NCP NI ASHRA

CUES NURSING NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS

Subjective cues: Acute After rendering 8 INDEPENDENT: After rendering 8

 The patient confusion hours of independent hours of independent
is confused related to and dependent 1. Introduce 1. These and dependent
as neurologic nursing interventions, yourself measures are nursing interventions,
evidenced trauma as the patient will be before any part of the goals were
by the evidenced by: able to: interaction reorientation. completely met as
patient and Too much evidenced by the
stated “Hindi -  Maintain a procedures. information at patient was able to:
ko maalala baseline level Explain care once might
kung kailan of in short and increase  Maintained a
at saan ako consciousness simple confusion and baseline level
naaksidente and will not sentences make the of
eh.” experience before and patient more consciousness
decreased throughout irritable. and will not
Objective cues: memory. the process. experience
 The decreased
patient’s  Respond   memory.
diagnosis is appropriately 2. Assess  
Traumatic to questions. sensory 2. Assessment of  Responded
Brain Injury awareness. sensory appropriately
secondary awareness is to questions.
to Vehicular crucial to patient
Accident safety. Injury to
Head the parietal lobe
Trauma. can cause loss
of sensory
 The patient perception and
is prevent
disoriented appropriate
to time and responses to
place. environmental
stimuli.
3. Assess
changes in 3. The upper
orientation cerebral
and functions are
personality. the first to be
affected when
there is altered
circulation or
oxygenation.
The damage
can occur
initially at the
onset of the
injury or develop
later due to
swelling or
bleeding. Motor,
cognitive,
perceptual, and
personality
changes can
develop and
may persist.
4. Assess the
patient’s 4. Cognitive
level of impairment can
cognitive interfere with
impairment. how the patient
with TBI
functions.
Assessing the
patient’s level of
cognitive
impairment can
help determine
appropriate
rehabilitation.
5. Ensure
patient 5. Patients with
safety. acute confusion
are not able to
follow
directions. It is
important to
promote patient
safety by
providing a
hazard-free
6. Reorient the environment.
patient as
needed. 6. Patients with
mild TBI may be
disoriented and
may exhibit
short-term
memory loss.
Frequent
reorientation is
essential before
any interaction
to promote a
trusting
relationship and
cooperation
7. Keep from the patient.
explanations
and activities 7. This allows the
short and patient to better
simple. understand the
instructions and
procedures
performed. It is
vital to give
these
explanations
before and
 throughout the
patient’s care.
They are
unlikely to
remember long
instructions so
keep teaching
8. Eliminate sessions short.
extraneous
noise as 8. This can help
necessary. reduce the
patient’s anxiety
, confusion, and
exaggerated
emotional
responses
associated with
sensory
overload.