Medical Surgical Nursing

(Tina Sui) #1

  • Suction or encourage coughing cautiously as needed (suctioning and coughing


increase ICP).



  • Humidification of oxygen may help loosen secretions.



  1. Sensory deprivation



  • Periorbital edema may impair vision, announce presence to avoid startling the patient;


cool compresses over eyes and elevation of HOB may be used to reduce edema if not


contraindicated.



  1. Enhancing self-image



  • Encourage verbalization.

  • Encourage social interaction and social support.

  • Attention to grooming.

  • Cover head with turban and, later, a wig.



  1. Monitor I&O, weight, blood glucose, serum and urine electrolyte levels, and


osmolality and urine specific gravity.


  1. Preventing infections



  • Assess incision for signs of hematoma or infection.

  • Assess for potential CSF leak.

  • Instruct patient to avoid coughing, sneezing, or nose blowing, which may increase the


risk of CSF leakage.



  • Use strict aseptic technique.

  • Patient teaching for self-care


Seizures


  • Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a


combination of these) resulting from a sudden, abnormal, uncontrolled electrical


discharge from cerebral neurons



  • Classification of seizures Partial seizures: begin in one part of the brain

  • Simple partial: consciousness remains intact

  • Complex partial: impairment of consciousness

  • Generalized seizures: involve the whole brain

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