Patients Name: O.

M Age: 33 y/old Medical Diagnosis: Epidural Right frontal area secondary to vehicular crash Nursing Diagnosis: Impaired skin integrity related to surgery AEB destruction of skin layers and surface and invasion of body structures secondary to head injury Short Term Goal: After 2 days of NI, the patient will achieve timely wound healing. Long Term Goal: After 7 days of NI, the patient will exhibit improved skin lesions or wounds. ASSESSMENT S> NURSING SCIENTIFIC NURSING RATIONALE > To provide evidence of the effectiveness of the skin care regimen. After 2 days of NI, the patient shall have

Gender: Male

EVALUATION STANDARD Short term: CRITERIA Short term:

DIAGNOSIS EXPLANATION INTERVENTIONS Impaired The procedure >Inspect skin every shift, describe and document skin condition, and report changes.

skin integrity is invasive in O > The patient manifests: -immobility -destruction in skin integrity -redness on the area -trauma -pain -surgical incision/wound related to surgery AEB destruction of skin layers and surface and invasion of body structures secondary to head injury nature since it will require an incision and the use of mechanical implants. There is destruction on the skin layers of the affected part.

After 2 days of NI, the patient shall have achieved timely

achieved timely wound healing. wound healing.

>To promote >Assist with general hygiene and comfort measures. >To promote >Maintain proper environmental comfort and sense of wellbeing. After 7 days of NI, the patient shall have patients sense exhibited of well-being. improved skin Long term:

Long term:

After 7 days of NI, the patient shall have exhibited improved skin lesions or wounds.

>The patient may manifest: -edema -swelling -itching

conditions. >To minimize skin >Use a foam mattress, bed cradle, or other devices. >To reduce potential for >Warn against tampering with the wound or dressings. >To reduce pressure, >Position patient for comfort and minimal pressure on bony prominences and change his position at least every 2 hours. >To encourage compliance. promote circulation and minimize skin breakdown. infection. breakdown.

lesions or wounds.

>Instruct family members in a skin care regimen. >To maintain or modify current therapy. >Perform prescribed treatment regimen for the skin condition involved; monitor progress. >To relieve the patient of pain.

>Administer pain medication and monitor its effectiveness.

Patients Name: O.M Age: 33 y/old Gender: Male Medical Diagnosis: Epidural Right frontal area secondary to vehicular crash Nursing Diagnosis: Risk for infection related to tissue destruction Secondary to head injury Short Term Goal: After 2 days of NI, the patient will identify interventions to prevent/reduce risk of infection Long Term Goal: After 5 days of NI, the patient will manifest absence of infection. ASSESSMENT NURSING SCIENTIFIC NURSING INTERVENTIONS >Observe for localized signs of infection at sutures or surgical incision wound. >To check for any signs of infection. After 2 days of NI, the patient shall have identified >Note signs and symptoms of sepsis; fever, chills, diaphoresis. >To check for the presence of infection and give necessary interventions. After 5 days of >Change surgical/wound dressings, as >To facilitate wound healing and prevent NI, the patient shall have manifested After 5 days of NI, the patient shall have manifested absence of Long term: Long term: interventions to prevent/reduce risk of infection. After 2 days of NI, the patient shall have identified interventions to prevent/reduce risk of infection. RATIONALE EVALUATION STANDARD Short term: CRITERIA Short term:

DIAGNOSIS EXPLANATION S> Risk for infection O>The patient manifests: -presence of surgical incision/wound related to tissue destruction Secondary to head injury >The patient may manifest: The pt. manifest: -hyperthermia -chills -diaphoresis -increase WBC The surgical wound is at risk for infection since there is destruction in the first line of defense of the body which is the skin. This entitles different pathogenic organisms to invade the surgical wound. If it is not properly taken

-pain and swelling on the surgical site -alteration in VS -seizures

cared of like proper cleaning

indicated, using proper technique

infection by minimizing growth and spread of microorganisms.

absence of infection.

infection.

and changing of for dressings, there changing/disposing can be growth and spread of infectious microorganisms and so an infection will arise. >Teach family how to clean incision site daily and remind them to change dressings as needed. of contaminated materials.

