Nursing measures:
Add bed rails to prevent falling out of bed and guard it closely.
Do not over-restrain his speech and behavior, so as not to increase energy consumption, so that the intracranial pressure is further increased.
When restraining appropriately, the restraining belt should not be too tight and wrapped around the limbs, so as not to cause peripheral blood reflux obstruction, and it is appropriate to be able to accommodate a finger after restraining.
Appropriate use of sedatives as prescribed by the doctor, and observe the effect of medication.
Properly fix and protect all kinds of tubes to prevent tubes from twisting, dislodging and folding.
Strengthen skin care: change the contaminated and wet clothes and blankets after urination and defecation; keep the bed unit flat and clean, free of crumbs, and prevent abrasions.
Trimming the patient's nails, if necessary, give the patient gloves to prevent scratching.
Eliminate the triggers that cause patient agitation: (1) actively deal with cerebral edema and intracranial hypertension. (2) Turn over in time to prevent limb pressure, make the patient's position comfortable, and pay attention to keep warm. (3) patients with urinary retention, with the palm of the hand circular massage of the lower abdomen, corkscrew plugging the anus and other physical stimulation to make them urinate, if necessary, catheterization can be used to relieve urinary retention.
I. Prevent fear
Main performance:
1 Complaints of restlessness, panic, headache aggravation.
2 Crying, avoidance, provocative behavior.
3 Insomnia, nightmares, increased muscle tone, and refusal to cooperate with treatment and care.
Objectives of care:
1 The patient is able to state the cause of the fear.
2 The patient is able to correctly adopt methods to reduce fear.
3 The patient's fear is reduced.
Nursing interventions:
1 Encourage the patient to express and patiently listen to the cause of his/her fear and assess its extent.
2 Understand the patient's feelings of fear and talk to the patient frequently.
3 Introduce patients to cured cases to build up their confidence.
4 Reduce and eliminate the fear of medical factors, such as treatment, care before patiently explain the purpose, guide the patient how to cooperate.
5 Avoid direct contact with the patient to rescue the patient and the patient's death and other scenes, the use of screens to block the field of vision.
6 Appropriate arrangements for visitation, pediatric appropriate arrangements for accompaniment.
7 Timely affirmation and encouragement of the patient's progress, so that the patient to establish confidence, to overcome the sense of fear.
II. Somatic mobility disorder
Related factors:
1 Inability to move the body purposefully due to impaired consciousness.
2 Reluctance to move the trunk because of pain and discomfort.
3 Limited movement of the trunk due to paralysis of a limb.
4 Restriction of movement due to bed rest.
Main manifestations:
1 Decreased range of trunk movement.
2 Inability or unwillingness to move.
3 Passive position and use of restraining belts.
Goals of care:
1 Patient's life needs are met.
2 The patient has no complications such as decubitus ulcers, thrombophlebitis, or pulmonary atelectasis.
Nursing measures:
1 Keep the patient in a comfortable position.
2 Turn over and pat the back once every 2 hours.
3 Do life care. Oral care 2 times a day; wipe bath 2 times a day in summer, 1 time a day in winter; regular feeding diet; timely cleaning of the perianal area and perineum after urination and defecation.
4 agitation, consciousness disorder patients, the use of bed rails, restraining belts, in order to prevent falling out of bed.
5 Maintain the functional position of the limbs, and parallel limb massage, 3 times a day.
6 Replenish enough water, eat more fiber-rich food to prevent constipation.
3. Self-care deficits
Associated factors:
1 Consciousness, mental, and visual impairment.
2 Paralysis.
3 Bed-ridden with activity limitations.
4 Decreased endurance, which reduces mobility.
5 Altered state of comfort: headaches.
Main manifestations:
1 The patient is unable to independently perform daily activities such as eating, washing, bathing, and urinating and defecating.
2 The patient can not purposefully complete the turning movement.
Nursing goals:
1 The patient's needs are met while in bed.
2 The patient is comfortable and free from stomatitis, decubitus ulcers, and falling beds.
Nursing measures:
1 Doing the patient's daily life care, such as oral care 2 times a day; wiping bath 2 times a day in summer, 1 time a day in winter; regular feeding diet.
