The document describes a nursing diagnosis for a patient at risk of injury from complications of a mild traumatic head injury. The patient complains of headache and confusion and has a 3cm laceration on their temporal area. The diagnosis code is 00035. Nursing outcomes and interventions are provided to prevent falls and monitor the patient.
The document describes a nursing diagnosis for a patient at risk of injury from complications of a mild traumatic head injury. The patient complains of headache and confusion and has a 3cm laceration on their temporal area. The diagnosis code is 00035. Nursing outcomes and interventions are provided to prevent falls and monitor the patient.
The document describes a nursing diagnosis for a patient at risk of injury from complications of a mild traumatic head injury. The patient complains of headache and confusion and has a 3cm laceration on their temporal area. The diagnosis code is 00035. Nursing outcomes and interventions are provided to prevent falls and monitor the patient.
The document describes a nursing diagnosis for a patient at risk of injury from complications of a mild traumatic head injury. The patient complains of headache and confusion and has a 3cm laceration on their temporal area. The diagnosis code is 00035. Nursing outcomes and interventions are provided to prevent falls and monitor the patient.
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Nursing Diagnosis: Domain 11 Class 2 Diagnosis Code 00035 Risk for Injury related to complications of mild traumatic head
injury
Definition of Diagnosis: Susceptible to physical damage due to environmental conditions interacting with the individual's adaptive and defensive resources, which may compromise health. CUES/ Defining Characteristics Nursing Outcomes Classifications Nursing Interventions Classifications Evaluation Subjective: NOC 1: Balance NIC 1: Fall Prevention After hospital stay, Patient will be able to 020206 Dizziness achieve desired outcomes as evidenced by: Patient is responsive but complains Identify cognitive or physical deficits Decreased complaints of headaches Outcome Rating: Maintained at 2 of headache and confusions of the patient that may increase and confusions increased at 5 potential of falling in a particular Patient will be able to perform fall Objective: 1- Severe environment techniques to minimize injury 2- Substantial Swelling on temporal area with a 3 Place articles within easy reach of the 3- Moderate cm laceration patient 4- Mild Ears & Nose are unremarkable 5- None Instruct patient to call for assistance with movement, as appropriate NOC 2: Physical Injury Severity 191303 Lacerations Teach patient how to fall as to Outcome Rating: Maintained at 2 minimize injury increased at 5 Use side rails of appropriate length and 1- Severe height to prevent falls from bed, as 2- Substantial needed 3- Moderate NIC 2: Surveillance 4- Mild Establish the frequency of data 5- None collection and interpretation, as Closed Head Injuries indicated by status of the patient Outcome Rating: Maintained at 2 Monitor patient’s ability to do self-care increased at 5 activities 1- Severe Monitor neurological status 2- Substantial Monitor vital signs, as appropriate 3- Moderate Compare current status with previous 4- Mild status to detect improvements and 5- None deterioration in patient’s condition