> To educate the family about the right procedure to clean and change dressings.

>Note and report laboratory values.

>To provide a global view of the patients immune function and nutritional status.

>Administer/monitor >To determine

medication regimen and note patients response

effectiveness of therapy.

Patients Name: O.M Age: 33 y/old Gender: Male Medical Diagnosis: Epidural Right frontal area secondary to vehicular crash Nursing Diagnosis: Risk for infection related to tissue destruction Secondary to head injury Short Term Goal: Within 1 day of medical and nursing interventions, client will be able to manifest: Improve/Stable level of consciousness Improve/Stable GCS score No pupillary changes, seizures, widening of pulse pressure, irregular respirations, hypotension and bradycardia. Long Term Goal: Within 2 weeks of medical and nursing interventions, client will be able to improve level of consciousness. NURSING DIAGNOSI S WITH ETIOLOGY Ineffective Cerebral Tissue Perfusion related to the interruption of the blood flow to the brain. INTERVENTIO NS Independent: Assessment Assess mental status and changes in the level of consciou sness EVALUATION RATIONALE
STANDARD CRITERIA

CUES Subjective cues: None Objective cues: With pupillary size of 4 mm on right eye, 2 mm on left eye, both eyes with negative reaction to light Muscle grade of 1/5 for slight

SCIENTIFIC REASON

Therapeutic Position client in lowfowlers

To check for affected cranial nerve functions in the brain (for GCS); check for cerebral hypoperf usion and hypoxia. Help

GCS of 5 (best eye opening-1, none; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)

GCS of 5 (best eye opening-1, none; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)

Patient is placed in low-Fowlers position; made comfortable in bed and

Patient is placed in low-Fowlers position; made comfortable in bed and

muscle contraction on all extremities , no joint motion. With GCS of 6 (best eye openingopens to pain; verbal response-1 with ET attached to VR; motor response3, flexes arms and extension of legs to pain) Babinski reflexpositive, and oculoceph alic reflexnegative

position (30 degrees) Avoid extreme rotation of the neck

Avoid extreme hip flexion

Maintain

venous drainage from the brain and promote brain expansio n. This will compres s the jugular veins leading to an increase d intracrani al pressure. Increase in intraabdomin al and intrathoracic pressure leading to increase d intracrani al

adjusted pillows

adjusted pillows

Patient is Patient is monitored monitored frequently; frequently; positioned head positioned head and neck and neck cautiously and cautiously and placed a pillow placed a pillow on side for on side for support support Patient is Patient is repositioned repositioned cautiously and cautiously and provided with provided with pillows for pillows for support support

ET tube ET tube placement is placement is monitored if monitored if securely securely attached to attached to patient at the patient at the appropriate level appropriate level of 21 cm; of 21 cm; suctioned suctioned frequently for frequently for

patent airway

pressure. secretions Prevents build up of secretion s leading to increase in carbon dioxide and intracrani al pressure.

secretions

Dependent: Administ er medicatio ns such as diuretics (e.g. Mannitol) and anticonvu lsants (e.g. Amlodipi ne, Verapami l)

Mannitol 75 cc was given intravenously to patient; antihypertensive s such Amlodipine 20 mg per tablet and Verapamil 10 mg per tablet was also given to patient

Mannitol 75 cc was given intravenously to patient; antihypertensive s such Amlodipine 20 mg per tablet and Verapamil 10 mg per tablet was also given to patient

Collaborative: Review pulse oximetry

Diuretics are used and needed to decrease cerebral edema and anticonv ulsant medicati ons

Oxygen saturation patient ranges 98-99%

Oxygen saturation patient ranges 98-99%

With IV fluid of PNSS 1L x 63 cc per hour, patent and infusing well at left metacarpal vein of patient,

With IV fluid of PNSS 1L x 63 cc per hour, patent and infusing well at left metacarpal vein of patient,

with a rate of 21 with a rate of 21 drops per minute drops per minute Restore or maintain fluid balance Hypoxia is associate d with reduced cerebral tissue perfusion . It maximize s cardiac output and prevents decrease d cerebral perfusion associate d with hypovole mia.