2 After urination and defecation, clean the perianal area and perineum in a timely manner, and change the wet, polluted clothes and blankets at any time.
3 Assist the patient to turn over, pat the back, once every 2 hours.
4 Remove oral and nasal secretions and vomit at any time to keep the airway open.
5 Consciousness, mental disorders patients, the use of bed rails, restraining belts, if necessary, guarded.
6 Strictly grasp the hot water bag, ice bag use indications, to prevent scalding or frostbite.
Four, language communication disorders
Related factors:
1 Tracheal intubation or tracheotomy can not pronounce.
2 Consciousness, mental disorders can not speak or language with errors.
Main manifestations:
1 Difficulty in speaking or pronouncing words, slurred speech.
2 Failure to speak or inability to speak.
3 Inappropriate use of words or unclear expression.
Goals of care:
1 The patient takes the initiative to express his or her feelings and needs.
2 The patient's request to express needs is understood.
Nursing measures:
1 The patient takes the initiative to care for and inquire about the patient's feelings and needs.
2 Patiently listen to the patient's words and encourage the patient to express them clearly.
3 Encourage and teach patients to use sign language when they have trouble pronouncing words, so that they can express their needs.
4 For patients who cannot understand the language of medical staff, try to help explain.
6. Impaired consciousness
Related factors:
1 Cerebral edema causes functional and structural damage to brain tissue.
2 Cerebral hypoxia causes metabolic disorders in brain cells.
3 Impaired cerebral blood circulation due to elevated intracranial pressure.
Main manifestations:
1 Drowsiness. For the early milder impairment of consciousness, the patient is in a sleep state, given a slight stimulus to wake up, wake up to answer questions.
2 Hazy. The patient's ability to be aware of people, objects, time, and place is impaired, and he or she is unresponsive and unable to answer questions correctly.
3 Shallow coma. Most of the consciousness is lost, only swallowing, coughing, corneal and eyelash reflexes are present, and there are painful expressions and defense reflexes to painful stimuli.
4 Deep coma. Complete loss of consciousness, no response to external stimuli, all reflexes disappear.
5 GCS scoring <13.
Nursing goals:
1 The patient's degree of impaired consciousness is reduced.
2 Patient has no secondary injuries.
Nursing measures:
1 Monitor mental status and record the patient's response to external stimuli on a GCS scale every 0.5-1 hour.
2 Keep the patient comfortable in his own position and turn him and pat him on the back once every 2 hours.
3 Keep the airway open.
4 Prevent secondary injury.
(1) Protect the patient with bed rails and restraining straps to prevent falling out of bed.
(2) When swallowing and coughing reflexes are impaired, do not feed food and drink through the mouth, so as not to cause aspiration pneumonia and suffocation.
(3) patients with incomplete eyelid closure, chloramphenicol eye drops 3 times a day, tetracycline eye ointment coated eyes once a night, and eye pads to cover the affected eye to avoid exposure keratitis.
5 Do physiological care.
(1) Refer to the relevant content in the "physical mobility disorders" of this disease.
(2) Change wet sheets and pants at any time.
(3) When turning over, pay attention to maintain the functional position of the limbs.
Seven, clearing the airway ineffective
Related factors:
1 The role of tracheal intubation, tracheotomy, or ventilator, so that coughing and sputum expulsion is limited.
2 Inability to expectorate on their own due to impaired consciousness.
3 Impaired cough reflex due to posterior group cranial nerve injury.
4 Accumulation of sputum due to bed rest.
Main manifestations:
1 Awake patients complain of chest tightness, dyspnea, or afraid to cough.
2 The patient has phlegm sounds in the throat, cyanosis, dyspnea or snoring breathing.
3 The patient is extubated, tracheotomized, or ventilator-assisted breathing.
Goals of care:
1 Patient has no laryngeal sputum sounds.
2 Patient has no airway obstruction and no choking occurs.
Nursing measures:
1 Encourage and instruct the awake patient to cough and expectorate.
2 Keep the room clean, maintain room temperature 18-22 degrees, humidity 50%-60%, avoid dry air.
3 Closely observe the patient's breathing, color, consciousness, pupil changes every 0.5-1 hour.
4 Monitor body temperature every 4 hours.
5 Keep the airway open to prevent cerebral hypoxia.
(1) Remove respiratory secretions and vomit at all times.
