Head trauma with ICH (Intracranial Hemorrhage) | My Assignment Tutor

Student NameStudent IDDateHospitalInstructor Name Patients DataPatient’s name (First & surname):Healthcare Record Number (HRN):Age:Gender:Presenting Chief complaint:Head trauma with ICH (Intracranial Hemorrhage)Triage category:Infection status:Accompanied by:Source of data collection/gatheringPatient Family or significant other Caregiver EMS personnel Bystander Use of translatorMedical Diagnosis:Last oral intake: Mechanism of injury (if any)Types of Injuries (if any)Blast Forces (Explosions) Blunt Forces A. motor vehicle collisions, B. automobile versus pedestrian collisions C. motorcycle collisions, D. sports-related activities, E. falls Penetrating Forces A. Stab wounds B. Gunshot woundsType of Energy caused Injury/TraumaMechanical energy Thermal energy Electrical energy Chemical energyEffected Organ of the Injury/TraumaTrauma Score (Refer to Revised Trauma Score Appendix) Summary of the Primary Assessment: List all abnormalities based on primary assessment(refer to Primary Assessment Guidelines) History of Present Illness/injury/chief complaint (Repeat this table for each of the symptoms)Palliative FactorsProvocative FactorsQualityRegionRadiationSeverityTiming: OnsetTiming: DurationTiming: FrequencyTreatment prior to arrival Pathophysiology of the Disease/ Patient condition/ Medical Diagnosis Full Set of Vital Signs TimeBlood PressureTemperatureCentral & Peripheral PulseSpO2GCSPain SeverityLocationValueMAPRouteValueLocationRateRhythmQuality Diagnostic Examinations/Procedures: (Include Blood type, Lactate, ABGS, ECG, CTCO2, Lab Tests, radiographic studies, etc…)Test/ProcedureReference Value (Normal Results)Patient ResultsNursing Considerations Pain Assessment Palliative Factors Provocative Factors Quality Region Radiation Severity* Timing: Onset Timing: Duration Timing: Frequency * Pain Scale used for severity assessment: FACES pain rating scale for patients approximately 3 years of age and older Visual analog scale for school-age children and adolescents FLACC (Faces, Legs, Arms, Cry, Consolability) Scale for infants and preverbal children Numeric rating scale for older school-age children and adolescents Past Medical History Patient’s definition of own health past medical history (PMH), to include hospitalization/ surgeries: Current or preexisting diseases/illness/injuries/surgeries Respiratory disease Cardiovascular disease; risk factors Neurologic disease Endocrine disease Hepatic disease Infectious disease Hematologic disease Immunosuppression Autoimmune disease Psychological disorders psychiatric or mental health Others, Specify: Allergies Medication—prescription, OTC Food/beverages Latex Iodine Environmental Immunization status Pneumococci Influenza Tetanus Childhood illnesses Psychological/social/environmental factors Smoking: Substance and/or alcohol use/abuse: Safety Possible/actual assault, abuse, or intimate partner violence situations Use of seat belts Texting while driving Drinking and driving Psychiatric history (personal or family members): Literacy (level of Education) Behavior appropriate for age and developmental stage: Occupation/profession: Meaning of illness, injury, or event to patient/family: Patient’s/family’s expectations of care: Support system: Family structure Significant others Social agencies Religious affiliation Caregivers Responsibilities Self Family Business Community Cultural beliefs and practices: Spirituality: Living accommodations House Apartment Accessibility (e.g., stairs) Homeless, shelters Affordability and accessibility to care—socioeconomic status: History of descriptive and non-descriptive medications: Descriptive medications (Prescribed by physician/doctor): Generic Name & / Classification Trade Name Dosage Frequency Route Non-descriptive medications: Legal/ illegal, over the counter drugs (OTC): Generic Name & /Classification Trade Name Frequency Route Rationale Head-to-Toe Assessment (Review of Systems) Describe only abnormal findings: Refer to Chapter one (Nursing Assessment and Resuscitation)General appearanceSkin/mucous membranes/nail bedsHead and faceEyes/ Ear/ Nose/ Mouth/ NeckChestAbdomen/flanksPelvis/perineumExtremitiesPosterior Surfaces Currently Described MedicationsGeneric Name (Dosage, Route, Frequency)Trade Name/ ClassificationAdverse ReactionsNursing Responsibilities Treatments/Therapeutic Regimens/Doctor Orders rather than Medications (e.g. oxygenation, ventilation, intubation, cardioversion, IV therapy, etc.) NURSING CARE PLAN (Provide 3 Nursing Diagnosis and write one Nursing Diagnosis per Page) AssessmentPriority Nursing DiagnosisPlanningNursing interventionRationaleEvaluationSubjective Data: What the client says about this problemStatement of Problem (Nursing