Patients Name: O.M Age: 33 y/old Gender: Male Medical Diagnosis: Epidural Right frontal area secondary to vehicular crash Nursing Diagnosis: Risk for infection related to tissue destruction Secondary to head injury Short Term Goal: Within 1 day of medical and nursing interventions, client will be able to manifest: Clear breath sounds Decreased secretions Long Term Goal: Within 1 week of medical and nursing intervention, client will be able to mobilize secretions.

NURSING DIAGNOSIS CUES: WITH ETIOLOGY Subjective cues: Ineffective airway None clearance maybe with ET tube related to attached on hypoventilatio mechanical n secondary ventilator to brain stem injury Objective cues: Hooked to ventelate with settings Fi02100% IV-500 ml RR-20

SCIENTIFIC REASON

INTERVENTIONS

EVALUATION RATIONALE

Independent Assessment Assess respiration and breath sounds, noting rate and sounds (e.g. tachypnea, stridor, crackles, wheezes) Evaluate cough/gag reflex and swallowing ability

Respirations range between 16-21 breaths per minute, regular in rate and rhythm; adventitious breath sounds heard over left anterior lung, including ronchi To determine and wheezing ability to sounds protect own Patient exhibits airway swallowing and gag reflexes; with absent cough reflex These signs and symptoms are indicative of respiratory distress and/or accumulation of secretions.

Respirations range between 16-21 breaths per minute, regular in rate and rhythm; adventitious breath sounds heard over left anterior lung, including ronchi and wheezing sounds Patient exhibits swallowing and gag reflexes; with absent cough reflex

cpm AC mode

Assess airway for patency

Decrease d level of conscious ness (GCS of 6: best eye openingopens to pain; verbal response1 with ET attached to VR; motor response3, flexes arms and extension of legs to pain)

Maintaining the airway is always first priority, especially in cases of trauma.

Assess changes in mental status

Placement of ET tube on patient is monitored frequently at the appropriate level of 21 cm; suctioned frequently for presence of Lethargy and secretions. somnolence Patient is GCS are late signs 5 (no eye opening-1, with ET tube attached-1, and flexes arms and extends legs to painful stimuli-3)

Placement of ET tube on patient is monitored frequently at the appropriate level of 21 cm; suctioned frequently for presence of secretions. Patient is GCS 5 (no eye opening1, with ET tube attached-1, and flexes arms and extends legs to painful stimuli-3)

Note presence of sputum, assess quality,

Abnormalities maybe a result of infection. A sign of infection is

with whitish, tenacious secretions noted upon suctioning of

with whitish, tenacious secretions noted upon suctioning of the mouth and

color, amount, odor and consistency . Therapeutic Elevate head of bed and reposition every 2 hours and as needed.

discolored sputum. To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segments.

Routinely check the patients position so he does not slide down in bed.

Use humidifier.

the mouth and ET tube, ET tube, approximately 20 approximately cc 20 cc Patient was Patient was repositioned repositioned every two hours, every two made hours, made comfortable in comfortable in bed while bed while adjusting pillows; adjusting provided with pillows; chest provided with physiotherapy chest upon change of physiotherapy position This prevents upon change of abdominal contents from position pushing upward and inhibiting lung Patient is expansion. monitored Patient is frequently; with slight elevation of This loosens monitored secretions and frequently; with the foot part to sliding facilitates the slight elevation prevent of the foot part down the bed. removal. to prevent sliding down Helps clear the bed. Patients VR setsecretions. up cmes with a humidifier;

Institute suctioning of the airway.

