NURSING CARE PLAN FOR HEAD INJURY PATIENT WITH LACERATIONS OR POST SURGERY

PROBLEM NURSING OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
HEADACHE/ Pain/headache To relieve  Give Opioid analgesics e.g.  To block the pain receptors and  Pain relieved
PAIN related to physical pain within 1 morphine and pethidine to interfere with pain within 1 hour
trauma and hour.  As the condition improves, transmission process evidenced by
swelling, exposure offer diversional therapy for  To divert the patients mind away patient resting
of sensory nerve example charting with the -from the pain stimulus and verbalizing
endings of the skin patient, music or reading.  Raised intracranial pressure may pain relieve.
evidenced by  Watch for signs of raised increase headache and
patient being intracranial pressure restlessness
restless and
verbalizing it.
INEFFECTIVE  Ineffective  To  Assess the patency of airway.  To detect signs of airway Patient’s airway
AIRWAY airway maintain  Keep the unconscious patient in a obstruction remained patent
CLEARANCE clearance and patent supine position and head tilted to  To facilitate drainage of the secretions with good ventilation
AND ventilation airway the side with the head of the bed and to decrease intracranial venous throughout
VENTILATION related to and elevated to about 30 degrees pressure. hospitalization
unconsciousnes adequate  Establish effective suctioning  To facilitate drainage of the secretions. evidenced by oxygen
s and hypoxia ventilation procedures regularly  To recognise inadequacy in saturation of above
evidenced by throughou  Monitor arterial blood gas values tissue perfusion on time and offer 90% and absence of
low oxygen t intervention secretions
saturation unconscio
below 90% and us period
presence of
secretions

IMPAIRED  Impaired  To assess  Use Glasgow coma scale  To assess the level of  Patient attained
NEUROLOGICA neurological improvem consciousness improvement in

1
L STATUS AND status and ent in  Pin point and non responsive pupils to orientation and
DISORIENTAT disorientation orientatio  Check pupils for size and reaction light indicate brainstem dysfunctioning neurological
ION related to n and to light. at the level of the pons. status during
spine/ brain neurologic  Assess the patient’s best verbal  Damage to the cranial nerves hospitalisation
injury al status response leads to phonation problems. evidenced by full
throughou  Evaluate motor function by  To rule out paralysis and possible motor and
t asking patient to lift affected spinal cord trauma sensory
hospitalisa limb against the force of functioning with
tion gravity or by inflicting pinch Glasgow coma
pain scale of 15/15

RISK FOR Risk for open -To prevent -Daily wound cleaning and -To prevent bacterial colonization of -The wound site
OPEN WOUND wound infection wound covering it with sterile gauze the wound remained free of
INFECTION related to infection - daily changing of dressing and -To prevent bacterial colonization infection throughout
exposure to throughout inspection of the wound and for early detection of signs of hospitalization
environmental hospitalizatio - Give prescribed prophylactic infection. evidenced by the
contaminants or n period antibiotics -To combat any form of bacterial wound drying
bacterial invasion growth from the open wound site without discharge or
swelling
ALTERED  Altered nutrition  To  Patient on mechanical ventilation  To be used as a route for feeds  The patient’s
NUTRITION LESS less than body improve should have a nasogastric tube 3hourly until the swallowing reflex is altered
THAN BODY requirement nutritional inserted which should be kept in initiated and removal of endotracheal nutritional status
REQUIREMENT related to status of situ. tube is done. was corrected
metabolic the patient  Observe the ability of the patient  to prevent abdominal and maintained
changes, fluid throughou to retain and eliminate distension,regurgitation,and aspiration throughout
restriction and t nasogastric tube feeds hospitalisation
inadequate intake hospitalisa adequately  To promote adequate hydration and evidenced by
evidenced by  A continuous intravenous fluids prevent cerebral oedema and
tion adequate
changes in skin with caution(risk of raising the maintain electrolyte balance. elimination and
turgor and intracranial pressure) should be
normal skin

2
 reduced urine given such as Normal saline and turgor.
output of less Ringers Lactate
than 500ml/24  Patients should be given fluids of
hours mixed diet such as proteins,  For tissue repair, energy for
carbohydrates and vitamins 3 metabolism and boosting immunity
hourly via NGT against Nosocomial infections
respectively.

RISK FOR  Risk for injury  To prevent  Use padded side rails or wrap the  To protect the patient from injury and  Patient was kept
INJURY(SELF related to further patient’s hands in mitts. dislodging of the body from the bed free fro injury
DIRECTED OR disorientation and injury  Never leave the patient out of  To monitor him during throughout
DIRECTED restlessness during site alone e.g in screens restlessness and prevent falling of hospitalisation
TOWARDS hospitalisa  Assess condition for suitability to bed. evidenced by no
OTHERS) tion sedation  To calm and rest the patient fresh skin
 Ensure adequate ventilation to  Hypercarbia will lead to increased ICP damages
maintain partial pressure of due to vasodilatation leading to more
arterial CO2 of about 35mmHg. restlessness.

SELF CARE Self care deficit To help the  Pass NGT for 3 hourly feeds  To meet the body’s caloric
DEFICIT related to loss of patient in  Do bed baths and oral toilet requirements
consciousness feeding, twice daily
related to brain dressing,
trauma and toileting,
mechanical and bathing
ventilation activities
evidenced by during
patient unable to unconsciou
maintain own s phase
hygiene, feeding
and toileting

3
4