Referenced Ackerman book and NANDA 1) Risk for ineffective cerebral tissue perfusion r/t increased ICP secondary to hematoma/intracranial bleeding aeb complaint of HA, sensitivity to sound/light, previous episodes of N/V. Interventions: VS and neuro check Q4H, HOB raised, maintaining room dark to reduce stimulation, assessment of pain PRN, administer ordered pain and antiemetic meds PRN, consultations with neurosurgery. 2) Pain r/t injuries caused by MVA aeb complaints of pain ranging between 6-8 without medication. Interventions: Assessment of pain PRN, administer ordered pain meds PRN, ensure patient is aware of available pain meds and next available time, close communication with the physician regarding effectiveness of pain meds. 3) Ineffective coping r/t inadequate choices of practiced responses to stress, inadequate resources, insufficient sense of control, insufficient social support aeb drug taking bx, skipping school, family situation (absence of father, siblings with major problems), Dx. of depression, substance abuse, possibly destructive behavior toward self (we don't know if the accident was d/t overdose or an attempt to harm self), attempt to ran away from the hospital. Interventions: Consultations with social work, psychologist, and psychiatrist, sitter at bedside, drug rehab information provided by physician.
Nursing Assessments and Interventions 1) Assessment: Neuro/VS check Q4H, including level of consciousness, worsening HA, N/V. Goal: Patient has no episode of altered mental status before discharge. d/t worsening hematoma/concussion. Interventions: Conduct neuro/VS check Q4H as ordered. Educate patient and parent of signs of worsening hematoma and instruct them to report if any symptoms are experienced. Watch for sings/symptoms of worsening hematoma. 2)Assessment: Pain assessment PRN. Goal: Patient's pain is controlled between 0-2 where patient feels comfortable before discharge. Interventions: Make sure patient is aware of available pain medications and the time they are available, explore other ways to help decrease pain (pt responded rest). 3) Assessment: Assess if patient displays any signs and symptoms of depression, assess for SI (done by medical resident). Goal: Patient does not develop any symptoms of depression before discharge. Interventions: Provide regular rounds, encouraged to verbalize any feelings, identify any causes for ineffective coping, identify any stressors.