Patients VR set-up cmes with a humidifier; monitored frequently from getting used up Patient suctioned frequently of presence secretions

monitored frequently from getting used up is for of

Patient suctioned frequently presence is secretions

Dependent Administer medication s (e.g. antibioticsLevofloxaci n, Vigocid; mucolytic agents, bronchodila torsSalbutamol ) as ordered, noting effectivene ss and side effects. Collaborative Check and monitor VR set-up and

These for promote of clearance airway secretions and bronchodilatio n decreases airway Patient was resistance. given ILN Salbutamol 1 nebule via face mask; with respiratory rate of 17-21 breaths per minute, regular, The basis for non-labored; setting every with no side parameter of effects such as the ventilator hypotension or depends on bradycardia. the patient. Maintaining

Patient was given ILN Salbutamol 1 nebule via face mask; with respiratory rate of 17-21 breaths per minute, regular, non-labored; with no side effects such as hypotension or bradycardia.

With ET tube at 21 cm attached to patient connected to a functional

patients response.

the correct settings for every parameter ensures the proper ventilation to the patient.

With ET tube at 21 cm attached to patient connected to a functional ventilator; with VR set-up of: tidal volume450 ml, peak flow-50, back up rate-16 breaths per minute, FIO230%, and assist-control mode; weaned to T-piece at 40% and 8 liters of oxygen

ventilator; with VR set-up of: tidal volume-450 ml, peak flow-50, back up rate-16 breaths per minute, FIO230%, and assistcontrol mode; weaned to Tpiece at 40% and 8 liters of oxygen

Patients Name: O.M Age: 33 y/old Gender: Male Medical Diagnosis: Epidural Right frontal area secondary to vehicular crash Nursing Diagnosis: Risk for infection related to tissue destruction Secondary to head injury Short Term Goal: Within 1 day of medical and nursing interventions, client will be able to manifest: Clear breath sounds Decreased secretions Long Term Goal: Within 1 week of medical and nursing intervention, client will be able to mobilize secretions.

Subjective/Objectiv e cues:

Objective cues: GCS 5 best motor response is in decorticate position graded as 3 Unable to perform active range of motion exercises on all extremities Grade 1/5 in the muscle

Nursing Diagnosis with Etiology Impaired physical mobility related to limitation in independent purposeful physical movement of the body secondary to motor never compressio n on frontal

Goals of Care General/Specific

Interventions

Rationale

Evaluation

General: Independent: Within 2 weeks of Assessment: medical and Assess for nursing developing interventions, client thrombophle will be able to bitis (calf maintain or pain, increase strength Homans of the body and sign, extremities. redness, localized Specific: swelling, and Within 1 week of hyperthermia medical and ) nursing

or Patient displays no clot signs of calf pain, redness and swelling on lower extremities, or hyperthermia . Regular examination of the skin Bed rest immobility promotes formation

grading scale lobe (slight muscle contraction on all extremities, no joint motion) Hand grasp of 0/3-none on both hands

interventions, client will be able to: Improve muscle strength on all extremities Perform passive exercises on all extremities

Assess skin integrity

especially on bony prominences will allow for prevention or early recognition and treatment of pressure sores.

Therapeutic Keep side rails up and bed in low position

Skin is dry, wrinkled, and rebounds instantly; with no signs of pressure or This promotes a sores safe environment redness over bony prominences . Turning position optimizes circulation to all tissues and relieves Patient is pressure. frequently monitored; secured raised side Maintaining proper alignment rails at all pf extremities times; placed in low or prevents semicontractures. Fowlers position Exercise Patient is promotes

Turn patient every two hours

Maintain limbs in functional alignment

increased venous return, prevents stiffness, and maintains muscle strength. This prevents tissue breakdown

repositioned every 2 hours, massaged bony prominences , and placed pillows or rolled cloth for limbs and body support. Patient was provided with pillows and properly rolled cloth to maintain alignment and support on all limbs. Passive range of motion exercises was provided to patient on all extremities with proper support and

Perform passive ROM exercises on all extremities

Antispasmodic medications may reduce muscle spasms that interfere with mobility.

