Medical Surgical Nursing

Because the unconscious patient's protective reflexes are impaired, the quality of nursing care provided literally may mean the ...

Maintaining Fluid Balance and Managing Nutritional Needs Hydration status is assessed by examining tissue turgor and mucous memb ...

Maintaining Body Temperature High fever in the unconscious patient may be caused by infection of the respiratory or urinary trac ...

Promoting Bowel Function The abdomen is assessed for distention by listening for bowel sounds and measuring the girth of the abd ...

placement (Bond, Draeger, Mandleco, et al., 2003). Families may benefit from participation in support groups offered through the ...

 Achieves healthy oral mucous membranes  Maintains normal skin integrity  Has no corneal irritation  Attains or maintains th ...

 Brain stem herniation  Diabetes insipidus  SIADH Planning and Goals The goals for the patient include maintenance of a paten ...

The Valsalva maneuver, which can be produced by straining at defecation or even moving in bed, raises ICP and is to be avoided. ...

Aseptic technique must be used when managing the system and changing the ventricular drainage bag. The drainage system is also c ...

 Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching dea ...

o Follows verbal commands; answers questions correctly  Attains desired fluid balance o Maintains fluid restriction o Demonstra ...

Other nursing diagnoses may include impaired communication (aphasia) related to insult to brain tissue and high risk for impaire ...

o Maintain patient on controlled ventilation if prescribed to maintain normal ventilatory status; monitor arterial blood gas res ...

o Assess patient's level of responsiveness/consciousness; decreased level of consciousness may be the first sign of increased IC ...

o Administer prescribed antiseizure agents; monitor antiseizure medication blood levels. o Observe for status epilepticus, which ...

o No evidence of inflammation or infection at surgical site o Absence of seizures o No evidence of DVT or GI bleeding Nursing Pr ...

Reducing Fear of Seizures Fear that a seizure may occur unexpectedly can be reduced by the patient's adherence to the prescribed ...

wear a medical information bracelet. The patient and family need to be educated about medications as well as care during a seizu ...

 Sustains no injury during seizure activity o Complies with treatment regimen and identifies the hazards of stopping the medica ...

Chapter 62 Management of Patients with Cerebrovascular Disorders Cerebrovascular Disorders Functional abnormality of the CNS th ...