(2) Turn over to be patted on the back, in order to make the respiratory tract phlegm crusts loose, easy to drain.
(3) Inhale pure oxygen or hyperventilate before suctioning, each suction time <15 seconds to prevent cerebral hypoxia.
(4) When the sputum is thick, follow the doctor's advice of endotracheal drip every hour, airway wetting or nebulized inhalation every 4-8 hours, and airway flushing to wet the sputum if necessary.
(5) For those with impaired consciousness and reverse swallowing and coughing disorders, prepare a tracheotomy bag at the bedside.
(6) For tracheotomy, pay attention to aseptic operation and post-tracheotomy care.
(7) Give nasal juice to the patient to feed the diet of elevated head of the bed, eating 1 hour without moving the patient, to prevent food backflow into the airway.
Eight, central hyperthermia
Related factors:
Damage or lesions of the lower thalamus, brainstem, and upper cervical medulla, resulting in central thermoregulatory malfunction.
Main manifestations:
1 Hyperthermia with a temperature of >39°C. Mostly appeared within 48 hours after surgery, the patient complained of fever and discomfort.
2 Often accompanied by impaired consciousness, dilated pupils, increased respiratory rate and increased pulse rate.
Nursing goals:
1 The patient's temperature is in the normal range.
2 The patient has no complications.
Nursing measures:
1 Monitor the patient's temperature every 1-4 hours.
2 Temperature > 38 ℃ or more, that is, take cooling measures.
(1) When the body temperature is 38-39 ℃, give warm water bath.
(2) body temperature >39 ℃, 30% -50% alcohol 200-300mL bath, placed in the large blood vessels in the ice bag, the head of the ice cap.
(3) In summer, electric fans and air conditioners can be used to reduce the ambient temperature, and quilts can be removed if necessary.
(4) Cooling blanket continuous cooling.
4 After the above treatment, the body temperature still does not fall, available hibernation hypothermia therapy to reduce body temperature:
(1) before the use of medication, pay attention to the observation of the patient's vital signs, such as a rapid pulse, respiratory slowdown, low blood pressure, should be reported to the doctor to change the drug.
(2) Half an hour after the use of drugs with the use of physical hypothermia.
(3) The speed of cooling should not be too fast.
(4) regular temperature measurement and observation of the whole body, cooling has an anal temperature of 32-34 ℃ is appropriate to avoid complications.
(5) patients with chills, goose bumps, muscle tension, should be temporarily removed from the ice pack, to be added after sedation.
(6) Due to the lower metabolic rate of the body, gastrointestinal function is weakened, generally not from the gastrointestinal intake, fluid input should not be >1500mL per day.
(7) Hibernation hypothermia should not be too long, generally 3-5 days, to prevent complications such as lung infections, frostbite, decubitus ulcers and other complications.
(8) When hibernation therapy is stopped, the physical cooling should be stopped first, and the patient should be covered with bedding so that the body temperature can rise naturally, and if necessary, the hot water bag should be used to rewarm the body or use hormones and other medicines in accordance with the doctor's instructions.
5 Cooling process should pay attention to:
(1) Alcohol bath is prohibited to wipe the forehead, neck and abdomen, so as to avoid reflexive slowing of the heartbeat; alcohol allergy, can not be alcohol bath.
(2) alcohol bath head placed in an ice bag, foot hot water bag.
(3) hot water bag, ice bag should be wrapped in double cotton cloth or double cloth cover, every half hour to change the part, to prevent burns, frostbite.
(4) Replace sweaty clothes and blankets at any time, and keep the bed sheets dry to prevent the patient from getting cold.
6 Encourage the patient to drink more water, eat a light, easy to digest, high-calorie diet to supplement the body's consumption of heat and water.
