output is irreversible equal or close brain damage to intake & free from 5.provide adequate seizure rest periods activity. to regain energy through resting 6. instruct client to increase fluid intake to control possible fluid loss, to replace fluid loss & permit heat loss 7.Encourage client to eat balance diet and nutritious foods to meet increase metabolic demands 8. instruct pt to avoid tight fitting clothes

Problem # 2: Acute Pain

ASSESSMENT

PROBLEM

BACKGROUND KNOWLEDGE Pain may arise from obstruction of the common blood on the brain. Inflammation and swelling depress the free nerve endings and cause the pain. Headaches following a head injury may be mild, moderate or severe and the extent of the injury itself is not always indicative of the severity of headaches. Mild headaches following a head injury are those that usually don't prevent a person from functioning daily.

OBJECTIVE

INTERVENTION

EVALUATION

S> O> The patient may manifest the following: >guarding behavior on RUQ portion of the skull >nausea vomiting >facial grimace >unable freely to move and

Acute Pain

Short Term: After 4 hours of NI, the patient will be able to verbalize a decrease in pain. Long Term:

> self focusing >skull heaviness >narrowed focus >expressive favor >sleep disturbance

1.Monitor & recorded VS for baseline data 2.Assess patient quality onset, duration, location and intensity of pain. to be specific of the kind of pain experienced 3. Provide comfort measure such as quite environment using relaxation techniques, backrub, comfortable positioning to promote rest and enhance the effects of analgesics given 4. Provide individuals with opportunities to discuss fear and acknowledge the difficulty of situation. to assist patient and family to respond optimally to the individuals pain experience 5. Provide diversional activities to divert focus of the pt. to the pain. 6. Educate client regarding medications, dosage, side effects Understanding of all medications allows formore appropriate

Short term: The pt shall have maintained core temp will decrease from 39C to 37.5C.

Long- term

Problem # 3: Altered cerebral tissue perfusion related to hematoma

ASSESSMENT

PROBLEM

BACKGROUND KNOWLEDGE

OBJECTIVE

INTERVENTION

EVALUATION

S>

Altered Altered tissue cerebral perfusion is the O> The patient may tissue decrease in oxygen manifest the perfusion resulting in the following: related to failure to nourish hematoma the tissues at the >aletered mental capillary level. status Traumatic brain injury is a >speech devastating abnormalities problem with both high subsequent >behavioral morbidity and high changes mortality. Injury to the brain occurs >restlessness both at the time of the initial trauma >change in motor (the primary injury) response and subsequently due to ongoing >extremity cerebral ischemia weakness (secondary injury). Cerebral edema, >paralysis hypotension, and hypoxic conditions >changes in are well recognized papillary reactions causes of this secondary injury. In >difficulty in the intensive care swallowing unit, raised intracranial pressure (intracranial hypertension) is seen frequently after a severe diffuse brain injury (one that occurs over a widespread area) and leads to cerebral ischemia by compromising cerebral perfusion.

Short Term: After 4 hours of NI, the patient will demonstrate behavior changes to improve circulation like relaxation techniques and dietary program Long Term: After 3 days of NI, the patient will verbalize understanding of condition, therapy regimen, side effects of medications, and when to contact health care provider

1.Monitor & recorded VS Rationale: for baseline data 2. Determine factors related to individual situation, cause for coma, decreased cerebral perfusion, and potential for ICP. Rationale: Influences choice of interventions. Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity, which requires that client be admitted to critical care area for monitoring of ICP and for specific therapies geared to maintaining ICP within a specified range. 3. Monitor and document neurological status frequently and compare with baseline. Rationale: Assesses trends in LOC and potential for increased ICP and is useful in

Short term: The pt shall have demonstrate behavior changes to improve circulation like relaxation techniques and dietary program

Long- term The patient shall have verbalized understanding of condition, therapy regimen, side effects of medications, and when to contact health care provider

Problem # 4: Altered Thought Processes related physiological changes

ASSESSMENT

PROBLEM

BACKGROUND KNOWLEDGE Disturbed thought processes is the disruption in cognitive operation and activities. Due to presence of predisposing and pecipitating factors, there is decreased blood supply in the frontal lobe. There is damaged in this are which causes psychotic manifestations.

OBJECTIVE

INTERVENTION

EVALUATION

S>

Altered Thought O> Pt may manifest Processes the following: related to altered level of - Memory deficits or consciousnes problems s and confusion - Inaccurate interpretation of environment - Inappropriate non reality based thinking

Short term:

1.Monitor & recorded VS After 4 of NI, Rationale: for the pt will baseline data recognize 2.Establish rapport changes in Rationale to gain thinking trust and to establish cooperation of the patient 3.Assess pt. condition Long term: Rationale to identify underlying After 3 days of health problems and NI, the pt will to identify demonstrate appropriate behaviors/ interventions to lifestyle correct the changes to problems seen prevent minimize 4. Utilize safety changes in measures to protect mentation client Rationale During acute phase, clients delusional thinking might dictate to them that they might have to hurt others for their safety 5. Be aware that clients delusions represent the way that he experiences reality Identifying the clients experiences allows the nurse to understand the clients feelings

Short term: The pt shall have maintained recognize changes in thinking

Long- term the pt shall have demonstrated behaviors/ lifestyle changes to prevent minimize changes in mentation

-Cognitive dissonance

Problem # 5: Impaired physical mobility related to motor, sensory, proprioceptive deficits, depressed consciousness level

ASSESSMENT

PROBLEM

BACKGROUND KNOWLEDGE Impaired physical mobility is the limitation of in independent, purposeful physical movement of the body or of one or more extremities. In head injury the head experienced a trauma in different lobes of the brain and by these the patient can experience restlessness and should be at bed rest at the moment.

OBJECTIVE

INTERVENTION

EVALUATION

S>

Impaired physical O> Pt may manifest mobility the following: related to motor, sensory, proprioceptiv > Edema (none deficits, pitting) depressed consciousnes Limited ROM s level Limited muscle strength or control Inability to move purposefully in the environment Impaired coordination

> After 4-6 of NI patient will verbalize understanding of situation and individual treatment regimen and safety measures

1.Monitor & recorded VS Rationale:for baseline data 2.Assess patients general condition

Short term: The pt shall have verbalized understanding of situation and individual treatment Rationale:To regimen and determine present safety measures health status 3. Determine comfortable position for patient

Rationale:To > Long- term: determine the need Long- term for repositioning After 2-3 days The patient shall 4. Provide safety by of NI, patient have will raising side rails demonstrated demonstrate behaviors that behaviors that enable enable resumption of resumption of Rationale:Prevent activities activities injury from falls 5. Provide adequate rest Rationale:Provide energy for exercise 6. Encourage intake of nutritious foods Rationale:To provide optimum nutrition for fast healing 7.Provide early ambulation and out