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Neurological disorders continues...... - Coggle Diagram

- - - - Risk for ineffective breathing pattern related to the impairment of innervation of the diaphragm.
        Risk for trauma related to temporary weakness of the spinal column.
        Acute pain related to physical injury.
    - - Adequate ventilation as evidenced by absence of respiratory distress.
        Maintain proper alignment of spine without further spinal cord damage.
        Report relief or control of pain or discomfort.
    - - Difficulty in breathing.
        Risk for trauma
        Acute pain.
    - - Assess respiratory function by asking patient to take a deep breath.
        Note presence or absence of spontaneous effort and quality of respirations (labored, using accessory muscles).
        Note strength or effectiveness of cough.
        Administer oxygen by appropriate method (nasal prongs, mask, intubation, ventilator).
        Maintain bedrest and immobilization device(s) such as sandbags, traction, halo, hard or soft cervical collars, brace.
        Assess for presence of pain. Help patient identify and quantify pain (location, type of pain, intensity on scale of 0–10)
        Provide comfort measures (position changes, massage, ROM exercises, warm or cold packs, as indicated).
    - - The client is breathing well on room air.
        Not at risk for trauma.
        No pain complaint.
- - - - Decreased intracranial adaptive capacity injury with cerebral edema.
        Risk for fluid deficient volume related to use of hyperosmotic agents.
        Risk for seizures related to head I jury
    - - Patient maintains optimal cerebral perfusion as evidenced by stable neurological status..
        Patient remains normovolemic as evidenced by systolic BP that is equal or greater than 90mm Hg.
    - - Acute pain.
        Memory loss
    - - Assess the patient neurological status and level of consciousness.
        Monitor patient vital signs.
        Assess for pain, fever, and shivering as they increase intracranial pressure.
        Nurse the patient in a Semi-Fowler's position.
        Monitor intake and output of the patient.
        Replace fluid output as directed.
    - - No pain complain from the patient.
        No signs of confusion.