7 Strengthen oral care, turn over in time.
Nine, there is a risk of insufficient body fluids
Related factors:
1 High fever, vomiting, diarrhea, gastrointestinal bleeding.
2 Water and salt loss due to uremia.
3 Hypertonic diuretic use.
4 Leakage of cerebrospinal fluid.
5 Neurogenic diabetes mellitus that produces osmotic diuresis.
Main manifestations:
1 Persistent elevation of body temperature, sweating, vomiting, diarrhea, black stools, and cerebrospinal fluid leakage from the ears or nose.
2 Withdrawal of coffee-colored fluid from the stomach, excessive urination (>200mL/h), and positive urine sugar.
3 Cerebral edema on dehydrating diuretic medications.
Goals of care:
1 Patient's fluid loss is reduced or controlled.
2 Patient water and electrolyte balance is maintained.
Nursing measures:
1 Accurately record the amount of water in and out of the 24-hour period, and report any abnormalities to the physician.
2 When high fever and excessive urination, encourage the patient to drink saline boiled water to replace the lost water or salt.
3 When high fever, take timely cooling measures.
4 Temporarily fasting when vomiting, diarrhea, blood in stool, so as not to aggravate the gastrointestinal burden, aggravate diarrhea, blood in stool and vomiting.
5 Reasonable use of antiemetic, antidiarrheal and antiemetic drugs as prescribed by the doctor. If gastric bleeding to ice saline 300mL plus norepinephrine. 1mg gastric lavage.
6 Urine (urine volume >4000mL/d or >200mL/h), urine sugar positive, follow the doctor's instructions to use antidiuretic and hypoglycemic drugs, such as long-acting uradine, insulin.
7 Strictly grasp the indications for the use of hypertonic diuretics, and pay attention to observe the effect of diuresis.
8 In the case of cerebrospinal fluid leakage, accurately record the amount of leakage.
X. Risk of injury
Related factors:
1 Impaired consciousness.
2 Mental disorder.
3 Seizures.
4 Sensory disorders.
5 Physical mobility disorders.
Main manifestations:
1 Impaired consciousness, mental abnormality, seizures, dulled or absent sensation, paralysis of limbs.
2 Improper methods of operation such as turning, heat, ice, and protective measures.
Goal of care:
No accidental injury to the patient.
Nursing measures:
1 Use an air mattress bed for bedridden patients.
2 Assist the patient in position with gentle, steady, and correct movements.
3 Restraint of the limbs of patients with agitation, mental excitement, hallucinations, etc., can not be wrapped around the limbs, and the tightness of the restraints to accommodate a finger is appropriate, to prevent the cause of the limb blood reflux obstacles, ischemic necrosis of the distal limb.
4 For agitation, mental disorders, patients sent special guards, if necessary, follow the doctor's orders to give sedatives.
5 Seizures, the correct use of dental pads, do not force pressure on the limb, so as not to cause tongue bite and fracture.
6 Good daily life care.
7 Strictly grasp the indications for the use of hot water bags, ice bags, the use of the correct method to prevent burns and frostbite.
XI. Possibility of malnutrition
Related factors:
1 Inability to eat due to impaired consciousness or swallowing disorders.
2 Vomiting, diarrhea, gastrointestinal bleeding.
3 High fever and increased metabolism.
4 Repair of the body with increased needs.
Main manifestations:
1 Persistent fever, temperature >37.2°C, repeated vomiting, diarrhea, gastrointestinal bleeding.
2 Impaired consciousness, impaired swallowing reflex.
Nursing goals:
1 The patient's nutritional needs are met.
2 Factors contributing to malnutrition are reduced or controlled.
Nursing measures:
1 If the patient is awake at 6 hours postoperatively, without vomiting and swallowing disorders, a small amount of fluid diet is given.
2 Consciousness, dysphagia patients 24 hours postoperative nasal fluid.
3 Patients with abdominal distension, vomiting, diarrhea, gastrointestinal bleeding symptoms, timely report to the physician to deal with the symptoms lifted to a small amount of fluid test feeding, if there is no abnormality, that is, gradually increase the number of times and the amount of food and drink, and gradually transitioned to a high-protein diet.
4 Ensure the supply of calories for gastrointestinal nutrition. Fluid diet 6-8 times/d, 200mL each time; soft food 4-5 times/d; high protein diet 3 times/d; in order to make the daily calorie supply in 1.25-1.67MJ (3000-4000kcal).
