Nursing Care Plan: Epidural Hematoma Post Craniotomy

NURSING CARE PLAN

Patient’s Name/Bed #: Mr. A SICU0 Medical Diagnosis: epidural hematoma, right FTP area, S/P craniotomy, evacuation of subdural hematoma, right FTP (0/0/0); S/P repeat craniotomy, evacuation of epidural and subdural hematoma, JP drain (0/0/0)

Subjective/Objective cues:

Nursing Diagnosis with Etiology

Goals of CareGeneral/Specific

Interventions Rationale Evaluation

Subjective cues:None-with ET tube attached to mechanical ventilator

Objective cues: With pupillary

size of 4 mm on right eye, 2 mm on left eye, both eyes with negative reaction to light

Muscle grade of 1/5 for slight muscle contraction on all extremities, no joint motion.

With GCS of 6 (best eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs

Ineffective Cerebral Tissue Perfusion related to the interruption of the blood flow to the brain.

General:Within 2 weeks of medical and nursing interventions, client will be able to improve level of consciousness.

Specific:Within 1 day of medical and nursing interventions, client will be able to manifest:

Improve/Stable level of consciousness

Improve/Stable GCS score

No pupillary changes, seizures, widening of pulse pressure, irregular respirations, hypotension and bradycardia.

Independent:Assessment

Assess mental status and changes in the level of consciousness

Therapeutic Position client in

low-fowler’s position (30 degrees)

Avoid extreme rotation of the neck

Avoid extreme hip flexion

To check for affected cranial nerve functions in the brain (for GCS); check for cerebral hypoperfusion and hypoxia.

Help venous drainage from the brain and promote brain expansion.

This will compress the jugular veins leading to an increased intracranial pressure.

Increase in intra-abdominal and intra-thoracic pressure leading to increased intracranial

GCS of 5 (best eye opening-1, none; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)

Patient is placed in low-Fowler’s position; made comfortable in bed and adjusted pillows

Patient is monitored frequently; positioned head and neck cautiously and placed a pillow on side for support

Patient is repositioned cautiously and provided with pillows for support

to pain) Babinski reflex-

positive, and oculocephalic reflex-negative

Maintain patent airway

Dependent:

Administer medications such as diuretics (e.g. Mannitol) and anticonvulsants (e.g. Amlodipine, Verapamil)

Collaborative:

Review pulse oximetry

Restore or maintain fluid balance

pressure.

Prevents build up of secretions leading to increase in carbon dioxide and intracranial pressure.

Diuretics are used and needed to decrease cerebral edema and anticonvulsant medications

Hypoxia is associated with reduced cerebral tissue perfusion.

It maximizes cardiac output and prevents decreased cerebral perfusion associated with hypovolemia.

ET tube placement is monitored if securely attached to patient at the appropriate level of 21 cm; suctioned frequently for secretions

Mannitol 75 cc was given intravenously to patient; antihypertensives such Amlodipine 20 mg per tablet and Verapamil 10 mg per tablet was also given to patient

Oxygen saturation patient ranges 98-99%

With IV fluid of PNSS 1L x 63 cc per hour, patent and infusing well at left metacarpal vein of patient, with a rate of 21 drops per minute






Subjective cues:None- with ET tube attached on mechanical ventilator

Objective cues: Adventitious

breath sounds heard at left anterior lung such as ronchi and wheezing

Presence of whitish, tenacious secretions approximately 20 cc

Decreased level of consciousness (GCS of 6: best eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)

Ineffective airway clearance maybe related to hypoventilation secondary to brain stem injury

GeneralWithin 1 week of medical and nursing intervention, client will be able to mobilize secretions.

SpecificWithin 1 day of medical and nursing interventions, client will be able to manifest:

Clear breath sounds

Decreased secretions

IndependentAssessment

Assess respiration and breath sounds, noting rate and sounds (e.g. tachypnea, stridor, crackles, wheezes)

Evaluate cough/gag reflex and swallowing ability

Assess airway for patency

Assess changes in mental status

These signs and symptoms are indicative of respiratory distress and/or accumulation of secretions.

To determine ability to protect own airway

Maintaining the airway is always first priority, especially in cases of trauma.

Lethargy and somnolence are late signs

Respirations range between 16-21 breaths per minute, regular in rate and rhythm; adventitious breath sounds heard over left anterior lung, including ronchi and wheezing soundsPatient exhibits swallowing and gag reflexes; with absent cough reflex

Placement of ET tube on patient is monitored frequently at the appropriate level of 21 cm; suctioned frequently for presence of secretions.Patient is GCS 5 (no eye opening-1, with ET tube attached-1, and flexes arms and extends legs to painful stimuli-3)

Note presence of sputum, assess quality, color, amount, odor and consistency.

Therapeutic Elevate head of

bed and reposition every 2 hours and as needed.

Routinely check the patient’s position so he does not slide down in bed.

Use humidifier.

Institute suctioning of the airway.

Abnormalities maybe a result of infection. A sign of infection is discolored sputum.

To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segments.

This prevents abdominal contents from pushing upward and inhibiting lung expansion.

This loosens secretions and facilitates the removal.

