Page 265 - Critical Care Nursing Demystified

250 CRITICAL CARE NURSING DeMYSTIFIED

1 , 2 , and 4 Nursing Diagnoses Expected Outcomes
Discomfort associated with head- Patient will be relieved of neurological
aches, stiff neck, and photophobia symptoms
Discomfort will be reduced to within
acceptable levels

Nursing Interventions
Ask patient to rate his or her level of discomfort on a scale of 0 to 10.
Provide frequent neurological assessments to detect signs of improvement or
deterioration.
Administer analgesic medications as prescribed to reduce discomfort.
Provide distraction measures such as guided imagery.

Reduce levels of environmental stimuli.
Provide a quiet, relaxed atmosphere for patient recovery.

Surgical Conditions Requiring Complex Neurological Care Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.

The purposes of surgery for head trauma victims are to control hemorrhag-
ing; remove blood clots, bone matter, and tumors; repair torn and severed
blood vessels; prevent a shift in brain tissue; and ultimately to prevent brain
herniation.

Brain Tumors

What Went Wrong?
These are abnormal growths occurring in the brain as either a benign or
metastatic lesion. Causes of why or what precipitates their growth is unclear.
The most common type of brain tumor is identified as the glioblastoma
multiforme. Astrocytomas and meningiomas fall within the glioblastoma
category.

Hallmark Signs and Symptoms
If a brain mass is large, papilledema will be present upon assessment in 70% to
75% of all brain tumor cases caused by increased intracranial pressure due to
the tumor pressing on the optic nerve. Severe headaches and blindness may
rapidly result if the pressure is unrelieved.