5 Keep the fluids and intravenous nutrition smooth. Follow the doctor's instructions to enter 20% fat emulsion 200-500mL, 20% albumin 50mL, etc. per day.
XII, there is the possibility of skin damage
Related factors:
1 The patient due to impaired consciousness, limb paralysis, pain in the wound and can not change their position, resulting in prolonged local pressure.
2 Restricted position.
3 Systemic malnutrition.
4 Local physical and chemical stimuli.
Main manifestations:
1 Impaired consciousness, limb paralysis, wound pain.
2 Postoperative restriction of position, urine, sweat irritation.
3 Elderly; generalized emaciation, edema; itchy skin.
Goals of care:
Patient has no skin lesions.
Nursing measures:
1 Assess the patient's generalized nutritional status and skin condition.
2 Regularly assist the patient to change the position and massage the bony prominence. For those who restrict the position, decompression of the pressure area is rotated.
3 Replace sweaty, wet urine, wet clothes, and wash the local area in time.
4 For the patient to wipe the bath, the use of neutral soap, water temperature of about 50 ℃, avoid rubbing, rubbing, pressurized parts of the pouncing talcum powder.
5 The patient's itchy skin, should be properly restrained hands, so as not to scratch the skin.
6 Cut nails frequently to prevent self-injury.
7 Strengthen the dietary care, improve the nutritional status of the whole body, and enhance the resistance of the body.
Thirteen, there is the possibility of drainage abnormality
Related factors:
1 Postoperative retention of ventricular drainage, trabecular drainage, pus cavity drainage, subdural drainage.
2 Drainage bag positioned too high, too low, drainage tube dislodged, twisted.
Main manifestations:
1 Excessive or poor drainage.
2 Drainage fluid color changes from light to dark.
3 The patient shows signs of increased intracranial pressure such as headache, vomiting, impaired consciousness, and dilated pupils.
Nursing measures:
1 Postoperative patient, immediately receive the drainage bag at the bedside.
2 Keep the drainage smooth, the drainage tube should not be pressurized, twisted, folded.
3 Appropriate head braking, turning and nursing operations to avoid pulling the drainage tube.
4 Replace the drainage bag every day, and accurately record the amount and color of drainage.
5 Drainage bag is usually placed for 3-4 days to avoid retrograde infection.
Strengthening the care of the drainage tube:
(1) the care of ventricular drainage: ① drainage bag hanging from the lateral ventricle at a height of 10-15cm to maintain normal intracranial pressure. ② Early contraindicated drainage too fast, so as not to lead to epidural or subdural hematoma, tumor stroke (brain tumor hemorrhage), brain hernia formation. If necessary, hang the drainage bag appropriately to slow down the drainage speed. ④Control the cerebrospinal fluid drainage, and supplement water and electrolytes as prescribed by the doctor when the drainage is high. ⑤ The cerebrospinal fluid is slightly yellowish 1-2 days after operation, if it is bloody, or the color of bloody cerebrospinal fluid deepens after operation, it suggests that there is intraventricular hemorrhage, and should be reported to the doctor for emergency surgery to stop bleeding. (6) Clamp the drain tube 1 day before extubation and observe closely, if the patient has headache, vomiting and other symptoms, report to the doctor immediately to open the drain tube. (7) After extubation, if there is cerebrospinal fluid leakage at the incision, the doctor should be informed to suture it to avoid intracranial infection.
(2) Nursing care of traumatic drainage: ① Within 48 hours after surgery, the drainage bag is placed in a consistent position in the head traumatic cavity to maintain a certain fluid pressure in the traumatic cavity to avoid brain tissue displacement. ② After 48 hours after surgery, gradually lower the drainage bag, so that the liquid in the traumatic cavity faster drainage, in order to eliminate the local dead space, to prevent intracranial pressure increase. ③ The traumatic cavity connected with the ventricles should be elevated appropriately to avoid excessive drainage.
