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    NCP Tbi

    Uploaded by

    Wyen Cabatbat
    The nursing care plan addresses a client experiencing hypoxia and ineffective airway clearance. Goals include improving ventilation and respiratory status. Interventions include assessing respiratory rate and sounds, providing oxygen, positioning, and evaluating response. A second client has increased blood pressure from intracranial pressure and vasoconstriction. Goals are to decrease blood pressure through rest, diet, medication and monitoring. A third client has a risk of brain injury. Goals are understanding risk factors and taking steps to correct them through education on disease, monitoring, and providing information.

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    © All Rights Reserved
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    NCP Tbi

    Uploaded by

    Wyen Cabatbat
    874 views4 pages
    The nursing care plan addresses a client experiencing hypoxia and ineffective airway clearance. Goals include improving ventilation and respiratory status. Interventions include assessing respiratory rate and sounds, providing oxygen, positioning, and evaluating response. A second client has increased blood pressure from intracranial pressure and vasoconstriction. Goals are to decrease blood pressure through rest, diet, medication and monitoring. A third client has a risk of brain injury. Goals are understanding risk factors and taking steps to correct them through education on disease, monitoring, and providing information.

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    NCP TBI.docx

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    The nursing care plan addresses a client experiencing hypoxia and ineffective airway clearance. Goals include improving ventilation and respiratory status. Interventions include assessing respiratory rate and sounds, providing oxygen, positioning, and evaluating response. A second client has increased blood pressure from intracranial pressure and vasoconstriction. Goals are to decrease blood pressure through rest, diet, medication and monitoring. A third client has a risk of brain injury. Goals are understanding risk factors and taking steps to correct them through education on disease, monitoring, and providing information.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    874 views4 pages

    NCP Tbi

    Uploaded by

    Wyen Cabatbat
    The nursing care plan addresses a client experiencing hypoxia and ineffective airway clearance. Goals include improving ventilation and respiratory status. Interventions include assessing respiratory rate and sounds, providing oxygen, positioning, and evaluating response. A second client has increased blood pressure from intracranial pressure and vasoconstriction. Goals are to decrease blood pressure through rest, diet, medication and monitoring. A third client has a risk of brain injury. Goals are understanding risk factors and taking steps to correct them through education on disease, monitoring, and providing information.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4
    At a glance
    Powered by AI
    The key takeaways are that brain injuries can be caused by both internal and external factors and occur due to a wide range of reasons. Common causes include physical trauma, head injury, disorders, and congenital maladies.

    Common causes of brain injuries include traumatic brain injury from physical trauma or head injury, increased intracranial pressure, and brain damage from disorders or conditions like hypoxia.

    Factors that contribute to the risk of injury include individual lifestyle choices, medical conditions, and situations that could result in physical harm.

    NURSING CARE PLAN

    CUES NURSIN INFEREN GOAL/PL NURSING RATIONA EVALUATI


    G CE AN INTERVENTI LE ON
    DIAGNO ON
    SIS
    No Ineffective Hypoxia is Following  Assessed  Provide At the end of
    Subjectiv airway a an 8-hr respiratory s a basis the shift, the
    e Cues clearance pathologic nursing rate. for client was
    related to al interventio evaluati able to
    Objective hypoxia. condition n, the ng display
    : in which client will adequac patency of
     Dyspn the body be able to:  Noted chest y of airway as
    ea; use as a whole  Normal movement; ventilati manifested
    of (generalize breathin use of on. by:
    access d hypoxia) g accessory  Client’s
    ory or a region pattern: muscles  Use of respirator
    muscle of the RR = during accessor y rate is
    s for body 12-20 respiration. y within
    respira (tissue cpm muscles normal
    tion: hyoxia) is of range:
    elevate deprived  Auscultated respirati RR-18
    d of breath on may bpm.
    should adequate sounds; occur in
    ers. oxygen noted areas respons
     Increa supply. with e to
    se in presence of ineffecti
    respira adventitiou ve
    tory s sounds. ventilati
    rate: on.
    RR-25
    cpm  Crackle
    s
    indicate
    accumul
    ation of
    secretio
    ns and
    inability
    to clear
    airways.

    CUES NURSING INFERENC GOAL/PL NURSING RATION EVALUAT


    DIAGNOSI E AN INTERVEN ALE ION
    S TION
    No Ineffective Increased After 4 > Monitored > To > After 4
    Subjective cerebral cardiac hours of blood know the hours of
    Cues tissue output that nursing pressure base line nursing
    perfusion injures the interventio every 4hours. of BP > intervention
    related to endothelial n the pt > Instructed Sodium the
    Objective: increased cells of the blood to have tends to be patient’s
    PR = 85 intracranial arteries and pressure enough rest excreted at blood
    bpm pressure the action of will on semi a faster pressure
    RR = 30 and prostaglandi decrease fowlers rate. was
    bpm vasoconstri ns. from 160/ position. > decreased
    160/100m ction of Vasoconstri 100mmHg Instructed to > To from
    mHg blood ction occurs to eat low fat reduce 160/100mm
    vessels and blood 120/80mm and low salt edema that Hg to
    pressure Hg. diet. > may 140/90mm
    increases. Administered activate Hg.
    anti- renin
    hypertensive angiotensi
    drug as n-
    ordered. aldosteron
    e system.
    > To
    control the
    BP and to
    avoid
    other
    complicati
    ons.

    CUES NURSING INFEREN GOAL/PL NURSING RATIONA EVALUATI


    DIAGNO CE AN INTERVENTI LE ON
    SIS ON
    No Risk for Brain After 3 Monitor •To assess After 3 hours
    Subjecti injury damage or hours of peripheral baseline of nursing
    ve Cues related to "brain nursing pulses and data intervention,
    brain injury" interventio vital signs, •To assist the client
    damage. (BI); n, the client especially the client to verbalized
    Objectiv means the will be able heart rate reduce or understandin
    e: destruction to verbalize every hour to correct g of
    T: 36.7 or understandi every four individual individual
    PR: 65 degenerati ng of hours risk factor. factors that
    bpmRR: on of brain individual depending on contribute to
    18 cells, often factors that the client’s possibility of
    cpmBP: with an contribute condition. injury and
    120/70 implication to • take steps to
    mmHg that the possibility Provide correct
    loss is of injury information situations.Go
    significant and take regarding al was met
    in terms of steps to disease/conditi
    functionin correct on that may
    g or situations result in
    conscious increased risk
    experience of injury.
    . It is a
    common
    and very
    broad in
    scope,
    such that
    in
    medicine a
    vast range
    of specific
    diagnoses
    exist.
    Brain
    injuries
    occur due
    to a wide
    range of
    internal
    and
    external
    factors. A
    common
    category
    with the
    greatest
    number of
    injuries is
    traumatic
    brain
    injury
    (TBI)
    following
    physical
    trauma or
    head injury
    from an
    outside
    source, and
    the term
    acquired
    brain
    injury
    (ABI) is
    used in
    appropriate
    circles, to
    differentiat
    e brain
    injuries
    occurring
    after birth
    from
    injury due
    to a
    disorder or
    congential
    malady.

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