SHADOW HEALTH FOCUSED EXAM: PEDIATRIC
TRAUMATIC BRAIN INJURY (DAMIEN BROOKS)
why would a nursing dx of acute confusion be correct compared to impaired
memory? - ANSWERS-The most effective nursing diagnosis for Damien is acute
confusion because his symptoms are a lack of orientation to place and a 14/15 on
the Glasgow Coma Scale. This indicates that the patient is dealing with confusion,
rather than severe or impaired memory loss.
Short term goal - ANSWERS-the pt will verbalize his orientation to person, place,
and time by the end of his hospital stay
interventions - ANSWERS-1.Promote continuity of care by avoiding frequent
changes in staff and surroundings
2. Reduce sensory exposure by eliminating excessive noise, using appropriate
lighting based on time of day, and establishing a calm environment
3. Inform patient of time, place, and person as needed and provide information
slowly and in small doses with frequent rest periods
intervention rationales - ANSWERS-These interventions will address Damien's
acute confusion in a variety of ways. The proposed interventions will assist in
orienting Damien to place, while being careful to not overstimulate or overwhelm
him.
, data collections - ANSWERS-Re-evaluate the patient's orientation to person,
place, and time
explain the rationale behind your nursing dx - ANSWERS-Tim, Damien's diagnosis
is acute confusion related to his head injury. This diagnosis is evidenced by his
score of 14/15 on the Glasgow Coma Scale and lack of orientation to place.
Explain to Tim your goal and the interventions and data collections through which
you will achieve it. - ANSWERS-Tim, I'm going to have a conversation with you and
Damien about the ways we can address and manage Damien's acute confusion.
We'll work together in this discussion, and I will explain what interventions I
recommend to treat Damien. Our goal today is to reorient Damien to person,
place, and time by the end of his hospital stay.
explicitly ask for tims consent to the care plan - ANSWERS-does this plan i just
talked about sound good to you?
inform tim you will now begin educating him - ANSWERS-Tim, if you don't have
any other questions, I'm going to speak with Damien now.
explain the rationale behind your nursing dx - ANSWERS-Damien, you are
exhibiting symptoms of acute confusion related to your head injury. I'm going to
go over some basic information with you so that you can feel more comfortable
with your diagnosis. I will also go over my plan to help treat your acute confusion,
including simple things you and your stepfather can do to help you feel better.
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