(3) pus drainage care: ① drainage bag is lower than the pus cavity more than 30cm, the patient lying down when the pus cavity is located in a high position, in order to drain the pus faster. ② 24 hours after surgery before intracapsular flushing, so as not to cause diffuse intracranial infection. ③When rinsing, each rinsing volume of about 10-20mL, slowly injected, and then gently withdrawn, not excessive pressure. ④Inject the medicinal solution after flushing and clamp the drainage tube for 2-4 hours to maintain the efficacy of the medication. ⑤ The drainage tube is gradually withdrawn outward until it is removed.
(4) the care of subdural drainage: ① the patient lying down or head down feet high position, in order to facilitate the position of drainage. ② drainage bag is lower than the trauma cavity 30cm. ③ postoperative not use dehydrating agents, do not limit water intake, so as not to intracranial low pressure so that the subdural space is not easy to close.
Fourteen, potential complications - intracranial hemorrhage
Related factors:
1 Changes in intracranial pressure, so that the hemostasis again bleeding.
2 Insufficient intraoperative hemostasis.
3 Coagulation disorders.
Main manifestations:
1 Altered consciousness. The patient's consciousness is clear and then gradually from drowsiness into coma.
2 One side of the pupil dilation, light reflex retardation; advanced bilateral pupil dilation, light reflex disappearance.
3 High fever, convulsions, and disorders of vital signs.
Nursing objectives:
1 Be alert to the aura of intracranial hemorrhage, once intracranial hemorrhage occurs, cooperate with the physician in time to take surgical hemostasis preparations in order to save the patient's life.
2 Avoid elevated intracranial pressure as a result of inappropriate care.
Nursing measures:
1 Monitor consciousness, pupil, vital signs, abnormalities, timely report to the physician.
2 Avoid elevated intracranial pressure.
(1) Use dehydration medications promptly and accurately as prescribed.
(2) Turn over gently and steadily, to avoid head twisting to make breathing difficult.
(3) Keep the airway open; high-flow oxygen infusion.
(4) Keep warm to prevent increased cerebral oxygen consumption due to cold and fever.
(5) Keep the patient's bowels clear, and ask the patient not to defecate with force.
(6) Control or reduce seizures.
(7) Proper care of various drains.
3 As soon as signs of intracranial hemorrhage are detected, report to the physician and follow medical advice.
(1) Accurately apply dehydration drugs and observe the effect of dehydration.
(2) Cooperate with a good CT examination to determine the site of bleeding and the amount of bleeding.
(3) Cooperate to prepare for reoperation.
XV. Potential Complications - Uremia
Related Factors:
1 Damage to the fiber bundle from the supraoptic nucleus to the posterior lobe of the pituitary gland caused by lesions or injuries in the vicinity of the pyriform region.
2 Surgical trauma.
Main manifestations:
1 Thirsty mouth, excessive drinking, polyuria, urine volume >4000mL/d, or even up to 10,000mL/d, specific gravity of urine <1.005, and positive for urinary glucose.
2 Apathy, poor mental or aggravated disorders of consciousness, dry and poorly elastic skin and mucous membranes.
3 Hyponatremia (Na+<130mmol/L) anemia, hypochlorhydria (Cl-<95mmol/L) anemia.
Goal of care: reduction or control of uremia.
Nursing measures:
1 Monitor urine volume, glucose, and specific gravity of urine in patients undergoing surgery near the pterygoid saddle, every 0.5-1 hour, and accurately record water intake and output over 24 hours.
2 Closely observe the mental state, pupil, vital signs, every 1-2 hours.
3 When urine volume >200mL/h, urine specific gravity <1.005, urine sugar positive:
(1) Report to the physician in time, follow the doctor's instructions to apply antidiuretic drugs (pituitary posterior lobe hormone or long-acting avalanche) and insulin, and observe the effect of medication.
(2) Encourage and instruct the patient to drink salted water to replace lost water and salt.
(3) Prohibit the intake of sugary foods and medications, so as not to elevate blood glucose and produce osmotic diuresis, which increases urine output.
(4) Monitor blood glucose every 2-8 hours.
(5) Follow the doctor's instructions to draw blood for E4A (K+, Na+, Cl-, CO2CP) and trace the lab results in time to guide treatment.
