Nursing Care Plan for Head Injury

https://hindinewslive321.blogspot.com/2024/12/comprehensive-nursing-care-plan-for_31.html

Nursing Care Plan for Head Injury

1. Patient Information   ):

Name: [Patient's Name]

Age: [Age]

Diagnosis: Head Injury (e.g., Concussion, Contusion)

Date: [Date of Care Plan]

2. Assessment (Left Column):

Physical Findings:

LOC, GCS Score, Headache, Vomiting

Pupil reactions, Seizures (if applicable)

Bruising or swelling

Psychosocial Findings:

Anxiety, Memory Loss, Confusion

3. Nursing Diagnoses (Central Column):

Risk for Increased ICP

Acute Pain

Impaired Mobility

Risk for Infection

Impaired Cognitive Function

4. Goals (Right Column):

Goal 1: Prevent Increased ICP

Goal 2: Manage Pain Effectively

Goal 3: Improve Mobility

Goal 4: Prevent Infection

Goal 5: Enhance Cognitive Function

5. Interventions (Underneath the Goals):

Risk for Increased ICP:

Monitor vital signs and neurological status

Elevate head of bed (30 degrees)

Administer prescribed medications

Limit environmental stimuli

Acute Pain:

Use pain scale for assessment

Administer analgesics

Apply cold compress (if appropriate)

Impaired Mobility:

Encourage physical therapy

Assist with turning and repositioning

Monitor for DVT signs

Risk for Infection:

Use sterile technique for wounds

Observe for signs of infection

Administer antibiotics as ordered

Impaired Cognitive Function:

Provide reorientation

Engage in cognitive exercises

Maintain a calm environment

6. Evaluation (Footer Section):

ICP Status: Stable

Pain Level: < 4/10

Mobility: Improved

Infection Status: No infection signs

Cognitive Status: Improved orientation and memory

7. Notes Section (Optional):

Any special considerations or follow-up instructions, like discharge planning, patient education, or follow-up care.