Head Injury ATI Template PDF

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Summary

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Description

ACTIVE LEARNING TEMPLATE:

System Disorder

ST UDENT NAME _____________________________________

Head Injury DISORDER/DISEASE PROCESS __________________________________________________________

Alterations in Health (Diagnosis) Contusion/Laceration/skull fracture by direct trauma

Pathophysiology Related to Client Problem Brain function may be impaired by direct damage to brain tissue

14 REVIEW MODULE CHAPTER ___________

Health Promotion and Disease Prevention -Wear helmet/seat belt -If injured:do not move pers

ASSESSMENT

SAFETY CONSIDERATIONS

Risk Factors

Expected Findings

-Lack of supervision -Inappropriate/absent safety practices -Improper use of safety devices

Laboratory Tests -Arterial blood gases -Blood alcohol screening -CBC w/differential -Liver function tests

-Possible loss of consciousness -n/v -blurred vision -headache

Diagnostic Procedures -Cervical spine x-rays -Computerized tomography/ magnetic resonance imaging of head and neck

PATIENT-CENTERED CARE

Nursing Care -Care is determined by the extent of brain trauma -Ensure spine is stable -Maintain airway/oxygen

Therapeutic Procedures -Transfontanel percutaneous aspiration -Subdural drains -Placement of burr hole -Craniotomy

ACTIVE LEARNING TEMPLATES

-Helmets/seat belts -Teach children to look both ways before crossing streat -Use gates on stairways and doors -Discuss sports safety with child

Complications Medications -Mannitol: to decrease ICP -Antiepileptics: to prevent/treat seizures -Antibiotics: in cases of CSF leakage or penetrating injuries -Analgesics: for pain

Client Education -Rest -Teach parents s/s of worsening injury

Interprofessional Care -Physical, occupational, recreational, and speech therapists -Rehabilitation facilities

-Epidural hematoma: bleeding between the dura and skull -Subdural hemorrhage: bleeding between the dura and arachnoid membrane -Cerebral edema -Brain herniation

THERAPEUTIC PROCEDURE

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