4 Replace wet urine, seepage wet clothing at any time.
Sixteen, potential complications - epilepsy
Related factors:
1 Trauma to the cerebral cortex provocation or damage.
2 Intracranial occupations, cerebrovascular disease.
3 Cerebral hypoxia.
Major manifestations:
1 Grand mal seizure: sudden loss of consciousness, spasmodic convulsions of the whole body, mostly lasting several minutes.
2 Minor seizures: brief loss of consciousness or localized muscle twitching.
3 Limiting seizures: localized muscle twitching or abnormal sensations.
4 Psychomotor seizures: predominantly psychotic symptoms, with multiple hallucinations, illusions, and automatisms.
Nursing goals:
1 The awake patient is able to describe the aura and trigger of the seizure.
2 Seizures are reduced or controlled.
3 The patient is free of secondary injury.
Nursing measures:
1 The patient is placed on bed rest to minimize physical exertion and lower the metabolic rate.
2 High-flow oxygen delivery to keep the airway open to prevent cerebral hypoxia.
3 Follow the doctor's advice to give sedative and antiepileptic drugs, such as dalentine and luminal, in time to prevent seizures.
4 Eliminate or reduce morbidity triggers.
(1) The patient sleeps adequately, and non-therapeutic needs do not disturb the patient's sleep.
(2) Care for the patient, avoid the patient's emotional excitement.
(3) The medication should be administered on time, and should not be stopped, reduced, or changed abruptly.
(4) Keep warm and prevent colds.
(5) Prohibit spicy, stimulating, excitatory food and drugs.
5 Strengthen the care of seizures:
(1) Specialized guarding.
(2) Place dental pads between upper and lower molars during grand mal seizures to prevent tongue bite.
(3) Do not forcefully press the patient's limbs to prevent dislocations or fractures.
(4) Dentures should be removed quickly, and clothes, buttons, and pants should be unbuttoned in time, with the head tilted to one side to prevent blockage of the airway and restriction of breathing.
(5) High-flow oxygen delivery to improve cerebral hypoxia.
(6) When the seizure stops, the patient's consciousness is not fully recovered, do not feed water, so as not to cause choking on drinking water, or even suffocation.
(7) Detailed records of seizure time, nature, duration, in order to assist in the treatment.
6 Frequent grand mal seizures in a short period of time, intermittent unconsciousness (epileptic status persistent), follow the doctor's instructions to control seizures and correct the imbalance of the internal environment.
Seventeen potential complications - gastrointestinal bleeding
Related factors:
1 Injury to the subthalamus, brainstem injury.
2 Surgery near the saddle area, third ventricle, fourth ventricle, brainstem.
Main manifestations:
1 The patient vomits or aspirates coffee-colored or dark-red fluid from the stomach with eructation, bloating, black stools, or blood in the stool.
2 Anemia, shock.
Goals of care:
1 Reduce or control gastrointestinal bleeding.
2 Patient does not asphyxiate and has no perianal erosion.
Nursing measures:
1 Closely observe the patient for eructation, abdominal distension, vomiting, vomiting blood, and blood in stool.
2 Temporary fasting when the patient has gastrointestinal bleeding, so as not to aggravate the gastrointestinal burden.
3 Nursing measures for gastrointestinal bleeding:
(1) Comfort awake patients, family members, advice not to be nervous, cooperate with nursing.
(2) Obstructed consciousness and vomiting patient's head to one side, to prevent aspiration, suffocation.
(3) Immediately after suctioning the residual fluid in the stomach through the gastric tube as prescribed by the doctor, the stomach was washed repeatedly with ice saline 300mL plus norepinephrine 1mg, and then injected with aluminum hydroxide gel 30-50mL in order to stop hemorrhage and protect the gastric mucosa.
(4) Intravenous or intramuscular injection of hemostatic drugs as prescribed by the doctor.
(5) After the bleeding stops, try to feed a small amount of milk, and then gradually increase the amount of diet.
4 Closely observe the vital signs, the effect of hemostasis, and record the bleeding time, frequency and volume in time.
5 Repeated bleeding, follow the medical advice of blood transfusion.
6 Patients with bleeding in the stool, clean the bed sheet at any time, clean the perianal area, wipe and wash the perineum and buttocks, if necessary, use antimicrobial ointment to protect the perineum, perianal area, to prevent perianal ulceration.
