NURSING DIAGNOSES Ineffective airway clearance related to altered LOC

GOALS To maintain a patent airway and ensure ventilation

NURSING ACTION Elevate the head of the bed 30 degrees. Position the patient in a lateral or semi prone position. Suctioning should also be done. Chest physiotherapy and postural drainage may be initiated. Auscultate the chest every 8 hours.

RATIONALE To prevent aspiration. To promote drainage of secretions. To remove secretions. To promote pulmonary hygiene.

EXPECTED OUTCOME Maintains clear airway and demonstrates appropriate breath sounds.

Risk of injury related to decreased LOC

To protect the patient from injury

Ensure that side rails are padded and kept in raised position for the day and three nights Provide privacy, and inform the patient to every nursing care to be

To detect adventitious breath sounds or absence of breath sounds. To prevent Experiences no occurrence of injury injuries. due to fall.

To ensure patient’s dignity.

Deficient fluid volume related to inability to take fluids by mouth

To maintain fluid balance and managing nutritional needs

done. Hydration status should be assessed. Administering the required IV fluid.

To know the status of the patient. To meet fluid needs.

Impaired oral mucous membrane related to mouth breathing, absence of pharyngeal reflex and altered fluid intake

To provide mouth care.

For patient with To minimize the intracranial possibility of conditions, the IV increased ICP. solutions must be administered slowly To administer fluid If the patient does and enteral not recover quickly, feedings. gastrotomy tube will be inserted. Mouth should be To remove cleansed and secretions and rinsed crust. To keep it moist. Put a thin coating of petrolanum TO prevent drying, cracking, and encrustations.

Attains or maintains adequate fluid balance a. Has no clinical signs or symptoms of dehydration b. Demonstrates normal range of serum electrolytes c. Has no clinical signs or symptoms of overhydration Achieves healthy oral mucous membranes

Risk for impaired

To maintain skin

For patient with ET To prevent tube, the tube ulceration. should be moved to opposite side of the mouth daily Regular turn the To avoid pressure.

Maintains normal

skin integrity related to prolonged immobility

and joint integrity.

patient side by side. After turning, the patient should be repositioned carefully. Dragging or pulling the patient should be avoided. Maintain correct body position and passive exercise. Use of splints or foam boots. To prevent ischemic necrosis over the pressure areas. To prevent shearing force and friction on the skin surface. To prevent contractures.

skin integrity

Use of trochanter rolls.

To help prevent foot drop and eliminates the pressure of bedding on the toes. To support the hip joints and keep the legs in proper alignment. To decrease pressure on bony prominences. To remove debris and discharges.

Fluidized or low-airloss beds may be use. Impaired tissue integrity of cornea To preserve corneal Eyes should be integrity. cleansed with

Has no corneal irritation

related to diminished or absent corneal reflex

cotton balls with sterile normal saline Instill artificial tears every 2 hours if prescribed. If cold compress is prescribed, care must be exerted. Environment can be adjusted, depending on the patient’s condition.

To prevent dryness.

To avoid contact with the cornea.

Ineffective thermoregulation related to damage to hypothalamic center

To maintain body temperature

To promote a normal body temperature.

Attains or maintains thermoregulation

Remove all bedding To lessen the heat. over the patient. Administer acetaminophen as prescribed. Give cool sponge baths and allow an electric fan to blow over the patient. Using a hypothermia blanket. Frequent To reduce fever.

To increase surface cooling.

To help reduce heat. To assess the

temperature monitoring.

Impaired urinary elimination related to impairment in neurologic sensing and control

If the patient is not voiding, an indwelling urinary catheter is inserted and connected. The patient is observed for fever and cloudy urine. An intermittent catheterization program may be initiated. Monitor the number and consistency of bowel movements and perform a rectal examination. Administer glycerin suppository if indicated. Enema the patient every other day.

patient’s response to therapy To prevent an excessive decrease in temperature. To drain urine. To monitor urine output. To assess urinary tract infection. To ensure complete emptying of the bladder at intervals. To detect fecal impaction.

Has no urinary retention

Bowel incontinence related to impairment in neurologic sensing and control and also related to changes in nutritional delivery methods

Has no diarrhea or fecal impaction.

To soften stool. To empty the lower colon.

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