LIST OF PRIORITY PROBLEMS:

1. Acute pain related to multiple injury and abrasions

2. Decreased intracranial adaptive capacity related to injury with cerebral edema

NURSING CARE PLAN

Cues/Needs Nursing Rationale Goals and Interventions Rationale Evaluation

Diagnosis Objectives
Subjective: Acute pain Multiple abrasion on After 2 hours of Independent After 2 hours of
“Medyo related to face and legs continuous continuous
masakit pa multiple stimulates the nursing care nursing care
din yung mga injury and nociceprors, free interventions,  Accept client’s description • Pain is subjective interventions,
mga sugat abrasions nerve endings in the the patient will of pain. Acknowledge the experience and cannot the client was
ko” as skin that respond be able to pain experience and convey be felt by others. able to verbalize
verbalized by only to intense, verbalize relief of acceptance of client’s relief of pain. As
the patient. potentially pain. As response to pain. manifested by:
damaging stimuli. manifested by:  Encourage the client to • This helps alleviate  Pain scale
Pain scale of Once the  With 1 discuss problems related to anxiety. Client may feel of 3/10
5/10 nociception is being no current condition need to relieve the (With 1
initiated, the pain and traumatic experience being no
Objective: nociceptive action 10 being  Move patient slowly and pain and
 Guarding potentials are severe deliberately • This reduces muscle 10 being
behavior transmitted by the pain, the tension or guarding, severe
towards his peripheral nervous patient’s which may help pain)
hands and system. The first- pain would minimize pain of  Less facial
legs order neurons travel be <5  Encourage use of these movement mask of
 Facial Mask from the periphery  Less facial techniques: pain
of pain (skin) to the spinal mask of  Distraction techniques
cord via the dorsal pain GOAL IS FULLY
horn. This results to MET
activation of the • These heighten one’s
ascending system. concentration upon non-
Once activated, the painful stimuli to
inhibitory decrease one’s
interneural fibers in awareness and
the dorsal horn  Relaxation exercises, experience of pain.
inhibit or turn off breathing exercises, Some methods are
the transmission of and music therapy breathing modification
noxious stimulating and nerve stimulation.
information in the • Techniques are used to
ascending pathway. bring about a state of
Thus, pain is felt. physical and mental
 Encourage client to awareness and
Sources: eliminate additional tranquility. The goal of
stressors or sources of these techniques is to
• Brunner and discomfort whenever reduce tension,
Suddharth’s possible. subsequently reducing
Textbook of pain.
Medical Nursing • Client may experience
11th edition, an exaggeration in pain
volume 1;p264, or a decreased ability to
265 tolerate painful stimuli if
 Instruct client to have rest environmental and
periods to facilitate comfort, intrapersonal, or
sleep and relaxation intrapsychic factors are
further stressing them.
• The client’s experience
of pain may become
exaggerated as the
result of fatigue in a
cyclic fashion; pain may
result in fatigue which
may result in
 Instruct patient to refrain exaggerated pain and
from excessive exertion, exhaustion. A quiet
such as: environment, a
 Crying darkened room, and the
 Coughing disconnected phone are
 Straining all measures geared
toward facilitating rest.
  Blowing the nose • This prevents undue
and strain on injured site
 Sleeping on the
injured side

DEPENDENT

 Administer mefenamic acid

500 mg 1 capsule every 6
hours
• This is an aspirin-like
drug that has analgesic,
antipyretic and anti-
inflammatory activities.
These activities appear
to be due to its ability to
inhibit cyclooxygenase
and also antagonize
certain effects of
prostaglandins.
Mefenamic acid displays
central and peripheral
activities.

Cues/Needs Nursing Rationale Goals and Interventions Rationale Evaluation

Diagnosis Objectives
Subjective: Decreased After 8 hours of Independent
“Nahihilo ako intracranial Hematoma which nursing Goal was fully
pag umuupo adaptive resulted from the interventions, met
ako” as capacity accident , increases the patient will  Assess neurological status • Deteriorating
verbalized by related to the pressure within maintain an according to GCS- pupil neurological signs After 8 hours of
the patient. injury with the cranial vault. optimal cerebral size, reaction and symmetry indicates increased nursing
cerebral During trauma, tissue perfusion to light; speech and thought cerebral ischemia. A interventions,
Pain scale of edema there is a as evidenced by processes; motor sensory decreased level of the patient
disturbance in ICP less than 10 maintained an
5/10 auutoregulation and mmhg; GCS signs and reflexes consciousness is the first optimal cerebral
intracranial pressure within normal. sign of increased ICP. tissue perfusion
Objective: is increased.  Evaluate presence or • Loss of protective as evidenced by
 vomiting absence of protective reflexes increases risk ICP less than 10
 decreased reflexes (swallowing, for injuries such as mmHg; GCS
pupil gagging, blinking and aspiration. within normal; no
activity coughing) vomiting noted
• Elevation promotes and improved
 Elevate head of the bed 30 venous outflow. A pupil reactivity.
degrees and keep head in neutral head position
neutral alignment. prevents venous
obstruction

• Valsalva increases
 Avoid valsalva maneuver intracranial pressure

DEPENDENT:
• Mannitol reduces
 Administer Mannitol 100 ml cerebrospinal pressure
every 6 hours by increasing plasma
osmolality.