Eighteen, potential complications - infection
Related factors:
1 Trauma to skin breakage.
2 The airway is open to the outside world after tracheotomy.
3 Leakage of cerebrospinal fluid.
4 Invasive intracranial pressure monitoring.
5 Indwelling drains: ventricular drainage, indwelling catheterization, etc.
Main manifestations:
1 Localized erythema, oozing, and ulceration.
2 Increased respiratory secretions, dry and wet rales in the lungs, dyspnea.
3 Altered or worsened consciousness.
4 Abnormal drainage volume and color, such as turbid ventricular drainage fluid, flocculent, increased drainage volume.
5 Elevated temperature >37.5°C, ICP >2kPa (15mmHg).
Goals of care:
1 Patient is free of infection.
2 Signs of infection in the patient are recognized in time to be controlled.
Nursing measures:
1 Control visitation to reduce exogenous infection factors.
2 Encourage and assist the patient to eat nutritious food to enhance the body resistance.
3 Proper care of tracheotomy and other tubes:
(1) Sterilization of endotracheal tube, every 4-6 hours; wound dressing change, every 4-6 hours; attention to aseptic operation when suctioning.
(2) The drainage bag should not be elevated to prevent retrograde infection.
(3) Change the drainage bag every day (every other day in winter).
(4) Clean and disinfect the urethra twice a day for patients with indwelling catheters; keep the perineum clean during menstruation for female patients.
6 If there is skin breakage, change the medicine in time to prevent pressure.
7 Do a good job of cerebrospinal fluid leakage care (refer to the "craniocerebral injury patients standard care plan" in the relevant content).
8 Monitor temperature every 4-8 hours.
19 Premonitory grief
Related factors:
1 Paralysis of the limbs.
2 Facial nerve injury: facial paralysis, incomplete eyelid closure.
3 Altered social roles: gynecomastia, beard growth in women, juvenile body image, etc.
4 Lifestyle changes: bedridden, wheelchair, claudication, hypogonadism, etc.
Main manifestations:
1 Sadness, tears, sighs, self-blame or blame others, irritability, and even self-injury or hurtful behavior.
2 Reluctance to contact with the outside world, food refusal, loss of confidence in life.
3 Changes in lifestyle, self-image.
Nursing goals
1 The patient can face reality and accept changes in lifestyle and self-image.
2 Live positively and optimistically.
Nursing measures:
1 Tell and explain the necessity of surgery to the patient before the operation, so that the patient understands the possible image change and lifestyle change after the operation.
2 For the sequelae of the patient to strengthen psychological care, encourage the patient to face the reality, actively cooperate with the treatment, so that the sequelae to reduce.
(1) For patients with facial paralysis, remove secretions from the corners of their mouths at any time, and perform facial massage three times a day; each time for more than 30 minutes.
(2) For patients with incomplete eyelid closure, use chloramphenicol eye drops 3 times a day; tetracycline eye ointment on the eyes, once a night; wear eye shields to prevent exposure keratitis.
(3) People with limb paralysis, adhere to muscle training.
3 Discharged life:
(1) For those who have lost the ability to take care of themselves, assist them in their daily life, and do not blame the patient arbitrarily.
(2) Talk to the patient at any time, communicate ideas, allow the patient to properly vent their sorrow, crying, and sympathize with the patient's feelings.
(3) Understand the patient's psychological state, when there is a tendency of self-injury, hurt people, avoid letting the patient alone, do not let the patient contact with objects that can hurt people.
(4) Allow the patient to participate in healthy and beneficial activities, such as the disabled association, so that the patient can feel the joy of life.
4 Grooming tips for patients:
(1) Dress gynecomastia patients loosely.
(2) Female patients with long beards avoid heavy makeup and use hair removers, such as brightening creams, when necessary.
(3) For patients with bone flap defects, it is advisable to wear long hair and hats, and to prevent hard objects from touching. Larger bone flap defects, half a year after surgery, bone flap repair surgery.
5 Teach patients to redesign their self-image and adapt to the post-disease lifestyle.
(1) Use of wheelchair and precautions.
(2) Use of crutches and precautions.
(3) Precautions for bedridden life.