- Maintain cervical spine stability until cleared by an x-ray. - Report presence of cerebrospinal fluid (CSF) from nose or ears to the provider. - Provide a calm, restful environment (limit visitors, minimize noise). - Implement measures to prevent complications of immobility (turn every 2 hr, footboard, and splints). Specialty beds can be used. - Monitor fluid and electrolyte values and osmolarity to detect changes in sodium regulation, the onset of diabetes insipidus, or severe hypovolemia. - Provide adequate fluids to maintain cerebral perfusion and to minimize cerebral edema. When a large amount of IV fluids are prescribed, monitor for excess fluid volume which could increase ICP. - Maintain safety and seizure precautions (side rails up, padded side rails, call light within the client's reach). - Even if the level of consciousness is decreased, explain to Luz 9/2/18
[Type here] the client the actions being taken and why. > Hearing is the last sense affected by a head injury 10. Pituitary disorder: Monitoring client at risk for Diabetes Insipidus Excretion of a large quantity of diluted urine Inappropriate antidiuretic hormone (SIADH)--> kidneys retain water, urine output decreases, and extracellular fluid volume is increased 11. Disorders of the eye: Evaluating teaching following cataract extraction -signs of infection: yellow or green drainage -pain with nausea/vomiting -lid swelling, decreased vision, bleeding or discharge, a sharp/sudden eye pain, and/or flashes of light or floating shapes -preventing infection -admin ophthalmic meds -providing pain relief -teaching the pt about self care and fall prevention Avoid after surgery: -bending over at the waist -sneezing, coughing, straining -head hyperflexion -restrictive clothing, such as tight shirt collars -sexual intercourse 12. Acute and infectious respiratory illnesses: Caring for a toddler who is postoperative following a tonsillectomy Look for bleeding Monitor for diff breathing Assess airway and vital signs - Analgesics (acetaminiphine and codeine) - Provide ice collar - Offer ice chips or sips of water - Discourage coughing, throat clearing or blowing nose - Refrain from putting objects in the back of the mouth - Alert parents that there may be clots or blood-tinged mucus in vomit 13. Fractures: Discharge instructions Educate the client and parents about the length of treatment that can be needed and long - term antibiotic therapy. Remind the client and parents to limit movement of the affected limb and avoid bearing any weight until cleared by the provider Advise the parents to provide for diversional activities consistent with the client’s level of development. Educate the client about the need for proper nutrition Luz 9/2/18
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- Fall '19
- Intracranial pressure, Cerebrospinal fluid, cerebral blood flow, Luz 9/2/18