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Head Injury, Nursing Interventions: Ensure pt airway, Monitor vitals, LOC, o2 sat, cardiac, Pupil size and reactivity, Keep pt warm, Monitor spec gravity, urine glucose, serum electrolytes, osmolality, I&O, Skin care, ROM, voiding, Diagnostic tests, Meds IV fluids, Physical therapy, Teach client s&s increased drowsiness, N/V, Headache. Stiff neck. No alcohol, Avoid driving. Medical Diagnosis Head Injury Signs & Symptoms: alterations in consciousness Scalp laceration Fracture or depression in skull Bruises or contusions on the face such as Battle's sign which is bruising behind the ears. Racoon eyes. Central neurologic hyperventilation Cheyne-Stokes respirations Decreased o2 sat, Pulmonary edema Unequal or dilated pupils Asymmetric facial movements Gargled or abusive speech Confusion, Combativeness, Involuntary Movements, Swizures, Bowel or Bladder Incontinance, Flaccidity, Depressed or hyperactive reflexes. Decerebrate or decorticate posturing, CSF leaking from ears or nose., Nursing Interventions: Ensure pt airway, Monitor vitals, LOC, o2 sat, cardiac, Pupil size and reactivity, Keep pt warm, Monitor spec gravity, urine glucose, serum electrolytes, osmolality, I&O, Skin care, ROM, voiding, Diagnostic tests, Meds IV fluids, Physical therapy, Teach client s&s increased drowsiness, N/V, Headache. Stiff neck. No alcohol, Avoid driving. Medical Diagnosis Head Injury Risk Factors: Scalp laceration Scalp Fractures Minor head trauma (concussion) Major head trauma (contusion/ lacerations), Nursing Interventions: Ensure pt airway, Monitor vitals, LOC, o2 sat, cardiac, Pupil size and reactivity, Keep pt warm, Monitor spec gravity, urine glucose, serum electrolytes, osmolality, I&O, Skin care, ROM, voiding, Diagnostic tests, Meds IV fluids, Physical therapy, Teach client s&s increased drowsiness, N/V, Headache. Stiff neck. No alcohol, Avoid driving. Medical Diagnosis Head Injury Complications: Epidural Hematoma Subdural Hematoma Intracerebral Hematoma Brain Death Seizures Cerebral Edema, Nursing Interventions: Ensure pt airway, Monitor vitals, LOC, o2 sat, cardiac, Pupil size and reactivity, Keep pt warm, Monitor spec gravity, urine glucose, serum electrolytes, osmolality, I&O, Skin care, ROM, voiding, Diagnostic tests, Meds IV fluids, Physical therapy, Teach client s&s increased drowsiness, N/V, Headache. Stiff neck. No alcohol, Avoid driving. Medical Diagnosis Head Injury Diagnostic Procedures & Medications: CT Scan, MRI, PET, Transcranial doppler studies Cervical Spine x-ray, GCS, Crainotomy, Crainectomy, Cranioplasty, lubricating eye drops, Antiemetic drugs, Codeine., Nursing Interventions: Ensure pt airway, Monitor vitals, LOC, o2 sat, cardiac, Pupil size and reactivity, Keep pt warm, Monitor spec gravity, urine glucose, serum electrolytes, osmolality, I&O, Skin care, ROM, voiding, Diagnostic tests, Meds IV fluids, Physical therapy, Teach client s&s increased drowsiness, N/V, Headache. Stiff neck. No alcohol, Avoid driving. Medical Diagnosis Head Injury Pathophysiology: Diffuse Axonal Injury, Nursing Interventions: Ensure pt airway, Monitor vitals, LOC, o2 sat, cardiac, Pupil size and reactivity, Keep pt warm, Monitor spec gravity, urine glucose, serum electrolytes, osmolality, I&O, Skin care, ROM, voiding, Diagnostic tests, Meds IV fluids, Physical therapy, Teach client s&s increased drowsiness, N/V, Headache. Stiff neck. No alcohol, Avoid driving. Medical Diagnosis Head Injury Possible Nursing Dx: Ineffecrtive tissue perfusion Hypernatremai Acute pain Impaired physical mobility Risk for seizure