Nurse Base

Inspection for external trauma, such as scalp or facial swelling, abrasions, laceration, or ecchymosis, can indicate TBI. Palpable step-off or depression indicates skull fracture, which may be associated with contusion of the brain, laceration of the dura or brain, and cerebrospinal
fluid (CSF) leak. Significant scalp swelling in the infant may be indicative of hemorrhage, which can cause anemia with pallor and tachycardia. A basilar skull fracture at the base of the anterior fossa causes “raccoon’s eyes,” or periorbital ecchymoses and can be associated with rhinorrhea (CSF leak from the nares). Fracture in the base of the middle fossa causes “battle sign,” or postauricular ecchymoses, and can be associated with otorrhea (leak of CSF from the ear). Hemotympanum can indicate temporal or basilar skull fracture. Otorrhea indicates disruption of the tympanic membrane related to temporal skull fracture. The cervical spine must be immobilized and protected from spinal cord injury until radiographic clearance is accomplished. The entire spine is immobilized, inspected, and palpated for deformity, swelling, tenderness, and crepitance.

Every patient assessment must begin with evaluation of adequate airway, breathing, and circulation, which are vital to sustain life. A decreased level of consciousness (LOC) after TBI can interfere with protection of the pediatric airway. Inadequate ventilation results in hypercarbia and hypoxia, which cause vasodilation and secondary ischemic brain injury. Vasodilation and resultant ischemia contribute to further increases in ICP. Vital control centers located within the brainstem regulate respiratory and cardiac functions. Brainstem pathophysiology can be identified by changes in the vital signs. The following abnormal respiratory rate and patterns indicate neurologic dysfunction secondary to progressive brainstem compression as a result of increasing ICP:

1. Cheyne-Stokes: repeated cycles of breaths that gradually increase and decrease in rate and depth, followed by a respiratory pause – indicates bilateral hemispheric or diencephalic injury.
2. Central Neurogenic Hyperventilation: increased rate and depth of respirations – indicates midbrain/ upper pons injury.
3. Apneustic: a pause at full or prolonged (slow and deep) inspiration – indicates injury to the upper pons.
4. Ataxic: no pattern in rate or depth – indicates medulla or lower brainstem dysfunction with impending herniation; injury to the respiratory centers in the medulla (also known as agonal respirations).
5. Apnea: respirations cease.

The child’s LOC, and whether it is worsening or improving, is the most important indicator of neurologic status. The neurologically intact child is awake, alert, and responsive to his/her surroundings. Level of responsiveness varies with the developmental age of the child. Infants should respond to feeding and measures to console them. Toddlers and older children should recognize and respond to their parents. Older children and adolescents should be able to follow commands. Children of all ages should respond to and withdraw from painful stimulus. After neurologic injury, pediatric head-injured victims may have alteration in LOC, first subtly, becoming restless, disoriented, and confused. Further decreases in the LOC leads to somnolence (arouses to full consciousness and resumes sleep if not stimulated), lethargy (requires vigorous stimulation to arouse to full consciousness), stupor (nearly unconscious, may moan or withdraw from pain), and finally comatose (unresponsive). A worsening LOC suggests neurologic deterioration. Any subtle change from documented baseline, including parent’s concern that child is “not acting right,” must be taken seriously and reported to the physician.

The adage that “children are not just small adults” holds true when discussing pediatric head trauma. The pediatric craniocerebral anatomy increases the child’s vulnerability to head trauma as well as protects them against worsened severity or outcome. In general, children under the age of 2 years or who are nonverbal require a higher level of suspicion for injury, as the assessment is less revealing secondary to the child’s developmental age.

