Supportive Measures
- Respiratory support; intubation and mechanical ventilation
- Seizure precautions and prevention
- NG to manage reduced gastric motility and prevent aspiration
- Fluid and electrolyte maintenance
- Pain and anxiety management
- Nutrition
Nursing Process: The Care of the Patient with Brain Injury
Assessment
- Health history with focus upon the immediate injury, time, cause, and the direction
and force of the blow
- Baseline assessment
- LOC—Glasgow Coma Scale
- Frequent and ongoing neurologic assessment
- Multisystem assessment
Nursing Process: Diagnoses
- Ineffective airway clearance and impaired gas exchange
- Ineffective cerebral perfusion
- Deficient fluid volume
- Imbalanced nutrition
- Risk for injury
- Risk for imbalanced body temperature
- Risk for impaired skin integrity
- Disturbed thought patterns
- Disturbed sleep pattern
- Interrupted family process
- Deficient knowledge