A patient presenting with a head injury can pose a lot of complications and the nurse needs to assess and monitor the patient thoroughly. Management of traumatic brain injury focuses on stabilisation of the patient and prevention of secondary neurologic damage due to high intracranial pressure. Assessment of the brain injury hinges on evaluation of the Glasgow coma scale, GCS and examination of the pupils (Chesnut, 2006, p.1). Nurses make important clinical decisions everyday and these decisions have an effect on the patient’s healthcare and the actions of other health care professionals, as the emergency department treats patients with various complex needs nurses need to rely on sound decision making skills and assess monitor and
The nurse knows that this particular type of fracture can cause damage to the nerve pathways, cranial nerves, or vital centers. Jeff's vital signs and neurologic status will be monitored frequently. 1. Which assessment technique allows the nurse to assess for Battle's sign? A) Assess Jeff's pupillary response to light.
Nursing Sensitive Indicators Nurse sensitive indicators included in this case are Mr. J’s use of restraints, complications of pressure ulcers, and patient satisfaction. Had the nurse who was caring for Mr. J been aware about the risks of pressure ulcer development with the use of restraints, the beginning stage of a pressure ulcer could have been prevented. Better RN assessment of Mr. J’s restraints, repositioning Mr. J every two hours and a thorough skin assessment should be done at every shift. The NA should be instructed to notify RN if they see anything out of the ordinary with patients, such as the redness to the lower spine of Mr. J. The nursing staff assigned to Mr. J will need additional training about restraints as far as appropriate use of restraints and how to care for a patient who is restrained.
1.3 Outline agreed ways of working that relate to managing pain and discomfort. To follow the patients care plan, a detailed explanation on how to care for the patient. This should include full medication details and any information on illnesses and diseases the patient may have. For instance Mrs Smith suffers with arthritis in her wrists, she is prescribed co-codamol on an as needed (PRN) basis, when she shows signs of distress or discomfort, staff may offer the stated dose of the medication on the box to the patient to relieve pain and discomfort. All this information would be available in the clients care plan and on the MAR-Sheet.
* Assess patient’s pain level and administers appropriate pain relief measures. * Maintains patient’s safety(airway, circulation, prevention of injury) * Administer medication, fluid and blood component therapy, if prescribed. * Assess patient’s readiness for transfer to in hospital unit or for discharge home based on institutional policy. 2. Identify priority nursing care to prevent potential complications following this type of surgery.
The nurse knows that this particular type of fracture can cause damage to the nerve pathways, cranial nerves, or vital centers. Jeff's vital signs and neurologic status will be monitored frequently. 1. Which assessment technique allows the nurse to assess for Battle's sign? B) Observe the area behind Jeff's ears.
The nurse must be very observant and watch for signs of pain. According to Herr, pain assessment in unresponsive patients should be achieved by direct observation using the Pain Assessment in Advanced Dementia Scale (PAINAD) or the Pain Assessment for Seniors with Limited Ability to Communicate (PASCLAC) scale (2010). Each of these scales provides a pain score based on observations of the patient, such as body language, facial expression, breathing, and activity
A critical analysis of the dashboard reveals that the areas where enhanced performance was recorded are the courtesy of registered nurses, management and prevention of falls among patients, as well as a high number of patients, who are assessed for pressure ulcers within 24 hours. One of the areas where poor performance was recorded is the management of patients to prevent pressure ulcers. The first step in pressure ulcers prevention nursing plan is the identification of risk factors followed by identification of the body parts of patients that are at risk of developing pressure ulcers. Development of a risk assessment plan to assess the risk factors and the number of patients at risk of pressure ulcers is also a core component of the prevention plan. Finally, practical interventions need to be developed to address all cases pressure
As a health care professional trained in different approach, I assessed my client based on the theory and learning experience that I have had. The client was been diagnosed with dementia, limited mobility, and inadequate verbal communication. I undertook a full assessment to a client with a sacral pressure sore. Assessment using observation was been completed to the sacral area, and graded the level of pressure ulcer using the Braden scale. The nurse mentor was been informed about the type of dressing and intervention that should be provided to the client, along with the explanation with the rationale to the procedure that I have decided to use.
Yet the contribution of each component will be specific to each individual and his or her situation. Palliative care utilizes an interdisciplinary approach to patient care, relying on input from doctors, pharmacists, nurses, chaplains, social workers, psychologists, and other allied health professionals in formulating a plan of care to relieve total pain and suffering in all areas of a patient's life (Krouse, 2008). In this essay I will discuss the impact that the interdisciplinary team may have on total pain in a patient suffering from a life limiting illness. Total Pain: Pain is a common symptom of end-stage illness, affecting between 70 and 90 percent of patients with advanced cancer and large numbers of patients experiencing other life-threatening illnesses (Hospice of the Western Reserve, 2003). It is a complex and individual experience, often requiring creative approaches to identify causes and seek solutions for relief (Middleton-Green, 2008).