The physically larger and proportionately heavier pediatric cranium, together with the increased laxity of the cervical spine, create a fulcrum leading to an increased propensity for traumatic injury of the head and cervical spine. The skull consists of eight cranial bones, which are separated by sutures until around 18–24 months. Open cranial sutures are protective against gradual increases in intracranial pressure (ICP), for example as a result of tumors or hydrocephalus increased. Rapidly expanding mass lesions, however, are not tolerated and result increased ICP. The head circumference of infants should be measured and recorded on admission and daily, as a rapidly increasing head circumference is indicative of increased ICP. Presence of bulging or firm fontanels, with infant calm and in an upright posture, can also be an indicator of increased ICP. The infant’s skull is thinner, softer, and more deformable when fractured, but heals quickly after fracture due to accelerated bone growth.

The pediatric brain is softer due to a higher water content and less myelination. The subarachnoid space is wider. The thin pediatric skull, soft brain, and large subarachnoid space allow increased movement of the brain within the skull, which makes the child more susceptible to brain injury, including extraparenchymal hemorrhage, shearing or tearing of neuronal processes, and diffuse axonal injury.

Children have a smaller intracranial space in which smaller increases in volume produce exponentially larger increases in ICP. The pediatric skull can absorb a significant impact with little external evidence of significant intracranial injury. When evaluating the head-injured child, the nurse must consider all external indications such as bruising, swelling and lacerations, as well as the mechanism of injury and the degree of neurologic deficit.

Related Factors
To be developed
[Condition affecting muscles/joints impairing ability to walk]

Defining Characteristics
SUBJECTIVE OR OBJECTIVE
Impaired ability to walk required distances, walk on an incline/ decline, or on uneven surfaces, to navigate curbs, climb stairs
[Specify level of independence—refer to ND impaired physical Mobility, for suggested functional level classification]

Desired Outcomes/Evaluation
Criteria—Client Will:
• Be able to move about within environment as needed/desired within limits of ability or with appropriate adjuncts.
• Verbalize understanding of situation/risk factors and safety measures.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Identify condition/diagnoses that contribute to difficulty walking (e.g., advanced age, acute illness, weakness/chronic illness, recent surgery, trauma, arthritis, brain injury, vision impairments, pain, fatigue, cognitive dysfunction).
• Determine ability to follow directions, and note emotional/ behavioral responses that may be affecting the situation.
NURSING PRIORITY NO. 2. To assess functional ability:
• Determine degree of impairment in relation to suggested functional scale (0 to 4), noting that impairment can be either temporary/permanent or progressive.
• Note emotional/behavioral responses of client/SO to problems of mobility.
NURSING PRIORITY NO. 3. To promote safe, optimal level of independence in walking:
• Assist with treatment of underlying condition causing dysfunction as needed/indicated by individual situation.

• Consult with PT/OT to develop individual mobility/walking program and identify appropriate adjunctive devices.
• Demonstrate use of adjunctive devices (e.g., walker, cane, crutches, prosthesis).
• Schedule walking/exercise activities interspersed with adequate rest periods to reduce fatigue.
• Provide ample time to perform mobility-related tasks.
• Advance levels of exercise as able.
• Provide safety measures as indicated, including environmental management/fall prevention.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Involve client/SO in care, assisting them to learn ways of managing deficits to enhance safety for client and SO(s)/caregivers.
• Identify appropriate resources for obtaining and maintaining appliances, equipment, and environmental modifications to promote mobility.
• Instruct client/SO in safety measures as individually indicated (e.g., maintaining safe travel pathway, proper lighting/ handrails on stairs, etc.) to reduce risk of falls.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Individual findings, including level of function/ability to participate in specific/desired activities.
PLANNING
• Plan of care and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge/long-range needs, noting who is responsible for each action to be taken.
• Specific referrals made.
• Sources of/maintenance for assistive devices.

