脑外伤相关护理查房英文版本.pptVIP

* Vital signs: T: 36.5, P: 65 /min, R: 28/min, BP: 135/86 mmHg He was found semiconscious by emergency rescue personnel and transported to hospital. On arrival, the patient responded only to deep pain, was unable to follow commands. Pupils were unequal and nonreactive bilaterally. His breath was irregular and had difficulty in breathing. His Glasgow Coma Scale (GCS) score was 8 He was prepared to be operated through Craniotomy at 7pm immediately Case report 1 Altered level of consciousness related to primary brain injury (意识改变) Ineffective tissue perfusion related to disruption in cerebral （组织灌注不足） blood flow Ineffective breathing pattern related to neurological （无效型呼吸形态） impairment of respiratory Potential complications cerebral herniation （潜在并发症） Preoperative nursing diagnosis Case report 2 10-12 11:30pm: operation was finished and Tim was sent to NICU with tracheal intubation and a drainage tube, and he was semicomatose and the pupils were 2.5 mm, and were equal and have reactions to light; vital signs were stable, the muscle strength of right limbs was grade 0 10-13 6am: still unconscious with tracheal intubation, his temperature was 38.8oC and was normal through physical methods 10-14 8am: level of consciousness was better, had reactions to verbal commands, and the tracheal intubation and drainage tube were pull out; his right limbs were unable to move 10-15 4pm: he complained the bad headache and vomiting, and was relieved after taking medications of mannitol and lasix 10-16 to 10-25: he had medications and rehabilitation exercise daily, his right limbs were able to move slightly 10-26 10am: Tim was discharged from the ward Postoperative nursing diagnosis Altered level of consciousness related to increased intracranial （意识改变） pressure resulting from brain injury Pain (headache) related