diagnosis from NANDA list) R/T: Related to (Etiology) AEB: As Evidenced by (supportive S & O Data)Goal: To (General statement reverse the statement of problem) Objectives: Patient will (specific statement define what will be observed when the goal is met which is measurable & provide time frame)Short Term Goal (achievable within hours to day) Long Term Goal (achievable within days, weeks, or month)Could be 1. Re-assessment (to look for improvement and prevent complications) 2. Independent (can be implemented without doctor order) 3. Dependent (based on doctor order) 4. Collaborative (together with other health care providers such as nutritionist, physical therapist)Scientific principles, theories or concepts underlying nursing Interventions to tell why each intervention should help achieve the goalMust have statement for each actionGive specific text references for each intervention (name of text and page number).Be sure to attach a bibliography.Evaluation of Goals: Write a summary statement of each goal (the goal met, partially me or non-met), Evaluation of Objectives: write specific statement for each objective define what is observed, give measurement and specific date and time, describe how the patient looks, feels or behaves after nursing interventions have been implemented.Objective Data: What you observe: see, hear, feel, smell, and measure + Client lab values, test Results + Medications + Doctor’s diagnosis from patient chart AssessmentPriority Nursing DiagnosisPlanningNursing interventionRationaleEvaluationSubjective Data: What the client says about this problemStatement of Problem (Nursing diagnosis from NANDA list) R/T: Related to (Etiology) AEB: As Evidenced by (supportive S & O Data)Goal: To (General statement reverse the statement of problem) Objectives: Patient will (specific statement define what will be observed when the goal is met which is measurable & provide time frame)Short Term Goal (achievable within hours to day) Long Term Goal (achievable within days, weeks, or month)Could be 1. Re-assessment (to look for improvement and prevent complications) 2. Independent (can be implemented without doctor order) 3. Dependent (based on doctor order) 4. Collaborative (together with other health care providers such as nutritionist, physical therapist)Scientific principles, theories or concepts underlying nursing Interventions to tell why each intervention should help achieve the goalMust have statement for each actionGive specific text references for each intervention (name of text and page number).Be sure to attach a bibliography.Evaluation of Goals: Write a summary statement of each goal (the goal met, partially me or non-met), Evaluation of Objectives: write specific statement for each objective define what is observed, give measurement and specific date and time, describe how the patient looks, feels or behaves after nursing interventions have been implemented.Objective Data: What you observe: see, hear, feel, smell, and measure + Client lab values, test Results + Medications + Doctor’s diagnosis from patient chart AssessmentPriority Nursing DiagnosisPlanningNursing interventionRationaleEvaluationSubjective Data: What the client says about this problemStatement of Problem (Nursing diagnosis from NANDA list) R/T: Related to (Etiology) AEB: As Evidenced by (supportive S & O Data)Goal: To (General statement reverse the statement of problem) Objectives: Patient will (specific statement define what will be observed when the goal is met which is measurable & provide time frame)Short Term Goal (achievable within hours to day) Long Term Goal (achievable within days, weeks, or month)Could be 1. Re-assessment (to look for improvement and prevent complications) 2. Independent (can be implemented without doctor order) 3. Dependent (based on doctor order) 4. Collaborative (together with other health care providers such as nutritionist, physical therapist)Scientific principles, theories or concepts underlying nursing Interventions to tell why each intervention should help achieve the goalMust have statement for each actionGive specific text references for each intervention (name of text and page number).Be sure to attach a bibliography.Evaluation of Goals: Write a summary statement of each goal (the goal met, partially me or non-met), Evaluation of Objectives: write specific statement for each objective define what is observed, give measurement and specific date and time, describe how the patient looks, feels or behaves after nursing interventions have been implemented.Objective Data: What you observe: see, hear, feel, smell, and measure + Client lab values, test Results + Medications + Doctor’s diagnosis from patient chart References

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