Medical Surgical Nursing

circulation and leads to tissue necrosis. Potential areas of breakdown need to be
identified early to avoid the development of pressure ulcers. Specific nursing measures
include the following:

 Assessing all body surfaces and documenting skin integrity every 8 hours

 Turning and repositioning the patient every 2 hours

 Providing skin care every 4 hours

 Assisting the patient to get out of bed to a chair three times a day

Improving Cognitive Functioning
Although many patients with head injury survive because of resuscitative and
supportive technology, they frequently have significant cognitive sequelae that may not
be detected during the acute phase of injury. Cognitive impairment includes memory
deficits, decreased ability to focus and sustain attention to a task (distractibility),
reduced ability to process information, and slowness in thinking, perceiving,
communicating, reading, and writing. Psychiatric, emotional, and relationship problems
develop in many patients after head injury (Hsueh-Fen & Stuifbergen, 2004). Resulting
psychosocial, behavioral, emotional, and cognitive impairments are devastating to the
family as well as to the patient.
These problems require collaboration among many disciplines. A neuropsychologist
(specialist in evaluating and treating cognitive problems) plans a program and initiates
therapy or counseling to help the patient reach maximal potential (Eslinger, 2002).
Cognitive rehabilitation activities help the patient to devise new problem-solving
strategies. The retraining is carried out over an extended period and may include the
use of sensory stimulation and reinforcement, behavior modification, reality
orientation, computer-training programs, and video games. Assistance from many
disciplines is necessary during this phase of recovery. Even if intellectual ability does
not improve, social and behavioral abilities may.
The patient recovering from a traumatic brain injury may experience fluctuations in the
level of cognitive function, with orientation, attention, and memory frequently affected.
Many types of sensory stimulation programs have been tried, and research on these
programs is ongoing (Davis & Gimeniz, 2004). When pushed to a level greater than the
impaired cortical functioning allows, the patient may show symptoms of fatigue, anger,
and stress (headache, dizziness). The Rancho Los Amigos Level of Cognitive Function
is a scale frequently used to assess cognitive function and evaluate ongoing recovery
from head injury. Nursing management and a description of each level are included in
Table 63-2. Progress through the levels of cognitive function can vary widely for
individual patients.

Preventing Sleep Pattern Disturbance
Patients who require frequent monitoring of neurologic status may experience sleep
deprivation as they are awakened hourly for assessment of LOC. To allow the patient
longer times of uninterrupted sleep and rest, the nurse can group nursing care activities
so that the patient is disturbed less frequently. Environmental noise is decreased, and
the room lights are dimmed. Back rubs and other measures to increase comfort can
assist in promoting sleep and rest.

Supporting Family Coping
Having a loved one sustain a serious head injury can produce a great deal of prolonged
stress in the family. This stress can result from the patient's physical and emotional
deficits, the unpredictable outcome, and altered family relationships. Families report