Prepare nursing care plan for client with head injury

Answer 1

Assessment:
- The patient presents with a head injury and is currently experiencing symptoms such as headache, dizziness, confusion, and nausea.
- The patient has a history of hypertension and is currently taking antihypertensive medication.
- The patient is alert and oriented to person, place, and time, but is demonstrating difficulty with short-term memory and concentration.

Diagnosis:
Impaired cerebral tissue perfusion related to head injury as evidenced by headache, dizziness, and confusion.

Plan:
1. Monitor vital signs, especially blood pressure, and neurological status frequently to assess for any changes in condition.
2. Keep the patient on bed rest with the head of the bed elevated to reduce intracranial pressure.
3. Administer prescribed pain medication as needed to help alleviate headache.
4. Encourage the patient to perform deep breathing exercises to improve respiratory function and promote oxygenation to the brain.
5. Provide a calm and quiet environment to reduce sensory overload and promote rest.
6. Educate the patient and family on signs and symptoms of worsening head injury and when to seek medical attention.
7. Collaborate with other healthcare team members, such as neurologists and physical therapists, to develop a comprehensive care plan for the patient's recovery and rehabilitation.

Evaluation:
- The patient's neurological status remains stable, with no changes in symptoms of headache, dizziness, or confusion.
- The patient reports feeling more comfortable and is able to participate in activities of daily living with assistance.
- The patient and family demonstrate understanding of the importance of monitoring for signs of worsening head injury and when to seek medical attention.