Taxonomy II: Safety/Protection—Class 3 Violence (00138) [Diagnostic Division: Safety] Submitted 1980;
Revised 1996
Definition: At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally,
and/or sexually harmful to others

Risk Factors/[Indicators]*
HISTORY OF VIOLENCE:
Against others (e.g., hitting, kicking, scratching, biting or spitting, or throwing objects at someone; attempted rape, rape, sexual molestation; urinating/defecating on a person)
Threats (e.g., verbal threats against property/person, social threats, cursing, threatening notes/letters or gestures, sexual threats)
Antisocial behavior (e.g., stealing, insistent borrowing, insistent demands for privileges, insistent interruption of meetings; refusal to eat or to take medication, ignoring instructions)

*NOTE: Although a risk diagnosis does not have defining characteristics (signs and symptoms), the factors identified here can be used to denote an actual diagnosis or as indicators of risk for/escalation of violence.

Taxonomy II: Activity/Rest—Class 2 Activity/Exercise (00154)
[Diagnostic Division: Safety]
Submitted 2000
Definition: Meandering, aimless, or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles

Related Factors
Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, language (primarily expressive) defects
Cortical atrophy
Premorbid behavior (e.g., outgoing, sociable personality; premorbid dementia)
Separation from familiar people and places
Emotional state, especially frustration, anxiety, boredom, or depression (agitation)
Physiological state or need (e.g., hunger/thirst, pain, urination, constipation)
Over/understimulating social or physical environment; sedation
Time of day

Defining Characteristics
OBJECTIVE
Frequent or continuous movement from place to place, often revisiting the same destinations
Persistent locomotion in search of “missing” or unattainable people or places; scanning, seeking, or searching behaviors
Haphazard locomotion; fretful locomotion or pacing; long periods of locomotion without an apparent destination
Locomotion into unauthorized or private spaces; trespassing
Locomotion resulting in unintended leaving of a premise
Inability to locate significant landmarks in a familiar setting; getting lost
Locomotion that cannot be easily dissuaded or redirected; following behind or shadowing a caregiver’s locomotion
Hyperactivity
Periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping)

Desired Outcomes/Evaluation
Criteria—Client Will:
• Be free of injury, or unplanned exits.
Caregiver(s) Will:
• Modify environment as indicated to enhance safety.
• Provide for maximal independence of client.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess degree of impairment/stage of disease process:
• Ascertain history of client’s memory loss and cognitive changes.
• Note results of diagnostic testing, confirming diagnosis and type of dementia.
• Evaluate client’s mental status during daytime and nighttime, noting when client’s confusion is most pronounced, and when client sleeps.
• Monitor client’s use/need for assistive devices such as glasses, hearing aids, cane, and so forth.
• Assess frequency and pattern of wandering behavior to determine individual risks/safety needs.
• Identify client’s reason for wandering if possible (e.g., looking for lost item, desire to go home, boredom, need for activity, hunger, thirst, or discomfort).
• Ascertain if client has delusions due to shadows, lights, and noises.

NURSING PRIORITY NO. 2. To assist client/caregiver to deal with situations:
• Provide a structured daily routine. Decreases wandering behavior and minimizes caregiver stress.
• Encourage participation in family activities and familiar routines such as folding laundry, listening to music, walking outdoors. Activities and exercises may reduce anxiety and restlessness.
• Bring client to bathroom on a regular schedule.
• Provide safe place for client to wander, away from safety hazards (e.g., hot water/kitchen stove, open stairway) and other noisy clients. Arrange furniture and other items to accommodate wandering.
• Make sure that doors have alarms and that alarms are turned on. Provide door and window locks that are not easily opened to prevent unsafe exits.
• Provide 24-hour reality orientation. (Client can be awake at any time and fail to recognize day/night routines.)

• Sit with client and talk. Provide TV/radio/music.
• Avoid overstimulation from activities or new partners/roommate during rest periods when client is in a facility.
• Use pressure-sensitive bed/chair alarms to alert caregivers of movement.
• Avoid using physical or chemical restraints (sedatives) to control wandering behavior. May increase agitation, sensory deprivation, and falls, and may contribute to wandering behavior.
• Provide consistent staff as much as possible.
• Provide room near monitoring station; check client location on frequent basis.

