Primary Nursing Diagnosis

Ineffective airway clearance related to hypoventilation or airway obstruction

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level

INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring


MEDICAL. Endotracheal intubation and mechanical ventilation are critical to ensure oxygenation and ventilation and to decrease the risk of pulmonary aspiration. A PaO2 greater than 100 mm Hg and a PaCO2 between 28 and 33 mm Hg may decrease cerebral blood flow and intracranial swelling. The routine use of hyperventilation is controversial, and some physicians are using SjvO2 (saturation of jugular venous bulb) monitoring to assess the response to changes in PaO2 and PaCO2. Generally, the PaCO2 is maintained at 35 to 40 mm Hg.

SURGICAL. Surgical management is the evacuation of the clot, control of the hemorrhage, and resection of nonviable brain tissue. Rapid surgical intervention is essential. If surgical evacuation is delayed for more than 4 hours, these lesions produce a higher mortality rate. The surgeon exposes the area involved, the clot is evacuated, bleeding from surface vascular structures is controlled with bipolar coagulation, and bridging veins are controlled with Gelfoam or muscle tissue. The surgical site may be drained postoperatively by using a Jackson-Pratt drain for 24 to 48 hours. Possible postoperative complications include intracranial hypertension, reaccumulation of the clot, intracerebral hemorrhage, and development of seizures.

864 Subdural Hematoma

Patients with critical head injuries who have a high probability of developing intracranial hypertension may require invasive ICP monitoring with an intraventricular catheter. Some physicians use a Glasgow Coma Scale score of less than 7 as an indicator for monitoring ICP. The goal is to maintain the ICP at less than 10 mm Hg and the CPP greater than 80 mm Hg. Management of intracranial hypertension may also be done by draining CSF through a ventriculostomy, either intermittently or continuously according to a predetermined ICP measurement.

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