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Nursing

By | December 2012
Page 1 of 3
  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...
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