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Acute head injury

Acute head injury result from a trauma to the head leading to brain injury or bleeding within the brain, It's can
make edema and hypoxia. Head injury cases is the leading cause of death in the first four decades of life. A head
injury also called Traumatic Brain Injury (TBI) is classified by brain injury type; fracture, hemorrhage (epidural,
subdural, intracerebral or subarachnoid) and trauma.

The management or nursing care plan (NCP) for patient with an acute head injury are divided on the several levels
including prevention, pre-hospital care, immediate hospital care, acute hospital care, and rehabilitation.

In order to give accurate nursing care plan to the patients, The nurses should understand the principles behind
medical treatments. It focuses on the evidence based practice that nurses use in assessing, intervening and
managing a severe head injury.
A. Assessment Findings on Acute Head Injury

Possible causes of acute head injury are assault, automobile accident, blunt trauma, fall and penetrating trauma.
The medical team should be perform serious and critical care to handle this cases, So that they can finding correct
assessment may happened to the patients such as:

Disorientation to time, place or person


Unequal pupil size, loss of pupillary reaction
Decreased LOC
Paresthesia
Otorrhea, rhinorea, frequent swallowing.

To quickly asses a patient's level of consciousness and to uncover baseline change, use the Glasgow Coma Scale.
If the patient has already applied with an endotracheal tube and can't response verbally, use the abbreviation "T"
score.

B. Diagnostic Evaluation for Acute Head Injury


The doctors are who responsible to the patient in the emergency department, they will order some examination
trough CT scan or MRI (possible for hemorrhage, cerebral edema, or shift of midline structure), EEG (may reveal
seizure activity), ICP monitoring (possible increased of ICP) and skull X-ray (may be fracture).
C. Nursing Diagnose in Acute Head Injury

Ineffective tissue perfusion (cerebral)


Risk for Injury
Decreased intracranial adaptive capacity.

D. Treatment of Acute Head Injury

Cervical collar (until neck injury is ruled out)


Craniotomy; surgical incision into te cranium (may be necessary to evacuate a hematoma or evacuate
contents to make room for swelling to prevent herniation)
Oxygen (O2) Therapy; intubation and mechanical ventilation (to provide controlled hyperventilation to
decrease elevate ICP)
Restricted oral intake for 24 to 48 hours
Ventriculostomy; insertion of a drain into the ventricles (to drain CSF in the presence of hydrocephalus,
which may occur as a result of head injury; can also be used to monitor ICP).

E. Drug Therapy Options for Head Injury Cases

Analgesic; codein phosphate


Anesthetic; Lidocin (Xylocaine)
Anticonvulsant; Phenytoin (Dilantin)
Barbiturate; pentobarbital (Nembutal), if unable to control ICP with diuresis
Diuretic; mannitol (Osmitrol), furosemide (Lasic) to combat cerebral edema
Dopamine (Intropin) to maintain cerebral perfusion pressure above 50 mmHg (if blood pressure is low and
ICP is elevated)
Glucocorticoid; dexamethasone (Decadron) to reduce cerebral edema
Histamin-2 (H2) receptor antagonist such as cimetidine (tagamet), ranitidine (Zantag), famotidine (Pepcid),
nizatidine (Axid)
Mucosal barriel fortifier; sucralfate (Carafate)
Posterior pituitary : vasopressin (Pitressin) if client develops diabetes insipidus.

F. Planing and Goal on Nursing Care Plan

The patient will have improved cerebral perfusion


The patient will have decreased ICP
The patient will have remain free from injury.

