脑外伤护理查房英文版本课件.ppt

* Altered nutrition (less than body requirements) * Assess neurological status of clients every 15 to 60 minutes. Note findings on Glasgow Coma Scale. Compare findings to previous assessments to uncover changes in condition Administer oxygen as ordered to supply a high concentration of oxygen to the brain Position client with head of the head up 30 degree and client’s head at midline to promote venous drainage from the head Minimize physical activity to prevent increasing metabolic demands * Assess respiratory status every 15 to 30 minutes Provide mechanical ventilation if necessary Continually assess the patterns of respiratory, (frequency, depth, rate, dyspnea, Spo2) to identity need for assisting respirations to prevent vasodilatation in the brain and increasing intracranial pressure Administer oxygen as ordered to maintain blood oxygen concentration * * First Aid: A B C, protect spine Preoperative preparation: skin and blood preparation, catheterization, medications, monitor and record Postoperative monitor: GCS or level of consciousness, pupils, ICP, muscle strength, Intake and output, chief complains, potential complications Nursing record: objectively, timely, accurately Rehabilitation exercise: function trainings, acupuncture and moxibustion When the danger to life is over, the problems of recovery have to be tackled. Patients have to learn again how to take notice of the world around them, to think and talk, to look after themselves, and to get back to strength and mobility. This process starts with the move from the ICU to an ordinary ward. Patients will still need expert nursing care. They may not yet be able to swallow properly and may still need the nasal-gastric tube. They may not have got enough strength back to hold their head up or sit on their own, and they may not yet be saying anything with meaning. They will however know, even if it is in a confused way, that their family and friends are with them, and this will be a comfort and a