Ncp Epidural Hem

Patient’s Name: O.M Age: 33 y/old Gender: MaleMedical Diagnosis: Epidural Right frontal area secondary to vehicular crashNursing Diagnosis: Impaired skin integrity related to surgeryAEB destruction of skin layers and surface and invasion of body structures secondary to head injuryShort 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.

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

NURSING

INTERVENTIONSRATIONALE

EVALUATION

STANDARD CRITERIA

S > ø

O > The

patient

manifests:

-immobility

-destruction in

skin integrity

-redness on

the area

-trauma

-pain

-surgical

incision/wound

>The patient

Impaired

skin integrity

related to

surgery

AEB destruction of skin layers and surface and invasion of body structures secondary to head injury

The procedure

is invasive in

nature since it

will require an

incision and the

use of

mechanical

implants. There

is destruction

on the skin

layers of the

affected part.

>Inspect skin

every shift,

describe and

document skin

condition, and

report changes.

>Assist with

general hygiene

and comfort

measures.

>Maintain proper

environmental

> To provide

evidence of

the

effectiveness

of the skin

care regimen.

>To promote

comfort and

sense of well-

being.

>To promote

patient’s sense

of well-being.

Short term:

After 2 days of

NI, the patient

shall have

achieved timely

wound healing.

Long term:

After 7 days of

NI, the patient

shall have

exhibited

improved skin

lesions or

Short term:

After 2 days of NI,

the patient shall

have achieved timely

wound healing.

Long term:

After 7 days of NI,

the patient shall

have exhibited

improved skin

lesions or wounds.

may manifest:

-edema

-swelling

-itching

conditions.

>Use a foam

mattress, bed

cradle, or other

devices.

>Warn against

tampering with

the wound or

dressings.

>Position patient

for comfort and

minimal pressure

on bony

prominences and

change his

position at least

every 2 hours.

>To minimize

skin

breakdown.

>To reduce

potential for

infection.

>To reduce

pressure,

promote

circulation and

minimize skin

breakdown.

>To

encourage

compliance.

wounds.

>Instruct family

members in a

skin care

regimen.

>Perform

prescribed

treatment

regimen for the

skin condition

involved; monitor

progress.

>Administer pain

medication and

monitor its

effectiveness.

>To maintain

or modify

current

therapy.

>To relieve the

patient of pain.

Patient’s Name: O.M Age: 33 y/old Gender: MaleMedical Diagnosis: Epidural Right frontal area secondary to vehicular crashNursing Diagnosis: Risk for infection related to tissue destruction Secondary to head injuryShort 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

DIAGNOSIS

SCIENTIFIC

EXPLANATION

NURSING

INTERVENTIONS

RATIONALE EVALUATION

STANDARD CRITERIA

S> ø

O>The patient

manifests:

-presence of

surgical

incision/wound

>The patient

may manifest:

The pt.

manifest:

-hyperthermia

-chills

-diaphoresis

-increase WBC

Risk for

infection

related to

tissue

destruction

Secondary

to head

injury

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

>Observe for

localized signs of

infection at

sutures or surgical

incision wound.

>Note signs and

symptoms of

sepsis; fever,

chills, diaphoresis.

>Change

surgical/wound

dressings, as

>To check for

any

signs of

infection.

>To check for

the presence of

infection and

give

necessary

interventions.

>To facilitate

wound healing

and prevent

Short term:

After 2 days of

NI, the patient

shall have

identified

interventions to

prevent/reduce

risk of infection.

Long term:

After 5 days of

NI, the patient

shall have

manifested

Short term:

After 2 days of NI,

the patient shall

have identified

interventions to

prevent/reduce risk

of infection.

Long term:

After 5 days of NI,

the patient shall

have manifested

absence of

-pain and

swelling on the

surgical site

-alteration in

VS

-seizures

cared of like

proper cleaning

and changing of

dressings, there

can be growth

and spread of

infectious

microorganisms

and so an

infection will

arise.

indicated, using

proper technique

for

changing/disposing

of contaminated

materials.

