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    Risk For NCP Tbi

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    Camille T. Sanchez
    The document describes a nursing diagnosis for a patient at risk of injury from complications of a mild traumatic head injury. The patient complains of headache and confusion and has a 3cm laceration on their temporal area. The diagnosis code is 00035. Nursing outcomes and interventions are provided to prevent falls and monitor the patient.

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    Risk For NCP Tbi

    Uploaded by

    Camille T. Sanchez
    21 views2 pages
    The document describes a nursing diagnosis for a patient at risk of injury from complications of a mild traumatic head injury. The patient complains of headache and confusion and has a 3cm laceration on their temporal area. The diagnosis code is 00035. Nursing outcomes and interventions are provided to prevent falls and monitor the patient.

    Original Title

    RISK-FOR-NCP-TBI

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    The document describes a nursing diagnosis for a patient at risk of injury from complications of a mild traumatic head injury. The patient complains of headache and confusion and has a 3cm laceration on their temporal area. The diagnosis code is 00035. Nursing outcomes and interventions are provided to prevent falls and monitor the patient.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    21 views2 pages

    Risk For NCP Tbi

    Uploaded by

    Camille T. Sanchez
    The document describes a nursing diagnosis for a patient at risk of injury from complications of a mild traumatic head injury. The patient complains of headache and confusion and has a 3cm laceration on their temporal area. The diagnosis code is 00035. Nursing outcomes and interventions are provided to prevent falls and monitor the patient.

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    © All Rights Reserved
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    Nursing Diagnosis: Domain 11 Class 2 Diagnosis Code 00035 Risk for Injury related to complications of mild traumatic head

    injury

    Definition of Diagnosis: Susceptible to physical damage due to environmental conditions interacting with the individual's adaptive and defensive resources, which may
    compromise health.
    CUES/ Defining Characteristics Nursing Outcomes Classifications Nursing Interventions Classifications Evaluation
    Subjective:  NOC 1: Balance NIC 1: Fall Prevention After hospital stay, Patient will be able to
    020206 Dizziness achieve desired outcomes as evidenced by:
     Patient is responsive but complains  Identify cognitive or physical deficits  Decreased complaints of headaches
    Outcome Rating: Maintained at 2
    of headache and confusions of the patient that may increase and confusions
    increased at 5
    potential of falling in a particular  Patient will be able to perform fall
    Objective: 1- Severe
    environment techniques to minimize injury
    2- Substantial
     Swelling on temporal area with a 3  Place articles within easy reach of the
    3- Moderate
    cm laceration patient
    4- Mild
     Ears & Nose are unremarkable 5- None  Instruct patient to call for assistance
    with movement, as appropriate
     NOC 2: Physical Injury Severity
    191303 Lacerations  Teach patient how to fall as to
    Outcome Rating: Maintained at 2 minimize injury
    increased at 5  Use side rails of appropriate length and
    1- Severe height to prevent falls from bed, as
    2- Substantial needed
    3- Moderate NIC 2: Surveillance
    4- Mild  Establish the frequency of data
    5- None collection and interpretation, as
    Closed Head Injuries indicated by status of the patient
    Outcome Rating: Maintained at 2  Monitor patient’s ability to do self-care
    increased at 5 activities
    1- Severe  Monitor neurological status
    2- Substantial  Monitor vital signs, as appropriate
    3- Moderate  Compare current status with previous
    4- Mild status to detect improvements and
    5- None deterioration in patient’s condition

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