Use pressurerelieving devices as indicated

Dependent: Administer

Prolonged bed rest, lack of exercise, and physical inactivity contribute to constipation. A variety of

medications as ordered such as antispasmodi c drugs (e.g. Vitamin B complex)

Collaborative: Set-up a bowel program (e.g. adequate fluid, foods high in bulk, physical activity, stool softeners, laxatives) as needed. Record bowel activity level.

interventions will execution. promote normal eliminations. Placement of pillows or rolled cloth to prevent pressure of skin contact to surface; gentle massage on bony prominences was provided Vitamin B complex (Polynerv) 500 mg was given to patient

IV fluid of PNSS 1L x 63 cc per hour, patent

and infusing well at left metacarpal vein of patient, adjusted at a rate of 21 drops per minute; nutrition given through osteorized tube feeding of 1, 800 kcal in 6 equal feedings plus 6 egg whites; patient was also ordered with Lactulose 30 cc; no bowel movement noted since last week

Subjective/Objectiv e cues:

Objective cues: presence of surgical wound stitched across the right part of the head about 12 inches, vertical; with dry, intact 2 x 3 inches dressing on right parietal part of head increased WBC (laboratory result of 28.4x10g/L) Presence of an indwelling foley catheter

Nursing Diagnosis with Etiology Risk for infection related to tissue destruction susceptible for invasion of pathogens.

Goals of Care General/Specific

Interventions

Rationale

Evaluation

General: Independent: Within 2 weeks of Assessment: medical and Observe for nursing localized interventions, client signs of will be able to infection at prevent/reduce risk surgical for infection. incision wound. Specific: Note signs Within 1 week of and medical and symptoms of nursing sepsis; fever, interventions, client chills, will be able to diaphoresis. manifest: Therapeutic: Absence of Change serosanguin surgical/wou ous nd dressings, drainage as indicated, from the using aseptic surgical site. technique for changing/ disposing of Decrease or contaminated normal materials. WBC value. Health Teachings: Teach family how to clean

of To check for any Signs signs of infection infection were not noted; no visible signs To check for the of redness or presence of pus around infection and surgical site. give necessary With normal interventions. temperature To facilitate ranges from wound healing 35.6 C to 37. and prevent 1 C taken at axilla; infection by left chills and minimizing diaphoresis growth and spread of not noted microorganisms. Staff nurse on duty To educate the performed family about the changing of right procedure surgical to clean and dressing, as indicated. change dressings.

incision site daily and remind them to change dressings as needed. Dependent: Administer or monitor medication regimen (e.g. antibiioticsLevofloxacin 750 mg, Vigocid 2.25 gm) and note patients response. Collaborative: Note and report laboratory values

To determine effectiveness of therapy. Significant other was instructed to follow correct hand washing and aseptic technique whenever in contact with a surgical wound. Medications as directed follows the treatment duration for a certain number of days; completed the treatment regimen; temperature is within normal level of 35.6 C

To provide a global view of the patients immune function and nutritional status.

37 C;

Latest lab values for WBC was not checked by student nurses

Patients Name: O.M Age: 33 y/old Gender: Male Medical Diagnosis: Epidural Right frontal area secondary to vehicular crash Nursing Diagnosis: Risk for infection related to tissue destruction Secondary to head injury Short Term Goal: Within 1 day of medical and nursing interventions, client will be able to manifest: Clear breath sounds Decreased secretions Long Term Goal: Within 1 week of medical and nursing intervention, client will be able to mobilize secretions

Subjective/Objective cues:

Nursing Diagnosis with Etiology

Goals of Care General/Specific

Interventions

Rationale

Evaluation

Objective cues: Unable to pass stool since last week; with diet of osteorized tube feeding of 1, 800 kcal in 6 equal feeding plus 6 egg whites Inactivity, GCS 5 best motor response is in decorticate position graded as 3 muscle grade of 1/5 (muscle contraction on all extremities but no joint motion

