Question

explain how the Nursing process would help you care for a patient in the following situation.

A 44-year-old patient admitted with head trauma. On initial rounds the patient was arousable, followed simple commands, pupils were equal and reactive, BP 140/80, HR 82, RR 20. One hour later your patient care tech called you into the room concerned about this patient. How would the nursing process help you determine his care?

Answer 1

In agreement with the client, the nurse addresses each of the problems identified in the diagnosing phase. When there are multiple nursing diagnoses to be addressed, the nurse prioritizes which diagnoses will receive the most attention first according to their severity and potential for causing more serious harm. The most common terminology for standardized nursing diagnosis is that of the evidence-based terminology developed and refined by NANDA International, the oldest and one of the most researched of all standardized nursing languages.^[9] For each problem a measurable goal/outcome is set. For each goal/outcome, the nurse selects nursing interventions that will help achieve the goal/outcome, which are aimed at the related factors (etiologies) not merely at symptoms (defining characteristics). A common method of formulating the expected outcomes is to use the evidence-based Nursing Outcomes Classification to allow for the use of standardized language which improves consistency of terminology, definition and outcome measures. The interventions used in the Nursing Interventions Classification again allow for the use of standardized language which improves consistency of terminology, definition and ability to identify nursing activities, which can also be linked to nursing workload and staffing indices. The result of this phase is a nursing care plan.

All the nursing interventions of head injury have presented in the following:

1. Assess neurologic and respiratory status to monitor for the sign of increased ICP (Increased intracranial pressure) and respiratory distress.
2. Have to monitor and record major symptoms and intake and output, increased intracranial pressure, hemodynamic variables, cerebral perfusion pressure, specific gravity, laboratory studies and pulse oximetry to detect early sign of compromise.
3. Observe for the sign of increasing increased intracranial pressure (ICP) to avoid treatment delay and prevent neurologic compromise.
4. Assess for CSF leak as evidenced by otorrhea or rhinorrhea. Cerebrospinal fluid (CSF) leak could leave the patient at risk for infection.
5. Assess for pain. Pain may cause anxiety and increase increased intracranial pressure (ICP).
6. Check a cough and gag reflex to prevent aspiration.
7. Have to check for different symptoms of diabetes insipidus (High urine output, low urine specific gravity) to maintain hydration.
8. Administer I.V fluids to maintain hydration.
9. Administer oxygen to maintain position and patency of endotracheal tube if present, to maintain the airway and hyperventilate the patient and to lower increased intracranial pressure (ICP).
10. Provide suctioning; if the patient is able, assist with turning, coughing and deep breathing to prevent pooling of secretions.
11. Maintain position, patency and low suction of NGT to prevent vomiting.
12. Maintain seizure precautions to maintain patient safety.
13. Administer medication as a prescription to decrease increased intracranial pressure (ICP) and pain.
14. Allow a rest period between nursing activities to avoid the increase in increased intracranial pressure (ICP).
15. Encourage the patient to express feeling about changes in body image to allay anxiety.
16. Provide appropriate sensory input and stimuli with frequent reorientation to foster awareness of the environment.
17. Provide means of communication, such as a communication board to prevent anxiety.
18. To prevent tissue damage, provide eye, skin and mouth care.
19. Turn the patient every 2 hours or maintain in a rotating bed if condition allows preventing skin breakdown.