G. Implementation of Nursing Care Plan Procedure

1. Assest neurologic and respiratory status to monitor for sign of increased ICP and respiratory distress
2. Monitor and record vital sign and intake and output, hemodynamic variables, ICP, cerebral perfusion
pressure, specific gravity, laboratory studies, and pulse oximetry to detect early sign of compromise.
3. Observe for sign of increasing ICP to avoid treatment delay and prevent neurologic compromise
4. Assess for CSF leak as evidenced by otorhea or rinorrhea. CSF leak could leave the patient at risk for
infection
5. Assess for pain. Pain may cause anxiety and increase ICP
6. Check cough and gag reflex to prevent aspiration
7. Check for sign of diabetes insipidus (low urine specific gravity, high urine output) to maintain hydration
8. Administer I.V fluids to maintain hydration
9. Administer Oxygen to maintain position and patency of endotracheal tube if present, to maintain airway
and hyperventilate the patient and to lower ICP
10. Provide suctioning; if patient is able, assist with turning, coughing, and deep breating to prevent pooling of
secretions
11. Maintain postion, patency and low suction of NGT to prevent vomiting
12. Maintain seizure precautions to maintain patient safety
13. Administer medication as prescription to decrease ICP and pain
14. Allow a rest period between nursing activities to avoid increase in ICP
15. Encourage the patient to express feeling about changes in body image ot allay anxiety
16. Provide appropriate sensory input and stimuli with frequent reorientation to foster awarness of the
environtment
17. Provide means of communication, such as a communcation board to prevent anxiety
18. Provide eye, skin, and mouth care to prevent tissue damage
19. Turn the patient every 2 hours or maintain in a rotating bed if condition allows to prevent skin breakdown.

H. Evaluation of Goals in the Nursing Care Plan

The patient has improved LOC


The patient hasdoest not exhibit signs of increased ICP
The patient hasremains free from injury

NCP Nursing Care Plan For Urinary Tract Infections (UTIs). Urinary tract infections (UTIs) are common and usually occur because of the
entry of bacteria into the urinary tract at the urethra the two forms of lower urinary tract infection (UTI) are cystitis (infection of the bladder)
and urethritis (infection of the urethra). Urinary tract infection (UTI) more common in females than in males. UTI is prevalent in girls. In
adult males and in children, lower UTIs typically are associated with anatomic or physiologic abnormalities and therefore need close
evaluation. Most UTIs respond eadily to treatment, but recurrence and resistant bacteria flare-up during therapy are possible.
Urinary reflux is one reason that bacteria spread in the urinary tract. Vesicourethral reflux occurs when pressure increases in the bladder
from coughing or sneezing and pushes urine into the urethra. When pressure returns to normal, the urine moves back into the bladder,
taking with it bacteria from the urethra. In vesicoureteral reflux, urine flows backward from the bladder into one or both of the ureters,
carrying bacteria from the bladder to the ureters and widening the infection. If they are left untreated, UTIs can lead to chronic infections,
pyelonephritis, and even Systemic sepsis and septic shock. If infection reaches the kidneys, permanent renal damage can occur, which
leads to acute and chronic renal failure.

Causes for Urinary tract infection (UTI)


Most lower UTIs result from ascending infection by a single gram-negative, enteric bacterium, such as Escherichia coli, Klebsiella, Proteus,
Enterobacter, Pseudomonas, and Serratia. In a patient with neurogenic bladder, an indwelling urinary catheter, or a fistula between the
intestine and bladder, a lower UTI may result from simultaneous infection with multiple pathogens.
Studies suggest that infection results from a breakdown in local defense mechanisms in the bladder that allows bacteria to invade the
bladder mucosa and multiply. These bacteria can't be readily eliminated by normal urination.
The pathogen's resistance to the prescribed antimicrobial therapy usually causes bacterial flare-up during treatment. Even a small number
of bacteria in a midstream urine specimen obtained during treatment casts doubt on the effectiveness of treatment.
In almost all patients, recurrent lower UTIs result from reinfection by the same organism or by some new pathogen. In the remaining
patients, recurrence reflects persistent infection, usually from renal calculi, chronic bacterial prostatitis, or a structural anomaly that is a
source of infection. The high incidence of lower UTI among females probably occurs because natural anatomic features that facilitate
Urinary tract infection (UTI).

