Craniotomy Nursing Care Plan 16n5q

Cues

Nursing Diagnosis Acute pain related to post operative procedure (craniotomy) as evidenced by guarding behavior

Objective:

Goal/ Plan After 1 hour of nursing intervention the patient’s pain will be controlled as evidenced by less guarding behavior, decrease in BP, and less withdraws to pain

Nursing Intervention INDEPENDENT: Determine pain characteristics through client’s gestures and response to interventions

Establishes baseline for assesing improvement/change

Monitor vital signs

High Bp indicates pain; to check patient’s reponding well to interventions

Positioning of client

Avoids direct pressure(intra cranial pressure) to area of post op wound which could result in vasoconstriction/ increased pain.

INTERFERENCE:

Guarding behavior

Behavior response to avoid pain

Restlessness

Expressing behavior for pain

Irritability

Expressing behavior for pain

Change in BP

Elevation of blood pressure promotes vasoconstriction which makes pain increased

Rationale

DEPENDENT: ister specific pain management drugs as prescribed by the physician

Appropriate pain killers to provide relief of discomfort when unrelieved by other measures (e.g. acitaminophen, and anti-inflammatory drugs)

Provide rest periods to facilitate comfort, sleep, and relaxation

The patient’s experiences of pain may become exaggerated as the result of fatigue

COLLABORATIVE: Collaborate with the people from the laboratory

To have a close monitor of the client’s progress regarding its wound and properties biological properties related to her post-op condition

Collaborate with the nuerologist

To update patients prognosis after craniotomy

Evaluation After 1 hour of nursing intervention the patient’s pain is under control as evidenced by less guarding behavior , decreased bp, and less withdraws to pain

Cues

Nursing Diagnosis Ineffective breathing pattern related to neuromuscular dysfunction secondary to Post operative surgery

Planning After 30 minutes of nursing intervention the patient will be able to establish effective respiratory pattern as evidenced by normal respiratory rate, absence of tachypnea

Nursing Intervention INDEPENDENT: Monitor Mechanical ventilator especially the manual RR

To obatain baseline for assesing improvement /change in client’s breathing .

Assess for pain

May limit respiratory effort

Suction airway as needed

To clear out secretions Semi-fowler’s provide good breathing pattern

Objective:

INTERFERENCE:

With oxygen ventilator

The patient needs oxygen to be saturated and assist in breathing

Place head 30 degrees elevated

Tachypnea

The client experiences RR of 3040 Normal is 1:2 ratio

DEPENDENT:

1:1 lung expansion Low hemoglobin

Low concentration of hemoglobin makes poor transport of oxygen

Low potassium

Low potassium weakens muscle strength an neuron function; affects breathing

Pain

Pain makes breathing difficult

Rationale

Adjust oxygen at lowest concentration indicated and prescribed respiratory medications

To suffice needed oxygen requirement of the patient

Give combivent nebule q 6 hrs as prescribed by the phycisian

To provide normal breathing if other measures are ineffective

COLLABORATIVE: Referal to the laboratory

For the CT scan and montioring of patient’s prognosis

evaluation After 30 minutes of nursing intervention the patient established effective

Cues

Diagnosis

Planning

Intervention

Impaired skin integrity related to presence of suture over the head

After 4 days of nursing intervention the patient will display timely wound repair/healing

INDEPENDENT:

INTERFERENCE:

Rationale

Evaluation

Monitor vital signs

To obtain baseline data

After 4 days of nursing intervention the patient displayed timely wound repair/healing

Note changes in color, texture, and turgor

To assess extent of injury

Provide wound care

To assist client in correcting/minimizing condition and to promote optimal healing

Emphasize aseptic technique

A first line defense against nosocomial infections and cross conatmination

Keep the patients position and ensure the suture is intact

To avoid pressure on the wound and to keep it from accidental reopening

Objective: With intact suture on right side of the head

closed site of wound from the post -operation (craniotomy)

Swelling of suture site

Swelling always occurs after surgery and may stay for 5 days; indication risk for infection

DEPENDENT: Hyperthermia

Incision induce elvated temperature

Provide optimum nutrion, increased protien and Vit. C

To aid in healing and for tissue repair

COLLABORATIVE:

The physician knows the time intervals, right frequency of tending the surgical wound and remving of suture.

Assist physician to wound care regimens

Cues

Nursing Diagnosis Risk for infection related to increased WBC count secondary to post-op surgery

Objective data:

INTERFERENCE:

Post-op surgery

Invasive procedure increases risk for invading pathogenic organisms

Inadequate secondary defense

Decreased hemoglobin count

Goal/ Plan

Nursing Intervention

After INDEPENDENT:

DEPENDENT:

COLLABORATIVE: WBC count slightly increased

Swelling of incision site

Signs of potential infection proliferation

Rationale

Evaluation

Cues

Nursing Diagnosis

Subjective Data:

Goal/ Plan

Nursing Intervention

Afte INTERFERENCE:

INDEPENDENT:

Objective data:

DEPENDENT:

COLLABORATIVE:

Rationale

Evaluation