Medical Surgical Nursing

Develops over weeks to months Causative injury may be minor and forgotten Clinical signs and symptoms may fluctuate Treatment i ...

Supportive Measures Respiratory support; intubation and mechanical ventilation Seizure precautions and prevention NG to manage ...

Collaborative Problems/Potential Complications Decreased cerebral perfusion Cerebral edema and herniation Impaired oxygenation ...

I&O and daily weights Monitor blood and urine electrolytes and osmolality and blood glucose Measures to promote adequate nu ...

Patient and family teaching Spinal Cord Injury (SCI) Definition: Fracture or displacement of one or more vertebrae causing da ...

and bowel control (usually with urinary retention and bladder distention), loss of sweating and vasomotor tone, & marked red ...

Nursing Process: The Care of the Patient with SCI Assessment Monitor respirations and breathing pattern Lung sounds and cough M ...

Lung sounds Early and vigorous pulmonary care to prevent and remove secretions Suctioning with caution Breathing exercises Assi ...

Nursing Process The Patient with a Traumatic Brain Injury Assessment Depending on the patient's neurologic status, the nurse may ...

 Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness  Disturbed thought ...

Vital Signs Although a change in LOC is the most sensitive neurologic indication of deterioration of the patient's condition, vi ...

maintaining optimal oxygenation to preserve cerebral function. An obstructed airway causes carbon dioxide retention and hypovent ...

Preventing Injury Often, as the patient emerges from coma, a period of lethargy and stupor is followed by a period of agitation. ...

circulation and leads to tissue necrosis. Potential areas of breakdown need to be identified early to avoid the development of p ...

difficulties in coping with changes in the patient's temperament, behavior, and personality. Such changes are associated with di ...

hours after injury. Bleeding also may increase the volume of contents within the rigid, closed compartment of the skull, causing ...

Promoting Home and Community-Based Care Teaching Patients Self-Care Teaching early in the course of head injury often focuses on ...

 Avoids injury o Shows lessening agitation and restlessness o Is oriented to time, place, and person  Maintains normal body te ...

 Motor ability is tested by asking the patient to spread the fingers, squeeze the examiner's hand, and move the toes or turn th ...

arterial blood gas values. Early and vigorous attention to clearing bronchial and pharyngeal secretions can prevent retention of ...