>Teach family how

to

clean incision

site daily and

remind them to

change dressings

as needed.

>Note and report

laboratory values.

>Administer/

infection by

minimizing

growth

and spread of

microorganisms.

> To educate

the family about

the right

procedure to

clean and

change

dressings.

>To provide a

global view of

the patient’s

immune function

and nutritional

status.

>To determine

absence of

infection.

infection.

monitor medication

regimen and note

patient’s response

effectiveness of

therapy.

Patient’s Name: O.M Age: 33 y/old Gender: MaleMedical Diagnosis: Epidural Right frontal area secondary to vehicular crashNursing Diagnosis: Risk for infection related to tissue destruction Secondary to head injuryShort 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.

CUES

NURSING DIAGNOSI

S WITH ETIOLOGY

SCIENTIFIC REASON

INTERVENTIONS RATIONALE

EVALUATION

STANDARD CRITERIA

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

Ineffective Cerebral Tissue Perfusion related to the interruption of the blood flow to the brain.

Independent:Assessment

Assess mental status and changes in the level of consciousness

Therapeutic Position

client in low-fowler’s

To check for affected cranial nerve functions in the brain (for GCS); check for cerebral hypoperfusion 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)

Patient is placed in low-Fowler’s position; made comfortable in bed and

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-Fowler’s position; made comfortable in bed and

muscle contraction on all extremities, no joint motion.

With GCS of 6 (best eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)

Babinski reflex- positive, and oculocephalic reflex-negative

position (30 degrees)

Avoid extreme rotation of the neck

Avoid extreme hip flexion

Maintain

venous drainage from the brain and promote brain expansion.

This will compress the jugular veins leading to an increased intracranial pressure.

Increase in intra-abdominal and intra-thoracic pressure leading to increased intracranial

adjusted pillows

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

Patient is repositioned cautiously and provided with pillows for support

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

adjusted pillows

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

Patient is repositioned cautiously and provided with pillows for support

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

patent airway

Dependent:

Administer medications such as diuretics (e.g. Mannitol) and anticonvulsants (e.g. Amlodipine, Verapamil)

Collaborative:

Review pulse oximetry

pressure.

Prevents build up of secretions leading to increase in carbon dioxide and intracranial pressure.

Diuretics are used and needed to decrease cerebral edema and anticonvulsant medications

secretions

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

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,

secretions

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

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,

Restore or maintain fluid balance

Hypoxia is associated with reduced cerebral tissue perfusion.

It maximizes cardiac output and prevents decreased cerebral perfusion associated with hypovolemia.

with a rate of 21 drops per minute

with a rate of 21 drops per minute


Clear breath sounds Decreased secretions

Long Term Goal: Within 1 week of medical and nursing intervention, client will be able to mobilize secretions.

CUES:

NURSING DIAGNOSIS

WITH ETIOLOGY

SCIENTIFIC REASON

INTERVENTIONSRATIONALE

EVALUATION

Subjective cues:

None

with ET tube attached on mechanical ventilator

Objective cues:

Hooked to ventelate with settings Fi02-

100% IV-500

ml RR-20

Ineffective airway clearance maybe related to hypoventilation secondary to brain stem injury

IndependentAssessment

Assess respiration and breath sounds, noting rate and sounds (e.g. tachypnea, stridor, crackles, wheezes)

Evaluate cough/gag reflex and swallowing ability

These signs and symptoms are indicative of respiratory distress and/or accumulation of secretions.

To determine ability to protect own airway

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 soundsPatient exhibits swallowing and gag reflexes; with absent cough reflex

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 soundsPatient exhibits swallowing and gag reflexes; with absent cough reflex

cpm AC

mode

Decreased level of consciousness (GCS of 6: best eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)

Assess airway for patency

Assess changes in mental status

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

Lethargy and somnolence are late signs

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 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 opening-1, 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.

Routinely check the patient’s position so he does not slide down in bed.

Use humidifier.

discolored sputum.

