Need help with care plan: Unresponsive patient

[AwesomeNiks]

Hey everyone. I'm new here. My name's Nicole :)

I'm currently trying to do a care plan for school, and I'm confused as to what diagnoses to use.

The patient had a subdural hematoma (from a fall while he was on blood thinners), was brought in and received a craniotomy. It had been almost 2 weeks since the craniotomy, and the patient is not awake. He only responds to painful stimuli, and the response is very small. If you hold his eyelids open, he is able to follow you with his eye movements. Also, when suctioning, he does have a gag reflex. However, these are his only responsive actions.

I'm unsure as to what nursing diagnoses would take priority?

Any help would be appreciated.

Thanks so much!

[Lacie, BSN, RN]

http://www.careplans.com/pages/library/problemlist.asp

Here's a site that may help you. May have to research abit. :)

Perfusion, skin integrity, increased ICP amoung a few I can think of just to throw out.

[Silverdragon102, BSN]

Moved to the general student discussion forum

We have several threads discussing care plans

[Spencer2002]

remember pressure ulcers (q2 turns), urinary output, bowel impactions, bm in within 3 days and dehydration. look at the at risk diagnosis

[SolaireSolstice, BSN, RN]

Look for risks involved with immobility.

And how is this patient being fed? Chances are with a g-tube? What are the risks of being tube fed? (Though maybe TPN.)

[shescoolie]

I'm thinking risk for impaired skin integrity should be your priority due to the patient's immobility.

[morningland]

How about Risk or actual skin impairment related to immobility???

[Spencer2002]

how about risk or actual skin impairment related to immobility???

unless you see impaired skin and can document it, it's an at risk dx. with skin impairment you also have to worry about infection which will lead to sepsis. it seems like thats all they talked about when i was in ns. with tube feeding the head of bed has to be 30 degrees or great or they are at risk of reflux and aspiration. q4 residual checks on tube feeding to make sure it's being digested. usually place tf on hold if greater than 60cc, depends on hospital policy.

[morningland]

unless you see impaired skin and can document it, it's an at risk dx. with skin impairment you also have to worry about infection which will lead to sepsis. it seems like thats all they talked about when i was in ns. with tube feeding the head of bed has to be 30 degrees or great or they are at risk of reflux and aspiration. q4 residual checks on tube feeding to make sure it's being digested. usually place tf on hold if greater than 60cc, depends on hospital policy.

wouldn't the hematoma be actual skin impairment? my patient also has hematoma (very large so it would be ecchemosis (sp), right?) and i was thinking about writting a diagnosis on this. i don't think you can actually say hematoma though because it's a medical diagnosis though, right? thanks for the help!

[Spencer2002]

Bruises are not as bad as broken skin. Yes, compromised skin is always a concern with pt’s that are unresponsive and immobile. Look at the Foley and skin of the peri area. It seems like those areas are always overlooked. Pt’s can develope excoriated skin and yeast infections in these areas. Wet skin from sweating or urine can cause all sorts of problems. But I would look deeper into how the bruises got there? The staff being rough with the pt moving him around? Maybe they have a broken bone. Look at HR and things that are measureable. I hope this helps :)

[Spencer2002]

They probably have the pt on a blood thinner to keep them from developing DVT r/t lack of mobility. Bruising is a very common sign of person being on a blood thinner. Especially if they are older.

[morningland]

Bruises are not as bad as broken skin. Yes, compromised skin is always a concern with pt's that are unresponsive and immobile. Look at the Foley and skin of the peri area. It seems like those areas are always overlooked. Pt's can develope excoriated skin and yeast infections in these areas. Wet skin from sweating or urine can cause all sorts of problems. But I would look deeper into how the bruises got there? The staff being rough with the pt moving him around? Maybe they have a broken bone. Look at HR and things that are measureable. I hope this helps :)

My patient has end stage cirrosis due to long term drinking. My instructor told me that that her hematoma may be related to her disease because of something to do with the blood cappilaries. Can you maybe explain that a little more if you have a better understanding or, better yet, direct me to a good medical site where I can find that information... my textbooks didn't reveal anything. Thanks