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Head Injury (TBI) (Assessment (Fall from 8ft ladder, Loss of consciousness…
Head Injury (TBI)
Assessment
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Localizing Motor Response- removal of offending stimuli during pain pressure on proximal nail bed (5)
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Implementation
(2) Maintain patient airway: suctioning, intubation if necessary
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(4) Monitor Temperature: Keep them warm! us warming lights, warm IV fluids, and warm O2.
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(7) Monitor Vitals: O2sat, GCS score, cardiac rhythm, pupil size, change in consciousness, frequent neurological assessments
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Nursing Diagnosis
Hyperthermia r/t increased metabolism, infection, and hypothalamic injury
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Risk for ineffective cerebral tissue perfusion r/t cerebral hemorrhage, hematoma, and edema
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Complications
Epidural Hematoma- loss of consciousness at moment of injury, declining conscious and neurological status shortly after.
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Hematoma is a major complication of head injuries, as any vessels in the brain may rupture due to the force of impact.
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Pathophysiology
Any damage to scalp, skull, or brain
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Planning
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attain maximal cognitive, motor, and sensory function
Evaluation
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Achieve maximal cognitive, motor, and sensory function
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(Hypoxia, Ischemia, Hypotension, Edema, increased ICP)