Collaborative Problems/Potential Complications
- Decreased cerebral perfusion
- Cerebral edema and herniation
- Impaired oxygenation and ventilation
- Impaired fluid, electrolyte, and nutritional balance
- Risk of posttraumatic seizures
Nursing Process: Planning
— Major goals may include
— Maintenance of patent airway,
— Adequate cerebral perfusion pressure (CPP),
— Fluid and electrolyte balance,
— Adequate nutritional status,
— Prevention of secondary injury,
— Maintenance of normal temperature,
— Maintenance of skin integrity,
— Improvement of cognitive function,
— Prevention of sleep deprivation,
— Effective family coping,
— Increased knowledge about rehabilitation process, and
Nursing Process: Interventions
- Ongoing assessment and monitoring is vital
- Maintenance of airway
- Positioning to facilitate drainage of oral secretions with HOB usually elevated
30° to decrease venous pressure - Suctioning with caution
- Prevention of aspiration and respiratory insufficiency
- Monitor ABGs, ventilation, and mechanical ventilation
- Monitor for pulmonary complications, potential
- Positioning to facilitate drainage of oral secretions with HOB usually elevated