ncp epidural hem
DESCRIPTION
,mn,mnTRANSCRIPT
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
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:
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
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:
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 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
Subjective/Objective cues:
Nursing Diagnosis
with Etiology
Goals of CareGeneral/Specific
Interventions Rationale Evaluation
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
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:
Clear breath sounds Decreased secretions
Long Term Goal: Within 1 week of medical and nursing intervention, client will be able to mobilize secretionsSubjective/Objective
cues:Nursing
Diagnosis with Etiology
Goals of CareGeneral/Specific
Interventions Rationale Evaluation
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
Subjective/Objective cues:
Nursing Diagnosis with
Etiology
Goals of CareGeneral/Specific
Interventions Rationale Evaluation
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
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:
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 CareGeneral/Specific
Interventions Rationale Evaluation
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