(^214) Medical-Surgical Nursing Demystified
INTERPRETING TEST RESULTS
- Skull x-ray shows fractures.
- MRI shows edema and hemorrhage.
- CT scan shows hemorrhage, cerebral edema, displacement of midline
structures. - EEG indicates focal seizure activity.
TREATMENT
- Surgical interventions may be necessary (craniotomy):
- Removal of hematoma
- Ligation of bleeding vessel
- Burr holes (drilling holes) for decompression
- Debridement of foreign material and dead cells
- Administer antibiotics for open head injuries to prevent infection.
- Ventilatory assist if needed—intubation and mechanical ventilation.
- Administer low-dose opioids for restlessness, agitation, and pain in ventilator-
dependent patients:- morphine sulfate or fentanyl citrate
- Administer osmotic diuretics to reduce cerebral edema:
- mannitol
- Administer loop diuretics to decrease edema and circulating blood volume:
- furosemide
- Administer analgesics:
- acetaminophen (Tylenol)
- High-protein, high-calorie, high-vitamin diet.
- Platelet and packed RBC transfusions—if blood counts warrant transfusion.
NURSING DIAGNOSES
- Risk for injury
- Ineffective tissue perfusion
- Decreased intracranial adaptive capacity
- Risk for disturbed thought processes