Constipation related to inhibited defecation reflex secondary to compression of the pudendal nerve on the medial prefrontal lobe of the brain

General: Within 3 weeks of medical and nursing interventions, client will be able to pass out soft, formed stool Specific: Within 1 day of medical and nursing interventions, client will be able to: maintain normal bowel sounds within the range of 532 gurgling or clicking sounds perform passive ROM exercises on all

Independent Assessment assess usual pattern of elimination; compare with present pattern, include size, frequency, color, and quality normal frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is normal for each individual chronic use of laxatives causes the muscles and nerves of the colon to function inadequately in producing an urge to defecate. Over time, the colon becomes atonic and distended. Prolonged

evaluate laxative use, type, and frequency

assess activity level

extremities

evaluate current medication usage that may contribute to constipation

Therapeutic provide fluid intake of 2000 to 3000 mL/day, if not contraindicat ed medically

bed rest, lack of exercise, and inactivity causes constipation Drugs that can cause constipation include the following: narcotics, antacids, antidepressan ts, anticholinergic s, antihypertensi ve, general anesthetics, hypnotics, and iron and calcium supplements Patients, especially older patients, may have cardiovascular limitations that require that less fluid be taken

provide passive ROM exercises on all extremities

Health Teachings reinforce to caregiver the importance of the following: a balanced diet consisting of adequate fiber, fresh fruits, vegetables and grains

Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitates defecation These steps lead to reestablishing regular bowel habits Twenty grams of fiber per day is recommended

adequate fluid intake (2000-3000 mL/day)

Increased hydration promotes softer fecal mass Exercise strengthen

regular exercise and activity

abdominal muscles and stimulate peristalsis Successful bowel training relies on routine

regular meals

This laxative is characterized by a shorter colon transit time and accelerated bowel movement.

Dependent

administer drugs such as Lactulose, as ordered

Collaborative

This increase fluid, gaseous, and solid bulk of intestinal contents Softens stool

Health teachings teach use of medications as ordered, as in the following: bulk fiber (Metamucil)

stool softeners (Colace)

and lubricates intestinal mucosa These irritate the bowel mucosa and cause rapid propulsion of contents and small intestine Softens stool and stimulates rectal mucosa Softens stool

chemical irritants (castor oil, cascara, milk of magnesia)

suppositories oil retention

enema

Nursing Goals of Care Diagnosis with General/Specific Etiology Objective cues: Risk for Aspiration General: related to GCS of 6 (best decreased level of Within 1 week of

Subjective/Objective cues:

Interventions

Rationale

Evaluation

eye openingopens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain) Absent cough reflex Presence of endotracheal, and nasogastric tubes attached to patient

consciousness medical and nursing secondary to intervention, cerebral patients risk will hypoperfusion decrease as a result of ongoing assessment and early interventions Specific: Within 1 day of medical and nursing interventions, patient will be able to: Maintain a patent airway

Patients Name: O.M

Age: 33 y/old

Gender: Male

Medical Diagnosis: Epidural Right frontal area secondary to vehicular crash Nursing Diagnosis: Risk for infection related to tissue destruction Secondary to head injury Short Term Goal: Within 1 day of medical and nursing interventions, client will be able to manifest: Clear breath sounds Decreased secretions Long Term Goal: Within 1 week of medical and nursing intervention, client will be able to mobilize secretions.

Subjective/Objective cues: Objective cues: GCS of 6 (best eye openingopens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain) Grade 1/5 in the muscle grading scale (slight muscle contraction on all extremities, no joint motion)

Nursing Diagnosis with Etiology Self-Care Deficit related to decreased level of consciousness secondary to cerebral hypoperfusion and compression of the motor nerve on the frontal lobe

Goals of Care General/Specific General: Within 3 weeks of medical and nursing interventions, patient will be able to safely perform (to maximum ability) self-care activities Specific: Within 1 day of medical and nursing interventions, patient will be able to: Exhibit good hygiene and

Interventions

Rationale

Evaluation

grooming Hand grasp of 0/3-none on both hands