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

This prevents abdominal contents from pushing upward and inhibiting lung expansion.

This loosens secretions and facilitates the removal.

Helps clear secretions.

the mouth and ET tube, approximately 20 cc

Patient was repositioned every two hours, made comfortable in bed while adjusting pillows; provided with chest physiotherapy upon change of position

Patient is monitored frequently; with slight elevation of the foot part to prevent sliding down the bed.

ET tube, approximately 20 cc

Patient was repositioned every two hours, made comfortable in bed while adjusting pillows; provided with chest physiotherapy upon change of position

Patient is monitored frequently; with slight elevation of the foot part to prevent sliding down the bed.

Patients VR set-up cmes with a humidifier;

Institute suctioning of the airway.

Dependent Administer

medications (e.g. antibiotics-Levofloxacin, Vigocid; mucolytic agents, bronchodilators-Salbutamol) as ordered, noting effectiveness and side effects.

Collaborative Check and

monitor VR set-up and

These promote clearance of airway secretions and bronchodilation decreases airway resistance.

The basis for setting every parameter of the ventilator depends on the patient. Maintaining the correct settings for

Patients VR set-up cmes with a humidifier; monitored frequently from getting used up

Patient is suctioned frequently for presence of secretions

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.

monitored frequently from getting used up

Patient is suctioned frequently for presence of secretions

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

patient’s response.

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 volume-450 ml, peak flow-50, back up rate-16 breaths per minute, FIO2-30%, 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, FIO2-30%, and assist-control mode; weaned to T-piece at 40% and 8 liters of oxygen




Subjective/Objective cues:

Nursing Diagnosis

with Etiology

Goals of CareGeneral/Specific

Interventions Rationale Evaluation

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

Impaired physical mobility related to limitation in independent purposeful physical movement of the body secondary to motor never compression on frontal

General: Within 2 weeks of medical and nursing interventions, client will be able to maintain or increase strength of the body and extremities.

Specific:Within 1 week of medical and nursing

Independent:Assessment:

Assess for developing thrombophlebitis (calf pain, Homan’s sign, redness, localized swelling, and hyperthermia)

Bed rest or immobility promotes clot formation

Regular examination of the skin

Patient displays no signs of calf pain, redness and swelling on lower extremities, or hyperthermia.

grading scale (slight muscle contraction on all extremities, no joint motion)

Hand grasp of 0/3-none on both hands

lobe interventions, client will be able to:

Improve muscle strength on all extremities

Perform passive exercises on all extremities

Assess skin integrity

Therapeutic Keep side

rails up and bed in low position

Turn patient every two hours

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

This promotes a safe environment

Turning position optimizes circulation to all tissues and relieves pressure.

Maintaining proper alignment pf extremities prevents contractures.

Exercise promotes

Skin is dry, wrinkled, and rebounds instantly; with no signs of pressure sores or redness over bony prominences.

Patient is frequently monitored; secured raised side rails at all times; placed in low or semi-Fowler’s position

Patient is

Maintain limbs in functional alignment

Perform passive ROM exercises on all extremities

Use pressure-relieving devices as indicated

Dependent: Administer

medications

increased venous return, prevents stiffness, and maintains muscle strength.

This prevents tissue breakdown

Antispasmodic medications may reduce muscle spasms that interfere with mobility.

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

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

as ordered such as antispasmodic 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 promote normal eliminations.

execution.

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


Nursing Diagnosis

with Etiology



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

Risk for infection related to tissue destruction susceptible for invasion of pathogens.

General: Within 2 weeks of medical and nursing interventions, client will be able to prevent/reduce risk for infection.

Specific:Within 1 week of medical and nursing interventions, client will be able to manifest:

Absence of serosanguinous drainage from the surgical site.

Decrease or normal WBC value.

Independent:Assessment:

Observe for localized signs of infection at surgical incision wound.

Note signs and symptoms of sepsis; fever, chills, diaphoresis.

Therapeutic: Change

surgical/wound dressings, as indicated, using aseptic technique for changing/ disposing of contaminated materials.

