I.

ASSESSMENT

DEFINITION: Accentuated risk of accidental tissue injury, such as burns or fractures.

Age Gender Level of education Developmental factors, including tendency to test independence and take risks (especially in company of peers), feelings of indestructibility, high level of energy, need for peer, approval, and access to potential safety hazards (such as complex machinery or tools, farm equipment, car, motorcycle, jet ski, or snowmobile) Health history, including allergies, sports accidents, auditory or visual impairments, and seizure disorders. Social history, including academic performance, sports, hobbies, social activities, and occupation. Neurologic status, including level of consciousness and orientation.

Access to alcohol, drugs (prescription, overthe-counter, or illicit), poisons, or other toxic substances Access to vehicles Developmental stage and level of maturity Frequent unsupervised activities with peers History of chronic or periodic substances abuse Lack of experience operating a car, motorcycle, or other vehicle (such as driving at excessive speed or after using alcohol or drugs) Participation in contact sports Use of complex power tools or machinery (at work, school, or home)

Headache Confusions Difficulty falling or staying asleep Irritable, mood or angry outburst Difficulty concentrating Hypervigilance Exaggerated startle response

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Trauma-focused cognitive-behavior therapy this treatment is generally administered over 10 to16 treatment sessions and includes a number of components. Psychoeducation regarding the nature of typical emotional and physiologic reactions to traumatic events Stress inoculation in which they are guided to use muscle relaxation, focused breathing, affective modulation, thought stopping, and cognitive coping techniques to diminish feelings of helplessness and distress. Gradual exposure may then be introduced as a technique to recall, first in small segments and then in increasing amounts, the details of the traumatic exposure and described thoughts, feelings, and physical sensations experienced during trauma, as well in retelling the event. Cognitive processing identifying those thoughts, feelings, and ideas that may be inaccurate and serve to cause additional impairement to the victim, so that reframing of the thoughts and feelings can help them alleviate the sense of being incapacipated by them. Parental treatment component provides parent management strategies for the parent to use to enhance the childs ability to communicate proactively and elicit support from the parents.

Crisis intervention/psychologic debriefing typically consist of several sessions immediately after an exposure to a traumaticevent in which a traumatized child or adolescent is encouraged to describe the traumatic event in the ccontext of a supportive environment. Psychopharmacologic treatment clonidine (Catapres) and propranolol (Inderal), treat symptoms especially nightmares and exaggerated startle reponse

Risk for trauma related to feelings of personal invulnerability.

Adolescent will recover from injury while in hospital Adolescent wont experience additional injury while in hospital Adolescent will identify risks and behaviors he should avoid Adolescent will state understanding of appropriate safety precautions (for example obeying speed limits, following fire prevention precautions, never driving while intoxicated, wearing helmet or seat belt, and using protective clothing or equipment) Adolescent will state intention to adopt appropriate safey precautions.

Follow a medical regimen to treat the adolescents injury to promote recovery. Document risk factors and unsafe practices discovered through observation or through dicussions with the adolescent to plan effective interventions. Select a teaching topics that will help the adolescent prevent future injuries and promote personal health for example, automotive and motorcycle safety, proper use of protective equipment in sports, or alcohol and drug awareness. Teaching the adolescent increases his knowledge and reinforces the notion that hes responsible for ensuring personal safety. Demonstrates the use of appropriate safety equipment, such as protective sports gear, and have the adolescent perform a return demonstration to reinforce learning. Include the adolescents parents or guardian in teaching sessions. If properly informed,family and friends can help the adolescent improve safety practices.

Adolescent recovers from existing injuries, if present. Adolescent remains free from further injury during hospital stay. Adolescent identifies risks and behaviors he should avoid. Adolescent demonstrates proper use of safety devices and equipment, as appropriate (for example, using protective sports gear, seat belt, and motorcycle helmet). Adolescent states intention to adopt safety precautions.

I.

ASSESSMENT

DEFINITION: Head Injury A traumatic head injury can result in a multitude of mental health problems for a client, including amnesia; depression; anxiety; irritability; decreased attention, concentration, and cognition; dementia; and mood and personality changes. Head injuries are usually caused by trauma sustained during falls, diving, vehicular accidents, risky stunts, assault, physical abuse, or contact sports. Traumatic head injury is a leading cause of neurologic disability among adolescents. It is most common in young men and is often associated with substance abuse.

At risk for injury as a result of environmental conditions interacting with the individuals adaptive and defense resources.

Inappropriate or unacceptable social behavior Sensory or memory deficits Impulsive behavior Impaired cognition Inability to distinguish potentially harmful situations Lack of awareness of physical or cognitive impairement

Immediate The client will: Be safe and free from injury Respond to limits regarding safety Respond to cues from others regarding acceptable social behaviors Stabilization The client will: Refrain from unnecessary risks Perform daily routines safely; including self-care activities, responsibilities, and recreation Demonstrate socially appropriate behavior Community The client will: Use community resources to ensure safety Collaborate with case manager or significant other in decision-making

NURSING INTERVENTIONS WITH RATIONALES Provide a safe environment. The clients safety is a priority. The clients behavior may be unsafe due to impaired judgement or impulsivity. Intervene if the client is exhibiting behavior that is unsafe. Use a matter-of-fact approach. Do not scold or chastise the client or become angry with him or her. The client may lack ability to determine the safety of his or her behavior; he or she is not misbehaving willfully. The client may response to verbal corrections but have a negative response if you are scolding or angry. Being matter-of-fact decreases embarrassment and avoids a power of struggle.

Set and reinforce limits regarding safe behavior. The clients ability to recognize unsafe actions is impaired. Give positive feedback for appropriate behavior. Positive feedback increases the desired behavior. Provide the client with safe opportunities to release tension (e.g, exercising in the gym). Physical activity provides the client with a way to relieve tension in a healthy. Safe manner.

Inability to modify lifestyle/behavior in a manner consistent with a change in health status.

Irritability Mood swings Negativism Apathy Low self-esteem Poor jugement Impaired cognition Resistance to or noncompliance with therapy Lack of insight or complication

Immediate The client will: Verbalize feelings openly and honestly Participate in planning treatment Demonstrates a daily routine, including self-care activities, responsibilities and recreation Respond to cues from others regarding acceptable social behaviors Comply with the therapeutic regimen, eg/ take medications as given Stabilize

The client will: Verbalize increased feelings of self-worth, eg. Verbally identify capabilities and strengths Demonstrates socially appropriate behaviors, eg. Listening to others Verbalize knowledge of condition and abilities, treatment, or safe use of medication, if any

Community The client will: Demonstrate progress in the grief process Perform functional role within his or her limitations

NURSING INTERVENTIONS WITH RATIONALES: Encourage the client to verbalize feelings openly. Expressing feelings is an essential step toward dealing with those feelings. Encourage appropriate expression of anger or resentment. The client may benefit from permission to express negative feelings safely. Do not attempt to cheer the client with statements such as At least your alive; thats something to be thankful for. The client may not agree with your opinion or could feel that his or her feelings are belittled. Assist the client to specify his or her losses in concrete terms. It is easier to deal with a loss stated in specific terms, rather than overwhelming vague terms. Give positive feedback for expression of honest feelings. Avoid reinforcing only hopeful or cheerful client statements. The client must feel free to express actual feelings, not just those that are happy or optimistic.

Client verbalizes feelings openly Responds to limit injury Demonstrates socially appropriate behavior Uses community resources to ensure safety Participates in planning treatment Complies with therapeutic regimen, eg, take medications as given

Maternal and child (4th edition) Adolescent health care Handbok of adolescent medicine and health promotion Lippincotts manual