Helps clear secretions.

with whitish, tenacious secretions noted upon suctioning of the mouth and ET tube, approximately 20 cc

Patient was repositioned every two hours, made comfortable in bed while adjusting pillows; provided with chest physiotherapy upon change of position

Patient is monitored frequently; with slight elevation of the foot part to prevent sliding down the bed.

Patients VR set-up cmes with a humidifier; monitored frequently from getting used up

Patient is suctioned frequently for presence of secretions

Dependent Administer

medications (e.g. antibiotics-Levofloxacin, Vigocid; mucolytic agents, bronchodilators-Salbutamol) as ordered, noting effectiveness and side effects.

Collaborative Check and

monitor VR set-up and patient’s response.

These promote clearance of airway secretions and bronchodilation decreases airway resistance.

The basis for setting every parameter of the ventilator depends on the patient. Maintaining the correct settings for every parameter ensures the proper ventilation to the patient.

Patient was given ILN Salbutamol 1 nebule via face mask; with respiratory rate of 17-21 breaths per minute, regular, non-labored; with no side effects such as hypotension or bradycardia.

With ET tube at 21 cm attached to patient connected to a functional ventilator; with VR set-up of: tidal volume-450 ml, peak flow-50, back up rate-16 breaths per minute, FIO2-30%, and assist-control mode; weaned to T-piece at 40% and 8 liters of oxygen






Objective cues: GCS 5 –best

motor response is in decorticate position graded as 3

Unable to perform active range of motion exercises on all extremities

Grade 1/5 in the muscle grading scale (slight muscle contraction on all extremities, no joint motion)

Hand grasp of 0/3-none on both hands

Impaired physical mobility related to limitation in independent purposeful physical movement of the body secondary to motor never compression on frontal lobe

General:Within 2 weeks of medical and nursing interventions, client will be able to maintain or increase strength of the body and extremities.

Specific:Within 1 week of medical and nursing interventions, client will be able to:

Improve muscle strength on all extremities

Perform passive exercises on all extremities

Independent:Assessment:

Assess for developing thrombophlebitis (calf pain, Homan’s sign, redness, localized swelling, and hyperthermia)

Assess skin integrity

Therapeutic Keep side rails

up and bed in low position

Bed rest or immobility promotes clot formation

Regular examination of the skin especially on bony prominences will allow for prevention or early recognition and treatment of pressure sores.

This promotes a safe environment

Patient displays no signs of calf pain, redness and swelling on lower extremities, or hyperthermia.

Skin is dry, wrinkled, and rebounds instantly; with no signs of pressure sores or redness over bony prominences.

Patient is frequently monitored; secured raised side rails at all times; placed in low or semi-Fowler’s position

Turn patient every two hours

Maintain limbs in functional alignment

Perform passive ROM exercises on all extremities

Use pressure-relieving devices as indicated

Dependent: Administer

medications as ordered such as antispasmodic drugs (e.g. Vitamin B complex)

Turning position optimizes circulation to all tissues and relieves pressure.

Maintaining proper alignment pf extremities prevents contractures.

Exercise promotes increased venous return, prevents stiffness, and maintains muscle strength.

This prevents tissue breakdown

Antispasmodic medications may reduce muscle spasms that interfere with mobility.

Patient is repositioned every 2 hours, massaged bony prominences, and placed pillows or rolled cloth for limbs and body support.

Patient was provided with pillows and properly rolled cloth to maintain alignment and support on all limbs.

Passive range of motion exercises was provided to patient on all extremities with proper support and execution.

Placement of pillows or rolled cloth to prevent pressure of skin contact to surface; gentle massage on bony prominences was provided

Vitamin B complex (Polynerv) 500 mg was given to patient

Collaborative: Set-up a bowel

program (e.g. adequate fluid, foods high in bulk, physical activity, stool softeners, laxatives) as needed. Record bowel activity level.

Prolonged bed rest, lack of exercise, and physical inactivity contribute to constipation. A variety of interventions will promote normal eliminations.

IV fluid of PNSS 1L x 63 cc per hour, patent and infusing well at left metacarpal vein of patient, adjusted at a rate of 21 drops per minute; nutrition given through osteorized tube feeding of 1, 800 kcal in 6 equal feedings plus 6 egg whites; patient was also ordered with Lactulose 30 cc; no bowel movement noted since last week






Objective cues: presence of

surgical wound stitched across the right part of the head about 12 inches, vertical; with dry, intact 2 x 3 inches dressing

Risk for infection related to tissue destruction susceptible for invasion of pathogens.

General:Within 2 weeks of medical and nursing interventions, client will be able to prevent/reduce risk for infection.

Specific:Within 1 week of medical

Independent:Assessment:

Observe for localized signs of infection at surgical incision wound.

Note signs and symptoms of sepsis; fever,

To check for any signs of infection

To check for the presence of infection and give

Signs of infection were not noted; no visible signs of redness or pus around surgical site.

With normal temperature ranges from 35.6 C to 37. 1 C taken at left

on right parietal part of head

increased WBC (laboratory result of 14. 6 meq/L on January 7, 2013 )

Presence of an indwelling catheter and endotracheal tube

and nursing interventions, client will be able to manifest:

Absence of serosanguinous drainage from the surgical site.