Health Teachings: Teach family

how to clean

To check for any signs of infection

To check for the presence of infection and give necessary interventions.

To facilitate wound healing and prevent infection by minimizing growth and spread of microorganisms.

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

Signs of infection were not noted; no visible signs of redness or pus around surgical site.

With normal temperature ranges from 35.6 C to 37. 1 C taken at left axilla; chills and diaphoresis not noted

Staff nurse on duty performed changing of surgical dressing, as indicated.

incision site daily and remind them to change dressings as needed.

Dependent: Administer or

monitor medication regimen (e.g. antibiiotics-Levofloxacin 750 mg, Vigocid 2.25 gm) and note patient’s response.

Collaborative: Note and

report laboratory values

To determine effectiveness of therapy.

To provide a global view of the patient’s immune function and nutritional status.

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 –

37 C;

Latest lab values for WBC was not checked by student nurses



Long Term Goal: Within 1 week of medical and nursing intervention, client will be able to mobilize secretionsSubjective/Objective

cues:Nursing

Diagnosis with Etiology



Objective cues:

Unable to pass stool since last week; with diet of osteorized tube feeding of

Constipation related to inhibited defecation reflex secondary to compression

General:

Within 3 weeks of medical and nursing interventions, client will be able

IndependentAssessment

assess usual pattern of elimination; compare with

normal frequency of passing stool varies from

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

of the pudendal nerve on the medial prefrontal lobe of the brain

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 5-32 gurgling or clicking sounds

perform passive ROM exercises on all extremities

present pattern, include size, frequency, color, and quality

evaluate laxative use, type, and frequency

assess activity level

evaluate current medication usage that may contribute to constipation

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 bed rest, lack of exercise, and inactivity causes constipation

Drugs that can cause

Therapeutic provide fluid

intake of 2000 to 3000 mL/day, if not contraindicated medically

provide passive ROM exercises on all extremities

constipation include the following: narcotics, antacids, antidepressants, anticholinergics, antihypertensive, general anesthetics, hypnotics, and iron and calcium supplements

Patients, especially older patients, may have cardiovascular limitations that require that less fluid be taken

Ambulation and/or abdominal exercises strengthen abdominal muscles that

Health Teachings

reinforce to caregiver the importance of the following:

a balanced diet consisting of adequate fiber, fresh fruits, vegetables and grains

adequate fluid intake (2000-3000 mL/day)

regular exercise and activity

facilitates defecation

These steps lead to reestablishing regular bowel habits

Twenty grams of fiber per day is recommended

Increased hydration promotes softer fecal mass

Exercise strengthen abdominal muscles and stimulate peristalsis

Successful bowel training relies on routine

regular meals

Dependent

administer drugs such as Lactulose, as ordered

Collaborative

Health teachings teach use of

medications as ordered, as in the following:bulk fiber (Metamucil)

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

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

Softens stool and lubricates intestinal mucosa

These irritate the bowel mucosa and cause rapid propulsion of

stool softeners (Colace)

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

suppositories oil retention enema

contents and small intestine

Softens stool and stimulates rectal mucosa

Softens stool


Nursing Diagnosis with

Etiology



Objective cues:

GCS of 6 (best eye opening-opens 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

Risk for Aspiration related to decreased level of consciousness secondary to cerebral hypoperfusion

General:

Within 1 week of medical and nursing intervention, patient’s risk will 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





Nursing Diagnosis with

Etiology



Objective cues: GCS of 6 (best

eye opening-opens to pain; verbal response-1 with ET attached to VR; motor

Self-Care Deficit related to decreased level of consciousness secondary to cerebral hypoperfusion and compression of the motor

General:

Within 3 weeks of medical and nursing interventions, patient will be able to safely perform (to maximum ability)

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)

Hand grasp of 0/3-none on both hands

nerve on the frontal lobe

self-care activities

Specific:

Within 1 day of medical and nursing interventions, patient will be able to:

Exhibit good hygiene and grooming

Ncp Epidural Hem

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