N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide Nursing diagnosis for head injury: • Ineffective breathing pattern and airway clearance related to brain injury • Sensory alterations related to altered sensory transmission, secondary to increased ICP • Fall risk related to decreased level of consciousness • Risk for self-care deficit related to decreased level of consciousness • Knowledge deficit related to signs of increased ICP, medications, and outcomes Nursing interventions for head injury: • Assess frequently for changes; especially signs of increased ICP: o Level of consciousness o Pupil response o Nausea/vomiting o High fever o Wide pulse-pressure o Bradycardia o Decreased respirations o Agitation or behavior changes • Assist patient with maintaining fluid balance: weights, intake, and output • Give IV nutrition; TPN or G-Tube feedings if long-term • Give medications per MD order: o Diuretics: Help to reduce swelling in the brain by pulling fluid into the blood and filtering it out through the kidneys. o Anti-seizure medications: Dilantin, pentobarbital, and benzodiazepines can help to reduce intracranial pressure and reduce or prevent seizures. o Corticosteroids: Used to reduce swelling in the brain, increase blood flow, and increase function in the neurons. • Assist with drainage of secretions; elevate the head of bed, perform chest physiotherapy, suction lightly (not deeply), and turn every two hours; straining and coughing can cause transient increased ICP • Give oxygen if needed or manage ventilator care • Maintain stability of the patient’s head and neck • Maintain safety; side rails up, bed low, and seizure precautions • Keep visitors to a minimum and maintain a quiet environment • Offer comfort for pain; pain medications should not contain narcotics due to sedative effects • Assist with ADLs, range of motion, and feeding • Teach family and caregivers about course of recovery, signs of increased ICP, treatment, safety, and prognosis ©2017 Achieve Test Prep Page 108 of 204