Decrease or normal WBC value.

chills, diaphoresis.

Therapeutic: Change

surgical/wound dressings, as indicated, using aseptic technique for changing/ disposing of contaminated materials.

Health Teachings: Teach family how

to clean incision site daily and remind them to change dressings as needed.

Dependent: Administer or

monitor medication regimen (e.g. antibiiotics-Levofloxacin 750 mg, Vigocid 2.25 gm) and note patient’s response.

Collaborative: Note and report

laboratory values

necessary interventions.

To facilitate wound healing and prevent infection by minimizing growth and spread of microorganisms.

To educate the family about the right procedure to clean and change dressings.

To determine effectiveness of therapy.

To provide a global view of the patient’s immune function and nutritional status.

axilla; chills and diaphoresis not noted

Staff nurse on duty performed changing of surgical dressing, as indicated.

Significant other was instructed to follow correct hand washing and aseptic technique whenever in contact with a surgical wound.

Medications as directed follows the treatment duration for a certain number of days; completed the treatment regimen; temperature is within normal level of 35.6 C – 37 C;

Latest lab values for WBC was not checked by student nurses





Objective cues:

Unable to pass stool since last week; with diet of osteorized tube feeding of 1, 800 kcal in 6 equal feeding plus 6 egg whites

Inactivity, GCS 5 –best motor response is in decorticate position graded as 3

muscle grade of 1/5 (muscle contraction on all extremities but no joint motion

Constipation related to inhibited defecation reflex secondary to compression of the pudendal nerve on the medial prefrontal lobe of the brain

General:

Within 3 weeks of medical and nursing interventions, client will be able to pass out soft, formed stool

Specific:

Within 1 day of medical and nursing interventions, client will be able to:

maintain normal bowel sounds within the range of 5-32 gurgling or clicking sounds

perform passive ROM exercises on all extremities

IndependentAssessment

assess usual pattern of elimination; compare with present pattern, include size, frequency, color, and quality

evaluate laxative use, type, and frequency

assess activity level

evaluate current medication usage that may contribute to

normal frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is “normal” for each individual

chronic use of laxatives causes the muscles and nerves of the colon to function inadequately in producing an urge to defecate. Over time, the colon becomes atonic and distended.

Prolonged bed rest, lack of exercise, and inactivity causes constipation

Drugs that can cause constipation include the

constipation

Therapeutic provide fluid

intake of 2000 to 3000 mL/day, if not contraindicated medically

provide passive ROM exercises on all extremities

Health Teachings reinforce to

caregiver the importance of the following:

a balanced diet consisting of

following: narcotics, antacids, antidepressants, anticholinergics, antihypertensive, general anesthetics, hypnotics, and iron and calcium supplements

Patients, especially older patients, may have cardiovascular limitations that require that less fluid be taken

Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitates defecation

These steps lead to reestablishing regular bowel habits

Twenty grams of fiber per day is

adequate fiber, fresh fruits, vegetables and grains

adequate fluid intake (2000-3000 mL/day)

regular exercise and activity

regular meals

Dependent

administer drugs such as Lactulose, as ordered

Collaborative

Health teachings teach use of

medications as ordered, as in the following:bulk fiber (Metamucil)

recommended

Increased hydration promotes softer fecal mass

Exercise strengthen abdominal muscles and stimulate peristalsis

Successful bowel training relies on routine

This laxative is characterized by a shorter colon transit time and accelerated bowel movement.

This increase fluid, gaseous,

stool softeners (Colace)

chemical irritants (castor oil, cascara, milk of magnesia)

suppositories

oil retention enema

and solid bulk of intestinal contents

Softens stool and lubricates intestinal mucosa

These irritate the bowel mucosa and cause rapid propulsion of contents and small intestine

Softens stool and stimulates rectal mucosa

Softens stool





Objective cues:

GCS of 6 (best eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)

Risk for Aspiration related to decreased level of consciousness secondary to cerebral hypoperfusion

General:

Within 1 week of medical and nursing intervention, patient’s risk will decrease as a result of ongoing assessment and early interventions

Specific:

Within 1 day of medical

Absent cough reflex

Presence of endotracheal, and nasogastric tubes attached to patient

and nursing interventions, patient will be able to:

Maintain a patent airway





Objective cues: GCS of 6 (best

eye opening-opens to pain; verbal response-1 with ET attached to VR; motor response-3, flexes arms and extension of legs to pain)

Grade 1/5 in the muscle grading scale (slight muscle contraction on all extremities, no joint motion)

Hand grasp of 0/3-none on both hands

Self-Care Deficit related to decreased level of consciousness secondary to cerebral hypoperfusion and compression of the motor nerve on the frontal lobe

General:

Within 3 weeks of medical and nursing interventions, patient will be able to safely perform (to maximum ability) self-care activities

Specific:

Within 1 day of medical and nursing interventions, patient will be able to:

Exhibit good hygiene and grooming

Documents

Nursing Care Plan: Epidural Hematoma Post Craniotomy