The affected person is a 68-year-old man who sustained a head harm after falling within the toilet. He arrives within the emergency division (ED) cheerful, alert, and oriented to individual. On bodily examination, he has a big hematoma on his left brow. He stories a headache within the left temporal space, which he charges as an eight/10. His spouse was current in the course of the incident. Admission very important indicators are: blood stress, 170/92 mm Hg; pulse, 92 beats/min; respirations, 14 breaths/min; and temperature, 98.7° F. The doctor orders a one-time dose of acetaminophen 650 mg orally for the affected person’s headache, which the nurse promptly administers. The affected person stories a ache stage of 5/10 at 1 hour after the intervention.
1. Why is it vital to find out the circumstances of the autumn for this affected person?
2. Focus on the significance of acquiring baseline conduct and data from the spouse.
3. The ED doctor orders computed tomography (CT) of the mind for the affected person. What’s the function of this take a look at, and what are the nursing duties in making ready the affected person for this process?
four. As a result of the affected person is in danger for elevated intracranial stress, clarify how the affected person needs to be positioned and moved in mattress.
5. The CT and different diagnostic outcomes are unfavorable and the affected person is recognized with a minor head harm and contusion to the appropriate extremity. He’s discharged to residence. Assessment the affected person educating directions that needs to be given to the affected person and his spouse.
6. The spouse seems unwilling to take her husband residence and she or he states that she doesn’t perceive the discharge directions. What can the nurse do on this scenario?
7. Use the main focus charting methodology (often known as the DAR methodology—knowledge, motion, response) to doc the administration of acetaminophen, together with applicable follow-up.
