Medical-surgical Nursing Demystified

CHAPTER 5 Nervous System^229

• furosemide


• mannitol

NURSING DIAGNOSES

• Impaired physical mobility


• Disturbed thought processes

NURSING INTERVENTION

• Range of motion exercises—active or passive.


• Turn and position patient.


• Monitor neurologic status for changes—typically use Glasgow Coma Scale
  or similar tool to grade response to stimuli (highest score 15)
  
  
  • Eye-opening response spontaneous^4
    to sound 3
    to pain 2
    none 1
  
  
  • Motor responses obeys commands^6
    localizes pain 5
    withdrawal (normal) 4
    abnormal flexion 3
    extension 2
    none 1
  
  
  • Verbal responses oriented^5
    confused conversation 4
    inappropriate words 3
    incomprehensible sounds 2
    none 1
  
  
  
  


• Provide a quiet environment to decrease unnecessary stimulation.


• Monitor fluid input and output.


• Explain to the patient and family:
  
  
  • Home care needs.
  
  
  • Necessity of turning and positioning.
  
  
  • Medication actions, side effects, and interactions.