NURSING PRIORITY NO. 3. To Promote Wellness (Teaching/ Discharge Considerations):
• Identify problems that are remediable and assist client/SO to seek appropriate assistance and access resources. (Encourages problem solving to improve condition rather than accept the status quo.)
• Notify neighbors about client’s condition and request that they contact client’s family or local police if they see client outside alone. Community awareness can prevent/reduce risk of client being lost or hurt.
• Use community resources, such as Alzheimer’s Association Safe Return Program, to assist in identification, location, and safe return of individual with wandering behaviors.
• Help client/SO develop plan of care when problem is progressive.
• Refer to community resources such as day care programs, support groups, and so forth.
• Refer to NDs: acute Confusion; disturbed Sensory Perception, (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory); risk for Injury, risk for Falls.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings, including individual concerns, family involvement, and support factors/availability of resources.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses of client/SO(s) to plan interventions and actions performed.

• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-range needs and who is responsible for actions to be taken.
• Specific referrals made.

The nursing process is complex and consists of three principle components: assessment, problem identification, and problem management. Since the early 1990s, there has been an ongoing effort to develop and promote a standardized nursing language.

Until recently, good information from nursing documentation has been difficult to utilize in decision-making processes in areas such as the cost and quality of nursing care, resource allocation, effective research, and level of staffing. The documentation was inconsistent and nonstandardized, and it provided a poor assessment of the knowledge and skill that nursing brings to healthcare.

One basic component of any data collection process is a standardized language. Standardized language involves defining a series of terms or phrases that can be applied where there are many ways of saying the same thing. In the case of nursing, there was a need for a common language that addressed and linked the three components of nursing care data elements—diagnoses, interventions, and outcomes. In the case of the SNLs, three different sets of nomenclatures are needed.

All respiratory diseases characterized by chronic obstruction to airflow fall under the broad classification of COPD, also known as chronic airflow limitations (CAL). COPD is a condition of chronic dyspnea with expiratory airflow limitation that does not significantly fluctuate. Within that broad category, the primary cause of the obstruction may vary; examples include airway inflammation, mucous plugging, narrowed airway lumina, or airway destruction. The term COPD includes chronic bronchitis and emphysema. Although asthma also involves airway inflammation and periodic narrowing of the airway lumina (hyperreactivity), the condition is the result of individual response to a wide variety of stimuli/triggers and is therefore episodic in nature with fluctuations/exacerbations of symptoms. Because client response and therapy needs can be similar, asthma has been included in this plan of care.

Asthma: Sometimes called chronic reactive airway disease, asthma is a chronic inflammatory disorder characterized by episodic exacerbations of reversible inflammation and constriction of bronchial smooth muscle, hypersecretion of mucus, and edema. Precipitating factors include allergens (e.g., foods, animals, latex, plants, molds), emotional upheaval, air pollution, cold weather, exercise, chemicals, medications, and viral infections. The prevalence of asthma is rising, accounting for the sixth most common chronic disease in the United States.

Chronic bronchitis: Widespread inflammation of airways with narrowing or blocking of airways, increased production of mucous/sputum (productive cough), and marked cyanosis.

Emphysema: Most severe form of COPD characterized by recurrent inflammation that damages and eventually destroys alveolar walls to create large blebs or bullae (air spaces) and collapsed bronchioles on expiration (air-trapping). Clinically, emphysema typically presents with nonproductive or minimally productive cough and progressive dyspnea.

Note: Chronic bronchitis and emphysema coexist in many clients and are most commonly seen in hospitalized COPD clients when acute exacerbations occur. Chronic bronchitis and emphysema are usually irreversible, although some effects can be mediated.

CARE SETTING
Primarily community level; however, severe exacerbations may necessitate emergency and/or inpatient hospital stay.

RELATED CONCERNS
Heart failure: chronic, Pneumonia, Psychosocial aspects of care, Ventilatory assistance (mechanical), Surgical intervention