Complications for Urinary tract infections (UTIs)


If untreated, chronic UTI can seriously damage the urinary tract lining. Infection of adjacent organs and structures (for exa mple,
pyelonephritis) may also occur. When this happens, the prognosis is poor.

Nursing Assessment Nursing care plans for Urinary tract infections (UTIs)
Patients History. The patient with a UTI has a variety of symptoms that range from mild to severe. The typical complaint is of one or more
of the following: frequency, burning, urgency, nocturia, blood or pus in the urine, and suprapubic fullness. The patient may complain of
urinary urgency and frequency, dysuria, bladder cramps or spasms, itching, a feeling of warmth during urination, nocturia. Other complaints
include low back pain, malaise, nausea, vomiting, pain or tenderness over the bladder, chills, and flank pain. Inflammation of the bladder
wall also causes hematuria and fever. Ask the patient about risk factors, including recent catheterization of the urinary tract, pregnancy or
recent childbirth, neurological problems, volume depletion, frequent sexual activity, and presence of a sexually transmitted infection (STI).
Physical Examination. Physical examination is often unremarkable in the patient with a UTI, although some patients have costovertebral
angle tenderness in cases of pyelonephritis. On occasion, the patient has fever, chills, and signs of a systemic infection. Inspect the urine
to determine its color, clarity, odor, and character. Surveillance for STIs is recommended as part of the examination.

Diagnostic tests Urinary tract infections (UTIs).


Several tests are used to diagnose lower UTIs:

Leukocyte esterase dip test


Clean-catch urinalysis.
Clean-catch collection is preferred to catheterization, which can reinfect the bladder with urethral bacteria.
Sensitivity testing is used to determine the appropriate antimicrobial drug.
Stained smear of urethral discharge can be used to rule out sexually transmitted disease.
Voiding cystourethrography or excretory urography

Nursing diagnosis Nursing care plans for Urinary tract infections (UTIs).

Acute pain
Deficient knowledge (prevention)
Disturbed sleep pattern
Impaired urinary elimination
Risk for infection
Risk for injury
Sexual dysfunction

Nursing Key outcomes nursing care plans for Urinary tract infections (UTIs)
The patients will:

Report increased comfort.


Identify risk factors that exacerbate the disease process or condition and modify his lifestyle accordingly.
Verbalize feeling well rested after undisturbed periods of sleep.
Remain free from signs or symptoms of infection.
Avoid or minimize complications.
Reestablish sexual activity at the preillness level.
Patient and family will demonstrate skill in managing elimination problem.

Nursing interventions Nursing care plans for Urinary tract infections (UTIs)
Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic
Administration Use of pharmacologic agents to reduce or eliminate pain. Environmental Management Comfort Manipulation of the
patients surroundings forpromotion of optimal comfort
Teaching the patient of a teaching program about UTIs, how to prevent recurrent lower UTIs, and therapy.
Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving
the ability and willingness to receive information
Sleep Enhancement to Facilitation of regular sleep/wake cycles. Simple Relaxation Therapy Use of techniques to encourage and
elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety.
Environmental Management Manipulation of the patients surroundings for therapeutic benefit
Urinary Elimination Management Maintenance of an optimum urinary elimination pattern. Urinary Catheterization Insertion of a
catheter into the bladder for temporary or permanent drainage of urine. Perineal Care Maintenance of perineal skin integrity and
relief of perineal discomfort
Infection Protection to Prevention and early detection of infection in a patient at risk. Infection Control Minimizing the acquisition
and transmission of infectious agents. Surveillance Purposeful and ongoing acquisition, interpretation, and synthesis of patient
data for clinical decision making
Risk Identification Analysis of potential risk factors, determination of health risks, and prioritization of risk reduction strategies for
an individual or group. Purposeful and ongoing collection and analysis of information about the patient and the environment for
use in promoting and maintaining patient safety
Sexual Counseling Use of an interactive helping process focusing on the need to make adjustments to sexual practice or to
coping with a sexual event/disorder. Teaching/Assisting individuals to understand physical and psychosocial dimensions of sexual
growth and development

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